Obs Flashcards
What is normal labour?
When diagnosed?
Process where foetus and placenta are expelled from uterus
Painful uterine contractions + dilation/effacement of cervix
Mechanical factors in labour?
power
passage
passenger
Braxton-Hicks contractions?
painless uterine contractions from 30/40
can be palpated
who has poor uterine activity?
nulip
induced labour
where is the ‘pacemaker’ of the uterus?
junction of fallopian tube and uterus
physiological changes due to contractions?
permanent shortening of muscle fibres –> distension
what causes pain in contractions?
ischaemia in myometrial fibres
RFs for abnormal lie?
polyhydramnios
multip
fetal/uterine abnormalities
preterm
what position in extended breech?
buttocks present; legs extended by head
what is presentation?
part of fetus occupying the lower segment of uterus
how common is abnormal lie?
1/200
3 main parts of passage?
bony pelvis -inlet, mid cavity, outlet
ishial spine - used to assess descent
soft tissues - cervical dilation, vagina and perineum
what does station 0 mean?
head level with ischial spines
+ve = below
-ve = above
which presentation is best?
Vertex (narrowest diameter)
occipito-anterior normal deliver
3 stages of labour
1 - initiation to full cervical dilatation
- -> Latent - slow dilation up to 3cm
- -> Active - about 1cm/hr
2 - full cervical dilation to delivery of fetus
- -> passive - til head reaches pelvic floor (desire to push)
- -> active - mother pushing
3 - delivery of foetus to delivery of placenta
- -> normall 15 mins
- -> expectant or active management
how to epidurals affect labour?
remove desire to push
so labour is longer
expectant management of 3rd stage?
active?
light massage of uterus through abdo
IM - syntocinon
normal blood loss in delivery?
VD?
CS?
VD = 500ml CS = 1000ml
Identifying abnormal labour?
partogram
most common cause of slow progress in primip?
inefficient uterine action
what is the worry in multip with slow progress in labour?
malposition –> uterine rupture is more likely
when do you use tocolysis?
iatrogenic uterine hyperactivity eg prostaglandin
why is eating discourage in labour?
whats this called?
aspiration of stomach contents
under anaesthetic = Mendelson’s syndrome
general care points in labour?
physical - obs, mobility, delivery positions
mental - environment, control, partner
what to do in persistent inefficient uterine action?
augmentation (ARM)
Hyperactive uterine action can lead to…?
placental abruption
mx of hyperactive uterine action?
if no evidence of abruption –> tocolytic eg salbutamol
usually LSCS
what is augmentation? egs?
artificial strengthening of contractions in established labour
ARM, amniotomy, artificial oxytocin
nulip with slow 1st stage?
poor descent in passive 2nd stage?
longer than 1h in active second stage?
augementation –> if no full dilation by 16h –> LSCS
P2nd - oxytocin infusion
A2nd -> episiotomy, ventouse
how frequent do you auscultate fetal heart?
1st stage - /15mins
2nd - /5mins
intrapartum fetal problems?
meconium aspiration
fetal blood loss
trauma
infection (GBS)
what is fetal destress?
signs?
hypoxia that could lead to fetal damage / death
colour of meconium, auscultate fetal heart, CTG, fetal blood sampling (scalp)
CTG mnemoic
DR C BRAVADO (normal values) Define risk Contractions / 10mins (<5) Base rate (110-160) Variability (>5) Accelerations (with movement/contractions) Deceleration Overall assessment
What might fetal tachycardia indicate?
Fetal bradycardia?
fever, infection, hypoxia
sustained deterioration –> distress due to hypoxia
what do early, variable and late deceleration suggest?
early - synchronous with contraction = normal
variable - cord compression causing hypoxia
late - persist after contraction = hypoxia
what to do with sustained fetal brady?
deliver urgently!
pain relief in labour?
non-pharma –> warm towel / massage
pharma –> entonox, opiates (+antiemetic), epidural
perineal trauma degrees?
mx?
1 - skin only
2 - perianal muscles but not sphincter
3 - involving anal sphincter
4 - anal sphincter + epithelium
1/2 - suture under LA
3/4 - epidural + physio
how frequently do you USS in multiple pregnancy?
monthly from 20/40
gestration for an elective CS?
