Obstetric Procedures and Management
Shoulder Dystocia
Clinical Management Protocol
Shoulder dystocia is an obstetric emergency where, after delivery of the head, the anterior shoulder of the infant cannot pass below the pubic symphysis.
The management of shoulder dystocia involves a sequence of manoeuvres. An assistant should monitor time, as each manoeuvre should generally be attempted for no more than 30-60 seconds.
| Step | Manoeuvre/Action | Description |
|---|---|---|
| 1 | Call for Help | Immediately summon additional obstetric, anesthesia, and pediatric staff. The HELPERR mnemonic is a tool to recall the sequence of interventions for managing shoulder dystocia: - H - Call for Help - E - Evaluate for Episiotomy - L - Legs (McRoberts Manoeuvre) - P - Suprapubic Pressure - E - Enter Manoeuvres (Internal Rotation) - R - Remove the posterior arm - R - Roll the patient |
| 2 | Evaluate for Episiotomy | Consider performing an episiotomy to create more room for internal manoeuvres. |
| 3 | McRoberts Manoeuvre | Hyperflex the mother’s thighs against her abdomen. This flattens the sacrum and rotates the pubic symphysis. |
| 4 | Suprapubic Pressure (Rubin I) | Apply pressure to the suprapubic area to dislodge the anterior shoulder. |
| 5 | Internal Manoeuvres | - Rubin II: Insert fingers vaginally and push on the posterior aspect of the anterior shoulder. - Wood’s Corkscrew: Push on the anterior aspect of the posterior shoulder to rotate it. - Reverse Wood’s Corkscrew: Similar to Wood’s Corkscrew, but rotating in the opposite direction. |
| 6 | Remove Posterior Arm | Deliver the posterior arm, which reduces the diameter of the shoulders. |
| 7 | Roll Patient (Gaskin Manoeuvre) | Roll the patient onto her hands and knees (all-fours position). This can widen pelvic outlets. |
| 8 | Methods of Last Resort | If primary manoeuvres fail: - Zavanelli’s Manoeuvre: Push the fetal head back in and perform a caesarean section. - Symphysiotomy: Surgically divide the cartilage of the pubic symphysis. - Cleidotomy: Intentionally fracture the fetal clavicle. |
| 9 | Post-Delivery Care | - Examine: Carefully check for any maternal lacerations or fetal injuries (e.g., fractured clavicle/humerus from manuevers). - Explain: Communicate clearly with the mother about what happened. - Document: Thoroughly document the entire event, including the sequence of manoeuvres and timing. |
https://www.youtube.com/watch?v=joTTDjRCCug https://www.youtube.com/watch?v=nTbltEuM3Y0 https://www.youtube.com/watch?v=VIyHZyij0Bg
Postpartum Hemorrhage (PPH) Management
| Step | Instruction |
|---|---|
| 1 | Call for help. |
| 2 | Manage ABC (Airways, Breathing, Circulation). Insert two wide-bore cannulae, take blood samples for clotting factors, and insert a catheter. |
| 3 | Examine the uterus and perform a vaginal examination to remove any clots. |
| 4 | Increase oxytocin infusion. |
| 5 | Perform Uterine massage. If ineffective |
| 6 | Perform Bimanual uterine compression. If ineffective → |
| 7 | Administer Uterotonic drugs (Ergometrine, misoprostol, carbetocin, oxytocin, or tranexamic acid). If ineffective → |
| 8 | Transfer patient to theatre for exploration to exclude local causes (lacerations, haematoma). |
| 9 | Insert a Bakri’s balloon. If ineffective → |
| 10 | Perform Laparotomy and consider surgical options in order: 1. B-Lynch (Uterine compression sutures). 2. Ligation (Ligation of the uterine and utero-ovarian arteries). 3. Embolization (Uterine artery embolization). 4. Hysterectomy. |
| 11 | Explain to the mother. |
| 12 | Debriefing & documentation. |
Manual Removal of the Placenta
Active Management of 3rd Stage of Labour
- Control cord traction.
- Ergometrine (i.m) or Syntocinon (iv).
Signs of Placental Separation
- Sudden gush of blood.
- Elongation of the cord.
- Palpable firm rounded mass above the symphysis pubis.
Management of Delayed Placental Separation
If placenta not separated for more than half an hour:
- Massage of the uterus.
- Intra umbilical injection of oxytocin.
- If failed Manual removal of the placenta.
- If failed Manual removal of the placenta. If you can’t remove it, leave it.
NB: Documentation & debriefing
Breech Delivery
Technique
- Delivery of the buttocks.
- Delivery of the legs and lower body
- Delivery of the shoulders
- Delivery of the head
- Mauriceau–Smellie–Veit manoeuvre: (finger in the mouth and one on each maxilla) Or
- Use forceps (Piper forceps).
Types of Vaginal Breech Deliveries
- Spontaneous breech delivery: No manipulation is used.
- Assisted breech delivery: The infant is allowed to spontaneously deliver up to the umbilicus, and then manoeuvres are initiated to assist in the delivery of the remainder of the body, arms, and head.
- Total breech extraction.
Important Steps
- Introduce yourself.
- Take consent.
- Explain the procedure briefly to the patient.
- Wrap the baby. https://www.youtube.com/watch?v=nbz_WKgfhj0 https://www.youtube.com/watch?v=xOqWT06qVS8
External Cephalic Version (ECV)
Procedure
- At 36 -37 weeks.
- Make sure that there is no fetal anomaly and the placenta is not low lying and liquor is adequate.(doing US or revising anomaly scan)
- Then do the procedure under ultrasound guidance and after giving tocolytics (to relax the uterus).
- Hold the head by one hand and buttocks by other hand then turn the baby gently.(procedure can be done with or without assistant)
- Documentation & debriefing.