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Yr4: Obstetrics & Gynaecology > Obstetrics: Labour & Delivery Emergencies > Flashcards

Obstetrics: Labour & Delivery Emergencies Flashcards

1
Q

State some obstetric emergencies during labour & delivery

A
  • Shoulder dystocia
  • Umbilical cord prolapse
  • Amniotic fluid embolism
  • Maternal sepsis
  • Uterine rupture
  • Uterine inversion
  • Post-partum haemorrhage
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2
Q

What is shoulder dystocia?

A

Impaction of anterior fetal shoulder behind pubic symphysis of mother’s pelvis after head has been delivered

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3
Q

State some risk factors for shoulder dystocia

A
  • Previous shoulder dystocia
  • Fetal macrosomia/>4.5kg (hence association with maternal diabetes mellitus)
  • Maternal BMI >30/high maternal BMI
  • Diabetes mellitus
  • Prolonged labour
  • Assisted vaginal delivery
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4
Q

How does shoulder dystocia present?

A
  • Difficult delivering face and head
  • Obstruction of shoulders after delivery of head
  • Failure of restitution (head remains occipto-anterior)
  • Turtle neck sign (head is delivered but then retracts back into vagina)
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5
Q

Discuss the management options for shoulder dystocia

A

Managed by experienced midwives & obstetricians:

  • Escalate & call for help (senior staff, paediatrician, anaesthetist)
  • Advise mother to stop pushing
  • Avoid downwards traction on head, only use axial traction (keeping head in line with spine)
  • Consider episiotomy (doesn’t relieve obstruction but makes access for manoeuvres easier)
  • First line manoeuvres:
    • McRoberts manoeuvre: hyperflexion of mothers hip (bring knees to chest) to provide posterior pelvic tilt to help move pubis symphysis out of the way. Often combined with suprapubic pressure.
    • Suprapubic pressure: pressure in suprapubic region to apply pressure behind/on posterior aspect of anterior shoulder to disimpaction it
  • Second line manoeuvres:
    • Rubin’s & wood’s screw/corkscrew manoeuvre: put pressure on posterior aspect of baby’s anterior shoulder to help move it under pubic symphysis (Rubin’s manoeuvre). Then use other hand to put pressure of anterior aspect of posterior shoulder and push top shoulder forwards and bottom shoulders backwards, rotating the baby to help delivery. Can try reverse motion also
    • Posterior arm: insert hand into sacral hollow and grasp posterior arm to delivery
  • Third line (RARELY USED):
    • Zavenelli: pushing baby’s head back into vagina so can be delivered by emergency caesarean
    • Symphysiotomy: cutting pubic symphysis
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6
Q

State some potential maternal complications of shoulder dystocia

State some potential fetal complications of shoulder dystocia

A

Maternal

  • Perineal tears
  • Post-partum haemorrhage
  • Psychological trauma

Fetal/baby

  • Brachial plexus injury (Erb’s palsy)
  • Fracture (humerus or clavicle)
  • Hypoxic brain injury → cerebral palsy
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7
Q

Discuss some important aspects of management following shoulder dystocia

A
  • Explanation/debrief with parents
  • Assess for perineal tears (do PR to exclude 3rd degree perineal tear)
  • Paediatric review for baby
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8
Q

What is umbilical cord prolapse? Describe the 2 types

A

Umbilical cord prolapse is where the umbilical cord descends through the cervix, with (or before) the presenting part of the fetus. It affects 0.1 – 0.6% of births.

Cord prolapse occurs in the presence of ruptured membranes, and is either occult or overt:

  • Occult (incomplete) cord prolapse – the umbilical cord descends alongside the presenting part, but not beyond it.
  • Overt (complete) cord prolapse – the umbilical cord descends past the presenting part and is lower than the presenting part in the pelvis.

**NOTE: cord presentation – the presence of the umbilical cord between the presenting part and the cervix. This can occur with or without intact membranes.

