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However, it is unclear whether oxytocin plays a role in the early phases of uterine activation or whether its sole function is in the expulsive phase of labor. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation. Moving the woman to an operating room for this attempt, which could be followed by immediate cesarean delivery if operative delivery fails, has merit. J Assist Reprod Genet 33(5):647, 2016 Bouyer J, Coste J, Fernandez H, et al: Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. However, venous access is advantageous during the immediate puerperium to administer oxytocin prophylactically and at times therapeutically when uterine atony persists. For prevention, intraoperative goals strive to minimize bowel manipulation, avoid excess intravenous fluids or profound hypovolemia, and limit surgery length (Bragg, 2015). As with convulsions, however, the fetus is likely to recover more quickly in utero once maternal cardiac output is reestablished. An international Tay-Sachs carrier-screening campaign was initiated in the 1970s and met with unprecedented success in the Ashkenazi Jewish population. Serious metritis is treated with intravenous broad-spectrum antibiotics listed in Table 37-2. Sherer and colleagues (1996) assessed the number of fetal movements in 465 pregnancies during biophysical profile testing in relation to amnionic fluid volume. This in turn leads to ventricular dilation and redistribution of middle cerebral artery blood flow. Epochs denoted within rectangles represent contemporaneous ongoing events related to these rates. Obstet Gynecol 127(3):426, 2016 Hirakawa E, Ibara S, Tokuhisa T, et al: Extracorporeal membrane oxygenation in 61 neonates: Single-center experience. Gestational Choriocarcinoma this is the most common type of trophoblastic neoplasm to follow a term pregnancy or a miscarriage, and only a third of cases follow a molar gestation (Soper, 2006). This avoids incision extension into and laceration of the adjacent uterine artery. When the head distends the vulva and perineum enough to open the vaginal introitus to a diameter of 5 cm or more, a gloved hand may be used to support the perineum. Following this, a woman is instructed to palpate the strings each month after menses. As discussed earlier, women with a very early abruption may develop chronic abruption-oligohydramnios sequence. In the more common hypotonic uterine dysfunction, there is no basal hypertonus, and uterine contractions have a normal gradient pattern (synchronous). Most cases of sensitization to minor antigens result from incompatible blood transfusions. No differences were found in postoperative infection rates when single- and twolayer uterine closures were compared (Hauth, 1992). Some Indications for Cesarean Delivery the reasons for persistently significant cesarean rates are not completely understood, but some explanations include the following: 1. Rather, their effectiveness depends more on cervical mucus thickening and endometrial atrophy. Reports link heavy intake of approximately five cups of coffee per day-about 500 mg of caffeine-with a slightly greater abortion risk (Cnattingius, 2000; Klebanoff, 1999). Maternal expulsive efforts are again used in conjunction with downward traction to affect delivery. Careful palpation above the symphysis may disclose the fetal head to be above the pelvic inlet. First, the fetal shoulders are rocked from side to side by applying force to the maternal abdomen. With hemorrhage and edema, axonal function may be temporarily impaired, but the recovery chances are good.

