Mar 25, 2021
In this podcast, Dr. Dennis Mohling, a board certified OB-GYN physician with Western OB-GYN, provides an insight into obstetric emergencies and how to deal with them if and when they occur.
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The first stage of labor involves regular contractions affecting cervical changes up to complete cervical dilation. The next stage is the pushing and delivery of the baby, and the third stage follows delivery, ending in delivery of the placenta.
The placenta is "retained" if it is still in the uterus after 30 minutes. The uterus cannot contract at this point and with approximately 500mls of blood going across the placenta-uterine interface retained placenta increases the risk for hemorrhage. Incidence is around 3%.
A long list of risk factors for retained placenta include: preterm delivery, history of retained placenta, placental abnormalities, velamentous cord, and uterine abnormalities - like bicornuate uterus or septate uterus. Prior C-sections are also a risk factor, as well as intrauterine growth restrictions, and severe preeclampsia.
After the 30-minute mark, preparation for manual extraction needs to begin. It's the "call for help" action step that will be a recurring theme in the discussion today. This includes the very important step of calling anesthesia. Manual extraction is a painful process, and great analgesia and sedation is a necessity.
Manual extraction: using the umbilical cord as a pathway to the uterus with the dominant hand and supporting the uterine fundus with the other. Use fingers to create a dissection plan and gradually peel away the placenta from the uterus, removing it in its entirety. Post-removal the uterus will contract, but IV Pitocin, IM methergine, and TXA can be given as well. Pitocin dosing: 20 units in a liter of LR, run wide open.
Average placental delivery can range from right away to 60 minutes post-delivery of the baby; but retained placenta can have a delayed presentation. This can cause prolonged bleeding requiring extraction days, to weeks postpartum.
There are three stages of abnormal placental attachment. Placenta accreta: the stria layer between the placenta and uterus is absent. Placenta increta: the placenta is invading the muscle wall of the uterus. Placenta percreta: the placenta has grown through the uterus and into other organs. With uterine wall involvement, this will result in a c-section and likely a hysterectomy.
Uterine inversion is yet another scary presentation and can result in severe hemorrhage, shock and death. The uterus can be mildly inverted and protruding or fully inverted outside of the pelvis.
Post-delivery, and in active management of the third stage, gentle cord contraction is the goal. Uterine inversion is thought to be the result of excessive cord traction, but the data on this is mixed. Incidence is 1 in 35,000, rare but still real. Larger babies, long labors and sometimes fast short fast labors, severe preeclampsia, retained placenta and other uterine abnormalities are risk factors, through these are only present in 50% of uterine inversion cases.
Treatment is non-surgical. The uterus needs to be returned as soon as it's discovered. Insert that, "call for help" step. Anesthesia, more personnel, including nurses and lab techs are part of that "help" response.
In order to return the uterus back inside the pelvis, pitocin should be stopped and uterine relaxant agents, like inhalation agents or nitroglycerin may be needed. The uterus is then pushed back through the vagina and cervix to its normal position. Once back in place, the placenta needs to stay intact. Uterine relaxant agents are turned off, and uterine tonic agents and TXA are started. Manual extraction of the placenta follows. As the uterus is never meant to be outside the body, antibiotics are started as well.
3: Cord Prolapse
In delivery, the head of the baby should act as a barrier. If the umbilical cord slips in front, it will become compressed as the baby delivers, causing fetal asphyxia. Incidence is 2 in 1000.
Risk factors include: polyhydramnios, prematurity, breach, transverse lie, twin gestation, and after rupturing of membranes or other intrapartum procedures like cervical ripening with balloon catheter.
Presentation is generally obvious with visualization or palpation of a pulsatile mass in the vagina or out on the bed. The fetal monitor, with normal being 120-160 bpm, will show a slowing heart rate, with variable decelerations.
C-section is the eventual fix, but in preparation for that intervention, the compression on the cord must be reduced. This is accomplished by lifting or pushing the baby's head more cephalad for as long as it takes, until a C-section can be performed. The cord should not be cut, instead if it is outside the vagina, it should be covered in warm moist towels.
4: Shoulder Dystocia
Shoulder dystocia is scary and way more common. It's the failure of the anterior shoulder to deliver after the head, and is instead stuck behind the pubic bone. Baby is at risk for brachial plexus injury as well as brain injury from asphyxia.
Unfortunately, this is not a predictable dilemma. Sometimes having bigger babies does increase risk of this, but that is not always the case. Advanced maternal age, maternal age, maternal obesity and diabetes can result in bigger babies. History of shoulder dystocia in the past is also a risk factor.
In the event of shoulder dystocia, a "turtle sign" may be noticed, where the baby's head comes out, then retreats between contractions.
Dr. Mohling's Steps for Shoulder
Step 1: Preparation. Position the mother appropriately right at the edge of the bed, give gentle traction, have a stool ready for suprapubic pressure.
Step 2: Do not make it worse, by pulling harder.
Step 3: McRoberts maneuver (hyperflexion of maternal legs) combined with suprapubic pressure, and of course "call for help".
Usually the dystocia is relieved in less than a minute. If this doesn't work, a generous episiotomy is done to give room to maneuver. Next step is delivery of the posterior arm, by reaching in and finding the hand. If not found, press the antecubital fossa to flex the arm. Risk of humerus fracture with delivery of the posterior arm is 1 in 5.
Ritgen Maneuver: Adduction of the posterior shoulders by placing the fingers behind the scapula and adducting the anterior or posterior shoulder to reduce the AP diameter.
Woodscrew: Corkscrew the baby out, which sounds easier than it is.
Clavicle Fracture: Pulling the bone away from the baby so as not to cause lung injury. Difficult to do with the size of the bone and slippery conditions during delivery.
As last resort, the zavanelli maneuver, or attempting to return the baby back up the birth canal to the uterus for emergent c-section, may be performed.
Thank-you for listening.