E.O.C.

Common Obstetric Emergencies

OBJECTIVES

• To recognize when an obstetric emergency (prolapsed cord,

shoulder dystocia, breech delivery) has occurred

• To practice effective management of the emergencies

Breech Delivery
Learning objective:

• To conduct a safe breech vaginal delivery

BreechPresentation
Incidence of breech presentation
• 4% at term
• Earlier in pregnancy the incidence is significantly greater.
• International trial of term breech delivery,concluded that the
safest mode of delivery is by caesarean section.
External cephalic version

In late pregnancy, it may be possible to perform an External

Cephalic Version (ECV) if a breech presentation is diagnosed.
ECV can be performed from 36 weeks onwards in multigravida
and at 37 weeks in primigravida. It is easier to do this
• if the presenting part (the breech) is not engaged in the
maternal pelvis.
• if there is adequate liquor volume
• if the baby is not too large
• if the fetal legs are flexed rather than extended (straight).
 Pre requisite of ECV
• A thorough fetal assessment is performed to exclude pre-
existing fetal distress by CTG.
• The procedure must be carefully explained to the mother
• The position of the baby must be assessed by ultrasound, and
conditions such as placenta praevia excluded.
• The success rate for ECV can be considerably increased by the
use of a tocolytic drug such as salbutamol or terbutaline. 250
micrograms of terbutaline may be given by sub-cutaneous
injection ten to fifteen minutes prior to the procedure.
External cephalic version

• A full preparation of emergency LSCS should be done prior to

procedure.
Vaginal Breech delivery

• If ECV is not possible or the mother does not present until she
is in established labour, then a decision must be made as to
whether the labour should be allowed to continue or a
caesarean section should be performed.
Contra-indications to vaginal breech
labour
• A co-existing reason for caesarean section (e.g. placenta
praevia)
• A footling breech presentation (feet first)
• A known case of hyper-extension of the fetal neck
• A fetus of more than 3.5 kgs estimated birthweight
• Previous caesarean section
• Clinically inadequate pelvis
• Lack of availability of an experienced SBA
Management

• If there are no contra-indications and a mother presents in

spontaneous labour with a breech presentation then a vaginal
breech delivery may be considered.
• It is really important to monitor both the progress in labour and
the fetal condition with great care.
• In general, the progress of the labour is a good guide to the ease
of the delivery. If the labour progresses smoothly.
• However, if there is poor progress in labour then an attempt at
vaginal delivery should be abandoned.
• Oxytocin should never be used to augment a breech labour
• Once the mother becomes fully dilated, the breech should be
allowed to descend as low as possible in the pelvis before the
mother commences expulsive efforts, provided there is no sign
of fetal distress.
• If the mother develops an urge to push then she should be
allowed to do so.
• It is sometimes necessary to perform a caesarean section at full
dilation if the mother’s efforts do not then result in the breech
descending to the perineum and causing perineal distension.
• An episiotomy should not be performed until the perineum is
well distended and the breech does not retract during
contractions.
Breech Birth

In general, the principle of delivering a breech baby is to

keep ‘hands off the breech’ as much as possible.
Breech Birth
• Once the breech distends the perineum, encourage the mother to push
with contractions.
• Aim not to touch the baby at all until it is delivered up to the level of the
umbilicus.
• If the legs are flexed they will usually deliver spontaneously.
• If they are extended then once the baby is delivered up to the umbilicus
you can gently help deliver the legs by flexing at the knee and push the
back of the knee upwards and outwards, by a combination of flexion and
abduction.
• If the umbilical cord is very tight and causing tension on the umbilicus then
gently pull down a small loop of cord, but otherwise leave the cord alone.
• The fetal spine should remain uppermost.
• Any manipulation required in order to achieve this should be done by
holding the baby by the pelvis with your thumbs on the baby’s sacrum and
forefingers on the iliac crests.
• Never hold the baby by the abdomen as in doing so you run the risk
of causing the rupture of liver, spleen or kidneys.
Breech Birth- Lovsett’s manoeuvre
• The upper trunk and arms may deliver spontaneously but if not then once
the scapulae are visible, Lovsett’s manoeuvre can be carried out.
• The baby is held by the pelvis, as above, and the trunk rotated through 90
degrees until one shoulder becomes anterior and descends below the
pubic symphysis. At this point run your fingers over the baby’s shoulder
and down to the elbow, and gently sweep the arm out across the chest.
• Next rotate the trunk through 180 degrees to bring the other shoulder
down below the pubic symphysis and deliver the arm as before.
• The baby should then be allowed to hang down, allowing gravity to assist
with the flexion and descent of the head into the maternal pelvis.
Delivery of the head
Mauriceau-Smellie-Viet manoeuvre.
• Once the nape of the neck is visible perform the delivery of the
head by Mauriceau-Smellie-Viet manoeuvre.
• If the head is difficult to deliver sometimes supra-pubic pressure
from an assistant may help in getting the head to flex and
descend through the maternal pelvis.
• Alternatively obstetric forceps may be applied. If all else fails a
symphysiotomy may be considered.
Key points

• Consider ECV from 36 weeks onwards

• Consider vaginal breech delivery if there are no contra-
indications
• Close monitoring of progress in labour is essential
• When delivering, hold the baby by the bony pelvis if necessary,
not the abdomen
• Handle the limbs at joints, not in the middle of long bones
• Hands off the breech!
Shoulder Dystocia
SHOULDER DYSTOCIA

