obstetric emergencies Flashcards
(31 cards)
1
Q
Can bleeding be normal in pregnancy?
A
No bleeding is normal, even small spotting could indicate a much larger concealed bleed.
2
Q
Which conditions are more likely to cause haemorrhage in early pregnancy?
A
- Miscarriage
- Ectopic pregnancy
- May be unaware they are pregnant– ask last menstrual period, possibility of pregnancy, previous pregnancies, miscarriages, presence of coil or pelvic infections
3
Q
What is miscarriage, and how does it present?
A
- Spontaneous pregnancy loss up to 24 weeks
- Commonest between 6 and 14 weeks, calculated from first day of last menstrual period.
- Natural event, occurs in up to 20% of clinical pregnancies
- Can be associated with significant haemorrhage
- Vaginal bleeding, often heavy with clots, jelly-like gestation sack, crampy severe lower abdominal pain.
- Cervical shock: hypotension out of proportion to blood loss. Caused by retained miscarriage tissue stuck in cervix.
4
Q
What is an ectopic pregnancy? When does it occur?
A
- Where the ovum implants outside the uterus, normally within the fallopian tube, but can be ovary, abdomen or c-section scar
- Leading cause of maternal death in first 12 weeks of pregnancy
- Usually occurs at about 6-8 weeks gestation
- Greater suspicion if woman has had previous ectopic pregnancy, coil or previous pelvic infections
5
Q
What are the signs/symptoms of an ectopic pregnancy?
A
- Common symptoms: acute lower abdo pain, slight vaginal bleeding or brown loss
- May be tachycardic and show signs of hypovolemia due to intra-abdominal blood loss
- May also complain of shoulder-tip pain (pain at the bottom of the scapula) and unusual bowel symptoms-diarrhoea, fainting episodes may indicate a rupture
6
Q
What is antepartum haemorrhage and what are the two main types?
A
- Bleeding that occurs in the later stages of pregnancy & before birth
- Two main types; placenta praevia and placental abruption
7
Q
What is placenta praevia?
A
- Placenta develops abnormally in the lower segment of the uterus
- Partially or completely covers cervical opening
- Woman unlikely to be able to have a normal birth
- Significant risk of major haemorrhage when the uterus contracts, but can occur at any point of the pregnancy
8
Q
What is placental abruption?
A
- Partial or complete separation of the placenta from uterine wall
- Obvious or significant fresh vaginal bleeding, or no bleeding at all
9
Q
What are revealed and concealed bleeding?
A
- Revealed bleeding – obvious vaginal bleeding, clinical signs of hypovolaemic shock, often painless. Normally associated with placenta praevia
- Concealed bleeding – occurs into abdomen or uterus, maybe with minimal vaginal bleeding, usually associated with significant pain, signs of hypovolaemic shock, hard, woody painful uterus.
10
Q
How do you manage prehospital antepartum haemorrhage?
A
- Estimate blood loss, bring any blood soaked materials or clots
- Consider fluid resuscitation even if mother has central or radial pulses, especially if there is a high indication of significant blood loss
- Evidence of blood loss >500ml or signs of hypovolaemic shock: IV access with large bore cannula, 250ml bolus of fluid, high flow 02 with non-rebreather mask, analgesia/Entonox.
- Encourage left lateral positioning, or manually displace uterus to reduce pressure on inferior vena cava
- Pre-alert to nearest consultant-led obstetric unit for conveyance and transfer without delay
- Compensation can occur for a very long time, have a low threshold for iv fluids.
11
Q
What are the associations of uterine rupture?
A
- associated with previous caesarean or uterine surgery
- most common during labour
- associated with severe bleeding and severe constant abdominal pain and foetal compromise.
- Similar signs to placental abruption.
12
Q
What is the key history for gynaecological bleeding?
A
- Potentially pregnant
- Older women have a higher risk of malignancies
- Previous gynaecological history
- Recent gynaecological interventions
- History of trauma
- Abdo pain
- Volume of blood loss
- Signs of infection
13
Q
What are the 3 types of eclampsia/hypertension?
