Obstetrics Flashcards
1
Q
Describe the airway changes in pregnancy (3)
A
- Engorgement and friability of the respiratory tract + mucosal oedema and capillary engorgement of nasal/OP/laryngeal - leads to increased iatrogenic trauma due I+V
- Increased weight and breast size makes laryngoscopy more difficult
- Delayed gastric emptying, increased gastric pressure + gastro-oesophageal incompetence increased risk of aspiration
1 in 250 failed airways
2
Q
Describe the respiratory changes in pregnancy (4)
A
- Increased TV and RR secondary to increased oxygen demand
- TV increases at expense of ins. and exp. reserve volume which decrease function residual capacity
- Gravid uterus decreases use of IC muscles
- Diaphragm rises late in pregnancy (thoracostomies should be higher)
3
Q
Describe circulatory changes in pregnancy (8)
A
- Steady decrease BP in 1st trimester caused by progesterone which is profoundly vasodilatory. Normal by 3rd following activation of renin-angiotensin syndrome (increases retention of water and Na+)
- Gradual increase in SV by increase in ventricular wall muscle mass and end-diastolic volume (from increase in blood volume)
- HR increase 10-20bpm
- By second trimester CO increased by 40%
- Increased plasma volume leads to dilutional aneamia
- SVR decreases by 30% = postural hypotension
- Aortovacal compression by late second trimester
- Blood diverted away from uterus during haemorrhage which means up to 35% circulating volume can be lost without tachycardia
4
Q
Where should IOs be sited in pregnancy?
A
Humeral
5
Q
Which antibiotics are c/i in pregnancy?
A
Trimethoprim and tetracyclines (doxy)
6
Q
When should NSAIDs be avoided in pregnancy?
A
3rd trimester
7
Q
Which opiate is preferred in pregnancy?
A
DH118
8
Q
What anti-hypertensives should be avoided in pregnancy?
A
Ace inhib/ ARBS
9
Q
Which anti-epileptics should be avoided in pregnancy?
A
Sodium valporate
10
Q
When are pregnant women at increased risk of aortic dissection?
A
3rd trimester
11
Q
What is the increased risk of ACS in pregnancy?
A
3-4 x
12
Q
What is posterior reversible encephalopathy syndrome (PRES)?
A
- 3rd trimester headache, with pre-eclampsia
- headaches/seizures/corticul blindness
- vasogenic brain oedema
13
Q
How do you treat Posterior Reversible Encephalopathy Syndrome (PRES)? (2)
A
- Anti-hypertensives
- Magnesium
14
Q
What is Reversible Cerebral Vasoconstriction Syndrome (RCVS)?
A
Post partum headache
Severe HTN and thunderclap headache
Multifocal segmental cerebral artery vasoconstriction
15
Q
How do you treat Reversible Cerebral Vasoconstriction Syndrome (RCVS) ?
A
Nimodopine
16
Q
What is HELLP syndome?
A
Haemolysis
Elevated Liver enzyems
Low Platelets
17
Q
Which women with bleeding in pregancy should get anti-resus D and at what dose?
A
- All
- 250 IU if < 20 weeks
- 500 IU if > 20 weeks
18
Q
What is the Kleihauer test?
A
Gives indication of feto-maternal haemmorhage
19
Q
:In gestational HTN under what value should we aim for and what value should we admit for?
A
- Less than 135/85
- Over 160/110
20
Q
What is 1st, 2nd and 3rd line for gestational HTN?
A
- Labetalol PO 1st
- Nifedipine PO 2nd line
- Methyldopa PO 3rd line
21
Q
What are the diagnostic criteria for pre-eclampsia?
