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PHASE 4 LECTURE
DR HAKIM GHARIB BILAL
UNIKL RCMP
Cord prolapse
Definition, predisposing factors, fetal complications,
management including prevention.
Shoulder dystocia
Definition, incidence, associated factors, complications to
mother and fetus, management including prevention
Uterine inversions
Types, causes, symptoms & sign of uterine inversion,
complications to mother, management (manual reduction,
hydrostatic and surgical method) and prevention.
LEARNING OBJECTIVES
Aim: To guide students to understand
obstetrics emergencies (e.g. cord prolapsed,
shoulder dystocia & uterine inversion)
Objectives:
To discuss and recognize obstetric
emergencies (cord prolapsed, shoulder
dystocia & uterine inversion)
To manage cases accordingly and know the
complications
SHOULDER DYSTOCIA
It is defined as the need for
additional obstetric maneuvers to
release the shoulders after gentle
downward traction has failed
(RCOG)
Risk factors
Maternal: GDM, Short stature,
Previous
shoulder dystocia,
Obesity
Fetal
: Macrosomia, post
maturity
Intrapartum: Prolong labour,
intrumental delivery
Pathophysiology
Size discrepancy between fetal
shoulders and maternal pelvic inlet
Macrosomia
Large chest:BPD
Absence of truncal rotation
Fetal shoulders remain A-P or descent
simultaneously
Video illustration
Risk Factors
Antepartum
Macrosomia (>4500g)
DM/GDM (increases overall risk by 70%)
Multiparity
Intrapartum
Male
AMA
Short maternal stature
Abnormal pelvic shape/size
Unpredictable
25-50% have no defined risk factor!
50% of cases occur in infants whose
birth weight is <4000g
84% of patients did not have
prenatal dx. of macrosomia by US
82%of infants with brachial plexus
palsy did not have macrosomia
Complications
Maternal
Hemorrhage
4th degree laceration
Fetal
Fx of humerus or clavicle
Brachial plexus injury (Erbs/Klumpkes
palsy)
Asphyxia/cord compression
Physician
Litigation: 11% of all obstetrical suits
Management
Goal: Safe delivery before neontal
asphyxia and/or cortical injury
Episiotomy
Suprapubic Pressure
McRoberts Maneuver
Woods or Rubin Maneuvers
Zavenelli
Push back the delivered fetal head into birth
canal and perform an emergent c/s
HELPER Algorithm
H: Call for Help; Shoulder dystocia is
called if shoulders cannot be
delivered with gentle traction
E: Evaluate for Episiotomy: Not
routinely indicated; maybe needed
when attempting intra-vaginal
maneuver
L: Legs (McRoberts): Hyperflexion
and abduction of hipsinitial
maneuver
McRoberts Maneuver
42% success rate
+ Suprapubic pressure = 54-58%
Video illustration
COMPLICATIONS OF SHOULDER
DYSTOCIA
Maternal
Postpartum hemorrhage
Third- or fourth-degree episiotomy or tear
Uterine rupture
Fetal
Summary
Cannot accurately predict
BE PREPARED!
Consider risk factors
Be prepared to perform various
maneuvers
Diagnose and treat quickly
Obtain assistance from nursing staff and
NICU
CORD PROLAPSE
Umbilical cord presentation is
defined as the presence of umbilical
cord below the fetal presenting part
when the membranes are intact.
Cord prolapse is the presence of the
cord below the presenting part when
the membranes are ruptured.
INCIDENCE
It has an incidence of 1:500
deliveries and it occurs when the
fetal presenting part does not fit well
into the maternal pelvis.
Risk factors
Maternal causes
- Pelvic tumours ( fibroid in the lower segment)
- Narrow pelvis
Fetal causes
- Malpresentation
- Multiple pregnancy
- Polyhydromnios
- Placenta praevia,
- large baby
- Prematurity
Prevention
Ultrasound examination for
malpresentation and cord
presentation.
Avoid ARM in unengaged head.
Routinely doing VE following
spontaneous ruprture of membranes
Controlled ARM in poluhydromnios
stabilizing induction.
Management
Avoid pressure on presenting part over
the cord by digital or manual pressure,
minimmal handling of the cord.
Instruct the patient not to push.
Tocolysis; Terbulaline subcut?
Bladder filling with 500ml saline
Positioning of the patient:
-Knee chest position
-Trendelenburg position
UTERINE INVERSION
It is a rare complication occuring
during the third stage of labour.
Incidence is between 1:2000 and
1:6000
The uterine fundus descends either
to the cavity or through the cervix
and veru rarely through the introitus
Etiology
It is caused by traction on the
umbilical cord before the placenta
has seperated and can occur after
after vaginal delivery or C/ section
It has also been associated with a
short cord, a fundal placenta and a
morbidly adherent placenta.
Diagnosis
The prolapsed uterus stretching the
cervix causes vagal stimulation, thus
the women will demonstrate signs of
cardiovascular collapse and shock.
Haemorrhage maybe present however
the symptoms maybe out of proportion
to the estimated blood loss.
The inverted uterus maybe obvious at
the introitus.
Other signs
- Lack of palpable uterus in the
abdomen or the feeling of a dimple
in the uterine fundus on abdominal
examination.
MANAGEMENT
Resuscitate the patient using the structured
ABC approach.
It is very important not to remove the placenta
if it is still attached.
Replace the uterus through the cervix through
manual compression.
If that failed, hydrostattic pressure can e applied
by pouring warm saline into the vagina, usually
via a silc cup ventouse.
Tocolytic maybe helpful to relax the cervical ring
Management
Surgery, to reposition the uterus
from above should be used as a last
resort.
After replacement uterine contraction
is maintained with an oxytocin.
Video illustration
THANK
YOU