L&D ComplicationsL&D ComplicationsLecture 11Lecture 11

Dystocia: Dystocia: “prolonged labor” difficult labor. “prolonged labor” difficult labor. Shoulder dystocia: difficult birth d/t shoulders.Shoulder dystocia: difficult birth d/t shoulders.Indicators:Indicators: long & difficult labor long & difficult labor Cephalo-pelvic disproportion - big baby/small pelvis. Cephalo-pelvic disproportion - big baby/small pelvis. Shoulder dystocia: Shoulder dystocia: insert hand in vagina; Sweep arm insert hand in vagina; Sweep arm

that’s posterior across chest.  that’s posterior across chest.  McRobert’s Maneuver: Sharply flex legs on maternal McRobert’s Maneuver: Sharply flex legs on maternal

abdomen; symphysis pubis rotates & sacrum is abdomen; symphysis pubis rotates & sacrum is straightened. Widens pelvic opening. 50-60% cases straightened. Widens pelvic opening. 50-60% cases resolvedresolved

Nursing Interventions:Nursing Interventions: Monitor fetal/maternal status; provide O2/fluids Monitor fetal/maternal status; provide O2/fluids CClear & repeated descriptions of labor progress. lear & repeated descriptions of labor progress. Careful assessment labor; assess maternal exhaustion.Careful assessment labor; assess maternal exhaustion. Accept patientAccept patient’’s frustration/anxiety. s frustration/anxiety. Prepare for poss.emer.delivery.Prepare for poss.emer.delivery.

PsychePsyche:: • Anxiety/fear r/t pain leads to cycle of fear & Anxiety/fear r/t pain leads to cycle of fear &

anxiety. anxiety. ^ catecholamine release- leads to ^ physical ^ catecholamine release- leads to ^ physical

distress.distress. Ineffective uterine activity; longer, more dysfunctional Ineffective uterine activity; longer, more dysfunctional

labor.labor.

Interventions: Interventions: Empower client; assure her sheEmpower client; assure her she’’s in control s in control DonDon’’t force exams; explain procedures; privacy. t force exams; explain procedures; privacy. Childbirth education helpful. Childbirth education helpful. Relaxation techniques: music, focal points, Relaxation techniques: music, focal points,

breathing exercises. breathing exercises. Give Pain relief as ordered; idea of epidural Give Pain relief as ordered; idea of epidural

relaxes pt.relaxes pt. Be Pt. advocate. Be Pt. advocate.

Hypertonic Labor PatternsHypertonic Labor Patterns:: Contractions; normal duration - within 1 minute of Contractions; normal duration - within 1 minute of

each other; 5 or more in 10 minutes. each other; 5 or more in 10 minutes. Painful but ineffective in dilating/effacing cervix. Painful but ineffective in dilating/effacing cervix.

Prolonged latent phase. Prolonged latent phase. Common w. Cervidil or PitocinCommon w. Cervidil or PitocinMaternal implicationsMaternal implications: Possible placental : Possible placental

abruption, uterine rupture, infection, fever, abruption, uterine rupture, infection, fever, difficult contractions. Maternal effects: difficult contractions. Maternal effects: exhaustion; loss of control. exhaustion; loss of control.

Fetal ImplicationsFetal Implications: Hypoxia; Can cause ↓ : Hypoxia; Can cause ↓ uteroplacental blood flow; cause FHR uteroplacental blood flow; cause FHR decelerations d/t contx’s that are too decelerations d/t contx’s that are too strong/frequent. May lead to fetal distress/death. strong/frequent. May lead to fetal distress/death.

InterventionsInterventions: stop infusion of oxytocin til uterine : stop infusion of oxytocin til uterine contx. return to normal. L lateral position, O2, contx. return to normal. L lateral position, O2, rest, analgesics.rest, analgesics.

Hypotonic Labor PatternsHypotonic Labor Patterns:: • More common than hyperstimulation. More common than hyperstimulation. • Contraction of uterus w. insufficient force, ↓ Contraction of uterus w. insufficient force, ↓ frequency or both. frequency or both. • Often in primagravidas in active stage of labor; Often in primagravidas in active stage of labor; • caused by ^ sedation, early admin. of anesthesia, twins, caused by ^ sedation, early admin. of anesthesia, twins,

polyhydramnios, overdistention of uterus [macrosomia] , polyhydramnios, overdistention of uterus [macrosomia] , CPD or malpresentaton of uterus. CPD or malpresentaton of uterus.

