DRANZCOG/Obstetrics Flashcards
Risk factors for shoulder dystocia
At least 50% of shoulder dystocias have no identifiable risk factors!
Antenatal (5):
- previous shoulder dystocia
- macrosomia
- maternal DM
- maternal obesity
- post-term pregnancy
Intrapartum (5)
- prolonged 1st stage
- prolonged 2nd stage
- labour augmentation
- instrumental delivery
- post-term pregnancy
Consequences of a shoulder dystocia
Neonatal (4)
- brachial plexus injury (Erb’s palsy)
- fractures (humeral and clavicular)
- hypoxia
- stillbirth
Maternal (6)
- PPH
- severe vaginal and perineal trauma (3rd and 4th degree tears)
- cervical tears
- uterine rupture
- bladder rupture
- psychological distress
When to suspect shoulder dystocia
- prolonged birth of face and chin
- head emerges and retracts against the perineum (turtle sign)
- fetus fails to undergo external rotation
- the anterior shoulder does not emerge with routine axial traction
Reassuring features on intrapartum CTG
Baseline FHR 110-160 bpm
Baselines variability of 5-25 bpm
No decels OR early decles OR variable decelerations with NO concerning features for less than 90 minutes
Non-reassuring features on intrapartum CTG
Baseline FHR 100-109 OR 161-180
Variability <5 for 30-50 minutes OR >252 for 15-25 minutes
Variable decels WITHOUT concerning characteristics for 90 minutes +
OR
variable decels with any concerning characteristics in <50% of contractions for 30 minutes +
OR
variable decels with any concerning characteristics in OVER 50% of contractions for LESS than 30 minutes
OR
Late decels in >50% of contractions for <30 minutes with no maternal or fetal clinical risk (e.g. signficicant mec, PV bleeding etc. )
ABNORMAL features of an intrapartum CTG
Baseline FHR <100 or >180
Variability <5 for more than 50 minutes OR >25 for more than 25 minutes OR Sinusoidal
Variable decels with any concerning characteristics in >50% of contractions for 30 minutes (or less if maternal of fetal clinical risk factors)
OR
Late decels for 30 minutes
OR
Acute bradycardia, or single prolonged deceleration lasting 3 minutes or more
Concerning characteristics of variable decelerations
>60 seconds duration Reduced baseline variability within the deceleration Failure to return to baseline Biphasic (W) shape No shouldering
Interpretation of normal v suspicious etc. intrapartum CTG
Normal = all reassuring features
Suspicious = 1 non-reassuring feature + 2 reassuring features
Pathological - 1 ABNORMAL feature OR 2 non-reassuring features
Urgent intervention required: acute bradycardia, or single prolonged deceleration 3+ minutes
Features to assess when describing decelerations on CTG
- timing related to peak of contractions
- duration of individual decels
- if FHR returns to baseline
- how long have decelerations been present
- do they occur with >50% of contractions
- presence of a biphasic (W) shape)
- presence or absence of shouldering
- normal or reduced variability WITHIN the deceleration
Definition of antepartum haemorrhage
Bleeding from the genital tract after the 20th week of pregnancy, and before the onset of labour
Epidemiology of antepartum haemorrhage
Occurs in 2-5% of all pregnancies
Up to 20% of preterm babies are born in association with APH
Causes of antepartum haemorrhage
- (non-vaginal e.g. PR bleed)
- Distal genital tract/gynae causes
- cervical (ectropion, polyp, cervicitis, cervical dilatation, cervical incompetence)
- Placental (praevia, abruption, abnormal placentation, abnormal shape, marginal bleed)
- Uterine (rupture)
- Foetal (vasa praevia)
Relevant history to obtain in woman presenting with antepartum haemorrhage
Gestation
Location of placenta
Bleeding: time of first bleed, pattern, previous APH (this pregnancy or previous)
- Potential causes (postcoital, trauma, exertion)
- CST results
- Pain (site, commencement, frequency, strength, duration)
Maternal assessment in antepartum haemorrhage
ABCs
Abdominal palpation (gently) for SFH, lie, presentation, tenderness
USS: placental location if not known
Blood loss (amount, colour, consistency)
Uterine activity and consistency
Bloods (CBE, Group and save +/- crossmatch if heavy bleeding, coagulation profile, Kleihauer if Rh negative)
Speculum examination - swabs (STI, LVS, HVS) and consider CST if not performed in the last 3 months + clear cervical bleeding
(CTG for fetal assessment)
Epidemiology of placental abruption
1% of births
- 20-35% of these are concealed, rest are revealed
Perinatal mortality rate of 11.9%
