18 - Obstetric Emergencies Flashcards
What is cord prolapse and what are some risk factors for this?
Umbilical cord descends below presenting part of fetus through cervix into vagina. Presenting part of fetus can compress cord and also exposure to cold air causes arterial vasospasm which can both cause fetal hypoxia
Abnormal lie after 37 weeks is biggest risk factor
What are the clinical features of cord prolapse?
Suspect whenever there is any signs of fetal distress on CTG (non-reassuring fetal heart rate) and ruptured membranes
Can diagnose with vaginal and speculum examination
How is cord prolapse managed?
(Important card)
OBSTETRIC EMERGENCY CALL FOR HELP!
NEED IMMEDIATE DELIVERY EITHER INSTRUMENTAL OR C-SECTION
- Avoid touching, keep warm and wet to avoid vasospasm
- Manually elevate the presenting part off of the cord or fill bladder with 500mls warm saline if in community
- Lie woman in left lateral position or knee chest position to draw fetus away from pelvis and reduce compression
- Give tocolytics (Terbutaline) to minimise contractions whilst waiting for delivery via C-section
- C-SECTION
What is shoulder dystocia and the risk factors for this?
After delivery of the head the anterior shoulder of baby becomes stuck behind pubic symphysis
Usually due to macrosomia secondary to gestational diabetes
How does shoulder dystocia present?
- Difficulty delivering face/chin
- Failure of restitution (head remains downwards and does not turn sideways)
- Head delivered but then retracts back into vagina (turtle neck sign)
How is shoulder dystocia managed?
OBSTETRIC EMERGENCY - CALL HELP (senior midwife, anaesthetics, pads, obstetrician)
1st Line: McRoberts Manoeuvre and Suprapubic pressure. This pushes anterior shoulder down
2nd Line (if above fails): Rubin manoeuvre and Wood’s Screw manoeuvre. Can do episiotomy to allow more room for manoeuvres but won’t unblock obstruction as it is bony stuck
3rd Line: Cleidotomy/Symphysiotomy (division of the foetal clavicle or maternal symphysial ligament) or Zavanelli manoeuvre
Post delivery care: see later flashcard
What is McRoberts manoeuvre?
Hyperflexion of the mother at the hip and tell her to stop pushing
Provides posterior pelvic tilt lifting the pubic symphysis up
What is a Rubins and Wood’s screw manoeuvre?
Rubin: reach into vagina and rotate anterior shoulder towards the foetal chest.
Wood’s Screw: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
What is the Zavanelli manoeuvre?
Push the baby’s head back into vagina so it can be delivered via c-section
What are the complications of shoulder dystocia?
Fetus:
- Fetal hypoxia and cerebral palsy
- Brachial Plexus injury and Erb’s palsy
- Humerus or Clavicle fracture
Mother
- 3rd or 4th degree perineal tears
- PPH
What is the post-delivery management following a shoulder dystocia?
Mother
- Active management of 3rd stage due to risk of PPH
- PR exam to check for 3rd degree tear
- Debrief mother and birth partners
- Physio review as woman likely to have nerve damage and pelvic floor weakness
Baby
- Review by neonatologist to look for brachial plexus injury, hypoxic brain injury and humerus/clavicle fractures
What is eclampsia?
Occurrence of one or more seizures in a pre-eclamptic woman
Obstetric emergency
Most seizures occur in post-natal period
What are the clinical features of eclampsia?
(Image is important)
New onset tonic-clonic seizure with post-octal phase. Can cause fetal distress and bracycardia
Also pre-eclampsia signs relating to end organ dysfunction
What are some maternal and fetal complications of eclampsia?
Always need to think of HELLP, DIC and AKI
What are some differentials for seizures in pregnancy?
Eclampsia usually have features of severe pre-eclampsia making diagnosis easier
What investigations are done in eclampsia?
Look for reversible causes and complications e.g DIC and HELLP
- FBC
- U+Es
- LFTs
- Clotting studies
- Blood glucose
- Abdominal US to rule out placental abruption
Eclampsia is an obstetric emergency. How is it managed?
- Resuscitation: lie patient in left lateral position, secure airway, give oxygen
2. Cessation of seizures: Give IV Magnesium Sulfate. Assess for signs of hypermagnesiumaemia and continuous CTG monitoring
3. Blood pressure control: IV Labetalol and Hydralazine aiming for sys<120. Continuous CTG
4. Prompt delivery of baby and placenta: ONLY ONCE mother is stable do C-section then monitor in HDU until controlled BP, adequate urine output and discontinuation of MgSO4
5. Monitoring: Fluid balance monitoring to prevent pulmonary oedema and detect AKI. Monitor platelets, transaminases and creatinine
What post natal care is given to women with eclampsia?
