Labour and Delivery Flashcards

Question

What are the options for induction of labour?

Answer 1

* Membrane sweep- should induce labour within 48 hrs, typically offered from 40 weeks in ANC * Vaginal prostaglandins E2 (dinoprostone) (PGE2)- NICE say this is the preferred method of induction unless there are specific contraidnicates/ reasons to not use * Cervical ripening ballon (CRB)- passed through endocervical canal and gently inflated to dilate cervic * Artifical rupture of membranes - amniotomy * Maternal oxytocin infusion * Oral mifepristone (anti-progesterone) plus misoprostol- intrauterine death

Answer 2

**Inserting a finger into the cervix** to stimlate the cervix: finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua Can be performed in **antenatal clinic** by midwife and if successful should produce the onset of labour within 48 hours Seen as an **adjunct to** the full induction of labour. Used from **40 weeks gestation** to attempt to initiate labour in women over their EDD

Answer 3

Inserting a **gel**, **tablet** (Prostin) or **pessary** (**propess**) into the vagina. The pessary is similar to a tampon, slowly releasing local **prostaglandins** over 24 hours. Stimulates uterus and causes the onset of labour. Usually done in the hospital setting so the woman can be monitored before being allowed home to await the full onset of labour.

Answer 4

Silicone ballow which is **inserted** into the **cervix** and gently inflated to **dilate** the cervix Used ias an alternative where vaginal prostaglandins are not preferred, usually in women with a **previous C-section** or where **vaginal prostaglandins** have failed or multiparous women (para 3)

Answer 5

With an **oxytocin infusion** can also be used to induce labour. This is used there there are reasons not to use vaginal prostaglandins, can be used also to progress the induction of labour after vaginal prostaglandins have been used

Answer 6

**Cartiotocography** (CTG) to assess the fetal heart rate and uterine contractions before the induction of labour **Bishop score** before and during the induction of labour to monitor the progress

Answer 7

**Most** women will give **birth within 24 hours** of the start of induction of labour The options where there is slow or no progress include: - **Further vaginal prostaglandins** - **Artificial rupture of membranes** and oxytocin infusion - **Cervical ripening balloon (CRB)** - **Elective caesarean section**

Answer 8

Uterine hyperstimulation - causing fetal distress and compromise Refers to prolonged and frequent uterine contractions - sometimes called tachysystole Potential consequences- * Itermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia * Emergency CS * Uterine rupture (rare) Mx- * Remove vaginal prostaglandins or stop oxytocin infusion * Tocolysis with terbutaline

Answer 9

Varies between guidelines, two criteria often used are: - Individual uterine contractions lasting more than 2 minutes in duration - More than 5 uterine contractions every 10 minutes

Answer 10

Measures the **fetal heart rate** and the **contractions of the uterus**

Answer 11

Hormone secreted by the **posterior pituitary gland** (produced in the hypothalamus). Stimulates ripening of the cervix & contractions of uterus during labour and delivery, plays a role in lactation during BF Role of infusions * Induce labour * Progress labour * Improve frequency & strength of uterine contractions (most receptors in myometrium) * Best used where membranes have ruptured, whether spontaneously or after amniotomy * Has been shown to increase cervical prostaglandin levels Syntocinon is a synthetic version of oxytocin that is used in the active management of third stage of labour. It stimulates the contraction of the uterus reducing the risk of postpartum haemorrhage. It is also used to induce labour.

Answer 12

Medication to **stimulate smooth muscle contraction**, both in uterus and blood vessels Derived from **ergot plants** Useful for **delivery of the placenta** and reduces post partum bleeding * used as an alternative to oxytocin in the active management of third stage of labour. By constricting vascular smooth muscle of the uterus it can decrease blood loss. * (Only used after delivery of baby, not in 1st/2nd stage) * S/E: htn, diarrhoea, vomiting, angina (coronary artery spasm) * Avoid in eclampsia, used in caution in pts with htn

Answer 13

Combination drug containing **oxytocin** (syntocinon) and **ergometrine** Used for **prevention/treament of PPH**

Answer 14

Dinoprostone- prostaglandin E2 used for induction of labour Comes as vaginal pessary/ tablet/ gel Prostaglandins stimulate uterine contraction and ripen cervix prior to delivery

Answer 15

Treating **dysmenorrhoea** (painful periods) as they reduce painful cramping (e.g. **ibruprofen and mefenamic acid**) * NSAIDs inhibit action of prostaglandins * Prostaglandins act as vasodilators and lower bp * NSAIDs can increase BP