A
2 of the following:
1. BP >140/90
2. Proteinurea (++ protein)
3. Oedema
22
Q
What are the symptoms of pre-eclampsia? (5)
A
- Frontal headache
- RUQ pain
- Visual symptoms
- Oedema
- N/v
23
Q
What are the signs/symptoms of severe pre-eclampsia? (6)
A
- Ongoing headache
- Visual schotomata
- Epigastric pain
- Oliguria
- Progressive worsening biochem
- BP >160/110
24
Q
What signs suggest pre-eclamptic patients are moving towards eclampsia? (3)
A
- Confusion
- Tremor/twitching
- Hyper-reflexia
25
What is the medical management of eclampsia (3)
1. 4 g Mg2+ IV 5-15 mins followed by:
2. 1g/hr for 24hours
1g = 4mmol
26
If a patient has a further seizure whilst on treatment for eclampsia what should be done medically? (2)
1. Further 2-4g IV magnesium
2. Extend infusion 1g/hr for further 24hours
27
What anti-hypertensive should be used in eclampsia? (3)
1. Labetalol (PO/IV)
2. Nifedipine (PO)
3. Hydralazine (IV)
28
What is the definitive management of eclampsia?
Delivery
29
What is placental abruption?
Premature separation of placenta
30
What are the risk factors for placental abruption? (6)
1. Pre-eclampsia
2. Previous abruption
3. Trauma
4. Smoking
5. Cocaine
6. Multi-parous
31
What can placental abruption lead to? (3)
1. Concealed haemorrhage
2. DIC
3. Labour
32
What is placenta praevia?
Placenta partly/completely lies over lower uterine segment + os
33
What are risk factors for placenta praevia? (5)
1. Over 35 years
2. Increased parity
3. Previous placenta praevia
4. Twins
5. Uterine abnormalities including previous c-section
34
How does placenta praevia present?
Painless, bright red bleeding in 3 rd trimester
35
What is the treatment of placenta praevia?
C-section
36
What is vasa praevia?
Abnormal fetal blood vessels attach to membranes over cervical os below presenting fetal part
37
How does vasa praevia present?
Rupture of membranes with massive bleeding which can lead to fetal exsanguination
38
What should you give a mother following delivery of baby?
Oxytocin 5U IM + ergometrine 500mcg IM (unless maternal HTN)
39
What is the Brandt-Andrews technique?
To remove placenta - given pull on cord whilst exerting upward pressure on uterus to prevent inversion
40
When should magnesium be given in pre-eclampsia?
Any of the severe features
1. Ongoing or recurring severe headaches
2. Visual schotomata
41
When does JRCALC recommend time critical transfer in imminent birth?
Failure to progress after 10 mins
42
When does JRCALC recommend time critical transfer in third stage of labour?
Placenta still in situ after 20 mins
43
How long does JRCALC recommend delaying cord clamping?
At least 60 seconds whilst assessing baby and keeping warm
44
What questions should we ask a pregnant patient in our history? (11)
1. Number of weeks
2. Single or multiple pregnancy
3. Parity
4. Complications (current or previous pregnancies)
5. LMWH/aspirin
6. Contractions
7. Bleeding
8. Waters broken and what colour
9. Safeguarding
10. Midwife
11. Hopsital notes
45
What does JRCALC define as imminent birth?
Regular contractions 1-2 mins intervals
AND one of:
- urge to push or bear down
- head visible and advancing
46
If birth becomes imminent during transport to hospital what should be done?
Pull over and deliver
47
What is 'crowning' ?
Visible head and doesn't slip back between contractions
48
What should be done to prepare for an imminent birth? (7)
1. Request additional resources
2. Apply PPE
3. Equipment -dry towels, maternity pack, baby hat, thermal mattress
4. Set up neonatal resus area
5. Advise patient adopt most comfortable position for them
6. Warm room/close windows etc - ideally 25 degrees C
6. Offer entonox
49
What does JRCALC recommend re: cord clamping
1. If baby well wait until cord goes white
2. If cord short and prevents back being held clamp and cut at 60 secs
3. First clamp 5cm from baby and second 5cm further on.
50
What occurs in the first stage of labour? (3)
1. Painful, regulation contractions (3-4 every 10mins)
2. Cervical effacement and dilatation to 10cm
3. Fetal head descends and rotates as passes down through pelvis
51
What occurs in second stage of labour?
