Oops She

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Oops Shes Delivering!

• OB Workshop Module

Peter Hutten-Czapski MD President SRPC 00-02
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Oops Shes Delivering
You work in a rural hospital without obstetrical
capacity with the nearest surgeon 1 hour away.
Your partners have gone to the RCC CME event
and you are the only doctor left in town. You are
paged by the duty nurse who informs you of Mrs
Smith a G6P5 has arrived in the ER and the nurse
thinks that the patient is delivering!
What do you do now?
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One Thing at a Time

• Dont Panic
• The Hitchhiker's Guide to the Universe
• Remember if pregnancy was intrinsically
  pathological the human race would be in trouble
• The vast majority of women deliver themselves

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Overview

• Rural Practice Patterns
• The Breech
• Post Partum Haemorrage
• The Impacted Shoulder

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Practice Style - Emergency

• As community size decreases the percentage of
  physicians providing ER coverage increases
• maximal effect of 58 at under 8,000 pop

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Practice Style - Obstetrics

• As distance from a city hospital increases the
  percentage of physicians providing intrapartum
  care increases
• maximal effect of 37 at under gt87Km

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Broadening Practice Patterns
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Breech

• it comes out this way?

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Breech Types
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60
30
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Breech Incidence

• 25 of deliveries before 25 weeks
• 7 of deliveries at 32 weeks
• 3 of deliveries at term
• not surprising prematurity and low birth weight
  (lt 2500gm) are associated with breech

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Breech Complications

• Term intrapartum fetal death 1 (RR 161)
• Cord prolapse Increased 5- to 20-fold
• Birth trauma Increased 13-fold
• Arrest of aftercoming head 8.8
• Spinal cord injuries with extended head 21
• Major anomalies 6-18

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Plan to deliver by C/S

• For breech presentation at term, planned cesarean
  section has better neonatal outcome than planned
  vaginal birth particularly for developed
  countries
• Hannah ME, Hannah WJ, Hewson SA, Hodnett ED,
  Saigal S, Willan AR. Planned caesarean section
  versus planned vaginal birth for breech
  presentation at term a randomised multicentre
  trial. Lancet 2000 356 1375-1383.

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If not 90 require no helpLet it Be !
X
Extension of the head can trap it and cause
spinal cord injury!
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(optional) delivery of the legs

• After spontaneous expulsion to the umbilicus, the
  legs may be delivered by external rotation of
  each thigh
• Delivery of the leg is aided by rotating the
  fetal pelvis away from that side

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The left leg

• Delivery of the leg is aided by rotating the
  fetal pelvis away from that side
• counterclockwise rotation of the fetal pelvis as
  the operator externally rotates the fetal left
  thigh

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(optional) Delivery of the arm

• When the scapulae appear under the symphisis, the
  operator reaches over the left shoulder, sweeps
  the arm across the chest

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The left arm delivers

• Sweep the left arm and extend the elbow
• Gentle rotation of the shoulder girdle
  facilitates delivery of the left arm.

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Delivery of the head

• the fetus is wrapped in a towel for control and
  slightly elevated. The fetal face and airway may
  be visible over the perineum. AVOID Excessive
  elevation of the trunk

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Keep the neck flexed

• Maintain cephalic flexion by pressure on the
  fetal maxilla (not mandible!)
• delivery of the head is easily accomplished with
  continued expulsive forces from above and gentle
  downward traction

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Alternate delivery of head

• Piper forceps are applied from the side below the
  fetal trunk while an assistant supports the fetus

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Piper Forceps

• The fetus may be laid on the forceps and
  delivered with gentle downward traction

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Post Partum Haemorrhage

• The sound of blood dripping...