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For example, sedation may prolong the latent phase, and myometrial stimulation shortens it. Although once considered a surgical condition, current management of a hepatic hematoma usually consists of observation unless bleeding is ongoing. Immunological maladaptive tolerance between maternal, paternal (placental), and fetal tissues 3. Given the parallels to severe preeclampsia, delaying delivery to effect fetal therapy should be considered only with caution. Mechanisms that cause pregnancy loss are discussed along with treatment in Chapter 59 (p. Notably, the decision to continue or discontinue resuscitative efforts must be individualized (Perlman, 2015). In this case, serious fetal hemorrhage follows laceration of these vessels at the time of membrane rupture (Swank, 2016). For this, the feet are grasped in one hand and drawn upward over the inner thigh of the mother. Some Commonly Used Regimens for Preinduction Cervical Ripening and/or Labor Induction Cervical "Favorability" One quantifiable method used to predict labor induction outcomes is the score described by Bishop (1964) and presented in Table 26-2. The cardinal movements of labor are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. On our service, puerperal tubal ligation is performed by a surgical team dedicated to this role the morning after delivery. The pathophysiology of sinusoidal patterns is unclear, in part due to various definitions. Newborns whose mothers took anticonvulsant drugs are at higher risk because these suppress maternal hepatic synthesis of some of these factors. This is because of an alveolar endothelialepithelial leak, and it is compounded by decreased oncotic pressure from a low serum albumin concentration. When the fetus lies with the long axis transversely, the shoulder is the presenting part. If both parents are carriers, chorionic villus sampling or amniocentesis can help determine whether the fetus has inherited one or both of the parental mutations. Contracted Inlet Using clinical measures, it is important to identify the shortest anteroposterior diameter through which the fetal head must pass. The American College of Obstetricians and Gynecologists (2016b) has concluded that the evidence favors predelivery administration. It has been used for prophylaxis of preterm, at-risk newborns and for rescue of those with established disease. Heart rate changes follow this pattern, and blood pressure similarly returns to nonpregnant values. Embolization can be used primarily, or more likely secondarily, if surgical attempts at hemostasis have failed or if the hematoma is difficult to access surgically (Distefano, 2013; Lee, 2012; Poujade, 2012). Preoperative preparation of the abdominal wall skin is effective to prevent wound infection. When this distinction is known, it can have clinical consequences in terms of sensitization risk and need for anti-D immune globulin. A small-gauge spinal needle is then introduced through the epidural needle into the subarachnoid space-this is called the needle-through-needle technique. Biswas and coworkers (1999) performed placental bed biopsies in 50 women with a previa and in 50 control women. The right pacemaker usually predominates over the left and starts most contractile waves. In many more cases, concern for an abnormal or "nonreassuring" fetal heart rate tracing prompts cesarean delivery. Other benefits of first-trimester sonography in women who elect aneuploidy screening include accurate assessment of gestational age and early detection of multifetal gestation or fetal demise. The cannula is gradually pulled back toward the os and is slowly turned circumferentially to cover the entire surface of the uterine cavity.

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Thus, variable decelerations represent fetal heart rate reflexes that reflect either blood pressure changes due to interruption of umbilical flow or changes in oxygenation. Decreased movement was associated with various placental abnormalities including infarction. This high rate was attributable to infection, prematurity, and placental abruption (Gunnarsson, 2017). Semin Perinatol 30(5):235, 2006 Menderes G, Athar Ali N, et al: Chlorhexidine-alcohol compared with povidone-iodine for surgicalsite antisepsis in cesarean deliveries. Three-Tier Fetal Heart Rate Interpretation System A few studies have assessed this three-tiered system. This practice attempts to make all phases of childbearing as natural as possible and to foster early mother-child relationships. There is no good evidence that placing a woman absolutely flat on her back for several hours is effective in preventing this headache. Neural blockade from epidural analgesia does not diminish their frequency or intensity. They defined this segment as the smallest measurement between urine in the maternal bladder and amnionic fluid. Obstet Gynecol 103:407, 2004 American College of Obstetricians and Gynecologists: External cephalic version. Comparing rotational operative delivery and second-stage cesarean delivery, maternal and neonatal morbidity rates are similar (Aiken, 2015; Bahl, 2013; Stock, 2013). Because of the remarkably greater survival rates of the latter currently, and despite the elevated cesarean delivery rate, the overall rate of cerebral palsy has remained essentially unchanged. The deceleration denoted by "A" is very much like that seen with complete umbilical cord occlusion in experimental animals. If the fluid reaccumulates, a trocar and