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Year 3- placement > Obstetric core conditions 4 > Flashcards

Obstetric core conditions 4 Flashcards

1
Q

Membrane sweep

A
  • Involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
  • Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit
  • Membrane sweeping is regarded as an adjunct to induction of labour
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2
Q

Complications of inducing labour- Uterine hyperstimulation

A
  • The main complication of induction of labour
  • Refers to prolonged and frequent uterine contractions - sometimes called tachysystole
  • Potential consequences= intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia, uterine rupture (rare)
  • Management= removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started, tocolysis with terbutaline
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3
Q

Failure to progress in the first stage of labour

A
  • Less than 2cm of cervical dilation in 4 hours
  • Slowing of progress in multiparous women
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4
Q

Failure to progress in the second stage of labour

A

When the active second stage (pushing) lasts over:
- 3 hours in nulliparous women
- 2 hour in multiparous women

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5
Q

Delay in the 3rd stage of labour

A
  • More than 30 minutes with active management
  • More than 60 minutes with physiological management
  • Active management= intramuscular oxytocin and controlled cord traction
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6
Q

Cord prolapse definition

A

When the umbilical cord descends through the cervix and into the vagina after rupture of the fetal membranes. Danger of the cord getting compressed resulting in fetal hypoxia

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7
Q

Risk factors for cord prolapse

A
  • Abnormal lie after 37 weeks gestation i.e. unstable transverse or oblique
  • Twins
  • Polyhydramnios
  • Artificial rupture of membranes
  • External cephalic version, stabilising induction of labour= over 50% of cord prolapses have an iatrogenic cause
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8
Q

Diagnosis of cord prolapse

A

Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.

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9
Q

Management of cord prolapse

A
  • Emergency caesarean section
  • Cord should be kept warm and wet, minimal handling whilst waiting for delivery
  • If the baby is compressing the cord it can be pushed upwards
  • The women can lie in the left lateral position (pillow under hip) or the knee chest position (on all fours)
  • Tocolytic medication i.e. terbutaline can minimise contractions
  • Filling the bladder i.e. inserting a catheter and the filling the bladder with 500ml of normal saline. Bladder should be empties prior to caesarean section

Medical emergency= will develop vasospasm and fetal hypoxia

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10
Q

Signs of fetal distress

A
  • Changes in fetal heart rate- higher or lower
  • Fetus moves less for an extended period of time
  • Low amniotic fluid, meconium in the amniotic fluid
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11
Q

Causes of fetal distress

A
  • Too frequent contractions (tachysystole).
  • Fetal anemia.
  • Oligohydramnios (low amniotic fluid).
  • Pregnancy-induced hypertension
  • Preeclampsia.
  • Abnormally low blood pressure.
  • Late-term pregnancies (41 weeks or more).
  • Fetal growth restriction (very small baby).
  • Placental abruption, Placental previa.
  • Umbilical cord compression.
  • Chronic condition like diabetes, kidney disease or heart disease.
  • Expecting identical twins.
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12
Q

Complications of fetal distress

A

Encephalopathy, seizures, cerebral palsy and neurodevelopment delay

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13
Q

Treating fetal distress

A
  • Changing your position. This may increase the blood return to your heart and oxygen supply to the fetus.
  • Giving oxygen through a mask.
  • Giving fluids through an IV line.
  • Giving medicine to slow or stop contractions- tocolysis
  • Amnioinfusion (a procedure that places fluid in your amniotic sac to relieve umbilical cord compression).
  • Emergency birth
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14
Q

Treating babies who need respiratory support post partum

A
  • Clearing the airway and warming
  • Drying the baby
  • Positive pressure ventilation (PPV)
  • Supplemental oxygen, intubation, chest compressions
  • Pharmacological therapy
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15
Q

Investigations into fetal distress

A
  • Continuous measurements of the fetal heart rate- CTG or doppler
  • Non stress test: measures contractions and fetal heart rate
  • Fetal scalp blood testing- tocheck for lactic acidosis and metabolic acidosis
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16
Q

