PPH: The first thing is to ___________ that it is a PPH - I would check b____ l_____ and if it appears to be over _ _ _ml this would mean it is a recognised I would therefore _____ ____ _______. I would want a senior midwife and senior obstetrician for their experience, an anaesthetist to manage the airway and in case its necessary to go to theatre, a porter either for transfer to theatre or to collect blood and a scribe to write all the procedures undertaken. The first important thing to ensure is that the bed is flat in case CPR needs to be administered and to administer any high flow oxygen depending on the level of shock as loss of blood volume can lead to rapid hypoxia. The legs may be raised to help blood flow to the heart. Keep the woman warm as hypothermia can lead to clotting impairment. For the purpose of the demonstration once help arrives all the procedures I'll describe will be happening simultaneously. I would ask the senior midwife and obstetrician to cannulate each arm with 2 wide bore cannulas and I would ask the anaesthetist to manage the airway and perform observations every 5 minutes to determine maternal condition. I would first want to consider the condition of the uterus - this would be to check whether it's well contracted as Tone problems account for 70% of PPHs. If the uterus feels boggy and high I would manually rub up a contraction to help the uterus contract. I would also expel any clots from the vagina as clots can interfere with uterine tissue to appose and stop bleeding. If rubbing up a contraction fails to stop bleeding I could also consider bi-manual compression by placing one hand on the fundus and placing another into the vagina - by manually clamping the 2 this may help the living ligatures to come together to stop bleeding. It's important to note that if the cause wasn't a tone problem it may be a tissue problem. Retained tissue, similar to clots can prevent the wound site from apposing to stop bleeding - I would therefore want someone to check the placenta to see if it is complete. It may also be a trauma problem - if the woman has a tear it might bleed, this may be a tear that isn't immediately visible such as a cervical tear so it's important to inspect the genital tract. It may also be a thrombin problem where impaired clotting means the body is unable to clot to stop the bleeding - this may be seen in pools of blood on the floor that hasn't clotted. It may also be pertinent to empty the bladder as a full bladder can impair the effectiveness of contractions. It's also important to attach a urometer to be able to check urine output as impaired renal function may be a complication of PPH. Measure output hourly. While I am managing the uterus, I would want my senior midwife to be cannulating one arm and taking urgent bloods - I would want them to take FBC - to check Hb levels; Group and Crossmatch 4 units so that blood can be readily available if a transfusion is necessary, a clotting screen and fibrinogen to check maternal clotting function. I would also want the midwife to put up up to 2L of IV crystalloid fluids such as Hartmann's or 0.9% Sodium chloride to replace lost circulating volume whilst waiting for blood. If bleeding is life-threatening, emergency o-ve blood given through a fluid warmer may be given. Other blood products may be considered such as fresh frozen plasma to replace lost plasma volume and platelets and fibrinogen for clotting. In the other arm I would want the obstetrician to also cannulate and give drugs to help stop bleeding. Ergometrine 500mcg IM/IV (not if raised BP), Syntocinon 10IU IM/IV = both are oxytocics that help the uterus contract; Tranexamic acid 1g slow IV (1ml/min) - aids rapid clotting; Syntocinon infusion 40IU over 4hrs @ 10IU/hr - to give continued maintenance of oxytocics after management completes, Carboprost 250mcg DEEP IM every 15 minutes (Max x 8 - Consider moving to theatre after second dose)(note carboprost may have some unpleasant side effects such as vomiting, diarrhoea, headache, pyrexia and is contraindicated in woman with cardiac/pulmonary conditions including severe asthma), Misoprostol 600-1000mcg PR = both are artificial prostaglandins to help the uterus stay contracted. The anaesthetist would continue to manage the airway and perform observations every 5 minutes to help determine maternal condition and level of shock. In theatre if bleeding continues despite these measures the obstetricians may consider further measures such as a Uterine balloon tamponade, laparotomy, B-lynch suture, interventional radiology, uterine vessel and internal iliac artery ligation or hysterectomy if all else fails. Weigh all swabs and