Obstetric emergencies

Question 1

What are the risk factors for cord prolapse?

Answer 1

Preterm labour

Artificial rupture of membranes
- the head may not be fully engaged when this is done

Polyhydramnios

Placenta previa

Question 2

List some interventions that can be done whilst waiting for help to arrive in a cord prolapse:

Answer 2

Tilt the bed back

Apply pressure to presenting part to relieve pressure off cord

Catheterise and inject saline into bladder to push presenting part back

Place mother on all fours or modified sims position

Question 3

What is the advised delivery method for the fetus in a cord prolapse?

Answer 3

C-section

Question 4

In a vaginal delivery what are the definitions of a PPH?

Answer 4

> 500ml

Major PPH is >1000ml

Question 5

List some antenatal and intrapartum risk factors for PPH:

Answer 5

Antenatal:

• previous PPH
• pre-eclampsia
• placenta previa/ abruption
• multiple pregnancy

intra-partum:

• large baby
• multiple pregnancy
• prolonged labour
• pyrexia in labour

Placenta previa carries the highest risk for PPH

Question 6

In a Major PPH what bloods do you want to take and how will you monitor the mother?

Answer 6

Bloods:

• FBC
• Coagulation studies
• Cross match (if not already done)
• U&Es
• LFTs

Monitor:

• vitals
• blood loss measurements
• urine output

*document on Obstetric Early Warning Score Chart/ OEWS

Question 7

Why should any retained products be removed off the cervix immediate?

Answer 7

This can stimulate vagal tone reducing the blood pressure

Question 8

What blood can be salvaged and reused for the patient?

Answer 8

Blood from laparotomy or C-section.

*note from the vagina due to the blood being contaminated.

Question 9

When there is maternal collapse, how long should CPR be going on for when Emergancy C-section should be done?

Answer 9

4 minutes.

After 4 mins there should an Emergancy C-section

Question 10

There are a set of factors which make CPR more challenging in a female, what are they?

Answer 10

Laryngeal oedema

Increased weight in the abdomen

Decreased residue capacity of the lungs

Question 11

In a >24 week year old female who collapses and has no respiratory effort - who should be called?

Answer 11

Cardiac arrest team

Obstetric team

Neonatal team

Question 12

What are some risk factors for shoulder dystocia?

Answer 12

Macrosomia

Induction of labour

Previous shoulder dystocia

Pre-longed labour

Question 13

What are the complications of shoulder dystocia?

Answer 13

Maternal:

• perineal tears
• PPH

Fetus:

• HIE
• Brachial plexus injury
• Fractured clavicle

Question 14

What is the preventative options for shoulder dystocia?

Answer 14

Estimated fetal weight of:
>4.5kg in a diabetic
or
>5kg

= C-section

Question 15

What is the definition of retained placenta and what are some aetiologies?

Answer 15

definition:
- Active management - no placenta after 30mins
- Physiological management - no placenta after 60mins

Causes:

• uterine atony
• Trapped placenta (cervix closes to quickly)
• Placenta acreta/ percreta

Question 16

What is the pathology behind uterine prolapse?

Answer 16

Neurogenic shock

Question 17

What are the degrees of a tear?

Answer 17

1st degree: Vaginal tissue only/ skin

2nd degree: Perineum tissue but not anal sphincets

3rd grade a: <50% of sphincter complex
3rd grade b: >50% of sphincter complex
3rd grade c: both external and internal are torn

4th degree: Involvement of anorectal mucosa

Question 18

What is needed following a perineal tear repair?

Answer 18

Analgesia
Laxatives to prevent too much pressure
Physiotherapy appointment

*sphincter tone should be measured

Question 19

Following an ectopic with a salpingoectomy - what contraception should be avoided?

