Obstetrics Flashcards
Describe the airway changes in pregnancy (3)
- Engorgement and friability of the respiratory tract + mucosal oedema and capillary engorgement of nasal/OP/laryngeal - leads to increased iatrogenic trauma due I+V
- Increased weight and breast size makes laryngoscopy more difficult
- Delayed gastric emptying, increased gastric pressure + gastro-oesophageal incompetence increased risk of aspiration
1 in 250 failed airways
Describe the respiratory changes in pregnancy (4)
- Increased TV and RR secondary to increased oxygen demand
- TV increases at expense of ins. and exp. reserve volume which decrease function residual capacity
- Gravid uterus decreases use of IC muscles
- Diaphragm rises late in pregnancy (thoracostomies should be higher)
Describe circulatory changes in pregnancy (7)
- Gradual increase in SV and HR increase 10-20bpm
- Second trimester CO increased by 40%
- Steady decrease BP in 1st trimester which normal by 3rd
- SVR decreases by 30% = postural hypotension
- Increased plasma volume leads to dilutional aneamia
- Aortovacal compression by late second trimester
- Blood diverted away from uterus during haemorrhage which means up to 35% circulating volume can be lost without tachycardia
Where should IOs be sited in pregnancy?
Humeral
Which antibiotics are c/i in pregnancy?
Trimethoprim and tetracyclines (doxy)
When should NSAIDs be avoided in pregnancy?
3rd trimester
Which opiate is preferred in pregnancy?
DH118
What anti-hypertensives should be avoided in pregnancy?
Ace inhib/ ARBS
Which anti-epileptics should be avoided in pregnancy?
Sodium valporate
When are pregnant women at increased risk of aortic dissection?
3rd trimester
What is the increased risk of ACS in pregnancy?
3-4 x
What is posterior reversible encephalopathy syndrome (PRES)?
- 3rd trimester headache, with pre-eclampsia
- headaches/seizures/corticul blindness
- vasogenic brain oedema
How do you treat Posterior Reversible Encephalopathy Syndrome (PRES)? (2)
- Anti-hypertensives
- Magnesium
What is Reversible Cerebral Vasoconstriction Syndrome (RCVS)?
Post partum headache
Severe HTN and thunderclap headache
Multifocal segmental cerebral artery vasoconstriction
How do you treat Reversible Cerebral Vasoconstriction Syndrome (RCVS) ?
Nimodopine
What is HELLP syndome?
Haemolysis
Elevated Liver enzyems
Low Platelets
Which women with bleeding in pregancy should get anti-resus D and at what dose?
- All
- 250 IU if < 20 weeks
- 500 IU if > 20 weeks
What is the Kleihauer test?
Gives indication of feto-maternal haemmorhage
In gestational HTN over what value should we aim for and what value should we admit for?
- Less than 135/85
- Over 160/110
What is 1st, 2nd and 3rd line for gestational HTN?
- Labetalol PO 1st
- Nifedipine PO 2nd line
- Methyldopa PO 3rd line
What are the diagnostic criteria for pre-eclampsia?
2 of the following:
1. BP >140/90
2. Proteinurea (++ protein)
3. Oedema
What are the symptoms of pre-eclampsia? (5)
- Frontal headache
- RUQ pain
- Visual symptoms
- Oedema
- N/v
What are the signs/symptoms of severe pre-eclampsia? (6)
- Ongoing headache
- Visual schotomata
- Epigastric pain
- Oliguria
- Progressive worsening biochem
- BP >160/110
What signs suggest pre-eclamptic patients are moving towards eclampsia? (3)
- Confusion
- Tremor/twitching
- Hyper-reflexia
What is the medical management of eclampsia (3)
- 4 g Mg2+ IV 5-15 mins followed by:
- 1g/hr for 24hours
1g = 4mmol
If a patient has a further seizure whilst on treatment for eclampsia what should be done medically? (2)
- Further 2-4g IV magnesium
- Extend infusion 1g/hr for further 24hours
What anti-hypertensive should be used in eclampsia? (3)
- Labetalol (PO/IV)
- Nifedipine (PO)
- Hydralazine (IV)
What is the definitive management of eclampsia?
Delivery
What is placental abruption?
