Term
| Friedman’s Criteria for phases/stages of labor |
|
Definition
First Stage of Labor is divided into Latent and Active phase
● Latent phase - is the beginning of contractions which may be irregular or in a pattern and slow minimal cervical change. (Friedman based this on duration not dilation)
○ Nulliparas - < 20 hours
○ Multiparas - < 14 hours
● Active phase - begins with the rate of dilation increases. (Friedman chose the arbitrary number of 3cm but admitted it was not accurate to base this labor phase on dilation because it was different with different women)
○ Nulliparas - should dilate at least 1.2 cm/hr
○ Multiparas - should dilate at least 1.5 cm/hr
Second Stage of Labor - begins when the cervix is completely dilated and ends with the birth of the baby.
● Active descent begins during the deceleration phase.
○ Nulliparas - should have a descent of 1 cm/hr
○ Multiparas - should have a descent of 2 cm/hr
According to Friedman protracted and/or arrested descent can only be diagnosed in Second Stage. |
|
|
Term
| Friedman's Arrest Disorders were comprised of what criteria |
|
Definition
○ no dilation for 2 hours during First Stage Active Phase.
○ no descent for 1 hour during Second Stage |
|
|
Term
| contemporary research describes the stages of labor as |
|
Definition
First Stage of Labor
● Latent phase - no set time restriction
● Active phase - usually begins for most women at approximately 5 - 6 centimeters. This is considered active only when there is active contractions and active dilation.
○ Nulliparas - should dilate 0.3 - 0.5 cm/hr or 0.5 - 0.7 cm/hr
○ Multiparas - should dilate 0.5 - 1.3 cm/hr
It is considered not uncommon for women to have no cervical change in a 2 hour period, and also found faster dilation as labor progresses.
Second Stage of Labor - begins with Ferguson’s Reflex (The urge to push) |
|
|
Term
| that a diagnosis of protracted labor or labor arrest not be made before the women is |
|
Definition
|
|
Term
| When do experts reccomend a cesarean be considered? |
|
Definition
● Cervical dilation of at least 6 centimeters
● Ruptured Membranes
● No cervical change in 4 hours with adequate uterine activity or
● At least 6 hours of Pitocin when unable to attain adequate uterine activity |
|
|
Term
| List possible complications associated with augmentation of labor with oxytocin |
|
Definition
● Uterine Tachysystole (hyperstimulation - too many contractions)
● Fetal Heart Rate decelerations - caused by disruption in fetal oxygenation (Bradycardia, prolonged bradycardia, late decelerations, repetitive late decelerations)
● Uterine Rupture - in extreme cases - usually prior uterine injury or C/S |
|
|
Term
| AMOL is associatied with a decreased |
|
Definition
|
|
Term
| Possible indications for Induction |
|
Definition
| Abruptio placenta, chorioamnionitis, fetal demise, PROM, postterm, maternal medical condition (diabetes, renal disease, chronic pulm. disease, chronic HTN, antiphospholipid syndrome), fetal compromise (severe FGR, isoimmunization, oligo), preeclampsia, eclampsia, gest diabetes |
|
|
Term
| Contraindications for induction |
|
Definition
| : Vasa previa or complete placenta previa, transverse fetal lie, umbilical cord prolapse, previous transfundal uterine surgery (classical uterine incision), previous myomectomy entering endometrial cavity, active genital herpes outbreak |
|
|
Term
| Clinical considerations which are not absolute contraindications to IOL include |
|
Definition
| One or more previous low-transverse c/sections, breech presentation, maternal heart disease, multifetal pregnancy, polyhydramnios, presenting part above pelvic inlet, severe HTN, abnormal fetal heart rate patterns not necessitating emergent delivery. |
|
|
Term
| List possible complications associated with oxytocin when used for induction of labor. |
