WORKSHOP FROM: A.L.A.R.M. International -The Society of Obstetricians and Gynecologists of Canada- -FIGO- -Philippine Obstetrical and Gynceological Society-

Vaginal Breech Delivery Secure consent Ask for assistance Adequate analgesia/anesthesia (epidural,saddle block,pudendal block) Consider episiotomy when buttock is crowning Allow spontaneous expulsion up to the umbilicus keeping the fetus in sacrum anterior position

Vaginal Breech Delivery Deliver legs by performing Pinard’s maneuver apply pressure in popliteal fossa, lateral rotation/abduction of the thigh, flexion of the knee, grasp the foot and deliver the leg. Repeat the Pinard’s maneuver on the other leg. Support the baby around the hips using a dry towel with the thumbs on the sacrum and the fingers around the hips.

Vaginal Breech Delivery Ask the mother to push until the wing of the scapula is seen. Rotate the body until the arm is anterior Perform the Loveset maneuver. Splint the arm, sweep across the face and chest and deliver the arm. Rotate the body 180 degrees and perform the Loveset maneuver on the other arm, splint the arm, sweep across the face and chest and deliver the other arm

Vaginal Breech Delivery Support body in horizontal position or allow to hang until the nape of the neck appears at the introitus. Apply suprapubic pressure to avoid over extension of the head Deliver the head by performing Mauriceau-Smellie-Veit maneuver. Straddle the body of the baby in one arm. Apply 2 fingers on the malar eminences to flex the head and the other hand at the nape of the neck with maternal expulsive effort and suprapubic pressure, deliver the head with gentle traction, following the axis of the birth canal downwards and then upwards

Vaginal Breech Delivery Check for any head injuries then place the baby on mother’s abdomen and dry (EINC) Clamp and cut the cord once pulsation has stopped. (perform AMTSL) Inspect for injuries and lacerations. Repair if needed. Documentation

SHOULDER DYSTOCIA A – Ask for help L – Lift the legs Ensure appropriate equipment and personnel are available. Get cooperation of mother and partner. Establish and practice nursery protocol L – Lift the legs Hyperflex both legs (Mc Robert’s maneuver). Shoulder dystocia is resolved in 70% of cases by this procedure alone.

Mc Robert’s Maneuver

SHOULDER DYSTOCIA A – Anterior disimpaction of shoulder Abdominal approach: suprapubic pressure on applied on the heel of the clasped hand to the posterior aspect of the anterior shoulder to dislodge it (Mazzanti Maneuver) Vaginal approach: adduction of the shoulder by pressure applied to the posterior aspect of the shoulder, pushing the shoulder towards the chest (Rubin’s maneuver). This results in the smallest possible diameter

SHOULDER DYSTOCIA R – Rotation of the posterior shoulder Wood’s screw-like maneuver – pressure applied to the posterior shoulder attempting to rotate the shoulder 180 degrees to anterior oblique position Anterior disimpaction maneuver and Wood’s maneuver may be done simultaneously and repetitively to achieve disimpaction of anterior shoulder

Mazzanti and Wood’s maneuvers

SHOULDER DYSTOCIA M – Manual removal of the posterior arm Flex the posterior arm at the elbow. Pressure in the antecubital fossa can assist the flexion. The hand is grasped, swept across the chest and delivered E – Episiotomy R – Roll over to knee postion on all Fours (Gaskin maneuver) to allow easier access to the posterior shoulder

Gaskin’s Maneuver

SHOULDER DYSTOCIA S – Symphysiotomy, cleidotomy, Zavanelli Check for lacerations on the baby and perineum Documentation

ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR Consent Within one minute of delivery of the baby administer oxytocin 10 units IM At the height of each contraction apply controlled traction on the cord while counter pressure at the suprapubic area If there is resistance during the initial efforts at the traction, stop pulling wait for the next uterine contraction and try again

ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR As the placenta appears at the introitus grasp it with both hands, slowly rotate it 360 degrees at the same time slowly pulling it downward until the membranes are delivered as well. Check for the completeness of placenta and membranes Massage the uterus until it is felt to be contracted Palpate for a contracted uterus every 15 minutes. Repeat massage as needed Inspect for laceration/injuries and repair Documentation

FORCEPS DELIVERY Consent A – Anesthesia for adequate pain relief Assistance for neonatal support B - Bladder – empty the bladder C – Cervix – must be fully dilated, membranes ruptured D – Determine – position, station and pelvic adequacy, think of possible shoulder dystocia E – Equipment – Check quality and functionality of equipment

FORCEPS DELIVERY F – Forceps Phantom application - Left blade, left hand, maternal left side, pencil grip and vertical insertion with the right thumb directing the blade - Right blade, right hand, maternal right side, pencil grip and vertical insertion left thumb directing the blade - Lock blade and suppport

FORCEPS DELIVERY Check the application: 1. Posterior fontanelle must be 1 cm above the plane of the shanks 2. Fenestration no more that 1 fingerbreadth between it and the scalp 3. Sagittal suture must be perpendicular to the plane of the shanks 4. Occipital suture 1 cm above the respective blades

FORCEPS DELIVERY G – Gentle Traction applied with contraction / expulsive effort H – Handle elevated – Traction in axis of the birth canal. Do not elevate the head too early I – Incision – Consider episiotomy J – Jaw – Remove the forceps when the jaw is reachable or delivery is assured Check for lacerations and injuries on the baby and perineum. Do episiorrhaphy Documentation

VACUUM DELIVERY Consent A – Anesthesia for adequate pain relief Assistance for neonatal support B - Bladder – empty the bladder C – Cervix – must be fully dilated, membranes ruptured D – Determine – position, station and pelvic adequacy, think of possible shoulder dystocia E – Equipment – inspect vacuum cup, pump and tubing. Check pressure

VACUUM DELIVERY F – Fontanelle – position the cup over the posterior fontanelle. Sweep the finger around the cup to clear maternal tissues G – Gentle traction - 100 mm Hg initially between contractions - Pull with contractions only - As the contraction begins Increase pressure to 600 mm Hg Prompt woman for good expulsive effort Traction in axis of the birth canal

VACUUM DELIVERY H – Halt - No progress with 3 traction-aided contractions - Vacuum pops off 3x - No significant progress after 20 minutes I - Incision - Consider episiotomy if laceration is imminent J - Jaw – Remove vacuum when the jaw is reachable or delivery is assured Check for lacerations and injuries on the baby and perineum. Do episiorrhaphy Documentation

For CREED VISIT Please learn properly the procedures designated per year level such as: NSD Completion curettage / D and C Fractional Curettage Cesarean section Adnexal procedures CS hysterectomy TAHBSO Etc.

NSD TECHNIQUE * Consent Patient placed on dorsal lithotomy position Asepsis and antisepsis Bladder catheterized IE done Infiltration with local anesthesia then ME or RMLE performed Patient instructed to push, then fetal slowly delivered with one hand supporting the perineum and the other hand keeping the fetal head in a flexed position

NSD Shoulder and thorax delivered with gentle traction, rest of the body readily follows Delivered to a live baby ---- in occiput anterior position, AS: 99 Intravenous sedation given after delivery of the fetus Cord doubly clamped and cut (EINC) Placenta delivered (ATMSL) Uterus well contracted

NSD Cervico-vaginal inspection done. No cervical laceration noted Episiorrhaphy using Chromic 2-0 (Repair of Third degree laceration from episiotomy done with Chromic 2-0) Perineum cleansed. Povidone-iodine applied Rectal examination done Procedure was well tolerated Estimated blood loss: _____ ml