Obstetric emergencies Flashcards
What is the most effective step in neonatal resuscitation?
ventilation!
-not chest compressions or drugs
in newborn life support, what are the three main questions we need to ask ourselves?`
- is the newborn term or not term?
- does the baby have good tone?
- is the baby crying or breathing?
what is routine care in newborn life support?
thermoregulation and monitoring
when do we consider IV adrenaline in a neonate during resuscitation?
when the HR is below 60bpm and has failed chest compression and adequate ventilation
what is the adrenaline dose for neonatal resuscitation?
10-30mcg/kg
what might we consider for volume expansion during neonatal resuscitation?
normal saline
or
O neg blood
how best might we measure neonatal HR?
auscultation of the fetal heart
what do we consider as bradycardia in a neonate?
Less than 100bpm
what are some reasons neonates may fail to respond to intubation in resuscitation?
tube in the oesophagus tube too far pneumothorax pleural effusion diaphragmatic hernia
when do we consider cardiac compressions during neonatal resuscitation?
when the fetal HR is still less than 60bpm despite adequate ventilation for 30secs
what is the ratio of compressions:breaths during neonatal resuscitation?
3 compressions to 1 breath
when are medications required in neonatal life support?
indicated when the fetal HR less than 60bpm after 30s of chest compressions + effective ventilation
what are some special considerations for preterm neonates requiring resuscitation?
Special needs for preterm=
Supplemental O2
what is the most effective way of gaining IV access in a neonate?
via the umbilical vein
what are the two obstetric indications for preterm labour?
pre-eclampsia and fetal growth restriction
what are the manouevers that we can perform in the case of shoulder dystocia?
- McRobertson’s position
- Suprapubic pressure is applied
- applying direct pressure either in front or behind the anterior/posterior shoulder to rotate the baby
- removal of the posterior arm (this is very likely to work)
- roll the patient onto all fours (Gaskin)
Of last resort:
- cleidotomy- pulse the fetal clavicle out
- Zavanelli= push baby back into pelvis and do a c-section
- hysterotomy
- symphysiotomy- opens the pubic symphysis if c-section cannot be performed (very very rare)
how do we prevent shoulder dystocia?
anticipate the complication- e.g. manage maternal obesity, maternal DM etc
?caesarean section or ?early induction of labour for macrosomia?
what is the relationship between c-sections and placenta accreta?
increasing no of c-sections leads to increased risk of placental accreta in future pregnancies
what is the risk of having vaginal birth after a previous caesarean?
primary risk= uterine rupture with 5-6% chance of fetal death
define antepartum haemorrhage?
vaginal bleeding> 50mls between 20 weeks of gestation til the onset of labour
describe the HELPERR acronym protocol for shoulder dystocia?
H- call for help! E- evaluate for episiotomy L- legs- mcrobert's position P- suprapubic pressure E- enter rotational manoeuvers R- remove the posterior arm R- roll patient onto all fours
what are some causes of antepartum haemorrhage?
placenta praevia placental abruption marginal placental bleeding uterine rupture vasa praevia
what must we consider if a pregnant woman presents frequently with small volume vaginal bleeds?
intimate partner DV
how do we dx a placental abruption?
clinical diagnosis only
what is placental abruption?
premature separation of a normally implanted placenta prior to delivery of the fetus
what is the clinical presentation of uterine rupture causing antepartum haemorrhage?
sudden abdominal pain, abdominal distension and hypovolemic collapse
how do we manage uterine rupture causing antepartum haemorrhage?
aggressive maternal resuscitation
immediate laparotomy
a woman known to be in early pregnancy (less than 20weeks) reports some vaginal bleeding. what do you think?
threatened miscarriage or possibly ectopic pregnancy
what are some risk factors for placental abruption?
