Obstetric emergencies

Question 1

What is shoulder dystocia?

Answer 1

When additional manoeuvres are required after normal downward traction has failed to deliver the shoulders after the head has delivered.

Question 2

What does excessive traction on the neck cause during shoulder dystocia in labour?

Answer 2

Damage to the branchial plexus which causes Erb’s palsy (waiter’s tip) which is permanent in 10% of cases.

Question 3

What are the risk factors for shoulder dystocia?

Answer 3

Large baby
Gestational/maternal diabetes
Previous shoulder dystocia
Obesity

Question 4

What is the management of shoulder dystocia?

Answer 4

Gentle downward traction is used.

Initially, the mothers legs are hyperextended onto the abdomen (McRoberts’ manoeuvre) and supra-pubic pressure is also applied. This works in 90% of cases.

If this fails, internal methods are used, usually with an episiotomy so the hand can enter the vagina. The shoulders can be rotated (Wood’s screw manoeuvre).

Last resorts are symphysiotomy (cartilage of the public symphysis is divided to widen the pelvis).

Zavanelli manoeuvre - replacement of the head and caesarian section, but by this time damage is usually irreversible.

Question 5

What is a cord prolapse?

Answer 5

This occurs when, after the membranes have ruptured, the umbilical cord descends below the presenting part. Untreated, the cord will go into spasm or be compressed, causing foetal hypoxia and distress.

Question 6

What are the risk factors for cord prolapse?

Answer 6

Breech presentation
Artificial rupturing of the membranes (50% of cord prolapses occur here)
Preterm labour 
Polyhydramnios 
Twin pregnancy

Question 7

What is the management for cord compression?

Answer 7

Presenting part is pushed up by the examining finger or tocolytics are used (e.g. terbutaline).
If the cord is out of the introitus, it should be kept warm and moist but not forced back inside.
The patient is asked to go on all fours whilst preparations for delivery by the safest route are undertaken - immediate caesarian section is usual.

Question 8

What is an amniotic fluid embolism?

Answer 8

When liquor enters the maternal circulation, causing anaphylaxis with sudden dyspnoea, hypoxia and hypotension, often accompanied by seizures and cardiac arrest.

Question 9

When would amniotic fluid embolism typically occur?

Answer 9

At rupture of the membranes, but can also occur during labour, at caesarian section and even at termination of pregnancy.

Question 10

How is amniotic fluid embolism managed?

Answer 10

Resuscitation and supportive management.
Blood for clotting, FBC, electrolytes and cross-match are undertaken. Treatment of massive obstetric haemorrhage will be required.

Question 11

What is uterine rupture?

Answer 11

When the uterus tears de novo or an old scar can open. The foetus is extruded, the uterus contracts down and bleeds from the rupture site, causing acute foetal hypoxia and massive internal maternal haemorrhage.

Question 12

What are the different severities for places of rupture of the uterus?

Answer 12

Lower transverse scar rupture is usually less serious because the lower segment is not very vascular, heavy blood loss and extrusion of the foetus is less likely.

Primary rupture of rupture of a classic caesarian scar are more serious.

Question 13

What makes you suspect uterine rupture?

Answer 13

Foetal heart rate abnormalities or a constant lower abdominal pain. Vaginal bleeding, cessation of contractions and maternal collapse may also occur.

Question 14

What are the risk factors for uterine rupture?

Answer 14

Labours with a scarred uterus
Neglected obstructed labour
Congenital uterine abnormalities

Question 15

What is the management for uterine rupture?

Answer 15

Maternal resuscitation with fluids and bloods.
Foetus is delivered
Uterus is repaired or removed.
Uterine rupture has a high recurrence rate in subsequent pregnancies and so early caesarian delivery is required.

Question 16

What is uterine inversion?

Answer 16

When the fundus inverts into the uterine cavity - usually follows traction on the placenta.

Question 17

What happens when a uterus inverts?

Answer 17

Pain, shock, haemorrhage

Question 18

What is the management of an inverted uterus?

Answer 18

Attempt to push the fundus up via the vagina.
If not possible, a general anaesthetic is given and replacement performed with hydrostatic pressure of several litres of warm saline, which is run past a clenched fist into the introitus of the vagina.

Question 19

How are maternal epileptiform seizures managed?

Answer 19

Airway is cleared with suction and oxygen is administered.
The patient is not restrained but is prevented from hurting herself.
Cardiopulmonary resuscitation may be required.
In the absence of cardiopulmonary collapse, diazepam will normally stop the fit in the first instance.
It is wise to assume the fit is due to eclampsia until examination and lab findings suggest otherwise.
Magnesium sulfate is not useful for non-epilectic seizures and therefore is not given unless you know what the seizure is from.
Magnesium sulfate is better than diazepam for eclamptic seizures though, but should not be given when diagnosis is uncertain.