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child birth conditions Flashcards

1
Q

antepartum haemorrhage + commonest causes

A

bleeding from genital tract >=24wks gestation + before 2nd stage of labour

commonest causes = placental abruption + placenta praevia

1/5 very preterm babies are born in assoc with APH

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2
Q

causes of antepartum haemorrhage

A

placenetal problem
- placenta praevia
- placental abruption
local causes
- ectropion
- polyp
- infection
- carcinoma

uterine problem - rupture
vasa praevia

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3
Q

spotting vs minor vs major vs massive bleed

A

spotting = staining, streaking, wiping

minor = <50ml settled

major = 50-100ml no shock

massive = > 1000ml and/or shock

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4
Q

3 causes of antepartum haemorrhage with high morbidity/mortality

causes of spotting or minor bleeding in pregnancy

A
  1. placenta praevia
  2. placental abruption
  3. vasa praevia

spotting/minor
- cervical ectropion
- infection
- vaginal abrasions from intercourse or procedures

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5
Q

placental abruption

A

separation of a normally implanted placenta from uterine wall, resulting in maternal haemorrhage into intervening space - partially or totally before birth of fetus

  • clinical diagnosis
  • 1% of pregnancies, 40% of APH
  • high perinatal mortality - responsible for 15% of perinatal deaths
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6
Q

placental abruption risk factors

A

unknown - 70% occur in low risk pregnancies
PET/hypertension
multiple pregnancy
trauma
smoking/cocaine
previous abruption

renal dise, diabetes
polyhydramnios
preterm
abnormal placenta - “sick” placenta

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7
Q

pathophysio pf placental abruption

A

vasospasm followed by arteriole rupture into the decidua, blood escapes into amniotic sac or further under placenta + into myometrium

  • causes tonic contraction + interupts placental circulation -> hypoxia
    -> Couvelaire uterus (tense + rigid)
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8
Q

presentation of placental abruption

A

continuous severe abdominal pain (labour intermittent pain)
tender uterus
woody hard utterus - large haemorrhage
bleeding - may be concealed (cervical os remains closed + bleeding remains in uterine cavity)
fetal parts difficult to identify

unwell distressed patient
backache if posterior placenta

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9
Q

management of placental abruption

A

ABCDE
resuscitate moth
assess + deliver baby
- 2 large bore IV access
- bloods - FBC, clotting, LFT, U&Es, crossmatch 4-6units
- IV fluids - careful with PET
- catheterise

assess getal heart
- CTG
- USS if no fetal heart (USS will fail to detect 3/4 cases of abruption but excludes placenta pravia)

delivery
- urgent C-section
- induction of labour - by amniotomy

manage complications + debrief parents (immediate +/- 6weeks postntally)

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10
Q

prevention of placental abruption

A

recurrence 10%
antiphospholipid syndrome - LMWH + low dose aspirin
drug misuse agencies
smoking cessation
folic acid
prevent domestic violence

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11
Q

placental abruption complications

A

maternal
- hypovolaemic shock
- PPH in 25%
- anaemia
- renal failure - from renal tubular necrosis
- coagulopathy
- infection
- VTE
- psychological

fetal
- fetal death
- hypoxia
- prematurity
- SGA/FGR

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12
Q

placental praevia

A

where placenta is attached in lower portion of uterus, lower than the presenting part of the fetus

  • low lying placenta = when placenta is within 20mm of internal cervical os (after 16/40)
  • placenta pravia = only when placenta is OVER internal cervical os

20% of APH
C-section is assoc with increased risk placenta praevia in subsequent pregnancies - risk increases with no. of c-sections

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13
Q

what is the lower segment of the uterus?

