Delivery Flashcards
what are the three stages of labour?
First stage – from the onset of labour (true contractions) until 10cm cervical dilatation
Second stage – from 10cm cervical dilatation until delivery of the baby
Third stage – from delivery of the baby until delivery of the placenta
what does first stage involve
cervical dilation and effacement. the show (mucus plug in cervix, preventing bacteria from entering uterus) falls out, creating space for baby to pass through
the stages of the first stage
Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
what are braxton hicks contractions
NOT indicate labour
clinical fx of braxton hicks
occasional irregular contractions - mild cramping
in second or third trimester
do not progress or become regular
improve with hydration and relaxing
O/E onset of labour
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
latent first stage NICE guildelines
Painful contractions
Changes to the cervix, with effacement and dilation up to 4cm
established first stage of labour NICE guidelines
Regular, painful contractions
Dilatation of the cervix from 4cm onwards
rupture of membranes definition
amniotic sac ruptured
spontaneous rupture of memrbanes definition
amniotic sac ruptures spontaneously
prelabour rupture of memrbanes definition
amniotic sac ruptured before onset of labour
preterm prelabour rupture of membrnaes def
amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).
prolonged rupture of membranes def
The amniotic sac ruptures more than 18 hours before delivery.
prematurity def
<37 weeks gestation
when non viable
<23 weeks
WHO classification of prematurity
Under 28 weeks: extreme preterm
28 – 32 weeks: very preterm
32 – 37 weeks: moderate to late preterm
prophylaxis of preterm labour options
vaginal progesterone - decrease activity of myometrium and prevent cervix remodeeling
cervical cerclage - stitch in cervix to add support/keep closed, removed when enter labour, used in prev issues. ‘rescue’ version offered when cervical dilation with rupture of membranes
diagnosis of preterm prelabour rupture of membranes
examination - pooling of amniotic fluid in vagina
IGFBP-1 - protein in amniotic fluid, test of vaginal fluid
PAMG-1 - similar
mx of preterm prelabour rupture of membranes
prophylactic abx to prevent chorioamnionitis - erythromycin 250mg x4 a day for 10 days or until labour established, if within 10 days
induction of labour if >34 weeks offered
preterm labour with intact membranes diagnosis
<30 weeks - clinical assessment
>30 weeks - transvaginal USS to assess cervical length (<15mm)
fetal fibronectin - 50ng/ml
mx of preterm labour with intact membranes
Fetal monitoring (CTG or intermittent auscultation)
Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
tocolysis definition
using meds to stop uterine contractions
can be used between 24 and 33+6
tocolysis examples of meds
nifedipine - CCB
atosiban - oxytocin receptor antagonist (if nifedipine is c/i)
when give antenatal steroids
prevent ARDS
used in women with suspected preterm labour of babies less than 36 weeks gestation.
antenatal steroids dose
x2 doses IM betamethason, 24 hours apart
when give mag sulfate
protect foetal brain in prematurity
to reduce risk of cerebral palsy
mag sulfate dosing
given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth
close monitor for mg toxicity - obs and tendon reflexes
signs of mg toxicity
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
when induction of labour offered
41-42 weeks gestation
or when beneficial to start labour early ->
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
scoring system used to determine whether to induce labour
Bishop score
bishop score
Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)
8 or more - successful induction of labour, otherwise ripening required
options for inducing labour
membrane sweep - insert finger into cervix to stimulate, if >40 weeks
vaginal prostaglandin E2 (dinoprostone) - gel/tablet/pessary
cervical ripening balloon - alternative to vaginal prostaglandins, or in prev caesarean or para>3
oxytocin infusion - artificial rupture of membranes, after vaginal prostagladins or alternative
oral mifepristone (anti-progesterone) plus misoprostol - where IUFD has occured
monitors used during induction of labour
Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
Bishop score before and during induction of labour to monitor the progress
when slow progression (>24 hours) of labour options
Further vaginal prostaglandins
Artificial rupture of membranes and oxytocin infusion
Cervical ripening balloon (CRB)
Elective caesarean section
main complication of using vaginal prostaglandins
