Intrapartum and Postpartum Care and Complications Flashcards
Define antepartum haemorrhage?
(no of weeks varies but in UK)
Bleeding from the genital tract after 24 weeks gestation and before the end of teh seconds stage of labour
Commonest causes of APH?
commonest causes are placental abruption (40%) and placenta praevia (20%)
Definition of placental abruption?
separation of a normally implanted placenta partially or totally before the birth of the fetus (it is a clinical diagnosis)
Causes of placental abruption?
in majority of cases no specific predisposing factor can be identified for a particular episode
associations include hypertensive disease, maternal thrombophilia, FGR, trauma, domestic violence
Contrast the symptoms and signs of placenta praevia vs placental abruption?
placental abruption:
painful bleeding
blood doesnt necessarily correlate to maternal condition as can be concealed
fetal lie is stable and longitudinal usually
uterus has increased tone
placenta praevia:
painless bleeding
amount of blood correlates to maternal condition
fetal lie is unstable and malpresentation common
uterus has normal tone
Signs of placental abruption?
unwell patient, tender uterus, woody hard uterus, FHR may be low or absent, CTG shows irritable uterus
Management of placental abruption?
Resus mother and ABC if needed
admit patient to hospital and assess fetal growth
if fetus is alive and close to term or fetus dead can do IOL ASAP
if the fetus is compromised then should do C section
if fetus is preterm aim to prolong pregnancy if can and if both stable then can get them to stay in hospital until bleeding and pain gone and then get them back in for IOL at 37-38 weeks
Describe recurrence rate of placental aburption?
recurrence rate is high both throughout pregnancy if baby not delivered and in subsequent pregnancies
Define placenta praevia?
placenta praevia is when the placenta lies directly over the internal os, low lying placenta means the placenta is close to the internal os
Placenta praevia is more common in?
multiparous women, in pregnancy of multiple pregnancy and where there has been one or more previous C sections
Describe placenta praevia and when it is picked up?
checked for at anomaly scan when 5% of women will have it, these women are referred on for subsequent scans because as they get closer to term this number drops to 0.5%
Investigations for placenta praevia?
transvaginal US is superior to abdominal for diagnosing PP and LLP, MRI should be done if placenta accreta suspected
Symptoms of placenta praevia?
painless bleeding (usually unprovoked but can be triggered by coitus), fetal movements present
Signs of placenta praevia?
unlike abruption the patient’s condition is directly proportional to the amount of observed bleeding, malpresentation of fetus and unstable lie, normal uterine tone
Examination of placenta praevia?
can do a speculum exam but should NEVER do digital vaginal exam until excluded PP as could irritate the placenta
Management of placenta praevia?
Admit, rhesus screen, FBC, cross match, CTG, anti D if Rh neg, steroids if 24-36 weeks, prevent and treat anaemia, try and plan delivery near term, if stopped bleeding can send patient home with advice and plan delivery near term, if still bleeding may need to activate the major haemorrhage protocol and may need to deliver
Definition of placenta accreta?
placenta is abnormally adherent to the uterine wall (5-10% of placenta praevia) because it has invaded the myometrium
Risk of placenta accreta increases with ______
multiple C sections
What is placenta accreta associated with?
severe bleeding, PPH and may end up having hysterectomy
Define uterine rupture?
full thickness opening of uterus including serosa
Risk factors for uterine rupture?
previous C section or uterine surgery, multiparity and use of prostaglandins/ syntocinon, obstructed labour
Symptoms of uterine rupture?
severe abdo pain, shoulder tip pain, maternal collapse, PV bleeding
Signs of uterine rupture?
if intrapartum get loss of contractions, PP rises, peritonism and acute abdo, fetal distress, IUD
Define Post partum haemorrhage?
blood loss equal to or exceeding 500ml after the birth of the baby
Define primary, secondary, minor and major PPH?
Primary within 24h of delivery
Secondary >24h - 6/52 post delivery
Minor: PPH 500ml- 1000ml ( without clinical shock)
Major PPH : >1000ml or signs of cardiovascular collapse or on-going bleeding
What is it important to remember about PPH?
Visual blood loss may be underestimated!
Total blood volume depends on maternal body weight!
100mls/kg blood volume in pregnancy
Causes of primary PPH?
From most to least common:
1) Tone: uterine atony
2) trauma: vaginal tear, cervical laceration, rupture
3) tissue: RPOC
4) thrombin: a coagulopathy
Explain how uterine atony can cause PPH?
