Obstetrics Flashcards
(141 cards)
1
Q
Medical abortion
- which drugs are used
- how do the drugs work
- what happens if <10 weeks
- what happens for 10-24 weeks
A
Oral mifepristone (anti-progesterone) followed by a misoprostol pessary (prostaglandin) 48 hours later
Mifepristone ends the pregnancy by blocking the progesterone which causes the uterus lining to break down
Misoprostol causes the uterus to contract (cramping and bleeding) allowing for expulsion of products
<10 weeks: take mifepristone in clinic, then go home. Take misoprostol at home 48 hours later. Abortion completed at home.
10-24 weeks: take mifepristone in clinic, then go home. Second appt in clinic 48 hours later for misoprostol. Abortion completed in clinic with analgesia and observation. May require surgery to if all products havent been expelled. Anti-D needed if Rh-ve. If >22weeks, digoxin or KCl may be injected to stop foetal heartbeat.
2
Q
Contraindications to medical abortion
A
?ectopic, CKD, liver disease, allergies to the drugs, long term steroid use, haemorrhagic disease, currently on anticogulation
3
Q
Surgical abortion
- what happens
- <15 weeks
- 15-24 weeks
A
Cervical preparation with misoprostol and dilators to soften and dilate the cervix
<15 weeks: vacuum aspiration. Under LA if <14weeks and under GA if <15 weeks.
15-24 weeks: dilatation and evacuation under GA.
4
Q
Complications of TOP
A
retained products, haemorrhage, infection, sepsis, psychological distress, DIC
Iatrogenic trauma: uterine perforation, cervical injury
5
Q
Folic acid requirements pre-pregnancy and during pregnancy
A
400 micrograms taken daily from 12 weeks prior to conception until 12 weeks gestation, to prevent neural tube defects
5mg recommended for women on antiepileptics, or those with a family history or past obstetric history of neural tube defects
6
Q
Where is b-hCG produced?
What is the role of b-hCG?
What is the trend of b-hCG levels at the beginning of pregnancy?
How do pregnancy tests work?
A
Produced by the embryo initially, and then by the placental trophoblast
Main role is to prevent disintegration of the corpus luteum
Levels double every 48 hours in the first few weeks and peak at 8-10 weeks
b-hCG in the woman’s urine travels up the test strip and binds to a pigmented antibody on the test strip -> creates a pigmented line on the test strip to confirm pregnancy
7
Q
Naegele rule
Factors affecting the accuracy of naegele rule
A
Expected delivery date = LMP + 9 months + 7 days
Relies on the woman’s accuracy of recalling her last period
Relies on regular cycles
Doesnt consider presence of early or light bleeding
The use of OCP or breast feeding could affect ovulation timings
8
Q
At what gestation should singletons and multiple pregnancies stop air travel?
A
Singleton up to 37 weeks
Uncomplicated multiple pregnancy up to 32 weeks
9
Q
Obstetric conditions which cause an increased AFP
Obstetric conditions which cause a reduced AFP
A
Increased: neural tube defects, abdominal wall defect, multiple pregnancy
Reduced: down’s syndrome, trisomy 18 (edwards), maternal diabetes mellitus
10
Q
Antenatal care timetable (brief detail)
A
- <10wks: Booking visit
- 10-13+6: dating scan
- 11-13+6: combined tests for Downs (21), Edwards (18), Pataus (13)
- 15-20: triple/ quadruple test for Down’s
- 16: review blood tests and screening results. OGTT is woman has had GDM in a previous pregnancy.
- 18-20+6: foetal anomaly scan
- 25: only for primip. BP, urine dip, symphysis-fundal height (SFH)
- 28: anti-D if Rh-ve, OGTT if high risk, second anaemia screen, routine BP/ urine dip/ SFH
- 31: primip. BP, urine dip, SFH
- 34: second anti-D, discuss labour/birth plan, BP, urine dip, SFH
- 36: check foetal presentation (offer ECV if breech), BP, urine dip, SFH
- 38: routine BP, urine dip, SFH
- 40: primip BP, urine dip, SFH, discuss prolonged pregnancy
- 41: induce labour or membrane sweep
11
Q
What happens at the booking visit? and when is it?
A
<10 weeks (usually 8-10)
- Provide general advice about food, alcohol, smoking, antenatal classes
- Check BP, urine dip, BMI (pre-eclampsia risk factors)
- Vitamins: folate 400mcg until 12wks, vit D 10mcg daily
Routine tests:
- FBC (anaemia)
- G+S (rhesus state, rhesus isoimmunisation)
- Electrophoresis (haemoglobinopathies)
- Infection screen (syphillis, hep B, HIV, rubella)
- Urinalysis (glycosuria, proteinuria, haematuria, bacteruria)
12
Q
When is the dating scan and what happens?
A
10 - 13+6 weeks
Crown-rump measurement - allows you to date the pregnancy and provide an EDD
Can also check for ectopic pregnancy, multiple pregnancies and abnormal early development
13
Q
When is the combined test and what happens?
What happens with abnormal results?
A
11 - 13+6 weeks
Combined test check for down’s (21), edwards (18) and pataus (13)
Nuchal translucency scan, serum b-hCG and serum pregnancy-associated plasma protein-A (PAPP-A)
Nuchal translucency is an US observation referring to the black space within the back of the foetal neck (Down’s has increased nuchal translucency)
If results suggest a high probability, a diagnostic amniocentesis is offered at 15-20 weeks
14
Q
What happens at the triple/quadruple test and when is it?
A
15 - 20 weeks. Offered to women who havent had a combined test (eg. late bookers). Tests for Down’s.
Serum b-hCG, unconjugated oestriol, AFP (+/- inhibin A)
15
Q
When is OGTT carried out antenatally?
A
16 weeks if woman has had GDM in a previous pregnancy
28 weeks if high-risk
16
Q
When is anti-D given during pregnancy?
A
28 weeks and 34 weeks
17
Q
Physiological changes to the uterus during pregnancy
A
Hypertrophy of myometrium
From 28 weeks, lower third of uterus becomes thinner and less vascular (allows for C-section)
Uterine artery branches into spiral arteries to supply the decidua (maternal section of placenta)
18
Q
Normal trophoblast invasion
What happens when there is incomplete trophoblast invasion?
A
Trophoblast invasion widens arteries -> reduced resistance -> increased flow by 16 weeks
If there is incomplete trophoblast invasion:
- Increased resistance causes reduced flow -> reduced nutrients to foetus -> IUGR
- Increased resistance also causes increase BP in the system -> causes clots in the maternal placental bed which further reduced flow -> backlogs into systemic circulation -> maternal HTN/ pre-eclampsia
- During labour, the foetus receives less oxygen as a result of reduced flow -> foetal distress
19
Q
Physiological changes to cardiorespiratory systems in pregnancy
A
CVS:
- Stroke vol and heart rate increases -> CO increases.
