CH 19. DYSTOCIA

3,731 views

Published on

0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,731
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
257
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

CH 19. DYSTOCIA

  1. 1. CH 19. DYSTOCIA 부산백병원 산부인과 R2 서 영진
  2. 2. <ul><li>Face presentation </li></ul><ul><li>Brow presentation </li></ul><ul><li>Transverse lie </li></ul><ul><li>Compound presentation </li></ul><ul><li>Persistent occiput posterior position </li></ul><ul><li>Persistent occiput transverse position </li></ul><ul><li>Shoulder dystocia </li></ul><ul><li>Hydrocephalus as a cause of dystocia </li></ul><ul><li>Fetal abdomen as a cause of dystocia </li></ul>
  3. 3. Fetal presentation in 68,094 (Parkland hospital) <ul><li>Presentation Percent Incidence </li></ul><ul><li>Cephalic 96.8 - </li></ul><ul><li>Breech 2.7 1:36 </li></ul><ul><li>Trnasverse 0.3 1:335 </li></ul><ul><li>Compound 0.1 1:1000 </li></ul><ul><li>Face 0.05 1:2000 </li></ul><ul><li>Brow 0.01 1:10000 </li></ul>
  4. 4. FACE PRESENTATION <ul><li>The head: hyperextended </li></ul><ul><li>occiput-contact with fetal back </li></ul><ul><li>presenting part-chin(mentum) </li></ul><ul><li>-mentum posterior : brow is compressed against </li></ul><ul><li>the maternal symphysis pubis </li></ul><ul><li>-mentum anterior: typical </li></ul><ul><li>-> convert spontaneosly anterior(←posterior) </li></ul>
  5. 5. FACE PRESENTATION <ul><li>Diagnosis </li></ul><ul><li>: vaginal examination & palpation </li></ul><ul><li>(mouth, nose, malar bone , orbital ridge) </li></ul><ul><li>-> mistake a breech </li></ul><ul><li>anus-mouth </li></ul><ul><li>ischial tuberosities-malar bone </li></ul><ul><li>: radiologic demonstration </li></ul>
  6. 6. FACE PRESENTATION <ul><li>Etiology </li></ul><ul><li>: favors extension, prevents head flexion </li></ul><ul><li>-> marked enlargement of the neck </li></ul><ul><li>coils of cord about the neck </li></ul><ul><li>anencephalic fetus </li></ul><ul><li>pelvic contracture </li></ul><ul><li>large infants </li></ul><ul><li>multiparous </li></ul>
  7. 7. FACE PRESENTATION <ul><li>Mechanism </li></ul><ul><li>:rarely observed above pelvic inlet </li></ul><ul><li>brow presentation-converted into face presentation </li></ul><ul><li>:cardinal movement-descent, int. rotation, flexion </li></ul><ul><li>accessory movement-extension, ext. rotation </li></ul><ul><li>:descent-when resistance is encountered </li></ul><ul><li>‘ occiput-pushed toward the back </li></ul><ul><li>‘ chin-decsent </li></ul>
  8. 8. FACE PRESENTATION <ul><li>:int. rotation </li></ul><ul><li>chin-under the symphysis pubis </li></ul><ul><li>neck-sustend post. surface of symphysis pubis </li></ul><ul><li>:if the chin rotates posterorly </li></ul><ul><li>short neck cannot span the anterior sulface of </li></ul><ul><li>the sacrum (12cm) </li></ul><ul><li>->head delivery is impossible unless the shoulder </li></ul><ul><li>enter the pelvis </li></ul>
  9. 10. FACE PRESENTATION <ul><li>:after anterior rotation and descent </li></ul><ul><li>->chin and mouth appear at the vulva </li></ul><ul><li>->the head is delivered by flexion </li></ul><ul><li>:appear in seccession over the ant. margin of the </li></ul><ul><li>perineum-nose, eye, brow, occiput </li></ul><ul><li>:next, ext. rotation-original side </li></ul><ul><li>shoulders are born as the cephalic presentation </li></ul>
