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Abstract: The pregnant woman in this case was a transwoman who came to the hospital for delivery. During delivery, after the fetal head was delivered, the fetal neck retracted and the fetal chin pressed tightly against the perineum, and the delivery of the fetal shoulder was obstructed, immediately under the lateral perineal incision, giving flexion of the thighs while applying pressure on the pubic symphysis, using 4 times back and forth.
Basic information】Female, 33 years old
Type of disease】Shoulder obstructed labor
Hospital】General Hospital of Heilongjiang General Bureau of Agricultural Reclamation
Date of Consultation】March 2021
Treatment plan】Flexion of thigh method + suprapubic pressure method + perineal laceration disinfection + lateral incision suture
Treatment Period】4 days of hospitalization and outpatient review after 42 days
Results】Mother and child were safe and discharged with good recovery
I. Initial consultation
The pregnant woman is 39+6 weeks of menopause and has delivered two children naturally, both of whom are healthy. Her glucose fluctuated between 4.5-5.2 mmol/L before meal and 5.8-6.6 mmol/L 2 hours after meal, and her glucose control was stable until late pregnancy. She was given fetal heart monitoring in the outpatient clinic, and irregular contractions were seen. The response to fetal heart monitoring was good, because she was in labor and might enter labor soon, she was told that she needed to be hospitalized.
II. Treatment
After she was admitted to the hospital, she was given routine blood, urine, hematocrit, coagulation, ECG and other laboratory tests, and was given a routine pelvic assessment, with a transverse pelvic outlet diameter of 8.5 cm. “You are a transwoman and there are no obvious abnormalities, the fetus is about 8 pounds, there are no obvious contraindications to vaginal trial of labor, but the fetus is large and there is an increased risk of failed trial of labor due to difficult shoulder, assisted labor, perineal lateralization, perineal laceration, and intrauterine hypoxia during labor. The pregnant woman and her family deliberated and considered a vaginal trial of labor and were willing to take the risk. One day after admission, the pregnant woman started to have regular contractions, and the uterine orifice was fully opened after 5 hours due to regular contractions of a transwoman, and after one hour of effort after the uterine orifice was fully opened, a lateral episiotomy was performed, and the fetal head was delivered, but at this time, the fetal head was tightly attached to the perineum by the chin and the fetal neck was retracted, and the midwife gently pulled the fetal head, but it was not delivered. The fetal shoulder was delivered with difficulty, but the perineum was lacerated at II°, so the perineum was disinfected and the lateral incision was sutured.
III. Treatment results
The mother delivered a male baby weighing 4050g with Apgar scores of 8 and 10 at 1 and 5 minutes, respectively. Because the mother had gestational diabetes mellitus and a giant newborn, the newborn needed to be monitored for blood glucose immediately after birth, which showed a value of 3.9mmol/L. The mother and her family were told to feed sugar water to the newborn, and the blood glucose was 4.4mmol/L at 2 hours, and the mother needed to be closely observed vaginal bleeding to prevent postpartum hemorrhage. The gestational diabetes mellitus during pregnancy, postpartum monitoring of blood glucose fasting <5.0mmol/L, 2 hours postprandial blood glucose <6.5mmol/L, review ultrasound: endometrial thickness of about 1.3cm, echogenicity is not uniform, and there is no obvious swelling and pain in the lateral perineal incision, good recovery, discharge was granted at 4 days of hospitalization.
IV. Notes
We are glad that after active treatment, a baby boy was delivered safely, but after discharge, we should closely monitor blood sugar and pay attention to perineal care, while a healthy diet is very helpful after delivery.
1, need to pay attention to diet more food containing dietary fiber, appropriate exercise, avoid overeating, while controlling the intake of sugar.
2, although the postpartum monitoring of blood glucose values in the normal range, but still need to monitor blood glucose after discharge, to avoid hyperglycemic conditions, to meet their own nutritional needs in daily life, to avoid the situation of starvation blood glucose fluctuations, if there are abnormalities in a timely manner to consult a doctor.
3. Keep the vulva clean, prevent infection, and return to the hospital promptly if there is bleeding, purulent discharge, pain and other uncomfortable symptoms.
4.Prohibit bathing, sexual intercourse and swimming, review 42 days after delivery, and perform glucose tolerance test.
V. Personal insight
1.Shoulder obstructed labor is mainly related to huge baby, gestational diabetes and pelvic abnormality. Once the shoulder obstructed labor occurs, the first time to perform lateral perineal incision, empty the bladder, call experienced medical care, prepare for neonatal resuscitation and deliver the fetus through the maximum diameter of the pelvis by changing the fetal position.
2. The fetus should be delivered within a short period of time in a difficult shoulder delivery, so there should be no delay and the situation should be handled in time to ensure the safety of mother and child.
3, because of the maternal diabetes during pregnancy, it is recommended that all pregnant women should actively control their weight and blood sugar during pregnancy, because gestational diabetes has the potential to increase the number of huge babies and may cause obstructed shoulder delivery during labor.