After the placenta is delivered, these contractions help compress the bleeding vessels in the area where the placenta was attached. If the uterus does not contract strongly enough, called uterine atony, these blood vessels bleed freely and hemorrhage occurs.
What is the most common cause of PPH?
uterine atony
Antenatal risk factors for PPH?
anaemia previous caesarean section placenta praevia, percreta, accreta previous PPH Previous retained placenta Multiple pregnancy Polyhydramnios Obesity Fetal macrosomia
Prevention of PPH?
Identify intrapartum risk factors: prolonged labour operative vaginal delivery caesarean section retained placenta
Active management of third stage:
Syntocinon/syntometrine IM/IV
Management of Primary PPH?
SIMULTANEOUS MANAGEMENT:
1) stop the bleeding: massage of uterus, IV syntocinon, may need surgery
2) assess: determine cause, blood stamples, vitals
3) fluid replacement: 2 large bore IV access, fluid crystalloid, blood transfusion early
Causes of secondary PPH?
retained placental tissue (RPOC), intrauterine infections, rare things such as trophoblastic disease and abnormal vasculature
Management of secondary PPH?
exclude RPOC with USS
treatment depends on whether bleeding is light or heavy and if signs of sepsis
if light bleeding observe and course of antibiotics
if heavy and signs of infection IV broad spectrum antibiotics and EUA are indicated
In primary PPH what do most women respond to?
IV syntocinon
Symptoms of rubella?
causes a flu like illness associated with a polyarthritis and a facial vesicular rash that spreads to the limbs and trunk
Women not immune to rubella are at risk of what in the first trimester?
miscarriage
Are you at higher risk of congenital rubella syndrome if you get infected early or late pregnancy?
early pregnancy
IgG vs IgM if checking for exposure vs past infection?
IgG means you have been infected (cant tell if in past or not)
IgM if taken 10 days after exposure if positive means you have recently been exposed
Triad in congenital rubella syndrome?
cataract, cardiac abnormalities and deafness
If early gestation and recent exposure to rubella what should be considered?
TOP
Symptoms of measles vs chickenpox?
measles: fever, red blotchy rash that first appears on the forehead, red inflammed eyes, cough, Kopliks spots (white spots) inside mouth
chicken pox: red spots appear first on chest, face and back, fever, fatigue, loss of appetite, spots turn to blisters
Measles effect on pregnancy?
Measles is non teratogenic
However high fever can cause IUGR, microcephaly, miscarriage, still birth and preterm birth
high mortality if mother develops pneumonia or encephalitis
Chickenpox effect on pregnancy?
early on < 28 weeks there is a risk of fetal varicella syndrome, if > 28 weeks risk of neonatal VZV (which is life threatening)
Treatment if chickenpox in pregnancy?
blood test can be done to check immunity to the virus
if non-immune woman should be offered VZIG as PEP ASAP up to 10 days after exposure
oral aciclovir if within 24 hours of rash and > 20 weeks gestation
if severe disease IV aciclovir
may need referral to fetal medicine specialist
What is the most common cause of congenital infection?
CMV
What is the leading non-genetic cause of sensorineural deafness/ disability?
CMV
When is the risk of congenital infection with CMV higher?
if primary and if in last trimester
Describe when symptoms develop with congenital CMV?
13% of those with congenital CMV are symptomatic at birth, of asymptomatic 8-23% go onto have hearing loss
if confirmed infection refer to specialist and fetal MRI and if scans normal should still be followed up into the neonatal period
Fetal infection with parvovirus is associated with what?
severe anaemia, heart failure and hydrops fetalis
Risk is higher for fetus if infection with parvovirus when?
before 20 weeks
Management of exposure to parvovirus if pregnant?
refer to fetal medicine specialist- serial USS and fetal MCA doppler
Mumps effect on pregnancy?
no ill effect on pregnancy
Influenza effect on pregnancy?
no ill effect
Is the flu vaccine safe in pregnancy and breastfeeding?
yes
How does the zika virus affect pregnancy?
the majority of people have no symptoms but can cause serious birth defects
Advice for women regarding zika virus?
if pregnant or trying to get pregnant dont travel to a zika area, if been to zika area avoid pregnancy for 6 months
COVID19 effect on pregnancy?
don’t seem at increased risk of becoming infected or of severe disease
Risk of fetal infection is ____ in primary genital HSV?
high
Management of HSV infection in pregnancy?
primary infection in early 1st or 2nd trimester or recurrent infection can be managed with oral antiviral agents, these women can have a vaginal delivery unless they have active lesions around the time of delivery in which case they need a C section
if woman has primary infection towards end of 3rd trimester then risk of infection to fetus is much higher (esp if active lesions), these women need a C section, may also need started on iV aciclovir, fetal monitoring and started on feta antiviral agents
If a woman has HIV when can she have a vaginal delivery? When is baby tested?
