Labor and Delivery at Risk

v High Risk Pregnancy

 Threatens the health or life of the mother or fetus
 The goal is to identify mothers at risk for developing complications
 Promote risk-appropriate care that will enhance maternal and fetal outcomes
 Factors to be considered are demographic, medical, obstetric, sociocultural, lifestyle
and environmental risks
 No cause-and-effect relationship between risk factors and poor outcomes has been
established.

v Risk Factors
 Existing health conditions (High BP, diabetes, HIV positive)
 History of prior pregnancy complications
 Complications that arise during pregnancy such as diabetes or preeclampsia
 Being overweight or obese
 Carrying more than one fetus
 Being ≤ 18 years of age or of Advanced maternal age
 Lifestyle (smoking, drinking alcohol, drugs)
 Housing, financial, psycho-social and environmental risks
 Access to healthcare

v Existing Health Conditions

Ø High Blood Pressure
– Uncontrolled high blood pressure
– Increased risk for preeclampsia/eclampsia
– Renal damage in mother
– increase the risk for low birth weight

Ø Polycystic Ovary Syndrome (PCOS)

– increased rates of pregnancy loss before 20 weeks
– Increased rates of gestational diabetes
– Increased rates of Preeclampsia
– Increased rates of cesarean section

Ø Kidney disease
– Women with mild kidney disease often have healthy pregnancies
– Increased rates of infertility and miscarriage
– preterm delivery
– low birth weight
– Preeclampsia

Ø Nearly one-fifth of women who develop preeclampsia early in pregnancy are found
to have undiagnosed kidney disease.
 Ø Autoimmune disease (Lupus, Multiple sclerosis, etc.)
– increased risk for preterm birth and stillbirth
– medications may be harmful to the fetus
– Symptoms may get better or worse with other complications

Ø Thyroid disease
 The thyroid is a small gland in the neck that makes hormones that help control
heart rate and blood pressure.
 Uncontrolled thyroid disease can cause fetal heart failure, poor weight
gain, poor brain development

Ø Obesity
 Obesity before pregnancy is associated with an increased risk of structural
problems with the baby’s heart.
 Increased risk of gestational diabetes

v Infection Risk
Ø Sexually transmitted infections (STI)
 Can pass to the fetus during pregnancy or to the infant during delivery, but the
risk of transmission can be lowered or even eliminated with appropriate
treatments

 Some STIs such as syphilis, cross the placenta and infect the baby in the womb.

 Some STIs, like gonorrhea, chlamydia, hepatitis B, and genital herpes, can pass
from the mother to the baby during passage through the birth canal.

 HIV can cross the placenta during pregnancy and infect the baby during delivery.

 For infections, such as gonorrhea, a pregnant woman and her sexual partner can
be treated before the birth, and the infant can be treated at birth to prevent
infection

 Erythromycin eye ointment after birth prevents blindness in infants exposed

to gonorrhea or chlamydia during

Ø Complications of infections can include:

– Miscarriage(fetal loss before 20 weeks)
– Ectopic Pregnancy
– Preterm labor and delivery (before 37 completed weeks of pregnancy)
– Low birth weight
– Congenital anomalies: blindness, microcephaly, deafness, bone deformities, and
intellectual disability, etc.
– Fetal demise
– Illness in the newborn period (first month of life)
– Newborn death
 – Health complications in the mother

Ø Group B streptococcus (GBS)

 Passed to the infant during labor and delivery from colonize genital tract of the
mother
 Causes pneumonia, meningitis and sepsis in the newborn

Ø Hepatitis B virus (HBV)

 The likelihood of transmission depends on when during pregnancy the mother
was infected. If the mother gets the infection later in the pregnancy, the risk that
the virus will infect her fetus is quite high. If the infection occurs early in
pregnancy, the risk of the virus infecting the fetus is much lower
 Chronic liver disease or liver cancer later in life
 High risk of becoming carriers of HBV and can spread the infection to
others
 All healthy infants should be vaccinated against HBV to give them
lifelong protection.
 Infants born to women with evidence of ongoing HBV infection (HBV
surface antigen positive) should also receive hepatitis B hyperimmune
globulin as soon as possible after birth.

