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Obs & Gyn > Labour & Delivery > Flashcards

Labour & Delivery Flashcards

1
Q

Labour is dependant on what 3 mechanical factors?

A

Power expelling the fetus (POWER)
Pelvis dimensions + resistance of soft tissues (PASSAGE)
Fetal head diameter (PASSENGER)

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2
Q

What structures allow for uterine contractions to push DOWNWARDS

How does the cervix become effaced/dilated?

What 2 factors can cause reduced uterine activity?

A

Cardinal + uterosacral ligaments = lower uterus attached to pelvis

Intermittent uterus contractions / fetal head pushing

Nulliparous + Induction

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3
Q

What are the 3 main planes of the pelvis and their rough diameters?

A

Inlet - 13cm transverse (x 11 AP)
Mid-Cavity - 11x11cm
Outlet - 12.5cm AP (x 11 transverse)

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4
Q

Describe the physiology behind cervical ‘ripening’

A

Prostaglandins → inhibit collagen synthesis / stimulate collagenase activity

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5
Q

Which 3 factors of the fetal head determines its ease through the pelvis?

A

Attitude (presentation)
Rotation
Size

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6
Q

What are the 2 fontanelles called?

A

Bregma (frontal/brow)

Occiput

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7
Q

How is diagnosis of labour confirmed?

A

Painful uterine contractions AND cervical effacement/dilation
OR
Painful uterine contractions AND show / rupture of membranes

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8
Q

Describe the mechanism of labour in 6 steps

A
  1. Oblong head enters inlets in OT (occipital-transverse) position
  2. The neck flexes / head descends / cervix dilates (measured by ischial spine station)
  3. Internal rotation in the mid-cavity to OA (occipito-anterior) position (in 5% rotates to OP) + shoulders enter inlet
  4. Head descends / delivered by extension of neck
  5. External rotation (transverse - L/R) so shoulders enter AP diameter
  6. Anterior then posterior shoulder delivered by lateral flexion
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9
Q

What 4 things are managed in the mother during the 1st/2nd stage of labour?

A

Fluid
Position
Analgesics
Observations

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10
Q

How is the fetus managed during the 1st/2nd stage of labour?

A

Intermittent auscultation / CTG
FBS if HR abnormal (only possible in 1st stage)
LSCS if fetal distress

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11
Q

How is progression of the 1st stage assessed and what 2 interventions can be done to augment it?

A

1st stage progression assessed by VE (cervical dilation)

If nulliparous / slow progression - augment with ARM ± Oxytocin

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12
Q

How is progression augmented in the 2nd stage?

At what stage would instrumental delivery be done?

A

Oxytocin if nulliparous ± station high

If not delivered after 1hr of pushing

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13
Q

What does the 1st stage consist of?

+ time periods/cervical dilation of Latent + Active phase

A

1st stage = labour Dx → full 10cm dilation
Latent = 3cm, several hrs
Active 1-2cm/hr, shouldn’t be >12hrs

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14
Q

What does the 2nd stage consist of?

What happens/time periods of Passive + Active Phase

A

2nd stage = full dilation → delivery
Passive = head to pelvic floor + maternal desire to push; few mins
Active = mother pushing, 20-40m (dep on parity)

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15
Q

What is the 3rd stage? / time period
What happens?

How is it managed (what does the midwife do)?

A

Delivery of placenta, approx. 15mins
Uterine contractions compress / shear away vessels
Blood loss approx. 500ml

Suprapubic pressure + gentle continuous traction on cord

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16
Q

What time frame classes the 3rd state as ‘retained placenta’?
What is the incidence of retained placenta

A

3rd stage >30mins

2.5% deliveries

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17
Q

What is the main complication of a retained placenta?

How is a retained placenta managed?

A

Partial separation → intrauterine blood loss

Oxytocin infusion via umbilical cord vv
If still retained + absence of bleeding for 1hr → manually remove (under GA/Spinal)

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18
Q

Define 1st - 4th degree tears

A

1st: skin only
2nd: perineal muscles

  1. a: <50% anal sphincter
  2. b: >50%
  3. c: internal anal sphincter involved

4th: anal sphincter + mucosa involved

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19
Q

How are 1st - 4th degree tears repairs

A

1st + 2nd → local anaesthetic + sutured

3rd/4rd repaired under spinal/epidural in theatre

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20
Q

What is the incidence of 3rd/4th degree tears?

