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Fetal Malpresentation

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161. Gynecologic Myomectomy (Overview)

. Pedunculated myomas can undergo torsion, causing the same severe pain as torsion of the ovary. Large myomas can outgrow their blood supply, leading to infarction and necrosis (degenerating myoma), which can be extremely painful. Lastly, prolapse of a myoma can be acutely painful. Although general agreement is lacking on the mechanism, myomas are also thought to be related to infertility, fetal malpresentations, and preterm labor. Possible mechanisms for infertility include distortion of the endometrial

2014 eMedicine.com

162. Eclampsia (Overview)

has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness that vaginal delivery is preferable from a maternal standpoint. Adequate maternal pain relief for labor and delivery is vital and may be provided with either systemic opioids or epidural anesthesia. In the absence of fetal malpresentation or fetal distress, oxytocin or prostaglandins may be initiated to induce labor. Cesarean delivery may be considered in patients with an unfavorable (...) of hypertension with proteinuria has been demonstrated to occur in 38% of cases reported in the United Kingdom. [ ] Similarly, hypertension was absent in 16% of cases reviewed in the United States. [ ] The clinical manifestations of maternal preeclampsia are hypertension and proteinuria with or without coexisting systemic abnormalities involving the kidneys, liver, or blood. There is also a fetal manifestation of preeclampsia involving fetal growth restriction, reduced amniotic fluid, and abnormal fetal

2014 eMedicine.com

163. Early Pregnancy Loss (Overview)

, and malpresentation, although many women with such defects may have uncomplicated pregnancies. Most commonly, the complications result from impaired vascularization and fetal growth restriction. The incidence of uterine anomalies is estimated to be 1 per 200-600 women, depending on the method used for diagnosis. When manual exploration is performed at the time of delivery, uterine anomalies are found in approximately 3% of women. However, uterine abnormalities are present in approximately 27% of women (...) with a history of pregnancy loss. Uterine müllerian anomalies The most common uterine defects include septate, unicornuate, bicornuate, and didelphic uteri. Of these, the unicornuate uterus is least common, but can result in malpresentation and fetal growth restriction. The highest rate of reproductive losses are found in bicornuate uteri (47%) compared with unicornuate uteri (17%), but both are frequently associated with second trimester loss and preterm delivery. Women with unicornuate and didelphys uteri

2014 eMedicine.com

164. Eclampsia (Treatment)

delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness that vaginal delivery is preferable from a maternal standpoint. Adequate maternal pain relief for labor and delivery is vital and may be provided with either systemic opioids or epidural anesthesia. In the absence of fetal malpresentation or fetal distress, oxytocin or prostaglandins may be initiated to induce labor. Cesarean delivery may (...) in the absence of hypertension with proteinuria has been demonstrated to occur in 38% of cases reported in the United Kingdom. [ ] Similarly, hypertension was absent in 16% of cases reviewed in the United States. [ ] The clinical manifestations of maternal preeclampsia are hypertension and proteinuria with or without coexisting systemic abnormalities involving the kidneys, liver, or blood. There is also a fetal manifestation of preeclampsia involving fetal growth restriction, reduced amniotic fluid

2014 eMedicine.com

165. Early Pregnancy Loss (Treatment)

, and malpresentation, although many women with such defects may have uncomplicated pregnancies. Most commonly, the complications result from impaired vascularization and fetal growth restriction. The incidence of uterine anomalies is estimated to be 1 per 200-600 women, depending on the method used for diagnosis. When manual exploration is performed at the time of delivery, uterine anomalies are found in approximately 3% of women. However, uterine abnormalities are present in approximately 27% of women (...) with a history of pregnancy loss. Uterine müllerian anomalies The most common uterine defects include septate, unicornuate, bicornuate, and didelphic uteri. Of these, the unicornuate uterus is least common, but can result in malpresentation and fetal growth restriction. The highest rate of reproductive losses are found in bicornuate uteri (47%) compared with unicornuate uteri (17%), but both are frequently associated with second trimester loss and preterm delivery. Women with unicornuate and didelphys uteri

