Obstetric emergencies Prolapsed cord Shoulder dystocia Breech delivery

Obstetric emergencies Prolapsed cord Shoulder dystocia Breech delivery Twin delivery

Aims ü To recognise the above emergencies ü To practise the skills needed to manage them ü To achieve competence in those skills

Prolapsed cord ü The umbilical cord is felt at the vagina following rupture of the membranes or is felt on vaginal examination to be coming down below the presenting part

Prolapsed cord ü Look at or gently feel the cord to check if there are pulsations – if pulsating the fetus is alive ü Determine the lie and the presenting part; baby may be in transverse lie and if so the mother requires caesarean section ü Perform VE to determine the status of the labour

ü Next step depends on the stage of labour…

If cord pulsating and first stage of labour… ü Stop presenting part pressing on cord § Knee-elbow position § Manually displace the presenting part § Fill the bladder and clamp the catheter § Do not wrap the cord in warm towel ü Refer for CS üConsider tocolytics ü salbutamol 0. 2 mg iv slowly over 2 minutes

If cord pulsating and second stage of labour… ü Expedite delivery with episiotomy and vacuum extraction (or forceps) ü If the baby is breech, perform a breech extraction ü Prepare to resuscitate the newborn

If cord not pulsating… ü If the cord is not pulsating the fetus is dead ü If fetus is pre-viable or grossly abnormal deliver in manner safest for mother

Shoulder dystocia ü Not predictable ü Fetal head delivered but shoulders stuck behind symphysis pubis ü Suspect if; § Unable to deliver shoulder § Fetal head delivered but remains tightly applied to the vulva § Chin retracts and depresses the perineum § Traction on the head fails to deliver the shoulder (should we not delete this last statement? )

Shoulder dystocia ü Call for help ü Mc. Robert’s § Position knees as far as possible up to the chest and abduct and rotate legs outwards

Shoulder dystocia ü Apply suprapubic pressure using the heel of the hands ü This should be done from directly above the patient, not from the left or the right of the patient

Shoulder dystocia ü Make adequate episiotomy to reduce soft tissue obstruction and make room for other manoeuvres ü Apply firm continuous traction on the fetal head but do not pull or tug the neck (Should this not read apply firm downward pressure on the head? )

Shoulder dystocia ü Apply pressure to the anterior shoulder in the direction of the baby’s chest, to rotate the shoulder and decrease the intershoulder diameter OR ü Apply pressure to the posterior shoulder in the direction of the sternum

Shoulder dystocia Try to deliver posterior shoulder first: ü grasping the humerus of the posterior arm keeping the arm flexed at the elbow, ü sweep the arm across the chest- this will provide room for the anterior shoulder to move under the symphysis

Shoulder dystocia ü Keep Mc. Roberts throughout even when moving on to other manoeuvres ü If all the above fails then consider fracturing the clavicle

Breech ü May be diagnosed at abdominal examination or on vaginal examination during delivery ü For vaginal delivery to be possible § The breech must be frank or complete § Pelvis must be adequate § Must not have had previous CS for CPD § Fetus must not be too large (< 3. 5 kg)

Breech ü Allow delivery to proceed until fetal buttocks visible ü ‘Hands off’ ü As perineum distends decide whether episiotomy necessary and perform ü Allow buttocks to deliver until back and then shoulder blades are seen ü DO NOT INTERFERE!

Breech ü Gently take hold baby around bony pelvis but do not pull

Breech ü If legs do not deliver spontaneously, deliver one leg at a time

Breech ü Allow arms to disengage spontaneously one by one ü Hold newborn by hips (Bony structures!) ü Do not pull ü Ask mother to push with contractions ü After delivery of first arm lift buttocks towards mother’s abdomen to allow second arm to deliver

Breech ü If arm does not deliver spontaneously, place one or two fingers in the elbow and bend the arm bringing hand down over face

Breech ü If arms stretched above the head or folded around the neck use Lovset’s manoeuvre § Hold newborn by hips and turn half circle keeping the back uppermost § Apply downward traction so posterior arm becomes anterior and deliver arm under pubic arch § Draw arm over chest as elbow is flexed § Deliver second arm by turning back half a circle, back uppermost and applying downward traction

Breech ü If body cannot be turned to deliver anterior arm then deliver posterior arm § Hold and lift newborn by ankles § Move newborn’s chest towards mother’s inner leg to deliver posterior shoulder § Deliver the arm and the hand § Lay newborn down by the ankles to deliver anterior shoulder § Deliver arm and hand

Delivery of the head ü Allow baby to hang from the perineum until hair line is seen ü ONLY prevent baby from dropping off ü This allows gradual decent and engagement of the head (moulding has not taken place like in the cephalic presentation, so this process may be slow

Breech Mauriceau-Smellie-Veit ü Hold newborn’s body over your hand arm ü Place first and third fingers on newborn’s cheek bones ü Use other hand to grasp newborn’s shoulders ü With two fingers of this hand flex the newborn’s head towards chest

Breech üRaise the newborn, still astride the arm until the mouth and nose are free

Breech For the stuck head ü Apply firm pressure above mother’s pubic bone and push head through pelvis ü Consider symphysiotomy

Twin delivery ü Can be discovered: § routine abdominal palpation, § during ultrasound or § after delivery of the first baby § Abdominal palpation or VE

Twin delivery- first baby ü Start iv infusion ü Check presentation § If vertex allow labour to progress as for single vertex § If transverse lie or breech deliver by CS ü After the delivery of the 1 st baby leave a clamp on the maternal end of the cord and do not attempt to deliver the placenta until the 2 nd baby is delivered

Twin delivery- second baby ü Check FH ü Check IV is running, may be needed for augmentation if contractions are not adequate, may also be needed to manage/prevent PPH ü Palpate abdomen to determine lie of second baby ü Perform VE to determine § If cord has prolapsed § Whether membranes are intact § Confirm presentation ü Correct to longitudinal lie by external version if possibleintact membranes

Twin delivery – second baby ü For vertex üRupture membranes if intact üCheck FH between contractions üAnticipate spontaneous delivery üAugment labour if necessary üVaginal delivery as normal

Twin delivery- second baby ü For breech üIf contractions inadequate augment üIf membranes intact and breech has descended, rupture membranes üCheck FH between contractions üAssisted vaginal delivery üBreech extraction if membranes rupture during vaginal examination üIf vaginal delivery not possible deliver by C/S

RECAP üRecognition and management of Obstetric emergencies: üCord prolapse üShoulder dystocia üTwin delivery üSkills in providing assisted deliveries