37/40
comps of multiple pregnancy?
prem
twin-twin transfusion?
when is it concerning?
arterial blood flow from donor through placenta to vein of recipient
if >30% discordance
comps of twin-twin transfusion?
donor - IUGR, oligohydramnios, hypovolaemia, hypotension, anaemia
recipient - poyhydramnios, hypertension, polycythaemia, oedema, kernicterus, CHF
mx of twin-twin transfusion?
doppler analysis
therapeutic amniocentesis to decrease polyhydramnios of recipient
+/- intra-uterine blood transfusion
RFs for shoulder dystocia?
high birth weight, maternal DM, induced labour, prev shoulder dystocia, oxytocin, abnormal lie
what is shoulder dystocia?
failure of the shoulder to deliver
comps of shoulder dystocia?
cord compression
asphyxiation
Erb’s palsy
mx of shoulder dystocia
HELPERR "Help!" Episiotomy Legs (McRoberts) Pressure (suprapubic) Enter (rotational manouevers) Remove posterior arm Roll patient onto hands + knees
last resort in shoulder dystocia?
deliberate clavicular fracture
Zavanelli’s (push head back in + CS)
abdo surgery with hysterectomy
RFs for cord prolapse?
preterm breech abnorm lie multiples **AMNIOTOMY**
mx of cord prolapse
elevate presenting part to prevent cord comp
tocolytics (nifedipine, terbutaline)
CS
Pres of amniotic fluid embolus?
sudden dyspnoea, hypoxia, hypotension
can occur at any time in pregnancy
–> ARDS
mech of amniotic fluid embolus?
liquor enters maternal circulation –> anaphylaxis +/- seizures and cardiac arrest
mx of amniotic fluid embolus?
O2, fluids
bloods
blood transfusion + FFP
ICU
RFs for uterine rupture?
labour with scared uterus
CS / prev
obstructed labour
sx of uterine rupture
fetal heart rate abnomalities constant abdo pain VB cessation of contractions maternal collapse
comps of uterine rupture
fetal hypoxia
massive internal haemorrhage
high recurrence rate
mx of uterine rupture
maternal resus
urgent laparotomy for delivery
uterine inversion?
pres?
fundus inverts into uterine cavity PPH lower abdo pain vaginal mass CV collapse
mx of uterine inversion
GA fluid replacement 1 - manually push back 2 - fill with warm saline 3 - laparotomy
mx of epileptiform seizures?
clear airway, O2
diazepam if epilepsy
MgSO4 if eclampsia
induction vs augmentation?
induction = artificial initiation of labour augmentation = promotes contractions when spont contractions are inadequate
what is a ripe cervix? how can you ripen it?
soft, short, think, anterior cervix with open os
prostaglandin
CIs for induction of labour?
fetal distress
cord presentation
pelvic tumour
praevia
comps of induced labour
failure infection bleeding cord prolapse instrumental / CS
Bishops score?
pre-labour scoring
? IoL is required
how to induce labour?
if bishops<6 –> cervical ripening with PG
Induction:
amniotomy, monitor fetal HR, oxytocin IV
when do you use misoprostol?
after intra uterine death –> to deliver
mx for BV in pregnancy?
oral metronidazole (if not in 1st trimester)
RF for preterm labour?
prev BV short cervix bacteiruria prev abdo surgery polyhydramnios fetal hydrops
maternal causes of preterm labour?
infection
HTN, DM, chronic illness
prev surgery
smoking, alcohol, drugs
what is fetal fibroniectin?
glycoprotein in amniotic fluids
what is fetal hydrops?
abnormal fluid in >=2 areas = underlying disease
mx of preterm labour?
hydration
tocolytics (nifedipine, terbutaline)
dexamethasone
CI for tocolytics?
absolute - fetal death, chorioamnionitis, poor maternal condition
relative - pre-eclampsia, placenta praevia, cervix > 4cm, pulm oedema
periventricular malacia?
white matter surround ventricles is deprived of blood –> cerebral palsy
when is cervical cerclage performed? removed?
indications?
sutures placed at internal os at the end of 1st trimester
removed in 3rd trimester
cervical incompetence, silent cervical dilation
Define PROM?
rupture of membranes prior to labour at any gestational age
Define prolonged ROM?
