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Obstetric Emergencies Clinical Guideline - | Health - obstetric cervical laceration repair cpt

Canberra Hospital and Health ServicesClinical GuidelineObstetric EmergenciesContents TOC \o "1-2" \h \z Contents PAGEREF _Toc430260495 \h 1Introduction PAGEREF _Toc430260496 \h 3Scope PAGEREF _Toc430260497 \h 3Section 1: Postpartum Haemorrhage PAGEREF _Toc430260498 \h 3Background PAGEREF _Toc430260499 \h 31.1 – Risk Factors PAGEREF _Toc430260500 \h 41.2 – Management/Resuscitation PAGEREF _Toc430260501 \h 6Section 2: Uterine Inversion PAGEREF _Toc430260502 \h 102.1: Causes and risk factors PAGEREF _Toc430260503 \h 102.2: Signs of Uterine Inversion PAGEREF _Toc430260504 \h 102.3: Initial management PAGEREF _Toc430260505 \h 112.4: Maternal resuscitation PAGEREF _Toc430260506 \h 112.5: Manual replacement in Operating Theatre PAGEREF _Toc430260507 \h 122.6: Post replacement care PAGEREF _Toc430260508 \h 12Section 3: Cord Prolapse/Presentation PAGEREF _Toc430260509 \h 12Background PAGEREF _Toc430260510 \h 133.2: Predisposing factors PAGEREF _Toc430260511 \h 133.3: Prevention PAGEREF _Toc430260512 \h 133.4: Diagnosis PAGEREF _Toc430260513 \h 143.5: Management Antepartum PAGEREF _Toc430260514 \h 143.6: Management Intrapartum PAGEREF _Toc430260515 \h 14Section 4: Shoulder Dystocia PAGEREF _Toc430260516 \h 17Background PAGEREF _Toc430260517 \h 174.1 – Predisposing factors that could lead to shoulder dystocia PAGEREF _Toc430260518 \h 184.2 – Recognition of impending shoulder dystocia PAGEREF _Toc430260519 \h 184.3 – HELPERR- Systematic emergency management of shoulder dystocia PAGEREF _Toc430260520 \h 184.4 – Manoeuvres of last resort PAGEREF _Toc430260521 \h 214.5 – Cord management PAGEREF _Toc430260522 \h 214.6 – Complications and care post birth PAGEREF _Toc430260523 \h 22Implementation PAGEREF _Toc430260524 \h 22Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc430260525 \h 22References PAGEREF _Toc430260526 \h 23Definition of Terms PAGEREF _Toc430260527 \h 24Search Terms PAGEREF _Toc430260528 \h 25Attachments PAGEREF _Toc430260529 \h 26Attachment 1: Management of postpartum haemorrhage flowchart PAGEREF _Toc430260530 \h 27IntroductionTo provide guidelines for care and management of a woman who is experiencing an obstetric emergency such as a postpartum haemorrhage (PPH), uterine inversion, cord prolapse or shoulder dystocia. ScopeThis document provides guidelines to the staff of Centenary Hospital for Women and Children regarding the prevention, early recognition and management of obstetric emergencies. This document applies to:Medical Officers and Midwives who are working within their scope of practice Midwifery students under direct supervisionBack to Table of ContentsSection 1: Postpartum HaemorrhageBackgroundPostpartum haemorrhage (PPH) remains a major cause of maternal morbidity and mortality.PPH is a potentially life-threatening complication of vaginal and caesarean section births. In addition to maternal death PPH can result in:anaemiaprolonged hospital staydelay or failure of breastfeedingpituitary infarctionneed for blood productshaemorrhagic shock and hypotensioncoagulopathyacute tubular necrosis/renal failureemergency surgical or angiographic intervention hysterectomy.PPH is defined as blood loss of 500mL or more during and after childbirthSignificant PPH is defined as blood loss of 1000mL or more OR any amount of blood loss postpartum that causes haemodynamic compromiseA primary PPH occurs within the first 24 hours following birthA secondary PPH occurs between 24 hours and 6 weeks postpartumAlert:Generally, the degree of haemodynamic compromise or shock parallels the amount of blood lost, but some women will become compromised with a relatively small blood loss. This may include women with pregnancy-induced hypertension, women with anaemia, and women of small stature.Haemodynamic changes of pregnancy may sustain a woman’s circulatory status at near normal levels (initially there may even be a small rise in BP) despite large blood loss, until such time as a critical level is reached and there is a sudden and profound change in blood pressure and pulse to indicate shock.Manual removal of the placenta at elective or emergency caesarean section is associated with increased maternal blood loss and risk of infection. 1.1 – Risk FactorsAntenatal and intrapartum risk factors for PPHCause AetiologyClinical risk factorsAbnormalities ofuterinecontraction(Tone)70%Atonic uterusPhysiological management of the third stage Prolonged third stage (>30 minutes)Over distended uterus PolyhydramniosMultiple pregnancyMacrosomiaUterine muscle exhaustion High parityRapid or incoordinate labourProlonged labour (1st or 2nd stage)Labour dystociaLabour augmented with oxytocinIntra-amniotic infection PyrexiaProlonged ruptured membranes (>24 hours) Drug-induced uterine hypotoniaMagnesium sulphate, nifedipine, salbutamolGeneral anaesthesia Functional or anatomic distortion of the uterusFibroid uterusUterine anomaliesGenital tracttrauma(Trauma)20%Episiotomy or lacerations (cervix, vagina or perineum)Induced labourAugmented labourAbnormal labour (dystocia)MalpositionPrecipitous birthInstrumental birth (forceps or vacuum)Extensions / lacerations at caesarean sectionMalpositionDeep engagementUterine rupture Previous uterine surgery Uterine InversionStrong cord traction in 3rd stage (especially with fundal placenta)Short umbilical cordHigh