UST-FMS

Obstetrics JI OSCE Reviewer

OB ROTATION OSCE
I. Intrapartum Electronic Fetal Monitoring
II. Clinical Pelvimetry
III. Partograph & Stages of Labor
IV. Management of the 2nd stage of labor
• Cardinal movements
• Pudendal Block Anesthesia
• Episiotomy
• Operative Vaginal Delivery
• Maneuvers of Delivery
V. EINC & Active management of the 3rd stage of labor
VI. Instrument Identification
VII. Knot Tying
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I. Intrapartum Electronic Fetal Monitoring
Performed to assess if the fetus can tolerate the stress of labor
Parameters to be identified in an EFM Tracing
• Fetal Components (Fetal heat rate)
o Baseline Fetal Heart Rate
o Variability
o Accelerations
o Decelerations
• Maternal Components (Uterine contractions)
o Duration
o Interval
o Intensity
Baseline Fetal Heart Rate
• Approximate mean fetal heart rate which recurs in a 10-minute segment excluding
decelerations, accelerations, contractions and periods of marked variability.
o Look at the area of a tracing which is least variable
o It must be sustained for at least 2min
• Normal value: 110-160bpm (term); 160bpm (preterm)
o Report in increments of 5bpms
o Fetal bradycardia - <110bpm for >10min
o Fetal tachycardia - >160bpm for >10min
Baseline Variability Beat to beat fluctuation of FHR
• Fluctuations in the baseline FHR that are irregular in amplitude and frequency
Variability Change in BFHR
Absent – not anymore included in the new guidelines, it is Undetectable/absent
now part of minimal
Most important parameter is
variability: cardiovascular
activity) Minimal <5bpm
Most common cause of
minimal variability: baby is Moderate 6-25bpm
asleep ( stimulate/fetal
acoustic stimulation); if not,
baby is acidotic (sign of
Marked >25bpm
fetal acidemia)

Most important parameter as it reflects CNS activity
•
Sinusoidal Fetal Heart Rate Pattern – wave-like undulating pattern with a cycle
•
frequency of 3 to 5 beats per minute that continues for at least 20 minutes or more with
loss of variability. Ominous sign of fetal anemia à CS!
Accelerations
• Abrupt increase in FHR of at least
o 15bpm above the baseline for at least 15seconds (15s-2min), AOG >32w
o 10bpm above the baseline for at least 10seconds (10s-2min), AOG <32w
• Prolonged acceleration – acceleration sustained for >3min but less than 10min
• Change to Baseline FHR – if acceleration is sustained for >10min
• Presence of acceleration in the intrapartum period is indicative of a reactive and a
healthy fetus.

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UST-FMS Obstetrics JI OSCE Reviewer

Decelerations – decrease in BFHR of at least 15bpm lasting >15s

Deceleration Definition Cause Management
Visually apparent, Head compression
symmetrical & gradual There will be an
decrease in BFHR of increase of ICP via
>15bpm lasting for >15s. baroreceptors
à
Begins with the onset of Stimulation of the
a contraction, nadir vagus
Early occurs with the peak of à None. This is
the contraction and Tonic influence of normal.
recovery occurs in the heart
conjunction with the end à
of the uterine Decrease FHR to
contraction. decrease blood flow
“Mirror Image” to the brain (to
lessen ICP)
Uteroplacental
insufficiency

Each fetus has an
Late Visually apparent, O2 reserve in the
Most ominous symmetrical & gradual uteroplacental
decrease in BFHR of space
>15bpm lasting for >15s. à
Contraction Do intrapartum resuscitation.
The deceleration is (deprivation of O2) Reposition:
compression
attempt to remove the cord

delayed in timing, with à

the nadir of the Fetus uses up its
deceleration occurring reserve
after the peak of the à Intrauterine
contraction If reserve is used resuscitation
“Late talaga” up, (30min)
chemoreceptors to -Stop oxytocin
tell the heart to -Maternal
decrease HR to repositioning to
conserve O2 lateral decubitus
à -Oxygen
Late dec because supplementation
chemoreceptors -IV fluid hydration
need to reach a run 200-300cc
threshold first
Visually apparent If persistent
decrease in BFHR of despite above
>15bpm lasting for >15s. Cord compression & measures, deliver!
Variable sudden cessation of
Occurs before, during, or umbilical blood flow
after the contraction or
even without
contractions.
Prolonged Visually apparent Usually associated
decrease in BFHR of with rebound
>15bpm lasting for 3min tachycardia and loss
but <10min of variability = heart
is trying its last few
efforts to increase
HR

