ABNORMAL BIRTH ACTION (DISTOCIA)
• dystocia; In short, it means difficult birth. The expression nonprogressive action is also used to describe dystocia.
Dystocia due to uterine dysfunction
• Abnormalities in action are basically divided into 2 parts; prolongation of action and cessation of action. However, in order for these diagnoses to be made, the cervical opening must be at least 6 cm and the membranes must be ruptured. In addition, the cervical dilation should not progress, although the contraction force obtained in every 10-minute periods in the last 4 hours is 2: 200 Montevideo units.
• Epidural analgesia prolongs both the 1st and 2nd stages of labor and slows down the fetal descent.
|
Abnormal
labor diagnoses and approaches |
||||
|
action pattern |
Nullipar |
multiparous |
Recommended Treatment |
Alternative Treatment |
|
Prolongation of the latent phase |
> 20 hours |
> 14 hours |
Rest cure |
Oxytocin or C/S in an emergency |
|
prolongation of active phase |
<1.2 cm/hour |
<1.5 cm/hour |
Wait |
C/S on BPU |
|
elongation of descent |
1 cm/hour |
2 cm/hour |
Wait |
C/S on BPU |
|
Prolonged deceleration - Dilatation
arrest - Descent arrest |
>3 hours |
>1 hour |
C/S if no BPU oxytocin if BPU |
C/S |
Prolongation of the second stage of labor
► The second stage of labor lasts an average of 2 hours in nulliparous and 1 hour in multiparas. Epidural anesthesia prolongs these periods by 1 hour. Exceeding these times requires intervention.
Dystocias of the Birth Tract
• They are dystocias originating from the bony pelvis and soft tissues.
Bone Pelvis Dystocia
► Pelvic entrance, mid pelvis and pelvic outlet dystocias can be seen.
Soft Tissue Dystocias
► Tumoral formations or congenital anomalies occupying space in the birth canal cause dystocia by making more presentation anomalies.
Fetal Dystocia (Malpresentations)
• Situs and presentation anomalies
• Big baby
• Malformed baby (hydrocephalus, anencephaly, meningomyelocele, sacrococcygeal teratoma)
• conjoined twins
• Locked in twin birth
Complications of Dystocia
• Chorioamnionitis
• Postpartum pelvic infections
• Postpartum bleeding due to atony
• Uterine rupture
• Vesicovaginal, vesicocervical, rectovaginal fistulas
• Pelvic floor damage (prolapse, urinary-anal incontinence)
• Peroneal nerve damage
• Increased risk of cesarean section
• Increased risk of peripartum fetal sepsis
• Cephal hematoma
• Caput succedanum (edema in vertex)
• Molding; is the movement of the skull bones over each other.
Vesicovaginal fistulas are the most common of the urinary fistulas and the most common cause of vesicovaginal fistula is dystocia.
MALPRESENTATIONS
• The most common malpresentation is breech presentation (3-4%). It is followed by transverse arrivals (1/340), compound arrivals (1/1.000), hundred arrivals (1/2.000) and forehead arrivals (1/10.000).
Breech Arrivals
• It is the most common presentation anomaly (3-4%). While it is seen in 45% at the 24th week of pregnancy; After the 36th week, the rate drops below 5%.
Risk factors
1. Premature (most common cause)
2. Hydramniosis
3. Oligohydramnios
4. Multiple pregnancies
5. Grand multiparity
6. Hydrocephalus
7. Anencephaly
8. History of previous breech birth
9. Uterine anomalies 10. Placenta previa
11. Pelvic tumors
12. History of previous cesarean section
complications (in persistent breech presentation)
1. Cord prolapse: The risk increases in small fetuses and impure breech presentations.
2. Placenta previa
3. Congenital anomalies
4. Uterine anomalies and tumors
5. Difficult childbirth
6. Increased maternal morbidity and mortality
a. Increased rate of invasive delivery and cesarean section
b. genital tract injuries
c. Uterine rupture during version
D. Uterine atony and postpartum bleeding
to. increased risk of infection
7. Increased perinatal morbidity and mortality
a. Prematurity
b. Congenital anomalies
c. Birth traumas
I. Humerus, clavicle, femur fractures
ii. Separation of epiphyses in scapula, humerus, femur
iii. Upper extremity paralysis (due to brachial plexus injury)
iv. Skull, neck fractures
v. Testicular damage, anorchia
D. mortality
I. concussion
ii. Brain damage➔ The breech is one of the most frequently injured organs at birth.
iii. Intracranial hemorrhage
iv. cord prolapse; more common than cephalic presentations.
v. Intrapartum asphyxia
Hip dislocations are more common in breech presentations than vertex presentations; but this is not due to the mode of birth.
