iSilo The Johns Hopkins Manual of Gynecology and Obstetrics

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The role of prophylactic episiotomy, however, is debated. a. Technique. An incision is made vertically in the perineal body (midline episiotomy) or at a 45-degree angle off the midline (mediolateral episiotomy). The incision should be approximately half the length of the perineal body. The incision should extend into the vagina 2–3 cm. Excessive blood loss can result from performing the episiotomy too early. The episiotomy can be performed either before or after the application of forceps or a vacuum.

Variable decelerations may start before, during, or after the uterine contraction starts (hence the designation variable). They usually show an abrupt onset and return, which gives them a characteristic V shape. Variable decelerations are caused by umbilical cord compression. 2. Early decelerations are shallow and symmetric and reach their nadir at the peak of the contraction. They are caused by vagus nerve–mediated response to fetal head compression. 3. Late decelerations are U-shaped decelerations of gradual onset and gradual return, reach their nadir after the peak of the contraction, and do not return to the baseline until after the contraction is over.

Heart rate acceleration in response to these stimuli indicates the absence of acidosis. 07. Conversely, about a 50% chance of acidosis exists in a fetus who fails to respond to VAS in the setting of an otherwise nonreassuring heart rate pattern. 2. Invasive management a. Amniotomy. If the fetal heart rate cannot be adequately monitored externally, an amniotomy should be performed if necessary to allow access for internal monitoring. The amount and character of fluid should be noted. After amniotomy, examination should be performed to verify that the cord is not prolapsed.

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