parityUterine relaxationPlacenta accreta (especially with fundal placenta)Congenital uterine anomalies or weaknessAntepartum or intrapartum use of magnesium sulphate or oxytocinRetainedpregnancy tissue(Tissue)10%Retained productsAbnormal placentaRetained cotyledon Succenturiate lobeIncomplete placenta at birthPlacenta accretaPrevious uterine surgeryHigh parityAbnormal placenta on ultrasoundAbnormalities ofcoagulation(Thrombin)1%Retained blood clots Atonic uterusCoagulation disorders acquired during pregnancyIdiopathic thrombocytopenicpurpura (ITP)Von Willebrand’s diseaseHaemophiliaThrombocytopenia with preeclampsiaDisseminated intravascular coagulation (DIC)Pre-eclampsiaRetained dead fetusSevere infectionPlacental abruptionAmniotic fluid embolismBruisingElevated blood pressureFetal deathFeverAntepartum haemorrhageSudden collapse Therapeutic anticoagulationHistory of thrombo-embolism1.2 – Management/ResuscitationPrevention of PPHAntenatallyExplain, inform and educate the woman and her partner about active and physiological management of third stage, ideally this information will have been discussed during antenatal visits.Check haemoglobin level during pregnancy.Document identified risk factors. Explanations given and interventions initiated in Maternity Card and Birthing Outcomes System (BOS). Discuss transfusion options – including any barriers to transfusion such as religious/cultural beliefs or the presence of red cell antibodies. Pre-birth collection of a group and screen to ensure testing is complete and compatible blood be available should an emergent situation arise.Intrapartum management of women with identified risk factorsActive management of the third stage of labour is recommended. Insert 16 gauge IV cannula in labour.Midwife to remain vigilant for changes in progress of labour which increase risk of PPH.Take blood for full blood count and group and screen (pink top).Alert: Risk management: Visual estimation of blood loss has been recognised as unreliable. Blood loss is to be estimated by weighing linen, drapes, pads and swabs. Management/resuscitation?If the woman is at risk of PPH ensure oxytocin 40 units in Hartmann’s Solution 1 litre (at room temperature) is available. Commence oxytocin infusion as a sideline at 250 mL/hr (10 units/hr) with a mainline infusion of Hartmann’s solution (rate as per medical orders) after birth if there are signs of PPH (Advanced Life Support in Obstetrics (ALSO) manual, 2015).If there is a blood loss >500mL after normal birth or 600mL after caesarean section follow the clinical pathway ‘Postpartum Haemorrhage Management’ and act promptly to:Call for additional help - midwifery, medical and Code Blue/Medical Emergency Team (MET) if MET criteria met.Consider activation of Critical Bleeding Massive Transfusion procedure.Maintain airway, breathing and circulation (ABC), as clinically indicated.Give reassurance and explanation to the woman and her support people.Gain informed consent to interventions whenever possible.Perform abdominal uterine massage continuously until the woman’s uterus is empty and well contracted.Insert two wide bore (16g) cannulas (one if IVC already in situ).Have assistant check placenta for completeness.Take blood for:??? full blood count (FBC) (pink top)group and cross-match (pink top)coagulation profile including fibrinogen (blue top).Ensure rapid and appropriate fluid replacement in a volume at least three times the measured volume lost; IV fluids should be administered at room temperature.Blood is the ideal replacement fluid in PPH.Commence first line medication managementCommence oxytocin 40 units infusion as a sideline at 250 mL/hr (10 units/hr) with a mainline infusion of Hartmann’s solution (run at rate ordered by the Medical Officer) (ALSO manual, 2015).Insert indwelling urinary catheter on free drainage or hourly measure as indicated.If the placenta is not delivered:Active third stage: initiate active management with oxytocin 10units intramuscularly (IM) and controlled cord traction. Physiological third stage: recommend change to active management. Commence second line medication managementIf the placenta is born, administer combined oxytocin 5 units/ergometrine 500?micrograms (syntometrine?) or ergometrine 250- 500?micrograms IM (if diastolic BP is below 90mmHg and there has been no history of hypertension during the pregnancy). If the placenta is retained, prepare for manual removal in the Operating Theatre (OT).If PPH is due to trauma apply pressure, clips or vaginal plug.Maintain maternal thermo-regulation, hypothermia increases the risk of disseminated intravascular coagulation and other complications. Consider Misoprostol 800 microgram per rectum (PR), only after the bleeding is controlled. Misoprostol PR is slow acting and helps to maintain tone after 1 – 2 hours.Activate Critical Bleeding Massive Transfusion procedure if estimated blood loss (EBL) is >1500 mL.If bleeding continues:Transfer to Operating Theatres.Consider activating the massive transfusion procedure.Inform and get help from:gynaecological surgeon experienced in management of massive intractable PPHanaesthetisthaematologistOT, pathology and ICU staff.Bi-manual compression.Examination under anaesthetic, repair lacerations.Commence third line medication managementConsider carboprost 250 mcg in 1ml up to 8 doses, deep IM injection.+/-Pack uterus/vagina. Haemostatic Balloon (Bakri).B-Lynch suture.Hysterectomy.