Why these key questions: -Term/post-dates/macrosomia/diabetes/Maternal obesity: Increased risk of shoulder dystocia. -Preterm deliveries: increased risk of breech/prolapsed cord/ precipitous delivery/ sick fetus. -
Posterolateral placement of the episiotomy decrease the risk of
Childbirth emergencies (2)
Emergencies of Childbirth
Daniel J. Bartgen
Who its happened to. ..
° Indiana Community ER: 2-3 per month
° Christ ER: 4 last yr
° Edwards Hospital: 1 in past 6 yrs
° Colleen Crowe: 2 in first yr
- Chicago paramedic: 1-2 per shift
- ER doc volunteered 1 yr in Guatemala: 40-50
Complications encountered by attendings. ..
Shoulder dystocia, nuchal cords, breech, footling breech,
perimortumc-sections, preemies, twins, retained
placentas, cord prolapse
FOR MOM FOR BABY
- OB KIT - Pediatric Airway Box
- Scissors - Pediatric Code Cart
' Hem°5tat5 ° Key things for baby
— Towels/ Drapes _ En. tube
— Sterile gloves _ 3_5if; erm
_ Alc°h°l ° 3ifpreemie
— Bulb suction _ Laryngoscope:
° 00 if preemie
— Neonatal suction: respiratory
takes care of this.
Key Questions. ..
Term/ Preterm/ Post-dates?
G's and P's?
Size of fetus? Diabetes?
Case 1: 20 yo 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 = the dreaded "turtle sign”
* NOW WHAT?
A. Panic p 1
B. Hide :
C. Drop out & apply
D. Be a Hero
CALL FOR HELP!
Last ditch efforts
— Clavicle Fracture
Be a Hero
s Provides extra hand
room for maneuvering.
'4' Does not help with the
- ‘ * —* . . ii-. ~;; _§-‘
?§Lll”J7li’i; i l l
. F§! ..Iil+‘, %Ei'. ".l ll —->
‘l. .tl. il't§)! €;I. €§i+: §
At vaginal examination apply pressure as
indicated. If shoulders move into the oblique
diameter, attempt delivery.
Rubin II + Woods corkscrew maneuver
If unsuccessful, add the Woods corkscrew
maneuver and continue rotation in the same
direction. Use both hands and apply pres-
sure as indicated. If shoulders now move
into the oblique, attempt delivery. If this is
unsuccessful, continue rotation 180 degrees
Reverse Woods corkscrew maneuver
If the last maneuver is unsuccessful, change
to reverse Woods corkscrew maneuver. Slide
fingers down to back of posterior shoulder
and attempt 180-degree rotation in the
ii: ;:r': : Rubin I = suprapubrc pressure.
Desperate Times Call for Desperate Measures
(assuming no OB backup)
- Clavicle cracking time (just push on them)
— Lido w/ epi
— # 20 or 21 blade,
cut till it opens
- If OB backup,
Zavanelli then OR
doi: l 0.1 3 7 l / journal. pmed. O040071 . g0O1
OB Blooper #1
° Who was involved in the following conversation?
— Doctor: So you are 30 wks pregnant?
— Woman: No, my sister who is in the bathroom is 30 wks
pregnant, do I look pregnant?
— Doctor: No, but this is awkward, so I'll come back later.
A: Dan Bartgen B: Jess Sinnot C: Vijay Menon D: Christian Badillo
: M _ r_ )1
Case Two — Cord Prolapse
- 22 yo female G1 at 34 wks, contractions q 5
min, and felt a gush of fluid immediately prior
to arrival in ER.
° Cervix exam reveals 6cm dilation and a
prolapsed umbilical cord.
Cord Prolapse - Who it happens to. ..
**THESE BABIES ARE S| CKER**
**10—20% Perinatal morta| ity**
Cord Prolapse - What to do. ..
6: Relieve pressure
° Gently place cord in vagina
- Cold air & rough handling causes spasms
* Gently palpate cord for pulsations
6 Fill bladder
6 If pulsations, go to OR
° No pulsations, deliver
Questions on Case 2
o ‘P? ?'? ??'P? ?'P? ‘PT? ‘PT? 'P'P? 'P'P? ?'P'P'P'P'P? 'P’P'P? 'P? ?'P? 'P
OB Blooper # 2
s Q: Which of the following residents attempted
to palpate the cervix though the rectum?
A: Dan Bartgen B: JoE| lenChannon C. Mark Hinton D: Big Party Riccardi
1"? ’/: ‘A"‘i’sD'(£/13/""‘? §) -
x <~. .2
‘Q, 3/ . ‘.2?’ l I
‘Y ‘:5 F. (
A a _r' y_. - . .
. . 1.7 f, ‘ _ ‘
‘ _ .
_ _ , _‘i l
‘W . ,5 ’ / .
. - / . y
1’ ’ /
' I; _ l
Last Case — Breech Delivery
24 yo female G1 at 32 wks, SROM, in labor.
Cervix is dilated to 7cm.
You palpate feet.
What do you do? *- ~
- Limb fractures
° C-spine and brachial plexus injuries
° Increased risk of cord prolapse prior to delivery
° Delivery of head naturally compresses cord
**THESE BABIES ARE S| CKER**
* If not fully dilated, no pushing.
0 Once belly button shows, help
— Hip flexion with external rotation
— Keep slack on umbilical cord
° Once scapulas show, help deliver arms
— Sweep arms over chest
— Rotating baby may help
Delivering the Head
- Deliver head (2-3 minute window)
— Mauriceau-Smellie-Veit maneuver
- Pay attention to. ..
° The good
— Using a towel
— Hooking the shoulders out
— Hand position during head delivery
- The Bad
— Didn't use suprapubic pressure
— Take your time, traction is bad
http: //www. youtube. com/ watch? v=DHF08Au LiUc
Take Home Points
Expect the worst, be prepared.
Shoulder dystocia: Turtle sign. McRoberts and
suprapubic CPR is key. Lots of techniques,
Prolapsed cord: relieve pressure, check for
pulsation, keep cord warm, get to OR.
Breech delivery: relax, don't pull.
The cervix is located in the vagina, not the
Ouzounian JG, Korst LM, Ahn MO, et al. Shoulder
dystocia and neonatal brain injury: significance of the
head—shou| der interval. Am J ObstetGyneco|
I Baskett, Thomas. Essential Management of Obstetric
Emergencies. Clinical Press Limited, 2004.
http: // primary -surgery. org
Gabbe: Obstetrics: Normal and Problem Pregnancies,
Tintinelli, Judith. Emergency Medicine, A
comprehensive study guide. 6"‘ Ed.