Obstetric Emergencies Flashcards
What is shoulder dystocia?
It occurs when, after delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis
Describe the pathophysiology of shoulder dystocia
In normal labour, the fetal head is delivered via extension out of the pelvic outlet
This is followed by restitution of the fetal head, so it lies in a neutral position in relation to its spine
This means that the fetal shoulders now lie in an anterior-posterior position
Shoulder dystocia occurs when there is impaction of the anterior fetal shoulder behind the maternal pubic symphysis
Between which two cardinal movements does shoulder dystocia occur?
Extension and restitution
What are the three risk factors of shoulder dystocia?
Macrosomia
Gestational Diabetes
Previous Shoulder Dystocia
What is macrosomia?
It is defined a as a fetal weight larger than average
This is generally a fetal weight above 4.5kg
Why does gestational diabetes increase the risk of shoulder dystocia?
This is due to the fact that the baby’s weight distribution is disproportionately bigger in the abdomen region compared to the head
What are the three clinical features of shoulder dystocia?
Fetal Head Delivery Difficulty
Restitution Failure
Turtleneck Sign
What is restitution failure?
It occurs when the fetal head remains in the occipital anterior position after delivery by extension and therefore doesn’t turn sideways as expected
What is the turtleneck sign?
It is is when the fetal head retracts slightly back into the pelvis, so that the neck is no longer visible
What are the six management options for shoulder dystocia?
Episiotomy
McRoberts Manoeuvre
Suprapubic Pressure
Posterior Arm
Corkscrew Manoeuvre
Zavenelli Manoeuvre
What is an episiotomy?
It is a surgical cut made at the opening of the vagina during childbirth
This can enlarge the vaginal opening and can make access easier for manoeuvres
What is a McRoberts manouevre? How is it used to manage shoulder dystocia?
It involves the mother lying supine with both hips fully flexed and abducted
This widens the pelvic outlet by lifting the pubic symphysis up and out of the way and increasing the lumbosacral angle
What is the first line management option?
McRoberts manouevre
What is suprapubic pressure? How is it used to manage shoulder dystocia?
It involves pressing on the suprapubic region of the abdomen
This puts press pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis
What is the posterior arm manoeuvre?
It involves inserting a hand posteriorly and grasping the posterior arm to deliver
What is the corkscrew manoeuvre?
It involves reaching into the vagina to put pressure in the posterior aspect of the baby’s anterior shoulder
The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder
This is used to move the baby into an oblique position
What is the Zavenelli manoeuvre?
It involves pushing the baby’s head back into the vagina so that the baby can be delivered by an emergency c-section
What do we do if all the manoeuvres fail?
We roll the patient onto all fours and repeat
This may widen the pelvic outlet as the legs are abducted and flexed
What are the four complications of shoulder dystocia?
Fetal Brachial Plexus Injury
Fetal Hypoxic Brain Injury
Perineal Tears
Postpartum Haemorrhage
What postpartum haemorrhage (PPH)?
It refers to bleeding after delivery of the baby and placenta
What blood loss after a vaginal delivery is classified as postpartum haemorrhage?
500ml
What blood loss after a c-section is classified as postpartum haemorrhage?
1000ml
What are the two classifications of postpartum haemorrhage?
Primary Postpartum Haemorrhage
Secondary Postpartum Haemorrhage
What is primary postpartum haemorrhage?
It is defined as bleeding within 24 hours of delivery
What is secondary postpartum haemorrhage?
It is defined as bleeding from 24 hours to 6 weeks after delivery
What are the four categories of postpartum causes?
Thrombin
Tissue
Tone
Trauma
What are the four thrombin causes of postpartum haemorrhage?
Pre-Eclampsia
Placenta Abruption
Bleeding Disorders
Endometritis
What are the two tissue causes of postpartum haemorrhage?
Retained Placenta
Retained Products of Conception
What are the four tone causes of postpartum haemorrhage?
Uterine Atony
Multiple Pregnancy
Placenta Praevia
Previous PPH
What is the most common cause of PPH?
Uterine atony
What are the four trauma causes of postpartum haemorrhage?
Perineal Tear
C-Section
Macrosomia
Episiotomy
What are the seven immediate management options for postpartum haemorrhage?
Call for help
ABCDE
Check uterine tone, trauma and tissue
O2 therapy
Further IV access
Fluid replacement
Bloods
What six blood tests do we conduct in postpartum haemorrhage patients?
