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Flashcards in Obstetrics 3 Deck (112):
1

What is a PPH?

Primary postpartum haemorrhage, blood loss >500ml within 24 hours of delivery

2

What is the criteria for PPH in CS?

1L of blood loss

3

Common causes of PPH?

Retained placental fragments
Atonic uterus
Perineal trauma

4

Less common causes of PPH?

Uterine rupture
Cervical or high vaginal tear

5

In whom is atony more common?

Prolonged labour (fatigue)
Grand multiparity (lax uterus)
Overdistention of uterus (Polyhydramnios and multiple pregnancy)
Fibroids

6

Administration of what in the 3rd stage of labour reduces the risk of PPH?

Oxytocin (rather than ergometrine in hypertensive women)

7

What is a secondary PPH?

Excessive blood loss occurring between 24 hours of delivery and 6 weeks postpartum

8

What is the most common cause of secondary PPH?

Endometritis +/- retained placental tissue

9

If the uterus is enlarged and tender with open cervical os and there is postpartum bleeding, what does this suggest?

Endometritis

10

3 most important bacterial causes of puerperal sepsis?

Group A strep (pyogenes)
Staph
E. coli

11

Common sites and causes of postpartum pyrexia?

Genital tract sepsis - Endometritis, wound infection
Chest infection
Mastitis
UTI

12

What is lochia?

Uterine discharge which may be bloodstained for up to 4 weeks

13

Signs of genital tract sepsis?

Offensive lochia
Enlarged and tender uterus

14

What important causes of mortality throughout pregnancy are even more common in the puerperium?

VTE
Pre-eclampsia/Eclampsia

15

Endocrine cause of postnatal depression?

Postpartum thyroiditis

16

Urinary trouble postpartum?

Urinary retention common
UTI
Stress incontinence

17

Excruciating perineal pain presenting a few hours after delivery?

Paravaginal haematoma

18

Advice regarding postnatal contraception?

Lactation is important but not adequate on its own
Usually start 4-6 weeks after delivery; COCP not okay if breastfeeding but POP fine
IUD is also fine at 6 weeks

19

How is labour diagnosed?

Cervical dilatation and effacement
Uterine contraction

20

What constitutes the first stage of labour?

Onset of contractions -> full (10cm) cervical dilatation

21

What constitutes the second stage of labour?

Full cervical dilatation to delivery of fetus

22

What constitutes the third stage of labour?

From delivery of fetus to delivery of placenta

23

3 constituent parts of the labour process (things that can go wrong)?

Powers
Passage
Passenger

24

Rate and timing of contractions in established labour?

For 45-60s every 2-3 mins

25

In whom is poor uterine contractility a common cause of failure to progress in labour?

Nulliparous
IoL

26

What does station mean when describing fetal head position?

Position of occiput related to ischial spines
E.g. Station -2 is 2cm above ischial spines

27

What 3 factors does cervical dilatation depend on?

Fetal head pressure
Uterine contraction
Ability of cervix to soften and efface

28

What is the anterior fontanelle of the baby called?

Bregma

29

What is the attitude of the Fetal head?

The degree of flexion/extension

30

Disorders of attitude (presentation) in labour?

Ideally vertex (full flexion)
Varying degrees of extension can cause brow or face presentation

31

What is localised swelling of the Fetal head due to pressure on fontanelles called?

Caput seccadeum

32

What is the term for rotation of fetus once head delivers to deliver the shoulders?

Restitution

33

What are Braxton Hix contractions?

Irregular involuntary uterine contractions typically occurring in 3rd trimester in absence of cervical dilatation and effacement

34

How long does the first stage of labour take in nulliparous vs multiparous women?

6 for multi, 10 (up to 12) for Nulli

35

What 2 subphases constitute the first stage of labour?

Latent phase - slow cervical dilatation to 3cm over several hours
Active phase - 3-10cm at rate of 1-2cm/hour depending on parity

36

Progression of second stage of labour?

Full dilatation -> passive stage -> desire to push -> active stage -> delivery

37

Over how long is abnormal for the second stage of labour?

Over 1 hour

38

What graphing system is used for monitoring in labour?

Partogram

39

What part of labour does augmentation aim to help?

The powers - inefficient uterine contraction

40

2 things which constitute augmentation?

