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The wire electrode penetrates the fetal scalp, and the second pole is a metal wing on the electrode. In the planned vaginal delivery group, 57 percent were actually delivered vaginally. This should be started by 60 seconds of life, if not sooner, once the initial steps are completed. Studies by Matsuda and coworkers (2003, 2013) reported that 20 percent of survivors developed cerebral palsy. Data curves for both women show blood pressure measurements near the 25th percentile until 32 weeks. Dietary and Lifestyle Modifications Dietary "treatment" for preeclampsia has produced some interesting abuses (Chesley, 1978). Placement generally requires a speculum and positioning of the woman on an examination table. If the cervical length measures <25 mm, cerclage is offered to this group of women. Others have documented high perinatal mortality rates caused by placental abruption. Problems identified or anticipated during prenatal care should be displayed prominently in the pregnancy record. Vitamin K is virtually absent, and thus, an intramuscular dose is given to the newborn (Chap. Fortunately, because of effective antimicrobials, maternal mortality from infection has become uncommon. These include renal, gastrointestinal, hepatic, or cardiac injury; hematological abnormalities; or combinations of these. During this transformation, the cervical matrix changes its total amounts of glycosaminoglycans, which are large linear polysaccharides, and proteoglycans, which are proteins bound to these glycosaminoglycans. Thus, clinicians must simultaneously make every woman and her supporters feel comfortable, yet ensure safety for the mother and newborn if complications suddenly develop. For example, a change in hydrogen ion concentration associated with a fall in pH from 7. J Fam Plann Reprod Health Care 42(2):83, 2016 American College of Obstetricians and Gynecologists: Brand versus generic oral contraceptives. Progestin-Only Pills So-called mini-pills are progestin-only contraceptives that are taken daily. Comparisons of oral misoprostol and oxytocin and of oral misoprostol and dinoprostone also found significantly reduced rates of cesarean delivery with misoprostol. Management Ideally, an operative procedure is initiated only after it has been ascertained that tracheal intubation has been successful and that adequate ventilation can be accomplished. The shoulders then descend rapidly and undergo internal rotation, with the bisacromial diameter occupying the anteroposterior plane. For example, despite improvements in the proportion with independent ambulation, most children who received fetal surgery were not able to ambulate independently, and nearly 30 percent were not able to ambulate at all. Am J Obstet Gynecol 214:115, 2016 Monari F, Pedrielli G, Vergani P, et al: Adverse perinatal outcome in subsequent pregnancy after stillbirth by placental vascular disorders. Other Issues with Lactation With inverted nipples, lactiferous ducts open directly into a depression at the center of the areola. Once in place, the tube is used for tracheal suctioning only for a suspected obstructed airway. In contrast, the well-known abortifacient action of uncontrolled diabetes mellitus is detailed in Chapter 57 (p. Although less effective in inducing abortion or labor in women later in pregnancy, mifepristone appears to have some effect on cervical ripening and on increasing myometrial sensitivity to uterotonins (Berkane, 2005; Chwalisz, 1994a). Planned cesarean delivery may be considered for the nondiabetic woman with a fetus whose estimated fetal weight is >5000 g or for the diabetic woman whose fetus is estimated to weigh >4500 g. Differences in attitude of the fetal body in (A) vertex, (B) sinciput, (C) brow, and (D) face presentations. In our experiences, they are unique in that they do not usually respond to traditional analgesia, but they frequently improve after magnesium sulfate infusion. Practice Advisory July 11, 2016b American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine: Magnesium sulfate use in obstetrics.