- Systolic BP should remain the same
- Diastolic BP reduced in tri 1 and 2, and returns to normal in tri 3
- Enlarged uterus may interfere with venous return -> ankle oedema, supine hypotension, varicose veins
Resp:
- Progesterone acts on resp centre -> increased tidal vol -> ventilation increases
- Ventilation increases by 40% but only 20% more O2 is needed -> hyperventilation leads to reduced pCO2 -> leads to a sense of dyspnoea (worsened by uterus displacing the diaphragm)
20
Q
Physiological changes to the blood in pregnancy
A
Blood vol increases (mostly in 2nd half of pregnancy) - allows for gas/nutrient exchange and reduces impact of blood loss in labour
Autotransfusion: blood loss in labour is compensated for by autotransfusion of 300-500ml of blood from the contracting uterus into the venous system
RBCs increase by 20% but plasma vol increases by 50% -> haemodilution -> iron and folate needed to restore the relative low Hb
Increased coagulant activity (increased fibrinogen, and factors VII, VIII, X) and reduced fibrinolytic activity: prevents excessive bleeding in labour but creates a hypercoagulable state
21
Q
Physiological changes to the urinary system in pregnancy
A
Blood flow to the kidneys increases
GFR increases
Elevated sex steroids -> increased salt and water retention
Urinary protein losses increases
Progesterone causes urine stasis in the ureters and renal pelvis -> more prone to infection
22
Q
Dizygotic vs monozygotic twins
Types of monozygotic twins
A
Dizygotic: non-identical, two separate eggs fertilised at the same time
Monozygotic twins: identical, one egg which divides to form 2 embryos
Monochorionic monoamniotic: one placenta, one sac
Monochorionic diamniotic: one placenta, two sacs
Dichorionic diamniotic: two placentas, two sacs
23
Q
Predisposing factors for twins
A
Previous twins, family history, incresaed maternal age, multigravida, induced ovulation/IVF, afro-caribbean
24
Q
Obstetric complications of twins
Foetal complications of twins
Labour complications of twins
A
Obstetric: polyhydramnios, pregnancy induced HTN, pre-eclampsia, eclampsia, anaemia, antepartum haemorrhage
Foetal: perinatal mortality, miscarriage, vanishing twin syndrome, prematurity, low birth weight, malformation
Twin to twin transfusion: only seen in monochorionic twins. Placenta diverts blood from one foetus to the other foetus. One gets too much blood (CVS overload and develops polyhydramnios) and the other receives insufficient blood (develops oligohydramnios and IUGR)
Labour: post-partum haemorrhage due to over-distended uterus and large placental area, malpresentation, cord prolapse/entanglement
25
Antenatal care for twins
When to deliver twins
Additional appointments for monochorionic twins
Additional appointments for dichorionic twins
Mode of delivery for twins
Indications for C-section
Additional appointments
Additional iron and folate
Prophylactic aspirin from 12 weeks if nulliparous
2 obstetricians present at delivery
Deliver monochorionic twins by 36 weeks and dichorionic twins by 37 weeks
No cut off point for delivery of dizygotic twins
Additional appts for monochorionic twins:
- US every 2 weeks for 16 weeks until delivery (monitor for twin to twin transfusion and check growth)
- IOL by 36 weeks (give steroids before delivery to encourage lung maturation in the twins)
Additional appts for dichorionic twins:
- US at 24,28, 32, 36 wks (check growth, abnormalities and umbilical artery doppler)
- IOL by 37 weeks (mode of delivery depends on presentation and lie of foetus 1)
Mode of delivery:
- Vaginal birth if foetus 1 is head first, otherwise C-section
- Not advised to have vaginal birth for twins if you have previously had a C-section
Indications for C-section:
Foetus 1 is breech or transverse, low lying placenta, monochorionic twins, previous history of difficult delivery
26
Obesity complications in pregnancy
```
Foetal monitoring is more difficult (SFH inaccuracies)
GDM
Pre-eclampsia and eclampsia
Miscarriage and stillbirth
Macrosomia
Impaired foetal development
Prematurity
```
27
Antenatal management for obesity depending on different BMIs
BMI 30-34: folate 5mg preconception until 12wks gestation, vit D, assess VTE risk, OGTT at 28 weeks, advise weight loss
BMI 35-39: all of the above plus, consultant-led care, assess pre-eclampsia risk, consider prophylactic aspirin, serial growth scans, frequent BP checks
BMI 40+: all of the above plus, antenatal anaesthetic review, manual handling and tissue viability risk assessment
28
Pre-existing diabetes mellitus during pregnancy
- preconception advice
- additional antenatal care
- intrapartum care
- postpartum care
Preconception: aim for fasting glucose 5-7, start on 5mg folate until 12wks gestation
Additional antenatal care: aim for fasting glucose <5.3, review DM medication, retinal assessment/ treat any retinopathy, measure HbA1c, switch oral hypoglycaemics to insulin (exc. metformin), attend diabetic antenatal appts every 1-2 weeks, prophylactic aspirin from 12wks until delivery
Intrapartum care: if uncomplicated DM, IOL/C-section at 37-38+6. consider insulin sliding scale during labour
Post-partum:
- Insulin treated DM: reduce insulin immediately after birth back to pre-pregnancy regime, due to increased risk of hypoglycaemia in post-natal period
- Eat a snack before breastfeeding
- If breastfeeding, continue metformin but avoid all other hypoglycaemics
29
Complications of DM during pregnancy
Miscarriage, IUGR, foetal obesity, foetal growth acceleration, polyhydramnios, birth defects
30
Epilepsy in pregnancy
- contraception advice
- preconception counselling
- Additional antenatal care
Contraception: avoid unplanned pregnancies, copper IUDs are contraception of choice, women on enzyme-inducing AEDs (carbamazepine, phenytoin) should be counselled about the risk of failure with some hormonal contraceptions
Preconception counselling: 5mg folate daily preconception until 12wks gestation.
Review AEDs: Stop valproate. Carbamazepine and lamotrigine are considered safe. Use lowest effective dose. Dont stop AEDs suddenly.
Additional antenatal care: 5mg folate until 12wks gestation, regular assessment of risk factors for seizures, serial growth scans due to risk of SGA baby
31
Epilepsy in pregnancy
- intrapartum care
- post-partum care
Intrapartum: risk of seizures in labour is low, adequate analgesia and appropriate care minimises risk factors of seizures, AEDs should be continued.
If seizure occurs, it should be terminated ASAP with benzodiazepine to reduce risk of hypoxia to mum and foetus
Long acting benzodiazepine (clobazam) should be continued if there is high risk of seizure
Post-partum: babies should have IM vit K 1mg to prevent haemorrhagic disease of the newborn, minimise seizure risk factors (sleep deprivation, pain, stress, etc), if AEDs were increased in pregnancy then review within 10 days of delivery to avoid toxicity. Safe to breastfeed.
