5.6 Obstetric Emergencies

Question 1

State the 8 Obstetric emergencies

Answer 1

Antepartum:
1) PET/Eclampsia
2) Antepartum Hemorrhage

Intrapartum:
1) Cord Prolapse
2) Uterine Rupture
3) Shoulder Dystocia
4) Acute Uterine Inversion

Post-Partum:
1) PPH - Post-partum haemorrhage
2) Amniotic Fluid embolism

Question 2

Define Cord Prolapse

Answer 2

Obstetric emergencty where cord presents first during delivery associated with severe CTG abnormalities and perinatal asphyxia

Question 3

What are the RF for Cord Prolapse?

Answer 3

Same as breech:
1) Chance
2) Obstruction to outlet (Low lying fibroid, placenta previa, ovarian cyst)
3) Polyhydramnios
4) Multiple pregnancy
5) Uterine anomaly (Mullerian duct anomalies e.g. Bicornuate uterus)
6) Fetal anomaly

Question 4

Why is it important to return the cord back into vaginal during cord prolapse?

Answer 4

While we are transferring the mother to theatre for delivery, exposure of the umbilical cord to the cold may cause vasopasm and perinatal asphyxia. This will prevent that

Question 5

What is the role of tocolytics in cord prolapse?

Answer 5

It can reverse the induction

Question 6

Why is the bladder filled with 500ml saline in the management of cord prolapse?

Answer 6

To relieve pressure on the cord and prevent perinatal asphyxia

Question 7

In the management of cord prolapse, it is important to ensure if the foetus is still alive. In the case that it is, how would you manage Cord prolapse

Answer 7

It is an obstetric emergency -> call for help for IV cannulation, group and crossmatch..

If ruptured membrane 2 options:
1) Instrumental delivery if meets criteria (fully dilated, longitudinal lie, station 0/1, cephalic presentation, no foetal distress)
2) Otherwise go with Emergency C-section as below

If membrane Intact: Emergency C-section with goal of relieving pressure on cord:
a) Put cord back in to prevent vasospasm
b) Tocolytics + stop any induction (e.g. remove pessary-PGE2)
c) Fill bladder with 500 ml saline
d) Position the patient in trendelenberg position or in all 4 position.

Question 8

What are the top 3 RF of uterine rupture?

Answer 8

1) Previous uterine surgery e.g. myomectomy, C-section, any laparoscopic/laparotomy involving uterus
2) Hyperstimulation from induction agents (oxytocin, prostaglandin)

Question 9

Why is the foetus not palpable on vaginal exam in intrapartum uterine rupture?

Answer 9

No presenting part on VE why? Foetus palpated in abdomen (no longer in uterus)

Question 10

Uterine rupture is a cause of Antepartum haemorrhage as well as intrapartum. What is the presentation of Uterine rupture?

Answer 10

Abdominal pain
Vaginal bleeding
No presenting part on VE/Foetus palpated in abdomen why? (no longer in uterus)
Foetal distress on CTG

Question 11

How would you manage Uterine rupture (in any case)

Answer 11

Emergency => Call for help, ABCDE, cannulation, crossmatch 4 units of blood.
!!Emergency Laparotomy to deliver the baby

Question 12

Define Shoulder dystocia

Answer 12

Impaction of the anterior shoulder against the maternal symphysis pubis

Question 13

How does shoulder dystocia present?

Answer 13

Turtle’s sign where the head delivers yet the shoulder fails to deliver as the anterior shoulder is stuck behind the symphysis pubis

Question 14

Inappropriate downward traction application after Turtle’s sign will cause Erb’s palsy
What nerve roots are affected in Erb’s palsy?
What type of traction should instead be implemented after delivery of the head?

Answer 14

Nerve roots C5,C6

Cautious Axial traction = traction at the level of the spine

Question 15

During delivery, the head has been delivered. You perform cautious axial traction to support the mother yet the head returns to its place. State all the steps you will perform.

Answer 15

1) Call for help
2) Mcrobert’s manoeuvre
3) Suprapubic pressure
4) Pringle manoeuvre
5) Wood’s Screw Manoeuvre
6) Evaluate for Episiotomy
7) Gaskin position
8) Methods of last resort
a) Clavicular fracture
b) Zavanelli manouvre
c) Symphysiotomy

Question 16

Explain Mcrobert’s maneuver
How would you confirm that it is done properly?

Answer 16

Full hip flexion of both legs which would tilt the pelvis backwards (originally tilted forward) and is confirmed by having the bottom off the bed

Question 17

What is the aim of suprapubic pressure?

Answer 17

In CPR position, this will push the shoulder and dislodge it from the pubic symphysis + rotates slightly

Question 18

Explain the Pringle Manoeuvre

Answer 18

Internal maneuver Hands like youre going into a pringle can and insert at the base (6oclock) with the aim of delivering the posterior arm to gain more space

Question 19

Explain Wood’s Screw maneuver

Answer 19

Internal Maneuver whereby the one hand is at the back of the anterior shoulder and the other at the front of the posterior shoulder. The physician will then rotate. This is done in conjunction with suprapubic pressure in the same direction

Question 20

What is Gaskin position?

Answer 20

All 4s

Question 21

What are the methods of last resort when all has failed

Answer 21

1) Clavicular fracture
2) Zavanelli maneuver
3) Symphysiotomy

Question 22

Explain Zavanelli maneuver

Answer 22

This is where the head is returned back and emergency C-section delivery is performed

Question 23

Are the majority of shoulder dystocia caused by LGA?