Perineal tear

A

When the external vaginal opening is too narrow for the baby, causes skin and tissues to tear as the baby’s head passes

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17
Q

Risk factors for perineal trauma

A
  • First births (nulliparity)
  • Large babies (over 4kg)
  • Shoulder dystocia
  • Asian ethnicity
  • Occipito-posterior position
  • Instrumental deliveries
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18
Q

Classification of Perineal tears

A
  • First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
  • Second-degree – including the perineal muscles, but not affecting the anal sphincter
  • Third-degree – including the anal sphincter, but not affecting the rectal mucosa
  • Fourth-degree – including the rectal mucosa
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19
Q

Management of a perineal tear

A
  • Broad-spectrum antibiotics to reduce the risk of infection
  • Laxatives to reduce the risk of constipation and wound dehiscence
  • Physiotherapy to reduce the risk and severity of incontinence
  • Follow up to monitor for longstanding complications
  • When perineal tears are larger than first degree, sutures are required
  • 3rd or 4th degree tear will need repairing in theatre
  • If symptomatic after 3rd or 4th degree tears, an elective caesarean is offered
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20
Q

Complications of a perineal tear

A
  • Urinary incontinence
  • Anal incontinence and altered bowel habit (third and fourth-degree tears)
  • Fistula between the vagina and bowel (rare)
  • Sexual dysfunction and dyspareunia (painful sex)
  • Psychological and mental health consequences
  • Pain, infection, bleeding, wound dishiscence
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21
Q

Prevention of a perineal tear

A
  • Episiotomy: cutting the perineum, in anticipation of needing more room for a larger baby, under local anaesthetic. A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter. This is called a mediolateral episiotomy. The cut is sutured after delivery.
  • Perineal massage- massaging the area between the vagina and the anus
22
Q

Third degree perineal tear

A
  • 3a: less than 50% of EAS thickness torn
  • 3b: more than 50% of EAS thickness torn
23
Q

Retained placenta

A

Placenta that has not undergone placental expulsion within 30 minutes of the babys birth where the third stage of labour has been managed actively

Signs- infection and haemorrhage

24
Q

Categories for a retained placenta

A
  • Placenta adherens: when the uterus fails to contract enough to expel the placenta
  • Trapped placenta: when the placenta detaches from the uterus but doesn’t leave the body
  • Placenta accreta: the placenta attaches to the muscular layer of the uterine wall rather than the uterine linning
25
Q

Risk factors for a retained placenta

A
  • > 30
  • Giving birth after the 34th week of pregnancy or premature
  • Having a prolonged 1st or 2nd stage of labour
  • Stillborn baby
26
Q

Shoulder dystocia

A

After the birth of the fetal head, it’s the impaction of the fetal shoulders into the maternal bony pelvis

27
Q

Risk factors for shoulder dystocia

A
  • Raised BMI >30KG/M
  • Maternal diabetes
  • Induction of labour
  • Previous shoulder dystocia and assisted vaginal delivery
  • Fetal macrosmia (birth weight >4.5kg)
28
Q

Management of shoulder dystocia

A
  • McRoberts manoeuvre: produces a posterior pelvic lift
  • Pressure to the anterior shoulder: by pressing on the suprapubic region of the abdomen to encourage it under the pubic symphysis
  • Rubins manouevre: reaching into the vagina and putting pressure on the babies anterior shoulder to move it under the pubic symphysis
  • Episiotomy allows for better access for internal manoeuvres
  • Wood screw anoeuvre
  • Zanaelli manouvre
29
Q

Shoulder dystocia- complications

A
  • Maternal: postpartum haemorrhage, perineal tears
  • Fetal: brachial plexus injury (Erb’s palsy), neonatal death
30
Q

Shoulder dystocia- presentation

A
  • Failure of restitiution- face remains downwards (occipito-anterior) and does not turn sideways
  • Turtle-neck sign: the head is delivered but then retracts back into the vagina
31
Q

