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O&G > Delivery + Post natal > Flashcards

Delivery + Post natal Flashcards

1
Q

What is cord prolapse

A
  • after ROM the umbillical cord descend below the presenting part of the fetus
  • The cord can be compressed or go into spasm leading to hypoxia and even fetal death
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2
Q

How often does cord prolapse occur

A

1/500 births

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3
Q

Risk factors of cord prolapse

A 
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
placenta praevia
long umbilical cord
high fetal station
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4
Q

Management of Cord prolapse

A
  • presenting part of fetus must e pushed back in
  • patient gets onto all fours
  • Tocolytics can be used
  • Immediate c section
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5
Q

When do you not push the cord back into the uterus

A

If the cord is past the level of the introitus, it should be kept warm and moist

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6
Q

What is the role of Tocolytics

A

reduce cord compression and allow Caesarean delivery

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7
Q

What are the complications of PROM

A

fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis

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8
Q

How often does PROM occur

A

2% of pregnancies

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9
Q

What is the management of PROM

A 
admission
regular observations
Oral erythromycin 10/7
antenatal corticosteroids 
Consider delivery at 34 weeks
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10
Q

What is the role of antenatal corticosteroids

A

Dexamethasone reduces the chance of respiratory distress syndrome in a premature baby

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11
Q

What examinations should be completed if PROM is suspected

A
  • speculum
  • DO NOT DO A VAGINAL EXAMINATION
  • may use nitrazine sticks to detect pH change
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12
Q

When does ‘baby blues’ occur

A

start day 3, peak day 5, subside day 10

Occurs in 50% of women

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13
Q

Characteristics of baby blues

A

tearfulness
irritability
anxiety about the baby
poor concentration

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14
Q

What is McRoberts Manouvre

A
  • hyperflex legs and apply suprapubic pressure
  • babies with shoulder dystocia
  • works 90%
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15
Q

what is post natal depression

A

Seen in one in ten women with a peak around 3 months following birth.

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16
Q

how do we grade post natal depression

A
  • Edinburgh Postnatal Depression Scale
  • screening tool or postnatal depression.
  • There are 10 questions, scores are out of 30 and a score of 10 or more may indicate postnatal depression.
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17
Q

What is Postpartum Thyroiditis

A
  • changes in thyroid function following delivery
  • May present with symptoms of hypo or hyper
  • ,Over time the thyroid function returns to normal
  • small proportion remain hypothyroid
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18
Q

What is the theory behind postpartum thyroiditis

A
  • During pregnancy there is immunosuppression due to increased circulating steroids
  • Following delivery, increased immune system activity and expression of antibodies affecting the thyroid leading to hyper or hypothyroid
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19
Q

What are the stages of postpartum thyroiditis

A

First: hyperthyroid (usually in the first 3 months)
Second: Hypothyroid (usually from 3-6 months)
Third: Thyroid function returns to normal (usually within one year)

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20
Q

What is the management of postpartum thyroiditis

A

Hyperthyroidism: symptomatic control with propranolol.
Hypothyroidism: levothyroxine

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21
Q

What is Sheehan’s Syndrome

A
  • Complication of PPH as drop in circulating blood volume leads to avascular necrosis of the pituitary gland
  • only affects the anterior pituitary (ADH and oxytocin spared)
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22
Q

Where does the anterior pituitary get it’s blood from

A

low pressure system called the hypothalamo-hypophysial portal system. This system is susceptible to rapid drops in blood pressure.

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23
Q

Where does the posterior pituitary get it’s blood from

A

various arteries, and is therefore not susceptible to ischaemia where there is a drop in blood pressure.

