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Complications in Labour Flashcards

1
Q

What is primary post partum haemorrhage

A

Bleeding from the genital tract within 24 hours of the birth of a baby

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2
Q

What is secondary post partum haemorrhage

A

Bleeding from the genital tract 24 hours - 6 weeks after delivery

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3
Q

What volume of blood loss is classed as major PPH

A

<1000mls

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4
Q

Risk factors for PPH

A

Hx of PPH
Prologed labour
Polyhydramnios
Macrosomia
Sepsis
Low lying or morbidly adherent placenta
Multiple pregnancy
Bleeding disorders
Fibroids

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5
Q

Risk factors for PPH

A

Hx of PPH
Prologed labour
Polyhydramnios
Macrosomia
Sepsis
Low lying or morbidly adherent placenta
Multiple pregnancy
Bleeding disorders
Fibroids

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6
Q

What are the four T’s of causes of PPH

A

Tone (uterine anatomy)
Trauma
Tissue
Thrombin (coagulopathy)

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7
Q

Causes of PPH - Tone

A

Previous PPH
Uterine relaxants
Placenta praevia
Overdistention of uterus (multiple preg, polyhydramnios, macrosomia)
Porlonged uterotonics in labour
Grand mulitpara
Advanced maternal age

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8
Q

Causes of PPH - Trauma

A

C section
Episiotomy
Vagina, perineal or cervical trauma
Lacerations
Haematoma
Ruptures

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9
Q

Causes of PPH - Tissue

A

Retained placenta
Placenta accreta
Retained products of conception

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10
Q

Causes of PPH - thrombin

A

Amniotic fluid embolism
Use of anti-coagulants
Pre-eclampsia
Placental abruption
Pyrexia in labour
Bleeding or clotting disorders

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11
Q

Most common cause of PPH

A

Tone of uterus - 80%

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12
Q

General management of PPH in labour

A

A-E
IV access and bloods
IV fluids
Active management of third stage
Treat cause of bleeding

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13
Q

Management of PPH in labour - tone

A

Bimanual compression
Empty bladder
Uterotonics
Bakri balloon
Surgery

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14
Q

Management of PPH in labour - trauma

A

Repair perineum
Exam under anaesthesia
Repair lacerations
In caesareans repair uterine angle extensions

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15
Q

Management of PPH in labour - tissue

A

Manual removal of placenta/products

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16
Q

Management of PPH in labour - thrombin

A

Treat sepsis with abx
Reverse bleeding with FFP and clotting factors

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17
Q

Examples of uterotonics

A

Syntocinon
Synthometrine
Misoprostol
Haematbate
Tranexamic acid

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18
Q

Surgical options for treating PPH - tone

A

B lynch suture, internal iliac ligations, hysterectomy

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19
Q

Causes of secondary PPH

A

Infection
Retained products of conception

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20
Q

What is Sheehan’s syndrome

A

Rare complication of PPH where the drop in the circulating blood volume leads to avascular necrosis of the pituitary gland

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21
Q

Pathophysiology of Sheehan’s syndrome

A

Low BP and reduced perfusion to the pituitary gland leads to ischaemia of the cells in the pituitary. This affects only the anterior pituitary due to differing blood supplies.

