abnormal labor and delivery - jo an.ppt
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CLINICAL PRACTICE GUIDELINES ON
ABNORMAL LABOR AND DELIVERY
Jo-An Marie G. Aguedan, M.D.
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ELECTRONIC FETAL MONITORING
DURING ABNORMAL LABOR AND
DELIVERY
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Definition of Terms:
A. Bse!ine
B. Bse!ine "ri#i!it$
C. A%%e!ertionD. Er!$ &e%e!ertion
E. Lte &e%e!ertion
F. Vri#!e &e%e!ertionG. Pro!on'e& &e%e!ertion
(. Sin)soi&! *ttern
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BASELINE
• The mean fetal heart rate (FHR) roundedto increments of 5 beats per minute
during a 10-minute segment, ecluding!
" #eriodic or episodic changes
" #eriodic of mar$ed FHR %ariabilit&
" 'egments of baseline that defer b& more than
5 beats per minute
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BASELINE
• The baseline must be for a minimum of
minutes in an& 10-minute segment, or thebaseline for that time period is
indeterminate
• *n this case, one ma& refer to the prior 10-
minute +indo+ for determination of
baseline
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BASELINE
• Norm! FHR baseline! 110-10 beats perminute
• T%+$%r&i! FHR baseline is greater than
10 beats per minute
• Br&$%r&i! FHR baseline is less than
110 beats per minute
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BASELINE VARIABILITY
• Fluctuations in the baseline FHR that areirregular in amplitude and freuenc&
•.ariabilit& is %isuall& uantified as theamplitude of pea$-to-trough in beats per
minute
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BASELINE VARIABILITY
• A#sent " amplitude range undetectable• Minim! " amplitude range detectable but
5 beats per minute or fe+er
• Mo&erte ,Norm!- " amplitude range -
5 beats per minute
• Mre& " amplitude range greater than 5
beats per minute
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ACCELERATION
• efore /0 1ees of gestation, an
acceleration has a pea$ of 10 beats per
minute or more above baseline, ith a
duration o! 10 seconds or more but less
than 2 minutes from onset to return
• #rolonged acceleration lasts minutes or
more but less than 10 minutes in duration
• *f an acceleration lasts 10 minutes or
longer, it is a baseline change
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EARLY DECELERATION
• .isuall& apparent usuall& s&mmetrical
gradual decrease and return of the FHR
associated +ith a uterine contraction
• 2radual FHR decrease is defined as from
the onset to the FHR nadir of 0 secondsor more
• The decrease in FHR is calculated from
the onset to the nadir o! the deceleration
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EARLY DECELERATION
• The nadir of the deceleration occurs at thesame time as the pea" o! the contraction
• *n most cases the onset, nadir, and
reco%er& of the deceleration are coincident
+ith the beginning, pea$, and ending ofthe contraction, respecti%el&
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LATE DECELERATION
• .isuall& apparent usuall& s&mmetricalgradual decrease and return of the FHR
associated +ith a uterine contraction
• / gradual FHR decrease is defined as
from the onset to the FHR nadir of 0seconds or more
• The decrease in FHR is calculated !rom
the onset to the nadir o! the deceleration
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LATE DECELERATION
• The deceleration is dela&ed in timing, +iththe nadir of the deceleration occurring
a!ter the pea" o! the contraction
• *n most cases the onset, nadir, and
reco%er& of the deceleration occur after the
beginning, pea$, and ending of the
contraction, respecti%el&
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VARIABLE DECELERATION
• .isuall& apparent abrupt decrease in FHR• /n abrupt FHR decrease is defined as
from the onset of the deceleration to the
beginning of the FHR nadir less than 0
seconds
• The decrease in FHR is calculated from
the onset to the nadir of the deceleration
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VARIABLE DECELERATION
• The decrease in FHR is 15 beats per
minute or greater, lasting 15 seconds or
greater, and less than 2 minutes in
duration
• 3hen %ariable decelerations are
associated +ith uterine contractions, their
onset, depth and duration commonl& %ar&+ith successi%e uterine contractions
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PROLONGED DECELERATION
• .isuall& apparent decrease in FHR belo+
the baseline
• 4ecrease in FHR from the baseline that is
15 beats per minute or more, lasting minutes or more but less than 10 minutes
in duration
• *f a deceleration lasts 10 minutes or
longer, it is a baseline change
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SINUSOIDAL PATTERN
• .isuall& apparent, smooth, sine +a%e-li$eundulating pattern in FHR baseline +ith a
c&cle freuenc& of -5 per minute +hich
persists for 0 minutes or more
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• lassification of FHRTracings " Three
Tiered '&stem for theategori6ation of FHR
#atterns
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Categ
ory
FHR
Tracin
gs
Defnition
I Norm
al
• Category I FHR tracings
are strongly predictive of
normal fetal acid-basestatus at the time of
observation.