2014 eMedicine.com

166. Face Presentation (Treatment)

along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively. In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying (...) : Outcomes The incidence of perinatal morbidity and mortality and maternal morbidity has decreased due to the increased incidence of cesarean section delivery for malpresentation, including face and brow presentation. Neonates delivered in the face presentation exhibit significant facial and skull edema, which usually resolves within 24-48 hours. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress. In addition, fetal

2014 eMedicine.com

167. Premature Rupture of Membranes (Follow-up)

hours, expectant management and waiting for spontaneous labor may be considered in selected patients for the first 12-24 hours if a patient desires expectant management. The use of expectant management after the first 24 hours is questionable. Digital vaginal examinations should be avoided until labor is initiated; however, fetal presentation should be documented to avoid discovering malpresentation of the fetus long after admission for ROM. All patients with ROM should be asked to come (...) to the hospital to ensure fetal well being. The neonatal risks of expectant management of PROM include infection, placental abruption, fetal distress, fetal restriction deformities and pulmonary hypoplasia, and fetal/neonatal death. Fetal death does occur in approximately 1% of patients with PROM after viability who have been expectantly managed [ ] and in about 1:1000 term PROM. [ ] The primary determinant of neonatal morbidity and mortality is gestational age at delivery, again stressing the importance

2014 eMedicine.com

168. Abnormal Labor (Overview)

dilatation or lack of descent), and cephalopelvic disproportion (CPD). Friedman's original research in 1955 defined the following three stages of labor [ ] : The first stage starts with uterine contractions leading to complete cervical dilation and is divided into latent and active phases. In the latent phase, irregular uterine contractions occur with slow and gradual cervical effacement and dilation. The active phase is demonstrated by an increased rate of cervical dilation and fetal descent. The active (...) for multiparous women . [ ] ACOG has also stated that extending the time from 2 to 4 hours with oxytocin augmentation appears effective. Irrespective of the duration, maternal and fetal well-being status must be confirmed. In another study it was found that extending oxytocin augmentation for an additional 4 hours, up to 8 hours total, in patients who were dilated at least 3cm and had unsatisfactory progress resulted in a greater number of vaginal deliveries (38% delivered vaginally) without any evidence

2014 eMedicine.com

169. Early Pregnancy Loss (Follow-up)

, and malpresentation, although many women with such defects may have uncomplicated pregnancies. Most commonly, the complications result from impaired vascularization and fetal growth restriction. The incidence of uterine anomalies is estimated to be 1 per 200-600 women, depending on the method used for diagnosis. When manual exploration is performed at the time of delivery, uterine anomalies are found in approximately 3% of women. However, uterine abnormalities are present in approximately 27% of women (...) with a history of pregnancy loss. Uterine müllerian anomalies The most common uterine defects include septate, unicornuate, bicornuate, and didelphic uteri. Of these, the unicornuate uterus is least common, but can result in malpresentation and fetal growth restriction. The highest rate of reproductive losses are found in bicornuate uteri (47%) compared with unicornuate uteri (17%), but both are frequently associated with second trimester loss and preterm delivery. Women with unicornuate and didelphys uteri

2014 eMedicine.com

170. Eclampsia (Follow-up)

delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness that vaginal delivery is preferable from a maternal standpoint. Adequate maternal pain relief for labor and delivery is vital and may be provided with either systemic opioids or epidural anesthesia. In the absence of fetal malpresentation or fetal distress, oxytocin or prostaglandins may be initiated to induce labor. Cesarean delivery may (...) in the absence of hypertension with proteinuria has been demonstrated to occur in 38% of cases reported in the United Kingdom. [ ] Similarly, hypertension was absent in 16% of cases reviewed in the United States. [ ] The clinical manifestations of maternal preeclampsia are hypertension and proteinuria with or without coexisting systemic abnormalities involving the kidneys, liver, or blood. There is also a fetal manifestation of preeclampsia involving fetal growth restriction, reduced amniotic fluid

2014 eMedicine.com

171. Surgical Management of Mullerian Duct Anomalies (Follow-up)

outcomes are generally poor in this group. Unicornuate uterus is associated with the poorest fetal survival among all müllerian anomalies. [ ] Cesarean delivery rates are high. Common obstetrical complications include malpresentation, intrauterine growth retardation, and preterm birth. [ , ] A review of compiled data from several studies of uterine anomalies and pregnancy outcomes revealed that the unicornuate uterus had the poorest overall reproductive outcomes of all the uterine anomalies. Problems

