Abnormal Labor and Delivery - Jo An.ppt

8/16/2019 Abnormal Labor and Delivery - Jo An.ppt

1/154

CLINICAL PRACTICE GUIDELINES ON

ABNORMAL LABOR AND DELIVERY

Jo-An Marie G. Aguedan, M.D.


2/154

ELECTRONIC FETAL MONITORING

DURING ABNORMAL LABOR AND

DELIVERY


3/154

Definition of Terms:

A. Bse!ine

B. Bse!ine "ri#i!it$

C. A%%e!ertionD. Er!$ &e%e!ertion

E. Lte &e%e!ertion

F. Vri#!e &e%e!ertionG. Pro!on'e& &e%e!ertion

(. Sin)soi&! *ttern


4/154

BASELINE

• The mean fetal heart rate (FHR) roundedto increments of 5 beats per minute

during a 10-minute segment, ecluding!

" #eriodic or episodic changes

" #eriodic of mar$ed FHR %ariabilit&

" 'egments of baseline that defer b& more than

5 beats per minute


5/154

BASELINE

• The baseline must be for a minimum of

minutes in an& 10-minute segment, or thebaseline for that time period is

indeterminate

• *n this case, one ma& refer to the prior 10-

minute +indo+ for determination of

baseline


6/154

BASELINE

• Norm! FHR baseline! 110-10 beats perminute

• T%+$%r&i! FHR baseline is greater than

10 beats per minute

• Br&$%r&i! FHR baseline is less than

110 beats per minute


7/154


8/154


9/154

BASELINE VARIABILITY

• Fluctuations in the baseline FHR that areirregular in amplitude and freuenc&

•.ariabilit& is %isuall& uantified as theamplitude of pea$-to-trough in beats per

minute


10/154

BASELINE VARIABILITY

• A#sent " amplitude range undetectable• Minim! " amplitude range detectable but

5 beats per minute or fe+er

• Mo&erte ,Norm!- " amplitude range -

5 beats per minute

• Mre& " amplitude range greater than 5

beats per minute


11/154


12/154

ACCELERATION

• efore /0 1ees of gestation, an

acceleration has a pea$ of 10 beats per

minute or more above baseline, ith a

duration o! 10 seconds or more but less

than 2 minutes from onset to return

• #rolonged acceleration lasts minutes or

more but less than 10 minutes in duration

• *f an acceleration lasts 10 minutes or

longer, it is a baseline change


13/154


14/154

EARLY DECELERATION

• .isuall& apparent usuall& s&mmetrical

gradual decrease and return of the FHR

associated +ith a uterine contraction

• 2radual FHR decrease is defined as from

the onset to the FHR nadir of 0 secondsor more

• The decrease in FHR is calculated from

the onset to the nadir o! the deceleration


15/154

EARLY DECELERATION

• The nadir of the deceleration occurs at thesame time as the pea" o! the contraction

• *n most cases the onset, nadir, and

reco%er& of the deceleration are coincident

+ith the beginning, pea$, and ending ofthe contraction, respecti%el&


16/154


17/154

LATE DECELERATION

• .isuall& apparent usuall& s&mmetricalgradual decrease and return of the FHR

associated +ith a uterine contraction

• / gradual FHR decrease is defined as

from the onset to the FHR nadir of 0seconds or more

• The decrease in FHR is calculated !rom

the onset to the nadir o! the deceleration


18/154


19/154

LATE DECELERATION

• The deceleration is dela&ed in timing, +iththe nadir of the deceleration occurring

a!ter the pea" o! the contraction

• *n most cases the onset, nadir, and

reco%er& of the deceleration occur after the

beginning, pea$, and ending of the

contraction, respecti%el&


20/154


21/154

VARIABLE DECELERATION

• .isuall& apparent abrupt decrease in FHR• /n abrupt FHR decrease is defined as

from the onset of the deceleration to the

beginning of the FHR nadir less than 0

seconds

• The decrease in FHR is calculated from

the onset to the nadir of the deceleration


22/154

VARIABLE DECELERATION

• The decrease in FHR is 15 beats per

minute or greater, lasting 15 seconds or

greater, and less than 2 minutes in

duration

• 3hen %ariable decelerations are

associated +ith uterine contractions, their

onset, depth and duration commonl& %ar&+ith successi%e uterine contractions


23/154


24/154

PROLONGED DECELERATION

• .isuall& apparent decrease in FHR belo+

the baseline

• 4ecrease in FHR from the baseline that is

15 beats per minute or more, lasting minutes or more but less than 10 minutes

in duration

• *f a deceleration lasts 10 minutes or

longer, it is a baseline change


25/154


26/154

SINUSOIDAL PATTERN

• .isuall& apparent, smooth, sine +a%e-li$eundulating pattern in FHR baseline +ith a

