Obstetrics L&D Pathology The Medical Education



L&D complications are all about what happens when mom doesn't follow the natural normal time course that is something happens that's supposed to happen but just doesn't happen at the right time let's start with rupture of membranes and then use that to build on abnormalities of ruptures of membranes before we move into preterm labor and post dates so rupture of membranes is something that is supposed to happen baby is contained in a sac and in order to come out of mom that sac has to rupture baby can be delivered in the SAC but the normal process is that that sac ruptures and baby comes out so as the sac ruptures a bunch of fluid comes out now this can happen spontaneously and it's supposed to happen about within one hour from delivery onset now again a baby can come out in the sack but generally you want that membrane ruptured so it can also be occurred artificially that is we do it we purposely go in and rupture that sac or if it happens too soon it can be a result of an infection and so it can be pathologic but the normal rupture of membranes is spontaneous and occurs within one hour of delivery on set and what mom will experience is a rush of fluid it may have blood in it and it's not just a little spotting it's a rush of fluid that's going to soak the gown her clothes or the bed now I it's a first time mom the sight of a rush of fluid that's bloody it's gonna prompt her to come in and see it right away if it's a multiparous woman who knows what this means she's gonna come in and see you and the first thing you're gonna do of course is make sure that this actually was a rupture membranes and the first thing that you to do to determine that is a speculum exam and the speculum exam will show you pooling of fluid in the vagina and then you're going to do the nitrile Azim blue test application of nitrile zine to that fluid turns it blue or you can look under it look at it under a microscope and see the fern sign and then this is not necessary but you can confirm that it actually was all the amniotic fluid that came out of the sack with an ultrasound if you see all ego hydra miios after rupture of membranes that is anticipated and expected but they had the right amount of fluid in when the sac was intact sac ruptures all of that fluid comes out all I go high-drama Neos thereafter no more fluid in the SAC the treatment if it was normal rupture of membranes is just expectant delivery expectant management essentially just continued delivery so this is supposed to happen this is normal rupturing of membranes what happens if it is premature rupture of membranes and premature means baby is ready mom is not it is caused by an ascending infection and you're gonna have to can get this differentiated from preterm rupture of membranes peopre premature rupture of membranes its baby is ready the gestational age is at term babies ready to come out there just aren't any contractions so mom's not ready baby's ready moms not premature rupture of membranes all you're going to do is diagnose that ruptured membranes has actually happened which is the same as wrong you're gonna do a speculum exam and see the pooling of fluid which responds nitrile is een by turning blue and you're gonna see the fern sign and then oh like a Hydra meows the thing that's different is that this ascending affection lead to premature rupture of membranes it wasn't delivery so because it's an infection you're gonna treat with antibiotics because it's caused by most commonly ecoli you're gonna treat with amp and Jen you cannot give for quinolones because she's pregnant this was premature ruptured membranes baby's ready moms not caused by infection if you have preterm rupture of membranes it is by definition also premature so it's written pee prom the path is still an ascending infection most commonly with you coli only now the difference being babies not that term so baby's not ready and mom's not ready but there was still rupture of membranes the diagnosis of rupture of membranes has made the same way as her rupture of membranes you're gonna see pooling in the back of the vagina you're gonna get an ID rousing test which it's gonna turn it blue you're gonna see the fern sign and all that go Hydra meows on ultrasound but now the treatment isn't just treat the infection and deliver the problem is now you have to figure out is baby ready to come out now if it was greater than 36 weeks that's technically premature ruptured membranes deliver with antibiotics if it's less than 24 weeks that's not going to be viable you deliver but it's actually called an abortion but it's in between if it's in between baby will benefit from being inside mom longer even though there's an increased risk of that infection getting to baby so if they're in between 24 and 36 weeks and they have a preterm premature rupture of membranes you want to keep baby inside mom and give baby steroids steroids are going to increase lung development now you give them to mom and this mom gives them to baby of course you're also going to treat with antibiotics and Jen for both of these conditions you never do a digital exam the reason being even if you're wearing sterile gloves you're going to introduce the vaginal flora into the uterus and you can cause a serious infection that we'll talk about in just one second so that is premature rupture of membranes baby ready mom not and preterm rupture of membranes neither baby nor mom is ready and because it is preterm it is inherently premature what happens now if ROM happens or one of these conditions happens and it's too long from the onset of ROM to delivery prolonged ROM is defined as greater than 18 hours from ROM onset to delivery it can be a totally normal delivery that just takes too long maybe because mom's brand-new at this so if ruptures and membranes occurs and there's 18 hours from ROM to delivery there is an increased risk of Group B Strep infection so the patient is going to be just that it's going to be someone who has had rom regardless of whether it's preterm premature or normal but it takes longer from that ROM to delivery than 18 hours the diagnosis all you need to do is confirm that ROM had happened so you're gonna do the same thing that you did before the nitrile is a in fern test and all they call high drama nails but now you need to treat as if baby's been infected with Group B Strep they're going to profile acts with amoxicillin so this is the case where mom's goes through a totally normal pregnancy she just takes too long to get baby out you want to make sure she's not GBS infected so your profile acts with amoxicillin and the reason why you don't want to leave rom open for too long and the risk you run of dealing with preterm and premature rom is that you can get that ascending infection into the uterus that is chorioamnionitis and endometritis this is also caused by an ascending infection the same ascending infection that caused premature and preterm roam the only difference now is that if the infection gets into the amniotic sac that is baby is still in its core um nightís and it's endometritis if that infection got in when baby is out it only gets into mom's uterus the patient is going to present with mom generally preterm or premature rom and a