2014 eMedicine.com

172. Cesarean Delivery (Follow-up)

clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. The most common indications for primary cesarean delivery include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the primary cesarean delivery rate will require different approaches for these indications, as well as others. Increasing (...) . [ ] The emerging consensus is that a randomized prospective study is required to address this issue. [ ] Fetal indications Fetal indications for cesarean delivery include the following: Situations in which neonatal morbidity and mortality could be decreased by the prevention of trauma Malpresentations Certain congenital malformations or skeletal disorders Infection Prolonged acidemia A fetus in a nonvertex presentation is at increased risk for trauma, cord prolapse, and head entrapment. Malpresentation

2014 eMedicine.com

173. Cervical Ripening (Follow-up)

with an "unfavorable" or unripened cervix. Previous Next: Contraindications to Cervical Ripening Contraindications to cervical ripening include, but are not limited to, the following: Active herpes Fetal malpresentation Nonreassuring fetal surveillance History of prior traumatic delivery Regular contractions Unexplained vaginal bleeding Placenta previa Vasa previa Prior uterine myomectomy involving the endometrial cavity or classical cesarean delivery Previously, a history of a prior low transverse cesarean (...) in response to uterine contractions, allowing the cervix to easily pass over the presenting fetal part during labor. In late pregnancy, hyaluronic acid content increases in the cervix. This leads to an increase in water molecules that intercalate among the collagen fibers. The amount of dermatan sulfate decreases, leading to reduced bridging among the collagen fibers and a corresponding decrease in cervical firmness. Chondroitin sulfate also decreases. Cervical ripening is associated with decreased

2014 eMedicine.com

174. Face Presentation (Follow-up)

along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively. In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying (...) : Outcomes The incidence of perinatal morbidity and mortality and maternal morbidity has decreased due to the increased incidence of cesarean section delivery for malpresentation, including face and brow presentation. Neonates delivered in the face presentation exhibit significant facial and skull edema, which usually resolves within 24-48 hours. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress. In addition, fetal

2014 eMedicine.com

175. Umbilical Cord Complications (Follow-up)

the cervix into the vagina is significant. Occult prolapse occurs when the cord lies alongside the presenting part. Cord prolapse occurs in 0.6% of deliveries. The risk is increased with fetal malpresentations, especially when the presenting part does not fill the lower uterine segment, as is the case with incomplete breech presentations (5-10%), premature infants, and multiparous women. [ ] Causes include abnormal presentation, a long umbilical cord, polyhydramnios, prematurity, and an unengaged (...) Complications Updated: Jun 01, 2018 Author: Marie Helen Beall, MD; Chief Editor: Christine Isaacs, MD Share Email Print Feedback Close Sections Sections Umbilical Cord Complications Overview Overview Umbilical cord abnormalities are numerous, ranging from false knots, which have no clinical significance, to vasa previa, which often leads to fetal death. As prenatal ultrasonography becomes increasingly sophisticated, many of these conditions are being diagnosed in utero. However, many are not apparent before

2014 eMedicine.com

176. Uterine Rupture in Pregnancy (Follow-up)

=aHR0cHM6Ly9yZWZlcmVuY2UubWVkc2NhcGUuY29tL2FydGljbGUvMjc1ODU0LW92ZXJ2aWV3 processing > Uterine Rupture in Pregnancy Updated: Jul 05, 2018 Author: Gerard G Nahum, MD, FACOG, FACS; Chief Editor: Christine Isaacs, MD Share Email Print Feedback Close Sections Sections Uterine Rupture in Pregnancy Overview Overview Uterine rupture in pregnancy is a rare and often catastrophic complication with a high incidence of fetal and maternal morbidity. Numerous factors are known to increase the risk of uterine rupture, but even in high-risk subgroups, the overall incidence (...) clinically significant fetal morbidity becomes inevitable. Fetal morbidity occurs as a result of catastrophic hemorrhage, fetal anoxia, or both. The premonitory signs and symptoms of uterine rupture are inconsistent, and the short time for instituting definitive therapeutic action makes uterine rupture in pregnancy a much feared event for medical practitioners. Definition Uterine rupture during pregnancy is a rare event and frequently results in life-threatening maternal and fetal compromise. It can

