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Reproduction and Sexual Health > Intrapartum and Postpartum Care and Complications > Flashcards

Intrapartum and Postpartum Care and Complications Flashcards

1
Q

Define antepartum haemorrhage?

A

(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

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2
Q

Commonest causes of APH?

A

commonest causes are placental abruption (40%) and placenta praevia (20%)

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3
Q

Definition of placental abruption?

A

separation of a normally implanted placenta partially or totally before the birth of the fetus (it is a clinical diagnosis)

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4
Q

Causes of placental abruption?

A

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

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5
Q

Contrast the symptoms and signs of placenta praevia vs placental abruption?

A

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

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6
Q

Signs of placental abruption?

A

unwell patient, tender uterus, woody hard uterus, FHR may be low or absent, CTG shows irritable uterus

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7
Q

Management of placental abruption?

A

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

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8
Q

Describe recurrence rate of placental aburption?

A

recurrence rate is high both throughout pregnancy if baby not delivered and in subsequent pregnancies

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9
Q

Define placenta praevia?

A

placenta praevia is when the placenta lies directly over the internal os, low lying placenta means the placenta is close to the internal os

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10
Q

Placenta praevia is more common in?

A

multiparous women, in pregnancy of multiple pregnancy and where there has been one or more previous C sections

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11
Q

Describe placenta praevia and when it is picked up?

A

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%

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12
Q

Investigations for placenta praevia?

A

transvaginal US is superior to abdominal for diagnosing PP and LLP, MRI should be done if placenta accreta suspected

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13
Q

Symptoms of placenta praevia?

A

painless bleeding (usually unprovoked but can be triggered by coitus), fetal movements present

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14
Q

Signs of placenta praevia?

A

unlike abruption the patient’s condition is directly proportional to the amount of observed bleeding, malpresentation of fetus and unstable lie, normal uterine tone

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15
Q

Examination of placenta praevia?

A

can do a speculum exam but should NEVER do digital vaginal exam until excluded PP as could irritate the placenta

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16
Q

Management of placenta praevia?

A

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

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17
Q

Definition of placenta accreta?

A

placenta is abnormally adherent to the uterine wall (5-10% of placenta praevia) because it has invaded the myometrium

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18
Q

Risk of placenta accreta increases with ______

A

multiple C sections

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19
Q

What is placenta accreta associated with?

A

severe bleeding, PPH and may end up having hysterectomy

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20
Q

Define uterine rupture?

A

full thickness opening of uterus including serosa

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21
Q

Risk factors for uterine rupture?

A

previous C section or uterine surgery, multiparity and use of prostaglandins/ syntocinon, obstructed labour

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22
Q

Symptoms of uterine rupture?

A

severe abdo pain, shoulder tip pain, maternal collapse, PV bleeding

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23
Q

Signs of uterine rupture?

A

if intrapartum get loss of contractions, PP rises, peritonism and acute abdo, fetal distress, IUD

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24
Q

Define Post partum haemorrhage?

A

blood loss equal to or exceeding 500ml after the birth of the baby

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25
Q

Define primary, secondary, minor and major PPH?

A

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

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26
Q

What is it important to remember about PPH?

A

Visual blood loss may be underestimated!
Total blood volume depends on maternal body weight!
100mls/kg blood volume in pregnancy

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27
Q

Causes of primary PPH?

A

From most to least common:

1) Tone: uterine atony
2) trauma: vaginal tear, cervical laceration, rupture
3) tissue: RPOC
4) thrombin: a coagulopathy

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28
Q

Explain how uterine atony can cause PPH?

A

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.

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29
Q

What is the most common cause of PPH?

A

uterine atony

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30
Q

Antenatal risk factors for PPH?

A 
anaemia 
previous caesarean section
placenta praevia, percreta, accreta 
 previous PPH
Previous retained placenta
Multiple pregnancy
Polyhydramnios
Obesity
Fetal macrosomia
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31
Q

Prevention of PPH?

A 
Identify intrapartum risk factors:
 prolonged labour
 operative vaginal delivery 
caesarean section 
retained placenta

Active management of third stage:
Syntocinon/syntometrine IM/IV

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32
Q

Management of Primary PPH?

A

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

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33
Q

Causes of secondary PPH?

A

retained placental tissue (RPOC), intrauterine infections, rare things such as trophoblastic disease and abnormal vasculature

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34
Q

Management of secondary PPH?

A

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

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35
Q

In primary PPH what do most women respond to?

A

IV syntocinon

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36
Q

Symptoms of rubella?

A

causes a flu like illness associated with a polyarthritis and a facial vesicular rash that spreads to the limbs and trunk

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37
Q

Women not immune to rubella are at risk of what in the first trimester?

A

miscarriage

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38
Q

Are you at higher risk of congenital rubella syndrome if you get infected early or late pregnancy?

A

early pregnancy

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39
Q

IgG vs IgM if checking for exposure vs past infection?

