Antenatal Care pt 2 Flashcards
How do you give antenatal steroids?
· 2x 12mg IM Betamethasone (given 24hrs apart)
· Optimal benefit is seen 24 hours after initiation of therapy and lasts for about 7 days
· Alternative: 4 doses of 6 mg IM dexamethasone 12 hours apart
What is a partogram?
It is a pictorial assessment of the progress of labour -> allows rapid identification of slow/obstructed labour
Who needs a partogram?
o All women in active labour (> 4 cm dilated, contracting > 3 in 10)
o All women on syntocinon
o Threatened premature labour with the use of atosiban (inhibits oxytocin and vasopressin)
What are the components of a partogram?
Maternal HR – every 30 mins
BP and temperature – every 4 hours
Contractions – every 30 mins
Colour of liquor – every 30 mins
Cervicograph
Abdominal descent
Cervical dilatation – every 4 hours
Nulliparous – 0.5 cm/hour
Parous – 0.5-1 cm/hour
What are the components of a partogram?
Maternal HR – every 30 mins
BP and temperature – every 4 hours
Contractions – every 30 mins
Colour of liquor – every 30 mins
Cervicograph
Abdominal descent
Cervical dilatation – every 4 hours
Nulliparous – 0.5 cm/hour
Parous – 0.5-1 cm/hour
What is the alert line?
ALERT line is at 0.5 cm/hour
If the plotted dilatation moves to the right of the alert line, this may suggest prolonged labour
What is the action line?
ACTION line is 4 hours right of the alert line and if the cervical dilatation crosses this, urgent obstetric review is needed
Why may slow progress happen?
o May be due to malposition
o Epidural analgesia can slow progress
What is the management of slow progress?
o ARM (perform VE 2 hours later)
o Syntocinon if there are inadequate contractions
o Instruments -> may be used in some women if you don’t want them to push (e.g. because of hypertension)
§ Ventouse – same diameter for the mum, but can be distressing for the baby
§ Forceps – increases the diameter of the baby’s head but doesn’t upset the baby
What is postnatal care after a vaginal delivery?
Stitches
Toilet use needs monitoring
Haemorrhoid care
Lochia advice
Breast advice
What advice do you give for using a toilet?
inform the midwife if you are struggling to pee/unpleasant smell/painful. Drink plenty of water (dilutes the urine) and eat a healthy balanced diet (not pooing for a few days is normal)
· A small amount of leaking urine is normal (try pelvic floor exercises)
What advice do you give about haemorrhoids?
very common after birth but disappear within a few days, avoid straining on the toilet
What advice do you give for lochia?
usually quite heavy at first so may need highly absorbent sanitary pads (avoid tampons until 6 weeks postnatal check because of infection risk), this may carry on for a few weeks, but it will eventually become brown and stop à USS if persistent past 6 weeks
· Normal lochia process: Rubra (red) -> serosa (yellow) -> alba (white)
· Infection = any offensive smell, or greenish colour
What advice do you give about breasts?
initially produces yellowish liquid (colostrum), breasts may feel tight and tender initially, breastfeeding may cause a cramping sensation as it makes the uterus contract
What advice do you give post C section?
§ Average stay is about 3-4 days (regular painkillers, encourage baby contact, encourage mobilisation)
§ Wound: gently clean and dry every day, wear loose cotton clothing, take painkillers, watch out for signs of infection, non-dissolvable stitches are taken out by midwife after 5-7 days
§ Scar fades with time
§ Stay mobile and return to normal activities
§ Caution should be taken with certain activities including driving, exercising, heavy lifting, sex
· These activities should be delayed until 6 weeks after delivery
If you have a 6 week pregnant woman with PV bleeding and abdominal pain, what are the key aspects of the history you need?
§ PC – PV bleeding and abdominal pain
§ Quantify bleeding and SOCRATES the pain
§ Ensure you get a sexual hx, smear hx and identify any ectopic risk factors
If you have a 6 week pregnant woman with PV bleeding and abdominal pain, what are the Ddx?
Ectopic pregnancy
PID
Miscarriage
Ectropion
Cancer
Cervical polyp
Ectopic -> pain (may or may not have bleeding)
Miscarriage -> bleeding (may or may not have pain)
If you have a 6 week pregnant woman with PV bleeding and abdominal pain, what exams would you do?
Sequence of exams: abdominal exam -> speculum exam -> bimanual exam
§ N.B. bimanual exam contraindicated in placenta praevia
How does bHCG change in pregnancy?
§ Normally doubles every 48 hours
§ Ectopic -> doubles, but at a rate less than double every 48 hours
If there is a woman who is 32 weeks pregnant with PV bleeding and abdominal pain, what are your differentials?
