Oops She’s Delivering!

OB Workshop Module

Peter Hutten-Czapski MD President SRPC ‘00-02

Oops She’s 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?

One Thing at a Time

• Don’t 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

Overview

• Rural Practice Patterns

• The Breech

• Post Partum Haemorrage

• The Impacted Shoulder

Practice Style - Emergency

• As community size decreases the percentage of physicians providing ER coverage increases

• maximal effect of 58% at under 8,000 pop 0

10

20

30

40

50

60

>56

0K

114-

559

37-1

14

8-37

<8K

%GP in ER

Practice Style - Obstetrics

• As distance from a city hospital increases the percentage of physicians providing intrapartum care increases

• maximal effect of 37% at under >87Km

0

5

10

15

20

25

30

35

40

<2K

m 2-5

5-17

17-8

7

>87

Km

%GP OB

Broadening Practice Patterns

Rural Participation in 2001 1997

Obstetrics 30% 25%Casting 73% 66%ER 77% 75%Palliative care 89% 77%Chronic Disease 93% 81%

Janus Survey Data CFPC 1997,2001

Breech

… it comes out this way?

Breech Types

60%30%10%

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 (< 2500gm) are associated with breech

Breech Complications

• Term intrapartum fetal death 1% (RR 16:1) • 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%

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.

If not… 90% require no helpLet it Be !

XExtension of the head can trap it and cause spinal cord injury!

(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

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

(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

The left arm delivers

• Sweep the left arm and extend the elbow

• Gentle rotation of the shoulder girdle facilitates delivery of the left arm.

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

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

Alternate delivery of head

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

Piper Forceps

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

Post Partum Haemorrhage

The sound of blood dripping...

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

Etiology of PPH

70

20

10

10.06

0.01

0.07

AtonyLacerationsRetained PlacentaCoagulopathyRuptureInversion

Management of PPH

• Call for help

• Airway

• Breathing

• Circulation

• Uterine massage

• Oxytocics

• Cause specific management

Oxytocics

• Oxytocin 10U im or 20U/1l at 250cc/h

• Ergometrine 0.25mg im (will raise BP)

• Prostaglandins– F2ά Carboprost 0.25 im or intramyometrially– 86% effective in cases where other means

failed

Specific Treatments

• Lacerations - surgical repair

• Retained placenta - manual removal

• Placenta accreta - hysterectomy

• Uterine Inversion - prompt relocation

• Uterine Rupture - surgery to repair

• Coagulopathy - transfusion

Shoulder Dystocia

… the pH is dropping

Impacted ShoulderImpacte

d Shoulder

Shoulder Dystocia Risks

• 1% of births have prolonged head to body delivery (>60s)

• 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

Shoulder Dystocia Effects

• Umbilical blood flow may stop

• pH drops @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 Erb’s palsy(C5 C6 roots)

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 it’s not working try something else

• the order of maneuvers is not important

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

McRoberts

McRoberts and

Suprapubic Pressure

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

Rubin II

Rubin Maneuver

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

Reverse Woods Screw

Woods Screw

Maneuver

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

Remove the Arm• Follow posterior

arm down to elbow – usually anterior

to fetal chest

• Flex arm at the elbow

Remove the Arm• Sweep forearm

across fetal chest– grasping hand

directly and pulling outward may lead to fractures

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

Attempt to deliver posterior shoulder first

Simms Position

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.

Tocolysis helpfulImmediate cesarean required

Zavanelli Manouver

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