•Category I FHR tracings
may be monitored in a
routine manner, and no
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II
Indeter
mi-nate
• not predictive of abnormal fetal
acid-base status, yet presently
there is no adequate evidence to
classify these as Category I or
Category III.
• require evaluation and
continued surveilance and
reevaluation, taing into account
the entire associated clinical
circumstances.
• In some circumstances, either
ancillary tests to ensure fetal !ell
bein or intrauterine
Catego
ry
FHR
Tracings
Defnition
C t FHR D f iti
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III Abnorm
al
• associated !ith abnormal fetal
acid-base status at the time ofobservation.
• require clinical evaluation
•"epending on the clinical
situation, e#orts to e$peditiouslyresolve the abnormal FHR pattern
may include but are not limited
to provision of%
&.maternal o$ygen'.change in maternal position
(. discontinuation of labor
stimulation
).treatment of maternal
Catego
ry
FHR
Tracings
Defnition
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III Abnormal
If category IIItracing does not
resolve !ith these
measures, delivery
should be
undertaen.
Categ
ory
FHR
Tracings
Defnition
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C!ini%! Consi&ertion n&
Re%ommen&tions
1 Fetal sur%eillance in labor, +hether b&
intermittent auscultation (*/) or b& 7F8
should be recommended to all +omen
#$evel %%%, Grade &'
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• Freuenc& of */ is as follo+s!
" For lo+ ris$ patients " e%er& 0 minutes for 1st
stage, then e%er& 15 minutes for the nd stage
" For high ris$ patients " e%er& 15 minutes for 1st
stage, then e%er& 5 minutes for the nd stage
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ased on a%ailable data, there is no clearbenefit for the use of 7F8 o%er */ 7itheroption is acceptable in patients +ithout
complications
#$evel %%%, Grade &'
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A met2n!$sis s$nt+esi3in' res)!ts of
rn&omi3e&%ontro! tri!s ,RCTs- %om*rin' mo&!ities
+& t+e
follo+ing conclusions! #$evel %, Grade A'
• The use of 7F8 compared +ith */ increased
the o%erall cesarean deli%er& rate (RR, 1,
95: * 10-1) and the cesarean deli%er&
rate for abnormal FHR or acidosis or both (RR
;, 95: * 1
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• The use of 7F8 did not reduce perinatal
mortalit& (RR 0
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*n ideal settings, continuous 7F8 shouldbe offered and is recommended for high
ris$ pregnancies +here there is increasedris$ of perinatal death, cerebral pals& orneonatal encephalopath&
#$evel %%-2 to %%%, Grade &'
= urrent e%idence does not support the useof admission tocogram in lo+ ris$pregnanc&
#$evel %%%, Grade &'
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• 5 ased on careful re%ie+ of a%ailable
terminologies, a three-tiered s&stem ofcategori6ation of FHR interpretation is
recommended
#$evel %%%, Grade &'
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Category I II III
Baseline
FHR
&&+-&+
beats per
minute
radycardia not
accompanied by
absent baseline
variability or
achycardia
radycar
dia
Baseline
variabilit
y
/oderate /inimal baseline
variability
0bsent baseline
variability !ith no
recurrent
decelerations
/ared baseline
variability
0bsent
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Decelerati
ons
0bsent
early, late
or
variable
Recurrent
variable
decelerations
accompanied by
minimal or
moderatebaseline
variability
1rolonged
decelerationmore than '
minutes but less
than &+ minutes
Recurrent late
Recurrent
late
deceleratio
ns
Recurrent
variabledeceleratio
ns
Category I II III
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Accelerati
ons
1resent
or 0bsent
0bsence of
induced
accelerations
after fetal
2inusoidal
pattern
Decelerat
ions
0bsent
early,
late or
variable
.ariable
decelerations +ith
other
characteristics such
as slo+ return to
baseline,o%ershoots, or
>shoulders?
