Labour and delivery and their complications Flashcards
Discuss limitations of the ED for the delivery of babies
Unlike the obstetric suite the ED is often lacking appropriate resources suchas a tocydnamometry, intrauterine pressure monitors, vacuum extractors and forceps
In addition the obstetrician typically has prenatal care infomariotn including accurate gestational dates, presence of placental anatomy and prior documented obstretric complications. This information is often difficult or impossible to obtain while preparing for precipitus labour
C-section is sometimes indicated and this is not performed in the ED unless in dire perimortem circumstances
Discuss epidemiology of the emergency delivery
in the US the perinatal mortality rate is 6.26/1000 live births at 28 weeks of gestation or more.
Delivery complications and mortality is much high in the ED approx 8-10%
THe ed is often selected by an obsetric population that has psychosocial factors such as drug or alcohol abuse, domestic violence or lack of access to health care. THese women often have little or no antenatal care
Antepartum haemorrhage, PROM, eclampsia, prmature labor, abruptio placentae, malpresenation and umbilical cord emergenices are overrepresented in the ED
Discuss distinguishing true and false labor
Whenever a women in her thrid trimester presents to the ED there is always the chance that hse is in labor. A wide array of non specific symptoms may herald the onset of labour. Abdojminal pain, back pain, cramping, nausea and vomtiing, urinary urgency, stress incontinence and anxiety can all be symptoms of labour
Braxton Hicks contraction occur after 30 weeks of gestation in which the previously small and uncoordinated contractions of the uterus become more synchronous and may be percieved by the mother.
THey do not escalate in intensity or frequency, are not associated with cervical dilatation or effacement. Membrans should be intact be carfeul to not rupture prematurely and induce premature labour
Discuss bloody show
At the onset of labour the cervical mucous plug may be expelled resulting in “nbloody show””. Bleeding is usually slight and is due to the increase in cervical vasuclarity that occurs in pregnancy.
Does not contraindicate vaginal examination.
If larger amount of bleeding consider antenatal haemorrhage causes
Discuss the first stage of labour
The first stage of labour is the cervical stage ending with compeltey dilated fully effaced cervix. It is divided into a latent phase with slow cervical dilatation and an active phase with more rapid dilatation.
The rapid phase begins after 3cm of cervical dilataion
Most women who deliver in the ED arrive in the active phase of stage 1 or early stage 2
Nulliparious women the first stage takes 8 hours and 5 hours for multiparous
Discuss estimating foetal age based on fundal height
Fundus is at the umbilcus at 20 weeks Every cm higher than this represents a week until 36 weeks at which time the foetus drops into the pelvis
Discuss leopolds maneuvers
Used to confirm the lie of the foetus
Four steps
1)reveals which foetal part occupires the fundus
2) revelas the foetal back
3) Foetal part lying in the pelvic inlet
4) the cephalic prominence
Ultrasound can also be used to determine lie of the foetus
Discuss physical exam to determine stage of labour
Sterile approach using sterile gloves, sterile spec and iodine solution is indicated to prevent ascending infection
1) effacement refers to the thickness of the cervix. A paper thin cervix is 100% effaced
2) dilation indicates diameter of cervical opening
3) position describes the relationship of the feotal presenting part to the birth canal. The most common position of the head is occiput anteiror
4) Station indicates the relationship of the presenting foetal part to the maternal ischial spines (Head at the level of the ischaial spines is 0 station range from +5 to -5)
5) Presentation specifies the anatomic part of the foetus leading throught he birth canal
On digital exam the presenting part is the occiput on vertex in 95% of deliveries. On digital exam the smooth surface and bony contours are felt. There are 4 suture lines extending from the anterior fontenelle and 3 form the posterior
Describe the second stage of labour
The second stage of labour is characterized by a fully dialted cervix accompanied by the urge to bear down.
Median duration is 50 minutes in nulparrous and 20 minutes in multiparous
As stage 2 progresses preparation for delivery shoudl be underway A radiant warmer should be available and heated. Neonatal resuscitation adjucts avaialbe inlcluding towels, scissors, umbilical clamps, bulb suction, airway equipment and equipment to achieve vascular access.