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Because of these differing definitions, the incidence of shoulder dystocia varies. Ultrasound Obstet Gynecol 41(3):247, 2013 Akolekar R, Beta J, Picciarelli G, et al: Procedure-related risk of miscarriage following amniocentesis and chorionic villus sampling: a systematic review and meta-analysis. Anesthesiology 62:827, 1985 Ohashi Y, Baghirzada L, Sumikura H, et al: Remifentanil for labor analgesia: a comprehensive review. Additionally, these tests cannot diagnose coagulopathies stemming from platelet dysfunction or antiplatelet drugs. Other topics include lung-maturing corticosteroids, magnesium sulfate neuroprophylaxis, group B streptococcus antibiotic prophylaxis, tocolytics, and neonatal resuscitation efforts. Knowledge regarding cervical dilatation, cervical effacement, and presenting part station is essential for preparation. It becomes extremely difficult if amnionic fluid is scant and the uterus is tightly contracted around the fetus. Hypertension 59(3):395, 2012 Suzuki Y, Yamamoto T, Mabuchi Y, et al: Ultrastructural changes in omental resistance artery in women with preeclampsia. Similar incidences have been reported by others (Kramer, 2013; Mehrabadi, 2013; Patterson, 2014). Rouse and associates (1994) found that amniotomy with oxytocin augmentation for arrested active-phase labor shortened the time to delivery by 44 minutes compared with that of oxytocin alone. In these and others, inflammatory mediators may be an underlying theme (Kalagiri, 2016; Sjaarda, 2017). The least desirable cases are those in which traction without progress or multiple disengagements occur following correct cup application and appropriate traction. Foley balloon catheter placement can be another option for procedure-associated bleeding (Timor-Tritsch, 2015a). Scalp Stimulation Clark and coworkers (1984) have suggested that fetal scalp stimulation is an alternative to scalp blood sampling. The most common underlying causes of death are those attributed to labor and delivery events, to congenital anomalies, and to infection. With the fall in pulmonary arterial blood pressure, the ductus arteriosus normally closes. Weight loss from pregnancy itself is likely to be maximal by the end of the second week postpartum. Occasionally, retention of a succenturiate lobe may cause postpartum hemorrhage (Chap. As the placenta reaches the perineum, the cord is lifted, which in turn lifts the placenta out of the vagina. Their predictive accuracy is higher for early-onset preeclampsia (Redman, 2015b; Tsiakkas, 2016). Lower extremity nerve injury in the mother can follow prolonged second-stage labor. Methods most commonly used for preinduction cervical ripening and induction include several prostaglandin analogues. Disturbingly, these investigators found that few caregivers were aware that others were using different definitions of station! When the thinning of the lower uterine segment is extreme, as in obstructed labor, the ring is prominent and forms a pathological retraction ring. Symptoms ranged from lethargy, confusion, and blurred vision to obtundation and coma. The abdomen is unusually wide, whereas the uterine fundus extends to only slightly above the umbilicus. Although hypoxemia prompts supplemental oxygen, excess oxygen can damage the pulmonary epithelium, retina, and other immature tissues. The resulting fertilized egg is triploid with two chromosome sets being donated by the father. Although specific evidence supporting this practice is lacking, nipple pain usually subsides by 10 days (Dennis, 2014). More severe lacerations usually manifest as external hemorrhage or as a hematoma, however, they may occasionally be unsuspected. Parametrial Phlegmon For some women in whom metritis develops following cesarean delivery, parametrial cellulitis is intensive and forms an area of induration-a phlegmon- within the leaves of the broad ligament. With such a nuchal arm, delivery is more difficult and can be aided by rotating the fetus through a half circle in such a direction that the friction exerted by the birth canal will draw the elbow toward the face.

