Best practice & research. Clinical obstetrics & gynaecology
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Fetuses that present by the breech are at increased risk of trauma and hypoxia during delivery. The threshold for Caesarean section for breech presentation had been low for several years. The result of the term breech trial confirms that planned Caesarean section is the best method of delivering the singleton frank or complete breech at term. ⋯ Vaginal breech delivery will be unavoidable in certain circumstances and it is therefore important to be adept with the techniques of vaginal breech delivery. The atraumatic technique of delivery of the baby presenting by the breech at times of Caesarean section is similar to that of assisted vaginal breech delivery. The number of vaginal breech deliveries is falling, and regular teaching using video clips or practising with mannequins will be necessary to preserve the skills of vaginal breech delivery.
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Measured blood loss up to 1000 ml is well tolerated by healthy pregnant women. This is partly due to physiological increases in plasma volume and red cell mass during pregnancy. Nevertheless, hypovolaemic shock is a major cause of maternal mortality. ⋯ Rapid access to blood or blood products for transfusion is necessary, as well as laboratory back-up. Further management includes accurate assessment of the site of bleeding; control of the bleeding; diagnosis and management of the underlying condition; supportive therapy; and monitoring of the clinical, haematological and biochemical response to treatment. Bedside diagnostic ultrasound has several applications in the evaluation of obstetric hypovolaemic shock.
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Best Pract Res Clin Obstet Gynaecol · Aug 2001
Review Case ReportsCare of the critically ill parturient: oliguria and renal failure.
The incidence of acute renal failure in pregnancy has decreased. This decrease is less marked in developing countries in which resources are more scarce. The clinical diagnosis of acute renal failure is crude due to the variability of clinical signs and the late occurrence of basic biochemical abnormalities. ⋯ The evidence for the efficacy of other prophylactic medical interventions, such as the use of loop diuretics, mannitol, low-dose dopamine and others, is poor. Management of established acute renal failure includes restoration of intravascular volume, treatment of any reversible causes, especially pregnancy complications such as pre-eclampsia, strict fluid balance and correction of any electrolyte abnormality or metabolic acidosis. Dialysis is a supportive measure until the kidneys recover.
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Best Pract Res Clin Obstet Gynaecol · Aug 2001
ReviewVentilation and the critically ill parturient.
Positive-pressure ventilation is the keystone in the management of pulmonary dysfunction in the critically ill. An increased understanding of both the benefits and hazards has led to a general consensus regarding the optimal techniques to ensure adequate gas exchange. Unfortunately, the same cannot be said for ventilation terminology which, due to a lack of standardization, lends itself to confusion. ⋯ Ventilation strategies are now designed to recruit as much available lung tissue as possible while simultaneously minimizing the injurious effects of alveolar over-distension. Upon resolution of the underlying pathology mechanical ventilation may be withdrawn. Recent evidence suggests that this final stage need not be protracted, and if certain criteria are fulfilled, rapid weaning is feasible.
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Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. ⋯ Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit.