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EOY4 > Antepartum Care > Flashcards

Antepartum Care Flashcards

1
Q

Describe the blood supply within the placenta

A

Maternal artery and maternal vein are established by 14 weeks

Maternal artery brings oxygenated blood into the placenta and pools in the intervillous space

Umbilical vein then takes oxygenated blood from the intervillous space to the foetus

2x Umbilical arteries take deoxygenated blood away from the foetus

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2
Q

How do molecules get from the maternal blood supply to the foetal blood supply?

A

There is no direct mixing but both blood supplies come into close contact across the placental membrane (v thin)

Allows diffusion!

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3
Q

What are the 5 functions of the placenta?

A

RENIE

Respiratory

Excretion of waste products

Nutrition (glucose, Fe, Folate)

Immunity - IgG can pass but IgM is too big

Endocrine - HcG then progesterone after 5 weeks to maintain the endometrium and Oestrogen to soften ligaments and muscles etc

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4
Q

Describe normal placentation

A

Ideal place to implant is the posterosuperior 2/3 of the uterus

Decidua basalis separates myometrium from the placenta

Fibrin layer separates endometrium from placenta

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5
Q

What is the function of the fibrin layer during placentation? What is the clinical significance of this?

A

Prevents implantation becoming too deep

Allows clean cleavage during the 3rd stage of labour

Disruption can lead to:
morbidly adherent placenta +/- retained placenta
PPH/SPH
Placental abruption
Vasa/placenta praevia
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6
Q

What are the 3 types of morbidly adherent placenta?

A

Placenta Accreta

Placenta Increta

Placenta Percreta

Increases in depth as you go down the list and increase in maternal morbidity

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7
Q

Describe the 3 types of MAP

A

Accreta = placental villi are attached to the myometrium

Increta = placental villi have invaded the myometrium

Percreta = placental villi pass through the myometrium into the serosa and maybe into other structures e.g. bladder

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8
Q

How does a morbidly adherent placenta normally present?

A

Painless, bright red PV bleeding

Hopefully diagnosed antenatally on USS

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9
Q

What are the modifiable risk factors for MAP?

A

Essentially anything that scars the uterus e.g.

Repeated caesareans
Repeated TOP
IVF
Endometrial ablation

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10
Q

When should MAP/retained placenta be suspected (if not already diagnosed)?

A

Suspect if the placenta HAS NOT been delivered within:

  • 30 mins of baby in an actively managed labour
  • 1 hour of baby in a physiological 3rd stage
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11
Q

What is the immediate management of MAP/retained placenta?

A

IV access, FBC, Cross match (should already have)

Physiological labour becomes active = oxytocin into umbilical vein +/- cord traction

Manage haemorrhage as and when

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12
Q

What is the definitive management of MAP/retained placenta?

A

Not removed within 30 mins =

theatre for Manual removal (scrape it with hand whilst putting pressure on uterus with other hand)

+ antibiotic prophylaxis

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13
Q

What are the maternal complications of MAP/retained placenta?

A

Some general surgical - bleeding/ VTE/ Injury to surrounding structures/ infection

Specific - emergency hysterectomy

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14
Q

What are the neonatal complications of MAP/retained placenta?

A

Stillbirth/death

Small for gestational age

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15
Q

Define antepartum haemorrhage

A

Bleeding from the genital tract during pregnancy

At or after 24 weeks gestation

Before the onset of labour

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16
Q

What are the dangerous placental causes of antepartum haemorrhage?

A

Placenta praevia

Placental abruption

Vasa praevia

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17
Q

What are the cervical causes of antepartum haemorrhage?

A

polyps
erosions
carcinoma
cervicitis

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18
Q

What are the non-dangerous placental causes of antepartum haemorrhage?

A

Circumvallate placenta (chorionic plate is too small so doubles back on foetal side)

Placental sinuses

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19
Q

What is placental abruption?

A

Premature separation of a normally located placenta from the uterine wall before delivery of the foetus

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20
Q

What is the pathophysiology of placental abruption thought to be?

A

Rupture of maternal vessels in basal layer of endometrium

Blood accumulates = splitting of placental attachment from basal layer

Foetal compromise happens quickly as placenta can’t do its job

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21
Q

What are the 2 types of placental abruption?

A

Concealed

Revealed

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22
Q

Describe a concealed placental abruption

A

Bleeding stays in uterus, usually retroplacentally

No PV bleed but can still lead to systemic shock!

