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Abnormal Labour Flashcards

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1
Q

What is antepartum haemorrhage?

A

Haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby

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2
Q

Give causes of antepartum haemorrhage

A

Placenta praevia

Vasa praevia

Placental abruption

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3
Q

What is vasa praevia?

A

Abnormally unprotected fetal blood vessels, in which they travel through the membrane and run near the internal opening of the uterus, exposing them to rupture

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4
Q

Give risk factors for vasa praevia

A

IVF

Multiple pregnancy

Low lying placenta (placenta within 20mm of cervical os, wheras praevia is covering)

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5
Q

How does vasa praevia present?

A

Painless vaginal bleeding following membrane rupture

Pulsating fetal vessels on examination

Fetal heart rate abnormalities/bradycardia

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6
Q

How is vasa praevia managed?

A

Elective c section 34-36 weeks with glucocorticoids

Emergency c section if antepartum haemorrhage

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7
Q

What is placenta praevia?

A

Implantation of the placenta within the lower uterine segment, below the presenting part of the fetus

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8
Q

Describe grade 1 placenta praevia

A

Placenta on the lower segment of uterus but does not reach cervical os, also known as low lying

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9
Q

Describe grade 2 placenta praevia

A

Placenta reaches the cervical os but still does not cover it, also known as low lying

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10
Q

Describe grade 3 placenta praevia

A

Placenta partially covers the cervical os

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11
Q

Describe grade 4 placenta praevia

A

Placenta completely covers cervical os

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12
Q

What are risk factors for placenta praevia?

A

Multiparity

Multiparous

Increased maternal age (>35)

Intrauterine fibroids

Maternal smoking

Previous C-Section, as in future pregnancies placenta attaches to scar

Previous placenta praevia

IVF

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13
Q

How does placenta praevia present?

A

May be asymptomatic and often incental as stable maternal and fetal condition

Painless bright red bleeding

Malpresentation of the fetus, usually transverse

Soft, non tender uterus

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14
Q

Why can placenta praevia only be officially diagnosed in the third trimester?

A

Although can be seen on original booking scan, a significant number will migrate up, so can only be diagnosed officially in third trimester

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15
Q

What US is used in placenta praevia diagnosis?

A

Transvaginal

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16
Q

What is the management of placenta praevia?

A

Planned c section at 36-37 gestation

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17
Q

What is the management of placental praevia haemorrhage?

A

Emergency c section

Blood transfusion

Intrauterine balloon tamponade

Uterine artery occlusion

Emergency hysterectomy

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18
Q

What is placental abruption?

A

Premature separation of the placenta from the uterine wall during pregnancy

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19
Q

What are the categories of placental abruption?

A

Revealed, haemorrhage is apparent externally as the blood escapes through the cervical os

Concealed, haemorrhage occurs between the placenta and uterine wall and so does not escape through os

Mixed

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20
Q

Give risk factors for placental abruption

A

PET/HTN

Multiple pregnancy

Polyhydramnios

Smoking

>Age

Multiparity

Previous abruption

Cocaine

Trauma

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21
Q

How does placental abruption present?

A

Severe sudden continous abdominal pain in 3rd trimester

Dark red vaginal bleeding, although absence does not rule out diagnosis as in the case of concealed

Increased uterine activity/tone/contractions

Couvelaire uterus/bruising

‘Woody’ hard uterus

Cold to touch

Longitudinal fetus

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22
Q

How is placental abruption managed?

A

Urgent involvement of a senior obstetrician, midwife and anaesthetist

2 x grey cannula

Crossmatch 4 units of blood

Fluid and blood resuscitation as required

CTG monitoring of the fetus and monitoring of the mother

Attempt vaginal delivery or emergency aesarean section

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23
Q

What is amniotic fluid embolism?

