Obs Flashcards
Common physiological changes in preg
- Cardio: heart function and plasma volume increase; But the inferior vena cava gets compressed
- Circulation: decreased albumin and osmotic pressure (risk of oedema)
- Lungs: increased tidal volume
- GI: N+V; delayed gastric emptying, prolonged small bowel transit time; GI reflux
Also: changes in oxidative enzymes in liver; Increased GFR in kidneys
Types of antepartum haemorrhage
- Placental Abruption
- Placental Previa
- Onset of labour
Rare:
- Vasa Previa
- Uterine rupture
Can also be from DOMESTIC VIOLENCE. But 50% of time cause = unkown
Small could be: cervical ectropion
Placental abruption
Sudden detachment of placenta from uterine wall causing bleeding (usually comes out through vagina) and continuous severe abdo pain
- can cause hypovolemic shock
- can see CTG (cardiotocography) changes: shows fetal distress
What is suggestive of a large antepartum haemorrhage on abdo exam
Abdo feels ‘woody’ on palpation
Stages of severity of antepartum haemorrhage
- Spotting: spots of blood noticed on underwear
- Minor haemorrhage: less than 50ml blood loss
- Major haemorrhage: 50 – 1000 ml blood loss
- Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
Dx of Antepartum haemorrhage
Diagnosed via clinical presentation.
Be aware of CONCELED HAEMORRHAGE where cervical os remains closed so vaginal bleeding is disproportionate to uterine bleeding.
Acute Mx of major/massive antepartum haemorrhage
- Urgent involvement of a senior obstetrician, midwife and anaesthetist + admit to hopsital
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch/Group and save 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
Non-acute management of antepartum haemorrhage
- USS to exclude placenta praevia
- Antenatal steroids at 24-34+6 wks gestation (matures fetal lungs incase preterm)
-
If parent = Rhesus-D -ve -> need anti-D prophylaxis
- dose determined via Kleihauer test
- Group + save
- CTG for foetal monitoring
- If unstable -> emergency c-section
- FBC, U+E, Group + save
- Active management of third stage for postpartum haemorrhage
RFx for placental abruption
- PMHx of abruption
- PRE-ECLAMPSIA
- TRAUMA
- Multiple pregnancy; bleeding early in preg
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
Placental praevia
placenta is over the internal cervical os -> some vaginal bleeding
Placental abruption vs praevia
Abruption is painful and there is fetal distress. Patients may be shocked.
Praevia is painless but increases in severity and frequency over time. Fetus is often breech/transverse. Don’t do vaginal exam.
Types of placental abnormalities (placenta accreta spectrum)
- Superficial placenta Accreta (grows into surface of myometrium so doesn’t deteach post-partum)
- Placenta Increta (deeply into myometrium - through to serosa / perimetrium)
- Percreta (goes all the way through wall - can potentially grow into other organs e.g. bladder)
Caused by abnormal decidualisation from defective endometrial-myometrial interface - usually due to scars
Vasa previa
Malformation of umbilical vessels resulting in them running through PLACENTAL membrane instead of umbilical cord AND passing on/near internal cervical os (uncommon)
Px as - brisk PAINLESS bleeding on rupture of amniotic membrane with FOETAL DISTRESS
- typically haemorrhage triggered by dilatation of cervical os / movement of presenting part
These vessels can rupture without a ROM too which leads to the foetus bleeding out + intrauterine haemorrhage
Picked up antenatally on USS OR as bleed post SROM (check with VE - can feel vessels)
Uterine rupture Px
Sudden PAIN + PV BLEEDING
Sudden STOP IN CONTRACTIONS and foetal distress on CTG
Hypotension, Tachycardia, possible collapse
gynae causes of antepartum bleeding
Cervical polyps/Cancer
Miscarriage
Early: spontaneous termination before 12wks gestation
Late = 12-24wks
Types of miscarriage
- Missed miscarriage
- Threatened
- Inevitable
- Incomplete
- Complete (everything gone)
- Anemryonic preg (sac present but no embryo)
Missed miscarriage + management
- Uterus empty before 20 wks but cervical os is closed so any bleeding is contained -> asymp
Threatened miscarriage
Painless uterine bleeding but cervix is closed. Fetus is still alive at first.
