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Obs and gynae > Labour and puerperium > Flashcards

Labour and puerperium Flashcards

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1
Q

What is induction of labour

A

Start labour artificially

Needed in 20% of pregnancies

When safer to deliver baby than keep in utero

Can be to optimise maternal health

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2
Q

What are the indications for induction of labour

A

Prolonged gestation

Premature rupture of membranes

Maternal health problems

Fetal growth restriction

Intrauterine fetal death

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3
Q

When should induction of labour be used in prolonged gestation

A

Uncomplicated pregnancies, offer between 40+0 and 40+14

Prolonged gestation associated with fetal compromise and stillbirth

If mother declines induction, increased monitoring after 42 weeks

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4
Q

When should induction of labout be used in premature rupture of membranes

A

If >37 weeks
- Offer induction of labour or expectant management for 24 hours

If 34-37 weeks
- Time induction based on risk vs benefit

If < 34 weeks
- Delay induction (unless have fetal compromise)

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5
Q

What maternal health problems should lead to consideration for induction of labour

A

Hypertension

Pre-eclampsia

Diabetes

Obstetric cholestasis

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6
Q

What are the absolute contraindications for induction of labour

A

Cephalopelvic disproportion

Major placenta praevia

Vasa praevia

Cord prolapse

Transverse lie

Active primary genital herpes

Previous classical C-section

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7
Q

What are the relative contraindications for induction of labour

A

Breech presentation

Triplet(+) pregnancy

2+ previous low transverse C-sections

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8
Q

What are the methods of induction of labour

A

Vaginal prostaglandins

Amniotomy

Membrane sweep

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9
Q

How are vaginal prostaglandins used in the induction of labour

A

Primary method

Ripen cervix

Help with uterine contractions

Maximum 1 cycle per day (1 pessary, or 1 tablet/gel repeated after 6 hours)

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10
Q

What is amniotomy

A

Artificially rupture membranes using amnihook

Get release of prostaglandins, hope to start labour

Only when cervix is ripe

Can be given alongside syntocinon

Not first line (unless prostaglandins contraindicated) - risk of uterine hyperstimulation

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11
Q

What is a membrane sweep

A

Not a formal method of induction

Gloved finger through cervix, aim to separate membrane and release prostaglandins

Increases chances of spontaneous labour

Nulliparous: offer at 40 and 41 weeks

Multiparous: offer at 41 weeks

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12
Q

What methods of monitoring are used during induction of labour

A

Bishop score

CTG (if using oxytocin, use CTG throughout)

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13
Q

What is a Bishop score

A

Assessment of cervical ripening based on vaginal examination

Used before and during induction

> 7 = cervix favourable (high chance of response)

<4 = unlikely to progress naturally, will need prostaglandin induction

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14
Q

What are the complications of induction of labour

A

Failure of induction (offer more prostaglandins or C-section)

Uterine hyperstimulation (manage with tocolytic (anti-contraction) agents)

Cord prolapse

Infection

Pain (more severe than with natural labour)

Increased need for further intervention

Uterine rupture

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15
Q

What is operative vaginal delivery and what are the methods used

A

Use of instruments to aid delivery

Up to 3 pulls with one instrument, then switch to a different one

Ventouse

Forceps

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16
Q

How is ventouse used in operative vaginal delivery

A

Low risk of maternal complications

Attach cup to fetal head using vacuum, apply traction with each contraction

Electrical pump, or kiwi (used to rotate fetus)

Lower success rate, less maternal perineal injury, less pain, more cephalhematoma, more subgaleal haematoma, more fetal retinal haemorrhage

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17
Q

How are forceps used in operative vaginal delivery

A

Lower risk of fetal complications

2 blades, go around fetal had, apply traction with contractions

Higher rates of 3rd/4th degree tears, not ideal for rotation, no need for maternal effort

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18
Q

What are the maternal indications for operative vaginal delivery

A

Inadequate progress

  • 2 hours of pushing in nulliparous
  • 1 hour of pushing in multiparous

Exhaustion

Medical conditions where active pushing should be limited (intracranial pathology, congenital heart defects, severe hypertension)

