Labour (Postpartum haemorrhage; maternal sepsis; amniotic fluid embolism; uterine rupture and inversion)

Question 1

Define what is meant by PPH [1]

Describe the two types [2]

Answer 1

Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery or 1000ml after a caesarean section

Primary PPH:
- bleeding within 24 hours of birth

Secondary PPH:
- from 24 hours to 12 weeks after birth

Question 2

What is the difference between: minor, major, moderate and severe PPH? [4]

Answer 2

Minor PPH – under 1000ml blood loss

Major PPH – over 1000ml blood loss

Moderate PPH – 1000 – 2000ml blood loss

Severe PPH – over 2000ml blood loss

Question 3

What are the 4Ts of primary PPH? [4]

Answer 3

Tone (most common):
- reduction in uterine tone, typically the result of prolonged labour, macrosomia, twins, uterine anomalies or polyhydraminos. ‘Active’ management of the third stage reduces the risk.

Trauma:
- usually due to episiotomy, extensive perineal tears or uterine rupture.

Tissue:
- refers to retained placenta and placenta accreta.

Thrombin:
- refers to either pre-
existing or newly developed coagulopathies. Coagulopathies may also result from significant APH or PPH!

Question 4

What causes secondary PPH? [2]

Answer 4

Secondary PPH most commonly occurs secondary to retained products of conception and endometritis.

Question 5

State 5 antepartum risk factors for PPH [5]

Answer 5

• Abruption
• Placenta praevia
• Multiple pregnancy
• Pre-eclampsia, gestational hypertension
• Previous PPH
• Ethnicity (i.e. Asian)
• Obesity (i.e. BMI > 30)
• Anaemia
• Uterine anomalies, fibroids

Question 6

State 5 intrapartum risk factors for PPH [5]

Answer 6

C-Section (Emergency > Elective)
Induction of Labour (IOL)
Retained placenta
Episiotomy
Instrumental
Prolonged labour
> 4kg baby
Pyrexia in labour

Question 7

Describe the management for PPH [+]

Answer 7

ABC approach:
- two peripheral cannulae, 14 gauge
- lie the women flat and communicate with her
- bloods including group and save
- commence warmed crystalloid infusion

mechanical:
* palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
* catheterisation to prevent bladder distension and monitor urine output

medical:
* IV oxytocin: slow IV injection followed by an IV infusion
* ergometrine slow IV or IM (unless there is a history of hypertension)
* carboprost IM (unless there is a history of asthma)
* misoprostol sublingual
* there is also interest in the role tranexamic acid may play in PPH
* oxygen regardless of sats

Surgical:
- intrauterine balloon tamponade
- 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

Question 8

Which surgical management is the first line surgical managment if medical management fails in PPH? [1]

Answer 8

Intrauterine balloon tamponade

Question 9

TOMTIP: describe the dosing of oxytocin in PPH [1]

Answer 9

TOM TIP: The intravenous infusion of oxytocin is given as 40 units in 500 mls. You may hear midwives or obstetricians referring only to “40 units” without specifying the drug. They are referring to an oxytocin infusion for PPH.

Question 10

What are the septic six? [6]

Answer 10

3 in:
- Oxygen
- Fluids
- Abx

3 Out
* Lactate
* Blood cultures
* urine outpute

Question 11

What are the two key causes of sepsis in pregnancy? [2]

Answer 11

Chorioamnionitis
Urinary tract infections

Question 12

What is the major risk of chorioamnionitis? [1]

How do you treat? [2]

Answer 12

preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens

Tx:
- Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics

Question 13

Alongside non-specific signs of sepsis, what would indicate chorioamniotitis? [4]

How would you dx? [4

Answer 13

• Abdominal pain
• Uterine tenderness
• Vaginal discharge
• Amniotic fluid might have foul odour/appear purulent

Dx:
- WCC, ESR raised
- Lactic acid raised
- Amniotic fluid: +ve gram stain; decreased glucose; increased WCC
- Histopathological infection

Question 14

How do you manage maternal sepsis?

Answer 14

Continuous maternal and fetal monitoring is required

General anaesthesia is usually required for women with sepsis, as spinal anaesthesia is avoided.

Abx treatment:
- piperacillin and tazobactam (tazocin) & gentamicin
- amoxicillin, clindamycin and gentamicin.