|
Definition
| tachysystole and water intoxication |
|
|
Term
| 5. Discuss use of PGE2 (dineprostone) and PGE1 (misoprostol) for cervical ripening including side effects, effectiveness in achieving vaginal delivery within 24 hours and cesarean section rates. |
|
Definition
● increase likelihood of vag delivery within 24 hours
● do not reduce rate of c/section
● increase risk of uterine tachysystole with assoc FHR changes |
|
|
Term
| 1. Discuss the diagnostic criteria for preterm labor. |
|
Definition
| regular uterine ctx that cause cervical change and a cervix which is at least 2-3cm dilated, 80% effaced, ruptured membranes, or bloody show |
|
|
Term
| 2. Why is preterm labor difficult to diagnose |
|
Definition
| 1. Because many women experience preterm contractions without significant cervical change as well as back pain, pressure, and menstrual like cramps which occur normally in pregnancy |
|
|
Term
| less than 10% of women who present with preterm ctx will acutally |
|
Definition
| give birth within the next 7 days |
|
|
Term
| 3. What is the role of fetal fibronectin in diagnosing preterm labor |
|
Definition
| 1. A Negative fetal fibronectin in combination with adequate cervical length is strongly predictive of no preterm birth and can help prevent further unnecessary interventions. |
|
|
Term
| 4. What is the role of sonographic measurement of cervical length in diagnosing preterm labor? |
|
Definition
| if it is short and the FFN is positive, strong indication of possible delivery in 7-14 days, if cervical length simple begins to decrease this is also an indication, and a cervical length that is shorter than 25mm is a strong indication that delivery will occur prior to 35wks |
|
|
Term
| know the fx and side effects of Beta-mimetics (ritodrine and terbutaline) |
|
Definition
smooth muscle relaxer
Side Effects:
1. Maternal: CV-flushing, tachy, palpitations, hypotension, arrythmia, chest pain, myocardial ischemia, SOB, PULMONARY EDEMA, ARDS. Metabolic-hyperglycemia, hypokalemia. Nervous, N/V
2. Fetal: Tachycardia, hyperinsulinemia, fetal hyperglycemia, neonatal hypoglycemia, hypotension, ileus |
|
|
Term
| know the mech of action of Calcium channel blockers (nifedipine) |
|
Definition
| Promote uterine relaxation by decreasing influx of Ca+ into uterine muscle cells (inhibits MLCK) |
|
|
Term
| what are the side effects of CCB (nifedipine) |
|
Definition
1. Maternal-transient hypotension, tachycardia, HA, flushing, dizziness, N, palpitations, edema
2. Fetal: NONE |
|
|
Term
| know the MOA of Prostaglandin inhibitors (indomethacin) |
|
Definition
| Reducing synthesis of prostaglandins (inhibits COX, an enzyme responsible for the formation of specific prostaglandins |
|
|
Term
| what are the side effects of Prostaglandin inhibitors (indomethacin) |
|
Definition
1. Maternal-Gastritis, N, proctitis with hematochezia, impaired renal fxn, increased pp hemorrhage, hypertension, platelet dysfunction
2. Fetal-Oligohydramnios, premature constriction of ductus arteriosus, NEC, intraventricular hemorrhage |
|
|
Term
| what is the MOA of MgSO4? |
|
Definition
| hyperpolarizing plasma membrane and competes with intracelluar Ca+ to inhibit MLCK activity. |
|
|
Term
| what are side effects of MgSO4? |
|
Definition
1. Maternal- Flushing, N/V, diplopia, blurred vision, HA, lethary, ileus, hypocalcemia, muscle weakness, pulmonary edema, cardiac arrest
2. Fetal-decreased FHR variability, hypotonia, lethargy, bone demineralization |
|
|
Term
| what are the benefits of steriod use in PTL? |
|
Definition
| acceleration of fetal lung maturity, decrease chance of NEC, respiratory distress, intracrainial hemorrhage, early systemic infections, and neonatal death |
|
|
Term
| what are risk of using steriods during PTL? |
|
Definition