What are the RFs? (3)

A

1-3% deliveries

RFs: large baby, nulliparous, forceps

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21
Q

What instances are episiotomies reserved for? (not routine practice)

A

Large tear likely
Fetal distress
Failure of head to pass perineum despite effort

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22
Q

What 5 factors determine the Bishops score

At what scores are interventions done?

A 
Cervical dilation
Cervical length
Cervical consistency
Cervical position (post/anterior)
Station of head (relative to ischial spines)

Score ≥6 → Prostaglandins
Score <6 → ARM + Prostaglandins

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23
Q

What are the 3 methods of induction of labour?

A

Prostaglandins (insert suppository in posterior fornix)
→ 2 doses max (if 1st fails), min 6hrs b/wn

ARM (amniotomy(hook) ± oxytocin)
→ if no labour induced within 2hrs, IV oxytocin

Natural induction (cervical sweeping)

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24
Q

What are the fetal indications for induction? (5)

What are the materno-fetal indications? (2)

A 
Prolonged pregnancy
Suspected IUGR
APH
Poor ObHx
Prelabour term rupture of membranes

Pre-Eclampsia
Maternal Diabetes

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25
Q

What are the absolute contraindications of IoL? (5)

What are the relative contraindications? (2)

A 
Placenta praevia
Acute fetal compromise
Abnormal lie
Pelvic obstruction (disproportion/mass)
> 1 previous C-Section

Prematurity
1 previous C-Section

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26
Q

When is CTG required in IoL?

A

1hr CTG required 1h after induction method

Also required if oxytocin used

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27
Q

What are some complications of Induction of Labour (5)

A

Failed/slowed uterine activity → Instrumental/LSCS
Uterine hyperstimulation

Amniotomy can → umbilical cord prolapse

Increased risk of PPH
Increased risk of intrapartum/postpartum infection

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28
Q

What is the incidence of prolonged pregnancies?

A

6-10% pregnancies ≥42wks

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29
Q

How is maternal hypotension with an epidural managed?

A

IV fluids + ephedrine

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30
Q

What is pyrexia (>37.5) in labour usually due to?

When are Abx given?

A

Usually due to chorioamnionitis

Abx if >38 or if other risk factors for sepsis

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31
Q

What is uterine hyperactivity assoc w.?

How is it managed?

A

Too much oxytocin
SE of Prostaglandins
Placental Abruption

LSCS / IV salbutamol

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32
Q

What is recorded on the partogram? (5)

A 
Progress of cervical dilation
Progress of head descent
Maternal Observations
Fetal HR
Liquor colour
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33
Q

What is the incidence of meconium staining of liquor in normal pregnancies? (+ in prolonged pregnancies)

Why can it sometimes suggest fetal compromise

How is it graded

A

15%
40% in ≥42wks

Related to parasymp relaxation of anal sphincter - poss due to hypoxia

Grade 1-3 depending on liquor content and meconium consistency (thicker = worse)

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34
Q

What may affect maternal supply to the placenta? (2)

A

Hyperstimulation

Spinal/epidural may → hypo perfusion of placenta

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35
Q

What may fetal hypoxia lead to intrapartum?

A 
Peripheral vasoconstriction (blood → heart/brain)
ACIDOSIS (from anaerobic)
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36
Q

What are some neonatal complications of prolonged vasoconstriction in fetal hypoxia?

A

Necrotising Enterocolitis
Acute Renal Failure
Resp Distress

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37
Q

What investigations can identify fetal hypoxia?

A

CTG/Fetal HR (increased baseline HR - high false +ve rate)

Fetal scalp sample

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38
Q

What are the indications for fetal scalp sampling? (4)

What cervical dilation to make scalp sampling possible?

A

Variable/Late/Prolonged decelerations on CTG
Signif meconium staining of liquor (Grade 2/3) PLUS CTG abnormal
Persistent fetal tachycardia
Prolonged loss of baseline variability

Cervix must be at least 2-3cm dilated

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39
Q

What are the contraindications for fetal scalp sampling? (5)

A

Risk of maternal infection transmission to baby
Fetal bleeding tendency
Placenta praevia
<34wks (don’t want to induce labour/want to delay)
Fetal membranes intact

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40
Q

How does pH reflect fetal status?

