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YEAR 5 SPECIALTIES KEY INFO > INTRO TO OBSTETRICS: General principles, antenatal, intrapartum, postnatal > Flashcards

INTRO TO OBSTETRICS: General principles, antenatal, intrapartum, postnatal Flashcards

1
Q

What are the trimesters in pregnancy?

A

1st trimester = 0-14w
2nd trimester = 14-28w
- 24w = point of viability
3rd trimester = 28-42w
-37-42w = term

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2
Q

What are the stages of labour?

A

1ST STAGE = Onset of spontaneous, regular, painful contractions until 10cm cervical dilation and full dilation
- LATENT = until 4cm dilation + full effacement, typically 3-8hrs
- ACTIVE = from 4-10cm dilation, typically 2-6hrs

2ND STAGE = Full dilation to delivery of baby
- PASSIVE = 1-2hrs
- ACTIVE = <2hrs

3RD STAGE = Delivery of placenta
- typically <30mins

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3
Q

What is classed as a prolonged second stage?

A

Nulliparous = >2hrs since onset of active 2nd stage

Multiparous = >1hr since onset of active 2nd stage

Allow an extra hour if epidural analgesia

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4
Q

What are birth options for normal delivery?

A

Spontaneous vaginal delivery

ELCS (abdominal wall layers inc: skin, subcutaneous tissue, rectus sheath, rectus muscle, parietal peritoneum, uterus inc. visceral peritoneum)

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5
Q

How is difficulty starting labour managed?

A

Induction of labour
- prostaglandins (pessary/gel)
- balloon catheter
These dilate and ripen the cervix
- then can have ARM

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6
Q

How is difficulty progressing managed?

A

Augmentation of labour:
- Artificial rupture of membranes (ARM) -> natural release of prostaglandins
- Synthetic oxytocin/syntocinon improves quality of contractions

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7
Q

What options are there for emergency delivery?

A

Instrumental delivery - ventouse or forceps

Emergency C-section (category 1 within 30mins, category 2 within 75mins)

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8
Q

How can obstetrics management be structured?

A

Maternal = manage acute medical issue, develop ongoing plan

Foetal = ongoing monitoring for remainder of pregnancy, delivery may be only cure

Labour = timing, mode and interventions to assist delivery

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9
Q

What are RFs and complications of placenta praevia?

A

Sx = painless, bright red bleeding

RFs = prev. C-sections

Complications = maternal haemorrhage, foetal IUGR

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10
Q

How is placenta praevia diagnosed?

A

Abdo exam = soft, non-tender uterus, abnormal foetal position

TVUSS = measure distance between placenta and os

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11
Q

How is placenta praevia managed?

A

MATERNAL:
- admit + observe for 48hrs if stable
- usually manage conservatively until 36w
- consider fluid replacement and blood products for low BP and low Hb, fibrinogen etc.

FOETUS:
- CTG
- monitor for IUGR w/US
- consider steroids (<34w) to enable earlier delivery

DELIVERY:
- C-section preferred mode
- vaginal birth possible if >2cm from os
- consider admission from 34w for major placenta praevia

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12
Q

What are RFs and complications for placental abruption?

A

Sx = sudden abdominal pain and bleeding

RFs = prior abruptions, pre-eclampsia, cocaine use

Complications = DIC, foetal death (if caused by arterial bleeding), oligohydramnios, IUGR (venous bleeding)

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13
Q

How is placental abruption diagnosed?

A

ABDO EXAM: woody, tender, enlarged uterus

TVUSS: not diagnostic but rules out praevia

Abruption is a diagnosis of exclusion

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14
Q

How is placental abruption managed?

A

MATERNAL
- A to E resuscitation
- blood products if severe bleeding or DIC

FOETAL
- CTG
- consider steroids
- delivery if >36w or if distressed <36w

DELIVERY
- c-section if there’s foetal distress
- otherwise, vaginal birth usually preferred
- DIC makes c-sections risky

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15
Q

When do pregnancy-related conditions appear?

A

Post 20 weeks
- gestational HTN
- pre-eclampsia
- gestational diabetes

Anything before 20w is a chronic condition that will remain after pregnancy

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16
Q

How is hypertension in pregnancy managed?

A
  1. Labetalol - alpha and beta blocker, oral or IV (CI in asthma)
  2. Nifedipine - CCB, oral, safe in asthma
  3. Methyldopa - alpha 2 agonist, oral or IV
  4. Hydralazine - direct acting smooth muscle relaxant and vasodilator, oral IM or IV
17
Q

What is pre-eclampsia?

A

New high BP diagnosed >20w + clinically significant proteinuria

Sx = headaches, oedema, RUQ pain, visual disturbances, low PLTs

18
Q

What are RFs for pre-eclampsia?

A

MODERATE
- 1st pregnancy, multiple pregnancy, FHx, age >40, BMI >35, >10yr pregnancy interval

HIGH
- hypertensive disease in prev. pregnancy, chronic HTN, CKD, autoimmune disease, diabetes

19
Q

How is the risk of pre-eclampsia reduced?

A

Give aspirin from 12w onwards if 2 or more moderate RFs OR 1 or more high RFs present

20
Q

How is pre-eclampsia managed?

