Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Intrapartum Care and Obstetric Emergencies Flashcards

24 sample cards from the Intrapartum Care and Obstetric Emergencies deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. Outline the medical (uterotonic) management of atonic PPH in sequence.

   Bimanual uterine compression and uterotonics: IV/IM oxytocin (and infusion), ergometrine $500\ \mu\text{g}$ IM/IV (avoid in hypertension), carboprost (Hemabate, $\ce{PGF2\alpha}$) $250\ \mu\text{g}$ IM every 15 min (avoid in asthma), and misoprostol $800\ \mu\text{g}$ rectally/sublingual. Add tranexamic acid $1\ \text{g}$ IV.

2. What surgical and mechanical options are used for refractory PPH?

   Intrauterine balloon tamponade (Bakri), uterine compression sutures (B-Lynch), stepwise uterine/internal iliac artery ligation, interventional radiology uterine artery embolisation, and ultimately hysterectomy as a life-saving measure.

3. What is the HELPERR mnemonic for shoulder dystocia management?

   H — call for Help; E — Evaluate for episiotomy; L — Legs (McRoberts position); P — suprapubic Pressure; E — Enter manoeuvres (internal rotation, e.g. Rubin/Woodscrew); R — Remove the posterior arm; R — Roll the patient onto all fours. McRoberts plus suprapubic pressure resolves the majority.

4. What is McRoberts' manoeuvre and why is it effective in shoulder dystocia?

   Hyperflexion and abduction of the maternal hips, bringing the thighs onto the abdomen. This flattens the lumbosacral curve and rotates the symphysis pubis cephalad, increasing the functional pelvic outlet to free the impacted anterior shoulder. It is the first-line manoeuvre.

5. What are recognised fetal complications of shoulder dystocia?

   Brachial plexus injury (Erb's palsy), fractured clavicle or humerus, hypoxic-ischaemic injury from delayed delivery, and (rarely) death. Maternal complications include PPH and third/fourth-degree perineal tears.

6. Describe the immediate management of umbilical cord prolapse.

   Call for help, avoid handling the cord (minimise vasospasm), elevate the presenting part manually or fill the bladder with ~$500\ \text{mL}$ saline, position the woman knee-chest or in left lateral with head-down/Trendelenburg, consider tocolysis, and expedite delivery — usually emergency caesarean if not fully dilated.

7. Define acute uterine inversion and its initial management.

   Uterine inversion is the uterine fundus collapsing into the cavity/through the cervix, often causing profound vagal shock and haemorrhage out of proportion to blood loss. Management: immediate manual replacement (Johnson manoeuvre), do not remove the placenta first, fluid resuscitation, and hydrostatic (O'Sullivan) or surgical replacement if needed.

8. What are the classic features and management priorities of amniotic fluid embolism?

   Sudden cardiovascular collapse, hypoxia/respiratory distress, and disseminated intravascular coagulation, typically peri-delivery. It is a clinical diagnosis of exclusion. Management is supportive: high-quality CPR/resuscitation, oxygenation, circulatory and coagulation support (massive transfusion), and perimortem caesarean if cardiac arrest.

9. What blood pressure and proteinuria thresholds define pre-eclampsia?

   New-onset hypertension after $20$ weeks: systolic $\geq 140\ \text{mmHg}$ or diastolic $\geq 90\ \text{mmHg}$, with proteinuria (urine protein:creatinine ratio $\geq 30\ \text{mg/mmol}$ or $\geq 0.3\ \text{g/24h}$) and/or maternal organ dysfunction. Severe hypertension is $\geq 160/110\ \text{mmHg}$.

10. What is the magnesium sulfate regimen for eclampsia and its therapeutic role?

    Loading dose $4\ \text{g}$ $\ce{MgSO4}$ IV over 5–10 minutes, then maintenance $1\ \text{g/hour}$ for 24 hours (after seizure or birth). Further $2$–$4\ \text{g}$ bolus for recurrent seizures. It prevents and treats eclamptic seizures; monitor reflexes, respiratory rate, and urine output for toxicity.

11. What is the antidote and signs of magnesium sulfate toxicity?

    Toxicity progresses with loss of deep tendon reflexes (>$5\ \text{mmol/L}$), respiratory depression (>$6$), then cardiac arrest. The antidote is calcium gluconate $1\ \text{g}$ ($10\ \text{mL}$ of $10\%$) IV over 10 minutes. Stop the infusion and support ventilation.