At what pH are interventions carried out? (and what done if borderline?)

A

pH = momentary
pH <7.20 → LSCS / instrumental
pH 7.20-7.25 → repeat at 30-60m

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41
Q

How does Base Excess reflect fetal status?

What is normal value for base excess + what value reflects metabolic acidosis

A

Reflects longer-term change
Normal = BE > -6
Metab acidosis = BE < -8

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42
Q

What interventions done if abnormal fetal blood sample?

A

if in 1st stage → LSCS

if in 2nd stage → Instrumental

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43
Q

What measures/investigations done to predict a long-term prognosis of fetal hypoxic injury? (4)

A

CTG (can represent time in hypoxia)
Apgar scores (immediate status - prolonged low suggestive)
Neonatal behaviour (maintenance of respiration / abnormal tone + reflexes / altered consciousness or seizures)
Neonatal brain imaging

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44
Q

What % of fetal hypoxic injuries are antenatally caused and what % caused in labour?

List some antenatal causes of fetal hypoxic injury (6)

A

90% antenatal, 10% in labour

Intrauterine infection
IUGR
Csomal / congenital abn
Coagulation disorder
APH
Prematurity
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45
Q

List some RFs for Fetal Compromise (13)

A

Placental insufficiency (IUGR/Pre-Eclampsia/Abruption)
Cord Prolapse
Uterine rupture

Pre/post-maturity
Multiple Pregnancy
Oligohydramnios

Induction
Prolonged labour
Uterine hyperstimulation

Maternal Diabetes
Maternal hypotension (e.g. epidural)
Maternal pyrexia
Chorioamnionitis

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46
Q

What general measures are done if suspect fetal compromise? (3)

A

L lateral position
O2
CTG (if abnormal → VE to exclude malpresentation/prolapse and to assess progress)

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47
Q

What is the management of fetal compromise due to maternal hypotension?
+ due to maternal dehydration / ketosis
+ due to uterine hyperstimulation

A

Hypotension → fluid bolus
Dehydration/ketosis → IV fluids

Uterine hyperstim → stop syntocin infusion + start tocolytics (salbutamol, ritodrine)

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48
Q

What are some non-medical methods of pain relief in labour? (best for early labour) (5)

A 
Antenatal class prep
Back rubbing
TENS machine
Maintenance of mobility
Water at body temp
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49
Q

What can overuse of Entonox (gas and air) lead to?

A

Light-headedness
Nausea
Hyperventilation

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50
Q

Which systemic opiates can be used in pregnancy? (+ how administered?) (2)

3 disadvantages of opiate use

A

Pethidine + Diamorphine IM

Require anti-emetics
More sedative than analgesic
Can cause resp depression in newborn (requiring naloxone reversal)

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51
Q

Which space is an epidural inserted into?

A

L3/4

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52
Q

Advantages of an epidural (2)

Disadvantages of an epidural (6)

A

Pain-free
Can help lower BP in hypertensives

Reduced bladder sensation (can → urinary retention)
Requires midwifery supervision (check obs)
Increased incidence of instrumental deliveries
Immobility (→ pressure sores)
Hypotension
Maternal fever

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53
Q

What are 2 serious possible complications of an epidural?

A

Spinal tap (puncture dura mater) → CSF leakage → severe headache (worse sitting up)

Local anaesthetic into spine → total spinal analgesia + respiratory paralysis

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54
Q

Where is the local anaesthetic inserted in a spinal?

When is a spinal done? (2)

A

Through dura mater into CSF b/wn L3/4

C-Sections + Mid-Cavity instrumentals

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55
Q

What anatomical location is a pudendal nerve block inserted into?
When is it used?

