Post-Partum Issues Flashcards
What is shoulder dystocia
Anterior shoulder can’t pass below pubic symphysis after head delivered
What are the consequences of shoulder dystocia for mother and baby
Umbilical cord entrapment Chest can't expand Hypoxia Brain damage due to hypoxia Brachial plexus damage - Erbs' Fractured clavicle Tears PPH
RF for shoulder dystocia
Macrosomia Higher BMI DM Induced labour Previous shoulder dystocia
How do you manage shoulder dystocia?
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
What is the moueuvre known as
Wood screw
Internal rotation of posterior shoulder
What happens if fails
Symphiostomy
Zavenlli - high mortality
What increases risk of brachial plexus damage
Forceps
What is cord prolapse
Descent of umbilical cord through cervix alongside (occult) or past (overt)
In presence of ruptured membrane
What are signs of cord prolapse
Non reassuring foetal HR (variable deceleration)
Fetal Brady = suggestive
Ruptured membranes
Visible or palpable cord on VE
What are major RF for cord prolapse
Breech - reduced as C-section advised Abnormal lie Polyhydramnios Artificial rupture when foetus is high High fetal station Long umbilical cord
What are minor RF
Multiparity LBW Cephaic disproportion Unengaged Low lying placenta or praevia
What do you do for cord prolapse
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
What do you not do
Replace cord into uterus
What are complications of cord prolapse
Cord spasm
Hypoxia
CO2 accumulation
Acidosis
What is primary PPH
Blood loss >500ml within 24 hours of delivery of the baby
>1000 = severe
Uterine atony = most common cause
What is secondary PPH
Blood loss >500ml from 24 hours - 12 weeks
Commonly 5-12 days
What are 4 causes of PPH
Thrombin
Tissue
Tone
Trauma
What are thrombin causes of PPH
Bleeding disorders - vWF Anti-coagulant Pre-eclampsia DIC HELLP Anaemia
What are tissues causes of PPH
ROPC
Placenta accreta
Placenta praevia
Placenta abruption
What are tone causes of PPH
ATONY = 90% so uterus fails to contract Overdistension - multiple pregnancy / macrosomia / polyhydramnios Uterine relaxants Anaesthesia Tocolysis Induction of labour
What are trauma causes of PPH
CS
Instrumental delivery
Epiostomy
Tears
What are secondary causes of PPH
Infection - endometritis
RPOC
Tears
Trauma
If uterus not contracted when you feel it what does it suggest
Atony
What are RF for PPH
All of above causes Age Multiparity Previous PPH Previous RPOC Induced labour - oxytocin use Tocolysis Prolonged labour Oxytocin use High BMI
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
What do you do for secondary PPH
FBC Blood culture if pyrexia MSSU High vaginal swab USS to look for RPOC
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
What do you do once stable
Cord traction
Tranexamic acid - fibrinolytic
Manual removal of placenta
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
When is ergometrine CI
Hypertension
When is misoprostol CI
Asthmatic due to risk of bronchospasm
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
What do you do if won’t stop bleeding
Hysterectomy
Massive haemorrhage
2222
Who is at risk of tears
Prim
Large baby
Shoulder dystocia
Forceps
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
How do you treat
Epiostomy to prevent under LA - avoids damaging anal sphincter
Suture
Follow up
Risk of tears
Bowel / bladder issues
Bleeding / infection / haematoma/ breakdown
What is leading cause of maternal death
Sepsis
What is likely if pyrexia in labour
Chorioamnionitis
Requires fast delivery
What are common organisms of sepsis
Group B strep
E.coli
Group A
How does sepsis present
Atypical Pyrexia spike Rigors Diarrhoea or vomiting Rash Abdominal or pelvic pain Offensive discharge Urinary Sx
What does rash suggest
TSS
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
How do you Dx sepsis
Blood / urine culture Vaginal swab O2 sats CRP NOT ESR FBC, U+E, LFT, clotting, lactate, ABG
What must you monitor continuous in sepsis
CTG
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
What Ax
Benpen if in labour as group B strep
Vanc if allergy
Why is a high temp dangerous for baby
Susceptible to hypoxia
Encephalopathy
Cerebral palsy
Blood sampling inaccurate due to tachy
What is CI if temp
Spinal and epidural
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
What should you have a high suspicion of in a collapsed pregnant women
PE
More common than epilepsy
What are obstetric RF of VTE
Multiple pregnancy PET C-section Long labour Still birth Pre-term PPH Hyperemesis due to dehydration IVF
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
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
How do you treat
Same as cardio
How do you monitor
Not routine
If obesity / recurrent / renal = monitor anti-Xa activity
APTT if unfractioned heparin
How do you prevent VTE
TED stockings prophylaxis
Increase mobility and hydration
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
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
What is CI in pregnancy
DAOC
Warfarin
What do you do in labour
Stop LMWH
Avoid regional anaesthesia until 24 hours after last dose of LMWH
What do you do if massive PE
Thrombolysis
Percutaneous catheter
What are other differentials for PE
Aortic dissection
Mitral stenosis
Amniotic fluid embolism
What are symptoms of amniotic emboli
Post rupture Sweating Anxiety Cough CYanosis Hypotension Tachycardia Arrythmia MI Coagulopathy Cardio-respiratory arrest Neuro
What is the most common cardiac problem in pregnancy
Mitral stenosis
What are the symptoms
SOB Chest pain Tachycardia Hypertension Low sats Diastolic murmur Pulmonary oedema AF as enlarged aorta
What are the RF for MS
Rheumatic fever
Valve surgery
How do you treat MS
Balloon valvuloplasty
What are the complications of MS
Sudden deterioration
Resp arrest
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
What puts you at risk of aortic dissection
Marfan
Biscuspid valve
How do you Dx
CT
20mmhg diff pulse pressure
How do you treat
<28 weeks = repair
>32 = C-section followed by aortic repair
If RCA involved
MI - inferior
What are the baby blues
1-3 post natal Lasts usually <10 days Normal due to hormonal changes No functional affect Rx = monitor
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
How do you treat post natal depression
Reassure
CBT
SSRI
What should you avoid
Fluoxetine as long half life
What puts you at risk
Personal or FH
What do you use to screen
Edinburgh Depression Scale
Check thyroid
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
What is damaging to baby
Anti-psychotic
Benzo’s - Diazepam
How does Erb’s Palsy present
Upper plexus Water tip position Shoulder = Adduction + internal rotation Elbow = extended and pronated Wrist = flexed
Complications PPH
Shock
Death
Sheehan - lack of milk / amenorrhoea
What does Tranexamic acid do
Anti-fibrinolytic
Binds to receptor on plasminogen or plasmin and prevents degradation of fibrin
When is it used
Menorrhagia common
Role in major haemorrhage
Prophylaxis in C-section
When would you investigate lochia further with USS further
If persist >6 weeks
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
What can Sheehan cause
Amenorrhoea - lack of LH / FSH
Reduced lactation- lack of prolacitn
Adrenal insufficiency - lack of ACTH
Hypothyroid - lack of TSH
How does RPOC present after C-section
Pain
Vaginal bleeding / discharge
Boggy poorly contracted uterus
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
If temperature in first 14 days of delivery what is this
Peurpeural pyrexia
What is needed
Admission for IV Ax if suspect endometritis
What is likely cause
Endometritis = most common UTI Wound Mastitis VTE