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23
Q

Describe a revealed placental abruption

A

Bleeding can come down the side of the separation and out of cervix

Results in a PV bleed

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24
Q

What are the non-modifiable risk factors for placental abruption?

A

Underlying thrombophilia

Multiple pregnancy

Increased maternal age

Previous Hx Placental abruption

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25
Q

What are the modifiable risk factors for placental abruption? (4)

A

Past hx of PA

PWID/cocaine/smoking

Trauma

Pre-eclampsia/HTN

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26
Q

How would a placental abruption normally present?

A

PAINFUL, PV bleeding
(pain is sudden onset, constant and severe)

Woody hard abdomen

Later signs = maternal shock and foetal distress

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27
Q

Why does a woody hard abdomen occur in a placental abruption?

A

Bleeding causes irritation to the uterus

Irritation = contractions

Can lead to premature labour

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28
Q

What are the bedside tests to do for a placental abruption and why?

A

Do baseline obs to watch for signs of shock

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29
Q

Which blood tests should be done to manage a placental abruption? (6)

A

FBC - Hb

Cross match - in case a blood transfusion is needed

U&E - monitor kidney function in case haemorrhage = AKI. AND to check pre-eclampsia/HELLP

LFTs - exclude HELLP

Coagulation

Kleihauer - check rhesus status

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30
Q

What imaging can be done to manage a placental abruption?

A

USS to differentiate from placenta praevia

Foetal monitoring via CTG

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31
Q

What is the overall management for a placental abruption?

A

Admission and A→E
Get expert help

Conservative
Severe bleeding = put legs up
Catheterise

Medical
Severe = Fresh ABO Rh compatible or O Rh -ve blood

Surgical
Deliver if signs of foetal distress
IOL if at term

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32
Q

Define placenta praevia

A

When either the whole of the placenta or just a part is inserted into the lower segment of the uterus

Needs to still be low at 28 weeks as often implants lower but moves higher as the uterus grows

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33
Q

What is minor vs major placenta praevia?

A

Minor = placenta is in lower segment but does not cover the internal os

Major = placenta covers the internal os. Bad because a normal labour cannot occur

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34
Q

How does placenta praevia normally present?

A

PAINLESS, PV bleeding

Warning bleeds throughout pregnancy

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35
Q

What are the non-modifiable risk factors for placenta praevia?

A

Multiple pregnancy

Maternal age >40

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36
Q

What are the modifiable risk factors for placenta praevia?

A

Past hx of PP

Scarring of uterus e.g. IVF, TOP, previous caesarean

Fibroids

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37
Q

Are there any investigations to diagnose a placenta praevia?

A

YES

Should be diagnosed on USS antenatally (trans-vaginal) at 20 weeks

Acutely and if major bleeding is suspected, the same Ix should be done as for placental abruption

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38
Q

When should USS be repeated in a patient with diagnosed placenta praevia?

A

Minor - Repeat USS at 36 weeks

Major - Repeat USS at 32 and make a plan for delivery if still low

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39
Q

When should an elective caesarean be offered in a patient with known praevia?

A

38 weeks if major

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40
Q

Define vasa praevia

A

Foetal vessels run in membranes below the presenting foetal part

Unsupported by placental tissue or umbilical

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41
Q

Where do the vessels arise from in vasa praevia?

A

A velamentous umbilical cord
OR
An accessory placental lobe

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42
Q

What is a velamentous umbilical cord?

A

Cord inserts into foetal membranes rather than the centre of the placenta

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43
Q

How does vasa praevia normally present?

A

A triad!

Foetal bradycardia
PAINLESS pv bleeding

Membrane rupture

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44
Q

What are the non-modifiable risk factors for vasa praevia?

A

Accessory placental lobe

Velamentous umbilical cord

Multiple pregnancy

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45
Q

What are the modifiable risk factors for vasa praevia?

A

IVF pregnancy

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46
Q

What are the investigations for vasa praevia?

A

Investigate haemorrhage as per antepartum haemorrhage

Diagnose by TAS and TVS with doppler antenatally

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47
Q

How should a known vasa praevia be managed?

A

Elective c-section at 34-36 weeks if confirmed in 3rd trimester

+ ?prophylactic hospitalisation based on PROM risk factors

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48
Q

How should PROM or a spontaneous ROM be managed in a patient with vasa praevia?

A

Emergency c-section

49
Q

Which 2 medical conditions should you not breastfeed if you have?

