Complications in Labour Flashcards
What is primary post partum haemorrhage
Bleeding from the genital tract within 24 hours of the birth of a baby
What is secondary post partum haemorrhage
Bleeding from the genital tract 24 hours - 6 weeks after delivery
What volume of blood loss is classed as major PPH
<1000mls
Risk factors for PPH
Hx of PPH
Prologed labour
Polyhydramnios
Macrosomia
Sepsis
Low lying or morbidly adherent placenta
Multiple pregnancy
Bleeding disorders
Fibroids
Risk factors for PPH
Hx of PPH
Prologed labour
Polyhydramnios
Macrosomia
Sepsis
Low lying or morbidly adherent placenta
Multiple pregnancy
Bleeding disorders
Fibroids
What are the four T’s of causes of PPH
Tone (uterine anatomy)
Trauma
Tissue
Thrombin (coagulopathy)
Causes of PPH - Tone
Previous PPH
Uterine relaxants
Placenta praevia
Overdistention of uterus (multiple preg, polyhydramnios, macrosomia)
Porlonged uterotonics in labour
Grand mulitpara
Advanced maternal age
Causes of PPH - Trauma
C section
Episiotomy
Vagina, perineal or cervical trauma
Lacerations
Haematoma
Ruptures
Causes of PPH - Tissue
Retained placenta
Placenta accreta
Retained products of conception
Causes of PPH - thrombin
Amniotic fluid embolism
Use of anti-coagulants
Pre-eclampsia
Placental abruption
Pyrexia in labour
Bleeding or clotting disorders
Most common cause of PPH
Tone of uterus - 80%
General management of PPH in labour
A-E
IV access and bloods
IV fluids
Active management of third stage
Treat cause of bleeding
Management of PPH in labour - tone
Bimanual compression
Empty bladder
Uterotonics
Bakri balloon
Surgery
Management of PPH in labour - trauma
Repair perineum
Exam under anaesthesia
Repair lacerations
In caesareans repair uterine angle extensions
Management of PPH in labour - tissue
Manual removal of placenta/products
Management of PPH in labour - thrombin
Treat sepsis with abx
Reverse bleeding with FFP and clotting factors
Examples of uterotonics
Syntocinon
Synthometrine
Misoprostol
Haematbate
Tranexamic acid
Surgical options for treating PPH - tone
B lynch suture, internal iliac ligations, hysterectomy
Causes of secondary PPH
Infection
Retained products of conception
What is Sheehan’s syndrome
Rare complication of PPH where the drop in the circulating blood volume leads to avascular necrosis of the pituitary gland
Pathophysiology of Sheehan’s syndrome
Low BP and reduced perfusion to the pituitary gland leads to ischaemia of the cells in the pituitary. This affects only the anterior pituitary due to differing blood supplies.
Presentation of Sheehan’s syndrome
Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH
Presentation of Sheehan’s syndrome
Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH
Presentation of Sheehan’s syndrome
Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH
Management of Sheehans syndrome
Oestrogen and progesterone as HRT until menopause
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone
What is umbilical cord prolapse
When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after ROM
What is the danger around umbilical cord prolapse
The presenting part of the fetus can compress the cord which results in fetal hypoxia
Risk factors for umbilical cord prolapse
Fetus is an abnormal lie position after 37 weeks gestation - this provides space for cord to prolapse
Diagnosis of umbilical cord prolapse
Suspected when there are signs of fetal distress on the CTG. Diagnosed by vaginal examination.
