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Written > Intrapartum/postpartum > Flashcards

Intrapartum/postpartum Flashcards

1
Q

FHR control

A

Baseline HR - SA node, myocardial oxygenation & sufficient glycogen store
Progressive maturation of parasympathetic system - slower BSL HR with GA

Variability - functional ANS
Acceleration - adequate O2 for somatic n., voluntary movements
Decel - parasym vagus n. protective reflex reduce myocardial worklaod

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2
Q

Abnormal

A

Rising baseline - symp, catecholamine surge
- hypoxia or inflammatory to pyrexia

Unstable baseline - -ve myocardial energy balance

Reduced variability - suppressed ANS
Sleep state
hypoxia
Neuroinflammation
Intracranial events
Opioids

Increase variability - saltatory pattern
rapid evolving hypoxia with ANS instability, insufficient time at baseline to replenish O2

Shallow decel- severe hypoxia loss of protective response
Bradycardia - reduse CO, risk of MOF

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3
Q

Intrapartum

A

Corc compression:
- UA occlusion, increase PVR
- baroreceptor stimulation -> parasymp
- release -> catecholamine surge

Repetitive insults or interrupted blood supply -> progressive widening and deepening, baseline will rise

Uteroplacental insufficiency
- poor vascular remodelling and poor size of placental pool inadequate to meet demand
- RF: hyperstimulation, LGA, chorioamnionitis
- high CO2 -> chemo receptor vagal response
- gradual fall and recovery
Chronic hypixia -> reduce variability, higher bsl, repetitive shallows

Inflammatory demand
- neuroinflammation due to bacteria & toxins in fetal circ.
- blunt ability to redirect blood to myometrium
- increase overall oxygen demand
-sxs: tachy, absent cyclcing, saltatory, progressive decline/ terminal brady

Acute hypovolaemia/exsanguination
- ANS instability with sinusoidal

Test: FSL - chorio can cause vasodilation, mask central acidosis
Scalp stimulation - sleep vs acidosis

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4
Q

Cervical ripening

A

PG - cervical collagen remodelling, uterine contraction
CI: uterine surgery, malpresentation, ROM, PVB, grandmultip, Severe asthma w/ bronchospasm
Pros: easy/quick, higher chance spon labour, shorter time till birth
Cons: vaginal irritation, monitoring required, 4% hyperstimulation

Balloon - mechanical compression release local PG
CI: ROM, high head, poly, PVB
Pros: reversible, does not require repeat assessment/monitor, safe in prev scar/IUGR, no specific storage
Cons: discomfort, difficult insertion, incorrect placement

No diff in CS rate or infection

S&S - stimlate PG release
reduce need in IOL
No increase in infection

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5
Q

IOL

A

IOL> 37/40 COCHRANE
Fetal - less perinatal death/stillbirth, NICU admit, poor APGAR
No diff in neonatal encephalopathy, birth trauma
Maternal - less CS
No diff in AVB, trauma, PPH, BF

ARRIVE >39/40 LR primip
No diff in perinatal outcome (HIE/stillbirth/truama)
Reduce CS, resp support, maternal HTN

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6
Q

IOL PROM

A

70% spon labour in 24hrs

TERM PROM
Synto vs PG vs expectant
No diff in neonatal infection, CS rate
Less maternal chorioamnionitis, pyrexia
More positive experience w/ IOL

COCHRANE
Reduce neonatal sepsis, maternal chorio, admission to NICU

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7
Q

1st stage augmentation

A

COCHRANE
Reduce 2 hr duration of labour
No diff in MOD, maternal neonatal outcome

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8
Q

Pain in labour

A

1st stage
- T10 L1 symp.
- uterine contractions, difuse pain

  • S2-3 parasym pelvic sphlanic
  • cervical pain

2nd stage
- pudendal S2-4 somatic
- localised pain
- perineum & pelvic floor distension

CS
- T12 incision, up to T4 for peritoneal stretching
- wound & uterus involution

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9
Q

Analgesia options

A

Good evidence
EDB - LA & opioids to epidural space block central n. propagation
- most effective, little risk to newborn
- S/E maternal HoTN, fetal distress, high block, LA toxicity, haematoma, dural puncture

NO2 - endogenous opioid release
- effective, rapid onset/elimination
- SE N+V, hallucination

Moderate evidence
Water immersion - improve uterine perfusion
Improve relaxation, satisfaction

Relaxation - distract from pain
Reduce AVB, improve satisfaction

Inadequate evidence
Sterile water - subcut to sacrum, release Endogenous opioids

TENS - TC n. stimulation
Parental opioids - higher satisfaction
S/E neonatal resp depression

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10
Q

EDB COCHRANE

A

Effective, improve satisfaction
Increas AVB - effect not seen in later studies w/ lower dose infusion
No diff in CS, long term back pain, neonatal outcome
Increase risk HoTN, motor block, fever, urinary retention
Increase 2nd stage labour, oxytocin augment

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11
Q

EDB fetal HR

A

Hypotension -> bradycardia
Withdraw pain -> less catecholamine release -> increase uterine resting tone - repetitive decels
CNS depression from opioids -> reduce variability

