Labour and Delivery - done Flashcards
1
Q
When do labour and delivery normally occur?
A
Between 37 and 42 weeks gestation
2
Q
What are the three stages of labour?
A
First stage - from onset until 10cm cervical dilation
Second stage - from 10cm cervical dilation until delivery of baby
Third stage - from delivery of baby to delivery of placenta
3
Q
What changes to the cervix happen in the first stage of labour?
A
Cervical dilation - opening up
Effacement - getting thinner
4
Q
What is the “show” in a pregnant womans cervix?
A
Mucus plug = prevents bacteria from entering during the pregnancy
5
Q
What are the 3 phases to the first phase of delivery?
A
Latent phase = from 0 to 3cm - progresses at 0.5cm per hour - irregular contractions
Active phase = from 3 to 7cm - progresses at 1cm per hour - regular contractions
Transition phase = from 7 to 10cm - progresses at 1cm per hour - strong and regular contractions
6
Q
What are Braxton-Hicks contractions?
A
Occasional irregular contractions of the uterus (felt during 2nd and 3rd trimester)
Not indicating the onset of labour - staying hydrated and relaxing reduces these contractions.
7
Q
What are the signs of labour?
A
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
8
Q
What are the latent first stage of labour and the established first stage of labour?
A
Latent first stage = painful contractions, changes to the cervix, with effacement and dilatation up to 4cm
Established first stage = regular, painful contractions, dilatation of the cervix from 4cm onwards
9
Q
What does ROM stand for?
A
Rupture of membranes
10
Q
What does SROM stand for?
A
Spontaneous rupture of membranes
11
Q
What does PROM stand for?
A
Prelabour rupture of membranes (amniotic sac has ruptured before the onset of labour)
12
Q
What does P-PROM stand for?
A
Preterm prelabour rupture of membranes (P-ROM) - the amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm)
13
Q
What does PROM stand for?
A
Prolonged rupture of membranes (also PROM) - The amniotic sac ruptures more than 18 hours before delivery
14
Q
What is prematurity?
A
Birth before 37 weeks gestation
15
Q
When are babies considered non-viable?
A
Before 23 weeks gestation
16
Q
What chance of survival do babies born at 23 weeks have?
A
10% chance of survival
17
Q
What gestational age will a full resuscitation be offered from?
A
24 weeks
18
Q
What is the WHO classification of prematurity?
A
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
19
Q
What are the 2 options for prophylaxis of pre-term labour?
A
Vaginal progesterone
Cervical cerclage
20
Q
How does vaginal progesterone protect against pre-term labour?
A
Given as a gel or pessary
Decreases activity of the myometrium and prevents the cervix from remodelling in prep for delivery
21
Q
Who is vaginal progesterone offered to?
A
Women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation
22
Q
How does cervical cerclage work?
A
Putting a stitch into the cervix to add support and keep it closed, involves a spinal or general anaesthetic
23
Q
When is a cervical cerclage reversed?
A
When the woman goes into labour or reaches term
24
Q
Who is offered cervical cerclage?
A
Women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks
Previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy)
25
When is a **rescue** cervical cerclage offered?
Between **16 and 27+6 weeks** when there is cervical dilatation without rupture of membranes to prevent progression and premature delivery
26
What is preterm prelabour rupture of membranes?
Where the **amniotic sac ruptures before the onset** of labour and in a **preterm pregnancy** (under 37 weeks gestation)
27
How is P-PROM diagnosed?
Speculum examination revealing pooling of amniotic fluid in the vagina - **no tests are required**
28
What tests can be used to confirm the diagnosis of P-PROM?
- **Insulin-like growth factor-binding protein-1** (IGFBP-1)
- **Placental alpha-microglobin-1** (PAMG-1)
29
What is IGFBP-1?
A **protein** present in high concentrations in **amniotic fluid** which can be **tested on vaginal fluid** if there is doubt about rupture of membrane
30
What is PAMG-1?
Similar **alternative to IGFBP-1**
31
What is the management of P-PROM?
**Prophylactic antibiotics** given to prevent **chorioamnionitis**
32
What antibiotics are recommended to prevent chorioamnionitis?
**Erythromycin** 250mg 4 times daily for 10 days or until labour is established if within 10 days
33
When is induction of labour offered for P-PROM patients?
**From 34 weeks**
34
What is preterm labour with intact membranes?
**Preterm labour** with **intact membranes** with **regular painful contraction and cervical dilatation**, without rupture of the amniotic sac
35
How is preterm labour with intact membranes diagnosed?
**Clinical assessment** with **speculum examination** to **assess for cervical dilatation**
36
How is preterm labout with intact membranes diagnosed less than 30 weeks gestation and more than 30 weeks gestation?
**Less than 30 weeks gestation** = Clinical assessment alone
**More than 30 weeks gestation** = **Transvaginal ultrasound** can be used to assess the **cervical length** (if less than 15mm management of preterm labour can be offered - if more than 15mm then preterm labout is unlikely)
37
What is an alternative test for preterm labour without membrane rupture?
**Fetal fibronectin** (the "glue" between the chorion and the uterus and is found in the vagina during labour)
Result of less than 50ng/ml is considered negative and indicates that a preterm labour is unlikely
38
What is included in the management of preterm labour?
**Fetal monitoring** (CTG or intermittent auscultation)
**Tocolysis with nifedipine**: nifedipine is a calcium channel blocker that suppresses labour
**Maternal corticosteroids**: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
**IV magnesium sulphate**: can be given before 34 weeks gestation and helps protect the baby’s brain
**Delayed cord clamping or cord milking**: can increase the circulating blood volume and haemoglobin in the baby at birth
39
What is tocolysis?
**Medication** to stop uterine contractions - **nifedipine**, a CCB, is the medication of choice for tocolysis
40
What is an alternative to nidefipine for tocolysis?
**Atosiban**, an oxytocin receptor antagonist
41
When can tocolysis be used?
Between **24 and 33 + 6 weeks gestation** in preterm labour to delay delivery and buy time for **further fetal development**, administration of **maternal steroids** or transfer to a **more specialist unit** (e.g. with a neonatal ICU)
ONLY USED AS A SHORT TERM MEASURE - less than 48 hours
42
Why are antenatal steroids given?
Develop the fetal lungs and **reduce respiratory destress syndrome** after delivery
Used in women with **suspected preterm labour** of babies **less than 36 weeks gestation**
43
What is an example regimine of antenatal steroids?
**Two doses** of **intramuscular betamethasone,** 24 hours apart
44
What is IV magnesium sulphate given for?
