Intrapartum and postpartum Flashcards
Hormones involved in lactation
Prolactin
Oestrogen, progesterone, insulin, thyroid hormones, glucocorticoids - involved in priming the breast
What hormone is involved in milk release
Oxytocin
Can a baby with galactosaemia be breast fed?
No
Breast milk must be excluded from the diet
Can a baby with phenylketonuria be breast fed?
No
Breast milk must be excluded from the diet
Can a baby with alactasia be breastfed?
No
Breast milk must be excluded from the diet
What is the risk of tetracycline during breastfeeding?
Stains teeth
What is the risk of maternal metronidazole during breastfeeding
Alters taste of breast milk
Not contraindicated
Can women with mastitis breastfeed or express?
Yes.
Continued feeding or regular breast pumping should be recommended along with analgesia and antibiotics
What hormone maintains successful lactation
Prolactin
What hormone inhibits lactation
Dopamine
Constituents of human milk compared to cows milk
Less protein More fat More carbohydrate Low sodium Higher levels of IgA and lactoferrin
Can breast milk be given to babies with galactosaemia
No.
Precipitates hypoglycaemia
What is moulding
Change in anatomical relations of bones of detail skull during labour and delivery
Where is the fetal vertex
Between anterior and posterior fontanelles
Where is the fetal occiput
Posterior to the posterior fontanelle
Where is the fetal bregma
The area of the anterior fontanelle
Where is the fetal brow
Anterior to anterior fontanelle to root of nose
What is inadequate progress in labour for a nulliparous woman
Lack of continuing progress for 3 hours with regional anaesthesia.
or 2 hours without regional anaesthesia
What is inadequate progress in labour for a Multiparous woman
Lack of continuing progress for 2 hours with regional anaesthesia.
or 1 hour without regional anaesthesia
Conditions where forceps would be preferred to ventouse
Poor maternal effort
Operator or maternal preference, when either instrument would be suitable
Large amount of caput
Gestation of less than 34 weeks (at 34–36 weeks of gestation, ventouse is relatively contraindicated)
Marked active bleeding from a fetal blood-sampling site
After-coming head of the breech
Face presentation
Indications for FBS include:
pathological CTG in labour (cervix dilated >3 cm)
suspected acidosis in labour (cervix dilated >3 cm).
What is a normal FBS result
PH ≥7.25
Normal FBS result.
Repeat after 1 hour if CTG remains the same
What is the cut off for an abnormal FBS result
PH ≤7.20 - consider delivery
Contraindications to FBS
Contraindications include:
maternal infection (e.g. HIV, hepatitis viruses and herpes simplex virus)
Fetal bleeding disorders (e.g. haemophilia)
Prematurity (birth at less than 34 weeks of gestation)
Acute fetal compromise (e.g. prolonged fetal bradycardia of >3 minutes).
Limitations imposed by the use of continuous EFM
reduced mobility
possibility that woman will not be the centre of care in labour
increased intervention
variation in interpretation of CTG trace
chorioamnionitis could make interpretation unreliable
litigation
Normal CTG features
Baseline rate 100-160
Variability >5
Decelerations - none or early
Non-reassuring CTG features
Baseline rate 161-180
Variability 50% of contractions
Abnormal CTG features
Baseline rate 180
Variability 90 minutes
Late decelerations >30mins with >50% of contractions
Bradycardia/prolonged deceleration >3min
management of non-reassuring CTG
commence conservative measures – left lateral position, oral / intravenous fluids, stop oxytocin, consider tocolysis.
management of abnormal CTG
Offer to take fetal blood sample (FBS; for lactate or pH) after implementing conservative measures, or expedite birth if an FBS cannot be obtained and no accelerations are seen as a result of scalp stimulation.
What are late decelerations suggestive of
Fetal hypoxia
What are late decelerations controlled by
Reflex central nervous system response to hypoxia and acidaemia.
Consequences of maternal fever on the fetus
Fetal tachycardia.
Loss of variability
Increased oxygen demand
Late decelerations
How does fetal baseline variability change with gestation
Baseline variability is low in early pregnancy and increases with gestation
Non-hypoxia related causes of decreased variability
Anencephaly Central nervous system defects Drugs - opiates, magnesium sulphate, atropine Sepsis Defective cardiac conduction Quiet fetal sleep
Can cord compression cause decelerations?
Yes - variable decelerations
Most common type of deceleration in labour
80% variable decelerations
5% late decelerations
Isolated early decelerations - rare
change in blood volume in pregnancy
rapid increase in extracellular fluid - esp circulating plasma
Increase in total body water by 2L
What is the maternal mortality ratio?
The number of maternal deaths in population divided by the number of live births.
