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CRF Emergency Obstetric Management In and Out of Hospital setting 07.02.23 Professor Andrea Levy

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Summary

This on-demand teaching session is relevant to medical professionals and introduces the Three Delays Model, as well as obstetric emergency management strategies in settings outside of the hospital, such as refugee or IDP camps, natural disaster or conflict zones, or at-home births. It covers topics such as the assessment and management of intrapartum or antepartum hemorrhage, placenta previa, placental abruption, vasa previa, and other ethical considerations in this context. The presenter is a registered midwife in Toronto and has taught emergency obstetric management for the Association of Ontario midwives for 13 years and has worked on a disaster response team for nine years.
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Learning objectives

Learning Objectives: 1. Participants will be able to describe the three delays model and explain why babies are born outside of hospitals. 2. Participants will be able to explain common causes of intrapartum or antepartum hemorrhage, including placenta previa, placental abruption and visa previa. 3. Participants will be able to describe symptoms associated with each potential cause of intrapartum or antepartum hemorrhage and distinguish between concealed and frank bleeding. 4. Participants will be able to identify best practices for managing obstetric emergencies outside of the hospital setting such as staying calm, assessing the impact of each action and prioritizing communication. 5. Participants will be able to explain ethical considerations for managing obstetric emergencies, such as weighing the life of the mother versus the life of the baby.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay so hi everyone I can't see how many of you there are, um but anyways, I'll just get started, so my name is Andrea levy. I am a registered midwife in Toronto. Um I have um taught emergency obstetrical management for the Association of Ontario midwives for about 13 years, and I have taught um and worked on a disaster response team for about nine years and actually shortly after this lecture, um It looks like our team will be deploying to Turkey for the next couple of weeks, so it's interesting timing. Um Ok, so my email address is there there's a lot to cover mostly. I'm just going to be whipping through the um the content, please feel free to raise your hand or put something in the chat, and, and we'll watch out for that um. And um if we if we don't have time to cover all of the questions, please feel free to email me um at my email address afterwards, but keep in mind that I won't have good internet access for the next couple of weeks, so if I'm not responding, that's why okay, so our topic today is managing um obstetric emergencies out of the hospital setting, so out of hospital birth um Some some context where you might encounter, this would be an emergency medical team type one, either mobile or fixed, and you would find those for instance in a refugee or idp camp, natural disaster or conflict zone um It might be a setting in a lower income country where you have auroral or community health clinic um It could be at home either planned or unplanned or basically any other situation where the birth is imminent or there's an obstetric emergency happening and access to good um obstetric and neonatal care is not available. So in any of the about situations you might find yourself having to deliver a baby or manage an obstetrical emergency um without adequate um or appropriate access to supplies, medications or equipment, um, and of course if the birth is not imminent, and if there's time then always try to arrange for transfer to level two or three facility okay, So why on earth you might be asking our babies born out of the hospital. I'll tell you why um so there's something called the three delays model, which some of you may or may not be familiar with and this was a model first discussed by um the authors studies in maine, in 1994 and the purpose of this um theory was to guide program planning to reduce maternal morbidity and and mortality and here's the the citation, I've also included it in the references and you believe you will have access to these slides afterwards, excuse me okay, so let me elaborate on the three delays models, so basically what prevents um obstetric patient's from receiving appropriate care either in just normal birth or in an emergency situation would be three things, so first of all, there's the delay in seeking care and this could be either just patient's not aware that what's happening in their situation is an emergency and that they should seek care. It could be that they know they need to seek care, but there are barriers to seeking care for instants um transportation, no money to pay for the care. Um In some family structures, The pregnant patient is not the one to be making decisions. It might be the mother in law or the husband and they may not be prioritizing that so those are some reasons when care is sought another. The second delay would be in transportation and this could just be something as simple as uh roads flooded in a disaster response, um not good road infrastructure to begin with in a country, um No transportation available, no money for transportation, not sure where to go, so those would be some factors that cause a delay in seeking care. The third delay happens when people have sought care. They've arrived at a healthcare facility, but there's a delay in receiving treatment, and this could be that they've they've arrived at a care facility, but it's not the appropriate care facility, so it might be um a level one or two and and really what they need for their