Obstetric emergencies

Obstetric emergencies - Intrapartum

Table of Contents

Cord prolapse

Uterine rupture

Shoulder dystocia

Undiagnosed twin

Undiagnosed breech

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 multiple birth, 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 is a general practioner obstetrician in Lennox Head, NSW, Australia,

This page was last built on 10/01/03. It was originally posted on 3/5/98; 7:42:30 PM.

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