Amniotomy if needed and oxytocin

41

Most common positional abnormality of fetus causing trouble in labour?

OP position (back to back)

42

3 things which may indicate OP position in labour?

Backache
Long labour
Early desire to push

43

Management of OT position in labour?

Rotation with ventouse

44

Is brow presentation deliverable vaginally?

Nope - CS

45

Commonest cause of fetal damage in labour?

Hypoxia

46

What disease does meconium aspiration cause in the fetus?

Chemical pneumonitis

47

What Fetal investigation in labour can be carried out to indicate hypoxia and suggest need for delivery?

Fetal scalp blood monitoring -

48

DRCBRVADO of CTGs?

Define Risk
Contractions
Baseline Rate
Variability
Accelerations
Decelerations
Overall interpretation (reassuring?)

49

In practise what 2 investigations are most commonly used to measure Fetal distress?

Ctg and Fetal blood scalp monitoring

50

2 things that can help Fetal hypoxia?

Woman in left lateral position
Stop oxytocin

51

Non-medical pain management in labour?

TENS, water submerging, massage

52

Systemic opioid used in maternal labour pain management?

Pethidine

53

What can Pethidine cause in the newborn? How to fix?

Transient respiratory depression - give naloxone

54

Where does an epidural go?

Between L3 and L4

55

3 complications of epidural anaesthesia?

Spinal tap (headache)
Complete spinal block (resp arrest)
Hypotension, convulsion, cardiac arrest

56

What anaesthesia is suitable for instrumental delivery?

Pudendal nerve block

57

What anaesthesia is used for CS/instrumental delivery if epidural not in situ?

Spinal anaesthesia

58

What does active management of 3rd stage of labour aim to reduce?

PPH

59

What constitutes active management of third stage of labour?

Retained placenta - >30mins third stage
Give oxytocin

60

What type of perineal tear does episiotomy cause?

2nd degree but may extend to 3rd/4th

61

What is a first degree perineal tear?

Skin only

62

What is a second degree perineal tear?

Skin and perineal muscles but not anal sphincter

63

3rd degree perineal tear?

Involves anal sphincter but not mucosa

64

4th degree perineal tear?

Involves anal mucosa and sphincter

65

Which types of perineal tear require surgical management?

3 and 4

66

3 RFs for 3rd and 4th degree perineal tears?

Nulliparity
Macrosomia
Instrumentation

67

Normal dose of folic acid? High dose? Til when?

400micrograms
5mg if high risk e.g. DM, epilepsy
Til 12 weeks gestation

68

2 types of bloods to be taken at booking?

Infection screen
FBC and rbc related

69

Infection screen bloods taken at booking?

Rubella
STDs - Syphillis, asymptomatic bacturia
BBVs - hep b, hep c and HIV

70

FBC and rbc related screening at booking visit?

Anaemia
ABO and rhesus
SCD/thalassaemia if indicated by family questionnaire

71

When is routine rhesus prophylaxis given for rhesus negative women?

28 and 34 weeks

72

Presentation after what gestation defines gestational hypertension?

20 weeks

73

When should BP have normalised in gestational hypertension following delivery?

Within 3 months

74

Criteria for GDM diagnosis via OGTT at 26ish weeks?

Fasting >5.6
2 hour post prandial >7.8

75

What needs to be done between 28-36 weeks for gestational diabetics?

4 weekly growth and AFI scans

76

Pathophysiology behind obstetric cholestasis?

Oestrogen impairs bile acid sulfation

77

Is obstetric cholestasis responsive to antihistamine?

Nope

78

2 big RFs for obstetric cholestasis?

Previous obs chole (nearly always recurs)
Family history

79

When does obstetric cholestasis present in terms of gestation?

Over 30 weeks

80

What vitamin can become deficient in obstetric cholestasis?

K - give to prevent haem disease of newborn

81

What vitamins can become deficient in hyperemesis?

B - can develop Wernicke-korskaoff

82

When should delivery happen in obstetric cholestasis? With what assistance?

35-37 weeks, under steroid cover
As risk of stillbirth, preterm labour, clotting dysfunction, and also bile acids impair surfactant production

83

What is increasingly likely postpartum due to obs chole?

