Items in AFP with MESH term: Delivery, Obstetric
Family Physicians Make a Substantial Contribution to Maternity Care: The Case of the State of Maine - Graham Center Policy One-Pagers
ABSTRACT: Appropriate management of pregnant patients who have human immunodeficiency virus (HIV) disease can have a major impact on maternal and infant health. The goals of therapy are to properly manage the pregnancy, treat the maternal HIV infection and minimize the risk of vertical transmission of HIV. Early detection of HIV through aggressive screening programs is necessary to initiate timely therapy. Zidovudine therapy given antepartum and intrapartum to the mother and after birth to the newborn has been shown to decrease the risk of vertical transmission. Evidence suggests that more aggressive antiretroviral therapy for the mother, which allows suppression of viral loads to undetectable levels, may be safe and may provide significant additional benefits. However, treatment needs to be individualized, weighing the possible teratogenic risks against the benefits of decreased transmission. Multiple prospective cohort studies support elective cesarean section as an additional means to decrease vertical transmission, but its role in relation to other therapies has not been determined. As in nonpregnant patients infected with HIV, prevention of opportunistic infections and adequate psychosocial support are essential.
Repair of Obstetric Perineal Lacerations - Article
ABSTRACT: Family physicians who deliver babies must frequently repair perineal lacerations after episiotomy or spontaneous obstetric tears. Effective repair requires a knowledge of perineal anatomy and surgical technique. Perineal lacerations are classified according to their depth. Sequelae of obstetric lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. With lacerations involving the anal sphincter complex, particular attention must be given to anatomy and surgical technique because of the high incidence of poor functional outcomes after repair. An overlapping technique to repair the external anal sphincter, rather than the traditional end-to-end technique, is being investigated to determine if it might decrease the incidence of anal incontinence. Minimizing the use of episiotomy and forceps deliveries can decrease the occurrence of severe perineal lacerations.
ABSTRACT: Postpartum hemorrhage is a significant cause of maternal morbidity and mortality. Most postpartum hemorrhages are caused by uterine atony and occur in the immediate postpartum period. Expectant or physiologic management of the third stage of labor has been compared with active management in several studies. Active management involves administration of uterotonic medication after the delivery of the baby, early cord clamping and cutting, and controlled traction of the umbilical cord while awaiting placental separation and delivery. Good evidence shows that active management of the third stage of labor provides a better balance of benefits and harms and should be practiced routinely to decrease the risk of postpartum hemorrhage. Oxytocin, ergot alkaloids, and prostaglandins have been compared, as have timing and route of administration of these uterotonic medications. Oxytocin is the uterotonic agent of choice; it can be administered as 10 units intramuscularly or as 20 units diluted in 500 mL normal saline as an intravenous bolus, and can safely and effectively be given to the mother with the delivery of the baby or after the delivery of the placenta.
Spontaneous Vaginal Delivery - Article
ABSTRACT: Vaginal delivery is a natural process that usually does not require significant medical intervention. Management guided by current knowledge of the relevant screening tests and normal labor process can greatly increase the probability of an uncomplicated delivery and postpartum course. All women should be screened for group B streptococcus; women who test positive should be treated with antibiotics during labor. Routine human immunodeficiency virus screening of all pregnant women, and treatment with antiretroviral medication for those who test positive, can reduce perinatal transmission of the infection. Once a woman is in labor, management should focus on the goal of delivering a healthy newborn while minimizing discomfort and complications for the mother. In a patient who tests negative for group B streptococcus, delaying admission to the labor ward until she is in active labor decreases the number of possible medical interventions during labor and delivery. Once a patient has been admitted to the hospital, providing her with continuous emotional support can improve delivery outcomes and the birthing experience. Epidural analgesia is effective for pain control and should not be discontinued late in labor to reduce the need for operative vaginal delivery. Epidurals prolong labor, but do not increase the risk of cesarean delivery. Research has shown that labor may not progress as rapidly as historically reported; this should be considered before intervening for dystocia. Routine episiotomy increases morbidity and should be abandoned. Once the infant has been delivered, active management of the third stage of labor decreases the risk of postpartum hemorrhage.
Diagnosis and Management of Preeclampsia - Article
ABSTRACT: Preeclampsia is a pregnancy-specific multisystem disorder of unknown etiology. The disorder affects approximately 5 to 7 percent of pregnancies and is a significant cause of maternal and fetal morbidity and mortality. Preeclampsia is defined by the new onset of elevated blood pressure and proteinuria after 20 weeks of gestation. It is considered severe if blood pressure and proteinuria are increased substantially or symptoms of end-organ damage (including fetal growth restriction) occur. There is no single reliable, cost-effective screening test for preeclampsia, and there are no well-established measures for primary prevention. Management before the onset of labor includes close monitoring of maternal and fetal status. Management during delivery includes seizure prophylaxis with magnesium sulfate and, if necessary, medical management of hypertension. Delivery remains the ultimate treatment. Access to prenatal care, early detection of the disorder, careful monitoring, and appropriate management are crucial elements in the prevention of preeclampsia-related deaths.
ACOG Issues Guidelines on Fetal Macrosomia - Practice Guidelines
Instruments for Assisted Vaginal Delivery - Cochrane for Clinicians
Rationale for a 39-Week Elective Delivery Policy - Editorials