Indications for cesarean section in breech presentation
1. Large fetus (3800-4000 g)
2. Preterm fetus
3. Fetus with severe IUGR
4. History of a child lost due to previous birth trauma
5. Stenosis in the bony pelvis
6. Head in hyperextension
7. History of previous cesarean delivery
8. Incomplete breech presentation or foot presentation
9. Fetal anomaly not suitable for vaginal delivery 10. The patient's request for cesarean section
11. Inexperienced physician
Cesarean section should be planned for breech presentations that have entered into labor between 24-32 weeks. Vaginal delivery can be planned if the estimated birth weight is >2500 g in breech presentations that enter labor between 32-37 weeks.
Vaginal Birth Types
1. Spontaneous breech birth: It is spontaneous birth without any intervention.
2. Partial breech extraction: No intervention up to the umbilicus level
3. Total breech extraction: The operator performs the entire delivery.
• In breech descent, descent and engagement occur with a bitrochanteric diameter.
Maneuvers used in Vaginal Birth
1. Pinard maneuver (total breech extraction): It is to remove the feet of the pure breech from the vagina.
2. Mauriceau maneuver (recovering the head from behind with the baby's back forward)
3. Modified Praque maneuver (recovering the head from behind if the baby's back is not turned forward)
4. Dührssen incision (freeing the stuck head): An incision is made in the cervix at the level of 2 and 10 o'clock.
5. Zavanelli maneuver (pushing the implanted head of the fetus into the uterine cavity and saving it with C/S)
Piper forceps or Laufe forceps can be used to save the head coming from behind.
The external cephalic version is a maneuver aimed at reversing the breech presentation. As a rule, the pregnancy should be past the 36th week and the labor should not have started. If the mother is Rh negative, anti-D Rh immunoglobulin should be administered after administration. Use of tocolytic agent before the procedure, polyhydramnios, multiparity,
The absence of engagement and the placement of the placenta on the posterior wall increase the chances of success.
External cephalic version contraindications
• Placenta previa
• Unreliable fetal well-being and fetal distress
• Membrane rupture
• Uterine malformation (unicornuate uterus etc.)
• Multiple pregnancy
• Recent uterine bleeding
• Previous cesarean section
• Fetal length cord on ultrasound
• Overt head-pelvis incompatibility,
• Oligohydramnios
IUGR
• History of abruptio placentae
Deflection Arrival
• It is the entry of the presenting fetal head into the birth canal in a position where it is not sufficiently flexed,
► Sinciput: The anterior fontanelle or bregma is the most anterior
► Get
► Face: It is full extension and the most advanced deflection.
face to face
► It is the most forward deflection of the head. Anencephalic fetuses usually present with a facial presentation . In addition, prematurity, an extremely thick neck, a cord in the neck, fetal malformations, hydramnios, pelvic stenosis, excessively large fetus and grand multiparity may also cause facial presentations.
► The position is determined according to the relationship of the chin with the symphysis and can be mentum anterior (60-80%) or mentum posterior (20-25%). Vaginal delivery is possible in mentum anterior presentations as long as there is no pelvic stenosis. In mentum posterior presentations, vaginal delivery is impossible and cesarean delivery is strictly indicated. Rotating the mentum posterior to the mentum anterior with vacuum or forceps is contraindicated.
come and go
► It is the rarest presenting anomaly. The reasons are the same as for face comings.
► Since the head comes with one of the largest diameters, the birth progresses slowly and takes a long time. Pregnancy is followed closely and it is expected that the head will return to the occiput or face. If there is no rotation, she must be delivered by cesarean section. The use of vacuum and forceps is strictly contraindicated.
Transverse Arrivals
• The leading part in transverse situs is the shoulder.
• Risk factors:
► Grand multiparity
► Preterm fetus
► Placenta previa
► Uterine anomaly
► Hydramnios
► Pelvic stenosis
• It is not possible for a transverse delivery to be delivered vaginally at term and a transverse delivery in labor is always delivered by cesarean section. If neglected, prolapse of the arm and subsequent uterine rupture develops.
• In cases where the fetus is small (800g and below) and the pelvis is wide, it is possible for the fetus to be born folded. This is called conduplicato corpore
Combined Presentation
It is the coming of an extremity next to the presenting part. The hand is most often next to the head. In the second frequency, the upper extremity comes next to the breech. The most common cause is prematurity.
