Obstetrics

Question 1

Well managed epidural analgesia benefits

Answer 1

Reduced material and feral acidosis
Increased uteroplacental flow
Reduction in uterine activity
Reduction in incoordinate uterine activity

Question 2

1st stage labour blockade requires which nerves to be blocked

Answer 2

T10-L1

Question 3

Second stage labour requires what nerves to be blocked

Answer 3

S234

Question 4

What is paracervical block and why shouldn’t it be used in labour

Answer 4

Paracervical block is local to the lateral fornix Vagina , blocks paracervical ganglion and provides analgesia to cervix and uterus

Used in gynae procedures

Not used labour as no benefit second stage and can cause profound fatal bradycardia, LAST, Infectuon, and neuropathy

Question 5

Causes of maternal death 2020

Answer 5

VTE commonest
Cardiac remains high as indirect cause
SUDEP worryingly high - refer anyone with nighttime or uncontrolled seizures

Other causes, sepsis, mental health, haemorrhage

Question 6

Amniotic fluid embolism presents with

Answer 6

Refecatory hypoxaemia (cyanosis) 
Pulmonary hypertension 
Systemic hypotension 
Petechiae
Seizures 
Foetal distress

Question 7

PDPH when should follow up happen and for how long

Answer 7

OOA guidance is reviewed within 24 hours then daily, and continue until headache resolves

Question 8

PDPH conservative treatment

Answer 8

Prolonged bed rest not recommended
Hydration
IV fluids only if oral not possible

Question 9

PDPH pharmacological management

Answer 9

Simple analgesia
Short term opiods
Caffeine

No evidence for theophylline acth steroids triptans gabapentinoids

Question 10

PDPH invasive treatments

Answer 10

No evidence for acupuncture occipital nerve blocks etc

Epidural saline may transiently improve ymsoykms

Epidural blood patch - when conservative therapy ineffective ans woman experiences difficulty performing activities of daily life and caring for her baby

Question 11

EBP timing and steps prior

Answer 11

Less than 48 hours reduction in efficacy
No investigations needed prior but if stays after two or is evolving or neurology need scan
Written consent

Question 12

Risks of ebp

Answer 12

Repeat Dural puncture
Back pain
Neurological complications

Question 13

Risks of not performing EBP

Answer 13

Insufficient evidence but suggestion is reduction headache prevention haematoma

Question 14

What level should EBP be done

Answer 14

Same level or one space lower
20ml
Review within 4 hours procedure
Verbal and written advice and write to GP and midwife

Question 15

Pathophyisology of PDPH

Answer 15

CSF leak
Reduction in ICO and downward traction on pain sensitive intracranial structures
Cerebral vascular venodilation

Question 16

Differential diagnosis of PDPH

Answer 16

Migraine 
CVT 
SUBDURAL 
SAH 
SOL 
Meninigitis 
Dehydration 
Caffeine withdrawal 
PET 
Tension headache 
Lactation headache

Question 17

Features PDPH

Answer 17

Frontonocciputal
Better supine
Pressure over abdomen temporarily relieves pain in some

Other features include 
CN palsies 
Visual disturbabce 
Neck stiffness 
Photophobia

Question 18

Prevention of PDPH

Answer 18

Spinal needle selection - smaller gauge and pencil point

Loss of resistance to saline

Replace stylet
? Bevel parrelel to fibres

Senior

Question 19

Define pre eclampsia

Answer 19

New hypertension more than 140/90
Over 20 weeks pregnant
Evidence of end organ damage ie proteinuria

Question 20

Initial treatment pre eclampsia

Answer 20

Labetalol 200mg oral or IV (incremental 50mg)

Nifedipine 10mg

Question 21

Management of pre eclampsia on labour ward

Answer 21

Antihypertensives 
Limit fluids 1ml kg hr
Foetal assessment 
Inform neonatal team 
Discuss with haematology 
Thromboprophylaxis

Question 22

Ga changes for pre eclampsia

Answer 22

Blunt laryngoscope response with ie opiates 
Avoid ergomettine 
Low volume syntocin infusion 
Senior presence 
Hdu post operatively 
Avoid nsaids

Question 23

Management of seizure in pre eclampsia

Answer 23

100% o2 left lateral 
Magnesium 4 gram over 5 minutes 
1 gram per hour 
Can have further magnesium if needed 
Monitor for OHS and deep tension reflexes

Question 24

Maternal risk factors amniotic fluid embolism

Answer 24

Strong uterine contractions
Uterine rupture
Multiparty

Question 25

Foetal risk factors for amniotic fluid embolism

Answer 25

Male fetus Polyhydraminos Multiple pregnancy Assisted delivery

Question 26

Immune theory afe

Answer 26

Phase 1 foetal cells in maternal blood stream, increased levels pulmonary vasoconstrictors leading to pulmonary hypertension and RV failure Phase 2 LV failure pulmonary oedema DIC atone haemorrhage Other theory is mechanical

Question 27

Maternal comorbidities associated with obesity

Answer 27

``` Gestational diabetes VTE Cardiomyopathy Preeclampsia OSA ```

Question 28

Obstetric complications increased in obesity

Answer 28

``` PPH Preterm labour Instrumental delivery Induction of labour Wound infections ```

Question 29

Patient factors contributing to difficult airway in pregnancy

Answer 29

Difficult face mask ventilation (increased fat stores) Difficult laryngoscopy (oedema) Increased reflux ( reduced lower oesophageal tone and angle of his) Reduced FRC

Question 30

Anaesthetic factors contributing to difficult airway obs

Answer 30

Time pressured Altered drug dosing Reduced exposure to obs GA Isolated site

Question 31

Obs difficult airway algorithm

Answer 31

1. Pre induction planning and prep RSI and consider 20cm h20 ventilation Laryngoscopy 2+1 2. Declare failed intubation Call for help Maintain oxygenation SGA x2 or FMV 3. Declare CICO 100% oxygen Exclude laryngospasm FONA

Question 32

Measures to minimise airway issues obs GA

Answer 32

``` Identify at risk patients Plan Position Antacids prophylaxis Video laryngoscopy Adequate paralysis Senior anaesthetist Safe extubation plan ```

Question 33

Risk factors pre eclampsia

Answer 33

``` Nulliparity Multiple pregnancy Previous Age over 40 Bmi over 35 Fix Diabetes Hypertension Renal disease Inter pregnancy gap more than ten years ```

Question 34

Iron deficiency in pregnancy

Answer 34

Who says 110 Iron def in obs increases maternal deaths Low birth weight Preterm labour