Complications of Labor and Delivery

I. Preterm Labor- uterine contraction with or without cervical dilation prior to 37 weeks gestation
a. Risk factors include smoking, previous premature delivery, vaginal bleeding during pregnancy
i. 75% of infant death; 7-10% of total pregnancies
b. Infants born prematurely often have visual or hearing impairement, developmental delays, cerebral palsy,
and lung disease
c. Etiology
i. Preterm premature rupture of fetal membranes vi. Uterine trauma
ii. Infection caused by prostoglandin endotoxin- vii. Placental abnormalities
producing bacteria viii. Substance abuse
iii. Dehydration ix. Advanced maternal age
iv. Incompetent cervix x. Patient with first trimester
v. Excessive uterine enlargement bleeding
d. Clinical manifestations
i. Regular uterine contractions between 20-35 weeks gestation
1. Change in cervix- length of cervix, normally long, will begin to shorten. Leads to
effacement and dilation
2. Cervical dilation- >2cm
3. Cervical effacement- >80%
ii. Can also include painful or painless contractions, pressure, menstrual-like cramps, watery or
bloody discharge, lower back pain
e. Diagnostics
i. Ultrasound iii. Ferning
ii. Secretions for fetal fibronectin- 99% accurate
f. Management
i. Bed rest ii. Hydration
iii. IV RL or normal saline- 500cc bolus
iv. Tocolytics
1. Terbutaline subcutaneously- beta agonist
2. MgSO4
a. Patient on MgSO4 must be admitted and monitored for side effects
i. Visual symptoms, DTRs decreased, cardiac abnormalities, pulmonary
edema (must perform lung evaluation)
v. Patients who respond to treatment are placed on oral terbutaline and are given home monitoring
vi. Amniocentesis- for suspicion of chorioamnionitis and to evaluate and fetal lung maturity
vii. Steroids betamethasone 12mg repeated in 24 hours
II. PROM/PPROM- 30-40% of pregnancies; patients will deliver within a week
a. Premature rupture of membranes and preterm premature rupture of membranes
b. PROM is rupture of amniotic membranes before onset of labor at or beyond 37 weeks gestation
c. PPROM is prior to 37 weeks
d. Risk of PROM increased if smoke during pregnancy, prior PROM, short cervical length, prior preterm
delivery, multiple gestation, bleeding early in pregnancy
i. Risk factor for both is infection iii. Leads to neonatal
ii. Can lead to cord prolapse/abruptio placentae complications
e. Clinical manifestations
i. Leaking fluid ii. Vaginal discharge
 iii. Pelvic pressure
iv. Ruptured membranes confirmed with direct visualization using sterile speculum, nitrazine paper
(amniotic fluid is a base- blue color), fern test
v. Ultrasound
f. Management
i. PROM-
1. Induction with prostoglandin cervical gel or oxytocin
ii. PPROM
1. <32 weeks do not induce delivery 4. bed rest
2. Steroids if <30-32 weeks gestation 5. NST, ultrasound for amniotic fluid index
3. Antibiotics 6. Surgical grafts to correct PROM
III. Placental Abruption- Rupture of placenta off of the wall of the uterus; after 20 weeks of gestation; occurs in
1% of pregnancies and has high mortality to the fetus (40%)
a. Separation of the placenta from the uterine wall
b. Can be due to trauma, hypertension, coagulopathy, retroplacental fibromyoma, short umbilical cord
c. Leads to bleeding into the deciduas basalis
d. This can push the placenta away from the wall of the uterus
e. Clinical manifestations
i. Consider in patients with PROM iv. Localized uterine tenderness
ii. Vaginal bleeding 80% v. Hypertonic uterine contractions- painful
iii. Abdominal/back pain vi. Fetal distress/death
f. Classification
i. Class 0- asymptomatic. Blood clot on placenta; usually diagnosed after delivery
ii. Class 1- mild. Minor vaginal bleeding. Minor uterine tenderness. Minor contractions; no maternal
or fetal distress
iii. Class 2- moderate. Moderate vaginal bleeding, moderate to severe uterine tenderness with tetany,