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12
Q

EDB acute events

A

High block
- cardio/resp depression
- diaphragm motor block

LA toxicity
- HoTN, HR anomaly, perioral tingling, paraesthesia
Tx 100mls intralipid

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13
Q

Reduce AVB

A

Low dose epidural infusion
1:1 support
Delay pushing 1-2 hr if EDB in
Judicious oxytocin in 2nd stage
Upright/lateral in 2nd stage

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14
Q

Spinal

A

T4-S5
12 hr post op cover
Less risk dural puncture, LA toxicity
Higher risk of motor/high block

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15
Q

Pudendal block

A

S2-S4, travels with a. & v.
Enter pelvis via sacral foramen
Leave greater sciatic, return lesser sciatic, posterior to sacrospinous ligament

Technique
Guarding till reach point of injection
Palpate ischial spine - 2cm medial inferior
Insert 1cm deep , through SSL loss of resistance
Aspirate, inject

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16
Q

Postpartum analgesia

A

Adequate analgesia improve mobility
reduce VTE, atelectasis
Improve BF

Avoid codeine -> ultrametaboliser, risk of neonatal toxicity

17
Q

Breech birth

A

3% at term, spon version low
ECV
- 40% in P0, 60% in multip, complete more likely
- CI multiple, APH, ROM, major fetal anomaly, uterine anomaly
- okay in prev CS
Risk: 1:200 em CS, abruption, cord accident, FMH/alloimmunisation, failure/reverse to breech
Technique - firm pressure elevate breech, pressure on head & body
Anteiror or posterior somersault
CTG pre/post, anti D
No more than 4 attempt/10 mins

CS
- avoid stillbirth >39/40, intrapartum risk
Trapped head @ CS
- tocolysis
- Mauriceau Smellie Veit
- Forceps
- extension

Vaginal breech
- motality 3:1000
CI: hyperextended head, LGA/FGR, footling, fetal anomaly, CI for vaginal birth
Allow passive descend to perineum prior to pushing
Handsoff, avoid stimulation

18
Q

TERM BREECH

A

CS - lower perinatal mortality & morbidity
No diff in maternal outcome
57% delivered vaginally

Critisism
- recruitment in labour
- inconsistent standard of care, degree of training, limited CS resources, did not assess fetal weight/altitude of head

PREMODA: prospective
with strict criteria, CEFM, routine CS
79% deliver vaginally
Higher rate of low apgar, birth trauma
No diff in serious neonatal mortality/morbidity composite

19
Q

Ventouse

A

Risk of failure:
obesity
short stature
LGA
OP>45 degree
Mid cavity

CI: <34/40, suspected bleeding/fracture risk, high risk blood bound infection

Prolonged 2nd stage asso.
- PPH, OASIS, infection
- no diff in neonatal morbidity

Cease if:
No descend 2 pulls
>3 pulls not imminent
2 pop off
20 min

20
Q

Forceps

A

Correct applicaton:
easy lock, post fontanelle <1cm from level of shank, blades equal distance from sagittal suture, fenestration admit <1 finger

Forceps vs ventouse:
x2 fold OASIS, vaginal trauma, altered continence
reduce failure by 40%
more likely for shoulder dystocia

21
Q

Abx ANODE

A

Operative delivery with augmentin 1.2g
Reduce maternal infection by 40%
Less sepsis, pain, wound breakdown

22
Q

Caesarean section

A

Elective optimisation
Pre op Hb, cease smoking, BSL optimise

Cleaning - chlorhex > iodine
Hair clipping > shaving
Vaginal iodine reduce endometritis

Intraop
Cephalo-caudal blunt extension reduce angle extension, blood loss
John Cohen reduce time, pain, blood loss
Routine IV oxytocin
TXA for PPH

GA vs neuraxial:
NA - less blood loss, higher satisfaction

Postop
Optimise pain, early skin to skin, ealry mobilisation

23
Q

Fully dilated CS

A

22% angle extension
risk of bladder/ureteric injury
6% ICU admission
Fetal trauma - ICH, spine/skull #
Cervical/vaginal injury - PTB
PPH/infection

Technique:
Push
Head down tilt
Fetal pillow
Reverse breech extraction
Patwardhan

24
Q

VBAC

A

70% success, 90% if prev NVD
PTB same success less rupture

Increase risk rupture
- J incision 9%, extension 2%
- short IDI
->1cm
- prev complex uterine surgery
- others: LGA/AMA/obesity/postdate, synt

Increase success:
vertex, spon labour, lower station, caucasian, no prev dystocia in labour

Benefit:
Less RDS (0.5% vs 3.5%)
reduce future placental disorder
Better mother/baby bonding
Quicker recovery - VTE/pain

Risk:
Failure for em CS
Blood transfusion/febrile morbidity
1:200 rupture 1:7 death, 1:10 hysterectomy. 0.7:1000 HIE

25
Q

Signs of rupture

A

Abnormal CTG
Continuous pain/scar pain
Loss of station
Loss effective contraction
Shoulder tip/chest pain, SOB
APH/PPH, haematuria
Shock

26
Q

PPH

A

Shock = organ hypoperfusion
>30% volume - shock sxs, paradoxical bradycardia, LOC, arrest

