Complicated labor


Preterm labor

  • Regular uterine contractions and cervix changes before 37wks

  • ↑↑ risk: Previous preterm birth, short cervical length (<2.5cm), multiparity

    • Cerclage short cervix at 12-14wks and avoid coitus

  • Other causes include infection, stress, placenta previa/abruption, smoking, bimodal age, low BMI

    • Stress ➔ HPA axis activation ➔ ↑ ACTH ➔ ↑ cortisol ➔ ↑ CRH ➔ prostaglandin activation ➔ cervical ripening and ROM

  • DX

    • Fetal fibronectin ↑ in labor (not in false labor)

    • Dilated >3cm

    • Cervical length <2cm (or <3cm with fetal fibronectin)

Induction of fetal lung maturity (24 to 33wks 6/7)

  • Antenatal steroids (IM betamethasone or IM dexamethasone) if at risk of delivery within 7d

    • 48hrs is ideal

    • Another dose if given >2wks ago

Tocolytics ⊣ uterus contractions (delays labor)

    • To prolong labor for up to 48hrs so steroids can work

    • 24-32wksindomethacin (NSAID) OR nifedipine (CBB) OR terbutaline (β-2 agonist)

      • MgSO4 can be used to reduce risk of cerebral palsy(neuroprotective) but is a less effective tocolytic

    • 32-34wks nifedipine OR terbutaline

  • Tocolysis contraindications: cervical dilation > 4 cm, chorioamnionitis, fetal distress, placental abruption, prolapsed cord

    • MgSO4 CI in myasthenia gravis

    • CBB CI in aortic regurg

GBS infection PPX

  • IV penicillin OR ampicillin OR cefazolin for at least 4hrs prior to delivery

Vaginal progesterone supplementation

  • Previous spontaneous preterm birth OR short cervical length (<2.5cm)

    • Unclear if benefit in twin pregnancies

Premature rupture of membranes (PROM)

  • Preterm PROM (PPROM): PROM before 37wks gestation

  • Rupture of membrane (amniotic sac) before onset of labor

  • Smoking, multiparity, hx of preterm delivery of PROM ➔ ↑ risk

  • Can ➔ Chorioamnionitis (infection of amniotic fluid), cord prolapse, placental abruption, premature labor/fetal distress/ARDS ➔ death

  • DX

    • Clinical and confirm with sterile speculum exam (avoid digital cervical exam out of concern for inoculation)

      • Fluid leaving cervix and pooling in vaginal fornix

      • Litmus/nitrazine (turns blue) amniotic fluid is more basic pH than vaginal fluid ➔ neutral/basic pH

  • TX

    • Prompt delivery if cord prolapse, placental abruption, chorioamnionitis

    • 24-31wks: Expectant management

      • Admit with fetal HR monitor, assess mom for infection (GBS screening)

        • PPX ABX: IV Ampicillin AND IV erythromycin, then PO amoxicillin and PO erythromycin

        • Betamethasone or dexamethasone for fetal lung development

        • Magnesium sulfate for fetal neuroprotection

    • 32-36wks:

      • PPX ABX: IV Ampicillin AND IV erythromycin, then PO amoxicillin and PO erythromycin

      • Betamethasone or dexamethasone for fetal lung development

      • Monitor and deliver by 37wks


Placental abruption

  • MC in 3rd trimester

  • MCC is HTN (pre-pregnancy/gestational)

  • EtOH, cocaine, ABD trauma, previous abruption, bi-modal age

  • SSX

    • Bleeding (usually painful) but can be retroplacental

    • Rigid, tender uterus

    • Premature labor

    • Fetal distress (decelerations)

  • DX

    • Clinical dx but US may show


    • Fetal HR monitoring

  • TX

    • Stable mother AND stable fetus

      • <34wks ➔ fetal lung maturity and tocolytics

      • 34-36wks ➔ expectant management

      • >36wks ➔ delivery

    • Emergency cesarean delivery regardless of gestational age if mom unstable

    • Fetal death and stable mom ➔ induced vaginal delivery

    • Rh negative moms need RhoGAM

    • BOLO DIC - Placenta has ↑ thromboplastin

Placenta Previa

  • Placenta implants covering internal cervical os ➔ ↑ risk of ruptured vessels

    • Low placenta: Edge of placenta < 2cm from internal cervical os

  • Risk factors:↑ maternal age, hx of placenta previa, curettage or cesarean

  • SSX

    • Painless bright red vaginal bleeding

    • Soft, non-tender uterus

    • Premature labor

    • ± fetal distress

  • DX

    • Transvaginal US is best test


    • Fetal HR monitoring

  • TX

    • Monitor placenta if discovered early with transvag US at 32wks then again at 36wks