most appropriate care would be a level two or three facility. It could be that they've actually arrived at the appropriate facility, but there may be our delays like having to wait to be seen by care providers, um where they've been seen and assessed, and determined to need to be transported to an upper level facility, and there can be delays in that process as well, okay, so just a few little um stats about the ukraine birth rate um is about 8.5 births per 1000 people compared to 17.5 globally, the maternal mortality rate is 19 per 100,000 live births, which is much lower than the global rate of 2 11 neonatal mortality rate is five per 1000 compared to 18 globally, and births attended by the trained personnel are 100% generally 2014 was the last year with that stat available um and the average global rate is 83%. So some basic principles of really any emergency management um would be to stay stay calm, of course keep track of the time, assess the effect of each of your actions. If what you're doing isn't working move on to something else, Communication is very important um not just with the patient in their family, but with the rest of your team is extremely important, be prepared and um some ethical considerations in this context would be one in particular is do we really use heroic measures to save the life of the baby at the expense of the life of the mother and this is a hard one to contemplate because of course no one wants to lose any patient especially not a baby, but you have to think. um. If you know, one example would, be you know heroically, doing an emergency caesarean section without the proper facilities to keep the mother alive, then you end up with a live baby, perhaps but you end up with a baby without at least one parent, possibly without two parents um and their siblings as well without parents, So you have to keep these sorts of things in mind okay, so just basically normal birth um And I do have a few videos throughout the the presentation, but I don't actually think we'll have time to go through them um. Hopefully, when you get um a copy of the slides, you'll be able to have a look at them and if if we do for some reason have time, we can go back um and and look okay so if a baby is just being born and generally when they're being born um quickly, these are the births that usually are the most straightforward so that's the good news babies just come out um So really you just need to stay calm um remember that both the most births are in fact normal, have the patient lie down as opposed to being an upright position. Um Once um the patient is pushing, um have them push with contractions, only once the head is born, wait until the next contraction before you deliver the shoulders, which can avoid a shoulder dystocia. Babies placed on to the patient's chest, skin to skin for maximum warmth clamp, and cut the umbilical cord. Um If it's possible to let it pulse for 30 to 60 seconds, that's ideal keep the patient in the baby warm and dry, clear secretions from the baby's mouth if necessary and once you've seen signs of placental separation, which would be things like the cord getting longer, small gush of blood, um guard the uterus, so you don't pull it out, use gentle cord traction with the next contraction to deliver it oops okay, um so the first emergency I'll talk about is intrapartum or um antepartum hemorrhage um and this would be vaginal bleeding that occurs between 20 weeks of pregnancy to delivery. Um So throughout pregnancy or labor, the incidence is 2 to 5% of all pregnancies and some common causes would be placenta previa, placental abruption, and visa previa. There are other causes, which would not necessarily be emergencies, but I'm just going to cover these three um um So placenta previa is when the placenta implants lower in the uterus and can either just be low lying, Those placentas tend to move throughout the pregnancy and cease to be a problem, A marginal previa where the placenta is partially like just sort of coming to the edge of the cervical loss. A partial is obviously partially covering and complete previous. When the placenta completely covers the cervix, um with marginal often but certainly with partial and complete previous um that that baby cannot be born vaginally. Um This happens in 2 to 3% of pregnant patient's um overall, uh but because the placenta does tend to migrate upwards during the pregnancy, the the incidents that term is just 0.3% so you can see in the picture, especially the last one there the complete previa the placenta is completely covering the cervical loss um That may be cannot commit that way. Um you may be in a situation where the patient has had no prenatal care or inadequate prenatal care or you do not have access to their records. Um Meaning you don't know if if the placenta previa has been ruled out, an ultrasound at some point, so if you do not know, if you can't confirm, especially if the patient presents with vaginal bleeding. You have to assume that there may be a placenta previa and all internal exams are contraindicated, So these are some associated factors, I'm not going to go through them, all in much detail, but you can have a look here. Um Some symptoms would be again if you have happen to have the records, it will have been diagnosed on sonography, um abnormal or high fetal presentation could be a sign the the vaginal bleeding is often painless and can be um scan turd, profuse theaters, tends to be soft and not painful to the touch. Um You may have an abnormal fetal heart rate and there may be signs of maternal shock, particularly if it's been a while Placental abruption is another cause of bleeding um and this is when the placenta um comes away from the uterine wall prematurely, so before the birth of the baby and you can see here. Um on the right is a concealed abruption where you