< 50 copies /ml she can be offered vaginal delivery, if higher C section is protective to the baby
baby is tested at birth and at regular intervals up to 2 years
Feeding advice for HIV positive women?
formula safest but if on ARV and undetectable viral load mother can choose
Describe Group B Streptococcus infection in pregnancy?
GBS is a common commensal in GI tract and in 25% of women in pregnancy in vagina
during vaginal delivery there is a risk of transmission to the neonate, the risk is increased in preterm delivery and prolonged rupture of membranes
neonatal infections can result in overwhelming sepsis
if risk factors for neonatal infection present use of intrapartum IV penicillin can reduce risk
Describe UTI infection in pregnancy?
women are more prone to UTIs in pregnancy as increased progesterone causes sphincters to relax
incidence of pyelonephritis in pregnancy is increased so important to screen for
Is vaginal trauma common in birth?
yes, it is quite common for first time mothers to suffer from some form of tear
How can small tears be treated?
they can be sutured by the midwife
Explain 1st, 2nd, 3rd and 4th perineal tears?
1st degree: tear of superficial tissues
2nd degree: involves superficial and deep perineal muscles
3rd degree: involvement of anal sphincters
4th degree: involvement of anal or rectal mucosa, usually also involves sphincters
Treatment of third and fourth degree perineal tears?
these are abnormal and need fixed by the obstetrician
Causes of puerperal sepsis?
endometritis wound infection perineal infection chest infection thrombophlebitis breast abscess
Explain what happens in endometritis?
the uterus is usually sterile and protected from the vagina by the cervix and the mucus plug
hence in labour the uterus is more vulnerable to infection
Risk factors for endometritis?
prolonged labour prolonged rupture of membranes multiple vaginal examinations retained placental tissue C section more complex deliveries e.g. forceps
Organisms involved in endometritis?
GBS, staph, e.coli and anaerobes
Progression of endometritis?
endometritis > salpingitis > pelvic infection > pelvic abscess > peritonitis
Management of endometritis and puerperal sepsis?
should start the sepsis six care bundle
Examination and symptoms of endometritis?
patient has fever, tachycardia, lower abdomen tender on palpation, patient may have secondary PPH, foul smelling vaginal discharge, bleeding and cervical excitation
Define fetal presention? What is normal presentation?
presentation: which part is pointing down into the pelvis (ie which part will come out first)
normal presentation is vertex presentation (the vertex is the area of the fetal skull outlined by the anterior and posterior fontanelles and the parietal eminences)
List some malpresentations?
breech (feet first) face (head is hyperextended) brow (somewhere between face and vertex) transverse shoulder/ arm
How is breech presentation best delivered?
C section
vaginal delivery risks head entrapment as because the legs are smaller they may stay delivering before the cervix is fully dilated
Will transverse or shoulder/ arm presentation deliver? Explain the risks?
transverse or shoulder/ arm presentation will not deliver, the uterus will keep contracting until exhaustion, severe sepsis, ruptured uterus and risk of maternal death
Define position?
position of the fetal head is defined as the relationship of the denominator to the fixed points of the maternal pelvis
the denominator of the head is defined as the most definable prominence at the periphery of the presenting part
What is thought to be the normal position?
occipitoanterior position (the back of the baby’s head is at the front > anterior fontanelle is bigger)
How can you tell back of baby’s head from front?
anterior fontanelle is bigger
Explain 2 examples of malposition? What are the risks?
occipitoposterior (back of baby’s head at back) and occipitotransverse (baby’s head in transverse plane)
most of the time the baby can be safely delivered in these positions although labour may take longer or need instrumental delivery
Define failure of progression of labour in stage 1?
< 2 cm dilation in 4hrs or slowing progress
Normal duration of second stage of labour?
primiparous- 2hrs no epi, 3 hrs epi
multiparous- 1hr no epi, 2 hrs epi
List some of the things recorded in a partogram?
fetal heart rate, liquor, caput and moulding, descent of fetal head, cervical dilation, strength and frequency of contraction, drugs, pulse and BP, urine
Describe what liquor is and what may be recorded in a partogram?
liquor = amniotic fluid
if ruptured colour can be recorded
meconium stained liquor can be a sign of fetal distress
Explain what caput and moulding are?
