Shoulder dystocia is defined as
Failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery
This document defines and discusses abnormal fetal positions and presentations that can occur during labor, including breech, face, brow, shoulder, transverse lie, and compound presentations. It provides the definitions, incidence rates, causes, diagnostic techniques, and management approaches for each atypical presentation. Key points covered include the different types of breech, face, brow, and shoulder positions, mechanisms of labor for each, and when external cephalic version, assisted vaginal delivery, or cesarean section are recommended.
Postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL following vaginal birth or 1000 mL following c-section. It can occur within 24 hours (primary PPH) or 24 hours to 12 weeks (secondary PPH) postpartum and is a leading cause of maternal mortality. The 4 T's of PPH include tonicity (uterine atony), tissue (retained placental fragments), trauma, and thrombin abnormalities. A case is presented of a woman with risk factors of preeclampsia and prolonged labor who develops PPH. Her management involves IV fluids, uterotonics, uterine massage, and monitoring for signs of deterioration requiring additional interventions like embolization
This document provides guidelines on the induction of labour. It defines induction of labour and related terms. Acceptable indications for induction include preeclampsia and maternal disease. Unacceptable indications are suspected fetal macrosomia and patient/provider convenience.
Prior to induction, an assessment including Bishop score should be done to determine likelihood of success. Options for cervical ripening include mechanical methods like Foley catheters and pharmacological agents like prostaglandins and misoprostol. Oxytocin is recommended for establishing labour once the cervix is favorable. Risks of different agents are outlined. Guidelines recommend timing and monitoring of inductions.
This document discusses the diagnosis and management of breech presentations and breech births. It notes that breech presentations occur in 3-4% of term births. Risk factors include primigravidity, uterine anomalies, and fetal anomalies. For a vaginal breech birth, the cervix must be fully dilated and the fetal anus visible. The breech should be allowed to descend spontaneously and maneuvers like Lovset's may be needed to deliver the arms. The Mauriceau-Smellie-Veit maneuver is then used to slowly deliver the head. Complications may require emergency cesarean section.
Abruptio placenta, or premature separation of the placenta from the uterine wall, can occur anytime after 20 weeks of pregnancy. It poses risks to both the mother and fetus, such as bleeding, shock, and restricted blood flow between the placenta and fetus. Risk factors include advanced maternal age, smoking, and prior abruption. Management may involve bed rest, monitoring of the fetus and mother, and sometimes surgical delivery of the baby via cesarean section.
Normal labor occurs between 37-42 weeks gestation. Preterm labor is before 37 weeks and postdate pregnancy is after 42 weeks. The longitudinal axis of the fetus relates to the long axis of the maternal uterus. The part of the fetus closest to the birth canal is the presenting part. Cervical dilation and effacement indicate the progression of labor. Contractions increase in intensity, frequency and duration as labor progresses.
Postpartum hemorrhage is defined as bleeding more than 500ml following childbirth. It can be primary within 24 hours or secondary between 24 hours to 6 weeks. The main causes of primary PPH are uterine atony, retained placental tissue, lacerations, and coagulation disorders. Risk factors include overdistention of the uterus, previous PPH, prolonged labor, and preeclampsia. Clinical presentation includes heavy bleeding and signs of shock. Management involves bimanual compression, B-Lynch brace suture, exclusion of retained tissue, and antibiotic treatment for endometritis in secondary PPH cases.
This document defines and discusses abnormal fetal positions and presentations that can occur during labor, including breech, face, brow, shoulder, transverse lie, and compound presentations. It provides the definitions, incidence rates, causes, diagnostic techniques, and management approaches for each atypical presentation. Key points covered include the different types of breech, face, brow, and shoulder positions, mechanisms of labor for each, and when external cephalic version, assisted vaginal delivery, or cesarean section are recommended.
Postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL following vaginal birth or 1000 mL following c-section. It can occur within 24 hours (primary PPH) or 24 hours to 12 weeks (secondary PPH) postpartum and is a leading cause of maternal mortality. The 4 T's of PPH include tonicity (uterine atony), tissue (retained placental fragments), trauma, and thrombin abnormalities. A case is presented of a woman with risk factors of preeclampsia and prolonged labor who develops PPH. Her management involves IV fluids, uterotonics, uterine massage, and monitoring for signs of deterioration requiring additional interventions like embolization
This document provides guidelines on the induction of labour. It defines induction of labour and related terms. Acceptable indications for induction include preeclampsia and maternal disease. Unacceptable indications are suspected fetal macrosomia and patient/provider convenience.
Prior to induction, an assessment including Bishop score should be done to determine likelihood of success. Options for cervical ripening include mechanical methods like Foley catheters and pharmacological agents like prostaglandins and misoprostol. Oxytocin is recommended for establishing labour once the cervix is favorable. Risks of different agents are outlined. Guidelines recommend timing and monitoring of inductions.
This document discusses the diagnosis and management of breech presentations and breech births. It notes that breech presentations occur in 3-4% of term births. Risk factors include primigravidity, uterine anomalies, and fetal anomalies. For a vaginal breech birth, the cervix must be fully dilated and the fetal anus visible. The breech should be allowed to descend spontaneously and maneuvers like Lovset's may be needed to deliver the arms. The Mauriceau-Smellie-Veit maneuver is then used to slowly deliver the head. Complications may require emergency cesarean section.
Abruptio placenta, or premature separation of the placenta from the uterine wall, can occur anytime after 20 weeks of pregnancy. It poses risks to both the mother and fetus, such as bleeding, shock, and restricted blood flow between the placenta and fetus. Risk factors include advanced maternal age, smoking, and prior abruption. Management may involve bed rest, monitoring of the fetus and mother, and sometimes surgical delivery of the baby via cesarean section.
