Other obstetric problems

From Primary Surgery

19 Other obstetric problems

19.2 The surfactant test for fetal maturity

The surfactant test is a simple way of estimating the maturity of a baby. It is seldom needed in the developed world, where the length of gestation can usually be obtained from a pelvic examination early in pregnancy, or by an ultrasound scan. Unfortunately, this does not apply in the developing world, where the surfactant test still has a useful place. It is not infallible, so don't rely on it alone-use it in conjunction with an estimate of gestation by dates, and an estimate of the baby's size. It is a test for the surfactant which his alveolar cells secrete, and which is necessary for the expansion of his lungs immediately after birth. If they don't expand, he develops the respiratory distress syndrome, so the test is a measure of the extent to which he is at risk from this.

The test normally becomes positive at 36 weeks, so it is a good sign that he is mature enough to induce. Obtaining amniotic fluid is easy and safe for him and his mother, and is no more painful than an intramuscular injection. Rare complications include rupture of the membranes and injury to his head. elements (see below) uses varying dilutions; we use only a 1:2 dilution. elements et al. The assessment of the respiratory distress syndrome by a rapid test for surfactant in amniotic fluid, The New England Journal of Medicine 1972;286:1077-81,

Fig. 19•1 THE SURFACTANT TEST normally becomes positive at 36 weeks, so it is a good sign that a baby is mature enough to induce.

THE SURFACTANT TEST

INDICATIONS. (1) There should be a legitimate reason for induction, but not one which is so strong that you would induce the patient anyway, such as severe gestational hypertension (17.4). Indications include an elective Caesarean section with uncertain dates, suspected growth retardation (19.13), and diabetes (in which the surfactant test is somewhat unreliable, 17.3). (2) If you are able to use ultrasound to localize the placenta, and find that it is in the way of the needle, reassess the need for the test. In practice little harm results from going through it. If however she is Rhesus-negative, putting a needle through the placenta increases the risk of rhesus immunization. (3) She must have a mobile presenting part, showing that she has enough liquor to aspirate. If there is not enough liquor, he is probably mature enough anyway. ASPIRATION. Take a sterile 10 ml syringe and a long 1 mm needle. If she is very obese, you may need an extra long one. Have a second syringe ready in case the first sample is bloodstained. Ask her to empty her bladder, so that you don't aspirate her urine. There is no need for local anaesthesia. Prepare the skin over her lower abdomen, preferably with iodine. Lay her supine. The lowest part of the baby is usually his head: feel it, lift it up out of her pelvis as far as you can, and then hold it there with your left hand. This will allow liquor to swirl around it, and fill her lower segment. While holding his head up, plunge the needle attached to the syringe into her uterus at right angles to the plane of her lower segment, as near to his head as is reasonable, remembering that you don't want to hit it. Remember also that the commonest complication is rupture of her membranes due to inserting the needle too low, too close to her cervix. Alternatively, aspirate at the level of her umbilicus on the side of his limbs. You need to be able to feel his position clearly. There is usually a good pool of liquor there. Injuring him is very unusual. Withdraw 5 to 10 ml of fluid. Record it as being clear, or bloodstained (indicating a traumatic tap), and the vernix in it as being absent, scanty, or plentiful. If you fail, try once more and then give up. EQUIPMENT. You need: (1) 1 ml of clear liquor, uncontaminated by meconium or blood. Only the faintest blood-staining is acceptable-a pale 'rose' colour at the most. If you cannot avoid blood contamination, centrifuge the liquor hard for 5 minutes and test the supernatant. (2) 95% alcohol. (3) Some completely clean glass test-tubes with an internal diameter 8-14 mm. (4) 'Parafilm' to cover the tubes. If you don't have this, use new corks or rubber stoppers. If you don't have these either, a very carefully washed, and even more carefully rinsed, finger is probably better than a used cork or stopper. METHOD. Take exactly 0.5 ml of liquor, 0.5 ml of saline, and 1.0 ml of alcohol (this mixes a 1 in 2 dilution of amniotic fluid with an equal volume of alcohol). Shake the mixture vigorously for exactly 15 seconds. Then don't move the tube. Wait 15 minutes before examining it in a good light against a dark background. No foam, score O. An incomplete ring of bubbles peripherally round the meniscus, score 1. A complete ring of bubbles round the meniscus, score 2. As above, but foam just covering the whole meniscus, score 3. Plentiful foam covering the whole meniscus thickly, score 4. At adilution of 1:2as above ascore of 1ormoremeansthat his lungs are mature. CAUTION! (1) Avoid contamination with anything greasy. (2) Meconium produces a false positive result, so don't do the test if there is meconium in the fluid. (3) Don't shake the tubes a second time. DIFFICULTIES WITH THE SURFACTANT TEST If you ASPIRATE NOTHING, have you been brave enough? Push the needle a little deeper and try again. If you ASPIRATE BLOOD, it may be fetal or maternal blood. Check the fetal heart half-hourly for 4 hours. If it rises steadily, he is bleeding (rare). Section her immediately. If her UTERUS BECOMES HARD, and there are other signs of placental abruption, she is bleeding behind her placenta (very rare). See Section 16.13. 19.3 Inducing labour at term If labour does not start when you would like it to, you may be able to start it. If it is going too slowly, you can speed it up. So distinguish between: (1) the induction of labour (the subject of this section) when the patient is not in labour, or only in the latent phase, and (2) the acceleration of labour, when she is in the active phase with her cervix more than 3 cm dilated. Here we are concerned with induction. For acceleration see M 22.2. If the continuation ofpregnancy would be harmful to a mother or to her baby, and especially if either of them is in danger of death, the logical solution might seem to be to induce labour and deliver them. Unfortunately, induction has its risks for both of them, so there are few indications for doing it in a district hospital. The commonest one is probably proven rupture of the membranes (19.5) lasting more than 12-24 hours, when she is near term (> 37 weeks). All the other indications below are rare and relative. Artificial rupture of the membranes (ARM), with an oxytocin drip or oral prostaglandins, is the most powerful way of inducing labour. Don't do it for minor indications, because: (1) You may introduce infection when you rupture her membranes. If labour starts soon, the risk is small, but if it is delayed, the risk is large, especially if the baby is dead. Minimize this by taking the most careful aseptic precautions. (2) If you try to induce her too soon: (a) he will be immature and have less chance of surviving, and (b) her labour is unlikely to start, and if it does start, it may so slow that you have to section her. So only induce labour, when the balance of risks favours it-when the surfactant test shows that he is mature, and Bishop's inducibility test shows that her cervix is ripe, and ready for labour. (3) Inducing labour increases your Caesarean section rate, with all the disadvantages this has (18.1). There are other risks: (4) Rupturing her membranes may cause the cord to prolapse. (5) Oxytocin may cause her uterus to rupture. And, (6) her placenta may separate. So never induce labour to suit your convenience or hers, but only for the soundest of obstetric reasons. If her cervix is unfavourable, you can try ripening it with prostaglandins (expensive), or you can insert the balloon of a Foley catheter into her extra-amniotic space (cheap and effective). INDUCING LABOUR AT TERM INDICATIONS. (1) Proven rupture of the membranes lasting > 12-24 hours when the baby is near term (> 37 weeks). (2) Severe pre-eclampsia if the cervix is ripe (17.4). (4) Diabetes (16.3). (5) Abruption (16.3). (6) Postmaturity (19.6) is an uncertain indication, because the diagnosis is rarely made in district hospital practice. BISHOP'S INDUCIBILITY SCORE. Assess the dilatation of a mother's cervix, its length, its consistency, its position in rela tion to the axis of her vagina, and the height of her baby's head. Work out the score like this: the higher it is, the more likely it is that induction will succeed. The highest score is 13, and a score of 7 or more is favourable for induction. Dilatation in cm: 0 cm, score nil. 1 cm to 2 cm, score one. 2 cm to 3 cm, score two. 3 cm to 4, cm score three. Length in cm: 3 cm, score nil. 2 cm, score one. 1 cm, score two. 0 cm, score three. Station of the head: 5/5, score nil. 4/5, score one. 3/5, score two. 2/5, score three. Consistency: Firm, score nil. Medium, score one. Soft, score two. Position of the cervix. Don't confuse this with the position of the presenting part (OA, OP, etc.): Posterior, score nil. In the middle, score one. Anterior, score two. RIPENING A CERVIX INDICATIONS, (1) When the cervix is not sufficiently ripe to enable you to rupture the membranes to induce labour. After ripening, labour will often start without any need to rupture the membranes. See also Section 16.4. METHODS, Here are three ways of ripening a cervix: A dinoprostone vaginal tablet in her posterior fornix. Insert one3mg PGE2 dinoprostone ('Prostin E2' Upjohn) tablet in her posterior fornix on the afternoon before you induce labour. Follow this by another 3 mg 6 to 8 hours later if labour is not established, and then, if necessary, a further one, to a maximum of 3. CAUTION! (1) The tablet must be close to her cervix in her posterior fornix; merely slipping one into her introitus does not work. (2) Avoid prostaglandins if she is para 5 or above. There may be hyperstimulation. (3) Observe her carefully for at least 2 hours. A dinoprostone tablet in her cervix. insert a 0.5 mg PGE2 oral tablet into her cervical canal. Repeat this 6-hourly up to 4 doses. A Foley catheter in the extra-amniotic space is useful if you have no prostaglandins. 12 to 18 hours before induction, with careful aseptic precautions, and under direct vision, use a Cusco's speculum to insert a 16 to 24 Ch Foley catheter, with a 30 to 45 ml balloon, into her extra-amniotic space. Inflate this with 30 to 45 ml of sterile water, and leave it in place. CAUTION! Whenever you induce labour, monitor the baby carefully. OXYTOCIN TO INDUCE LABOUR AT TERM IN DICATIONS. A high risk-factor, particularly for the baby, such as: (1) Diabetes (17.3). (2) Gestational hypertension (17.4). (3) Placental abruption (16.13). (4) An unstable lie (19.9). (5) A dead baby 3 weeks after fetal movements have stopped (16.4). (6) Postmaturity (19.6). CAUTION! (1) For all the above indications her cervix must be favourable, by the score given above. (2) This is oxytocin to induce labour at term. It has several other uses, see 16.4 and 18.4a. CONTRAIN DICATIONS, (1) CPD. Never give a multip oxytocin if there is ANY sign of CPD. (2) A previous Caesarean section. (3) Myomectomy. (4) Fetal distress. (5) Malpresentation. (5) Grand multiparity is a relative contraindication, but you can cautiously give a lower dose. (6) Placenta praevia. METHOD, Check the baby's lie and presentation, and try to make sure that one nurse stays with her all the time. Start in the morning with a dose of 5 units to 500 ml of 5% dextrose in water at 10 drops a minute. Vials of oxytocin usually contain 5 units, so this is one vial. Watch her closely and increase the drip rate every 30 minutes like this: 10 drops/minute, 20 drops/minute, 40 drops/minute, 60 drops/minute. Increase the infusion until her uterus is contracting 2 or 3 times every 10 minutes. If vaginal examination shows that her cervix is not dilating, increase the infusion to 60 drops/minute regardless of how frequently contractions occur. Don't go above 60 drops/minute. If you don't get the effect you want and she is a primip, increase the concentration to 10 units in 500 ml and start again at 10 drops/minute. When her cervix is more than 5 cm, and she is having good contractions, you may be able to reduce the rate of the drip. Do this gradually. If they go off, increase it again. If her membranes have not ruptured, and she has not gone into labour by 7 p.m., stop the drip and try again in the morning.lf her membranes have ruptured, induction must not stop. CAUTION! (1) Higher doses than these increase the uterine tone between contractions, and thus impair the placental circulation. Palpation does not detect this increased tone, unless it is gross. Too much oxytocin will cause prolonged tetanic contractions, and may rupture her uterus (especially if she is a multip). (2) In a multip, reduce the starting dose to 1 unit, and reduce or stop the drip as soon as regular contractions are established. (3) Assess her uterine contractions carefully. If there is no relaxation between contractions, stop the drip. If there is fetal distress, see 'Stop Press'. (4) Oxytocin in high doses (more than 10 units at 30 drops a minute) has an antidiuretic effect. So beware of 'water intoxication', and see Section 16.4. (5) If she is not delivered but is contracting satisfactorily and progressing well, you can use up to 21 of a solution of 10 units in 500 ml. With more than this volume there is a risk of water intoxication. If she is not nearly delivered, consider Caesarean section. (6) Don't give her>2 1/24 hours without reviewing her carefully. RUPTURING THE MEMBRANES TO INDUCE LABOUR CONTRAINDICATIONS. (1) A high mobile head (the cord may prolapse). (2) A dead baby (except in abruption; she will labour fast), because he is much more easily infected (19.5). (3) If she has hydramnios, start by withdrawing some amniotic fluid from her abdomen, so as to reduce her uterus to a normal size. The sudden release of much fluid can precipitate abruption, and make malpresentations, such as a shoulder presentation, more likely. METHOD. Make sure her bladder is empty. Check the fetal heart, put her into the the lithotomy position, and use careful aseptic precautions. Flood her vulva with antiseptic solution. Wearing sterile gloves, do a careful vaginal examination and measure Bishop's score (see above). Spread her labia widely, put two fingers into her vagina and then into her cervix. If necessary, stretch it to admit your 2 fingers. Gently sweep her membranes away from her lower segment without rupturing them. Feel carefully for the placenta, or the cord. If you can feel her placenta, she has placenta praevia and you have made a horrible mistake. You are unlikely to do this if the head was in contact with the brim. Section her if it is Type Three or Four (16.12). If you can feel the cord presenting through her membranes, leave them intact, turn her on her side and repeat the examjnation in about 2 hours. With luck, the cord will have floated away. If it has not and you want a live baby, you will have to section her. CAUTION! If she is in labour, rupture her membranes during a contraction, to minimize the risk of prolapse of the cord. If you cannot feel either the placenta or the cord presenting through her membranes, rupture them with Kocher's forceps. Hold these in your left hand, and guide them through her cervix with your right hand. As you prepare to tear them, ask an assistant to push the presenting part into her pelvis. This will allow the fluid to escape in a controlled way, and will minimize the risk of the cord prolapsing. Grip her membranes and tear them. If fluid flows, or there is fetal hair in your forceps, you have succeeded. Note the amount and colour of her amniotic fluid, make sure the cord has not prolapsed, and check the fetal heart. Enlarge the opening with your fingers. Keep them in her vagina until the head has descended against her cervix. With your fingers still in her vagina, check the fetal heart again. If she has a sudden persistent bradycardia: (1) She may have the supine hypotensive syndrome (A 16.6), so turn her on her side. (2) The cord may be trapped. Don't raise the baby's head, because the cord will probably prolapse further (19.10). Instead, turn her on her side and listen again; this usually solves the problem. Alternatively, do a 'membrane sweep' only, and don't rupture her membranes until she is well advanced in labour. This is effective, and there is less risk of infection than when her membranes are ruptured some time before delivery. 19.4 Preterm labour Strictly speaking, preterm labour is the onset of regular painful contractions before 37 weeks. In practice, you can treat labour between 34 and 36 weeks as if it was at term, so that it is only labour before 34 weeks that needs managing differently. It mayor may not be associated with rupture of the membranes. The management of preterm labour is controversial. We think you should avoid tocolytics and steroids. V sing them may lead you to think that you are doing something useful when you are not, and divert you away from the treatment of the cause of the premature labour, which may be antepartum haemorrhage, a urinary tract infection, or intrauterine growth retardation (IVGR), etc. In practice, when a mother does go into preterm labour there is little you can do about it. It often stops spontaneously, so that 70% of mothers are not delivered 48 hours later, and go into labour normally nearer term. PRETERM LABOUR If a patient goes into labour before 34 completed weeks, find out if her membranes have ruptured, if necessary by the methods in Section 19.5. If they have ruptured, manage her as in that section. If they have not ruptured, manage her like this: Ifsheisintheactivephase oflabour(hercervix is >3cm), don't try to delay delivery. Ifsheisin the latentphase of labour(hercervix is <3cm) assess her contractions by palpation. If she has regular contractions and her membranes are not ruptured, look for a possible cause, although you are unlikely to find one. Put her to bed, sedate her (give her pethidine 100 mg, or phenobarbitone 60 mg). Some obstetricians use tocolytics. If her contractions are doubtful, consider other common and less common causes of pain. Urinary tract infection (17.6)? Constipation? This is sometimes the result of pica, eating quantities of earth, etc. Abruption (16.13)? Appendicitis (12.1)? Gut obstruction (10.3)? Other abdominal conditions (10.2)? Put her to bed and observe her for 24 hours. WHEN SHE GOES INTO LABOUR her baby is at high risk, so, if she is a primip, make a liberal episiotomy, and control the delivery of his head with your hands. An episiotomy is usually unnecessary in a multip, because her perineum is no barrier, unless she has had a previous tear or an episiotomy. Handle him gently and keep him warm. 19.5 Premature rupture of the membranes (PROM) and intrauterine infection (IUI) When labour is normal, regular contractions start and the patient's cervix begins to dilate before her membranes rupture and amniotic fluid escapes. Sometimes, her membranes rupture first, before contractions start, either before 36 weeks (preterm rupture), or at term (prelabour rupture). When her membranes rupture early the risks are: (1) Intrauterine infection or 'lVI', which is much the most important but is usually not common, and (2) premature labour. Are you going to induce her or not? The advantages of expectant treatment (not inducing her) are that: (1) It increases the maturity of the fetus, which is important if she is less than 36 weeks. (2) It avoids the risks ofinduction, which are: (a) Failure, which means that you will have to section her, because you will have done repeated vaginal examinations. (b) The complications of oxytocin (18.4a). The disadvantage of expectant treatment is the risk of infection (chorioamnionitis) which may kill her and her baby. You can minimize this risk by: (1) Totally avoiding vaginal examination with your fingers until contractions are well established. (2) Avoiding speculum examinations as much as possible. (3) Practising reasonable vulval hygiene. (4) Observing her carefully for signs of infection, and inducing her and giving her antibiotics at the very first sign of infection. Many obstetricians feel that IVI is such a serious risk, after