(The risk of maternal death relative to the number of live births)
What is the maternal mortality rate?
Number of maternal deaths in a population divided by the number of women of reproductive age.
(Reflects risk of maternal deaths per pregnancy and level of fertility in the population)
Define stillbirth
Baby born > 24 weeks with no signs of life
Define perinatal death
Stillbirth > 24 weeks gestation or death within 7 days of birth
Define live birth
Any baby born with signs of life regardless of gestation
Define maternal death
Death of a woman while pregnant within 42 days of termination of pregnancy from any cause related to all aggravated by the pregnancy or its management.
Not accidental or incidental death
Define perinatal mortality rate
Number of stillbirths and early neonatal deaths per 1000 live births and stillbirths
Where is the foramen ovale located
Atrial septum
What carries oxygenated blood from the placenta to the fetus
Umbilical vein
What connects the pulmonary artery to the descending aorta in the fetus
Ductus arteriosus
What vessel shunts blood away from the liver in the fetus - from the umbilical vein to the vena cava
Ductus venosus
Why do women with an unstable lie need AN admission at term?
Risk of cord prolapse
Success rate of ECV
50%
What is placenta previa major
Insertion of the placenta in the lower section of the uterus overlying the cervical os
Names of the Fetal Skull bones
Frontal Parietal Temporal Sphenoidal Occipital
Names of Fetal skull sutures
Frontal Sagittal Coronal Lambdoidal Squamous
names of Fetal skull fontanelles
Anterior
Posterior
Sphenoidal
Mastoid
Bi-parietal diameter
9.5cm
What is the bregma
Anterior fomtanelle
Diamond shape
When does the anterior fontanelle close
18 months
When does the posterior fontanelle close
Two months
Minimum dose of anti-D required for a woman having cell salvage blood returned after CS
1500 IU minimum + do kleihauer
First line treatment of normocytic / microcytic anaemia in preg / PN
Oral ferrous sulphate
When should parenteral iron be used for anaemia in obstetrics
If PO iron not tolerated
Approaching term + insufficient time for PO iron.
How many days old can the sample be for transfusion if pregnant or within 3m of delivery
3/7
Major obstetric haemorrhage blood group
Group O, Rh -ve, kell -ve
When is intra-operative cell salvage recommended in obstetrics
When anticipated blood loss significant enough to cause anaemia
Or estimated blood volume >20%
In RBC transfusion when is FFP required
FFP 12-15ml/kg every 6 units of RBC during major haemorrhage
+ subsequent FFP guided by clotting - aim to maintain PT : APTT ratio
What is the critical level platelets must not fall below
50
Platelet transfusion trigger of 75 if ongoing bleeding
What group should platelet transfusion be
Same ABO group as patient
What group of women should recieve Intrapartum antibiotic prophylaxis (IAP)
Intrapartum antibiotic prophylaxis should be given to:
- Women with a previous baby with neonatal GBS disease
- Women who are pyrexial in labour (>38C)
- GBS bacteriuria identified during current pregnancy
- GBS detected on vaginal swab in current pregnancy
- Women with preterm rupture of membranes irrespective of GBS status
- Women in confirmed preterm labour even without known GBS colonisation
Who doesn’t require IAP:
Prelabour rupture of membranes (& not known to have GBS)
Planned caesarean section in the absence of labour and with intact membranes
UK incidence of neonatal herpes?
Neonatal herpes is rare
UK incidence 3 in 100,000 live births
But serious
what are the 3 types of neonatal herpes?
3 types of Neonatal herpes:
1. Restricted to skin/superfical infection (eye/mouth) = least severe form 2. CNS infection = mortality with antiviral treatment 6%, neurological sequelae 70% 3. Disseminated infection = mortality with antiviral treatment 30%, neurological sequelae 17%
70% of cases are disseminated or CNS involvement
Management 3rd trimester Acquisition of Genital Herpes (from 28 weeks)
Management 3rd trimester Acquisition of Genital Herpes (from 28 weeks)
Acicolvir 400 mg TDS, continue until delivery.
C-section delivery is advised for these patients in whom this is a 1st episode of HSV
What percentage of infants with congenital CMV infection are symptomatic?
10 -15%
For a patient with epilepsy what is the overall risk of experiencing a tonic-clonic seizure during labour / the 24 hours after
on average 1-4%
women may be reassured that the risk of a tonic-clonic seizure during labour and the 24 hours after birth is low
Maternal mortality rate per 100,000 in UK
Maternal mortality rate of 8.76 per 100,000 maternities
In 2017 in UK
Contraindications to cabergoline go stop lactation
Cabergoline is contraindicated in the following:
Pre-eclampsia
Cardiac valvulopathy (exclude before treatment)
History of pericardial fibrotic disorders
History of puerperal psychosis
History of pulmonary fibrotic disorders
History of retroperitoneal fibrotic disorders
hypersensitivity to ergot alkaloids
Most commonly used drugs for lactation suppression
Cabergoline and Bromocriptine
Which gender does congenital hip dislocation more commonly occur in
female
Risk factors for congenital hip dislocation
Risk factors for congenital hip dislocation
Incidence of congenital hip dislocation
1.3 per 1000 live births
What is Mendelsons syndrome?
