Week 4 Obstetrics (Q. 3 & 4) Flashcards
What do the terms Primigravida and Multigravida mean?
A “primigravida” is a woman who is pregnant for the first time or has been pregnant one time. A “multigravida” or “secundigravida” is a woman who has been pregnant more than one time.
What are some causes of Postpartum Haemorrhage?
Hint: The Four T’s in the CPG’s
- Tone (uterine atony)
- Trauma (to genital structures)
- Tissue (retention of placenta or membranes)
- Thrombin (coagulopathy)
An empty and contracted uterus does not bleed
Tear in the cervix or tissues of the vagina
- Tear in a blood vessel in the uterus
- Bleeding into a hidden tissue area or space in the pelvis
- Blood clotting disorders
- Placenta problems (Placenta Praevia; Abruption)
- Retained cotyledons, membranes
Primary Postpartum Haemorrhage (PPH) can be caused by an atonic uterus that fails to contract and there is bleeding from the placental site.
What are some causes for an atonic uterus?
- Incomplete placental seperation
- Placenta problems (Placenta Praevia; Abruption)
- Retained cotyledons, membranes
- Precipate Labour
- Prolonged Labour
- Polyhydramnios (excess amniotic fluid)
- Multiple preganancy
- Infection
- Mismanagement of 3rd Stage Labour
- Full Bladder in women
What are the signs and symptoms of PPH?
Obvious Signs:
- Visible Bleeding
- Maternal shock or collapse
Subtle Signs:
- Pallor
- Compensation/Decompensation
- Alt Con State
- Enlarged ‘Boggy’ Uterus
- The woman has a feeling of a full bladder
What is a cord prolapse?
A cord prolapse is when a loop of the umbilical cord (which is attached to the baby at one end, and the placenta at the other) falls past the baby, through the woman’s open cervix and into her vagina. If this occurs, rather than the baby leading the way down the vagina, the cord does.
What is shoulder dystocia?
Shoulder dystocia is a specific case of obstructed labour whereby after the delivery of the head, the anterior shoulder of the infant cannot pass below or requires significant manipulation to pass below, the pubic symphysis. It is diagnosed when the shoulders fail to deliver shortly after the foetal head. Shoulder dystocia is an obstetric emergency, and foetal demise can occur if the infant is not delivered, due to compression of the umbilical cord within the birth canal.
What are the risk factors for cord prolapse?
Prematurity Multi Fetus Polyhydramnios High presenting part of the foetus Multigravida
What is not a sequence in the delivery position for Shoulder Dystocia?
A. Knees to Nips (McRobert’s Manoeuvre)
B. Suprapubic Pressure whilst in McRobert’s Position
C. All Fours (Gaskin)
D. Downward Traction
D. Downward Traction is apart of the All Fours (Gaskin) Manoeuvre
- Rotate mother to all fours
- Hold the baby’s head and apply gentle downward traction - attempting to dis-impact and deliver the posterior shoulder (now uppermost)
How does a baby take its first breath?
A. Allowing the baby a minute to breath
B. Cabron Dioxide receptors respiratory centres
C. Cutting of the placenta cord
D. All the above
B. Cabron Dioxide receptors respiratory centres
Once carbon dioxide is no longer removed by the placenta, central acidosis occurs. This excites the respiratory centres to trigger the first inspiration. This requires tremendous effort – airways are tiny and the lungs are collapsed once the lungs inflate, surfactant in alveolar fluid helps to reduce surface tension
What is the difference between Primary Postpartum Haemorrhage and Secondary Postpartum Haemorrhage?
Primary PPH = bleeding within 24 hours
Secondary PPH = 24h-6/52
What is stage 1 of Birth?
Consists of two phases. Early and latent
Early
- 0 - 3 cm effacement of 0 - 30%
- Irregular contractions every 5 to 30 mins that last for 30 seconds; progress to regular contractions that are every 3 - 5 mins and lasts for 1 min or greater
- Once regular contractions start the cervix will be dilated from 3 - 6cm and effacement of 80%
Active
- Intense contractions that are 6 0 - 90 seconds and occur every 30 to 120 seconds
- Cervix dilation of 6 - 10cm and 100% effacement
- The amniotic sack will rupture at this point if it has not already
What happens in stage 2 of labour?
