3rd Stage + Postpartum Flashcards
Mx of blood transfusion reaction
Scenario 1 - PPH -> blood transfusion on ward, distressed with fever/chills/chest discomfort
Scenario 2 (gynae) - post TAH/BSO
DDx
- blood transfusion reaction
- sepsis
- I’m concerned about a transf reaction
- Cease blood transfusion
- Oxygenate patient
- Resuscitate with colloid
- Check label on blood and on patient
- IV Antihistamine + IV Hydrocortisone
- Consider IM adrenaline if anaphylaxis or severe reaction
- Contact Hematologist
- Blood products returned to Hematology for investigation
Counselling post shoulder dystocia cx & future pregnancy
Brachial plexus injury
- stretching of nerves of brachial plexus from traction
- w/o effecting timely delivery of the baby, far worse injury to baby (hypoxic brain injury)
- weakness in arm up to 12 months to fully resolve
- 90% cases there is no permanent injury
- pediatric team will be involved in assessment & mx of baby
SD
- hx of SD -> 1-16% recurrence
- macro/GDM/long1st/2nd/obesity
- elCS vs USS/IOL by 39/40
Mx of APO
(previous scenario = postopartum in context of RHD/moderate MS & pre-existing anaemia and new onset tachyarrhythmia)
- Emerg -> resp failure -> HD instability
- MDI - obs med/anesthetic/cardiology
- hx - SOB/CP/palpitation/cough
- exam - vitals, cardioresp, WOB
- ix (bloods) - FBE/UEC/LFT/ABG/resp pan
- ix (imaging) CXR +/- ECG +/- POCUS
- stabilization - NIV, vasopressor, diuretics
- rx cause (e.g. rate ctrl - AF)
- monitor - IDC - UOP, HDU/ICU
- supportive - analgesia, sedation, VTE
Mx of uterine inversion
- Emerg -> massive PPH/Sig mat M&M
- Activate hospital emergency response
- MDI - Obs/MW/Anaesthetic…
- Simultaneous
x2 WB IVC + IVT + IDC + O2
x2 PRBC matched, x4 FFP - Prep for OT
- Johson’s vs O’Sullivan’s
- Succes -> Utero-tonics
- OT- MROP +/- Bakri (stop re-inversion) + PRBC + Abx
- Unsuccessful -> Uterine relaxant (GTN x1 spray or IV salbutamol/terbutaline), re-attempt in OT, MTP, OT
- Surgical management - laparotomy - Haultain technique -> Hysterectomy
Postprocedure
- IV Abx
- clear documentation
- debrief pt/team
- MDT …
Johnson’s maneuver = manual replacement, cup fundus in palm of hand, apply pressure in direction of vagina toward umbilicus
O’Sullivan’s maneuver = trendelenberg, return uterus/placenta to vagina, seal vagina using kiwi cup/neonatal ventilation mask/large IDC -> free-flowing warm normal saline into vagina (hung at least 1m above patient)
Note - Haultain’s procedure (to prevent ischemic uterus) - traction on round ligament, incision through muscular ring of posterior uterine wall -> traction of round ligament + manual pressure on fundus from vagina -> close incision following uterine replacement.
Mx of no urine output post emCS (classical) in setting of severe PET
DDx
- retention post regional
- blocked catheter
- urinary traction infection
- renal failure 2nd to PET
- bladder/ureteric injury 2nd to emCS
Hx
- HOPC - hx of fluid input/output, postop E+D, mobility, bowel
- fluid balance chart (peri-op in/out)
- operation report (any complications)
- clarify any pre-existing renal impairment
- medications (renal toxic agents - anti-HTN - cease ACEI)
Exam
- skin turgor/mucous membrane (dehydration)
- abdo examination (wound, unexpected swelling, peritonism, urinoma)
- ensure IDC patent if still in-situ (exclude blocked catheter)
- bladder scanner (post renal cause)
- urine MCS (exclude UTI)
Ix
- UEC (ax Cr and EGR, ?AKI)
- renal tract USS (hydroureter/hydronephrosis) +/- CT-KUB
Mx
- strict fluid balance
- MDI - obs med vs urology
Mx of postpartum sepsis
Scenario 1 - PPROM->chorio on triple abx 4/24 post classical CS c/b 1.2L PPH, hypo/tachycardic/febrile/low O2 sats/elevated RR GCS13, not bleeding
Issues
- Sepsis most likely chorio
- Other sources may be possible
- ?Shock (unresponsive to fluids)
- Emergency response
- MDI - Obs/MW/Ano/ID/ICU/Paeds
- Resuscitation + Stabilization + Ix
Resus/Stabilization
