intestine obstraction

1. OBSTETRICAL EMERGENCY MANAGEMENT
BY: Andualem Gezahegn
Lecturer, SLU
June, 2023

2. UTERINE
RUPTURE

3. OBJECTIVES
 At the End of the class the students are able
 To know the symptoms of Uterine Rupture
 To Diagnose Uterine Rupture
 To manage uterine Rupture

4. UTERINE RUPTURE
Definition
 Ruptured uterus is a tear in the wall of the uterus
which commonly occurs in the lower segment of the
uterus.
Types
 The tear could be anterior, posterior, lateral or
combination of these. It could be transverse,
vertical or combination of these.
 Ante partum rupture commonly follows a classic CS
scar, VBAC or scars of other gynecologic operations.

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 Rupture of the uterus is classified in to two categories.
1. Complete (true):
 The tear extends through the whole thickness of the uterus
including the myometrium and the peritoneum so that there is
free communication with the peritoneal cavity.
2. Incomplete (occult):
 The tear extend through the myometrium but not through the
overlying peritoneum
 No free communication with the general peritoneal cavity

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Causes
 By far the commonest cause of uterine rupture is
 Neglected obstructed labor especially in multipara.
 Dehiscence of a previous cesarean section scar.
Other causes include:
 Oxytocin or prostaglandin
 Difficult instrumental delivery like high or mid forceps
 Difficult destructive delivery
 Internal podalic version and breech extraction
 Difficult manual removal of placenta
 Other surgical scars on the uterus (repaired ruptured uterus,
myomectomy)
 Vigorous fundal pressure and sharp penetrating trauma

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Clinical features:
 Diagnosis is usually made using clinical symptoms and
signs.
 Clinical features are variable and are largely dependent on:
• the time elapsed after the rupture
• the Site and extent of the rupture
• the degree of fetal and placental extrusion (the degree of
Intra peritoneal spill) and
• the tamponade effect offered by the fetus.
 Therefore, a high index of suspicion is needed for
diagnosis for those not presenting classically.

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The usual symptoms of impending (imminent) uterine rupture:
• Worsening abdominal pain especially suprapubic persisting
between contraction
• Strange feeling of the fetus moving upwards
The usual symptoms (practical) in uterine rupture include:
• Sudden cessation of contraction and fetal movement
• Sharp tearing pain with contraction
• Temporary relief of pain followed by diffuse continuous
abdominal pain
• Variable degree of vaginal bleeding
• Gross hematuria in anterior wall rupture with bladder rupture

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 The clinical signs are also variable and include:
• Normal vital signs to profound shock
• Variable pallor
• Variable abdominal tenderness and distension
• Absent uterine contraction and fetal heart beat
• In anterior rupture, defect in the uterine wall and easily
palpable fetal parts
• Variable shifting dullness
• Fetal presenting part may be jammed or retracted
Feeling a defect on vaginal examination or seeing the
defect at laparotomy makes definitive diagnosis of
uterine rupture.

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Management
 Includes
A. Supportive Management
B. Definitive Management
 The life of the patient depends:
 On the speed and efficacy with which hypovolemia is
corrected
 Hemorrhage is controlled and
 Infection is treated.
 Early referral should be made In places where
surgical intervention cannot be provided

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A. Supportive Management
 Objective is initiation of treatment and laparotomy.
 Components:
 Opening intravenous line with wide bore cannula.
 Vigorous infusion of crystalloids.
 Initiation of parenteral antibiotics
 Performing laboratory tests for hemoglobin and blood group/RH
status.
 Preparing at least two units of cross matched blood.
 Inserting naso-gastric tube and Foley catheter.

