Obstetric Emergencies Flashcards
What is shoulder dystocia?
When the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the fetal head
How is shoulder dystocia managed?
A series of manoeuvres are used to dislodge the fetal shoulder
Why is shoulder dystocia an emergency?
As fetal oxygen levels can drop steeply during the management of shoulder dystocia, effective teamwork and a well-rehearsed approach to management is essential
Who is involved in the MDT managing shoulder dystocia?
A senior obstetrician, a paediatrician to attend to baby immediately after the birth, a scribe to keep a note of timings which can help decide on what manoeuvre to try next
What is HELPERR?
- H – Call for Help
- E – Evaluate for Episiotomy - creates space to allow the internal manoeuvres to be attempted
- L – Legs (McRoberts Position) - flexing the hips ~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)
How many women are affect by postpartum haemorrhage?
8/100
What are the 5 main caused of post party haemorrhage?
- Thrombin
- Tissue
- Tone
- Trauma
- Other
How can thrombin cause PPH?
- Pre-eclampsia
- Placental disruption
- Pyrexia in labour
- Bleeding disorders: haemophilia, anticoagulation, vonWillebrand disease
How can tissue cause PPH?
- Retained placenta
- Placenta accreta - placenta grows too deeply into the uterine wall
- Retained products of conception
How can tone cause PPH?
- Placenta praaevia
* Ove distension of
How can tone cause PPH?
- Placenta praaevia - placenta partially or totally covering the cervix
- Over distension of the uterus: multiple pregnancy, polyhydramnios (excessive accumulation of amniotic fluid), macrosomia (>4kg baby)
- Uterine relaxants
- Previous PPH
How can trauma cause?
- Caesarean section
- Episiotomy (incision in the periosteum)
- Macrosomia
What are the other causes of PPH?
- Asian ethnicity
- Anaemia
- Induction
- BMI>35
- Prolonged labour
- Age
What is a primary PPH?
- In first 24 hours after delivery
- > 500ml blood (common 1/20 women)
- Severe Haemorrhage >2000ml (rare 6/1000)
- 99% of all PPH
What is a secondary PPH?
•>24 hours to up to 6 weeks post delivery
What is a secondary PPH?
•>24 hours to up to 6 weeks post delivery
What is cord prolapse?
The descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membrane
What is the incidence of cord prolapse?
- Overall incidence of cord prolapse ranges from 0.1–0.6%
* In the case of breech presentation, the incidence is higher at 1%
Why is cord prolapse an emergency?
When the umbilical cord prolapses below the presenting part of the fetus it is highly likely to become compressed and thus reduce oxygen supply to the foetus
What are the general risk factors for cord prolapse?
- Multiparity
- Low birthweight (<2.5kg)
- Preterm labour
- Foetal congenital abnormalities
- Breech presentation
- Transverse, oblique and unstable lie
- Second twin
- Polyhydramnios
- Unengaged presenting part
- Low-lying placenta
How is cord prolapse managed?
- Call for Help!
- Replace cord into vagina (not uterus) - reduces chance of the cord becoming compressed or of the vessels going into spasm due to low temp outside the body
- Perform digital elevation of the presenting part
- Catheterise and fill bladder to elevate presenting part - if no immediate access to C-section
- Encourage mother to adopt knee-chest or left lateral position with raised hips
- Consider tocolysis (anti-contraction medication)
- Arrange for a Category 1 C-Section
How is a PPH managed initially?
- Call for help!
- ABCDE
- Empty Bladder
- Rub up uterine fundus by massaging above the umbilicus
- Medications
- Surgery
- Manage on clinical signs not just EBL (estimate blood loss)
- Fluid Replacement +/- Blood Products
How is a PPH managed with medication?
- Oxytocin 5iu (1 unit) 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)
How is a PPH managed surgically?
- Intrauterine Balloon tamponade
- Interventional Radiology
- B-Lynch Suture
- Hysterectomy