• Occurs > labor established. Occurs > labor established. • Charac. by < 2-3 contractions in 10 min. Charac. by < 2-3 contractions in 10 min. Maternal ImplicationsMaternal Implications: Responds well to induction; 1st : Responds well to induction; 1st R/O CPD or malpresentation of fetus. Infection, exhaustion. R/O CPD or malpresentation of fetus. Infection, exhaustion. InterventionsInterventions lateral position; O2, IVF; lateral position; O2, IVF; Amniotomy [AROM]; may speed up labor. Amniotomy [AROM]; may speed up labor. Start pitocin induction as per MD. Start pitocin induction as per MD. Monitor mom VS; assess FHR w. fetal scalp electrode; Monitor mom VS; assess FHR w. fetal scalp electrode; assess contxassess contx’’s with IUPC. s with IUPC. Fetal Neonatal ImplicationsFetal Neonatal Implications: : Infection; fetal distress;Infection; fetal distress;hypoxia; fetal death if hypotonic labor prolonged & not hypoxia; fetal death if hypotonic labor prolonged & not corrected.corrected.

Prolonged Labor:Prolonged Labor: Labor > 24 hrs. Labor > 24 hrs.Causes: CPD, malpresentations, uterine contraction Causes: CPD, malpresentations, uterine contraction

Dysfunction, early anesthesia or macrosomia.Dysfunction, early anesthesia or macrosomia.

Maternal ImplicationsMaternal Implications: Labor that doesn’t progress : Labor that doesn’t progress

well: dehydration, exhaustion, rupture of uterus. well: dehydration, exhaustion, rupture of uterus.

Prolonged labor may contribute to maternal Prolonged labor may contribute to maternal infection, infection,

hemorrhage.hemorrhage.

Fetal ImplicationsFetal Implications: Can lead to neonatal infection; : Can lead to neonatal infection; hypoxia;hypoxia;

fetal death if not corrected.fetal death if not corrected.

ManagementManagement: Induce if able; possible C/S if : Induce if able; possible C/S if induction fails.induction fails.

Precipitous Labor:Precipitous Labor: Last < 3 hrs. Last < 3 hrs.Cause:Cause: Lack of resistance of uterus/cervix to Lack of resistance of uterus/cervix to

passage of passage of fetus or intense uterine contractions. fetus or intense uterine contractions. Often leads to unattended birth by MD/midwifeOften leads to unattended birth by MD/midwife

Maternal ImplicationsMaternal Implications: : Hematomas, vaginal, cervical Hematomas, vaginal, cervical lacerations; uterine rupture, hemorrhage; lacerations; uterine rupture, hemorrhage; infection. infection.

Fetal ImplicationsFetal Implications: facial bruising; intracranial : facial bruising; intracranial damage, nerve damage; hypoxia d/t quick del.damage, nerve damage; hypoxia d/t quick del.

Management:Management: Promote fetal oxygenation; Stop Promote fetal oxygenation; Stop pitocin induction; give O2 ; IV fluids; tocolytic pitocin induction; give O2 ; IV fluids; tocolytic drugs as ordered. Prepare for delivery. Note drugs as ordered. Prepare for delivery. Note bulging of membranes, crowning, urge to bear bulging of membranes, crowning, urge to bear down; monitor VS. down; monitor VS.

For For NON-COMPLICATEDNON-COMPLICATED delivery: Nurse can delivery: Nurse can

deliver baby: support head/body; check cord is deliver baby: support head/body; check cord is wrapped around babywrapped around baby’’s neck; Suction mouth then s neck; Suction mouth then nose. Deliver shoulders; Note time of delivery. nose. Deliver shoulders; Note time of delivery.                   