Normal labor occurs between 37-42 weeks gestation. Preterm labor is before 37 weeks and postdate pregnancy is after 42 weeks. The longitudinal axis of the fetus relates to the long axis of the maternal uterus. The part of the fetus closest to the birth canal is the presenting part. Cervical dilation and effacement indicate the progression of labor. Contractions increase in intensity, frequency and duration as labor progresses.
Postpartum hemorrhage is defined as bleeding more than 500ml following childbirth. It can be primary within 24 hours or secondary between 24 hours to 6 weeks. The main causes of primary PPH are uterine atony, retained placental tissue, lacerations, and coagulation disorders. Risk factors include overdistention of the uterus, previous PPH, prolonged labor, and preeclampsia. Clinical presentation includes heavy bleeding and signs of shock. Management involves bimanual compression, B-Lynch brace suture, exclusion of retained tissue, and antibiotic treatment for endometritis in secondary PPH cases.
1. Shoulder dystocia is a complication during vaginal birth where the baby's shoulder gets stuck in the mother's pelvis after delivery of the head.
2. Risk factors include fetal macrosomia, obesity, gestational diabetes, previous history of shoulder dystocia.
3. Management involves calling for help, applying gentle traction and performing maneuvers like McRoberts, suprapubic pressure, and Rubin's to manipulate the shoulder and allow delivery. Documentation of steps taken and fetal status is important.
Face presentation occurs when a baby's head is fully extended so the face is the leading part. It has an incidence of about 1 in 300 births. Face presentations are either primary, occurring during pregnancy due to fetal anomalies, or secondary, occurring during labor due to factors like a contracted pelvis. The most common positions are right and left mento-posterior and mento-anterior. Diagnosis is made through palpation and ultrasound. Labor progresses through engagement, flexion or rotation of the chin, and restitution. Failure of rotation to mento-anterior usually requires interventions like c-section.
3 malpresentations.warda (3)- FACE PRESENTATIONOsama Warda
Face presentations occur when the fetal chin is the presenting part instead of the vertex. They are classified into four positions based on the position of the chin. Mentoanterior positions are more common and favorable than mentoposterior positions. Labor is usually prolonged in face presentations due to delayed engagement and lack of molding of the facial bones. Management depends on the position, with mentoanterior positions usually allowing vaginal delivery while mentoposterior positions often requiring assistance. Brow presentations are the rarest type and usually do not have a defined mechanism of labor.
Fetal echocardiography should be performed to evaluate for any structural heart defects, as supraventricular arrhythmias can sometimes be associated with congenital heart disease. Conservative management with close monitoring would be reasonable if the echocardiogram is normal. C-section and amiodarone are not indicated based on the information provided.
retract the wound edges laterally using self-retaining
retractors to expose the peritoneal cavity
Operative Techniques
IV.Abdominal wall incision
Sub-umblical vertical midline incision
Disadvantages:
1. Poor cosmetic results
2. Higher incidence of incisional hernia
3. Limited exposure of adnexae
4. More pain in the postoperative period
5. Difficult to close the incision in obese patients
So Pfannenstiel incision is preferred in elective cases and midline
incision in emergency cases or when good exposure is needed.
The choice depends on the obstetrician preference and the
clinical situation.
6.Normal Labor,Delivery And The PuerperiumDeep Deep
The document summarizes normal labor, delivery, and the postpartum period. It describes the four main factors that determine labor (contractions, pelvis, fetus, psychology). It then explains the stages of labor and delivery in detail, including first, second and third stages. It discusses management of each stage. It also covers the postpartum period known as the puerperium, including typical uterine bleeding, lactation, and involution over 6 weeks.
The document discusses various aspects of fetal heart rate monitoring including:
1. Types of fetal heart rate tests including NST, CST, and acoustic stimulation test.
2. Components of fetal heart rate tracings including baseline rate, variability, accelerations, and decelerations.
3. Interpretation of normal, suspicious, and abnormal fetal heart rate tracing patterns.
4. Management recommendations based on the interpretation including continued monitoring, amniotomy, or discontinuing labor stimulating agents.
Management of Pre-eclampsiaand eclampsia Case discussionsMouafak Alhadithy
The document discusses the management of pre-eclampsia and eclampsia, defining the conditions and outlining diagnostic criteria and treatment approaches. It provides case studies of patients presenting with hypertension in pregnancy and describes how to evaluate and treat the patients, including through antihypertensive medication, magnesium sulfate administration, and decisions around delivery timing and method. The goal of management is to terminate the pregnancy safely while restoring the health of both the mother and newborn.
This document provides information on breech births, including definitions, types, diagnosis, and management. It begins with an introduction defining breech birth as birth where the baby exits the pelvis feet or buttocks first instead of head first. It then describes the different types of breech presentations (complete, incomplete, frank), discusses diagnosis using clinical exams and ultrasound, and outlines the management of breech births including external cephalic version, vaginal delivery or cesarean section depending on the situation. The conclusion states that breech presentations can be effectively managed with early diagnosis and skillful techniques from obstetricians.
This document provides an overview of several obstetric emergencies including the collapsed/unresponsive patient, sepsis, obstetric hemorrhage, eclampsia, amniotic fluid embolism, umbilical cord prolapse, shoulder dystocia, thrombosis and thromboembolism, uterine inversion, and uterine rupture. For each emergency, it describes signs, symptoms, risk factors, diagnosis, and management strategies with the goal of limiting maternal and fetal morbidity and mortality through a structured and methodical approach.
This document discusses unstable lie and version in pregnancy. It defines unstable lie as a condition where the fetal presentation constantly changes beyond 36 weeks of pregnancy when it should have stabilized. Causes include factors that prevent the presenting part from remaining fixed in the lower uterus. Complications include cord entanglement and increased risk of perinatal death. External cephalic version can be attempted to correct the malpresentation if there are no contraindications. Hospitalization is recommended at 37 weeks to monitor for premature rupture of membranes or cord prolapse. Elective c-section is often required, especially if complicating factors are present.
