OBS & GYNAE WK 5 Flashcards
NORMAL LABOUR - 3 STAGES
- Cervical effacement and dilatation
latent/active stage (8-24hrs) - FULL dilatation and delivery of the baby (0-30mins)
- BIRTH OF PLACENTA
3Ps - failure to progress or obstructed labour
management for each
power - insufficient uterine activity
passenger - baby too big
passage - mum has small pelvis
Artificial rupture of the amniotic membranes (ARM)
forceps/suction cup
malpresentation
mcroberts position - lifting legs up and in case of shoulder dystocia
Augmentation of labour
how to induce labour - pros and cons
breaking water, need to be dilated to rupture
propess
bring forward delivery to reduce risk to mum and baby eg. diabetes, reduced movements
more painful than the actual birth
need more exams and monitoring
breech position
instead of head first, its feet are
LUSCS - lower uterine segment caesarean section
ECV - External cephalic version
chorioamnionitis - and mx
intra-uterine infection, infection of placenta and the amniotic fluid - may be life threatening
abdo pain, offensive discharge, mum unwell
PPROM - preterm premature rupture of membranes
PROM
IV antibiotics, C-section DELIVERY
APH aka antepartum haemorrhage - before childbirth
CAUSES??
MX??
vaginal bleeding from 24 + 0 weeks until birth
don’t do digital exam until u can exclude PLACENTA PRAEVIA
caused by PLACENTAL ABRUPTION OR PRAEVIA
Kleihauer, anti-d, steroids for baby
cord prolapse - mx??
may obstruct blood supply to baby
RAPID DELIVERY via section
shoulder dystocia
risk factors ??
mx
baby anterior shoulder stuck against mother pelvis, pubic symphysis bone
causing delayed delivery and hypoxia
risk factors - diabetes, big head baby and narrow pelvis, BMI>30, short stature, slow labour, IOL, FORCEPS
HELPERR mx - call for help
evacuate for episiotomy
legs - mcroberts manoeuvre
external pressure - suprapubic
need to get baby out <4 mins or may risk permanent neurolgocial damage, Brachial plexus injury
may have to break baby’s clavicle to help narrow space
amniotic fluid embolism and maternal collapse
Rare complication of labour where amniotic fluid enters systemic circulation and causes acute respiratory and circulatory collapse with coagulopathy
Maternal collapse can arise from numerous pathologies including
Haemorrhage (Obstetric and non obstetric)
Pulmonary embolism
MI
AFE
Septic shock
Eclampsia/Epilepsy
uterine inversion
uterus turning inside out after delivery
neurogenic shock
push uterus back in
delivery of placenta and then theatre
vaginal / perineal tears and Obstetric Anal Sphincter Injury - degrees??
1st Degree
Vaginal mucosa / perineal skin only
2nd Degree - most common
Includes perineal skin + muscles but does not involve anal sphincter
3A tear
<50% of external anal sphincter torn
3B tear
>50% of EAS torn
3C tear
>50% EAS and IAS (internal) torn
4th degree tear
Tear involving anal/rectal mucosa
repair in theatre
maternal collapse
acute event involving the cardiorespiratory systems and/or CNS
maternal cardiac arrest may occur
most common cause of maternal collapse?? other specific condition causes
vasovagal
anaphylaxis
eclampsia
aortic dissection
hypoglycaemia
sepsis
PE
Drugs eg. MgSO4
amniotic fluid embolism
4Hs and 4Ts - causes of collapse in pregnancy
-hypovolaemia
-hypoxia
-hypokalaemia and hyponatraemia
-hypothermia
-toxicity
-thromboembolism
-tension pneumothroax
-tamponade
MEOWS score
modified early obstetric warning score
1 red / 2 amber = review
cpr in pregnant woman
SPECIAL MODIFICATIONS
During chest compressions, place your hands slightly higher than usual. This is because the pregnant woman’s diaphragm is elevated, and her heart is positioned higher in her chest.
manually displace the pregnant woman’s uterus to her left side, in a technique called “left lateral tilt.” = relieve pressure on IVC
perimortem caesarean
4 minutes post-arrest and completed at 5 minutes
PPH - what is major volume??
CAUSES, 4Ts
can be primary or secondary, up to 6 wks after birth
postpartum haemorrhage
>1000ml
but can be proportionate to body weight
tone - uterine atony
trauma - perineal tears, cervical tears
tissue - retained placenta
thrombin - coagulation problems
IV syntocinon
carboprost
misoprostol
calculating volume - body weight
50 kg -> 5000ml
PPH medical mx
ABCDE (may have to go to theatre)
UTERINE TONICS:
1. SYNTOCIN
2. ERGOMETRINE
tranexamic acid
PPH surgical mx
intrauterine balloon - saline inside
brace sutures
mx of 3rd stage - up to how long do you do this
delivery of placenta
30 mins max
morbidly adherent placenta
becoming more common if previous CS OR UTERINE SURGERY
placenta is abnormally stuck to womb, normally is at decidua
accreta (end of womb), increta, percreta
may have to have hysterectomy
uterine inversion
usually pulled the placenta cord too hard
v rare
postpartum sepsis
rx??
most common sources??
risk factors - anaemia, long labour, assisted delivery, raised BMI, diabetes, prolonged membrane rupture
most common - uterus (endometritis)
skin/wound infection
breasts
the fetal circulation - 3 shunts
ductus venosus
foramen ovale
ductus arteriosus
small fraction of RV output goes via lungs
umbilical cord has how many blood vessels?? what are they?
