controversies-LabourInterventions - In Labour Interventions...

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Unformatted text preview: In Labour Interventions Mohammed Abdalla, MD “In God we trust” ­ All others must show data… is the healthiest possible outcome for mother and baby. there are often there are often serious disagreements… … And over the years, the prevailing medical wisdom can swing as dramatically as clothing fashions and gasoline prices. Can Shoulder Dystocia ?Be Prevented Be Incidence of SD Incidence Overall (0.3 ­ 1% ) Birthweight >4000gm (5-7%) Birthweight >4500gm (8-10% ) Risk Factors Factors Neonatal birth weight. Instrumental vaginal delivery DM Prior infant with brachial palsy Brachial Palsy & Instrumental Delivery Delivery 18.3 20 18 16 18.3 14 12 OR 10 8 6 4 2 0 2.7 2.7 Vacuum 3.7 3.7 LFD MFD Brachial Palsy & Neonatal BW Brachial 21 25 21 20 2.4 15 OR 10 5 2.4 0 4001-4500 4001- 4500 > 4500 4500< RISK FACTORS FOR SHOULDER DYSTOCIA DYSTOCIA The main risk factor is: fetal macrosomia There are 2 controversial prophylactic measures Prophylactic labor induction Elective CS ACOG Issues Guidelines on Fetal Macrosomia 2000 2000 The diagnosis of fetal macrosomia is The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold's maneuvers). (Level A): . ACOG Issues Guidelines on Fetal Macrosomia 2000 2000 Prophylactic labor induction Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes. (Level B): . ACOG Issues Guidelines on Fetal Macrosomia 2000 2000 Elective CS? Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes. (Level B): . Prediction and prevention of shoulder dystocia shoulder When Elective CS? Planned cesarean delivery may be a reasonable strategy for diabetic pregnant women with estimated fetal weights exceeding 4,250­4,500 g (B: II­2). (. B: II-2( ACOG Issues Guidelines on Fetal Macrosomia 2000 2000 When CS? With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery. Level C . conclusion Beware of macrosomic infants Avoid midpelvic deliveries in macrosomics & GDMs Manage Shoulder Dystocia Don’t rush Avoid excessive traction Practical advice Practical Avoid poor judgment… Judgment comes from experience… Experience comes from poor judgment. Jeanty VACUUM­ASSISTED VACUUM­ASSISTED DELIVERIES ?A DANGER A DANGER VACUUM­ASSISTED DELIVERIES VACUUM­ASSISTED DELIVERIES ?A DANGER according to the U.S.FDA: At some hospitals, vacuum­ assisted deliveries have more than doubled. , based upon data from 1989­1995 VACUUM­ASSISTED ?DELIVERIES A DANGER FDA has received reports of 12 deaths and nine serious injuries among newborns on whom vacuum assisted delivery devices were used based upon data from 1989­1995 VACUUM­ASSISTED ?DELIVERIES A DANGER the FDA urged caution in use of the popular devices Afterward, ACOG became concerned that the FDA’s warning might itself endanger women and babies if it encouraged physicians to choose forceps or Caesarean over a properly performed vacuum­assisted delivery. ACOG issued an advisory to its members reiterating the contraindications for use of the devices but encouraging their continued use by trained physicians. Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity. The reduction in cephalhaematoma and retinal haemorrhages seen with forceps may be a compensatory benefit. Cochrane Library, Issue 2, 2002. Metal cups appear to be more suitable for 'occipito­posterior', transverse and difficult 'occipito­ anterior' position deliveries. The soft cups seem to be appropriate for straightforward deliveries. Cochrane Library, Issue 2, 2002 MANAGEMENT of MANAGEMENT of BREECH PRESENTATION The prevalence of breech presentation decreases as pregnancy progresses at 15% at weeks 29 weeks at 3-4% at term term The place of elective Caesarean section for breech presentation at term is unclear although 85% or more of breech presentations are now delivered by Caesarean section. The value of routine elective Caesarean section for preterm . breech delivery is unknown breech is While observational studies have usually found higher survival after Caesarean section, External cephalic version at term External after 36 weeks gestation, by a practitioner experienced in the technique, is good practice since it reduces the incidence of breech delivery of Caesarean section Following version, 67% of babies will proceed to a cephalic birth compared to 22% who turn spontaneously before delivery (ii). Cesarean Section for ?All Twins All Evidence­Based Decisions Evidence-Based Decisions Evidence-Based 1­ Vx­Vx pairs 2­ Vx­Non­Vx are considered are considered conceivable appropriate candidates for candidates for VD (with many VD (with few exceptions exceptions related to size related to size and/or and/or gestational age); gestational age); Evidence-Based Decisions Evidence-Based 3­ Non­Vx­Vx and Non­Vx­ Non­Vx are generally considered as an indication for CS, mainly due to lack of evidence about the safety of VD in breech­first pairs. Studies, which showed no difference in outcome for VD were criticized as having low statistical power or being non­ randomized. Vaginal birth after Vaginal birth after Caesarean (VBAC) After years of following the maxim “once a Caesarean, always a Caesarean,” there was a major push to allow most women to attempt to deliver vaginally. (VBAC) In VBAC, there is about a 1 percent chance that the uterus will rupture along the lines of the previous incision, creating the risk of bleeding in the mother and lack of oxygen to the baby. (VBAC) ACOG has issued a statement rejecting overall mandates requiring that VBAC be attempted, and called on their members to use individual factors — such as the type of incision used in the previous Caesarean and the availability of staff to deal with an emergency — to determine whether VBAC is wise. ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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