A

anatomical
- part of uterus below the utero-vesical peritoneal pouch superiorly + internal oss inferiorly
- thinner + contains less muscle fibres thsn upper segment

physiological
- part of uterus which does not contract in labour but passively dilates

metric
- part of uteris which is about 7cm from level of internal os

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14
Q

placenta praevia risk factors

A

previous c-section
previous TOP
age >40yrs
multiparity
assisted conception
smoking

deficient endometrium due to history of -
- uterine scar
- endometritis
- manual removal of placenta
- D+C
- submucous fibroid

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15
Q

placenta praevia presentation

A

painless bleeding >24wks
- usually unprovoked, coitus can trigger bleeding
- can be minor - spotting or severe
- fetal movements usually present

uterus soft, non-tender
malpresentation - breech, transverse, oblique
fetal heart, CTG usually normal

** DO NOT perform vaginal examination until you exclude

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16
Q

screening for placental praevia

A

20wk fetal anomaly scan should include placental localisation
rescan at 32 +26wks if persistent PP or LLP

*transvaginal scan > transabdominal

assess cervical length before 34wks for risk of preterm labour
MRI is placenta accreta suspected

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17
Q

diagnosis of placenta praevia

A

check anomaly scan
confirm by transvaginal US = 32, 36wks
MRI for excluding placenta accreta

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18
Q

management of placenta praevia

A

resus of mum, ABCDE - IV accesss + G+S
baby
- steroids 24-35+6wks
- MgSO4 if <32wks delivery likely, for neuroprotection

antiD is rhesus neg
conservative is stable + observe in hospital for at least 24hrs

*different Mx depending if bleeding or not (other cards) *

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19
Q

management of placenta praevia if not bleeding

A

advise to attend immediately if
- bleeding including spotting
- contraction or pain - including vague suprapubic period-like aches

NO sex

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20
Q

management of placenta praevia who are bleeding

A

2 large bore IV access
Xmatch 4-6units
major haemorrhage protocol - maybe
IV fluids, or tranfuse
antiD if rhesus neg

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21
Q

delivery timing in placenta praevia

A

consider at 34-36wks if history of PVB or other risk factors for preterm

uncomplicated - consider between 36-37wks

placenta covers os or <2cm - c-section

> 2cm from os + no malpresentation - vaginal delivery

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22
Q

uterine rupture

A

muscle layer of uterus (myometrium) ruptures
- if serosa intact - uterine dehisence (incomplete)
- serosa+myometrium rupture - complete rupture
–> contents of uterus released into peritoneal cavity (baby)

high morbid/mortal for mum + baby

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23
Q

uterine rupture risk factors

A

previous C-section/uterine surgery - scar = point of weakness
multiparity
use of prostaglandins/syntocinon
increased BMI
induction of labour
previous rupture
obstructed labour

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24
Q

uterine tupture presentation

A

severe abdominal pain
ceasing of uterine contractions
hypotension, tachycardia
maternal collapse
bleeding
acute abdomen