Inevitable miscarriage
Heavy bleeding with clots and pain
Cervical os is open
Incomplete miscarriage
Pain and vaginal bleeding through open cervical os but not all products of conception have been expelled
Dx of miscarriage
- fetal heartbeat should be present if crown-rump length bigger than 7mm
- if no heartbeat repeat after week to confirm
- fetal POLE should be present is gestational sac mean diameter >= 25mm
- if not; repeat after 1 wk to confirm anembryonic preg
Mx of miscarriage
- <6 wks = only expectant if no complications (just wait for it to happen) + preg test after 7-10 days to confirm
- > 6wks = referr to early preg assessment service (EPAU)
- USS to confirm
- Expectant +/- pain relief/anti-emetic if no risk factors
- Medical management = MISOPROSTOL (prostaglandin analogue) -> binds to prostaglandin receptors in cervix, softens it and stimulates uterine contractions
- Surgical: Manual vacuum aspiration (local anaesthetic, outpatient); Electric vac asp (general anaesth) - typically for incomplete
- need to give anti-D prophylaxis if resus -ve
What happens in stage 1 of labour
From onset till full dilation - 3 phases:
- Latent phase = 0-3/4cm (0.5 cm/hr + irregular)
-
Active = 3/4-7cm or till 10cm (1cm/hr + regular + stronger at end)
(- Transition phase = 7-10cm (1cm/hr + strong + regular))
Interventions for stage 1 labour
Membrane sweep (seperate sac from uterus) – can be done in community
Prostaglandin pessary – done as inpatient
Amniotomy (break sac) – not routine
Oxytocin – offered for delayed first stage
Stage 2 of labour
Full dilation to fetal delivery (~1 hour)
Stage 2 labour interventions
- Changing positions
- Oxytocin (stimulates uterine contractions if weak)
- Instrumental delivery:
- Ventouse (vacuum cup)
- Forceps
- Epiostomy (cutting perineum)
- C-section
- Classical C-section (rarely done as it involves upper part of uterus and contraindicates future vaginal delivery)
Analgesia just in general
Main complications associated with stage 2 of labour
- Shoulder dystocia
- cord prolapse
- Breech presentation
Shoulder dystocia
Anterior shoulder gets stuck behind pubic symphesis after head already delivered.
Oft due to macrosomia from gestational diabetes.
Diagnosis of shoulder dystocia
Clinical - can present with:
- Difficulty in delivery of the fetal head or chin.
- Failure of restitution - baby doesn’t turn to side
- Turtle neck sign - head delivered but then retracts back in (head still visible)
Mx of shoulder dystocia
It is an obs emergancy so get senior obs, midwife and peads
Get mum to stop pushing; only use axial (upward) traction on baby (pushing down can cause bracial plexus damage and pushing in can cause uterine rupture)
Consider episiotomy to increase space + reduce risk of tearing
First line manouver for shoulder dystocia
- McRoberts (hyperflex hip - knees up and out) -> posterior pelvic tilt lifting pubic symphysis + stop pushing
- Suprapubic pressure (sustained or rocking) - dislodge baby from behind pubic symphysis
Over 90% success
2nd line manouvers for shoulder dystocia
- Posterior arm (Rubins) – insert hand posteriorly into sacral hollow and grasp posterior arm to deliver.
- Internal rotation (“Wood’s screw manoeuvre”) – apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees or into an oblique position.
Repeat with patient on all 4s if not working
3rd line Mx for shoulder dystocia
- Cleidotomy – fracturing the fetal clavicle.
- Symphysiotomy – cutting the pubic symphysis.
- Zavenelli – returning the fetal head to the pelvis for delivery of the baby via caesarean section
Complications of shoulder dystocia
- Fetal hypoxia (and subsequent cerebral palsy)
- Brachial plexus injury and Erb’s palsy (arm paralysis); clavicle fracture
- Perineal tears (can extend into anal muscle/lining)
- Postpartum haemorrhage
More likely to get again in future
Umbilical cord prolapse
Umbilical cord falls out beneath presenting part of fetus after membrane rupture. Presenting part can compress cord -> fetal hypoxia and distress.
