obstetric emergencies Flashcards
what is shoulder dystocia
when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head
what is done to manage shoulder dystocia
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
at what point of labour would shoulder dystocia occur
after complete extension but before restitution
dangers of shoulder dystocia
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
what is done to manage shoulder dystocia - mnemonic
HELPERR
HELPERR
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)
what is McRoberts position
flex hips by around 60 degrees to open pelvis
head rest at 20 degrees
what is the role of episiotomy in shoulder dystocia management
creates space for internal manoeuvres to be performed
how common is post partum haemorrhage
8/100 women who give birth
what volume of blood loss classes as PPH
> 500ml after vaginal delivery
>1000ml after C section
what are the main causes of PPH
4Ts thrombin tissue tone trauma
other
causes of PPH - thrombin
pre-eclampsia
placental abruption
pyrexia in labour
bleeding disorders - haemophilia, anticoagulation, vonWillebrand disease
causes of PPH - tissue
retained placenta
placenta accreta
retained products of conception (RPOC)
causes of PPH - tone
placenta praevia
over distension of uterus - multiple pregnancy, polyhydramnios, macrosmia
uterine relaxants
previous PPH
causes of PPH - trauma
C section
episiotomy
macrosmia (>4kg baby)
causes of PPH - other
asian ethnicity anaemia induction BMI >35 prolonged labour age
types of PPH
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
management of PPH
call for help ABCDE empty bladder rub up uterine fundus (massage above umbilicus) medications surgical management fluid replacement +/- blood products
medications for PPH
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
surgical management of PPH
intrauterine balloon tamponade
interventional radiology
B-Lynch suture
Hysterectomy
what is important when managing PPH
manage on clinical signs not just EBL
what is cord prolapse
the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membrane
overall incidence of cord prolapse
0.1-0.6%
breech presentation - 1%
what is the danger with cord prolapse
when cord prolapses below the presenting part of the fetus it is highly likely to become compressed and reduce oxygen supply to the fetus
risk factors to cord prolapse - general
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
risk factors to cord prolapse - general
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
what is unstable lie
when the longitudinal axis of the fetus (lie) is changing repeatedly after 37+0 wks
procedure related risk factors for cord prolapse
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
management of cord prolapse
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
why do we replace the cord into the vagina during C section
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
