Transcript Shoulder Difficulty

Intrapartum
Emergencies
Max Brinsmead MB BS PhD
May 2015
Shoulder Dystocia
• Occurs after the head delivers but
the shoulders are stuck
• Occurs in 1:100 births
• 5 - 7% of those with BW >4500g
• Although there are many risk factors
• It is now agreed that the condition is
basically Unpredictable
Consequences of
Shoulder Dystocia
• Maternal trauma
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• Soft tissue e.g. 3rd and 4th degree tears
• Symptoms from symphyseal separation
• Femoral neuropathy
Postpartum haemorrhage
Brachial Plexus Injury in the Baby
Fracture of clavicle or humerus
Fetal hypoxia and Death
Risk Factors
• Large baby - Symphysis fundal height
>42cm
• Past history of shoulder difficulty
• Obese mother (>110kg)
• Diabetic mother with fetal macrosomia
• Slow progress in 2nd stage of labour with
turtle sign of head between contractions
• After assisted delivery of the fetal head
Management – HELPER
AB
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Send for Help
ELevate the legs (McRobert’s manoeuvre)
Pressure suprapubically
Episiotomy
Rotate the shoulders
Bring down the Posterior Arm
Be prepared for PPH
Suprapubic Pressure to dislodge the
anterior shoulder with Shoulder
Dystocia
Rotating the shoulders
Bringing down a Posterior Arm
Fetal Distress
• Diagnosed by heavy or fresh meconium,
FHR or CTG abnormalities
• Has a 50:50 chance of being a false
alarm
• But more serious for the Fetus at Risk…
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Too small or too big
Post dates
Malpresentation
Poor obstetric history
Management – COP HAX
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Cease any oxytocin
Oxygen by face mask
Change maternal Position
Send for Help
Assist the delivery
• Ventouse or Caesarean
• Relax the uterus
• Oral Nifedipine or IV Salbutamol
Eclamptic Seizure
• It is best to regard any grand mal seizure
as due to eclampsia
• Unless there is a clear history of epilepsy
• Or other cause e.g. meningitis, cerebral
malaria, stroke etc.
• Up to 30% occur postpartum
• Can be prevented by good antenatal care,
Mg sulphate prophylaxis, BP control and
delivery of patients with pre-eclampsia
Management – HAB&C IMB BD
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Send for Help
Airway, Breathing & Coma Position
IV Access
Mg Sulphate IV and IM Loading dose
Blood pressure control with Hydralazine
Bladder catheter
Deliver the patient
Cord Prolapse
• Should always be suspected when the membranes
rupture and there is ANYTHING other than a well
engaged head
• Diagnosed by vaginal examination
• Sometimes suspected by a very irregular Fetal
Heart
• Should always be checked by VE
• Before rushing to fetal salvage always ask
yourself “Will this baby live?”
• Check for cord pulsations
• Is the baby very premature?
• Is Caesarean safe for the mother?