Uterine Rupture
Deepa Mishra
Assistant Professor (OBG)
Introduction
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth
Symptoms while classically including increased pain, vaginal bleeding, or a change in contractions are not always present.
Disability or death of the mother or baby may result.
Definition
Uterine rupture is giving way of gravid uterus or dissolution in the continuity of uterine wall anytime after 28 weeks of gestation with or without expulsion of the fetus.
Incidence
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%
Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section.
In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000
Risk of death of the baby is about 6%
Etiology
Risk Factors
Previous cesarean section
Myomectomy
Dysfunctional labor
Labor augmentation by oxytocin or prostaglandins
High parity
First pregnancy- very rare
Types of uterine rupture
Complete Rupture
All the layers including peritoneum are torn and the uterine contents escape into the peritoneal cavity.
Usually results in death
Incomplete Rupture
Visceral peritoneum is intact and usually the fetus remains in the uterine cavity
Sign & Symptoms
Uterine dehiscence and abdominal pain and vaginal bleeding
Deterioration of fetal heart rate
Loss of fetal station on manual vaginal exam
Hypovolemic shock due to intrabdominal bleeding
Chest pain between the scapulae, pain during inspiration due to irritation of blood below the perineum
Cessation of uterine contractions
Palpation of fetus outside the uterus
Signs of abdominal pregnancy
Post term pregnancy
Diagnosis
Signs of obstructed labor with dehydration, exhaustion, tachycardia raised temperature tonic contraction , pathological retraction ring
Absent fetal heart sound
On PV hot, dry vagina with a large caput over the presenting part
Prevention
Early diagnosis and management of CPD mal presentation and obstructed labor
Proper selection of cases for vaginal delivery
Carefull monitoring of oxytocin infusion specially in multipara
Avoid intra uterine manipulation no version in single fetus
Instrumental delivery after cervical dilatation
Immediate CS in obstructed labor
Hospital delivery for high risk cases
ECV should be avoided during general anaesthesia
Careful manual removal of placenta
Treatment
Resuscitation with adequate hydration and blood transfusion
Laprotomy
Hysterectomy
Repair
Complication
Rupture uterus with haemorrhage, shock and sepsis
Fetal loss is high in spontaneous and traumatic rupture
Mortality is low in LSCS scar rupture
The document outlines caesarean section (CS), beginning with its history and definitions. It describes the procedure's increasing global epidemiology and classifications. Indications include maternal, fetal and combined conditions. Pre-op preparation, the surgical procedure, post-op care and complications are discussed. Robson's 10-group classification system for analyzing CS rate trends is presented. The document provides a comprehensive overview of CS.
Uterine inversion occurs when the uterus turns inside out, most commonly during delivery from excessive cord traction or fundal pressure. It can range from the fundus inverting into the cervix to the entire uterus prolapsing outside the body. Prompt diagnosis and management is needed to prevent shock. The uterus must be manually or surgically replaced before detaching the placenta to avoid hemorrhage. Prevention involves controlled cord traction and avoiding fundal pressure until the placenta separates naturally.
This document provides information on the history and indications of cesarean section (CS). It discusses how CS has evolved over time from ancient practices to modern techniques. The key points are:
1. CS has been performed for thousands of years by various ancient civilizations but modern antiseptic techniques increased survival rates in the late 19th century.
2. Common medical indications for CS include cephalo-pelvic disproportion, fetal distress, placenta previa, and failure to progress in labor.
3. Rates of CS have been increasing worldwide, reaching over 30% in some countries, due to various factors like previous CS, maternal request, and medico-legal fears. However, high rates
This document discusses different methods of fetal monitoring during labor, including electronic fetal monitoring (EFM) and intermittent auscultation. While EFM is commonly used, it has high rates of false positives and variable interpretations. Intermittent auscultation is a simpler, less invasive method that is well-liked by patients and may reduce rates of cesarean section. The document also questions whether EFM has been proven to effectively prevent brain damage, as its central hypotheses have never been tested. It argues intermittent auscultation is an acceptable alternative for low-risk patients. The document provides guidelines for appropriate fetal monitoring and interpreting EFM tracings.
This document discusses post-term pregnancy, which is defined as a pregnancy extending beyond 42 weeks of gestation. Risks of post-term pregnancy include fetal complications like meconium aspiration and fetal distress as well as maternal risks such as increased need for instrumental or cesarean delivery. Diagnosis involves assessing factors like menstrual history, fundal height, and ultrasound evaluations. Management may involve expectant monitoring for low-risk cases or induction of labor for cases with complications or signs of fetal distress.
Preterm labour & premature rupture of membranes (IL).pdfElhadi Miskeen
A 34-year-old patient presented at 27 weeks gestation with vaginal bleeding and contractions. She had a prior preterm delivery at 33 weeks. The next steps in evaluation and management are to monitor vital signs and perform a cervical exam to check for change in dilation or effacement. Antenatal steroids and antibiotics would be administered to improve neonatal outcomes if delivery is imminent. Tocolytic therapy may be given to delay delivery if the cervix has not changed and bleeding and contractions subside. The goal of treatment is to prolong the pregnancy as long as possible while preventing infection and complications of prematurity for mother and baby.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
Shoulder dystocia occurs when the fetal shoulders become lodged at the maternal pelvis during birth, prolonging delivery. It represents an obstetric emergency. Risk factors include macrosomia, gestational diabetes, and prolonged labor. Management involves maneuvers like McRoberts position, suprapubic pressure, and rotational maneuvers to disimpact the shoulders. Complications for the baby include brachial plexus injury. Early diagnosis and treatment are important to prevent neonatal asphyxia. Simulation training is useful for practicing the management of shoulder dystocia.