  10. 12. FACE PRESENTATION <ul><li>:face edema, head molding </li></ul><ul><li>increased the length of theoccipitomental diameter </li></ul>
  11. 13. FACE PRESENTATION <ul><li>Management </li></ul><ul><li>;successful vagianl delivery </li></ul><ul><li>->absence of a contracted pelvis </li></ul><ul><li>with effective labor </li></ul><ul><li>:full-term size-c/sec is frequently indicated </li></ul><ul><li>:Not attempt </li></ul><ul><li>‘ convert a face manually into a vertex </li></ul><ul><li>‘ manual or forcep rotation (chin: post->ant) </li></ul><ul><li>‘ internal podalic version and extraction </li></ul>
  12. 14. BLOW PRESENTATION <ul><li>:rarest presentataion </li></ul><ul><li>between the orbital ridge and the anterior fontanel </li></ul><ul><li>at the pelvic inlet </li></ul><ul><li>:midway between full flexion (occiput) </li></ul><ul><li>full extension (mentum or face) </li></ul><ul><li>unstable-converts to face or occiput </li></ul><ul><li>:Etiology- same as face presentation </li></ul>
  13. 15. BLOW PRESENTATION <ul><li>Diagnosis </li></ul><ul><li>: abdominal palpation </li></ul><ul><li>:vaginal examination </li></ul><ul><li>-frontal suture, large anterior fontanel, orbital ridge </li></ul><ul><li>eyes, and root of the nose </li></ul><ul><li>-neither, mouth & chin </li></ul>
  14. 16. BLOW PRESENTATION <ul><li>Mechanism of labor </li></ul><ul><li>:very difficult, because engagement is impossible </li></ul><ul><li>:possible-large pelvis, small fetus </li></ul><ul><li>marked molding </li></ul><ul><li>convert to occiput or face presentation </li></ul><ul><li>-> deforms the head </li></ul><ul><li>caput succedaneum-over the forehead </li></ul>
  15. 17. BLOW PRESENTATION <ul><li>Prognosis </li></ul><ul><li>: depends upon the ultimate presentation </li></ul><ul><li>: if the brow persists, </li></ul><ul><li>prognosis is poor </li></ul><ul><li>#Management </li></ul><ul><li>:same as those for a face presentation </li></ul>
  16. 18. TRANSVERSE LIE <ul><li>When the long axis of the fetus is approximately </li></ul><ul><li>perpendicular to that of the mother </li></ul><ul><li>:obligue lie, unstable lie </li></ul><ul><li>:shoulder-over the pelvic inlet </li></ul><ul><li>head-in one iliac fossa </li></ul><ul><li>breech-in the other iliac fossa </li></ul>
  17. 19. TRANSVERSE LIE <ul><li>:shoulder presentation </li></ul><ul><li>-acromion direction-> Rt. & Lt </li></ul><ul><li>:back </li></ul><ul><li>-anterior or posterior </li></ul><ul><li>-superior or inferior </li></ul><ul><li>(ex. Rt acrimidorsoanterior) </li></ul><ul><li>#Incidence: 0.3% </li></ul>
  18. 20. TRANSVERSE LIE <ul><li>Etiology </li></ul><ul><li>1. Unusual relaxion of the abdominal wall resulting </li></ul><ul><li>from high parity </li></ul><ul><li>2. Preterm ferus </li></ul><ul><li>3. Placenta previa </li></ul><ul><li>4. Abnormal uterus </li></ul><ul><li>5. Excessive amnionic fluid </li></ul><ul><li>6. Contracted pelvis </li></ul>
