Flashcards in Obstetrics 3 Deck (112):
What is a PPH?
Primary postpartum haemorrhage, blood loss >500ml within 24 hours of delivery
What is the criteria for PPH in CS?
1L of blood loss
Common causes of PPH?
Retained placental fragments
Less common causes of PPH?
Cervical or high vaginal tear
In whom is atony more common?
Prolonged labour (fatigue)
Grand multiparity (lax uterus)
Overdistention of uterus (Polyhydramnios and multiple pregnancy)
Administration of what in the 3rd stage of labour reduces the risk of PPH?
Oxytocin (rather than ergometrine in hypertensive women)
What is a secondary PPH?
Excessive blood loss occurring between 24 hours of delivery and 6 weeks postpartum
What is the most common cause of secondary PPH?
Endometritis +/- retained placental tissue
If the uterus is enlarged and tender with open cervical os and there is postpartum bleeding, what does this suggest?
3 most important bacterial causes of puerperal sepsis?
Group A strep (pyogenes)
Common sites and causes of postpartum pyrexia?
Genital tract sepsis - Endometritis, wound infection
What is lochia?
Uterine discharge which may be bloodstained for up to 4 weeks
Signs of genital tract sepsis?
Enlarged and tender uterus
What important causes of mortality throughout pregnancy are even more common in the puerperium?
Endocrine cause of postnatal depression?
Urinary trouble postpartum?
Urinary retention common
Excruciating perineal pain presenting a few hours after delivery?
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
How is labour diagnosed?
Cervical dilatation and effacement
What constitutes the first stage of labour?
Onset of contractions -> full (10cm) cervical dilatation
What constitutes the second stage of labour?
Full cervical dilatation to delivery of fetus
What constitutes the third stage of labour?
From delivery of fetus to delivery of placenta
3 constituent parts of the labour process (things that can go wrong)?
Rate and timing of contractions in established labour?
For 45-60s every 2-3 mins
In whom is poor uterine contractility a common cause of failure to progress in labour?
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
What 3 factors does cervical dilatation depend on?
Fetal head pressure
Ability of cervix to soften and efface
What is the anterior fontanelle of the baby called?
What is the attitude of the Fetal head?
The degree of flexion/extension
Disorders of attitude (presentation) in labour?
Ideally vertex (full flexion)
Varying degrees of extension can cause brow or face presentation
What is localised swelling of the Fetal head due to pressure on fontanelles called?
What is the term for rotation of fetus once head delivers to deliver the shoulders?
What are Braxton Hix contractions?
Irregular involuntary uterine contractions typically occurring in 3rd trimester in absence of cervical dilatation and effacement
How long does the first stage of labour take in nulliparous vs multiparous women?
6 for multi, 10 (up to 12) for Nulli
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
Progression of second stage of labour?
Full dilatation -> passive stage -> desire to push -> active stage -> delivery
Over how long is abnormal for the second stage of labour?
Over 1 hour
What graphing system is used for monitoring in labour?
What part of labour does augmentation aim to help?
The powers - inefficient uterine contraction
2 things which constitute augmentation?
Amniotomy if needed and oxytocin
Most common positional abnormality of fetus causing trouble in labour?
OP position (back to back)
3 things which may indicate OP position in labour?
Early desire to push
Management of OT position in labour?
Rotation with ventouse
Is brow presentation deliverable vaginally?
Nope - CS
Commonest cause of fetal damage in labour?
What disease does meconium aspiration cause in the fetus?
What Fetal investigation in labour can be carried out to indicate hypoxia and suggest need for delivery?
Fetal scalp blood monitoring -
DRCBRVADO of CTGs?
Overall interpretation (reassuring?)
In practise what 2 investigations are most commonly used to measure Fetal distress?
Ctg and Fetal blood scalp monitoring
2 things that can help Fetal hypoxia?
Woman in left lateral position
Non-medical pain management in labour?
TENS, water submerging, massage
Systemic opioid used in maternal labour pain management?
What can Pethidine cause in the newborn? How to fix?
Transient respiratory depression - give naloxone
Where does an epidural go?
Between L3 and L4
3 complications of epidural anaesthesia?
