Shoulder Dystocia, APH and LUSCS Flashcards
What is shoulder dystocia? What is the mechanical problem?
- Difficulty delivering the foetal shoulders following delivery of the head. Anterior shoulder stuck behind symphysis
- Foetal bisacromial diameter is too wide for the AP diameter of the pelvis - bony obstruction
- Only occurs in cephalic vaginal births
What are some of the potential complications of shoulder dystocia?
- Bone fracture, transient or permanent brachial plexus palsy, asphyxia, death
List some risk factors for shoulder dystocia
- Foetal macrosomia, previous shoulder dystocia, maternal DM with baby over 2.5kg, post-term, male, maternal obesity, prolonged/augmented labour
What are some signs in labour of shoulder dystocia
- Difficulty with birth of face and chin
- Head is born but stayed tightly applied to vulva
- Chin retracts into perineum (turtle sign)
- Anterior shoulder does not birth with normal downward traction
Describe the emergency management of shoulder dystocia
- H - help
- E - evaluate for episiotomy
- L - legs - McRoberts manouvre
- P - suprapubic pressure
- E - enter - rotational manouvres (Rubin)
- Try to decrease bisacromial diameter or rotate foetus into oblique plane
- R - remove the posterior arm
- R - roll the patient to her hands and knees
- Opens pelvis in AP plane
What is the McRoberts manouvre? When is it used?
- Abduct and hyperflex thighs, apply gentle downward traction (allows pelvic rotation, releases shoulder)
- Used during shoulder dystocia
Describe some indications for caesarean section
- Maternal
- Ante-partum - 2+ previous CS, uterine surgery, pelvic anomaly, prior shoulder dystocia etc. medical conditions e.g. cardiac disease, obstetric complications e.g. pre-eclampsia
- Intra-partum - failure to progress, unsuccessful instrumental delivery or induction
- Request
- Foetal
- Ante-partum - foetal anomalies, macrosomia, malpresentation, APH/abruption, severe IUGR, twins (if growth discordant or one not cephalic) or twins+, abnormal placentation
- Intra-partum - foetal distress, cord prolapse, uterine rupture
List some complications of a caesarean section
- Anaesthetics, haemorrhage, hysterectomy, infection, DVT/PE, damage to adjacent organs, wound breakdown, abnormal placentation in later pregnancy, scar rupture in future pregnancy, psychological impact, death
What are the requirements for a vaginal birth after Caesarean section? What are the main risks?
- Requirements
- Only 1 previous LUSCS
- Singleton, cephalic foetus
- Continuous monitoring
- Immediate theatre access
- Risk
- Uterine rupture (raised if labour induced or augmented)
What is antepartum haemorrhage? Give a differential
- Bleeding from the genital tract after 20 weeks
- Placenta praevia, abruption, vasa praevia, unclassified
What are the risk factors for placenta praevia? What are the likely history/examination findings?
- RFs - age, parity, smoking, previous praevia, previous CS
- Hx - unprovoked, painless bleeding (most at 32-34 weeks)
- Ex - high presenting part, malpresentation
How is placenta praevia diagnosed? What is it really important not to do before this in the setting of APH?
- Ultrasound
- Vaginal examination
What are the risk factors for placental abruption? The history/examination findings?
- RFs - maternal hypertension, blunt trauma, previous history, age, multiparity, smoking
- Hx - sudden onset abdominal pain (back if posterior), PV bleeding
- Ex - tachycardia, uterine tenderness, board-like abdomen, non-reassuring CTG. No VE until placental location established
Describe the general management of placenta praevia and placental abruption
- ABCDE
- IV access, bloods (FBE, UEC, G+H with crossmatch, coags) Kleihauer +/- anti-D
- Consider APTT, fibrinogen, FDP, platelets for DIC in abruption
- Holding pattern management (continuous CTG, steroids) until term if possible, else delivery
