O+G

ResponseGestation in weeks + any complications
Foetal lie/placental location
Blood type/Rh status
Previous pregnancy/birth complications
DOMESTIC VIOLENCE STUFF

ResponseFetal distress
Placental abruption
Amniotic fluid embolism
Uterine injury/rupture
Laceration of placenta or cord
Premature rupture of membranes
Premature labour
Foetomaternal haemorrhage
Direct fetal injury

ResponsePurpose – detect uterine contractions which might suggest abruption/uterine irritability, assess for foetal distress/hypoxia
Gestation – greater than 22-24 weeks – no role prior to that
Duration – 4-6 hours in minor trauma – 24 hours in severe trauma or if any abnormalities in first 4-6 hours
3 abnormalities – premature contractions, foetal tachycardia, foetal bradycardia, loss of beat-to-beat variability, late deceleration after contractions

ResponseUterine examination- fundal height, tenderness, contractions

ResponseCTG- role debatable between 24-28/40 but early sensitivity for abnormal fetal HR
Ultrasound- useful as FAST, examination of solid organ injury, confirm fetal presentation and gestation, placental location and amniotic fluid volume. Not a good predictor of placental injury.
Blood test- Kleihauer, to determine amount of Anti-D required for fetomaternal haemorrhage

ResponseIntentionally blank

ResponseAbdominal pain/tenderness
Vaginal bleeding.
Uterine contractions.
Uterine tenderness/tenseness/Woody feeling
Expanding fundal height.
Evidence of foetal compromise.
Maternal haemodynamic instability

ResponseLoss of palpable uterine contour
Palpable foetal parts.
Positive FAST scan.
Maternal shock.
Vaginal bleeding.

ResponseUterine contractions.
Bloody show.

ResponseFoetal distress on CTG.
Positive Kleihauer Betke test.

ResponseCardiorespiratory collapse/arrest
DIC (increased D-dimer /PT /APTT /FDPs,
decreased antithrombin /protein C / platelets
/fibrinogen /clotting factors).
Foetal distress on CTG.
Seizure.

ResponseAbsent FHR
Absent Foetal Movement

ResponsePASTED Mnemonic! - 2 patients, mother + baby.
2 teams - mother + Baby
Call O+G and paeds
Mgmt of rest of department
Equipment

• Maternal resus - airway, drugs, wedge for L lateral
• Neonatal - resusciataire, neonatal trolley, airway equipment, drugs
• Perimortem C section kit

Alert theaters, blood bank, U/S

ResponseResuscitate the mother if signs of shock – IV fluid boluses aiming for MAP > 60
Check fetal heartrate with USS +/- CTG if available
Urgently notify with O&G and theatre re possible placental abruption & possible need for urgent delivery of fetus
Large bore IV Access & bloods sent for Xmatch
Urgent USS to assess for fetal wellbeing, abruption, uterine rupture, placenta praevia
Speculum examination by O&G team to assess causes of bleeding
Steroids for fetal lung maturation (Betamethasone 12mg)

ResponseContinue CPR
Oxygenation BVM 15L/min
Adrenaline 1mg every 2nd cycle
Prepare for resuscitative hysterotomy
Seek + treat reversible causes
(As per ALS guidelines for asystole - pretty much unchanged from non pregnant)
CTG pads removed before shock

ResponseMaternal cardiac arrest
Within 5 mins of arrest (answers vary (4-15mins) - LITFL says if CPR doesn’t work by 4 mins start cutting, UK guidelines - “by 5 mins, or if maternal fatal injuries or prolonged pre hospital arrest”
Gestational age >20 (?24) weeks (Uterus palpable above umbilicus)

ResponsePrep skin with iodine/chlorhex (if time - one q specifically mentioned no marks for sterility)
Vertical incision from pubis to umbilicus (xyphoid in some resources)
Divide to peritoneum, (Blunt vs scissors) to open peritoneum
Vertical incision in uterus (Scalpal to allow scissors - then safety scissors for rest of incision)
Deliver baby: Hand through incision, deliver head, may require fundal pressure
Hand baby over to neonatal team assembled.
Clamp and cut cord
Deliver placenta - Scoop out with hand, gentle traction on cord
Fundus massage + Pack uterus
Syntocinon 30 U
Continue resuscitation of mother

ResponseFAST scan - similar sensitivity to non pregnant patient, identify free fluid
Formal U/S - confirm gestational age, FHR, fetal vulnerability/activity/presentation, amniotic fluid volume, solid organ injury
CTAP - Risk of radiation small compared to missed traumatic injury. Fetal vulnrability worst <15 weeks. Will define injuries + mgmt

ResponseFetal heart beat – does not negate the need for CTG
FAST exam – Accuracy limited by gravid uterus, positive scan still of use
Assessment for abruption – May miss up to 50%, poor Sensitivity
Pneumothorax – May be more accurate than CXR, can help identify site for
insertion of ICC

ResponsePurpose – detect uterine contractions which might suggest abruption/uterine irritability, assess for foetal distress/hypoxia
Gestation – greater than 22-24 weeks – no role prior to that
Duration – 4-6 hours in minor trauma – 24 hours in severe trauma or if any abnormalities in first 4-6 hours
3 abnormalities – premature contractions, foetal tachycardia, foetal bradycardia, loss of beat-to-beat variability, late deceleration after contractions

ResponseUse in Rh negative mother to assess severity of foetomaternal haemorrhage
Used to confirm the dose of Anti D required post a sensitising event (Trauma/bleed)
If Kleihauer >6 mL will need increased dose (more than usual 625 IU)

ResponseNormal examination with no abdominal tenderness, bruising or contractions
No PV loss or discharge
Normal fetal movements
Safe discharge environment- s/work, explored DV, increased antenatal surveillance