General Obs Flashcards
Define antepartum haemorrhage
bleeding from genital tract after 24 wks gestation
40% of antepartum haemorrhage is of UNDETERMINED ORIGIN. Name the other two COMMON causes of antepartum haemorrhage?
placenta praevia
placental abruption
Name two UNCOMMON causes of antepartum haemorrhage?
vasa praevia
uterine rupture
Blood vessels running in membrane in front of presenting part. May be punctured, with a foetal mortality of 60%! What is this condition called?
vasa praevia
have to stay as inpatient for 32 weeks!!
What is placenta praevia?
low lying placenta
placenta implants in lower uterine segment
A low lying placenta (praevia) may also be MORBIDLY ADHERENT to the uterine wall (particularly if placenta implants in previous caesarean scar). There are three grades of morbidly adherent placenta:
- accreta
- increta
- percreta
Define placenta accreta
chorionic villi attach to myometrium (rather than just decidua basalis)
Define placenta increta
chorionic villi invade INTO myometrium
Define placenta percreta
chorionic villi invade THROUGH myometrium (can go through to bladder/bowel!)
What is the placenta usually meant to attach to ?
Usually restricted to the decidua basalis. (shouldn’t attach to myometrium)
What is the difference between minor and major placenta praevia
major - covering internal cervical os
minor - near os but not covering
If an antepartum haemorrhage is PAINLESS, what is it likely to be?
Placenta praevia
If an antepartum haemorrhage is dark painful bleeding, what is it likely to be?
Placental abruption
Why don’t you do digital examination in placenta praevia?
Could put your finger through placenta!
Although transvaginal ultrasound is considered safe - more accurate than abdominal.
What are the symptoms/signs of placenta praevia?
painless antepartum haemorrhage abnormal lie (e.g. transverse)
Pregnant woman at 33 weeks presents with painless antepartum haemorrhage and transverse. Ultrasound confirms placenta praevia. You also do cross-match because she’s bleeding. What management do you do now?
- admit her, she’s bleeding
- treat shock, blood transfusion if necessary
- give steroids, she’s <34wks
- ANTI-D
CAESAREAN AT 36-38 WEEKS
Confirmed placenta praevia. When does she need a Caesarean?
at 36-38 weeks
What is the UK maternal mortality rate?
8.5 per 100,000
Placenta praevia picked up at 20 wk routine scan. This might have moved by the time for delivery. When would you rescan to check?
34 wks
Define placental abruption
separation of the placenta from the uterine wall
Name some RFs for placental abruption
pre-eclampsia
smoking
IUGR
previous abruption!
= RFs for placental abruption
What is the difference between REVEALED placental abruption and CONCEALED placental abruption?
revealed = pain + bleeding concealed = just pain
A woman at 28 weeks presents with dark painful antepartum haemorrhage and a woody hard abdomen. Likely diagnosis?
Placental abruption (revealed)
If placental abruption is minor, you use conservative management and do serial ultrasounds. If it is major….
Blood transfusion. Deliver
via Caesarean if foetal distress
if foetal death - induce labour (coagulopathy likely)
In antepartum haemorrhage, if there is maternal shock out of keeping with visible blood loss, what is the likely diagnosis?
Placental abruption
What are the four Ts which are the causes primary PPH?
Tissue
Tone
Tear
Thrombin
How does ‘Tissue’ cause PPH?
retained placenta (10%)
How does ‘Tone’ cause PPH?
uterus fails to contract (70%)
How does ‘Tear’ cause PPH?
bleed from episiotomy / peroneal / high vaginal tear (20%)
How does ‘Thrombin’ cause PPH?
coagulopathy (<1%) e.g. clotting disorder, anti-coags, DIC
Define PRIMARY post-partum haemorrhage
loss of >500ml within 24 hours of delivery
or >100ml if after Caesarean
What is the difference between MINOR and MAJOR post-partum haemorrhage ?
minor = <1500ml, no signs of shock major = >1500ml, signs of shock
Name some RFs for postpartum haemorrhage (there’s loads)
grand multiparity,
multiple preg,
fibroids, polyhydramnios
instrumental / Caesarean delivery
prolonged labour
coagulopathy
previous PPH!
previous APH
previous Caesarean
How do you medically manage PPH?
ABC estimate blood loss bloods - (coag, FBC, group+save) IV fluids + transfusion if necessary see if placenta remnants uterine massage --> bimanual compression IV ergometrine / syntocinon IV tranexamic acid IM carboprost
continuing? …… GO TO THEATRE
If ‘Tissue’ is the cause of PPH, how do you treat it?
removed retained placenta manually
If ‘Tone’ is the cause of PPH, how do you treat it?
IV ergometrin / IV syntocinon
… to CONTRACT uterus.
If fails: IM carboprost (prostaglandin)
Give some examples of SURGICAL management of PPH?
B-lynch suture
Ligation of uterine arteries or internal iliac arteries
Rusch balloon
Hysterectomy :/
How do you estimate 500ml blood loss?
fills a kidney dish
How do you estimate >1500ml blood loss?
blood spilling off bed onto floor
What amount of blood loss is threatening in PPH?