Answer 23

50% occur in normal weight babies and 50% in LGA

Question 24

Give 6 RFs for Shoulder Dystocia

Answer 24

1) Macrosomia + hx of big baby
2) GDM
3) Post-dates
4) Maternal obesity
5) Extremes of age
6) Pelvic anomalies
7) Hx of prior shoulder dystocia
8) Prolonged 1st or 2nd stage of labour
9) Chromosomal abnormalities/short stature

Question 25

What are the complications of Shoulder Dystocia (5)

Answer 25

Maternal: Use of operative delivery => Perineal injury PPH (trauma and Atony) Foetal: Brachial plexus injury (Erb's palsy) Perinatal asphyxia -> Hypoxic-ischemic injury Fracture of the clavicle/humerus Perinatal mortality (death)

Question 26

What is acute uterine inversion? What is observed on inspection? What is it associated with? How is it managed?

Answer 26

Inversion of the uterus such that it protrudes from the vagina Bluish-grey mass protruding from the vagina Associated with Fundal placenta Placenta is often still attached after delivery and it should be left in place until after reduction (which should be done quickly). Here you should carefully hold the fundus while pushing it back, cupping it. Then have a fist formation until it is reduced back to its original position. Inductive agents are then administered to deliver the placenta

Question 27

What are the normal amount of blood loss during delivery?

Answer 27

SVD <500ml C-section <1000ml

Question 28

Define Post-partum haemorrhage

Answer 28

Blood loss after delivery that exceeds 500ml for SVD and 1000ml for C-section

Question 29

What is considered a major haemorrhage? What is considered a massive haemorrhage?

Answer 29

Major 1000-2,500ml Massive >2,500ml or 5 units of transfusion

Question 30

State the causes of Post-partum haemorrhage

Answer 30

1) aTonic uterus (70%) 2) Trauma (20%) such as tears, lacerations (from operative delivery), uterine rupture (induction, previous C-section), and hematoma (from C-section) 3) retained Tissue (9%) such as placenta accreta, increta, and percreta 4) Thrombin (1%) from coagulopathies Use these to come up with RFs

Question 31

Give 5 Rfs for Atony in PPH?

Answer 31

a) Overdistension => Macrosomia, Polyhydramnios, and Multiple pregnancy b) Prolonged labour => nulliparity, can be compounded with maternal exhaustion c) High parity d) Chorioamnionitis

Question 32

State 8 RF for post-partum haemorrhage

Answer 32

1) Pre-eclampsia 2) Nulliparity (prolonged labour) 3) Overdistension (Macrosomia, Polyhydramnios, and Multiple pregnancy) 4) Previous PPH 5) Previous C-section 6) Prolonged 2nd stage labour 7) Episiotomy 8) Lacerations/trauma/tears 9) Operative delivery 10) Induction of labour (hyperstimulation)

Question 33

How would you diagnose post-partum haemorrhage?

Answer 33

1) Evidence of significant blood loss that exceeds 500ml for SVD and 1000ml for C-section (note that in C-section this can be concealed) 2) Signs of shock (tachycardia, tachypnea, pallor, lightheadedness, confusion, unexplained acidosis, reduced urine output)

Question 34

During 3rd stage of delivery, how do you know when the placenta has been detached?

Answer 34

1) Gush of blood 2) Globular uterine fundus on palpation 3) Lengthening of the cord

Question 35

What is the typical management of the 3rd stage of delivery?

Answer 35

1) Delivery of the placenta => IM 10 IU Syntocinon 2) Massage the fundus (check for globular fundus) 3) Controlled cord traction

Question 36

How would you know that the cause of a hemorrhage is due to atony

Answer 36

Atony means that the uterus is lacking tone and hence isnt contracting as it should => High fundus/uterus that is soft on palpation!!!!!

Question 37

What is the importance of massaging the fundus during 3rd stage of delivery?

Answer 37

To induce contractions and prevent atony

Question 38

How do you perform rubup contractions?

Answer 38

Bimanual rub with one hand on fundus and other on uterus (to excite it)

Question 39

What is the full management of Post-partum hemorrhage

Answer 39

This is performed in a manner to prevent Atony which is the most likely cause At this stage you have given the IM 10 IU Syntocinon. Identify that hemorrhage is occurring 1) Resuscutation: Lie mother flat, perform ABCDE giving oxygen, 2x large bore cannulas, administer hartmann's, cross match blood ready for transfusion, insert urinary catheter 2) Identify cause: Atony => High uterus soft on palpation This is assumed therefore management begins with the prevention of atony while the others are being ruled out Trauma => Check for cuts or lacerations Retained tissue => check placenta for any missing cotyledons Coagulopathy => Full coag screen when taking bloods before administering fluids 3) Prevent Atonic Uterus 1) With urinary catheter in situ to drain bladder, rub up contractions bimanually 2) IM 5 IU syntocinon 3) IV 40 IU Syntocinon infused in 500ml saline at a rate of 125ml/hour 4) IM 250mcg Ergometrine 5) PR 1mg Misoprostol 6) IM 250mg Carboprost 7) IV 1g tranexamic acid If this does not work, a !Balloon tamponade is inserted while the patient is transported to theatre 1) Iliac or uterine artery embolization by interventional radiology 2) B-lynch suture 3) Hysterectomy

Question 40

What is a B-lynch suture?

Answer 40

Compressive sutures to stop bleeding in PPH

Question 41

Define Amniotic fluid embolism Give 5 RF What clinical features will they have

Answer 41

Bolus of amniotic fluid that enters maternal pulmonary circulation leading to a massive perfusion failure => shock => Sudden collapse, dyspnea, cyanosis, fetal distress, hypotension, !profound DIC, coma, seizures, neurological signs RF: Precipitated by labour !!ECV !! Amniocentesis Abdominal trauma TOP (termination of pregnancy) Intrauterine death