Obstetrics: Labour, Delivery and the Puerperium Flashcards
(132 cards)
1
Q
How is labour defined?
A
Progressive effacement and dilatation of the cervix in the presence of regular uterine contractions.
2
Q
Define delivery?
A
Expulsion of the foetus and the placenta
3
Q
What is SRM?
A
Spontaneous rupture of membranes, can precede labour
4
Q
What is ARM?
A
Artificial rupture of membranes
5
Q
What is Gravidity?
A
Total number of pregnancies including present.
6
Q
What is Parity?
A
The state of having given birth.
7
Q
How long does labour normally take for a nulliparous and multiparous woman?
A
NP = 2-14 hours MP = 1-11 hours
8
Q
What factors influence the speed of Labour?
A
The passage:
- The pelvis, size of inlet and outlet
- The soft tissues (lower uterine segment, cervix, vagina, vulva, pelvic floor, perineum)
The powers:
- Contractions (speed and frequency)
The passenger:
- Lie
- Presentation
- Denominator
- Position
- Foetal head shape/circumference resulting from varying degrees of flexion
9
Q
Describe the stages in the mechanism of labour?
A
1) Engagement
2) Flexion
3) Descent
4) Internal Rotation
5) Extension
6) External Rotation
10
Q
At what rate do you expect contractions to occur?
A
Early Labour = every 3-4 minutes
Advanced Labour = every 2-3 minutes
11
Q
What is the foetal lie?
A
The relationship between the long axis of the baby and that of the mother (long, oblique, transverse)
12
Q
What is the foetal presentation?
A
The part of the foetus lowermost in the uterus e.g.
- Cephalic
- Vertex
- Brow
- Face
- Breech
- Shoulder
13
Q
What is the foetal denominator?
A
Part of foetus used as reference point to describe position in maternal pelvis (occiput, mentum, sacrum, acromion)
14
Q
What is the foetal position?
A
Relation of the foetal denominator to the maternal pelvis (occipitoanterior, occipitotransverse, occipitoposterior)
15
Q
What maternal monitoring is required during labour?
A
- Obs
- Hydration
- Analgesia
- Antacids
- Bladder care
- Position
- Progress (contractions, cervical dilatation, descent of presenting part)
- Perineum
- In 3rd stage of labour: active management, Oxytocics, controlled cord traction
16
Q
What are Oxytocics?
A
Medications such as…
- Oxytocin (Pitocin)
- Methylergonovine (Methergine)
used to…
- Induce labour
- Treat labour arrest
- Active management of labour
- Treat uterine atony and post-partum haemorrhage
17
Q
What is Controlled Cord Traction?
A
Controlled cord traction (CCT) is traction applied to the umbilical cord once the woman’s uterus has contracted after the birth of her baby, and her placenta is felt to have separated from the uterine wall, whilst counter-pressure is applied to her uterus beneath her pubic bone until her placenta delivers
18
Q
What foetal monitoring is required during labour?
A
- Foetal heart monitoring
- Colour of Liquor
19
Q
What are Braxton Hicks contractions?
A
Painful, practice contractions that occur from the first trimester but most commonly from the 36th week. About 1/4th as strong as regular contractions.
20
Q
When is Labour considered normal?
A
- After 37 weeks
- Resulting in spontaneous vaginal delivery of the baby within 24 hours of the onset of regular spontaneous contractions
- Often preceded by a ‘show’ a plug of cervical mucus and a little blood as the membranes strip from the os
21
Q
What happens in the first stage of Labour?
A
Latent phase:
- Painful irregular contractions
- Cervix initially effaces (gets shorter and softer
- Then dilates to 4cm
Established phase:
- Regular contractions
- Further dilation at a rate of about 0.5cm/hour, up to about 10cm
Takes 8-18 hours in a primip, 5-12 hours in a multip
22
Q
What monitoring is required during the first stage of Labour?
A
- Maternal BP, Temp every 4 hours. Also offer vaginal exam to look at dilation and foetal head position
- Pulse every hour
- Strength and frequency of contractions every half hour
- Auscultate foetal hart rate every 15 mins
Note liquor colour and frequency of bladder emptying.
23
Q
What happens in the second stage of labour?