c&cle freuenc& of -5 per minute +hich

persists for 0 minutes or more


27/154


28/154

• lassification of FHRTracings " Three

Tiered '&stem for theategori6ation of FHR

#atterns


29/154

Categ

ory

FHR

Tracin

gs

Defnition

I Norm

al

• Category I FHR tracings

are strongly predictive of

normal fetal acid-basestatus at the time of

observation.

•Category I FHR tracings

may be monitored in a

routine manner, and no


30/154

II

Indeter

mi-nate

• not predictive of abnormal fetal

acid-base status, yet presently

there is no adequate evidence to

classify these as Category I or

Category III.

• require evaluation and

continued surveilance and

reevaluation, taing into account

the entire associated clinical

circumstances.

• In some circumstances, either

ancillary tests to ensure fetal !ell

bein or intrauterine

Catego

ry

FHR

Tracings

Defnition

C t FHR D f iti


31/154

III Abnorm

al

• associated !ith abnormal fetal

acid-base status at the time ofobservation.

• require clinical evaluation

•"epending on the clinical

situation, e#orts to e$peditiouslyresolve the abnormal FHR pattern

may include but are not limited

to provision of%

&.maternal o$ygen'.change in maternal position

(. discontinuation of labor

stimulation

).treatment of maternal

Catego

ry

FHR

Tracings

Defnition


32/154

III Abnormal

If category IIItracing does not

resolve !ith these

measures, delivery

should be

undertaen.

Categ

ory

FHR

Tracings

Defnition


33/154

C!ini%! Consi&ertion n&

Re%ommen&tions

1 Fetal sur%eillance in labor, +hether b&

intermittent auscultation (*/) or b& 7F8

should be recommended to all +omen

#$evel %%%, Grade &'


34/154

• Freuenc& of */ is as follo+s!

" For lo+ ris$ patients " e%er& 0 minutes for 1st

stage, then e%er& 15 minutes for the nd stage

" For high ris$ patients " e%er& 15 minutes for 1st

stage, then e%er& 5 minutes for the nd stage


35/154

ased on a%ailable data, there is no clearbenefit for the use of 7F8 o%er */ 7itheroption is acceptable in patients +ithout

complications



36/154

A met2n!$sis s$nt+esi3in' res)!ts of

rn&omi3e&%ontro! tri!s ,RCTs- %om*rin' mo&!ities

+& t+e

follo+ing conclusions! #$evel %, Grade A'

• The use of 7F8 compared +ith */ increased

the o%erall cesarean deli%er& rate (RR, 1,

95: * 10-1) and the cesarean deli%er&

rate for abnormal FHR or acidosis or both (RR

;, 95: * 1


37/154

• The use of 7F8 did not reduce perinatal

mortalit& (RR 0


38/154

*n ideal settings, continuous 7F8 shouldbe offered and is recommended for high

ris$ pregnancies +here there is increasedris$ of perinatal death, cerebral pals& orneonatal encephalopath&

#$evel %%-2 to %%%, Grade &'

= urrent e%idence does not support the useof admission tocogram in lo+ ris$pregnanc&



39/154

• 5 ased on careful re%ie+ of a%ailable

terminologies, a three-tiered s&stem ofcategori6ation of FHR interpretation is

recommended



40/154

Category I II III

Baseline

FHR

&&+-&+

beats per

minute

radycardia not

accompanied by

absent baseline

variability or

achycardia

radycar

dia

Baseline

variabilit

y

/oderate /inimal baseline

variability

0bsent baseline

variability !ith no

recurrent

decelerations

/ared baseline

variability

0bsent


41/154

Decelerati

ons

0bsent

early, late

or

variable

Recurrent

variable

decelerations

accompanied by

minimal or

moderatebaseline

variability

1rolonged

decelerationmore than '

minutes but less

than &+ minutes

Recurrent late

Recurrent

late

deceleratio

ns

Recurrent

variabledeceleratio

ns

Category I II III


42/154

Accelerati

ons

1resent

or 0bsent

0bsence of

induced

accelerations

after fetal

2inusoidal

pattern

Decelerat

ions

0bsent

early,

late or

variable

.ariable

decelerations +ith

other

characteristics such

as slo+ return to

baseline,o%ershoots, or

>shoulders?

