Management of Shoulder Dystocia - HELPERR
H - HELP - note time of delivery of head, call for help, state clearly ‘this is a shoulder dystocia to arriving team’, attempt manoeuvers for 30 seconds, obstetrical/ surgical/ neonatal/ anaesthetic back up
E - EVALUATE FOR EPISIPOTOMY
L - LEGS - McRoberts Manoeuvre: Position - draw mother’s bottom to the edge of the bed, flatten top of bed, flex and abduct maternal hips with knees to nipples (straightens lumbosacral lordosis, increases AP diameter of pelvis and flexes fetal spine –> reduces 40% of shoulder dystocias)
P - PRESSURE - assistant applies suprapubic pressure (Rubin I) which should adduct anterior shoulder
E - ENTER - Internal Manoeuvres:
- Rubin II - approach anterior fetal shoulder from behind and exert pressure on scapula to adduct and rotate to oblique position
- Wood Screw Manoeuver - approach posterior fetal shoulder from the front and gently rotate shoulder towards symphysis
- Reverse Woods Screw - approach posterior shoulder from behind and rotate fetus in opposite direction
R - REMOVE POSTERIOR ARM - follow posterior arm down to elbow (usually anterior to fetal chest), flex arm at the elbow, sweep forearm across fetal chest and deliver posterior arm
R - ROLL THE WOMAN - onto all-fours McRoberts position which increases pelvic diameters + movement and gravity may dislodge impaction. Deliver posterior shoulder with gentle downwood traction, may attempt all “ENTER” manoeuvres in this position. (can’t to this if maternal obesity or epidural in place)
LAST RESORT - Zavanelli manoeuvre, clavicle #, symphysiotomy
Risk factors for shoulder dystocia
Shoulder dystocia is impaction of the anterior shoulder against the symphysis after birth of the fetal head. Incidence is increased with birth weight but >50% occur in normal weight infants Risk Factors: - previous shoulder dystocia - GDM - Post dates - macrosomia - maternal short stature - obesity pre-pregnancy + excessive weight gain during pregnancy - abnormal pelvic anatomy - prolonged 1st or 2nd stage - "Head bobbing" in 2nd stage - Instrumental vaginal delivery
Complications of Shoulder Dystocia
Maternal
- soft tissue injuries
- anal sphincter damage
- PPH
- Uterine rupture
- Symphyseal separation
Fetal Complications
- brachial plexus palsy
- Clavicular #
- Humeral #
- Fetal acidosis
- Hypoxic brain injury, Cerebral Palsy
- Death
RIsk Factors for PPH
- Pre-eclampsia
- Nulliparity
- Multiple gestation
- Previous postpartum haemorrhage
- Previous caesarean delivery
- High parity
- Induced &/or augmented labour
- Infection eg., chorioamnionitis
- Arrest of descent
- Assisted delivery (forceps, vacuum)
- Prolonged third stage (>30 minutes)
- Mismanagement of 3rd stage
- Episiotomy
- Lacerations (cervical, vaginal, perineal)
- (Retained 3rd stage)
Causes of PPH - the four ‘T’s
- Tone (70%)
- Trauma (20%)
- Tissue (10%)
- Thrombin (1%)
PPH Management (Blood loss >500mL and/or haemodynamic compromise)
RESUS - call for help, ABCs, insert 2 large bore IVs, O2, lab cross-match + FBC + coags, assess blood loss, consider fluids/transfusion, fundal massage, bimanual compression
TREAT CAUSE
- TISSUE: retained placenta - do not massage fundus, give oxytocics, apply CCT and attempt delivery, post delivery check placenta is complete, transfer to OT for manual removal +/- currettage
- TONE: Uterine atonia - fundal massage, give oxytocic, expel uterine clots, ensure bladder is empty, administer 1st line drugs (Oxytocin/Syntocinon, Ergometrine or Misoprostol PR), admisister 2nd line drugs (Intramyometrial PGF2 alpha). Consider OT management - intrauterine balloon tamponade, angiographic embolisation, laparotomy - B-Lynch suture, uterine artery ligation, hysterectomy
- TRAUMA: genital tract inspection (cervix, vagina, perineum), clamp obvious arterial bleeders, repair (secure apex), transfer to OT is unable to see/access trauma site
- THROMBIN: coagulopathy - send baseline bloods (FBC, coags, ELFTs, ABG, Ca), do not wait for results to treat, give RBC, FFP, platelets, cryoprecipitate is fibrinogen low, Calcium gluconate if calcium is low, avoid hypothermia and acidosis, transfer to OT to stop bleeding
- OTHER CAUSES/UNKNOWN: assess for uterine rupture + other weird causes, reassess for 4 Ts
Definition and Risk Factors for Uterine Rupture
Definition - separation of an old uterine incision with rupture of the fetal membranes so that the uterine cavity and the peritoneal cavity communicate directly. 0.05% of all pregnancies.
