Fetal distress, Abnormal labor, Obstetric complications during labor and delivery

1. Fetal distress, Abnormal labor, Obstetric complications during labor and delivery Song Yu

2. cardiotocograph

4. Case 1 A healthy 41-year-old para 3 gravida presented at 41 weeks gestation for induction of labor after an uneventful pregnancy. She was transferred to the delivery room, an oxytocin infusion started and her membranes ruptured artificially. At this stage, meconium staining of the amniotic fluid was noted and late decelerations of the fetal heart rate were present. A decision was therefore made to perform a caesarean section under general anaesthesia.

5. Case 1 A few minutes after delivery of the baby, she had a purpuric rash over her upper body, and was profoundly hypotensive. Abnormal bleeding from the surgical wound was noted. Catheterisation of the bladder produced heavily bloodstained urine which was devoid of protein.

6. Discussion 1. diagnosis 2. Assessment findings in this disease 3. risk factors 4. management

7. Assessment findings in amniotic fluid embolism • Sudden dyspnea • Tachypnea • Chest pain • Coughing with pink frothy sputum • Cyanosis • Hemorrhage • Shock disproportionate to blood loss • Increasing restlessness and anxiety

8. Risk factors 1. Induction of labor 2. Cesarean, vacuum, and forceps delivery 3. Placenta previa or abruptio placentae 4. Cervical laceration 5. Uterine rupture 6. Eclampsia and preeclampsia 7. Advanced maternal age (≥35 years) 8. Multiparity 9. Polyhydramnios 10. Meconium-stained amniotic fluid

9. management A. Multidisciplinary approach. Treatment of AFE is nonspecific. The best results are achieved using a multidisciplinary approach to support the patient's respiration and circulation. 1. The initial objective is to maintain adequate oxygenation and vital end-organ perfusion and to correct coagulopathy. 2. Appropriate intravenous access is required for resuscitation. a. Large-bore peripheral intravenous cannulae b. Consider central venous catheter placement 3. Antiallergic medication such as hydrocortisone should be administered immediately

10. management B. Cardiopulmonary resuscitation 1. Endotracheal intubation and mechanical ventilation are instituted. The goal is to maintain arterial partial pressure of oxygen and to minimize the likelihood of cerebral hypoxic insult. 2. Fluid resuscitation should be aggressive 3. Vasopressors will likely be required. C. CS should be performed as soon as possible after AFE diagnosis

11. management D. Blood product therapy 1. Blood product therapy is guided by serial analysis of coagulation studies, and clinical evidence of bleeding. 2. Patients with significant bleeding and thrombocytopenia should be treated with platelets. 3. Patients with a significantly elevated PT and/or decreased fibrinogen should be treated with fresh frozen plasma or cryoprecipitate to maintain fibrinogen. 4. Anemia should be treated with packed red blood cells as indicated. 5. Heparin is usually not administered to treat acute-onset DIC.

12. Case 2 A 39-year-old woman, gravida 2 para 1, at 41-week gestation, was admitted to our hospital with decreased variability in fetal heart rate monitoring associated with oligohydramnios. The ultrasound scan performed at admission showed a head presenting fetus with an estimated weight of 2800 g, reduced amniotic fluid index (AFI 40). Her previous obstetrical and medical history was unremarkable, and her current pregnancy was ordinary.

13. Case 2 Within 40 minutes of admission, an induction of labor with Oxytocin was performed under FHR monitoring. Two hours after the induction, we still observed a reduced variability in fetal heart rate (amplitude range of 5 beats/minute) with sporadic late decelerations, then we proceeded to amniorrhexis which revealed meconium-stained amniotic fluid. .

14. Case 3 A 33-year-old primigravida was admitted at 41w 2d gestation for induction of labor with the diagnosis of postdates pregnancy. Her Bishop score was 3 and she initially received 25 μg misoprostol per vaginam every 4 hours for a total of three doses, at which time her Bishop score has improved to 7. She was begun on oxytocin and her contractions increased in frequency and intensity. The fetal heart rate tracing remained reassuring. After 6 hours her cervix was 4 cm dilatated and completely effaced, with the vertex estimated at -2 station. An amniotomy was performed for augmentation of labor with return of a large amount of clear fluid. With the next contraction sustained fetal bradycardia was noted on the fetal monitor. A sterile vaginal examination was performed and revealed umbilical cord prolapsing through the cervix. The presenting part was elevated, the oxytocin discontinued, and she was urgently transferred to the operating room where she initially received terbutaline subcutaneously for uterine relaxation. An emergency CS was performed.

