Download - SCHHS Emergency Department

Question 3
You have just reviewed an 18 year old female who believes she is in premature
labour. She is Gravida 1 and Parity 0. She is approximately 26 weeks by date. She
has received minimal antenatal care. You have no obstetrics at your hospital.
a) What are 5 important factors to elicit on history
b) What are 5 factors to elicit on Examination
c) List 5 steps in your management of this patient
d) List 5 important factors in organizing Transfer
e) What are 5 important factors to elicit on history
- Gestational age
- Antenatal care – obtain results of any antenatal care – FBC, blood group,
hepatitis B status, HIV and syphilis
- Progression of the pregnancy
- Medical history – diabetes, hepatitis B, herpes simplex, any medications
patient is taking
- Onset and timing of contractions
- Presence and nature of fetal movements
- Rupture of membranes – vaginal bleeding or discharge
f)
-
What are 5 factors to elicit on Examination
Vital signs
Urinalysis – looking for infection, glucose or proteinuria
Abdominal exam – height of fundus, lie and presentation
Assess the frequency, regularity, duration and intensity of uterine
contractions
FHR – count for 1 minute, then for at least 30 seconds following
contraction – if bradycardia place mother left lateral position and give
oxygen
Vaginal exam – aseptic exam effacement, consistency and dilation of
cervix, nature and position of presenting part, exclude cord prolapse
The exception to performing a vaginal exam is the gravid patient with
active vaginal bleeding who should be evaluated with an USS to exclude
placenta praveia before performing a pelvic exam
g) List 5 steps in your management of this patient
- Immediate contact with nearest obstetric unit to obtain advice and
organize transfer of the mother or newborn
- After assessing – decision on whether to transport the patient
- Not for transfer if
o Cervical dilation >6cm in multiparous patients and 7-8cm in
primiparous
o Availability and type of transport and personnel and the distance
to be travelled must be considered
- If able to be transferred
o Consultation with obstetric service
o Slow or cease premature labour if appropriate with a tocolytic –
Nifedipine (Nifedipine 20mg PO with second dose after 30 minutes
if contractions persist), magnesium (4-6g IV over 20 mins), B2
agonists – Do not give magnesium and Nifedipine as can cause
hypotension
o Administration of corticosteroids for foetal lung maturation –
betamethasone 11.4mg q24h
o Antibiotics – penicillin 1.2g Q4-6h for Group B strep prophylaxis
o Monitoring of foetal wellbeing
- Preparation for delivery
o Ongoing assessment of maternal temperature, BP, HR and
contractions should be performed and recorded
o FHR should be counted every 15-30min
o Obtain delivery pack
o Resuscitation equipment for mum and baby
h)
-
List 5 important factors in organizing Transfer
Benefit of in-utero transfer and avoidance of delivery in transit
Consideration of mode of transport
Appropriate communication – patient, staff, receiving unit at tertiary
hospital
Staffing – to escort patient during transfer (number, type, experience
skills), or use of a retrieval team
Preparedness for potential delivery during transfer
Equipment – monitoring, maternal and fetal resuscitation
SAQ 7
A 13 year old girl presents with recent onset of abdominal pain
and PV blood spotting. Other findings on assessment include a Beta
HCG of 800 IU/L and an empty uterus on transabdominal
ultrasound.
a. List three differential diagnoses?
 Ectopic
 Very early pregnancy (too early to see anything on scan)
 Complete miscarriage
b. Briefly state five features of management for this patient?
 If any signs of shock from potential ectopic, needs
resuscitation
 Anti d given if rhesus negative
 Consent and social issues in a minor
i. Consensual vs non consensual sex
ii. Social worker review and child safety notification
 Gynaecology consult for further management/follow up
timeframes for further imaging/Beta HCG testing
 Analgesia
SAQ 3
You are notified by the ambulance of a 25 year old woman about to present to
your rural emergency department in advanced labour with the baby’s head on
view, and delivery is imminent. She is known to be 38/40 pregnant. There are no
obstetric or paediatric in-patient services at your hospital.
1: Outline your priorities in preparing for the arrival of this patient (2 marks)
2: Outline your management (2 marks)
Soon after arrival the head is delivered but the chin retracts back into the
perineum
3: What is the complication of delivery described above? How would you manage
this situation? (1 mark)
4: After delivery of the placenta the mother begins to bleed heavily. It is
estimated that she has lost 1 L in the first 20mins post delivery. Her HR is 120,
BP is 110/60.
List 4 possible causes of her PPH? (1 mark)
Outline your management. (2 marks)
1:
-Preparation for management of mother / delivery
+Delivery managed by Dr / midwife with most obstetric experience
+Equipment (Emergency delivery kit – clamps, scissors, drapes , towels, sutures
oxytocin, ergometrine,)
-Preparation for assessment and resuscitation of the newborn
-Separate team / Dr suitably paediatric experienced
+Neonatal Resus equipment (ETT, laryngoscopes, suction, warmed crib, umbi
catheters)
-Notification of imminent delivery to retrieval coordination / referral obstetric /
paediatric service
2: Rx Second stage
-Place IV and Xmatch if high risk of PPH. Dorsal Lithotomy position.
-Control delivery of head through perineum (pressure, avoid mother pushing)
-Check for / Remove cord from neck
Expect Restitution, deliver anterior shoulder with gentle traction and downward
pressure then posterior shoulder by lifting gently. Expect rapid delivery once
head through perineum (Beware shoulder dystocia if not)
-Analgesia –caution w opiods (neonatal resp depression) ?Nitrous Oxide
Prompt assessment of neonate once delivered. If poor tone / respirations / not
crying then clamp and cut cord + TF to crib for Drying / stimulation + Resus if
required.
Record Time of birth and APGAR. 1mg Vitamin K IM.
Rx Third stage
-After delivery (+ exclusion of a twin pregnancy) Give 10 U oxytocin IM
-Deliver placenta (gentle traction when separation occurs, inspect for
completeness.
-Rub uterus ensure contracted
3: Shoulder dystocia
-Mcroberts manouver (maternal hip hyperflexion)
-Suprapubic pressure
-IF above fails – Woods Corkscrew. Deliver posterior shoulder
Delivery within 5 mins essential
4:
-Uterine Atony
-RPOC preventing uterine contraction
-Uterine inversion
-Uterine Rupture
-Lower genital tract trauma
-Coagulopathy
Rx:
-IV Access /X match blood / Check Hb / Coags / Retrieval / Obstetric notification
/ advice
-Rub uterine fundus to stimulate contraction
-Examine and address lower genital tract tears
-Oxtocin – 5 u IV slow push then infusion @ 10 U / hr
-If still atonic – ergometrine 250ug IV
-Persistant PPH may need bimanual uterine compression / Bakri ballon while
awaiting T/F to obstetric service.
(Ref – Cameron 3rd edition emergency delivery section)
2. A 28 year old woman (G1P1) presents to the Emergency Department with a 12
hour history of headache. She delivered a healthy baby one week ago.
Her pregnancy was unremarkable.
Her vital signs are:
P 85 beats/min (regular)
BP 145/95 mmHg
RR 14 /min
SaO2 99 % on air
Temp 37C
a) List 4 differential diagnoses (4 marks)
Pre-eclampsia
Common primary headache: Migraine/tension headache
Acute vascular emergency
CNS infection
b) List your possible investigations and their clinical indications (4 marks)
Investigation
Indication
Urine
Proteinuria
FBC
Platelets (HELLP), WCC/neutrophilia or
neutropaenia (inflammatory)
LFT
HELLP
CT head
If focal neurology, decreased GCS,
possible SAH and concerns of raised ICP
or seizures
LP
Possible meningitis with no CI or ? SAH
with negative CT
2009.1 SAQ 1
With regards to haemodynamically stable 1st trimester bleeding
1. List the 3 MOST important differentials for 1st trimester
bleeding (3 marks)
Acceptable answers MUST include miscarriage and ectopic
Other acceptable answers are
 Trophoblastic disease
 Implantation bleeding
 Vaginal trauma
2. What the indications for Anti-D in a Rhesus negative pregnant
female in the 1st trimester (4 marks)
Answers are
 Miscarriage
 TOP
 Ectopic Pregnancy
 Chorionic Villus sampling
Ref: RANZCOG Guidelines update 2012
3. What is the dose of AntiD in 1st trimester sensitization? (1/2
mark)