Inpatient
- Regular symptom review
- Bloods at 72h (FBC, LFTs, Creatinine)
- Preconceptual Counselling (minimise risk factors and prophylaxis)
Outpatient
- Monitor BP daily for 2 weeks postpartum
- Follow up at 6 week looking at BP, proteinuria, creatinine. Repeat FBC, LFTs and Creatinine
What is a uterine rupture and what are the different types of this?
Muscle layer (myometrium) of the uterus ruptures. Very high morbidity and mortality for mother and baby
Incomplete: uterine serosa surrounding uterus remains intact
Complete: serosa ruptures with myometrium and contents of uterus are released into peritoneal cavity
What are the risk factors for uterine rupture?
What are the risk factors for uterine rupture?
PREVIOUS C-SECTION
- VBAC
- Previous uterine surgery
- Increased BMI
- High parity
- Induction of labour
- Use of oxytocin for contractions
How may uterine rupture present?
Acute unwell mother and abnormal CT
- Abdominal pain
- PV bleeding
- Shoulder tip pain
- Ceasing of uterine contractions
- Hypotension
- Tachycardia
- Collapse
What investigations can you do for uterine rupture?
All women with risk factors for rupture should be on continuous CTG
Do US and may see absent uterine wall, haemoperitoneum and abnormal lie of baby
How is uterine rupture managed?
OBSTETRIC EMERGENCY - ACTIVATE MASSIVE OBSTETRIC HAEMORRAGHE PROTOCOL
Resuscitation:
- Protect airway
- 15L 100% oxygen through non-rebreathe mask
- Insert two large bore (14G) cannulas and take blood samples. Give cross-matched blood as soon as it is available, until then give up to 2L of warmed crystalloid and 1-2L of warmed colloids, then transfuse O negative or uncross matched group specific blood.
- Monitor patient’s GCS
Surgical
- Emergency C-section within 30 minutes needs to be done
- Repair or remove uterus
*
Check if covered placental abruption in previous decks!!!
May need to come back and do these notes
What is an amniotic fluid embolism and why is it so dangerous?
Amniotic fluid passes into mother’s blood. Fluid contains fetal tissue so causes immune reaction from the mother leading to systemic illness
More like anaphylaxis than VTE
Mortality of 20%
What are some risk factors for amniotic fluid embolism?
- Multiple pregancies
- C-Section
- Induction of labour
- Increasing maternal age
What are the clinical features of amniotic fluid embolism?
May present like sepsis, PE or anaphylaxis
- SOB
- Hypoxia
- Hypotension
- Tachycardia
- Confusion
- Seizures
- Cardiac arrest
- DIC
How is amniotic fluid embolism managed?
- Transfer to ICU
- If the embolism has occurred before delivery then continuous foetal monitoring is necessary. If cardiac arrest then post-mortem section
- Oxygen and fluid resuscitation with bloods and fluids
- Treat any coagulopathy (fresh frozen plasma for prolonged PT, cryoprecipitate for low fibrinogen, platelet transfusion for low platelets).
What are the two main causes of sepsis in pregnancy?
- Chorioamionitis
- UTIs
What is chorioamnionitis and how does it present?
Infection of chorioamniotic membranes and amniotic fluid. Leading cause of maternal sepsis
What investigations should you do if you suspect maternal sepsis? (Always consider when maternal fever)
- FBC: WBC and neutrophils
- U+Es: Look for AKI
- LFTs: look for infection
- CRP
- Clotting: assess for DIC
- Blood cultures
- Blood gas: for lactate and pH
How is maternal sepsis managed?
- Sepsis Six: Cefuroxime/Met or Meropenem
- Continuous maternal and fetal monitoring
- Emergency c-section if fetal distress via general anaesthesia
What is uterine inversion and the different types?
Fundus of uterus drops down through the uterine cavity and cervix
Usually due to pulling too hard on cord during active third stage of labour
Incomplete: fundus descends inside uterus or vagina but not as far as introitus
Complete: uterus descends outside of the vaginal opening
How does uterine inversion present?
Often very large PPH
Maybe seen outside vagina or felt on vaginal examination
IT IS AN OBSTETRIC EMERGENCY AND MOTHER USUALLY IN SHOCK
How is uterine inversion managed?
Resus and give blood products as necessary
Initially: Johnson Manoeuvre, use a hand to push the fundus back up into abdomen and hold in place for several minutes and oxytocin
If above fails: Hydrostatic methods, fill vagina with fluid to inflate uterus back to normal position, need tight seal over vagina to achieve
Last line: Laparotomy surgery
What is the definition of a postpartum haemorraghe?
