Obstetric Emergencies

Question 1

What happens during labour to result in shoulder dystocia?

Answer 1

1. Intrauterine pressure is caused by maternal contractions

2. Anterior shoulder impacted on pubic symphysis

Question 2

Results of shoulder dystocia

Answer 2

Umbilical cord entrapment
Inability of childs chest to expand properly
Severe brain damage or death due to hypoxia or acidosis if delay in delivery
Brachial plexus damage

Question 3

Management of shoulder dystocia - HELPERR

Answer 3

Help (call)
Evaluate for episiotomy 
Legs (Macroberts position)
P (suprapubic) pressure
Enter manoeuvres (internal rotation)
Remove the posterior arm 
Roll the patient (onto all 4s)

Question 4

The 4T causes of PPH

Answer 4

Tissue
Trauma
Tone
Thrombin

Question 5

Thrombin causes of PPH

Answer 5

Pre-eclampsia 
Placental abruption
Pyrexia in labour
Bleeding disorders
- haemophilia, anticoagulation, VW disease

Question 6

Tissue causes of PPH

Answer 6

Retained placenta
Placenta accreta
Retained products of conception (POC)

Question 7

Tone causes of PPH

Answer 7

Placenta praevia 
Over distention of uterus
- multiple pregnancy 
- polyhydramnios
- macrosomnia
Uterine relaxants
Previous PPH

Question 8

Trauma causes of PPH

Answer 8

C section
Episiotomy
Macrosomnia (>4kg baby)

Question 9

Increased risk of PPH if…

Answer 9

Asian ethnicity
Anaemia
Induction 
BMI > 35
Prolonged labour
Age

Question 10

Treatment of PPH

Answer 10

ABCDE
Empty bladder
Rub up fundus 
Drugs
- oxytocin 
- ergometrine
- carboprost
- misoprostol 
Surgical 
- IU balloon tamponade
- Interventional radiology 
- B-lynch suture
- hysterectomy

Question 11

Definition of primary PPH

Answer 11

in first 24 hours of delivery, >500ml of blood (common) or severe haemorrhage >2000ml (rare)

Question 12

Types of PPH

Answer 12

primary

secondary

Question 13

Definition of secondary PPH

Answer 13

> 24 hours up to 6 weeks post delivery (often cause by RPOC)

Question 14

Definition of cord prolapse

Answer 14

The descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membrane

Question 15

When is the incidence of cord prolapse higher?

Answer 15

Breach presentation

Question 16

Risk factors for cord prolapse

Answer 16

Multiparity
low birthweight (<2.5kg)
Pre term labour (<37 weeks)
Foetal congenital abnormalities
Breech presentation 
Transverse, oblique and unstable lie
Second twin 
Polyhydramnios
Unengaged presenting part
Low lying placenta
Artificial rupture of membranes with high presenting part 
Stabilising induction of labour
Large balloon catheter IOL
vaginal manipulation of foetus with ruptured membranes

Question 17

Definition of unstable lie

Answer 17

The longitudinal axis of the foetus (lie) is changing repeatedly after 37 (+0) weeks

Question 18

Treatment of cord prolapse

Answer 18

Replace cord into vagina (not uterus)
Catheterise and fill bladder to elevate presenting part
Perform digital evaluation of presenting part
Encourage mother to have knee-chest or left lateral position with raised hips
Consider tocolysis
Arrange for category 1 C section

Question 19

What should NOT be given in shoulder dystocia?

Answer 19

Oxytocin

Question 20

What position should be used for the mother in umbilical cord prolapse?

Answer 20

On all fours, knees and elbows