Obstetric Emergencies

Question 1

What is shoulder dystocia?

Answer 1

After the delivery of the head, the anterior shoulder becomes impacted on the material pubis symphysis

Question 2

What are the risk factors for shoulder dystocia?

Answer 2

Pre-labour:

• previous shoulder dystocia
• macrosomia
• diabetes
• maternal BMI > 30
• induction of labour

Intrapartum:

• prolonged 1st stage of labour
• secondary arrest of labour
• prolonged 2nd stage
• augmentation of labour with oxytocin
• operative vaginal delivery

Question 3

What are the signs of shoulder dystocia in labour?

Answer 3

Failure of restitution - foetus doesn’t turn to the side after delivery of head
Turtle Neck sign - head retracts slightly so neck is no longer visible

Question 4

What is the immediate management of shoulder dystocia?

Answer 4

Call for help
Advise mother to stop pushing
Avoid downward traction
Consider episiotomy (doesn’t relieve obstruction but may make manoeuvres easier)

Question 5

What are the first line manoeuvres for shoulder dystocia?

Answer 5

McRoberts manoeuvre

Suprapubic pressure

Question 6

What is McRoberts manoeuvre?

Answer 6

Maternal knees to chest + tell her to stop pushing

- 90% success rate, higher when combined with suprapubic pressure

Question 7

What are the second line manoeuvres for shoulder dystocia?

Answer 7

Internal manœuvres:

• posterior arm (hand into sacral hollow and grasp posterior arm)
• internal rotation (corkscrew manoeuvre) - move baby 180 degrees or into oblique position

Question 8

What should be done if second line manoeuvres fail in shoulder dystocia?

Answer 8

Roll mother onto all fours + repeat

Question 9

What are the complications of shoulder dystocia?

Answer 9

Maternal:
- 3rd/4th degree tears
- post partum haemorrhage
Foetal:
- humerus or clavicle fracture
- brachial plexus injury
- hypoxic brain injury

Question 10

What is cord prolapse?

Answer 10

Umbilical cord prolapses through the cervix with or before the presenting part of the foetus –> foetal hypoxia

Question 11

What are the risk factors for cord prolapse?

Answer 11

Breech presentation
Unstable lie
Artificial rupture of membranes
Polyhydramnios
Prematurity

Question 12

How is cord prolapse managed?

Answer 12

Avoid handling cord to reduce vasospasm
Manually elevate the presenting part
Encourage into left lateral or knee-chest position
Consider totlysis (terbutaline) to stop contractions
Delivery usually via emergency C-section

Question 13

What are the clinical features of pre-eclampsia?

Answer 13

Headache
Hyper reflexia
Nausea + vomiting
Generalised oedema
RUQ pain +/- jaundice 
Visual disturbances
Changes in mental state

Question 14

What are the features of eclampsia?

Answer 14

New onset tonic-clonic seizure in presence of pre-eclampsia

Seizure usually around 60-75 seconds

Question 15

What are the maternal complications of eclampsia?

Answer 15

HELLP syndrome
DIC
AKI
Adult respiratory distress syndrome
Cerebrovascular haemorrhage
Permanent CNS damage
Death

Question 16

What are the foetal complications of eclampsia?

Answer 16

IUGR
Prematurity
RSD
Intrauterine death
Placental abruption

Question 17

What are the 5 stages of eclampsia management?

Answer 17

1. Resuscitation
2. Cessation of seizures
3. BP control
4. Prompt delivery of baby
5. Monitoring

Question 18

What is the management for cessation of seizures in eclampsia?

Answer 18

IV magnesium sulphate

Question 19

What is used for BP control in eclampsia?

Answer 19

IV labetalol or hydralazine

Question 20

What are the clinical features of amniotic fluid embolism?

Answer 20

Similar to anaphylaxis or septic shock:

• hypoxia, respiratory arrest
• hypotension
• seizures
• shock
• confusion
• cardiac arrest
• DIC