8: Prolonged second stage of labour in .NET framework Generator PDF 417 in .NET framework 8: Prolonged second stage of labour

8: Prolonged second stage of labour use visual .net qr bidimensional barcode development tocompose qr-codes on .net Console application and rotation QR Code for .NET is recommended where the fetal status is satisfactory. Two US randomized controlled trials (RCTs) of good quality have compared coached with uncoached pushing in the second stage of labour [13,14].

The mean duration of the second stage of labour was significantly shorter for women in the coached group compared with the uncoached group (46 min vs. 59 min, p 0.014) [13].

There were no differences noted in any other maternal or neonatal outcomes in either trial. There is therefore no high-level evidence that directed pushing affects outcomes..

Oxytocin augmentation Consideration qr codes for .NET should be given to the use of oxytocin, with the offer of regional analgesia, for nulliparous women if contractions are inadequate at the onset of the second stage [3]. However, caution is required, particularly for multiparous women.

While it may be possible to augment the uterine contractions with the use of oxytocin, clearly this should not be contemplated where uterine activity is already effective and if disproportion or obstructed labour is suspected.. A Cochrane re view of six randomized trials involving 4850 women found that as compared to routine use (73%), restrictive episiotomy use (28%) was more beneficial as it was associated with less posterior perineal trauma, less need for suturing and fewer healing complications [15]. On the other hand, it caused more anterior perineal trauma and there was no difference in severe vaginal or perineal trauma, dyspareunia, urinary incontinence or severe pain. The evidence overall was in favour of a restrictive approach to episiotomy.

A prospective observational study involving 241 women giving birth for the first time aimed to identify risk factors associated with third- and fourthdegree tears following childbirth [16]. Episiotomies angled closer to the midline were significantly associated with anal sphincter injuries (26 vs. 37 degrees, p 0.

01). The authors recommended that the angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy..

Assessment prior to operative delivery The vast majo rity of avoidable maternal and neonatal morbidity at operative vaginal delivery relates to inappropriate application of the instrument and operator inexperience [17]. Therefore an essential prerequisite for operative vaginal delivery is a skilled operator. The obstetrician must be able to assess the bony pelvis and unequivocally determine the fetal position and station, as well as any degree of flexion, caput, moulding and asynclitism.

The instrument must then be correctly placed and an appropriate amount of traction applied in the right direction. In such circumstances, successful operative vaginal delivery rates are high and morbidity low. However, these skills are not easy to acquire, and certainly cannot be self-taught.

In addition, the trainee obstetrician must know when to ask for help. Predictors of failed operative vaginal delivery include occipitoposterior position, high presenting part (station spines 0), inadequate analgesia and birthweight >4000 g, and these criteria should alert the obstetrician to be cautious and seek senior support [18,19]. The RCOG has recommended that obstetricians be confident and competent in the use of both vacuum and forceps, and that operators should choose the instrument most appropriate to the clinical circumstances and their level of skill [2].

Clear and detailed guidelines are available and should be. Role of episiotomy in prolonged second stage of labour Episiotomy ca n be used to facilitate delivery if there is a clinical need, such as for operative vaginal delivery or suspected fetal compromise (e.g. fetal bradycardia).

However, it should be limited to specific clinical indications and not employed routinely. This is reflected in guideline recommendations [3].  A routine episiotomy should not be carried out during spontaneous vaginal birth.

 An episiotomy should be performed if there is a clinical need, such as instrumental birth or suspected fetal compromise.  Where an episiotomy is performed, the recommended technique is a mediolateral episiotomy originating at the vaginal fourchette and usually directed to the right side. The angle to the vertical axis should be between 45 and 60 degrees at the time of the episiotomy.

 Tested effective analgesia should be provided prior to carrying out an episiotomy, except in an emergency due to acute fetal compromise..
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