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National Lecture Series - Perinatal Disasters

Christopher Doty, MD
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13:53
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Nurses Edition Commentary

Mizuho Spangler, DO, Kathy Garvin, RN, and Lisa Chavez, RN
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EM:RAP 2016 May Written Summary 626 KB - PDF

If we have to deliver a baby in the emergency department, we hope that everything runs smoothly. Sometimes, we get the unlucky ticket and there is a complication like shoulder discotica or cord prolapse. Does this bring up any feelings of anxiety? Chris Doty empathizes and is here to walk you through management of perinatal disasters.

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Kristopher L., M.D. -

Dr. Doty

Would you be willing to share your powerpoint presentation?

Thanks

Kris Lyon

Alex K. -

I can share whatever we make, but we're planning it more as a tabletop exercise pre-simulation.

Sean G., M.D. -

Wow!!!! Thank u! This was a game changer for me. My entire career I have dreaded these scenarios.... I even didnt like a normal delivery too much...in my OB rotation(decades ago) I was always befuddled...it seemed one nurse would be yelling "Push!" then suddenly someone would yell "Don't push!" meanwhile someone was twisting and turning the greased pig of a child like some kind of bizarre living turbine....it was all so confusing...most of my career I found myself hoping the few deliveries I had would essentially deliver themselves...despite me. Now I feel I have a grasp on my fear....I understand it, have a plan, and will know what at least I am supposed to be doing!
Thank u Thank u Thank u!
One question...during the breech delivery when u get to the last part where u are placing two fingers in the mouth and flexing the neck while applying slight traction engaging the cervix and (hopefully) completing the delivery....the baby is now back to the "butt up "position? Please clarify that....thanks much!

Rob O -

Here is Dr Doty's reply....
Sean- You have it right. In a breach delivery, after you have delivered to the umbilicus, make sure you get the child “butt up” and then deliver both shoulders. After delivering both shoulders, the child should be again in the “butt up” position. Allowing you to slide a hand underneath the child’s chest and up to the mouth. By putting a finger into the mouth, you can help you flex the head and provide traction without distracting the head from the neck.

Courtney W. -

I'm a family physician who practices in the ED and L&D. I'm also an Advanced Life Support in Obstetrics (ALSO) instructor. Several points in this talk were incorrect and a few could be dangerous if attempted.

New Neonatal Resuscitation Program (NRP) guidelines treat babies with meconium stained fluid like all other babies. No more intubation to suck out mec below the cords if the baby's floppy, because the aspiration has usually happened before the first breath. So, while mec aspiration is a serious thing, I don't know if meconium stained fluid would warrant transfer before birth.

Normal fetal heart rate is 110-160

DO NOT suction the mouth after the head comes out. That hasn't been standard practice for at least 5 years. Suctioning can lead to an apneic response at the very moment you want the baby to start breathing. You also don't want to slow it's momentum out or risk dropping the baby while fumbling with the bulb suction.

Turtle sign- the head comes out and gets sucked against the perineum. Think "have to almost peel back the labia to fully expose baby's chin and cheeks"
A shoulder dystocia is a bony impaction. As such, draining the bladder won't give you any more room and would be nearly impossible to achieve. The baby's head is in the way.
ALSO has a very helpful pneumonic for remembering what to do in a shoulder dystocia:
"HELPERR"
H- call for Help
E- Evaluate for Episiotomy (It will not get the baby out, it's so your hand can fit inside to do the maneuvers)
L- Legs back (McRobert's)
P- supraPubic Pressure with a fist pushing down and forward on the anterior shoulder. You have to tell an assistant which way to push as you can tell which shoulder's anterior (usually the way the baby's looking).
E- Enter maneuvers- put 2 fingers behind each shoulder to try to turn or corkscrew the baby out. Try "forwards" and "backwards." Whatever works.
R- Remover the posterior arm. **This has trumped the Enter maneuvers as it usually is more successful and especially for women who have smaller hands. Put your whole hand in posteriorly, grab the posterior hand or arm, pull it across the chest and out the vagina. The clavicle or humerus might break, but you're saving the baby's brain/life.
R- Roll the patient on hands and knees. It changes the diameter of the pelvis which can dislodge the impaction.