- DRABC - O2/IVCx2/IDC/IVT
- 1L stat/poor response ->pressors
- ABx - broad -> mero/clinda/gent
- Antipyretic - reduce metabolic demand
- VTE prophylaxis - LMWH/SCUDS
- HDU -> ICU (if circulatory supp req)
Investigations
- Target Hx/Exam
- FBE/UEC/LFT/CRP/Coag/VBG + BC
- Lactate >4 = hypoperfusion
- MCS - urine/resp/wound
- +/- pelvic USS, CTAP, CXR
Postpartum care plan
- post CS c/b sig PPH
Postpartum
- Ix: Hb/Ferritin
- Risks: infection, breast feeding
- Debrief: cause
- Supplements: PRBC vs Fe infusion vs PO Fe
- Contraception: …
- Breastfeeding: …
- Clinical audit: cause/mx/rx/improvement
- VTE prophylaxis: evaluate with other RFs ? extended
Future
- uterotonics (e.g. syntometrine)
- evaluate RFs antenatally
- optimize hemantenics
Describe B-lynch
- Exteriorize uterus
- Horizontal incision in lower segment of uterus
- Confirm uterus empty
- Compress uterus with bimanual
- Use absorbable suture on large needle 1 chromic catgut or 0 monocryl or 1 vicryl 3cm above and below incision
& 3-4cm from lateral uterus - suture pass over anterior uterus to back…
- Tighten ends to compress uterus
- Close hysterotomy or CS incision
see diagram in “The Updated Book”
PPH mx
Scenario 1 - Mx of PPH at VD
Fundal massage
IDC insertion
Uterotonics
- ergot IV/IM 250mcg q5min max1mg
- carbo IM 250mcg q15min max2mg
- txa 1g IV
- synto 40iu infusion
- misoprostol PR max 1mg
- Intra-uterine tamponade device - insertion in OT, use USS to check position, monitor output, iodine-soaked pack to keep in position, removal 12/24, IDC in-situ
- B-lynch
- UA or UOA ligation
- Pelvic packing
- Ligation of IIA
- Embolization
- Hysterectomy
Describe how to ligate the internal iliac artery
- divide pelvic peritoneum parallel to IP ligament to enter retroperitoneal space
- identify EIA/vein laterally on Psoas and ureters medially
- retract ureter medially to expose CIA
- identify IIA as a branch of CIA
- expose IIA and IIV runs underneath it
- ligate IIA distal to posterior division
- re-identify structures before IIA ligate
inadvertent ligation of posterior division of IIA -> ischemia of buttock & sciatic nerve
What are the branches of IIA - anterior & posterior division
Anterior
- obturator
- internal pudendal
- inferior gluteal
- umbilical
- vaginal
- uterine
- middle rectal
Posterior
- iliolumbar
- lateral sacral
- superior gluteal
Mx of retained placenta
Hx
- time/uterotonics given
- assoc injuries/EBL/analgesia
- IDC/IVC/IVT
- G&P, labor course, RF for PAD
- placental location
Exam
- vitals - HDS
Ix
- FBE/G&S
- Obs USS record
Mx
- Conservative -bladder/mobilise
- Attempt CCT again
- Manual pressure on uterus (Dublin’s)
- IDC/IVT/Syntocinon infusion
- Keep NBM
- Consent/Book OT +/- x-match 2 units
- Pre-op abx/vaginal prep
- Manual removal/check cervix
- Perineal repair
- Documentation
- Debrief +/-…
Mx of OASIS
Scenario 1- 3rd degree tear
Scenario 2 - 4th degree tear
- in OT w good lighting/analgesia
- support from senior colleague
- +/-2nd opinion from CR surgeons
- anal mucosa 3-0 vicryl continuous
- sphincter 3-0 PDS end-to-end
- routine repair of perineum
- abx/analgesia/aperients
- debrief/education/PT rv I/P
- PT/PF OPC 3/12 - sx/exam
- Anal manometry sx/future MOD
OASIS counselling
- 60-80% asx 12/12
- 20-35% have defect on anorectal USS
- risk of recurrence 5-7%
- if recurrence >44% incontinent
- > 15% worse sx even if no OASIS
- consider CS if no resolution of sx and/or abn anorectal USS
Demonstrate on mannequin of neo-resus
- call for help
- stimulation
- ax - resp effort/HR/colour/tone
- HR dictates ventilation req
- follow protocol on resuscitaire
- Good resp HR>100 - monitor/warm
- Poor resp HR<100, cyanotic -> PPV
- PPV 30/5 PIP/PEEP
- Watch chest rise & fall
- HR<60 after 30s of effective vent
- start chest compression 100% O2
- 3 compression to 1 inflation every 2s
- optimize airway, check response
- persistent HR <60s - venous access & vasopressor support