A

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

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40
Q

Triad in congenital rubella syndrome?

A

cataract, cardiac abnormalities and deafness

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41
Q

If early gestation and recent exposure to rubella what should be considered?

A

TOP

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42
Q

Symptoms of measles vs chickenpox?

A

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

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43
Q

Measles effect on pregnancy?

A

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

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44
Q

Chickenpox effect on pregnancy?

A

early on < 28 weeks there is a risk of fetal varicella syndrome, if > 28 weeks risk of neonatal VZV (which is life threatening)

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45
Q

Treatment if chickenpox in pregnancy?

A

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

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46
Q

What is the most common cause of congenital infection?

A

CMV

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47
Q

What is the leading non-genetic cause of sensorineural deafness/ disability?

A

CMV

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48
Q

When is the risk of congenital infection with CMV higher?

A

if primary and if in last trimester

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49
Q

Describe when symptoms develop with congenital CMV?

A

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

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50
Q

Fetal infection with parvovirus is associated with what?

A

severe anaemia, heart failure and hydrops fetalis

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51
Q

Risk is higher for fetus if infection with parvovirus when?

A

before 20 weeks

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52
Q

Management of exposure to parvovirus if pregnant?

A

refer to fetal medicine specialist- serial USS and fetal MCA doppler

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53
Q

Mumps effect on pregnancy?

A

no ill effect on pregnancy

54
Q

Influenza effect on pregnancy?

A

no ill effect

55
Q

Is the flu vaccine safe in pregnancy and breastfeeding?

A

yes

56
Q

How does the zika virus affect pregnancy?

A

the majority of people have no symptoms but can cause serious birth defects

57
Q

Advice for women regarding zika virus?

A

if pregnant or trying to get pregnant dont travel to a zika area, if been to zika area avoid pregnancy for 6 months

58
Q

COVID19 effect on pregnancy?

A

don’t seem at increased risk of becoming infected or of severe disease

59
Q

Risk of fetal infection is ____ in primary genital HSV?

A

high

60
Q

Management of HSV infection in pregnancy?

A

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

61
Q

If a woman has HIV when can she have a vaginal delivery? When is baby tested?

A

< 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

62
Q

Feeding advice for HIV positive women?

A

formula safest but if on ARV and undetectable viral load mother can choose

63
Q

Describe Group B Streptococcus infection in pregnancy?

A

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

64
Q

Describe UTI infection in pregnancy?

A

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

65
Q

Is vaginal trauma common in birth?

A

yes, it is quite common for first time mothers to suffer from some form of tear

66
Q

How can small tears be treated?

A

they can be sutured by the midwife

67
Q

Explain 1st, 2nd, 3rd and 4th perineal tears?

A

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

68
Q

Treatment of third and fourth degree perineal tears?

A

these are abnormal and need fixed by the obstetrician

69
Q

Causes of puerperal sepsis?

A 
endometritis
wound infection 
perineal infection 
chest infection 
thrombophlebitis 
breast abscess
70
Q

Explain what happens in endometritis?

A

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

71
Q

Risk factors for endometritis?

A 
prolonged labour 
prolonged rupture of membranes
multiple vaginal examinations 
retained placental tissue
C section
more complex deliveries e.g. forceps
72
Q

Organisms involved in endometritis?

A

GBS, staph, e.coli and anaerobes

73
Q

Progression of endometritis?

A

endometritis > salpingitis > pelvic infection > pelvic abscess > peritonitis

74
Q

Management of endometritis and puerperal sepsis?

A

should start the sepsis six care bundle

75
Q

Examination and symptoms of endometritis?

A

patient has fever, tachycardia, lower abdomen tender on palpation, patient may have secondary PPH, foul smelling vaginal discharge, bleeding and cervical excitation

76
Q

Define fetal presention? What is normal presentation?

A

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)

77
Q

List some malpresentations?

A 
breech (feet first)
face (head is hyperextended)
brow (somewhere between face and vertex)
transverse
shoulder/ arm
78
Q

How is breech presentation best delivered?

A

C section
vaginal delivery risks head entrapment as because the legs are smaller they may stay delivering before the cervix is fully dilated

79
Q

Will transverse or shoulder/ arm presentation deliver? Explain the risks?

A

transverse or shoulder/ arm presentation will not deliver, the uterus will keep contracting until exhaustion, severe sepsis, ruptured uterus and risk of maternal death

80
Q

Define position?

A

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

81
Q

What is thought to be the normal position?

A

occipitoanterior position (the back of the baby’s head is at the front > anterior fontanelle is bigger)

82
Q

How can you tell back of baby’s head from front?

A

anterior fontanelle is bigger

83
Q

Explain 2 examples of malposition? What are the risks?

A

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

84
Q

Define failure of progression of labour in stage 1?

A

< 2 cm dilation in 4hrs or slowing progress

85
Q

Normal duration of second stage of labour?