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19
Q

What are the fetal indications for operative vaginal delivery

A

Suspected fetal compromise in 2nd stage of labour (abnormal CTG/bloods)

Clinical concern (significant antepartum haemorrhage…)

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20
Q

What are the absolute contraindications for operative vaginal delivery

A

Unengaged fetal head (singleton)

Incompletely dilated cervix (singleton)

True cephalo-pelvic disproportion

Breech and face presentation

Preterm (<34 weeks) - for ventouse

Fetus high risk of coagulation disorders - for ventouse

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21
Q

What are the relative contraindications for operative vaginal delivery

A

Non-reassuring fetal status with head above pelvic floor

Delivery of twin 2, where head has not engaged or cervix has re-formed

Prolapse of umbilical cord when cervix is fully dilated

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22
Q

What are the pre-requisites for instrumental delivery

A

Fully dilated

Ruptured membranes

Cephalic presentation

Defined fetal position

Fetal head at least at ischial spine

Empty bladder

Adequate pain relief

Adequate maternal pelvis

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23
Q

What are the fetal complications of operative vaginal delivery

A

Neonatal jaundice

Scalp lacerations

Cephalhaematoma

Subgaleal haematoma

Facial bruising

Facial nerve damage

Skull fractures

Retinal haemorrhage

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24
Q

What are the maternal complications of operative vaginal delivery

A

3rd/4th degree vaginal tears

VTE

Incontinence

PPH

Shoulder dystocia

Infection

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25
What is premature rupture of membranes
ROM at least 1 hour before onset of labour At >37 weeks In 10-15% pregnancies Minimum risk to mother and baby
26
What is pre-term premature rupture of membranes
Rupture of membranes at <37 weeks 2% pregnancies High rates of maternal and fetal compromise 40% of pre-term pregnancies
27
What is the pathophysiology of PROM/P-PROM
Early weakening and rupture of membranes due to: - Early activation of normal physiological process (high apoptotic markers and enzymes) - Infection - Genetic predisposition
28
What are the risk factors for PROM/P-PROM
Smoking (especially at <28 weeks) Previous PROM/P-PROM Vaginal bleeding during pregnancy Lower genital tract infection Invasive procedures (amniocentesis...) Polyhydramnios Multiple pregnancies Cervical insufficiency
29
What are the clinical features of PROM/P-PROM
Typical history of 'waters breaking' Non-specific symptoms: gradual leaking, change in vaginal discharge Fluid pooling in posterior fornix on speculum examination Avoid digital vaginal examination until woman is in labour
30
What are the differential diagnoses for PROM/P-PROM
Urinary incontinence Normal vaginal secretions of pregnancy Increased sweat/moisture around perineum Increased cervical discharge Vesicovaginal fistula Loss of mucus plug
31
What investigations are used in PROM/P-PROM
High vaginal swab (look for GBS) Actim-PROM (swab to look for insulin like growth factor binding protein 1 in vaginal fluid) Amnisure (swab to look for alpha microglobulin 1) Nitrazine test (pH of vaginal fluid) Ferning test (fern pattern on slides)
32
What is the management of PROM/P-PROM at <34 weeks
Aim to get to 34 weeks Monitor for signs of choramnionitis Avoid sexual intercourse Prophylactic erythromycin for 10 days Corticosteroids
33
What is the management of PROM/P-PROM at 34-36 weeks
Induce labour once steroids have been given Monitor for signs of choramnionitis Avoid sexual intercourse Prophylactic erythromycin for 10 days Penicillin during labour if GBS found
34
What is the management of PROM/P-PROM at >36 weeks
Induce labour within 24-48 hours Monitor for signs of choramnionitis Penicillin during labour if GBS found
35
What are the complications of PROM/P-PROM
Outcomes correlate with gestational age Choramnionitis (inflammation of fetal membranes) Oligohydramnios (more if <24 weeks) Neonatal death (prematurity, sepsis, pulmonary hypoplasia) Placental abruption Umbilical cord prolapse