| Maternal glucose intolerance and pulmonary edema. Repeated doses may lead to reduced birth weight and head circumference. |
|
|
Term
| Should repeated courses of steroids be used? |
|
Definition
No, not within 7days of initial tx
-may be repeated once more if two weeks has passed and if less than 33wks and there is a strong belief that pt will delivery within 7days |
|
|
Term
| Should steriods be used with preterm PROM? |
|
Definition
| Single course for prom 24-32 weeks and with no evidence of chorioamionitis. (use btn 32-34 undecided, none before 24 weeks) |
|
|
Term
| what are the fetal complications associated with late-term and postterm pregnancy? |
|
Definition
| Neonatal convulsion, meconium aspiration syndrome, 5 min APGAR <4, increased rates of NICU admission, macrosomia, oligohydramnios, stillbirth, neonatal mortality, Birth asphyxia, Neonatal encephalopathy, Use of anticonvulsants, Pneumonia, Neurodevelopment at childhood follow-up, & Postmaturity syndrome |
|
|
Term
| what are the maternal risk associated with post term pregnancy? |
|
Definition
| Severe perineal lacerations, infection, pp hemorrhage, c/s, maternal anxiety. Mode of birth (caesarean section, vaginal), Operative vaginal birth (forceps or ventouse), Analgesia used, Prolonged labour, & Postnatal depression |
|
|
Term
| Define active management of labor |
|
Definition
● No admission until in active labor
● Continual support by a midwife
● Strict protocols for labor progress and interventions used in absence of progress.
○ Less than 1 centimeter per hour - Interventions begin
■ Amniotomy
■ High Dose pitocin begun and increased every 15 mins |
|
|
Term
| . Uterine tissue relaxes when exposed to |
|
Definition
|
|
Term
| prostaglandins are always |
|
Definition
| present in the myometrium |
|
|
Term
| when are oxytocin receptors present? |
|
Definition
| just prior and during labor |
|
|
Term
| when are oxytocin receptors present? |
|
Definition
| just prior and during labor |
|
|
Term
| Define late-term and postterm pregnancy |
|
Definition
Late term: 41 0/7-41 6/7 weeks (287-293 days)
Post term: 42 0/7 + (294 or + days) |
|
|
Term
| ● labour induction in post-term pregnancies decreases the caesarean rate but leads to no difference in the incidence of perinatal mortality and morbidity when |
|
Definition
| expectant management is utilized |
|
|
Term
| ● routine labour induction at 41 completed weeks or later, compared with waiting for the onset of labour for at least one week is associated with |
|
Definition
| fewer perinatal deaths and meconium aspiration syndrome |
|
|
Term
| when the fetus presents with flexion at knees and thighs (sitting crosslegged) |
|
Definition
|
|
Term
what is this fetal position?
flexion at thighs, knees extended (feet by head). Most common, ⅔ of all breech babies |
|
Definition
|
|
Term
| can be single or double, with extension at thighs and knees. Foot is the presenting part. Rare at term , more common if premature |
|
Definition
|
|
Term
| single or double, extension at thighs, flexion at knees. the knee is presenting part. very rare |
|
Definition
|
|
Term
| what are the possible complications associated with ECV? |
|
Definition
i. Abruption
ii. Fetal heart rate abnormalities
iii. Ruptured membranes
iv. Cord prolapse
● Alloimmunization or fetomaternal hemorrhage
● Potential labor |
|
|
Term
| what are the maternal risk for breech birth? |
|
Definition
i. Could turn into possible c/s
ii. Higher risk for cervical or vaginal lacerations
iii. Manipulations may also extend an episiotomy, create deep perineal tears, and increase infections risks |
|
|
Term
| what are the fetal risk of an ECV? |
|
Definition
i. birth through undilated cervix- body may fit through the cervix before complete dilation leading to early urge to push and entrapment of fetal parts.