Recurrent
late
decelerati
ons
Recurrent
variable
decelerati
ons
Category I II III
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Bse& on %ref)! re"ie1 of "i!#!e
termino!o'ies4 t+ree2tiere& s$stem of
%te'ori3tion of F(R inter*rettion is
re%ommen&e&. ,Le"e! III4 Gr&e C-
• The false-positi%e rate of 7F8 forpredicting cerebral pals& is high, atgreater than (().
#$evel %%-2 to %%%, Grade &'
• The use if 7F8 is associated +ith an
increased rate of both %acuum andforceps operati%e %aginal deli%er&, andcesarean deli%er& for abnormal FHRpatterns or acidosis or both
#$evel %%-2 to %%%, Grade &'
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• 3hen the FHR tracing includes recurrent
%ariable decelerations, amnioin!usion torelieve umbilical cord compression should
be considered
#$evel %%-1, Grade *'
• #ulse oimetr& has not been demonstrated
to be a clinicall& useful test in e%aluating
fetal status
#$evel %%%, Grade &'
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• There is high interobser%er and intraobser%er
%ariabilit& in interpretation of FHR tracing
#$evel %%%, Grade &'
• Reinterpretation of the FHR tracing, especiall&if the neonatal outcome is $no+n, ma& not be
reliable
#$evel %%%, Grade &'
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• The use of 7F8 does not result inreduction of cerebral pals&
#$evel %%%, Grade &'
• / three-tiered s&stem for thecategori6ation of FHR patterns is
recommended
#$evel %%%, Grade &'
• The labor of +omen +ith high-ris$
conditions should be monitored +ithcontinuous FHR monitoring
#$evel %%%, Grade &'
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• The terms h&perstimulation andh&percontractili& should be abandonded *t
is no+ calles uterine tach+s+stole (ie more
than 5 contractions in 10 minutes, a%eraged
o%er a 0-minute +indo+)
#$evel %%%, Grade &'
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C!ini%! Consi&ertion n&
Re%ommen&tions
/ncillar& tests a%ailable that can aid in themanagement of ategor& ** or ategor& ***fetal heart tracings include fetal scalp pHsampling, /llis clamp stimulation,
%ibroacoustic stimulation and digital scalpstimulation
#$evel %%-, Grade *'
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• ecause %ibroacoustic stimulation and
digital scalp stimulation is less in%asi%ethan the other t+o methods, the+ are
pre!erred methods.
#$evel %, Grade A'
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; / ategor& ** or ategor& *** FHR Tracing
reuires initial e%aluation and treatmentma& include the follo+ing!
a. 4iscontinuation of an& labor stimulating
agent
b er%ical eamination to determine
umbilical cord prolapsed, rapid cer%ical
dilatation, or descent of the fetal head
#$evel %%%, Grade &'
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• hanging maternal position to left or right
lateral recumbent position, reducingcompression of the %ena ca%a and
impro%ing uteroplacental blood flo+
• 8onitoring maternal for e%idence of
h&potension, especiall& in those +ith
regional anesthesia (if present, treatment+ith %olume epansion or +ith ephedrine
or both or phen&lephrine ma& be
+arranted)
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DYSTOCIA
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Definition of A#norm! Ptterns of L#or
LABOR ATT!RN Diagnostic CriteriaN"lli#aras $"lti#aras
rolongaton Disorder&. rolonged Latent
%ase
3 '+ hrs 3 &) hrs
rotraction Disorder&. rotracted Active
%ase Dilation 41hase
of ma$imum slope ofdilatation5
6 &.' cm7hr 6 &.* cm7hr
'. rotracted Descent
4ma$imum slope of
descent during the pelvic
6 & cm7hr 6 'cm7hr
LABOR ATT!RN Diagnostic Criteria
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Arrest Disorder
&. rolongedDeceleration %ase
4cervical dilatation arrested
at 8 to 9 cm5
3 ( hrs 3 & hr
'. &econdary Arrest o'Dilatation 4progressive
cervical dilatation stops at
the phase of ma$imum
slope5
3 ' hrs
(. Arrest o' Descent
4progressive descent stops
during pelvic division of
labor, station : &5
3 & hr
LABOR ATT!RN Diagnostic Criteria
N"lli#aras $"lti#aras
LABOR ATT!RN Diagnostic Criteria
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). Fail"re o' Descent
4station +5
;ac of e$pected descent
during deceleration phase
or second stage of labor
*. rolonged &econd
&tage
3 ( hrs !ith
regionalanesthesia or
3 ' hrs !ith
regionalanesthesia or
3 ' hrs
!ithoutregional
anesthesia
3 & hr
!ithoutregional
anesthesia
g
N"lli#aras $"lti#aras