Firm digital stretching of the perineum particulalry posteriorly may prevent tears or lacerations.
Controlled co-ordinated expulsion with coaching to sustain each push aids with crowning and delivery of the head.
The most vulnerable moment is when the foetal head begins to stretch and distend the perineum. Intructing the mother to pant and not push slows the passage of the head and shoulder.
The modified Ritgen maneuver may be used to support the perinuem and prevent maternal injury,
After the head is delivered the head is allowed to rotate toward the maternal thigh and clear the feotal face and airway, ensure cord not wrapped around feotal neck. THe shoulder usually anteiror shoulder clear the perineum. They often delivery spontaneously without aid from the physician. Gentle downward traction on the head promotes delivery. A subsequent upward motion pulls the posterior shoulder thorugh the pelvic outlet
As the infant clears the perineum attention focuses on the umbilical cord. The infant should be kept low or at the level of the perineum to promote blood flow to the infant. The cord is then clamped and curt. Clamps are placed 4-5 cm apart with a proximal clamp 10 cm from the umbi of the infant. An adequate umbi stump is improtant for venous access if needed. Suctioning of the nose and mouth at this time may reduce secreiton that can cause increased airway resistance .
Discuss episiotomy
With controlled deivery routine episiotomy is not recommended. Performed for breech or shoulder dystocia. Should be done before excessive stretching of the perineal muscles occur but near the time of delivery toavoid excessive bleeding.
COmmon parctice is to cut the episiotomy when the head is visible during a contraction and the introitus opens to a diameter of c-4 cm. Mediolateral incision is recommened to avoid tears and rectal involvement
Describe the third stage of labor
Involves the delivery of the placenta and frequent checks of of uterine tone.
Signs of placental separation include the uterus becoming firmer and rising, umbilcial lengths 5-10 cm or there is a gush of blood.
THis usually occurs wihtin 5-10 minutes of delivery of the child
Beyond 18 minutes there is an increase in PPH and at 30 minutes it is 6 times greater
ACtive management of the placenta includes administration of utertonics (oxytoxin 10 units IM) gentle traciton of the clamped umbilical cord with mild pressure abvoe the symphysis pubis and uterine massage after delivery
Any attempts to delivery the placenta before it separates is contraindicated
Examination of the umbilical and placenta is essential. 2 vesel umbi cord occur in 1/500 births. Common placental abnormalities include accessory lobes and abnormal cord insertion. Visible clots adherent to the uterus raise concerns about an abruption and missing tissue should be a warning to PPH
Discuss the fourth srtage of labour
First hour after delivery of the placenta and is a critcal period in which PPH can occur.
Vagina and fornices should be examined for deep laceration and oxytocin should be infused to promte contraction of the uterus and control haemorrhage.
Discuss antenatal foetal monitoring during labour
During laboru and delivery the indentification of foetal dsitres and appropirate intervention can reduce foetal morbidity and mortality
There are currently three methods of assessing the foetus in utero
1) clinical monitoring
2) electrical monitoring
3) ultrasonography
Discuss electronic feotal monitoring
Uses tracing of uterine contraction and foetal heart rate
Uterine activity is measured transabdominally by a pressure transducer, creating a record of the contraction frequency. Strenght of contraction correlates poorly with reading
Foetal heart has tracing have several components that can be assessed
1) base line heart rate
2) variability
3) acceleration
4) decelleration
5) diagnostic patterns
Discuss baseline heart rate one a CTG (cardiotocography)
THis is the average foetal heart rate during a 10 minute period (int eh absence of a uterine contraction) and is the most important aspect of foetal heart monitoring. Foetal bradycardia is defined as a heart rate lower than 110n, feotal tachycardia is greater than 160
Discuss variability on a CTG
This can be instantaneous (beat to beat) or long term (intervals >= 1minute) Both types of variability are indicators of foetal well being. Acceleration occur during foetal movement and reflect an alert and mobilr foetus. Normal variability is between 5-25
Decreased variability may indicate foetal acidaemia and hypoxemia or may be a side effect of a wide arry of durgs including analgesics, sedative hypnotics phenothiazines and ETOH
Discuss decelerations
Complicated and should be interpreated according to the clinical scenario. There are three types of deceleration - variable, early and late
Early deceleration
- start when uterine contractions begin and recover when uterine contraction stop.
