Episode 38: Obstetrics Part 1
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Marcus McMillan @1949LAN
25/09/19
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Guest Bios
Marcus McMillan
Marcus McMillan is a consultant obstetrician in Princess Royal Maternity in Glasgow. He has a special interest in abnormally invasive placentas and coordinates care for people with this in Glasgow. He works with the Scottish Multiprofessional Maternity Development Programme for teaching obstetric emergencies and management to maternity staff and other departments.
Show Notes
Marcus McMillan is a consultant obstetrician in Princess Royal Maternity in Glasgow. He has a special interest in abnormally invasive placentas and coordinates care for people with this in Glasgow. He works with the Scottish Multiprofessional Maternity Development Programme for teaching obstetric emergencies and management to maternity staff and other departments. Eoghan and Marcus discuss obstetric emergencies, and in this episode they focus on normal and problematic deliveries.
TAKE-HOME POINTS
Normal labour
Take a history if possible
Remember that the delivery will most likely take care of itself (you have to do very little)
stay calm and don’t interfere too much
Simple things:
don’t lie them completely flat
get IV access and take bold - especially G&S and FBC
main worry is bleeding (no. 1 cause of morbidity and mortality)
keep them as comfortable as you can
analgesia - entonox probably best
morphine/diamorphine best avoided if no metal monitoring
POSITION:
however mum feels most conformable; options include:
lithotomy position
hands and knees (or leaning over bed)
standing up or squatting
Mum will get urge to push
work out when contracting and encourage to push in time with contractions
‘guarding the perineum’ and ‘protecting the head’ can be done, but don’t worry if not
STAY CALM and let it happen!!!
HEAD POSITION
typically back of head comes out first with face towards mothers bottom
it then rotates to line up with shoulders (restitution) - will either look left or right
when head out can then guide head with the next push/contraction so that anterior shoulder gets past the pubic symphysis
the head should be guided towards mothers bottom to get anterior shoulder out then the opposite way when first shoulder delivered
so in lithotomy position it is down then up
on all fours it is up then down
is stressed and can’t remember then just let it come itself
BABY DELIVERED:
put baby on or next to mum
leave cord attached for one minute
delayed cord-clamping can reduce need for neonatal transfusion
then clamp and cut
Dry baby and perform usual checks
PLACENTA
generally we do nothing and allow it to separate and deliver naturally
can give up to 30 minutes if giving syntocinon or ergometrine and up to one hour if not
after this time, the risk of PPH starts to increase so can think abut delivering it
Signs of placental separation:
cord will lengthen a bit
might have a bit of bleeding
At that point - place hand on abdomen to feel uterus
apply gentle traction on placenta and stop if you feel uterus moving down
placenta may still be attached and uterus could invert
KNOWING WHEN TO TRANSFER
no reliable way to know
if obstetrics on-site then call someone down to assess
Post-partum haemorrhage
commonest complication and commonest cause of maternal death worldwide
causes:
tone, tissue, trauma, thrombin
TONE: uterus not contracting
feel for fundus; push down to pelvis and give it a good rub
can typically feel it tighten
muscle will contract around the bleeding vessels
if not working or recurs - start drugs in the following order:
Syntocinon (often given prophylactically for placental delivery)
10 units IM
Syntocinon 5 units IV
Ergometrine 500mcg IV or IM
can feel sick with it (smooth muscle stimulant)
can raise BP so avoid in pre-eclampsia
Haemabate/Carboprost (synthetic prostaglandin analogue)
250mcg IM (always)
needs kept in fridge
Misoprostol 800-1000mcg PR
IM drugs will have a lag time of around 10 minutes so if bleeding heavy - start with an IV preparation
BIMANUAL COMPRESSION: a temporary measure to get to theatre if above not working:
but hand/fist inside vagina
reach funds of uterus and fold over the hand inside
it is very tiring and very sore for mother
If no obstetrician then a surgeon could perform a hysterectomy.
Standard resus principles apply:
get two large IV cannulas sited (orange preferably)
Give tranexamic acid
Give blood products as required:
Bloods, platelets and FFP
pregnant patients need a bit more fibrinogen than normal patients (aim for a level of 4)
TRAUMA: a big tear in the perineum
treat with compression and packing
big swabs and pack tightyly
then bring legs down to apply more compression
can be sore for mum
TISSUE: retained placenta
uterus won’t contract until it is out
will need to go to theatre - if not an option, continue to give drugs as above to make uterus contract
THROMBIN: unknown serious clotting disorder is unlikely
many clotting disorders ‘normalise’ in pregnancy (which is pro-coagulant)
its more a reminder that they can develop clotting disorders because of the bleeding so remember to treat
Shoulder dystocia
head delivered but baby not = an obstetric emergency
typically the head is out but doesn't restitute (turn to face left or right side) and can retract back in (turtle-necking)
mum then pushes, and baby doesn’t deliver despite gentle traction
RISK FACTORS:
big baby; diabetic mother; previous dystocia; long labour
about 90% will deliver with simple Roberts Manoeuvre
bed last and bring patient bottom to edge of bed
bring knees up as far as they will go (up to ears)
this opens the pelvis providing bit more room for the shoulder tp sink under the symphysis pubis
Other manoeuvres require a knowledge of the lie of the baby and could be made worse if done wrong so best done by people trained to do it
there is a much higher risk of postpartum haemorrhage after a shoulder dystocia
give prophylactic syntocinon
Baby is likely to be compromised
they can have a palsy but nothing to be done in the moment
simply dry and wrap baby and give to mum (if well)
Cord Prolapse
if cord is visible then there is a high chance that baby is not going to survive
if pulsatile and baby still alive then get to theatre immediately for a c-sectiom
its not the prolapse that kills baby but what comes next pressing cord against pelvis which does the damage:
push the presenting part back up into pelvis to stop the compression
get gravity on-side:
if mum lying on back then tilt head-down
or get mum on all fours with head down and bum up
can put catheter in bladder and fill - this lifts baby out of pelvis