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Labour > Obstetric Emergencies > Flashcards

Obstetric Emergencies Flashcards

1
Q

What is the incidence of cord prolapse in the general population?

A

0.1 - 0.6%

RCOG Guideline

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2
Q

What is the incidence of cord prolapse in pregnancies affected by breech presentation?

A

1%

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3
Q

What are the two ways of elevating the presenting part in a cord prolapse?

A
  1. Manually: inserting two fingers of a gloved hand and lifting the presenting part
  2. Bladder filling: inserting a Foley catheter, connecting it to an IV / blood giving set and filling it with 500-750mL normal saline. The bladder will need to be emptied prior to delivery
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4
Q

What should women in the community with a suspected cord prolapse be advised to do?

A
  1. Knee-chest-face-down position
  2. Call ambulance
  3. Exaggerated Sims position (left lateral with lifted hip) during ambulance
  4. Transfer to nearest consultant-led unit for urgent delivery
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5
Q

What is the perinatal mortality rate of cord prolapse?

A

91 per 1000

Prematurity, congenital malformation and birth asphyxia

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6
Q

What is the definition of a cord prolapse?

A

Descent of the umbilical cord through the cervix alongside (occult) or past(overt) the presenting part in the presence of ruptured membranes

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7
Q

What is the definition of a cord presentation?

A

Presence of the umbilical cord between the fetal presenting part and the cervix, with or without intact membranes

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8
Q

What is the pathophysiology that explains the poor perinatal outcomes with cord prolapse?

A

Cord compression
Umbilical arterial vasospasm
Preventing venous and arterial blood flow to and from the fetus

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9
Q

How can cord prolapse present?

A

Abnormal FHR, especially after SROM / ARM

VE should be done with any abnormal FHR to exclude cord prolapse

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10
Q

What is the role of USS screening of cord presentation?

A

Should not be done routinely, as not sufficiently sensitive or specific for the identification of cord presentation antenatally
Does not predict increased probability of cord prolapse

Can be considered for women with breech presentation at term who are considering vaginal birth

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11
Q

For which women should admission to hospital be discussed, to reduce risk of perinatal mortality from cord prolapse?

A

Transverse, oblique or unstable lie after 37+0/40

PPROM with non-cephalic presentations (should not be discharged)

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12
Q

What is the perinatal mortality rate when cord prolapse is diagnosed outside of hospital compared to in the hospital

A

10x as common

Delay in diagnosis to delivery time is a contributory factor towards perinatal mortality

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13
Q

What is the definition of shoulder dystocia?

A

Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed

Occurs when either the anterior or less commonly, the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory, respectively

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14
Q

With shoulder dystocia, what is the risk of brachial plexus injury?

A

2.3 - 16%
Fewer than 10% result in permanent neurological dysfunction
Larger infants are more likely to suffer a permanent BPI
4% occur at CS

RCOG guideline

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15
Q

With shoulder dystocia, what is the risk of OASI and PPH

A

OASI = 3.8%

PPH = 11%

RCOG guideline

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16
Q

What are the antenatal risk factors for shoulder dystocia?

A

Previous shoulder dystocia ( x10)
Macrosomia (EFW > 4.5kg in RCOG guideline)
Diabetes (2-4x, with same fetal weight when compared to non-diabetics)
Maternal BMI > 30
IOL

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17
Q

What are the intrapartum risk factors for shoulder dystocia?

A 
Prolonged first stage
Secondary arrest
Prolonged second stage
Oxytocin augmentation
Assisted vaginal delivery
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18
Q

What intervention reduces the incidence of shoulder dystocia in women with Diabetes Mellitus?

A

IOL
NICE diabetes guideline recommend elective IOL at 38/40 (with normal fetal growth)

If diabetes with macrosomia, EFW > 4.5kg, El LSCS should be considered

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19
Q

Does IOL reduce the incidence of shoulder dystocia in non-diabetic women with macrosomic foetuses?