A

Bilaterally around pudendal nerve, near ischial spines

Low-Cavity instrumentals

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56
Q

Which type of instrumentals allow for delivery with correction of presentation (OP→OA)

A

Ventouse + Keillands (rotational) forceps

57
Q

What are some maternal complications of forceps delivery? (3)
And fetal complications of forceps delivery? (3)

A

Vaginal laceration
3rd degree tear
Blood loss

Facial nerve damage
Scalp laceration
Skull/neck fractures

58
Q

List 4 indications for instrumental delivery

A

Prolonged 2nd stage
Fetal distress
Prophylactic (avoid pushing in e.g. severe cardiac / hypertension)
Breech (forceps to after-coming head to control delivery)

59
Q

What is the Caesarean section rate in developed countries?

A

20-30%

60
Q

What cases would a rare Classical Caesarean section be carried out?

A

Multi-fibroids
Extreme prematurity
Transverse lie

61
Q

Describe the anatomical incision of LSCS

A

Suprapubic transverse incision

62
Q

Indications for emergency C-Section (2)

A

Prolonged 1st stage

Fetal distress

63
Q

Elective C-sections carried out at what gestation?

What must be administered if earlier than this gestation?

A

39wks (maximise lung development)

<39wks → Steroids

64
Q

List some absolute indications for C-Section (5)

List some relative indications for C-Section (6)

A 
Placenta Praevia
Severe antenatal fetal comprimise
Uncorrectable abnormal lie
Previous vertical (Classical) C-Section
Gross pelvic deformity
Previous C-Section
Breech
Severe IUGR
Twins
Diabetes / other medical disease
Older nulliparous women
65
Q

What are the operative risks of a C-Section (5)

What is the risk for subsequent pregnancies after a C-section (2)

A 
Haemorrhage (/need for transfusion)
Wound / uterus infection
Bladder / bowel damage
Post-op pain/ immobility
VTE

Increased incidence of placenta praevia
Risk uterine rupture

66
Q

What is placenta accreta and placenta percreta?

How are they diagnosed

A 
Accreta = Placenta implanted within myometrium
Percreta = placenta implanted in surrounding structures (e.g. bladder)
67
Q

What is the incidence of shoulder dystocia

What structure can shoulder dystocia lead to the damage of?

A

1/200

Can damage brachial plexus (→ Erb’s palsy)

68
Q

What are the RFs for shoulder dystocia (6)

A

Large baby (>50% cases >4kg)
Diabetes
High maternal BMI
Short women

Previous shoulder dystocia

Instrumental delivery

69
Q

How is shoulder dystocia managed in 90%?

How else may it be managed?

A

in 90% McRobert’s manouvre + suprapubic pressure works

in others, poss internal manoeuvres + episiotomy

70
Q

What are the RFs for cord prolapse? (6)

A 
Preterm
Breech
Abnormal lie
Polyhydramnios
Twins
ARM
71
Q

How is cord prolapse diagnosed?

A

Palpable cord vaginally

Fetal HR abnormal

72
Q

How is cord prolapse managed? (3)

A

Push up + position all fours
Tocolytics
Emergency LSCS / Instrumental if cervix fully dilated + head low

73
Q

What is the incidence rate of amniotic embolism?

And the mortality rate

A

1/50,000

Mortality rate 80%

74
Q

What happens to the mother in amniotic embolism?

A 
Anaphylaxis
Sudden dyspnoea - Hypoxia / Pulm Oedema
Seizures
Hypotension / Cardiac arrest
DIC/ARDS
75
Q

What are the RFs for amniotic embolism? (3)

A

Caesarean
Termination
Strong contractions with polyhydramnios

76
Q

What investigations can be done for amniotic embolism? (3)

Why is Dx not usually made until post-mortem?

A

ECG - shows RV strain
Coag abnormal
ABG shows reduced O2

Can be confused with other causes of maternal collapse

77
Q

What are the management steps in amniotic embolism? (RIO FFADSI)

A

Resuscitation
Intubation
O2 100%

Fluids - restore circ vol
FFP (fresh frozen plasma) - if fibrinogen low
Acidosis correction
Dopamine + Steroids - poss
ITU transfer
78
Q

List some causes for massive antepartum haemorrhage (6)

A

3 main ones:
Placenta praevia
Placental abruption
Undetermined origin

Genital tract pathology
Vasa praevia
Uterine rupture

79
Q

How is massive APH managed?