ii. Arrest of aftercoming head
iii. Cord prolapse & Early ROM
iv. Cord compression
v. Aspiration
vi. Rapid compression & Decompression of the head
vii. Birth injuries due to maneuvers to deliver breech baby |
|
|
Term
| review the suggested guidelines for consideration of vaginal breech birth |
|
Definition
1. Term, uncompromised baby
2. EFW less than 4000Gm
3. Frank or complete breech presentation
4. Head flexed and normal size
5. adequate pelvic measurements
6. Spontaneous onset of labor and normal progress of labor |
|
|
Term
| Guidelines for breech labor management: |
|
Definition
1. Maintain intact membranes as long as possible
2. Expect steady progress- if arrest of labor abort plans for vaginal breech- steady progress is the best indicator of adequate fetal-pelvic proportions
3. Make sure the cervix is fully dilated
4. Enable the mother to reach 2nd stage physically and psychologically ready with the ability to push and birth the baby on her own
5. Insure empty bladder
6. Adopt a position comfortable for mother to push effectively (AVOID hands and knees position as this will encourage extension of the head!!) Best position is at the edge of bed to assist with birth.
7. Keep hands OFF presenting part (touching the baby could cause gasping and traction on the fetus can cause extension of the head and difficult delivery.
8. Do NOT speed delivery
9. Be aware of time but be patient
10. From umbilicus to airway should not exceed 5 minutes
11. Unnecessary interventions increase the risk in breech births however, most breeches are assisted. Avoid maneuvers not needed
12. Continuous EFM is preferable in the 1st stage and mandatory in the 2nd
13. When membranes rupture, immediate vaginal exam is recommended to r/o prolapse
14. Induction of labor is not recommended however, oxytocin augmentation is acceptable in the presence of uterine dystocia
15. A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended.
16. The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary
17. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery |
|
|
Term
| Contraindications to vaginal breech birth |
|
Definition
a. cord presentation
b. Fetal growth restriction or macrosomia
c. Any presentation other than frank or complete breech with a flexed or neutral head attitude
d. Clinically inadequate maternal pelvis
e. Fetal anomaly incompatible with vaginal delivery |
|
|
Term
| Head is hyperextended, occiput is in contact with fetal back |
|
Definition
|
|
Term
| 1. Identify the presenting part, attitude, denominator, and presenting fetal diameter for face presentation |
|
Definition
Presenting part: face
Attitude: complete extension
Denominator: chin |
|
|
Term
| Identify the presenting part, attitude, denominator, and presenting fetal diameter for military presentation. |
|
Definition
Presenting part: vertex
Attitude: neither flexion nor extension, occiput and brow are at the same level in pelvis
Denominator: occiput |
|
|
Term
| Identify the presenting part, attitude, denominator, and presenting fetal diameter for brow presentations. |
|
Definition
Presenting part: area between orbital ridges and bregma
Attitude: partial (halfway) extension
Denominator: forehead |
|
|
Term
| Discuss implications of persistent brow presentations. |
|
Definition
● Position is usually transitory
● Head either flexes to occiput presentation or extends to become face presentation
● Most do not deliver spontaneously
● Failure to recognize problem results in prolonged/traumatic labor
● Passage through pelvis slower, harder
● Perineal laceration inevitable and can extend into vaginal fornices/rectum due to large diameter of head compared to outlet
● Mortality rate is high in fetus
● Excessive molding can cause brain damage
● Mistakes in diagnosis/treatment are main causes of poor fetal prognosis |
|
|
Term
| 2. Discuss implications of persistent military presentations. |
|
Definition
● Labor little longer
● Labor little harder
● Prognosis reasonably good
● Many cases flex and proceed to normal delivery |
|
|
Term
| 3. Identify the mechanisms of labor for face presentation. |
|
Definition
Extension
● Head does not flex
● Head extends and leads the way
Descent
● Slow and late
● Head does not settle into pelvis until ROM and cervix fully dilated
Internal Rotation
● Forehead rotates 45 degrees anteriorly so face comes to lie behind symphysis
● Considerable amount of internal rotation must take place between ischial spines and tuberosities
Flexion
● Face impinges under pubis
● Head pivots
● Bregma, vertex & occiput born over perineum
Extension
● Head falls back into extension
● Mouth, nose, chin slip under symphysis
Restitution
● Neck untwists
● Head turns 45 degrees back to original side
External Rotation
● Shoulder rotates anteriorly from oblique to anteroposterior diameter of pelvis
● Head turns back another 45 degrees
Molding elongates head in anteroposterior diameter, flattening from above downward, forehead/occiput protrude |
|
|
Term
| cardinal movements for LMA: |
|
Definition
EXTENSION: The head does not flex - it extends resulting in either RMA or LMA (Instead of LOP or ROP). baby enters the pelvis chin first with a presenting diameter of around 9.5 cm
DESCENT: Since chin is leading, engagement takes place in the Right oblique diameter of the pelvis. Descent is slower than in flexed attitudes. face will be low in pelvis before biparietal diameter passes the brim.