+/- embolisation.If consumptive coagulopathy present with continued widespread bleedingAbdominal packing.Angiographic embolisation.Urgent administration of blood products in conjunction with advice from the haematologist. See Attachment 1: Flowchart – Management of Postpartum haemorrhage.PPH Medication Summary Table1st Line Medication Management Administer oxytocin 10 units IM if not previously givenCommence oxytocin infusion 40 units/1 litre Hartmann’s solution at 250mL/hour (ensure IV fluid is at room temperature) as a sideline with a mainline of Hartmann’s solution2nd Line Medication ManagementOxytocin 5 units with ergometrine 500 micrograms (as 1mL Syntometrine?) IMORErgotmetrine? 250 to 500 micrograms IM3rd Line Medication ManagementCarboprost 250 micrograms every 15 minutes IM. Maximum of 8 doses (2mg) Consider misoprostol 800 micrograms PRObservations/InterventionsAs per Maternity MEWS, every 15-30 minutes until stable, if MET activated observations should be recorded every 5 minutes until a medical management plan is established.Massage the uterine fundus continuously until uterus contracted, then as clinically indicated at least every 15 minutes after bleeding controlled.Measure and record vaginal blood loss continuously then at least every 15 minutes after bleeding controlled until bleeding has stopped.Measure blood loss by weighing all blood stained lines sponges, pads etc. Blood loss from procedures performed in operating theatre to be recorded on the operation record.Ensure a cumulative blood loss is accurately assessed, reported recorded and acted on.Documentation:Document all interventions and care on the:Partogram Clinical pathway ‘Postpartum Haemorrhage-Immediate Management’Progress notesFluid balance chartOperation recordMaternity MEWS chart/ Medical emergency/ Code Blue record if a MET is activatedMedication chartBOSComplete/ commence all appropriate clinical pathways and enter variations as indicated.Accoucheur to complete RISKMAN.Ongoing Postnatal careObservations as per Maternity MEWS.Ensure ongoing blood loss is noted and the cumulative total blood loss is updated contemporaneously and recorded.First 24 hours postnatal ThromboprophylaxisExcess blood loss and blood transfusions are risk factors for venous thromboembolism (VTE).Commence thromboprophylaxis when immediate risk of haemorrhage is reduced.Antiembolic stockings are recommended until woman is fully mobile.Encourage foot and leg exercises.Update total blood loss on BOS.Remove indwelling catheter (IDC) if observations and diuresis are normal (ensure urinary competence following IDC removal). Obstetric registrar to remove uterine haemostatic balloon 24 hours post insertion.Cease IVT if oral fluids are tolerated and blood results are satisfactory.If the woman is well, normalise postnatal care.Women who remain symptomatic require ongoing midwifery care and assistance to care for the baby.Care of a woman post PPH The woman needs to be cleared for transfer to postnatal/antenatal ward by the Medical Officer.After a significant PPH, if the woman needs intensive monitoring and is not eligible for admission to the High Dependency Unit (HDU) or Intensive Care Unit (ICU) the woman is to return to Birthing. 24-48 hours postnatalCheck FBC at 6 hours and 48 hours or prior to discharge.Offer postnatal de-briefing by midwife or medical staff involved.Ensure prescription for iron supplements are provided.Advise General Practitioner (GP) follow-up and FBC check at 6 weeks.Back to table of ContentsSection 2: Uterine InversionClassification According to Severity of Uterine InversionFirst degree: The fundus reaches the internal os.Second degree: The body or corpus of the uterus is inverted to the internal os.Third degree: The uterus, cervix and vagina are inverted and are visible.Classification According to Timing of the Event Acute: Occurs within 24 hours of birth.Subacute: Occurs after 24 hours, within 4 weeks.Chronic: Occurs after 4 weeks (rare).Alert:Concurrent maternal resuscitation with manual uterine replacement is the first line of management.If the placenta is still adherent following uterine inversion – leave in place to reduce blood loss. There is no place for fundal pressure during third stage.2.1: Causes and risk factorsThese include:Premature or excessive cord traction during active management of the third stage.A combination of fundal pressure and cord traction to birth the placenta, or use of fundal pressure when the uterus is atonic during placental birth.Abnormally adherent placenta.Spontaneous inversion of unknown etiology.Short umbilical cord.Sudden emptying of a distended uterus.Multiparity.Chronic endometritis. Fetal macrosomia.Vaginal birth after caesarean.Myometrial weakness. Precipitate labour. Fundal placement of the placenta.Antepartum use of magnesium sulphate.2.2: Signs of Uterine InversionSymptoms of uterine inversion may include:Fundus of the uterus cannot be palpated abdominally after birth of the placenta.Fostpartum haemorrhage.Shock – thought to be due to the parasympathetic effect caused by traction of the ligaments supporting the uterus, and hypotension with inadequate tissue perfusion.Severe abdominal pain.Shysical examination can reveal first or second degree uterine inversion.2.3: Initial managementMaternal resuscitation while attempting uterine replacement should be initiated simultaneously.Call for additional help – midwifery, medical and Code Blue/Medical Emergency Team (MET) if MET criteria met.Maintain airway, breathing and circulation (ABC), as clinically indicated. Alert the operating theatre and anaesthetist.If the placenta is still in situ, leave in place until uterine replacement is complete.Attempt manual replacement of the uterus Using sterile gloves, grasp the uterus and insert it through the cervix towards the umbilicus back to its normal position using the other hand to support the uterus through the abdominal wallThe clinician is to maintain bimanual compression until an oxytocic infusion can be commenced and blood loss is controlled. If uterine replacement is unsuccessful or no medical attention is immediately available, or if the woman’s condition indicates, activate a MET according to Code Blue Procedure (dial 8 and call for MET). 