Postpartum haemorrhage

A
  • Some bleeding from the genital tract following the 3rd stage of labour routinely occurs, up to 500mls is normal.
  • Any blood loss greater than this constitutes a postpartum haemorrhage. PPH can be primary (from the time of birth, up to 24 hours after) or secondary (after 24 hours and up to six weeks following birth).
  • Blood loss >1500mls is considered a major obstetric haemorrage and therefore the relevant major haemorrhage protocol should be employed.
32
Q

There are 4 main causes of PPH- the 4 T’s

A
  • TONE – Uterine Atony (the uterus is unable to contract to arrest bleeding – this is the most common cause)
  • TISSUE – Retained products such as placenta or membranes.
  • TRAUMA – To external genitalia, vaginal wall, cervix or uterus.
  • THROMBIN – Coagulopathies (either pre existing or caused by heavy bleeding).
33
Q

Risk factors for primary PPH include

A
  • Previous PPH
  • Prolonged labour
  • Pre-eclampsia
  • Increased maternal age
  • Polyhydramnios
  • Emergency Caesarean section
  • Placenta praevia, placenta accreta
  • Macrosomia
34
Q

Management of PPH

A
  • ABC approach: two peripheral cannulas, lie the woman flat. Bloods including group and save. Commence warmed crystalloid infusion
  • Mechanical: palpate the uterine fundus and sub it to stimulate contraction. Catheterisation to prevent bladder distension and monitor urine output
35
Q

Medical management of PPH

A
  • IV oxytocin: slow IV injection followed by an IV infusion
  • Ergometrine slow IV or IM (unless there is a history of hypertension)
  • Carboprost IM (unless there is a history of asthma)
  • Misoprostol sublingual
  • Tranexamic acid
36
Q

Surgical management of PPH

A
  • Surgical options are only done when medical options fail
  • An intrauterine balloon tamponade is the first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
  • Other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
  • If severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
37
Q

Secondary PPH

A

Occurs between 24 hours - 6 weeks. It is typically due to retained placental tissue or endometritis.

38
Q

Antepartum haemorrhage

A

Bleeding from the genital tract after 24 weeks gestation

39
Q

Causes of antepartum haemorrhage

A
  • Placental abruption: complete or partial detachment of the placenta from the uterine wall.
  • Placenta praevia: placenta completely or partially covers the internal cervical os.
  • Vasa praevia: rare complication where foetal vessels run through the membranes and close to/over the cervical os.
  • Other causes: cervical ectropion/polyps, genital tract infection, carcinoma, vulval varicosities, trauma and ‘show’.
  • Uterine rupture: ruptured uterus or c/s scar.
40
Q

Antepartum haemorrhage- risk factors

A
  • Placental abruption: multips, pre-eclampsia, HELLP, hypertension, previous abruptions, smoking, trauma, cocaine use in pregnancy, maternal age, thrombophilia.
  • Placenta praevia: mulitips, previous c/s, smoking, assisted conception, maternal age, multiple pregnancy, previous TOP
  • Vasa Praevia: IVF pregnancy, low lying placenta, multiple pregnancy
  • Uterine rupture: previous c/s, malpresentation, second stage dystocia.
41
Q

Antepartum haemorrhage- clinical features/findings (placental abruption/placental praevia)

A
  • Placental abruption: abdominal pain (back pain if placenta is posterior), PV bleed (not if concealed bleed), signs of shock, a tense, “woody” abdomen, changes in foetal heart rate.
  • Placenta praevia: painless PV bleed, non-tender uterus, low-lying placenta at 20/40 USS, abnormal foetal lie/presentation. Small bleeds before large
42
Q

Antepartum haemorrhage- clinical features/findings (vasa praevi/uterine rupture)

A
  • Vasa praevia: painless PV bleed, ruptured membranes, a soft, non-tender uterus, foetal bradycardia (vasa praevia is the only APH where blood loss is directly from the foetus).
  • Uterine rupture: sudden severe abdo pain, cessation of contractions (if labouring), changes in foetal heart rate, vaginal bleeding
43
Q