Risk factors for placental abruption
Maternal:
- hypertension
- thrombophilias
- increased parity
- poor nutrition
- previous abruption (~10% risk of recurrent)
- cigarette smoking
- substance abuse (esp. cocaine)
Uterine factors:
- Prolonged ROM (especially if PPROM)
- chorioamnionitis
- severe IUGR
- polyhydramnios (sudden decrease in uterine volume post SROM)
- Multiple pregnancy (sudden decrease in uterine volume following delivery of twin 1)
- abdominal trauma
- ECV
Presentation in placental abruption
Vaginal bleeding associated with PAIN, usually very distressed (out of proportion to amount of bleeding)
Usually dark, non-clotting b lood
Abdominal pain Or uterine contractions/tenderness/irritability
Can be associated with faint/collapse or haemorrhagic shock
Complications/associations of placental abruption (9)
- preterm labour
- foetal compromise
- uterine irritability (>5:10 contractions)
- coagulopathy
- disseminated intravascular coagulopathy
- postpartum haemorrhage
- renal failure
- Acute tubular necrosis (from hypovolaemia and DIC)
- perinatal mortality
What is the most common OBSTETRIC cause of coagulopathy
Placental abruption
Management in placental abruption
- IV access
- IDC and fluid balance
- Close maternal obs + CTG
- Resuscitation as indicated
- Urgent Group and cross-match, CBE, Coagulation studies, D-dimer, fibrinogen levels, EUC, LFT
- Anti-D prophylaxis for Rh neg (+ Kleihauer)
- delivery (LSCS if acute fetal compromise or other indication - be prepared for precipitous labour)
- prepare for increased risk of PPH
- examine placenta and send for histopathology
Perineal injury classifications
1st deg: injury to skin only
Second degree: injury to perineal muscles but NOT the anal sphincter
3rd degree: injury involving anal sphincter complex
3a: <50% external anal sphincter thickness torn
3b: >50% external anal sphincter rotn
3c: Internal anal sphincter town
4th degree: injury involving anal sphincter complex AND anal epithelium
Appropriate analgesia to use for perineal repair
1% lignocaine +/- adrenaline (or equiv)
Without adrenaline is preferred for labial tears to reduce risk of tissue ischaemia
Preferred suturing technique for vaginal wall and muscle layer
Continuous, non-locked
Approximate epidemiology of perineal injury
25% of NVD: intact perineum
12% episiotomy
40% tear requiring repair
Other minor tears that don’t require repair
Women with epidural higher risk of instrumental delivery and associated perineal morbidities
Antenatal methods to protect against perineal morbidity
- Perineal massage 1-2x/week from 35/40
- Pelvic floor muscle training for women (Continence Foundation of Australia)
Insufficient evidence to recommend raspberry leaf tea
Intrapartum care to protect from perineal morbidity
No specific position or pushing technique recommended
Warm compresses and perineal massage: lowers risk of 3rd and 4th degree tears
During crowning:
- minimise active pushing following crowning to ensure slower descent of head. - If rapid, consider counter pressure on foetal head if appropriate
- maximise flexion to help reduce presenting diameter
When to use episiotomy
Imminent perineal tear
OR
High risk of severe laceration:
1. Soft tissue dystocia
2. Foetal compromise indicating expedited delivery
3. Instrumental delivery (not always required for vacuum)
4. History of female genital mutilation
5. Past history of pelvic floor repair or third-degree tear
Anatomy involved in episiotomy
Vaginal mucosa
Perineal skin
Bulbocavernosus muscle
Transverse perineal muscle
Technique to perform episiotomy
Appropriate analgesia (e.g. 1% lignocaine) Incision 3-5cm length from the fourchette ad 60-80 degree angle from midline (will become 45 degrees following delivery, loss of distension)
Immediate postpartum perineal care
Repair if indicated
Rectal NSAID unless PPH if torn
If tear within close proximity of urethra, consider indwelling catheter
Postpartum perineal care recommendations
Cold packs (10-20 minute intervals) first 1-3 days
PRN PO paracetamol and NSAID
Urinary alkalinisers
Avoid opioids
Fibre rich, balance diet, adequate hydration
Support perineal wound when coughing or defecating Correct toileting position Avoid constipation Wash and pat dry post toileting Shower at least daily Check wound daily with hand mirror
Pelvic floor muscle training for women
Avoid sitting/propped positions (dependent perineal oedema)
Avoid increased intra-abdominal pressure for 6-12 weeks (e.g. straining, lifting etc.)
