Obstetric Emergencies

Assisted breech delivery
Shoulder dystocia
Cord prolapse
Twin delivery

Assisted breech delivery

• Hand off the breech!
• Keep spine 'facing' upwards
• If legs do not deliver, deliver one at a time by splinting femur with finger & sweeping legs across baby's abdomen
• Do not pull. Do not squeeze the abdomen as this may results in visceral injury
• When shoulder blades are seen allow arms to disengage spontaneously. If they do not, hook one or two fingers in the elbow & bend the arm bringing the hand down over the face
• If arms outstretched above the head or folded around the neck, use Lovset's manoeuvre (holding the hips turn the baby through a half circle keeping the back uppermost then draw the arm down over the chest. Deliver the second arm by turning back half a circle)
• Deliver the head by Mauriceau-Smellie-Veit (hold body over your right forearm, place first & third fingers on cheekbones using other hand to grasp the shoulders & two finders of this hand to flex the occiput of newborns head
• Supra-pubic pressure can help with flexion of the head
• Forceps or symphysiotomy can be used for a stuck head

Shoulder dystocia 

A bony obstruction of the fetal shoulder against the mother's pelvis

Call for HELP

Manoeuvres

• M - MacRoberts
• A - Anterior shoulder
• P - Posterior shoulder
• S - Salvage

Supra-public (NOT fundal) pressure can aid rotation of the anterior shoulder

An episiotomy can make room to allow for other manoeuvres

Cord prolapse 

The umbilical cord lies below the presenting part following rupture of the membranes. Cord compression leads to fetal hypoxia.

Call for HELP

If first stage:

• Stop presenting part pressing on the cord: Knee-elbow position, manually displace the presenting part, fill the bladder
• Refer for Caesarean section
• Salbutamol 0.2mg IV over 2 minutes

If second stage:

• Expedite delivery with vacuum extraction or forceps
• Prepare to resuscitate the newborn

Twin delivery

Check presentation

• If first twin cephalic allow labour to progress as for singleton
• If first twin breech deliver by CS
• If transverse lie deliver by CS

Twin Vaginal delivery

• Monitor both babies
• After delivery of the first twin
  • Clamp the cord. Do not attempt to deliver the placenta until second baby is delivered
  • Do not administer ocytocin
  • Palpate abdomen to determine life of second twin, correct lie to longitudinal if possible by ECV, and check FH
  • Perform VE to determine if cord has prolapsed, whether membranes are intact, & presentation of second twin
• Augment contractions if necessary
• ARM once presenting part is engaged 
• Deliver by CS if delivery does not occur within 2 hours or if fetal distress develops
• Active management of the third stage & be prepared for PPH