331 teri campbell - cmcgc.com
TRANSCRIPT
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2011-09-19
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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 copyright 2006 www.brainybetty.com; All Rights Reserved. 3
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Delivery Complications
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
Delivery Complications
Imminent Delivery
• BSI principles• “Most experienced”• Privacy / Positioning• OB “kit”• Infant resuscitation equipment
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Breathe! Breathe! (you not her)
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• Crowning of the head• One hand support the head• One hand supports the perineum• Most are OA
The Head Is Out!
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• 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
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• 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
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• Suction• Dry• Bake at 350 for 30 “• Basic NRP• Put to breast • Uterine massage
Precipitous delivery
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• 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!
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• 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
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• Vasospasm of the umbilical vessels• Compression by presenting part• Drop in temp of prolapsed cord
Risk Factors
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• Multiparity• Prematurity• Macrosomia• Breech• High Fetal station with ROM• Polyhydramnios
Kids Don’t Try This at Home
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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
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• Shoulder diameter wider than head• Macrosomia• ↑ 4000 GMS• IDDM moms• “Turtle”• OMG!
Purple Face…The Baby And You
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• 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
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Resolves ≥ 50% of dystocias with suprapubic pressure
Snip, Snip
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• 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”!
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Harmful Maneuvers• Fundal pressure• Excessive traction on fetal head/neck• Twisting or bending of neck
Last Option?
Zavenelli: C/S with cephalic replacement
Breech
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• Presenting fetal part: buttock or feet• Incidence 3-4%• ≤ 28 weeks, 1/3rd
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Just a Bad Sense of Direction?
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• Premature gestation (gravity)• Multiple gestation• Polyhydramnios• Placenta previa•‘Hydrocehalus• Uterine anomaly
Types
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• Complete: 10%• Incomplete (footling): 25%
- 17% risk of prolapse cord• Frank: 65%
Risks
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• Fetal- Umbilical cord compression- ↑ Birth trauma- Head entrapment
• Maternal - “Blasted bottom” and then a C/S
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Blue Feet
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• 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
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• Thumbs over the sacrum, fingers over hips• Gentle downward traction• Scapula delivers• Fetal back rotates laterally
Now The Shoulders
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• 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
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• 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
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• 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
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• Incidence: 0.3-1.7% (previous uterine scar)
• Etiology:Ruptured uterine scar (9%)TraumaUterine hyperstimulation (cocaine)Uterine over-distension
Presentation
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• 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
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• T&C• Order lots of RED stuff- EBL 2 liters (50%)
• Crash C/S
• Emergency hysterectomy
Perimortum C/S
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• Viable fetus • Maternal arrest with in 5 minutes (17 min)• Continue CPR• Prepare for poor neonatal presentation• Procedure
On That Happy Note…
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Are there any questions?
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Have I Mentioned That I Hate OB?
Delivery Complications
Teri Campbell RN, BSN, CEN, CFRNFlight NurseUniversity of Chicago Aeromedical Network