331 Teri Campbell - cmcgc.com

2011-09-19

1

Have I Mentioned That I Hate OB?

Delivery Complications

Teri Campbell RN, BSN, CEN, CFRNFlight NurseUniversity of Chicago Aeromedical Network

2011-09-19 copyright 2006 www.brainybetty.com; All Rights Reserved. 2

Objectives

• NSVD

• Precipitous delivery

• Cord Prolapse

• Shoulder dystocia

• Breech

• Uterine rupture

• Perimortum C/S

A Word From Our Sponsors…

• Birth Control…. Not just when you feel like it


2011-09-19

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Imminent Delivery NSVD

• Regular contractions• Urge to bear down / feeling of BM• Bloody show• Crowning• “The baby is coming!!!”

I want nothing to do with this…

Delivery alternatives


Imminent Delivery

• BSI principles• “Most experienced”• Privacy / Positioning• OB “kit”• Infant resuscitation equipment

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Breathe! Breathe! (you not her)


• Crowning of the head• One hand support the head• One hand supports the perineum• Most are OA

The Head Is Out!


• En caul• Control the delivery of the head (yeah right)• Check for nuchal cord / reduce / clamp/cut• Suction the gooey stuff

I Hope He’s Not a Linebacker


• Natural rotation (**)• Gentle traction down for anterior shoulder• Gentle traction up for posterior shoulder• CAUTION! Greased baby to follow!• Expect a loud cry

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The “beer bong”

Keep the baby level with the perineum

Just a Quick Note About Junior


• Suction• Dry• Bake at 350 for 30 “• Basic NRP• Put to breast • Uterine massage

Precipitous delivery


• Labor of less than 3 hours• Rapid second stage• May be R/T co-morbidities• They NEVER lie (about this)

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Classic signs… don’t blink!


• Spontaneous pushing• Vaginal bleeding• Labial separation• Anal dilation: “rosebud” “brown hair”• Clearly “theirs” not “your”!

“Damage control”Counter pressure on the perineum

Does Your Face Hurt?

Bruising and respiratory issues

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Did anyone hear that?

A transport story…

Hair raising??Mary ↓

Prolapsed cord

• Incidence:- Vertex: 0.4%- Frank breech: 0.5%- Complete breech: 4-6%- Footling breech: 15-18%

• Definition- Frank- Occult

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Kinking of the hose


• Vasospasm of the umbilical vessels• Compression by presenting part• Drop in temp of prolapsed cord

Risk Factors


• Multiparity• Prematurity• Macrosomia• Breech• High Fetal station with ROM• Polyhydramnios

Kids Don’t Try This at Home


Maternal position

Our position

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No, We Don’t Stuff It Back In

• Cord handling

• Terbutaline 0.25 mg

• “Phone first”

Shoulder Dystocia


• Shoulder diameter wider than head• Macrosomia• ↑ 4000 GMS• IDDM moms• “Turtle”• OMG!

Purple Face…The Baby And You


• Suprapubic pressure- pressure over bladder not fundus- Oblique downward and anterior pressure- Initial pressure 30-60 seconds- Then rocking motion (like CPR)

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Turn Her Into Gumby


Resolves ≥ 50% of dystocias with suprapubic pressure

Snip, Snip


• Cut a generous episiotomy- ML, LML, RML

• Does NOT affect bony obstruction• More room for rotational maneuvers

They Make It Sound Easy

H: Call for helpE: Evaluate for episiotomyL: McRoberts maneuverP: External pressure /suprapubicE: Enter: rotational maneuversR: Remove posterior armR: Roll the patient to hands / knees

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Mama Said “NO”!


Harmful Maneuvers• Fundal pressure• Excessive traction on fetal head/neck• Twisting or bending of neck

Last Option?

Zavenelli: C/S with cephalic replacement

Breech


• Presenting fetal part: buttock or feet• Incidence 3-4%• ≤ 28 weeks, 1/3rd

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Just a Bad Sense of Direction?


• Premature gestation (gravity)• Multiple gestation• Polyhydramnios• Placenta previa•‘Hydrocehalus• Uterine anomaly

Types


• Complete: 10%• Incomplete (footling): 25%

- 17% risk of prolapse cord• Frank: 65%

Risks


• Fetal- Umbilical cord compression- ↑ Birth trauma- Head entrapment

• Maternal - “Blasted bottom” and then a C/S

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Blue Feet


• If feet present, reduce and deliver the legs• Do NOT pull on the legs!• Towel, gentle downward traction• Back rotates anteriorly• Spontaneous delivery up to the umbilicus

So Far, So Good


• Thumbs over the sacrum, fingers over hips• Gentle downward traction• Scapula delivers• Fetal back rotates laterally

Now The Shoulders


• Deliver the posterior shoulder first• Upward, gentle traction• Deliver the anterior shoulder second• Reduce the arms if necessary

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Now Would Be a Good Time to Pray


• Fetal chin is usually posterior (down)• Mauriceau maneuver• Hook 2 fingers on either side of the fetal neck• Gentle downward traction until subocciput delivered• Gentle upward traction• Deliver the mouth, nose and rest of the head

Breech Pearls


• Prepare for C/S• BIG episiotomy• Dry towel• McRobert’s position

• Change YOUR diaper after the delivery!

• Etiologies• Suctioning• Current practices• “Thickest mec I’ve ever seen”

When the meconium hits the fan…

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Meconium

Neonatal preparation

Uterine Rupture


• Incidence: 0.3-1.7% (previous uterine scar)

• Etiology:Ruptured uterine scar (9%)TraumaUterine hyperstimulation (cocaine)Uterine over-distension

Presentation


• Classic signs (unreliable)- Sudden tearing pain- Vaginal bleeding

• Fetal distress - “fetal parts”

• Maternal distress:- Tachycardia- Hypotension- Shock

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Only One Thing Will Make This Better


• T&C• Order lots of RED stuff- EBL 2 liters (50%)

• Crash C/S

• Emergency hysterectomy

Perimortum C/S


• Viable fetus • Maternal arrest with in 5 minutes (17 min)• Continue CPR• Prepare for poor neonatal presentation• Procedure

On That Happy Note…


Are there any questions?

2011-09-19

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Have I Mentioned That I Hate OB?


Teri Campbell RN, BSN, CEN, CFRNFlight NurseUniversity of Chicago Aeromedical Network

Documents

331 Teri Campbell - cmcgc.com