1. Oops She’s Delivering! OB Workshop Module Peter Hutten-Czapski MD President SRPC ‘00-02

2. 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?

3. 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

4. Overview Rural Practice Patterns The Breech Post Partum Haemorrage The Impacted Shoulder

5. Practice Style - Emergency As community size decreases the percentage of physicians providing ER coverage increases maximal effect of 58% at under 8,000 pop

6. 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

7. Broadening Practice Patterns

8. Breech … it comes out this way?

9. Breech Types 60%30% 10%

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

11. 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%

12. 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.

13. If not… 90% require no help Let it Be ! X Extension of the head can trap it and cause spinal cord injury!

14. (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

15. 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

16. (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

17. The left arm delivers Sweep the left arm and extend the elbow Gentle rotation of the shoulder girdle facilitates delivery of the left arm.

18. 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

19. 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

20. Alternate delivery of head Piper forceps are applied from the side below the fetal trunk while an assistant supports the fetus

21. Piper Forceps The fetus may be laid on the forceps and delivered with gentle downward traction

22. Post Partum Haemorrhage The sound of blood dripping...

23. 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

24. Etiology of PPH

25. Management of PPH Call for help Airway Breathing Circulation Uterine massage Oxytocics Cause specific management

26. 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

27. Specific Treatments Lacerations - surgical repair Retained placenta - manual removal Placenta accreta - hysterectomy Uterine Inversion - prompt relocation Uterine Rupture - surgery to repair Coagulopathy - transfusion

28. Shoulder Dystocia … the pH is dropping

29. Impacted Shoulder

30. 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

31. 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)

32. 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

33. 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

34. McRoberts McRoberts and Suprapubic Pressure

35. 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

36. Rubin II Rubin Maneuver

37. 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

38. Reverse Woods Screw Woods Screw Maneuver

39. 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

40. Remove the Arm Follow posterior arm down to elbow –usually anterior to fetal chest Flex arm at the elbow

41. Remove the Arm Sweep forearm across fetal chest –grasping hand directly and pulling outward may lead to fractures

42. 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

43. Attempt to deliver posterior shoulder first Simms Position

44. 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.

45. Tocolysis helpful Immediate cesarean required Zavanelli Manouver

46. 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