OFP treatment questions

• Breech - one foot, hand or arm presenting

  Do not attempt to deliver

  Tx urgently to an appropriate maternity service unit with notification

  Consult with PIPER for advice
• Breech - imminent birth, buttocks or both feet presenting

  Request urgent assistance

  Prepare obstetrics equipment

  Provide a warm and clean environment

  Provide analgesia

  Allow the birth to occur spontaneously

  Position mother with buttocks to bed edge and legs supported to allow gravity to assist

  Do not touch baby as it emerges

  Hands off the breech

  The birth of buttocks/feet will occur slowly
• Breech - buttocks first presentation

  DO NOT attempt to pull baby out

  Encourage mother to push hard

  Feet and legs should spring free

  Await further descent

  Keep body warm by wrapping in a towel and bubble wrap if needed

  Let baby hang until the nape of the neck is visible

  Assist birth of the head using modified mauriceau smellie veit manoeuvre
• breech - modified mauriceau smellie veit manoeuvre

  Place index finger and ringer finger of non dominant hand on the babys shoulders and middle finger on the occiput to assist with flexion of the head

  Place dominant hand under the baby to support the body, with ring and index fingers on the babys cheekbones

  Slowly lift the baby straight up in a circle onto the mothers abdomen, allowing the head to birth slowly

  An assistant can aid flexion of head by applying direct pressure behind pubic bone
• breech - back not uppermost

  The babys neck needs to remain uppermost

  If legs delivered and back is not uppermost

  • Hold baby by placing thumbs on bony sacrum with fingers around thighs
  • Do not squeeze the abdomen
  • Rotate/turn baby between contractions taking care of babys spine
  • Take great care to never pull the baby
• breech - legs dont birth spontaneously

  If extended legs

  • Slip one hand along the leg of the baby lying anteriorly
  • Place a finger behind the baby's knee and deliver it by flexion and abduction
• Breech - arms dont birth spontaneously - lovetts manoeuvre

  Hold baby by sacrum

  Turn baby 90 degrees so that one shoulder is in the antero-posterior diameter

  Insert a finger into the brachial plexus and sweep the arm down over the babys chest

  Turn the baby 180 degrees so that the opposite shoulder is in the antero-posterior diameter

  Repeat the finger manoeuvre

  Await further descent

  Do not pull or apply traction
• Cephalic birth - preparation

  Prepare equipment for normal birth

  Provide a warm and clean environment

  Provide analgesia
• Cephalic birth - birth of head

  As head advances, encourage the mother to push with each contraction

  If head is birthing too fast, ask mother to pant with an open mouth during contractions instead

  Place fingers on babys head to feel strength of descent of head

  Apply gentle pressure to the perineum to reduce risk of perineal tears

  If precipitous, apply gentle backward and downward pressure to control sudden expulsion of the head - do not hold back forcibly

  Note the time once head is delivered
• Cephalic birth - umbilical cord check

  Following the birth of the head, check for umbilical cord around neck

  If loose and wrapped around neck;

  • Slip over baby's head with appropriate traction

  If tight;

  • Mother should be encouraged to push
  • Where the baby does not descend and cord still cannot be loosened, clamp and cut cord
• Cephalic birth - head rotation

  With the next contraction the head will turn to face one of the mothers thighs (restitution)

  • This indicates internal rotation of shoulders in preparation for birth of body
• Cephalic birth - birth of shoulders and body

  May be passive or guided birth

  Hold baby's head between hands and if required apply gentle downwards pressure to deliver the anterior shoulder

  Once the baby's anterior shoulder is visible, if necessary to assist birth, apply gentle upward pressure to birth posterior shoulder

  Support the baby

  Note the time of birth

  Place baby skin to skin with mother on her chest to maintain warmth unless baby is not vigorous / requires resuscitation

  Following delivery of baby, gentle palpate abdomen to ensure second baby is not present
• Cephalic birth - clamping and cutting the cord