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Take all the variables assessed for FHR and conclude what they mean using the Three-Tiered
Fetal Heart Rate Interpretation System

Three-Tiered Fetal Heart Rate Interpretation System

Tracing Interpretation Features
Category I: Tracings in this category are strongly Baseline rate 110-160bpm
Normal predictive of normal acid-base status at the Moderate variability
time of observation (+)/(-) Accelerations
(+)/(-) Early dec
(-) Late or Variable dec
Category II: Tracings in this category are not predictive of All tracings not categorized
Indeterminate abnormal acid-base status, however there is as category I or III
insufficient data to classify them as either
category I or category III
Absent variability & any of
Category III: Tracings in this category are predictive of the ff:
Abnormal abnormal acid-base status at the time of -Recurrent late dec
observation - Recurrent variable dec
- Bradycardia

Sinusoidal pattern


Uterine Contractions
• Duration – measure from the beginning to the end of 1 contraction
• Interval – measure from the beginning of 1 contraction to the beginning of the next
contraction
o Normal uterine activity: <5 contractions in 10min, averaged over a 30-minute
period
o Uterine Tachysytole: >5 contractions in 10min, averaged over a 30-min period
• Intensity
o 0-100mmHg
§ 0-40: Mild
§ 40-80: Moderate
§ >80: Strong
o Montevideo Units (MVU) – assessed using intrauterine pressure catheter

§ Montevideo units are calculated by subtracting the baseline uterine
pressure from the peak contraction pressure for each contraction in a 10-
minute window and adding the pressures generated by each contraction
§ In the example shown, there were five contractions, producing pressure
changes of 52, 50, 47, 44, and 49 mm Hg, respectively. The sum of these
five contractions is 242 Montevideo units.

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 UST-FMS Obstetrics JI OSCE Reviewer

II. Clinical Pelvimetry












Pelvic Inlet – measure the adequacy of the pelvic inlet using the:
• Diagonal Conjugate – distance between the symphysis pubis & the sacral promontory,
must be approximately >11.5cm. Insert fingers like in the picture, using your tallest
Diagonal conjugate: to measure finger (know the length), try to reach for the sacral promontory = dapat hindi abot para
the AP diameter
adequate THEN say: “The sacral promontory is not accessible, the diagonal conjugate is
probably >11.5cm and is adequate”
o True conjugate – upper border of the symphysis pubis (S) to sacral promontory
(P), not measurable.
o Obstetric conjugate – shortest distance b/w S & P, clinically significant but not
measurable. (>10cm)
o Diagonal conjugate – what we can measure, an estimate of the obstetric
conjugate. Diagonal conjugate – 1.5 or 2cm = Obstetric conjugate

• Engagement
o Academic definition: Engagement has occurred when the biparietal diameter of
the fetal head has passed through the pelvic inlet. Can not be assessed clinically,
so:
o Clinical definition: Engagement has occurred when the biparietal diameter of the
CPD: diagnosed by trial of labor
fetal head is at the level of the ischial spines (at station 0)
• Muller-Hillis Technique To assess the transverse diameter
o Push the uterine fundus downward while IE fingers are in the vagina, then if the
head of the fetus reaches the ischial spine = (+) adequate pelvic
inlet/engagement has occured
o Head is at ischial spine = station 0 = head is engaged

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Midpelvis – measure the adequacy of the midpelvis by assessing
• Transverse diameter (Interischial spinous/Interspinous diameter)
o Distance between the 2 ischial spines
o Smallest pelvic diameter. Adequate if >10cm
o Feel for the sacrum
o Feel the ischial spines
o Assess convergence of the sidewalls
o Then say: “Ischial spines are not prominent, the sacrum is curved and the pelvic
sidewalls are not convergent”







•

Pelvic Outlet – assess adequacy of the pelvic outlet
• Subpubic arch must be >90°
o Estimate the angle of the subpubic arch (see pic)
o Then say “The subpubic arch is >90° therefore is wide and adequate”
• Bituberous diameter must be >8.5 cm
o Say: “The bituberous diameter can accommodate 4 knuckles indicating it is
>8.5cm and is therefore adequate”

Least problem: bec u can do episiotomy and can do for eps extraction

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Speech
Inlet “The sacral promontory is not accessible, the diagonal conjugate is probably
>11.5cm and is adequate”
“I will assess if the head is engaged, if not, I will perform the Muller Hillis
maneuver”
Midpelvis “Ischial spines are not prominent, the sacrum is curved and the pelvic
sidewalls are not convergent”
Outlet “The subpubic arch is >90° therefore is wide and adequate”
“The bituberous diameter can accommodate 4 knuckles indicating it is >8.5cm
and is therefore adequate”



