OSCE Emergencies

ECLAMPSIA / PRE ECLAMPSIA

A dangerous multiorgan disease of pregnancy, concerning hypertension. There are three levels: -Pregnancy Induced Hypertension - Raised Blood Pressure after the point of viabilitySevere Hypertension - two BP readings (15 mins + apart) > 170 systolic or >110 diastolic or >125 MAPPre eclampsia - More severe form, coupled with proteinuria with or withoutoedema or epigastric pain or visual disturbancesEclampsia - More severe, coupled with seizures and/or coma

Severe Pre eclampsia affects 1% of all pregnancies. Eclampsia affects 4.9 per 1000 maternities. (38% antenatally, 18% intrapartum period, 44% postnatally).

Causes of Pre eclampsia / EclampsiaThere is no known cause of this disease. However theories are listed below• Genetic disposition• Immunological disorder• Abnormal placental implantation• Platelet activation• Coagulation abnormalities• Cardiovascular system not adapting to pregnancy

Risk factors• Nulliparity• >40 years old• multiple pregnancy• family history• renal disease• chronic hypertension• diabetes• previous pre-eclampsia (with same partner)

Signs of Pre eclampsia• BP >160/180 mmHg systolic or > 110 mmHg diastolic (or >30 mmHg rise from booking BP)• Proteinuria• &c^y; serum creatinine• 'I urine output - ogliuria <500mls a day• Pulmonary oedema• Thrombocytopaenia (reduced platelets)• Hepatic dysfunction

• IUGR• Headaches• Visual disturbances• Epigastric pain• Seizures (in Eclampsia)

Symptoms / Effects of Severe Pre eclampsia• Severe Hypertension AND one or more out of• ++ proteinuria on dipstick (or >1g on 24 hour collection)• <100mls urine in 4 hours (or creatinine >100)• CNS signs - altered consciousness, increased muscle tone• Flashing lights, blurred vision• Persistent headaches• Epigastric pain• LFT raised (alanine aminotransferase (ALT) > 50 iu/L)

Symptoms / Effects of Eclampsia• Convulsion between viability and 10 days postpartum which has no other known cause• Usually preceded by Pre eclampsia or CNS excitability• Usually within 48 hours of delivery

Symptoms / Effects of HELLP Syndrome, a severe variant of pre eclampsiaHaemolysis Red Blood Cells are damaged as they pass through blood vessels with a damagedendothelium tissue and fibrin depositsElevated Liver Enzymes Fibrin is deposited in the hepatic sinusoids, creating liver damage and elevated enzymesLow Platelets There is a decrease in the life span of the platelets and wide aggregation

Management of Severe Hypertension• Try to keep BP in region of 140-150 / 90-100• Compare BP with manual sphygmometer (or take with if different)• Use 4th karotkoff sound for diastolic• Avoid sharp drop in BP• Continuous CTG up to 1 hour after BP stable following treatment• Labetalol is first drug of choice• Monitor Fluid Balance hourly - total of 85mls per hour in• Too little = renal failure• Too much = pleural effusion• Don't forget fluid leaks into the extra vascular space• Start 24 hour urine collection• Take bloods• FBC• Urates and electrolytes• Liver Function Test• Clotting (including platelets)

• Group and Save• Repeat U&Es and LFT bloods every 6 - 12 hoursManagement of severe pre eclampsia antenally• Should be in consultant led unit with NICU facilities• Inform relevant staff• Consultant Obstetrician• On call Anaesthetist• Senior Midwife• SCBU / Neonatologist• Mode and Timing of Delivery must be considered• Delay to stabilise woman or to give steroids to mature fetal lungs• Transfer to an area where 1 to 1 care can be given• Labour ward or other high dependency area• Site two large bore venflons• Take bloods• FBC• Urates and electrolytes• Liver Function Test• Clotting (including platelets)• Group and Save• Repeat bloods every 6 - 12 hours• Monitor Mother (at this level until 24 hours after delivery)• Monitor Fluid Balance• Too little = renal failure• Too much = pleural effusion• Don't forget fluid leaks into the extra vascular space• Catheterise• Indwelling catheter with hourly measurement bag• Send sample for culture• Start 24 hour urine collection• Pulse oximeter & Sats continuously

