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Abnormal Labour Flashcards

1
Q

What is antepartum haemorrhage?

A

Haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby

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2
Q

Give causes of antepartum haemorrhage

A

Placenta praevia

Vasa praevia

Placental abruption

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3
Q

What is vasa praevia?

A

Abnormally unprotected fetal blood vessels, in which they travel through the membrane and run near the internal opening of the uterus, exposing them to rupture

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4
Q

Give risk factors for vasa praevia

A

IVF

Multiple pregnancy

Low lying placenta (placenta within 20mm of cervical os, wheras praevia is covering)

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5
Q

How does vasa praevia present?

A

Painless vaginal bleeding following membrane rupture

Pulsating fetal vessels on examination

Fetal heart rate abnormalities/bradycardia

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6
Q

How is vasa praevia managed?

A

Elective c section 34-36 weeks with glucocorticoids

Emergency c section if antepartum haemorrhage

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7
Q

What is placenta praevia?

A

Implantation of the placenta within the lower uterine segment, below the presenting part of the fetus

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8
Q

Describe grade 1 placenta praevia

A

Placenta on the lower segment of uterus but does not reach cervical os, also known as low lying

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9
Q

Describe grade 2 placenta praevia

A

Placenta reaches the cervical os but still does not cover it, also known as low lying

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10
Q

Describe grade 3 placenta praevia

A

Placenta partially covers the cervical os

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11
Q

Describe grade 4 placenta praevia

A

Placenta completely covers cervical os

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12
Q

What are risk factors for placenta praevia?

A

Multiparity

Multiparous

Increased maternal age (>35)

Intrauterine fibroids

Maternal smoking

Previous C-Section, as in future pregnancies placenta attaches to scar

Previous placenta praevia

IVF

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13
Q

How does placenta praevia present?

A

May be asymptomatic and often incental as stable maternal and fetal condition

Painless bright red bleeding

Malpresentation of the fetus, usually transverse

Soft, non tender uterus

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14
Q

Why can placenta praevia only be officially diagnosed in the third trimester?

A

Although can be seen on original booking scan, a significant number will migrate up, so can only be diagnosed officially in third trimester

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15
Q

What US is used in placenta praevia diagnosis?

A

Transvaginal

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16
Q

What is the management of placenta praevia?

A

Planned c section at 36-37 gestation

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17
Q

What is the management of placental praevia haemorrhage?

A

Emergency c section

Blood transfusion

Intrauterine balloon tamponade

Uterine artery occlusion

Emergency hysterectomy

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18
Q

What is placental abruption?

A

Premature separation of the placenta from the uterine wall during pregnancy

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19
Q

What are the categories of placental abruption?

A

Revealed, haemorrhage is apparent externally as the blood escapes through the cervical os

Concealed, haemorrhage occurs between the placenta and uterine wall and so does not escape through os

Mixed

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20
Q

Give risk factors for placental abruption

A

PET/HTN

Multiple pregnancy

Polyhydramnios

Smoking

>Age

Multiparity

Previous abruption

Cocaine

Trauma

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21
Q

How does placental abruption present?

A

Severe sudden continous abdominal pain in 3rd trimester

Dark red vaginal bleeding, although absence does not rule out diagnosis as in the case of concealed

Increased uterine activity/tone/contractions

Couvelaire uterus/bruising

‘Woody’ hard uterus

Cold to touch

Longitudinal fetus

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22
Q

How is placental abruption managed?

A

Urgent involvement of a senior obstetrician, midwife and anaesthetist

2 x grey cannula

Crossmatch 4 units of blood

Fluid and blood resuscitation as required

CTG monitoring of the fetus and monitoring of the mother

Attempt vaginal delivery or emergency aesarean section

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23
Q

What is amniotic fluid embolism?

A

Anaphylactic reaction to the presence of amniotic fluid and fetal matter into the maternal lungs, leading to HTN and hypoxia

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24
Q

Give the prognosis of amniotic fluid embolism

A

80% mortality

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25
Q

How does amniotic fluid embolism present?

A

Occurs shortly after labour

Hypoxia, including cyanosis

Hypotention

Coagulopathy, showing increased PT

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26
Q

How is amniotic fluid embolism managed?

A

Oxygen and fluid resucitation

Treat coagulopathy

Immediate delivery

Supportive management thereafter

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27
Q

What is preterm labour?