Ø Rubella (German measles)

 Dangerous to get during the first trimester
 Vaccinate at least 28 days before conception/cannot vaccinate during pregnancy
since it is a live virus
 90% chance of passing to the fetus during the early first trimester
 Congenital rubella syndrome can cause miscarriage, fetal demise, cataracts,
blindness, heart defects, deafness, and mental retardation

Ø Toxoplasmosis
 caused by a parasite that can be present in cat feces or used cat litter, it can
intellectual disabilities, blindness

Ø Zika
 Spread by mosquitoes
 Causes microcephaly. As a result, can have seizures, feeding issues, hearing loss,
vision abnormalities and learning difficulties.

v Age Related Risks

Ø Young age: greater risk of
 pregnancy-related high blood pressure
 anemia
 preterm labor
 sexually transmitted infection
 less likely to get prenatal care or to keep prenatal appointments.
 Ø First-time pregnancy after age 35: at higher risk for
 gestational hypertension and gestational diabetes
 Pregnancy loss
 Ectopic pregnancy
 Cesarean section
 Intra and postpartal hemorrhage
 Prolonged labor (lasting more than 20 hours)
 Labor that does not advance
 Genetic disorders

Ø Alcohol use
 increase the baby’s risk for fetal alcohol spectrum disorders (FASDs)
 sudden infant death syndrome
 Intellectual and developmental disabilities
 behavior problems; abnormal facial features; and disorders of the heart, kidneys,
bones, and hearing
 more likely to have a miscarriage or stillbirth.

Ø Tobacco use
 preterm birth
 congenital anomalies
 sudden infant death syndrome (SIDS)
 smoking doubled or even tripled the risk of stillbirth after 20 weeks
 leads to changes in an infant’s immune system

Ø Drug use
 Research shows that smoking marijuana and using illegal drugs doubled the risk
of stillbirth
 smoking marijuana during pregnancy can interfere with normal brain
development in the fetus, possibly causing long-term problems.

v Conditions of pregnancy
Ø Multiple gestation
 increases the risk of infants being born prematurely
 Both giving birth after age 30 and taking fertility drugs have been linked with
multiple births
 Having three or more infants increases the chance that a woman will need to have
the infants delivered by cesarean section
 Twins and triplets are more likely to be smaller for their size than single infants
(increase in neonatal respiratory problems)

Ø Previous preterm
 at high risk for preterm labor and birth because of a previous preterm birth, giving
progesterone can help delay the birth
 pregnancy within 12 months after the latest delivery may be at increased risk for
preterm birth.
 Ø Preeclampsia and eclampsia
 can affect the mother’s kidneys, liver, and brain

v Preterm birth
Ø Spontaneous: unintentional and unplanned: infection, inflammation. A history of
delivering preterm is one of the strongest predictors for subsequent preterm births
Ø Medically indicated: recommended when a serious medical condition presents
(preeclampsia). Goal is to keep the baby in the womb as long as possible.
Ø Non-medically indicated (elective preterm delivery): not recommended; should
wait until 39 weeks for induction or c-section.

v Management of Preterm labor:

 focus is on delaying delivery for 48-72 hours to administer antenatal steroids and
allow time to facilitate fetal lung maturity
 Tocolytic drugs: medications that suppress uterine contractions (usually used
between 24-34 weeks’ gestation)
– Calcium channel blockers: (Nifedipine)
– NSAIDS: (Indomethacin)
– Beta-adrenergic receptor agonists (Terbutaline, Ritodrine)
 Antibiotics: not for those with intact membranes; only with PPROM and those
with group B strep colonization
 Progesterone prophylaxis: for those with history of spontaneous preterm birth:
limits production of prostaglandins and inhibits contraction-associated protein in
the myometrium. Not used in multiple gestations.

« Tocolytics are not recommended if membranes are ruptured with active labor.

v Fetal Protection
Ø Magnesium Sulfate
o neuroprotective; reduces microcapillary brain hemorrhage in the neonate
(before 32 weeks’ gestation)
Ø Corticosteroid Therapy (Betamethasone)
o single course between 24- and 34-weeks’ gestation who are at risk of delivery
within 7 days.
o Antenatal steroids accelerate fetal lung maturity, and decreasing the severity
of respiratory distress syndrome, IVH, necrotizing enterocolitis, and infectious
morbidity

Cervical Insufficiency
« The inability of the uterine cervix to retain a pregnancy in the absence of the signs and
symptoms of clinical contractions, or labor, or both in the second trimester.
 Risks to women: repeated 2nd trimester or early 3rd trimester births
 Risks to fetus: Preterm birth and consequences of prematurity
 Symptoms: asymptomatic or non-specific symptoms: back ache, contractions,
vaginal spotting, pelvic pressure or mucoid vaginal discharge
  Management: cerclage
 Prophylactic: Placed at 13-14 weeks gestation
 Rescue: placed after dilation with no perceived contractions up to 24 weeks
gestation
 Who is eligible for cerclage?
 singleton pregnancy
 prior spontaneous preterm birth at less than 34 weeks
 short cervical length (less than 25mm) before 24 weeks gestation

v Multiple Gestation Risks

Ø Increased rate of perinatal mortality and neurologic injury in monochorionic,
diamniotic twins compared with dichorionic pairs.

