EM OB 3: Emergency Delivery, part 3

Question 1

Other common complications of labor and delivery

Answer 1

1. Umbilical cord prolapse
2. Shoulder dystocia
3. Breech presentation
4. Postpartum hemorrhage
5. Uterine inversion and rupture
6. Amniotic fluid embolus
7. Cardiac arrest - you may have to do resuscitative hysterotomy (perimortem cesarean section)

Question 2

Remarks on umbilical cord prolapse

Answer 2

1. Umbilical cord compression is **life-threatening to the fetus.
2. Obtain immediate obstetric assistance, as emergent cesarean delivery is indicated.

Question 3

What to do in umbilical cord prolapse

Answer 3

1. Should the speculum or bimanual examination reveal a palpable, pulsating umbilical cord, elevate the presenting fetal part to reduce compression on the cord.
2. Keep your hand in the vagina while the patient is transported and prepared for surgery to prevent further compression of the cord by the fetal head.
3. Place the mother in the Trendelenburg position.
4. Do not try to reduce the prolapsed cord.

Question 4

Remarks on shoulder dystocia

Answer 4

Typically, the anterior shoulder is trapped behind the pubic symphysis and prevents delivery of the rest of the infant.

Turtle sign - after the infant’s head is delivered, the head retracts tightly against the perineum

Question 5

What’s to first maneuver to do in shoulder dystocia?

Answer 5

McRoberts maneuver: immediately place the mother in the extreme lithotomy position, with her legs sharply flexed up to the abdomen and the knees held as widely apart as possible

Simultaneously apply suprapubic pressure
if a second assistance is available, he/she should place his hands in a CPR position and apply downward pressure just above the pubic symphysis for 1-2 minutes to disimpact the anterior shoulder

The combination of the McRoberts position and suprapubic pressure relieves about 50% of shoulder dystocias

Do not compress the uterine fundus. This worsens impaction

Question 6

If the initial manauver is unsuccesful in shoulder disimpaction, what to do next?

Answer 6

**delivery of the posterior arm*
1. Identifying the posterior arm, flexing the elbow, and sweeping the arm across the fetal chest.

2. Rubin maneuver: place a hand on the back surface of the posterior shoulder and rotate the fetus toward the fetal face
3. Wood’s corkscrew maneuver: place a hand on the anterior surface of the posterior shoulder and rotate toward the fetal back
4. Sling procedures: a finger or 12F or 14F suction catheter is placed through the axilla of the posterior arm and moderate traction is applied to deliver the posterior shoulder

All of the above maneuvers require an episiotomy to allow the provider to place a hand in the vagina

5. Gaskin maneuver: place patient on all fours; exert gentle downward traction on the infant’s head.
   in 80% of cases, Gaskin maneuver allows the posterior shoulder to successfully deliver

Question 7

remarks on breech presentations

Answer 7

occur most frequently in the delivery of premature infants (25-30%)
only 3-4% of term pregnancies

in frank and complete breech deliveries, the buttoks dilate the cervix almost as well as the fetal head; therefore emergency delivery may be able to proceed in an uncomplicated fashion

Footling and incomplete breech positions are not safe for vaginal delivery due to the risk of cord prolapse or incomplete dilatation of the cervix
Immediately obtain emergency obstetric consultation for any breech presentation

Question 8

how to delivery the legs and body in breech babies?

Answer 8

1. Allow the delivery to proceed spontaneously to the level of the umbilicus and do not apply traction.
2. The legs will typically delivery spontaneously at this time, or one can insert a finger behind the knee to flex and abduct the baby’s thigh to deliver the legs.
3. Once the umbilicus is evident, gently place your thumbs on the sacrum and gently grasph the fetal pelvis with your hands.
   Keep the trunk at no more than 45 degrees to the horizontal.
   You may need to kneel on the floor
   Maintain or redirect the baby’s sacrum anterior
4. Allow each arm to delivery with slight fetal oblique rotation for each arm, and then maintain sacrum anterior position.
   You can have an assistant place the baby’s torso in a towel fashioned like a sling for better support.

Question 9

how to deliver the head in breech babies?

Answer 9

1. To safely deliver the head, maintain cervical flexion by placing one hand on the fetal occiput and shoulders, and apply flexing pressure on the occiput; and place the fingers of the other hand on the infant’s maxillae to aid in cervical flexion.
2. An assistant can apply suprapubic pressure to the mother to maintain cervical flexion.
3. Maintain cervical flexion, and the baby’s body will then deliver in a large arc, with the sling providing support.

