Obstetrics Emergencies Flashcards
Causes of antepartum haemorrhage
- Placenta praevia
- Abruptio placenta
- “Show”
- Local lesion of the genital tract
- Vasa praevia
- Ruptured uterus
- Idiopathic
- Other source eg. haematuria, bleeding from a haemorrhoid
What do you do when a pregnant patient arrives bleeding vaginally
Maternal Condition:
Degree of shock
Blood Pressure
Haemoglobin
Active bleeding
Clotting pro ile
Urine output/proteinuria
Fetal Condition:
Viability/ Gestational age
Presence of Fetal Heart
Quality of Fetal Heart (CTG)
Differentiate between placenta previa and abruption
1) Maternal condition: Good depending on
blood loss
Poor - usually
Shocked
2) Fetal condition: Good Usually demised
3) Uterus: Soft Hard-woody
4) Presenting part: High/unstable
Dif icult to palpate
5) Maternal Hb: May be low Very low
6) Coagulation defect: No May be present &
severe
7) Delivery: No hurry unless
Expedite: Urgent Maternal Condition
Poor
8) Diagnosis: Clinically/ultrasound Clinically, CTG
9) Predisposing factors: Previous uterine
trauma
Hypertension,
e.g. C/Section
Trauma
10) Pain: Classically none
Continuous,
Posterior placenta may
cause severe backache
Sudden abdominal
pain & cramps
.
How to manage placenta previa if GA is <37weeks
- Maintain nil per mouth, intravenous infusion and cross match blood.
- Perform a speculum examination once.
- Transfer the patient to the antenatal ward once bleeding and
contractions have settled. - If baby is < 34 weeks, administer bethamethasone.
How to manage placenta previa if GA<37 weeks
- Prepare for theatre.
- Proceed directly to Caesarean Section if the diagnosis has been
de initely con irmed. - If the diagnosis is in doubt, perform a careful examination under
anaesthesia including a speculum examination and proceed according
to the diagnosis. - In experienced hands, a lower segment Caesarean Section may be
performed, preferably delivering around rather than through the
placenta. In less experienced hands, or where there is no formed lower
segment, a classical Caesarean Section is preferable. - The infant’s haemoglobin and haematocrit must be repeatedly assessed
after delivery.
Indications for delivery if a patient has previa
- Electively at 37 weeks
- Bleeding (the later in pregnancy, the less required)
- Labour or rupture of membranes
- Fetal compromise
- Other conditions e.g. GPH, IUGR
Types of placenta previa
Major and Minor
How to diagnose Major Placenta Previa
Clinically suspicious
US localisation of placenta
Management of major placenta Previa
NO VAGINAL EXAMINATIONS
Before 37/52: conservative if bleeding slight and ceases
Top up transfusion if necessary
X-match blood and keep in reserve
Bed rest in hospital
Elective caesarean section at 37-38/52
Beware that IUGR may occur if there is repeated bleeding,
therefore the need for repeat ultrasound for fetal growth
Investigations in a pt with placental abruption
Investigations:
Hb
Clotting time
Blood clotting screen
CTG for differential diagnosis/fetal wellbeing
Blood gases
Check renal function
PV to assess cervix if diagnosis certain
Anaemia:
Transfuse with red blood cells until Hb corrected
Clotting Defects:
With the tissue destruction that occurs with the placenta shearing, there is
release of thromboplastin, which causes diffuse intravascular coagulation that
results in ibrinolysis, and depletion of ibrinogen; therefore bleeding continues.
If severe, the patient may bleed from nose, needle sites, etc.
Management of placental abruption
Fluid Resuscitation
Crystalloids
Colloids
Fresh whole blood
Plasma constituents: FFP, Platelet concentrations, Fibrinogen concentrate
Renal function:
Catheterise
Strict intake/ output – At least hourly
Cardiovascular system:
Patients with severe blood loss will have:
Rapid, thready pulse
Hypotension
In addition with a severe placental abruption, shock lung may occur
Maintenance of the cardiovascular system should be based on the
pulse, BP.