Ø Because they share the same amniotic sac, monoamniotic twins have a fetal mortality
rate of 50%-60% due to entanglement of umbilical cords.

Ø Monochorionic twins are at risk for complications such as twin-to-twin transfusion

syndrome (TTTS) or twin anemia-polycythemia sequence (TAPS) which can be
lethal or associated with serious morbidity.

v Multiple Gestation

§ Dichorionic/diamniotic twin pregnancy: when the division occurs within 3 days

of fertilization
§ Monochorionic/diamniotic twins: when the division occurs within 4-8 days of
fertilization
§ Monochorionic/monoamniotic twins: when the division occurs on day 12 or 13
§ After day 13, the division leads to conjoined twins.

v TTTS and TAPS

 10 to 15 percent of monochorionic twin pregnancies
 imbalance in blood flow due to placental vessel connections
  One twin (called the “donor” twin) gives too much blood to the “recipient” twin;
causes circulatory overload and heart failure in one twin, and under perfusion and
anemia of the co-twin (TAPS)
 The extra blood causes the recipient’s kidneys to produce more urine, which creates a
large bladder
 Can lead to polyhydramnios
 Prenatal heart failure or excessive swelling (hydrops)
 The donor twin doesn’t have any or enough amniotic fluid (TTTS)
 Progressive condition: usually develops between weeks 16 and 26 of pregnancy and
can be easily detected with ultrasound.

v Macrosomia
 Rates have decreased with continuous glucose monitoring
 Even with well-controlled blood glucose, macrosomia is a function of pregravid BMI
 Overweight women with well controlled GDM on diet alone have a 50% greater risk
compared to normal weight women
 In utero metabolic environment affects fetal fat mass and not lean body mass
 Neonates of overweight and obese women are significantly heavier at birth as
compared with lean or average weight women. These neonates are heavier because of
an increase in fat and not lean body mass.
 In the third trimester obese women have higher triglyceride, cholesterol and lower
HDL concentrations as compared with lean women
 Increased risk of spontaneous abortion, congenital anomalies, stillbirth, shoulder
dystocia, and cesarean delivery
 Increased risk of childhood obesity
 Increased transfer of glucose stimulates the release of insulin by the fetal beta cell and
macrosomia
 Maternal glucose control decreased perinatal morbidity and mortality

v Gestational Hypertension
Ø High blood pressure after 20 weeks of pregnancy without proteinuria (greater than
140/90)
Ø Preeclampsia (high blood pressure after 20 weeks of pregnancy, protein in your urine,
and symptoms such as swelling, blurry vision, and headaches)
Ø Complications: Mother
« Placental abruption, stroke, preeclampsia, eclampsia and need for labor
induction
Ø Complications: Fetal
Ø Poor fetal growth, low birth weight, IUGR, premature birth, fetal demise, renal,
hepatic, brain, cardiac
BISHOP SCORE: A score of 8 or higher indicates that an induction would likely result in a
vaginal delivery, while a score of 10 indicates that labor is likely to start on its own within a
matter of days and an induction is likely unnecessary. A score of 6 or below indicates that the
cervix is not favorable for an induction.

v Augmenting Labor: Power

 Pitocin: strengthen and regulate contractions
 Nipple massage: can increase the production of oxytocin and lead to stronger
contractions
 Acupressure: increase oxytocin production
 Rupture of membranes: releases prostaglandins, moves the presenting part to the
cervix, triggers hormone release
 Cervical stripping and membrane sweep

v Induction of Labor
 PROSTAGLANDINS: soften cervix (Misoprostol (Cytotec) and Dinoprostone
(Cervidil) most common
 OXYTOCIN: induces uterine contractions
 BALLOON CATHETER: dilates and ripens the cervix

v Vaginal Birth after Cesarean

Ø Benefits: No abdominal surgery, shorter recovery time, lower infection
risk, less blood loss, fewer problems with future childbirth
Ø Risks: Uterine dehiscence, uterine rupture, increase in cesarean birth
§ Prostaglandins for cervical ripening increase the risk of uterine rupture.
§ low-dose oxytocin and intracervical balloons to facilitate induction is
recommended
§ Unable to have a TOL (trial of labor) if previous upper or contractile portion
of the uterus surgery history, due to increased risk of uterine rupture
§ Scheduled cesarean at 36-38 6/7 weeks gestation
v Complications of Labor and Delivery
 Failure to Progress
 Non-reassuring fetal status
 Perinatal asphyxia
 Shoulder dystocia
 Maternal Hemorrhage
 Malposition
 Placenta Previa
 Cephalo-pelvic disproportion
 Intraamniotic Infection
 Uterine Rupture
 Rapid Labor
 Amniotic Fluid Embolism (anaphylactic syndrome of pregnancy