cannula may be inserted through the fetal chest wall, and a double-pigtail shunt may be placed to drain the effusion. If a goiter is found, determination of fetal hyper- or hypothyroidism is essential, and thyroid hormone levels may be measured in amnionic fluid or fetal blood. Evidence linking anal incontinence with operative vaginal delivery is conflicting. Data on individual drugs are available through the National Institutes of Health website, LactMed, which can be found at toxnet. Problems identified or anticipated during prenatal care should be displayed prominently in the pregnancy record. For example, prostaglandin synthesis is high and unchanging in the decidua during phase 2 and 3 of parturition. Last, Bahl and associates (2007) noted that the incidence of neurodevelopmental morbidity was similar in those undergoing successful forceps delivery, failed forceps with cesarean delivery, or cesarean delivery without forceps. Although the depth of placental invasion does not correspond with perinatal outcome, it is of paramount maternal significance (Seet, 2012). Twin Pregnancy Rarely, in some twin pregnancies, one chromosomally normal fetus is paired with a complete diploid molar pregnancy. Terms presented in Table 23-2 and their diagnostic criteria more precisely describe abnormal labor. Reprod Toxicol 27(1):85, 2009 Tanaka Y, Mimura K, Kanagawa T, et al: Three-dimensional sonography in the differential diagnosis of interstitial, angular, and intrauterine pregnancies in a septate uterus. Its depressant effect in the fetus follows closely behind the peak maternal analgesic effect. High forceps, in which instruments are applied above 0 station, have no place in contemporary obstetrics. Last, prostaglandin treatment of myometrial tissue in vitro sometimes causes contraction, dependent on the prostanoid tested and the physiological status of the tissue treated. Fetal Death Most women with a prior cesarean delivery and fetal death in the current pregnancy would prefer a vaginal delivery. In term infants, opening pressures of 30 to 40 cm H2O typically will expand the alveoli without causing barotrauma.

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This fetal lie is more common remote from term, as earlier in pregnancy each fetal pole has similar bulk. Moreover, Eller and Mengert (1947) noted that the relationship between the intertuberous and interspinous diameters of the ischium is sufficiently constant that narrowing of the interspinous diameter can be anticipated when the intertuberous diameter is narrow. Importantly, when the fetus is dead, the maternal R waves are still detected by the scalp electrode as the next best signal and are counted by the cardiotachometer. For example, the risk of preeclampsia is appreciably enhanced in circumstances in which formation of blocking antibodies to placental antigenic sites might be impaired. Inclusive medical and surgical disorders are diverse and discussed throughout this text. Effective contractions, adequate head flexion, and average fetal size together permit most posteriorly positioned occiputs to rotate promptly as soon as they reach the pelvic floor, and labor is not lengthened appreciably. Topical Hemostatic Agents Several agents can be used to control persistent surgical oozing. In suspect cases, amnionic fluid will fern on a microscope slide or will have a pH >7, or oligohydramnios will be seen on sonography (Sugibayashi, 2013). Urine osmolality rises, urine:plasma creatinine ratio is elevated, and fractional excretion of sodium is low, which all indicated that a prerenal mechanism is involved. In individual women, however, these terms are nonspecific, and it is reasonable to specify the cause and gestational age as descriptors. However, because of the complex phenotypic expression of preeclampsia, it is doubtful that any one candidate gene will be found responsible. As shown in Table 32-2, each of five easily identifiable characteristics-heart rate, respiratory effort, muscle tone, reflex irritability, and color-is assessed and assigned a value of 0, 1, or 2. When this situation is encountered, pudendal block or systemic analgesia or rarely general anesthesia may be added. With oxytocin use, the American College of Obstetricians and Gynecologists (2016) recommends fetal heart rate and uterine contraction monitoring. They reported that rates for uterine dehiscence or uterine rupture for these closures did not differ significantly. The second stage significantly lengthened concomitantly with increasing first-stage duration. Preeclampsia Syndrome Preeclampsia is best described as a pregnancy-specific syndrome that can affect virtually every organ system. If hydrops is detected in the first trimester, the aneuploidy risk is nearly 50 percent, and most have cystic hygromas. Obstet Gynecol Surv 65(3):183, 2010 Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, et al: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. Atony, abnormal placentation, and coagulopathy are frequent sources, whereas surgical trauma is a rare cause. However, Harper and associates (2014) analyzed maternal and neonatal adverse outcomes related to first-stage labor lengths. Young and Zhang (2004) have shown that the initiation of each contraction is triggered by a tissue-level bioelectrical event. Blood Transfus 12:570, 2014 Daniels G: Variants of RhD-current testing and clinical consequences. The first theory suggests that in response to acute and severe hypertension, cerebrovascular overregulation leads to vasospasm (Trommer, 1988). Of African Americans, 1 in 12 has sicklecell trait, 1 in 40 carries hemoglobin C, and 1 in 40 carries the trait for - thalassemia. Am J Obstet Gynecol 148(7):886, 1984 Meyers C, Adam R, Dungan J, et al: Aneuploidy in twin gestations: when is maternal age advanced Baltimore, Johns Hopkins University Press, 2004 Mujezinovic F, Alfirevic Z: Analgesia for amniocentesis or chorionic villus sampling. Notably, the American College of Obstetricians and Gynecologists (2016d) does not recommend routine use of chromosomal microarray testing of first-trimester fetal tissues. Following use, the female condom outer ring should be twisted to seal the condom so that no semen spills. The fetus is gently manipulated to permit pulse oximetry monitoring and to establish venous access, in case fluids or blood are emergently needed. One of several suitable bipolar grasping devices is placed across the fallopian tube at the uterotubal junction. Persistent or refractory hypertension is likely aggravated by mobilization of pathological interstitial fluid and redistribution into the intravenous compartment, underlying chronic hypertension, or usually both (Sibai, 2012; Tan, 2002).

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However, changing gloves by the surgical team after placental delivery does not (Atkinson, 1996). The cervix is pulled outward and upward toward the symphysis with a tenaculum, and a long 18gauge needle is inserted through the posterior vaginal fornix into the retrouterine cul-de-sac. Fetal distress in labor, however, also frequently developed in those pregnancies with variable decelerations but with normal amounts of amnionic fluid. With completion of the uterine contraction and cord compression, the fetal heart rate returns to baseline. In not a few cases, however, particularly in occipito-posterior presentations, its employment as a rotator is attended by most happy results. Anderson and colleagues (2011) measured the ability of 12 individuals to detect critical signals in fetal heart rate tracings on one, two, or four monitors. According to Devi Wold and colleagues (2006), 15 percent of women with three or more consecutive miscarriages will be found to have a congenital or acquired uterine anomaly. Low-magnification photomicrograph shows generalized edema and cistern formation (black asterisks) within avascular villi. In contrast, Samueloff and associates (1994) evaluated variability in 2200 consecutive deliveries and concluded that variability by itself could not be used as the only indicator of fetal well-being. Other have correlated first- and second-trimester bleeding with third-trimester placental abruption (Ananth, 2006; Weiss, 2004). Most involve variations of uterine ischemic necrosis with peritonitis (Gottlieb, 2008; Joshi, 2004; Ochoa, 2002; Treloar, 2006). Periventricular Leukomalacia this pathological description refers to cystic areas deep in brain white matter that develop after hemorrhagic or ischemic infarction. Availability of anesthesia personnel to permit the start of a cesarean delivery within 30 minutes of the decision to perform the procedure. Obstet Gynecol 124(1):57, 2014 Le Ray C, Audibert F, Goffinet F, et al: When to stop pushing: effects of duration of second-stage expulsion efforts on maternal and neonatal outcomes in nulliparous women with epidural analgesia. By comparison, at the University of Alabama at Birmingham Hospital, labor is induced in approximately 20 percent of women, and another 35 percent are given oxytocin for augmentation-a total of 55 percent. With this practice, one Cochrane review found lower rates of anesthesia block use and no greater adverse neonatal or maternal effects compared with traditional labor (Cluett, 2009). Hypotonic contractions and no cervical dilation after an additional 2 to 3 hours result in stimulation of labor using the high-dose oxytocin regimen described in Chapter 26 (p. If chest compressions are to be performed, the woman is placed in the left-lateral position to allow left uterine displacement. After signs of placental separation, the uterus should be massaged if it is not contracted firmly, and placental descent is indicated by a slack umbilical cord. There are also conditions for which risk may be refined by detection of associated sonographic abnormalities or by gender determination if X-linked. For these deliveries, a vacuum is disproportionately selected, and the vacuum-to-forceps delivery ratio is nearly 5:1 (Merriam, 2017). It may be repeated in 1 to 2 days, and one large trial reported that 22 percent of women required a second dose (Zhang, 2005). Contraception 87(5):583, 2013 Ronnerdag M, Odlind V: Health effects of long-term use of the intrauterine levonorgestrel-releasing system. N Engl J Med 250:87, 1954 Raab W, Schroeder G, Wagner R, et al: Vascular reactivity and electrolytes in normal and toxemic pregnancy. At 12 mEq/L or higher levels, respiratory paralysis and respiratory arrest follow (Somjen, 1966). Increases in arteriovenous oxygen content difference reflect a relative rise in tissue oxygen extraction, although overall oxygen consumption falls. Conversely, approximately 40 percent of placentas that covered the os at midpregnancy continued to do so until delivery. All that said, it would appear that for the preterm breech fetus, planned cesarean delivery confers a survival advantage compared with planned vaginal delivery. In more advanced moles with considerable concealed uterine hemorrhage, moderate iron-deficiency anemia develops.