2.4: Maternal resuscitationCall for additional help - midwifery, medical and Code Blue/Medical emergency Team (MET) if MET criteria met.Maintain airway, breathing and circulation (ABC), as clinically indicated.Lie the woman flat.Administer oxygen via a face mask.Insert two 16 gauge intravenous cannulae. Obtain bloods for: Group and cross-match 4 units of blood Full blood count and coagulation studies.Commence intravenous fluids.If not already administered, withhold the oxytocic until uterine replacement is complete.Commence PPH pathway: every 5 - 15 minutes blood pressure, pulse, respirations, oxygen saturation levels and sedation score.Insert an indwelling catheter and monitor urine output.Maintain a strict fluid balance.If the replacement of the uterus is not possible, resuscitate the woman, call Operating Theatres and transfer the woman there immediately for hydrostatic reduction of the uterus.2.5: Manual replacement in Operating TheatreStabilise the woman and obtain effective anaesthesia.Relax the uterus with tocolytics.Replace the uterus with hydrostatic pressure.Maintain the hand in situ until a firm contraction is palpated.SURGICAL MANAGEMENTLaparotomy with open reduction of the uterine inversion may be necessary if the previous methods are unsuccessful.2.6: Post replacement careIf the uterus is successfully returned to its normal position then the placenta can be manually removed in an operating theatre under anaesethesia.Uterine atony and PPH are common after replacement of the uterus. Follow Section 1 PPH, of this procedure.Administer prophylactic antibiotics.Inform the woman that reinversion of the uterus may occur.Physiotherapy review will?be attended as part of routine post-natal care (as per post-natal pathway); referral should be made for earlier review?if concerns exist.Back to Table of ContentsSection 3: Cord Prolapse/PresentationPresentation and prolapse of the umbilical cord may occur in any situation where the presenting part does not ‘fit’ well in the maternal pelvis. Cord presentation occurs when a loop of cord lies below the presenting part of the fetus in the presence of intact membranes. Cord prolapse occurs when the umbilical cord descends below the presenting part in the presence of ruptured membranes (usually during labour).Occult cord presentation: occurs when a loop of cord lies beside the presenting part and is often related to unexplained signs of fetal compromise (deep variable decelerations of the fetal heart) in labour. With cord presentation or prolapse, blood flow through the umbilical vessels may be compromised from compression of the cord between the fetus and the uterus, cervix or pelvic inlet. Cord prolapse is a life threatening obstetric emergencies that may result in fetal asphyxia or death. Caesarean section is the safest birth option for the viable fetus, especially in the first and early second stages of labour. BackgroundNeonatal asphyxia is associated with cord prolapse and may also result in hypoxic-ischaemic encephalopathy and cerebral palsy. A finding of cord presentation on ultrasound is associated with an increased risk of cord prolapse; however, the majority of sonographic cord presentations are not followed by cord prolapse. Cord presentation/prolapse is more likely to occur after artificial rupture of the membranes or sudden spontaneous rupture of the forewaters (with malpresentation or high presenting part) than in association with a hindwater leak. 3.2: Predisposing factorsPresenting part not well applied to the cervix.High or poorly fitting presenting part.Malpresentation – cephalic (0.4%); breech, footling (15-18%); complete (4-6%); frank (0.5%); transverse lie, shoulder presentation.Polyhydramnios.Multiple pregnancy (especially the second twin).Placenta praevia (minor more likely than major).Fibroids. Multiparity.Low birth weight less than 2500g.Fetal congenital anomalies.Prematurity less than 37 weeks.Unusually long cord.Procedure related:artificial rupture of membranesvaginal manipulation of the fetus with ruptured membranesexternal cephalic versioninternal podalic version.3.3: PreventionIdentify risk factors. Intrapartum: Controlled artificial rupture of the membranes (ARM) by senior medical or midwifery staff in the following situations: high, ill-fitting presenting part unstable lie polyhydramnios. Ensure emergency theatre is available and consider the need to exclude cord presentation on ultrasound before ARM. 3.4: DiagnosisThe sudden appearance of large fetal variable decelerations or prolonged fetal bradycardia on the cardiotocograph in labour or after spontaneous rupture of the membranes is an indication to perform