Obstetric Emergencies Flashcards
When is the highest risk of VTE?
In the post-partum period or first half of pregnancy
If someone has a DCT Well’s score of >2 (highly likely of DVT), what would be the investigations?
- Proximal compressed doppler ultraosund of iliofemoral region
If negative
- D-Dimer and
- Proximal leg vein ultraosound within 4 hours
- Proximal leg vein ultrasound within 24 hours and start parenteral anticoagulants
What would be the investigations for someone who has a DVT Well score of (<1)?
- Proximal compressed doppler ultrasound within 4 hours or within 24 hours anticoagulation
What is the management of someone with a DVT? And what should you screen for before starting treatment?
Do thrombophillia screen
LMWH until birth and continue for 6 weeks postnatally
Compression stockings also for acute DVT
What is the prophylaxis of someone with a DVT, (clue high risk and moderate risk)
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
How is the dose adjusted for LMWH?
Weight and Factor 10xa
What are the organisms causing maternal sepsis during pregnancy?
- Group A streptococcus
- E-coli
- Gram negative and gram positive (chorioamnionitis)
What are the risk factors for developing maternal sepsis?
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
Why is infection/sepsis an issue in pregnant women?
Because disease progression is much faster
Infection- also causes pre-term labour
How would you manage mother with sepsis, and which antibiotics used?
- 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
What is the definition of fetal distress?
Hypoxia which results in fetal damage or distress if not reversed or the fetus is not delivered
pH ,7.2
Neurological damage <7
What are the factors in the investigations which may indicate fetal distress, and how do you diagnose fetal distress?
- Stained liqour with meconium
- Abnormalities in FHR auscultation eg bradycardia
- 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
Give examples of 2 tocolytics, what their function is and what class of drug they belong to?
Prevent uterine contractions, and therefore delay the onset of labour
B2 agonists
Nifedipine and Terbutaline
What is the management of fetal distress
- Lie the mother in left lateral position (prevent aortocaval compression)
- Vaginal examination- exclude cord prolapse
- O2- 4/5 litres per minute
- Stop oxytocin (stop contractions and therefore more oxygen to baby)- and consider starting tocolytics
- Delivery decisions
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?
C-section
Repeat fetal blood sample in 30 minutes, if can’t repeat then C-section
Characteristically when does a cord prolapse occur? And what would raise suspicion of cord prolapse
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
What are the three types of cord prolapse?
- Overt prolapse- when presenting part doesn’t fit the pelvis and the cord slips past and descends into vagina
- Occult prolapse- cord lies alongside fetal presenting part
- Cord presentation- when the cord prolapses below the presenting part with or without membrane rupture
What are the two complications which arise with cord prolapse?
- Compression by fetal presenting part
2. Vasospasm- because cord is exposed to cold air and temperature drops
What are the risk factors for cord prolapse? (Clue anything which prevents descent or tight snug in pelvis)
Breech presentation- footling presentation Abnormal lie- transverse lie Cephalopelvic disproportion Multiple pregnancy Polyhydroamnios Pre-term birth Multiparity
Low lying placenta and long umbilical cord
How do you investigate cord prolapse, and what are findings?
- Changes in FHR- they will have bradycardia suggests prolonged compression, and variable decelerations
- Confirm diagnosis by vaginal examination- if occult then palpable and if pulsating means fetus is alive
- Colour doppler studies- may show loops of cord in front of fetal presenting part
What is the management of cord prolapse? (clue preventing compression and preventing vasospams)
- O2 4/5 litres a min
- Preventing compression- Trendelburg position or on all fours, fill bladder with fluid, manually elevate fetal presenting part
- Preventing vasospasm- keep cord warm and moist, don’t handle it
- Delivery
- can give tocolytics if waiting for C-section
- if cervix fully dilated- insturmental delivery
- not fully dilated then- C-section
What is shoulder dystocia?
Failure of the anterior shoulder to pass under the pubic symphysis after delivery of the head, despite downwards traction to deliver the shoulders
What are the fetal consequences of shoulder dystocia?
- 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
What are the maternal consequences of shoulder dystocia?
- 3rd and 4th degree perineal tears
- Vaginal lacerations
- PPH
- Uterine rupture
- Sacroilliac joint dislocation
What are the risk factors for shoulder dystocia?
Marcosomia Maternal diabetes, high BMI, low height, disproportion between fetus and mother Labour induction Use of oxytocin Instrumental delivery
What are the signs of shoulder dystocia?
- Difficulty delivering the face
- Face stuck to the vulva or retracting- turtle neck sign
- Lack of descent of the shoulders
What is the management of shoulder dystocia
CLUE: include McRoberts manouvre, Zanavelli Manouvre
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
