Dr Fran Berard MD CCFP

ASA April 2015

Dr Fran Berard MD CCFP

No conflict of interest to disclose

MD89 CCFP91 MB

23 years- Notre Dame de Lourdes-small rural francophone community

Small hospital Clinic ER PCH Teaching Obstetrics-

PN care emergency obs low volume intrapartum care

Team Rural nurses 3 FPs sharing obs Midwifery group

Low risk obs is mostly uncomplicated but we focus on the worst case scenario

Pregnant women value the involvement of their FP

Pregnant women need caregivers close to home can be at risk if they have to travel

Providing intrapartum care makes me better at prenatal and emergency obs care

Basic interventions really improve outcomes in obstetrical emergencies

httpswwwyoutubecomvNcHdF1eHhgcversion=3ampstart=44ampend=117ampautoplay=0amphl=en_USamprel=0

MP

Dr Fran Berard MD CCFP

No conflict of interest to disclose

MD89 CCFP91 MB

23 years- Notre Dame de Lourdes-small rural francophone community

Small hospital Clinic ER PCH Teaching Obstetrics-

PN care emergency obs low volume intrapartum care

Team Rural nurses 3 FPs sharing obs Midwifery group

Low risk obs is mostly uncomplicated but we focus on the worst case scenario

Pregnant women value the involvement of their FP

Pregnant women need caregivers close to home can be at risk if they have to travel

Providing intrapartum care makes me better at prenatal and emergency obs care

Basic interventions really improve outcomes in obstetrical emergencies

httpswwwyoutubecomvNcHdF1eHhgcversion=3ampstart=44ampend=117ampautoplay=0amphl=en_USamprel=0

MP

MD89 CCFP91 MB

23 years- Notre Dame de Lourdes-small rural francophone community

Small hospital Clinic ER PCH Teaching Obstetrics-

PN care emergency obs low volume intrapartum care

Team Rural nurses 3 FPs sharing obs Midwifery group

Low risk obs is mostly uncomplicated but we focus on the worst case scenario

Pregnant women value the involvement of their FP

Pregnant women need caregivers close to home can be at risk if they have to travel

Providing intrapartum care makes me better at prenatal and emergency obs care

Basic interventions really improve outcomes in obstetrical emergencies

httpswwwyoutubecomvNcHdF1eHhgcversion=3ampstart=44ampend=117ampautoplay=0amphl=en_USamprel=0

MP

Low risk obs is mostly uncomplicated but we focus on the worst case scenario

Pregnant women value the involvement of their FP

Pregnant women need caregivers close to home can be at risk if they have to travel

Providing intrapartum care makes me better at prenatal and emergency obs care

Basic interventions really improve outcomes in obstetrical emergencies

httpswwwyoutubecomvNcHdF1eHhgcversion=3ampstart=44ampend=117ampautoplay=0amphl=en_USamprel=0

MP

httpswwwyoutubecomvNcHdF1eHhgcversion=3ampstart=44ampend=117ampautoplay=0amphl=en_USamprel=0

MP

Review diagnosis and management

- Shoulder Dystocia

- Postpartum hemorrhage

Anticipate Prepare team

Early Identification

Mobilize team call for help

Early Intervention

Debrief and Document

=Better Outcomes

Rachelle 30 yo G2P1 ndash in labor at term

Rh+ GBS negative

Previous uncomplicated vaginal delivery

Uncomplicated prenatal course

Admitted at 6 cm dilatation progresses to fully dilated and pushing over the next 2-3hours

Baby now crowning

Vertex delivers and then is sucked back against the perineum The anterior shoulder does not deliver with the usual traction

The babys head does not restitute

WHO Reproductive Health Library

Diagnosis

Turtle sign

Shoulder dystocia

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Anticipate Prepare team

Early Identification

Mobilize team call for help

Early Intervention

Debrief and Document

=Better Outcomes

Rachelle 30 yo G2P1 ndash in labor at term

Rh+ GBS negative

Previous uncomplicated vaginal delivery

Uncomplicated prenatal course

Admitted at 6 cm dilatation progresses to fully dilated and pushing over the next 2-3hours

Baby now crowning

Vertex delivers and then is sucked back against the perineum The anterior shoulder does not deliver with the usual traction