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22
Q

Presentation of Sheehan’s syndrome

A

Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH

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23
Q

Presentation of Sheehan’s syndrome

A

Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH

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23
Q

Presentation of Sheehan’s syndrome

A

Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH

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24
Management of Sheehans syndrome
Oestrogen and progesterone as HRT until menopause Hydrocortisone for adrenal insufficiency Levothyroxine for hypothyroidism Growth hormone
25
What is umbilical cord prolapse
When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after ROM
26
What is the danger around umbilical cord prolapse
The presenting part of the fetus can compress the cord which results in fetal hypoxia
27
Risk factors for umbilical cord prolapse
Fetus is an abnormal lie position after 37 weeks gestation - this provides space for cord to prolapse
28
Diagnosis of umbilical cord prolapse
Suspected when there are signs of fetal distress on the CTG. Diagnosed by vaginal examination.
29
Management of umbilical cord prolapse
Emergency caesarean Cord should be kept warm and wet while waiting for delivery Push presenting part of the fetus back up to prevent compression of cord Woman can lie in left lateral position or knee chest position Tocolytic medication
30
What is shoulder dystocia
Anterior shoulder of baby is stuck behind pubic symphysis of the pelvis after head has been delivered
31
Risk factors for shoulder dystocia
Macrosomia secondary to gestational diabetes
32
Presentation of shoulder dystocia
Difficulty delivering the face and head, obstruction in delivering shoulders, may be failure of restitution or turtle neck sign
33
What is the turtle neck sign
Where the head is delivered but then retracts back into the vagina
34
Options for management of shoulder dystocia
Episiotomy McRoberts manoeuvre Pressure to the anterior shoulder Rubins manoeuvre Wood screw manoeuvre Zavanelli manoeuvre
35
What is an episiotomy
Cut is made to enlarge the vaginal opening and reduce risk of perineal tears - not always necessary
36
What is McRoberts manoeuvre
Mother's hip is hyperflexed which provides posterior pelvic tilt, lifting pubic symphysis up and out of the way
37
What does pressure to the anterior shoulder do in shoulder dystocia
Pressure is applied on the suprapubic region of the abdomen which puts pressure on the posterior aspect of the baby's anterior shoulder. This encourages it down and under pubic symphysis
38
What is Rubin's manoeuvre
Reaching into the vagina to put pressure on the posterior aspect of the baby's anterior shoulder to help it move under the pubic symphysis
39
What is the Woodscrew manoeuvre
Performed during Rubin's manoeuvre where the other hand is used to reach inside the vagina to put pressure on the anterior aspect of the posterior shoulder. So the top shoulder is pushed forward and the bottom shoulder is pushed backward to rotate the baby and help delivery
40
What is the Zavanelli manoeuvre
Pushing the baby's heda into the vagina to the baby can be delivered by caesarean
41
Complications of shoulder dystocia
Fetal hypoxia Brachial plexus injury and Erb's palsy Perineal tears Postpartum haemorrhage
42
Indications of using instruments during delivery
Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions Increased risk when epidural is in place
43
Risks of using instruments during delivery
PPH Episiotomy Perineal tears Injury to anal sphincter Incontinence of bladder or bowel Nerve injury - femoral or obturator Cephalohaematoma Facial nerve palsy Subgleal haemorrhage, intracranial haemorrhage, skull fracture and spinal cord injury are serious risks to baby
44
Options for instrumental delivery
Ventouse suction cup or forceps
45
When are perineal tears more common
First births, large babies over 4kg, shoulder dystocia, asian ethnicity, occipito-posterior position, instrumental deliveries
46
What is involved in a first degree tear
Injury limited to frenulum of labia minora and superficial skin
47
What happens in a second degree tear
Tear includes the perineal muscles but does not affect the anal sphincter
48
What happens in a third degree tear
Includes the anal sphincter, but not the rectal mucosa, and is classified into A, B, C depending on % of anal sphincter affected
49
What does a fourth degree tear
Includes the rectal mucosa
50
Management of perineal tears
Broad spec antibiotics Repair in theatre or sutures Laxatives Physiotherapy Follow up
51
Complications of perineal tears
Pain, infection, bleeding, wound dehiscence or breakdown
52
What is chorioamniotitis
Infection of the chorioamniotic membranes and amniotic fluid
53
Generalised symptoms of chorioamniotitis in pregnancy
Fever Tachycardia Raised resp rate Altered consciousness Hypotension Reduced urine output Raised WCC Fetal compromise on CTG
54
Specific symptoms of chorioamniotitis
Abdominal pain Uterine tenderness Vaginal discharge
55
Management of chorioamniotitis
Continuous maternal and fetal monitoring Sepsis six Early delivery GA and avoid spinal anaesthesia Abx regimine
56
What is an amniotic fluid embolism
Where the amniotic fluid passes into the mothers blood which usually occurs around labour and delivery
57
Consequences of amniotic fluid embolism
Causes an immune reaction from the mother which leads to systemic illness. Rare but mortality 20%
58
Consequences of amniotic fluid embolism
Causes an immune reaction from the mother which leads to systemic illness. Rare but mortality 20%
59
Risk factors for amniotic fluid embolism
Increasing maternal age Induction of labour Caesarean section Multiple pregnancy
60
Presentation of amniotic fluid embolism
SOB Hypoxia Haemorrhage Hypotension Coagulopathy Tachycardia Confusion Seizures Cardiac arrest
61
Management of amniotic fluid embolism
Overall management is supportive including A-E and there are no specific treatments
62
What is uterine rupture
When the myometrium ruptures during labour
63
What defines an incomplete rupture
Uterine serosa (peritoneum) surrounding the uterus remains intact
64
What defines a complete uterine rupture
Serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity
65
Risk factors for uterine rupture
Previous caesarean VBAC Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions
66
Presentation of uterine rupture
Acutely unwell mother Abnormal CTG Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse
67
Management of uterine rupture
Emegency caesarean Stop bleeding and repair or remove uterus (hysterectomy) Resus adn transfusion may be required
68
What is uterine inversion
Fundus of uterus drops down through the uterine cavity and cervix turning the uterus inside out. Very rare
69
What is an incomplete uterine inversion
Fundus descends inside the uterus or vagina but not as far as the introitus
70
What is a complete uterine inversion
Involves uterus descending through vagina into introitus
71
Presentation of uterine inversion
Large PPH Maternal shock or collapse Incomplete may be felt with manual vaginal exam Complete may see the uterus as the introitus of the vagina
72
Management of uterine inversion
Johnson manoeuvre Hydrostatic methods Surgery

Obstetrics (8 decks)

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