Pregnancy Flashcards
What does Laxin do?
Relaxes joints
This includes non-mobile joints like the pubic symphysis
Why is anaesthesia dangerous in pregnancy?
It often leads to aspiration
Why are pregnant women likey to get oedema?
They are less likely to secrete sodium ions, leading to accumulation of fluid
What is oedema associated with in pregnancy?
Preeclampsia
How much weight do women tend to gain in pregnancy?
10-14kg
Split in to 2kg in first semester, 5kg in second/third
Why are pregnant women more susceptible to thyroid issues?
Relative iodine pregnancy as actively transported to child
Thyroid often increases in size
Note - if already deficient, can lead to goitre
What are the changes in breast in pregnant women?
Increased size and vascularity Increased pigmentation of areola/nipple Secondary areola ppears Montogomery tubercles appear on areola Fluid can be secreted from 3rd month
What was the biggest cause of maternal death in pregancy in previous years?
Cardio vascular diseasecomplications
What are the cardiovascular changes in pregnant women?
Increased circulating blood volume (50-70%)
Systemic vascular resistance falls (prostaglandins partially responsible)
Increased blood flow
Increase Cardiac output, and heart rate (upto 10-20)
Increase oxygen consumption
Why is it dangerous to be in the supine position when pregnant?
Can compress IVC
Why are epidurals the preferred pain reduction method?
Anaesthesia can cause regurg
Also reduces peripheral resistance so decreases cardiac problems
What are the intrapartum cardiovascular changes?
Autotransfusions of contractions
Pain due to increasing catecholamines
Cardiac outputs increase by 10% in labour
By 80% in post delivery hour although not safe until after 3 months
What are the respiratory changes in a pregnant woman?
Increase in oxygen demand
Increase in ventilation/resp rate
Increased tidal volume
PEFR + PEV1 unchanged
PCO2 decreases (like mild respiratory alkalosis)
Work harder, but reduced expansion potential
What are the renal changes in a pregnant woman?
Dilation or urinary collecting system, more dramatic on right
Increased renal plasma flow
Increased GFR + creatine clearance (up to 50%)
Protein excretion increased
Microscopic haematuria may be present
Glycosuria common
Decreased urea, increased urate, decreased ceatinine
How does uric acid change in pregnancy?
Increases with gestational age
Almost 10x per gestational week
Also rises in preeeclampsia
Above 600 risk of neonatal death
What are the haematological changes in pregnancy?
Plasma volume increases Decreased haemoglobin (dilutional) Decreased platlet count Increased need of iron (iron def. anaemia common) + folate WCC increases (although relative immunocompromised) Hypercoagulable (DVT ~1%) Albumin drop (oedema common) Alk phos up (placenta, within thousands)
What is labour?
The process where the placenta, foetus and membranes are expeled into the birth canal
What is normal labour?
Wher labour occurs spontaneously at term(37-42 weeks)
WIth foestus presenting by vertex and resulting in spontaneous vaginal birth
May not feel normal to mother
What must occur for labour to happen?
Cervix softening
Myometrial tone changes to allow for co-ordinated contractions
Progesterone decreases whilst oxytocin increases to initiate labour
What are the subcategories of the first stage of labour?
Latent stage
Established stage
What is the latent part of the first stage of labour?
Stage of intermittent, often irregular, painful contractions
Bring some cervical enlargement up to 4 cm
Can last a long time
What is the established part of the first stage of labour?
Regular, painful contractions resulting in progressive effacement and dilation of cervix from 4cm
When is the first stage of labour complete?
At 10 cm dilation
What is the anticipated progress of the first stage of labour?
0.5-1cm/hour
How long does the first stage of labour take?
In a primagravida (first time pregnant) around 8 hours
In a multigravida (more than once) around 5 hours
What are the parts to the second stage of labour?
Passive phase
Active phase
What s the second stage of labour?
From full cervical dilation to the birth of the baby
What is the passive phase of the second stage of labour?
Finding of full dilatation of cervix before (or in abscence of) inv9oluntary expulsive contractions
Allow for further foetal descent
What is the active phase of the second part of labour?
Presenting part is visible
Expulsive contractions with finding of full cervix
Active maternal effort following confirmation of full cervix dilatation in absecen of expulsive contractions
How long is birth expected within the second (active phase) of labour starting?
2 hours in primagravida
1 hour in multigravida
What is the third stage of labour?
From after birth of baby, to expulsion of placenta/membranes
What does the active management of the third stage of labour entail?
Routine use of uterotonic drugs
Deferred clamping/cutting of the cord
Controlled cord traction after signs of seperation of placenta
What does the physiological management of the third stage of labour entail?
No routine use of uterotonic drugs
No clamping of cord until pulsation has stopped
Delivery of placenta by maternal effort
When do you diagnose a prolonged 3rd stage of labour?
30 minutes if active management
60 minutes if physiological management
What investigations should be used to monitor labour + its progress?
Stats (BP, HR, temp, RR, O2, urine output + urinalysis)
Abdominal palpation
Vaginal examination
Monitor of liquor after rupture of membrane
Foetal heart auscultation (intermittent/continous)
Palpation of uterine muscle contractions
External signs
What are the external signs of labour?
Rhomboid of michaelis (sacrum pushing outwards)
Anal cleft line restlesness
What are you looking for in a vaginal examination during labour?
