Shoulder Dystocia, Caesarean section, Antepartum Haemorrhage

Question 1

What is shoulder dystocia?

Answer 1

Difficulty delivery the fetal shoulders following delivery of the fetal head

Question 2

Why does shoulder dystocia occur?

Answer 2

Anterior fetal shoulder generally wedge under maternal symphysis pubis
Bony obstruction

Question 3

What are signs of SD occurring?

Answer 3

• There is difficulty with the birth of the face and chin
• The head is born but remains tightly applied to the vulva
• The chin retracts into the perineum (the turtle sign)
• The anterior shoulder does not birth with normal
downward traction

Question 4

What are fetal complications of SD?

Answer 4

Fractures - clavicle, humerus
Transient/Permanent brachial plexus palsy
Asphyxia / hypoxic ischaemic encephalopathy (0.3%):
- generally from cord compression
Death

Question 5

What are the maternal complications of SD?

Answer 5

Less common
Birth canal trauma
Haemorrhage
Uterine rupture
Psychological impact

Question 6

What are risk factors for shoulder dystocia?

Answer 6

Prior SD
Fetal macrosomia
Maternal DM
Post-term delivery

Question 7

What is the HELPERR?

Answer 7

H - call for help
E - Evaluate for episiotomy
L - Legs - McRoberts maneuver
P - Suprapubic pressure
E - Enter rotational maneuver 
R - Remove posterior arm (Barnum)
R - Roll patient to hands and knee (Gaskin)

Question 8

What are the last resort manoeuvres?

Answer 8

Deliberate cleidotomy:
• Fracture of the fetal clavicle by pulling it outward •

Zavanelli manoeuvre:
• Fetal head is pushed back up inside the vagina/uterus and held there until caesarean is performed

Hysterotomy / transabdominal rotation
• If fetal head cannot be replaced, uterus can be incised and internal attempts made at rotating fetus

Symphysiotomy:
• Extremely morbid; reserved for situations in which recourse to caesarean section is not available

Question 9

What the major intrapartum indications for CS?

Answer 9

Failure to progress

Fetal distress

Question 10

How do you prepare for a CS?

Answer 10

• Review of maternal history, antenatal investigations
• Consent (cf. complications)
- Difficult in the emergency context
• IV access, bloods (group & hold, FBE +/- coags, etc.)
• Communication with OT / anaesthetics / paediatrician
• Positioning the patient
- Supine with left-lateral tilt
• Urinary bladder drainage (IDC)
• Auscultation of fetal heart; confirm fetal presentation
• Antibiotic prophylaxis (ideally pre-incision)

Question 11

When is oxytocic administered?

Answer 11

Vaginal: After shoulder is delivered
CS: After baby is delivered (before placenta)

Question 12

What are complications of caesarean?

Answer 12

• Anaesthetic complications
• Haemorrhage (immediate and after)
  
  • Risks of transfusion of blood products
• Hysterectomy
• Infection (wound, endometritis, urinary, sepsis)
• Deep venous thrombosis / pulmonary embolism
• Damage to adjacent organs (esp. after previous surgery)
• Wound breakdown
• Abnormal placentation in future pregnancy
• Scar rupture in future pregnancy (ante/intrapartum)
• Regret / psychological impact
• Death

Question 13

What is the difference between placenta accreta/encreta/percreta

Answer 13

Depth of infiltration of placenta into the myometrium

Question 14

What is antepartum haemorrhage?

Answer 14

Bleeding from or into genital tract between 20 weeks and labour

Question 15

What causes APH?

Answer 15

Placental abruption
Placenta praevia
Marginal placental bleeding
Local causes: cervical/vaginal/uterine pathology
Uterine rupture (rare)
Vasa praevia (rare)