Obstetrics Flashcards
Well managed epidural analgesia benefits
Reduced material and feral acidosis
Increased uteroplacental flow
Reduction in uterine activity
Reduction in incoordinate uterine activity
1st stage labour blockade requires which nerves to be blocked
T10-L1
Second stage labour requires what nerves to be blocked
S234
What is paracervical block and why shouldn’t it be used in labour
Paracervical block is local to the lateral fornix Vagina , blocks paracervical ganglion and provides analgesia to cervix and uterus
Used in gynae procedures
Not used labour as no benefit second stage and can cause profound fatal bradycardia, LAST, Infectuon, and neuropathy
Causes of maternal death 2020
VTE commonest
Cardiac remains high as indirect cause
SUDEP worryingly high - refer anyone with nighttime or uncontrolled seizures
Other causes, sepsis, mental health, haemorrhage
Amniotic fluid embolism presents with
Refecatory hypoxaemia (cyanosis) Pulmonary hypertension Systemic hypotension Petechiae Seizures Foetal distress
PDPH when should follow up happen and for how long
OOA guidance is reviewed within 24 hours then daily, and continue until headache resolves
PDPH conservative treatment
Prolonged bed rest not recommended
Hydration
IV fluids only if oral not possible
PDPH pharmacological management
Simple analgesia
Short term opiods
Caffeine
No evidence for theophylline acth steroids triptans gabapentinoids
PDPH invasive treatments
No evidence for acupuncture occipital nerve blocks etc
Epidural saline may transiently improve ymsoykms
Epidural blood patch - when conservative therapy ineffective ans woman experiences difficulty performing activities of daily life and caring for her baby
EBP timing and steps prior
Less than 48 hours reduction in efficacy
No investigations needed prior but if stays after two or is evolving or neurology need scan
Written consent
Risks of ebp
Repeat Dural puncture
Back pain
Neurological complications
Risks of not performing EBP
Insufficient evidence but suggestion is reduction headache prevention haematoma
What level should EBP be done
Same level or one space lower
20ml
Review within 4 hours procedure
Verbal and written advice and write to GP and midwife
Pathophyisology of PDPH
CSF leak
Reduction in ICO and downward traction on pain sensitive intracranial structures
Cerebral vascular venodilation
Differential diagnosis of PDPH
Migraine CVT SUBDURAL SAH SOL Meninigitis Dehydration Caffeine withdrawal PET Tension headache Lactation headache
Features PDPH
Frontonocciputal
Better supine
Pressure over abdomen temporarily relieves pain in some
Other features include CN palsies Visual disturbabce Neck stiffness Photophobia
Prevention of PDPH
Spinal needle selection - smaller gauge and pencil point
Loss of resistance to saline
Replace stylet
? Bevel parrelel to fibres
Senior
Define pre eclampsia
New hypertension more than 140/90
Over 20 weeks pregnant
Evidence of end organ damage ie proteinuria
Initial treatment pre eclampsia
Labetalol 200mg oral or IV (incremental 50mg)
Nifedipine 10mg
Management of pre eclampsia on labour ward
Antihypertensives Limit fluids 1ml kg hr Foetal assessment Inform neonatal team Discuss with haematology Thromboprophylaxis
Ga changes for pre eclampsia
Blunt laryngoscope response with ie opiates Avoid ergomettine Low volume syntocin infusion Senior presence Hdu post operatively Avoid nsaids
Management of seizure in pre eclampsia
100% o2 left lateral Magnesium 4 gram over 5 minutes 1 gram per hour Can have further magnesium if needed Monitor for OHS and deep tension reflexes
Maternal risk factors amniotic fluid embolism
Strong uterine contractions
Uterine rupture
Multiparty
Foetal risk factors for amniotic fluid embolism
Male fetus
Polyhydraminos
Multiple pregnancy
Assisted delivery
Immune theory afe
Phase 1 foetal cells in maternal blood stream, increased levels pulmonary vasoconstrictors leading to pulmonary hypertension and RV failure
Phase 2 LV failure pulmonary oedema DIC atone haemorrhage
Other theory is mechanical
Maternal comorbidities associated with obesity
Gestational diabetes VTE Cardiomyopathy Preeclampsia OSA
Obstetric complications increased in obesity
PPH Preterm labour Instrumental delivery Induction of labour Wound infections
Patient factors contributing to difficult airway in pregnancy
Difficult face mask ventilation (increased fat stores)
Difficult laryngoscopy (oedema)
Increased reflux ( reduced lower oesophageal tone and angle of his)
Reduced FRC
Anaesthetic factors contributing to difficult airway obs
Time pressured
Altered drug dosing
Reduced exposure to obs GA
Isolated site
Obs difficult airway algorithm
- Pre induction planning and prep
RSI and consider 20cm h20 ventilation
Laryngoscopy 2+1 - Declare failed intubation
Call for help
Maintain oxygenation
SGA x2 or FMV - Declare CICO
100% oxygen
Exclude laryngospasm
FONA
Measures to minimise airway issues obs GA
Identify at risk patients Plan Position Antacids prophylaxis Video laryngoscopy Adequate paralysis Senior anaesthetist Safe extubation plan
Risk factors pre eclampsia
Nulliparity Multiple pregnancy Previous Age over 40 Bmi over 35 Fix Diabetes Hypertension Renal disease Inter pregnancy gap more than ten years
Iron deficiency in pregnancy
Who says 110
Iron def in obs increases maternal deaths
Low birth weight
Preterm labour