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Re%ommen&tions
5. Pro!on'e& Ltent P+se #rotracted /cti%e #hase 4ilatation
/rrest 4isorders
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Pro!on'e& Ltent P+se
• /%oid admission to the labor anddeli%er& area until acti%e labor isestablished
#$evel %%%, Grade &'
• 4e%elop a plan to meet the +oman@s
need either at home or in a non-laboring hospital unit
#$evel %%%, Grade &'
P ! & L t t P+
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Pro!on'e& Ltent P+se
• Friedman (19;) reported that
prolongation of the latent phase did notad%ersel& influence fetal or maternalmorbidit& and mortalit&
#$evel %%%, Grade &'
• 4ata sho+ that patients +ith prolongedlatent phase are no more prone to
de%elop problems than gra%idas +ithnormal latent phase
#$evel %%%, Grade &'
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Pro!on'e& Ltent P+se
• Abser%ation, rest and therapeutic
analgesiaBstrong sedati%es arefa%ored o%er a more acti%e approachof amniotom& and o&tocin induction
#$evel %%%, Grade &'
• 'upport and information from
caregi%ers to pro%ide copingstrategies
#$evel %%%, Grade &'
P ! & L t t P+
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Pro!on'e& Ltent P+se
• / patient +ho has a latentphase longer than 0 hrsshould be epected to e%ol%e a
normal subseuent dilatationand descent if allo+ed to doso
#$evel %%%, Grade &'
P ! & L t t P+
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Pro!on'e& Ltent P+se
- *t cannot be too strongl& stated thatpatients +ho are deli%ered b&
cesarean section (') during the
latent phase for no other reason thantheir lac$ of progress are being
subCected to this operation
unnecessaril& most of the time
#$evel %%%, Grade &'
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• Friedman@s recommended approach is
support and therapeutic rest b& the use of
large doses of narcotic analgesics
#$evel %%%, Grade &'
P ! & L t t P+
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Pro!on'e& Ltent P+se
• 7ceptionall&, o&tocin ma& be underta$en
directl& if additional to 10 hours dela& b&
rest +ould be clinicall& unacceptable as in
the presence of chorioamnionitis
#$evel %%%, Grade &'
R & ti
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Re%ommen&tions
1 #rolonged Datent #hase
0. Protr%te& A%ti"e P+se Di!ttion
/rrest 4isorders
P t t & A ti P+
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Protr%te& A%ti"e P+se
Di!ttion
• #h&sical and emotional support
#$evel %, Grade A'
• ontinuous support during labor fromcaregi%ers should be encouraged because it is
beneficial for +omen and their ne+borns
#$evel %, Grade A'
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• /mniotom& +ith earl& o&tocin
augmentation shortens labor b& as much
as hours compared to epectant care but
has not been sho+n to change cesareandeli%er& rates
#$evel %, Grade A'
Protr%te& A%ti"e P+se
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Protr%te& A%ti"e P+se
Di!ttion
• /mniotom& ma& enhance progress in theacti%e phase and negate the need for o&tocin
augmentation but ma& increase the ris$ of
chorioamnionitis
#$evel %, Grade A'
• A&tocin should be used to achie%e adeuate
contractions (at least 00 8onte%ideo units)before operati%e deli%er& is considered
#$evel %, Grade *'
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• High-dose o&tocin regimens result in
shorter labors than lo+ dose regimens
+ithout ad%erse effects to the fetus
#$evel %, Grade *'
• Rule out #4
#$evel %%%, Grade *'
• *f +ith #4, do '
#$evel %%%, Grade *'
Re%ommen&tions
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Re%ommen&tions
1 #rolonged Datent #hase
#rotracted /cti%e #hase 4ilatation
/. Arrest Disor&ers
Arrest Disor&ers
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Arrest Disor&ers
• ontinuous support during labor from
caregi%ers should be encouraged because itis beneficial for +omen and their ne+borns
#$evel %, Grade A'
• E-ra& pel%imetr& alone as a predictor ofd&stocia has not been sho+n to ha%e benefit,and therefore is not recommended
#$evel %, Grade *'• Rule out #4
#$evel %%%, Grade *'
Arrest Disor&ers
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Arrest Disor&ers
• *f +ith #4, do '
#$evel %%%, Grade *'
• efore an arrest disorder can bediagnosed in the first stage of labor, thelatent phase should be completed, and theuterine contraction pattern eceeds 200
Montevideo units !or 2 hours ithoutcervical change.
