Transcript Inter-facility Transport (IFT)Part 2Obstetrics

HKCEM College Tutorial
Inter-facility
Transport (IFT)
Part 2
Obstetrics
Author
Dr.
Oct., 2013
The scenario
▪ A Para 0 30 years old pregnant lady from mainland
China attends for regular abdominal pain. She is at
term gestation. Examination shows cervix dilates to
4 cm. There is no obstetric service at your hospital.
After consultation, she needs to be transferred to a
tertiary hospital.
How would you manage potential
second stage of labour
during transfer?
Active second stage of labour
▪ From complete cervical dilation till the baby is delivered
▪ Patient experiences regular contractions every 2-3 minutes with an
expulsive urge
▪ Video clip
▪ http://www.youtube.com/watch?v=Xath6kOf0NE
Recognition
▪ Careful observation of frequency of contractions and expulsive
urge
▪ Abdominal palpations to confirm uterine contractions >45 sec
each time
▪ Vaginal examinations to detect fully cervical dilation
Evaluation
▪ ABC for identifying the life threatening situation
▪ Inspect for signs of impending delivery:
1. Anus pouting and gapping
2. Vulva gapping and bulging perineum
3. Presenting part is appearing e.g. crowning of the head
• Abdominal palpations:
– Gestation age, fetal lie, presence of expulsive uterine contractions
• Vaginal examinations:
– Confirm the presentation part (vertex, breech, face or shoulder)
– Cervix is fully dilated (up to 10cm) / effaced (thinned to 1mm)
– Relationship of the presenting part to ischial spines
• Continuous non-invasive monitoring of vital signs
– Closely assess the uterine activity
– Measure FHR Q5mins (N 110-160 bpm)
Support
▪ If the delivery is momentary, we have to deliver the baby even
during the transport
1. The mother is placed in dorsal lithotomy position, tilted slightly
to the left side in order to lessen vena caval obstruction
2. As time allows, the perineum can be prepared by washing with
mild soap and water and swabbing with povidone-iodine
3. With each contraction the vaginal outlet bulges to accommodate
a greater portion of the fetal head, episiotomy may be necessary
to allow delivery without laceration
4. As the head emerges, the palm of the hand should keep the
head well flexed until crowned when it is allowed to extend. This
avoids rapid delivery and minimizes the risk of traumatic
perineum injury. The other hand should protect the perineum
• The baby’s neck region should be palpated to check for a nuchal cord. If
the cord is loose, it should be reduced over the infant’s head. On the
contrary, the cord should be clamped and cut if it is tight.
• Before the delivery of shoulders and thorax, baby’s face should be wiped
and the mouth and nose should be suctioned to clear the airway.
• Deliver the anterior shoulder by gentle downward traction and then
gentle upward traction will deliver the posterior shoulder. The posterior
shoulder should not be allowed to pop out uncontrolled, as this may
lacerate the anal sphincter.
• The umbilical cord is clamped and cut. Give 10mg syntocinon injection to
improve uterine contractions after the baby is delivered and the
possibility of twin pregnancy excluded.
• The infant is dried and wrapped in warm towels
Transportation
▪ If the delivery is not momentary, continue transportation to the
receiving facility as planned with close monitoring.
• Otherwise, transport need to be suspended in case of emergency
delivery or the ambulance may need to go to the nearest facility
with emergency services instead of the destination
• After the emergency delivery, the mother and baby are closely
monitored and transported to the receiving facility
• Paediatric and obstetric units should be notified beforehand
What other complications can occur
during transfer?
Breech presentation
Breech Presentation
▪ Commonest malpresentation
▪ Major concern is head entrapment during a vaginal delivery
▪ Higher incidence of umbilical cord prolapse and fetal distress
Recognition
▪ Antenatal history is vital
▪ Usually the diagnosis has been made in antenatal check up
▪ Abdominal palpation
▪ Vaginal examinations
▪ USG
Evaluation
• Patient’s ABC need to be incorporated as priority for identifying
life-threatening situation
• Inspect for any signs of impending delivery
• Abdominal palpation:
– Longitudinal lying fetus, no head is felt in pelvis but a ballotable
smooth round mass (head) in the fundus
• Vaginal examinations:
– Assess cervical dilation, labour status and the presenting parts
• FHR and the uterine contractions are monitored continuously as
usual
Support
• Set up intravenous line with supplemental oxygen
• Frank or complete breech presentation
– Emergency delivery may be allowed to progress spontaneously
– Refrain from touching the fetus until scapulae are visualized
– Infant is gently supported by a warm towel wrapping around the lower
half
– Rotate the infant until one arm emerges
– And then rotate to opposite way to allow delivery of the other arm
– Cautious not to pull out the fetus hard, as this may increase the
pressure on the head within the pelvis and entrap the extended fetal
arm
▪ Footling and incomplete breech positions
▪ Unsafe for vaginal delivery even in a hospital setting because of high
chance of cord prolapse with incomplete dilation of the cervix
▪ The obstetrician and pediatrician are informed about the progress at
once
▪ Patient is transported to a nearest appropriate facility as soon as
possible while the patient is supported and monitored continuously
Transportation
▪ Prompt transport of breech presentation patients to a nearest
appropriate facility is of paramount importance
▪ Always keep the obstetrician and pediatrician informed, their
opinions will be most valuable
▪ Video clip
▪ http://www.youtube.com/watch?v=EPklRwlMV1Y
Shoulder dystocia
Shoulder Dystocia
• Impaction of fetal shoulder at the pelvic outlet after the head
delivered
• Carries high fetal morbidity and mortality if it is not managed
appropriately
• Fetal complications include brachial plexus injury, spinal cord
injuries, musculoskeletal injuries and hypoxic events
• Maternal morbidities include uterine atony, rupture, vaginal tears
and severe postpartum haemorrhage.