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25
uterine rupture management
ABCDE / resuscitation emergency caesarean, stop bleeding + repair/remove uterus (hysterectomy)
26
vasa praevia
where fetal vessels are within fetal membranes (chorioamniotic membranes) + travel across internal cervical os ->these exposed vessels are prone to bleeding, particularly when membranes are ruptured during labour / amniootomy mortality = 60%
27
types of vasa praevia
type I = when vessel is connected to a velamentous cord type II = when it connects the placenta with succenturiate
28
vasa praevia presentation
may present with antepartum haemorrhage (2/3 trimester) may detect by vaginal examination during labour - pulsating vessels seen through dilated cervix may detect during labour when fetal distress + dark red bleeding following rupture of membranes
29
vasa praevia diagnosis
US TA + TV with doppler (antenatal) sudden dark red bleeding + fetal bradycardia/death post rupture of membranes
30
management for vasa praevia (antenatally)
steroids from 32wks inpatient mx if risks of preterm birth (32-34wk) *elective c-section at 34-36wks placenta for histology antepartum haemorrhage -> emergency C-section
31
post partum haemorrhage blood loss criteria
in first 24hrs - SVD >500ml operative vaginal delivery >750ml c-section >1000ml (major PPH >1000ml)
32
primary vs secondary PPH
primary - within 24hr secondary - >24hrs - 6wks post delivery
33
why might blood loss be underestimated?
total blood volume depends on maternal weight 50kg - 5000ml -> 20% vs 75kg - 7500ml -> 13%
34
PPH risk factors
previous PPH multiple pregnancy obesity large baby failure to progress to 2nd stage prolonged 3rd stage pre-eclmapsia placenta accreta instrumental delivery
35
causes of PPH
4Ts tone (70%) - uterine atony trauma 20% - perineal tears, cervical tears tissue 10% - retained placenta thrombin <1% - coagulation problems
36
preventative measure in PPH
treating anaemia during antenatal period giving birth with an empty blaffer - full bladder reduced uterine contraction active management of 3rd stage - IM oxytocin IV tranexamic acid - used during c-section
37
mechanical mangement of PPH
*uterine massage - stimulate contraction 5units IV syntocinon stat 40units syntocinon in 500ml Hartmanns *catheter - bladder distension prevents uterine contractions most respond but may need to progress to drugs
38
pharmacological mangement of PPH
oxytocin - slow injection followed by continuous infusion ergometrine - IM, not if high BP carboprost - IM, prostaglandin analogue, not in asthmatics misoprostol - sublingual, prostaglandin analogue, not in asthmatics transexamic acid - antifibronlytic that reduces bleeding
39
surgical management of PPH
intrauterine balloon tissue sealants intervential radiology - arterial embolisation brace sutures - require laparotomy, fine if already c-section (B-lynch suture) uterine artery ligation hysterectomy
40
delay in 3rd stage
>30mins with active mx - adv - decrease PPH risk - disadv - N+V, risk of cord avulsion, uterine inversion >60mins in physiological mx - maternal effort alone, increased PPH risk
41
active management of 3rd stage
uterotonic - syntocinon (oxytocinon), syntometrine (oxytocinon+ergometrine) controlled cord traction cord clamped
42
mx of retained placenta
gaunlet, pull it out
43
causes + investigations for secondary PPH
retained products of conception (RPOC) infection (endometritis) investigations - US - for RPOC endocervical + high vaginal swabs for infection
44
placenta accreta
morbidly adherent placenta to uterine wall - difficult to separate placenta after delivery of baby invading myometrium -> increta penetrating uterus to bladder -> percreta - 5-10% placenta praevia - severe PPH, may have hysterectomy - major RF -> placenta praevia + prior c-section
45
placenta accreta risk factors
previous placenta accreta lowlying or placenta praevia previous c-section previous endometrial curettage procedures - miscarriage or TOP multigravida increase maternal age
46
presentation of placenta accreta
no symptoms during pregnancy can present with bleeding (antepartum haemorrhage) in 3rd trimester
47
diagnosis of placenta accreta
antenatal USscan - may be diagnosed at birth when becomes difficult to deliver if seen when opening for elective c-section, abdomen can be closed until special services are put in place - if discovered after delivery -> hysterectomy recommended
48
What can cause uterine inversion
pulling too hard on umbilical cord during active management of 3rd stage - obstetric emergency - rare large PPH, maternal shock/collapse
49
management of uterine inversion
