Labour and puerperium Flashcards
What is induction of labour
Start labour artificially
Needed in 20% of pregnancies
When safer to deliver baby than keep in utero
Can be to optimise maternal health
What are the indications for induction of labour
Prolonged gestation
Premature rupture of membranes
Maternal health problems
Fetal growth restriction
Intrauterine fetal death
When should induction of labour be used in prolonged gestation
Uncomplicated pregnancies, offer between 40+0 and 40+14
Prolonged gestation associated with fetal compromise and stillbirth
If mother declines induction, increased monitoring after 42 weeks
When should induction of labout be used in premature rupture of membranes
If >37 weeks
- Offer induction of labour or expectant management for 24 hours
If 34-37 weeks
- Time induction based on risk vs benefit
If < 34 weeks
- Delay induction (unless have fetal compromise)
What maternal health problems should lead to consideration for induction of labour
Hypertension
Pre-eclampsia
Diabetes
Obstetric cholestasis
What are the absolute contraindications for induction of labour
Cephalopelvic disproportion
Major placenta praevia
Vasa praevia
Cord prolapse
Transverse lie
Active primary genital herpes
Previous classical C-section
What are the relative contraindications for induction of labour
Breech presentation
Triplet(+) pregnancy
2+ previous low transverse C-sections
What are the methods of induction of labour
Vaginal prostaglandins
Amniotomy
Membrane sweep
How are vaginal prostaglandins used in the induction of labour
Primary method
Ripen cervix
Help with uterine contractions
Maximum 1 cycle per day (1 pessary, or 1 tablet/gel repeated after 6 hours)
What is amniotomy
Artificially rupture membranes using amnihook
Get release of prostaglandins, hope to start labour
Only when cervix is ripe
Can be given alongside syntocinon
Not first line (unless prostaglandins contraindicated) - risk of uterine hyperstimulation
What is a membrane sweep
Not a formal method of induction
Gloved finger through cervix, aim to separate membrane and release prostaglandins
Increases chances of spontaneous labour
Nulliparous: offer at 40 and 41 weeks
Multiparous: offer at 41 weeks
What methods of monitoring are used during induction of labour
Bishop score
CTG (if using oxytocin, use CTG throughout)
What is a Bishop score
Assessment of cervical ripening based on vaginal examination
Used before and during induction
> 7 = cervix favourable (high chance of response)
<4 = unlikely to progress naturally, will need prostaglandin induction
What are the complications of induction of labour
Failure of induction (offer more prostaglandins or C-section)
Uterine hyperstimulation (manage with tocolytic (anti-contraction) agents)
Cord prolapse
Infection
Pain (more severe than with natural labour)
Increased need for further intervention
Uterine rupture
What is operative vaginal delivery and what are the methods used
Use of instruments to aid delivery
Up to 3 pulls with one instrument, then switch to a different one
Ventouse
Forceps
How is ventouse used in operative vaginal delivery
Low risk of maternal complications
Attach cup to fetal head using vacuum, apply traction with each contraction
Electrical pump, or kiwi (used to rotate fetus)
Lower success rate, less maternal perineal injury, less pain, more cephalhematoma, more subgaleal haematoma, more fetal retinal haemorrhage
How are forceps used in operative vaginal delivery
Lower risk of fetal complications
2 blades, go around fetal had, apply traction with contractions
Higher rates of 3rd/4th degree tears, not ideal for rotation, no need for maternal effort
What are the maternal indications for operative vaginal delivery
Inadequate progress
- 2 hours of pushing in nulliparous
- 1 hour of pushing in multiparous
Exhaustion
Medical conditions where active pushing should be limited (intracranial pathology, congenital heart defects, severe hypertension)
What are the fetal indications for operative vaginal delivery