maternal tachycardia; fetal distress when monitoring heart rate
iv. Class 3- severe. Heavy vaginal bleeding, tetany, maternal shock, disseminated intravascular
coagulation (in mother); leads to maternal or fetal death
g. Diagnosis
i. Ultrasound retro-placental hematoma
ii. Blood-hemoglobin, hematocrit, prothrombin time, fibrinogen, D-dimer, fibrin/fibrinogen
degradation products
h. Management
i. Treat hypovolemia- oxygen and IV fluids
ii. Fetal monitoring- for fetal distress
iii. Monitor vital/urine output in mother- deceased urine output( one of the first signs of shock)
iv. Immediate delivery by c-section if fetus is in distress- monitor if not in distress
v. Watch for DIC- in the mother
i. Complications
i. Maternal
1. Hemorrhagic shock 3. Uterine rupture
2. DIC/coagulopathy
ii. Fetal complications
1. Hypoxia- no blood 3. Growth retardation
2. Anemia- no blood 4. Fetal death
IV. Placenta Previa
a. Implantation of placenta in the lower uterine segment
b. Four types: complete (completely covers os), partial, marginal (edge covers os), and low lying (does not
cover os but is low to the oz)
c. Incidence varies with trimester- more common is second trimester
d. Most resolve by third trimester
e. Risks include advanced maternal age, previous abortion, multiparity
f. Clinical manifestations
i. Sudden, bright red vaginal bleeding v. Normal fetal heart tones
ii. Painless vi. DO not perform vaginal or rectal
iii. Can have intermittent bleeding episodes exams
iv. Soft non-tender uterus
g. Diagnosis
i. Transvaginal ultrasound iv. Fibrin split products/fibrinogen levels
ii. Beta hCG v. PT/apt- test for DIC
iii. Rh compatibility
h. Management
i. IV fluids for hypovolemia iv. Betamethasone
ii. Fetal monitoring v. Tocolytics
iii. Delivery if patient near term- c-section
i. Complications
i. Maternal morbidity iii. Intrauterine growth retardation
ii. Re-bleeding
iv. Complete placenta previa have poor prognosis
V. Uterine Rupture
a. Tearing of uterus
b. Associated with VBAC-2 (vaginal birth after C-section) or more previous c-sections, structural uterine
problems, excessive uterine stimulation
c. Clinical presentation
i. Present with sudden fetal bradycardia or fetal distress. Might have uterine pain, vaginal
hemorrhage, cessation of uterine contractions, regression of fetus
d. Diagnosis
i. Sonogram
ii. Management includes surgery for prompt delivery and control of maternal hemorrhage
iii. May require transfusions and hysterectomy
VI. Placenta Accreta
a. Placenta attaches itself too deeply into the wall of the uterus
b. Classified by degree of adherence
i. Placenta accreta- adhere to superficial lining of myometrium (most common)
ii. Placenta increta- deeper in myometrium
iii. Placenta percreta- penetrates the entire myometrium and might invade other organs
c. Risk factors include placenta previa
d. Clinical Manifestations
i. Present with postpartum hemorrhage
ii. Diagnosed by color Doppler or sonography
 iii. Management: fluid and blood replacement. If bleeding is minimal, placenta left in situ. Separate by
curettage
iv. Hysterectomy
VII. Postpartum Hemorrhage
a. Excessive bleeding in minutes and hours after delivery
b. Blood loss in excess of 500cc
c. Uterine atony most common cause- placenta previa is a cause
d. Other causes include retained placenta, lacerations of lower genital tract, coagulation defects
e. Uterine atony
i. Contractions constrict spiral arteries preventing excess bleeding from placental site
ii. Risks include overdistended uterus, rapid or prolonged labor, high parity, Macrosomia,. Presents as
boggy uterus
iii. Management: oxytocin, uterine massage. Surgery ligation of uterine arteries
VIII. Dystocia
a. Leading indication for cesarean section
b. Cervix fails to dilate progressively over time and fetus fails to descend
