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Reproduction/Sexual Health > Week 5 > Flashcards

Week 5 Flashcards

1
Q

Define labour

A

Labour is a physiological process during which the fetus, membranes, umbilical cord and placenta are expelled from the uterus.

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2
Q

Ferguson’s reflex

A

neuroendocrine reflex in which the fetal distension of the cervix stimulates a series of neuroendocrine responses, leading to oxytocin production

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3
Q

Hormonal factors influencing onset of labour

A

Progesterone: This keeps the uterus settled, prevents gap junctions, prevents contractility
Estrogen: makes uterus contract, promotes prostaglandin
Oxytocin: initiates and sustains contractions

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4
Q

How does cervix ripen?

A

Decrease in collagen fibre alignment
Decrease in collagen fibre strength
Decrease in tensile strength of the cervical matrix
Increase in cervical decorin

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5
Q

5 elements of Bishop’s score

A

Position
Consistency
Effacement
Dilatation
Level of presenting part/station in Pelvis

Determines when it’s safe to induce labour

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6
Q

Stages of labour

A

First Stage
Latent phase up to 3-4cms dilatation
Active stage 4cms -10cms (full dilatation)
Second Stage
Full dilatation –delivery of baby
Third Stage
Delivery of baby

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7
Q

Describe latent phase

A

mild irregular uterine contractions, cervix shortens and softens, duration variable,
May last an uncomfortable few days

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8
Q

Describe active phase

A

4cms onwards to full dilatation,
Slow decent of the presenting part
Contractions progressively become more rhythmic and stronger
Normal progress is assessed at 1-2 cms per hour
Analgesia

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9
Q

Describe second stage of labour

A

Starts with complete dilatation of the cervix fully dilated =(10cms) –to delivery of the baby

Nulliparous - prolonged if >3h with reg analgesia, 2h without
Multiparous - prolonged if >2h with rgional analgesia, 1h without

Vaginal exam every 4 hours to decr risk of infection

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10
Q

Describe third stage of labour

A

Delivery of the baby to expulsion of the placenta and fetal membranes
Average duration 10 minutes but can be 3 minutes or longer

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11
Q

Management 3rd stage of labour

A

Expectant management- spontaneous delivery of the placenta
Active management: use of oxytocic drugs and controlled cord traction is preferred for lowering risk of post partum haemorrhage

Surgical - 1h prep for surgical removal of placenta under reg analgesia or GA

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12
Q

Describe Braxton Hicks contractions

A

Braxton-Hicks contractions are sometimes called “false labour” because they give the woman a false sensation that she is having real contractions.
Tightening of the uterine muscles, thought to aid the body prepare for birth

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13
Q

How do you know if it’s true labour?

A

True labour is when the timing of contractions become evenly spaced, and the time between them gets shorter and shorter (three minutes apart, then two minutes, then one).
Length of time contraction lasts also increases

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14
Q

3 factors influencing labour

A

POWER: Uterine Contraction
PASSAGE: Maternal Pelvis
PASSENGER: Fetus

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15
Q

Pacemaker of uterus

A

region of tubal ostia, wave spreads in a downward direction

Synchronisation of contractions waves from both ostia

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16
Q

4 types of pelvis

A

Gynaecoid pelvis (best for birth)
Anthropoid pelvis
Android pelvis
Platypelloid

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17
Q

Normal foetal position

A

Longitudinal Lie
Cephalic Presentation
Presents with vertex
Best if occipito-anterior presention
Flexed head

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18
Q

Abnormal foetal position

A

Presentation; breech, oblique, Transverse lie
Position; frequently “occipito –posterior”

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19
Q

When can sagittal suture be felt?

A

5-6cm dilated

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20
Q

Analgesia for birth

A

Paracetamol/ Co-codamol
TENS
Entonox
Diamorphine
Epidural
Remifentanyl
Combined spinal/epidural

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21
Q

Which shoulder delivered first?

