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Obs & Gynae > Anatomy of pregnancy > Flashcards

Anatomy of pregnancy Flashcards

1
Q

What does this describe: the space between the pubic symphysis, superior boarder of pubic crest, pubic tubercle, pectineal line, iliopubic eminence, arcuate lines, alar of sacrum & sacral promontory (S1 body)?

A

The pelvic inlet

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2
Q

What does this describe: wider antero-posteriorly; transverse ~11cm, AP = ~11.5; 25 degree angle to horizontal?

A

the pelvic outlet

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3
Q

What does this describe:

Separates true (above) & false (below) pelvis

60 degrees to horizontal (angle of inclination) - pelvis tilted, ASIS and pubic tubercle in same vertical plane

wide _transversely (_transverse ~13cm, AP (conjugate) ~12cm)

A

The pelvic inlet

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4
Q

What does this describe:

diamond shaped, pubic symphysis, inferior pubic rami, ischial rami, ischial tuberosity, sacrotuberous ligament. coccyx?

A

pelvic outlet!

[diamond shaped, pubic symphysis, inferior pubic rami, ischial rami, ischial tuberosity, sacrotuberous ligament. coccyx]

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5
Q

What route does the foetus take in the bony pelvis?

A

the pelvic axis

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6
Q

What muscles make up the pelvic floor?

A

Levator ani

  • iliococcygeus
  • pubococcygeus
  • puborectalis

& coccygeus muscle on each side

+ anterior support by perineal membrane & muscles in deep perineal pouch

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7
Q

What shape / gender pelvis are these?

  • android
  • anthropoid
  • gynaecoid
  • platypelloid
A
  • android = male
  • anthropoid = long antero-posteriorally
  • gynaecoid = female
  • platypelloid = wide laterally
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8
Q

At what spinal level does the dura mater terminate at?

A
  • S2

(cauda equina ~L1-L5; comes off conus medularris ~T12)

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9
Q

What changes to the uterus occur during pregnancy?

A

Uteral changes:

  • Enlargement of uterus beyond pelvic cavity into the abdominal cavity – by 12 weeks (tri. #1)
  • Increased vascularity & cellularity of uterus.
  • Development of lower uterine segment.
  • Relative shift of uterine tubes due to fundal enlargement.
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10
Q

What changes occur to the genitals during pregnancy?

A
  • Softening of cervix & glandular hypertrophy.
  • Blue tinge of lower genital tract due to Venous congestion
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11
Q

What changes occur to the skeleton during pregnancy?

A
  • Softening & relaxation of ligamentous joints.
  • Shift of centre of gravity→lumbar lordosis.
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12
Q

What changes occur to skin/tissues in pregnancy?

A
  • Breast enlargement.
  • Stretching of musculature of the anterior abdominal wall.
    • –>Striae gravidarum from Rupture of connective tissue fibres - e.g. stretch marks
  • Increased pigmentation eg
    • linea nigra,
    • cloasma,
    • nipples.
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13
Q

during delivery how does the foetus:

1) enter
2) turn
3) extend
4) get shoulders out?

A

1) enters transversely
2) turns 90 degrees @ pelvic floow
3) extends neck when it reaches ischial spines
4) turns 90d again to get shoulders out

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14
Q

Where does the babys head need to fit between for delivery?

A

needs to fit between the symphysis pubis and sacrum - e.g. the biparietal diameter of the baby’s head ~9.5cm

  • TF you want the babys occiput anterior (symphysis pubis) and head tucked in - makes smaller diameter
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15
Q

When is the uterus palpable O/E?

A

10-12wks

e.g. end of tri. #1

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16
Q

When does the uterus reach the umbilicus?

A

20wks

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17
Q

When does the uterus reach the xipisternum?

A
  • at 36 wks
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18
Q

When can you start measuring fundal height (cm)?

A

roughly corresponds to gestational age in weeks between 16 - 36 weeks

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19
Q

What is the ideal/normal positioning for a foetus at term?

A
  • longitudinal lie
  • cephalic presentation
  • L occiput –> anterior position
  • head not yet engaged
  • listen on shoulder for HR
  • symphiso-fundal height ~consistent with age
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20
Q

At what stage of labour does the foetal head enter into the pelvic inlet transversely?