Postpartum perineal care methods that lack evidence currently
Sitz baths
Perineal ultrasound for perineal pain or dyspareunia
Topical anaesthetics
Ray lamps
Donut cushions (may lead to more dependent oedema)
Herbal remedies e.g. arnica
Anatomy of the Bartholin glands
Paired glands located in labia minor at 4 and 8 o’clock positions
Approx 5mm in diameter
Secrete mucus into 2.5cm ducts which emerge either side of vagina, inferior to the hymen
Pathophysiology of Bartholin gland cyst
Nonspecific inflammation or trauma -> obstruction of opening of duct -> distension of gland or duct
Pathophysiology of bartholin gland abscess
Either secondary to infected cyst, or a primary gland infection
Usually polymicrobial
Rarely caused by STIs
Epidemiology of Bartholin gland disease
2% of women of reproductive age will experience swelling of at least one Bartholin gland
Typically in women 20-30y
Rare in women >40y (malignancy should be considered)
Clinical presentation of Bartholins cyst
Painless (unless very large) labial swelling, usually unilateral
No signs of surrounding cellulitis
Discharge if has spontaneously ruptured will be non-purulent
Clinical presentation of Bartholin’s Gland Abscess
Acute painful unilateral labial swelling
Dyspareunia
Pain with walking and sitting
Sudden relief of pain followed by discharge (suggests spontaneous rupture)
Can occur spontaneously or on history of a painless cyst
Very tender with surrounding erythema and oedema
may have surrounding cellulitis
Purulent discharge if spontaneously ruptured
Management of Bartholin Gland Disease
Asymptomatic uncomplicated cyst:
- Sitz baths 3x per day for several days (may induce resolution +/- rupture)
Abscess:
Incision and drainage +/- marsupialisation
Antibiotics only required if significant surrounding cellulitis
Definitions of postpartum haemorrhage:
Traditionally primary postpartum haemorrhage = blood loss >500mL in first 24h
Minor: 500-1000mL
major: >1000mL (moderate 1000-2000mL, severe >2000mL)
note that some centres consider PPH as >600mL following NVD or >750mL following LSCS
Risk factors for PPH
2/3 of women who have PPH have no risk factors identified
Background risk:
- PPH in previous pregnancy
- grand multiparity (4+)
- Nulliparity
- Advanced maternal age (>35y)
- known coagulopathies or liver disease
- obesity
- previous LSCS
Antenatal complications:
- multiple pregnancy
- antepartum haemorrhage (esp placental abruption or previa)
- known placenta accreta
- anaemia
- pre-eclampsia
- macrosomia
Intrapartum: - need for/use of oxytocics - prolonged labour (especially 2nd stage) Pyrexia in labour operative delivery Episiotomy Placental retention Shoulder dystocia
Causes of PPH (general groups and %)
Tone (70%)
Trauma (20%)
Tissue (10%)
Thrombin (<1%)
Atonic causes o PPH
Uterine atony (e.g. physiological or prolonged 3rd stage)
Over-distended uterus (polyhydramnios, multiple gestation, macrosomia)
Uterine muscle exhaustion (rapid labour, prolonged labour, high parity, augmentation with oxytocin)
Intra-amniotic infection (PROM >24h)
Drug-induced (magnesium, nifedipine, salbutamol, GA)
Functional or anatomical distortion of the uterus (fibroids, placenta praevia, uterine abnormalities, bladder distention)
Tissue causes of PPH
Retained products
Abnormal or adherent placenta
Retained cotyledon or succenturiate lobe
Trauma causes of PPH
Lacerations to cervix, vagina, perineum (precipitous labour, operative delivery) Uterine rupture (high parity, fundal placenta) Extensions/lacerations at LSCS (malposition, deep engagement)
Thrombin causes of PPH
Non-obstetric abnormalities (Haemophilia, vWd, hereditary coagulopathies, liver disease)
Acquired in pregnancy (ITP, PET, DIC, IUFD, severe infection, abruption, AFE)
Therapeutic anti-coagulation (e.g. clexane for VTE)
Blood loss and signs of Class I hypovolaemic shock in late pregnancy
15% (1000mL) RR: normal HR: <100 BP: Normal Mental state: anxious Urine output: normal
Blood loss and signs of Class II hypovolaemic shock in late pregnancy
15-30% (1300mL) RR: 20-30 HR: >100 BP: Normal/increased diastolic Mental status: anxious/confused
Blood loss and signs of Class III hypovolaemic shock in late pregnancy
30-40% (2000mL) RR: 30-40 HR: >120 BP: reduced systolic and diastolic Mental state: confused/agitated
Blood loss and signs of Class IV hypovolaemic shock in late pregnancy
>40% (2700mL) RR: >40 HR: >140 BP: decreased systolic and diastolic Mental state: lethargic Negligible urine output
Indications for intrapartum antibiotics (general)
- prevention of early onset GBS infection
- women at risk of chorioamnionitis, or where infection is suspected (temp >38 on one occasion or >38.5 on two occasions)
- women with cardiac lesions susceptible to infective endocarditis
Relative contraindications to amniotomy
- Maternal HBV, HCV, HIV, HSV infection - minimise risk of vertical transmission to foetus
- high and mobile presenting part
Factors to assess progress in the second stage of labour
Flexion
Rotation
Descent of head
Risk factors for pre-eclampsia (11)
Antiphospholipid syndrome Previous history of PET Pre-existing diabetes Nulliparity Multiple pregnancy Family history of PET Obesity (BMI >30) Systolic BP >130 <20/40 Diastolic BP >80 <20 weeks Age >40y Overweight (BMI 25-29.9) Underlying renal disease Chronic autoimmune disease Inter-pregnancy interval >10y
Early onset pre-eclampsia definition (i.e. gestation)
Onset <32 weeks
Systems which can be involved in pre-eclapmsia
Neurological Pulmonary Haematological Hepatic Renal Uteroplacental
Requirements for renal dysfunction in diagnosis of PET
Proteinuria >300mg/24h PR PCR >30
Creatinin >90
Oliguria <80mL/4h
Criteria for hameatological end organ dysfunction in diagnosis of PET
Platelets <100
Haemolysis (shistocytes or red cell fragments on film, raised bilirubin, raised LDH >600, reduced haptoglobin)
Disseminated intravascular coagulopathy
Criteria for hepatic end organ dysfunction in diagnosis of PET