Recurrent

late

decelerati

ons

Recurrent

variable

decelerati

ons

Category I II III


43/154

Bse& on %ref)! re"ie1 of "i!#!e

termino!o'ies4 t+ree2tiere& s$stem of

%te'ori3tion of F(R inter*rettion is

re%ommen&e&. ,Le"e! III4 Gr&e C-

• The false-positi%e rate of 7F8 forpredicting cerebral pals& is high, atgreater than (().

#$evel %%-2 to %%%, Grade &'

• The use if 7F8 is associated +ith an

increased rate of both %acuum andforceps operati%e %aginal deli%er&, andcesarean deli%er& for abnormal FHRpatterns or acidosis or both

#$evel %%-2 to %%%, Grade &'


44/154

• 3hen the FHR tracing includes recurrent

%ariable decelerations, amnioin!usion torelieve umbilical cord compression should

be considered

#$evel %%-1, Grade *'

• #ulse oimetr& has not been demonstrated

to be a clinicall& useful test in e%aluating

fetal status



45/154

• There is high interobser%er and intraobser%er

%ariabilit& in interpretation of FHR tracing


• Reinterpretation of the FHR tracing, especiall&if the neonatal outcome is $no+n, ma& not be

reliable



46/154

• The use of 7F8 does not result inreduction of cerebral pals&


• / three-tiered s&stem for thecategori6ation of FHR patterns is

recommended


• The labor of +omen +ith high-ris$

conditions should be monitored +ithcontinuous FHR monitoring



47/154

• The terms h&perstimulation andh&percontractili& should be abandonded *t

is no+ calles uterine tach+s+stole (ie more

than 5 contractions in 10 minutes, a%eraged

o%er a 0-minute +indo+)



48/154

C!ini%! Consi&ertion n&

Re%ommen&tions

/ncillar& tests a%ailable that can aid in themanagement of ategor& ** or ategor& ***fetal heart tracings include fetal scalp pHsampling, /llis clamp stimulation,

%ibroacoustic stimulation and digital scalpstimulation

#$evel %%-, Grade *'


49/154

• ecause %ibroacoustic stimulation and

digital scalp stimulation is less in%asi%ethan the other t+o methods, the+ are

pre!erred methods.

#$evel %, Grade A'


50/154

; / ategor& ** or ategor& *** FHR Tracing

reuires initial e%aluation and treatmentma& include the follo+ing!

a. 4iscontinuation of an& labor stimulating

agent

b er%ical eamination to determine

umbilical cord prolapsed, rapid cer%ical

dilatation, or descent of the fetal head



51/154

• hanging maternal position to left or right

lateral recumbent position, reducingcompression of the %ena ca%a and

impro%ing uteroplacental blood flo+

• 8onitoring maternal for e%idence of

h&potension, especiall& in those +ith

regional anesthesia (if present, treatment+ith %olume epansion or +ith ephedrine

or both or phen&lephrine ma& be

+arranted)