A
Passive stage:
- Complete cervical dilation
- No pushing
- Ideally should last 1-2 hours
Active stage:
- Mother uses abdominal muscles and valsalva maoeuvre until baby is born
- Head descends, perineum stretches, anus gapes
- Expect birth within 3 hours NP, 2 MP.
- Refer if not imminent at 2/1 hours.
- Can give oxytocin if contractions waver at this stage
24
Q
What monitoring is required during the second stage of Labour?
A
- Temp 4 hourly
- BP and pulse hourly
- Assess contractions half hourly
- Auscultate for heartbeat every 5 mins (for 1 minute)
- ## Record urination during second stage
25
How long do you wait after birth before clamping the cord?
1 min in healthy babies, 3 mins in premature babies (reduces risk of anaemia).
26
What is involved in the third stage of labour?
Delivery of the placenta:
- Uterus contracts
- Placenta separates
- Buckles and a small about of retroplacental haemorrhage occurs.
Normally takes an hour.
27
How can the third stage of labour be reduced?
Delivery of Syntometrine (combination of oxytocin and ergometrine maleate) reducesd third stage to 5 minutes and decreases the incidence of PPH.
CIs: Pre-eclampsia, Severe HTN, Liver or Renal impairment, Severe heart disease
28
What are the most common problems which occur in labour?
- Failure to progress (a delay in the first or second stage)
- Malpresentation /Malposition
- Suspected Foetal Compromise (foetal distress)
- VBAC (Vaginal deliver after birth) complications
- Operative Delivery
- Shoulder Dystocia
29
What are the issues with breech presentation?
- Increased perinatal morbidity and mortality
- Higher incidence of foetal abnormality and neuro-developmental problems regardless of mode of delivery
- Complications at delivery: head can become trapped, cord can prolapse, intracranial haemorrhage..
30
What are the delivery options for a breech presentation baby?
- External Cephalic Version (a manoeuvre where the baby is flipped around while still in the uterus)
- Elective Caesarean Section
- Vaginal breech delivery (risk)
31
What is a CTG?
Cardiotocography (CTG) is used during pregnancy to monitor fetal heart rate and uterine contractions.
32
What features on a CTG could indicate suspected foetal compromise
- Baseline tachycardia or bradycardia
- Reduced baseline variability
- Absence of acceleration (non-reactive)
- Presence of decelerations
33
What test needs to be performed if suspected foetal compromise on CTG and why?
CTG has high sensitivity and low specificity, so need to confirm something is really wrong with...
Fetal Acid-Base Status (following fetal scalp blood sampling)
If unable to do FBS deliver by speediest route.
34
What are some causes of foetal compromise during labour?
- Uterine hyperstimulation
- Hypotension
- Poor foetal tolerance of labour (e.g. if IUGR)
- Cord compression
- Infection
- Maternal disease
35
How should confirmed foetal compromise be managed?
- Look for and treat any reversible causes (e.g. maternal hypotension)
- Put mother in LLP
- Stop oxytocics
- Confirm compromise by blood sampling
- If possible deliver by speediest route if unable to correct or if significant acidosis
36
What is VBAC and what risks are associated with it?
When a woman who has previously had a C section goes on to have a vaginal birth.
Risks:
- Emergency need for a C section
- Uterine scar dehiscence or rupture
37
What precautions should be taken for a mother going for VBAC?
- IV access and G+S
- Continuous electronic foetal monitoring
- Avoid prolonged labour
- Augmentation or induction should only be senior decision
38
What are the indications for an operative delivery?
- Failure to progress in stage 2 of labour
- Foetal distress in 2nd stage
- Maternal reasons.
39
What are the prerequisites for operative delivery?
- Full dilatation
- Absent membranes
- Cephalic presentation
- Clearly defined presentation
- Presenting part engaged
- No evidence of CPD
- Adequate analgesia
- Empty bladder
40
What are the possible complications of operative delivery?
- Failure
- Fetal trauma
- Cephalhaematoma
- Maternal trauma
- Postpartum haemorrhage
- Urinary retention
41
What are the indications for C section?
- Failure to progress
- Fetal distress due to maternal reasons
- Malpresentation or malposition
- Failed instrumental delivery
42
What are the possible complications from C section?
