Obstetrics emergencies Flashcards
When does shoulder dystocia occur?
the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the fetal head
What can drop during the manoeuvres manangement for shoulder dystocia?
fetal oxygen levels
when would shoulder dystocia occur?
between complete extension and restitution (external rotation)
Dangers of shoulder dystocia (4)
umbilical cord entrapment
inability of childs chest to expand properly
severe brain damage or death due to hypoxia or acidosis
- brachial plexus damage
What is intrauterine pressure caused by?
maternal contractions
- the anterior shoulder is impacted on the pubic symphysis
Management of Shoulder Dystocia
H – Call for Help E – Evaluate for Episiotomy L – Legs (McRoberts Position) P – Suprapubic Pressure E – Enter Manouvers (Internal Rotation) R – Remove the Posterior Arm R – Roll the Patient (Onto all Fours)
What is McRoberts position and what is it used for?
involves flexing the hips by around 60 degrees to open up the pelvis. The episiotomy creates space to allow the internal manoeuvres (internal rotation and removal of posterior arm) to be attempted.
- for shoulder dystocia
PPH - TONE features (4)
- placenta praevia
- over distention of the uterus, multiple pregnancy, polyhydraminos
- uterine relaxants
- previous PPH
PPH - TRAUMA features (3)
CS
Episiotomy
macrosomia >4kg baby
PPH - TISSUE features
retained placenta
placenta accreta
retained products of contraception (RPOC)
PPH - THROMBIN features
pre-eclampsia
placental abruption
pyrexial in labour
bleeding disorders, haemophilla, anticoagulation, vonWillebrand disease
PPH - other causes
Asian ethnicity anemia introduction BMI> 35 prolonged labour age
main risk factors for PPH - examples (5)
Multiple pregnancy previous pph pre-eclampsia fetal macrosomia failure to progress in 2nd stage
what may be discussed for women with higher risk of PPH? (4-5)
benefit of giving birth in hospital with the woman, prophylactic intravenous cannulae insertion during labour, discussing active management of third stage of labour with the woman in advance, possible use of tranexamic acid before or early on in a haemorrhage, and cell salvage use during caesarean section.
Secondary PPH often caused by?
RPOC
Primary PPH caused by
> 500ml blood
Severe Haemorrhage >2000ml (rare 6/1000)
Management of PPH - non medication
Call for help!
ABCDE…
Empty Bladder
Rub up uterine fundus by massaging above the umbilicus
Management of PPH - medication
Oxytocin 5iu slow iv injection
Ergometrine 0.5mg slow iv injection (not if high BP)
Oxytocin infusion
Tranexamic acid 1g IV
Carboprost 0.25mg im (max 8 doses Misoprostol 800 micrograms)
Management of PPH - surgical (6)
Intrauterine Balloon tamponade Interventional Radiology B-Lynch Suture Hysterectomy Manage on clinical signs not just EBL. Fluid Replacement +/- Blood Products
Cord Prolapse - what is it
When the umbilical cord prolapses below the presenting part of the fetus it is highly likely to become compressed and thus reduce oxygen supply to the fetus.
cord prolapse is slightly higher in?
breech presentation
Risk factors for cord prolapse - general
multiparity low birthweight preterm labour congential abnormalties breech
Risk factors for cord prolapse - procedure related (5)
artificial rupture of membrane with high presenting part
vaginal manipulation
stabilising induction of labour
large balloon catheter induction of labour
Cord prolapse management (6)
Replace cord into vagina (not uterus)
Perform digital elevation of the presenting part
Catheterise and fill bladder to elevate presenting part.
Encourage mother to adopt Knee-Chest or left lateral position with raised hips
Consider tocolysis
Arrange for a Category 1 C-Section.
Replacing the cord into the vagina during cord prolapse does what?
reduces the chance of it becoming compressed or of the vessels going into spasm because of the lower temperature outside the body
cord prolapse is still at risk of compression due to?
fetal presenting part being above it.
cord prolapse - maternal position and use of hand
gloved hand into vagina pushes the fetus upward and off the chord
knee-chest = uses gravity to shift fetus out of the pelvis - womans thighs at right angles - chest on the bed
- womens hip elevated with 2 pillows- combined with the Trendelenburgh position