32
Pre-existing hypertension during pregnancy
- first line antihypertensive
- additional antenatal care
- High risk of pre-eclampsia
- Labetalol is first line antihypertensive in pregnancy (then methyldopa, nifedipine)
- Start prophylactic aspirin at 12wks until delivery
- Check signs of pre-eclampsia at each visit (BP, urine dip)
33
Hep B in pregnancy
- screening
- risk of transmission
- management for baby
- risk of breastfeeding
Screened for at booking
90% chance of transmitting it to baby
Baby should receive a complete course of vaccination and hep B immunoglobulin immediately after birth to reduce transmission by 90%
Breastfeeding is safe
34
HIV in pregnancy
- screening
- how to reduce vertical transmission
- what to avoid if spontaneous labour occurs
Screened for at booking
Reduce vertical transmission by:
- Maternal antiretroviral therapy during pregnancy
- C section if there is a detectable viral load
- IV antiretroviral therapy 4 hours before C-section
- Neonatal antiretroviral therapy for 6 weeks
- Avoid breastfeeding
If spontaneous labour occurs, avoid ARM or foetal blood sampling
35
Pre-existing cardiac disease in pregnancy
- what drugs to consider stopping
- additional antenatal care
Stop ACE inhibitors and diuretics, all other medications are safe
Regular growth scans form 28 weeks due to risk of IUGR from reduced cardiac output
36
Anaemia in pregnancy
- screening
- causes
- management
- complications if untreated
Screened at booking and at 28 weeks
Causes: poor intake of folate/ B12/ iron (doesnt match increased demand), poor absorption (vomiting, increased pH of gastric acid, lack of vit C), increased utilisation (twins, veggie mother, grand multiparity, pregnancies close together)
Management: supplements
Complications:
- Iron deficiency: prematurity, low birth weight, blood transfusions, post-partum depression, anaemic baby, developmental delays in child
- Folate deficiency: neural tube defects, low birth weight
- Vit B12 deficiency: neural tube defects, preterm labour
37
Gestational diabetes
- antenatal care
- management of GDM
- postpartum care
Antenatal:
- usually diagnosed at 16 weeks or 28 weeks (fasting glucose >5.6 or OGTT >7.8)
- appointments every 1-2 weeks at diabetic antenatal clinic
- 32 weeks: US growth scan and amniotic fluid vol
- 36 weeks: US growth scan and amniotic fluid vol. Discuss birth plan, changes to medication during/after birth, care of baby postpartum, breast feeding, contraception
uncomplicated GDM should give birth no later than 40+6 weeks
If fasting glucose <7.0 at time of diagnosis, then trial diet and exercise changes, if glucose targets not met in 1-2 weeks, start metformin, if still not met then add insulin
If fasting glucose >7.0 at time of diagnosis, start straight away on insulin
If plasma glucose 6-6.9 and evidence of complications (eg. macrosomia, hydramnios) start straight away on insulin
Post partum:
- Weight loss, diet, exercise
- Fasting plasma glucose test at 6-13 weeks postpartum
- Annual HbA1c for GDM women who don't have DM postpartum
38
Pre-eclampsia definition and risk factors
= Pregnancy induced HTN after 20 weeks + proteinuria
Risk factors identified at booking: Age >40, nulliparity, pregnancy interval >10yrs, FHx, previous pre-eclampsia, BMI >30, pre-existing vascular disease (eg. HTN), pre-existing renal disease, multiple pregnancy
39
Pre-eclampsia presentation
```
Severe headache
Sudden swelling of face, hands, feet
Visual problems (blurring, flashing)
Severe pain below the ribs
Vomiting
```
40
Investigations for pre-eclampsia
Urinalysis: proteinuria (+++)
MSU and 24hr collection to exclude UTI if only +1 protein
Frequent BP measurements for high risk women
A single diastolic reading of 110 or 2 consecutive reading of 90 at least 4 hours apart and/or significant proteinuria requires surveillance
Two consecutive systolic readings >160 at least 4 hours apart requires management
Bloods:
- FBC (low platelets and Hb = ?HELLP)
- U+Es (May be raised)
- LFTs (high ALT and AST, low albumin) (high GGT and bilirubin= ?HELLP)
41
Management and prophylaxis of pre-eclampsia
Prophylactic low dose aspirin from week 12 until delivery if high risk
Management:
- Delivery by 38 weeks is the only cure
- Treat HTN with labetalol (or nifedipine or methyldopa)
- Regular monitoring of BP, urinalysis, FBC, U+E, LFT, US growth scans and CTG due to risk of abruption or progression into eclampsia
- Magnesium sulphate reduces risk of seizures (eclampsia)
42
Complications of pre-eclampsia
```
IUGR due to uteroplacental insufficiency
HELLP syndrome (haemolysis, elevated LFTs, low platelets) - manage the same as pre-eclampsia
Pulmonary oedema due to low albumin and vasc endothelial dysfunction
DIC
Cerebral haemorrhage
Placental abruption
Eclampsia
Prematurity
Multi-organ failure
Cardiac failure
```
43
Obstetric cholestasis
- what is it
- cause
- foetal complications
- diagnosis
- management
Jaundice and itching (no rash) due to increased bile
Disappears after delivery
Thought to be due to high oestrogen levels
Foetal complications: prematurity, still birth, passing meconium before birth
Diagnosis: itch + jaundice + abnormal LFTs and bile acid tests
Blood tests and USS can be done to exclude other conditions
Management:
- Delivery at 37 weeks (IOL or C-section)
- Creams and antihistamines to relieve itching
- Ursodeoxycholic acid to reduce bile levels and improve LFTs
- May require daily vit K due to clotting problems
- Vit K for the baby after delivery to prevent haemorrhagic disease of the newborn
44
UTis in pregnancy
Progesterone + enlarged uterus -> kinked dilated ureters => stasis and reflux -> risk of UTI and pyelonephritis
E coli
Ix: dipstick, MSU for MC+S
Mx of UTI or asymptomatic bacteruria: 7 days nitrofurantoin
If trimethoprim given in tri 1 then give 5mg folate too, avoid trimethoprim if folate deficient
mx of acute pyleonephritis: cefalexin 10-14 days
45
Investigations for VTE in pregnancy
Treat a ?VTE with LMWH until diagnosis is excluded
Do baseline FBC, coag screen, U+E and LFTs before starting LMWH
?DVT -> compression duplex USS
?PE -> CXR and ECG. If signs of DVT too then also do compression duplex USS, if no signs of DVT then do V/Q scan or CTPA (discuss which one with patient and radiologist)
46
Management of VTE in pregnancy
Antenatal care for a woman who has had a VTE in a previous pregnancy
Prophylaxis for high risk women
Subcut LMWH for remainder of pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment has been given in total
Prophylactic LMWH required during pregnancy if woman has had VTE in previous pregnancy
Women with 3 or more risk factors requires prophylactic LMWH from 28 weeks until 6 weeks postnatal
Women with 4 or more risk factors requires prophylactic LMWH immediately, until 6 weeks postnatal
Avoid DOACs and warfarin in pregnancy
47
Hyperemesis gravidarum
- when?