Spinal tap (headache)
Complete spinal block (resp arrest)
Hypotension, convulsion, cardiac arrest
What anaesthesia is suitable for instrumental delivery?
Pudendal nerve block
What anaesthesia is used for CS/instrumental delivery if epidural not in situ?
What does active management of 3rd stage of labour aim to reduce?
What constitutes active management of third stage of labour?
Retained placenta - >30mins third stage
What type of perineal tear does episiotomy cause?
2nd degree but may extend to 3rd/4th
What is a first degree perineal tear?
What is a second degree perineal tear?
Skin and perineal muscles but not anal sphincter
3rd degree perineal tear?
Involves anal sphincter but not mucosa
4th degree perineal tear?
Involves anal mucosa and sphincter
Which types of perineal tear require surgical management?
3 and 4
3 RFs for 3rd and 4th degree perineal tears?
Normal dose of folic acid? High dose? Til when?
5mg if high risk e.g. DM, epilepsy
Til 12 weeks gestation
2 types of bloods to be taken at booking?
FBC and rbc related
Infection screen bloods taken at booking?
STDs - Syphillis, asymptomatic bacturia
BBVs - hep b, hep c and HIV
FBC and rbc related screening at booking visit?
ABO and rhesus
SCD/thalassaemia if indicated by family questionnaire
When is routine rhesus prophylaxis given for rhesus negative women?
28 and 34 weeks
Presentation after what gestation defines gestational hypertension?
When should BP have normalised in gestational hypertension following delivery?
Within 3 months
Criteria for GDM diagnosis via OGTT at 26ish weeks?
2 hour post prandial >7.8
What needs to be done between 28-36 weeks for gestational diabetics?
4 weekly growth and AFI scans
Pathophysiology behind obstetric cholestasis?
Oestrogen impairs bile acid sulfation
Is obstetric cholestasis responsive to antihistamine?
2 big RFs for obstetric cholestasis?
Previous obs chole (nearly always recurs)
When does obstetric cholestasis present in terms of gestation?
Over 30 weeks
What vitamin can become deficient in obstetric cholestasis?
K - give to prevent haem disease of newborn
What vitamins can become deficient in hyperemesis?
B - can develop Wernicke-korskaoff
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
What is increasingly likely postpartum due to obs chole?
PPH due to clotting dysfunction
What must be checked postpartum if mum has had obs chole?
LFTs at 3 weeks
What factors are upregulated in pregnancy to predispose to VTE?
8,9,10 and fibrinogen
Besides the usual RFs, 4 other RFs for VTE in pregnancy?
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
Management of TTTS?
Laser ablation of communicating placental vessels
What 3 defects does tight glycaemic control before conception help prevent in diabetic women?
Cardiac, skeletal and NTD
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%)
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
When should diabetic women deliver by? Why?
Risk of stillbirth primarily, also macrosomia, NRDS, neonatal hypoglycaemia
What drugs are used during labour for diabetic woman?
Sliding scale GKI infusion (glucose potassium insulin)
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
What scan should be offered for epileptic women who are pregnant in first trimester?
Early anomaly scan between booking/dating and anomaly
What needs to be given postnatally for baby of epileptic woman?
Vit K - risk of haem disease of newborn
What symptoms may be present in the couple of weeks preceding labour?
Constipation and urinary frequency, due to baby head in pelvis
What constitutes Fetal monitoring in 'normal' first stage of labour?
Auscultation every 15 mins
Fetal monitoring in 'normal' active second stage of labour?
Auscultation every 5 mins
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
Abx cover if PPROM?
Erythromycin 10 day course
5 indications for forceps delivery?
Mum has pre-existing obstetric condition
Prolonged 2nd stage (DTA of head, OP arrest, poor uterine contractions)
Aiding breech delivery
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)
What is Turtle sign and what does it indicate?
Head pops out of vagina and then back in, indicating shoulder dystocia
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)
What forms the pelvic outlet?
Tip of coccyx
Inferior margin of pubic arch
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
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
5 things included in bishops score?
Station of presenting part
What score indicates unsuitability for spontaneous labour?
5 or under
What 5 things are included in an APGAR?
Activity (muscle tone)