Complications Flashcards
Uterine inversion
Rare
May be due to mismanagement of third stage of labour - cord traction in an a tonic uterus and a fundal insertion of the placenta.
Reduce risk by abdo traction on uterus while pulling gently on cord.
May be completely revealed or partial when uterus still remains within the vagina.
Even without haemorrhage the mother may become profoundly shocked.
The ease with which the uterus is replaced depends on the amount of time elapsed since inversion, as a tight ring forms at the neck of the inversion.
- If noted early, before shock sets in, may be replaceable by hand.
- If later, rushed to theatre.
Amniotic fluid embolism
Presents with sudden dyspnoea and hypotension, sometimes seizures. Also DIC in 50%.
If survive initial collapse, 70% develop pulmonary oedema/acute resp distress syndrome.
20% mortality
An anaphylactic type of response to amniotic fluid in maternal circulation.
Presents often at end of first stage of labour or shortly after delivery but can complicate many pregnancy events eg amniocentesis, TOP, abruption, Caesarian.
Cases are few, should be reported to national amniotic fluid embolism register.
Retained placenta
The third stage of labour is considered delayed if not complete by:
- 30mins with active management
- 60mins with physiological management
The danger is haemorrhage.
Avoid excessive traction - cord may snap or uterus may invert. Check not in vagina or trapped by cervix, rub up a contraction.
May need to take to theatre to be removed manually.
Rarely, does not separate (placenta accreta) and hysterectomy needed.
Postpartum haemorrhage
Loss of greater than 500mls in the first 24hrs after delivery.
Occurs in 6% of deliveries, major PPH (>1L) in 1.3%.
Causes:
- uterine atony (90%)
- genital tract trauma (7%)
- clotting disorders (3%)
Death rate 2/yr in UK
Secondary PPH if excessive blood loss from genital tract after 24hrs from delivery.
- usually occurs from days 5-12
- usually due to retained placenta or clot
- secondary infection common
- if bleeding slight and no signs of infection, may be managed conservatively
- if heavier loss, suggestion of retained products on US, or tender uterus with open os, exploration required
Uterine rupture
Rare
Associated maternal mortality 5% and fetal mortality 30%
70% of ruptures in UK are due to dehiscence of Caesarian section scars (and less likely with lower section scars)
Other risk factors:
- obstructed labour in multiparous esp oxytocin used, prev cervical surgery, high forceps delivery, internal version, breech extraction.
Rupture usually (in third trimester or) in labour. Pain and PV bleed variable, suspect if sudden shock or disappearance of presenting part and contractions stop.
Take to theatre to deliver baby/ repair.
Vaginal birth after Caesarian section (trial of scar):
- successful in 72-76%
- following complications are more common than if had second elective Caesarian:
- endometritis
- need for blood transfusion
- uterine rupture
- perinatal death - mainly stillbirths at 39wks
- less neonatal resp problems
- 24-28% undergo repeat emergency section
Mendelson’s syndrome
Name given when inhale gastric acid during general anaesthesia.
Develop:
- cyanosis
- bronchospasm
- pulmonary oedema
- tachycardia
May be difficult to differentiate from amniotic fluid embolism or cardiac failure
Turn to one side, aspirate pharynx, aspirate bronchial tree using bronchoscope, give aminophylline and hydrocortisone and antibiotics.
Meconium stained liquor
In late pregnancy it is normal for some babies to pass Meconium (bowel contents) which stains the amniotic fluid a dull green. Not significant.
May be in response to stress of delivery or a sign of distress so transfer for monitoring just in case.
Aspiration of fresh Meconium can cause severe pneumonitis.
If light staining, observe babies for 2 hours.
If dark staining, observe for 12 hours.
Prolapsed cord
descent of cord brought the cervix (in presence of ruptured membranes)
- either alongside presenting part (occulta)
- or in front of next presenting part (overt)
Emergency -> cord compression causes fetal asphyxia
Incidence 0.1-0.6%, with speedy intervention neonatal deaths may be <10%
If noted prior to ROM, do Caesarian
If noted after ROM, try stop progression and push back in. Either deliver v quickly or do emergency section.
Fetal cord samples to exclude intrapartum hypoxia brain injury.
Fetal distress
Signifies hypoxia.
Prolonged or repeated hypoxia causes fetal acidosis.
Signs:
- passage of Meconium in labour (early sign)
- persistent fetal tachycardia
- loss of variability
- late decelerations
- if HR<100, urgent assessment required
Confirm hypoxia by fetal blood sampling from scalp blood.
Deliver promptly by fastest route.
Obstetric shock - 7 causes
Causes:
- severe haemorrhage
- ruptured uterus
- inverted uterus
- amniotic fluid embolus
- pulmonary embolism
- septicaemia
- adrenal haemorrhage
Usually associated with severe haemorrhage.
- with placental abruption bleeding may be in excess of what is revealed PV
Vomiting, diarrhoea, and abdo pain may be signs of genital sepsis.
DIC may develop
Causes of APH
Avoid PV examination - placenta praevia can bleed catastrophically.
Dangerous causes:
- placental abruption
- placenta praevia
- vasa praevia (baby may bleed to death)
Other uterine causes:
- circumvallate placenta
- placental sinuses
Lower genital tract causes:
- cervical polyps
- cervical erosions
- cervical carcinoma
- cirvicitis
- vaginitis
- vulval varicosities
7 features of placental abruption
- shock out of keeping with visible blood loss
- pain constant
- tender, tense uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
7 features of placenta praevia
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie and presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds before large
