OBSTETRIC EMERGENCIES

PRESENTERS:
TEH YU CHIN
JULIA LIM SHIN YI
HARRIS IZZUDDIN IMRAN
LEE JUN RUI

SUPERVISED BY DR ANG
SHOULDER DYSTOCIA
OUTLINE

 Definition
 Risk factors
 Diagnosis
 Management
 Complications
 Documentation
 DEFINITION

A vaginal cephalic delivery that require

additional obstetric manoeuvres to deliver
the fetus after the head has delivered and
gentle traction has failed.
RISK FACTORS

Pre-labour Intrapartum
History of previous shoulder dystocia Prolonged first stage of labour
Suspected macrosomic baby Secondary arrest
Diabetes mellitus Prolonged second stage of labour
Maternal obesity Oxytocin augmentation
Induction of labour Assisted vaginal delivery
RECOGNITION AND DIAGNOSIS

 Difficulty with delivery of face and chin

 Head remain tightly applied to the vulva and even retracting (turtle-neck sign)
 Failure of restitution of the fetal head
 Failure of the shoulder to descend
‘HELPER’

• Senior obstetrician, paediatricians.

• Secure 2 large bore branula.
Call for Help • Discourage maternal push and no fundal pressure.
• Lithotomy position.

• Evaluate the patient.

Episiotomy • Perform if need of rotational maneuvers.
‘HELPER’
McRoberts Maneuver
• Flexion and abduction of maternal hips, positioning the
maternal thighs on her abdomen
Legs • Increase AP diameter of pelvis by straightening
lumbosacral angle and rotating maternal pelvis towards
mother’s head
‘HELPER’
Suprapubic Pressure
• Applied by an assistant from the side of fetal back in a
downward and lateral direction just above the maternal
Pressure symphysis pubis
• Reduces fetal bisacromial diameter by pushing the
posterior aspect of anterior shoulder towards chest
 ‘HELPER’

Rubin II Manoeuvres
• Inserting fingers of one hand vaginally to posterior
Enter manoeuvres aspect of anterior shoulder
• Adduct fetal shoulder girdle and reducing its diameter
‘HELPER’
Woodscrew Manoeuvre
• Inserting 2 fingers on the anterior aspect of fetal
posterior shoulder and apply gentle upward pressure
Enter manoeuvres around the circumference of the arc in the same
direction of Rubin II manoeuvre
• Can combine with Rubin II Manoeuvre
‘HELPER’

Reverse Woodscrew manoeuver

• Fingers are placed behind fetal posterior shoulder and
Enter manoeuvres the fetal is rotate in opposite direction as in
Woodscrew manoeuver
‘HELPER’
• Grasp fetal wrist and gently withdraw fetal posterior
Remove the arm from the vagina in a straight line
posterior arm • Reduces diameter of fetal shoulders
• Risk of humeral fracture
‘HELPER’

Gaskin Manoeuver
On all four • Apply gentle downward traction to deliver posterior
shoulder with the aid of gravity
LAST RESORT

 Cleidotomy

 Symphysiotomy

 Zavanelli Manoeuver
 Cephalic replacement followed by caesarean section
 Rotating the fetal head into a direct occiput anterior position, then flexing and pushing the
vertex back into birth canal
 COMPLICATIONS

 Mother • Fetal
 Post partum haemorrhage • Brachial plexus injury
 Third and forth degree perineal tears • Erb palsy
 OASIS (obstetric anal sphincter injury) • Humerus fracture
 Uterine rupture • Clavicle fracture
• Birth asphysia
 Cervical tear
• Hypoxic Brain Injury
 Bladder rupture
 Symphyseal separation
 Sacroiliac joint dislocation
 Lateral femoral cutaneous neuropathy
DOCUMENTATION

 Time of delivery of the head and the body

 Anterior shoulder at the time of dystocia
 Manoeuver performed (timing and sequence)
 Maternal perineal and vaginal examination
 Estimated blood loss
 Staff in attendance and the time they arrived
 General condition of baby (Apgar score)
 Umbilical cord blood acid-base measurement
 Neonatal assessment of the baby
UTERINE INVERSION