Typically happens when fetus in abnormal lie (enough room for card if head is down)
Dx of cord prolapse
Suspect if CTG shows distress!
found with VE or speculum examination.
Mx of cord prolapse
Is an obs emergancy -> c-section
Don’t push cord back in; minimal handling (can cause vasospasm); keep it warm and wet
- Push up presenting part if compressing
- Lie in left lateral position with + pillow under hip OR on all fours (relieves pressure)
- Can give Tocolytic meds (terbutaline) - minimises contractions
Stage 3 of Labour
Post-fetal delivery; placental delivery
Interventions to stimulate stage 3 labour + when is it classed as delayed
Active:
- IM oxytocin
- clamp cord after 1 min
- controlled cord traction (pulling)
Physiological - clamp cord after pulsation stops
>30 mins with Active Mx OR >60 mins with Physiological = prolonged
- need to do VE with analgesia + consider manual removal
Define Postpartum haemorrhage (PPH)
- 500ml blood after vaginal
- 1000ml blood after c-section
minor = <1000ml
major mod = 1000-2000 ml
major severe = >2000ml
Primary vs Secondary PPH
- Primary PPH: bleeding within 24 hours of birth
- Secondary PPH: from 24 hours to 12 weeks after birth
Causes of primary PPH
Four Ts:
– Tone (uterine atony = utermine muscles don’t contract enough to clamp blood vessels - main cause)
- Trauma (e.g. perineal tear)
– Tissue (retained placenta)
– Thrombin (bleeding disorder)
Rare: cervical/high vaginal tear or uterine rupture
Mx of primary PPH
- ABCDE
- Lie flat
- 2x large cannulas
- Bloods + clotting screen
- Group + save/crossmatch 4 units
- IVfluids/blood as required
- OXYGEN
- Fresh frozen plasma (if clotting abnormal/still needing more blood)
Mechanical treatment to stop PPH
- Rub uterus (stimulate contraction)
- Cathetarise (distended bladder stops uterus contraction)
Medical treatment of PPH
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine (intravenous or intramuscular) - stimulates smooth muscle contraction (contraindicated in hypertension)
- Carboprost/PGF2a (intramuscular) - stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual)
- Tranexamic acid (intravenous) - antifibrinolytic
Surgical treatment of PPH
- Intrauterine balloon tamponade – 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 (one or more arteries) – reduce the blood flow
- Hysterectomy (last resort)
Causes of secondary PPH
Endometritis +/- retained tissue
Rare: Gestational trophoblastic disease or gynae causes
Investigate secondary PPH with
- USS (? anything in uterus)
- Endocervical and high vaginal swabs for infection
Management of secondary PPH
- Surgical evaluation of retained products of conception
- Antibiotics for infection
if severe may need endoscopic exploration + histology
Gestational diabetes
Diabetes cuased by REDUCED INSULIN SENSITIVITY during pregnancy
- typically resolves after birth
Defined as glucose intolerance with fasting blood glucose >= 5.6 mmol/L or 2-hr plasma glucose >= 7.8 mmol/L on a 75g Oral Glucose Tolerance Test
RFx for gestational diabetes
- PHx of gestational diabetes
- BMI > 30 (obesity)
- Ethnicity (black caribbean, middle eastern and south asian)
- FHx of diabetes in 1st degree relatives
- Previous macrosomic baby
- Maternal Hx of stillbirth / perinatal death
Screening for gestational diabetes
Oral glucose tolerance test
- drink 75g glucose in morning (no food before)
- Blood sugar measured before and 2 HOURS after
Normal max values:
- 5.6 mmol/l fasting
- 7.8 mmol/l at 2 hours
(5-6-7-8)
Used if any ONE of RFx or Signs are present
- routine screening is done between 24-28 wks
- if Sx (glycosuria) then test then itself
For people without RFx -> Just screen based on URINALYSIS at ANC
Signs indicative of gestational diabetes
- Large for date fetus (/macroscomic)
- Polyhydraminos (increased amniotic fluid)
- Glucose on urine dip
- Diabetes Sx (thirst, polyuria etc)
Management of gestational diabetes
Inform + explain. USS every 4 weeks at 28, 32, 36 wks (check fetal growth + aminotic fluid). Monitor blood glucose 4 times a day.
