child birth conditions Flashcards
antepartum haemorrhage + commonest causes
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
causes of antepartum haemorrhage
placenetal problem
- placenta praevia
- placental abruption
local causes
- ectropion
- polyp
- infection
- carcinoma
uterine problem - rupture
vasa praevia
spotting vs minor vs major vs massive bleed
spotting = staining, streaking, wiping
minor = <50ml settled
major = 50-100ml no shock
massive = > 1000ml and/or shock
3 causes of antepartum haemorrhage with high morbidity/mortality
causes of spotting or minor bleeding in pregnancy
- placenta praevia
- placental abruption
- vasa praevia
spotting/minor
- cervical ectropion
- infection
- vaginal abrasions from intercourse or procedures
placental abruption
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
placental abruption risk factors
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
pathophysio pf placental abruption
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)
presentation of placental abruption
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
management of placental abruption
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)
prevention of placental abruption
recurrence 10%
antiphospholipid syndrome - LMWH + low dose aspirin
drug misuse agencies
smoking cessation
folic acid
prevent domestic violence
placental abruption complications
maternal
- hypovolaemic shock
- PPH in 25%
- anaemia
- renal failure - from renal tubular necrosis
- coagulopathy
- infection
- VTE
- psychological
fetal
- fetal death
- hypoxia
- prematurity
- SGA/FGR
placental praevia
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
what is the lower segment of the uterus?
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
placenta praevia risk factors
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
placenta praevia presentation
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
screening for placental praevia
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
diagnosis of placenta praevia
check anomaly scan
confirm by transvaginal US = 32, 36wks
MRI for excluding placenta accreta
management of placenta praevia
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) *
management of placenta praevia if not bleeding
advise to attend immediately if
- bleeding including spotting
- contraction or pain - including vague suprapubic period-like aches
NO sex
management of placenta praevia who are bleeding
2 large bore IV access
Xmatch 4-6units
major haemorrhage protocol - maybe
IV fluids, or tranfuse
antiD if rhesus neg
delivery timing in placenta praevia
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
uterine rupture
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
uterine rupture risk factors
previous C-section/uterine surgery - scar = point of weakness
multiparity
use of prostaglandins/syntocinon
increased BMI
induction of labour
previous rupture
obstructed labour
uterine tupture presentation
severe abdominal pain
ceasing of uterine contractions
hypotension, tachycardia
maternal collapse
bleeding
acute abdomen
uterine rupture management
ABCDE / resuscitation
emergency caesarean, stop bleeding + repair/remove uterus (hysterectomy)
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%
types of vasa praevia
type I = when vessel is connected to a velamentous cord
type II = when it connects the placenta with succenturiate
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
vasa praevia diagnosis
US TA + TV with doppler (antenatal)
sudden dark red bleeding + fetal bradycardia/death post rupture of membranes
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
post partum haemorrhage blood loss criteria
in first 24hrs -
SVD >500ml
operative vaginal delivery >750ml
c-section >1000ml
(major PPH >1000ml)
primary vs secondary PPH
primary - within 24hr
secondary - >24hrs - 6wks post delivery
why might blood loss be underestimated?
total blood volume depends on maternal weight
50kg - 5000ml -> 20%
vs
75kg - 7500ml -> 13%
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
causes of PPH
4Ts
tone (70%) - uterine atony
trauma 20% - perineal tears, cervical tears
tissue 10% - retained placenta
thrombin <1% - coagulation problems
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
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
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
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
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
active management of 3rd stage
uterotonic - syntocinon (oxytocinon), syntometrine (oxytocinon+ergometrine)
controlled cord traction
cord clamped
mx of retained placenta
gaunlet, pull it out
causes + investigations for secondary PPH
retained products of conception (RPOC)
infection (endometritis)
investigations
- US - for RPOC
endocervical + high vaginal swabs for infection
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
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
presentation of placenta accreta
no symptoms during pregnancy
can present with bleeding (antepartum haemorrhage) in 3rd trimester
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
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
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
what should be excluded before vaginal examination
placenta praevia
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
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)
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
complications of shoulder dystocia
fetal
- hypoxia
- brachial plexus injury
- fracture of clavicle/humerus
- intracranial haemorrhage
- death
maternal - PPH, trauma, pelvic injuries
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
risk factors of perineal tears
nilliparity
large babies
shoulder dystocia
OP position
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
where is an episiotomy cut?
45degrees laterally
mediolateral episiotomy
risk factors for maternal sepsis
prenatal invases diagnostic procedures
cervical suture
prolonged rupture of membranes
operative delivery
RPOC
diabetes
obesity
anaemia
immunosuppression
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
2 key causes of sepsis in pregnancy
chorioamnionitis
UTI
sepsis 6 management
give o2 to keep sats above94%
take blood cultures
give iv antibiotics
give a fluid challenge
measure lactate
measure urine output
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)
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
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
MEOWs
maternity early obstetric warning system
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
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
endometritis + risk factors
infection of uterine lining following delivery or miscarriage
- operative delivery
- prolonged labour
- retained products of conception
endometritis presentation
- Foul smelling discharge pr lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- sepsis
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
