Complications

Retained POC

• Definition: Either delayed third stage (>30 mins) or signs of incomplete POC³
• Urgent input is required from an obstetrics team
• IV Uterotonic agents can be considered to deliver a placenta in the presence of life-threatening bleeding
• If uterine exploration (+/- manual removal of POC) is deemed necessary, transfer urgently to an obstetric unit.

Postpartum Haemorrhage

• Definition: Loss of >500mL of blood from the genital tract within 24 hours of birth^3,8
• Minor PPH = 500-1000mL / Major = >1000mL (Of which Moderate = 1000-2000mL and Severe = >2000mL)³
• Causes: Uterine atony (most common cause), retained POC, genital/perineal trauma and coagulopathy [Can be remembered as the “4 Ts” (Tone, Tissue, Trauma and Thrombin)]^1,3,8.

Management:

• Initial measure should include emptying the bladder and uterine massage
• In Major PPH consider boluses of uterotonic agents⁸:
  Oxytocin 10iU intravenous
  OR Ergometrine 0.5mg IM
  OR Syntometrine 5iU/0.5mg IM
  *Repeat boluses may be required is bleeding is not controlled*
• Manage as per local obstetric haemorrhage protocols (ABO-Negative, Rhesus-negative and K-Negative blood should be transfused, or in emergency can utilise O-Rhesus D negative red cells). Discuss with your local transfusion laboratory to minimise transfusion error and delay⁹.
• Platelet +/- FFP transfusions may be required and directed by full blood count results and coagulation screens⁹.
• Controlled cord traction if placenta has not yet been delivered
• Arrange emergency transfer to an obstetric-led unit
• If initial measures are not effective, may require additional bonuses of prostaglandin agents (Misoprostol/Carboprost) 
• Consultation with haematology re adjuvant clotting factor administration (fVIIa)
• Intrauterine tamponade (via Balloon tamponade) is recommended whilst awaiting surgical intervention. If tamponade devices are not available, pack the uterine cavity with gauze/haemostatic gauze⁸.
• Tranexamic acid is not a recommended intervention in PPH due to lack of evidence for its efficacy and the increased risk of thromboembolic disease⁸.  However in the case of life-threatening haemorrhage or Maternal Cardiac Arrest, Tranexamic acid is recommended by the Resuscitation council UK⁴.

Shoulder Dystocia

Definition: Impaction of the anterior foetal shoulder behind the Pubic symphysis (PS) or the posterior shoulder behind the sacral promontory⁵.

Occurs infrequently (0.56-0.70% of vaginal deliveries) but requires quick and definitive action as it is associated with a high degree of maternal and peri-natal mortality (haemorrhage, fourth degree perineal tears, uterine rupture, brachial plexus injury and hypoxia/death of the newborn)¹.

• During delivery, observe for:
  – Difficulty with delivery of the face and chin
  – Failure of anterior shoulder descent with assistance >60 seconds after delivery of the head
  – Retraction of the foetal head into the vulva/perineum (“Turtle sign”)

Once recognised, instruct the mother to stop pushing. There are a number of manoeuvres that can then be attempted:

1. McRobert’s manoeuvre:

• Lie the mother flat with no pillows under the back
• Place one assistant on either side of the mother and move both maternal hips into complete flexion and slight abduction (i.e. knees-chest)
• The assistants should then hold the knees in place against the chest
• McRobert’s is associated with a high degree of success when performed correctly (as high as 90%)
• If shoulder delivery is not improved, applying suprapubic pressure (see next point) can be useful in assisting delivery.

2. Mazzanti manoeuvre:

• Ask an assistant to apply rolling pressure to the suprapubic region (can use a similar hand position to that adopted during CPR) in a downward and lateral direction in an attempt to disengage the impacted shoulder under the PS (DO NOT apply fundal pressure here as this will worsen the dystocia).

3. Wood-screw/Reverse Wood-screw manoeuvre:

• In this manoeuvre we are attempting to rotate the foetus within the birth canal to an oblique position to assist delivery of the anterior shoulder
• Insert two gloved fingers into the vagina aiming for the posterior surface of the anterior shoulder
• Insert your other hand with two fingers placed on the anterior surface of the posterior shoulder
• Apply pressure to the posterior shoulder and attempt to rotate the foetus anti-clockwise within the birth canal
• REVERSE Wood-screw can be attempted by applying pressure to the posterior surface of the posterior shoulder to rotate the infant clockwise.

4. Delivery of the posterior arm:

• Pass one hand into the vagina along the posterior arm to the elbow
• Flex the arm until the forearm can be gripped and swept across the foetal chest to deliver the posterior arm and shoulder
• If this does not aid delivery, it may be necessary to rotate the trunk to bring the freed arm into the anterior position, however this carries a high risk of orthopaedic injuries (clavicular/numeral fractures).

5. The “All Fours”/Gaskin manoeuvre:

• Position mother on her hands and knees. Apply gentle downward traction in an axial manner to the baby’s head.

