Intrapartum and Postpartum care Flashcards
Approach surgically to placenta accreta/percreta
- MDM pre-op reviewing USS + MRI with interventional radiology, vascular, gynae onc and urology
- Deliver between 35-36 weeks +/- Steroids (if absence of risks for PTB). RCOG recommend delivery 34-36+6 if symptomatic or at risks of pre-term delivery.
- Consider pre-op cystoscopy and stenting and internal iliac balloons
- Consent for caesarean section should be standard + massive obstetric haemorrhage, increased risk of lower urinary tract damage, the need for blood transfusion and the risk of hysterectomy.
- Inform haematology and have 4-6 units packed red cells on stand-by and cell salvage for bleeding.
- 2x large bore IV cannulae and consider ART line placement
- General anaesthetic with epidural in situ
- Bair hugger to keep patient warm
- Flotrons and TEDS
- IV antibiotic prophylaxis with broad spectrum e.g. Cefazolin IV
- Midline incision
- USS directly on the uterus to define site prior to making incision
- Make a fundal (classical incision) far away from the placental site
- Deliver the baby
- Decision to take placenta give ecbolics and wait to see if the placenta will separate:
If separates, remove and carry on
If does not separate move on to Caesarean hysterectomy - Decision for uterine conservation/Placenta to be left in situ (not recommended in women presenting with major bleeding as it is unlikely to be successful and risks delaying definitive treatment and increasing morbidity):
50% risk of severe haemorrhage
58% risk of secondary hysterectomy up to 9 months after the birth
MTX adjuvant therapy should not be used for expectant management as it is of unproven benefit and has significant adverse effects.
Post-op:
Debrief immediately and 6 weeks later
ICU
VTE prophylaxis
Contraception
Ligating the internal iliac artery
Divide the pelvic peritoneum parallel to the infundibular pelvic ligament to enter retroperitoneal space.
Identify the external iliac artery and vein laterally and ureter medially
Retract ureter medially to expose common iliac
Identify the internal iliac as it branches from common iliac
Ligate distal to the posterior division by using a right angle clamp to divide the tissue between internal iliac artery and vein and pass a ligature around the artery OR a surgical clip around artery.
Care to avoid damage to internal iliac vein
Before ligating the internal iliac artery re identify the external iliac vessels and ureter to ensure the correct vessel is ligated.
Branches of internal iliac artery
2:4:4 rule
At the bifurcation of common iliac at vertebrae level L4
2 - Back body wall
Iliolumbar artery
Lateral sacral artery
4 - Outside of pelvis Obturator artery Superior gluteal artery Inferior gluteal artery Internal pudendal artery
4 - Supply pelvis Umbilical artery Vaginal artery Uterine artery Middle rectal artery
(iliolumbar, lateral sacral and superior gluteal) are branches of the posterior division of the internal iliac artery, the remaining branches are of the anterior division.
Ligation of the posterior division may produce symptomatic ischaemia of the buttocks and sciatic nerve.
Local Anaesthetic Toxicity Treatment
- Call for help
- Stop epidural,
- Request intralipid 20% bolus 100 mL IV over 2-3 mins (1.5ml/kg)
- Followed by infusion of 200-250 mL over 15-20 mins. - Bolus can be repeated once or twice; double infusion rate if patient is persistently unstable.
- Continue infusion for at least 10 mins after haemodynamic stability achieved.
- Max dose 12 mL/kg.
How to insert Bakri Balloon
- Check cavity is empty first
- Collapsed balloon is inserted into uterine cavity
- Once in the correct position, sterile saline is used to inflate the balloon to a maximum volume of 500mls. Usually 100-300mL. Document amount of fluid in balloon.
- When inflated, the balloon adopts the shape of the uterine cavity to tamponade endometrial bleeding and controls atony in upper segment.
- The central lumen allows drainage of blood which can be measured and recorded
- Patient will need adequate analgesia post operatively
- Leave the balloon inflated for 8-24 hours & remove it either all at once or gradually over several hours
- IDC and vaginal pack should also be in situ
- Consider antibiotics.
