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
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?
Incidence of SD

Overall
(0.3 - 1% )

Birthweight >4000gm
(5-7%)

Birthweight >4500gm ( 8-10%)
Risk Factors




Neonatal birth weight.
Instrumental vaginal delivery
DM
Prior infant with brachial palsy
Brachial Palsy & Instrumental
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
21
25
21
20
2.4
15
OR
10
5
2.4
0
4001-4500
4001- 4500
> 4500
>4500
RISK FACTORS FOR SHOULDER
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
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
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
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
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: II-2).
(B: II-2).
ACOG Issues Guidelines on Fetal
Macrosomia 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
Avoid poor judgment…
Judgment comes from experience…
Experience comes from poor judgment.
Jeanty
VACUUM-ASSISTED
DELIVERIES
A DANGER?
VACUUM-ASSISTED DELIVERIES
A DANGER?
 according
to the U.S.FDA:
At some hospitals,
vacuum-assisted deliveries
have more than doubled.
based upon data from 1989-1995,
VACUUM-ASSISTED
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 1989-1995
VACUUM-ASSISTED
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
vacuum-assisted 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 'occipito-posterior',
transverse and difficult 'occipitoanterior' position deliveries.
The soft cups seem to be
appropriate for straightforward
deliveries.
Cochrane Library, Issue 2, 2002
MANAGEMENT of
BREECH
PRESENTATION
 The
prevalence of breech
presentation decreases as
pregnancy progresses
15% at
29 weeks
3-4% at
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.
 While
observational studies have
usually found higher survival after
Caesarean section,
External cephalic version at
term
 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?
Evidence-Based Decisions
Evidence-Based Decisions

1- Vx-Vx pairs
are considered
appropriate
candidates for
VD (with few
exceptions
related to size
and/or
gestational age);

2- Vx-Non-Vx
are considered
conceivable
candidates for
VD (with many
exceptions
related to size
and/or
gestational age);
Evidence-Based Decisions

Non-Vx-Vx and NonVx- Non-Vx
3-
are generally considered as an indication
for CS, mainly due to lack of evidence
about the safety of VD in breech-first
pairs. Studies, which showed no difference
in outcome for VD were criticized as
having low statistical power or being nonrandomized.
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.