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Obs & Gynae > Post-Partum Issues > Flashcards

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
Q

How do you monitor PPH / how do you prevent

A

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
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26
Q

What do you do for secondary PPH

A 
FBC
Blood culture if pyrexia
MSSU
High vaginal swab
USS to look for RPOC
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27
Q

What do you do for PPH 1

A 
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
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28
Q

What do you do once stable

A

Cord traction
Tranexamic acid - fibrinolytic
Manual removal of placenta

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29
Q

How do you get the uterus to contract

A 
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
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30
Q

When is ergometrine CI

A

Hypertension

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31
Q

When is misoprostol CI

A

Asthmatic due to risk of bronchospasm

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32
Q

What do you do for PPH 2 or PPH 1 not controlled by medical

A 
Intrauterine balloon = 1st line if pharmacology fails 
Interventional radiology
EUA and manual evacuation 
B-lynch suture
Ligatation of uterine / iliac vessels
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33
Q

What do you do if won’t stop bleeding

A

Hysterectomy

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34
Q

Massive haemorrhage

A

2222

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35
Q

Who is at risk of tears

A

Prim
Large baby
Shoulder dystocia
Forceps

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36
Q

How do you Dx and how do you grade

A 
VE + PR
1st degree = labia and superficial skin
2nd degree = above + perineal muscles
3rd degree = above + anal sphincter
4th = above + rectal mucosa
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37
Q

How do you treat

A

Epiostomy to prevent under LA - avoids damaging anal sphincter
Suture
Follow up

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38
Q

Risk of tears

A

Bowel / bladder issues

Bleeding / infection / haematoma/ breakdown

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39
Q

What is leading cause of maternal death

A

Sepsis

40
Q

What is likely if pyrexia in labour

A

Chorioamnionitis

Requires fast delivery

41
Q

What are common organisms of sepsis

A

Group B strep
E.coli
Group A

42
Q

How does sepsis present

A 
Atypical
Pyrexia spike
Rigors
Diarrhoea or vomiting 
Rash 
Abdominal or pelvic pain 
Offensive discharge
Urinary Sx
43
Q

What does rash suggest

A

TSS

44
Q

What are the RF for sepsis in mother

A 
Obesity
DM
Immunosuppressed 
Pelvic infection
Hx group B strep
Invasive procedures
Prolonged rupture membranes >24 hours
Anaemia
45
Q

How do you Dx sepsis

A 
Blood / urine culture
Vaginal swab
O2 sats
CRP NOT ESR
FBC, U+E, LFT, clotting, lactate, ABG
46
Q

What must you monitor continuous in sepsis

A

CTG

47
Q

How do you treat sepsis

A 
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
Q

What Ax

A

Benpen if in labour as group B strep

Vanc if allergy

49
Q

Why is a high temp dangerous for baby

A

Susceptible to hypoxia
Encephalopathy
Cerebral palsy
Blood sampling inaccurate due to tachy

50
Q

What is CI if temp

A

Spinal and epidural

51
Q

Why is VTE more likely in pregnancy

A 
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
Q

What should you have a high suspicion of in a collapsed pregnant women

A

PE

More common than epilepsy

53
Q

What are obstetric RF of VTE

A 
Multiple pregnancy
PET 
C-section 
Long labour 
Still birth
Pre-term
PPH 
Hyperemesis due to dehydration 
IVF
54
Q

Other RF

A 
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
Q

How do you deal with VTE risk

A

Assess risk at booking
Antenatal, labour and post
FBC, U+E, LFT, clotting
Leg doppler if suspected DVT

56
Q

How do you treat

A

Same as cardio

57
Q

How do you monitor

A

Not routine
If obesity / recurrent / renal = monitor anti-Xa activity
APTT if unfractioned heparin

58
Q

How do you prevent VTE

A

TED stockings prophylaxis

Increase mobility and hydration

59
Q

What do you do if there is 3+ RF or previous VTE as prophylaxis

A

Prophylactic anti-coagulation
LMWH - Dalteparin
Continue until 6 weeks post partum
3 months if before delivery