Antenatal screen RF, mitigate risk, indivdiualised plan
RFs: multiple preg, grandmultip, LGA, prev PPH, fibroid, plc disorder, hx APH
Intrapartum risk: precipitous/prolonged labour, augment, AVB, sepsis

Intrapartum
- avoid hyperstimulation
- active third stage reduce PPH 50%
prophylatic synto, CCT placenta
- measure accumulative loss

27
Q

PPH medications

A

Oxytocin - oxytocin R contraction
Carbetocin - as effective in CS
- long acting convenient
- saturate R. hence further bolus not effectiive
- normal storage

Ergometrine - dopamine/serotonin/adrenergic receptor, myometrial contraction
CI: HTN, cardio vavulopathy @ risk of pulm HTN

Carboprost
- PGF2
CI: severe asthma

Misoprostol - PGE1

28
Q

Surgical PPH management

A

Bakri - reduce hysterectomy 85%, compress blood vessels

B Lynch - brace compression suture
Technique
- manual uterine compression
6cm bite anterior lower seg, 4cm from broad lig, suture over fundus, horizontal bite lower segment of posterior uterus, cross fundus, 6cm bite cranial to caudal tie off

Hysterectomy
IR UAE

29
Q

TXA

A

Prevent plasminogen -> plasmin and bind to fibrin clots
Anti-fibrinolytic

WOMAN’s trial
Reduce death 2nd to bleeding
Early administration <3hrs
No diff in other cause of death, hysterectomy
Safe no additional adverse events

Hysterectomy -> mostly decided at time of randominisation hence does not alter by use of TXA

30
Q

OASIS

A

2nd degree muscles:
Bulbospongiosis, transverse perineii

Perineal injury complications:
Anal incontinence 5%
10% with 3rd, 1:4 with 4th
Pain -> retention, diff defecation, sexual dysfunction/dyspareunia

Risk for OASIS: asian, P0, AVB, midline epic, prolonged 2nd stage, SD, OP,LGA

Prevention:
High evidence
- warm compression 50%
- perineal massage 9% tears requiring repair in P0

Some evidence
- selective episiotomy
sign reduction in recurrence(80%), AVB

Inadequate
- hands on technique

31
Q

OASIS repair

A

EAS - voluntary, striated muscle encircles anal canal
- tonic contraction at rest

Repair with interrupted/horizontal mattress

Overlap vs End to end
- reduce faecal urgency, anal incontinence at 12 months
- no diff by 36 months
- no diff in pain, dyspareunia or QOL

IAS - involuntary, controlled by ANS, paler layer continuation of longitudinal rectal muscle
controls continence at rest
Repair separately

Recovery - 60-80% asymptomatic by 1 year
Recurrence: 7%, 20% risk worsen sxs

32
Q

Postpartum sepsis

A

11% of all maternal deaths
Most common GAS, ECOLI, GBS

Obstetrics Modified qSOFA
>2 increase in hospital motality
- GCS<15, RR>22, SBP<100

Lactate level -> indicate tissue ischaemia

Treatment:
Unknown - IV amp gen metro

GAS - IV benpen + clindamycin

33
Q

Breast feeding

A

Neonatal:
Acute - physiological stability, pain threshold
Improve IQ
Reduce childhood metabolic syndrome
Reduce childhood leukemia
Reduce infant infection mortalituy

Maternal:
Acute - reduce blood loss/anxiety
Reduce T2DM
Reduce ovarian/breast ca
Lower BMI pospartum

CI if: HIV, lithium, newborn PKU/galactosaemia

Improve success:
skin to skin
support person
E+D in labour
Refer HR patient (DM, obese, prev breast surgery)
room in
Avoid feeding newborn with other food/fluid

34
Q

Evidence in BF scenario

A

Colostrum
- no high level evidence on efficacy or safety on infant outcome
- both general and DM population
- risk of stimulate labour onset

DM
- in utero hyperglycaemia -> hyperinsulinaemia -> ex utero hypoglycaemia
- maternal poor glycameic control, PPH. CS all delay/reduce lactogenesis

35
Q

Postpartum psychosis

A

1:1000, recurrence 1:3
Sxs: though disorder, dellusion, bizzare behaviours, mood sxs, hallucitations
Onset <2 weeks
2nd gen antipsychotics safe in BF
Treat insomnia
Mood stabiliser if bippolar
Adjunct psychotherapy

36
Q

Postpartum depression

A

Blues - 80% D4-5, resolve within 2 weeks
Asso sad/irritable/insomnia/anxiety
Tx support, insomnia, CBT

Postpartum depression:
Major depression within 4 weeks
10% incidence

37
Q

Pre-existing

A

Antenatal screening

ANRQ - 9 item >23 high risk
Identify women at risk of MH disorder and benefit from extra support

EPDS
90% sensitive for depression
10 item >13 refer
Q10 +ve immediate review

Bipolar:
High risk of relapse
HD folic acid
Check lithium use

Pre-existing MH
- MDT care
- screen substance use, DV
- monitor teratogenicity, growth, PET/GDM
- lifestyle modification

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