Obstetrics emergencies

Question 1

When does shoulder dystocia occur?

Answer 1

the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after delivery of the fetal head

Question 2

What can drop during the manoeuvres manangement for shoulder dystocia?

Answer 2

fetal oxygen levels

Question 3

when would shoulder dystocia occur?

Answer 3

between complete extension and restitution (external rotation)

Question 4

Dangers of shoulder dystocia (4)

Answer 4

umbilical cord entrapment
inability of childs chest to expand properly
severe brain damage or death due to hypoxia or acidosis
- brachial plexus damage

Question 5

What is intrauterine pressure caused by?

Answer 5

maternal contractions

- the anterior shoulder is impacted on the pubic symphysis

Question 6

Management of Shoulder Dystocia

Answer 6

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)

Question 7

What is McRoberts position and what is it used for?

Answer 7

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

Question 8

PPH - TONE features (4)

Answer 8

• placenta praevia
• over distention of the uterus, multiple pregnancy, polyhydraminos
• uterine relaxants
• previous PPH

Question 9

PPH - TRAUMA features (3)

Answer 9

CS
Episiotomy
macrosomia >4kg baby

Question 10

PPH - TISSUE features

Answer 10

retained placenta
placenta accreta
retained products of contraception (RPOC)

Question 11

PPH - THROMBIN features

Answer 11

pre-eclampsia
placental abruption
pyrexial in labour
bleeding disorders, haemophilla, anticoagulation, vonWillebrand disease

Question 12

PPH - other causes

Answer 12

Asian ethnicity 
anemia
introduction 
BMI> 35
prolonged labour
age

Question 13

main risk factors for PPH - examples (5)

Answer 13

Multiple pregnancy
previous pph
pre-eclampsia
fetal macrosomia
failure to progress in 2nd stage

Question 14

what may be discussed for women with higher risk of PPH? (4-5)

Answer 14

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.

Question 15

Secondary PPH often caused by?

Answer 15

RPOC

Question 16

Primary PPH caused by

Answer 16

> 500ml blood

Severe Haemorrhage >2000ml (rare 6/1000)

Question 17

Management of PPH - non medication

Answer 17

Call for help!
ABCDE…
Empty Bladder
Rub up uterine fundus by massaging above the umbilicus

Question 18

Management of PPH - medication

Answer 18

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)

Question 19

Management of PPH - surgical (6)

Answer 19

Intrauterine Balloon tamponade
Interventional Radiology
B-Lynch Suture
Hysterectomy
Manage on clinical signs not just EBL.
Fluid Replacement +/- Blood Products

Question 20

Cord Prolapse - what is it

Answer 20

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.

Question 21

cord prolapse is slightly higher in?

Answer 21

breech presentation

Question 22

Risk factors for cord prolapse - general

Answer 22

multiparity 
low birthweight
preterm labour
congential abnormalties
breech

Question 23

Risk factors for cord prolapse - procedure related (5)

Answer 23

artificial rupture of membrane with high presenting part
vaginal manipulation
stabilising induction of labour
large balloon catheter induction of labour

Question 24

Cord prolapse management (6)

Answer 24

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.

Question 25

Replacing the cord into the vagina during cord prolapse does what?

Answer 25

reduces the chance of it becoming compressed or of the vessels going into spasm because of the lower temperature outside the body

Question 26

cord prolapse is still at risk of compression due to?

Answer 26

fetal presenting part being above it.

Question 27

cord prolapse - maternal position and use of hand

Answer 27

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