JULIA LIM
INTRODUCTION

 It is somewhat rare, but a very serious condition

 Most commonly occurs in the 3rd stage of labor
 Can be partial or complete
 Incidence varies from a minimum of 1:2000 to 1:35000
 The mortality rate of the mother was somewhat 85% historically
 But now it’s now only 15%
 Rates are much higher in developing country
DEFINITION

 It is the folding of the fundus of the uterus into the uterine cavity

 In other words, when uterus turns inside out

CLASSIFICATION

 1st degree – the inverted fundus extends to, but not through the cervix

 2nd degree - the inverted fundus extends through the cervix but remains in the vagina

 3rd degree – the inverted fundus extends outside the vagina

 4th degree – the vagina and the uterus are inverted

CLASSIFICATION IN RELATION OF DIAGNOSIS AND TIME OF
DELIVERY

 Acute – occurs within 24 hrs of delivery

 Sub-acute – occurs between 24 hrs till 4 weeks of delivery

 Chronic – occurs beyond 4 weeks of delivery or in non pregnant stage

AETIOLOGY

As most of it correlates to mismanagement of the 3rd stage of labor.

1. Short umbilical cord

2. Excessive traction on the umbilical cord

3. Morbidly adherent placenta

4. Retained placenta
AETIOLOGY

5. Chronic endometritis

6. Vaginal birth after LSCS

7. Rapid or long labours

8. Previous episode of uterine inversion

9. Unicornuate uterus
SIGNS AND SYMPTOMS
• Hemorrhage • Mass in the vagina on VE

• Severe abdominal pain • Sudden CVS collapses

• Hypotension with • Abdominal tenderness

bradycardia
• Hypovolemic shock
• Uterine fundus not palpable
abdominally
 MANAGEMENT

 Repositioning of the uterus should be performed immediately. With time, the constricting
ring around the uterus becomes more rigid and the uterus more engorged with blood
 INITIATE RED ALERT
 GXM blood
 A 3rd degree inversion should be converted into a 2nd degree by positioning patient in
Trendelenburg position to maintain the inverted mass within the vagina instead of leaving it
hanging outside.
 Thoroughly cleanse the inverted uterus using antiseptic solution
 Apply compression to the inverted uterus with a moist warm sterile towel until ready for the
procedure
 IF PLACENTA IS STILL ATTACHED, DO NOT REMOVE IT !!
 TECHNIQUE 1 – MANUAL TECHNIQUE

 Urgent manual replacement of the uterus

 Preferably done under GA esp under the influence of halothane as it has uterine
relaxation effect
 Other option is Pethidine and Diazepam in slow bolus
 Aseptic technique
 Grasp the uterus and push it through the cervix toward the umbilicus to its normal
position
 Another hand should be placed on the abdomen as counter support
 If replacement is successful, give Ergometrine with the hand still within the cavity of the
uterus until the uterus contracts
 If correction is not achieved, procced hydrostatic correction.
 TECHNIQUE 2 – HYDROSTATIC

 Preference of use when manual replacement fails

 Place the patient in Trendelenburg position
 Prepare douche system with a double nozzle and a long tubing and a
warm water reservoir 3-5 L
 Identify the posterior fornix place the nozzle of the douche in the
posterior fornix with the other hand holding the labia sealed over the
nozzle and use the forearm to support the nozzle
 Ask assistant to start the douche with full pressure
 The fluid distends the posterior fornix and increases the circumference
of the orifice , relieves cervical constriction and result in the correction
of the inversion
POST PROCEDURE CARE

 Give IM Ergometrine 0.5mg and maintain a slow syntocinon infusion

 Cover with single dose antibiotics of IV Ampicilin 1g and IV Metronidazole 500mg

after correcting the inverted uterus.
CORD PROLAPSE

BY HARRIS IZZUDDIN
 DEFINITION

 Cord prolapse = umbilical cord descend beyond fetal presenting part, often through

cervical os, into or beyond the vagina

 Usually membrane is absent

 Cord presentation = umbilical cord descend alongside the presenting part (but, do not

pass)

