Antenatal care Flashcards
1
Q
what are the determinants of gestational age
A
- SFH up to 18 weeks
- ultrasound < 24 weeks
- LNMP with sure dates
(cycle needs to be regular and not on hormonal contraceptives)
2
Q
how is EDD calculated
A
SFH
ULTRASOUND
Naegeles rule (1st date of LNMP + 7 DAYS + 9 MONTHS)
3
Q
name 9 screening indications for a OGTT
A
- previous GDM
- BMI >25
- Age > 35
- 1st degree relative with diabetes
- previous big baby
- previous unexplained still birth
- previous RDS at term
- 2 episodes of glycosuria
- macrosomnia and polyhydromnions
4
Q
how does a OGTT work
A
you need a fasting blood test
fasting
<5,5 is normal
5,5 to 7 is IGT
>7 is GDM
give 75g of glucose –> test in 2 hours
- Test glucose in 2hrs
- <7.8 mmol/L normal
- 7.8-11 mmol/L IGT
- >11 mmol/LGDM
5
Q
what is a Gravidogram for and how does it work
A
- Monitors foetal growth
- Should stay on same centile line throughout
- If SFH crosses a line investigate and refer
- Note:
- Make sure you write the date for each plot
- Plot on the 50th centile for patients who don’t know how far they are.
- Write your name above the date where you recorded
- Tick/circle if it’s by dates or U/S
6
Q
causes of enlarged SFH for dates:
A
- Incorrect dates
- Multiple pregnancy
- Macrosomia
- Polyhydramnios (fetal abnormality, maternal diabetes, multiple pregnancy, infection
- Uterine pathology
- Full bladder
7
Q
causes of Smaller SFH:
A
- Incorrect dates
- IUGR
- Oligohydramnios
- IUD
- ROM
8
Q
what is the management of enlarged SFH
A
- Ensure empty bladder
- Recheck gestational age by reviewing initial method use and comparing it to others.
- If more than 2 weeks difference between SFH and dates, use SFH - Ultrasound to exclude multiple pregnancy, EFW and fetal biometry, uterine pathology
- Amniotic fluid index to exclude polyhydramnio
9
Q
what is the management for smaller SFH
A
- Recheck gestational age by reviewing initial method use and comparing it to others.
- If more than 3 weeks difference between SFH and dates, use SFH - Ultrasound to exclude IUGR, EFW and fetal biometry
- Amniotic fluid index (5-20 N) to exclude oligohydramnios, may indicate ROM
- Auscultate FHR to exclude IUD
- CTG
- Count FM
- Doppler studies
- Biophysical profile
- Sterile speculum to exclude ROM, red litmus paper turning blue, Ferning, amniosure
10
Q
What are the risk factors for IUGR
A
- Malnutrition
- Smoking
- Substance abuse
- Previous IUGR baby
- HPT
- APH
- Multiple pregnancy
11
Q
What are the clinical findings of IUGR
A
- SFH small for GA
- Small hard head
- Oligohydramnios
- Irritable uterus
12
Q
What is the management of IUGR
A
- Identify cause and find reversible factors
- Monitor fetal growth
- Ultrasound biometry (BPD, HC, AC, FL), AFI - Monitor fetal well-being
- Doppler, CTG, fetal movements - Decide when is best time to deliver fetus
13
Q
What are the uses of U/S
A
- Diagnose pregnancy
- Determine GA < 24 weeks
- Diagnose multiple pregnancies
- Identify placenta site
- Diagnose severe congenital anomalies
- Assess fetal growth by biometry (BPD, HC, AC, FL)
- Assess amniotic fluid (AFI)
- Assess fetal heart movement when decreased FM and suspected IUD
- Difficult abdominal palpation
14
Q
What are the causes of decreased fetal movement
A
- Fetus sleep (40mins)
- Fetal growth restriction
- Small for gestational age
- Placental insufficiency
- Oligohydramnios
- APH
- IUD
- Intrauterine infections
15
Q
what is the fetal kick/movement chart for and how does it work
A
- Chart that mother’s take home to document fetal movements when there is concern
of decreased fetal movements and it is confirmed that the fetus is not in immediate
risk by measuring SFH, u/s, auscultate FHR and if needed CTG - Mom must sit down in quiet area at home 4 times a day for half an hour and tick
