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Umbilical Cord Prolapse

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121. Vacuum Extraction (Overview)

relationship, operator skill, and a judgment of the severity of risk dictate the mode of delivery. In most cases, cord prolapse, , or persistent bradycardia at a high station, even with full dilation with an engaged head are best managed by a cesarean delivery. Evaluation must be undertaken to assess if vaginal delivery can be safely and readily achieved before proceeding. Maternal medical disorders Certain maternal disorders preclude the ability of the mother to safely Valsalva. Typically, cardiac (...) , Guzman ER, Knuppel RA. Effect of vacuum extraction on umbilical cord blood acid-base measurements. J Matern Fetal Med . 1996 Jan-Feb. 5(1):11-7. . Nilsen ST. Boys born by forceps and vacuum extraction examined at 18 years of age. Acta Obstet Gynecol Scand . 1984. 63:548-54. Johanson RB, Heycock E, Carter J. Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse. Br J Obstet Gynaecol . 1999 Jun. 106(6):544-9

2014 eMedicine.com

122. Management of the Third Stage of Labor (Follow-up)

women; therefore, caregivers and institutions must have management strategies in place to deal with these problems promptly when they arise. Signs of placental separation Traditionally, 4 signs of placental separation are taught. [ , ] The most reliable sign is the lengthening of the umbilical cord as the placenta separates and is pushed into the lower uterine segment by progressive uterine retraction. Placing a clamp on the cord near the perineum makes it easier to appreciate this lengthening (...) . Never place traction on the cord without countertraction on the uterus above the symphysis; otherwise, one may mistake cord lengthening due to impending prolapse or inversion for that of uncomplicated placental separation. The uterus takes on a more globular shape and becomes firmer. This occurs as the placenta descends into the lower segment and the body of the uterus continues to retract. This change may be clinically difficult to appreciate. The uterus rises in the abdomen. The descent

2014 eMedicine.com

123. Malposition of the Uterus (Follow-up)

or advanced diastasis recti associated with advanced multiparity. Presentation The clinical presentation is striking. A history of prior abdominal surgery or cesarean delivery via a midline incision or a prior, unrepaired umbilical hernia is noted. Beginning in the midtrimester when the uterus is sufficiently large so as to become an abdominal organ, it progressively prolapses anteriorly into the hernia sac. [ ] Varying degrees of this condition are observed. In the most extreme cases, the fundus (...) ) or in the immediate postpartum state, are simply normal variants. Uncommonly, obstetric complications result from acute or chronic changes in uterine shape or position prior to labor (retroversion or incarceration, prolapse, torsion, herniation or sacculation), during labor (pathologic retractions rings), or postpartum (acute or chronic inversion). [ ] The most common uterine malpositioning seen during pregnancy, retroversion with incarceration, is depicted below. Uterine retroversion and incarceration

2014 eMedicine.com

124. Congenital Malformations, Larynx

report documented survivors of such lesions. Etiology and pathogenesis Failure of recanalization of the laryngotracheal tube during the third month of gestation leads to laryngeal atresia. Clinical presentation Laryngeal atresia manifests as an acute airway obstruction in the newborn immediately after clamping the umbilical cord. Examination reveals a neonate with severe respiratory distress marked by strong respiratory efforts and inability to inhale air or cry. Without immediate airway management (...) , prenatal tests are not available to help establish this diagnosis because polyhydramnios is absent. Management The management of laryngeal atresia involves immediate tracheotomy at birth. If the diagnosis is anticipated, avoid clamping the umbilical cord until the tracheotomy is secured to maximize oxygenation of the newborn. In patients with fistulas, mask ventilation and esophageal intubation can be used as temporary measures until a tracheotomy is performed. Laryngeal Cysts Epidemiology Laryngeal