Assessing presentation Engagement + station (how far down) Position Cervical effacement + dilatiation Membranes (present/absent?)
What are you monitoring with abdominal palpitations?
Foetal lie
Presentation
Attitude (posture of foetus - flexion, deflexion, extension)
Denominator (a bony landmark used to denote position, differs by lie)
Position
Engagement
What are the different foetal lies?
Longitudinal (cephalic, breech)
Oblique
Transverse
What is the presentation that has the smallest diameter of the baby’s head through the pelvis?
Subocccipitobregmatic
Where baby has chin on chest, with back/top coming first
What determines the position in labour?
It is in relation to the occiput (posterior fontanelle)
What are the mechanisms of labour?
Descent Flexion Internal rotation of head Crowning/extension of head Restitiution Internal rotation of shoulders External rotation of head Lateral flexion
What analgesia is used in labour?
Breathing, massage, tens, parecetamonl, dihydrocodeine Water Entonox Opioids Epidural Maternal position
What are the risks of induction?
Too many contractions (stresses baby)
More pain relief may be needed
What are the indications of induction?
Dibates (usually earlier than due date)
Post dates
Maternal health problem necessitating it
Foetal reasons (growth concerns etc)
What is induction?
Artificially instigating labour through medications and/or devices
Followed by artifical rupture of uterine membranes
What is used to determine if induction will be successful?
Bishop’s score
What tools are used to “ripen” the cervix?
Prostaglandin pessarie (pharmacological opening) Cook baloon (mechanical opening)
How do you rupture the foetal membranes?
With a sharp device - amniohook
When should you adminster Oxytocin IV?
After water has been brken
Does not give as good a response if unbroken water
What are the benefits of the baloon to the pessary?
Only takes 12-24 hours (instead of 2-3 days)
No risk of hyperstimulation of uterus (contractions)
What is meant by powers, passage and passenger?
Powers - contraction
Passage - birth canal
Passenger - baby
What can lead to inadequate progress?
Cephalopelvic disproportion (rare!) Malposition Malpresentation Inadequate uterine activity Other obstruction
What is the risk of an obstructed uterus?
Uterine rupture
What is used to determine the progress of labour?
Cervical effacement + dilation
Descent of foetal head through maternal pelvis
What is inadequate uterine activity?
Where contractions are inadequate resulting in no descent of the foetal head through the pelvis
Cervix does not dilate
What is presentation?
Is the part of the baby heading towards the vagina
Why is cord prolapse an obstetric emergency?
The cord vasospams when it hits cold air and starves child of oxygen
Needs immediate delivery
What is malposition?
Where cervic presentation isn’t Occiptal anterior
What positions can be birthed?
OA
OP (with some difficulty)
How do you monitor the foetus during labour?
Austlation of heart (intermittent/continuous)
Foetal blood sampling
Foetal ECG
When would you take a foetal blood sample?
When there is an abnormal CTG
What does a goetal blood sample provide?
pH + base excess
pH = hypoxia? (if acidic)
How do you interpret a CTG?
Deceleration = stress
Multiple changes is good
Flat, long to change bad
When do you advise against labour?
Obstruction to birth canal Malpresentations (transverse, shoulder, hand) Some medical conditions Specific previous labour complications Foetal conditions
What are the two types of instruments used to help birth?
Forceps
Vacuum cup
What are the benefits/negatives of a c section?
Carries risk of bleeding, visceral injury + VTE
Reduced risk of perniela injury
What are the 4ts of post partum haemorrhage?
Tears (trauma)
Tone
Tissue
Thrombin
What are the complications of the 3rd stage of labour?
Retained placenta
Post partum haemorrhage
What is the puerperium?
A post partum period where you bleed after giving birth
How is the mother managed after giving birth?
Midwife looks after for first 9-10 days
GP checks after 6 weeks
Look for signs of abnormal bleeding
Evidence of infection
What are teh common problems with mothers after birth?
Problems with infant feeding
Problems with bonding
Social issues
What are the common post natal problems?
Post partum haemorrhage Venous thromboembolism Sepsis Psychiatrid disorders Pre-eclampsia
What is primary post partum haemorrhage?
Blood loss great than 500mls within 24 hours of delivery
What is secondary post partum haemorrhage?
Blood loss more than 500ml from 24hours post partum to 6 weeks
What can cause secondary post partum haemorrhage?
Retained tissue
Endometritis
Tears/trauma
When should you suspect thromboembolic disease?
Women with unilateral leg swelling/pain
SOB/chest pain
Unexplained tachycardia
C-section/immobilisation
Retain high index of suspicion in pregnant/post natal woman as hypercoaguable state
How do you investigate thromboembolic disease in pregnancy/post partum?
ECG
Leg gopplers
CXR / VQ scan
NOT D-dimer
How do you treat thromboembolic disease in pregnant women?
LMWH (heparin)
Warfarin in breast feeding okay, but teratogenic
What is the leading cause of maternal death?
Sepsis
How should you treat sepsis in a pregnant woman (or suspicion of)
IV antibiotics ASAP
What are the types of psychiatric problems post natally?
Baby blues (normal) Post-natal depression (classical depressive symptoms - treat) Puerperal psychosis (dangerous to baby/mum should be detained)
When do most eclamptic periods occur?
In post natal period
May worsen several days following delivery, or develop post natally