  There is no urgency, wait for cord to stop pulsating. Allow partner to cut if they wish. Should ideally be done prior to extraction

  To cut cord, apply clamp 10cm from baby and second clamp a further 5cm from the first, then cut between the two clamps

  For uncomplicated births, attached while transporting is permissable
• Cephalic birth - birthing placenta

  1. Passive management

  2. Allow placental separation to occur spontaneously without intervention

  3. This may take from 15mins up to 1hr

  4. Position mother sitting or squatting to allow gravity to assist expulsion

  5. Breast feeding may assist separation or expulsion

  6. Do not pull on cord - wait for signs of separation

  7. Placenta and membranes are birthed by maternal effort

  8. Use two hands to support and remove placenta using a twisting motions

  9. Note time of delivery of placenta

  10. Place placenta and blood clots into a container and transfer

  11. Inspect placenta and membranes for completeness

  12. Inspect fundus is firm, contracted and central

  13. Continue to monitor fundus do not massage once firm
• Post Partum Haemorrhage - firm fundus

  High flow oxygen

  Analgesia

  BP <90mmHg:

  • Consider saline IV (max. 40mL/kg) titrated to response
  • Consult for further fluid, 20mL/kg

  Mx any visible laceration with a dressing and firm pressure
• Post Partum Haemorrhage - fundas not firmed initial

  Manage as per firm fundus

  Avoid fundal massage prior to placental delivery

  Massage fundus until firm and blood loss reduces

  Encourage mother to empty bladder

  Encourage baby to suckle breast
• Post Partum Haemorrhage - fundus not firm next

  Oxytocin 10 IU IM

  Repeat dose after 5 mins if bleeding continues

  Tranexamic acid 1g IV over 10 mins (in 100mL NS or dextrose or slow push)
• Post partum haemorrhage - intractable haemorrhage

  Perform external abdominal aortic compression

  • Point of compression is just above umbilicus and slightly to left
  • Apply downward pressure with closed fist directly through the abdominal wall
• Cord Prolapse - birth not imminent, mother management

  Position patient semi-prone with hips elevated over folded towels

  High flow 02
• Cord Prolapse - birth not imminent, cord management

  Minimise cord handling

  Keep cord warm and moist. Use 2 fingers to gently place cord in vagina

  If unsuccessful cover with warm saline packs
• Cord prolapse - birth not imminent, presenting part management

  If there is pressure on the cord by presenting part itself fingers into vagina and push the presenting part (head) away from the cord

  Maintain pressure until birth commences or advised to release
• Cord prolapse - birth commencing

  Instruct mother to push

  Assist in delivery

  Prepare for newborn resuscitation
• Newborn resuscitation - apnoeic or gasping or no muscle tone


  Stimulate by drying

  Maintain warmth

  Place supine with head/neck in neutral position

  Suction only if airway obstruction is suspected
• Newborn resuscitation - HR < 100 and/or apnoeic or gasping


  IPPV @ 40-60 per minute on room air

  Pulse oximetry (right)

  ECG monitoring if not already attached

  Reassess after 30s
• Newborn resuscitation - HR <60


  CPR @ 3:1 ratio with oxygen (5L/min)

  Consult PIPER
• Newborn resuscitation - HR 60-100

  IPPV @ 40-60 per min

  If no increase in HR - IPPV oxygen 5L/min
• Newborn resuscitation - HR > 100, SpO2 <90%


  Breathing laboured;

  • IPPV at 40-60 per min
  • Titrate O2 (1-5L/min) to meet target

  Breathing normally;

  • Titrate oxygen 1-2L/min via nasal cannula
  • Discontinue O2 where SpO2 > 90%
• Pre-term Labour

  Birth not imminent <34 weeks

  • 50mg GTN patch to abdomen
  • Another patch after 1hr if contractions persist (max. 20mg/24hrs)

  Birth imminent;

  • Consider other causes
  • Mx symptomatically

  Birth not imminent >34 weeks

  • Basic care
  • Reassure