By Dr.

CK
1.Breach devilry steps
1. Introduction
2. Explanation
3. Consent
4. Open iv lines
5. Equipment
6. Position lithotomy
7. Call for help
8. Hand washing & put non sterile gloves
9. Cleaning genital area
10.Os must be dilateds
11. Catheterization
12.PV check position & station
13.Local anesthesia & episiotomy
14.Hand off method
15.Wait until buttocks are visible &spontaneous leg out
16.Pinard maneuver
17.Cord separate
18.Baby hold and wrapping towel
19.Watch until scapula visible
20. Loveset maneuver(ante & posterior shoulder)
21.Wait until hair lines visible
22. MSV maneuver
23. Forceps pipers forceps
24. Delivery baby
25. Cut cord(after 2-3min)
26. Give neonatal resuscitation team
27. Placental delivery give oxytocine 10IU-IM & Massage
28. Early breast feeding stable baby
29. Repair episiotomy and check any tear
30. Clean & hand wash & cover & thanks pts &staffs
31.Documentation & explain and counseling
2. Shoulder dystocia
1. Introduction
2. Explanation
3. Consent
4. Open iv lines
5. Equipment
6. Call for help
7. Hand washing & sterile gloves
8. Ensure shoulder dystocia(turtle sing)
9. Position McRobert Maneuver(ever step 30sec)
10.Gentle traction
11. Episiotomy
12.Suprapubic pressure (Robbin one)
13.Delivery anterior arm
14.Woods corkscrew maneuver
15.Reverse Woods corkscrew maneuver
16.Delivery posterior arm (Robbin two)
17.Knee chest position (if failure all maneuver)
18.Symphostomy
19.Break clavicle
20. Z.Manuever
21.If baby delivery active third stage and repair genital lacerations
22. Thanks mother and staffs
3. Manual Vacuum extraction
1. Indications
➢ Prolong second stage
➢ Fetal distress
➢ Maternal exhausted
➢ Placental abortion
➢ Cord prolapsed
2. Conditions
➢ Cervical full dilated
➢ Head engaged
➢ Cephalic presentation
➢ Membrane rupture
➢ Adequate anesthesia
3. Introduction
4. Explanation’
5. Consent
6. Equipment
7. Position lithotomy and exposure
8. catheter
9. Call for help
10.Hand wash and put gloves and clean genital area
11. Drape mother
12.Prepare vacuum and test vacuum your hand
13.Nerve block
14.PV (asses fetal head)
15.Identify posterior fontanel
16.Apply the cup posterior fontanel between contraction
17.Episiotomy
18.Check application and there is no maternal soft tissue
19.Create vacuum
20. Waite until maximum negative pressure applied
21.Start gentle traction
22. If baby delivery release vacuum and remove cups
23. End procedure
4.Cord prolapsed
1. Introduction
2. Explanation
3. Consent
4. Position lithotomy
5. Call for help
6. Hand washing & put non sterile gloves
7. Check cord is pulsatile
8. If pulsatile ,check lie and presentation
9. If baby transverse go to the theater C/S
10.If the first stage
➢ Knee chest position
➢ Push presentation
➢ Insert folly Cather
➢ Give sulbtamol
➢ Transverse to theater
11. If second stage
➢ If vertex ,perform vacuum and episiotomy
➢ If breach perform breach extraction
12.If no pulsatile delivery easily way
13.End procedure
5. Twin delivery
1. Introduction
2. Explanation
3. Consent
4. Open iv lines
5. Equipment
6. Position lithotomy
7. Bowel and bladder preparation
8. Call for help
9. Hand washing & put non sterile gloves
10.Perform PV and abdominal examination
11. Check
➢ Lie and presentation
➢ Cervical fully dilated and membrane rupture
➢ If vertex allow progression labor
➢ If breach same as breach delivery
➢ If transverse C/S
12.Perform after first baby delivery
➢ Presentation
➢ Cord
➢ Membrane
13.If vertex
➢ Check fetal head and membrane
➢ Check FHR
➢ If poor contraction give augmentation
➢ If no spontaneous delivery 2hr perform vacuum and C/S
➢ If breach same as breach delivery
➢ If transverse C/S
14.End procedure
6. Manual removal placental
1. Introduction
2. Explanation
3. Consent
4. Open iv lines
5. Equipment
6. Position lithotomy
7. Bowel and bladder preparation
8. Call for help
9. Check sings of placenta separation <30min
➢ Gush blood
➢ Lengthens cord
➢ Raised fundus and frim
10.Hand washing & put long sterile glove
