1 / 32

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

tale
Download Presentation

Intrapartum Emergencies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related