obs Flashcards
A 26-year-old woman has just delivered her first baby after a long labour. The baby is placed on her chest for skin-to-skin contact. She has opted for natural delivery of the placenta which hasn’t occurred yet.
What stage of labour is the woman in?
3rd stage - begins after delivery of baby, involves delivery of placenta
cervicitis bleeding
light
A 32-year-old woman at 28 weeks gestation presents with painless, bright red vaginal bleeding. She has no history of abdominal trauma, and the bleeding is not associated with contractions. The foetus is in a normal position, and the woman’s vital signs are stable.
Which condition is most likely responsible for her bleeding?
placenta praaevia
chorioamnionitis organism
group B strep (Streptococcus agalactiae) and E coli
Woman G3P2 with PPH first line surgical management
and 2,3,4,5th
Intrauterine balloon tamponade is a first-line surgical intervention for managing postpartum haemorrhage due to uterine atony.
2nd line = B-Lynch suture
3rd = Stepwise uterine devascularisation
4th = Uterine artery embolisation
5th = hysterectomy
incomplete vs missed miscarriage
incomplete - Single dose of misoprostol
missed - Oral mifepristone + misoprostol 48 hours later
hemodynamically viable patient with an ectopic pregnancy less than 35 mm in size and a serum HCG level under 5000 IU/l, management
For a stable, hemodynamically viable patient with an ectopic pregnancy less than 35 mm in size and a serum HCG level under 5000 IU/l, methotrexate is typically the first line treatment option.
ectopic management options
expectant = if low risk and bHCG dropping off, indicating self resolution, no or minimal symptoms, require follow up
medical = methotrexate
surgical
when is surgical ectopic management required
1 Patient is unable to attend follow-up
2 - Serum hCG level of 5000 IU/L or higher -
3 Adnexal mass of 35mm or greater -
4 Foetal heartbeat is visible on ultrasound scan -
5 Patient is in significant pain -
6 Patient is haemodynamically unstable
Also offered second line in cases where medical manamgement has failed
The preferred surgical management is a salpingectomy, where the fallopian tube containing the ectopic pregnancy is removed.
2ndary PPH cause
Endometritis is the most common cause of secondary postpartum haemorrhage, and typically presents between 2 and 10 days postpartum
category 1 c sec indications
cord prolapse, foetal scalp pH under 7.2,
at what week can you offer membrane sweep in normal pregnancy
Post-term pregnancy is associated with adverse fetal outcomes. Induction of labour should be offered to all women between 41 and 42 weeks, usually when patient is 12 days post due date (NICE 2008).
what would be an abnormal finding on speculum exam in pregnancy
A clear-white, odourless fluid in the posterior vaginal vault during pregnancy could indicate premature rupture of membranes, requiring further assessment for potential preterm labour.
is blue cervix normal
yes due to increased blood flow
missed miscarriage Mx
200mg mifepristone followed by 800mcg misoprostal 48 hours later
causes of polyhydramnios
Excess production can be due to increased foetal urination:
Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome
Insufficient removal can be due to reduced foetal swallowing:
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
Most cases, however, are idiopathic.
rupture of membranes followed immediately by vaginal bleeding. ?
vasa praevia
ECV CI
Antepartum haemorrhage during the last 7 days
most common place for fertilisation and ectopic
ampulla
when is ECV offered
If the foetus is found to be in breech past 36 weeks, management can be undertaken. ECV is the first-line management and is offered at 36 weeks for nulliparous, and at 37 weeks for multiparous women. Therefore, as this woman has previously had a child, ECV should be offered at 37 weeks.
what can you give to improve success of ECV
terbutaline
Abx in PPROM
In cases of preterm premature rupture of membranes, erythromycin or clarithromycin is recommended to reduce the risk of maternal and fetal infections due to ascending genital tract infection.
PPH Mx if not in shock
uterine massage
indications for elective C sec
Indications for elective caesarean section include:
Abnormal presentation e.g. breech or transverse.
Twin pregnancy if first twin is not cephalic.
Maternal HIV.
Primary genital herpes in third trimester.
Placenta praevia.
Anatomical reasons
bishop score
score is calculated by assessing five key factors: cervical position, consistency, effacement, dilation, and foetal station.
Certain circumstances such as pre-eclampsia, previous vaginal deliveries, post-dates pregnancy, and premature pre-term rupture of membranes can add or subtract points to the score.
next steps after feeling that water broke early at home
PPROM - In pre-labour rupture of membranes at term, a sterile speculum examination is crucial for confirming the diagnosis, assessing the risk of infection, and evaluating fetal position and cord prolapse.