Protect the **fetal brain** during premature delivery. Reduces the risk and severity of **cerebral palsy.**
45
When is IV magnesium sulphate given?
Within 24 hours of **delivery** of preterm babies of **less than 34 weeks gestation**
Given as a bolus followed by an infusion for up to 24 hours of up until birth
46
What do mothers that are given IV magnesium sulphate need monitoring for?
**Magnesium toxicity** at least four hourly
Monitor **tendon reflexes** (usually patella reflex)
- Reduced resp rate
- Reduced blood pressure
- Absent reflexes
47
What is induction of labour?
**Use of medication** to stimulate the onset of labour
48
When is induction of labour offered?
**Between 41 and 42 weeks gestation**
49
When is induction of labour offered?
- **Preterm rupture** of membranes
- Fetal **growth restriction**
- **Pre-eclampsia**
- **Obstetric cholestasis**
- **Existing diabetes**
- **Intrauterine fetal death**
50
What is the Bishop Score?
**Scoring system** used to determine **whether to induce labour**
51
What is assessed in the Bishop's criteria and what is the maximum score?
**Fetal station** (scored 0 – 3)
**Cervical position** (scored 0 – 2)
**Cervical dilatation** (scored 0 – 3)
**Cervical effacement** (scored 0 – 3)
**Cervical consistency** (scored 0 – 2)
52
What Bishop score predicts a successful induction of labour?
**8 or more** (a score below this suggests cervical ripening may be required to prepare the cervix)
53
What are the options for induction of labour?
**Membrane sweep**
**Vaginal prostaglandins E2** (dinoprostone)
**Cervical ripening ballon** (CRB)
**Artifical rupture of membranes**
**Oral mifepristone** (anti-progesterone) plus misoprostol
54
What is a membrane sweep?
**Inserting a finger into the cervix** to stimlate the cervix and begin labour.
Can be performed in **antenatal clinic** and if successful should produce the onset of labour within 48 hours
Seen as an **assistance** fore the full induction of labour.
Used from **40 weeks gestation** to attempt to initiate labour in women over their EDD
55
What does a vaginal prostaglandin E2 (dinoprostone) involve?
Inserting a **gel**, **tablet** (Prostin) or **pessary** (**propess**) into the vagina.
The pessary is similar to a tampon, slowly releasing local **prostaglandins** over 24 hours.
Stimulates uterus and causes the onset of labour.
Usually done in the hospital setting so the woman can be monitored before being allowed home to await the full onset of labour.
56
What is a **cervical ripening ballon**?
Silicone ballow which is **inserted** into the **cervix** and gently inflated to **dilate** the cervix
Used ias an alternative where vaginal prostaglandins are not preferred, usually in women with a **previous C-section** or where **vaginal prostaglandins** have failed or multiparous women (para 3)
57
What is the artificial rupture of membranes?
With an **oxytocin infusion** can also be used to induce labour.
This is used there there are reasons not to use vaginal prostaglandins, can be used also to progress the induction of labour after vaginal prostaglandins have been used
58
When are **oral mifepirstone** (anti-progesterone) plus **misoprostol** used?
To induce labour where **intrauterine fetal death** has occured
59
What are the two means for monitoring during the induction of labour?
**Cartiotocography** (CTG) to assess the fetal heart rate and uterine contractions before the induction of labour
**Bishop score** before and during the induction of labour to monitor the progress
60
What is the ongoing management of IOL?
**Most** women will give **birth within 24 hours** of the start of induction of labour
The options where there is slow or no progress include:
- **Further vaginal prostaglandins**
- **Artificial rupture of membranes** and oxytocin infusion
- **CRB**
- **Elective caesarean section**
61
What is the **main complication** of using **vaginal prostaglandins to induce labour**?
Uterine hyperstimulation - causing fetal distress and compromise
62
What is the criteria for uterine hyperstimuation?
Varies between guidelines, two criteria often used are:
- Individual uterine contractions lasting more than 2 minutes in duration
- More than 5 uterine contractions every 10 minutes
63
What adverse outcomes can uterine hyperstimuation lead to?
- Fetal compromise, with hypoxia and acidosis
- Emergency C-section
- **Uterine rupture**
64
What is the management of uterine hyperstimuation?
- Removing the vaginal prostaglandins, stopping the oxytocin infusion
- **Tocolysis** with **terbutaline**
65
What does **cartiotocography** do?
Measures the **fetal heart rate** and the **contractions of the uterus**
66
What is **cartiotocography** also known as?
**Electronic fetal monitoring**
67
Where are the **transducers** for CTG placed?
**One above the fetal heart** to monitor the fetal heartbeat
**One near the fundus of the uterus** to monitor the uterine contractions
68
How does the transducer above the fetal heart monitor the heartbeat?
Using **doppler ultrasound**
69
How does the transducer above the fundus measure **uterine contraction**?
Using ultrasound to assess **tension**
70
What are the indications for using continuous CTG measuring in labour?
**Sepsis**
**Maternal tachycardia** (\> 120)
**Significant meconium**
**Pre-eclampsia** (particularly blood pressure \> 160 / 110)
**Fresh antepartum haemorrhage**
**Delay in labour**
**Use of oxytocin**
**Disproportionate maternal pain**
71
What are the five key features to look for on a CTG?
**Contractions** – the number of uterine contractions per 10 minutes
**Baseline rate** – the baseline fetal heart rate
**Variability** – how the fetal heart rate varies up and down around the baseline
**Accelerations** – periods where the fetal heart rate spikes
**Decelerations** – periods where the fetal heart rate drops
72
What do **number of contractions** indicate?
The **activity of labour**
73
What do too few or too many uterine contractions indicate in labour?
Too few = labour isnt progressing
Too many = uterine hyperstimuation
74
What are accelerations a sign of?
Good sign that the **fetus is healthy** particularly when occuring alongside contractions of the uterus
75
What are the different categories for baseline rate on an CTG?
**Reassuring**
**Non-reassuring**
**Abnormal**
76
What baseline rate and varability on a CTG is reassuring?
**Baseline rate** = 110-160
**Variability** = 5-25
77
What baseline rate and variability is **non-reassuring**?
**Baseline rate** = 100-109 or 161-180
**Variability** = less than 5 for 30-50 mins or more than 25 for 15-25 mins
78
What CTG baseline rate and variability is considered **abnormal**?
**Baseline rate** = Below 100 or above 180
**Variability** = Less than 5 for over 50 mins or more than 25 for over 25 mins
79
What are **decelerations**?
