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

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 The Peer Teaching Society is not liable for false or misleading information… 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 90 o into transverse position – in which it entered the pelvis  Next contraction = shoulder delivered The Peer Teaching Society is not liable for false or misleading information…

Normal labour Types of tear during delivery:  1 st degree = minor damage to the fourchette  2 nd degree = tear involving the perineal muscles  3 rd degree = tear affecting the anal sphincter  4 th degree = tear involving the anal mucosa The Peer Teaching Society is not liable for false or misleading information…

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

Complications & Emergencies Antepartum Haemorrhage = Bleeding after 24 weeks gestation Causes: 1.Placenta Praevia 2.Placental Abruption 3.Vasa Praevia The Peer Teaching Society is not liable for false or misleading information…

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

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

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 Complications & Emergencies The Peer Teaching Society is not liable for false or misleading information…  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 & Emergencies The Peer Teaching Society is not liable for false or misleading information…

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

Complications & Emergencies Postpartum Haemorrhage (PPH)  Primary PPH = 1 st 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. The Peer Teaching Society is not liable for false or misleading information…

Complications & Emergencies Postpartum Haemorrhage (PPH)  For causes remember the 4 Ts: -TONE = atomy -TRAUMA = from delivery -TISSUE = retention of the placenta -THROMBIN = coagulation disorders The Peer Teaching Society is not liable for false or misleading information…

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

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

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

Complications –Developmental delay –Chronic lung disease  Respiratory distress syndrome due to a lack of surfactant (give IM corticosteroids) –Cerebral palsy –Visual/hearing impairment Prematurity

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

The Peer Teaching Society is not liable for false or misleading information… Exam tips  What 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