UTERINE HYPERSTIMULATION - contraction of uterus if prolonged and frequent…
Fetal compromise, with hypoxia and acidosis
Emergency caesarean section
Uterine rupture
criteria for uterine hyperstimulation
Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes
mx of uterine hyperstimulation
Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline
cardiotocography use
to measure the fetal heart rate and the contractions of the uterus
how get CTG readout
One above the fetal heart to monitor the fetal heartbeat using doppler
One near the fundus of the uterus to monitor the uterine contractions by assessing tension in wall
indications for continuous CTG monitoring
Sepsis
Maternal tachycardia (> 120)
Significant meconium
Pre-eclampsia (particularly blood pressure > 160 / 110)
Fresh antepartum haemorrhage
Delay in labour
Use of oxytocin
Disproportionate maternal pain
key fx of CTG monitoring
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – the baseline fetal heart rate
Variability – how the fetal heart rate varies up and down around the baseline
Accelerations – periods where the fetal heart rate spikes(good sign, esp with uterine contractions)
Decelerations – periods where the fetal heart rate drops (concerning)
baseline heart rate NICE guidelines interpretation
reassuring - 110-160, with 5-25 variability
non reassuring - 100-109 or 161-180, with <5 for 30-50mins or >25 for 15-25mins
abnormal - <100 or >180, with <5 for >50 mins, >25 for >25 mins variability
why does foetal HR drop
in response to hypoxia
4 types of decelerations
Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations
early decelerations
gradual dips and recoveries
correspond with uterine contractions
not pathological
caused by uterus compressing head of fetus, stimulating vagus nerve
late decelerations
gradual falls in HR start after uterine contractions had already begun
The lowest point of the declaration occurs after the peak of the contraction. Late decelerations are caused by hypoxia in the fetus, and are more concerning
causes include excessive uterine contractions, maternal hypotension or maternal hypoxia
variable decelerations
abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.
prolonged decelerations
last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are always abnormal and concerning.
mx based off what aspect of CTG
Baseline rate
Variability
Decelerations
4 catergories of outcomes from CTG
Normal
Suspicious: a single non-reassuring feature
Pathological: two non-reassuring features or a single abnormal feature
Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes
mx following outcome of CTG
Escalating to a senior midwife and obstetrician
Further assessment for possible causes, such as uterine hyperstimulation, maternal hypotension and cord prolapse
Conservative interventions such as repositioning the mother or giving IV fluids for hypotension
Fetal scalp stimulation (an acceleration in response to stimulation is a reassuring sign)
Fetal scalp blood sampling to test for fetal acidosis
Delivery of the baby
rule of 3’s for fetal bradycardia
3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)
what is a sinusoidal CTG
rare pattern
severe fetal compromise, eg: severe anaemia
sine wave- smooth regular waves up and down that have an amplitude of 5 – 15 bpm
mneumonic for fx of CTG
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
oxytocin mechanism and indications
ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding.
infusions of oxytocin indications
Induce labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage
oxytocin AKA
brand name - syntocinon
atosiban mechanism
oxytocin receptor antagonist
atosiban indication
alternative to nifedipine for tocolysis in premature labour (when nifedipine is contraindicated).
ergometrine mechanism
stimulates smooth muscle contraction in uterus and blood vessles
ergometrine indications
delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. It is only used after delivery of the baby, not in the first or second stage.
ergometrine s/e
HTN
N+V
diarrhoea
angina
ergometrine c/i
eclampsia
HTN patients
syntometrine what and use
a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.
prostaglandins mechanism
stimulating contraction of uterine muscles
ripening cervix
prostaglandins example
dinoprostone-
Vaginal pessaries (Propess)
Vaginal tablets (Prostin tablets)
Vaginal gel (Prostin gel)
dinoprostone use
induction of labour
what drug is generally avoided in pregnancy
NSAIDS- inhibit prostaglandins
increasing BP
misoprostol mechanism
prostaglandin analogue
misoprostol uses
medical mx in miscarriage
used alongside mifepristone for abortions, and induction of labour after intrauterine fetal death.