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24
Q

What is the common presentaiton of Sheehan’s Syndrome

A 
It leads to hypopituitarism:
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal Insufficiency (lack of ACTH)
Hypothyroidism (lack of TSH)
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25
Q

What is the management of Sheehan’s Syndrome

A

treating each of the hormone deficiencies in turn

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26
Q

What is the management of postpartum anaemia

A

Hb <100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily)
Hb < 80 g/l – give an iron infusion in addition to oral iron (e.g. monofer infusion)
Hb < 70 g/l – give a blood transfusion in addition to oral iron

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27
Q

What is mastitis

A
  • inflammation of breast tissue, with or without infection due to milk stasis in the milk ducts
  • Can lead to breast abscess
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28
Q

What pathogen causes infective mastitis

A
  • Bacteria can enter at the nipple and backtrack into the ducts, leading the mastitis.
  • most common bacteria is staph aureus.
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29
Q

What is the presentation of mastitis

A

Breast pain and tenderness (unilateral)
Erythema
Local warmth and inflammation
Fever

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30
Q

What is the management of mastitis

A
  1. Conservative: expressing & analgesia
  2. Flucloxacillan & send milk to lab for culture and sensitivities (erythromicin if pen allergic)
    - Continue breast feeding, not bad for baby, helps clear mastitis by encouraging flow EVEN if infected
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31
Q

What is covered in the 6 week maternal health check

A

General wellbeing
Mood
Bleeding (menstruation)
Scar healing after episiotomy / caesarean
Contraception?
Breast feeding
Fasting blood glucose if gestational diabetes
Blood pressure (particularly if hypertensive or has pre-eclampsia)
Urine dipstick for protein if pre-eclampsia

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32
Q

What are Braxton Hicks

A

These are like “practice contractions”
They are irregular
They usually occur from the third trimester
Initially they are mild and crampy, but can be quite strong
They last for a few minutes then disappear.
They are not felt by everyone

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33
Q

What are signs of labour

A

Show (mucus plug from the cervix)
Rupture of membranes
Regular painful contractions

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34
Q

Why might you induce labour

A

Macrosomia
Reduced fetal movements
Pre-eclampsia
Premature rupture of membranes

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35
Q

What is the Bishop Score

A
  • A Score that indicates the liklihood of natural labour
  • Score from 0-15
  • <5 unlikely to start a natural labour
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36
Q

What methods are there to induce labour

A
  • Membrane sweep
  • Vaginal prostaglandin pessaries (“Propess”)
  • Artificial rupture of membranes (oxytocin infusion)
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37
Q

What is a membrane sweep

A
  • inserting a finger into the cervix to stimulate the cervix - can be performed in antenatal clinic, and if successful should stimulate the onset of labour within 48 hours.
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38
Q

How to vaginal pesseries induce labour

A

nvolves inserting a pessary into the vagina, similar to a tampon, that slowly releases local prostaglandin E2. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored for a period before being allowed home to wait for the full onset of labour.

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39
Q

What are the indications for continuous CTG

A 
Sepsis
Oxytocin
Meconium
Pre-eclampsia (with blood pressure >160 / 110)
Antepartum haemorrhage
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40
Q

What do you assess in a CTG

A 
Contractions
Baseline Rate
Variability
Accelerations
Decelerations
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41
Q

What is syntocin

A
  • Synthetic version of oxytocin.

- Oxytocin is a hormone that is responsible for starting labour and stimulating the contractions of labour.

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42
Q

What is ergometrine

A

Ergometrine is derived from ergot plants, and is used to stimulate contractions in the uterus during labour.

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43
Q

What is syntometrine

A

Syntometrine is a combination drug of syntocinon and ergometrine that is used to stimulate labour and uterine contractions.

44
Q

What are vaginal prostaglandins

A

Prostaglandin E2 vaginal pessaries (e.g. Propess) are used for induction of labour.

