Shoulder Dystocia

Shoulder dystocia is a true emergency in the sense that, time is a critical factor. It needs the necessary expertise within a limited time, no more than minutes, to get a good outcome and prevent an adverse outcome.

What is shoulder dystocia?

shoulder-dystocia-yellow_434Shoulder dystocia is diagnosed when the shoulders get stuck  at the pelvic brim when the head has been delivered. 

This means, the head is out, the baby’s neck is stretched within the birth canal (vagina) and the rest of the baby is stuck within the abdomen. 

 Size of baby and shoulder dystocia:

While it is true that larger babies are more at risk of shoulder dystocia, it is also true that the majority of cases of shoulder dystocia occur with babies of normal (average) weight. It is very difficult, probably  impossible, to accurately predict shoulder dystocia. 

Risk factors for shoulder dystocia:

  • Gestational diabetes especially with a suspected large baby
  • Maternal short stature
  • A prolonged second stage of labor despite strong regular contractions
  • Previous shoulder dystocia
  • Need for instrumental delivery (forceps or ventouse)
  • Postmaturity
  • A macrosomic (above average size) baby

The  idea that recognition of risk factors (above) will facilitate prediction and therefore avoidance of the complication is seductive but ultimately very simplistic and of limited practical value.  The vast majority of those who fall within the identified ‘at risk’ groups do actually achieve successful uncomplicated vaginal deliveries. Conversely, most of mothers who experience shoulder dystocia do not have any of the mentioned or any other identifiable risk factors. That is the practical difficulty.

Dealing with shoulder dystocia:

Once recognized, shoulder dystocia calls for immediate action. Obstetricians and midwives involved in delivery will be familiar with the mnemonic HELPERR. 

This is meant to help them remember the steps involved in the emergency manoeuvre to deliver the stuck baby. Each letter in the mnemonic represent an action (in sequence)  The majority of cases of shoulder dystocia will be overcome using the manoeuvre. Delivery is usually achieved within minutes. Occasionally, injuries can result from  these efforts (see next page)

When this manoeuvre fails, a measure of last resort known as the Zavanelli manoeuvrecan be employed. This involves replacing the head back into the abdomen, giving a general anesthetic and performing a cesarean section to deliver the baby.


Phantom Pregnancy

When a woman has a phantom pregnancy she is not setting out to deceive. In fact, she believes absolutely, that she is pregnant. She will exhibits all or most of the usual pregnancy signs and symptoms. These would include lethargy, nausea and vomiting, breast engorgement, increasing abdominal size and, of-course, she will not have menstrual periods.

Phantom pregnancy which is also medically termed ‘Pseudocyesis’ (Greek: pseudes[false] and kyesis [pregnancy])is not a new phenomenon. The most famous historical sufferer was probably Queen Mary I, the daughter of King Henry VIII and ruler of England in the mid-16thcentury. Even Hippocrates ‘The Father of Medicine’ described cases of pseudocyesis all those centuries ago.

Causes of Phantom Pregnancy

Nobody knows for sure what causes phantom pregnancy. However, one thing binds sufferers together: The extreme desire to bear a child. Contrary to some descriptions, Phantom Pregnancy is not the same as ‘feigned pregnancy’. There is one important difference: Women with phantom pregnancy are absolutely convinced that they are pregnant. Even a negative pregnancy test and a negative ultrasound scan are not sufficient to shake their belief. They are not trying to deceive anybody and will describe all the common experiences of a pregnant woman including fetal movements.

Feigned pregnancy merely refers to women who set out to deceive others that they are pregnant for a variety of reasons. This includes the women criminals who put out an elaborate plan, the end of which is meant to be the stealing of infants from other women and passing them off as their own newborns after a well demonstrated ‘pregnancy’. That is not Phantom pregnancy.

True phantom pregnancy is thought to have a deep psychological basis, strong enough to bring about the hormonal changes which cause the display of the physical features such as absence of periods, breast engorgement and abdominal swelling which is merely gaseous distension of the bowel.

Treating Phantom Pregnancy

Phantom pregnancy is quite uncommon. However, women who suffer from this do require sympathetic specialised counselling by a psychotherapist. It is a condition that affects women of any age even though it is more common for women in their 30s and 40s. It could and often does affect women who already have children.


Pregnancy Symptoms

Causes of the common pregnancy symptoms

Morning sickness or just plain nausea is the most common and most widely experienced early pregnancy symptom. It is believed to be hormonal.

There are many hormones produced by the fetus and the placenta. 

The onset of morning sickness is usually within three to four weeks of conception and will normally subside and disappear around ten to twelve weeks of gestation. Sometimes it persists for up to 14 to 16 weeks and, in exceptional cases, it may continue throughout the pregnancy. 