Episiotomy is not always necessary (as this will not relieve the bony obstruction), however may be required if more space is needed within the vagina to perform digital manoeuvres⁵.

If the above procedures fail then specialised obstetric techniques may be required such as the Zavanelli manoeuvre (Vaginal replacement of the head to allow for Caesarean section), Cleidotomy (Surgical division of the clavicle or bending with a finger) or Symphysiotomy (dividing the anterior fibres of the symphysial ligament)⁵.

Breech presentation

Occurs in 3-4% of pregnancies and is associate with a 3-4 times higher morbidity rate than cephalic presentation (due to foetal distress, cord prolapse and head entrapment)^1,7.

To view a simulation of Breech delivery, follow this link.

Management:^1,7

Minimise touching the foetus and provide support below the level of the perineum to allow spontaneous delivery. Providing immediate traction to the foetus may extend the foetal head and lead to entrapment which increases the risk of asphyxiation. Direct assistance is required only in the event of an incomplete breech delivery¹.

• Delivery of the legs: If the legs are flexed (i.e. in a pike position), place a hand behind the foetal thigh and press gently in a lateral direction to allow delivery of each leg in turn. Continue to support the foetal pelvis (a towel may be useful to avoid slippage). Place your fingers over the anterior superior iliac crest with thumbs resting over the sacrum (this will prevent injury to the foetal abdominal soft tissue).
• Delivery of the arms: Rotate the foetus 90 degrees in either direction to create an anterior shoulder. Spontaneous delivery of the arms and shoulders may occur or may require sweeping of the arm across the chest with your fingers to facilitate delivery.
• Then rotate the foetus 180 degrees in the other direction to deliver the second arm.
• Delivery of the head: Rotate the infant so the sacrum is anterior again. Ask an assistant to apply suprapubic pressure to flex the head (NOT fundal pressure as this will worsen head entrapment).
• If the head does not deliver spontaneously, place your arm under the foetus for support and reach into the birth canal. Apply pressure to the maxilla with your index finger and middle finger on either side of the nose. Keep the Foetal body parallel to the floor (as excessive angulation upwards will hyperextend the neck and cause spinal cord injury)
• Using your other hand, hook the index and middle finger on each side of the neck, applying gentle downward traction to the shoulders until the suboccipital region appears under the pubis symphysis
• Elevate the foetal body upward toward the mother’s abdomen to complete delivery of the head.

Umbilical Cord Prolapse

Definition: Descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes (i.e. the cord presents between the presenting part and the cervix)⁶.

Although infant mortality in cord prolapse is high, incidence is low (0.1-0.6%)¹, with risk factors including; breech presentation, multiparity, low birthweight, preterm rupture of membranes, polyhydramnios, and multiple procedure-related factors such as artificial rupture of membranes with a high presenting part¹.

Patients at risk of cord prolapse should have been identified during antenatal screening. A high degree of suspicion should be held if risk factors are present. 

Speculum examination should be performed in these cases to assess for prolapse. Digital examination may be beneficial but can provoke cord prolapse through vasospasm of the cord and therefore it is recommended that the cord is not “handled” in an attempt to reinsert above the presenting part into the uterus^1,6.

If cord prolapse is diagnosed before full dilatation (i.e. vaginal birth is not imminent) then immediate transfer to a consultant-led obstetric facility should be arranged as urgent operative delivery will be required:

• The mother should be placed in either the knee-chest face-down position or the exaggerated Sims position (Left lateral with pillow under hip)⁶.
• Elevation of the presenting part (to minimise cord compression) can be performed either manually using two gloved-fingers inserted into the vagina, or by filling the urinary bladder using a Foley catheter attached to a blood giving set (Once the bladder is filled to distension with approx. 500-750mL, the catheter should be clamped until just prior to delivery)^(1,6)
• Tocolysis (e.g. Terbutaline 0.25mg SC) can be used to reduce contractions and limit bradycardia⁶, however this should only be delivered in ED with assistance from a senior obstetrician. 

If delivery is imminent, birth can be attempted at full dilatation using standard techniques and taking care to avoid impingement of the cord when possible¹.

Uterine inversion

• High risk for inability to reduce uterus and significant haemorrhage (Prepare appropriately)¹.
• Do not attempt to remove the placenta
• Attempt manual reduction by placing a hand in the vagina and applying counter pressure to the fundus towards the umbilicus
• If not promptly reduced, the lower uterine segment and cervix can contract and make further attempts futile. Urgent obstetric advice and review will be required including potential for surgical correction¹.

Learning bites

• When preparing for imminent delivery in the ED, call for senior help and request immediate presence of obstetrics, midwifery, paediatric and intensive care/anaesthetics.
• Establish 2 Resus spaces and 2 teams (Maternal and neonatal)
• 90% of deliveries will require minimal medical intervention
• Once the anterior shoulder is delivered, administer 10 units of Oxytocin via intramuscular injection
• Frequently monitor and prepare for complications including cord prolapse, shoulder dystocia, PPH, breech presentation and uterine inversion.