Dr Sue Page
Aboriginal Health
Women's Health
Antenatal Diagnosis of Congenital Abnormality
Emotional aspects of menopause
Endoscopic Surgery in Gynaecology
Obstetric Emergencies - Antepartum
Obstetric Emergencies - Intrapartum
Obstetric Emergenies - Postpartum
Preventable Causes of Congenital Abnormalities
The Principles of Antenatal Care
Table of Contents |
Cord prolapse
If the cord is apparent and the fetus is still alive, immediate transfer for LSCS delivery should be made unless vaginal delivery will occur more quickly (eg. fully dilated and pushing multip.) This situation is most likely to happen in conjunction with some other problem such as multiplebirth, malpresentation (eg. breech), or increased liquor volume.
(1) Maintain left lateral position with elevation of the mother's pelvis.
(2) Try not to handle the cord as this may precipitate vessel spasm, but keep it within the vagina if able, or else wet with saline packs.
(3) Use a hand in the woman's vagina to try to keep the baby from crushing the cord during contractions.
(4) Consider using tocolytics (eg. s/c terbutaline 0.25mg, or IV salbutamol infusion) to arrest labour during transfer). A full bladder via IDC can also help, so long as the transfer itself is not delayed by the process.
Uterine rupture
Uncommon in the general practice setting, this can occur with
obstructed labour, especially if malposition or larger infant in
combination with previous uterine scar. The result is internal and/or
external blood loss, abdominal pain and tachecardia, the infant
easily felt through the abdominal wall, and progressive maternal or
fetal demise. Arrange immediate resuscitation, and transfer for
laparotomy.
Shoulder dystocia
Macrosomic infants will often be detected antenatally, but if the
infant's fat face remains squashed against perineum and delivery
fails to occur, consider that the shoulders may be too broad to
descend through the pelvis. Meanwhile, the cord is being compressed
against the mother so the infant will die before transfer.
(1) Call for any assistance that can reach you in less than 2-3
minutes.
(2) Flex the mother's knees up to her chest, preferably using two
helpers.
(3) Arrange that the mother's buttocks slightly overhang the end of
the bed, and, if needed, cut a wide episiotomy to fit your hand
beside the head.
(4) Have an assistant apply suprapubic pressure while you attempt to
move the infant's head posteriorally, aiming to bring the top
shoulder out from under the pubis. If this fails, try gently rocking
the infant up and down to ease one or other shoulder into the pelvis
(much like pulling a wine cork).
(5) If this fails, insert a hand into the vagina to locate the
infant's posterior arm. Sweep the arm towards the infant's chest
until the hand can be reached and drawn across the chest and out of
the vagina. Now rotate the infant's body so the exposed axilla lies
under the pubis, and apply downwards pressure to deliver the torso.
Expect a flat infant, possibly with shoulder injuries including
fractures, and a mother with pelvic floor trauma.
Undiagnosed twin
If the woman in labour is large, with no antenatal records
(including no ultrasound) to exclude multiple gestation, it is
prudent not to give syntocinon until the birth is completed and an
empty belly palpated. An undiagnosed twin will then usually deliver
spontaneously within 15 minutes,
with only the usual risks associated (eg. PET, malposition,
post-partum haemorrhage).
If syntocinon has been given with the first twin's shoulder, however,
transverse lie should be excluded, then membranes ruptured. The
infant is then turned to be extracted in the breech position by
grasping and delivering each foot in turn, before the uterus has time
to contract
around it and separate its placenta. The first scenario is obviously
preferable.
Undiagnosed breech
The worst event is a breech premature infant whose body can slip
through a partly dilated cervix, unlike its larger head, which can
then crush the cord. Even at term, breech infants have a higher risk
of cord prolapse, intracranial haemorrhage (due to abrupt pressure
changes in the rapid descent of an aftercoming head), brachial and
cervical trauma, and internal injuries. Breech deliveries ideally
occur with LSCS facilities on standby, and a paediatrician in the
room, precluding most rural centres. In the acute setting, however,
the principles of delivery are:
(1) Have the woman in lithotomy position with buttocks slightly
overhanging the edge of the bed. Empty bladder via IDC.
(2) As the anus becomes visible over the perineum, consider an
episiotomy.
(3) Allow the breech to deliver unaided to the level of the knees
/umbilicus.
(4) Deliver the legs by lateral abduction and flexion of the knees,
and check there is sufficient length to the exposed portion of
cord.
(5) Rotate the sacrum anteriorally, and from this point on, support
some of the weight of the infant's body to minimise traction on the
neck. Hold the infant at all times by bony parts such as thighs or
pelvis, to reduce the risk of liver trauma. Drape the infant to
reduce heat loss.
(6) As the scapulas appear, deliver the shoulders, holding the infant
by its pelvis to rotate the body as required.
(7) The arms are delivered by using a finger to sweep them across the
infant's chest and out past the torso.
(8) At this stage bring the sacrum again to face anteriorally, and
raise the infant's body to hang vertically, upside-down. Take care
not to allow the head to suddenly swing free, nor to overextend the
neck.
(9) If the infant is held in one hand by its ankles, the forefinger
of the free hand can then be put into its mouth to maintain flexion
of the neck as the head is delivered in a slow and controlled manner.
If forceps are required, an assistant needs to hold the child's
ankles.
Sue
Page,cmitchel@om.com.au
General Practioner
Lennox Head
NSW
Australia 2477
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