 Membrane can be intact / absent

COMMON RISK FACTORS

 Inadequate filling of the maternal pelvis by the fetus

 Artificial ruptured of membrane

 ARM should be avoided whenever possible if the presenting
part is mobile and/or high..
OTHER CONTRIBUTING FACTORS

1. Fetal malpresentation – breech (footling carry higher risk), transverse /

oblique
2. Premature delivery
3. Multiple gestation
4. Multiparity
5. Ruptured of membrane – ARM / spontaneous
6. Polyhydramnios
7. Obstetric procedures like ECV, internal podalic version, IOL, stabilizing
induction
DIAGNOSIS

 Abnormal CTG: severe, prolonged bradycardia / moderate to severe

variable deceleration after a previously normal tracing CTG
 in case of intact membrane – cord presentation should be suspected
 Sudden appearance loop of cord at introitus just after ARM
 Vaginal examination -
 Cord - soft pulsating structure
 breech/malpresentation with SROM
 Ultrasound - cord presentation
MANAGEMENT

 1. Initiate red alert

 2. Confirm viability of fetus by fetal heart auscultation or ultrasound
 3. If fetus is still viable – arrange for immediate delivery via the fastest mode possible
(usually via Caesarean section). If os is fully dilated, instrumental delivery can be
attempted
 4. Relieve cord compression by:
 Gently replace cord in the vagina
 Minimal handling of cord
 Elevate the presenting part manually by examining finger, or fill bladder with 500mls NS via
Foley’s catheter
 Position mother in Trendelenburg (raised buttock on pillows), knee-chest or Sims lateral position
RELIEVE PRESSURE ON THE CORD

1. DO NOT REMOVE YOUR FINGER! DO NOT TOUCH THE CORD!

2. ELEVATE THE PRESENTING PART OFF THE CORD
3. TOCOLYTIC
4. Place pt in TRENDELENBURG / KNEE CHEST POSITION /
EXAGGERATED SIM POSITION
5. If the cord is outside the introitus – COVER IT WITH WARM TOWEL
6. FILL UP THE BLADDER using Foleys catheter with 500cc of normal
saline
POST PARTUM HEMORRHAGE

BY LEE JUN RUI

GOALS


Able to identify and appreciate the severity of PPH

To understand and identify the main causes of PPH

To be able to manage PPH
 DEFINITION


Primary PPH - Loss of blood more than 500ml from the genital tract post delivery (WHO)
in the first 24 hours of delivery
 Minor 500-1000ml with no clinical shock
 Major: >1000ml
 Massive: >1500
 Severe PPH (RCOG): 2000ml

Secondary PPH – abnormal or excessive bleeding from the genital tract after the first 24
hours post partum until 6 weeks after delivery
 HAEMORRHAGIC SHOCK


Classification of haemorrhagic shock in relation to clinical criteria
and percentage of total blood volume lost

Total blood volume at term is approximately 100ml/kg

Blood loss >40% of total blood volume consider life-threatening
 OBSTETRIC SHOCK INDEX


Defined as HR/SBP

Early marker of compromise in shock

For pregnant population, normal SI ranges from 0.7- 0.9; SI >1
predicts adverse clinical outcome
 SIGNS AND SYMPTOMS
Class % Blood loss (est BP (mmHg) SSx
body weight
50kg)
Compensated 10-15 normal Palpitations,
Shock (up to 750ml) dizziness,
tachycardia
Mild 15-30 Slight drop Palpitations,
(750-1500ml) tachycardia, thirst,
weak, sweaty
Moderate 30-35 70-80 Restless, pallor,
(1500-1750ml) oliguria

Severe 35-40 50-70 Pallor, cyanosis,

(1750-2000ml) collapse

Profound 40-50 50 / unrecordable Collapse. Airhunger,

(>2000ml) anuria
 CAUSES OF PPH

4 Ts

Tone (abnormality of uterine contraction – uterine atony)

Tissue (retained products of conception)

Trauma (of genital tract)

Thrombin (coagulation abnormality)
 TONE (UTERINE ATONY)


75-90% of Cases

Uterine hyperdistention
 Macrosomic baby
 Multiple pregnancy


Previous PPH

Percipitated or prolonged labour

Chorioamnionitis/infection

Obesity (BMI>35)

