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Obs & Gynae > Delivery methods and complications > Flashcards

Delivery methods and complications Flashcards

1
Q

What 2 instruments can be used to assist delivery?

A

Ventouse suction cup

Forceps

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2
Q

Which part of the baby does instrumental delivery aim to assist in delivering?

A

The baby’s head

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3
Q

What medication is used prophylactically after instrumental delivery to reduce the risk of maternal infection?

A

Co-amoxiclav - single dose

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4
Q

What are key indications to perform an instrumental delivery?

A

Failure to progress
Fetal distress
Maternal exhaustion
Control of head in various fetal positions

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5
Q

There is an increased risk of requiring an instrumental delivery when an _______ is in place for analgesia

A

Epidural

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6
Q

What are risks to the mother of having an instrumental delivery?

A 
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to anal sphincter
Incontinence bowel/bladder
Nerve injury (obturator/femoral nerve)
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7
Q

What are key risks to the baby with ventouse and with forceps?

A

Ventouse - cephalohaematoma

Forceps - facial nerve palsy

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8
Q

What are serious risks to the baby if instrumental delivery goes wrong?

A

Subgaleal haemorrhage *most dangerous
Intracranial haemorrhage
Skull fracture
Spinal cord injury

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9
Q

How does ventouse delivery work?

A

Suction cup goes on baby’s head and is pulled from vagina

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10
Q

How does forceps delivery work?

A

Tongs go either side of baby’s head and grip head to pull from vagina

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11
Q

Which nerves can be affected by instrumental delivery? (List 5)

A 
Femoral nerve
Obturator nerve
Lateral cutaneous Nerve of the thigh
Lumbosacral plexus
Common peroneal nerve
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12
Q

What are the two broad types of C-section?

A

Emergency

Elective

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13
Q

What anaesthetic is used for an elective C-section?

A

Spinal anaesthetic - lidocaine

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14
Q

When are elective C-sections usually performed?

A

39 weeks gestation

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15
Q

What are indications for elective C-sections?

A 
Previous C-section
Symptomatic after previous significant perineal tear
Placenta praevia
Vasa praevia
Breech presentation
Multiple pregnancy
Uncontrolled HIV infection
Cervical cancer
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16
Q

What are the 4 main categories of emergency C-section?

A

Cat 1. Immediate thereat to life of mother/baby. (Decision -> delivery time = 30 min)

Cat 2. - No imminent threat to life but C-section required urgently due to compromise of mother/baby. (Decision -> delivery time = 75 min)

Cat 3. - Delivery required but mother and baby are stable

Cat 4. - Elective C-section

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17
Q

What is the most commonly used skin incision for C-sections?

Give the 2 possible types of this.

A

Transverse lower uterine segment incision

Pfannenstiel incision
Joel-cohen incision - *recommended

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18
Q

When can a vertical incision be used in C-section?

A

Rarely used.

Very premature deliveries
or
Anterior placenta praevia

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19
Q

What is exteriorisation in C-section?

A

Taking uterus out of the abdomen

*To be avoided if possible!

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20
Q

What are 4 pharmacological measures used in C-sections to reduce risks?

A

H2 receptor antagonist/PPI before procedure (reduce aspiration pneumonitis risk due to lying flat a lot)

Prophylactic antibiotics

Oxytocin (reduce risk of PPH)

VTE prophylaxis with LMWH

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21
Q

What are C-section postpartum complications?

A

Postpartum haemorrhage
Wound infection
Wound dehiscence
Endometritis (pain/discharge)

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22
Q

Which local structures can be damaged during C-section?

A

Ureter
Bladder
Bowel
Blood vessels

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23
Q

What effects can C-section have on the abdominal organs?

A

Ileus
Adhesions
Hernias

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24
Q

What effects can C-section delivery have on future pregnancies?

A

Increased risk of repeat C-section
Increased risk of uterine rupture
Increased risk of placenta praevia
Increased risk of stillbirth

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25
Q

What 2 complications can C-section have on the baby?

A

Risk of laceration (from knife)

Risk of transient tachypnoea of newborn

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26
Q

What are contraindications to VBAC (vaginal birth after Caesarean)? List 3.

A

Previous uterine rupture

Classical Caesarean scar (vertical incision)

The usual contraindications to vaginal delivery (e.g. placenta praevia)

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27
Q

Why is VTE an important risk to consider in C-section deliveries?