may not actually have any bleeding or very scant bleeding because the blood is trapped behind the between the placenta and the uterine wall um and with um the other the one on the left you see there's frank bleeding. Some associated factors again, I won't go through these now signs of an abruption can be similar to a previa, but can also be different so heavy bleeding, large clots um like I said you may have scant or light bleeding. If it's concealed, the uterus will possibly be irritable, You may have titanic contractions um and it can be quite rigid that's because of the blood pooling behind the placenta. Um There may be abdominal or lower back pain. You may have an abnormal fetal heart rate and you may you may have maternal shock, but it may not match with the amount of blood loss. You're seeing because of the concealed eruptions, so you have to be mindful of that. Ok visa previa is when um the, the, the umbilical cord presents ahead of the baby that the babies had a breach. Um This is extremely rare one in 5000 births. Um These are some risk factors really just a couple. Um signs and symptoms generally you will detect this. If you do an internal exam and you can actually palpate the the vessels in the membranes. Um If the membranes rupture, you may have heavy bleeding and you may have an abnormal fetal heart rate, so if you do an internal exam and you feel vessels through the membranes, you need to remove your your fingers immediately and assume that that's what's happening okay, so general management of any heavy bleeding. Anti parliament or intrapartum would be a left lateral position. Oxygen uh 1 to 2 iv infusions with ringers or normal saline monitor. The vital signs frequently, um place, an indwelling urinary catheter monitor, blood loss keep the patient warm if possible, transferred to a level two or three facility, and if the patient is in labor um and if it's possible then try to expedite the delivery and prepare for neonatal resuscitation. Postpartum hemorrhage. Um is the next one and this one happens obviously after the birth, um after vaginal birth. It's defined as more than 500 mills and after c section it's over 1000 An early PPH occurs within the 1st 24 hours of the birth and a late PPH, which is less common, um but can still happen occurs between 25 years after the birth and six weeks. They're generally just four things that cause a postpartum hemorrhage and you can remember them by referring to the forties. Um Tone accounts for the majority 70% that's a uterus that is not well contracted, trauma is 20% so those would be lacerations or hemotomas, tissue 10% include retained bits of placenta, membranes, or clots um that are preventing the uterus from being well contracted and thrombin is the least likely, and these are plotting disorders um So tone being the most common um These are some of the causes of um lack of urine tone following the birth um so basically anything that makes uterus work harder than than normal um or if it's been over distended. If there's infection or any kind of an atomic distortion of the uterus can cause uterus to not be well contracted after the birth um for trauma. This includes things like lacerations in hemotomas um if the uterus has ruptured, which is way more common if the patient has had previous uterine surgery. Um When the the scar opens up during labor or uterine inversion, this is very rare. Um that happens when the uterus is actually pulled out upon delivery of the placenta. Um tissue is when there's been tissue left behind, which can be um even the tiniest fragment of placenta can cause a hemorrhage. Um could be trailing membranes. If when you're delivering the, the membranes, sometimes they tear and a bit gets left behind and can sometimes be passed even weeks later, patient notices the membranes coming out um or clots sitting in the cervix um or abnormal presentation. So these would be things like a previa, accreta perk, rita, and increa to or various degrees of the placenta in implanting um invasively into the wall of the uterus and some will actually go right through the uterus and invade surrounding organs. That's very rare that can happen. Regulation disorders in our include either pre existing or acquired um could be acquired during pregnancy, but again very rare and you're not you can do a verbal history to see if the patient has um uh history of of coagulopathy, but otherwise you may not have any um lab facilities to confirm this, so the one thing that can that can be the most effective at preventing a postpartum hemorrhage would be active management of the third stage, so this is routine after every single birth. Regardless of risk factors management, to keep the bleeding normal. Um once you've plant and cut the cord, you performed controlled contraction to deliver the placenta followed immediately by uterine massage, express any clots that may be present and you can administer one or more of any of these medications. Oxytocin or Pitocin is the most common um uh sent to Metron might be used instead of oxytocin, misoprostal. I think in this context is actually the best option because it's stable at room temperature, they're they're tablets, so you don't need to worry about drawing medication up from a vial or having sharps to dispose of um and it's extremely effective and you can actually split that dose up um to do um so you can give it sublingual or perect um sublingual works faster, but last not as long. NpR tends to take a bit longer to work, but last longer and so often what we'll do is break that dosage up into sometimes 206 100 or 400 400 so you get um the effects of both and tranexamic acid is also a drug that is being more commonly used for any kind of bleeding really trauma or post partum hemorrhage, but you do need iv access to administer that okay, so if you've done your active management