Inter-facility Transport (IFT) Part 2 Obstetrics

1. HKCEM College Tutorial Inter-facility Transport (IFT)Part 2Obstetrics Author Dr. Oct., 2013

2. The scenario • A Para 0 30 years old pregnant lady from mainland China attends for regular abdominal pain. She is at term gestation. Examination shows cervix dilates to 4 cm. There is no obstetric service at your hospital. After consultation, she needs to be transferred to a tertiary hospital.

3. How would you manage potential second stage of labourduring transfer?

4. Active second stage of labour • From complete cervical dilation till the baby is delivered • Patient experiences regular contractions every 2-3 minutes with an expulsive urge • Video clip • http://www.youtube.com/watch?v=Xath6kOf0NE

5. Recognition • Careful observation of frequency of contractions and expulsive urge • Abdominal palpations to confirm uterine contractions >45 sec each time • Vaginal examinations to detect fully cervical dilation

6. Evaluation • ABC for identifying the life threatening situation • Inspect for signs of impending delivery: 1. Anus pouting and gapping 2. Vulva gapping and bulging perineum 3. Presenting part is appearing e.g. crowning of the head

7. Abdominal palpations: • Gestation age, fetal lie, presence of expulsive uterine contractions • Vaginal examinations: • Confirm the presentation part (vertex, breech, face or shoulder) • Cervix is fully dilated (up to 10cm) / effaced (thinned to 1mm) • Relationship of the presenting part to ischial spines • Continuous non-invasive monitoring of vital signs • Closely assess the uterine activity • Measure FHR Q5mins (N 110-160 bpm)

8. Support • If the delivery is momentary, we have to deliver the baby even during the transport

9. The mother is placed in dorsal lithotomy position, tilted slightly to the left side in order to lessen vena caval obstruction • As time allows, the perineum can be prepared by washing with mild soap and water and swabbing with povidone-iodine • With each contraction the vaginal outlet bulges to accommodate a greater portion of the fetal head, episiotomy may be necessary to allow delivery without laceration • As the head emerges, the palm of the hand should keep the head well flexed until crowned when it is allowed to extend. This avoids rapid delivery and minimizes the risk of traumatic perineum injury. The other hand should protect the perineum

10. The baby’s neck region should be palpated to check for a nuchal cord. If the cord is loose, it should be reduced over the infant’s head. On the contrary, the cord should be clamped and cut if it is tight. • Before the delivery of shoulders and thorax, baby’s face should be wiped and the mouth and nose should be suctioned to clear the airway. • Deliver the anterior shoulder by gentle downward traction and then gentle upward traction will deliver the posterior shoulder. The posterior shoulder should not be allowed to pop out uncontrolled, as this may lacerate the anal sphincter. • The umbilical cord is clamped and cut. Give 10mg syntocinon injection to improve uterine contractions after the baby is delivered and the possibility of twin pregnancy excluded. • The infant is dried and wrapped in warm towels

11. Transportation • If the delivery is not momentary, continue transportation to the receiving facility as planned with close monitoring.

12. Otherwise, transport need to be suspended in case of emergency delivery or the ambulance may need to go to the nearest facility with emergency services instead of the destination • After the emergency delivery, the mother and baby are closely monitored and transported to the receiving facility • Paediatric and obstetric units should be notified beforehand

13. What other complications can occur during transfer?

14. Breech presentation

15. Breech Presentation • Commonest malpresentation • Major concern is head entrapment during a vaginal delivery • Higher incidence of umbilical cord prolapse and fetal distress

16. Recognition • Antenatal history is vital • Usually the diagnosis has been made in antenatal check up • Abdominal palpation • Vaginal examinations • USG

17. Evaluation • Patient’s ABC need to be incorporated as priority for identifying life-threatening situation • Inspect for any signs of impending delivery • Abdominal palpation: • Longitudinal lying fetus, no head is felt in pelvis but a ballotable smooth round mass (head) in the fundus • Vaginal examinations: • Assess cervical dilation, labour status and the presenting parts • FHR and the uterine contractions are monitored continuously as usual

18. Support • Set up intravenous line with supplemental oxygen • Frank or complete breech presentation • Emergency delivery may be allowed to progress spontaneously • Refrain from touching the fetus until scapulae are visualized • Infant is gently supported by a warm towel wrapping around the lower half • Rotate the infant until one arm emerges • And then rotate to opposite way to allow delivery of the other arm • Cautious not to pull out the fetus hard, as this may increase the pressure on the head within the pelvis and entrap the extended fetal arm

19. Footling and incomplete breech positions • Unsafe for vaginal delivery even in a hospital setting because of high chance of cord prolapse with incomplete dilation of the cervix • The obstetrician and pediatrician are informed about the progress at once • Patient is transported to a nearest appropriate facility as soon as possible while the patient is supported and monitored continuously

20. Transportation • Prompt transport of breech presentation patients to a nearest appropriate facility is of paramount importance • Always keep the obstetrician and pediatrician informed, their opinions will be most valuable • Video clip • http://www.youtube.com/watch?v=EPklRwlMV1Y

21. Shoulder dystocia

22. Shoulder Dystocia • Impaction of fetal shoulder at the pelvic outlet after the head delivered • Carries high fetal morbidity and mortality if it is not managed appropriately • Fetal complications include brachial plexus injury, spinal cord injuries, musculoskeletal injuries and hypoxic events • Maternal morbidities include uterine atony, rupture, vaginal tears and severe postpartum haemorrhage.