a bad obstetric history. (4) She has gestational hypertension. (5) She has markedly reduced fetal movements. If induction is impossible or fails, section her. 19.7 The hopelessly malformed fetus With most congenital malformations a baby is not large enough, or misshapen enough, to cause difficulty during labour. The important exceptions are anencephaly and hydrocephaly, for which you should use the methods below. If you have the misfortune to find a double monster, Caesarean section is the method of choice. Anencephaly is complicated in 90% of cases by polyhydramnios (M 15.4); so when you diagnose this, X-ray a mother to see if her baby has a head. If he has not, he is usually stillborn, and even when he is born alive, he does not survive more than a few hours. When you have explained the diagnosis to her, she will usually insist that her pregnancy is induced. Hydrocephaly is not always easy to diagnose clinically, and is often missed during pregnancy. A common mistake is to misdiagnose a brow presentation (when the head feels big) for hydrocephaly. If you suspect it, confirm the diagnosis by X-ray. If the diagnosis is then obvious, proceed as described below. If it is doubtful, wait. Even during labour the diagnosis is easily missed, if widely distended sutures and fontanelles cannot be felt. THE HOPELESSLY MALFORMED FETUS ANENCEPHALY. If this is accompanied by polyhydramnios, drain the mother's amniotic sac slowly by draining her hindwaters with a Drew-Smythe catheter. Alternatively, rupture her forewaters by making a small hole with an amnion hook. Give her an escalating oxytocin drip (19.3), and she will probably deliver promptly. If anencephaly is not accompanied by polyhydramnios (10% of cases), pregnancy may be prolonged up to a year or more (rare), and make delivery difficult. Try PGE2 pessaries first (the ideal indication for them). Then try surgical induction and an escalating oxytocin drip (19.3). These will probably succeed. If you cannot induce her (19.3), you will have to do a Caesarean section-this is tragic, so avoid it if you can. HYDROCEPHALY. If you make the diagnosis during pregnancy, induce labour, and try to avoid Caesarean section. If you diagnose hydrocephaly when labour with a cephalic presentation has been in progress for some time, and the baby's head is more than minimally enlarged, you will have to make it smaller before you can deliver him. If he is dead, drain his CSF with a lumbar puncture needle. Some obstetricians would do this even if he is alive (draining his CSF does not kill him), others would wait for his heart to stop. If you are not sure of the diagnosis, or don't feel you can risk sacrificing him, you may be forced to section her. To perforate his head, wait until dilatation has passed 3 cm, then drain his cerebrospinal fluid with a large needle between his widely separated skull bones, or, less satisfactorily, with Simpson's perforator. His collapsed head will slowly settle into his mother's pelvis, and he will deliver. CAUTION ! If possible, perforate him before she is 5 cm dilated, because her over-distended lower segment may rupture if you don't. If you diagnose hydrocephaly during a breech presentation, he will probably deliver spontaneously as far as his umbilicus (19.8). Progress will then be arrested as his hydrocephalic head fails to enter her pelvic brim. Draining his CSF will be less messy than a craniotomy: (1) If, at this stage you see the commonly-associated meningomyelocele, pass a steel or gum elastic male catheter through the spinal defect into his ventricles, to drain off his CSF. If he has no spina bifida, you can easily do a laminectomy with a scalpel, to allow the catheter to enter. Or, (2) pass a needle through his occipital bone into his skull. Or, (3) make sure that her bladder is empty, and then tap his aftercoming head abdominally with a large spinal needle. 19.8 Breech presentation If a baby presents by his breech, he is about 4 times more likely to die than if he presents by his vertex. This is so, even if you exclude the excess mortality due to the higher rate of prematurity and fetal abnormality that is associated with breech deliveries. This increased mortality is due to: (1) The rapid compression and decompression of his unmoulded head. (2) Asphyxia due to the delayed delivery of his head, if there is any CPD, or if his mother has an incompletely dilated cervix. (3) The aspiration of meconium, if he tries to breathe while his head is still in her pelvis. (4) The increased risk of his cord prolapsing. External cephalic version (ECV, M 19.1). If you can reduce the number of breeches you deliver, you can reduce the perinatal mortality associated with them. Turning a breech presentation in the third trimester will do this, but it is of little value before 34 weeks in a primip, or 36 weeks in a multip, because many breech presentations spontaneously correct themselves before this. After 36 weeks a baby gradually becomes less mobile, which makes version more difficult. On the other hand, if version does succeed, it is more likely to be permanent. The knee-chest position (M 19.1) is an alternative to ECV which often works. It is also safer, but has never been objectively evaluated; this is being done as we go to press. Ask a mother to spend 10 minutes three times a day in the kneechest position. This may allow her baby's breech to disimpact in her pelvis, so that he can turn spontaneously. Ifextemal version or the knee-chest position fail, you can deliver a breech:

(1) Vaginally, by assisted breech delivery (M 19.1). (2) Vaginally, by breech extraction. Or, (3) abdominally, by Caesarean section. In breech extraction you, rather than his mother, provide the power for pulling the baby down. You exert traction on his legs, groins and pelvis, so it is potentially more dangerous than an assisted breech delivery, which is the usual way of delivering a breech. Breech extraction is described here, but not in Primary Mother Care, and is only indicated on the rather unusual indications given below.

What should your policy be towards Caesarean section in breech deliveries? Liberal use of it will reduce your perinatal mortality, but you will have to weigh this against the increased maternal morbidity and mortality that will follow from it (18.1). In the developed world the risks of breech delivery have fallen so much, that it is hardly more dangerous than delivery by the vertex. This is the result of: (1) Safer Caesarean section. (2) Quicker section if the cord prolapses, or there is unexpected delay in the second stage. (3) Greater emphasis on controlled delivery of the head, often assisted by forceps and epidural anaesthesia.

(4) Less CPD owing to better maternal nutrition. (5) An increased readiness to section mothers with borderline pelvises, very small breech babies, and footlings (a breech with one foot down and one up). These factors have combined to make Caesarean section so popular in some centres in the developed world, that their section rate for breeches is now over 50%

