Case scenario in obstetric emergencies for undergraduate

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• CASE SECNARIO IN OBSTETRIC EMERGANCIES

Prepared by Dr MANAL BEHERY ASSISTANT PROFESSOR
Zagazig University
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Definition of Obstetrical Emergencies

• Life -or -death situation
• Infrequent, unanticipated, unpredictable
  nightmare

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Case 1Shoulder dystocia
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20 years G2P1, with diabetes, 42 wks pregnant,
and her first baby was 9 lbs. Now fully dilated
and pushing

• Head delivers, then retracts
• tightly against the
• perineum
• turtle sign

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NOW WHAT?

• A. Panic
• B. Hide
• C. Drop out apply for dermatology
• D. Be a Hero

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Be a Hero

• CALL FOR HELP!
• Stop Pushing!
• McRoberts
• Suprapubic CPR
• Episiotomy?
• Maneuvers
• Roll patient
• Clavicle Fracture
• Symphysiotomy

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McRobertsSuprapubic CPR
McRoberts Suprapubic CPR
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How McRoberts work?

• hyperflexion of maternal hips
• Increases intrauterine pressure
• (1,653mmHg - 3,262 mmHg)
• Increases amplitude of contractions
• (103mm Hg to 129mm Hg)

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Episiotomy?

• Provides extra hand room for maneuvering.
• Does not help with the body impaction.

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Maneuvers

• 1. Rubin II
• 2. Ruben II
• Woods
• Corkscrew
• 3. Reverse Woods Corkscrew

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Rubins Maneuver

• Adduction of the most accessible shoulder
• Moves the fetus into an oblique position and
  decreases the biacromial diameter

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Woods Cork Screw Maneuver

• Abduct posterior shoulder exerting pressure on
  anterior surface of posterior shoulder

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Deliver posterior arm(Barnum Maneuver)

• grasp the posterior arm and
• sweep it across the anterior
• chest to deliver

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All-Fours Maneuver(Gaskin Maneuver

• Roll Patient
• Can increase
• outlet by 20
• mm.
• Apply downward traction to disimpact post
  shoulder

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Suprapubic Pressure

• direct posterior or oblique suprapubic
• pressure

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Zavanelli Maneuver

• cephalic replacement via reversal of the cardinal
  movements of labor

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Clavicular Fracture

• Fracture the anterior clavicle by pushing it
  against the pubic ramus or using a closed pair of
  scissors

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Symphysiotomy()

• Foley
• Betadine
• 20 or 21 blade, cut till it opens

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To easy remember

• Help obstetrician, pediatrician
• Episiotomy
• Legs elevate (McRoberts)
• Pressure - suprapubic
• Enter vagina Rubins and Woods screw
• Roll or Remove posterior arm
• Zavanelli, Clavicular , Symphysiotomy

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Case Two Cord Prolapse
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• 22 years G1 at 34 wks, contractions every 5 min,
  and felt a gush of fluid immediately prior to
  arrival in ER.
• Cervix exam reveals 6cm dilation and a prolapsed
  umbilical cord.

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Cord Prolapse - Who it happens to

• Malpresenations
• Prematurity
• Abnormal fetus
• Placenta previa

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WHAT to do?

• Lift presenting part off the cord
• Relieve pressure
• Gently place cord in vagina
• (Cold air rough handling causes spasms)
• Gently palpate cord for pulsations
• Instruct NOT to push

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Position the patient

• Knee chest Trendelenburg

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Management (cont..)

• Full bladder
• Vulval pad
• Replacement of cord
• Tocolysis (ritodrine)
• Forceps (Cx fully dilated)
• Second twin internal podalic version and breech
  extraction
• Stat C-section
• Occult Aminoinfusion

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Case 3 Breech Delivery
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• 24 years female G1 at 32 wks, SROM, in labor.
• Cervix is dilated to 7cm.
• You palpate feet.

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What do you do?
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Go Slow

• If not fully dilated,
• no pushing.

