obst emergencies

Question 1

Antepartum hemorrhage

Answer 1

placenta praevia 1% of births
placental abruption 1% of births
-usually occurs T3
-sig cause of maternal morbidity

Question 2

Intrapartum emergencies - mother

Answer 2

• placental abruption
• uterine rupture
• Eclampsia
• cord prolapse
• shoulder dystocia

Question 3

intrapartum emerg - fetus

Answer 3

acute feral distress (CTG compromised)

Question 4

Post partum emergencies

Answer 4

Eclampsia
PPH
Acute uterine inversion
Postpartum psychosis

Question 5

Placental abruption

Answer 5

-pain pv bleeding
- concealed/relvealed
-retroplacental hemorrhage
STABLIZE PT. consider need for emerge delivery.
-NO PV EXAM until praevia ruled out

Question 6

Praevia

Answer 6

lower uterine segment location

- 4 grades.

Question 7

Pre-eclampsia complications - maternal

Answer 7

• Eclampsia
• Hemorrhagic stroke
• Placental abruption and DIC
• HELLP Syndrome
• Renal failure
• Pulmonary oedema
• Acute respiratory arrest

Question 8

Pre-eclampsia complications - fetal

Answer 8

• IUGR
• Oligohydramnios
• Hypoxia from placental insufficiency
• placental abruption
• premature delivery

Question 9

Rx Mild pre-eclampsia

Answer 9

reaches 150-160 - oral labetalol

Question 10

Rx Severe pre-eclampsia

Answer 10

> 180 - IV labetalol, nifedipine, hydralazine - get BP to 150

- consultant and anaesthetist present.

Question 11

mg sulphate

Answer 11

primary prophylaxis - severe eclampsia and birth planned in next 24hrs.

• secondary prophl - after eclamptic fit.
• *continue for 24hrs postpartum

Question 12

eclampsia seizure control

Answer 12

HELP
Airway - left lateral position
Breathing - high flow oxygen
circulation - IV access, bloods
control seizures
Mg Sulphate 4g IV over 5mins
- maintenance 1g/hr for 24hrs at least after last seizure.
Recurrent seizures - 2g bolus over 5 mins.

Question 13

cord prolapse - predisposing factors

Answer 13

• prematurity
• malpresentation
• polyhydramnios
• second twin (multiple gestations)

Question 14

Cord prolapse Mx

Answer 14

• see on CTG - variable decles, brady or both.
• Morph scan - placenta location
• Speculum: see the cord.
• Digits in vagina - pressure on presenting part.
• minimal handling of cord/keep warm in the vagina.
• Call for help. emergency C/S
• Position - knee elbow position (trendelenburg)
• oxygen for mother
• If transport requ - IDC and fill bladder.
• consider tocolysis
• Emergency transport to e c/s facility.

Question 15

Shoulder dystocia

Answer 15

Help + timer 30sec/manuever. no traction.
Episiotomy
Legs up McRoberts position
P Suprapubic pressure
(this should resolve 90% cases)
Enter digits - cork-screw to dislodge ant shoulder from pubis.
Roll over - all 4s
- UNDER GA: repeat above
Still lodged:
- cleidotomy - deliberate # of fetal clavicle
- Zavanelli maneuver - push head back and C/S
- symphisiotomy

Question 16

SHoulder dystocia risk factors

Answer 16

Macrosomic >4000g 
CPD
Prev dystocia
Maternal Obesity
Maternal diabetes

Question 17

Uterine inversion

• multigravida
• injudicious cord traction uncontracted uterus
• maternal shock - out of proportion to blood loss

Answer 17

HELP - obst and anaes
ABC oxygen.
Alert theatre
IV cannulas fluid resusc. cross match 4units
-replacement of uterus: manually or UA in OT.
-successful - PPH management (commonly due to atonic uterus)
- unsuccessful - OT. EUA. Uterine relaxants (GTN, GA). attmept replacemnt - manually/hydrostatic
- laparotomy if still unsuccessful.

Question 18

Maternal collapse

Answer 18

ABC. determine cause

• Head: eclampsia, epilepsy, CVA, vasovagal response
• heart : MI, arrhythmia, peripartum cardiomyopathy, CHD, dissection of aorta
• hypoxia: asthma, PE, Pulmo oedema, anaphly
• hemorrhage: abruption, preavia, PPH, uterine rupture, uterine inversion
• whole body and hazards: hypoglycaemia, amnio fluid embo, septicaemia, trauma, complications of GA.

Question 19

Rapid evaluation maternal and fetal condition

Answer 19

Obstetric and clinical history
- GA
- Prev uterine surg/C/S
- Position of placenta
- Abdo pain
Exam
- General - signs shock/perfusion/vitals
- estimate blood loss
- Uterine palpation - tone, tenderness, position
- abdo palp - peritonism, exutero fetal parts
- assess placental site - USD
- praevia excluded - spec

Question 20

PPH high risk

Answer 20

• prev PPH
• placenta previa/accreta
• Fibroids. multiple preg. polyhydrmanios
• anemia
• haemorrhagic disorders
• women decline blood products

Question 21

PPH

Answer 21

> 500mls blood loss from genital tract, or any loss <500mls associated with haemodynamic changes in the mother

Question 22

PPH incidence

Answer 22

2-11% deliveries

Question 23

PPH mx

Answer 23

anticipate
active 3rd stage labour
oxytocics IMI 10IU after delivery of anterior shoulder
- early cord clamping
- controlled cord traction with fundal support.

Question 24

Metabolic acidosis - fetus

Answer 24

pH 12mmol/L

Question 25

Metabolic acidosis - CTG features

Answer 25

• prolonged brady >100bpm for >5mins
• absent baseline variability
• sinusoidal pattern
• complicated variable decals with reduced/absent variability
• late decals with reduced variability

Question 26

Fetal resus in utero

Answer 26

- correct reversible causes eg maternal hypotension
stop oxytocin
- reposition mother
- emergency tocolysis
- emerg C/S

Question 27

AFE

Answer 27

asso with :
- precipitous/fast labour
- advanced maternal age
- C/S and instrumental delivery
- pravia and abruption
grand multiparity >5
patho:
- enters maternal cicul via endocervical veins, uterine trauma site, placental insertion site
- cardiogenic shock, respiratory failure, anaphylactoid response
- clinically:
hypotension, respiratory failure and hypoxemia, DIC, coma or seizures.
Rx:
- cardiopulmo resus, correct coagulopathy, supportive

Question 28

Peuperal psychosis

Answer 28

med emergency - woman more likely to commit suicide or infanticide.
- acute mx: hospitalisation –> safety. antipsychotic meds, tx underlying disorder