A

Replace blood losses (to normovolaemia)
Stop bleeding if poss
Correct any coagulopathy (e.g. DIC)
Delivery

80
Q

What are the 8 principle causes of maternal deaths?

A 
Infection
VTE
Hypertensive disorders
Cardiac disorders (e.g. VSD)
Ectopic pregnancy and abortion
Haemorrhage
Neurological disorders
Psychiatric disorders / suicide
81
Q

What are the 5 principle causes of perinatal mortality?

A 
Unexplained antepartum stillbirth
IUGR
Prematurity
Congenital abnormalities
Intrapartum hypoxia
Antepartum haemorrhage
82
Q

What proportion of multiple pregnancies are Dizygotic

What proportion of monozygotics are mono/dichorionic

A

2/3rds DZ (dichor/diamnio)

70% DZ monichorionic diamniotic
30% DZ dichorionic diamniotic

83
Q

What 3 antenatal problems are commoner in multiple pregnancy?

A

Anaemia
Gestational Diabetes
Pre-Eclampsia

84
Q

What further increases the risk of mortality / long-term handicap in multiple pregnancies? (3)

A

Preterm
IUGR
Monochorionic

85
Q

List some complications of MC (monochorionic) twins (3)

A

Twin-twin transfusion syndrome
IUGR
Congenital abnormalities

86
Q

What is the main cause of death in monoamniotic twins

A

V rare but cords entangle

87
Q

What type of twins does Twin-Twin Transfusion Syndrome occur in?

A

(MZ) Monochorionic Diamniotic

88
Q

List the complications of a multiple pregnancy

Multiple Pregnancy Is A Lot More Terrible And Painful

A 
Mortality (perinatal)
Preterm / miscarriage
IUGR
Abnormalities (congenital)
Malpresentation
Twin-Twin Transfusion Syndrome
APH/PPH
Pre-Eclampsia, Anaemia, DM
89
Q

What is there increased risk of to the 2nd twin in delivery? (5)

A 
Cord Prolapse
Breech
Placental Abruption
Tetanic uterine contraction
Hypoxia
90
Q

What extra USS scans are done antenatally in multiple pregnancy?

A 
USS cervix (to identify preterm risk)
Serial USS growth scans (28/32/36) checking for IUGR
91
Q

How is delivery managed differently in multiple pregnancy?

A

if 1st not cephalic → C-section (even in uncomplicated)
36-37wks MC
37wks DC

if 1st cephalic → NVD (+try ECV for 2nd)

Syntocinon post-delivery (prevent PPH)

92
Q

What is Twin-Twin Transfusion syndrome?

What % of MC twins does it occur in?

A

Unequal disturb of blood within placenta → unequal liquor/blood/growth
Occurs in 15% MC twins

93
Q

What features occur in the recipient in Twin-Twin Transfusion Syndrome? (6)

A 
Larger, 
Polyhydramnios, 
Fluid overload
Cardiomegaly + heart failure
Hydrops fetalis
Polycythaemia
94
Q

What features occur in the donor in Twin-Twin Transfusion Syndrome (4)

A 
Smaller
Oligohydramnios
Volume depleted
Anaemia
IUGR
95
Q

What are the complications of Twin-Twin Transfusion Syndrome? (4)

A

Late miscarriage
Severe preterm
Neurological damage
Death in utero

96
Q

What new intervention can be done in Twin-Twin Transfusion Syndrome ( + its fetal survival rates)

A

Laser ablation therapy

85% one twin survives
60% both twins survive

97
Q

What are the 3 types of Breech presentation?

A

Extended
Flexed
Footling

98
Q

What are the 4 causes / aetiological circumstances in which breech may occur?

A

Preterm
Room to move (polyhydramnios, high parity/lax uterus)
Turning prevented (twins, fetal/uterine abnormality)
Engagement prevented (praevia, pelvic tumours)

99
Q

List 3 complications of breech babies

A

Increased risk neuro handicap (regardless of delivery method)
Cord Prolapse
Trapped head

100
Q

How/when is ECV carried out?

What is the success rate?