INTERNAL ROTATION: with descent and molding the chin reaches the pelvic floor where it is directed down, forward, and medially. Baby rotates 45 degrees anteriorly toward the symphysis (LMA to MA). The long axis of the face is then in the anteroposterior diameter of the pelvis. Shoulders are still in oblique diameter(neck is twisted 45 degrees). THE CHIN MUST ROTATE ANTERIORLY (UNDER THE SYMPHYSIS) OR SPONTANEOUS DELIVERY IS NOT POSSIBLE! This does not happen until late in labor - don’t give up too soon!
FLEXION: Head is born by flexion. Chin, mouth, nose, and eyes “crown” and the submental portion of the neck is impinged at the symphysis pubis. Due to the curvature of the pelvic opening the head flexes forward (Up toward the SP) and is pivoting. When head is out the head falls back (gravity).
RESTITUTION: As head is released, neck untwists and the chin turns back the 45 degrees toward the original side.
EXTERNAL ROTATION: As anterior shoulder reaches the pelvic floor it rotates toward the symphysis (bringing the bisacromial diameter from the oblique to the AP diameter of the pelvic outlet). chin rotates another 45 degrees in line with shoulders.
MOLDING will lead to an elongated head in its AP diameter, with a flattened appearance and forehead and occiput protruding. Will last 24+ hours and head will go to “normal”. |
|
|
Term
| review cardial movements for LMT |
|
Definition
Extension: Instead of flexion to ROT, extension to LMT
Descent: Engagement takes place in the transverse diameter of the pelvis. SLOW!!
Internal Rotation: Chin rotates anteriorly to the midline (LMT to LMA to MA)
Then steps are the same as for LMA |
|
|
Term
| ● An extremity prolapses alongside the presenting part and both present simultaneously in the pelvis |
|
Definition
|
|
Term
| 2. Recognize maternal and fetal predisposing factors for compound presentation. |
|
Definition
● Any condition that prevents filling and occlusion of the pelvic inlet by the presenting part
● Prematurity most common
● High presenting part with ROM
● Polyhydramnios
● Multiparity
● Contracted pelvis
● Pelvic mass
● Twins
● More common with labor involving floating presenting parts
● External cephalic version (fetal limb can become “trapped” before fetal head) |
|
|
Term
| 3. Describe intrapartum midwifery management of compound presentations. |
|
Definition
● Prolapsed part should be left alone
● If arm prolapsed alongside head, condition observed closely to see if arm retracts out of way or if it appears to prevent descent of head
● If fails to allow descent of head or presenting part, gently push upward on arm/hand while fundal pressure to head provided simultaneously downward
● Risk for ischemic necrosis for presenting part if arm/hand
● In absence of other complications and with conservative management results no worse than with other presentations
● Risk of arrested progress is greater
● Masterful inactivity is best treatment
● As long as progress being made, no interference needs to happen
● C/S if reposition not possible or other condition prevents vag delivery |
|
|
Term
| Discuss implications of fetal growth restriction (FGR) on intrapartum care. |
|
Definition
● Common result of placental insufficiency from faulty maternal perfusion
● Can be aggravated by labor
● Diminished AFI increases likelihood of cord compression
● Should undergo “high-risk” intrapartum monitoring
● Incidence of C/S increased
● Increased risk of being born hypoxic or with meconium aspiration
● Severely FGR at risk for hypothermia, hypoglycemia |
|
|
Term
|
Definition
| ● fetal macrosomia is suspected when the fetal weight estimate is >5000 g and is diagnosed when the birth weight is >4500 g. |
|
|
Term
| the practitioner attempts to abduct the posterior shoulder by exerting pressure on to the anterior surface of the posterior shoulder. |
|
Definition
| Woods’ corkscrew maneuver |
|
|
Term
| pressure is applied to the posterior surface of the most accessible part of the fetal shoulder (ie, either the anterior or posterior shoulder) to effect shoulder adduction. |
