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Obstetrics > Complications in Labour > Flashcards

Complications in Labour Flashcards

1
Q

What is primary post partum haemorrhage

A

Bleeding from the genital tract within 24 hours of the birth of a baby

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2
Q

What is secondary post partum haemorrhage

A

Bleeding from the genital tract 24 hours - 6 weeks after delivery

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3
Q

What volume of blood loss is classed as major PPH

A

<1000mls

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4
Q

Risk factors for PPH

A

Hx of PPH
Prologed labour
Polyhydramnios
Macrosomia
Sepsis
Low lying or morbidly adherent placenta
Multiple pregnancy
Bleeding disorders
Fibroids

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5
Q

Risk factors for PPH

A

Hx of PPH
Prologed labour
Polyhydramnios
Macrosomia
Sepsis
Low lying or morbidly adherent placenta
Multiple pregnancy
Bleeding disorders
Fibroids

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6
Q

What are the four T’s of causes of PPH

A

Tone (uterine anatomy)
Trauma
Tissue
Thrombin (coagulopathy)

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7
Q

Causes of PPH - Tone

A

Previous PPH
Uterine relaxants
Placenta praevia
Overdistention of uterus (multiple preg, polyhydramnios, macrosomia)
Porlonged uterotonics in labour
Grand mulitpara
Advanced maternal age

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8
Q

Causes of PPH - Trauma

A

C section
Episiotomy
Vagina, perineal or cervical trauma
Lacerations
Haematoma
Ruptures

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9
Q

Causes of PPH - Tissue

A

Retained placenta
Placenta accreta
Retained products of conception

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10
Q

Causes of PPH - thrombin

A

Amniotic fluid embolism
Use of anti-coagulants
Pre-eclampsia
Placental abruption
Pyrexia in labour
Bleeding or clotting disorders

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11
Q

Most common cause of PPH

A

Tone of uterus - 80%

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12
Q

General management of PPH in labour

A

A-E
IV access and bloods
IV fluids
Active management of third stage
Treat cause of bleeding

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13
Q

Management of PPH in labour - tone

A

Bimanual compression
Empty bladder
Uterotonics
Bakri balloon
Surgery

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14
Q

Management of PPH in labour - trauma

A

Repair perineum
Exam under anaesthesia
Repair lacerations
In caesareans repair uterine angle extensions

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15
Q

Management of PPH in labour - tissue

A

Manual removal of placenta/products

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16
Q

Management of PPH in labour - thrombin

A

Treat sepsis with abx
Reverse bleeding with FFP and clotting factors

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17
Q

Examples of uterotonics

A

Syntocinon
Synthometrine
Misoprostol
Haematbate
Tranexamic acid

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18
Q

Surgical options for treating PPH - tone

A

B lynch suture, internal iliac ligations, hysterectomy

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19
Q

Causes of secondary PPH

A

Infection
Retained products of conception

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20
Q

What is Sheehan’s syndrome

A

Rare complication of PPH where the drop in the circulating blood volume leads to avascular necrosis of the pituitary gland

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21
Q

Pathophysiology of Sheehan’s syndrome

A

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.

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22
Q

Presentation of Sheehan’s syndrome

A

Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH

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23
Q

Presentation of Sheehan’s syndrome

A

Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH

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23
Q

Presentation of Sheehan’s syndrome

A

Reduced lactation - prolactin
Amenorrhoea - LH and FSH
Adrenal insufficiency and adrenal crisis from low cortisol - ACTH
Hypothyroidism with low thyroid hormones - TSH

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24
Q

Management of Sheehans syndrome

A

Oestrogen and progesterone as HRT until menopause
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone

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25
Q

What is umbilical cord prolapse

A

When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after ROM

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26
Q

What is the danger around umbilical cord prolapse

A

The presenting part of the fetus can compress the cord which results in fetal hypoxia

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27
Q

Risk factors for umbilical cord prolapse

A

Fetus is an abnormal lie position after 37 weeks gestation - this provides space for cord to prolapse

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28
Q

Diagnosis of umbilical cord prolapse

A

Suspected when there are signs of fetal distress on the CTG. Diagnosed by vaginal examination.