11. Single dose ABX(amox,2g iv, flgyl 500mg iv )
12.Give pethadine and diazepam
13.Hold placenta cord with clump
14.Pull gently
15.Place the finger of right hand in to the vagina until placenta located
16.If located placenta release left hand and place abdomen to support fundus
17.If not separated assume placenta accrete
18.When placenta complete separation
➢ Remove all the placenta tissue in side uterus
➢ Slow withdrawal hand
➢ Give oxytocin 20nit –one liter 60drop/min
➢ If heavy bleeding give ergometrin 0.2mg or PGE
➢ Uterus massage and check all tears
➢ Monitor vital signs and bleeding every (15m for 1hr)
➢ End procedure
7. Cervical swab
1. Introduction
2. Explanation
3. Consent
4. Chaperone
5. Equipment
➢ Speculum
➢ Sample spot
➢ End cervical brush
➢ Ectocervical spatula
➢ Gloves and lubricant
➢ Light
6. Position lithotomy
7. Bowel and bladder preparation
8. Hand washing & put sterile glove
9. Clean genital area
10.Inspection
➢ Scars, redness , bleeding ,discharge
➢ Notice pt Insert speculum with lubricant ( erosion,ulcer,mass,discharge)
➢ Rotate 5times clockwise direction
➢ Take sample endocevical cytobrush
➢ Take sample ectocervical spatula
11. Remove speculum
12.Disposal sample container and labeled
13.Disposal equipment
14.Documentation
15.Thanks mother
16.Hand wash
17.End procedure
8. Vaginal examination
1. Introduction
2. Explanation
3. Consent
4. Chaperone
5. Position lithotomy
6. Exposure
➢ Pair of gloves
➢ Speculum and lubricant
➢ Smear brush and cytological spots and swabs
➢ light
7. Bowel and bladder preparation
8. Hand wash wear gloves and clean genital area
9. General inspection
➢ Hirtutism , 2nd sexual charac,
➢ Acne, BMI
10.Close inspection
➢ Scars , redness , swelling , ulcer , prolapsed , warts discharge bleeding
11. Note mother and lubricant insert two fingers
12.Assess
➢ Vagina(smoothness , tone moist , warm ,glands )
➢ Cervical(smooth mobile tender mass )
➢ Uterus (size , position , mass)
➢ Adnex (mass)
13.Remove hand and assess any bleeding discharge
14.Disposal equipment and cover the pt and thanks
15.Hand washing
 9. Pregnant abdominal examination

1. Introduction
2. Explanation
3. Consent
4. Chaperone
5. Position
6. Exposure
7. Empty bladder
8. General inspection
➢ Comfortable position
➢ Obese and wt loss
➢ Facial edema
➢ BMI
9. Close inspection
➢ Size , shape, symmetric ,scars
➢ Fetal movement , linear nigra , steria gravidum
10.Palpation
➢ FH
➢ Fetal lie
➢ Fetal number
➢ Presentation part
➢ Engagement
➢ Amniotic fluid
11. Auscultation(pinard and Doppler )
12.Check legs edema and CVA , sacral edema
10. Perform leopard maneuver
1. First maneuver (fundal grip )
➢ Palpate upper abdomen with both hands
➢ Find first fundus
➢ Assess (size , consistency , shape , mobility for personating part)
➢ Head is hard ,round, mobile
➢ Buttocks is soft , symmetric
➢ Shoulder is feel limbs , bony prominence
2. Second maneuver (umbilical grip)
➢ Palpate lateral sides both hands
➢ One fixed and one palpate
➢ Back is firm, smooth
➢ Extremity is irregular protrusions
3. Third maneuver (pelvic grip , paw licks grip)
➢ What fetal part lying above pelvic prim and lower abdomen
4. Fourth maneuver (2nd pelvic grip )
➢ Attitude
➢ Engage
11. EXAMINATION OF PLACENTA
1. Introduction
2. Explanation
3. Gain consent
4. Equipment
A. Disposable bag of placenta
B. Weighting scales
C. Specimen jar
D. Scissors
E. Apron
F. Pair of gloves
5. Wash hand and apply gloves
6. Note size, shape, smell, color
7. Observe irregularities
8. Note the length of the cord and insertion point
9. Check presence two arteries and one vein
10.Ensure all cotyledons are present
11. Note any blood clot and area infraction
12.Examine membrane completeness
13.Look , holes, vessels, lobes
14.Separate chorion and amnion
15.Sample of the cord and sample of maternal side
16. Sample of chorion and amnion
17.Place in the specimen container
18.Place in the disposable bag and weight
19.Some cases need placenta swab required
20. Some cases need placenta sent to lab