1. Shoulder dystocia is a complication during vaginal birth where the baby's shoulder gets stuck in the mother's pelvis after delivery of the head.
2. Risk factors include fetal macrosomia, obesity, gestational diabetes, previous history of shoulder dystocia.
3. Management involves calling for help, applying gentle traction and performing maneuvers like McRoberts, suprapubic pressure, and Rubin's to manipulate the shoulder and allow delivery. Documentation of steps taken and fetal status is important.
Face presentation occurs when a baby's head is fully extended so the face is the leading part. It has an incidence of about 1 in 300 births. Face presentations are either primary, occurring during pregnancy due to fetal anomalies, or secondary, occurring during labor due to factors like a contracted pelvis. The most common positions are right and left mento-posterior and mento-anterior. Diagnosis is made through palpation and ultrasound. Labor progresses through engagement, flexion or rotation of the chin, and restitution. Failure of rotation to mento-anterior usually requires interventions like c-section.
3 malpresentations.warda (3)- FACE PRESENTATIONOsama Warda
Face presentations occur when the fetal chin is the presenting part instead of the vertex. They are classified into four positions based on the position of the chin. Mentoanterior positions are more common and favorable than mentoposterior positions. Labor is usually prolonged in face presentations due to delayed engagement and lack of molding of the facial bones. Management depends on the position, with mentoanterior positions usually allowing vaginal delivery while mentoposterior positions often requiring assistance. Brow presentations are the rarest type and usually do not have a defined mechanism of labor.
Fetal echocardiography should be performed to evaluate for any structural heart defects, as supraventricular arrhythmias can sometimes be associated with congenital heart disease. Conservative management with close monitoring would be reasonable if the echocardiogram is normal. C-section and amiodarone are not indicated based on the information provided.
retract the wound edges laterally using self-retaining
retractors to expose the peritoneal cavity
Operative Techniques
IV.Abdominal wall incision
Sub-umblical vertical midline incision
Disadvantages:
1. Poor cosmetic results
2. Higher incidence of incisional hernia
3. Limited exposure of adnexae
4. More pain in the postoperative period
5. Difficult to close the incision in obese patients
So Pfannenstiel incision is preferred in elective cases and midline
incision in emergency cases or when good exposure is needed.
The choice depends on the obstetrician preference and the
clinical situation.
6.Normal Labor,Delivery And The PuerperiumDeep Deep
The document summarizes normal labor, delivery, and the postpartum period. It describes the four main factors that determine labor (contractions, pelvis, fetus, psychology). It then explains the stages of labor and delivery in detail, including first, second and third stages. It discusses management of each stage. It also covers the postpartum period known as the puerperium, including typical uterine bleeding, lactation, and involution over 6 weeks.
The document discusses various aspects of fetal heart rate monitoring including:
1. Types of fetal heart rate tests including NST, CST, and acoustic stimulation test.
2. Components of fetal heart rate tracings including baseline rate, variability, accelerations, and decelerations.
3. Interpretation of normal, suspicious, and abnormal fetal heart rate tracing patterns.
4. Management recommendations based on the interpretation including continued monitoring, amniotomy, or discontinuing labor stimulating agents.
Management of Pre-eclampsiaand eclampsia Case discussionsMouafak Alhadithy
The document discusses the management of pre-eclampsia and eclampsia, defining the conditions and outlining diagnostic criteria and treatment approaches. It provides case studies of patients presenting with hypertension in pregnancy and describes how to evaluate and treat the patients, including through antihypertensive medication, magnesium sulfate administration, and decisions around delivery timing and method. The goal of management is to terminate the pregnancy safely while restoring the health of both the mother and newborn.
This document provides information on breech births, including definitions, types, diagnosis, and management. It begins with an introduction defining breech birth as birth where the baby exits the pelvis feet or buttocks first instead of head first. It then describes the different types of breech presentations (complete, incomplete, frank), discusses diagnosis using clinical exams and ultrasound, and outlines the management of breech births including external cephalic version, vaginal delivery or cesarean section depending on the situation. The conclusion states that breech presentations can be effectively managed with early diagnosis and skillful techniques from obstetricians.
This document provides an overview of several obstetric emergencies including the collapsed/unresponsive patient, sepsis, obstetric hemorrhage, eclampsia, amniotic fluid embolism, umbilical cord prolapse, shoulder dystocia, thrombosis and thromboembolism, uterine inversion, and uterine rupture. For each emergency, it describes signs, symptoms, risk factors, diagnosis, and management strategies with the goal of limiting maternal and fetal morbidity and mortality through a structured and methodical approach.
This document discusses unstable lie and version in pregnancy. It defines unstable lie as a condition where the fetal presentation constantly changes beyond 36 weeks of pregnancy when it should have stabilized. Causes include factors that prevent the presenting part from remaining fixed in the lower uterus. Complications include cord entanglement and increased risk of perinatal death. External cephalic version can be attempted to correct the malpresentation if there are no contraindications. Hospitalization is recommended at 37 weeks to monitor for premature rupture of membranes or cord prolapse. Elective c-section is often required, especially if complicating factors are present.
Uterine Rupture
Deepa Mishra
Assistant Professor (OBG)
Introduction
Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth
Symptoms while classically including increased pain, vaginal bleeding, or a change in contractions are not always present.
Disability or death of the mother or baby may result.
Definition
Uterine rupture is giving way of gravid uterus or dissolution in the continuity of uterine wall anytime after 28 weeks of gestation with or without expulsion of the fetus.
Incidence
Rates of uterine rupture during vaginal birth following one previous C-section, done by the typical technique, are estimated at 0.9%
Rates are greater among those who have had multiple prior C-sections or an atypical type of C-section.