Maternal: chronic HT, preeclampsia, thrombophilia, smoking, cocaine/ice use, previous abruption, chorioamnionitis
Other: sudden drop in uterus size (e.g. reduction of amniotic fluid in polyhydramnios or delivery of one twin); trauma from MVA
what is something you must monitor for in a woman who comes in with placental abruption?
risk of DIC so must monitor coagulation factors including fibrinogen and prothrombin time
what are some medications/drugs we should consider in a mother who has placental abruption?
Anti-D immunisation in rhesus negative mothers
Corticosteroids if less than 32 weeks gestation
Magnesium sulfate for neuroprotection if less than 30 weeks
Tocolytics should not be used due to vasodilating effects
what are the top 3 causes of APH
45% due to vaginal or lower genital tract causes of bleeding
25% due to placental abruption
35% due to placenta praevia
what are the main clinical differences between placental abruption and placenta praevia causing APH?
placental abruption- PAINFUL bleeding
placental praevia- PAINLESS bleeding
a young woman comes into ED with vaginal bleeding and abdominal pain. She says was 8 weeks pregnant. What are your first ix and what are you worried about?
transvaginal ultrasound and serial quantitative bHCG measurements
ectopic pregnancy
at what bHCG level should you see intrauterine pregnancy contents on transvaginal ultrasound?
> 1500 IU/L
how do we prevent uterine atony?
active management of the 3rd stage of labour using oxytocin
main causes of PPH?
The common causes are ‘tone’ (uterine atony), ‘tissue’ (retained placental tissue), ‘trauma’ (birth canal laceration) and ‘thrombin’ (coagulopathy).
what should we do if a pregnant woman with known placenta praevia experience vaginal bleeding during pregnancy?
All symptomatic women requires an INPATIENT admission!
After bleeding event, the rest of the pregnancy is usually in hospital
NB: bleeding from minor PP also warrants inpatient admission
a pregnant woman is diagnosed with major placenta praevia. She hasn’t however had any vaginal bleeding. what do you do as her obstetrician?
Major asymptomatic PP:
Usually an inpatient admission is required > 34 weeks gestation so plan that ahead
Plan for an elective caesarean section around 37 weeks
what is the key difference between bleeding from placenta praevia and placental abruption vs vasa praevia?
placenta praevia and placental abruption–> maternal blood loss
vasa praevia–> fetal blood loss
what is the management of vasa praevia?
Antenatal diagnosis is ideal, then plan for a c-section PRIOR to labour. Delivery usually considered by 35-36 weeks gestation.
Any bleeding requires INPATIENT admission–>e.g. if CTG is abnormal, indication for an urgent c-section.
what is the common underlying mechanism (pathophysiology) of placental abruption?
Placental bed ischaemia
The most common mechanism for abruption appears to be ischaemia of vessels in the placenta bed producing necrosis of anchoring villi and placental separation.
when does the lower uterine segment form in pregnancy?
From approximately 26 to 28 weeks’ gestation, there is progressive development of a lower uterine segment (LUS) by stretching of the uterine tissues between the histological and anatomical internal os of the cervix.
Like the cervix, the LUS has a fibromuscular composition and is easily recognised as it is covered by loose peritoneum.
what is the main risk of cord prolapse during labour?
birth asphyxia of the baby
what are some causes of fetal bradycardia
Cord compression/cord prolapse Head compression/rapid descent Regional anaesthesia Maternal hypotension Tetanic uterine contraction (syntocinon?) Maternal seizure congenital heart abnormality post-maturity normal baseline loss of contact- tracing the mum or the baby?
what is your management if you notice the CTG indicates fetal bradycardia?
Assess- vaginal examination for cervical dilation, maternal vitals, CTG, abdominal palpation
Resuscitation- stop syntocinon, left lateral tilt, O2, fluid resuscitation, correct hypotension, tocolysis
Delivery- caesarean or vaginal (if fully dilated)
what do we mean by uterine hyperstimulation?
When excessive uterine muscular activity (uterine tachysystole) is associated with fetal compromise –> uterine hyperstimulation
what fetal scalp blood lactate requires urgent medical attention and possible delivery?
