Post Partum Care

Question 1

Brexanolone is

Answer 1

Allopregnanolone
Given IV
Modulator of GABA-a receptors
Used to treat postnatal depression

Question 2

Zuranolone is

Answer 2

Allopregnanolone
Neuroactive steroid
GABA-A receptor modulator

Question 3

Pain management after c/s

Answer 3

Intrathecal diamorphine max 300 mcg or 3mg via epidural OR

Intrathecal morphine 100mcg + 15mcg fentanyl or 3mg morphine via epidural

Oral morphine sulfate, paracetamol and ibuprofen +/- dihydrocodeine
Tramadol or oxycodone if not sufficient

Question 4

C/S wound care

Answer 4

Negative pressure wound therapy if BMI >35

Remove dressing 6 to 24 hours after

Question 5

Risk of stress incontinence after c/s

Answer 5

4%

Question 6

PPH target parameters

Answer 6

Hb >80 g/l
Plts >50 x 10(9)/l
PT and APTT <1.5 x normal
Fib > 2g/l

Question 7

Use of FFP in PPH

Answer 7

1 unit for every 4 units RBC (15ml/kg) if PPH ongoing

> 15ml/kg if PT/APPT >1.5 x normal

Use immediately after thawing

Question 8

Incidence of primary minor PPH

Answer 8

18% deliveries

Question 9

Incidence of primary major PPH

Answer 9

1-5%

Question 10

Define secondary PPH

Answer 10

Excessive vaginal bleeding 24h to 12 weeks postpartum

Question 11

Incidence of secondary PPH in high income countries

Answer 11

0.47 - 1.44%

Question 12

Active management of third stage reduces PPH by

Answer 12

RR 0.34
66%

Question 13

Prevention of PPH for women without risk factors

Answer 13

Oxytocin 10 units IM for SVD
5 units slow IV for c/s

Question 14

Prevention of primary PPH in women with risk factors

Answer 14

Syntometrine for SVD
Oxytocin + consider TXA for C/S

Question 15

MDT for major PPH

Answer 15

Midwife in charge
Band 6 midwife
Obs reg
Anaesthetic reg
On call clinical haematologist
Porters

Alert consultant obstetrician, anaesthetist and blood lab

Question 16

Resuscitation for minor PPH without shock

Answer 16

IV access
FBC, coag, G&S
HR, RR, BP every 15 mins
Warmed crystalloid infusion

Question 17

Resuscitation for major PPH with ongoing bleeding or signs of shock

Answer 17

Assess airway
Start 15L oxygen
Continuous HR, RR, BP (use ECG)
Temp every 15 minutes
2 x cannulae
Cross match 4 units, FBC, coag, U&E, LFT
Keep warm and lie flat
Give blood if signs of shock or Hb <70 with ongoing bleeding
Give 2L warm crystalloid then 1.5L warm colloid pending blood
Catheter
HDU/ICU care
Consider art line

Question 18

Use of cryoprecipitate

Answer 18

2 pools if fib <2 g/L
If no clotting result then: 2 pools cryo + 1 platelet for every 8 units RBC

Question 19

Dose of syntometrine

Answer 19

5 units oxytocin
500 micrograms ergometrine

Question 20

Dose carboprost

Answer 20

250 micrograms repeated every 15 minutes up to 2mg (8 x doses)

Question 21

Side effects of carboprost

Answer 21

Bronchospams
Hypertension
Vasodilation
Increased risk infection

Question 22

Dose of misoprostol

Answer 22

800 micrograms SUBLINGUAL
(Can be oral or rectal)

Question 23

Oxytocin dose for fluid restricted women

Answer 23

30 units in 26 crystalloid
10ml/hr through syringe driver

Question 24

Surgical management of PPH

Answer 24

1st line - balloon tamponade
2nd line - brace suture
3rd line vascular ligation
4th line - hysterectomy

Question 25

Incidence of retained placenta

Answer 25

3%

Question 26

Risk of secondary PPH after retained placenta

Answer 26

1-2% Occurs 8-14 days later due to sloughing of placental site

Question 27

Placement of brace suture

Answer 27

3cm above and below incision line

Question 28

Effectiveness of brace suture

Answer 28

75% prevention hysterectomy

Question 29

Stepwise uterine devasculariation

Answer 29

One uterine artery, then both One ovarian artery, then both

Question 30

Effectiveness of stepwise uterine devascularisation

Answer 30

100% avoidance hysterectomy

Question 31

Internal iliac artery ligation risks

Answer 31

Ureteric injury

Question 32

Success of internal iliac artery ligation

Answer 32

61% avoidance of hysterectomy

Question 33

Effectiveness of Selective arterial occlusion (interventional radiology)

Answer 33

86.5% arrested bleeding

Question 34

Protamine sulphate is used for ____

Answer 34

Reversal of unfractionated heparin or LMWH (partial effect)

Question 35

Side effects of protamine sulphate

Answer 35

Bronchospasm Anaphylaxis

Question 36

Protamine sulphate protocol

Answer 36

5mg/min for 5 minutes Max dose 50mg over 10 minutes

Question 37

Management of women who decline blood products

Answer 37

Advanced directive Counsel without partner/family Active 3rd stage Consider cell salvage for both c/s and SVD Prophylactic interventional radiology on high risk (PAS) Consider alternatives (inc EPO)

Question 38

Causes of secondary PPH

Answer 38

Endometritis RPOC Abnormal involution of placental site Pseudoanuerysms and AV malformation

Question 39

How many secondary PPHs present with massive haemorrhage?

Answer 39

10%

Question 40

When does secondary PPH present

Answer 40

19% in first 7 days 41% day 8-14 23% days 15-21 12% days 22-28

Question 41

Risk of uterine perforation with SEVAC postpartum

Answer 41

1.5%

Question 42

Commonest organism causing c/s wound infection

Answer 42

Staph aureus

Question 43

Risk of nec fash after c/s

Answer 43

1.8 in 1000