Obstetric Emergencies

Question 1

What is shoulder dystocia?

Answer 1

Additional measures are required after normal downward traction has failed to deliver the shoulders after the head has delivered.

Question 2

What are the consequences of should dystocia?

Answer 2

Excessive traction on the neck damages the brachial plexus, resulting in Erb’s palsy, which is permanent in about 50% of cases.

Question 3

What are the risk factors for shoulder dystocia?

Answer 3

The principal risk is a large baby. Previous shoulder dystocia, increased maternal BMI, labour induction, low height, maternal diabetes and instrumental delivery.

Question 4

How do you manage shoulder dystocia?

Answer 4

Additionally help should be called as soon as shoulder dystocia is identified and McRoberts’ manoeuvre should be performed. This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen. This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.

Question 5

What is the Zavanelli manoeuvre?

Answer 5

Replacement of the head after shoulder dystocia and C section, by this time fetal damage is usually irreversible

Question 6

What is cord prolapse?

Answer 6

After the membranes have ruptured, the umbilical cord descends below the presenting part.

Question 7

What are the consequences of a cord prolapse?

Answer 7

Untreated, the cord will be compressed or go into spasm and the baby will rapidly become hypoxic.

Question 8

What are the risk factors for cord prolapse?

Answer 8

Preterm labour, breech presentation, polyhydramnios, abnormal lie and twin pregnancy.

Question 9

How do you diagnose cord prolapse?

Answer 9

When the fetal heart rate becomes abnormal and the cord is palpated vaginally, or if it appears at the introitus.

Question 10

How do you manage cord prolapse?

Answer 10

Initially, the presenting part must be prevented from compressing the cord; it is pushed up by the examining finger or tocolytics are given. If the cord is out of the introitus, it should be kept warm and moist but not forced back inside. The patient should be on all fours. Usually, instrumental delivery occurs.

Question 11

What is an amniotic fluid embolism?

Answer 11

This is when liquour enters the maternal circulation, causing anaphylaxis with sudden dyspnoea, hypoxia and hypotension, often accompanies by seizures and cardiac arrest. Acute heart failure is evident

Question 12

What are the consequences of amniotic fluid embolism?

Answer 12

Many women die. If the women survives for 30 minutes, she will rapidly develop DIC, and often pulmonary oedema and adult respiratory distress syndrome.

Question 13

When does amniotic fluid embolism usually occur?

Answer 13

Typically occurs when the membranes rupture, but may occur during labour, at C section and even at termination of pregnancy

Question 14

What are the risk factors for amniotic fluid embolism?

Answer 14

Strong contractions in the presence of polyhydramnios, but prevention is impossible

Question 15

How do you manage amniotic fluid embolism?

Answer 15

Resuscitation and supportive treatment as for any cause of collapse is key. Oxygen and fluid. Blood for clotting, FBC, electrolytes and crossmatch. Blood and fresh frozen plasma will be required. Transfer to ICU

Question 16

What causes uterine rupture?

Answer 16

The uterus can tear de novo or an old scar (e.g. C section) can open.

Question 17

What happens after a uterine rupture?

Answer 17

The fetus is extruded, the uterus contracts down and bleeds from the rupture site, causing acute fetal hypoxia and massive internal maternal haemorrhage.

Question 18

It a de novo tear or a tear through an old scar more risky?

Answer 18

From a lower transverse C section scar is usually less serious than a primary rupture or one from a classic C section.

Question 19

Why is a lower transverse C section scar rupture less serious?

Answer 19

The lower segment is not very vascular and heavy blood loss and extrusion of the fetus into the abdomen are less likely

Question 20

What are the clinical features of a uterine rupture?

Answer 20

The diagnosis is suspected from a fetal heart rate abnormality or a constant lower abdominal pain, vaginal bleeding, cessation of contractions and maternal collapse may occur

Question 21

What are the risk factors for uterine rupture?

Answer 21

Labours with a scarred uterus; neglected obstructed labour; congenital uterine abnormality

Question 22

How do you prevent uterine rupture?

Answer 22

Avoid induction and caution when using oxytocin in women with a previous C section and elective C section in women with a uterine scar not in the lower segment

Question 23

How do you manage uterine rupture?

Answer 23

Maternal resuscitation with IV fluid and blood. Uterus may need to be removed to stop massive blood loss.

Question 24

Does uterine rupture often recur?

Answer 24

Yes, it has a high recurrence rate so early C section delivery is required

Question 25

What is uterine inversion?

Answer 25

When the fundus inverts into the uterine cavity, usually following traction on the placenta

Question 26

What are the symptoms of uterine inversion?

Answer 26

Haemorrhage, pain and profound shock are normal.

Question 27

How do you manage uterine inversion?

Answer 27

A brief attempt is made immediately to push the fundus up via the vagina. May need replacement performed with hydrostatic pressure of several litres of warm saline, which is run past a clenched fist at the introitus into the vagina

Question 28

What is a stillbirth?

Answer 28

Fetus born dead at 24+ weeks

Question 29

What is neonatal death?

Answer 29

Neonate dies <28 days after delivery (early is <7 days)

Question 30

What is perinatal mortality?

Answer 30

Stillbirths plus early neonatal deaths, if ‘corrected’ excludes congenital abnormalities

Question 31

What are the main causes of perinatal mortality?

Answer 31

Unexplained antepartum; IUGR; preterm labour; congenital abnormalities; APH; intrapartum haemorrhage; PE

Question 32

What is maternal mortality?

Answer 32

Mother dies during or within 42 days of pregnancy from any cause related to (direct) or aggravated by (indirect) the pregnancy or its management, but not from accidental or incidental causes

Question 33

What are the main causes of maternal mortality?

Answer 33

Direct: sepsis, VTE, HTN disease, haemorrhage, amniotic fluid embolism, ectopic
Indirect: cardiac disease, neurological or psychiatric disease