Full cervix dilatation 10cm until the baby is born
Head
- Encourage mum to push, if the baby is birthing to fast, ask mum to pant with mouth open during contractions
- Apply pressure to Perineum to reduce risk of tears
- Apply backwards, downwards pressure for precipitous birth - Note Time of Delivery Umbilical Cord Check
- If Loose and wrapped around head = slip over babies head with appropriate tractions
- if tight = encourage the mother to push; where the baby does not descend and cord still cannot be loosened; clamp and cut cord Normal Birth - Head Rotation
- Restitution should occur, indicating internal rotation of the shoulders in preparation for the birth of the body
Normal Birth
- Birth of the Shoulders and Body
- Birth baby
- Gentle pressure to assist shoulder delivery
- Note time of birth
- Give baby skin to skin contact with mother on her chest for warmth unless the baby is not vigorous or requires resuscitation
Normal Birth - Clamping and Cutting
- Do not cut cord if needed
- If necessary, wrap placenta while still attached to baby
- Attach first clamp 10cm from the baby and the second clamp a further 5cm down and cut between the two.
Normal Birth - Placenta (Stage 3 Labour)
What occurs during stage 3 of labour and Mx by paramedics? In particular, what are the signs of placental separation?
HINT: CULT
- Placenta separation and delivery
- Uterine contractions to ensure there are not placental remnants
C - Cramping/Contractions Return
U - Uterus becomes rounded, firm, smaller
L - Lengthening of the cord
T - Trickling or gushing of vaginal blood
CPG
- Expulsion time is 15 to 60mins
- Wait for signs of separation (CULT)
- Do Not Pull
- Use two hand see-saw motion to help placenta out
- Note the placental delivery time and store in a container for hospital and inspect placenta for completeness
- Inspect the fundus is firm, contracted and central
- Continue to monitor fundus, do not massage once firm
- If Fundus is not firm or blood loss >500mL, Mx as per PPH CPH M0401
What signs and symptoms of Stage 2 Labour?
- Bulging or stretching perineum
- Presenting part on the view
- Anal pouting
- Uncontrollable urge to push
- Grunting
Explain your thinking for Pain Relief during Labour?
Stage 1 - Opioids are an allowed Morphine, Fentanyl, Methoxy
Stage 2 - Opioids are C/I for late second stage labour Methoxy is a good choice because the drug cannot cross the placental membrane (Nitric Oxide for other Ambulance services)
What is restitution?
Babies head turns to face one of the mother’s thighs. Shoulders internally rotate = preparation for the birth of the body.
APGAR Scoring System
What are some causes of APGAR < 7
HINT: RIP DOC
Respiratory Depression Intracranial Trauma Pre-term Infant Drugs Obstructed Airway Congenital Abnormalities
APGAR Scoring system
What does APGAR stand for?
When is it completed?
Must be taken 1 - 5mins post birth
Repeated at 5 min intervals
Appearance
- 0 points = Blue Pale
- 1 point = Body Pink, Extremities Blue
- 2 Points = Totally Pink
Pulse
- 0 points = Absent
- 1 points = < 100 BPM
- 2 Points = > 100 BPM
Grimace - 0 Points = None
- 1 Points = Grimaces
- 2 Points = Cries
Activity
- 0 Points = Limp
- 1 Points = Flexion
- 2 Points = Active Motion
Respiratory Effort
- 0 Points = Absent
- 1 Point = Weak, gasping, ineffective
- 2 Points = Good Strong Cry
7 - 10 = Satisfactory
4 - 6 = Mod depression needs ongoing support
0 - 3 = needs resus and ETT CPG - N0301
What are the 3 warning signs of shoulder dystocia? Hint: NPT
N - No Restitution
P - Prolonged head to body birth >60 seconds
T - Turtle sign (head appears to be returning to the vagina)
What are some risk factor for Shoulder Dystocia?
Macrosomia (large baby) Gestational Diabetes Overweight Mothers Mother 35+ Platypelloid Pelvis (flat pelvis)
What is Breech Birth and what are the 3 types?
A breech birth is a birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umbilicus
- Frank Breech (Both legs straight)
- Complete Breech (Legs crossed)
- Footling (One or both feet present - not flexed or extended) Cord Prolapse is common with breech presentations.
What is Placenta Praevia in your own words?
Placenta Praevia is a condition where the placenta lies at the bottom of the uterus, covering the cervix or close by.
Placenta normally sits in the upper segment of the uterus.
What is Placental Abruption (Abruptio Placentae)?
Is the premature separation of the placenta from the uterine wall
This results in bleeding due to decidua basalis separating the placenta from its attachment
Can be concealed (no haemorrhage is seen) or revealed.
What are the 3 types of Placenta Praevia
Marginal (Type 1 and 2) = Placental margin encroaches on the lower uterine segment but does not cover the cervical os
Major (Type 3)= Placental margin encroaches onto the cervical os when it is closed
Complete (Type 4) = Placental margin covers the cervical os and the opposing uterine wall
What are the three 3 types of Abnormal Placental Implantation?