A

37wks
Use tocolytic
CTG
Anti-D to Rh-ve

50% success rate (where fails, approx 3% spontaneously turn before delivery)

101
Q

When/who is ECV less effective? (6)

A 
Nulliparous
High uterine tone
Caucasians
Obese women
Engaged breech
Reduced liquor volume
102
Q

What are the risks of ECV (5)

A 
Fetal damage
Placental Abruption
Uterine Rupture
SROM
Cord entanglement
103
Q

What are the contraindications to ECV? (5)

A 
Fetal compromise
NVD contraindicated anyway (e.g. praevia)
Twins
Ruptured membranes
Recent APH
104
Q

What are the contraindications to vaginal breech birth? (8)

A 
PROM
Slow / no progress in labour (in 30%)
Lack of birth attendants
Severe prematurity
IUGR / placental insufficiency
Footling
Fetus >4kg
Fetal compromise
105
Q

What is the incidence of placental abruption?

What % are ‘concealed’?

A

Occurs in 1% pregnancies (many undetermined APHs have element of PA)
20% concealed (haemorrhage within uterus)

106
Q

List the RFs for placental abruption (8)

A 
Pre-Eclampsia / Pre-existing Hypertension
Maternal Smoking / cocaine use
IUGR
Multiple pregnancy
High parity
Previous abruption (6% risk)

Trauma
Sudden reduction in uterine volume (e.g. polyhydramnios + SROM)

107
Q

What investigations might be done (if clear clinical Dx can’t be made)

A

CTG
FBC / Clotting
Transvaginal USS

108
Q

What are the Signs/Symptoms of Placental Abruption

A 
Dark vaginal bleeding
Abdo pain
Hard (woody), tender uterus
Tachycardia
Pallor
Signs of fetal distress / absent heart sounds
109
Q

List some other possible features of major placental abruption (3)

A

Maternal collapse
Coagulopathy
Renal failure / reduced urine output

110
Q

What are the principles of management in major placental abruption?

A 
Fetal condition: CTG
Maternal condition: fluid balance, renal func, FBC + clotting
IV fluids
Steroids if <34wks
Early delivery
Transfuse blood ± Anti-D
111
Q

How is delivery managed in placental abruption (dependant on fetal distress + gestation)

A

Preterm + No fetal distress → steroids (<34wks) + serial USS
No fetal distress + >37wks → IoL + amniotomy
Fetal distress → LSCS

112
Q

What is the incidence of placenta praevia at term?

What are the 2 classifications of placenta praevia?

A

0.4% pregnancies at term (many ‘low-lying’ at 20wks but lower uterus segment grows in 3rdT)

Marginal (lower seg, not covering os)
Major (completely/partially covering os)

113
Q

List the RFs for placenta praevia (P SMAC SMAC)

A 
Previous PP
Structural anomaly
Multiple preg
Age
C-Sec previously
Smoking
Multiparity
Assisted Conception
114
Q

List the maternal complications of placenta praevia (4)

A

Air embolism
Haemorrhage (lower seg less able to contract/constrict)
Sepsis

115
Q

What complication may arise with placenta praevia in a pt with previous LSCS

A

Praevia + previous LSCS scar → Accreta in 10%

May → massive haemorrhage at delivery + require hysterectomy

116
Q

What are the possible fetal complications of placenta praevia? (3)

A

Hypoxia
Malpresentation
Prematurity

117
Q

What are the clinical features of placenta praevia (4)

How is it diagnosed?

A

Recurrent painless APHs (increase in freq)
Head high/not engaged
Post-coital / post-VE bleeding (exclude before VE)
Malpresentation

Dx USS (3D USS Dx accreta)

118
Q

How is placenta praevia managed if presenting with bleeding?

And if asymptomatic?

A

Bleeding → admission (risk massive APH)
FBC / Clotting / Cross-match / G&S / IV access
CTG
Steroids if <34wks

If asymp → delayed admission until 37wks / labour (but will need quick hosp access)

Both → delivery by C-Section 39wks

119
Q

What are some indications for earlier C-Section in placents praevia (3)

A

≥37wks
Maternal/fetal compromise
Massive bleed (>1.5L) ± continuing

120
Q

How is a C-Section carried out in accreta/percreta?

