Intrapartum care: tears, uterine rupture, amniotic fluid embolism

Question 1

What are perineal tears

Answer 1

tears in perineum caused by childbirth

Question 2

What % of deliveries have perineal trauma

Answer 2

80

Question 3

What are 5 RFs for perineal tear

Answer 3

Episiotomy 
Macrosoma
Instrumental delivery 
Shoulder dystocia 
Nulliparous 
IOL

Question 4

What is a first-degree tear

Answer 4

Tear in mucosa

Question 5

How are first degree tears handled

Answer 5

Appose themselves

Question 6

What is a second-degree tear

Answer 6

Tear in underlying perineal muscles

Question 7

What is used to repair second-degree tears

Answer 7

Absorbable sutures

Question 8

What is 3A degree tear

Answer 8

Tear in external anal sphincter <50%

Question 9

What is 3B degree tear

Answer 9

Tear in external anal sphincter >50%

Question 10

What is 3C degree tear

Answer 10

Tear in internal anal sphincter

Question 11

How is third-degree tear investigated

Answer 11

Rectal exam

Question 12

How is third-degree tear managed immediately

Answer 12

Take to theatre - suture under GA

Antibiotics

Question 13

What is used to manage third-degree tears long-term

Answer 13

Lactulose and high-fibre diet for 10d

Physiotherapy

Question 14

How long is a high-fibre diet and lactulose given

Answer 14

10d

Question 15

If pain or incontinence following a third degree tear where should the person be referred and why

Answer 15

Refer to colorectal surgeon for mamonetry or US

Question 16

what is a fourth degree tear

Answer 16

tear in external anal sphincter, internal anal sphincter and rectal mucosa

Question 17

explain management for fourth-degree tear

Answer 17

• Theatre for suture under GA
• Antibiotics
• Physio
• Lactulose and high–fibre diet

Question 18

what is a uterine rupture

Answer 18

break in muscle and overlying serosa of the uterus

Question 19

what is an incomplete uterine rupture

Answer 19

perineum remains intact - meaning uterine contents remain in uterus

Question 20

what is complete uterine rupture

Answer 20

perineum disrupted - remaining uterine contents enter peritoneal cavity

Question 21

what is the biggest risk factor for uterine rupture

Answer 21

c-section (especially classical scar)

Question 22

what are 5 risk factors for uterine rupture

Answer 22

multiparous 
multiple pregnancy 
past C-section 
past uterine surgery 
induction w/prostaglandins

Question 23

what are the clinical features of uterine rupture

Answer 23

severe pain persistent between contractions

shoulder tip pain

Question 24

how may women with uterine rupture present

Answer 24

hypovolaemic shock

Question 25

if at risk of uterine rupture what should be ordered

Answer 25

CTG

Question 26

what can be used to diagnose uterine rupture

Answer 26

US

Question 27

how is uterine rupture approached

Answer 27

``` A-E approach Airways - Breathing - 15L oxygen Cardiac - 2 large bore cannula, cross-match, fluid D E ```

Question 28

what is the definitive management for uterine rupture

Answer 28

Emergency C-section | Hysterectomy or repair

Question 29

how quickly should hysterectomy or repair be performed

Answer 29

Within 30-minutes

Question 30

what is an amniotic fluid embolism

Answer 30

foetal cells or amniotic fluid enters maternal circulation and stimulates an autoimmune reaction

Question 31

how common is amniotic fluid embolism

Answer 31

rare cause of maternal collapse

Question 32

what time frame does amniotic fluid embolism occur

Answer 32

30-minutes into labour

Question 33

what is the clinical presentation of amniotic fluid embolism

Answer 33

'anaphylaxis-type' picture - Hypoxia, Hypotension - Foetal distress - Shock - DIC

Question 34

what will patients with amniotic fluid embolism all develop within 4h

Answer 34

DIC

Question 35

how should amniotic fluid embolism be managed

Answer 35

A-E approach | - Contact anaesthetist for HDU admission

Question 36

what is the problem with diagnosis amniotic fluid embolism

Answer 36

No definitive diagnostic test (whilst alive) hence diagnosis of exclusion

Question 37

explain management of amniotic fluid embolism

Answer 37

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.

Question 38

what is the only definitive way to diagnose amniotic fluid embolism

Answer 38

post-mortem: foetal squamous cells in pulmonary vasculature

Question 39

what is the mortality rate for amniotic fluid embolism

Answer 39

high (50%)