- Haemorrhage
- Infection
- Bladder/bowel injury
- Thromboembolic disease
- Requirement for blood transfusion
- Transient Tachypnoea of the New-born
- Trauma to the foetus
43
What is shoulder dystocia?
Inability to deliver shoulders after delivery of head as anterior shoulder does not enter pelvic inlet
44
What are the risks of shoulder dystocia?
- Foetal death
- Asphyxia with resulting hypoxic damage (e.g. brain)
- Birth trauma e.g. Erb's palsy, fractured bones
45
What babies are most at risk of shoulder dystocia?
- Macrosomic foetus
- Foetus of diabetic mother
- Rotational instrumental delivery
46
What obstetric manoeuvres can be used to manage shoulder dystocia risk?
- The McRoberts position (flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen)
- Suprapubic pressure
47
What are the main causes of delay in labour?
- Power (inadequate contractions)
- Passenger (malpresentation or malposition of the foetus)
- Passage (inadequate pelvis)
In all likelihood it's a combination of the three
48
How is 'normal' labour progression conceptualised?
Cervix dilation of roughly 2cm per 4 hours of active labour.
Other factors should be bared in mind (e.g. descent of the head and effacement of the cervix) and assessment should be made dynamically throughout.
49
Define a delay in the 1st stage of labour?
Less than 2cm dilation in 4h in any women, or slowing progress in 2nd/3rd/4th... labours.
50
What assessments do you make if you observe a delay in the first stage of labour?
- Assess woman, review notes and obstetric history
- Palpate her abdomen for lie, palpable head, contractions
- Check foetal heart rate
- Colour of amniotic fluid
- Vaginal assessment; dilatation, effacement, caput, moulding, station of the head, position
- Does the mother need analgesia and rehydration
51
How would you manage a delay in the first stage of labour?
- Offer ARM, reassess in 2 hours
- Empty bladder as this can prevent descent of the head + reduce frequency of contractions
- If membranes are already ruptured; Oxytocin infusion, reassess after 4 hours (often takes 8 to work)
- Start continuous foetal heart rate monitoring with Oxytocin
- Consult senior if multiparous or previous C section, as increased risks related to rupture.
- Consider epidural and put mother in LLP
- If progress remains slow consider C section
52
Define a delay in the 2nd stage of labour?
No birth after 2 hours of active pushing for a primip or 1 for a multip.
Reasons are the same but also add maternal exhaustion.
53
How do you manage delay in the second stage of labour?
- Obstetric review
| - Then consider for Instrumental Delivery or C section
54
What is the puerperium?
Time between delivery until the anatomic and physiological changes of pregnancy have resolved (approx. 6 weeks).
Significant physical, social, emotional adaptation
55
What are the main physiological changes that occur during the puerpium?
- Lochia and Uterine Involution
- Lactation
- Menstruation and resumption of ovulation
56
What is Lochia?
Uterine discharge after birth. Made up of blood, mucus and uterine tissue.
- Bloody for first day
- Sero-sanguinous for 7-10 days
- Clear for 6 weeks
57
How does uterine involution occur?
- Placenta delivered
- Uterus becomes a pelvic organ by 10 days
- Os closes by 3 weeks
58
What hormones trigger lactation?
- Oestrogen stimulates duct growth
- Progesterone stimulates alveolar growth
- Placental lactogen affects growth of epithelium in alveoli
- Initiation of lactation is dependent on fall in oestrogen which stimulates release of prolactin from hypothalamus
- Milk ejection needs oxytocin from posterior pituitary
59
What is collostrum?
The first milk produced within the first 3 days post-birth.
Very concentrated, babies only need about a teaspoon full at each feeding (but will want to feed every hour, this drops off as milk matures)
60
When does menstruation resume in women post-natally?
If not lactating:
- Approx 8 weeks
- First ovulation approx 10 weeks
- About 40% of first cycles involve ovulation
If lactating for less than 1 month:
- Menstruation resumes at approx 10 weeks
If lactating for more than 1 month:
- Average interval to first ovulation is about 16 weeks
61
For how long post-partum is breast feeding a secure method of contraception?
9 weeks, no more.
62
What needs to be discussed between birth and discharge?