fever this isn't just an infection within her vagina and by the way the ascending infections before or vaginal organisms so if you've got a culture of the of the fluid you just see normal mechanisms now those vaginal organisms have gotten into moms sterile uterus she is responding to the infection so you'll see systemic signs of infection not just ruptured membranes the diagnosis is presumed from this presentation so your job is to rule out other infections you don't want to assume that mom has endometritis when she could have a pneumonia a UTI or meningitis so if the look at the clinical vignette look at the scenario and just decide is this the most likely source of fever while you do that you're going to treat with broad-spectrum antibiotics generally this means if Tazo which is those you're covering for essentially all infections including those that cause vaginal infections and infections that would lead to P ROM or P problem that's going to conclude our talk about premature rupture of membranes and infections that can result let's move on now to another labor and delivery complication preterm labor preterm labor can occur for a whole variety of reasons the pathogenesis is essentially unknown but risk is increased when women are smoking when mom is very young generally less than 20 years old when there's multiple gestation x' or there's been premature preterm rupture of membranes or abnormal uterine anatomy for whatever reason that she goes into labor mom is going to begin having contractions but baby is at a gestational age less than term and that is the definition she'll have contractions and she'll have cervical change that's saying she is going into labor but baby's not ready that is essentially the definition but baby has to be between twenty and thirty six weeks here's why if you are between 40 and 36 weeks you are said to be full-term any more than that opposed dates but less than 20 weeks is considered an abortion viability is really only present after 24 weeks for the delivery between twenty and thirty six is considered preterm and if you are born at 24 weeks you have a very tumultuous course in the NICU developing up to turn but what you have to do is simply diagnose and confirm that she is in labor it is a clinical diagnosis and the treatment is gonna focus around two things keeping baby in mom that is stopping labor so that baby can develop and giving baby the assistance it needs to develop its lungs so you're going to delay delivery and generally these mechanisms only work to buy you hours to days not days to weeks well you can try mag sulfate beta agonists like terbutaline calcium channel blockers like nifedipine and prostaglandins like in new medicine these are all tocolytics designed to delay contractions to prevent cervical change and to let baby stay in longer while you delay delivery because you're only going to get a couple of days you want to develop baby and the goal is the lungs give mom steroids especially if the lesson does fing go my linh ratio is less than two to one if you get some amniocentesis and some an erotic fluid and identify that baby's not ready give them steroids now there are certain exceptions to delaying labor that is the contraindications to delaying labor come in three parts maternal causes are something like preeclampsia where delivery of the fetus is the only way to prevent seizures from coming on if moms preeclamptic babies coming out doesn't matter where they're at and they're just a tional age if there's feel demise this is a fetal complication what's the point of keeping baby in and finally this anatomical reasons such as rupture of membranes that occurred too soon or conditions that are going to kill mom like a percentile abruption placental reasons feeder reasons maternal reasons look for contouring occasions to delay delivery and if they're not present delay for as long as possible with tocolytics and develop baby with steroids this is what happens when baby comes out too soon what happens when babies in too long that is the final thing we're going to close with the post dates fetus post dates is defined by greater than 40 weeks from conception but conception is a difficult time to narrow down so if you have a reasonably good idea of when those dates work by an ultrasound of the first trimester you can kind of use that or we define it by greater than 42 weeks from the last known menstrual period last normal menstrual period in the problem with post dates babies is that they're a going to be big which puts them at risk for shoulder dystocia and they're going to be dis match or you're going to learn more about the dis mature neonate in pediatrics but just know that overdevelopment is not good under development is not good either babies need to be delivered at turn to diagnose a baby post dates you simply look at how long baby's been in and the treatment is going to depend on how sure you are and how ready mom is so it's dependent on the dates on cervical favorableness that determines the treatment if you are sure of the dates and as you got that first trimester ultrasound or she was doing family planning you know that she is for sure post dates if mom has a cervix that is favorable that is she's ready to deliver you can induce with pitocin but if you're sure the baby's post dates and mom is not ready then you go to c-section the question on your test is going to be we think but we're not sure the baby's post dates and so it doesn't matter what mom is you are going to use the biophysical profile that is you're going to get a non-stress test and an amniotic fluid index with ultrasound and you're going to decide how is baby doing remember if you if you find a woman in the third trimester that's when you diagnosed her pregnancy the ultrasound is not going to give you reliable dates as the variability is plus minus three weeks so that's the difference between someone who is going to be preterm versus someone who's going to be both dates so what you want to do is not just use the ultrasound to find out how old they are but find out how well baby is doing if baby's doing good and you're not shorts post dates or not let it cook longer if there's any sign of distress well then then you need to go to the livery either through induction or c-section okay so in this lecture we talked about a lot of the different pathologies that can occur in labor and delivery labor and delivery is supposed to take a normal time course but if baby comes out too soon preterm labor you need to recognize how to keep baby in to let it cook a little longer if baby stays in too long that's not good either you need to know when baby needs to come out and then you need to understand the pathology of rupture of membranes the idea is that abnormal timing is caused by an ascending infection you have to treat the infection before it gets into mom's uterus causing endometritis and also that prolonged rupture of membrane even though it may have been a normal delivery up to that point puts baby at risk for Group B Strep and you need to prophylaxis a instead that is L&D complications we make these videos for free and we need your help please donate because without your donations we can't make any more videos please donate

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