OSCE notes - Obstetric Emergencies

I found my old OSCE notes and thought I'd post them here. These are the cord prolapse ones, if you think they'd be useful shout and I'll put up the other topics


Cord prolapse occurs, after the membranes have ruptured, when the umbilical cord presents in front of or alongside the fetus (occurs 3 in 1,000 deliveries). Prior to the membranes rupturing it is called a funic presentation. (occurs in 12-25 in 10,000 pregnancies) - Boyle & Katz (2005)

There are two types of cord prolapse:
and
Overt/frank cord prolapse Occult cord prolapse
(cord into (or hanging out of) the vagina) (cord alongside the fetus)

There are three ways of discovering cord prolapse:

See it Hear it Feel it
(hanging out of the vagina) (decelerations or bradycardia) (On VE)

Who is at highest risk?

• Prematurity
• IUGR
• Breech
• Transverse Lie
• Multiple pregnancy (especially twin 2)
• High parity
• Non-engagement of head
• Polyhydramnios
• Artifical Rupture of Membranes
• ECV

Treatment when discovered

· Call for help
· Senior obstetrician
· Obstetrician to assist (potential caesarean section)
· Anaesthetist
· ODP
· Senior midwife
· Scribe
· Paediatrician
· Inform SCBU
· Explain to woman and partner all along
· Relieve cord compression
· Place woman into position to take gravity away from cervix


Exaggerated Sims
Knee chest put wedge/pillow under the hip

· Apply digital pressure to keep presenting part off cervix
· Handle cord as little as possible, but replace into vagina if hanging out
· Ascertain fetal viability
· If cord pulsating then alive
· If fetal heart tones heard then alive (monitor if possible)
· If neither check with ultrasound scan (occasionally heart movement later)
· If fetus alive
Check dilation if fully dilated and low head then instrumental (or multip may proceed quickly to SVD)
· Crash caesarean section (usually under GA – see contentious issues)
· 2 large bore venflons to be sited (+ bloods)
· catheterise
· maintain digital pressure until birth of baby
· Have paediatrician ready, due to high chance of resuscitation following hypoxia
· Take cord blood gases after birth to assess hypoxia
· If intrauterine death
· Proceed with vaginal birth
· Explain to parents
· Offer usual care for stillbirths
· Record Keeping, as contemporaneously as possible, when writing up notes include original scribe’s transcripts

Contentious issues

• Vago first suggested bladder filling in 1970. A no. 16 Foley catheter is placed in the maternal bladder, and filled with 400-750mls of normal saline. This is then clamped and not released till ready for knife to skin. The full bladder can inhibit uterine contractions and displace presenting part from the pelvis. Katz & Shoham (1988) found in their 5 year study (n=51) that there were NO perinatal deaths and only 8 continued fetal distress (pre bladder filling, 33 )
  

· If there is no fetal distress and/or pressure on the presenting part (ie transverse position) or woman has an effective epidural is there a need for a GA? Due to increased maternal mortality (3 deaths in last Why mothers Die from GA complications)
· Homebirths – if woman is upstairs needs to get downstairs as fast as possible, to reduce pressure on cord – fastest way is probably for her to go down the stairs normally as quickly as she can, then resume knee chest/sims position. For this reason many midwives recommend homebirths are on the ground floor. Transfer in ambulance should be in exaggerated sims



Reading

Boyle K & Katz V (2005) Umbilical cord prolapse in current obstetric practice Journal of Reproductive Medicine 50(5):303-6
Katz, Z, Shoham, Z, Lancet, M, Blickstein, I, Mogilner, BM, Zalel, Y (1988)
Management of labor with umbilical cord prolapse: a 5-year study
Obstetrics and Gynecology 72: 278-281

Re: OSCE notes - Cord Prolapse

Wow this is ace. but scary