1. IV/M syntoncinon, IM ergometrine/syntometrine 2. IM carboprost 3. Bakri balloon tamponade 4. other measures eg B-lynch suture, hysterectomy EMERGENCY: bimanual compression

Obstetric emergencies Flashcards by Toby Curtis-Mackenzie

after any emergency

Datix
Debrief pt
Document

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Sepsis what do?

3in 3out
If hypotensive and/or lactate >4 initial 20ml/g crystalloid
If no response vasopressors for hypotn., aim MAP >65
If persistent hypotn, aim CVP >8mm or CVO2s >70% or MVO2s >6%

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Antepartum haemorrhage

Admit until bleeding stopped
ABC (IV access and fluids)
FBC, G+S, CM, ?kleihauer
Anti-D if indicated
CTG if >27wk  (IOL if early compromise)
NOT bimanual risk of placentia praevia
TVUSS for praevia

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Placenta praevia Definitions

Applies >16w
Praevia: directly over os
low lying placenta: edge <2cm from internal osP

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Placenta praevia Ix

FBC, clotting, G+S, Rh status, Kleihauer
TVUSS
CTG
NOT bimanual
admit for obs for 48hr if bleed settles

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Symptomatic Mx of placenta praevia

only if minimal bleed and clearly of local vaginal origin
as long as cervical ca. excluded
DO NOT HAVE SEX IF YOU HAVE PP

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Placenta praevia del.

c-section delivery

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Low lying placenta at 20w scan

only 10% go on to have LLP late in preg
Rescan at 32w (avoid sex, consider ass. cervical length to determine risk PTL
If low at 36w recommend elective c-section
AN CS 24-34w
if high presenting part or abnormal lie at 37w -> csec
If major placenta praevia completely covering os admit 34w

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Placenta praevia w/bleeding

Admit until it stops
ABC 
IV access and fluids
FBC, G+S, crossmatch, kleihauer
Steroids 24-34wks
CTG if <27w
Growth and UAD every 2wk
Consultant lead care
Final USS 36-37w to determine delivery (vaginal only if grade 1)
IOL if fetal compromise
if major praevia with bleed admit from 34wk

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PACES counselling for praevia

RF: Hx, multiple preg, prev.c-sec, AMA
Low-lying placenta:
- increased risk bleed, 90% will move away from os, rescan at 32w, avoid sex
Praevia and bleed:
- admit 48hrs (or until bleed stops), admit until del. if >34w, importance of monitoring, discuss del.
risks of del: blood loss, transfusion, maybe hysterectomy

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Placenta accreta

Specialist Mx
?MRI to supplement USS
Plan del 35-37w
Explain risk of needing emergency hysterectomy

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Vasa praevia

immediate c-sec

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PPH minimising risk

Proph. uterotonics to manage stage 3 of labour (IM oxytocin 10iU)
If delivering by c-sec use IM oxytocin 5iU
Syntometrine in absence of HTN and increased risk PPH
In women at risk of PPH consider TXA + oxytocin

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Minor PPH

500-1000ml w/o shock
IV access
G+S, FBC, coag screen + fibrinogen
PR, RR, BP every 15min
Commence warmed crystalloid

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Major PPH

>1000ml
Call for help 
ABC
patient flat and warm
10-15/min O2
2 large bore cannulae
FBC, clotting, G+S, cross match
Transfuse ASAP if req.
foley cath for output

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Who to call in major PPH

Emergency buzzer consultant
anaesthetic team
haematologist
blood transfusion lab

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Major PPH Mx

IV/M syntoncinon, IM ergometrine/syntometrine
IM carboprost
Bakri balloon tamponade
other measures eg B-lynch suture, hysterectomy
EMERGENCY: bimanual compression

Prolonged third stage of labour

Placenta not emergef after 30min active or 2hr phys. Mx

Manual removal in theatre

Eclampsia

RF: Hx HTN, first preg, AMA, obesity
call 2222
secure airway
seizres self terminate 2-3min
Discuss need for urgent del.
?steroids
HDU

Eclapmsia first line anticonvulsant

MgSO4 ASAP
4g over 10min
1g/hr for 24 hrs after delivery
(narrow therapetic window)

