dr. fran berard md ccfp asa april 2015
TRANSCRIPT
![Page 1: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/1.jpg)
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
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
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
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
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
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
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
![Page 2: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/2.jpg)
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
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
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
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
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
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
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
![Page 3: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/3.jpg)
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
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
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
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
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
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
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
![Page 4: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/4.jpg)
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
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
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
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
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
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
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
![Page 5: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/5.jpg)
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
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
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
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
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
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
![Page 6: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/6.jpg)
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
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
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
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
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
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
![Page 7: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/7.jpg)
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
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
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
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
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
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
![Page 8: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/8.jpg)
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
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
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
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
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
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
![Page 9: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/9.jpg)
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
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
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
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
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
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
![Page 10: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/10.jpg)
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
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
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
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
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
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
![Page 11: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/11.jpg)
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
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
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
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
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
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
![Page 12: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/12.jpg)
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
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
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
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
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
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
![Page 13: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/13.jpg)
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
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
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
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
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
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
![Page 14: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/14.jpg)
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
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
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
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
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
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
![Page 15: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/15.jpg)
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
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
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
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
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
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
![Page 16: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/16.jpg)
- 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
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
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
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
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
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
![Page 17: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/17.jpg)
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
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
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
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
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
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
![Page 18: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/18.jpg)
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
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
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
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
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
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
![Page 19: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/19.jpg)
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
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
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
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
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
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
![Page 20: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/20.jpg)
- 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
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
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
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
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
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
![Page 21: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/21.jpg)
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
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
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
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
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
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
![Page 22: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/22.jpg)
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
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
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
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
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
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
![Page 23: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/23.jpg)
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
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
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
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
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
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
![Page 24: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/24.jpg)
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
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
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
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
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
![Page 25: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/25.jpg)
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
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
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
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
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
![Page 26: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/26.jpg)
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
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
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
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
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
![Page 27: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/27.jpg)
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
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
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
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
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
![Page 28: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/28.jpg)
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
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
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
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
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
![Page 29: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/29.jpg)
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
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
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
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
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
![Page 30: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/30.jpg)
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
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
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
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
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
![Page 31: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/31.jpg)
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
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
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
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
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
![Page 32: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/32.jpg)
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
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
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
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
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
![Page 33: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/33.jpg)
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
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
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
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
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
![Page 34: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/34.jpg)
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
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
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
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
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
![Page 35: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/35.jpg)
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
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
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
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
![Page 36: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/36.jpg)
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
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
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
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
![Page 37: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/37.jpg)
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
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
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
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
![Page 38: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/38.jpg)
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
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
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
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
![Page 39: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/39.jpg)
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
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
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
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
![Page 40: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/40.jpg)
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
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
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
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
![Page 41: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/41.jpg)
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
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
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
![Page 42: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/42.jpg)
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
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
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
![Page 43: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/43.jpg)
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
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
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
![Page 44: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/44.jpg)
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
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
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
![Page 45: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/45.jpg)
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
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
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
![Page 46: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/46.jpg)
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
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
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
![Page 47: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/47.jpg)
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
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
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
![Page 48: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/48.jpg)
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
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
![Page 49: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/49.jpg)
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
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
![Page 50: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/50.jpg)
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
![Page 51: Dr. Fran Berard MD CCFP ASA April 2015](https://reader030.vdocuments.mx/reader030/viewer/2022012916/61c69a38eda11704fe6fa164/html5/thumbnails/51.jpg)
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