You are delivering a 26-year-old G3P2002 at 40 weeks’ gestation. She has a history of two previous uncomplicated vaginal deliveries, and has had no problems during this pregnancy. After 15 minutes of pushing, the baby’s head delivers spontaneously, but then retracts back against the perineum. As you apply gentle downward traction to the head, the baby’s anterior shoulder fails to deliver.
Which of the following is the best next step in the management of this patient?
In this clinical scenario, a shoulder dystocia is encountered. A shoulder dystocia occurs when the fetal shoulders fail to spontaneously deliver secondary to impaction of the anterior shoulder against the pubic bone after delivery of the head has occurred. Shoulder dystocia is an obstetric emergency; the first step should always be to call for help when such a situation is encountered. An episiotomy may be necessary to allow the obstetrician to have adequate room to perform a number of manipulations to try to relieve the dystocia. Such maneuvers include the following—suprapubic pressure, McRoberts maneuver (flexing maternal legs upon the abdomen), Wood’s corkscrew maneuver (rotating the posterior shoulder), Rubin maneuver (rotate accessible shoulder toward anterior surface of the chest), and delivery of the posterior shoulder (sweeping the posterior arm across the chest). There is no role for fundal pressure, because this action further impacts the shoulder against the pubic bone and makes the situation worse. A Zavanelli maneuver is replacement of the fetal head into the pelvis so that cesarean delivery can be performed. It should only be attempted when all other methods have failed. A symphysiotomy involves cutting the pubic symphysis and has a high morbidity for the mother.
After performing the appropriate maneuvers, the baby finally delivers. The pediatricians note that the right arm is hanging limply to the baby’s side with the forearm extended and internally rotated.
Which of the following is the baby’s most likely diagnosis?
Shoulder dystocias can be associated with significant fetal morbidity including brachial plexus injuries, clavicular fractures, and humeral fractures. Fractures of the clavicle and humerus usually heal rapidly and do not have any long-term orthopedic or neurologic consequences. Brachial plexus injury usually results from downward traction on the brachial plexus during delivery of the anterior shoulder. Injury to the brachial plexus may be localized to the upper or lower roots. In Erb palsy, the upper roots of the brachial plexus are injured (C5-C6), resulting in paralysis of the shoulder and arm muscles; the arm hangs limply to the side and is extended and internally rotated. In the case of Klumpke paralysis, the lower nerves of the brachial plexus are affected (C7-T1) and the hand is paralyzed.
A 41-year-old G1P0 at 39 weeks, who has been completely dilated and pushing for 4 hours, has an epidural in place and remains undelivered. She is exhausted and crying and tells you that she can no longer push. Her temperature is 38.3°C (101°F). The FHR is in the 190s with decreased variability. The patient’s membranes have been ruptured for over 24 hours, and she has been receiving intravenous penicillin for a history of colonization with group B streptococcus. The fetal head is in the direct OA position and is visible at the introitus between pushes. Extensive caput is noted, but the fetal bones are at the +3 station.
Which of the following is the most appropriate next step in the management of this patient?
Indications for an operative vaginal delivery with a vacuum extractor or forceps occur in situations where the fetal head is engaged, the cervix is completely dilated, and there is a prolonged second stage. It may also be indicated when there is suspicion of potential fetal compromise, or need to shorten the second stage for maternal benefit. In this clinical scenario, all of these indications for operative delivery apply. This patient has been pushing for 4 hours, which meets criteria for protracted second stage of labor in a nulliparous patient with an epidural, based on contemporary data. In addition, potential maternal and fetal compromise exists since the patient has the clinical picture of chorioamnionitis, and the FHR is nonreassuring. It is best to avoid cesarean delivery if possible, since it would take more time to achieve, and because the patient is infected.
A 28-year-old G1 at 38 weeks had a normal progression of her labor. She has an epidural and has been pushing for 2 hours. The fetal head is direct occiput anterior at +3 station. The FHR tracing is 150 beats per minute with recurrent variable decelerations. With the patient’s last push, the FHR had a prolonged deceleration to the 80s for 3 minutes. You recommend operative vaginal delivery due to the nonreassuring FHR tracing.
Compared to the use of the vacuum extractor, forceps are associated with an increased risk of which of the following neonatal complications?
Corneal abrasions and ocular trauma are more common with forceps versus the vacuum, unless the vacuum is inadvertently placed over the eye. Vacuum deliveries have a higher rate of neonatal cephalohematomas, scalp lacerations, retinal hemorrhages, intracranial hemorrhages, and jaundice.
You performed a forceps-assisted vaginal delivery on a 20-year-old G1 at 40 weeks for maternal exhaustion. The patient had pushed for 3.5 hours with an epidural for pain management. A second-degree episiotomy was cut to facilitate delivery. Eight hours after delivery, you are called to see the patient because she is unable to void and complains of severe pain. On examination you note a large fluctuant purple mass inside the vagina.
What is the best management for this patient?
The described mass is a vaginal hematoma. Following operative vaginal delivery, the symptoms of severe pain and urinary retention should lead to a vaginal examination to evaluate for a fluctuant mass consistent with hematoma. Small vulvar hematomas identified postpartum may be treated expectantly. If severe pain occurs, or if the hematoma continues to expand, the best treatment is incision and evacuation of the blood clots, with ligation of the bleeding vessels if they can be identified. Often no sites of active bleeding are found, in which case the defect should be closed and the vagina packed for 12 to 24 hours. Laparotomy may be indicated if the hematoma extends into the broad ligament. Embolization of the vaginal branch of the internal pudendal artery, uterine artery, and internal pudendal artery can be performed if bleeding is intractable.
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