Suspected fetal compromise in 2nd stage of labour (abnormal CTG/bloods)
Clinical concern (significant antepartum haemorrhage…)
What are the absolute contraindications for operative vaginal delivery
Unengaged fetal head (singleton)
Incompletely dilated cervix (singleton)
True cephalo-pelvic disproportion
Breech and face presentation
Preterm (<34 weeks) - for ventouse
Fetus high risk of coagulation disorders - for ventouse
What are the relative contraindications for operative vaginal delivery
Non-reassuring fetal status with head above pelvic floor
Delivery of twin 2, where head has not engaged or cervix has re-formed
Prolapse of umbilical cord when cervix is fully dilated
What are the pre-requisites for instrumental delivery
Fully dilated
Ruptured membranes
Cephalic presentation
Defined fetal position
Fetal head at least at ischial spine
Empty bladder
Adequate pain relief
Adequate maternal pelvis
What are the fetal complications of operative vaginal delivery
Neonatal jaundice
Scalp lacerations
Cephalhaematoma
Subgaleal haematoma
Facial bruising
Facial nerve damage
Skull fractures
Retinal haemorrhage
What are the maternal complications of operative vaginal delivery
3rd/4th degree vaginal tears
VTE
Incontinence
PPH
Shoulder dystocia
Infection
What is premature rupture of membranes
ROM at least 1 hour before onset of labour
At >37 weeks
In 10-15% pregnancies
Minimum risk to mother and baby
What is pre-term premature rupture of membranes
Rupture of membranes at <37 weeks
2% pregnancies
High rates of maternal and fetal compromise
40% of pre-term pregnancies
What is the pathophysiology of PROM/P-PROM
Early weakening and rupture of membranes due to:
- Early activation of normal physiological process (high apoptotic markers and enzymes)
- Infection
- Genetic predisposition
What are the risk factors for PROM/P-PROM
Smoking (especially at <28 weeks)
Previous PROM/P-PROM
Vaginal bleeding during pregnancy
Lower genital tract infection
Invasive procedures (amniocentesis…)
Polyhydramnios
Multiple pregnancies
Cervical insufficiency
What are the clinical features of PROM/P-PROM
Typical history of ‘waters breaking’
Non-specific symptoms: gradual leaking, change in vaginal discharge
Fluid pooling in posterior fornix on speculum examination
Avoid digital vaginal examination until woman is in labour
What are the differential diagnoses for PROM/P-PROM
Urinary incontinence
Normal vaginal secretions of pregnancy
Increased sweat/moisture around perineum
Increased cervical discharge
Vesicovaginal fistula
Loss of mucus plug
What investigations are used in PROM/P-PROM
High vaginal swab (look for GBS)
Actim-PROM (swab to look for insulin like growth factor binding protein 1 in vaginal fluid)
Amnisure (swab to look for alpha microglobulin 1)
Nitrazine test (pH of vaginal fluid)
Ferning test (fern pattern on slides)
What is the management of PROM/P-PROM at <34 weeks
Aim to get to 34 weeks
Monitor for signs of choramnionitis
Avoid sexual intercourse
Prophylactic erythromycin for 10 days
Corticosteroids
What is the management of PROM/P-PROM at 34-36 weeks
Induce labour once steroids have been given
Monitor for signs of choramnionitis
Avoid sexual intercourse
Prophylactic erythromycin for 10 days
Penicillin during labour if GBS found
What is the management of PROM/P-PROM at >36 weeks
Induce labour within 24-48 hours
Monitor for signs of choramnionitis
Penicillin during labour if GBS found
What are the complications of PROM/P-PROM
Outcomes correlate with gestational age
Choramnionitis (inflammation of fetal membranes)
Oligohydramnios (more if <24 weeks)
Neonatal death (prematurity, sepsis, pulmonary hypoplasia)
Placental abruption
Umbilical cord prolapse
When is an emergency caesarean section used
Failure to progress
Fetal compromise
What are the categories of emergency caesarean sections
Category 1
- Immediate threat to life of mother or fetus
- Birth within 30 mins
Category 2
- Maternal/fetal compromise, not immediately life-threatening
- Birth within 60-75 mins