Recognition
▪ First recognized after the delivery of the fetal head
▪ When routine downward traction is insufficient to deliver the
anterior shoulder
▪ Turtle sign :appearance and retraction of the fetal head (analogous
to a turtle withdrawing into its shell)
Evaluation
• Patient’s airway, breathing and circulation need to be incorporated
as priority for identifying life-threatening situation
• Shoulder dystocia is identified by the “turtle sign”
• After the infant’s head delivered, the head retracts tightly against
the perineum
• Abdominal palpations and vaginal examinations should be done
as in usual delivery
• The vital signs of the mother, fetal heart rate and uterine activity
should be monitored closely
Support
▪ Apply suction to infant’s nose and mouth
▪ Managements as a set sequence of actions with the mnemonic
“HELPERR” is helpful
HELPERR
▪ H: Call for Help
▪ E: Ensure a generous episiotomy with adequate maternal
anesthesia.
HELPERR
• L: Legs:
Attempt McRoberts Maneuver – By hyperflexing the mother's and
bringing her feet to her ears, the lumbar-sacral lordosis is
straightened and the sacral promontory, which serves as an
obstruction, is removed. Then, attempt delivery with gentle
downward traction
• P: Suprapubic Pressure
Have an assistant apply suprapubic pressure.
This causes the shoulder to move under the symphysis pubis.
HELPERR
HELPERR
• E: Enter with internal Manipulation –
• Try Rubin II maneuver by approaching anterior fetal shoulder from
behind. Exert pressure on scapula to adduct most accessible
shoulder and rotate to oblique position.
• If unsuccessful, combine Rubin II maneuver with the Woods’ Screw
maneuver that approach the baby’s posterior fetal shoulder from
the front. Gently rotate the posterior shoulder toward symphysis
until the shoulder passes under the symphysis.
• If still unsuccessful, change to Reverse Woods’ Screw maneuver
that approach posterior shoulder from behind and rotate in
opposite direction from Rubin II or Woods’ Screw maneuver.
HELPERR
▪ R:Remove the arm
▪ Try to deliver the posterior arm first to decrease bisacromial
diameter and then rotate the anterior shoulder into the oblique
position for delivery
HELPERR
▪ R:Roll the patient
▪ The “all fours” maneuvers may be tried for reduction of shoulder
dystocia as this increase the pelvic diameter of the labouring
woman
Transportation
• Transport may need to be suspended in case of emergency
delivery
• Then, the patient need to be transported to the nearest facility with
emergency services instead of the designated facility
• After the emergency delivery, the mother and neonate should be
stabilized and closely monitored
• Communication with the obstetrician, paediatrician and receiving
facility about the progress is essential
Video clip
▪ http://www.youtube.com/watch?v=K5kLHkl5RsI
Umbilical cord prolapse
Umbilical Cord Prolapse
• A real obstetric emergency
• Risk of cord compression causing fetal asphyxia
• The incidence is increased in
– Preterm labour
– Prematurity
– Twin pregnancy and
– Breech presentations especially footling breech
• The objective of treatment is to
– Detect it promptly
– Evacuate the fetus quickly
– Transfer mother to labour ward as soon as possible
Recognition
• Should always be considered if malpresentation is noticed
• It is suggested by severe drop in FHR after rupture of membrane
• Rapid recognition may save the fetus life
– Direct visual inspection and
– Vaginal examination
• A palpable, pulsating cord is revealed which extruding from the
vagina, coiled in the vagina or wrapped across the presenting part
Evaluation
• The woman should be evaluated to ensure patent airway, sufficient
ventilation and stable haemodynamic state.
• Visual inspections and vaginal examinations should be performed
in order to diagnose cord prolapse, to assess cervical dilation and
the status of labour.
• The maternal and fetal status need to be closely monitored during
transport by using the non-invasive devices.
Support
• Supplemental oxygen and intravenous fluid may be given if necessary
• The patient can be placed in head down position (Sims or knee-chest) to
avoid compressing the cord by the presenting part .
• Not to handle the cord excessively
• If the cord is protruded out of the vulva, the cord ought to be replaced
gently into vagina, and then packed with moist gauze
• In active labour, the examiner’s hand should continuously elevate the
presenting part to enhance the umbilical flow until delivery is
accomplished
• May try to fill up the bladder by infusing 500-700ml of normal saline or
tocolysis (subcutaneous terbutaline 0.25mg) if the woman is in active
labor.
Transportation
• During the whole transport, the examiner’s hand should keep in
the vagina to elevate the presenting part in order to prevent
compression of the cord by the fetus presenting part
• The obstetrician and pediatrician of the receiving facility should be
informed immediately
• The patient should be transported to the nearest appropriate
facility for emergency Cesarean section
• Close monitoring of fetal and maternal status should be continued
Video clip
▪ http://www.youtube.com/watch?v=AEoa8fomMUA
The end
THANK YOU