The increased safety ofbreech delivery in the developed world has made obstetricians there look closely at the small risks of ECV, which include: (1) Knotting of the cord. (2) Placental abruption. And, (3) uterine rupture. In the developed world, the risks of ECV, small though they are, are commonly held to be more than those of breech delivery, so that ECV is increasingly out of favour. However, in the developing world, the risks ofbreech delivery and section are much greater, and grand multiparity is much commoner, so that ECV still has an important place here. It is therefore described in Primary Mother Care. Unfortunately, ECV is not done by doctors as often as it should be, or by experienced midwives (it should not be done by inexperienced ones). If your excess perinatal mortality with breech deliveries is more than 20/1000, after correcting for prematurity and fetal abnormality (see below), the risks of ECV are worth taking. Don't attempt it under general anaesthesia. Ifthere is any question of CPD before the second stage of labour, section the mother. In communities where contracted pelves are common, the risks of a breech delivery are great, so that if you want these babies to survive, you may have to section 25% of your breeches. A mother with a true conjugate of less than 9 cm should not be allowed to deliver a full term breech baby vaginally. A baby with ruGR or prematurity presenting by his breech is a problem. Much depends on his age: (1) Under 28 weeks' gestation « 1000 g) his chances of life are small, the lower segment is poorly formed, and it is questionable if section will be any less traumatic than vaginal delivery. (2) From 28 to 32 weeks (1000-1500 g) he may have a better chance with Caesarean section, especially if he is a footling presentation. However, about 20% of these babies have severe abnormalities, and ifyou don't have ventilators, even the normal ones have a poor chance of surviving. So, in an area of high parity and high perinatal mortality, you should rarely section a premature baby presenting by his breech. Symphysiotomy needs skill (see below), and is best kept only for unbooked patients, who are admitted in the second stage of labour, whose pelves you cannot assess, and when there is no time for section. You can do a symphysiotomy to help deliver a baby's shoulders, or you can keep it until unsuspected CPD has delayed the delivery of his head-but you will have to be quick, and have a solid-bladed scalpel and a catheter ready! Epidural anaesthesia (A 7.2) will prevent a mother bearing down before she is fully dilated, and it will make any manipulations that you have to do in the second stage of a vaginal delivery, much easier. Alas, it is seldom practical under the conditions in which you work. If the difficulties of vaginal breech delivery worry you, and you are tempted to section all breeches, remember the dangers of Caesarean section from anaesthesia, bleeding, and sepsis. An occasional 'stuck breech', and a dead baby, are more acceptable than a maternal death. As your skill and experience and that of your staff improve, so will your successful vaginal deliveries. Armon PJ, 'The management of singleton breech presentations'. Tropical Doctor 1984;167-169. Lovset J, 'Shoulder delivery by breech presentation'. Journal of Obstetrics and Gynaecology of the British Empire 1937;44:696. Thornton JG, 'External cephalic version. Tropical Doctor 1985;173-174. BREECH PRESENTATION CORRECTING A BREECH PRESENTATION THE KNEE-CHEST POSITION. Ask her to spend 10 minutes in the knee-chest position 3 times a day. If this fails try external cephalic version. EXTERNAL CEPHALIC VERSION can be done at any time after 34 weeks, until labour starts. It is not necessary before 34 weeks. You may not succeed after 36 weeks, but it is sti 11 worth trying. Contraindications. Take a history from her and examine her to exclude: (1) Multiple pregnancy. (2) Antepartum bleeding in this pregnancy. (3) A previous Caesarean section. (4) The need to do a Caesarean section in this pregnancy for some other reason. (5) A diastolic blood pressure greater than 100 mm. (5) A fetal abnormality, if you can detect it. (6) A Rhesus-negative mother and no anti-Rh imunoglobulin to give her. Method. Explain carefully what you are going to do. Ask her to empty her bladder and lie on her back tilted a little to one side. Make sure your hands are warm and she is comfortable. You may find it helpful to lubricate your hands and her abdomen with glove powder. Find which side the baby's back is. Count his heart rate. Place one hand below his breech, and your other hand above his head. Flex him between your hands, so that you make him do a for- CORRECTING A BREECH PRESENTATION External cephalic version c The position I\ Fig. 19-2 CORRECTING A BREECH PRESENTATION. A, to C, external cephalic version. Flex him between his hands so that you make him do a forward somersault. D, the knee-chest position. Ask his mother to spend 10 minutes 3 times a day like this. ward somersault (turn head over heels). Listen to his heart. If his heart rate slowed to less than 100, turn her on her side and wait until it is more than 100. If his heart rate has not started to recover within 2 minutes, turn him into his original position. His umbilical cord may be tight round his neck. If a forward somersault fails, try turning him in a backward somersauIt. If you fail, rest her with the foot of her bed raised. If she is anxious give her diazepam 5 mg by month. Try again in an hour. If you fail again, try again at the next visit. If you succeed, see her again one week later to make sure the presentation is still cephalic. If you cannot turn her by 37 weeks, manage her as a breech delivery. THE INDICATIONS FOR CAESAREAN SECTION IN A BREECH DELIVERY If she has a normal or or large pelvis, and he is a normal-sized baby, she will probably deliver vaginally. If you cannot touch her sacral promontory easily, and her diagonal conjugate is >11 cm (true conjugate >9cm), she probably has a large enough pelvis. If you can touch her sacral promontory easi ly, and her diagonal conjugate is less than 11 cm, she has a small pelvis. Most additional factors, which compromise the wellbeing of a baby, are indications for section. Only a healthy normalsized mother with a baby less than 3.7 kg (as indicated by a fundal height of <40 cm), who progresses normally in both stages of labour, should be allowed a vaginal delivery. In more detail the indications for section are these: ANTENATAL INDICATIONS FOR ELECTIVE CAESAREAN SECTION. (1) CPO or suspected CPO. (2) A large baby; feel the size of his head. If he feels as if he is big, that is > 3.7 kg (fundal height >40 cm), regardless of the size of her pelvis, section her. (3) The scar from a previous section. (4) Other obstetric hazards, such as placenta praevia, diabetes, gestational hypertension, or APH. (5) An elderly primigravida, or a long history of infertility. (6) A previous stillbirth, especially if it was associated with a breech. (7) Postmaturity > 42 weeks. (8) Perhaps a baby with IUGR, or prematurity, weighing 1000-1500 g, especially if he is a footling. INDICATIONS FOR CAESAREAN SECTION DURING LABOUR. (1) A prolonged active phase. (2) Arrest at the brim, or delay in the descent of the breech during the second stage. (3) A footling presentation. A multip is likely to develop an irresistible desire to push before full dilatation, as her baby's feet enter her vagina. This can result in his head being caught behind her undilated cervix. Other obstetric indications such as: (4) Cord presentation or prolapse. (5) Fetal distress. (6) Prolonged rupture of the membranes. ASSISTED BREECH DELIVERY CAUTION! For breech delivery you need a quiet atmosphere and good communication with the patient. A crowd of supporters crying 'Push, push' is not what you want. Quiet them and explain what is happening. You will need an assistant THE FIRST STAGE. If her cervix dilates at less than 1 cm per hour in the active phase, or there are any other signs of delay, section her. Until his buttocks are delivered, you can turn back and do a Caesarean section. Only when his buttocks have been delivered have you reached the point of no return. If there is any delay before the delivery of his buttocks, section her. THE SECOND STAGE. A common fault is to try to deliver a breech through an incompletely dilated cervix, which may extend his arms and make his head difficult to deliver. Full dilatation may not be easy to diagnose in a breech, so don't consider that the second stage has started until his anterior buttock is easily visible. Put her into the lithotomy position (essential if you do the Burns Marshall manoeuvre or apply forceps to his aftercoming head) when his posterior buttock is distending her perineum. As soon as she wants to bear down, do a vaginal examination to make sure that her cervix is fully dilated. His breech should advance with every contraction. Infiltrate her perineum, and do an episiotomy, when his buttocks are distending it, and you can see a boy's scrotum (or a girl's labia). Protect his scrotum (you don't want the episiotomy to castrate him!). His buttocks and legs will then deliver. THE BURNS-MARSHALL MANOEUVRE A B swing free his his head mouth clear and suck him out Fig. 19-3 THE BURNS-MARSHALL MANOEUVRE for delivering the head in a breech delivery, if it does not deliver spontaneously. A, allow his body to hang, until you can see the hair at the back ofhis neck. B, hold his feet. C, swing his feet upwards over his mother's abdomen. Free his mouth and pause while you clean it. D, finish delivery by swinging him over her abdomen. When his umbilicus delivers there is often a temporary halt in descent. Look at the clock. He should be delivered in 5 minutes. Wait for progress to resume with the next contraction. His shoulders and arms should deliver with a twisting movement, and his head should follow immediately. Don't touch him, or try to disentangle his legs, until you see his umbilicus. Touching him promotes breathing movements and the aspiration of meconium. Put your hand on her fundus, observe each contraction, and keep a steady gentle pressure on his head. -When his umbilicus appears, disengage his extended legs and pull down a loop of his cord, which may be stretched. CAUTION! Encourage him to turn so that his back is uppermost. Never allow his ventral surface to face upwards. When his anterior scapula appears (and not before), search for his arms in front of his chest. If, as is usual, his arms are not extended, they will both be in front of his chest. You should be able to deliver one or both of them. If you have difficulty, feel up to his shoulder and from there feel down his arm, first one then other. Allow his body to hang, as in A, Fig. 19-3. His own weight will make his head descend through her birth canal. It will have been entering her pelvis, and will be compressing his cord. Assist its descent with gentle suprapubic pressure. He must be able to breathe in the next 5 minutes. If his head does not immediately deliver spontaneously when his arms are out, try the BURNS-MARSHALL manoeuvre. Wait until you can see the the hairs on the nape of his neck (A, Fig. 19-3). Stand with your back to her left leg, take his legs in your right hand (B), pull him outwards a little and draw him outwards over her pubis. Guard her perineum with your left hand and prevent his head from emerging too quickly. As soon as his mouth and nose appear, pause, and ask your assistant to clear his airways and allow him to breathe (C). Then, carefully deliver the rest of his head (D). If you cannot get at least his mouth and nose into fresh air with the Burns-Marshall method: (1) use the MAURICEAU -SMELLIE -VEIT manoeuvre, or (2) apply forceps to his aftercoming head (see under 'Difficulties' below). Rest his belly and chest on your right forearm; put your right middle finger in his mouth, and your index and ring fingers on his malar bones. Put your left hand over his back; put your middle finger on his occiput and your index and ring fingers over his shoulders. This will give you some control over the flexion and rotation of his head. Grip his skull and guide it through her birth canal. Ask her to stop pushing. Ask your assistant to put his fist on the baby's head, which is still palpable above her pubis, and to press obliquely downwards in the direction of her coccyx. You will feel a 'plop' indicating that his head has gone into her pelvis, and further delivery by the Mauriceau-Smellie-Veit manoeuvre shouId then be easy. CAUTION! This is a method for getting a grip directly on his head. NEVER pull on his shoulders, you can too easily distract his cervical vertebrae and damage his cord. NOTE: Although Mauriceau-Smellie-Veit is a cumbersome eponym, it is preferred to the alternative which is 'jaw shoulder traction' since this suggests, although it does not intend, traction on the neck, which is very dangerous. EARLY DIFFICULTIES DELIVERING A BREECH CAUTION! (1) Do an episiotomy (except in a grand multip with a very lax outlet) before you do any manipulations, because there is a high risk of a perineal tear. (2) Don't squeeze his abdomen! (3) If his head fails to descend, don't pull on his neck. (4) If his head becomes impacted and he dies, don't sever his neck, or be tempted to open her uterus from above. If his breech is DELAYED AT THE BRIM, or in midcavity, this is probably a warning sign of CPD; section her. Don't try to deliver her with oxytocin. If section is impossible, consider reaching for his anterior groin with a finger and bringing down his leg. This was once the traditional method, and will probably injure him seriously. If his breech is DELAYED AT TH E OUTLET, make sure that the episiotomy is adequate. There may be CPD. If her pelvis TWO MORE METHODS FOR DELIVERING THE HEAD A Forceps to the ) The Mauriceau-Smellie-Veit manoeuvre assistant middle finger presses onB/ his occiput Fig. 19-4 TWO METHODS FOR DELIVERING THE HEAD IN A BREECH PRESENTATION. A, applying forceps to the aftercoming head. B, the Mauriceau-Smellie-Veit manoeuvre is a method for getting a grip directly on a baby's head. Rest his belly and chest on your right forearm; put your right middle finger in his mouth, and your index and ring fingers on his malar bones. Put your left hand over his back; put your middle finger on his occiput and your index and ring fingers over his shoulders. This will give you some control over the flexion and rotation of his head. Guide his head through his mother's birth canal and don't pull on his shoulders. The finger in his mouth is for convenience only. D c B pubis backwards as (PUll backwards as you turn him you turn him G HI J a 90° turn first 180° turn third 180° turn will bring his shoulders front to back K L LOVSET'S MANOEUVRE He may arrest in position A with both arms up or in positions S, C, or D, and he may have only one arm up Fig. 19-5 IDVSET'S MANOEUVRE for the delivery of the shoulders in a breech presentation. The bottom row ofdrawings show a view from the patient's perineum. The top row shows the same stage viewed from her left. Remember "Ifyou don't know which way to turn him, keep his back anterior, so that it passes under her clitoris". Many obstetricians merely wiggle him one way then the other, pull, and try to find an arm: but this is the detailed manoeuvre. Practise it on a model. feels contracted, or he is large, section her. If all is otherwise well, do gentle groin traction, as for breech extraction (see below). If you have delivered his legs but BOTH HIS SHOULDERS HAVE NOW STUCK above his mother's pelvic brim, his arms are probably extended (A, Fig. 19-5). Normally you can put a finger up her posterior vaginal wall and easily bring them down. If you cannot, they are probably extended. Try .LOVSET:S manoeuvre. It is a breech extraction for obstruction late In delivery, and should rarely be necessary. The delivery of his shoulders is prevented by two obstructions at different levels; (1) her sacral promontary is higher than (2) her pubis. The principle of this method is that, by pulling him tightly down on to both, and by turning him through 180°, the shoulder which was held up above her pubis will turn to pass into the hollow of her sacrum, and the shoulder which was above her sacrum will now be above her pubis. Two further 'unscrewing' half-turns like this, each bringing his shoulders progressively below these obstructions will deliver him. Grasp his thighs and pelvis with both hands (if he is slippery use a gauze swab or small towel), your thumbs along his sacrum, your forefingers on his symphysis, and your remaining fingers round his thighs. If, in the extreme case, he obstructs transversely (A), start by turning him through 90° (A to B), so that his back faces to her left. His left shoulder will then be above her symphysis, and his right shoulder above her sacrum (B). With your first 180° turn (B to C), bring his left shoulder under her sacrum. With your second second turn (C to D) bring his right shoulder under her sacrum. His left arm will now be low enough for you to gently sweep it down. With your third turn turn (D to E) bring his right shoulder under her pubis; it will now be low enough for you to bring his right arm down. CAUTION! (1) These three 180° turns are in opposite directions, so that his back always passes under her clitoris, and the arm which started posterior always drags across his face. His belly should never pass under her clitoris. (2) In the worst case you start in A with both arms extended, so you have to begin with a 90° turn, followed by three 180° turns. If he arrests at a later stage, with only one arm extended, you may only need two turns, or perhaps only one. (3) The first two turns release the shoulder which was arrested above her symphysis when you started it. The third enables you to bring down his right arm. (5) Don't squeeze his belly, or back, or you may rupture his liver, kidneys, spleen, or adrenals (huge in the newborn). If you hold his chest, take care not to compress his abdomen. (6) Remember that the upper part of the birth canal, in which he has stuck, is directed backwards, so start by pulling him backwards. If LOVSETS MANOEUVRE FAILS TO DELIVER HIS SHOULDERS (uncommon), it is usually a failure of technique. You may have to be a little firmer, or reach up a little higher to get his arm down. A broken arm will soon heal, so it is no disaster (71.17), and is better than letting him die. DIFFICULTY DELIVERING HIS HEAD CPD is the most important cause. IF HIS HEAD IS STUCK ABOVE THE BRIM, you are in trouble. You may be able to draw it into her pelvis with the Mauriceau-Smellie-Veit manoeuvre. If this fails, he will probably be dead, and the best treatment will be craniotomy (see below). If HIS HEAD HAS ENTERED THE PELVIS and the MAURICEAU-SMELLIE-VEIT manoeuvre fails to deliver it, rotating his head in her pelvis may help. Stop struggling and think. What is the cause? If it is CPD, and you are an experienced symphysiotomist with an equally experienced obstetric team, a quick symphysiotomy may save him. On the other hand, an unskilful symphysiotomy may cause pelvic trauma and laceration of her urinary tract, so only attempt this if you and your te'am are expert. If CPD IS THE CAUSE orSHE IS NOT FULLY DILATED, and you cannot deliver him, let him die and avoid harming her. While she is still in the lithotomy position, sedate her with pethidine 50 mg and let him hang for a while. His head will usually mould, or her cervix will dilate, so that he is delivered in less than an hour. Alternatively, if his head has stuck in her incompletely dilated cervix (uncommon) either: (1) Apply standard obstetric forceps, such as those of Neville Barnes, inside it. While you apply gentle traction, try to slip her cervix over his head. Or, (2) if this fails, cut her cervix boldly with scissors at 4 and 8 o'clock, and repair your incisions afterwards (M 24.2). Some contributors consider this a relatively safe and successful method, one considers it bloody and dangerous. This complication usually happens to premature breech del iveries, who may not be worth the risk involved. If the ABOVE MEASURES FAIL and CPD is severe, you may have to do a CRANIOTOMY through his foramen magnum (unpleasant but effective). See Section 18.5 for the general principles of destructive operations. A craniotomy is best done in the theatre under general anaesthesia; but you can do