Emergencies Flashcards
Commonest Causes of Stillbirth A) Preeclampsia B) Abruption C) unexplained D) Infection including GBS E) Congenital abnormality
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Types of breech
Frank breech 45-50%
Complete breech 10-15%
Incomplete breech 35-45%
Mx of Breech labour
Call support set up empty bladder legs in stirrups Scissors ready in trolley help available Hand gently supporting the emerging breech, keeping the sacrum anterior. Lovsett manoeuvre Mariceau Smellie Veit manoeuvre
Incidence of breech and options prior to labour
30/40 - 15%
35/40 - 6%
term - 3% - Cephalic version - may give tocolytic
Risk factors for cord prolapse
Malpresentation, prematurity, polyhydramnios, high presenting part, long cord, fibroid, twin, low laying placenta
Mx of Cord prolapse
Recognize non-reassuring tracing
Visually inspect / palpate cord to diagnose
Assess fetal status (CTG, ultrasound) - if fetes is dead don’t C section,
Assess labour progress (dilatation, station) - if multi and you can deliver quicker then Caesarian.
Do not attempt to replace cord - Dr Foast said yocan
Hold presenting part off cord
Foley catheter
Position change (Trendelenburg, knee-chest) if bradycardia fetes
IV access
Immediate deliver if live baby
Cat 1 caesarian
if fully dilated multi instructment assist
if you can’t then fill bladder with 500ml to hold baby up
Tocolysis if in labour
Presentation of cord prolapse in different presentation
Vertex 0.4%
complete breech 4-6%
Frank breech 0.5%
Footling breech 15-18%
Risk factors of uterine rupture
Grand multiparity Undiagnosed feto pelvic disproportion, malpresentation oxytocin stimulation Macrocosmic-hydrocephalic fetes Prior instrumental abortion Uterine anomalies eg rudimentary horn
Symptoms and signs of uterine rupture
Abdominal pain, acute onset of scar tenderness
Abnormal progress in labour, prolonged first or second stage of labour
Vaginal bleeding
FHR
Prolonged, persistent and profound bradycardia
Undetectable fetal heart beat
fetal compromise
Palpable fetal body parts
Cessation of previous efficient contractions
loss of station of the presenting part
Chest pain or shoulder tip pain
Maternal tachycardia, hypotension or shock
Most common sign is the sudden appearance of fetal distress during labor
Mx of uterine rupture
Immediate C section.
Why is shoulder dystocia so important
Time is of essence - fetal pH falls by 0.04 per minute - no perfusion from cord while stuck in the birth canal. Max time in healthy baby - 6 min
How common is shoulder dystocia
Incidence - varies by birth weight
0.3% in infants weighing 2500-4000 grams
5-7% in infants weighing 4000-4500 grams
>50% occur in normal weight infants
Risk factors for shoulder dystocia
Maternal Previous shoulder dystocia gestational diabetes Maternal short stature High pre-pregnancy Weight and weight gain Abnormal pelvic anatomy Prolonged 1st stage - slowing toward the end of first stage. Prolonger 2rd stage “head bobbing” in 2rd stage Instrumental vaginal delivery - often. Fetal Macrosomia Over due Fetal anomalies Risk factors limited as half happen in mums without risk factors
Complications of shoulder dystocia
Maternal maternal soft tissue injuries - 3rd and 4th degree tear Anal sphincter damage Post-partum haemorrhage Uterine rupture Symphyseal separation Fetal Neonatal brachial plexus palsy Erb’s palsy C5-6 Klumpke’s palsy C7/8T1 Clavicular fracture Humeral fracture Fetal acidosis Hypoxic brain injury Asphyxia Death
Signs of shoulder dystocia
Fetal head retracts against perineum - turtle sign
Gentle traction does not effect delivery
Mx of Shoulder dystocia
HELPERR
H- Help
activate institutional protocol
Appropriate notification
Additional staff
additional back-up
neonatal resuscitation personnel
Obstetric/surgical back up
anaesthesia
E - evaluate for episiotomy
shoulder dystocia is not a soft-tissue dystocia
Consider when additional room needed for advanced manoeuvres
Decision based on clinical judgement and response to initial manoeuvres
L - legs
McRoberts Manoeuvre:
– Flex maternal hips so that thighs are on abdomen
• Effects: Straightens the lumbosacral lordosis, Increases AP diameter of pelvis, Flexes the fetal spine
• Reduces >40% of shoulder dystocias
P - Pressure
Supra-pubic pressure by assistant (Rubin I): CPR-style hand position, Force should act to adduct anterior shoulder. Initially continuous, but can involve a rocking motion. Push the anterior shoulder to move from AP to lateral
Attempt for 30-60 seconds
With McRoberts manoeuvre will reduce 50% of shoulder dystocias
E - Enter
Rubin II Manoeuvre: Approach anterior fetal shoulder from behind. Exert pressure on scapula to adduct most accessible shoulder and rotate to oblique position. Continue McRoberts manoeuvre
Woods Screw Manoeuvre. Approach posterior fetal shoulder from the front. Gently rotate shoulder toward symphysis.
Reverse Woods Screw manoeuvre: Approach posterior shoulder from behind. Rotate fetes in opposite direction from Rubin or Woods Screw manoeuvres.
R - Remove the posterior arm
Follow posterior arm down to elbow usually anterior to fetal chest. Flex arm at the elbow. Sweep forearm across fetal chest. Grasping hand directly and pulling outwards may lead to fractures.
R - Roll the woman
Roll woman to McRoberts “all-fours” position. Increases pelvic diameters. Movement and gravity may also contribute to dislodging the impaction. Deliver posterior shoulder with gentle downward traction. May attempt all “enter manoeuvres” in this position.
Last resort - Zavanellib manoeuvre, clavicle fracture and symphysiotomy.
30s each and move on.