RFs:
- previous Classical caesarian (>5% after)
- previous LSCS (0.8% after)
- grand multiparity
- fetopelvic disproportion, malpresentation
- oxytocin stimulation
- macrosomic/ hydrocephalic fetus
- prior instrumental abortion
- uterine abnormalities
Presentation of Uterine Rupture - signs and symptoms
- abdo pain
- shock
- PV bleeding
- Fetal Distress during labour
- undetectable fetal heart beat/ fetal death
- palpable fetal body parts
- cessation of contractions
- signs of intrauterine bleeding
Diagnosis of GDM
OGTT 24-28weeks 75g
- fasting >5
- 1hr >10
- 2hr >8.5
If risk factors for GDM to a first trimester screen (2hr 75g OGTT or HbA1c)
Postpartum care for GDM Newborn
- keep warm, skin to skin contact
- prevention and detection of newborn hypoglycemia (BSL <2.6)
- early feeding within 30 - 60 mins of birth
- BSL before 2nd feed (within 3 hours of birth)
- if has not fed: BSL at 2 hours of age
- BSL monitoring every 4-6hours pre-feeds
- cease monitoring is BSL >2.6 for 24hrs, feeding well and has no other issues
Criteria for diagnosis of pre-eclampsia
BP >140/90 AND one of more of the following:
- proteinuria: >300mg in 24hr urine collection or spot PCR >30
- renal insufficiency: creatinine >80
- Liver dysfunction: elevated AST/ALT or severe epigastric/RUQ pain (thought to result from hepatocellular necrosis, ischemia and oedema that stretches the Glisson capsule)
- Neurological problems: convulsions (eclampsia), hyperreflexia with clonus, severe headaches with hyperreflexia, persistant visual disturbances, stroke
- Haematological disturbances: thrombocytopaenia, haemolysis, DIC
- Fetal Growth Restriction
- Pulmonary oedema
Risk Factors for pre-eclampsia
- primigravid (or first preg with new partner)
- increasing maternal age
- FHx
- medical problem: DM, HTN, CKD, CT disorder, thrombophilia
- multiple pregnancy
- ? Indigenous
- molar pregnancy
Management of pre-eclampsia/HTN in pregnancy >140/90
Management:
- admit for close monitoring
- detailed examination with daily scrutiny for clinical findings such as headache, visual disturbances, epigastric pain and rapid weight gain
- weight on admittance and every day thereafter
- Urinalysis for proteinuria on admittance and at least every 2 days thereafter
- BP readings (sitting) every 4hrs except from midnight to morning
- measurement of plasma or serum creatinine, hematocrit, plts, coags, LFTs - frequency depends on severity
- frequently evaluate fetal size and amiotic fluid volume either clinically or with ultrasonography
- daily CTG
- daily review by obstetrician
- consider VTE prophylaxis
- consider glucocorticoids to enhance fetal lung maturation if remote from term
- initiate antihypertensives if BP >160/100, consider if >140/90 (labetalol, methyldopa 1st line)
- consider seizure prophylaxis with MgSO4 infusion
- strict BP control and fluid management
- birth if anything is not controlled/ deteriorating/ >37 weeks
Management of eclampsia
Basically: resus, control seizures, control HTN, birth
- RESUS: ABC
- Control Seizures: IV MgSO4 loading dose + maintenance (Calcium gluconate is antidote), if seizures ongoing can give diazepam/ clonazepam / midazolam
- Control HTN if >160/100: nifedipine PO (Ca2+ channel blocker), hydralazine IV (relaxes smooth muscle), labetalol IV (combined alpha and beta blocker), diazoxide IV
- BIRTH: ASAP, close fetal monitoring, stabilize mother, do not use Ergometrine, consider VTE prophylaxis
