Obstetric emergencies Prolapsed cord Shoulder dystocia Breech delivery Twin delivery

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

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

Next step depends on the stage of labour… Next step depends on the stage of labour…

If cord pulsating and first stage of labour… Stop presenting part pressing on cord 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 Refer for CS Refer for CS Consider tocolytics salbutamol 0.2 mg iv slowly over 2 minutes

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

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

Shoulder dystocia Not predictable Not predictable Fetal head delivered but shoulders stuck behind symphysis pubis Fetal head delivered but shoulders stuck behind symphysis pubis Suspect if; 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 Call for help Call for help McRobert’s McRobert’s  Position knees as far as possible up to the chest and abduct and rotate legs outwards

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

Shoulder dystocia Make adequate episiotomy to reduce soft tissue obstruction and make room for other manoeuvres Make adequate episiotomy to reduce soft tissue obstruction and make room for other manoeuvres 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?) 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 Apply pressure to the anterior shoulder in the direction of the baby’s chest, to rotate the shoulder and decrease the inter- shoulder diameter Apply pressure to the anterior shoulder in the direction of the baby’s chest, to rotate the shoulder and decrease the inter- shoulder diameterOR Apply pressure to the posterior shoulder in the direction of the sternum Apply pressure to the posterior shoulder in the direction of the sternum

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

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

Breech May be diagnosed at abdominal examination or on vaginal examination during delivery May be diagnosed at abdominal examination or on vaginal examination during delivery For vaginal delivery to be possible 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 (< 3.5kg)

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

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

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

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

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

Breech If arms stretched above the head or folded around the neck use Lovset’s manoeuvre 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 If body cannot be turned to deliver anterior arm then deliver posterior arm 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 Allow baby to hang from the perineum until hair line is seen Allow baby to hang from the perineum until hair line is seen ONLY prevent baby from dropping off ONLY prevent baby from dropping off 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 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 Mauriceau-Smellie-Veit Hold newborn’s body over your hand and arm Hold newborn’s body over your hand and arm Place first and third fingers on newborn’s cheek bones Place first and third fingers on newborn’s cheek bones Use other hand to grasp newborn’s shoulders Use other hand to grasp newborn’s shoulders With two fingers of this hand flex the newborn’s head towards chest With two fingers of this hand flex the newborn’s head towards chest

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

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

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

Twin delivery- first baby Start iv infusion Start iv infusion Check presentation Check presentation  If vertex allow labour to progress as for single vertex  If transverse lie or breech deliver by CS 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 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 Check FH Check FH Check IV is running, may be needed for augmentation if contractions are not adequate, may also be needed to manage/prevent PPH Check IV is running, may be needed for augmentation if contractions are not adequate, may also be needed to manage/prevent PPH Palpate abdomen to determine lie of second baby Palpate abdomen to determine lie of second baby Perform VE to determine Perform VE to determine  If cord has prolapsed  Whether membranes are intact  Confirm presentation Correct to longitudinal lie by external version if possible- intact membranes Correct to longitudinal lie by external version if possible- intact membranes

Twin delivery – second baby For vertex For vertex Rupture membranes if intact Rupture membranes if intact Check FH between contractions Check FH between contractions Anticipate spontaneous delivery Anticipate spontaneous delivery Augment labour if necessary Vaginal delivery as normal

Twin delivery- second baby For breech For breech If contractions inadequate augment If contractions inadequate augment If membranes intact and breech has descended, rupture membranes If membranes intact and breech has descended, rupture membranes Check FH between contractions Check FH between contractions Assisted vaginal delivery Assisted vaginal delivery Breech extraction if membranes rupture during vaginal examination Breech extraction if membranes rupture during vaginal examination If vaginal delivery not possible deliver by C/S If vaginal delivery not possible deliver by C/S

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RECAP Recognition and management of Obstetric emergencies: Recognition and management of Obstetric emergencies: Cord prolapse Cord prolapse Shoulder dystocia Shoulder dystocia Twin delivery Twin delivery Skills in providing assisted deliveries Skills in providing assisted deliveries