every time baby kicks. Add up ticks for each half hour. Then add total of half hours. - If less than 10 a day or more than 3 periods pass without kicking report to
hospital for CTG
16
Q
what are the maternal indications for a CTG
A
- Severe HPT, pre-eclampsia
- Induction/augmentation of labour
- Previous C/S in labour
- Suspected growth restriction
- Chorioamnionitis, sepsis, or pyrexia
- Previous stillbirth or HIE
- Prolonged pregnancy
- VBAC
- Pelvic bleeding
17
Q
What are the fetal indications for a CTG
A
- Post-dates
- IUGR/oligohydramnios
- Meconium stained liquor
18
Q
what are the features of a CTG
A
- Contractions
- Heart rate
- Variability
- Accelerations
- Decelerations
19
Q
What to look at for contractions on a CTG
A
- Always ensure it is 1cm per minute
- Size of peaks of contractions are irrelevant
- Should not last more than 60 seconds
- Should return to the baseline pressure between contractions
- Increased contractions will result in fetal hypoxia >reduced blood flow in placenta
during contraction
20
Q
what are the 9 things to note when describing a CTG
A
- PT ID, Date, time
- Paper speed
- Contractions
- Baseline FHR
- Variability
- Accelerations
- Decelerations
- Categorise: normal, suspicious, pathological
- Management
21
Q
Management of pathological CTG
A
- Change maternal position to left lateral
- IV fluids
- Oxygen by face mask
- Call for experienced opinion
- Stop oxytocin
- Tocolysis if needed
- Delivery: instrumental or c/s
22
Q
what is the first stage of labour made of
A
latent and active phase
23
Q
explain the latent phase of labour
A
- Latent phase= start of onset of labour until cervix <5cm dilated
- 2hrly: FHR and maternal HR, contractions
- 6hrly: maternal observations (BP, temp, RR), VE
- Repeat VE earlier if:
➢ Frequency/intensity/duration of contractions change
➢ Subjective impression that women is in APL
➢ Request for opiate analgesia
➢ Urge to bear down
➢ Non-reassuring fetal or maternal condition - Refer when:
➢ Maternal and/or fetal condition non-reassuring
➢ ROM >12hrs and still in latent
➢ MSL in latent phase
➢ PV bleeding
➢ Latent stage after 12hrs
24
Q
describe active first of labour
A
- Active phase= cervix 5cm dilated until fully dilated
- Usually <12hrs primi, <10hrs multi
- Start by plotting dilation on alert line
- 30mins: FHR and maternal HR
- 2hrly: contractions
- 4hrly: maternal observations (BP, temp, RR), VE (once 8cm 2hrly)
- Urine when passed
- May last up to 24hrs
25
when does the second stage of labour start
* From full dilation until baby is delivered
26
when does the third stage of labour start
* Once fetus is delivered until placenta and membranes are delivered
* < 30mins
27
what happens in intrapartum resuscitation
* Ask the woman to lie on the left side
* Administer oxygen through face mask
* Start IV or Ringer’s lactate
* Stop oxytocin, tocolysis if needed
* Deliver by quickest possible route
28
causes of haematuria in pregnancy
* Acute nephritis
* APH
* Uterus rupture
* UTI
29
what is Pre-eclampsia
* Proteinuria with BP >140/90mmHg
* Severe pre-eclampsia 160/110mmHg
* Imminent eclampsia: headache, visual disturbances, epigastric pain, SOB, renal angle
tenderness, increased tendon reflexes, tachy
30
when is Magnesium sulphate used and how
* When there are signs of imminent eclampsia and increased blood pressure
* 4 grams in 200ml 5% Dextrose water as loading dose over 30mins then 4 grams in
200ml 5% Dextrose water through a mini dropper at 50dpm for maintenance (1g/hr)
* Discontinue if:
- Arereflexic
- Urine output <30ml/hr
* Antidote for toxicity:
- 10% calcium gluconate 10ml IV over 10mins
31
what is CPD and how is the diagnosis made
* Absolute= normal size baby but small or abnormal shaped pelvis. Contracted pelvis.