- Inform GP
- Arrange for midwife and health visitor
- Anti-D if indicated
- Discuss contraception
- Discuss breast feeding
- Perineal care and give post-natal exercises
63
What examinations should be performed on a woman who's given birth?
- Obs
- Uterine size and involution
- Vaginal bleeding
- Lochia/discharge
- CS wound
- Perineum and peri-vaginal tissue
- Breast
- Lower limbs (DVT)
- Look for incontinence (both)- check again at 6 week check.
64
What issues are there with the COCP post-partum and what alternatives should be considered?
- Reduces breast milk volume
- Excreted in breast milk
Consider POP, Depot injections, barrier contraception or IUCD
65
What are the advantages of breast feeding?
To new-born:
- Easily digested nutrients
- Antibodies in colostrum lower risk of gastroenteritis, resp infections, otitis media
- Avoid milk allergies
- Good source Vit C, D, Iron
- Cannot overfeed
- Lower risk of hypocalcaemia
To mother:
- Promotes bonding
- Improves uterine involution
- Safe and cheap
- Contraception (9 weeks)
66
What are the difficulties associated with breastfeeding?
- Nipple inversion (corrected by breast shields in late pregnancy)
- Maternal fatigue (up every few hours)
- Emotional stress
67
What advice can be given to encourage breast feeding?
Mothers sleeping in same room as baby
68
What advice would you give a mother if her baby is still hungry after feeding?
- Weigh before and after feeding
- Can be fed more often
- Can give supplements
69
When is breastfeeding not recomended?
- HIV
- TB
- Certain medications (e.g. amiodarone, lithium, all chemo drugs, retinoids, iodides)
70
What advice should be given for women taking medication while breastfeeding?
Cannot take certain meds (e.g. amiodarone, lithium, all chemo drugs, retinoids, iodides)
However, all meds are excreted in milk, to varying degrees. Mothers should try to take medications AFTER breast feeding to avoid peak concentrations.
71
What are the symptoms of mastitis?
Fever, chills, malaise, pain, erythema, tenderness, induration, tender axillary lymphadenopathy, milk may be purulent
72
How should mastitis be managed?
- Empty breast (as pain can come from engorgement)
- Cold compresses
- Give antibiotics if suspected infection/prophylactically
- If abscess; drain
- Women can continue feeding during mastitis
73
How can lactation be suppresed?
- Firm supporting bra, analgesia, ice packs
- No milk expression or nipple stimulation (increases lactation)
- Can use pharm option (BROMOCRIPTINE) but not normally necessary
74
Define puerperal pyrexia?
Temp of 38+ on any occasion in the 6 weeks following delivery
75
What are the most common causes of puerperal fever?
- UTI
- Endometritis
- Breast infection
- Chest infection
- DVT/PE
76
What investigations should be considered in puerperal pyrexia of unknown cause?
- MSU (UTI)
- High vaginal swab
- Blood cultures
- Sputum sample if chesty
- Ultrasound or V/Q if PE suspected
SEPSIS 6 Pathway! Puerperal sepsis can rapidly progress to fulminating septicaemia, must be addressed rapidly.
77
Define secondary postpartum haemorrhage? What are it's two most common causes?
Bleeding after the first 24 hours?
Retained produces/clots or infection.
78
How would you manage PP haemorrhage?
Normally conservative
- ABs if you're concerned about infection
- Evacuation of retained products under GA
79
What are the maternal risk factors for VTE?
- Operative delivery
- History of VTE
- Fam Hx of VTE
- Obesity
- Thrombophilia
- Maternal age above 35
- Immobilisation
- Prolonged laour
80
What prophylactic measures should be put in place to reduce VTE risk
- TED stockings for all women
- LMW heparin if patient has risk factors (esp. after C section)
- Heavy monitoring + high index of suspicion in PP period
81
What are the most common urinary problems post pregnancy, and how are they managed?
Transient urinary retention:
- Common due to physiological effects of pregnancy e.g. pain
- Most cases resolve spontaneously
- Mx = catheterisation +/- prophylactic antibiotics
Urinary incontinence:
- Normally respond to pelvic floor exercises (form of stress UI)
82
What women are at risk of faecal incontinence?
Vaginal birth, particularly forceps delivery.
83
Define Breech presentation?
Non-cephalic presentation (presentation = leading part of the foetus).
