1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 Problems During Labor and Delivery CAPT Mike Hughey, MC, USNR

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

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

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