III. Partograph & Stages of Labor

Partograph
• Plots Cervical dilatation in cm (Y1) & fetal descent in stations (Y2) against time in hours
(X)
• Time 0h = time of admission
• Allows identification of various disorders of labor














Amniotomy

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Before we proceed with the disorders of labor, we must know first what is normal
Stage 1 Stage 1 Stage 2 Stage 3
Latent Active Phase
Phase
Begins Regular > 4cm cervical 10 cm cervical Delivery of
contractions dilatation dilatation neonate
Ends <4cm cervical 10 cm cervical Delivery of Delivery of
dilatation dilatation neonate placenta
Normal <14h in multipara <4h in <30min in <30 mins
duration multipara multipara
<20h hrs in (CD (Descent
primipara >1.5cm/hr) >2cm/h)

<5h in <60min in
primipara primi
(CD > 1.2 (Descent
cm/hr) >2cm/h)

Traditional management:
Wait for the signs of placental
separation. Sudden gush of blood. The
uterus becomes an abdominal organ
(Calkin's sign). The lengthening of the
cord. Then do gentle traction and
suprapubic retraction.

Active management of labor:

10cc of oxytoxin then gentle protration
nd suprapubic retraction.
Check for the completeness of
placenta. Then do uterine massage.

Signs of completing curettage.

There is a gritty feeling.
Frothy
Bright red blood
Means tou already opened the sinuses.

Stages of Labor
1st stage: Contractions & cervical dilatation
• Begins: With the onset regular uterine contractions of sufficient frequency, intensity,
and duration
• Ends: Full cervical dilatation & effacement
• 1st stage is further divided into the Latent Phase & the Active Phase (then the active
Phase is further divided into 3 more phases)



8cm: dilational divison; it will
now descent

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• Latent Phase (Start of regular UCs up to <4cm cervical dilatation)
o Primi: <20h; Multi: <14h
• Active Phase (4-10cm cervical dilatation)
o Primi: <5h; Multi: <4h
o Acceleration phase (4-5cm cervical dilatation)
§ Transition from latent to active phase
o Phase of Maximum Slope (5-8cm cervical dilatation)
§ Coincides with the dilatational division of labor as during this time, there
is rapid cervical dilatation (steep slope in the curve)
§ Primi: >1.2cm/hour
§ Multi: >1.5cm/hour
o Deceleration phase (8-10cm cervical dilatation) – descent must begin at 8-9cm
CD. This marks the beginning of the pelvic division of labor

nd
2 stage: Fetal descent & delivery
• Begins: Full cervical dilatation (10cm) & effacement (100%)
• Ends: Delivery of the neonate
• Usual duration: Primi <1h; Multi <30min
• Rate of descent: Primi >1cm/h; Multi >2cm/h
• Phase 1: Passive
o 10cm to further descent
o Pelvic floor musculature begins to distend, initiating spontaneous urge to push
“nadudumi na”
• Phase 2: Active
o Onset of active pushing “push mommy!”
3rd stage: Placental delivery
• Begins: Delivery of the neonate
• Ends: Delivery of the placenta
• Duration: Primi & multi: 30min

Functional Divisions of Labor PDP
1. Preparatory Division
• Begins: Latent phase of the 1st stage (Stage 1 Latent)
• Ends: Acceleration phase of 1st stage’s Active phase (Stage 1 Active: Acceleration)– look
at the graph para di magulo
2. Dilatational Division
• Coincides with the Phase of Maximum Slope (Stage 1 Active: PMS)
3. Pelvic Division
• Begins: Deceleration phase of Stage 1 Active
• Ends: Delivery of the neonate

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ABNORMAL LABOR PATTERNS

Labor Pattern Diagnostic Criteria Etiology Treatment
Excessive sedation, Bed rest + sedatives.
CD remains at <4cm for: conduction analgesia, Oxytocin –if bed rest
Prolonged Latent >20h (Primi) Unfavorable cervix is C/I.
Phase >14h (Multi False labor
Uterine dysfunction CS – (+) CPD, fetal
distress
CD ≥4cm, but dilatation PPP Problem Assess PPP
Protracted Active slowly progresses at: Exessive sedation,
Phase Dilatation <1.2cm/h (Primi) CPD, malposition, Expectant
Active <1.5cm/h (Multi) conduction analgesia monitoring
phase
CS – (+) CPD
Secondary Arrest CD ≥4cm & MVU >200,
in Cervical but dilatation STOPS for
Dilatation >2h (Primi & Multi)
CS – (+) CPD
Prolonged CD ≥8cm not reaching Oxytocin – (-) CPD
Deceleration 10cm for:
Phase >3h (Primi) or >4h (w/
epid)
Stage 2 >1h (Multi) or >2h (w/
epid)