Deliver as quickly as possible:
Induction and vaginal delivery if baby dead.
Vaginal delivery if baby OK and quick delivery anticipated..
CS if baby in distress and delivery not imminent
C
NB: Epidural analgesia is contra-indicated, due to potential coagulopathy,
and resultant danger of spinal cord compression by blood
Continue to correct clotting defect
Post-partum haemorrhage is common due to poor uterine contraction and
an oxytocin infusion should be maintained – “Couvellaire uterus”
Correct anaemia by blood transfusion
How to manage vasa Previa
Diagnosis made by blood examination, to detect fetal cells Kleihauer & Apt
test (NaOH)
Management:
Proceed with delivery:
1) Caesarean section if alive and normal CTG
2) Vaginal delivery if fetus is dead
Managemt of abruption of placenta
Management:
Correct shock
Laparotomy and procede to either repair or abdominal hysterectomy
Immediate Management of cord prolapse
Immediately:
Summons help
Listen to and record the fetal heart
Gently replace the cord in the vagina, avoid handling the cord or repeatedly
checking for pulsation.
Elevate the presenting part off the cord by vaginal manipulation and/or
overdistention of the bladder with 500mls saline and retained by means of
a clamped Foley’s catheter to prevent cord compression.
Patient in knee/chest position OR far over onto left side OR steep head tilt
Administer oxygen
If uterus is contracting administer Salbutamol 2,5 gm bolus dose. Stop
oxytocic if being used.
Check fetal heart frequently
Initiate referral or arrange theatre – depends where patient presents (MOU
or hospital)
Record what was found and done.
If the cord is no longer pulsating
Listen for the fetal heart – if the heart is con irmed, proceed as for cord
prolapse with a pulsating cord
If there is no fetal heart, look for the cause of the prolapse. Dangerous
causes for the mother = malpresentations (TV lie or brow presentation and
CPD). If these are present refer, even if it is too late to save the baby.
If lie is longitudinal and vertex or breech presentation continue labour in
clinic unless multiparous. Deliver if progress is normal. Refer if progress is
slow.
MAINTENANCE MANAGEMENT
o Stabilise for transport or transfer
o Continue tocolytic if major delay
o Reassure patient and family
o Written record and referral letter if appropriate
o De inite handover between staff members
Definitive management of cord prolapse
Caesarean Section is applicable in most cases. Pressure must be kept off
the cord until delivery. In cases of transverse lie a classical Caesarean
Section should be considered.
Pre-viable (less than 26-28 weeks) cases and cases with known congenital
abnormalities are generally allowed to proceed in labour unless obstructed.
Multiparous patients at almost full dilatation may occasionally be delivered
rapidly vaginally with Ventouse assistance if necessary. However,
disproportion must be excluded and the results of attempted vaginal
delivery are not good.
If the fetus is dead, the mode of delivery will depend on the size and lie of
the fetus and the presence of other complications. Although a Caesarean
Section should be avoided if possible, there is no place in modern obstetrics
for “heroic” vaginal manipulation or destructive operations.
Permissible destructive operations - perforation of a hydrocephalic head
RF for shoulder distocia
- Obese patients
- Diabetic patients
- Suspected or predicted large baby
- History of previous shoulder dystocia
- Patients with abnormal fetus
- Instrumental deliveries
How to predict shoulder distocia
Possible shoulder dystocia can be predicted if the head tends to
“ascend” between bearing-down efforts or if external rotation of the
head fails to occur spontaneously.
A delay of more than 60 seconds between delivery of the head and the
anterior shoulder.
May also be delay in the late 1st stage (8-9 cm) especially in
multiparous patients.
