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Obstetric emergencies Flashcards

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1
Q

What are the 4 steps of calling for help in an obstetric emergency?

A
  1. Pull the emergency bell
  2. Tell an appropriate person to call 2222 stating the appropriate name of emergency + accurate location
  3. Tell the person to feedback to you when they are done
  4. Tell someone to bring the appropriate equipment trolley
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2
Q

How do you approach any obstetric emergency?

A

Is it safe to approach?

ABCDE

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3
Q

How do you check the patients Airway?

A
  1. Is the patient talking
  2. look inside the mouth for obstruction
  3. Flatten the bed
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4
Q

How do you asses B?

A
  1. SATS
  2. RR
  3. Chest auscultation
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5
Q

How do you asses Circulation

A
  1. Pulse
  2. BP
  3. Cap refill time
  4. Cold periphery
  5. IV Access - take bloods and give fluids if indicated
  6. Urine output + catheter if indicated
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6
Q

How do you assess Disability?

A
  1. AVPU
  2. Blood sugar
  3. light reflex
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7
Q

How do you asses exposure?

A
  1. Head to toe assessment

2. Review ABCDE again

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8
Q

Which 4 people do you call for help in any obstetric emergency?

A
  1. Scribe
  2. Obs
  3. Anaesthatist
  4. Paediatricin
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9
Q

What are the 5 D’s of OBS?

A
  1. Document
  2. De-brief
  3. Datix
  4. Duty of candor
  5. DVT
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10
Q

What is the commonest organism that causes sepsis in pregnant women?

A

Group A strep

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11
Q

What is sepsis?

A

Bodies response to an infection

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12
Q

When are women at a high risk of developing sepsis?

A

6 weeks postnatally due to cardiovascular and immune changes

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13
Q

Name 8 causes of maternal sepsis (infections)

A
  1. Mastitis
  2. UTI
  3. Pneumonia
  4. Episiotomy infection
  5. Gastrointestinal infection
  6. Spinal site infection
  7. Vaginal infection
  8. Wound infection
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14
Q

How do you prevent sepsis?

A
  1. Proper hand hygiene + use of anti-septics
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15
Q

What are the symptoms of sepsis?

A

Depends on the cause -
Fever, diahrrhoea, vomiting, abdominal pain, soar throat, URTI, offensive vaginal discharge, wound infection, heavy lochia

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16
Q

List 7 signs of sepsis?

A
  1. Rash
  2. tachycardia
  3. tachypnoea
  4. pyrexia/hypothermia
  5. hypotension
  6. low urine output
  7. pallor
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17
Q

List 6 Red flags associated with sepsis

A
  1. Pyrexia > 38 or hypothermia <36
  2. Tachycardia >90
  3. RR >20
  4. Abdominal/chest pain
  5. Diarhhoea/N + V
  6. Uterine tenderness
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18
Q

What does Puerperium mean?

A

The period after childbirth - up to 6 weeks

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19
Q

List 6 risk factors for developing sepsis during pregnancy

A
  1. Obeisity
  2. HIV
  3. Diabetes
  4. PROM
  5. Anaemia
  6. Previous pelvic infection
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20
Q

List 7 risk factors for developing sepsis during the puerperium period

A
  1. Obeisity
  2. Anaemia
  3. Diabetes
  4. CS
  5. Wound haematoma
  6. Retained products of conception
  7. History of pelvic infection
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21
Q

List 4 organism that can cause sepsis during pregnancy

A
  1. Group A strep
  2. E-coli
  3. Staph
  4. MRSA
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22
Q

what is the initial management for sepsis?

A
  1. Call for help
  2. ABCDE
  3. High flow oxygen
  4. Left lateral position
  5. Wide bore cannula
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23
Q

List sepsis 6 protocol

A

Take:

  1. Blood cultures
  2. Serum lactate
  3. UO

Give:

  1. Oxygen
  2. IV fluids
  3. IV AB
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24
Q

What 3 antibiotics could you give to manage sepsis?