In those who do have uterine scarring, the risk during a vaginal birth is about 1 per 12,000
Risk of death of the baby is about 6%
Etiology
Risk Factors
Previous cesarean section
Myomectomy
Dysfunctional labor
Labor augmentation by oxytocin or prostaglandins
High parity
First pregnancy- very rare
Types of uterine rupture
Complete Rupture
All the layers including peritoneum are torn and the uterine contents escape into the peritoneal cavity.
Usually results in death
Incomplete Rupture
Visceral peritoneum is intact and usually the fetus remains in the uterine cavity
Sign & Symptoms
Uterine dehiscence and abdominal pain and vaginal bleeding
Deterioration of fetal heart rate
Loss of fetal station on manual vaginal exam
Hypovolemic shock due to intrabdominal bleeding
Chest pain between the scapulae, pain during inspiration due to irritation of blood below the perineum
Cessation of uterine contractions
Palpation of fetus outside the uterus
Signs of abdominal pregnancy
Post term pregnancy
Diagnosis
Signs of obstructed labor with dehydration, exhaustion, tachycardia raised temperature tonic contraction , pathological retraction ring
Absent fetal heart sound
On PV hot, dry vagina with a large caput over the presenting part
Prevention
Early diagnosis and management of CPD mal presentation and obstructed labor
Proper selection of cases for vaginal delivery
Carefull monitoring of oxytocin infusion specially in multipara
Avoid intra uterine manipulation no version in single fetus
Instrumental delivery after cervical dilatation
Immediate CS in obstructed labor
Hospital delivery for high risk cases
ECV should be avoided during general anaesthesia
Careful manual removal of placenta
Treatment
Resuscitation with adequate hydration and blood transfusion
Laprotomy
Hysterectomy
Repair
Complication
Rupture uterus with haemorrhage, shock and sepsis
Fetal loss is high in spontaneous and traumatic rupture
Mortality is low in LSCS scar rupture
The document outlines caesarean section (CS), beginning with its history and definitions. It describes the procedure's increasing global epidemiology and classifications. Indications include maternal, fetal and combined conditions. Pre-op preparation, the surgical procedure, post-op care and complications are discussed. Robson's 10-group classification system for analyzing CS rate trends is presented. The document provides a comprehensive overview of CS.
Uterine inversion occurs when the uterus turns inside out, most commonly during delivery from excessive cord traction or fundal pressure. It can range from the fundus inverting into the cervix to the entire uterus prolapsing outside the body. Prompt diagnosis and management is needed to prevent shock. The uterus must be manually or surgically replaced before detaching the placenta to avoid hemorrhage. Prevention involves controlled cord traction and avoiding fundal pressure until the placenta separates naturally.
This document provides information on the history and indications of cesarean section (CS). It discusses how CS has evolved over time from ancient practices to modern techniques. The key points are:
1. CS has been performed for thousands of years by various ancient civilizations but modern antiseptic techniques increased survival rates in the late 19th century.
2. Common medical indications for CS include cephalo-pelvic disproportion, fetal distress, placenta previa, and failure to progress in labor.
3. Rates of CS have been increasing worldwide, reaching over 30% in some countries, due to various factors like previous CS, maternal request, and medico-legal fears. However, high rates
This document discusses different methods of fetal monitoring during labor, including electronic fetal monitoring (EFM) and intermittent auscultation. While EFM is commonly used, it has high rates of false positives and variable interpretations. Intermittent auscultation is a simpler, less invasive method that is well-liked by patients and may reduce rates of cesarean section. The document also questions whether EFM has been proven to effectively prevent brain damage, as its central hypotheses have never been tested. It argues intermittent auscultation is an acceptable alternative for low-risk patients. The document provides guidelines for appropriate fetal monitoring and interpreting EFM tracings.
This document discusses post-term pregnancy, which is defined as a pregnancy extending beyond 42 weeks of gestation. Risks of post-term pregnancy include fetal complications like meconium aspiration and fetal distress as well as maternal risks such as increased need for instrumental or cesarean delivery. Diagnosis involves assessing factors like menstrual history, fundal height, and ultrasound evaluations. Management may involve expectant monitoring for low-risk cases or induction of labor for cases with complications or signs of fetal distress.
Preterm labour & premature rupture of membranes (IL).pdfElhadi Miskeen
A 34-year-old patient presented at 27 weeks gestation with vaginal bleeding and contractions. She had a prior preterm delivery at 33 weeks. The next steps in evaluation and management are to monitor vital signs and perform a cervical exam to check for change in dilation or effacement. Antenatal steroids and antibiotics would be administered to improve neonatal outcomes if delivery is imminent. Tocolytic therapy may be given to delay delivery if the cervix has not changed and bleeding and contractions subside. The goal of treatment is to prolong the pregnancy as long as possible while preventing infection and complications of prematurity for mother and baby.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
Shoulder dystocia occurs when the fetal shoulders become lodged at the maternal pelvis during birth, prolonging delivery. It represents an obstetric emergency. Risk factors include macrosomia, gestational diabetes, and prolonged labor. Management involves maneuvers like McRoberts position, suprapubic pressure, and rotational maneuvers to disimpact the shoulders. Complications for the baby include brachial plexus injury. Early diagnosis and treatment are important to prevent neonatal asphyxia. Simulation training is useful for practicing the management of shoulder dystocia.
Shoulder dystocia occurs when a baby's shoulders become lodged inside the mother's pelvis during childbirth. It can cause injuries to the baby like brachial plexus injury or fractures. Risk factors include fetal macrosomia, obesity, diabetes, and instrumental delivery. Diagnosis involves signs like head recoiling or a flushed face. Management follows the ALARMER mnemonic - asking for help, applying leg maneuvers, and potentially rotating or delivering the posterior arm. More invasive maneuvers like clavicle fracture or Zavanelli maneuver may be tried if initial attempts fail.