84
What are the three types of breech presentation
In order of how common they are:
- Frank Breech = Buttocks lead first, flexed at him and extended at knee (legs appear stretched out)
- Complete Breech = Buttocks and feet lead, baby is sat cross legged.
- Footling Breech = Only feet lead, and often emerge through the cervix before full dilation.
85
What are the risk factors for a baby having breech presentation?
- Previous breech
- Congenital abnormalities
Factors leading to unstable lie:
- Multiparity (abdominal walls relax allowing baby to move about more)
- Polyhydramnios (common in mothers with diabetes)
Factors preventing the baby from moving about normally:
- Uterine septum
- Fibroids
- Placenta praevia
86
How do women with breech babies present?
Normally asymptomatic. Picked up on USS or by midwife on abdominal palpation.
87
At what point do you intervene with breech babies and why?
Wait till 36 weeks, if still breech intervene.
This is because while breech birth is risky and should be taken seriously, up to 50% of babies are breech at 24 weeks, therefore should be left to try and flip round normally.
88
What needs to be considered for a baby breech at 36 weeks +?
- External Cephalic Version will almost always be performed
- Consider elective C section
EVERY SINGLE baby who was breech at 36 weeks requires a USS at 6 weeks post delivery to check for DDH.
89
When is ECV performed?
@ 36 weeks if nullip
| @ 37 weeks if multip
90
What are the risks/benefits of ECV?
Generally very safe procedure, 50% success rate with low rate of complications, however can get:
- Maternal pain
- Rhesus sensitisation (need Kleihauer-Betke test)
- May need emergency C section
- Foetus can revert soon after procedure
- Foetal heart rate changes
91
What are the delivery options like following a ECV?
If successful:
- Normal vaginal birth
- Elective C section
If not:
- C section
- Breech birth (not ideal)
92
What are some issues with Breech births?
- 40% need emergency C section
- 2% chance of perinatal mortality
- Cord prolapse
- Intra partum passage of meconium
- Cerebral tentorial tears
- Cephalohaematoma
93
What are some risks of VBAC?
Risks come from scared uterus:
- Uterine rupture (scar), even riskier if prostaglandins or syntocin are applied
- Placental disease
94
How would uterine rupture in VBAC present?
Obvious presentation is acute maternal abdominal pain, but this will normally be preceded by foetal distress, therefore need continuous CTG.
95
How can you reduce risk of complications from VBAC?
Wait 12 months between pregnancies, allows scars to heal.
96
Define prematurity?
Infant born before 37 weeks gestation.
97
Define extreme prematurity?
Infant born before 28 weeks gestation
98
Why is prematurity such a concern?
- Single greatest cause of neonatal mortality and morbidity in the UK.
- Major long term consequence = neurodevelopmental disability
- Risk of respiratory distress syndrome (if they survive, at significant risk of chronic lung disease)
- Intraventricular haemorrhage
- Necrotizing enterocolitis (tissue of the intestines become inflamed and start to die, risk of perforation)
- Risk of Sepsis
99
What is PPROM?
Preterm Prelabour Rupture of Membranes; essentially a rupture occurs in the amniotic sac causing amniotic fluid to leak out through cervix into vagina.
Dx = Before 37 weeks but also before onset of labour.
Most common identifiable cause of preterm birth.
100
What are the major risks associated with PPROM?
- Prematurity (and all the risks related to that)
- Chorioamnionitis (bacteria from lower genital tract travel upwards and into ruptures sac, causing infection and possibly...)
- Sepsis
- Cord prolapse (cord dragged down by gravity out of womb into cervix, requires emergency delivery as can rapidly cause foetal hypoxia)
- Pulmonary hypoplasia (fluid is essential for lung development, loss of fluid causes arrested development, RF for RDS)
101
How would a women experiencing PPROM present?
- Gush of fluid from vagina
- Leaking vaginal fluid
- Increased watery discharge
- Concern or uncertainty about UI!!
102
How would you examine a woman with suspected PPROM?
NO DIGITAL VAGINAL EXAM (too great a risk of infection + stimulating cervix can lead to labour)
Sterile speculum examination, looking for fluid:
- May see it pooled, Dx confirmed
- May not see it in which case you need to test for it with ActimPROM or AmniSure
Also- FBC, CRP, HVS (basically looking for infection)
103
What does Actim-Prom test for?