Concerning finding, fetal heart rate drops in response to **hypoxia** (fetal heart rate is slowing to conserve oxygen for the vital organs)
80
What are the four types of decelerations?
**Early** decelerations
**Late** decelerations
**Variable** decelerations
**Prolonged** decelerations
81
What are early decelerations?
**Gradual dips and recoveries in HR** that correspond with uterine contractions
82
What are **early decelerations**?
**Gradual dips** and recoveries in **HR** which **correspond** with uterine contrations (lowest point of deceleration corresponds to the peak of the contraction)
83
What causes early decelerations, are they a worry?
Caused by the **uterus compressing the head** of the fetus, **stimulating** the **vagus nerve** of the fetus, slowing the HR.
Normal and **not considered pathological**
84
What are **late decelerations**?
Gradual falls in HR, which start after the uterine contraction has already begun - **delay between uterine contraction and deceleration** - lowest point of the deceleration occurs after the peak of the contraction
85
What causes **late decelerations**?
Caused by **hypoxia** in the fetus and are a more concerning finding, may be caused by excessive uterine contractions, maternal hypotension/hypoxia
86
What are **variable decelerations**?
* Abrupt decelerations which may be unrelated to uterine contractions, **fall of more than 15bpm from the baseline**
* **Lowest point** occurs within **30 seconds** and the **deceleration lasts less than 2 minutes** in total
87
What do variable decelerations indicate?
**Intermitten compression** of the **umbilical cord** causing **fetal hypoxia**
88
What is a reassuring sign of variable decelerations?
**Brief accelerations** before and after the deceleration, known as **shoulders** (reassuring sign that the fetus is coping)
89
What is a **prolonged deceleration**?
A deceleration which **lasts more than 15 bpm** from baseline - often indicating compression of the umbilical cord causing **fetal hypoxia**. These are **abnormal and concerning**
90
When is the **CTG reassuring**?
**No decelerations**
**Early decelerations**
**Less than 90 mins** of **variable decelerations** with no concerning features
91
What CTG findings are classed as non-reassuring?
**Regular variable decelerations**
**Late decelerations**
92
What CTG findings are always abnormal?
**Prolonged decelerations**
93
What categoried are the CTGs interpreted upon?
- Baseline rate
- Variability
- Decelerations
94
What are the four categoties for CTF?
**Normal**
**Suspicious:** a single non-reassuring feature
**Pathological:** two non-reassuring features or a single abnormal feature
**Need for urgent intervention**: acute bradycardia or prolonged deceleration of more than 3 minutes
95
What management options are there for a concerning CTG?
Escalating to a senior midwife and obstetrician
**Further assessment for possible causes**, such as uterine hyperstimulation, maternal hypotension and cord prolapse
**Conservative interventions** such as **repositioning the mother** or giving IV fluids for hypotension
**Fetal scalp stimulation** (an acceleration in response to stimulation is a reassuring sign)
**Fetal scalp blood sampling** to test for **fetal acidosis**
**Delivery of the baby** (e.g. instrumental delivery or emergency caesarean section)
96
What is the **rule of 3s** for fetal bradycardia?
**3 minutes** – call for help
**6 minutes** – move to theatre
**9 minutes** – prepare for delivery
**12 minutes** – deliver the baby (by 15 minutes)
97
What is a **sinusoidal CTG**?
Rare pattern to be aware of as it can indicate **severe fetal compromise**
Pattern similar to a **sine wave** with smooth regular waves up and down which have an amplitude of 5-15bpm
Usually associated with **severe fetal anaemia** e.g. caused by **vasa praevia** with **fetal haemorrhage**
98
What is the mneumonic for assessing a CTG in a structured way?
**DR C BRaVADO**
**DR – Define Risk** (define the risk based on the individual woman and pregnancy before assessing the CTG)
**C** – Contractions
**BRa** – Baseline Rate
**V** – Variability
**A** – Accelerations
**D** – Decelerations
**O** – Overall impression (given an overall impression of the CTG and clinical picture)
99
How can the **overall impression** of a CTG be given?
**Normal** (all features are reassuring)
## Footnote
**Suspicious**
**Pathological**
**Need for urgent intervention**
100
What are the medications commonly used during labour?
**Oxytocin**
**Ergometrine**
**Prostaglandins**
**Misoprostol**
**Mifepristone**
**Nifedipine**
**Terbutaline**
**Carboprost**
**Tranexamic acid**
101
What is **oxytocin**?
Hormone secreted by the **posterior pituitary gland** (produced in the hypothalamus)
102
What is the role of oxytocin during labour and delivery?
**Stimulates** the **ripening of the cervix** and **contractions of the uterus**
Also plays a role in **lactation** during **breastfeeding**
103
What is **oxytocin** used for in **labour**?
**Induce** labour
**Progress** labour
**Improve the fequency and strength** of uterine contractions
**Prevent** or treat PPH
104
What is a brand name for oxytocin?
**Syntocinon**
105
What is **atosiban**? When is it used?
**Oxytocin receptor antagonist** which can be used as an alternative to nifedipine for **tocolysis** in premature labour (when nifedipine is contraindicated)
106
What is ergometrine?
Medication to **stimulate smooth muscle contraction**, both in uterus and blood vessels
Derived from **ergot plants**
Useful for **delivery of the placenta** and reduces post partum bleeding
107
When can ergometrine be used?
**Only in the 3rd stage** of labour (delivery of the placenta - not in 1st or 2nd) and **postpartum** to **prevent and treat PPH**
108
Whar are the side effects of ergometrine?
Due to action on smooth muscle and GI tract:
## Footnote
**Hypertension**
**Diarrhoea**
**Vomiting**
**Angina**
109
When should ergometrine be avoided?
**Eclampsia** (and with significant caution in those with hypertension)
110
What is **syntometrine**? When is it used?
Combination drug containing **oxytocin** (syntocinon) and **ergometrine**
Used for **prevention/treament of PPH**
111
How do prostaglandins work in labour?
**Stimulating contraction** of the uterine muscles
**Ripening the cervix** before delivery
112
What prostaglandin is used in inducting labour?
**Dinoprostone** which is **prostaglandin E2**
113
What form does **dinoprostone** come in?
**Vaginal pessaries** (Propess)
**Vaginal tablets** (Prostin tablets)
**Vaginal gel** (Prostin gel)
114
How do prostagandins act in general?
**Vasodilators,** lowering blood pressure
115
What is the action of NSAIDS? Examples? Are they used in pregnancy?
Action = **inhibit the action of prostaglandins**
Examples = Ibruprofen, naproxen
**Avoided in pregnnacy**
116
When are NSAIDs used in gynaecology?