Management of shoulder distocia
- Call for help
- Inform pt shoulder is stuck
- Move pt to end of the bed
- Use McRoberts by hyperflexing hips, while steadying the fetal head, attempting
to rotate her pelvis over the impacted shoulders - Anterior shoulder: Apply suprapubic pressure to the anterior shoulder, try move shoulder upwards towards fetus chest and down. May be done with McRoberts and downwards traction of head
- Posterior Arm: Attempt to deliver posterior arm by getting hold of posterior forearm and reliever. Episiotomy May be useful
- Salvage Maanuevers:
-All FOURS
- Posterior arm axillary sling traction
-Fracture clavicle
-Zavanelli: flex fetal neck and gently replace it back and CS. Tocolyse (success of this is low
Conmplications of shoulder distocia
Fetal
Brachial plexus injury
CP
Hypoxia
Fractures
Laceration
Bruising
Maternal
Cervical tear
Perineal trauma
3rd/4th degree tears
PPH
Lateral femoral nerve palsy
Postpartum infection
Differentiate between Primary and Secondary PHH (add PPH after C/S)
Primary PPH.
Blood loss ≥ 500mls within irst 24hrs after vaginal delivery
Secondary PPH.
Signi icant blood loss after 24 hours up to 6weeks.
PPH at/ after Caesarean Section.
Revealed or concealed bleeding g ≥ 1000mls
Causes of PPH
4Ts
Uterus ATony
Trauma
Retained Placenta
Following Previa or Abruption
Uterine Inversion
Causes of PPH after CS
ATony
Trauma
Placenta site bleeding
How to prevent placenta Previa
Routine iron supplementation in pregnancy to prevent anaemia
At risk women (eg APH, grand multipara, previous PPH, multiple
pregnancy, prolonged labour) to deliver in hospital.
Prevent prolonged labour
Active Management of the Third Stage of Labour.
Routine postpartum monitoring of vital signs and bleeding
NB: EARLY DETECTION WITH ACCURATE MEASUREMENT OF BLOOD LOSS
USING CALIBRATED BLOOD COLLECTION DRAPE OR COLLECTION DEVICE
ENABLES EARLY DETECTION AT 500mls
Management of PPH
Call for help and PPH box
E-Motive
Early detection
Massage uterus
Oxytocin
Tranexamic acid
IV Fluids
Escalate to next level of care if needed
Algorithm
Call for help and the PPH box
Massage the uterus to expel clots to induce contraction
Insert an Intravenous line and infuse 10 IU Oxytocin in 100 or 200mls
luid in 5-10 minutes. NB. Some practitioners may omit this and rather
commence 20 IU oxytocin infusion
Infuse Tranexamic acid (TXA) 1000gms in 100 or 200mls luid in 10
minutes
Infuse 20 IU oxytocin in one litre Sodium Chloride 0,9% or Ringers
Lactate over 4-8 hours as a maintenance infusion
Insert a second IV line and run fast if the patient is haemodynamically
unstable
Ensure the bladder is empty
Examine for genital tract tears and suture if present
Examine placenta for completeness (see section on retained placenta)
Retained Placenta
Perform vaginal examination: remove placenta if felt in cervical os
If not separated, Manual Removal of Placenta with analgesia / anaesthesia
IV oxytocin 20u/litre infusion to contract uterus
Five day course of broad spectrum antibiotics to prevent infection
Management of Refractory PPH.
Refractory PPH refers to persistent bleeding after the irst response measures
have been performed . Senior assistance must be sought and referral may be
necessary.
It requires a stepwise approach:
Aortic compression; apply irm and sustained pressure to the
aorta above the level of the umbilicus while awaiting help
Intensify resuscitation with up to 3 litres crystalloid and emergency
blood transfusion. Cross match extra blood and order fresh frozen
plasma
Urgent examination in theatre for identi ication of high
vaginal/cervical tears, manual exploration of the uterus for
rupture and for retained products.
A short trial of balloon tamponade (UBT) could be considered
Laparotomy with uterine compression suture (Hayman),
systematic devascularisation (uterine and ovarian arteries), or
hysterectomy.