Answer 16

**Prostalandin analogue** (binds to prostaglandin receptors and activates them) Mifepristone is used in combination with misoprostol to terminate pregnancies. Also used for induction of labour after intrauterine fetal death

Answer 17

**CCB** which acts to **reduce smooth muscle contraction** in **blood vessels** and the **uterus** 2 uses in pregnancy- reduce bp in htn and pre-eclampsia; tocolysis in premature labour where it suppresses uterine activity and delays onset of labour

Answer 18

**Beta-2-agonist** similar to salbutamol Acts on s.m. of uterus to suppress contractions Used for tocolysis in uterine hyperstimulation

Answer 19

**Synthetic prostaglandin analogue** - stimulating uterine contraction Given as deep IM injection in PPH where ergometrine and oxytocin have been inadequate Avoid/ caution in asthma- can cause life-threatening attack

Answer 20

**Antifibrinolytic** which reduces bleeding (binds to **fibrinogen** and **prevents it from converting** to **plasmin**) Used in prevention and treatment of PPH

Answer 21

The 3 Ps: **Power** (uterine contractions) **Passenger** (size, presentation and position of the baby) **Passage** (the shape and size of the pelvis and soft tissues)

Answer 22

**Less than 2cm** of cervical dilatation in 4 hours **Slowing of progress** in a **multiparous women** **Causes:** * Most common: inefficient uterine actions (power) * Malposition/ malpresentation of fetus (passenger) * Inadequate pelvis (passage) * Or, a combo of the above

Answer 23

From **10cm dilation of the cervix** to **delivery of the baby** - success depends on: the three Ps

Answer 24

When the active second stage (pushing) lasts over: **2 hours in a nulliparous** woman **1 hour in a multiparous** woman

Answer 25

* POWER: strength of uterine contractions * Weak contractions- give oxytocin infusion * Passenger: size, attitude, lie, presentation * Passage * Change positions * Encouragement * Analgesia * Episiotomy * Instrumental delivery * CS

Answer 26

**More than 30 minutes with active** management **More than 60 minutes with physiological** management

Answer 27

* Intramuscular syntometrine (ergometrine 0.5mg + oxytocin 5IU) or oxytocin 10IU IM (this is preferred by NICE due to fewer side effects) is given as the anterior shoulder of baby is born * A dish is placed at the introitus to collect the placenta and any blood loss, and the left hand is placed on the abdomen over the uterine fundus. * As the uterus contracts to 20-wk size, the placenta separates from the uterus through the spongy layer of the decidua basalis. * The uterus will then feel globular and firmer, the cord will lengthen, and there is often a trickle of fresh blood (separation bleeding). * Controlled cord traction (CCT)- Applied with the right hand, whilst supporting the fundus with the left hand (Brandt–Andrew’s technique) (exclude multiple pregnancy before giving uterotonixcs) Physiological mx- * No Syntometrine® or oxytocin is given. * Cord is allowed to stop pulsating before it is clamped and cut. NICE (2014) recommends that the cord should not be clamped at least for 1min, unless the baby’s heart rate is \<60bpm and not picking up. * Currently equipment are available that can be kept by the side of the mother to help resuscitation with the cord intact. * Cord should be clamped before the end of 5mins. * The placenta is delivered by maternal effort alone.

Answer 28

**Amniotomy,** also known as artificial rupture of membranes (ARM) for women with intact membranes **Oxytocin** infusion **Instrumental** delivery **Caesarean** section

Answer 29

**Oxytocin** to stimulate contractions during labour - **started at a low rate** and then **titrated up** at **intervals of at least 30 minutes** as required

Answer 30

4-5 contractions per 10 minutes (too may can cause fetal compromise as it doesn't have the time to recover between contractions)

Answer 31

**Understanding** what to expect Having **good support** Being in a **relaxed environment** **Changing position** to stay comfortable **Controlled breathing** **Water births** may help some women **TENS machines** may be useful in the early stages of labour