52/154

DYSTOCIA


53/154


54/154

Definition of A#norm! Ptterns of L#or

LABOR ATT!RN Diagnostic CriteriaN"lli#aras $"lti#aras

rolongaton Disorder&. rolonged Latent

%ase

3 '+ hrs 3 &) hrs

rotraction Disorder&. rotracted Active

%ase Dilation 41hase

of ma$imum slope ofdilatation5

6 &.' cm7hr 6 &.* cm7hr

'. rotracted Descent

4ma$imum slope of

descent during the pelvic

6 & cm7hr 6 'cm7hr

LABOR ATT!RN Diagnostic Criteria


55/154

Arrest Disorder

&. rolongedDeceleration %ase

4cervical dilatation arrested

at 8 to 9 cm5

3 ( hrs 3 & hr

'. &econdary Arrest o'Dilatation 4progressive

cervical dilatation stops at

the phase of ma$imum

slope5

3 ' hrs

(. Arrest o' Descent

4progressive descent stops

during pelvic division of

labor, station : &5

3 & hr


N"lli#aras $"lti#aras



56/154

). Fail"re o' Descent

4station +5

;ac of e$pected descent

during deceleration phase

or second stage of labor

*. rolonged &econd

&tage

3 ( hrs !ith

regionalanesthesia or

3 ' hrs !ith

regionalanesthesia or

3 ' hrs

!ithoutregional

anesthesia

3 & hr

!ithoutregional

anesthesia

g

N"lli#aras $"lti#aras


57/154

Re%ommen&tions

5. Pro!on'e& Ltent P+se #rotracted /cti%e #hase 4ilatation

/rrest 4isorders


58/154

Pro!on'e& Ltent P+se

• /%oid admission to the labor anddeli%er& area until acti%e labor isestablished


• 4e%elop a plan to meet the +oman@s

need either at home or in a non-laboring hospital unit


P ! & L t t P+


59/154


• Friedman (19;) reported that

prolongation of the latent phase did notad%ersel& influence fetal or maternalmorbidit& and mortalit&


• 4ata sho+ that patients +ith prolongedlatent phase are no more prone to

de%elop problems than gra%idas +ithnormal latent phase



60/154


• Abser%ation, rest and therapeutic

analgesiaBstrong sedati%es arefa%ored o%er a more acti%e approachof amniotom& and o&tocin induction


• 'upport and information from

caregi%ers to pro%ide copingstrategies


P ! & L t t P+


61/154


• / patient +ho has a latentphase longer than 0 hrsshould be epected to e%ol%e a

normal subseuent dilatationand descent if allo+ed to doso


P ! & L t t P+


62/154


- *t cannot be too strongl& stated thatpatients +ho are deli%ered b&

cesarean section (') during the

latent phase for no other reason thantheir lac$ of progress are being

subCected to this operation

unnecessaril& most of the time



63/154


64/154

• Friedman@s recommended approach is

support and therapeutic rest b& the use of

large doses of narcotic analgesics


P ! & L t t P+


65/154


• 7ceptionall&, o&tocin ma& be underta$en

directl& if additional to 10 hours dela& b&

rest +ould be clinicall& unacceptable as in

the presence of chorioamnionitis


R & ti


66/154

Re%ommen&tions

1 #rolonged Datent #hase

0. Protr%te& A%ti"e P+se Di!ttion

/rrest 4isorders

P t t & A ti P+


67/154

Protr%te& A%ti"e P+se

Di!ttion

• #h&sical and emotional support

#$evel %, Grade A'

• ontinuous support during labor fromcaregi%ers should be encouraged because it is

beneficial for +omen and their ne+borns

#$evel %, Grade A'


68/154

• /mniotom& +ith earl& o&tocin

augmentation shortens labor b& as much

as hours compared to epectant care but

has not been sho+n to change cesareandeli%er& rates

#$evel %, Grade A'



69/154


Di!ttion

• /mniotom& ma& enhance progress in theacti%e phase and negate the need for o&tocin

augmentation but ma& increase the ris$ of

chorioamnionitis

#$evel %, Grade A'

• A&tocin should be used to achie%e adeuate

contractions (at least 00 8onte%ideo units)before operati%e deli%er& is considered

#$evel %, Grade *'


70/154

• High-dose o&tocin regimens result in

shorter labors than lo+ dose regimens

+ithout ad%erse effects to the fetus

#$evel %, Grade *'

• Rule out #4

#$evel %%%, Grade *'

• *f +ith #4, do '


Re%ommen&tions


71/154

Re%ommen&tions

1 #rolonged Datent #hase

#rotracted /cti%e #hase 4ilatation

/. Arrest Disor&ers

Arrest Disor&ers


72/154

Arrest Disor&ers

• ontinuous support during labor from

caregi%ers should be encouraged because itis beneficial for +omen and their ne+borns

#$evel %, Grade A'

• E-ra& pel%imetr& alone as a predictor ofd&stocia has not been sho+n to ha%e benefit,and therefore is not recommended

#$evel %, Grade *'• Rule out #4


Arrest Disor&ers


73/154

Arrest Disor&ers

• *f +ith #4, do '


• efore an arrest disorder can bediagnosed in the first stage of labor, thelatent phase should be completed, and theuterine contraction pattern eceeds 200

Montevideo units !or 2 hours ithoutcervical change.