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Endocrine Factors According to Arredondo and Noble (2006), 8 to 12 percent of recurrent miscarriages are caused by endocrine factors. This is necessary in 15 to 20 percent of women treated with single-dose therapy (Cohen, 2014a; Kirk, 2007). Suspension of the body of the fetus in a towel effectively holds the fetus up and helps keep the arms and cord out of the way as the forceps blades are applied. Wiklund and coworkers (1991a,b) studied 83 children between ages 5 and 16 years who were born at term and who developed hemiplegic cerebral palsy. Atkinson and colleagues (2015) identified fetal cells in peripheral blood in only 4 percent of 68 women with a placental abruption. Cardiovascular System Cardiovascular disturbances are common with preeclampsia syndrome. The soft cup is a pliable bell-shaped dome, whereas the rigid type has a firm flattened mushroom-shaped cup and circular ridge around the cup rim (Table 29-2). In the fetus, respiratory and metabolic acidemia and ultimately tissue acidosis are most likely part of a progressively worsening continuum. According to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017), oral intake of moderate amounts of clear liquids is reasonable for women with uncomplicated labor. The deeper myometrial arterioles thus do not lose their endothelial lining and musculoelastic tissue, and their mean external diameter is only half that of corresponding vessels in normal placentas (Fisher, 2015). Whereas analgesia is maximal 30 to 45 minutes after an intramuscular injection, it develops almost immediately following intravenous administration. The Network addressed issues of increased morbidity in a cohort of 30,132 women who had from one to six repeat cesarean deliveries (Silver, 2006). However, in isolated cases of fetal anemia, supraventricular tachycardia, hydrothorax, and bladder outlet obstruction, successful fetal treatment resulted in resolution of both fetal hydrops and maternal mirror syndrome (Goa, 2013; Livingston, 2007; Llurba, 2012; Midgley, 2000). No cases of aspiration occurred during the study, although approximately a third of women in each study arm vomited during labor or delivery. Intravenous prostaglandin E2-sulprostone-is used in Europe, but it is not available in the United States (Schmitz, 2011). With positioning, legs are not separated too widely or placed one higher than the other. Traditionally, the diagnosis was made after delivery of a massively edematous neonate, often stillborn. The chance of acidemia in the fetus that fails to respond to stimulation in the presence of an otherwise nonreassuring pattern approximates 50 percent (Clark, 1984; Smith, 1986). Although the rates of fetal death have declined, the contribution of abruption as a cause of stillbirth remains prominent because other causes have also decreased. As the legs emerge, successively higher portions are grasped, first the calves and then the thighs. Incomplete Abortion During abortion, bleeding follows partial or complete placental separation and dilation of the cervical os. For intracranial hemorrhage, some studies have associated vacuum extraction with higher rates, whereas others show similar rates with either of the two methods (Towner, 1999; Wen, 2001; Werner, 2011). From the foregoing, it is apparent that significant blood loss accompanies up to a fourth of vaginal deliveries. The prognosis after hemorrhage depends on its location and extent (see Table 33-5). This is in addition to carrier screening for cystic fibrosis and spinal muscular atrophy, which are offered to all women who are considering pregnancy or who are currently pregnant. Conversely, extravascular volume is increased because of the capillary leak caused by endothelial cell activation (Chap.

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A few small randomized studies have evaluated postcesarean wound infection rates with a disposable plastic barrier retractor (Alexis-O). During the early puerperium, lactogenesis and milk let-down begin in mammary glands (Chap. Of these, compression of nerve ganglia in the cervix and lower uterine segment by the contracting myometrium is an especially attractive hypothesis. Am J Obstet Gynecol 180:1446, 1999 Fairweather D: Obstetric management and follow-up of the very low-birth-weight infant. The goal of this triad is to limit postpartum hemorrhage (Begley, 2015; Jangsten, 2011; Westhoff, 2013). Screening should be offered before pregnancy if both members of a couple are of Ashkenazi Jewish, French-Canadian, or Cajun descent, or if there is a family history of Tay-Sachs disease. One classification is anatomical and describes vulvar, vulvovaginal, paravaginal, and retroperitoneal hematomas. In another study, its incidence was nearly 1 percent following vacuum-assisted deliveries (Simonson, 2007). Even a careful search for evidence of preexisting end-organ damage may be futile, as many of these women have mild disease and no evidence of ventricular hypertrophy, retinal vascular changes, or renal dysfunction. Strict criteria were used to select 2526 of these for planned vaginal delivery, and 71 percent of that group were delivered vaginally. This presumptive method obviates many of the uncertainties in diagnosing labor during earlier stages of cervical dilation. The