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Obs/Gyn > Obstetric emergencies > Flashcards

Obstetric emergencies Flashcards

1
Q

What are the potential complications of shoulder dystocia?

A

Hypoxia
Erb’s palsy
Death

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2
Q

What are the risk factors for shoulder dystocia?

A

High birth weight (over 4000gm, almost inevitable over 4500gm)
Maternal diabetes
Older maternal age
Maternal obesity
Post term delivery
Previous shoulder dystocia
Male sex of foetus
Iatrogenic (pulling the baby out too fast)

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3
Q

How is the diagnosis of shoulder dystocia made?

A

Subjective diagnosis, essentially when routine gentle downward traction of the foetal head fails to work

Turtle sign- When the foetal head retracts into the perineum after expulsion

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4
Q

What are some simple things that can be down with shoulder dystocia to help?

A
  • Start timer
  • Tell patient not to push until manoeuvres completed
  • Patients buttocks flush with the edge of the bed to facilitate ease of access
  • Release a tight nuchal cord over the head but do not cut it
  • If bladder is distended then place a catheter
  • Mediolateral episiotomy may help
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5
Q

What are some of the manoeuvres to help relieve shoulder dystocia?

A

McRoberts maneouvre
Delivery of posterior arm
Rubin manoeuvre
Woods screw manoeuvre
Clavicular fracture
Gaskin all fours manoeuvre

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6
Q

What are the main causes of primary postpartum haemorrhage?

A

Tone (uterine atony) 70%
- Most common cause of any PPH
Trauma 20%
- laceration, rupture, instrumentation etc, Most common cause of massive PPH
Tissue 10%
- retained tissue, blood clots or placenta accreta spectrum
Thrombin 1%
- DIC, HELLP, FDIU, amniotic fluid embolism, RPOC

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7
Q

What is the definition of primary post partum haemorrhage?

A

Occurs within 1st 24hrs
- >500mls post vagainal delivery
- >1000mls is severe/major
- >1000mls post C-section
Or bleeding associated with signs and symptoms of hypovolaemia

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8
Q

What is the classification of PPH?

A

Can use ATLS guidelines ie
Class I: 0-15% blood loss
Class II: 15-30%
Class III: 30-40%
Class IV: >40%

CMQCC staging
Stage 0: every patient in labour
Stage 1: 500-1000mls lost, shock index (SI) 0.9, PPH protocl activated
Stage 2: 1000-1500mls or instability, MTP and PPH protocol
Stage 3: >1500mls or DIC or unstable or >2units PRBC given, needs surgical intervention

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9
Q

What are the risk factors for uterine atony?

A

Prolonged labour
prior uterine atony
Magnesium sulfate use
Chorioamnionitis
Uterine overdistension
Uterine inversion
Induced labour

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10
Q

What is the sequence of medications given in PPH in australia?

A

Make sure to perform fundal massage

Uterotonics
- 1st line Oxytocin 10 IU IM
- 2nd line Ergometrine 0.25-0.5mg IM/IV (contraindicated with HTN), or 2nd oxytocin 10 IU IM
- 3rd line Carboprost 0.25mg IM, contraindicated with asthma/HTN
- 4th line Misoprostol 800mcg PR or Buccal
- Consider starting 10IU/hr infusion of oxytocin max 40IU

Tranexamic Acid 1gm over 10mins given for all causes of PPH

Once bleeding controlled, give prophylactic medications to prevent further bleeding

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11
Q

What will neuroimaging typically show in someone with eclamptic seizures?

A

vasogenic oedema predominantly localised to the posterior cerebral hemispheres

Essentially identical to imaging in patients with reversible posterior leukoencephalopthy syndrome (PRES) seen in hypertensive crisis

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12
Q

When does eclampsia typically occur during a pregnancy?

A

40% between 30-37 weeks, 20% 2-30 weeks, 20% intrapartum and 20% within 6-8 weeks post partum

Seizures before 20weeks is highly unusual and an alternative diagnosis should be sort (ie molar pregnancy)

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13
Q

What is the management of an eclamptic seizure?

A
  • normal seizure treatment (02, airway, resus area, IV access)
  • Left lateral/wedge
  • IV/IM benzodiazepines if meeting status epilepticus criteria
  • Aim SBP <160 and DBP <110, Labetalol 20mg IV and infusion start 1mg/min
  • If seizure terminated start Mag Sulf loading dose 5gm (20mmols) IV over 20mins then 1gm/hr
  • If seizure not terminated give 5gm IV over 5mins or 10gm IM (5gm to each buttock)
  • Most seizures self terminate and do not become SE, however often recurrent hence starting magnesium and lowering BP
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14
Q

What are the signs of magnesium toxicity?

A

> 3.5mmol/L
Respiratory depression, reduced GCS, hypotonia and loss of deep tendon reflexes
Reduced urine output

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15
Q

What is the antidote to magnesium toxicity?

A

IV calcium (gluconate or chloride)
Directly antagonises Magnesium

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16
Q

What is the purpose of the foetal fibronectin swab test (fFN)?

A

Positive during labour, usually used to differentiate pre-term labour from false labour

17
Q

What are the principal medications in pre-term labour

A

Tocolysis (ie Nifedpine 20m PO or Terbutaline 250mcg IV)
ABx prophylaxis (Ampicillin 2gm IV and Erythromycin 250mg PO)
Mag sulf 6gm IV
Betamethasone 11.4mg IM

18
Q

What are the potential clinical findings in Pre-eclampsia?

