Obstetric Complications Flashcards
How to investigate PROM
Maternal Obs:
Trolly: BP, pulse, sats, temp
RR, Urinalysis
Obstetric examination:
- Determine soft/tender uterus
- Fundal height
- Fetal lie & presentation
Speculum:
Look for pooling of liquor (comment on colour & if it foul smelling) and exclude preterm labour (comment if Os is open/closed) any signs of labour.
Infection:
Do high vaginal swabs
Bloods: FBC & CRP
Tx PROM
Depends on gestation.
< 34 weeks
Conservative management with aim of gaining fetal maturation. Close observations for infection or labour.
Consider steroid injections to ↑ fetal lung maturity
Prophylactic antibiotics to reduce the risk of infections such as chorioamnionitis
What is primary & secondary PPH
Primary PPH: blood loss of 500ml + form the genital tract occurring within 24 hours of delivery or >1000ml after Caesarean.
Secondary PPH: excessive loss occurring between 24 hours & 6 weeks after delivery.
Most common causes of PPH
Uterine atony
Trauma
Retained products of conception
Causes of uterine atony
APH Fibroid Grand multiparity Overdistension (twins, polyhydramnios) Large placenta site (twins)
When would you give an infusion of oxytocin in addition to the bolus doses?
High risk conditions:
- prolonged labour
- known placenta praevia
- polyhydramnios
- Twin pregnancy
- High parity
- Uterine fibroids
- abrupted placenta
- uterine fibroids
- Prv PPH
How would you recognise PPH
Any clinical signs of shock, PV bleeding or if fundus above umbilicus and feels boggy
Treatment for major PPH
Call: senior help & anaesthetist
Immediate resuscitation with restoration of circulating volume and rapid Tx of underlying cause.
ABC High Flow O2 2 large bore cannulas Crossmatch, clotting FBC, U&E, LFT Fluid/ Blood replacement
Vaginal examination:
Exclude uterine inversion or trauma
Uterus is bimanually compressed
Ask allergies or asthma
Atonic:
- 10mg Oxytocin or synometrine
- Other drugs
Investigations under GA
What are you options to stop a PPH bleed
Pharmacological
- IM: 10mg oxytocin - ampule of syntometrine
Can have 2 doses
- 5 units oxytocin (syntocinin) in 500 mls 0.9% saline IV infusion
- Hamabate (carboprost) 0.25mg IM (CI in asthma)
- Ergometrine (not advised in placenta still inside)
Mechanical:
- Uterine massage
- Balloon Tamponade
- Haemostatic brace suturing
- Bilateral ligation of the uterine arteries
- Hysterectomy
What are the main two causes of secondary PPH. How do they present differently and management.
Infection, endometritis
Pyrexia, ↑ WBC, offensive lochia, closed Os -> IV antibiotics
Retained products of conception
Bleeding, passage of of tissue, open Os, failure of uterine involution (uterus large for number of days PP) -> theatre for evacuation + syntocinon/erogmetrine. USS for formal diagnosis.
List some serious third stage problems
- Failure of placental separation
- Incomplete placental seperation
- PPH
- Uterine atony
- Tear of genital tract
- Collapse (excessive fit, eclamptic fit, amniotic fluid embolus, cardiac failure, cerebral haemorrhage, diabetic coma)
- Uterine inversion
What complication can occur from profound hypotension that is specific to obstetrics?
Sheehan’s syndrome: hypotension leads to avascular necrosis of pituitary gland. If anterior = ↓ FSH, LH, TSH, GH, prolactin & ACTH
-> secondary amenorrhoea, atrophy of breasts & genital organs, osteoporosis, hypothyroidism, addisonian symptoms.
Definition of obstetric emergency
Sudden collapse antenatally or in 1st 6 weeks PP.
Causes of collapse + clinical features
Bleed: Threatened miscarriage, APH, PPH
PE
- pleuritic chest pain, sudden dyspnoea, cough, haemoptysis
Amniotic fluid embolism: sudden dysponea, fetal distress + hypotension -> cardiac arrest +- seizures.
Anaphylaxis: Cyanosis, hypotension, wheeze, pallor, tachy +- urticaria
Septic shock
Cerebrovascular event
N & V + headache: Hx PIH or ICH
Eclampsia
Tonic clonic seizure
MI
Chest pain, sweating, pale
Tension pneumothorax
Pleuritic chest pain, ↓ BS
Uterine inversion
Profound hypotension
The pneumonic for the management of shoulder dystocia is PALE SISTER. What does this stand for?
Prepare: Have plan & inform team
Assistance: Senior Help
Legs -> McRoberts’ Manoeuvre
Episiotomy
Suprapubic pressure (works in 90%) (30-60 seconds)
Internal rotation: push forward anterior shoulder, couterpressure on posterior clavicle.
Screw Manoeuvre: pressure on posterior aspect of posterior shoulder
Try recovering posterior arm
Extreme measures: Push baby back and CS (Zavanelli Manoevre)
Repair, record, relax
