Obstetric emergencies Flashcards
Define shoulder dystocia.
When the anterior shoulder of the foetus becomes impacted behind the maternal pubic symphysis during vaginal delivery
What are the antenatal risk factors for shoulder dystocia?
- Previous shoulder dystocia
- Macrosomia (>4.5kg)
- Diabetes mellitus
- Induction of labour
What are the intrapartum risk factors for shoulder dystocia?
- Prolonged 1st stage of labour
- Secondary arrest
- Prolonged 2nd stage of labour
- Oxytocin augmentation
- Assisted vaginal delivery
What is the management of shoulder dystocia?
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
What are the maternal complications of shoulder dystocia?
- Postpartum haemorrhage
- Perineal tears
What are the foetal complications of shoulder dystocia?
- Brachial plexus injury (Erb’s palsy)
- Fractured clavicle or humerus
- Death
Define cord prolapse.
When the umbilical cord descends below the presenting part of the baby following rupture of membranes.
What are the risk factors for cord prolapse?
- Artificial amniotomy (>1/2 of all cases)
- Preterm labour
- Breech
- Polyhydramnios
- Abnormal lie
- Twin pregnancy
How should cord prolapse be managed?
- 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
What should be done if the cord is past the level of the introitus?
- Minimise handling, but ensure cord is kept warm and moist
- Make preparations for ECS
Define amniotic fluid embolism.
Rare but life-threatening condition caused by entry of foetal cells and debris from amniotic fluid into maternal circulation
What the risk factors for amniotic fluid embolism?
- Multiparity
- Complicated labour
What are the clinical features of amniotic fluid embolism?
- Features begin shortly after delivery (~30 mins)
- hypoxia
- dyspnoea
- hypotension
- cardiac arrest
- disseminated intravascular coagulation (if mother survives >30 mins)
How is amniotic fluid embolism diagnosed?
- Mainly clinical
- Supported by respiratory acidosis and prolonged prothrombin time
How is amniotic fluid embolism managed?
Intrapartum:
- EmCS
Post-partum:
- Mainly supportive measures with involvement of critical care team
- May require initiation of massive obstetric haemorrhage protocol
What are the clinical features of uterine rupture?
- FHR abnormalities
- Constant lower abdominal pain
- Vaginal bleeding
- Cessation of contractions
- Maternal collapse
- Palpable foetal parts through the rupture
What are the risk factors for uterine rupture?
- Labour with a scarred uterus (not as much if scar is in lower segment)
- Neglected obstructed labour
- Congenital uterine abnormalities
What are the preventive measures for uterine rupture?
- Avoidance of IOL and caution when using oxytocin
- ElCS in women with a uterine scar that is not in the lower segment
What is the management for uterine rupture?
- Immediate laparotomy with emergency CS
- Supportive: Fluid resuscitation, blood transfusions
Define uterine inversion.
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
What are the risk factors for uterine inversion?
- Uncontrolled cord traction and/or excessive fundal pressure during the 3rd stage of labour
- Foetal macrosomia
- Previous uterine inversion
What are the clinical features of uterine inversion?
- 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
What is the management of uterine inversion?
- 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
Define primary postpartum haemorrhage.
Blood loss of 500+mL from the genital tract occurring within 24h of delivery