2014 eMedicine Surgery

125. Cesarean Delivery (Follow-up)

. [ ] 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 (...) of antibiotic prophylaxis for cesarean delivery administered up to 60 minutes before skin incision rather than after umbilical cord clamping. [ , ] There is no benefit from oral antibiotics for eradication of MRSA colonization among patients in the health care setting, and oral antibiotics are not currently routinely recommended for the purpose of MRSA decolonization. Routine screening of obstetric patients for MRSA colonization is not recommended. For obstetric patients known to be MRSA colonized, a single

2014 eMedicine.com

126. Vacuum Extraction (Follow-up)

relationship, operator skill, and a judgment of the severity of risk dictate the mode of delivery. In most cases, cord prolapse, , or persistent bradycardia at a high station, even with full dilation with an engaged head are best managed by a cesarean delivery. Evaluation must be undertaken to assess if vaginal delivery can be safely and readily achieved before proceeding. Maternal medical disorders Certain maternal disorders preclude the ability of the mother to safely Valsalva. Typically, cardiac (...) , Guzman ER, Knuppel RA. Effect of vacuum extraction on umbilical cord blood acid-base measurements. J Matern Fetal Med . 1996 Jan-Feb. 5(1):11-7. . Nilsen ST. Boys born by forceps and vacuum extraction examined at 18 years of age. Acta Obstet Gynecol Scand . 1984. 63:548-54. Johanson RB, Heycock E, Carter J. Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse. Br J Obstet Gynaecol . 1999 Jun. 106(6):544-9

2014 eMedicine.com

127. Evaluation of Fetal Death (Follow-up)

of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory (...) influence estimates of recurrence and future preconceptional counseling, pregnancy management, prenatal diagnostic procedures, and neonatal management. Many institutions use a selective workup based on clinical findings. For example, when clinical findings strongly suggest a cause for the fetal demise at Santa Clara Valley Medical Center, either no further testing or limited testing is performed. Causes deemed fairly obvious include cord accident (ie, prolapse, entanglement, true knot, tight nuchal cord

2014 eMedicine.com

128. Breech Presentation (Follow-up)

and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation. Technique and tips for assisted vaginal breech delivery The fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent overt . Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned (...) , "star gazing"). Risks Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis. Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in 0-8.5% of vaginal breech deliveries. [ ] This percentage is higher with preterm

2014 eMedicine.com

129. Subcutaneous Fat Necrosis of the Newborn (Diagnosis)

, [ ] placenta previa, umbilical cord prolapse, anoxia, seizures, [ ] preeclampsia, maternal cocaine abuse, [ ] gestational diabetes, [ ] maternal use of calcium antagonists during pregnancy, [ ] familial dyslipidemia, and a family history of thrombophilia. [ ] Some evidence implicates a maternal hypercoagulable state such as protein C deficiency and antiphospholipid syndrome. [ ] Local pressure trauma during delivery from forceps, from prolonged labor, and from being large for gestational age (macrosomia

2014 eMedicine.com

130. Chronic Pain Syndrome (Diagnosis)

with multiple problems is complex, usually requiring specific treatment, simultaneous psychological treatment, and physical therapy (PT). [ , ] PT techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasonographic therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations. Other treatments include nerve blocks, spinal cord stimulation, and intrathecal morphine pumps. Next: Etiology The pathophysiology of chronic pain syndrome (CPS (...) [ , , , , ] Polymyalgia rheumatica Mechanical low back pain Muscular strains and sprains Pelvic floor myalgia (levator ani spasm) Piriformis syndrome (see the image below) Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full thickness of the nerve (sciatic neuritis). Rectus tendon strain Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian, perineal, umbilical) Abdominal wall myofascial pain (trigger points) Chronic

2014 eMedicine.com

131. Breech Presentation (Diagnosis)

and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation. Technique and tips for assisted vaginal breech delivery The fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent overt . Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned (...) , "star gazing"). Risks Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis. Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in 0-8.5% of vaginal breech deliveries. [ ] This percentage is higher with preterm

