Intrapartum Complications

Question 1

General ‘template’ for Mx of intrapartum emergencies:

Answer 1

• Get help
• Prep for maternal and baby resus
• O2 on Mum
• CTG if >24/40 (viable)
• Consider:
  –> Stop pushing, tocolytics
  –> OT

Question 2

Umbilical Cord Prolapse

Answer 2

RFs: non-cephalic, small baby, PROM, oligohydramnios.

FB sensation, visualised, pulsatile mass felt

• OXYGEN ON MUM
• Head down, bum up
  –> (or MacRoberts with bed tilt)
• Replace any external cord into vagina
• Push presenting part off
• Don’t touch cord itself

If delay to OT:
–> Tocolytics
–> Fill bladder (to lift pres part)
–> Assisted vaginal delivery

Question 3

Uterine Inversion

Answer 3

• Analg/sedation
• Leave placenta in situ if attached
• Gentle manual reduction through vagina and cervix
• Tocolytics PRN to assist this
• If replaced- tocolytics
• If not- OT

Question 4

Risk factors for Uterine Rupture

Answer 4

• Grand multip
• Previous C-section
• Abnormal uterus: bicornate, percreta, CT disorder
• Misoprostol (oxytocin okay)

Question 5

Signs of uterine rupture

Answer 5

Pain
Peritonism
PV bleed
Palpable defect or fetal parts
Loss of fetal station
Fetal distress
Maternal shock

….Mx: O2 ON MUM, supportive, OT

Question 6

Management of Breech delivery

Answer 6

Head doesn’t dilate up the birth canal like usual. So, head can get stuck up above cervix - Don’t pull!!

If early, tocolytic and OT for caesar. If presenting part on show- Mx in ED.

• O2 on Mum
• Allow spontaneous delivery to umbilicus
• Hook knees to deliver legs
• Hold pelvis and gentle traction
• Rotate so shoulders are AP
• Deliver ANT then POST shoulders
• “Daddy hold” and deliver head face down with gentle suprapubic pressure

https://www.youtube.com/watch?v=EWjKswZ3Mm8

Question 7

Shoulder Dystocia

Answer 7

Complications: FTP, fetal asphyxia, brachial plexus injury, clavicle injury

Once you see ‘turtle sign’:
–> Stop pushing
–> O2 on, IDC in
–> Prepare for urgent delivery and Neoresus

EXTERNAL MANOEUVRES
1- McRoberts
2- Suprapubic pressure -50% success at this point
3- All Fours (with SP pressure)

Next line:

INTERNAL MANOEUVRES
+- episiotomy for hand room
1- Wood’s Screw
–> Hands in behind/in front ant/post shoulders, and rotate baby face-down
–> ‘Reverse woodscrew’ is other direction
2- Deliver posterior arm
–> Hook axilla, across chest + out

Next line
Repeat internal manoeuvres on All Fours

Last resort
- Break clavicles with pressure over middle

Question 8

Tocolytic options:

Answer 8

Remember:
MgSo4
–> 4g over 5mins then 1-2g/hr

If hypoTN: Salbutamol
–> 5microg/kg (max 250) –> same as infusion.
If no IV: Nifedipine
–> 20-40mg PO
GTN
–> any route

Question 9

Uterotonic options:

Answer 9

As per PPH:
Oxytocin 10units IM/IV stat –> 40units in 1L over 4 hours
Ergometrine 0.5mg IM
Misoprostol, syntometrine,

Question 10

Management of Preterm Labour:

Answer 10

TOCOLYTIC
- Nifedipine 20mg PO
—> Repeat x2 30 minutely if contractions persist
—> Then Q6H
2nd line: GTN, salbutamol

<35/40: STEROIDS
- Bethamethasone 12mg IM x2, 12-24 hours apart

<30/40: MgSO4 (neuroprotection)
- 4g load then 1g/hr for 24/24