A

Incision should avoid placenta,

if accreta - leave placenta in situ or consent for hysterectomy

121
Q

List some other causes of APH (3)

A

Undetermined origin (often small placental abruptions)
Vasa praevia
Uterine rupture
Gynaecological (cervical/endometrial carcinoma)

122
Q

Define a primary and secondary PPH

A

Primary = within 24hrs; >500ml vaginal + >1000ml LSCS

Secondary = 24hrs - 6wks (usually b/wn 7-14d)

123
Q

What are the 4 categories of causes of primary PPH (TTTT)

A

Tone - atonic uterus
Trauma - tear (perineal, cervical, high vaginal), LSCS
Tissue - retained placenta fragments
Thrombotic disorders

124
Q

List the RFs for primary PPH (PP PARTUM)

A

Prolonged labour
Previous LSCS / PPH

Polyhydramnios
APH (+Age)
Retained placenta
Twins (/multiple)
Uterine fibroids
Multiparity (lax uterus)
125
Q

What investigations are done for primary PPH

A

Bloods - FBC/Clotting/Cross-match)
Obs (BP, Pulse, sats)
Urine output
VE + fundal ht

126
Q

How is primary PPH prevented (3)

A

Treat anaemia during pregnancy
Identify pts at risk
Oxytocin in 3rd stage

127
Q

What are the general management measures in primary PPH (3)

If if due to atonic uterus

If due to DIC

A

Rh Grp
Catheterise + estimate blood loss
Establish cause + treat

Atonic (high uterus on palp): IV syntometrine + Prostaglandins

DIC: call haematologist + keep APTT/platelets/fibrinogen over good level

128
Q

When is the puerperium?

A

From delivery of placenta → 6wks after

129
Q

List some of the physiological changes that occur in the puerperium

A 
Uterus contracts + occludes vessels
Blood-stained 'lochia' discharge
Menstruation delayed (6wks due to lactation)
BP/CO/Plasma Vol return to normal (loss of oedema up to 6wks)
Hb + Haematocrit return to normal (if w/o haemorrhage)
U&amp;Es return to normal (due to reduced GFR)
130
Q

List some aspects of general care in the puerperium period

A 
Mobility
Breastfeeding guidance
Check daily: lochia / BP / pulse / temp / perineal wound
Monitor any signs postnatal depression
Check FBC before discharge
Pelvic floor exercises
Analgesics for perineal wounds
131
Q

List some aspects of postnatal perineal care (LADS PAIS)

A 
Local cooling + topical
Anaesthetic (local)
Diclofenac suppositories
Swabs for culture
Pus drainage
Abx (broad spec)
Irrigate wound (twice/day)
Surgical repair (if gaping wound + no infection/cellulitis/exudate)
132
Q

List the advantages of breast feeding

A 
Cost saving
Bonding
Cancer protection (in mother)
Infection protection (neonate)
Cannot give too much
133
Q

What is a secondary PPH usually due to?

+ What are the symptoms / Ix / Tx

A

Endometritis
S/s: Enlarged + Tender uterus, open cervical os
Ix: USS but poor (can’t diff b/wn clot + placenta)
Tx: Abx / ERPC (if heavy bleeding)

134
Q

List the causes of postpartum pyrexia (7)

A 
UTI (10%)
Wound infection (C-Sec)
Endometritis
DVT
Chest infection
IV site infection
Mastitis
135
Q

How long can postpartum pyrexia take to develop after birth?
When is it commonest

Symptoms
What pathogens often causative?

A

Up to 14d (temp ≥ 38)
Commonest after C-Sec (give props abx)

Large/tender uterus
Offensive lochia

Grp A Strep, staph, E.Coli

136
Q

What urinary problems can occur postpartum?

A

UTI
Urinary retention
Fistula
Stress incontinence

137
Q

What is the incidence of 3rd day blues + PND?

Who is more likely to get PND? (3)

What is a DDx

A

50% 3rd day blues
10% PND

PMH PND, after-birth problems, socially/emotionally isolated

DDx - postpartum thyroiditis

138
Q

What bowel problems can occur after pregnancy? (4)

A

Constipation + haemorrhoids (in 20%)

Incontinence / flatulence (from pudendal nn / anal sphincter damage)

139
Q

List some RFs for postpartum bowel problems

A

Shoulder dystocia
Persistent OP position
Forceps
Large babies

Obs & Gyn (4 decks)

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