Answer 19

IUD

- increases the risk of ectopic pregnancy

Question 20

Which bacterial infection are pregnant females at risk of developing causing meningitis and list an obstetric complications of this:

Answer 20

Listeria monocytogenes
- gram positive

Premature labour or Septic abortion

Question 21

Outline the Classifications of urgent C-sections:

Answer 21

Grade 1: Immediate - life threatening to mother and child

Grade 2: Not immediately life threatening but compromise

Grade 3: Requires early deliver

Grade 4: Elective

Question 22

Give some reasons for a grade 1 emergency C -section:

Answer 22

Fetal distress

• Abnormal CTG - 10min bradycardia
• Abnormal FBS suggesting acidosis

Cord prolapse

Severe maternal compromise (Haemorrhage)

Question 23

Following a C-section how many sutures closures are done?

Answer 23

2 to uterus
1 to rectus shealth
1 to skin

Question 24

What are the short term and long risks of a C section:

Answer 24

Short term:

• haemorrhage
• Anaesthetic risks
• Pain
• Surgicla injuries to bladder/ bowel

Long term:

• increased risk of sub-fertility from scars
• increased risk of uterine rupture
• placenta previa

Question 25

What are the layers transected through on a C-section?

Answer 25

Skin 
Sub-cut tissue 
Camper fascia 
Scarpa facia 
Anterior rectus sheath 
Rectus abdominins muscle 
Transverse fascia 
Parietal peritonieum 
Visceral peritonium 
Uterus

Question 26

What level is the spinal given before C-section?

Answer 26

L3/4

Question 27

What are the major risks for VBAC? what percentage are successful?

Answer 27

Uterine rupture

20% require emergency C-section

Fetal death
- increased with VBAC

Prognosis:
- 75% are successful

**should be done in an obstetric unit

**TOLAC - trial of labour after C-section is the term for trying

Question 28

How long is the second stage of labour when fully dilated allowed to go on for before interventions?

Answer 28

4 hours

Question 29

What are some contraindications to instrumental delivery?

Answer 29

Forceps:

• not fully dilated
• Bleeding disorders of baby
• Malprsentation
• Anything that contraindicated a vaginal birth (placenta previa)

Ventous:

• face presenting
• <34 weeks due to risk of cephlahaematoma

Question 30

Indications for instrumental delivery:

Answer 30

Prolonged labour
Fetal distress
Maternal fatigue

Question 31

What surgical procedure usually has to be done during an instrumental delivery and list some complications of an instrumental delivery:

Answer 31

Episiostomy
- usually always has to be done

Complications to mother:

• PPH
• Perineal tear

Fetal complications:

• Subgaleal haemorrhage (extra-cranial haematoma which can be fetal)
• Cephlahaematoma
• Facial palsy
• Injuries

Question 32

What are the risk factors for a molar pregnancy?

Answer 32

<16 years old pregnancy

> 45 years old pregnancy

Previous molar pregnancy

Question 33

When is a molar pregnancy officially diagnosed and what are the two main types?

Answer 33

Partial molar pregnancy:
- 69 chromosomes

Completely molar pregnancy
- 46 chromosomes

*only officially diagnosed after tissue is removed and histological analysis is done

Question 34

Compare and contrast complete and partial molar pregnancies:

Answer 34

Complete:

• 46 chromosomes
• Bunch of grapes
• Diffuse trophoblast hyperplasia

Incomplete:

• 69 chromosomes
• Focal trophoblastic hyperplasia

Question 35

What is the management of shoulder dystocia?

Answer 35

HELPERR-Z

• Help - shout for help
• Episiotomy
• Legs - McRoberts manoeuvre
• Pressure - suprapubic
• Enter into vagina for intra-vaginal manoeuvres
• Release posterior shoulder
• Roll mother over onto all fours
• Zavanelli - pushed back up and C-section

Question 36

Some of the parameters for sepsis change during labour due to the extreme physiological demands placed on the mother, what are some of the changes?

Answer 36

Temperature: >37.5

HR: >110 - whilst in labour

RR: >22 - whilst in labour

WCC - >20 whilst in labour