Week 2- Delivery and complications

Question 1

Childbirth: Uncomplicated

Answer 1

1. Position pt supine on a firm surface with head and shoulder’s slightly raised, legs flexed and abducted at hips and knees
2. Place plastic sheet/ bag/ towel/ drape under pt
3. Observe for water break ( if not already ruptured) and note colour of fluid
4. With non-dominat hand guard the perineum w 4x4
5. Deliver the head in a control manner
6. Apply gentle pressure to vertex (neonate’s head) to control delivery of the head
7. Allow for restitution of head to occur naturally
8. Observe for nuchal cord (if cord present and loose, slip over baby’s head/ if nuchal cord tight & can’t be slipped, clamp and cut cord)
9. Encourage pt to push on next contraction
10. Provide gentle lateral flexion, followed by gentle upward flexion to deliver shoulders and body (Note time of delivery)
11. Place baby directly on Mom’s abdomen, prone with head to side allowing airway to drain
12. Dry, stimulate newborn, and assess tone, breathing, crying
13. Cover newborn with a new blanket/ towel to maintain warmth
14. Allow cord to pulse before clamp & cut (2 mins) unless nenonatal resus or multiples
15. Clamp 15cm from infant’s abdo and approx 5cm apart. Cut the cord
16. Assess for placental detachment

Question 2

How to deliver the placenta?

Answer 2

1. Guard the uterus: place a hand on lower abdo
2. With other hand apply gentle controlled cord traction (work w pt contraction) using up and downward motion, until completely delivered
3. When membrane trail is seen; ask pt to cough or laugh and gently tease out in up & down motion
4. Observe wholeness of placenta. Preform external uterine massage
5. Place placenta into provided plastic bag and transport. Label with pt’s name and document time of delivery

Question 3

What are some complications of childbirth?

Answer 3

• Nuchal cord
• Prolapsed cord
• Malpresentation
• Breech delivery
• Shoulder dystocia
• PPH

Question 4

Childbirth complication: prolapsed cord

Answer 4

1. Gain consent to inspect pernieum for prolapsed cord
2. Explain procedure and expected outcome
3. Consider extrication
4. Assist into knee-chest position or exaggerated sims
5. Encourage pt to breathe through contractions
6. Keep pt informed
7. Gently cradle the cord in hand and replace into vagina, insert fingers to lift fetal part of the cord

Question 5

Childbrith complications: Breech Delivery

Answer 5

1. Assess for signs of imminent breech birth
2. Position pt to allow gravity to birth the baby (upright or supported squat position OR bring buttocks to edge of bed, place feet on chair)
3. Hands off breech
4. Consider manual delivery of legs (apply pressure to popliteal fossa once visible, sweep foot down & out)
5. Hands off breech
6. Note time of delivered umbilicus (you have 4 mins to deliver head)
7. Consider manual delivery of arms (if hand or elbow visible on fetal chest)
8. Allow baby to descent with gravity
9. Another medic may apply gentle suprapubic pressure to maintain flexion of head
10. Initiate MSV when hairline/nape or head does not deliver within 3 mins after the umbilicus is visible

Question 6

During breech, what to do if head doesn’t deliver within 3 mins?

Answer 6

1. Maintain MSV and transport

Question 7

How to do the MSV manoeuvre?

Answer 7

1. Discourage pt from pushing during the manoeuvre
2. Support baby with forearm, palm supporting chest. Place fingers on cheekbones
3. Place other hand on baby’s back
4. Ensure controlled delivery of baby’s head

Question 8

What to do if limb presentation?

Answer 8

• Cover limb with dry sheet to maintain warmth and discourage from pushing

Question 9

Childbirth complication: Shoulder Dystocia

Answer 9

1. Assess signs of imminent shoulder dystocia birth
2. Inform pt, support person(s) and partner of the emergency situation
3. Explain procedure and expected outcome, obtain consent
4. Position pt supine on the edge of a firm surface
5. Note time of baby’s head delivered (you have 8 mins to complete delivery)
6. Preform ALARM Manoeuvers
7. If first ALARM unsuccessful (paramedic partner tries)
8. If second ALARM unsuccessful (transport immediately, preform ALARM en route)

Question 10

What is the first A and what do we do?

