Obstetric 00 / 21 , all cards and bookmarks
The mother first 01 / 21 Resuscitate the mother and displace the uterus; no circulation by 4 minutes, deliver by 5.
Obstetric haemorrhage, in order 02 / 21 Haemorrhage leads maternal death: massage, oxytocin, second uterotonic at dose, then red cells, plasma, fibrinogen.
The leading cause Uterotonics, in order Blood products Bleed Give Large bleed on clinical signs → , open its explanation Start red cells without waiting for labs Massive obstetric haemorrhage → , open its explanation Red cells and plasma about 1:1, early fibrinogen; then coagulation‑guided Large bleed, placental abruption → , open its explanation Early fibrinogen, coagulation studies, prepare massive transfusion Still bleeding after balanced transfusion → , open its explanation Cryoprecipitate with red cells Recombinant factor VIIa → , open its explanation Not recommended: off‑label, adverse events reported
Bleeding after caesarean Report a problem with card 2: Obstetric haemorrhage, in order
Labour analgesia 04 / 21 Offer neuraxial unless she refuses; it lengthens the second stage, not the caesarean rate.
Situation Decision Declines all analgesic drugs in labour → , open its explanation Support choice: water immersion and massage Later accepts medication → , open its explanation Neuraxial block remains most effective Absolute contraindication to labour epidural → , open its explanation Patient refusal; not late dilation, trial after caesarean, platelets 100,000 Epidural effect on second stage → , open its explanation May lengthen it; possibly more instrumental delivery Epidural effect on caesarean rate → , open its explanation No increase; does not speed delivery Opioid use disorder in labour → , open its explanation Offer neuraxial; continue methadone or buprenorphine; no antagonist Severe mitral stenosis in labour → , open its explanation Early, carefully titrated epidural unless coagulopathy Suspected or confirmed COVID‑19 in labour → , open its explanation Pandemic advice: consider suspending nitrous; neuraxial, steroids, magnesium continue
Report a problem with card 4: Labour analgesia
Platelets and bleeding disorders before neuraxial 05 / 21 Judge the count and the disorder; no added test predicts an epidural haematoma.
Finding Decision Mild, bleeding‑free platelet fall late in pregnancy → , open its explanation Gestational thrombocytopenia; if early or deeper, immune thrombocytopenia Thrombocytopenia: thromboelastography (TEG), rotational thromboelastometry (ROTEM), platelet function analyser (PFA), prothrombin time (PT), aPTT → , open its explanation Decide on platelet count; no test predicts epidural haematoma von Willebrand disease at delivery → , open its explanation Expect extra bleeding von Willebrand factor below 50 IU/dL → , open its explanation Give prophylaxis; type 1 rarely needs it Type 2 von Willebrand disease, low levels → , open its explanation Replace von Willebrand factor; desmopressin release unhelpful Type 1 von Willebrand disease needing treatment → , open its explanation Desmopressin first
Report a problem with card 5: Platelets and bleeding disorders before neuraxial
Planning the caesarean anaesthetic 06 / 21 Choose the technique the airway and the blood allow; dose antibiotics by weight.
Surgery and drugs during pregnancy 07 / 21 Operate when needed with a full-stomach induction; monitor the fetus when viable; paracetamol, never late non-steroidal anti-inflammatory drugs (NSAIDs).
Surgery in pregnancy Situation Decision Laparoscopy, any trimester → , open its explanation Do not delay; keep carbon dioxide normal, monitor fetus Fetal heart check around surgery (ACOG) → , open its explanation Before/after: Doppler previable, electronic viable; intraoperative individualised Symptomatic reflux beyond first trimester, general anaesthesia → , open its explanation Full stomach: rapid‑sequence induction, cuffed tracheal tube Cerebral bleed needing induction → , open its explanation Modified rapid sequence: lidocaine pretreatment, propofol, high‑dose rocuronium or suxamethonium
Analgesics in pregnancy Report a problem with card 7: Surgery and drugs during pregnancy
Drugs that contract or relax the uterus 08 / 21 Match the uterotonic to the patient; volatiles and nitroglycerin relax the uterus.
