In the Name of God Obstetrics Study Guide 2 Mitra Ahmad Soltani 2008 Med-ed-online.org References 1- All India Medical Pre PG. Fetal maturity &length of foetus. 2007. See: www.aippg.net/forum/viewtopic.php?t=33005
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Mitra Ahmad Soltani
1- All India Medical Pre PG. Fetal maturity &length of foetus. 2007.
2-Brinholz J. Gestational age.American Journal of Roentgenography. 1984. 142 (4): 849
3- Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc Graw Hill, 2005.
4- Durham J .Transition to Parenthood: How accurate is your due date. 2004
see: www.transitiontoparenthood.com/ttp/parented/pregnancy/duedate.htm and
5- Friedman E. Obstetrical Decision Making. Harvard Medical School. 1981
6- Military Obstetrics and Gynecology. BrooksidePress. Estimating Gestational age. 2006
See: www.brooksidepress.org/.../Pregnancy /estimating_ gestational_age.htm
7-Mitchell P. A Comparison of Gestational Age Information Derived from the Birth Certificate, 1990 – 1998 . Alaska Vital Sign.2000. 8 (1):1-7
8- Mittendorf R, Williams M, Berkey C, Cotter P. . The Length of Uncomplicated Human Gestation. Obstetrics & Gynecology.1990 . 75(6):929-932
Pictures and material on Breech and C/S are adapted from emedicine e-Journal with permission:
9-Fischer R. Breech Presentation.emedicine.2006
10- Sehdev H. Cesarean Delivery. emedicine. 2005
• At 12 weeks, the uterus is just barely palpable above the pubic bone, using only an abdominal hand.
• At 16 weeks, the top of the uterus is 1/2 way between the pubic bone and the umbilicus.
• At full term, the top of the uterus is at the level of the ribs. (xyphoid process).
8x 5 =40 cm
Fundal height (cm) above the pubic symphysis minus 12 if Vertex above Ischial Spine or minus 11 if below Ischial Spines- should be multiplied by 155. This will be fetal weight in grams.
Unknown or uncertain
Gathering other data:
1-Date of intercourse
2- Date of positive Pregnancy test
3-Signs of pregnancy
4-First heard FHR
6-Rate of uterine growth
Matches clinical gestational age
Doesn’t match with clinical gestational age
US does not match clinical gestational age.
Either wrong estimate of gestational age or IUGR
B-maternal and fetal tachycardia
2 drops /min, add 2 drops every 15 min if FHR and contractions are normal
Amp ampicillin 2gr iv qid +gentamicinim 80mg stat then 60 mg TDS
AMP clindamycin 900 mg iv TDS for allergic women to penicillin(continue antibiotics after delivery until the mother is a febrile
OTHER: Control of vital sign hourly
Intracervical gel(Prepidil ):2.5 mL/0.5 mg
Vaginal insert(cervidil) 10 mg
Footling breech presentation: umbilicus.
A singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
Assisted vaginal breech delivery1: Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
Assisted vaginal breech delivery2: common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
Assisted vaginal breech delivery3: No downward or outward traction is applied to the fetus until the umbilicus has been reached.
Assisted vaginal breech delivery4: traction is applied to the fetus until the umbilicus has been reached.
With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
Assisted vaginal breech delivery5: traction is applied to the fetus until the umbilicus has been reached.
The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
Assisted vaginal breech delivery6: The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
Assisted vaginal breech delivery7: 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
Assisted vaginal breech delivery8: Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
Fetal head entrapment . This occurs in 0-8.5% of vaginal breech deliveries. This percentage is higher with preterm fetuses (<32 wk).
Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment.
The Zavanelli maneuver involves replacement of the fetus into the abdominal cavity followed by cesarean delivery.
Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions.
Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. Risks may be reduced by avoiding rapid extraction of the infant during delivery of the body.
To relieve nuchal arms, rotate the infant so that the fetal face turns toward the maternal symphysis pubis; this reduces the tension holding the arm around the back of the fetal head.
Cervical spine injury is predominantly observed when the fetus has a hyper-extended head (star gazing) prior to delivery.
1- gestational age>37 weeks
2- EFW< 4000 g,
3-A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse,
4-The fetus should show no neck hyperextension on ultrasound images
Prepare for the possibility of cesarean delivery:
Perform an ultrasound to confirm breech, check growth and amniotic fluid volume, and rule out anomalies associated with breech.
Perform a NST (biophysical profile as backup) prior to ECV to confirm fetal well-being.
Adapted from :
Sehdev H. Cesarean Delivery. emedicine. 2005
At least one of these criteria must be met in a woman with normal cycles and no immediate antecedent use of OCP:
Infraumbilical incision :
The Pfannenstiel incision is curved slightly cephalad at the level of the pubic hairline. The incision extends slightly beyond the lateral borders of the rectus muscle bilaterally and is carried to the fascia.
Then, the fascia is incised bilaterally for the full length of the incision.
Then, the underlying rectus muscle is separated from the fascia both superiorly and inferiorly with blunt and sharp dissection.
A vertical incision also may be considered in:
Cap cephalexin 500 mg qid
Cap mefenamic acid 500 mg tds
Cap hematinic (according to Hb)
NPO from 12 am
Prep 2 units of PC
1000 cc Ringer IV fluid q8 hrs the night before surgery
Amp keflin 2 gr iv stat half an hour before surgery
Inform in cases of ROM or bleeding or pain