A

Onset of labour before 37 completed weeks gestation

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28
Q

Describe mildly preterm

A

32-36

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29
Q

Describe very preterm

A

28-32

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30
Q

Describe extremely preterm

A

24-28

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31
Q

Give risk factors for preterm labour

A

Idiopathic

Multiple pregnancy

Extremes of maternal age

Heavy stressful work

Smoking

Substance of misuse

Cervical Incompetence

Uterine anomalies

Polyhydramnios

Previous pre-term delivery

Group B Streptococci

APH

Pre-eclampsia

Infection/UTI

Premature rupture of membranes associated with infection

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32
Q

What is the main cause of preterm labour?

A

Idiopathic

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33
Q

What investigations are used in PPROM?

A

Fetal fibronectin

  • Protein released from gestational sac, associated with early labour

Speculum examination

  • Pooling of amniotic fluid in the posterior vaginal vault
  • Avoid digital examination to reduce the risk of introducing infection to the uterus

US

  • Used if still expected but no pooling of amniotic fluid in posterior vaginal vault
  • Oligohydramnios
34
Q

What is fetal fibronectin?

A

Protein released from gestational sac, associated with early labour

35
Q

How is PPROM managed?

A

Admission and observation for chorioamnionitis

Oral Erythromicin for 10 days

2 doses IM steroids for neonate lung maturity

Delivery at 34 weeks

36
Q

What steroid is given in PPROM?

A

Dexamethasone

37
Q

Give neonatal complications of pre-term labour

A

Respiratory distress syndrome

Intraventricular haemorrhage

Cerebral palsy

Nutrition

Temperature control

Jaundice

Infection

Visual impairment

Hearing loss

38
Q

What is induction of labour?

A

When an attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix”, followed usually by artificial rupture of membranes (performing an amniotomy)

39
Q

How many pregnancies are induced?

A

Approx 1/5

40
Q

Give indictations for induced labour

A

Gestational diabetes

Post dates, term + 7 days

Maternal health problem that necessitates planning of delivery, such as DVT, PET

Fetal reasons

  • Suspected IUGR
  • Oligohydramnios
  • IUD

Social reasons

Maternal request

Pelvic pain

Big babies

Pre-labour rupture of membranes

41
Q

Give disadvantages of induced labour

A

Less efficient and more painful

Requires fetal monitoring

Risk of uterine hyperstimulation with prostaglandin/oxytocin induction

42
Q

Give contraindications for induced labour

A

Obstruction to birth canal

  • Major placenta praevia
  • Masses

Malpresentation

  • Transverse
  • Shoulder
  • Breech

Medical conditions where labour would not be safe for women

Specific previous labour complications: Previous uterine rupture

Fetal conditions

43
Q

Give complications of induced labour

A

>Risk of instrumental and operative delivery

Uterine hyperstimulation

Failed induction

Cord prolapse

Uterine rupture

44
Q

What score is used to clinically assess the cervix

A

Bishop score

45
Q

What does the Bishop score assess?

A

Used to clinically assess the cervix

The higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful

46
Q

What Bishop score suggests labour is unlikely to start without induction?

A

Less than 5

47
Q

Describe the induction process

A

Membrane sweep

Vaginal prostaglandin pessaries or a Cook balloon is used to ripen/open the cervix

Once cervix has dilated and effaced, an amniotomy can be performed

Once amniotomy is performed, IV oxytocin is used to achieve adequate contractions, although misoprostol can also be used

48
Q

What are the properties of a Cook balloon?

A

Inflates os

No hyperstimulation

Works within 12-24 hours

49
Q

What are the properties of vaginal pessaries

A

Initiates contractions

Takes 2-3 days

Risk of hyperstimulation

50
Q

What is an amniotomy?

A

Artificial rupture of membranes/amniotic fluid

51
Q

What Bishop score is favourable of amniotomy?

A

7 or more

52
Q

What Bishop score suggests labour is likely to commence spontaneously?

A

Over 9

53
Q

Why can oxytocin only be given if no obstruction?

A

Can cause uterine rupture

54
Q

How many contractions should be aimed for in induced labour with oxytocin?

A

4/5 in 10 minutes

55
Q

What is the most common malpresentation?

A

Breech

56
Q

What can cause malpresentation?

A

Often no cause identified

Multiple pregnancy

Polyhydramnios

Uterine abnormalities

Placenta praevia

Congenital abnormalities

57
Q

What is the management of breech malpresentation?

A

External cephalic version at 36 weeks, as baby may move spontaneously before this

If remains breech, caesarean delivery is recommended due to risk of head entrapment

58
Q

What is the management of face malpresentation?