A

No

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20
Q

What are four signs of a shoulder dystocia

A

Difficulty with delivery of the face and chin
Head remaining tightly applied to the vulva, or retracting
Failure of restitution
Failure of the shoulders to descend

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21
Q

What does HELPER stand for

A

H - Call for help
E - Consider episiotomy to allow performance of internal manoeuvres
L - Legs up i.e. McRoberts manoeuvre
P - Suprapubic pressure
E - Enter: rotational manoeuvres, delivery of the posterior arm
R - Rotate to hands and knees

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22
Q

Describe the McRoberts Manouevre

A

Flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen
Bed flat
Straightens lumbosacral angle, rotates the maternal pelvis towards the mother’s head and increases the relative AP diameter of the pelvis

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23
Q

How should suprapubic pressure be applied?

A

From the side of the fetal back in a downward and lateral direction just above the maternal symphysis pubis
This reduces the fetal bisacromial diameter by pushing the posterior aspect of the anterior shoulder towards the fetal chest
No clear difference in efficacy between continuous pressure and rocking movement

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24
Q

Describe the internal rotation manoeuvres for shoulder dystocia

A

Pressing on the anterior or posterior aspect of the posterior shoulder
The shoulders should be rotated into the wider oblique diameter, resolving the shoulder dystocia

If pressure on the posterior shoulder in unsuccessful, an attempt should be made to apply pressure on the posterior aspect of the anterior shoulder

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25
Q

Describe delivery of the posterior arm

A

The fetal wrist should be grasped and the posterior arm should be gently withdrawn from the vagina in a straight line
Reduces the diameter of the fetal shoulders by the width of the arm

Associated with numeral fractures

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26
Q

What are the third-line manoeuvres for shoulder dystocia

A

Cleidotomy: surgical division of the clavicle or bending with a finger
Symphysiotomy: dividing the anterior fibres of the symphysis always ligament
Zavanelli manoeuvre: vaginal replacement of the head and delivery by CS

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27
Q

In collapse / CPR, what are the reversible causes to consider? (4Hs and 4Ts)

A

Hypoxia
Hypocalcaemia
Hyperkalaemia / electrolyte disturbances
Hypothermia

Tension pneumothorax
Toxicity
Thromboembolism
Tamponade (cardiac)

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28
Q

What is the incidence of amniotic fluid embolism?

A

1.25 - 12.5: 100,000 maternities

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29
Q

How does an amniotic fluid embolism present?

A

Collapse during labour or delivery or within 30 minutes of delivery

Acute hypotension, respiratory distress and acute hypoxia, chest pain

Seizures and cardiac arrest

Pink, frothy sputum, cyanosis, bleeding from IV signs

30
Q

What is the leading cause of direct maternal death in Aus and NZ

A

Amniotic fluid embolism

RANZCOG Webinar

31
Q

What are the risk factors for amniotic fluid embolism?

A 
AMA
Placenta Praevia
Placental abruption
Operative delivery
IOL

But also, comment from RANZCOG Webinar that it is such a rare entity that “there are no true risk factors)

32
Q

How does amniotic fluid enter the maternal circulation in an AFE?

A

Breach in the barrier of the fetal membranes
Breach at a number of sites: endocervical veins, placentation site, sites of uterine trauma

Conditions that increase intrauterine pressure may contribute to the passage of amniotic fluid into the maternal circulation
E.g. augmentation with oxytocin

33
Q

What does amniotic fluid contain, that contributes to the pathophysiology of AFE?

A

A number of potentially vasoactive substances
Substances that may interfere with coagulation

Tissue factor (acts as a pro-coagulant)
Plasminogen activation inhibitor-1 (involved in fibrinolysis)
34
Q

What is the effect of AFE on CVS?

A

Severe pulmonary vasospasm and pulmonary hypertension
Sever RV failure resulting in impaired LV filling and MI

Severe ventilation and perfusion mismatch
Cardiogenic pulmonary oedema (secondary to LV failure)
Non-cardiogenic oedema (capillary damage from amniotic fluid)

35
Q

What is the definition of anaphylaxis?

