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O&G > Obstetric emergencies > Flashcards

Obstetric emergencies Flashcards

1
Q

Define shoulder dystocia.

A

When the anterior shoulder of the foetus becomes impacted behind the maternal pubic symphysis during vaginal delivery

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2
Q

What are the antenatal risk factors for shoulder dystocia?

A
  • Previous shoulder dystocia
  • Macrosomia (>4.5kg)
  • Diabetes mellitus
  • Induction of labour
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3
Q

What are the intrapartum risk factors for shoulder dystocia?

A
  • Prolonged 1st stage of labour
  • Secondary arrest
  • Prolonged 2nd stage of labour
  • Oxytocin augmentation
  • Assisted vaginal delivery
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4
Q

What is the management of shoulder dystocia?

A

Call for help –> McRobert’s manoeuvre –> Suprapubic pressure –> Consider episiotomy –> Rotation manoeuvres (Woodscrew manoeuvre) –> Remove posterior arm –> Patient on all fours or repeat

LAST RESORT**: Symphysiotomy and Zavanelli manoeuvres

**Fracturing foetus’ clavicle would even be considered before these, so vv last resort

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5
Q

What are the maternal complications of shoulder dystocia?

A
  • Postpartum haemorrhage

- Perineal tears

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6
Q

What are the foetal complications of shoulder dystocia?

A
  • Brachial plexus injury (Erb’s palsy)
  • Fractured clavicle or humerus
  • Death
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7
Q

Define cord prolapse.

A

When the umbilical cord descends below the presenting part of the baby following rupture of membranes.

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8
Q

What are the risk factors for cord prolapse?

A
  • Artificial amniotomy (>1/2 of all cases)
  • Preterm labour
  • Breech
  • Polyhydramnios
  • Abnormal lie
  • Twin pregnancy
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9
Q

How should cord prolapse be managed?

A
  • Push the presenting part of the foetus back into the uterus
  • Administer tocolytics (terbutaline) to reduce contractions (in preparation for ECS)
  • Ask patient to go on all fours whilst preparations for ECS are made
  • Retrofill the bladder with saline to elevate the presenting part
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10
Q

What should be done if the cord is past the level of the introitus?

A
  • Minimise handling, but ensure cord is kept warm and moist

- Make preparations for ECS

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11
Q

Define amniotic fluid embolism.

A

Rare but life-threatening condition caused by entry of foetal cells and debris from amniotic fluid into maternal circulation

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12
Q

What the risk factors for amniotic fluid embolism?

A
  • Multiparity

- Complicated labour

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13
Q

What are the clinical features of amniotic fluid embolism?

A
  • Features begin shortly after delivery (~30 mins)
  • hypoxia
  • dyspnoea
  • hypotension
  • cardiac arrest
  • disseminated intravascular coagulation (if mother survives >30 mins)
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14
Q

How is amniotic fluid embolism diagnosed?

A
  • Mainly clinical

- Supported by respiratory acidosis and prolonged prothrombin time

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15
Q

How is amniotic fluid embolism managed?

A

Intrapartum:
- EmCS

Post-partum:

  • Mainly supportive measures with involvement of critical care team
  • May require initiation of massive obstetric haemorrhage protocol
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16
Q

What are the clinical features of uterine rupture?

A
  • FHR abnormalities
  • Constant lower abdominal pain
  • Vaginal bleeding
  • Cessation of contractions
  • Maternal collapse
  • Palpable foetal parts through the rupture
17
Q

What are the risk factors for uterine rupture?

A
  • Labour with a scarred uterus (not as much if scar is in lower segment)
  • Neglected obstructed labour
  • Congenital uterine abnormalities
18
Q

What are the preventive measures for uterine rupture?

A
  • Avoidance of IOL and caution when using oxytocin

- ElCS in women with a uterine scar that is not in the lower segment

19
Q

What is the management for uterine rupture?

A
  • Immediate laparotomy with emergency CS

- Supportive: Fluid resuscitation, blood transfusions

20
Q

Define uterine inversion.

A

An obstetric emergency in which the uterine fundus collapses into the endometrial cavity, resulting in a complete or partial inversion of the uterus, usually following vaginal delivery

21
Q

What are the risk factors for uterine inversion?

A
  • Uncontrolled cord traction and/or excessive fundal pressure during the 3rd stage of labour
  • Foetal macrosomia
  • Previous uterine inversion
22
Q

What are the clinical features of uterine inversion?

A
  • Brisk postpartum haemorrhage
  • Low abdominal pain
  • Round mass (inverted uterus) protruding from the cervix or vagina
  • Absent fundus at the periumbilical position during transabdominal palpation
23
Q

What is the management of uterine inversion?

A
  • Call for help
  • Johnson manoeuvre - immediate replacement of the uterus by pushing up the fundus through the using using the palm of the hand
  • Supportive measures: fluid replacement, blood transfusion, administer tocolytic agents, leave placenta in situ if still attached
  • If these fail then O’Sullivan’s technique: hydrostatic repositioning
24
Q

Define primary postpartum haemorrhage.

A

Blood loss of 500+mL from the genital tract occurring within 24h of delivery

25
Q

Define minor PPH.

A

500-1,000mL of blood loss

26
Q

Define major PPH.

A

> 1,000mL of blood loss

27
Q

Define secondary PPH.

A

Excessive blood loss from the genital tract occurring 24h to 6 weeks after delivery.

28
Q

What are the antepartum risk factors for PPH?

A
  • Placental abruption
  • Placenta praevia
  • Multiple pregnancy
  • Pre-eclampsia, gestational hypertension
  • Previous PPH
  • Obesity
  • Anaemia
  • Uterine abnormalities, fibroids
29
Q

What are the intrapartum risk factors for PPH?

A
  • C-section
  • Induction of labour
  • Retained placenta
  • Episiotomy
  • Instrumental
  • Prolonged labour
  • > 4kg baby
  • Pyrexia in labour
30
Q

What are the potential causes of PPH?

A
  1. Tone (most common):
    - Uterine atony (most common)
    - Macrosomia
    - Twins
    - Uterine abnormalities (such as inversion)
    - Polyhydramnios
  2. Trauma:
    - Episiotomy
    - Perineal tear
    - Uterine rupture
  3. Tissue:
    - Retained placenta
    - Placenta accreta
  4. Thrombin:
    - Pre-existing or newly developed coagulopthies
31
Q

What is the management of major obstetric haemorrhage?

A
  1. Empty uterus
    - delivery foetus
    - remove placenta and any retained tissue
  2. Massage the uterus
  3. Give drugs to increase uterine contractions
  4. Apply bimanual compression
  5. Repair any genital tract injuries (including cervical tears)
  6. Uterine tamponade with Rusch balloon
  7. Surgical intervention: laparotomy and further measures
32
Q

State the drugs used in management of massive obstetric haemorrhage, in the order they would be given in.

A
  • Oxytocin 40IU infusion
  • Ergometrine 500mcg IV or IM
  • Misoprostol 800-1000mcg
  • Carboprost 250mcg
33
Q

State the surgical interventions used in management of massive obstetric haemorrhage, in the order they would be done.

A
  • Oversewing and insertion of a Rusch balloon
  • B-lynch or vertical compression sutures (if uterus is atonic and not responding to drugs)
  • Internal iliac or uterine artery ligation
  • Uterine artery embolisation
  • Total or subtotal hysterectomy (sub-total and quicker and safer)

O&G (17 decks)

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