- Document and debrief afterwards
Management of PPH
Recognition, Communication, Resuscitation, Monitoring and investigation & Management of PPH
Recognition:
Weigh blood loss
Continue to evaluate – weighing of ongoing losses
Observe for clinical signs of shock
Communication:
This is an obstetric emergency
Call for help
- Senior obstetric and midwifery staff
- Anaesthetics
- Liase with haematology / transfusion specialists
- ICU
Resuscitation: ABC approach Assessment of airway and breathing, administer high flow oxygen 2x large bore IV cannulas FBC, coags, x-match 4 units IVF 2L (warmed)
Monitoring and investigation:
BP, RR every 10-15 minutes
Continuous monitoring of HR & O2 sats while unstable
Urine output, temperature
Management of PPH:
Address the cause
- Consider the 4 T’s (Tone, trauma, tissue, thrombin)
Given pharmacological management
1. Syntocinon 10IU IV
2. Bolus and infusion (40 units in 500ml IV over 4 hours)
3. TXA 1g IV
4. Can repeat ergometrine 0.5mg IM
5. IM 250mcg Carboprost up to 8 doses
6. Misoprostol 800mcg
Early transfer to theatre if ongoing bleeding
Entrapment of aftercoming head in breech
• A vaginal examination if not fully can the cervix be pushed over the head.
• If the fetal head has entered the pelvis, perform Mauriceau-Smellie-Viet manoeuvre combined with suprapubic pressure from an assistant in a direction that maintains descent and flexion of the head.
• Rotate the fetal body to a lateral position and apply suprapubic pressure to flex the fetal head.
• Apply traction then rotate the fetal back to sacroanterior position and birth after coming head by Neville-Barnes forceps (or clinicians preference).
If above unsuccessful consider alternative manoeuvres:
• Reassess cervical dilatation. If cervix is not fully dilated (especially if preterm) consider Duhrssen incision at 2, 6 and 10 o’clock
• If unsuccessful, symphisiotomy should be performed by an experienced clinician
• Alternatively, a caesarean section may be performed in operating theatre if the baby is still alive. It is necessary for the baby to be pushed from below.
Vaginal breech birth
-Call for extra help
-Ask for the delivery trolley with episiotomy scissors, local anaesthetic +/-pudendal block & operative delivery pack/ forceps,
-Ensure IV access & FBC & group & hold
- CEFM
- Lithotomy
- Local anaesthetic infiltration or pudendal nerve block +/- epis as necessary
- Allow for spontaneous delivery of limbs & trunk:
If need to, apply pressure to popliteal fossae to release legs
Correct position to sacro-anterior - bony prominences only
Allow spontaneous delivery until scapulae are visible
Loveset manoeuvres to deliver arms if they do not do so spontaneously.
Allow baby to hang until nape neck visible
- Assistant on hand to give suprapubic pressure to assist flexion of head
- May need Mauriceau-Smellie-Veit manoeuvre to deliver after coming head: support baby’s body with arm, first and third finger on cheekbones & gentle traction with other hand applied to shoulders, using two fingers to flex occiput
Manage Cord Prolapse
• Call for help
• Give explanations to the woman and her birth partner
• Move the woman into the knee-chest (all fours with buttocks elevated) or exaggerated Sims’ position (left lateral with pillow under the hips)
• If oxytocin augmentation is in progress, discontinue immediately
• Elevate the presenting part digitally or by bladder filling (attach N. Saline via urology set and fill 500-750mls)
• To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina
• Continue to assess fetal heart rate
• Expedite the birth of the baby. At full dilatation, vaginal birth may be an option depending on parity
and engagement of head
• Transport the woman to the operating theatre, if required
• Tocolysis (Terbutaline 250 microgram subcutaneous (SC)) can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically or when the delivery is likely to be delayed. May allow time for regional anaesthesia to be administered.