mifepristone mechanism
anti-progestogen…blocks action of progesterone…ripening cervix and enhances effects of prostaglandins to stimulate uterine contraction
mifepristone uses
used alongside misoprostol for abortions, and induction of labour after intrauterine fetal death. It is not used during pregnancy with a healthy living fetus.
nifedipine mechanism
CCB - reduce smooth muscle contraction in blood vessels and uterus
nifedipine uses
Reduce blood pressure in hypertension and pre-eclampsia
Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour
terbutaline mechanism
beta-2 agonist - acts on smooth muscle of uterus to suppress uterine contractions
terbutaline uses
tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour
carboprost mechanism
sythetic prostaglandin analogue - stimulates uterine contraction
carboprost uses
IM injection in PPH where ergometrine and oxytocin not worked
carboprost c/i
asthma
tranexamic acid mechanism
antifibrinolytic - binds to plasminogen and prevents converting to plasmin…so not dissolve fibrin ….so prevent breakdown of clots
tranexamic acid sues
preventing and tx of PPH
Progress in labour influences
3P’s
Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)
and PSYCHE
classification of delay in first stage of labour
Less than 2cm of cervical dilatation in 4 hours
Slowing of progress in a multiparous women
how monitored for progression in their first stage
partogram
what is recorded on a partogram
Cervical dilatation (measured by a 4-hourly vaginal examination)
Descent of the fetal head (in relation to the ischial spines)
Maternal pulse, blood pressure, temperature and urine output
Fetal heart rate
Frequency of contractions
Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium
Drugs and fluids that have been given
how are uterine contractions measured
contractions per 10 minutes. When the midwife says “she is contracting 2 in 10”, it means she is having 2 uterine contractions in a 10 minute period.
what indicates on partogram that labour is not progressing
These are labelled “alert” and “action”. The dilation of the cervix is plotted against the duration of labour (time). When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines.
indication for amniotomy
crossing the alert lines
if cross action line - escalate
second stage influencing fx
“the three Ps”: power, passenger and passage
delay in second stage (pushing) classification
2 hours in a nulliparous woman
1 hour in a multiparous woman
how power affects delivery
uterine contractions - if poor - oxytocin infusion
what does passenger refer to
SIZE
ALTITIUDE
LIE
PRESENTATION
altitude def
the posture of the fetus. For example, how the back is rounded and how the head and limbs are flexed.
lie def
refers to the position of the fetus in relation to the mother’s body:
Longitudinal lie – the fetus is straight up and down
Transverse lie – the fetus is straight side to side
Oblique lie – the fetus is at an angle
presentation def
refers to the part of the fetus closest to the cervix:
Cephalic presentation – the head is first
Shoulder presentation – the shoulder is first
Breech presentation – the legs are first. This can be:
Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)
Frank breech – with hips flexed and knees extended, bottom first
Footling breech – with a foot hanging through the cervix
passage
size and shape of passeway
PELVIS
intervention to aid prolonged delivery in second stage
Changing positions
Encouragement
Analgesia
Oxytocin
Episiotomy
Instrumental delivery
Caesarean section
delay in 3rd stage classification
More than 30 minutes with active management
More than 60 minutes with physiological management
active mx of third stage delay
IM oxytocin
controlled cord traction
mx of failure to progress
Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section
non medical mx of pain during labour
Understanding what to expect
Having good support
Being in a relaxed environment
Changing position to stay comfortable
Controlled breathing
Water births may help some women
TENS machines may be useful in the early stages of labour
simple analgesia - types and when use
early labour - paracetamol and codeine
gas and air - when use, what, how
mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief. The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases.
s/e of gas and air
lightheadedness, nausea, sleepiness
pethidine and diamorphine when use, s/e
opioid medications, usually given by intramuscular injection. They may help with anxiety and distress. They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult
PCA during labour
intravenous remifentanil
requires input from anaesthetist
s/e - resp depression (require naloxone), bradycardia (require atropine)
epidural what involved
inserting a small tube (catheter) into the epidural space in the lower back. This is outside the dura mater, separate from the spinal cord and CSF. Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord,
options for epidural
levobupivacaine or bupivacaine, usually mixed with fentanyl.