use a Meows chart. Document including procedures carried out and any drugs given, the clinicians in attendance and total estimated blood loss, Datix, Debrief and thank your team. Shoulder dystocia: First of all it's important to recognise that it's a shoulder dystocia. This may be evidenced by difficulty with birth of face and chin, a head that remains tightly applied to the vulva, the 'turtle-neck' sign where the chin retracts and depresses the perineum or the inability to deliver the anterior shoulder with routine axial traction. Once you recognise it's a shoulder dystocia it's important to call for help. I would want a senior midwife and senior obstetrician for their experience, possibly an anaesthetist in case it's necessary to go to theatre, neonatalogists as neonates are more likely to require resuscitation after a shoulder dystocia and a scribe to write all the procedures undertaken. As they arrive I would tell them clearly that we have a shoulder dystocia and the time of the delivery of the head. Swift action is important as RCOG report very low rates of hypoxic ischaemic injury if the head-to-body delivery time was less than five minutes. You would then ask the woman to STOP PUSHING!! - pushing is discouraged as it may increase impaction. You would then begin manoeuvres to help resolve the impaction. The first manoeuvre is the McRoberts manoeuvre. It's good to start with this manoeuvre as there are reported success rates of as high as 90% and also it's the least invasive. We lie the woman flat and hyperflex her legs towards her abdomen. McRoberts increases the anteroposterior diameter of the pelvic inlet, giving more space for the shoulder to be released. Routine axial traction is then employed to try to deliver the baby - this is traction in line with the spine and is preferred to downward traction as it can reduce risks of brachial plexus injury. (Note: You may consider all-fours if alone as a practitioner as it has the same effect without needing assistance.) If this fails to work we can then we can apply suprapubic pressure - this aims to resolve shoulder dystocia by reducing the diameter of the shoulders and by rotating the anterior shoulder into the wider oblique diameter of the pelvis. Suprapubic pressure is done by applying either continuous or a rocking pressure downwards and laterally. There is no evidence that either is better or that doing it for 30 seconds is effective. While applying suprapubic pressure an assistant can help deliver the baby by routine axial traction. If this fails we would next consider the need for an episiotomy as the next steps will involve the need for internal access - an episiotomy may provide more space for the clinician to perform the manoeuvres but will not resolve the dystocia itself as shoulder dystocia is a bony obstruction. We will then start internal manoeuvres. The first is attempting to deliver the posterior shoulder. This is to reduce the diameter to come through the vagina by the width of an arm. We use a pringle hand to gain access to the sacral hollow - this is where there is the most space to perform the manoeuvres. Once we gain access, if you can reach the wrist you can sweep it across the face and pull it out, if not you can put pressure on the antecubital fossa which stimulates the reflexes to raise the arm to access the wrist. Try routine axial traction. If we are unable to deliver the posterior arm we can use internal rotational manoeuvres. This is done by using the fingers to put pressure on either the anterior or posterior aspect of the posterior shoulder. By doing this we can rotate the shoulder into a wider pelvic diameter (the oblique or transverse) to ease delivery. Try routine axial traction. If all these manoeuvres fail to deliver the baby you can repeat the manoeuvres or there are several last resort manoeuvres that are possible. A cleidotomy - the surgical division of the clavicles. A symphysiotomy - the surgical division of the symphysis pubis ligament. The Zavanelli manoeuvre is where the head is replaced into the uterus and a caesarean section is subsequently performed. Use of a posterior axillary sling has also been reported. Once baby is born suggest an active third stage as shoulder dystocia is a risk factor for PPH due to prolonged 2nd stage. Delayed cord clamping if baby born in good condition - if not immediately clamp and cut the cord and hand to neonatologists. Send cord gases. Document - e.g. time of birth of head, manoeuvres performed, staff in attendance, condition of baby, Datix, Debrief and thank your team. Breech: The first thing that's important is to recognise the breech, the sacrum or foot may be visible or may