Obstetric emergencies

Question 1

PPH RFs

Answer 1

assisted delivery (eg ventouse delivery)
macrosomia (>4kg)
multiparity
advanced maternal age
BMI>35
placental issues
prolonged labour

Question 2

PPH initial mx

Answer 2

Resucitation with ABCDE approach
Consider activation of a major haemorrhage protocol
Lie the woman flat
Insert two large bore cannulas
Bloods including Group/Save and Crossmatch
Oxygen
Consider fresh frozen plasma if clotting abnormalities

Question 3

PPH mechanical mx

Answer 3

palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)

catheterisation to prevent bladder distension and monitor urine output

Question 4

PPH medical mx

Answer 4

IV oxytocin: slow IV injection followed by an IV infusion
ergometrine slow IV or IM (unless there is a history of hypertension)

carboprost IM (unless there is a history of asthma)

misoprostol sublingual

Question 5

PPH surgical mx

Answer 5

intrauterine balloon tamponade if atony is cause

B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

hysterectomy

Question 6

placental abruption mx if alive & <36

Answer 6

fetal distress: immediate caesarean

no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Question 7

placental abruption mx if alive & >36

Answer 7

fetal distress: immediate caesarean

no fetal distress: deliver vaginally

Question 8

placental abruption mx if dead

Answer 8

induce vaginal delivery

Question 9

obstetric cholestasis mx

Answer 9

• A-E approach – everything is stable other than rash on hands and feet?
• Clarify she is stable/unstable?
• Bloods including FBC, U+E, LFT, bile acids, urinalysis
• Admit for observation  
• Fetal observation – CTG  
• Ursodeoxycholic acid  
• Emollient for itch and anti-histamine – promethazine or chlorphenamine
• Offer leaflet for obstetric cholestasis and consider induced delivery from 37 weeks gestation  

Question 10

PE mx

Answer 10

• ABC approach  
• Ensure airway patency 
• Breathing – RR, sats; give oxygen; ABG; CXR – if normal then V/Q
• Circulation – HR, CRT, BP, IV Access; don’t need to do D-Dimer as elevated  in pregnancy anyway; ECG 
• Definitive management: LMWH subcutaneous throughout the remainder of pregnancy 

Question 11

amniotic fluid embolus mx

Answer 11

MDT // supportive

Question 12

PRROM mx

Answer 12

• Rule out chorioamnionitis: CTG, Abdominal exam, FBC, inflammatory markers  
• AVOID PV examination  
• Admit for 48hrs; observe vitals and CTG 
• Erythromycin 250mg QDS for 10 days  
• Betamethasone 12mg IM 2 doses 24hrs apart  
• If labour starts –iv magnesium sulphate  
• If evidence of infection, may have to deliver – if not try and get to 34 weeks and safety net + continuous monitoring

Question 13

sepsis 2ry to c-sec scar mx

Answer 13

Patient 4: Sepsis secondary to C/S scar wound infection
* A-E and buffalo structure  
* Airway is patent  
* Breathing – RR, equal air entry, sats are low – start 15l non rebreathe, ABG/ VBG because she is now on oxygen, chest auscultation normal
* C – BP is low, fluid bolus 500ml 0.9% saline. HR, CRT >2 seconds, IV access. JVP, heart sounds normal. Bloods – buffalo cultures, FBC, CRP, PCT, lactate urine output decreased should be monitored hourly
* D: pupils equal and reactive, GCS 13/15 eyes only reactive to verbal, confused. Glucose normal.  
* E – no rashes, bruising, no bleeding  
* Recheck previous interventions.  
* IV Abx according to trust guidelines
* Senior  
* Admit for observation

Question 14

umbilical cord prolapse mx

Answer 14

push presenting part back
minimal cord handling, keep it warm & moist
on all fours (left lateral position alternative)
tocolytics reduce uterine contractions
retrofilling of bladder elevate presenting part
c-sec (or instrumental vaginal if cervix dilated & head low)