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Prevention of Labor Dystocia

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162. Diabetes Mellitus and Pregnancy (Treatment)

pregnant women, the incidence is 2- to 4-fold higher in women with diabetes. Common birth injuries associated with diabetes are brachial plexus injury, facial nerve injury, and cephalohematoma. With strict glycemic control, the birth injury rate has been shown to be only slightly higher than controls (3.2 vs 2.5%). Currently, clinical ability to predict shoulder dystocia is poor. Warning signs during labor (labor protraction, suspected fetal macrosomia, need for operative vaginal delivery) successfully (...) Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes mellitus after 24 weeks of pregnancy. The recommendation applies to asymptomatic women with no previous diagnosis of type 1 or type 2 diabetes mellitus. [ , ] The recommendation does not specify whether the 1-step or 2-step screening approach would be preferable. Type 1 diabetes The disease is typically diagnosed during an episode of hyperglycemia, ketosis, and dehydration It is most commonly diagnosed in childhood

2014 eMedicine.com

163. Prenatal Nutrition (Treatment)

weight is defined as a BMI of 18.5-24.9 kg/m 2 . Overweight is defined as a BMI of 25-29.9 kg/m 2 . Obesity is defined as a BMI that exceeds 30 kg/m 2 . [ ] Birth weight is affected by pre-pregnancy BMI, independent of actual weight gain during pregnancy. Women who are underweight are at increased risk for low birth weight babies; women who are overweight or obese are at increased risk for macrosomic infants. Macrosomic infants are at increased risk for shoulder dystocia and brachial plexus injuries (...) women. Folate supplements should be administered 3 months prior to conception and throughout the first trimester. If the mother had a prior child affected by a neural tube defect, supplementation in the subsequent pregnancy should be increased to 4 mg/d. [ ] The US Preventative Services Task Force recommends a daily supplement of folic acid (0.4 to 0.8 mg) for all women who are planning or capable of pregnancy. [ ] Niacin Niacin is a water-soluble vitamin involved in the release of energy from cells

2014 eMedicine.com

164. Postterm Pregnancy (Treatment)

weeks gestation including meconium and meconium aspiration, neonatal acidemia, low Apgar scores, macrosomia, and, in turn, birth injury. For example, since postterm infants are larger than term infants, with a higher incidence of fetal macrosomia (defined as estimated fetal weight ≥ 4,500 g) [ ] , they are, in turn, at greater risk for other complications. [ , ] Such complications associated with fetal macrosomia include prolonged labor, cephalopelvic disproportion, and shoulder dystocia (...) elective induction of labor to expectant management of pregnancy. [ ] However, elective induction of labor is increasingly being used as a management strategy. [ , ] While this management may be reasonable in a practice that allows 48 hours or more for the management of the latent phase and the first stage of labor overall, in a setting where induction of labor is called a failure after 18-24 hours, it will likely further increase the cesarean delivery rate. Previous Next: Prevention of Postterm

2014 eMedicine.com

165. Forceps Delivery (Treatment)

studies have not found this association. [ ] In addition, cerebral palsy and subtly lower IQ (2.5 points) have been described in infants delivered by forceps; however, it is not apparent whether the association of shoulder dystocia and fetal CNS injury is with the forceps delivery per se, or with prolonged and difficult labors. Towner et al examined the risk of intracranial hemorrhage in 583,340 live-born singleton infants born to nulliparous women between 1992 and 1994 and weighing between 2500 g (...) the procedure. Maternal verbal consent should be obtained prior to the forceps attempt, although the procedure may need to be performed emergently or after the mother has been medicated. If a planned forceps delivery is to be performed (ie, for maternal medical indications), counseling and consent may be completed prior to the onset of active labor. The type of forceps to be used depends on the specific indications and conditions. The most commonly used forceps are Simpson forceps, which are used to deliver

2014 eMedicine.com

166. Breech Presentation (Treatment)

is imminent, even in multiparas, as it may help prevent soft tissue dystocia for the aftercoming head (see the images below). Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid. Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery (...) . Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia. The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only after the fetal umbilicus has been reached. Pressure is exerted in the popliteal space of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina. No traction should be exerted on the infant until the fetal umbilicus is past the perineum

2014 eMedicine.com

167. Birth Trauma (Treatment)

of labor must be appropriate. Occasionally, injury may be sustained in utero. Previous Next: Bone Injury Fractures are most often observed following breech delivery, shoulder dystopia, or both in infants with excessive birth weights. Clavicular fracture The clavicle is the most frequently fractured bone in the neonate during birth; this is most often an unpredictable, unavoidable complication of normal birth. [ ] Some correlation with birth weight, midforceps delivery, and shoulder dystocia (...) damage, edema, hemorrhage, or fracture in the neonate. The use of obstetric instrumentation may further amplify the effects of such forces or may induce injury alone. Under certain conditions, cesarean delivery can be an acceptable alternative but does not guarantee an injury-free birth. Factors predisposing to injury include the following: Prima gravida Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies Prolonged or rapid labor Deep, transverse arrest of descent