Treating **dysmenorrhoea** (painful periods) as they reduce painful cramping (e.g. **ibruprofen and mefenamic acid**)
117
What is **misoprostol**?
**Prostalandin analogue** (binds to prostaglandin receptors and activates them)
118
When is misoprostol used?
Medical managment in miscarriage to **help complete the miscarriage**
Used **alongside mifepristone** for **abortions and induction of labour after intrauterine fetal death**
119
What is **mifepristone**?
**Anti-progesterone** medication which **blocks the action of progesterone** halting the pregnancy and ripening the cervix
**Enhances the effects** of prostaglandins to stimulate contraction of the uterus
**Not used in pregnancy** with a healthy living fetus
120
What type of drug is nifedipine?
**CCB** which acts to **reduce smooth muscle contraction** in **blood vessels** and the **uterus**
121
What are the two main uses of **nifedipin****e**?
**Reduce blood pressure** in hypertension and pre-eclampsia
**Tocolysis in premature labour,** where it suppresses uterine activity and delays the onset of labour
122
What is **terbutaline**?
**Beta-2-agonist** similar to salbutamol
123
How does **terbutaline** work in labour?
Acts on **smooth muscles of the uterus** to suppress uterine contractions
Used for **tocolysis** in **uterine hyperstimuation** notably when the uterine contractions become excessibe during **induction of labour**
124
What is **carboprost**?
**Synthetic prostaglandin analogue** - stimulating uterine contraction
125
How is carboprost given?
As a **deep intramuscular injection** in **PPH** where **ergometrine** **and oxytocin have been inadequate**
126
Who should **carboprost** be used in caution with?
Patients with **asthma** (can cause life threatening asthma)
127
What is **tranexamic acid**?
**Antifibrinolytic** which reduces bleeding (binds to **fibrinogen** and **prevents it from converting** to **plasmin**)
128
What is plasmin?
An **enzyme** which helps break down **fibrin blood clots** (thus tranexamic acid helps prevent the breakdown of blood clots)
Also **inhibits the action of fibrin** a protein involved in the formation of blood clots.
129
What is tranexamic acid used for?
**Prevention and treatment** of **PPH**
130
What is **progress in labour** influenced by?
The 3 Ps:
**Power** (uterine contractions)
**Passenger** (size, presentation and position of the baby)
**Passage** (the shape and size of the pelvis and soft tissues)
131
What is 'the 4th P'?
**Psyche** - referring to the support and antenatal preparation for labour and delivery
132
What is the three phases of the **first stage of labour**?
**Latent phase** – from **0 to 3cm dilation of the cervix**. This progresses at around **0.5cm per hour**. There are irregular contractions.
**Active phase** – from **3cm to 7cm** dilation of the cervix. This progresses at around **1cm per hour,** and there are regular contractions.
**Transition phase** – from **7cm to 10cm** dilation of the cervix. This progresses at around **1cm per hour,** and there are strong and regular contractions.
133
What suggests **delay in the 1st stage of labour**?
**Less than 2cm** of cervical dilatation in 4 hours
**Slowing of progress** in a **multiparous women**
134
What are **partograms**?
Graph of progress of labour
135
What is recorded on a partogram?
**Cervical dilatation** (measured by a 4-hourly vaginal examination)
**Descent of the fetal head** (in relation to the ischial spines)
**Maternal pulse, blood pressure, temperature and urine output**
**Fetal heart rate**
**Frequency of contractions**
**Status of the membranes**, presence of liquor and whether the liquor is stained by blood or meconium
**Drugs and fluids** that have been given
136
How are **uterine contractions** measured on a **partogram**?
Contractions per 10 minutes
137
What are the **two lines on the partogram** which indicate when **labour may not be progressing**?
**'Alert'**
**'Action'**
138
If the **line on the partogram** crosses over **'alert'**, what should be done?
**Amniotomy** (artificially rupturing the membranes) repeat examination in 2 hours
139
If the **line on the partogram** crosses over **'alarm'**, what should be done?
Care needs to be **escalated** to **ostetric-led care** and senior decision makers
140
What is the second stage of labour?
From **10cm dilation of the cervix** to **delivery of the baby** - success depends on: the three Ps
141
How is **delay in the second stage** classified?
When the active second stage (pushing) lasts over:
**2 hours in a nulliparous** woman
**1 hour in a multiparous** woman
142
What does **power** refer to?
**Strength of** **uterine contractions**
143
How can power be improved?
**Oxytocin infusion** can be used to stimulate the uterus
144
What does **passenger** refer to?
4 descriptive qualities of the fetus:
**Size** of the baby (macrosomic babies more difficult e.g. shoulder dystocia, large size of head)
**Attitude** refers to the posture of the fetus (how back is rounded and head and limbs are flexed)
**Lie** (position of the fetus in relation to the mother's body - longitudinal / transverse / oblique)
**Presentation** (cephalic / shoulder / breeech: complete, frank or footling)
**Passage**: size and shape of the passageway, mainly the pelvis
145
What are the possible interventions during the **second stage of labour**?
**Changing positions**
**Encouragement**
**Analgesia**
**Oxytocin**
**Episiotomy**
**Instrumental delivery**
**Caesarean section**
146
What is a **delay in the third stage of labour** defined as?
**More than 30 minutes with active** management
**More than 60 minutes with physiological** management
147
What does active management of the third stage of labour involve?
**Intramuscular oxytocin** and **controlled cord traction**
148
What are the management options for failure to progress in labour?
**Amniotomy,** also known as artificial rupture of membranes (ARM) for women with intact membranes
**Oxytocin** infusion
**Instrumental** delivery
**Caesarean** section
149
What is used first line in **failure to progress** during labour?
**Oxytocin** to stimulate contractions during labour - **started at a low rate** and then **titrated up** at **intervals of at least 30 minutes** as required
150
When using oxytocin in labour, what is the number of contractions to aim for?
4-5 contractions per 10 minutes (too may can cause fetal compromise as it doesn't have the time to recover between contractions)
151
What can help with managing pain in labour (without medications)
**Understanding** what to expect
Having **good support**
Being in a **relaxed environment**
**Changing position** to stay comfortable
**Controlled breathing**
**Water births** may help some women
**TENS machines** may be useful in the early stages of labour
152
What pain relief is used in early labour?
**Paracetamol** (codeine may be added for additional effect - NSAIDs are avoided)
153
What else can be used after paracetamol for pain relief in labour?