A

Severe, life threatening generalised or systemic hypersensitivity reaction

36
Q

What organ systems are affected by anaphylaxis?

A

Respiratory: upper airway occlusion secondary to angioedema, bronchospasm, mucous plugging of smaller airways
Cutaneous: flushing, urticaria, angioedema
Circulatory: significant intravascular volume redistribution, can be complicated by acute LV failure and MI
GI disturbance
Collapse

37
Q

What is the mortality rate of anaphylaxis?

A

1%

38
Q

What is the incidence of PPH?

A

5-15%

RANZCOG

39
Q

What is the definition of PPH and severe PPH, primary and secondary PPH

A

PPH: blood loss of 500mL or more during puerperium

Severe PPH: blood loss of 1000mL or more during puerperium

Primary PPH: within 24 hours of delivery

Secondary: between 24 hours and six weeks postpartum

RANZCOG

40
Q

What is the blood flow to the placental bed at term?

A

Approximately 750mL / min

RANZCOG PPH Guideline

41
Q

What is the total maternal blood volume at term?

A

Approximately 100ml / kg

42
Q

What are the 5 Ts in managing a PPH

A 
4 Causes
Tone
Tissue
Trauma
Thrombin

5th T: Consider Theatre (RANZCOG Guideline)

43
Q

What are the doses of ecbolics used in a PPH?

A

Syntocinon
- 5IU by slow IV / 10 IU by IM
- 40IU in an IV infusion over 4 hours
Ergometrine: 0.25mg by slow IV or IM injection, 5 minutely up to a maximum of 1.0mg (4 doses)
Misoprostol up to 1000mcg recalls.
Prostaglandin and analogues
- 15-methyl-PGF2alpha (Carboprost)
- IM injection 0.35mg in repeated doses q15minutely, total dose 2.0mg (8 doses)
- Intramyometrial injection of 0.5mg under responsibility of administering clinician

44
Q

What are possible traumatic causes for PPH

A 
Perineum, vaginal, cervical trauma
Ruptured uterus
Broad ligament haematoma
Subcapsular liver rupture
Ruptured spleen
Ruptured splenic artery
Hepatic artery
Pancreatic artery aneurysm

RANZCOG Guideline

45
Q

What are the surgical options / interventions available for management of PPH

A 
Bakri balloon: 
B-Lynch suture
Bilateral ligation of uterine arteries
Bilateral ligation of internal iliac arteries
Selective arterial embolisation
Hysterectomy

RANZCOG Guideline

46
Q 
During a PPH, what are the therapeutic goals for the following haematological parameters
Hb
Plt
PT
APTT
Fibrinogen
A 
HB > 80
Plt > 50 (start infusing when <75)
PT > 1.5
APTT > 1.5x normal
Fibrinogen > 2
47
Q

What are three causes of a secondary PPH

A

Infection
RPOC
Subinvolution of the placental implantation site

48
Q

What is a 1st degree uterine inversion?

A

Incomplete inversion

Fundus inside the endometrial cavity

49
Q

What is a 2nd degree uterine inversion?

A

Complete inversion

Fundus protrudes through the cervical os

50
Q

What is a 3rd degree uterine inversion?

A

Uterine prolapse

Fundus projects to or beyond the vaginal introitus

51
Q

What is a 4th degree uterine inversion?

A

Total uterine and vaginal inversion

Inversion of both uterus and vagina

52
Q

What is the incidence of uterine inversion?

A

1: 1200-8000

53
Q

What is the maternal mortality rate of uterine inversion?

A

15%!

54
Q

What degrees of uterine inversion comprise of 90% of cases

A

2nd: Complete inversion
3rd: Uterine prolapse

55
Q

What are 4 risk factors for uterine inversion?

A

Uncontrolled cord traction
Excessive fundal massage
Partially detached placenta
Invasive placental ion

Uterine inversion can occur with minimal predisposing risk factors

56
Q

What is the first line management option for Uterine inversion?
When should this be done?

