Obstetric emergencies

Question 1

Shoulder dystocia pathophysiology

Answer 1

Shoulder dystocia occurs when there is impaction of the anterior fetal shoulder behind the maternal pubic symphysis, or impaction of the posterior shoulder on the sacral promontory.

A delay in delivery of the fetal shoulders leads to hypoxia in the fetus, proportional to the time delay to complete delivery.

Shoulders lie in anterior-posterior position

Question 2

Pre-labour risk factors for shoulder dystocia

Answer 2

Previous shoulder dystocia – increases recurrence risk by x10

Macrosomia – fetal weight above >4.5kg. However 48% happen in babies weighing <4kg.

Diabetes – increases risk by x2-4 (due to increased risk of macrosomia – baby’s weight distribution is disproportionately bigger in abdomen compared to head)

Maternal BMI > 30

Induction of labour

Question 3

Intrapartum risk factors for shoulder dystocia

Answer 3

Prolonged 1st stage of labour

Secondary arrest (when there is initially good progress in labour and then progress stops, usually due to malposition of the baby)

Prolonged second stage of labour (time whilst fully dilated and pushing)

Augmentation of labour with oxytocin

Assisted vaginal delivery (e.g forceps or ventouse)

Question 4

Clinical features of shoulder dystocia

Answer 4

Delay in delivery of the shoulders following the head during a vaginal delivery with the next contraction after using normal traction.

Difficulty in delivery of the fetal head or chin.

Failure of restitution – the fetal remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’.

‘Turtle Neck‘ sign – the fetal head retracts slightly back into the pelvis, so that the neck is no longer visible, akin to a turtle retreated into its shell.

Question 5

Management of shoulder dystocia

Answer 5

call for help
stop pushing
avoid downwards traction on fetal head
consider episiotomy

Question 6

first line manoeuvres for shoulder dystocia

Answer 6

McRobers manoeuvre

Suprapubic pressure

Question 7

mcrobers manoeuvre

Answer 7

hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing.

This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle.

This single manoeuvre has a success rate of about 90% and is even higher when combined with ‘suprapubic pressure’, (see below).

Question 8

suprapubic pressure

Answer 8

applied in either a sustained or rocking fashion to apply pressure behind the anterior shoulder to disimpact it from underneath the maternal symphysis.

Question 9

second line manoeuvres for shoulder dystocia

Answer 9

posterior arm

internal rotation

Question 10

posterior arm

Answer 10

insert hand posteriorly into sacral hollow and grasp posterior arm to deliver

Question 11

internal rotation

Answer 11

apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees or into an oblique position.

Question 12

further manoeuvers for shoulder dystocia

Answer 12

cleidotomy- fracturing the fetal clavicle
symphysiotomy- cutting pubic symphysis
zavenelli- returning fetal head to pelvis for delivery of baby via c section

Question 13

post-delivery for shoulder dystocia

Answer 13

Active management of third stage
PR examination to exclude 3rd degree tear
Debrief with mother and partner
physiotherapist review before discharge: pelvic floor, musculoskeletal pain and temporary nerve damage
paediatric review is recommended: brachial plexus injury, humeral fracture, hypoxic brain injury

Question 14

complications of shoulder dystocia

Answer 14

maternal: 3rd or 4th degree tears, PPH
fetal: humerus or clavicle fracture, brachial plexus injury, hypoxic brain injury

Question 15

cord prolapse types

Answer 15

Occult (incomplete) cord prolapse – the umbilical cord descends alongside the presenting part, but not beyond it.

Overt (complete) cord prolapse – the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis.

Cord presentation – the presence of the umbilical cord between the presenting part and the cervix. This can occur with or without intact membranes.

Question 16

pathophysiology of cord prolapse

Answer 16

fetal hypoxia: occlusion or arterial vasospasm

Question 17

risk factors for cord prolapse

Answer 17

breech presentation
unstable lie
artificial rupture of membranes
polyhydramnios
prematurity

Question 18

clinical features of cord prolapse

Answer 18

Non-reassuring fetal heart rate pattern and absent membranes
external inspection or DVE
decelerations, fetal bradycardia
PV bleeding; heavily blood-stained loquor with ruptured membranes (placental abruption or vasa praevia)

Question 19

management of cord prolapse

Answer 19

avoid handling the cord to reduce vasospasm

manually elevate the presenting part

encourage into left lateral position

consider tocolysis (terbutaline)

delivery via c section (emergency)

Question 20

moderate risk factors for eclampsia

Answer 20

Nuliparity.
Maternal age ≥ 40 years.

Maternal BMI ≥ 35 at initial presentation.

Family history of pre-eclampsia.

Pregnancy interval > 10 years.

Multiple pregnancy.

Question 21

high risk factors for eclampsia

Answer 21

Chronic hypertension

HTN, pre-eclampsia or eclampsia in previous pregnancy.

Pre-existing chronic kidney disease

Diabetes Mellitus.

Autoimmune diseases (e.g. SLE, antiphospholipid syndrome)

Question 22

clinical features of eclampsia

Answer 22

new-onset tonic-clonic type seizure in presence of eclampsia 
post-ictal phase 
Headache (usually frontal).
Hyper-reflexia.
Nausea and vomiting.
Generalised oedema.
Right upper quadrant pain +/- jaundice.
Visual disturbances e.g. flashing lights, blurred or double vision.
Change in mental stage.

Question 23

maternal complications of eclampsia

Answer 23

HELLP syndrome (3 %)
Disseminated Intravascular Coagulopathy (DIC) (3 %)

Acute Kidney Injury (4 %)

Adult respiratory distress syndrome (3 %)

Cerebrovascular haemorrhage (< 2 %)

Permanent CNS damage.

Death (1.8 %)

Question 24

fetal complications of eclampsia

Answer 24

Intrauterine growth restriction (IUGR).
Prematurity.

Infant respiratory distress syndrome.

Intrauterine fetal death.

Placental abruption.

Question 25

investigations for eclampsia

Answer 25

FBC: ↓ Hb, ↓ platelets.
U&Es: ↑ urea, ↑ creatinine, ↑ urate, ↓ urine output.
LFTs: ↑ ALT, ↑ AST, ↑ bilirubin.
Clotting studies
Blood glucose

abdominal USS
full neuro work-up

Question 26

management of eclampsia

Answer 26

resuscitation, left lateral position
cessation of seizures: MgSO4
blood pressure control: IV labetalol and hydralazine, target of <120mmHg, continuous CTG during and for 30minutes after giving IV anti-hypertensives
prompt delivery of baby and placenta: C-section,
monitoring: fluid balance

Question 27

post-natal care and follow-up eclampsia

Answer 27

Inpatient care:
Regular symptom review – e.g headaches, epigastric pain.
Bloods 72 hrs post-partum – FBC, LFTs, creatinine.
Pre-conceptual counselling – advice regarding minimising risk factors and prophylaxis for future pregnancies.
Step-down care to community – when reached target BP and asymptomatic

Outpatient care:
Consider CT Head – if persistent neurological deficit.
Measure BP – in the UK, blood pressure is checked daily for 2 weeks post-partum.
Follow-up at 6 weeks – check BP, proteinuria and creatinine. Repeat FBC, LFTs and creatinine if not previously returned to normal