Another less common scenario is where the symptoms disappear as expected at about twelve weeks, only to come back towards the end of pregnancy.

Smoking exacerbates morning sickness. The severe form of pregnancy-related nausea and vomiting is regarded as path­ological and is discussed in a later. It is called hyperemesis gravidarum.

Dizziness and bloatedness in pregnancy

Normally, diziness starts later on in pregnancy. 

The cause is partially hormonal: Progesterone hormone, which is abundant during pregnancy, causes blood pressure to fall, especially when one is rising from a recumbent (lying) position.

The other cause of dizziness, if the mother has been lying on her back, is the pressure of the pregnant womb on the big blood vessels in her abdominal cavity. This interferes with the blood-flow back to the heart and, on sitting or standing up, she may feel faint. In fact, this flat-on-your-back position is discouraged during pregnancy, because it also reduces the blood supply to the womb and therefore the fetus.

Bloatedness or the feeling of uncomfortable fullness is also a result of the high levels of progesterone. Progesterone has the effect of causing fluid retention. 

Breasts changes in early pregnancy

Several hormones also act to promote increased breast size, which is a physiological preparation for feeding the baby. The breasts will therefore feel heavy, slightly engorged and may even feel a little tender.

Bowel habit changes in pregnancy

Constipation is quite common in pregnancy and again the culprit is the hormone progesterone.

Some women experience heartburn; again this is caused by progesterone. Both problems clear up after the birth and treatment of the symptoms in pregnancy is usually unsatisfactory.

Sugar in the urine during pregnancy (Glycosuria)

Don’t panic if sugar is detected in your urine during pregnancy. This is not necessarily abnormal. Changes in blood-flow through the kidneys mean that loss of sugar through the urine may occur in pregnancy, with the woman being perfectly healthy. 

Urine sugar cannot and should never be used to monitor diabetes management in pregnancy. 

In the presence of other suspicious features – such as undue thirst, large fetal size and excessive amniotic fluid volume, sugar in the urine may prompt investigation for diabetes in pregnancy. 

When sugar in urine is found in isolation, it is of little or no significance.


Fetal Distress

Fetal distress is a term in common usage. It may, therefore, surprise many that, even experts in the field don’t agree on the exact meaning of the term.

In essence, fetal distress refers to a state where insufficient oxygen is reaching the fetus. If oxygen deficiency is severe and prolonged, permanent damage to the baby could result. It is, therefore, the norm, to err on the side of caution.

Causes of fetal distress before labor

There are several potential causes.

Fetal distress is commonly a feature of established labor but could occur before labor onset. This is uncommon.

Placental abruption which is a condition where the placenta. (afterbirth) detaches from its base partially or wholly, is one of the more common causes of pre-labor fetal distress.   

Vigorous fetal activity sometimes leads to a cord accident, which may be in the form of a knot or entanglement of the cord around a limb. This could lead to partial occlusion of the vessels in the cord, leading to distress.

Vasa previa is usually undiagnosed before labor and will cause sudden bleeding and acute fetal distress in labor.

Sometimes the cause of fetal distress remains unestablished even after the baby is born. 

Causes of fetal distress during labor

Any activity that reduces the blood supply to the fetus will cause fetal distress.

If the cord is compressed, either as a result of being around a fetal limb, neck, trunk or simply by being compressed by the fetal head against the pelvic side-wall, features of fetal distress will follow. 

Correction to this can occur spontaneously as a result of fetal movement or the cord sliding away from the pressure point, hence relieving the compression. Sometimes this does not occur and a rescue procedure needs to be carried out.

Hyper-stimulation of the womb and fetal distress

Over-stimulation of the uterus can occur spontaneously or following the infusion of oxytocin. If the uterus contracts strongly, with the contractions being prolonged and coming close together, this will reduce the amount of blood (and therefore oxygen) that is getting to the placenta and ultimately to the baby.

If over-stimulation is sustained over several minutes, fetal distress will ensue.

Overcoming uterine hyper-stimulation

Hyper-stimulation of the womb is overcome quite easily simply by stopping the oxytocin infusion, if this was the cause.

If the hyper-stimulation occurs spontaneously, an intravenous injection of a tocolytic drug can be given and this will very quickly calm the over-stimulation. These drugs (tocolytics) are also available in an inhalational (aerosol) form but this method is associated with a slight delay in action. 

Tocolytic drugs work by relaxing the muscles of the womb to negate the effect of sustained strong contractions.


4D Ultrasound Scan In Pregnancy

In all the fascination and excitement that has inevitably accompanied the advent of 4D baby ultrasound, there is always that quite legitimate pause, seeking an answer to the question. Is it safe?  4D Ultrasound is safe and here I set out to explain why I can make such a n explicit and unambiguous statement.

