Obstetric Ermergencies

Front 1

term

Back 1

> 37 weeks

Front 2

preterm

Back 2

24 - < 37 weeks

Front 3

first stage labour

Back 3

onset of regular painful contractions to full cervical dilation

Front 4

second stage labour

Back 4

full cervical dilation to delivery of baby

Front 5

questions to ask pt about previous pregnancys (4)

Back 5

1 - number of
2 - c-sections / interventions
3 - complications / problems with previous pregnancies
4 - length of previous labours

Front 6

current pregnancy questions

Back 6

1 - how many weeks
2 - how many are you expecting
3 - have your membranes ruptured? what was the colour of the fluid
4 - are you having contractions?
5 - do you have an urge to push
6 - have you felt any fetal movements more/less or same
7 - any recent hospital intervention
8 - do you anticipate any problems
9 - have you had any ante-natal care
10 - any current complaints
- vaginal bleeding pv loss
- high bp
- pain
- trauma
- any other issue

Front 7

physiological differences in pregnant women: Cardiovascular
-BP
- HR
- CO
- ECG
- SVR

Back 7

BP: minimal change - initial decrease in 1st and 2nd trimester, 3rd normal SBP > 160mmHG and DBP > 110mmHg

HR: > 15 - 20 (normal pregnancy HR 80 - 100 bpm)

CO: > 30 - 40% (normal volume 6 - 7 L/min during pregnancy)

ECG: non specific ST changes. Q waves - III and AVF, atrial and ventricular ectopics.

SVR: < due to progesterone and BV

Front 8

physiological differences in pregnant women: respiratory
- RR
- O2 demand
- minute ventilation
- TV
- arterial pH
- PaO2
- PaCO2

Back 8

RR: > by 2 - 3 breaths ( 14 - 19 min/at term)
O2 demand: > by 15/20%
minute ventilation: > by 25 - 50% (11 - 19L kg)
TV: > by 25 - 40% (8 - 10ml kg/at term)
arterial pH: > to 7.4 - 7.45
paO2: > by 10mmHg (104-108 mmHg at term)
paCO2: < 27 - 32mmHg

Front 9

physiological differences in pregnant women: haematological
- BV
- Hb
- haematocrit
- plasma volume

Back 9

bv: > 30 - 50% vol (5,500mL at term)
Hb (h/dL): < 100 - 140 red cell mass > by 20 - 30% but is less than blood vol increase
haematocrit (%): < 32 - 42 (physiological anaemia)
plasma volume (mL): > 30 - 50%

Front 10

basic care of patient:
position
- normal
- spinal injury
supplemental high flow 02L: (1)
IV access and fluid therapy: (3)
stabilisation: (1)

Back 10

position: (IF > 20 weeks)
1. left lateral tilt can help reduce aorta-caval compression and subsequent hypotension.
2. a 30 degree tilt can be achieved by placing a wedge (using blankets or pillows if required) under the Pt's right hip. This can significantly improve BP.
3. if Pt requires spinal immobilisation, then she should be packaged and tilted as an entire unit

supplemental high flow O2: to counter physiological anaemia

IV access and fluid therapy:
1. early IV access in emergencies
2. high compensatory ability. mother may lose up to 30 - 35% (2L) circulating BV before showing signs of shock.
3. fetus may be compromised even when the mother appears stable.

stabilisation: assessment and resuscitation of the mother must take priority as ultimately the welfare of the fetus is optimised by providing the best available care to the mother.

Front 11

obstetric emergencies: basic car
Trauma triage.

Back 11

triage:
1. fetal morbidity and mortality can occur following seemingly minor blunt trauma
2. all injured pregnant women should have an obstetric assessment due to risk of placental abruption
3. even minor injuries may be associated with complications such as feto-maternal haemorrhage.

