Episiotomy and Laceration Repairs
Perineal anatomy
The perineum is the space between the vaginal and anal orifices.
- Perineal muscles:
- Superficial transverse perineal muscle
- Bulbocavernosus muscle
- Anorectal sphincter complex:
- The entire complex measures approximately 4 cm.
- External anal sphincter:
- Thick, circular, striated muscle surrounding the anal orifice
- Responsible for solid, liquid, and gas continence at rest and during rectal distention
- Under voluntary control
- Internal anal sphincter:
- Thin condensation of the smooth muscle of the distal colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix submucosa
- Responsible for continence at rest
Muscular anatomy of the perineum and pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor, external view
Image by BioDigital, edited by Lecturio
Anorectal anatomy
Image by Lecturio.
Lacerations
Lacerations are spontaneous tears that occur due to the trauma of the infant passing through the vaginal canal during delivery.
- Epidemiology:
- Up to 80% of women will sustain some type of laceration at vaginal delivery.
- Most are 1st- and 2nd-degree tears.
- Location:
- Perineal (most common)
- Periclitoral
- Periurethral
- Labial
- Classifications of perineal lacerations:
- 1st-degree:
- Tear extends to the vaginal epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium and vulva Vulva The vulva is the external genitalia of the female and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulb, and greater vestibular glands. Vagina, Vulva, and Pelvic Floor skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin only.
- No perineal muscle injury
- 2nd-degree:
- Tear extends to the perineal muscles.
- No injury to the anal sphincter
- 3rd-degree:
- Tear extends through the perineal muscles and
- Injury to the external anal sphincter
- 4th-degree:
- Tear extends through the entire external anal sphincter and into rectal mucosa.
- Most severe form
- 1st-degree:
- Risk factors for anal sphincter injury:
- Operative vaginal delivery
- Midline episiotomy
- Macrosomia
- Primiparity (1st delivery)
- Prevention of anal sphincter injury:
- Perineal massage antenatally and intrapartum
- Manual perineal support at delivery (poor-quality data, but commonly done)
- Warm compresses
- Treatment:
- Adequate analgesia
- Surgical repair (suturing) in layers
- Single dose of antibiotics for the 3rd- and 4th-degree lacerations
- Complications of 3rd- and 4th-degree lacerations:
- Wound breakdown
- Fecal incontinence
- Pelvic organ prolapse Pelvic Organ Prolapse Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. Pelvic Organ Prolapse
- Rectovaginal fistulas
- Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, including dyspareunia
Degrees of perineal lacerations
Image by Lecturio.Episiotomy
An episiotomy is an intentional 3–5-cm incision made by the delivering provider to enlarge the vaginal opening at the time of delivery.
- Not recommended for routine deliveries
- Indications:
- Woman at high risk for a 3rd- or 4th-degree laceration.
- Nonreassuring fetal heart rate tracing that warrants hastening vaginal delivery
- Create space for the provider to:
- Perform internal maneuvers to relieve a shoulder dystocia
- Safely apply forceps or a vacuum for an operative vaginal delivery
- Types/location:
- Mediolateral
- Incision is cut at an angle toward the ischial tuberosity (about 45 degrees from midline).
- Preferred because ↓ risk of extension into the anal sphincter
- Midline
- Mediolateral
- Episiotomy ↑ risk of:
- Extension to 3rd- and 4th-degree lacerations (especially with midline incisions)
- 3rd- or 4th-degree lacerations in subsequent deliveries
- Greater blood loss
- Infection and dehiscence
- Dyspareunia at 1 year postpartum
Midline versus mediolateral episiotomy
Image: “Medio-lateral-episiotomy” by Jeremykemp. License: Public Domain, edited by Lecturio.Operative Vaginal Delivery
Overview
Operative vaginal delivery is the use of obstetric forceps or a vacuum extractor to effect delivery of a fetus.