CD≥8cm but descent of PPP Problem Expectant
Stage 2 the Fetal head is at a Exessive sedation, monitoring
Protracted slow rate of: CPD, malposition,
Descent <1cm/h (Primi) conduction analgesia CS – (CPD)
<2cm/h (Multi)
CD≥8cm but there is no
Arrest of Descent change in descent for
>1h (Primi & Multi)
Failure of Descent CD≥8cm but descent has CS – (+) CPD
not occurred at all, with Oxytocin – (-) CPD
fetal head above or at
station 0. (Primi & Multi)

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IV. Management of the 2nd stage of labor
• The 2nd stage of labor begins at full cervical dilatation & effacement and ends with the
expulsion of the neonate

Cardinal movements


LOT












• Engagement
o Academic definition: Engagement has commenced when the biparietal diameter
of the fetal head has passed through the pelvic inlet. Can not be assessed
clinically, so:
o Clinical definition: Engagement has occurred when the biparietal diameter of the
fetal head is at the level of the ischial spines (at station 0)
o At the level of the pelvic inlet, the maternal bony pelvis is sufficiently large to
allow descent of the fetal head
o At station 0, the fetal head is at the bony ischial spines and fills the maternal
sacrum
o Primigravidas – occurs by 38 weeks AOG; Multigravidas – at the onset of labor

LOT

Engagement

Descent

Flexion
Internal
rotation
Extension

External rotation
(Restitution)

Expulsion

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• Descent
o Downward passage of the presenting part through the pelvis which occur
intermittently with contractions
o Factors facilitating descent
§ Fundus upon the breech
§ Contraction of the abdominal muscles and extension
§ Straightening of the fetal body
§ Thinning of the lower uterine segment
§ Pelvic configuration, size and position of the presenting part may also
play a part
o The rate is greatest during the deceleration phase of the first stage and during
the second stage of labor
• Flexion
o Results when the descending head meets resistance from the cervix, walls of
pelvis, pelvic floor
o Chin is brought closer to the fetal thorax = presenting diameter shifts to the
shorter suboccipitobregmatic diameter (vertex, flexed) from the longer
occipitofrontal diameter (vertex, military)

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• Internal Rotation

LOT More AP: Almost OA




à







o Occiput gradually moves anteriorly toward the symphysis pubis (or less
commonly, posteriorly toward the hollow of the sacrum)
o IR is the Rotary movement of the fetal head from the transverse to the antero-
posterior position
o Starts at about the level of the ischial spines and is generally completed as the
head reaches the pelvic floor
o Pre-requisites for anterior rotation of the head
§ Well-flexed head
§ Efficient uterine contractions
§ Favorable mid-pelvic plane
§ Tone of the levator ani muscles


• Extension

OA OA




à







o Upon contact of the base of the occiput with the inferior margin of the
symphysis pubis, there is upward resistance from the pelvic floor and downward
forces from the uterine contractions that causes the occiput to extend and
rotate around the symphysis (walang choice yung head kundi mag-extend due to
the said forces at play)
o The occiput serves as a hinge allowing the extension of the fetal head
o Progressive distension of the perineum and vaginal opening à increasingly
larger portion of the occiput gradually appears
o Head is born as the occiput, bregma, forehead, nose, mouth, and finally the chin
pass successively over the anterior margin of the perineum

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• External Rotation (Restitution)

OA LOT





à






o Delivered fetal head undergoes restitution
§ Return of the fetal head to the correct anatomic position in relation to
the fetal torso
§ If the occiput was originally directed toward the left, it rotates toward the
left ischial tuberosity; if it was originally directed toward the right, the
occiput rotates to the right
o Followed by completion of external rotation to the transverse position
o Rotation of the fetal body
o Fetus resumes its face forward position, with the occiput and spine lying in the
same plane
o One shoulder is anterior behind the symphysis and the other is posterior SO YOU
DELIVER THE ANTERIOR SHOULDER FIRST THEN THE POSTERIOR SHOULDER. Why
in this sequence?
§ We deliver the anterior shoulder 1st because the symphysis pubis
presents as a marked bony resistance anteriorly as opposed to the
muscles and soft tissues of the pelvic floor over the posterior shoulder