Premature Rupture of MembranesPremature Rupture of Membranes (PROM) (PROM) Spontaneous rupture @ least 1 hr. prior to onset of labor. Spontaneous rupture @ least 1 hr. prior to onset of labor. Assoc. with:Assoc. with: sexual intercourse; AMA > 35; multiparitysexual intercourse; AMA > 35; multiparity Incompetent cervix; Infections [BV, GBS, gonorrhea]; Incompetent cervix; Infections [BV, GBS, gonorrhea]; Low weight gain;Low weight gain; Delivery of pregnancy @ term. Vaginal exam not done [poss. Delivery of pregnancy @ term. Vaginal exam not done [poss.

intrauterine infection] – sterile speculum to estimate intrauterine infection] – sterile speculum to estimate dilation. dilation.

Dx of PROM confirmed by amniotic fluid leakingDx of PROM confirmed by amniotic fluid leaking

Tests to determine pH: Tests to determine pH: 1. nitrazine paper - amniotic fluid - alkaline 1. nitrazine paper - amniotic fluid - alkaline ““blueblue””. . 2. microscopic exam - ferning - glass slide.2. microscopic exam - ferning - glass slide. If L/S ratio indicates immature fetal lungs & mom/fetus are If L/S ratio indicates immature fetal lungs & mom/fetus are

healthy, delivery delayed if no complications exist.healthy, delivery delayed if no complications exist.

Maternal ImplicationsMaternal Implications: Chorioamnionitis; : Chorioamnionitis; Endometritis Endometritis

[infection of inner lining of uterus]. [infection of inner lining of uterus]. Neonatal ImplicationsNeonatal Implications: Chorioamnionitis; fetal : Chorioamnionitis; fetal

tachycardia; tachycardia; risk of RDS w. premature birth; umbilical cord risk of RDS w. premature birth; umbilical cord

compression; compression; fetal distress.fetal distress.ManagementManagement: Temp & pulse q 4h. Bed rest w. BRP.: Temp & pulse q 4h. Bed rest w. BRP.For contractions: For contractions: 1. Tocolytics [stop labor if not dilated> 4cm].1. Tocolytics [stop labor if not dilated> 4cm].2. AB for PROM > 12 h. 2. AB for PROM > 12 h. 3. Pitocin given to induce labor 3. Pitocin given to induce labor 4. Steroids up to 34 wks4. Steroids up to 34 wks

+ chorioamnionitis s/s: fever; ^ maternal & fetal + chorioamnionitis s/s: fever; ^ maternal & fetal HR; tender, painful uterus; foul odor of amniotic HR; tender, painful uterus; foul odor of amniotic fluid. fluid.

Prolapsed CordProlapsed Cord

Umbilical cord precedes fetal Umbilical cord precedes fetal presenting part placing pressure on presenting part placing pressure on cord and diminishing blood flow to cord and diminishing blood flow to fetusfetus

Bed rest recommended if Bed rest recommended if engagement has not occurred and engagement has not occurred and membranes have rupturedmembranes have ruptured

Assess for nonreassuring fetal statusAssess for nonreassuring fetal status Bradycardia common; emergency Bradycardia common; emergency

C/S stat!C/S stat!

Preterm LaborPreterm Labor:: (PTL) Labor @ 20 - 36 wks. May be (PTL) Labor @ 20 - 36 wks. May be painless. painless.

Risk factorsRisk factors: PROM, multiple gestation, smoking, : PROM, multiple gestation, smoking, UTI; bacterial vaginosis; previous preterm delivery; UTI; bacterial vaginosis; previous preterm delivery; stress; long working hours; short rest periods.stress; long working hours; short rest periods. S/S: S/S: contractions regular & cervical effacement contractions regular & cervical effacement

80% or dilation > 1cm. 80% or dilation > 1cm. Contractions > than every 10 mins. persisting Contractions > than every 10 mins. persisting 1 hour or more; painless or painful. 1 hour or more; painless or painful. *Lower abdominal cramping with diarrhea, low back *Lower abdominal cramping with diarrhea, low back

pain, menstrual like cramps, urinary frequency; pain, menstrual like cramps, urinary frequency; vaginal discharge: blood, ROM.vaginal discharge: blood, ROM.

Fetal/Neonatal ImplicationsFetal/Neonatal Implications: : Preterm labor leading cause of perinatal Preterm labor leading cause of perinatal

morbidity/mortality.morbidity/mortality.Rate is increasing; Affects 8 -10 % births USA/year. Rate is increasing; Affects 8 -10 % births USA/year.