Front 12

APH assess:

Back 12

1 - PSA
2 - external bleeding
3 - patient hx
4 - abdominal pain
5 - > 20 weeks gestation

Front 13

APH no signs of altered perfusion mx?
- position
- tx

Back 13

1- place pt in left lateral position (if greater than 20 weeks)
2 - tx to hospital

Front 14

APH any clinical signs of altered perfusion
- position
- tx
- fluid
- pain

Back 14

1 - place pt in left lateral position
2 - tx to hospital with notification
3 - fluid resuscitation 'hypovol' guideline
- uncontrolled haemorrhage?
4 - mx pain as per pain relief

nb: internal bleeding may greatly exceed visible external bleeding
- signs of poor perfusion may present late and are always significant

Front 15

pre-eclampsia / eclampsia S/S (5)

Back 15

1 - headache
2 - visual disturbances
3 - neausea / vomiting
4 - heartburn / epigastric or abdominal pain
5 - hyper-reflexia.

Front 16

what may signify placental abruption?

Back 16

uterine pain or PV bleeding

Front 17

the most common cause of seizure in pregnancy is ? new onset seizures in the latter period of pregnancy usually indicate?

Back 17

1. previous epilepsy
2. eclampsia

Front 18

the only definitive Rx of eclampsia or pre-eclampsia is what?

Back 18

1. delivery of the baby

Front 19

pre/eclampsia assess: (4)

Back 19

1. hypertension
2. pre-eclampsia S/S
3. seizure activity
4. gestation > 20 weeks.

Front 20

pre/eclamspia normal BP (2)

Back 20

1. consider other causes
2. mx symptomatically

Front 21

pre/eclampsia SIGNIFICANT hypertension range?
- SBP
- DBP

Back 21

1. SBP 140 - 170
2. DBP 90 - 100

Front 22

pre/eclampsia SEVERE hypertension range?
- SBP
- DBP
- pain

Back 22

1. SBP >170 &/or
2. DBP > 110 &/or
3. RUQ abdo pain

Front 23

pre/eclampsia seizure activity - eclampsia mx?
- seizure activity
- position
- O2

Back 23

1. mx as per continuous tonic clonic seizure
2. left lateral tilt
3. high flow O2

Front 24

pre/eclamspsia post seizure activity mx?
- airway
- delivery
- APH

Back 24

1. assess for aspiration and rx symptomatically
2. mx as per precipitous delivery as per normal birth
3. mx placental abruption as per antepartum haemorrhage.

Front 25

normal birth - what is the CI for opiates in second stage labour??

Back 25

do not give !!

Front 26

normal birth - not imminent mx (4)

Back 26

1. reassure
2. monitor for change
3. tx to obstetric facility
4. provide analgesia as per pain relief
- penthrane

Front 27

imminent normal birth - preparation (4)

Back 27

1. reassure including cultural consideration
2. prepare equipment for normal birth
3. provide a warm clean environment
4. provide analgesia as per pain relief

Front 28

imminent normal birth - birth of head mx (4)
- pushing
- speed of head descent

Back 28

1. as head advances, encourage mother to push with each contraction.
2. if head is birthing to fast, ask mother to pant with and open mouth during contractions instead
3. place fingers on babys head to feel strength of descent of head
4. if fast, apply gentle backward pressure to control sudden expulsion of head
- do not force back.

Front 29

imminent normal birth - umbilical cord check
- loose
- tight

Back 29

if umbilical cord around the neck:
1. if loose: slip over babys head and check not wrapped around more than once
2. if tight: apply umbilical clamps and cut in between

Front 30

normal birth - head rotation

Back 30

1. with the next contraction the head will turn to face one of the mothers thighs (restitution)
- indicative of internal rotation of shoulders in preparation for birth of the body.

Front 31

normal birth - birth of shoulders and body (7) technique

Back 31

1. may be passive or guided or both
2. hold baby's head between hands and if required apply gentle downward pressure to deliver the anterior (top) shoulder
3. once the babys anterior shoulder is visible, if necessary to assist birth, apply gental upward pressure to birth posterior (lower) shoulder - the body will follow quickly.
4. support the baby
5. note time of birth
6. place baby skin to skin with mother on her chest to maintain warmth unless baby is not vigorous / requires resuscitation.
7. if body fails to deliver in < 60 seconds mx as per shoulder dystocia.