• Blood Pressure every 15 minutes (30 if stable)• Temperature hourly• Dipstick for urine hourly• Monitor fetus• CTG for at least 1 hour 3* daily• If non-reassuring then continuous• Ultrasound scan• Growth and liquor volume• Umbilical Cord Doppler Flow• Deliver• Induce labour• Caesarean Section

Management of Eclampsia• Call for help• Senior obstetrician• Obstetrician to assist (potential caesarean section)• Anaesthetist• ODP• Senior midwife• Scribe• Paediatrician (if antenatal)• Inform SCBU (if antenatal)• Notify Haematologist• Porter• Turn onto left lateral• Remove pillows• Aspirate material from mouth• Give facial oxygen (10L)• Insert guedal airway (when/if possible)• Give magnesium sulphate• 4 - 6g loading dose IV over 15-20 minutes• 2g IV for secondary fit• 1-3g/hr for maintenance• Cannot use at same time as nifedipine• Diazepam PR (if magnesium fails or no IV access)• Then site IV access if none• Catheterise• Indwelling catheter with hourly measurement bag• Consider delivery (if antenatal)• Monitor mother hourly while on magnesium sulphate• Knee jerk (stop if absent)• Respiratory (stop if <10breaths a minute)

• Urine output (reduce to 0.5g/hr if <30mls)• Give antidote to magnesium sulphate• Calcium Gulgonate 10mls of 10% (1g) IV over 3 minutes• Blood levels should be 2-4mmols/l for therapeutic levels• 5mmols/l loss of knee jerk reflex, weakness, blurred vision, slurred speech• 7.5mmols/l muscle paralysis & respiratory arrest• 12mmols/l cardiac arrest

Bloods (order with vaccutainer system as preservatives can affect results) Blue - Clotting Screen

Purple - FBC Pink - Group & Save

Contentious issues• In the last triennium there were 16 maternal deaths from Pre eclampsia/eclampsia (8 from HELLP) - this decreased due to antenatal detection and treatment up to 1999. Now roughly constant, but two deaths were alone in hospital so still improvements and 6 had substandard care.• Chien et al (1996) found that magnesium sulfate was associated with 60 to 70 percent fewer recurrent seizures than were diazepam and phenytoin

MATERNAL RESUSCITATIONMaternal resuscitation is usually needed following cardiac arrest, when a pregnant woman needs help to restart her cardio-pulmonary system. Itoccurs in every 30,000 pregnancies.Some potential causes of collapse, necessitating CPR

• Pulmonary Embolism• Amniotic Fluid Embolism• Trauma• Haemorrage• Eclampsia• Anaesthetic Problems• Anaphylaxis• Cardiac Problems

Anatomy and Physiology changes in pregnancy affecting resuscitation

• 90% of term pregnant women completely occlude the vena cava when lying supine

• Stroke volume is 30% of a non-pregnant woman (returns almost to normal when fetus is delivered)• 20% decrease in lung volume due pressure from the uterus on lungs and diaphragm• 20% increase in oxygen demands to meet needs of fetus and uterus• Increase in progesterone means the oesophageal sphincter is relaxed so more likely to force air into the stomach or regurgitate stomach contents

Treatment of visibly pregnant woman• Lie flat• Call for help• Senior obstetrician• Obstetrician to assist (potential caesarean section)• Anaesthetist• ODP• Senior midwife• Scribe• Paediatrician• Inform SCBU• Porter• Displace uterus to remove aorto-caval compression (15-30°)• Cardiff Wedge / other support under right hip to place into left lateral position • And/or lift uterus up and to the left

• Check Airways• Place hand on mother's forehead and gently tilt head back.• Put fingertips under the point of mother's chin and lift the chin• A jaw thrust may be required - fingers behind the angle of the jaw and moving jaw anteriorly to displace tongue from the pharynx.• Remove visible debris• Check Breathing• Cheek near mouth to feel breath and watch chest for rising and falling• Agonal gasps are not a sign of life• Check circulation• Simultaneously feel carotid artery for pulse• Don't spend more than 10 seconds• If no circulation (or unsure)• 30 chest compressions

