A 20-year-old G1 at 41 weeks has been pushing for 2½ hours. The fetal head is at the introitus and beginning to crown. It is necessary to cut an episiotomy. The tear extends through the sphincter of the rectum, but the rectal mucosa is intact.
How should you classify this type of episiotomy?
A first-degree tear involves the vaginal mucosa or perineal skin, but not the underlying tissue. In a second-degree laceration, the underlying subcutaneous tissue (the fascia and muscles of the perineal body) is also involved, but not the rectal sphincter or rectal mucosa. Third degree lacerations involve the anal sphincter. A fourth-degree laceration involves a tear that extends into the rectal mucosa to expose the lumen of the rectum.
A 16-year-old G1P0 at 38 weeks’ gestation presents to labor and delivery for the second time during the same weekend that you are on call. She initially presented at 2:00 pm Saturday afternoon complaining of regular uterine contractions. Her cervix was 1-cm dilated, 50% effaced with the vertex at −1 station, and she was sent home after walking for 2 hours in the hospital without any cervical change. It is now Sunday night at 8:00 pm, and the patient returns to labor and delivery with increasing pain. She is exhausted because she did not sleep the night before because her contractions kept waking her up. The patient is placed on the external fetal monitor. Her contractions are occurring every 2 to 3 minutes. You reexamine the patient and determine that her cervix is unchanged.
Which of the following is the best next step in the management of this patient?
This patient is either experiencing prolonged latent labor or is in false labor. Friedman criteria for the normal progress in labor were established in the 1950s, and until recently, were used for assessment and management of labor. Friedman data indicated that the transition from the latent to the active phase of labor occurred around 4 cm of cervical dilation, and that active phase dilation should proceed at 1.2 cm per hour for nulliparous women, and 1.5 cm per hour for multiparous women. However, contemporary data suggests that changes in obstetric and anesthesia practices have resulted in changes in typical labor, and therefore, criteria for labor progress have been reviewed and revised based on data from the Consortium for Safe Labor (CSL). This data showed that cervical change between 3 cm and 6 cm is much slower than originally thought, and that the active phase of labor is more likely to start around 6 cm dilation. Women who dilate at a rate less than 1 cm per hour before 6 cm are still likely to proceed to spontaneous vaginal delivery. Data needed to establish the normal range for the duration of labor in the latent phase are not readily available because the onset of the latent phase in most women occurs outside the hospital and therefore cannot be accurately determined. One way to manage a protracted latent labor is to administer a strong sedative such as morphine along with intravenous fluids. This is sometimes referred to as “hydration and sedation.” This is preferred over augmentation with Pitocin or performing an amniotomy, because 10% of patients will actually have been in false labor. Patients who are not truly in labor will usually stop contracting after administration of morphine and hydration with rest. If a patient truly is in labor, then, after the sedative wears off, she will have undergone cervical change and will have benefited from the rest in terms of having additional energy to proceed with labor. An epidural would not be recommended because the patient may not truly be in labor. There is no role for cervical ripening in this patient, because if she is not in labor, she can go home and wait for natural cervical ripening and spontaneous labor.
A 25-year-old G1P0 patient at 37 weeks presents to labor and delivery reporting gross rupture of membranes and painful uterine contractions. The tocometer shows contractions every 2 to 3 minutes, and the fetal heart tracing is category I. On cervical examination, she is 4-cm dilated and completely effaced with the presenting part at -3 station. The presenting part is soft and felt to be the fetal buttock. A bedside ultrasound reveals a breech presentation with both hips flexed and knees extended. The estimated weight of the fetus is approximately 6 lb.
Which of the following is the best method to achieve delivery?
The patient described here has a fetus in frank breech presentation, which occurs when both hips are flexed and both knees are extended so that the feet lie in close proximity to the head and the fetal buttocks is the presenting part. With a complete breech presentation, both hips and knees are flexed. In the case of an incomplete breech presentation, one or both hips are not completely flexed; this may result in single footling or double footling presentations. Due to improved outcomes, it is generally recommended that fetuses with breech presentations undergo cesarean delivery. External cephalic version is a procedure whereby the presentation of the fetus is changed from breech to cephalic by manipulating the fetus externally through the abdominal wall. It is not indicated in this patient because the membranes are ruptured and the risk of cord prolapse is great. In addition, this procedure generally requires that the uterus be soft and relaxed, which is not the case with this patient in labor. Internal podalic version is a procedure used in the delivery of a second twin. It involves turning the fetus by inserting a hand into the uterus, grabbing both feet, and delivering the fetus by breech extraction.
What type of breech presentation is described?
Click to expand