A

Johnson’s Manoeuvre
Manual reduction of uterine inversion
Hand is placed inside the vagina
Pressure applied towards the umbilicus

Immediately
The earlier this is attempted, the higher the chance of success AND of minimising blood loss
Delay leads to increased failure rate due to the formation of a constriction ring as the cervix begins to contract, which minimises the space to perform Johnson’s Manoeuvre

If fails

  • stop uterotonics
  • consider uterorelaxants - GTN
57
Q

What are the second and third line options for managing uterine inversion?

A
  1. Hydrostatic reduction
  2. Surgical correction with laparotomy
    - Huntington procedure: retract fundus superiority with Allis Forceps
    - Haultain’s procedure: sharp dissection of the posterior aspect of the uterus to release the constriction ring, allowing extra space for manual replacement of Huntington procedure, and then close the uterus
58
Q

With uterine inversion, when should the placenta be delivered?

A

After repositioning of the uterus
MROP in most cases
Followed by administration of uterotonics

Removing the placenta prior to replacement increases blood loss

59
Q

What after-care is important with uterine inversion

A

Broad spectrum antibiotics to prevent endometritis

VTE prophylaxis with TEDS a/o Enoxaparin

Debrief

60
Q

What were the findings of the Cochrane Review looking at active vs expectant management for women in the third stage of labour?

A

Reduces mean maternal blood loss at birth

Probably reduces

  • rate of primary PPH
  • the use of therapeutic uterotonics
  • the mean BW of baby (early cord clamping interferes with placental transfusion resulting in lower blood volume)

May increase

  • maternal diastolic BP
  • vomiting after birth
  • after pains
  • use of analgesia from birth up to discharge from the labour ward
  • women returning to hospital with bleeding
61
Q

Does TXA have a role in preventing PPH?

Cochrane Review

A

Yes
Decreases postpartum blood loss and prevents PPH and blood transfusions

Following VD and CS
In women at low risk of PPH

62
Q

What is the obstetric cause of brachial plexus injury

A

Shoulder dystocia
Forceful downward traction of the head when the shoulder is impacted under the symphysis pubis, which can result in further impaction.
This causes over stretching and injury of the brachial plexus

63
Q

What are symptoms / signs of a Brachial Plexus injury?

A

Arm weakness
Atrophy of muscles in arm
Limited sensation in affected arm
Pain in affected arm

64
Q

What are three treatments for a Brachial Nerve Injury

Erb’s Palsy or Kumpke’s palsy

A

Nerve transplant

Subscapularis release

Latissimus Dorsi Tendon Transfers

65
Q

What % of uterine inversion is associated with PPH?

Outline your management of a PPH following uterine inversion replacement.

A
  • Removal of placenta
  • Uterotonics
  • May need Bakri balloon (for tone and prevents reinversion).
  • Broad spectrum antibiotics.
66
Q

What clinical findings may you find when a woman has a uterine inversion?

A
  • Sudden maternal shock
  • Placenta still in situ
  • Excessive bleeding
  • Loss of palpable fundus
  • Abnormal soft mass in vagina or visualisation of uterine fundus at introitus
67
Q

What are the main therapeutic goals of a massive transfusion protocol?

A

Maintaining:

  • Hb >80
  • Plt >50
  • PT <1.5 x normal
  • APTT <1.5 times normal
  • Fibrinogen >2
68
Q

For PPH management:

List step-wise uterine devascularisation steps:

A
  • One uterine artery –> both
  • Low uterine arteries
  • One ovarian artery –> both
69
Q

What type of hysterectomy should ideally be performed for life-threatening PPH?

A

SUBtotal hysterectomy unless trauma to cervix or morbidly adherent placenta on lower segment.

70
Q

PPH management:

What rare complication as a result of massive PPH should you consider screening for?

A

Sheehan syndrome (postpartum hypopituitarism).

Labour (12 decks)

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