Management – HIP BT
• Send for Help
• Incline the patient
• Knee chest position or tilted left lateral
• And hold the head off the cord and cervix if
contracting
• Prepare for theatre
• Catheter in the Bladder
• And fill with water or saline
• Consider Tocolysis
• Oral Nifedipine or IV Salbutamol
Cord Prolapse Positions
Unplanned Breech
• Usually do quite well if they progress rapidly in
labour
• But the biggest part of the baby is coming last
• And the head must traverse the pelvis in 8 – 12
minutes instead of the usual 8 – 12 hours
• Breech babies who are…
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Large for dates (EFW>3.5Kg)
Footling or Flexed Leg Presentations
Shows signs of fetal distress
Do not spontaneously deliver the breech
• Are better delivered by Caesarean
Preparing for Breech Delivery
• Explain the procedure to the
mother
• And get her cooperation
• Have someone standing by to care
for the baby
• A theatre may be required
• If Caesarean becomes the better option
• Lithotomy position is best
• Empty bladder is desirable
Delivery Tips – HSS SPM
• Hands off the baby until the knees
appear
• Episiotomy may assist
• Spread the hips and bend the knees
• If the legs are extended
• Sweep arms down or Rotate for
Shoulders (Lovset)
• Support the baby until the hairline
appears
• Suprapubic pressure may help
• Deliver the head by the Mauriceau
technique
Mauriceau Technique for
Delivery of the Head
Unplanned Twins
• Preparation
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Get extra help – someone to care for the babies
A theatre may be required
IV Line, Group and Save
Will require two delivery bundles
• Inform and Involve the Patient
• Explain what may happen
• Reassure “Two for the Price of One” and not
“Twice as Hard”
Delivery Tips – DEM SAB
• Deliver the 1st twin as you would a
singleton
• Examine abdominally and external version
of the 2nd twin (if required)
• Monitor the FH of the 2nd twin
• Delivery within 20 – 30 min is desirable
• Stimulate the uterus with Syntocinon
required)
(if
• Amniotomy with caution
• Only after a pole (head or breech) is down in the
pelvis
• Internal version through intact membranes is best
Delivery Tips 2 – DEM SAB
• Assist the delivery of the 2nd twin (if
required)
• Ventouse if cephalic
• Brech extraction (after internal
version if required)
• Find a foot and bring it down
• Bring down the second leg
• Keep the back uppermost
• Thereafter as for Breech Delivery
• Be Prepared for PPH
• Active management of the 3rd stage
• Syntocinon infusion
Assisting Delivery by Vacuum
Extraction
• Requirements for Safe Vacuum Delivery
include…
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Pregnancy >34 completed weeks
Cephalic presentation
Full dilatation
Head engaged (no more than 1/5th palpable)
Adequate space in the pelvis
Position must be known with certainty
Skilled and experienced operator
A contracting uterus
A cooperative mother
Preparing for Vacuum Delivery
• Someone standing by to care for the baby
• Adequate analgesia
• Infiltrate the perineum with local
anaesthetic
• Assemble all the equipment and check
that it is working
• Test it on your gloved hand
• Position the mother
• Lithotomy with lateral tilt
Delivery Tips – AT E3 EB
• Apply the cup to the flexion point of the
head
• Midline , at least 3 cm beyond the anterior
fontanelle as close to the occiput as possible
• Take up the pressure and ensure no maternal
tissue is under the cup
• Traction only with contractions
• And ask the mother to push
• Requires descent with every pull to a
maximum of 3
• And within 20 minutes of the application of suction
Cup Attachment to the
Flexion Point of the Head
The Direction of Pull
Delivery Tips 2 – AT E3 EB
• Pull down, then out, then up to deliver
• Pull at 90 degrees to the cup
• Keep two fingers and thumb on the anterior lip of
the cup to detect detachment
• Episiotomy may be required
• Detachment is prone at crowning
• If detachment occurs...
• Send for help
• Attempt reapplication only ONCE
• Be prepared for...
• Shoulder difficulty
• And PPH
Acute Uterine Inversion
• Occurs when there is…
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Uncontrolled cord traction and…
A non-contracted uterus
A fundal placenta
Sometimes morbid attachment placenta
• Should be suspected when…
• There is maternal “shock” out of all proportion to
blood loss
• The uterus is dimpled or disappears from the
abdomen
• Will be obvious if it is out between the legs
• But should not be confused with uterine prolapse
• When the cervix appears at or beyond the introitus
Management – HR AR HR
• Send for Help
• Resuscitate
• IV Cannula
• Take blood for X-match
• Administer 1 – 2L N Saline
• Analgesia
• Nitrous oxide or Pethidine IV 25 mg
• Attempt manual replacement
• Most likely to be successful if done within 5 –
10 minutes of the inversion
• Do not remove the placenta if it is still
attached
Incomplete Uterine Inversion
Management 2 – HR AR HR
• O’Sullivan’s Hydrostatic Replacement
• Requires 2 – 6 litres of fluid into the vagina
• Needs a watertight seal at the introitus
• Use hand around the vulva and wrist or a
ventouse cup
• Replacement can be confirmed by
manual exploration of the uterus and
removal of the placenta (if required)
• But thereafter keep the uterus
contracted
• By Syntocinon infusion ± Misoprostol
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