- fully dilated cervix, regular contractions 1-2 mins intervals and urge to push
- baby face down initially, rotates left or right for anterior shoulder then posterior shoulder
52
How do the PROMPT cards describe actions for normal delivery? (7)
1. Prepare birth area
2. Once crowning advise panting to slow down birth of head and protect perineum
3. Support head then both and lift onto mothers abdomen
4. Dry baby and assess
5. Remove wet towel, new dry one and hat
6. Allow cord to stop pulsing before clamping
7. 2 clamps around 15cm from umbilicus and 3 cm apart
53
Describe the 3rd stage of labour
- delivery of placenta
- usually physiological cord lengthening, rising uterus and small gush of blood indicating placenta seperation
- can take 15-20mins
54
What should be done to help with third stage labour?
encourage woman to empty bladder and pushing in squatting position
55
Following delivery of placenta what should be done?
keep placenta for midwife or hospital
56
When and what uterotonics should be given by appropriately trained staff
Following birth but before cord clamping
- Syntometrine 1ml IM/IV (EEAST carry)
- Oxytocin 5IU IV / 10IU IM
57
When should shoulder dystocia be suspected?
If, following birth of head, rest of baby not born within 2 contractions
58
How should a newborn baby be assess initially (JRCALC)? (4)
1. Colour
2. Tone
3. RR (>40)
4. HR (stethoscope) - >100bpm
59
If either baby or mother is unwell, what should occur with respects to conveying? (4)
1. Seperate DSA (compassionately explained)
2. Ensure same hospital
3. Place mothers ID wrist band on baby
4. Do not convey unwell children in car seat
60
What should be expected/done differently if twins/triplets etc (5)?
1. Request second and third resource (or more)
2. First twin has cord cut immediately, last chid born can have delayed cord clamping
3. Following first birth, placenta can deliver at any point
4. Following first birth, contractions should ease and if possible should convey in this time window.
5. If any of the babies need resus convey in seperate DSAs
61
If amniotic membrane is presenting part what should be avoided and what should be done?
1. Dont burst membranes
2. If unable to see presenting part behind sac then time critical conveyance
3. If sac bursts and presenting part is head then can stay and prepare for birth, if anything else then time critical transfer
62
What should be done if a baby is born en caul?
1. Pull membranes away from baby and try to tear with fingers
2. If too tough to tear then use tips of scissors to make small cut
3. Remove membranes from baby, clamp and cut cord and assess
4. Document colour of amniotic fluid
63
In the JRCALC maternity decision making tool what does the following mean:
1. All greens
2. 1 amber
3. More than one amber flag
4. Any red flag
1. Consider calling maternity unit and getting advice
2. Convey, 15 mins obs, consider pre-alert
3. Time critical transfer, 5mins obs
4. Time critical transfer, 5 mins obs
64
How much bleeding in women <20/40 triggers JRCALC:
- amber flag
- red flag
1. Maternity pad not fully soaked within 30 mins
2. Maternity pad fully soaked within 30 mins
65
What is cord prolapse?
Not just seeing cord during deliver (common) but seeing cord and no head
66
How common is cord prolapse and what makes it more common?
1. <1%
2. Breech
67
What actions do the PROMPT cards suggest for cord prolapse? (6)
1. Place woman immediately on all 4s, knee to chest
2. Walk them to ambulance (avoid carry chair if possible)
3. On DSA place on side with pillows under hips to raise pelvis above head (right side allows for reassurance)
4. If possible use catheter to fill bladder with 500ml normal saline to raise presenting part
5. Entonox to decrease urge to push
6. Do no attempt to replace - cover with dry padding and use underwear to keep in place
68
What percentage of births are breach?
3-4%
69
What is a breach birth and what are the 3 types?
Presenting part not head
1. Frank - buttocks present with knees extended
2. Flexed - as buttocks present with knees flexed
3. Footling- feet present
70
What does JRCALC cards recommend for breach delivery? (5)
Prepare for NLS, request additional resources
1. Mother to end of bed with legs supported or sit edge of bed/chair or all 4s position
2. Baby should be 'tum to bum' whatever position mum is in - 'hands poised' (use hips to rotate not abdomen)
3. Once buttocks born start a timer and encourage continous pushing- must be delivered < 5mins (<3mins from umbilicus)
4. Loveset/Pinards/MSV as needed
71
What maneuver should be performed in breech delivery if there is a delay caused by:
1. Legs
2. Arms
3. Head
1. Pinards maneuver = if extended then gentle pressure on popliteal fossa to flex knee
2. Loveset maneuver = hold bony pelvis and rotate infant 90 degrees in each direction.
- Once arm/shoulder visible can use 2 fingers to sweep arms off face and downwards to aid delivery
3. Mauriceau-Smellie-Velt maneuver =
- assistent provides suprapubic pressure
- support baby with arm and place left hand into vagina along anterior infant + place pressure on cheekbones with index and middle fingers to flex head
- right hand provides gentle traction on shoulders using 2 fingers to flex occiput
72
What is Pinard maneuver and what is it for?
