Emergencies

Question 1

CXR findings of a PE

Answer 1

Normal
wedge-shaped infarction,
pleural effusion,
atelectasis,
area of translucency in
underperfused lung

Question 2

Give 3 causes of painful uterine contractions in early pregnancy

Answer 2

1) Threatened miscarriage
2) Inevitable or incomplete miscarriage (more painful + more bleeding)
3) Septic miscarriage (+ fever)
4) Pregnancy in a uterine horn (colicky pain)

Question 3

Give 3 causes of painful uterine contractions in late pregnancy

Answer 3

1) Late miscarriage
2) Preterm labour (uterine over distension e.g. multipreg, polyhydraminos, fibroids)
3) Uterine irritability (abruption, chorioamnionitis pyelonephritis)

Question 4

Give 3 causes of painful uterine contractions during labour

Answer 4

1) Uterine hyperstimulation (too much oxytocin)
2) Placental abruption
3) Uterine scar rupture
4) Intrapartum infections (chorioamnionitis, pyelonephritis)

Question 5

Give 3 causes of painful uterine contractions after delivery

Answer 5

1) Retained products of conception

2) Acute inversion of the uterus (bradycardia and hypotension)

Question 6

When might a fluid thrill be heard over a tender gravid uterus?

Answer 6

Polyhydraminos

Question 7

Sharp uterine pain + late/prolonged CTG decelerations

Answer 7

Acute fetal compromise secondary to placental abruption or scar rupture

Question 8

Pain + increased contraction frequency (>6-10 per min)

Answer 8

uterine hyperstimulation/

irritability

Question 9

Pain + increased baseline tone of contractions

Answer 9

Placental abruption, impending uterine

rupture. After rupture, the contractions may not be recordable

Question 10

How to Tx uterine hyperstimulation?

Answer 10

• Stop oxytocin
• IV fluids
• Left lateral postition
• Acute tocolysis

Question 11

Dx of greyish frothy discharge + strawberry punctation of the cervix

Answer 11

Trichomoniasis

Treat with metronidazole

Question 12

Dx urinary frequency

Answer 12

> 7 day + 1 night

**Exclude infection and then reassure, normal in pregnancy even before the 1st period missed

Question 13

Mx of urinary retention in pregnancy

Answer 13

• Catheter
• ## Test for UTI

Question 14

Causes of low UO intrapartum?

Answer 14

• Dehydration

- Retention - Descent of fetal head + epidural

Question 15

How does urinary frequency change following delivery?

Answer 15

Increased UO D2-5 due to dieresis of increased extracellular fluid vol.

Enlarged uterus can continue to give frequency and urgency symptoms

Question 16

Why is monitoring postpartum UO important?

Answer 16

Over distention can lead to serious longstanding voiding difficulties, chronic infection and renal damage

**If UO on catheterisation is >800mls keep catheter in for at least 24hours + after removal measure until >100mls per void

Question 17

What is the significance of reduced fetal movements?

Answer 17

• Not particularly useful
• Historically theorized that reduced fetal movements = hypoxic fetus trying to save energy 12-24hrs prior to fetal death
• However, this doesn’t show benefits in outcome when considering increased interventions + anxiety
• Should prompt monitoring

Question 18

If you are investigating reduced fetal movements, why would you ask about previous pregnancies and the father?

Answer 18

• Placental insufficiency is more common in first pregnancy and uncommon if previous baby was well grown + same father

Question 19

Assessment of reduced fetal movements

Answer 19

• Establish risk
• BP
• SFH
• Fetal movements
• Fetal heart beat may reassure parents
• US for growth + liquor volume
• Umbilical artery + middle cerebral artery doppler as an indicator of uteroplacental insufficiency (at term this isn’t useful)
• CTG

Question 20

What is the sequence of placental dysfunction?

Answer 20

1) Slowing of growth (small size)
2) Increased resistance in umbilical artery
3) Doppler (reduced end- diastolic frequencies)
4) Absent/ reversed enddiastolic frequencies in umbilical artery Doppler
5) Abnormal venous Doppler (ductus venosus Doppler)
6) Intrauterine death.

Question 21

Is it worth doing daily umbilical artery dopplers?

Answer 21

A loss of end-diastolic frequency will not occur in <7days so weekly monitoring is acceptable

Question 22

What does loss of end-diastolic frequency indicate?

Answer 22

Only occurs when >75% of the placental vascular bed is obliterated. It indicates a 85% chance the fetus is hypoxic + 50% chance the fetus is acidaemic

Question 23

What does reversed end-diastolic frequency suggest?

Answer 23

Pre-terminal, will not survive without delivery

Question 24

What parameters are assessed in a biophysical profile?

Answer 24

• Fetal accelerations/ HR (non-stress test)
• Fetal breathing movements
• Fetal movements
• Fetal limb extension and flexion
• Amniotic fluid index

Question 25

Which features on CTG are reassuring?

Answer 25

- At least 2 accelerations (.15bpm for >15 sec) in 20mins - Baseline HR 110-160bpm - Baseline HR variability 5-25bpm - Absence of decelerations - Sporadic decelerations <40bpm, for <15sec is acceptable or <30 sec if followed by an acceleration - Moderate tachycardia 160-180bpm is reassuring - Bradycardia (100-110) without decelerations is reassuring

Question 26

Which features on CTG are suspicious?