#$evel %%%, Grade &'
Arrest Disor&ers
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Arrest Disor&ers
• The >-hour rule? for the diagnosis of arrest inacti%e labor has been challenged
• *n a clinical trial, 5= +omen +ere managedb& a protocol in +hich, after acti%e phasearrest +as diagnosed, o&tocin +as initiated+ith the intent to achie%e a sustained uterinecontraction pattern of greater than 008onte%ideo units
#$evel %%%, Grade &'
Arrest Disor&ers
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Arrest Disor&ers
• esarean deli%er& is not performed forlabor arrest until there ere at least
hours o! sustained uterine contraction
pattern o! greater than 200 Montevideo
units, or a minimum o! / hours o! o+tocinaugmentation if the contraction pattern
could not be achie%ed
#$evel %%%, Grade &'
Arrest Disor&ers
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Arrest Disor&ers
• The protocol resulted in a high rate of
%aginal deli%er& (9:) +ith no se%ere
ad%erse maternal or fetal outcomes
• 7tending the minimum period of o&tocin
augmentation for acti%e phase arrest from
hours appears effecti%e
#$evel %%%, Grade &'
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• BREEC( PRESENTATION
• E6TERNAL CEP(ALIC VERSION
• PERSISTENT OCCIPUT POSTERIOR4
OCCIPUT TRANSVERSE
• BRO7 PRESENTATION
• FACE PRESENTATION• FETAL MACROSOMIA
• S(OULDER DYSTOCIA
• TRANSVERSE LIE8OBLI9UE LIE• COMPOUND PRESENTATION
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BREEC( PRESENTATION
BREEC( PRESENTATION
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BREEC( PRESENTATION
• Re%ommen&tions:
• #lanned cesarean section (') for babies inbreech presentation has a reduced ris$ forperinatal death and neonatal morbidit&compared to planned %aginal birth
#$evel %, Grade A'
• #lanned ' for babies in breech presentationis associated +ith a modest increase in shortterm maternal morbidit&
#$evel %, Grade A'
Re%ommen&tions:
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Re%ommen&tions:
• *nformation is limited about the potential forproblems +ith future pregnancies
#$evel %, Grade &'
• /fter t+o &ears, there +ere no differences inthe combined outcome >death orneurode%elopmental dela&?@ 8aternal
outcomes +ere also similar
#$evel %, Grade A'
Re%ommen&tions:
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Re%ommen&tions:
• There is no data to uantif& ris$s of ' tothe mother (scar dehiscence in asubseuent pregnanc&, increased ris$ torepeat ', placenta accreta)
#$evel %%%, Grade &'
• There is no e%idence that the long termhealth of babies +ith a breechpresentation deli%ered at term is
influenced b& ho+ the bab& is born
#$evel %, Grade A'
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Re%ommen&tions:
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Re%ommen&tions:
• For a +oman +ith suspected breech
presentation, pre- or earl& labor ultrasound
should be performed to assess t&pe of
breech presentation, fetal gro+th and
estimated +eight, and attitude of fetal
head *f ultrasound is not a%ailable, ' isrecommended
#$evel %%, Grade A'
Re%ommen&tions:
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• ontraindications to labor
include!a) ord presentation #$evel %%, Grade A'
b) Fetal gro+th restriction or macrosomia#$evel %, Grade A'
c) /n& presentation other than a fran$ or
complete breech +ith a fleed or
neutral head attitude
#$evel %%%, Grade *'
Re%ommen&tions:
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• ontraindications to labor
include!d)linicall& inadeuate maternal pel%is #$evel
%%%, Grade *'
e)Fetal anomal& incompatible +ith %aginal
deli%er&
#$evel %%%, Grade *'
Re%ommen&tions:
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• .aginal breech deli%er& can be offered +hen the
estimated fetal +eight is beteen 2500 g and
000 g.