Increased transaminases
Severe epigastric and/or RUQ pain
Criteria for neurological end organ dysfunction in diagnosis of PET
Convulsions (=eclampsia) Hyperreflexia with sustained clonus Persistent, new headache Persistent visual disturbances (photopsia, scotomata, cortical blindness, posterior reversible encephalopathy syndrome, retinal vasospasm) Stroke
Criteria for pulmonary end organ dysfunction in diagnosis of PET
Pulmonary oedema
Criteria for uteroplacental end organ dysfunction in diagnosis of PET
Fetal growth restriction
Prophylaxis for women at risk of hypertensive disorders of pregnancy
Aspirin 50-150mg daily from diagnosis of pregnancy (aim for <16 weeks - 37 weeks) Calcium supplementation (esp if high risk and low calcium intake diet) 1.5g/day from <20/40 until delivery
Investigations in assessment for hypertensive disorders of pregnancy
Urine PCR
CBE (Hb, PLT)
EUC
Urate (not actually in diagnostic criteria)
LFTs
Coagulation studies (depending on severity of presentation)
USS: foetal growth, AFI, umbilical artery doppler assessment
Definition of SEVERE pre-eclampsia
BP >/= 160/110 with proteinuria
OR BP 140/90-159/109 with at least ONE of the following - severe headache - visual disturbances - severe pain below ribs OR vomiting - papilloedema - clonus (3+ beats) - liver tenderness - HELLP syndrome - PLT <100 - abnormal liver enzymes
Antihypertensives that can be considered during pregnancy
Methyldopa Labetalol Nifedipine XR Nifedipine IR Hydralazine
Antihypertensives for use in acutely lowering severe hypertension of pregnancy (and dose)
Nifedipine IR 10-20 mg repeated in 30 minutes if BP still above threshold
Labetalol 200mg PO repeated in 30 minutes if not below threshold OR 20mg IV with repeat doses 40-80mg every 10 minutes until BP controlled (max 4 dose)
Hydralazine f not controlled by nifedipine - 5mg IV bolus/5 minutes, repeated every 20 minutes until BP controlled (max 30mg)
Antihypertensives and doses for sustained BP control in pregnancy
Methyldopa 250-750mg every 8 hours
Labetalol 100-400mg every 8 hours
Nifedipine XR 30-60mg BD
Side effects of antihypertensives in pregnancy
Methyldopa:
- depression
- dry mouth
- sedation
- blurred vision
Labetalol:
- bradycardia (maternal and fetal)
- bronchospasm
- headache
- nausea
- scalp tingling
Nifedipine: - constipation - severe headache in first 24h - peripheral oedema tachycardia - flushing
Hydralazine:
- flushing
- headache
- nausea
- tachycardia
Onset of action of antihypertensives used to acutely lower blood pressure in pregnancy
Labetalol: peak effect within 5 minutes of each dose
Nifedpine IR: onset 30-45 minutes
Hydralazine: onset of action 20 minutes
(Methyldopa only used for sustained BP control, has slow onset over 24 hours)
Contraindications to specific antihypertensives used in pregnancy
Methyldopa: depression
Labetalol: Asthma/COAD
Nifedipine: Aortic stenosis
Hydralazine:
Treatment of severe pre-eclampsia
- Stabilise
- control BP (labetalol, nifedipine IR or hydralazine)
- MgSO4 loading + maintenance dose) - Monitor
- vital signs
- urine output/strict fluid balance
- neurological status
- clotting factors
- fetal conditions (CTG) - Plan for labour/birth
Indications for birth in women with pre-eclampsia (13)
Maternal:
- > 37/40 gestation
- falling PLT count
- intravascular haemolysis
- HELLP syndrome
- deteriorating LFTs
- deterioration renal function
- persistent neurological symptoms
- persistent epigastric pain, nausea or vomiting with abnormal liver function
- pulmonary oedema
Fetal:
- placental abruption
- severe fetal growth restriction
- non-reassuring fetal status
Additional considerations of management of PET
Thromboprophylaxis
Monitoring of PLT at least daily (peripartum bleeding complications nor significantly increased until PLT <50)
AND monitoring for intravascular haemolysis (CBE, blood film, LDH, haptoglobins)
Pregnancy complications associated with bipolar affective disorder (i.e. more likely in BPAD than in general population)
Pre-eclampsia Gestational diabetes Gestational hypertension Antepartum haemorrhage Severe fetal growth restriction Neonatal morbidity
Pregnancy complications associated with schizophrenia (i.e. more likely in pregnant schizophrenics than in general population)
Pre-eclampsia
Gestational hypertension
Pregnancy complications with a higher risk in borderline personality disorder
Gestational diabetes PPROM Chorioamnionitis VTE Caesarean section Preterm birth
High rates of substance abuse, referral to child protective services, anticipation of traumatic delivery and frequent request of early delivery
Optimising use of nitrous oxide
Start inhalation 30-50 seconds prior to contraction
Dosages of nitrous oxide
Start at 30% N2O, max of 70% N2O to prevent hypoxia
Adverse effects of nitrous oxide
If used with oxygen (as always should be in labour):
- nausea
- vertigo
- megaloblastic anaemia
N2O alone:
- increased maternal heart rate
- respiratory depression
Contraindications to nitrous oxide use
Inability to hold mouthpiece
Impaired consciousness
Impaired oxygenation (e.g. respiratory disease)
Women who have received excessive amounts of other sedating medications
Vitamin B12 deficiency (can cause megaloblastic anaemia)
Recent ear surgery
Hypersensitivity to N2O
Any condition where air is trapped within a cavity and expansion may be dangerous (e.g. occluded middle ear, cysts, gross abdominal distension, maxillofacial injuries)
Use >24h
Preconception management
(full history of woman and partner if possible - optimise any medical conditions)
Imms: MMR, VZV, HBV
Weight: reduce obesity BMI <30 ideal
Nutrition: ?vegan/vego, assess and manage for nutritional deficiencies (B12, iron, VitD)
Avoid excess caffeine (3-4 cup/day)
CARD: cease all prior to conception. Aim for paternal smoking cessation pre-conception also
Travel: avoid to areas particularly affected by Zika. mosquito and sexual protection if cannot avoid.