Answer 26

- Non-reactive (no accelerations) for 40mins - Baseline heart rate tachy 140-160 or brady 100-110 - Reduced baseline variability (5– 10 bpm for >40 min) - Baseline variability >25 bpm in the absence of accelerations - Sporadic decelerations of any type unless severe ***Interpretation/ action— continue or repeat CTG within 24 hours/ AFI/ BPP / fetal Doppler flow velocity waveform analysis.

Question 27

What are pathological features on CTG?

Answer 27

- Baseline heart rate <100 bpm or >180 bpm - Silent pattern (baseline variability <5 bpm) for >40 min - Sinusoidal pattern (oscillation frequency <2– 5 cycles/ min, amplitude of >10 bpm for >40 min with no accelerations and no area of normal baseline variability) - Repeated late, prolonged (>1 min) and severe variable (>40 bpm) decelerations **Interpretation/ action— further evaluation (VAS, AFI, BPP , Doppler). Deliver if clinically appropriate.

Question 28

What are the most common causes of stillbirth

Answer 28

1) Unknown (27%) 2) Placental conditions (12%) 3) Antepartum haemorrhage (11%) 4) Congenital abnormalities

Question 29

Give 3 RF for stillbirth

Answer 29

1) Obesity 2) Smoking 3) >35 4) Nulliparity 5) Illicit drug use

Question 30

What are the mandatory investigations for the mother following SB or IUD

Answer 30

FBC, coag, fibinogen - DIC BGL and HbA1C - DM TFTs and T4

Question 31

Causes of prolonged decelerations

Answer 31

1) Cord compression - oligohydramnios, cord prolapse, knots 2) Uteroplacental insufficiency - uterine hyperstimulation or prolonged contractions, placental abruption or uterine rupture 3) Maternal hypoxia - Hypotension, amniotic fluid embolism, seizures, valsalva manoeuvre 4) Fetal haemorrhage - vasa praevia, aminocentesis 5) Fetal vagal reaction - cervical exam, fetal scalp electrode placement, fetal blood sampling and impending birth

Question 32

You are called to a woman with prolonged decelerations, what do you do?

Answer 32

- Assess immediate risk, senior? - left lateral position - stop oxytocin - IV bolus - Check obs; BP, pulse, temp - Review CTG - Abdo/vaginal ex - FBC/G&S - ?theatres

Question 33

What is an abnormal (borderline) fetal blood sample?

Answer 33

lactate >4.9 (4.2) | pH <7.2 (7.24)

Question 34

Signs/Sx of scar rupture

Answer 34

- Change to severe pain and continuous - Cessation of contractions - PV bleeding - Abnormal CTG - Maternal tachy/hypotension - Loss of presenting part from the pelvis - Peritonism * * fluid resus + blood * * laparotomy

Question 35

RF for abruption in labour

Answer 35

- Hx antepartum haemorrhage - Pre-eclampsia - IUGR - Polyhydraminos

Question 36

Si/Sx abruption in labour

Answer 36

``` Severe and continuous pain PV bleeding Abnormal CTG Maternal tachy/hypotension Hard uterus ```

Question 37

What is fetal distress?

Answer 37

A condition of significant impairment of oxygen transport resulting in progressive fetal hypoxia, acidosis, and asphyxia. It is the second commonest cited indication for instrumental delivery in the second stage of labour, after prolonged second stage. Fetal pH falls quicker in the second stage so delivery should be completed within 20–30 minutes of decision to deliver for ‘fetal distress’

Question 38

Indications for instrumental delivery for fetal distress

Answer 38

* Prolonged bradycardia * Abnormal CTG * Non-reassuring CTG with fresh meconium or abnormal FBS results * Acute event (e.g. abruption, cord prolapse).

Question 39

Contraindications for instrumental delivery

Answer 39

• Fetal malpresentation (brow, face mento-posterior) • Unengaged fetal head (fetal head is above the ischial spines or more than one-fifth of the head palpable abdominally) • Cephalopelvic disproportion • Fetal coagulopathy or bone demineralization disorder • Not fully dilated cervix

Question 40

What is shoulder dystocia?

Answer 40

A vaginal cephalic delivery that requires the use of additional obstetric manoeuvres, following delivery of the head and failure to deliver using gentle traction. Shoulder dystocia is a bony obstruction, which occurs when the fetal shoulder impacts on the symphysis pubis (anteriorly) or, less commonly, the sacral promontory (posteriorly).

Question 41

HELPERR algorithm for the management of shoulder dystocia

Answer 41

• Help— SOAPS: Senior midwife, Obstetrician, Anaesthetist, Paediatrician, & Scribe. • Evaluate for episiotomy—increases room available for further manoeuvres. • Legs (McRoberts manoeuvre)—hyperflexion of thighs onto abdomen increases the ‘pelvic space’ available. • Pressure (directed suprapubic)—aims to rotate anterior shoulder forward off symphysis. ‘CPR grip’ to be used behind the fetal back. • Enter the pelvis (Wood’s screw manoeuvre)—aims to internally rotate anterior shoulder to become posterior and bring the new ‘anterior’ shoulder below symphysis in a ‘corkscrew’ fashion. • Remove posterior arm—posterior arm flexed and swept over fetal chest to exteriorize and then perform rotation as above. • Roll onto all fours—change in position may improve pelvic diameters and space available.