#$evel %%, Grade *'
• linical pel%ic eamination should be performed to
rule out pathological pel%ic contraction Radiologic
pel%imetr& is not necessar& for a safe trial of labor
good progress in labor is the best indicator o!
adeuate !etal-pelvic proportions
#$evel %%%, Grade *'
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Re%ommen&tions:
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• *nduction of labor is not recommended for breech
presentation
#$evel %%, Grade *'
• A&tocin augmentation is acceptable in the
presence of h&potonic uterine d&sfunction
#$evel %%, Grade A'
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• / passi%e second stage +ithout acti%e pushing
ma& last up to 90 minutes, allo+ing the breech to
descend +ell into the pel%is Ance acti%e pushingcommences, i! deliver+ is not imminent a!ter /0
minutes, & is recommended
#$evel %, Grade A'
The acti%e second stage of labor should ta$e place
in or near an operating room +ith euipment and
personnel a%ailable to perform a timel& ' section
if necessar&
#$evel %, Grade A'
Re%ommen&tions:
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• / health care professional s$illed in neonatal
resuscitation should be in attendance at the time of
deli%er&
#$evel %%%, Grade A'
• The health care pro%ider for a planned %aginal
breech deli%er& needs to possess the reuisite
s$ills and eperience
#$evel %%, Grade A'
Re%ommen&tions:
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• /n eperienced obstetrician-g&necologist comfortable
in the performance of %aginal breech deli%er& should be
present at the deli%er& to super%ise other health carepro%iders, including a trainee
#$evel %, Grade A'
• The health care pro%ider should ha%e rehearsed a plan
of action and should be prepared to act promptl& in the
rare circumstance of a trapped a!tercoming head or
irreducible nuchal arms s+mph+siotom+ or emergenc+
abdominal rescue can be li!e saving
#$evel %%%, Grade *'
Re%ommen&tions:
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• Total breech etraction is inappropriate !or termsingleton breech deliver+
#$evel %%, Grade A'
• 7ffecti%e maternal pushing efforts are essential tosafe deli%er& and should be encouraged
#$evel %%, Grade A'
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• /t the time of deli%er& of the aftercoming head, an
assistant should be present to appl& suprapubic
pressure to fa%or fleion and engagement of thefetal head
#$evel %%, Grade *'
Re%ommen&tions:
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• 'pontaneous or assisted breech
deli%er& is acceptable Fetal tractionshould be a%oided, and !etalmanipulation must be applied onl+a!ter spontaneous deliver+ to the level
o! the umbilicus
#$evel %%%, Grade A'
• Guchal arms ma& be reduced b&
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& &
Do%set maneu%er .
#$evel %%%, Grade *'
Re%ommen&tions:
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• The fetal head ma& deli%er spontaneousl&, +ith theassistance of suprapubic pressure, b& Mauriceau-
mellie-3eit maneuver, or ith the assistance o!4iper !orceps
#$evel %%%, Grade *'
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-
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Re%ommen&tions:
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• The consent discussion and chosen plan
should be +ell documented and
communicated to labor room staff
#$evel %%%, Grade *'
• Hospitals offering a trial of labor should
ha%e a +ritten protocol for eligibilit& and
intrapartum management
#$evel %%%, Grade *'
Re%ommen&tions:
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• 3omen +ith a contraindication to a trialof labor should be ad%ised to ha%e a' 3omen choosing to labor despitethis recommendation ha%e right to doso and should not be abandoned The&
should be pro%ided the best possiblein-hospital care
#$evel %%%, Grade A'
Re%ommen&tions:
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• / ph&sician is free to choose +hom he +ill ser%e
He ma& refuse calls, or other medical ser%ices forreasons satisfactor& to his professional
conscience
• He should, ho+e%er, al+a&s respond to an&
reuest for his assistance in an emergenc& Ance
he underta$es a case, he should not abandon nor
neglect it
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• *f for an& reason he +ants to be released from it,
he should announce his desire pre%iousl&, gi%ing
sufficient time or opportunit& to the patient or hisfamil& to recei%e another medical attendant
Re%ommen&tions:
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• Theoretical and hands-on breech birth
training simulation should be part of
basic obstetrical s$ills taining programs
such as /D/R8, to prepare health care
pro%iders for unepected %aginal breech
births
#$evel %%%, Grade *'
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E6TERNAL CEP(ALIC VERSION
E6TERNAL CEP(ALIC VERSION
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• is a procedure of manipulation of the fetus
through the maternal abdomen to a
cephalic presentation
• The rationale behind 7. is to reduce theincidence of breech presentation at term
and therefore the associated ris$s,
particularl& of a%oiding '
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Re%ommen&tions
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• 3omen should be counseled that 7.reduces the chance of breech presentation at
deli%er&
#$evel %, Grade A'
• 7. reduces the chances of ha%ing a '
#$evel %, Grade A'
• 3ith a trained operator about 50) of 7.attempts +ill be successful
#$evel %%%, Grade *'
Re%ommen&tions
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• The use of tocol&sis +ith beta
s&mpathomimetic drugs ma& be offered to
+omen undergoing 7. as it has been
sho+n to increase the success rate
#$evel %, Grade A'
• 7. before +ee$s is not associated
+ith significant reduction in noncephalicbirths or '
#$evel %%, Grade *'
Re%ommen&tions
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• There is insufficient e%idence to support
the use of postural management as a
method of promoting spontaneous %ersion
o%er 7.