s/e of epidural
Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
when urgent review post epidural
signicant motor weakness - can not straight leg raise
maybe in subarachnoid space rather than epidural
cord prolapse definition
when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
most significant risk fx for cord prolapse
fetus in abnormal lie after 37 weekes gestation
provides space for cord to prolapse below presenting part
diagnosis of umbilical cord prolapse
CTG - foetal distress
definitive - vaginal exam with speculum
mx of cord prolapse
emergency caesarean section
cord should be kept warm and wet and have minimal handling whilst waiting for delivery (causes vasospasm)
woman lies in left lateral position or knee chest position on all fours - draws foetus away from pelvis and reduce compression
tocolytic meds to minimise contractions until caesarean
shoulder dystocia definition
OBSTETRIC EMERGENCY
when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered
strongest risk fx for shoulder dystocia
macrosomia secondary to gestational diabetes
how does shoulder dytocia present
difficult delivering head and face
failure of restitution - head remain face downwards not turn sideways as expected
turtle-neck sign - head is delivered but retracts back into vagina
mx of shoulder dystocia
EMERGENCY
ask for help - anaesthetics and paeds, midwifes and obs
episiotomy - enlarge vaginal opening
mcrobert’s manoeuvre - hyperflexion of mother at hip bringing knees to abdomen…posterior pelvic tilt lifting pubic symphtsis
pressure to anterior shoulder - pressing on suprapubic so puts pressure on baby’s anterior shoulder
rubins manoeuvre - reaching into vagina nad put pressure on posterior aspect of anterior shoulder
wood’s screw manoeuvre - during rubins, other hand is used to put pressure on anterior aspect of posterior shoulder, top shoulder pushed forward and bottom backwards, rotating baby
zavanelli manoeuver - pushing baby’s head back into vagine so delivered by caesarean
key complications of shoulder dystocia
Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
instrumental delivery definition
refers to a vagina delivery assisted by either a ventouse suction cup or forceps.
what given post instrumental delivery
single dose of co-amoxiclav
indications of instrumental delivery
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in various fetal positions
risk fx for instrumental delivery
epidural given
risks to mother instrumental delivery
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)
risks to baby instrumental delivery
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
other:
Subgaleal haemorrhage (most dangerous)
Intracranial haemorrhage
Skull fracture
Spinal cord injury
how does ventouse work
suction cup on cord, placed on baby’s head and careful traction to cord to help pull baby out
how forceps work
grip the head to apply careful traction and pull head from vagina
most likely nerves affected by instrumental delivery
femoral - weakness of knee extension, loss of patellar reflex and numbness to anterior thigh and medial lower leg
obturator - weakness of hip abduction, rotation and numbness of medial thigh
nerve injuries in birth, not necessarily instrumental delivery
Lateral cutaneous nerve of the thigh
Lumbosacral plexus
Common peroneal nerve
perineal tear definition
where the external vaginal opening is too narrow to accommodate the baby. This leads to the skin and tissues in that area tearing as the baby’s head passes.