**Gas and air** (entonox)
50% nitrous oxide and 50% oxygen used during contractions for short term pain relief - takin **deep breaths** at the start of a contraction
154
What are the side effects of gas and air?
**Lightheadedness**, **nausea** or **sleepiness**
155
What **opioid** medications can be given during labour?
**Pethidine** and **diamorphine** given by IM injections to help with **anxiety** and **distress**
156
What are some **side effects** of using **pethidine** or **diamorphine**?
**Drowziness** or **nausea** in the mother and can cause **respiratory depression** in the neonate if given too close to birth
**Effect on baby** may make the **first feed more difficult**
157
What PCA may a woman be offered in labour?
**Remifentanil** (short acting opiate medication) - administered by pressing a button at the start of a contraction to abminister a bolus
158
What are the side effects of PCA in labour?
**Respiratory depression** (treated with naloxone)
**Bradycardia** (treated with atropine)
Need input from an anaesthetist
159
What does an epidural involve?
Interting a small tube (catheter) into the **epidural space** in the lower back (**outside the dura mater,** separate from spinal cord and CSF)
**Local anaestehtic medication** is then infused through the catheter into the **epidural space** where they take effect
160
What are the anaesthetic options in epidurals?
**levobupivacaine** or **bupivacaine,** usually mixed with **fentanyl**
161
What are some adverse effects of epidurals?
**Headache** after insertion
**Hypotension**
**Motor weakness** in the legs
**Nerve damage**
**Prolonged second stage**
**Increased probability of instrumental delivery**
162
When do women need **urgent anaesthetic review** during **epidurals**?
Significant **motor weakness** (unable to straight leg raise)
Catheter may be **incorrectly sited** in the **subarachnoid space** (within the spinal cord) rather than epidural space
163
What is **cord prolapse**?
When the **umbilical cord** descends **nelow the presenting part of the fetus** and through the cervix, into the vagina
164
What is the worry in cord prolapse?
Danger of the presenting part compressing the cord, resulting in **fetal hypoxia**
165
What is the **most significant risk factor** for **cord prolapse**?
Fetus is in an **abnormal lie** after 37 weeks gestation (unstable, transverse or oblique)
166
When should an **umbilical cord prolapse** be suspected and how is it diagnosed?
**Signs of fetal distress** on the CTG
Diagnosed with **vaginal examination** with speculum confirming
167
What is the management for a prolapsed cords?
**Emergency C-Section** pushing cord back in is not recommended!
Cord should be kept **warm and wet** and have **minimal handling** as this causes **vasospasm**
168
What can help managing a prolapsed cord when waiting for a C-section?
**Presenting part of baby** can be **pushed upwards** to prevent cord compression
Woman can **lie** in the **left lateral position** (with a pillow under hip) or on all fours
**Tocolytic medication** (e.g. **terbutaline**) can be used to **minimise contractions** whilst waiting for delivery by C-section)
169
What is **shoulder dystocia**?
When **anterior shoulder** of the baby becomes stuck behind the **pubic symphysis** of the pelvis after the head has been delivered
## Footnote
**Obstetric emergency**
170
What is shoulder dystocia often caused by?
**Macrosomia** secondary to **gestational diabetes**
171
How does shoulder dystocia present?
172
What is the **turtle neck sign**?
Where the **head is delivered** but then retracts back into the vagina
173
What are the **managment options of shoulder dystocia**?
Get help (incl anaesthetics and paediatrics)
**Episiotomy**
**McRoberts manoeuvre** hyperflexion of the mother at the hip (bringing knees to abdomen) providing a **posterior pelvic tilt** lifting the pubic symphysis up and out of the way
**Pressure to the anterior shoulder** = pressing on the suprapubic region, putting pressure on the posterior aspect of the baby's anterior shoulder to encourage it **under pubic symphysis**
**Rubins manoeuvre** = reaching into vagina, putting pressure on the posterior aspect of the baby's anterior shoulder
**Wood's screw manoeuvre** = performed during a Rubin's manoeuvre - other hand is used to put pressure on the anterior aspect of the posterior shoulder - to rotate the baby, reverse motion can be tried
**Zavanelli manoeuvre** pushing the baby's head back into the vagina so it can be delivered by emergency C-section
174
What are the key complications of shoulder dystocia?
**Fetal hypoxia** (and subsequent cerebral palsy)
**Brachial plexus injury** and **Erb’s palsy**
**Perineal** tears
**Postpartum haemorrhage**
175
What does an **instrumental delivery** refer to?
Using a **ventouse suction cup** or **forceps** (about 10% of births are assisted with an instrumental delivery)
176
Where is an instrumental delivery performed?
Usually on **labour ward** however if there are concerns over success then moved to **theatre** so that **rapid delivery by C-Section can be performed**
177
What is given prophylactically after an instrumental delivery?
Single dose of **co-amoxiclav**
178
What are some indications for an instrumental delivery?
**Failure to progress**
Fetal **distress**
Maternal **exhaustion**
**Control of the head** in various fetal positions
179
What does an epidural for anaesthesia create an increased risk of?
Requiring an instrumental delivery
180
What are the **risks to the mother** for an **instrumental delivery**?
**Postpartum haemorrhage**
**Episiotomy**
Perineal **tears**
**Injury** to the **anal sphincter**
**Incontinence** of the bladder or bowel
**Nerve injury** (obturator or femoral nerve)
181
What are the **key risks to the baby** during an instrumental delivery?
**Cephalohaematoma** with ventouse
**Facial nerve palsy** with forceps
182
What are the **serious risks to the baby** during an **instrumental delivery**?
**Subgaleal haemorrhage** (most dangerous)
## Footnote
**Intracranial haemorrhage**
**Skull fracture**
**Spinal cord injury**
183
What is a ventouse?
A suction cup on a cord placed on the baby's head
184
What is the main complication when using a ventouse?
**Cephalohaematoma** (collection of blood **between the skull and periosteum**)
185
What is the main complication of using forceps during delivery?
**Facial nerve palsy** with facial paralysis on one side
**Bruises** on the babys face
**Fat necrosis** leading to hardened lumps which resolve spontaneously over time
186
What **nerve injury** can there be **in the mother** following an **instrumental delivery**?
**Femoral nerve** - compressed against the inguinal canal during a forceps delivery - causing **weakness of knee extension**, loss of the **patella reflex** and **numbness of the anterior thigh** and **medial lower leg**
**Obturator nerve** - compressed by forceps or by fetal head during normal delivery - weakness of **hip adduction** and **rotation** and **numbness** of the medial thigh
187
What **other nerve injuries** can occur during birth (unrelated to instrumental delivery)? And **how**?
