Labour Complications

Question 1

What is Eclampsia?

Answer 1

One or more convulsions in pre-eclamptic women. Can occur ante, intra or postpartum.

Question 2

How does Eclampsia present?

Answer 2

S&S of Pre Eclampsia
New onset Tonic Clonic/ Convulsions
Headache
Behavioural changes
Nausea/vomiting 
Generalised Oedema
Visual disturbances

Question 3

Eclampsia DD?

Answer 3

Epilepsy
Brain tumour
Cerebral aneurism 
Stroke
Septic Shock
Meningitis 
Hypoglycaemia

Question 4

Eclampsia Management.

Answer 4

• ABCDE and intervention as appropriate
• Rule out DD (esp. epilepsy)
• If history of hypertension/ pre-eclampsia turn to lateral position left side
• Obtain IV access NO fluids
• O2 sats titrate to 94-98%
• If convulsions >2/3 mins or second fit occurs administer Magnesium Sulphate or Diazepam - See JRCALC
• TC transfer to appropriate destination
• Pre Alert
• Assess and Reassess

Question 5

What is Umbilical Cord Prolapse?

Answer 5

Umbilical Cord Prolapse is where the umbilical cord descends through the cervix with or before the presenting foetus.

Question 6

Cord Prolapse can be Overt or Occult meaning…

Answer 6

Overt - Umbilicus has descended lower than presenting foetus

Occult - Umbilicus descends along with presenting part but not beyond it

Question 7

Umbilical Cord Prolapse can result in foetal hypoxia by two mechanisms, what are they?

Answer 7

Occlusion - the presenting part of the foetus presses on umbilicus occluding blood flow

Arterial Vasospasm - Exposure of umbilical cord to cold atmosphere causes umbilical arterial vasospasm reducing blood flow to foetus

Question 8

Umbilical Cord Prolapse risk factors?

Answer 8

Pre-term
Breech
Unstable Lie
Arterial rupture of membranes

Question 9

Umbilical Cord Prolapse Management.

Answer 9

• Using a dry pad replace the umbilical cord within the opening of the Vagina
• Position knee chest position
• entonox
• When ready walk woman to ambulance
• Place woman in right lateral position with blanket below hip
• Assess for imminent birth
• Entonox
• prep newborn life support
• TC transfer to appropriate destination
• Take maternity notes

Question 10

What is a Postpartum Haemorrhage?

Answer 10

An excessive loss of blood after delivery. Divided into primary and secondary PPH.

Question 11

What is primary PPH?

Answer 11

Loss of >500ml of blood within 24 hours of delivery. Divided into minor (500-1000ml) and Major PPH (>1000ml)

Question 12

What is Secondary PPH?

Answer 12

Excessive vaginal bleeding <24 hours after birth up to 12 weeks.

Question 13

The causes of Primary PPH are the 4 T’s. What are they?

Answer 13

Tone
Tissue
Traume
Thrombin

Question 14

Discuss PPH:

1) Tone
2) Tissue
3) Trauma
4) Thrombin

Answer 14

1) Tone - AKA Uterine Atony, is the most common cause of PPH. This is where the uterine fails to contract following birth due to a lack of tone in uterine muscle.
2) Tissue - Retention of placental tissue preventing uterine contraction
3) Trauma - Damage sustained to reproductive tract during delivery, vaginal/cervical tears
4) Thrombin - Coagulopathies and vascular abnormalities that result in PPH.

Question 15

PPH S&S

Answer 15

Excessive bleeding from Vagina
Haemorrhage symptoms
Dizziness
Dyspnoea
Palpitations

Question 16

PPH Management

Answer 16

-Rule out local trauma
-Admin O2 94-98%
-If Placenta delivered and fundus soft then fundal massage
-If BP <140/90 admin Synometrine 1ml
If BP >140/90 give misoprotosol sublingual
-Obtain IV access and commence fluids
-For ongoing bleeding admin TXA
-Entonox
-If fundus still fails to contract consider Bi-manual compression
-TC transfer to appropriate destination
-Assess and Reassess
-Pre-alert

Question 17

What is Breech Presentation?

Answer 17

Breech presentation is when the baby presents buttocks or feet first instead of cephalic presentation.

Question 18

What are the three presentations of breech?

Answer 18

Complete (flexed) breech - Baby is sitting cross legged
Frank (extended) breech - baby’s legs are flexed at hip and knee, fully extended upwards with bum presenting.
Footling breech - baby legs are extended at hip so feet are presenting part

Question 19

Breech management.

Answer 19

• Request midwife
• prep newborn life support
• position on edge of bed on all fours
• HAND OFF (allow gravity)
• Encourage woman to push
• using 4 finger pelvis turn to achieve bum to tum
• pinky hook if limb becomes stuck
• Support baby as head births
• apply neck flexion by pushing back of baby’s head if necessary

Question 20

What is shoulder Dystocia?

Answer 20

Refers to a situation where after birth of head the anterior shoulder of baby becomes impacted on the maternal pubic symphysis.

Question 21

Indications of Shoulder Dystocia?

Answer 21

• Delay in delivery of shoulders
• Turtle neck - head retracts when a contraction ends
• Failure of restitution

Question 22

Shoulder Dystocia Management?

Answer 22

• Request midwife
• McRoberts Position
• Apply suprapubic pressure turn baby for 30 seconds - encourage push
• Attempt intermittent rocking
• Change woman to all fours and encourage push
• TC transfer to appropriate destination
• Lateral position with blanket between legs
• Entonox
• Prep newborn life support
• Pre-alert

Question 23

In all birth complications/abnormal labour the best clinical management is…

Answer 23

TC transfer to appropriate destination

For guidance on transfer vs stay on scene see JRCALC

Question 24

What are some means to assess for potential complications?

Answer 24

• Take history

- Refer to patients maternity pack