23. Recognition • First recognized after the delivery of the fetal head • When routine downward traction is insufficient to deliver the anterior shoulder • Turtle sign :appearance and retraction of the fetal head (analogous to a turtle withdrawing into its shell)

24. Evaluation • Patient’s airway, breathing and circulation need to be incorporated as priority for identifying life-threatening situation • Shoulder dystocia is identified by the “turtle sign” • After the infant’s head delivered, the head retracts tightly against the perineum • Abdominal palpations and vaginal examinations should be done as in usual delivery • The vital signs of the mother, fetal heart rate and uterine activity should be monitored closely

25. Support • Apply suction to infant’s nose and mouth • Managements as a set sequence of actions with the mnemonic “HELPERR” is helpful

26. HELPERR • H: Call for Help • E: Ensure a generous episiotomy with adequate maternal anesthesia.

27. HELPERR • L: Legs:Attempt McRoberts Maneuver – By hyperflexing the mother's and bringing her feet to her ears, the lumbar-sacral lordosis is straightened and the sacral promontory, which serves as an obstruction, is removed. Then, attempt delivery with gentle downward traction • P: Suprapubic PressureHave an assistant apply suprapubic pressure. This causes the shoulder to move under the symphysis pubis.

28. HELPERR

29. HELPERR • E: Enter with internal Manipulation – • Try Rubin II maneuver by approaching anterior fetal shoulder from behind. Exert pressure on scapula to adduct most accessible shoulder and rotate to oblique position. • If unsuccessful, combine Rubin II maneuver with the Woods’ Screw maneuver that approach the baby’s posterior fetal shoulder from the front. Gently rotate the posterior shoulder toward symphysis until the shoulder passes under the symphysis. • If still unsuccessful, change to Reverse Woods’ Screw maneuver that approach posterior shoulder from behind and rotate in opposite direction from Rubin II or Woods’ Screw maneuver.

31. HELPERR • R:Remove the arm • Try to deliver the posterior arm first to decrease bisacromial diameter and then rotate the anterior shoulder into the oblique position for delivery

32. HELPERR • R:Roll the patient • The “all fours” maneuvers may be tried for reduction of shoulder dystocia as this increase the pelvic diameter of the labouring woman

33. Transportation • Transport may need to be suspended in case of emergency delivery • Then, the patient need to be transported to the nearest facility with emergency services instead of the designated facility • After the emergency delivery, the mother and neonate should be stabilized and closely monitored • Communication with the obstetrician, paediatrician and receiving facility about the progress is essential Video clip • http://www.youtube.com/watch?v=K5kLHkl5RsI

34. Umbilical cord prolapse

35. Umbilical Cord Prolapse • A real obstetric emergency • Risk of cord compression causing fetal asphyxia • The incidence is increased in • Preterm labour • Prematurity • Twin pregnancy and • Breech presentations especially footling breech • The objective of treatment is to • Detect it promptly • Evacuate the fetus quickly • Transfer mother to labour ward as soon as possible

37. Recognition • Should always be considered if malpresentation is noticed • It is suggested by severe drop in FHR after rupture of membrane • Rapid recognition may save the fetus life • Direct visual inspection and • Vaginal examination • Apalpable, pulsating cord is revealed which extruding from the vagina, coiled in the vagina or wrapped across the presenting part

38. Evaluation • The woman should be evaluated to ensure patent airway, sufficient ventilation and stable haemodynamic state. • Visual inspections and vaginal examinations should be performed in order to diagnose cord prolapse, to assess cervical dilation and the status of labour. • The maternal and fetal status need to be closely monitored during transport by using the non-invasive devices.

39. Support • Supplemental oxygen and intravenous fluid may be given if necessary • The patient can be placed in head down position (Sims or knee-chest) to avoid compressing the cord by the presenting part . • Not to handle the cord excessively • If the cord is protruded out of the vulva, the cord ought to be replaced gently into vagina, and then packed with moist gauze • In active labour, the examiner’s hand should continuously elevate the presenting part to enhance the umbilical flow until delivery is accomplished • May try to fill up the bladder by infusing 500-700ml of normal saline or tocolysis (subcutaneous terbutaline 0.25mg) if the woman is in active labor.

41. Transportation • During the whole transport, the examiner’s hand should keep in the vagina to elevate the presenting part in order to prevent compression of the cord by the fetus presenting part • The obstetrician and pediatrician of the receiving facility should be informed immediately • The patient should be transported to the nearest appropriate facility for emergency Cesarean section • Close monitoring of fetal and maternal status should be continued Video clip • http://www.youtube.com/watch?v=AEoa8fomMUA

42. The end THANK YOU