fter head delivery, a inger should be passed across the fetal neck to determine whether it is encircled by one or more umbilical cord loops. If present, these are slipped over the head. The head is rotated to an occiput transverse position, which aligns the fetal bisacromial diameter vertically. The sides of the head are grasped with two hands, and gentle downward traction is applied until the anterior shoulder enters the hysterotomy incision (Fig. 30-8). Next, by upward movement, the posterior shoulder is delivered. During delivery, abrupt or powerful force is avoided to avert brachial plexus injury. With steady outward traction, the rest of the body then readily follows. Gentle fundal pressure may aid this.
With some exceptions, current American Heart Association neonatal resuscitation recommendations eschew suctioning immediately following birth, even with meconium present (Wyckof, 2015). A fuller discussion of this and delayed umbilical cord clamping is found in Chapter 27 (p. 518). he umbilical cord is clamped, and the newborn is given to the team member who will conduct resuscitative eforts as needed.
Comparing elective cesarean under neuraxial anesthesia and spontaneous vaginal deliveries, studies show that the need for neonatal resuscitation is not practically signiicant between the two (Atherton, 2006; Gordon, 2005; Jacob, 1997). he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that "a qualiied person who is skilled in neonatal resuscitation should be in the delivery room." At Parkland Hospital, pediatric nurse practitioners attend uncomplicated, scheduled cesarean deliveries. Notably, as anticipated neonatal risks rise, so too should the resuscitative skills of the attendants (Wyckof, 2015).
To promote breastfeeding, the American College of Obstetricians and Gynecologists (2017b) recommends skin-to-skin contact between newborn and mother in the delivery room.
FIGURE 30-7 A.The first cesarean forceps blade is placed. B. Slight upward and outward traction is used to lit the head through the incision.
Although most randomized trials focus on vaginal birth, several small studies support such contact following cesarean delivery, and this our practice (Moore, 2016; Stevens, 2014).
After birth, an intravenous infusion containing two ampules or 20 units of oxytocin per liter of crystalloid is infused at 10 mLlmin. Some prefer higher infusion dosages, however, nondilute boluses are avoided because of associated hypotension (Roach, 2013). Once the uterus contracts satisfactorily, the rate can be reduced. An alternative is carbetocin-a longer-acting oxytocin derivative that is not available in the United Statesthat provides suitable, albeit more expensive, hemorrhage prophylaxis Qin, 2016). Ergot-alkaloids are second-tier agents and carry hypertensive side efects. Carboprost, a IS-methyl derivative of prostaglandin F2> is another second-tier agent used to treat uterine atony. Some but certainly not all studies indicate that misoprostol appears to perform similarly to oxytocin (Chaudhuri, 2014; Conde-Agudelo, 2013). Finally, some recommend the use of tranexamic acid added to a standard oxytocin infusion to decrease blood loss (Simonazzi, 2016; Wang, 2015). Its antifibrinolytic action and efects on thromboembolism rates in pregnant surgical patients are unclear. Larger trials are needed before widespread use. Additional discussions of all these agents are found in Chapter 41 (p. 759).