Obs emergency

Question 1

Brachial plexus

Answer 1

10% following SD
Cause:
excessive downward axial traction
lateral stretch of nerves
Avoid: excessive traction, sudden pressure application, rocking motion

Erbs - C5-6 int rotation adduction of arm, pronation forearm, waiters tip flexed wrist
90% recovery

Klumpkes - Clawed hand 60% recovery C8-T1

Horner’s - ptosis, anhidrosis

Question 1

Shoulder dystocia

Answer 1

RF: LGA, DN, prev (10%), obesity, IOL, AVB, prolonged labour

Sxs: diff head/chin delivery, turtling, no resititution, ant should not descending

Risk: death/HIE/CP/fracture/BP injury

HELLPER
- episiotomy reduce OASIS, improve access for internal

McRoberts - knee to chest
increase pelvic AP diameter

Suprapubic - dislodge ant shoulder under pubic synthesis
- reduce bisacromial diameter, oblique relationship

Rubin II - push ant shoulder to chest
Wood screw - push ant shoulder to chest, posterior shoulder to back
Reverse wood screw- reverse
Post arm removal

All 4s, repeat

Others: Zavanelli’s, deliberate clavical #, symphysiotomy

Question 2

Maternal collapse

Answer 2

Pregnancy risk factors:
Increase CO -> rapid blood loss
Gravid uterus - reduce venous return
Resp change - prone to hypoxia, diff intubate & ventilate
Low GI sphincter pressure -> aspiration risk

Consider:
Obstetrics
- eclampsia
- PPH, inversion/rupture/abruption
- AFE
- septic shock

Non obstetrics
- cardiac
- massive PE
- non eclamptic seizure
- anaphylaxis
- E/BSL derrangement

Perimortem CS
- reduce O2 demand
- improve venous return
- improve ventilation
- better CPR

Question 3

AFE

Answer 3

RF: precipitous birth, grandmultip
Sxs: peripartum shock, hypoxia, haemorrhage, arrest

Patho:
Amniotic fluid/debris enter maternal circulation widespread anaphylatic reaction
- pulm vasculature occlusion -> pulm HTN
- VQ mismatch resp failure, cardiogenic shock
- DIC 2nd endothelial damage & systemic inflammatory response

Inv: CXR, DIC screen, fetal ab
Tx: correct shock, correct coagulopathy

Question 4

Uterine inversion

Answer 4

Massive PPH, or shock disproportion to blood loss

Cease uterotonics
Manual replacement
Hydrostatic pressure - sterile warm water
Huntington’s procedure
post replacment uterotonics + IV Abx

Question 5

Cord prolapse

Answer 5

ROM, descend of cord through cervix -> compression/ umb a. spasm

Prevent: admit 37/40 for unstable lie. PROM with nonvertex presentation, avoid ARM if high head

Treatment:
Knee to chest or left lateral position
Cat 1 if abnormal CTG, cat 2 if normal
Back fill bladder, elevate presenting part, minimal handling fo cord, tocolysis

Question 6

Eclampsia

Answer 6

Resus, left lateral
MgSO4 4g 20mins, 1g/hr 24 hrs
- dose reduce 50% in renal disease

Aim BP<160/110
Prolonged seizure give:
Diazepam 5-10
Miazolam 5-10

MgSO4 toxicity
- routine level not required
- sxs: absent reflex, bradypnoea <12, altered LOC
- monitor hourly reflex, UO vitals

Tx: 10% calcium gluconate 100mls / 10mins

Question 7

Trauma/MVA

Answer 7

8% incidence
T3- reduce uterine wall thickness, AFI

Risk: haemorrhage, rupture, fetal trauma, PTB, abruption

Stabilise mother w/ MTP, TXA
Assess CTG, US FMHQ
Monitor signs of PTB /abruption

DONOT withhold drug or investigation for fetal wellbeing if unstable

MTP:
Reduce turnover time for products - less PRBC less cross matching
Maintain perfusion of end organ
Correct coagulopathy early to achieve haemostasis and further loss
Cost effective - less pRBC without compromise mortality