Published on August 26, 2007
Slide1: Dystocia Fetal Causes and Position of the Woman Fetal Causes: Fetal Causes Maybe caused by: Anomalies Excessive fetal size Malpresentation Malposition Multifetal pregnancy Complications: Complications Neonatal asphyxia Fetal injuries or fractures Maternal vaginal lacerations Anomalies: Anomalies Gross ascites Large tumors Open neural tube defects Myelomeningocele Hydrocephalus Cephalopelvic Disproportion: Cephalopelvic Disproportion Also called Fetopelvic disproportion (FPD) Often associated with Macrosomia Excessive fetal size (4000g or more) Associated with: Maternal DM Obesity Multiparity Large size of one or both parents Can be also due to maternal pelvis is too small, abnormally shaped or deformed Malposition: Malposition Most common: Persistent Occipitoposterior Position Manifestations: Prolonged labor (especially 2nd stage) Mother complains of severe back pain the pressure of the fetal head pressing against her sacrum Slide7: Management: Management Pain Back rub Change of Position Application of heat or cold Fetal Rotation Assist px to lie on side opposite of fetal back or Maintain Hands-Knees Position Void every 2 hours Keep bladder empty Malpresentation: Malpresentation 3rd most commonly reported complication of labor and birth Highest incidence rate: women 40-54 y/o Most common form: Breech presentation 4 main types: Frank Breech Complete Breech Incomplete Breech A Incomplete Breech B FHR best heard at or above the umbilicus Slide10: Thighs flexed, knees extended Slide11: Thighs flexed, knees flexed Slide12: Foot extends below the buttocks Causes: Causes Multifetal gestation Preterm birth Fetal and maternal anomalies Hydramnios Oligohydramnios Diagnosis Abdominal palpation Vaginal exam UTZ Slide14: Delivery Piper forceps To deliver the head External cephalic version To turn fetus to a vertex presentation CS may be necessary Commonly performed when the fetus is estimated andgt;3800g or andlt;1500g Usually necessary for fetus in shoulder presentation Slide15: Other forms: Face Brow Shoulder Dystocia: Shoulder Dystocia There are two main signs that a shoulder dystocia is present: The baby's body does not emerge with standard moderate traction and maternal pushing after delivery of the fetal head. The 'turtle sign'. the fetal head suddenly retracts back against the mother's perineum after it emerges from the vagina. baby's cheeks bulge out, resembling a turtle pulling its head back into its shell. caused by the baby's anterior shoulder being caught on the back of the maternal pubic bone, preventing delivery of the remainder of the baby. Slide17: Slide18: Multifetal Pregnancy: Multifetal Pregnancy Gestation of twins, triplets, quadruplets, or more infants Rapid escalation of incidence since 1980 was likely related to: use of fertility-enhancing meds and procedures Older age of childbearing women 35yrs and older are much likely to have multifetal pregnancy Complications: Complications Fetal distress and asphyxia Umbilical Cord prolapse Onset of early placental separation Risk for long term problems such as Cerebral palsy Slide21: Assessment: Assessment Always assess fetal heart sounds immediately after rupture of the membranes occurring either spontaneously or by amniotomy To rule out cord prolapse Management: Management Labor Instruct to come in hospital earlier Assess HCT and BP closely Relieve pressure on cord Gloved hand in vagina, manually elevating the fetal head off the cord Place woman into knee-chest or Tredelenburg position Oxygenation 10LPM Tocolytic agent Reduce uterine activity Do not attempt to push any exposed cord back into vagina Position of the Woman: Position of the Woman Can either provide mechanical advantage or disadvantage to the mechanisms of labor Altering effects of gravity Body-part relations Standing: Standing Advantages Excellent for oxygenation of fetus Uses gravity Contractions are more effective and less painful Helps speed up labor Helps create pushing urge Disadvantages Poor control of delivery Visualization very hard for birth attendant Walking: Walking Advantages Uses gravity Contractions often less painful Encourages uterine contractility Baby well-aligned in pelvis May speed up labor Reduces backache Encourages descent Disadvantages Often mother can't use if she has high blood pressure Can't be used with continuous electronic fetal monitoring Sitting: Sitting Advantages Good for resting Uses gravity Can be used with continuous electronic monitoring Can be used with birth ball to encourage descent Disadvantages Possibly can't be used if mother has high blood pressure Sitting on Toilet: Sitting on Toilet Advantages Helps relax perineum Mother accustomed to open-leg position and pelvic pressure in this environment Uses gravity Disadvantages Pressure from toilet seat can cause pain Semi-sitting: Semi-sitting Advantages Comfortable for mother Good use of gravity Good resting position Works well in hospital beds Good visibility at delivery for mom, dad and others present Good access to FHTs (Fetal Heart Tones) Disadvantages Access to perineum can be poor Mobility of coccyx is impaired Some stress on perineum, but less than lithotomy Lithotomy: Lithotomy Disadvantages Compression of all major vessels Laceration or need for episiotomy is more likely No use of gravity to aid delivery Side-Lying: Side-Lying Advantages Good fetal oxygenation Good resting position for mother Helpful if mother has elevated blood pressure Useful if mother has epidural anesthesia Often makes contractions more effective May promote progress of labor Easier for mom to relax between contractions during second stage Allows posterior sacral movement in second stage Can slow precipitous delivery Partner may need to support leg Partner can assist in delivery Lowers chance of laceration or need for episiotomy Access to perineum is excellent Disadvantages Access to FHTs poor if mother is lying on same side as baby’s back No help from gravity Mother must support her leg under knee if no one is there to hold leg Mother may feel too passive Leaning: Leaning Advantages Great for rotation of posterior presentation Uses gravity Contractions often less painful Contractions often more productive Baby is well-aligned in pelvis Relieves backache Facilitates use of back pressure May be more restful than standing Disadvantages Hard for attendant if used at delivery Kneeling, Leaning Forward w/ Support: Kneeling, Leaning Forward w/ Support Advantages Helpful with persistent posterior presentation Assists rotation of baby Good for pelvic rocking Good for use with birth ball Less strain on wrists and arms Squatting: Squatting Advantages Encourages rapid descent Uses gravity May increase rotation of baby Allows freedom to shift weight for comfort Excellent for access to the perineum Excellent for fetal circulation May increase pelvis diameter by as much as two centimeters Requires less bearing-down effort Upper trunk presses on fundus to encourage descent Thighs keep baby well-aligned Disadvantages Often tiring to mother Sometimes hard to hear FHTs May be hard for mother to assist in delivery Hands and Knees: Hands and Knees Advantages Good for bradycardia (low heart tones) Good for back labor Useful with birth ball Assists with rotation of posterior presentation Takes pressure off hemorrhoids Best position to avoid laceration or need for episiotomy Good delivery position for large baby Excellent for shoulder dystocia Disadvantages Hard to maintain eye contact with mother Hard for mother to see Baby must be passed through mother’s legs Can be disorienting to inexperienced attendant.