Question 10

Remarks on postpartum hemorrhage

Answer 10

Usually occurs within the first 24 hours of delivery and is referred to as primary postpartum hemorrhage
- uterine atony (Tone)
- lower genital tract lacerations (Trauma)
- retained placental fragments (Tissue)
- uterine rupture
- uterine inversion
- hereditary coagulopathy (Thrombin)

Question 11

Remarks on secondary postpartum hemorrhage

Answer 11

Occurs after the first 24 hours and up to 6 weeks postpartum

Common causes
- failure of the uterine lining to subinvolute at the former placental site
- retained placental tissue
- genital tract wounds
- uterogenital infection

Question 12

Excessive blood loss in the postpartum period is defined as

Answer 12

10% drop in the hematocrit
need for transfusion of PRBCs
volume loss that generates symptoms of hypovolemia

Question 13

Remarks on hematologic changes in pregnancy

Answer 13

Normally, plasma volume increases by 40% and RBC volume by 25% by the end of the third trimester

Question 14

Most cases of postpartum hemorrhage are due to

Answer 14

uterine atony

risk factors
- preeclampsia
- protracted use of uterotonics or tocolytics
- prolonged labor
- multifetal gestation
- fetal macrdosomia
- multiparity
- retained placenta
- uterine infection

Question 15

What to do in uterine atony

Answer 15

1. Bimanual uterine massage: place a fist in the anterior fornix and compress the uterine fundus against the hand in a suprapubic location
2. Hemostatic brace sutures (B-Lynch sutures)
3. Peripartum hysterectomy

Question 16

How to manage uterine inversion?

Answer 16

1. Uterine inversion requires immediate manual replacement of the uterus
2. A Rüsch balloon catheter can be applied to correct uterine inversion

Of note, the correction of uterine inversion is a very painful and difficult procedure and may require general anesthesia and tocolytic agents

Question 17

primary risk factor for uterine rupture

Answer 17

previous cesarean section

Question 18

fetal size >______ increases the rate of rupture during a trial of labor

Answer 18

3500 grams

Question 19

anatomic abnormality associated with uterine rupture

Answer 19

bicornuate uterus

Question 20

some other risk factors for postpartum hemorrhage

Answer 20

preeclampsia
transverse fetal lie
fetal age <32 weeks of gestation
fetal birth weight >4500 grams

Question 21

Most cases of amniotic fluid embolus occur when:?

Answer 21

before delivery

Question 22

treatment of amniotic fluid embolus

Answer 22

Treatment is supportive.
There are no specific interventions currently available.

The physician should prevent and/or treat hypoxia, hypotension, and hypoperfusion.
Place the woman in the left lateral decubitus position to minimize vena cava compression;
give oxygen by NRM or ETT;
resuscitate with **fluid and blood;
and administer pressors to support maternofetal circulation until emergency delivery of the fetus is performed

Obtain emergency obstetric consultation

Question 23

Other remarks on amniotic fluid embolus

Answer 23

If the gravid patient canot be resuscitated, perimortem cesarean delivery within 5 minutes of cardiac arrest increases the chances of neonatal survival

Question 24

Remarks on perimortem cesarean section

Answer 24

aka resuscitative hysterotomy

the decision to perform the procedure should be made after 4 minutes of CPR and the delivery should be accomplished by 5 minutes (“4-Minute Rule” and “5-Minute Rule”)
“This is very difficult to accompllish”

Timing to delivery is critical, so do not move the patient to another location

Question 25

Required items in resuscitative hysterotomy

Answer 25

skin antiseptic
scalpel
scissors
suction
Kelly clamps or umbilical cord clamps
retractors

Question 26

Procedures of resuscitative hysterotomy

Answer 26

1. Apply the antiseptic solution to the abdomen.
2. Place a drape if available.
3. Make a vertical incision with the scalpel, starting at the xiphoid process and extending to the pubic symphysis.
   The incision should go through the skin, fat, fascia, and peritoneum.
4. Be careful to identify the bladder and retract it.
5. Carefully incise the uterus with the scalpel, with an incision large enough to accommodate two finger.
6. In order to protect the fetus from injury, insert two fingers through the initial incision and elevate the uterine wall off the fetus.
7. Use the scissors to divide the uterus between the fingers, and extend the incision in a vertical fashion.
8. Deliver the fetus.

Question 27

What to do after delivering fetus in resuscitative hysterotomy?

Answer 27

1. The mouth and nose should be suctioned if possible
2. Doubly clamp and cut the cord
3. If the decision to continue CPR is made, the placenta must be delivered, with gentle traction on the cord.
4. Once the placenta is delivered, the endometrial cavity needs to be swept with a clean, moist lap pad and inspected for any residual membrains.
5. Pitocin should be administered if possible.
6. At this point the provider may decide to pack both the uterus and incision to allow closure by a surgeon in the operating room

Question 28

What to do if there is a need to close the uterus?

Answer 28

1. Once the uterine cavity is empty, the uterus can be closed with the 0 or 1-0 delayed absorbable suture in a running fashion
2. The second layer of the uterine closure is usually closed in a running fashion
3. In some cases, a third layer may be required.
4. The rest of the incision is closed in mass