  19. 21. TRANSVERSE LIE <ul><li>Diagnosis </li></ul><ul><li>: easily, by inspection </li></ul><ul><li>-wide abdomen </li></ul><ul><li>Ut fundus extends to only slightly above umbilicus </li></ul><ul><li>: palpation </li></ul><ul><li>-no fetal pole in the fundus </li></ul><ul><li>ballottable head in one iliac fossa </li></ul><ul><li>breech in the other </li></ul><ul><li>-anterior->back(hard resistance) </li></ul><ul><li>posterior-> irregular nodulations small parts </li></ul>
  20. 22. TRANSVERSE LIE <ul><li>: vaginal examination </li></ul><ul><li>-the side of the thorax </li></ul><ul><li>-further dilatation: scapula or clavicle </li></ul><ul><li>-axilla: shouler direction </li></ul><ul><li>-later in labor </li></ul><ul><li>->shoulder become tightly wedged in the pelvis </li></ul><ul><li>->a hand and arm frequently prolapse </li></ul>
  21. 23. TRANSVERSE LIE <ul><li>Course of labor </li></ul><ul><li>:spontaneous delivery is impossible with a persistent </li></ul><ul><li>transverse lie </li></ul><ul><li><neglected transverse lie> </li></ul><ul><li>After ROM, labor continue </li></ul><ul><li>:fetal shoulder is forced into the pelvis, the corresponding </li></ul><ul><li>arm frequently prolapse </li></ul><ul><li>After some descent </li></ul><ul><li>:shoulder is arrested in pelvis, with the head is in the one </li></ul><ul><li>iliac fossa and breech in the other </li></ul>
  22. 24. TRANSVERSE LIE <ul><li>As labor continues </li></ul><ul><li>:the shoulder is impacted fermly in the upper part of </li></ul><ul><li>the pelvis </li></ul><ul><li>:contracts vigorously </li></ul><ul><li>After a time </li></ul><ul><li>:a retraction ring rises increasingly higher </li></ul><ul><li>->if not promptly managed </li></ul><ul><li>uterine rupture, mother & fetus die </li></ul>
  23. 26. TRANSVERSE LIE <ul><li>: conduplicato corpore </li></ul><ul><li>if small fetus(<800g), large pelvis </li></ul><ul><li>in spontaneous delivery </li></ul><ul><li>->the head and thorax pass through the pelvic </li></ul><ul><li>cavity at the same time </li></ul><ul><li>#Prognosis </li></ul><ul><li>:maternal, fetal hazard: increased </li></ul><ul><li>:even with the best care, morbidity is incereased </li></ul><ul><li>->placenta previa, cord prolapse </li></ul>
  24. 27. TRANSVERSE LIE <ul><li>Management </li></ul><ul><li>:the onset of active labor- c/sec </li></ul><ul><li>:conversion to a longitudinal lie (before or early labor) </li></ul><ul><li>-with the membrane intact, no indication of c/sec </li></ul><ul><li>-at 39 wks </li></ul><ul><li>-next several contraction: fix the head in the pelvis </li></ul><ul><li>:if c/sec-vertical incision </li></ul><ul><li>difficulty in extraction of the fetus </li></ul><ul><li>(not foot or head on incision site) </li></ul>
  25. 28. COMPOUND PRESENTATION <ul><li>An extremity prolapse alongside the presenting </li></ul><ul><li>part , with both presenting in the pelvis </li></ul><ul><li>#Incidence: 1 of 700 delivery </li></ul><ul><li>#Etiology </li></ul><ul><li>prevent complete occlusion of the pelvic inlet </li></ul><ul><li>by the fetal head </li></ul>
  26. 29. COMPOUND PRESENTATION <ul><li>Prognosis and management </li></ul><ul><li>:perinatal loss-preterm delivery, cord prolapde </li></ul><ul><li>traumatic obstetrical procedures </li></ul><ul><li>:prolapsed part –be left alone, not interfere labor </li></ul><ul><li>:close observation-prolapsed part prevent descent </li></ul><ul><li>if prevent->arm should be gently pushed upward </li></ul><ul><li>head:downward (fudus pressure) </li></ul>
