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OBSTERIC EMERGENCIES

PHASE 4 LECTURE
DR HAKIM GHARIB BILAL
UNIKL RCMP

Cord prolapse
Definition, predisposing factors, fetal complications,
management including prevention.

Shoulder dystocia
Definition, incidence, associated factors, complications to
mother and fetus, management including prevention

Uterine inversions
Types, causes, symptoms & sign of uterine inversion,
complications to mother, management (manual reduction,
hydrostatic and surgical method) and prevention.

Diagnosis and management of cord prolapse,


shoulder dystocia and uterine inversion

LEARNING OBJECTIVES
Aim: To guide students to understand
obstetrics emergencies (e.g. cord prolapsed,
shoulder dystocia & uterine inversion)

Objectives:
To discuss and recognize obstetric
emergencies (cord prolapsed, shoulder
dystocia & uterine inversion)
To manage cases accordingly and know the
complications

SHOULDER DYSTOCIA
It is defined as the need for
additional obstetric maneuvers to
release the shoulders after gentle
downward traction has failed
(RCOG)

Risk factors
Maternal: GDM, Short stature,
Previous
shoulder dystocia,
Obesity
Fetal
: Macrosomia, post
maturity
Intrapartum: Prolong labour,
intrumental delivery

Pathophysiology
Size discrepancy between fetal
shoulders and maternal pelvic inlet
Macrosomia
Large chest:BPD
Absence of truncal rotation
Fetal shoulders remain A-P or descent
simultaneously

Video illustration

Risk Factors
Antepartum
Macrosomia (>4500g)
DM/GDM (increases overall risk by 70%)
Multiparity

Intrapartum

Prolonged deceleration phase of labor


Prolonged 2nd stage
Protracted descent
Operative delivery (vacuum>forceps)

Risk factors cont


No evidence based data:

Male
AMA
Short maternal stature
Abnormal pelvic shape/size

Unpredictable
25-50% have no defined risk factor!
50% of cases occur in infants whose
birth weight is <4000g
84% of patients did not have
prenatal dx. of macrosomia by US
82%of infants with brachial plexus
palsy did not have macrosomia

Complications
Maternal
Hemorrhage
4th degree laceration

Fetal
Fx of humerus or clavicle
Brachial plexus injury (Erbs/Klumpkes
palsy)
Asphyxia/cord compression

Physician
Litigation: 11% of all obstetrical suits

Management
Goal: Safe delivery before neontal
asphyxia and/or cortical injury

Episiotomy
Suprapubic Pressure
McRoberts Maneuver
Woods or Rubin Maneuvers
Zavenelli
Push back the delivered fetal head into birth
canal and perform an emergent c/s

HELPER Algorithm
H: Call for Help; Shoulder dystocia is
called if shoulders cannot be
delivered with gentle traction
E: Evaluate for Episiotomy: Not
routinely indicated; maybe needed
when attempting intra-vaginal
maneuver
L: Legs (McRoberts): Hyperflexion
and abduction of hipsinitial
maneuver

HELPER Algorithm cont.


P (Suprapubic Pressure): No fundal
pressure; combination of McRoberts and
suprapubic pressure resolves most
shoulder dystocias
Enter (Internal Maneuvers):
Woods: Insert hand into posterior vagina and
rotate posterior shoulder clockwise or
counterclockwise
Rubin: Push posterior or anterior shoulder
toward fetal chest to adduct shoulders

Remove: Delivery posterior arm

McRoberts Maneuver
42% success rate
+ Suprapubic pressure = 54-58%

Brings pelvic inlet and outlet into more vertical


alignment
Flattens sacrum
Cephalad rotation of pubic symphysis
Elevates anterior shoulder and flexes fetal
spine
Increases IUP by 97%
Increases amplitude of contractions
+31N of pushing force

Video illustration

Cork Screw Method

Video cork screw manoevre

COMPLICATIONS OF SHOULDER
DYSTOCIA
Maternal
Postpartum hemorrhage
Third- or fourth-degree episiotomy or tear
Uterine rupture

Fetal

Brachial plexus palsy


Clavicle fracture
Fetal death
Fetal hypoxia, with or without permanent neurologic
damage
Fracture of the humerus

Summary
Cannot accurately predict
BE PREPARED!
Consider risk factors
Be prepared to perform various
maneuvers
Diagnose and treat quickly
Obtain assistance from nursing staff and
NICU

CORD PROLAPSE
Umbilical cord presentation is
defined as the presence of umbilical
cord below the fetal presenting part
when the membranes are intact.
Cord prolapse is the presence of the
cord below the presenting part when
the membranes are ruptured.

Cord presentation and Cord


prolapse

INCIDENCE
It has an incidence of 1:500
deliveries and it occurs when the
fetal presenting part does not fit well
into the maternal pelvis.

Risk factors
Maternal causes
- Pelvic tumours ( fibroid in the lower segment)
- Narrow pelvis
Fetal causes
- Malpresentation
- Multiple pregnancy
- Polyhydromnios
- Placenta praevia,
- large baby
- Prematurity

Diagnosis of cord prolapse


It is diagnosed by seeing the cord at
the introitus, or feeling it during
vaginal examination.
Abnormal fetal heart rate may
suggest it; variable deceleration and
bradycardia on CTG following rupture
of membrane.

Prevention
Ultrasound examination for
malpresentation and cord
presentation.
Avoid ARM in unengaged head.
Routinely doing VE following
spontaneous ruprture of membranes
Controlled ARM in poluhydromnios
stabilizing induction.

Management
Avoid pressure on presenting part over
the cord by digital or manual pressure,
minimmal handling of the cord.
Instruct the patient not to push.
Tocolysis; Terbulaline subcut?
Bladder filling with 500ml saline
Positioning of the patient:
-Knee chest position
-Trendelenburg position

Emergency C/ section is required


unless if the cervix is fully dilated
and assisted delivery can be easily
and safely performed.

UTERINE INVERSION
It is a rare complication occuring
during the third stage of labour.
Incidence is between 1:2000 and
1:6000
The uterine fundus descends either
to the cavity or through the cervix
and veru rarely through the introitus

Etiology
It is caused by traction on the
umbilical cord before the placenta
has seperated and can occur after
after vaginal delivery or C/ section
It has also been associated with a
short cord, a fundal placenta and a
morbidly adherent placenta.

Diagnosis
The prolapsed uterus stretching the
cervix causes vagal stimulation, thus
the women will demonstrate signs of
cardiovascular collapse and shock.
Haemorrhage maybe present however
the symptoms maybe out of proportion
to the estimated blood loss.
The inverted uterus maybe obvious at
the introitus.

Other signs
- Lack of palpable uterus in the
abdomen or the feeling of a dimple
in the uterine fundus on abdominal
examination.

MANAGEMENT
Resuscitate the patient using the structured
ABC approach.
It is very important not to remove the placenta
if it is still attached.
Replace the uterus through the cervix through
manual compression.
If that failed, hydrostattic pressure can e applied
by pouring warm saline into the vagina, usually
via a silc cup ventouse.
Tocolytic maybe helpful to relax the cervical ring

Management
Surgery, to reposition the uterus
from above should be used as a last
resort.
After replacement uterine contraction
is maintained with an oxytocin.

Video illustration

THANK
YOU