How to disimpact the deeply impacted, deflexed OP fetal head
Call for assistance from experienced obstetrician
Attempt to disimpact head with entire hand under babies head to flex and lift.
Change and use non-dominant hand and do not flex wrist as this increases risk of uterine tearing.
GTN or other tocolytic to help relax uterus and give more room for baby to move up into the uterine cavity.
Bed as low as it can go and standing stool and maternal trendelunberg.
Consider gentle elevation of head by experienced practitioner from below. Careful to spread force across entire hand rather than 1-2 fingers to prevent fetal injury.
Reverse breech extraction - to give more room for this consider T incision at uterotomy and extending skin and sheath excisions.
Prepare for management of PPH.
Abruption management
777 obstetric emergency
MDT approach: obstetrics/anaesthetics/midwifery/theatre/haematology and blood bank/ICU
• A/B: ensure patent airway and spontaneous breathing, record RR and O2 saturations, administer high flow oxygen via face mask, keep patient warm
• C: record HR, BP, cap refill, 2 large 16G IVL, take bloods for FBC, G&S, cross-match 4-6u, Kleihauer, coagulation screen, baseline renal function (creatinine, U+E), LFTs to complete PET screen in context of abruption, attempt to estimate blood loss (weigh, revealed vs. concealed)
• Rapid infusion with 2-3L warmed crystalloid through pressure bags
• Consider IDC and aim for UO >30mL/hour
• Close monitoring of maternal haemodynamic status
• Early consideration of blood products if ongoing HD instability ?may require activation of MTP
• Correct coagulopathy as needed
• If ongoing heavy bleeding and HD instability despite resuscitative measures - for EM CS under GA to reduce maternal morbidity/mortality
• Discussion with patient/family regarding diagnosis (abruption, IUFD) and severity of situationx
• Consent - may need to be verbal if situation life-threatening, risk for hysterectomy to be discussed
• Ongoing correction of any coagulopathy
• Senior obstetric/anaesthetic staff present
• Anticipate PPH, may necessitate hysterectomy
• Post-operatively may require ICU/HDU bed
• Once mother stable - open disclosure/discussion with patient/family, documentation
Counsel previous 3rd degree tear
Vaginal delivery not contraindicated 5 - 7% risk re-injury with 17% risk worsening Sx
Only way to prevent is Caesarean
Prophylactic episiotomy not proven – judicious use recommended; is recommended with instrumental
If symptomatic consider endoanal USS and refer to gen surg
Following your perimortem CS what is your next course of action?
o Transfer to theatre to close uterus and abdomen.
Consider washout and IV antibiotics given performed in a dirty field.
Consider blood transfusion if significant bleeding has occurred.
o Postpartum:
Admit to HDU/ICU
Clexane prophylaxis 6 hours postop if no ongoing bleeding concerns
Debrief with woman and family. Consider referral for psychologist support given traumatic experience. Screen for postnatal depression and anxiety.
Breastfeeding support
Discuss contraception and advice re: pregnancy spacing.