#$evel %, Grade A'
• Dabor +ith a cephalic presentation
follo+ing 7. is associated +ith a higher
rate o! obstetric intervention than hen
6&3 has not been reuired
#$evel %, Grade *'
Re%ommen&tions
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• A#so!)te %ontrin&i%tions for 7.
that are li$el& to be associated +ith
increased mortalit& or morbidit&!
" 3here cesarean deli%er& is reuired
" /ntepartum hemorrhafe +ithin the last ; da&s " /bnormal cardiotocograph
" 8aCor uterine anomal&
" Ruptured membranes
" 8ultiple pregnanc& (ecept deli%er& of
second t+in)
#$evel %%%, Grade &'
Re%ommen&tions
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• Re!ti"e %ontrin&i%tions +here 7.might be more complicated!
" 'mall for gestational age fetus +ith abnormal4oppler parameters
" #roteinuric pre-eclapmsia
" Aligoh&dramnios
" 8aCor fetal anomalies " 'carred uterus
" nstable lie
#$evel %%%, Grade &'
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• PERSISTENT OCCIPUT POSTERIOR4
OCCIPUT TRANSVERSE
PERSISTENT OCCIPUT POSTERIOR4
OCCIPUT TRANSVERSE
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OCCIPUT TRANSVERSE
4efinition
• 3ith effecti%e contractions, adeuate
fleion of the head, and a fetus of a%erage
si6e, most posteriorl& positioned occiputsroute promptl& as soon as the& reach the
pel%ic floor
PERSISTENT OCCIPUT POSTERIOR4
OCCIPUT TRANSVERSE
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OCCIPUT TRANSVERSE
• #oor contractions, fault& fleion of the
head, or epidural analgesia, +hich
diminishes abdominal muscular pushing
and relaes the muscles of the pel%ic floorma& predispose to incomplete rotation
PERSISTENT OCCIPUT POSTERIOR4
OCCIPUT TRANSVERSE
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OCCIPUT TRANSVERSE
• *f rotation is incomplete, trans%erse arrest
ma& result
• *f no rotation to+ard the s&mph&sis ta$es
place
• The occiput ma& remain in the direct
occiput posterior position, a condition
$no+n as persistent occiput posterior
Re%ommen&tions
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• 4igital rotation should be considered +henmanaging the labor of a fetus in theoccipito-posterior position This maneu%ersuccessfull& rotates the fetus reducing theneed for ', instrumental deli%er&, andother complications associated +ith
persistent occiput posterior
#$evel %%%, Grade *'
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BRO7 PRESENTATION
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BRO7 PRESENTATION
BRO7 PRESENTATION
R d ti
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Recommendations!
• 7pectant management is reasonable as
long as the fetal heart tracing remains
reassuring and dilation and descent are
progressing normall& because
spontaneous con%ersion to %erte or facema& occur
#$evel %%, Grade *'
Re%ommen&tions
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• The use of forceps or manual con%ersionto con%ert a bro+ presentation to a more
fa%orable position is contraindicated.
