Obstetric Emergencies Flashcards
TREATMENT of PRETERM LABOUR (20wks – 37 wks)
Betamethasone: 11.4mg IM Antibiotic MgSO4 if <30weeks Tocolysis (24 - 34wks): -Nifedipine 20mg PO q30min for 3 doses then q6hrly (max 160mg/24hrs) -Salbutamol: 10mg obstetric salbutamol in 90ml NS, start at 6ml/hr then increase by 3ml/hr q10mins up to 30ml/hr
TREATMENT of Postpartum Haemorrhage
PPH – think Tone, Tissue, Trauma, Thrombin Oxytocin 5-10U IM or 5U IV slowly Ergometrine 500mcg IM or 50mcg IV slowly Oxytocin infusion: 40U in 1000ml NS, infusion @ 250ml/hr Syntometrine combo drug: 1ml IM = 5U oxytocin and 500mcg ergometrine
TREATMENT of PreEclampsia
MAGNESIUM *** each 5ml ampule contains 10mmol MgSO4 or 2.5g MgSO4 *** 4g (16mmol) over 15minutes then 1g (4mmol) per hour for 24hrs ***IF SEIZURE give 4g over 10 mins and can be repeated if re-seizes -serum therapeutic range is 1.7 – 3.5mmol/L -signs of toxicity= reduced reflexes, prolonged PR and QRS, respiratory depression/arrest, high grade SA/AV block, CNS depression -antidote is 10ml 10% Calcium Gluconate over 10 mins ANTI-HYPERTENSIVES: Hydralazine 5 - 10mg slow IV injection, q20mins Labetalol 20mg IV every 10minutes up to 200mg
Preeclampsia RISK FACTORS
Obstetric risk factors •primigravida (incidence 5-10%) •prior pre-eclampsia •multiple pregnancy •hydatidiform mole •multigravida with a new partner •positive family history Other risk factors •obesity •renal disease •hypertension •diabetes mellitus •autoimmune diseases •thrombophilia Dunn
Preeclampsia Diagnosis
1) pregnancy onset hypertension with BP at > 20 weeks of gestation ->140/90 mmHg on 2 measurements 4 hours apart OR -one reading > 160/110 mmHg OR -rise from baseline of -> 20 mmHg systolic -> 10 mmHg diastolic 2) proteinuria > 300 mg in 24 hours, not from other cause 3) and at least one of the following -rapid onset generalised oedema -renal insufficiency (Cr > 0.09 mmol/L or oliguria) -liver disease (abnormal transaminases, RUQ pain) -neurological abnormalities -hyperreflexia with clonus -headache -visual scotoma -seizures (eclampsia) -haematological abnormalities -thrombocytopenia -DIC -haemolysis -fetal growth retardation Dunn
Shoulder Dystocia
Shoulder dystocia
- impaction of the fetal anterior shoulder behind the maternal pubic bone
- may occur during any labour
- indicated by failure to deliver the shoulder within 1 minute of delivering the head
Features
•turtle sign
- the fetal head suddenly retracts back against the mother’s perineum after first emerging from the vagina
- the baby’s cheeks bulge, resembling a turtle pulling its head back into its shell
- delayed delivery of baby’s chin
- failure of normal rotation of head after crowning
Risk factors
- large baby
- delayed 2nd stage in a multiparous woman
- history of shoulder dystocia
Management
•H - Call for help
•E - Evaluate for episiotomy
- not that helpful, initially
- provides better access for internal manoeuvres if initial methods fail
•L - Legs (McRoberts position)
- lie flat
- position maternal buttocks over edge of bed
- flex hips up to the nipple level if possible
- hyperflex maternal knees
- try to keep knees together
- increases the AP diameter of the maternal pelvis
- will require at least 2 assistants to hold this position
•P - Pressure in suprapubic area (not over the fundus)
- substantial pressure required (similar to a chest compression) using a clenched fist
- requires a dedicated person to apply it
- usually requires the person to stand on steps by the bed to get above patient to be able to apply adequate pressure
- aim to push the anterior fetal shoulder forward to disengage it from under the pubic symphysis
- 95% of shoulder dystocias will be overcome by this time
•E - Enter internal rotation manoeuvres
- some skip these due to low success rate
- Rubin manoeuvre
- insert hand into the vagina and apply pressure over the posterior aspect of the anterior shoulder to push it towards the fetal chest and rotate the shoulders forward into an oblique diameter
- Wood Screw manoeuvre
- while maintaining pressure as in the Rubin manoeuvre, insert the other hand to apply pressure over the anterior aspect of the posterior shoulder to rotate the shoulders into the oblique diameter, then attempt delivery
- if unsuccessful continue rotation through 180°and attempt delivery again
•R - Remove posterior arm
- insert hand into the vagina over the chest of the fetus to identify the posterior arm and elbow
- if the hand is near the neck - apply traction to deliver the arm
- if the arm is straight, apply pressure to the antecubital fossa to flex the elbow in front of the body, then grasp the posterior hand to sweep the arm across the chest and deliver the arm
- if the arm is folded behind the back, it may be impossible to deliver
- rotate the fetus into the oblique diameter of the pelvis, or through 180°, bringing the anterior shoulder under the symphysis pubis
•R - Roll the patient over onto all fours
Do not
- persist with any of the above techniques for more than one minute before progressing to the next technique
- apply downward traction on baby’s head with contraction
- attempt to rotate the baby’s body by rotating its head
Last resort methods
Caesarian section
- push head back into the vagina
- immediate Caesarean section
- preferred next step if available
Break fetal clavicle
- not particularly difficult to do
- apply sustained pressure over the mid shaft of the clavicle(s) with your thumb until you feel it break
- healing is usually complete without functional impairment
- recovery is far better than that following cerebral hypoxia
Reset and repeat
•try returning to a straight legged position and start the HELPERR sequence again
Symphysiotomy