12. Which antihypertensives are used for acute severe hypertension in pregnancy?

    Labetalol (oral or IV), nifedipine (oral), and hydralazine (IV) are first-line for acute control. The target is to reduce blood pressure below $160/110\ \text{mmHg}$ while avoiding precipitous falls that compromise placental perfusion. ACE inhibitors/ARBs are contraindicated.

13. What modifications are needed for CPR in a pregnant woman beyond ~20 weeks?

    Manual left uterine displacement (or 15–30° left lateral tilt) to relieve aortocaval compression, hand position slightly higher on the sternum, early airway management (aspiration/intubation difficulty), and preparation for perimortem caesarean if no return of circulation.

14. When should a perimortem (resuscitative hysterotomy) caesarean be performed in maternal cardiac arrest?

    It should be commenced if there is no return of spontaneous circulation within $4$ minutes of arrest, aiming to deliver by $5$ minutes. Beyond ~20 weeks it aids maternal resuscitation by relieving aortocaval compression and improving venous return and cardiac output.

15. Define the APGAR score and its five components.

    The APGAR score assesses the newborn at 1 and 5 minutes, each component scored $0$–$2$ (max $10$): Appearance (colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. It reflects condition and response to resuscitation, not prognosis alone.

16. Outline the initial steps of newborn resuscitation per Resuscitation Council.

    Dry, wrap, keep warm and start the clock; assess tone, breathing, and heart rate. If not breathing/floppy: open airway (neutral position) and give $5$ inflation breaths. Reassess; if heart rate remains $<60\ \text{bpm}$ despite effective ventilation, start chest compressions at a $3:1$ ratio with ventilation.

17. At what newborn heart rate are chest compressions started and at what ratio?

    Chest compressions are started if the heart rate remains below $60\ \text{bpm}$ despite 30 seconds of effective ventilation. The compression-to-ventilation ratio in newborn resuscitation is $3:1$, aiming for about $90$ compressions and $30$ breaths per minute.

18. What are the WHO/UK recommendations for initiation and exclusivity of breastfeeding?

    Initiate breastfeeding within the first hour (skin-to-skin contact), feed on demand, and exclusively breastfeed for the first $6$ months, with continued breastfeeding alongside complementary foods up to $2$ years and beyond. Avoid routine supplementation that undermines establishment.

19. What are common lactation problems and a key management point for each?

    Poor latch — review positioning/attachment. Engorgement — frequent feeding, expression, analgesia. Cracked/sore nipples — correct attachment. Mastitis — continue feeding/expressing, analgesia, antibiotics (flucloxacillin) if systemically unwell or not improving; breast abscess needs drainage.

20. Differentiate the baby blues, postnatal depression, and postpartum psychosis.

    Baby blues: transient low mood/tearfulness in 50–80%, peaks day 3–5, resolves by ~day 10 without treatment. Postnatal depression: onset within weeks–months, persistent low mood needing treatment. Postpartum psychosis: rare (~1–2/1000), rapid onset within days, with mania/delusions/hallucinations — a psychiatric emergency requiring admission (often mother-and-baby unit).

21. What is secondary postpartum haemorrhage and its common causes?

    Secondary PPH is abnormal/excessive bleeding from the genital tract between $24$ hours and $12$ weeks postpartum. Common causes are endometritis (infection) and retained products of conception. Management includes assessment for sepsis, antibiotics, uterotonics, and evacuation if retained tissue is present.

22. What are the features and management of postpartum sepsis (puerperal infection)?

    Features: fever, tachycardia, lower abdominal pain, offensive lochia, uterine tenderness, with risk of rapid deterioration (notably group A streptococcus). Management follows the Sepsis Six: blood cultures, broad-spectrum IV antibiotics within 1 hour, IV fluids, lactate, oxygen, and urine output monitoring, plus source control.

23. What routine postnatal maternal observations and red-flag symptoms should be checked?

    Monitor temperature, pulse, blood pressure, uterine involution, lochia, perineum/wound, bladder/bowel function, and mood. Red flags include heavy/secondary bleeding, signs of sepsis, severe headache/visual disturbance (pre-eclampsia), calf pain/breathlessness (VTE), and thoughts of self-harm.

24. Why is venous thromboembolism a key postnatal concern and how is it mitigated?

    Pregnancy and the puerperium are prothrombotic (Virchow's triad: stasis, hypercoagulability, endothelial injury); VTE is a leading cause of direct maternal death. Mitigation: risk assessment, early mobilisation, hydration, mechanical prophylaxis, and LMWH thromboprophylaxis for those at risk, especially after caesarean.

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