Maternal collapse/CPR
Unresponsive proceed to CPR
S - send for help
Lay flat and manually displace the uterus or place on a wedge for a left lateral tilt
Commence CPR 30:2
Apply defibrillator pads and assess rhythm
Airway and breathing asess for need of adjuncts and apply high flow O2 via a non re-breath mask
2 x Large bore IV cannulas
Takes bloods: FBC, U&Es, Mg, Ca, LFTs, Co-ags, lactate and blood gas
Commence IV fluids
Think causes 4Hs and 4Ts Hypoxia Hypovoleamia Hyper/hypo kaleamia or Glycaemia Hyer/hypothermia Tamponade Tension pneumothorax Toxicity Thrombosis Amniotic fluid embolis
Consider IV adrenaline 1mg +/- Amiodarone 300mg depending on rhythm
If no ROSC within 4 mins proceed to perimortem c-section
Anaphylaxis treatment
Oxygen via mask with resovir bag Adrenaline 500mcg/0.5ml 1:1000 IM repeated every 5 mins if still perisistent hypotension or bronchospasm Other drugs: Chlorophenamine 10mg IV Hydrocortisone 200mg IM/IV Salbutamol Nebuliser 5mg IV fluids
NLS
Prevent heat loss
Ensure airway patent
Stimulate
HR <100 or gasping or apnoea
Start positive pressure ventilation
Re-check HR if still below 100 after 1 min
Ensure airway open, reduce any leakage and increase O2 concentration
HR below 60
Start chest compression 3:1
Oxygen on 100 and consider intubation
Eclampsia
Give 4g magnesium sulfate IM (into buttock as still fitting and then establish an IV line). Then continue 1g /hour loading dose. Will need monitoring for toxicity: reflexes and RR
Give antihypertensive
Labetalol IV 20mg every 10mins max 80mg
Hydrazlazine IV 10mg every 20mins max 30mg
15 minutely observations
Bloods: FBC, EUC, LFT, coags and Mg level
IDC: urine PCR and to monitor urine output.
Fluid balance / restrict 80ml/hr
HDU / ICU
Check neurological status: pupils, reflexes and tone for signs of intracranial haemorrhage
Observe end organ function over next 24 hours
If seizure is prolonged could consider Diazepam 5-10mg IV or Midazolam 5-10mg IV/IM
Shoulder Dystocia
Head-to-body delivery time of 60 seconds plus.
Emergency call for help
Re-set legs to McRoberts and back of bed flat
Supra-pubic pressure 30secs continuous and 30 secs intermittent
Internal manouvres - consider episiotomy:
2 fingers on anterior aspect of posterior shoulder
2 fingers on posterior aspect of anterior shoulder and 2 fingers on anterior aspect of posterior shoulder to rotate
Reverse both of the above
Attempt to deliver the posterior arm
Place on all 4s and repeat
Last resort:
- Break fetal clavicle
Zavanelli - vaginal replacemtn of the fetal head and do c-section
Symphysiotomy
Hand baby to peads once delivered
Prepare for PPH
Document which shoulder was impacted
Debreief team and woman
3rd/4th degree repair
3rd degree: injury to perineum involving anal sphincter complex
3A - <50% EAS
3B - >50% EAS
3C EAS & IAS torn
4th degree: injury to perineum involving anal sphincter complex (EAS & IAS) and anal epithelium
Consent: bleeding, infection, wound breakdown, fistula, dyspareunia, Incontinence, pain, scarring
Consider colorectal input/senior gynaecologist
WHO sign in
FBC, UEC, CRP
GA and dorsal lithotomy
Good lighting
IDC
Abx: cefuroxime and metronidazole
PR exam and vaginal exam
Rectal mucosa: close from apex with interrupted or continuous 3/0 Vicryl sutures with knots in the lumen
Dissection of EAS and IAS if necessary laterally
IAS: end to end repair with interrupted 3/0 PDS suture
EAS: end to end or overlapping repair with 3/0 PDS suture
Check bulk of sphincter prior to
Repair perineal muscles and skin continuously with 2/0 Vicryl Rapide
PR at end to ensure no sutures in rectum
Post-op: debrief, document, DVT prophylaxis, discuss breastfeeding, contraception, postnatal depression
2/52 laxatives, 7-10 days prophylactic Abx, physio, review in clinic 6/52, consultation in early pregnancy in next pregnancy
B Lynch
obilise the uterus
Lower segment incision with
exploration of the cavity, removal or any RPOC, figure 8 sutures to any
bleeding points
Using 1 vicryl on a CTX
-
1 (large needle)
Take a bite 3cm below your incision lateral to your right angle coming up 3cm superior to the
incision.
Pass the suture over th
e uterine fundus and take a bite in superiorly and out inferiorly at similar
corresponding levels on the posterior wall of the uterus on the right side
The suture is then passed horizontally to the left side of the uterus.