A

Anterior

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22
Q

7 cardinal movements of the foetus at birth

A

1…Engagement
2…Decent
3…Flexion
4…Internal Rotation
5…Crowning and extension
6…Restitution and external rotation (head goes into optimum pos for shoulder)
7…Expulsion (ant shoulder first)

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23
Q

3 classic signs to indicate separation of placenta from uterus

A

Uterus contracts, hardens and rises
Umbilical cord lengthens permanently
Frequently a gush of blood variable in amount

Placenta and membranes appear at introitus

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24
Q

Acitve management of 3rd stage labour

A

Prophylactic administration of Syntometerine
OR
Oxytocin 10 units

Cord clamping/cuttting, controlled cord traction, bladder emptying

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25
Q

Where does placenta separate from?

A

Plane of separation: Spongy layer of decidua basali

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26
Q

Augmentation vs induction of labour

A

Augmentation is induction after waters have broken

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27
Q

Methods to induce labour

A

Artificial rupture of membranes;
- quickest method
- cervix has to be dilated >1cm

Propess (vaginal prostaglandin);
- inpatient only
- risks of uterine hyperstimulation

Cooks balloon (mechanical cervical dilatation);
- outpatient
- only cervical priming method suitable for previous caesarean section

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28
Q

Signs of obstructed labour

A

Slow/no cervical dilatation
No descent or high presenting part
Caput/moulding of presenting part
Haematuria
“Too good” CTG
Ascites at CS
Bandl’s ring

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29
Q

Describe chorioamnionitis

A

Intrauterine infection that can be life threatening to baby and to mother
Risks of chorio increase with duration of time between SRM and delivery, particularly if pre-term

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30
Q

Management chorioamionitis

A

“Golden Hour” of prompt recognition and starting IV antibiotics
Delivery needs to be expedited

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31
Q

PPROM vs PROM

A

PPROM (Pre-term, pre-labour rupture of membranes)
Antibiotic prophylaxis with erythromycin
Steroids depending on gestation

PROM (Prolonged rupture of membranes)
At term expectant management for first 24 hours after SRM
Offer induction

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32
Q

Signs of maternal sepsis due to chorioamnionitis

A

Increase MHR, RR, Temp, White Cell Count, CRP, Lactate
Fetal tachycardia/abnormal CTG
Offensive/blood stained liquor
Abdominal pain
Intrauterine pus at section

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33
Q

When would you not do vaginal exam in APH?

A

Placenta Praevia

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34
Q

Signs of uterine rupture

A

May have high PP or not in pelvis
Significant abdominal pain despite epidural
Shoulder tip pain
Acute abdomen
Fetal distress

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35
Q

4 Ts for management of PPH

A

Tone – Use uterotonics to improve
Trauma – Repair tear/uterus
Tissue – Make sure uterus is empty with no placental tissue/membranes
Thrombin – Consider blood products, tranexamic acid

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36
Q

Describe cord prolapse

A

Descent/prolapse of umbilical cord following rupture of membranes
More common in ARM
Life threatening to baby due to vasospasm of cord

Manage with rapid emergency section

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37
Q

Risk factors for cord prolapse

A

transverse/unstable lie, polyhydramnios, induced labour with high PP

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38
Q

Describe shoulder dystocia

A

Bony obstruction of fetal shoulder against maternal pelvis causing delayed delivery and hypoxia

Can cause injuries incl:
- erb’s palsy
- fetal fracture
- PPH
- vaginal tears
- IE
- fetal demise

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39
Q

Risk factors for shoulder dystocia

A

Previous shoulder dystocia
Diabetes (T1>T2>GDM) even without macrosomia
Fetal macrosomia (i.e. EFW >97th centile, LBW >4.5kg)
Narrow pelvic outlet

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40
Q

Management of shoulder dystocia

A

80% cases resolved by McRoberts position alone
10% further by suprapubic pressure
Internal manoeuvres then utilised aiming to reduce diameter of shoulders i.e. Woodscrew
Can consider all 4s position and reattempt manoeuvres
May need section or very rarely symphysiotomy to manage

