Dystocia caused by fetal anomalies

Dystocia means "slow or difficult labor or delivery." Fetal dystocia is abnormal fetal size or position resulting in difficult delivery Fetal dystocia may occur when the fetus is too large for the pelvic opening (fetopelvic disproportion) or is abnormally positioned (eg, breech presentation, shoulder dystocia).

Macrosomia Abnormally large size baby weighing more than 4kg is considered macrosomic. (D.C Dutta)

Causes Hereditary , race , size of the parents – particularly the mother (obesity). Poorly controlled maternal diabetes and gestational diabetes. Post maturity Multi parity Male fetus

Diagnosis Disproportionate increase in uterine size. Clinically the fetus is felt big Ultrasonographic measurement of fetal - BPD - HC - FL - AC Are done to predict the estimated fetal weight

Dangers Involves both the fetus and mother. Fetal hazards: Surprise dystocia due to cephalopelvic disporption. Brachial plexus injury Asphyxia Birth trauma Meconium aspiration.

Injury to the maternal soft tissues (vagina, perineum) Cont… Maternal hazards: Injury to the maternal soft tissues (vagina, perineum) PPH and puerperal sepsis Management Prophylactic induction of labour (pre term) to reduce the risk of shoulder dystocia Elective caesarean delivery in diabetic women.

Shoulder Dystocia

Definitions Difficulty in the birth of the shoulder (Varney) Vertex delivery in which genital lateral head traction and normal maternal pushing efforts fail to deliver the shoulders, in the absence of causes of dystocia or slow progress. (Piper and Mc donald 1994) Further progress delivery is prevented by impaction of the fetal shoulder within or above the normal pelvic. (seeds 1991)

Signs of shoulder dystocia Turtle necking: This occurs as the baby’s chin retracts into the mother’s perineum Head bobbing describes jerking movement of the head as it stretches forward to attempt delivery but moves back to the perineum as the shoulder is trapped. Gentle traction to facilitate delivery does not work.

Normal labour and Shoulder dystocia Birth. At birth (turtle sign)

Predisposing factors Fetal macrosomia – 50% of cases of shoulder dystocia occur with normal sized baby. Obesity Diabetes Mid pelvic instrumental delivery Post maturity Multi parity Anencephaly Fetal ascites

Fetal hazards: Fetal asphyxia Injury to the brachial plexus Fracture hummers Clavicle or sternomastoid haematoma during delivery Perinatal morbidity and mortality are high.

Maternal hazards: Increased operative delivery and morbidity. Prevention: Prediction of shoulder dystocia is not possible accurately. So care is to be taken to reduce the time internal delivery of the head to that of the body.

Diagnosis: 1.Define recoil of the head back against the perineum. 2. Inadequate spontaneous restitution.

Management principles DONT’s Do not be panicky Do not give traction over baby’s head Do not apply fundal pressure. DOS’s Call for extra help Clear the infant’s mouth and nose Involve the anesthetist and the pediatrician Perform a wide mediolateral episiotomy.

Intervention maneuvers Unilateral shoulder dystocia is usually easily dealt by standard technique.

c Gentle pressure on the fetal vertex in a dorsal direction will move the posterior fetal shoulder deeper into the maternal pelvic hollow , usually resulting in easy delivery of the anterior shoulder. Excessive angulation(>45 degree)is avoided.

Increase relative pelvic space: - Fetal shoulder rotation to the oblique

Altering pelvic angles Mc Roberts maneuver Sharply flex the mother’s thigh on to her abdomen. This will result in cephalic rotation of the pelvis , releasing the shoulder.

Decreasing passenger shoulder diameter Suprapubic pressure Delivery of the posterior arm Wood’s or Rubin’s screw maneuver

Moderate supra pubic pressure is often the only additional maneuver necessary to disimpact the anterior fetal shoulder. Stronger pressure can only be exerted by an assistant.

After proper suprapubic pressure,the fetal head will reassume a natural relationship to the shoulders which are in the opposite oblique diameter of the maternal pelvis

This type of suprapubic pressure by an assistant may reduce the impaction in some cases.

Best method for supra pubic pressure . This demonstrates the use of palm of the hand giving lateral pressure.

Supra pubic pressure

Supra pubic pressure is applied by an assistant. Midwife to direct the assistant to baby’s back. Hand’s are held in CPR style’s position Pressure is applied above the symphysis pubis to adduct the anterior shoulder. Initially continuously, then in a rocking motion for 30-60 seconds.

Wood’s corkscrew maneuver. Place the hand behind the posterior shoulder and rotate in 180degree towards the anterior shoulder

Wood’s screw maneuver. The shoulder must be rotated utilizing pressure on the scapula and clavicle. The head is never rotated.

If less invasive maneuvers fail to affect this impaction, delivery should be facilitated by manipulative delivery of the posterior arm by inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulder with delivery over the perineum

Rubin technique Move to the side of the bed opposite to the infants face. Instruct the mother to stop pushing. Apply firm pressure on the back side of the infant’s anterior shoulder and shove in the direction’s of infants face. Decreases shoulder to shoulder diameter.

Hibbard maneuver Release the anterior shoulder is initiated by firm pressure against the infant’s jaw and neck in a posterior and upward direction. An assistant is poised , ready to apply fundal pressure after proper suprapubic pressure.