A

Extended period of time lying with reduced mobility

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28
Q

________ is the leading ‘direct’ cause of maternal death in the UK.

A

Pulmonary embolus

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29
Q

What are signs/symptoms of pulmonary embolism?

A

Chest pain
Dyspnoea

Tachycardia
Raised RR
Raised JVP
Chest abnormalities

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30
Q

How is a pulmonary embolism diagnosed?

A

CXR
Blood gas analysis
CT
VQ mismatch scanning

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31
Q

How is DVT diagnosed?

A

Doppler exam
Venogram
Pelvic MRI

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32
Q

Pregnant woman who get DVT get it on which part of their body?

A

Iliofemoral - Left side

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33
Q

Why is warfarin not used in the management of VTE?

A

Teratogenic

Fetal bleeding

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34
Q

What investigation must be performed before treatment with subcut LMWH in the management of VTE?

A

Thrombophilia screen

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35
Q

What are non-pharmacological methods to manage VTE?

A

Mobilisation
Hydration
Compression stockings (if LMWH contraindicated - during/after surgery)

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36
Q

What are 2 major risk factors for VTE?

A

Any previous VTE
High risk thrombophilia
Low risk thrombophila with any family hx

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37
Q

What is shoulder dystocia?

A

When anterior shoulder of baby becomes stuck behind public symphisis of pelvis, AFTER the head has been delivered

*Obstetric emergency

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38
Q

What is shoulder dystocia often caused by?

A

Macrosomia of the baby secondary to mother’s GDM

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39
Q

What is failure of restitution during delivery?

A

Head remains face downards (occipito-anterior) and does not turn sideways as expected after delivery of the head

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40
Q

What is the turtle-neck sign during delivery?

A

Head delivered but then retracts back into the vagina.

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41
Q

How is shoulder dystocia managed? Give at least 3 techniques.

A 
Episiotomy
McRoberts manoeuvre (knees to abdomen)
Pressure to anterior shoulder
Rubins manouevre 
Wood's screw manoeuvre
Zavanelli manoeuvre (push head back into vagina so C-section can then deliver)
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42
Q

What are the 4 key complications of shoulder dystocia?

A

Fetal hypoxia (+ cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage

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43
Q

What are the 3 possible conditions in the postnatal mental illness spectrum?

A
  1. Baby blues
  2. Postnatal depression
  3. Puerperal psychosis
44
Q

What % of women does baby blues occur in?

When does it typically present?

A

50%+ (particularly first-time mothers)

First week or so after birth

45
Q

What symptoms may a mother with baby blues present with?

A 
Mood swings
Low mood
Anxiety
Irritability
Tearfulness

*Symptoms are mild, last only few days, resolve within 2 weeks postpartum

46
Q

What are possible causes of baby blues?

A 
Significant hormone changes
Recovery from birth
Fatigue/sleep deprivation
Caring responsibility for neonate
Establishing feeding
All other changes/events around the time
47
Q

How are baby blues managed?

A

Symptoms are mild, last only few days, resolve within 2 weeks postpartum

No treatment required

48
Q

What is the classic triad of postnatal depression?

A

Low mood
Anhedonia
Low energy

49
Q

What is the time period that women are affected by postnatal depression for after birth?

A

3 months

*symptoms should last at least 2 weeks before PND is diagnosed

50
Q

How are mild cases of postnatal depression treated?

A

Additional support, self-help and followup with GP

51
Q

How are moderate cases of postnatal depression treated?

A

Antidepressant meds (SSRIs) and CBT

52
Q

How are severe cases of postnatal depression treated?

A

Input from specialist psychiatry services and inpatient care on mother + baby unit

53
Q

What scale is used to assess how the mother has felt over the past week, as a screening tool for postnatal depression?

A

Edinburgh Postnatal Depression Scale

*10 qs. 30 score. A score of 10+ suggests postnatal depression

54
Q

What is the mother and baby unit for?

A

Specialist unit for pregnant women and women that have given birth in the past 12 months.

Designed so that the mother and baby can remain together and continue to bond.

Mothers are supported to continue caring for their baby while they get specialist treatment.

55
Q

How are women with existing mental health concerns before/during pregnancy managed?