A

primiparous- 2hrs no epi, 3 hrs epi

multiparous- 1hr no epi, 2 hrs epi

86
Q

List some of the things recorded in a partogram?

A

fetal heart rate, liquor, caput and moulding, descent of fetal head, cervical dilation, strength and frequency of contraction, drugs, pulse and BP, urine

87
Q

Describe what liquor is and what may be recorded in a partogram?

A

liquor = amniotic fluid
if ruptured colour can be recorded
meconium stained liquor can be a sign of fetal distress

88
Q

Explain what caput and moulding are?

A

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

89
Q

Explain descent of the fetal head measurement on partogram?

A

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

90
Q

Explain what failure to progress is due to?

A

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)

91
Q

Is continuous electrical fetal monitoring done in low risk women?

A

no- it increases intervention but is not shown to improve outcome so women are just monitored at intervals

92
Q

CEFM with ____ is a screening tool for fetal hypoxia

A

CTG

93
Q

Risk factors for fetal hypoxia that warrant CEFM?

A 
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
94
Q

Describe aetiology of fetal hypoxia?

A

can be acute (abruption, cord prolapse, rupture, haemorrhage, vasa praevia, epidural) or chronic (placental insufficiency or fetal anaemia)

95
Q

Explain DR C BRAVADO for CTG interpretation?

A 
DR- define risk, why is patient on CTG
Contractions 
BRA- baseline rate
V- variability
A- acccelerations 
D- decelerations 
O- overall impression
96
Q

Describe contractions on CTG?

A

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

97
Q

Describe BRA on CTG?

A

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

98
Q

Describe V on CTG?

A

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

99
Q

Describe A on CTG?

A

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

100
Q

Describe D on CTG?

A

decelerations, opp of A, abnormal, need review (decelerations can be early before the contractions or late)

101
Q

What two things should you beaware of on CTG?

A

terminal bradycardia and terminal decelerations

102
Q

What does operative vaginal delivery involve and what is the aim?

A

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

103
Q

Ventouse vs forceps?

A

ventouse causes less perineal trauma than forceps but is more likely to fail

104
Q

List some indications for operative vaginal delivery?

A

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

105
Q

Requirements for forceps delivery?

A

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)

106
Q

Roughly what percentage of women end up with C section?

A

30%

107
Q

Main indications for C section?

A

previous C section, fetal distress, failure to progress in labour, breech presentation, maternal request

108
Q

When is induction of labour done?

A

when risk to mother or child of continuing pregnancy exceeds the risk of inducing labour

109
Q

Indications for induction of labour?

A

prolonged pregnancy (an excess of 42 weeks), pre-eclampsia, placental insufficiency and IUGR, APH, rhesus isoimmunisation, diabetes, chronic renal disease

110
Q

What allows you to determine likely outcome of IOL? What determines method?

A

bishops score

methods determined by whether membranes are still intact and score on cervical assessment

111
Q

Examples of IOL?

A

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

112
Q

Describe use of narcotic analgesia in labour?

A

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

113
Q

Describe use of inhalational analgesia in labour?

A

etonox (N3 and O2), AKA gas and air, often used in early labour, sometimes inadequate as labour progresses

114
Q

Describe advantages of epidural use in labour?

A

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

115
Q

Describe disadvantages of epidural use in labour?

A

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

116
Q

What is pudendal nerve block often used for?

A

operative vaginal delivery

117
Q

What is spinal anaesthesia commonly used for?

A

operative delivery

118
Q

When is general anaesthesia used?

A

fast onset so used in emergencies but woman doesnt get birth experience

119
Q

2 risks to baby in forceps and ventouse delivery?

A

ventouse: cephalohaematoma
forceps: facial nerve palsy

120
Q

In women with a previous baby with early or late onset GBS disease?

A

offer maternal IV antibiotc prophylaxis during labour

121
Q

Explain what vasa praevia is?

A
  • 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
122
Q

Explain the two types of vasa praevia?

A

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
123
Q

Risk factors for vasa praevia?

A
  • Low lying placenta
  • IVF pregnancy
  • Multiple pregnancy
124
Q

Presentation of vasa praevia?

A
  • 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
125
Q

Management of vasa praevia?

A
  • 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
126
Q

Explain what umbilical cord prolapse is and why it is bad?

A
  • 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
127
Q

Risk factors for umbilical cord prolapse?

A
  • 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
128
Q

Presentation/ diagnosis of umbilical cord prolapse?

A
  • 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
129
Q

Management of umbilical cord prolapse?

A
  • 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
130
Q

Describe screening for GBS and management?

A

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

131
Q

Brief overview of IOL?

A

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

132
Q

In cord prolapse what is correct procedure if cord is passed the level of the introitus?

A

there should be minimal handling and it should be kept warm and moist to avoid vasospasm

Reproduction and Sexual Health (20 decks)

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