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Intrapartum Emergencies

Intrapartum Emergencies. Max Brinsmead PhD FRANZCOG July 2011. Shoulder Dystocia. Occurs after the head delivers but the shoulders are stuck Occurs in 1:100 births 5 - 7% of those with BW >4500g Although there are many risk factors

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Intrapartum Emergencies

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  1. Intrapartum Emergencies Max Brinsmead PhD FRANZCOG July 2011

  2. Shoulder Dystocia • Occurs after the head delivers but the shoulders are stuck • Occurs in 1:100 births • 5 - 7% of those with BW >4500g • Although there are many risk factors • It is now agreed that the condition is basically Unpredictable

  3. Consequences of Shoulder Dystocia • Maternal trauma • Soft tissue e.g. 3rd and 4th degree tears • Symptoms from symphyseal separation • Femoral neuropathy • Postpartum haemorrhage • Brachial Plexus Injury in the Baby • Fracture of clavicle or humerus • Fetal hypoxia and Death

  4. Risk Factors • Large baby - Symphysis fundal height >42cm • Past history of shoulder difficulty • Obese mother (>110kg) • Diabetic mother with fetal macrosomia • Slow progress in 2nd stage of labour with turtle sign of head between contractions • After assisted delivery of the fetal head

  5. Management – HELPER AB • Send for Help • ELevate the legs (McRobert’s manoeuvre) • Pressure suprapubically • Episiotomy • Rotate the shoulders • Bring down the Posterior Arm • Be prepared for PPH

  6. Suprapubic Pressure to dislodge the anterior shoulder with Shoulder Dystocia

  7. Rotating the shoulders

  8. Bringing down a Posterior Arm

  9. Fetal Distress • Diagnosed by heavy or fresh meconium, FHR or CTG abnormalities • Has a 50:50 chance of being a false alarm but more serious for the Fetus at Risk… • Too small or too big • Post dates • Malpresentation • Poor obstetric history

  10. Management – COP HAX • Cease any oxytocin • Oxygen by face mask • Change maternal Position • Send for Help • Assist the delivery • Ventouse or Caesarean • Relax the uterus • Oral Nifedipine or IV Salbutamol

  11. Eclamptic Seizure • It is best to regard any grand mal seizure as due to eclampsia • Unless there is a clear history of epilepsy • Or other cause e.g. meningitis, cerebral malaria, stroke etc. • Up to 30% occur postpartum • Can be prevented by good antenatal care, Mg sulphate prophylaxis, BP control and delivery of patients with pre-eclampsia

  12. Management – HAB&C IMB BD • Send for Help • Airway, Breathing & Coma Position • IV Access • Mg Sulphate IV and IM Loading dose • Blood pressure control with Hydralazine • Bladder catheter • Deliver the patient

  13. Cord Prolapse • Should always be suspected when the membranes rupture and there is ANYTHING other than a well engaged head • Diagnosed by vaginal examination • Sometimes suspected by a very irregular Fetal Heart • Should always be checked by VE • Before rushing to fetal salvage always ask yourself “Will this baby live?” • Check for cord pulsations • Is the baby very premature? • Is Caesarean safe for the mother?

  14. Management – HIP BT • Send for Help • Incline the patient • Knee chest position or tilted left lateral • And hold the head off the cord and cervix if contracting • Prepare for theatre • Catheter in the Bladder • And fill with water or saline • Consider Tocolysis • Oral Nifedipine or IV Salbutamol

  15. Cord Prolapse Positions

  16. Unplanned Breech • Usually do quite well if they progress rapidly in labour • But the biggest part of the baby is coming last • And the head must traverse the pelvis in 8 – 12 minutes instead of the usual 8 – 12 hours • Breech babies who are… • Large for dates (EFW>3.5Kg) • Footling or Flexed Leg Presentations • Do not spontaneously deliver the breech • Shows signs of fetal distress • Are better delivered by Caesarean

  17. Preparing for Breech Delivery • Explain the procedure to the mother • And get her cooperation • Have someone standing by to care for the baby • A theatre may be required • If Caesarean becomes the better option • Lithotomy position is best • Empty bladder is desirable