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9
Q

Umbilical cord prolapse can cause fetal hypoxia in two ways; describe these

A
  • Occlusion – the presenting part of the fetus presses onto the umbilical cord, occluding blood flow to the fetus
  • Arterial vasospasm – the exposure of the umbilical cord to the cold atmosphere results in umbilical arterial vasospasm, reducing blood flow to the fetus
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10
Q

State some risk factors for umbilical cord prolapse

A
  • Abnormal presentation or lie (e.g. breech, transverse lie)
  • Prematurity
  • Artificial rupture of membranes (~50% occur following this)
  • Polyhydramnios
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11
Q

How is umbilical cord prolapse diagnosed?

A
  • Signs of fetal distress on CTG
  • Can diagnose via vaginal examination
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12
Q

Discuss the management of umbilical cord prolapse

A
  • Delivery via quickest method:
    • Emergency caesarean
    • However, if fully dilated & vaginal delivery appears imminent then consider vaginal delivery +/- instrumental delivery
  • Cord management:
    • Pushing back in is not recommended
    • Keep cord warm & wet
    • Minimal handling (handling causes vasospasm)
    • Presenting part of fetus can be pushed back in to avoid compression
    • Lift presenting part off the cord by vaginal digital examination
    • Alternatively, can fill bladder with 500ml of saline and this can help to elevate presenting part
  • Alter woman’s position to try and move fetus away from pelvis to reduce pressure on cord:
    • Knee to chest position/all fours
    • Left lateral position is alternative
  • Tocolysis with terbutaline may be used to minimise contractions
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13
Q

What is amniotic fluid embolism?

A

Rare complication, that usually occurs around labour and delivery, in which amniotic fluid passes into mothers blood.

Amniotic fluid contains fetal tissue and it is believed this causes a maternal immune reaction leading to systemic illness

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14
Q

State some risk factors for amniotic fluid embolism

A
  • Increasing maternal age
  • Induction of labour
  • Caesarean section
  • Multiple pregnancy

*NOTE: many risk factors been associated but no clear cause proven

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15
Q

Describe presentation of amniotic fluid embolism

A

Most commonly presents around labour & delivery but can present post-partum. Can present similar to sepsis, PE, anaphylaxis with acute onset of:

  • Shortness of breath
  • Hypoxia
  • Hypotension
  • Coagulopathy e.g. DIC
  • Haemorrhage
  • Tachycardia
  • Confusion
  • Seizures
  • Cardiac arrest
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16
Q

Discuss the management of amniotic fluid embolism

A
  • Escalate/call for help (obstetricians, anaesthetist, intensive care, haematologists etc..)
  • A-E approach
    • A – Airway: Secure the airway
    • B – Breathing: Provide oxygen for hypoxia
    • C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage
    • D – Disability: Treat seizures and consider other neurological deficits
    • E – Exposure
  • If go into cardiac arrest, CPR and immediate caesarean section required (see cardiac arrest in pregnancy FC)
  • Management is mostly supportive- often require ICU
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17
Q

How is amniotic fluid embolism diagnosed?

A

Can only make definitive diagnosis post-mortem

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18
Q

Amniotic fluid embolism has high mortality; true or false?

A

True

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19
Q

Is uterine rupture dangerous?

A

YES, has high morbidity and mortality for mother & baby

20
Q

What is uterine rupture?

Describe the 2 main types

A

Rare complication of labour in which myometrium ruptures. Two types:

  • Incomplete: serosa of uterus is intact hence uterine contents remain within uterus
  • Complete: serosa of uterus ruptures along with myometrium hence contents of uterus are released into peritoneal cavity
21
Q

State some risk factors for uterine rupture- highlight the main one

A
  • Previous caesarean section (scar= weakness)
  • Previous uterine surgery
  • High BMI
  • High parity
  • Increased age
  • Induction of labour
  • Use of oxytocin to stimulate uterine contractions
22
Q

Describe the presentation of uterine rupture

A

Acute onset of:

  • Severe abdominal pain that persists between contractions
  • Shoulder tip pain
  • Vaginal bleeding
  • Cessation of uterine contractions
  • Hypotension
  • Tachycardia
  • Abnormal CTG/evidence of fetal distress
23
Q

Discuss the management of uterine rupture

A
  • Escalate/call for help (obstetricians, anaesthetists, paediatricians)
  • A-E approach (transfusion & resuscitation may be required)
  • Emergency caesarean section
  • Surgical repair of uterus or hysterectomy
24
Q

What is uterine inversion?