of third stage and the patient is still bleeding heavily. Um The first steps you will take will to massage the uterus. This can can elicit a, during contraction, which can minimize bleeding. If the placenta has delivered if it's not delivered. Um you should not do that, repeat the medications as indicated. Monitor vital signs frequently pack or repair any lacerations or bleeding vessels that you found and examine the placenta and membranes to ensure that they are actually complete. If the bleeding is still continuing, you, you need to treat for shock, so oxygen, lateral position, and keep the patient warm and other medications you can administer so the ergometrine you can give again uh sent to metron, you can give again. Misoprostal is just a single time uh dose um carboprost and uh you can run an oxytocin infusion with 20 to 40 units in the bag of fluid if the bleeding still continues and the placenta has not delivered yet. Um You can perform a manual removal of the placenta this may or may not be in your scope, so um please be mindful of that, um but you can see here, the practitioners hand has gone in and sort of shape the placenta off of the uterine wall and is cutting it to, to bring it out of the vagina and then once the placenta is delivered, you can proceed with the other measures that we've discussed by manual compression is a great one um once with with the placenta in or out, so you can see the practitioners, one hand has gone through the vagina and the other one is on the abdomen compressing the uterus between the two hands and this uh cuts off the blood flow from the uterine vessels. Aortic compression is another measure you can take um so this would be applying downward pressure above and to the left of the umbilicus and you know it's been successful if, if you can no longer palpate the femoral pulse, so this has to be um continuous deep pressure, so it can be a little bit tiring to do that can be effective and the three that I've just mentioned if you're in a situation where you have limited access to medications. You can use these three manual removal by manual compression and aortic compression okay, should I just keep plugging on, I haven't heard any questions okay, so I'll just keep going um okay, so shoulder dystocia is when the baby's interior shoulder gets impacted behind the pubic bone and uh you know that this is what you're dealing with when the baby shoulders don't deliver spontaneously after the routine maneuvers of maternal pushing efforts and downward traction, applying down retraction in the field head. It's not too common 0.2 to 2% but the incidents it does increase with the size of the baby, um but about 50% of the time. There are actually no predisposing factors so you need to be prepared for this um with every delivery and these are some of the predisposing factors that can come into play. Um Some associated complications for the patient would be a hemorrhage, a large perineal aspiration, uterine rupture, or infection, and for the baby. Um you might be looking at a baby with a brachial plexus injury, fractured clavicle or humerus, hypoxia, or even death, and that that is rare that can happen to prevent um a shoulder dystocia. Really the basic principles are to keep the bladder empty during the labor and to allow the patient to push spontaneously with contractions in the second stage, um but when maneuver, which can be really effective is called the two step maneuver and uh this is when um once the head is being born, rather than you know, sort of panicking which many care providers will do and apply traction on the fetal head right away. It's better to wait for the next contraction and or spontaneous restitution of the body. Sometimes babies just decide they're ready to come and you can see the body being born spontaneously, um But if you if you can wait, just take a deep breath with the next contraction or when the baby starts to deliver spontaneously, you can avoid actually causing the interior shoulder to be become impacted behind the pubic bone. One sign that you might see if you're dealing with the shoulder dystocia is called the turtle sign and this is when the head is born and then retract back against the pyrenean. Uh You also might see cyanosis of the fetal head or lack of restitution and here you can see the turtle sign uh the head kind of it comes out and then goes back in again and the cheeks get a bit fatter and you can know that this is a sign that you're likely dealing with the shoulder dystocia. Some basic principles again stay calm. You have 6 to 8 minutes to deliver the baby before you can anticipate too much trouble in terms of hypoxia or fetal death. Um Really important I'm gonna walk you through some of these maneuvers so this isn't going to make a lot of sense yet perhaps but uh basically you want to not have the patient push while you're performing the maneuver and then once you perform the maneuver, encourage munching work through them systematically. Um And then if the baby is still not delivering, you can go back to the beginning and go through them systematically. Again, it's uncommon that people need to do that um systematically, will help you to not only stay common focused, but um will help you to not forget any of the maneuvers. Consider an m. P.'s, Iata me not because it helps the body to deliver, but because it just makes more room for your hands to perform the maneuvers, and after each maneuver, used gentle traction on the baby's head, encouraged the patient to push and attempt to deliver the baby and prepare for neonatal resuscitation. This is the first maneuver and this is a very basic one um called nick roberts where you get the patient to hyperflex her knees back, and this changes the diameter of the public outlet, which is often enough just to dislodge the baby more effective. If you you