it in the labour ward. Ask an assistant to pull down his his body. Retract her anterior vaginal wall with a Sims' speculum and expose the back of his neck. Pick up a fold of of the skin over his cervical spine with toothed forceps, and incise it transversely. Use curved Mayo's scissors to cut a tunnel under his skin up to his occipital bone, and push scissors into his head. Open the scissors a few times to break up his brain compartments. Pull gently on his neck while his brain gradually escapes. Or, make a transverse incision over his highest cervical spine and push a straight metal catheter through it on into his his foramen magnum. Or perforate his occiput. He should now deliver quite easily by the Mauriceau-Smellie-Veit manoeuvre. If he still does not deliver, pass a crotchet up the tunnel and hook it on to the base of his skull. If he has HYDROCEPHALY, see Section 19.7. If she is brought in with HIS DEAD BODY PROTRUDING FROM HER VULVA (not uncommon), examine to feel if her cervix is fully dilated or not. If it is fully dilated, proceed directly to decompress his head with a craniotomy (see above). If it is not fully dilated, hang a weight of 1 kg on his trunk. His head will usually mould and deliver within an hour. If this fails, do a craniotomy as above. CAUTION! Don't try to pull his head foroefully through her undilated cervix. You may cause tears which extend into her lower segment. If his NECK HAS BEEN SEVERED, and his head has gone back into her uterus, it will be difficult to find and remove. Use craniotomy equipment. If his CORD PROLAPSES, manage her as you would with a cephalic presentation-section her, unless her cervix is fully dilated, and she is about to deliver. Cord prolapse is more common with breech deliveries, especially with a footling. OTHER METHODS FOR BREECH DELIVERY BREECH EXTRACTION uses your pulling forces, rather than her pushing forces. It is a quick way of delivering a small breech baby, usually a second twin. It may be indicated for: (1) Delay with the second twin. (2) Fetal distress with the second twin. (3) Cord prolapse at full dilatation with a breech. (4) A transverse lie in a second twin, following internal version. (5) A dead baby. Method. She must be in the lithotomy position. Proceed as for an assisted breech delivery. You will need good anaesthesia: a subarachnoid (spinal) anaesthetic, an epidural or a pudendal block. Avoid general anaesthesia. An episiotomy is vital. Hook the index fingers of each hand into his groins and pull, preferably during a contraction. When his umbilicus appears, hook out his legs by flexing his knees. Do this by applying lateral and dorsal pressure in his popliteal fossae, and by sweeping each leg laterally and downwards. Pull on his pelvis, keeping his back anterior. Pull posteriorly. A common error is to pull him towards you, which is not in the axis of her birth canal. When you see his scapulae, hook out his arms. If his arms are not across his chest do Lovset's manoeuvre. Push his head into his mother's pelvis from above. Then, if necessary, consider applying forceps to his aftercoming head. The main difficulty is that his arms are more likely to be extended above his head, and his head is more likely to become deflexed. Lovset's manoeuvre and the Mauriceau-Smellie-Veit manoeuvre should solve these problems (see above). Alternatively, if he is dead: (1) Pull on his leg(s), if you can reach them, or (2) use a combined breech hook and crotchet (Section 15.1a, and Figure 15-2). Pass the blunt hook end of this instrument over an extended leg into his groin, and pull on that. If he is macerated his leg may be pulled off. If it is pulled off, turn the instrument round and hook the sharp crotchet end over his iliac crest. FORCEPS FOR THE AFTERCOMING HEAD. Standard obstetric forceps, such as those of Nevi lie Barnes: (1) Are not easy to use on the aftercoming head. (2) Are liable to misuse if they are in the labour ward at all. (3) Create the impression for midwifery students that a breech delivery is something that only doctors can do. They must see methods used that they can use themselves at home or in a clinic. Outlet forceps (Wrigley's) are not long enough when you really need them. If they will reach his head they are hardly necessary in a breech delivery. If you are going to use them, wait until you see his hair line. Ask your asistant to lift him by his ankles, then apply the left blade, followed by the right one. Slowly and gradually deliver his head with them. THE CORRECTED PERINATAL MORTALITY FOR BREECH DELIVERIES (see above). This should be fairly easy to calculate from your labour ward record books, which should routinely record presentation, birth weight, obvious abnormalities, and live and still births. (1) Work out your perinatal mortality for all babies, excluding breeches, babies <2.5 kg, twins, and babies with obvious malformations. The perinatal period lasts from the 28th week to the end of the first week of life. (2) Do the same for breech deliveries only. Subtract (1) from (2). If the difference is >20/1000, do external version. In many district hospitals it is 50/1000. 19.9 More malpresentations A transverse lie occurs most frequently in multips, and in mothers with polyhydramnios. When you diagnose it, don't forget the possibility that it may have been caused by twins, a major degree of placenta praevia, or CPD. Rarer causes include a congenital uterine abnormality, a grossly abnormal pelvic brim, a fibroid, an ovarian tumour, and an extrauterine pregnancy. When labour is obstructed by a transverse lie, the lower segment is particularly vulnerable, so don't stretch it any more by doing an internal version in advanced labour with a dead baby. Do a destructive operation (18.7). MORE MALPRESENTATIONS TRANSVERSE LIE If a patient is 32 weeks pregnant or more, do an external cephalic version (19.8). This is safe provided there is no antepartum haemorrhage, hypertension with a blood pressure of < 100 mm, or twins. If you fail, try again a week later. See also M 19.2. For obstructed labour with a transverse lie, see Sections 18.4 and 18.7 (destructive operations). For a transverse lie with twins see Section 19.11. If she goes into labour with a transverse lie, when she is less than 30 weeks, or her baby feels as if he is under 1.5 kg, she may deliver spontaneously, although he is unlikely to survive. She also runs an increased risk of prolapse of the cord. If you see her in the latent phase of labour, when she still has intact membranes and uterine contractions which are not strong, do an external version to produce a cephalic presentation. If this is successful, and she has no signs of CPD, and the position is still unstable, rupture her membranes while an assistant holds her baby's head over her pelvis. If she is of low parity, start an oxytocin drip (M 22.2). Check his lie and fetal heartbeat every 15 minutes, until his head is fixed in her pelvic brim. If she has a small pelvis with an estimated true conjugate of < 9 cm, section her. If he is alive and she is in the active phase of labour with intact or ruptured membranes, and her cervix is < 8 cm, section her. If her membranes are still intact, and you can feel a leg through her lower segment, you can deliver him through a lower segment transverse incision. But if her membranes have ruptured, and especially if his arm has prolapsed, a de Lee incision (18.9) is better, because you can extend this into the upper segment as necessary. If he is alive and she is fully dilated or nearly so: (1) If she is a primip or a multip with a tight uterus, section her. (2) If she is a multip with intact membranes, and a uterus which is not tight, an internal version and breech extraction is sometimes advised. It is however very dangerous, and at least one contributor considers that the only indication for this manoeuvre is the transverse lie of a second twin with intact membranes (19.11). If he is dead, and her cervix is not yet 8 cm dilated, do a lower segment section, and a transabdominal destructive operation. Use large scissors to decapitate him through the uterine incision (18.9, 18.10). If he is dead, with an impacted shoulder, and her cervix is >8 cm dilated, and her uterus is not ruptured, do a destructive operation (18.7). A BROW PRESENTATION A brow presentation is often missed: (1) During labour. The head is high, but by the time it comes lower, the sutures and fontanelles by which it might have been diagnosed, have become obscured by caput. (2) At Caesarean section a brow presentation is not diagnosed until the typical moulding makes the diagnosis obvious. Unless the baby is premature, or his mother's pelvis is enormous, he will not deliver vaginally. If you diagnose a brow presentation and she is early in labour, her pelvis is large, and he is of normal size, his head may flex, and he may deliver vaginally. You may be able to assist flexion by putting your hand through her cervix, pushing his head up and trying to flex it. But, if you fail to flex his head, if her membranes rupture, or if she fails to progress, or if there is any sign of obstruction, section her. A FACE PRESENTATION If her pelvis is large and there are no signs of CPD, allow her labour to progress. He is most likely to be mento-Iateral, and will probably rotate anteriorly and deliver spontaneously. You may be able to help by turning him with your hand. If he remains mento-posterior, you will have to section her. If she is delayed in the second stage and he is in the mento• anterior position, with less than 2/5 of his head above her pelvic brim, you can do a symphysiotomy if CPD is mild, but section would be wiser. Remember that the head moulds less in a face presentation. If CPD is more than mild, section her. CAUTION! (1) Remember the possibility of anencephaly. Anencephalic babies often present by the face, but usually deliver easily. You should be able to distinguish anencephaly, a face, and a breech vaginally, once her cervix is 8 cm dilated; feel for his brow and his mouth. Occasionally, a lateral X-ray is useful. (2) If you are going to use oxytocin, use it with the greatest caution. (3) Never use a vacuum extractor! 302 19.10 Prolapse and presentation of the cord If a mother's cervix is not well applied to the presenting part, her baby's cord can prolapse when her membranes rupture, especially if his head is high, or she has a transverse lie, a breech, a face presentation, or twins. The cord is said to be presenting when it lies below the presenting part, inside her intact membranes. Both prolapse and presentation can obstruct the circulation in it, and so endanger his life. Other presenting parts press less firmly on his cord than does his head, but don't let this delay you. PROLAPSE AND PRESENTATION OF THE CORD PROLAPSE, ALWAYS do a vaginal examination immediately a mother's membranes rupture spontaneously, unless: (1) She is <36 weeks and is not having contractions, and you are considering non-operative management. Or, (2) her baby's head is well down (not more than 2/5 above the brim). If you find a prolapsed cord, DON'T take your hand out of her vagina! Instead, push his head (or breech) off the cord. While you are holding his head, ask an assistant to insert a Foley catheter and fill her bladder with 500 ml of Ringer's lactate or saline. A full bladder will keep his head away from the cord and inhibit the contractions of her uterus. Listen to his heart, to find out if he is still alive. It may still be beating, even if his cord is not (cord spasm). Assess his size, and try to exclude gross congenital abnormalities, particularly hydrocephalus. Remove your fingers, and apply a pad to her perineum, so that the cord remains in her vagina. Turn her on to her side with the foot of her bed raised. Or put her into the knee-elbow position (19-2). Set up an isoprenaline infusion (M 19.6). Put her on a trolley, and take her to the theatre for section as soon as possible. Don't pass a stomach tube; instead give her an antacid. Don't empty her bladder until you are ready to incise her parietal peritoneum. Always section her unless: (1) She is fully dilated and the head is only 2/5 or less above the brim (unusual). If so, apply forceps (if you are experienced with them because they are quicker), or a vacuum extractor. (2) Prolapse of the cord complicates the delivery of a second twin with a cephalic presentation. If there is no CPO, you can usually apply a vacuum extractor, or do a breech extraction preceded by internal version if necessary. PRESENTATION OF THE CORD, If you feel the cord vaginally when she has intact membranes, observe carefully for the fetal heart changes which indicate cord compression (M 18.56): (1) Put her into the head-down or knee-chest position. Nurse her with the foot of her bed raised for 24 hours. This will nearly always allow it to rise above his head. Or, (2) before 37 weeks, try external version. Turning him may draw the cord from under the presenting part. Or,(3) section her, unless he is dead or too small to survive. PROLAPSE OF THE CORD Fig. 19-6 TREATING PROLAPSE OF THE CORD BY FILLING THE BLADDER. A, the head pressing on the cord. B, the patient's bladder has been filled through a catheter, and the cord is now free. A full bladder also inhibits contractions of the uterus. 40 21 1410843 Fig. 19•7 HOW TWINS PRESENT. In 40% of cases both twins are cephalic. In 21% the second twin is a breech. In 14% the first twin is a breech. In 10% ofcases both twins are breeches. In all remaining cases one or other twin, or occasionally both, are transverse. 19.11 Multiple pregnancies You can deliver most twins vaginally, and only section their mother on the same indications as for a singleton pregnancy (18.4). Twins do however have problems: (1) Labour is more often premature, which puts them at risk. (2) Uterine inertia is more common; this delays the first and second stages of labour, and makes postpartum haemorrhage more likely. (3) Malpresentations are more common, especially with the second twin. (4) Prolapse of the cord is also more common. (5) When the first twin has been born, the second may suffer as the uterus retracts and constricts the placental site. As soon as you diagnose twins plan for: (1) Hospital delivery. (2) Rest from 32 to 37 weeks, at home if possible, or at a hospital or health centre. You will usually have to admit a mother at 34-35 weeks to the mother's waiting area. (3) A clinical pelvic assessment at 36 weeks. She is more likely to become anaemic, so be sure she is on iron and folic acid. Watch for gestational hypertension (17.4). She should not labour for longer with twins than she would with a single pregnancy. If you do decide to use oxytocin, use it with the greatest care. Deliver triplets (or quadruplets) as you would twins. Expect the same problems as with twins, but expect them more often. 'After you. ' 'No, after you' MULTIPLE PREGNANCIES FIRST STAGE. As soon as a mother is admitted in labour, determine the lie and presentation of the first twin by abdominal palpation. Confirm this by examining her vaginally, and at the same time assess her pelvis, if this has not already been done at 36 weeks. Manage her as for a singleton pregnancy and use a partogram. If there is delay during the active stage, manage this as for a singleton pregnancy, and apply the same criteria for the use of oxytocin and Caesarean section (see below). If the first twin is cephalic, or a fully-flexed breech, manage the first stage as an ordinary trial of labour, unless he is very big, or her pelvis is very contracted. If the first twin has a transverse lie, or is a footling (one leg flexed and one extended), section her, unless he is very small (less than 1.5 kg). He is likely to slip through an undilated cervix, and runs an increased risk of cord prolapse. SECON 0 STAGE. Find an assistant who will be ready to look after the first twin, while you deliver the second. Be prepared for an operative delivery of the second twin, and for a postpartum haemorrhage. Have equipment for a drip ready, and ergometrine and oxytocin in easy reach. Preferably, have a drip up routinely. Deliver the first twin as usual for a cephalic or breech presentation. Immediately he has been born, divide his cord between clamps, and then replace the maternal one by a tie. CAUTION! As soon as the first twin is born, look at the clock. Deliver the second twin as soon as possible, but without undue hurry. 20 minutes is a reasonable time. Feel her abdomen through a sterile towel to find the lie, presentation, and level of the presenting part of the second twin. Then do a vaginal examination to feel how it fits her pelvis. Use 4 fingers or even your whole hand, instead of the usual two; there will always be room for them immediately after delivery of the first twin. The head of the second twin is likely to be high, and you may not be able to reach it with it with two fingers. If you have a skilled assistant, ask her to do the abdominal palpation and external version of the second twin, and to hold his head steady, while you rupture the patient's membranes. Listen for the fetal heart, but don't waste too much time doing this; it may be difficult to hear and you will have to deliver him promptly anyway. CAUTION ! (1) Be sure you know what the presenting part is before you rupture her membranes. (2) The second twin may be larger than the first one. If you are unskilled, a timely section (rarely necessary) is better than the vacuum extraction of a high head, or pulling down the leg of a high-sitting breech. But, if you are expert, a vaginal delivery will always be quicker. Don't be too keen on section: CPO is unusual with twins. It the second twin is lying longitudinally, rupture his membranes, and deliver him as a vertex or a breech. If he is a vertex, ask your assistant to push his head into her pelvic brim, as you rupture his membranes (to avoid prolapse of the cord). It the second twin is transverse, correct his lie by manipulating him through a towel on her abdomen, so that his head presents (external cephalic version). The external version of a second twin is usually easy, provided you do it without delay, immediately after the first twin has been delivered, while the membranes remain intact, and before uterine contractions restart. Your assistant can usually do the version, while you check vaginally that he has turned correctly. If immediate delivery of the second twin in the labour ward by external cephalic version is not possible, try to keep her membranes intact. Rupturing them while he is transverse risks obstructed labour and rupture of her uterus. Arrange for speedy IF THE SECOND TWIN IS LYING TRANSVERSELY B If you succeed, do a vaginal examination and rupture, his membranes First try external A version. When you have brought down a leg, he should deliver If you fail to turn Fig. 19-8. IF THE SECOND TWIN IS TRANSVERSE, first try external cephalic version. Ifyou succeed, rupture his membranes. Ifyou fail, bring down a leg so as to make him into a breech presentation. This is internal podalic version. Keep the membranes intact if you can, until you have found a foot. In C, and D, they have been broken. him, put a hand into her uterus and bnng down a leg Internal version c delivery in the theatre by internal podalic version so that you can bring down a leg (see below), or if this fails by Caesarean section. THIRD STAGE, Manage this actively to minimize blood loss. Give her intravenous ergometrine with oxytocin ('Syntometrine') with the birth of the anterior shoulder of the second twin, and then deliver the placentas by controlled cord traction. If bleeding continues or her uterus is lax, also give her 10 units of oxytocin in 500 ml of fluid at 10 drops a minute. PARTICULAR METHODS FOR MULTIPLE PREGNANCIES INTERNAL PODALIC ('foot') VERSION can often be done . without general anaesthesia. It is kinder however to give her diazepam 10 mg and pethidine 50 mg intravenously. Put her into the lithotomy position. Make sure her bladder is empty. Prepare her vulva as usual, and preferably her abdominal wall also (sterile sheets are a nuisance, and you want to feel what you are doing). Wait until she is relaxed between contractions, then put your gloved right hand through her vagina and fully dilated cervix into her uterus, until you can feel her intact membranes. Keep them intact if you can. Often, you have to rupture them before you can get a grip on a foot. Feel her abdomen with your left hand. Grope around for a foot, which you will recognize by its heel. If this is difficult (unusual), work out which way he is lying, and then feel in the direction of his buttocks. Find a leg and follow this down. Use your other hand if this seems easier. When you have found a foot, bring this down. Hold his ankle between your index and middle finger, with your thumb on the dorsum of his foot. Gently pull his foot, so as to bring one of his legs over her pelvic brim, and down her vagina as far as you can, if possible as far as her vulva. His buttocks and other leg will follow. At the same time push his head towards her fundus. Only now rupture her membranes. Keep pulling on his leg in the direction of the floor. If necessary squat to do this. As more leg appears, hold it higher along its length. When his anterior buttock appears on her perineum, pull horizontally, and then upwards (breech extraction). When his buttocks are out, deliver his shoulders by Lovset's manoeuvre and his head by the Mauriceau-Smellie-Veit manoeuvre (19.8). Occasionally, it is enough to pull down a leg into her vagina, and let her do the pushing (an assisted breech delivery); but don't rely on this, and be ready to assist her if she is uncooperative or exhausted. CAUTION! (1) Internal podalic version is only for the second twin with intact or recently ruptured membranes, during a delivery which you have been supervising. It is not suitable if she is admitted with a transverse second twin and ruptured membranes. If so, manage her as a neglected transverse lie: if he is alive section her, if he is dead, do a destructive operation. (2) Make quite sure it is a foot, and not a hand that you are feeling. Don't, in exasperation, bring down any limb-it is sure to be an arm! (3) If you don't know what is presenting, don't waste time waiting for the presenting part to come down. While you wait, her membranes will probably rupture spontaneously, and the presenting part may be an arm! CAESAREAN SECTION is indicated if she has: (1) A contracted pelvis with a diagonal conjugate of < 11 cm, or a true conjugate <9.5 cm. (2) A major malpresentation of the leading baby, such as a transverse lie or an incomplete breech. (3) Lack of progress in labour. (4) A second twin with a transverse lie which you cannot correct. The scar from a previous Caesarean section is a relative contraindication to vaginal delivery. 