failure rate of conservative measures was 15 percent in surgical and embolization procedures. Hauth and colleagues (1986) described an effective and safe protocol for oxytocin augmentation for active-phase arrest. Rarely, the cervix, and occasionally a portion of the uterine body, may protrude from the vulva following delivery. Normal umbilical cord blood pH and blood gas values at delivery in term newborns are summarized in Table 32-3. There also may be hemorrhage in the basal ganglia or pons, sometimes with rupture into the ventricles. Salpingo-oophorectomy Because of the large adnexal vessels and their close proximity to the uterus, it may be necessary to remove one or both adnexa to obtain hemostasis. At this time, careful assessment is again performed as described in Chapter 22 (p. Magnesium will prevent proportionately more seizures in women with correspondingly worse disease. Complete release of sperm stored in the reproductive tract beyond the interrupted vas deferens takes approximately 3 months or 20 ejaculations. Contraceptive Failure Rates During the First Year of Method Use in Women in the United States No contraceptive method is completely without side effects, but contraception usually poses less risk than pregnancy. Thus, serial interrupted sutures incorporate sphincter fibers and perisphincter connective tissue, to bring sphincter ends together. Support for this latter approach comes only from small randomized trials and retrospective cohort studies (Berhan, 2014; Jeve, 2016; Nooh, 2017). They summarized that such monitoring, although it has been used in 85 percent of the almost 4 million annual births in the United States, has failed as a public health screening program. Other factors include insult severity and duration as well as restoration of cerebrovascular hypoperfusion. Whitridge Williams (1903) More than 100 years ago, the approach to fetal assessment was rather primitive. Milk also contains factors that act as biological signals for promoting cellular growth and differentiation. This converts an arterial pressure system into one with pressures approaching those in the venous circulation. J Reprod Med 30:549, 1985 Jacobs-Jokhan D, Hofmeyr G: Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section.

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The cis configuration is more prevalent among Southeast Asians, whereas those of African descent are more likely to inherit the trans configuration. After a mean follow-up of almost 15 years, the incidence of chronic hypertension was fivefold higher in those who had gestational hypertension, 3. These recommend allowing a nullipara to push for at least 3 hours and a multipara to push for at least 2 hours before second-stage labor arrest is diagnosed. The membranes are then ruptured, the child is seized by one foot and rapidly extracted. From its most superficial surface inward, the scalp is composed of skin, subcutaneous tissue, galea aponeurotica, subgaleal space, and calvarium periosteum. Hypertens Pregnancy 22:185, 2003 Saito Y, Tano Y: Retinal pigment epithelial lesions associated with choroidal ischemia in preeclampsia. Importantly, separation and delivery of the placenta by cord traction, especially when the uterus is atonic, may cause uterine inversion. Using this conservative definition of fever, Filker and Monif (1979) reported that only about 20 percent of women febrile within the first 24 hours after vaginal delivery were subsequently diagnosed with pelvic infection. Postoperatively, gum chewing enhances early bowel function recovery by nearly 7 hours after cesarean delivery (Zhu, 2014). The frequency at Parkland Hospital from 1988 through 2003 for nearly 250,000 births was 2. 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. One supported by the Society for Family Planning is bleeding that prompts a clinical response or bleeding in excess of 500 mL (Kerns, 2013). High, negative intrathoracic pressures are required to permit the initial entry of air into the fluid-filled alveoli. This increased turnover, rather than loss of collagen to achieve cervical remodeling, is supported by mouse and human studies that document no changes in collagen content between nonpregnant states and term pregnancy (Akins, 2011; Myers, 2008; Read, 2007; Yoshida, 2014). This phenomenon is not as apparent in women with a prior abortion (Strickland, 1986). Fertil Steril 100(3):638, 2013 Apantaku O, Rana P, Inglis T: Broad ligament ectopic pregnancy following in-vitro fertilization in a patient with previous bilateral salpingectomy. In humans, nitric oxide likely is the compound that maintains the normal low-pressure vasodilated state characteristic of fetoplacental perfusion (Myatt, 1992; Weiner, 1992). Of these, moderate suprapubic pressure can be applied by an assistant, while downward traction is applied to the fetal head. But, correlation was not found between meconium aspiration and markers of acute asphyxia-for example, umbilical artery acidosis (Bloom, 1996; Richey, 1995). Characteristics include gradual decline in the heart rate with the contraction nadir, and recovery occurring after the end of the contraction. Two major studies have assessed whether stillbirth risk factors could be identified either before or shortly after pregnancy confirmation. The use of an automated bladder scanner