Obstetric Emergencies

Question 1

When is the highest risk of VTE?

Answer 1

In the post-partum period or first half of pregnancy

Question 2

If someone has a DCT Well’s score of >2 (highly likely of DVT), what would be the investigations?

Answer 2

1. Proximal compressed doppler ultraosund of iliofemoral region

If negative

2. D-Dimer and
   - Proximal leg vein ultraosound within 4 hours
   - Proximal leg vein ultrasound within 24 hours and start parenteral anticoagulants

Question 3

What would be the investigations for someone who has a DVT Well score of (<1)?

Answer 3

1. Proximal compressed doppler ultrasound within 4 hours or within 24 hours anticoagulation

Question 4

What is the management of someone with a DVT? And what should you screen for before starting treatment?

Answer 4

Do thrombophillia screen

LMWH until birth and continue for 6 weeks postnatally
Compression stockings also for acute DVT

Question 5

What is the prophylaxis of someone with a DVT, (clue high risk and moderate risk)

Answer 5

High risk, >3 or more risk factors: LMWH started at 28 weeks and continued for 6 weeks postpartum

Moderate risk >2: LMWH for 10 days postpartum

Question 6

How is the dose adjusted for LMWH?

Answer 6

Weight and Factor 10xa

Question 7

What are the organisms causing maternal sepsis during pregnancy?

Answer 7

• Group A streptococcus
• E-coli
• Gram negative and gram positive (chorioamnionitis)

Question 8

What are the risk factors for developing maternal sepsis?

Answer 8

Diabetes, impaired glucose tolerance, immunosuppression
Previous history of pelvic infection, group B strep, and group A in close contacts
Amniocentesis, other invasive procedures, cervical cerclage
Vaginal discharge

Question 9

Why is infection/sepsis an issue in pregnant women?

Answer 9

Because disease progression is much faster

Infection- also causes pre-term labour

Question 10

How would you manage mother with sepsis, and which antibiotics used?

Answer 10

• Bloods: FBC, lactate, glucose, ESR/CRP, U +E’s. Blood cultures, throat swabs, MSU, High vaginal swab
• Urinary output every hour
• Fluids: IV crystalloid if hypotensive or lactate >4mmol/L
• Antibiotics: Co-amoxiclav, clinadmycin or gentamycin
• Lactate
• Oxygen

Question 11

What is the definition of fetal distress?

Answer 11

Hypoxia which results in fetal damage or distress if not reversed or the fetus is not delivered

pH ,7.2
Neurological damage <7

Question 12

What are the factors in the investigations which may indicate fetal distress, and how do you diagnose fetal distress?

Answer 12

1. Stained liqour with meconium
2. Abnormalities in FHR auscultation eg bradycardia
3. CTG
   DR- risk factors eg fever, pre-eclapmsia, IUGR fetus
   C- hyperstimulation eg >5 contractions in 10 mins
   Bradycardia (<110), loss of baseline variability, presence of variable and late decelerations

Question 13

Give examples of 2 tocolytics, what their function is and what class of drug they belong to?

Answer 13

Prevent uterine contractions, and therefore delay the onset of labour
B2 agonists
Nifedipine and Terbutaline

Question 14

What is the management of fetal distress

Answer 14

1. Lie the mother in left lateral position (prevent aortocaval compression)
2. Vaginal examination- exclude cord prolapse
3. O2- 4/5 litres per minute
4. Stop oxytocin (stop contractions and therefore more oxygen to baby)- and consider starting tocolytics
5. Delivery decisions

Question 15

Fetal distress

What would you do in the case of pH <7.2 or persistent bradycardia?

What would you do if pH is >7.2 but FHR abnormalities?

Answer 15

C-section

Repeat fetal blood sample in 30 minutes, if can’t repeat then C-section

Question 16

Characteristically when does a cord prolapse occur? And what would raise suspicion of cord prolapse

Answer 16

After the membranes rupture

FHR abnormalities or changes in fetal condition after ROM
On abdo exam- if fetal presenting part is ill fitting or not engaged then increases the risk of cord prolapse

Question 17

What are the three types of cord prolapse?

Answer 17

1. Overt prolapse- when presenting part doesn’t fit the pelvis and the cord slips past and descends into vagina
2. Occult prolapse- cord lies alongside fetal presenting part
3. Cord presentation- when the cord prolapses below the presenting part with or without membrane rupture

Question 18

What are the two complications which arise with cord prolapse?

Answer 18

1. Compression by fetal presenting part

2. Vasospasm- because cord is exposed to cold air and temperature drops

Question 19

What are the risk factors for cord prolapse? (Clue anything which prevents descent or tight snug in pelvis)

Answer 19

Breech presentation- footling presentation
Abnormal lie- transverse lie 
Cephalopelvic disproportion 
Multiple pregnancy 
Polyhydroamnios 
Pre-term birth
Multiparity 

Low lying placenta and long umbilical cord

Question 20

How do you investigate cord prolapse, and what are findings?

Answer 20

1. Changes in FHR- they will have bradycardia suggests prolonged compression, and variable decelerations
2. Confirm diagnosis by vaginal examination- if occult then palpable and if pulsating means fetus is alive
3. Colour doppler studies- may show loops of cord in front of fetal presenting part

Question 21

What is the management of cord prolapse? (clue preventing compression and preventing vasospams)

Answer 21

1. O2 4/5 litres a min
2. Preventing compression- Trendelburg position or on all fours, fill bladder with fluid, manually elevate fetal presenting part
3. Preventing vasospasm- keep cord warm and moist, don’t handle it
4. Delivery
   - can give tocolytics if waiting for C-section
   - if cervix fully dilated- insturmental delivery
   - not fully dilated then- C-section

Question 22

What is shoulder dystocia?

Answer 22

Failure of the anterior shoulder to pass under the pubic symphysis after delivery of the head, despite downwards traction to deliver the shoulders

Question 23

What are the fetal consequences of shoulder dystocia?

Answer 23

• Pneumothorax
• Fetal hypoxia- acidosis- permanent brain damage (due to the chest not being able to expand because stuck under symphysis)
• Erbs palsy (traction on the neck)
• Fractured clavicle and humerus

Question 24

What are the maternal consequences of shoulder dystocia?

Answer 24

• 3rd and 4th degree perineal tears
• Vaginal lacerations
• PPH
• Uterine rupture
• Sacroilliac joint dislocation

Question 25

What are the risk factors for shoulder dystocia?

Answer 25

Marcosomia 
Maternal diabetes, high BMI, low height, disproportion between fetus and mother 
Labour induction 
Use of oxytocin 
Instrumental delivery

Question 26

What are the signs of shoulder dystocia?

Answer 26

• Difficulty delivering the face
• Face stuck to the vulva or retracting- turtle neck sign
• Lack of descent of the shoulders

Question 27

What is the management of shoulder dystocia

CLUE: include McRoberts manouvre, Zanavelli Manouvre

Answer 27

H- Call for help, seniar obstetrician, midwife, consultant paediatrician
E- evaulaute for episiotmy
L- Hyperextend legs onto abdomen as in McRoberts manouvre
P- apply suprapubic pressure
E- do episiotomy now to allow hand into pelvic
R- Rotational manouvres ie Woods
R- Replace posterior shoulder, put pressure on posterior shoulder to increase space ie Roberts
R- replace head and C-section ie Zanavelli manouvre