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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
Q

uterine rupture management

A

ABCDE / resuscitation

emergency caesarean, stop bleeding + repair/remove uterus (hysterectomy)

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26
Q

vasa praevia

A

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%

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27
Q

types of vasa praevia

A

type I = when vessel is connected to a velamentous cord

type II = when it connects the placenta with succenturiate

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28
Q

vasa praevia presentation

A

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

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29
Q

vasa praevia diagnosis

A

US TA + TV with doppler (antenatal)

sudden dark red bleeding + fetal bradycardia/death post rupture of membranes

30
Q

management for vasa praevia (antenatally)

A

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
Q

post partum haemorrhage blood loss criteria

A

in first 24hrs -

SVD >500ml
operative vaginal delivery >750ml
c-section >1000ml

(major PPH >1000ml)

32
Q

primary vs secondary PPH

A

primary - within 24hr

secondary - >24hrs - 6wks post delivery

33
Q

why might blood loss be underestimated?

A

total blood volume depends on maternal weight

50kg - 5000ml -> 20%
vs
75kg - 7500ml -> 13%

34
Q

PPH risk factors

A

previous PPH
multiple pregnancy
obesity
large baby
failure to progress to 2nd stage
prolonged 3rd stage
pre-eclmapsia
placenta accreta
instrumental delivery

35
Q

causes of PPH

A

4Ts
tone (70%) - uterine atony
trauma 20% - perineal tears, cervical tears

tissue 10% - retained placenta
thrombin <1% - coagulation problems

36
Q

preventative measure in PPH

A

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
Q

mechanical mangement of PPH

A

*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
Q

pharmacological mangement of PPH

A

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
Q

surgical management of PPH

A

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
Q

delay in 3rd stage

A

> 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
Q

active management of 3rd stage

A

uterotonic - syntocinon (oxytocinon), syntometrine (oxytocinon+ergometrine)

controlled cord traction
cord clamped

42
Q

mx of retained placenta

A

gaunlet, pull it out

43
Q

causes + investigations for secondary PPH

A

retained products of conception (RPOC)
infection (endometritis)

investigations
- US - for RPOC
endocervical + high vaginal swabs for infection

44
Q

placenta accreta

A

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
Q

placenta accreta risk factors

A

previous placenta accreta
lowlying or placenta praevia
previous c-section
previous endometrial curettage procedures - miscarriage or TOP
multigravida
increase maternal age

46
Q

presentation of placenta accreta

A

no symptoms during pregnancy
can present with bleeding (antepartum haemorrhage) in 3rd trimester

47
Q

diagnosis of placenta accreta

A

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
Q

What can cause uterine inversion

A

pulling too hard on umbilical cord during active management of 3rd stage
- obstetric emergency
- rare

large PPH, maternal shock/collapse

49
Q

management of uterine inversion

A

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
Q

what should be excluded before vaginal examination

A

placenta praevia

51
Q

risk factors for shoulder dystocia

A

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
Q

presentation of shoulder dystocia

A

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
Q

shoulder dystocia mx

A

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
Q

complications of shoulder dystocia

A

fetal
- hypoxia
- brachial plexus injury
- fracture of clavicle/humerus
- intracranial haemorrhage
- death

maternal - PPH, trauma, pelvic injuries

55
Q

different degrees of perianal tears

A

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
Q

risk factors of perineal tears

A

nilliparity
large babies
shoulder dystocia
OP position

57
Q

management of perineal tears

A

> 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
Q

where is an episiotomy cut?

A

45degrees laterally

mediolateral episiotomy

59
Q

risk factors for maternal sepsis

A

prenatal invases diagnostic procedures
cervical suture
prolonged rupture of membranes
operative delivery
RPOC

diabetes
obesity
anaemia
immunosuppression

60
Q

maternal sepsis presentation

A

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
Q

2 key causes of sepsis in pregnancy

A

chorioamnionitis
UTI

62
Q

sepsis 6 management

A

give o2 to keep sats above94%
take blood cultures
give iv antibiotics
give a fluid challenge
measure lactate
measure urine output

63
Q

management of maternal sepsis

A

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
Q

chorioamnionitis

A

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
Q

chorioamnionitis risk factors

A

invasive pre natal diagnosis
prolonged rupture of membranes
prolonged labour
repeat digital examination in context of ruptured membranes
nulliparity
meconium stained liquor

66
Q

MEOWs

A

maternity early obstetric warning system

67
Q

management chorioamnionitis

A

broad spectrum antibiotics
delivery
- IOL or LUSCs
- increase PPH risk - reduce with active 3rd stage syntocinon infusion
- avoid post partum intra-uterine contraception

68
Q

when should GBS antibiotic prophylaxis be given?

A

group b strep -> benzylpenicillin or clindamycin

GBS detected antenatally
previous baby has been affected by infection
delivery <37wks

69
Q

endometritis + risk factors

A

infection of uterine lining following delivery or miscarriage

  • operative delivery
  • prolonged labour
  • retained products of conception
70
Q

endometritis presentation

A
  • Foul smelling discharge pr lochia
  • Bleeding that gets heavier or does not improve with time
  • Lower abdominal or pelvic pain
  • Fever
  • sepsis
71
Q

endometritis diagnosis + management

A
  • 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

repro (33 decks)

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