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Obstetric emergencies Prolapsed cord Shoulder dystocia Breech delivery Twin delivery

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.

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Obstetric emergencies Prolapsed cord Shoulder dystocia Breech delivery Twin delivery

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  1. Obstetric emergencies Prolapsed cord Shoulder dystocia Breech delivery Twin delivery

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

  3. 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

  4. Prolapsed cord • 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 • Perform VE to determine the status of the labour

  5. Next step depends on the stage of labour…

  6. If cord pulsating and first stage of labour… • 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 • Consider tocolytics • salbutamol 0.2 mg iv slowly over 2 minutes

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

  8. 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

  9. Shoulder dystocia • Not predictable • Fetal head delivered but shoulders stuck behind symphysis pubis • 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?)

  10. Shoulder dystocia • Call for help • McRobert’s • Position knees as far as possible up to the chest and abduct and rotate legs outwards

  11. Shoulder dystocia • 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

  12. Shoulder dystocia • 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?)

  13. 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 OR • Apply pressure to the posterior shoulder in the direction of the sternum

  14. Shoulder dystocia Try to deliver posterior shoulder first: • 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

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

  16. Breech • May be diagnosed at abdominal examination or on vaginal examination during delivery • 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)

  17. 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!

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

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

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

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

  22. Breech • 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

  23. Breech • 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

  24. Delivery of the head • Allow baby to hang from the perineum until hair line is seen • 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

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

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

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

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

  29. Twin delivery- first baby • Start iv infusion • 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 1st baby leave a clamp on the maternal end of the cord and do not attempt to deliver the placenta until the 2nd baby is delivered

  30. Twin delivery- second baby • Check FH • 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 • 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

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

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

  33. ?

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

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