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29
Q

Management of umbilical cord prolapse

A

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

30
Q

What is shoulder dystocia

A

Anterior shoulder of baby is stuck behind pubic symphysis of the pelvis after head has been delivered

31
Q

Risk factors for shoulder dystocia

A

Macrosomia secondary to gestational diabetes

32
Q

Presentation of shoulder dystocia

A

Difficulty delivering the face and head, obstruction in delivering shoulders, may be failure of restitution or turtle neck sign

33
Q

What is the turtle neck sign

A

Where the head is delivered but then retracts back into the vagina

34
Q

Options for management of shoulder dystocia

A

Episiotomy
McRoberts manoeuvre
Pressure to the anterior shoulder
Rubins manoeuvre
Wood screw manoeuvre
Zavanelli manoeuvre

35
Q

What is an episiotomy

A

Cut is made to enlarge the vaginal opening and reduce risk of perineal tears - not always necessary

36
Q

What is McRoberts manoeuvre

A

Mother’s hip is hyperflexed which provides posterior pelvic tilt, lifting pubic symphysis up and out of the way

37
Q

What does pressure to the anterior shoulder do in shoulder dystocia

A

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

38
Q

What is Rubin’s manoeuvre

A

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

39
Q

What is the Woodscrew manoeuvre

A

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

40
Q

What is the Zavanelli manoeuvre

A

Pushing the baby’s heda into the vagina to the baby can be delivered by caesarean

41
Q

Complications of shoulder dystocia

A

Fetal hypoxia
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

42
Q

Indications of using instruments during delivery

A

Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
Increased risk when epidural is in place

43
Q

Risks of using instruments during delivery

A

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

44
Q

Options for instrumental delivery

A

Ventouse suction cup or forceps

45
Q

When are perineal tears more common

A

First births, large babies over 4kg, shoulder dystocia, asian ethnicity, occipito-posterior position, instrumental deliveries

46
Q

What is involved in a first degree tear

A

Injury limited to frenulum of labia minora and superficial skin

47
Q

What happens in a second degree tear

A

Tear includes the perineal muscles but does not affect the anal sphincter

48
Q

What happens in a third degree tear

A

Includes the anal sphincter, but not the rectal mucosa, and is classified into A, B, C depending on % of anal sphincter affected

49
Q

What does a fourth degree tear

A

Includes the rectal mucosa

50
Q

Management of perineal tears

A

Broad spec antibiotics
Repair in theatre or sutures
Laxatives
Physiotherapy
Follow up

51
Q

Complications of perineal tears

A

Pain, infection, bleeding, wound dehiscence or breakdown

52
Q

What is chorioamniotitis

A

Infection of the chorioamniotic membranes and amniotic fluid

53
Q

Generalised symptoms of chorioamniotitis in pregnancy

A

Fever
Tachycardia
Raised resp rate
Altered consciousness
Hypotension
Reduced urine output
Raised WCC
Fetal compromise on CTG

54
Q

Specific symptoms of chorioamniotitis

A

Abdominal pain
Uterine tenderness
Vaginal discharge

55
Q

Management of chorioamniotitis

A

Continuous maternal and fetal monitoring
Sepsis six
Early delivery
GA and avoid spinal anaesthesia
Abx regimine

56
Q

What is an amniotic fluid embolism

A

Where the amniotic fluid passes into the mothers blood which usually occurs around labour and delivery

57
Q

Consequences of amniotic fluid embolism

A

Causes an immune reaction from the mother which leads to systemic illness. Rare but mortality 20%

58
Q

Consequences of amniotic fluid embolism

A

Causes an immune reaction from the mother which leads to systemic illness. Rare but mortality 20%

59
Q

Risk factors for amniotic fluid embolism

A

Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy

60
Q

Presentation of amniotic fluid embolism

A

SOB
Hypoxia
Haemorrhage
Hypotension
Coagulopathy
Tachycardia
Confusion
Seizures
Cardiac arrest

61
Q

Management of amniotic fluid embolism

A

Overall management is supportive including A-E and there are no specific treatments

62
Q

What is uterine rupture

A

When the myometrium ruptures during labour

63
Q

What defines an incomplete rupture

A

Uterine serosa (peritoneum) surrounding the uterus remains intact

64
Q

What defines a complete uterine rupture

A

Serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity

65
Q

Risk factors for uterine rupture

A

Previous caesarean
VBAC
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions

66
Q

Presentation of uterine rupture

A

Acutely unwell mother
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse

67
Q

Management of uterine rupture

A

Emegency caesarean
Stop bleeding and repair or remove uterus (hysterectomy)
Resus adn transfusion may be required

68
Q

What is uterine inversion

A

Fundus of uterus drops down through the uterine cavity and cervix turning the uterus inside out. Very rare

69
Q

What is an incomplete uterine inversion

A

Fundus descends inside the uterus or vagina but not as far as the introitus

70
Q

What is a complete uterine inversion

A

Involves uterus descending through vagina into introitus

71
Q

Presentation of uterine inversion

A

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

72
Q

Management of uterine inversion

A

Johnson manoeuvre
Hydrostatic methods
Surgery

Obstetrics (8 decks)

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