Pearls of Wisdom, JL Reynolds

Tags: randomized trials, University of Manitoba, sterile water, contractions, varicosities, Injection sites, somersault, Women's Health, intrapartum care, ruptured membranes, CCFP, head water injection, technique, Women's Health Obstetrics Pearls of Wisdom J.L. Reynolds
Content: Women's Health
Obstetrics Pearls of Wisdom J.L. Reynolds, MD, CCFP, MSC, FCFP, MHSc As presented at the University of Toronto's Family Medicine Forum (November 2004)
The following are some of the things I have learned over the 30 odd years I have been involved in intrapartum care. The difficult ARM Being able to perform artificial ruptured membranes (ARM) is usually seen as a simple skill, but it can be difficult. The difficulty comes in situations where one is proceeding with ARM in an induction and the cervix is not favourable, despite preinduction techniques. We know oxytocin works better if the membranes are ruptured. Also, when the woman is tense, obese or when the cervix is posterior, an ARM may be quite difficult to perform. Some physicians find it helpful to have the woman form her hands into fists and put them under her sacrum to tilt the pelvis. Others use an inverted bed pan to achieve the same results. Another technique I have found
helpful is to use a scalp clip with an introducer and navigate this through the cervix. The scalp clip ruptures the membranes and the fluid gushes out through the introducer. This often works quite well, but one should resist the desire to place the scalp clip on the baby's scalp unless there is a clinical indication to do so. The somersault maneuver Every now and again, babies are born with the umbilical cord around their neck. Often, it is easy to loop the cord over the baby's head or to clamp and cut it; however, when the cord is very tight, neither of these options is possible. By exerting the usual downward pressure on the baby's head, the cord will tighten even more. A simple procedure is the somersault maneuver, which
Kim's case · Kim, 27, is in labour. · She has made relatively good progress in the first stage, but in the second stage, has made no real progress after almost an hour of pushing. · The baby is fine with a normal heart rate and clear amniotic fluid. Here are questions you might consider asking: 1. Is the cervix fully dilated? 2. Is the bladder empty? 3. Is there a malposition? (Slow second stages in multips are commonly due to occipital posterior presentation.) 4. Does Kim need analgesia? 5. Does she need a rest? 6. Does she need fluids? 7. Are the contractions adequate? 8. Primips--she may need oxytocin, but beware of augmentation of the second stage and multips. 9. Does she need to push differently (i.e., squatting, all fours or lying on her side)?
The Canadian Journal of Diagnosis / April 2005
Women's Health
involves pressing the baby's head water injection over the posterior
towards the mother's thigh. This superior iliac spines, approxi-
technique allows the shoulders mately 3 cm or 4 cm inferiorial-
and the body to somersault out ly and a couple centimetres medi-
and the baby to be born without ally. This is basically four injec-
difficulty. The somersault maneu- tions over the sacroiliac joint. The
ver is very simple and highly patients will feel pain for about
20 seconds after injection. These
injections are best
Sterile water injections result in 90% of women having pain relief for
given during a contraction. Injections result in 90% of women
approximately 90 minutes. having significant pain relief for
approximately 90
Sterile water for low back pain
minutes. The amount injected under the skin is 0.1 mL. Remember, this technique uses
About 30% of women experience sterile water, not normal saline.
low back pain during labour. Sterile injections have proven
Often, this is unremitting and effective in randomized trials. It
occurs even without contractions. is easy to learn and nurses can
One unique technique that also add this to their scope of
relieves this pain is small practice.
amounts of intradermal sterile Another alternative that is
slightly less painful, but also works
Dr. Reynolds is a professor of family medicine, UNIVERSITY OF MANITOBA, and a staff physician, St. Boniface General Hospital, Winnipeg, Manitoba.
well is to substitute 0.50 mL of sterile water subcutaneously rather than intradermally. Figure 1 shows the sites of injection.
x x
x x
Figure 1. Injection sites for sterile water. Bleeding from perineal varicosities It is not uncommon for multiparous women to have painful vulvar and perineal varicosities. While these are a nuisance during pregnancy, they can occasionally become life-threatening during childbirth if a tear occurs and involves varicosity. Bleeding from a varicosity can be extremely heavy, but by moving the woman into a flat or headdown position, the varicosities will collapse and the bleeding will stop. This allows you time to achieve hemostasis through appropriate suturing. Dx
The Canadian Journal of Diagnosis / April 2005

JL Reynolds

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Title: 069-W's Health-Maternity
Author: JL Reynolds
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