Question 15

Define amniotic fluid embolism [1]

Answer 15

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates an immune reaction.

This usually occurs around labour and delivery.

Question 16

The cause for amniotic fluid embolisation is unknown, but what is there a clear link between? [1]

Answer 16

A consistent link has been demonstrated with maternal age and induction of labour

Question 17

D

Describe the presentation of amniotic fluid embolisation [+]

Answer 17

It can present similarly to sepsis, pulmonary embolism or anaphylaxis:
- chills, shivering, sweating, anxiety and coughing.
- cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

• Shortness of breath
• Hypoxia
• Hypotension
• Coagulopathy
• Haemorrhage
• Tachycardia
• Confusion
• Seizures
• Cardiac arrest

Question 18

How do you manage amniotic fluid embolisation? [1]

Answer 18

Critical care unit by a multidisciplinary team, management is predominantly supportive

Question 19

Define what is meant by uterine rupture? [1]

What is the difference between incomplete and complete rupture? [2]

Answer 19

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures

Incomplete rupture:
- the uterine serosa (perimetrium) surrounding the uterus remains intact.

Complete rupture:
- serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Question 20

What are key risk factors for uterine rupture? [5]

Answer 20

Previous caesarean section
– this is the greatest risk factor for uterine rupture.
- Classical (vertical) incisions carry the highest risk.

Previous uterine surgery
– such as myomectomy.

Induction
– (particularly with prostaglandins) or augmentation of labour.

Multiple pregnancy.

Multiparity

Question 21

Describe the presentation of uterine rupture

Answer 21

Uterine rupture presents with an acutely unwell mother and abnormal CTG:
- Ceasing of uterine contractions
- Hypotension
* Tachycardia
* Collapse
* Abdominal pain
* Vaginal bleeding

Question 22

What is meant by Bandl’s ring? [1]

Answer 22

A warning sign of impending uterine rupture

Question 23

Describe what is meant by uterine invesion [1]

What is the difference between complete and incomplete uterine inversion? [2]

Answer 23

The fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out.

Incomplete uterine inversion (partial inversion)
- is where the fundus descends inside the uterus or vagina, but not as far as the introitus (opening of the vagina).

Complete uterine inversion
- involves the uterus descending through the vagina to the introitus.

Question 24

What is a key risk factor for uterine inversion during pregnancy? [1]

Answer 24

Uterine inversion may be there result of pulling too hard on the umbilical cord during active management of the third stage of labour.

Question 25

Describe the presentation of uterine inversion [1]

What are the managment options? [3]

Answer 25

Uterine inversion typically presents with a large postpartum haemorrhage. There may be maternal shock or collapse.

Management
* Johnson manoeuvre - using a hand to push the fundus back up into the abdomen and the correct position. The whole hand and most of the forearm will be inserted into the vagina to return the fundus to the correct position. It is held in place for several minutes, and medications are used to create a uterine contraction (i.e. oxytocin).
* Hydrostatic methods: This involves filling the vagina with fluid to “inflate” the uterus back to the normal position. It requires a tight seal at the entrance of the vagina, which can be challenging to achieve.
* Surgery: A laparotomy is performed (opening the abdomen) and the uterus is returned to the normal position.

Question 26

Uterine rupture:

What is the difference between scar dehiscence and rupture? [1]

Answer 26

Scar dehiscence
* Herniation of an intact amniotic membrane into an existing uterine scar

Scar rupture:
- Separation of the scar along its entire length, often with involvement of amniotic membranes

Question 27

What is the most common sign of uterine rupture? [1]

How does this differ for women with a scar? [1]

Answer 27

• The most common sign is sudden appearance of fetal distress during labor

NB: signs and symptoms vary in a women with or without uterine scar . In women with uterine scar lower abdominal tenderness is the commonest sign; in women without a scar, shock is the commonest sign, followed by abdominal pain and easily palpable fetal parts

Question 28

During VBAC, need to consider uterine rupture. What are the key considerations? [+]

Answer 28

Early recognition
during VBAC watch out for:
* Fetal heart abnormalities
* Maternal tachycardia
* Vague abdominal pain in-between contractions Suprapubic/scar tenderness
* Vaginal bleeding