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This high incidence of pelvic contraction should be kept in mind when considering management. Several other reports also note that maternal obesity lengthens the first stages of labor by 30 to 60 minutes (Chin, 2012; Kominiarek, 2011). Until recently, a small quantity of dilute indigo carmine dye was often injected before removing the needle from the first sac, with return of clear amnionic fluid anticipated following needle placement into the second sac. Intermittent auscultation or continuous electronic monitoring is considered an acceptable method of intrapartum surveillance in both low- and high-risk pregnancies. In nulliparas with normal pelvic capacity, the presenting part at term commonly descends into the pelvic cavity before labor onset. Clinical Examination Important tests in stillbirth evaluation are neonatal autopsy, chromosomal analysis, and examination of the placenta, cord, and chorioamnionic membranes (Pinar, 2014). The sides of the anterior triangle are the pubic rami, and its apex is the inferoposterior surface of the symphysis pubis. Thromboelastometry and thromboelastography are point-of-care tests used as adjuncts to conventional laboratory studies (Abdul-Kadir, 2014). Surgical Procedures these include uterine compression sutures, pelvic vessel ligation, angiographic embolization, and hysterectomy. That said, estrogen can advance progesterone responsiveness and, in doing so, promote uterine quiescence. Maintenance of a hyperpolarized membrane potential attenuates smooth muscle cell excitation and is regulated by ion channels. Silver and colleagues (2016), with data from the Stillbirth Collaborative Research Network, found that most maternal and fetal thrombophilias were not associated with stillbirth and recommended against routine testing. Last, although uncommon, an unrecognized bowel injury may be responsible for otherwise unexplained fever and poor bowel function. Importantly, progression from one maneuver to the next should be organized and methodical. Conditions included in the panel should have a carrier frequency of at least 1:100, which correlates with a population frequency, at minimum, of 1:40,000. Dev Med Child Neurol 54(12):1102, 2012 Kamel H, Navi B, Sriram N, et al: Risk of a thrombotic event after the 6-week postpartum period. Also, in the event of hemorrhage, a 26F Foley catheter with a 30-mL balloon can be placed intracervically and inflated to effect hemostasis by vessel tamponade and to monitor uterine drainage. Contemporary Ob/Gyn, September 15, 2006 Dollberg S, Livny S, Mordecheyev N, et al: Nucleated red blood cells in meconium aspiration syndrome. For example, neonates who are either small or large for gestational age are at greater risk for hypoglycemia and polycythemia, and measurements of blood glucose and hematocrit are indicated. For many years, we have administered 30 mL of Bicitra-sodium citrate with citric acid-a few minutes before anesthesia induction by either general or major neuraxial block. Approximately 30 percent of women in each arm of the study underwent cesarean delivery. In this manner, maternal tissues are protected from amnionic fluid constituents that could prematurely accelerate decidual or myometrial activation or could promote adverse events such as amnionic fluid embolism. Sonographic identification of a nuchal arm may warrant cesarean delivery to avoid neonatal harm (Sherer, 1989). This proposal was based on the observation that heart rate acceleration in response to pinching the fetal scalp with an Allis clamp just before obtaining blood was invariably associated with a normal pH. Although only one injection may be elected, usually an indwelling catheter is placed for subsequent agent boluses or infusion via a volumetric pump. If the head is unusually molded or if caput succedaneum formation is extensive, or both, engagement might not have taken place although the head appears to be at 0 station. The combination of fetal macrosomia and maternal diabetes mellitus escalates the frequency of shoulder dystocia (Langer, 1991; Nesbitt, 1998). Other contraindications include any genital abnormalities such as hypospadias and a family history of a bleeding disorder, unless excluded in the newborn. Spinal (Subarachnoid) Block Anesthetic in this block can be given as a single dose, can be partnered with an epidural catheter as combined spinal-epidural analgesia, or can be administered as a continuous infusion.