  18. Delivery Tips – HSS SPM • Hands off the baby until the knees appear • Episiotomy may assist • Spread the hips and bend the knees • If the legs are extended • Sweep arms down or Rotate for Shoulders (Lovset) • Support the baby until the hairline appears • Suprapubic pressure may help • Deliver the head by the Mauriceau technique

  19. Mauriceau Technique for Delivery of the Head

  20. Unplanned Twins • Preparation • Get extra help – someone to care for the babies • A theatre may be required • IV Line, Group and Save • Will require two delivery bundles • Inform and Involve the Patient • Explain what may happen • Reassure “Two for the Price of One” and not “Twice as Hard”

  21. Delivery Tips – DEM SAB • Deliver the 1st twin as you would a singleton • Examine abdominally and external version of the 2nd twin (if required) • Monitor the FH of the 2nd twin • Delivery within 20 – 30 min is desirable • Stimulate the uterus with Syntocinon (if required) • Amniotomy with caution • Only after a pole (head or breech) is down in the pelvis • Internal version through intact membranes is best

  22. Delivery Tips 2 – DEM SAB • Assist the delivery of the 2nd twin (if required) • Ventouse if cephalic • Brech extraction (after internal version if required) • Find a foot and bring it down • Bring down the second leg • Keep the back uppermost • Thereafter as for Breech Delivery • Be Prepared for PPH • Active management of the 3rd stage • Syntocinon infusion

  23. Assisting Delivery by Vacuum Extraction • Requirements for Safe Vacuum Delivery include… • Pregnancy >34 completed weeks • Cephalic presentation • Full dilatation • Head engaged (no more than 1/5th palpable) • Adequate space in the pelvis • Position must be known with certainty • Skilled and experienced operator • A contracting uterus • A cooperative mother

  24. Preparing for Vacuum Delivery • Someone standing by to care for the baby • Adequate analgesia • Infiltrate the perineum with local anaesthetic • Assemble all the equipment and check that it is working • Test it on your gloved hand • Position the mother • Lithotomy with lateral tilt

  25. Delivery Tips – AT E3 EB • Apply the cup to the flexion point of the head • Midline , at least 3 cm beyond the anterior fontanelle as close to the occiput as possible • Take up the pressure and ensure no maternal tissue is under the cup • Traction only with contractions • And ask the mother to push • Requires descent with every pull to a maximum of 3 • And within 20 minutes of the application of suction

  26. Cup Attachment to the Flexion Point of the Head

  27. The Direction of Pull

  28. Delivery Tips 2 – AT E3 EB • Pull down, then out, then up to deliver • Pull at 90 degrees to the cup • Keep two fingers and thumb on the anterior lip of the cup to detect detachment • Episiotomy may be required • Detachment is prone at crowning • If detachment occurs... • Send for help • Attempt reapplication only ONCE • Be prepared for... • Shoulder difficulty • And PPH

  29. Acute Uterine Inversion • Occurs when there is… • Uncontrolled cord traction and… • A non-contracted uterus • A fundal placenta • Sometimes morbid attachment placenta • Should be suspected when… • There is maternal “shock” out of all proportion to blood loss • The uterus is dimpled or disappears from the abdomen • Will be obvious if it is out between the legs • But should not be confused with uterine prolapse • When the cervix appears at or beyond the introitus

  30. Management – HR AR HR • Send for Help • Resuscitate • IV Cannula • Take blood for X-match • Administer 1 – 2L N Saline • Analgesia • Nitrous oxide or Pethidine IV 25 mg • Attempt manual replacement • Most likely to be successful if done within 5 – 10 minutes of the inversion • Do not remove the placenta if it is still attached

  31. Incomplete Uterine Inversion

  32. Management 2 – HR AR HR • O’Sullivan’s Hydrostatic Replacement • Requires 2 – 6 litres of fluid into the vagina • Needs a watertight seal at the introitus • Use hand around the vulva and wrist or a ventouse cup • Replacement can be confirmed by manual exploration of the uterus and removal of the placenta (if required) • But thereafter keep the uterus contracted • By Syntocinon infusion ± Misoprostol

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