45
Q

What is involved in active management of the third stage

A
  • Empty womans bladder
  • IM syntocinon after birth of the baby
  • Cord clamping and cutting within 1 minute of birth
  • Palpate the abdomen and wait for a uterine contraction prior to delivery of the placenta
  • Controlled cord traction is applied to carefully deliver the placenta (stopping if there is resistance). At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse.
  • The aim is to delivery the placenta in one piece.
  • Examination of the placenta afterwards to ensure no products remain in the uterus.
46
Q

What is first line drug in stimulating contractions during labour

A
  • Syntocinon: started at 0.001-0.004 units / minute and titrated up in 30 minute intervals as required.
  • The aim is for up to a maximum of 4 contractions per 10 minutes.
47
Q

What are the indications for a caesarrean Section

A 
Previous caesarean
Placenta praevia
Breech presentation
Cephalopelvic Disproportion (large baby small pelvis)
Female choice (after full discussion about pros and cons)
IUGR
Post-maturity
Uncontrolled HIV infection
Cervical cancer
48
Q

What is a Cat 1 section

A

There is immediate threat to the life of the mother or baby. Target decision to delivery time of 30 minutes.

49
Q

What is a cat 2 section

A

There is not imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Target is 75 minutes.

50
Q

What is a cat 3 section

A

Delivery is required but mother and baby are stable.

51
Q

What is a cat 4 section

A

Elective section

52
Q

What is a spinal anaesthetic

A
  • involves giving an injection of a local anaesthetic (such as lidocaine) into cerebrospinal fluid at the the lower back. This blocks the nerves from the abdomen downwards.
  • Safer than a GA
  • Takes longer to intiate
  • Awake during the procedure
53
Q

What are the risks of a caesarean section

A
  • general anaesthetic risk
  • Risk of local damage to structures
  • Generic surgical risks
  • effect on abdominal organs
  • Effects on future pregnancies
54
Q

What are the general risks in any surgery

A
  • Bleeding
  • Infection
  • Pain
  • Venous thromboembolism
  • Risks to baby
55
Q

What effects can surgery have on abdominal organs

A

Ileus
Adhesions
Hernias

56
Q

What effect to sections have on future pregnancies

A

Increased risk of repeat caserean
Increased risk of uterine rupture
Increased risk of placenta praevia
Increased risk of stillbirth

57
Q

What risks are there to baby during a caesarrean section

A

Risk of lacerations

Increased incidence of transient tachypnoea of newborn

58
Q

What is VBAC

A
  • vaginal birth after a previous caesarean section: only if another sectoin unlikely
  • An assessment of the likelihood of success should be made in each individual case.
  • Success rate of VBAC is around 75%.
  • Uterine rupture risk in VBAC is about 0.5%
59
Q

What are the contraindications of VBAC

A
  • Previous uterine rupture
  • Classical caesarean scar
  • Other normal contraindications to vaginal delivery (e.g. placenta praevia)
60
Q

What should all woman having an emergency section get following

A
  • Ted stocking
  • 10 days LMWH
  • Elective caesarean sections do not LMWH unless there are other health problems that pre-dispose to VTE.
61
Q

What is the WHO definition of prematurity

A
  • Extreme preterm: < 24 weeks
  • Very preterm: 28 – 34 weeks
  • Moderate to late preterm: 32 – 37 weeks
  • Term: > 37 weeks
62
Q

How do vaginal progesterones prevent labour

A
  • This involves giving progesterone vaginally (via gel or pessary).
  • Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery.
  • Offered to women with a cervical length <25mm on vaginal ultrasound between 16 and 24 weeks gestation.
63
Q

How can prevent preterm labour

A
  • Vaginal Progesterone

- Cervical Cerclage

64
Q

What is Cervical Cerclage

A
  • This involves putting a stitch in the cervix to add support and keep it closed.
  • This involves a spinal or general anaesthetic.
  • The stitch can them be removed when the woman goes into labour or reaches term.
  • Offered to women with a cervical length <25mm on vaginal ultrasound between 16 and 24 weeks gestation who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).
65
Q

What is considered pre-term labour with ROM

A

The amniotic sac ruptures, releasing amniotic fluid in prior to the onset of labour and in a pre-term (<37 weeks gestation) pregnancy.