Category 3
- No maternal/fetal compromise, but need early delivery
What are the indications for caesarean section
Breech presentation
Malpresentation
Twins (twin 1 not cephalic)
Fetal compromise
Transmissible disease (poorly controlled HIV)
Primary genital herpes in 3rd trimester
Placenta praevia
Maternal diabetes
Previous major shoulder dystocia
Previous 3rd/4th degree tear
Maternal request
Benefits of caesarean section
Reduced risk of:
- Perianal trauma
- Pain
- Urinary/anal incontinence
- Uterovaginal prolapse
- Late stillbirth
- Early neonatal infection
What are the immediate complications of caesarean section
PPH (>1000 ml)
Wound haematoma
Intra-abdominal haemorrhage
Bladder/bowel trauma
Neonatal: transient tachypnoea of newborn, fetal lacerations
What are the intermediate complications of caesarean section
Infection (UTI, endometritis, respiratory)
VTE
What are the late complications of caesarean section
Urinary tract trauma
Subfertility
Negative psychological effects
Rupture/dehiscence of scar in next labour
Placenta praevia/accrete
Caesarean scar ectopic pregnancy
Risks and benefits of VBAC
Shorter hospital stay and recovery
Higher risk of uterine rupture
Risk of anal sphincter injury
Lower risk of maternal death
Good chances of success of future VBACs
Risk of respiratory difficulties/hypoxic ischaemic encephalopathy in neonate
Increased risk of stillbirth beyond 39 weeks
Risks and benefits of elective repeat caesarean section
Longer recovery
Small risk of uterine rupture
No risk of anal sphincter injury
Higher risk of maternal death
Subsequent pregnancies need to be caesarean
Higher risk of neonatal respiratory morbidity
Increased risk of placental problems
Increased risk of adhesions
What is uterine rupture, and what are the risk factors for it in VBAC
Full-thickness disruption of uterine muscle and overlying serosa
An obstetric emergency
Can get fetal hypoxia/large maternal haemorrhage
Risk factors in VBAC: previous C-section, induction of labour, obstruction of labour, multiple pregnancy, multiparity
How are VBAC deliveries managed
Deliver in hospital setting
Continuous CTG monitoring
Avoid induction where possible
Get guidance from seniors
After 39 weeks, recommendation is repeat C-section
What are the absolute contraindications for VBAC
Classical caesarean scar
Previous uterine rupture
Normal contraindications for vaginal birth
What are the relative contraindications for VBAC
Complex uterine scar
> 2 previous lower segment C-sections
What is shoulder dystocia
When fetal shoulder gets impacted after delivery of the head
An obstetric emergency
Anterior shoulder on maternal pubic symphysis/posterior shoulder on sacral promontory
What is the pathophysiology of shoulder dystocia
Impaction of shoulder
Delayed delivery = hypoxia of fetus
Can get brachial plexus injury when applying traction
What are the pre-labour risk factors for shoulder dystocia
Previous shoulder dystocia
Macrosomia
Diabetes
BMI >30
Induction of labour
What are the intrapartum risk factors for shoulder dystocia
Prolonged 1st stage of labour
Secondary arrest (initial good progress, then stop due to malposition)
Prolonged second stage of labour
Oxytocin augmentation
Assisted vaginal delivery
What are the clinical features of shoulder dystocia
Difficulty delivering fetal head/chin
Failure of restitution (fetus stays in OA position)
Turtle-neck sign (head retracts slightly into pelvis)
What are the immediate management steps for shoulder dystocia
Call for help
Advise mother to stop pushing (can worsen impaction)
Avoid downward traction of head
Do not apply fundal pressure (can cause uterine rupture)
Consider episiotomy (does not relieve obstruction, but makes manoeuvres easier)
What are the first line manoeuvres used for shoulder dystocia
McRoberts manoeuvre
- Hyperflexion of hips (knees to chest)
- Stop pushing
- Get widening of pelvic outlet
Suprapubic pressure
- Sustained or rocking pressure
- Puts pressure behind anterior shoulder to disimpact it from pubic symphysis