- Due to increased feotal intracranial pressure causing increased vagal tone
- Quickly resolves post contraction
- Physiological not pathalogical
Variable
- Variable in there duration and may not have any relationship to uterine contractions
- Usually caused by umbilical cord compression
- Umb vein is often occluded first causing an acceleration – artery is then occluded causing a rapid decel, when pressure on the cord is reduced another acceleration occurs and then the baseline rate returns
- Accelerations before and after variable dcel are called shoulder of decleration and indicate the foetus is not yet hypoxic
- Maternal position change sometimes helps
- If nil shoulder persistent or prolonged concern for hypoxia
Late decel
- Begin at the peak of contraction and recover after the contraction ends
- indicates insufficient blood flow to the uterus and placenta - leading to foetal hypoxia and acidosis
- Causes include
- –materanal hypotension
- –pre-eclampsia
- –uterine hyperstimulation
Discuss diagnostic patterns
Sinusoidal tracing
- Smooth regular wave like pattern
- freqeuncy of around 2-5 cycles a minute
- stable baseline rate around 120-160
- no beat to beat variability
The sinusoidal tracing is an ominous finding that is often premorbid and has a DDX of
1) erythroblastosis foetalis, placental abruption, foetal haemorrhage and amniotiis
Define preterm labour and causes of the same
Uterine contrqaction with cervical changes before 37 weeks of gestation. Is assoicated with 5-18% of all pregnancies and is the leading cause of neonatal death.
Causes Maternal -UTI -PROM -Chorio -Pre-eclampsia -Drug ise
Foetal
- Congential abdnomaloities Diwbs
- Multiparus
Placnetal, uterine
-polyhydraminos
Discuss feature linked to premature labour
Demographic and psychosocail
- extremes of age >40 and teenagers
- Lower socioeconomic status
- tabacco use
- Cocaine abuse
- prolonged standing
- psychosocial stressors
Reproductive and gynecological
- prior prem
- diethylstilbestrol exposure
- mutliple gestations
- anatomic endometrial cavity anomalise
- cervical incompetence
- low preganncy weight gain
- first trimester vaginal bleeding
- placenta pravia or abruption
Surgical
- prior reproductive organ surgery
- prior paraendometrail surgery other than genitourinary
INfection
-UTI
-non uterine infection
0genital tract infections
Discuss the management of preterm labour + absolute (7) and relative (5)
A viable foetus and a healthy mother are indication for medical management to prolong the gestation. Preterm labour should not be post poned if there is feotal compromise, major congenital anomalies, intrauterine infection, placental abruption, eclampsia, significant cervical dilation or PROM
Treatment of preterm labour involve multiple modalities and is usually performed outside of the ED. Tocolytics and foetal maturation therapy combined with bed rest and hydration are used with hope of prolonging pregnancy,
Tocolytic agents incldue
- magnesium sulfate (4-6g IV bolus over 20 min) (2-4g/hr IV infusion (neuroprotection against cerebral palsy and other types of severe motor dysfunction)
- NSAIDS indomethasone 50mg can be used 24-32 weeks asincreased risk of closure
- Nifedapine 20 mg loading than 10mg Q6 hourly
- Salbuatmol
- Terbutaline (5-10mg PO Q4-6H)
- Ritodrine (10mg PO q2-4 hours)
Contraindications to tocolytics Absolute -foetal distress -acute vaginal bleeding -lethal foetal anomaly -chorioamniionitis -pre-eclampsia or eclampisa -sepsis -DIC
Relative
- Chronic HTN
- Cardiopulmoanry disease
- Stable placenta Previa
- Cervical dilation >5 cm
- Placental abruption
Reason for delay is to facilitate the use of IM: 12 mg every 24 hours for a total of 2 doses to avoid Respiratory distress syndrome, intracranial hemorrhage, NEC and death
Discuss PROM
Defined as rupture of the amniotic and chorionic membranes before the onset of labour. It affects 3% of all gestations.