PPH due to clotting dysfunction

84

What must be checked postpartum if mum has had obs chole?

LFTs at 3 weeks

85

What factors are upregulated in pregnancy to predispose to VTE?

8,9,10 and fibrinogen

86

Besides the usual RFs, 4 other RFs for VTE in pregnancy?

Multiple pregnancy
CS
High parity
Pre-eclampsia

87

Management of pregnant woman at high risk of VTE?

LMWH til 12 hours before labour
Stop during labour
Recommence 6-12 hours after delivery
Carry on until 6 weeks

88

Management of TTTS?

Laser ablation of communicating placental vessels

89

What 3 defects does tight glycaemic control before conception help prevent in diabetic women?

Cardiac, skeletal and NTD

90

What should Hba1c be less than before getting pregnant in pre-existing diabetic? Absolute contraindication?

Should ideally be less than 47mmol/mol (6.5%)
Absolute contraindication is 86mmol/mol (>10%)

91

3 times BM should be measured during the day in gestational/diabetic women? Desired targets?

Fasting pre-meal less than 5.3
Post prandial less than 7.8
Bedtime BM

92

When should diabetic women deliver by? Why?

38 weeks
Risk of stillbirth primarily, also macrosomia, NRDS, neonatal hypoglycaemia

93

What drugs are used during labour for diabetic woman?

Sliding scale GKI infusion (glucose potassium insulin)

94

What should be done pre-conception for epileptic women?

Good seizure control - preferably 2 years without seizure
Try to taper down meds, be on maximum one (not valproate)
Need high dose folic acid til 12 weeks

95

What scan should be offered for epileptic women who are pregnant in first trimester?

Early anomaly scan between booking/dating and anomaly

96

What needs to be given postnatally for baby of epileptic woman?

Vit K - risk of haem disease of newborn

97

What symptoms may be present in the couple of weeks preceding labour?

Constipation and urinary frequency, due to baby head in pelvis

98

What constitutes Fetal monitoring in 'normal' first stage of labour?

Auscultation every 15 mins

99

Fetal monitoring in 'normal' active second stage of labour?

Auscultation every 5 mins

100

3 criteria for defining preterm labour?

Less than 37 weeks gestation
Contractions every 5-10 mins, lasting over 30 seconds, for over 60 min
Dilation of cervix to 2.5cm, 75% effacement

101

Abx cover if PPROM?

Erythromycin 10 day course

102

5 indications for forceps delivery?

Maternal exhaustion
Mum has pre-existing obstetric condition
Prolonged 2nd stage (DTA of head, OP arrest, poor uterine contractions)
Fetal distress
Aiding breech delivery

103

What should be done in 3rd stage of labour for women with severe pre-eclampsia?

Deliver 37 weeks with steroid and MgSO4 cover
Active 3rd stage management (oxytocin)

104

What is Turtle sign and what does it indicate?

Head pops out of vagina and then back in, indicating shoulder dystocia

105

What forms the pelvic inlet (brim)?

Sacral prominence and ala
Arcuate line of ileum and pectineal line of pubis
Upper margin of symphysis pubis (pubic crest)

106

What forms the pelvic outlet?

Tip of coccyx
Sacrotuberous ligament
Ischial tuberosities
Inferior margin of pubic arch

107

Features of female pelvic making it more suitable for childbirth?

Wider and shallower
Round/oval brim (as opposed to heart shaped male one)
Large pelvic outlet
Pelvic arch is over 100 degrees
Wider sciatic notch
Curved sacrum

108

5 things included on Partogram?

Maternal and Fetal obs - half hourly, look for trends
Contractions - each hour frequency, strength, regularity
Cervical dilatation - PV every 4 hours
Head descent - PV every 4 hours, look at station and engagement
Liquor - each hour. Intact? Otherwise colour - bloody, meconium

109

5 things included in bishops score?

Cervical dilatation
Cervical consistency
Cervical length
Cervical position
Station of presenting part

110

What score indicates unsuitability for spontaneous labour?

5 or under

111

What 5 things are included in an APGAR?

Appearance
Pulse
Grimace
Activity (muscle tone)
Respiration

112

When is APGAR done after birth? What score indicates need for escalation?

1 and 5 mins
Less than 7 indicates need for paeds support, O2