Wk 5: mat emergencies 1 Flashcards
Define shoulder dystocia
“vaginal cephalic delivery that requires additional manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed” (RCOG 2012)
What is the cause of a shoulder dystocia?
= bony impaction of the fetal anterior shoulder (usually) behind the maternal symphysis pubis. Occasionally the fetal posterior shoulder impacts over the maternal sacral promontory.
What documentation needs to be recorded in a shoulder dystocia?
- Time of birth of the head
- The time and sequence of manoeuvres used
- Which was the anterior shoulder
- The time of birth of the body
- The condition of the baby
- Umbilical cord lactates/gases
- Estimated blood loss
- Assessment of perineum and vagina
- Staff members present during emergency.
What are some risk factors for shoulder dystocial?
- infant of a diabetic mother
- maternal obesity
- gestational age (risk increases with age)
- prolonged first stage
- prolonged second stage
- IOL (except for maternal diabetes and suspected macrosomia where evidence supports it reduces the risk of shoulder dystocia in this group of women)
- Labour augmentation
- Instrumental/assisted vaginal birth
*fetal size is not a good predictor alone as the majority of new borns >4500g do not develop shoulder dystocia.
** in majority of shoulder dystocia cases there are no risk factors
What complications are associated with shoulder dystocia?
Maternal
- increased risk of PPH
- 3rd and 4th degree tear
- uterine rupture
- future obstetric issues
- psychological side effects
Neonatal
- increased risk of need for resus
- brachial plexus injury
- a network of nreves that conduct signals from the spinal cord to the arm and hand. Can result in erb’s palsy= flacid upper arm (recovers in 12 months usually)
- Klumpe’s Palsy is less common and is characterized by a limp hand and no movement of the fingers.
- fractured humerus/clavicle
- can occur unintentionally or intentionally. Quick to heal
- hypoxia
- death
Explain the steps of management for shoulder dystocia.
- call for help
- McRobers’ manoeuvre
- suprapubic pressure + routein axial traction
- ?episiotomy
- delivery of posterior arm
or - internal rotation maneuvers
*Repeat from top or try all fours
If still no release consider;
- cleidotomy
- zavanelli manoeuvre
- symphysiotomy
Recall some signs of shoulder dystocia?
- There is difficulty with the birth of the face and chin
- The head is born but remains tightly applied to the vulva
- The chin retracts into the perineum (the turtle sign)
- The anterior shoulder does not birth with normal downward traction
What is the goals of the manouvers?
- Increase the functional size of the bony pelvis
- Decrease the bisacromial diameter of the fetus
- Change the relationship of the bisacromial diameter within the bony pelvis by rotating the fetus into the wider oblique diameter
What are some key practice points in the management of a shoulder dystocia?
- shoulders must be rotated using pressure on the scapula or clavicle. Never rotate the head
- AVOID EXCESSIVE TRACTION AT ALL TIMES= anything but gentle axial pressure has been shown to cause increased harm with no benefit.
- avoid fundal pressure= increased risk of brachial plexus injury, uterine rupture and haemorrhage from
potential detachment of fundal placenta.
Explain McRobers manoeuvre
- Remove or lower the bottom of the bed and manipulate her buttocks to the extreme edge.
- With the aid of an assistant either side
- legs are straightened and then thighs are abducted and hyperflexed onto the abdomen
(McRobert’s position).
Explain Suprapubic pressure (also known as Rubin 1)
- The accoucheur applies gentle downwards traction to the baby’s head.
- Simultaneously the assistant adopts a CPR-hand position over the anterior shoulder.
- The initial pressure applied is continuous.
- If delivery is unsuccessful, a rocking motion may be applied.
*aim is to reduce the diameter of the fetal shoulders and rotate the anterior shoulder into oblique diameter to slip the shoulder under symphysis pubis.
Explain the use of episiotomy in a shoulder dystocia
- may be used to assist with the effectiveness of internal maneuvers
- consider completing it during rubins 1 if predicting that baby will not come.
- assistant may be required to elevate the baby’s head to improve the view of the perineum (thereby reducing potential trauma to the baby’s face).
- This allows the accoucheur to use both hands to cut (or extend) the episiotomy.
- The accoucheur applies gentle downwards traction to the baby’s head.
WHat is the correct hand position and insertion point for internal maneuvers during a shoulder dystocia?
- sacral hollow as it is the most spacious part
- hand position has been described ‘as if putting on a tight bracelet’ where the fingers are compressed and the thumb tucked in to the palm.
Describe rubins 2
- accoucheur’s hand is inserted into the vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest. This rotates the shoulders forward into the more favourable oblique diameter.
- Completion of the birth is then attempted using normal downward traction.
Explain the combined Rubins 2 and wood screw
- While maintaining the McRobert’s position
- the accoucheur introduces their second hand and locates the anterior aspect of the posterior shoulder.
- Pressure is applied to rotate the posterior shoulder.