a vaginal examination to exclude or confirm the presence of cord prolapse. The presence of cord should be excluded during all routine vaginal examinations in labour and after spontaneous rupture of membranes where risk factors are present or if fetal heart rate abnormalities commence immediately following rupture of membranes (ROM).Diagnosis can be made during a vaginal examination when a soft, usually pulsating structure is felt.On examination, the cord may be presenting (alongside the presenting part), or prolapsed (in the vagina or at the introitus).3.5: Management AntepartumSpeculum or vaginal examination immediately after rupture of the membranes for women with a high risk of cord prolapse. If cord prolapse is diagnosed, call for immediate medical assistance by pushing ‘Staff Assist’ button.Immediate assessment of clinical circumstances: gestationpresentationcervical dilatationfetal wellbeing. Obstetric emergency management will depend on gestation and viability and discussion with the woman.If no cord pulsation or fetal heart heard, confirm presence or absence of fetal heart with portable ultrasound.In cases of viability, expedite birth and manage as per intrapartum. 3.6: Management IntrapartumOnce cord presentation/prolapse is diagnosed, treat as an obstetric emergency and call for immediate medical assistance (obstetrician, anaesthetist, neonatal registrar) to expedite birth. Discontinue oxytocin infusion if in progress. The mode of birth will depend on whether a fetal heart is present or absent and the stage of labour. Explain findings to the woman including the emergency measures that may be needed. Aim to maintain the fetal circulation by preventing/minimising cord compression until birth occurs. Note time of diagnosis of cord presentation/prolapse and maintain a contemporaneous record of events until birth occurs. Cord pulsating Determine stage of labour by vaginal examination. Cervix is not fully dilated (first stage of labour) Arrange immediate caesarean section (Category A caesarean section) as per SOP Maternity: Non- Elective Caesarean Section Classification.Cannulate in accordance with Procedure Peripheral Intravenous Cannula, Adults and Children (Not neonates).Obtain and send group and hold.Ensure continuous CTG until in OT and commencing caesarean section or until after vaginal birth. The priority is to relieve pressure on the cord by elevating the presenting part while preparations are made for emergency caesarean section. This can be achieved by:Positioning the woman in the deep knee-chest position or on the left side with head down. Elevate the foot of the bed where possible. Manually elevating the presenting part is reasonable if there is immediate access to OT – insert sterile gloved fingers into the vagina to elevate the presenting part away from the cord. Avoid excessive handling of the cord. Acute intravenous tocolysis may be an effective adjunct treatment. Bladder filling: In cases where a delay in transfer to OT for caesarean section is expected – consider elevation of the presenting part through rapid instillation of sodium chloride 0.9 % (at least at room temperature) into the maternal bladder (by inserting the end of a blood giving set into a Foley catheter). Position head down in left lateral position before passing urinary catheter. Clamp the catheter once 500 –750mL has been instilled. Ensure the bladder is emptied before any delivery attempt. If the pulsating cord is prolapsed outside of the vagina, the cord may be replaced in the vagina or a pad soaked in warm sodium chloride 0.9 % may be used to cover the cord. Ensure minimal handling of the cord. Cervix fully dilated (Second stage of labour) If the woman is in the second stage of labour and vaginal birth is feasible with the presenting part at or below spines, encourage her to push her baby out. If there is a delay the medical officer should prepare for immediate assisted birth (vacuum extraction or instrumental). If immediate vaginal birth is not feasible, expedite birth by caesarean section. Cord not pulsating If no cord pulsation or fetal heart heard, confirm presence or absence of fetal heart with portable ultrasound. If fetal heart rate present proceed to urgent delivery and inform neonatal team.Commence neonatal resuscitation as per Newborn Advanced Life Support (NALS) guidelines.If fetal death confirmed allow labour to proceed as for vaginal birth of fresh stillbirth.If the cord is prolapsed outside the vagina wrapping the cord in a pad soaked in warm sodium chloride 0.9% may improve the woman’s comfort. Post birth Obtain arterial and venous cord blood gases immediately after birth.Document details of birth and outcome in the clinical record, in BOS and complete RISKMAN.Postpartum follow up Staff involved in the care of the woman should follow her up in the postnatal period to offer her de-briefing about the events of the cord prolapse and the opportunity to ask questions.Management of Cord Prolapse Flow ChartBack to table of contentsSection 4: Shoulder DystociaBackgroundShoulder dystocia is a complication of cephalic vaginal births. The anterior fetal shoulder becomes impacted against the maternal symphysis pubis after the fetal head is born. Shoulder dystocia is further defined as a prolonged head-to-body birth time (e.g. more than 60 seconds) or the need for ancillary obstetric manoeuvres.The Incidence of shoulder dystocia There is a wide variation in the reported incidence of shoulder dystocia. Large studies report incidences between 0.58% and 0.70%. Macrosomia is a weak predictor as up to 50% of shoulder dystocia occur in babies within normal weight range. 