36
When is an emergency caesarean section used
Failure to progress Fetal compromise
37
What are the categories of emergency caesarean sections
Category 1 - Immediate threat to life of mother or fetus - Birth within 30 mins Category 2 - Maternal/fetal compromise, not immediately life-threatening - Birth within 60-75 mins Category 3 - No maternal/fetal compromise, but need early delivery
38
What are the indications for caesarean section
Breech presentation Malpresentation Twins (twin 1 not cephalic) Fetal compromise Transmissible disease (poorly controlled HIV) Primary genital herpes in 3rd trimester Placenta praevia Maternal diabetes Previous major shoulder dystocia Previous 3rd/4th degree tear Maternal request
39
Benefits of caesarean section
Reduced risk of: - Perianal trauma - Pain - Urinary/anal incontinence - Uterovaginal prolapse - Late stillbirth - Early neonatal infection
40
What are the immediate complications of caesarean section
PPH (>1000 ml) Wound haematoma Intra-abdominal haemorrhage Bladder/bowel trauma Neonatal: transient tachypnoea of newborn, fetal lacerations
41
What are the intermediate complications of caesarean section
Infection (UTI, endometritis, respiratory) VTE
42
What are the late complications of caesarean section
Urinary tract trauma Subfertility Negative psychological effects Rupture/dehiscence of scar in next labour Placenta praevia/accrete Caesarean scar ectopic pregnancy
43
Risks and benefits of VBAC
Shorter hospital stay and recovery Higher risk of uterine rupture Risk of anal sphincter injury Lower risk of maternal death Good chances of success of future VBACs Risk of respiratory difficulties/hypoxic ischaemic encephalopathy in neonate Increased risk of stillbirth beyond 39 weeks
44
Risks and benefits of elective repeat caesarean section
Longer recovery Small risk of uterine rupture No risk of anal sphincter injury Higher risk of maternal death Subsequent pregnancies need to be caesarean Higher risk of neonatal respiratory morbidity Increased risk of placental problems Increased risk of adhesions
45
What is uterine rupture, and what are the risk factors for it in VBAC
Full-thickness disruption of uterine muscle and overlying serosa An obstetric emergency Can get fetal hypoxia/large maternal haemorrhage Risk factors in VBAC: previous C-section, induction of labour, obstruction of labour, multiple pregnancy, multiparity
46
How are VBAC deliveries managed
Deliver in hospital setting Continuous CTG monitoring Avoid induction where possible Get guidance from seniors After 39 weeks, recommendation is repeat C-section
47
What are the absolute contraindications for VBAC
Classical caesarean scar Previous uterine rupture Normal contraindications for vaginal birth
48
What are the relative contraindications for VBAC
Complex uterine scar >2 previous lower segment C-sections
49
What is shoulder dystocia
When fetal shoulder gets impacted after delivery of the head An obstetric emergency Anterior shoulder on maternal pubic symphysis/posterior shoulder on sacral promontory
50
What is the pathophysiology of shoulder dystocia
Impaction of shoulder Delayed delivery = hypoxia of fetus Can get brachial plexus injury when applying traction
51
What are the pre-labour risk factors for shoulder dystocia
Previous shoulder dystocia Macrosomia Diabetes BMI >30 Induction of labour
52
What are the intrapartum risk factors for shoulder dystocia
Prolonged 1st stage of labour Secondary arrest (initial good progress, then stop due to malposition) Prolonged second stage of labour Oxytocin augmentation Assisted vaginal delivery
53
What are the clinical features of shoulder dystocia
Difficulty delivering fetal head/chin Failure of restitution (fetus stays in OA position) Turtle-neck sign (head retracts slightly into pelvis)
54
What are the immediate management steps for shoulder dystocia
Call for help Advise mother to stop pushing (can worsen impaction) Avoid downward traction of head Do not apply fundal pressure (can cause uterine rupture) Consider episiotomy (does not relieve obstruction, but makes manoeuvres easier)
55