IGFBP-1 (Insulin-like growth factor binding protein 1)
Major protein in amniotic fluid, not normally found in vagina.
N.B: Actim-Prom is highly specific and sensitive for PPROM
104
How is PPROM managed?
- Admit for observation for at least 48h-72h
- Inform NICU to be on stand-by
- Once sent home, have to check temp twice a day and come back in if raised
- CORTICOSTEROIDS: For lung maturity, if between 24 weeks and 33+6 weeks
- ERYTHROMYCIN: Prophylaxis, for 10 days or until labour
- Monitoring: CRP, WBC, Temperature, Maternal HR, Foetal HR
- Delivery: Unless signs of foetal or maternal distress, wait till 37 weeks (earlier if colonised with GBS)
105
What is PTL?
Pre-term Labour; Regular contractions resulting in cervical changes (dilatation or effacement) before 37 weeks. May or may not be associated with PPROM.
Leading cause of perinatal death and disability, immense psychosocial and emotional effects on the family, increased cost for health services.
106
What are some risk factors for Pre-Term Labour?
- Smoking or Drug use in pregnancy
- Teenage pregnancy or advanced maternal age
- Multiple pregnancy
- Previous cervical surgery e.g. LETZ
- Previous miscarriage or preterm delivery
- Asymptomatic bacteriuria or Bacterial vaginosis
107
How can PTL be prevented?
Identification of high risk women:
- Previous spontaneous preterm birth
- Previous mid-trimester loss (16 weeks+)
- PPROM
- Women with cervical trauma
High risk women then get increased monitoring:
- TV USS cervical length
- HVS to look for bacterial vaginosis (linked to increased risk of PTL)
If TV USS shows cervical shortening between 16-24 weeks, intervene:
- Prophylactic vaginal progesterone
- Cervical cerclage (must be removed before labour)
108
How do women with PTL present?
Varied:
- Menstrual cramping
- Mild irregular contractions
- Lower back pain
- Pressure sensation in vagina or pelvis
- Vaginal discharge which might be clear, pink, mucusy
- Spotting or light bleeding
109
How would you examine a woman with
- Abdo Ex: Firmness, tenderness, foetal size and position
- Contractions: Frequency, intensity, duration
- Review FHR
- Speculum to assess for cervical dilatation, look for blood and fluid
- TV USS for cervical length
- Foetal fibronectin = best bedside table test for PTL diagnosis (if USS is unclear or unavailable)
110
What is the gold standard diagnostic test for PTL?
TV USS for Cervical Length:
- Less than 15mm = confirmed PTL, offer treatment
- More than 15mm = unlikely PTL, discuss risks and benefits of going home vs staying in for in hospital monitoring.
Foetal Fibronectin or Actim-Partus can be used if USS not available.
111
What are the management options for threatened PTL?
- Admission (may need to transfer to more appropriate hospital) + Liaise with neonatology
- If not in established labour BUT having regular contractions can give NIFEDIPINE or ATOSIBAN to slow down contractions (allowing time for steroids and hospital transfer)
- CORTICOSTEROIDS if before 34 weeks.
- Can give a rescue cerclage in some cases
112
When would a PTL case be considered for rescue cerclage?
- Dilated cervix
- Exposed foetal membranes
- Before 28 weeks
- no PPROM (intact membranes)
- no infection
- no contractions
113
What are the management options for established PTL?
- Magnesium sulphate given to mother for neuroprotection of the foetus
- Prophylactic Antibiotics
- Continuous CTG monitoring
114
What are the 3 types of obstetric haemorrhage?
- Antepartum
- Intrapartum
- Postpartum
115
How is PPH defined? How is it classified?
Blood loss of 500mls + from the genital tract within 24 hours after delivery.
Classification:
- Minor (500-1000mls)
- Moderate (1000-2000mls)
- Massive (2000mls+ OR more than 150mls/min
116
What are some antepartum causes of PPH (i.e. risk factors present before the onset of labour)?
