Problems During Labor and

Delivery
CAPT Mike Hughey, MC, USNR

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 1

Preterm Labor
Prior to 38 weeks
Cause unknown, but half are
associated with intrauterine
infection
Some caused by abruption
Judgment when to treat
Tocolytic drugs
Steroids

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 2

Compound Presentation
Hand plus Head, eg.
Pinching hand may cause it to
withdraw
If the fetus is small and the
pelvis large, vaginal delivery
may be possible, but with
some risk of injury to the
arm.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 3

Orientation of the Head

Anterior
Fontanelle

Posterior
Fontanelle

Anterior and posterior

fontanelles can be palpated
vaginally.
Anterior fontanelle is
junction of 4 suture lines
Posterior fontanelle is
junction of 3 suture lines

Left Occiput
Anterior

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 4

Prolonged Latent Phase Labor

>20 hours (1st baby)
>14 hours (multip)
Maternal risk of
exhaustion, infection
Treatments:

Rest
Ambulation
Hydration
Analgesia
Oxytocin

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 5

Arrest of Active Labor

Less than 1.2 cm/hour
progress in dilation
No change in 2 hours
Inadequate contractions
Too infrequent (>4 min)
Too short (<30 sec)

Mechanical impediment
Absolute FPD (rare)
Relative FPD (common)
Malposition

Rx: Oxytocin and time

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 6

Shoulder Dystocia
Shoulder wedged behind the pubic
bone after delivery of the head
Turtle sign
Excessive downward traction can lead
to temporary or permanent injury to
the brachial plexus.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 7

MacRoberts Maneuver
Flexing the maternal
thighs tightly against
the maternal abdomen
Straightens the birth
canal, giving a little
more room for the
shoulders to squeeze
through.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 8

Suprapubic Pressure
Downward suprapubic pressure, in
combination with other maneuvers,
can nudge the fetal shoulder past its
obstruction.
Downward/lateral suprapubic
pressure can nudge the shoulder to
an oblique diameter, allowing it to
slip past the pubic bone.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 9

Delivery of Posterior Arm

Episiotomy, if needed
Reach in posteriorly and sweep
the posterior arm over the chest
and out of the vagina.
Easier described than
performed
Risk of injury (Fx, dislocation)
to the posterior arm

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 10

Rotation of the Baby

Small rotation moves the baby
to an oblique diameter,
facilitating delivery
Similar to unscrewing a light
bulb
After the anterior shoulder is
rotated 180 degrees, continue
to rotation another 180 degrees
in the same direction

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 11

Breech Delivery
Most will deliver
spontaneously without
any special maneuvers,
although cesarean
section is often selected
If it gets stuck, gentle
downward traction, with
suprapubic pressure to
keep the head flexed will
achieve a safe delivery.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 12

Breech Delivery
Direct the traction downward and
never above the horizontal plane.
Lifting the baby above the horizontal
can result in spinal injury.
Try to have the mother do the
pushing rather than you doing much
pulling

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 13

Twin Delivery
40% of twins are
vertex/vertex, favoring
vaginal delivery
C/S often performed for fetal
malposition
After delivery of 1st twin,
labor stops, then resumes
After 2nd twin delivers, both
placentas deliver

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 14

Prolapsed Umbilical Cord

Impairs blood flow to the fetus
Immediate delivery is best solution
Place mother in knee-chest
position to relieve pressure on the
cord
Elevate the fetal head out of the
pelvis with your hand in the
vagina to relieve cord compression

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 15

Umbilical Cord Around Neck

Nearly half of babies have the cord
wrapped around some part of their
body.
Usually this isnt a problem
If tight, it can impair cord flow
If loose, leave it alone or slip it over
the fetal head.
If tight, double clamp the cord and cut
between the clamps.
Then deliver the rest of the baby.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 16

Retained Placenta
Gentle cord traction with Crede
maneuver (pushing the uterus
away with the abdominal hand)
After about 30 minutes of waiting
for separation
Manual removal
Be prepared to deal with a
placental abnormality
(abnormally adherent placenta)

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 17

Post Partum Hemorrhage

Average loss is about 500 cc (about 10% of
the blood volume)
Most cases are caused by the uterus failing
to contract effectively
Expell clots from the uterus with fundal
pressure
Uterine massage
Oxytocin, methergine, prostaglandin
Bimanual compression
Uterine packing

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 18

Post Partum Hemorrhage

Transfuse early, based on:
Estimated blood loss
Clinical circumstances
Likelihood of continuing loss

Dont wait for traditional signs of

tachycardia, tachypnea, hypotension and
confusion as post-partum patients often
look rather well despite substantial
blood loss, then suddenly collapse.

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 19

Chorioamnionitis

>100.4
Uterine tenderness
Foul-smelling amniotic fluid
Fetal tachycardia
Elevated maternal WBC
Treat aggressively with IV
antibiotics
Prompt delivery
Tylenol to decrease maternal fever

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 20

Group B Streptococcus
May screen for carriers
May treat during labor, those with positive
screens or those with risk factors:

Previous GBS diseased infant

Documented GBS infection during pregnancy
Delivery <37 weeks
Ruptured BOW >18 hours
Temp of 100.4 or more

Pen G, Amp, Clinda, Erythro

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 21

Post Partum Fever

>100.4, twice, 6 hours apart
Uterine tenderness, foul
lochia
Often due to strep (childbed
fever)
Treat aggressively and early
with IV antibiotics as these
patient can become
desperately ill very quickly

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 22

Operational Obstetrics & Gynecology Bureau of Medicine and Surgery 2000

Slide 23