Answer = 250IU


4. What is the bHCG “zone of discrimination” for (1/2 mark each)
Tranabdominal USS = 6500
Tranvaginal USS = 1500
Answer a = 6500, b= 1500
5. Her USS shows a viable intrauterine gestation with a small
perigestational haematoma. She is pain free, Rhesus +ve, Hb is
130 and the bleeding has settled. She has a follow up USS and
BHCG with her GP in 1 week. List 3 indications for
representation you would outline to her. (1/2 mark each)
Acceptable answers include
 Increasing bleeding
 Passing large blood clots
 Increasing Pain
 Fevers
 Systemically unwell
 Dizzyness
 Palpitations
Question 6
You are working in an urban district hospital with no obstetric or neonatal
services. A 28 week pregnant woman presents in premature labour. Examination
reveals and absence of bleeding and a closed cervical os.
a) What are your initial management priorities (4 marks)
b) Under what circumstances is suppression of labour NOT indicated (4
marks)
Question 6 Answers
a) What are your initial management priorities (4 marks)


Consultation with an obstetric service: Notification and
management and transfer
Slowing or cessation of premature labour with tocolytic if
appropriate.
o Nifidipine: 20mg stat then 2 further doses at 30 minute
intervals


o NSAIDS: Indomethacin or Ketorolac
o Magnesium:
o B2 Agonists Salbutamol: 10mg in 1L of Hartmann’s
commence at 10ml/Hr
Administration of corticosteroids for foetal lung maturation
o Betamethasone 11.4mg IM 2 doses 24 hours apart if < 34
weeks
Psychosocial support for patient and partner.
b) Under what circumstances is suppression of labour NOT indicated (4
marks)
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Gestation > 34 weeks
Foetal death in utero
Foetal malformation when palliative care only is planned
Suspected fetal compromise on USS or CTG requiring delivery
Placental abruption
Chorioamnionitis
Pre-Eclampsia
References:
ACEM Examiner’s Report 2011.2
Dunn’s page 881 – Abnormal labour