A

Galactosaemia

HIV

50
Q

Give 6 [classes of] drugs that should be avoided in pregnancy

A 
Trimethoprim
NSAIDs
ACEI
Warfarin
Anticonvulsants e.g. Valproate
Vitamin A e.g. Retinoids
51
Q

When would Erb’s palsy occur and how does it present?

A

Damage to the upper brachial plexus most commonly from shoulder dystocia

adduction + internal rotation of arm + pronation of forearm (waiter’s tip)

52
Q

Which screening tool is for postnatal depression?

A

Edinburgh scale

53
Q

Define an amniotic fluid embolism

A

when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in cyanosis, hypotension bronchospasm etc

Usually occurs during labour

54
Q

When is the dating scan?

A

10-13+6 weeks

55
Q

When is the Down’s syndrome + nuchal scan?

A

11-13+6 weeks

56
Q

When is the foetal anomaly scan?

A

18 - 20+6 weeks

57
Q

When should rhesus negative women be given anti-D?

A

28 weeks

34 weeks

Within first 72h of birth

58
Q

Give 4 non-pharmacological methods of analgesia during labour

A

Education - about labour, breathing exercises

TENS - not in established labour

Water birth - not if high risk. Have to keep water below 37.5

A consistent and supportive birth partner!

59
Q

How does inhaled nitrous oxide (entonox) work?

A

Inhibit NMDAr = Increases GABA activity = mild analgesia and anxiolytic but mainly dissociative about pain less

60
Q

What are the benefits and disadvantages of using entonox?

A

+ves = cheap, fast, reversible. Doesn’t affect baby. Good for 1st stage as don’t push so protects perineum

-ves = CI if severe asthma or pneumothorax, ADRs = N&V, drowsy

61
Q

What are the benefits and disadvantages of giving systemic opioids e.g. Pethidine, diamorphine during labour?

A

Not many benefits

-ves = limited analgesic effect, V emetic, significant Session e.g. mother = drowsy, N&V, pethidine is associated with fits, baby = short term RDS, drowsy)

62
Q

What is epidural anaesthesia?

A

A catheter is inserted into the epidural space which allows continuous anaesthesia/can be topped up

Does not cross ligament flavour

Analgesic effect is at nerve roots leaving dura rather than on the whole spinal cord

63
Q

What are the benefits and disadvantages of epidural anaesthesia?

A

+ves = can give regular top ups, good analgesia, can help Lower BP in pre-eclampsia, can do anywhere in spine (theoretically)

-ves = takes 30-45 mins to work, increases risk of operative delivery (so tears and PPH too), post puncture headache, hypotension

64
Q

What is spinal anaesthesia?

A

A single injection of anaesthetic into the subarachnoid space so injected directly into the CSF and acts directly on the spinal cord

Do between L3-L5 to avoid conus medullar is (L1-L2) = avoid spinal cord injury

Get a complete motor and sensory block below the level of injection

65
Q

What are the benefits and disadvantages of giving a spinal anaesthetic?

A

+ves - quick onset, for shorter procedures

-ves = can move up the SA space to brainstem = LOC, respiratory depression. Might wear off in procedure is prolonged, more profound hypotension

66
Q

Are NSAIDs ok to use during pregnancy and the puerperium?

A

Not really - avoid before and after 30 weeks

BUT

ok to use if breastfeeding

67
Q

Define a first degree tear

A

Superficial and do not involve the perineal muscle

Only requires suturing if the edges are well apposed to aid healing

68
Q

Define a second degree tear

A

Perineal muscles are involved

repair to episiotomy level

69
Q

Define a third degree tear

A

Damage involves the anal sphincter (vajanus)

a = circular fibres of external anal sphincter = >50% torn
b = external anal sphincter thickness = >50% torn
c = ex and int anal sphincters are >50% torn
70
Q

Define a fourth degree tear

A

Anal/rectal mucosa is also involved

71
Q

What is the aftercare of a fourth degree tear?

A

Abx prophylaxis (same with 3rd degree)

High fibre diet + lactulose for 10 days

Pelvic floor physio

72
Q

Why would an episiotomy be carried out?

A

Enlarge the outlet e.g. baby coming too quick, operative delivery

prevention of 3rd degree tear

73
Q

Which tissues are cut in an episiotomy?

A

vag epithelium + perineal skin

bulbocavernous muscle

superficial + deep transverse perineal muscles

? anal sphincters and elevator ani

74
Q

What are the complications of an episiotomy and how can this be managed?

A

Pain - ice packs, salt packs, rectal diclofenac

Bleeding +/- haematoma

Infection

Damage to surrounding structures

75
Q

What is lochia?

