complications of labour Flashcards
30 y/o women
SVD 4.4kg baby 70 mins ago
midwife-led unit
not yet passed placenta
EBL 700ml and ongoing PV loss
what is going on?
PPH
define PPH
> 500 mls in first 24 hours
- SVD > 500 ml
- operative vaginal delivery >750ml
- CS > 1000ml
major PPH >1000ml
what are the 4 main causes of PPH?
- Tone (uterine atony)
- Trauma (perineal tears, cervical tears)
- Tissue (placenta, fragment of placenta)
- Thrombin (coagulation problems)
PPH management?
- ABCDE
- people
- drugs
- other interventions - surgery…
what drugs can you give someone in management of PPH?
- uterotonics - synctocinon (oxytocin), ergametrine (IM can’t give to those w raised BP), carboprost, misoprostol, tranexamic acid (slows down bleeding)
what uterotonics are not recommended to those w asthma?
- carboprost
- misoprostol
> both prostaglandins
what are some surgical options for PPH?
- intrauterine balloon
- brace sutures - (stitch around uterus however requires laparotomy)
- interventional radiology - (block vessels off uterine artery or iliac balloons)
- hysterectomy
what are two types of management of 3rd stage of labour?
- physiological (up to 60 mins)
- active (up to 30 mins)
in physiological management of 3rd stage labour what happens?
- no uterotonics given
- placenta is delivered by maternal effort alone
what are the disadvantages to physiological management in the 3rd stage of labour?
- increased length of 3rd stage
- increased risk of PPH
- increased need for blood transfusion
what does active management in the 3rd stage of labour involve?
- uterotonics - synctocinon, ergmaetrine
- cord clamped
- controlled cord traction
what are the advantages to active mx in 3rd stage of labour?
- decreased PPH, decreased length of 3rd stage
what are the disadvantages to active mx in 3rd stage labour?
- nausea/vomiting
- risk of cord avulsion
- uterine inversion
what is morbidly adherent placenta?
- affects 1:7000 pregnancies
- more common if previous CS or uterine surgery
- can be undiagnosed until delivery
a normal placenta is separated from the uterine wall by what?
- by a fine fibrinous layer
what is a placenta accreta?
- where placenta attaches firmly to the uterine wall lining
what is placenta increta?
- placenta invades at least half way through uterine wall
what is placenta percreta?
- invasion through the uterine wall, sometimes into nearby tissues, like the bladder
what is uterine inversion?
- rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out
how common is a uterine inversion?
- very rare occurence
- however life-threatening obstetric emergency
what is an imcomplete uterine inversion?
- partial inversion, where fundus descends inside uterus or vagina but not as far as introitius (opening of the vagina)
- complete - descend to introitus
why can uterine inversion occur?
- pulling too hard on umbilical cord during active management of third stage of labour
how does uterine inversion present?
- presents w a large postpartum haemorrhage
- maternal shock or collapse
- an incomplete uterine inversion may be felt w manual vaginal examination
mx of uterine inversion?
- johnson manoeuvre -> using hand to push fundus back up into abdomen, done under GA
- hydrostatic methods
- surgery
what is one of the main complications of shoulder dystocia?
- brachial plexus injury
what are some antenatal risk factors for shoulder dystocia?
- previous shoulder dystocia, fetal macrosomia, diabetes, BMI > 30, short stature
what are some intrapartum risk factors for shoulder dystocia?
- slow 1st and/or 2nd stage labour, induction of labour, instrumental delivery
what are some other fetal complications of shoulder dystocia?
- hypoxia, fracture of clavicle/humerus, intracranial haemorrhage, death, brachial plexus injury
what are some maternal complications of shoulder dystocia for mum?
- PPH, genital tract trauma, pelvic injuries
what is mx for shoulder dystocia?
H - call for help
E - evaluate for episiotomy
L - legs: Roberts manoeuvre
P - external pressure: suprapubic
E - enter: rotational manoeuvre
R - remove the posterior arm
R - roll the patient to her hands and knees
what structures are involved in genital tract trauma in labour
- perineum
- anal sphincters
- cervix
- labial
- clitoral
what is 1st degree perineal tear?
- to perineal skin only
what is 2nd degree perineal tear?
- injury involving perineal skin and muscle but not anal sphincters
what is a 3rd degree perineal tear?
- injury involving anal sphincters
3A - <50% external anal sphincter
3B - >50% external anal sphincter
3C - involvement of both external and internal anal sphincter
what is 4th degree perineal tear?
