Normal Pregnancy Flashcards
What constitute Low Risk Midwifery led care during pregnancy?
- Booking appointment – before 12+6 weeks gestation
- Dating Scan – 12 weeks gestation
- 16 week appointment
- 20 week gestation – anomaly scan
- 25 week gestation – nulliparous
- 28 week gestation – start fundal height measurement
- 31 week gestation
- 34 week gestation
- 36 week gestation
- 38 week gestation
- 40 week gestation – primips only – offer membrane sweep
- 41 week gestation – offer membrane sweep and consider planning induction of labour
Antenatal growth scans - how are scans differentiated from fundal height measurements?
X fundal height measurement
o scan measurement
High Risk ANC pathway: Maternal characteristics
BMI > 30 kg/m2 BMI<18 KG/m2 Smoking Age> 40 Teenage mothers
High Risk ANC pathway: Past medical History
- Cardiac disease
- Renal Disease
- Endocrine disease, Diabetes
- HIV
- Hematological disease
- Autoimmune disorders
- Epilepsy requiring treatment
- Severe asthma
- Recreational drugs
High Risk ANC pathway: Obstetrics Issues
- Recurrent miscarriage
- Preterm birth
- Eclampsia, preeclampsia
- HELLP
- RH isoimmunization
- Significant blood group antibodies
- APH, PPH on 2 occasions
- > 6 pregnancies
- Stillbirth/neonatal death
- SGA < 5TH centile
- LFGA < 5 th centile
- Birth weight <2.5 kg,>4.5 kg
- Fetal congenital anomaly: structural, chromosomes
widest diameter of pelvis
inlet - transverse is widest
outlet - anterior posterior is widest
Shape of fontanelles on infant
- Anterior fontanelle-bregma (diamond)
- Posterior fontanelle- Occiput (triangle)
- Area between the two- vertex
Mechanical Factors of labour- 3 Ps
- Power ( force expelling fetus: uterine contractions)
* Passage : Pelvic dimensions, Soft tissue resistance • Passenger ( diameters of fetal head)
Important factors on Power in mechanism of labour
- In established labour contraction for 45-60 seonds every 2-4 minutes.
- This leads to cervical effacement and dilatation aided by pressure of head
- Poor contractions common in nulliparous and induced labours but rare in multiparous.
Mechanism of labour: Passage Bony pelvis
3 planes
• Inlet: Transverse 13cm wider that AP 11 cm
• Mid-cavity: Round ( Transverse and AP similar)
• Outlet : AP AP 12.5 > Transverse 11 cm
• Ischial spine is the palpable landmark to assess descent
• Station 0 : Head at level of spines.
Mechanism of labour: Passage: Soft tissue
- Cervix: Dilatation depends on contractions, Pressure of fetal head on cervix
- Vagina ( tear, episiotomy)
Mechanism of labour steps
Engagement – Head enters the pelvis in occipito transverse postion
Descent of flexed head
at ischael spines internal rotation to AP
delivery by extension of head
shoulders turn to AP
Restitution - Head rotates back to 90 degrees to the same position in which it entered the inlet to enable delivery of shoulders
delivery by lateral flexion
Mechanism of labour: Passenger factors
- Presentation: Cephalic/Breech ( part of the fetus that occupies the lower segment)
- Presenting part: Lowest part of fetus palpable on vaginal examination
- Attitude of head describes the degree of flexion- vertex/brow/face
Fetal skull - what is Atitude of fetus
Attitude is degree of flexion of the head on the neck.
Maximum flextion- vertex presentation
- Vertex: Presenting diameter 9.5 cm
- Brow: 90 degree extension Presenting diameter 13 CM • Face: further 30 degree extension
- Extension makes the fetal presenting diameter larger
Movements of the head in labour
- Engagement ( head enters pelvis) in occipito-transverse as it is oblong and transverse diameter of pelvis is longer
- Descentandflexion
- Internal Rotation 90 degrees to occipito-anterior OA
- Descent
- Extension to deliver
- Restitution and delivery of shoulders
Signs of placental separation
gush fresh blood
cord lengthening
First stage of labour
Average 8 hours nulliparous, 5hours multiparous Latent ,4m, active 4-10 cm
Cervix dilates
Head remains flexed during descent
90 degree rotation from OT to OA
Second stage of labour
Contractions continue, Full dilatation to delivery Head descends, flexes and rotation completed
Pushing starts when head reaches levator ani (active second stage)
Delivery: Head extends as it delivers over the perineum
Head restitutes, rotating back to transverse before shoulders deliver.