Answer 32

**Paracetamol** (codeine may be added for additional effect - NSAIDs are avoided) Gas and Air (entonox) - mixture of 50% nitrous oxide and 50% oxygen to give short term pain relief during contraction * Can cause lightheadedness, sleepiness, nausea IM pethidine or diamorphine * Opioids * May help with anxiety & distress Pt controlled analgesia- remifentanil * Careful monitoring, input from anaesthetist * Access to naloxone for respiratory depression * Access to atropine for bradycardia Epidural * Small catheter into epidural space in lower back * Local anaesthetic medications infused through into the epidural space here they diffuse to the surrounding tissues and through to the spinal cord where they have an analgesic effect * Levobupivacaine, bupivacaine, usually mixed w/ fentanyl * Adverse effects: headache after insertion, hypotension, motor weakness in legs (assessment urgently by anaesthetist to see if the epidural is in the correct place not the SA space), nerve damage, prolonged 2nd stage, increased probability of instrumental delivery

Answer 33

When the **umbilical cord** descends **nelow the presenting part of the fetus** and through the cervix, into the vagina Occurs in 1/500 deliveries Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Answer 34

Most significant- Fetus is in an **abnormal lie** after 37 weeks gestation (unstable, transverse or oblique) Others- * Prematurity * Multiparity * Polyhydramnios * Twin pregnancy * Artificial rupture of membranes

Answer 35

**Signs of fetal distress** on the CTG - fetal HR becomes abnormal Diagnosed with **vaginal examination** with speculum confirming diagnosis- cord may be palpable vaginally or visible beyond the level of the introitus (vaginal opening)

Answer 36

**Emergency C-Section** recommended; instrumental vaginal may be possible if the cervix is fully dilates and the head is low Cord should be kept **warm and wet** and have **minimal handling** as this causes **vasospasm** the patient is asked to go on 'all fours' until preparations for an immediate caesarian section have been carried out -Alternative position: left lateral position Tocolytics to reduce uterine contractions Retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part If treated early, fetal mortality in cord prolapse is low. Incidence has been reduced by the increase in caesarian sections being used in breech presentations.

Answer 37

When **anterior shoulder** of the baby becomes stuck behind the **pubic symphysis** of the pelvis after the head has been delivered ## Footnote **Obstetric emergency**

Answer 38

**Antenatal** * **Macrosomia** secondary to **gestational diabetes** * High maternal BMI \>30 and excessive weight gain in pregnancy * Diabetes mellitus * Post-term pregnancy * Previous hx of shoulder dystocia Intrapartum * Prolonged labour - lack of progress in late 1st or 2nd stage labour * Instrumental vaginal delivery (esp. rotational deliveries)

Answer 39

* Usually the anterior shoulder is impacted against the symphysis pubis, often due to the failure of internal rotation of the shoulders * Fetal deterioration is rapid, often without cord acidosis, largely due to cord compression and trauma.

Answer 40

Where the **head is delivered** but then retracts back into the vagina

Answer 41

Get help (incl anaesthetics and paediatrics) **Episiotomy** **McRoberts manoeuvre** hyperflexion of the mother at the hip (bringing knees to abdomen) providing a **posterior pelvic tilt** lifting the pubic symphysis up and out of the way **Pressure to the anterior shoulder** = pressing on the suprapubic region, putting pressure on the posterior aspect of the baby's anterior shoulder to encourage it **under pubic symphysis** **Rubins manoeuvre** = reaching into vagina, putting pressure on the posterior aspect of the baby's anterior shoulder **Wood's screw manoeuvre** = performed during a Rubin's manoeuvre - other hand is used to put pressure on the anterior aspect of the posterior shoulder - to rotate the baby, reverse motion can be tried **Zavanelli manoeuvre** pushing the baby's head back into the vagina so it can be delivered by emergency C-section Pnemonic HELPERR * H Call for help (including additional midwife, senior obstetrician, neonatologist, anaesthetist). * E Episiotomy—remember shoulder dystocia is a bony problem, but an episiotomy may help with internal manoeuvres. * L Legs into McRoberts’ (hyperflexed at hips with thighs abducted and externally rotated). * P Suprapubic pressure applied to posterior aspect of anterior shoulder (must know which side fetal back is on) to dislodge it from under symphysis pubis; if continuous pressure fails, a rocking movement may be tried. * E Enter pelvis for internal manoeuvres, which include: * pressure exerted on the posterior aspect of anterior shoulder to adduct and rotate the shoulders to the larger oblique diameter (Rubin II) * if this fails combine it with pressure on the anterior aspect of the posterior shoulder (Woods’ screw) * if this fails, reversing manoeuvre may be tried with pressure on the anterior aspect of anterior shoulder and posterior aspect of posterior shoulder in opposite direction (reverse Woods’ screw). * R Release of posterior arm by flexing elbow, getting hold of fetal hand, and sweeping fetal arm across chest and face to release posterior shoulder. * R Roll over to ‘all fours’ may help aid delivery by the changes brought about in the pelvic dimensions (Gaskin manoeuvre).