FBC
U&Es
LFTs
Group & cross match
Clotting tests
Lactate
What are the two conservative management options for postpartum haemorrhage? Describe how
Uterus Massage - By massaging the uterus through the abdomen, a uterine contraction is stimulated. This can help stop the bleeding.
Catheterisation - A catheter can be placed into the bladder to empty it. This can help stop bleeding as bladder distention prevents uterus contractions.
What five pharmacological treatments for postpartum haemorrhage?
Oxytocin
Ergometrine
Carboprost
Misoprostol
Tranexamic Acid
What is the function of oxytocin?
It stimulates uterine contraction
What is the function of ergometrine?
It stimulates smooth muscle contraction
When is ergometrine contraindicated?
Hypertension
What class of drug is carboprost? What is its functions?
A prostaglandin analogue
It stimulates uterine contraction
When should we take caution when prescribing carboprost to patients?
If they have asthma
What class of drug is misoprostol? What is its functions?
Prostaglandin analogue
It stimulates uterine contraction
What class of drug is tranexamic acid? What is its functions?
Antifibrinolytic
It reduces bleeding
What are the four surgical treatments for PPH?
Intrauterine Balloon Tamponade
B-Lynch Suture
Uterine Artery Ligation
Hysterectomy
What is intrauterine balloon tamponade?
It is a surgical procedure that involves inserting an inflatable balloon into the uterus to press against the bleeding
What is B-lynch suture?
It involves placing a suture around the uterus to compress it
What is uterine artery ligation?
It involves ligation of one or more of the arteries supplying the uterus to reduce the blood flow
What is hysterectomy?
It is a surgical procedure to remove the uterus
What is lochia?
It is vaginal discharge for three to four weeks after birth, however it should be like a period or less with the absence of large clots
In what five ways can we prevent postpartum haemorrhage?
Optimise antenatal haemoblogin levels
IV access
Active management of the 3rd labour stage
Tranexamic acid
Oxytocin infusion in high risk patients
What is umbilical cord prolapse?
It is when the cord descends through the cervix, with or before the presenting part of the fetus
What are the two classifications of umbilical cord prolapse?
Occult Cord Prolapse
Overt Cord Prolapse
What is another name for occult cord prolapse?
Incomplete cord prolapse
What is occult cord prolapse?
It occurs when the umbilical cord descends alongside the presenting part, but not beyond it
What is another name for overt cord prolapse?
Complete cord prolapse
What is overt cord prolapse?
It occurs when the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis
What are the four risk factors of umbilical cord prolapse?
Breech Presentation
Unstable Lie
Polyhydramnios
Amniotomy
How is a breech presentation a risk factor for umbilical cord prolapse?
It means that the cord can easily slip between and past the fetal feet and into the pelvis.
What is the an unstable lie?
It is when the presentation of the fetus changes between transverse, oblique and breech
What is the most significant risk factor for umbilical cord prolapse?
Unstable lie, especially after 37 weeks’ gestation
What is polyhydraminos?
Excessive amniotic fluid around the fetus
What is amniotomy?
The artificial rupture of membranes
What two investigations are used to diagnose umbilical cord prolapse?
CTG
Vaginal examination
What is the sign of umbilical cord prolapse on a CTG?
There are signs of fetal distress
Subtle signs = decelerations with contractions
Obvious signs = fetal bradycardia
What is the main complication of umbilical cord prolapse?
Fetal hyopxia
What are the two mechanisms in which umbilical cord prolapse can result in hypoxia?
Occlusion of the umbilical cord can occur when the presenting part of the fetus presses upon it. This occludes blood flow to the fetus.
Arterial vasospasm occurs when the exposure of the umbilical cord to the cold atmosphere results in a spasm, thus reducing blood flow to the fetus.
What are the two conservative managements for umbilical cord prolapse?
We manually push the presenting part of the foetus back into the vagina. This is to prevent compression of the umbilical cord and therefore hypoxia.
We ask the mother to go on all fours, on knees and elbows
What is the pharmacological management for umbilical cord prolapse?
Terbutaline
How does terbutaline treat umbilical cord prolapse?
It used to relax the uterus, minimise contractions and relieve pressure off the cord
When is terbutaline used to treat umbilical cord prolapse?
It is prescribed to patients whilst waiting for delivery by c-section
What is the surgical management for umbilical cord prolapse?
Emergency c-section
What category c-section does umbilical cord prolapse require?
Category one