Arrest Disor&ers


74/154

Arrest Disor&ers

• The >-hour rule? for the diagnosis of arrest inacti%e labor has been challenged

• *n a clinical trial, 5= +omen +ere managedb& a protocol in +hich, after acti%e phasearrest +as diagnosed, o&tocin +as initiated+ith the intent to achie%e a sustained uterinecontraction pattern of greater than 008onte%ideo units


Arrest Disor&ers


75/154

Arrest Disor&ers

• esarean deli%er& is not performed forlabor arrest until there ere at least

hours o! sustained uterine contraction

pattern o! greater than 200 Montevideo

units, or a minimum o! / hours o! o+tocinaugmentation if the contraction pattern

could not be achie%ed


Arrest Disor&ers


76/154

Arrest Disor&ers

• The protocol resulted in a high rate of

%aginal deli%er& (9:) +ith no se%ere

ad%erse maternal or fetal outcomes

• 7tending the minimum period of o&tocin

augmentation for acti%e phase arrest from

hours appears effecti%e



77/154


78/154

• BREEC( PRESENTATION

• E6TERNAL CEP(ALIC VERSION

• PERSISTENT OCCIPUT POSTERIOR4

OCCIPUT TRANSVERSE

• BRO7 PRESENTATION

• FACE PRESENTATION• FETAL MACROSOMIA

• S(OULDER DYSTOCIA

• TRANSVERSE LIE8OBLI9UE LIE• COMPOUND PRESENTATION


79/154

BREEC( PRESENTATION

BREEC( PRESENTATION


80/154

BREEC( PRESENTATION

• Re%ommen&tions:

• #lanned cesarean section (') for babies inbreech presentation has a reduced ris$ forperinatal death and neonatal morbidit&compared to planned %aginal birth

#$evel %, Grade A'

• #lanned ' for babies in breech presentationis associated +ith a modest increase in shortterm maternal morbidit&

#$evel %, Grade A'

Re%ommen&tions:


81/154

Re%ommen&tions:

• *nformation is limited about the potential forproblems +ith future pregnancies

#$evel %, Grade &'

• /fter t+o &ears, there +ere no differences inthe combined outcome >death orneurode%elopmental dela&?@ 8aternal

outcomes +ere also similar

#$evel %, Grade A'

Re%ommen&tions:


82/154

Re%ommen&tions:

• There is no data to uantif& ris$s of ' tothe mother (scar dehiscence in asubseuent pregnanc&, increased ris$ torepeat ', placenta accreta)


• There is no e%idence that the long termhealth of babies +ith a breechpresentation deli%ered at term is

influenced b& ho+ the bab& is born

#$evel %, Grade A'


83/154

Re%ommen&tions:


84/154

Re%ommen&tions:

• For a +oman +ith suspected breech

presentation, pre- or earl& labor ultrasound

should be performed to assess t&pe of

breech presentation, fetal gro+th and

estimated +eight, and attitude of fetal

head *f ultrasound is not a%ailable, ' isrecommended

#$evel %%, Grade A'

Re%ommen&tions:


85/154

• ontraindications to labor

include!a) ord presentation #$evel %%, Grade A'

b) Fetal gro+th restriction or macrosomia#$evel %, Grade A'

c) /n& presentation other than a fran$ or

complete breech +ith a fleed or

neutral head attitude


Re%ommen&tions:


86/154

• ontraindications to labor

include!d)linicall& inadeuate maternal pel%is #$evel

%%%, Grade *'

e)Fetal anomal& incompatible +ith %aginal

deli%er&


Re%ommen&tions:


87/154

• .aginal breech deli%er& can be offered +hen the

estimated fetal +eight is beteen 2500 g and

000 g.