  27. 30. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>Most often, occiput posterior position udergo </li></ul><ul><li>spontaneous anterior rotation </li></ul><ul><li>:failure of spontaneous rotation </li></ul><ul><li>-transverse narrowing of the midpelvis </li></ul><ul><li>:labor and delivery need not differ remarkably </li></ul><ul><li>from that with the occiput anterior </li></ul><ul><li>:in most instances, delivery can usually be </li></ul><ul><li>accompliched without great difficulty once the head </li></ul><ul><li>reaches the perineum </li></ul>
  28. 31. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>The possibilities for vaginal delivery </li></ul><ul><li>1. Await spontaneous delivery </li></ul><ul><li>2. Forceps delivery with the occiput directly posterior </li></ul><ul><li>3. Forceps rotation of the occiput to the anterior </li></ul><ul><li>position and delivery </li></ul><ul><li>4. Manual rotation to the anterior position followed by </li></ul><ul><li>spontaneous or forceps delivery </li></ul>
  29. 32. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>Spontaneous delivery </li></ul><ul><li>:pelvic outlet-roomy </li></ul><ul><li>vaginal outlet-somewhat relaxed </li></ul><ul><li>:vaginal outlet is resistant, perineum is firm </li></ul><ul><li>->late 1 st stage or the 2 nd stage-prolonged </li></ul><ul><li>:forceps delivery is indicated </li></ul><ul><li>:generous episiotomy is usually needs </li></ul>
  30. 33. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>Forceps delivery as an occiput posterior </li></ul><ul><li>:more traction </li></ul><ul><li>larger episiotomy </li></ul><ul><li>complete analgesia </li></ul><ul><li>:the head may not even be engaged </li></ul><ul><li>(BPD may not have passed through the pelvic inlet) </li></ul><ul><li>->prompt c/sec is appropriate </li></ul>
  31. 35. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>Manual rotation </li></ul>
  32. 36. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>Forceps rotation </li></ul><ul><li>:head is engaged </li></ul><ul><li>cervix fully dilated </li></ul><ul><li>the pelvis adequate </li></ul><ul><li>:skilled operator </li></ul><ul><li>ineffective expulsive effort during the 2nd stage </li></ul>
  33. 37. PERSISTENT OCCIPUIT POSTERIOR POSITION <ul><li>Outcome </li></ul><ul><li>:labor was prolonged </li></ul><ul><li>-parous: 1 hrs </li></ul><ul><li>nulliparous 2 hrs </li></ul><ul><li>:episiotomy extension was increased </li></ul><ul><li>:65% required operative intervention(1994) </li></ul><ul><li>:Parkland hospital </li></ul><ul><li>-manual rotation->forceps delivery </li></ul><ul><li>or forceps delivery </li></ul><ul><li> failure: c/sec </li></ul>
  34. 38. PERSISTENT OCCIPUIT TRANSVERSE POSITION <ul><li>In the absence of a pelvic architecture abnormality </li></ul><ul><li>:most likely a transitory one </li></ul><ul><li>:rotates to the anterior position </li></ul><ul><li>#Delivery </li></ul><ul><li>-the occiput may be manually rotated anteriorly </li></ul><ul><li>or posteriorly and forceps delivery carried out </li></ul>
