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Obstetrics and Gynaecology > Labour and Delivery - done > Flashcards

Labour and Delivery - done Flashcards

1
Q

When do labour and delivery normally occur?

A

Between 37 and 42 weeks gestation

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2
Q

What are the three stages of labour?

A

First stage - from onset until 10cm cervical dilation

Second stage - from 10cm cervical dilation until delivery of baby

Third stage - from delivery of baby to delivery of placenta

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3
Q

What changes to the cervix happen in the first stage of labour?

A

Cervical dilation - opening up

Effacement - getting thinner

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4
Q

What is the “show” in a pregnant womans cervix?

A

Mucus plug = prevents bacteria from entering during the pregnancy

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5
Q

What are the 3 phases to the first phase of delivery?

A

Latent phase = from 0 to 3cm - progresses at 0.5cm per hour - irregular contractions

Active phase = from 3 to 7cm - progresses at 1cm per hour - regular contractions

Transition phase = from 7 to 10cm - progresses at 1cm per hour - strong and regular contractions

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6
Q

What are Braxton-Hicks contractions?

A

Occasional irregular contractions of the uterus (felt during 2nd and 3rd trimester)

Not indicating the onset of labour - staying hydrated and relaxing reduces these contractions.

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7
Q

What are the signs of labour?

A

Show (mucus plug from the cervix)

Rupture of membranes

Regular, painful contractions

Dilating cervix on examination

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8
Q

What are the latent first stage of labour and the established first stage of labour?

A

Latent first stage = painful contractions, changes to the cervix, with effacement and dilatation up to 4cm

Established first stage = regular, painful contractions, dilatation of the cervix from 4cm onwards

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9
Q

What does ROM stand for?

A

Rupture of membranes

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10
Q

What does SROM stand for?

A

Spontaneous rupture of membranes

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11
Q

What does PROM stand for?

A

Prelabour rupture of membranes (amniotic sac has ruptured before the onset of labour)

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12
Q

What does P-PROM stand for?

A

Preterm prelabour rupture of membranes (P-ROM) - the amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm)

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13
Q

What does PROM stand for?

A

Prolonged rupture of membranes (also PROM) - The amniotic sac ruptures more than 18 hours before delivery

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14
Q

What is prematurity?

A

Birth before 37 weeks gestation

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15
Q

When are babies considered non-viable?

A

Before 23 weeks gestation

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16
Q

What chance of survival do babies born at 23 weeks have?

A

10% chance of survival

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17
Q

What gestational age will a full resuscitation be offered from?

A

24 weeks

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18
Q

What is the WHO classification of prematurity?

A

Under 28 weeks: extreme preterm

28 – 32 weeks: very preterm

32 – 37 weeks: moderate to late preterm

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19
Q

What are the 2 options for prophylaxis of pre-term labour?

A

Vaginal progesterone

Cervical cerclage

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20
Q

How does vaginal progesterone protect against pre-term labour?

A

Given as a gel or pessary

Decreases activity of the myometrium and prevents the cervix from remodelling in prep for delivery

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21
Q

Who is vaginal progesterone offered to?

A

Women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation

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22
Q

How does cervical cerclage work?

A

Putting a stitch into the cervix to add support and keep it closed, involves a spinal or general anaesthetic

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23
Q

When is a cervical cerclage reversed?

A

When the woman goes into labour or reaches term

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24
Q

Who is offered cervical cerclage?

A

Women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks

Previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy)

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25
Q

When is a rescue cervical cerclage offered?

A

Between 16 and 27+6 weeks when there is cervical dilatation without rupture of membranes to prevent progression and premature delivery

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26
Q

What is preterm prelabour rupture of membranes?

A

Where the amniotic sac ruptures before the onset of labour and in a preterm pregnancy (under 37 weeks gestation)

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27
Q

How is P-PROM diagnosed?

A

Speculum examination revealing pooling of amniotic fluid in the vagina - no tests are required

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28
Q

What tests can be used to confirm the diagnosis of P-PROM?

A
  • Insulin-like growth factor-binding protein-1 (IGFBP-1)
  • Placental alpha-microglobin-1 (PAMG-1)
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29
Q

What is IGFBP-1?

A

A protein present in high concentrations in amniotic fluid which can be tested on vaginal fluid if there is doubt about rupture of membrane

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30
Q

What is PAMG-1?

A

Similar alternative to IGFBP-1

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31
Q

What is the management of P-PROM?

A

Prophylactic antibiotics given to prevent chorioamnionitis

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32
Q

What antibiotics are recommended to prevent chorioamnionitis?

A

Erythromycin 250mg 4 times daily for 10 days or until labour is established if within 10 days

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33
Q

When is induction of labour offered for P-PROM patients?

A

From 34 weeks

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34
Q

What is preterm labour with intact membranes?

A

Preterm labour with intact membranes with regular painful contraction and cervical dilatation, without rupture of the amniotic sac

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35
Q

How is preterm labour with intact membranes diagnosed?

A

Clinical assessment with speculum examination to assess for cervical dilatation

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36
Q

How is preterm labout with intact membranes diagnosed less than 30 weeks gestation and more than 30 weeks gestation?

