Obstetric Emergency

Question 1

What is the cause of shoulder dystocia?

Answer 1

Shoulder dystocia is when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered. This requires additional obstetric manoeuvres to enable delivery of the rest of the body. Shoulder dystocia is an obstetric emergency.

Shoulder dystocia is often caused by macrosomia secondary to gestational diabetes.

Question 2

What are the effects of shoulder dystocia?

Answer 2

delay in delivery combined with unskilled attempts at delivery may cause brain injury or death - excessive traction on the neck damages the brachial plexus (Erb’s palsy), which is permanent in 10% cases

Question 3

What are the risk factors of shoulder dystocia?

Answer 3

Large baby (4kg) 
maternal diabetes doubles the risk 

previous shoulder dystocia and obesity

intrapartum risk factors: dystocia and instrumental delivery.

Question 4

What is the management of shoulder dystocia?

Answer 4

Episiotomy

McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen

Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.

Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery.

Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Question 5

What is symphysiotomy?

Answer 5

lateral replacement of the urethra with a metal catheter and the Zavanelli manoeuvre.

Involves replacement of the head and C-section, but by this time, foetal damage is usually irreversible

Also increases maternal morbidity

Question 6

What is cord prolapse?

Answer 6

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

Question 7

What are the risk factors for cord prolapse?

Answer 7

preterm labour
breech presentation
Polyhydramnios 
Abnormal lie
Twin pregnancy

Question 8

What is the management of cord prolapse?

Answer 8

For management of cord prolapse, the presenting part of the fetus may be pushed back into the uterus to avoid compression.

Tocolytics may be used.

If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside.

patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out. Although this is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Question 9

What is amniotic fluid embolism?

Answer 9

When liquor enters the maternal circulation, causing anaphylaxis with sudden dyspnoea, hypoxia and hypotension, often accompanied by seizures and cardiac arrest - acute heart failure is evident

Question 10

What are the effects of amnotic fluid embolism?

Answer 10

Anaphylaxis
dyspnoea and hypotension

IF the mother survives for 30 minutes, she will rapidly develop DIC and often pulmonary oedema and ARDS

Question 11

When does amniotic fluid embolism occur?

Answer 11

traditionally when the membranes rupture - but may occur during labour, at C-section and even termination

there are multiple predisposing factors and prevention = impossible

Question 12

What are the management options for amniotic fluid embolism?

Answer 12

A-E
resuscitation and supportive treatment as for any cause of collapse - blood for clotting, FBC, electrolytes and cross match

treatment of massive obstetric haemorrhage will be required

Question 13

What is uterine rupture?

Answer 13

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. May be incomplete or complete

Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Question 14

What happens as a result of uterine rupture?

Answer 14

Foetus is extruded, the uterus contracts down and bleeds from the rupture site, causing acute foetal hypoxia and massive internal haemorrhage

Foetus will rapidly die if extruded from the uterus and blood loss may be faster than can be replaced

Question 15

Which is more serious - rupture of lower transverse C-section or classicl?

Answer 15

Classical - rupture of Lower transverse usually less serious because the lower segment is not very vascular and heavy blood loss/extrusion of the foetus into the abdomen is less likely.

Question 16

In how many pregnancies does uterine rupture occur in?

Answer 16

1 in 1500 pregnancies

0.5% women who attempt a vaginal delivery after a previous LSCS

Question 17

What are the risk factors fo uterine rupture?

Answer 17

Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions

Question 18

What are the prevention methods for uterine rupture?

Answer 18

Avoiding induction and caution when using oxytocin in women with previous C-section

Elective C-section in women with a uterine scar not in the lower segment

Question 19

What is uterine inversion?

Answer 19

Uterine inversion is a rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out. Very rare

Uterine inversion may be there result of pulling too hard on the umbilical cord during active management of the third stage of labour.

Question 20

What are clinical presentations of uterine inversion?

Answer 20

haemorrhage, pain and profound shock are normal

Question 21

What is the management of uterine inversion?

Answer 21

Johnson manoeuvre, which involves using a hand to push the fundus back up into the abdomen and the correct position. The whole hand and most of the forearm will be inserted into the vagina to return the fundus to the correct position. It is held in place for several minutes, and medications are used to create a uterine contraction (i.e. oxytocin). The ligaments and uterus need to generate enough tension to remain in place.

If this fails - hydrostatic methods can be used. This involves filling the vagina with fluid to “inflate” the uterus back to the normal position. It requires a tight seal at the entrance of the vagina, which can be challenging to achieve.

Where both non-surgical methods fail, surgery is required - laparotomy .

Question 22

What is the cause of epileptiform seizure?

Answer 22

Most commonly, the result of maternal epilepsy or eclampsia

Can also be due to hypoxia from any cause

Question 23

What is the management of epileptiform seizure?

Answer 23

In the absence of cardiopulmonary collapse - diazepam will normally stop the fit

Magnesium sulphate is not useful in non-eclamptic seizures - therefore inappropriate were the diagnosis uncertain

Question 24

What is the effect of local anaesthetic toxicity?

Answer 24

transient cardiac, respiratory and neurological consequences - occasionally resulting in cardiac arrest

Question 25

What is the managment of local anaesthetic toxicity?

Answer 25

prevention = more important

treatment involves resuscitation and even intubation until the effects have worn off