#$evel %%, Grade *'
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• FACE PRESENTATION
FACE PRESENTATION
Recommendations
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Recommendations
• ontinuous 7F8 is considered mandator+
b& man& authors because of the increased
incidence of abnormal FHR patterns
andBor fetal compromise areful
application of the electrode must beensured the mentum is recommended site
o! application
#$evel %%%, Grade *'
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Re%ommen&tions
• /ttempts to manuall& con%ert the face to
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• /ttempts to manuall& con%ert the face to%erte (Thom maneu%er) or to rotate a
posterior position to a more fa%orable anteriormentum position are rarel& successful and areassociated +ith high perinatal mortalit& andmaternal morbidit&
• *nternal podalic %ersion and breech etractionare no longer recommended in the modernmanagement of the face presentation
#$evel %%%, Grade *'
Re%ommen&tions
• Forceps ma& be used if the mentum is anterior
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• Forceps ma& be used if the mentum is anterior
/n& t&pical forceps including Ieilland forceps,
can be used
#$evel %%%, Grade *'
• The mechanisms of labor in the term infant can
occur onl& if the mentum is anterior
#$evel %%%, Grade *'
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FETAL MACROSOMIA
FETAL MACROSOMIA
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• The term fetal macrosomia implies fetal
gro+th be&ond a specific +eight, usuall+
000 gm #7 lb 1 o8' or 500 gm #( lb
o8' regardless of the fetal gestational age
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• 'uspected fetal macrosomia is not an
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'uspected fetal macrosomia is not an
indication !or induction o! labor because
induction does not impro%e maternal or fetaloutcomes
#$evel %%, Grade *'
Re%ommen&tions
• Dabor and %aginal deli%er& is not
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• Dabor and %aginal deli%er& is not
contraindicated for +omen +ith estimated
fetal +eights up to 5,000 g in the absenceof maternal diabetes
#$evel %%, Grade *'
• 3ith an estimated fetal +eight more than
=,500 g, a prolonged second stage o! labor
or arrest o! descent in the second stage is
an indication !or cesarean deliver+
#$evel %%, Grade *'
Re%ommen&tions
• /lthough the diagnosis of fetal
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/lthough the diagnosis of fetal
macrosomia is imprecise, proph&lactic
cesarean deli%er& ma& be considered forsuspected fetal macrosomia +ith
estimated fetal +eights more than 5,000 g
in pregnant omen ithout diabetes and
more than ,500 g in pregnant omen ith
diabetes.
#$evel %%%, Grade &'
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• 'uspected fetal macrosomia is not
contraindication to attempted %aginal birth
after a pre%ious cesarean deli%er&
#$evel %%%, Grade &'
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• S(OULDER DYSTOCIA
S(OULDER DYSTOCIA
Recommendations
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Recommendations
• Ris$ assessments for the prediction of
shoulder d&stocia are insufficientl&
predicti%e to allo+ pre%ention of the large
maCorit& of cases
#$evel %%, Grade *'
• *nduction of labor in +omen +ith diabetes
mellitus does not reduce the maternal or
neonatal morbidit& of shoulder d&stocia
#$evel %, Grade A'
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Re%ommen&tions
• 7pisiotom& is not necessar& for all cases
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7pisiotom& is not necessar& for all cases,
is reser%ed to facilitate maneu%ers such as
deli%er& of posterior arm or internalrotation of shoulders
#$evel %%%, Grade &'
• Mc9oberts is the single most e!!ective
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Mc9obert s is the single most e!!ective
intervention and should be per!ormed !irst
#$evel %%%, Grade &'
Re%ommen&tions
• 'uprapubic pressure is useful
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'uprapubic pressure is useful
#$evel %%%, Grade &'
• 'uprapubic pressure can be emplo&edtogether +ith 8cRobert@s maneu%er toimpro%e success rates
#$evel %%%, Grade &'
Re%ommen&tions
• Ather maneu%ers such as Rubin@s, 3ood@s
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Ather maneu%ers such as Rubin s, 3ood s
scre+ maneu%er, Ja%anelli, cleidotom&
and s&mph&siotom& ha%e been emplo&edbut no controlled trials ha%e been made
#$evel %%%, Grade &'
• Rubin 8aneu%er
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Rubin 8aneu%er
• 3ood@s scre+ maneu%er
-
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3ood s scre+ maneu%er
• Ja%anelli maneu%er
-
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a a e a eu e
• '&mph&siotom&
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& p & &
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• TRANSVERSE LIE8OBLI9UE LIE
TRANSVERSE LIE8OBLI9UE LIE
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Recommendation
• Trans%erse lie and obliue lie +ill benefit
from a trial of %ersion to cephalic
presentation follo+ing the criteria and
recommendations of 7. for breechpresentations
#$evel %%%, Grade &'
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• COMPOUND PRESENTATION
COMPOUND PRESENTATION
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Recommendations
• *f the hand has not prolapsed be+ond the
presenting part , causing the hand to
retract often is accomplished, if necessar&
*t can be ignored as long as labor isprogressing normall&
#$evel %%%, Grade &'
COMPOUND PRESENTATION
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Recommendations
• *n contrast, if the hand or arm has
prolapsed past the presenting part ,
abdominal %aginal deli%er& and proceeding
to cesarean deli%er& is +ise
#$evel %%%, Grade &'
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