Supplements:
- Folic acid from 1/12 prior. 400mcg/day if low risk, 5mg/day if high risk (NTD hx, DM, AEDs, BMI >35, haemolytic anaemia)
- Vit D if high risk group
- B12 6mcg/day if vego/vegan or bariatric surgery
- Calcium 1200mg/day if low dietary intake
Iodine 150microg/day
- iron if deficient, vego/vegan
Genetic counselling:
If high risk refer to geneticist, iff low risk, offer carrier screening e.g. Eugene (out of pocket currently)
Folic acid supplement dose in pregnancy/pre-conception
400 microg/day if low risk 5mg/day if high risk: - DM - personal or FHx of NTD - BMI >35 - AEDs - multiple pregnancy - haemolytic anaemia
Vitamin B12 in pregnancy
6mcg/day if vegetarian/vegan/bariatric surgery
Immunisations to consider pre-conception
MMR
VZV
HBV
Risks of smoking in pregnancy
Pre-conception:
- delayed conception by 2 months
- 60% increased risk of female infertility
- male infertility
Obstetric:
- Miscarriage
- Preterm labour (2x)
- placenta praevia (2x)
- placental abruption (1.5x)
- stillbirth (3x)
- Ectopic (2.5x)
- PPROM (2x)
Fetal:
- low birth weight (<2500g) (2x)
- SGA (3x)
- Birth defects (limbs, clubfoot, cleft palate, eye defects, GI defects)
Postpartum:
- less breastmilk production
Child/adult:
- SIDS (2.5x)
- Behavioural issues (ADHD, CD, antisocial)
- Respiratory disease (asthma, recurrent infection, reduced lung function)
- Cognition (reduced academic performance)
- T2DM
- Obesity
- HTN
- Dyslipidaemia
- Pyschiatric disorders early adulthood
- Nicotine deopendence
Management of smoking in pregnancy
- Counselling and QuitLine referral
- NRT (1st line is intermittent short acting forms, if patches required make sure are removed at bedtime 16h patches)
Champix and Bupropion not evidenced to be safe or effective in pregnancy
Risks of heroin use during pregnancy
IUGR Pre-term labour Placental abruption intrauterine passage of meconium Neonatal abstinence syndrome Foetal and neonatal death
Other associations:
- inadequate antenatal care
- poor nutrition
- BBV exposure
- overdose
- financial hardship
- unstable accommodation
- pyschological instability
Opioid substitution therapy in pregnancy
Methadone and buprenorphine both cross the placenta
Methadone has been used for longer, more experience with it. >50% of exposed neonates will show signs of NAS
Buprenorphine - only the mono therapy (without naloxone) is offered to pregnant women. Evidence suggests associated with fewer neonatal complications than methadone (less frequency, less severe NAS and less medication and admission durations)
Concentrations in breastmilk are low, breastfeeding should be encouraged while on OST if no other contraindications
Features of neonatal abstinence syndrome
Develops within first 48-72 hours of birth
- lasts from 1-several weeks depending on type of opioid use
- difficulty feeding
- central and autonomic hyperactivity
- poor suckling
- irritability
- hyperactivity
- sleep disturbances
- high-pitched cry
- seizures (in 5%)
Management of neonatal abstinence syndrome
Close monitoring in special care nursery for prolonged period Observation with standardised NAS scoring Oral morphine (dose and duration based on NAS scoring)
Complications of alcohol in pregnancy
Miscarriage Stillbirth Low birth weight Premature birth Brain damage Birth defects Foetal alcohol spectrum disorders
Common impact on child(and then adult) from alcohol used in pregnancy
Hyperactivity/inattention/impulsivity Aggression Impaired social interactions Antisocial personality traits Disrupted schooling Substance use disorders Mental health issues Employment/financial/independent living issues Criminal system contact
Advice for alcohol and breastfeeding
Safest not to use alcohol at all while breastfeeding
Definitely no alcohol in first month postpartum and until BF established
If chooses to drink after than, limit consumption as much as possible
Avoid drinking immediately prior to breastfeeding
Option to express prior to alcohol consumption
Diagnostic features of foetal alcohol syndrome
- evidence of prenatal alcohol exposure
- Growth deficiency (pre or post natal <10th centile)
- Facial features (** = sentinel)
- epicanthal folds
- flat nasal bridge
- short palpebral fissures**
- upturned nose
- smooth/flat philtrum**
- thin upper lip ** - Neurological dysfunction
- Structural:
- -HC <10%
- -structural brain abnormality on imaging
- Neurological
- -any neurological issues NOT due to postnatal event
- Functional
- -performance below expected for age
Foods to recommend avoiding during pregnancy
Risk of listeriosis:
- pre-prepared salad vegies (e.g. salad bars)
- raw, undercooked, chilled pre-cooked meats, pate and meat spreads
- unpasteurised dairy, soft, semi-soft and surface-ripened cheeses
Risk of salmonella
- raw eggs/foods containing raw eggs
Risk of mercury
- shark/flake, marlin, broadbill/swordfish, catfish
Risk of hepatitis A
- frozen berries
- bean sprouts