be felt on vaginal examination, it's also important to know for sure that the woman is fully dilated and full term as if not head entrapment may occur. Once we've recognised the breech it's important to call for help. I would want a senior midwife and senior obstetrician for their experience, possibly an anaesthetist in case it's necessary to go to theatre, neonatalogists as neonates are more likely to require resuscitation after a breech delivery due to increased cord compression and a scribe to write all the procedures undertaken. Once the breech is visible, active pushing can be encouraged. It its important that once the buttocks have passed the perineum that we start the clock as a delay of more than five minutes from buttocks to head is associated with poor fetal condition. Allow for spontaneous birth of the limbs and trunk. It is important that we keep hands off the breech as much as possible as traction can cause nuchal arm and may stimulate baby to breathe in-utero. Handling of the cord can cause vasospasm and hence reduced blood flow to fetus. It's important that back remains uppermost so that the fetal head that flex correctly - handling should be careful, you can hold the baby on the bony prominences of the pelvis to reduce the risk of tissue damage. If you need to assist in the delivery of the legs you can place pressure on the popliteal fossa to release the legs. Once we see the scapulae, the arms will be born next. If they are not born spontaneously we can use the lovesett manoeuvre, by holding the baby over the bony prominences and rotating the baby to release each arm. If we need to, we can put some pressure on the antecubital fossa to help release the arms. We then continue to allow the baby to advance until we see the nape of the neck. The head may be born spontaneously but if assistance is necessary we can use the Mauriceau-Smellie-Veit manoeuvre to deliver the head. We support the body on the arm, place two fingers on the cheek bones and support the back of the head with the middle finger of the other arms and two fingers on the shoulders. This is to promote flexion of the head and reduce the diameter of the head so that it can be born. Supra-pubic pressure can also be done by an assistant to further promote flexion. If these manoeuvres fail to deliver the baby, the obstetrician may choose to assist delivery with forceps. Once baby is born delayed cord clamping if baby born in good condition - if not immediately clamp and cut the cord and hand to neonatologists. Send cord gases. Document - e.g. time of birth of head, manoeuvres performed, staff in attendance, condition of baby, Datix, Debrief and thank your team. Neonatal Resuscitation: Meconium present : the resuscitation council advises that if visible meconium is present in the oropharynx it is reasonable to immediately clamp and cut the cord, take the baby to the resuscitaire and suction any particulate seen before stimulating the baby and carrying out the rest of the algorithm. But notes that it is important to do this quickly as inflation and ventilation of the airways should be commenced within a minute. If baby is born in a poor condition it is important to start the clock - so that we know how long resuscitation has taken and call for help - we want a senior midwife for her experience and to assist with caring for mum while I'm assisting with neonatal resuscitation. We also want the neonatologists to assist with resuscitation. It is important first (or then after mec) to dry the baby, remove the wet towel and wrap in a dry towel. We are aiming to maintain a body temperature of 36.5 - 37.5. Newborns are born with a large body surface to mass ratio and thus prone to quick heat loss and hypothermia. It is important to prevent hypothermia as there is a strong link with mortality and morbidity. Drying the baby may also stimulate baby to breathe, thus avoiding any additional measures. While drying we assess colour, tone and breathing - these can indicate the level of hypoxia. We can then listen to the heart rate once the baby is wrapped. If baby is gasping or not breathing or heart rate is low our next consideration is the airway. We want to open the airway by putting the baby's head in the neutral position with the head parallel with the surface and then give 5 inflation breaths. Inflation breaths will force any fluid in the lungs out and replace it with air We could also consider pulse oximetry at this point as well to help us assess the level of hypoxia. We then re-assess colour, tone, breathing and heart rate. If the heart rate remains below 60secs we then would go on to ventilation breaths. (Note: If there is no chest rise, we can