This time a bite is taken on th
e posterior wall 3cm superior to and taken out 3cm inferior to the
corresponding incision site on the anterior uterine wall
Once again the suture is passed over the fundus this time back to the anterior surface of the uterus
on the left side
A final bite i
s taken by entering 3cm superior to the incision lateral to the left angle coming out 3cm
inferior to the incision.
The uterus is compressed bimanually and the suture pulled tight. The two suture ends are tied
anteriorly in the midline.
The hysterotomy
incision is then closed in a routine 2 layer fashion
ECV
Absolute contraindications to ECV that are likely to be associated with increased mortality or morbidity:
• where caesarean delivery is required for e.g. placenta praevia
• antepartum haemorrhage within the last 7 days
• abnormal cardiotocography
• ruptured membranes
Review gestation, incation, scans and Rh status, exclude contraindications CTG US to confirm presentation and attitude, growth, placental location, exclude uterine and fetal abnormalities Consent Consider tocolysis Ensure ability to delivery if emergency Awake patient, empty bladder, positioned left lateral, slightly head down Disengage breech from pelvis wit h dominant hand Flex fetal head with other hand and encourage forward or backward somersault If successful, stabilise cephalic presentation manually Rescan to confirm presentation Repeat CTG Anti - D if required D/C when comfortable Advise to present for R /V if needed
ECV
Absolute contraindications to ECV that are likely to be associated with increased mortality or morbidity:
• where caesarean delivery is required for e.g. placenta praevia
• antepartum haemorrhage within the last 7 days
• abnormal cardiotocography
• ruptured membranes
Relative contraindications where ECV might be more complicated:
• small-for-gestational-age fetus with abnormal Doppler parameters
• pre-eclampsia
• oligohydramnios
• major fetal anomalies
• uterine anomalies (ECV is less likely to be successful)
Should be carried out from 37 weeks onwards
1:200 need EmLSCS
Complications: abruption, cord prolapse, ROM or APH
Success 60% multip 40% prinip
Review gestation, incation, scans and Rh status
CTG
US to confirm presentation
Consent
Consider tocolysis
Ensure ability to delivery if emergency
Awake patient, empty bladder, positioned left lateral, slightly head down
Disengage breech from pelvis with dominant hand
Flex fetal head with other hand and encourage forward or backward somersault
If successful, stabilise cephalic presentation manually
Rescan to confirm presentation
Repeat CTG
Anti-D if required
D/C when comfortable
Classical c-section
Carefully asses if the incision is adequate and extend if necessary before proceeding to the uterine incision
Uterine incision
Locate the round ligaments and assess whether the uterus is rotated or not ,if rotate then centre it
A classical uterine incision is made by incising the uterus parallel to the longitudinal axis of the uterus through the contractile portion of the myometrium
Deepen the centre of the incision steadily, not to wound the baby.
As soon as in the uterine cavity ,put two fingers into the wound and
complete it upwards and downwards using to cut the between the
fingers
Delivery of the baby Deliver the baby as breech
Clamp the cord and cut it and hand the baby to paediatrician
Deliver the uterus outside the abdominal cavity
As soon as her uterus has contracted, deliver her placenta and
membranes
Remove any shreds of membrane that remain by wiping the inside of her uterus with a swab.
Repair the uterus in layers
Closure of a classical incision
— Classical uterine incisions are much thicker and they are normally repaired in three layers. Space needs to be obliterated to achieve hemostasis and reduce the chance of hematoma formation. Sutures should be interrupted and absorbable continuous sutures to close the inner myometrial layer/interrupted sutures, including interrupted vertical figure of eight sutures.
Assistant manually reapproximate the incision by pushing the
myometrium on each side toward the midline as each suture is placed and tied. This reduces tension on the incision and helps prevent the suture from tearing through the myometrium, especially when closing the first layer.
The mid-portion of the thick myometrial layer is closed with a second line of sutures, leaving approximately 1 cm of outer myometrium still open.
