Emergency Precipitous Delivery, Shoulder Dystocia & Perimortem C-Section
Mastery of emergency field and ED deliveries and obstetric catastrophes: precipitous vaginal delivery, shoulder dystocia management (HELPERR mnemonic, McRoberts maneuver, Zavanelli), umbilical cord prolapse, resuscitative hysterotomy (the 4-minute rule for perimortem cesarean section), vasa previa, uterine rupture, and postpartum hemorrhage uterotonics.
Resuscitation Quick Actions • First 2 Minutes
Normal Delivery Stages
Support crowning perineum with sterile towel; check for nuchal cord (slip over head or clamp and cut); deliver anterior shoulder with gentle downward traction, then posterior shoulder with upward traction.
Shoulder Dystocia Recognition
Turtle sign (fetal head retracts tightly against perineum after delivery). Time is critical: brain injury begins within 4-5 minutes of head-to-body delivery interval.
HELPERR Mnemonic
H: Call for Help/Neonatology; E: Evaluate for Episiotomy; L: Legs hyperflexed onto abdomen (McRoberts Maneuver: flattens sacral promontory and increases AP diameter of pelvic inlet); P: Suprapubic Pressure (push downward and obliquely to dislodge anterior shoulder; NEVER fundal pressure); E: Enter rotational maneuvers (Rubin II/Woods screw); R: Remove posterior arm; R: Roll to all fours (Gaskin maneuver).
Last-Resort Maneuver
Zavanelli maneuver (flex fetal head, push back into vagina, immediate emergency C-section) or intentional clavicle fracture.
Umbilical Cord Prolapse
Insert sterile gloved hand into vagina and manually elevate the presenting fetal part off the pulsating cord; place mother in steep Trendelenburg or knee-chest position; transport immediately to OR for STAT C-section.
Resuscitative Hysterotomy (4-Minute Rule)
If pregnant patient >= 20 weeks (fundus at or above umbilicus) remains in cardiac arrest without ROSC at 4 minutes of CPR, make a vertical midline incision from epigastrium to pubic symphysis, enter uterus, deliver infant, and clamp cord by minute 5. Relieves vena caval compression, dramatically improving maternal resuscitation chances.
Bottom-Line Clinical Pearl
In shoulder dystocia, DO NOT push on the uterine fundus or pull forcefully on the fetal head. Execute HELPERR: immediately hyperflex maternal hips (McRoberts maneuver) and apply firm downward suprapubic pressure. In maternal cardiac arrest >= 20 weeks gestation, if ROSC is not achieved within 4 minutes, perform Resuscitative Hysterotomy immediately on site to deliver by minute 5.
ABSOLUTE CONTRAINDICATION: Fundal Pressure in Shoulder Dystocia
Applying fundal pressure in shoulder dystocia drives the impacted anterior shoulder further behind the pubic symphysis, directly causing fetal brachial plexus avulsion (Erb's palsy), clavicle/humeral fracture, and maternal uterine rupture. Apply SUPRAPUBIC PRESSURE ONLY, pressing downward and diagonally on the anterior shoulder to adduct and dislodge it.
| Step | Mnemonic/Maneuver | Mechanical Action & Technique | Anatomical Rationale |
|---|---|---|---|
| 1 | Call for Help | Call OB, Neonatology, Anesthesia, and additional nursing staff | Ensures immediate resuscitation team for newborn and mother |
| 2 | Evaluate Episiotomy | Perform generous mediolateral episiotomy if room needed for internal maneuvers | Relieves soft tissue obstruction (does not relieve bony dystocia) |
| 3 | Legs Hyperflexed (McRoberts) | Hyperflex and abduct maternal hips sharply against abdomen (knees to ears) | Flattens sacral promontory, cephalad rotation of pubic symphysis; resolves >40-50% of dystocias alone |
| 4 | Suprapubic Pressure | Assistant applies firm continuous or rocking pressure just above pubic bone obliquely | Forces anterior shoulder into an oblique diameter and adducts shoulder under the pubic bone |
| 5 | Internal Rotation (Rubin II & Woods Screw) | Insert fingers behind anterior shoulder (Rubin) or anterior to posterior shoulder (Woods) and rotate 180° | Rotates fetal shoulders into the wider oblique or transverse diameter of pelvis |
| 6 | Remove Posterior Arm | Follow posterior arm to elbow, flex forearm across chest, grasp wrist, and pull arm across face and out | Reduces shoulder diameter by the width of the arm; highly effective |
| 7 | Roll to Hands & Knees (Gaskin) | Patient turns over onto hands and knees ('all fours') | Gravity and positional pelvis changes widen the pelvic conjugate diameter |
| 8 | Zavanelli Maneuver (Last Resort) | Rotate head back to direct OA/OP position, flex head, push back into vagina with continuous pressure | Enables immediate emergency cesarean delivery in the operating room |
PPH is defined as blood loss > 1,000 mL or bleeding accompanied by signs of hypovolemia within 24 hours of delivery. Causes: The 4 T's (Tone [uterine atony 70%], Trauma [lacerations 20%], Tissue [retained placenta 10%], Thrombin [coagulopathy 1%]).
1. Bimanual Uterine Compression: Insert gloved fist into anterior vaginal fornix, press against anterior uterine wall, and compress posterior wall from the abdomen with the other hand. 2. Uterotonic Pharmacology: - Oxytocin (Pitocin): 10-40 units in 1 L NS wide open, or 10 units IM. - Tranexamic Acid (TXA): 1 g IV over 10 min within 3 hours of birth (WOMAN trial). - Methylergonovine (Methergine): 0.2 mg IM q2-4h (CONTRAINDICATED in hypertension/preeclampsia). - Carboprost (Hemabate/PGF2a): 250 mcg IM q15-90 min (CONTRAINDICATED in asthma/bronchospasm). - Misoprostol (Cytotec): 800 to 1,000 mcg rectally or sublingually. 3. Bakri Balloon Tamponade: Insert balloon catheter into uterine cavity, inflate with 300-500 mL sterile warm saline; tamponades bleeding from placental bed.
- Delaying resuscitative hysterotomy for fetal heart tones or ultrasound: If maternal cardiac arrest is refractory to 4 minutes of CPR in pregnancy >= 20 weeks, begin hysterotomy IMMEDIATELY; the primary goal is maternal survival by relieving IVC obstruction!
- Giving Methergine to a preeclamptic patient: Causes acute malignant hypertensive crisis, intracranial hemorrhage, and stroke.
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