A

Vaginal delivery is possible in mento-anterior (chin lying behind symphysis pubis)

Ventouse delivery is contraindicated

59
Q

What is the management of transverse malpresentation?

A

Stabilizing induction with external cephalic version

Followed by artificial rupture of membranes, otherwise caesarean section

60
Q

When is external cephalic version contrainindicated?

A

Where caesarean delivery is required

Antepartum haemorrhage within the last 7 days

Abnormal cardiotocography

Major uterine anomaly

Ruptured membranes

Multiple pregnancy

61
Q

Give absolute contraindications to external cephalic version

A

Caesarean section is already indicated for other reason

Ante-partum haemorrhage has occurred in the last 7 days

Non-reassuring cardiotocograph

Major uterine abnormality

Placental abruption or placenta praevia

Membranes have ruptured

Multiple pregnancy, but may be considered for delivery of the second twin

62
Q

Give a complication of transverse malpresentation

A

Risk of cord prolapse if spontaneous rupture of membranes

63
Q

What is cord prolapse?

A

Descent of the umbilical cord through the cervix alongside or past the presenting part of the fetus, increasing risk that fetus will compress the cord and cause hypoxia

64
Q

Give risk factors for cord prolapse

A

Prematurity

Multiparity

Polyhydramnios

Multiple pregnancy

Cephalopelvic disproportion

Malpresentation

Placenta praevia

Long umbilical cord

High fetal station

65
Q

What is the most common cause of cord prolapse?

A

Artificial amniotomy

66
Q

How does cord prolapse present/how is it diagnosed?

A

Suspected in CTG fetal distress

Confirmed with speculum

67
Q

What are the indications for continuous CTG monitoring during labour?

A

Ssuspected chorioamnionitis or sepsis, or a temperature of 38°C or above

Severe hypertension 160/110 mmHg or above

Oxytocin use

Presence of significant meconium

Fresh vaginal bleeding that develops in labour

68
Q

How is cord prolapse managed?

A

Call for help

Elevate presenting part either manually or by filling the urinary bladder

Knees and elbows position while waiting for surgery

Tocolytic medication can be used to minimise contractions while waiting for surgery

Immediate delivery

  • Forceps vaginal delivery if cephalic presentation and fully dilated
  • Emergency caesarean section

Once delivered, neonatal resuscitation as appropriate

69
Q

Give complications of cord prolapse

A

Infant death

Cerebral palsy and hypoxic encephalopathy, caused by cord compression and vasospasm

70
Q

What is shoulder dystocia?

A

Anterior shoulder impacts on maternal symphysis pubis and so delivery requires additional obstetric manoeuvres to release

71
Q

Give risk factors for shoulder dystocia

A

Previous shoulder dystocia

Macrosomia

Diabetes mellitus

BMI>30

Induction of labour

Prolonged first and second stage labour

Forceps/Ventouse delivery

Oxytocin

72
Q

Give the management for shoulder dystocia

A

HELPERR

Call for help

Evaluate for episiotomy

McRobert’s manoeuvre

Suprapubic pressure

Internal rotation of anterior shoulder

Remove posterior arm

Roll the patient onto all fours and begin the cycle

73
Q

What is McRobert’s manoeuvre?

A

Flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen

74
Q

Give complications of shoulder dystocia

A

Fetal mortality

Hypoxic encephalopathy

Cerebral palsy

Brachial plexus injury

Erb’s palsy

PPH

Significant perineal trauma

75
Q

What is Chorioamnionitis?

A

Preterm premature rupture of the membranes

  • Exposes the normal sterile environment of the uterus to potential pathogens
  • However can occur when membranes are still intact
76
Q

How does chorioamnionitis present?

A

Abdominal pain

Uterine tenderness

Flu like symptoms

Pyrexia

Foul smelling discharge

77
Q

How is chorioamnionitis managed?

A

Prompt delivery, C section if necessary

Administration of IV antibiotics

78
Q

Give complications of chorioamnionitis

A

Maternal and fetal mortality, obstetric emergency

79
Q

What is placenta accreta?

A

Describes the attachment of the placenta to the myometrium, due to a defective decidua basalis

As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage

80
Q

Give risk factors for placenta accreta

A

Previous C section

Placenta praevia

81
Q

How is placenta accreta managed?

A

Hysterectomy

  • Delayed placental delivery

Reproduction (18 decks)

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