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what is shoulder dystocia?
- difficulty in delivering the fetal shoulders after delivery of the head
- requiring additional manoeuvres
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what is the incidence of shoulder dystocia?
1/200
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what is a major risk from the treatment of shoulder dystocia? and why?
- Erb's palsy (waiter's tip)
- due to excessive traction on the neck which damages the brachial plexus
- permanent in 50%
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what actually happens in shoulder dystocia?
anterior shoulder abuts the pubic symphysis, stays behind there and fails to rotate
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what are the risk factors for SD?
- large baby
- previous SD
- high maternal BMI
- labour induction
- low height
- maternal diabetes
- instrumental delivery
- slow labour
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what is the pneumonic for treatment of SD?
- HELPERR
- H: call for HELP - obs, midwife, pads as pH drops by 0.01/min so easily hypoxic
- E: evaluate for EPISIOTOMY
- L: LEGS are hyperflexed = Mc Roberts position, this flattens the sacral promontory and thereby increases the AP diameter of pelvic inlet and allows shoulders to come down
- P: PRESSURE - suprapubic sustained pressure (Rubin's manoeuvre) towards the face for 30s, if doesn't work do rocking pressure, should dislodge shoulder (someone puts pressure while obs gets baby out)
- E: ENTER - wood's screw manoeuvre: 2 fingers in vagina from below and try to push anterior shoulder down to rotate it to the widest diameter, if this doesn't work then b) other hand put fingers on posterior shoulder and push it the other way. still doesn't work then c) fully rotate baby backwards = reverse wood's screw and delivery the baby the other way
- R: REMOVAL of posterior arm: sweep up past its face and the anterior goes down
- R: ROLL on all 4's: can easily see posterior arm
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what are the 2 main last resorts for SD Rx?
- symphiosotomy: after lateral replacement of urethra with a metal catheter
- zavanelli manoeuvre: replace head back into pelvis and do C-section - but fetal damage very high risk and irreversible
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what is a major problem to the mum after SD? and why?
- PPH
- due to episiotomy and uterine atony
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what are the complications to the fetes after SD?
- asphyxia
- neurological damage, death
- brachial plexus injury: Erbs palsy, T1, C8 injury
- fractured clavicle
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what happens in uterine rupture - 4 things:
- 1. rupture - so fetes is extruded
- 2. uterus contracts down and bleeds from rupture site
- 3. causing fetal hypoxia
- 4. massive internal maternal bleed so shock
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what type of rupture is less serious and why?
- rupture from LSCS scar
- as lower segment is less vascular so less bleeding
- extrusion of fetes is less likely
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what is neonatal mortality from uterine rupture of LSCS scar rupture?
10%
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how would you suspect diagnosis of uterine rupture? ie what are signs and symptoms?
- fettle extrusion = feel fettle parts easily on abdo palpation
- uterine contractions stopped
- maternal collapse as massive internal bleeding
- PV bleed
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what are main complications of uterine rupture?
- fetal morbidity, mortality
- maternal collapse as massive bleed
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what are 3 main risk factors for uterine rupture?
- 1. labours with scarred uterus - previous uterine classical CS, deep myomectomy
- 2. obstructed labour (more in west)
- 3. congenital uterine abnormalities - may get rupture before labour
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how can uterine rupture be prevented?
careful augmentation using oxytocin in VBAC
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what is Rx of uterine rupture?
- help - call senior obs, midwife in charge, haematologist, scribe, paeds, porter, lab to cross match blood
- ABC - maternal resuscitation
- 2 large bore cannulae into antecubital fossa
- iv fluids and blood into one
- blood tests from other: FBC (check Hb), U&E, cross match
- urgent laparotomy - delivery fetes and repair or remove uterus to stop maternal bleeding
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what is prognosis of uterine rupture for future?
- high recurrence rate
- next pregnancy needs EARLY CS
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what is uterine inversion?
when fundus inverts into uterine cavity
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when does uterine inversion usually happen?
after traction on the placenta (3rd stage labour)
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what are 3 signs of uterine inversion?
- bleeding
- profound shock
- pain
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what is Rx of uterine inversion?
- 1st brief attempt to immediately push fundus up via vagina
- if impossible - then GA given and replace with hydrostatic pressure of several litres of WARM SALINE - run past a clenched fist at the introits into the vagina
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what is cord prolapse?
- after ROM
- cord descends below the presenting part
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what happens if cord prolapse is untreated?
- cord will be compressed or go into spasm
- baby becomes HYPOXIC
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what is prevalence of cord prolapse?
1 in 500
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what are 5 risk factors for cord prolapse?
- preterm labour
- breech presentation esp FOOTLING
- polyhydramnios
- multiple pregnancy
- abnormal lie - tranverse
- maternal causes: pelvic mass eg fibroid, contracted pelvis
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what may cause cord prolapse?
artificial ARM
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when is diagnosis of cord prolapse made?
- FHR abnormal
- cord palpated vaginally or appears at introits
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what has reduced incidence of cord prolapse?
widespread practice of delivering breech by CS
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why do you get asphyxia in cord prolapse? 2 reasons
- compression of cord between presenting part and bony pelvis
- spasm of cord vessels when exposed to cold/manipulations
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what is management of cord prolapse?
- HELP - emergency buzzer, obs spr, SHO, paeds, anaesthetist
- check if fetes is viable - scan to confirm fettle heart present
- DO NOT FEEL CORD FOR PULSATIONS
- if viable
- then do VE to see if fully dilated
- if fully and head is low - then consider ventouse delivery
- if not fully then push up presenting part to prevent compression
- fill bladder
- if fettle bradycardia = tocolysis 2 puffs salbutamol
- transfer to theatre ASAP - monitor FHR all times and prior to CS
- if FH stable and bladder filled, can have spinal anaesthetic
- release bladder clamp at skin incision
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what to do after Rx for cord prolapse?
- cord gases
- documentation
- debrief woman
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what is amniotic fluid embolism?
when liquor enters the maternal circulation
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what are symptoms of AF embolism?
- sudden dyspnoea
- hypoxia
- hypotension
- seizures
- cardiac arrest - acute heart failure
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what % die in AF embolism?
80%
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what are complications of AF embolism?
- DIC - consumptive coagulopathy so can bleed
- pulmonary oedema
- ARDS
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when does AF embolism occur?
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what are risk factors for amniotic fluid embolism?
strong contractions in presence of polyhydramnios
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what is prevention?
impossible!
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what is Rx of AF embolism
- ABC, resus
- fluids
- oxygen
- bld tests: FBC U&E clotting screen cross match!!
- need to give blood and ffp
- transfer to ITU
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what is eclampsia?
convulsions superimposed on pre-eclampsia
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what is Rx of eclampsia?
- help: senior obs, anaesthetist, senior MW, paeds, scribe
- ABC
- A: left lateral, maintain patent airway
- B: oxygen, ventilation
- C: call arrest team if needed - start CPR
- iv access
- PET bloods: FBC LFT U&E clotting uric acid, G&S, cross match
- control seizures: MgSO4 loading dose then maintenance dose
- if fails consider diazepam
- monitor vital obs, patellar reflexes - reduced but should be present - stop infusion if reflexes absent (MgSO4 toxicity!)
- Rx HTN: labetolol, hydralazine, nifedipine
- deliver baby: MDT effort.
- DO NOT USE ERGOMETRINE
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what is antidote for MgSO4?
calcium gluconate
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What are the 4 things that should happen after any obstetrics emergency?
- cord gases
- document: staff attended, what done
- debrief woman
- risk management form
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