• Middle of lower half of sternum• Arms straight• Depress about 4-5cm• Rate of 100 beats a minute• 2 ventilation breaths (lasting 1 second)• Change staff frequently if exhausted• If no breathing but circulation• Ventilation breaths• Rate of 10 per minute• Recheck each minute• Anaesthetist will intubate as soon as possible• Gain IV access• If no signs of life within 5 minutes• Perimortem caesarean section• No need to go to theatre• Minimal blood loss if no cardiac output• Continue CPR throughout• May consider open cardiac massage when abdomen open• Stopping CPR is a consultant decision• Consider Defibrillation if appropriate• Consider Adrenaline• 1:10,000 -1ml (10mls) IV every 3-5minutes for cardiac arrest• 1:1,000 500mcg (0.50ml) IM every 5 minutes for general anaphylaxis• If successful make mother as comfortable as possible• Give oxygen via facemask (15L/minute)• Record Keeping, as contemporaneously as possible, when writing up notes include original scribe's transcripts

Contentious issues • In a comprehensive review of post-mortem caesarean deliveries between 1900 and 1985 (n=61) by Katz et al., 70% of infants delivered within five minutes (42) survived and all developed normally. However, only 13% of those delivered at 10 minutes (8) and 12% of infants delivered at 15 minutes (7) survived. One infant in both of these groups of later survivors had neurological sequelae.• No doctor has been found liable for performing a post-mortem caesarean section. Despite no consent they are seen as acting in the best interest of the patient• A perimortem caesarean is performed to try and increase the chance of saving the mothers life, as CPR is unlikely to succeed with a gravid uterus. The fetus has no rights in law

NEONATAL RESUSCITATIONOccurs when the neonate has problems transitioning to extrauterine life, and refers to the additional means given to aid this transition. This is usually a respiratory problem.Who is at increased risk?

• Mother under 17• Mother over 35• Diabetic mothers• Drug Abuse• Pre-eclampsia• Abruption• Prolonged labour• Prolonged rupture of membranes• pethidine• rapid birth• prematurity• breech• meconium• multiple pregnancy• congenital abnormalities• Fetal Heart rate abnormalities

Types of Apnea• First / Primary Apnea.• ^heart rate ^tone• pH levels 7 - 7.2• If baby born now will respond well to stimulation and oxygen• If pregnancy continues fetus will deteriorate• Start deep, irregular gasps• Then stop breathing• Now in Secondary / Terminal Apnea• ^heart rate ^fetal BP ^tone• pH levels <7• If baby born now will need full CPR, possible ventilation• Will take longer to resuscitate, may not be successful

How to resuscitate a neonate· If suspect a need for resuscitation then leave a long (at least 2inches) umbilical cord stump.· Note time of birth / start clock on resuscitaire· Call for help· Paediatrician· Senior Midwife· Take baby to resusitaire or resuscitation area· Dry and stimulate baby· Change towel· Airway – place head in a neutral position - hyperextension or flexion can block the airway· Assess breathing and heartrate· Inflate the lungs · Inflation breaths *5 (Pressure at 30cm of water for at least 2-3 seconds)· Check by seeing abdomen rise & HR &shy;· Repeat if lungs not inflated· Recheck head position· Need help maintaining airway? (second person/guedel airway)· Blockage? Do you need suction· Only suction under direct supervision – be careful not to stimulate vagal reflex· Reassess per cycle (30 seconds)· If HR <60bpm then start chest compression· Two thumbs at midpoint between the nipples· Hands enclosing baby

