Obstetric Emergencies

Question 1

what is shoulder dystocia?

Answer 1

• Occurs when anterior foetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of foetal head

Signs include retraction of the baby’s head back into the vagina, known as “turtle sign”

These images show the normal process of birth of the fetal head. A shoulder dystocia would occur in between the stages in image 5 and 6.

Question 2

what is the management of shoudler dystocia?

Answer 2

• A series of manoeuvres are used to dislodge the foetal shoulder
• As foetal oxygen levels can drop steeply during the management of shoulder dystocia, effective teamwork and a well-rehearsed approach to management is essential

Management of Shoulder Dystocia:

H – call for help

E – evaluate for episiotomy (creates space to allow the internal manoeuvres (internal rotation and removal of posterior arm) to be attempted)

L – legs (McRoberts Position - involves flexing the hips by around 60 degrees to open up the pelvis)

P – suprapubic pressure

E – enter manouvers (internal rotation)

R – remove the posterior arm

R – roll the patient (onto all fours)

Question 3

what is postpartum haemorrhage? (PPH)

Answer 3

Postpartum haemorrhage (PPH) is a rare complication where you bleed heavily from the vagina after your baby’s birth

Question 4

what are the causes of PPH?

Answer 4

Question 5

what are the risk factors and associated levels of risk of PPH?

Answer 5

Question 6

what ar ehte types of PPH?

Answer 6

• Primary (99% of all PPH) – in first 24 hours after delivery >500ml blood (common 1/20 women) severe haemorrhage >2000ml (rare 6/1000)
• Secondary - >24 hours to up to 6 weeks post delivery (often cause by RPOC – retained products of conception)

Question 7

what is the management of PPH?

Answer 7

• Call for help!
• ABCDE…
• Empty Bladder
• Rub up uterine fundus by massaging above the umbilicus
• Medications: Oxytocin 5iu slow iv injection, Ergometrine 0.5mg slow iv injection (not if high BP), Oxytocin infusion, Tranexamic acid 1g IV, Carboprost 0.25mg im (max 8 doses), Misoprostol 800 micrograms
• Surgical: Intrauterine Balloon tamponade, Interventional Radiology, B-Lynch Suture, Hysterectomy
• Manage on clinical signs not just EBL.
• Fluid Replacement +/- Blood Products

Question 8

what is cord prolapse?

Answer 8

the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the present part of the foetus in the presence of ruptured membrane

As it passes the presenting part of the foetus it is highly likely to come compressed thus reduce oxygen supply to the foetus

The overall incidence of cord prolapse ranges from 0.1–0.6%. In the case of breech presentation, the incidence is higher at 1%.

Question 9

what are the risk factors of cord prolapse?

Answer 9

Question 10

what is the management of cord prolapse?

Answer 10

• Call for Help!
• Replace cord into vagina (not uterus) - vagina reduces the chance of it becoming compressed or of the vessels going into spasm because of the lower temperature outside the body
• Perform digital elevation of the presenting part
• Catheterise and fill bladder to elevate presenting part.
• Encourage mother to adopt Knee-Chest or left lateral position with raised hips
• Consider tocolysis
• Arrange for a Category 1 C-Section

Question 11

Summary:

• Very ________ overall
• Require a calm and confident ________
• Require teamwork, communication and situational awareness (helicopter view)
• ______ is key

Answer 11

common

approach

Training