We then close the serosa and outer layer using a baseball stitch, which is haemostatic and minimizes exposed raw surfaces, and thus may reduce adhesion. The baseball stitch is a continuous, unlocked stitch in which the needle is driven through the cut edge of the myometrium to exit the serosa a few millimetres from the incision for each needle bite.
This brings the serosal surfaces together to cover the infolded edges of the incision.
Ventouse Delivery
Prerequisites
o Must be able to consent
o Fully dilated
o Mid or low cavity, 0-1/5 palpable abdominally
o Bladder empty
o Adequate maternal effort/contractions
o Fetal position determined with confidence
o Cephalic
Senior midwife, inform senior obstetrician, paeds in room, designate someone to document and keep time
Gain consent
Adequate analgesia (pudendal block, perineal LA, epidural)
Empty bladder
CEFM
Vacuum
Centre of cup on flexion point 2 - 3cm anterior to posterior fontanelle in midline
Suction to 20mmHg, check for maternal tissue entrapment, increase to 80mmHg, check for entrapment
Await for suction to establish for 1 -2 minutes
Traction with contractions, shape of a J
Consider episiotomy
Maximum of 3 popoffs, no descent with 3 pulls, 20 minutes from application
Re-asses if instrument working at about 12 minutes
If no descent – transfer to OT for CS
If descent but pop-offs due to incorrect cup placement or too much caput, consider forceps
Remove cup when jaw delivered
Consider shoulder dystocia risk Active mgmt. 3rd stage Cord bloods Inspect and repair perineum Vitamin K for baby Post-op: document, debrief DVT prophylaxis, discuss breastfeeding and contraception, anti-D, postnatal depression, follow-up 6 weeks
Foreps
Prerequisites
o Must be able to consent
o Fully dilated
o Mid or low cavity, 0-1/5 palpable abdominally
o Bladder empty
o Adequate maternal effort/contractions
o Fetal position determined with confidence
o Cephalic
Senior midwife, inform senior obstetrician, paeds in room, designate someone to document and keep time
Gain consent
Adequate analgesia (pudendal block, perineal LA, epidural)
Empty bladder
CEFM
Forceps
Check forceps
Lubricate forceps
Guard maternal vagina with right hand
Left hand pencil grip insert left maternal blade first
Ask as assistant to stablise blade
Pencil grip to apply right maternal blade
Lock forceps, should lock easily
Position for safety
o Posterior fontanelle in midline, equidistant from blades
o Cannot fit more than one finger in fenestration
o Sagittal suture in midline
Traction with contraction ideally, J shape, downward pressure and traction simultaneously
Maximum 3 pulls no descent
Remove in reverse order when jaw delivered
Consider shoulder dystocia risk Active mgmt. 3rd stage Cord bloods Inspect and repair perineum Vitamin K for baby Post-op: document, debrief DVT prophylaxis, discuss breastfeeding and contraception, anti-D, postnatal depression, follow-up 6 weeks
Repair of injury to bladder
- Identify the location and extent of the injury, paying particular attention to whether the injury is limited to the dome of the bladder or whether there is suspicion of damage to the posterior bladder near the trigone. If it is the latter or there is any doubt, request urology attendance to help identify the extent of injury and carry out the necessary repair (Indigo carmine dye may need to be given to ensure the ureters are unaffected)
- If the injury is isolated to the bladder dome, repair can be done in 2 layers using an absorbable suture such as Vicryl, provided that the gynaecologist is experienced in and competent at the procedure. If in doubt, request urology attendance.
- Check the integrity of the repair by backfilling the bladder with an appropriate dye (e.g. methylene blue). This also ensures that there are no other bladder injuries to contend with
- IDC to remain in for a minimum of 7 days (this allows the suture line to heal without the bladder being distended and threatening its integrity)
- Request a cystourethrogram or CT cystogram for the day that trial of removal is planned to ensure that the bladder has healed before the IDC is removed
- Ensure that appropriate reports are made to the hospital’s adverse outcome monitoring systems and organise appropriate after-care (e.g. referral to ACC for treatment injury in New Zealand)