A

Less than 30 weeks gestation = Clinical assessment alone

More than 30 weeks gestation = Transvaginal ultrasound can be used to assess the cervical length (if less than 15mm management of preterm labour can be offered - if more than 15mm then preterm labout is unlikely)

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37
Q

What is an alternative test for preterm labour without membrane rupture?

A

Fetal fibronectin (the “glue” between the chorion and the uterus and is found in the vagina during labour)

Result of less than 50ng/ml is considered negative and indicates that a preterm labour is unlikely

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38
Q

What is included in the management of preterm labour?

A

Fetal monitoring (CTG or intermittent auscultation)

Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour

Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality

IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain

Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

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39
Q

What is tocolysis?

A

Medication to stop uterine contractions - nifedipine, a CCB, is the medication of choice for tocolysis

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40
Q

What is an alternative to nidefipine for tocolysis?

A

Atosiban, an oxytocin receptor antagonist

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41
Q

When can tocolysis be used?

A

Between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU)

ONLY USED AS A SHORT TERM MEASURE - less than 48 hours

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42
Q

Why are antenatal steroids given?

A

Develop the fetal lungs and reduce respiratory destress syndrome after delivery

Used in women with suspected preterm labour of babies less than 36 weeks gestation

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43
Q

What is an example regimine of antenatal steroids?

A

Two doses of intramuscular betamethasone, 24 hours apart

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44
Q

What is IV magnesium sulphate given for?

A

Protect the fetal brain during premature delivery. Reduces the risk and severity of cerebral palsy.

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45
Q

When is IV magnesium sulphate given?

A

Within 24 hours of delivery of preterm babies of less than 34 weeks gestation

Given as a bolus followed by an infusion for up to 24 hours of up until birth

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46
Q

What do mothers that are given IV magnesium sulphate need monitoring for?

A

Magnesium toxicity at least four hourly

Monitor tendon reflexes (usually patella reflex)

  • Reduced resp rate
  • Reduced blood pressure
  • Absent reflexes
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47
Q

What is induction of labour?

A

Use of medication to stimulate the onset of labour

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48
Q

When is induction of labour offered?

A

Between 41 and 42 weeks gestation

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49
Q

When is induction of labour offered?

A
  • Preterm rupture of membranes
  • Fetal growth restriction
  • Pre-eclampsia
  • Obstetric cholestasis
  • Existing diabetes
  • Intrauterine fetal death
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50
Q

What is the Bishop Score?

A

Scoring system used to determine whether to induce labour

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51
Q

What is assessed in the Bishop’s criteria and what is the maximum score?

A

Fetal station (scored 0 – 3)

Cervical position (scored 0 – 2)

Cervical dilatation (scored 0 – 3)

Cervical effacement (scored 0 – 3)

Cervical consistency (scored 0 – 2)

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52
Q

What Bishop score predicts a successful induction of labour?

A

8 or more (a score below this suggests cervical ripening may be required to prepare the cervix)

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53
Q

What are the options for induction of labour?

A

Membrane sweep

Vaginal prostaglandins E2 (dinoprostone)

Cervical ripening ballon (CRB)

Artifical rupture of membranes

Oral mifepristone (anti-progesterone) plus misoprostol

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54
Q

What is a membrane sweep?

A

Inserting a finger into the cervix to stimlate the cervix and begin labour.

Can be performed in antenatal clinic and if successful should produce the onset of labour within 48 hours

Seen as an assistance fore the full induction of labour.

Used from 40 weeks gestation to attempt to initiate labour in women over their EDD

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55
Q

What does a vaginal prostaglandin E2 (dinoprostone) involve?

A

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.

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56
Q

What is a cervical ripening ballon?

A

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)

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57
Q

What is the artificial rupture of membranes?

A

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

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58
Q

When are oral mifepirstone (anti-progesterone) plus misoprostol used?

A

To induce labour where intrauterine fetal death has occured

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59
Q

What are the two means for monitoring during the induction of labour?

A

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

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60
Q

What is the ongoing management of IOL?

A

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
  • CRB
  • Elective caesarean section
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61
Q

What is the main complication of using vaginal prostaglandins to induce labour?

A

Uterine hyperstimulation - causing fetal distress and compromise

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62
Q

What is the criteria for uterine hyperstimuation?

A

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
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63
Q

What adverse outcomes can uterine hyperstimuation lead to?

A
  • Fetal compromise, with hypoxia and acidosis
  • Emergency C-section
  • Uterine rupture
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64
Q

What is the management of uterine hyperstimuation?

A
  • Removing the vaginal prostaglandins, stopping the oxytocin infusion
  • Tocolysis with terbutaline
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65
Q

What does cartiotocography do?

A

Measures the fetal heart rate and the contractions of the uterus

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66
Q

What is cartiotocography also known as?

A

Electronic fetal monitoring

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67
Q

Where are the transducers for CTG placed?

A

One above the fetal heart to monitor the fetal heartbeat

One near the fundus of the uterus to monitor the uterine contractions

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68
Q

How does the transducer above the fetal heart monitor the heartbeat?

A

Using doppler ultrasound

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69
Q

How does the transducer above the fundus measure uterine contraction?

A

Using ultrasound to assess tension

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70
Q

What are the indications for using continuous CTG measuring in labour?