- disruption of anal epithelium/mucosa
what are the 2 key causes of sepsis in pregnancies?
- chorioamnionitis
- urinary tract infections
what is chorioamnionitis?
- an infection of the chorioamniotic membranes and amniotic fluid
- leading cause of maternal sepsis
- usually occurs in later pregnancy and during labour
chorioamnionitis can be caused by a large variety of bacteria including?
- gram-positive bacteria
- gram-negative bacteria
- anaerobes
examples -> E. coli, mycoplasma, anaerobes, group B strep
how does chorioamnionitis present?
non-specific signs of sepsis e.g. fever, tachy, raised RR, reduced o2 stats, low bp, reduced UO, raised WCC, fetal compromise on CTG
specific signs - abdominal pain, uterine tenderness, vaginal discharge, offensive PV loss, fetal CTG concern.
chorioamnionitis: additional signs and symptoms related to a UTI include?
- dysuria
- urinary frequency
- suprapubic pain or discomfort
- renal angle pain (pyelonephritis)
- vomiting (pyelonephritis)
Ix for chorioamnionitis?
- FBC - WBCs and neutrophils
- U+Es - assess kidney function and for AKI
- LFTs - liver function, source of infection? (acute cholecystitis)
- CRP to assess inflammation
- clotting - assess for disseminated IV coagulopathy
- blood cultures - assess for bacteraemia
- blood gas - assess lactate, pH, glucose
additional ix for chorioamnionitis to find suspected source of infection?
- urine dip and culture
- high vaginal swab
- throat swab
- sputum culture
- wound swab after procedures
- lumbar puncture - men or encephalitis
Mx for sepsis and chorioamnionitis
- septic 6
- early delivery may be required - under GA as spinal anaesthesia avoided
- IV antibiotics - co-amox within golden hour +/- gentamicin depending on severity and clindamycin if sore throat (GAS)
- clinda and genta if pen allergeic
- taxocin, clinda and genta if septic shock
- keep sats above 94
- blood cultures
- fluid challenge
- lactate
- measure urine output
sources of postpartum sepsis?
- uterus (endometritis)
- skin/wound
- urine
- breasts (mastitis)
- chest
- other
risk factors for chorioamnionitis?
- invasive pre-natal diagnostics
- prolonged rupture of membranes
- prolonged labour
- repeat digital examinations in context of ruptured membranes
- nulliparity
- meconium stained liquour
if early delivery is mx for chorioamnionitis what kind of delivery is it?
- IOL
- LUSCS
> give syntocinon infusion for 3rd stage to reduce risk of PPH
avoid postpartum intrauterine contraception (PPIUC)
what are risks of group B strep in relation to neonatal sepsis, pneumonia and meningitis?
- common bacteria found in genital tract
- most babies have no problem when exposed to it
- however risks inc w pre-term labour or PROM (prelabour rupture of membranes)
recommendations for GBS mx
- no routine screening required
- offer intrapartum antibiotic prophylaxis (benzylpenicillin or clinda) if GBS detected antenatally, previous baby has been affected by GBS infection, delivery <37 weeks
what is endometritis?
- infection of uterine lining following delivery or miscarriage
what are risk factors for endometritis?
- operative delivery
- prolonged labour
- retained products of conception
how does endometritis present?
- typically presents w abdominal pain, abnormal PV bleeding, offensive PV loss
what is tx for endometritis?
- co-amoxiclav +/- surgical evacuation of uterus if sig RPOC (retained products of conception)
-> co-trimoxazole and metronidazole if pen allergic
what is mastitis?
- usually unilateral painful and inflamed breast in breastfeeding mothers
1st line mx for mastitis?
- ensuring breast emptying by feeding +/- expressing. warm compresses and NSAIDs
- may require flucloxacillin if not improving or signs of sepsis - clinda if pen allergic
if no response to antibiotics in a women w mastitis what is next line mx?
- refer to breast team for USS +/- drainage
as could indicate breast abscess
what is a rare complication of epidural abscess?
- sepsis
what is signs of sepsis in women who have an epidural abscess
- back pain or fever and potential for euro deficit as it progresses
dx for sepsis in women w epidural abscess
- MRI
tx for sepsis related to epidural abscess?
- vancomycin, metronidazole and cefotaxime to cover MRSA, anaerobes and gram -ve bacteria
- choice between open surgery vs CT guided aspiration to drain collection
