Delivery methods and complications Flashcards
What 2 instruments can be used to assist delivery?
Ventouse suction cup
Forceps
Which part of the baby does instrumental delivery aim to assist in delivering?
The baby’s head
What medication is used prophylactically after instrumental delivery to reduce the risk of maternal infection?
Co-amoxiclav - single dose
What are key indications to perform an instrumental delivery?
Failure to progress
Fetal distress
Maternal exhaustion
Control of head in various fetal positions
There is an increased risk of requiring an instrumental delivery when an _______ is in place for analgesia
Epidural
What are risks to the mother of having an instrumental delivery?
Postpartum haemorrhage Episiotomy Perineal tears Injury to anal sphincter Incontinence bowel/bladder Nerve injury (obturator/femoral nerve)
What are key risks to the baby with ventouse and with forceps?
Ventouse - cephalohaematoma
Forceps - facial nerve palsy
What are serious risks to the baby if instrumental delivery goes wrong?
Subgaleal haemorrhage *most dangerous
Intracranial haemorrhage
Skull fracture
Spinal cord injury
How does ventouse delivery work?
Suction cup goes on baby’s head and is pulled from vagina
How does forceps delivery work?
Tongs go either side of baby’s head and grip head to pull from vagina
Which nerves can be affected by instrumental delivery? (List 5)
Femoral nerve Obturator nerve Lateral cutaneous Nerve of the thigh Lumbosacral plexus Common peroneal nerve
What are the two broad types of C-section?
Emergency
Elective
What anaesthetic is used for an elective C-section?
Spinal anaesthetic - lidocaine
When are elective C-sections usually performed?
39 weeks gestation
What are indications for elective C-sections?
Previous C-section Symptomatic after previous significant perineal tear Placenta praevia Vasa praevia Breech presentation Multiple pregnancy Uncontrolled HIV infection Cervical cancer
What are the 4 main categories of emergency C-section?
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
What is the most commonly used skin incision for C-sections?
Give the 2 possible types of this.
Transverse lower uterine segment incision
Pfannenstiel incision
Joel-cohen incision - *recommended
When can a vertical incision be used in C-section?
Rarely used.
Very premature deliveries
or
Anterior placenta praevia
What is exteriorisation in C-section?
Taking uterus out of the abdomen
*To be avoided if possible!
What are 4 pharmacological measures used in C-sections to reduce risks?
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
What are C-section postpartum complications?
Postpartum haemorrhage
Wound infection
Wound dehiscence
Endometritis (pain/discharge)
Which local structures can be damaged during C-section?
Ureter
Bladder
Bowel
Blood vessels
What effects can C-section have on the abdominal organs?
Ileus
Adhesions
Hernias
What effects can C-section delivery have on future pregnancies?
Increased risk of repeat C-section
Increased risk of uterine rupture
Increased risk of placenta praevia
Increased risk of stillbirth
What 2 complications can C-section have on the baby?
Risk of laceration (from knife)
Risk of transient tachypnoea of newborn
What are contraindications to VBAC (vaginal birth after Caesarean)? List 3.
Previous uterine rupture
Classical Caesarean scar (vertical incision)
The usual contraindications to vaginal delivery (e.g. placenta praevia)
Why is VTE an important risk to consider in C-section deliveries?
Extended period of time lying with reduced mobility
________ is the leading ‘direct’ cause of maternal death in the UK.
Pulmonary embolus
What are signs/symptoms of pulmonary embolism?
Chest pain
Dyspnoea
Tachycardia
Raised RR
Raised JVP
Chest abnormalities
How is a pulmonary embolism diagnosed?
CXR
Blood gas analysis
CT
VQ mismatch scanning
How is DVT diagnosed?
Doppler exam
Venogram
Pelvic MRI
Pregnant woman who get DVT get it on which part of their body?
Iliofemoral - Left side
Why is warfarin not used in the management of VTE?
Teratogenic
Fetal bleeding
What investigation must be performed before treatment with subcut LMWH in the management of VTE?
Thrombophilia screen
What are non-pharmacological methods to manage VTE?