Closer delivery is to term, ^ survival & lower Closer delivery is to term, ^ survival & lower morbidity morbidity

d/t technologic advances. Premies have ^ d/t technologic advances. Premies have ^ morbidity. morbidity.

Health care costs > $3 billion/yr. [NICU]Health care costs > $3 billion/yr. [NICU]

Interventions:Interventions: PTL not associated with PTL not associated with bleeding or leaking amniotic fluid can be stopped in bleeding or leaking amniotic fluid can be stopped in

50% 50% of patients with bed rest and hydration. of patients with bed rest and hydration. Admit to L&D for monitoring of FHR, contxAdmit to L&D for monitoring of FHR, contx’’s, & s, &

cervical cervical changes. changes.

ManagementManagement

TocolyticsTocolytics to stop labor; can to stop labor; can’’t use if dilation >t use if dilation >4 cm. or with acute fetal distress. 4 cm. or with acute fetal distress. MgSO4 drug of choiceMgSO4 drug of choice. . CNS depressant & smooth muscle relaxant CNS depressant & smooth muscle relaxant Causes vasodilation and bronchodilation; relaxes Causes vasodilation and bronchodilation; relaxes

uterus. uterus. Magnesium sulfate given over 24 - 48 hoursMagnesium sulfate given over 24 - 48 hours

Side Effects: decreased reflexes & respirations; Side Effects: decreased reflexes & respirations; decreased decreased

urine output. Foley catheter. urine output. Foley catheter. Brethine, Terbutaline, RitrodrineBrethine, Terbutaline, Ritrodrine: : Causes bronchodilation, ^ HR; take pulse before Causes bronchodilation, ^ HR; take pulse before

giving med. Steroids to mature lungs and giving med. Steroids to mature lungs and antibiotics to mom Notify MD for HR 120 or ^.antibiotics to mom Notify MD for HR 120 or ^.

New Testing: Fetal Fibronectin (fFN): Test for New Testing: Fetal Fibronectin (fFN): Test for Preterm DeliveryPreterm Delivery

To help predict PT delivery, some doctors screening for To help predict PT delivery, some doctors screening for fetal fibronectin (fFN).fetal fibronectin (fFN).

fFN: protein acts like “glue” attaching fetal sac to uterine fFN: protein acts like “glue” attaching fetal sac to uterine lining. Present in vaginal secretions during 1st trimester & lining. Present in vaginal secretions during 1st trimester & up to 22 wks.up to 22 wks.

indicates ^ risk of preterm delivery; suggests that "glue" is indicates ^ risk of preterm delivery; suggests that "glue" is disintegrating ahead of schedule - alerts doctors to disintegrating ahead of schedule - alerts doctors to possibility of preterm deliverypossibility of preterm delivery

After 22 wks, no longer detected until 1-3 wks before laborAfter 22 wks, no longer detected until 1-3 wks before labor

Absence of fFN is reliable predictor that pregnancy will Absence of fFN is reliable predictor that pregnancy will continue for at least another two weeks.continue for at least another two weeks.

Ruptured UterusRuptured Uterus –– Tearing of intact uterus. Tearing of intact uterus.

Causes: weak incision, OB trauma, CPD, Causes: weak incision, OB trauma, CPD, • mismanagement of oxytocin induction. mismanagement of oxytocin induction.

Monitor for uterine hyperstimulation. Monitor for uterine hyperstimulation. In labor, old scar ruptures w .contractions; over In labor, old scar ruptures w .contractions; over

distended uterus; multifetal presentation, distended uterus; multifetal presentation, malpresentation, external/internal version of malpresentation, external/internal version of fetus. fetus.

Prevention best treatment. S/S silent. Close Prevention best treatment. S/S silent. Close observation.observation.

Complete rupture: may c/o sudden, sharp, shooting Complete rupture: may c/o sudden, sharp, shooting

abd.pain & state abd.pain & state ““something gave waysomething gave way””. . • If in labor, contractions If in labor, contractions will stopwill stop & pain relieved. & pain relieved. • May exhibit signs of hemorrhagic shock: May exhibit signs of hemorrhagic shock:

hypotension, hypotension, • tachypnea, pallor, cool, clammy skin. tachypnea, pallor, cool, clammy skin.