What are the second line (internal) manoeuvres used in shoulder dystocia
Posterior arm
- Insert hand, grab fetal arm and pull to delivery
Internal rotation (corkscrew)
- Apply pressure in front of one shoulder and behind the other
- Move baby into oblique position
If not working, repeat with patient on all 4s (widens pelvic outlet)
What is the post-delivery management for shoulder dystocia
Active management of 3rd stage of labour (increased risk of PPH)
PR examination (exclude 3rd degree tears)
Debrief mother and partner (can be traumatic)
Consider physiotherapy review before discharge
Paediatric review (for brachial plexus injury, humeral fracture, hypoxic brain injury)
What is an umbilical cord prolapse
Umbilical cord comes through cervix with/before presenting part of fetus
High mortality rates for babies
Obstetric emergency
What are the 2 types of cord prolapse
Occult (incomplete) prolapse
- Cord descends alongside presenting part (not beyond it)
Overt (complete) prolapse
- Cord descends past presenting part
What is cord presentation in umbilical cord prolapse
Presence of umbilical cord between presenting part and cervix
With or without intact membranes
Which babies is umbilical cord prolapse more common in
Pre-term babies (more likely to be breech and have congenital defects)
How does umbilical cord prolapse cause fetal hypoxia
Occlusion
- Presenting part presses onto umbilical cord
- Occlusion of blood flow to fetus
Arterial vasospasm
- Exposure of umbilical cord to cold atmospheres
- Get umbilical arterial vasospasm
- Reduced blood flow to fetus
What are the risk factors for umbilical cord prolapse
Breech presentation
Unstable like (if >37 weeks, consider admission until delivery)
Artificial rupture of membranes
Polyhydramnios
Prematurity
What are the clinical features of umbilical cord prolapse
Always consider if have non-reassuring fetal heart rate and absent membranes (strong link to fetal bradycardia)
Confirm via external/PV examination
What are the differential diagnoses for umbilical cord prolapse
If have PV bleeding or blood-stained liquor with rupture of membranes, consider placental abruption/vasa praevia
What is the management for umbilical cord prolapse
Call for help
Avoid handling cord (worsens vasospasms)
Manually elevate presenting part (reduce occlusion)
Encourage into left lateral/knee-chest position
Consider tocolysis (terbutaline) reduces uterine contractions
Delivery via emergency C-section
What is eclampsia
Convulsions in pre-eclamptic woman in absence of neurological/metabolic causes
An obstetric emergency
High maternal and fetal mortality rate
Most seizures in post-partum period
What are the moderate risk factors for eclampsia
Nulliparity
Age >40
BMI >35
Family history
Pregnancy interval >10 years
Multiple pregnancy
What are the high risk factors for eclampsia
Chronic hypertension
HTN/pre-eclampsia/eclampsia in previous pregnancy
Pre-existing CKD
Diabetes
Autoimmune diseases (SLE, antiphospholipid syndrome…)
What are the clinical features of eclampsia
New onset tonic-clonic seizures in presence of pre-eclampsia
Seizures lasting 60-75 seconds
Convulsions can cause fetal distress/bradycardia
What are the signs/symptoms of end-organ damage in eclampsia
Frontal headaches
Hyper-reflexia
Nausea and vomiting
Generalised oedema
RUQ pain
Jaundice
Visual disturbances
Changes in mental age
What are the maternal complications of eclampsia
HELPP syndrome
DIC
AKI
Adult respiratory distress syndrome
Cerebrovascular haemorrhage
Permanent CNS damage
Death
What are the fetal complications of eclampsia
Intrauterine growth restriction
Prematurity
Infant respiratory distress syndrome
Intrauterine death
Placental abruption
What are the differential diagnoses for eclampsia
Hypoglycaemia
Pre-existing epilepsy
Head trauma
Haemorrhagic stroke
Meningitis
Medication-induced
Brain tumour
Cerebral aneurysm
Septic shock
Ischaemic stroke
What investigations are used for eclampsia