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41
Q

Describe amniotic fluid embolism

A

Rare complication of labour where amniotic fluid enters systemic circulation and causes acute respiratory and circulatory collapse with coagulopathy
Risks include hyperstimulation and intrauterine demise

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42
Q

Causes of amniotic fluid embolism

A

Haemorrhage (Obstetric and non obstetric)
Pulmonary embolism
MI
AFE
Septic shock
Eclampsia/Epilepsy
Local anaesthetic toxicity/high block
Uterine inversion

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43
Q

Management maternal collapse

A

2222 citing maternal collapse and location
ABCDE multidisciplinary approach, remember left lateral and uterine displacement to improve resuscitation
Stabilise and deliver followed by postpartum management and ITU care

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44
Q

Describe uterine inversion

A

Literally uterus turning inside out after delivery of baby
Usually due to trying to pull a placenta that has not separated
Causes neurogenic shock followed by PPH
- low BP, no tachcardia, often strong bradycardia

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45
Q

Management of uterine inversion

A

Prompt recognition and replacement of uterus with manual pressure or using high volume warmed saline via a suction cup into vagina.

Placenta then left in situ

Delivery of placenta or ongoing management of inversion then done in theatre

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46
Q

Risk factors for OASI

A

Risk factors include primiparity, operative birth, macrosomia, hands off approach, previous OASI and quick delivery

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47
Q

Define maternal collapse

A

acute event involving cardio resp system or CNS causing reduced/absent conscious level at any stage in pregnancy and up to 6 weeks after birth

can result in cardiac arrest if not treated properly

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48
Q

What are the physiological and anatomical changes in pregnancy that affect resuscitation?

A

Aortocaval compression
- significantly reduces cardiac output from 20 weeks
Respiratory changes
- lung function, diaphragmatic splinting and increased oxygen consumption makes pregnant women become hypoxic more readily
Intubation
- more difficult esp with laryngeal oedema and bigger boobs
Aspiration
- more likely due to progestrogenic effect on oeso sphincter
Circulation

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49
Q

Causes of maternal collapse

A

Drugs
PE
AFE
Haemorrhage
Anaphylaxis
Aortic dissection
Cardiac cause
Hyoglycaemia
Sepsis

50
Q

4H and 4T and 1E causes of maternal collapse

A

Hypovolaemia
Hypoxia
Hypo/hyperkalaemia/hyponatraemia
Hypothermia

Thromboembolism
Toxicity
Tension pneumothorax
Tamponade

Eclampsia/pre-eclampsia

51
Q

How to relieve aortocaval compression?

A

Left lateral tilt from head to toe during maternal CPR
- 15-30deg

52
Q

When should you consider perimortem CPR?

A

Initiate after 4 mins CPR
Achieve delivery after 5 mins CPR
- rationale is due to the fact pregnant women get hypoxic much more quickly
- irreversible brain damage to mother can occur within 4-6 mins
Should be done where collapse and resus take place - not time for moving the pt

53
Q

PPH definition

A

SVD >500ml
Operative vaginal delivery >750ml
C-section >1000ml

54
Q

4 T causes of PPH

A

tone (uterine atony)
trauma (perineal tears, cervical tears)
tissue (placenta, fragment of placenta)
thrombin (coag problems)

55
Q

Uterotonics used in PPH

A

Syntocinon
Ergometrine
Carboprost

56
Q

How much tranexamic acid for 10% blood loss?

A

1g

57
Q

Management PPH without drugs

A

IU balloon
- presses on BVs from inside out, stays in for 24h
Brace sutures
- sutures the whole way around uterus and pull down, only via laparotomy/C-section
IR
- blocking of uterine arteries
Hysterectomy
- as last resort

58
Q

Active management of 3rd stage

A

Up to 30 mins
Uterotonics
Cord clamping
Controlled cord clamping

59
Q

Define morbidly adherent placenta

A

Placenta abnormally adherent to womb, e.g. within increta, accreta, percreta, outwith uterus
Main risk factor: multiple C-sections

