Every Mom’s Dream…...

1. Every Mom’s Dream…...

2. OBSTETRICAL EMERGENCIES

3. Care is a state in which something does matter ; it is the source of human tenderness

4. DEFINITION • AN UNFORESEEN COMBINATION OF CIRCUMSTANCES OR THE RESULTING STATE THAT CALLS FOR IMMEDIATE ACTION • LIFE -OR -DEATH SITUATION • INFREQUENT, UNANTICIPATED, UNPREDICTABLE NIGHTMARE

5. Patient -1 • A 38 weeks G4P3 lady presents with ROM and contractions. She is quite distressed and thinks the baby is coming out. You perform a pelvic examination and next to the head you feel a pulsatile cord…

6. Cord Prolapse • Presentation: Cord in front of presenting part before the rupture of membranes • Prolapse: Cord in front of presenting part after rupture of membranes

7. Occult prolapse Cord lying alongside the presenting part

8. Incidence (Anita pal, Kushgla, Sood 2006) • Primigravida 0.45% • Multigravida 0.66% (Risk ratio 2:3) • Cephalic 0.3% • Frank breech 0.9% • Complete breech 5% • Footling 10% • Shoulder 15% • Contracted pelvis 4-6 times

9. Causes • Malpresentation - face, brow, breech and shoulder • Prematurity • Polyhydramnios • Multiple pregnancy • Long cord (90-100 cm) • PROM • CPD • Obstetric interventions - Amniotomy, Intrauterine pressure catheter, scalp electrode, external cephalic version, PROM, expectant management in preterm

10. Dangers • Mortality rate as high as 50% • Hypoxia • Spasm of vessels • Operative trauma to suboxgenatedfetus • More with vertex than breech • Descent in front than behind • More in primi than multi

11. Diagnosis • Cord pulsations • CTG shows variable decelerations • Cord lying outside vulva • USG – cord loops • Fundal pressure causes bradycardia • Violent activity of baby • Meconium stained liquor

12. Prevention • Refer to level II care • USG for malpresentation and cord presentation • Foetalmointoring • Avoid ARM in an unengaged head • PV exam after ROM

13. Management • Lift presenting part off the cord • Instruct NOT to push • Position patient Knee chest Trendelenburg Exaggerated position

14. Knee chest position

15. Trendelenburg position

16. Exaggerated sim’s position

17. Management (cont..) • Full bladder (Vago 1970) • Vulval pad • Replacement of cord • Tocolysis (ritodrine) • Forceps (Cx fully dilated) • Second twin – internal podalic version and breech extraction • Stat C-section • Occult: Aminoinfusion

18. Management (cont…) • Funic Reduction • Manual replacement of cord into uterus • Cord gently pushed above presenting part while other cord decompression techniques are applied • Rapid vaginal delivery

19. Fetal Mortality • Overall - 50% • 1st stage of labour - 70% • 2nd stage of labour -30% • Neonatal death - 4% • Perinatal mortality- 20% < 5 minutes, prognosis good, > 5 mins, damage and death.

20. VASA PRAEVIA • Fetal blood vessel lies in front of presenting part • Rupture - exsanguination of the fetus

21. Cause and Management • Velamentous insertion Fresh bleeding vaginally with rupture of membranes • Management: Signs of fetal distress Stat C.S Send cord blood for Hbestimation

22. PATIENT -2Mother is pushing with each contraction and the baby’s head starts to come out. However, with each push, the baby’s head comes out and then retracts back in towards the perineum. You quickly recognize this as the “turtle sign”

23. Obstructed labour • No advancement of presenting part despite strong, uterine contractions • Causes: Cephalo-pelvic disproportion Malpresentation - shoulder/brow/persistent mento posterior Deep transverse arrest Pelvic mass Fetal abnormalities - Hydrocephalus, conjoined twins

