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Flashcards in Intra/post - Obstetric emergencies Deck (33):
1

what is shoulder dystocia

specific case of obstructed labour - after delivery of the head, the anterior shoulder cannot pass below the pubic symphysis

2

how can shoulder dystocia be diagnosed

clinical diagnosis - when the shoulders fail to emerge after the head

turtle sign - appearance and retraction of the fetal head (like a turtle going back into its shell)

red puffy face of baby - facial flushing

3

what risk factors predispose to shoulder dystocia

Age >35

Short in stature

Small or abnormal pelvis

More than 42 weeks gestation

Estimated fetal weight > 4500g

Maternal diabetes (2-4 fold increase in risk)

4

what are factors than can increase risk/ are warning signs for shoulder dystocia

Need for oxytocics

Prolonged first or second stage of labour

Turtle sign (head bobbing in the second stage)

Failure to restitute

No shoulder rotation or descent

Instrumental delivery

5

is there a risk of recurrence of shoulder dystocia

yes - if shoulder dystocia present in a previous delivery the risk is 10% higher than general population (~0.3-1%)

6

what are dangers of shoulder dystocia to the child

umbilical cord entanglement

inability of chest to properly expand

severe brain damage due to hypoxia or acidosis if delayed delivery

brachial plexus damage

7

what are complications of shoulder dystocia to the mother

post partum haemorrhage

Vaginal lacerations and 3rd/4th degree tears - extended episiotomies

Uterine rupture

8

what is the management of shoulder dystocia

remember HELPERR

H - call for help
E - evaluate for episiotomy
L - legs (McRoberts position)
P - suprapubic pressure (Rubin 1)
E - enter manoeuvres (internal rotation)
R - remove the posterior arm
R - roll the patient onto all fours

9

what is the McRoberts position

involves hyper flexing the mothers legs tightly to her abdomen

this widens the pelvis and flattens the spine in the lower back

10

what is Rubin I

Suprapubic pressure applied whilst in McRoberts position - gently pull on babied head whilst applying pressure

11

what are the three manoeuvres that follow after Rubin I

1. Wood screw
2. Jacquemiers/Barnums
3. Gaskins

12

what occurs in the wood screw manoeuvre

the anterior shoulder is pushed towards the baby's chest - the posterior shoulder is pushed towards the baby's back

13

what occurs in Jacquemiers/Barnums manoeuvre

delivery of the posterior shoulder first - the forearm and hand are identified in the birth canal, and gently pulled

14

what occurs in Gaskins manoeuvre

moving the mother to an all fours position with the back arched - widens the pelvic outlet

15

what are the 5 groups of causes of post part haemorrhage

thrombin
tissue
tone
trauma
other

16

give examples of thrombin causes of PPH

pre-eclampsia

placental abruption

pyrexia in labour

bleeding disorders

17

give examples of tissue causes of PPH

retained placenta

placenta accreta

retained products of the conception (RPOC)

18

give examples of tone causes of PPH

placenta praevia (placenta grows in the lowest part of the womb)

over distension of the uterus (multiple pregnancy, polyhydramnios, macrosomia)

uterine relaxants

previous PPH

19

give examples of trauma causes of PPH

c-section

episiotomy

macrosomia (>4kg baby)

20

give examples of other causes of PPH

asian ethnicity

anaemia

induction

BMI >35

prolonged labour

age

21

what are the types of PPH

primary (account for 99%) and secondary

22

define a primary PPH

haemorrhage in the first 24hrs after delivery - from loss of >500ml blood (common 1/20) to severe haemorrhage >2000ml (rare 6/1000)

23

define a secondary PPH

occurs >24hrs and up to 6 weeks post delivery

24

what often causes a secondary PPH

RPOC - retained product of conception

25

what is the initial management of PPH

call for help
ABCDE
empty bladder
rub up fundus
drugs

26

what are the drugs used in the management of PPH

Oxytocin 5iu slow iv injection

Ergometrine 0.5mg slow iv injection (not in HTN)

Oxytocin infusion

Carboprost 0.25mg im (max 8 doses

Misoprostol 800 micrograms

27

what is the secondary management of PPH

surgical
- intrauterine balloon tamponade
- B-Lynch suture
- hysterectomy

manage on clinic signs not just estimated blood loss (EBL)

fluid replacement +/- blood products

28

what is cord prolapse

descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of a ruptured membrane

29

what is the incidence of cord prolapse

normal presentation - 0.1-0.6%

breech presentation - >1%

30

what are some general risk factors for cord prolapse

multiparity
preterm labour
low birthweight
fetal congenital abnormalites
breech
transverse, oblique on unstable lie
second twin
polyhydramnios
unenaged presenting part
low lying placenta

31

what are some procedure related risk factors for cord prolapse

artificial rupture of membranes with high presenting part
vaginal manipulation of the foetus with ruptures membranes
external cephalic version (turning breech baby around)
internal podalic version (turning baby so feet sticking out)
stabilising induction of labour
insertion of intrauterine pressure transducer
large balloon catheter induction of labour

32

what is the management of cord prolapse

call for help!
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

33

if initial management of cord prolapse is unsuccessful what are the next steps

consider tocolysis

arrange for a category 1 c-section