Loss of >500ml of blood following vaginal delivery
OR
Loss of >1000ml of blood following c-section
What are the different classifications of PPH?
- Primary: Within 24 hours of delivery
- Secondary: From 24 hours of delivery to 12 weeks postpartum
- Minor PPH – under 1000ml blood loss
- Major PPH – over 1000ml blood loss
- Moderate PPH – 1000 – 2000ml blood loss
- Severe PPH – over 2000ml blood loss
What are some antepartum and intrapartum risk factors for a PPH?
Antepartum
- Antepartum haemorraghe e.g abruption or Placenta praevia
- Multiple pregnancy
- Previous PPH
- Pre-eclampsia, gestational hypertension
- Ethnicity (i.e. Asian)
- Obesity (i.e. BMI > 30)
- Anaemia
- Uterine anomalies, fibroids
Intrapartum
- C-Section (Emergency > Elective)
- Induction of Labour (IOL)
- Retained placenta
- Episiotomy
- Instrumental
- Prolonged labour
- > 4kg baby
- Pyrexia in labour
What are the four causes of PPH?
FOUR T’s
Tone: Uterine atony most common
Trauma: Perineal tear
Tissue: Retained tissue
Thrombin: Bleeding disorder
What are some causes of uterine atony?
- Prolonged labour
- Macrosomia
- Twins
- Uterine abnormalities
- Polyhydraminos
What are the main causes of secondary PPH, if primary PPH is due to the four T’s?
- Retained products of conception
- Endometritis
What are some methods used to prevent PPH or at least reduce the severity of it?
- Active management of the third stage
- Always have IV access in every labour
- Take FBC, G+S and Crossmatch at start of labour
- Treat anaemia during antenatal period
- Giving birth with empty bladder (full bladder reduces uterine contraction)
- IV tranexamic acid: during caesarean section (third stage) in higher-risk patients
PPH is an obstetric emergency. The patient needs to be stabilised and then their bleeding needs to be stopped. How is a woman with PPH stabilised?
- Resus ABCDE approach
- Lie woman flat, keep her warm and communicate with her and partner
- Oxygen (regardless of saturations)
- Insert two large-bore cannulas
- Bloods for FBC, U&E and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
- Consider activating obstetric haemorraghe protocol
What is the obstetric haemorrhage protocol?
When there is a major PPH call 2222
Activates team of obstetricians, midwives, anaesthetists, theatre, porters, blood bank and haematologists
Runner needs to take FBC, crossmatch and coagulation screen to blood bank and they send back 4 units of cross-matched or O- blood and FFP
What are the specific management options for a primary PPH to stop the bleeding?
Mechanical
- Uterine massage of fundus
- Bimanual compression
- Catheterisation
Medical
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine (contraindicated in hypertension)
- Carboprost (IM) is a prostaglandin analogue. Caution in asthma
- Misoprostol (sublingual) is also a prostaglandin analogue
- Tranexamic acid (IV)
Surgical (if medical does not work)
- Intrauterine balloon tamponade
- B-Lynch suture around the uterus to compress it
- Uterine artery ligation supplying the uterus to reduce the blood flow
- Hysterectomy: “last resort” but may save woman’s life
What investigations and management are done for a secondary PPH?
Usually due to infection or retained products of conception
Ix:
- US for retained products of conception
- Endocervical and high vaginal swabs for infection
Mx
- Surgical evacuation of retained products of conception
- Antibiotics for infection
What is bimanual compression?
Used to help treat PPH
What are the side effects and contraindications of the following drugs used to treat uterine atony?
What are the risks and benefits of C-Section?
What is normal fetal movements?
Feel by 20 weeks
Plateau by 32 weeks but should not decrease in frequency
Normal movements means CNS and MSK system of baby is intact
Does the lie and presentation of a baby affect fetal movements?
Presentation does not but position does e.g anterior spine less movements
What advice should you give a woman on when to contact MAU for reduced fetal movements?
Do not not wait until the next day for assessment of fetal wellbeing.
If women are unsure whether movements are reduced after 28+0 weeks of gestation, lie on their left side and focus on fetal movements for 2 hours. If they do not feel 10 or more discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.
What investigations should be done for reduced fetal movements?
- Handheld doppler to confirm heartbeat
- CTG
- US
What thromboprophylaxis is used in pregnancy?
Any woman with four or more current risk factors should be considered for prophylactic low-molecular-weight heparin (LMWH) throughout the antenatal period and will usually require prophylactic LMWH for 6 weeks postnatally but a postnatal risk reassessment should be made