2014 eMedicine.com

132. Cesarean Delivery (Diagnosis)

. [ ] 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 (...) of antibiotic prophylaxis for cesarean delivery administered up to 60 minutes before skin incision rather than after umbilical cord clamping. [ , ] There is no benefit from oral antibiotics for eradication of MRSA colonization among patients in the health care setting, and oral antibiotics are not currently routinely recommended for the purpose of MRSA decolonization. Routine screening of obstetric patients for MRSA colonization is not recommended. For obstetric patients known to be MRSA colonized, a single

2014 eMedicine.com

133. Evaluation of Fetal Death (Diagnosis)

of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy. The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory (...) influence estimates of recurrence and future preconceptional counseling, pregnancy management, prenatal diagnostic procedures, and neonatal management. Many institutions use a selective workup based on clinical findings. For example, when clinical findings strongly suggest a cause for the fetal demise at Santa Clara Valley Medical Center, either no further testing or limited testing is performed. Causes deemed fairly obvious include cord accident (ie, prolapse, entanglement, true knot, tight nuchal cord

2014 eMedicine.com

134. Labor and Delivery, Normal Delivery of the Newborn

by uterine stimulation in 14% of patients in the prostaglandin arm, but none of those in the catheter arms, and mean cord arterial pH was lower in the prostaglandin arm (7.25 vs 7.26 in the catheter arms [ P =.050]). [ ] For more information, see article. Previous Next: Contraindications See the list below: While most full-term newborns in the United States are delivered vaginally, vaginal birth is contraindicated in some circumstances, including those described in this section. Cord prolapse When cord (...) prolapse is detected on pelvic examination, the clinician should leave the hand in place, applying pressure against the presenting fetal part to keep it as far out of the pelvis as possible to prevent cord compression. The incidence of cord prolapse is directly proportional to cord length. The treatment is immediate conversion to cesarean delivery. If not treated emergently, cord prolapse is associated with high perinatal mortality. Brow presentation This may convert to face or vertex presentation

2014 eMedicine.com

135. Down Syndrome (Follow-up)

is needed because of the associated risk of cervical spine instability. Preoperative evaluation for anesthesia must include adequate evaluation of the airway and the patient’s neurologic status. Cervical radiography (with flexion and extension views) should be performed when any neurologic deficit suggests spinal-cord compression. During laryngoscopy and intubation, the patient’s head should be maintained in a neutral position, and hyperextension should be avoided. Anticholinergics can be prescribed (...) difficulties that persist through the adolescent years Provide antibiotic prophylaxis during dental and surgical procedures in the presence of mitral valve prolapse Consider bone marrow transplantation if leukemia occurs Discuss sleep apnea, treat airway obstruction medically and surgically. Pay special attention to perioperative modalities because of atlantoaxial instability and problems with the respiratory system Screen for hypothyroidism and diabetes mellitus Manage neurologic problems, including

2014 eMedicine Pediatrics

136. Disorders of the Umbilicus (Follow-up)

. (F) Umbilical sinus ending in a fibrous cord attaching to the ileum. (G, H) Omphalomesenteric cyst and sinus without intestinal attachments. Photograph of newborn with intestinal prolapse through a patent omphalomesenteric duct. Both the proximal and distal limbs of the intestine have prolapsed. The umbilicus was explored, the bowel was easily reduced, and the patent duct was excised. The child was discharged from the hospital 2 days later. Anatomic relationship between the umbilicus and its (...) for a small port to perform laparoscopy. The umbilical vein (round ligament), the umbilical arteries (medial umbilical ligaments), and the urachus (median umbilical ligament) can often be identified. Umbilical region viewed from the posterior surface of the abdominal wall of an infant with the umbilical cord attached. UA: Umbilical artery; UV: Umbilical vein; RL: Round ligament (obliterated umbilical vein); UR: Umbilical ring; UL: Umbilical ligament; medial (obliterated umbilical arteries); median

