Transcript Obstetrics 2(b) - Peer Teaching Society

Phase 3a
Vishal Ram
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Topics to cover
•Normal labour
•Complications & Emergencies
•Prematurity
•Puerperium
•Exam Qs and Tips
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Normal labour
First Stage: Time between onset of regular contractions
and full dilation of the cervix.
Uterine contractions
Cervical ripening = softening
Cervical effacement = change in shape of cervix from bulb to flat
Cervical dilation = normal rate is 1-3cm/hr
Pink/white mucus (+ liquor) secretion from cervix
Latent phase = 0-4cm
Full dilation of cervix to 10cm
Descent, flexion and internal rotation of the baby
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Normal labour
Second Stage: From full dilation to delivery
Descent, flexion and internal rotation completed followed by
extension of the baby’s head as it delivers.
Passive phase = head reaches pelvic floor (engagement, rotation
and flexion are complete) – mum experiences a desire to push.
Active phase = mum pushes (valsava manoeuvre) – due to pressure
of the head on the pelvic floor.
Delivery:
 Perineum stretches and often tears!
 Restitution = head rotates 90o into transverse position – in which it entered the
pelvis
 Next contraction = shoulder delivered
https://www.youtube.com/watch?v=duPxBXN4qMg
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Normal labour
Types of tear during delivery:
1st degree = minor damage to the fourchette
2nd degree = tear involving the perineal muscles
3rd degree = tear affecting the anal sphincter
4th degree = tear involving the anal mucosa
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Normal labour
Third Stage: Time from delivery of fetus to delivery of
placenta (approx. 15 mins)
Delivery of placenta and membranes and the control of bleeding
During this time uterine contractions occur to compress the blood
vessels supplying the placenta.
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Complications & Emergencies
Antepartum Haemorrhage
= Bleeding after 24 weeks gestation
•Causes:
1. Placenta Praevia
2. Placental Abruption
3. Vasa Praevia
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Complications & Emergencies
Placenta Praevia:
Low-lying placenta – common at 2o weeks – but moves
‘upwards’ as pregnancy continues
Classification = proximity of placenta to internal os of
cervix:
Major = covers the internal os
Minor = in lower segment (but does not cover internal os)
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Complications & Emergencies
Placenta Praevia:
Clinical Features:
-Intermittent PAINLESS bleeding – red/profuse
-Often an incidental finding on ultrasound scan.
-Breech pregnancy + transverse lie are common (fetal head not engaged – its
high)
(Note: vaginal examination can provoke a massive bleed – NEVER performed
unless placenta praevia excluded)
Investigations:
-Ultrasound – confirms diagnosis
Management:
-Delivery = Elective c-section at 39 weeks (if major = c-section, if minor = aim
nvd unless 2cm from internal os).
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Complications & Emergencies
Placental Abruption:
Part/all of the placenta separates from the lining of the
uterus before delivery of the fetus (occurs after 24 weeks)
Main complications:
Main causes
-Fetal death (common)
-DIC
-Renal failure
-Maternal death
-IUGR
-Pre-eclampsia
-Maternal smoking
-Cocaine usage
-PH of placental abruption
-Multiple pregnancy
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Complications & Emergencies
Placental Abruption:
Clinical Features:
-PAINFUL bleeding – blood behind placenta + in myometrium – blood often
DARK
-May be concealed (pain, no blood) or revealed (pain with blood).
-On examination = Tachycardia, hypotension (MASSIVE blood loss), tender
uterus. In severe – uterus is ‘woody’ – fetus difficult to feel.
(Note: volume of blood is not proportional to the severity)
Investigations:
-CTG (ultrasound not useful unless to exclude placenta praevia)
Management:
-IV fluids and steroids, blood transfusion considered, opiate analgesia
-Delivery = Fetal distress = urgent c-section; if no fetal distress = elective csection (after 37 2wweeks)
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Complications & Emergencies
Vasa Praevia:
Umbilical cord inserts into the membrane (choriamniotic membrane)
NOT the placenta – known as velamentous cord insertion
This leads to vulnerable vessels which are prone to rupture when
membranes break during delivery.
