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Post-Partum Issues Flashcards

1
Q

What is shoulder dystocia

A

Anterior shoulder can’t pass below pubic symphysis after head delivered

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2
Q

What are the consequences of shoulder dystocia for mother and baby

A 
Umbilical cord entrapment 
Chest can't expand
Hypoxia 
Brain damage due to hypoxia 
Brachial plexus damage - Erbs'
Fractured clavicle 
Tears 
PPH
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3
Q

RF for shoulder dystocia

A 
Macrosomia 
Higher BMI
DM 
Induced labour 
Previous shoulder dystocia
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4
Q

How do you manage shoulder dystocia?

A

HELP
Help
Evaluate for epiostomy (easier for internal manoeuvre)
Legs in McRobert - hyperflex legs to abdomen
Suprapubic pressure
Enter manoeuvre - internal rotation posterior shoulder (Wood sew)
Remove posterior arm
Role patient onto all 4’s

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5
Q

What is the moueuvre known as

A

Wood screw

Internal rotation of posterior shoulder

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6
Q

What happens if fails

A

Symphiostomy

Zavenlli - high mortality

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7
Q

What increases risk of brachial plexus damage

A

Forceps

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8
Q

What is cord prolapse

A

Descent of umbilical cord through cervix alongside (occult) or past (overt)
In presence of ruptured membrane

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9
Q

What are signs of cord prolapse

A

Non reassuring foetal HR (variable deceleration)
Fetal Brady = suggestive
Ruptured membranes
Visible or palpable cord on VE

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10
Q

What are major RF for cord prolapse

A 
Breech - reduced as C-section advised 
Abnormal lie 
Polyhydramnios
Artificial rupture when foetus is high
High fetal station
Long umbilical cord
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11
Q

What are minor RF

A 
Multiparity
LBW 
Cephaic disproportion
Unengaged
Low lying placenta or praevia
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12
Q

What do you do for cord prolapse

A 
HELP
Replace cord into vagina
Push foetus back into uterus 
Digital elevation of presenting part 
Catheterise and fill bladder
Knee- chest or left lateral whilst someone elevates
Tocolysis
C-section
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13
Q

What do you not do

A

Replace cord into uterus

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14
Q

What are complications of cord prolapse

A

Cord spasm
Hypoxia
CO2 accumulation
Acidosis

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15
Q

What is primary PPH

A

Blood loss >500ml within 24 hours of delivery of the baby
>1000 = severe

Uterine atony = most common cause

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16
Q

What is secondary PPH

A

Blood loss >500ml from 24 hours - 12 weeks

Commonly 5-12 days

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17
Q

What are 4 causes of PPH

A

Thrombin
Tissue
Tone
Trauma

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18
Q

What are thrombin causes of PPH

A 
Bleeding disorders - vWF 
Anti-coagulant 
Pre-eclampsia
DIC
HELLP 
Anaemia
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19
Q

What are tissues causes of PPH

A

ROPC
Placenta accreta
Placenta praevia
Placenta abruption

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20
Q

What are tone causes of PPH

A 
ATONY = 90% so uterus fails to contract
Overdistension - multiple pregnancy / macrosomia / polyhydramnios
Uterine relaxants 
Anaesthesia
Tocolysis 
Induction of labour
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21
Q