Premature separation of placenta
What are the risk factors for placental abruption? (6)
- Pre-eclampsia
- Previous abruption
- Trauma
- Smoking
- Cocaine
- Multi-parous
What can placental abruption lead to? (3)
- Concealed haemorrhage
- DIC
- Labour
What is placenta praevia?
Placenta partly/completely lies over lower uterine segment + os
What are risk factors for placenta praevia? (5)
- Over 35 years
- Increased parity
- Previous placenta praevia
- Twins
- Uterine abnormalities including previous c-section
How does placenta praevia present?
Painless, bright red bleeding in 3 rd trimester
What is the treatment of placenta praevia?
C-section
What is vasa praevia?
Abnormal fetal blood vessels attach to membranes over cervical os below presenting fetal part
How does vasa praevia present?
Rupture of membranes with massive bleeding which can lead to fetal exsanguination
What should you give a mother following delivery of baby?
Oxytocin 5U IM + ergometrine 500mcg IM (unless maternal HTN)
What is the Brandt-Andrews technique?
To remove placenta - given pull on cord whilst exerting upward pressure on uterus to prevent inversion
When should magnesium be given in pre-eclampsia?
Any of the severe features
- Ongoing or recurring severe headaches
- Visual schotomata
When does JRCALC recommend time critical transfer in imminent birth?
Failure to progress after 10 mins
When does JRCALC recommend time critical transfer in third stage of labour?
Placenta still in situ after 20 mins
How long does JRCALC recommend delaying cord clamping?
At least 60 seconds whilst assessing baby and keeping warm
What questions should we ask a pregnant patient in our history? (9)
- Number of weeks
- Single or multiple pregnancy
- Parity
- Complications (current or previous pregnancies)
- Bleeding
- Waters broken and what colour
- Safeguarding
- Midwife
- Hopsital notes
What does JRCALC define as imminent birth?
Regular contractions 1-2 mins intervals
AND one of:
- urge to push or bear down
- head visible and advancing
If birth becomes imminent during transport to hospital what should be done?
Pull over and deliver
What is ‘crowning’ ?
Visible head and doesn’t slip back between contractions
What should be done to prepare for an imminent birth? (7)
- Request additional resources
- Apply PPE
- Equipment -dry towels, maternity pack, baby hat, thermal mattress
- Set up neonatal resus area
- Advise patient adopt most comfortable position for them
- Warm room/close windows etc - ideally 25 degrees C
- Offer entonox
What does JRCALC recommend re: cord clamping
- If baby well wait until cord goes white
- If cord short and prevents back being held clamp and cut at 60 secs
- First clamp 5cm from baby and second 5cm further on.
What occurs in the first stage of labour? (3)
- Painful, regulation contractions (3-4 every 10mins)
- Cervical effacement and dilatation to 10cm
- Fetal head descends and rotates as passes down through pelvis
What occurs in second stage of labour?
- fully dilated cervix, regular contractions 1-2 mins intervals and urge to push
- baby face down initially, rotates left or right for anterior shoulder then posterior shoulder
How do the PROMPT cards describe actions for normal delivery?
- Prepare birth area
- Once crowning advise panting to slow down birth of head and protect perineum
- Support head then both and lift onto mothers abdomen
- Dry baby and assess
- Remove wet towel, new dry one and hat
- Allow cord to stop pulsing before clamping
- 2 clamps around 15cm from umbilicus and 3 cm apart
Describe the 3rd stage of labour
- delivery of placenta
- usually physiological cord lengthening, rising uterus and small gush of blood indicating placenta seperation
- can take 15-20mins
What should be done to help with third stage labour?
encourage woman to empty bladder and pushing in squatting position
Following delivery of placenta what should be done?
keep placenta for midwife or hospital
When and what uterotonics should be given by appropriately trained staff
Following birth but before cord clamping
- Syntometrine 1ml IM/IV (EEAST carry)
- Oxytocin 5IU IV / 10IU OM
When should shoulder dystocia be suspected?
If, following birth of head, rest of baby not born within 2 contractions
How should a newborn baby be assess initially (JRCALC)? (4)
- Colour
- Tone
- RR (>40)
- HR (stethoscope) - >100bpm
If either baby or mother is unwell, what should occur with respects to conveying? (4)
- Seperate DSA (compassionately explained)
- Ensure same hospital
- Place mothers ID wrist band on baby
- Do not convey unwell children in car seat
What should be expected/done differently if twins/triplets etc (5)?