Shoulder dystocia occurs when the fetal shoulders become lodged in the birth canal during delivery after the head has been delivered, requiring additional obstetric maneuvers to assist delivery. It has an incidence between 0.23-2.09% of deliveries and can cause injuries to the baby such as brachial plexus injuries and fractures. The document outlines various maneuvers to manage shoulder dystocia including the McRoberts maneuver, suprapubic pressure, internal rotation maneuvers like Woods corkscrew and Rubins, and as a last resort, the Zavanelli maneuver which involves replacing the baby's head for c-section delivery. Advanced maneuvers should only be considered if initial maneuvers like McRobert
This document discusses shoulder dystocia, which refers to a situation where the anterior shoulder of the fetus becomes impacted during delivery after the head has been delivered. It has an incidence of 0.6-0.7% of all deliveries. Risk factors include maternal diabetes, obesity, post-term pregnancy, large baby, and prior history of shoulder dystocia. Management involves calling for help, performing an episiotomy, and using maneuvers like McRoberts, suprapubic pressure, or rotating the shoulders to disimpact the anterior shoulder. Complications can include brachial plexus injury, fractures, or rarely maternal injuries. Proper management requires training and a coordinated response from the obstetrician and
Abnormal labor can occur due to issues with the powers of labor (uterine contractions), the passenger (fetus), or the passages (maternal pelvis). Dystocia is defined as difficult or dysfunctional labor that is abnormally slow. The three Ps that can cause dystocia are: power (weak contractions), passenger (fetal issues like size or position), and passages (maternal pelvic abnormalities). Fetopelvic disproportion is a common cause of dystocia and can involve a small pelvis, large fetus, or issues like face or brow presentations that make descent difficult. Management depends on the specific issue but may include assisted delivery or cesarean section.
The ability of the fetus to successfully negotiate the pelvis during labor involves changes in the position of its head during its passage in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies.
Shoulder dystocia occurs when a baby's shoulder becomes stuck behind the public bone during vaginal delivery, after the head has been delivered. It can lead to injuries in both the mother and baby if not resolved quickly. Risk factors include large baby size, gestational diabetes, and previous shoulder dystocia. The first steps in management involve changing the mother's position using maneuvers like McRoberts, followed by techniques like Rubin and Wood's to rotate the baby's posture if needed. Calling for help from a team and proceeding systematically through established protocols can help deliver the baby safely.
This document discusses the normal process of labor and delivery. It begins by defining labor and childbirth as the period from the onset of regular uterine contractions until expulsion of the placenta. It then discusses fetal positioning including lie, presentation, attitude, and position. The cardinal movements of labor are also summarized, including engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. Mechanisms of labor for both vertex and occiput posterior presentations are presented. Changes in fetal head shape during labor from molding and caput succedaneum formation are also described.
This document discusses shoulder dystocia, which refers to difficulty delivering the fetal shoulders during birth. It occurs in 0.2-2% of births and can cause fetal asphyxia or physical injury if not managed properly. The document defines shoulder dystocia and reviews risk factors, signs, the HELPERR pneumonic for management, and potential complications for both mother and baby. It also discusses techniques like the McRoberts maneuver, internal rotation maneuvers, and in rare cases procedures like clavicle fracture or cephalic replacement.
Learn what is "fetal attitude", "fetal lie", different types of fetal presentation (cephalic, breech, compound, shoulder), how to determine fetal position, and how to do Leopold's maneuvers
This document discusses shoulder dystocia, an obstetric emergency where the fetal shoulders do not deliver easily after the head is delivered. It defines shoulder dystocia and outlines risk factors such as macrosomia. It examines techniques to predict, prevent, and manage shoulder dystocia. While macrosomia is a main risk factor, shoulder dystocia is difficult to predict accurately. Prophylactic induction of labor or cesarean delivery for suspected macrosomia is not routinely recommended. Standard management techniques for shoulder dystocia include McRoberts maneuver, suprapubic pressure, and delivery of the posterior arm.
This document defines shoulder dystocia and describes the risk factors, diagnosis, management, and complications. Shoulder dystocia is an obstetric emergency where the fetal shoulders are impacted at the birth canal after delivery of the head. Risk factors include previous shoulder dystocia, macrosomia, and prolonged labor. Diagnosis involves failure of shoulder delivery after head delivery. Management begins with non-traction maneuvers like McRoberts position and suprapubic pressure, followed by rotational maneuvers if needed. Complications include brachial plexus injury, fractures, and hypoxic ischemic encephalopathy.
Shoulder dystocia is when the fetal shoulders become lodged at the maternal pelvis after delivery of the head, occurring in 0.2-2% of births. Risk factors include maternal diabetes, obesity, macrosomia, and prior shoulder dystocia. Management involves calling for help, applying suprapubic pressure and the McRoberts maneuver to widen the pelvis, and rotating the shoulders using maneuvers like Woods screw or Rubin. If unsuccessful, procedures include delivering the posterior arm or rarely symphysiotomy. Fetal risks are brachial plexus injury, fractures, and hypoxic brain injury. Maternal risks include perineal tears and postpartum hemorrhage. Prevention focuses
Shoulder dystocia dr Ahmed Walid Anwar MoradWalid Ahmed
This document discusses shoulder dystocia, including its definition, incidence, causes, risk factors, classification, recognition, management, complications, and prevention. Shoulder dystocia occurs when the fetus's shoulders become lodged inside the mother's pelvis during childbirth. It has an incidence of 0.6-1.4% of deliveries and risks increase with larger fetal size. Management involves maneuvers to dislodge the shoulders, starting with the McRoberts maneuver and sometimes also requiring more advanced techniques. Prevention focuses on induction or C-section for suspected large babies, especially in diabetic mothers. Proper management training and a systematic approach are important to avoid injuries.