01 FFICU LTI ES WITH MULTIPLE PREGNANCIES If there is DELAY IN THE FIRST STAGE, you can use oxytocin, provided there is no CPO. Rupture the membranes of the first twin. If CONTRACTIONS STOP after delivery of the first twin, and your are sure the presentation of the second is cephalic or breech, rupture her membranes. If contractions don't start immediately, put up an oxytocin drip at 2.5 units to 500 ml, and run this at 60 drops a minute. Try to deliver the second twin within 30 minutes of the first, or preferably less. It, when you do a vaginal examination after the delivery of the first twin, you feel the head or breech of the second twin, but her CERVIX ONLY SEEMS TO BE 7 OR 8 CM DILATED, rupture her membranes and make her push. Her cervix will dilate again, as soon as the presenting part of the second twin comes down. Contraction of her cervix will not delay delivery of the second twin, and is no reason for waiting. If the SECOND TWIN IS SO HIGH IN HER BIRTH CANAL, that you cannot reach him with your whole hand, and her cervix only admits two fingers, she has a CONTRACTION RING. It may go if you give her pethidine and diazepam, but if it doesn't section her. If she BLEEDS HEAVILY BEFORE THE DELIVERY OF THE SECOND TWIN, the placenta of the first one has probably separated. Deliver the second twin quickly, and then deliver both placentas together. If either twin is a BREECH, and she pushes well and the breech descends well, it will be an assisted breech delivery. If there is fetal distress, or delay, or poor pushing, don't hesitate to apply more traction, and turn delivery into a breech extraction (19.8). 19.11a Postpartum haemorrhage-PPH Perhaps you have just done a vacuum extraction, and are just taking your gloves off, when there is an ominous splashing ofblood into the bucket. Or, a midwife calls you in the middle of the night to say that a patient has had a severe postpartum haemorrhage. What are you going to do? A PPH can often be prevented, and can almost always be treated. Here is its management in hospital, which supplements that in Primary Mother Care. PPH is caused by: (1) Bleeding from the placental site because the uterus has failed to contract-much the most important cause. (2) Tears of the genital tract-rupture of the uterus, cervical tears, tears of the upper vagina, and vulval tears, especially near the urethra and clitoris. (3) Occasionally by a clotting defect, especially DIC (disseminated intravascular coagulation), which produces a fibrinogen deficiency. . Aim to resuscitate the patient, to stop the bleeding, and to monitor her carefully. Bleeding most often occurs from the placental site,'so your first objective must be an empty well-contracted uterus with the placenta out. Obstetricians differ in what they do for the few patients who continue to bleed from a contracted uterus with the placenta out, who have no obviously suturable tear or bleeding vessel to tie, and no clotting defect. Some pack the uterus, some stitch quite minor tears (the parturient cervix is normally ragged so they may be stitching the normal), and some do nothing except transfuse. Of those who pack, some explore, inspect, and suture the uterus first, and only pack if they find no tear worth suturing. Others pack, and only explore if packing fails to control bleeding. We side with those who pack when exploring and suturing have failed. When you pack, do so on the correct indications, and after all proper steps have been taken. Packing is messy and time-consuming, andneedslargequantities ofsteriledressings. Ifthereis asteady ooze, blood is scarce, and HIV common, packing may save a mother's life. In theory, packing is undesirable; in practice it is very useful as a near last resort, before tying her uterine or her iliac arteries, or removing her uterus (see 'Stop Press'). It is much less effective in controlling bleeding from her uterus, than from her cervix. Much the best way to do this is to give her oxytocics to make her uterus contract-if it will. DIC is probably the commonest cause of a massive PPH, when the uterus is empty, and is satisfactorily contracted. It is the commonest clotting defect, and is an important and preventable cause of maternal death. It is uncommon after a normal delivery, and is more common after abruption (16.13), an obstructed labour (18.3), or an intrauterine death (16.4). Try to keep two bottles of fibrinogen (one gram) in the refrigerator of your maternity unit. This is the only clotting factor which it is practicable for you to stock. If you cannot get it, or any fresh frozen plasma, you will have to give her fresh blood. To do this, you will find it helpful if all your permanent medical and nursing staff know their blood groups, and can be called upon in an emergency. Bergstrom Steffan. (1) Modrahalsovard I U-Land. (2) Forlossningsvard I U-Land. Reklam and Katalogtryck Uppsala 1988. IF SHE HAS LOST MORE THAN A LITRE OF BLOOD, OR SHOWS SIGNS OF HYPOVOLAEMIA, REQUEST 2 UNITS OF BLOOD URGENTLY (decide how much she needs when it comes) POSTPARTUM HAEMORRHAGE ('PPH') PREVENTING PPH BEFORE LABOUR RISK FACTORS FOR PPH IDENTIFIABLE DURING PREGNANCY. If a mother has a history of any of these, she is more likely to have a PPH and should deliver in hospital: (1) Grand multiparity (>5 children). (2) An antepartum haemorrhage in this pregnancy. (3) A postpartum haemorrhage, or a retained placenta, in a previous pregnancy. (4) Multiple pregnancy or other cause of polyhydramnios. (5) Hypotonic uterine action in a previous pregnancy. RISK FACTO.RS FOR PPH IDENTIFIABLE DURING LABOUR. (1) Prolonged labour. (2) General anaesthesia, usually with ether or halothane. (3) A full bladder. (4) 'Fiddling with the uterus' during the third stage. (5) Placenta praevia. (6) Placental abruption, mainly because this causes a clotting defect. (7) A clotting defect, especially DIC. (8) Incomplete expulsion of the placenta. CAUTION! (1) A postpartum haemorrhage may occur without there being any risk factors. (2) When you 'rub up a uterus', use the flat of your hand on the fundus. 'Fiddling' is all kinds of pushing, pulling, and rubbing, which cause partial separation of the placenta before the uterus has contracted firmly. PREVENTING PPH DURING LABOUR Give every mother, especially those with risk factors, an oxytocic drug: (1) Ergometrine with oxytocin ('Syntometrine') 1 ml intramuscularly. Or, (2) 5 units of oxytocin intramuscularly. Or, (3) ergometrine 0.5 mg intramuscularly (usually one ampoule). They will work quicker if you give them intravenously, but there may be nobody around who can do this routinely. Give a mother one of these, as soon as her baby is born — and you are sure there is no twin in her uterus. Then deliver her placenta by controlled cord traction. If supplies are short, you may only be able to give an oxytocic drug to 'at risk' mothers. If she has a risk factor for PPH, and you have sufficient intravenous fluids and drip sets, set up a drip of dextrose in water before she reaches the second stage. When her baby and her placenta have been delivered, add 20 units of oxytocin to the drip (500 ml), and run this in at about 30 drops a minute for at least 3 hours. Also, give her ergometrine as usual. Unfortunately, this is an expensive routine, and you may have to wait until amotherhasalready lost500 mI, beforeyou can afford to put up a drip. CONTROLLED CORD TRACTION. As soon as her uterus is contracting firmly from the action of oxytocin or ergometrine, put your left hand on her abdomen, above her pubic symphysis, and turn your palm towards her head. Grasp her uterus. As soon as it feels hard from the effect of the oxytocic, push it upwards towards her umbilicus (deliver the placenta more by pushing her uterus up than by pulling on the cord). Wind two or three loops of cord round your index finger and gently pull on the cord, first downwards and backwards, and then more anteriorly as the cord comes out. As soon as the placenta is delivered check to make sure that: (1) it is complete and that no lobes of it have been left behind (see below) and, (2) that there are no obvious tears in her birth canal. Keep her in the labour ward, and monitor her for at least an hour, before returning her to the ward. Check that her uterus is well contracted and note any bleeding. Opinions differ about the use of controlled cord traction, without the use of an oxytocic drug. Ideally, you should never apply controlled cord traction before the uterus has hardened under the effect of an oxytocic drug, and if you don't have one, CONTROLLED CORD TRACTION Only do this if she has had ergometrine or oxytocin! B as soon as the uterus feels hard, lift it towards her umbilicus first pull downwards and backwards then more anteriorly Fig. 19-9 CONTROLLED CORD TRACTION. As soon as her uterus is contracting firmly from the action ofoxytocin or ergometrine, grasp her uterus, push it upwards towards her umbilicus and gently pull on the cord, first downwards and backwards, and then more anteriorly as the cord comes out. you should not use it. In practice, little harm results provided there are signs ofplacental separation (lengthening ofthe cord, hardness and mobility of the uterus). Although it is a very valuable procedure, there is a risk, particularly if you do it incorrectly, that you may turn her uterus inside out (inversion of the uterus), see below. CAUTION! Don't squeeze her uterus to try to get the placenta out. This is so painful that it may cause shock. ASSESSMENT AND RESUSCITATION FOR PPH As soon as you are called to a patient with a PPH, quickly call an assistant: at least 2 people are needed. Assess and, if necessary, resuscitate her vigorously, as you would any other hypovolaemic patient (53.2). What is the state of her peripheral circulation? How much blood has she lost? Is it clotting normally in the receiver used to collect it? It may clot to start With, and then stop clotting later. What has been done so far? Monitor the volume of blood she continues to lose, her pulse and blood pressure, and her urine output. If she is still bleeding: Is her uterus still contracted? Is the placenta out and complete? Does she have any obvious lacerations of her vulva, vagina or perineum? If she is not still bleeding, is her uterus well contracted? CAUTION! Put someone in charge of her, and make sure that she is that person's sole responsibility, until bleeding has stopped, and her condition is stable. Poor supervision is an important cause of death in PPH. PPH WITH THE PLACENTA IN Try to make her uterus contract. (1) If you have not given her ergometrine, or, better, 'Syntometrine', give it now. (2) If this fails to stimulate a contraction, gently massage her uterus ('rub up' a contraction). (3) Remove her placenta by controlled cord traction (see above), as soon as her uterus is contracting firmly. It should deliver immediately. If controlled cord traction fails to deliver her placenta, remove it manually. Before doing a formal manual removal, you may be wise to do a vaginal examination, and see if it has stuck in her cervix, from which you can remove it quite easily. While preparing to do a manual removal concentrate on: (1) resuscitating her, and (2) keeping her uterus contracted by putting 20 or perhaps 40 units of oxytocin into the bottle (500 ml) of her intravenous drip (not the tubing, it is needed as a continuous infusion). (3) If the oxytocin does not work, gently rub up a contraction. MANUAL REMOVAL OF THE PLACENTA can either be fairly easy, or rather difficult. It is usually best done in the the labour ward (which must be equipped for anaesthetic resuscitation, A 3.1) rather than the theatre, which will cause delay and require moving her. You will need stirrups to maintain the lithotomy position and a good light. Before you start, set up a drip of saline or Ringer's lactate, or if she is very collapsed, two drips. If she is already being given an oxytocin drip, stop this just before manual removal to allow her cervix to relax, so that you can get your fingers through it. Scrub up and gown yourself, then put her into the lithotomy position, and clean her vulva and the protruding cord. Cover her with a lithotomy towel (a towel cut to expose the vulva). Unless she is very collapsed, she needs analgesia. Give her pethidine 25 to 50 mg and diazepam 10 to 20 mg intravenously. Or, if this is difficult, give her intravenous ketamine (A 8.1). Give them intravenously slowly, into the tubing of the drip, or into a vein. Manual removal without analgesia or an anaesthetic is very uncomfortable, particularly if it turns out to be difficult. Inexpert general anaesthesia, which may be all there is, is unnecessary, and potentially dangerous (18.1a). POST PARTUM A HAEMORRHAGE Bimanual compression B c Packing the uterus Fig. 19-10. POSTPARTUM HAEMORRHAGE (PPH). A, bimanual compression of a bleeding uterus between a fist in the patient's vagina and a hand on her abdominal wall. B, manual removal ofthe placenta. Gently separate it from the wall ofher uterus with a slow sawing movement with the side ofyour hand. C, packing the uterus is only occasionally necessary. Its main use is to control bleeding from the cervix. It is much less effective in controlling bleeding from the uterus. Much the best best way to do this, is to give drugs to make it contract. C, kindly contributed by Robert Lange. Hold the cord in your left hand. Put the tips of the fingers of your right hand together, and introduce it into the upper part of her vagina. If her placenta has stuck in her cervix, grasp it and slowly remove it. Now let go of the cord, and place your left hand on her fundus (over the towel). Prevent her fundus from being pushed up, as you gradually work your way into her uterus with your right hand. Feel for the part of the placenta which has already separated, and push your fingers between it and the wall of her uterus. Gently separate her placenta from the wall of her uterus with a slow sawing movement, with the side of your hand. CAUTION! All this time keep your left hand pressing on her fundus, so as to bring her uterus as close to your right hand, as you can. If you don't do this there is a danger you may tear it. As soon as the placenta has separated, grasp it with your right hand, remove it, and ask your assistant to inspect it. While this is being done, and whether it looks complete or not, explore her uterus for any pieces that may have been left behind, and remove them. Only now remove your right hand from her uterus. Finally, give her a further dose of intravenous 'Syntometrine', or ergometrine (0.5 mg), and wait for her uterus to contract. As it begins to do this, remove your hand. As you do so, check that the lower segment is intact. Before you finish make sure that there are no other sites of bleeding; so explore her uterus as described below. Inspect her placenta to see if: (1) a piece of it has been left inside, or (2) a vessel is running off one edge of it. This may lead to an extra lobe which has been left inside. If either of these things have happened, the missing piece of placenta must be removed. If she continues to bleed, apply BIMANUAL COMPRESSION (A, Fig. 19-10). Put your right hand into her upper vagina. Put your left hand on her abdomen, and use it to push her fundus down onto your right hand. Press for at least 5 minutes, and then review the situation. If she continues to bleed, you are now in the situation of 'PPH with the placenta out', so see below. Continue the oxytocin drip. Add 20 units of oxytocin to the intravenous fluid (500 ml), and run it in at a rate that will keep her uterus contracted. Continue the drip for at least 12 hours, using more intravenous fluid and oxytocin• as necessary. Monitor her carefully. Some obstetricians would also give her an antibiotic. Keep her in hospital for at least 5 days, because of the increased risk of puerperal sepsis, particularly endometritis. A few days later check her haemoglobin. PPH WITH TH E PLACENTA OUT Failure of the uterus to contract is the most important cause, so aim for an empty, well-contracted uterus. Feel her fundus. It should be hard and round, and below her umbilicus. If it is soft and difficult to feel, it may be relaxing. Rub it up to make it contract. This may expel some blood and clots. If her bladder is full, catheterize it. Give her ergometrine 0.5 mg, or 'Syntometrine' 1 ml, intravenously or intramuscularly (if she has not already had it). Resuscitate her. Ideally, put up two drips of saline or Ringer's lactate (in practice you may have to use a single drip). To the first add 20 units of oxytocin to the intravenous fluid (500 ml). Run it in fast, until her uterus contracts well. Then slow it to 40 drops a minute. Continue this drip for two hours afterwards. Use the second drip to replace the blood she has lost. Give her a plasma substitute (dextran), or blood. If her blood pressure falls below 80 mm systolic (90 mm is the usual value, but you will probably be worried about HIV), run it in rapidly. As soon as her blood pressure reaches 90 mm systolic, slow it to 40 drops a minute. Inspect her placenta for missing pieces with great care, if you have not already done so. If a piece is retained it will have to be removed. If there are any obvious perineal tears, suture them. If bleeding stops, continue to monitor her, to resuscitate her if necessary, and to give her intravenous oxytocin. If she continues to bleed with an empty uterus (5% chance), note the following and take the appropriate action: (A) Is her uterus still poorly contracted, despite the oxytocin? If so, increase the rate of infusion. If this fails, she may have a piece of placenta remaining inside, or, much less commonly, a ruptured uterus. So explore her uterus (see below), if you have not already done so. Fig. 19-11 REPAIRING A CERVICAL TEAR. A, search all round the patient's cervix with ring forceps, until you find the tear. B, a longer tear being sutured. C, ifmidwives cannot control bleeding they are asked to apply ring forceps, tie the patient's legs together, and refer her to you like this.