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In one review of 1177 shoulder dystocia cases, brachial plexus injury was diagnosed in 11 percent and clavicular or humeral fracture in 2 percent (Chauhan, 2014). The key feature to distinguish fetal compromise in association with tachycardia seems to be concomitant heart rate decelerations. Abdominal palpation can be performed throughout the latter months of pregnancy and during and between the contractions of labor. Despite this, Tulman and Fawcett (1988) reported that only half of mothers regained their usual level of energy by 6 weeks. Routine intubation and suctioning of meconiumstained amnionic fluid is no longer recommended for the nonvigorous newborn (American College of Obstetricians and Gynecologists, 2017b; Perlman, 2015). If it is not firm, then vigorous fundal massage usually prevents postpartum hemorrhage from atony (Hofmeyr, 2013). This is because of background spontaneous losses, that is, losses that would have occurred between the first and second trimester in the absence of a fetal procedure. J Pediatr Surg 52(5):881, 2017 Peleg D, Cada S, Peleg A, et al: the relationship between maternal serum thyroid-stimulating immunoglobulin and neonatal thyrotoxicosis. Thus, urinary retention and bladder overdistention is common in the early puerperium. The carrier frequency of Tay-Sachs disease in Jewish individuals of Eastern European (Ashkenazi) descent approximates 1 in 30, but it is much lower, only about 1 in 300, in the general population. It is hypothesized that the change in threshold compensates for the contribution of donor cells in the initial transfusion, because donor cells (from adults) have a smaller mean corpuscular volume. The force generated during a uterine contraction is directed centripetally at and above the level of the pathological retraction ring. The overall need for transfusion was significantly lower with the combination regimen. Doppler ultrasound of the umbilical artery has been subjected to more extensive assessment with randomized controlled trials than has any previous test of fetal health. These derangements result in part from microangiopathic hemolysis caused by endothelial disruption with platelet adherence and fibrin deposition. The insertion site is marked with a sterile pen 8 to 10 cm proximal to the medial condyle of the humerus. Their current role may serve to guide blood product replacement, discussed later (p. Severe encephalopathy is manifest by coma, multiple seizures, and recurrent apnea. Obstet Gynecol 112(2 Pt 1):271, 2008 Kok M, Cnossen J, Gravendeel L, et al: Ultrasound factors to predict the outcome of external cephalic version: a meta-analysis. The initial 4-g loading dose of magnesium sulfate can be safely administered regardless of renal function. Expectant Management of Preterm Severe Preeclampsia Theoretically, antihypertensive therapy has potential application when severe preeclampsia develops before intact neonatal survival is likely. A small trocar and cannula are then inserted into the fetal bladder under sonographic guidance. Gradient distortion may result from more forceful contraction of the uterine midsegment than the fundus, from complete asynchrony of the impulses originating in each cornu, or from a combination of these two. An abundant abdominal coating of ultrasound gel permits this and also minimizes painful skin friction (Vallikkannu, 2014). Friedman developed the concept of three functional labor divisions to describe the physiological objectives of each division. Whitridge Williams (1903) the term dystocia as described by Williams in the first edition of this text still applies today. This profile of a 23-week fetus with nonimmune hydrops secondary to B19 parvovirus infection depicts scalp edema (arrowheads) and ascites (*). It is taken as a single 30-mg tablet up to 120 hours after unprotected intercourse (Brache, 2010; Watson, 2010). Other causes of fetal tachycardia include fetal compromise, cardiac arrhythmias, and maternal administration of parasympathetic inhibiting (atropine) or sympathomimetic (terbutaline) drugs. Laughon and associates (2012) compared the duration of spontaneous labor at term in nulliparas delivered in the United States between 1959 and 1966 to that of those delivered from 2002 to 2008. The frequency and intensity of thrombocytopenia vary and are dependent on the severity and duration of the preeclampsia syndrome (Heilmann, 2007; Hupuczi, 2007).

