Obstetric emergencies Flashcards
What is shoulder dystocia?
Any delivery that requires additional obs manoeuvres after gentle downward tracion on the head has failed to dliver the shoulder
1:200 pregnancies
Usually anterior shoulder is pushed against symphysis pubis due to failed internal rotation of shoulder
Rapid foetal deterioration occurs due ot cord compression and trauma
Risk factors and comlications of shoulder dystocia
RF: macrosomia, prev. hx, BMI >30, instrumental delivery, DM
Foetal: hypoxia, cerebral palsy, brachial plexus palsy, clavicle/ humerus fracture, intracranial haemorrhage, cervical spine injruy, foetal death
Maternal: PPH, genital tract trauma
Management of shoulder dystocia
H: call for help
E: episiotomy
L: legs to McRoberts
P: suprapubic pressure
E: enter pelvis for internal manoeuvres
R: release of posterior arm by flexing elbow, getting hold o foetal headand sweeping foetal arm across chest and face
R: roll over onto hands and knees (Gaskin manoeuvre)
80% deliver with McRoberts and pressure
Zanvanelli = pushing head back in
What is massive obstetric haemorrhage?
Blood loss >1000ml +/- signs of shock
Important cause of death
Causes:
Antepartum: abruption, praevia, sepsis, retained products
Intrapartum: abruption, uterine rupture, amniotic fluid embolism, complications of CS, acreta/ increta/percreta
Postpartum: tone, trauma, tissue, low thrombin
Discuss primary PPH
Within 24hrs
a) Tone: uterus feels boggy, soft, fundus above umbilicus
I: USS, bloods, coag profile
Tx: uterotonic agents e.g. oxytocin, ergot alkaloids, uterine balloon/ tamponade
b) Tears/ trauma: bleeding, uterine rupture, tears during c-section
I: inspect during c-section, USS to look for free fluid and rupture
Tx: repair trauma, pelvic artery embolisation
c) Retained tissue: placenta and membranes
I: examination under anaesthesia
Tx: manual removal
d) Coagulopathy: continued bleeding, contracted uterus
I: U&E, FBC, coagulation profile
Tx: medical: blood + clotting factors + platelets
Surgical: only if unresponsive to medication
Discuss secondary PPH
24hrs - 12 weeks PP
a) Endometritis: uterine tenderness, guarding and rebound tenderness
I: high vaginal swabs, USS to rule out retained products
Tx: oral antibiotics, admit for IV if unwell
b) Pseudoaneurysm: uterine artery, mostly due to CS, result in profuse bleeding and shock
I: doppler, MRI, angiography
Tx: antibiotics if infection, uterine artery embolisation
c) Retained tissue: foul or offensive discharge, fever, tenderness
I: USS
Tx: oral or IV antibiotics/ surgery to remove tissue
What is PPH?
>500ml blood loss PP
Minor haemorrhage = <50ml
Major = 50-100ml
Massive = >1000ml
70% due to uterine atony
Methods to control or reduce risk of PPH
Bimanual uterine compression
Medication: syntocinon, syntometrine, misoprostol
