22. Abnormal labor (dystocia). Classification and management. Flashcards
what is shoulder dystocia ?
where wide range of additional obstetric maneuvers are needed to deliver the fetus after the head has been when gentle traction has failed to deliver the shoulder.
Shoulder dystocia occurs when the anterior shoulder impacts on the maternal symphysis or on the sacral promontory
risk factors for shoulder dystocia
macrosomia > defines as more than 4.5 kg
diabetic mother , or BMI >30
induced labour
anencephaly
what is the diagnosis of shoulder dystocia ?
recoil of the head back
inadequate spontaneous resuscitation
fetal face becomes filled with blood and bodily fluid
failure of shoulder to descend
what is the clinical management of shoulder dystocia ?
to clear the infants mouth and nose
NEVER APPLY FUNDAL PRESSURE - creates further impaction
Advise the mother to stop pushing – this can worsen the impaction.
empty the bladdes
Avoid downwards traction on the fetal head (increases risk of brachial plexus injury) – use “routine” axial traction
mediolateral epstiotomy
========
call for help
legs hyperflexed to abdomen and abducted
Mcroberts manuever
with axial traction
apply suprapubic pressure laterally with axial traction
shoulder disimpaction by rubin manuever
put two fingers through the vagina the behind the anterior shoulder rotated towards the fetus chest
wood screw -
general anesthesia
if this is not useful then keep this pressure and put two fingers into the anterior aspect of the posterior shoulder - lies in the oblique diameter of pelvic outlet
then go to reverse wood screw - try the opposite way
remove the posterioir arm/ pringle manuever
operators whole hand introduced into the posterior part of the vagina behind the posterior arm posterioir arm is is swept across the chest and delivered by gentle traction
roll onto all fours
exert downward traction on the posterior shoulder and axial traction
==== if still not working====
fracture of fetal clavicle - for dead foetus or first choice in anaecephaly
zavanelli manuever - pushing the fetus back to the uterus and delivery by s c section
symphysiotomy - very rare - separation of he maternal pubic bone
complication of shoulder dystocia ?
asphyxia,
brachial plexus injury
fracture of humerus of clavicle
Maternal:
PPH (11%), cervical laceration, vaginal tear,
perineal tear (3rd and 4th degree), rupture of uterus,
what is dynamic dystocia ?
abnormal progress of labor due to inadequate uterine contractility
there are two types of dystocia what are they ?
hypotonic - less than 2 contractions per 10 min
amplitude less than 30mmhg
hypertonic
uterine tachysystole
what is hypotonic uteri and what causes it ?
characterized by a
decreased intensity, frequency and duration of uterine contraction from the fundus spreading down
due to :
uterus hyperplasia,
fibrosis due to previous c section or endometritis ,
excessively stretched uterus -hydroamnion, multiple pregnancy, large fetus,
large amounts of analgesia
or anesthesia
what is the management of hypotonic uterus ?
emptying of bladder and rectum
oxytocin
for augmentation of labour
0.5-2mU /min increasing every 1-2mU /min every 15-40 minutes
forceps and vacuum
c sectio
what is normal uterine contraction parameters ?
occur every 3- 5 minutes lasting 60 seconds uterine fundus cannot be indented with an intenisty of 75-90 mmhg and resting tone of 25 mmhg
what is hypertonic uterus ?
one uterine contracation lasting more than 2 minutes
what is uterine tachysystole and what usually causes it ?
more than 5 contrcation every 10 minutes in rapid succes and these contrcation do not contain enough pressure to push
usually following prostaglandin e1 , or oxytocin administration
placental abruption
what are the major complication of uterine tchysystole or hypertonic uteri ?
fetal asphyxia
what is the management in uterinetachycardia and tetanus uteri
discontinue the uterine stimulating drug
change maternal position to lateral recumbent (usually works best on maternal left side,
Tocolysis- Terbutaline IV
beta agonist
analgesics
