Unexpected Situations & Emergencies
during Childbirth in the Maternity Unit
Vaginal Breech Delivery
Postpartum Haemorrhage
Shoulder Dystocia
Vaginal Breech Delivery
Identify breech presentation
1.
2.
Remember
Epidural analgesia need
not be routinely advised
Episiotomy need not be
routinely used
1.
2.
3.
4.
Reassure parents
Call for team support from Obs SpR, LW co-ordinator &
neonatologist
Prepare room (lithotomy poles available)
Prepare for neonatal resuscitation
Await descent onto perineum before pushing
If breech not through or distending perineum
or deliverable by episiotomy
consider caesarean section
If slow/no progress of legs during contraction then consider popliteal pressure
1. splint thigh, flex leg at knee and abduct leg in direction of hip
2. repeat with second leg if required
3. NO DOWNWARD TRACTION
Hands off to allow breech to descend
If slow/no progress of delivery of shoulders / arms during contractions then:
1. holding shoulder girdle rotate baby towards maternal symphysis pubis & bring down arm lying under SP,
rotate baby back round to face other direction & bring down arm lying under SP
2. NO DOWNWARD TRACTION
Hands off to allow breech to descend
If slow/no progress of delivery of head and / or concerns about fetal wellbeing then:
1. Franks nudge – press baby’s clavicle bone and rotate occiput around maternal symphysis pubis
2. Mauriceau Smellie Veit - 2 fingers to apply pressure on occiput, 2/3 fingers on cheek bones and chin
- Flexion before gentle traction
2
Post partum haemorrhage
Identify PPH
Call for help:
Pull Emergency bell
Call 2222 state ‘obstetric emergency’ and your location
Identify cause
Check uterus (tone)
check for trauma
check placenta is complete (tissue)
check blood is clotting (thrombin)
check bladder
Action Give drugs and replace fluids
Action 1. Rub up contraction
Action –
Observations and communication
1.
2.
3.
4.
5.
2.
3.
4.
5.
1.
2.
3.
4.
Give IV ergometrine 500g
Site 2 large bore cannula
Take blood (FBC, Clotting and Xmatch 6 Units)
Commence:
a.
b.
c.
Repair trauma
Remove placenta from uterus
Empty bladder
Bimanual compression
Observe colour & consciousness
Airway management [Commence O2]
B/P & pulse every 5 mins
Reassure and explain to parents
IVI of NaCl or Hartmanns
Commence IVI syntocinon
Commence Blood/Blood
replacement products
1.
2.
Hemabate IM 250microgms every 15 mins
Misoprostol PR
3.
Prepare for theatres:
a. Antiemetics
b. Labels
c. Consent form
Documentation/Paperwork – complete proforma
4.
Transfer to theatre
Blood loss of over 1500mls that is not controlled escalate to a MASSIVE Obstetric
haemorrhage and request consultant obstetrician and anaesthetist to attend in person
3
Shoulder dystocia
The order in which these manoeuvres are done depends on the individual case & clinical judgement,
however McRoberts and suprapubic pressure are recommended as first line management
Identify shoulder dystocia
Call for help & phone 2222
1.
2.
3.
4.
Assistance: Obs SpR, senior MW, neonatologist
Prepare for neonatal resuscitation
Communicate and reassure parents
Commence timing + documentation
McRoberts
1.
2.
lie flat & elevate legs, knees towards armpits
Attempt to deliver baby
Suprapubic pressure
1.
2.
30 seconds continuous or rocking pressure
Attempt to deliver baby
Evaluate for episiotomy if required to do internal manoeuvres
Internal manoeuvres
1. pressure on posterior aspect of anterior shoulder –
2.
3.
adduct shoulders & push baby into oblique (attempt
to deliver baby)
pressure on posterior aspect of anterior shoulder &
anterior aspect of posterior shoulder rotate 180o
pressure on posterior aspect of posterior shoulder –
rotate 180o in other direction
Remove posterior arm
Attempt to deliver baby
Roll onto all 4’s & Attempt to deliver baby
If unsuccessful consider:
NEVER apply excessive traction
or flexion to foetal head
Repeat all manoeuvres
(Zavanelli manoeuvre)
4