Surgical Complications, FGM, Birth Trauma, Life Threatening Conditions Flashcards
Poor midwifery care can be linked to maternal deaths. What factors contribute to this
- Poor communication
- Inadequate documentation
- Failure to perform observations
- Failure to act when a woman reported feeling unwell
- Failure to visit or revisit during the postnatal period
What are some of the leading causes of direct maternal deaths
Sepsis
Pre-eclampsia and eclampsia
Thrombosis and thromboembolism and
Amniotic fluid embolism
What are some of the leading causes of direct maternal deaths in Australia
Obstetric haemorrhage
Thromboembolism
Hypertensive disease
Define: Umbilical cord presentation
is a condition in which the umbilical cord is interposed between the leading part of the fetus and the internal os of the uterine cervix but the amniotic membranes remain intact.
- A fetal heart rate (FHR) trace with deep decelerations may be an early sign of this complication.
- As labour advances, intermittent umbilical cord compression causes variable FHR decelerations.
Define: Cord Prolapse
Cord prolapse is defined as descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes
- Dramatic changes in the fetal heart rate are often the first signs of a cord prolapse
Define: Ocult (hidden) cord prolapse
An occult prolapse occurs when the membranes break and the cord is trapped between the presenting part and the walls of the maternal pelvis
List risk factors for Cord Prolapse
- Multiparity/ Twins
- ARM
- LBW
- Non-engaged presenting part
- ECV
- Preterm
- Malpresentation
- Polyhyrdaminos
What is the effect/ signs of cord prolapse on the fetus
Unresolved ongoing cord compression will result in fetal hypoxia, an increase in the severity of the decelerations and, depending on the ability of the fetus to withstand episodic hypoxia, eventually to prolonged fetal bradycardia.
The presence of repetitive, early FHR decelerations on an electronic fetal heart tracing may be indicative of umbilical cord compression or occult cord presentation
How is a cord presentation diagnosed
loops of cord are palpated through the membranes. The presence of umbilical cord lying in front of the presenting part can also be visualised using colour Doppler studies
How is a cord prolapse diagnosed
diagnosis is made by visual inspection or palpation of a pulsing umbilical cord during a vaginal examination. The umbilical cord is felt below or beside the presenting part.
How is occult (hidden) cord prolapse diagnosed
is rarely felt on vaginal examination and the only indication may be FHR changes.
How is overt cord prolapse diagnosed
the umbilical cord can be seen protruding from the introitus or loops of cord palpated within the vaginal canal.
Explain: Management of cord prolapse
- Call for help
- Change maternal position: usually exaggerated Sims position
- VE to determine cord compression sight
- Use fingers or positioning to remove pressure from cord
- Cannulate
- Prepare for theatre
- IF NECESSARY!: insert a catheter into maternal bladder with 500ml N-Saline to keep fetal head from compressing umbilical cord
Define: Shoulder dystocia
he fetal head is born, but the midwife is unable to birth the anterior shoulder because it is impacted behind the symphysis pubis.
- the fetal head may do the ‘turtle’ sign (slow extension of the head with the chin remaining tight against the maternal perineum)
List some risk factors/associations of Shoulder dystocia
- Obesity/ high BMI
- GDM
- Prolonged labour
- Previous shoudler dystocia
- Pelvic structure anomaly
- LGA
- Macrosomia
Explain: Management for Shoudler dystocia
Use of HELPERR H- help E- evaluate for episiotomy L- legs: McRoberts Maneuver P- external pressure: suprapubic E- enter: rotational maneuvers R- remove posterior arm R- roll patient to hands and knees
What are some complications of Shoulder Dystocia
Maternal:
- Postpartum haemorrhage
- Rectovaginal fistula
- Symphyseal separation or diastasis
- Third- or fourth-degree episiotomy or tear
- Uterine rupture
Fetal:
- Brachial plexus palsy
- Clavicle fracture
- Death
- Hypoxia, with or without permanent neurological damage
- Fracture of the humerus
What are the degrees of Uterine Inversion
First degree —the fundus reaches the internal os.
Second degree—the body or corpus of the uterus is inverted to the internal os.
Third degree—the uterus, cervix and vagina are inverted and are visible.
Define: Amniotic fluid embolism
a rare obstetric emergency in which it was postulated that amniotic fluid, fetal cells, hair or other debris enter the maternal circulation, causing cardiorespiratory collapse
- More than half of those who develop AFE will experience disseminated intravascular coagulopathy (DIC), which is difficult to control
List some associated factors of Amniotic fluid embolism
Multiparity • Physiologically intense uterine contractions • Drug-induced intense uterine contractions • Age > 30 years • Caesarean section • Cervical tear • Premature placental separation • Intrauterine fetal death • Placental abruption • Abdominal trauma • 80% occur in labour
Define: DIC
Disseminated Intravascular Coagulopathy
is characterised by systemic activation of blood coagulation (clotting cascade), which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome (MODS)
List associated risk facotrs of DIC
Placental abruption Placenta praevia Preeclampsia Eclampsia HELLP syndrome Retained fetus syndrome Infection
List some warning signs of DIC
- Profound haemorrhage.
- Blood fails to clot.
- Petechiae appear.
- Bleeding from the woman’s eyes, nose, gums or vagina and from venipuncture, surgical and episiotomy sites occurs.
- Haematomas,
- flank pain,
- abdominal distension,
- swollen extremities,
- neurological abnormalities,
- hypotension,
- tachycardia
- cool skin temperature, pallor and diaphoresis
may indicate profuse internal bleeding
Define: Ruptured uterus
defined as a catastrophic tearing-open of the uterus into the abdominal cavity. Its onset was often marked only by sudden fetal bradycardia, and treatment required rapid surgical attention for good neonatal and maternal outcomes.
Complete uterine rupture: refers to a full-thickness tear through the myometrium and serosa. The entire thickness of the uterine wall and usually the overlying broad ligament rupture
Incomplete rupture of the uterus: include partial separation (dehiscence) and healing defects.
- Uterine scar dehiscence is a separation of a pre-existing scar that does not disrupt the overlying visceral peritoneum (uterine serosa) and that does not significantly bleed from its edges
What are the classifications of FGM
TYPE 1: Excision of the prepuce, with or without excision of part or the entire
clitoris (clitoridectomy or circumcision).
TYPE 2: Excision of the clitoris with partial to total excision of the labia minora
(excision).
TYPE 3: Excision of part or all of the external genitalia and stitching/narrowing of
the vaginal opening (infibulation).
TYPE 4: Unclassified: includes pricking, piercing, or incising of the clitoris and/or
labia; stretching of the clitoris and/or labia; cauterisation by burning of the
clitoris and surrounding tissue; scraping of the tissue surrounding the
vagina
Define: De-infibulation
The surgical procedure to open up the closed vagina of FGM/C Type III
Explain: Management of FGM in pregnancy, labour/birth and postnatal
Pregnancy
- examination of area and type
- Normal care if type 1 or 2
- education about de-infibulation (done around 28wks)
- implications if nil consent for de-infibulation
Labour/Birth
- explain de-infibulation is likely to occur during this time if nil consent was given during pregnancy
- PPH risk: medications ready
Postnatal
- care of area following birth (hygiene due to likelyhood of infection, ill-healing)
- will not be re-infibulated
- pain relief