Answer 42

**Fetal hypoxia** (and subsequent cerebral palsy) **Brachial plexus injury** and **Erb’s palsy** **Perineal** tears **Postpartum haemorrhage**

Answer 43

Using a **ventouse suction cup** or **forceps** (about 10% of births are assisted with an instrumental delivery)

Answer 44

Single dose of **co-amoxiclav**

Answer 45

**Failure to progress** Fetal **distress** Maternal **exhaustion** **Control of the head** in various fetal positions

Answer 46

**Postpartum haemorrhage** **Episiotomy** Perineal **tears** **Injury** to the **anal sphincter** **Incontinence** of the bladder or bowel **Nerve injury** (obturator or femoral nerve)

Answer 47

**Cephalohaematoma** with ventouse **Facial nerve palsy** with forceps

Answer 48

**Subgaleal haemorrhage** (most dangerous) ## Footnote **Intracranial haemorrhage** **Skull fracture** **Spinal cord injury**

Answer 49

A suction cup on a cord placed on the baby's head

Answer 50

**Cephalohaematoma** (collection of blood **between the skull and periosteum**)

Answer 51

**Facial nerve palsy** with facial paralysis on one side **Bruises** on the babys face **Fat necrosis** leading to hardened lumps which resolve spontaneously over time

Answer 52

**Femoral nerve** - compressed against the inguinal canal during a forceps delivery - causing **weakness of knee extension**, loss of the **patella reflex** and **numbness of the anterior thigh** and **medial lower leg** **Obturator nerve** - compressed by forceps or by fetal head during normal delivery - weakness of **hip adduction** and **rotation** and **numbness** of the medial thigh

Answer 53

**First births** (nulliparity) **Large babies** (over 4kg) **Shoulder dystocia** **Asian** ethnicity **Occipito-posterior position** **Instrumental deliveries**

Answer 54

**First-degree** – superficial damage with no muscle involvement, no repair required, simple vaginal mucosa torn **Second-degree** – **including the perineal muscles**, but **not affecting the anal sphincter,** require suturing on the ward by a suitably experienced midwife or clinician Third-degree – **including the anal sphincter complex (EAS and IAS)**, but **not affecting the rectal mucosa** * 3a: less than 50% of EAS thickness torn * 3b: more than 50% of EAS thickness torn * 3c: IAS torn * Require repair in theatre **Fourth-degree** – tear to anal sphincter complex (EAS and IAS) and including the **rectal mucosa** * Require repair in theatre

Answer 55

**3A** – less than 50% of the external anal sphincter affected **3B** – more than 50% of the external anal sphincter affected **3C** – external and internal anal sphincter affected

Answer 56

Do not require any sutures normally

Answer 57

Requires sutures

Answer 58

**Broad-spectrum antibiotics** to reduce the risk of infection **Laxatives** to reduce the risk of constipation and wound dehiscence **Physiotherapy** to reduce the risk and severity of incontinence **Followup to monitor for longstanding complications**

Answer 59

**Pain** **Infection** **Bleeding** **Wound dehiscence** or wound breakdown

Answer 60

**Urinary incontinence** **Anal incontinence** and altered bowel habit (third and fourth-degree tears) **Fistula** between the vagina and bowel (rare) **Sexual dysfunction** and dyspareunia (painful sex) **Psychological** and **mental health consequences**

Answer 61

Where the obstetrician / midwife cuts the perineum before the baby is delivered - done in anticipation of needing more room e.g. forceps delivery - performed under **local anaesthetic** **Cut** is made at around **45 degrees diagnonally** from the opening of the vaginal down and out to **avoid damaging the anal sphincter** - called a **mediolateral episiotomy** Cut is sutured after delivery

Answer 62

Method for reducing the risks of perineal tear - **massaging the skin between the vagina and anus** (perineum) - in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery

Answer 63

**Physiological management** **Active management**

Answer 64

Placenta is delivered by **maternal effort** without medication or cord traction No Syntometrine or oxytocin is given. * Cord should be clamped before the end of 5mins. * The placenta is delivered by maternal effort alone.