(8) Does the blood coming from her uterus clot normally? If it fails to clot, she probably has a clotting defect (see below).

(C) Does her uterus remain well contracted, but she bleeds in spite of it? If so, explore her genital tract for tears, from her fundus to her clitoris. If you find tears, suture them. If you don't find any tears (and her blood clots), pack her uterus and vagina. If it does not clot, see below.

EXPLORATION FOR PPH INDICATIONS. (1) As a normal part of any manual removal (see above). (2) A mother who continues to bleed with the placenta out. Also see below on the indications for packing. METHOD. Scrub up and put on gloves. Towel her, as for manual removal. Catheterize her. Give her intravenous analgesia (see above). Put her into the lithotomy position, get a good light, and find a Sims' speculum, and an assistant to help hold it. Wipe out the blood in her vagina with cotton wool swabs. Look at its walls. Check that her vaginal wall, and her perineal and vulval skin are intact. To inspect her cervix, use two swabholding forceps. Grasp the front lip of her cervix with one of them. Pull her cervix gently down, and look for lacerations on it. If there are no lacerations in that bit of cervix, use the second forceps to pull down the next bit of cervix, and look at that. Go right round her cervix in this way, looking at every part, as in Fig. 19-11. Then put your hand into her uterus and carefully feel its front, sides, back, and fundus. Feel for a rupture of her uterus (18.17), and for any pieces of adherent placenta. If she has lacerations of her perineum, vagina, or cervix which are big enough to suture, suture them. Only suture a cervical tear, if it is causing arterial bleeding. A venous ooze is not a sufficient indication for suturing. A CERVICAL TEAR A A larger cervical tear. B / If she is bleeding from multiple small tears rather than one large one which you can easily stitch, orthere is a steady ooze, pack her uterus and vagina as described below. If a piece of placenta remains inside, scrape it off with your fingers. If you cannot get it all off, she has an abnormally adherent placenta, leave it. If you find a rupture in her uterus, apply bimanual compression (if the bleeding is severe), until you can get the theatre organized for a laparotomy (18.17). PACKING THE UTERUS AND VAGINA FOR PPH INDICATIONS. (1) Continued bleeding, when there is no clotting defect, and no tear in the upper vagina, cervix, or uterus, which is large enough to repair surgically, and when other methods to control bleeding, particularly the adequate use ofoxytocic drugs, have failed. (2) Continued bleeding after a clotting defect has been corrected, or when you are unable to correct it. Note: one contributor packs before exploring and only explores when packing has failed (and the blood clots), see above. METHOD. Scrub up and glove yourself. Put her into the lithotomy position. Pack her uterus and vagina with a wide roll of sterile gauze, or laparotomy pads, or failing these, maternity pads, which are less satisfactory, because they may get lost inside. Start by packing her fundus and work downwards. Use ring forceps to push lengths of gauze through her vagina into her uterus, until both are firmly packed down to her perineum. Pack tightly to press on her cervix from below. The pack should fi 11 her uterus. However, if both her cervix and her uterus are well contracted, you may not be able to pack her uterus completely. If so, a well packed vagina may press adequately on a bleeding cervix. CAUTION ! (1) Be sure to pack her whole genital tract, from her fundus to her introitus if you possibly can, for which you will need large quantities of gauze. (2) Don't only pack her vagina, because she will bleed above the pack and her uterus will fill with blood, the only sign of which may be increasing shock. (3) If you use maternity pads or separate pieces of gauze, you must tie them together, or they will get lost. When you have packed her uterus, she will have difficulty in passing urine, so pass a Foley's catheter, and connect this to a bag. If the pack controls bleeding, continue to monitor her and to give her intravenous fluid or blood as necessary. Remove the pack at 24 to 48 hours, preferably at 24 hours. DIFFICULTIES WITH PPH If a patient is BLEEDING SEVERELY and there Is going to be some delay before you can treat her, compress her aorta. Stand on her left and feel for her left femoral pulse with your left hand. Clench your right fist and with your index finger level with her umbilicus and your knuckles in the line of her spine, press firmly through her abdominal wall so as to compress her aorta against her spine. You will feel it pulsating. Press so that you no longer feel any pulsations and obliterate her femoral pulse. If necessary, this method can be kept up for hours, while she is referred or while preparations for surgery are being made, changing hands and workers as required. If her legs become numb, allow a little blood to flow through them. A method described by Staffan BergstrOm (see above). Ifyou CANNOTGETYOURWHOLE HANDTHROUGHHER CERVIX TO DO A MANUAL REMOVAL (not uncommon if she has been given a lot of ergometrine shortly before the manual removal is done, or there has been a long delay), you are in difficulty. Avoid this problem, if you can, by using intravenous oxytocin in the drip, rather than ergometrine, and by discontinuing the drip just before manual removal. Try to get one or two fingers through her cervix, and push her fundus well down with your other hand. Usually, her cervix relaxes gradually so that, if you are slow and gentle, you can put your whole hand into her uterus. If her placenta seems abnormally adherent to her uterus (PLACENTA ACCRETA or increta), remove what you safely can piecemeal, without perforating her uterus, and leave the rest. If her uterus does not contract well, she will not bleed from these areas, but only from the separated ones. The placenta which you have to leave will be slowly absorbed. She is at serious risk from sepsis and secondary postpartum haemorrhage. Continue the oxytocin drip for 48 hours, then stop if she is satisfactory. Give her antibiotics (chloramphenicol and metronidazole, 2.9). Monitor her carefully, and keep her in hospital for 12 to 14 days. If YOU PUT YOUR FINGERS THROUGH HER UTERINE WALL as you remove the placenta (easily done, but this should be rare if you do the procedure properly), do a laparotomy and inspect the tear. If it is a minor one, you may be able to repair it. If it is a large tear, repair it, and if bleeding is not controlled, tie her internal iliac arteries. If you don't think it is safe for her to labour again, and her relatives agree, tie her tubes. A hysterectomy is seldom necessary. If her blood FAILS TO CLOT in the receiver as it comes from her vagina, she probably has DIC (DISSEMINATED INTRAVASCULAR COAGULATION). If necessary, you can confirm this with a bedside clotting test (16.13), but don't let this delay you; control is urgent. Give her 2 g of fibrinogen by rapid intravenous infusion. Give her 2,4, or 6 units of blood with 10 ml of 10% calcium gluconate after the third bottle. Give her another gram of fibrinogen 15 to 30 minutes later, if necessary. If her problem is DIC causing afibrinogenaemia, this should be enough. If you don't have fibrinogen, give herfresh whole blood. Her clotting defect will probably correct itself within 12 hours of delivery of the placenta, so if you can only keep her alive during this period, she will probably live. . If she CONTINUES TO BLEED FROM AN EMPTY UTERUS, DESPITE ALL THE ABOVE MEASURES, try oxytocin 40 units to 500 ml of fluid in a fast running drip and repeated doses of ergometrine 0.5 mg intravenously. Try prostaglandins if you have them. If this fails, tie her uterine (see 'Stop Press') or her internal iliac arteries (3.5), and only if all these measures fail (rare) resort to hysterectomy (20.12). She may have a small rupture of her uterus, which you can only diagnose at laparotomy. Some contributors consider hysterectomy easier than tying the iliac arteries, particularly under inadequate anaesthesia. If her uterus TURNS INSIDE OUT as her placenta is delivered (rare), she has INVERSION OF HER UTERUS. This may happen spontaneously, or as a complication of controlled cord traction, particularly in elderly multips. Untreated, she can easily die. Immediately push it back. If you can return it immediately, it should go back easily. If there is any delay, she INVERSION OF THE UTERUS Fig. 19-12 INVERSION OF THE UTERUS. A, D, and e, increasing degrees ofinversion. Ifthis happens spontaneously (rare), or as a complicationofcontrolledcordtraction, immediatelypushitback.Ifthere is any delay, replacing it will be much more difficult. D, Haultain's operation for chronic invenion.. After 'Bonney's Gynaecological Surgery', Fig. 431. Bailliere Tindall, permission requested. may become shocked, and replacing it will be much more difficult. Wash her prolapsed uterus with warm saline, give her an antibiotic, resuscitate her, give her a general anaesthetic, and put her into the lithotomy position. There are two methods. (1) Use an enema nozzle and a douche can of warm saline suspended a metre above her. Wash out her vagina with fluid, insert the nozzle, and close her vagina with you left forearm. The hydrostatic pressure of saline will slowly return her fundus over 15-30 minutes. Replace it slowly and manipulate it as little as possible. Check that reduction is adequate. (2) Slowly and gently replace it manually, her fundus last. See also Primary Mother Care. If she presents after several weeks with CH RON IC INVE RSION (rare), do a laparotomy. You will probably find that, whereas her uterus is protruding a considerable distance from her vulva, internally it seems to be inverted from her lower segment, which is much congested. Her tubes may enter pits on either side of her evaginated uterus and be attached at their bottoms. Isolate her bladder from the lower part of her uterus and divide its rolled-over rim where it is inverted and constricted. Alternatively, pull it up with a volsellum and incise the posterior rim of the depression in her uterus through both thicknesses of its inverted wall (Haultain's operation, 19-12). This should allow you to withdraw her fundus from inside, aided if necessary by a finger passed through the incision into her vagina. Repair the wound you have made in her uterus in 2 layers. CAUTION! (1) Inversion of the uterus is much less common than prolapse of the swollen cervix through the vulva. You can easily push this back and it seldom recurs. (2) See also prolapsed fibroids (20-4). 19.11b Secondary postpartum haemorrhage (puerperal haemorrhage) This is vaginal bleeding between 48 hours and 6 weeks after delivery, usually between 6 and 14 days, and typically on the 10th day. It is usually due to infection, particularly in association with: (1) Retained pieces of placenta. (2) Obstructed labour, causing necrosis of the cervix and vaginal wall. (3) Caesarean section and breakdown of the the uterine wound (6.8). PUERPERAL HAEMORRHAGE If bleeding is mild, observation may be all the patient needs. If she continues to bleed, or has signs of infection, give her antibiotics, such as chloramphenicol and metronidazole (2.9). If bleeding is severe, she will need antibiotics, resuscitation, and exploration of her uterus for retained pieces of placenta. Be sure she is well resuscitated before you start exploring her! EXPLORING AND EVACUATING A SEPTIC UTERUS is difficult. Sterilize 2 ring forceps (or swab holders), a Sims' speculum, and a big, blunt curette. Add them to the vaginal examination tray. Scrub up, put on gloves and put her into the lithotomy position. Cover her with a lithotomy towel (a towel cut to expose her vulva). Give her ergometrine 0.5 mg, and pethidine 50 mg, and diazepam 10 mg intravenously. Inject the pethidine slowly. Or give her a general anaesthetic. Clean her vulva with an antiseptic solution. If her cervix is wide open, insert two fingers into her uterus, and try to remove any pieces of placenta that you can feel. They are not easy to find, because her uterine cavity is large and its walls irregular. If you cannot remove pieces of placenta with your fingers, use ring forceps and a large curette, like this: Put the Sims' speculum into her vagina. Ask a helper to hold it, so that you can see her cervix. Hold the front of her cervix with one ring forceps. Put the other ring forceps into her uterus. Push it in very gently, until it is at her fundus. Feel the size of her uterine cavity. Open the handles, turn the forceps and close them again. Pull out any placenta you have grasped. Do this several times in different parts of her uterus, until nothing more comes out. Curette her uterus. Scrape it down the anterior wall, then the two side walls, and then the posterior wall. Lastly, scrape it across the fundus. Don't scrape too hard, or you may harm its lining. It will still feel irregular when you have finished scraping. CAUTION! Emptying a uterus in the puerperium is difficult, and can be dangerous. Its wall is soft, and you can easily perforate it. Never use a small curette, or any small instrument, because they will make a hole very easily. Work gently and carefully, and don't use a sound. If her uterus is empty and she is still bleeding severely, pack it and her vagina (19.11a). If packing her uterus fails to control bleeding (very unusual), proceed to laparotomy, and tie her uterine (see 'Stop Press') or internal iliac arteries (3.5). If this also fails (rare) do a hysterectomy (20.12). If she has a secondary postpartum haemorrhage after Caesarean Section, see 'Stop Press'. 19.12 Resuscitating the neonate A baby should breathe within a minute ofbirth, and usually does so. If he does not, he needs resuscitating, which may make all the difference between normality and brain damage. 'Flat' babies, who don't breathe, are often a surprise, but you should be able to predict and prepare for most of them as described below. Most follow difficult deliveries, which are more likely to damage his brain by anoxia during and after delivery, than by trauma during it. The aim of resuscitation is to make sure that his lungs expand, he is well oxygenated, his circulation and temperature are normal, and he is breathing normally. Mask ventilation and intubation will not help him if he does not need them; so follow the indications below. Ideally, all your midwives should be able to intubate a baby. They can learn how to do it on a fresh stillbirth. But if normal deliveries are done by a continuously changing succession of midwives in training, you will not be able to train all of them to intubate the occasional baby who needs it. For these babies immediate bag and mask, or mouth to mouth ventilation, will be much better than intubation delayed by the time it takes to call you. Traditionally, the Apgar score has been used to decide which babies to resuscitate. The instructions given below simplify this, and use only the heart rate and the respirations, on the grounds that if these are unfavourable, the other parts of the score will be unfavourable too. See also Primary Anaesthesia Chapter 13. • LARYNGOSCOPE, neonatal, straight-bladed, Seward, with two blades sizes 0 (80 mm) and 1(110 mm), also ten spare batteries and five spare bulbs, two laryngoscopes only. You will need a spare laryngoscope-at least one of them must be working always!. • TUBES, tracheal, neonatal, transparent, plastic or rubber, non-disposable (or disposable but reusable), either Cole pattern with neck and T-piece, or straight pattern with uniform diameter and stylet (optional), sizes 2.5 mm (10 Ch), 3 mm (12 Ch), and 3.5 mm (14 Ch), ten only of each size. Pack these locally in sets. • ADAPTOR, tracheal, neonatal, various sizes, five only. This fits the tracheal tubes to the Ambu bag.

