Intrapartum and Postpartum care Flashcards
Approach surgically to placenta accreta/percreta
- MDM pre-op reviewing USS + MRI with interventional radiology, vascular, gynae onc and urology
- Deliver between 35-36 weeks +/- Steroids (if absence of risks for PTB). RCOG recommend delivery 34-36+6 if symptomatic or at risks of pre-term delivery.
- Consider pre-op cystoscopy and stenting and internal iliac balloons
- Consent for caesarean section should be standard + massive obstetric haemorrhage, increased risk of lower urinary tract damage, the need for blood transfusion and the risk of hysterectomy.
- Inform haematology and have 4-6 units packed red cells on stand-by and cell salvage for bleeding.
- 2x large bore IV cannulae and consider ART line placement
- General anaesthetic with epidural in situ
- Bair hugger to keep patient warm
- Flotrons and TEDS
- IV antibiotic prophylaxis with broad spectrum e.g. Cefazolin IV
- Midline incision
- USS directly on the uterus to define site prior to making incision
- Make a fundal (classical incision) far away from the placental site
- Deliver the baby
- Decision to take placenta give ecbolics and wait to see if the placenta will separate:
If separates, remove and carry on
If does not separate move on to Caesarean hysterectomy - Decision for uterine conservation/Placenta to be left in situ (not recommended in women presenting with major bleeding as it is unlikely to be successful and risks delaying definitive treatment and increasing morbidity):
50% risk of severe haemorrhage
58% risk of secondary hysterectomy up to 9 months after the birth
MTX adjuvant therapy should not be used for expectant management as it is of unproven benefit and has significant adverse effects.
Post-op:
Debrief immediately and 6 weeks later
ICU
VTE prophylaxis
Contraception
Ligating the internal iliac artery
Divide the pelvic peritoneum parallel to the infundibular pelvic ligament to enter retroperitoneal space.
Identify the external iliac artery and vein laterally and ureter medially
Retract ureter medially to expose common iliac
Identify the internal iliac as it branches from common iliac
Ligate distal to the posterior division by using a right angle clamp to divide the tissue between internal iliac artery and vein and pass a ligature around the artery OR a surgical clip around artery.
Care to avoid damage to internal iliac vein
Before ligating the internal iliac artery re identify the external iliac vessels and ureter to ensure the correct vessel is ligated.
Branches of internal iliac artery
2:4:4 rule
At the bifurcation of common iliac at vertebrae level L4
2 - Back body wall
Iliolumbar artery
Lateral sacral artery
4 - Outside of pelvis Obturator artery Superior gluteal artery Inferior gluteal artery Internal pudendal artery
4 - Supply pelvis Umbilical artery Vaginal artery Uterine artery Middle rectal artery
(iliolumbar, lateral sacral and superior gluteal) are branches of the posterior division of the internal iliac artery, the remaining branches are of the anterior division.
Ligation of the posterior division may produce symptomatic ischaemia of the buttocks and sciatic nerve.
Local Anaesthetic Toxicity Treatment
- Call for help
- Stop epidural,
- Request intralipid 20% bolus 100 mL IV over 2-3 mins (1.5ml/kg)
- Followed by infusion of 200-250 mL over 15-20 mins. - Bolus can be repeated once or twice; double infusion rate if patient is persistently unstable.
- Continue infusion for at least 10 mins after haemodynamic stability achieved.
- Max dose 12 mL/kg.
How to insert Bakri Balloon
- Check cavity is empty first
- Collapsed balloon is inserted into uterine cavity
- Once in the correct position, sterile saline is used to inflate the balloon to a maximum volume of 500mls. Usually 100-300mL. Document amount of fluid in balloon.
- When inflated, the balloon adopts the shape of the uterine cavity to tamponade endometrial bleeding and controls atony in upper segment.
- The central lumen allows drainage of blood which can be measured and recorded
- Patient will need adequate analgesia post operatively
- Leave the balloon inflated for 8-24 hours & remove it either all at once or gradually over several hours
- IDC and vaginal pack should also be in situ
- Consider antibiotics.