à







• Expulsion
o Anterior shoulder appears under the symphysis pubis, and the perineum soon
becomes distended by the posterior shoulder
o After delivery of the shoulders, the rest of the body quickly passes

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Synclitism
• The sagittal suture is midway between the symphysis pubis and the sacral promontory

Asynclitism
• Describes the fetal head that is directed anteriorly towards the symphysis pubis or
posteriorly towards the sacral promontory
• NAEGELE’S OBLIQUITY: anterior parietal bone presents and the sagittal suture is more
posterior aka ANTERIOR asynclitism
• LITZMANN’s OBLIQUITY: the posterior parietal bone presents and the sagittal suture is
more anterior aka POSTERIOR asynclitism

Anterior Asynclitism Posterior Asynclitism
(Naegele’s Obliquity) (Litzmann’s Obliquity)
Parietal bone Anterior Posterior
Sagittal suture Posterior Anterior

Pudendal Nerve Block

Pudendal Nerve
• Sensory, autonomic & motor nerve
• Roots: S2, S3, S4
• Sensory innervation to the perineum, anus, and the more medial and inferior parts of
the vulva and clitoris
• Passes beneath the posterior surface of the sacrospinous ligament just as the ligament
attaches to the ischial spine
o Courses between the piriformis and coccygeus muscles – exits through the
greater sciatic foramen in a location posteromedial to the ischial spine
o Courses along obturator internus muscle within the pudendal canal (Alcock
canal), which is formed by splitting of the obturator fascia
• Branches
o Dorsal nerve of the clitoris – innervates the skin of the clitoris
o Perineal branch – muscles of the perineum, skin of the labia majora, labia minora
& the vestibule
o Inferior rectal branch – external anal sphincter, mucous membrane of the anal
canal & perianal skin

Pudendal Nerve Block
• The nerve is blocked in the area of the sacrospinous ligament, proximal to its terminal
branches
• Indications
o Analgesia for the 2nd stage of labor
o Repair of an episiotomy or perineal laceration
o Forceps delivery
o Minor surgeries of the lower vagina & perineum

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• Contraindications
o Patient refusal, non-cooperative patient, sensitivity to local anesthetics
o Infections in the ischiorectal space & adjacent structures, including the vagina &
perineum
o Coagulation disorders
• Methods
o Transvaginal PNB
§ More reliable, most often used
o Transcutaneous PNB
§ Used when an engaged head makes vaginal palpation of the spine more
difficult
• Speech
o Once the head is at the pelvic floor/station +4, I will aspirate 10ml of 2%
Lidocaine using a syringe
o I will connect a Gauge 21-23 spinal needle to the syringe
o After which, I will insert the index & middle fingers of my right hand into the
introitus to palpate the right ischial spine. Once localized, I will guide the Iowa
trumpet between my 2 fingers using my left hand and direct the ball 1cm medial
& inferior to the ischial spine then secure the trumpet with my thumb
o I will insert the spinal needle & stab the sacrospinous ligament
o I will then aspirate to make sure not to inject the anesthetic intravascularly
o I will then administer 5ml of Lidocaine, once administered, I will retract the
needle into the trumpet and then withdraw the trumpet from the introitus.
o I will elicit the anal wink response by gently stroking/pinching the ipsilateral
perineum/perineal body/posterior fourchette to establish adequacy of the block,
once established:
o I will repeat the same steps on the contralateral side











o I will then ask the patient to bear down, then I will perform mediolateral
episiotomy (Station +5)
o I will perform the Ritgen’s maneuver to prevent further laceration & to facilitate
the cardinal movement of head extension
o I will proceed to restitute the fetal head by rotating it in such a way that the
occiput lies on the same plane as the fetal spine. I will then deliver the anterior
shoulder by applying gentle downward traction then proceed to the delivery the
posterior shoulder by gentle upward traction then to the delivery of the rest of
the neonate. I will slide my hand along the fetal back to grasp the lower
extremities & place the neonate on the mother’s abdomen
o I will then proceed to EINC followed by active management of the 3rd stage of
labor


Assisted Vaginal Delivery
• Operative vaginal birth
• Refers to the use of vacuum or forceps during the second stage of labor to achieve a
vaginal delivery
o Vacuum – traction
o Forceps = traction, rotation, flexion, extension

