Obstetric Emergencies Quiz (May 2011)

1 What is McRoberts position, and how does it work?
A position where the woman is flat on her back with her legs abducted and flexed to as close to her shoulders as possible, this is used to aid in cases of shoulder dystocia and resolves up to 88% of them. It works by tilting the pelvis so that the symphysis pubis bone moves from diagonal to horizontal and allows the coccyx to drop to allow extra room.
2 You are attending Phoebe at a planned homebirth, she is a gravid 4 para 3 who was 7cm 2hours ago. She SROMs and a loop of cord appears at the introitus. What do you do now?
Call for help (999),
VE to assess dilation - if fully dilated and head low consider getting her to push and get baby out ASAP and prepare to resuscitate (really need baby out in 7 minutes)
Lift the presenting part off of the cord with your fingers.
Turn her into a knee chest position (head lower than hips),
Consider filling her bladder with 500mls-1litre of normal saline to lift baby out of the pelvis.
3 What is the difference between primary and secondary apnea?
A baby with primary apnea has decreased tone and heartrate but respond well to stimulation and oxygen. Cord gases between 7.2 and 7.0. Secondary apnea occurs after the fetus has gone through primary apnea and then starts trying to gasp. These babies have decreased tone, heartrate and blood pressure. The cord gas pH is below 7.0. This baby will need full blown resuscitation but may not be successful.
4 Katy is in established labour. She is having an epidural sited when her waters break. As she sits back after the epidural she starts having trouble breathing and then collapses with no pulse. What may have happened?
The epidural may have been sited incorrectly and have too high a block.She may have had an amniotic fluid embolism.She may have had a cardiac arrest for something completely unconnected with the pregnancy or labour.She may be allergic to the epidural drugs.
5 You are looking after a woman who has a major antepartum haemorrhage. Name 5 members of staff who you would need to call?
Senior Obstetrician
Obstetrician to assist (for possible lscs)
Anaesthetist
ODP
Senior Midwife
Someone to scribe
Paediatrician
Haematologist
Porter
6 Anna is 38 weeks pregnant when she starts fitting on the antenatal ward, what do you do?
Call for help
Make area safe (so she can’t fall off bed etc)
Turn onto left lateral
Aspirate material from mouth
Insert guedal airway
Give oxygen
Give magnesium sulphate loading dose (4-6g over 15-20minutes) if IV access available
Diazepam PR if no IV access
Once stable site IV access if none
Catheterise
Consider delivery once stable
Maintain magnesium sulphate maintence dose for 24hours
Monitor hourly (urine, reflexes) and 5-15minutes (BP, pulse, resps)
7 In a vaginal breech birth there is a chance that the head can become entrapped if the cervix is not completely dilated. What can be done (by obstetricians) if this happens?
Duhrssens incision – cutting the cervix
Symphsiotomy – surgically dividing the symphysis pubis.
8 You deliver a baby on labour ward and the mother has requested active third stage – as you apply CCT the placenta delivers and you notice a large purply red organ attached. What now?
Emergency bellExplain to woman and familyGet uterine inversion box (someone else, you don’t leave her)Replace the uterus – either by hand or through hydrostatic pressure (using water and a ventouse cup)Do NOT try to remove placentaUterine relexant (some sort of tocolytic or GA)Continue bimanual compression
Consider theatre for surgical replacement/possible hysterectomyWhen uterus in abdomen use some oxytoxic to try and keep it in then MROP
9 What are the 4 Ts and what is the most common?
The reasons for PPH Tone, Tissue, Trauma, Thrombin. Tone (uterus not contracting properly) accounts for 70% of all PPHs.
10 What is shoulder dystocia?
when the shoulders do not deliver spontaneously with gentle traction. It is caused by the anterior shoulder becoming impacted against the symphysis pubis, after delivery of the head. It occurs when the breadth of the shoulders is greater than the biparietal diameter of the head. It occurs in between 0.3 – 1% of all births. If birth weight >4kg then 5-7% risk & birth weight <4.5kg 8-10% risk but 50% occur in normal birth weight babies
Bonus – what is a secondary PPH and when is it most likely to occur?
A bleed of more than 500mls from the vagina more than 24 hours post delivery. Usually occurs around day 10.