Intrapartum care: tears, uterine rupture, amniotic fluid embolism Flashcards
What are perineal tears
tears in perineum caused by childbirth
What % of deliveries have perineal trauma
80
What are 5 RFs for perineal tear
Episiotomy Macrosoma Instrumental delivery Shoulder dystocia Nulliparous IOL
What is a first-degree tear
Tear in mucosa
How are first degree tears handled
Appose themselves
What is a second-degree tear
Tear in underlying perineal muscles
What is used to repair second-degree tears
Absorbable sutures
What is 3A degree tear
Tear in external anal sphincter <50%
What is 3B degree tear
Tear in external anal sphincter >50%
What is 3C degree tear
Tear in internal anal sphincter
How is third-degree tear investigated
Rectal exam
How is third-degree tear managed immediately
Take to theatre - suture under GA
Antibiotics
What is used to manage third-degree tears long-term
Lactulose and high-fibre diet for 10d
Physiotherapy
How long is a high-fibre diet and lactulose given
10d
If pain or incontinence following a third degree tear where should the person be referred and why
Refer to colorectal surgeon for mamonetry or US
what is a fourth degree tear
tear in external anal sphincter, internal anal sphincter and rectal mucosa
explain management for fourth-degree tear
- Theatre for suture under GA
- Antibiotics
- Physio
- Lactulose and high–fibre diet
what is a uterine rupture
break in muscle and overlying serosa of the uterus
what is an incomplete uterine rupture
perineum remains intact - meaning uterine contents remain in uterus
what is complete uterine rupture
perineum disrupted - remaining uterine contents enter peritoneal cavity
what is the biggest risk factor for uterine rupture
c-section (especially classical scar)
what are 5 risk factors for uterine rupture
multiparous multiple pregnancy past C-section past uterine surgery induction w/prostaglandins
what are the clinical features of uterine rupture
severe pain persistent between contractions
shoulder tip pain
how may women with uterine rupture present
hypovolaemic shock
if at risk of uterine rupture what should be ordered
CTG
what can be used to diagnose uterine rupture
US
how is uterine rupture approached
A-E approach Airways - Breathing - 15L oxygen Cardiac - 2 large bore cannula, cross-match, fluid D E
what is the definitive management for uterine rupture
Emergency C-section
Hysterectomy or repair
how quickly should hysterectomy or repair be performed
Within 30-minutes
what is an amniotic fluid embolism
foetal cells or amniotic fluid enters maternal circulation and stimulates an autoimmune reaction
how common is amniotic fluid embolism
rare cause of maternal collapse
what time frame does amniotic fluid embolism occur
30-minutes into labour
what is the clinical presentation of amniotic fluid embolism
‘anaphylaxis-type’ picture
- Hypoxia, Hypotension
- Foetal distress
- Shock
- DIC
what will patients with amniotic fluid embolism all develop within 4h
DIC
how should amniotic fluid embolism be managed
A-E approach
- Contact anaesthetist for HDU admission
what is the problem with diagnosis amniotic fluid embolism
No definitive diagnostic test (whilst alive) hence diagnosis of exclusion
explain management of amniotic fluid embolism
If baby is not delivered and patient is stable initiate continuous foetal monitoring with aim of delivery.
If cardiac arrest or maternal compromise occur, perimortem section is indicated to facilitate CPR or mother.
what is the only definitive way to diagnose amniotic fluid embolism
post-mortem: foetal squamous cells in pulmonary vasculature
what is the mortality rate for amniotic fluid embolism
high (50%)