During pregnancy the chorionic and amniotic membranes protect the foetus from infection and provied an envirnement for foetal growth,
Preterm PROM occurs when rupture happens prior to 37 weeks of gestation
PROM is the inciting event in one third of all preterm deliveries
Discuss the diagnosis of PROM
Typically the patient will suggest the condition and be correct. Typically describes a spontaneous gush of watery fluid followed by a mild persistent seepage.
Direct digital examination of the cervix is avoided. Visualisation of the ccervix is performed to identify any prolapsed cord or small feotal part.
Culture specimens for GBS, chlamydia and gonorrhoe should be obtained
Nitrazine paper will show the more alkaine (6.5) amniotic fluid as blue and leave the normal vaginal secrtion ph 5.5 as yellow
Discuss the management of PROM
Management depends on many factors include gestational age, foetal maturity, presence of active labour, presence or abscence fo infection, presence of complications such as abruption
CTG and obs consult should be performed in all cases. IN premature kids 24-32weeks treatment to speed maturation of the foetus should be performed.This includes steroids to speed lung development
All patient should be investigated for the possibility of intraamniotic infection
Preterm PROM should be treated with ABs either IV amp, clinda or erythromycin
Treatment of PROM is indicated if patient is GBS positive
Discuss risk factors for chorioamnionitis and AB choice
PROM, recurrent vaginal examns, prolonged 1st or 2nd stage of labour.
Ampi gent reasonable ABs
Ceft, gent +metro
Discuss dystocia
Dystocia or abnormal labor progression accounts for one third of all c-sections and half of primary c-section.
Can be divided into three categories of causative factors 3 Ps (passage, passenger, power)
1) issue with pelvic architecture
2) issue with foetal size or presentation
3) inadequate uterine expulsive force
Discuss relative incidence of malpresentations
Breech presentation 1/25 live births
shoulder dystocia 1/300 live births
Face presentation 1/550 live birhts
Brow presentation 1/1400 live briths
Discuss Breech delivery
Most common malpresentation occuring in just less than 4% of deliveries. There are three types of breech presentation
1) Frank
- 60-65% of presentations
- hips flexed,knees extended
- buttocks act as good dilating wedge
- incidence of cord prolapse 0.5%
2) compelte breech
- 5% of presentations
- hips and knees flexed
- buttocks act as good dilating wedge
- incidence of cord prolapse 5-6%
3) incomplete (footling) breech
25-35% of presentation
-incomplete hipflexion, single or double footling
-poor wedge
-increased incidence of prolapsed cord 15-18%
Discuss compications of breech delivery
One third of breach foetal deaths are belived to be preventable
- asphyxia is often due to imbilical cord prolapse or entrapment of the head
- other complciations include
- -labour arrest
- brachial plexus injury
- foetal head and neck trauma
Discuss IX of breech delivery
Leopold’s maneuvers faciliate the diagnosis of breech presentation. if in active labour in the ED the use of leopolds maneuvers may be restricted and vaginal exam is warrented
Whenever a fontanel is not identified on examination a breech presentation should be suspected - useful to remeber that the face and skull have a complete circle of bone whereas the anus is gflanked by bone on only two sides
If time permits ultrasound is useful in identifying time of breech
Discuss management of breech delivery
Premature infants in the breech position often deliver spontaneously without difficulty.
Actions to do as able
- monitor foetal heart rate
- diagnosis breech lie
- determine cervical dilation and station
- obtain US
- Evaluate for proloapsed cord if there is SROM
- Perform generous episiotomy
- flex knee and sweep out legs
- pull 10-15 cm of cord (room to work) after the umbilicus clears the perineum
- use the bony pelvis as a means of holding the infant
- keep face and abdomen away from the symphysis and use rotation to dliver the more accessible arm
- Perform the Mauriceau maneuver
Discuss the mauriceau maneuver
The use of the foetal oral aperture to flex the foetal neck and draw in the chin. Foetal neck extension is asscoiated with cord injuries and worsening dystocia. Should only be attempted once the feotal elbows and chin have entered the pelvic inlet to avoid inducing the moro reflex
Discuss shoulder dystocia
Unlike breech presentation which can be diagnosed in the antenatal period shoulder dystocia develops in the intrapartum period.