Delay to delivery in breech babies due to legs being stuck
= if extended then gentle pressure on popliteal fossa to flex knee
- once knee flexed grab babies ankle and pull out
73
What is the Loveset maneuver and what is it used for?
Delay to delivery in breech babies due to arm being stuck
- Hold bony pelvis and rotate infant 90 degrees to deliver shoulder/arm
- then counter-rotate 180 degrees and deliver second arm
- Can also use 2 fingers to sweep arms off face and downwards to aid delivery
74
What is the Mauriceau-Smellie-Veit maneuver and what is it used for?
For breech babies delayed due to failure to deliver head
= assistant provides suprapubic pressure
- support baby with arm and place left hand into vagina along anterior infant + place pressure on cheekbones with index and middle fingers to flex head
- right hand provides gentle traction on shoulders using 2 fingers to flex occiput
75
When does JRCALC advise to leave scene immediately in the event of breach delivery? (3)
1. Buttocks not visible or not advancing
2. Footling breech
3. Hand or arm presenting but buttocks not immediately visible
76
Once the buttocks have been delivered in a breech delivery what should occur according to JRCALC?
1. Start clock (should be fully born <5mins)
2. Women should push continously from this point (do not wait for contractions) as hypoxia increases as baby descends further down birth canal.
77
If needing to convey a women with breech delivery, how should this be done?
- walk to DSA (towel or sling if some parts of baby exposed)
- lie on side with folded pillow (or similar) between legs to reduce pressure on presenting parts
78
How common is shoulder dystocia?
1% deliveries
79
How common is:
1. Cord prolapse
2. Breech delivery
3. Shoulder dystocia
1. <1%
2. 3-4%
3. 1%
80
What is shoulder dystocia?
Bony impaction of anterior shoulder o symphysis pubis
81
When should shoulder dystocia be suspected? (2)
1. Following second contraction after birth of head (gentle axial traction applied for second contraction)
2. Turtles sign - head retracts into vagina
82
What are the 5 steps that PROMPT suggest trying in shoulder dystocia in order?
1. McRoberts position
2. Gentle axial traction
3. Suprapubic pressure
4. All 4s position
5. Walk to DSA
83
Describe McRoberts position and what it is for
Shoulder dystocia
- lie flat and bottom to end of bed
- knees to chest, thighs to abdomen
- 1 person supporting each leg
84
Describe the suprapubic pressure in shoulder dystocia
- CPR hands above symphysis pubis and pish on same side as fetal back in downwards and lateral direction
- aims to move shoulder under pubic arch
85
How should the all 4 positions be used to help shoulder dysocia? (4)
1. All 4s with hips well flexed
2. Any movement of pelvis can release shoulder
3. Mum should continue to push
4. Consider gentle axial traction
86
How should women with shoulder dystocia needing to be conveyed be so?
1. Walk to DSA - may lead to birth
2. Keep on side with pillow under hips
87
In shoulder dystocia how should axial traction be applied?
Gently and keeping head in line with spine - do not pull down or laterally
88
What is the definition of PPH?
>500ml blood loss following the second stage of labour
89
What is primary and secondary PPH?
1. <24 hours
2. 24hour to 6 weeks
90
What is major and massive PPH (RCOG) (2)?
1. >1L
2. >50% blood volume within 3 hours birth
91
What are the 4 T's of PPH?
Tone (>common, no contraction following birth, 'boggy' uterus)
Trauma (perineal/vaginal/cervical)
Tissue (retained products stops uterus contracting)
Thrombin (clot abnormalities)
92
How should PPH be managed? (5)
1. Examination including palpation uterus and external genitalia for tears
2. Uterotonics
- syntometrine 11ml IM (if no HTN)
- Misoprostol 800mcg PR
- Oxytocin 5IU IV (can be repeated once) or 10IU IM
3. If placenta delivery then massage uterus fundus (find top of uterus uterus and cup between to hands and massage). If not delivered cautious as can lead to partial seperation of placenta (on do if life threatening)
4. TXA
5. Bimanual compression (gloved hand pressure anterior vaginal wall, second hand on abdomen pushing down on posterior wall compressing uterus between them.