Antepartum haemorrhage- investigations and management

A
  • A-E approach: abdominal palpitation, speculum examination, digital vaginal examination (avoid if suspected placental praevia) and USS
  • Bedside: BP, pulse, respiratory rate, oxygen sats, temp
  • Bloods: FBC, U&E, LFT’s, Clotting profile, group and save, crossmatch
  • CTG and doppler ultrasound: to assess the fetus
    If significant haemorrhage the baby should be delivered by caesarean

If significant haemorrhage the baby should be delivered by caesarian

44
Q

Dengue fever

A

Transmitted by female Aedes mosquitos. Four main serotypes DEN-1, 2, 3 and 4

45
Q

Dengue fever-pathophysiology

A
  1. Increased vascular permeability and plasma leakage
  2. Abnormal haemostasis which includes - capillary fragility, impaired platelet function, bone marrow suppression and coagulopathy.
  3. 3 types of dengue fever are identified based on severity – Dengue Fever, Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS). WHO now classifies the above into – dengue (DF) and severe dengue (DHF and DSS).
46
Q

Dengue fever- clinical features

A
  • Travel history
  • Abrupt onset of high grade fever which follows a remittent pattern
  • A maculopapular pinpoint rash on day 3-4
  • Severe retro-orbital and back pain
  • Generalised arthralgia and myalgia
  • Self limiting, runs a course of 5-7 days
47
Q

Dengue haemorrhagic fever- 3 phases

A
  1. Febrile phase: high fever, rash and flu symptoms
  2. Critical phase (due to plasma leak): excessive vomiting, bleeding (petechial rash, epistaxis, GI bleeding), impaired levels of consciousness, oliguria, pulmonary oedema and ascites leading to DSS characterised by shock, multi organ failure, metabolic acidosis and electrolyte imbalances. This lasts for 24 – 48 hours
  3. Convalescence phase – shift of fluid into intravascular compartment and recovery.
48
Q

Complications of dengue fever in pregnancy

A
  1. Maternal- increased risk of DHF/DSS, increased risk of miscarriage, preterm labour, APH (retro placental haematomas), PPH, puerperal sepsis, severe thrombocytopenia
  2. Foetal- Low birth weight/IUGR, foetal distress, ARDS, IUD, Trans placental transmission causes cardiac, neural and pulmonary conditions (higher risk of foetal complications in third trimester infections).
49
Q

Dengue fever- investigations

A

Tourniquets’ sign, thrombocytopenia, neutropenia, elevated haematocrit, NS1 antigen testing (detectable on day 3), ELISA testing for anti – dengue IgM, (typically detected on day 5 of illness).

50
Q

Dengue fever- management

A
  • Identify the severity of illness. Dengue fever can be managed on an outpatient basis provided information regarding red flag symptoms has been given to the mother.
  • Admission is required for suspected cases of DHF and DSS. The mainstay of treatment is fluid resuscitation.
  • Crystalloids or colloids (0.9% NaCl or Ringer’s Lactate) can be used to resuscitate the mother over 24 – 48 hours.
  • Platelet transfusion may be required if platelet count is less than 50,000. ITU admission for inotropic support maybe required in severe cases.
  • Antivirals and steroids have no role in controlling the viral illness.
51
Q

Dengue fever- considerations in pregnancy

A
  • In case of maternal or foetal compromise, an MDT decision involving the anaesthetist is required to decide time and mode of delivery.
  • Delivery (IOL/LSCS) should be avoided in critical phase. The use of tocolytics to inhibit spontaneous uterine activity should be a clinical judgement by a senior Obstetrician.
  • Active management of third stage is required to minimise the risk of PPH. Some obstetricians suggest 1 unit of PRBC transfusion even with blood loss less than 500 mls.
  • Breast feeding should be avoided until mother has fully recovered (end of convalescent phase).

Year 3- placement (34 decks)

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