      • As lower uterus lengthens the placenta moves up

    • Gestate until 37wks unless active bleeding or fetal distress

    • Lower segment cesarean delivery (vaginal delivery only attempted in OR)

    • Hemorrhage ➔ ligation of uterine and internal iliac arteries

    • Severe hemorrhage ➔ cesarean hysterectomy

Vasa previa

  • Fetal vessels in membranes near internal cervical os ➔ bleeding when ROM occurs

    • Velamentous umbilical cord insertion (abnormal insertion of umbilical cord in chorioamniotic membrane)

  • Risk factors: Placenta previa, low-lying placenta, multiparity, IVF

  • SSX

    • Painless vaginal bleeding (from fetus) suddenly after ROM

    • Fetal distress (exsanguination can occur quickly)

  • DX

    • Transvag US with doppler shows fetal vessels overlying internal os and ↓ fetal vessel flow

  • TX

    • Emergency cesarean delivery

    • BOLO retained placental tissue


Umbilical cord

  • Compression of umbilical cord ➔ hypoxia

  • Sudden change in FHR to severe decelerations/brady

  • Induction ➔ ↑ risk (oxytocin ➔ ↑ contractions ➔ ↑ compression)

TX is to reposition mom (knees to chest, trendeleburg, LLR)

  • Manual decompression using finger/hand to elevate presenting part off cord

  • Tocolytics while waiting for OR for emergency C-section

Overt (MC) cord prolapse - Between fetus and pelvic

  • With rupture of membrane

Occult cord prolapse - Pressing against fetus

Cord presentation - Between fetus and pelvic wall

  • Without rupture of membrane

Nuchal cord - Wrapped around neck


  • Anterior shoulder (MC) impacted behind maternal pubic symphysis

  • Risk factors: Hx of dystocia, macrosomia/maternal obesity

  • Complications

    • Hypoxia - baby can die if not delivered within 5mins

    • Brachial plexus injury Erb palsy (C5-6) later in life (adducted, extended, pronated, medially rotated arm)

      • Klumpke palsy (C8-T1) ➔ weakness of hand ➔ claw hand

    • Clavicle/humerus fracture

    • Mom at ↑ risk of PPH and lacerations

  • SSX

    • Arrested active phase of labor

    • Head partially delivered but retracts til chin catches perineum ➔ turtle sign

  • TX

    • Never apply pressure to fundus or pull fetal head

    • McRoberts maneuver first line : Mom stops bearing down, move butt to edge of bed and go supine

      • Then abduct, externally rotate, and hyperflex maternal hips (grab behind your knees and bring them to your ears)

    • OR Woods screw maneuver

    • Last resort: Fracture clavicle or symphysiotomy (divide the symphysis pubis)

Breech Presentation

  • Oligoanhydroamniosis (MC RF)

  • Butt or feet are presenting first

    • Frank breech (MC): Butt first (feet near head)

    • Complete breech: Cannonball - knees and hips flexed (feet and butt first)

    • Single Footling breech: One foot

    • Double Footling breech: Both feet

  • Cesarean delivery is preferred route of delivery

Birth Trauma (fetal)

  • Mechanical factors ➔ injury of newborn

  • Risk factors: Forceps/vacuum, rapid/prolonged labor, abnormal presentation (breech, dystocia) macrosomiaHead

  • Head

    • Caput succedaneum: Pitting edema that extends across suture lines and resolves in days

    • Molding: Elongation that resolves in days

    • Cephalohematoma: Hemorrhage between skull and periosteum limited to sutures, resolves in wks-mos

    • Subgaleal hematoma: Hemorrhage between periosteum and epicranial aponeurosis (↑ risk of shock)

  • Peripheral facial nerve palsy

    • MCC forceps

    • Peripheral facial nerve ➔ forehead involvement (can't get baby to lift eyebrows)

      • Incomplete eye closure (one), absent nasolabial fold

      • Usually self resolves

Episiotomy: Incision of perineum to enlarge vaginal opening during delivery

  • Indications: breech, shoulder dystocia, assisted delivery (forceps/vacuum)