93
How can uterine inversion be caused? (2)
1. Spontaenous
2. Uncontrolled traction of cord during 3rd stage
94
How does uterine inversion present? (3)
1. Severe abdominal pain
2. Uterus not palpable at umbilicus
3. Severe PPH +/- vaginally mediated shock
95
How should uterine inversion be managed?
If visible place gently back into vagina and keep patient flat
96
If maternal cardiac arrest, aside from RH, what else should be done differently? (7)
1. Uterine displacement (pull don't push)
2. Early ETT
3. Decompress stomach
4. Consider 0.5-1.0mm smaller ETT due to oedema
5. Thoracostomies 1-2 rib space higher
6. Hand position should may need to be 2-3cm higher in late pregnancy
7. IO should be humeral
97
Following RH - what should be immediate actions in terms of mother? (4)
1. Following cord clamping give uterotonics
2. Remove placenta with 'scooping' hand (if possible)
3. May need to manually compress uterus as will likely be atonic
4. Pack with celox/gauze as needed
98
How should an episiotomy be performed?
Mediolateral
Incision 45 degrees and start off midle
99
What is the blood loss estimation for:
1. Tampon soaked
2. Inco pad
3. Vomit bowl
4. Bed pan
5. Kidney dish
6. PPH bed
7. PPH bed and floor
1. 100ml
2. 250ml
3. 300ml
4. 500ml
5. 600ml
6. 1L
7. 2L
100
What is the dose of:
1. oxytocin
2. ergometrine
3. syntometrine
4. misoprostol
1. 10IU IV or IM (or 5IU IV followed by second if needs)
2. 0.25mg and repeat up to 1mg
3. Ergometrine 0.5mg and 5IU oxytocin
4. 800mcg SL/PR
101
When should ergometrine/syntometrine be avoided?
HTN
102
When is oxytocin c/i and why?
Cardiac disease because it decreases SVR and BP leading to drop in CO
103
When are all uterotonics c/i?
If another fetus suspected in uterus
104
How should a uterus be assessed following delivery if PPH?
- palpate abdomen and feel for top of uterus (fundus)
- assess for height - if below umbilicus then tone likely to be good
- assess tone, should be hard like a cricket ball
If unable to feel this hard/central structure then assume poor tone and commence uterine massage (cupped hand in circular motion). Should feel uterus become firm.
105
When can pre-eclampsia present from?
24-28/40 but can be from 20/40
106
What are risk factors for pre-eclampisa? (10)
1. first child (or first with new partner)
2. Previous severe pre-eclampsia
3. HTN
4. Diabetes
5. Obesity
6. Pre-existing CV disease
7. Renal disease
8. Maternal age >35yrs
9. Young maternal age <16yrs
10. Twins or more
107
When does JRCALC recommend urgent transfer to consultant led obstetric unit in terms of HTN in labour/birth? (2)
1. BP >140SBP or >90DBP on TWO occasions in labour or immediately after birth
2. BP of 150/100 in pregnancy/labour or immediately after birth
108
When and what doe JRCALC recommend for an eclamptic seizure?
Seizure of 2-3 mins
IV diazepam if no IV magnesium available
109
What is the definition of miscarriage?
Spontaneous loss of pregnancy before the baby reaches 24 weeks
110
When can an ambulance clinician confirm a miscarriage (JRCALC?)
Observe a deceased baby delivered and patient has a scan confirmed 1 pregnancy
or: hospital confirmed US scan confirming non-viable
111
What are the red flags according to JRCALC for bleeding <20/40? (5)
1. Maternity pad soaked within 30 mins (approx 50mls)
2. Total blood loss >500mls
3. Signs/symptoms suggestive of cervical shock (brady/shock without lots of bleeding)
4. Shock
5. Signs ectopic
112
What does JRCALC recommend in confirmed miscarriage and excessive bleeding?