A

High dose cefuroxime, metronidazole OR co-amoxiclav

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25
When would you start IV fluids for sepsis (under what conditions)?
1. Hypotensive | 2. High lactate >4
26
What fluid would you give a patient with sepsis? how much and over how long?
0.9% normal saline either 1. 500 ml over 15 mins 2. 20 mg/Kg
27
What do you use to monitor a patient with sepsis? and how often?
MEOWS chart every 15 mins
28
Name 8 cultures you would send for a patient with sepsis
1. Blood 2. vaginal 3. urine 4. woun 5. stool 6. throat 7. sputum 8. placental
29
What further investigation do you do in a patient with sepsis?
Depends on cause CXR abdominal US CT abdo/pelvis
30
What condition does sepsis increase the risk of developing?
DVT
31
How do you escalate any obstetric emergency?
SBAR Situation Background Assessment Review
32
How does the umbilical cord present normally?
Presence of the umbilical cord between the foetal presenting part and the cervix +/- ROM
33
What is cord prolapse?
Where the umbilical cord descends through the cervix alongside or past the presenting foetal part in the presence of ruptured membrane
34
Name 8 pregnancy related risk factors for cord prolapse
1. Unengaged presenting part 2. Multiple pregnancy 3. Multiparity 4. Malpresentation, malposition or unstable lie 5. Polyhydraminous 6. Prematurity 7. Low lying placenta/ placenta privea 8. Foetal congenital abnormality
35
Name 5 procedure related risk factors for cord prolapse
1. ARM - artificial rupture of membrane 2. ECV 3. Controlled ARM for IOL with high head 4. Rotational instrumental delivery 5. Vaginal manipulation of the foetus with ruptured membrane - FSE
36
What percentage of cord prolapse are preceded by an obstetric procedure?
50%
37
How do you manage cord prolapse?
If membranes are intact, stop VE to avoid ARM Exaggerated SIMS Monitor foetal heart Escalate Consider operative birth
38
Four steps of managing cord prolapse (4 r's)
1. Recognise 2. Run for help 3. Relieve 4. Remove
39
How do you recognise cord prolapse?
1. Cord visible/protruding from vagina 2. Palpable cord 3. Abnormal foetal heart on auscultation/CTG
40
How do you relieve cord prolapse?
1. Exaggerated SIMs position 2. Knee chest position 3. Manually elevating the presenting part 4. Trendelenburg position 5. tocolysis - if premature
41
What is Eclampsia?
1+ convulsions associated with pre-eclampsia
42
When is the highest risk of developing seizures?
Postoartum > antepartum > intrapartum
43
What is the commonest cause of death associated with Eclampsia?
Cerebral haemorrhage
44
What type of seizure does eclampsia present with?
Generalised seizure
45
Who do you call for help in eclampsia?
Senior midwife Experienced OBS Anaesthatist
46
How do you treat eclampsia?
1. Seizures are self limiting 2. ABCDE - be careful with fluid 3. Left lateral position/ manual displacement of placenta
47
Why do you put women with eclampsia in a left lateral position?
To avoid IVC/SVC obstruction
48
What bloods do you take in eclampsia?
G+S, FBC, U+E, Clotting, LFT
49
Medical management of seizures in eclampsia
1. Control seizures 2. Magnesium sulphate loading dose 4g IV over 5/10 mins. (20 ml of 20% preloaded) 3. Magnesium sulphate maintenance dose 1g/hr IV for 24 (50 ml of 20%) hours after last seizure
50
How do you treat recurrent seizures (eclampsia)
2g bolus IV over 10 min
51
What is the therapeutic level of MgSo4
2-4 mmol
52
How do you review a patient on magnesium sulphate?
1. Patella reflexes – every 30 mins for the first 2 hours then hourly 2. STOP if reflexes absent/depressed 3. Check RR hourly 4. Stop if RR <10 5. Ensure O2 sat >94% 6. Listen to lungs – Pulmonary oedema 7. BP + pulse every 14 mins for an hour then every 30 min 8. Strict fluid balance – ensure UO = 20 mls/hr OR 80 mg/hr – monitor creatinine if less 9. Restrict fluid intake to 1ml/kg/hour 10. Look out for symptoms of toxicity and check serum levels
53
What are the features of magnesium sulphate toxicity?
1. Motor paralysis 2. Absent reflex’s 3. respiratory depression 4. cardiac arrhythmia/arrest
54
What is the anecdote for magnesium sulphate?
10 ml 10% calcium gluconate IV over 10 mins
55
How do you calculate the Mean arterial pressure?
MAP = 1/3 (Systolic-diastolic) + diastolic
56
What level does the blood pressure need to be maintained at in eclampsia?
< 160/105 MAP <125
57
How do you manage HTN in eclamptic patients?
1. Labetalol 200 mg IV infusion 2. Hydralazine IV 3. Nifedipine 10 mg oral
58
MKUH HTN associated with eclampsia guidelines
Nifedipine 10 mg modified release BD Labetalol 200 mg QDS
59
How much labetalol is administered in eclampsia and at what rate?
5mg/ml 4ml/hour via syringe pump Double rate every 30 mins maximum 32 ml/hour OR 160 mg/hour
60