- Fasting glucose <7: diet + exercise for 2 wks. Continue if working, otherwise progress to metformin, then insulin.
- Fasting glucose > 7 mmol/l: start insulin ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Can also give glibenclaminde (sulphonylurea) if not tolerating others (other diabetes meds can be teratogenic) but risk of neonatal hypoglycaemia
Carry on glucose testing postpartum to ensure the GDM resolves (can develop T2DM)
Glucose target levels for diabetes during preg
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
Complications of gestational diabetes
Foetal
- Macrosomia +/- shoulder dystocia
- Neonatal hypoglycaemia
- Childhood obesity
- Polycythaemia (raised haem specifically)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
- Premmie delivery
- Increased risk of sacral agenesis
- Long term risk of baby developing T2DM / METABOLIC SYNDROME in later life
Maternal
- Increased risk of HTN / Pre-eclampsia
- Future risk of developing GDM in subsequent preg
- 60% get T2DM
- Increased CVD risk
Neonatal hypoglycaemia after gestational diabetes
Caused due to babies being accoustomed to high levels of sugar in blood - struggle to maintain with oral feeding after birth
Need to be closely monitored
Give IV dextrose or nasogastric feeding if blood sugar <2 mmol/l or Sx - otherwise monitor + feed
Pre-eclampsia
Defined as: pregnancy-induced hypertension associated with organ damage, notably proteinuria but also other organ dysfunction or placental dysfunction
Characteristic:
- HTN
- proteinuria
- oedema
Pre-eclampsia pathophys
After 20wks gestation the spiral arteries of the placenta form abnormally causing high vascular resistance
Complications of pre-eclampsia
- organ damage/failure
- fetal growth restriction
- seizures (eclampsia)
- EARLY LABOUR
- placental abruption
- Death
pre-eclampsia vs gestational HTN vs eclampsia
Gestational HTN by itself has NO PROTEINURIA
Eclampsia is when seizures occur as a result of pre-eclampsia
RFx for pre-eclampsia
High
- HTN
- PMHx
- Autoimmune (e.g. SLE)
- DIABETES
- CKD
Moderate
- AGE: >40 years old
- Nulliparity (never given birth before)
- > 10 yrs since last preg
- Multiple pregnancy
- Obesity
- FHx
Previous vascular disease
Pre-eclampsia prophylaxis
ASPIRIN
From 12 wks until birth if people have 1 high-ridk factor or 2/more moderate-risk factors
Sx of pre-eclampsia
Symptoms are caused by the complications (HTN comps baso)
Can be asymp
- Headache
- Visual disturbance or blurriness
- Upper abdominal pain (due to liver swelling)
- Nausea and vomiting
- Oedema
- Reduced urine output
- Brisk reflexes
- Reduced foetal movements
How is proteinuria quantified
- Urine protein:creatinine ratio (above 30mg/mmol is significant)
- Urine albumin:creatinine ratio (above 8mg/mmol is significant)
Diagnosis of pre-clempsia
Test placental growth factor (protein which stimulates angiogenesis) levels once between 20-35 weeks
- LOW in pre-eclampsia
Pre-eclampsia screening
Every pregnant person is monitered every antenatal appointment
- Blood pressure
- Symptoms
- Urine dipstick for proteinuria
management / investigations for gestational HTN (no proteinuria)
- Regular BP READINGS
- Treating to aim for a blood pressure below 135/85 mmHg
- Admission for women with a blood pressure above 160/110 mmHg
- Urine dipstick testing at least weekly (2+ = pre-eclampsia)
- sFLT : PLGF ratio (placental growth factor) testing ONCE (>85 = diagnostic)
Additionally:
- Weekly BLOODS (full blood count, liver enzymes and renal profile)
- Monitoring fetal growth by SERIAL GROWTH SCANS
- SERIAL UA DOPPLER
- CTG:
- on Dx
- if pain
- PV bleed
- Sx deterioration
- reduced foetal movements
