Obs - Instrumental Delivery

Question 1

What are the risk factors for shoulder dystocia?

Answer 1

Macrosomia
 50% cases in babies >4kg
 Previous shoulder dystocia
  Maternal BMI
 Labour induction
 Low height
 Maternal DM
 Instrumental delivery

Question 2

Define shoulder dystocia. List some complications

Answer 2

When after the delivery of fetal head, the shoulders get trapped at the pubic bone.

Complications:
Foetus:brachial plexus injury (erbs palsy), clavicle fracture, Klumpkes paralysis
Mother: perineal tears, uterine rupture, pubic symphysis separation,

Question 3

What are the nerves of the brachial plexus?

Which are affected in erbs palsy? And klumpke’s paralysis?

Answer 3

C5-C8, T1

Erbs palsy - C5-C6

Klumpke’s - lower root injury: C8,T1

Question 4

In shoulder dystocia, how does klumpke’s palsy present?

Answer 4

Paralysis of intrinsic hand muscles.
C8/t1 dermatome numbness
T1 can cause hornets syndrome

Question 5

How does erbs palsy present?

Answer 5

Inability to abduct arm from shoulder
Can’t externally rotate arm from shoulder
Can’t supinate forearm

Hand grasp normal. Bicep reflex absent.

Get waiters tip appearance

Question 6

How is shoulder dystocia managed?

Answer 6

In this order:
Call for help
Mcroberts manouvre
Supra pubic pressure 
Wood screw manoeuvre - pressure on shoulders. 
Episiotomy if needed

-> call consultants

Internal manoeuvres
All 4s positoin / do all again
Zavenelli or Symphisiotomy

Question 7

List some risk factors for cord prolapse?

Answer 7

Preterm labour
 Breech
 Polyhydramnios
 Abnormal Lie
 Twin

Question 8

How is cord prolapse managed?

Answer 8

Detection: abnormal fetal HR, cord palpated on VAGINAL EXAMINATION - digital

Call for MDT help - inc consultants

Lay mum on left lateral position, fill bladder. Might need tocolysis

Birth; is an emergency so needs to be fast - urgency depends on HR.

whichever method allows expidetious delivery:
Cat 1 emergency section or vaginal
Birth in labour ward.

Question 9

What are the risks of a uterine rupture?

Answer 9

Foetus: hypoxia

Mother: internal haemorrhage, PPH

Question 10

How do you manage a uterine rupture?

Answer 10

Resus : in fluids and blood

Remember baby is still in there;
Immediate Laparotomy - uterine repair or hysterectomy

See osakwe notes

Question 11

Woman presents with anaphylaxis with dyspnoea, hypoxia and hypotension. Her blood film shows severe low platelets, prolonged PT and PTT, low fibrinogen, high d-dimer. What is the Dfx? Meaning of blood results?
Complications?

Answer 11

Dfx: amniotic fluid embolism

Bloods show DIC

Complications of AFE ; cardiac arrest, seizures.

They Rapidly develop DIC, pulmonary oedema and ARDs

Question 12

What are risk factors for amniotic fluid embolism?

Answer 12

Typically when membranes rupture
 Labour, CS and even TOP
 Strong contractions in presence of polyhydramnios

Question 13

How is amniotic fluid embolism managed?

updated

Answer 13

ABCDE Approach

Resus
Oxygen - high flow
ITU admission
Fresh frozen plasma

o Poor prognosis = 10% survival

Question 14

What are differentials for epilepsy in pregnancy?

Rx?

Answer 14

Eclampsia - mgso4
Maternal epilepsy

Both:
Airway cleared with suction and O2
CPR
In absence of cardiopulmonary collapse, diazepam will stop fit
Mg sulphate not useful for non-eclamptic seizures

Question 15

what are the conditions to be met before instrumental delivery and mmemonic?

Answer 15

F - Fully dilated cervix
O - Occipito anterior position
R - Ruptured membrane
C - Cephalic presentation
E - Engaged presenting part
P - Pain relief is adequate