The babys head does not restitute

WHO Reproductive Health Library

Diagnosis

Turtle sign

Shoulder dystocia

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Rachelle 30 yo G2P1 ndash in labor at term

Rh+ GBS negative

Previous uncomplicated vaginal delivery

Uncomplicated prenatal course

Admitted at 6 cm dilatation progresses to fully dilated and pushing over the next 2-3hours

Baby now crowning

Vertex delivers and then is sucked back against the perineum The anterior shoulder does not deliver with the usual traction

The babys head does not restitute

WHO Reproductive Health Library

Diagnosis

Turtle sign

Shoulder dystocia

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Vertex delivers and then is sucked back against the perineum The anterior shoulder does not deliver with the usual traction

The babys head does not restitute

WHO Reproductive Health Library

Diagnosis

Turtle sign

Shoulder dystocia

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

WHO Reproductive Health Library

Diagnosis

Turtle sign

Shoulder dystocia

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Diagnosis

Turtle sign

Shoulder dystocia

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

What is it

Anterior shoulder of baby impacted against the mothers symphysis pubis

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

DeathAsphyxia of Baby

Fractures- ClavicleHumerus

Brachial Plexus Injury

Maternal Post partum Hemmorhage

Maternal Uterine Rupture

Severe Perineal Tearing

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Incidence 3-5

Hoffman et al 2011 June

13200 births 2000 shoulder dystocias (15) 100 =neonatal injury 36 brachial plexus injuries clavicle fracture 5 neonatal encephalopathies 0 deaths

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

50- NO RISK FACTORS

Big babyPost-term pregnancy gt 42 weeksMultiparityMaternal diabetes mellitusPrevious shoulder dystocia Previous big babyExcessive weight gain - more than

20 kg Maternal BMI gt 50

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

- Ultrasound is not an accurate measure or predictor of macrosomia

Induction of labor for suspected macrosomiaor diabetes does not prevent shoulder dystocia or brachial plexus palsy

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Assisted vaginal birth- vacuum or forceps

Prolonged labor (maybe)

Induction of labor

Epidural anesthesia

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

1Do not pull (on the head)

2 Push (on the fundus)

3 Panic

4 Pivot (severely angulate the head using the coccyx as a fulcrum)

5 Do not cut a nuchal cord

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Increase size of pelvic opening

Rotate the baby so the shoulders are in the oblique position

Reduce the width of babys shoulders

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

- Notify your team

- Call for backup- who is that

- Explain to mother and partner coach etc and enlist their help

- Document time

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Wait till next contraction after turtle sign

- this does not alter fetal acidosis

Do not cut nuchal cord

Ask mother to stop pushing while doing internal maneuvers

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Does not resolve the dystocia

Allows more room for internal maneuvers

Mediolateral

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

A 2011 retrospective study by Leung involving 205 cases

Legs up- 25 resolution

Legs up + Rotation or Posterior shoulder delivery=72 resolution

Legs up + Rotation + Post shoulder delivery= 946 resolution

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

httpswwwyoutubecomvjsC9aUzx510version=3ampstart=401ampend=436ampautoplay=0amphl=en_USamprel=0

WHO Reproductive Health Video Library

Fracture clavicle

Symphysiotomy

Zavenelli maneuver (cephalic replacement) followed by Csection

Review possible interventions

Prepare the woman her partner and the Team for Leg lift maneuver and the potential for rolling over

Placing a stool at the side of the bed corresponding to the fetal back to facilitate suprapubic pressure

Rachelles baby boy delivers with Leg lift ( McRoberts) and suprapubic pressure and responds well to stimulation

Post shoulder dystocia delivery care

Cord gases

Check baby and mother for injury

Debrief with team including parents

Document

1 Oxytocin 10 units IM or 5-10 units IV over 1-2 mins ( as long as no twin) (Misoprostol PO in low resource)

2 Controlled cord traction

3 Delayed cord clamping gt 1 min

- Early breastfeeding- inspect placenta- cord gases

Many cases- NO RISK FACTOR

Multiples polyhydramnios big baby

Rapid or long labor Induction High parity

Previous uterine surgery Previous PPH

Review interventions for PPH

Discuss with team including patient and attendants

IV access

Plan IV Oxytocin 20-40 units in a litre NS after birth

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

Review possible interventions

Prepare the woman her partner and the Team for Leg lift maneuver and the potential for rolling over

