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Reproduction and Sexual Health > complications of labour > Flashcards

complications of labour Flashcards

1
Q

30 y/o women
SVD 4.4kg baby 70 mins ago
midwife-led unit
not yet passed placenta
EBL 700ml and ongoing PV loss

what is going on?

A

PPH

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2
Q

define PPH

A

> 500 mls in first 24 hours
- SVD > 500 ml
- operative vaginal delivery >750ml
- CS > 1000ml

major PPH >1000ml

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3
Q

what are the 4 main causes of PPH?

A
  • Tone (uterine atony)
  • Trauma (perineal tears, cervical tears)
  • Tissue (placenta, fragment of placenta)
  • Thrombin (coagulation problems)
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4
Q

PPH management?

A
  • ABCDE
  • people
  • drugs
  • other interventions - surgery…
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5
Q

what drugs can you give someone in management of PPH?

A
  • uterotonics - synctocinon (oxytocin), ergametrine (IM can’t give to those w raised BP), carboprost, misoprostol, tranexamic acid (slows down bleeding)
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6
Q

what uterotonics are not recommended to those w asthma?

A
  • carboprost
  • misoprostol

> both prostaglandins

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7
Q

what are some surgical options for PPH?

A
  • intrauterine balloon
  • brace sutures - (stitch around uterus however requires laparotomy)
  • interventional radiology - (block vessels off uterine artery or iliac balloons)
  • hysterectomy
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8
Q

what are two types of management of 3rd stage of labour?

A
  • physiological (up to 60 mins)
  • active (up to 30 mins)
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9
Q

in physiological management of 3rd stage labour what happens?

A
  • no uterotonics given
  • placenta is delivered by maternal effort alone
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10
Q

what are the disadvantages to physiological management in the 3rd stage of labour?

A
  • increased length of 3rd stage
  • increased risk of PPH
  • increased need for blood transfusion
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11
Q

what does active management in the 3rd stage of labour involve?

A
  • uterotonics - synctocinon, ergmaetrine
  • cord clamped
  • controlled cord traction
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12
Q

what are the advantages to active mx in 3rd stage of labour?

A
  • decreased PPH, decreased length of 3rd stage
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13
Q

what are the disadvantages to active mx in 3rd stage labour?

A
  • nausea/vomiting
  • risk of cord avulsion
  • uterine inversion
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14
Q

what is morbidly adherent placenta?

A
  • affects 1:7000 pregnancies
  • more common if previous CS or uterine surgery
  • can be undiagnosed until delivery
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15
Q

a normal placenta is separated from the uterine wall by what?

A
  • by a fine fibrinous layer
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16
Q

what is a placenta accreta?

A
  • where placenta attaches firmly to the uterine wall lining
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17
Q

what is placenta increta?

A
  • placenta invades at least half way through uterine wall
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18
Q

what is placenta percreta?

A
  • invasion through the uterine wall, sometimes into nearby tissues, like the bladder
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19
Q

what is uterine inversion?

A
  • rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out
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20
Q

how common is a uterine inversion?

A
  • very rare occurence
  • however life-threatening obstetric emergency
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21
Q

what is an imcomplete uterine inversion?

A
  • partial inversion, where fundus descends inside uterus or vagina but not as far as introitius (opening of the vagina)
  • complete - descend to introitus
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22
Q

why can uterine inversion occur?

A
  • pulling too hard on umbilical cord during active management of third stage of labour
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23
Q

how does uterine inversion present?

A
  • presents w a large postpartum haemorrhage
  • maternal shock or collapse
  • an incomplete uterine inversion may be felt w manual vaginal examination
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24
Q

mx of uterine inversion?

A
  • johnson manoeuvre -> using hand to push fundus back up into abdomen, done under GA
  • hydrostatic methods
  • surgery
25
Q

what is one of the main complications of shoulder dystocia?

A
  • brachial plexus injury
26
Q

what are some antenatal risk factors for shoulder dystocia?

A
  • previous shoulder dystocia, fetal macrosomia, diabetes, BMI > 30, short stature
27
Q

what are some intrapartum risk factors for shoulder dystocia?

A
  • slow 1st and/or 2nd stage labour, induction of labour, instrumental delivery
28
Q

what are some other fetal complications of shoulder dystocia?

A
  • hypoxia, fracture of clavicle/humerus, intracranial haemorrhage, death, brachial plexus injury
29
Q

what are some maternal complications of shoulder dystocia for mum?

A
  • PPH, genital tract trauma, pelvic injuries
30
Q

what is mx for shoulder dystocia?

A

H - call for help
E - evaluate for episiotomy
L - legs: Roberts manoeuvre
P - external pressure: suprapubic
E - enter: rotational manoeuvre
R - remove the posterior arm
R - roll the patient to her hands and knees

31
Q

what structures are involved in genital tract trauma in labour

A
  • perineum
  • anal sphincters
  • cervix
  • labial
  • clitoral
32
Q

what is 1st degree perineal tear?

A
  • to perineal skin only
33
Q

what is 2nd degree perineal tear?

A
  • injury involving perineal skin and muscle but not anal sphincters
34
Q

what is a 3rd degree perineal tear?