Front 32

normal birth - clamping and cutting the cord
- vigorous
- non-vigorous
- clamp locations

Back 32

1. if the nb is vigorous, the cord can be cut at a convenient time over 1 - 3 minutes
2. if the nb is not vigorous, cut the cord earlier
3. clamp twice, the first 10cm form the baby and the second 5cm further
4. cut between the two clamps

Front 33

birthing placenta -
- allow to occur ?
- time to deliver
- position of mother
- signs of separation
- method of removing placenta
- record time
- firm fundus
- any PPH. mx?

Back 33

1. allow placental separation to occur spontaneously
2. this may take 15min to 1 hr
3. position mother sitting or squatting to allow gravity to assist expulsion
4. DO NOT PULL ON CORD - wait for signs of separation
- lengthening of cord
- uterus becomes rounded, firmer, smaller
- trickle or gush of blood from vagina
- cramping / contractions return
5. placenta and membranes are birthed by maternal effort
6. use two hands to support and remove placenta using a twisting see-saw motion to ease placenta out slowly
7. note time of placenta delivery
8. place placenta and clots into container and tx
9. inspect placenta and membranes for completeness
10. inspect the fundus is firm
11. continue to monitor fundus but DO NOT massage fundus once firm
12. if fundus not firm and blood loss > 500ml mx as per PPH.

Front 34

breech presentations - if breech is non-imminent

Back 34

1. tx to obstetric unit with surgical capabilities
2. notify hospital

Front 35

types of breech presentation: breech with extended legs (frank)

Back 35

1. buttocks present first with flexed hips and legs extended on abdomen
most common = half of all breeches

Front 36

types of breech presentation: breech with flexed legs (complete)

Back 36

1. buttocks present first with flexed hips and flexed knees

Front 37

types of breech presentation: footling

Back 37

1. one or both feet present as neither hips nor knees are fully flexed. feet are palpated lower than the buttocks. `

Front 38

breech / compound presentation: assess (3)

Back 38

1. stage of labour and birth imminent
2. buttocks or both feet presenting first
3. one foot or hand / arm presenting first

Front 39

breech / compound presentation: STOP! (3)

Back 39

1. opiods are CI in late second stage labour
2. do not attempt delivery of one foot or hand / arm presentation
3. only proceed with delivery if birth is imminent

Front 40

breech / compound presentation: non-imminent birth (2)

Back 40

1. tx to booked obstetric unit with notification
2. general maternal care

Front 41

breech / compound presentation: one foot, hand or arm presenting (3)

Back 41

1. DO NOT attempt to deliver
2. Tx urgently to an obstetric unit with notification
3. consult with PIPER for advice

Front 42

breech / compound presentation: imminent breech birth - buttocks or both feet presenting technique (10)

Back 42

mx as per normal birth except for:
1. request urgent assistance
2. reassure
3. prepare obstetrics equipment
4. provide a warm clean environment
5. provide analgesia
6. allow birth to occur spontaneously
7. position mother with buttocks to edge of and legs supported to allow gravity to assist
8. DO NOT TOUCH THE BABY AS IT EMERGES
9. HANDS OFF THE BREACH
10 the birth and buttocks with occur slowly

Front 43

buttocks first presentation - back uppermost - delivery of body/legs

Back 43

1. DO NOT ATTEMPT TO PULL BABY OUT
2. encourage mother to push hard with contractions
3. feet and legs should spring free
4. await further descent
5. keep body warm by wrapping in a towel or bubble wrap if needed
6. the body will further descend to the clavicles and arms should spring free
7. let the baby hand until the nape of the neck is visible
8. the baby should face downward
9. assist birth of head using the modified mauriceau smellie veit manoeuvre