Third stage of labour
average 15 minutes, Placenta delivered by controlled cord traction to prevent uterine inversion
Physiological management or Active management (to reduce blood loss in women at risk of PPH - overstretched uterus such as twins, polyhydramnos)
How long is postnatal period?
up to 6 weeks
still at risk of DVT, PE, eclampsia, infection
Lochia
discharge from the uterus may be blood stained for 4
weeks later on it is yellow or white
Cardiovascular changes in puerperium
- BP usually normal in 6 weeks
* Cardiac output and plasma volume returns prepregnant level with in a week
Postnatal review history
- Privacy
- Mother and baby should be together
- Early mobilization
- Check blood loss
- Pain
- Bladder –passing urine
- Bowel – opened or not
- Lochia
- Diet
- Mobility
- Breast feeding/bottle feeding/both
- Mood-normal/low/elevated
- Postnatal debrief about delivery events
- Fasting blood sugar in 6 weeks for gestational diabetics
Postnatal review-examination
- Vitals
- Abdominal palpation- uterus
- Examine calves-DVT
- Episiotomy /caesarean scar
- Risk score all women according to RCOG guidelines for risk for DVT and start appropriate prophylactic treatment
- Breast for mastitis
- Chest/throat
- Uterine tenderness
- LSCS wound
- Look for signs of DVT • Dip urine
- Take vaginal swab
- Lochia-foul smelling • Perineal wound
Postnatal Advise
- Contraception advise • Perineal care
- Pelvic floor exercises Post
LSCS- • Wound care • No heavy lifting for 6 weeks • Future pregnancies-VBAC • Driving as per insurer terms • Delay pregnancy for at least 12months
Postnatal review: Women with third/forth degree perineal tears
- Perineal care/hygiene
- Laxatives
- Antibiotics
- Analgesia
- Review in 6 weeks
Colostrum
yellow fluid containing fat laden cells, proteins including immunoglobulin A and minerals – passed first 3 days
Advantages of breast feeding
- Protection against infection
- Bonding
- Protect mother against cancer
- Cost saving
- Combined pills supress lactation/ hence progesterone only pill is safer
Lactation is dependent on which hormones?
- Prolactin from anterior pituitary stimulates milk secretion
- Oxytocin from posterior pituitary stimulates ejection in response to suckling
Approach to Postpartum pyrexia
- Maternal fever ≥38°C in the first 14 days • Genital tract sepsis
- Group A streptococcus, Staphylococcus, E. Coli. • Urinary tract infection (10%)
- Chest infection/pharyngitis
- Infection at IV (intravenous) sites
- Mastitis
- Perineal infection
- Wound infection after LSCS
- Infection of epidural site
- Deep Vein thrombosis –low grade pyrexia
Definition of Postpartum pyrexia
Maternal fever ≥38°C in the first 14 days
Postnatal Red flag’ signs and symptoms
- pyrexia more than 38°C
- sustained tachycardia more than 90 beats/minute
- breathlessness (respiratory rate more than 20 breaths/minute; a serious symptom)
- abdominal or chest pain
- diarrhoea and/or vomiting
- uterine or renal angle pain and tenderness
- woman is generally unwell or seems unduly anxious or distressed.
