Obstetric emergency Flashcards
What is shoulder dystocia?
• When additional manoeuvres are required after normal downward traction has failed to deliver the shoulders after the head has delivered. 1 in 200
• 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% of cases
What are the risk factors for shoulder dystocia?
• The principal risk is a large baby (>4kg)
maternal diabetes doubles the risk at any given birthweight
Obesity
Previous shoulder dystocia
What is the management for shoulder dystocia?
gentle downward traction
legs are hyperextended into on the abdomen (McRobert’s
manoeuvre) and suprapubic pressure is applied
• If this fails, internal manoeuvres are required (episiotomy) to rotate the shoulders into an oblique position or even 180O
alternatively the posterior arm is grasped and by flexion of the elbow, the hand is brought down, narrowing the obstructed diameter by the width of the arm
What is the last resort management for shoulder dystocia?
is symphysiotomy- 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
What is cord prolapse?
• Occur when the membranes have ruptured and the umbilical cord descends below the presenting part of the foetus
untreated, the cord will be compressed or go into spasm and the baby will rapidly become hypoxic
• Occurs in 1 in 500 deliveries
What are the risk factors for cord prolapse?
o Preterm labour o Breech presentation o Polyhydramnios o Abnormal lie o Twin pregnancy
What is the management for a cord prolapse?
initially pushing the cord up by the examining finger or tocolytics are given (terbutaline) to prevent compression of the cord
if the cord is out of the introitus, it should be kept warm and moist but not forced back inside – the patient is asked to go on all fours while preparations for delivery by the safest route are undertaken
immediate C-section is normally used, but instrumental vaginal delivery can be used in cervix is fully dilated and the head is low
What is amniotic fluid embolism?
• 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
• If the women survives for 30 mins, she will rapidly develop DIC and often pulmonary oedema and ARDS-
in a few, haemorrhage from DIC is the 1st appearance
• Traditionally occurs when the membranes rupture, but may occur during labour, at C-section and even at termination- there are multiple predisposing factors and prevention is impossible
What is the management for amniotic fluid embolism?
• Resuscitation and supportive treatment as for any cause of collapse
blood for clotting, FBC, electrolytes and cross match are undertaken
treatment of massive obstetric haemorrhage (MOH) will be required
What is uterine rupture?
• The uterus can tear de novo or an old scar can open
the foetus is extruded, the uterus contracts down and bleeds from the rupture site- causing acute foetal hypoxia and massive internal maternal haemorrhage
• Rupture of a lower transverse C-section scar is usually less serious than a primary rupture or one from a classic C-section (vertical cut)- the lower segment is not very vascular and heavy blood loss/extrusion of foetus into the abdomen is less likely
How is a uterine rupture diagnosed?
suspected from foetal heart rate abnormalities or a constant lower abdominal pain
vaginal bleeding cessation of contractions and maternal collapse may also occur
What are the risk factors for uterine rupture?
o Labours with a scarred uterus- classic C-section or deep myometectomy carries higher risk than previous LSCS
o Neglected obstructed labour, rare in the West, but common obstetric emergency in developing countries
ongenital uterine abnormalities- occasionally causes rupture before labour
What are the prevention measures for uterine rupture?
• Prevention measures include 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
• The foetus will very rapidly die if extruded from the uterus and blood loss may be faster than can be replaced
the uterus is repaired or removed, it has a high recurrence rate in subsequent pregnancy and early C- section is required
What is uterine inversion?
- When the fundus inverts into the uterine cavity- usually follows traction on the placenta, occurs in 1 in 20,000 deliveries
- Haemorrhage, pain and profound shock are normal- a brief attempt is immediately made to push the fundus up via the vagina
- If impossible, a GA is given and replacement performed with hydrostatic pressure of several litres of warm saline, which is run past a clenched fist at the introitus into the vagina
What is an epileptiform seizure?
- Most commonly the result of maternal epilepsy or eclampsia, also be due to hypoxia from any cause
- In the absence of cardiopulmonary collapse- diazepam will normally stop the fit, but it is wise to assume the cause is eclampsia until it is excluded
- Magnesium sulphate is not useful in non-eclamptic seizures, therefore inappropriate where the diagnosis is uncertain
