User:Artsenic17/Childbirth

A post-term pregnancy (also known as prolonged pregnancy) is a pregnancy 42 weeks of gestation and greater from the last date of a patient's period. While the causes of post-term birth are unknown, there are a variety of risk factors thought to contribute to a post-term pregnancy. Examples include genetic predisposition, first childbirth of the birthing parent, as well obesity in the birthing parent.

Complications to the fetus or newborn that are associated with post-term pregnancy include (but are not limited to) increased risk of neonatal seizures, meconium aspiration syndrome, lower five-minute Apgar scores, increased rate of NICU admissions, increased risk of macrosomia ( larger than appropriate newborn), post-maturity syndrome, and oligohydramnios.

Studies have suggested that complications to the birthing parent that are associated with this post-term pregnancy may include (but are not limited to) injury to the perineum ( perineal cuts), postpartum hemorrhage, increased risk of a cesarean section, and increased rate of anxiety in the birthing parent.

Antenatal/Antepartum testing between 40 and 42 weeks may be performed via methods including nonstress testing, biophysical profile, modified biophysical profile, and contraction stress testing. Due to a lack of sufficient evidence proving a mortality reduction rate for the fetus/neonate, no specific recommendations or guidelines have been suggested around testing.

Medical induction of labor after 42 weeks of term is typically recommended. Induction of labor between 41 and 42 weeks may be considered after appropriate counseling to the patient.

Preterm babies can develop respiratory distress syndrome, which is a syndrome caused by having immature lungs with insufficient surfactant. Surfactant is a substance that reduces surface pressure in the lungs, so that the lungs can inflate with breathing. Administering a corticosteroid, such as betamethasone, to the pregnant parent will allow the fetal lungs to mature more rapidly.

If a pregnant person enters preterm labor, delivery can be delayed by giving medications called tocolytics that delay labor by inhibiting contractions of the uterine muscles that progress labor. The most widely used tocolytics include beta agonists, calcium channel blockers, and magnesium sulfate. The goal of administering tocolytics is not to delay delivery to the point that the child can be delivered at term, but instead to give the corticosteroids up to 48 hours to mature the fetal lungs enough to reduce morbidity and mortality from respiratory distress syndrome.

A Caesarean section, also called a C section, can be the safest option for delivery in some pregnancies. During a C section, the patient is usually numbed  with an epidural or a spinal block, but general anesthesia can be used as well. A cut is made in the patient’s abdomen and then in the uterus to remove the baby. A C section may be the best option  when the small size or shape of the parent’s pelvis makes delivery of the baby impossible, or the lie or presentation of the baby as they prepare to enter the birth canal is dangerous. Other medical reasons for C section are placenta previa (the placenta blocks the baby’s path to the birth canal), uterine rupture, or fetal distress, like due to endangerment of the baby’s oxygen supply. Before the 1970s, once a patient delivered one baby via C section, it was recommended that all of their future babies be delivered by C section, but that recommendation has changed. Unless there is some other indication, patients can attempt a trial of labor and most are able to have a vaginal birth after C section (VBAC).

Like any procedure, a C section is not without risks. Having a C section puts the parent at greater risk for uterine rupture and abnormal attachment of the placenta to the uterus in future pregnancies (placenta accreta spectrum). The rate of deliveries occurring via C section instead of vaginal deliveries has been increasing since the 1970s. The WHO recommends a C section rate of between 10 to 15 percent because C sections rates higher than 10 percent are not associated with a decrease in morbidity and mortality.

According to the WHO, hemorrhage is the leading cause of maternal death worldwide accounting for approximately 27.1% of maternal deaths. Within maternal deaths due to hemorrhage, two-thirds are caused by postpartum hemorrhage. The causes of postpartum hemorrhage can be separated into four main categories: Tone, Trauma, Tissue, and Thrombin. Tone represents uterine atony. Trauma includes lacerations or uterine rupture. Tissue includes conditions that can lead to retained placentas. Thrombin which is a molecule used in the human body’s blood clotting system represents all coagulopathies.

Uterine atony, the most common cause of postpartum hemorrhage, is a top five cause of maternal mortality globally. Uterine atony is when the myometrium ( the muscle layer of the uterus) inadequately contracts. The lack of contraction prevents the spiral arteries from clotting as they rely on the contraction to induce hemostasis. During childbirth, the absence of hemostasis will cause continual bleeding leading to postpartum hemorrhage. Retained placenta and abnormal placentation can cause postpartum hemorrhage and are more likely to occur if there was an incomplete delivery of the placenta or a previous uterine surgery. Incomplete placenta delivery can occur in placenta accreta. Placenta accreta is when the placenta incorrectly invades the uterine myometrium and implants deeper than it should. In a normal pregnancy, the placenta attaches to the endometrium, allowing it to be easily expelled/delivered.

Placenta accreta can be identified early on prenatal ultrasound, so providers will often recommend a scheduled Caesarean hysterectomy to mitigate the complications of postpartum bleeding. The child is first delivered by Cesarean section, while taking effort not to disturb or forcibly remove the adhered placenta. Then the uterus is removed with the placenta still inside. Placenta accreta can also be discovered during active labor when the placenta does not deliver spontaneously. If placenta accreta is discovered mid-delivery, the patient is prepared for an emergency hysterectomy to avoid the high risk of postpartum hemorrhage.

Similar delivery and management strategies are used in cases of placenta increta and placenta percreta, which are more severe presentations on the placenta accreta spectrum. With placenta increta, the placenta grows deep into the muscle layer of the uterus. With placenta percreta, the placenta grows through the wall of the uterus and can even grow into structures near the uterus, like the bladder.

Laceration can occur during any operation including childbirth if forceps or devices are utilized to assist in the delivery. For this reason, great care is taken by the provider to avoid unnecessary contact that can result in large lacerations. Coagulopathies are any disorders that interfere with the body's natural ability to stop bleeding. For example, Von Willebrand disease is a condition where clotting is impaired leading to excessive bleeding. If a pregnant person has any coagulopathies, early identification allows for extra hemorrhage control measures to be in place and cross-typed blood to be available for transfusion.