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Emergency Obstetrical Skills

With complements to and permission of the American Academy of Family Physicians and the developers of

Advanced Life Support in Obstetrics- ALSO -

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Normal Delivery

What is the birth attendant’s responsibility in a normal,

uncomplicated vaginal delivery?

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Normal Delivery• Assure a clean, warm, well-lit setting• Monitor progress of labor and potential complications• Provide sterile, safe cutting of the cord• Prepare for newborn care• And don’t let the baby fall on the floor!

Two Powerful Interventions To Improve Reproductive Health

Major modes of decreasing maternal morbidity and mortality continue to be:

• Reduce family size

• Provide quality obstetric care at time of delivery

Provide Quality Obstetric CareBeyond contraception/family planning, the best opportunity to improve maternal outcomes lies in quality obstetrical care.

What are the most essential elements of quality obstetrical care?

Provide Quality Obstetric CareWHO recommends essential obstetrical care include:

• Monitored labor• Labor-induction & augmentation capability• Recognition of common complications• Treatment for shock, hemorrhage, sepsis, anemia, and HTN• Manual procedures for breech, shoulder dystocia, twins, & vacuum extraction• Anesthesia and surgical delivery capability• Resuscitation for neonates

Intervention To Improve Maternal Outcomes

Research shows that even

providing some of these elements

can result in major improvements in birth outcomes.

Question

What are the leading causes of maternal death?

What Are The Potential Causes Of Post-Partum Hemorrhage?

Potential Causes Of Post-Partum Hemorrhage

• Tone: Uterine atony (70%)• Trauma: Laceration of cervix, vagina, perineum; uterine inversion (20%)• Tissue: Retained placenta (10%)• Thrombin: Coagulopathy (uncommon)

What Are The Steps To Evaluate Post-Partum Hemorrhage?

Steps To EvaluatePost-Partum Hemorrhage

• Palpation of uterus: boggy or firm?

• Inspection of the vagina, cervix and perineum for lacerations, and for uterine inversion

• Sweep of the uterine cavity for retained tissue

• Evaluation for blood clotting

What Is The Single Most Essential Emergency

Treatment For Uterine Atony?

Question

What medications are useful to treat uterine atony?

Medications for Uterine Atony

• Oxytocin 10 U IV or IM (routine)

• Cytotec (misoprostal) 800 mcg rectally

• Methergine (methylergonovine) 0.2 mg IM (caution in HTN, seizures)

Question

In order, the steps to control post partum hemorrhage are:

A. Repair laceration, check for uterine inversion, check and give medication for uterine tone, explore the uterus for retained placentaB. Check and give medicine for uterine tone, check for uterine inversion, repair laceration, explore the uterus for retained placentaC. Check for uterine tone and treat, inspect for laceration and uterine inversion, explore for retained placenta, repair lacerationD. Explore the uterus for retained placenta and inversion, repair laceration, check for and treat atony.

Answer

In order, the steps to control post partum hemorrhage are:

A. Repair laceration, check for uterine inversion, check and give medication for uterine tone, explore the uterus for retained placentaB. Check and give medicine for uterine tone, check for uterine inversion, repair laceration, explore the uterus for retained placentaC. Check for uterine tone and treat, inspect for laceration and uterine inversion, explore for retained placenta, repair lacerationD. Explore the uterus for retained placenta and inversion, repair laceration, check for and treat atony.

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What Are the Risk Factors for Shoulder

Dystocia?

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What Are The Potential Complications Of

Shoulder Dystocia?

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What Are The Signs That Shoulder Dystocia Has

Occurred?

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What Is The Management Of

Shoulder Dystocia?

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What Are The Maneuvers Of Last

Resort?

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Malpresentations

Occiput Posterior Presentation

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What Is the Management of Occiput Posterior

Presentation?

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Manual Rotation of OP• Flex fetal head

• Attempt rotation during contraction, with maternal pushing

• Gently rotate shortest distance (clockwise or counterclockwise) to achieve occiput anterior position

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Malpresentations

Breech Presentation

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26A

26B

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What Is the Management of Breech Presentation?

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BONUS

• This obese 92-yr-old woman has chronic abdominal fullness (40+ years!) after an MVA

• What is your diagnosis?

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