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Presumably, declining amnionic fluid and space account for diminished activity at term. In contrast, significant acute hemorrhage is poorly tolerated by the fetus and may cause profound fetal neurological impairment from cerebral hypoperfusion, ischemia, and infarction. The preterm neonatal brain responds quite differently to an ischemic episode compared with that of a term newborn. Additionally, requests for special instrumentation should be addressed preoperatively to prevent potential patient compromise and intraoperative delays. Am J Obstet Gynecol 209(2):89, 2013 Coletta J, Murphy E, Rubeo Z, et al: the 5-tier system of assessing fetal heart rate tracings is superior to the 3-tier system in identifying fetal acidemia. When the fetus is preterm, the tendency is to temporize in the hope that additional weeks in utero will reduce the risk of neonatal death or serious morbidity from prematurity. Less than a year later, the College (1999) recommended that physicians should be immediately available. Using local analgesia, symphysiotomy surgically divides the intervening symphyseal cartilage and much of its ligamentous support to widen the symphysis pubis up to 2. Randomized Comparative Trials of Prophylaxis with Magnesium Sulfate and Placebo or Another Anticonvulsant in Women with Gestational Hypertension the largest comparative study was Magnesium Sulfate for Prevention of Eclampsia reported by the Magpie Trial Collaboration Group (2002). Chesley and coworkers (1959) demonstrated a decrease in sodium space of approximately 2 L during the first week postpartum. Death before discharge occurred significantly more frequently in the lower-oxygen saturation group-20 versus 16 percent. Postpartum, the bladder has an increased capacity and a relative insensitivity to intravesical pressure. Second Stage of Labor this stage begins with complete cervical dilation and ends with fetal delivery. In contemporary practice, after birth of a first twin, a pathological ring may still develop occasionally as an hourglass constriction of the uterus. Cleavage of the placenta is aided greatly by the loose structure of the spongy decidua. Obstet Gynecol 114(5):1017, 2009 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine: Safe prevention of the primary cesarean delivery. The typical dose is 400 g given vaginally or buccally 3 to 4 hours prior to D & E. Management is similar in many regards to that used for second-trimester induced abortion, described later (p. When oxygen therapy is initiated, the pulmonary vascular bed dilates, and the shunt reverses. The first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. If placental location remains in question, then transvaginal sonography is the most accurate method of assessment. Two rows of mattress sutures travel through both sphincter ends to recreate the anal ring. Arch Pediatr Adolesc Med 166(6):558, 2012 Takenouchi T, Kasdorf E, Engel M, et al: Changing pattern of perinatal brain injury in term infants in recent years. If sonography is not readily available, diagnosis by clinical examination is done using the double set-up technique because it requires that a finger be passed through the cervix and the placenta palpated. Atrial flutter is characterized by a much higher atrial rate, generally 300 to 500 bpm, with varying degrees of atrioventricular block. Unrepaired cystotomy can manifest as hematuria, oliguria, abdominal pain, ileus, ascites, peritonitis, fever, urinoma, or fistula. Women with septic thrombophlebitis usually have symptomatic improvement with antimicrobial treatment, however, they continue to have fever. They may occur as frequently as every other beat, known as blocked atrial bigeminy. At Parkland Hospital, we administer an initial oral 100-g dose, which may be repeated after 6 hours for inadequate labor. All three of these are recommended as first-line agents by the American College of Obstetricians and Gynecologists (2017a). Sadovsky and coworkers (1979b) classified fetal movements into three categories according to both maternal perceptions and independent recordings using piezoelectric sensors. If severe, hypoxemia may lead to neonatal death or long-term neurological sequelae in survivors.