2014 eMedicine Pediatrics

168. Birth Trauma (Overview)

of labor must be appropriate. Occasionally, injury may be sustained in utero. Previous Next: Bone Injury Fractures are most often observed following breech delivery, shoulder dystopia, or both in infants with excessive birth weights. Clavicular fracture The clavicle is the most frequently fractured bone in the neonate during birth; this is most often an unpredictable, unavoidable complication of normal birth. [ ] Some correlation with birth weight, midforceps delivery, and shoulder dystocia (...) damage, edema, hemorrhage, or fracture in the neonate. The use of obstetric instrumentation may further amplify the effects of such forces or may induce injury alone. Under certain conditions, cesarean delivery can be an acceptable alternative but does not guarantee an injury-free birth. Factors predisposing to injury include the following: Prima gravida Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies Prolonged or rapid labor Deep, transverse arrest of descent

2014 eMedicine Pediatrics

169. Cesarean Delivery (Diagnosis)

of maternal trauma and fetal trauma (eg, Erb-Duchenne or Klumpke palsy and metabolic acidosis) from a shoulder dystocia. [ , ] Among women who have a uterine scar (prior transmural myomectomy or cesarean delivery by high vertical incision), a cesarean delivery should be performed prior to the onset of labor to prevent the risk of , which is approximately 4-10%. [ ] Contraindications There are few contraindications to performing a cesarean delivery. If the fetus is alive and of viable gestational age (...) 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

2014 eMedicine.com

170. Diabetes Mellitus and Pregnancy (Diagnosis)

pregnant women, the incidence is 2- to 4-fold higher in women with diabetes. Common birth injuries associated with diabetes are brachial plexus injury, facial nerve injury, and cephalohematoma. With strict glycemic control, the birth injury rate has been shown to be only slightly higher than controls (3.2 vs 2.5%). Currently, clinical ability to predict shoulder dystocia is poor. Warning signs during labor (labor protraction, suspected fetal macrosomia, need for operative vaginal delivery) successfully (...) Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes mellitus after 24 weeks of pregnancy. The recommendation applies to asymptomatic women with no previous diagnosis of type 1 or type 2 diabetes mellitus. [ , ] The recommendation does not specify whether the 1-step or 2-step screening approach would be preferable. Type 1 diabetes The disease is typically diagnosed during an episode of hyperglycemia, ketosis, and dehydration It is most commonly diagnosed in childhood

2014 eMedicine.com

171. Breech Presentation (Diagnosis)

is imminent, even in multiparas, as it may help prevent soft tissue dystocia for the aftercoming head (see the images below). Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid. Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery (...) . Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia. The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only after the fetal umbilicus has been reached. Pressure is exerted in the popliteal space of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina. No traction should be exerted on the infant until the fetal umbilicus is past the perineum

2014 eMedicine.com

172. Pregnancy, Breech Delivery (Diagnosis)

. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia. Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached. Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal (...) the Table below). However, the overall frequency is 3-4% at delivery. [ ] Table. Gestational age and frequency of breech birth Gestational Age, Weeks Breech, % 21-24 33 25-28 28 29-32 14 33-36 9 37-40 3-4 International The international incidence has been reported at 3-4%. [ ] Mortality/Morbidity See the list below: Many complications are associated with a breech presentation in labor. This may be due to the underlying etiology of the breech presentation, such as fetal anomalies or polyhydramnios

2014 eMedicine Emergency Medicine

173. Uterine Rupture in Pregnancy (Treatment)

, shoulder dystocia, manual extraction of placenta) Fundal pressure Uterine trauma includes the following: Direct uterine trauma (eg, motor vehicle accident, fall) Violence (eg, gunshot wound, blunt blow to abdomen) Next: Rupture of the Unscarred Uterus The normal, unscarred uterus is least susceptible to rupture. Grand multiparity, neglected labor, malpresentation, breech extraction, and uterine instrumentation are all predisposing factors for uterine rupture. A 10-year Irish study by Gardeil et al (...) after cesarean, VBAC, trial of labor (TOL), trial of labor after cesarean (TOLAC), uterine scar dehiscence, and pregnancy and myomectomy. Standard reference tracing was also used. Articles published from 1976 through May, 2012 that described the incidence of uterine rupture and that included sufficient information regarding the authors' definitions of uterine rupture and of uterine scar dehiscence were incorporated for review. All studies were observational or reviews. A total of 133 published

