Problems During Labor and Delivery

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Problems During Labor and Delivery
CAPT Mike Hughey, MC, USNR
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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

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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.

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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
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Prolonged Latent Phase Labor

• gt20 hours (1st baby)
• gt14 hours (multip)
• Maternal risk of exhaustion, infection
• Treatments
• Rest
• Ambulation
• Hydration
• Analgesia
• Oxytocin

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Arrest of Active Labor

• Less than 1.2 cm/hour progress in dilation
• No change in 2 hours
• Inadequate contractions
• Too infrequent (gt4 min)
• Too short (lt30 sec)
• Mechanical impediment
• Absolute FPD (rare)
• Relative FPD (common)
• Malposition
• Rx Oxytocin and time

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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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MacRoberts 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.

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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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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

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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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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.

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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

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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

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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

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Umbilical Cord Around Neck

• Nearly half of babies have the cord wrapped
  around some part of their body.
• Usually this isnt 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
• Oxytocin, methergine, prostaglandin
• Bimanual compression
• Uterine packing

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Post Partum Hemorrhage

• Transfuse early, based on
• Estimated blood loss
• Clinical circumstances
• Likelihood of continuing loss
• Dont 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

• gt100.4
• Uterine tenderness
• Foul-smelling amniotic fluid
• Fetal tachycardia
• Elevated maternal WBC
• Treat aggressively with IV antibiotics
• Prompt delivery
• Tylenol to decrease maternal fever

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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 lt37 weeks
• Ruptured BOW gt18 hours
• Temp of 100.4 or more
• Pen G, Amp, Clinda, Erythro

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Post Partum Fever

• gt100.4, 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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