sonography system has been studied to detect high bladder volumes and thus postpartum urinary retention (Buchanan, 2014; Van Os, 2006). Regarding pelvic shape, an anthropoid pelvis and narrow subpubic angle can predispose (Barth, 2015; Ghi, 2016). That said, it is not necessary to activate massive transfusions until at least four to five units of red cells have been given within 2 hours or so. Malpractice litigation related to fetal injury during spontaneous or operative vaginal delivery continues to contribute to the present cesarean delivery rate. This time frame was extended to 6 hours if activity of 200 Montevideo units or greater could not be sustained. Many studies have shown that infection and cytokines can directly damage the immature brain (Chau, 2014; Yoon, 1997a). Quick and accurate localization can be accomplished using standard sonographic techniques (American Institute of Ultrasound in Medicine, 2013). During cup placement, maternal soft tissue entrapment predisposes the mother to lacerations and virtually ensures cup dislodgement, colloquially called a "pop off. Severe narrowing of a cardiac outflow tract may result in progressive myocardial damage in utero, and a goal of fetal intervention is to permit muscle growth and preserve ventricular function (Walsh, 2011). In another review of nearly 46,000 first-trimester abortions, the postoperative infection rate was <0.

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A limitation of using this technique for aneuploidy assessment is that because of mitotic nondisjunction, mosaicism of the blastomeres may not reflect the chromosomal complement of the developing embryo (American Society for Reproductive Medicine, 2008). But in those with severe decompensated disease, all hormonal methods are avoided (Kapp, 2009a). Decelerations During Nonstress Testing Fetal movements commonly produce heart rate decelerations. Pediatrics 108(3):776, 2001 American College of Obstetricians and Gynecologists: Prevention of Rh D alloimmunization. To prevent this, the forceps may be removed, and delivery is then completed by maternal pushing. In this chapter, fetal anemia and thrombocytopenia as well as immune and nonimmune fetal hydrops are reviewed. Even with proper fitting and correct use, pregnancy rates with this method are higher that with the diaphragm (Gallo, 2012b; Mauck, 1999). Unfortunately, uterine activity that causes discomfort, but that does not represent true labor, may develop at any time during pregnancy. Importantly, an intact coagulation system is not necessary for postpartum hemostasis unless there are lacerations in the uterus, birth canal, or perineum. In one example, Blackwell and colleagues (2011) asked three Maternal-Fetal Medicine specialists to independently interpret 154 fetal heart rate tracings. These women, who consequently lack normal pregnancy hypervolemia, are much less tolerant of even normal blood loss than are normotensive pregnant women. The more important risk is from bacterial contamination of platelets, which are stored at room temperature. That said, some low-intensity myometrial contractions are felt during the quiescent phase, but they do not normally cause cervical dilation. Importantly, however, fetal acidemia rates are not increased with operative delivery (Contag, 2010; Walsh, 2013). Another rare injury is when the entire vaginal portion of the cervix is avulsed-annular or circular detachment. Also, Military Combat Trauma Units in Iraq used a target hematocrit of 21 volume percent (Barbieri, 2007). Anatomical Changes Sheehan and Lynch (1973) frequently found changes identifiable at autopsy by light and electron microscopy in the kidneys of eclamptic women. If the membranes begin to tear, they are grasped with a clamp and removed by gentle teasing. Couvelaire Uterus At the time of cesarean delivery, it is not uncommon to find widespread extravasation of blood into the uterine musculature and beneath the serosa. Dosing begins ideally within 72 hours of unprotected coitus but may be given up to 120 hours. Of placentas not covering the internal os, previa did not persist, and none subsequently had placental hemorrhage. These findings have value for prediction of fetal-growth restriction but not preeclampsia (American College of Obstetricians and Gynecologists, 2015). Clinical staging is assigned without regard to histological findings, even if available. The bladder is then filled with a marker fluid to demonstrate integrity of the repair. Femoral fractures are rare and usually are associated with vaginal breech delivery. Last, the third stage begins immediately after delivery of the fetus and ends with the delivery of the placenta. Sonographically, a complete mole appears as an echogenic uterine mass with numerous anechoic cystic spaces but without a fetus or amnionic sac. A variable deceleration is defined as an abrupt drop in the fetal heart rate beginning with the onset of the contraction and reaching a nadir in less than 30 seconds. Management Surgical management with either cornual resection or cornuostomy may be performed via laparotomy or laparoscopy, depending on patient hemodynamic stability and surgeon expertise (Hoffman, 2016; Zuo, 2012). Such subinvolution is accompanied by varied intervals of prolonged lochia as well as irregular or excessive uterine bleeding.