caput is a diffuse swelling of the scalp caused by the pressure of the scalp against the dilated cervix in labour, it’s associated with moulding
moulding refers to the bones overlapping so head fits through the pelvis, significant moulding can be a sign of cephalo-pelvic disproportion, up to 2+ is normal
Explain descent of the fetal head measurement on partogram?
descent of the fetal head is recorded by assessing the level of presenting part in cm above or below the ischial spine and marked as +1, +2, +3 if below the spines and -1, -2, -3 if above the spines
Explain what failure to progress is due to?
this is due to the 3Ps
powers- inadequate contractions in frequency and/ or strength
passages- short stature/ trauma/ shape
passenger- big baby, malposition (relative cephalo pelvic disproportion)
Is continuous electrical fetal monitoring done in low risk women?
no- it increases intervention but is not shown to improve outcome so women are just monitored at intervals
CEFM with ____ is a screening tool for fetal hypoxia
CTG
Risk factors for fetal hypoxia that warrant CEFM?
small fetus preterm or post dates APH hypertension or pre eclampsia diabetes meconium epidural analgesia VBAC (vaginal birth after C section) PROM > 24 hours sepsis (temp > 38 C) induction/ augmentation of labour
Describe aetiology of fetal hypoxia?
can be acute (abruption, cord prolapse, rupture, haemorrhage, vasa praevia, epidural) or chronic (placental insufficiency or fetal anaemia)
Explain DR C BRAVADO for CTG interpretation?
DR- define risk, why is patient on CTG Contractions BRA- baseline rate V- variability A- acccelerations D- decelerations O- overall impression
Describe contractions on CTG?
these are peaks at the bottom of the trace, a small box = 1 minute, CTG only demonstrates contraction frequency not strength, expect 3-5 contractions in 10 mins in established labour
Describe BRA on CTG?
baseline rate, the fetal baseline HR should be approx 110-160 bpm, look at average rate over last 10 mins ignoring accelerations or decelerations, tachycardia is >160, bradycardia is < 110
Describe V on CTG?
variability is good, should be 5-25 bpm as this reflects the integrity of the autonomic nervous system, < 5bpm would be a reduced variability, it can be reduced by fetal sleep state but this shouldn’t last > 40 mins
Describe A on CTG?
accelerations, increase in FHR by at least 15 bpm for 15 s or more, this is associated with fetal movemement, this is a good sign of a healthy baby
Describe D on CTG?
decelerations, opp of A, abnormal, need review (decelerations can be early before the contractions or late)
What two things should you beaware of on CTG?
terminal bradycardia and terminal decelerations
What does operative vaginal delivery involve and what is the aim?
involves the use of either forceps or vacuum extraction/ ventouse
the aim is to use the instrument to facilitate the same cardinal movements of the fetus during delivery as occurs in spontaneous vertex delivery
Ventouse vs forceps?
ventouse causes less perineal trauma than forceps but is more likely to fail
List some indications for operative vaginal delivery?
failure to progress in 2nd stage
fetal distress
maternal exhaustion
special scenarios where second stage needs shortened e.g. severe PET, heart disease, haemorrhage or cord prolapse
Requirements for forceps delivery?
Fully dilated cervix
OA position
ruptured membranes
cephalic presentation
engaged presenting part (head musnt be palpable abdominally and must be below the ischial spines
pain relief
sphincter - bladder empty (need to catheterise the bladder)
Roughly what percentage of women end up with C section?
30%
Main indications for C section?
previous C section, fetal distress, failure to progress in labour, breech presentation, maternal request
When is induction of labour done?
when risk to mother or child of continuing pregnancy exceeds the risk of inducing labour
Indications for induction of labour?
prolonged pregnancy (an excess of 42 weeks), pre-eclampsia, placental insufficiency and IUGR, APH, rhesus isoimmunisation, diabetes, chronic renal disease
What allows you to determine likely outcome of IOL? What determines method?
bishops score
methods determined by whether membranes are still intact and score on cervical assessment
Examples of IOL?
stripping of membranes, artificial ROM, medical induction following artificial ROM with syntocinon, medical induction by cervical ripening by administering prostaglandins, mechanical cervical ripening using balloon catheter
Describe use of narcotic analgesia in labour?
e.g. pethidine and morphine
helpful if women unsuitable for regional analgesia, can cause fetal resp depression particularly if given within 2 hours of delivery
Describe use of inhalational analgesia in labour?
etonox (N3 and O2), AKA gas and air, often used in early labour, sometimes inadequate as labour progresses
Describe advantages of epidural use in labour?
complete pain relief in majority of women
can be commenced at any time
doesnt increase risk of c section
can be topped up to allow operative deliveries
Describe disadvantages of epidural use in labour?