• SUCTION CATHETERS, 4, 6,8, and 10 Ch, ten only of each size. These fit down the tracheal tubes. • AIRWAYS, neonatal, sizes 00 and 000, five only of each size. One contributor considers these outmoded. • MASK, neonatal, soft and clear, sizes 00, 0, and 1, Ambu (A MS) Laerdal, Bennett, or Samson, two only of each size. • BAG, self-inflating, neonatal or infant size 250 or500 ml, Cardiff, Laerdal, or Ambu (AMB), with reservoir or extension tube, and expiratory pressure release valve, one only. The pressure release valve will prevent you inflating him at >40 cm of water. The valves must be present and working. • SUCTION DEVICE, electric, with overflow bottle and gauge, maximum vacuum 100-120 mm Hg (0.16-0.26 Bar), as Ide Vilbiss 721 Vacu Aide' (deV), one only. Don't use a standard anaesthetic sucker-it sucks much too powerfully. Alternatively, use a mucus extractor, see below.

• FOOTPUMp, 'minipump' Ambu (AMB), one only. You will need this if you don't have electricity, or it fails. • MUCUS EXTRACTOR tube and fluid trap, 10 Ch (CHI), five only. If necessary, you can make these from old drip sets. The danger with a mucus extractor is that you may get secretions in your mouth, which

is not acceptable where HIV is a risk. Unfortunately, there is presently no mouth-operated sucker which avoids this. • STETHOSCOPE, with small head, one only. MAKE SURE YOUR MIDWIVES CAN INTUBATE NEONATES RESUSCITATING THE NEWBORN 'AT RISK' MOTH ERS AN D BABI ES. Causes arising during labour (1) Fetal distress. (2) Meconium staining of the liquor. (3) Caesarean section. (4) Vacuum or forceps delivery (except a simple 'lift our). (5) Abnormal presentation, commonly breech delivery. (6) Prolapsed cord. (7) APH, especially placenta praevia. (8) Prolonged labour. Maternal conditions. (1) Diabetes. (2) Fever. (3) Other maternal illnesses. (4) Extremes of maternal age « 16 or >35 years). (5) Heavy sedation. The excessive administration of pethidine (> 100 mg 4-hourly during labour). Contrary to popular belief, pethidine in reasonable doses (100 mg 6-to 8-hourly) causes only minimal neonatal depression. (6) Babies whose mothers have severe gestational hypertension (pre-eclampsia) which has required heavy sedation, particularly with diazepam, or phenobarbitone (not advised). Fetal conditions (1) Multiple pregnancy. (2) Pregnancy of abnormal length « 37 weeks, or >42 weeks). (3) Prematurity. (4) IUGR (19.13). (5) Isoimmunization. (6) Abnormal babies. CAUTION! When you start any operative delivery, make sure that the midwife who is helping you is completely ready to resuscitate the baby. WARMTH. The first principle in caring for a baby is to keep him warm and keep him fed. Hypothermia is one of the most easily avoidable causes of neonatal death in low birthweight babies, even in 'warm' countries, so keep him warm and dry during all the procedures which follow! He can easily lose 3°C in 15 minutes, with dangerous consequences, which include hypoglycaemia, respiratory distress, and acidosis. If you can keep the whole room at 30°C (very uncomfortable for adults), you will not need an additional heater. If you cannot maintain this temperature, keep the room as warm as you can (24-26°C is a good compromise) and provide a radiant heater (a lamp is almost useless) over the resuscitation platform, with sides to prevent drafts. Use dry towels and keep them warm near a radiator or in a warm cupboard. Survey the temperatures of babies arriving in your neonatal ward. You may be surprised by how cold some of them are! Later, the best place to keep him warm is between his mother's breasts, which will also assist breast-feeding and bonding. OXYGEN (with spare cylinders) is desirable, but not essential. It must reach him at a pressure of not more than 30 cm of water (20 cm is is the usual working pressure), so there must be a blow-off valve which prevents it exceeding this pressure. Provide one by using aT-tube and a water manometer, as in U, Fig. 19-13, if necessary made from old drip sets. If you don't have oxygen, you will have to ventilate him by mouth (see below). TH ERESUSCITATION PLATFORM can be horizontal, or slightly sloping head-down. It can be the top of a suitably prepared trolley, or a broad shelf attached to the wall at a convenient height. OTHER EOUIPMENT AND DRUGS should be kept immediately available on a trolley. Besides the special equipment listed above, you will need: Warm towels. Feeding tubes 6 and 8 Ch. Needles 0.5, 0.6 and 0.8 mm. A stopclock indicating seconds and minutes. Scalp vein sets and paediatric infusion sets. 1 cm adhesive tape to secure the tube. 'BMstix' or 'Dextrostix' to measure the blood glucose; note the expiry date, and economize by cutting strips in half lengthwise. Blood sugar bottles. 10 ml ampoules of 8.4% (1 mmol/ml) sodium bicarbonate, 10% calcium gluconate, 5% and 10% dextrose in water, and 0.9% sodium chloride. 100/0 oral dextrose. Naloxone hydrochloride (expensive but seldom needed): neonatal 20µg/ml for intravenous use, or adult 400 µg/ml. Dilute 1 ml of the adult naloxone with 20 ml of saline for neonatal use. Don't have both because you can easily mistake them. 1 mg ampoules of vitamin Kt. 3 ml ampoules of 1:10,000 adrenalin. If you only have 1 ml ampoules of 1:1000 adrenalin, dilute one of these with 10 ml of saline. CAUTION! (1) Ask another person to check all drugs before you give them. (2) Don't use nikethamide, caffeine, or aminophylline, or other central stimulants. (3) Older drugs, such as nalorphine and levallorphan, may cause respiratory depression, if you don't give them at exactly the right dose for a particular situation. (4) Keep all drugs in their original boxes and not together as 'mixed ampoules'. Check the equipment regularly, keep a log book, and sign it. Clean and disinfect the equipment after use (2.5, 28a.2). INTRAVENOUS INJECTIONS. Catheterizing the umbilical vein is more likely to cause infection; a scalp vein drip is safer. If a baby needs intravenous injections, give them into the drip or directly into the umbilical vein with a syringe and needle; be sure you are in the vein and not in the tissues. IMMEDIATELY AFTER BIRTH Start the clock. Hold him for a moment with his head lower than his legs, so that fluid drains from his respiratory tract. Place him on the resuscitation platform. Quickly dry him with a warm towel; dry his hair, axillae, and groins. Remove the wet towel and cover him with a dry one. Leave his cord at least 3 cm long, with the nearest tie at least 2 cm from him, so that it can be used for intravenous injection if necessary. Don't apply alum powder to it for at least 24 hours. If he is BREATHING NORMALLY AND CRYING VIGOROUS• LY, with a good heart rate and normal colour and muscle tone, he usually needs no suction. But if there are copious secretions or blood in his mouth, gently suck out his oropharynx (see below). Briefly clear his nose, and hand him to his mother. If he has MECONIUM•STAINED LIQUOR, you MUST clear his airway. Ifpossible, do this as soon as his head is delivered, before he takes his first breath. When he has been delivered, hold his chest to prevent inspiration, until you have cleared his pharynx and larynx under direct vision with a laryngoscope. This is difficult, and it may be easier to intubate and suck through the tracheal tube. If there is only a little meconium, intubate him, and aspirate it with a suction catheter through the tube. If there is much meconium, aspirate immediately with the largest possible catheter, or quickly connect suction to a tracheal tube. If a catheter or tracheal tube blocks, remove it and quickly replace it with another. Continue until all meconium is cleared, unless there is bradycardia «60/minute); if so intubate him immediately. If his condition allows it, avoid ventilation until you have removed as much meconium as you can. If his BREATHING IS SHALLOW AND IRREGULAR, estimate his heart rate by listening to it, by feeling his umbilical cord pulsating or his brachial pulse. If it is >100/min, and he is well perfused, with good tone, apply tactile stimulation and an airway. Gently flick the soles of his feet, or rub his back for a few seconds. Be gentle, and if there is no prompt response, stop, suck out his oropharynx and start mask ventilation. If itis < 100/min, insert an airway and start mask ventilation. If he NEVER BREATHED, or STARTED TO BREATHE AND THEN STOPPED, start bag and mask ventilation. If his heart rate is still < 100 after one minute of ventilation (he is usually pale and limp), apply suction briefly and intubate him immediately. SUCKING HIM OUT If necessary (see above), first suck out his mouth, then his nose with a sterile, wide, soft rubber or plastic catheter, or use a standard 'disposable but reusable' mouth sucker with a fluid trap. Give one long, strong suck, and don't push the catheter > 5 cm from his mouth. CAUTION! Before you start to ventilate him by any method, be sure to suck him out. Sucking out his trachea is as important as ventilating him. If you don't suck him out, you may push liquor, mucus, or meconium deeply into his bronchi. NEONATAL RESUSCITATION T Fig. 19-13 NEONATAL RESUSCITATION. A, a transparent laerdal selfinflating bag; note the valve. B, compress the bag with your finger tips. e, a straight-sided tube. D, a Cole tube with side arm and stylet (optional). E, lift his epiglottis. Or F, put the blade ofthe laryngoscope into his vallecula. G, and H, lift his tongue forwards to view his larynx. I, gently press on his trachea with your 5th finger. J, or ask an assistant to do this. K, and L, the correct position for resuscitation. M, his neck is too extended. N, it is too flexed. 0, the correct size ofmask. P, it overlaps his chin. Q, it is too small. R, it overlaps his eyes. S, and T, inserting infant airway. U, a T-tube and water manometer adjusted so as not to exceed a pressure of20 cm ofwater. V, mouth to mouth ventilation. Blow gently from your cheeks only, about 40 times a minute. Lift up his chin, extend his head and keep him warm. BAG AND MASK VENTILATION Slightly extend his neck, if necessary with a small pad under his shoulders. Insert an oral airway (optional). Put a finger under his mandible to hold it forwards, without compressing the soft tissues of his neck K, and L, Fig. 19-13. Choose the largest mask which will not overlap his eyes or his chin (0). Gently compress the bag with your finger tips (B), so as to inflate him 30-60 times a minute with as high a concentration of oxygen as you can, usually at a flow of 2-6 litres/minute. You can increase the oxygen concentration by fitting a reservoir or additional length of hose over the air intake (A). Watch his chest, it should rise with each breath. Don't compress the bag suddenly and forcefully. The object of each inflation with the mask is to expand his lungs and start him breathing. If his chest does not rise with each breath: (1) Check that the mask makes an adequate seal with his face. (2) If necessary, clear his airway again by sucking out his mouth and nose. (3) Does the bag leak? (4) If necessary, insert an infant airway (S, and T). If this fails, intubate him. If you cannot intubate him, try compressing the bag harder. If mask ventilation fails, intubate him promptly. INTUBATION INDICATIONS. The failure of mask ventilation. Don't intubate him unless his heart rate and general condition deteriorate, and not untiIafteryou have sucked out hispharynx and larynx under direct vision. Unskilled attempts at intubation do more harm than good. Most 'floppy' babies can survive without it, provided you ventilate them in some other way. METHOD. Neonatal intubation resembles adult intubation (A 13.1). Prepare the tracheal tube you think you will need. Cole tubes (C) do not require a stylet. If you use a stylet, curve it to the shape of the tube and don't let it protrude beyond the end. <1250 g or <28 weeks 2.5 mm tube. 1250 g-2 kg or 29-34 weeks 2.5 or 3 mm tube. >2 kg or >34 weeks 3 or 3.5 mm tube. 'Big baby' 3.5 mm tube. Slightly extend his head on his neck (K and L). First try to ventilate him with a mask for a few breaths. Gently insert a laryngoscope with a straight blade (size 0 blade for a small preterm baby and size 1 for a larger one) with your left hand, holding his lips apart with the fingers of your right hand. Guide the blade over the surface of his tongue, pushing it to the left. Continue until you see his leaf-like epiglottis. Either lift his epiglottis gently (E), or insert the blade into his vallecula (F). Lift his tongue forwards, so that you can see his larynx (G and H). If you insert the blade too far into his oesophagus, withdraw it gradually until you can see his larynx. Clear his vocal cords and posterior pharynx with a sucker. Gently press on his trachea with your 5th finger (I) (or ask an assistant to press it, J) until you can see his cords. Using your right hand pass the tube between his cords from the right, until the shoulder (Cole type) or mark (straight type) is just above his cords. CAUTION! (1) Make sure his trachea remains central. (2) Don't force the shoulder of a Cole tube through his cords. (3) If his cords are obscured by secretions, ask your assistant to hand you the suction catheter and gently clear his airway. (4) Don't overextend his neck; the 'sniffing position' (A 13-7) is ideal. (5) If he is seriously in need of ventilation, intubation is best-if you are sure the tube is in his trachea. If you are not sure, mask ventilation is safer. Rest your hand gently on his face, hold the tube firmly, and gently remove the laryngoscope (and stylet if you are using one). Connect the tube to the oxygen supply, and adjust it to deliver 4 I of oxygen per minute at 20 to 30 cm of water (use a lower pressure for a very small baby). Inflate his lungs by occluding the outlet of the tube (U), or the T-piece of a Portex tube, and watching the column of air in the manometer. Or squeeze an Ambu bag. If he has never made any inspiratory effort (primary apnoea), his lungs will be more difficult to expand, so apply more pressure (the 'opening pressure') for slightly longer with his first breath. Inflate him for 2-3 seconds initially, and then for about half a second at 30-60 breaths per minute. If he has taken a few breaths and then stopped (secondary apnoea), he wi II need less pressure to inflate his lungs. Often, you cannot distinguish primary from secondary apnoea. Observe: (1) His chest moving; and check that the movements are equal both sides. (2) His breath sounds; and check that they are also equal both sides. (3) An increase in his heart rate. (4) An improvement in his colour. As soon as you are ventilating him effectively, so that his heart rate is > 100, dry him and replace the wet towel with a dry one. Continue ventilating him until he breathes spontaneously himself Note the time at which he first breathes. If he does not start breathing spontaneously in a few minutes, strap the tube in place with tape and continue ven tilating. If you fail to intubate him within 20-30 seconds, withdraw the tube and ventilate him with a mask (to improve his colour and increase his heart rate) before you try to intubate him again. If his chest movement is poor after intubation, check the flow-meter. Is the oxygen on? Is the oxygen cylinder empty? Is the tube blocked (suck it out) or kinked (straighten it)? If none of these are responsible, it is probably in his oesophagus, so remove it and try again. If secretions are copious pass a suction catheter down the tube and aspirate them. If his breath sounds and chest movements are asym metrical, the tube is probably in his right main bronchus. Slowly withdraw it 0.5 cm at a time, listening for his breath sounds to become equal. If they continue to be inadequate, he may have a pneumothorax, a diaphragmatic hernia, a pleural effu sion, or hypoplastic lungs (not described here). If his heart rate remains <100, check that the tube is not in his right main bronchus (see above). If it is <50 he needs cardiac compression (see below). ENDING VENTILATION. When he is pink and his heart rate is > 150, stop ventilation and watch him carefully; if his heart slows, start ventilating him again. Let him try breathing on his own, when his heart rate is >150. He may need an occasional puff before regular breathing restarts. When he is breathing regularly remove the tube. CARDIAC A COMPRESSION CAUTION! (1) Don't remove him from the labour ward with the tube in place. (2) Don't leave him on a sloping resuscitation platform: the weight of his liver pressing on his diaphragm will make breathing difficult. (3) If he has been in any way abnormal, watch him carefully for 24 hours. If he does not start breathing or his heart rate remains <50 for 30-45 minutes, stop. He is unlikely to survive. EXTERNAL CARDIAC COMPRESSION INDICATIONS. If his heart beat is <50/minute (bradycardia), compress his heart in the hope of strengthening or restarting It. He IS usually pale. If his heart is not beating at birth, external cardiac massage is unlikely to start it. METHOD. Grasp his chest with both hands and place your thumbs over his sternum at the level of his nipples (A, Figure 19-14). Gently compress his chest 1-1.5 cm. When you relax, keep your fingers on his chest. While you intermittently compress his heart 120 times a minute (B, C, and D), ask a colleague to inflate him 60 times a minute (E and F): Time this by calling out to your assistant "One, two, (compressions)-breathe" (One contributor advises 100 compressions and 30 breaths in which case it is about three compressions to a breath). Check his heart rate after 30-60 seconds and thereafter periodically. Observe or feel his pulses or listen to his heart. CAUTION! (1) Don't press over his liver. (2) He needs cardiac compression and ventilation. DRUGS FOR NEONATAL RESUSCITATION Prompt ventilation will correct his acidosis and will be safer than giving him a bolus injection of sodium bicarbonate. Difficult intravenous injections have a low priority; ventilation is critical. If he has persistent bradycardia (<50) in spite of adequate ventilation and cardiac compression, give him 2 mmol/kg of sodium bicarbonate intravenously. Either give 2 ml/kg of 8.4% sodium bicarbonate (1 mmol/ml) or 4 ml/kg of the 4.2% solution (this is a more convenient dilution to give: make it by diluting the 8.4% solution with an equal volume of 5% dextrose or water). One contributor gives sodium bicarbonate to any 'flat' baby. Ifyou have catheterized his umbilical vein, always flush with 0.9 % saline beJore and after giving sodium bicarbonate. If he has persistent bradycardia or no heart beat after bicarbonate, give him 0.1 ml/kg of 1:10,000 adrenalin intravenously, or down the tracheal tube. If necessary, repeat the dose after10-15 minutes. tf adrenalin fails to improve persistent severe bradycardia or make his heart beat return, give him 1-2 ml (0.1-0.2 g) of 10% calcium gluconate intravenously slowly. Never give this with sodium bicarbonate. Flush with saline or 5% dextrose first. CAUTION! Continue ventilation and cardiac compression. If his respiration is depressed and his mother has had a narcotic (pethidine), ventilate him first if necessary, and give him one dose of naloxone. Either 200 µg intramuscularly (60 µg/kg). Or, 40 µg intravenously (10 µg/kg). HYPOGLYCAEMIA IN NEONATES DIAGNOSIS. Hypoglycaemia is one of the more preventable causes of death in the first hours or days of a baby's life. He is at risk if: (1) He is underweight, either premature or 'small for dates' (IUGR). (2) He has been hypoxic perinatally. (3) His mother had gestational hypertension ('pre-eclampsia'), uncontrolled diabetes, or severe sepsis. The symptoms of hypoglycaemia are ill-defined. Think of it in any baby you have resuscitated who is jittery, tremulous, apnoeic, lethargic, hypotonic, or who has an abnormal cry, or who feeds poorly or has convulsions. MANAGEMENT. Give him 5 ml/kg of 10% dextrose intravenous ly. If he improves becomes more alert and stops convulsing, continue giving him dextrose 100 ml/kg/24 hours intravenously and small volumes of expressed breast milk. If possible, test a heel-prick sample of his blood with 'BMstix', and repeat this 6-hourly, just before feeds, for the first 24 hours or longer if necessary. If 'BMstix' reads < 2.5 mmol/l, he is hypoglycaemic. If possible, send a specimen for his blood sugar to be measured in the laboratory. Continue to monitor his blood sugar with 'BMstix' for 48 hours. Alternatively, if you cannot give him a drip, you may be able to manage him orally. Pass a nasogastric tube, and aspirate his whole gastric contents. This tells you how much of his previous feed, if any, is left in his stomach, and avoids overfilling his stomach, with the risk of regurgitation. Hypoglycaemia reduces the motility of the gut, so this is a danger in 'at risk' babies. If the aspirate contains meconium or blood, lavage his stomach with 10 ml of water or saline. Then give him 10 to 15 ml of 10% dextrose by nasogastric tube, alternating with expressed breast milk 2-hourly, so that he has 100 ml/kg/day of fluid. LATER IN THE RESUSCITATION OF A NEONATE Check that he is pink and well perfused, his heart is normal (110-130), his pulses are easily palpable, he has good tone and spontaneous movement, he is warmer than 36°C, his breathing is regular (40-60/min) and is without distress. Give all 'at risk' babies vitamin Kt (phytomenadione) 0.5 mg intramuscularly. Avoid synthetic analogues, such as menadiol sodium diphosphate ('Synkavit'), because of the risk of kernicterus. Give him to his mother. She will have been worried while you were resuscitating him. Even if he needs special care, give her a chance to hold him before you remove him. In the ward watch his colour and his breathing, and monitor his blood glucose with test strips. Correct his blood glucose as necessary (especially if he has IUGR). An efficient way to keep him warm is in the 'kangaroo pouch' between his mother's breasts, when she is well wrapped up, and he wears a hat (he can lose much heat from his head). DIFFICULTIES WITH NEONATAL RESUSCITATION If you DON'T HAVE A BAG AND MASK and CANNOT INTUBATE HIM, what you and especially your midwives should do depends on the prevalence of HIV in your area: If HIV IS RARE, use MOUTH TO MOUTH VENTILATION. Bend his head gently backwards over a rolled up towel. Put your mouth over his mouth and nose. Blow in gently. Blow with small breaths, about 40 times a minute. Don't blow from your lungs. Blow from your cheeks only. You need very little air to blow up the lungs of a small baby-20-50 ml only. If you blow too hard you will cause a pneumothorax. His chest should move as you blow, as if he was breathing himself. Most babies start breathing with your first two breaths. So stop after two breaths and see if he breathes. After a few inflations he should start breathing and become pink. His heart should beat faster. If HIV IS COMMON, use the form of artificial ventilation which is known in some areas (Papua New Guinea) as 'FROG BREATHING'. Gently extend his neck over a rolled up towel, as for Intubation. If you have oxygen, pass this through one nostril. Pinch his nose between your finger and thumb. With your other hand pull down his jaw, and then pull it up and close his mouth. This raises his upper ribs and increases the capacity of his chest, so that air is drawn into his lungs. Repeat this rhythmically to imitate breathing. It is surprisingly effective. If he is VERY PRETERM « 26 weeks) or very small (1000 g), suck him out and do only minimal resuscitation. You will not be able to ventilate him long-term, so don't start. If you keep him warm, he may surprise you and do well. Manage him as in Primary Child Care Section 26.22. If the OXYGEN IS NOT WORKING, very gently blow down the tube intermittently using your cheeks. Practise by blowing down the manometer to see what a pressure of 30 cm of water feels like. Don't go above this. KEEP HIM WARM AND KEEP HIM FED 19.13 Intrauterine growth retardation (IUGR) It used to be thought that prematurity and IUGR, both ofwhich are difficult to treat, and fetal abnormalities, which are impossible to treat, were the commonest causes of perinatal deaths in the developing world, as they are in the developed world. This does not appear to be so, since most perinatal deaths occur in SYMPHYSIS -FUNDUS MEASUREMENTS 50 45 40