Women at high risk for pre-eclampsia, including those over 40 years old with BMI greater than 35 kg/m² and pregnant after a long interval since last delivery, may be given
low-dose aspirin from week 12 to reduce the risk.
Women with polyhydramnios have an increased risk of
cord prolapse during labour. This is because the excess amniotic fluid can prevent engagement of the head and leave room for the cord to extend past the presenting part. This is a serious complication as it may lead to cord compression and subsequent fetal hypoxia
maternal factor causing polyhydramnios
Maternal diabetes mellitus is a recognised cause of polyhydramnios as it causes fetal hyperglycaemia. This results in fetal polyuria and thus polyhydramnios
when to offer induction of labour after ROM
Following rupture of membranes if spontaneous labour does not occur within 24 hours induction of labour should be offered
Tocolysis is contraindicated in cases of
Tocolysis is contraindicated in cases of suspected chorioamnionitis,
Maternal treatment during confirmed preterm labour includes
betamethasone for fetal lung maturation and antibiotics such as benzylpenicillin to reduce Group B Streptococcus infection.
classical triad of vasa praevia
The classical triad of clinical features is painless vaginal bleeding, rupture of membranes and fetal bradycardia (fetal heart rate <100bpm)
Frank breech
A frank breech presentation is where the legs are fully extended up to the shoulders and the presenting part is the buttocks
footling breach vs complete breech
Footling breech is where one or both legs are fully extended towards the pelvic inlet, with the foot or feet being the presenting part
Complete breech is where the hips and knees are both flexed and the presenting part is the buttocks
key signs of placental separation in 3rd stage of labour
Key signs of this stage include a gush of blood, lengthening of the umbilical cord, and ascension of the uterus in the abdomen.
3b tear
A third degree (3b) tear extends more than 50% of the thickness of the external anal sphincter, but with the internal anal sphincter remaining intact
active management of third stage of labour
Intramuscular oxytocin (10 IU) is given first line in active management
Oxytocin is preferred over Syntometrine, which is associated with greater side-effects
Active management reduces blood loss in the third stage of labour and reduces the risk of anaemia
Oxytocin increases the risk of nausea and vomiting
After oxytocin is given, there is lengthening of the cord
NICE recommend the use of oxytocin over syntometrine because it is associated with fewer side-effects
A 28-year-old woman (para 1, gravida 3) presents to birth options clinic to create a delivery plan for her current dichorionic twin pregnancy. She has no significant medical history other than a previous classical Caesarean section three years ago.
Which of the following is the best advice to offer?
Recommend a Caesarean section at 37 weeks gestation
A previous classical Caesarean section is an absolute contraindication to normal vaginal delivery. There is a risk of uterine rupture and the foetus may be expelled into the peritoneal cavity. Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days
A 20-year-old patient at 38 weeks gestation presents to labour ward concerned that she ‘her waters have broken’. Examination is significant for offensive-smelling liquor stained underwear. She appears sweaty and distressed. Her observations are: T38.1C, HR 89, BP 112/78mmHg.
Which of the following is the most appropriate next step?
Take blood cultures
This patient likely has chorioamnionitis, which requires treatment with broad spectrum antibiotics. Blood should be taken for culture before antibiotics are given
A 30-year-old trans man has had a long second stage of labour and is becoming exhausted. In addition, he is finding it increasingly difficult to push as a consequence of his epidural. He decided to attempt Ventouse delivery, however there is no foetal descent with 3 pulls.
Which of the following is the most appropriate next step in management?
Convert to lower segment Caesarean section
When attempting instrumental delivery, the procedure should be abandoned if there is no foetal descent following 3 pulls. A lower segment caesarean section is the gold standard approach for surgical delivery following this.
You receive a bleep from a midwife who is attending a patient after her delivery. They estimate that the patient has lost around 800ml of blood and is still bleeding. The patient’s heart rate is 97bpm and blood pressure is 100/75mmHg.
Which of the following is the most appropriate first step in management?
Insert large bore IV cannulae for group and save, cross match, FBC and coagulation studies and start fluid resuscitation
Postpartum haemorrhage is a medical emergency and as such resuscitation measures must be the first priority. The patient is becoming shocked and continuing to become more hypovolaemic. As such, the above blood tests and fluid resuscitation should be the first step in management whilst awaiting blood products.
You are bleeped to a patient on labour ward who has just delivered a healthy baby. The midwife reports that while he was performing controlled cord traction, the patient began to bleed and the uterine fundus is no longer palpable in the abdomen.
Given the most likely diagnosis, what is the most appropriate next step in management?
Immediately replace the fundus through the cervix with the palm of the hand
Swift action is required when there’s a concern of uterine inversion, aiming to restore the normal position of the uterus as soon as possible to prevent severe bleeding and other complications.