A

Anaphylactic reaction to the presence of amniotic fluid and fetal matter into the maternal lungs, leading to HTN and hypoxia

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24
Q

Give the prognosis of amniotic fluid embolism

A

80% mortality

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25
How does amniotic fluid embolism present?
Occurs shortly after labour Hypoxia, including cyanosis Hypotention Coagulopathy, showing increased PT
26
How is amniotic fluid embolism managed?
Oxygen and fluid resucitation Treat coagulopathy Immediate delivery Supportive management thereafter
27
What is preterm labour?
Onset of labour before 37 completed weeks gestation
28
Describe mildly preterm
32-36
29
Describe very preterm
28-32
30
Describe extremely preterm
24-28
31
Give risk factors for preterm labour
Idiopathic Multiple pregnancy Extremes of maternal age Heavy stressful work Smoking Substance of misuse Cervical Incompetence Uterine anomalies Polyhydramnios Previous pre-term delivery Group B Streptococci APH Pre-eclampsia Infection/UTI Premature rupture of membranes associated with infection
32
What is the main cause of preterm labour?
Idiopathic
33
What investigations are used in PPROM?
Fetal fibronectin * Protein released from gestational sac, associated with early labour Speculum examination * Pooling of amniotic fluid in the posterior vaginal vault * Avoid digital examination to reduce the risk of introducing infection to the uterus US * Used if still expected but no pooling of amniotic fluid in posterior vaginal vault * Oligohydramnios
34
What is fetal fibronectin?
Protein released from gestational sac, associated with early labour
35
How is PPROM managed?
Admission and observation for chorioamnionitis Oral Erythromicin for 10 days 2 doses IM steroids for neonate lung maturity Delivery at 34 weeks
36
What steroid is given in PPROM?
Dexamethasone
37
Give neonatal complications of pre-term labour
Respiratory distress syndrome Intraventricular haemorrhage Cerebral palsy Nutrition Temperature control Jaundice Infection Visual impairment Hearing loss
38
What is induction of labour?
When an attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix”, followed usually by artificial rupture of membranes (performing an amniotomy)
39
How many pregnancies are induced?
Approx 1/5
40
Give indictations for induced labour
Gestational diabetes Post dates, term + 7 days Maternal health problem that necessitates planning of delivery, such as DVT, PET Fetal reasons * Suspected IUGR * Oligohydramnios * IUD Social reasons Maternal request Pelvic pain Big babies Pre-labour rupture of membranes
41
Give disadvantages of induced labour
Less efficient and more painful Requires fetal monitoring Risk of uterine hyperstimulation with prostaglandin/oxytocin induction
42
Give contraindications for induced labour
Obstruction to birth canal * Major placenta praevia * Masses Malpresentation * Transverse * Shoulder * Breech Medical conditions where labour would not be safe for women Specific previous labour complications: Previous uterine rupture Fetal conditions
43
Give complications of induced labour
\>Risk of instrumental and operative delivery Uterine hyperstimulation Failed induction Cord prolapse Uterine rupture
44
What score is used to clinically assess the cervix
Bishop score
45
What does the Bishop score assess?
Used to clinically assess the cervix The higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful
46
What Bishop score suggests labour is unlikely to start without induction?
Less than 5
47
Describe the induction process
Membrane sweep Vaginal prostaglandin pessaries or a Cook balloon is used to ripen/open the cervix Once cervix has dilated and effaced, an amniotomy can be performed Once amniotomy is performed, IV oxytocin is used to achieve adequate contractions, although misoprostol can also be used
48
What are the properties of a Cook balloon?
Inflates os No hyperstimulation Works within 12-24 hours
49
What are the properties of vaginal pessaries
Initiates contractions Takes 2-3 days Risk of hyperstimulation
50
What is an amniotomy?
Artificial rupture of membranes/amniotic fluid
51
What Bishop score is favourable of amniotomy?
7 or more
52
What Bishop score suggests labour is likely to commence spontaneously?
Over 9
53
Why can oxytocin only be given if no obstruction?
Can cause uterine rupture
54
How many contractions should be aimed for in induced labour with oxytocin?
4/5 in 10 minutes
55
What is the most common malpresentation?
Breech
56
What can cause malpresentation?