A
- Essential (chronic) - Diagnosed before pregnancy or in first 20 weeks, continues during pregnancy, Absence of proteinuria – no protein in urine
- Pregnancy induced - New diagnosis in pregnancy, after 20 weeks, Absence of significant proteinuria
- Pre-eclampsia - - New diagnosis of hypertension after 20 weeks, with significant proteinuria
14
Q
What are the risks of severe pre-eclampsia?
A
- Hypertension can lead to intercranial haemorrhage and stroke
- Renal failure
- Liver failure
- Abnormal blood clotting, eg low platelets and disseminated intravascular coagulation
- Can elicit severe frontal headache, epigastric pain due to stretching of liver capsule, visual disturbances and light intolerance, extra brisk reflexes, muscle twitching or tremor, nausea, vomiting and confusion
- Intra-cerebral and subarachnoid haemorrhage most common cause of death. Present with sudden collapse or severe headache with rapid deterioration
15
Q
What are the risks of eclampsia?
A
- Eclamptic seizure – generalised tonic/clonic seizure, self-limiting, lasting 60-90 seconds
- Usually occurring after 24 weeks
- Many will have pre-existing pre-eclampsia
- One thirds of cases of eclamptic seizure occur after birth
- BP may be only mildly elevated
16
Q
What is the management of severe pre-eclampsia and eclampsia?
A
- Time critical transfer to nearest consultant-led obstetric unit
- ABCDEF
- BP and BM important
- IV access
- History: seizures, severe frontal headache, visual disturbances, epigastric pain, brisk reflexes, confusion, oedema
17
Q
What are the additional considerations in maternal cardiac arrest?
A
- Supine with left manual uterine displacement
- Higher risk of aorto-caval compression if after 20 weeks. Leads to 70% reduction in stroke volume, 40% of cardiac output.
- Manage airway – high risk of gastric aspiration but more difficult to intubate, more difficult to ventilate
- Immediate transfer to hospital for caesarean
- Pre-alert maternal cardiac arrest, request obstetrician, maternity team and neonatal team
- Survival is low due to physiological changes hampering effective cpr efforts, Foetus can use oxygen and cardiac output, hindering resuscitation efforts
18
Q
What is the management of pre-term birth?
A
- Less than 22 weeks: transfer to A&E/gynaecology department
- 22-37 weeks birth not imminent: transfer to consultant-led unit
- Prepare for birth and resuscitation
- Use less pressure for inflation breaths
- If less than 32 weeks, do not dry baby. Place into plastic wrap. Use heated mattress covered by towel to prevent burns. Monitor temperature
- Pre-alert
19
Q
What are the things about Pre-term birth?
A
- Between 22-37 weeks
- Unknown causes
- Premature organ development, low body weight, minimal fat stores which affect metabolism and heat insulation
- No lung surfactant at less than 32 weeks so lungs are more difficult to inflate with greater respiratory effort needed
- Highly likely to need resuscitation and NICU care
- Greater risk of hypothermia, hypoglycaemia and infection
- Greater risk of intercranial bleeds at less than 32 weeks
20
Q
What are the associations with multiple births?
A
- Increased risk of maternal haemorrhage
- Babies more likely to be pre-term
- Once first baby is born, transport mother and baby to nearest obstetric unit if possible
- More likely to be complications with 2nd twin ie malposition or cord prolapse
21
Q
What is, and how do you recognise shoulder dystocia?
A
- Anterior foetal shoulder impacted on mother’s symphysis pubis
- Difficult birth of face or chin
- Head remains tightly applied to vulva
- Chin retraction/turtle neck
- No sign of neck/shoulder descending with next contraction
- Anterior shoulder fails to release after 2 contractions
22
Q
What is the management of shoulder dystocia?
A
- Do not cut cord before baby’s body is born
- Do not push on the top/fundus of the uterus
- Call for help, prepare neonatal resuscitation
- McRobert’s position with legs up to try and lift the symphysis pubis. Thighs to abdomen. Bottom to end of bed. Consider gentle axial traction. If does not release with next contraction, move to the next step.
