Antepartum Haemorrhage, Shoulder Dystocia, CS

Question 1

list the risk factors for shoulder dystocia in the antenatal period

Answer 1

Shoulder dystocia = DOpe

• DM
• Obesity

Question 2

recognise the signs of shoulder dystocia in labour

Answer 2

• ‘turtling’ of baby’s head

Question 3

describe how to manage shoulder dystocia in an emergency situation

Answer 3

HELPERR
H) send for Help
E) consider Episiotomy
L) legs flexed & abducted into McRobert's position
P) pressure on suprapubic bone
E) entry & corkscrew rotation
R) remove posterior arm
R) reverse - push baby back in & CS (Zavanelli manouvere)

Question 4

describe the indications for caesarean section

Answer 4

MATERNAL

• 2+ prev CS
• previous shoulder dystocia, uterine surgery or pelvic abnormality
• obstruction of labour & unsuccessful induction

FETAL

• macrosomia, IUGR
• malpresentation
• twins non-cephalic
• APH, placenta praevia, cord prolapse, fetal distress

Question 5

distinguish between an elective and an emergency caesarean section

Answer 5

Elective CS = booked ahead of time, optimal delivery 39wks, not time critical

Emergency CS = time critical!

Question 6

outline the operation itself

Answer 6

1. consent pt, explain risks (damage ureter/bladder, haemorrhage, infection, future pregnancy risks - further CS, placenta acreta)
2. G&H, IV access and IDC
3. Auscultate baby heart
4. Abx prophylaxis
5. Technique
   a. skin incision (usually LUS transverse cut) –> fat –> rectus sheath –> peritoneum –> bladder flap –> uterus (2 layers + serosa)
   b. deliver baby + cord clamp
   c. oxtocin administration –> deliver placenta & confirm empty uterus
   d. close uterus + check surrounding anatomy + remove blood etc.
   e. close other layers (peritoneum, rectus sheath, etc.)
   d. dressings, confirm contracted uterus
   e. debrief pt.

Question 7

list the possible complications of a caesarean section, both in the short and longer term

Answer 7

Short term:

• haemorrhage, infection
• injury: baby laceration, bladder, ureters
• hysterectomy, further surgery, ICU
• longer recovery time, VTE

Long term:

• need for further deliveries as CS
• uterine rupture, placenta accreta

Question 8

appraise the advantages and disadvantages of caesarean section for both the mother and baby.

Answer 8

Adv: hysterectomy (deliver gravid uterus <20/40), emergency CS with failure induction, delivery for shoulder dystocia/macrosomia risks, choice of delivery date, perimortem CS (preserve maternal life)

Disadv: longer recovery time, increased need subsequent CS, surgical risks

Question 9

consider a differential diagnosis for APH

Answer 9

“Show” occulum = blood stained mucous plug from cervix, normally 3rd trimester

Question 10

differentiate between placenta praevia and abruption placentae from history and clinical examination findings

Answer 10

P.Praevia = Hx: multiparity, multiple pregnancy, prior PP, CS or ToP, adv maternal age
= Exam: note - do not perform PV exam, speculum exam may reveal placenta overlying os, but confirm with US. Vitals may suggest haemo compromise

P.Abruption: Hx: prev P.A, HTN preg dx, smoker/cocaine, trauma, PPROM. Uterine cramps + pain (back)
Exam: speculum = uterine tenderness; Vitals = mother haemodynamic compromise (if significant blood loss); Ix (CTG) = non-reassuring fetal status

Question 11

appreciate the need for teamwork in the management of APH.

Answer 11

Maternal haemodynamic instability = obstetric emergency: need senior ob/gyn, anaesthesist, midwife support + early haemotological support
(once maternal stabilised –> fetal Ix, where fetal compromise may mean urgent delivery)