- Foetal HR (offer at every appointment - aka 2 weekly)
Pre-eclampsia initial management
Similar to gestational HTN BUT:
- Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- Blood pressure monitored at least every 48 hours
- Urine dipstick testing is not routinely necessary (the diagnosis is already made)
-
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
- bloods to check for organ dysfunction
- CTG as required (aka if on ward with something concerning)
- Check FHR
Pre-eclampsia Tx
Prevention = 75mg ASPIRIN OD from 12wks
- Labetolol
- Nifedipine (modified-release)
- Methyldopa (needs to be stopped within two days of birth)
Consider induction / c-section at 37 wks
- Severe ICU care = Intravenous hydralazine
- IV magnesium sulphate - during labour and in the 24 hours afterwards to prevent seizures
- Fluid restriction - during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
NB: switch to Enalapril (1st line) (or Nifedipine/amlodipine 2nd) after birth
Treatment of eclampsia
IV magnesium sulphate + Emergancy section
HELLP syndrome
combination of features occuring from complications of pre-eclamsia/eclampsia
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
Main infections relevent to pregnancy
- Herpes Simplex (can get verticle transmission through vesicles so c-section if attack within 6wks of delivery)
- Group A strep
- Group B strep
- HIV
Group A strep in preg
Cause perinatal sepsis and chorioamnionitis
treat with IV Abx
Group B strep
Commensal in in birth canal -> neonatal sepsis
Treat with IV PENICILLIN if risk factors present
Risk factors for neonatal Strep B infection
- previous infected child,
- ROM >18hr
- maternal fever in labour
Complications of HIV in preg
- Inter-Uterine Growth Restriction (IUGR)
- Still birth
- Pre-eclampsia
- Prematurity
- Gestational DM
Prevention of vertical transmission of HIV in preg
- Maternal ART (anti-retroviral therapy)
- Elective C/S
- Avoid breast feeding
- Neonatal ART
Complications of gonorrhoea in preg
- prematurity
- early labour
- perinatal mortality
- VERTICAL TRANSMISSION leading to:
- GONOCOCCAL CONJUNCTIVITIS - eye pain, redness + discharge
Management of gonorrhoea in preg
- Prophyl antibiotics to prevent gonococcal conjunctivitis
- otherwise same as usual - 1 dose IM CEFTRIAXONE 1g
Any infected babies urgent referral to prevent blindness
Preg women at higher risk of developing UTIs. What are the complications associated with UTI in preg?
- PRETERM DELIVERY
- Low birth weight
- Pre-eclampsia
Other adverse preg outcomes
Management of UTI risk in preg
Preg women tested for ASYMP BACTERIURIA at booking + routinely:
**MSU -> MS+C **
(don’t usually test if asyp but must do in preg because of risk of complications)
Treatment of UTI in preg
Needs 7 days as it is complicated
- Nitrofurantoin (NOT IN 3RD TRIMESTER -> neonatal haemolysis)
- Amoxicillin (only if sensitivites known)
- Cefalexin
- Trimethoprim (NOT IN 1ST TRIMESTER - folate antagonist -> neural tube defects)
How can you seperate between monochorionic and dichorionic diamniotic twins on USS?
- Dichorionic = lambda/twinpeak sign
- Monochorionic = T sign (the chorion doesn’t peak, is flat)
Complications of multiple preg for mother
- ANAEMIA
- Polyhydramnios
- Hypertension
- Malpresentation (head not down in labour)
- Spontaneous preterm birth
- Instrumental delivery (ventouse or forceps used) or caesarean
- Postpartum haemorrhage
Complications to baby in multiple pregnancy
- Miscarriage
- Stillbirth
- Fetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
Twin-Twin Transfusion Syndrome (TTTS)
Occurs in some monochorionic diamniotic pregs
One fetus (recipient) recieves the majority of the blood while the other (donor) is starved.