Amniotic fluid embolism

ABCDE
poor prog. 10% survival
supportive Mx in ICU
no spec. Mx

Cord prolapse

Digital exam immediately
call for help
Prepare for emergency del (generally emergency c-sec)
Prevent compression by elevating presenting part or filling bladder
?tocolytics
maternal position
CTG

should I just grab the cord and put it back in during cord prolapse?

no it’ll spasm so just keep warm and moist

maternal position if cord prolapse

all fours
knees to chest
left lateral
ideally head slightly declined

Shoulder dystocia RF

Macrosomia high maternal BMI DM Prolonged labour

What to do if dystocia

1. stop pushing 2. call for senior help 3. McRoberts (hips flexed + abducted 4. suprapubic pressure 5. Consider episiotomy 6. Deliver posterior arm and consider internal rotation manoeuvres 7. all fours 8. symphysiotomy, cleidotomy, Zananelli

Internal rotation manoeuvers

Rubin + Rubin II, Woods screw and reverse woods screw | Rubin II: insert hand behind ant. shoulder and push toward chest

DVT/PE in pregnancy

any woman w/Sx should have testing and LMWH until Dx excluded therapetic dose calc on booking wt.

DVT in pregnancy what do?

Compression duplex USS# - negative and low suspicion stop anticoag - negative and high suspicion stop anticoag and repeat USS d3-7

PE in pregnancy what do

- ECG and CXR if CXR abnormal and suspicion of PE order CTPA - If Sx of DVT compression duplex USS NO Sx of DVT: VQ or CTPA

CTPA/VQ scan and malignancy

VQ inc. chilld, CTPA inc. risk for mother breast cancer bu absolute risks v small

IVC filter in PE/DVT in pregnancy

perpartum if iliac vein VTE or pts w/proven DVT | or recurrent PE despite anti-coag

Massive PE in pregnancy Mx

options: IV heparin, consdier urgent thrombolysis in confmirmed, surgical embolectomy IV unfrac. hep first line if massive PE w/CV compromise Urgent portable echo/CTPA

Maintenance Rx of VTE in pregnancy

Therapeutic dose of sc. LMWH continued for preg. and at least 6w PN for total of 3m Mx Self injection taught Offer alternative: oral anti-coag (req. INR) NOACs if pt cant tolerate heparin neither heparin nor warfarin are CI bf

beware in long term LMWH

heparin induced TCP | heparin allergy

Anti-coagulation during labour and del.

If VTE at term IV unf. heparin considered If on LMWH and enter labour do not inj. more If planned del. LMWH discontinued 24hrs before Regional anaesthetic needs 24hr window since last LMWH Do not give LMWH if within 4hrs of spinal anaesthesia/epidural catheter removed Continuous heparin and high risk of haemorrhage should have IV unfrac. heparain

Prevention of post-thrombotic syndrome in pregnancy

``` Prolonged LMWH (>12w) a/w lower risk of PTS Graduated elastic compression stocings ```

Patients at risk of VTE in pregnancy

Age>35, BMI >30, parity >3, smoker, pre-eclampsia, Hx, varicose veins, low risk throbmbphilia 4+ = immediate LMWH and 6wks PN 3 = initiate LMWH at 28wks until 6wk PN

PACES counselling of VTE in pregnancy

``` RF: (F)Hx, AMA, obesity, Dx: blood clot Importance: breathing difficulties Mx: injections (until 6wkPN), no dose within 24hr planned del. compression stockings - CTPA/VQ/CXR: absolute risk v low CTPA maternal breast ca VQ childhood ca benefits outweigh risks ```

Uterine inversion

Clinical Fx: significant bleeding, Hb shock, bradycardia ABCDE call help IV fluid resus, catheter, pain Mx Attempt manual replacement if unsuccessful try hydrostatic replacement: 3L warm saline via tubing into vagina using hands to create seal surgically: hysterectomy

Uterine rupture

Urgent laparotomy Vaginal exam delivery ASAP however quickest`

peurperal pyrexia

>38C, first 14d after del. causes: endometritis (most common), UTI, SSI, mastitis Refer to hosp. IV clindamycin + gentamicin until afebile >24hr