- what causes it?
- risk factors
- protective factor
- triad
- investigations
- management
- complications
Usually between weeks 8 and 12 but may be up to week 20
Due to raised b-hCG
Risk factors: twins, trophoblastic disease, hyperthyroidism, nulliparity, obesity
Smoking is a protective factor
Triad: 5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
Investigations: pregnancy-unique quantification of emesis (PUQE score)
Management:
- First line: promethazine (antihistamine) or cyclizine
- Second line: ondansetron or metoclopramide
- Admission for IV hydration in severe cases
- Thiamine to prevent Wernicke's encephalopathy
```
Complications:
Wernickes encephalopathy
Mallory-Weiss tear
Central pontine myelinolysis
Acute tubular necrosis
Foetal complications: SGA, pre-term delivery
```
48
Ways to assess foetal growth
```
Abdominal palpation of fundal height
Symphysis fundal height measurement
USS measurement
Head circumference measurement
Abdominal circumference measurement
Femur length
```
49
What is the definition of a small for gestational age baby?
| What are the causes of symmetrical IUGR and asymmetrical IUGR?
<10th population centile for gestational age
May be due to incorrect measurements of size or incorrect dates (woman is earlier through pregnancy than what has been estimated)
Symmetrical IUGR: abdominal circumference and head circumference equally small
-Race, maternal size, sex of foetus, alcohol/smoking/drugs, poor placenta, twins, malnutrition, ToRCH
Asymmetrical IUGR: abdominal circumference slows its growth relative to the head
-HTN, pre-eclampsia, smoking/drugs, chromosomal or congenital abnormalities
50
Maternal and foetal monitoring for SGA babies during pregnancy
Maternal monitoring: BP, urine dip, monitor maternal disease
Foetal monitoring: serial growth measurements every 2-4 weeks, foetal movement, foetal doppler, amniotic volume measurement, biophysical profile
51
Doppler wave forms
- normal end diastolic flow
- abnormal end diastolic flow
- reverse end diastolic flow
- complication
Normal end-diastolic flow: flow to placenta is present during diastole
Abnormal end-diastolic flow: flow to placenta is compromised during diastole
Reversed end-diastolic flow: pressure in placenta causes blood to flow in opposite direction away from foetus during diastole
Abnormal and reversed end diastolic flow (AREDF) causes significant malnutrition to foetus and compromises life
52
Timing and mode of delivery for small foetuses, depending on foetal doppler
Normal umbilical artery doppler: delay delivery until at least 37 weeks
AREDF with normal additional assessment: deliver if gestation >34 weeks
AREDF with abnormal additional assessment (abnormal CTG, BP, doppler) : deliver even if gestation <34 weeks
Mode of delivery depends on gestation, presentation, foetal condition and maternal factors
53
Complications of IUGR foetus
Perinatal death, need for resuscitation, hypothermia, hypoglycaemia, respiratory distress syndrome, necrotising enterocolitis, neurodevelopmental disability, cerebral palsy, adult disease
54
Definition of large for gestational age baby, and factors causing LGA babies
Which factors can give a false impression of an LGA baby?
>90th popilation centile for gestational age
Factors:
- Maternal: DM, obesity, increased maternal age, multiparity, large stature
- Foetal: constitutionally large (ie. large mum), male, postmaturity, genetic disorders
Polyhydramnios, a pelvic mass and uterine fibroids can give a false impression of a LGA baby
55
Complications of LGA babies
Maternal: prolonged labour, caesarean, PPH, genital tract trauma
Foetal: birth injury, perinatal asphyxia, shoulder dystocia, erbs palsy, hypoglycaemia, childhood obesity, metabolic syndrome
56
What is breech presentation
| Different types of breech presentation
Foetal buttocks occupies the lower uterine segment, rather than the head
Frank breech: buttocks presenting with the legs extended
Complete breech: legs flexed so the feet present behind the buttocks
Footling breech: one or both feet presents below the buttocks
57
Causes of breech presentation
Maternal: grand multiparity, uterine abnormalities, pelvic tumour, full bladder during labour
Placental: placenta praevia, oligohydramnios, polyhydramnios
Foetal: multiple pregnancy, foetal abnormality, prematurity
58
Management of breech presentation
If diagnosed antenatally, offer external cephalic version
| If breech at term then do elective C-section
59
External cephalic version
- what happens?
- complications
- rate of success
- contraindications
Manipulate the lie of the foetus into a cephalic presentation with the aid of tocolysis to relax the uterus
1% risk of cord accident or abruption. Risk of PROM
If performed <37 weeks: 40% success rate if primiparous and 60% success rate if multiparous
Contraindications for ECV:
- PROM or PPROM
- APH in last 7 days
- Multiple pregnancy
- Uterine abnormalities
- Previous C section
- Abnormal CTG
60
Transverse vs oblique lie
Transverse: head and buttocks are found in the flanks
Oblique: diagonal with either the head or buttocks found in an iliac fossa
61
Management of Transverse and oblique lie
If diagnosed at term, then hospital admission is required until delivery due to high risk of cord prolapse if membranes rupture
Elective C-section if cause is known (eg. placenta praevia)
If cause unknown, observe patient until lie stabilises in cephalic for >48 hours, at which stage labour can be induced
62
Placenta praevia grading
1 - reaches lower uterine segment but not internal os (minor)
2 - reaches but doesn't cover internal os (minor)
3 - covers internal os when NOT dilated (major)
4 - covers internal os even when dilated (major)
63
Risk factors for placenta praevia
previous placenta praevia, multiple pregnancy, age >40, high parity, history of endometritis, previous C section, curettage to endometrium (miscarriage, TOP, etc)
64
Investigations for placenta praevia
Transvaginal ultrasound scan
Usually picked up on foetal anomaly scan (18-20+6)
If grade 1 or 2 -> rescan at 36 weeks
If grades 3 or 4 -> rescan at 32 weeks -> plan delivery
Bloods: FBC, G+S, coag screen, U+E, LFT, crossmatch, Kleihauer test (Rh-ve)
CTG if >26 weeks to check foetal wellbeing
65
Oligohydramnios
- definition
- causes
- diagnosis
- management
Normal amniotic fluid 500-1500ml
Oligohydramnios = <500ml at 32-36 weeks and/or an amniotic fluid index (AFI) < 5th percentile.