A

Referral to perinatal mental health services for advice/specialist input.

Decisions on psych meds

Plan put in place for after delivery to ensure good multi-disciplinary followup.

56
Q

Neonatal abstinence syndrome can be caused by which class of drugs?

A

SSRIs

57
Q

How does neonatal abstinence syndrome present?

A

First few days after birth

Irritability
Poor feeding

58
Q

How is neonatal abstinence syndrome managed?

A

Supportive management only

59
Q

When is the usual onset of puerperal psychosis?

A

2-3 weeks postpartum

60
Q

What are the psychotic symptoms experienced with puerperal psychosis?

A 
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
61
Q

How are women with puerperal psychosis managed?

A

Admission to mother + baby unit
CBT
Meds (antidepressant, antipsychotic, mood stabilisers)
ECT (rarely)

62
Q

Before which gestational age is abortion legal?

A

24 weeks gestational age

63
Q

An abortion can be performed at ANY time during a pregnancy if?

A

Continuing pregnancy will risk mother’s life

Terminating the pregnancy will prevent grave permanent injury to physical/mental health of the woman

Substantial risk that child would suffer physical/mental abnormalities making it seriously handicapped

64
Q

The legal requirements for an abortion are what?

A

2 registered medical practitioners must sign to agree abortion is indicated

Must be carried out by a registered medical practitioner in an NHS hospital or approved premise

65
Q

Where can pre-abortion services be accessed?

A

Self-referral
Referral by GP, GUM, family planning clinic referral

Charities - Marie Stopes UK

66
Q

Which 2 drugs can be used to induce a medical abortion

A

Mifepristone (anti-progestogen)

Misorostol (prostaglandin analogue) 1-2 days later

*Rhesus -ve women having TOP should have anti-D prophylaxis

67
Q

What are the 2 options for surgical abortion?

A

Cervical dilatation and suction of uterus contents (<14 weeks)

Cervical dilatation and evacuation using forceps (14 to 24 weeks)

*Rhesus -ve women having TOP should have anti-D prophylaxis

68
Q

What post-abortion blood test is done to confirm complete termination of pregancy?

A

Urine pregnancy test (bHCG)

69
Q

What are complications of termination of pregnancy?

A

Bleeding
Infection
Pain
Failure of abortion (pregnancy continues)
Damage to cervix, uterus or other structures

70
Q

A tumouur that grows like a pregnancy inside the uterus is called what?

A

Molar pregnancy

71
Q

What are the 2 types of molar pregnancy?

A

Complete mole and partial mole

72
Q

A complete mole occurs when 2 sperm cells fertilise a ________ ovum

A

Empty ovum (no genetic material)

No fetal material forms, only sperm combine genetic material to form a tumour

73
Q

A partial mole occurs when 2 sperm cells fertilise a ______ ovum

A

Normal ovum (containing genetic material)

3 sets of chromosomes all round. Tumour forms. Some fetal material may form.

74
Q

What are the similarities between molar and normal pregnancy?

A

Periods will stop

Hormonal changes of pregnancy will occur

75
Q

What are the distinguishing features of a molar pregnancy (vs normal pregnancy)?

A 
More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis (due to hCG mimicing TSH and stimulating thyroid to produce excess T3 and T4)
76
Q

What characteristic feature does USS of molar pregnancy show?

A

“Snowstorm appearance”

77
Q

Which investigations are used to diagnose molar pregnancy?

A

USS

Confirm with histology of mole after evacuation

78
Q

How is a molar pregnancy treated?

A

Evacuation of uterus to remove the mole

Send products of conception for histological examination to confirm molar pregnancy.

Refer patient to gestational trophoblastic disease centre for management and followup

hCG levels monitored until returning to normal

Occasionally chemotherapy needed as mole can metastasise.

79
Q

Early miscarriage is before __ weeks gestation, late miscarriage is between _______ gestation

A

<12 weeks

12-24 weeks

80
Q

Definition of ________ miscarriage is:

Miscarriage with fetus no longer alive, but no symptoms have occurred

A

Missed miscarriage

81
Q

Definition of ________ miscarriage is:

Miscarriage with vaginal bleeding with a closed cervix and fetus that is alive

A

Threatened miscarriage

82
Q

Definition of ________ miscarriage is:

Miscarriage with vaginal bleeding with an open cervix

A

Inevitable miscarriage

83
Q

Definition of _________ miscarriage is:

Miscarriage with retained products of conception remain in uterus after the miscarriage.