2 indications for category 1 C sec
Scalp pH <7.2 is an indication for category 1 Caesarean section, as is cord prolapse
what follows delivery of fetal head
Following delivery of the fetal head, the fetus externally rotates (restitution) to bring the shoulders into an antero-posterior position to facilitate delivery of the anterior shoulder and then body.
prophylactic before C sec
A prophylactic proton-pump inhibitor is given before Caesarean sections, as pregnant women are physiologically at increased risk of gastric reflux.
when to give anti D
rhesus negative mother with positive baby
CI to PV exam
Undiagnosed vaginal bleeding is a contraindication to digital vaginal examination, due to the risk of haemorrhage in cases of placenta praevia.
type of pressure needed in shoulder dystocia
suprapubic
A 25-year-old parous woman attends her local maternity unit in established labour at 39+7 weeks. She had a spontaneous vaginal delivery 2 years prior and has had no problems during either pregnancy. She is experiencing regular, painful contractions. She has not experienced any vaginal loss.
A cardiotocograph is performed upon admission, which reveals a foetal heart rate of 110 beats per minute, with deep decelerations with contractions that are slow to recover.
The woman is transferred to theatre for an emergency caesarean section, and a live male infant is delivered.
As the midwife examines the placenta to check the membranes are complete, she describes the umbilical cord as “velamentous”.
What is the most likely cause of the intrapartum foetal distress?
Vasa praevia
Vasa praevia occurs when the vessels in the umbilical cord run within the foetal membranes. These vessels may rupture spontaneously in early labour. Vasa praevia can be divided into types; in type 1 vasa praevia, the umbilical cord is inserted into the membranes rather than directly into the placenta (also known as a velamentous insertion) and in type 2 vasa praevia, the umbilical vessels run from the placenta to a succenturiate placental lobe.
induction -A midwife performs a vaginal examination and describes her cervix as long, closed, firm, and posterior. Her Bishops score is 0.
What is the most appropriate management?
Intravaginal prostaglandin E2 analogue e.g. Propess
Intravaginal prostaglandin E2 analogues such as Propess and Prostin are the first-line treatment in the induction of labour where there are no contraindications. These aim to soften and ripen the cervix in preparation for labour.
Artificial rupture of membranes
An artificial rupture of membranes (ARM) can only be performed where the cervix is favourable, the foetus is well engaged, and there is space to access the cervical os.
A patient has been admitted with severe pre-eclampsia and has been advised that she will need regular blood tests and asks for more information about these.
Which of the following represents the tests she will need and their frequency?
U&E, FBC, transaminases and bilirubin three times per week
Patients with severe pre-eclampsia should have blood tests three times per week to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving haemolysis, elevated liver enzymes and low platelets
In multipsarous women near term labour with sudden onset of foetal bradycardia and decelerations, and a gush of fluid, consider
umbilical cord prolapse as a possible diagnosis.
prolonged second stage of labour ?
This is defined as three hours or more from full dilatation in a nulliparous woman with epidural anaesthesia.
forceps
first stage of labour normal CTG
Baseline rate: 125bpm. Variability: 15bpm. Accelerations: present. Decelerations: absent
multiple pregnancy and VTE
give LMWH prophylactically
explain mcroberts
Hyperflex and abduct her hips so they are against her abdomen
PPROM examination
In a patient with suspected preterm prelabour rupture of membranes, a sterile speculum examination is indicated to check for amniotic fluid draining from the cervix after the mother has been laying down for 30 minutes and to check for cord prolapse.
PPROM vaginal exam\?
NO
Vaginal examination is appropriate here to rule out cord prolapse. However, in prelabour premature rupture of membranes, vaginal examination is avoided to minimise the infection risk.
waiters tip - erbs palsy
C5-6
33 year old woman at 22 weeks of gestation presents with decreased foetal movements. She has a history of two prior miscarriages and a past medical history of myocardial infarction, Hashimoto’s thyroiditis, and type 1 diabetes mellitus (T1DM). Transvaginal ultrasound reveals no foetal movements, confirming intrauterine foetal death.
Which of the following will be the most useful investigation to identify the underlying cause?
Lupus anticoagulant and anticardiolipin antibodies
The patient has multiple risk factors for antiphospholipid syndrome (APS), including recurrent pregnancy loss, a history of myocardial infarction (suggesting hypercoagulability), and an autoimmune disease (Hashimoto’s thyroiditis). APS is a major cause of second-trimester IUFD. NICE and RCOG recommend testing for acquired thrombophilia, particularly with lupus anticoagulant and anticardiolipin antibodies.