Mobilisation
Hydration
Compression stockings (if LMWH contraindicated - during/after surgery)
What are 2 major risk factors for VTE?
Any previous VTE
High risk thrombophilia
Low risk thrombophila with any family hx
What is shoulder dystocia?
When anterior shoulder of baby becomes stuck behind public symphisis of pelvis, AFTER the head has been delivered
*Obstetric emergency
What is shoulder dystocia often caused by?
Macrosomia of the baby secondary to mother’s GDM
What is failure of restitution during delivery?
Head remains face downards (occipito-anterior) and does not turn sideways as expected after delivery of the head
What is the turtle-neck sign during delivery?
Head delivered but then retracts back into the vagina.
How is shoulder dystocia managed? Give at least 3 techniques.
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)
What are the 4 key complications of shoulder dystocia?
Fetal hypoxia (+ cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
What are the 3 possible conditions in the postnatal mental illness spectrum?
- Baby blues
- Postnatal depression
- Puerperal psychosis
What % of women does baby blues occur in?
When does it typically present?
50%+ (particularly first-time mothers)
First week or so after birth
What symptoms may a mother with baby blues present with?
Mood swings Low mood Anxiety Irritability Tearfulness
*Symptoms are mild, last only few days, resolve within 2 weeks postpartum
What are possible causes of baby blues?
Significant hormone changes Recovery from birth Fatigue/sleep deprivation Caring responsibility for neonate Establishing feeding All other changes/events around the time
How are baby blues managed?
Symptoms are mild, last only few days, resolve within 2 weeks postpartum
No treatment required
What is the classic triad of postnatal depression?
Low mood
Anhedonia
Low energy
What is the time period that women are affected by postnatal depression for after birth?
3 months
*symptoms should last at least 2 weeks before PND is diagnosed
How are mild cases of postnatal depression treated?
Additional support, self-help and followup with GP
How are moderate cases of postnatal depression treated?
Antidepressant meds (SSRIs) and CBT
How are severe cases of postnatal depression treated?
Input from specialist psychiatry services and inpatient care on mother + baby unit
What scale is used to assess how the mother has felt over the past week, as a screening tool for postnatal depression?
Edinburgh Postnatal Depression Scale
*10 qs. 30 score. A score of 10+ suggests postnatal depression
What is the mother and baby unit for?
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.
How are women with existing mental health concerns before/during pregnancy managed?
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.
Neonatal abstinence syndrome can be caused by which class of drugs?
SSRIs
How does neonatal abstinence syndrome present?
First few days after birth
Irritability
Poor feeding
How is neonatal abstinence syndrome managed?
Supportive management only
When is the usual onset of puerperal psychosis?
2-3 weeks postpartum
What are the psychotic symptoms experienced with puerperal psychosis?
Delusions Hallucinations Depression Mania Confusion Thought disorder
How are women with puerperal psychosis managed?
Admission to mother + baby unit
CBT
Meds (antidepressant, antipsychotic, mood stabilisers)
ECT (rarely)
Before which gestational age is abortion legal?
24 weeks gestational age
An abortion can be performed at ANY time during a pregnancy if?
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
The legal requirements for an abortion are what?
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
Where can pre-abortion services be accessed?
Self-referral
Referral by GP, GUM, family planning clinic referral
Charities - Marie Stopes UK
Which 2 drugs can be used to induce a medical abortion
Mifepristone (anti-progestogen)
Misorostol (prostaglandin analogue) 1-2 days later
*Rhesus -ve women having TOP should have anti-D prophylaxis
What are the 2 options for surgical abortion?
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
What post-abortion blood test is done to confirm complete termination of pregancy?
Urine pregnancy test (bHCG)
What are complications of termination of pregnancy?
Bleeding
Infection
Pain
Failure of abortion (pregnancy continues)
Damage to cervix, uterus or other structures
A tumouur that grows like a pregnancy inside the uterus is called what?
Molar pregnancy
What are the 2 types of molar pregnancy?
Complete mole and partial mole
A complete mole occurs when 2 sperm cells fertilise a ________ ovum
Empty ovum (no genetic material)
No fetal material forms, only sperm combine genetic material to form a tumour
A partial mole occurs when 2 sperm cells fertilise a ______ ovum
Normal ovum (containing genetic material)
3 sets of chromosomes all round. Tumour forms. Some fetal material may form.