> 24h between rom and onset of labour
Define preterm ROM?
ROM < 37/40
Define PPROM?
ROM < 37/40 AND prior to onset of labour
what is cervical effacement?
change in shape from bulb to flat
normal rate of cervical dilation?
1-3cm/h
Define APH?
Bleeding >24/40
Causes of APH?
placenta previa, placental abruption, vasa previa
What is placenta praevia?
major?
minor?
low lying placenta (common <20/40 but moves ‘upwards’ as pregnancy continues)
minor - in lower segment, does not cover os
major - covers internal os
features of placenta praevia?
intermittent PAINLESS bleeding - red/profuse
ix in placenta praevia?
USS (often incidental finding)
NEVER do vaginal examination
FBC + cross match if bleeding
Mx of placenta previa?
delivery
if major –> elective c-section at 39/40
what is placental abruption?
part/all of placenta separates from the lining of the uterus before delivery of fetus
complications of placental abruption?
fetal death
DIC
maternal death
causes of placental abruption?
IUGR
pre eclampsia
smoking, cocaine
multiples
pres of placental abruption?
signs?
PAINFUL bleeding - dark
can be concealed bleeding
o/e –> tachycardia, hypotension, tender uterus
WOODY, HARD ABDOMEN
ix in placental abruption
CTG
mx of placental abruption?
admission
IV fluids +/- blood transfusion
urgent CS
what is vasa praevia?
fetal blood vessels running in front of presenting part. When membranes rupture, fetal blood vessels rupture –> massive fetal bleeding –> copious bleeding and fetal death
pres of vasa previa?
membrane rupture –> painless VB + fetal bradycardia
mx of vasa praevia?
immediate CS
often too slow to save fetus
define primary PPH?
> 500mls of blood loss in first 24h after delvery
causes of primary PPH?
4T's Uterine aTony Tissue (retained placenta) Trauma (uterine rupture) Thrombin (clotting disorder)
mx of primary PPH?
oxytocin
bimanual compression
blood transfusion
what is uterine atony?
RFs?
reduced tone –> doesnt compress vessels
prev atony
uterine abnorm
large placenta
placenta previa/abruption
Define secondary PPH?
Excess blood loss after 24h
Causes of secondary PPH?
retained placental tissue
clot
Ix in secondary PPH?
USS - identify retained products
mx of secondary PPH?
ampicillin + metronidazole (prevent 2dary infection)
curette of uterus
comps of prematurity
developmental delay
CLD
cerebral palsy
visual/hearing impairment
egs of teratogenic drugs?
warfarin ACEi carbimazole propylthiouracil angiotensin II antagonists anitepileptics (bar lamotrigine) MTX isotretinoin alocohol cocaine
When are the 3 trimesters?
1 - LMP-12/40
2 - 13/40-27/40
3 - 28/40-40/40
Pre-existing HTN defined as?
mx?
> 140/90 before 20/40
labetalol or nifedipine
DO NOT USE ACEi –> teratogenic
Diagnosis of pre-eclampsia?
Sx?
BP > 140/90 + proteinuria > 0.3g/24h [20/40]
Headache, visual disturbance, N+V, epigastric pain, oedema
Comps of pre-eclampsia?
Eclampsia -> MGSO4 CVA Renal failure DIC ARDS HELLP IUGR
What is HELLP?
Haemolysis elevated liver enzymes low platelet count
pres of HELLP?
mostly 27-37/40
non-specific: malaise, fatigue, RUQ/epigastric pain
Ix in HELLP?
raised bilirubin
raised LDH
raised AST / ALT
Platelets < 100
mx of HELLP
if after 34/40 -> deliver
if <34/40 -> corticosteroids
blood transfusion / FFP
BP control
+/- liver transplant
Mx of pre-eclampsia?
admit
labetalol if >150/100
regular monitoring
+/- delivery
Diagnosis of DM?
glucose >7mmol/l fasting
HbA1c > 48mmol/L
mx of gestational DM?
lifestyle
monitor BMs
metformin –> insulin if severe
rhesus isoimmunisation?