4.1 – Predisposing factors that could lead to shoulder dystocia Pre-labourPrevious shoulder dystocia.Macrosomia > 4.5kg.Maternal Diabetes Mellitus.Maternal body mass index >30kg/m?.Induction of labour.Post dates pregnancy.Maternal short stature.Abnormal pelvic anatomy.IntrapartumProlonged 1st stage of labour.Secondary arrest.Prolonged 2nd stage of labour.‘Head bobbing’ in 2nd stage - the head comes down towards the introitus with pushing but retracts well back between contractions.Oxytocin augmentation.Instrumental vaginal birth.Document in clinical record and report predisposing factors that could lead to shoulder dystocia.4.2 – Recognition of impending shoulder dystociaManagement of shoulder dystocia requires prompt recognition. Observe for:Long second stage with head ‘bobbing’.Difficulty with delivery of the head and chin.‘Turtling’- the delivered head becomes tightly applied to the perineum or even retracts. No restitution of the fetal head is seen.The fetal shoulders do not descend into the maternal pelvis.Commence ‘Shoulder Dystocia’ clinical pathway.4.3 – HELPERR- Systematic emergency management of shoulder dystociaThe H.E.L.P.E.R.R mnemonic (ALSO, 2015) is a clinical tool that can provide midwives and obstetricians with a structured framework in which to deal with a shoulder dystocia.The order of the steps need not always be done in the same order as the mnemonic suggests.H -Summon Help (ALSO, 2015). Ask for extra midwives, medical staff including obstetric registrar/and or obstetrician on call, neonatal registrar and anaesthetistCall a neonatal code blue, dialling 8 and asking for neonatal code blue to the locationAllocate a team member for documentation to record times and manoeuvres usedProvide explanation and reassurance to the woman and support people.AlertAvoid excessive traction at all times (strong downward traction or jerking without disimpacting the shoulder is associated with neonatal trauma including permanent brachial plexus injury).NEVER USE FUNDAL PRESSURE (this is associated with high neonatal complication rate and may result in uterine rupture and haemorrhage from potential detachment of a fundal placenta).MATERNAL PUSHING SHOULD BE DISCOURAGED (this may exacerbate impaction of the shoulders).E- Episiotomy (ALSO, 2015). Evaluate the need for an episiotomy (remembering that it is a bone on bone impaction not a soft tissue trauma). Episiotomy may be required to create more space for facilitating internal vaginal manoeuvres.L- Legs in McRoberts (ALSO, 2015). There is no evidence that the use of the McRoberts manoeuvre before delivery of the fetal head prevents shoulder dystocia. Therefore, prophylactic McRoberts positioning before delivery of the fetal head is not recommended. The woman should be laid flat and any pillows should be removed from under her back.Remove or lower the bottom of the bed and bring her buttocks to the extreme edge. If the woman is in lithotomy remove her legs from the lithotomy supports. Flex the maternal hips, thus positioning the maternal thighs up onto the maternal abdomen (knees to nipples). This will:straighten the lumbosacral lordosis increase the anterior/posterior diameter of pelvis flex the fetal spine. Reported success rates as high as 90% (Royal College of Obstetrics and Gynaecology RCOG 2012). AlertAttempt each manoeuvre for approximately 30-60 seconds.Throughout these manoeuvres the shoulders must be rotated using pressure on the scapula or clavicle. Never rotate the head.P- Pressure (Rubin’s 1 manoeuvre) (ALSO, 2015). If the shoulders do not dislodge proceed to suprapubic pressure by applying continuous pressure over the suprapubic region on the side of the fetal back to reduce the diameter of the fetal shoulders and rotate the anterior shoulder into the oblique diameter. If this is achieved the shoulder should slip under the symphysis pubis.If delivery of the shoulders does not occur, then proceed to a ‘CPR’ style rocking motion to attempt to dislodge the shoulder from behind the pubic symphysis.E- Enter (ALSO, 2015). If the shoulder is still undeliverable, then proceed to the enter manoeuvres.Maintain McRoberts position.Normal downward traction should be attempted after each manoeuvre to try to effect delivery.Rubin’s 2 Manoeuvre (ALSO, 2015).Approach anterior fetal shoulder from behind. Exert pressure on scapula to adduct most accessible shoulder and rotate to oblique position.Woods Screw Manoeuvre (ALSO, 2015).Approach posterior fetal shoulder from the front.Gently rotate shoulder towards symphysis.Combine with Rubin Manoeuvre.Reverse Woods Screw Manoeuvre (ALSO, 2015).Approach posterior shoulder from behind.Rotate fetus in opposite direction from Rubin or Wood Screw Manoeuvres.R- remove posterior arm (ALSO, 2015). The posterior arm can be removed to facilitate delivery of the posterior shoulder by following posterior arm down to elbow, (usually anterior to fetal chest). Flex arm at the elbow, then sweep forearm across fetal chest.Delivery of the posterior arm is associated with humeral fractures with an incidence of 2% to 12%. Alert:Grasping hand directly and pulling outward may lead to fetal fracturesR- roll woman over (ALSO, 2015). Roll the patient to all fours position (Gaskin Maneouvre), to increase