Brief History of Medical Ultrasound

Medical ultrasound has been with us for well over 60 years; that is since the 1940s when first used by Karl Dussick in Austria. It has been a mainstream investigative and diagnostic tool in pregnancy care since the 1970s and it is often described as an extension of an obstetrician’s hand. That is how dependent we have become on this technology.

Mainstream 3D and 4D ultrasound scan is largely a 21st century development. Whilst the technology has been around since at least the early 1990s, it has been almost exclusively a research tool, the computing power and huge cost being the main limiting factors. Computing power has increased exponentially, something that has allowed the cost to drop to realistic levels for the technology to come into the sphere of the ordinary consumer.

In the last 5 to 6 years, the use of 3D and 4D ultrasound scan in pregnancy has taken off at an astonishing rate all across the globe.

How does 4D Ultrasound differ from ‘standard’ Ultrasound?
First things first. It is important to make it clear from the outset that 3D and 4D ultrasound is exactly the same technology as the conventional 2D ultrasound that everybody is familiar with.

Ultrasound is basically very high frequency sound waves. These sound waves are at a frequency well beyond the perception of the human ear and therefore no sound is actually audible.

Conventional or ‘standard’ ultrasound gives an image in two dimensions. 3D ultrasound, as the name suggests, gives a three-dimensional image. However, as is the convention, 3D describes a static image. With this technological development, you can see the baby in 3D and see the motion as well. It is the motion that is described as the fourth dimension hence the term 4D. In other words, you can see your baby in three dimensions and see all the action taking place in the womb.


Pain Unrelated To Pregnancy

Non-pregnancy related pain

A lot of times, pain experienced by a pregnant woman has nothing to do with the pregnancy. Below, we cover the more commonly encountered causes. Pathological conditions which are incidental in pregnancy (i.e. which may have similar symptoms in a non-pregnant state) include:   

· Appendicitis

· Kidney (renal) stones 

· Urinary tract infection (UTI)

· Gallbladder inflammation (cholecystitis) or stones

· Gastric or duodenal ulcer

· Torsion of ovarian cyst

· Pancreatitis

· Bowel obstruction

· Inflammatory bowel disease                 

This is by no means everything, all the more reason why an expectant mother should refrain from making her own diagnosis. It is important that any pain in pregnancy is assessed by an expert, to rule out disease. 

Some causes, such as appendicitis or urinary tract infection, will require immediate treatment, while others (such as gallstones) may be managed conservatively in pregnancy.

Pain in pregnancy is, in most cases, innocent. In other cases, it is not, and an expert should be allowed to make the distinction.

Appendicitis in pregnancy

The susceptibility is neither increased nor decreased by pregnancy. One in every 2,000 (0.05%) pregnancies will be complicated by appendicitis. A correct diagnosis is very important, as fetal loss is quite high if the appendix perforates. The mother’s life is also endangered by appendix rupture.

Gallstones and pancreatitis in pregnancy

Gallstones are generally uncommon in the teens and twenties. The condition becomes more common from the mid-thirties. Obesity is a predisposing factor even at a younger age. 

Pregnancy clearly makes pre-existing gallstones worse and symptoms may appear for the first time in preg­nancy. Moreover, this may be complicated by inflammation of the gallbladder, a condition seen in 0.1 per cent of all pregnancies (1 in 1000).

As mentioned before, gallstones in pregnancy are usually managed conservatively, but sometimes an oper­ation becomes necessary. Also important is the fact that gallstones predispose to acute pancreatitis, another important, albeit uncommon, cause of pain in pregnancy.

 


Eczema Medication

Treating eczema during pregnancy

Eczema is a fairly common condition the symptoms of which can persist after conception. Treatment to control the lesions commonly consists of an emollient, a steroidal skin preparation, occasionally oral medication or a combination of any of these. 

Emmolients are meant to soothe and rehydrate the skin. There are many such preparation with many different proprietary names. Common ones include E45®, Oilatum®, Neutrogena®, Vaseline®, aqueous cream, white soft paraffin etc. 

There is no evidence of adverse effect from the use of these emmolients during pregnancy. Steroidal skin (topical) preparations, when used as recommended, are also regarded  to be safe to use during pregnancy.

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Change in skin pigmentation during pregnancy

Increased pigmentation around the nipples (areola), the navel and the perineum is common in pregnancy. 

Also common is the formation of a dark line extending from the navel down to the pubis, known as the linea nigra

All this is hormonal and the increased pigmentation is always temporary, clearing up within weeks of delivery.  

Carpal Tunnel Syndrome in Pregnancy

This is a condition where there is pain, numbness and even weakness of some of the fingers in one or both hands. This condition is not an exclusive pregnancy condition but may occur for the first time during pregnancy. 