- Completion of the birth should be attempted once the shoulders move into the oblique diameter.
- If this movement is unsuccessful continue rotation through 180°
and attempt delivery
Explain reverse wood screw
- Pressure is applied to the posterior aspect of the posterior shoulder attempting to rotate it through 180° in the opposite direction to that described in the Wood’s screw manoeuvre.
Explain ‘removal of the posterior arm’ in a shoulder dystocia
- The accoucheur passes their hand into the vagina over the chest of the fetus to identify the posterior arm and elbow.
- Apply pressure to the antecubital fossa to flex the elbow in front of the body, and / or grasp the posterior hand to sweep the arm across the chest and deliver the arm.
- This is followed by rotation of the fetus into the oblique diameter of the pelvis, or through 180°, bringing the anterior shoulder under the symphysis pubis.
- The fetus is usually in an attitude of flexion with the arms flexed over the chest.
Explain rotation onto all fours in the context of shoulder dystocia
- may facilitate delivery by increasing the pelvic diameters and allowing better access to the posterior shoulder.
Explain posterior axilla sling traction (PAST) tachnique
- uses a sling that is placed around the posterior axilla.
- is typically a suction catheter or an in-out urinary catheter which is folded into a loop and threaded through the baby’s posterior axilla.
- Downward traction can then be applied to the sling to deliver the posterior shoulder.
- If the posterior arm does not follow, it can be swept out more easily as room has been created by removing the posterior shoulder.
- The sling can also be used to rotate the shoulders if traction on the shoulder fails.
- In order to rotate the shoulders, traction should be applied laterally towards the baby’s back then anteriorly while digital pressure is applied behind the anterior shoulder to assist rotation.
- double sling may be used
- The ends of the sling can be clamped to allow greater tration
Recall the definition of a PPH
= as a blood loss of 500 ml or more from the genital tract, within 24 hours after birth.
Recall the definition of a severe/major PPH
= a blood loss of 1000ml or more after birth.
Recall the definition of a secondary PPH
is a blood loss of 500ml or more occurring from 24 hours postpartum until 6 weeks postpartum
Recall the most common cause of a PPH
Uterine atony is the most common cause of PPH- 70-90%
Explain why we must assess each women blood loss in relation to her and not just these numerical values.
- normal adult blood volume is approximately 70ml/kg however in pregnancy this increases to approximately 100ml/kg.
= This is a physiological process to assist in protecting women against haemorrhage. - Young, healthy women often compensate extremely well during haemorrhage and often signs of clinical deterioration are not as clear cut and negatively reassure us as healthcare professionals that the women is not clinically compromised.
- This masking of clinical deterioration suggests that any sign/s of hypovolaemia should be taken seriously and resuscitation commence promptly.
What are the four T causes of a PPH?
TONE: (70%) - uterine atony, distended uterus, uterine muscle exhaustion
TISSUE: (10%) - retained products of conception, invasive placenta e.g. placenta percreta/accreta
TRAUMA: (19%) - cervical, vaginal or perineum, pelvic haematoma, uterus
THROMBIN: (1%) - blood clotting disorders, inherited or acquired including Disseminated intravascular coagulation (DIC)
Explain the initial non-pharmacological management of a PPH?
- Lie flat
- Administer O2
- Keep warm
- Insert IDC
- Assess blood loss
- Massage uterus and expel clots
Explain the initial pharmacological management of a PPH?
Oxytocin 10 units IM/IV
Syntometrine 1ml IM
or
Ergometrine 250microg IM and 250microg IV
**(Hypertension -Syntometrine &
Ergometrine contraindicated)
What obs are necessary and at what frequency in the initial management of a PPH?
BP, HR, RR and SaO2 5/60
Temp 15/60
Blood loss
1/24 urine output
What other actions may need to occur in the initial management of a PPH?
- Intravenous access 2 x 14 or 16g
- Collect blood samples (FBE, clotting,
x-match, fibrinogen) - Rapid fluid replacement
-Give 2L initially - Commence fluid balance chart
- Avoid excessive crystalloid use.
- ?blood products (O-ve RBC)
- Use rapid infuser/warmer FFP, Platelets, cryoprecipitate
What are the management options for tone related PPH?
- Fundal massage
- Expel clots
- Drugs:
- oxytocin/Syntometrine/ergometrine if not already
- Tranexamic acid 1g 100ml 0.9% NaCI IV
- Carboprost 250microg/1ml IM
- Oxytocin infusion 40 units/1L/4 hours
- Misoprostol 600microg PR or buccal - Bi-manual compression
- Bakri balloon
What are the management options for trauma related PPH?
- inspection for tear (vaginal and vervix)
- repair lacerations
- ?packing uterus/vagina
- consider presence of vaginal haematoma
What are the management options for tissue related PPH?
- Deliver the placenta
- Expel clots from uterus and vagina
- Inspect placenta and membranes
- ?need for surgical removal of retained products