  35. 39. PERSISTENT OCCIPUIT TRANSVERSE POSITION <ul><li>:if failure of spontaneous rotation is caused by </li></ul><ul><li>hypotonic uterine dysfunction without CPD. </li></ul><ul><li>oxytocin may be infused with close observation </li></ul><ul><li>:platypelloid(anteroposteiorly flat) </li></ul><ul><li>android(heart-shaped) pelvis </li></ul><ul><li> c/sec </li></ul>
  36. 40. SHOULDER DYSTOCIA <ul><li>Incidence </li></ul><ul><li>:varies depending on the criteria used for diagnosis </li></ul><ul><li>:0.9%  ture shouder dystocia-0.2% (1987) </li></ul><ul><li>:maneuvers were required </li></ul><ul><li>so, ceuurent report-0.6~1.4% </li></ul><ul><li>#increasing factor(1960-1980) </li></ul><ul><li>:increasing birthweight </li></ul><ul><li>:shoulder-to-head, chest-to head disproportions </li></ul><ul><li>:increased attention </li></ul>
  37. 41. SHOULDER DYSTOCIA <ul><li>Use of maneuvers – define shoulder dystocia </li></ul><ul><li>:but, use of one or more maneuvers-NO diagnosis </li></ul><ul><li>:TIME INTERVAL (head to body) </li></ul><ul><li>-normal: 24 seconds </li></ul><ul><li>-shoulder dystocia: 79seconds </li></ul><ul><li> exceeding 60 seconds: define shoulder dystocia </li></ul>
  38. 42. SHOULDER DYSTOCIA <ul><li>Maternal consequences </li></ul><ul><li>:postpartum hemorrhage- atony </li></ul><ul><li>lacerations (vag. or Cx.) </li></ul><ul><li>:puerperal infection </li></ul><ul><li>Fetal consequences </li></ul><ul><li>:significant fetal morbidity and mortality </li></ul><ul><li>:transient brachial plexus palsy (m/c) </li></ul><ul><li>clavicle Fx, humeral Fx, neonatal death </li></ul><ul><li>persistent brachial plexus palsy </li></ul>
  39. 43. SHOULDER DYSTOCIA <ul><li>:Wood maneuver (direct fetal manipulation) </li></ul><ul><li>-not associated with an increased rate of fetal </li></ul><ul><li>injury </li></ul><ul><li>#Brachial plexus injury </li></ul><ul><li>:result from down traction on the brachial plexus </li></ul><ul><li>during delivery of the anterior shoulder </li></ul><ul><li>:Erb palsy (C 5-6,7) –hanging upper arm </li></ul><ul><li>extended elbow </li></ul><ul><li>:C 7- T 1:hand (clawhand deformity) </li></ul><ul><li>:may occur even prior to labor, recovery-13 months </li></ul>
  40. 44. SHOULDER DYSTOCIA <ul><li>#Clavicular fracture </li></ul><ul><li>:0.4% </li></ul><ul><li>:often without any clinical events </li></ul><ul><li>:unavoidable </li></ul><ul><li>unpredictable </li></ul><ul><li>no clinical consequence </li></ul>
  41. 45. SHOULDER DYSTOCIA <ul><li>Risk factor </li></ul><ul><li>:maternal factor-incresed birthweight </li></ul><ul><li>obesity, multiparity, diabetes </li></ul><ul><li>postterm pregnancy(>42wks) </li></ul><ul><li>:Intrapartum complication </li></ul><ul><li>-midforceps delivery, prolonged 1 st and 2 nd stage </li></ul><ul><li>:increased birthweight (common) </li></ul><ul><li>but, 50%-<4,000g </li></ul><ul><li>2260g-dystocia reported </li></ul>
  42. 46. SHOULDER DYSTOCIA <ul><li>Summary </li></ul><ul><li>1.cannot be predicted or prevented-no accurate </li></ul><ul><li>methods </li></ul><ul><li>2.ultrasonic measurements to estimate macrosomia </li></ul><ul><li>have limited accuracy </li></ul><ul><li>3.planned c/sec due to macrosomia </li></ul><ul><li>-not reasonable strategy </li></ul><ul><li>4.planned c/sec may be reasonable </li></ul><ul><li>-nondiabetes (>5,000g) </li></ul><ul><li>-diabetes (4,5000g) </li></ul>