> 4.8
what does labour dystocia mean?
failure to progress during labour
what are the complications of prolonged labour?
Prolonged labour is associated with a number of undesirable consequences including maternal and fetal infection (chorioamnionitis), fetal traumatic injury, fetal hypoxia, postpartum haemorrhage and damage to the maternal pelvic floor.
what are the three management options for prolonged labour?
- ongoing observation
- augmentation of the labour with an oxytocin infusion
- delivery.
what are some considerations for prolonged labour that might help guide your management?
need to consider fetal wellbeing and previous maternal history of c-sections
need to consider presentation, lie and station of the fetus, and whether the cervix has dilated
need to consider contraindications to augmentation such as fetal compromise
need to consider whether instrumental vaginal delivery or c-section is required
need to anticipate and prepare for shoulder dystocia if vaginal delivery
what are the maternal and fetal consequences of obstructed labour
sepsis, fetal death, genital tract fistula in a primigravida
uterine rupture, maternal death in the multigravida
what are the signs of obstructed labour?
Lack of progress (contractions, cervical dilatation, station) in association with:
Maternal tachycardia Fetal tachycardia Maternal pyrexia Macroscopic haematuria Retraction ring on abdominal examination Cervical oedema
what IS obstructed labour?
when the presenting part of the fetus cannot negotiate the maternal pelvis leading to compression and ischaemia of the soft tissues in the pelvis and reduced uterine contractions/progress of labour
What is erbs palsy, and what are the signs and symptoms of this condition?
Brachial plexus injury due to shoulder dystocia
Excessive traction on the shoulders will lead to a traction injury of the upper segments (C5 to C7) of the brachial plexus= Erb’s palsy.
The child cannot abduct the arm at the shoulder and has weakness of elbow flexion
describe the mc robert’s position for shoulder dystocia?
abduct and hyperflex maternal thighs onto maternal abdomen bilaterally
apply gentle downward traction
what is your management of cord prolapse and what is the main risk of this situation?
main risk= fetal hypoxia due to cord compression
call for help! this is an obstetric emergency and requires an experienced team of obstetricians, midwives, anaesthetist, paediatrician. also call to get theatre ready
place woman in steep trendelenberg position to relieve compression on cord
attempt to push the cord prolapse past the presenting part of the fetus or physically prevent the presenting part from compressing the cord
trial delivery but low threshold for emergency caesarean section if required
what are the four Ts of PPH?
The common causes are ‘tone’ (uterine atony), ‘tissue’ (retained placental tissue), ‘trauma’ (birth canal laceration) and ‘thrombin’ (coagulopathy).
what is the most common cause of secondary PPH
infection with retained products of conception
what is your management of primary PPH?
DRSABCDE- treat as if for uterine atony as it is the main cause.
Send for HELP!
- Check that the placenta is complete
- Control shock; gain IV access, take blood- start fluids
- send blood off and cross-match of 4 units of blood
- check for genital tract trauma/tears–> apply compression or repair if present
- Insert IDC as a full bladder will further reduce uterine contractions
Meanwhile these manouveres should be performed to manage excessive bleeding:
Uterine fundal massage
Oxytocin administration +/- ergometrine if not contraindicated +/- misoprostol per rectum
Prepare for theatre and potential blood transfusion (monitor ongoing blood loss volume)
+/- Balloon tamponade +/- Compression sutures +/- direct injection of PgF2a into uterine muscle wall
Surgical exploration of uterus and removal of retained products of conception if present
Internal iliac ligation
Last line= > 3L blood loss then radical surgery–> hysterectomy
how do you manage secondary PPH
A full clinical assessment is needed to ascertain the degree of blood loss and whether any resuscitation is required.
A haemoglobin check is needed and a vaginal swab is taken for microbiological study.
Oxytocics (e.g. ergometrine, misoprostol) variably assist with controlling acute bleeding.
Antibiotic therapy is commenced even if the woman is afebrile, since endometritis is likely.
