Obstetrics

Question 1

Example Exam Question: What are the two main types of malpresentation as discussed in the UK Ambulance Services Clinical Practice Guidelines (2019)? Define each one. (4 marks)

Answer 1

Shoulder Dystocia – An arrest of spontaneous birth; when birth of the baby’s shoulders is delayed because the baby’s anterior shoulder is stuck behind the symphysis pubis.

Vaginal Breech – Vaginal Breech birth is where the feet or buttocks of the baby present first rather than the baby’s head.

Question 2

Example Exam Question: You are called to a 24-year-old female called Elena who is 40 weeks pregnant and in labour. Her contractions are 1 minute apart, occurring every 3 minutes. This is her first pregnancy and she has been categorised as ‘low risk’ by her Midwife. On arrival you conduct a primary survey and notice the patient is ‘crowning’, you can see the top of the baby’s head. 3 contractions go by and you have witnessed the ‘turtle-neck’ sign with failure to deliver the shoulders.

What type of presentation is this? Discuss your immediate management of this presentation as per the UK Ambulance Services Clinical Practice Guidelines (2019). (12 marks)

Answer 2

• Shoulder Dystocia (2 Marks)
• Request a midwife and additional resources
• Prepare for newborn resuscitation
• Lone clinicans consider putting the patient on all fours first
• McRoberts manoeuvre – Lay the woman supine, bring her knees up onto her abdomen and the legs will naturally abduct, consider supporting her legs. Get the woman to push on the next contraction.
• Gentle outward axial traction while maintaining McRoberts, can be applied if the shoulders are not released from McRoberts position alone
• If un-delivered after 30 seconds apply constant suprapubic pressure from the maternal side where the babies back is, while maintaining McRoberts for 30 seconds with axial traction
• If un-delivered after 30 seconds apply intermittent suprapubic pressure from the maternal side where the babies back is, while maintaining McRoberts for 30 seconds with axial traction
• If un-delivered after 30 seconds position the women on all fours with her hips well flexed with axial traction
• If un-delivered transfer the woman in the lateral position placing a pre-alert/blue call/priority to the nearest obstetric unit
• Internal manoeuvres can be carried out if the paramedic has had the appropriate training

Question 3

Example Exam Question: Identify the common causes of antepartum haemorrhage in late (>24 weeks) pregnancy as discussed in the UK Ambulance Services Clinical Practice Supplementary Guidelines 2017 and define each one. (4 marks)

Answer 3

Placenta Praevia – The placenta develops low down in the uterus and partially or completely covers the internal opening of the cervical canal. With the development and growth of the uterus, bleeding is inevitable.

Placental Abruption – Bleeding occurs between the placenta and the wall of the uterus, detaching an area of the placenta from the uterine wall.

Question 4

Example Exam Question: Critically discuss the key considerations for managing an eclamptic patient actively seizing. (8 marks)

Answer 4

• DR©ABCDE
• Pregnant women with high BMIs can have difficult airways to manage
• If over >20 weeks gestation place the women in the full lateral ‘recovery’ position
• If over >20 weeks gestation do not use the supine position with a left lateral tilt or manual uterine displacement
• Oxygen if Sp02 <94%
• Obtain a blood glucose reading incase hypoglycaemia is the cause of the seizure
• If convulsing for longer than 2-3 minutes or they have a second or subsequent convulsion administer diazepam IV/PR
• IV magnesium sulphate can be given if available