Sprengel's deformity and congenital muscular torticollis are congenital musculoskeletal conditions. Sprengel's deformity involves an elevated scapula due to interrupted migration during development. It causes limited shoulder movement and deformity. Congenital muscular torticollis is caused by sternocleidomastoid muscle shortening, resulting in head tilt and facial asymmetry. Both are typically noticed at birth and can be treated conservatively or with surgery depending on severity. Physiotherapy focuses on improving range of motion and muscle strength.
This document summarizes the normal labor process and its stages. It describes the first stage of labor as dilation of the cervix, usually taking 12 hours for first-time mothers and 6 hours for mothers who have given birth before. The second stage is described as beginning with full cervical dilation and ending with delivery of the fetus, typically taking 2 hours for first-time mothers and 30 minutes for others. The third stage involves delivery of the placenta, usually within 15 minutes. Key parameters like fetal position and presentation are also defined. The document provides details on managing each stage of labor.
Shoulder dystocia by dr salma khwaga jaanAayeeshahKhan
Shoulder dystocia occurs when the fetal shoulders become stuck after delivery of the head. It has an incidence of 0.2-1% and can be unilateral or bilateral. Risk factors include obesity, diabetes, macrosomia and previous shoulder dystocia. It is diagnosed when gentle traction fails to deliver the baby. Management involves maneuvers to disimpact the shoulders like McRoberts position, suprapubic pressure, and rotating the posterior arm. More aggressive maneuvers include the Woods corkscrew or Zavanelli maneuver. Complications for the baby include injury, asphyxia and death while maternal complications are tears and hemorrhage. Prevention focuses on elective c-section or induction for high risk cases.
This document discusses shoulder dystocia, which occurs when a baby's shoulder becomes lodged behind the mother's pubic bone during childbirth. It defines shoulder dystocia and lists associated risk factors. The document outlines how to diagnose shoulder dystocia and the "shoulder dystocia drill" procedure to release the trapped shoulder through maneuvers like McRoberts position, suprapubic pressure, and delivering the posterior arm. It also lists potential maternal and fetal complications of shoulder dystocia. Thorough documentation is emphasized to reduce litigation risks.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
shoulder-dystocia.pdf
1. SHOULDER
DYSTOCIA
Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
5. SHOULDER DYSTOCIA
■ This happens when the anterior fetal shoulder
becomes wedged behind the symphysis pubis
and fail to deliver using normally exerted
downward traction and maternal pushing.
■ Because the umbilical cord is compressed
within the birth canal, this dystocia is an
emergency.
■ Several maneuvers may be performed to free
the shoulder à requires a team approach, in
which effective communication and
leadership are critical.
Image grabbed from:
https://www.erbs-palsy.co.uk/
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
6. SHOULDER DYSTOCIA
■ Consensus regarding a specific definition of
shoulder dystocia is lacking.
■ These investigators proposed that a head-to-
body delivery time >60 seconds be used to
define shoulder dystocia.
■ Currently, the diagnosis continues to rely on
the clinical perception that the normal
downward traction needed for fetal shoulder
delivery is ineffective.
Image grabbed from:
https://www.erbs-palsy.co.uk/
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
7. Maternal and Neonatal Consequences
■ shoulder dystocia poses greater risk to the fetus than to the mother.
■ The main maternal risks are serious perineal tears and postpartum hemorrhage,
usually from uterine atony but also from lacerations
■ Neonatal injuries include:
– brachial plexus injury
– clavicular or humeral fracture
– Asphyxia/acidosis
– hypoxic ischemic encephalopathy (HIE)
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
8. Management
■ Because of ongoing cord compression with this dystocia, one goal is to reduce the head-
to-body delivery time.
■ the second goal is avoiding fetal and maternal injury from aggressive manipulations.
■ An initial gentle attempt at traction, assisted by maternal expulsive efforts, is
recommended. Adequate analgesia is certainly ideal.
■ Some clinicians advocate performing a large episiotomy to provide room for
manipulations. Episiotomy itself does not lower brachial plexus injury rates but raises
third- and fourth-degree laceration rates
– Episiotomy may be needed to complete needed maneuvers.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
10. Suprapubic pressure/
Mazzanti maneuver
■ moderate suprapubic pressure can be
applied by an assistant, while downward
traction is applied to the fetal head.
■ Pressure is applied with the heel of the
hand to the anterior shoulder wedged
above and behind the symphysis.
■ The anterior shoulder is either depressed
or rotated, or both, so the shoulders
occupy the oblique plane of the pelvis.
Here, the anterior shoulder can be freed.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
11. McRoberts Maneuver
■ The maneuver consists of removing the legs from
the stirrups and sharply hyperflexing them up
toward the abdomen.
■ Suprapubic pressure is often concurrently applied
■ the procedure caused straightening of the sacrum
relative to the lumbar vertebrae, rotation of the
symphysis pubis toward the maternal head, and a
decrease in the angle of pelvic inclination.
■ Although this does not increase pelvic dimensions,
pelvic rotation cephalad tends to free the
impacted anterior shoulder.
FIGURE 27-5 The McRoberts maneuver. The maneuver consi
legs from the stirrups and sharply flexing the thighs up toward
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
12. Delivery of the posterior
shoulder
■ With delivery of the posterior shoulder, the operator
carefully sweeps the posterior arm of the fetus across
its chest, followed by delivery of the arm
■ If possible, the operator’s fingers are aligned parallel
to the long axis of the fetal humerus to lower bone
fracture risks.
■ The shoulder girdle is then rotated into one of the
oblique diameters of the pelvis with subsequent
delivery of the anterior shoulder.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
13. Rotational maneuver: Woods corkscrew
maneuver
■ By progressively rotating the
posterior shoulder 180 degrees in a
corkscrew fashion, the impacted
anterior shoulder could be released.
the posterior shoulder 180 degrees in a corkscrew fashion, the impacted anterior
shoulder could be released. This is frequently referred to as the Woods corkscrew
maneuver (Fig. 27-7). Rubin (1964) recommended two maneuvers. First, the fetal
shoulders are rocked from side to side by applying force to the maternal abdomen.