ABCDE, resus johnson manoeuvre - push fundus back up + hold for couple mins - oxyocin used to create uterine contraction - ligaments/uterus need to generate tension to stay put hydrostatic method - filling vagina with fluid surgery
50
what should be excluded before vaginal examination
placenta praevia
51
risk factors for shoulder dystocia
antenatal - previous shoulder dystocia - fetal macrosomia - diabetes BMI>30 - short stature intrapartum - slow 1st and/or 2nd stage labour - induction of labour - instrumental delivery
52
presentation of shoulder dystocia
failure of restitution - head remain face downwards (OA) + does not turn sideways as expected turtle neck sign - head is delivered but retracts back into vagina (>10mins = death or extreme hypoic brain injury)
53
shoulder dystocia mx
episiotomy McRoberts manoeuvre - knees up to abdomen pressure to suprapubic region - pushes on anterior shoulder Rubins manoeuvre - reaching into vagina to put pressure on posterior part of shoulder wood screws manoeuvre - done with rubins, puts pressure on posterior shoulder (other one) Zavanelli manoeuvre - pushing babys head back into vagina so can be delivered by Csection
54
complications of shoulder dystocia
fetal - hypoxia - brachial plexus injury - fracture of clavicle/humerus - intracranial haemorrhage - death maternal - PPH, trauma, pelvic injuries
55
different degrees of perianal tears
1st - perineal skin only 2nd - perineal kin + muscle 3rd - injury involving anal sphincters 3A <50% external anal sphincter 3B >50% 3C involvement of both external + internal anal sphincter 4th - disruption of anal epithelium/mucosa
56
risk factors of perineal tears
nilliparity large babies shoulder dystocia OP position
57
management of perineal tears
>1st degree require sutures 3rd + 4th likely need repairing in theatre antibiotics, laxatives, physio Women who are symptomatic after 3rd/4th degree tears are offered elective caesarean in future pregnancies
58
where is an episiotomy cut?
45degrees laterally mediolateral episiotomy
59
risk factors for maternal sepsis
prenatal invases diagnostic procedures cervical suture prolonged rupture of membranes operative delivery RPOC diabetes obesity anaemia immunosuppression
60
maternal sepsis presentation
typical signs high WCC sore throat rash wound erythema Signs of chorioamnionitis o Abdominal pain o Uterine tenderness o Vaginal discharge Signs related to UTI o Urinary frequency, dysuria o Suprapubic pain or discomfort o Renal angle pain
61
2 key causes of sepsis in pregnancy
chorioamnionitis UTI
62
sepsis 6 management
give o2 to keep sats above94% take blood cultures give iv antibiotics give a fluid challenge measure lactate measure urine output
63
management of maternal sepsis
ABCDE + sepsis 6 FBC, U&E, LFT, Coag, glucose, lactate, CRP bacteriology screen for source -> blood cultures, throat swab, wound swab IV co-amoxiclav within "golden hour" - +/- gentamicin depending on severity + clindamycin if sore throat (GAS) (clindamycin + gent if penicillin allergic) (tazocin, clindamycin + gentamicin if septic shock)
64
chorioamnionitis
inflammation of amniochorionic (fetal) membrane of the placenta, typicallu in response to microbial invasion - leading cause of maternal sepsis - occurs later in pregnancy + during labour - 1% of live births 96% caused by ascending infection + usually polymicrobial from ecoli, mycoplasma, anaerobes
65
chorioamnionitis risk factors
invasive pre natal diagnosis prolonged rupture of membranes prolonged labour repeat digital examination in context of ruptured membranes nulliparity meconium stained liquor
66
MEOWs
maternity early obstetric warning system
67
management chorioamnionitis
broad spectrum antibiotics delivery - IOL or LUSCs - increase PPH risk - reduce with active 3rd stage syntocinon infusion - avoid post partum intra-uterine contraception
68
when should GBS antibiotic prophylaxis be given?
group b strep -> benzylpenicillin or clindamycin GBS detected antenatally previous baby has been affected by infection delivery <37wks
69
endometritis + risk factors
infection of uterine lining following delivery or miscarriage - operative delivery - prolonged labour - retained products of conception
70
endometritis presentation
- Foul smelling discharge pr lochia - Bleeding that gets heavier or does not improve with time - Lower abdominal or pelvic pain - Fever - sepsis
71
endometritis diagnosis + management
- vaginal swabs - urine culture + sensitivities - US to rule out RPOC Management Co-amoxiclav +/- surgical evacuation of uterus if significant RPOC o Co-trimoxazole + metronidazole if penicillin allergic - Sepsis 6

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