Medical Archive

Introduction

Face presentation
Effective labor? ?? ?? ?? ??? ???.
??? ?? ??? (internal podalic version) ?? ??!!

Brow presentation
?? ????? face? occiput?? ??.
?? ???? ?? ??. ?? ??? face? ??

Compound presentation
???? ???? ??? ?? ???? ?? ??
??? ?? ??.

Trensverse lie
Persistent: ???? ???. ??? ???? ?? C/S (vertical ??)
???? ?? neglected shoulder presentation?? ???? ??.

Preparation for delivery

Occiput anterior position

Crowning ? episiotomy ? Modf. Ritgen Maneuver (head extention ??)
Vulva opening? ?? ??? 5cm ??? ??.
Delayed umbilical cord clamping – ?????

Delivery of the head

Delivery of the shoulders

Cord clamping

Occiput transverse position

Persistent occiput posterior position

2-10%.
??? ??? x. ???? ?? OA? ???? ?? portion? POPP
Morbidity, blood loss, vaginal laceration ?

Morbidity

Delivery

Shoulder dystocia

• Head-to-body delivery > 60 sec
• Risk factor
  • Fetal macrosomia (fetal weight >4.5kg)
    • Post-term pregnancy (?42 weeks gestation)
    • Maternal obesity, GDM, excessive maternal weigh gain during pregnancy.

Maternal and neonatal consequences

• Brachial plexus injury, acidosis/hypoxia?

Prediction and prevention

• Warning signs of an impending dystocia
  • Prolonged first or second stage of labor
  • Retraction of the fetal head into the perineum after delivery (eg, turtle sign)

Management

• B: breathe; do not push
• E: elevate legs & flex hips, thighs against abdomen (McRobets)
  • To increase the diameter of the bony pelvis
• C: call for help
• A: apply suprapubic pressure
• L: enlarge vaginal opening with episiotomy
• Maneuvers
  • Deliver posterior arm
  • Rotate posterior shoulder (Woods screw) – apply pressure to anterior aspect of the posterior shoulder
  • Adduct posterior fetal shoulder (Rubin) – apply pressure to the posterior aspect of the posterior shoulder
  • Mother on hands & knees – “all fours” (Gaskin)
  • ??? C/S (>5kg, DM?? >4.5kg) 
    • Replace fetal head into pelvis for cesarean delivery (Zavanelli)
  • ? ? Rubin/intentional clavicle fracture

• 

• 

Special populations

Home birth

Water birth

Female genital mutilation

Prior pelvic reconstructive surgery

Surgery	Trial of labor contraindicated?
Low transverse cesarean delivery (horizontal incision)	No
Classical cesarean delivery (vertical incision)	Yes
Abdominal myomectomy with uterine cavity entry	Yes
Abdominal myomectomy without uterine cavity entry	No

Anomalous fetuses

Third stage of labor

Delivery of the placenta

3rd stage of labor: signs of placenta separation
???? ?? ??
??? ???? ????
??? ? ??? ? ??
??? ?? ??? ????

Management of the third stage

Immediate postpartum care

Birth canal lacerations

Vaginal mucosa ? perineal body ? anal sphicter ? rectal mucosa

Episiotomy

2nd stage ????. OA? ?? presentation, ??, prineal rupture ??? ?? ?.

(???? ICH???? ?? ??? ????)

??? 4cm?? ? ??! ??? bleeding ??, ??? laceration ?? ??
Midline vs. Mediolateral

Midline
??? ??, faulty healing? ??, post op. pain? ??
anatomically good result, blood loss ?, ??? ??, dyspareunia? rare
??? ??? ??? ??? extension?? ??? ???.
??? ?? ??? hematoma, cellulitis ?????.

Laceration and episiotomy repairs

Perineal laceration care