Contraindications of labetalol
Severe asthma
61
How is IV hydrazine administered in eclampsia?
Bolus 10-20 mg over 10-20 mins + BP measurments every 5 mins Followed by 40 mg in 40 ml normal saline at 1-5 ml/hour
62
What do you do after managing a women with pre-eclampsia?
1. Transfer mum to ITU/HDU | 2. plan for delivery once the mum is stable
63
Steps of management of labour in eclampsia
1. Intrapartum foetal monitoring 2. Measure BP every 15 min 3. Epidural analgesia encourages 4. Normal active second stage is safe unless BP is high or severe symptoms
64
Which uterotonic drugs are contraindicated in eclampsia?
Ergometrin/syntometrin
65
What drug is used for management of third stage of labour?
1. Use syntotocin 10 units IV/IM OR 2. Syntotocin infusion 40 U in 500 ml normal saline @ 125ml/hour
66
Post-natal care in eclampsia
1. Monitor BP for 72 hours 2. 25% increase risk of pre-eclampsia in next pregnancy 3. Low dose aspirin 75 mg during the next pregnancy 4. VTE score 5. Inform them that breast feeding is safe
67
What is shoulder dystocia?
Shoulder dystocia is the impaction of foetal anterior shoulder against maternal symphysis pubis after the foetal head has been delivered
68
How is shoulder dystocia diagnosed?
When manoeuvres are required to delivered the foetal shoulders after normal gentle downwards traction has failed
69
List 5 risk factors for shoulder dystocia
1. Previous SD 2. Macrosomia 3. Maternal diabetes 4. Prolonged 1 + 2 stage 5. Instrumental delivery
70
Early signs of shoulder dystocia (4)
1. Difficulty with birth of face 2. Head remains applied in vulva 3. Chin retracts and depresses perineum 4. Anterior shoulder fails to release with maternal pushing and axial traction
71
What is the purpose of manoeuvres in shoulder dystocia?
1. Increasing the diameter of the pelvic outlet | 2. Changing or reducing bisacromial diameter (presenting part)
72
What position effectively relieves shoulder dystocia? describe it? ALARMER
Mc-roberts position Thighs flexed, abducted and rotated outwards so they touch mums abdomen Drop/remove the end of the bed Lie mum flat ``` Alert senior Legs up - mcroberts Apply suprapubic pressure Release shoulder Woods manœuvre Episiotomy Roll on all fours ```
73
Why do we apply suprapubic pressure in Shoulder dystocia?
Pressure applied to the posterior aspect of the anterior shoulder at 45 angle +/- rocking motion to help deliver shoulders
74
What is Breech presentation?
Breech is the part of the foetus that occupies the lower uterine segment Breech presentation: presentation of the buttock
75
Name 8 causes of breach delivery
1. No cause 2. Previous breech 3. Prematurity 4. Foetal/uterine abnormalities 5. Twin pregnancy 6. Placenta previa 7. Pelvic tumour 8. Pelvic deformity
76
Name 4 complications of a breech baby
Perinatal mortality increased Foetal abnormalities are more common Labour – hypoxia/birth trauma High rates of long term neurological handicap
77
How do you diagnose a breech baby?
Important after 37 weeks – change of resolving before Hard ballotable head at fundus US confirms the diagnosis
78
What are the 3 types of breech?
1. Extended/frank - flexed at hips and extended at knees 2. Complete/flexed - Knees and hips flexed 3. Footling - Feet presenting
79
What is ECV and when is it done?
External cephalic version to attempt to turn the baby to cephalic lie done at 37 weeks
80
How is ECV preformed
1. With anaesthetic 2. Labour ward 3. Uterine relaxant 4. US guidance 5. Breech is disengaged and moved up Forward somersault movement CTG performed straight after Injection of anti-D given in rhesus -ve
81
Name 3 complications of ECV
1. Placental abruption 2. Uterine rupture 3. Urgent LCS
82
Name 5 factors affecting ECV success
1. Breech engaged 2. Obeisity 3. Liquor reduced 4. Big baby 5. Nulliparous
83
Name 6 contraindications for ECV
1. Foetal distress 2. Placenta previa 3. Twins 4. Membranes have ruptured 5. Uterine/foetal anomalies 6. One pre LSCS is not a contraindication
84
What other modes of delivery are available for breech babies if ECV fails
elective caesarean section at 39 weeks
85
When is vaginal delivery of breech baby risky
1. if foetal weight >3.8 Kg 2. extended head 3. footling breech 4. foetal distress
86
How is the first stage of labour managed in a breech baby (5)
1. Monitor progress in labour 2. Upright maternal position to aid decent 3. Consider VE after SROM to exclude cord prolapse 4. Continuous CTG 5. Choice of analgesia- no evidence to advise epidural
87
How is the second stage of labour managed in a breech baby
1. VE is indicated to confirm full dilatation 2. Allow passive decent with maternal effort- await visualisation at the perineum before active pushing is encouraged 3. Ensure continuous CTG 4. Consider position- end of bed removed 5. HANDS OFF!! Avoid traction on 6. Paediatrician must be present
