obstetric emergencies

Question 1

Causes of maternal collapse?

Answer 1

Obstetric
• M assive obstetric haemorrhage (may be concealed): placenta praevia, placental abruption, PPH, uterine rupture, supralevator haematoma following genital tract trauma.
Severe pre-eclampsia with intracranial bleeding.
• Eclampsia.
• Amniotic fluid embolism.
• Neurogenic shock due to uterine inversion.
• Surgical complications: bleeding after CS, pelvic/broad ligament haematoma.
• Severe sepsis, e.g. chorioamnionitis.
• Cardiac failure, e.g. peripartum cardiomyopathy.

Medical: Massive PE, cardiac failure, shock (anaphylaxis, septic), Inta-abdo bleed (hepatic, aortic, splenic), IC haemorrhage, diabetic coma

Question 2

Ix for sudden maternal collaspe?

Answer 2

ECG, CXR, ABG
V/Q scan
doppler USS of calf veins
cerebral imaging

Question 3

Complications of shoulder dystocia?

Answer 3

Fetal: Hypoxia and neurological injury (cerebral palsy).
• Brachial plexus palsy.
• Fracture of clavicle or humerus.
• Intracranial haemorrhage.
• Cervical spine injury.
• Rarely, fetal death.

Maternal: PPH, G genital tract trauma including 3rd and 4th degree perineal tears.

Question 4

Mechanisms of shoulder dystocia?

Answer 4

usually anterior shoulder impacted against pubic symphysis - caused by failure of internal rotation of shoulders

rarely - posterior shoulder impacted aqgainst sacral promontory

Question 5

Anticipatory factors of shoulder dystocia?

Answer 5

limited or slow delivery of head - McRoberts’ manoeuvre is often used prophylactically

Question 6

RFs for shoulder dystocia?

Answer 6

Antenatal
• Previous history of shoulder dystocia.
• Fetal macrosomia.
• BMI >30 and excessive weight gain in pregnancy.
• Diabetes mellitus.
• Post-term pregnancy.

Intrapartum
• Lack of progress in late first or second stage of labour.
• Instrumental vaginal delivery (especially rotational deliveries).

Question 7

Shoulder dystocia Mx?

Answer 7

HELLPER
call for Help
Episiotomy (may help with internal manoeuvres)
Legs into McRoberts’
P suprapubic Pressure applied to posterior aspect of anterior
shoulder
Enter pelvis for internal manoeuvres
R - Release posterior arm by flexing elbow, getting hold of fetal
hand, and sweeping fetal arm across chest and face to release
posterior shoulder.
R - Rollover to ‘all fours’ may help aid delivery by the changes brought about in the pelvic dimensions (Gaskin manoeuvre).

80% of babies will deliver with suprapubic pressure and
McRoberts’ manoeuvre. If these fail, delivery of posterior arm is probably
the best next manoeuvre.

Question 8

Define McRoberts position

Answer 8

hyperflexed at hips with thighs abducted

and externally rotated

Question 9

Manoevres for Shoulder dystocia?

Answer 9

McRoberts position - hyperflexed at hips with thighs abducted
and externally rotated

Roll over to ‘all fours’ may help aid delivery by the changes
brought about in the pelvic dimensions (Gaskin manoeuvre).

Symphysiotomy - can
result in severe maternal morbidity (urethral injury, incontinence,
altered gait, and chronic pelvic pain)

Question 10

Predisposing factors for cord prolapse?

Answer 10

abnormal lie or presentation (transverse lie, breech).
M ultiple pregnancy.
P olyhydramnios.
P rematurity.
H igh head.
U nusually long umbilical cord.

Question 11

Mx of cord prolapse?

Answer 11

Deliver fetus as rapoidly as possible - either instrumental or CS

P revent further cord compression during transfer for CS by:
• k nee-to-chest position
• fi ll the bladder with about 500mL of warm normal saline to
displace the presenting part upwards (remember to unclamp the
catheter before entering the peritoneal cavity at CS)
• a hand in the vagina to push up the presenting part (may not
always be practical).