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Forceps Delivery
• Maternal Indications
o Maternal exhaustion – most common
o To shorten 2nd stage of labor & avoid the need for prolonged bearing-down in
women with SLE, Pre-eclampsia, Heart disease, Pulmonary injury or compromise,
Intrapartum infection, Certain neurological conditions
• Fetal Indications
o Non-reassuring fetal heart rate pattern
o Premature placental separation
• Classification of Forceps Delivery
Criteria Notes
High Above/at Station 0 No place in contemporary
forceps obstetrics as it is associated with
fetal morbidity & mortality
Mid Between Station 0 & +2 Head is engaged (below the
forceps ischial spines) but is not at the
level of the perineal floor yet
Low Leading point of the skull is at Station > +2 but not Designed to prevent fetal
forceps on the pelvic score and; asphyxia & to reduce injury and
*2 types 1. Rotation is <45o (LOA or ROAàOA // LOP or suffering of mother.
ROPàOP) or Done together with an
o
2. Rotation is >45 episiotomy.
Saves the mother a period of
bearing-down o Less damaging
than prolonged pounding of
the head on the perineum
Outlet Scalp visible at introitus w/o separating labia. Fetal head is at or on the
forceps Fetal skull has reached pelvic floor. perineum
Sagital suture is in the AP diameter or OA, OP, ROA
or LOA position Elective & prophylactic only for
Rotation does not exceed 45° outlet forceps

• Pre-requisites for Forceps Delivery
A ADDRESS Consent
ANESTHESIA Mid/low = general/regional anesthesia, Outlet = pudendal blockade
ASSISTANCE For neonatal support
ABSENCE Absence of a contraindications: CPD, bone demineralization, coagulopathy
B BLADDER Bladder empty for more space for the instruments
C CERVIX Fully dilated & effaced, membranes ruptured, vertex presentation
CONTRACTIONS Adequate
D DETERMINE Position, station, and pelvic adequacy
Think possible shoulder dystocia
E EQUIPMENT Check proper equipment
F “PH”ANTOM LEFT blade, LEFT hand, maternal LEFT side, pencil grip and vertical insertion,
APPLICATION with right thumb directing blade.
RIGHT blade, RIGHT hand, maternal RIGHT side, pencil grip and vertical
insertion with left thumb directing blade.
LOCK blade and support- check application
G GENTLE Applied with contraction/expulsive efforrt
TRACTION
H HANDLE Traction in axis of birth canal. Do not elevate handle too early
ELEVATED.
HALT Know when to stop: Failure of proper application, rotation &
Inadequate descent with traction
I INCISION Consider episiotomy
J JAW Remove forceps when jaw is reachable or delivery assured
o For vacuum extrac&on, fetuses should be at least 34 weeks AOG

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• Complications: Brachial plexus injury, fetal scalp injuries
• If forceps cannot be satisfactorily applied, then the procedure is stopped and either
vacuum extraction or cesarean delivery is performed
• Factors associated with operative delivery failure are:
o Persistent OP position
o Absence of regional/general anesthesia
o BW > 4,000g
• Forceps design
o Consists of 2 crossing branches, each branch has 4 components
§ Blade – has 2 curves
• Cephalic curve – grasps the fetal head
• Pelvic curve – curved in a plane 90° from
the cephalic curve to fit the maternal pelvis
§ Shank
• Connects the blades to the handles and
provide the length of the device
§ Lock – articulation between shanks
• English lock - consists of a socket located on the shank
at the junction with the handle, into which
fits a socket similarly located on the opposite shank
• French lock – used in Kielland forceps
§ Handle - allows the operator to hold the device and to apply traction to
the fetal head

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Vacuum Delivery
• Reserved for 34w AOG & beyond
• With vacuum delivery technique, suction is created within a cup placed on the fetal
scalp such that traction on the cup aids fetal expulsion
• Maternal Indications
o Inadequate voluntary effort
o Soft tissue obstruction
o Elective avoidance of valsalva maneuver due to cardiac or cerebrovascular
disease
o Malpresentation of the vertex
• Fetal Indications
o Anticipated or evident fetal intolerance of continued labor
o (+) occult or overt cord prolapse in a multiparous patient at complete dilatation
o Delivery of the 2nd vertex twin from high station when cervix has already been
traversed by 1st twin and there is an indication for intervention



