Answer 10

Ask for assistance

• ask pt to lay flat, on a firm surface
• Ask for help to assist during ALARM
• Ask partner to help

Question 11

What does L stand for and what do we do?

Answer 11

Legs Abduction (McRobert’s manoeuver)

• Hyperflex hips by lifting legs & knees
• Aim to: bring knees to ear, form a squatting position
• Best preformed by 2 people holding legs

Question 12

What is the second A and what do we do?

Answer 12

Adduct shoulder (suprapubic pressure)

• Apply pressure before the next contraction (preformed by partner)
• Maintain throughout entire contraction
• Instruct pt to push in this position
• Apply gentle downward lateral flexion of the head

Question 13

What does the R stand for and what do we do?

Answer 13

Roll over (Gaskin Manoeuver)

• If steps 1, 2, 3 are unsuccessful: (preform hands and knees)
• Ask pt to roll over onto hands-and-knees position
• Apply upward lateral flexion of the baby’s head to facilitate delivery of the body

Question 14

What does the M stand for and mean?

Answer 14

Manually Release Posterior Arm

If hand visible:
- Follow humorous
- Sweep arm across fetal chest and out
- Deliver the posterior arm

Question 15

After delivery of the baby, what should you encourage Mom to do?

Answer 15

• Encourage infant latching/nipple simulation
• Encourage pt to void her bladder

Question 16

External Bi Manual Compression- Placenta In

Answer 16

1. Attempt to deliver placenta; guard uterus use gentle controlled cord traction during contraction with pt pushing
2. If delivery is unsuccessful & pts is exhibiting signs of PPH; preform bimanual compression

Question 17

How do you do bimanual compression?

Answer 17

1. Place one hand on lower abdo; cup hand supporting the lower portion
2. Place other hand at the top of the uterine fundus
3. Compress the uterus between each hand continuously compressing the uterus (preform as long as possible; may require rotation) until PPH stops

Question 18

What to do if Placenta is out and PPH occurs?

Answer 18

1. Preform uterine massage
2. If EUM is unsuccessful, preform external bi-manual compression

Question 19

How to do external uterine massage?

Answer 19

Conduct eum one placenta has been delivered if the fundus remains soft/”boggy” or PPH

1. Place one hand on the lower portion of the abdo in a cupped position supporting the lower portion of the uterus
2. Place one hand at the top of the uterine fundus
3. Begin massaging with the upper hand using circular motion. The lower hand should remain still, supporting the lower portion of uterus
4. If PPH doesn’t stop switch to bimanual compressions

Question 20

What are some complications/ considerations of uterine massage?

Answer 20

• Should not be conducted until after placenta delivery

Question 21

What are some complications/ considerations of Shoulder Dystocia?

Answer 21

• Baby’s head emerges slowly and chin may have difficulty sliding over perineum
• Turtling sign
• Cyanosis to baby’s head
• Failure of spontaneous restitution
• Preform a Max of 2 ALARMS on scene

Question 22

What should be documented with shoulder dystocia?

Answer 22

• Color of fluid
• Time of birth of head
• Turtle sign, if present
• Time each manoeuvre and attempt to deliver baby
• Time partner attempted ALARM and time of each manoeuvre
• Time of birth of baby
• Time of delivery of placenta
• Amount of bleeding- minimal/ moderate/ large amounts/ clots

Question 23

What are some complications/ considerations with breech delivery?

Answer 23

• Nuchal cord
• Cord prolapse
• Hypoxic damage and asphyxia
• Damage to internal organs
• Limb presentation
• Death (neonate resus)

Question 24

What are some signs of imminent breech birth?

Answer 24

• Fresh dark meconium at perineum
• Breech, foot/ leg visibly protruding from vagina

Question 25

What should you document during breech delivery?

Answer 25

- Breech visible on the perineum - Time umbilicus is visible - Manual release of legs and arms - Time hairline is visible - MSV manoeuvre - Time of birth of baby - Time of placenta delivery - Amount of bleeding