A

Sepsis

Maternal tachycardia (> 120)

Significant meconium

Pre-eclampsia (particularly blood pressure > 160 / 110)

Fresh antepartum haemorrhage

Delay in labour

Use of oxytocin

Disproportionate maternal pain

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71
Q

What are the five key features to look for on a CTG?

A

Contractions – the number of uterine contractions per 10 minutes

Baseline rate – the baseline fetal heart rate

Variability – how the fetal heart rate varies up and down around the baseline

Accelerations – periods where the fetal heart rate spikes

Decelerations – periods where the fetal heart rate drops

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72
Q

What do number of contractions indicate?

A

The activity of labour

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73
Q

What do too few or too many uterine contractions indicate in labour?

A

Too few = labour isnt progressing

Too many = uterine hyperstimuation

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74
Q

What are accelerations a sign of?

A

Good sign that the fetus is healthy particularly when occuring alongside contractions of the uterus

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75
Q

What are the different categories for baseline rate on an CTG?

A

Reassuring

Non-reassuring

Abnormal

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76
Q

What baseline rate and varability on a CTG is reassuring?

A

Baseline rate = 110-160

Variability = 5-25

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77
Q

What baseline rate and variability is non-reassuring?

A

Baseline rate = 100-109 or 161-180

Variability = less than 5 for 30-50 mins or more than 25 for 15-25 mins

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78
Q

What CTG baseline rate and variability is considered abnormal?

A

Baseline rate = Below 100 or above 180

Variability = Less than 5 for over 50 mins or more than 25 for over 25 mins

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79
Q

What are decelerations?

A

Concerning finding, fetal heart rate drops in response to hypoxia (fetal heart rate is slowing to conserve oxygen for the vital organs)

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80
Q

What are the four types of decelerations?

A

Early decelerations

Late decelerations

Variable decelerations

Prolonged decelerations

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81
Q

What are early decelerations?

A

Gradual dips and recoveries in HR that correspond with uterine contractions

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82
Q

What are early decelerations?

A

Gradual dips and recoveries in HR which correspond with uterine contrations (lowest point of deceleration corresponds to the peak of the contraction)

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83
Q

What causes early decelerations, are they a worry?

A

Caused by the uterus compressing the head of the fetus, stimulating the vagus nerve of the fetus, slowing the HR.

Normal and not considered pathological

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84
Q

What are late decelerations?

A

Gradual falls in HR, which start after the uterine contraction has already begun - delay between uterine contraction and deceleration - lowest point of the deceleration occurs after the peak of the contraction

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85
Q

What causes late decelerations?

A

Caused by hypoxia in the fetus and are a more concerning finding, may be caused by excessive uterine contractions, maternal hypotension/hypoxia

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86
Q

What are variable decelerations?

A
  • Abrupt decelerations which may be unrelated to uterine contractions, fall of more than 15bpm from the baseline
  • Lowest point occurs within 30 seconds and the deceleration lasts less than 2 minutes in total
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87
Q

What do variable decelerations indicate?

A

Intermitten compression of the umbilical cord causing fetal hypoxia

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88
Q

What is a reassuring sign of variable decelerations?

A

Brief accelerations before and after the deceleration, known as shoulders (reassuring sign that the fetus is coping)

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89
Q

What is a prolonged deceleration?

A

A deceleration which lasts more than 15 bpm from baseline - often indicating compression of the umbilical cord causing fetal hypoxia. These are abnormal and concerning

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90
Q

When is the CTG reassuring?

A

No decelerations

Early decelerations

Less than 90 mins of variable decelerations with no concerning features

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91
Q

What CTG findings are classed as non-reassuring?

A

Regular variable decelerations

Late decelerations

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92
Q

What CTG findings are always abnormal?

A

Prolonged decelerations

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93
Q

What categoried are the CTGs interpreted upon?

A
  • Baseline rate
  • Variability
  • Decelerations
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94
Q

What are the four categoties for CTF?

A

Normal

Suspicious: a single non-reassuring feature

Pathological: two non-reassuring features or a single abnormal feature

Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes

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95
Q

What management options are there for a concerning CTG?

A

Escalating to a senior midwife and obstetrician

Further assessment for possible causes, such as uterine hyperstimulation, maternal hypotension and cord prolapse

Conservative interventions such as repositioning the mother or giving IV fluids for hypotension

Fetal scalp stimulation (an acceleration in response to stimulation is a reassuring sign)

Fetal scalp blood sampling to test for fetal acidosis

Delivery of the baby (e.g. instrumental delivery or emergency caesarean section)

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96
Q

What is the rule of 3s for fetal bradycardia?

A

3 minutes – call for help

6 minutes – move to theatre

9 minutes – prepare for delivery

12 minutes – deliver the baby (by 15 minutes)

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97
Q

What is a sinusoidal CTG?

A

Rare pattern to be aware of as it can indicate severe fetal compromise

Pattern similar to a sine wave with smooth regular waves up and down which have an amplitude of 5-15bpm

Usually associated with severe fetal anaemia e.g. caused by vasa praevia with fetal haemorrhage

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98
Q

What is the mneumonic for assessing a CTG in a structured way?

