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Managing Labor and Delivery

Labor management decisions. Tension between Hope for successful vaginal delivery and fear of emergency cesarean deliveryAvoidance of desultory labor and avoidance of impatience. Goals. Healthy momHealthy babyMeaningful birth experienceMaternal dignityEnvironment of safety. Labor problems. Grea

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Managing Labor and Delivery

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    1. Managing Labor and Delivery For your obese patient

    2. Labor management decisions Tension between Hope for successful vaginal delivery and fear of emergency cesarean delivery Avoidance of desultory labor and avoidance of impatience

    3. Goals Healthy mom Healthy baby Meaningful birth experience Maternal dignity Environment of safety

    4. Labor problems Greater number of inductions Difficult to monitor Difficult placement and function of epidurals Dysfunctional labor patterns ?Effect on duration of labor Failed inductions, more cesareans

    5. Management of medical co-morbidities Diabetes Monitoring Insulin Hypertension/preeclampsia Magnesium Antihypertensives Cardiac disease

    6. Chance of primary cesarean Observational cohort study 2007 4341 consecutive term, singleton nulliparas OR 3.8 for BMI >35 compared with BMI <25 after adjustment for variables No single explanation

    7. Cesarean section for abnormal labor Increased number of large-for-gestational-age infants Suboptimal uterine contractions Increased fat disposition in the soft tissues of the pelvis

    8. Complications of delivery More operative vaginal deliveries Postpartum hemorrhage Increased rate of primary cesarean birth Increased OR time Increased wound infections Increased rate of endometritis Risk of thromboembolic events And massive obestiy probably get rid of this and make a separate slide about massive obesity if possible And massive obestiy probably get rid of this and make a separate slide about massive obesity if possible

    9. Maternal morbidity - Complications of delivery Weiss 2004 (compare normal, obese and morbidly obese) Induction of labor OR 1.6 Failed induction 7.9%, 10.3%, 14.6% Primary cesarean delivery 20.7%, 33.8%, 47.4% Shoulder dystocia 1%, 1.8%, 1.9% Increased operative vaginal delivery Increased emergency cesarean delivery Reed weiss carefullyReed weiss carefully

    10. VBAC Hibbard 2006 (SMFMU) 14,142 TOL 14,304 ERCS 4 BMI categories (morbid obesity >40 BMI) No data about counseling, indication for prior delivery, intrapartum care. Inadequate data to assess death or neurologic damage Success of VBAC Normal weight 85% Morbid obesity 60% Rupture/dehiscence Normal weight 0.9% Morbid obesity 2.1 %

    11. VBAC Compare TOL vs ERCS in morbidly obese

    12. VBAC Hibbard, 2006 Compare successful and failed VBAC

    13. Anesthesia consultation Difficult IV access Airway obstruction Rapid desaturation with apnea (?FRC) Difficulty with ventilation Challenging regional anesthesia Slower pace of initiating anesthesia for cesarean section Consider prophylactic epidural

    14. Delivery considerations Type and screen, CBC Consider thromboprophylaxis Place a block of wood to support under the toilet of the patients bathroom Equipment: appropriate sized wheelchair, commode, bed

    15. What else helps? Ultrasound Internal fetal monitoring Maternal monitoring Careful BP cuff size Serial BP/pulse oximetry ?Arterial line Careful Is and Os

    16. Mechanics Assess ability to flex, external rotation Labor and push on side Assistance for thigh retraction Suprapubic pressure under pannus Step stools at side of bed Take care to avoid maternal injury

    17. Prevent wound infection Diabetes treat hyperglycemia Rupture of membranes avoid early AROM Multiple vaginal exams- limit exams Treat chorioamnionitis

    18. Postpartum care Early ambulation after delivery Sequential compression devices until ambulatory without assistance Or continue heparin until ambulatory without assistance Assure that patient completely changes position in bed q 2 hours

    19. Breast is best Decreases rate of obesity in offspring Helps mom lose weight

    20. Guiding questions What is the patients BMI? Are there co-morbidities? Is there a history of surgical or anesthesia complications? Does my hospital have the necessary equipment, personnel, protocols?

    21. Elements of care plan Frank discussion regarding risks-consider written document/consent Anesthesia consult EFW before admission (?how) ?early delivery/avoid macrosomia Criteria for primary cesarean

    22. Elements of care plan Safety huddle on admission (? repeat) Assure all team members are available Equipment check list Identify roles for Emergency cesarean Shoulder dystocia

    23. Elements of care plan Lab: Type and screen, CBC Secure IV access Thromboprophylaxis Maternal and fetal monitor Continuous EFM, toco BP cuffs Glucometer

    24. Other considerations ? Postpone other elective patient care Set expectations for labor progress When to consider cesarean When to consider (or not) operative vaginal delivery Induction issues Cervical ripeness criteria Duration of ROM Minimize length of hospitalization

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