A
  • Hypertension
  • Epigastric/RUQ tenderness
  • Hyperreflexia
  • Clonus
  • Peripheral oedema
  • APO
  • Oliguria
  • AMS/stroke symptoms/post ictal
  • Visual disturbance (flashes, blurred, visual fields, blindness)
19
Q

What measures can be taken to prevent or reduce the risks associated with Primary PPH?

A
  • Treat antenatal anaemia
  • Identify at risk women
  • Active management of 3rd stage
  • Empty the bladder
  • Watch for slow trickles
  • TXA
  • Syntocinon
  • Have blood products available
20
Q

What is the most common cause of secondary PPH?

A

Usually RPOC or endometritis (or both)
- Usually occurs at 10-14days
- Milk production is affected
- Often needs D&C

21
Q

What is the definition of a Breech birth?

A
  • Buttocks or feet closest to cervix
  • Foetus in longitudinal lie
22
Q

What are the risk factors for breech birth?

A
  • Prematurity
  • Multiple gestation
  • polyhydramnios
  • Placenta praevia
  • Foetal abnormalities
  • Uterine abnormalities (tumours, fibroids, congenital, PID)
23
Q

What are the main issues with breech delivery?

A
  • High risk of cord prolapse
  • High risk of head or shoulders becoming stuck
  • High likelyhood of needing neonatal resuscitation if vaginal delivery
24
Q

What are some delivery tips for managing a breech delivery?

A
  • Empty bladder
  • Minimal handling except to support babies body
  • Keep woman upright
  • Birth the head gently (risk of decapitation)
25
Q

What are the risk factors for cord prolapse?

A
  • Malpresentations (ie breech)
  • Low birth weight
  • Polyhydraminions
  • Abnormal uterine anatomy
  • Abnormal placentation
  • Long umbilical cord
  • High head at onset of labour
  • Artificial ROM
26
Q

What is the intrapartum management of cord prolapse?

A

Obstetric emergency
- Place woman in knee to chest or in exagerrated Sims position
- Push cord back into vagina
- relieve pressure on cord if possible
- Fill the bladder
- 02, large bore IV access, CTG
- Stop oxytocin, consider tocolysis

27
Q

What is the HELPERR mnemonic for shoulder dystocia?

A
  • Call for Help
  • Evaluate for Episiotomy
  • Legs (mcroberts manouvre)
  • Pressure suprapubically
  • Enter maneouvres (internal rotation)
  • Remove posterior arm
  • Roll (the woman and deliver posterior shoulder)
28
Q

What are the indications for a Bakri Balloon (Uterine tamponade)?

A
  • Isolated refractory uterine bleeding
  • Os is still open
  • Uterus is large and atonic

Insert balloon into uterus, use gravity to fill balloon to maximum of 500mls, dont force fluid in

29
Q

How is precipitous labour managed in the ED?

A

Call obs/paeds +/- anaes
Resus bay with neonate equipment
IM 10units oxytocin prepared
Assess for crowning/presenting part, as well as vaginal loss
Deliver baby
Prepare for 3rd stage management
Transfer to ward/other hospital when able

Equipment
- Clamps
- Episiotomy scissors
- Neonatal resus equipment

Meds
- PPH drugs (oxytocin, ergometrine, TXA etc)
- Vitami K for baby
- Resus drugs

30
Q

How does cervical length on ultrasound correspond with risk of pre-term labour?

A
  • > 3cm almost excludes labour
  • <3cm higher risk
  • <1.5cm strongly predictive
31
Q

How should PPH post a home birth or where birth details are not known be handled?

A
  • Confirm stage of labour and confirm that all babies + placenta are indeed out!
32
Q

What are the clinical details of placenta praevia?

A

Basics
- Should be suspected in any PV bleeding post 20 weeks
- Do not perform a VE before getting imaging
- High risk of PPH and often need a C-section
- Many previas detected at 20 weeks actually resolve before term

RF’s
- Previous praevia
- Multiple gestation
- Preveious C-section

33
Q

What is the DR C BRAVADO mnemonic for CTG interpretation?

A

DR - Define risk
- Ie high risk pregnancy, IUGR, chroioamnionitis etc

C- Contractions
- Frequency (ie 3-4 in 10minutes)
- Duration

BRA- Baseline rate
- Ie foetal tachycardia, bradycardia (may indicate hypoxia, choriamnionitis etc)

V- Variability
- Normal 5-25bpm from baseline
- Doesnt include Accels/Decels
- Decreased (drugs, Mg+, hypoxia, foetal sleep)

A- Accelerations
- Defined as rise >15bpm for >15s
- Usually occur during foetal movement

D- Decelerations
- Variable decels (80%) have small accels either side, usually caused by cord compression with contractions
- Late decels occur at end of contraction, Usually a sign of hypoxia/lack of blood flow
- Early decels coincide with contractions, usually due to head compression with vagal tone (not pathological)

O- Overall impressions
- Reassuring, non-reassuring or abnormal

34
Q

What is the NICE classification for CTG risk?

A

Concerning Variable Decels
- >60secs
- Biphasic shape
- No shouldering
- Failure to return to baseline
- Reduced baseline variability

Overall risk
- Normal = all reassuring features
- Suspicious = 1 non-reassuring but otherwise reassuring
- Pathological = 2 non-reassuring and/or 1 abnormal feature

Obs/Gyn (4 decks)

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