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The characteristic "snowstorm" appearance is due to an echogenic uterine mass, marked by calipers, that has numerous anechoic cystic spaces. Lancet 381(9865):476, 2013 Laine K, Pirhonen T, Rolland R, et al: Decreasing the incidence of anal sphincter tears during delivery. Of note, misoprostol is suitable for early pregnancy failure in those with prior uterine surgery (Chen, 2008). Of the 35 laboring patients with uterine rupture, the decision-to-delivery time was <18 minutes in 17, and none of these infants had an adverse neurological outcome. At Parkland Hospital, labor is induced soon after admission when ruptured membranes are confirmed at term. Moreover, longitudinal studies suggest that initial pelvic floor advantages gained from cesarean delivery are lost as women age (Dolan, 2010; MacArthur, 2011, 2013; Nelson, 2010). Several other reports also note that maternal obesity lengthens the first stages of labor by 30 to 60 minutes (Chin, 2012; Kominiarek, 2011). With delivery, the maternal serum levels of progesterone and estrogen decline abruptly and profoundly. Tranexamic acid inhibits clot lysis to help forestall bleeding by preventing plasmin from degrading fibrin. Radiology 178(2):375, 1991 Bukulmez O, Arici A: Luteal phase defect: myth or reality. This situation is particularly dangerous because fatal transtentorial herniation can result. In general, the extent of abnormal waveforms correlates with severity of fetal involvement (Ghidini, 2008; Groom, 2009). Fever, headache, mental confusion, diffuse macular erythematous rash, subcutaneous edema, nausea, vomiting, watery diarrhea, and marked hemoconcentration are usual findings. After the study, she should pump her breasts to maintain milk flow but discard all milk produced during the time that radioactivity is present. Both will likely increase blood loss and theoretically may increase the incidence of persistent trophoblastic disease (American College of Obstetricians and Gynecologists, 2016; Tidy, 2000). However, data indicate that hypoglycemia, if promptly treated, creates no adverse sequelae (McKinlay, 2015). Although important because of the severity of infections they cause, clostridial species rarely cause puerperal infections (Chong, 2016). This creates a wedge shape into the myometrium, which is then closed in layers with delayed-absorbable suture. For a given health condition, each method is categorized 1 through 4 (Table 38-2). Decidua is endometrium that is hormonally prepared for pregnancy, and the degree to which the endometrium is converted with ectopic pregnancy is variable. Preoperative preparation of the abdominal wall skin is effective to prevent wound infection. In another study, Towers and coworkers (1999) administered magnesium sulfate, terbutaline, or both to 95 of 131 women with abruption diagnosed before 36 weeks. If undertaken, the caveats that mandate delivery shown in Table 40-10 should be strictly heeded. Of other prostaglandins, studies to evaluate their use for induction are contradictory. Amniotomy is then performed, and labor progress determined at the next 2-hour evaluation. Br J Anaesth 107(5):757, 2011 Tulandi T, Al-Jaroudi D: Nonclosure of peritoneum: a reappraisal. Cryoprecipitate is an ideal source of fibrinogen when levels are dangerously low and there is oozing from surgical incisions. The biomechanical properties of these structures and of the vaginal wall change markedly during parturition. Classification Therapeutic abortion refers to termination of pregnancy for medical indications.


