problems during labor and delivery

Labor and Delivery ProblemsSlide *
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
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Some caused by abruption
Judgment when to treat
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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.
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Anterior
Fontanelle
Posterior
Fontanelle
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Treatments:
Rest
Ambulation
Hydration
Analgesia
Oxytocin
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No change in 2 hours
Inadequate contractions
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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.
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Flexing the maternal thighs tightly against the maternal abdomen
Straightens the birth canal, giving a little more room for the shoulders to squeeze through.
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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.
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Episiotomy, if needed
Reach in posteriorly and sweep the posterior arm over the chest and out of the vagina.
Easier described than performed
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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
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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.
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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
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C/S often performed for fetal malposition
After delivery of 1st twin, labor stops, then resumes
After 2nd twin delivers, both placentas deliver
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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
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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.
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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)
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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
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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.
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Chorioamnionitis
>100.4
Prompt delivery
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May screen for carriers
May treat during labor, those with positive screens or those with risk factors:
Previous GBS diseased infant
Delivery <37 weeks
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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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problems during labor and delivery

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