- Request second and third resource (or more)
- First twin has cord cut immediately, last chid born can have delayed cord clamping
- Following first birth, placenta can deliver at any point
- Following first birth, contractions should ease and if possible should convey in this time window.
- If any of the babies need resus convey in seperate DSAs
If amniotic membrane is presenting part what should be avoided and what should be done?
- Dont burst membranes
- If unable to see presenting part behind sac then time critical conveyance
- If sac bursts and presenting part is head then can stay and prepare for birth, if anything else then time critical transfer
What should be done if a baby is born en caul?
- Pull membranes away from baby and try to tear with fingers
- If too tough to tear then use tips of scissors to make small cut
- Remove membranes from baby, clamp and cut cord and assess
- Document colour of amniotic fluid
In the JRCALC maternity decision making tool what does the following mean:
1. All greens
2. 1 amber
3. More than one amber flag
4. Any red flag
- Consider calling maternity unit and getting advice
- Convey, 15 mins obs, consider pre-alert
- Time critical transfer, 5mins obs
- Time critical transfer, 5 mins obs
How much bleeding in women <20/40 triggers JRCALC:
- amber flag
- red flag
- Maternity pad not fully soaked within 30 mins
- Maternity pad fully soaked within 30 mins
What is cord prolapse?
Not just seeing cord during deliver (common) but seeing cord and no head
How common is cord prolapse and what makes it more common?
- <1%
- Breech
What actions do the PROMPT cards suggest for cord prolapse? (6)
- Place woman immediately on all 4s, knee to chest
- Walk them to ambulance (avoid carry chair if possible)
- On DSA place on side with pillows under hips to raise pelvis above head (right side allows for reassurance)
- If possible use catheter to fill bladder with 500ml normal saline to raise presenting part
- Entonox to decrease urge to push
- Minimal handling of cord - 1 gentle attempt. If not cover with dry padding and use underwear to keep in place
What percentage of births are breach?
3-4%
What is a breach birth and what are the 3 types?
Presenting part not head
- Frank - buttocks present with knees extended
- Flexed - as buttocks present with knees flexed
- Footling- feet present
Why is minimal handling advised in breach deliveries?
Startle reflex can lead to extension of arms/neck and make situation worse
What do the PROMPT cards recommend for breach delivery? (3)
- Mother to end of bed with legs supported or sit edge of bed/chair or all 4s position
- Baby should be ‘tum to bum’ whatever position mum is in - only place hands on baby to correct this (use hips to rotate not abdomen)
- Once nape of neck allow slow spontaneous birth of head
What maneuver should be performed in breech delivery if there is a delay caused by:
1. Legs
2. Arms
3. Head
- Pinards maneuver = if extended then gentle pressure on popliteal fossa to flex knee
- Loveset maneuver = hold bony pelvis and rotate infant 90 degrees in each direction.
- Can also use 2 fingers to sweep arms off face and downwards to aid delivery - Mauriceau-Smellie-Velt maneuver =
- assistent provides suprapubic pressure
- support baby with arm and place left hand into vagina along anterior infant + place pressure on cheekbones with index and middle fingers to flex head
- right hand provides gentle traction on shoulders using 2 fingers to flex occiput
What is Pinard maneuver and what is it for?
Delay to delivery in breech babies due to legs being stuck
= if extended then gentle pressure on popliteal fossa to flex knee
What is the Loveset maneuver and what is it used for?
Delay to delivery in breech babies due to arm being stuck
= Hold bony pelvis and rotate infant 90 degrees in each direction.
- Can also use 2 fingers to sweep arms off face and downwards to aid delivery
What is the Mauriceau-Smellie-Velt maneuver and what is it used for?
For breech babies delayed due to failure to deliver head
= assistant provides suprapubic pressure
- support baby with arm and place left hand into vagina along anterior infant + place pressure on cheekbones with index and middle fingers to flex head
- right hand provides gentle traction on shoulders using 2 fingers to flex occiput
When does JRCALC advise to leave scene immediately in the event of breach delivery? (3)
- Buttocks not visible or not advancing
- Footling breech
- Hand or arm presenting but buttocks not immediately visible
Once the buttocks have been delivered in a breech delivery what should occur according to JRCALC?