- Epidemiology:
- Overall incidence: approximately 3% of deliveries
- Forceps: 0.5% of all vaginal births
- Vacuum: 2.6% of all vaginal births
- Indications:
- Fetal distress in the 2nd stage of labor (2nd stage: time from complete dilation through delivery of the fetus; “pushing”)
- Prolonged or arrested 2nd stage of labor
- Shortening of the 2nd stage of labor for maternal medical indications (conditions that prevent safe maternal pushing):
- Maternal cardiac disease (e.g., heart failure)
- Maternal intracranial pathology (e.g., berry aneurysms)
- Maternal exhaustion
- Criteria required to perform operative vaginal deliveries:
- Vertex presentation
- Ruptured fetal membranes
- Full cervical dilation (10 cm)
- At least +2 station (fetal head is 2 cm below the maternal ischial spine)
- Knowledge of the fetal position (e.g., occiput anterior versus posterior)
- Adequate anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
- Empty maternal bladder
Forceps and vacuum deliveries
Image by Lecturio.
Fetal head position:
Image by Lecturio.
Position is determined by the location of the fetal occiput (posterior portion of the head located behind the smaller triangular shaped fontanelle) relative to the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis (anterior/posterior and right/left). For example, ROA stands for right occiput anterior and means that the fetal occiput is against the right anterior portion of the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis.
Fetal station:
Image by Lecturio.
The presenting fetal part is measured in centimeters from the ischial spine. Negative numbers denote a higher fetal station, while positive numbers denote a lower fetal station as the fetus descends in the birth canal.
Vacuum-assisted delivery
- Technique:
- A vacuum extractor is applied to the fetal vertex.
- Centered over the sagittal suture
- Avoid placement over the fontanelles.
- Steady downward traction is applied during contractions with maternal pushing.
- A vacuum extractor is applied to the fetal vertex.
- Maternal complications
- 2-fold ↑ risk of 3rd- and 4th-degree perineal lacerations (involves the anal sphincter)
- Vulvar and vaginal hematomas
- Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract injury
- Lower rates of maternal complications with vacuum as compared with forceps and cesarean deliveries
- Fetal complications:
- Fetal scalp lacerations
- Cephalohematoma → hyperbilirubinemia
- Intracranial hemorrhage
CT scan of fetal head demonstrating an intracranial hemorrhage:
This is a potential complication of operative vaginal deliveries.
Forceps-assisted delivery
- Technique:
- Obstetric forceps are applied around the fetal head.
- Steady downward traction is applied during contractions with maternal pushing.
- Maternal complications:
- 6-fold ↑ risk of 3rd- and 4th-degree perineal lacerations
- Vulvar and vaginal hematomas
- Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract injury
- Fetal complications:
- Facial lacerations
- Facial nerve injury
- Skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
- Intracranial hemorrhage
Shoulder Dystocia
Overview
Shoulder dystocia is when the baby’s anterior shoulder becomes impacted behind the maternal pubic symphysis, preventing delivery of the fetal body. Shoulder dystocia is a true obstetric emergency.
- Definition:
- Failure to deliver the fetal shoulders with gentle downward traction, where additional maneuvers are required to deliver the baby
- This is a bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones-on- bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones obstruction → episiotomy will not relieve shoulder dystocia
- During the dystocia, the fetus is not getting any oxygen.
- Epidemiology:
- Incidence: 0.2%–3% of vaginal births in the vertex presentation
- Risk of recurrence: 10%–16%
- Unpredictable and can occur in any laboring woman
- Risk factors (though shoulder dystocia often occurs in the absence of risk factors):
- Fetal macrosomia
- Maternal diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus (pregestational or gestational)
- Previous shoulder dystocia
- Maternal obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
- Operative vaginal delivery
- Prolonged 2nd stage of labor
- Clinical presentation:
- Failure of the fetal shoulders to deliver with gentle downward traction on the fetal head
- Turtle sign: retraction of the fetal head tightly against the maternal perineum
- Abnormal progression of the 2nd stage of labor
Initial management
Shoulder dystocia is an obstetric emergency.
- Call for help.
- Have mother stop pushing.
- Pushing is only further forcing the shoulder into the pubic symphysis.
- Relaxing allows room for maneuvers to dislodge the shoulder.
- Immediately have mother assume the McRoberts position:
- Abduction + hyperflexion of the maternal hips
- “Knees to armpits”
- Causes cephalad rotation of the pubic symphysis and flattens the lumbar lordosis → maximizes the pelvic diameter
- Suprapubic pressure:
- Attempts to push the shoulder down and inward
- Slightly rotates the fetus and dislodges the impacted shoulder
- Avoid fundal pressure, which may make the dystocia worse.
- Manual delivery of the posterior
arm
Arm
The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior).
Arm
- Reduces the bisacromial diameter
- ↑ Risk of clavicular and/or humerus fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
- 95% of shoulder dystocias will be relieved with the management described.