NB: remember the pelvic inlet is wider transversely

A

in the 2nd stage of labour

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21
Q

When is the foetal head described as “engaged”?

A

when the head lies in the true pelvis

e.g. 3/5ths of the head felt in the abdo

NB: the true pelvis is above the pelvic inlet and the false pelvis is below

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22
Q

What turns the babys head 90 degrees when they reach the pelvic outlet and why?

A

the levator ani (pelvic floor) turns the babys head 90 degrees

because the pelvic outlet has a greater AP diameter

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23
Q

At what anatomical landmark does the babys neck extend at when it reases?

A

the babys neck extends when it reaches the ischial spines

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24
Q

What does restitution refer to during labour?

A

restitution = the second 90 degree turn allowing the baby’s shoulders to be delivered

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25
Q

what injury becomes possible at “restitution” during labour?

A

upper brachial plexus (Erbs palsy) injury is possible at restitution

e. g. restitution = where the shoulders are able to be delivered due to the 2nd 90 degree turn
* NB:(the first was turning the head 90 deg. to go into the pelvic outlet that has a greater AP diameter)*

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26
Q

What is shoulder dystocia?

A

An obstetric emergency!

where the shoulders become stuck & the babys thorax is compressed

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27
Q

How do you feel for the position of the foetus? which is the widest part of the foetal head?

A

feel fontanelles!

anterior/posterior aka the longitudinal diameters are the widest part of the foetal head

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28
Q

What position of the baby during delivery does this describe?

  • Baby’s face to sacrum
  • Feel anterior fontanelle - at 6 o’clock (sacrum is 12 o’clock)
  • Smallest diameter, one that presents optimally in labour
A

Occipito-anterior position (ideal)

  • head flexion
  • head deflexion
29
Q

What position of the baby during delivery does this represent?

  • -Baby’s face to pubic symphysis
  • -Feel baby’s eyes on delivery
  • -Anterior fontanelle at 12 o’clock

is delivery possible?

A
  • Occipito-posterior position

(rotated this way by pelvic floor)

  • Delivery possible
30
Q

What position of the baby during delivery is this:

Feel baby’s eyes, nose & mouth on delivery

is it deliverable?

A
  • brow presentation
  • abdominal delivery necessary!
    • e.g. occipito frontal diameter / mento-vertical diameter is big so –> c section
31
Q

What does it mean if a baby is coming out with the sub-mento-vregmatic diameter?

A
  • this means the ramus of mandible to centre of anterior fontanelle e.g.
  • FACE PRESENTATION!
    • the head is completely extended unlike occipito-frontal/mento vertical (brow px)
  • in theory vaginal delivery of face px is possible if the chin is anterior… TF if mento-anterior - allow vaginal delivery
  • if mento-posterior = no more flexion is possible for baby to come out –> C-SECTION
32
Q

What does it mean if O/E you feel the sacrum of the baby?

A

Breach position! - RCOG recommends all breach delivered abdominally

  • can be complete = where knees are bend and feet and bottom are closest to birth canal
  • incomplete = one of babys knees bent
  • frank = both legs straight - just bum at bottom
  • footling = one foot out other knee bent

Can deliver vaginally (if trained person around?) if FRANK/EXTENDED breach

33
Q

How would you deliver a frank breach baby? (in theory)

A
  1. rotare baby so back is uppermost
  2. pull each leg out in turn
  3. let baby hang
  4. pull each arm out in turn
  5. then pull out head
34
Q

How do you perform manual pelvimetry?

A

if fist fits between ischial tuberosities, baby will fit

35
Q

What are the 2 types of cepalo-pelvic disproptortion and what do they mean?

A
  1. absolute
    • the baby is never going to get out (maybe due to pelvic shape)
  2. relative
    • the position of the baby is impairing delivery e.g. occipito-posterior ir de-flection of foetal head
36
Q

What is looked for in a vaginal exam done during labour?

