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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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.

8. Mc Robert’s Maneuver

9. 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

10. 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

11. Mazzanti and Wood’s maneuvers

12. 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

13. Gaskin’s Maneuver

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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

26. 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

27. 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