If a woman loses more than 40% it’s life threatening. (for 70kg woman this is around 2,800mls)
Excessive blood loss 24hrs - 6wks after delivery. What’s this called?
Secondary PPH
*** RECENTLY ITS BEEN CHANGED TO 12WKS AFTER!
What causes secondary PPH?
endometritis
retained placental tissue
rare - gestational trophoblastic disease
What do you find about the uterus and the internal os on a woman with secondary PPH?
uterus = enlarged and tender
internal os = still open!
What is the treatment for secondary PPH? (which is only rarely massive bleeding - usually small amounts)
Antibiotics
Utertonics - syntocinon / syntometrine / carboprost
If continuing - ERPC
Investigations for secondary PPH (x3)?
- high vaginal swab - endometritis?
- abdo US - retained placenta?
- bloods (fbc, u+e, group+save etc)
Why is ERPC risky in post partum period
uterus still soft - risk of perforation
What is syntometrine
oxytocin + ergometrine
What is carboprost?
prostaglandin F2
Name me some Uterotonics plz Kate
syntocinon
syntometrine
misoprostol
carboprost
(ergometrine is good for starting contractions. miso good for maintaining them)
What is misoprostol?
prostaglandin E1
What is syntocinon?
oxytocin
Artificial strengthening of contractions in established labour. What’s this called?
Augmentation
Define induction
artificial initiation of labour
What are the three Ps as causes of failure to Progress in labour?
Power
Passenger
Passage
How does ‘Power’ cause failure to Progress in labour?
ineffective uterine contractions
How does ‘Passenger’ cause failure to Progress in labour?
malpresentation
foetal size
How does ‘Passage’ cause failure to progress in labour?
cephalo-pelvic disproportion
After the latent phase (aka after 3cm dilated) usually dilate about __cm per hour. At the minimum, should dilate __ cm every two hours!
usually 1cm per hour
minimum us 1cm every 2 hours
What graph tracks progress in labour?
partogram
this is according to DILATION OF CERVIX AND DESCENT OF HEAD
What two measures does partogram use to measure progress in labour
dilation of cervix
descent of head
How often should you do a VE to assess progress in labour?
every 4 hrs
Which lines on a partogram help identify abnormal progress in labour
ALERT and ACTION lines
As well as measuring progress in labour, partogram also tracks what?
foetal wellbeing (colour of liquor, foetal HR)
medications
maternal vital signs
In active first stage of labour, how frequent should contractions be, how long in duration, and how strong?
4 every 10mins
lasting 1 min each
strong
Why is stressiness bad in labour?
adrenaline inhibits uterine contractions
change position, keep hydrated, relaxing environment
26 yr old primip will failure to progress in labour due to ineffective uterine contractions (trouble with Power!). Has been at 5cm dilation for past 6hrs. Admitted to labour ward. What physiological management? If doesn’t work what then?
physiological:
- change position, hydrate on IV fluids, reassure, discuss pain management,
- start partogram!
if still failure to progress:
- artificial rupture of membranes
- CTG
- VEs 4hrly
- maybe start syntocinon
- may need Caesarean depending on CTG
a 33 yr old multip at 38 wks arrives on ward having ruptured her membranes four hours ago. Regular contractions, increasing intensity. A meconium stained liquor is noted on the pad (may be sign of foetal distress). Cervix is 3cm dilated but midwife not sure of presenting part. What is possible diagnosis?
trouble with Passenger: malpresentation.
need ULTRASOUND to see baby’s position. (if breech cant do ECV anyway bc membranes ruptured).
would be instrumental or Caesarean depending on presentation
Why is occipito-posterior malposition a problem?
larger diameter needing to get through pelvic outlet.
A lady is having a really painful labour, back ache and an early desire to push. What are you thinking?
(Clue: it’s a trouble with the Passenger)
occipito-posterior malposition
Name two rare malpresentations
face presentation
brow presentation
What kind of delivery might occipto-transverse malposition need if it fails to spontaneously rotate?
Ventouse
Occipito-posterior malposition may need augmentation of labour. May spontaneously rotate. If not, what kind of delivery?
Kielland’s forceps (they rotate the baby)
Malpresentations are all presentations of the foetus other than vertex presentation. Apart from breech, name three more.
Shoulder
Face
Brow
Why would there be cephalo-pelvic disproportion?
big foetal head or narrow pelvis!
Why is cephalo-pelvic disproportion higher in low-income countries?
poor nutrition - rickets, osteomalacia, poorly healed pelvic fractures
Apart from small pelvis / large head ,what else could block engagement and descent of head?
pelvis mass such as ovarian tumour or fibroids
–> caesarean
Foetal distress is usually said to mean foetal hypoxia. But what are 4 other causes of foetal distress?