use it in conjunction with super pubic pressure, where you have an assistant put either um consistent or rocking motion pressure above the pubic bone, not directly on the pubic bone, but think about sort of getting behind it to dislodge that shoulder and these two maneuvers combined will resolve more than 90% of all cases, but if they don't work, then you can try the rubens maneuver and you can see the practitioners hand here going in and abducting the interior shoulder to decrease the shoulder to shoulder diameter. Would screw is similar, um but you're really just trying to wriggle the baby free. So you start with two fingers on the back of the baby's post your your shoulder, two fingers on the front of the anterior shoulder and um if you can rotate the baby, then you can switch your hands around and do that in the opposite direction. The Gaskin maneuver is getting the patient on hands and knees, um sometimes even just changing position can be enough to um to dislodge that shoulder. If you think of, um you know if if you picture yourself going from lying to hands and knees, you can imagine the the pelvic pelvic diameter opening up and that can sometimes alone give more room for the baby to be born, but if not then you can attempt to deliver in this position, delivering the post your arm can often help if you can get your hand in there. Um you just uh sweep the posterior arm across the baby's chest and here you can see the practitioner pulling the arm out and that also decreases the shoulder to shoulder diameter of the baby and once you deliver the post your arm, you go back to the interior. Um with your downward attraction to try and deliver the baby, Accelera traction is another one that there's been some research about lately um and that's where you're just using your your fingers under the the artery and the baby's um under arm of the posterior arm and and uh apply traction and that can often deliver the baby if you have to you can fracture the clavicle. I know that probably sounds horrifying um the, what what you do is you uh push the baby's clavicle up against the pubic grimace. Um There, it's actually not too hard to do you'll hear an awful sound and you'll feel terrible, but ultimately that's better than not being able to deliver the baby and the good news is babies will have. Uh we think a small amount of pain as it heals, but they tend to heal quickly and without any trouble and without any interventions needed, they just heal on their own. Uh This is a video that I won't play for you right now because it's quite a few minutes long, but it is a really great video that walks you through all of those maneuvers, So I do recommend you have a look at it at some point, and it uses a pneumonic, which helps make it easier to remember all the steps, but keep in mind sometimes um you might do those steps out of order. There is actually no particular order, especially if you're a more experienced practitioner practitioner, you may have a sense that one might work better in a particular situation than another, so you can switch it up. There's no um absolute order to them okay. So moving right along um cord prolapse is when the cord um prolapses or comes out um through the cervix and or through the vagina before the baby. More common you can see here. This is a footling breech presentation and and so when the baby's not head down um and with the head filling the pelvis like a like a little cork, um you're more likely to have a cord that that prolapse is and that this is an acute emergency. Um It happens only after the membranes have ruptured. It can happen at the time of membrane rupture or sometime after. Um It can cause cord occlusion because the cord can get occluded between uh the baby and the public bones can cause fetal hypoxia or death luckily, it's very rare 0.3% of all births. These are some associated factors um basically any situation where you have lots of fluid or a very high fetal head or um um al, presentation like breach or oblique. Sometimes the shoulders presenting or an arm, then it's more likely to happen if the birth is imminent imminent, then just get the baby born that's the best thing to do, but if it's not imminent um place the patient in a knee chest position um or sidelining research shows um that that can be just as effective um and you must get your hand in there and I don't usually mean two fingers but probably your whole hand because uterine contractions are very uh forceful and you'll need a lot to apply a lot of pressure to, to hold the head off the off of the cord and prepare for neonatal resuscitation, so here you can see the, the, this is the ideal position um like I said sideline may also be okay, but if the cord is actually um protruding from the vagina, this will be the best position and um if you're transporting the patient, unfortunately she'll have to transport in this position with your hand holding the head off the cord until delivery is possible okay, so um some babies choose to not be born head down, so you may have um an undiagnosed breach. Um Again, in this context of out of hospital birth that maybe undiagnosed because of a lack of prenatal care or no access to records um and there are four different kinds it happens 3 to 4% of births. Um All breaches if undiagnosed breach would be slightly less than that. These are some respect ear's um she can go over. Later. Risks to the baby include hypoxia, birth injury, intracranial hemorrhage, or a placental abruption, um So to manage the breach. Um If you have a patient present and you've done an internal exam where she's pushing and you can see the presenting part. Um you'll see the bum, presenting first, um she's made, don't encourage the patient to push until you can actually see the breach on the perineum and then you can encourage pushing with contractions, make sure the