Intrapartum/postpartum

Question 1

FHR control

Answer 1

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

Question 2

Abnormal

Answer 2

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

Question 3

Intrapartum

Answer 3

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

Question 4

Cervical ripening

Answer 4

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

Question 5

IOL

Answer 5

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

Question 6

IOL PROM

Answer 6

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

Question 7

1st stage augmentation

Answer 7

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

Question 8

Pain in labour

Answer 8

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

Question 9

Analgesia options

Answer 9

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

Question 10

EDB COCHRANE

Answer 10

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

Question 11

EDB fetal HR

Answer 11

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

Question 12

EDB acute events

Answer 12

High block
- cardio/resp depression
- diaphragm motor block

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

Question 13

Reduce AVB

Answer 13

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

Question 14

Spinal

Answer 14

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

Question 15

Pudendal block

Answer 15

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

Question 16

Postpartum analgesia

Answer 16

Adequate analgesia improve mobility
reduce VTE, atelectasis
Improve BF

Avoid codeine -> ultrametaboliser, risk of neonatal toxicity

Question 17

Breech birth

Answer 17

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

Question 18

TERM BREECH

Answer 18

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

Question 19

Ventouse

Answer 19

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

Question 20

Forceps

Answer 20

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

Question 21

Abx ANODE

Answer 21

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

Question 22

Caesarean section

Answer 22

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

Question 23

Fully dilated CS

Answer 23

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

Question 24

VBAC

Answer 24

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

Question 25

Signs of rupture

Answer 25

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

Question 26

PPH

Answer 26

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

Question 27

PPH medications

Answer 27

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

Question 28

Surgical PPH management

Answer 28

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

Question 29

TXA

Answer 29

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

Question 30

OASIS

Answer 30

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

Question 31

OASIS repair

Answer 31

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

Question 32

Postpartum sepsis

Answer 32

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

Question 33

Breast feeding

Answer 33

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

Question 34

Evidence in BF scenario

Answer 34

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

Question 35

Postpartum psychosis

Answer 35

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

Question 36

Postpartum depression

Answer 36

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

Question 37

Pre-existing

Answer 37

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