- foetal hypoxia
- infection in labour e.g. GBS
- meconium aspiration
- trauma e.g. forceps, shoulder dystocia
- foetal blood loss
What does meconium aspiration cause in the foetus?
chemical peritonitis
Long labour, use of oxytocin and epidural can be RFs for foetal hypoxia. Name 3 other acute causes of foetal hypoxia…
- placental abruption
- cord prolapse
- maternal hypotension (haemorrhage)
*pre-eclampsia and IUGR also RFs for foetal hypoxia
What might cause foetal blood loss leading to foetal distress?
vasa praevia (rare)
The management of malpresentation is dependent on what type it is. What is the management for breech?
ECV before labour
vaginal breech delivery
C section
Management of face malpresentation depends on where the chin is! Tell me more…
If the chin is posterior (mento-posterior), then need C section!
If the chin in anterior (mento-anterior), then normal labour poss but still risk of C section
What is the foetal lie? Name the three types of foetal lie.
“The relationship between the long axis of the fetus and the mother.”
Longitudinal, transverse or oblique
What is the foetal presentation?
“The fetal part that first enters the maternal pelvis”.
Cephalic vertex presentation is most common and safest
What is the foetal position? Name the three types.
“The position of the fetal head as it exits the birth canal.”
Occipito-anterior
Occipito-posterior
Occipito-transverse
When is the ideal time to attempt ECV?
after 37wks
The manipulation of the fetus to a cephalic presentation through the maternal abdomen. What’s this?
ECV (external cephalic version)
ECV is contraindicated in women who’ve had a previous C section. True or false?
True!
What’s the success rate of ECV?
about 50%
Complications of ECV are rare, but include…
foetal distress
placental abruption
emergency C-section
What are the three types of breech presentation ?
complete (flexed)
frank (extended)
footling
Quite a few babies are breech earlier on in the pregnancy but then go on to switcheroo. Past how many weeks does breech presentation become significant?
past 34 wks
only 3% breech at term
Name 2 FOETAL risk factors for breech.
polyhydramnios (swimming around)
prematurity (higher incidence earlier)
You feel breech on abdo ex. Where might you hear the foetal heartbeat compared to usual?
higher up
When the lie changes day to day, such as in polyhydramnios, what is this called?
unstable lie
A lady has ruptured membranes. You suspect breech. can you do ECV?
no, once ruptured membranes it’s too late
You’ve just performed ECV and want to check you’ve not caused foetal distress. How?
CTG straight after ECV
Describe the management of breech presentation at term.
- ECV
- if not, elective Caesarean
- may still choose vaginal breech birth :(
Which type of breech presentation is where both legs are flexed at the hips and knees?
complete (flexed)
Name 2 MATERNAL risk factors for breech.
pesky fibroid
multiparity
placenta praevia
Name 2 FOETAL risk factors for breech.
polyhydramnios
macrosomia
prematurity
In around 20% of cases, breech presentation is not diagnosed until labour. What might things make you suspect?
foetal distress - meconium liquor
feel foot on VE!
What are the TWO main differentials for breech presentaiton.
Oblique lie
Transverse lie
(unstable lie)
You suspect breech. What investigation to confirm?
Ultrasound
shows whether flexed/extended/footling
A lady, who’s previous child was delivered via C section, presents at 37 wks with breech. You do an ultrasound which confirms this. Her membranes are intact. Do ECV?
NO - previous C section is contraindication to ECV
as is recent APH
Give me 3 contraindications to ECV
ruptured membranes
previous C section
recent APH
When would you do C section for breech?
if ECV contradindicated / unsuccessful, or mother wants
Some women with breech still opt for vaginal delivery. What is the contraindication for this?
FOOTLING breech
they get stuck with just the legs dangling
What is the Golden Rule when conducting a vaginal breech delivery?
“Hands Off the Breech”
dont wanna get the head trapped
Vaginal breech delivery: if baby doesnt deliver spontaneously, what specific manoeuvres might be requiddd?
Lovsett’s manoeuvre
Mariceau-Smellie-Veit
The umbilical cord drops down below the presenting part of the baby, and becomes compressed. What’s this?
cord prolapse
What is cord prolapse?
umbilical cord drops below presenting part and gets compressed
What is the presenting part in cord prolapse?
the actewal cord itself
What is the difference between occult and overt cord prolapse?
occult - the cord is ALONGSIDE the presenting part
overt - the cord is below the presenting part
Tell me a major complication of breech that has a high mortality rate.
cord prolapse
What is the cause of foetal death in cord prolapse?
foetal HYPOXIA.
cord get squashed.
cord gets cold causing arterial vasospasm.
Why does cord prolapse cause foetal hypoxia?
cord gets squashed.
cord gets cold causing arterial vasospasm.
Name 3 risk factors for cord prolapse.
FOOTLING breech
unstable lie
ARM
Describe the management of cord prolapse, an obstetric emergency. (x4)
CALL FOR HELP!
left lateral position, manually elevate presenting part
tocolysis
EMERGENCY CAESAREAN
Why avoid handling cord when dealing with cord prolapse?
vasospasm
Give me 2 complications of breech.
cord prolapse
birth asphyxia
Why give tocolysis (e.g. terbutaline) in cord prolapse?
suppress contractions
- to take the pressure off
