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GOSH > Obstetrics (Intrapartum care): Abnormal pregnancy > Flashcards

Obstetrics (Intrapartum care): Abnormal pregnancy Flashcards

1
Q

What is malposition?

A

Abnormal lie - a malposition of the foetus whilst in cephalic (vertex)

  • occipito-posterior (most common)
  • occipito-transverse
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2
Q

What are the possible RF for malposition?

A

Too much room to move - polyhydramnios, multiparty
Too little room to move - placenta praaevia, pelvic obstruction, twins, uterine or foetal abn.
Others - flat sacrum, poorly flexed head, weak uterine contractions (not enough power to cause head to rotate on pelvis)

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3
Q

What is the management of occipito-posterior malposition?

A

No action require before 37 weeks

  1. Admission at 37 weeks
  2. CTG monitoring
  3. Epidural
  4. Fluid balance and rests
  5. Normal vaginal delivery - if foetus rotates to OA
  6. CS or forceps are often required
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4
Q

What is malpresentation?

A

All presentations of foetus that is not cephalic (vertex)

  • Breech (most common)
  • Transverse
  • Oblique
  • Unstable
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5
Q

What is Breech birth? what are the subtypes?

A

Breech birth is presentation of the foetus bum first

  • Extended (frank) 70%
  • Flexed (complete) 15%
  • Footling (incomplete) 15%
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6
Q

What are the key examinations you would do for a suspected breech birth and what are the findings?

A
  1. Abdominal/Vaginal exam
    - Subcostal pain (upper abdomen)
    - Head felt at the fundus
    - Foetal HR heard loudest above umbilicus
    - Soft mass felt in pelvis
    - Buttocks, leg or sacrum felt at pelvic inlet
  2. USS - confirms diagnosis
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7
Q

What is the management of a Breech birth?

A
  1. ECV - external cephalic version
    - USS first to confirm position
    - Forward roll technique to move foetus into normal cephalic position
    - Anti-D for Rh-ve mothers
    - Tocolytics (terbutaline or nifedipine) to relax uterus - improves success
  2. Delivery
    a. Vaginal (not common) - criteria includes: foetal weight < 4kg, extended breech, non-extended neck, foetus not compromised, spontaneous onset of labour
    b. CS (common) - if ECV failed and vaginal delivery not appropriate
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8
Q

What are the three key things to not if attempting vaginal delivery for Breech?

A

Do not push until buttocks presents
Give epidural to discourage pushing until dilatation
Do not touch umbilicus

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9
Q

What are the complications of Breech?

A

High mortality and morbidity

  • Cord prolapse
  • Trauma - Erb’s palsy (brachial plexus)
  • Developmental dysplasia of hip - USS at 36 weeks for all breech
  • Pre-term labour
  • Hypoxia or Asphyxia due to cord compression
  • Intracranial haemorrhage
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10
Q

What are the examination findings of a transverse lie foetus?

A
  1. Abdominal/Vaginal exam
    - Maternal abdomen wide
    - Fundus much lower than expected
    - Head can be felt at lateral side of abdomen
    - Neither foetal pole is palpable at pelvic inlet
    - Pelvis empty (on vaginal exam)
    - Cord prolapse following rupture of membranes
  2. USS - confirms diagnosis and cause
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11
Q

What is the management of a transverse lie?

A
  1. ECV
    - often doesn’t work, foetus just flips back
    - if spontaneous version > 48hrs, discharge
  2. Admission at 37 weeks
    - risk of rupture of membranes
  3. Elective CS
    - vaginal delivery is unlikely
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12
Q

What is the difference between Brow and Face position and how can you tell them apart clinically?

A
  1. Brow - head occupies position somewhere between full extension (face) and full flexion (vertex)
    - Abdo/vag exam - large 13.5cm presenting diameter; ant fontanelle, supra-orbital grooves and nose felt
  2. Face - head is in full extension
    - Abdo/vag exam - small 9.5cm presenting diameter; mouth, nose and eyes palpable
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13
Q

What is the management for (a) Brow (b) Face?

A
  1. Brow
    - Watch and wait - may spontaneously become vertex
    - CS if not corrected and brow persists
  2. Face
    - Vaginal delivery if chin is mento-anterior position
    - CS if mento-posterior
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14
Q

What is the rate of twins and triplets?