A
  1. station of presenting part in relation to the ischial spines
  2. dilation (if full dilation = cant feel cervix)
  3. feel sutures & fontanelles
37
Q

What does -2 or +1 station mean?

A

the station is the presenting part in relation to the ischial spines

-2 = 2cm ABOVE ischial spines

+1 = 1cm below ischial spines

38
Q

in feeling sutures and fontanelles:

what is moulding and caput?

A

caput is associated with moulding

  • Moulding = compression of head,
    • AKA can feel sutures overlying eachother
  • Caput = cant feel the sutures and fontaelles because of swelling from squashing of head–> occludes lymphatic/venous return –> swelling!
39
Q

Why are fontanelles useful for guiding forceps?

A

fontanelles guide placement of forceps so as not to cause fractured skull

40
Q

How are pelvic measures taken in obstetrics using imaging?

Why is this useful?

What parameters are looked at

A
  • MRI is used - no radiation
  • these measurement help predict the liklihood of successful vaginal delivery, they look at:
    • Sagittal inlet and outlet,
    • & inbetween: maximum transverse inlet diameter, bispinous outlet
41
Q

What are the landmarks of sagital inlet and sagittal outlet seen on MRI for pelvic measures in obstetrics?

A

sagittal inlet: between sacral promontory (S1) & top of pubic symphysis

sagittal outlet: top of coccyx to inferior margin of pubic symphysis

42
Q

Where does ectopic pregnancy most commonly occur?

A

in the ampulla

43
Q

what conditions predispose to ectopic pregnancy?

A

anything kind of blocking/scarring the area?

  1. infection
  2. PID
  3. chlamydia
  4. appendicitis
  5. fibrosis from endometriosis
  6. coil!
44
Q

What are the 3 main killers in pregnancy?

A
  1. Haemorrhage
  2. hypertensive disorders
  3. venos thromboembolism
45
Q

What are the 4 grades of pelvic diaphragm tear?

A
  1. fourcechette & superficial perineal skin & _vaginal mucosa_l
  2. extends to perineal muscles and fascia
  3. extends to anal sphincter
  4. extends to rectal mucosa (e.g. breaks rectal wall)

NB: even if not torn, muscles weaken after surgery

46
Q

What does this this describe:

incision made into perineal body to enlarge the vaginal orifice & allow the head of the fetus to pass through vagina?

Why is it done and what variations are there?

A

Episiotomy = done to cause less trauma to the peritoneum

  • Median cut - incises the perineal body
  • Medio-lateral - incision 45 degrees from the midnline
    • –> avoids the perineal body,
    • —> instead cuts the bulbospongiosus and superficial transverse muscle
47
Q

Why can the foetal anomaly scan happen at 12 weeks?

A

at 12 weeks the foetus is fully formed and just needs to grow

e.g. brain, palate, heart chambers, femur length, head, abdomen

48
Q

When is the early pregnancy USS scan done and what can it show?

A

early pregnancy USS scan 6-11w

scan shows if there is a:

  • pregnancy/
  • ectopic/
  • age/
  • foetal HR present

to determine the age of foetus = use crown-rump length

49
Q

What are the 3Ps of labour?

A
  • Passenger
  • Passages
  • Power
50
Q

What factors of “passenger” affect labour?

A
  • babys head measurements
  • position
51
Q

What factors of “passages” affect labour?

A
  1. engagement of foetal head
  2. boundaries of pelvis - inlet and outlet
  3. pelvic tilt
  4. levator ani muscles - the origin and insertion
  5. perineaum - implication & tears, episiotomies
52
Q

What factors of “power” affect labour?

A

these involve things affecting the UTERUS - which contracts to expel baby

  • Anatomy: corpus & cervix, 3 layers, oxytocin
  • nerve supply: symp = lumbar splanchnic, para = pelvic splanchnic
    • –> these are affected by:
      • Epidural
      • pudendal nerve block
53
Q

What are the stages of labour?

A
  • stage 1
    • effacement & dilation of cervix (latent)
    • after 3cm –> dilation occurs at 1cm/hr = active
  • stage 2
    • full dilation & expulsion of foetus
  • Stage 3
    • expulsion of placenta
54
Q

What do these represent?