88
What complication do we worry about in the second stage of labour of a breech baby
Cord compression
89
What is the time interval between buttock and shoulder delivery in a breech baby
2 mins
90
How can we assist the birth of the legs in a breech baby?
Applying popliteal pressure to aid flexion
91
What are nuchal arms?
occurs in breech babies where the foetal trunk is turned towards the pubic symphysis
92
What is luvseat manoeuvre used for?
Assisted birth of extended arms
93
Describe lovestts manœuvre
1. Gently rotate the baby so that one arm is uppermost 2. Place index finger over shoulder and follow arm to the antecubital fossa, apply pressure to flex arm and deliver 3. Keep back uppermost and rotate baby 180 degrees and repeat to release the second arm
94
When do you stop performing a lovesset manouver
when there is resistance
95
How long do you allow for the head to be delivered after shoulder decent?
30 seconds - if not successful then apply suprapubic pressure
96
Why is slow controlled delivery of breech foetal head recommended
to reduce the risk of neonatal cerebral tentorial tears
97
How do you support babies during breach delivery?
Support them on your forearm
98
What is MSV manoeuvre
1. Support baby’s body on your forearm 2. Position two fingers on the cheekbones (not in the mouth) 3. Use the other hand to apply pressure to the occiput with the middle finger, similtaneously place the other fingers on the shoulders to promote flexion
99
Ideal criteria for vaginal breech delivery (5)
1. foetus not compromised 2. Foetal weight <4 Kg 3. Spontaneous labour 4. Extended breech 5. Non-extended neck
100
Which type of breech increases risk of cord prolapse
Footling
101
What is PPH?
Blood loss >500 ml after vaginal delivery OR >1000 ml at LSCS within 24 hours of delivery
102
What is Major PPH?
Blood loss > 1000 after vaginal and >1500 after LCSC in 24 hours
103
What are the 4 T's of PPH?
1. Tone 2. Trauma 3. Tissue 4. Thrombus
104
Aetiology of PPH (6)
1. 4 T's 2. Uterine causes 3. vaginal causes 4. retained placenta 5. cervical tear 6. coagulopathy
105
Name 10 risk factors of PPH
1. Multiple pregnancy 2. previous PPH 3. general anaesthesia 4. Pre-eclampsia 5. Foetal macrosomia 6. Failure to progress in 2/3 stage 7. retained placenta 8. placenta accrete 9. episiotomy/perineal laceration 10. cervical tear/vaginal tear
106
How to prevent PPH? (4)
1. Use of oxytocin in third stage of labour 2. Use of oxytocin infusion 5 iu in LSCS 3. Use or syntometrine 4. IV tranexamic acid 0.5-1.0 g with oxytocin
107
Clinical features of PPH - 4
1. Vitals: Low BP + tacky 2. Abdominal examination: enlarges soft uterus 3. Vaginal examination: vaginal/vulval/cervical tears 4. Examining the placenta: complete.missing parts
108
How do you manage minor PPH without clinical shock?
1. ABCDE 2. IV Access – 2 wide bore cannula 3. Urgent bloods – G+S, FBC, Coagulation screen 4. Vitals every 15 min 5. Start fluid bolus
109
How is Major PPH managed differently?
1. Blood is transfused ASAP | 2. Insert Foley catheter to monitor UO
110
How is PPH monitored?
MEOWS chart - allows us to escalate
111
What is the ratio of blood to platelets?
6:4
112
How do we stimulate myometrial contractions?
1. palpate the fundus and rub it 2. ensure that the bladder is empty (Foley catheter, leave in place) 3. oxytocin 5 iu by slow IV injection 4. ergometrine 0.5 mg by slow intravenous or intramuscular injection 5. oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour) 6. carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of eight doses 7. misoprostol 1000 micrograms per rectally.
113
How is PPH treated surgically?
1. Intrauterine ballon tamponade (Rusch balloon) - when uterine atony is the cause 2. Brace suture technique 3. Hysterectomy - especially in uterine rupture or placenta accrete 4. Stepwise uterine devascularisation
114
Name the stepwise uterine devasculisation steps
1. one uterine artery 2. both uterine arteries 3. low uterine arteries 4. one ovarian artery 5. two ovarian arteries 6. internal iliac artery ligation 7. uterine artery embolisation
115
What is secondary PPH?
Blood loss occurring between 24 hours and 6 weeks post delivery
116
Name 3 causes of secondary PPH?
1. Endometritis 2. Retained placental tissue 3. Gestational trophoblastic tissue
117
How is secondary PPH investigated?
1. High vaginal and endocervical swabs 2. FBC 3. US
118
How is secondary PPH treated?
1. AB 2. evacuation of retained products of conception 3. Histology - to rule out molar pregnancy
119
Why would you use an US to diagnose breech babies?
1. To rule out placenta previa/tumours 2. Type of breech 3. Estimated weight 4. Liquor volume

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