**Lateral cutaneous nerve of the thigh** - runs
## Footnote
**Lumbosacral plexus**
**Common peroneal nerve**
188
When are perineal tears more common?
**First births** (nulliparity)
**Large babies** (over 4kg)
**Shoulder dystocia**
**Asian** ethnicity
**Occipito-posterior position**
**Instrumental deliveries**
189
What are the four degrees of perineal tears?
**First-degree** – injury **limited to the frenulum of the labia minora** (where they **meet posteriorly**) and **superficial skin**
**Second-degree** – **including the perineal muscles**, but **not affecting the anal sphincter**
Third-degree – **including the anal sphincter**, but **not affecting the rectal mucosa**
**Fourth-degree** – including the **rectal mucosa**
190
What are the subcategories of third-degree tears?
**3A** – less than 50% of the external anal sphincter affected
**3B** – more than 50% of the external anal sphincter affected
**3C** – external and internal anal sphincter affected
191
What is the management of a first degree tear?
Do not require any sutures normally
192
What is the managment of a **perineal tear** larger than first degree?
Requires sutures
193
What is the management of a 3rd or 4th degree tear?
Repairing in theatre
194
What are the **additional measure** taken to reduce the risk of complications in perineal tears?
**Broad-spectrum antibiotics** to reduce the risk of infection
**Laxatives** to reduce the risk of constipation and wound dehiscence
**Physiotherapy** to reduce the risk and severity of incontinence
**Followup to monitor for longstanding complications**
195
What are women who are symptomatic after third or 4th degree tears offered?
**Elective C-Section** in subsequent pregnancies
196
What are the short term complications of a perineal tear repair?
**Pain**
**Infection**
**Bleeding**
**Wound dehiscence** or wound breakdown
197
What are the lasting complications of a perineal tear?
**Urinary incontinence**
**Anal incontinence** and altered bowel habit (third and fourth-degree tears)
**Fistula** between the vagina and bowel (rare)
**Sexual dysfunction** and dyspareunia (painful sex)
**Psychological** and **mental health consequences**
198
What is an episiotomy?
Where the obstetrician / midwife cuts the perineum before the baby is delivered - done in anticipation of needing more room e.g. forceps delivery - performed under **local anaesthetic**
**Cut** is made at around **45 degrees diagnonally** from the opening of the vaginal down and out to **avoid damaging the anal sphincter** - called a **mediolateral episiotomy**
Cut is sutured after delivery
199
What is a **perineal massage**?
Method for reducing the risks of perineal tear - **massaging the skin between the vagina and anus** (perineum) - in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery
200
What are the two options for the third stage of labour?
**Physiological management**
**Active management**
201
What is **physiological management**?
Placenta is delivered by **maternal effort** without medication or cord traction
202
What is active management of the third stage?
**Dose of intramuscular oxytocin** (to help uterus contract)
**Traction** to the umbilical cord to guide the placenta out
203
Why is **active management of the third stage** sometimes used? What are the adverse effects?
**Reduces risk of bleeding** but associated with **nausea and vomiting**
204
When is active management initiated?
**Haemorrhage**
**More than 60 min delay** in delivery of the placenta (prolonged third stage)
205
What are the **steps in active management of the third stage**?
**IM dose of oxytocin** after delivery of the baby
**Cord is clamped** and cut within 5 mins of birth (delay of 1-3 mins)
**Abdo palpated** to assess for a uterine contraction before delivery of the placenta
**Controlled cord traction** is applied (stopping if resistance)
**Other hand** preeses the **uterus upwards** to prevent utering prolapse
**After delivery** the **uterus is massaged** until it is contracted and firm - placenta is examined to ensure it is complete
206
What is Postpartum haemorrhage (PPH)?
Bleeding after delivery of the baby and placenta
207
What is the classification of PPH?
Loss of:
## Footnote
**500ml after a vaginal delivery**
**1000ml after a caesarean section**
208
What are the different categoties of PPH?
**Minor** PPH – under 1000ml blood loss
**Major** PPH – over 1000ml blood loss
**Moderate** PPH – 1000 – 2000ml blood loss
**Severe** PPH – over 2000ml blood loss
209
What is the difference between primary and secondary PPH?
**Primary PPH:** bleeding within 24 hours of birth
**Secondary PPH:** from 24 hours to 12 weeks after birth
210
What are the four causes of PPH?
**T** – **Tone** (uterine atony – the most common cause)
**T** – **Trauma** (e.g. perineal tear)
**T** – **Tissue** (retained placenta)
**T** – **Thrombin** (bleeding disorder)
211
What are the risk factors for PPH?
**Previous PPH**
**Multiple pregnancy**
**Obesity**
**Large baby**
**Failure to progress in the second stage** of labour
**Prolonged third stage**
**Pre-eclampsia**
**Placenta accreta**
**Retained placenta**
**Instrumental delivery**
**General anaesthesia**
**Episiotomy** or perineal tear
212
What are the preventative measures for PPH?
**Treating anaemia** during the **antenatal period**
**Giving birth with an empty bladder** (a full bladder reduces uterine contraction)
**Active management of the third stage** (with intramuscular oxytocin in the third stage)
**Intravenous tranexamic acid** can be used during caesarean section (in the third stage) in higher-risk patients
213
What is involved in the management of PPH?
Resuscitation with an **ABCDE approach**
**Lie the woman flat,** keep her warm and communicate with her and the partner
**Insert two large-bore cannulas**
**Bloods for FBC, U&E and clotting screen**
**Group and cross match 4 units**
**Warmed IV fluid and blood resuscitation** as required
**Oxygen** (regardless of saturations)
**Fresh frozen plasma** is used where there are clotting abnormalities or after 4 units of blood transfusion
214
How are severe cases of PPH managed?
By **activating** the **major haemorrhage protocol** giving rapid access to 4 units of crossmatched or O negative blood
215
What are the diferent type of treatment options for stopping the bleeding?
**Mechanical**
**Medical**
**Surgical**
216
What are the mechanical options for stopping PPH?
**Rubbing the uterus through the abdomen** to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
**Catheterisation** (bladder distention prevents uterus contractions)
217
What are the medical options for stopping PPH?
**Oxytocin** (slow injection followed by continuous infusion)
**Ergometrine** (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
**Carboprost** (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
**Misoprostol** (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
**Tranexamic acid** (intravenous) is an antifibrinolytic that reduces bleeding
218
How is the IV infusion of oxytocin given for PPH?
40 units in 500mls often just referred to as **"40 units"** without specifing the drug
219
What are some medical treatment options for PPH?