|
Definition
| the Rubin’s (reverse Woods’) maneuver |
|
|
Term
| The Mauriceau-Smellie-Viet Maneuver for breech delivery |
|
Definition
a. With the baby resting on your dominant forearm, reach that hand up into the vagina. Place the middle finger into the baby’s mouth and place the 1st & 3rd finger on the miller processes (Cheekbones) on either side of the baby’s nose. The other hand placed over the baby’s back with the 1st & 3rd fingers hooked over the shoulders. Try to distance your fingers from the neck where nerve damage is a risk. The middle finger should be extended to press on the occiput The head can be flexed with upward pressure on the occiput and downward traction on the maxilla. Do not pull on the mandible which will not affect flexion, but will only open the mouth.
b. The head can then be delivered by rotating the head upward and proceeding to clear the airway and have the mother breathe the head out slowly |
|
|
Term
| 9. Use the Burns Maneuver to deliver the head during a breech birth |
|
Definition
a. Grab the baby by the feet keeping stretched
b. The baby is then lifted upward so the occiput pivots under the pubic angle and the face is born
c. An assistant can support the baby’s body while you support the perineum and prevent the head from popping out
d. The baby’s airway can be cleared at this time
e. The head is delivered slowly |
|
|
Term
| Describe hand maneuvers for assisted breech birth. |
|
Definition
1. Keep hands off until the umbilicus is seen
2. Draw down a loop of cord
3. Place a warm towel around the body if the room is cool
4. When the scapula is visible, if there is delay, deliver the anterior arm. Run a finger up the back and down the arm to the bend in the elbow splinting the humerus with your finger, sweep the arm out across the chest
5. Lift the baby to deliver the posterior shoulder by lateral flexion or by sweeping arm across the chest.
6. To handle the baby safely, grasp the body by the pelvic girdle with thumbs on the sacrum and fingers on the iliac crests (be careful not to grasp the baby by pressure into the abdomen)
7. Allow the baby to hang while the mother pushes and the head descends. Suprapubic pressure by an assistant may help to maintain flexion
8. When the hairline is visible, the head has descended enough for the occiput to impinge under the pubic bone |
|
|
Term
| 11. Discuss success rates of external cephalic version and its impact on rates of cesarean section. |
|
Definition
increased parity, ample AFI, unengaged fetus, tocolysis
● Posterior placenta or complete breech more successful
● Reduced need for C/S if successful version
● Twofold increase in intrapartum C/S despite external version |
|
|
Term
| ECV not as successful when the following things are present |
|
Definition
| engaged presenting part, difficult palpation of head, uterus tense to palpation, maternal obesity, anterior placenta, cervical dilation, fetal spine in anterior/posterior position, labor |
|
|
Term
| 2. Recognize risk factors for and potential problems associated with transverse lie. |
|
Definition
● Uterine rupture
● Fetal death
● Cord prolapse |
|
|
Term
| 2. Describe intrapartum midwifery management of transverse lie. |
|
Definition
● Usually indication for C/S
● Attempts at external version are worthwhile in absence of other complications, must be done before ROM and before or in early labor, if fetal head can be maneuvered by abdominal manipulation into pelvis, hold there during next several contractions to attempt to fix head into pelvis
● Vertical incision may be indicated in C/S due to difficult fetal extraction |
|
|
Term
| Causes for deflexion attitudes (extension or hyperextension) |
|
Definition
● Fetal anomalies. The most common anomaly that causes face presentation is anencephaly. Anencephalic babies present face first because of the faulty development of the cranium. Tumors on the neck or back may also cause extension of the head.