#$evel %%, Grade *'

• linical pel%ic eamination should be performed to

rule out pathological pel%ic contraction Radiologic

pel%imetr& is not necessar& for a safe trial of labor

good progress in labor is the best indicator o!

adeuate !etal-pelvic proportions



88/154

Re%ommen&tions:


89/154

• *nduction of labor is not recommended for breech

presentation

#$evel %%, Grade *'

• A&tocin augmentation is acceptable in the

presence of h&potonic uterine d&sfunction

#$evel %%, Grade A'


90/154

• / passi%e second stage +ithout acti%e pushing

ma& last up to 90 minutes, allo+ing the breech to

descend +ell into the pel%is Ance acti%e pushingcommences, i! deliver+ is not imminent a!ter /0

minutes, & is recommended

#$evel %, Grade A'

The acti%e second stage of labor should ta$e place

in or near an operating room +ith euipment and

personnel a%ailable to perform a timel& ' section

if necessar&

#$evel %, Grade A'

Re%ommen&tions:


91/154

• / health care professional s$illed in neonatal

resuscitation should be in attendance at the time of

deli%er&

#$evel %%%, Grade A'

• The health care pro%ider for a planned %aginal

breech deli%er& needs to possess the reuisite

s$ills and eperience

#$evel %%, Grade A'

Re%ommen&tions:


92/154

• /n eperienced obstetrician-g&necologist comfortable

in the performance of %aginal breech deli%er& should be

present at the deli%er& to super%ise other health carepro%iders, including a trainee

#$evel %, Grade A'

• The health care pro%ider should ha%e rehearsed a plan

of action and should be prepared to act promptl& in the

rare circumstance of a trapped a!tercoming head or

irreducible nuchal arms s+mph+siotom+ or emergenc+

abdominal rescue can be li!e saving


Re%ommen&tions:


93/154

• Total breech etraction is inappropriate !or termsingleton breech deliver+

#$evel %%, Grade A'

• 7ffecti%e maternal pushing efforts are essential tosafe deli%er& and should be encouraged

#$evel %%, Grade A'


94/154

• /t the time of deli%er& of the aftercoming head, an

assistant should be present to appl& suprapubic

pressure to fa%or fleion and engagement of thefetal head

#$evel %%, Grade *'

Re%ommen&tions:


95/154

• 'pontaneous or assisted breech

deli%er& is acceptable Fetal tractionshould be a%oided, and !etalmanipulation must be applied onl+a!ter spontaneous deliver+ to the level

o! the umbilicus


• Guchal arms ma& be reduced b&


96/154

& &

Do%set maneu%er .


Re%ommen&tions:


97/154

• The fetal head ma& deli%er spontaneousl&, +ith theassistance of suprapubic pressure, b& Mauriceau-

mellie-3eit maneuver, or ith the assistance o!4iper !orceps



98/154


99/154

Re%ommen&tions:


100/154

• The consent discussion and chosen plan

should be +ell documented and

communicated to labor room staff


• Hospitals offering a trial of labor should

ha%e a +ritten protocol for eligibilit& and

intrapartum management


Re%ommen&tions:


101/154

• 3omen +ith a contraindication to a trialof labor should be ad%ised to ha%e a' 3omen choosing to labor despitethis recommendation ha%e right to doso and should not be abandoned The&

should be pro%ided the best possiblein-hospital care


Re%ommen&tions:


102/154

• / ph&sician is free to choose +hom he +ill ser%e

He ma& refuse calls, or other medical ser%ices forreasons satisfactor& to his professional

conscience

• He should, ho+e%er, al+a&s respond to an&

reuest for his assistance in an emergenc& Ance

he underta$es a case, he should not abandon nor

neglect it


103/154

• *f for an& reason he +ants to be released from it,

he should announce his desire pre%iousl&, gi%ing

sufficient time or opportunit& to the patient or hisfamil& to recei%e another medical attendant

Re%ommen&tions:


104/154

• Theoretical and hands-on breech birth

training simulation should be part of

basic obstetrical s$ills taining programs

such as /D/R8, to prepare health care

pro%iders for unepected %aginal breech

births



105/154


106/154


107/154


108/154

E6TERNAL CEP(ALIC VERSION

E6TERNAL CEP(ALIC VERSION


109/154

• is a procedure of manipulation of the fetus

through the maternal abdomen to a

cephalic presentation

• The rationale behind 7. is to reduce theincidence of breech presentation at term

and therefore the associated ris$s,

particularl& of a%oiding '


110/154

Re%ommen&tions


111/154

• 3omen should be counseled that 7.reduces the chance of breech presentation at

deli%er&

#$evel %, Grade A'

• 7. reduces the chances of ha%ing a '

#$evel %, Grade A'

• 3ith a trained operator about 50) of 7.attempts +ill be successful


Re%ommen&tions


112/154

• The use of tocol&sis +ith beta

s&mpathomimetic drugs ma& be offered to

+omen undergoing 7. as it has been

sho+n to increase the success rate

#$evel %, Grade A'

• 7. before +ee$s is not associated

+ith significant reduction in noncephalicbirths or '

#$evel %%, Grade *'

Re%ommen&tions


113/154

• There is insufficient e%idence to support

the use of postural management as a

method of promoting spontaneous %ersion

o%er 7.

