Problems During Labor and Delivery Preterm Labor


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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






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