pelvic diameters. The movement of the woman and gravity may also assist in dislodging the impaction. The posterior shoulder is then delivered with gentle downward traction.4.4 – Manoeuvres of last resortDeliberate fracture of clavicle. Muscle relaxation.Symphysiotomy.Zavanelli Manoeuvre.4.5 – Cord managementShoulder dystocia, either without or with the presence of a nuchal cord places the baby at particular risk of hypovolaemia. Compression on the cord or body of a tight fitting fetus may cause more fetal blood than usual to be extruded into the placenta. This may contribute to the baby being born in a poor condition. Cutting a tight nuchal cord prior to the birth of the shoulders has the potential to increase the baby’s risk of asphyxia, cerebral palsy and even death if there is severe shoulder dystocia. It is advisable to maintain an intact cord as far as possible. Call a Neonatal Code Blue immediately and prepare resuscitation equipment.Until Neonatal MET arrives, maintain airway, breathing and circulation (ABC), as clinically indicated (follow NALS guidelines).Once the shoulders are free there are several options for management. Slip the cord over the head or down around the shoulders and slide the baby through the cord. Initiate the Somersault Manoeuvre. Deliver the baby slowly and bring the head as it is born towards the mother’s thigh. Keep the baby low near the perineum while the body is delivered so that little traction is exerted on the cord. Avoid cutting the nuchal cord immediately after birth as the dynamics of cord compression will likely have resulted in an increased transfer of blood to the placenta. Pale colour and poor fetal tone equate with hypovolaemia of the baby. A delay in cord clamping is required for blood volume to equalise after birth and assist with the transition to neonatal life. If the cord needs to be cut immediately after birth the restoration of the baby’s blood volume can be assisted by rapidly milking the cord two to four times from the introitus to the baby’s umbilicus before cutting the cord. DocumentationDocument on ‘Shoulder Dystocia’ pathway.Complete RISKMAN after birth. 4.6 – Complications and care post birthComplications associated with shoulder dystocia:WomanBaby3rd and 4th degree perineal tears vaginal lacerationscervical tearsbladder rupturesymphyseal separationsacroiliac joint dislocationlateral femoral neuropathypostpartum haemorrhage uterine rupture future obstetric issuespsychological effects of birth traumabrachial plexus palsy clavicle/humeral fracturefetal acidosis hypoxic brain injury deathPost birthObserve the woman closely for post partum haemorrhage and severe perineal tears.Until Neonatal MET arrives, maintain airway, breathing and circulation (ABC), as clinically indicated (follow NALS guidelines).The baby should be examined for injury by a neonatal clinician. Take cord blood for paired cord sampling (venous and arterial) for pH, base excess and lactate.All women will be offered the opportunity to discuss their birth with a midwife or obstetrician.Back to Table of ContentsImplementation This guideline will be:Discussed at Maternity in-service education.Discussed at Maternity multidisciplinary education.Placed on notice boards in tea rooms.Distributed to maternity staff via email.Available on Sharepoint.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationCritical Bleeding Massive Transfusion Clinical Procedure.Labour: 1st 2nd and 3rd Stage Care Clinical procedure.Non-Elective Caesarean Section Standard Operating Procedure.SOP Maternity: Non- Elective Caesarean Section Classification.Back to Table of ContentsReferencesAlexander, J, Thomas P, Sanghera J. (2002) Treatments for secondary postpartum haemorrhage (Cochrane Review). In: The Cochrane Library, 1, Oxford.Advanced Life Support in Obstetrics (ALSO) (2015) Course Syllabus. Postpartum hemorrhage: third stage emergency.Advanced Life Support in Obstetrics (ALSO), (2015) Course manual, shoulder dystocia. American Academy of Family Physicians KansasCombs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage in caesarean deliveries. Obstet Gynecol 1991; 77 :77-82 69212.East Cheshire National health Service Trust (2012) Guideline for the Management of shoulder dystociaElbourne DR, Prendiville WJ, Caroli G, Wood J, McDonald S. (2002) Prophylactic use of oxytocin in the third stage of labour (Cochrane Review). In: The Cochrane Library, 1 Oxford. Ford JB, Roberts CL, Bell JC, Algert CS, Morris JM. Postpartum haemorrhage occurrence and recurrence. MJA 2007: 187(7); 391-393Gülmezoglu AM, Forna F, Villar J, Hofmeyr GJ. (2007)Prostaglandins for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000494.Integrated Management Of Pregnancy And Childbirth IMPAC (2007): Managing Complications in Pregnancy and Childbirth. A guide for midwives and doctors. Correcting uterine inversion NSW Health Department. PD2010_064 Maternity - Prevention, Early Recognition & Management of Postpartum Haemorrhage (PPH)King Edward memorial Hospital, 2010, Complication of the postnatal period, postpartum haemorrhage uterine inversionKing Edward Memorial Hospital (2013) Section B obstetrics and midwifery guidelines, 5 Intrapartum Care, 5.9 second stage of labourPairman, S, Tracey, S Thorogood, C Pincombe, J 2010, Midwifery, Churchill Livingstone publisher, 2nd edition Prendiville WJ, Elbourne D, McDonald S.