Uterotonic by coexisting disease Disease Uterotonic to give or avoid Asthma or pre‑eclampsia → , open its explanation Give oxytocin as the uterotonic Asthma → , open its explanation Avoid carboprost: bronchospasm Pre‑eclampsia → , open its explanation Avoid methylergometrine: hypertension, vasospasm Wheeze after a second uterotonic, asthma → , open its explanation Suspect carboprost, a prostaglandin F2α analogue Asthma, other uterotonics have failed → , open its explanation Carboprost with caution, as last resort
Relaxing the uterus Report a problem with card 8: Drugs that contract or relax the uterus
Normal pregnancy or not 09 / 21 Know what pregnancy raises, lowers and leaves alone; a diastolic murmur it never explains.
What pregnancy raises at term System Rises Breathing → , open its explanation Tidal volume, inspiratory reserve, minute ventilation Breathing in labour → , open its explanation Pain raises minute ventilation further Heart and blood → , open its explanation Cardiac output, stroke volume, heart rate, red cell mass Clotting → , open its explanation Fibrinogen; factors VII, VIII, IX, X, XII
What pregnancy lowers at term System Falls Lung volumes → , open its explanation Expiratory reserve volume (ERV), residual volume, functional residual capacity (FRC) Blood gas → , open its explanation PaCO2 (28‑32 mmHg) and bicarbonate; pH near normal Vessels → , open its explanation Systemic vascular resistance (SVR) Clotting → , open its explanation Factors XI and XIII, and protein S, fall Plasma proteins → , open its explanation Albumin, total protein, plasma cholinesterase, modestly
What pregnancy leaves alone Heart and airway findings Metabolic and gut findings Finding Verdict Gastric emptying after delivery → , open its explanation Normal within about a day; aspiration‑prone until then Insulin resistance → , open its explanation Normal, hormonal: placental lactogen, progesterone, oestrogen, cortisol Ketosis during fasting labour → , open its explanation Expected; harmless without diabetes, settles with carbohydrate Routine intravenous fluids for that ketosis → , open its explanation Not needed Thromboxane, cyclo‑oxygenase‑1 (COX‑1) product → , open its explanation Aggregates platelets, constricts; never dilates or raises uterine flow
Sources: AHA/ACC 2024 · §6.3
Report a problem with card 9: Normal pregnancy or not
The hypertensive disorders 11 / 21 Pressure 160/110 or any other severe feature makes pre-eclampsia severe; haemolysis, elevated liver enzymes and low platelets (HELLP) by its labs; delivery cures.
Naming the disorder Severe features of pre-eclampsia (ACOG, as listed in Faust) Feature (any one) Severe when Blood pressure, two readings ideally 4 hours apart → , open its explanation Systolic ≥160 or diastolic ≥110 mmHg Platelets → , open its explanation Below 100,000 per microlitre Liver → , open its explanation Enzymes over twice normal; severe right‑upper‑quadrant or epigastric pain Kidney → , open its explanation Creatinine above 1.1 mg/dL, or doubled Lungs → , open its explanation Pulmonary oedema Brain and eyes → , open its explanation New headache, unexplained and unrelieved by analgesia; visual disturbance Proteinuria (amount) → , open its explanation Not a severe feature; pre‑eclampsia can be diagnosed without it
Circulation in severe pre-eclampsia Treatment Report a problem with card 11: The hypertensive disorders
Placenta accreta spectrum 12 / 21 Accreta adheres, increta invades, percreta perforates; each prior caesarean scar with previa raises the risk.
Nerve injury after delivery 13 / 21 Map the deficit to the nerve; a long second stage, not the epidural, usually causes it.
Magnesium and eclampsia 14 / 21 Magnesium prevents and treats fits, drops pressure and reflexes, potentiates relaxants; calcium reverses toxicity.
Hypotension in the parturient 15 / 21 Displace the uterus, give phenylephrine unless the heart is slow; look for the cause.
