Obstetric emergencies Flashcards
What is antepartum haemorrhage defined as
Bleeding from/within the genital tract at >20wks and prior to delivery
Aetiology of antepartum haemorrhage
Placenta praevia
Vasa praevia
Placenta accreta
Placental abruption
List the complications of antepartum haemorrhage
Maternal:
- anaemia
- shock
- ATN
- DIC
Foetal:
- hypoxia
- IUGR
- prematurity
- foetal death
Describe the management of antepartum haemorrhage
Fluid resus (crystalloids, vasopressors, blood)
Tranexamic acid
Emergency caesarean
Where is the placental positioned for it to be classed a placenta praevia
<20mm from cervical os
Risk factors for placental praevia
Prev placenta praevia, CS or TOP Multiple pregnancy Maternal age >40 Smoking ART, IVF
Management of placenta praevia
If asymptomatic:
- see if it resolves with time
- follow up at 36wks
- if persistent –> CS
- if >20mm –> can do VB
Acute:
- achieve haemodynamic stability
- consider emergency CS
- magnesium sulfate
- corticosteroids
- anti-D
Management of vasa praevia
Planned caesarean if detected prior to labour
Emergency caesarean if detected during labour
Aetiology of placenta abruption
Trauma
HELLP/Pre-eclampsia
Risk factors of placental abruption
Maternal: Low BMI Advanced maternal age Smoking Drugs Multiparity
Pregnancy: Prev abruption PET ECV Polyhydramnios
How can you distinguish between placenta praevia and placenta abruption clinically?
Placental abruption –> PV bleeding with pain
Placenta praevia –> painless PV bleeding
Ix for placental abruption
CTG
FBC, coags
US
Management of placental abruption
Emergency caesarean
Fluid resus +/- blood and vasopressors
Monitor for DIC
Management of placenta accreta
Optimise maternal iron and Hb stores
Planned preterm delivery for 35-36wks
High risk hysterectomy
Risk factors for cord prolapse
Breech (footling) presentation. Prematurity Polyhydramnios High presenting part Long cord Grand multiparity (p>5) 2nd twin AROM
Complications of cord prolapse
Cord compression --> foetal hypoxia - birth asphyxia - cerebral palsy - death Emergency CS
Management of cord prolapse
HELP!
Emergency caesarean
CTG
Trendelenburg position (prone, knees to chest)
Digital elevation of presenting part of foetus to move it off the cord
Fill bladder with 500mL isotonic solution to elevate the presenting part off the cord
Risk factors for uterine rupture
VBAC (1 in 200) Hx uterine rupture Grand multiparity IOL with oxytocin Malpresentation Short inter-delivery interval <2yrs Birth weight >4kg
Clinical features of uterine rupture
Foetal bradycardia and broad decels Sudden abdo pain with PV bleeding Loss of station of presenting part Intraperitoneal bleeding Shock
Complications of uterine rupture
Foetal:
98% fatality rate
HIE –> cerebral palsy, cognitive impairment, seizures
Maternal:
Hysterectomy
Death
Blood transfusion
Management of uterine rupture
Immediate delivery by caesarean +/- hysterectomy
Delivery w/in 20 mins.
ICU transfer
Define shoulder dystocia
Impaction of the anterior shoulder of the baby against the pubic symphysis after the birth of the foetal head
Risk factors for shoulder dystocia
Prenatal risk factors:
- prev hx of shoulder dystocia
- damage to pelvis e.g. trauma
- Ricketts
- maternal short stature
- abnormal pelvic anatomy
Antenatal risk factors:
- GDM
- macrosomia
- postdates
- high pre-pregnancy weight and weight gain
Intrapartum risk factors:
- prolonged 1st or 2nd stages of labour
- head bobbing in 2nd stage
- instrumental vaginal delivery
- syntocinon
Prevention of shoulder dystocia
Routine CS is not recommended - only CS if multiple risk factors
Complications of shoulder dystocia
Maternal:
- soft tissue injury
- anal sphincter damage
- PPH
- symphyseal separation
Foetal:
- brachial plexus palsy
- # of humerus or clavicle
- foetal acidosis
- hypoxic ischemic encephalopathy (have 4 mins to get baby out)
Clinical signs of shoulder dystocia
Turtle sign
Failure of restitution
Gentle traction does not assist with delivery
Management of shoulder dystocia
HELPERR
H - Help
- notify staff
- tell mum to stop helping
E - Evaluate for episiotomy
- won’t solve the problem but can make more room for performing advanced manoeuvres.
L - Legs
- McRoberts manoeuvre: flex hips (knees to chest)
P - Pressure
- Suprapubic pressure: put hands in CPR position behind the posterior shoulder of baby and exert downward pressure
E - Enter (internal manoeuvres)
- Rubin II manoeuvre (insert fingers and rotate the anterior shoulder of baby)
- Woods screw manoeuvre
- Reverse woods screw manoeuvre
R - Remove the posterior arm
- flex the arm at the elbow and and cross the arm across the foetal chest
R - Roll/rotate the woman
- all fours position
Last resort:
- Zavanelli manourvre (push foetal head back into vagina, tocolysis and immediate CS)
- Deliberately fracture the baby’s clavicle
- Symphysiotomy
What blood volume is lost in postpartum haemorrhage
> 500mL in vaginal birth
>1000mL in CS
Aetiology of PPH
The 4 T’s = tone, trauma, tissue, thrombin
TONE: Atonic uterus (failure of uterus to contract in 3rd stage of labour). Risk factors: - grand parity - prolonged labour - excess syntocinon - uterine distension (macrosomia, polyhydramnios) - chorioamnionitis
TRAUMA:
- uterine rupture or inversion
- lacerations of cervix, vagina and perineum
TISSUE:
Retained placenta
THROMBIN:
- bleeding disorders
- DIC
- thrombocytopenia
- HELLP syndrome
Complications of PPH
Hypovolemic shock Renal or liver failure DIC ARDS Death Sheehan syndrome
Outline prevention strategies for PPH
Antenatal:
- identify and treat anaemia
- identify high risk patients
Intrapartum:
- active management of 3rd stage of labour reduced PPH risk by 50% (controlled cord traction, uterine stabilisation, syntocinon)
- fundal pressure
- IV access
- group and hold, crossmatch
Approach to initial management of minor PPH (<1000mL and no shock)
Call for help Fundal massage to make uterus contract Bimanual compression of uterus IV access FBC, group and hold IV cystalloids Treat the cause
Initial management of major PPH (>1000mL)
Call for help Resus: - lie flat - fundal massage - dual IV access - IV fluids: warmed crystalloids and colloids until blood is available - send bloods for crossmatch - O2 mask - Blood transfusion
IDC (empty bladder helps uterus contract)
Approach to treating the cause of PPH
Tone: -fundal massage - bimanual compression - misoprostol - syntocinon - tranexamic acid Trauma: repair in OT Tissue: manual removal of placenta Thrombin: correct coagulopathy
Describe the options for surgical management of PPH
Remove placenta Suture lacerations Bakri balloon B lynch suture Hysterectomy Vessel ligation
Outline the medications used for PPH
- Syntocinon
- oxytocin –> uterine contraction
- prevents and treats PPH - Ergometrine
- stimulates uterine contraction and vasoconstricts
3, Misoprostol
- prostaglandin analogue
- dilates and softens the cervix and induced uterine contractions
- Tranexamic acid
- antifibrinolytic
- inhibits clot breakdown by preventing plasmin from binding to fibrin
Management of secondary PPH
Treat underlying cause
ABX
Evacuation of retained POC