 Lead to copious bleeding and stillbirth
Diagnostic triad:
1. Membrane rupture
2. Painless vaginal bleeding
3. Fetal bradycardia
Treatment = immediate emergency c-section (following rupture of
membranes)
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Complications & Emergencies
Postpartum Haemorrhage (PPH)
Primary PPH = 1st 24hrs after delivery; blood loss > 500ml
-Causes = Uterine atony (reduced tone), uterine rupture, clotting
disorders
(RFs for atony = PMH, uterine abnormality, large placenta, placenta
praevia/abruption)
-Management = Oxytocin, bimanual compression, blood transfusion
Secondary PPH = Excess blood loss after 24hrs
-Causes = Retained placental tissue, clot
-Management = USS to identify retained products, give ampicillin and
metronidazole as secondary infection is common, careful curette of
uterus – histology for choriocarcinoma.
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Complications & Emergencies
Postpartum Haemorrhage (PPH)
For causes remember the 4 Ts:
-TONE = atomy
-TRAUMA = from delivery
-TISSUE = retention of the placenta
-THROMBIN = coagulation disorders
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Complications & Emergencies
Shoulder Dystocia
Shoulder cannot be delivered after the head has been delivered =
anterior shoulder is stuck behind the symphasis pubis
•Causes:
– Diabetes mellitus
– Fetal macrosomia
– Maternal obesity
– Prolonged labour
– Too much oxytocin (increased uterine contractions)
– Abnormal fetal lie
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Complications & Emergencies
Shoulder Dystocia
The mothers pelvis constricts the baby’s chest, and there is also
often cord compression, thus asphyxiation is the main risk.
-Usually acidosis and asphyxiation will set in after about 4-5
minutes in the shoulder dystocia position.
•Management:
-Get mum into McRobert’s position
-Try other manoeuvres – Rubin , Woodscrew
-Maternal Symphisiotomy
-Push the head back in – emergency c-section (last choice)
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Prematurity
• Risk Factors:
– Smoking
– Cervical weakness
– Genital infection (e.g. BV, UTI)
– PH of prematurity
– Pre-eclampsia
– Gestational diabetes
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Prematurity
• Primary Prevention: Reducing population risk:
– Smoking/STD prevention
– Cervical Assessment at 20 weeks (1. Transvaginal cervical ultrasound
2. Qualitative fetal fibronectin test)
– Reducing multiple pregnancies
• Secondary Prevention: Methods to diagnose and treat existent
disease
• Tertiary Prevention: Treatment after diagnosis
– Prompt diagnosis and referral
– Drugs = Tocolytics (terbutaline, nifedipine, progesterone)
– Corticosteroids
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Prematurity
• Complications
– Developmental delay
– Chronic lung disease  Respiratory distress
syndrome due to a lack of surfactant (give IM
corticosteroids)
– Cerebral palsy
– Visual/hearing impairment
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Puerperium
• Postnatal care – 6 weeks following birth
• Common problems = Perineum damage, urinary
incontinence (approx. 50%), constipation and
haemorroids, mastitis, backache and postnatal
depression.
• Serious maternal health problems:
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Postnatal Psychosis = mania or depression
PPH
Postnatal anaemia (common and overlooked)
Puerperal pyrexia
Thromboembolism (more common following c-section = DVT/PE)
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Exam tips
What we had:
•MEQ:
– Abdominal pain during pregnancy
– Abdominal mass, pain, vaginal bleeding
•EMQ:
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Treatment for infertility and sexual dysfunction
Diagnosis of breast lump
Diagnosis of vaginal discharge
Diagnosis of medical conditions in pregnancy
Management of complications in pregnancy
-Diagnosis of abnormal vaginal bleeding in pregnancy and puerperium
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