60
Q

Features of uterine inversion

A

Uterus flips inside out
Can be due to cord avulsion etc
Massive vagal response from mum due to excessive bleeding
Put hand it to flip back up

61
Q

HELPERR management of shoulder dystocia

A

Call for Help
Evaluate for Episiotomy
Legs (McRobert’s)
External Pressure (suprapubic)
Enter (rotational manoeuvres)
Remove posterior arm
Roll patient onto hands and knees

62
Q

Risk factors for post-partum sepsis

A

Anaemia
Prolonged rupture of membranes
Long labour
Assisted delivery
Raised BMI
Diabetes

63
Q

Sources of PP sepsis

A

Uterine e.g. endometritis
Skin/wound esp episiotomy
Urine
Breast e.g. mastitis
Chest
Other

64
Q

Why are pregnant women at higher risk of sepsis?

A

Relative immunosuppresion in pregnancy, maternal population at increased risk of sepsis
Shift from cell mediated to humoral immunity

65
Q

Risk factors for maternal sepsis

A

Pre-natal invasive diagnostic procedures (i.e. amniocentesis, CVS)
Cervical suture
Prolonged rupture of membranes
Operative delivery
RPOC

Diabetes
Obesity
Anaemia
Immunosuppression

66
Q

Signs/symptoms of maternal infection

A

Offensive PV loss
Sore throat
Rash
Abdominal pain
Urinary frequency, dysuria
Productive cough
Wound erythema, purulent discharge
Breast erythema, tenderness

(dependent on origin of infection e.g. mastitis, endometritis)

67
Q

Signs of systemic inflammatory response synrome (SIRS)

A

Temp >/38Cor <36C
HR >100bpm
Resp rate >20/min
White cells >16x109/L or <6x109/L
Altered mental state (confusion/hyperactivity)
Unexplained coag (prolonged PTR etc)

68
Q

Blood to order in sepsis

A

FBC, U+E, LFTs, Coag, Glucose, Lactate, CRP
Paired cultures

69
Q

Antibiotic management of suspetced maternal sepsis

A

IV co-amoxiclave within 1h
+/- gentamicin depending on severity
Clindamycin if sore throat (GAS)

If penicillin allergic: Clinda + gent
If septic shock: Tazocin, clindamycin + gentamicin

70
Q

Antenatal/intrapartum sources of infection

A

Chorioamnionitis
Genitourinary
- Including HSV
Respiratory
- Influenza
- COVID
- CAP

71
Q

Post-natal sources of infection

A

Endometritis +/- RPOC
LUSCS wound/episiotomy
Mastitis
Urinary tract (especially if catheterised)
CNS (if regional anaesthetic, suspect meningitis e.g. in spinal block)

72
Q

Define chorioamnionitis

A

Inflammation of the amniochorionic (fetal) membranes of the placenta, typically in response to microbial invasion
Org: E.coli, mycoplasma, anaerobes, group B strep
Risk of neonatal sepsis

73
Q

Presentation of chorioamnionitis

A

offensive PV loss, fetal CTG concerns, maternal pyrexia and abdominal pain

74
Q

Management chorioanionitis

A

Broad spectrum IV antibiotics
Delivery
If not in established labour needs IOL or LUSCS
Manage risk of PPH with active 3rd stage syntocinon infusion
Avoid PP IU contraception

75
Q

Stratifying risk of Group B strep

A

Most babies to GBS colonised mothers will be fine
Higher risk in pre-term labour or PRM
Rarely cause neonatal pneumonia/meningitis and sepsis
5% mortality risk in GBS infection, 7% long-term disability

76
Q

When to offer intrapartum antibiotics in GBS?

