The stuck breech, inside out uteri, difficult forceps - revisiting difficult intrapartum obstetrics

Dr Cathy CluverUniversity of Stellenbosch, South Africa

Difficult intrapartum obstetrics

Difficult intrapartum obstetrics

• On call for labour ward

• Urgent call

• “Please help- my patient has delivered her baby and placenta but there is a tumour growing from the placenta”

• Send her in urgently

ConsultantCONSULTANT

Uterine Inversion

• On call for labour ward

• Urgent call

• “Please help- my patient has delivered her baby and placenta but there is a tumour growing from the placenta”

• Send her in urgently

Uterine Inversion

• Rare

• Fundus collapses into uterine cavity

• DANGEROUS

Haemorrhagic shock

(Neurogenic shock)

• Grade

• Classify: Acute, subacute, chronic

Uterine Inversion

RISK FACTORS:

• Fundal pressure

• Excessive cord traction

Uterine Inversion

MANAGEMENT

Help

➢Manage the shock

➢Replace the uterus

➢Prevent

Uterine Inversion

PLACENTA

Vaginal

Surgical

Uterine Inversion

VAGINAL

➢Johnson procedure

Tocolytic

➢Hydrostatic reduction

Uterine Inversion

SURGICAL

➢B-Lynch Non-Instrumental Stepwise Reduction

➢Huntington

➢Haultain procedure

or Ocejo incision

Uterine Inversion

• Juniors on for labour ward

• Difficult caesarean section

➢Correct the inversion

➢Contract uterus

➢Antibiotics

Breech delivery

36-year-old multigravida

39 weeks

Examination: two feet

Difficult breech delivery

23 year old primigravida

32 weeks

Unexplained polyhydramnios

Ruptured membranes

Examination

Entrapped head

Entrapped head

RISK FACTORS

Preterm infants

Incomplete cervical dilatation

PROBLEM

Complete cord occlusion

MANAGEMENT

Try to slip cervix over the head

Duhrssen incisions

10

6

2

Delivery 2nd Twin

• Twin

• 37 weeks

• Delivery plan

• Vaginal delivery

Delivery 2nd Twin

Leading twin cephalic

Breech

External version or Breech extraction

➢External version: 40 to 50%

➢Breech extraction: 96 to 100%.

Contraindications:

• EFW 2nd twin ≥20% presenting twin

• Delivery presenting twin difficult

• GA< 28 weeks

• EFW of 2nd twin <1500 gm

• 23-year-old primigravida

• 40 weeks

• Spontaneous labour

• 3.7kg

• Fully dilated

• Prolonged second stage

• LOP

1. Wait for spontaneous rotation

2. Rotation

➢Digital rotation

➢Manual rotation

➢Rotational ventouse

➢Rotational forceps

DIGITAL ROTATION

• Fingers

• Less painful

• Not as effective

1. 2 fingers

2. Suture line- moulding

3. Exert pressure upwards

MANUAL ROTATION

1. Analgesia

2. Whole hand

3. Fingers- post parietal

Thumb- ant parietal

4. Between contractions:

push up and flex head

5. Rotate

6. Contraction- push

7. May need assisted delivery

ROTATIONAL VENTOUSE

• Bird or Kiwi cup

• Flexion point-far back

• Measure distance

• Apply the cup

• Downward traction

• Natural internal rotation

ROTATIONAL FORCEPS

Thank you