A

MATERNAL
- antihypertensives
- monitor bloods (FBCs, U&Es, LFTs - HELLP is indication for delivery)
- treat eclampsia w/magnesium sulfate (also indication for delivery)
- monitor BP 4x/day whilst in hospital

FOETAL
- weekly USS and doppler to assess for IUGR and abnormal umbilical artery EDF (end-diastolic flow)
- CTG
- consider steroids if early delivery likely

DELIVERY
- consider delivery from 34w onwards
- intrapartum BP and CTG monitoring
- encourage epidural, avoid ergometrine
- c-section if BP uncontrollable

21
Q

How is gestational diabetes diagnosed?

A

New diabetes diagnosed >20w

Ix = fasting blood glucose >5.6 or OGTT >7.8

22
Q

What effects does pregnancy have on pre-existing diabetes?

A
  • increased insulin requirements
  • increased risk of hypos
  • deterioration of existing complications like retinopathy and nephropathy
23
Q

What effects does diabetes have on pregnancy?

A
  • miscarriage and stillbirth
  • macrosomia and congenital malformations
  • pre-eclampsia, infections
  • complicated birth, shoulder dystocia

NOTE: complications worse w/pre-existing diabetes vs gestational diabetes

24
Q

How is diabetes in pregnancy managed?

A

MATERNAL
- joint diabetes and antenatal clinic
- diabetes treatment (metformin +/- insulin, start insulin straight away if fasting glucose >7)
- renal and retinal screening
- high dose 5mg folate preconception until 12w if pre-existing diabetes
- postnatal follow up

FOETAL
- serial USS for foetal growth and amniotic fluid volume (every 4w from 28-36w GA)
- assessment of cardiac outflow tracts at 20w anomaly scan

DELIVERY
- elective birth between 37-39w
- if mother is on insulin, manage blood glucose during labour w/sliding scale, aiming for blood glucose of 4-7

25
Q

What is the in-depth medical management of diabetes management?

A

Fasting glucose >7 or 6-6.9 w/evidence of complications = insulin

Everyone else =
1. diet and exercise 1-2w trial
2. metformin (alternative is glibenclamide)
3. add insulin

Monitoring =
- BMs checked 7x per day (fasting, pre-meal, 1hr post meal, bedtime)

Targets =
- fasting <5.3
- 1hr post-prandial <7.8
- 2hr post-prandial <6.4

26
Q

How is intrapartum sepsis managed?

A

MATERNAL
- A-E resus
- Sepsis six
- Septic screen - looking for a source of infection
- Monitor the progression of labour
- priority = stabilising mother before considering interventions for childbirth, legally speaking mother takes priority over unborn child

FOETAL
- CTG to assess for foetal distress and how urgently baby needs to be delivered

DELIVERY - decided by situation

27
Q

What are the requirements to be able to facilitate an instrumental delivery?

A
  • fully dilated cervix
  • ruptured membranes
  • cephalic presentation
  • engaged presenting part (not palpable abdominally)

Provide pain relief and empty bladder via catheterisation

28
Q

What is the difference between ventouse and forceps?

A

VENTOUSE =
- more baby complications e.g cephalohaematoma, subgaleal haemotoma
- fewer maternal complications, less pain
- lower success rate

FORCEPS =
- more maternal complications e.g. vaginal tears, incontinence
- maternal effort not required
- Neville Barnes for OA deliveries
- Kielland’s for rotational deliveries

29
Q

What questions should be asked in a postnatal history?

A

BUBBLE
Breasts
Uterus
Bowels
Bladder
Lochia
Episiotomy (or C-section wound)

30
Q

What is the generic structure for postnatal management?

A

MOTHER
- managed acute medical issues
- plan for postnatal recovery

FOETAL
- refer baby’s care onto paediatrics

31
Q

What are the causes of primary PPH?

A

> 500ml vaginally or >1L in c-section within 24hrs

Tone
Trauma
Tissue
Thrombin

32
Q

What are causes of secondary PPH?

A

after first day and up to 6w later

Endometritis
Retained placenta

33
Q

How is PPH managed?

A

A-E APPROACH

A = airway management unlikely to be required in early stages
B = high flow oxygen 15L/min
C = lie flat, raise legs, 2 large bore cannulae, fluid infusion, blood products, Foley catheter (alleviate distended bladder that might be preventing uterine contractions)

PPH PATHWAY
Initial uterine massage
1. Syntocinon or ergometrine or syntometrine (CI = HTN)
2. Carboprost = synthetic prostaglandin (CI = asthma)
3. Bakri balloon tamponade
4. Other surgical procedures (B-lynch suture, hysterectomy)

34
Q

What postnatal care advice should be given?

A

Breasts – might feel tight and tender and produce a yellowish colostrum​

Uterus – may contract and cause afterpains especially whilst breastfeeding, may take 6 weeks to return to normal size​

Bowels – may not open for a few days, haemorrhoids are common​

Bladder – peeing may be initially painful, incontinence issues should be reported​

Lochia – normal bleeding after delivery which lasts up to 6 weeks​

Episiotomy/wounds – bathe every day, gently pat dry​

35
Q

What specific advice should be given for c-section recovery?

A

Average hospital stay is 3-4 days​

Encourage contact with the baby​

Offer regular painkillers but avoid opiates​

Gently clean and dry the wound every day, and get stitches removed at 5-7 days​

Caution with driving, heavy lifting, exercise and sex for 6 weeks​

Avoid getting pregnant again for 12-18 months, so discuss contraception​

YEAR 5 SPECIALTIES KEY INFO (16 decks)

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