0071643192.pdf

OBSTETRICS AND GYNECOLOGY

Shoulder Dystocia

A failure of the fetal shoulders to deliver after delivery of the fetal head; occurs
when the anterior shoulder impacts behind or above the pubic symphysis;
most likely to occur with large fetal size or in the presence of abnormal pelvic
anatomy

SYMPTOMS/EXAM

■ Turtle sign: Fetal head pulled tight against perineum

TREATMENT

■ Obtain immediate OB backup.
■ Empty the bladder and make a generous episiotomy.
■ Apply firm suprapubic (notfundal) pressure to dislodge the impacted fetal
shoulder.
■ McRobert maneuver: Sharply flexing hips and legs (successful alone about
half the time)
■ Twisting/corkscrew manipulation of fetal shoulders
■ Fracture of fetal clavicle or symphysiotomy is last resort.

Breech Presentation

The major risk of breech delivery is entrapment of the fetal head and resul-
tant fetal hypoxia.

TREATMENT

■ The delivery should be allowed to progress as spontaneously as possible
until the fetal umbilicus appears.
■ At this point provider assistance and fetal rotation will be needed for delivery
of fetal legs and arms.
■ If the fetal head becomes entrapped apply suprapubic pressure and insert
fingers to draw the fetal chin to the fetal chest.

Amniotic Fluid Embolus

Results from release of amniotic fluid into maternal circulation, typically during
labor but may be also seen following uterine trauma

SYMPTOMS/EXAM

■ Sudden hypoxia and hypotension
■ DIC may develop.

DIAGNOSIS/TREATMENT

■ A clinical diagnosis after consideration and evaluation for pulmonary
embolism, sepsis, and anaphylaxis
■ Treatment is supportive.

POSTPARTUM HEMORRHAGE

Postpartum hemorrhage is divided into early (<24 hours) and late (>24 hours)
hemorrhage. Early postpartum hemorrhage can have brisk bleeding, and
shock can develop rapidly. Maternal vital signs may remain normal while
large volumes of blood accumulate in the uterus.