baby's back always stays interior to the patient, um and you can um position the patient in a way that um so that her bottom is at the edge of a stretcher or bed, so that the baby's body can hang and these measures can help to ensure that the fetal head stays flexed as opposed to extend it. Very very important to always keep your hands off the breach except for uh certain times which will go into in a moment. Um If you pull on the baby, you can actually cause the head to extend and um then it can be entrapped and then you'll have a really hard time getting it delivered. Um only guide the baby's body enough to keep the the sacrum oriented interiorly to the patient uh to the mother, continue to keep your hands off until after the umbilicus is born. If the cord is being pulled taught, then gently pull a loop down, but you have to be very gentle, so you don't cause vasoconstriction in um and then ideally the delivery is complete within 3 to 5 minutes after that you might run into some trouble with the baby, um and there is a video of this, you can have a look after um so that some of these may not make too much sense until you're watching it. Um In terms of delivering the legs usually, they just pop out on their own. Um you keep your hands off unless they don't deliver on their own, in which case you perform pen or it's maneuver and you can see here the practitioner um putting some pressure in the popliteal fossa flexing the baby's leg and then pulling sweeping the baby's leg out. You can picture it almost like the baby stepping out of the vagina okay, so then again hands off the breach, wait for the baby to descend further. The arms again usually will come out on their own, but if they don't especially if they're extended over the baby's head, they may not you might need to help them out, you use the Love set maneuver and you can see here. The practitioner has their hands placed over the baby's um sac roman and pelvic bones. You do not want to place your hands over any soft tissues you can cause organ damage um and with your hands place there, you just rotate the baby basically from side to side, always keeping the back interior to the pubic bone and you're just sort of rocking the arms out one at a time, so then again hands off the breach, let the baby descend further on its own Once the baby is born to the hairline. Um Again, usually, the head deliver spontaneously. In fact, in most breaches, you have to be very careful because these babies can literally just jump out you have to be aware of that um so that you're catching the baby, um but if the head is not delivering on its own, you need to use something called the more so smelly beat maneuver, which I'll show you in a second um and if that does not work, you can use that Mcroberts maneuver with um super pubic pressure to try and flex the baby's head and of course you want to prepare for neonatal resuscitation, So here you see the maurice Mileva maneuver. Um You have an assistant apply superpubic pressure and then the practitioners, right hand goes over the baby's shoulders with your your index finger um just gently pushing the baby's head to keep it flexed and then your left hand, we'll go over the baby's face with one finger on the mallard bones um On each side, do not put your fingers in the baby's mouth because that can cause damage and here's the video that you can watch later on and you're on time again really good video which walks you through all of those uh maneuvers step by step okay if you have twins. Um If the, if the patient has not had any prenatal care or maybe hasn't had um sonography done at any point about 20% will actually be undiagnosed prior to labor, although there obviously are other signs um like very high fondle height uh Sometimes patient can perceive to baby's moving um but believe it or not often with the absent in the absence of sin ah graffiti many of them can go undetected. Um A couple of things that might make you suspect a second baby would be um if you've been anticipating a large baby due to the maternal size, um thinking she's going to be delivering a large baby in the note pops that we one um uh and or after delivery, the uterus remains higher than you expect and you might be able to palpate fetal parts so really important, especially in this context where you're not delivering patient's who you know or who you've been taken care of during their pregnancy, really important to rule, pull this out to just get into the habit of ruling it out before you administer the Pitocin or any other uterotonic for your active management of third stage. because that that large dose of oxytocin can be very detrimental to um that second twin that's still inside all right, so once you have determined that there is a second twin, you need to inform the parents that's always an interesting conversation, um If they have not been expecting a twin and communicate with your other team members. Uh He's made clamp cut and identified twente's cord usually by double clamping, you can do that um and past 22 to someone else to take care of well. The patient delivers twin B, um confirm through external palpitation that twin B is in a longitudinal presentation, don't worry too much if it's head first or bum, first, just get it longitudinal, so you're not dealing with an oblique baby, who can't be born sideways, um if possible transport the patient to um a facility or an upper level facility, um but keeping in mind that most twin babies will be born within half an hour and so they're just may not be time for that. Um prepare for neonatal resuscitation, which will be more likely with twin B okay. Um We're almost done um In terms of an abnormal fetal heart rate, now keep in mind that this um fetal heart rate um surveillance is a whole full day course in and of itself, so I'm not going into all of the details, um