  43. 47. SHOULDER DYSTOCIA <ul><li>Management </li></ul><ul><li>:shoulder dystocia-cannot be predicted </li></ul><ul><li>:well versed in the management principles </li></ul><ul><li>:great importance to survival </li></ul><ul><li>-reduction in the interval of time from delivery </li></ul><ul><li>of the head to body </li></ul><ul><li>:gentle traction, assisted by maternal expulsive effort </li></ul><ul><li>next, large episiotomy, analgesia, clear the infant’s </li></ul><ul><li>mouth and nose </li></ul>
  44. 48. SHOULDER DYSTOCIA <ul><li>1.Moderate suprapubic pressure </li></ul><ul><li>-by an assistant while downward traction </li></ul><ul><li>2.McRoverts maneuver </li></ul><ul><li>-flexing the legs upon the abdomen </li></ul><ul><li>-not increase pelvic diameter </li></ul><ul><li>straightening of the sacrum </li></ul><ul><li>symphysis pubis-toward the maternal head </li></ul><ul><li> decrease the angle of pelvic inclination </li></ul>
  45. 49. SHOULDER DYSTOCIA
  46. 50. SHOULDER DYSTOCIA <ul><li>3.Woods corkscrew maneuver </li></ul><ul><li>-rotating the posterior </li></ul><ul><li>shoulder 180 degrees </li></ul><ul><li>-anterior shoulder could be </li></ul><ul><li>released </li></ul>
  47. 51. SHOULDER DYSTOCIA <ul><li>4.Delivery of the posterior </li></ul><ul><li>shoulder </li></ul><ul><li>-post. arm: across the chest </li></ul><ul><li>then delivery </li></ul><ul><li>-next, shoulder girdle rotation </li></ul><ul><li>into one of the oblique </li></ul><ul><li>diameters of the pelvis </li></ul><ul><li> delevery of ant. shoulder </li></ul>
  48. 52. SHOULDER DYSTOCIA <ul><li>5.Rubin maneuver </li></ul><ul><li>-1 st , the fetal shoulder are </li></ul><ul><li>rocked from side to side </li></ul><ul><li>by applying force to the </li></ul><ul><li>abdomen </li></ul><ul><li>-if not successful, </li></ul><ul><li>push the ant. shoulder toward </li></ul><ul><li>the anterior surface of the </li></ul><ul><li>chest </li></ul>
  49. 53. SHOULDER DYSTOCIA <ul><li>6.Hibbard (1982) </li></ul><ul><li>-press the fetal jaw and neck in the direction of </li></ul><ul><li>the maternal rectum </li></ul><ul><li>-strong fundal pressure </li></ul><ul><li> anterior shoulder delivery </li></ul><ul><li>-only fundal pressure, absence of other maneuver </li></ul><ul><li>:77% complication </li></ul><ul><li>fetal prthoprdic and neurologoc damage </li></ul>
  50. 54. SHOULDER DYSTOCIA <ul><li>7.Zavanelli maneuver </li></ul><ul><li>-cephalic replacement into </li></ul><ul><li>the pelvis and then c/sec </li></ul><ul><li>-return fetal head </li></ul><ul><li>flex head </li></ul><ul><li>push head back into vagina </li></ul><ul><li>-terbutaline: Ut relaxation </li></ul><ul><li>-fetal injury </li></ul><ul><li>neonatal death </li></ul><ul><li>stillbirth, brain damage </li></ul>
  51. 55. SHOULDER DYSTOCIA <ul><li>8. Fracture of the clavicle </li></ul><ul><li>-pressing the anterior clavicle against the ramus of </li></ul><ul><li>the pubis </li></ul><ul><li>-heal rapidly </li></ul><ul><li>-not nearly as serious as a brachial nerve injury </li></ul><ul><li>9.Cleidotomy </li></ul><ul><li>-cutting of the clavicle </li></ul><ul><li>-usually used on the a dead fetus </li></ul>
  52. 56. SHOULDER DYSTOCIA <ul><li>10. Symphysiotomy </li></ul><ul><li>-maternal morbidity increased </li></ul><ul><li>-urinary tract injury </li></ul>