1. Uterotonics
2. TXA
113
What does the FPHC consensus statement recommend with respects to airway in pregnancy? (4)
1. NP relatively c/i due to increased friability of mucosa in pregnancy
2. Use smaller ETT due to swelling
3. Use second generation SGA
4. Use vertical incision for front of neck as increased tissue oedema seen in pregnancy makes landmarking more challenging
114
What does FPHC recommend for pregnancy trauma patients with respects to breathing? (2)
1. High flow oxygen in all trauma patients
2. Thoracostomies/chest drains should be 3rd or 4th IC space
115
What does FPHC recommend with respects to circulation in pregnant trauma patients? (7)
1. Limited reliance on BP as marker of hypovolaemia
2. Examination of uterus and external genitalia mandatory in evaluation of haemorrhage
3. Tilt/manual displacement recommended at all times for pregnant trauma patients
4. IV access above diaphragm
5. Early blood products as fluid will exacerbate pre-existing haemodilution that occurs in pregnancy
6. TXA
7. Pelvic binders
116
What does FPHC recommend in pregnant patients being resusitated? (2)
1. Supine with manual displacement of uterus
2. RH within 15mins of witnessed arrest with ongoing CPR
117
What does FPHC recommend for all pregnant trauma patients in terms of conveyance/destination? (3)
1. All trauma patients should be seen in the ED not maternity
2. If >20/40 should go to nearest TU with maternitry (if trauma negative) or MTC with maternity (if positive). If <20/40 can go to hospital without maternity
3. All MTCs should have co-located obstetrics
118
What percentage of booked deliveries are end up being emergency pre-hospital deliveries?
< 1%
119
How common is PPH?
10% of all deliveries
120
What are the haematological changes that occur in pregnancy? (4)
1. Hypercoagulable state
2. Platelet production increases, however platelet count overall drops due to haemodilution and increased platelet destruction
3. All clotting factors increase except for XI and XII
4. Overall reduced fibrinolytic activity
121
What is the difference between the active and passive phases of the second stage of childbirth?
Passive = full dilatation but no active/involuntary pushing
Active = active or involuntary pushing at 10cm dilatation or baby is visible
122
When defibrillating a pregnant patient who is undergoing CTG, what must be done first?
Remove CTG as it can lead to burns
123
Summarise the recent systematic review into peri-mortem c-section (4)
1. Approx 66 patients undergoing peri-mortem c-section in any enviroment following OOHCA
2. Maternal survival 4.5% and neonatal 45%
3. Longest survival with good neurological outcome was 30mins in mothers and 45mins in neonates
4. 28/40 gestation was lowest with good outcome.
124
What is the triad of signs/symptoms of amniotic fluid embolism?
1. Hypoxia
2. CV collapse
3. Intravascular coagulopathy
125
What is the incidence of cardiac arrest in amniotic fluid embolism?
80%
126
What has been linked to increased incidence of amniotic fluid embolism? (6)
1. Short labour
2. Induced labour
3. Assisted delivery
4. Maternal age >35
5. Multiparous
6. Placenta abnormality
127
What are the 2 theories for the underlying pathophysiology of amniotic fluid embolism?
Mechanical theory - obstructive shock
Immune-mediated theory - anaphalactoid-like reactions
128
What is the underlying pathophysiology of HELLP?
Vascular endothelial damage secondary to raised BP. Leads to red cell damage and activation of clotting system.
Liver damage secondary to vascular congestion
Pulmonary oedema secondary to LVF
129
What signs pre-hospital might point to HELLP over severe pre-eclampsia?
Pulmonary oedema or retinal detachment
130
What are the 2 anatomical landmarks that an episiotomy should be between?
Posterior fourchette and Bartholin's gland
131
What is the definition of antepartum haemorrhage (RCOG)?
Blood loss from 24 weeks to birth
132
What is considered major and massive obstetric haemorrhage for APH (RCOG)?
Major =500-1000 mls with no signs shock
Massive = >1000mls or shock
133
What are the 3 main causes of APH?
1. Placental abruption
2. Placenta praevia
3. Local causes - bleeding form vagina/vulva/cervix
134
When should steroids be given in pregnancy and why (RCOG)?
If >24/40 and concern over pre-term delivery in order to augment foetal lung maturation
135
What are the most common complications to the mother (2) and neonate (1) of shoulder dystocia (RCOG)?
