Obs & Gynae

Question 1

Types of Vaginitis

Answer 1

Question 2

1. Additional manoeuvres required to birth foetus after head has delivered

+ gentle, routine traction in axial direction (in line with the foetal spine) has failed

=?

2. Common associations

Answer 2

SHOULDER DYSTOCIA

• Anterior fetal shoulder impacts on maternal symphisis pubis
• (less common) posterior fetal shoulder impacts against sacral promontory

RISK FACTORS

• Previous history
• Macrosomia
• Diabetes (ges. diabetes increases risk 3 fold)
• Induction of labour
• Short stature + small abnormal pelives
• BMI > 30

Question 3

Shoulder dystocia: interpartum characteristics that indicate impending SD

Answer 3

• High head at term
• Prolonged first a/o second stage of labour
• Oxytocin augmentation
• Failure of head to ascend
• Instrumental births (4.8% in assisted group v 0.17% spontaenous cephalic group)
• Head retraction between contractions
• Failure of restitution (f. head realigning w f. body post delivery)
• ‘Turtle sign’ (f. head pushes back against woman’s perineum + baby’s cheeks bulge out)

Question 4

Shoulder dystocia maternal complications

Answer 4

• PPH due to uterine atony or trauma (11% of cases)
• Soft tissue injuries e.g.
  
  • 3rd of 4th degree perineal tears (risk of recto-vaginal fistula)
  • Lacerations and/or haematoma
  • Uterine rupture

Less common maternal complications

• Transient maternal femoral neuropathy
• Symphyseal seperation
  
  • Both associated with use of McRoberts manoeuvre

Question 5

Shoulder dystocia: neonatal complications

Answer 5

Hypoxic ischaemic encepalopathy (HIE)

• Very serious, compression of umbilical cord leads ot fetal hypoxia

Drop in foetal blood pH, ideal head to delivery time is less than 5 minutes

• If manoeuvre not working don’t delay move on

Brachial plexus injury (BPI) e.g. Erb’s or Klumpke’s palsy

• Injury to medial trunk (C8, T1) = Klumpke’s palsy - paralysed ‘claw hand’ w good shoulder +elbow funtion
• Injury to lateral trunk (C5, C6, C7) = Erb’s palsy - adducted shoulder, entended elbow, flexed wrist ‘waiters tip’

Fracture of clavicle a/o humerus

Question 6

Shoulder dystocia management plan: manoeuvres

Answer 6

Additional points

• Discourage pushing
• Identify anterior shoulder