Obstetric emergencies Flashcards
Name some obstetric emergencies
- Shoulder Dystocia
- Cord prolapse
- PPH
- AF embolism
- Eclampsia
- Uterine rupture
Maternal Sepsis
2 key causes?
- Chorioamnionitis
- UTI
an infection of the chorioamniotic membranes* & *amniotic fluid.
can be caused by a large variety of bacteria, including gram-+, gram- & anaerobes.
Postpartum haemorrhage
- define
- types (2)
- what is massive PPH?
is defined as blood loss of > 500mls and may be primary or secondary
- Primary PPH: bleeding w/in 24 hrs of birth
►Loss of 500ml+ of blood w/in 24 hrs of vaginal delivery
►Loss of 1L of blood within 24 hours of C-section
- Secondary PPH: after 24 hrs to 12 wks after birth
Minor PPH – under 500ml-1000ml loss
Major PPH – over 1000ml loss
MASSIVE PPH: loss of >1500mLs
Postpartum haemorrhage risk factors (6)
PARTUM
Prolonged labour/ Polyhydramnios/ Previous C-section
APH
Recent Hx of bleeding
Twins
Uterine fibroids
Multiparity
PPH
Causes (5)
TTTTurned inside out
(uterine inversion is another one too)
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
Minimising risk/prevention of PPH
- Treating antenatal Anaemia
All pregnant women should have a FBC at booking and at 28 weeks. treat w/ oral IRON and monitor for improvement. (if not respond to oral–> paraentral)
- Active management of the 3rd stage labor
vaginal delivery –> should be administered 10U of IM Oxy
C-section –> should be administered 5U of slow IV infusion Oxy
Clinicians should consider the use of IV tranexamic acid, in addition to oxytocin, at C- section to reduce blood loss in women at increased risk of PPH.
The mx of primary PPH should include the simultaneous delivery of TRIM
Teamwork (Immediate Mx)
include the midwife in charge and midwives, obstetricians, anaesthetists, blood bank, clinical haematologist and porters. .
Resuscitation (Immediate Mx)
Investigations and Monitoring (Immediate Mx )
Monitoring should include RR, O2 sats, HR, BP, temp every 15 mins. Consider catheterisation and insertion of a central venous line.
Measures to arrest bleeding (Definitive Mx)
PPH
immediate Management
- (resus)*
- in severe cases?..*
CALL FOR HELP!!!!!—Ask for senior midwife, obstetrics registrar and SHO, anaesthetic registrar, ( if massive haemorrhage call 2222 to alert haematologist, blood bank, porters, and theatres.)
Communication with pxt and partner is important
Airway: Protect airway
Breathing: 15L of 100% oxygen through non-rebreathe
Circulation: lie flat, keep warm, Cap refill, HR, BP, ECG
- 2 large bore (14G) cannulas: take bloods (FBC, U&E’s, LFT’s, Clotting, Coagulation screen (include fibrinogen)
- X-matched blood and Warmed crystalloid IV fluid and blood resuscitation
- Additional blood productions i.e. factor VIIa in Hemophilia A, if major haemorrhage protocol activated may need to FFP, platelets,. (Discussion with blood bank)
Disability: Monitor (GCS).
Exposure: identify bleeding sources.
In severe cases, activate the _major haemorrhage protocol._ which gives rapid access to 4U of crossmatched or O negative blood.
PPH
Definitive Management
(stop the bleeding)
treat the cause!
- Mechanical
- Pharmacological
- Surgical
- Uterine Atony:*
- retained placenta:*
- Tear*
Mechanical treatment for PPH
‘rubbing up the fundus’ and emptying the bladder to stimulate uterine contractions represent first-line Mx of PPH.
bladder distention prevents uterus contractions, catheterise using Foley catheter
Medical treatment for PPH
and their mode of administration
COME
Oxytocin (slow injection followed by continuous infusion)
🧂Ergometrine (IV or IM) stimulates sm contraction (contraindicated in hypertension)
💪🏽🌬Carboprost (IM): Pg analogue & stimulates uterine contraction (caution in asthma)
👅Misoprostol (sublingual): Pg analogue & stimulates uterine contraction
🩸Tranexamic acid (IV ) antifibrinolytic that reduces bleeding
surgical treatments for PPH
Intrauterine balloon tamponade: 1st-line ‘surgical’ for women if uterine atony is the only or main cause PPH
insert an inflatable balloon in uterus to press against the bleeding
- B-Lynch suture – putting a suture around the uterus to compress it
- Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
- Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
Uterine Atony Treatment
ROxy Ego Oxy CaM
- Rubbing up the fundus & ensure empty bladder (Foley catheter, leave in place)
- Oxytocin 5 IU by slow IV injection (may have repeat dose)
- Ergometrine 0.5 mg by slow IV or IM (contraindicated in women with hypertension)
- Oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour) unless fluid restriction is necessary
- Carboprost 0.25 mg by IM repeated at intervals of not less than 15 minutes to a max of 8 doses (use with caution in women with asthma)
- Misoprostol 800 micrograms sublingually
common cause of 2ndry PPH?
how may it present? (signs)
The most common cause is ENDOMETRITIS
other: retained products of conception
- Signs of sepsis: tachycardia, hypotension and pyrexia.
- On palpation: uterus may be tender or bulky on
- On speculum : cervical os may be open and foul-smelling discharge may be present.
how to investigate and manage 2ndry PPH?
Assessment of vaginal microbiology (high vaginal and endocervical swabs) and antibiotics if endometritis suspect
►combo of ampicillin + metronidazole. (clindamycin if penicillin allergic)
►Gentamicinshould be added to the above combination in cases of endomyometritis (tender uterus) or overt sepsis.
Pelvic USS –> exclude retained products of conception
Surgical evacuation of retained placental tissue
A blood transfusion should be considered if haemoglobin is below 80g/L and the patient is symptomatic of anaemia.
complications of PPH (6)
- Anaemia
- Hypovolaemic shock leading to organ dysfunction such as AKI
- PTSD
- DIC
- Sheehan’s syndrome (postpartum pituitary gland necrosis)
- Death
Maternal collapse
causes?
- Haemorrhage
- AF embolism
- Drug overdose/toxicity
- CVS–> MI, Aortic dissection, cardiomyopathy
- Sepsis
- anaphylaxis
VTE
Shoulder dystocia
managment
complications (4)
when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.
- Call for help/ pull the emergency
- tell mum to stop pushing
- McRobert’s Position
- Suprapubic pressure
- Bleep the paediatricans
Complications
- Fetal hypoxia (and subsequent cerebral palsy)
- Brachial plexus injury & Erb’s palsy
- Perineal tears
- PPH
initial management of maternal collapse?
Call for help! and put out a maternal collapse call via switchboard (2222 in the UK)
TILT-->pressure of uterus off aorta and IVC
- *Airway:** head tilt and chin lift.
- *Breathing**.
Circulation: if u need to do CPR in women 5 months must be done in left lateral position (place a wedge under the woman or tilt the table). if NO pulse still after 5 mins –> CESEREAN
(This is not to save the fetus—it is essential for maternal resuscitation. In obstetrics, haemorrhage is a common cause of collapse so check vaginally for bleeding)
