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Emergencies in obstetrics
- 1. Emergencies in Obstetrics Dr. Indunil Piyadigama Consultant Obstetrician and Gynaecologist Pre-intern Progam Ministry of Health, Sri Lanka 4th October 2021
- 2. • Your 1st week at the obstetric unit. You are oncall at the labour ward. 1725 the labour ward nursing sister calls you • 34 year old diabetic mother. Induction of labour at 39 weeks of getation. She was induced with prostaglandin yesterday. ARM done at 0517. Was on syntocinon for augmentation due to slow progress. • Babies head was delivered. But the body has not followed.
- 4. How would you suspect or diagnose? Difficulty with delivery of the face and chin Turtleneck sign or head remaining tightly applied to the vulva Failure of restitution of the head Failure of descend of the shoulders Routine axial traction does not deliver
- 5. What is the problem? • HIE • Injury Fetus • PPH • Tears • Damage to bladder, nerves ect Maternal
- 6. What would you do? H – Call for help E – Evaluate for episiotomy L – Legs in McRobets position P – Suprapubic pressure E – Enter the pelvis R – Roll over R – Record keeping
- 7. Initial steps Stop pushing Call for additional help No fundal pressure
- 11. Records • Medico legal issues • Contemporanous documentation • Times and the intervensions • The anterior and posterior shoulders should be documented
- 13. Breech delivery
- 14. Types of breech presentations
- 16. Steps Lithotomy position Keep your hands off the breech till anatomical landmarks appear Episiotomy – When anterior buttock climbs up the perineum until the anus is visible with a bead of meconium. Breech does not recede with contractions In complete breech maternal effort alone will deliver the legs and lower trunk Extended breech abduction at the hip and flexion at the knee is needed. Attempt the anterolateral limb and then rotate the breech so that other limb is anterolateral and perform the same manoeuver Bring down a loop of cord
- 17. Remainder of the abdomen and lower thorax should deliver with maternal effort alone. At this time fetal head will enter the pelvis causing compression of the umbilical cord. Therefore, rest of the delivery should occur within 2-3 minutes. Once the lower border of the anterior scapula is visible pass 2 finger over the shoulder and along the humerus splinting the arm across the chest Turn 90 degrees and do the same to release the other arm Should grasp the fetus at the thighs with thumbs over the sacrum and index across the iliac crest Let the body partially hang. Assistant should apply suprapubic pressure When the hairline is visible deliver the head
- 18. Important points
- 19. Uterine inversion Folding of the fundus into the uterine cavity 1 in 4000 70% placenta still attached
- 20. Types • 1-4th degree – Cervix, introitus, 4th within the vagina • Acute /Subacute (24hr to 30 days)/Chronic
- 23. How can this happen? Mismanaged 3rd stage – inappropriate traction or too rapid manual removal of placenta Squeezing the uterine fundus to deliver placenta Fundally placed placenta with a short umbilical cord Sudden increase in intra-abdominal pressure with a relaxed uterus Acute tocolysis - anaesthesia Morbidly adhered placenta
- 24. Presentation PPH Mass at the introitus Shock without vaginal bleeding - Neurogenic due to traction on adjacent structures
- 25. Management Manage shock Replace the uterus as soon as possible Manual replacement • With or without GA • May need uterine relaxants • Last part first
- 26. O’Sullivans hydrostatic technique Incising the vaginal ring via a vaginal approach Laparotomy
- 27. Thank you