A

DR C BRaVADO

DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)

C – Contractions

BRa – Baseline Rate

V – Variability

A – Accelerations

D – Decelerations

O – Overall impression (given an overall impression of the CTG and clinical picture)

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99
Q

How can the overall impression of a CTG be given?

A

Normal (all features are reassuring)

Suspicious

Pathological

Need for urgent intervention

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100
Q

What are the medications commonly used during labour?

A

Oxytocin

Ergometrine

Prostaglandins

Misoprostol

Mifepristone

Nifedipine

Terbutaline

Carboprost

Tranexamic acid

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101
Q

What is oxytocin?

A

Hormone secreted by the posterior pituitary gland (produced in the hypothalamus)

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102
Q

What is the role of oxytocin during labour and delivery?

A

Stimulates the ripening of the cervix and contractions of the uterus

Also plays a role in lactation during breastfeeding

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103
Q

What is oxytocin used for in labour?

A

Induce labour

Progress labour

Improve the fequency and strength of uterine contractions

Prevent or treat PPH

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104
Q

What is a brand name for oxytocin?

A

Syntocinon

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105
Q

What is atosiban? When is it used?

A

Oxytocin receptor antagonist which can be used as an alternative to nifedipine for tocolysis in premature labour (when nifedipine is contraindicated)

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106
Q

What is ergometrine?

A

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

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107
Q

When can ergometrine be used?

A

Only in the 3rd stage of labour (delivery of the placenta - not in 1st or 2nd) and postpartum to prevent and treat PPH

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108
Q

Whar are the side effects of ergometrine?

A

Due to action on smooth muscle and GI tract:

Hypertension

Diarrhoea

Vomiting

Angina

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109
Q

When should ergometrine be avoided?

A

Eclampsia (and with significant caution in those with hypertension)

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110
Q

What is syntometrine? When is it used?

A

Combination drug containing oxytocin (syntocinon) and ergometrine

Used for prevention/treament of PPH

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111
Q

How do prostaglandins work in labour?

A

Stimulating contraction of the uterine muscles

Ripening the cervix before delivery

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112
Q

What prostaglandin is used in inducting labour?

A

Dinoprostone which is prostaglandin E2

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113
Q

What form does dinoprostone come in?

A

Vaginal pessaries (Propess)

Vaginal tablets (Prostin tablets)

Vaginal gel (Prostin gel)

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114
Q

How do prostagandins act in general?

A

Vasodilators, lowering blood pressure

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115
Q

What is the action of NSAIDS? Examples? Are they used in pregnancy?

A

Action = inhibit the action of prostaglandins

Examples = Ibruprofen, naproxen

Avoided in pregnnacy

116
Q

When are NSAIDs used in gynaecology?

A

Treating dysmenorrhoea (painful periods) as they reduce painful cramping (e.g. ibruprofen and mefenamic acid)

117
Q

What is misoprostol?

A

Prostalandin analogue (binds to prostaglandin receptors and activates them)

118
Q

When is misoprostol used?

A

Medical managment in miscarriage to help complete the miscarriage

Used alongside mifepristone for abortions and induction of labour after intrauterine fetal death

119
Q

What is mifepristone?

A

Anti-progesterone medication which blocks the action of progesterone halting the pregnancy and ripening the cervix

Enhances the effects of prostaglandins to stimulate contraction of the uterus

Not used in pregnancy with a healthy living fetus

120
Q

What type of drug is nifedipine?

A

CCB which acts to reduce smooth muscle contraction in blood vessels and the uterus

121
Q

What are the two main uses of nifedipine?

A

Reduce blood pressure in hypertension and pre-eclampsia

Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour

122
Q

What is terbutaline?

A

Beta-2-agonist similar to salbutamol

123
Q

How does terbutaline work in labour?

A

Acts on smooth muscles of the uterus to suppress uterine contractions

Used for tocolysis in uterine hyperstimuation notably when the uterine contractions become excessibe during induction of labour

124
Q

What is carboprost?

A

Synthetic prostaglandin analogue - stimulating uterine contraction

125
Q

How is carboprost given?

A

As a deep intramuscular injection in PPH where ergometrine and oxytocin have been inadequate

126
Q

Who should carboprost be used in caution with?

A

Patients with asthma (can cause life threatening asthma)

127
Q

What is tranexamic acid?

A

Antifibrinolytic which reduces bleeding (binds to fibrinogen and prevents it from converting to plasmin)

128
Q

What is plasmin?

A

An enzyme which helps break down fibrin blood clots (thus tranexamic acid helps prevent the breakdown of blood clots)

Also inhibits the action of fibrin a protein involved in the formation of blood clots.

129
Q

What is tranexamic acid used for?

A

Prevention and treatment of PPH

130
Q

What is progress in labour influenced by?

A

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)

131
Q

What is ‘the 4th P’?

A

Psyche - referring to the support and antenatal preparation for labour and delivery

132
Q

What is the three phases of the first stage of labour?

A

Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.

Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.

Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

133
Q

What suggests delay in the 1st stage of labour?

A

Less than 2cm of cervical dilatation in 4 hours

Slowing of progress in a multiparous women

134
Q

What are partograms?