Front 44

buttocks first presentation - back uppermost - delivery of head modified mauriceau smellie veit manoeuvre

Back 44

1. place the index and ring finger of non dominant hand on the babys shoulders and middle finger on the occiput to with flexion of the head
2. place dominant hand under the babys body with ring and index fingers on the babys cheekbones
3. slowly lift the baby straight up in a circle onto the mother abdomen, allowing the head to birth slowly
4. an assistant can aid flexion of head by applying direct pressure behind the pubic bone

Front 45

buttocks first presentation -buttocks not uppermost

Back 45

1. The baby’s back needs to remain uppermost.
2. If legs delivered and back is not uppermost:
- Gently hold the baby by placing thumbs on bony sacrum with fingers around thighs.
- Do not squeeze the abdomen
- Rotate/turn baby uppermost between contractions taking care of baby’s spine
- Take great care to never pull the baby

Front 46

buttocks first presentation - legs don't birth spontaneously

Back 46

1. If extended legs (frank breech):
- slip one hand along the leg of the baby lying anteriorly
- place a finger behind the baby’s knee and deliver it by flexion and abduction

Front 47

buttocks first presentation - arms don't birth spontaneously lovesetts.

Back 47

Lovesetts manoeuvre
1. Hold baby by the sacrum
2. Turn baby 90 degrees so that one shoulder is in the antero-posterior diameter
3. Insert a finger into the brachial plexus and sweep the arm down over the baby’s chest
4. Turn baby 180 degrees so that the opposite shoulder is in the antero-posterior diameter
5. Repeat the finger manoeuvre
6. Turn the baby 90 degrees again so that the back is uppermost
7. Await further descent.
8. Do not pull or apply traction

Front 48

during all breech labour (special notes)

Back 48

Keep mother informed of progress. Encourage mother to push hard with contractions

Position mother with buttocks to bed edge with legs supported (lithotomy position) if on a stretcher or bed. Standing or squatting may be preferred by the mother and is more anatomically and physiologically sound though not suited to transport or imminent birth.

Hands off approach encourages the baby to maintain a position of flexion during birth which simplifies birth

Only touch to gently support – if too much stimulus the baby will extend flexed head

Main force of birth is maternal effort. Do not attempt to pull baby out. The key is to allow the birth to occur spontaneously with minimal handling of the newborn.

Most additional manoeuvres are only required in the event of delay

Prevent hypothermia by maintaining a warm environmental temperature if possible and/or using towel/bubble wrap if the body is exposed for a prolonged period. Cool air may stimulate breathing efforts with head still unborn.

Front 49

Preterm labour - assess and status.

Back 49

assess:
1. Ruptured membranes?
2. Check for cord prolapse?
3. Stage of labour?

status:
1. uterine contractions
- @ 20 - 37 weeks.

Front 50

preterm labour - cord prolaps

Back 50

manage as per cord prolapse

Front 51

preterm labour: birth imminent mx

Back 51

1. consider other causes of complain
2. mx symptomatically

Front 52

pre-term labour: birth not imminent mx > or + 34 weeks

Back 52

1. basic care
2. reassure

Front 53

preterm labour: birth not imminent < 34 weeks mx
- consult for?
- where is it applied?
- max dose in how long?

Back 53

1. consult for GTN patch (0.4mg/hr) applied to abdomen
2. a further 50 mg GTN patch (0.4mg/hr) may be added after 1 hr if contractions persist (max. 20mg/ 24hr)

Front 54

pre-term labour: special notes
1. there is a high possibility of what?
2. what are tocolytics contra-indicated in, with regards to pre-term labour.

Back 54

1. abnormal presentation.
2. Tocolytics are drugs intended to suppress premature labour. They are contraindicated in the setting of:

• massive maternal haemorrhage (APH), pregnancy
• induced hypertension (Pre eclampsia/Eclampsia)

Front 55

cord prolapse: special notes
1. time criticality ?
2. who must you notify?
3. what is the preferred method of birth?
4. mx when birth is imminent? and when does this apply?
5. what must you prepare for in this situation?
6. cord prolapse is associated with? (in regards to presentation)
7. what should be kept to a minimum and why ?
8. what type of hx is important in this situation?