Answer 65

**Dose of intramuscular oxytocin** (to help uterus contract) **Traction** to the umbilical cord to guide the placenta out (controlled cord traction) Clamping and cutting of the cord

Answer 66

**Reduces risk of bleeding** Reduce rates of PPH \>1000mL Reduce mean blood loss and postnatal anaemia Reduce length of third stage Reduce need of blood transufsions Adverse effects: nausea and vomiting, headache

Answer 67

routinely offered to reduce PPH **Haemorrhage** **More than 60 min delay** in delivery of the placenta (prolonged third stage)

Answer 68

**IM dose of oxytocin** after delivery of the baby **Cord is clamped** and cut within 5 mins of birth (delay of 1-3 mins) **Abdo palpated** to assess for a uterine contraction before delivery of the placenta **Controlled cord traction** is applied (stopping if resistance) **Other hand** presses the **uterus upwards** to prevent uterine prolapse **After delivery** the **uterus is massaged** until it is contracted and firm - placenta is examined to ensure it is complete

Answer 69

Bleeding after delivery of the baby and placenta- needs to be a loss of: * 500ml after a vaginal delivery * 1000ml after a caesarean section

Answer 70

**Minor** PPH – under 1000ml blood loss **Major** PPH – over 1000ml blood loss **Moderate** PPH – 1000 – 2000ml blood loss **Severe** PPH – over 2000ml blood loss

Answer 71

**Primary PPH:** bleeding within 24 hours of birth **Secondary PPH:** from 24 hours to 12 weeks after birth

Answer 72

**T** – **Tone** (uterine atony – the most common cause)- *soft boggy uterus* **T** – **Trauma** (e.g. perineal tear)- *laceration or uterine inversion- re-place inverted uterus* **T** – **Tissue** (retained placenta)- *or clot* **T** – **Thrombin** (bleeding disorder)- *blood not clotting, observe clotting, check coag studies, replace clotting factors, plts, supply FFP*

Answer 73

Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in the second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery CS General anaesthesia Episiotomy or perineal tear

Answer 74

**Treating anaemia** during the **antenatal period** **Giving birth with an empty bladder** (a full bladder reduces uterine contraction) **Active management of the third stage** (with intramuscular oxytocin in the third stage) **Intravenous tranexamic acid** can be used during caesarean section (in the third stage) in higher-risk patients

Answer 75

Resuscitation with an **ABCDE approach** **Lie the woman flat,** keep her warm and communicate with her and the partner **Insert two large-bore cannulas** **Bloods for FBC, U&E and clotting screen** **Group and cross match 4 units** **Warmed IV fluid and blood resuscitation** as required **Oxygen** (regardless of saturations) **Fresh frozen plasma** is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 76

By **activating** the **major haemorrhage protocol** giving rapid access to 4 units of crossmatched or O negative blood

Answer 77

**Rubbing the uterus through the abdomen** to stimulates a uterine contraction (referred to as “rubbing up the fundus”) **Catheterisation** (bladder distention prevents uterus contractions)

Answer 78

**Oxytocin** (slow injection IM or IV 10 IU followed by continuous infusion 40 IU over 4 hrs) **Ergometrine** (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)- 500mcg IM **Carboprost** (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) -250mcg every 15 mins, up to 8 doses **Misoprostol** (sublingual) is also a prostaglandin analogue and stimulates uterine contraction - 800mcg PR **Tranexamic acid** (intravenous) is an antifibrinolytic that reduces bleeding - 1gram IV give early (slow), 2nd dose after 30mins if PPH persists- slow dose 1g

Answer 79

**Intrauterine balloon tamponade** – inserting an inflatable balloon into the uterus to press against the bleeding **B-Lynch suture** – putting a suture around the uterus to compress it **Uterine artery ligation** – ligation of one or more of the arteries supplying the uterus to reduce the blood flow **Hysterectomy is the “last resort”** but will stop the bleeding and may save the woman’s life

Answer 80

**Retained products of conception** (RPOC) **Infection** (i.e. endometritis).

Answer 81

**Ultrasound for retained products** of conception **Endocervical and high vaginal swabs** for infection

Answer 82

**Surgical evacuation** of retained products of conception **Antibiotics** for infection

Answer 83

**Spinal anaesthetic**

Answer 84

**Previous caesarean** **Symptomatic after a previous significant perineal tear** **Placenta praevia** **Vasa praevia** **Breech presentation** **Multiple pregnancy** **Uncontrolled HIV infection** **Cervical cancer**