Diagnosed clinically by the inbaility to deliver either shoulder. The foetal head may appear to retract towards the maternal perineum otherwise knwon as the turtle sign. Traction on the head extends and abducts the shoulders increasing the bisacromial diamter and worsening dystocia
Normally the shoulders negotiate the maternal pelvis in sequential fashion, anterior shoudler first. with shoulder dysotica both shoulders attempt to clear the maternal pelvis simultaneously. Usually a vertical axis of the sholders rather than oblique
Discuss risk factors for the developemtn of shoulder dystocia
Maternal
- diabetes
- obseity
- precipitous or protacted labour
Foetal
- macroscomia
- postmaturity
- erythroblastosis foetaliss
Discuss compolciations of shoudler dystocia
Infant
- Traumatic brachail plexus injuries,
- clavicular fractures
- hypoxic brain injury
Maternal
- vaginal, perineal and anal sphincter tears
- urinary incontinence
Discuss management of shoulder dystocia
Rapid resolution is important to avoid foetal asphyxia and resultant CNS injury.
Initial attempts to resolve shoulder dysotica involve increasing the AP diameter of the passage. An episiotomy may be used for foetal maneuviering by allwoing access to the psoterior shoulder. Anteriorly draining the bladder with a foleys cathetr cna gernate room
McRoberts i the most important first step
Maternal leg flexion to a knee chest position may disengage the anterior shoulder allowing delivery - this maneuver walks the pubic symphysis over the anterior shoulder and flattens the sacrum helping the foetus pass thorugh the birth canal one shoulder at a time .
If McRoberts fails suprapubic pressure may accomplish this by forcing the anterior shoulder to slip beneath the pubis or posterior shoulder to retreat into the hollow of the sacrum.
Digital pressure on the posterior shoulder (through an episiotomy) may help facilitate posterior shoulder retreat
If still impossible the next step is Rubin’s maneuver.- the goal of this maneuver is to decrease the bisacromial diameter by pushing the most accesssible shoulder toward the foetal chest
If still impacted the next step is Woods maneuver - In this process the imapcted shoulder are released through rotation of the foetus 180 degrees- foetal rotation is achieved by pushing the most accessible shoulder in toward the chest.
If still not released consideration of delivery of an arm is approrpiate. A hand is introduced along the psoterior aspect of the posterior shoulder. The arm is swept across the chest bringing the foetal hand hup to the chin.
The foetal hand is grasped and pulled out of the brith canal across the faced delivering the posterior shoulder
Discuss the HELPER pneumonic for shoulder dystocia
Help - obs, neonataology, anase4theisa Episiotomy -- generous Legs - McRoberts Pressure - superpubic Enter vagin - Rubins and Woods maneuver Remove posterior arm
Discuss multiple gestations
Increasing in incidence due to increased use of assisted fertility treatments
Multiple gestation pregnancy have a higher incidence of preterm labor and low birth weights, maternal and foetal complications rates are correspondingly increased
Short latent phase but increased active phase often allowing for obstetric aid to be called upon.
Vertex presentationin both feotuses occur in 42% of cases, one in vertex in 35-40% and the rest neither in vertex
Discuss delivery in multiple gestation delivery
Twins who are vertex vertex can be deliveried vaginally barring any other obstestric complciations. If Twin B is not vertex c-section is preferred - extenral cephalic version and breech extraction can be performed if precipitous vaginal delivery
If both twins are non vertex c-section is preferred as they can become interlocked resulting in high mortality. In such cases efforts should be made to delay labour until surgical intervention can be performed
usually Twin B will follow the delivery of A within minutes. If not the case should prompt in utero assessment of twin B. If CTG is reassuring the deliver of twin B should not be hastened
Discuss Umbilical cord prolapse
Occurs when the umbilcal cord precedes the foetal presenting part or when the presenting part does not fill the canal.