Suprapubic pressure being used to dislodge and internally rotate an impacted shoulder in shoulder dystocia
Image: “Suprapubic-pressureforSD” by Henry Lerner. License: CC BY 4.0
McRoberts position with suprapubic pressure
Image: “McRoberts maneuver” by geraldbaeck. License: CC0 1.0Additional maneuvers
Additional maneuvers to attempt if the dystocia persists include:
- Rotational maneuvers:
- Attempt to manually rotate the shoulders
- Rubin’s maneuver: rotate the anterior or posterior fetal shoulder anteriorly toward the fetal face
- Woods screw maneuver: rotate the posterior fetal shoulder backward
- Gaskin maneuver:
- Have mother assume a position on her hands and knees.
- Repeat above maneuvers in this position.
- May be helpful in women who are not anesthetized
- Intentional clavicular
fracture
Fracture
A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma.
Overview of Bone Fractures:
- Pop the anterior clavicle outward to ↓ the bisacromial diameter.
- ↑ Risk of injury to vasculature and pulmonary structures
- Less morbidity than procedures of last resort
- Episiotomy:
- Episiotomy will not relieve shoulder dystocia.
- Consider cutting one to allow space to adequately perform the maneuvers.
- Repeat all above maneuvers several times before moving on to procedures of last resort.
- Procedures of last resort:
- Zavanelli maneuver:
- Replace the fetal head in the abdomen by reversing the cardinal movements of labor and perform an urgent cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery.
- High morbidity and mortality
- Abdominal rescue:
- Make a hysterotomy, manually reduce the impacted shoulder, and deliver vaginally.
- Done when the head is unable to be manually replaced during attempted Zavanelli maneuver
- Symphysiotomy:
- Surgical division of the cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage of the pubic symphysis
- Only used when an OR is unavailable
- Zavanelli maneuver:
To remember the management of a shoulder dystocia, remember HELPERR:
- Call for Help.
- Consider an Episiotomy (to allow space for maneuvers).
- Elevate the Legs.
- Apply suprapubic Pressure.
- Enter the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor for internal rotational maneuvers.
- Reliever the posterior arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm.
- Rotate the woman to hands-and-knees position.
Complications
- Brachial plexus injury
- Erb palsy:
- Stretching of the C5 and C6 nerves from continuous downward traction on the head
- Often reversible
- 75% of brachial plexus injury
- Klumpke palsy: stretching of C8 and T1 nerves
- Erb palsy:
- Clavicular fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
- Humerus fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
- Fetal asphyxia
- Contusions and lacerations
Brachial plexus injuries Brachial plexus injuries The brachial plexus is a network of nerves that originate from the lower cervical and upper thoracic nerve roots. The causes of brachial plexopathies include traumatic injuries, birth-related injuries, iatrogenic procedures, neoplastic processes, and previous treatment with radiation. Brachial Plexus Injuries associated with shoulder dystocia
Image by Lecturio.Amniotic Fluid Embolism
Overview
Amniotic fluid embolism (AFE) is a complication of labor affecting the mother in the immediate postpartum period.
- Caused by entry of amniotic fluid into the maternal circulation by:
- Placental tears
- Uterine vein rupture
- Incidence: 1 in 40,000 deliveries
- Mortality:
- 80% mortality rate
- AFE causes 10% of maternal deaths in developed countries.
Risk factors
- Cesarean delivery
- Operative vaginal deliveries
- Placental abnormalities Placental abnormalities Normal placental structure and function are essential for a healthy pregnancy. Some of the most common placental abnormalities include structural anomalies (such as a succenturiate lobe or velamentous cord insertion), implantation anomalies (such as placenta accreta and placenta previa), and functional anomalies (such as placental insufficiency). Placental Abnormalities (e.g., placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity previa)
- Preeclampsia/eclampsia
Pathogenesis
- Unclear
- Amniotic fluid enters maternal circulation and triggers:
- Intense pulmonary vasoconstriction:
- ↑ Pulmonary pressure → right ventricular failure → systemic hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
- Hypoxemic respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
- Pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema
- An abnormal immune response:
- Intense inflammatory response (similar to SIRS) is activated.
- Inflammatory mediators activate the coagulation cascade systemically → DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation
- Intense pulmonary vasoconstriction:
-
DIC
DIC
Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage.