Often no cause identified Multiple pregnancy Polyhydramnios Uterine abnormalities Placenta praevia Congenital abnormalities
57
What is the management of breech malpresentation?
External cephalic version at 36 weeks, as baby may move spontaneously before this If remains breech, caesarean delivery is recommended due to risk of head entrapment
58
What is the management of face malpresentation?
Vaginal delivery is possible in mento-anterior (chin lying behind symphysis pubis) Ventouse delivery is contraindicated
59
What is the management of transverse malpresentation?
Stabilizing induction with external cephalic version Followed by artificial rupture of membranes, otherwise caesarean section
60
When is external cephalic version contrainindicated?
Where caesarean delivery is required Antepartum haemorrhage within the last 7 days Abnormal cardiotocography Major uterine anomaly Ruptured membranes Multiple pregnancy
61
Give absolute contraindications to external cephalic version
Caesarean section is already indicated for other reason Ante-partum haemorrhage has occurred in the last 7 days Non-reassuring cardiotocograph Major uterine abnormality Placental abruption or placenta praevia Membranes have ruptured Multiple pregnancy, but may be considered for delivery of the second twin
62
Give a complication of transverse malpresentation
Risk of cord prolapse if spontaneous rupture of membranes
63
What is cord prolapse?
Descent of the umbilical cord through the cervix alongside or past the presenting part of the fetus, increasing risk that fetus will compress the cord and cause hypoxia
64
Give risk factors for cord prolapse
Prematurity Multiparity Polyhydramnios Multiple pregnancy Cephalopelvic disproportion Malpresentation Placenta praevia Long umbilical cord High fetal station
65
What is the most common cause of cord prolapse?
Artificial amniotomy
66
How does cord prolapse present/how is it diagnosed?
Suspected in CTG fetal distress Confirmed with speculum
67
What are the indications for continuous CTG monitoring during labour?
Ssuspected chorioamnionitis or sepsis, or a temperature of 38°C or above Severe hypertension 160/110 mmHg or above Oxytocin use Presence of significant meconium Fresh vaginal bleeding that develops in labour
68
How is cord prolapse managed?
Call for help Elevate presenting part either manually or by filling the urinary bladder Knees and elbows position while waiting for surgery Tocolytic medication can be used to minimise contractions while waiting for surgery Immediate delivery * Forceps vaginal delivery if cephalic presentation and fully dilated * Emergency caesarean section Once delivered, neonatal resuscitation as appropriate
69
Give complications of cord prolapse
Infant death Cerebral palsy and hypoxic encephalopathy, caused by cord compression and vasospasm
70
What is shoulder dystocia?
Anterior shoulder impacts on maternal symphysis pubis and so delivery requires additional obstetric manoeuvres to release
71
Give risk factors for shoulder dystocia
Previous shoulder dystocia Macrosomia Diabetes mellitus BMI\>30 Induction of labour Prolonged first and second stage labour Forceps/Ventouse delivery Oxytocin
72
Give the management for shoulder dystocia
**HELPERR** Call for help Evaluate for episiotomy McRobert's manoeuvre Suprapubic pressure Internal rotation of anterior shoulder Remove posterior arm Roll the patient onto all fours and begin the cycle
73
What is McRobert's manoeuvre?
Flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen
74
Give complications of shoulder dystocia
Fetal mortality Hypoxic encephalopathy Cerebral palsy Brachial plexus injury Erb's palsy PPH Significant perineal trauma
75
What is Chorioamnionitis?
Preterm premature rupture of the membranes * Exposes the normal sterile environment of the uterus to potential pathogens * However can occur when membranes are still intact
76
How does chorioamnionitis present?
Abdominal pain Uterine tenderness Flu like symptoms Pyrexia Foul smelling discharge
77
How is chorioamnionitis managed?
Prompt delivery, C section if necessary Administration of IV antibiotics
78
Give complications of chorioamnionitis
Maternal and fetal mortality, obstetric emergency
79
What is placenta accreta?
Describes the attachment of the placenta to the myometrium, due to a defective decidua basalis As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage
80
Give risk factors for placenta accreta
Previous C section Placenta praevia
81
How is placenta accreta managed?
Hysterectomy * Delayed placental delivery

Reproduction (18 decks)

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