Obstetric emergencies

Prolapsed cord
Shoulder dystocia
Twin delivery

IN PARTNERSHIP WITH
Liverpool School of Tropical Medicine
Liverpool Associates in Tropical Health
 Aims
 To recognise the above emergencies

 To practise the skills needed to manage them

 To achieve competence in those skills

 Shoulder dystocia

 May be very difficult to predict

 Some ‘at risk’ patients e.g. women likely to deliver a

large baby
 Maternal obesity
 Previous history of ‘big/large’ baby
 Women with Diabetes in pregnancy
 Diagnosis
 Fetal head delivered but shoulders stuck
behind symphysis pubis
 Fetal head delivered but remains tightly
applied to the vulva
 Chin retracts and depresses the perineum
 Traction on the head fails to deliver the
shoulder
 Shoulder dystocia

 Call for help

 McRobert’s
 Position knees as far as possible up to the chest
and abduct and rotate legs outwards
 Shoulder dystocia

 Apply suprapubic
pressure using the heel
of the hands
 Shoulder dystocia
 Make adequate episiotomy to reduce soft
tissue obstruction and make room for other
manoeuvres

 Apply firm continuous traction on the fetal

head
 Shoulder dystocia
 Apply pressure to the anterior shoulder in the
direction of the baby’s chest, to rotate the
shoulder and decrease the inter-shoulder
diameter
OR
 Apply pressure to the posterior shoulder in
the direction of the sternum
 Shoulder dystocia
Try to deliver posterior shoulder first:

 grasping the humerus of the posterior arm

keeping the arm flexed at the elbow,

 sweep the arm across the chest- this will

provide room for the anterior shoulder to
move under the symphysis
 Shoulder dystocia

 Keep McRoberts throughout even when

moving on to other manoeuvres
 Consider
Applying traction with a hook in the axilla of the
posterior arm
All fours
? Fracturing the clavicle
 Twin delivery

 Can be discovered:
 routine abdominal palpation,
 during ultrasound or
 after delivery of the first baby
 Abdominal palpation or VE
 Twin delivery- first baby
 Start iv infusion
 Check presentation
 If vertex allow labour to progress as for single vertex
 If breech apply guidelines for single breech
 If transverse lie deliver by CS
 After the delivery of the 1st baby leave a clamp on
the maternal end of the cord and do not attempt to
deliver the placenta until the 2nd baby is delivered
 Twin delivery- second baby
 Check FH
 Check iv is running, may be needed for augmentation if
contractions are not adequate, needed to manage/prevent
PPH
 Palpate abdomen to determine lie of second baby
 Perform VE to determine
 If cord has prolapsed
 Whether membranes are intact
 Confirm presentation
 Correct to longitudinal lie by external version if possible-intact
membranes
 Twin delivery – second baby
 For vertex

Rupture membranes if intact

Check FH between contractions
Anticipate spontaneous delivery
Augment labour if necessary
Vaginal delivery as normal
 Twin delivery- second baby
 For breech
 If contractions inadequate augment
 If membranes intact and breech has descended, rupture
membranes
 Check FH between contractions
 Assisted vaginal delivery
 Breech extraction if membranes rupture during vaginal
examination
 If vaginal delivery not possible deliver by CS-late
presentation
?
 RECAP
Recognition and management of
Obstetric emergencies:
Cord prolapse
Shoulder dystocia
Twin delivery
Skills in providing assisted deliveries