Low-lying placenta (-> placenta praevia (non painful) after 32 weeks)
Placenta accreta
Placental abruption (painful)
Uterine rupture (painful)
Vasa praevia (non painful) (placental vein blocks os and baby breaks it)
Preterm labour
What is the classifications of placenta praevia?
Type I- low lying
Type II- marginal placenta
Type III- partial praevia
Type IV- complete praevia
What is placenta praevia?
the placenta can implant on the anterior, posterior or fundus
What is the difference between low lying and placenta praevia?
If the placenta adheres to the Lower Uterine Segment (LUS), then it is preferred to as a “Low Lying Placenta”. If the placenta remains there until week 32, then it becomes placenta praevia
· See image below for types and the location of the LUS
What is the management of placenta praevia?
depends upon severity and foetal wellbeing
· Caesarean section if emergency
What is pre term labour?
painful, regular contractions with cervical change (effacement and dilatation) before 37 weeks of pregnancy
If you don’t have these things, this could just be normal Braxton-Hicks contractions
What is the most common cause of pre term labour?
Infection
What is the management of pre term labour?
· Non-infection cause -> tocolytics and steroids until term
· Infection:
o Tocolytics and steroids for at least 24 hours (gives time for the steroids to work)
o Review if contractions continue after you stop tocolytics
o Deliver after 24 hours if labour-like contractions begin again (as prolonged steroids in infection can be dangerous and so cannot be continually given)
What are the general landmarks of uterine fundus at 12 and 20 wks?
· 12 weeks pregnancy -> fundus at pelvic brim
· 20 weeks pregnancy -> fundus at umbilicus
What are the key findings in placental abruption?
· Pain ± bleeding -> ectopic
· Bleeding ± pain -> miscarriage
· Pain and bleeding -> placental abruption
Why is there pain in placental abruption?
massive blood loss; bleeding may not be overt (may be internal)
· Pain is from irritation and stretching of the myometrium
· This can lead to sustained contractions (different from labour)
What are the RFs for placental abruption?
Twin pregnancy
Cocaine use
Abdominal trauma
Polyhydramnios
Macrosomia
Previous CS (0.5% chance after CS)
What do you do in cord prolapse?
Summon senior help/ monitor with CTG
Prevent further cord compression
Place mother in either all fours or left lateral position
(Knee to chest position (baby will ‘fall’ back into the uterus) Ideally have the head slightly declined)
Deliver ASAP either by emergency C section or expediated vaginal delivery
What are the RFs of cord prolapse?
malpresentation, multiple pregnancy, polyhydramnios, placenta praevia, macrosomia
How do you Prevent further cord compression?
perform a digital vaginal examination…
o Elevate presenting part or fill the bladder (reduces pressure on the prolapsed cord)
o Tocolytics (nifedipine (CCB), atosiban (oxytocin receptor antagonist), terbutaline (beta-agonist))
o Avoid handling the cord (causes cord spasm) -> if cord past introitus, keep it warm/moist and don’t push back in
What are the types of perineal tears?
1st Degree: superficial damage with no muscle involvement
2nd Degree: injury to the perineal muscle, but not involving the anal sphincter
3rd Degree: injury to perineum involving the anal sphincter complex (EAS and IAS)
4th Degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
What are the types of 3rd degree tears?
o 3a: <50% of EAS
o 3b: >50% of EAS
o 3c: IAS torn
What is OASIS?
3rd and 4th degree tear = OASIS = Obstetric Anal Sphincter Injury
What is the management of perineal tears?
(GP alone can manage 1st and 2nd degree tears):
o Repair undertaken in the operating theatre + antibiotics (broad spectrum)
o Post-op care -> analgesia, laxatives, physiotherapy, gynaecology OP follow-up for incontinence review
What do you do for future pregnancies if someone has OASIS?
§ Do not need prophylactic episiotomy (only do if clinically indicated in new pregnancy)
§ Measure anorectal manometry pressure to see if ELCS should be offered in future pregnancies
What are the contra-indicated antibiotics in pregnancy?
Sulphonamides (NTDs)
Chloramphenicol (grey baby)
Ciprofloxacin
Tetracycline
Trimethoprim
What are the contra-indicated psychiatric drugs in pregnancy?
BDZ (Cleft lip)
Lithium (Ebstein’s)
Sodium valproate (NTDs)
Carbamazepine (NTDs)
Paroxetine (malformations)
What are the contra-indicated misc drugs in pregnancy?
ACEi
Liraglutide
Methotrexate
Gliclazide
NSAIDs
Warfarin (1st, 3rd)
What are the contra-indicated antibiotics in breastfeeding?
Sulphonamides (kernicterus)
Chloramphenicol (BM toxic)
Ciprofloxacin
Tetracycline
What are the contra-indicated psychiatric drugs in breastfeeding?
BDZ
Lithium
Clozapine
What are the contra-indicated miscellaneous drugs in breastfeeding?