Interventions:Interventions: D/C oxytocin & give tocolytic med. D/C oxytocin & give tocolytic med.

Poss.emergency C/S, hysterectomy, blood Poss.emergency C/S, hysterectomy, blood transfusion. transfusion.

Monitor maternal VS, O2, IVF, antibiotics > delivery.Monitor maternal VS, O2, IVF, antibiotics > delivery.

After birth, assess for ^ bleeding & s/s shock.After birth, assess for ^ bleeding & s/s shock.

Fetal-Neonatal ImplicationsFetal-Neonatal Implications: Fetal distress most : Fetal distress most reliable reliable

sign uterine rupture. Prolonged late decels & sign uterine rupture. Prolonged late decels & bradycardia.bradycardia.

Do NBN VS; transfer to NICU. Neonatal death if not Do NBN VS; transfer to NICU. Neonatal death if not

delivered in time.delivered in time.

Fetal Malposition: Fetal Malposition: • Occiput aka posterior; back of fetal head directed Occiput aka posterior; back of fetal head directed

towards back of maternal pelvis. towards back of maternal pelvis. • Common; 25% of time.Common; 25% of time.• Labor (2Labor (2ndnd stage) prolonged & mom c/o severe stage) prolonged & mom c/o severe

back pain.back pain.

Interventions: counter-pressure on lower Interventions: counter-pressure on lower sacral sacral

area; heat/cold applications, knee press area; heat/cold applications, knee press position. position.

Attempts to rotate fetal head include lateral Attempts to rotate fetal head include lateral abdominal stroking, all fours position, abdominal stroking, all fours position,

squatting, squatting, pelvic rocking, lunges.pelvic rocking, lunges.

Fetal MalpresentationFetal Malpresentation: (brow, face, breech, : (brow, face, breech, shoulder) shoulder)

Depends on degree of flexion.Depends on degree of flexion.Breech most common (3-4%). Breech most common (3-4%). Dx: abdominal palpation, vaginal exam; ultrasound. Dx: abdominal palpation, vaginal exam; ultrasound.

Interventions: Monitor FHR. External cephalic Interventions: Monitor FHR. External cephalic version may version may

be attempted to turn breech to vertex presentation. be attempted to turn breech to vertex presentation. Complications to neonate rare. Done > epidural to relax Complications to neonate rare. Done > epidural to relax

uterus. uterus.

Breech PresentationBreech Presentation: 3: 3rdrd most common reason for most common reason for C/S. C/S.

Transverse lieTransverse lie: 1 in 300-400 deliveries. Reasons: : 1 in 300-400 deliveries. Reasons: grand multip, polyhydramnios, prematurity, fibroids, grand multip, polyhydramnios, prematurity, fibroids, ovarian cysts, placenta previa, multiple preg., ovarian cysts, placenta previa, multiple preg., Main danger assoc.w. transverse lie is premature Main danger assoc.w. transverse lie is premature

ROM & ROM & cord prolapse. Intervention: attempt version [MD]; cord prolapse. Intervention: attempt version [MD];

C/S.C/S.

Multiple GestationMultiple Gestation: Gestation of twins, triplets, : Gestation of twins, triplets, more. more.

Assoc.w. ^ maternal dysfunctions - hemorrhage.Assoc.w. ^ maternal dysfunctions - hemorrhage.Higher risk for perinatal mortality r/t preterm birth Higher risk for perinatal mortality r/t preterm birth

or IUGR. or IUGR. Cord prolapse or placental separation w. 1Cord prolapse or placental separation w. 1stst fetus fetus

may may cause distress/hypoxia in 2cause distress/hypoxia in 2ndnd..

Pregnancy ComplicationsPregnancy Complications: PTL & delivery, HTN, pre-: PTL & delivery, HTN, pre-eclampsia, placental abruption, anemia, eclampsia, placental abruption, anemia,

hydramnios, UTI, hydramnios, UTI, hemorrhage, C/S.hemorrhage, C/S.