A

Prophylaxis (benzylpenicillin/clindamycin)

If GBS detected antenatally
Prev baby affected by GBS
Delivery <37 weeks

77
Q

Risk factors for endometritis

A

Operative delivery
Prolonged labour,
Retained products of conception

78
Q

Presentation of endometritis

A

abdominal pain, abnormal PV bleeding, offensive PV loss following delivery/miscarriage/termination

79
Q

Management of endometritis

A

Treatment with co-amoxiclav +/- surgical evacuation of uterus if significant RPOC
Co-trimoxazole +metronidazole if penicillin allergic

80
Q

Pres of mastitis

A

Usually unilateral painful and inflamed breast in breastfeeding mothers

81
Q

Management of mastitis

A

First line - complete breastemptying via feeding/expressing, warm compress and NSAIDs
Antibiotics - fluclox if no improvement/signs of sepsis
No response to antibiotic , suspicion of fluctuant swelling - ref to breast team for USS and drainage

82
Q

Features of epidural abscess

A

Rare cause of sepsis in those having had regional anaesthesia

Presents with back pain, fever, potential neuro deficit
High mortality/morbidity if undiagnosed

83
Q

Management of epidural abscess

A

Consider imaging with MRI to diagnose
Treatment with IV antibiotics +/- surgical decompression if no response or neurological concerns
- vanc, metro, cefotaxime
- open vs CT guided surgery to drain

84
Q

Define APH/bleeding in late pregnancy

A

> / 24 weeks and before end of second stage of labour (essentially before baby delivered)

Most commonly placental abruption and placenta praevia

Ensure it’s actually coming form vagina!!!!!

85
Q

Causes of APH

A

Placental Problem- Placenta Praevia
Placental Abruption
Uterine problem- rupture
Vasa Praevia
Local causes- ectropion, polyp, infection. carcinoma
Indeterminate

86
Q

Quantification of APH

A

Spotting (staining, wiping)
Minor (<50ml, settled)
Major (50-1000ml, no shock)
Massive (>1000ml, maybe shock)

87
Q

Describe placental abruption

A

separation of a normally implanted placenta

vasospasm, arteriole rupture, blood escapes into amniotic sac or into myometium

tonic contraction, interrupts placental circ = hypoxia

results in couvelaire uterus (blood goes into peritoneal cavity)

88
Q

RFs of placental abruption

A

PET
Unknown
Trauma
Smoking, drugs
Thrombophilia, renal disease, diabetes, hypothyroid
Polyhydramnios
Multiples
Preterm
Plac insufficiency
prev abruption

89
Q

Presentation of placental abruption

A

Severe continuous abdo pain, differentiated from intermittent contractions
Bleeding
Preterm labour
Maternal collapse (maybe if mother shocked, hypotensive from blood loss etc)

Generally disteressed pt, signs not always consistent with revelaed blood

90
Q

Abdo exam signs in plaental abruption

A

Uterus LFD or normal
Uterine tenderness
Woody hard uterus
Fetal parts difficult to identify
May be in preterm labour

91
Q

Fetal signs of placental abruption

A

Bradycardic, absent heart rate (IU death0
CTG shows irritabile uterus (low conractions, FH abnormality)

92
Q

Complications placental abruption

A

Hypovolaemic shock
Anaemia
PPH (25% )
Renal failure from renal tubular necrosis
Coagulopathy/DIC (FFP, cryoprecipitate)
Infection
Complications of blood transfusion
Thromboembolism
Prolonged hospital stay
Psychological sequelae
Mortality - rare

93
Q

Prevention of placental abruption in APS

A

LMWH and low dose aspirin

94
Q

Define placenta praevia

A
  • placenta lies directly over the internal os
  • after 16 weeks, low lying + less than 20 mm from internal os on TA or TV scanning
95
Q

Risk factors for placenta praevia

A
  • previous placenta praevia
  • incr number of prior C-sections
  • prev termination
  • multiples, multiparity, assisted conception
  • smoking
  • deficient/abnormal uterus
96
Q

How is placenta praevia identified?

A
  • placental location at fetal anomaly 20 week scan
  • if persistent PP or lowlying = scan at 32 and 36 weeks
  • via TV scan
97
Q
A
98
Q

Presentation of placenta praevia

A
  • Painless bleeding >24 weeks;
  • Usually unprovoked but coitus can trigger bleeding
  • Bleeding can be minor eg spotting/ severe
  • Fetal movements usually present
  • Proportional systemic effects to volume of blood loss etc
99
Q

Exam findings in placenta praevia

A
  • Soft non tender uterus
  • High presenting part
  • Malpresentation
  • CTG normal
  • Obs depends on blood loss/level of distress/etc
100
Q

What exam should you never perform in placenta praevia?

