Obstetric emergencies Flashcards
What are the 4 steps of calling for help in an obstetric emergency?
- Pull the emergency bell
- Tell an appropriate person to call 2222 stating the appropriate name of emergency + accurate location
- Tell the person to feedback to you when they are done
- Tell someone to bring the appropriate equipment trolley
How do you approach any obstetric emergency?
Is it safe to approach?
ABCDE
How do you check the patients Airway?
- Is the patient talking
- look inside the mouth for obstruction
- Flatten the bed
How do you asses B?
- SATS
- RR
- Chest auscultation
How do you asses Circulation
- Pulse
- BP
- Cap refill time
- Cold periphery
- IV Access - take bloods and give fluids if indicated
- Urine output + catheter if indicated
How do you assess Disability?
- AVPU
- Blood sugar
- light reflex
How do you asses exposure?
- Head to toe assessment
2. Review ABCDE again
Which 4 people do you call for help in any obstetric emergency?
- Scribe
- Obs
- Anaesthatist
- Paediatricin
What are the 5 D’s of OBS?
- Document
- De-brief
- Datix
- Duty of candor
- DVT
What is the commonest organism that causes sepsis in pregnant women?
Group A strep
What is sepsis?
Bodies response to an infection
When are women at a high risk of developing sepsis?
6 weeks postnatally due to cardiovascular and immune changes
Name 8 causes of maternal sepsis (infections)
- Mastitis
- UTI
- Pneumonia
- Episiotomy infection
- Gastrointestinal infection
- Spinal site infection
- Vaginal infection
- Wound infection
How do you prevent sepsis?
- Proper hand hygiene + use of anti-septics
What are the symptoms of sepsis?
Depends on the cause -
Fever, diahrrhoea, vomiting, abdominal pain, soar throat, URTI, offensive vaginal discharge, wound infection, heavy lochia
List 7 signs of sepsis?
- Rash
- tachycardia
- tachypnoea
- pyrexia/hypothermia
- hypotension
- low urine output
- pallor
List 6 Red flags associated with sepsis
- Pyrexia > 38 or hypothermia <36
- Tachycardia >90
- RR >20
- Abdominal/chest pain
- Diarhhoea/N + V
- Uterine tenderness
What does Puerperium mean?
The period after childbirth - up to 6 weeks
List 6 risk factors for developing sepsis during pregnancy
- Obeisity
- HIV
- Diabetes
- PROM
- Anaemia
- Previous pelvic infection
List 7 risk factors for developing sepsis during the puerperium period
- Obeisity
- Anaemia
- Diabetes
- CS
- Wound haematoma
- Retained products of conception
- History of pelvic infection
List 4 organism that can cause sepsis during pregnancy
- Group A strep
- E-coli
- Staph
- MRSA
what is the initial management for sepsis?
- Call for help
- ABCDE
- High flow oxygen
- Left lateral position
- Wide bore cannula
List sepsis 6 protocol
Take:
- Blood cultures
- Serum lactate
- UO
Give:
- Oxygen
- IV fluids
- IV AB
What 3 antibiotics could you give to manage sepsis?
High dose cefuroxime, metronidazole OR co-amoxiclav
When would you start IV fluids for sepsis (under what conditions)?
- Hypotensive
2. High lactate >4
What fluid would you give a patient with sepsis? how much and over how long?
0.9% normal saline
either
- 500 ml over 15 mins
- 20 mg/Kg
What do you use to monitor a patient with sepsis? and how often?
MEOWS chart every 15 mins
Name 8 cultures you would send for a patient with sepsis
- Blood
- vaginal
- urine
- woun
- stool
- throat
- sputum
- placental
What further investigation do you do in a patient with sepsis?
Depends on cause
CXR
abdominal US
CT abdo/pelvis
What condition does sepsis increase the risk of developing?
DVT
How do you escalate any obstetric emergency?
SBAR
Situation
Background
Assessment
Review
How does the umbilical cord present normally?
Presence of the umbilical cord between the foetal presenting part and the cervix +/- ROM
What is cord prolapse?