Causes: increased loss of fluid, or reduced foetal urine production or excretion
Kidney agenesis, urinary problems, chromosomal abnormalities, viral abnormalities
IUGR, post-term pregnancy, PROM, placental abruption, twin-to-twin transfusion, maternal dehydration, uteroplacental insufficiency, HTN, pre-eclampsia, DM, etc
Diagnosis: USS (measure amniotic fluid index)
Management:
Before term: antepartum surveillance, continuous foetal heart rate monitoring during labour
At term: deliver baby
66
Polyhydramnios
- definition
- causes
- symptoms
- management
- complications
>1500ml amniotic fluid (or amniotic fluid index >95th percentile)
Reduced foetal swallowing, increased foetal urination, secretions of foetal lung fluid and foetal oral and nasal cavities
Causes: idiopathic, congenital anomalies, GI atresia, CVS defects, neural tube defects, diabetes, foetal anaemia
Symptoms: abdo tenderness, reduced sensation of foetal movement, increased symphysis-fundal height
Diagnosis: USS
Management:
- Treat underlying cause and bed rest
- Regular antenatal checks and serial USS checks to assess risk of preterm labour due to overdistended uterus
- IOL if foetal distress develops
- Corticosteroids given if preterm delivery is considered (to help lung maturity)
- Prostaglandin synthetase inhibitors (reduce renal blood flow -> reduced foetal urine)
Complications: PROM, placental abruption, PPH, cord prolapse
67
Chorioamnionitis
- what is it
- risk factors
Inflammation of the foetal membranes due to bacterial infection
Often due to prolonged labour
Risk of chorioamnionitis increases with each vaginal examination in the final month
68
Placenta praevia
- what is it
- why may there be bleeding
- management
Implantation of the placenta into lower uterine segment -> classified according how close the leading edge of placenta is to the internal cervical os
Bleeding may occur due to thinning of the cervix and lower segment of the uterus in late pregnancy/labour (level of shock is in keeping with the level of blood loss)
Management:
- If bleeding occurs -> admit until delivery is necessary
- Regular Hb checks
- 4 units crossmatch readily available just incase
- C section at term unless uncontrollable bleeding in which case premature delivery is needed
69
Placenta accreta
- what is it
- risk factors
- complication
Attachment of placenta to myometrium
Risk factors: previous placenta praevia, previous c section
Major complication is PPH
70
Vasa praevia
- what is it
- risks
Foetal blood vessels run near internal cervical os
Risks: vaginal bleeding, rupture of membranes, foetal compromise
71
Prolonged pregnancy
- definition
- risk factors
- complications
Pregnancy lasting >42 weeks
Risk factors: nulliparity, age >40, increased BMI, previous prolonged pregnancy, FHx
Complications: needs caesarean, passage of meconium before birth, meconium aspiration, baby dry flaky skin,
LGA, oligohydramnios, reduced foetal movement
72
Placental abruption features
- what is it
- mild abruption features
- major abruption features
Premature separation of part of the placenta from the uterus before delivery
Bleeding occurs from the placental bed and a haematoma develops beneath the placenta, shearing it from the uterus
PV bleeding may occur, or it may be concealed entirely inside the uterus -> so the level of shock isnt in keeping with the amount of PV bleeding
Mild abruption: small amount of pain or bleeding that settle spontaneously with no apparent effect on foetal wellbeing
Major abruption: constant lower abdo/back pain, varying amounts of PV bleeding (depends on concealment), haemodynamic instability
73
Risk factors for placental abruption
```
HTN
Pre-eclampsia
Previous abruption
Multiple pregnancy
DM
Drugs
Smoking
Trauma
```
74
Management of placental abruption
Admit for continuous CTG and observations
Cross match 4 units of blood
Correct any coagulopathies
Deliver the baby (vaginal birth carries less risk and less blood loss, only do C-section if bleeding is uncontrolled or if there is foetal compromise)
Anti-D within 72 hours if Rh-ve
75
Clinical features of placental abruption
```
Shock out of keeping with visible loss
Constant pain
Tender, tense uterus
Normal lie and presentation
Foetal heart: absent/distressed
Coagulation problems
Beware pre-eclampsia, DIC, anuria
```
76
Complications of placental abruption
DIC
Low clotting factors, fibrinogen, platelets
Renal failure
PPH due to coagulopathy and poor contractile uterus
Foetal hypoxia and intrauterine death due to sudden reduction in gas exchange
77
Placenta praevia vs placental abruption
PP painless, PA constant pain or high-frequency contractions
PP clinical condition relates to visible blood loss, PA clinical condition out of keeping with blood loss visible
PP soft non-tender uterus, PA tense tender uterus
PP high presenting part of malpresentation, PA may be unable to palpate foetal parts due to tense uterus but usually have normal presentation
PP ultrasound diagnosis, PA clinical diagnosis but can consider USS
PP low risk to foetus, PA high risk to foetus
PP caesarean section (usually at term), PA vaginal delivery (C-section only if uncontrollable bleeding or foetal compromise)
78
Group B streptococcus
- what does it cause
- risk factors
- management
Most common cause of early-onset severe neonatal infection
RFs: prematurity, prolonged ROM, previous GBS infection, maternal pyrexia
Management:
- Screening only given to high risk women (previous GBS)
- Women who have had a previous GBS pregnancy should be informed that their risk is 50% for current pregnancy
- Women who have had a previous GBS pregnancy should be offered maternal IV benzylpenicillin prophylaxis, OR high vaginal swab test at 35-37 weeks and then given IV benzylpenicillin if test is positive
- Maternal IV benzylpenicillin prophylaxis should be offered to ALL women in preterm labour regardless of GBS status, and should also be given to ALL women with pyrexia >38 during labour
79
Prelabour Rupture Of Membranes
- what is it
- presentation
- risk factors
- diagnosis
- foetal complications
- maternal complications
- management
Breakage of amniotic sac >1hour before onset of labour, at or after 37 weeks
Features: painless gush of PV fluid
Risk factors: chorioamnionitis, prior PRM, bleeding in late pregnancy, smoking, underweight mother, polyhydramnios
Clinical diagnosis but may be supported by testing vaginal fluid (amnisure protein and actin-PROM protein), USS, or high vaginal swab to check GBS
Foetal complications: premature birth, cord compression, infection
Maternal complications: placental abruption, postpartum endometriosis
Management:
- IOL if spontaneous labour does not occur in 48 hours
- Infection risk > prematurity risk when PROM is at term
- Risks of delaying IOL includes foetal distress, infection, sepsis and abruption
80
Preterm Prelabour Rupture Of Membranes
- what is it
- risk factors
- diagnosis
- management
Rupture of membranes prior to onset of labour, occurring before 37 weeks gestation
Risk factors: multiple pregnancies, smoking, previous preterm delivery, vaginal bleeding, lower genital tract infection, chorioamnionitis, polyhydramnios, amniocentesis, cervical incompetence
Diagnosis: speculum exam, test fluid for amnisure protein and actin-PROM protein), high vaginal swab for GBS
Management:
- Prophylactic PO erythromycin 10days or until labour established (delays delivery, reduces infection and improves resp function of baby)
- Corticosteroids (matures lungs for delivery and promotes surfactant production)
- Magnesium sulphate can provide foetal neuroprotection, depending on gestation
- Nifedipine (tocolytic) may be used if labour needs to be suppressed
- If >34 weeks, labour can be induced if sufficient foetal lung maturation (risk of infection > risk of prematurity)
- Avoid digital examination
- Consider cervical cerclage
81
Complications of PPROM
```
Chorioamnionitis
Prematurity
GBS
Umbilical cord prolapse
Placental abruption
Oligohydramnios
Postpartum haemorrhage
Neonatal death/ still born
```
82
3 stages of labour
1. Onset of true labour is when the cervix is fully dilated
2. Delivery of the foetus
3. Delivery of the placenta and membranes
83
Signs of labour
Regular and painful uterine contractions
A show (shedding of mucous plug)
Rupture of membranes (not always)
Shortening and dilation of the cervix
84
Monitoring during labour
Foetal heart rate every 15 mins or continuous CTG
Contraction assessment every 30 mins
Maternal pulse check every 60
Maternal BP and temp check every 4 hours
Vaginal exam offered every 4 hours
Maternal urine check for ketones and protein every 4 hours
85
Bishops score
Position: posterior (0), middle (1), anterior (2)
Consistency: firm (0), medium (1), soft (2)
Effacement 0-30% (0), 40-50% (1), 60-70% (2), 80%+ (3)
Dilation: closed (0), 1-2cm (1), 3-4cm (2), 5+cm (3)
Station: -3 (0), -2 (1), -1/0 (2), +1/+2 (3)
A score <5 = labour unlikely to start without induction
A score >9 = labour will start spontaneously
5-9 = clinical judgement
86
Reading a CTG
DR C BRAVADO
1. DR: define risk of pregnancy
2. C: Contractions /10min: assess duration and intensity
3. BRa: baseline rate of foetal heart: normal is 100-160
4. V: variability: reassuring, non-reassuring, abnormal, sinusoidal
6. A: Accelerations (abrupt increase in foetal HR of >15bpm for >15sec - reassuring, usually occurs alongside contraction)
7. D: decelerations (abrupt decrease in foetal HR of >15bpm for >15s - early, variable, late, prolonged)
8. O: overall/ outcome (abnormal, normal, emergency, etc)
87
Causes of baseline bradycardia
Causes of severe prolonged bradycardia
Management
<100
Increased foetal vagal tone, maternal beta blockers
Severe prolonged (<80): prolonged cord compression, cord prolapse, anaesthesia, maternal seizure, rapid foetal descent
Management: category 1 or 2 emergency C section if the cause cant be corrected
88
Causes of baseline tachycardia
>160
| Maternal pyrexia, chorioamnionitis, hypoxia, prematurity, foetal or maternal anaemia
89
Baseline variability:
-What is it and what is it an indicator of
- Reassuring
- Non-reassuring
- Abnormal
- Sinusoidal
- Causes of non-reassuring variability
- Causes and management of sinusoidal pattern
Variation of foetal HR form one beat to the next
Good indicator of foetal health: occurs from interaction between nervous system, chemoreceptors, baroreceptors, and cardiac responsiveness
Reassuring: 5-25bpm variability between beats
Non-reassuring: <5bpm for 30-50min, or >25bpm for 15-25 min
Abnormal: <5bpm for >50min, >25bpm for >25min
Sinusoidal pattern: smooth, regular wave-like pattern, with stable baseline, no variation
Causes of non-reassuring: <5bpm variability if foetus is sleeping, foetal tachycardia, drugs (opiates, benzo, mag sulphate, methyldopa), congenital heart defects, prematurity, foetal acidosis due to hypoxia)
Causes of sinusoidal: high rates of foetal morbidity and mortality, due to severe foetal hypoxia/anaemia, foetal/ maternal haemorrhage
Mx: immediate C-section (usually poor outcome)
90
CTG decelerations
- early decelerations
- variable decelerations
- late decelerations (+ causes, + management)
- prolonged decelerations (+ management)
Early (physiological): deceleration starts when contraction begins and recovers when contraction stops, due to increased foetal ICP causing increased vagal tone
Variable: rapid decline in HR with variable recovery phase, may have no relationship with uterine contractions (often due to oligohydramnios or cord compression)
Late: HR drops at peak of contraction and recovers after the end of contraction. Insufficient blood flow to uterus and placenta, causing reduced blood flow to foetus -> hypoxia and acidosis
Causes: maternal hypotension, pre-eclampsia, uterine hyperstimulation
Mx: foetal blood sampling for pH (if acidotic -> significant foetal hypoxia -> emergency C section)
Prolonged deceleration:
If lasting 2-3 mins = non-reassuring
If >3mins = abnormal
Urgent Mx: foetal blood sampling (+/- emergency C section)
91
Indications for continuous CTG
```
Use of oxytocin
Maternal tachycardia >120 min
Temp >38
? chorioamnionitis
? sepsis
Abnormal pain
Significant meconium
Fresh PV bleeding in labour
Severe HTN (160/110)
Raised proteinuria
Delayed labour
Long/frequent contractions
```
92
Labour and delivery complications
```
Abnormal presentation
PROM, PPROM
Premature delivery
Prolonged delivery (IOL)
Umbilical cord prolapse
Amniotic fluid embolism
Perineal tear
```
93
Classification of perineal tears
First degree: superficial damage, no muscle involvement
Second degree: injury to perineal muscle, not involving anal sphincter
Third degree: injury to perineum involving anal sphincter
3A: <50% of external anal sphincter thickness torn
3B: >50% of external anal sphincter thickness torn
3C: internal anal sphincter torn
Fourth degree: injury to perineum involving entire anal sphincter complex (external and internal anal sphincter) and rectal mucosa
94
Risk factors for perineal tears
```
Primigravida
Large babies
Precipitant labour (fast labour)
Shoulder dystocia
Forceps delivery
```
95
Contraindications to instrumental delivery
```
Unengaged foetal head
Incompletely dilated cervix
True cephalopelvic disproportion
Breech/ face presentation
Coagulopathy
```
Relative contraindications: severe non-reassuring foetal status, delivery of twin 2 when head not engage, cord prolapse
96
Indications for forcep delivery
Indications for instrumental delivery in general
Fetal distress in the second stage of labour
Maternal distress in the second stage of labour
Failure to progress in the second stage of labour
Control of head in breech delivery
Indications for instrumental delivery in general:
Baby not moving out of birth canal
Concerns about baby wellbeing
Unable to/ advised not to push during labour
97
Induction of labour
- indications
- method
Indications: prolonged pregnancy (>12 days from EDD), PROM where labour hasn't started in 48 hours, maternal DM >38 weeks, rhesus incompatibility
Method: membrane sweep, intravaginal prostaglandin pessary (propess), artificial rupture of membranes, oxytocin IV drip (syntocin)
98
Ventouse vs forceps
Ventouse: suction cap attached to baby's head. During contraction the mum pushes whilst doctor gently pulls at the head to help deliver the baby
Forceps: tongs that fit around the baby's head. During a contraction mum pushes whilst doctor gently pulls at the head
99
Caesarean section categories
| Indications for cat 1 and cat 2
1: emergency. Baby must be out within 30 minutes due to immediate threat of life (baby or mum)
Indications: foetal bradycardia >9 minutes, cord prolapse, eclampsia, APH, cardiac arrest of mum, failed ventouse/forceps
2: emergency. Baby must be out within 90 minutes.