66
Q

How do you diagnose pre-term labour with ROM

A
  • Speculum examination reveals pooling of amniotic fluid in the vagina (this is diagnostic and no further tests are required)
  • Insulin-like Growth Factor-Binding Protein-1 (IGFBP-1) can be tested on vaginal fluid if there is doubt. This is a protein present in high concentrations in amniotic fluid.
  • Placental Alpha-Microglobin-1 (PAMG-1) is a similar alternative to IGFBP-1.
67
Q

What should do for woman with pre-term ROM

A
  • Prophylactic antibiotics should be given to prevent them developing chorioamnionitis
  • NICE recommend erythromycin 250mg four times daily for 10 days
68
Q

What is Tocolysis

A
  • Medication to stop uterine contractions.
  • Nifedipine
  • It is used to delay delivery to buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with neonatal ICU).
69
Q

why do we give IV magnesium Sulphate

A
  • helps protect the fetal brain during premature delivery. - It reduces the risk and severity of cerebral palsy.
  • They are used in the 24 hours around delivery of preterm babies of less than 34 weeks gestation.
  • Mothers need close monitoring for magnesium toxicity.
70
Q

Why do we give antenatal steroids

A
  • Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery.
  • They are used in women with suspected preterm labour of babies less than 36 weeks gestation.
  • An example regime would be betamethasone 12mg IM, 2 doses, 24 hours apart.
71
Q

How do you assess for preterm labour without ROM

A
  • Clinical assessment should include speculum examination to assess cervical dilatation.
  • If <30 weeks gestation, clinical assessment along is enough to offer management of preterm labour.
  • If >30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. If this is <15mm, then management of preterm labour can be offered.
  • Fetal fibronectin is an alternative test to vaginal ultrasound. It is the “glue” between the chorion and the uterus and is found in the vagina during labour.
72
Q

What is considered a PPH

A

500ml after normal vaginal delivery

1L after caesarean section

73
Q

What are the RF for PPH

A 
Previous PPH
Multiple pregnancy
Grand multipara (5 or more normal vaginal deliveries)
Large baby
Slow or failure to progress in second stage of labour
Pre-eclampsia
Retained placenta
Anaesthetic
74
Q

What are the causes for PPH

A

Tone
Trauma
Tissue
Thrombin (bleeding disorder)

75
Q

How can we prevent PPH

A
  • Treat anaemia during antenatal period
  • Women should have an empty bladder to allow uterine contraction
  • Give oxytocin during third stage of labour
  • Tranexamic acid can be used IV during caesarean section (in the third stage) in higher risk patien
76
Q

What is the management of PPH

A
  • Resuscitation (ABCDE approach including IV fluid / blood)
  • Large bore cannula
  • Group and cross match.
  • Get experienced help.
  • In severe cases “activate the major haemorrhage protocol”,
77
Q

What does activating the major haemorrhage protocol do

A

give quick access to 4 units of crossmatched or O -ve blood

78
Q

What is the mechanical treatment of PPH

A
  • Rubbing the uterus from the abdomen. This stimulates a uterine contraction
  • Catheterisation (bladder distention prevents uterus contractions)
79
Q

What is the medical management of a PPH

A
  • IV 10 units syntocinon / 500mcg ergometrine stat
    “40 units” of syntocinon can be given as a continuous infusion in a woman with severe PPH
  • Carboprost
  • Misoprostol
  • Tranexamic acid 1g stat has been shows to reduce bleeding
80
Q

What is carboprost

A

a prostaglandin analogue and stimulates uterine contraction (caution in asthma)

81
Q

What is misoprostol

A

prostaglandin analogue and stimulates uterine contraction

82
Q

What is the surigcal management of a PPH

A
  • Balloon tamponade
  • B-Lynch suture
  • Uterine artery ligation. This involves ligation of one or more of the arteries supplying the uterus to reduce the blood flow and slow the bleeding.
  • Hysterectomy. This is the “last resort” but will stop the bleeding and may save the woman’s life.
83
Q

What is balloon tamponade

A

. This involves inserting an inflatable balloon into the uterus to press against the bleeding.