• Concomitant cord prolapse in 10-20% of cases. (the most important cause of fetal loss). In the birth of compound presentations, if the extremity next to the incoming part does not prevent the descent, it is not intervened. If it hinders the descent, try to gently push the extremity in. If the extremity cannot be pushed in, a cesarean section should be planned.
BIRTH INDUCTION
General Information
• Initiation of contractions in the inactive uterus. In all cases where labor induction is planned, first of all, it should be evaluated whether the pelvis is suitable for vaginal delivery by examination.
Indications and Contraindications of Labor Induction
indications
1. Premature rupture of membranes ➔ Most common indication for induction
2. Gestational hypertension
3. Oligohydramnios
4. Postterm pregnancy
5. Chronic hypertension and diabetes
6. Serious IUGR
7. Isoimmunization
8. Pregnancy cholestasis
9. Fetal death
contraindications
1. Previous uterine surgical incision (metroplasty, classical cesarean section)
2. Contracted pelvis, deformed pelvis
3. Placenta previa
4. Active genital herpes
5. Cervical cancer
6. Macrosomia (normally >5000 g, in diabetics >4500 g)
7. Severe hydrocephalus
8. Malpresentation (transverse presentation, mentum posterior facial presentation, incomplete breech presentation)
9. Unsafe fetal condition
10. History of uterine rupture
11. Cord prolapse
Complications:
► Increasing cesarean rate
► Chorioamnionitis
► Rupture from existing uterine incision
► Uterine atony and postpartum bleeding
► Uterine rupture
► Postpartum hysterectomy
• There are some factors that increase the success of induction. These include young age, multiparity, BMI below 30, cervical compliance, and birth weight below 3500 g.
• It is a prerequisite that the cervix is mature in inducing labor. Bishop scoring is used to determine this. 5 parameters are used to determine the Bishop score:
► Dilatation (cm)
► Efesman (deletion){%}
► Level (from -3 to +2)
► The consistency of the cervix
► Position of the cervix
|
Bishop
scoring system |
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|
Point |
0 |
1 |
2 |
3 |
|
Cervical dilation (cm) |
0 |
1--2 |
3--4 |
>=5 |
|
Cervical effacement (%) |
0-30 |
40-50 |
60-70 |
>=80 |
|
Level |
3 |
2 |
-1 |
3 |
|
the consistency of the cervix |
Hard |
Middle |
Soft |
- |
|
position of the cervix |
Back |
Middle |
Front |
|
• If the Bishop score is 9 and above, the probability of being successful in induction is high. If the score is below 4, induction cannot be started. In these cases, cervical ripening methods should be applied before induction. The aim is to minimize induction failures and reduce rates of interventional births.
Cervical Maturation and Induction Methods
Pharmacological Methods
► Prostaglandin E2 (Dinoprostone): Local application intracervically is a frequently used method.
► Prostaglandin E1 (Misoprostol): When used orally or vaginally, it increases cervical ripening and induces labor. Vaginal PgE1 is more effective in labor induction and cervical ripening than PgE/.
► Oxytocin: It is the most effective and widely used method of induction of labor and is also an effective cervical ripening agent when used in low doses. Oxytocin has a half-life of 3-5 minutes and is used by IV infusion. The amino acid structure of oxytocin is similar to arginine vasopressin. Therefore, it has a pronounced antidiuretic effect. When used in high doses (20 mU/min), the renal clearance of water decreases and water intoxication and convulsions related to it and even death may occur. It rarely causes hypotension, myocardial ischemia and chest pain if undiluted IV is used. If fetal heartbeat changes and fetal distress develop, it can be discontinued and restarted if the picture returns to normal.
Mechanical Methods
► Transcervical Catheter: It is the process of applying downward traction with a Foley catheter placed in the cervical canal. It is used for both cervical ripening and labor induction.
► Hygroscopic Dilators: They swell by absorbing cervical secretions and provide mechanical dilatation. There are natural (laminaria} or synthetic (polyvinyl alcohol polymer, hydrogel) forms.
► Amniotomy: Following the artificial rupture of the membranes, there is an increase in endogenous prostaglandins, which induces labor.
OPERATIVE BIRTHDAYS
episiotomy
• An episiotomy is an incision applied to the perineum and is actually a second degree perineal laceration. It should not be used routinely. Episiotomy not only reduces anterior perineal injury, but increases the risk of anal sphincter injury, rectal injury, and gas/fecal incontinence.
• Indications include shoulder dystocia, breech delivery, macrosomic fetus, occiput posterior delivery, forceps and vacuum application, too short perineal length. It is applied mediolaterally or medianly.