Recepient - FLUID OVERLOAD -> HF and POLYHYDRAMNIOS
Donor - GROWTH RESTRICTION, ANAEMIA, OLIGOHYDROAMNIOS
Connection between blood supplies can be destroyed with laser treatment if severe
Twin Anaemia Polycythemia Sequence
Similar to TTTS but less acute
One twin ANAEMIC, the other POLYCYTHEMIC
What is a partogram
A compositie graphical record of key data from both fetus and parent, USED DURING 1st stage of LABOUR, all on the same sheet of paper; all against time on the x-axis
What information is recorded on a partogram
- CERVICAL DILATION (vaginal exam every 4 hours)
- DESCENT of FETAL HEAD (in relation to ischial spines on maternal pelvis)
- Vitals:
- Maternal pulse, BP, urine output + TEMP
- Fetal Heartrate, colour of amniotic fluid, moulding of fetal skull
- FREQUENCY OF CONTRACTIONS (measured in contractions / 10 mins)
- State of MEMBRANES + ?MECONIUM STAINED LIQUOR (when baby opens bowels before waters burst)
- RECORDS OF ANY DRUGS + FLUIDS GIVEN
If labour is too slow, will cross ‘Alert’ and then ‘Action’ lines:
- Consider Amniotomy (artificially rupture membranes - uncommon)
- Escelated to Obstetrics/senior decision makers + take action
- Threshold for taking action may be lower if something abnormal with measurements
What is the aimed for uterine contraction frequency in labour
4-5 per 10 minutes
What factors determine the sucess of Stage 2 of labour
the 3 P’s:
- Power (strength of contract)
- Passenger:
- Size of fetus
- Attitude i.e POSTURE
- Lie - Longitudinal, Transverse or Oblique
- Presentation - Passage (size + shape of passageway/pelvis)
Puerperium meaning
The period of ~6 wks after from placental delivary; when maternal reproductive organs return to non-preg condition + the initiation/suppression of lactation
Non-medical management of pain during labour
- Education of what to expect + Good Support
- Relaxed environement
- Change position as required to stay comfortable
- Controlled BREATHING
- Potentially water births (ineligible if needing regular monitoring/pre-eclampsia)
- Potentially TENS machine (Transcutaneuos Electirical Nerve Stimulation) at start of labour (stimulates endorphins + can reduce need for opioids for 5 hrs after)
Options for Medical Mx of pain relief in labour
- Simple analgesia (NOT NSAIDS)
- Gas + Air (Entenox) = 50% NO + 50% O2 (ONLY SHORT TERM)
- IM Pethidine OR Diamorphine
- Patient controlled analgesia (REMIFENTANIL = short-acting opiate)
- EPIDURAL
- Levobupivacaine
- Bupivacaine
- Fentanyl
Pain pathway in 1st vs 2nd stage of labour
1st stage:
- Pain from lower UTERINE + CERVIAL change
- VISCERAL AFFERENT nerve fibres
- T10 - L1 Segments
2nd stage:
- Distension of PELVIC FLOOR, VAGINA + PERINEUM
- SOMATIC nerve fibres, PELVIC SPLANCHNIC + PUDENDAL nerve
- S2 - S4
Pros + Cons of Entenox
Pros
- Works immediately
Cons:
- Lightheaded, Nausea, Sleepiness, Tiring, Drys mouth
- Have to take deep breaths at start of contraction so Too distracting to use while pushing
Diamorphine (/ Pethidine) functioning +
- can give IM or SC
- Take around 30 mins to work
SE:
- Baby: SLEEPY, SLOW BREATHING, POOR FEEDING initially
- Mum: SICKNESS + Sleepiness
Patient Controlled Analgesia pros + cons
- Useful for those for whom neuroaxial anaesthesis is Contranindicated e.g. Clotting disorder, spinal abnormalities etc
- Works within 30 SECONDS
- Oft used alongside entox
Cons:
- Gotta press button for each contraction
- Not as effective in 2nd stage
- Wears of after a few minutes
- Baby - may be slow to breath
- Mum - Sickness, sleepiness, slow breathing/bradycardia, O2 may be needed via nasal cannula
Epidural + CSE functioning
- 1:10 may not work as well + need replacing
- Take ~ 20 minutes to work
- CSE = FASTER