A serum hCG should be performed if the bleeding is unusual or persistent, suggesting trophoblastic disease.
An ultrasound will be requested to exclude substantive retained products of conception that will require curettage for removal.
Finally send to theatre for surgical exploration of uterus
what is the difference between ‘cord prolapse’ and ‘cord presentation’?
Cord Prolapse: the umbilical cord lies in front of or beside the presenting part in the presence of ruptured
membranes.
Cord presentation: the presence of the umbilical cord between the presenting part of the fetus and the cervix.
In both conditions a loop of the cord is below the presenting part.
The difference is in the condition of the
membranes; if intact it is cord presentation and if ruptured it is cord prolapse.
what are the risk factors for cord prolapse?
- High / ill fitting presenting part
- High parity
- Prematurity
- Multiple pregnancy
- Polyhydramnios
- Malpresentations
- Obstetric manipulation
fetal HR becomes abnormal soon after rupture of membranes. what must you consider?
cord prolapse
what is your management of confirmed cord prolapse?
- Summon medical assistance- code GREEN
- Place the woman in knee to chest position or exaggerated SIMs position
- Push the presenting part up and out of the vagina to prevent cord compression
- Cease oxytocin if present
- Oxygen to mother
- Decide depending on the situation whether LUSCS or assisted vaginal delivery required
- Monitor and document fetal HR
Paired umbilical cord blood sampling
what is the rubin 2 manouever during management of shoulder dystocia?
applying suprapubic pressure
what are the signs and symptoms of chorioamnionitis?
Tender abdomen
Larger than expected uterus size
Maternal fever
malodourous vaginal discharge that may be purulent
Signs of compromised fetal wellbeing (if before delivery)
in the case of secondary PPH and prevention of endometritis, what antibiotics do we use?
gentamicin
penicillin
metronidazole
why do we use a BLUNT currette and not a sharp currette when performing D and C
A sharp currette can cause Asshermann’s syndrome whereby the uterine walls stick together and render the woman infertile
what is your management of shoulder dystocia?
Management of Shoulder Dystocia:
- Call for help!
- Note the time! 10-15 mins (> 15mins risk of HIE)
- Consider cutting an episiotomy if you haven’t already done it; reposition the mother
- McRobert’s position–> leg flexion
- Apply suprapubic pressure
- Corkscrew/woodscrew internal manuoevre
- Posterior arm removal
- Zamenelli restitution–> push back baby back in and do an emergency caesarean section
a woman in labour experiences SROM. soon after she becomes unconscious. what do you think is happening?
amniotic fluid embolism
what is your management of suspected placental abruption. Assume that the fetus is still live and FDIU has not occurred.
- Send for help and admit the patient
- Assess severity of situation e.g. fetal/maternal factors
- Ensure maternal wellbeing by assessing/supporting the airway, giving oxygen via mask if required and gaining IV access.
- Auscultate fetal heart and apply CTG. Work out gestational age
- Take maternal bloods- Hb, Plts, WCC, CRP, LFTs, UEC, D dimer, Kleihaur test, cross-match 4-6 units of blood
- Give IV fluid resuscitation if maternal haemodynamic instability evident and give pain relief as appropriate
- Administer IM anti-D immunoglobulin in mother is Rh-negative
• If there are signs of fetal compromise consider urgent delivery
• If fetus is okay and preterm-administer corticosteroids and watch and wait with close monitoring
If fetus is okay and near term- aim for vaginal delivery via induction
what are some causes of intrapartum fetal compromise as detected on CTG?
• Epidural causing maternal hypotension • Uterine hyperstimulation • Placental abruption • Chronic placental insufficiency (post dates pregnancy) • Cord compression Vasa praevia haemorrhage
what is your general INITIAL management of intrapartum fetal compromise?
reposition mother to left lateral tilt
cease oxytocin if you suspect uterine hyperstimulation
apply CTG and if it is non-reassuring –> perform fetal scalp lactate
