Obstetric emergencies Flashcards
Name 3 common obstetric emergencies
- Shoulder dystocia
- Post-partum haemorrhage
- Umbilical cord prolapse
What is shoulder dystocia?
Occurs after vaginal delivery of the head, the baby’s anterior shoulder gets caught above the mother’s pubic bone.
How can shoulder dystocia cause long term brain damage or death for the baby?
Foetal oxygen levels can drop steeply due to:
- Umbilical cord entrapment
- Inability of the child’s chest to expand properly due to compression.
Hypoxia or acidosis occur as a result
Which nerve plexus can be damaged as a result of shoulder dystocia? How is it damaged?
Brachial plexus
Forceful downward traction of the head when the shoulder is impacted under the symphysis pubis can potentially result in further impaction and cause overstretching and injury to the plexus.
What does the acronym ‘HELPERR’ stand for in the management of shoulder dystocia?
H - Call for help
E - Evaluate for episiotomy - incision made in the perineum
L - Legs (McRoberts position)
P - Suprapubic Pressure
E - Enter manouvers (internal rotation) - apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees or into an oblique position.
R - Remove the posterior arm - insert hand posteriorly into sacral hollow and grasp posterior arm to deliver.
R - Roll the patient (onto all fours) and repeat 2 steps above
What is the McRoberts position?
- McRoberts position involves flexing the hips by around 60 degrees to open up the pelvis.
- The mother tilts her head back so she is lying almost flat on the bed.
- This tilts and opens the pelvis to create more space.
What is post-partum haemorrage?
Postpartum hemorrhage is excessive bleeding following the birth of a baby.
- It is more likely with a cesarean section
- Hemorrhage most commonly occurs after the placenta is delivered
- Can be primary or secondary
What are some common causes of post-partum haemorrhage?
When thinking about the causes of PPH remember the 4 T’s:
-
Tone
- Atonic uterus - failure to contract - 70% PPH caused by this
-
Trauma 20%
- C-section
- Episiotomy
- Cervical, vaginal or perineal lacerations
- Pelvic haematoma
- Macrosomia (>4kg baby)
- Uterine rupture
-
Tissue 10%
- Retained tissue
- Invasive placenta - whole or part of the placenta grows into the uterine wall and fails to detach from it during the delivery.
-
Thrombin 1%
- Coagulopathies i.e haemophilia or vonWiliebrand disease
What are the 2 different types of post-partum haemorrhage?
Primary
- Makes up for 99% of PPH
- Blood loss of >500 ml within 24 hours of delivery
- Severe haemorrhage >2000 ml (rare 6-1000)
Secondary
- >500ml blood loss from >24 hours up to 6 weeks post delivery
- Often caused by retained products of conception (RPOC) i.e placental and/or fetal tissue that remains in the uterus after a miscarriage, termination or preterm birth. Also caused by endometritis or tears/trauma
Which medications are administered during PPH?
1st line = Oxytocin
2nd line = Ergometrine
What is the immediate management for all PPH?
- Get help
- ABCDE
- Empty bladder - to assist with uterine contraction
- Palpate uterus for atony and commence fundal massage
- Commence oxytocin
- Monitor observations
- Document fluid balance
Immediate medications administered for PPH?
- Fundal massage, empty bladder and consider bimanual uterine massage
- 1st line = Oxytocin – Start oxytocin infusion.
- 2nd line = Consider a repeat dose of oxytocin or first dose of Ergometrine, Transexamic acid, Misoprostol or carbopost
- Remember to inspect vulva, vagina and cervix for trauma/lacerations
In order to prevent PPH there needs to be active management in place during the third stage of labour for women who are at risk of bleeding.
What does the ‘active management’ involve?
In the active management of PPH during the 3rd stage of labour you should give:
- IV oxytocin (syntocinon) - prevents excessive bleeding through uterine contraction
Other option:
- Ergometrine and oxytocin - intramuscular injection
Surgical management options for major PPH
- Intrauterine Balloon tamponade - the balloon adapts to the shape of the uterine cavity to stop uterine bleeding. The catheter allows drainage and is designed to monitor ongoing bleeding above the level of the balloon
- Interventional Radiology - image guided minimally invasive surgery
- B-Lynch Suture - a form of compression suture used in obstetrics. It mechanically compresses an atonic uterus.
- Hysterectomy
Also fluid replacement +/- blood products
What is cord prolapse?
When the umbilical cord presents first before the presenting part of the foetus
- It is highly likely to become compressed and thus reduce oxygen supply to the fetus.
- It affects 0.1 – 0.6% of births.
What is the immediate management of umbilical cord prolapse?
Get help - obstetric emergency! Delivery is usually via emergency Caesarean section.
- Replace cord into vagina (not uterus) to reduce the chance of it becoming compressed and subsequent hypoxia for the foetus. This also prevents the vessels going into spasm
- Elevate the presenting part off the cord:
- By bimanual vaginal exam.
- Alternatively, you can fill the bladder to elevate the presenting part - this can take time though so it may be omitted, however, it can be useful if delivery is taking place in the community and you need to wait for an ambulance.
- Encourage mother to adopt Knee-Chest or left lateral position with raised hips
- Consider tocolysis - relax the uterus and stop contractions, relieving pressure off the cord.
