Obstetric Emergencies (1)

Question 1

Post-Partum Haemorrhage:
What is its diagnosis criteria?

What are its risk factors?

What causes it?

How can it be prevented?

Answer 1

➊ • 500ml loss after vaginal delivery
• 1000ml loss after c-section

➋ Previous PPH, Multiple pregnancy, Macrosomia, Prolonged 3rd stage, Induced/Augmented/Instrumental delivery, Polyhydramnios

➌ 4 T’s:
• Tone - Uterine atony – Most common cause
‣ Contraction of uterus after delivery helps compress the vessels and slow down blood loss
• Trauma e.g. perineal tear
• Tissue - Retained placenta
• Thrombin - Coagulopathy

➍ • Emptying bladder before delivery – full bladder can reduce uterine contraction
• Active management of 3rd stage with IM Syntometrine

Question 2

What are the mechanical management options?

What are the medical management options?

What are the surgical management options?

What is Secondary PPH?
→ What are the most common causes of it?
→ What do investigations include?

Answer 2

➊ * Rubbing uterus through abdomen stimulates a contraction
* Catheterisation – A distended bladder prevents uterine contractions

➋ * Oxytocin
* Ergometrine – Stimulates smooth muscle contraction
‣ CI in hypertension
* Carboprost or Misoprostol – Prostaglandin analogue
‣ Caution in asthmatics
* Tranexamic acid – Antifibrinolytic for high-risk patients

➌ * Intrauterine balloon tamponade – Inflatable balloon into uterus to press against the bleeding
* B-Lynch suture around uterus to compress it
* Uterine artery ligation to reduce blood flow
* Hysterectomy – LAST RESORT - Will stop bleeding and may save the mother’s life

➍ Bleeding 24hrs – 12 wks post-partum
→ * Retained Products of Contraception (RPOC)
* Endometritis (infection)
→ * TVUS for retained products
* Endocervical/high vaginal swabs for infection

Question 3

Maternal Sepsis:
What is the most common cause?
→ How does this present?

What’s another key cause?

How is it managed?

Answer 3

➊ Chorioamnionitis – Infection of membranes in uterus and amniotic fluid
→ Abdo pain, Uterine tenderness, Vaginal discharge, Fever, Maternal and foetal tachycardia

➋ UTI

➌ • Sepsis 6 (Take – Lactate, Blood culture, Urine output; Give – O2, Abx, IVF)
• Emergency c-section if signs of foetal distress

Question 4

Cord Prolapse:
What occurs here?

What are its risk factors?

When should it be suspected?
→ What should you NOT do after diagnosing a prolapse? Why?

What can be done to relieve pressure on the cord?

How else is it managed?

Answer 4

➊ Umbilical cord descends below presenting part of the foetus, therefore causing cord compression → foetal hypoxia

➋ Abnormal foetal lie, Multiple pregnancy, Polyhydramnios

➌ When signs of foetal distress on CTG, and diagnosed O/E
→ Don’t try and push the cord back as it can cause vasospasm!

➍ • Women to lie in left lateral position (with pillow under hip) or knee-chest position (on all fours) to draw foetus away from pelvis
• Fill the bladder with fluid to push the foetal head away

➎ • Emergency instrumental delivery or C-section
• Tocolytics to stop uterine contractions

Question 5

Shoulder Dystocia:
What occurs here?

What are its risk factors?
→ What is Anticipation?

How can it present?

What are the complications that can occur here?

What are the 2 Brachial plexus injuries that can occur?

Answer 5

➊ Anterior shoulder becomes stuck behind pubic symphysis

➋ Macrosomia, GDM, Anticipation, Maternal birth weight, Maternal obesity
→ Big baby, Prolonged 1st/2nd stage, Instrumental delivery

➌ * Difficult delivery of the face and head
* Failed descent of the shoulders following delivery of the head
* Failure of restitution where the head remains face downwards and doesn’t turn back sideways as expected after delivery of it
* Turtle-neck sign – Head is delivered but then retracts back into the vagina

➍ * Foetal hypoxia (and subsequent cerebral palsy)
* Brachial plexus injury (Erb’s palsy)
* Perineal tears
* PPH

➎ Erb’s palsy (C5/C6) and Klumpke’s palsy (C8/T1)

N.B. Erb’s palsy - C5 + C6 = 11 erbs and spices.