ACEi
Cytotoxic drugs
Sulphonylurea Carbimazole, Fluconazole
Aspirin
Amiodarone
Which anti epileptics can be used in pregnancy?
(RCOG recommends either lamotrigine or carbamazepine): o Lamotrigine (and carbamazepine) are ok in pregnancy o Use lowest dose possible if it must be used at all
What can phenytoin/ carbamazepine do in pregnancy?
Foetal Hydantoin Syndrome:
IUGR
Microcephaly
Cleft lip / palate
Mental retardation
Hypoplastic fingernails
Distal limb deformities
When is contraception not required?
no contraception required within 21 days postpartum
How do you give the COCP post partum?
NO: <6w post-partum + breastfeeding;
WARNING: 6w-6m postpartum + breastfeeding
NOT breastfeeding -> can start from day 21, if starting >21 days, use barrier for 7 days
How do you give the POP post partum?
start ANY TIME but if starting after day 21 post-partum, use barrier for 2 days
How do you give the IUD/IUS post partum?
within 48 hours of childbirth (uncomplicated CS or SVD) OR after 4 weeks
How do you give the Lactational post partum?
98% effective if: FULLY breastfeeding (no bottle), amenorrhoeic, <6m postpartum
How do you examine the pregnant abdomen?
o Exposure below breasts to pubic symphysis
o Inspect linea nigra or striae
o SFH – i.e. 32 weeks = 30-34cm - face down tape measure, do 3 times
o Lie of child - longitudinal lie (head down or up - most common), transverse lie, oblique lie
o Spine - described in relation to mother – i.e. spine on maternal left
o Presentation - describe where the baby’s head is (head down = cephalic; bum down = breach)
o If cephalic - engagement - depth into the pelvis - described by how many fifths the head is in
I.E. head is free or maybe 5/5ths palpable
o Once head is 3/5ths or less palpable, the head is ENGAGED
o Listen to baby heart rate - a Doppler is used
o Listen over the anterior shoulder of the baby
What is Gravida and parity?
o Gravida = number of times pregnancy, regardless of outcome (ectopics and miscarriages count)
o Parity = number of live/stillbirths after 24 weeks
TWINS = G1P2 (one pregnancy, two babies)
What do you do for the vaginal exam?
o Abdominal exam - ALWAYS ON THE RIGHT
o “Lie flat and ankles together and let your legs go floppy”
o Outer vulval inspection
o Part labia and insert 2 fingers in the vagina to under the cervix
o Left hand on top of tummy - all fingers pointing same direction
o Ballot uterus
o Examine adnexa – stroke on each side of the cervix
• N.B. Cusco’s and speculum require a ‘horse and rider approach’ – “ankles together and let your legs go floppy”
What do you ask about in an obstetric history?
o High risk = any medical conditions at all
o Ask where the placenta is
o Ask for foetal movements (reduced can mean miscarriage)
o Rhesus -ve Mother’s needs anti D to prevent HDN in any future pregnancies
28 weeks is the time for anti d in d negative mothers
o “Have you been pregnant before? What was the outcome of the pregnancies?”
o Twins are parity 2 at imperial!
What is Neagles rule?
Add 9 months and 7 days (if cycle >28 days, add the number of days above to the EDD)
I.E. 25th August, 31 day cycles -> May 25th + 7 + 3 -> June 4th (the next year)
How does energy change in changes of pregnancy?
• Energy demands -> 14% increased demand:
o Increased fat storage (4kg stored)
o Less protein requirement
o Insulin sensitivity decreases:
Mother absorbs less glucose
More glucose available for baby
How does anatomy change in changes of pregnancy?
o Striae gravidarum (abdomen)
o Stria distensae (medial thigh)
o Linea nigra
o Chloasma gravidarum (mask of pregnancy)
How does the heart change in changes of pregnancy?
o CO increased 50%
o SV increased 35% (more volume)
o Less peripheral resistance (progesterone)
o HR increased 15-25%
o LAD on CXR due to compensatory LVH
How does the resp tract change in changes of pregnancy?
o Tidal volume increased 30-50%
Increased minute ventilation
Feeling of breathlessness
o FRC decreases
o RR does not change
How does the kidneys change in changes of pregnancy?
o More aldosterone created (fluid retention)
o GFR increases (1st trimester)
How does the haematology change in changes of pregnancy?
o Macrocytosis
o Neutrophilia
o Thrombocytopenia
o Dilutional anaemia
o Increased VWF, F7, F8, fibrinogen, PAI-1/2
o Decreased protein S
How does endocrinology change in changes of pregnancy?
o Biggest increase = oestriol
o Less increase = oestrone, oestradiol
o LH, FSH supressed
What is this?
A partogram
Where does the weight come from?