Situation Action Spinal hypotension at caesarean → , open its explanation Phenylephrine preferred; ephedrine also acceptable Spinal hypotension with maternal bradycardia → , open its explanation Ephedrine Cause of severe spinal hypotension in pregnancy → , open its explanation Low systemic vascular resistance plus lost sympathetic tone Term hypotension on lying flat → , open its explanation Supine hypotension syndrome: left uterine displacement, tilt or wedge Bispectral index (BIS) below 40, mild hypotension, slow pulse, total intravenous anaesthesia (TIVA) → , open its explanation Too deep: reduce propofol until BIS 40‑60 first Hypotension in mitral stenosis, including after epidural → , open its explanation Pure alpha agonist (phenylephrine); avoid heart‑rate‑raising drugs
Report a problem with card 15: Hypotension in the parturient
The airway fails at caesarean 16 / 21 Oxygenate first, in six steps: better look, supraglottic airway, wake or proceed; nothing oxygenates: front-of-neck access.
1 First laryngoscopy fails 2 Intubation fails 3 Oxygenating through the supraglottic device 4 Cannot intubate, cannot oxygenate (CICO) 5 Front-of-neck access 6 After front-of-neck access Report a problem with card 16: The airway fails at caesarean
Sudden collapse 17 / 21 Collapse in labour or just after birth is embolism until proven otherwise; name which.
Amniotic fluid embolism: diagnostic criteria (Miller) Which embolism Presentation Diagnosis Sudden hypoxia, hypotension, then coagulopathic bleeding in labour → , open its explanation Amniotic fluid embolism Seizure or bronchospasm in amniotic fluid embolism → , open its explanation Seizures in about half; bronchospasm rare, under 15% Amniotic fluid embolism: commonest symptom, commonest sign → , open its explanation Symptom dyspnoea; signs hypotension and fetal distress Amniotic fluid embolism after second‑trimester termination → , open its explanation Can occur; a diagnosis of exclusion Collapse minutes after amniotomy, even with heavy bleeding → , open its explanation Amniotic fluid embolism until proven otherwise Postpartum CT pulmonary angiography filling defect → , open its explanation Thrombotic pulmonary embolism; amniotic fluid embolism has no imaging sign
Confirming pulmonary embolism Report a problem with card 17: Sudden collapse
Risk factors and Zika 20 / 21 Plain facts: Zika means microcephaly; endometriosis follows early menarche, pre-eclampsia nulliparity and obesity.
Traps Check these before you finish 1 card · about 1 min 21 Traps
Traps 21 / 21 The tempting choice is the familiar one; the books often name another.
Clinical situation Right call, not the tempting one Peroneal palsy for foot drop after long labour → , open its explanation Lumbosacral trunk compression by fetal head, not epidural Local anaesthetic itself raises uterine flow → , open its explanation Falling sympathetic tone raises uterine flow; hypotension lowers it Suxamethonium crosses the placenta → , open its explanation Small lipid‑soluble poorly ionised drugs cross; neuromuscular blockers barely do Asthma with pre‑eclampsia: ergot once carboprost excluded → , open its explanation Oxytocin; carboprost barred by asthma, ergot by pre‑eclampsia Diastolic murmur as normal in pregnancy → , open its explanation Abnormal; normal is systolic ejection murmur, else accentuated S1 Ephedrine for spinal hypotension at caesarean → , open its explanation Phenylephrine preferred unless bradycardic; ephedrine acceptable, not first More clear fluid once haemoglobin has fallen → , open its explanation Red cells plus plasma en route to theatre Rapid intravenous methylergometrine bolus → , open its explanation Give 0.2 mg IM; slow monitored IV only last resort Wheeze as the sign of amniotic fluid embolism → , open its explanation Rare, under 15%; collapse, hypoxia, coagulopathy dominate Smoking as pre‑eclampsia risk factor → , open its explanation Lowers risk (Stoelting, Barash); Faust lists it: dissent Amniotic fluid embolism with CT filling defect → , open its explanation Thrombotic pulmonary embolism; amniotic fluid embolism diagnosed by exclusion Midazolam for seizure on magnesium → , open its explanation Further 1–2 g magnesium bolus, then check plasma level Bladder dysfunction after long low‑dose epidural → , open its explanation Prolonged second stage, pelvic floor; not epidural or catheter
Report a problem with card 21: Traps
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Sheet 05 · Obstetric 21 / 21
That is Obstetric, all 21 cards.
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