phase 3a vishal ram the peer teaching society is not liable for false or misleading information…

Phase 3a

Vishal Ram

The Peer Teaching Society is not liable for false or misleading information…

•Normal labour•Complications & Emergencies•Prematurity•Puerperium•Exam Qs and Tips


Topics to cover

First Stage: Time between onset of regular contractions and full dilation of the cervix.

Uterine contractions Cervical ripening = softeningCervical effacement = change in shape of cervix from bulb to flatCervical dilation = normal rate is 1-3cm/hrPink/white mucus (+ liquor) secretion from cervix

Latent phase = 0-4cm Full dilation of cervix to 10cmDescent, flexion and internal rotation of the baby


Normal labour

Normal labourSecond Stage: From full dilation to deliveryDescent, 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


https://www.youtube.com/watch?v=duPxBXN4qMg

Normal labourTypes of tear during delivery:

1st degree = minor damage to the fourchette2nd degree = tear involving the perineal muscles3rd degree = tear affecting the anal sphincter4th degree = tear involving the anal mucosa


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 bleedingDuring this time uterine contractions occur to compress the blood vessels supplying the placenta.

Complications & Emergencies

Antepartum Haemorrhage = Bleeding after 24 weeks gestation

•Causes:1. Placenta Praevia2. Placental Abruption 3. Vasa Praevia


Complications & EmergenciesPlacenta 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 osMinor = in lower segment (but does not cover internal os)


Complications & EmergenciesPlacenta 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).


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:-Fetal death (common)-DIC-Renal failure-Maternal death



Main causes-IUGR-Pre-eclampsia-Maternal smoking-Cocaine usage-PH of placental abruption-Multiple pregnancy

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 c-section (after 37 2wweeks)



Complications & EmergenciesVasa Praevia:Umbilical cord inserts into the membrane (choriamniotic membrane) NOT the placenta – known as velamentous cord insertionThis leads to vulnerable vessels which are prone to rupture when membranes break during delivery.

Lead to copious bleeding and stillbirth

Diagnostic triad:1. Membrane rupture2. Painless vaginal bleeding3. Fetal bradycardia

Treatment = immediate emergency c-section (following rupture of membranes)


Complications & EmergenciesPostpartum 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.


Complications & EmergenciesPostpartum Haemorrhage (PPH)

For causes remember the 4 Ts:

-TONE = atomy-TRAUMA = from delivery-TISSUE = retention of the placenta-THROMBIN = coagulation disorders


Complications & EmergenciesShoulder DystociaShoulder 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


Complications & EmergenciesShoulder DystociaThe 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)


Prematurity


• Risk Factors:– Smoking– Cervical weakness– Genital infection (e.g. BV, UTI)– PH of prematurity– Pre-eclampsia– Gestational diabetes

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



• Complications– Developmental delay– Chronic lung disease Respiratory distress

syndrome due to a lack of surfactant (give IM corticosteroids)

– Cerebral palsy– Visual/hearing impairment

Prematurity


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:– Postnatal Psychosis = mania or depression– PPH– Postnatal anaemia (common and overlooked)– Puerperal pyrexia– Thromboembolism (more common following c-section =

DVT/PE)


Exam tipsWhat we had:•MEQ:

– Abdominal pain during pregnancy– Abdominal mass, pain, vaginal bleeding

•EMQ:– 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

phase 3a vishal ram the peer teaching society is not liable for false or misleading information…

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