but in this context where you're dealing with and out of hospital birth, you're very unlikely to have access to a continuous fetal monitor, so you'll be monitoring the fetal heart rate with either fetoscope, which is like a stethoscope but made for or pregnancy, um or a hand help Doppler. Um So you're not going to necessarily know that the uh or to have that that tracing of a continuous fetal heart rate. Um It should so you should be listening to the field heart rate every 15 minutes in the first stage of labor, so that's 4 to 10 centimeters and every five minutes in the second stage, which is basically uh through the pushing until delivery normal, is considered to be 1 10 to 160 BPM. If there are risk factors that you know of, um making it more likely that you'll have an abnormal heart rate, again attempt to transfer um if that's not possible or or during transport, um you can try to auscultate as frequently as possible and auscultation means that you're listening for about 60 seconds immediately following a contraction. These are some risk factors of some things that make it more likely that you'll have an abnormal feel heart rate uh basically uh anything that prevents the delivery of oxygen to the baby and your basic management will be to change maternal position that often will um resolve an abnormal fetal heart rate that you've just heard once or twice because in in a certain position, the cord might be being compressed and a change in position um can resolve that perform an internal exam um to rule out other prolapse cord or potentially the patient is dilating quickly and is suddenly fully dilated that can sometimes cause a decrease in the fetal heart rate. If the patient's been pushing for a while temporarily cease pushing efforts to give the baby a bit of a break and recover before you resume, give an iv fluid bolus. Consider a talk politic. If you have one to um reduce the strength and frequency of uterine contractions. Again, the principle of giving the baby a bit of a break, expedite the birth if possible um or transfer to an upper level facility if if possible and prepare for you natal resuscitation okay, so neonatal resuscitation. Again, this is a full day course in and of itself um and in these contexts, um you certainly will not have access to everything you need for um a full on resuscitation. Um The good news is that most babies 85% will begin breathing on their own within a minute of the birth um and won't require any assistance. You just need to dry them off and keep them warm, 5% require positive pressure ventilation, about 2% need to be intubated and three in 1000 will require chest compressions and or medications like epinephrine, so just some practical and ethical considerations. Um If you are working sorry in an EMT type one, mobile or fixed, the minimum technical standard as per the World health organization is to provide basic neonatal resuscitation and this would include an oral or nasal pharyngeal airway and bag valve mask ventilation, so you might have a self inflating bag and mask. Um you will not be able to perform intubation. You may or may not have epinephrine on hand and remember you need the neonatal dose, which is one in 10,000 as opposed to one in 1000 for an adult. Um You need to consider when you're delivered when you've delivered a baby who clearly needs resuscitation or you're anticipating that this baby will need resuscitation, you need to consider the baby's prognosis and your capacity for sustained resuscitative efforts um without access to upper level care. Um you really can't or shouldn't initiate an extensive resuscitation if the prognosis is poor for this baby um and or if you just have no way to sustain. Like if you've intubated for some reason because you you have the capacity to or the equipment to, but you don't have event that you can attach the baby to then. It's you can perform manual ventilation for a certain period of time, but that's not practical in the, for the long term um And with very sick babies, you just may not have access to the the upper level care that they need um to to end up with a good good outcome um and again not really nice to think about but very practical and if um the baby does require care outside of your scope or your capabilities, for example, the the baby might be extremely preterm or have um profound asphyxia, then place the baby skin to skin with their parent and provide supportive care. These are some risk factors, so things that make it more likely that the baby will need to be resuscitated um intrapartum risk factors and um so the very basic algorithm again keeping in mind that you're not going to have access to everything you need for fillon resuscitation. Um If the baby's delivered, um the first thing you ask yourself is this baby term, so 37 weeks and onwards does the baby have good tone is the baby breathing or crying. Then you're you're fine if not but pepsi's meat, then you want to warm, dry, and stimulate position the airway into the sniffing position. Suction the baby if there are lots of secretions present, if the baby has apnea or as gasping and or if the heart rate is less than 100. Um sorry, If if not if, if these things are not present but the baby has labored breathing or persistent sign osis, um suction. Again, it might just be secretions obstructing the airway, provide free, free flow oxygen or Cpap. Um if possible If you have the equipment, and if you have the oxygen, if there is apnea or gasping um, you can perform PPV. Again, if you have a self inflating bag and mask and keeping in mind, you may or may not have access to oxygen tanks okay, so that's everything these are the references, um. And again you can email questions to me If we don't have time to get to them right now, I think we have about 10 minutes left, are there any questions yes, yes, okay go