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The capillary of the normal glomerulus shown on the left has wide endothelial fenestrations, and the pedicels emanating from the podocytes are widely spaced (arrow). In the 10 women with generalized edema, three became comatose and had imaging findings of transtentorial herniation, from which one died. Hagerstown, Lippincott, 1990 Hoffman M: A comparison of obstetric maneuvers for the acute management of shoulder dystocia. First, branches of the medial antebrachial cutaneous nerve can be injured during implant or needle insertion that is too deep or during exploration for a lost implant. With an all-fours maneuver, also called the Gaskin maneuver, the parturient rolls onto her knees and hands. Vacuum Pressure Conversions Once suction is created, the instrument handle is grasped, and traction is initiated. The muscular fibers at the level of the internal cervical os are pulled upward, or "taken up," into the lower uterine segment. In those with an unfavorable cervix and no or few contraction, prostaglandin E1 (misoprostol) is chosen to promote cervical ripening and contractions. Thus, plasmin activity usually declines until after delivery (Hale, 2012; Hui, 2012). Although uterine contractions are usually assessed with electronic monitoring, they can be quantitatively and qualitatively evaluated manually (Chap. Am J Obstet Gynecol 185:878, 2001 Gesteland K, Oshiro B, Henry E, et al: Rates of placenta previa and placental abruption in women delivered only vaginally or only by cesarean section. Obstet Gynecol 108:656, 2006 Greenwood C, Lalchandani S, MacQuillan K, et al: Meconium passed in labor: how reassuring is clear amniotic fluid Am J Obstet Gynecol 181:1122, 1999 Hammacher K, Huter K, Bokelmann J, et al: Foetal heart frequency and perinatal conditions of the fetus and newborn. The patch may be applied to buttocks, upper outer arm, lower abdomen, or upper torso, but the breasts are avoided. Cornual resection removes the gestational sac and surrounding cornual myometrium by means of a wedge excision. One interpretation of the paradoxical respiratory motion might be coughing to clear amnionic fluid debris. Traditionally, fetal blood sampling was performed to detect fetal thrombocytopenia and to tailor therapy, with transfusion of platelets if the fetal platelet count was <50,000/L. Given the importance of identifying and treating supraventricular tachyarrhythmias, a fetus with premature atrial contractions is often monitored with heart rate assessment every 1 to 2 weeks until the ectopy resolves. Other causes include endotoxins from gram-negative bacteria and exotoxins from gram-positive bacteria. Ambulation and Wound Care As discussed earlier, women undergoing cesarean delivery have an increased risk of venous thromboembolism compared with those delivering vaginally. Fox and associates (2014) reported 14 women with prior uterine rupture and 30 women with prior uterine dehiscence. That said, unless the woman is already under general anesthesia, intravenous nitroglycerine is preferred by many in such situations. As the head descends through the pelvis, the perineum begins to bulge and the overlying skin becomes stretched. Int Urogynecol J 21(5):535, 2010 Duggal N, Poddatoori V, Noroozkhani S, et al: Perioperative oxygen supplementation and surgical site infection after cesarean delivery: a randomized trial. This pathological cycle of coagulation and fibrinolysis becomes clinically important when coagulation factors and platelets are sufficiently depleted to create consumptive coagulopathy. Med Hypotheses 64:17, 2005 Baltajian K, Bajracharya S, Salahuddin S, et al: Sequential plasma angiogenic factors levels in women with suspected preeclampsia. To augment the last parameter, Burgos and coworkers (2014) administered a preprocedural 2-L intravenous fluid bolus. Suprapubic pressure is used initially by most practitioners because it has the advantage of simplicity. These trophoblasts invade the decidua and extend into the walls of the spiral arteriole to replace the endothelium and muscular wall to create a dilated low-resistance vessel. The use of intermittent nitrous oxide for labor pain is generally regarded as safe for the mother and newborn, but pain control is less effective than epidural analgesia (Barbieri, 2014; Likis, 2014). For women in labor with a breech presentation, continuous epidural analgesia is advocated by some.