· Press down 1/3 of width· Rate 3chest compressions to 1 breath· 120 interventions per minute· Reassess per cycle (30 seconds)· If HR>100 or increasing but no breathing· Ventilation breaths *15· Every other second· Reassess per cycle (30 seconds)· Continue until spontaneous breathing by baby or paediatrician makes decision to end treatment (may be considered after 10 minutes effective resuscitation if no signs of life)· APGARs should be noted every 5 minutes, until above 8· If no signs of improvement the paediatrician may consider drugs· These are administered through an umbilical vein cannula· Adrenaline – 0.1ml/kg of 1:10,000 solution (10 micrograms)· If this fails 0.3ml/kg can be used (30 micrograms) · Sodium Bicarbonate – 2-4ml/kg of 4.2% solution· Dextrose – 2.5ml/kg of 10% dextrose

Contentious issues

· Wrap very preterm infants in food grade plastic wrapping to maintain body temperature (if hypothermia sets in very difficult to resuscitate)· With asphyxia the pH drops by 0.04 per minute, so will decrease 0.28 in 7 minutes. Much more difficult to resuscitate if pH below 7.· There is not enough evidence to recommend suctioning meconium on the perineum· No evidence to support ‘waving’ oxygen, this may stimulate baby but also cools them down· There is a debate over resuscitating with air or oxygen. Pure oxygen should not be used (can cause retinal damage), but if no improvement with room air then add supplementary oxygen

POSTPARTUM HAEMORRHAGEA postpartum haemorrhage is any bleeding from the genital tract, following the birth of a baby, of more than 500mls or any amount that adversely affects the mother. A primary postpartum haemorrhage occurs within the first 24 hours, a secondary postpartum haemorrhage occurs after this - usually around day 10. Variance ranges from 4 -11% of all births.Potential risk factors for postpartum haemorrhage

• Multiple pregnancy• Macrosomia• Polyhydramnios• Grandmultiparity• Retained placenta• Augmented labour• Placenta previa• Antepartum haemorrhage• Instrumental birth• Caesarean Section• Clotting Disorders• Previous PPH

There are 4 categories that cause postpartum haemorrhage

Tone (70%) Trauma Tissue Thrombin· Grand Multiparity· Multiple pregnancy· Polyhydraminos· Macrosomia· Abnormalities: fibroids· Prolonged labour· Precipitate labour· Dysfunsctional labour· Intrauterine infection· Uterine relaxing agents(Magnesium / general anaesthetic/ tocolytics)

· Operative delivery· Cervical / vaginal lacerations· Previous caesarean section increases risk of morbidly adherent placenta

· Retained placental tissue or membranes

· Pre-eclampsia· HELLP Syndrome· Placental abruption· Amniotic Fluid Embolism· Sepsis· Bleeding disorders· Drugs (aspirin / heparin)

Potential Con sequences of PPH

• Shock• Maternal Death• DIC• Hysterectomy

Treating a Primary Postpartum Haemorrhage· Call for help· Senior Obstetrician· Senior Midwife· Anaesthetist· ODP· Senior midwife· Scribe· Porter· Notify Haematologist· Site two large bore venflons· Take bloods· FBC· Clotting (including platelets)· Crossmatch· Get 4-6 units of blood ready in case of blood transfusion· Stabilise mother· Frequently assess maternal observations (usually Anaesthetist’s job)· Maternal oxygen 8L/min· Monitor fluid input/output· IV Crystalloid or Colloid Hartmanns/normal Saline (NOT DEXTROSE) – fast i.e. 5-10mins if major PPH· IV Plasma substitute (Haemacell 500mls) · Include blood transfusion in fluid in balance· Catheterise · Need at least 30mls/hr· Continually assess volume of blood loss· Check uterine tone· If lax/boggy· Rub up a contraction· Repeat/give syntometrine (or ergometrine)· Syntometrine (1ml = 5IU of syntocinon and 500mcg ergometrine)· Ergometrine 0.5mg (500mcg) IV· Do not give if hypertensive· Set up IV syntocinon – 40IU/500mls normal saline over 4 hours (check policy)

