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Acute OBGYN

9 emergencies4 simulations

Recognise it, name it, make the first moves. Four of these have simulations where the vitals move while you decide; the rest are here to be known cold.

Simulations

clock runs from the first decision
  1. Bleeding after the placentaA normal birth, a complete placenta, and then a fundus that will not stay firm.Postpartum · core
  2. A seizure on the antenatal wardAdmitted overnight with a headache and a blood pressure of 158/104, awaiting bloods. The nurse calls: she is fitting.GA 36+1 · core
  3. The head is out and nothing followsA big baby, a diabetic mother, a head that delivers and pulls back against the perineum.GA 40+0 · advanced
  4. The membranes rupture and the rate fallsAn unengaged head, a gush of fluid, and a fetal heart rate that drops to 70 and stays there.GA 38+0 · core

Recognise and act

One row each. The left column is what you see; the right is what you do in the first minutes, in order.

  1. 01 Postpartum haemorrhage

    Loss of 500 mL or more after birth, or any loss with tachycardia or hypotension; a soft, boggy fundus.

    Run the simulation Module

    1. 1Call for help and name it
    2. 2Rub up a contraction, empty the bladder
    3. 3Two cannulas, bloods, crossmatch, oxytocin then the next uterotonic, tranexamic acid
    4. 4Find the cause: tone, trauma, tissue, thrombin
    Postpartum haemorrhage training demonstrationPROMPT Maternity Foundation on YouTube

    Team drill: recognition, the four Ts, uterotonics in sequence, bimanual compression.

  2. 02 Eclampsia

    A generalised seizure in a pregnant or postpartum patient with hypertension.

    Run the simulation Module

    1. 1Call for help, protect the airway, left lateral
    2. 2Magnesium sulfate 4 g over 5 minutes then 1 g per hour
    3. 3Control the blood pressure
    4. 4Deliver once stable

  3. 03 Shoulder dystocia

    The head delivers and retracts (the turtle sign); the shoulders do not follow with gentle traction.

    Run the simulation Module

    1. 1Call it, note the time, stop pushing, no fundal pressure
    2. 2McRoberts and suprapubic pressure
    3. 3Posterior arm or internal rotation manoeuvres
    4. 4Paediatrics present; document; cord gases
    Shoulder dystocia trainingPROMPT Maternity Foundation on YouTube

    The PROMPT drill: call for help, McRoberts, suprapubic pressure, internal manoeuvres, documentation.

    Shoulder dystocia OSCE demonstrationHELM, University of Nottingham on YouTube

  4. 04 Umbilical cord prolapse

    Cord felt or seen after rupture of membranes, usually with a fetal bradycardia.

    Run the simulation Module

    1. 1Call for help, keep the hand in and elevate the presenting part
    2. 2Knee-chest or Trendelenburg; fill the bladder if delivery is delayed
    3. 3Tocolysis if contractions continue
    4. 4Deliver by the fastest safe route

  5. 05 Ruptured ectopic pregnancy

    Shock with a positive pregnancy test; shoulder tip pain; free fluid on a bedside scan.

    Module

    1. 1Two large cannulas, crossmatch, activate massive transfusion if needed
    2. 2Do not wait for a formal ultrasound
    3. 3Theatre: laparoscopy or laparotomy by stability
    4. 4Anti-D if Rh negative

  6. 06 Ovarian torsion

    Sudden severe unilateral pain with vomiting; an enlarged oedematous ovary, often with a cyst.

    Module

    1. 1Analgesia and antiemetic
    2. 2Ultrasound with Doppler, but flow does not exclude it
    3. 3Laparoscopy for detorsion; preserve the ovary

  7. 07 Uterine inversion

    The fundus is not palpable; a mass at the introitus; shock out of proportion to the loss.

    Module

    1. 1Call for help; stop uterotonics
    2. 2Replace the uterus by hand immediately
    3. 3Tocolysis if a contraction ring prevents replacement
    4. 4Uterotonics once replaced; treat the shock

  8. 08 Amniotic fluid embolism

    Sudden collapse, hypoxia, hypotension and coagulopathy during labour or just after.

    Module

    1. 1Call the arrest team; high-quality CPR with left uterine displacement
    2. 2Perimortem caesarean at 4 minutes if no return of circulation and the uterus is at the umbilicus or above
    3. 3Massive transfusion for the coagulopathy

  9. 09 Maternal cardiac arrest

    Unresponsive, not breathing normally, at any gestation.

    Module

    1. 1Standard ALS with manual left uterine displacement after 20 weeks
    2. 2Prepare for perimortem caesarean at 4 minutes
    3. 3Think of the causes: haemorrhage, embolism, anaesthetic, magnesium, eclampsia, sepsis