Postpartum hemorrhage
- Massage the fundus immediately after the placenta delivers, and do bimanual massage early if you're concerned. This will save a lot of bleeding. You have to put your whole hand inside up to the wrist to do it correctly.
- Drain the bladder. If it's full, it will impede the contraction of the lower uterine segment which is often a source of bleeding if the funds is firm.
- Get meds on board fast if you're worried. No methergine if she's hypertensive. Hemabate will cause diarrhea but works well. Give misoprostol rectally (better if she might vomit or need to be intubated)

To Sean G, MD's question- Once the legs come out, you always rotate the baby to back or butt up position as it facilitates sweeping the arms in front of the body and then flexing the head so the baby's looking down when it's delivered.

Rob O -

Here is Dr Doty's response ....

I do not think the actions I recommend are dangerous, specifically in reference to clearing of the mouth of fluid and the possible apneic or bradycardic response to that. The literature to the contrary is fairly weak. One study did show that the mean oxygen saturations were lower in babies suctioned were lower in the 1st, 3rd, 4th, 5th, and 6th minute of life but not the 2nd. I question how good this data is and why the 2nd minute is special. That casts doubt on the entire data set for me. Also, in that study, the mean APGAR in both groups (no suction, and suction) was less than 1 point and both groups had a score above 9. This is a good example of something that is statistically significant but not clinically relevant. There is no evidence that there were any adverse outcomes for suctioned patients. PMID: 16113579 There is a reasonably well done equivalency study that showed no difference in clinically relevant, patient-centered outcomes for the two groups. PMID: 23739521
I did try to deemphasize the suctioning of the mouth in the lecture and try to convince practitioners that a perfectly clean oropharynx is not important and it should not take much time or attention of the practitioner. Presently, oral suction is not routinely recommended, but that is a new recommendation and this lecture was written and delivered several years ago. Suctioning is recommended if you suspect the child’s airway is obstructed.
I disagree with the suggestion that meconium staining may not indicate a more complicated course for the neonate. I stand by my statement that in a community ED without a lot of obstetrical resources, that if a gravid patient presents with meconium staining of amniotic fluid, that the practitioners should consider if a transfer can be done safely to a center with more resources. Deliveries in the ED are relatively infrequent and somewhat high risk for the emergency physician. Therefore, siphoning off high-risk cases or transfer is a prudent thing to do.I agree that a shoulder dystocia is a bony impaction of the anterior shoulder under the pubic synthesis. If a practitioner were to be able to “in-and-out cath” the patient and gain 1 or 2 mm of soft tissue space in the pelvis, I still think that would be a good idea. However, this has never been studied and is just in opinion.I appreciate the clarifications on the HELPERR-C mneumonic.

Alex K. -

Hi Chris,

We're doing crash delivery simulation teaching in my ED in Gresham, OR. Do you have a link to a delivery preparedness checklist or something of the sort? What are the essential supplies to have ready for the patient being brought by ambulance in active labor with impending ED delivery?

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Snake Bites and The Missed MI Full episode audio for MD edition 256:35 min - 298 MB - M4AEM:RAP 2016 May Aussie Edition Australian 42:06 min - 58 MB - MP3EM:RAP 2016 Mai Résumé en Francais Français 64:00 min - 88 MB - MP3EM:RAP 2016 Mayo Resumen Español Español 78:00 min - 107 MB - MP3EM:RAP 2016 May Canadian Edition Canadian 25:09 min - 35 MB - MP3EM:RAP 2016 May German Edition Deutsche 107:44 min - 148 MB - MP3EM:RAP 2016 May Board Review Answers 172 KB - PDFEM:RAP 2016 May Board Review Questions 159 KB - PDFEM:RAP 2016 May MP3 329 MB - ZIPEM:RAP 2016 May Written Summary 626 KB - PDF

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