Mulitple Fetuses: Mulitple Fetuses: ^ risk for prematurity, IUGR, birth defects, ^ risk for prematurity, IUGR, birth defects, significant discordance {> than 20% weight diff.}; significant discordance {> than 20% weight diff.}; vanishing twin [one gets reabsorbed]; cord entanglement; vanishing twin [one gets reabsorbed]; cord entanglement; lowered blood/O2 supply to one/both infants. lowered blood/O2 supply to one/both infants. May result in death of one/both. May result in death of one/both.

Interventions:Interventions: prevent PTL; Complete bedrest if needed prevent PTL; Complete bedrest if needed

Identical Twins: Identical Twins: monozygotic; formed from one zygote; monozygotic; formed from one zygote; same sex; same sex;

same genetic material. same genetic material. Division occurs by day 4-8; 2 amniotic sacs & 1 placenta. Division occurs by day 4-8; 2 amniotic sacs & 1 placenta. If division occurs > day 8, share amniotic sac & placenta; If division occurs > day 8, share amniotic sac & placenta;

possible cord tangling & fetal death. possible cord tangling & fetal death. If division occurs > day 12, cojoining occurs [siamese]If division occurs > day 12, cojoining occurs [siamese]

Fraternal TwinsFraternal Twins: dizygotic; 2 separate zygotes; diff. : dizygotic; 2 separate zygotes; diff. genetic material; could be same sex or not.genetic material; could be same sex or not. 2 placentas & 2 sacs. 2 placentas & 2 sacs. 70% of time [2 ova & 2 sperm]70% of time [2 ova & 2 sperm]

Intrauterine Fetal Death {fetal demise}Intrauterine Fetal Death {fetal demise}Cessation of fetal movement. Cessation of fetal movement. 20 wks. or < 20 wks. or < ““spontaneous ABspontaneous AB”” or miscarriage. or miscarriage. > 20 wks. > 20 wks. ““StillbornStillborn””

Risk Factors: Maternal age {high & low}, multiple Risk Factors: Maternal age {high & low}, multiple gestation, chronic HTN, preeclampsia, uncontrolled DM,gestation, chronic HTN, preeclampsia, uncontrolled DM,viral/bacterial infections, congenital malformations (35%), viral/bacterial infections, congenital malformations (35%), IUGR, placental abruption, PROM.IUGR, placental abruption, PROM.

Confirm with ultrasound Confirm with ultrasound –– no FHR. no FHR.At prenatal visit - mom reports no FM. At prenatal visit - mom reports no FM. Induce w. cervidil/Pitocin; may take 1-2 days to deliver. Induce w. cervidil/Pitocin; may take 1-2 days to deliver.

Support parents; bereavement team/social worker Support parents; bereavement team/social worker involved; bereavement box contains photos/lock of involved; bereavement box contains photos/lock of hair etc. ID bands, footprint sheets.hair etc. ID bands, footprint sheets.

Placenta AccretaPlacenta Accreta: chorionic villi attach directly to : chorionic villi attach directly to myometrium of uterus. myometrium of uterus.

~ 1 in 7,000. ~ 1 in 7,000. Hx previous C/S. Hx previous C/S. Abnormally firm attachment of placenta to Abnormally firm attachment of placenta to

uterine wall uterine wall Retained placenta may interfere w.uterine Retained placenta may interfere w.uterine

contractions necessary to control bleeding > contractions necessary to control bleeding > delivery. delivery.

Severe bleeding results. Severe bleeding results. Major source of maternal morbidity/mortality.Major source of maternal morbidity/mortality.

Treatment: Hysterectomy to control bleeding; Treatment: Hysterectomy to control bleeding; Transfusions in > 50% of pts. Transfusions in > 50% of pts. Main OR w.experienced staff; Have blood products Main OR w.experienced staff; Have blood products

ready.ready.

Cont.Cont.Risk Factors: # 1 placenta previa; 10% of all Risk Factors: # 1 placenta previa; 10% of all

accretas.accretas.Rare; previous C/S’s, AMA >35; D&CRare; previous C/S’s, AMA >35; D&C‘‘s. s. Woman not prepared for poss. hysterectomy/loss of Woman not prepared for poss. hysterectomy/loss of fertility. fertility.