Where the umbilical cord descends through the cervix alongside or past the presenting foetal part in the presence of ruptured membrane
Name 8 pregnancy related risk factors for cord prolapse
- Unengaged presenting part
- Multiple pregnancy
- Multiparity
- Malpresentation, malposition or unstable lie
- Polyhydraminous
- Prematurity
- Low lying placenta/ placenta privea
- Foetal congenital abnormality
Name 5 procedure related risk factors for cord prolapse
- ARM - artificial rupture of membrane
- ECV
- Controlled ARM for IOL with high head
- Rotational instrumental delivery
- Vaginal manipulation of the foetus with ruptured membrane - FSE
What percentage of cord prolapse are preceded by an obstetric procedure?
50%
How do you manage cord prolapse?
If membranes are intact, stop VE to avoid ARM
Exaggerated SIMS
Monitor foetal heart
Escalate
Consider operative birth
Four steps of managing cord prolapse (4 r’s)
- Recognise
- Run for help
- Relieve
- Remove
How do you recognise cord prolapse?
- Cord visible/protruding from vagina
- Palpable cord
- Abnormal foetal heart on auscultation/CTG
How do you relieve cord prolapse?
- Exaggerated SIMs position
- Knee chest position
- Manually elevating the presenting part
- Trendelenburg position
- tocolysis - if premature
What is Eclampsia?
1+ convulsions associated with pre-eclampsia
When is the highest risk of developing seizures?
Postoartum > antepartum > intrapartum
What is the commonest cause of death associated with Eclampsia?
Cerebral haemorrhage
What type of seizure does eclampsia present with?
Generalised seizure
Who do you call for help in eclampsia?
Senior midwife
Experienced OBS
Anaesthatist
How do you treat eclampsia?
- Seizures are self limiting
- ABCDE - be careful with fluid
- Left lateral position/ manual displacement of placenta
Why do you put women with eclampsia in a left lateral position?
To avoid IVC/SVC obstruction
What bloods do you take in eclampsia?
G+S, FBC, U+E, Clotting, LFT
Medical management of seizures in eclampsia
- Control seizures
- Magnesium sulphate loading dose 4g IV over 5/10 mins. (20 ml of 20% preloaded)
- Magnesium sulphate maintenance dose 1g/hr IV for 24 (50 ml of 20%) hours after last seizure
How do you treat recurrent seizures (eclampsia)
2g bolus IV over 10 min
What is the therapeutic level of MgSo4
2-4 mmol
How do you review a patient on magnesium sulphate?
- Patella reflexes – every 30 mins for the first 2 hours then hourly
- STOP if reflexes absent/depressed
- Check RR hourly
- Stop if RR <10
- Ensure O2 sat >94%
- Listen to lungs – Pulmonary oedema
- BP + pulse every 14 mins for an hour then every 30 min
- Strict fluid balance – ensure UO = 20 mls/hr OR 80 mg/hr – monitor creatinine if less
- Restrict fluid intake to 1ml/kg/hour
- Look out for symptoms of toxicity and check serum levels
What are the features of magnesium sulphate toxicity?
- Motor paralysis
- Absent reflex’s
- respiratory depression
- cardiac arrhythmia/arrest
What is the anecdote for magnesium sulphate?
10 ml 10% calcium gluconate IV over 10 mins
How do you calculate the Mean arterial pressure?
MAP = 1/3 (Systolic-diastolic) + diastolic
What level does the blood pressure need to be maintained at in eclampsia?
< 160/105
MAP <125
How do you manage HTN in eclamptic patients?
- Labetalol 200 mg IV infusion
- Hydralazine IV
- Nifedipine 10 mg oral
MKUH HTN associated with eclampsia guidelines
Nifedipine 10 mg modified release BD
Labetalol 200 mg QDS
How much labetalol is administered in eclampsia and at what rate?
5mg/ml 4ml/hour via syringe pump
Double rate every 30 mins maximum 32 ml/hour OR 160 mg/hour
Contraindications of labetalol
Severe asthma
How is IV hydrazine administered in eclampsia?
Bolus 10-20 mg over 10-20 mins + BP measurments every 5 mins
Followed by 40 mg in 40 ml normal saline at 1-5 ml/hour
What do you do after managing a women with pre-eclampsia?
- Transfer mum to ITU/HDU
2. plan for delivery once the mum is stable
Steps of management of labour in eclampsia
- Intrapartum foetal monitoring
- Measure BP every 15 min
- Epidural analgesia encourages
- Normal active second stage is safe unless BP is high or severe symptoms
Which uterotonic drugs are contraindicated in eclampsia?