● Pelvic contractures or android pelvis. Accounts for about 40% of face presentations.
● Fetopelvic disproportion
● Multiparity
● Preterm birth
● Polyhydramnios. When the membranes rupture the rush of fluid may cause the head to extend as it descends.
● Coils of umbilical cord around the neck. |
|
|
Term
| ● Risk factors for shoulder dystocia |
|
Definition
○ longer labors
○ rapid fetal descent
○ prolonged second stage
○ excessive weight gain
○ short stature
○ obesity
○ previous shoulder dystocia delivery
○ maternal diabetes leads to increased fetus size
○ maternal DM babies have shoulders that are bigger as compared to bodies of non-DM babies, different body configuration |
|
|
Term
| ● Maternal sequelae associated with shoulder dystocia |
|
Definition
○ increased risk for PPH
○ genital tract lacerations
○ symphyseal separation
○ uterine rupture (rare) |
|
|
Term
| ● Fetal sequelae associated with shoulder dystocia |
|
Definition
○ brachial plexus injury (4-21%)
○ permanent plexus dysfunction (<10%)
○ clavicle or humerus fractures
○ fetal hypoxia with/without permanent neurological damage
■ shoulder dystocia <5 minutes not associated with hypoxia unless nuchal cord is clamped and cut before delivery
○ fetal death (rare |
|
|
Term
| Steps to Deliver a Shoulder Dystocia: |
|
Definition
1. Moment shoulder dystocia is realized STOP pushing, assess position of shoulders by vag exam
2. If anterior shoulder impacted calmly & clearly state “I have a shoulder dystocia”
3. Request help (additional nurses, MD, NICU, anesthesia)
4. Place woman in McRoberts position, do not let woman push
5. Direct someone to perform suprapubic pressure at slight angle in between contractions
6. Combo of McRoberts and suprapubic pressure likely relieves most shoulder dystocias
7. Rubin’s maneuver: insert hand or as many fingers possible behind anterior shoulder on fetal back, try to rotate shoulder forward into oblique position (collapsing the shoulders move) to reduce bisacromial shoulder diameter, have woman push in coordination with hand rotation of shoulder and directed suprapubic pressure. If not working, do not repeatedly attempt (brachial plexus injury risk!)
8. Deliver posterior arm by hand in posterior aspect of vagina, follow infants arm to elbow, grasp hand or put gentle foward pressure on elbow to sweep arm across chest and out of vagina. This is associated with lowest risk of plexus injury
9. Move gently and with purpose
10. Cut episiotomy only if more room needed to insert hand
11. Coach woman to not push and keep informed, you need her cooperation
12. Gaskin maneuver: woman on hands and knees, if dystocia not resolved, back to McRobert’s position
13. Wood screw maneuver: hand firmly against either posterior or anterior shoulder, push shoulder clockwise or counterclockwise in attempt to rotate 180 degrees until impaction resolved
14. Allow consulting MD to assist in birth
15. Intentional fracture of clavicle can decrease bisacromial diameter but difficult to do in emergent situation
16. At 5 minutes, risk of asphyxia starts to rise, rescue maneuvers may be needed (cephalic replacement or C/S) |
|
|
Term
| Review the acronym HELPERR for shoulder dystocia |
|
Definition
H -- Call for help
E -- Evaluate for episiotomy
L -- Legs into McRoberts
P -- Suprapubic pressure
E -- Enter maneuvers (internal rotation)
R -- Remove posterior arm
R -- Roll the patient |
|
|
