obstetric emergencies

Question 1

what is shoulder dystocia

Answer 1

when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head

Question 2

what is done to manage shoulder dystocia

Answer 2

series of manoeuvres to dislodge the shoulder - macroberts manoeuvre, suprapubic pressure, attempt to deliver posterior arm, rotational manoeuvres

effective teamwork and well-rehearsed approach is essential

Question 3

at what point of labour would shoulder dystocia occur

Answer 3

after complete extension but before restitution

Question 4

dangers of shoulder dystocia

Answer 4

umbilical cord entrapment
inability of child’s chest to expand properly
severe brain damage/death due to hypoxia/acidosis if delay in delivery
brachial plexus damage

Question 5

what is done to manage shoulder dystocia - mnemonic

Answer 5

HELPERR

Question 6

HELPERR

Answer 6

H - call for help
E - evaluate for episiotomy
L - legs (McRoberts position)
P - suprapubic pressure
E - enter manoeuvers (internal rotation)
R - remove posterior arm 
R - roll patient (onto all fours)

Question 7

what is McRoberts position

Answer 7

flex hips by around 60 degrees to open pelvis

head rest at 20 degrees

Question 8

what is the role of episiotomy in shoulder dystocia management

Answer 8

creates space for internal manoeuvres to be performed

Question 9

how common is post partum haemorrhage

Answer 9

8/100 women who give birth

Question 10

what volume of blood loss classes as PPH

Answer 10

> 500ml after vaginal delivery

>1000ml after C section

Question 11

what are the main causes of PPH

Answer 11

4Ts
thrombin
tissue
tone 
trauma 

other

Question 12

causes of PPH - thrombin

Answer 12

pre-eclampsia
placental abruption
pyrexia in labour
bleeding disorders - haemophilia, anticoagulation, vonWillebrand disease

Question 13

causes of PPH - tissue

Answer 13

retained placenta
placenta accreta
retained products of conception (RPOC)

Question 14

causes of PPH - tone

Answer 14

placenta praevia
over distension of uterus - multiple pregnancy, polyhydramnios, macrosmia
uterine relaxants
previous PPH

Question 15

causes of PPH - trauma

Answer 15

C section
episiotomy
macrosmia (>4kg baby)

Question 16

causes of PPH - other

Answer 16

asian ethnicity
anaemia
induction
BMI >35
prolonged labour 
age

Question 17

types of PPH

Answer 17

1y - 99%, in first 24hrs after delivery, >500ml common (1/20 women), severe haemorrhage >2L rare (6/1000)

2y - >24 hrs to up to 6wks post delivery, often caused by RPOC

Question 18

management of PPH

Answer 18

call for help
ABCDE
empty bladder
rub up uterine fundus (massage above umbilicus)
medications
surgical management 
fluid replacement +/- blood products

Question 19

medications for PPH

Answer 19

oxytocin 5iu slow IV injection
erfometrine 0.5mg slow IV injection (not if high BP)
oxytocin infusion
tranexamic acid 1g IV
carboprost 0.25mg im (max 8 doses)
misoprostol 800micrograms

Question 20

surgical management of PPH

Answer 20

intrauterine balloon tamponade
interventional radiology
B-Lynch suture
Hysterectomy

Question 21

what is important when managing PPH

Answer 21

manage on clinical signs not just EBL

Question 22

what is cord prolapse

Answer 22

the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membrane

Question 23

overall incidence of cord prolapse

Answer 23

0.1-0.6%

breech presentation - 1%

Question 24

what is the danger with cord prolapse

Answer 24

when cord prolapses below the presenting part of the fetus it is highly likely to become compressed and reduce oxygen supply to the fetus

Question 25

risk factors to cord prolapse - general

Answer 25

multiparity
low birthweight (<2.5kg)
preterm labour (<37+0 wks)
fetal congenital anomalies
breech presentation
transverse, oblique and unstable lie
2nd twin
polyhydramnios
unengaged presenting part
low lying placenta

Question 26

risk factors to cord prolapse - general

Answer 26

multiparity
low birthweight (<2.5kg)
preterm labour (<37+0 wks)
fetal congenital anomalies
breech presentation
transverse, oblique and unstable lie
2nd twin
polyhydramnios
unengaged presenting part
low lying placenta

Question 27

what is unstable lie

Answer 27

when the longitudinal axis of the fetus (lie) is changing repeatedly after 37+0 wks

Question 28

procedure related risk factors for cord prolapse

Answer 28

artificial rupture of membranes with high presenting part
vaginal manipulation of the fetus with ruptured membranes
external cephalic version (during procedure)
internal podalic version
stabilising induction of labour
insertion of intrauterine pressure transducer
large balloon catheter induction of labour

Question 29

management of cord prolapse

Answer 29

call for help
replace cord into vagina (NOT UTERUS)
perform digital elevation of the presenting part
catheterise and fill bladder to elevate presenting part
encourage mother to adopt knee-chest or left lateral position w/ raised hips
consider tocolysis
arrange cat I C section

Question 30

why do we replace the cord into the vagina during C section

Answer 30

reduces the chance of it becoming compressed or of the vessels going into spasm because of the lower temp outside of the body

still at risk of compression to to fetal presenting part being above it