Ergometrin/syntometrin
What drug is used for management of third stage of labour?
- Use syntotocin 10 units IV/IM
OR
- Syntotocin infusion 40 U in 500 ml normal saline @ 125ml/hour
Post-natal care in eclampsia
- Monitor BP for 72 hours
- 25% increase risk of pre-eclampsia in next pregnancy
- Low dose aspirin 75 mg during the next pregnancy
- VTE score
- Inform them that breast feeding is safe
What is shoulder dystocia?
Shoulder dystocia is the impaction of foetal anterior shoulder against maternal symphysis pubis after the foetal head has been delivered
How is shoulder dystocia diagnosed?
When manoeuvres are required to delivered the foetal shoulders after normal gentle downwards traction has failed
List 5 risk factors for shoulder dystocia
- Previous SD
- Macrosomia
- Maternal diabetes
- Prolonged 1 + 2 stage
- Instrumental delivery
Early signs of shoulder dystocia (4)
- Difficulty with birth of face
- Head remains applied in vulva
- Chin retracts and depresses perineum
- Anterior shoulder fails to release with maternal pushing and axial traction
What is the purpose of manoeuvres in shoulder dystocia?
- Increasing the diameter of the pelvic outlet
2. Changing or reducing bisacromial diameter (presenting part)
What position effectively relieves shoulder dystocia? describe it?
ALARMER
Mc-roberts position
Thighs flexed, abducted and rotated outwards so they touch mums abdomen
Drop/remove the end of the bed
Lie mum flat
Alert senior Legs up - mcroberts Apply suprapubic pressure Release shoulder Woods manœuvre Episiotomy Roll on all fours
Why do we apply suprapubic pressure in Shoulder dystocia?
Pressure applied to the posterior aspect of the anterior shoulder at 45 angle +/- rocking motion to help deliver shoulders
What is Breech presentation?
Breech is the part of the foetus that occupies the lower uterine segment
Breech presentation: presentation of the buttock
Name 8 causes of breach delivery
- No cause
- Previous breech
- Prematurity
- Foetal/uterine abnormalities
- Twin pregnancy
- Placenta previa
- Pelvic tumour
- Pelvic deformity
Name 4 complications of a breech baby
Perinatal mortality increased
Foetal abnormalities are more common
Labour – hypoxia/birth trauma
High rates of long term neurological handicap
How do you diagnose a breech baby?
Important after 37 weeks – change of resolving before
Hard ballotable head at fundus
US confirms the diagnosis
What are the 3 types of breech?
- Extended/frank - flexed at hips and extended at knees
- Complete/flexed - Knees and hips flexed
- Footling - Feet presenting
What is ECV and when is it done?
External cephalic version to attempt to turn the baby to cephalic lie done at 37 weeks
How is ECV preformed
- With anaesthetic
- Labour ward
- Uterine relaxant
- US guidance
- Breech is disengaged and moved up
Forward somersault movement
CTG performed straight after
Injection of anti-D given in rhesus -ve
Name 3 complications of ECV
- Placental abruption
- Uterine rupture
- Urgent LCS
Name 5 factors affecting ECV success
- Breech engaged
- Obeisity
- Liquor reduced
- Big baby
- Nulliparous
Name 6 contraindications for ECV
- Foetal distress
- Placenta previa
- Twins
- Membranes have ruptured
- Uterine/foetal anomalies
- One pre LSCS is not a contraindication
What other modes of delivery are available for breech babies if ECV fails
elective caesarean section at 39 weeks
When is vaginal delivery of breech baby risky
- if foetal weight >3.8 Kg
- extended head
- footling breech
- foetal distress
How is the first stage of labour managed in a breech baby (5)
- Monitor progress in labour
- Upright maternal position to aid decent
- Consider VE after SROM to exclude cord prolapse
- Continuous CTG
- Choice of analgesia- no evidence to advise epidural
How is the second stage of labour managed in a breech baby
- VE is indicated to confirm full dilatation
- Allow passive decent with maternal effort- await visualisation at the perineum before active pushing is encouraged
- Ensure continuous CTG
- Consider position- end of bed removed
- HANDS OFF!! Avoid traction on
- Paediatrician must be present
What complication do we worry about in the second stage of labour of a breech baby
Cord compression
What is the time interval between buttock and shoulder delivery in a breech baby
2 mins
How can we assist the birth of the legs in a breech baby?
