A 24-year-old P0 at 25 weeks’ gestation presents in active preterm labor in breech presentation. She changes from 4 cm to 6 cm dilation and is contracting regularly.
For each clinical description, select the most appropriate procedure.
Cesarean delivery is indicated in this extremely preterm breech fetus. At 25 weeks, the lower uterine segment is likely to be poorly developed, and therefore classical uterine incision is indicated.
A 34-year-old P2002 with no prenatal care presents in labor. She is completely dilated and effaced. She progresses within minutes to vaginal delivery of a 2500 g infant. Because the uterus still feels large, you do a vaginal examination. A second set of membranes is bulging through a fully dilated cervix, and you feel a small part presenting in the sac. A fetal heart is auscultated at 60 beats per minute.
For the clinical description, select the most appropriate procedure.
Twins are typically diagnosed during pregnancy with the use of routine ultrasound. Therefore, it is rare these days to diagnose twins at the time of delivery.
Delivery of the second twin is probably the only remaining situation where internal podalic version is indicated. Some obstetricians might perform a cesarean delivery for a noncephalic second twin; however, in this case, fetal bradycardia dictates that immediate delivery be undertaken, and internal podalic version is the quickest procedure.
A 24-year-old woman (G3P2) is at 37 weeks’ gestation. The fetal presentation is a transverse lie by ultrasound.
A transverse lie is undeliverable vaginally. At 37 weeks, one treatment option is to do nothing and hope that the lie will be longitudinal by the time labor commences. However, in order to try to increase the chance of cephalic presentation at the time of labor, the next best step is to offer the patient an external cephalic version. This maneuver should be done in the hospital, with monitoring of the fetal heart rate.
No progress in descent for 4 hours or more in nulliparous women with an epidural or 3 hours or more in multiparous women with an epidural.
Select the most appropriate diagnosis for the clinical situation described.
The diagnosis of arrest and protraction disorders is based on deviation from norms that have recently been reevaluated by the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the National Institute of Child Health and Human Development. For many years, Friedman curves were used to assess whether labor was progressing normally. However, more recent data indicates that labor in nulliparous women takes longer than expected based on Friedman curves, and that the active phase of labor does not start for most women until they are at least 6 cm dilated. This has changed how patients are managed in labor and has resulted in new definitions, which are the basis for these three questions.
No cervical change for 4 hours or more with adequate uterine contractions and 6 cm or greater dilation with membrane rupture, or 6 hours or more with inadequate contractions.
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