re-check head position, consider a 2-person airway - one person jaw thrust, one person inflating or insert a guedel airway - with laryngoscope inserted from the left so that we can visualise with torch, to keep airway open and then repeat 5 inflation breathes and re-assess.) We do ventilation breaths for 30 seconds which equals 15 breaths and then re-assess colour, tone, breathing and heart rate. If still below 60 we would then move on to compressions - compressions will help to circulate oxygen from the lungs to heart and then around the body and deliver oxygen to the tissues. We do 30 seconds of chest compressions at a rate of 3 compressions to 1 ventilation breath which is 45 compressions to 15 breaths. Effective compressions are achieved just below the line between the nipples and by depressing into the chest cavity by a third of its depth. We re-assess colour, tone, breathing and heart rate after 30 seconds. If the heart rate has increased above 60 but still below 100 we can continue with ventilation breaths until the heart rate is above 100 to mimic breathing until the heart rate improves and the baby can maintain sufficient breathing and heart rate on its own. If the heart rate remains low despite ventilation and compression, drugs may be administered through an umbilical venous catheter but this would be a decision for the neonatologists. These are kept in the neonatal resuscitation box or trolley and may include adrenaline 1:10000, sodium bicarbonate 4.2% or glucose 10%. Emergency o-ve blood may be occasionally needed if the infant is severely anaemic at birth (especially after abruption and vasa previa). Once the heart rate is above 100 and the colour, tone, breathing have improved, we can hand the baby back to mum and encourage skin to skin and breastfeeding as these will help to minimise the risk of hypothermia. Document - e.g. condition of baby at birth, resuscitation manoeuvres performed, time taken to resuscitate, staff in attendance, Datix, Debrief and thank your team. Cord Prolapse: The first thing that's important is to recognise the cord prolapse. It might be seen, felt or heard. It may be seen protruding through the vulva or through a speculum, felt on vaginal examination or heard on the CTG monitor as repetitive variable decelerations or bradycardia. Once we've recognised the cord prolapse it's important to call for help. I would want a senior midwife and senior obstetrician for their experience, possibly an anaesthetist in case it's necessary to go to theatre, neonatalogists as neonates are more likely to require resuscitation after a cord prolapse delivery due to risk of vasospasm and hypoxia and a scribe to write all the procedures undertaken. Once help arrives it's important to state the problem clearly to the arriving team 'cord prolapse' (dilation cm, stage of labour, primip/multip, gestation etc.). The next important consideration is to relieve pressure on the cord. Firstly, this can be done by changing maternal position - either in the knee to chest position or exaggerated sims - where a pillow can be placed under the left hip in left lateral. These positions use to gravity to relieve the pressure of the head off of the cord. Exaggerated sims may be useful for ambulance transfer. Using your fingers to manually push the head off of the cord also can help to relieve the pressure and increase blood flow. You can use a dry pad to manually place the cord and minimise vasoconstriction from the cold air before doing this. In addition it's important to turn off any oxytocin infusions and consider giving terbutaline 0.25mg sc to reduce contractions - contractions increase the pressure on the cord and may also further bring the head down onto the cord. Also, bladder filling can also help to relieve pressure as a full bladder can displace the uterus - the bladder should be catheterised and a bag of 500ml normal saline attached to the catheter. Bladder filling can be especially useful when there is a delay for transfer. It can be clamped once full, it's important to remember to empty the bag before delivery to avoid any bladder damage. While relieving pressure it is also important to make sure the fetus is continuous monitored on a CTG. The next consideration is the plan for birth. If fully dilated with a normal CTG instrumental vaginal delivery may be chosen. If not fully dilated - caesarean section. With a suspicious or pathological CTG - cat 1 section - delivery within 30mins but if the CTG is normal a category 2 section - within 75 minutes may be appropriate. Document - manoeuvres performed to relieve pressure, staff in attendance, condition of baby, Datix, Debrief and thank your team.