- Document and debrief afterwards
Management of PPH
Recognition, Communication, Resuscitation, Monitoring and investigation & Management of PPH
Recognition:
Weigh blood loss
Continue to evaluate – weighing of ongoing losses
Observe for clinical signs of shock
Communication:
This is an obstetric emergency
Call for help
- Senior obstetric and midwifery staff
- Anaesthetics
- Liase with haematology / transfusion specialists
- ICU
Resuscitation: ABC approach Assessment of airway and breathing, administer high flow oxygen 2x large bore IV cannulas FBC, coags, x-match 4 units IVF 2L (warmed)
Monitoring and investigation:
BP, RR every 10-15 minutes
Continuous monitoring of HR & O2 sats while unstable
Urine output, temperature
Management of PPH:
Address the cause
- Consider the 4 T’s (Tone, trauma, tissue, thrombin)
Given pharmacological management
1. Syntocinon 10IU IV
2. Bolus and infusion (40 units in 500ml IV over 4 hours)
3. TXA 1g IV
4. Can repeat ergometrine 0.5mg IM
5. IM 250mcg Carboprost up to 8 doses
6. Misoprostol 800mcg
Early transfer to theatre if ongoing bleeding
Entrapment of aftercoming head in breech
• A vaginal examination if not fully can the cervix be pushed over the head.
• If the fetal head has entered the pelvis, perform Mauriceau-Smellie-Viet manoeuvre combined with suprapubic pressure from an assistant in a direction that maintains descent and flexion of the head.
• Rotate the fetal body to a lateral position and apply suprapubic pressure to flex the fetal head.
• Apply traction then rotate the fetal back to sacroanterior position and birth after coming head by Neville-Barnes forceps (or clinicians preference).
If above unsuccessful consider alternative manoeuvres:
• Reassess cervical dilatation. If cervix is not fully dilated (especially if preterm) consider Duhrssen incision at 2, 6 and 10 o’clock
• If unsuccessful, symphisiotomy should be performed by an experienced clinician
• Alternatively, a caesarean section may be performed in operating theatre if the baby is still alive. It is necessary for the baby to be pushed from below.
Vaginal breech birth
-Call for extra help
-Ask for the delivery trolley with episiotomy scissors, local anaesthetic +/-pudendal block & operative delivery pack/ forceps,
-Ensure IV access & FBC & group & hold
- CEFM
- Lithotomy
- Local anaesthetic infiltration or pudendal nerve block +/- epis as necessary
- Allow for spontaneous delivery of limbs & trunk:
If need to, apply pressure to popliteal fossae to release legs
Correct position to sacro-anterior - bony prominences only
Allow spontaneous delivery until scapulae are visible
Loveset manoeuvres to deliver arms if they do not do so spontaneously.
Allow baby to hang until nape neck visible
- Assistant on hand to give suprapubic pressure to assist flexion of head
- May need Mauriceau-Smellie-Veit manoeuvre to deliver after coming head: support baby’s body with arm, first and third finger on cheekbones & gentle traction with other hand applied to shoulders, using two fingers to flex occiput
Manage Cord Prolapse
• Call for help
• Give explanations to the woman and her birth partner
• Move the woman into the knee-chest (all fours with buttocks elevated) or exaggerated Sims’ position (left lateral with pillow under the hips)
• If oxytocin augmentation is in progress, discontinue immediately
• Elevate the presenting part digitally or by bladder filling (attach N. Saline via urology set and fill 500-750mls)
• To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina
• Continue to assess fetal heart rate
• Expedite the birth of the baby. At full dilatation, vaginal birth may be an option depending on parity
and engagement of head
• Transport the woman to the operating theatre, if required
• Tocolysis (Terbutaline 250 microgram subcutaneous (SC)) can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically or when the delivery is likely to be delayed. May allow time for regional anaesthesia to be administered.
How to disimpact the deeply impacted, deflexed OP fetal head
Call for assistance from experienced obstetrician
Attempt to disimpact head with entire hand under babies head to flex and lift.