Describe the two types

A
  • Rare complication of delivery in which fundus of uterus drops down through uterine cavity and cervix turning uterus inside out
  • Two types:
    • Incomplete/partial uterine inversion: fundus descends inside uterus or vagina but not as far as introitus
    • Complete uterine inversion: uterus descends through the vagina to the introitus
25
Q

State a potential cause of uterine inversion

A

May occur as a result of pulling too hard on umbilical cord in active management of 3rd stage of labour

26
Q

Describe presentation of uterine inversion

A
  • Typically presents with large PPH (may have maternal shock or collapse)
  • In complete inversion may see uterus at introitus of vagina
  • In incomplete/partial may feel uterus during manual vaginal examination
27
Q

Discuss the management of uterine inversion

A

Treatment to correct uterine inversion

  • First line= Johnson manoeuvre
    • Use hand to push fundus back up into correct position- whole hand and most of forearm will end up inserted into vagina. Hold in place for several minutes and give medications e.g. oxytocin to cause uterine contractions as you need ligaments & uterus to generate enough tension to stay in place
  • Second line= hydrostatic methods
    • Fill vagina with fluid to ‘inflate’ uterus back to normal position. Requires tight seat at vaginal entrance which can be difficult
  • Third line= surgery
    • Laparotomy to return uterus to normal position

Treatment to manage complications

  • Management of PPH
  • Transfusions
  • Resuscitation
28
Q

State 2 key causes of maternal sepsis

A
  • Chorioamnionitis
  • Urinary tract infections
29
Q

What is chorioamnionitis?

What are the risk factors? Highlight main one

A
  • Infection of the chorioamniotic membranes and amniotic fluid. Usually occurs in later pregnancy & labour
  • Risk factors:
    • Premature rupture of membranes (including P-PROM)
    • prolonged membrane rupture
    • prolonged labour
    • infection (group B streptococcus colonisation; bacterial vaginosis)
30
Q

What monitoring (like NEWS-2) is used in pregnant women?

A

MEOWS (maternity early obstetric warning system)

31
Q

Describe presentation of maternal sepsis

A
  • Fever
  • Tachycardia
  • Raised respiratory rate (often an early sign)
  • Reduced oxygen saturations
  • Hypotension
  • Altered consciousness
  • Reduced urine output
  • Raised white blood cells on a full blood count
  • Evidence of fetal compromise on a CTG
32
Q

What additional symptoms & signs, alongside those of sepsis, would make you think chorioamnionitis is cause of maternal sepsis?

What additional symptoms & signs, alongside those of sepsis, would make you think UTI is cause of maternal sepsis?

A

Chorioamnionitis

  • Abdominal pain
  • Uterine tenderness
  • Vaginal discharge

UTI

  • Dysuria
  • Urinary frequency
  • Suprapubic pain or discomfort
  • Renal angle pain (with pyelonephritis)
  • Vomiting (with pyelonephritis)
33
Q

What investigations are required if you suspect maternal sepsis?

A

Arrange blood tests for patients with suspected sepsis:

  • FBC: assess cell count including white cells and neutrophils
  • U&Es: assess kidney function and for acute kidney injury
  • LFTs: assess liver function and as a possible source of infection (e.g. acute cholecystitis)
  • CRP: assess inflammation
  • Clotting: assess for disseminated intravascular coagulopathy (DIC)
  • Blood cultures: assess for bacteraemia
  • Blood gas: assess lactate, pH and glucose

Additional investigations can be helpful based on the suspected source of infection:

  • Urine dipstick and culture
  • High vaginal swab
  • Throat swab
  • Sputum culture
  • Wound swab after procedures
  • Lumbar puncture for meningitis or encephalitis
34
Q

Discuss the management of maternal sepsis

A
  • Escalate/call for help (obstetrician, midwives, paediatricians)
  • Sepsis 6
    • Give 3: empirical broad spec abx, oxygen, fluids
    • Take 3: blood culture, lactate, monitor urine output
  • Continuous maternal & fetal monitoring
  • May need emergency caesarean section (with GA- avoid spinal in sepsis)
35
Q

What bleeding is normal after birth?

A
36
Q

What do we mean by post-partum haemorrhage (PPH)?