Placing a stool at the side of the bed corresponding to the fetal back to facilitate suprapubic pressure

Rachelles baby boy delivers with Leg lift ( McRoberts) and suprapubic pressure and responds well to stimulation

Post shoulder dystocia delivery care

Cord gases

Check baby and mother for injury

Debrief with team including parents

Document

1 Oxytocin 10 units IM or 5-10 units IV over 1-2 mins ( as long as no twin) (Misoprostol PO in low resource)

2 Controlled cord traction

3 Delayed cord clamping gt 1 min

- Early breastfeeding- inspect placenta- cord gases

Many cases- NO RISK FACTOR

Multiples polyhydramnios big baby

Rapid or long labor Induction High parity

Previous uterine surgery Previous PPH

Review interventions for PPH

Discuss with team including patient and attendants

IV access

Plan IV Oxytocin 20-40 units in a litre NS after birth

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

Rachelles baby boy delivers with Leg lift ( McRoberts) and suprapubic pressure and responds well to stimulation

Post shoulder dystocia delivery care

Cord gases

Check baby and mother for injury

Debrief with team including parents

Document

1 Oxytocin 10 units IM or 5-10 units IV over 1-2 mins ( as long as no twin) (Misoprostol PO in low resource)

2 Controlled cord traction

3 Delayed cord clamping gt 1 min

- Early breastfeeding- inspect placenta- cord gases

Many cases- NO RISK FACTOR

Multiples polyhydramnios big baby

Rapid or long labor Induction High parity

Previous uterine surgery Previous PPH

Review interventions for PPH

Discuss with team including patient and attendants

IV access

Plan IV Oxytocin 20-40 units in a litre NS after birth

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

1 Oxytocin 10 units IM or 5-10 units IV over 1-2 mins ( as long as no twin) (Misoprostol PO in low resource)

2 Controlled cord traction

3 Delayed cord clamping gt 1 min

- Early breastfeeding- inspect placenta- cord gases

Many cases- NO RISK FACTOR

Multiples polyhydramnios big baby

Rapid or long labor Induction High parity

Previous uterine surgery Previous PPH

Review interventions for PPH

Discuss with team including patient and attendants

IV access

Plan IV Oxytocin 20-40 units in a litre NS after birth

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

Many cases- NO RISK FACTOR

Multiples polyhydramnios big baby

Rapid or long labor Induction High parity

Previous uterine surgery Previous PPH

Review interventions for PPH

Discuss with team including patient and attendants

IV access

Plan IV Oxytocin 20-40 units in a litre NS after birth

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

Review interventions for PPH

Discuss with team including patient and attendants

IV access

Plan IV Oxytocin 20-40 units in a litre NS after birth

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

1 hour postpartum-

Rachelle complains of feeling unwell and you are called back to see her

The nurses are concerned about the amount of vaginal bleeding

Post partum hemorrhage

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

Definition

-500 ml blood loss in a vaginal birth

-Greater then 1000 ml Csection

- any blood loss that has the potential to produce hemodynamic instability

- Less blood loss required with prexisting anemia

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

occurs in 5 births worldwide

Leading cause of maternal mortality

Canada- 34 direct maternal deaths per million live births

PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 25 per

year if delivering 5000 babies per year)

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

MILDlt 20 Diaphoresis Delayed capillary refill time Cool extremities Anxiety

MODERATE20-40 Above plus tachycardia Tachypnea postural hypotension Oliguria

SEVEREgt 40 Above plus hypotension agitationconfusion hemodynamic instability

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=54ampend=90ampautoplay=0amphl=en_USamprel=0

Assess mother- VS alertness estimate amount of blood loss

Attention- young women compensate well for blood loss

CAB- call for help

IV access- NS

Labs- CBC crossmatch coag studies

If placenta not out- may need manual removal

External uterine massage-check tone-remove clots

Empty bladder

IV Oxytocin 20-40units in a litre NS- run wide open

T- Tone Uterine atony gt 70

T-Tissue- Retained tissue

T-Trauma Lacerations

T-Thrombin Coagulation disorders lt1

Empty bladder

Bimanual compression

Exploration uterus- retained tissue

Second line drugs

Trauma- inspect for laceration

Compress and repair

Thrombin ndashConsider coagulation issues

Resistant bleeding

Bleeding from other sites

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=1020ampend=1098ampautoplay=0amphl=en_USamprel=0