2014 eMedicine.com

177. Polyhydramnios and Oligohydramnios (Overview)

of the membranes (PROM), abruptio placenta, malpresentation, and postpartum hemorrhage. [ ] Studies show an increased risk of associated fetal anomalies in more severe forms of polyhydramnios. In a series, 20% of cases of polyhydramnios involved associated fetal anomalies, including problems of the gastrointestinal system (40%), central nervous system (26%), cardiovascular system (22%), or genitourinary system (13%). [ ] Among these cases of polyhydramnios, multiple gestations occurred in 7.5%, 5% were due (...) > Polyhydramnios and Oligohydramnios Updated: Sep 20, 2017 Author: Brian S Carter, MD, FAAP; Chief Editor: Dharmendra J Nimavat, MD, FAAP Share Email Print Feedback Close Sections Sections Polyhydramnios and Oligohydramnios Overview Background The amniotic fluid that bathes the fetus is necessary for its proper growth and development. It cushions the fetus from physical trauma, permits fetal lung growth, and provides a barrier against infection. Normal amniotic fluid volume varies. The average volume increases

2014 eMedicine Pediatrics

178. Polyhydramnios and Oligohydramnios (Diagnosis)

of the membranes (PROM), abruptio placenta, malpresentation, and postpartum hemorrhage. [ ] Studies show an increased risk of associated fetal anomalies in more severe forms of polyhydramnios. In a series, 20% of cases of polyhydramnios involved associated fetal anomalies, including problems of the gastrointestinal system (40%), central nervous system (26%), cardiovascular system (22%), or genitourinary system (13%). [ ] Among these cases of polyhydramnios, multiple gestations occurred in 7.5%, 5% were due (...) > Polyhydramnios and Oligohydramnios Updated: Sep 20, 2017 Author: Brian S Carter, MD, FAAP; Chief Editor: Dharmendra J Nimavat, MD, FAAP Share Email Print Feedback Close Sections Sections Polyhydramnios and Oligohydramnios Overview Background The amniotic fluid that bathes the fetus is necessary for its proper growth and development. It cushions the fetus from physical trauma, permits fetal lung growth, and provides a barrier against infection. Normal amniotic fluid volume varies. The average volume increases

2014 eMedicine Pediatrics

179. Abnormal Labor (Diagnosis)

dilatation or lack of descent), and cephalopelvic disproportion (CPD). Friedman's original research in 1955 defined the following three stages of labor [ ] : The first stage starts with uterine contractions leading to complete cervical dilation and is divided into latent and active phases. In the latent phase, irregular uterine contractions occur with slow and gradual cervical effacement and dilation. The active phase is demonstrated by an increased rate of cervical dilation and fetal descent. The active (...) for multiparous women . [ ] ACOG has also stated that extending the time from 2 to 4 hours with oxytocin augmentation appears effective. Irrespective of the duration, maternal and fetal well-being status must be confirmed. In another study it was found that extending oxytocin augmentation for an additional 4 hours, up to 8 hours total, in patients who were dilated at least 3cm and had unsatisfactory progress resulted in a greater number of vaginal deliveries (38% delivered vaginally) without any evidence

2014 eMedicine.com

180. Labor and Delivery, Normal Delivery of the Newborn

delivery is not imminent, placenta previa, suspected or confirmed cephalopelvic disproportion, fetal malpresentation, maternal instability, a history of multiple prior abdominal deliveries or of a vertical uterine scar, or active genital herpes. Controlled maternal pushing helps prevent deep perineal tearing. Prophylactic episiotomy is not recommended for routine births. The incidence of shoulder dystocia is increasing. A higher incidence is associated with macrosomia, although most cases occur (...) of the head after delivery to facilitate shoulder delivery Several clinical parameters are followed. The fetal presentation is determined by the first fetal body part that passes through the birth canal. Most commonly, this is the occiput or the vertex of the head. The fetal station is the relation of the fetal head to the maternal ischial spines. The station is defined as -5 cm to +5 cm; 0 station is at the level of the ischial spines. The fetal position is the orientation of the fetal vertex (the top

2014 eMedicine.com

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