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Once belly button shows, help deliver
legsHip flexion with external rotationKeep
slack on umbilical cord
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Deliver Shoulders

• Once scapulas show, help deliver arms
• Sweep arms over chest
• Rotating baby may help

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Delivery of the Head

• Deliver head (2-3 minute window)
• Mauriceau-Smellie-Veit maneuver
• Suprapubicpresure

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Pay attention to

• The good
• Using a towel
• Hooking the shoulders out
• Hand position during head delivery
• The Bad
• Didnt use suprapubic pressure
• Take your time, traction is bad

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• CASE 4
• Inversion Of The Uterus

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• Mother in third stage of labour. Using the
  controlled cord traction, the midwife tries to
  deliver the placenta. Unfortunately, notices the
  descent of uterus instead of placenta.

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Uterine Inversion

• Most commen Causes
• Fundal attachment of placenta (75)
• uterine atony (40)
• Short cord
• Placenta accreta
• Excessive cord traction

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What to do ?

• Treat hypovolumia
• Uterine relaxant(terbutaline 0.25 mg) iv followed
  by 2 g of mgso4 over 10 min)

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Without placenta

• Repositioning

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Repositioning
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With placenta

• Do not remove placenta
• 2.Replace uterus
• 3.Bimanual compression
• 4.Hydrostatic pressure
• 5.Start oxytocin
• 6.Laparotomy

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• CASE 5
• Rupture Uterus

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• A mother in second stage of labour
• suddenly complains of persistent pain, and
  bleeding per vagina becomes profuse and the
  monitor shows decelerations in fetal heart rate.

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• Incidence 1/2000 deliveries
• Types
• Complete
• Incomplete
• Rupture Vs
• Dehiscense of
• C.S scar

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Causes during delivery

• Internal version
• Difficult forceps delivery
• Breech extraction
• Difficult manual removal of placenta
• Fetal anomaly
• Acquired
• Placenta increta / percreta
• Retroverted uterus (sacculation)

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How to Diagnose?

• Prolonged fetal decelerations (70.3)
• Bleeding (3.4) Pain (7.6)
• Monitor tracing demonstrating fetal heart rate
  decelerations, increase in uterine tone, and
  continuation of uterine contractions in a patient
  with uterine rupture monitored with an
  intrauterine pressure catheter.

Monitor tracing demonstrating fetal heart rate
decelerations, increase in uterine tone, and
continuation of uterine contractions in a patient
with uterine rupture monitored with an
intrauterine pressure catheter.
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How to Manage?

• Simple repair
• Total Hysterectomy
• Sub total hysterectomy

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a

• CASE 6
• Placenta accreta

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• Mother has just delivered a male baby. You
  wait for 30 minutes But no signs of placental
  separation and descent is present. Manual removal
  fails.

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• Incidence 1 in 2,562 deliveries
• Firm adherence of placenta to uterine wall
• Placenta increta Villi invade the myometrium
• Placenta percreta Villi penetrate myometrium

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Most common risk factors

• placenta previa
• Previous cesearean scar
• uterine curettage
• Grand multiparity

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How to manage

• Abdominal exploration
• Uterine artery ligation
• Hysterectomy

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• CASE 7
• AMNIOTIC FLUID EMBOLISM

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• A pregnant mother on oxytocin induction suddenly
  becomes short of breath and tachypneic. Vital
  signs drop and the patient goes into asystolic
  arrest.

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Amniotic Fluid Embolism
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• Incidence 1 in 3,500 to 1 in 80,000
• Amniotic fluid enters the maternal circulation
  and reaches pulmonary capillaries through a tear
  in amnion and chorion
• Opening in maternal circulation
• Increased intrauterine pressure

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What are risk factors?

• Multiparity
• Large fetus
• Meconium in amniotic fluid
• Intrauterine fetal death
• Precipitate labour
• Placental abruption
• Intrauterine catheter
• Rupture of uterus

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Manifestations

• Phase I
• Pulmonary vasospasm
• Hypoxia
• Hypotension
• Cardiovascular collapse
• Phase II
• Left ventricular failure
• Pulmonary edema
• Hemorrhage
• Coagulation disorder

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How to manag?

• Intubation Mechanical ventilation
• CVP monitoring
• Blood transfusion I.V. Fluids
• Dopamine 2-20mg/kg/min
• IV Digitalization (0.1 - 1.0mg)
• Prostaglandin
• Morphine
• Aminophylline
• Hydrocortisone

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Be prepared, except the unexpected and above
all, communicate

• Communicate
• Careful, sympathetic and
• optimal communication
• Avoid medical jargon
• Psychological support- one member - Touch
• Talking through the process
• Smile of reassurance
• Information and support to partners

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Thank you