Re: My most stressful case this week! (obs)
From: art fougner, md (evsono@pipeline.com)
Thu Jul 20 08:42:35 2000
are you trying to prove Hannah's point?
art
At Wed, 19 Jul 2000, Griffiths Malcolm wrote:
>
>I had a case a week ago on Wednesday.
>
>Patient is at term with previous term normal vaginal delivery.
>
>A (previously undiagnosed) breech is found at 6cm in rapidly progressing
>labour.
>
>Senior resident diagnoses footling but by then she's 8cm. I am called.
>Couple are keen to avoid CS and in our unit there is no blanket ban on
>footling breech vag deliveries (strikes me there is no need to debate that
>as in fact it has no real bearing on the problems of this case).
>
>She is progressing so quickly that when I see her I think she is probably
>fully dilated. I suggest we move to theatre and put in a spinal. Aim for
>vag del but set up for CS.
>
>This all happens very quickly, but spinal is not easy and has to be
>abandoned because breech is now crowning.
>
>The breech delivers without traction and no real maternal effort to just
>beyond the umbilicus. There is then no further descent at all.
>
>Lovset's manoeuvre failed - the trunk wasn't really low enough, nether
>shoulder was in the pelvis.
>
>I was unable to get above either shoulder to bring one down. Traction was
>ineffective as was maternal pushing.
>
>At this point I had the partner taken outside and asked for a GAB.
>
>Under GA it was almost as difficult. I was though able to disimpact the
>left arm. In the meantime I had instructed my senior resident to start CS.
>Patient was still in lithotomy. Once uterus was open we could not deliver
>the head. This was despite pushing up on baby, forceps, putting legs down.
>
>Accordingly I got my SR to help me push the remaining nuccal arm down
>across the fetal face & chest so that I could disimpact it below. Then I
>easily delivered the head by MSV.
>
>I should point out that this was not a problem of footling breech coming
>through an incompletely dilated cervix. The cervix was definitely fully on
>vaginal and abdominal examination.
>
>The problems was of two nuccal arms in a good sized (3.9Kg) breech.
>
>There was concern about this being due to a decision to allow vaginal
>delivery. IN fact if we had decided on vaginal delivery the same sequence
>would have happened. She would have been taken to theatre. The anaesthetist
>would have failed to have got the spinal in before the breech delivered,
>the arms would have been misplaced.
>
>My understanding has really been that nuccal arms arise as a result of
>traction and stimulation of the baby and don't occur if management is hands
>off - I may be wrong!
>
>Any comments?
>
>Needless to say the babe was born assystolic and was resuscitated including
>adrenaline to restart the heart. Cord pH was 7.174 - obviously not really
>reflecting fetal status as the cord was occluded for most of this time.
>
>I was very frank in my conversations with the parents and warned about HIE
>CP etc.
>
>Baby has done really well. He did not fit. He has been cardiovascularly
>stable. He was taken off ventilator after <24 hours. He commenced feeds
>today (aged 48h). He seems possibly to have a mild brachial plexus injury
>but no bony problems. He is somewhat bruised!
>
>I think I have had a very near miss and don't want to repeat this
>experience for a long time!
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
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