A
  • injury involving anal sphincters
    3A - <50% external anal sphincter
    3B - >50% external anal sphincter
    3C - involvement of both external and internal anal sphincter
35
Q

what is 4th degree perineal tear?

A
  • disruption of anal epithelium/mucosa
36
Q

what are the 2 key causes of sepsis in pregnancies?

A
  • chorioamnionitis
  • urinary tract infections
37
Q

what is chorioamnionitis?

A
  • an infection of the chorioamniotic membranes and amniotic fluid
  • leading cause of maternal sepsis
  • usually occurs in later pregnancy and during labour
38
Q

chorioamnionitis can be caused by a large variety of bacteria including?

A
  • gram-positive bacteria
  • gram-negative bacteria
  • anaerobes

examples -> E. coli, mycoplasma, anaerobes, group B strep

39
Q

how does chorioamnionitis present?

A

non-specific signs of sepsis e.g. fever, tachy, raised RR, reduced o2 stats, low bp, reduced UO, raised WCC, fetal compromise on CTG

specific signs - abdominal pain, uterine tenderness, vaginal discharge, offensive PV loss, fetal CTG concern.

40
Q

chorioamnionitis: additional signs and symptoms related to a UTI include?

A
  • dysuria
  • urinary frequency
  • suprapubic pain or discomfort
  • renal angle pain (pyelonephritis)
  • vomiting (pyelonephritis)
41
Q

Ix for chorioamnionitis?

A
  • FBC - WBCs and neutrophils
  • U+Es - assess kidney function and for AKI
  • LFTs - liver function, source of infection? (acute cholecystitis)
  • CRP to assess inflammation
  • clotting - assess for disseminated IV coagulopathy
  • blood cultures - assess for bacteraemia
  • blood gas - assess lactate, pH, glucose
42
Q

additional ix for chorioamnionitis to find suspected source of infection?

A
  • urine dip and culture
  • high vaginal swab
  • throat swab
  • sputum culture
  • wound swab after procedures
  • lumbar puncture - men or encephalitis
43
Q

Mx for sepsis and chorioamnionitis

A
  • septic 6
  • early delivery may be required - under GA as spinal anaesthesia avoided
  • IV antibiotics - co-amox within golden hour +/- gentamicin depending on severity and clindamycin if sore throat (GAS)
  • clinda and genta if pen allergeic
  • taxocin, clinda and genta if septic shock
  • keep sats above 94
  • blood cultures
  • fluid challenge
  • lactate
  • measure urine output
44
Q

sources of postpartum sepsis?

A
  • uterus (endometritis)
  • skin/wound
  • urine
  • breasts (mastitis)
  • chest
  • other
45
Q

risk factors for chorioamnionitis?

A
  • invasive pre-natal diagnostics
  • prolonged rupture of membranes
  • prolonged labour
  • repeat digital examinations in context of ruptured membranes
  • nulliparity
  • meconium stained liquour
46
Q

if early delivery is mx for chorioamnionitis what kind of delivery is it?

A
  • IOL
  • LUSCS

> give syntocinon infusion for 3rd stage to reduce risk of PPH
avoid postpartum intrauterine contraception (PPIUC)

47
Q

what are risks of group B strep in relation to neonatal sepsis, pneumonia and meningitis?

A
  • common bacteria found in genital tract
  • most babies have no problem when exposed to it
  • however risks inc w pre-term labour or PROM (prelabour rupture of membranes)
48
Q

recommendations for GBS mx

A
  • no routine screening required
  • offer intrapartum antibiotic prophylaxis (benzylpenicillin or clinda) if GBS detected antenatally, previous baby has been affected by GBS infection, delivery <37 weeks
49
Q

what is endometritis?

A
  • infection of uterine lining following delivery or miscarriage
50
Q

what are risk factors for endometritis?

A
  • operative delivery
  • prolonged labour
  • retained products of conception
51
Q

how does endometritis present?

A
  • typically presents w abdominal pain, abnormal PV bleeding, offensive PV loss
52
Q

what is tx for endometritis?

A
  • co-amoxiclav +/- surgical evacuation of uterus if sig RPOC (retained products of conception)
    -> co-trimoxazole and metronidazole if pen allergic
53
Q

what is mastitis?

A
  • usually unilateral painful and inflamed breast in breastfeeding mothers
54
Q

1st line mx for mastitis?

A
  • ensuring breast emptying by feeding +/- expressing. warm compresses and NSAIDs
  • may require flucloxacillin if not improving or signs of sepsis - clinda if pen allergic
55
Q

if no response to antibiotics in a women w mastitis what is next line mx?

A
  • refer to breast team for USS +/- drainage
    as could indicate breast abscess
56
Q

what is a rare complication of epidural abscess?

A
  • sepsis
57
Q

what is signs of sepsis in women who have an epidural abscess

A
  • back pain or fever and potential for euro deficit as it progresses
58
Q

dx for sepsis in women w epidural abscess

A
  • MRI
59
Q

tx for sepsis related to epidural abscess?

A
  • vancomycin, metronidazole and cefotaxime to cover MRSA, anaerobes and gram -ve bacteria
  • choice between open surgery vs CT guided aspiration to drain collection

Reproduction and Sexual Health (29 decks)

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