Proper supra pubic pressure is continued. As the anterior shoulder slips free, fundal pressure is applied, and pressure against the neck is shifted slightly towards the rectum. Proper supra pubic pressure is continued. Shifted sightly

Continued fundal and suprapubic pressure results in an upward – inward rotation of the newly freed anterior shoulder and a further decent in a position beneath the pubic symposia

As a result of the previous maneuvers ,the transverse diameter of the shoulder is reduced. The lateral (upward) flexion of the head releases the posterior shoulder into the hollow of the sacrum

With both shoulders freed, delivery is accomplished without the necessity of additional fundal pressure.

Internal maneuvers ( wood screw & rubin technique)

Internal maneuvers( delivery of the posterior shoulder)

Mazzanti technique Instruct the mother to stop pushing until supra pubic pressure has been applied. Apply direct downward pressure above the maternal symphsis -Dislodges the anterior shoulder by pushing it under the maternal symphysis Do not use fundal pressure.

Cleidotomy One or both clavicles may cut with scissors to reduce the shoulder girth. This is applicable to an anencephalic baby as a first choice or to a dead baby.

Zavanelli maneuver. The fetal head is flexed and the fetus is replaced to the uterus. Thereafter the baby is delivered by emergency caesarean section. This maneuver is not practical

Nursing implications Intrapartum: Identify ante partum risk factors Identify and report deviations from normal labour progress. Prepare for potential shoulder dystocia. * personal * supplies * empty maternal bladder * Maternal positioning for birth

Birth: Observe for turtle sign Document emergence of head Call for if not already there Document any additional maneuvers attended. Assist with maternal position Support the mother about bearing down when instructed. If vaginal birth is not successful Prepare for the surgical birth Continuously monitor the fetus

Post birth Assess for- - Hematoma -Uterine atony - excessive bleeding - Bladder injury - Rectal injury Provide explanations to family as needed. Document birth events

Broken clavicle management -Minimize pain or discomfort Neonatal: Neonatal resuscitation as needed Assess for broken clavicle Asses for brachial plexus injury Broken clavicle management -Minimize pain or discomfort Immobilize the affected arm. Brachial plexus injuries -weakness or total paralysis of the muscle - 0.5to 2.0% per 1000 live births

Hydrocephalus Excessive accumulation of CSF (0.5-1.5L) in the ventricles with consequent thinning of the brain tissue enlargement of the cranium.

Minor degree may escape attention Diagnosis Antenatally: Minor degree may escape attention Severe degree presents with following features: The head is felt larger, globular and softer than the normal head The head is high up and impossible to push down to the pelvis. FHS is felt high up above the umbilicus. X-ray ; Cranial shadow is globular rather than the normal ovoid. Fontanels and sutures are wide.

Internal examination during labour reveals Cont.. Vault bones thinner Sonography: Dilatation of the lateral ventricles, dangling choroid plexus, and thinning out of the cerebral cortex. Internal examination during labour reveals Gaping sutures and fontanells Crackling sensation on pressing the head.

Prognosis Fetal outlook is extremely poor expect in mild variety The fetus is either delivered stillborn or dies in neonatal period. Babies which survive may be mentally defective. Maternal prognosis is not unfavorable in diagnosed cases but in undiagnosed cases and cases left uncared for during labour, obstructed labour with its consequence may occur. Rupture may occur even before the cervix is fully dilated because of too much distension of the lower segment by the head.

Management The pregnancy is to be continued until a stage (beyond 36 weeks) when induction can be achieved sucessfully. Induction is done by low rupture of the membranes. As soo as the labour is established and the cervix is 3-4 cm dilated, decompression of the head is done by a sharp pointed scissors or with bore (17 gauge) long needle.

Anencephaly Incidence 1 in 1000 live births. The anomaly results from deficient development of the vault of the skull and brain tissue but the facial portion is normal.

About 70% of anencephalic fetuses are females. Cont.. About 70% of anencephalic fetuses are females. More prevalent in first birth and in young and elderly mothers. Genetic and environmental factors are probably involved. Diagnosis: Alpha-feto protein in amniotic fluid and confirmed by sonography.

Tendency of post maturity Shoulder dystocia Obstructed labour. complications Hydramnios (70%) Malpresentation Premature labour. Tendency of post maturity Shoulder dystocia Obstructed labour.

Management If confirmed before 20 weeks by high alpha – fetoprotein level in liquor amnii and supplemented by sonography termination of pregnancy is to be done. The couples are counselled in either situation. During labour if tendency of delay, shoulder dystocia should be managed by cleidotomy.

Prevention Pre-pregnancy counseling is essential Folic acid supplementation beginning 1 month before conception to 12 weeks reduce the incidence of NTD significantly. A dose of 4mg daily is recommended. Risk of recurrence is about 2% in subsequent pregnancy.

Enlargement of fetal abdomen The enlargement of fetal abdomen sufficient to produce dystocia may be due to ascites, distended bladder or enlargement of kidney by a tumour or an umbilical hernia.

Antenatal diagnosis can be made accidently by sonography which shows an appearance resembling that of the “buddha position” Usually the diagnosis is made when there is difficulty in delivery of the trunk following birth of the head. Confirmation is done by introducing the hand and palpating the huge distended abdomen The decompression of the abdomen is done by simply puncture with a wide bore needle which is soon followed by spontaneous delivery

Conjoined twins

Diagnosis Ultrasonography Radiological examination. Managemnent Destructive operation when the fetus is dead. Caesarean section offers best chance for fetal survival.

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