instrumentals Flashcards
how to manage a subgaleal haemorrhage ?
it is a medical emergency
Immediate discussion with a neonatologist
a. Stabilisation should not be delayed by any attempts to confirm the diagnosis with
imaging.
b. Aggressive resuscitation to restore circulating blood volume, provide circulatory support,
correct acidosis and to correct coagulopathy is the mainstay of management.
c. Head wrapping may be difficult to perform, and does not appear to be of benefit.
d. Frequent re-evaluation of haemodynamic stability and response to blood and blood products if necessary
What are the levels for monitoring the neonatal for a subgaleal after an instrumental?
Level 1
all instrumentals
Baseline obs, avoid hats, monitor behaviour
Level 2
Risks for SGH - difficult delivery, more then 3 pulls, more then 2 pop offs, suction over 20 minutes
5 minute APGAR <5 - concern at level 1
Cord gases
formal obs for 12 hours
monitor head
level 3
Subgaleal suspected - paeds review
Risk of a subgaleal with different instruments?
What are other risk factors?
Vaccum OR 7.17
Forceps 2.66
Nullip 5 minute APGAR <7 Cup marks on the sagittal suture leading edge of cup closer then 3 cm from anterior fontanelle failed ventouse
difficult delivery with pop offs, prolonged suction or excessive number of strength
What is the technique to avoid a subgaleal?
Cup placement should be:
i. Placed evenly across the sagittal suture, rather than being applied to one or other
parietal bone to avoid asynclitism with traction.
ii. The edge of the cup should be placed at least 3 cm from the anterior fontanelle to
avoid extension of the fetal head during traction (assuming a standard 6cm
cup is being used).
iii. Appropriate cup placement may be impossible if there is significant deflexion or
asynclitism of the head and a “large soft-stemmed” device is being used,
because it cannot be placed sufficiently posteriorly
Traction should be steady, applied only with contractions and only with maternal effort.
c. Adequate descent should be verified (with the non-pulling hand) during each pull.
d. Traction should not be unduly prolonged
Contraindications for ventouse?
Under 34 weeks
34-36 is a relative contraindication
Suspected bleeding disorders eg thrombocytopenia or haemophilia
Osteogenesis imperfect as increased risk skull fracture
Incidence SGH
All deliveries
forceps
ventouse
All deliveries 0.6/1000
Vaccum 4.6-5.9/1000
60-90 % of SGH are from ventouse
Signs of SGH
The initial localised signs of a SGH are of vague, generalised scalp swelling and a laxity of the
scalp, most commonly seen at the site of cup application following vacuum assisted birth. As further
haemorrhage accumulates, the lesion becomes fluctuant; the sensation on palpation having been
likened to ‘an old leather pouch filled with fluid’. A ballotable lesion that crosses the suture lines
should alert the carer to the possibility of a SGH, as should the presence of ‘pitting oedema’
extending over the head, and in front of the ears. The fluid is gravity dependent, and will shift to the
dependent side as the infant is repositioned. Crepitus, or a fluid ‘thrill’, may be noted, this
sometimes being described as a “flick test”.
With progressive haemorrhage, elevation and displacement of the ear lobes, and puffiness of the
eyelids (peri-auricular and periorbital oedema) follows
Generalised signs of a SGH relate to blood loss
5-minute Apgar score < 7, without evidence of
asphyxia; particularly if delivery was affected by prolonged or complicated vacuum extraction.
Irritable cry
Later signs relating to haemodynamic instability include tachycardia, tachypnoea, poor activity and
pallor, anaemia, coagulopathy, hypotension, acidosis and death
Anatomy
Where does the epicranial aponeurosis attach>
The epicranial aponeurosis is a sheet of fibrous tissue covering the entire cranial vault, extending
from the orbital ridges to the nape of the neck and laterally to the ears. Separation of the
epicranial aponeurosis from the underlying periosteum thus creates a compartment large enough
that approximately 250 ml of blood could be accommodated, with only a 1 cm increase in scalp
thickness.
How much blood fits in the subgaleal space?
250 ml of blood could be accommodated, with only a 1 cm increase in scalp
thickness.1
Due to this large capacity, some infants can lose 50-75% of their blood volume into the
subaponeurotic space, resulting in hypovolaemic shock, anaemia, coagulopathy and death.
Among babies admitted to NICU with SGH, neonatal mortality ranges from 12%2
to 25%.
What is the risk reduction of OASIS in primips performing a episitotomy for forceps and ventouse?
he evidence shows that performing an episiotomy in women having their first vaginal birth led to 24% fewer OASI when forceps were used and 16% fewer OASI when ventouse was used and
therefore should be considered.
What many babies are born with instrumentals?
10 % in NZ
What are the risks of second stage caesareans?
Tears in relation to uterine excision hemorrhage blood transfusion Bladder trauma Requirement for ICU
What is the rate of SVD in future pregnancies after an instrumental
80-90 %
What are non operative measures to reduce instrumental birth?
Continuous midwifery support
upright or lateral positions in second stage
No current evidence that epidurals increase instrumentals especially since lower dose techniques are now used (since about 2005)
Judicious use of oxytocin - second stage synto in a woman with an epidural reduces the need for instrumental - care in a multip!
In a primip with a epidural if no urge to push, then delaying for 2 hours decreases the midcavity or rotational instrumental
Manual removal reduces the need for caesarean and increases the rate of vaginal birth
Why is second stage dangerous for babies?
Greatest time of potential compromise is a few hours before birth
fetal descent may precipitate cord compression
Uterine activity + maternal effort reduces placental blood flow