90th 50th 35 10th 30 25 20 15 10 162024 2832 364044 weeks Fig. 19-15 A FUNDAL HEIGHT CHART. Iflow-birthweight babies are common in your district, you will find many mothers falling below the 10th centile, either because their babies have IUGR or because they are genetically small (the relative importance of these factors is unknown). normally formed, normally grown babies weighing > 2.5 kg, as the result of birth trauma and asphyxia related to CPD, preeclampsia, abruption, cord prolapse, and malpresentation. These deaths are much more preventable than those from IUGR. Babies who are sufficiently small to be classified as being of low birthweight « 2500 g) may: (1) have been born after a pregnancy which was abnormally short, or (2) have grown abnormally slowly during a pregnancy of normal length. These 'small for dates' babies suffer from intrauterine growth retardation or IUGR. In the developing world 25% of babies may be low birthweight, and of these 70% may have IUGR. Its causes in approximate order of frequency include: malnutrition, placental malaria, gestational hypertension, essential hypertension, recurrent antepartum haemorrhage, sickle-cell disease, malformations and chromosome abnormalities, virus infections, smoking, and alcohol. There is also an 'idiopathic' group (30% in the developed world) in whom there is no obvious cause, but who are generally considered to be suffering from uteroplacental vascular insufficiency. A hungry starving baby from any of these causes readily dies, particularly during early labour, when his heart suddenly stops. Because of the overwhelming importance of malnutrition as a cause, 21 of the 22 million low birthweight babies who are born each year are in the developing world. Their chances of dying are 20 times higher than those of other babies. Malnutrition is also the most potentially preventable cause. IUGR is not easy to detect clinically. The risk factors for it, some of which are determined by malnutrition, include: (1) IUGR in previous pregnancies. (2) Low weight before pregnancy began. (3) Low weight-gain during pregnancy. (4) Multiple pregnancy. (5) Smoking. Even so, 30% to 50% of cases commonly remain undiagnosed. The only way you have of diagnosing IUGR is to encourage your midwives to measure the fundal height as carefully as they can between 20 and 36 weeks. If the uterus is 5cm lower than it should be, and there are <10 movements in 12 hours (M 28.3), you can diagnose IUGR. Unfortunately, many mothers are unsure of their dates, and most health workers (including doctors) are unable to record the height of the fundus with sufficient accuracy. Even ifwecan, it isoflittlevalueinmultiplepregnancy, polyhydramnios, atransverse lie, or in a very obese mother. The fundal height chart in Fig. 19-15 is derived from women in Wales (no fundal height charts for the developing world have yet been devised). If low birthweiglit babies are common in your district, you will find many mothers falling below the 10th centile, either because their babies have IUGR or because they are genetically small (the relative importance of these factors is unknown). If you diagnose IUGR during pregnancy, and decide to deliver a mother before term (it is not one of the indications for induction in Section 19.3), don't do so before 34 weeks. Do the surfactant test (19.2), in case her dates are wrong. You then have a choice between inducing labour (19.3) and elective Caesarean section (18.9). Babies with IUGR tolerate asphyxia badly. Babies with IUGR born at term have only a slightly increased risk of a major handicap, such as cerebral palsy or mental retardation. But between 1% and 30% of them have some minimal cerebral dysfunction, such as problems with speech, language, and learning. The babies at greatest risk of some major handicap associated with IUGR, particularly cerebral palsy, are: (1) The badly asphyxiated baby with severe IUGR born at or past term. (2) The baby with IUGR delivered before 34 weeks. Try to diagnose and deliver babies in the 'window' between 34 and 36 weeks-if you can. Delivering a baby whose mother has diabetes (17.3) presents similar problems in judging the best time for delivery, the main ditference being that he is too big rather than too small. Much of the effort of modern obstetrics is devoted to detecting babies with IUGR, monitoring them, and getting them out into the world at just the right moment, when the risks outside the uterus are less than those inside it. If the moment of induction can be judged successfully, it may increase a child's chance of survival. Unfortunately, despite a massive investment in resources, a baby suspected of having IUGR is often found to be normal, and vice versa. It is thus not surprising that IUGR is seldom diagnosed in the district hospitals of the developing world, and even with the sophisticated technology of the industrial world, the diagnosis is often wrong. However, you can treat the more manageable causes of perinatal mortality, some of which express themselves as IUGR-malaria, gestational hypertension, syphilis, obstructed labour, and poorly managed breech and twin deliveries.