- Start clock (should be fully born <5mins)
- Women should push continously from this point (do not wait for contractions) as hypoxia increases as baby descends further down birth canal.
When does JRCALC recommend handling baby/maneuvers ? (3)
- Part of baby that is born is not well perfused and has no movement or tone
- White/empty umbilical cord
- No movement/absent tone
If needing to convey a women with breech delivery, how should this be done?
- walk to DSA (towel or sling if some parts of baby exposed)
- lie on side with folded pillow (or similar) between legs to reduce pressure on presenting parts
How common is shoulder dystocia?
1% deliveries
How common is:
1. Cord prolapse
2. Breech delivery
3. Shoulder dystocia
- <1%
- 3-4%
- 1%
What is shoulder dystocia?
Bony impaction of anterior shoulder o symphysis pubis
When should shoulder dystocia be suspected? (2)
- Following second contraction after birth of head (gentle axial traction applied for second contraction)
- Turtles sign - head retracts into vagina
What are the 5 steps that PROMPT suggest trying in shoulder dystocia in order?
- McRoberts position
- Gentle axial traction
- Suprapubic pressure
- All 4s position
- Walk to DSA
Describe McRoberts position and what it is for
Shoulder dystocia
- lie flat and bottom to end of bed
- knees to chest, thighs to abdomen
- 1 person supporting each leg
Describe the suprapubic pressure in shoulder dystocia
- CPR hands above symphysis pubis and pish on same side as fetal back in downwards and lateral direction
- aims to move shoulder under pubic arch
How should the all 4 positions be used to help shoulder dysocia? (4)
- All 4s with hips well flexed
- Any movement of pelvis can release shoulder
- Mum should continue to push
- Consider gentle axial traction
How should women with shoulder dystocia needing to be conveyed be so?
- Walk to DSA - may lead to birth
- Keep on side with pillow under hips
In shoulder dystocia how should axial traction be applied?
Gently and keeping head in line with spine - do not pull down or laterally
What is the definition of PPH?
> 500ml blood loss following the second stage of labour
What is primary and secondary PPH?
- <24 hours
- 24hour to 6 weeks
What is a massive PPH?
> 50% blood volume within 3 hours birth
What are the 4 T’s of PPH?
Tone (>common, no contraction following birth, ‘boggy’ uterus)
Trauma (perineal/vaginal/cervical)
Tissue (retained products stops uterus contracting)
Thrombin (clot abnormalities)
How should PPH be managed? (5)
- Examination including palpation uterus and external genitalia for tears
- Uterotonics
- syntometrine 11ml IM (if no HTN)
- Misoprostol 800mcg PR
- Oxytocin 5IU IV (can be repeated once) or 10IU IM - If placenta delivery then massage uterus fundus (find top of uterus uterus and cup between to hands and massage). If not delivered cautious as can lead to partial seperation of placenta (on do if life threatening)
- TXA
- Bimanual compression (gloved hand pressure anterior vaginal wall, second hand on abdomen pushing down on posterior wall compressing uterus between them.
How can uterine inversion be caused? (2)
- Spontaenous
- Uncontrolled traction of cord during 3rd stage
How does uterine inversion present? (3)
- Severe abdominal pain
- Uterus not palpable at umbilicus
- Severe PPH +/- vaginally mediated shock
How should uterine inversion be managed?
If visible place gently back into vagina and keep patient flat
If maternal cardiac arrest, aside from RH, what else should be done differently? (8)
- Uterine displacement (pull don’t push)
- Early ETT
- Decompress stomach
- Binder use okay
- Thoracostomies 1-2 rib space higher
- Hand position should may need to be 2-3cm higher in late pregnancy
- May need ETT 0.5-1.0mm smaller due to oedema
- IO should be humeral
Following RH - what should be immediate actions in terms of mother? (4)
- Following cord clamping give uterotonics
- Remove placenta with ‘scooping’ hand (if possible)
- May need to manually compress uterus as will likely be atonic
- Pack with celox/gauze as needed
How should an episiotomy be performed?