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B. Definitive Management
 Immediate laparatomy should be performed.
 The surgical options include
• Repair of the rupture with bilateral tubal ligation
• Sub-total abdominal hysterectomy
• Total abdominal hysterectomy

13. Counseling:
 Counseling about future pregnancy:
Your suggestion on
when to have a pregnancy?

14. Counseling about future pregnancy
If the rupture occurs
1.At the uterine fundus
 Testing fetal lung maturity at 34-35weeks then
 if the test is +ve delivery by C/S
 If the test is –Ve giving corticosteroids then delivery by c/s after
48 hrs.
NB- but the severity of Prematurity is very high
Admitting the mother and waiting until 37 weeks and delivery by
CS is the best. But labor shouldn't be started and we should
decide emergency c/s irrespective of Gestational Age if the
women feels any symptoms
2.Lower Uterine Segment- Admitting the mother and delivery
by C/S at 37 weeks is best

15. SHOULDER DYSTOCIA

16. SHOULDER DYSTOCIA
Definition:
 is a difficulty in shoulder delivery.
Incidence:
 about 0.5% of deliveries.
Causes:
1. Large shoulders which may be due to :
o Maternal obesity.
o Diabetic mothers.
o Post-term pregnancy.
o Anencephaly.
2. Failure of shoulder rotation.
3. Contracted and platypelloid pelvis.

17. Prediction:
1. Presence of risk factors of macrosomia.
2. Ultrasonographic assessment of foetal weight.
Clinical Picture:
 The head is delivered and the chin is applied
firmly against the perineum.
 There is no further progress in spite of gentle
traction on the head.

18. Management:
(A) Prophylaxis:
 Proper antenatal care particularly for risky
mothers i.e diabetics.
 Antepartum assessment of foetal weight
(macrosomic babies should be delivered by
caesarean section).

19. (B) of shoulder dystocia:
 Calling urgently an anesthetist and pediatrician.
The following methods are used in a rapid
succession when the previous one failed:
(1) Rotation of the anterior shoulder :if unrotated by
fingers transvaginally to bring it in the antero -
posterior diameter.
(2) Generous episiotomy + gentle downward
traction + suprapubic pressure by an assistant
obliquely to flex the anterior shoulder against the
foetal chest.

20. (3) Mc Roberts' manoeuvre:- is sharp flexion of the
maternal thighs against her abdomen. This can
free the shoulders by:
i- backward displacement of the sacral promontory.
ii- upward displacement of the symphysis pubis.
iii- Decrease the inclination of the pelvic inlet.
iv- Decrease in lumbar lordosis.

21. 4) Woods screw manoeuvre:
Woods (1943) described this manoeuvre to rotate the
foetus as a screw between the resisted promontory
and symphysis.
 Two fingers of the right hand is pressing from the
posterior aspect of the posterior shoulder to rotate
it 180o anteriorly where it escapes from below the
symphysis.
 The left hand is placed on the mother’s abdomen
and assists this rotation by pressing on the foetal
buttock in the same direction of rotation.

22. Cont…
(5) Extraction of the posterior arm:by pressing with 2 fingers
against the cubital fossa to sweep the posterior arm in
front of the chest and deliver it giving space for the
anterior shoulder to escape from below the
symphysis.This is aided by suprapubic pressure.
(6) Zavanelli manoeuvre (cephalic replacement):
1. Prepare for caesarean section.
2. Subcutaneous terbutaline (tocolytic) is given to relax the
uterus.
3. Rotate the head manually to the antero-posterior diameter
(pre-restitution position).
4. Flex the head and press on it firmly and constantly to
replace it intravaginally where it is supported by an assistant
5. Immediate caesarean section is performed

23. 7) Clavicular fracture:
 was described to reduce the diameter of the
shoulders. It is done by upward pressure against its
midportion to avoid injury of the subclavian
vessels.
(8) Cleidotomy:
 It is cutting of the clavicle and usually reserved for
a dead foetus.
(9) Symphysiotomy:
 It is advocated by some authors to overcome
contracted pelvis in women living in uncivilised

24. Complications:
(I) Foetal :
1. Asphyxia and death.
2. Brachial plexus injury causing Erb's palsy.
3. Fracture clavicle or humerus.
(II) Maternal :
 Injuries from manoeuvres which may extend up
to rupture uterus.

25. THANK YOU!