Obstetric emergencies

Question 1

What is shoulder dystocia?

Answer 1

This is where the shoulders fail to deliver after the head has delivered

Question 2

What are the consquences of shoulder dystocia if it is not managed properly?

Answer 2

It can lead to brain injury or death

Inappropraite manipulation leads to brachial pleux injuries such as erb’s palsy

Question 3

What are the risk factors for shoulder dystocia?

Answer 3

Large babies are the main risks
Maternal diabetes doubles the risk at any birthweight
Babies over 4.5kg should have c-section considered

Question 4

What is the management of shoulder dystocia?

Answer 4

It is managed by gentle downward traction to reduce risk of brachial plexus injury
The mcroberts manouvre is used involving flexion of the legs onto the abdomen to tilt the pelvis and open this birth canal, suprapubic pressure is used to press the anterior shoulder of the baby
If this doesnt work episiotomy allows a hand to enter the vagina and rotate the babies shoulder
Last resorts inlude symphysiotomy or replacement of head a and c section

Question 5

What is cord prolapse?

Answer 5

This is where the membranes rupture and the cord descends below the presenting part of the baby
This can cause it to become compressed and cause fetal hypoxia

Question 6

What are the risk factors for cord prolapse?

Answer 6

Preterm labour
Breech presentation
Polyhydramnios
Abnormal lie

Question 7

What is the management of cord prolapse?

Answer 7

Initiallyif the cord is protruding through the cervix then it should be kept warm and moist, it should not be pushed back in
Patient is asked to go on all fours whilst prep for emergency c section is done

Question 8

What is amniotic fluid embolism and what are the symptoms?

Answer 8

This is where liquor enters the maternal circulation causing anaphylaxis, dyspnoea, hypoxia, hypotension, seizures and cardiac arrest
If the mother survives 30 mins she will develop disseminated intravascular coagulopathy and adult respiratory distress syndrome

Question 9

What are the risk factors for amniotic fluid embolism?

Answer 9

It usually occurs when membranes rupture but can occur in labour or at c-section

Question 10

What is the management of amniotic fluid embolism?

Answer 10

Diagnosis often confused with eclampsia
resuscitation and supportive treatment are key
Bloods for clotting, FBC, U and E, cross match
Treatment of massive obstetric haemorrhage will be required

Question 11

What is uterine rupture?

Answer 11

This is where the uterus tears allowing the fetus to leave the uterus
It can be de novo or through an old c section scar
The uterus then contracts down and bleeds from the rupture
This causes acute fetal hypoxia
It presents with fetal heaert rate abnormalities or a constant lower abdo pain, cessation of contractions, maternal collapse

Question 12

What are the risk factors of uterine rupture?

Answer 12

Previously scarred uterus

Preventative measures involve avoidance of induction and cautious use of oxytocin in patients with previous c section

Question 13

What is the management of uterine rupture?

Answer 13

Resuscitation with IV fluids and blood
Bloods for clotting, FBC, cross match
Arrange an immediate laparotomy
Fetus will die rapidly and blood can be lost faster than it can be replaced
Uterus is repaired or removed

Question 14

What is the management of uterine inversion?

Answer 14

This can happen when there is tension on the umbilical cord
It causes haemorrhage, pain and a vasovagal response
An attempt is made to push the fundus back up via the vagina
If this fails hydrostatic pressure with saline is used under general anaesthetic

Question 15

What are the causes of maternal epileptiform seizures?

Answer 15

Commonly caused by eclampsia and maternal epilepsy however can be caused by hypoxia

Question 16

What is the management of epileptiform seizures?

Answer 16

A-E
Airway cleared with suction, given oxygen
Patient prevented from hurting herself but not restrained
Diazepam given however eclapsia must be considered as the cause
magnesium sulphate is only useful for eclampsia so should not be used where the diagnosis is uncertain

Question 17

Why is warfarin not used in treatment of PE in preganacy?

Answer 17

It is teratogenic

Question 18

What are some of the maternal risk factors for VTE to consider?

Answer 18

Previous VTE
High risk thrombophilia
Low risk with family history
Obesity (BMI over 40)
Surgical procedure
Major medical comorbidity
Smoking
age over 35

Question 19

What prophylactic measures are taken for vte in pregnancy?

Answer 19

Non pharma:
-Mobilisation and maintenance of hydration
-Compression stockings
Pharma:
-LMWH based on weight (40mg for 70kg person)
-In high risk antenatally
-Postpartum used more and continued for at least 10 days

Question 20

What is teh definition of postpartum haemorrhage?

Answer 20

This is loss of more than 500mls blood less than 24 hours following pregnancy

Question 21

What is the deition of massive obstetric haemorrhage?

Answer 21

This is more than 1500mls blood

Question 22

What are the causes of postpartum haemorrhage?

Answer 22

Retained placenta causes blood to accumulate in the uterus
Uterine causes (80%) uterus fails to contract properly (atonic) due to retained products, more common in prolonged labour, multiparity and polyhydramnios
Vaginal causes (20%) - perineal or episiotomy, high vaginal tears
Coagulopathy - usually picked up antenatally

Question 23

How can postpartum haemorrhage be prevented?

Answer 23

Use of oxytocin in the thrid stage of labour

Question 24

What are the clinical features of postpartum haemorrhgae?

Answer 24

The uterus will be enlarged (above level of uterus)

Question 25

What is the management of postpartum haemorrhage?

Answer 25

A-E resuscitation
If blood loss exceeds 1500mls then MOH protocol should be activated
This requires haematological and obstetric senior help
Blood is crossmatched and fluid and blood are given
Fresh frozen plasma and cryoprecipitate are given to treat coagulopathy, TXA also reduces bleeding
Bimanual uterine compression to encourgae uterine contraction
Ergometrine or oxytocin to cause uterine contraction if this doesn’t work
Surgical management includes rusch balloon, laparotomy and embolisation if these things fail

Question 26

What are the causes and management of secondary postpartum haemorrhage?

Answer 26

Due to endometritis from retained products

This is managed with antibiotics and evacuation of retained products

Question 27

What are the causes and management of puerperium?

Answer 27

Endometritis, wound, perineal, urine, beast, chest infection
VTE
It is managed with cutures, venous lactate and observations
Give antibiotics IV fluid and oxygen

Question 28

What is the management of puerpartum urinary retention?

Answer 28

Due to epidural or delivery, particularly forceps

Catheterise for at least 24 hours