A

Graph of progress of labour

135
Q

What is recorded on a partogram?

A

Cervical dilatation (measured by a 4-hourly vaginal examination)

Descent of the fetal head (in relation to the ischial spines)

Maternal pulse, blood pressure, temperature and urine output

Fetal heart rate

Frequency of contractions

Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium

Drugs and fluids that have been given

136
Q

How are uterine contractions measured on a partogram?

A

Contractions per 10 minutes

137
Q

What are the two lines on the partogram which indicate when labour may not be progressing?

A

‘Alert’

‘Action’

138
Q

If the line on the partogram crosses over ‘alert’, what should be done?

A

Amniotomy (artificially rupturing the membranes) repeat examination in 2 hours

139
Q

If the line on the partogram crosses over ‘alarm’​, what should be done?

A

Care needs to be escalated to ostetric-led care and senior decision makers

140
Q

What is the second stage of labour?

A

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

141
Q

How is delay in the second stage classified?

A

When the active second stage (pushing) lasts over:

2 hours in a nulliparous woman

1 hour in a multiparous woman

142
Q

What does power refer to?

A

Strength of uterine contractions

143
Q

How can power be improved?

A

Oxytocin infusion can be used to stimulate the uterus

144
Q

What does passenger refer to?

A

4 descriptive qualities of the fetus:

Size of the baby (macrosomic babies more difficult e.g. shoulder dystocia, large size of head)

Attitude refers to the posture of the fetus (how back is rounded and head and limbs are flexed)

Lie (position of the fetus in relation to the mother’s body - longitudinal / transverse / oblique)

Presentation (cephalic / shoulder / breeech: complete, frank or footling)

Passage: size and shape of the passageway, mainly the pelvis

145
Q

What are the possible interventions during the second stage of labour?

A

Changing positions

Encouragement

Analgesia

Oxytocin

Episiotomy

Instrumental delivery

Caesarean section

146
Q

What is a delay in the third stage of labour defined as?

A

More than 30 minutes with active management

More than 60 minutes with physiological management

147
Q

What does active management of the third stage of labour involve?

A

Intramuscular oxytocin and controlled cord traction

148
Q

What are the management options for failure to progress in labour?

A

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes

Oxytocin infusion

Instrumental delivery

Caesarean section

149
Q

What is used first line in failure to progress during labour?

A

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

150
Q

When using oxytocin in labour, what is the number of contractions to aim for?

A

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

151
Q

What can help with managing pain in labour (without medications)

A

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

152
Q

What pain relief is used in early labour?

A

Paracetamol (codeine may be added for additional effect - NSAIDs are avoided)

153
Q

What else can be used after paracetamol for pain relief in labour?

A

Gas and air (entonox)

50% nitrous oxide and 50% oxygen used during contractions for short term pain relief - takin deep breaths at the start of a contraction

154
Q

What are the side effects of gas and air?

A

Lightheadedness, nausea or sleepiness

155
Q

What opioid medications can be given during labour?

A

Pethidine and diamorphine given by IM injections to help with anxiety and distress

156
Q

What are some side effects of using pethidine or diamorphine?

A

Drowziness or nausea in the mother and can cause respiratory depression in the neonate if given too close to birth

Effect on baby may make the first feed more difficult

157
Q

What PCA may a woman be offered in labour?

A

Remifentanil (short acting opiate medication) - administered by pressing a button at the start of a contraction to abminister a bolus

158
Q

What are the side effects of PCA in labour?

A

Respiratory depression (treated with naloxone)

Bradycardia (treated with atropine)

Need input from an anaesthetist

159
Q

What does an epidural involve?

A

Interting a small tube (catheter) into the epidural space in the lower back (outside the dura mater, separate from spinal cord and CSF)

Local anaestehtic medication is then infused through the catheter into the epidural space where they take effect

160
Q

What are the anaesthetic options in epidurals?

A

levobupivacaine or bupivacaine, usually mixed with fentanyl

161
Q

What are some adverse effects of epidurals?

A

Headache after insertion

Hypotension

Motor weakness in the legs

Nerve damage

Prolonged second stage

Increased probability of instrumental delivery

162
Q

When do women need urgent anaesthetic review during epidurals?

A

Significant motor weakness (unable to straight leg raise)

Catheter may be incorrectly sited in the subarachnoid space (within the spinal cord) rather than epidural space

163
Q

What is cord prolapse?

A

When the umbilical cord descends nelow the presenting part of the fetus and through the cervix, into the vagina

164
Q

What is the worry in cord prolapse?

A

Danger of the presenting part compressing the cord, resulting in fetal hypoxia

165
Q

What is the most significant risk factor for cord prolapse?

A

Fetus is in an abnormal lie after 37 weeks gestation (unstable, transverse or oblique)

166
Q

When should an umbilical cord prolapse be suspected and how is it diagnosed?

A

Signs of fetal distress on the CTG

Diagnosed with vaginal examination with speculum confirming

167
Q

What is the management for a prolapsed cords?

A

Emergency C-Section pushing cord back in is not recommended!

Cord should be kept warm and wet and have minimal handling as this causes vasospasm

168
Q

What can help managing a prolapsed cord when waiting for a C-section?