Bloods (FBC, U&ES, LFTS, clotting studies, blood glucose)
USS (rule out placental abruption)
CTG monitoring
Consider full neurological workup
What are the main steps of management of eclampsia
Resuscitation
Cessation of seizures
Blood pressure control
Prompt delivery of baby and placenta
Monitoring
What is involved in the cessation of seizures step of eclampsia management
Give magnesium sulphate
Assess patient for hypermagnesemia (hyperreflexia, respiratory depression)
Continuous fetal CTG monitoring
What is involved in the blood pressure control step of eclampsia management
Give IV labetalol and hydralazine
Target mean arterial pressure <120
Continuous CTG monitoring
What in-patient care is needed post-natally for eclampsia
Regular symptom review
Bloods 72 hours post-partum
Pre-conception counselling (minimise risks for future pregnancies)
Step-down to community
What out-patient care is needed post-natally for eclampsia
Consider CT head (if neurological symptoms persist)
Measure blood pressure (daily for 2 weeks post-partum)
Follow-up at 6 weeks
What is uterine rupture
Full-thickness disruption of uterine muscle and overlying serosa
Can extend to affect bladder/broad ligament
Significant maternal and fetal morbidity and mortality
What are the main types of uterine rupture
Incomplete
- Peritoneum overlying uterus is intact
- Uterine contents remain in uterus
Complete
- Peritoneum torn
- Uterine contents in peritoneal cavity
What are the risk factors for uterine rupture
Previous C-section (higher risk with vertical incision)
Previous uterine surgery
Induction/augmentation of labour
Obstruction of labour
Multiple pregnancy
Multiparity
What are the signs and symptoms of uterine rupture
Sudden severe abdominal pain (persisting between contractions)
Shoulder tip pain
Vaginal bleeding
What would you find on examination in uterine rupture
Regression of presenting part
Scar tenderness
Palpable fetal parts on abdominal examination
What would fetal monitoring show in uterine rupture
Fetal distress
Absent heart sounds
What are the differential diagnoses for uterine rupture
Placental abruption (woody uterus)
Placenta praevia (painless PV bleeding)
Vasa praevia (ruptured membranes, painless PV bleeding, fetal bradycardia)
What investigations are used in uterine rupture
Intrapartum CTG monitoring
USS for diagnosis (abnormal fetal lie/presentation, haemoperitoneum, absent uterine wall)
How is uterine rupture managed
Call for help
Resuscitate
Surgery (immediate C-section, repair/remove uterus)
What is thought to be linked to amniotic fluid embolism
Strong uterine contractions
Excessive amniotic fluid
Disruption of uterine vessels
What are the risk factors for amniotic fluid embolism
Multiple pregnancy
Increased maternal age
Induction of labour
Uterine rupture
Placenta praevia
Placental abruption
Cervical lacerations
Eclampsia
Polyhydramnios
C-section/instrumental delivery
What are the clinical features of amniotic fluid embolism
Sudden onset
Hypoxia/respiratory arrest
Hypotension
Fetal distress
Seizures
Shock
Confusion
Cardiac arrest
DIC
What are the differential diagnoses for amniotic fluid embolism
PE
Anaphylaxis
Sepsis
Eclampsia
Myocardial infarction
What are the investigations and management for amniotic fluid embolism
Resuscitate
Bloods
ECG (ischaemic changes)
CXR
Arrange ITU admission
Manage DIC
Deliver baby (even if post-partum section)
What is the definitive diagnosis for amniotic fluid embolism
On post-mortem
Fetal squamous cells and debris in pulmonary vasculature
What is primary post-partum haemorrhage
Loss of >500mls of blood PV within 24 hours of delivery
What are the 2 main types of primary post-partum haemorrhage
Minor PPH
- 500-1000 mls blood loss
Major PPH
- >1000 mls blood loss
What are the 4 main groups of causes of primary PPH
Tone
Tissue
Trauma
Thrombin
What is the significance of ‘tone’ in primary PPH
Uterine atony most common cause of PPH
Uterus not able to contract fully due to lack of tone
