Complications of Labour Flashcards
What is shoulder dystocia?
Difficulty in labour when the head is delivered but the shoulders get stuck
Why is dystocia an issue?
When head is delivered the baby can inhale but the chest cannot expand as stuck in the pelvic brim
What are the causes of dystocia?
Un-coordinated uterine contractions
Small pelvic brim & inlet
Fetal position
What are the signs of dystocia?
Failure to restitute
Difficulty delivering the face
Failure of shoulders to descend
Turtle-neck sign: Head remaining tightly applied to the vulva/retracting
How is dystocia diagnosed?
Head delivered but extended time and shoulders still not delivered (5mins)
How is dystocia managed?
McRobert’s: Hyperflex & abducts hips against abdomen flattening lumbosacral angle & inc AP diameter of pelvis
Episiotomy
What are the main causes of a perineal tear?
Trauma (labour)
Vaginal delivery
Forceps delivery
Dystocia
How is a perineal tear managed?
Analgesia/ LA
1/2: Polyglactin continuous sutures
3/4: Monofilament suture material, 6-12week follow-up
What are the different degrees of perineal tears?
1st: Fourchette-perineal skin only
2nd: Posterior vaginal walls & perennial muscle
3rd: Injury to perineum involving anal sphincter
a: <50% external anal sphincter thickness torn
b: >50% thickness torn
c: Both external & internal sphincter torn
4th: Anal canal is opened and the tear may spread to the rectum (anal sphincter & epithelium)
What is placenta praevia?
The placenta is overlying the cervical os. It can be complete, partial, marginal, or low-lying.
How is placenta praevia caused?
Blastocyst implants in the lower uterine segment near the cervical os. Most cases are probably accidental and simply the result of normal variation in placentation
What are the signs & symptoms of placenta praevia?
Painless, intermittent, fresh vaginal bleeding
Soft, non-tender uterus
High head/malpresentation (placenta blocks birth canal)
CONTRAINDICATED: VAGINAL EXAM (cause massive bleed)
How is placenta praevia investigated?
USS with colour flow doppler at 20w repeated at 34w
FBC
Surgery: Cross-match
How is placenta praevia managed?
No labour: Monitor USS 28-32w, rest, corticosteroids <34weeks
Preterm Labour: Tocolytics (Terbutaline), corticosteroids, C-section
Full term: Elective C-section at 39weeks
Bleeding: Emergency C-section, CTG, FFP
What are the complications of placenta praevia?
Anaemia Prematurity C-Section complications IUGR Haemorrhage Abnormally adherent placenta
How is placenta praevia classified?
Complete: Covers entire internal os.
Partial: Covers portion of internal os.
Marginal: Edge lies within 2 cm of internal os.
Low-lying placenta: Edge lies within 2-3.5 cm of internal os.
Vasa praevia: Fetal vessels overlying cervical os.
Resolved praevia: Low-lying in early pregnancy that has migrated away from the os.
What is abruption?
The premature separation of a normally located placenta from the uterine wall that occurs before delivery of the fetus.
What are the causes of placental abruption?
Direct trauma
Indirect trauma (shearing)
Cocaine
Chronic inflammation
What are the signs & symptoms of abruption?
Vaginal bleeding Constant, severe Abdo/pelvic/back pain Uterus 'woody' (tonic contraction) Uterine tenderness & irritable Difficult to palpate fetal parts, loss of fetal movements Maternal shock
How is placental abruption investigated?
USS
CTG- fetal distress
Coag studies, Hb
Kleihauer-Betke test
What are the risk factors for abruption?
Cocaine use Chronic HTN Pre-eclampsia Smoking Trauma Multiple pregnancy Prev/FHx Chorioamnionitis
How is placental abruption managed?
Stabilise mother: Hb >100, Hot >30% CTG monitoring <34 weeks: Conservative, steroids Stable: Vaginal delivery Unstable/major bleed: Urgent C-Section
What are the complications of placental abruption?
IU death due to hypoxia DIC HypoV Shock IUGR Prematurity Neurological impairment of the neonate Surgical/anaesthetic risk
Define stillbirth
Death of a baby inutero after 24weeks
What are the causes of stillbirth?
Congenital abnormality Placental insufficiency Haemorrhage Obstetric complications Pre-eclampsia Placental abruption
How is a stillbirth managed?
IOL within 2-3days
Bereavement care
Registering a stillbirth
What are the baby blues?
First week after childbirth many women comment on feeling blue, down or depressed at a time when they expected to be happy
What is the pathophysiology of baby blues?
Related to hormonal changes that occur during pregnancy & again after a baby is born.
Produce chemical changes in the brain that result in depression
What is PPH?
Blood loss >500mls from the genital tract within 24hours of delivery
What is classed as a minor & major PPH?
Minor= <1000mls
Major=>1000mls
What are the causes of PPH?
UTERINE ATONY
Trauma
Retained placenta/clots
Thrombin (pre-existing/ acquired coagulopathy)
What are the RFs of PPH?
Placenta praevia Multiple pregnancy Antepartum haemorrhage IOL Pre-eclampsia Prev PPH C-Section
How is PPH investigated?
Bloods: Cross-match 4u, group &save, FBC, Coag Screen, U&E, LFTs
Obs: Pulse, BP, RR, Urine output, temp every 15mins
How is PPH managed?
MINOR: IV access (14G) Urgent bloods for: G&S, FBC, coagulation screen, including fibrinogen Obs: pulse, RR and BP every 15 minutes Start warmed crystalloid infusion.
MAJOR:
ABC assessment
Position the patient flat
Keep warm
Transfuse blood ASAP, if clinically required
Until blood is available, infuse up to 3.5L warmed clear fluids, initially 2L of warmed isotonic crystalloid
Further fluid resus can continue with additional isotonic crystalloid or colloid (succinylated gelatin)
What are complications of PPH?
DIC HypoV shock AKI ARDS Liver failure Death
What can be given as an infusion for cerebral protection <32weeks?
Magnesium Sulphate
What are the RFs for PP?
Older women
Smokers
Prev uterine surgery: LSCS, myomectomy, curettage
What is the presentation of someone with vasa praevia?
Small amount of blood loss <500ml- FETAL
Painless
CTG abnormalities (due to cervical dilatation & ROM)
How is vasa praevia managed?
Immediate C-Section
?Neonatal blood transfusion
What is the most likely diagnosis?
A primigravida is induced at term +14 w/ARM. No cord is seen in the cervix but heavily blood-stained liquor. The mother doesn’t complain of pain but the CTG shows significant abnormalities
Vasa Praevia
What are the RFs for uterine rupture?
Uterine surgery: LSCS, myomectomy
Excessive Oxytocin use
Obstructed labour
High parity
What are the signs & symptoms of uterine rupture?
Pain Vaginal bleeding Maternal shock Sudden termination of contractions CTG abnormalities (fetal distress) Fetus particularly easy to palpate on abdo exam
How is uterine rupture managed?
Laparotomy
Control maternal haemorrhage
How is PPH caused by uterine atony managed?
Treatments for major PPH along with: Bimanual uterine compression Empty bladder (Foley catheter) Oxytocin: 5u slow IV Ergometrine: 0.5mg slow IV/IM Oxytocin infusion (40 iu in 500 ml isotonic crystalloids Carboprost 0.25mg IM Misoprostol 800mcg sublingual Surgical: Balloon tamponade, haemostatic brace suturing, hysterectomy