- Supra pubic pressure from the side of baby’s back to try and move shoulder. Consider gentle axial traction.
- All four’s position with hips well flexed. Encourage pushing and consider gentle axial traction.
- Time critical transfer to consultant-led obstetric unit with pre-alert of shoulder dystocia.
- Place mother on side with pillow under hips to raise pelvis.
23
Q
What are the potential injuries to baby from shoulder dystocia?
A
- Brachial plexus injury (erbs palsy) caused by pulling down on the baby’s head. Damage to a nerve.
- Fractures to humerus and clavicle
- Hypoxia and stillbirth due to cord compression
- Maternal trauma
24
Q
What are the risk factors for breech birth?
A
- Previous breech
- Pre-term
- High parity (no of previous children)
- Multiple pregnancy
- Low-lying placenta
- Increased or reduced amniotic fluid around the baby
- Foetal/uterine abnormalities
25
What is the management of breech birth?
- If foot/feet, arm, hand without buttocks visible, transfer immediately to consultant-led obstetric unit
- Semi-recumbent or all-fours position. Can be sat on the edge of the bed. Hands poised ready, but stay off.
- Keep the woman pushing as there is a high risk of hypoxia as the cord may be compressed or start to spasm when it hits the cold air. Avoid touching it, do not cut of clamp until head is completely born.
- Start timer when buttocks born. After 5 minutes, move on the manoeuvres. Try each manoeuvre once.
- May need to rotate the baby to optimal position of baby’s bum to mum’s tum. If necessary to correct position of baby, use bony prominences of hips.
- Leg’s delayed: apply gentle pressure behind the baby’s knees to release the legs.
- Arms delayed: Hook your finger inside the elbow and draw the arm down. Do each arm. May need to rotate the baby’s arms into view by placing your hands around the baby’s pelvis. Rotate the baby until the shoulder is uppermost. Place a finger into the vagina and move the arm down using the elbow. May need to rotate the baby the other way for the other arm. The rotate the baby bum to tum.
- Head delayed: MSV manoeuvre: one finger on the occiput and 2 fingers on the cheek bones. Flex the head down. Raise the baby upward to lift through the curve of the pelvis to deliver the baby.
- If mother is in ‘All-fours’ consider shoulder-press manoeuvre.
26
What are the risk factors for cord prolapse?
- Breech, transverse or oblique presentation
- Premature birth
- Extra amniotic fluid
- Second twin
27
What is the management of cord prolapse?
- Avoid handling cord to avoid vasospasm
- Use dry pad, gently replace cord in opening of vulva and use pad to prevent further prolapse. Can use underwear to keep in place
- Knee-chest position if waiting for ambulance, kneeling on the floor with the bum in the air
- Avoid using chair when getting mother to ambulance if possible
- Rapid transfer to consultant-led obstetric unit
- Position mother on her side with pillows/padding so pelvis is higher than her head
28
What is the definition of PPH?
- Primary PPH: blood loss more than 500ml within 24 hours. Usually immediate. Massive PPH is loss of more than 50% blood volume in first 3 hours.
- Secondary PPH: occurs more than 24 hours after birth.
29
What are the causes of PPH?
- Tone: uterus doesn’t contract after birth. Boggy. Most common cause
- Tissue: retained placenta or membrane prevent proper contraction of uterus
- Trauma: perineal/vaginal/cervical tears can cause significant bleeding.
30
What are the risk factors for PPH?
- Grand multiparity – 5 or more previous births
- Long labour
- Antepartum bleeding
- Placenta praevia
- Operative vaginal birth (forceps or vacuum)
- Previous PPH
31
What is the management of PPH?
- Lie mother down and give high-flow o2
- Administer (syntometrine, unless hypertensive, first but NWAS doesn’t have) misoprostol 800mcg (4 tablets) orally or rectally and TXA
- Massage uterus using cupped hand
- Check for tears, apply pressure
- Large bore cannula, administer fluids if more than 500ml lost, absent radial pulse, capillary refill decreased . Low threshold.
- Transfer with pre-alert, monitor on route.
- Support midwife with bi-manual pressure if applicable