A

Twins - 1 in 80

Triplets - 1 in 1000

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15
Q

What is the different types of multiple pregnancies you can have? in terms of chorionicity and amnionicity?

A

DCDA - split at 3d (separate placenta and amnion)
MCDA - split at 4-8d (same placenta, separate amnion)
MCMA - late split at 9-14d (same placenta + amnion)
Conjoined - incomplete split

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16
Q

What are the initial examination findings which would suggest multiple pregnancy?

A

Abdominal/Vaginal exam

  • Uterus large for dates at 12 weeks
  • Uterus palpable before 12 weeks
  • 3 or more poles palpable
17
Q

What is the diagnostic confirmation of multiple pregnancy?

A

Early USS

  • measure translucency and determine chrorionicity
  • monochorionic = T sign
  • dichorionic = lambda sign, widely separate, different sex, dividing membranes
18
Q

What is the antenatal management of multiple pregnancy?

A
  1. Serial USS to measure growth
    - 28, 32, 36 weeks
  2. Down’s screening
    - map foetal position
    - combined test (nuchal trans, B-HCG, PAPP-A) at 11+0 to 13+6 wks
  3. USS to monitor twin-twin-transfusion
    - weekly from 16 weeks
  4. HTN management
    - measure BP and protein to screen for HTN disease
    - aspirin 75mg OD
  5. Folic acid and iron supplementation
  6. Selective reduction
    - if triplets or more
    - twins usually okay
19
Q

What is the intra-partum management of multiple pregnancy?

A
  1. Induction of labour
    - MC = 34-37wks
    - DC = 37-38 wks
  2. CTG
    - high risk of hypoxia for 2nd baby
  3. Check lie
    - esp in 2nd baby, as likely to not be cephalic
    - ECV if not cephalic
  4. Oxytocin
    - labour not particularly prolonged but uterine contractions may decrease

5a. Elective CS (common)
5b. Vaginal delivery possible (but rare)
6. Oxytocin to prevent PPH

20
Q

What are the antepartum complications for (a) mother (b) foetus

A

A. Mother

  1. Gestation DM
  2. Pre-eclampsia and other HTN disease
  3. Anaemia

B. Foetus

  1. High Mortality and Morbidity
  2. Foetal loss - miscarriage
  3. Twin-to-Twin Transfusion:
    - donor twin: volume depleted, anaemia, IUGR
    - recipient twin: volume overload, polycythaemia, CV failure, polyhydramnios
  4. Congenital abnormalities
21
Q

What are the intra-partum/post-partum complications?

A
  1. Malpresentation and malposition - Breech is common
  2. Foetal distress
  3. Post-partum haemorrhage?
22
Q

What are the predictors of success in VBAC?

A 
Low maternal BMI and age 
Previous CS was elective 
Singleton 
Small foetus 
Inter-pregnancy interval < 2 years 
Previous normal vaginal delivery 
Spontaneous labour 
Engagement of head 
Caucasian
23
Q

What are the CI to VBAC and what is the alternative?

A

Multiple repeat CS i.e. > 2
Previous uterine rupture
Previous vertical uterine scar - classic CS
Placenta praaevia or pelvic inlet obstruction

Alternative is a elective repeat CS (ERCS)

24
Q

What are the risks and benefits of VBAC?

A

Benefits:

  • 70% successful VBAC
  • Fewer overall complications
  • low perinatal death

Risks:

  • Uterine rupture (1 in 200) due to previous scar tear, further increased risk if IOL of prostaglandins and oxytocin
  • Infection
  • Blood transfusion
25
Q

What are the risks and benefits of ERCS?

A

Benefits:
- low perinatal death

Risks:

  • Placenta praevia ± accreta
  • Pelvic adhesions
  • Neonatal respiratory morbidity
26
Q

What are the features of uterine rupture and how can it be managed?

A 
Features: 
Pain + tenderness of uterus 
Vaginal bleeding 
Maternal increased HR and shock 
Uterine contractions halt 
Foetal distress 
Management: 
100% O2 via NRBM 
Tranexamic acid 
Blood transfusion if required 
Prophylactic Abx 
Emergency CS

GOSH (14 decks)

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