Most cases are unexpected and occur during the second stage of labour
Malpresentation account for 50% of all cord prolapse cases
Discuss risk factors for cord prolapse
●Malpresentation (breech, transverse, oblique, or unstable lie) ●Prematurity ●Low birth weight ●Second twin ●Low lying placentation ●Pelvic deformities ●Uterine malformations/tumors ●External fetal anomalies ●Multiparity ●Polyhydramnios ●Long umbilical cord ●Unengaged presenting part ●Prolonged labor
Discuss management of cord prolapse
When occurs c-section is the delivery of choice
If surgery is available maneuvers to preserve umbilical circulation should be institued
-the mother should be placed in the knee to chest postion with the bed in the trendelenburg position - this elevates the presenting part off the umbilical cord.
-mother should be instructed to refrain from pushing
-placement of a foley catheter and instillation of 500-750 mls of saline into the bladder may help lift the foetus of the cord
Urgent surgery should be organsed with time from prolapse to surgery being and important prognostic factor
If surgery is not a timely option - funic reduction should be performed
same maneuvers as above but gently push the cord above the presenting part and delivery the child as normal - manipulation of the cord and cord trauma should be kept as close to minimal as possible to avoid reflex vasospasm
Define postpartum haemorrhage
Haemorrhage of more than 500 mls after a vaginal delivery it effects 5-10% of all deliveries and accounts for up to 25% of maternal deaths
Primary PPH occurs wihtin the first 24 hours post delivery
Secondary occurs 24 horus to 6 weeks after
Discuss causes of PPH
T: tone – uterine atony
Tissue - retained products
thrombosus - coagulopathy
trauma
Dicuss uterine atony
Atony accounts for 75-90% of PPH - most common serius immediate cause of postpartum haemorrhage
Normally post partum bleeding from the placenta implantation site is limited by contraction of the myometrium constricting the spiral arteries. If this does not occur the uterus will continue to bleed
Predisposing factors inlcude
- overdistension of the uterus (eg multiple pregnancy, foetal macrosomia, polyhydraminios)
- prolonged labour
- tocolytics
- GA with halogenated compounds
As a diagnosis of exclusion examination for obstetric trauma or retained products should be undertaken
Discuss maternal birth trauma
Second most common cause of PPH Risk factors include - uncontrolled deliveyr -macrosomia -episiotomy - nulliparitiy -maternal coagulopathy - operative delivery - prolonged second stage -pre-eclampsia -malpresentation
Tears and laceration may involve
- perineum
- rectum
- cervix
- vagina
- vulva
- urethra
Blood vessels beneath the vulvar or vaginal epithelium can also be injured without frank hemorrhage resulting in large haematomas that can go unnoticed for hours slowly enlarging and can lead to haemorrhagic shock
Discuss Classification of tears
First degree - perineal skin and vaginal mucous membrane only
Second degree
- extend through the skin into the fascia and muscles of the perineal body
third degree
- extend into the anal sphincter
4th degree
- extend through all layres including the rectal mucosa
Discuss retained products of conception
10% of cases of PPH
Normally the plane of cleavage between the zona basalis and spongiosa result in a clean speration of the pacenta from the uterus - when this occur the plancetal tissue is delivered as a unit
-Any placental defect on review should race the question of retained product
Agressive traction during the 3rd stage of labour can result in retained products which may cause primary or secondary PPh
IX include US and may require surgical removal of products
Placenta, accreta increata and percreta describe various degrees of abnormal placental attachment .
- When the placenta adheres to the myometrium without intervening decidua basalis it is termed accreta
- increta the villi extend into the myometrium
- percretia penetrates the full thickness of the myometrium
Risk factors
- multiparity
- prior c-section
- placdenta preavia
- previous curettage and uterine anomalies
Discuss Coagulopathy as cause of PPH
All women with severe PPh should be evaulatuated for DIC.