Change and use non-dominant hand and do not flex wrist as this increases risk of uterine tearing.
GTN or other tocolytic to help relax uterus and give more room for baby to move up into the uterine cavity.
Bed as low as it can go and standing stool and maternal trendelunberg.
Consider gentle elevation of head by experienced practitioner from below. Careful to spread force across entire hand rather than 1-2 fingers to prevent fetal injury.
Reverse breech extraction - to give more room for this consider T incision at uterotomy and extending skin and sheath excisions.
Prepare for management of PPH.
Abruption management
777 obstetric emergency
MDT approach: obstetrics/anaesthetics/midwifery/theatre/haematology and blood bank/ICU
• A/B: ensure patent airway and spontaneous breathing, record RR and O2 saturations, administer high flow oxygen via face mask, keep patient warm
• C: record HR, BP, cap refill, 2 large 16G IVL, take bloods for FBC, G&S, cross-match 4-6u, Kleihauer, coagulation screen, baseline renal function (creatinine, U+E), LFTs to complete PET screen in context of abruption, attempt to estimate blood loss (weigh, revealed vs. concealed)
• Rapid infusion with 2-3L warmed crystalloid through pressure bags
• Consider IDC and aim for UO >30mL/hour
• Close monitoring of maternal haemodynamic status
• Early consideration of blood products if ongoing HD instability ?may require activation of MTP
• Correct coagulopathy as needed
• If ongoing heavy bleeding and HD instability despite resuscitative measures - for EM CS under GA to reduce maternal morbidity/mortality
• Discussion with patient/family regarding diagnosis (abruption, IUFD) and severity of situationx
• Consent - may need to be verbal if situation life-threatening, risk for hysterectomy to be discussed
• Ongoing correction of any coagulopathy
• Senior obstetric/anaesthetic staff present
• Anticipate PPH, may necessitate hysterectomy
• Post-operatively may require ICU/HDU bed
• Once mother stable - open disclosure/discussion with patient/family, documentation
Counsel previous 3rd degree tear
Vaginal delivery not contraindicated 5 - 7% risk re-injury with 17% risk worsening Sx
Only way to prevent is Caesarean
Prophylactic episiotomy not proven – judicious use recommended; is recommended with instrumental
If symptomatic consider endoanal USS and refer to gen surg
Following your perimortem CS what is your next course of action?
o Transfer to theatre to close uterus and abdomen.
Consider washout and IV antibiotics given performed in a dirty field.
Consider blood transfusion if significant bleeding has occurred.
o Postpartum:
Admit to HDU/ICU
Clexane prophylaxis 6 hours postop if no ongoing bleeding concerns
Debrief with woman and family. Consider referral for psychologist support given traumatic experience. Screen for postnatal depression and anxiety.
Breastfeeding support
Discuss contraception and advice re: pregnancy spacing.
Maternal collapse/CPR
Unresponsive proceed to CPR
S - send for help
Lay flat and manually displace the uterus or place on a wedge for a left lateral tilt
Commence CPR 30:2
Apply defibrillator pads and assess rhythm
Airway and breathing asess for need of adjuncts and apply high flow O2 via a non re-breath mask
2 x Large bore IV cannulas
Takes bloods: FBC, U&Es, Mg, Ca, LFTs, Co-ags, lactate and blood gas
Commence IV fluids
Think causes 4Hs and 4Ts Hypoxia Hypovoleamia Hyper/hypo kaleamia or Glycaemia Hyer/hypothermia Tamponade Tension pneumothorax Toxicity Thrombosis Amniotic fluid embolis
Consider IV adrenaline 1mg +/- Amiodarone 300mg depending on rhythm
If no ROSC within 4 mins proceed to perimortem c-section
Anaphylaxis treatment
Oxygen via mask with resovir bag Adrenaline 500mcg/0.5ml 1:1000 IM repeated every 5 mins if still perisistent hypotension or bronchospasm Other drugs: Chlorophenamine 10mg IV Hydrocortisone 200mg IM/IV Salbutamol Nebuliser 5mg IV fluids
