Intra/post - Obstetric emergencies Flashcards
what is shoulder dystocia
specific case of obstructed labour - after delivery of the head, the anterior shoulder cannot pass below the pubic symphysis
how can shoulder dystocia be diagnosed
clinical diagnosis - when the shoulders fail to emerge after the head
turtle sign - appearance and retraction of the fetal head (like a turtle going back into its shell)
red puffy face of baby - facial flushing
what risk factors predispose to shoulder dystocia
Age >35
Short in stature
Small or abnormal pelvis
More than 42 weeks gestation
Estimated fetal weight > 4500g
Maternal diabetes (2-4 fold increase in risk)
what are factors than can increase risk/ are warning signs for shoulder dystocia
Need for oxytocics
Prolonged first or second stage of labour
Turtle sign (head bobbing in the second stage)
Failure to restitute
No shoulder rotation or descent
Instrumental delivery
is there a risk of recurrence of shoulder dystocia
yes - if shoulder dystocia present in a previous delivery the risk is 10% higher than general population (~0.3-1%)
what are dangers of shoulder dystocia to the child
umbilical cord entanglement
inability of chest to properly expand
severe brain damage due to hypoxia or acidosis if delayed delivery
brachial plexus damage
what are complications of shoulder dystocia to the mother
post partum haemorrhage
Vaginal lacerations and 3rd/4th degree tears - extended episiotomies
Uterine rupture
what is the management of shoulder dystocia
remember HELPERR
H - call for help E - evaluate for episiotomy L - legs (McRoberts position) P - suprapubic pressure (Rubin 1) E - enter manoeuvres (internal rotation) R - remove the posterior arm R - roll the patient onto all fours
what is the McRoberts position
involves hyper flexing the mothers legs tightly to her abdomen
this widens the pelvis and flattens the spine in the lower back
what is Rubin I
Suprapubic pressure applied whilst in McRoberts position - gently pull on babied head whilst applying pressure
what are the three manoeuvres that follow after Rubin I
- Wood screw
- Jacquemiers/Barnums
- Gaskins
what occurs in the wood screw manoeuvre
the anterior shoulder is pushed towards the baby’s chest - the posterior shoulder is pushed towards the baby’s back
what occurs in Jacquemiers/Barnums manoeuvre
delivery of the posterior shoulder first - the forearm and hand are identified in the birth canal, and gently pulled
what occurs in Gaskins manoeuvre
moving the mother to an all fours position with the back arched - widens the pelvic outlet
what are the 5 groups of causes of post part haemorrhage
thrombin tissue tone trauma other
give examples of thrombin causes of PPH
pre-eclampsia
placental abruption
pyrexia in labour
bleeding disorders
give examples of tissue causes of PPH
retained placenta
placenta accreta
retained products of the conception (RPOC)
give examples of tone causes of PPH
placenta praevia (placenta grows in the lowest part of the womb)
over distension of the uterus (multiple pregnancy, polyhydramnios, macrosomia)
uterine relaxants
previous PPH
give examples of trauma causes of PPH
c-section
episiotomy
macrosomia (>4kg baby)
give examples of other causes of PPH
asian ethnicity
anaemia
induction
BMI >35
prolonged labour
age
what are the types of PPH
primary (account for 99%) and secondary
define a primary PPH
haemorrhage in the first 24hrs after delivery - from loss of >500ml blood (common 1/20) to severe haemorrhage >2000ml (rare 6/1000)
define a secondary PPH
occurs >24hrs and up to 6 weeks post delivery
what often causes a secondary PPH
RPOC - retained product of conception
what is the initial management of PPH
call for help ABCDE empty bladder rub up fundus drugs
what are the drugs used in the management of PPH
Oxytocin 5iu slow iv injection
Ergometrine 0.5mg slow iv injection (not in HTN)
Oxytocin infusion
Carboprost 0.25mg im (max 8 doses
Misoprostol 800 micrograms
what is the secondary management of PPH
surgical
- intrauterine balloon tamponade
- B-Lynch suture
- hysterectomy
manage on clinic signs not just estimated blood loss (EBL)
fluid replacement +/- blood products
what is cord prolapse
descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of a ruptured membrane
what is the incidence of cord prolapse
normal presentation - 0.1-0.6%
breech presentation - >1%
what are some general risk factors for cord prolapse
multiparity preterm labour low birthweight fetal congenital abnormalites breech transverse, oblique on unstable lie second twin polyhydramnios unenaged presenting part low lying placenta
what are some procedure related risk factors for cord prolapse
artificial rupture of membranes with high presenting part
vaginal manipulation of the foetus with ruptures membranes
external cephalic version (turning breech baby around)
internal podalic version (turning baby so feet sticking out)
stabilising induction of labour
insertion of intrauterine pressure transducer
large balloon catheter induction of labour
what is the management of cord prolapse
call for help!
replace cord into vagina (not uterus)
perform digital elevation of the presenting part
catheterise and fill bladder to elevate presenting part
encourage mother to adopt knee-chest or left lateral position with raised hips
if initial management of cord prolapse is unsuccessful what are the next steps
consider tocolysis
arrange for a category 1 c-section
