Obstetrics (Intrapartum care): Abnormal pregnancy Flashcards
What is malposition?
Abnormal lie - a malposition of the foetus whilst in cephalic (vertex)
- occipito-posterior (most common)
- occipito-transverse
What are the possible RF for malposition?
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)
What is the management of occipito-posterior malposition?
No action require before 37 weeks
- Admission at 37 weeks
- CTG monitoring
- Epidural
- Fluid balance and rests
- Normal vaginal delivery - if foetus rotates to OA
- CS or forceps are often required
What is malpresentation?
All presentations of foetus that is not cephalic (vertex)
- Breech (most common)
- Transverse
- Oblique
- Unstable
What is Breech birth? what are the subtypes?
Breech birth is presentation of the foetus bum first
- Extended (frank) 70%
- Flexed (complete) 15%
- Footling (incomplete) 15%
What are the key examinations you would do for a suspected breech birth and what are the findings?
- 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 - USS - confirms diagnosis
What is the management of a Breech birth?
- 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 - 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
What are the three key things to not if attempting vaginal delivery for Breech?
Do not push until buttocks presents
Give epidural to discourage pushing until dilatation
Do not touch umbilicus
What are the complications of Breech?
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
What are the examination findings of a transverse lie foetus?
- 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 - USS - confirms diagnosis and cause
What is the management of a transverse lie?
- ECV
- often doesn’t work, foetus just flips back
- if spontaneous version > 48hrs, discharge - Admission at 37 weeks
- risk of rupture of membranes - Elective CS
- vaginal delivery is unlikely
What is the difference between Brow and Face position and how can you tell them apart clinically?
- 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 - Face - head is in full extension
- Abdo/vag exam - small 9.5cm presenting diameter; mouth, nose and eyes palpable
What is the management for (a) Brow (b) Face?
- Brow
- Watch and wait - may spontaneously become vertex
- CS if not corrected and brow persists - Face
- Vaginal delivery if chin is mento-anterior position
- CS if mento-posterior
What is the rate of twins and triplets?
Twins - 1 in 80
Triplets - 1 in 1000
What is the different types of multiple pregnancies you can have? in terms of chorionicity and amnionicity?
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
What are the initial examination findings which would suggest multiple pregnancy?
Abdominal/Vaginal exam
- Uterus large for dates at 12 weeks
- Uterus palpable before 12 weeks
- 3 or more poles palpable
What is the diagnostic confirmation of multiple pregnancy?
Early USS
- measure translucency and determine chrorionicity
- monochorionic = T sign
- dichorionic = lambda sign, widely separate, different sex, dividing membranes
What is the antenatal management of multiple pregnancy?
- Serial USS to measure growth
- 28, 32, 36 weeks - Down’s screening
- map foetal position
- combined test (nuchal trans, B-HCG, PAPP-A) at 11+0 to 13+6 wks - USS to monitor twin-twin-transfusion
- weekly from 16 weeks - HTN management
- measure BP and protein to screen for HTN disease
- aspirin 75mg OD - Folic acid and iron supplementation
- Selective reduction
- if triplets or more
- twins usually okay
What is the intra-partum management of multiple pregnancy?
- Induction of labour
- MC = 34-37wks
- DC = 37-38 wks - CTG
- high risk of hypoxia for 2nd baby - Check lie
- esp in 2nd baby, as likely to not be cephalic
- ECV if not cephalic - 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
What are the antepartum complications for (a) mother (b) foetus
A. Mother
- Gestation DM
- Pre-eclampsia and other HTN disease
- Anaemia
B. Foetus
- High Mortality and Morbidity
- Foetal loss - miscarriage
- Twin-to-Twin Transfusion:
- donor twin: volume depleted, anaemia, IUGR
- recipient twin: volume overload, polycythaemia, CV failure, polyhydramnios - Congenital abnormalities
What are the intra-partum/post-partum complications?
- Malpresentation and malposition - Breech is common
- Foetal distress
- Post-partum haemorrhage?
What are the predictors of success in VBAC?
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
What are the CI to VBAC and what is the alternative?
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)
What are the risks and benefits of VBAC?
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