A
  • vaginal exam!!!!!
  • speculum may be done by specialist
101
Q

When is MRI used in placenta praevia?

A

to exclude placenta accreta

102
Q

Deciding on method of delivery in placenta praevia

A

to exclude placenta accreta

103
Q

Management of bleeding placenta praevia

A

Admit and RESUS
2 grey IVs
Bloods etc
Fluids
Anti D

Xmatch 4-6 units RBC
May need Major Haemorrhage protocol

104
Q

Differences with C section in placenta praevia

A
  • consent includes hysterectomy and risk of GA
  • cell salvage
  • vertical incisions of skin an uterus before 28 weeks
  • avoid cutting placenta
105
Q

Define placenta accreta

A
  • A morbidly adherent placenta: abnormally adherent to the uterine wall
  • Multiple C sections
106
Q

Management of placenta accreta at delivery

A

Prophylactic internal iliac artery balloon
Caesarean hysterectomy
Blood loss >3L expected
Conservative Management – incision upper segment

107
Q

Defien uterine rupture

A

Full thickness opening of uterus
Including serosa
If serosa is intact
- dehiscence

108
Q

Risk factors for uterine rupture

A

previous caesarean section/ uterine surgery eg myomectomy
Multiparity and use of prostaglandins/ syntocinon increase risk
Obstructed labour

109
Q

Symptoms of uterine rupture

A

Severe abdominal pain
Shoulder-tip pain
Maternal collapse
PV bleeding

110
Q

SIgns of uterine rupture

A

Intra-partum - loss of contractions
Acute abdomen
Presenting part rises
Peritonism
Fetal distress / IUD

111
Q

Define vasa praevia

A

Unprotected fetal vessels traverse the membranes below the presenting part over the internal cervical os

Rupture during labour or at amniotomy
Fetal mortality ~60%

112
Q

Diagnosis of vasa praevia

A

Ultrasound TA & TV with doppler
Clinical
- ARM and sudden dark red bleeding and fetal bradycardia / death

113
Q

Types of vasa praevia

A

Type I
- when the vessel is connected to a velamentous umbilical cord
Type II
- when it connects the placenta with a succenturiate or accessory lobe.

114
Q

Risk factors for vasa praevia

A

PLacental anomalies - bilobed, vessel abnorms
Low lying placental history
Multiple pregnancy
IVF

115
Q

Management of vasa praevia

A

Antenatal diag
Steroids from 32w
Inpatient management if preterm risk 32-34w
Elective C section before labour 34-36w
APH from vasa praevia - emergency C section
Placenta histology

116
Q

Causes of vasa praevia

A

Cervical causes
ectropion
Polyp
carcinoma
Vaginal causes
Unexplained (1/3)

117
Q

Key prevention of PPH

A

ID intrapartum risks
Active management of 3rd stage
- Syntocinon/syntometrine IM/IV

118
Q

How to stop the bleeding in PPH?

A

TRABEXAMIC ACID
Uterine massage- bimanual compression
Expel clots
5 units IV Syntocinon stat
40 units Syntocinon in 500ml Hartmanns - 125 ml/h
Foleys Catheter- hrly volumes
500 micrograms Ergometrine
Carboprost, misoprostol
Theatre if req

119
Q

Bleeding repairs in PPH

A

Non - Surgical
Packs & Balloons – Rusch Balloon, Bakri Balloon
Tissue Sealants
Interventional Radiology : Arterial Embolisation

Surgical
Undersuturing
Brace Sutures – B-Lynch Suture
Uterine Artery Ligation
Internal Iliac Artery Ligation
Hysterectomy

120
Q
A

Reproduction/Sexual Health (9 decks)

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