Risk factors: maternal profile (age >40, BMI >35, asian), uterine over-distension (multiple pregnancy, macrosomia…), induced/prolonged labour, placental problems (praevia, abruption, previous PPH)
What is the significance of ‘tissue’ in primary PPH
Retention of placental tissue
Prevents uterus from contracting
What is the significance of ‘trauma’ in primary PPH
Damage sustained during delivery (vaginal/cervical tears)
Risk factors: instrumental delivery, episiotomy, C-section)
What is the significance of ‘thrombin’ in primary PPH
Vascular causes (placental abruption, hypertension, pre-eclampsia)
Coagulopathies (Von Willebrand’s disease, haemophilia, DIC, HELPP)
What are the signs and symptoms of primary PPH
Bleeding PV
If large blood loss: dizziness, palpitations, shortness of breath
What would you find on examination in primary PPH
Abdominal examination (signs of uterine rupture)
Speculum examination (sites of localised trauma)
Placenta (ensure placenta is complete)
What investigations are needed in primary PPH
Bloods (FBC, coagulation profile, U&Es, LFTs)
Cross-match 4-6 units of blood
What is the general method of managing primary PPH
TRIM
- Teamwork
- Resuscitation
- Investigations and monitoring
- Measures to arrest bleeding
What is the definitive management for primary PPH due to uterine atony
Bimanual compression (apply pressure to abdomen with other hand)
Pharmacological
- Syntocinon (synthetic oxytocin)
- Ergometrine
- Carboprost (prostaglandin analogue)
- Misoprostol (prostaglandin analogue)
Surgical
- Intrauterine balloon tamponade
- Haemostatic sutures around uterus
- Uterine/iliac artery ligation
- Hysterectomy
What is the definitive management for primary PPH due to ‘trauma’
Repair laceration
May need hysterectomy
What is the definitive management for primary PPH due to ‘tissue’
IV oxytocin
Manual removal of placenta
Prophylactic antibiotics
What is the definitive management for primary PPH due to ‘thrombin’
Correct coagulation abnormalities with blood products
What are the methods of preventing primary PPH
Active management of 3rd stage of labour
IV/IM oxytocin
What is secondary post-partum haemorrhage
Excessive vaginal bleeding between 24 hours and 12 weeks post-partum
What are the risk factors for secondary post-partum haemorrhage
Uterine infection
Retained placental fragments/tissue
Inadequate closure of spiral arteries
Trophoblastic disease
Previous history of PPH
What are the clinical features of secondary post-partum haemorrhage
Excessive vaginal bleeding (spotting, occasional gush of fresh blood)
Endometritis (fever, lower abdominal pain, foul smelling discharge)
Lower abdominal tenderness, high uterus
What investigations are needed for secondary post-partum haemorrhage
Bloods
FBC, U&Es, CRP, coagulation profile, group and save
Blood cultures
USS pelvis (look for retained placental tissue)
What is the management for secondary post-partum haemorrhage
Antibiotics (ampicillin and metronidazole)
Uterotonics (syntocinon…)
Surgical (balloon catheter insertion)
Manage massive secondary PPH as primary PPH
What are the core symptoms of depression during pregnancy
Low mood
Lethargy
Anhedonia
Poor sleep
Poor appetite
When should an urgent mental health referral be made for depression in pregnancy
Risk of self harm/suicide
Evidence of self neglect
Psychotic symptoms
Manic behaviour
Previous diagnosis of MH issues
Previous suicide attempts
What is post-natal depression
Depressive episode within first 12 months post-partum
Peaks around first 2 months
Not the same as baby blues (at day 3-4, for 7 days)
Negative thoughts about motherhood and ability to cope
Anxieties about baby
What is post-partum psychosis
Severe mental illness
Can develop within a few hours
More common in women with previous bipolar disorder/psychotic illness
50% chance of recurrence in future pregnancies
How do patients with post-partum psychosis present
Confused/distracted
Relatives report: withdrawn, agitated/distressed
Bizarre ideas
Auditory hallucinations
May appear manic
Sleep disturbances