DIC can occurs as a consequence of placental abruption, eclampsia, amniotic fluid emoblism, postpartum infection and dilution of clotting factors by aggresive volume resus
Retained products and dead foetal tissue contain excess thromboplastin which can precipitate DIC
Discuss Management of PPH at blood loss of >500ml vaginal or >1lire at c-section but <1500mls wiht ongoing excessive bleeding - (greater than 1000ml of PPH is severe)
Move patient to appropriate location and notify teams - anaethetics, o&G
Establish IV access
Resus with crystalloid and blood – should be approached in a similar fashion to trauma resus wiht early replacement with blood if available can ROTEM guide it - MTP ?Factor VII
Bloods product and ROTEM guided replacement should be implemented at this stage aiming for HD stability and perfusion indicated by Urine output and -HB >75 Platelets >50 -fibrinogen greater than 300mg/dl -PT time less than 1.5 control APTT less than 1.5 control
Perform thorough vaginal abdominal and rectal examintaion –
Assess uterine tone
Assess for uterine rupture or RPOC
Assess for uterine inversion
Admin TXA 1 gram infused over 10-20minutes with a second dose given if bleeding persist - WOMAN trial found that TCA reduced death from bleeding with PPH by 20-30 percent - with nil increase in adverse effects
Begin treatment of the cause of bleeding
ATONY
- Perform uterin massage and compression - one hand is made into a fist and placed vaginally into the anterior fornix - the other hand massages the fundus while firmly compressing it against the vaginal hand
- Administer oxytocin 40 units in 1 litre at a rate sufficeint to control uterine atony or 10 units IM - higher dose do not appear to more effective
-IF not ceasing use misoprostol – 400 mcg sublingual oral and rectal administration take longer to reach peak concentration
-Syntometrine - Ergot 0.2mg IM 2-4 hourly
REPAIR
-repair heavily bleeding vaginal and cervical lacerations
TAMPONADE
If unable to control bleeding with above tamponade may be needed which can be achieved with a balloon catheter or intrauterine pack
-Bakri balloon
-Intrauterine packs
If bleeding uncontrolled and blood loss >1500mls patient will nil to be moved to theatre or for embolization if available
ionised calcium need to be kept above 1 as lower than this impairs clotting and puts patient at risk of cardiac arrest – if need be calcium gluconate or chloride can be used
Discuss uterine inversion and list risk factors
Uncommon but serious complications of delivery that occurs in stage 4 of labor
The resultant PPH can be severe and life threatening
Risk factors include excessive fundal pressure, forceful traction, placenta accreta, maternal congenital abnormalities use of magnesium sulfate and primpiparity
Discuss clinical features of uterine inversion
Sudden onset severe abdominal pain
Abdominal exam reveals tenderness and an absence of the uterine corpus which is potentially visualised at the cervical os or buldging from the introitus.
Discuss management of uterine inversion
Initial management as per PPH with aggressive fluid resus, TXA and ROTEM guided replacement
The best chance of successful repositioning of the uterus is immediately after the inversion -
Do not try to remove placenta while inverted
push through the introitus to try to reposition
Contrqaction of the cervical uterine segments can create a muscular ring preventing reposition as such uterotonic agents should be withheld on diagnosis of inversion.
If initial attempts fail and a cervical ring develops pharmocological attempts to relax the uterus should be made with tocolytics and sedation. -once reduced the tocolytics should be stoped and oxytoxin and PG should be given
Discuss uterine rupture
Rare but increased with VBAC
Can occur late in pregnancy or as a stage 1 of labour transitions into the active phase
Defined as a full thickness uterine wall perforation the severity of rupture ranges from simple scar to dehiscence to foetal extrusions. May be spont but is more likley linked to pervious c-section.
Can be hard to diagnose as pain is not always present. Presentation ranges from nonreassuring foetal heart rate pattern to frank maternal haemorrhagic shock.
Prolonged decelleration is the most reliable sign of foetal extrusion.
If suspected delivery should be hastened to limit foetal hypoxia. Emergent c-section is the treatment of choice
Discuss postpartum endometritis
Puerperal ( period of about 6 weeks after childbirth) infections affect 5% of vaginal births and 10% of c-section.