  53. 57. SHOULDER DYSTOCIA <ul><li>Shoulder dystocia drill </li></ul><ul><li>1.call for help </li></ul><ul><li>2.generous episiotomy </li></ul><ul><li>3.suprapubic pressure </li></ul><ul><li>-simple, only one assistant </li></ul><ul><li>-while normal downward traction </li></ul><ul><li>4.McRoverts maneuver </li></ul><ul><li>-two assistants </li></ul><ul><li> resolve most case </li></ul><ul><li>if fail, next steps may be attempted </li></ul>
  54. 58. SHOULDER DYSTOCIA <ul><li>5. the woods screw maneuver </li></ul><ul><li>6. posterior arm delivery is attempted </li></ul><ul><li>7. other technique </li></ul><ul><li>-Zavanelli maneuver </li></ul><ul><li>-fracture of ant. clavicle, humerus </li></ul>
  55. 59. HYDROCEPHALUS AS A CAUSE OF DYSTOCIA <ul><li>Hydrocephlus is an excessive accumulation of </li></ul><ul><li>cerebrospinal fluid with consequent cranial </li></ul><ul><li>enlargement </li></ul><ul><li>:associated defects are common (neural tube defect) </li></ul><ul><li>#head circumference: 32-38cm, fluid: 500-1500ml </li></ul><ul><li>hydrocephalus: 50-80cm, fluid: 5l </li></ul><ul><li>:1/3-breech, but whatever presentation, </li></ul><ul><li>gross CPD and serious dystocia </li></ul>
  56. 60. HYDROCEPHALUS AS A CAUSE OF DYSTOCIA <ul><li>Diagnosis </li></ul><ul><li>:sonography </li></ul><ul><li>-compare the diameter of the lateral ventricle to </li></ul><ul><li>the BPD of the head </li></ul><ul><li>-evaluate the thickness of the cerebral cortex </li></ul><ul><li>-compare the size of the head to that of the </li></ul><ul><li>thorax and abdomen </li></ul>
  57. 61. HYDROCEPHALUS AS A CAUSE OF DYSTOCIA <ul><li>Management </li></ul><ul><li>:the size of the hydrocephalic head must be reduced </li></ul><ul><li>in vaginal delivery and c/sec </li></ul><ul><li>: cephalocentesis </li></ul><ul><li>-be limited to fetuses with severe associated </li></ul><ul><li>abnormalities </li></ul><ul><li>-recommended that all others be delivered </li></ul><ul><li>abdominally </li></ul>
  58. 62. HYDROCEPHALUS AS A CAUSE OF DYSTOCIA <ul><li>Technique of cephalocentesis </li></ul><ul><li>#cephalic presentation </li></ul><ul><li>-Cx :3-4cm dilatation </li></ul><ul><li>vetricle may be tapped (8-inch, 17-gauge needle) </li></ul><ul><li>#breech presentation </li></ul><ul><li>-after breech and trunk delivered </li></ul><ul><li>the face toward the martenal back </li></ul><ul><li>transvaginally, below the ant. vaginal wall </li></ul><ul><li>protect the birth canal </li></ul>
  59. 63. HYDROCEPHALUS AS A CAUSE OF DYSTOCIA <ul><li>#via martenal abdomen into the fetal head </li></ul><ul><li>-bladder: empty </li></ul><ul><li>skin: cleansed </li></ul><ul><li>the needle: in the midline below the maternal </li></ul><ul><li>umbilicus </li></ul><ul><li>-before oxytocin stimulation </li></ul><ul><li>-more successfully: sono-guided </li></ul>
  60. 64. FETAL ABDOMEN AS A CAUSE OF DYSTOCIA <ul><li>Enlargement of the fetal abdomen </li></ul><ul><li>:greatly distended bladder </li></ul><ul><li>ascites </li></ul><ul><li>enlargement of the kidney or liver </li></ul><ul><li>edematous fetal abdomen </li></ul><ul><li>:before delivery, decision is made </li></ul><ul><li>:but, prognosis is very poor </li></ul>

×