Foods containing saturated fats, added salts and sugars
Recommended maximum daily caffeine intake per day during pregnancy
300g (3-6 cups coffee/tea per day)
Recommended water intake during pregnancy
750-1000mL above daily pre-pregnancy needs
Vitamin supplements that can be associated with harm if taken antenatally
Vitamin C (preterm birth, perinatal death, PPROM) Vitamin E (PPROM) Vitamin A (congenital malformation)
Physical activity advice in pregnancy
- Specifically designed programs can prevent pelvic girdle pain and reduce severity of back pain
- Yoga associated with less stress, enhanced relationships, reduced back pain and less reported pain in labour
- can prevent urinary incontinence
- low-moderate intensity exercise is safe throughout pregnancy
Impacts of pregnancy on oral health
Reduced immune system (increased risk of periodontal infections)
Vomiting/reflux in pregnancy increases acidity -> enamel damage -> decay
Frequent snacks/soft drinks and other cravings (often sweet) can increase risk of tooth decay
Recommendations to reduce impact of pregnancy induced vomiting on oral health:
Rinse mouth with bicarb soda after vomiting
Avoid tooth brushing directly after vomiting
Use fluoridated mouthwash and toothpaste
Small protein-rich non-cariogenic foods throughout the day
Chew sugar-free gum (esp ones containing xylitol or CPP-ACP) after meals/sugar/acidic drinks
Women in whom you should screen for haemoglobinopathies (pre-natal or antenatally)
- family history of anaemia or haemoglobinopathy
- MCV <80 OR MCH <27
Following ethnic backgrounds: - Southern European
- African
- Middle Eastern
- Chinese
- Indian subcontinent
- Central and SE asian
- Pacific Islander/Maori
- South American
- Caribbean
- Northern WA/NT ATSI communities
What to include in a haemoglobinopathy screen
FBE (for MCV+MCH)
Ferritin (exclude Fe def)
Hb electrophoresis
DNA testing if indicated (microcytosis with normal iron and Hb electrophoresis and risk of disease)
Hb electrophoresis results in beta-thalassaemia
High HbA2 (>3.5%)
Normal HbA2 with low MCV and normal ferritin may be alpha thalassaemia
Diagnosing alpha-thalassaemia
Requires DNA analysis for definitive diagnosis. Suggested with low MCV and normal Hb eletrophoresis + ferritin level
Hormones involved in the onset of labour
Progesterone
- suppresses uterine contractility
- systemic or functional withdrawal (due to reduced responsiveness due to inc. PR-A:PR-B intrauterine expression) leads to increased uterotonin production
Prostaglandins:
- stimulate contractions, cervical softening and rupture of membranes
- synthesis is catalysed by COX-2
- increase the intrauterine PR-A:PR-B ratio-> feed forward mechanism
Benefits of water immersion in labour
- more tolerable labour pains
- lower use of pharmacological analgesia
- lower augmentation rates
- lower bleeding, reduced risk of PPH
- shorter labour
Definition of the puerperium
the 6 weeks following delivery during which woman’s physiology returns to pre-pregnancy state
Expected course on uterine involution postpartum
Fundus at level of umbilicus immediately post delivery
By day 5-7 halfway between umbilicus and pubic symphysis
By 2 weeks not palpable
By 6 weeks almost back to pre-pregnancy state
Cause of involution and lochia
Contractions and reduction of size of myometrial muscle (Cause of after pains)
Thrombosis and hyalinisation of blood vessels -> decidual shedding
Normal progress of lochia
Until day 5-6: lochia rubra
Until day 10-12: lochia serosa (darker brown)
Then becomes lochia alba (yellowish/white)
Timing of return of ovarian function post partum
In non-lactating women usually by 10 weeks, can be as early as 4-6 weeks
In lactating women highly variable
Make sure to offer contraception from 4 weeks if sexually active
Healing time of perineal injury
Most 1st/2nd and episiotomies will heal within 3 weeks
Care of perineal injuries
Keep dry and clean, clean from front to back
Warm sitz baths
Avoid constipation
Advise to watch for excessive pain/PV discharge or malodourous discharge
Abstinence for 6 weeks, advise may be some discomfort when resumes
When to resume sexual activity postpartum
Advise abstinence for 6 weeks if any tears
If no tears, as soon as desired/comfortable
Lactating women can have vaginal atrophy and may require topical oestrogen (after BF established) or lubrication
Diet and exercise recommendations postpartum
Regular diet ASAP
Full ambulation ASAP
Abdominal strength exercises after delivery pains have subsided (usually 1 day post NVD, 6 weeks post LSCS) - curl-ups while lying in bed (flexing knees and hips)
Bladder changes postpartum
Massive diuresis can occur immediately post-partum due to withdrawal of oxytocin
Cathartics use postpartum
Psyllium husk
Docusate or
Bisacodyl
Should be given to all women with OASI injury postpartum, and to other women if BNO day 3 (or if otherwise desired)