Applying popliteal pressure to aid flexion
What are nuchal arms?
occurs in breech babies where the foetal trunk is turned towards the pubic symphysis
What is luvseat manoeuvre used for?
Assisted birth of extended arms
Describe lovestts manœuvre
- Gently rotate the baby so that one arm is uppermost
- Place index finger over shoulder and follow arm to the antecubital fossa, apply pressure to flex arm and deliver
- Keep back uppermost and rotate baby 180 degrees and repeat to release the second arm
When do you stop performing a lovesset manouver
when there is resistance
How long do you allow for the head to be delivered after shoulder decent?
30 seconds - if not successful then apply suprapubic pressure
Why is slow controlled delivery of breech foetal head recommended
to reduce the risk of neonatal cerebral tentorial tears
How do you support babies during breach delivery?
Support them on your forearm
What is MSV manoeuvre
- Support baby’s body on your forearm
- Position two fingers on the cheekbones (not in the mouth)
- Use the other hand to apply pressure to the occiput with the middle finger, similtaneously place the other fingers on the shoulders to promote flexion
Ideal criteria for vaginal breech delivery (5)
- foetus not compromised
- Foetal weight <4 Kg
- Spontaneous labour
- Extended breech
- Non-extended neck
Which type of breech increases risk of cord prolapse
Footling
What is PPH?
Blood loss >500 ml after vaginal delivery OR >1000 ml at LSCS within 24 hours of delivery
What is Major PPH?
Blood loss > 1000 after vaginal and >1500 after LCSC in 24 hours
What are the 4 T’s of PPH?
- Tone
- Trauma
- Tissue
- Thrombus
Aetiology of PPH (6)
- 4 T’s
- Uterine causes
- vaginal causes
- retained placenta
- cervical tear
- coagulopathy
Name 10 risk factors of PPH
- Multiple pregnancy
- previous PPH
- general anaesthesia
- Pre-eclampsia
- Foetal macrosomia
- Failure to progress in 2/3 stage
- retained placenta
- placenta accrete
- episiotomy/perineal laceration
- cervical tear/vaginal tear
How to prevent PPH? (4)
- Use of oxytocin in third stage of labour
- Use of oxytocin infusion 5 iu in LSCS
- Use or syntometrine
- IV tranexamic acid 0.5-1.0 g with oxytocin
Clinical features of PPH - 4
- Vitals: Low BP + tacky
- Abdominal examination: enlarges soft uterus
- Vaginal examination: vaginal/vulval/cervical tears
- Examining the placenta: complete.missing parts
How do you manage minor PPH without clinical shock?
- ABCDE
- IV Access – 2 wide bore cannula
- Urgent bloods – G+S, FBC, Coagulation screen
- Vitals every 15 min
- Start fluid bolus
How is Major PPH managed differently?
- Blood is transfused ASAP
2. Insert Foley catheter to monitor UO
How is PPH monitored?
MEOWS chart - allows us to escalate
What is the ratio of blood to platelets?
6:4
How do we stimulate myometrial contractions?
- palpate the fundus and rub it
- ensure that the bladder is empty (Foley catheter, leave in place)
- oxytocin 5 iu by slow IV injection
- ergometrine 0.5 mg by slow intravenous or intramuscular injection
- oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour)
- carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of eight doses
- misoprostol 1000 micrograms per rectally.
How is PPH treated surgically?
- Intrauterine ballon tamponade (Rusch balloon) - when uterine atony is the cause
- Brace suture technique
- Hysterectomy - especially in uterine rupture or placenta accrete
- Stepwise uterine devascularisation
Name the stepwise uterine devasculisation steps
- one uterine artery
- both uterine arteries
- low uterine arteries
- one ovarian artery
- two ovarian arteries
- internal iliac artery ligation
- uterine artery embolisation
What is secondary PPH?
Blood loss occurring between 24 hours and 6 weeks post delivery
Name 3 causes of secondary PPH?
- Endometritis
- Retained placental tissue
- Gestational trophoblastic tissue
How is secondary PPH investigated?
- High vaginal and endocervical swabs
- FBC
- US
How is secondary PPH treated?
- AB
- evacuation of retained products of conception
- Histology - to rule out molar pregnancy
Why would you use an US to diagnose breech babies?
- To rule out placenta previa/tumours
- Type of breech
- Estimated weight
- Liquor volume