Ø Failure to progress
 If failure to progress happens during the active phase of labor, medical
intervention may be necessary.
§ Primipara >20hours
§ Multipara >14 hours

Ø Non-reassuring fetal status

 IUGR, anemia, insufficient O2 levels, maternal hypotension

Ø Shoulder dystocia
 Maternal complications: uterine, vaginal, cervical and rectal tearing, heavy post-
partum bleeding
 Infant complications: newborn brachial plexus injury (nerve damage affecting
the shoulder, arm and hand); humerus or clavicle fracture; HIE (hypoxic ischemic
brain injury)

Ø Placenta Previa
 Bleeding without pain in the 3rd trimester

Ø Cephalopelvic disproportion
 Large baby, large infant head, unusual position, pelvic shape/size

Ø Malposition
 Breech, transverse or face-up (harder for the baby’s head to go under the pubic
bone in face-up (occiput posterior)
 Umbilical cord: nuchal cord, cord compression, prolapse

Ø Rapid Labor (precipitous labor) 3–5-hour length of labor

 Not enough time to get to the hospital
 Increased risk of tearing and hemorrhage
 Increased risk of maternal shock
 Ø Maternal Hemorrhage: more than 500 ml of blood after a vaginal delivery; more
than 1,000 ml after a C-Section delivery
 Low BP, organ failure, shock, death
 Multiple gestation, clotting disorders, obesity, prolonged labor
 Placenta accreta (attaches deeply) , increta (through uterine wall to muscle) or
percreta (through the uterus and attaches to other organs: bladder/intestines)

Ø Perinatal Asphyxia: lack of blood flow/gas exchange to or from the fetus

 Immediately before, during or after the birth process
 Causes respiratory distress, pulmonary hypertension, liver, myocardial and renal
dysfunction
 Cause of HIE

Ø Intraamniotic Infection (Chorioamnionitis): infection of the amniotic fluid,

placenta, membranes around the fetus, the fetus or a combination.
§ PROM; Long delay between ROM and delivery of the baby
§ Meconium
§ May cause preterm delivery, neonatal sepsis/pneumonia/meningitis/fever/seizures
§ Maternal fever, fetal or maternal tachycardia, uterine tenderness, purulent
discharge, elevated maternal WBC

Ø Uterine Rupture: tearing of the uterus

 Late in pregnancy or during delivery; previous history of uterine surgery
 Can be complete (through all layers) or partial
 Most commonly associated with VBAC
 If presenting fetal part is in the pelvis, loss of station
 Maternal hypovolemia and fetal compromise

Ø Amniotic Fluid Embolism (Anaphylactic Syndrome of Pregnancy)

§ Very rare; Severe allergic response when amniotic fluid mixes with the mother’s
blood
§ Can occur during pregnancy, labor, birth or the first 24 hours after birth
§ Maternal mortality between 61-86%, those who survive 85% have permanent
neurological injury
§ Unpreventable and unpredictable

Operative Vaginal Delivery

Ø Forceps
 Outlet: Head is visible on the perineum/skull has reached the pelvic floor
 Low: Head is at +2 or lower
 Fully dilated cervix
 Suspicion of immediate or potential fetal compromise
 Prolonged 2nd stage-lack of progress: 3hr with primip/ 2hr with multip with
regional anesthesia
 Maternal cardiac or pulmonary disease that contraindicates pushing efforts
 At least 34 weeks’ gestation
 « Risks:
§ Maternal: lacerations, hemorrhage, hematoma, bladder trauma,
infection
§ Newborn: cephalohematoma, nerve injuries, lacerations, skull
fractures, Intracranial hemorrhage

Ø Vacuum Assisted Delivery

 Easier application over forceps
 Less maternal soft tissue damage
 Fewer fetal injuries
 Fetal head needs to be engaged, and cervix fully dilated
 Maximum of 3 attempts for a period of 15 minutes: the 3 Pull Rule
 Cup detachment from head (pop offs) is a warning that too much pressure or
ineffective force is being exerted
 Suspicion of immediate or potential fetal compromise
 Need to shorten the second stage for maternal benefit
 Prolonged second stage: 3hr with primip/ 2hr with multip with regional
anesthesia
 Fetus at 36 weeks, head engaged, at least at 0 station
« Risks:
§ Maternal: vaginal and cervical lacerations, extension of episiotomy,
bladder trauma, infection
§ Newborn: Cephalohematoma, increased risk of jaundice, scalp lacerations
and bruising, Intracranial hemorrhage and retinal hemorrhage