Rh -ve mother mounts an immune response against Rh +ve baby via anti-D antibodies
sensitising events in rhesus isoimmunisation?
delivery, ToP, ectopic, intrauterine death, invasive uterine procedure
prevention of Rhesus disease?
Anti-D to Rh -ve women at 28/40 + after sensitising events
how does anti-D work?
mops up fetal RBCs without initiation of immune response
mx of epilepsy in pregnancy?
carbamazepine / lamotrigine
mx of VTE in pregnancy?
LMWH
mx of depression in pregnancy?
TCA / SSRI
mx of bipolar in pregnancy?
haloperidol / olanzipine
[Lithium causes Epstein’s anomaly]
mx of hyperemesis gravidarum?
metoclopramide/cyclizine/ondansetron + thiamine
which infections can be teratogenic in pregnancy?
how do you treat them?
CHRiST
CMV: hearing/visual/mental impairmnet -> gancyclovir
HZV: rare -> Ig + aciclovir
RUBELLA: hearing/visual/mental impairment -> TOP if <16/40
SYPHILLIS: miscarriage, congenital disease or still birth -> Benzypenicillin
TOXOPLASMOSIS: retardation, convulsions, visual impairment -> Spiramycin
infection causing maternal death?
Group A strep -> sepsis
mx of Group B strep in pregnancy?
penicillin - prevents transmission to baby
types of miscarriage?
threatened - fetus alive, os closed
inevitable - os open
incomplete - some fetal parts passed + os open
complete - fetal tissue passed, bleeing stopped, uterus no longer enlarged, os closed
septic - contents infected
missed - no fetus, os closed
drugs given post miscarriage?
IM ergometrine -> uterine contraction
Anti-D
how many miscarriages = recurrent?
common cause?
mx?
3
anti-phospholipid syndrome –> low dose aspirin
ectopic pregnancy?
egg implants outside uterine cavity (95% in fallopian tubes)
RFs for ectopic?
PID prev ectopic endometriosis smoking pelvic surgery assisted conception
pres of ectopic?
abdo pain, PV bleeding, adnexal tenderness
ix in ectopic?
any female of childbearing age that present with collapse needs a pregnancy test
USS
Mx of ectopic?
Medical; MTX
surgical: salpingectomy / sapingotomy
when is booking visit?
<10/40 - screen for complications
when is combined test?
11-13/40
when is anomaly scan?
18-21/40
what is involved in combined test?
PAPP-A
B-hCG
Nuchal translucency
PAPP-A is low in downs
what happens in anomaly scan?
what is measured?
look for obvious abnormalities
measure - HC, AC, FL
screening for pre-eclampsia?
regular GP, urinalysis
prevention of pre-eclampsia?
75mg aspirin <16/40 in high risk women
which maternal antibodies can cross placenta?
IgG
scalp pH indicating fetal hypoxia?
<7.2
dx of hyperemesis gravidarum?
severe vomiting with dehydration and electrolyte imbalances
+ wt loss + ketosis
mx of hyperemesis gravidarum?
IV fluids
anti-emetics
thiamine
cause of gestational DM?
increased insulin resistance
physiological increase allows the fetus to absorb more glucose from the placenta
Dx of gestational DM?
GTT at 24-28/40
Mx of gestational DM?
1 - metformin
2 - insulin
mx of cholestasis of pregnancy?
induce at 37/40
ursodeoxycholic acid
Vit K if prolonged clotting
surgical mx of PPH?
- rusch ballon
- brace suture
- hysterectomy
CI to entonox?
pneumothorax
RF for hyperemesis?
young
primip
hyperthyroid
multiples
placenta accreta?
chorionic villi penetrate decidua basalis to attach to the myometrium
placenta increta?
chorionic villi penetrate deeply into the myometrium
placenta percreta?
chorionic villi breech myometrium into the peritoneum
mx of placenta accretas?
CS +/- hysterectomy
mx of miscarriage?
mifepristone (progesterone inhibitor)
misoprostol (prostaglandin)
