Delivery Flashcards
Easy surgical repair Rare faulty healing Minimal postoperative pain Excellent anatomical result Less blood loss Rare dyspareunia Common extensions
Midline episiotomy
More difficult surgical repair More common faulty healing Common postoperative pain Occasionally faulty anatomical results More blood loss Occasional dyspareunia Uncommon extensions
Mediolateral episiotomy
Lowest risk of maternal and fetal comorbidity
Inc risk for pelvic floor disorder
SVD
50 minutes in nullipara
20 minutes in mutlipara
Healthy neonate with minimal trauma to the mother is the culmination
Second stage of labor
Done when HEAD distends vulva and expulsive efforts are inadequate
Forward pressure on fetal chin in front of maternal coccyx by one hand
Other hand exerts pressure superiorly against the occipit
Promotes controlled delivery of the head
Promotes neck extension so that the smallest diameter of the head passes through the introitus
Modified Ritgen Maneuver
Attendant does not touch perineum during delivery of the head
Compared with traditional perineal support, does not appear to offer greater third degree laceration protection
Hands-poised method
Done after fetus had undergone restitution and external rotation to transverse position and shoulders appear at the vulva
Hooking fingers in the axillae is avoided
Shoulder delivery
Anterior fetal shoulder becomes wedged behind symphysis pubis and fail to deliver using normally exerted downward traction and maternal pushing
Shoulder dystocia
Removing legs from stirrup and flexing the thighs up unto the abdomen also providinf suprapubic pressure
McRoberts maneuver
Hand is placed behind posterior shoulder and shoulder rotated 180 degrees until anterior shoulder is released
Woods corckscrew maneuver
Cephalic replacement into the pelvis followed by CS
Terbutaline 0.25 mg is given SQ to induce uterine relaxation
Zavanelli maneuver
Shoulder-to-shoulder diameter is aligned vertically then accessible shoulder is pushed toward anterior chest of wall of the fetus
Rubin maneuver
Third stage of labor
Placental delivery
Uterotonic administration
Signs of placental separation
Globular and firmer uterus
Sudden gush of blood into the vagina
Uterus rises in abdomen
The umbilical cord protruding further out the vagina
Downward pressure above symphysis pubis while pushing uterus cephalad when with delayed placental separation
Kristeller’s maneuver
First 1 hr after delivery
Repair of lacerations
WOF postpartum hemorrhage
Fourth stage of labor
Superficial tear involving skin and mucous membrane, fourchette and periurethral skin
First degree
Tears extend into fascia and muscles
Bulbocavernosus and superficial transverse perineal
Forms irregular triangle due to extension upward and one or both sides
Second degree
Extends into or through external anal sphincter
Third degree
Extension into anorectal muscle with disruption of both external and internal anal sphincter
Fourth degree
More hemorrhage
Cuts through blood vessels
Less severe extension to anorectal area as sole advantage
Mediolateral ep
Two most important discriminators of risk for both mother and infant using forceps delivery
station
rotation
Outlet - scap visible
Low - + 2 head station
Mid - 0 + 2 head station
High - no place in modern OB
A persistent occiput posterior
Transverse position of fetus
use
Forceps
Indications for forceps delivery
Maternal heart disease Pulmo compromise Intrapartum infection Neurologic conditions Maternal exhaustion Non-reassuring fetal heart rate pattern Premature placental separation and prolonged second stage of labor (most common) prolonged by regional anesthesia
Forceps with fenestrated blades
Best used for delivery of molded head
Curved blade fits the pelvis
Common in nulliparous
Simpson of Elliot forceps
Also used for molded head but ideal for head rotation because of no pelvic curvature
No fenestration in central opening
Kielland forcep
Best used for rounded head because of its thin, smooth blades
Tucker-Mclane forceps
Maternal morbidity from forceps delivery
Postpartum urinary retention
Bladder dysfunction
Urinary fecal and flatus incontinence
Fetal morbidity following forceps delivery
Facial nerve palsy
Skull fracture
Intracranial hemorrhage
Same indications as forceps but cannot be used for face presentation or fetal coagulopathy (use forceps)
Rigid or soft cup places 3cm in front of posterior fontannel centering sagittal sutures
Vacuum generated from machine slowly up to 600mmHg creating chignon or artificial caput on feral head
Vacuum extraction
Abandon when no descent of head despite adequate traction or if cup dislodges 3x
Vacuum extraction complications mostly fetal
Scalp laceration Bruising Subgaleal hematoma Cephalhematoma ICH
Most common breech presentation in delivery
Frank breech (buttocks)
Breech predisposing factors
Oligohydramnios/Polyhydramnios High parity Multiple fetus Preterm fetus - most common Fetal malformation - 17% preterm and 9% term Uterine anomalies or fibroids Placenta previa Fundal placement implantation Pelvic tumors High parity with uterine relaxation Prior breech delivery
Lower extremities are flexed at hips
Knees extended
Pike position feet lie beside the head
50-70%
Frank breech
One or both knees flexed
Flexed at hips against the abdomen with one or both knees flexed
Buddah position
Cannonball position
5-10%
Complete breech
One or both hips extended and one or both feet or knees lies below the breech such that foot or knee is lowermost in the birth cana
Footling
10-30%
Incomplete breech
Single footling - one leg extended and the other flexed
Double - both legs extended below level of buttocks, possible risk of umbilical cord accident
Breech may be delivered vaginally
Frank
Complete
More common in breech presentation
Umbilical cord prolapse
CS indications
Large fetus >4000 g Any degree of pelvic contraction (platypelloid, android) Hyperextended head (stargazer fetus) Uncontrolled pre-eclampsia Uterine dysfunction Incomplete or footling breech PPROM Severe FGR Previois perinatal death from birth trauma
Spontaneous delivery up to umbilicus and rest of the fetal body is delivered with assisted maneuvers and traction
Most commonly employed
Avoids prolonged cord compression
Partial breech extraction
Done in footling breech
Total breech delivery
Delivery of the aftercoming head with fetal head being delivered, flexion of the head is maintained by suprapubic pressure provided by an assistant
Pressure on maxilla is applied simultaneously by the operator as upward and outward traction
Breech
Mauriceau Maneuver
Used for persistent backdown fetuses
2 fingers grasping the fetal shoulders from below while the feet are drawn upward up towards the maternal abdomen
Modified Prague Maneuver
Use of forceps when Mauriceau and Prage fails
Piper of Laufe forceps
Decomposes breech
Pinard’s maneuver
Performed when there is entrapment of aftercoming head and gentle traction on the fetal body does not help occiput slip out
2 oclock
10 oclock
6 oclock incisions
Duhrssen incision
