Problems During Labor and Delivery CAPT Mike Hughey

Problems During Labor and Delivery CAPT Mike Hughey, MC, USNR Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 2

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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3

Orientation of the Head Anterior Fontanelle Posterior Fontanelle • Anterior and posterior fontanelles can be palpated vaginally. • Anterior fontanelle is junction of 4 suture lines • Posterior fontanelle is junction of 3 suture lines Left Occiput Anterior Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4

Prolonged Latent Phase Labor • >20 hours (1 st baby) • >14 hours (multip) • Maternal risk of exhaustion, infection • Treatments: – – – Rest Ambulation Hydration Analgesia Oxytocin Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6

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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7

Mac. Robert’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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8

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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11

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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 13

Twin Delivery • 40% of twins are vertex/vertex, favoring vaginal delivery • C/S often performed for fetal malposition • After delivery of 1 st twin, labor stops, then resumes • After 2 nd twin delivers, both placentas deliver Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 14

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15

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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16

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) Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18

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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 19

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 20

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21

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 Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22

Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23