A

All the shit that comes out after having a baby

endometrial slough, red cells, white cells

1-3 days = red
then yellow
then white @ 10 days

76
Q

How would endometritis present?

A

Maternal pyrexia
Offensive lochia
Lower abdominal pain
Pain on bimanual

77
Q

How is endometritis managed?

A

IV abx

78
Q

What is lactational amenorrhoea?

A

No periods whilst breastfeeding

Disruption of frequency and amplitude of gonadotrophin surges = no ovulation

79
Q

Under which circumstances can lactational amenorrhoea be an effective method of contraception?

A

Fully breastfeeding day and night
<6 months postpartum
amenorrhoeic

= 98% effective

80
Q

When is the average 1st menstruation after having a baby if mother is breastfeeding?

A

28.4 weeks

81
Q

When can the POP be started after childbirth?

A

Any time really

If started after 21 days then need additional methods for 2 days

82
Q

When can the COCP be started after childbirth?

A

At 3 weeks IF NOT BREASTFEEDING

DONT USE IF BREASTFEEDING UNTIL AFTER 6 MONTHS although can be used at 6 weeks if other methods aren’t acceptable

83
Q

When can emergency contraception be started after childbirth?

A

Any time - don’t need the 21 day thing

84
Q

When can the depot be given after childbirth?

A

After 6 weeks if breastfeeding

Can be given 5 days or straight away if bottle feeding (depending on type)

85
Q

When can the implant be put in after childbirth?

A

6 weeks if breastfeeding

21-28 days if bottle feeding

86
Q

When can the IUD be put in after childbirth?

A

Either within first 48hr postpartum OR 4 weeks post partum

To reduce risk of uterine perforation at insertion

87
Q

What is the triad seen with an amniotic fluid embolism?

A

Coagulopathy

Hypoxia

Hypotension

88
Q

Give 4 non-pharmacological methods of pain management during labour

A
  • Education about labour and breathing exercises
  • Transcutaneous Electrical Stimulation (not if established labour)
  • Water birth - temp <37.5 and not if high risk/opiates given in past 2 hours
  • Position - side or squatting as back can squash lumbosacral plexus

Actually, a supportive partner has the most evidence

89
Q

Give 2 medical methods of pain management during labour

A

Inhaled nitrous oxide (inhibits NMDAR so increases GABA - anxiolytic and dissociative)

Systemic opioids - pethidine and diamorphine

90
Q

What are the positives and negatives of entonox?

A

+ves

  • fast, reversible, cheap
  • doesn’t affect baby and good in first stage as protects perineum
  • ves
  • CI = severe asthma and pneumothorax
  • ADR = n&v and drowsy
91
Q

What are the limitations of using systemic opioids during labour?

A
  • Not much analgesic effect and makes mam drowsy
  • Crosses placenta so have to give 4 hours before birth so it is cleared but hard to know when this will be - RDS in neonate
  • V emetic so have to give anti-emetic too
  • Pethidine also associated with seizures
92
Q

Give 2 regional anaesthesia management options for pain during labour

A

Epidural - catheter into epidural space which allows continuous anaesthesia and can be topped up. Has effects on nerve roots leaving dura

Spinal - Single injection into subarachnoid space so directly into CSF. This means has a direct effect on spinal cord

93
Q

What is the anatomical difference between an epidural and a spinal anaesthetic

A

Spinal crosses ligamentum flavosum to get into the subarachnoid space

Spinal has to be done between L3-L5 to avoid the conus medullaris (L1-L2)

Spinal = complete motor and sensory block below level wherea epidural is just sensory?

94
Q

What are the benefits and limitations of an epidural?

A

+ves

  • Regular top ups
  • Good anaglesia
  • Can help reduce BP esp with pre-eclampsia
  • ves
  • 30-45 mins to work
  • Increased risk of operative delivery (and tears and PPH)
  • Post puncture headache
  • Hypotension
95
Q

What are the benefits and limitations of a spinal?

A

+ves
- Faster onset and offset so good for shorter procedures

  • ves
  • Can move up SA space to the brainstem = resp compression
  • might wear off if procedure is prolonged
  • More profound hypotension
96
Q

What are the definitions of primary PPH and secondary PPH?

A

Bleeding after 24 weeks!

Primary = within 24 Hours of delivery
Secondary = within 24hrs - 12 weeks post delivery
97
Q

What is the definition of a minor and major PPH?

A 
minor = 500-1000mls blood loss + no clinical shock
Major = 1000+mls + clinical shock

Vaginal delivery!!

