1. Problems During Labor and Delivery CAPT Mike Hughey, MC, USNR

2. 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

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 Anterior Fontanelle Posterior Fontanelle Left Occiput Anterior

5. Prolonged Latent Phase Labor • >20 hours (1st baby) • >14 hours (multip) • Maternal risk of exhaustion, infection • Treatments: • Rest • Ambulation • Hydration • Analgesia • Oxytocin

6. 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

7. 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.

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 • Manual removal • 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 • Uterine massage • Oxytocin, methergine, prostaglandin • Bimanual compression • Uterine packing

19. 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.

20. 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

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