• Technique
o Proper placement at the flexion point
o The entire cup circumference should be palpated both before and after the
vacuum has been created as well as prior to traction to exclude maternal soft
tissue entrapment
o Gradual vacuum creation is
advocated by some and is generated
by increasing the suction in
increments of 0.2 kg/cm2 every 2
minutes until a total negative
pressure of 0.8 kg/cm2 is reached
o Similar to forceps delivery, traction is
usually directed initially downward,
then progressively extended upward
as the head emerges
o Vacuum extraction should not be
attempted for more than 20 minutes.
Terminate if:
§ Unable to deliver
§ No progress of labor.
§ 3 cup detachments have
occurred
§ Evidence of fetal scalp trauma

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Episiotomy
• Intrapartum incision of the pudendum (external genital organs) to widen the introitus
• Should be considered for indications such as
o Shoulder dystocia, breech delivery, Macrosomic fetuses, operative vaginal
deliveries, persistent OP positions
o Other instances in which failure to perform an episiotomy will result in
significant perineal rupture
• Required analgesia
o Labor epidural analgesia
o Bilateral pudendal nerve blockade
o Infiltration of 1% lidocaine
• Timing: Typically, episiotomy is completed when the head is visible during a contraction
to a diameter of approximately 4 cm, that is, crowning.
• When used in conjunction with forceps delivery, most perform an episiotomy after
application of the blades
• Technique















o Midline/median
§ Fingers - insinuated between the crowning head and the perineum
§ Scissors - positioned at 6 o‘clock on the vaginal opening and directed
posteriorly
§ Incision length - varies from 2 to 3 cm depending on perineal length and
degree of tissue thinning
§ Incision is customized for specific delivery needs
§ Should stop before reaching external anal sphincter.
o Mediolateral
§ Scissors - positioned at 7 o‘clock or at 5 o‘clock
§ Incision - extended 3 to 4 cm toward the ipsilateral ischial tuberosity
§ Inc. in severe perineal lacerations
§ (+) protective effect against higher-order lacerations when used during
operative vaginal delivery


Median Mediolateral
Surgical repair Easy as muscles are not cut More difficult
Healing Better Faulty healing is common
Post-op pain Minimal Common
Anatomical results Excellent Occasionally faulty as
apposition of tissues is not so
good
Blood loss Less More
Dyspareunia Rare Occasional
Rectal extension Common Uncommon – relatively safe
from higher order lacerations

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UST-FMS Obstetrics JI OSCE Reviewer

Maneuvers of Delivery
• Ritgen’s Maneuver – delivery of a child's head by pressure on the perineum while
controlling the speed of delivery by pressure with the other hand on the head, helps
facilitate the cardinal movement of extension

• Mueller Hillis – also used in pelvimetry, to measure the adequacy of the pelvic inlet
Manual pressure on the term fundus while a finger in the vagina determines the descent
of the head into the pelvis.
• Pinard – In management of a frank breech presentation, pressure on the popliteal space
is made by the index finger while the other 3 fingers flex the leg while sliding it along the
other thigh as the foot of the flexed leg is brought down and out
• Mauriceau – a method of delivering the head in an assisted breech delivery in which the
infant's body is supported by the right forearm

• Prague – A method for delivering a fetus in breech position in which the infant's
shoulders are grasped from below by one hand while the other hand supports the legs









• External Cephalic Version – process by which a breech baby can sometimes be turned
from buttocks or foot first to head first. It is usually performed after about 37 weeks. It
is often reserved for late pregnancy because breech presentation greatly decreases with
every week.It can be contrasted with "internal cephalic version", which involves the
hand inserted through the cervix

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• McRobert’s – used in shoulder dystocia which involves hyperflexing the mother's legs
tightly to her abdomen. It is effective due to the increased mobility at the sacroiliac joint
during pregnancy, allowing rotation of the pelvis and and involves facilitating the release
of the fetal shoulder. If this maneuver does not succeed, an assistant applies pressure
on the lower abdomen (suprapubic pressure), and the delivered head is also gently
pulled













• Wood’s Corkscrew – attendant tries to turn the shoulder of the baby by placing fingers
behind the shoulder and pushing in 180 degrees
















• Rubin’s – like the Woods maneuver, 2 fingers are placed behind the baby's shoulder,
this time they are pushing in the directions of the baby's eyes, to line up the shoulders.

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• Zavanelli – pushing the baby’s head back to the vagina & performing a CS









• Gaskin - patient in hands and knees position to change the diameters of the pelvis

• Suprapubic pressure – this pressure is at the pubic bone, not at the top of the uterus.
This might allow the shoulder enough room to move under the pubis symphysis.

