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Lecture 55
Obstetrics and Gynecology
Obesity
Diabetes
A history of a
macrosomic infant
A history of prior
shoulder dystocia
Shoulder Dystocia Diagnosis
By a prolonged second stage of labor, recoil of the
perineum (“turtle sign”), and lack of spontaneous
restitution.
Shoulder Dystocia Treatment
In the event of dystocia, be the mother’s HELPER:
Help reposition.
Episiotomy.
Leg elevated (McRoberts’ maneuver).
Pressure (suprapubic).
Enter the vagina and attempt rotation (Wood’s
screw).
Reach for the fetal arm.
23 year old G2P1 delivering 42 weeks gestational, is noted to
be in second stage when fetus head is retracted back to the
introitus. The shoulder is not deliver with the push of the
mother. Which of the following maneuvered is best?
Physical
Sterile vaginal speculum exam
Minimize digital examination of cervix, regardless of gestational age, to
avoid risk of ascending infection/amnionitis
Assess cervical dilation and length
Obtain cervical cultures (Gonorrhea, Chlamydia)
Obtain amniotic fluid samples
Findings
Pooling of amniotic fluid in posterior vaginal fornix
Fluid per cervical os
PROM/PPROM: Diagnosis
Test
Nitrazine test
Fluid from vaginal exam placed on strip
of nitrazine paper
Paper turns blue in presence of alkaline
(pH > 7.1) amniotic fluid
Fern test
Fluid from vaginal exam placed on slide
and allowed to dry
Amniotic fluid narrow fern vs. cervical
mucus broad fern
PROM/PPROM: Diagnosis
False positive Nitrazine test
Alkaline urine
Semen (recent coitus)
Cervical mucus
Blood contamination
Vaginitis (e.g. Trichomonas)
Patient counseling
Expectant management vs. induction of labor
GBS prophylaxis NOT recommended
Antibiotics
Incomplete data
Corticosteriods NOT recommended
Management: PPROM
(< 24 wk gestation – “previable”)
Patient counseling
Outcomes at 18 to 22 Months Corrected Age*
Gestational Age
Death Before Death/ Profound
(In Completed Death/Moderate to Severe Neuro-
NICU Discharge Death Neurodevelopmental
Weeks) developmental Impairment
Impairment
Expectant management
Deliver at 34 wks
Unless documented fetal lung maturity
GBS prophylaxis
Antibiotics
Corticosteroids
No consensus, some experts recommend
Management: PROM
(> 34 wk gestation)
Proceed to delivery
Induction of labor
GBS prophylaxis
Management: Amniocentesis
Typically performed after 32 wks
Tests for fetal lung maturity (FLM)
Lecethin/Sphingomyelin ratio (not
commonly used, more for historic interest)
L/S ratio > 2 indicates pulmonary maturity
Phosphatidylglycerol
> 0.5 associated with minimal respiratory
distress
Flouresecence polarization (FLM-TDx II)
> 55 mg/g of albumin
Lamellar body count
30,000-40,000
If negative, proceed with expectant
management until 34 wks
Preterm Labor
External version
a. Labor allowed
b. Labor allow, low forceps/vacuum to shorten the 2nd
stage
c. Caesarian section near prior term of labor
d. Oxitoxin at 38 weeks
e. Caesarian section at 40-41 week
The best pregnancy management of a 40 years old
nullipara, prior myomectomy during which the
endometrial cavity was anterior:
a. Labor allowed
b. Labor allow, low forceps/vacuum to shorten the 2nd
stage
c. Caesarian section near prior term of labor
d. Oxitoxin at 38 weeks
e. Caesarian section at 40-41 week
Complications
INTRAOPERATIVE
Bleeding & the need for transfusion
Hysterectomy
Complications of anesthesia
Damage to the bladder, ureter, colon , retained placental tissue
Fetal injury
POSTOPERATIVE
Gaseous distension
Paralytic ileus
Wound dehiscence & infection
DVT & pulmonary embolism
Vesico uterine fistula
A 32 year old woman gravid 3 para 3 just delivered a viable female
infant weighting 4000 grams via cesarian section for nonreassuring
fetal heart rate pattern, she received intrathecal spinal anesthetic
and nacratic for pain relief during the procedure, her foley
catheter is left in place for several hours after the cesarian section
this will prevent?
a.stress incontinence
b.urge incontinence
c.overflow incontinence
d.mixed incontinence
e.preoperative urinary tract infection
A 32 year old woman gravid 3 para 3 just delivered a viable female
infant weighting 4000 grams via cesarian section for nonreassuring
fetal heart rate pattern, she received intrathecal spinal anesthetic
and nacratic for pain relief during the procedure, her foley
catheter is left in place for several hours after the cesarian section
this will prevent?
a.stress incontinence
b.urge incontinence
c.overflow incontinence
d.mixed incontinence
e.preoperative urinary tract infection
Post natal care
Blood loss must be monitored
Uterine fundus palpated
Effective parenteral analgesics
Deep breathing & coughing encouraged
Early mobilization
Fluid therapy &diet
Bladder & bowel function
Wound care
Breast care
Prophylaxis for thromboembolism
Mode of delivery in next pregnancy
Criteria for VBAC
Patient must agree to the procedure
A low transverse uterine incision
Non recurrent cause of the previous CS
No macrosomia, malposition, multiple gestation, breech
Uterine Atony
Genital tract trauma
Retained placental tissue
Diagnosis:
Palpation of a soft, enlarged, “boggy” uterus.
The most common cause of postpartum hemorrhage (90%).
Treatment:
Bimanual uterine massage (usually successful).
Oxytocin infusion.
Methergine (methylergonovine) if not hypertensive.
Prostaglandin (PGF2a).
Genital Tract Trauma
Risks:
Precipitous labor.
Operative vaginal delivery (forceps, vacuum extraction).
Large infant.
Inadequate episiotomy repair.
Diagnosis:
Manual and visual inspection of the lower genital tract for
any laceration > 2 cm long.
Treatment:
Surgical repair of the physical defect.
Retained Placental Tissue
Risks:
Placenta accreta/increta/percreta.
Placenta previa.
Uterine leiomyomas.
Preterm delivery.
Previous C-section/curettage.
Diagnosis:
Manual and visual inspection of the placenta and uterine cavity for
missing cotyledons.
Ultrasound.
Treatment:
Manual removal of remaining placental tissue.
Curettage with suctioning.
Postpartum Infections
Characterized by a temperature ≥ 38°C for at least two
of the first ten postpartum days (not including the first
24 hours).
Postpartum Infections Risk Factors
Emergent C-section
PROM
Prolonged labor
Multiple intrapartum vaginal exams
Intrauterine manipulations
Young age
Prolonged ruptured membranes
Bacterial colonization
Corticosteroid use
Postpartum Infections