#$evel %, Grade A'

• Dabor +ith a cephalic presentation

follo+ing 7. is associated +ith a higher

rate o! obstetric intervention than hen

6&3 has not been reuired

#$evel %, Grade *'

Re%ommen&tions


114/154

• A#so!)te %ontrin&i%tions for 7.

that are li$el& to be associated +ith

increased mortalit& or morbidit&!

" 3here cesarean deli%er& is reuired

" /ntepartum hemorrhafe +ithin the last ; da&s " /bnormal cardiotocograph

" 8aCor uterine anomal&

" Ruptured membranes

" 8ultiple pregnanc& (ecept deli%er& of

second t+in)


Re%ommen&tions


115/154

• Re!ti"e %ontrin&i%tions +here 7.might be more complicated!

" 'mall for gestational age fetus +ith abnormal4oppler parameters

" #roteinuric pre-eclapmsia

" Aligoh&dramnios

" 8aCor fetal anomalies " 'carred uterus

" nstable lie



116/154

• PERSISTENT OCCIPUT POSTERIOR4

OCCIPUT TRANSVERSE

PERSISTENT OCCIPUT POSTERIOR4

OCCIPUT TRANSVERSE


117/154

OCCIPUT TRANSVERSE

4efinition

• 3ith effecti%e contractions, adeuate

fleion of the head, and a fetus of a%erage

si6e, most posteriorl& positioned occiputsroute promptl& as soon as the& reach the

pel%ic floor


OCCIPUT TRANSVERSE


118/154

OCCIPUT TRANSVERSE

• #oor contractions, fault& fleion of the

head, or epidural analgesia, +hich

diminishes abdominal muscular pushing

and relaes the muscles of the pel%ic floorma& predispose to incomplete rotation


OCCIPUT TRANSVERSE


119/154

OCCIPUT TRANSVERSE

• *f rotation is incomplete, trans%erse arrest

ma& result

• *f no rotation to+ard the s&mph&sis ta$es

place

• The occiput ma& remain in the direct

occiput posterior position, a condition

$no+n as persistent occiput posterior

Re%ommen&tions


120/154

• 4igital rotation should be considered +henmanaging the labor of a fetus in theoccipito-posterior position This maneu%ersuccessfull& rotates the fetus reducing theneed for ', instrumental deli%er&, andother complications associated +ith

persistent occiput posterior



121/154

BRO7 PRESENTATION


122/154

BRO7 PRESENTATION

BRO7 PRESENTATION

R d ti


123/154

Recommendations!

• 7pectant management is reasonable as

long as the fetal heart tracing remains

reassuring and dilation and descent are

progressing normall& because

spontaneous con%ersion to %erte or facema& occur

#$evel %%, Grade *'

Re%ommen&tions


124/154

• The use of forceps or manual con%ersionto con%ert a bro+ presentation to a more

fa%orable position is contraindicated.

#$evel %%, Grade *'


125/154

• FACE PRESENTATION

FACE PRESENTATION

Recommendations


126/154

Recommendations

• ontinuous 7F8 is considered mandator+

b& man& authors because of the increased

incidence of abnormal FHR patterns

andBor fetal compromise areful

application of the electrode must beensured the mentum is recommended site

o! application



127/154

Re%ommen&tions

• /ttempts to manuall& con%ert the face to


128/154

• /ttempts to manuall& con%ert the face to%erte (Thom maneu%er) or to rotate a

posterior position to a more fa%orable anteriormentum position are rarel& successful and areassociated +ith high perinatal mortalit& andmaternal morbidit&

• *nternal podalic %ersion and breech etractionare no longer recommended in the modernmanagement of the face presentation