If this is not successful, the pelvic hand reaches the most easily accessible fetal
shoulder, which is then pushed toward the anterior surface of the chest. This
maneuver most often abducts both shoulders, which in turn produces a smaller
bisacromial diameter. This permits displacement of the anterior shoulder from
behind the symphysis (Fig. 27-8).
FIGURE 27-7 Woods maneuver. The hand is placed behind the posterior shoulde
of the fetus. The shoulder is then rotated in a corkscrew manner so that the
impacted anterior shoulder is released.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
14. Rotational maneuver: Rubin maneuvers
■ Rubin (1964) recommended two maneuvers:
– First, the fetal shoulders are rocked from
side to side by applying force to the maternal
abdomen.
– If the first maneuver is not successful, the
pelvic hand reaches the most easily
accessible fetal shoulder, which is then
pushed toward the anterior surface of the
chest à This maneuver most often abducts
both shoulders, which in turn produces a
smaller bisacromial diameter à This permits
displacement of the anterior shoulder from
behind the symphysis
FIGURE 27-8 The second Rubin maneuver. A. The bisacromial diameter is
aligned vertically. B. The more easily accessible fetal shoulder (the anterior is
shown here) is pushed toward the anterior chest wall of the fetus (arrow). Most
often, this results in abduction of both shoulders, which reduces the bisacromial
diameter and frees the impacted anterior shoulder.
If the above are initially unsuccessful, they may be repeated, and finally other
methods may be elected. With an all-fours maneuver, also called the Gaskin
maneuver, the parturient rolls onto her knees and hands. Here, downward traction
against the head and neck attempts to free the posterior shoulder (Bruner, 1998).
Challenges with this include immobility from regional analgesia and time lost in
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
15. Gaskin Maneuver/”all-fours” maneuver
■ the parturient rolls onto her knees and
hands.
■ downward traction against the baby’s
head and neck attempts to free the
posterior shoulder
■ Challenges with this include immobility
from regional analgesia and time lost
in patient repositioning.
Photo grabbed from www.emcurious.com
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
16. posterior axilla sling traction to deliver the
posterior arm
■ With this alternative method, a suction catheter is threaded under the axilla and
both ends are brought together above the shoulder.
■ Upward and outward traction on the catheter loop delivers the shoulder.
■ Neonatal injury may include humeral fracture and Erb palsy
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
17. Last resort maneuvers: fracture of the
anterior clavicle
■ Deliberate fracture of the anterior clavicle using the thumb to press it toward and
against the pubic ramus can be attempted to free the shoulder impaction.
■ In practice, however, deliberate fracture of a large neonate’s clavicle is difficult.
■ If successful, the fracture will heal rapidly and is usually trivial compared with
brachial nerve injury, asphyxia, or death.
■ Avoid puncturing the lungs of the baby!
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
18. Last resort maneuvers: Zavanelli
maneuver
■ involves replacement of the fetal head into the pelvis
followed by cesarean delivery
■ Terbutaline, 0.25 mg, is given subcutaneously to produce
uterine relaxation.
■ The first part of the maneuver consists of returning the
head to an OA or OP position.
■ The operator flexes the head and slowly pushes it back
into the vagina. Cesarean delivery is then performed.
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
Photo grabbed from: http://mdmspgprep.com/
19. Last resort maneuvers: Symphysiotomy
■ the intervening symphyseal cartilage and
much of its ligamentous support is cut to
widen the symphysis pubis.
■ Maternal morbidity can be significant due
to urinary tract injury.
Photo from: www.heidimates.blogspot.com
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
20. Shoulder Dystocia Drill
1. Call for help—mobilize assistants and anesthesia and pediatric personnel. Initially, a gentle
attempt at traction is made. Drain the bladder if it is distended.
2. A generous episiotomy may be desired at this time to afford room posteriorly.
3. Suprapubic pressure is used initially by most practitioners because it has the advantage of
simplicity. Only one assistant is needed to provide suprapubic pressure, while normal downward
traction is applied to the fetal head.
4. The McRoberts maneuver requires two assistants. Each assistant grasps a leg and sharply flexes
the maternal thigh toward the abdomen.
These maneuvers will resolve most cases of shoulder dystocia. If the above listed steps fail, the
following steps may be attempted, and any of the maneuvers may be repeated:
5. Delivery of the posterior arm is attempted. With a fully extended arm, however, this is usually
difficult to accomplish.
6. Woods screw maneuver is applied.
7. Rubin maneuver is attempted.
TIME LIMIT:
4 minutes
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
Sheffield JS (eds).William’s Obstetrics 25th
edition; chapter 23 Abnormal Labor
22. HELPERR mnemonics
■ Help: call for Help
■ Evaluate for Episiotomy
■ Legs: McRoberts position
■ Pressure: Suprapubic pressure
■ Enter Maneuvers: perform internal rotation
■ Remove the posterior arm
■ Roll patient onto all fours
Lok et al. BMC Pregnancy and Childbirth (2016) 16:334
23. BE CALM mnemonics
■ Breathe, do not push
■ Elevate the legs ito McRoberts position
■ Call for help
■ Apply suprapubic pressure
■ EnLarge the vaginal opening: perform episiotomy if more room is needed for
maneuvers
■ Maneuvers deliver the posterior arm or perform rotational maneuvers
Lok et al. BMC Pregnancy and Childbirth (2016) 16:334
24. ALARMER mnemonics
■ Apply suprapubic pressure and ask for help
■ Legs – hyperflex legs (McRoberts maneuver)
■ Anterior shoulder dysimpaction (suprapubic pressure)
■ Release posterior shoulder
■ Maneuver of Woods (Woods corkscrew maneuver)
■ Episiotomy
■ Roll onto all 4s
ALARM International
25. Thank you!
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