Obstetric Emergencies with Mr Tim Hookaway, Amy Borland and Stephanie Lamb

​Today we tried something different in a sim session… O&G Consultant Tim came down to ED with two of his registrars (Steph and Amy) and we rotated through two obstetric emergencies in ED stations… socially distanced of course but let me tell you, there is NOTHING socially distanced about the raw practice of delivering a baby!
 
Amy and Steph talked us through a normal delivery:  

Should present face down, deliver the head, then allow “Restitution” – where the baby rotates to fit the torso through the birth canal. On the next contraction – the anterior(upper) shoulder should deliver then posterior shoulder. Now breathe yourself…. And if the baby is breathing – there is no rush to cut cord, you can give the baby a quick dry and a rub and put it skin to skin with mum… job done!
 
 
Then, we talked through and delivered a baby with the absolutely EMERGENCY finding of Shoulder dystocia… code very, very scary…
 
This is where the baby’s shoulder is stuck behind mum’s symphysis pubis…
 
Risk factors – obesity in mum, gestational DM – big baby
Head may deliver slowly, ‘turtle necking’, undelivered chin.
May not restitute fully
No progression on second contraction
 
This is completely Time critical– as a team we have only a few minutes to prevent a hypoxic brain injury/death… here is the SOP:

• Call for help– 2222 declare “obstetric emergency, shoulder dystocia”, 
• McRoberts manoeuvre – lie supine, legs down straight then back up to chest (hugging knees)
• This solves most dystocias

 

• If no improvement progress to:
• Suprapubic pressure to baby’s posterior side 

 

• If no improvement progress to:
• Internal manoeuvres 
  • 1) Deliver posterior (lower) arm – insert hand into vagina (fingers together like reaching for pringles in tin) +/- episiotomy (8 o’clock position). Try to grab baby's hand/arm and deliver:

• 2) If this doesn’t work, or you have bigger hands (and cannot get into the pringle tin!!) rotate the baby – 2 fingers behind the anterior (upper) shoulder, 2 fingers in front of posterior (lower) shoulder. Rotate around – may need to reverse positions and rotate in the opposite direction.:

• If no improvement 
  • Consider change in operator
  • Reposition mum – all fours head down

 
Be aware that you may cause fractures to humerus/clavicle, this is totally OK if you can baby out alive…. Super scary… let’s hope those 2222 bleep holders can run fast and have mini, super strong hands!!
 
Give this a watch: https://www.youtube.com/watch?v=1HeXmlf_sp4
 
 
 
 
 
Our obstetric registrar friends also talked us through how to deliver a baby presenting as a Breech delivery…
 
First thing: This May be very quick in multiparous women – be prepared to catch!
​

​You will notice that buttocks are presenting.
The baby is facing posteriorly (down)…
 
Bring mum to the end of bed. 
 
This is a hands off situation. Minimal handling of the baby will avoid stimulation that will promote breathing (while head still inside)/increased metabolism/oxygen consumption.
 
If handling is required - only to the bony pelvis/hips of the baby.
 
Allow the buttocks to deliver – allow baby to hang down
The hips will probably be flexed and knees extended, you can use your finger to ‘flick’ them out:

​Allow delivery until the shoulder blades are seen
 
The arms  can be delivered by gentle rotation of baby at hips
Or
Sweeping the arms over the baby’s face with a finger

​The neck/head needs to flex to allow narrowest cross section to pass through the birth canal.

• To assist – assistant give suprapubic pressure to mum and 
• Do the Mauriceau – Smellie – Veit manoeuvre:

Lay the baby’s torso onto your forearm – palm of hand holding the head, place index finger on baby’s facial bones, with the other hand – place two fingers onto the baby’s occiput, flex the neck and raise the baby – delivering the head

​Again, have a watch of this: https://www.youtube.com/watch?v=EWjKswZ3Mm8
 
And that if that didn’t get our hearts racing fast enough, we also spent an hour chatting to Tim about resuscitating the pregnant patient in a peri-arrest or cardiac arrest situation, medications during pregnancy, post partum haemorrhage management and pre-eclampsia treatments…
 
The harsh fact is maternal mortality is not falling, despite improvements in care because patients are becoming increasingly complex…

​While we work at Derriford ED, we need to know a few things about obstetric emergencies:
 
 
30993 – Labour ward emergency phone – useful if putting out a 2222 – tell them what the problem is – so they know what to bring eg  – shoulder dystocia (run very, very fast and get here yesterday) vs PPH (come quickly).
 
