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Shoulder dystocia
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Randall C. Floyd, James S. Smeltzer
The recognition of the possibility of a large infant is definitely beneficial for management during labor. Labor disorders of all types are more common in pregnancies destined for shoulder dystocia (9,24,38). All studies with a significant number of operative vaginal delivery cases clearly indicate that there is a three- to sixfold increased risk for shoulder dystocia in association with abnormal labor curves. Infants over 4000 g with operative vaginal delivery, especially mid-pelvic delivery, have a several-fold increased risk (23%) for shoulder dystocia (9,38). Macrosomic infants of diabetic mothers have even a greater risk of shoulder dystocia (50%) and subsequent traumatic injury (24). It is uncertain whether operative vaginal delivery causes birth of the head when the shoulders are too large to follow or fails to give the shoulders time to follow the proper mechanism for birth. In any case, nonemergent operative vaginal delivery should be avoided in those patients with anticipated large infants. The mnemonic for the above becomes DODOPE (disordered labor, operative vaginal delivery, diabetes, obesity, prolonged pregnancy, and excessive fetal size or maternal weight gain), an association that is, hopefully, becoming extinct. The exceptions are cases of fetal distress and severe maternal disease, in which the actual risks of additional time to delivery or cesarean section must be weighed against the potential risk of shoulder dystocia individually.
Midwifery and obstetrics
Published in Roy Palmer, Diana Wetherill, Medicine for Lawyers, 2020
Beverley Gordon, Gareth Thomas
When labour fails to progress in the first stage there is no option but to deliver by EmLSCS. When there is failure to progress in the second stage and the presentation is by the head (cephalic) it is possible to effect most deliveries by operative vaginal delivery using mid-cavity forceps or, more commonly, the Ventouse vacuum extractor. The choice will depend mainly on the experience of the operator. Efforts are made to assist the uterine contractions and maternal effort in order to effect delivery. Guidelines suggest that it is unwise to persist through more than three contractions unless there is evidence of obvious progress.
Management of pregnancy with a history of shoulder dystocia and difficult delivery
Published in Minakshi Rohilla, Recurrent Pregnancy Loss and Adverse Natal Outcomes, 2020
A prolonged second stage during vaginal birth in diabetic women with estimated fetal weight of 4000–4500 g or 5000 g in nondiabetic mothers and therefore an increased incidence of operative vaginal delivery can predispose these women to the risk of shoulder dystocia. The principle of intrapartum cesarean delivery over and above low pelvic or outlet operative vaginal delivery in order to prevent morbidity from shoulder dystocia should be applied in such situations [3]. No specific abnormalities of the second stage of labor, such as either prolonged labor or precipitate labor, could predict the occurrence of shoulder dystocia or neonatal injury with accuracy. Results of the comparison of 276 consecutive cases of shoulder dystocia with 600 matched controls showed similar outcomes, even in diabetic women or with suspected fetal macrosomia. It is important for the attending clinicians to be fully aware of predisposing risk factors for shoulder dystocia in labor, and they should anticipate and be prepared to manage it if it occurs [36].
Enhancing interprofessional collaboration and interprofessional education in women’s health
Published in Medical Education Online, 2022
Laura Baecher-Lind, Angela C. Fleming, Rashmi Bhargava, Susan M. Cox, Elise N. Everett, David A. Forstein, Shireen Madani Sims, Helen K. Morgan, Christopher M. Morosky, Celeste S. Royce, Tammy S. Sonn, Jill M. Sutton, Scott C. Graziano
Obstetrics and Gynecology has long been a collaborative specialty. Even well into the 20th century, women sought care from traditional birth attendants for expertise in pregnancy and childbirth rather than from a physician. In the 1940s, nurse midwifery was promoted by public health nurses, social reformers, and obstetricians in order to reduce maternal morbidity and mortality [10]. Expertise in pregnancy and childbirth is now shared between obstetricians and other health-care providers including nurse midwives, family medicine physicians, women’s health nurse practitioners, physician assistants, and doulas. Nearly 13% of women in the USA choose a midwife rather than an obstetrician for their care [11]. Women receiving care with midwives experience fewer interventions in labor and have reduced risks of cesarean section or operative vaginal delivery [12]. It is recognized that increasing access to and learning best practices from nurse midwifery may be a primary strategy to continuing to reduce maternal morbidity and mortality in the USA [11–13]. Team-training, a form of interprofessional education, has been shown to reduce rates of adverse obstetric events including return to the operating room and birth injury [14].
Time and mode of delivery in diabetic pregnancy: a review
Published in Gynecological Endocrinology, 2020
Roman Kapustin, Olga Arzhanova, Elena Alekseenkova, Adrey Glotov
Taking into account the ambiguity of the obtained data, a randomized multicenter study was initiated by GINEXMAL (Gestational Diabetes Induction Expectant Management of Labor) in 2011 [37]. The main objective was to get a proper answer for two questions: (a) whether the IOL raises CS frequency for women with GDM and (b) whether the IOL decreases fetal macrosomia frequency. The study design was based on comparison of obstetrical indications in women with GDM who underwent IOL against expectant management until week 41 followed by IOL. The comparison gave the following main results:The weight of newborns in IOL group was definitely lower compared to the expectant management group.IOL definitely does not increase CS frequency (12.6% against 11.8%; RR 1.06, 95% CI 0.64–1.77).Cesarean and operative vaginal delivery frequency was 21.0% in IOL group and was equitable (22.3%) to that in expectant management group RR 2.46 95% CI 1.11–5.46).Neonatal outcomes showed higher hyperbilirubinemia rate in newborns from women with IOL at 38 week (10% against 4.1%, RR 2.46 95% CI 1.11–5.46).
The clinical management of factor XI deficiency in pregnant women
Published in Expert Review of Hematology, 2020
Allison P. Wheeler, Celeste Hemingway, David Gailani
Risk of intracranial hemorrhage in infants with severe and partial FXI deficiency is likely similar to that of infants without a bleeding disorder. However, the FXI status of the neonate will in most cases be unknown at the time of delivery and conservative management should be considered. Based on recommendations for delivery of neonates at risk of having severe hemophilia (factor VIII or IX deficiencies), certain traumatic procedures should be avoided in the intrapartum period and until the neonate’s factor activity is known. Operative vaginal delivery with forceps or vacuum assistance should be avoided, as well as invasive monitors such as fetal scalp electrodes. Vitamin K and Hepatitis B immunization can be administered by intramuscular injection; however, pressure should be held for 15 minutes after injection to reduce the chances of bleeding. Additional intramuscular injections, heel sticks, and invasive procedures, including circumcision for male neonates, should be delayed until FXI activity is known to allow for increased monitoring or hemostatic support if needed. Of note, normal FXI activity in neonates is substantially lower than in adults [61,62], and formal diagnosis of FXI deficiency may need to be delayed until the infant is 6 months old (corrected for gestational age).