What are the first line manoeuvres used for shoulder dystocia
McRoberts manoeuvre - Hyperflexion of hips (knees to chest) - Stop pushing - Get widening of pelvic outlet Suprapubic pressure - Sustained or rocking pressure - Puts pressure behind anterior shoulder to disimpact it from pubic symphysis
56
What are the second line (internal) manoeuvres used in shoulder dystocia
Posterior arm - Insert hand, grab fetal arm and pull to delivery Internal rotation (corkscrew) - Apply pressure in front of one shoulder and behind the other - Move baby into oblique position If not working, repeat with patient on all 4s (widens pelvic outlet)
57
What is the post-delivery management for shoulder dystocia
Active management of 3rd stage of labour (increased risk of PPH) PR examination (exclude 3rd degree tears) Debrief mother and partner (can be traumatic) Consider physiotherapy review before discharge Paediatric review (for brachial plexus injury, humeral fracture, hypoxic brain injury)
58
What is an umbilical cord prolapse
Umbilical cord comes through cervix with/before presenting part of fetus High mortality rates for babies Obstetric emergency
59
What are the 2 types of cord prolapse
Occult (incomplete) prolapse - Cord descends alongside presenting part (not beyond it) Overt (complete) prolapse - Cord descends past presenting part
60
What is cord presentation in umbilical cord prolapse
Presence of umbilical cord between presenting part and cervix With or without intact membranes
61
Which babies is umbilical cord prolapse more common in
Pre-term babies (more likely to be breech and have congenital defects)
62
How does umbilical cord prolapse cause fetal hypoxia
Occlusion - Presenting part presses onto umbilical cord - Occlusion of blood flow to fetus Arterial vasospasm - Exposure of umbilical cord to cold atmospheres - Get umbilical arterial vasospasm - Reduced blood flow to fetus
63
What are the risk factors for umbilical cord prolapse
Breech presentation Unstable like (if >37 weeks, consider admission until delivery) Artificial rupture of membranes Polyhydramnios Prematurity
64
What are the clinical features of umbilical cord prolapse
Always consider if have non-reassuring fetal heart rate and absent membranes (strong link to fetal bradycardia) Confirm via external/PV examination
65
What are the differential diagnoses for umbilical cord prolapse
If have PV bleeding or blood-stained liquor with rupture of membranes, consider placental abruption/vasa praevia
66
What is the management for umbilical cord prolapse
Call for help Avoid handling cord (worsens vasospasms) Manually elevate presenting part (reduce occlusion) Encourage into left lateral/knee-chest position Consider tocolysis (terbutaline) reduces uterine contractions Delivery via emergency C-section
67
What is eclampsia
Convulsions in pre-eclamptic woman in absence of neurological/metabolic causes An obstetric emergency High maternal and fetal mortality rate Most seizures in post-partum period
68
What are the moderate risk factors for eclampsia
Nulliparity Age >40 BMI >35 Family history Pregnancy interval >10 years Multiple pregnancy
69
What are the high risk factors for eclampsia
Chronic hypertension HTN/pre-eclampsia/eclampsia in previous pregnancy Pre-existing CKD Diabetes Autoimmune diseases (SLE, antiphospholipid syndrome...)
70
What are the clinical features of eclampsia
New onset tonic-clonic seizures in presence of pre-eclampsia Seizures lasting 60-75 seconds Convulsions can cause fetal distress/bradycardia
71
What are the signs/symptoms of end-organ damage in eclampsia
Frontal headaches Hyper-reflexia Nausea and vomiting Generalised oedema RUQ pain Jaundice Visual disturbances Changes in mental age
72
What are the maternal complications of eclampsia
HELPP syndrome DIC AKI Adult respiratory distress syndrome Cerebrovascular haemorrhage Permanent CNS damage Death
73
What are the fetal complications of eclampsia
Intrauterine growth restriction Prematurity Infant respiratory distress syndrome Intrauterine death Placental abruption
74
What are the differential diagnoses for eclampsia
Hypoglycaemia Pre-existing epilepsy Head trauma Haemorrhagic stroke Meningitis Medication-induced Brain tumour Cerebral aneurysm Septic shock Ischaemic stroke