c. Due to abnormalities with the passage, abnormalities of the passenger, abnormalities of power
d. Clinical manifestations
i. Inability to delver vaginally after full cervical dilatation
ii. Macrosomia, nonvertex position, adequacy of pelvis, cord prolapse
iii. Ultrasound
e. Amniotomy- for patients with prolonged latent phase. Inadequate uterine contractions- increase with
oxytocin
f. If maternal pushing inadequate, rest or assisted delivery with forceps or vacuum
g. Mal-position might need c-section
IX. Shoulder Dystocia
a. One of both shoulders of the fetus become trapped at the inlet or impacted at the pubic symphysis after
delivery of the head
b. Can result in nerve damage to arms. Brachial plexus- Erbs palsy
c. Can be due to Macrosomia, pelvic architecture, uterine abnormalities, abnormal contractions
d. Can result in death
e. Management
i. McRoberts maneuver- flexion and abduction of knees and legs to increase pelvic opening
ii. Zavanelli maneuver- cephalic replacement and c-section delivery
X. Prolapsed Umbilical Cord
a. Umbilical cord present in front of fetal presenting part on membrane rupture
b. Increased risk when presenting part does not fill lower uterine segment as in breech, premature infants,
multiple gestation, long umbilical cord, Polyhydramnios
c. As baby descends can put pressure on cord. Compression of cord leads to decreased oxygen and blood
supply
d. Need emergent vaginal delivery or c-section
e. Have mother get on knees and bend over
XI. Breech Presentation- 2% of term pregnancies
a. Occurs frequently in second and third trimester, most of these babies will turn vertex near term associated
with Prematurity, multiple pregnancy, Polyhydramnios
b. Three types
 i. Frank feet first iii. Incomplete- combo
ii. Complete- butt first
c. Diagnosis
i. Leopold maneuvers iii. Ultrasound
ii. Pelvic exam
d. Risk to fetus Prematurity, umbilical cord prolapse, birth trauma
e. Management
i. External cephalic version
ii. Avoid if preterm due to risk for birth trauma and avoid if weight >3800gm
iii. Criteria for normal vaginal delivery
1. Normal labor 4. Maternal pelvis adequate
2. Fetal weight 2000-3800gm 5. Normally flexed fetal head
3. Reassuring fetal tracing
f. Complications: Trapped head, cord compression, no time for head molding, hip/clavicle/brachial plexus
injury, cervix not fully dilated
XII. Cesarean Section- 20-30% of pregnancies
a. Increase due to availability of NICU and so premature infants now have greater likelihood of survival
b. Performed in breech presentations
c. Performed if signs of nonreassuring fetal status
d. Previous c-section at one time meant all future deliveries had to be c-section
e. Mortality for mother higher than NSVD
f. Risks include thromboembolic events, increased bleeding and development of infection
g. Indications
i. Failure of labor to progress iv. Breech presentation
ii. Repeat c-section v. Fetal well being
iii. Dystocia
h. Lower segment transverse- most common
i. Less blood loss iv. Few adhesions to bowel or
ii. Easy repair omentum
iii. .4% rate of rupture with subsequent VBAC
i. Classical
i. For cases where lower segment is not large enough for delivery
ii. Preterm delivery iii. Non-vertex position
j. Management
i. Prophylactic antibiotics after section
ii. Low transverse uterine incision used because of decreased blood loss, ease of repair and low
likelihood of rupture
XIII. VBAC
a. Success depends on the indication for previous c-section and number of previous c-sections
b. If reasons for previous c-section was dystocia, high rate of failure
c. Risk of uterine rupture in VBAC after low transverse incision low, but if it happens can lead to mortality
and morbidity
d. Contraindications
i. Unknown scar iii. Patient requesting repeat c-section
ii. Need for induction iv. Contraindications for vaginal deliver