Managing breast engorgement postpartum
If plans to BF:Hand expression in warm shower or pump between feeds, regular feed schedule, wear comfy nursing bra
If not wanting to BF: Supportive bra (avoid gravity), avoid nipple stimulation or manual expression, tight binding of breasts (e.g. with tight sports bra), cold packs and analgesia PRN
Post partum mental health changes
Transient depression is common in the first week - mood swings - irritability - anxiety - poor concentration - insomnia - crying spells Typically only mild and subsides by day 7-10
When to advise women to see their GP re: ?postpartum depression
- If depressive symptoms last >2 weeks post partum
- if symptoms interfering with daily life
- ANY suicidal or homicidal thoughts
Family planning recommendations post partum
Obstetric outcomes are improved by delaying conception until 18 months post delivery
MUST delay conception at least 4 weeks post live vaccines
Avoid combined oestrogen/progesterone contraceptives while lactation is being established
Vulnerable groups who are statistically less likely to breastfeed (thus require more support)
Aboriginal and Torres Strait Islander Women Younger women (especially <20y) Less educated women Obese women Lower socioeconomic status
Benefits of breastfeeding for the infant
- nutrients in perfect composition, bioavailability and readily absorbable state
- active and passive immunity
- improved visual acuity
- improved psychomotor and cognitive development (higher IQ with longer durations of breastfeeding)
Reduced risks of:
- malocclusion
- physiological reflux
- pyloric stenosis
- GI infections
- respiratory illness
- otitis media
- urinary tract infections
- meningitis
- SIDS
- NEC (in Prem babies)
- Atopy (breastfeeding during time of antigen introduction facilitates development of tolerance)
- Some childhood cancers
- T1DM/T2DM
- Coeliac diseae (if breastfeeding at time that gluten is introduced)
- IBD
- HTN, dyslipidaemia
- obesity
Maternal benefits of breastfeeding
- reduced risk of breast Ca
- reduced risk of ovarian Ca
- reduced risk of GDM women developing T2DM
- Promotes uterine involution (less bleeding -> preservation of iron stores)
- ?maybe helps return to pre-pregnancy weight
What to discuss around breastfeeding antenatally
- importance of exclusive breastfeeding to 6 months and recommend breastfeeding to at least 12 months for nutritional and protective benefits
- basic breastfeeding management
- anticipatory guidance for coping with minor problems
Factors that delay the initiation of lactation
- stressful delivery (due to reduced oxytocin release)
- Caesarean delivery
- Maternal T1DM (can delay lactation by 24h)
- retained placental fragment (persistent progesterone release)
- maternal obesity (higher levels of progesterone + attachment issues)
Correct technique for breastfeeding
- Mum upright/semi-reclined with good back/feet/arm support
- “C-hold” - if nipple erect, support outer area of breast, if flat/inverted should hold well behind areola from the bottom to shapebreast between thumb and index finger
- Support infant behind shoulders, body flexed around mum, nose at level of nipple
- Tease infant with underside of areola to encourage wide gape, then quickly bring INFANT to the BREAST
- should be no clicking or sucking in of infants cheeks, slow even rhythm with deep jaw movements, pauses are normal
- come off breast spontaneously
Number of breastfeeds per day
8-12 typically
Typically will establish pattern within first week
Absolute contraindications to breastfeeding
HIV infection (but discuss with specialist)
Active TB
Breast Ca treatment
Breast syphilis
Brucellosis
Infant metabolic conditions requiring special formula (e.g. galactosaemia)
Advice around smoking and breastfeeding
Ideally quit smoking during pregnancy and breastfeeding
If unable to quit, reduced as much as possible
COMPLETELY avoid smoking 60 minutes prior to feed (and during feed)
Never smoke in same room as infant
Champix and Zyban are not safe during pregnancy or lactation
Signs to monitor if breastfeeding has established
- Content neonate after feed (though may cluster feed at certain period of each day)
- time remaining on breast (should never be >60 mins)
- passing urine at least 1x/day first few days (6+ times/day as volume increases)
- transitional stools by 24-48h-> breastfed stools by day 3-4
- appropriate weight gain (averaged over 4 week period)
What is lactogenesis stage I
After maturation of alveoli of breasts due to prolactin, progesterone and human placental lactogen -> breast able to secrete small amounts of specific milk components (e.g. lactose)
- complete by mid pregnancy
Milk production is inhibited in late pregnancy by high progesterone levels
What is lactogenesis stage II
Rapid increase in milk production in the first 30-40h following delivery of placenta (due to progesterone withdrawal)
Average breast milk production per day