75
What investigations are used for eclampsia
Bloods (FBC, U&ES, LFTS, clotting studies, blood glucose) USS (rule out placental abruption) CTG monitoring Consider full neurological workup
76
What are the main steps of management of eclampsia
Resuscitation Cessation of seizures Blood pressure control Prompt delivery of baby and placenta Monitoring
77
What is involved in the cessation of seizures step of eclampsia management
Give magnesium sulphate Assess patient for hypermagnesemia (hyperreflexia, respiratory depression) Continuous fetal CTG monitoring
78
What is involved in the blood pressure control step of eclampsia management
Give IV labetalol and hydralazine Target mean arterial pressure <120 Continuous CTG monitoring
79
What in-patient care is needed post-natally for eclampsia
Regular symptom review Bloods 72 hours post-partum Pre-conception counselling (minimise risks for future pregnancies) Step-down to community
80
What out-patient care is needed post-natally for eclampsia
Consider CT head (if neurological symptoms persist) Measure blood pressure (daily for 2 weeks post-partum) Follow-up at 6 weeks
81
What is uterine rupture
Full-thickness disruption of uterine muscle and overlying serosa Can extend to affect bladder/broad ligament Significant maternal and fetal morbidity and mortality
82
What are the main types of uterine rupture
Incomplete - Peritoneum overlying uterus is intact - Uterine contents remain in uterus Complete - Peritoneum torn - Uterine contents in peritoneal cavity
83
What are the risk factors for uterine rupture
Previous C-section (higher risk with vertical incision) Previous uterine surgery Induction/augmentation of labour Obstruction of labour Multiple pregnancy Multiparity
84
What are the signs and symptoms of uterine rupture
Sudden severe abdominal pain (persisting between contractions) Shoulder tip pain Vaginal bleeding
85
What would you find on examination in uterine rupture
Regression of presenting part Scar tenderness Palpable fetal parts on abdominal examination
86
What would fetal monitoring show in uterine rupture
Fetal distress Absent heart sounds
87
What are the differential diagnoses for uterine rupture
Placental abruption (woody uterus) Placenta praevia (painless PV bleeding) Vasa praevia (ruptured membranes, painless PV bleeding, fetal bradycardia)
88
What investigations are used in uterine rupture
Intrapartum CTG monitoring USS for diagnosis (abnormal fetal lie/presentation, haemoperitoneum, absent uterine wall)
89
How is uterine rupture managed
Call for help Resuscitate Surgery (immediate C-section, repair/remove uterus)
90
What is thought to be linked to amniotic fluid embolism
Strong uterine contractions Excessive amniotic fluid Disruption of uterine vessels
91
What are the risk factors for amniotic fluid embolism
Multiple pregnancy Increased maternal age Induction of labour Uterine rupture Placenta praevia Placental abruption Cervical lacerations Eclampsia Polyhydramnios C-section/instrumental delivery
92
What are the clinical features of amniotic fluid embolism
Sudden onset Hypoxia/respiratory arrest Hypotension Fetal distress Seizures Shock Confusion Cardiac arrest DIC
93
What are the differential diagnoses for amniotic fluid embolism
PE Anaphylaxis Sepsis Eclampsia Myocardial infarction
94
What are the investigations and management for amniotic fluid embolism
Resuscitate Bloods ECG (ischaemic changes) CXR Arrange ITU admission Manage DIC Deliver baby (even if post-partum section)
95
What is the definitive diagnosis for amniotic fluid embolism
On post-mortem Fetal squamous cells and debris in pulmonary vasculature
96
What is primary post-partum haemorrhage
Loss of >500mls of blood PV within 24 hours of delivery
97
What are the 2 main types of primary post-partum haemorrhage
Minor PPH - 500-1000 mls blood loss Major PPH - >1000 mls blood loss
98
What are the 4 main groups of causes of primary PPH
Tone Tissue Trauma Thrombin
99
What is the significance of 'tone' in primary PPH
