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Problems During Labor and Delivery. CAPT Mike Hughey, MC, USNR. Preterm Labor. Prior to 38 weeks Cause unknown, but half are associated with intrauterine infection Some caused by abruption Judgment when to treat Tocolytic drugs Steroids. Compound Presentation. Hand plus Head, eg.
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Problems During Labor and Delivery CAPT Mike Hughey, MC, USNR
Preterm Labor • Prior to 38 weeks • Cause unknown, but half are associated with intrauterine infection • Some caused by abruption • Judgment when to treat • Tocolytic drugs • Steroids
Compound Presentation • Hand plus Head, eg. • Pinching hand may cause it to withdraw • If the fetus is small and the pelvis large, vaginal delivery may be possible, but with some risk of injury to the arm.
Orientation of the Head • Anterior and posterior fontanelles can be palpated vaginally. • Anterior fontanelle is junction of 4 suture lines • Posterior fontanelle is junction of 3 suture lines Anterior Fontanelle Posterior Fontanelle Left Occiput Anterior
Prolonged Latent Phase Labor • >20 hours (1st baby) • >14 hours (multip) • Maternal risk of exhaustion, infection • Treatments: • Rest • Ambulation • Hydration • Analgesia • Oxytocin
Arrest of Active Labor • Less than 1.2 cm/hour progress in dilation • No change in 2 hours • Inadequate contractions • Too infrequent (>4 min) • Too short (<30 sec) • Mechanical impediment • Absolute FPD (rare) • Relative FPD (common) • Malposition • Rx: Oxytocin and time
Shoulder Dystocia • Shoulder wedged behind the pubic bone after delivery of the head • Turtle sign • Excessive downward traction can lead to temporary or permanent injury to the brachial plexus.
MacRobert’s Maneuver • Flexing the maternal thighs tightly against the maternal abdomen • Straightens the birth canal, giving a little more room for the shoulders to squeeze through.
Suprapubic Pressure • Downward suprapubic pressure, in combination with other maneuvers, can nudge the fetal shoulder past its obstruction. • Downward/lateral suprapubic pressure can nudge the shoulder to an oblique diameter, allowing it to slip past the pubic bone.
Delivery of Posterior Arm • Episiotomy, if needed • Reach in posteriorly and sweep the posterior arm over the chest and out of the vagina. • Easier described than performed • Risk of injury (Fx, dislocation) to the posterior arm
Rotation of the Baby • Small rotation moves the baby to an oblique diameter, facilitating delivery • Similar to “unscrewing a light bulb” • After the anterior shoulder is rotated 180 degrees, continue to rotation another 180 degrees in the same direction
Breech Delivery • Most will deliver spontaneously without any special maneuvers, although cesarean section is often selected • If it gets stuck, gentle downward traction, with suprapubic pressure to keep the head flexed will achieve a safe delivery.
Breech Delivery • Direct the traction downward and never above the horizontal plane. • Lifting the baby above the horizontal can result in spinal injury. • Try to have the mother do the pushing rather than you doing much pulling
Twin Delivery • 40% of twins are vertex/vertex, favoring vaginal delivery • C/S often performed for fetal malposition • After delivery of 1st twin, labor stops, then resumes • After 2nd twin delivers, both placentas deliver
Prolapsed Umbilical Cord • Impairs blood flow to the fetus • Immediate delivery is best solution • Place mother in knee-chest position to relieve pressure on the cord • Elevate the fetal head out of the pelvis with your hand in the vagina to relieve cord compression
Umbilical Cord Around Neck • Nearly half of babies have the cord wrapped around some part of their body. • Usually this isn’t a problem • If tight, it can impair cord flow • If loose, leave it alone or slip it over the fetal head. • If tight, double clamp the cord and cut between the clamps. • Then deliver the rest of the baby.
Retained Placenta • Gentle cord traction with Crede maneuver (pushing the uterus away with the abdominal hand) • After about 30 minutes of waiting for separation • Manual removal • Be prepared to deal with a placental abnormality (abnormally adherent placenta)
Post Partum Hemorrhage • Average loss is about 500 cc (about 10% of the blood volume) • Most cases are caused by the uterus failing to contract effectively • Expell clots from the uterus with fundal pressure • Uterine massage • Oxytocin, methergine, prostaglandin • Bimanual compression • Uterine packing
Post Partum Hemorrhage • Transfuse early, based on: • Estimated blood loss • Clinical circumstances • Likelihood of continuing loss • Don’t wait for traditional signs of tachycardia, tachypnea, hypotension and confusion as post-partum patients often look rather well despite substantial blood loss, then suddenly collapse.
Chorioamnionitis • >100.4 • Uterine tenderness • Foul-smelling amniotic fluid • Fetal tachycardia • Elevated maternal WBC • Treat aggressively with IV antibiotics • Prompt delivery • Tylenol to decrease maternal fever
Group B Streptococcus • May screen for carriers • May treat during labor, those with positive screens or those with risk factors: • Previous GBS diseased infant • Documented GBS infection during pregnancy • Delivery <37 weeks • Ruptured BOW >18 hours • Temp of 100.4 or more • Pen G, Amp, Clinda, Erythro
Post Partum Fever • >100.4, twice, 6 hours apart • Uterine tenderness, foul lochia • Often due to strep (childbed fever) • Treat aggressively and early with IV antibiotics as these patient can become desperately ill very quickly