Re%ommen&tions

• Forceps ma& be used if the mentum is anterior


129/154

• Forceps ma& be used if the mentum is anterior

/n& t&pical forceps including Ieilland forceps,

can be used


• The mechanisms of labor in the term infant can

occur onl& if the mentum is anterior



130/154

FETAL MACROSOMIA

FETAL MACROSOMIA


131/154

• The term fetal macrosomia implies fetal

gro+th be&ond a specific +eight, usuall+

000 gm #7 lb 1 o8' or 500 gm #( lb

o8' regardless of the fetal gestational age


132/154

• 'uspected fetal macrosomia is not an


133/154

'uspected fetal macrosomia is not an

indication !or induction o! labor because

induction does not impro%e maternal or fetaloutcomes

#$evel %%, Grade *'

Re%ommen&tions

• Dabor and %aginal deli%er& is not


134/154

• Dabor and %aginal deli%er& is not

contraindicated for +omen +ith estimated

fetal +eights up to 5,000 g in the absenceof maternal diabetes

#$evel %%, Grade *'

• 3ith an estimated fetal +eight more than

=,500 g, a prolonged second stage o! labor

or arrest o! descent in the second stage is

an indication !or cesarean deliver+

#$evel %%, Grade *'

Re%ommen&tions

• /lthough the diagnosis of fetal


135/154

/lthough the diagnosis of fetal

macrosomia is imprecise, proph&lactic

cesarean deli%er& ma& be considered forsuspected fetal macrosomia +ith

estimated fetal +eights more than 5,000 g

in pregnant omen ithout diabetes and

more than ,500 g in pregnant omen ith

diabetes.



136/154

• 'uspected fetal macrosomia is not

contraindication to attempted %aginal birth

after a pre%ious cesarean deli%er&



137/154

• S(OULDER DYSTOCIA

S(OULDER DYSTOCIA

Recommendations


138/154

Recommendations

• Ris$ assessments for the prediction of

shoulder d&stocia are insufficientl&

predicti%e to allo+ pre%ention of the large

maCorit& of cases

#$evel %%, Grade *'

• *nduction of labor in +omen +ith diabetes

mellitus does not reduce the maternal or

neonatal morbidit& of shoulder d&stocia

#$evel %, Grade A'


139/154

Re%ommen&tions

• 7pisiotom& is not necessar& for all cases


140/154

7pisiotom& is not necessar& for all cases,

is reser%ed to facilitate maneu%ers such as

deli%er& of posterior arm or internalrotation of shoulders


• Mc9oberts is the single most e!!ective


141/154

Mc9obert s is the single most e!!ective

intervention and should be per!ormed !irst


Re%ommen&tions

• 'uprapubic pressure is useful


142/154

'uprapubic pressure is useful


• 'uprapubic pressure can be emplo&edtogether +ith 8cRobert@s maneu%er toimpro%e success rates


Re%ommen&tions

• Ather maneu%ers such as Rubin@s, 3ood@s


143/154

Ather maneu%ers such as Rubin s, 3ood s

scre+ maneu%er, Ja%anelli, cleidotom&

and s&mph&siotom& ha%e been emplo&edbut no controlled trials ha%e been made


• Rubin 8aneu%er


144/154

Rubin 8aneu%er

• 3ood@s scre+ maneu%er


145/154

3ood s scre+ maneu%er

• Ja%anelli maneu%er


146/154

a a e a eu e

• '&mph&siotom&


147/154

& p & &


148/154

• TRANSVERSE LIE8OBLI9UE LIE

TRANSVERSE LIE8OBLI9UE LIE


149/154

Recommendation

• Trans%erse lie and obliue lie +ill benefit

from a trial of %ersion to cephalic

presentation follo+ing the criteria and

recommendations of 7. for breechpresentations



150/154


151/154

• COMPOUND PRESENTATION

COMPOUND PRESENTATION


152/154

Recommendations

• *f the hand has not prolapsed be+ond the

presenting part , causing the hand to

retract often is accomplished, if necessar&

*t can be ignored as long as labor isprogressing normall&


COMPOUND PRESENTATION


153/154

Recommendations

• *n contrast, if the hand or arm has

prolapsed past the presenting part ,

abdominal %aginal deli%er& and proceeding

to cesarean deli%er& is +ise



154/154

Abnormal Labor and Delivery - Jo An.ppt

Documents

Transcript of Abnormal Labor and Delivery - Jo An.ppt