24. Causes Malpresentation:

25. Signs of obstructed labour • Presenting part fails to advance • Cervical dilatation slow • Formation of retraction ring • Early rupture of membranes • Formation of elongated sac of forewaters • If neglected, dehydration, ketosis • Caput succedaneum and moulding • urine output decreases • fetal distress

26. Management • Careful assessment of progress of labour • Correct hydration • Internal version • Forceps application • Stat C.Section

27. Shoulder Dystocia • Incidence: 0.23% to 2.09% • Impaction of fetal shoulders in maternal pelvis • Head to body delivery time > 60s

28. Risk factors • Maternal Diabetes Mellitus • Short stature • Macrosomia • Post-term • Obesity • Fetal shoulder circumference 40.9 ± 1.5cm Vs 39.5 ± 1.5 cm

29. Complications Fetal morbidity: • Brachial plexus injury • Clavicular fracture • Facial nerve paralysis • Asphyxia • CNS injury • complication rate up to 20%

30. Management • Help – obstetrician, pediatrician • Episiotomy • Legs – elevate (McRoberts) • Pressure - suprapubic • Enter vagina – Rubin’s and Woods’ screw • Roll or Remove posterior arm • Zavanelli, Clavicular# , Symphysiotomy

31. McRoberts Maneuver • hyperflexion of maternal hips • Increases intrauterine pressure (1,653mmHg - 3,262 mmHg) • Increases amplitude of contractions (103mm Hg to 129mm Hg)

32. All-Fours Maneuver(Gaskin Maneuver) • Ina May Gaskin (1976) • changes pelvic dimensions in a similar way to McRoberts maneuver • apply downward traction to disimpact the posterior shoulder

33. Suprapubic Pressure • direct posterior or oblique suprapubic pressure

34. Rubin’s Maneuver • adduction of the most accessible shoulder • moves the fetus into an oblique position and decreases the bisacromial diameter

35. Woods’ Cork Screw Maneuver • Abduct posterior shoulder exerting pressure on anterior surface of posterior shoulder

36. Deliver posterior arm(Barnum Maneuver) grasp the posterior arm and sweep it across the anterior chest to deliver

37. Zavanelli Maneuver • cephalic replacement via reversal of the cardinal movements of labor

38. Clavicular Fracture • fracture the anterior clavicle by pushing it against the pubic ramus or using a closed pair of scissors • Symphysiotomy

39. Complications • Maternal morbidity • 4th degree perineal lacerations • Cervical & Vaginal lacerations • Bladder injury • Postpartum hemorrhage • Endometritis

40. Patient - 3 • Mother in third stage of labour. Using the controlled cord traction, the midwife tries to deliver the placenta. Unfortunately, notices the descent of uterus instead of placenta.

41. Uterine Inversion • 1/20,000 deliveries Causes: • uterine atony (40%) • Increase in intra abdominal pressure • Fundal attachment of placenta (75%) • Short cord • Placenta accreta • Excessive cord traction

42. Degrees of uterine inversion • 1st - Dimpling of fundus, remains above internal os • 2nd - fundus passes through the cervix, but lies inside vagina • 3rd - (complete) Endometrium with or without placenta is outside the vulva

43. Dangers • Shock - Neurogenic Pressure on ovaries Peritoneal irritation • Hemorrhage • Pulmonary embolism • Infection

44. Management • Uterine relaxant (terbutaline 0.25 mg IV followed by 2 g of MgSO4 over 10 min) • Treat hypovolumeia • Without placenta: Repositioning

45. Uterine Inversion

46. Management(cont…) • With placenta: Do not remove placenta • Replace uterus • Bimanual compression • Hydrostatic pressure (O’Sullivan 1945) • Start oxytocin • Laparotomy

47. Patient - 4 A mother in second stage of labour suddenly complains of persistent pain, and bleeding per vagina becomes profuse and the monitor shows decelerations in fetal heart rate.

48. Uterine Rupture • 1/2000 deliveries Types: • Complete • Incomplete • Rupture Vs Dehiscense of C.S scar