V. EINC with Active management of the 3rd stage of labor
EINC
• EINC – Essential Intrapartum Newborn Care
o Immediate and thorough drying of the newborn
§ To prevent hypothermia
§ Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes,
head, front and back, arms & legs.
o Early skin-to-skin contact between mother and the newborn
§ To inoculate normal flora on the fetal skin & facilitate breast feeding
§ If a baby is crying & breathing normally, avoid any manipulation, such as
routine suctioning, that may cause trauma or introduce infection. Place
the newborn prone on the mother’s abdomen or chest skin-to- skin.
§ Cover newborn’s back with a blanket & head with a bonnet. Place
identification band on ankle.
o Properly-timed cord clamping and cutting
§ Wait for 1-3min or once there is no more pulsation on the cord (to lessen
the incidence of anemia)
§ Put ties tightly around the cord at 2cm (Clamp) & 5cm (Kelly) from the
newborn’s abdomen
§ Cut between ties with sterile instrument.
§ Observe for oozing blood.
§ Do not milk the cord towards the newborn.
§ After cord clamping, ensure oxytocin 10 IU IM is given to the mother

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o Non-separation of the mother and her newborn for early breastfeeding initiation
§ Observe the newborn. Only when the newborn shows feeding cues (e.g.,
opening of mouth, tonguing, licking, rooting), make verbal suggestions to
the mother to encourage her newborn to move toward the breast (e.g.,
nudging).
§ Counsel on positioning and attachment. When the baby is ready, advise
the mother to:
• Make sure the newborn’s neck is neither flexed nor twisted.
• Make sure the newborn is facing the breast, with the newborn’s
nose opposite her nipple and chin touching the breast.
• Hold the newborn’s body close to her body.
• Support the newborn’s whole body, not just the neck & shoulders.
• Wait until her newborn’s mouth is opened wide.
• Move her newborn onto her breast, aiming the infant’s lower lip
well below the nipple.
• Look for signs of good attachment & suckling:
o Mouth wide open
o Lower lip turned outward
o Baby’s chin touching breast
o Suckling is slow, deep with some pauses
• If the attachment or suckling is not good, try again & reassess.

rd
Active management of the 3 stage of labor
• The 3rd stage of labor begins from the delivery of the neonate & ends with the delivery
of the placenta
• Active Management of the 3rd stage of labor
o Do not wait for signs of placental separation – lessens the incidence of post-
partum hemorrhage
§ Change in the shape of the uterus becoming globular and firmer (Calkin’s
sign)
§ Sudden gush of blood
§ Uterus rises in the abdomen
§ Umbilical cord lengthens or protrudes further out of the introitus
o Mechanism of placental delivery
§ Schultze Mechanism – placental separation begins at the central portion
of the placenta. Placenta is expelled as an inverted sac with the fetal
surface presenting.
§ Duncan Mechanism – separation occurs at the periphery; placenta is
expelled with the maternal surface presenting.
o As soon as baby is out and you are sure there is no second baby, infuse oxytocin.
Incorporate 10u Oxytocin in the IV fluid (30ggts/min) or administer 10u Oxytocin
IM to allow uterine contraction
o At the height of uterine contraction, apply gentle & controlled downward cord
traction with suprapubic countertraction to prevent uterine inversion
o When placenta is at introitus, slowly rotate 360° to allow complete delivery of
the membranes
o Inspect umbilica placenta and membranes
§ Placenta: shiny – fetus, rough – mother where the cotyledons are
§ Umbilical cord – AVA
§ Fetal surface – chorion & amnion
§ Maternal surface – cotyledons
§ Placental infarcts – may suggest uteroplacental insufficiency
o Massage the uterus to further contract the uterus

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Lacerations
• 1st degree laceration – involves the fourchette, perineal skin, vaginal mucosa but not
the underlying fascia and muscle
• 2nd degree laceration – involves the fascia and muscles of the perineum body but not
the anal sphincter
• 3rd degree laceration – extends from the vaginal mucosa, perineal skin, fascia up to the
anal sphincter but not the rectal mucosa
• 4th degree laceration – encompasses extension up to the rectal mucosa

Pain during labor & delivery
• VISCERAL PAIN – caused by uterine contraction and cervical dilatation and effacement
• SOMATIC PAIN – induced by streching of vagina and perineum by fetus during descent
in the pelvis


VI. Instrument Identification
• See powerpoint


VII. Knot Tying
• Instrument
• One-hand
• Two-hand

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