Answer 85

**Category 1:** There is an **immediate threat to the life** of the mother or baby. Decision to delivery time is **30 minutes.** * Placental abruption with abnormal FHR or uterine irritability * Cord prolapse * Scar rupture * Prolonged bradycardia * Scalp pH \<7.2 **Category 2:** There is not an imminent threat to life, but caesarean is required urgently due to **compromise of the mother or baby**. Decision to delivery time is **75 minutes.** * Failure to progress with pathological CTG **Category 3:** Delivery is required, but **mother and baby are stable.** (scheduled CS) * Severe pre-eclampsia * IUGR with poor fetal function tests * Failured induction of labour **Category 4**: Elective CS- usually after 39 wks unless indicated, as the risk of respiratory morbidity (transient tachypnoea of the newborn) is increased at lower gestational ages * Term singleton breech * Twin pregnancy with non-cephalic 1st twin * Maternal HIV * Primary genital herpes in 3rd trimester * Placenta praevia * Previous hysterotomy or classic CS

Answer 86

**Pfannenstiel incision** is a curved incision two fingers width above the pubic symphysis- *superior cosmetic result* **Joel-cohen incision** is a straight incision that is slightly higher (this is the recommended incision)- *allows quicker entry into the abdomen*

Answer 87

* **Skin** * **Subcutaneous tissue** * **Fascia / rectus sheath** (the aponeurosis of the transversus abdominis and external and internal oblique muscles) * **Rectus abdominis muscles** (separated vertically) * **Peritoneum** * **Vesicouterine peritoneum** (and bladder) – the bladder is separated from the uterus with a bladder flap * **Uterus** (perimetrium, myometrium and endometrium) * **Amniotic sac**

Answer 88

An **injection** of a **local anaesthetic** (such as **lidocaine**) into the CSF at the lower back ## Footnote **Blocking the nerves from the abdomen downwards**

Answer 89

**H2 receptor antagonists** (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure **Prophylactic antibiotics** during the procedure to reduce the risk of infection **Oxytocin** during the procedure to reduce the risk of postpartum haemorrhage **Venous thromboembolism (VTE)** prophylaxis with low molecular weight heparin

Answer 90

To **reduce the risk** of **aspiration pneumonitis** caused by acid reflux and aspiration during prolonged period of lying flat

Answer 91

**Bleeding** **Infection** **Pain** Venous thromboembolism

Answer 92

**Postpartum haemorrhage** **Wound infection** **Wound dehiscence** **Endometritis**

Answer 93

**Ureter** **Bladder** **Bowel** **Blood vessels**

Answer 94

**Ileus** **Adhesions** **Hernias**

Answer 95

Increased **risk** of **repeat caesarean** Increased **risk** of **uterine rupture** Increased **risk** of **placenta praevia** Increased **risk** of **stillbirth**

Answer 96

**Risk of lacerations** (about 2%) **Increased** incidence of **transient tachypnoea of the newborn**

Answer 97

Possible, provided the cause of the caesarean is unlikely to recur. Assessment of **likelihood of success** should be **made in each case**

Answer 98

**Previous uterine rupture** **Classical caesarean scar** (a vertical incision) **Other usual contraindications** to vaginal delivery (e.g. placenta praevia)

Answer 99

Early **mobilisation** **Anti-embolism stockings** or intermittent pneumatic compression of the legs **Low molecular weight heparin** (e.g. **enoxaparin**)

Answer 100

Condition where body **launches a large immune response to infection** causing **systemic inflammation** and affecting the functioning of the organs of the body ## Footnote **Significant cause of maternal death**

Answer 101

When sepsis results in **organ dysfunction** such as **hypoxia**, **oliguria** or **raised lactate**

Answer 102

When arterial blood pressure drops and results in **organ hypo-perfusion**

Answer 103

**Chorioamnionitis-** infection of chorioamniotic membranes and amniotic fluid, usually occurs in later pregnancy and labour ## Footnote **Urinary tract infections**

Answer 104

**MEOWS chart** - maternity early obstetric warning system

Answer 105

**Fever** **Tachycardia** **Raised respiratory rate** (often an early sign) **Reduced oxygen saturations** **Low blood pressure** **Altered consciousness** **Reduced urine output** **Raised white blood cells on a full blood count** **Evidence of fetal compromise on a CTG**

Answer 106

**Full blood count** to assess cell count including white cells and neutrophils **U&Es** to assess kidney function and for acute kidney injury **LFTs** to assess liver function and as a possible source of infection (e.g. acute cholecystitis) **CRP** to assess inflammation **Clotting** to assess for disseminated intravascular coagulopathy (**DIC**) **Blood cultures to assess for bacteraemia** **Blood gas to assess lactate**, pH and glucose