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The obstetrical plane of the midpelvis extends from the inferior margin of the symphysis pubis through the ischial spines and touches the sacrum near the junction of the fourth and fifth vertebrae. In a prospective, randomized study of five different spinal needles, Vallejo and associates (2000) concluded that Sprotte and Whitacre needles had the lowest risks of postdural puncture headaches. The failure rate of conservative measures was 15 percent in surgical and embolization procedures. Sonographic examination is performed to confirm nonvertex presentation, document amnionic fluid volume adequacy, exclude obvious fetal anomalies if not done previously, and identify placental location and fetal spine orientation. During the course of progressive hypoxia that led to death over 2 to 13 days, monkey fetuses invariably exhibited late decelerations before development of acidemia. Diagnostic and management options for ectopic gestation are described in Chapter 19 (p. Fetal blood sampling is often performed near the placental cord insertion site, where it may be easier to enter the cord if the placenta lies anteriorly. Facial Paralysis Trauma to the facial nerve commonly occurs as it emerges from the stylomastoid foramen, and this can cause facial paralysis. Further, it is unaffected by maternal levels of fetal hemoglobin or by fetal levels of hemoglobin A. After a seizure, the woman is postictal, but in some, a coma of variable duration ensues. If this weight increase is associated with severe persistent postpartum hypertension, then diuresis with intravenous furosemide is usually helpful in controlling blood pressure. When the catheter is removed, a voiding trial is completed to demonstrate an ability to void appropriately. For residents completing training in 2015, the Accreditation Council for Graduate Medical Education reported a median of only five forceps deliveries, and that for vacuum deliveries was 16. In addition, because so many disorders can be diagnosed from amnionic fluid specimens, fetal blood sampling is now rarely, if ever, indicated for genetic diagnoses. Whether quantification of blood loss improves accuracy is controversial (Hamm, 2017; Toledo, 2007). Moreover, the poor accuracy of antepartum fetal weight prediction should be considered as well (Hoopmann, 2010; Malin, 2016; Noumi, 2005). But, as discussed, antimicrobial prophylaxis at the time of cesarean delivery has remarkably reduced the postoperative pelvic and wound infection rates. The improved case-fatality rate for general anesthesia is especially notable considering that such anesthesia is now used for the highest-risk patients and the most hurried emergencies, that is, decision-to-incision intervals <15 minutes (Bloom, 2005). A few investigators have truncated this therapy duration to 12 hours and found no seizures (Anjum, 2016; Ehrenberg, 2006; Kashanian, 2016). For example, resection of large thoracic masses may be accomplished by fetal thoracotomy performed with intact placental circulation. Earlier reports suggested that the uterine rupture risk in a subsequent pregnancy was greater than the risk in those with a prior low-transverse hysterotomy and normally formed uterus (Ravasia, 1999). Stillbirth Rates within 1 Week of a Normal Antepartum Fetal Surveillance Test the severity of maternal disease is another. Second, dilute intravenous infusion of oxytocin is administered to treat certain types of uterine dysfunction. Once-daily dosing and multiple-dosing with gentamicin both provide adequate serum levels, and either method has similar cure rates (Livingston, 2003). Cellular and humoral components of this inflammation are expressed in endometrial tissue and in fluid filling the uterine cavity and fallopian tubes. This maneuver most often abducts both shoulders, which in turn produces a smaller bisacromial diameter. Concurrently, the uterus must initiate extensive changes in its size and vascularity to accommodate fetal growth and prepare for uterine contractions. In one early cohort of 1335 treated women, pregnancy rates at 10 years were 12 percent (Sokal, 2008). As the legs begin to emerge through the vulva, downward gentle traction is continued.