OSCE: ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR

OXYTOCIN
- administer oxytocin 10 units after delivery of anterior shoulder/fetal head

CORD CLAMPING
- Mentions: delayed cord clamping to prevent fetal anemia

TRACTION
- Mentions: traction start
When there is contraction/uterus is hard
- Demonstrates: gentle controlled cord traction with simultaneous suprapubic
support of the uterus

PLACENTA
- Mentions: stop traction
 If there is resistance encountered.
 If fundus of uterus descends with each traction

DELIVERY OF THE PLACENTA

- Mentions: feel if placenta is already at the vagina
- Demonstrates: Gentle digital exam along the cord
 If placenta is already at the introitus, hold it ad rotate to facilitate full
detachment of the membranes

UTERINE MASSAGE
After Placental delivery:
- Mentions: need to assess the fundus; massage fundus
- Demonstrates: proper uterine massage

PLACENTAL INSPECTION
Check the placenta for:
- Completeness or absence of cotyledons
- Possible accessory lobe

DOCUMENTATION

CASTRO NOTES Page 1

 OSCE: SHOULDER DYSTOCIA
ASK FOR ASSISTANCE
- Ask for assistance from colleagues, anaesthesiologists, or pediatricians

LIFT THE LEGS

- Do McRobert’s Maneuver (demonstrate correctly)

ABDOMINAL
- Anterior shoulder disimpaction
- Mentions: Mazzanti
- Demonstrates:
 uses correct hand
 heel of clasped hand over the posterior aspect of anterior shoulder OSCE: SHOULDER DYSTOCIA
 suprapubic pressure (Cont.)

VAGINAL EPISIOTOMY
- Mentions: Rubin - Do episiotomy if not yet done
- Demonstrates:
 uses correct hand ROLL OVER INTO 4’s
 2nd & 3rd over the anterior aspect of the posterior shoulder - Mentions: Gaskin’s
 pushes towards the chest - Demonstrates:
 uses correct hand
ROTATION  grasps the posterior arm up to antecubital fossa
- Mentions: “Wood’s Screw”  applies pressure on the antecubital fossa
- Demonstrates:  holds arm, sweeps it against chest and deliver
 uses correct hand
 2nd & 3rd over the anterior aspect of the posterior shoulder - Bring the patient back to lithotomy position, proceed with either:
 rotates shoulder 190 to anterior oblique position o Cleidotomy
o Symphysiotomy
MANUAL REMOVAL OF POSTERIOR ARM o Zavanelli
- Demonstrates:  bring back baby’s head into the uterus
 uses correct hand  performs reverse cardinal movement
 grasps the posterior arm up to antecubital fossa  perform cesarean section/abdominal delivery
 applies pressure on the antecubital fossa
 holds arm, sweeps it against chest and deliver - Inspect the birth canal for any laceration
- Document

CASTRO NOTES Page 2

 OSCE: FORCEPS

*Secure consent

ASK FOR ASSISTANCE

- Assistance
- Anesthesia

BLADDER
- Bladder must be empty

CERVIX
- Cervix must be fully dilated
- Membranes must be ruptured

DETERMINE
- Determine the following:
o Station
o Position
o Adequacy of the pelvis
o Possibility of shoulder dystocia

EQUIPMENT
- Check the equipment in terms of:
OSCE: FORCEPS
o Quality
(Cont.)
o Functionality
GENTLE TRACTION
FORCEPS - Apply only with contraction or expulsive effort
- Phantom application
- Insert LEFT blade first HANDLE ELEVATION
o Left blade, left hand, maternal left side - Demonstrates:
o Pencil grip and vertical incision with right thumb directing blade  Traction along axis of birth canal

- Insert RIGHT blade - Mentions:

o Right blade, right hand, maternal right side  Do not elevate handle too early
o Pencil grip and vertical incision with left thumb directing blade
INCISION
- Lock blade and support - Do an episiotomy

- Check application JAW

o Posterior fontanelle is 1 cm above the plane of shanks - Remove forceps when jaw is reachable or delivery is assured
o Fenestration is no more than one fingerbreadth between it and scalp - Inspect for any lacerations/injuries (cervical, vaginal, clitoral areas)
o Sagittal suture is perpendicular to the plane of the shanks, with the - Document
occipital sutures 1 cm above the respective blades

CASTRO NOTES Page 3

 OSCE: VAGINAL BREECH DELIVERY

CONSENT Secure consent

ANESTHESIA Request for anesthesia

EPISIOTOMY Do episiotomy

SPONTANEOUS DELIVERY
- Mentions: Partial Breech Extraction (PBE)
- Wait! Don’t pull!
- Demonstrates correctly: holds baby when umbilicus is out

DELIVERY OF LEGS
- Mentions: Pinard’s
o Lateral rotation of thighs
o Flexion of knees
o Keep sacrum anterior

DELIVERY OF ARMS
- Delivery starts when wing of scapula is seen
- Rotate arm to anterior

- Mentions: Loveset Maneuver

o Sweep humerus across the chest and deliver

- Rotate other arm to anterior and repeat the Loveset maneuver to deliver

NAPE OF NECK
- Mentions and demonstrates correct positioning of fetus on the arm/opposite hand
- Mentions:
o Apply suprapubic pressure
o Avoid over extension

OSCE: VAGINAL BREECH DELIVERY

(Cont.)

DELIVERY OF AFTER-COMING HEAD

- Mentions: Mauriceau-Smellie-Veit Maneuver

- Demonstrates correctly:
o 2nd & 3rd fingers over the malar prominence
o 2nd & 3rd fingers over the nape of the baby

- Mentions: use of Piper’s forceps

INSPECTION
- Inspect the baby for any facture or injuries
- Inspect the birth canal for any lacerations

DOCUMENTATION

CASTRO NOTES Page 4

 OSCE: VACUUM

ADDRESS Secure consent

Request for anesthesia
Assistance

BLADDER Bladder must be empty

CERVIX Cervix must be fully dilated

Membranes must be ruptured
Contractions must be adequate

DETERMINE Position
Station
Pelvic adequacy
Possibility of shoulder dystocia

EQUIPMENT Inspect the vacuum cup, pump, tubing

Demonstrates: checking of pressure

FONTANELLE
- Position the cup just anterior to or over the posterior fontanelle OSCE: VACUUM
- Sweep finger around the cup to clear maternal tissue (Cont.)
- Bring pressure to 100 mmHg initially
HALT IF There’s no progress with three traction-aided contractions
GENTLE TRACTTION Vacuum pops off 3 times
- Start only when there is contraction Already more than 20 minutes total application
o Increase pressure to approximately 600 mmHg, prompting mother for
good expulsive effort INCISION Do an episiotomy if needed
o Pull only with contractions
JAW
- Apply traction along the axis of the birth canal - Remove the vacuum when the jaw is reachable or delivery is assured
- Check for any lacerations
- Pressure may be maintained in between contractions, but no traction is to be
exerted - Document

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