Uterine atony most common cause of PPH Uterus not able to contract fully due to lack of tone Risk factors: maternal profile (age >40, BMI >35, asian), uterine over-distension (multiple pregnancy, macrosomia...), induced/prolonged labour, placental problems (praevia, abruption, previous PPH)
100
What is the significance of 'tissue' in primary PPH
Retention of placental tissue Prevents uterus from contracting
101
What is the significance of 'trauma' in primary PPH
Damage sustained during delivery (vaginal/cervical tears) Risk factors: instrumental delivery, episiotomy, C-section)
102
What is the significance of 'thrombin' in primary PPH
Vascular causes (placental abruption, hypertension, pre-eclampsia) Coagulopathies (Von Willebrand's disease, haemophilia, DIC, HELPP)
103
What are the signs and symptoms of primary PPH
Bleeding PV If large blood loss: dizziness, palpitations, shortness of breath
104
What would you find on examination in primary PPH
Abdominal examination (signs of uterine rupture) Speculum examination (sites of localised trauma) Placenta (ensure placenta is complete)
105
What investigations are needed in primary PPH
Bloods (FBC, coagulation profile, U&Es, LFTs) Cross-match 4-6 units of blood
106
What is the general method of managing primary PPH
TRIM - Teamwork - Resuscitation - Investigations and monitoring - Measures to arrest bleeding
107
What is the definitive management for primary PPH due to uterine atony
Bimanual compression (apply pressure to abdomen with other hand) Pharmacological - Syntocinon (synthetic oxytocin) - Ergometrine - Carboprost (prostaglandin analogue) - Misoprostol (prostaglandin analogue) Surgical - Intrauterine balloon tamponade - Haemostatic sutures around uterus - Uterine/iliac artery ligation - Hysterectomy
108
What is the definitive management for primary PPH due to 'trauma'
Repair laceration May need hysterectomy
109
What is the definitive management for primary PPH due to 'tissue'
IV oxytocin Manual removal of placenta Prophylactic antibiotics
110
What is the definitive management for primary PPH due to 'thrombin'
Correct coagulation abnormalities with blood products
111
What are the methods of preventing primary PPH
Active management of 3rd stage of labour IV/IM oxytocin
112
What is secondary post-partum haemorrhage
Excessive vaginal bleeding between 24 hours and 12 weeks post-partum
113
What are the risk factors for secondary post-partum haemorrhage
Uterine infection Retained placental fragments/tissue Inadequate closure of spiral arteries Trophoblastic disease Previous history of PPH
114
What are the clinical features of secondary post-partum haemorrhage
Excessive vaginal bleeding (spotting, occasional gush of fresh blood) Endometritis (fever, lower abdominal pain, foul smelling discharge) Lower abdominal tenderness, high uterus
115
What investigations are needed for secondary post-partum haemorrhage
Bloods FBC, U&Es, CRP, coagulation profile, group and save Blood cultures USS pelvis (look for retained placental tissue)
116
What is the management for secondary post-partum haemorrhage
Antibiotics (ampicillin and metronidazole) Uterotonics (syntocinon...) Surgical (balloon catheter insertion) Manage massive secondary PPH as primary PPH
117
What are the core symptoms of depression during pregnancy
Low mood Lethargy Anhedonia Poor sleep Poor appetite
118
When should an urgent mental health referral be made for depression in pregnancy
Risk of self harm/suicide Evidence of self neglect Psychotic symptoms Manic behaviour Previous diagnosis of MH issues Previous suicide attempts
119
What is post-natal depression
Depressive episode within first 12 months post-partum Peaks around first 2 months Not the same as baby blues (at day 3-4, for 7 days) Negative thoughts about motherhood and ability to cope Anxieties about baby
120
What is post-partum psychosis
Severe mental illness Can develop within a few hours More common in women with previous bipolar disorder/psychotic illness 50% chance of recurrence in future pregnancies
121
How do patients with post-partum psychosis present
Confused/distracted Relatives report: withdrawn, agitated/distressed Bizarre ideas Auditory hallucinations May appear manic Sleep disturbances

Obs and gynae (6 decks)

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