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

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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


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