Back 55

1. This is a time critical emergency – early diagnosis, immediate intervention and prompt transport to an appropriate facility are effective in reducing the perinatal mortality rate.

2. Notify the receiving hospital early.

3. In most instances Caesarean section is the preferred method of birth.

4. however if birth is imminent encourage mother to push – this ONLY applies when the presenting part is distending the perineum and the mother is pushing uncontrollably –

5. prepare for resuscitation of the newborn.

6. Cord prolapse is usually associated with an unstable lie or malpresentation.

7. Cord handling should be kept to a minimum as this can lead to vasospasm or contraction of umbilical vessels.

8. Key history is important: time membranes ruptured, how long has the cord been visible, due date, fetal movement felt, onset of labour, contractions present, fetal presentation if known, PV.

Front 56

cord prolapse: status

Back 56

umbilical cord visible at vulva with ruptured membranes

Front 57

cord prolapse: assess

Back 57

1. cord visible at vulva
2. ruptured membranes
3. stage of labour

Front 58

cord prolapse birth not imminent : mx of mother (3)
- position of mother
- O2

Back 58

1. Position patient on all fours, head down and buttocks up
2. Provide explanation and reassurance
3. High flow oxygen therapy

Front 59

cord prolapse birth not imminent: mx of cord (3)

Back 59

1.Minimise cord handling
2. Keep cord warm and moist. Use 2 fingers to gently place cord in vagina
3. If unsuccessful cover with warm saline packs (if possible).

Front 60

cord prolapse birth not imminent: mx of presenting part (2)

Back 60

1. If there is pressure on the cord by the presenting part insert fingers into vagina and push the presenting part (head) away from the cord
2. Maintain pressure until birth commences or advised to release.

Front 61

cord prolapse birth commencing (5)

Back 61

1. Instruct mother to push
2. Assist in delivery
3. Prepare for newborn resuscitation
4. Manage as per CPG Normal Birth
5. Manage as per CPG Newborn Resuscitation

Front 62

shoulder dystocia: special notes
1. time criticality?
2. time to deliver baby?
3. explain what to mum?
4. what times must you note?
5. what should you prepare for?
6. what must you be aware of in terms of resistence
7. what injury can typically occur?
8. who do you contact ?

Back 62

1.This is a time critical situation.
2. There is 5 – 7 minutes to deliver the baby due to compression of the cord against the pelvic rim.
3. Explain the situation to the mother to gain maximum co-operation
4. It is important to note times of birth of head, timing of manoeuvres and delivery of body
5. The newborn is likely to be compromised in this setting and require resuscitation
6. During procedures, be prepared for a sudden release of resistance and be prepared to take hold of the baby
6. The process of releasing the baby may cause
7. injury, particularly clavicle fracture. Manage any such injury appropriately including arm immobilisation
8. Discuss with PIPER when to abandon and instead transport.

Front 63

shouder dystocia: assess (8)

Back 63

1. Normal birthing procedure fails to accomplish delivery
2. Prolonged head-to-body delivery time (>60s)
3. Difficulty with birth of face and chin
4. Baby’s head retracts against perineum (turtle sign)
5. Failure of baby’s head to restitute
6. Failure of shoulders to descend
7. Difficulty reaching neck when attempting to check for cord around neck
8. Baby’s head colour turns purple then black

Front 64

shoulder dystocia: prolonged head to body delivery (> 60 sec)
1. note what time?
2. request?
3. explain?
4. mother position?
5. applying traction where?