2014 eMedicine.com

174. Malposition of the Uterus (Treatment)

retroversion, aneurysmal dilatation of the superior uterine wall (sacculation) may permit the uterus to expand abdominally. [ , , ] If this occurs, the pregnancy may progress even into the third trimester. In such instances, the correct diagnosis is established only when dystocia in labor ensues or when abdominal and/or pelvic examination reveals markedly unusual findings that lead to an MRI study. In the rare case that reaches the third trimester, the uterine malpositioning is fixed, cesarean delivery (...) [ ] Uterine Torsion, degrees (n = 212) Signs and Symptoms* Intestinal Urinary Pain Shock (Hemorrhage) Labor Dystocia Other† None ≤90 (n = 66) 10 5 43 4 (6) 7 13 9 >90 to 180 (n = 122) 17 91 22 (13) 19 19 14 >180 to 360 (n = 14) 7 10 14 6 (1) 3 3 0 >360 (n = 6) 0 0 6 6 (1) 6 6 0 Unknown (n = 4) 0 0 4 2 (0) 0 0 0 *Some cases include more than 1 sign or symptom. † Hypertonic uterus, PROM, pre-eclampsia, uterine rupture, etc Pathophysiology In a uterine torsion, the uterus twists more than 45° around its long

2014 eMedicine.com

175. Macrosomia (Treatment)

with reduced risk of shoulder dystocia, however the study was underpowered to detect a difference in brachial plexus injury and none occurred in either group. In addition, induction of labor did not increase cesarean section rate as people have feared. A Cochrane systematic review of four RCTs that included 1190 patients examined outcomes with induction of labor for large for gestational age. [ ] The Boulvain RCT contributed 800 of the 1190 patients and dominated the findings of the review. The review (...) concluded that induction of labor in suspected fetal macrosomia does not reduce the risk of brachial plexus injury but does reduce birth weight, as well as risk of skeletal injury and shoulder dystocia. [ ] Macrosomia is related to perinatal complications and the term fetus increases its body mass approximately 150-200g per week. Early term or 39-week induction of labor can reduce rates of macrosomia compared with expectant management, and therefore may decrease the complications of macrosomia

2014 eMedicine.com

176. Neonatal Brachial Plexus Palsies (Treatment)

mobility and strengthening initially are facilitated through age-appropriate developmental activities. As the child gets older, standard strengthening exercises are used and specific functional skills are introduced. Specific muscle groups can be targeted for strengthening through functional movement. Compensatory and substitute movements should be avoided, as they may perpetuate weak muscles and deformity. Static and dynamic splinting of the arm is useful to reduce contractures, prevent further (...) about whether EMG provides useful prognostic information to select appropriate surgical candidates (see Other Tests). [ ] Unfortunately, the lack of uniform outcome measures and of large, controlled studies has prevented this debate from being put to rest. Many authors do agree that early surgery should be considered in children who have injuries affecting the entire brachial plexus (ie, C5-T1). Two neurosurgical options (ie, neurolysis vs excision of the neuroma and nerve graft reconstruction

2014 eMedicine.com

177. Cesarean Delivery (Treatment)

of maternal trauma and fetal trauma (eg, Erb-Duchenne or Klumpke palsy and metabolic acidosis) from a shoulder dystocia. [ , ] Among women who have a uterine scar (prior transmural myomectomy or cesarean delivery by high vertical incision), a cesarean delivery should be performed prior to the onset of labor to prevent the risk of , which is approximately 4-10%. [ ] Contraindications There are few contraindications to performing a cesarean delivery. If the fetus is alive and of viable gestational age (...) 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

2014 eMedicine.com

179. Teratology and Drug Use During Pregnancy (Treatment)

of these medications. [ ] Thus, the 5-letter system is being phased out over the next 3 years in favor of a more comprehensive system with a narrative summary of the risks posed by drugs. The FDA, the government agency that oversees the safety of drugs, provides the most widely used system to grade the teratogenic effects of medications. Each drug summary will have three sections: pregnancy, lactation, and females and males of reproductive potential. “Pregnancy” merges previous categories of “pregnancy” and “labor (...) . If there is more than one risk based on human data, the information should be placed in order of clinical importance. Clinical Considerations See the list below: Relevant information is presented under the following five headings, to the extent information is available: - Disease-associated maternal and/or embryo/fetal risk - Dose adjustments during pregnancy and the postpartum period - Maternal adverse reactions - Fetal/Neonatal adverse reactions - Labor or Delivery Data --Under the subheading Data, labeling

2014 eMedicine.com

180. Prenatal Nutrition (Overview)

weight is defined as a BMI of 18.5-24.9 kg/m 2 . Overweight is defined as a BMI of 25-29.9 kg/m 2 . Obesity is defined as a BMI that exceeds 30 kg/m 2 . [ ] Birth weight is affected by pre-pregnancy BMI, independent of actual weight gain during pregnancy. Women who are underweight are at increased risk for low birth weight babies; women who are overweight or obese are at increased risk for macrosomic infants. Macrosomic infants are at increased risk for shoulder dystocia and brachial plexus injuries (...) women. Folate supplements should be administered 3 months prior to conception and throughout the first trimester. If the mother had a prior child affected by a neural tube defect, supplementation in the subsequent pregnancy should be increased to 4 mg/d. [ ] The US Preventative Services Task Force recommends a daily supplement of folic acid (0.4 to 0.8 mg) for all women who are planning or capable of pregnancy. [ ] Niacin Niacin is a water-soluble vitamin involved in the release of energy from cells

2014 eMedicine.com

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