Figure 10.6. Rubin Manouver. A. The shoulder-to-shoulder diameter is aligned vertically. B. The more easily accessible fetal shoulder the anterior is shown here is
pushed toward the anterior chest wall of the fetus arrow. Most often, this results in abduction of both shoulders, which reduces the shoulder-to-shoulder diameter and frees
the impacted anterior shoulder
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5. Rotate the posterior shoulder- Corkscrew Wood Maneuver
Woods 1943 reported that by progressively rotating the posterior shoulder 180 degrees in a corkscrew fashion, the impacted anterior shoulder could be released. This is
frequently referred to as the Woods corkscrew maneuver.
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Figure 10.7. Wood Maneuver. The hand is placed behind the posterior shoulder of the fetus. The shoulder is then rotated progressively 180 degrees in a corkscrew manner so
that the impacted anterior shoulder is released
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6. Manual removal of posterior arm
Schwartz and Dixon Maneuver
Pressure on antecubital fosa to flexi the forearm
move the forearm anteriorly.
Reach the forearm or the fingers
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Deliver the posterior shoulder
Figure 10.8. Schwart and Dixon Maneuver
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7. Episiotomy-consider
Help Wood Manouver or giving more space to deliver the posterior arm, rotate the chest and ease reaching the posterior shoulder
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8. Roll over All-Fours Manoeuvre Gaskin’s Manouvre
This manoeuvre consists of placing the labouring woman on her hands and knees and applying continuous and gentle axial traction on the fetal head, to release what was
previously the posterior shoulder Fig. 10.9. Its place in the shoulder dystocia management protocol is currently unclear, particularly in hospital environments. It is
mostly used in community settings when only one birth attendant is present and where an 83 success rate has been reported. In hospital settings, it may be attempted before
the exceptional manoeuvres described below are considered.
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Figure. 10.9 All-fours manoeuvre with axial traction being applied on the fetal head.
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9. Last Efforts
9.1. Break The Clavicle Deliberate fracture of the anterior clavicle by using the thumb to press it toward and
against the pubic ramus can be attempted to free the shoulder impaction. In practice, however, deliberate fracture of a large neonate clavicle is difficult. If successful, the
fracture will heal rapidly and is usually trivial compared with brachial nerve injury, asphyxia, or death.
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9.2. Cephalic replacement Zavenelli Manouver
Zavanelli’sManoeuvre Cephalic replacement followed by caesarean section was described for the first time in 1978, and it is performed in the operating theatre under
general anaesthesia with halogenated agents. The manoeuvre starts with slow rotation of the fetal head to an occiput-anterior position, followed by flexion of the fetal neck and
application of firm and continuous pressure for the reintroduction of the fetal head in the maternal pelvis Fig. 10.10. An immediate caesarean section follows. A small number of
case series are reported in the literature with varying success rates and usually low maternal morbidity, but uterine rupture and subsequent need for hysterectomy have also
been described. When fetal prognosis is reserved, maternal morbidity becomes the main priority, and this is probably the less traumatic alternative for her.
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Figure. 10.10. Zavanelli’s manoeuvre.
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9.3. Symphysiotomy This technique has been described for the resolution of obstructed labour since the nineteenth
century, but its current use in high-resource countries is limited to cases of shoulder dystocia and retention of the after-coming head. Symphysiotomy is associated with important
maternal morbidity, so it should probably be the last option when fetal prognosis is poor. The procedure can be performed under regional, general and local anaesthesia with opiate
sedation. It should be preceded by antibiotic prophylaxis, bladder catheterisation, shaving and disinfection of the pubic area. Before incision, two assistants hold the mother’s legs 60–
80° apart, after removing them from the bed stirrups. This avoids sudden leg abduction when the symphysis is opened, which can cause urethral injury.
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a
b
Figure. 10.11 The main steps of symphysiotomy
With a hand introduced in the vagina to push the urethra aside, a transabdominal vertical incision is performed with a long scalpel between the lower two-thirds and the upper third of
the pubic symphysis Fig. 10.11. Pushing the handle upwards will open the lower two- thirds. The scalpel is then reintroduced into the incision with the blade facing upwards and
the handle pushed downwards to open the remaining upper third. It is usually possible to separate the pubic bones by about 2–3 cm, and this allows the shoulders to be released. After
closing the abdominal skin, the maternal pelvis is bound with an orthopaedic strap, and bladder catheterisation is maintained for 48 hours.
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In the absence of complications, the patient is maintained in lateral decubitus for two days, and assisted walking starts on the third. Among the reported complications are para-urethral
lacerations, vulval oedema and skin incision haematomas. Difficulties in mobilisation may persist for several months in 1–2 of cases.
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10. After procedure
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• Post partum haemorrhage anticipation
• Exploration of lasceration and tear
• Examination of the baby
• Explain to the patient
• Record the procedure
Lecture 12 : DERMATO - EMERGEMENCIES Nyoman Suryawati
Objective
To understand the basic principle of acute blistering and exfoliative skin Able to identify a case with acute blistering and exfoliative skin
Able to manage and referral a case with acute and exfoliative skin
Abstract Stevens - Johnson Syndrome and Toxic Epidermal Necrolysis
Stevens–Johnson syndrome SJS and Toxic epidermal necrolysis TEN are acute life- threatening mucocutaneous reactions characterized by extensive necrosis and detachment of
the epidermis, with a mortality rate reaching 30. The pathophysiology of EN is still unclear; however, drugs are the most important etiologic factors. Both SJS and TEN are
differs only in the final extent of body surface involved: 1 SJS, less than 10 of body surface area BSA; 2 SJSTEN overlap, between 10 and 30; 3 TEN, more than 30
of BSA.