Indications: pathological CTG (can be boosted to cat1)
3: requires early delivery, must be out within 6 hours
4: elective
100
Indications for caesarean section
```
Absolute cephalopelvic disproportion
Placenta praevia 3 or 4
pre-eclampsia
Post-maturity
IUGR
Foetal distress in labour
Cord prolapse
Failure of labour to progress
Malpresentation
Placental abruption if foetal distress
Vaginal infection (eg. herpes)
Cervical cancer
```
101
Maternal risks of caesarean section
Foetal risk of C-section
```
Emergency hysterectomy
Need for further surgeries (retained placental tissue)
ICU admission
Thromboembolic disease
Injury to bladder and ureters
Death (1 in 12000)
Wound/abdo discomfort for months
Increased risk of subsequent C sections
Haemorrhage
Infection
```
Foetal risk: laceration
102
Future pregnancy risks following caesarean section
Increased risk of uterine rupture
Increased risk of antepartum still birth
Increased risk of subsequent placenta praevia and placenta accreta
Increased risk of needing subsequent c-sections
103
Vagina Birth After Caesarean (VBAC) advantages and disadvantages
What must you do during labour if patient decides on VBAC, and what should you ask patient when deciding whether they should do VBAC
Advantages:
- Avoids risks associated with repeated C sections, especially if planning more pregnancies
- Quicker recovery time
- Shorter stay in hospital
- Less pain and discomfort after birth
Disadvantages:
- Small risk of uterine rupture (C section scar tears= 0.5% of VBACs (1 in 200))
- Risk of uterine infections
- Risk of needing a blood transfusion
VBAC requires continuous CTG monitoring during labour
Must explore with the patient the reasons for the previous C section
104
Indications for repeating a C section rather than doing VBAC
Personal preference
Previous uterine rupture
Vertical rather than horizontal C section scar
Previous labour complication (eg. placenta praevia)
Previous operations for fibroids/uterine abnormalities
3+ previous C sections
Multiple pregnancy
IOL
105
Factors suggestive of a successful VBAC
Previous vaginal birth
Previous successful VBAC
Spontaneous labour
BMI <30
106
Risk factors for post-partum mental health illness
<16, unrealistic ideas of motherhood, pre-existing mental health illness, FHx of mental health, volatile or absent family relationships, social isolation, lack of positive supportive partner, poor or inadequate antenatal care, pregnancy complications, social problems
107
Score use for post-natal depression
Edinburgh postnatal depression score
10-item questionnaire with a maximum score of 30
Score >13 indicates depressive illness of varying severity
108
Postpartum blues
Baby blues
Affects 60-70% of women, more common in primips
Typically days 3-10, due to drop in progesterone
Anxious, tearful, irritable
Mx: usually self limiting (48hrs-2weeks). Reassurance and support (health visitor has key role).
109
Postnatal depression
Affects approx 10%
Symptoms may begin in the first week, typically within the first month, and peak at 3 months
May also have postnatal anxiety disorders
Mx:
- Reassurance and support
- Modified antenatal classes and postnatal support groups
- CBT is as effective as antidepressants
- SSRIs: sertraline or paroxetine may be used (secreted in breastmilk but not thought to be harmful)
110
Severe major postnatal depression
30% develop in first 3 weeks, 70% develop it between weeks 10-12
Features: guilt, worthlessness, anxiety, panic attacks, anorexia, loss of concentration, anhedonia
A third of sufferers have intrusive obsessional thoughts of harm coming to their children
Mx: TCAs or SSRIs for at least 6 months
30-50% risk fo recurrence in subsequent pregnancies
111
Puerperal psychosis
Psychiatric emergency
1/3 manic, 2/3 depressive psychosis
Abrupt onset at day 5 or within first few weeks (50% within first 2 weeks, 90% within first 3 months)
Restlessness, irritability, insomnia, mood lability. disorganised behaviour, delusions, hallucinations
High risk of suicide and infanticide
Mx:
- Admit to mother baby unit
- Antipsychotics: chlorpromazine (+procyclidine), risperidone, olanzapine
- Lithium
- ECT for severe depressive psychosis
50% recurrence
112
Safe mental health medication to give during pregnancy
Safe: (FINA) fluoxetine, imipramine, nortriptyline, amitriptyline
113
Side effects of lithium use in pregnancy
```
Avoid lithium in pregnancy
Foetal hypotonia
Poor reflex
Arrhythmias
Ebstein anomaly
Neonatal hypothyroidism
```
114
Neonatal withdrawal from SSRIs
Often paroxetine
Poor adaptation, jitteriness, irritability, poor gaze control
Withdrawal symptoms are usually self-limiting and generally occur within 24-48 hours and typically last 1-2 days (no mx needed)
115
Causes of postnatal/puerperial pyrexia
```
Endometritis (most common)
UTI
Wound infections
Mastitis
VTE
```
Management: If ?endometritis -> hospital for IV abx (clindamycin and gentamicin)
116
Prevention of postnatal mental health illnesses
```
Adequate pre-conceptual counselling
Antenatal and postnatal risk assessment
Patient education
Specialist MH care
Mx of high risk women
Antenatal and parenting classes
Provision of home help and lengthening of hospital stays
```
117
Physiology of breast feeding
From 18 wks gestation:
-Progesterone influences size of alveoli and lobes, and inhibits lactation before birth, so when progesterone falls after birth lactation is triggered
-Oestrogen stimulates milk ducts to grow and differentiate, and inhibits lactation before birth
-Prolactin contributes to growth and differentiation of alveoli and ducts. High levels during pregnancy increases insulin resistance, increases growth factor levels and modifies lipid metabolism in preparation for breast feeding.
Prolactin is the main factor maintaining tight epithelial junctions and regulating milk production
-Oxytocin after birth contracts the smooth muscle around the alveoli to squeese milk into the duct system
118
What is colostrum and what does it contain?
First milk expressed
| Contains white blood cells and antibodies (IgA) which lines the baby's intestines to help prevent pathogens
119
Milk-ejection reflex
suckling stimulates hypothalamus -> oxytocin release form posterior pituitary -> oxytocin contracts myoepithelial cells around the alveoli -> increased pressure causes milk to flow through the ducts and released through the nipple
Conditioned response (ie. to the cry of the baby)
120
Benefits to mum and infant of breastfeeding
Reduced maternal risk of: breast cancer, ovarian caner, osteoporosis, IHD, obesity
Reduced infant risk of: infections, diarrhoea, vomiting, sudden infant death syndrome, childhood leukaemia, obesity, CVD in adulthood
121
Mastitis vs engorgement vs galactocoele
Mastitis: inflamed breast tissue. Usually due to Staph aureus. treat with flucloxacillin. May get breast abscess (more detail in breast surgery flash cards)
Engorgement: usually occurs in first few days after delivery, usually bilateral, presents with breast pain just before feed, red breast, +/- fever, difficulties of infant to attach and suckle. Mx by hand expressing milk to relieve engorgement. Risk of developing mastitis.