Mediolateral
Incision 45 degrees and start off midle
What is the blood loss estimation for:
1. Tampon soaked
2. Inco pad
3. Vomit bowl
4. Bed pan
5. Kidney dish
6. PPH bed
7. PPH bed and floor
- 100ml
- 250ml
- 300ml
- 500ml
- 600ml
- 1L
- 2L
What is the dose of:
1. oxytocin
2. ergometrine
3. syntometrine
4. misoprostol
- 10IU IV or IM (or 5IU IV followed by second if needs)
- 0.25mg and repeat up to 1mg
- Ergometrine 0.5mg and 5IU oxytocin
- 800mcg SL/PR
When should ergometrine/syntometrine be avoided? (2)
- Not if retained placenta as may delay expulsion (give if bleeding ++)
- High BP
When is oxytocin c/i and why?
Cardiac disease because it decreases SVR and BP leading to drop in CO
When are all uterotonics c/i?
If another fetus suspected in uterus
How should a uterus be assessed following delivery if PPH?
- palpate abdomen and feel for top of uterus (fundus)
- assess for height - if below umbilicus then tone likely to be good
- assess tone, should be hard like a cricket ball
If unable to feel this hard/central structure then assume poor tone and commence uterine massage (cupped hand in circular motion). Should feel uterus become firm.
When can pre-eclampsia present from?
24-28/40 but can be from 20/40
What are risk factors for pre-eclampisa? (10)
- first child (or first with new partner)
- Previous severe pre-eclampsia
- HTN
- Diabetes
- Obesity
- Twins or higher
- Rena disease
- Maternal age >35yrs
- Young maternal age <16yrs
- Pre-existing CV disease
When does JRCALC recommend urgent transfer to consultant led obstetric unit in terms of HTN/pre-eclampsia? (2)
- BP >140SBP or >90DBP on TWO occasions in labour or immediately after birth
- BP of 150/100 in pregnancy/labour or immediately after birth
When and what doe JRCALC recommend for an eclamptic seizure?
Seizure of 2-3 mins
IV diazepam if no IV magnesium available
What is the definition of miscarriage?
Spontaneous loss of pregnancy before the baby reaches 24 weeks
When can an ambulance clinician confirm a miscarriage (JRCALC?)
Observe a deceased baby delivered and patient has a scan confirmed 1 pregnancy
or: hospital confirmed US scan confirming non-viable
What are the red flags according to JRCALC for bleeding <20/40? (5)
- Shock
- Maternity pad soaked within 30 mins (approx 50mls)
- Total blood loss >500mls
- Signs/symptoms suggestive of cervical shock (brady/shock without lots of bleeding)
- Signs ectopic
What does JRCALC recommend in confirmed miscarriage and excessive bleeding?
- UterOtonics
- TXA
What does the FPHC consensus statement recommend with respects to airway in pregnancy? (4)
- NP relatively c/i due to increased friability of mucosa in pregnancy
- Use smaller ETT due to swelling
- Use second generation SGA
- Use vertical incision for front of neck as increased tissue oedema seen in pregnancy makes landmarking more challenging
What does FPHC recommend for pregnancy trauma patients with respects to breathing? (2)
- High flow oxygen in all trauma patients
- Thoracostomies/chest drains should be 3rd or 4th IC space
What does FPHC recommend with respects to circulation in pregnant trauma patients? (7)
- Limited reliance on BP as marker of hypovolaemia
- Examination of uterus and external genitalia mandatory in evaluation of haemorrhage
- Tilt/manual displacement recommended at all times for pregnant trauma patients
- IV access above diaphragm
- Early blood products as fluid will exacerbate pre-existing haemodilution that occurs in pregnancy
- TXA
- Pelvic binders
What does FPHC recommend in pregnant patients being resusitated? (2)
- Supine with manual displacement of uterus
- RH within 15mins of witnessed arrest with ongoing CPR
What does FPHC recommend for all pregnant trauma patients in terms of conveyance/destination? (3)
- All trauma patients should be seen in the ED not maternity
- If >20/40 should go to nearest TU with maternitry (if trauma negative) or MTC with maternity (if positive). If <20/40 can go to hospital without maternity
- All MTCs should have co-located obstetrics
What percentage of booked deliveries are end up being emergency pre-hospital deliveries?
< 1%
How common is PPH?
10% of all deliveries