Fluid retention is thought to be partly to blame for carpal tunnel syndrome. It can be quite debilitating sometimes requiring surgical intervention to relieve the symptoms. This is uncommon. In most cases, merely splinting the fingers will help. It usually resolves after delivery.


Chlamydia Infection, Effect & fertility

Of all the sexually transmitted infections, (STIs), Chlamydia is believed to be the second commonest. Only Human Papilloma Virus (HPV) has a higher prevalence. In the UK, approximately 10% of all sexually active young people under 25 are believed to be infected. 

In the United States, Chlamydia infection has been reported since 1984. While in 1996 just under half a million cases were reported, nine years later in 2005, this had gone up by 98% to just over 970,000 recorded cases. It is also acknowledged that Chlamydia is the second most common STI in the US and that these figures may be conservative.

In Japan, a study carried out among high school students in Hokkaido in 2004 found 11.4% of them testing positive for Chlamydia. This was thought to reflect the state of prevalence of the infection among teens in the whole of Japan.

In some countries, there are established Chlamydia screening programs. Sweden has had such a program for over 25 years. A similar scheme (The National Chlamydia Screening Programme (NCSP).  is in the process of being finalised for implementation in England.

Chlamydia infection symptoms

Probably the most challenging aspect of Chlamydia infection is that it tends to remain symptom-free in the majority of cases. This is why it is sometimes called the ‘silent infection’. The infection can, indeed, remain silent and undiscovered for years. Between 70 and 90% of infected individuals will have no symptoms. This is partly why, among the young sexually active age-group, this infection is passed on so easily.

When chlamydia infection is symptomatic, the features include

     Vaginal discharge

     Light bleeding after sexual intercourse

     A burning sensation when passing urine

     Pain during sexual intercourse

     Light vaginal bleeding between periods

     Lower abdominal pain or discomfort

Effects of Chlamydia infection

Chlamydia infection, especially when not detected early, can have devastating long term consequences especially with regard to fertility. The inflammation inside the fallopian tubes is known to cause such damage that the functional capability of the tubes is seriously compromised. This might result in permanent scarring of the tubes leading to an increased risk of ectopic pregnancy and even complete inability to conceive naturally.


Breast Feeding & Bottle Feeding For Babies

Baby feeding: Trying to get it right 

Bottle-feeding: Why it remains controversial

In Britain, in August 2007, the Department of Health announced that it was piloting the baby growth charts recommended by the World Health Organisation (WHO) with a possible aim of these replacing the charts that have been in use over the last two decades. So, what is the drive behind this?

There has been a clamour for sometime from many nutritional experts that the existing charts were fuelling infant over-feeding. This usually affected those mothers who were breast-feeding. When it appeared that the infant was falling behind in the expected weight on the charts, there was pressure for the mother to supplement the breast milk with formula milk or in some cases, to abandon breast-feeding altogether.

The WHO growth charts are based on breast-fed infants and therefore the growth curve is gentler and regarded by many experts as more ‘natural’ and representative.

 Infant formula or artificial feeding is known to be more calorie-rich and therefore more prone to lead to overweight infants. However, its main weakness, which is impossible to overcome, is the absence of passive immunity components (antibodies) passed from mother to baby via breast milk.  There are other issues that surround bottle-feeding which are dealt with in more detail in our section on breast-feeding. 

Rates of breast-feeding in the western world differ greatly from country to country. By 6 months, over 75% of mothers will still be breast-feeding in Norway. The rate is 9% in Italy. Other countries fall somewhere in between. 

The Norway baby feeding Experience

Norway’s apparent success in the area of breast-feeding came after the authorities there put in place social policies that are conducive to it. 

Among other things, new mothers are entitled to 42 weeks of maternity leave with full pay. Also those returning to work are entitled to up to 90 minutes absence for breast-feeding. This could be going home to the baby or having the baby brought to the work-place where this is usually facilitated. 

Long-term issues for  overweight babies

Anything that promotes excessive weight gain at any stage in life should be a cause for major concern. This is more so when dealing with young children who would not have a say in what they are fed but who will have to live with the consequences. 

In the UK (total population: 60 million), over 1 million children under 16 are known to be obese. This is double the number just 10 years ago. The vast majority of these will be obese adults. The price that the individual and society in general pays for this is very high. It is difficult to know exactly in what proportion  the problem starts with excessive bottle-feeding during infancy but with the rate of breast-feeding at less than 1 in 4 at 6 months, it is likely to be substantial. Unfortunately, the artificial formula is, in many cases, followed by poor diet and a sedentary lifestyle in childhood where the most exercise a child gets is tapping the keyboard for hours on end.