• The fetal head has been delivered but the shoulders are stuck behind the symphysis
pubis and cannot be delivered

• Chin retracts and depresses the perineum

• Traction on the head fails to deliver the shoulder

Factors associated with Shoulder
Dystocia

• Previous shoulder dystocia

• Macrosomia >4.5kg
• Diabetes mellitus
• Maternal body mass index >30kg/m2
• Induction of labour
• Oxytocin augmentation
• Prolonged first stage of labour
• Prolonged second stage of labour
• Assisted vaginal delivery
Steps of Management

• Call for help

First Line Maneuvres

• McRoberts’ position
• Suprapubic pressure
• Do not apply fundal pressure
• Avoid excessive traction on the head

second Line Maneuvres

If this fails,Adequate episiotomy
• woodscrew maneuver
• Delivery of posterior shoulder OR
• All fours position
HELPERR
• H: Call for help
• E: Evaluate for episiotomy
• L: Legs in McRoberts
• P: Suprapubic pressure, constant then rocking
• E: Enter (internal procedures)
• R: Rotate fetus/ deliver posterior arm
• R: Rotate mother into all fours
Steps of Management
If all fails or post shoulder not in sacral hollow, attempt
Zavanelli , Symphysiotomy or cleidotomy.
McRoberts Position
• The maternal legs are kept hyper-flexed at hip joint.
• This manoeuvre increases the antero-posterior pelvic inlet
diameter
McRoberts Position
Suprapubic Pressure
Suprapubic pressure to the posterior aspect of the anterior
shoulder, displace it laterally into the slightly wider oblique
diameter of the pelvis and reduce the fetal bi-sacromial
diameter.
Suprapubic Pressure
Delivery of the
posterior arm
• The majority of cases of shoulder dystocia will be relieved by
the above measures but if they do not work then progress to
internal attempts to rotate the shoulders or retrieve the posterior
arm.
Delivery of posterior arm
All Fours Position
• If fetus remains undelivered after all these manoeuvres have
been attempted then rotate the mother into the all fours
kneeling position and attempt to deliver the posterior (now
anterior) arm.
All Fours Position
Post natal care
• The baby should be examined for injury by a neonatal clinician.
• The mother is at increased risk of vaginal and perineal tears
and postpartum haemorrhage.
• A full explanation of the problem should be given to the mother
after the delivery
Cord Prolapse
OBJECTIVE

-To recognize the cord prolapse

-To manage the women with cord prolapse

Definition

• A cord prolapse is defined as the passage of a loop of umbilical cord

through the cervix and alongside or past the fetal presenting part in the
presence of ruptured membranes
Risk Factors
• fetal malpresentation

• Polyhydramnios

• Preterm labour

• Induced labour

• Grand multiparity
PathoPhysiology
• Cord prolapse can occur when the membranes rupture (either artificially or
spontaneously) and the presenting fetal part is poorly applied to the
maternal cervix.

• The cord may then become compressed between the maternal pelvis and
the fetus, severely reducing fetal oxygenation

• Exposure to air if it prolapses beyond the vulva may cause vasospasm

and compromised cord blood flow.
Diagnosis

• The cord may be visible at or below the introitus

• May be felt on vaginal examination.

• Sudden fetal bradycardia should prompt the observer to perform a rapid

vaginal examination.

• Bradycardia occurring soon after membrane rupture is particularly likely to

be associated with cord prolapse
Management

• This depends upon whether the fetus is still alive or not.

• If pulsations felt in the cord then the fetus is alive,so handling of the cord
should be minimised as otherwise cord vasospasm may be provoked.

• The presenting part needs to be displaced upwards in order to minimize

the pressure on the cord.
Continue…
• There are three ways

• Manual displacement of the presenting part by upward pressure from

within the vagina by the operators’ fingers.
• Maternal position. The mother is placed on all fours in the knee-elbow
position with her bottom higher than her abdomen.
• The maternal bladder is catheterized and filled to 500-750 mls and then
the catheter clamped.
All Four Maternal position in cord
prolapse
Manual Replacement Of
Cord
Continue…
• If the cord prolapse occurs on the labour ward and there is immediate
access to an operating theatre then, it would be better to proceed
immediately to theatre for delivery.

• If the bladder has been catheterized and filled then it must be emptied
prior to any caesarean section being performed.
• If the mother is not going to be able to go directly to theatre or if she
needs to be moved from the community to a comprehensive facility then
in addition to the above measures,

• Tocolysis in the form of i.v. salbutamol (0.5 mg over 2 minutes) may be

useful.

• An alternative, if available, is terbutaline 0.25 mg given by sub-cutaneous

injection.
Delivery
• The mode of delivery depends upon the stage of labour and the descent and position
of the presenting part.

• If the cervix is not fully dilated an urgent caesarean section should be performed.

• If the mother has reached the second stage of labour it may be possible to expedite
the delivery using the vacuum

• The baby is likely to need resuscitation upon delivery and there should be skilled birth
attendant.
• In the case of confirmed fetal death then there is no rush to deliver and delivery
should take place by whatever means poses the least risk to the mother.