Medical Aid Films Clip-1730

If placenta not out- may need manual removal

External uterine massage-check tone-remove clots

Empty bladder

IV Oxytocin 20-40units in a litre NS- run wide open

T- Tone Uterine atony gt 70

T-Tissue- Retained tissue

T-Trauma Lacerations

T-Thrombin Coagulation disorders lt1

Empty bladder

Bimanual compression

Exploration uterus- retained tissue

Second line drugs

Trauma- inspect for laceration

Compress and repair

Thrombin ndashConsider coagulation issues

Resistant bleeding

Bleeding from other sites

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=1020ampend=1098ampautoplay=0amphl=en_USamprel=0

Medical Aid Films Clip-1730

T- Tone Uterine atony gt 70

T-Tissue- Retained tissue

T-Trauma Lacerations

T-Thrombin Coagulation disorders lt1

Empty bladder

Bimanual compression

Exploration uterus- retained tissue

Second line drugs

Trauma- inspect for laceration

Compress and repair

Thrombin ndashConsider coagulation issues

Resistant bleeding

Bleeding from other sites

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=1020ampend=1098ampautoplay=0amphl=en_USamprel=0

Medical Aid Films Clip-1730

Empty bladder

Bimanual compression

Exploration uterus- retained tissue

Second line drugs

Trauma- inspect for laceration

Compress and repair

Thrombin ndashConsider coagulation issues

Resistant bleeding

Bleeding from other sites

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=1020ampend=1098ampautoplay=0amphl=en_USamprel=0

Medical Aid Films Clip-1730

Trauma- inspect for laceration

Compress and repair

Thrombin ndashConsider coagulation issues

Resistant bleeding

Bleeding from other sites

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=1020ampend=1098ampautoplay=0amphl=en_USamprel=0

Medical Aid Films Clip-1730

httpwwwyoutubecomvqYGLIX0lH8oversion=3ampstart=1020ampend=1098ampautoplay=0amphl=en_USamprel=0

Medical Aid Films Clip-1730

Oxytocin running

Misoprostol ( Cytotec)

15-methyl prostaglandin F2

( Hemabate or Carboprost)

Ergonovine

Misoprostol (Cytotec) - off label

PO SL works quickest ndashonset 30 mins lasts 2 hours Rectal- effect lasts longer-onset 40-60min lasts 6hrs

200mcg Po or SL +600mcg rectal or 400mcg PO or SL + 400 mcg rectal

Contraindications allergy to PG Common sideffects Abdominal pain diarrhea

pyrexia

15-methyl prostaglandin F2α (fridge)(CarboprostHemabate) 250 micrograms IM

Repeat as needed every 15 minutes

max dose of 2mg (8 doses)

Common sideffects- Nausea vomiting diarrhea hyperthermiaflushing wheezing coughingnervousness

Asthma is a relative contraindication

Ergonovine maleate- 02-025 mg IM or IV(slowly) repeat q2-4h IM or IV(slowly) as needed - max 5 doses

Contraindications

Hypertensive disorders of pregnancy -even if their BP normal currently

Certain HIV drugs

Adverse effects Nausea dizziness hypertension

Ongoing bleeding inspite of meds

Tamponade- Bakri balloon

Tranexamic acid ( risk of thrombosis)

Invasive interventions-

Embolization

Laparotomy

Emergency hysterectomy

Bleeding resolves with Oxytocin IV and massage and Misoprostol

Followup care-

-Debrief with team and mother and supports

-FU Hgbs and iron

-Document

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

Misoprostol (Cytotec) - off label

PO SL works quickest ndashonset 30 mins lasts 2 hours Rectal- effect lasts longer-onset 40-60min lasts 6hrs

200mcg Po or SL +600mcg rectal or 400mcg PO or SL + 400 mcg rectal

Contraindications allergy to PG Common sideffects Abdominal pain diarrhea

pyrexia

15-methyl prostaglandin F2α (fridge)(CarboprostHemabate) 250 micrograms IM

Repeat as needed every 15 minutes

max dose of 2mg (8 doses)

Common sideffects- Nausea vomiting diarrhea hyperthermiaflushing wheezing coughingnervousness