risk fx for perineal tears
First births (nulliparity)
Large babies (over 4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental deliveries
classification of perineal tears
First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
Second-degree – including the perineal muscles, but not affecting the anal sphincter
Third-degree – including the anal sphincter, but not affecting the rectal mucosa
Fourth-degree – including the rectal mucosa
third degree tears subclassification
3A – less than 50% of the external anal sphincter affected
3B – more than 50% of the external anal sphincter affected
3C – external and internal anal sphincter affected
mx of perineal tears
first degree - not require sutures
larger - sutures
3rd or 4th - repairing in theatre
post perineal tear measures
Broad-spectrum antibiotics to reduce the risk of infection
Laxatives to reduce the risk of constipation and wound dehiscence
Physiotherapy to reduce the risk and severity of incontinence
Followup to monitor for longstanding complications
if sx following perineal tear, next pregnancy
elective caesarean
short term complications of perineal tear
Pain
Infection
Bleeding
Wound dehiscence or wound breakdown
long term complications of perineal tear
Urinary incontinence
Anal incontinence and altered bowel habit (third and fourth-degree tears)
Fistula between the vagina and bowel (rare)
Sexual dysfunction and dyspareunia (painful sex)
Psychological and mental health consequences
type of episiotomy to prevent perineal tear
mediolateral - avoid anal sphincter
perineal massage
used to reduce risk of perineal tear
massage skin and tissues between vagina and anus
mx of third stage of delivery
physiological - maternal effort
active - IM oxytocin and careful traction to umbilical cord –> decreased risk of bleeding but has N+V
steps post delivery
The cord is clamped and cut within 5 minutes of birth. There should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).
The abdomen is palpated to assess for a uterine contraction before delivery of the placenta. Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance. At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse. The aim is to deliver the placenta in one piece.
After delivery the uterus is massaged until it is contracted and firm. The placenta is examined to ensure it is complete and no tissue remains in the uterus.
definition of PPH
efers to bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death
classification of PPH
500ml after a vaginal delivery
1000ml after a caesarean section
It can be classified as:
Minor PPH – under 1000ml blood loss
Major PPH – over 1000ml blood loss
Major PPH can be further sub-classified as:
Moderate PPH – 1000 – 2000ml blood loss
Severe PPH – over 2000ml blood loss
primary v secondary PPH
Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birt
causes of PPH
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
risk fx for PPH
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in the second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear
how reduce risks and complications of PPH
Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
mx of PPH
OBSTETRIC EMERGENCY
Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
may require major haemorrhage protocol
mechanical tx of stopping bleeding
Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
Catheterisation (bladder distention prevents uterus contraction
medical tx of bleeding in PPH
Oxytocin (slow injection followed by continuous infusion) - 40 units in 500mls
Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
surgical tx of bleeding in PPH
Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
B-Lynch suture – putting a suture around the uterus to compress it
Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
secondary PPH definition
where bleeding occurs from 24 hours to 12 weeks postpartum
secondary PPH causes
due to retained products of conception (RPOC) or infection (i.e. endometritis).
ix for secondary PPH
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection
mx of secondary PPH
Management depends on the cause:
Surgical evaluation of retained products of conception
Antibiotics for infection
elective caesarean how work
spinal
after 39 weeks gestation
indications for elective caesarean
Previous caesarean
Symptomatic after a previous significant perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer
4 catergories of emergency caesarean
Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.
Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.
Category 3: Delivery is required, but mother and baby are stable.
Category 4: This is an elective caesarean, as described above.
skin incision caesarean
transverse lower uterine segment incision
2 possible ones -
Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis
Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)
what performed post incision in caesarean
Blunt dissection is used, after the initial incision with a scalpel, to separate the remaining layers of the abdominal wall and uterus. Blunt dissection involves using fingers, blunt instruments and traction to tear the tissues apart, rather than to cut them with sharp tools such as a scalpel. This results in less bleeding, shorter operating times and less risk of injury to the baby.
layers of abdomen required to be dissected
Skin
Subcutaneous tissue
Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles)
Rectus abdominis muscles (separated vertically)
Peritoneum
Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap
Uterus (perimetrium, myometrium and endometrium)
Amniotic sac
how stitch up caesarean
The uterus is closed inside the abdomen using two layers of sutures. Exteriorisation (taking the uterus out of the abdomen) is avoided if possible. The abdomen and skin are then closed.