**Intrauterine balloon tamponade** – inserting an inflatable balloon into the uterus to press against the bleeding
**B-Lynch suture** – putting a suture around the uterus to compress it
**Uterine artery ligation** – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
**Hysterectomy is the “last resort”** but will stop the bleeding and may save the woman’s life
220
What is secondary postpartum haemorrhage likely to be due to?
**Retained products of conception** (RPOC)
**Infection** (i.e. endometritis).
221
What are the investigations for secondary PPH?
**Ultrasound for retained products** of conception
**Endocervical and high vaginal swabs** for infection
222
What are the management options for **secondary PPH?**
**Surgical evaluation** of retained products of conception
**Antibiotics** for infection
223
What anaesthetic is an elective caesarean performed uner?
**Spinal anaesthetic**
224
When is an elective caesarean usually performed?
**After 39 weeks** gestation
225
What are some indications for an elective caesarean?
**Previous caesarean**
**Symptomatic after a previous significant perineal tear**
**Placenta praevia**
**Vasa praevia**
**Breech presentation**
**Multiple pregnancy**
**Uncontrolled HIV infection**
**Cervical cancer**
226
What are the **four categories** of **emergency caesarean**?
**Category 1:** There is an **immediate threat to the life** of the mother or baby. Decision to delivery time is **30 minutes.**
**Category 2:** There is not an imminent threat to life, but caesarean is required urgently due to **compromise of the mother or baby**. Decision to delivery time is **75 minutes.**
**Category 3:** Delivery is required, but **mother and baby are stable.**
**Category 4**: This is an **elective caesarean**, as described above.
227
What are the two possible incisions in a caesarean?
**Pfannenstiel incision** is a curved incision two fingers width above the pubic symphysis
**Joel-cohen incision** is a straight incision that is slightly higher (this is the recommended incision)
228
When may a **vertical incision** down the middle of the abdomen be performed?
Rarely, sometimes in **very premature deliveries** and **anterior placenta praevia**
229
When is **blunt dissection** used in caesareans?
After the inital incision to separate the remainging layers of the abdominal wall and uterus, using **fingers, blunt instruments and traction** to tear the tissue apart resulting in **less bleeding, shorter operating times** and **less risk of injury to the baby**
230
What are the layers of the abdomen which need dissecting during a caesarean?
**Skin**
**Subcutaneous tissue**
**Fascia / rectus sheath** (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
**Rectus abdominis muscles** (separated vertically)
**Peritoneum**
**Vesicouterine peritoneum** (and bladder) – the bladder is separated from the uterus with a bladder flap
**Uterus** (perimetrium, myometrium and endometrium)
**Amniotic sac**
231
How is the baby delivered in a caesarean?
**By hand** with the **assistance of pressure on the fundus**
## Footnote
**Forceps may be used if necessary**
232
How is the uterus closed after a caesarean?
Using **two layers of sutures**
**Exteriorisation** (taking the uterus out of the abdomen) is avoided if possible
233
What is involved in a spinal anaesthetic?
An **injection** of a **local anaesthetic** (such as **lidocaine**) into the CSF at the lower back
## Footnote
**Blocking the nerves from the abdomen downwards**
234
Why is a spinal anaesthetic better than a general anaesthetic?
Safer
Fewer complication
Faster recovery
235
What are the problems with a spinal anaesthetic?
Patient remains away (most patients tolerate this well)
Takes longer to initiate than a general anaesthetic
236
What are the risks associated with having an anesthetic?
**Allergic reactions or anaphylaxis**
**Hypotension**
**Headache**
**Urinary retention**
**Nerve damage** (spinal anaesthetic)
**Haematoma** (spinal anaesthetic)
**Sore throat** (general anaesthetic)
**Damage to the teeth or mouth** (general anaesthetic)
237
What are some measures to reduce the risk before a caesarean section?
**H2 receptor antagonists** (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
**Prophylactic antibiotics** during the procedure to reduce the risk of infection
**Oxytocin** during the procedure to reduce the risk of postpartum haemorrhage
**Venous thromboembolism (VTE)** prophylaxis with low molecular weight heparin
238
Why are H2 receptor antagonists / PPI given before a caesarean section?
To **reduce the risk** of **aspiration pneumonitis** caused by acid reflux and aspiration during prolonged period of lying flat
239
What are some general surgical risks during a caesarean?
**Bleeding**
**Infection**
**Pain**
Venous thromboembolism
240
What are some complication in the post partum period after a C-Section?
**Postpartum haemorrhage**
**Wound infection**
**Wound dehiscence**
**Endometritis**
241
What local structures can be damaged during a C-Section?
**Ureter**
**Bladder**
**Bowel**
**Blood vessels**
242
What effect does C-Sections have on the **abdominal organs**?
**Ileus**
**Adhesions**
**Hernias**
243
What effect do C-Sections have on future pregnancies?
Increased **risk** of **repeat caesarean**
Increased **risk** of **uterine rupture**
Increased **risk** of **placenta praevia**
Increased **risk** of **stillbirth**
244
What are the effects of a C-section on the baby?
**Risk of lacerations** (about 2%)
**Increased** incidence of **transient tachypnoea of the newborn**
245
When is it possible to have a vaginal birth after caesarean (VBAC)?
Possible, provided the cause of the caesarean is unlikely to recur.
Assessment of **likelihood of success** should be **made in each case**
246
What is the success rate of a VBAC?
75%
247
What are the risk of uterine rupture in VBAC?
0.5%
248
What are some contraindications to a VBAC?
**Previous uterine rupture**
**Classical caesarean scar** (a vertical incision)
**Other usual contraindications** to vaginal delivery (e.g. placenta praevia)
249
After a caesarean what prophylaxis should the woman be started on?
Early **mobilisation**
**Anti-embolism stockings** or intermittent pneumatic compression of the legs
**Low molecular weight heparin** (e.g. **enoxaparin**)
250
What is **Sepsis**?
Condition where body **launches a large immune response to infection** causing **systemic inflammation** and affecting the functioning of the organs of the body
## Footnote
**Significant cause of maternal death**
251
What is **severe sepsis**?
When sepsis results in **organ dysfunction** such as **hypoxia**, **oliguria** or **raised lactate**
252
What is **septic shock**?
When arterial blood pressure drops and results in **organ hypo-perfusion**
253
What are two key causes of spesis in pregnancy?
**Chorioamnionitis**
**Urinary tract infections**
254
What is **chorioamnionitis**?