- Previous PPH
- Placental abruption/ Praevia/ Accreta
- Grand multiparity (6+)
- Anaemia
- PET
- HELLP
- Obstetric Cholestasis
- Over distended uterus (e.g. polyhydramnios or fibroid uterus, prevent uterus clamping down after birth)
117
What are some intrapartum causes PPH (i.e. things that occur during labour that predispose someone to PPH)?
- Prolonged stage 1 or 2 of labour
- Oxytocin use
- Operative vaginal delivery
- Episiotomy
- Second stage C section
- Precipitate (abnormally rapid) labour
118
What are some postpartum causes of PPH?
- Uterine atony
- Retained products
- Trauma
- Thrombin
119
What is placenta previa?
Placenta lies in lower uterine segment, either partially or completely covering the cervical Os.
Normally presents as painless bleeding. Avoid bimanual exam, penetrative sex.
120
What are placenta Accreta, increta, and percreta
PA = Abnormal, morbid adherence of all or part of the placenta to the uterus
PI = infiltration into the myometrium
PP = infiltration into the serosa
All 3 are risk factors for PPH. Dx prenatally using colour Doppler, US, MRI.
121
What is Vasa praevia?
Some foetal vessels run across or very close to the internal opening of the cervix. These vessels are inside the membranes, unprotected by the umbilical cord or the placenta, and are at risk of damage during membrane rupture.
Detected antenatally by US, managed with C section.
122
Which modality is best for visualising the placenta and diagnosing placental issues?
TV USS is best for visualising and locating the placenta.
Combine with 3D Doppler or MRI to diagnose vasa praevia or placenta accreta.
123
What is placental abruption?
Placenta separates from uterine wall prior to labour (normally after 25 weeks)
Symptoms:
- Abdominal pain
- PV bleeding
Signs:
- Rigid uterus
- Low BP
MEDICAL EMERGENCY Foetal death is high in abruption, if live consider rapid delivery. Prepare to manage DIC in mother.
124
How do you manage a patient with placenta praevia?
Delivery at foetal maturity (OR in case of haemorrhage deliver immediately), avoid penetrative sex or manual examination
125
What steps should be taken in the antenatal management of a woman at risk of PPH?
- Consultant lead care and hospital delivery
- Optimise Hb antenatally
- Crossmatch
- Prophylactic IM Oxytocin should be offered, reduced risk of haemorrhage.
126
What is the intrapartum management for minor haemorrhage?
- Cannulation
- FBC
- Coagulation screen
- Group and Save
- Obs every 15 minutes
- Warmed crystalloid infusion e.g. Hartmann's
127
Practically, how can you judge haemorrhage size?
A certain amount is normal, even a bit of blood pooling can look like a lot but doesn't qualify as PPH.
If blood fills a kidney pot, drenches the sheets or drips off the bed consider major haemorrhage,
128
How do you manage significant PPH?
- Activate MOH protocol
- Resus
- High flow oxygen if needed
- Two large bore canulas
- Hartman's infusion to start, can also give Colloid until blood arrives, emergency group O- can be made available, switch to specific bloods as soon as feasable
- Monitor obs
- Empty bladder
- Bimanual compression of the uterus (try and induce contraction)
- If uterus still not contracted give meds in order
- If still bleeding after final med (Carboprost) take to theatre for examination under anaesthetic, consider surgical options
Search for and manage cause:
- Uterine atony
- Remove placenta
- Suturing
- Coagulation
129
What meds are used to try and stop PPH?
In order:
- Syntometrine
- Oxytocin
- Ergometrine
- Misoprostol
- Carboprostol
130
What are the surgical management options for PPH?
- Rusch balloon, balloon which externs direct pressure on uterus and should stop bleeding (causes uterine tamponade)
- If uterus still atonic but responds to compression consider B-lynch suture
- If still bleeding consider iliac artery or uterine artery ligation
- Last resort or extensive haemorrhage = subtotal or total hysterectomy
131
What are the 4 Ts of PPH? How is each broadly managed
- Tone (most cases, Mx = emptying bladder, massage uterus, oxytocin)
- Trauma (Mx = surgical repair)
- Tissue (i.e. retained products, Mx = uterine cavity exploration, surgical removal)
- Thrombin (Mx = correct any coagulopathy
132
What steps should be taken after PPH has been controlled/ once patient is stable?
- Inform blood bank, stop MOH protocol
| - Document haemorrhage using local proforma