Accreta = Attaches to the endometrium
Inccreta - Invades the uterine myometrium
Percreta - Perforates through the myometrium and serosa
Why is a Placental Abruption considered an emergency?
Maternal Factors
- Hypovolaemic Shock –> Death (if untreated)
- Renal Failure
- Sheehan Syndrome (Perinatal Pituitary Necrosis)
- DIC from the release of Thromboplastin
Fetal
- Intrauterine Hypoxia and Asphyxia
- Premature Birth
What is the difference between Vasa Praevia and Placental Praevia
Vasa Praevia is a condition where Fetal blood vessels rupture leading to fetal exsanguination
Placenta Praevia is a condition where the placenta lies at the bottom of the uterus, covering the cervix or close by.
What is Premature Rupture of Membranes (PROM)?
Hows is PROM different from Preterm Premature Rupture of Membranes (PPROM)?
PROM = when the bag of waters (amniotic fluid) surrounding your unborn baby breaks before the onset of labour.
PPROM is the term used when the pregnancy is less than 37 weeks.
Risk factors for PPROM include
- Previous PPROM
- Infections of the genital tract
- Bleeding in pregnancy
- Smoking
What does the HELLP stand for in Pre-Eclampsia?
H = Haemolysis EL = Elevated Liver Enzymes LP = Low Platelets
What are the risk factors for Pre-Eclampsia
A. Primigravida B. Multiple Gestations C. Age 35+ D. Hypertension E. Diabetes F. Obesity G. Family Hx
Placenta Praevia, generally occurs in which stage of pregnancy?
3rd Trimester
Placenta Praevia occurs in 0.5 - 1% of all pregnancies >28 weeks and is more common.
Older patients (35+), past uterine surgery (caesarean) and multiparity (multiple pregnancies) increase risk.
What are presentations of Placenta Praevia prehospital?
Painless, bright red bleeding Women who are 35+ No associated hypertension In women who smoke during fetal development Pregnancies >28 weeks (3rd Trimester)
What is the cause of Percreta Placental?
Perforates through the myometrium and serosa
Placenta Percreta – The placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder.
Bleeding between the uterine and placenta is known as?
Placenta Abruption
This results in bleeding due to decidua basalis separating the placenta from its attachment
Can be either partial or complete abruption and concealed (no haemorrhage is seen) or revealed.
Placenta Abruption occurs usually from degenerative uterine arteries, caused by smoking and hypertension
What is a sign of Pre Eclampsia (PE)?
A. Hypertension B. Glycosuria --> Kidney Disease C. Oedema of hands, feet and face D. A and C E. None of the Above
D. A and C
PE is the most common serious medical disorder of human pregnancy. Pregnant women can suffer from;
- Hypertension
- Proteinuria –> Kidney Disease
- Oedema in hands, feet and face
severe cases;
- dizziness,
- headaches –> migraines
- vision disturbances - blurred vision, fashing lights
If left untreated, it can lead to convulsions and other life-threatening problems for both mother and baby. Pre-eclampsia only occurs when a woman is pregnant, and currently, the only cure for it is to end the pregnancy, even if the baby is not yet ready for birth.
A systemic vascular disorder characterized by new-onset hypertension and proteinuria after 20 weeks of gestation is likely to be which condition?
A. Pre Eclampsia
B. Preterm Rupture of Membranes
C. Uncertain Antepartum Haemorrhage
D. Preterm Labour
A. Pre Eclampsia
This condition targets several organs, including the kidneys, liver and brain, and is the leading cause of maternal and perinatal morbidity and mortality.
Kidney = Oliguria and Proteinuria Liver = Elevation of liver enzymes and stretching of liver capsule --> epigastric pain
Brain - Oedema –> Headaches, Confusion and Seizures (Eclampsia)
Postpartum Eclampsia (seizures) occur between ____ hours after delivery?
D. 48 - 72 hours
Symptoms also include high blood pressure and difficulty breathing. About one-third of eclampsia cases occur after the delivery, and nearly half of those are more than 48 hours after the birth
Which is not a risk factor for Gestational Diabetes?
A. POCS B. Overweight C. 35+ women D. Family Hx of T2DM E. Being of Anglo-Saxon Ancestry
(Hint: POOFE)
E. Being of Anglo-Saxon Ancestry
Women who are from certain ethnic backgrounds, including
- South Asian,
- Vietnamese,
- Chinese,
- Middle Eastern and
- Polynesian/Melanesian
POOFE
P - POCS O - Overweight O - Olderwoman F - Fam Hx T2DM E - Ethnic Backgrounds