risks associated with different types of anaesthetic
Allergic reactions or anaphylaxis
Hypotension
Headache
Urinary retention
Nerve damage (spinal anaesthetic)
Haematoma (spinal anaesthetic)
Sore throat (general anaesthetic)
Damage to the teeth or mouth (general anaesthetic)
complications of elective caesarean
Generic surgical risks:
Bleeding
Infection
Pain
Venous thromboembolism
Complications in the postpartum period:
Postpartum haemorrhage
Wound infection
Wound dehiscence
Endometritis
Damage to local structures:
Ureter
Bladder
Bowel
Blood vessels
Effects on the abdominal organs:
Ileus
Adhesions
Hernias
measures to reduce risks during caesarean
H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure
Prophylactic antibiotics during the procedure to reduce the risk of infection
Oxytocin during the procedure to reduce the risk of postpartum haemorrhage
Venous thromboembolism (VTE) prophylaxis
risk of …. during caesarean section to mother
aspiration pneumonitis - so PPi given before
effects of caesarean on future pregnancies
Increased risk of repeat caesarean
Increased risk of uterine rupture
Increased risk of placenta praevia
Increased risk of stillbirth
effects of caesarean on baby
Risk of lacerations (about 2%)
Increased incidence of transient tachypnoea of the newborn
c/i of vaginal birth after caesarean
Previous uterine rupture
Classical caesarean scar (a vertical incision)
Other usual contraindications to vaginal delivery (e.g. placenta praevia)
2 key causes of sepsis in pregnancy
Chorioamnionitis
Urinary tract infections
how sepsis screened for
MEOWS - maternal early obstetric warning system
signs of sepsis
Fever
Tachycardia
Raised respiratory rate (often an early sign)
Reduced oxygen saturations
Low blood pressure
Altered consciousness
Reduced urine output
Raised white blood cells on a full blood count
Evidence of fetal compromise on a CTG
additional signs in chorioamnionitis
Abdominal pain
Uterine tenderness
Vaginal discharge
ix for sepsis
Full blood count to assess cell count including white cells and neutrophils
U&Es to assess kidney function and for acute kidney injury
LFTs to assess liver function and as a possible source of infection (e.g. acute cholecystitis)
CRP to assess inflammation
Clotting to assess for disseminated intravascular coagulopathy (DIC)
Blood cultures to assess for bacteraemia
Blood gas to assess lactate, pH and glucose
mx of sepsis in pregnancy
sepsis 6
Example regimes include piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin.
continous maternal and fetal monitoring
emergency caesarean if fetal distress with general anaesthesia
amniotic fluid embolism
when amniotic fluid passes into mother’s blood
he amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism.
risk fx for amniotic fluid embolus
Increasing maternal age
Induction of labour
Caesarean section
Multiple pregnancy
clinical fx of amniotic fluid embolism
Shortness of breath
Hypoxia
Hypotension
Coagulopathy
Haemorrhage
Tachycardia
Confusion
Seizures
Cardiac arrest
mx of amniotic fluid smbolus
MEDICAL EMERGENCY
seek help and ICU
A-E
supportive tx
what is uterine rupture
a complication of labour, where the muscle layer of the uterus (myometrium) ruptures
2 types of uterine ruptureq
an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
risk fx for uterine rupture
PREV CAESAREAN - scar on uterus becomes point of weakness and rupture
Vaginal birth after caesarean (VBAC)
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
clinical fx of uterine rupture
unwell and abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardia
Collapse
mx of uterine rupture
OBSTETRIC EMERGENCY
resus and transfusion - bleeding
caesarean
may need to remove uterus to stop bleeding
uterine inversion what
where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out
2 types of uterine inversion
Incomplete uterine inversion (partial inversion) is where the fundus descends inside the uterus or vagina, but not as far as the introitus (opening of the vagina). Complete uterine inversion involves the uterus descending through the vagina to the introitus.
a cause of uterin inversion
result of pulling too hard on the umbilical cord during active management of the third stage of labour
clinical fx of uterine inversion
PPH - maternal shock or collapse
An incomplete uterine inversion may be felt with manual vaginal examination. With a complete uterine inversion, the uterus may be seen at the introitus of the vagina.
mx for uterine inversion
Johnson manoeuvre - hand to push fundus back up into abdomen and held for a few mins and oxytocinm if fails….
Hydrostatic methods - filling vagina to inflate uterus bakck to normal position, if fails…
Surgery - laparotomy and uterus returned to normal position