Age > 40 years old

High parity
 TISSUE & TRAUMA


Tissue
 Retained placenta

Trauma
 5-10% of cases
 Operative vaginal delivery (vacuum/forceps)
 Caesarean section
 Mediolateral episiotomy
 Poor guarding of the perineum
THROMBIN


Pyrexia in labour

Placental abruption

Pre-existing bleeding disorder (e.g haemophilia)

Patient on anti-coagulant


Denggue

Traditional medications/herbs
 PREVENTION


Risk factors as mentioned

However, most cases of PPH have no identifiable risk factors

Active management of 3rd stage of labour lowers maternal blood loss
and reduce risk of PPH
 Use of uterotonic
 Uterine massage
 Control cord traction for delivery of placenta
 Uterotonic


Prophylactic Oxytocics should be given routinely as it reduces the
risk of PPH by 60%

Syntometrine (oxytocin+ergometrine) may be used in absence of
hypertension

For cases with no risk factors and delivering vaginally, give IM
Oxytocin 5 iu or 10 iu

For cases of Caesarean section, IV Oxytocin 5 iu by slow infusion
 Uterotonic continued


Syntometrine and Oxytocin have similar efficacy in prevention of
PPH

However major difference in the side effect.

Syntometrine : 5-fold increase of nausea, vomiting, elevation of BP
 FURTHER RISK FACTORS


All women with previous Caesarean section must be check for placental site and any
presence of placenta accreta

Role of prophylactic interventional radiology in case of antenatally diagnosed
placenta accreata
– Balloon occlusion
– Embolization of pelvic arteries

Studies done show the procedure have value in control of primary PPH and
secondary PPH
MANAGEMENT


Communication

Resuscitation

Monitoring and Investigations

Arrest the bleeding
 COMMUNICATION


Alert all relevant professionals, call for help

For major PPH activate RED ALERT
 Alert consultants
 Call specialist (O&G and Anesthetist)
 Alert blood bank
 Call for runner, for run for blood, sending of specimens/ blood
 One member to record the events, fluids, drugs and vital signs
 Communicate with patient and the partner with clear information of
what is happening
 RESUSCITATION


The measurement for resuscitation depends on condition and degree
of shock

Assess Airway and Breathing

– Give oxygen 10-15 L/min via face mask

– If airway is compromised due to impaired conscious level, need to
intubate with anaesthetic assistance
 RESUSCITATION CONTINUED


Evaluate Circulation

2 large-bore branula (14-16 gauge)

(Take blood for FBC, coagulation profile,

BUSE/Cr/LFT, Fibrinogen, GXM 4 units)

Position flat, lateral tilt, Keep patient warm

Give crystalloid infusion (Hartmann)

In Major PPH, activate MHP
 RESUSCITATION CONTINUED


Until blood is available, total volume of 3.5 litres crystalloid infuse
up to 2 L of warmed crystalloid Hartmann solution and/or colloid (1-
2 L) as rapidly as required if blood still not available.

May require DIVC regime

FFP : 4 units for every 4 units of Pack Cells or PT/APTT >1.5 x
normal

Platelet concentration : if Plt < 50 x 109/L

• Cryoprecipitate : if fibrinogen < 1g/L
 RESUSCITATION CONTINUED &
ARREST THE BLEEDING (THROMBIN)


Role of recombinant factor VIIa therapy (rFVIIa)

Used in treatment of haemophilia

Used in reducing the bleeding in PPH

In life-threatening PPH and in consultation with a haematologist,
rFVIIa is used as an adjuvant therapy

Dose 90 mcg/kg
 RESUSCITATION CONTINUED


The therapeutic goals of management of massive blood loss is to
maintain

– Hb > 8 g/dL

– Plt count > 75 x 109/L

– PT < 1.5 x mean control

– APTT < 1.5 x mean control

– Fibrinogen > 1.0 g/L
2006 Guideline of British Committee for Standards in Haematology
 MONITORING & INVESTIGATION


Take blood as mentioned

Monitor BP/PR every 15 minute is Minor PPH

Continous BP/PR/RR in Major PPH (using oximeter, cardiac
monitoring, automated BP recording)

