Obstetric emergencies

Question 1

What is shoulder dystocia?

Answer 1

Shoulder dystocia occurs when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the fetal head

Question 2

What are the stages of normal delivery?

Between what stages can shoulder dystocia occur?

Answer 2

1. Head floating, before engagement
2. Engagement, flexion, descent
3. Further descent, internal rotation
4. Complete rotation, beginning extension

5. Complete extension

6. Restitution (external rotation)

7. Delivery of anterior shoulder
8. Delivery of posterior shoulder

Question 3

What are the risks of shoulder dystocia?

Answer 3

• Umbillical cord entrapment
• Inability of childs chest to expand properly
• Severe brain damage or death due to hypoxia or acidosis if delivery is delayed
• Brachial plexus damage (Erbs palsy)

Question 4

How is shoulder dystocia managed?

Answer 4

Remember HELPERR

H - Call for Help

E - evaluate episiotomy

L - Legs (McRobert’s position)

P - Suprapubic pressure

E - Enter manoeuvers (internal rotation)

R - Remove the posterior arm

R - Roll the patient (onto all 4s)

Question 5

What is postpartum haemorrhage?

Answer 5

PPH is defined as the loss of more than 500 mls of blood within 24 hours after giving birth

Question 6

What are the causes of PPH? (4Ts)

Answer 6

Tone:

• placenta praevia
• previous PPH
• over distension of uterus - macrosomnia etc

Trauma:

• c-section
• episiotomy
• macrosomnia

Thrombin:

• pre-eclampsia
• placental abruption
• pyrexia in labour
• bleeding disorders (haemophilia etc)

Tissue:

• retained placenta
• placenta accreta (too deeply attached)

Question 7

What are some risk factors for PPH?

Aside from those already mentioned

Answer 7

Asian ethnicity

Anaemia

Induced labour

BMI >35

Prolonged labour

Age

Question 8

What are the types of PPH?

Answer 8

Primary:

• within 24 hours of delivery
• 99% of all PPH
• >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 ‘retained products of conception’ (RPOC)

Question 9

How is PPH managed?

Answer 9

Call for help

ABCDE…

Empty Bladder

Rub up uterine fundus by massaging above the umbilicus

Medications

Fluid replacement +/- Blood products

Question 10

What medications are given for PPH?

Answer 10

Oxytocin 5iu IV slow injection

Ergometrine 0.5mg slow IV injection (not if High BP)

Question 11

How can PPH be managed surgically?

Answer 11

Intrauterine Balloon tamponade

Interventional Radiology

B-Lynch Suture

Hysterectomy

Question 12

What is cord prolapse?

What is a big risk factor for cord prolapse?

Answer 12

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

Unlikely to happen - but more likely in breech presentations

Question 13

What are the risks associated with cord prolapse?

Answer 13

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 fetus