What are trauma causes of PPH

A

CS
Instrumental delivery
Epiostomy
Tears

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22
Q

What are secondary causes of PPH

A

Infection - endometritis
RPOC
Tears
Trauma

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23
Q

If uterus not contracted when you feel it what does it suggest

A

Atony

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24
Q

What are RF for PPH

A 
All of above causes 
Age 
Multiparity 
Previous PPH  
Previous RPOC 
Induced labour - oxytocin use
Tocolysis 
Prolonged labour 
Oxytocin use 
High BMI
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25
How do you monitor PPH / how do you prevent
BP every hour Temp Abdo exam for uterine tone Pad soakage / bloods Prevention - Empty bladder as full will prevent contraction - Treat anaemia prior - Oxytocin in 3rd stage to contract - Tranexamic acid during C-section
26
What do you do for secondary PPH
``` FBC Blood culture if pyrexia MSSU High vaginal swab USS to look for RPOC ```
27
What do you do for PPH 1
``` HELP - senior ABCDE IV access - 2 wide bore cannula 14G Fluid resus - 3l crystalloid / colloid Get uterus to contract Blood - 4 units Oxygen Catheter to empty bladder Uterine compression / fundal massage to encourage ACTIVATE MAJOR HAEMORRHAGE ```
28
What do you do once stable
Cord traction Tranexamic acid - fibrinolytic Manual removal of placenta
29
How do you get the uterus to contract
``` IV syntocin or syntometrine = 1st line Can give 2 times IV ergometrine = 2nd line IM carboprost = prostaglandin for contraction PR Misoprostol = prostaglandin THEATRE Intrauterine balloon if atony = 1st line surgical Rx Other surgical ```
30
When is ergometrine CI
Hypertension
31
When is misoprostol CI
Asthmatic due to risk of bronchospasm
32
What do you do for PPH 2 or PPH 1 not controlled by medical
``` Intrauterine balloon = 1st line if pharmacology fails Interventional radiology EUA and manual evacuation B-lynch suture Ligatation of uterine / iliac vessels ```
33
What do you do if won't stop bleeding
Hysterectomy
34
Massive haemorrhage
2222
35
Who is at risk of tears
Prim Large baby Shoulder dystocia Forceps
36
How do you Dx and how do you grade
``` VE + PR 1st degree = labia and superficial skin 2nd degree = above + perineal muscles 3rd degree = above + anal sphincter 4th = above + rectal mucosa ```
37
How do you treat
Epiostomy to prevent under LA - avoids damaging anal sphincter Suture Follow up
38
Risk of tears
Bowel / bladder issues | Bleeding / infection / haematoma/ breakdown
39
What is leading cause of maternal death
Sepsis
40
What is likely if pyrexia in labour
Chorioamnionitis | Requires fast delivery
41
What are common organisms of sepsis
Group B strep E.coli Group A
42
How does sepsis present
``` Atypical Pyrexia spike Rigors Diarrhoea or vomiting Rash Abdominal or pelvic pain Offensive discharge Urinary Sx ```
43
What does rash suggest
TSS
44
What are the RF for sepsis in mother
``` Obesity DM Immunosuppressed Pelvic infection Hx group B strep Invasive procedures Prolonged rupture membranes >24 hours Anaemia ```
45
How do you Dx sepsis
``` Blood / urine culture Vaginal swab O2 sats CRP NOT ESR FBC, U+E, LFT, clotting, lactate, ABG ```
46
What must you monitor continuous in sepsis
CTG
47
How do you treat sepsis
``` IV Ax - broad O2 Anti-pyretic to get temp down Deliver if can't IV fluid if hypotension or high lactate Vasopressor if BP doesn't respond DELIVERY Stabilise mother first if NOT intrauterine ```
48
What Ax
Benpen if in labour as group B strep | Vanc if allergy
49
Why is a high temp dangerous for baby
Susceptible to hypoxia Encephalopathy Cerebral palsy Blood sampling inaccurate due to tachy
50
What is CI if temp
Spinal and epidural
51
Why is VTE more likely in pregnancy
``` Hypercoagulable state Increase in fibrinogen / VII / VWF Decrease natural anti-coagulants Progestogen = muscle relaxant so stasis Vascular damage after surgery Immobilisation following anaesthetic / C-section ```
52
What should you have a high suspicion of in a collapsed pregnant women
PE | More common than epilepsy
53
What are obstetric RF of VTE
``` Multiple pregnancy PET C-section Long labour Still birth Pre-term PPH Hyperemesis due to dehydration IVF ```
54
Other RF
``` Age Obesity Smoking OCP Travel IVDA Dehydration Decreased mobility Surgery Previous VTE Inherited Thrombophilia - Factor V Leiden / Sickle cell Malignancy FH Vascular disease DM Nephrotic / cardiac Trauma ```
