Postpartum Hemorrhage (PPH)
In a patient with ongoing hemorrhage despite uterotonics, what is the most important early action that significantly improves outcomes but is often delayed?
Activate a massive transfusion/hemorrhage protocol early.
Rationale: delay in blood product replacement is a major contributor to morbidity. PROMPT emphasizes early escalation--not waiting for lab confirmation.
What is the single most effective first-line maneuver in shoulder dystocia?
McRoberts maneuver
What is the preferred approach when the fetal body delivers spontaneously to the umbilicus?
Hands-off (allow spontaneous delivery)
What is the immediate priority upon diagnosis of cord prolapse?
Relieve pressure on the cord
What is the primary purpose of magnesium sulphate in preeclampsia?
Seizure prophylaxis
You have uterine atony with a boggy uterus despite oxytocin and uterine massage. What is the next most appropriate pharmacologic agent, and what key contraindication must be considered?
Carboprost (Hemabate)--contraindicated in asthma.
Why should excessive traction be avoided during shoulder dystocia?
Risk of brachial plexus injury
What maneuver is used to deliver the after-coming head in breech?
Mauricea-Smellie-Veit maneuver
Name two positioning strategies to relieve cord compression.
Knee-chest
Trendelenburg
What is the earliest sign of magnesium toxicity?
Loss of deep tendon reflexes
During a PPH, the patient becomes tachycardic and normotensive. Labs are pending. What is the most likely physiological explanation?
Compensated hypovolemic shock
Rationale: BP may remain normal until significant blood loss--early signs are subtle
After McRoberts and suprapubic pressure fail, what is the next recommended maneuver?
Internal rotational maneuvers (Rubin 11 or Woods screw).
What is the most concerning complication during breech delivery once the body has delivered?
Head entrapment
Why should the cord NOT be handled excessively?
Risk of vasospasm --> decreased fetal perfusion
What antidote is used for magnesium toxicity?
Calcium gluconate
What is the recommended ratio of blood products during massive transfusion in obstetric hemorrhage?
1:1:1 (PRBC: FFP: Platelets)
Rationale: prevents dilutional coagulopathy
What is the role of episiotomy in shoulder dystocia?
Does not relieve the dystocia, but may provide space for internal maneuvers.
Why is premature traction during breech delivery dangerous?
It can lead to extension of the fetal head, complicating delivery.
What is the definitive management for cord prolapse with a viable fetus?
Emergency cesarean section
A patient on MgSO4 has decreased urine output. Why is this concerning?
Risk of magnesium accumulation --> toxicity
A patient continues bleeding despite uterotonics and TXA. Uterus is firm. What category of PPH cause should you now prioritize?
Trauma (e.g., laceration, hematoma)
Rationale: 4 Ts thinking: tone, trauma, thrombin, tissue
If all maneuvers fail, what is a last-resort maneuver that may be considered before proceeding to extreme measures?
Delivery of posterior arm
In a breech delivery, if the arms are extended, what maneuver is used to release them?
Lovset maneuver
While awaiting OR, what manual intervention can be performed?
Manual elevation of the presenting part.
In severe preeclampsia, what is the definitive treatment?
Delivery of the fetus and placenta