15. Discussion 1. diagnosis 2. Monitoring methods and tests that suggest fetal distress 3. Main causes of acute fetal distress

16. Monitoring methods and tests that suggest fetal distress • Nonreactive NST • Decreased baseline FHR variability • Recurrent severe variable decelerations or late decelerations • Sustained bradycardia or tachycardia with absent variability • Meconium stained amniotic fluid • Decreased fetal movement felt by the mother (less than 10 times/12 hours)

17. Causes of acute fetal distress • Placenta previa or abruptio placentae • 2. Umbilical cord prolapse • 3. Maternal hypoxia • 4. Improper use of oxytocin • 5. Eclampsia and preeclampsia

18. Case 4 A 41-year-old nulliparous woman with a twin pregnancy was admitted to the hospital because of diffuse itching at 35 weeks of gestation. Her medical history was noteworthy for hysteroscopic submucous myomectomy (10 years before). The pregnancy was uneventful. Laboratory evaluation revealed normal findings. Clinical evaluation on admission showed an unfavorable cervix and a twin pregnancy with viable fetuses. Nine hours after admission the patient reported severe abdominal pain. A pathologic retraction ring can be seen. Blood pressure decreased to 90/70 mm Hg with persistent maternal tachycardia. Ultrasound scan revealed bradycardia of the second twin. Her hemoglobin level decreased from 13.8-7.4 g/dL.

19. Discussion 1. diagnosis 2.Differential diagnosis 3. causes and risk factors for this disease 4.What’s a pathologic retraction ring

20. Causes and risk factors of uterine rupture Previous cesarean birth Previous uterine surgery Prolonged labor Cephalopelvic disproportion Multiple gestation Improper use of oxytocin Obstructed labor Traumatic maneuvers using forceps or traction

21. Understanding a pathologic retraction ring A pathologic retraction ring, is the most common type of constriction ring responsible for dysfunctional labor. It's a key warning sign of impending uterine rupture. A pathologic retraction ring appears as a horizontal indentation across the abdomen, usually during the second stage of labor. The myometrium above the ring is considerably thicker than it is below the ring. When present, the ring prevents further passage of the fetus, holding the fetus in place at the point of the retraction. The placenta is also held at that point.

22. Case 5 A 38-year-old gravida 3 para 1 woman with complete placenta praevia was admitted into the hospital at 35 weeks of gestation. After three days, she had a C section because of decreased variability in FHR patterns. An infant weighing 2900g with Apgar scores 9/10 was delivered. In the surgery, placenta adhesion was found. Manual extraction and uterine exploration were performed. Vaginal bleeding was estimated about 600ml, fundal height was at umbilicus level, uterus relaxed. 20 U of oxytocin was used immediately. Massage of the uterus to stimulate contraction and evacuation of clot from the lower uterine segment was performed.

23. Discussion 1. Definition of postpartum hemorrhage 2. etiology 3. Management of uterine atony

24. Definition • Refers to blood loss of 500 ml or more during the 24 hours after delivery of the fetus

25. etiology • Uterine atony (80%) • Retained placental fragments, placenta accreta • Lower genital tract lacerations • Coagulopathy

26. Management of uterine atony • Remove the causes of uterine atony • Uterine massage • Use of oxytocin • Uterine packing • Ligation of pelvic artery • Internal iliac artery embolization • A hysterectomy may be done as a last resort.

27. Case 6 A 30-year-old woman was admitted to the hospital at 8:00AM because of abdominal pain for 3 hours at 39 weeks of gestation. Her pregnancy has been uneventful up to now. Her abdominal pain starts at 5:00AM, regular, 10sec/10min. Reproductive history：0-0-1-0 Physical examination：T:36.4 。C P:80 /min R18/min BP:120/70mmmHg. Heart and lungs negative. Fundal height:38cm. Abdominal girth:83cm,FHR:140/min. Fetal position:ROA. External pelvic measurement:23-25-17-8cm B ultrasound：BPD:81cm. Abdominal girth:335cm femoral length:67cm. Normal AFI. Placenta maturity: grade ⅢB. Fetal position:ROA

28. Case 6 • 8:00 regular contractions, 20”/4-5’, moderate degree, cervix dilated 2cm，head presentation，vertex at station -1，amniotic sac emerged，FHR:145/min,transferred into delivery room. • 9:45 contractions 20”/3’,moderate,cervix dilated 8cm，vertex +1，FHR:155/min，Bp 118/72mmHg. • 10:45 contractions 20”/3’,moderate,cervix dilated 10cm, head presentation，+1,FHR152/min • 12:50 contractions 20”/3’,moderate, cervix dilated 10cm,head presentation，+3，FHR150/min,Bp 110/67mmHg。 • A female infant weighing 2335g with Apgar scores 9/9 was delivered by lowforceps delivery，placenta and fetal membrane was intact. Oligohydramnios was found. Umbilical cord was 30cm.

29. Discussion 1. diagnosis 2. When did the abnormality occurred? 3. Management

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