What are the similarities between molar and normal pregnancy?
Periods will stop
Hormonal changes of pregnancy will occur
What are the distinguishing features of a molar pregnancy (vs normal pregnancy)?
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)
What characteristic feature does USS of molar pregnancy show?
“Snowstorm appearance”
Which investigations are used to diagnose molar pregnancy?
USS
Confirm with histology of mole after evacuation
How is a molar pregnancy treated?
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.
Early miscarriage is before __ weeks gestation, late miscarriage is between _______ gestation
<12 weeks
12-24 weeks
Definition of ________ miscarriage is:
Miscarriage with fetus no longer alive, but no symptoms have occurred
Missed miscarriage
Definition of ________ miscarriage is:
Miscarriage with vaginal bleeding with a closed cervix and fetus that is alive
Threatened miscarriage
Definition of ________ miscarriage is:
Miscarriage with vaginal bleeding with an open cervix
Inevitable miscarriage
Definition of _________ miscarriage is:
Miscarriage with retained products of conception remain in uterus after the miscarriage.
Incomplete miscarriage
Definition of _________ miscarriage is:
Miscarriage when full miscarriage has occurred and there no products of conception left in the uterus.
Complete miscarriage
An __________ pregnancy is when a gestation sac is present but contains no embryo
Anembryonic pregnancy
What is the investigation of choice for diagnosing a miscarriage?
Transvaginal USS scan
What are features that sonographer looks for on USS to diagnose miscarriage?
Mean gestation sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
How is miscarriage managed at <6 weeks gestation?
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
How is miscarriage managed at >6 weeks gestation?
Refer to EPAU
USS - ?location ?viability of pregnancy - excludes ectopic pregnancy
What are the 3 broad options for managing a miscarriage?
Expectant management (allow miscarriage to occur normally)
Medical management (misoprostol)
Surgical management
What drug is used in the medical management of miscarriage?
Misoprostol (prostaglandin analogue)
What is the surgical management options for miscarriage?
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
Give 2 options for treating an incomplete miscarriage? (fetal/placental tissue remain in uterus)
Medical - misoprostol
Surgical - ERPC
*Evacuation of retained products of conception - done under GA. Uses vacuum aspiration and curettage. Complication is infection of endometrium.
Recurrent miscarriage is classed as ____ or more consecutive miscarriages
3+
Investigations are needed for recurrent miscarriages if more than:
3+ 1st trimester miscarriages
1+ 2nd trimester miscarriages
What are causes of recurrent miscarriage? Give at least 3.
Increasing age (idiopathic) Antiphospholipid syndrome Hereditary thrombophilias Uterine abnormalities Genetic factors in parents Chronic histiocytic intervillositis Other chronic diseases: diabetes, untreated thyroid disease, SLE
Antiphospholipid syndrome results in what happening to blood?
More prone to clotting (hyper-coagulable state)
Complications with pregnancy -> recurrent miscarriage
Antiphospholipid syndrome can occur on its own or secondary to an ________ condition
autoimmune
*e.g. SLE
How is the risk of miscarriage with antiphospholipid syndrome managed?
Aspirin
LMWH
What are the key inherited thrombophilias that can result in recurrent miscarriages?
Factor V Leiden *most common
Factor II (prothrombin) gene mutation
Protein S deficiency
What are different uterine abnormalities that can occur to cause recurrent miscarriages?
Uterine septum (partition through uterus)
Unicornuate uterus (single-horned uterus)
Bicornuate uterus (heart-shaped uterus)
Didelphic uterus (double uterus)
Cervical insufficiency
Fibroids
What is chronic histiocytic intervillositis?
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
How is chronic histiocytic intervillositis diagnosed?
What does it show?
Placenta histology - shows infiltrates of mononuclear cells in intervillous spaces
What investigations must be carried out for recurrent miscarriages?
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pevlic USS
Genetic test on products of conception
Genetic testing on parents
How is recurrent miscarriage treated pharmacologically?
Vaginal progesterone pessaries