· Haemobate/Carboprost 0.2mg IM every 15 minutes (max 8 doses – 2mg)· Obstetrician can give myometrically (directly into uterus)· Transfer to theatre for surgery if bleeding not stopped· Tie off/cauterise all ligaments (blood flow) to the uterus· Assess quickly for bleeding from trauma site· If obvious trauma transfer to theatre for suturing of cervix, perineum etc· Is placenta in situ?· Try to deliver placenta· Careful not to invert uterus· Get someone to check for completeness if out· Transfer to theatre for manual removal if adherent or pieces missing· Haematologist will instruct if clotting disorders· May need additional clotting factors infused· If no idea why bleeding is occurring / cannot stop it· Get Consultant if not already present· Apply bimanual compression· Or compress aorta· (fist just above umbilicus and to the left – if you can feel the femoral pulse you aren’t pressing hard enough)· Consider CVP line (Anaesthetist to insert)· Transfer to theatre if not already there· GA· Obstetrician to carry out manual exploration· Possible ruptured uterus· Possible Intrabdominal Bleeding· Broad Ligament Haematoma· Consider transfer to ITU when bleeding under control· May need additional blood transfusion / iron supplements· Record Keeping, as contemporaneously as possible, when writing up notes include original scribe’s transcripts

Contentious issues

· 10 women died of PPH in the last triennium (ten fold increase from previous triennium), although 2 were concealed pregnancies with an unattended PPH at home – possibly could have been treated and saved?· The main problem with such a catastrophic bleed is that DIC can occur (disseminated intravascular coagulation) when this happens the clotting mechanism in the blood 'goes all to ****' with little blood clots forming in the capillaries - this uses up all the clotting factors and means that it can’t clot where it’s meant to. If heparin is given it can cause those mini-clots to break down and reset the system. However it’s a balancing act, too little won’t do a thing, too much can kill her· Breastfeeding causes the body to release oxytocin, useful in case of minor bleed or to encourage placenta to come out· Anaemia does not increase the risk of a postpartum haemorrhage, however it will affect how the woman can cope with the blood loss, so may become symptomatic much early than someone with a high Hb.· RCOG recommend that an arterial balloon occlusion and embolism are used to reduce need for transfusions and hysterectomy where there is a known high risk of PPH – the balloon is placed in the iliac and uterine arteries prior to section for previa over old scar or known placenta accreta.· Due to the increased blood volume of a healthy pregnant woman at term, the woman won’t show signs of shock until she has lost a good deal of blood (over 1L) – don’t assume there is no danger because BP is normal· A B-lynch suture, where the uterus is sown up and over, in a belt and braces fashion, can stop haemorrhage effectively and preserve future fertility.

SHOULDER DYSTOCIA

There is no one definition for shoulder dystocia, but it occurs when the shoulders do not deliver spontaneously with gentle traction. It is caused by the anterior shoulder becoming impacted against the symphysis pubis, after delivery of the head. It occurs when the breadth of the shoulders is greater than the biparietal diameter of the head. It occurs in between 0.3 - 1% of all births. If birth weight >4kg then 5-7% risk & birth weight <4.5kg 8-10% risk but 50% occur in normal birth weight babiesWho is at greater risk?

• Age over 35• short mother (under 5 2)• small pelvis• postdates• macrosomia• maternal weight over 90kg• mother was macrosomic• diabetic• previous shoulder dystocia• male fetus• ocytocin• prolonged 1st stage• prolonged 2nd stage• head bobbing / turtling• instrumental delivery

Remember not all shoulder dystocias are not predicted by the existing riskfactors.

What to do when you identify a case of shoulder dystocia

· Call for help· Senior obstetrician· Senior midwife· Scribe· Paediatrician· Inform SCBU· Note time of birth of head

· Decide if episiotomy is required· Abduct and flex the woman’s legs to as close as her shoulders as possible (McRoberts position). This straightens the symphysis pubis and allows the coccyx to drop to give extra room. Lurie et al (1994) found this resolved 88% cases of shoulder dystocia (n=76)

· Try delivering shoulders & note time · Apply suprapubic pressure in the direction of the fetal back, this is to try and rotate the anterior shoulder into the oblique position. (Rubins I)· Apply continuous pressure for 30 seconds· Apply intermittent pressure for 30 seconds· If feel movements try delivering shoulders· Note time

· Enter the vagina to perform internal manoeuvres· Rubins II – enter along the fetal back then apply posterior pressure to the anterior shoulder. This is to try and rotate the anterior shoulder into the oblique.