Define:

  • Primary PPH- minor and major
  • Secondary PPH
A

PPH is bleeding after delivery of baby & placenta

  • Primary PPH= loss of ≥500ml of blood from the genital tract within 24 hours of the birth
    • Minor: 500ml-1000ml
    • Major: >1000ml
  • Secondary PPH= abnormal or heavy vaginal bleeding between 24 hours and 12 weeks after the birth
37
Q

What is classed as excess blood loss in caesarean section?

A

>1000ml (CHECK)!!!

38
Q

State some risk factors for primary PPH

A
  • Maternal characteristics
    • Previous PPH
    • BMI>35
  • Uterine over-distension
    • Multiple pregnancy
    • Fetal macrosomia
    • Polyhydramnios
  • Labour
    • Failure to progress
    • Prolonged
    • Induction
  • Placental problems
    • Pre-eclampsia
    • Placenta accreta
    • Retained placenta
39
Q

Causes of primary PPH can be remembered by the 4T’s; state these highlighting the most common cause

A
  • Tone (uterine atony) **MOST COMMON
  • Tissue (retained placenta) **SECOND MOST COMMON
  • Trauma (e.g. perineal tear, caesarean section, episiotomy)
  • Thrombin (coagulopathies or vascular abnormalities)
40
Q

State some preventative measures against PPH

A
  • Treating anaemia during the antenatal period
  • Giving birth with an empty bladder (a full bladder reduces uterine contraction)
  • Active management of the third stage (with intramuscular oxytocin in the third stage)
  • Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patient
41
Q

Management of primary post-partum haemorrhage- categorise your answer into:

  • Immediate management to stabiles pt
  • Treatment to stop bleeding

NOTE: massive secondary PPH would be managed similarly but see separate management for most common management of secondary PPH

A

Immediate Management to Stabilise

  • Activate major haemorrhage protocol
  • A-E approach
    • Oxygen (regardless of sats)
    • Insert two wide bore (14G) cannulas
    • Lie flat
    • Bloods: FBC, U&Es, LFTs, clotting screen, G&S, crossmatch 4-6 units
    • Warmed IV fluids
    • Additional blood products e.g. FFP

Treatment to stop bleeding

  • Mechanical
    • ‘Rubbing up the fundus’ rubbing uterus through abdomen to stimulate uterine contraction
    • Catheterisation to empty bladder as bladder distention prevents uterus contractions
  • Medical/pharmacological
    • Oxytocin: slow injection, followed by continuous infusion)
    • Ergometrine: IV or IM. Stimulates smooth muscle contractions
    • Carboprost: IM. Prostaglandin analogue that stimulates uterine contractions
    • Misoprostol: sublingual. Prostaglandin analogue that stimulates uterine contractions
    • Tranexamic acid: IV. Antifibrinolytic that reduces bleeding
  • Surgical
    • Intrauterine balloon tamponade (FIRST LINE SURGICAL): inflatable balloon in uterus to press against bleeding
    • B-Lynch suture: put suture around uterus to compress it
    • Uterine artery ligation: ligate 1 or more of arteries to reduce blood flow
    • Hysterectomy: last resort
42
Q

What are the 2 most likely causes of secondary postpartum haemorrhage?

A
  • Retained products of conception (RPOC)
  • Endometritis (uterine infection)

*Abnormal involution of placenta site (**inadequate closure and sloughing of the spiral arteries at the placental attachment site) is another potential cause

43
Q

How may secondary PPH present?

A
  • Not usually as severe as primary PPH
  • May complain of on-and-off spotting with occasional gush of fresh blood
  • May have features of underlying cause (e.g. if endometritis may have fever, lower abdo pain, foul smelling lochia)
44
Q

What investigations are required for secondary postpartum haemorrhage?

A
  • Endocervical & high vaginal swabs for infection
  • Bloods (FBC, U&E, LFT, CRP, blood culture if pyrexic, coagulation, G&S)
  • Ultrasound: assess for retained products of conception
45
Q

Discuss the management for secondary PPH (not a major haemorrhage)

A

Depends on cause but mainstay of management is with:

  • Antibiotics
  • Medications to cause uterine contractions (e.g. oxytocin, ergometrine, carboprost, misoprostol)

May require surgical intervention if excessive or continuing bleeding

Yr4: Obstetrics & Gynaecology (24 decks)

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