logging in or signing up controversies-LabourInterventions hamoda1992 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 108 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: October 28, 2009 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Slide 1: In Labour Interventions controversies Mohammed Abdalla, MD Slide 2: “In God we trust” - All others must show data… Slide 3: is the healthiest possible outcome for mother and baby. The goal in obstetric care Slide 4: 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? : Can Shoulder Dystocia Be Prevented? Incidence of SD : Incidence of SD Overall Birthweight >4000gm Birthweight >4500gm (5-7%) ( 8-10%) (0.3 - 1% ) Risk Factors : Risk Factors Neonatal birth weight. Instrumental vaginal delivery DM Prior infant with brachial palsy Brachial Palsy & Instrumental Delivery : Brachial Palsy & Instrumental Delivery 2.7 3.7 18.3 Brachial Palsy & Neonatal BW : Brachial Palsy & Neonatal BW 2.4 21 4001-4500 >4500 Slide 10: Playing Safe RISK FACTORS FOR SHOULDER DYSTOCIA : 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 : 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 : ACOG Issues Guidelines on Fetal Macrosomia 2000 Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes. . (Level B): Prophylactic labor induction ACOG Issues Guidelines on Fetal Macrosomia 2000 : ACOG Issues Guidelines on Fetal Macrosomia 2000 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): Elective CS? Prediction and prevention of shoulder dystocia : Prediction and prevention of shoulder dystocia Planned cesarean delivery may be a reasonable strategy for diabetic pregnant women with estimated fetal weights exceeding 4,250-4,500 g (B: II-2). (B: II-2). When Elective CS? ACOG Issues Guidelines on Fetal Macrosomia 2000 : ACOG Issues Guidelines on Fetal Macrosomia 2000 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 When CS? conclusion : Beware of macrosomic infants Avoid midpelvic deliveries in macrosomics & GDMs Manage Shoulder Dystocia Don’t rush Avoid excessive traction conclusion Practical advice : Practical advice Avoid poor judgment… Judgment comes from experience… Experience comes from poor judgment. Jeanty Slide 20: VACUUM-ASSISTED DELIVERIES A DANGER? Slide 21: 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? Slide 22: 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? Slide 23: the FDA urged caution in use of the popular devices VACUUM-ASSISTED DELIVERIES A DANGER? Slide 24: 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. Slide 25: ACOG issued an advisory to its members reiterating the contraindications for use of the devices but encouraging their continued use by trained physicians. Slide 26: 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. Slide 27: Metal cups appear to be more suitable for 'occipito-posterior', transverse and difficult 'occipito-anterior' position deliveries. The soft cups seem to be appropriate for straightforward deliveries. Cochrane Library, Issue 2, 2002 Slide 28: MANAGEMENT of BREECH PRESENTATION Slide 29: The prevalence of breech presentation decreases as pregnancy progresses 29 weeks term 15% at 3-4% at Slide 30: 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. : 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 : 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 Slide 33: 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? : Cesarean Section for All Twins? Evidence-Based Decisions 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 : Evidence-Based Decisions 3- Non-Vx-Vx and Non-Vx- Non-Vx 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 non-randomized. Slide 37: Vaginal birth after Caesarean (VBAC) : (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) : (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) : (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. Slide 41: Thank you You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
controversies-LabourInterventions hamoda1992 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 108 Category: Education License: All Rights Reserved Like it (0) Dislike it (0) Added: October 28, 2009 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Slide 1: In Labour Interventions controversies Mohammed Abdalla, MD Slide 2: “In God we trust” - All others must show data… Slide 3: is the healthiest possible outcome for mother and baby. The goal in obstetric care Slide 4: 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? : Can Shoulder Dystocia Be Prevented? Incidence of SD : Incidence of SD Overall Birthweight >4000gm Birthweight >4500gm (5-7%) ( 8-10%) (0.3 - 1% ) Risk Factors : Risk Factors Neonatal birth weight. Instrumental vaginal delivery DM Prior infant with brachial palsy Brachial Palsy & Instrumental Delivery : Brachial Palsy & Instrumental Delivery 2.7 3.7 18.3 Brachial Palsy & Neonatal BW : Brachial Palsy & Neonatal BW 2.4 21 4001-4500 >4500 Slide 10: Playing Safe RISK FACTORS FOR SHOULDER DYSTOCIA : 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 : 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 : ACOG Issues Guidelines on Fetal Macrosomia 2000 Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes. . (Level B): Prophylactic labor induction ACOG Issues Guidelines on Fetal Macrosomia 2000 : ACOG Issues Guidelines on Fetal Macrosomia 2000 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): Elective CS? Prediction and prevention of shoulder dystocia : Prediction and prevention of shoulder dystocia Planned cesarean delivery may be a reasonable strategy for diabetic pregnant women with estimated fetal weights exceeding 4,250-4,500 g (B: II-2). (B: II-2). When Elective CS? ACOG Issues Guidelines on Fetal Macrosomia 2000 : ACOG Issues Guidelines on Fetal Macrosomia 2000 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 When CS? conclusion : Beware of macrosomic infants Avoid midpelvic deliveries in macrosomics & GDMs Manage Shoulder Dystocia Don’t rush Avoid excessive traction conclusion Practical advice : Practical advice Avoid poor judgment… Judgment comes from experience… Experience comes from poor judgment. Jeanty Slide 20: VACUUM-ASSISTED DELIVERIES A DANGER? Slide 21: 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? Slide 22: 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? Slide 23: the FDA urged caution in use of the popular devices VACUUM-ASSISTED DELIVERIES A DANGER? Slide 24: 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. Slide 25: ACOG issued an advisory to its members reiterating the contraindications for use of the devices but encouraging their continued use by trained physicians. Slide 26: 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. Slide 27: Metal cups appear to be more suitable for 'occipito-posterior', transverse and difficult 'occipito-anterior' position deliveries. The soft cups seem to be appropriate for straightforward deliveries. Cochrane Library, Issue 2, 2002 Slide 28: MANAGEMENT of BREECH PRESENTATION Slide 29: The prevalence of breech presentation decreases as pregnancy progresses 29 weeks term 15% at 3-4% at Slide 30: 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. : 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 : 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 Slide 33: 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? : Cesarean Section for All Twins? Evidence-Based Decisions 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 : Evidence-Based Decisions 3- Non-Vx-Vx and Non-Vx- Non-Vx 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 non-randomized. Slide 37: Vaginal birth after Caesarean (VBAC) : (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) : (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) : (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. Slide 41: Thank you