- Catheter + IV fluids
Risks/SE of Epidural / CSE
- Low BP (but this is known + easily treatable)
-
Severe Headache; worse on sitting up + in bright light if needle punctures dura (typically due to CSF leaking out)
-> treat with Epidural Blood Patch + caffine drinks - Nerve damage / severe nerve injury
- need to do urgent anaesthetic review if they get motor weakness - Spinal / Epidural Abscess
- Meningitis
- Spinal Haematoma
- Increased probability of instrumental delivery
Which method to use for fetal monitoring
- INTERMITTENT AUSCULTATION if low risk
- Continuous CTG if HIGH RISK
How to carry out intermittent auscultation
in 1st stage:
- Palpate for at least 1 min immediately after palpated contraction
- Repeat every 15 mins
- Record any acels/decels
- Palpate maternal pulse every 1hr to ensure the FHR being heard is diff
In stage 2:
- 1 minute every 5 MINUTES after a contraction
When to increase fetal monitoring
- If increase in FHR of 20bpm or more since start of labour
- Decelerations
Carry out a FULL CLINICAL REVIEW as well
What to do if concerned about FHR
- Summon help
- Advise continuous CTG monitoring
- Transfer to CLC (consultant led care)
- Return to IA if continous CTG is normal after 20 minutes
Categories of c-section
- Cat 1
- Deliver within 30 MINUITES of making decision
- Cat 2
- Deliver within 75 MINUTES (e.g. in labour but FAILURE TO PROGRESS) - Cat 3
- Delvier within 24 HOURS (e.g. induced labour but not progressing enough) - Cat 4
- elective (plan months in advance)
Variations that can be seen in CTGs
- Variable = norm (baby should be able to push up HR when required)
- Reduced variability (loss of accelerations - could be due to baby tiring OR sleeping)
- Increased variability
- Sinosoidal (risk of FETAL COMPROMISE if had prev abnormal CTGs)
- Variable decels (tiring if antenatal - in labour could be due to cord/skull compression)
- Late decelerations (tiring fetus)
Physiology of puerperium
- Endocrine changes
- Decrease in placental hormones (human placental lactogen, hcg, oestrogen + progesterone)
- Increased prolactin
- Decrease in placental hormones (human placental lactogen, hcg, oestrogen + progesterone)
- Involution of uterus + genital tract
- Muscle ischaemia, autolysis + phagocytosis
- Decidua shedding as LOCHIA - Breast
- Lactogenesis / Lactation supression
Changes during involution of uterus + genital tract
- Should be able to feel hard muscle layer at umbilical level just after birth
- Height should decrease by ~1cm per day
- Returns to pelvis by day 10
- Continues for ~6wks
- Cervix internal os should be closed by 2nd weeks
- external os may remain dilated up to permanently
Diff stages of Lochia
- Rubra = day 0-4
- Blood + cervical discharge od Decidua (fetal membrane, vernix + meconium)
- Serosa = day 4-10 (pinky)
- Cervial mucus + exudate
- Fetal membrane; microbes; WCC
- Lochia Alba = day 10-28:
- Cholesterol + fat; Epithelial cells
- Microbes + Leukocytes
- Mucus
At no point should it smell offensive -> infection
Prolactin response
- Baby suckles / is in contact with nipple
- sensory impulse sent from nipple to brain
- prolactin secreted by ANTERIOR PIT GLAND -> blood -> breasts
- LACTOCYTES produce milk
More is secreted at night; Levels peak after feed to get milk for next feed
Supresses ovulation if exclusively breastfeeding - for 6 MONTHS
Oxytocin / Let-down reflex
- Suckling
- Sensory impulse to brain
- oxytocin secreted by POSTERIOR pit gland
- MYO-EPITHELIAL CELLS contract + EXPEL milk
Stimulated by sight, sound + smell of baby -> gets conditioned to release as soon as triggered by baby over time
Works BEFORE + DURING feeding to get milk flowing
Hindered by ANXIETY, STRESS, PAIN + DOUBT