Back 64

1.Note time of birth of head
2. Request urgent additional assistance
3. Explain to mother and ask her to push with focused effort when required
4. Position mother with buttocks at bed edge
5. Apply gentle downward traction to deliver anterior shoulder

Front 65

shoulder dystocia: delivery accomplished (2)

Back 65

1.Manage as per CPG Newborn Resuscitation
2. Assess for clavicle injury and immobilise if necessary

Front 66

shoulder dystocia: mother

Back 66

1.Basic care
2.Reassure

Front 67

shoulder dystocia: Delivery not accomplished – after 30-60 secs (2)
2. what must you NEVER do?

Back 67

1. Alternate the following sequence until baby is delivered.
- Provide high flow oxygen therapy
- Manage as per Delivery Accomplished if successful at any time.

2. At NO TIME attempt to rotate the baby’s head – rotate shoulders using pressure on the baby’s scapula instead

Front 68

shoulder dystocia: Delivery remains not accomplished after 30-60 secs (#1)
1. position
2. technique

Back 68

1. Hyperflexion of maternal hips (McRobert’s Manoeuvre) – knees to nipples
- Place mother in a recumbent position.
- Hips to edge of bed enabling better access for gentle downward traction
- Assist mother to grasp knees & pull her knees/thighs back as far as possible onto her abdomen (use assistant to assist maintaining position).

Front 69

shoulder dystocia: Delivery remains not accomplished after 30-60 secs (#2)

Back 69

1. Suprapubic pressure whilst in McRobert’s position
- Hands in CPR position behind symphysis pubis, at 45 degree angle along baby’s back (trying to rotate baby forward)
- Apply 30 secs firm downward pressure, then 30 secs rocking motion to get shoulder out from under brim, at rate of approx.1 per second

Front 70

shoulder dystocia: delivery remains not accomplished after 30 - 60 seconds (#3) GASKIN manoeuvre

Back 70

1. All Fours (Gaskin) manoeuvre
 Rotate mother to all 4s
 Hold baby’s head and apply gentle downward traction – attempting to dis-impact and deliver the posterior shoulder (now uppermost).

Front 71

shoulder dystocia: delivery acomplished

Back 71

 Manage as above
 The newborn is likely to require resuscitation

Front 72

shoulder dystocia: delivery remains unaccomplshed (#4)

Back 72

1. Consult with PIPER when to abandon manoeuvres and transport
2. If unable to consult, transport with notification - transport in McRobert’s manoeuvre position with 30º left lateral tilt.apu

Front 73

PPH special notes (#1)
- fundus massage
- four T's of PPH
- high risk pts of PPH
- when PPH can occur in relation to placenta

Back 73

Massaging a fundus that is firm, central and contracted may interfere with normal placental post birth separation and worsen bleeding. Fundal massage should only be applied when the fundus is not firm.

The four T’s of Primary Post Partum haemorrhage are:
- Tone (Uterine atony)
- Trauma (to genital structures)
- Tissue (retention of placenta or membranes)
- Thrombin (coagulopathy)
The most common cause of PPPH is uterine atony.

An empty and contracted uterus does not bleed.

Higher risk patients included multiple pregnancy, more than four pregnancies, past history of PPH, history of APH, large baby.

PPH can occur before or after the birth of the placenta

Front 74

PPH special notes (#2)
- misoprostol use
- misoprostol what it does
- misoprostol consent
- side effects of misoprostol

Back 74

Misoprostol is a synthetic prostaglandin which in Australia is licensed for prevention of gastric ulcers. However, because it can induce /augment uterine contractions it is used for inducing labour/ abortion as well as to treat haemorrhage after normal delivery. Its use in post partum haemorrhage is supported by major Victorian Obstetric Hospitals. Misoprostol is widely used in countries where there are no other medications available to control post partum haemorrhage. As its use in these circumstances is non-licensed in Victoria, verbal consent must be obtained prior to administration and appropriate notation made.

There may be some risks/complications and side effects which may include nausea; diarrhoea; or abdominal pain. In rare instances in women who have had a caesarean section the uterine scar may rupture which would require surgery.
Side effects are unlikely for the dosage that will be given.
Misoprostol and Oxytocin can be given to the same patient at the same event.