Surgery and Healing in the Developing World - Dartmouth-Hitchcock

15
130 Surgery and Healing in the Developing World
6. If still unable to deliver, an assistant may be asked to slide the fingers of one
hand between the fetus and the symphysis pubis to create a “ramp” to assist
with delivery of the anterior shoulder.
7. If still unable to deliver, place your hand behind the posterior shoulder of
the fetus and try to rotate the shoulders through an arc of 180 degrees until
the opposite shoulder is released. This is the Wood’s maneuver.
8. Consider next an attempt to deliver the posterior arm. Slide your hand to
the humerus of the posterior arm and palpate the elbow. Maintain flexion
at the elbow and sweep the arm across the chest of the fetus to enable you to
grasp the arm and deliver it past the ipsilateral side of the head with your
other hand. You can now rotate the shoulder girdle to deliver the other
shoulder.
9. If you are still unable to deliver the fetus, you must consider either deliberate
fracture of the anterior clavicle (either by pressing the clavicle against
the pubic ramus or by hooking the clavicle with your finger), or symphysiotomy
(as described below).
10. The Zavinelli maneuver, manual return of the fetal head to the pelvis and
subsequent delivery by Cesarean, is too problematic to be described here.
If you have strong reasons to anticipate a shoulder dystocia (e.g., known or suspected
fetal macrosomia), the American College of Obstetricians and Gynecologists
recommends execution of the McRoberts maneuver (maximum bilateral hip flexion)
and simultaneous suprapubic pressure while crowning is occurring, and immediately
delivering the shoulders and thorax without pausing for suctioning of the
oropharynx.
Following a difficult shoulder dystocia, be prepared for uterine atony and
hemorrhage.
The Placenta
Your primary concern with the placenta is to ensure that it is delivered completely!
As indicated previously, this should be accomplished within 30 minutes of
delivery of the infant. Signs that delivery of the placenta is imminent include an
apparent lengthening of that part of the cord that has been delivered, a rush of blood
from the vagina that signifies separation of the placenta from the uterus, and a
palpable firming of the fundus of the uterus. When you are ready for the placenta
exert gentle traction to the cord, while applying suprapubic pressure (a
Brandt-Andrews maneuver) in an effort to prevent uterine inversion. After delivery
of the placenta, explore the uterus to ensure that no clot or fragments are retained,
and begin vigorous fundal massage to encourage contraction of the uterus. If bleeding
continues or is excessive (greater than 500 cc), consider administration of one of
the following agents as available: (a) methylergonovine, 0.2 mg IM, with repeat
Q2-4 hours as needed; (b) 15-methylprostaglandin F2, 0.25 mg IM, repeated Q 15
minutes to a maximum of eight doses if needed; or (c) oxytocin, 10 units IM.
Placenta Accreta, Increta and Percreta
Delivery of the placenta may be complicated by an unusual adherence or attachment
of the placenta to the myometrium (accreta, increta, or percreta), such that
spontaneous delivery of the placenta is impossible and manual removal results in
hemorrhage and/or inversion of the uterus. The incidence of such abnormal placentation
is not well known. Estimates range widely but average about one per 2500