Management of umbilical cord prolapse
Emergency caesarean
Cord should be kept warm and wet while waiting for delivery
Push presenting part of the fetus back up to prevent compression of cord
Woman can lie in left lateral position or knee chest position
Tocolytic medication
What is shoulder dystocia
Anterior shoulder of baby is stuck behind pubic symphysis of the pelvis after head has been delivered
Risk factors for shoulder dystocia
Macrosomia secondary to gestational diabetes
Presentation of shoulder dystocia
Difficulty delivering the face and head, obstruction in delivering shoulders, may be failure of restitution or turtle neck sign
What is the turtle neck sign
Where the head is delivered but then retracts back into the vagina
Options for management of shoulder dystocia
Episiotomy
McRoberts manoeuvre
Pressure to the anterior shoulder
Rubins manoeuvre
Wood screw manoeuvre
Zavanelli manoeuvre
What is an episiotomy
Cut is made to enlarge the vaginal opening and reduce risk of perineal tears - not always necessary
What is McRoberts manoeuvre
Mother’s hip is hyperflexed which provides posterior pelvic tilt, lifting pubic symphysis up and out of the way
What does pressure to the anterior shoulder do in shoulder dystocia
Pressure is applied on the suprapubic region of the abdomen which puts pressure on the posterior aspect of the baby’s anterior shoulder. This encourages it down and under pubic symphysis
What is Rubin’s manoeuvre
Reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis
What is the Woodscrew manoeuvre
Performed during Rubin’s manoeuvre where the other hand is used to reach inside the vagina to put pressure on the anterior aspect of the posterior shoulder. So the top shoulder is pushed forward and the bottom shoulder is pushed backward to rotate the baby and help delivery
What is the Zavanelli manoeuvre
Pushing the baby’s heda into the vagina to the baby can be delivered by caesarean
Complications of shoulder dystocia
Fetal hypoxia
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
Indications of using instruments during delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
Increased risk when epidural is in place
Risks of using instruments during delivery
PPH
Episiotomy
Perineal tears
Injury to anal sphincter
Incontinence of bladder or bowel
Nerve injury - femoral or obturator
Cephalohaematoma
Facial nerve palsy
Subgleal haemorrhage, intracranial haemorrhage, skull fracture and spinal cord injury are serious risks to baby
Options for instrumental delivery
Ventouse suction cup or forceps
When are perineal tears more common
First births, large babies over 4kg, shoulder dystocia, asian ethnicity, occipito-posterior position, instrumental deliveries
What is involved in a first degree tear
Injury limited to frenulum of labia minora and superficial skin
What happens in a second degree tear
Tear includes the perineal muscles but does not affect the anal sphincter
What happens in a third degree tear
Includes the anal sphincter, but not the rectal mucosa, and is classified into A, B, C depending on % of anal sphincter affected
What does a fourth degree tear
Includes the rectal mucosa
Management of perineal tears
Broad spec antibiotics
Repair in theatre or sutures
Laxatives
Physiotherapy
Follow up
Complications of perineal tears
Pain, infection, bleeding, wound dehiscence or breakdown
What is chorioamniotitis
Infection of the chorioamniotic membranes and amniotic fluid
Generalised symptoms of chorioamniotitis in pregnancy
Fever
Tachycardia
Raised resp rate
Altered consciousness
Hypotension
Reduced urine output
Raised WCC
Fetal compromise on CTG
Specific symptoms of chorioamniotitis
Abdominal pain
Uterine tenderness
Vaginal discharge
Management of chorioamniotitis
Continuous maternal and fetal monitoring
Sepsis six
Early delivery
GA and avoid spinal anaesthesia
Abx regimine
What is an amniotic fluid embolism
Where the amniotic fluid passes into the mothers blood which usually occurs around labour and delivery
Consequences of amniotic fluid embolism
Causes an immune reaction from the mother which leads to systemic illness. Rare but mortality 20%
Consequences of amniotic fluid embolism
Causes an immune reaction from the mother which leads to systemic illness. Rare but mortality 20%
Risk factors for amniotic fluid embolism
Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy
Presentation of amniotic fluid embolism
SOB
Hypoxia
Haemorrhage
Hypotension
Coagulopathy
Tachycardia
Confusion
Seizures
Cardiac arrest
Management of amniotic fluid embolism
Overall management is supportive including A-E and there are no specific treatments
What is uterine rupture
When the myometrium ruptures during labour
What defines an incomplete rupture
Uterine serosa (peritoneum) surrounding the uterus remains intact
What defines a complete uterine rupture
Serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity
Risk factors for uterine rupture
Previous caesarean
VBAC
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
Presentation of uterine rupture
Acutely unwell mother
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
Management of uterine rupture
Emegency caesarean
Stop bleeding and repair or remove uterus (hysterectomy)
Resus adn transfusion may be required
What is uterine inversion
Fundus of uterus drops down through the uterine cavity and cervix turning the uterus inside out. Very rare
What is an incomplete uterine inversion
Fundus descends inside the uterus or vagina but not as far as the introitus
What is a complete uterine inversion
Involves uterus descending through vagina into introitus
Presentation of uterine inversion
Large PPH
Maternal shock or collapse
Incomplete may be felt with manual vaginal exam
Complete may see the uterus as the introitus of the vagina
Management of uterine inversion
Johnson manoeuvre
Hydrostatic methods
Surgery