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Episiotomy
differences |
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|
|
median |
mediolateral |
|
surgical repair |
Easy |
Difficult |
|
erroneous healing |
Rare |
common |
|
Postoperative pain |
Little |
very |
|
anatomical results |
Very good |
Bad |
|
blood loss |
LITTLE |
very |
|
dyspareunia |
Rare |
Sometimes |
|
Prolongation of the episode |
common |
Rare |
The most common cause of episiotomy dehiscence is infections. Other risk factors are coagulation disorders, smoking, HPV infection.
Forceps and vacuum applications
• The most common cause of operative deliveries is fatigue and prolongation of the second stage of labor.
• Indications:
► Maternal indications
0 Maternal heart disease
0 Maternal pulmonary disease
0 Intrapartum infection
0 Some neurological problems
0 Mother's fatigue
0 Prolongation of the second stage of birth
► Fetal indications
0 Premature separation of placenta
0 Unreliable fetal heart rate tracing
• Conditions:
► Experienced operator
► Head must be engaged
► Membranes must be ruptured
► Presentation should be vertex development (forceps can be attached to the mentum anterior face, but vacuum cannot be inserted)
► Cervical opening must be complete (10 cm)
► Head position must be known exactly
► There should be no head-pelvis incompatibility
► Fetal weight estimation should be made
► The bladder must be emptied
► There should be no fetal coagulopathy and bone mineralization disorder
• Factors reducing success in operative deliveries; persistent occiput posterior presentation, birth weight >= 4000 g.
Forceps Application
► In forceps application in the occiput anterior position, forceps are placed on the occipitomental diameter and applied.
Vacuum Application
► It is a method of assisting the delivery with uterine contractions and traction of the fetus by attaching a bell with vacuum power to the fetal head. Silastic bells are easier to apply and safer for scalp injuries than metal bells.
► Vacuum-specific conditions: The fetus must be at least 34 weeks old and fetal scalp blood sampling has not been performed recently.
|
Comparison
of vacuum and forceps complications |
||
|
Complications |
Vacuum |
Forceps |
|
intracranial hemorrhage |
1:860 |
1:664 |
Cesarean (C/S)
• It is the delivery of the fetus by abdominal route (laparotomy). Pfannenstiel incision; The skin, subcutaneous tissue of the anterior abdominal wall and the fascia of the rectus abdominis muscle are cut transversely, the rectus abdominis muscle is separated manually without cutting in the vertical plane, and the abdomen is entered by making a vertical incision into the peritoneum. Kerr (lower uterine segment transverse) requires an incision to be made into the uterus through the incision (hysterotomy). Planned cesarean deliveries are performed after the 39th week of pregnancy.
• Indications:
► Maternal
0 Previous cesarean section (most common)
0 Abnormal placentation
0 Maternal demands
0 Previous classical cesarean section (vertical uterine incision)
0 Unknown uterine scar
0 Opening the uterine incision
0 Previous full-thickness myomectomy
0 Mass in the genital tract obstructing the birth canal
0 invasive cervical cancer
0 Previous trachelectomy
0 Permanent cerclage
0 Prior pelvic reconstructive surgery
0 Pelvic deformity
0 Presence of HSV or HIV infection
0 Cardiac or pulmonary disease
0 Cerebral aneurysm or arterio-venous malformation
0 Pathological conditions requiring additional intraabdominal surgery
0 Perimortem cesarean section requirement
► Maternal - Fetal
0 Head pelvis incompatibility (most common)
0 Forceps fail in vacuum
0 placenta previa
0 Placental abruption
► Fetal
0 Unsafe fetal condition (most common)
0 Malpresentation (most common)
0 Macrosomia
0 Congenital anomaly
0 Impaired umbilical cord Doppler examination
0 Thrombocytopenia
0 History of neonatal birth trauma
|
Comparison of
vaginal and cesarean delivery complications |
||
|
Complications |
Caesarean section (%) |
Vaginal (%) |
|
General morbidity |
2.73 |
0.90 |
• Situations where peripartum hysterectomy may be required:
► Abnormal placentation (Most common)
► Atony
► Uterine rupture
► Cervical laceration
► Postpartum uterine infection
► Myoma uteri
► Invasive cervical cancer
► Ovarian neoplasia
Obstetric Analgesia and Anesthesia
• Maternal deaths due to anesthesia during cesarean section are more common in general anesthesia than in regional anesthesia. The most common complication in regional anesthesia for cesarean section is hypotension. The first and second stages of labor last longer and the need for more vacuum-forceps application arises in pregnant women who receive regional anesthesia compared to those who receive intravenous meperidine analgesia.