Obstetric Emergencies

1. Obstetric Emergencies NEDSim 2014

2. practical considerations / differences are there when resuscitating a pregnant woman? 1) Position: a partial roll, placing a knee, or wedge under the woman’s pelvis and preferably manually displacing the gravid uterus off the midline will help prevent / alleviate aorto-caval compression. 2) Have neonatal resus gear brought to the scene as well as your normal adult trolley – a resuscitation cot is ideal. 3) Late pregnancy = difficult airway / ventilation and rapid desaturation – so it might be better to intubate early, though this will depend on your skills and resources at the scene.  CPR still comes first. 4)  YES, defibrillation is OK.  Just take off  the wires for CTG etc – they are not useful anyway in an arrest!

3. Normal Delivery • Normal Births Ambulances will bring labouring women to ED if delivery is imminent i.e. presenting part on view. • Call the midwife and warm the resuscitaire. • Unless the mother is at high risk for PPH (e.g. grand multip) there is no need for a cannula. • Allow her to stand, lean against a bed or chair, lie flat, or go on all fours if she wants. • Reclining supine on a trolley at 45% is about the worst possible position for birth. • Advising her to push is probably unhelpful: she will push when she feels the urge.

4. Anticipate a delay of 1-2 minutes after the head is delivered, before the final contractions. • Support baby’s head, but do not flex the neck to deliver the shoulders: it doesn’t help and may even cause brachial plexus injury. • When you see the anterior shoulder at the introitus, get ready to catch! • When born, dry and wrap baby and place on the mother’s belly. • Assuming baby is at term and healthy, you can wait until the cord stops pulsating before clamping and dividing. This can take 10-15 minutes. • The placenta should detach spontaneously. Do not pull the cord as this can cause uterine inversion and prolapse. • It is normal for mothers to lose 200-400ml in the third stage of pregnancy. • If dad has a cigar, he should smoke it outside the hospital gates. –

5. Red Flags: Immediate O&G Attendance

6. Cord Prolapse • Incidence: 1/200 births. You have been struck by obstetric lightning. • Mortality: 15% neonatal demise. • Management: knee-elbow position: pressure on presenting part. • RUSH to OT for urgent Caesarian. • instillation of 500ml NS fluid into the bladder via catheter (Vago’s method) is of doubtful benefit at this late stage

7. Shoulder dystociaFailure to restitute and turtling. Meaning that the head won’t externally rotate when it is delivered, and it withdraws back into the maternal perineum following each contraction.

8. Incidence: 1/100 births. You have been hit by an obstetric curve-ball. • Mortality: about 50% of neonates will sustain a lethal injury if not delivered within 5 minutes. • Management: don’t tell her to push: it will make things worse. • 4 sequential manoeuvres at 30 second intervals. • Each with the aim of delivering the anterior shoulder. Go to the next if unsuccessful. manoeuvre 1 (t = 0 sec) McRobert’s: lie flat, hyperflex hips. Relieves 40% of shoulder dystocias - See more at: http://stem.org.au/stem/obstetric-nightmares?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+FOAMEM+%28FOAM+RSS%29#sthash.vLXwhVpD.CXPwybzi.dpuf

9. manoeuvre 1 (t = 0 sec) McRobert’s: lie flat, hyperflex hips. Relieves 40% of shoulder dystocias

10. manoeuvre 2 (t = 30 sec) - suprapubic pressure to rotate baby’s shoulders into oblique plane (sometimes called Ruben’s I). In combination relieves 60%

11. Shoulder dystocia - manoeuvre 3 (t = 60 sec) is invasive: pressure on backs of baby’s shoulders, again to rotate into oblique plane. This is called Ruben’s II if applied to anterior shoulder, or Wood’s screw if applied to posterior shoulder.

12. manoeuvre 4 (t = 90 sec) delivery of posterior arm by grasping the wrist (which is usually flexed against the baby’s chest) and pulling

13. Stage 5 • If you reach 2 minutes and the baby is still not out, roll the mother onto all fours. (Gaskin manoeuvre). • By this time, the cumulative odds of success are about 80%. • The prognosis is now poor but you have given it every reasonable shot. • Episiotomy doesn’t relieve the obstruction but may make it easier to accomplish the internal

16. Blood Loss >500ml

17. PPH • Incidence: about 7%. • Mortality: worldwide the biggest obstetric killer (in developed countries - • #5 behind sepsis, eclampsia, thromboembolism, and ectopics). • Causes: 80% caused by uterine atony and/or retained placenta.

18. PPH management • The O&G texts advise 2L crystalloid stat – but they would, wouldn’t they? Consider: tranexamic acid, early blood products, permissive hypotension until the bleeding is controlled. • Rub up a contraction (firmly massage the uterus with your fingers on the mother’s belly). The uterus should go hard like a grapefruit. • Catheterize. Emptying the bladder allows space for the uterus to contract. • Give 10 IU Syntocinon IM and start an infusion of 40 IU in 1L NS at 250ml/hr. • If the bleeding remains brisk, give 500mcg ergotamine IM. • If blood loss is severe or patient is shocked, apply bimanual compression(see next slide). The aim is to fold the uterus over a fist in the anterior fornix. This will be very painful – give analgesic dose ketamine (0.5-1.0 mg/kg) and convey to OT without removing pressure. -

20. Pre Eclampsia/ eclampsia Occurs from the second trimester to about 10 days post delivery Check bedside glucose level. Commence IV fluids – patients generally IV deplete Control seizures: IV diazepam if rapid control of seizure activity is required MgS04Loading dose 4 grams IV over 10-20 minutes Infusion of 1-2 grams per hour IV phenytoin Control hypertension. IV hydrallazine. - It is important not to administer antihypertensive drugs until intravascular volume replacement has commenced● 5-10 mg IV hydrallazine slow bolus may be given. This may be repeated in 20 minutes according to response. If more than 2 boluses are required commence a hydrallazine infusion at 5 mg per hour adjusted according to response. Deliver Baby

21. PeriMortem C Section • A horrible scenario.. • Aesthetically challenging however not technically challenging • Principle is do what’s best for mother • Important to consider if high likelihood of maternal demise • Survival of baby has been reported despite significant delays (15mins)

22. Peri-Mortem C Section • Perimortem C-section is indicated in maternal arrest for gestation estimated > 24 weeks. (~ a few fingers over the umbi).  • This is roughly the age of fetal viability and correlates with the time the gravid uterus exerts significant hemodynamic challenges that C-section might reverse.  • C-section should be done in the context of maternal cardio-respiratory arrest, no matter what the presumed aetiology • Perimortem CS should occur at the scene of the arrest – there is not time to “go to theatre”. This is a resuscitative move – like defib or empirical fluids. It needs to be done on the floor, bed or trolley where the woman arrests.

23. How to… • Equipment: one scalpel (disposable will do – 11 blade if you like), gloves, wall suction, a splash of betadine, a willing assistant to help retract layers • Assign roles. • Designate who the infant will be handed off to. • KEEP CPR GOING! • Prep the abdomen and drain the bladder For non-surgeons, GO MIDLINE Expect a large amount of bleeding. • Incise from the umbilicus to the symphysis pubis. • Avoid the bladder!

24. How to.. Make a small vertical incision in the lower uterine segment. Lift the uterine wall away with two fingers. Extend the incision superiorly with scissors up to the umbilicus May encounter the placenta which is commonly anterior CUT STRAIGHT THROUGH THE PLACENTA This will create more bleeding Find the head. Have someone apply FUNDAL PRESSURE Close!!