may reduce desire to bear down in second stage due to lack of pressure sensation at perineum
increased risk of associated vaginal delivery
causes abnormal fetal heart rate
risk of hypotension (although give meds to avoid this)
accidental dural puncture
postdural headache
atonic bladder
high block can cause resp depression in mother
What is pudendal nerve block often used for?
operative vaginal delivery
What is spinal anaesthesia commonly used for?
operative delivery
When is general anaesthesia used?
fast onset so used in emergencies but woman doesnt get birth experience
2 risks to baby in forceps and ventouse delivery?
ventouse: cephalohaematoma
forceps: facial nerve palsy
In women with a previous baby with early or late onset GBS disease?
offer maternal IV antibiotc prophylaxis during labour
Explain what vasa praevia is?
- Exposed/ fetal vessels within the fetal membranes that lie over the internal cervical os
- Usually the cord containing the fetal vessels inserts directly into the placenta and the fetal vessels are always protected by the umbilical cord or the placenta
Explain the two types of vasa praevia?
There are two instances when the fetal vessels can be exposed, outside the protection of the umbilical cord or placenta:
1. Velamentous umbilical cord- where the umbilical cord inserts into the chorioamniotic membranes and the fetal vessels travel unprotected through the membranes before joining the placenta
2. An accessory lobe of the placenta is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes
- These abnormalities can occur on their own and not be crossing the internal cervical os, so not vasa praevia
- If these abnormal vessels cross the internal cervical os then it is vasa praevia
Risk factors for vasa praevia?
- Low lying placenta
- IVF pregnancy
- Multiple pregnancy
Presentation of vasa praevia?
- Vasa praevia may be diagnosed by ultrasound during pregnancy, however it is not always easy to diagnose this antenatally
- It may present with painless antepartum haemorrhage
- It may be detected by vaginal exam during labour when pulsating fetal vessels are seen in the membranes through the dilated cervix
- Finally it may be detected during labour when fetal distress and dark-red bleeding occur following ROM, this carries a very high fetal mortality
Management of vasa praevia?
- Asymptomatic women should be given corticosteroids from 32 weeks to mature the fetal lungs and have a planned elective C section at 34-36 weeks gestation
- When APH occurs emergency C section is required to deliver the fetus before death occurs
- After stillbirths or unexplained fetal compromise during delivery the placenta is examined for evidence of vasa praevia as a possible cause
Explain what umbilical cord prolapse is and why it is bad?
- The umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina after rupture of the fetal membranes
- This is bad because the cord can be squeezed by the baby or the uterus during a contraction, this can reduce the amount of blood flowing through the cord and so can reduce oxygen supply to the baby
Risk factors for umbilical cord prolapse?
- The most significant risk factor is when the fetus is in an abnormal lie after 37 weeks gestation
- This is because if the fetus is in cephalic and the head is engaged there is generally not room for the cord to prolapse but an abnormal lie means there is more likely to be room
- also increased risk with artificial rupture of membranes
Presentation/ diagnosis of umbilical cord prolapse?
- Should suspect if there are signs of fetal distress on CTG
- It can be diagnosed by a vaginal exam to see if can feel the cord, speculum exam can also be helpful
Management of umbilical cord prolapse?
- This is an indication for a category 1 emergency C section
- (Category 1 section = immediate threat to mother or baby’s life, aim to be done in 30 minutes)
- Initial management whilst awaiting C section – when baby is compressing the cord push up the presenting part, put the women in left lateral position or knee chest position, can also give tocolytics e.g. terbutaline to minimize further contractions whilst awaiting C section
Describe screening for GBS and management?
screening for GBS is not routinely offered
However if GBS is found in urine, vagina or rectum during current pregnancy or if had a baby affected by GBS infection you should be offered antibiotics in labour to reduce risk of infection to baby
if in preterm labour should offer antibiotics regardless of status
women with pyrexia during labour should also be given IAP
benzylpenicillin is the antibiotic of choice in GBS prophylaxis
Brief overview of IOL?
Bishops < 6 need to prime cervix
Bishops > 6 more favourable
membrane sweep is more of an adjunct to IOL as opposed to part of IOL process
if cervix closed/ not favourable - vaginal prostaglandins or balloon (balloon good if worry over HS) then oxytocin plus or minus amniotomy
if cervix favourable can go straight to amniotomy plus oxytocin
In cord prolapse what is correct procedure if cord is passed the level of the introitus?
there should be minimal handling and it should be kept warm and moist to avoid vasospasm