**Infection** in the **chorioamniotic membrane** and **amniotic fluid** usually occuring in later pregnancy and **during labour**
255
What are **all patients** who are **admittted to the maternity inpatient unit** have **monitoring** socumented on?
**MEOWS chart** - maternity early obstetric warning system
256
What are the non-specific signs of sepsis?
**Fever**
**Tachycardia**
**Raised respiratory rate** (often an early sign)
**Reduced oxygen saturations**
**Low blood pressure**
**Altered consciousness**
**Reduced urine output**
**Raised white blood cells on a full blood count**
**Evidence of fetal compromise on a CTG**
257
What are some additional signs and symptoms of **chorioamnionitis**?
**Abdominal pain**
**Uterine tenderness**
Vaginal **discharge**
258
What are soem additional signs and symptoms of UTIs in pregnancy?
**Dysuria**
Urinary **frequency**
**Suprapubic pain** or discomfort
**Renal angle pain** (with pyelonephritis)
**Vomiting** (with pyelonephritis)
259
What are some investigations for suspected sepsis?
**Full blood count** to assess cell count including white cells and neutrophils
**U&Es** to assess kidney function and for acute kidney injury
**LFTs** to assess liver function and as a possible source of infection (e.g. acute cholecystitis)
**CRP** to assess inflammation
**Clotting** to assess for disseminated intravascular coagulopathy (**DIC**)
**Blood cultures to assess for bacteraemia**
**Blood gas to assess lactate**, pH and glucose
260
What are some additional investigations to find the suspected source of infection?
Urine **dipstick and culture**
**High vaginal swab**
**Throat swab**
**Sputum culture**
**Wound swab** after procedures
**Lumbar puncture for meningitis** or encephalitis
261
How to manage maternal sepsis?
- Follow **local guidelines**
- **Senior obstetricians** and midwives involved early
- **Continuous maternal and fetal monitoring**
- **Early delivery** (C-Section where there is fetal distress)
- **General anaesthesia for maternal sepsis**
- **Antibiotics guided by local guidelines**
- **Example regimes of abx:** piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin
262
What is the sepsis 6?
**Three tests:**
Blood **lactate** level
Blood **cultures**
**Urine output**
**Three treatments:**
**Oxygen** to maintain oxygen saturations 94-98%
Empirical broad-spectrum **antibiotics**
IV **fluids**
263
What is **amniotic fluid embolisation**?
**Amniotic fluid passes into the mothers blood** rare (2 per 100,000 births) but servere condition, usually **occuring around delivery**
264
What is the problem with amniotic fluid embolisation?
**Amniotic fluid** contains **fetal tissue** causing an **immune reaction** from the mother, leading to a **systemic illness** - more similarities to anaphylaxis than VTE - mortality is around 20% or above
265
What are the risk factors for amniotic fluid embolus?
**Increasing maternal age**
**Induction** of labour
**Caesarean** section
**Multiple pregnancy**
266
How does amniotic fluid embolus present?
Similarly to sepsis, PE or anaphylaxis:
## Footnote
**Shortness of breath**
**Hypoxia**
**Hypotension**
**Coagulopathy**
**Haemorrhage**
**Tachycardia**
**Confusion**
**Seizures**
**Cardiac arrest**
267
What is the overall managment of amniotic fluid embolisation?
**Supportive** - no specific treatments
268
What are the steps in amniotic fluid embolus management?
Medical emergency
Input of **experienced obstetricians**
**A – Airway:** Secure the airway
**B – Breathing**: Provide oxygen for hypoxia
**C – Circulation:** IV fluids to treat hypotension and blood transfusion in haemorrhage
**D – Disability:** Treat seizures and consider other neurological deficits
**E – Exposure**
269
What is **uterine rupture?**
Complication of labour, **myometrium** ruptures
270
What happens in an **incomplete rupture (uterine dehiscence)**?
**Uterine serosa** (perimetrium) surrounding the uterus remains intact
271
What happens with a **complete rupture**?
**Serosa** ruptures along with the myometrium with contents **released into the peritoneal cavity**
272
What is the consequence of uterine rupture?
**Significant bleeding** where the baby may be released from the uterus into the **peritoneal cavity** (high morbidity and mortality for baby and mother)
273
What are the main risk factors for uterine rupture?
**Previous caesarean section** as the scar is a point of weakness
274
What are the other risk factors for uterine rupture?
Vaginal birth after caesarean (**VBAC**)
**Previous uterine surgery**
Increased **BMI**
**High parity**
**Increased age**
**Induction of labour**
**Use of oxytocin to stimulate contractions**
275
How does a **uterine rupture present**?
Acutely unwell mother and abnormal CTG - may occur with induction or augmentation of labour:
## Footnote
**Abdominal pain**
**Vaginal bleeding**
**Ceasing of uterine contractions**
**Hypotension**
**Tachycardia**
**Collapse**
276
What is the management of a uterine rupture?
**Obstetric emergency** - resuscitation and transfusion may be necessary
**Emergency caesarean section** to remove the baby, stop any bleeding and repair or remove the uterus
277
What is uterine inversion?
Rare complication of birth where the **fundus of the uterus** drops down through the **uterine cavity and cervix, turning the uterus inside out**
Life threatening
278
What is **incomplete uterine inversion** (partial inversion) ?
**Fundus descends** inside the uterus or vagina **but not as far as the introitus** (opening of the vagina)
279
What is complete uterine inversion?
Uterus descends through the vagina to the introitus
280
What may uterine inversion be the result of?
**Pulling too hard** on the **umbilical cord** during **active management** of the **third stage of labour**
281
How does uterine inversion present?
**Large post partum haemorrhage** (maternal shock or collapse)
Incomplete inversion may be felt with **manual vaginal examination** with a complete uterine inversion, the uterus may be seen at the introitus of the vagina
282
What are the **three options** for **treating uterine inversion**?
Johnson manoeuvre
Hydrostatic methods
Surgery
283
What is the **johnson manoeuvre**?
Using a hand to **push the fundus** back up **into the abdomen**
Hand is **held in place** for several minutes and medications are used to create a uterine contraction (i.e oxytocin)
**Ligaments and uterus** need to generate enough tension to remain in place
284
What **hydrostatic methods** can be used for uterine inversion?
**Filling the vagina with fluid** to 'inflate' the uterus bacl to normal position - requiring a tight seal at the endtrance to the vagina which can be difficult
285
What surgery can be used for **uterine inversion**?
Laparotomy and uterus is returned to position
286
What else might be reuired in the management of uterine inversion?
Resuscitation
Treatment of PPH
Blood transfusion