Risk factors include
- Operative delivery
- Prolonged rupture of membranes
- lack of prenatal care
- prolonged second stage
- use of intrauterine monitoring
- frequent vaginal examination
Organisms involved include - gram positive cocci, gram-ve coliforms and less commonly chlamydia and mycoplasma
Endometritis is the most common puerperal infection - usually developing day 2-3 post partum. Typically the lochia has a foul smell and there is an elevated WBC - search for RPOC is warrented if suscpeted
Treatment is empirical and is directed at gram positive, gram -ve and anaerobic organisms with a combination of clindamycin and an aminoglycoside
Discuss progression of Lochia
Locia Rubra – dark red last 3-4 days after delivery is made up of blood bits of feotal membranes, meconium and cervical discharege
Lochia serosa - pinkish brown 4-10 days, contains less RBC and has more WBC wound dsicharge from the placental and other site and mucous from the cervix
lochia alba 10-28 days whitish turbid fluid drains from the vagina which mainly consists of decidual cells, mucous, WBC and epithelial cells
Discuss Peripartum cardiomyopathy
Risk factors icnlude
- advanced maternal age,
- pre-eclampsia
- gestational HTN
- multiparity
- African american
Usually occurs days to weeks after delivery with symptoms ranging from mild fatigue to florid pulmonary oedema
Cardiac function returns to normal in 23-32% of patients during the following 6 montsh
Describe approach to interpretation of CTG
Baseline - mean BPM over a 10 minute interval excluding peridodic changes, periods of makred variability and segments that differ more than 25 BPM
- Tachy >160
- Brady <110
Variability
- Absent
- Minimal (amplitude 0-5BPM)
- Moderate (Amplitude 6-25BPM
- Marked (amplitude >25BPM)
Acceleration - abrupt increase in FHR
- should last >15 and peak >15 seconds above baseline
- prolonged accelration is >2 minutes but less than 10
- > 10 indicates a change in baseline
Decelerations -
-early- gradual decrease and return to baseline of the FHR associated with a uterine contration. The Nadir of the FHR and the poeak of the contraction occur at the same time
- variable - Abrupt decrease in FHR bleow basline >15BPM >15sec and <2 minutes to return of baseline
- late gradual decrease and retun to baseline of the FHR associated with uterine contraction. The deceleration is delay in timing with the nadir of the deceleration occuring after the peak of the contraction
Give DDX of variable deceleration
Fall in maternal BP Tachysystole Placental abruption Uterine Rupture Vasa Previa Cord Prolapse Cord compression
Discuss DDX of late decleration
Reflex response to transient hypoxemia
Maternal hypoxemia or hypotension
Discuss chorioamniotis and micro
ACute inflammation of the membranes and the chorion of the placenta. Typically due to polymicrobial bacterial infection in women whose membranes have ruptured.
Common complciation associated with potentially serious adverse maternal, feotal and neontal affects and increased log term risks for CP and other neurodevelopemtn delay.
Treatment involve both AB and delivery of the infected products of conception.
Typically polymicrobial often involving vaginal or enteric flora
- gram -ve acinterobactor, e.coli, psuodomonas
- Grame +ve, strep and staph specifies, enterococcus, bacillus
- Anareobes
- Mycoplasma, cnadida, garnerella vaginalis
Discuss risk factors for the developement of chorio
Prolonged Labour Duration of ROM Multiple digital vaginal examination - esepcialy with ROM Cervical insufficienncy Nulliparity, Mec amniotic fluid internal feotal or uterine contraction moniting Alcohol and tobaco use
Discuss clinical finding of chorio
Fever Maternal leukocytosis Maternal tachy Foetal Tachy Uterine tenderness bacteremia - most common if associated with GBS or ecoli purulent or malodorous amniotic fluid
Discuss complciations of choro
Increase c-section increase uterine atony increase PPH Localised infection sepsis DIC
Discuss diagnositc criteria for chorio
Suspected: fever without source plus any of the following
1) baseline fotal tachycardia
2) maternal WBC greater than 15 in the absence of steroid
3) definite purulent fluid from the os
Confirmed - all of the above plus lab finding of infection
- postiive amniotic fluid gram stain for bacteria, low amniotic fluid flucose, high WBC in the abscence of bloody tap or positive amniotic fluid culture
- histpopath evidence of infection or inflammation or both in the placenta, feotal mebranes or the umb vessels
Discuss management of chorio
Delivery - women with confirmed triple I ( Triple I refers to intrauterine inflammation or infection or both) should be given Amp and gent and deliveried.
If c-sectipon should have anerobic cover 500mg of metronidaolze IV TDS or clindamycin 900mg TDS
