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1. Problems During Labor and Delivery
2. Preterm Labor Prior to 38 weeks
Cause unknown, but half are associated with intrauterine infection
Some caused by abruption
Judgment when to treat
3. 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.
4. 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
5. Prolonged Latent Phase Labor >20 hours (1st baby)
>14 hours (multip)
Maternal risk of exhaustion, infection
6. Arrest of Active Labor Less than 1.2 cm/hour progress in dilation
No change in 2 hours
Too infrequent (>4 min)
Too short (<30 sec)
Absolute FPD (rare)
Relative FPD (common)
Rx: Oxytocin and time
7. Shoulder Dystocia Shoulder wedged behind the pubic bone after delivery of the head
Excessive downward traction can lead to temporary or permanent injury to the brachial plexus.
8. 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.
9. 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.
10. 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
11. 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
12. 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.
13. 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
14. 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
15. 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
16. 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.
17. Retained Placenta Gentle cord traction with Crede maneuver (pushing the uterus away with the abdominal hand)
After about 30 minutes of waiting for separation
Be prepared to deal with a placental abnormality (abnormally adherent placenta)
18. 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
Oxytocin, methergine, prostaglandin
19. Post Partum Hemorrhage Transfuse early, based on:
Estimated blood loss
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.
20. Chorioamnionitis >100.4
Foul-smelling amniotic fluid
Elevated maternal WBC
Treat aggressively with IV antibiotics
Tylenol to decrease maternal fever
21. 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
22. 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