60
Q

How do you treat VTE

A

LMWH - Dalteparin if DVT confirmed before scan
Consider switching to warfarin post delivery but CI in pregnancy
Require LMWH next pregnancy

61
Q

What is CI in pregnancy

A

DAOC

Warfarin

62
Q

What do you do in labour

A

Stop LMWH

Avoid regional anaesthesia until 24 hours after last dose of LMWH

63
Q

What do you do if massive PE

A

Thrombolysis

Percutaneous catheter

64
Q

What are other differentials for PE

A

Aortic dissection
Mitral stenosis
Amniotic fluid embolism

65
Q

What are symptoms of amniotic emboli

A 
Post rupture
Sweating
Anxiety
Cough
CYanosis 
Hypotension
Tachycardia
Arrythmia
MI
Coagulopathy 
Cardio-respiratory arrest 
Neuro
66
Q

What is the most common cardiac problem in pregnancy

A

Mitral stenosis

67
Q

What are the symptoms

A 
SOB
Chest pain
Tachycardia
Hypertension
Low sats 
Diastolic murmur
Pulmonary oedema
AF as enlarged aorta
68
Q

What are the RF for MS

A

Rheumatic fever

Valve surgery

69
Q

How do you treat MS

A

Balloon valvuloplasty

70
Q

What are the complications of MS

A

Sudden deterioration

Resp arrest

71
Q

What are the symptoms of aortic dissection

A 
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
Q

What puts you at risk of aortic dissection

A

Marfan

Biscuspid valve

73
Q

How do you Dx

A

CT

20mmhg diff pulse pressure

74
Q

How do you treat

A

<28 weeks = repair

>32 = C-section followed by aortic repair

75
Q

If RCA involved

A

MI - inferior

76
Q

What are the baby blues

A 
1-3 post natal
Lasts usually <10 days 
Normal due to hormonal changes 
No functional affect
Rx = monitor
77
Q

What is post natal depression

A

Classic depressive symptoms that affects bonding and functioning
10% within 3-6 months
Usually within first month
Lasts >2 weeks

78
Q

How do you treat post natal depression

A

Reassure
CBT
SSRI

79
Q

What should you avoid

A

Fluoxetine as long half life

80
Q

What puts you at risk

A

Personal or FH

81
Q

What do you use to screen

A

Edinburgh Depression Scale

Check thyroid

82
Q

How do you treat peurperal psychosis

A 
Peri-natal mental health team
Inpatient / admission
Anti-psychotic 
2-3 weeks
Severe mood swings + auditory hallucination
Manic depression
Schizphrenia
83
Q

What is damaging to baby

A

Anti-psychotic

Benzo’s - Diazepam

84
Q

How does Erb’s Palsy present

A 
Upper plexus 
Water tip position 
Shoulder = Adduction + internal rotation 
Elbow = extended and pronated 
Wrist = flexed
85
Q

Complications PPH

A

Shock
Death
Sheehan - lack of milk / amenorrhoea

86
Q

What does Tranexamic acid do

A

Anti-fibrinolytic

Binds to receptor on plasminogen or plasmin and prevents degradation of fibrin

87
Q

When is it used

A

Menorrhagia common
Role in major haemorrhage
Prophylaxis in C-section

88
Q

When would you investigate lochia further with USS further

A

If persist >6 weeks

89
Q

What happens at 6 week post partum check

A 
General well being
Mood
Bleeding
Scar healing
Contraception
Breast feeding
Fasting BG if gestational
BP 
Urine dip
90
Q

What can Sheehan cause

A

Amenorrhoea - lack of LH / FSH
Reduced lactation- lack of prolacitn
Adrenal insufficiency - lack of ACTH
Hypothyroid - lack of TSH

91
Q

How does RPOC present after C-section

A

Pain
Vaginal bleeding / discharge
Boggy poorly contracted uterus

92
Q

What do you do

A

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
Q

If temperature in first 14 days of delivery what is this

A

Peurpeural pyrexia

94
Q

What is needed

A

Admission for IV Ax if suspect endometritis

95
Q

What is likely cause

A 
Endometritis = most common
UTI
Wound 
Mastitis
VTE

Obs & Gynae (23 decks)

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