right ahead, uh wouldn't be clerical breaking or the clavicle fracture with dangerous like in what way it's been broken uh outside or the inward uh bone of the clerical inward Because when the baby will take the first breath the broken clavicle when like uh obstruct the breathing of the lungs. Yes, that is correct, a broken clavicle. One of the side effects of that is a puncture in the lung um So you're keeping that in mind, but you know you just will have to deal with that. Ultimately, that's better than not being able to deliver the baby at all. It's it's not very common that uh clavicle fracture will will cause a new more threats, but it's possible shouldn't be prolapse of uh listen to uh or the listen to call with the same as was. Uh Prefects, construct seen as a wet story, the prolapse of the cord prolapse mhm, shouldn't that be same as uh I forgot the word was uh yes like a whatsapp previa um no, it's it's different in that with a visa previa, the membranes sorry the fetal vessels are actually running through the membranes and the danger with so that they're not cord membranes, it's completely separate from the cort, um so the danger with that is if when the water breaks when the memories rupture um those vessels can rupture as well causing bleeding, um but that that's a separate um sort of uh um situation than having the cord that that prolapse is a quote prolapse cord um can happen regardless of where the, the fetal vessels are implanted, um but typically it would not be normal to see fetal vessels within the membranes of the placenta. They're usually separate just in the cord, uh wouldn't be much more dangerous that for a while uh as a need, Let's just say a normal posture, part durations like if the mother the mother is pushing uh while pushing instead of uh like it's a healthy part oration. The baby is out normally but while the baby is coming out same as the time, the prolapse of the entire ukraine is occurring, occurring as the, as the child is been getting delivered. At the same time, the uh the entire uterus is getting prolapsed like just behind it is it possible and that's pretty much more dangerous. I think yeah it's possible that's extremely rare that's called your uterine inversion. Um It's extremely rare as an uterine uh inversion as in uh just simultaneously to the birth. Like as if the baby is coming out just with that after the baby comes out like the it, it wouldn't be that that common with the birth of the baby, but with the birth of the placenta, um Although I you know it's possible that it would happen with the birth of the baby, that would be extremely unlikely um more common with grand multiparity, so someone who's delivered previously five or more babies, um but usually it happens um when the care provider um uses too much cord traction, so pulls too hard on the cord. Um Then you can If the placenta hasn't detached yet on its own, you can actually just pull the whole uterus. It comes out like actually inside out and then you have to put it back in very carefully um right side out as opposed to the other way around, um but that's like that that's an upper upper level skill and it can be dangerous and you're not going to see that. Very often, any other questions, I have a few minutes. I think I don't know if I'm saying this correct, but you know when they're so shoulder dystocia can we break, is it. The pelvis of the mother. Hmm is that a possibility instead of the clavicle of the baby to deliver the baby. It is, it's called a synth, a. Z. Opposite, sorry, I'm not going to get this word right a symphysiotomy where you actually so the two pelvic bones are held right in the center at the front with the synthesis pubis, which is a ligament. Um You can cut through that ligament, but it's ultimately, if you look at patient outcomes, it's way more painful for the mother than it would be to fracture the baby's clavicle and healing is like, takes, weeks, if not months, so it's a much more dangerous procedure, um and it would be extremely rare, basically the only time you're you're going to see that happen is well. I don't even know, I've never heard of it happening in practice. It's just one of those theoretical things you could do. Um If you're really just not able to get the baby out, but you would you would save it as sort of a last resort option, the, the other um option which would be a last last resort option, so even after um doing that would be something called the seven l uh maneuver where you're actually pushing the baby back in and then performing a c section, but you obviously need c section capabilities for that to happen and that is very dangerous for the baby. Like you're you're almost certain to have a baby with a bad outcome if you've done that, so it's really really last resort option. Yeah Thank you do you want anything else uh that's the manipulation that you mentioned that we apply pressure, was it in the aorta, remember the name of the manipulation is that yeah, so is that done by a doctor or a midwife or anyone can do that anyone can do that. That's great, thank you. Any other questions, no it seems like that might be it okay well. If there's nothing else um looks like there's a link for some feedback, which is always very, very helpful and you guys can have a look at the sides. I do encourage you to watch those videos, cause they're really instructive and a lot of um I guess like a lot of instances in medicine in general, um teaching is always more effective when you can be in person and have demonstrations, so the video would be the next the next best thing um So please do have a look and feel free to email me any questions that you think of later on, I'm happy to answer, answer any emails and emails, it just may not be for a little while. Thanks. Everyone. Thank you.

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