Answer 107

- Follow **local guidelines** - **Senior obstetricians** and midwives involved early - **Continuous maternal and fetal monitoring** - **Early delivery** (C-Section where there is fetal distress) - **General anaesthesia for maternal sepsis** - **Antibiotics guided by local guidelines** - **Example regimes of abx:** piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin

Answer 108

**Three tests:** Blood **lactate** level Blood **cultures** **Urine output** **Three treatments:** **Oxygen** to maintain oxygen saturations 94-98% Empirical broad-spectrum **antibiotics** IV **fluids**

Answer 109

**Amniotic fluid passes into the mothers blood** rare (2 per 100,000 births) but severe condition, usually **occuring around delivery**

Answer 110

**Amniotic fluid** contains **fetal tissue** causing an **immune reaction** from the mother, leading to a **systemic illness** - more similarities to anaphylaxis than VTE - mortality is around 20% or above

Answer 111

**Increasing maternal age** **Induction** of labour **Caesarean** section **Multiple pregnancy**

Answer 112

Similarly to sepsis, PE or anaphylaxis: ## Footnote **Shortness of breath** **Hypoxia** **Hypotension** **Coagulopathy** **Haemorrhage** **Tachycardia** **Confusion** **Seizures** **Cardiac arrest**

Answer 113

**Supportive** - no specific treatments

Answer 114

Medical emergency Input of **experienced obstetricians** **A – Airway:** Secure the airway **B – Breathing**: Provide oxygen for hypoxia **C – Circulation:** IV fluids to treat hypotension and blood transfusion in haemorrhage **D – Disability:** Treat seizures and consider other neurological deficits **E – Exposure**

Answer 115

Complication of labour, **myometrium** ruptures Incomplete- uterine dehiscence- the uterine seorsa (perimetrium) surrounding the uterus remains intact Complete rupture- the serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity

Answer 116

**Significant bleeding** where the baby may be released from the uterus into the **peritoneal cavity** (high morbidity and mortality for baby and mother)

Answer 117

**Previous caesarean section** as the scar is a point of weakness * the scar becomes a point of weakness, may rupture with XS pressure eg XS stimulation by oxytocin VBAC Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 118

Acutely unwell mother and abnormal CTG - may occur with induction or augmentation of labour: ## Footnote **Abdominal pain** **Vaginal bleeding** **Ceasing of uterine contractions** **Hypotension** **Tachycardia** **Collapse**

Answer 119

**Obstetric emergency** - resuscitation and transfusion may be necessary **Emergency caesarean section** to remove the baby, stop any bleeding and repair or remove the uterus

Answer 120

Rare complication of birth where the **fundus of the uterus** drops down through the **uterine cavity and cervix, turning the uterus inside out** Life threatening

Answer 121

**Fundus descends** inside the uterus or vagina **but not as far as the introitus** (opening of the vagina)

Answer 122

Uterus descends through the vagina to the introitus

Answer 123

**Pulling too hard** on the **umbilical cord** during **active management** of the **third stage of labour**

Answer 124

**Large post partum haemorrhage** (maternal shock or collapse) Incomplete inversion may be felt with **manual vaginal examination** with a complete uterine inversion, the uterus may be seen at the introitus of the vagina

Answer 125

Johnson manoeuvre * Using a hand to push the fundus back up into the abdomen and the correct position * The whole hand and most of the forearm will be inserted into the vagina to return the fundus to the correct position * Held in place for several mins * Meds used to create uterine contraction (oxytocin) Hydrostatic methods * Where the Johnson manoeuvre fails * Filling the vagina with fluid to inflate the uterus back into the normal position Requires a tight seal at the entrance of the vagina Surgery * Laparotomy and return uterus to normal position

Answer 126

Royal college guidelines state woman with pyrexia during labour should receive GBS prophylaxis, which is **benzylpenicillin**. **Vancomycin** should be used if there is a known severe penicillin allergy. **Erythromycin** is used in woman with preterm prelabour rupture of membranes (PPROM).