Galactocoele: typically occurs in those who have recently stopped breastfeeding, due to occlusion of lactiferous duct. Build up of milk -> cystic lesion in the breast. Differentiated from an abscess by the fact that a galactocoele is usually painless, with no local or systemic signs of infection
122
Contraindications with breast feeding (conditions, and drugs which are contraindicated)
Galactosaemia
HIV
```
Drugs:
Ciprofloxacin, tetracyclines, chloramphenicol, sulphonamides
Lithium
Benzodiazepines
Aspirin
Carbimazole
Methotrexate
Sulfonylureas
Cytotoxic drugs
Amiodarone
```
123
Safe drugs in breast feeding
```
Penicillins, cephalosporins, trimethoprim
Glucocorticoids
Levothyroxine
Sodium valproate
Carbamazepine
Salbutamol
Theophylline
TCAs
Antipsychotics (Avoid clozapine)
Beta blockers
Hydralazine
Warfarin
Heparin
Digoxin
```
124
Eclampsia
- definition
- HTN definitions for pregnancy induced HTN and severe eclampsia HTN
- Investigations
- Presentation
- Mx
=Pre-clampsia (pregnancy induced HTN + proteinuria after 20wks gestation) + seizures
Pregnancy induced HTN = 140/90
Severe eclampsia HTN = 160/110
Ix: FBC (patelets), LFTs (abnormal), clotting, U_Es (especally if giving MgSO4), MSU, urine PCR, urates, fundoscopy, check for reflexes and clonus
Emergency presentation: seizure, LOC, confusion, maternal collapse
Mx:
- Magnesium sulphate IV bolus 4g over 5-10 mins followed by an infusion (neuroprotective): monitor UO, reflexes, resp rate, O2 sats
- Category 1 emergency C section
- IV labetalol (or hydralazine)
- Fluid restriction (avoid pulm oedema)
- Arterial line
- Catheter
- Consider diazepam to stop seizure
125
Primary post-partum haemorrhage
- when does it happen
- most common cause
- risk factors
>500ml blood loss
Occurs within 24 hours
Affects 5-7% of deliveries
Most common cause is uterine atony
Risk factors causing PPH: previous PPH, prolonged labour, pre-eclampsia, increased maternal age, polyhydramnios, emergency C section, placenta praevia, placenta accreta, macrosomia, ritodrine (tocolytic)
126
Secondary PPH
- when does it happen
- why does it happen
24hrs-2 weeks post delivery
| Due to retained placental tissue or endometritis
127
Management of postpartum haemorrhage
Call for help: obstetric emergency bleep and major haemorrhage protocol
HAEMOSTASIS:
- Help (ask for help): midwife in charge, obstetric registrar on call, obstetric SHO, anaesthetist, inform theatre, inform blood bank, activate major haemorrhage protocol
- Assess vitals and resuscitate (as many grey cannulas as possible, and examine with speculum, and lots of IV fluid pressure bags)
- Establibsh cause and ensure availability of blood and uterotonics
- Massage fundus
- Oxytocin (syntocinon or ergometrine) and prostaglandins (IM carboprost or misoprostol)
- Shift to theatre
- Tamponade test (balloon tamponade)
- Apply compression sutures
- Systematic pelvis devascularisation
- Interventional radiology/ internal iliac artery ligation
- Subtotal/total hysterectomy
128
4 T's common causes of PPH
Tone
Traumatic delivery
Tissues (retained products)
Thrombin
129
Shoulder dystocia risk factors
LGA (>90th centile), DM, obesity, small maternal pelvis, previous dystocia, baby position, prolonged labour, history of macrosomia (>4.5kg)
130
Management of shoulder dystocia
Baby must be delivered within 10 minutes, ideally within 3 minutes
HELPERR:
Help
Evaluate for episiotomy (dont do straight away though)
Legs: McRoberts position
Pressure (external pressure suprapubically)
Enter: internal rotations (woodscrew, reverse woodscrew)
Remove posterior arm
Roll patient to hands and knees
McRoberts position: flexion and abduction of maternal hips, bringing thighs towards abdo (increased relative anterior-posterior angle of pelvis)
131
Complications of shoulder dystocia
- maternal
- foetal
Maternal: PPH, perineal tears, bladder/urethral trauma
Foetal: erbs palsy, cerebral palsy, neonatal death
132
Cord prolapse risk factors
```
ARM (may bring cord down with the hook)
Polyhydramnios
Prematurity
Multiparity
Twins
Breech
Transverse or unstable lies
ECV (done to correct breech but if done after 37 weeks may cause cord prolapse)
```
133
Management of cord prolapse
Category 1 emergency caesarean section
Go on all fours until surgery (gravity assists in avoiding cord compression against pelvic cavity)
Foetal presenting part may be pushed back into uterus to avoid compression
Tocolytics may be used
If cord is past the level of the introitus, it should be kept worm and moist but not be pushed back in
Catheter tamponade (fill bladder)
134
Complications of untreated cord prolapse
Cord compression, cord spasm, foetal hypoxia, irreversible damage or death
135
Risk factors for uterine rupture
VBAC, other uterine scars, obstructed labour, IOL, trauma, cocaine use
136
Presentation of uterine rupture
Similar signs to APH: increased pain, PV bleeding, change in contractions
Foetal distress
May get shoulder tip pain (peritonitic)
Hypovolaemic shock
137
Management of uterine rupture
IV fluids and blood transfusion
| Emergency C section delivery
138
Amniotic fluid embolism
- what is it
- risk factors
- presentation
- diagnosis
- management
Foetal cells or amniotic fluid enters maternal blood stream
Risk factors: maternal age and IOL
Presentation: usually in labour, but may occur in C-section or immediately post-partum
Chills, shivering, sweating, anxiety, coughing
Signs: hypotension, tachycardia, bronchospasm, cyanosis, arrhythmia, MI, cardiac arrest
Clinical diagnosis of exclusion
Management: critical care MDT and supportive care (control BP, HR, etc). Often a perimortem c section is carried out
139
Causes of antepartum bleeding based on trimesters
Tri 1: hydatidiform mole, spontaneous abortion, ectopic
Tri 2: hydatidiform mole, spontaneous abortion, placental abruption
Tri 3: placental abruption, placenta praevia, bloody show, vasa praevia, amniotic fluid embolism, uterine rupture
Cervical trauma (post sex, ectropion, cervicitis from STIs, etc)
140
Causes of maternal collapse
Eclampsia
APH
Amniotic fluid embolism
Non-obstetric causes: PE, syncope, cardiomyopathy, hypoglycaemia, anaphylaxis
141
When do you activate the obstetric major haemorrhage protocol?
blood loss >1500ml or ongoing loss (UHL may be >1000ml with continuing blood loss or haemodynamic instability)
Or estimated to lose 50% blood loss in 3 hrs