84
Q

What is a B-Lynch suture

A

This involves putting a suture around the uterus to compress it.

85
Q

What is a perineal tear

A

the external vaginal opening is too narrow to accommodate the baby, leading to a ripping of the skin in that area and the babies head comes through.

86
Q

What are the indications for instrumental delivery

A

Failure to progress
Fetal or maternal distress
Control of the head in various fetal positions

87
Q

what are the risks of instrumental delivery

A

Increased haemorrhage

Increased tear / requirement for episiotomy

88
Q

What is an instrumental delivery

A
  • About 10% of UK births are assisted.
  • This involves use of instruments to assist in the second stage of labour (pulling the baby out with tools during the babies birth).
89
Q

What is a ventouse

A
  • suction cup on a cord that goes on the babies head and the doctors or midwife pulls on the cord to apply traction to the babies head.
90
Q

What are forceps

A
  • large metal salad tongs that go either side of the babies head and grip the head in a way that allows the doctor or midwife to apply traction and pull the baby out by the head.
91
Q

What is the main complication of ventouse

A

cephalohaematoma

92
Q

What is the main complication from using forceps

A
  • facial nerve palsy for the baby.
  • bruises on the babies face
  • Rarely, fat necrosis leading the hardened lumps of fat on the babies cheeks (that resolve spontaneously over time).
93
Q

What are the RF for uterine rupture

A 
Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Induction of labour
94
Q

What is a uterine rupture

A
  • Complication of labour where the muscle layer of the uterus (myometrium) ruptures
  • incomplete rupture, the peritoneal lining surrounding the uterus is still intact
  • complete rupture, this lining also ruptures and the contents of the uterus are released into the peritoneal cavity.
  • High morbidity and haemorrhage
95
Q

What is the management of uterine rupture

A

emergency laparotomy to stop any bleeding, repair or remove the uterus and perform a caesarean to save the baby.

96
Q

What is an amniotic fluid embolism

A
  • amniotic fluid passes into the mother’s blood
  • fetal cells, that will lead to an immune reaction from the mother’s immune system.
  • This immune reaction to cells from the foetus leads to a systemic illness.
97
Q

What are the risk factors for amniotic fluid embolism

A
  • Increasing maternal age

- Induction of labour

98
Q

What is the presentation of amniotic fluid embolism

A 
Shortness of breath
Cough
Respiratory failure
Tachycardia
Hypotension
Fever
Haemorrhage
99
Q

What is the management of an amniotic fluid embolism

A

Management is supportive and requires involvement from critical care.

100
Q

What is uterine inversion

A
  • fundus of the uterus drops down into through the cervix

- Complication of pulling too hard on the umbilical cord when trying to deliver the placenta

101
Q

What is the management of uterine inversion

A

Johnson’s manoeuvre, which involves using a hand to push the fundus back up into the abdomen and into the correct position.

102
Q

What is considered a first degree tear

A

Limited to the frenulum of the labia (at the posterior aspect of the vagina) and superficial skin of the perineum

103
Q

What is considered a second degree tear

A

Limited to the above plus the perineal muscles. Not affecting the anal sphincter.

104
Q

What is considered a third degree tear

A

The above plus the anal sphincter is involved. Not affecting the rectal mucosa.

105
Q

What is considered a fourth degree tear

A

The above plus the rectal mucosa.

106
Q

What is an episiotomy

A
  • obstetrician or midwife makes a cut in the perineum prior to the delivery of the baby
  • done in anticipation of there needing to be additional room for delivery of the baby (e.g. prior to forceps delivery)
107
Q

How do you do an episiotomy

A

A cut is made diagonally at around 45 degree from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. This can then be sutured after delivery.
- Done under local anaesthetic

O&G (13 decks)

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