800mL/day AVERAGE
Milk ejection reflex
Sucking -> pulse of oxytocin from posterior pituitary -> contraction of myoepithelial cells surrounding alveoli -> milk ejected into ducts and lactiferous sinuses
Symptoms women may get due to milk-ejection reflex
- No symptoms at all
- tingling/prickling/pins and needles sensation
- sudden feeling of fullness
- increase in skin temperature
- feeling of wellbeing/relaxation
- pain or nausea
- dripping/leaking from other breast
- intense thirst
- uterine contractions + gush of lochia
- slow sucking of infant (approx 1/sec)
Recommended nutrition for lactating women
- overall increased energy requirements
- intake affects micronutrient composition of breastmilk only
Vitamin D and iodine (150 microg/day supplementary) is recommended
Advice to give vegan mothers who choose to raise infant on vegan diet
Breastfeed as long as possible (ideally 2+ years)
If not, then soy-based formula for the first 2 years AND dietary advice
Likely will require supplements especially for iron and B12
Schedule of solids introduction in infants
From AROUND 6 months (4-6mo depending on infant signs)
First introduce IRON-RICH foods (iron-enriched cereals, pureed meat/poultry/fish, cooked tofu and legumes)
6-8 mo: purees -> mashed -> minced -> chopped foods
Ensure lumpy foods <9mo
8mo: finger foods
12mo: same foods as rest of family, continue iron-rich foods, small frequent servings of nutrient-dense foods
Recommended drinks to offer infants/children
NOTHING other than breastmilk/formula first 6 months
Cows milk: only with cereals etc <12mo, >24mo max of 500mL/day
Water (after 12mo)
Fruit juice, soft drinks, cordial should be avoided
Tea, coffee, caffeinated drinks are unsuitable
Foods to avoid in infancy
Honey - do not give <12months due to risk of botulism
Animal milks
- FSCM ONLY with cereals/custards etc. in first 12 months
- goat’s milk NEVER GIVE TO A CHILD
- unpasteurised milk NEVER GIVE
- plant based milks (only acceptable is soy follow-on formula)
- nutrient poor, high fat/salt/suagr foods (e.g cakes, biscuits, chips, lollies etc)
Definition of subgaleal haemorrhage
Bleeding into the space between the epicranial aponeurosis and the periosteum
Cause of subgaleal haemorrhage
Rupture of emissary veins (which connect dural sinusess to scalp veins)
Most commonly after vacuum delivery
Potential consequence of subgaleal haemorrhage
Life threatening haemorrhage
- up to 250mL (50-75% of neonatal blood volume) can bleed into subgaleal space, with only a 1cm increase in scalp thickness
Mortality associated with subgaleal haemorrhage
12-25% in infants admitted to NICU
Risk factors for subgaleal haemorrhage
- Instrumental delivery (esp vacuum)
- nulliparous
- 5 min apgar 7 or less
- cup marks on sagittal suture
- leadingedge of cup <3cm from anterior fontanelle
- failed vacuum extraction (requiring forceps/LSCS)
- high number of pulls/cup detachments/prolonged time from cup attachment to delivery
Clinical features of subgaleal haemorrhage
Insidious onset
Localised signs:
- vague generalised scalp swelling
- laxity of scalp - then becomes fluctuant
- ballotable lesion crossing suture lines
- pitting oedema over scalp/preauricular/periorbital
Generalised signs:
- 5 minute apgar 7 or less without asphyxia
- irritable cry or evidence of pain with handling
- haemodynamic instability (later sign) (tachycardia, tachypnoea, poor activity, pallor, anaemia, coagulopathy, acidosis, death)
Clinical features of caput succadaneum
Can cross suture lines and midline
Size and firmness starts to reduce 1h post delivery
Clinical features of cephalohaematoma
(bleeding between periosteum and underlying skull)
more common after instrumental delivery
Soft, fluctuant, localised swelling with well-defined outline
Does NOT cross suturelines
Canincrease in size over 12-24 hours
Prevention of subgaleal haematoma
Promote neonatal IM vitamin K after instrumental delivery +++
Avoid vacuum when contraindicated
Ensure correct placement of cup, correct traction, and abandonment if too many pulls/detachments/prolonged
Early diagnosis guidelines for subgaleal haematoma
Surveillance of different levels for all infants post instrumental delivery
If higher risk (ie lots of pulls/detachments etc, more difficult extraction, incorrect cup placement) should have regular formal observations for 12 h, and cord gas + Hb and platelets at delivery
Management of possible subgaleal haemorrhage
Immediately discuss with neonatologist
Prompt evaluation, resuscitation and supportive treatment
- restore circulating blood volume (IVT, blood products)
- circulatory support
- correct acidosis or coagulopathy
Transfer to NICU
Definition of neonatal hypoglycaemia
Low BGL <2.6mmol/L
(note that intervention thresholds may differ according to clinical situation e.g. preterm deliveries or at risk babies intervention threshold is lower at 2.0 due to expected drop in BGL)