A

Presenting part of baby can be pushed upwards to prevent cord compression

Woman can lie in the left lateral position (with a pillow under hip) or on all fours

Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by C-section)

169
Q

What is shoulder dystocia?

A

When anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered

Obstetric emergency

170
Q

What is shoulder dystocia often caused by?

A

Macrosomia secondary to gestational diabetes

171
Q

How does shoulder dystocia present?

A
172
Q

What is the turtle neck sign?

A

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

173
Q

What are the managment options of shoulder dystocia?

A

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

174
Q

What are the key complications of shoulder dystocia?

A

Fetal hypoxia (and subsequent cerebral palsy)

Brachial plexus injury and Erb’s palsy

Perineal tears

Postpartum haemorrhage

175
Q

What does an instrumental delivery refer to?

A

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

176
Q

Where is an instrumental delivery performed?

A

Usually on labour ward however if there are concerns over success then moved to theatre so that rapid delivery by C-Section can be performed

177
Q

What is given prophylactically after an instrumental delivery?

A

Single dose of co-amoxiclav

178
Q

What are some indications for an instrumental delivery?

A

Failure to progress

Fetal distress

Maternal exhaustion

Control of the head in various fetal positions

179
Q

What does an epidural for anaesthesia create an increased risk of?

A

Requiring an instrumental delivery

180
Q

What are the risks to the mother for an instrumental delivery?

A

Postpartum haemorrhage

Episiotomy

Perineal tears

Injury to the anal sphincter

Incontinence of the bladder or bowel

Nerve injury (obturator or femoral nerve)

181
Q

What are the key risks to the baby during an instrumental delivery?

A

Cephalohaematoma with ventouse

Facial nerve palsy with forceps

182
Q

What are the serious risks to the baby during an instrumental delivery?

A

Subgaleal haemorrhage (most dangerous)

Intracranial haemorrhage

Skull fracture

Spinal cord injury

183
Q

What is a ventouse?

A

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

184
Q

What is the main complication when using a ventouse?

A

Cephalohaematoma (collection of blood between the skull and periosteum)

185
Q

What is the main complication of using forceps during delivery?

A

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

186
Q

What nerve injury can there be in the mother following an instrumental delivery?

A

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

187
Q

What other nerve injuries can occur during birth (unrelated to instrumental delivery)? And how?

A

Lateral cutaneous nerve of the thigh - runs

Lumbosacral plexus

Common peroneal nerve

188
Q

When are perineal tears more common?

A

First births (nulliparity)

Large babies (over 4kg)

Shoulder dystocia

Asian ethnicity

Occipito-posterior position

Instrumental deliveries

189
Q

What are the four degrees of perineal tears?

A

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin

Second-degree – including the perineal muscles, but not affecting the anal sphincter

Third-degree – including the anal sphincter, but not affecting the rectal mucosa

Fourth-degree – including the rectal mucosa

190
Q

What are the subcategories of third-degree tears?

A

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

191
Q

What is the management of a first degree tear?

A

Do not require any sutures normally

192
Q

What is the managment of a perineal tear larger than first degree?

A

Requires sutures

193
Q

What is the management of a 3rd or 4th degree tear?

A

Repairing in theatre

194
Q

What are the additional measure taken to reduce the risk of complications in perineal tears?

A

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

195
Q

What are women who are symptomatic after third or 4th degree tears offered?

A

Elective C-Section in subsequent pregnancies

196
Q

What are the short term complications of a perineal tear repair?

A

Pain

Infection

Bleeding

Wound dehiscence or wound breakdown

197
Q

What are the lasting complications of a perineal tear?

A

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

198
Q

What is an episiotomy?

A

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

199
Q

What is a perineal massage?

A

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

200
Q

What are the two options for the third stage of labour?

A

Physiological management

Active management

201
Q

What is physiological management?

A

Placenta is delivered by maternal effort without medication or cord traction

202
Q

What is active management of the third stage?

A

Dose of intramuscular oxytocin (to help uterus contract)

Traction to the umbilical cord to guide the placenta out

203
Q

Why is active management of the third stage sometimes used? What are the adverse effects?

A

Reduces risk of bleeding but associated with nausea and vomiting

204
Q

When is active management initiated?

A

Haemorrhage

More than 60 min delay in delivery of the placenta (prolonged third stage)

205
Q

What are the steps in active management of the third stage?

A

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 preeses the uterus upwards to prevent utering prolapse

After delivery the uterus is massaged until it is contracted and firm - placenta is examined to ensure it is complete

206
Q

What is Postpartum haemorrhage (PPH)?

A

Bleeding after delivery of the baby and placenta

207
Q

What is the classification of PPH?

A

Loss of:

500ml after a vaginal delivery

1000ml after a caesarean section

208
Q

What are the different categoties of PPH?

A

Minor PPH – under 1000ml blood loss

Major PPH – over 1000ml blood loss

Moderate PPH – 1000 – 2000ml blood loss

Severe PPH – over 2000ml blood loss

209
Q

What is the difference between primary and secondary PPH?

A

Primary PPH: bleeding within 24 hours of birth

Secondary PPH: from 24 hours to 12 weeks after birth

210
Q

What are the four causes of PPH?

