Problems During Labor and Delivery Preterm Labor

Problems During Labor and Delivery

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

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