2014 eMedicine Pediatrics

137. Pediatric Urologic Gynecology (Treatment)

bladder with a nonocclusive dressing (eg, plastic food wrap) to protect the bladder plate. To prevent unnecessary trauma, ligating the umbilical cord with silk ties rather than a plastic or metal clamp is best. Some children with bladder exstrophy develop functional bladder capacities, whereas others go on to develop small and poorly compliant bladders. The reason for this is not completely understood. The surgical management of bladder exstrophy involves bladder closure within the first days of life (...) . Skene glands (paraurethral glands) These tubular glands arise from the urethral epithelium and are the counterparts to the male prostatic glands. In females, Skene glands may end up in the urethral meatus and hymen. Cysts (tense, yellow, thin-walled) arising partially within the urethral meatus but mostly external to it may resemble a bulging hymen associated with hydrometrocolpos or a prolapsing ureterocele but are usually separate from the urethral opening. [ , ] Bartholin glands The major

2014 eMedicine Pediatrics

138. Minimal Access Surgery (Treatment)

; this is minimized by using carbon dioxide instead of other gases. This complication has also been reported during insufflation in infants when using an umbiical incision for entry. Inadvertent preperitoneal insufflation in a patient with a patent umbilical vein can lead to devastating consequences [ ] and should be considered when choosing access techniques in patients younger than 1 month. These complications can be minimized with the use of low pressure and warm humidified gas insufflation, slight (...) is typically performed with three stab wounds without trocars. [ ] The average operating time is approximately 15 minutes. Most patients (>90%) are discharged home within 24 hours. The laparoscopic approach is not universally accepted, because similar results can be achieved by means of Ramstedt pyloromyotomy via an umbilical incision. There is some evidence to suggest that the complication rate is lower with the laparoscopic approach. The cosmetic results of laparoscopic pyloromyotomy are superior

2014 eMedicine Pediatrics

139. Omphalocele and Gastroschisis (Treatment)

defects. Am J Surg . 2017 Jan 6. . Frybova B, Kokesova A, Zemkova D, Mixa V, Vlk R, Rygl M. Quality of life in patients with gastroschisis is comparable with the general population: A questionnaire survey. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub . 2016 Dec 13. . Zajac A, Bogusz B, Soltysiak P, et al. Cosmetic outcomes of sutureless closure in gastroschisis. Eur J Pediatr Surg . 2016 Dec. 26 (6):537-41. . Media Gallery Baby with an intact omphalocele. Baby with an umbilical cord hernia (...) of the urinary collecting system Performance of bilateral orchiopexies Cloacal exstrophy Repair of cloacal exstrophy includes the following: The prolapsed ileum (the "elephant trunk") is reduced. The flayed-open cecum is separated from the central portion of the bifid bladder, and this placode of cecum is tubularized. The bladder halves are approximated and repaired as in bladder exstrophy. Later, the colostomy may be mobilized and anastomosed to the rudimentary hind gut and a stoma created; or an anus

2014 eMedicine Pediatrics

140. Minimal Access Surgery (Follow-up)

; this is minimized by using carbon dioxide instead of other gases. This complication has also been reported during insufflation in infants when using an umbiical incision for entry. Inadvertent preperitoneal insufflation in a patient with a patent umbilical vein can lead to devastating consequences [ ] and should be considered when choosing access techniques in patients younger than 1 month. These complications can be minimized with the use of low pressure and warm humidified gas insufflation, slight (...) is typically performed with three stab wounds without trocars. [ ] The average operating time is approximately 15 minutes. Most patients (>90%) are discharged home within 24 hours. The laparoscopic approach is not universally accepted, because similar results can be achieved by means of Ramstedt pyloromyotomy via an umbilical incision. There is some evidence to suggest that the complication rate is lower with the laparoscopic approach. The cosmetic results of laparoscopic pyloromyotomy are superior

2014 eMedicine Pediatrics

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