A

T – Tone (uterine atony – the most common cause)

T – Trauma (e.g. perineal tear)

T – Tissue (retained placenta)

T – Thrombin (bleeding disorder)

211
Q

What are the risk factors for PPH?

A

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

General anaesthesia

Episiotomy or perineal tear

212
Q

What are the preventative measures for PPH?

A

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

213
Q

What is involved in the management of PPH?

A

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

214
Q

How are severe cases of PPH managed?

A

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

215
Q

What are the diferent type of treatment options for stopping the bleeding?

A

Mechanical

Medical

Surgical

216
Q

What are the mechanical options for stopping PPH?

A

Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)

Catheterisation (bladder distention prevents uterus contractions)

217
Q

What are the medical options for stopping PPH?

A

Oxytocin (slow injection followed by continuous infusion)

Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)

Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)

Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction

Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

218
Q

How is the IV infusion of oxytocin given for PPH?

A

40 units in 500mls often just referred to as “40 units” without specifing the drug

219
Q

What are some medical treatment options for PPH?

A

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

220
Q

What is secondary postpartum haemorrhage likely to be due to?

A

Retained products of conception (RPOC)

Infection (i.e. endometritis).

221
Q

What are the investigations for secondary PPH?

A

Ultrasound for retained products of conception

Endocervical and high vaginal swabs for infection

222
Q

What are the management options for secondary PPH?

A

Surgical evaluation of retained products of conception

Antibiotics for infection

223
Q

What anaesthetic is an elective caesarean performed uner?

A

Spinal anaesthetic

224
Q

When is an elective caesarean usually performed?

A

After 39 weeks gestation

225
Q

What are some indications for an elective caesarean?

A

Previous caesarean

Symptomatic after a previous significant perineal tear

Placenta praevia

Vasa praevia

Breech presentation

Multiple pregnancy

Uncontrolled HIV infection

Cervical cancer

226
Q

What are the four categories of emergency caesarean?

A

Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.

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.

Category 3: Delivery is required, but mother and baby are stable.

Category 4: This is an elective caesarean, as described above.

227
Q

What are the two possible incisions in a caesarean?

A

Pfannenstiel incision is a curved incision two fingers width above the pubic symphysis

Joel-cohen incision is a straight incision that is slightly higher (this is the recommended incision)

228
Q

When may a vertical incision down the middle of the abdomen be performed?

A

Rarely, sometimes in very premature deliveries and anterior placenta praevia

229
Q

When is blunt dissection used in caesareans?

A

After the inital incision to separate the remainging layers of the abdominal wall and uterus, using fingers, blunt instruments and traction to tear the tissue apart resulting in less bleeding, shorter operating times and less risk of injury to the baby

230
Q

What are the layers of the abdomen which need dissecting during a caesarean?

A

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

231
Q

How is the baby delivered in a caesarean?

A

By hand with the assistance of pressure on the fundus

Forceps may be used if necessary

232
Q

How is the uterus closed after a caesarean?

A

Using two layers of sutures

Exteriorisation (taking the uterus out of the abdomen) is avoided if possible

233
Q

What is involved in a spinal anaesthetic?

A

An injection of a local anaesthetic (such as lidocaine) into the CSF at the lower back

Blocking the nerves from the abdomen downwards

234
Q

Why is a spinal anaesthetic better than a general anaesthetic?

A

Safer

Fewer complication

Faster recovery

235
Q

What are the problems with a spinal anaesthetic?

A

Patient remains away (most patients tolerate this well)

Takes longer to initiate than a general anaesthetic

236
Q

What are the risks associated with having an anesthetic?

A

Allergic reactions or anaphylaxis

Hypotension

Headache

Urinary retention

Nerve damage (spinal anaesthetic)

Haematoma (spinal anaesthetic)

Sore throat (general anaesthetic)

Damage to the teeth or mouth (general anaesthetic)

237
Q

What are some measures to reduce the risk before a caesarean section?

A

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

238
Q

Why are H2 receptor antagonists / PPI given before a caesarean section?

A

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

239
Q

What are some general surgical risks during a caesarean?

A

Bleeding

Infection

Pain

Venous thromboembolism

240
Q

What are some complication in the post partum period after a C-Section?

A

Postpartum haemorrhage

Wound infection

Wound dehiscence

Endometritis

241
Q

What local structures can be damaged during a C-Section?

A

Ureter

Bladder

Bowel

Blood vessels

242
Q

What effect does C-Sections have on the abdominal organs?

A

Ileus

Adhesions

Hernias

243
Q

What effect do C-Sections have on future pregnancies?

A

Increased risk of repeat caesarean

Increased risk of uterine rupture

Increased risk of placenta praevia

Increased risk of stillbirth

244
Q

What are the effects of a C-section on the baby?

A

Risk of lacerations (about 2%)

Increased incidence of transient tachypnoea of the newborn

245
Q

When is it possible to have a vaginal birth after caesarean (VBAC)?

A

Possible, provided the cause of the caesarean is unlikely to recur.

Assessment of likelihood of success should be made in each case

246
Q

What is the success rate of a VBAC?

A

75%

247
Q

What are the risk of uterine rupture in VBAC?

A

0.5%

248
Q

What are some contraindications to a VBAC?