· Woods Screw – leave first hand where it is, use other hand to enter

with two fingers along the fetal front – while using same pressure as before add anterior pressure to the posterior shoulder. This is to try and rotate the anterior shoulder into the oblique and as it moves it will ‘screw’ forward and down.· Reverse woods screw – remove second hand then drop the two fingers from the first hand to the posterior aspect of the posterior shoulder and apply pressure. This is to try and rotate the posterior shoulder to the anterior position as it moves it will ‘screw’ forward and down. Swap hands halfway through movement to complete rotation.

· If feel movements try delivering shoulders · Note time of each manoeuvre· Try to remove the posterior arm· Insert your whole hand (hand which the fetus is facing) under the fetus· Splint the posterior arm and bend at the elbow· Sweep over the chest and face in a cat lick manoeuvre· This should cause the fetus to drop down and allow the shoulders to deliver· Note time· Roll the mother onto all fours – known as the Gaskin Manoeuvre. The movement can help the fetus to rotate and prevent pressure on the coccyx· Note time of delivery· Be prepared for resuscitating neonate, have paediatrician there if possible· Record Keeping, as contemporaneously as possible, when writing up notes include original scribe’s transcripts

Manoeuvres can be performed in any order.

Complications - Maternal• 3rd/4th degree tears or extended episiotomy• Vaginal lacerations• Postpartum haemorrhage• Uterine rupture• Death

Complications - Baby• Brachial Plexus injuries• Erb's palsy• Klumpke's palsy)• Fractures• Clavicle• Humerus• Hypoxia• DeathContentious issues

• You have roughly 7 minutes to get baby out before irreversible brain damage sets in. The pH drops by 0.04 per minute, so will decrease 0.28 in 7 minutes. Much more difficult to resuscitate if pH below 7.• Alternative methods to deliver fetus - can't be done by midwife:• Zavanelli manoeuvre - replacing the fetal head into

the vagina to perform caesarean section

• Cleidotomy -deliberately breaking the clavicle to reduce diameter of the shoulders, occasionally happens by accident during internal manoeuvres

• Symphysiotomy - surgically separating the symphysis pubis to allow extra room- not often done in the Western world

• Despite a small study by Bruner et al (1998) (n=82) showing all cases resolved by Gaskin Manoeuvre, with no mortality or brachial plexus injuries most don't use this as a first line, often as unable to move mother especially if an epidural in situ. Often used in community.• Sometimes McRoberts is done in anticipation - there is no proof this works• The Advanced Life Suport In Obstetrics (ALSO) course teaches the HELPERR pneumonic, which is used in the UK as good practice• You can have a posterior shoulder dystocia, where the posterior shoulder is impacted behind the sacral prominary.

VAGINAL BREECH BIRTHA breech presentation, where the feet or buttocks lie nearest the cervix,occurs in 3-4% of all TERM pregnancies.

There are four types of breech presentation: (incomplete breech encompasses a partially flexed (one leg crossed) breech, footling and knee presentations)

• frank breech (both legs straight against the abdomen, feet by the head) - 6070%

• complete (or flexed) breech (legs are crossed) - 30-40%• footling breech (one or both feet below the buttocks) - 1%• knee breech (one or both knees below the buttocks) - rare

Potential Causes• Prematurity (20% at 28 weeks)• hydrocephaly• polyhydramnios• oligohydramnios• multiple pregnancy• bicornate uterus (septate uterus)• fibroids• placenta previa• fundal placenta• IntraUterineDeath• primigravida• grandmultips

Recommended Management of breech at termAt 37 weeks (or 36) women with an uncomplicated pregnancy should be offered an ECV. A cochrane review (Hofmeyr, 2003) showed that 67% of babies turn to cephalic with ECV, rather than the 22% who turn spontaneously. Babies aren't at increased risk with ECV.In 2000 an international RCT - the Hannah trial (n=2088) showed that it the perinatal mortality and morbidity rates were decreased by three quarters.People including one of the authors have criticised the study - but even when ability of practitioner, footling breech and augmentation of labour are taken into account there is a higher risk. This has lead to most hospitals recommending elective caesareans for all breech presentations. However Glazerman (2006) (one of the authors of the Hannah trial) did a 5 year follow up to the Term Breech Trial and found that despite this new policy the perinatal mortality and morbidity rates were unchanged.