  • Fully dilated
  • Occipital position
  • Ruptured membranes
  • Contractions
  • Empty bladder & episiotomy
  • Pain relief
  • Station (in relation to ischial spines)
A

the criteria for instrumental delivery!

55
Q

What is a morula?

A
  • >32 cell ball…
    • too many cells to count
  • Happens by day 4!
56
Q

What is a blastocyst?

A
  • the name of the morula once it has entered the uterus
  • It is a ball of cells & cyst of fluid

happens by day 5!

57
Q

What are the 3 layers of a blastocyst?

What do they do?

A
  • trophoblast
    • cells of blastocyst that invade endometrium and myometrium –> secrete bhCG
  • chorion
    • becomes placenta
  • amnion
    • becomes amniotic sac
58
Q

Where does the early embryonic nutrition come from?

A
  • reliant on cytoplasm inherited from oocyte
  • & histiotrophic
    • uterine secretions
  • haemotrophic
    • vascular contact between foetus and mum
59
Q

When is the “window for implantation”?

A

Day 5-6 e.g. after the blastocyst has formed from the morula on D4 upon entering the uterus

60
Q

When does the trophoblast produce bhCG?

A

at day 10

this maintains the corpus luteum which produces progesterone to prepare the endometrium for preg (= decidualisation) –> vital until placental steroidgenesis

(trophoblast supplys the embryo with nourishment and later forms the major part of placenta)

Its maximum amount of bhCG occurs at 9-11 weeks (only needed in early stages)

61
Q

What can the bhCG levels produced by the trophoblast be used for?

A
  • the basis of urinary pregnancy tests (qualitative measurement of beta subunit)
  • if bhCG falls = dx miscarriage
  • if bHCG rises too slowly = could be an ectopic pregnancy
62
Q

What are the functions of the placenta?

A
  1. Steroidogenesis
  2. nutrition
  3. removal of waste
  4. barrier: against infection e.g. bacteria, viruses AND drugs
  5. antibodies
63
Q

Why is the placenta useful for antibodies?

A

passes IgG on = passive immunity

NB: rubella gets across placenta

64
Q

What steroids are produced in placental steroidogenesis?

A
  • oestrogens
  • progesterone
  • Human placental lactogen (breaks down fats from mother to give for fuel to baby)
  • cortisol
65
Q

What nutrition does the placenta provide and what waste does it remove?

A

Gives: O2, carbs, fats, AA, vitamins, minerals

removes: CO2, urea, NH4, minerals

66
Q

What contains a huge low pressure uterine blood supply, has a huge reserve in function e.g. can lose parts of the uterus and still function & has a huge surface area in contact with maternal blood?

A

the placenta!

67
Q

What is the end purpose of these tissues invading the mothers uterus

  1. syncytiotrophoblast
  2. cytotrophoblast
  3. extraembryonic mesoderm
A

1 invades first then 2 then 3

they move down into linings and blend

the mesoderm differentiates into–> blood vessels and “pools” of maternal blood are found

the end point ==> mature branched vili

(theoretically there is TF no mixing of foetal/maternal blood: in practice a little bit always mixes)

68
Q

What disorders of the placenta are there/what can they cause?

A
  • Miscarriage: 15% pregnancies
  • Ectopic pregnancy
  • Hydatidiform mole: genetic, excessive trophoblastic activity (e.g. supposed to supply embryo with nourishment) can cause chorio-carcinoma
  • Pre-eclampsia
  • Placenta insufficiency: under-perfusion & growth restriction of the baby
  • Transfer of drugs, toxins, infections to foetus
69
Q

the trophoblast supplys the embryo with nourishment and later forms the major part of placenta.

What are the stages of trophoblast invasion ~10 when it produces bhCG?

A
  1. Early invasion
  2. decidualisation - thick layer of modified mucous membrane lining uterus
  3. stromal reaction - becomes oedematous/connective tissue
  4. angiogenesis - BV to provide nouishment etc
  5. erosion of the uterine decidua and glandular tissue by trophoblast = BV/mature villi left

Obs & Gynae (5 decks)

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