A

Previous uterine rupture

Classical caesarean scar (a vertical incision)

Other usual contraindications to vaginal delivery (e.g. placenta praevia)

249
Q

After a caesarean what prophylaxis should the woman be started on?

A

Early mobilisation

Anti-embolism stockings or intermittent pneumatic compression of the legs

Low molecular weight heparin (e.g. enoxaparin)

250
Q

What is Sepsis?

A

Condition where body launches a large immune response to infection causing systemic inflammation and affecting the functioning of the organs of the body

Significant cause of maternal death

251
Q

What is severe sepsis?

A

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

252
Q

What is septic shock?

A

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

253
Q

What are two key causes of spesis in pregnancy?

A

Chorioamnionitis

Urinary tract infections

254
Q

What is chorioamnionitis?

A

Infection in the chorioamniotic membrane and amniotic fluid usually occuring in later pregnancy and during labour

255
Q

What are all patients who are admittted to the maternity inpatient unit have monitoring socumented on?

A

MEOWS chart - maternity early obstetric warning system

256
Q

What are the non-specific signs of sepsis?

A

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

257
Q

What are some additional signs and symptoms of chorioamnionitis?

A

Abdominal pain

Uterine tenderness

Vaginal discharge

258
Q

What are soem additional signs and symptoms of UTIs in pregnancy?

A

Dysuria

Urinary frequency

Suprapubic pain or discomfort

Renal angle pain (with pyelonephritis)

Vomiting (with pyelonephritis)

259
Q

What are some investigations for suspected sepsis?

A

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

260
Q

What are some additional investigations to find the suspected source of infection?

A

Urine dipstick and culture

High vaginal swab

Throat swab

Sputum culture

Wound swab after procedures

Lumbar puncture for meningitis or encephalitis

261
Q

How to manage maternal sepsis?

A
  • 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
262
Q

What is the sepsis 6?

A

Three tests:

Blood lactate level

Blood cultures

Urine output

Three treatments:

Oxygen to maintain oxygen saturations 94-98%

Empirical broad-spectrum antibiotics

IV fluids

263
Q

What is amniotic fluid embolisation?

A

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

264
Q

What is the problem with amniotic fluid embolisation?

A

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

265
Q

What are the risk factors for amniotic fluid embolus?

A

Increasing maternal age

Induction of labour

Caesarean section

Multiple pregnancy

266
Q

How does amniotic fluid embolus present?

A

Similarly to sepsis, PE or anaphylaxis:

Shortness of breath

Hypoxia

Hypotension

Coagulopathy

Haemorrhage

Tachycardia

Confusion

Seizures

Cardiac arrest

267
Q

What is the overall managment of amniotic fluid embolisation?

A

Supportive - no specific treatments

268
Q

What are the steps in amniotic fluid embolus management?

A

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

269
Q

What is uterine rupture?

A

Complication of labour, myometrium ruptures

270
Q

What happens in an incomplete rupture (uterine dehiscence)?

A

Uterine serosa (perimetrium) surrounding the uterus remains intact

271
Q

What happens with a complete rupture?

A

Serosa ruptures along with the myometrium with contents released into the peritoneal cavity

272
Q

What is the consequence of uterine rupture?

A

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

273
Q

What are the main risk factors for uterine rupture?

A

Previous caesarean section as the scar is a point of weakness

274
Q

What are the other risk factors for uterine rupture?

A

Vaginal birth after caesarean (VBAC)

Previous uterine surgery

Increased BMI

High parity

Increased age

Induction of labour

Use of oxytocin to stimulate contractions

275
Q

How does a uterine rupture present?

A

Acutely unwell mother and abnormal CTG - may occur with induction or augmentation of labour:

Abdominal pain

Vaginal bleeding

Ceasing of uterine contractions

Hypotension

Tachycardia

Collapse

276
Q

What is the management of a uterine rupture?

A

Obstetric emergency - resuscitation and transfusion may be necessary

Emergency caesarean section to remove the baby, stop any bleeding and repair or remove the uterus

277
Q

What is uterine inversion?

A

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

278
Q

What is incomplete uterine inversion (partial inversion) ?

A

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

279
Q

What is complete uterine inversion?

A

Uterus descends through the vagina to the introitus

280
Q

What may uterine inversion be the result of?

A

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

281
Q

How does uterine inversion present?

A

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

282
Q

What are the three options for treating uterine inversion?

A

Johnson manoeuvre

Hydrostatic methods

Surgery

283
Q

What is the johnson manoeuvre?

A

Using a hand to push the fundus back up into the abdomen

Hand is held in place for several minutes and medications are used to create a uterine contraction (i.e oxytocin)

Ligaments and uterus need to generate enough tension to remain in place

284
Q

What hydrostatic methods can be used for uterine inversion?

A

Filling the vagina with fluid to ‘inflate’ the uterus bacl to normal position - requiring a tight seal at the endtrance to the vagina which can be difficult

285
Q

What surgery can be used for uterine inversion?

A

Laparotomy and uterus is returned to position

286
Q

What else might be reuired in the management of uterine inversion?

A

Resuscitation

Treatment of PPH

Blood transfusion

Obstetrics and Gynaecology (10 decks)

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