A

Incomplete miscarriage

84
Q

Definition of _________ miscarriage is:

Miscarriage when full miscarriage has occurred and there no products of conception left in the uterus.

A

Complete miscarriage

85
Q

An __________ pregnancy is when a gestation sac is present but contains no embryo

A

Anembryonic pregnancy

86
Q

What is the investigation of choice for diagnosing a miscarriage?

A

Transvaginal USS scan

87
Q

What are features that sonographer looks for on USS to diagnose miscarriage?

A

Mean gestation sac diameter

Fetal pole and crown-rump length

Fetal heartbeat

88
Q

How is miscarriage managed at <6 weeks gestation?

A

Bleeding managed

Expectant management (allow miscarriage to occur normally)

Do repeat urine HCG after 7-10 days - if negative then miscarriage has happened

*If bleeding worsening or persisted, do repeat USS and assessment - ?incomplete miscarriage

89
Q

How is miscarriage managed at >6 weeks gestation?

A

Refer to EPAU

USS - ?location ?viability of pregnancy - excludes ectopic pregnancy

90
Q

What are the 3 broad options for managing a miscarriage?

A

Expectant management (allow miscarriage to occur normally)

Medical management (misoprostol)

Surgical management

91
Q

What drug is used in the medical management of miscarriage?

A

Misoprostol (prostaglandin analogue)

92
Q

What is the surgical management options for miscarriage?

A

Manual vacuum aspiration (under local anaesthetic as an outpatient)

Electric vacuum aspiration (under general anaesthetic)

*Give anti-Rhesus D prophylaxis for rhesus negative women having surgical management of ectopic pregnancy

93
Q

Give 2 options for treating an incomplete miscarriage? (fetal/placental tissue remain in uterus)

A

Medical - misoprostol

Surgical - ERPC

*Evacuation of retained products of conception - done under GA. Uses vacuum aspiration and curettage. Complication is infection of endometrium.

94
Q

Recurrent miscarriage is classed as ____ or more consecutive miscarriages

A

3+

95
Q

Investigations are needed for recurrent miscarriages if more than:

A

3+ 1st trimester miscarriages

1+ 2nd trimester miscarriages

96
Q

What are causes of recurrent miscarriage? Give at least 3.

A 
Increasing age (idiopathic)
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors in parents
Chronic histiocytic intervillositis
Other chronic diseases: diabetes, untreated thyroid disease, SLE
97
Q

Antiphospholipid syndrome results in what happening to blood?

A

More prone to clotting (hyper-coagulable state)

Complications with pregnancy -> recurrent miscarriage

98
Q

Antiphospholipid syndrome can occur on its own or secondary to an ________ condition

A

autoimmune

*e.g. SLE

99
Q

How is the risk of miscarriage with antiphospholipid syndrome managed?

A

Aspirin

LMWH

100
Q

What are the key inherited thrombophilias that can result in recurrent miscarriages?

A

Factor V Leiden *most common

Factor II (prothrombin) gene mutation

Protein S deficiency

101
Q

What are different uterine abnormalities that can occur to cause recurrent miscarriages?

A

Uterine septum (partition through uterus)

Unicornuate uterus (single-horned uterus)

Bicornuate uterus (heart-shaped uterus)

Didelphic uterus (double uterus)

Cervical insufficiency

Fibroids

102
Q

What is chronic histiocytic intervillositis?

A

Rare cause of recurrent miscarriage (esp in 2nd trimester). Leads to IUGR and intrauterine death.

Histiocytes and macrophages build up in placenta and lead to inflammation

103
Q

How is chronic histiocytic intervillositis diagnosed?

What does it show?

A

Placenta histology - shows infiltrates of mononuclear cells in intervillous spaces

104
Q

What investigations must be carried out for recurrent miscarriages?

A

Antiphospholipid antibodies

Testing for hereditary thrombophilias

Pevlic USS

Genetic test on products of conception

Genetic testing on parents

105
Q

How is recurrent miscarriage treated pharmacologically?

A

Vaginal progesterone pessaries

Obs & Gynae (13 decks)

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