Nonspecific symptoms such as fever, headache, rhinitis, cough, or malaise may precede the mucocutaneous lesions by 1 to 3 days. Pain on swallowing and burning or
stinging of the eyes progressively develop, heralding mucous membrane involvement. The eruption is initially symmetrically distributed on the face, the upper trunk, and the proximal
part of limbs. The initial skin lesions are characterized by erythematous, dusky red, purpuric macules, irregularly shaped, which progressively coalesce. Nikolsky’s sign dislodgement of
the epidermis by lateral pressure is positive on erythematous zones. At this stage, the lesions evolve to flaccid blisters, which spread with pressure and break easily. The necrotic
epidermis is easily detached at pressure points or by frictional trauma. Mucous membrane involvement nearly always on at least two sites is observed in approximately 90 of cases
and can precede or follow the skin eruption.
SJS and TEN are a life-threatening disease that requires optimal management: early recognition and withdrawal of the offending drug and supportive care in an appropriate
hospital setting. The patient must be transferred to an intensive care unit or a burn center. Prompt referral reduces risk of infection, mortality rate, and length of hospitalization.
Specific therapy including immunosuppressive andor anti-inflammatory therapies, antibiotic therapy only if clinical infection is suspected. Supportive care consists of fluid replacement,
early nutritional support, aseptic and careful handing to reduce the risk of infection.
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Staphylococcal Scalded Skin Syndrome
Staphylococcal Scalded Skin Syndrome SSSS is the term used to define a potentially life- threatening, blistering skin disease caused by exfoliative toxins ETs of certain strains of
Staphylococcus aureus usually phage group 2. ETs are serine proteases that bind to the cell adhesion molecule desmoglein 1 and cleave it, resulting in a loss of cell–cell adhesion.
The onset of SSSS may either be acute with fever and rash or be preceded by a prodrome of malaise, irritability, and cutaneous tenderness, often accompanied by purulent
rhinorrhea, conjunctivitis, or otitis media. Within 1–2 days the rash progresses from an exanthematous scarlatiniform to a blistering eruption. Very superficial tissue paper-like
wrinkling of the epidermis, which is characteristic, progresses to large flaccid bullae in flexural and periorificial surfaces. A positive Nikolsky sign can be elicited by stroking the
skin, which results in a superficial blister. One or two days later, the bullae rupture and their roofs are sloughed, leaving behind a moist, glistening, red surface along with varnish-like
crusts. At this stage, the clinical appearance closely resembles that of extensive scalding. Mucous membranes are usually spared by bullae and erosions. Days later, due to generalized
shedding of the epidermis, scaling and desquamation progressively occur. The skin returns to normal in 2–3 weeks.
Patients with SSSS require hospitalization because, besides the appropriate systemic antibiotic therapy, intensive general supportive measures are needed. The mainstay of
treatment is to eradicate staphylococci from the focus of infection, which in most cases requires intravenous IV antistaphylococcal antibiotics. The use of suitable antibiotics,
combined with supportive skin care and management of potential fluid, and electrolyte abnormalities due to the widespread disruption of barrier function, will usually be sufficient
to ensure rapid recovery. Major complications of SSSS are serious fluid and electrolyte disturbances. The mortality in uncomplicated pediatric SSSS is very low 2 and is not
usually associated with sepsis.
LECTURE 13 : TRAUMA WHICH POTENTIALLY DISABLING AND LIFE THREATENING CONDITIONS
I Ketut Suyasa, IGN Wien Aryana AIMS:
Establish tentative diagnosis, provide initial management andor refer patient with: Trauma Which Potentially Disabling and Life Threatening Condition.
LEARNING OUTCOMES:
Establish tentative diagnosis, provide initial management andor refer patient with: Trauma Which Potentially Disabling and Life Threatening Condition
CURRICULUM CONTENTS:
1. Trauma Which Potentially Disabling and Life Threatening Condition 2. Diagnosis, provide initial management andor refer patient with: Trauma Which
Potentially Disabling and Life Threatening Condition
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ABSTRACTS
The initial assessment and management of seriously injured patients is a challenging task and requires a rapid and systematic approach. This systematic approach can be practised
to increase speed and accuracy of the process but good clinical judgement is also required. Although described in sequence, some of the steps will be taken simultaneously. The aim of
good trauma care is to prevent early trauma mortality. Early trauma deaths may occur because of failure of oxygenation of vital organs or central nervous system injury, or both.
Injuries causing this mortality occur in predictable patterns and recognition of these patterns led to the development of advanced trauma life support ATLS by the American College of
Surgeons. A standardised protocol for trauma patient evaluation has been developed. The protocol celebrated its 25th anniversary in 2005.
[
Good teaching and application of this protocol are held to be important factors in improving the survival of trauma victims
worldwide.
Initial assessment
Resuscitation and primary survey.