Mother: PPH and 3rd/4th degree tears
Neonate: brachial plexus injury
136
What are the factors associated with shoulder dystocia (pre-partum and intrapartum) 5 of each (RCOG)
Pre-partum:
1. Previous dystocia
2. Macrosomia (large foetus)
3. Diabetes
4. Large BMI (>30)
5. Induction of labour
Intrapartum:
1. Prolonged first stage
2. Secondary arrest
3. Prolonged second stage
4. Oxytocin augmentation
5. Assisted vaginal delivery
137
Describe the RCOG algorithm for shoulder dystocia?
Similar to PROMPT but does give option of internal manoeuvres following suprapubic pressure.
Internal manoeuvre is mainly entering vagina posterior to presenting part and trying to deliver posterior arm and then gentle pull in axial direction from the wrist (Pringle maneuver).
Main thing to remember is McRoberts and then add suprapubic pressure with gentle axial traction whilst doing McRoberts if no success.
138
During breech, when should the 'hands off' approach be replaced by attempting to expidite delivery? (3) (RCOG)
1. > 5 mins from delivery of buttocks to head
2. > 3mins delivery umbilicus to head
3. Evidence of poor condition of baby
139
What does RCOG recommend for prophx of PPH in:
- no increased risk PPH vaginal delivery
- no increased risk PPH c-section
- increased risk PPH no HTN
- increased risk PPH with HTN
1. 10IU IM oxytocin
2. 5IU IV oxytocin slow infusion
3. Syntometrine
4. Combination of treatment (e.g third line agents misoprostol or carboprost + oxytocin)
140
What level evidence is TXA in PPH according to RCOG?
A
141
What is carboprost and when is it c/i?
Third line uterotonic and is a prostaglandin analogue causing significant bronchospasm therefore c/i in asthmatics
142
In PPH, what does RCOG recommend for blood product resusitation initially?
4 units RBC followed by 15ml/kg FFP
143
What targets do RCOG give for fibrinogen and platelets in PPH?
1. Plts > 75
2. Fibrinogen >2.0
144
What is the first line surgical intervention in PPH where atony is the suspected cause?
Intra-uterine ballon tamponade
145
How often is meconium stained liquour found in birth?
10%
146
After giving birth how quickly do:
1. Progesterone levels drop
2. CV physiology return to normal
3. RR rate normalise
4. Clotting factors normalise?
1. < 24hours
2. 2 days
3. 2 days
4. 8-12 week
147
In women with risk of /expecting premature birth when should steroids be:
1. considered
2. given
1. 22-24 weeks
2. 24-34 weeks
148
What is the first line prophx abx in women with PROM?
Erythromycin 250 mg 4 times a day for a maximum of 10 days or until the woman is in established labour
149
What tocolytics are 1. first line and 2. second line according to NICE and what are the c/i?
1. Nifedipine
c/i = AS, cardiac disease
2. Atosiban (oxytocin receptor antagonist)
c/i = pre-eclampsia, increased risk PPH with abnormal placental implantation
150
What tocolytics do NICE state should not be offered?
Beta 2 agonist - salbumatol/ritodrine
151
When is the time critical aspect of a breech delivery, why and how quickly should baby be delivered?
When buttocks visible as increased risk of hypoxia (cord compressed)
Should be out < 5 mins ( < 3 mins umbilicus)
152
If McRoberts with suprapubic pressure + axial traction has not been successful in a shoulder dystocia, what should an appropriately trained team then attempt?
Internal manouevres:
Pringle best chance:
- Enter vagina posterior to presenting part and trying to deliver posterior arm and then gentle pull in axial direction from the wrist
- ensure suprapubic pressure ongoing (remember Tracey), trying to make baby as thin as possible
Then attempt:
- Corkscrew (Woods) = two fingers pushing posterior shoulder to attempt to rotate
- Reverse corkscrew (Rubins) = opposite
153
What is the advantage of Carbetocin over other uterotonics?
It doesn't need to be refrigerated
154
Apart from steroids, what has been shown to improve outcome with premature babies? (3)
1. Magnesium sulphate
2. Delayed cord clamping
3. Tocolytics