Aspiration of gastric contents under anaesthesia due to a gravid uterus increasing intra-abdominal pressure
What does the Bishops score measure?
Dilatation, length, consistency and position of the cervix.
And the station of the presenting part.
In preterm rupture of membranes are antibiotics recommended?
Yes
Reduces perinatal mortality
Following preterm rupture of membranes what percentage of women will deliver within one week?
75%
What is called prolapse associated with?
Breech presentation High head Twins Grand multip Preterm labour
Does smoking affect delivery?
Smokers have a 50% chance of premature labour
Effect of smoking on infant birthweight.
2x the risk of low birthweight
How does nifedipine produce its tocolytic effect
Calcium channel blocker - blocks voltage gated calcium channels.
Effect of bacterial vaginosis on
pregnant women
Late miscarriage, pre-term labour, pre-term birth, pre-term premature rupture of membranes, low birthweight, postpartum endometritis.
Post partum PID is commonly caused tb what organism?
Beta-haemolytic streptococci
Commonest antihypertensives used in pregnancy
Labetolol
Methyldopa
Side effect on baby of lithium while breast feeding
Hypotonia
Cyanotic episodes
Effect of aspirin while breast feeding
Reye’s syndrome
Impaired platelet function
Hypoprothrombinaemia
What is fetal hydantoin syndrome
Group of fetal defects caused by phenytoin or carbamazepine. Intrauterine growth restriction. Microcephaly. Hypoplastic phylanges and nails. Dysmorphic craniofacial features. Developmental delay.
Features of Down’s syndrome
Macroglossia Single palmar crease Hypotonia Brushfield spots Oblique palpebral fissures Prominent epicanthic folds Low set ears Sandal gap
Fetal abnormalities caused by varicella zoster
Segmental skin loss of scarring Limb hypoplasia or aplasia Growth retardation Microcephally Ophthalmic abnormalities
What heart defect occurs in fetal alcohol syndrome?
ASD
Heart defects associated with Down’s syndrome
Atrial septal defects
Ventricular septal defects
Atrioventricular Canal defects
What is the most common intra abdominal tumour of childhood?
Wilms’ tumour
What is Wilms tumour
Undifferentiated mesodermal tumour of the intermediate cell mass (primitive renal tubules and mesenchymal cells)
Features of congenital rubella syndrome
Loss of vision
Hearing loss
Heart defects
Mental retardation
Less frequent - CP
Effect of fetal syphilis
1/2 die during gestation or shortly after birth
Failure to thrive
Irritability
Blindness
What congenital infection caused retinochorditis
Toxoplasmosis
Definition of primary post partun haemorrhage
Blood loss of 500ml or more occurring within 24 hours of delivery.
Predisposing factors to primary post partum haemorrhage
Previous PPH Multiple pregnancy Macrosomic baby Polyhydramnios Increased maternal age Obesity
Causes of primary post partum haemorrhage
Uterine atonia
Genital tract trauma
Retained placental tissue
Thrombin
Define perinatal mortality
Sum of stillbirths and neonatal deaths in the first week of life per 1000 births after 24 weeks gestation
Risk factors for postnatal depression
Single Young Chronic life difficulties Social adversity Past history of psychiatric illness
What is the puerperal psychosis
Sudden out of character behaviour
In the first five days postnatally
Can include threats to harm oneself, one’s partner or the baby.
What is baby blues
Tearfulness but no loss of sense of reality.
Occurs in up to 30%
Recovers within 72 hours
incidence of cerebral palsy in babies born between 22 and 27 weeks?
14%
1st line drug for tocolysis in preterm labour (NICE)
Nifedipine = calcium channel blocker - first line.
If Nifedipine CI use an oxytocin antagonist (atosiban)
incidence of maternal postpartum haemorrhage in deliveries complicated by shoulder dystocia
10%
What is the primary role of magnesium sulphate in preterm labour
Neuroprotection
Reduce risk of CP
Most frequent cause of severe early-onset (< 7 days) infection in newborn infants
Group B streptococcus infection i
Causes of preterm labour
Chorio-amnionitis Polyhrdramnios Cervical incompetence Amniocentesis Multiple pregnancy Uterine abnormalities Peritonitis Pyelonephritis
