OB Emergencies

Course overview

Objectives Identify abnormal presentations and their management present during childbirth Explain the need for neonatal resuscitation during delivery Describe the routine care of a newborn not requiring resuscitation Content LESSON OBJECTIVES Identify abnormal presentations present during childbirth Discuss the management of a patient with an abnormal presentation during delivery Describe a nuchal cord presentation Discuss the procedures to take when a nuchal cord is present during delivery Recognize the need for neonatal resuscitation during delivery Discuss the management principles of neonatal resuscitation Describe the routine care of a newborn not requiring resuscitation LESSON CONTENT 1 Assessment and History Taking of a Pregnant Patient 2 Stages of Childbirth Dilation Expulsion Placental 3 Abnormal Presentations in Childbirth Breech Buttocks or both feet present first Management Prompt transport field delivery is not ideal When delivery is unavoidable Support buttock and legs Do not pull If head does not deliver within 3 minutes Arrange for immediate transport Insert gloved hand into the vagina and use fingers to form a V on either side of the infants nose Push the vaginal wall away from the infants face Limb presentation One leg or arm protruding from vagina Management Do not touch the limb Do not attempt field delivery Provide supportive care and transport in the knee chest position Multiple Births More than one fetus Management Manage as normal delivery recognizing the need for additional equipment and personnel Prolapsed Cord Umbilical cord presents from the vagina prior to fetus Management Immediate transport in Trendelenburg or knee chest position Insert two fingers of a gloved hand into the vagina to remove pressure off the cord Keep the cord moist with sterile dressing Do not attempt to pull the cord or push the cord back into the vagina Shoulder dystocia Shoulders unable to pass beyond pubic symphysis Turtle sign head delivers but retracts back into the perineum because the shoulders are trapped Management McRoberts maneuver buttocks off the end of the bed with thighs flexed upward and apply firm pressure with hand above the pubic symphysis Transport immediately even if delivery attempt is unsuccessful Nuchal cord Cephalic presentation but the umbilical cord is around the neck Common finding during delivery and rarely associated with adverse outcomes Management Attempt to slip the cord over the infants head If unable to slip the cord up and over the head clamp and carefully cut the cord Neonatal Resuscitation Assessment If yes is answered to these three questions the infant stays with the mother and standard care continues including maintaining the newborns temperature Full term gestation Good muscle tone Breathing or crying adequately If no is answered to any of the above assessment questions resuscitation efforts should be attempted in this sequence First 30 seconds postpartum Dry the infant then warm and maintain normal temperature Position airway Clear secretions Stimulate 30 to 60 seconds postpartum Heart rate below 100 per minute or gasping apnea Initiate positive pressure ventilation and monitor oxygen saturation Labored breathing or persistent cyanosis Position and clear the airway monitor oxygen saturation supplementary oxygen as needed After one minute postpartum Heart rate greater than 100 per minute Provide post resuscitation care Heart rate less than 100 per minute Check chest movement Correct ventilations as needed Endotracheal tube or appropriate supraglottic airway Heart rate greater than 60 per minute Begin chest compressions coordinated with positive pressure ventilation and 100 percent oxygen Place on ECG monitor Considerations Advanced airway 2015 AHA ECC Guidelines for Neonatal Resuscitation when meconium is present Suctioning in the presence of meconium staining Vigorous neonates with good respiratory effort and muscle tone born through meconium stained