#1 Goal #1 Goal : control blood loss. Control of bleeding : control blood loss. Control of bleeding achieved achieved

w.hysterectomy. Uterine embolization may preventw.hysterectomy. Uterine embolization may preventhysterectomy. U.arteries cauterized. May save hysterectomy. U.arteries cauterized. May save

uterus. uterus.

Maternal Complications Maternal Complications : hemorrhage, infection. : hemorrhage, infection. Definitive dx not poss.til delivery. May detect Definitive dx not poss.til delivery. May detect

abnormal abnormal pulsations w. sono near bowel/bladder. pulsations w. sono near bowel/bladder. Neonatal ComplicationsNeonatal Complications: prematurity : prematurity 2/3r2/3rdsds cases; cases;

34-35wks.34-35wks.

Amniotic Fluid EmbolismAmniotic Fluid Embolism AFE: obstetric emergency!AFE: obstetric emergency! Amniotic fluid, fetal cells, lanugo, other debris Amniotic fluid, fetal cells, lanugo, other debris

enter maternal pulmonary circulatio; causes enter maternal pulmonary circulatio; causes cardio-respiratory collapse.cardio-respiratory collapse.

Autopsy of maternal lungs reveals edema, Autopsy of maternal lungs reveals edema, alveolar hemorrhages, emboli [squamous cells, alveolar hemorrhages, emboli [squamous cells, fat, bile, lanugo].fat, bile, lanugo].

In many cases, mixture between maternal/fetal In many cases, mixture between maternal/fetal materials is harmless.materials is harmless.

Mixing causes series of physiological reactions Mixing causes series of physiological reactions resembling anaphylactic shock d/t contact with resembling anaphylactic shock d/t contact with debris. debris.

Blockage of maternal pulmonary vessels by Blockage of maternal pulmonary vessels by emboli. Releases thromboplastin into circulation; emboli. Releases thromboplastin into circulation; leads to DIC leads to DIC

CLINICAL FINDINGSCLINICAL FINDINGS

Mode of infusionMode of infusion Tear in amniotic sac and opening into maternal Tear in amniotic sac and opening into maternal

vasculature thru uterine veins.vasculature thru uterine veins. Amniotic fluid enters uterine/cervical veins d/t RAmniotic fluid enters uterine/cervical veins d/t R rupture of amniotic sac & pressure gradient from rupture of amniotic sac & pressure gradient from

uterus to veins [strong contractions]uterus to veins [strong contractions] Abrupt onset of hypotension, hypoxia, & Abrupt onset of hypotension, hypoxia, &

coagulopathycoagulopathy RARE; but once it occurs, common cause of RARE; but once it occurs, common cause of

maternal death. 1/ 20,000 deliveriesmaternal death. 1/ 20,000 deliveries 25% of women die within 1 hour of onset 25% of women die within 1 hour of onset

Risk Factors:Risk Factors: Multiparity; Age > 30; Large fetus Multiparity; Age > 30; Large fetus Intrauterine fetal death [saline to induce abortion] Intrauterine fetal death [saline to induce abortion] Meconium in amniotic fluid; Strong uterine Meconium in amniotic fluid; Strong uterine

contractions contractions

ClinicallyClinically: patient in either late stages of labor or : patient in either late stages of labor or immediately postpartum:immediately postpartum: 11stst phase: phase:

– gasp for airgasp for air– rapidly suffer seizure or cardiorespiratory arresrapidly suffer seizure or cardiorespiratory arres22ndnd phase: phase:– Very often complicated by DIC Very often complicated by DIC – massive hemorrhage; death.massive hemorrhage; death.

Management:Management: Circulatory support & O2Circulatory support & O2 Bronchodilators, vasodilators, volume Bronchodilators, vasodilators, volume

expanders. expanders. For DIC: plasma, cryoprecipitate, blood For DIC: plasma, cryoprecipitate, blood

transfusion transfusion With Cardiac arrest, C/S to improve newborn With Cardiac arrest, C/S to improve newborn

outcome.outcome.

Prognosis:Prognosis: Maternal death common; survivers may be Maternal death common; survivers may be

neurologically impaired r/t hypoxia.neurologically impaired r/t hypoxia. Infant may suffer residual neurological Infant may suffer residual neurological

impairment. impairment. ~ 70% of newborns survive.~ 70% of newborns survive.