* Relative= normal shaped pelvis but large baby/or malposition of foetal head
diagnosing CPD
* Delay in cervical dilation on partogram
* Other causes of poor progress excluded
* No change in station of presenting part
* Increasing caput and moulding of fetal head
32
What are the complications of CPD
* Shoulder dystocia
* Intracranial haemorrhage
* Umbilical cord prolapse
* PROM
* Fetal distress
* Uterine damage and rupture especially in parous women
* Bladder damage with formation of vesico-vaginal fistula
33
What Is the management of CPD
* Diagnose CPD
* Deliver asap with c/s
* Supress uterine contractions
34
Active management of third stage of labour
Aim to prevent PPH.
1. Use of Oxytocic drugs immediately following delivery of the baby:
- Be sure this is not a multiple pregnancy.
- Administer 10 units of Syntocinon intramuscularly with delivery of the anterior
shoulder.
2. Delivery of the Placenta:
- Delayed clamping of the cord of at least 1 minute has significant short and
median term benefits for the baby.
- Divide the umbilical cord between clamps.
- The placental end of the cord may remain clamped or be allowed to drain. (Must
be clamped in twin pregnancies and probably better to allow to drain in Rhesus
negative patients)
- Wait for the uterus to contract strongly - this is usually accompanied by slight
bleeding indicating placental separation
- Deliver the placenta by gentle, steady, controlled cord traction. Countertraction
being applied to the uterus suprapubically in a cranial direction
- Following delivery of the placenta, rub up the uterus until firmly contracted and
administer Ergometrine 0.5mg intramuscularly unless contra-indicated.
3. Check BP/pulse/pads every 15 minutes for first hour after delivery. Every 30 minutes
for second hour after delivery.
35
What is PPH
Excessive bleeding from genital tract after delivery. Blood loss > 500mls NVD, >1000mls c/s.
36
What are the risk factors of PPH
* APH
* Multigravida
* Previous PPH
* Multiple pregnancy
* Prolonged pregnancy
37
What are the causes of PPH
* Retained placenta or fragments of placenta
* retained membranes
* Trauma
4. Vaginal lacerations
5. Cervical tears
6. Perineal tears
7. Ruptured uterus
* Bleeding associated with c/s
* Uterine inversion
* Uterus atomy
38
What measures can be taken to prevent PPH
* Routine iron supplementation to prevent anaemia
* At risk women deliver in level 1-2 hospital
* Prevent prolonged labour
* Active management in third stage
* Routine post-partum monitoring of vitals and bleeding
* Empty bladder
* Cervix fully dilated before delivery or instrumental use
* Only push with contractions
39
WHAT IS THE MANAGEMENT OF PPH
Massage the uterus to expel clots to induce contraction
Insert an Intravenous line and infuse 10 IU Oxytocin in 100 or 200mls fluid in 5-10 minutes. NB. Some practitioners may omit this and rather commence 20 IU oxytocin infusion
Infuse Tranexamic acid TXA) 1000gms in 100 or 200mls fluid in 10 minutes
Infuse 20 IU oxytocin in one litre Sodium Chloride 0,9% or Ringers
Lactate over 4-8 hours as a maintenance infusion
Insert a second IV line and run fast if the patient is haemodynamically unstable
Ensure the bladder is empty
Examine for genital tract tears and suture if present
Examine placenta for completeness (see section on retained placenta)
40
Erythroblastosis fetalis result
1. Profound anaemia at birth
2. Respiratory distress, cardiac failure
3. Severe: massive extra medullary haematopoiesis, hydrops fetalis, IUD
41
management of multiple pregnancy
1.Diagnosis should be made as early as possible.
2. Treatment of complications as they arise.
3. Monitoring of haemoglobin and prevention of anaemia.
4. Physical activity: uncomplicated twin pregnancies can continue to exercise as in a singleton pregnancy.
5. Measuring cervical length from 16 weeks can be helpful in identifying women at risk for preterm labour, although evidence for this practice is sparse.
6. Ultrasound assessment of growth should be every 4-6 weeks after 20 weeks for dichorionic twins, and 2-4 weekly for monochorionic twins.