Disseminated Intravascular Coagulation leads to:
- Hemorrhage → further hemodynamic instability
- Ischemic multiorgan failure
- Mechanical obstruction from amniotic fluid debris likely does not play a significant role.
Clinical presentation
Amniotic fluid embolism typically presents dramatically, as sudden onset cardiopulmonary collapse occurring during labor or within 30 minutes after delivery.
- Signs:
- Cardiopulmonary collapse: loss of breathing and pulse
- Hypoxemia/cyanosis
- Dyspnea
- Hypotension
- Tachycardia
- Other symptoms:
- Nausea and vomiting
- Mental status changes
- Seizure
-
DIC
DIC
Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage.
Disseminated Intravascular Coagulation:
- Usually develops shortly after an AFE
- Leads to obstetric hemorrhage
- Bleeding from catheter sites and mucosal surfaces
- Fetal heart rate abnormalities indicating distress (e.g., late decelerations, terminal bradycardia) if still pregnant
Diagnosis
Amniotic fluid embolism is a clinical diagnosis based on presentation.
- Laboratory evaluation (primarily to help with resuscitation):
- Coagulation profile:
- ↑ Prothrombin time
- ↓ Fibrinogen
- ↑ D-dimer
- CBC:
- Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
- Leukocytosis
- Thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
- Arterial blood gas:
- Hypoxemia
- Acidosis (both respiratory and metabolic)
- Coagulation profile:
- Imaging (once woman is stable enough):
- Chest radiography: bilateral diffuse infiltrates
- Echocardiography to assess cardiac function, which may have become compromised
Chest x-ray in a woman with amniotic fluid embolism:
Diffuse infiltration is evident throughout the
lungs
Lungs
Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2.
Lungs.
Management
Survival depends on prompt diagnosis and effective resuscitation.
- Airway: Secure the airway.
- Breathing: mechanical ventilation
- Circulation:
- High-quality cardiopulmonary resuscitation (CPR)
- 2 large-bore IVs → fluid resuscitation
- Transfuse to combat
DIC
DIC
Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage.
Disseminated Intravascular Coagulation; typically a 1:1:1 ratio of:
- Packed RBCs
- Fresh frozen plasma
- Cryoprecipitate
- Vasopressors
- Immediate delivery if woman is still pregnant
Complications
- Hematologic: DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation
- Cardiovascular: hemorrhage and cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest
- Pulmonary-related: pulmonary edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome
- Permanent neurologic deficits due to cerebral hypoxia (85% of survivors)
References
- American College of Obstetrics and Gynecology Committee on Obstetrics. (2020). Practice bulletin no. 219: operative vaginal birth. Retrieved March 19, 2021, from https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/04/operative-vaginal-birth
- Wegner, E.K., Bernstein, I.M. (2021). Operative vaginal delivery. UpToDate. Retrieved March 19, 2021, from https://www.uptodate.com/contents/operative-vaginal-delivery
- American College of Obstetrics and Gynecology Committee on Obstetrics. (2020). Practice bulletin no. 178: shoulder dystocia. Retrieved March 19, 2021, from https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/05/shoulder-dystocia
- Rodis, J.R. (2019). Shoulder dystocia: Intrapartum diagnosis, management, and outcome. UpToDate. Retrieved March 19, 2021, from https://www.uptodate.com/contents/shoulder-dystocia-intrapartum-diagnosis-management-and-outcome
- Berkowitz, L.R., Roust-Wright, C.E. (2020). Approach to episiotomy. UpToDate. Retrieved March 20, 2021, from https://www.uptodate.com/contents/approach-to-episiotomy
- Toglia, M.R. (2020). Repair of perineal and other lacerations associated with childbirth. UpToDate. Retrieved March 20, 2021, from https://www.uptodate.com/contents/repair-of-perineal-and-other-lacerations-associated-with-childbirth
- American College of Obstetrics and Gynecology Committee on Obstetrics. (2018). Practice Bulletin No. 198: Prevention and management of obstetric lacerations at vaginal delivery. Retrieved March 20, 2021, from https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/09/prevention-and-management-of-obstetric-lacerations-at-vaginal-delivery
- Baldisseri, M.R., Leigh Clark, S. (2020). Amniotic fluid embolism. UpToDate. Retrieved Mar 17, 2021, from https://www.uptodate.com/contents/amniotic-fluid-embolism