 
As a refresher, we reminded ourselves of the physiological changes that occur in pregnancy, affecting every letter from A-E… check out the PROMPT course for more on that or read your ALS special circumstances chapter… Here area  few pearls from Tim’s talk:
 

• Beware of increased renal excretion – beware renally excreted drugs (increased clearance) eg will need a more frequent dose of enoxaparin to treat a PE (BD not OD).
• Shock is hard to spot – 35% blood volume loss before significant signs. The foetal-placental unit takes 500mls/min of the mother’s circulation. Increased foetal heart rate may be the first sign of hypovolaemia. Narrowing of pulse pressure will occur before before BP drops.
• Use MOEWS obs chart in ladies from about 20/40 
• Best care for baby is the best care for mum – don’t get side-tracked by pregnancy
• Regarding medications for the mum…. Does pregnancy affect treatment? Will treatment affect pregnancy? As a general rule – if it’s absorbed by the gut it will cross the placenta. Specific info about interactions with developing foetus are at http://www.uktis.org/, the UK teratology information service

Links to patient friendly information here:  https://www.medicinesinpregnancy.org/
 
Resuscitation in pregnancy…also a scary subject…
Same principles as any other resuscitation but do not forget: 

• Ensure uterine displacement off the IVC ideally manually by left lateral displacement of uterus (makes compressions more effective in CPR than using a wedge/ tilt
• A Resuscitative hysterotomy (previously known as a perimortem caesarean section) is for the benefit of mother, this need to be done very quickly in the event of a cardiac arrest….

         Consider at 3mins, start by 4mins, out by 5mins – some good outcomes even after long periods.
 
Now the thorny subject of PE/VTE disease in pregnancy….
A negative D-dimer is probably useful in low pre-test probability patients but what about imaging??
 
V/Q vs CTPA

• Modern CT is much more targeted. Risk is to breast tissue not the baby
• Risks of radiation in CTPA have likely been overplayed
• V/Q increases risk to the baby – leukaemia, mum remains radioactive for 24 hours
• V/Q is less likely to be diagnostic so you may end up doing a CTPA as well!

Our money is on a CTPA as the better, lower (but not zero) risk option during pregnancy…
 
We had a  great chat about managing Post-Partum Haemorrhage (PPH)
Primary PPH occurs up to 48 hours of delivery vs Secondary PPH which occurs after 48hours (secondary is much more likely to be infective)
 
Resuscitate – as for haemorrhagic shock – think blood products, rotem, calcium etc.
Give antibiotics if suspected infection (so nearly all secondary PPH)…
 
We all love the 4Hs and 4Ts of cardiac arrest causes… but in obstetrics, let’s not forget the 
 
4 T’s of PPH:
 
Tone– Most common, the uterus is exhausted after its big night out (push,push, push) and needs a hormone to increase uterine contraction – ergometrine/syntometrine/misoprostil. (caution if hypertensive). We keep ergometrine in our ED resus drug cupboard:

​Tim also reminded us about using Bimanual compression in these ladies: put a fist into the vagina while also applying  fundal pressure – it should be painful/tiring if effective (may need to change operator). Here is Tim showing us the desired effect on the tired atonic uterus….

On those 4Ts also think: 
 
Trauma–a simple perineal tear possibly…
– if arterial, can bleed quickly – fresh red blood is likely to be perineal: is it possible to put a quick suture in place and apply pressure?
 
Tissue– Retained products?
         Check the placenta after eth delivery of the baby and placenta, is there a chunk missing or ragged membranes, suggesting  some may remain in mum’s uterus?
 
And finally: 
Thrombin– Are they forming clots? – A DIC picture represents fairly advanced bleeding… we need ROTEM to help us… along with the expertise of the obstetric team… resuscitate with blood products asap.
 
Briefly, we considered another obstetric emergency presentation we may see in ED: Eclampsia
Usually we will see a patient presenting with a headache and Hypertension and/ or proteinuria (can occur without either but very rare). This is pre-eclampsia…
It is of unknown cause but may progress to seizures – give MgSO4 - 4g in 20mls saline over 20 mins (double the typical ED dose for asthma etc)
Use labetalol for BP control….
 
And that was our multiprofessional interactive, hands on, socially distanced morning…. More soon, watch this space!
 
 
With huge thanks to the obstetric team of Tim, Amy and Steph, to James Keitley for his unwavering enthusiasm for education  and awesome administrative support today and to Neil Spencer for lending me his notes to Annetticise…