How to diagnose a breech• Woman complaining of a pain/ hard lump under her ribs• States feels most movements low down• On palpation - Hard, ballotable pole in the fundus

• Softer presenting part on VE, may feel the anus, or a very prominent ridge (between buttocks)

• Thick ’toothpaste' meconium following rupture of membranes

• FHHR at or above umbilicus

• Confirm by USS

Risks involved with breech babies• Cerebral Palsy (with presentation NOT method of birth)• Congenital Hip Dysplasia (with presentation NOT method of birth)• Cord Prolapse• Premature placenta separation (if too upright in second stage)• Intracranial haemorrhage and tentorial tears (too rapid delivery of the head or by anoxia)• Fractures (mismanagement of manoeuvres)• Rupture of internal organs (mismanagement - holding abdomen)• Genital damage• Dislocation of jaw (if mauriceau-smellie-veit done incorrectly)• Hypoxia (cord compression)• Hypothermia

How to conduct a vaginal breech birth HANDS OFF THE BREECH

• Due to increased risk of hypoxia and cord prolapse, it is recommended that for a known breech presentation there is continuous monitoring (obviously this is for hospital births)• Confirm full dilatation by a vaginal examination• In the second stage move the mother into a position to allow the baby to hang with gravity, either lithotomy or all fours• Consider episiotomy when the breech is distending the perineum - theory being it will prevent the head getting stuck by the tissue, not always needed, use judgement. In a term well grown fetus the bitrochanteric diameter is 9.5cm so if bum gets through the head, if flexed, should be fine.• Some say cover/wrap baby to prevent hypothermia• Let mother push baby out on her own, if baby continues to descend on it's own then let it be. If stops descending with contraction, you may need to help as below at each point - after each intervention go back to hands off. Hands on can stimulate baby to breathe while in utero or stimulate the morrow reflex and extend the arms.• Baby needs to have its back to symphysis pubis• If the extended legs hold baby up, then use popliteal pressure. Splint the leg with your fingers, then abduct to the side and then flex the knee. Do

same for other leg if needed.• Note time of birth up to umbilicus - the umbilical cord will start to be compressed and fetus will stand 7 minutes without oxygen, so don't panic• If the arms are extended then you need to bring them down using Lovset's manoeuvre.• First hold by pelvic girdle and rotate up to 180° to bring the arm in front of the face.• Then the arm can be swept down and across the face as in a cat's lick, bringing the arm in front of the face.• If necessary repeat for the other arm.• Turn back to the original position afterwards• Back to hands off until you can see the nape of the neck (hairline) - hanging will keep baby well flexed.• Use mauriceau-smellie-veit to slowly deliver the head. Too fast may cause tentorial tears. Keep the head flexed by pressing forward with one hand, baby straddles your arm. The lower hand is on baby's cheeks and chin NOT in the mouth• Baby is more likely to need resuscitation so be prepared. If possible have a paediatrician present for the birth.• Record Keeping, as contemporaneously as possible, when writing up notes include original scribe's transcripts

Contentious issues• If there is any delay in the first (or second) stages, most people experienced in breech births will not augment and will proceed to caesarean - for this reason only about 57% of attempted vaginal breech births result in a vaginal birth.• The preterm breech is often more severely compromised during a vaginal birth- however a cochrane review (Grant and Glazer, 2003) said there was not enough evidence to routinely performed caesareans in this situation, although most obstetricians will.• The biggest fear is that of an entrapped head, hence why full dilation is confirmed by VE, this is more likely with a preterm or IUGR fetus. This can be managed by :• Durrssen's incisions (cutting the cervix) however this will result in a large blood loss• symphysiotomy (surgically separating the symphysis pubis to allow extra room)- not often done in the Western world