Put Foley catheter to monitor urine output

Transfer to ICU or HDW once bleeding is controlled

Central line by senior skilled-anaesthetist may required

Documentation of fluid balance, blood, blood products and
procedure
ARREST THE BLEEDING (UTERINE ATONY)


Depends on the cause of the massive bleeding

Common cause – Uterine Atony
– Mechanical
– Pharmacological
– Surgical
 MECHANICAL


Bimanual Uterine compression
to stimulate uterus to contract
(external and internal)
 MECHANICAL

Aortic Compression
 PHARMACOLOGY


Repeat IM Syntocinon or Syntometrine

IV Pitocin 40 units in 500 ml Hartmann’s solution, run at 125ml/hr

IM Carboprost (Haemabate®) 0.25mg - 0.50mg, may repeated at
interval not less than 15 min to a maximum 8 doses (contraindicated
in Asthma)

Misoprostol 1000 mcg rectally or cervagem per rectally
 SURGERY


First line is Balloon Tamponade

A ‘positive test’ : able to control PPH following inflation of the
balloon, indicate that laparotomy is not required

A ‘negative test’ : continued bleeding following inflation of the
balloon, indication to proceed to laparotomy

Most cases, 4-6 hours of tamponade is adequate to achieve
haemostasis

Should be remove during daytime hours with presence of appropriate
senior staff as further intervention may be necessary
 SURGERY


Haemostatic Brace Suturing
 B-Lynch suture (describe in 1997)
 Hayman suture, describe in 2002 withmodified compressive suture
which doesnot require hysterotomy
 Vertical compression sutures

Bilateral ligation of uterine arteries, Bilateral ligation of internal
iliac arteries, Selective arterial embolization

• Hysterectomy
 ARREST THE BLEEDING (RETAINED PLACENTA)


Case of RETAINED PLACENTA

empty bladder, attempt CCT

If fail, proceed with Manual Removal of Placenta (MRP) either under
sedation or GA

Take consent

If under sedation, give IV Pethidine 25-50mg
stat, IV Midazolam 2.5-5.0 mg stat

Continous SPO2 monitoring, Litothomy position

IV Ampicillin 1g stat, IV Flagyl 500 mg stat

Fully gown, mask, long-sleeve glove
ARREST THE BLEEDING (TRAUMA)


Management of Genital Tract Trauma

Suture the cervical / vaginal wall tear

May need vaginal packing

Cover with broad spectrum antibiotic
 SECONDARY PPH

Often associated with ENDOMETRITIS


Risk factor for endometritis

– Prolonged labor

– PROM

– Anemia

– Underlying Diabetes

– Chorioamnionitis

– Operative deliveries: MRP, C-section, Instrumental vaginal
delivery
 SECONDARY PPH


Ix : FBC, CRP, high & low vaginal swabs, blood culture if
pyrexia

Pelvic ultrasound, help in presence of POC

Treatment :
 Antibiotic : Ampicillin and Metronidazole
 Uterotonics
 If continuing bleeding, may need balloon tamponade or
ERPOC
 ARREST THE BLEEDING (THROMBIN)


Role of recombinant factor VIIa therapy (rFVIIa)

Used in treatment of haemophilia

Used in reducing the bleeding in PPH

In life-threatening PPH and in consultation with a haematologist,
rFVIIa is used as an adjuvant therapy

Dose 90 mcg/kg
 REFERENCES

 MHP protocol HSAJB (2020)

 Medaliar and Menon's Clinical Obstetrics, 11th edition, Sarala Gopalan and
Vanita Jain, Complications in Third Stage of Labour (pg: 422-428)
 DC Dutta's Textbook of Obstetrics, 9th edition
 Essentials of Obsterectric, Lakshimi Seshadri, Gita Arjun
 B-Lynch Compression Suture as an Alternative to Paripartum Hysterectomy
Christopher Balogun-Lynch and Tahira Aziz Javaid Submitted: May 5th
2015 Reviewed: August 18th 2015Published: November 11th 2015 DOI:
10.5772/61295
 2006 Guideline of British Committee for Standards in Haematology
THANK YOU