3 blood vessels – one vein which carries oxygenated blood to the baby, 2 arteries which carry deoxygenated blood back to the placenta
Duct smooth muscle __________ in response to oxygen.
constricts
thermoregulation - babies lose heat by what 4 methods
in utero/preparation vs after delivery
radiation
convection
conduction
evaporation
Mum responsible for thermoregulation
Lots of brown fat laid down between scapulae and around internal organs in 3rd trimester
Less in growth restricted or preterm infants
after delivery:
Heat produced by breakdown of stored brown adipose tissue in response to catecholamines
glucose homeostasis
-Babies in utero have a constant supply of glucose from the placenta
-blood sugar drops when born which is normal
watch out for babies w diabetes, too much insulin
breast feeding feedback loop
what is the earliest milk??
suckling - more feeding, more prolactin produced, more milk.
earliest milk is colostrum, v rich in immune and growth factors
what % is normal weight loss at beginning
10%
babies have excess fluid, water
PPHN
Persistent Pulmonary Hypertension of the Newborn
the pulmonary resistance does not drop for some reason, DUE TO
hypoxia, acidosis, cold stress, lung disease, sepsis
DIAGNOSIS AND MX OF PPHN
Measuring pre and post ductal oxygen saturations with a sats probe on the right hand and one on a foot helps to make the diagnosis. Usually there will be a 10-20% difference in saturation between the two.
Ventilation
Oxygen
Nitric oxide
Sedation
Inotropes
ECLS
transient tachypnoea
A more minor problem this time mainly with lung transition.
usually need more oxygen or CPAP
common reason for mums and babies to have to be separated in the first few hours of life and has an effect on feeding being established and on bonding
where do most of the oxygenated blood from the placenta go to, via what? what about the rest??
crosses straight over from right atrium (via the ductus venosus, inferior vena cava) to left atrium, via the foramen ovale
-> left ventricle
The rest, mixed with SVC return passes into the right ventricle.
what substance is produced in the placenta and metabolised quickly in lung
Prostaglandin
It maintains duct patency and may have a role in suppressing breathing in fetal life.
causes of Failure of cardiorespiratory adaptation
hypoxia
premature
cold stress
congenital pneumonia
meconium aspiration
placental abruption
vasospasm, blood gets into amniotic sac, blocks cervix
CTG - foetal heart, C-section
placental praevia
placenta lies directly over internal os
severe abdo pain
risk factors include previous C-sections
painless vag bleeding usually in 3rd trimester
vasa praevia
It occurs when the blood vessels from the placenta or umbilical cord block the birth canal.
triad of rupture of membrane, painless bleed and foetal bradycardia.
Assisted conception, such as IVF, a low-lying placenta and multiple pregnancies can increase the risk of vasa praevia.
US TA AND TV with doppler
maternal sepsis - signs
offensive discharge
sore throat
rash (meningitis?)
abdo pain
dysuria
urinary frequency, dysuria
productive cough
temp >38
hr > 100 bpm
resp rate > 20
confusion mental state
mx of sepsis
ABCDE
Sepsis 6 bundle
FBC, U+Es, LFTs, glucose, Lactate
HVS, throat swab (group A strep?), MSSU
IV co-amoxiclav within the GOLDEN HR
GBS - GROUP B STREP
pretty common
give Benz-penicillin
mastitis
inflammation of mammary gland, painful, unilateral
still need to breastfeed from that side
1.breastfeeding or expressing to empty breast, warm compresses
2. flucloxacillin if its staph
3.no response, referral
epidural abscess
rare cause of sepsis
back pain and fever
high death rate
IV antibiotics
what hormonal factors influence the onsset of labour ? - 3
progesterone - keeps uterus settled
oestrogen - uterus contracts
oxytocin - initiates and sustains contractions
bishops score
to see if it is safe to induce labour
position
consistency
effacement
dilatation
station in pelvis
4 or less score indicates unfavourable cervix
Braxton hicks contractions vs true labour contractions
false labour
giving false sense that woman is having real contractions
true = timing of contractions become evenly spaced and time between them gets shorter
delayed cord clamping
immediate clamping can reduce the red blood cells that infant receives, may cause more problems