98
Q

What are the 4 categories of causes of PPH?

A

TONE - uterine atony

TISSUES - retained products/MAP

TRAUMA - to genital tract

THROMBIN - coagulopathy (pre-eclampsia, abruption, anti-phospholipid, liver disease), Heparin use

99
Q

What are the antenatal risk factors for PPH?

A

NM = >35, uterine abnormality, low lying placenta

M = High BMI, previous PPH, para 4+

100
Q

What are the intrapartum risk factors for PPH?

A

Modifiable - IOL + oxytocin, prolonged stages, CS/VOD

101
Q

What are 4 complications of PPH?

A

Direct blood loss (hypovolaemic, DIC)

FLuid overload when replaced/acute transfusion reaction

ARDS

Sheehans Syndrome - hypo perfusion to pituitary (amenorrhoea, Addisons, hypothyroid)

102
Q

How does PPH lead to DIC?

A

depletion of: fibrinogen, platelets, coagulation factors

Endothelial injury = coagulation at site of injury = activates cascade = widespread organ injury

Easy bleeding at other sites

Paradoxical as have thrombosis and bleeding at same time

103
Q

Which blood tests should be done in PPH?

A

Clotting - APTT and PT are both prolonged, D-Dimer is increased

Others for baseline

104
Q

What is the A to E management of PPH?

A

Left lateral tilt

A
B - high flow O2
C - 2x grey cannula, 1L NaCl over 15 mins. RhD-ve, O-ve blood, FFP, Cryoprecipitate, Cell salvage
D
E - Catheter
105
Q

What is the medical management of uterine atony?

A

Pharmacological = tranexamic acid, Oxytocin (No HTN), Ergometrine

106
Q

What is the non-pharmacological management of uterine atony?

A

Uterine massage/bimanual compression

Balloon
Brace Suture
Hysterectomy (if can’t stop bleeding)

107
Q

What is the definition of shoulder dystocia?

A

Delivery requiring additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed

Anterior shoulder becomes impacted against pubic symphysis due to failed internal rotation

108
Q

What are the antenatal and intrapartum risk factors for shoulder dystocia?

A

Antenatal = macrosomia, previous Hx, BMI >30, post dates, DM

Intrapartum = IOL/oxytocin, prolonged 2nd stage, failure to progress, intstrumental deliver

109
Q

What is the management of shoulder dystocia?

A

HELPER A

Help and extra midwives, senior obstetrician, neonatologist, anaesthetist
Episiotomy
Legs - McRoberts Manoeuvre
Pressure (suprapubic)
Enter pelvis for internal manoeuvres :( :(
Roll mother to all fours

Anticipate PPH

110
Q

What are the maternal and foetal complications of shoulder dystocia?

A

Maternal = PPH, uterine rupture, 3rd-4th degree tear

Foetal = Death, hypoxia (+neuro injury), Erb’s Palsy (C5 and C6!)

111
Q

WHAT IS Erb’s palsy?

A

Injury to C5 and C6 nerves

Can’t abduct or externally rotate

112
Q

Define cord prolapse

A

Cord protrudes below the presenting part AFTER rupture of membranes

It is an emergency because it compresses the cord = foetal asphyxia

See cord + foetal bradycardia/decelerations according to contractions

113
Q

What is the management of cord prolapse?

A

Tell everyone on labour ward
Keep cord in vag but don’t handle too much due to vasospasm

Fill bladder with 500ml saline = obstructs
Tocolytics

Deliver ASAP

114
Q

What are the normal and abnormal findings on CTG? How do you confirm foetal distress?

A

Good variability between 5-10bpm = normal

Non-variable, non-reactive, decelerations = abnormal

Confirm by foetal scalp blood sampling for acid base status every hour

115
Q

What are the causes of suspected foetal compromise?

A

Power - uterine hyper stimulation, maternal hypotension, maternal infection

Passenger - IUGR

Passage

116
Q

What is the management of the foetal heart rate dipping below 100bpm?

A

3 mins = call for help

6 mins = theatre and delivery

117
Q

What is the chance of having a VBAC?

A

70-75%

Lower threshold to have c-section if have previous scarring or foetal compromise

118
Q

What are the risks of having a VBAC?

A

1 in 200 = scar rupture

2 in 1000 = foetal death during labour but this is the same as in first labour
Foetal death risk in having a planned caesarean = 1 in 1000

Risk of emergency c-section in which case risk of scar rupture is 5 in 1000

EOY4 (22 decks)

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