Asthma is a relative contraindication

Ergonovine maleate- 02-025 mg IM or IV(slowly) repeat q2-4h IM or IV(slowly) as needed - max 5 doses

Contraindications

Hypertensive disorders of pregnancy -even if their BP normal currently

Certain HIV drugs

Adverse effects Nausea dizziness hypertension

Ongoing bleeding inspite of meds

Tamponade- Bakri balloon

Tranexamic acid ( risk of thrombosis)

Invasive interventions-

Embolization

Laparotomy

Emergency hysterectomy

Bleeding resolves with Oxytocin IV and massage and Misoprostol

Followup care-

-Debrief with team and mother and supports

-FU Hgbs and iron

-Document

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

15-methyl prostaglandin F2α (fridge)(CarboprostHemabate) 250 micrograms IM

Repeat as needed every 15 minutes

max dose of 2mg (8 doses)

Common sideffects- Nausea vomiting diarrhea hyperthermiaflushing wheezing coughingnervousness

Asthma is a relative contraindication

Ergonovine maleate- 02-025 mg IM or IV(slowly) repeat q2-4h IM or IV(slowly) as needed - max 5 doses

Contraindications

Hypertensive disorders of pregnancy -even if their BP normal currently

Certain HIV drugs

Adverse effects Nausea dizziness hypertension

Ongoing bleeding inspite of meds

Tamponade- Bakri balloon

Tranexamic acid ( risk of thrombosis)

Invasive interventions-

Embolization

Laparotomy

Emergency hysterectomy

Bleeding resolves with Oxytocin IV and massage and Misoprostol

Followup care-

-Debrief with team and mother and supports

-FU Hgbs and iron

-Document

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

Ergonovine maleate- 02-025 mg IM or IV(slowly) repeat q2-4h IM or IV(slowly) as needed - max 5 doses

Contraindications

Hypertensive disorders of pregnancy -even if their BP normal currently

Certain HIV drugs

Adverse effects Nausea dizziness hypertension

Ongoing bleeding inspite of meds

Tamponade- Bakri balloon

Tranexamic acid ( risk of thrombosis)

Invasive interventions-

Embolization

Laparotomy

Emergency hysterectomy

Bleeding resolves with Oxytocin IV and massage and Misoprostol

Followup care-

-Debrief with team and mother and supports

-FU Hgbs and iron

-Document

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

Ongoing bleeding inspite of meds

Tamponade- Bakri balloon

Tranexamic acid ( risk of thrombosis)

Invasive interventions-

Embolization

Laparotomy

Emergency hysterectomy

Bleeding resolves with Oxytocin IV and massage and Misoprostol

Followup care-

-Debrief with team and mother and supports

-FU Hgbs and iron

-Document

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

Bleeding resolves with Oxytocin IV and massage and Misoprostol

Followup care-

-Debrief with team and mother and supports

-FU Hgbs and iron

-Document

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

Holland Anne Rubeo Zachary Flood Karen DAlton Mary 2013

Shoulder dystocia maneuvers and neonatal outcomesAmerican Journal of Obstetrics and Gynecology 2013

Vol208(1) ppS136-S136

Leung TY Stuart O Suen SS Sahota DS Lau TK Lao TT Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres a retrospective review BJOG 2011118(8)985-90

httpwwwpitterpattercommyshoulder-dystociaslide 14 picture

More OB Chapters on Shoulder Dystocia and Postpartum

Hemorrhage

World Health Organization Reproductive Health Library

httpappswhointrhlvideosenindexhtml

Medical Aid Filmshttpmedicalaidfilmsorgour-

filmsemergency-obstetric-newborn-care-skilledv=72407733

httpemedicinemedscapecomarticle275038-overviewaw2aab6b2b5

Shoulder Dystocia

Copyright copy 2004 - 2015 Dr Henry Lerner

httpshoulderdystociainfocomindexhtm

httpemedicinemedscapecomarticle275038-overviewaw2aab6b2b5

Shoulder Dystocia

Copyright copy 2004 - 2015 Dr Henry Lerner

httpshoulderdystociainfocomindexhtm

Active management of the third stage of labour prevention and treatment of postpartum hemorrhage ndashSOGC guideline

235 - Published October 2009

Principal Authors

Vyta Senikas Dean Leduc Andreacute Lalonde