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PPH Risks

• 3-5 of vaginal deliveries
• major cause of maternal mortality
• risks factors include
• nuliparity and grand multiparity
• instrumental delivery
• multiple gestation
• pre-eclampsia
• previous PPH

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Etiology of PPH
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Management of PPH

• Call for help
• Airway
• Breathing
• Circulation
• Uterine massage
• Oxytocics
• Cause specific management

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Oxytocics

• Oxytocin 10U im or 20U/1l at 250cc/h
• Ergometrine 0.25mg im (will raise BP)
• Prostaglandins
• F2? Carboprost 0.25 im or intramyometrially
• 86 effective in cases where other means failed

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Specific Treatments

• Lacerations - surgical repair
• Retained placenta - manual removal
• Placenta accreta - hysterectomy
• Uterine Inversion - prompt relocation
• Uterine Rupture - surgery to repair
• Coagulopathy - transfusion

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Shoulder Dystocia

• the pH is dropping

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Impacted Shoulder
Impacted Shoulder
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Shoulder Dystocia Risks

• 1 of births have prolonged head to body delivery
  (gt60s)
• risk factors include large baby, short stature,
  DM, instrumental delivery, previous SD
• 93 of high risk women deliver without shoulder
  dystocia
• 50 of shoulder dystocia occurs in women at
  normal risk and is unanticipated

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Shoulder Dystocia Effects

• Umbilical blood flow may stop
• pH drops _at_0.04/min you have 7 minutes
• 7-20 SD babies have brachial plexus injury, most
  recover in 6-12 months
• 1-2 SD Babies have permanent injury usually
  Erbs palsy(C5 C6 roots)

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Shoulder Dystocia Reduction

• turtle sign will give you the diagnosis
• AVOID excess traction!
• 1st call for help
• Try a series of maneuvers for 30 to 60 s each
• if its not working try something else
• the order of maneuvers is not important

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McRoberts

• Flexing the maternal hips to a knee chest
  simulates squatting and increases inlet diameter
• Suprapubic lateral pressure on the foetal scapula
  CPR fashion will dislodge the shoulder
• over 40 of shoulder dystocia can be reduced with
  these simple maneuvers

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McRoberts
McRoberts and Suprapubic Pressure
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Rubin II

• Insert your hand into the vagina behind the
  anterior foetal shoulder and push towards the
  foetal chest
• This adducts the shoulder girdle and disimpacts
  the symphysis by moving the shoulder into the
  oblique

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Rubin II
Rubin Maneuver
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Woods Screw and Reverse

• WS Insert two fingers into the vagina behind the
  anterior foetal shoulder and two fingers of your
  other hand in front of the posterior shoulder and
  rotate the shoulders
• Reverse WS Insert your hand into the vagina
  behind the posterior foetal shoulder and push
  towards the foetal chest

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Reverse Woods Screw
Woods Screw Maneuver
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Delivery of the Posterior Arm

• The bisacromial diameter is decreased by delivery
  of the posterior foetal shoulder
• flex the posterior foetal elbow and deliver the
  forearm by sweeping it over the anterior chest
  wall
• often the foetus rotates in a corkscrew manner
  clearing the anterior shoulder

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Remove the Arm

• Follow posterior arm down to elbow
• usually anterior to fetal chest
• Flex arm at the elbow

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Remove the Arm

• Sweep forearm across fetal chest
• grasping hand directly and pulling outward may
  lead to fractures

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Gaskin Manouver

• The foetal shoulder often dislodges during the
  act from turning from a supine posture to a all
  fours Simms position
• gentle traction with the aid of gravity may help
  deliver the posterior shoulder

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Simms Position
Attempt to deliver posterior shoulder first
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Zavanelli Manouver

• Tocolysis and cephalic replacement disimpacts the
  umbilical cord in preparation for immediate
  caesaerean section
• continue attempting to deliver vaginally until
  physicians capable of performing a caesarean are
  present.

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Zavanelli Manouver
Tocolysis helpful Immediate cesarean required
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Symphysiotomy

• Intentional division of the fibrous cartilage of
  the symphibis pubis
• it takes two minutes to perform so consider at
  the 4 minute mark if all else has failed
• 10 or 22 blade from the top until the pelvis
  falls open
• easy with little morbidity