(2002) Active versus expectant management in the third stage of labour (Cochrane Review). In: The Cochrane Library, 1, 2002. Oxford. National Blood Authority (2011).Patient Blood Management Guidelines. Module 1- Critical bleeding/.Massive Transfusion and module 5- Obstetrics and Maternity.Mousa HA, Alfirevic Z. (2007) Treatment for primary postpartum haemorrhage. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD003249. Royal College of Obstetricians and Gynaecologists (RCOG). Umbilical cord prolapse. Green-top Guideline No. 50. April 2008. Available from URL: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT50UmbilicalCordProlapse2008.pdfRoyal College of Obstetricians and Gynaecology (2012) Green Top Guideline No. 42 Shoulder Dystocia.Royal Women’s Hospital (2013) Shoulder Dystocia guideline.SA Maternal & Neonatal Clinical Network (2014) South Australian Perinatal Practice Guidelines – cord presentation and prolapsed. Back to Table of ContentsDefinition of Terms Accoucheur is defined as the person who has their hands on the baby during birth.Cord prolapse: is defined as the descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes. Cord presentation is the presence of the umbilical cord between the fetal presenting part and the cervix, with or without membrane rupture.DIC – Disseminated intravascular coagulation. Head bobbing: the fetal head comes down towards the introitus with pushing but retracts well back between contractions.Hypovolaemic shock is a life-threatening condition in which reduced circulatory volume results in inadequate tissue perfusion. In the early phases of haemorrhage, the body compensates for blood loss by raising systemic vascular resistance in order to maintain blood pressure and perfusion to vital organs. Clinically, this corresponds to a narrowing of the pulse pressure. As bleeding continues, however, further vasoconstriction is impossible resulting in decreased blood pressure, cardiac output, and end-organ perfusion. Compensatory homeostatic mechanisms are activated, including vasonconstriction, increased cardiac activity, reduced fluid excretion and increased platelet numbers. Blood flow to the heart, brain and adrenal glands is optimised at the expense of other organs. When persistent, irreversible cell damage occurs, and falling myocardial perfusion leads to a vicious cycle of myocardial failure and death. The clinical signs are delayed in newly parturient women due to the increased blood volume of pregnancy. By the time these vital signs are abnormal the woman will have lost at least 1500mL.Intrauterine haemostatic balloon is a balloon tamponade indicated for women not responding to uterotonics and uterine massage. It is used to control haemorrhage due to uterine atony in the upper segment of the uterus and to control bleeding in the lower uterine segment secondary to placental implantation in the lower uterine segment.Postpartum hemorrhage (PPH) is defined as blood loss of 500mL or more during and after childbirth: Major PPH is defined as such when there is continued bleeding and failure to respond to first line-management and cases where blood loss is approaching or exceeding 1000mL Significant PPH is defined as blood loss of 1000mL or more OR any amount of blood loss postpartum that causes haemodynamic compromisePrimary PPH: occurs within the first 24 hours following birthSecondary PPH is defined as a blood loss of >500mL after 24 hours and up to 6 weeks postpartum.Nuchal cord: the umbilical cord is wrapped around the neck of the fetus as it is being bornSymphysiotomy: a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there is a mechanical obstruction/problem. Tocolytics: Tocolytic agents inhibit uterine contractions.Turtling: in second stage- the born head becomes tightly applied to the perineum or even retracts. 3rd degree perineal tears: 3rd degree tear is a partial or complete disruption of the anal sphincter muscles. 4th degree perineal tears: 4th degree tear injures the anal sphincter muscles with a breach of the ano-rectal mucosa Cleidotomy; deliberate division of the fetal clavicle in shoulder dystocia. Zavanelli manoeuvre: the replacement of the partially born fetus into the uterus followed by Caesarean section.Back to Table of ContentsSearch Terms Postpartum haemorrhage, PPH, Postpartum bleeding, Blood loss, Postpartum blood loss, Postnatal blood loss, Postnatal haemorrhage, Primary Postpartum haemorrhage, Secondary Postpartum haemorrhage, Uterine inversion, Inversion, Prolapse,Inversion of the uterus, Cord prolapsed, Cord presentation, Cord accident, Prolapsed cord, Pulsating cord, Loop of cord, Presenting cord, Cord presenting, HELPERR, Impacted shoulders, McRobert’s, Rubin’s 1, Rubin’s 2, Shoulder dystocia, Woodscrew manoeuvre, Zavanelli manoeuvre.Attachments Attachment 1: Flowchart: Management of postpartum haemorrhage (NSW Health 2010)Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC ChairAttachment 1: Management of postpartum haemorrhage flowchart (NSW Health 2010)Continued over page

What procedure is followed in laceration repair? Some of the basic questions that you might ask your physician are as follows: What is a Laceration Repair? Why is this procedure necessary? ... How soon should I get it done? ... Who are the medical personnel involved in this procedure? Where is the procedure performed? What are the risks while performing the procedure? What are the complications that might take place, during recovery? How long will it take to recover? ... More items...