Answer 127

* prematurity * prolonged rupture of the membranes * previous sibling GBS infection * maternal pyrexia e.g. secondary to chorioamnionitis

Answer 128

Used during pregnancy/ labour to monitor fetal heart rate and uterine contractions * Fetal heart rate: transducer above fetal heart, contains doppler ultrasound * Uterine contractions: transducer at fundus of uterus, assesses tension of abdominal wall of mother providing an indirect indication of intrauterine pressure

Answer 129

Maternal medical illness * Gestational diabetes * Hypertension * Asthma Obstetric complications * Multiple gestation * Post-date gestation * Previous cesarean section * Intrauterine growth restriction * Premature rupture of membranes * Congenital malformations * Oxytocin induction/augmentation of labour * Pre-eclampsia Other risk factors * Absence of prenatal care * Smoking * Drug abuse

Answer 130

The baseline rate is the average heart rate of the fetus within a 10-minute window. A normal fetal heart rate is between 110-160 bpm.

Answer 131

Baseline HR \> 160 * Fetal hypoxia * Chorioamnionitis * Hyperthyroidism * Fetal or maternal anaemia * Fetal tachyarrhythmia

Answer 132

Baseline HR \< 100bpm It is common to have a baseline heart rate of between 100-120 bpm in the following situations: * Postdate gestation * Occiput posterior or transverse presentations Severe prolonged bradycardia (less than 80 bpm for more than 3 minutes) indicates severe hypoxia. Causes of prolonged severe bradycardia include: * Prolonged cord compression * Cord prolapse * Epidural and spinal anaesthesia * Maternal seizures * Rapid fetal descent

Answer 133

* Baseline variability refers to the variation of fetal heart rate from one beat to the next. * Variability occurs as a result of the interaction between the ***nervous system, chemoreceptors, baroreceptors and cardiac responsiveness.*** * It is, therefore, a good indicator of how healthy a fetus is at that particular moment in time, as a healthy fetus will constantly be adapting its heart rate in response to changes in its environment. * Normal variability indicates an intact neurological system in the fetus. * Normal variability is between **5-25** bpm. * To calculate variability you need to assess how much the peaks and troughs of the heart rate deviate from the baseline rate (in bpm) * Variability can be categorised as reassuring, non-reassuring or abnormal * Reassuring: 5 – 25 bpm * Non-reassuring: * less than 5 bpm for between 30-50 minutes * more than 25 bpm for 15-25 minutes * Abnormal: * less than 5 bpm for more than 50 minutes * more than 25 bpm for more than 25 minutes * sinusoidal

Answer 134

* Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause) * Fetal acidosis (due to hypoxia): more likely if late decelerations are also present * Fetal tachycardia * Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate * Prematurity: variability is reduced at earlier gestation (\<28 weeks) * Congenital heart abnormalities

Answer 135

Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds * Their presence is reassuring * Accelerations occurring alongside uterien contractions is a sign of a healthy fetus Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.

Answer 136

Early deceleration * start when the uterine contraction begin * recover when uterine contraction stops * due to increased fetal intracranial pressure causing increased vagal tone, hence quickly resolves once uterine contraction ends and the intracranial pressure reduces * ***_Physiological_*** NOT pathological Variable decelerations * rapid fall in baseline fetal heart rate with a variable recovery phase * variable in their duration and may not have any relationship to uterine contractions * most often seen during labour and in patients’ with reduced amniotic fluid volume * All fetuses experience stress during the labour process, as a result of uterine contractions reducing fetal perfusion. Whilst fetal stress is to be expected during labour, the challenge is to pick up pathological fetal distress * Variable decelerations are usually caused by umbilical cord compression * Umbilical vein is occluded first causing acceleration of fetal HR in response * Then the umbilical artery is occluded causing subsequent rapid deceleration * When the pressure on the cord is reduced another acceleration occurs and then the baseline HR returns * The accelerations before and after a variable deceleration are known as the shoulders of deceleration - indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow - if these are not present it can suggest the fetus is becoming hypoxic * Variable decelerations can resolve if mother changes position Late deceleration * begin at the peak of the uterine contraction and recover after the contraction ends * This type of deceleration indicates there is insufficient blood flow to the uterus and placenta * As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis * Causes- maternal hypotension, pre-eclampsia, uterine hyperstimulation Prolonged deceleration * Defined as a deceleration that lasts more than 2 minutes * 2-3 mins: non-reassuring * \>3 mins: abnormal

Answer 137

* Severe fetal hypoxia * Severe fetal anaemia * Fetal/maternal haemorrhage

Answer 138

* Lasting more than 60 seconds * Reduced baseline variability within the deceleration * Failure to return to baseline * Biphasic (W) shape * No shouldering