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In some, profuse hemorrhage may follow, but in other cases, the hematoma drains in the form of large clots and old blood. In one, the operator applies traction on the Kielland forceps using a bimanual grip described previously for conventional forceps (p. They had significantly less hindbrain herniation and were only half as likely to undergo ventriculoperitoneal shunting by the age of 1 year. Data are insufficient to determine the value of fetal monitoring before scheduled cesarean delivery in women without risk factors. However, because the study was carried out in the 1960s, there were inconsistent criteria to accurately assign cause. When outcomes of these women were compared with those of the general obstetrical population, bed rest was associated with a significantly reduced relative risk-0. Although the distended pregnant uterus is surprisingly resistant, pregnant women sustaining such trauma should be watched carefully for signs of a ruptured uterus (Chap. If epidural analgesia is allowed to dissipate before another injection of anesthetic drug, subsequent pain relief may be delayed, incomplete, or both. Other causes of fetal tachycardia include fetal compromise, cardiac arrhythmias, and maternal administration of parasympathetic inhibiting (atropine) or sympathomimetic (terbutaline) drugs. However, rates of blood loss >500 mL and perhaps of second-degree lacerations were increased. Thus, similar to shoulder dystocia at the symphysis, this "shoulder dystocia at the pelvic inlet" is overcome by traction forces but with concomitant stretch on the brachial plexus. Because dried milk is likely to accumulate and irritate the nipples, washing the areola with water and mild soap is helpful before and after nursing. Namely, approximately one in three women who give birth each year undergoes this surgery. This phenomenon presumably reflects less cardiovascular physiological wandering as beat-to-beat intervals shorten with a higher heart rate. The American College of Obstetricians and Gynecologists (2017c) reviewed studies and concluded that: 1. Because healthy fetuses may not move for periods of up to 75 minutes, some have considered that a longer duration of nonstress testing might increase the positive-predictive value of an abnormal, that is, nonreactive, test (Brown, 1981). A scalp electrode can be safely affixed to the buttock, but genitalia are avoided. Unless placental abruption is comorbid, plasma fibrinogen levels do not differ remarkably from levels found in normal pregnancy. Prolactin is essential for lactation, and women with extensive pituitary necrosis- Sheehan syndrome-do not lactate (Chap. If alloimmunization is detected and the titer is below the critical value, the titer is generally repeated every 4 weeks for the duration of the pregnancy (American College of Obstetricians and Gynecologists, 2016). Lancet 337:1583, 1991 Solt I, Jackson S, Moore T, et al: Teaching forceps: the impact of proactive faculty. In general, premature atrial contractions are not associated with major structural cardiac abnormalities, although they sometimes occur with an atrial septal aneurysm. The fetus, which is doubled upon itself and thus sometimes referred to as conduplicato corpore, is expelled. Their mechanisms have not been precisely defined, but prevention of fertilization is now favored. For first-stage labor, while most clinicians prefer continuous electronic monitoring, the fetal heart rate is recorded at a minimum of every 15 minutes. Am J Obstet Gynecol 194:834, 2006 Habli M, Bombrys A, Lewis D, et al: Incidence of complications in twin-twin transfusion syndrome after selective fetoscopic laser photocoagulation: a single-center experience. Treatment for women with chronic hypertension complicating pregnancy is discussed in detail in Chapter 50 (p. Although a third of these studies were normal, focal arterial infarction was seen in 22 percent; brain malformations in 14 percent; and periventricular white-matter injuries in 12 percent. Beat-to-beat variability is also under the control of the autonomic nervous system (Matsuura, 1996). In other connective tissues, decorin interacts with collagen to regulate the packing, order, and strength of collagen fibrils.

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