55
How do you deal with VTE risk
Assess risk at booking Antenatal, labour and post FBC, U+E, LFT, clotting Leg doppler if suspected DVT
56
How do you treat
Same as cardio
57
How do you monitor
Not routine If obesity / recurrent / renal = monitor anti-Xa activity APTT if unfractioned heparin
58
How do you prevent VTE
TED stockings prophylaxis | Increase mobility and hydration
59
What do you do if there is 3+ RF or previous VTE as prophylaxis
Prophylactic anti-coagulation LMWH - Dalteparin Continue until 6 weeks post partum 3 months if before delivery
60
How do you treat VTE
LMWH - Dalteparin if DVT confirmed before scan Consider switching to warfarin post delivery but CI in pregnancy Require LMWH next pregnancy
61
What is CI in pregnancy
DAOC | Warfarin
62
What do you do in labour
Stop LMWH | Avoid regional anaesthesia until 24 hours after last dose of LMWH
63
What do you do if massive PE
Thrombolysis | Percutaneous catheter
64
What are other differentials for PE
Aortic dissection Mitral stenosis Amniotic fluid embolism
65
What are symptoms of amniotic emboli
``` Post rupture Sweating Anxiety Cough CYanosis Hypotension Tachycardia Arrythmia MI Coagulopathy Cardio-respiratory arrest Neuro ```
66
What is the most common cardiac problem in pregnancy
Mitral stenosis
67
What are the symptoms
``` SOB Chest pain Tachycardia Hypertension Low sats Diastolic murmur Pulmonary oedema AF as enlarged aorta ```
68
What are the RF for MS
Rheumatic fever | Valve surgery
69
How do you treat MS
Balloon valvuloplasty
70
What are the complications of MS
Sudden deterioration | Resp arrest
71
What are the symptoms of aortic dissection
``` Sudden chest pain Loss of consciousness Syncope Hypertension Aortic regurg Cold Clammy Diff pulse pressure Radial radial delay - before subclavian Radial femoral - after subclavian Absent subclavian ```
72
What puts you at risk of aortic dissection
Marfan | Biscuspid valve
73
How do you Dx
CT | 20mmhg diff pulse pressure
74
How do you treat
<28 weeks = repair | >32 = C-section followed by aortic repair
75
If RCA involved
MI - inferior
76
What are the baby blues
``` 1-3 post natal Lasts usually <10 days Normal due to hormonal changes No functional affect Rx = monitor ```
77
What is post natal depression
Classic depressive symptoms that affects bonding and functioning 10% within 3-6 months Usually within first month Lasts >2 weeks
78
How do you treat post natal depression
Reassure CBT SSRI
79
What should you avoid
Fluoxetine as long half life
80
What puts you at risk
Personal or FH
81
What do you use to screen
Edinburgh Depression Scale | Check thyroid
82
How do you treat peurperal psychosis
``` Peri-natal mental health team Inpatient / admission Anti-psychotic 2-3 weeks Severe mood swings + auditory hallucination Manic depression Schizphrenia ```
83
What is damaging to baby
Anti-psychotic | Benzo's - Diazepam
84
How does Erb's Palsy present
``` Upper plexus Water tip position Shoulder = Adduction + internal rotation Elbow = extended and pronated Wrist = flexed ```
85
Complications PPH
Shock Death Sheehan - lack of milk / amenorrhoea
86
What does Tranexamic acid do
Anti-fibrinolytic | Binds to receptor on plasminogen or plasmin and prevents degradation of fibrin
87
When is it used
Menorrhagia common Role in major haemorrhage Prophylaxis in C-section
88
When would you investigate lochia further with USS further
If persist >6 weeks
89
What happens at 6 week post partum check
``` General well being Mood Bleeding Scar healing Contraception Breast feeding Fasting BG if gestational BP Urine dip ```
90
What can Sheehan cause
Amenorrhoea - lack of LH / FSH Reduced lactation- lack of prolacitn Adrenal insufficiency - lack of ACTH Hypothyroid - lack of TSH
91
How does RPOC present after C-section
Pain Vaginal bleeding / discharge Boggy poorly contracted uterus
92
What do you do
EUA to remove if >1 day Can do scan before to confirm and speculum to see if os open or closed IV Ax wil be needed
93
If temperature in first 14 days of delivery what is this
Peurpeural pyrexia
94
What is needed
Admission for IV Ax if suspect endometritis
95
What is likely cause
``` Endometritis = most common UTI Wound Mastitis VTE ```

Obs & Gynae (23 decks)

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