• All obstetrical procedures can be performed in spinal anesthesia
  • Preferred method for C/S
    • Unless patient is in chock


  • When spinal anesthesia fails
  • When spinal anesthesia is contraindicated
    • Shock due to
      • Sepsis
      • Hemorrhage
  • Combine with
    • atropine
    • valium
  • Recommended doses:
    • 1-5 mg/kg  IV  
    • 5-10 mg/kg IM
    • 1-2 mg/kg at rate of 0.5 mg/kg/min as infusion
      • solution of 1 mg/ml in Normal Saline or Glucose


  • Forceps Delivery
  • Episiotomy


  • Episiotomy
  • Symphysiotomy
  • C/S


  • Uterine Rupture
  • C/S in Eclampsia.


In lack of laboratory equipment for typing and crossmatching:

  • Take small samples of blood from recipient and donor
  • Centrifuge blood samples
  • Place a drop of serum from recipient on a white surface
  • Place a drop of red blood cells (the sediment) from donor beside
  • Mix the two drops
  • Read the result.
  • Does it clump together or not?

If blood transfusion set is not available:

  • Place recipient on floor
  • Place donor on a stretcher
  • Connect donor and recipient with an i.v. line
  • Enhance blood flow with venous stasis by a tourniquet on the donor’s arm
  • Stop transfusion when recipient and donor have same pink mucosal linings (equilibrium has been acchieved)

In lack of electric centrifuge:

Buy a handheld

Or make your own with a testtube and piece of string

Selfmade centrifuge


  • Palpate the prolapsed cord for pulsations

Pulsations present:

  • Place the patient in knee-chest position (“a la vache”)
  • Push the presenting part proximally with a hand in the vagina
  • Prepare for urgent C/S

Pulsations not present:

  • Proceed with vaginal delivery

Doubtful whether pulsations are present or not:

  • Check if fetal heart beats are present
  • Preferable with Doppler or ultrasound
  • Proceed accordingly


The advantages of forceps compared to vacuum extraction are:

  • Faster application
  • Faster extraction
  • No need for synchronized traction
  • More vigorous traction may be applied
    • For good and bad!


  • Determine rotational position of head
    • Palpate fontanelles
    • Feel for an ear
  • If exact position of the heads rotation is undetermined do not apply forceps

Two options:

  1. Apply the left branch (mothers left) first
    • Then the right branch over the left
  2. Apply the right branch first
    • Then the left branch under the right.
Forceps I
Forceps II


  • Not an indication for C/S per se
  • Avoid C/S


  • Vaginal delivery
  • Deliver the body
  • Leave body hanging
  • Puncture the head suprapubically with a wide bore needle
  • Drain the cerebrospinal fluid
  • Deliver the collapsed head with Mauriceau-Levret’s maneuver
Suprapubic Puncture of Hydrocephalic Head


  • Puncture the head with a wide bore needle
    • Through the open cervix
    • Suprapubically
      • Technically easier


  • Internal version and extraction on one foot or both feet
  • Deliver as a breech presentation  

AT CESAREAN SECTIO (in case of missed diagnosis)

  • Puncture head and drain cerebrospinal fluid before attempting to extract it through the uterine incision
  • Troublesome vaginal and/or uterine tears may otherwise be the result

Puncture and drainage of the head is not harmful to the child


The WHO partogram is complicated. This simplified version is easier for the staff to manage.

Simplified partogram
  • Mark the descent of the head as follows:

-2           or         “At Pelvic Inlet”                   or                   “Floating”

-1           –           “Above Spines”                   –                     “Dipping”

  0          –           “At Spines”                           –                     “Engaged”

+1          –           “Below Spines”                   –                      “Deeply Engaged” 

+2          –           “At Pelvic Floor”                  –                      “Active Pushing” 

  • Mark the dilatation of the cervix as follows:
    • 1 to 10 cm or 1 to 5 fingers
  • Connect the markings to form two separate lines
  • Expect delivery at the time corresponding to the point where the two lines intersect


Symptoms and signs:

  • Sudden onset of painfull uterine contractions
  • Vaginal bleeding
  • Shock
  • Uterus tender on palpation


  • Gestational age > 36 weeks   
    • Deliver by C/S
  • Gestational age < 36 weeks    
    • Vaginal delivery
  • Gestational age unknown
    • Use best guess


  • Vaginal delivery 
  • Destructive delivery if needed    

The uterus appears battered:


  • An overdistended uterus is unable to produce efficient contractions
  • Drain the excessive fluid
    • By rupturing the membranes
      • Risk of cord prolapse if cervix is open more than a finger
    • By external drainage with an i.v. cannula
      • No risk of cord prolapse



  • Atony of the uterus
  • Retained placental parts
  • Uterine rupture
  • Cervical and/or vaginal tears


  • Resuscitate with fluids
  • Massage the uterus manually
  • Apply firm and continuous pressure suprapubically with a closed fist for a full 10 minutes
    • Eyes on the watch!
  • Oxytocin infusion i.v. (preferred)
    • 30 units in 500 cc in Normal Saline
    • Infused over 2 to 4 hours
  • Misostoprol (Cytotec) tablets (if oxytocin is not available)
    • 2 – 4 tablets
      • Oral or rectal adminstration

Bleeding does not subside:

  • Bring patient to operating theater
  • Place legs in stirrups
  • Examine by intracavitary palpation
    • Placental parts present:
      • Remove
    • Uterine rupture present:
      • Laparotomy and repair
    • Neither retained placenta nor rupture of the uterus is present:
      • Pack firmly with gauze
      • Remove gauze pack in the operating theater after 24 hours
  • Transfuse one or two units of fresh blood

  • Perform hysterectomy as a last resort

Speculum Examination:

  • It is usually difficult and messy to identify bleeding site(s) from cervical tears
  • Attempts to suture the friable tissue results in further tearing and bleeding
  • Proceed directly with gauze packing in the absence of retained placental parts or ruptured uterus.