Common organisms –puerperal sepsis
- GAS, also known as - Group A Streptococcus pyogenes • Escherichia coli
- Staphylococcus aureus
- Streptococcus pneumoniae
- methicillin-resistant S. aureus(MRSA), • Clostridium septicum
- Morganella morganii
Managing Hypotension Bacterial Sepsis following Pregnancy
- In the event of hypotension and/or a serum lactate greater than 4 mmol/l: Deliver an initial minimum 20 ml/kg of crystalloid
- Apply vasopressors for hypotension In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or serum lactate greater than 4 mmol/l:
- Achieve a central venous pressure of ≥8 mmHg
Antibiotics for Bacterial Sepsis following Pregnancy
- Co-amoxiclav
- Metronidazole
- Gentamycin
- Clindamycin
- Tazocin (Piperacillin/Tazobactam)
- Discuss with microbiology consultant on call about treatment
Postnatal Psychiatric problems
- Postnatal blues -50%- need support and reassurance
- Postnatal depression affects -10% of women
- Puerperal psychosis- 0.2% of women, around 4th day
Postnatal Urinary problems
Retention of urine- is common after delivery
• Bladder scan to check for residual urine
• Cather for 24 hrs
Urinary infection in 10%
Incontinence in 20% women
Usually improve with pelvic floor exercise
Vaginal haematoma –severe pain and needs drainage under general anaesthesia
Constipation in 20% women Incontinence of faeces in 4% , transient
what is the NIPT test?
Maternal Blood test
• Diagnostic test: NIPT -free fetal DNA 99% accurate Results take > 1 week & expensive , not routine now
• NIPT used as near 100% sensitivity • Positive NIPT-needs invasive testing
Free fetal DNA
outline Ultrasound as a diagnostic test in pregnancy
- Anomaly scan ~ 20 weeks
- 25% identified earlier
- Cardiac – may remain undiagnosed even at 20 weeks • Some develop later gestation
Outline Amniocentesis
- Removal of amniotic fluid using fine gauge ultrasound needle under US guidance
- Performed after 15 weeks
- Used of chromosomal abnormalities, infections(CMV, Toxo)
- Inherited disorders(Sickle cell, thallasemia & CF)
- 1% chance of miscarriage
Outline Chorionic villus sampling
- Biopsy of trophoblast by fine needle through cervix or abdomen from 11 weeks
- Higher risk of miscarriage
- Earlier identification of abnormalities • Can offer TOP
How are samples from amnio and CV sampling tested?
• FISH(Fluorescence insitu hybridization) & PCR –result <48 hrs • Karyotyping-inspection of chromosomes by looking through
microscope
• Microarray-CGH-Comparative genomic hybridization techniques-closer or magnified inspection of chromosomes- smaller deletions or abnormalities
What is PGD (Pre-implantation genetic diagnosis)?
- Requires IVF
- Selection before implantation
- Expensive
- Ethical dilemmas
- Used in X linked ,trisomies & AD /AR conditions
What is Down syndrome due to?
- Trisomy 21
* Most common Non disjunction or balanced translocation(6%) • Features: mental handicap, facies, 50% cardiac disease
Risk factors for Down syndrome
- Maternal age
- Previous affected baby
- Balanced parental translocation
- Thick NT
- Structural abnormalities
- Absent or short nasal bone#
- Tricuspid regurgitation
- Severe FGR
- Low PAPP-A, High HcG, Low AFP, low estriol ,high inhibin
Screening for chromosomal abnormalities
- All pregnant women offered
- DS 75% sensitivity , 3% False positive
- 1 in < 150 high risk
- NIPT 1 in <1000
- Combined test: Maternal age , NT ,PAPPa & hcG
- Performance enhanced by presence or absence of nasal bone & TR
What is the rate of Structural abnormalities-CNS screened for in pregnancy?
- 1 in 200 pregnancies
- Spina bifida , anencephaly, ventriculomegaly
- Preconception folic acid 400mcg reduces NTD risk • Recurrence in 1 inn 10 pregnancies
- Higher dose 5mg reduces recurrence
What risk factors are there for fatal Cardiac defects
• 1% pregnancies
Cardiac defects
• Common in maternal diabetes, congenital cardiac defects, on antiepileptic drugs ,previous offspring affected 3%,other chromosomal defects & structural abnormalities
• 50% can be associated with high NT
• Less than 1/3 diagnosed prenatally
• Most are non lethal/Correctable after birth
• Arrthymias can be treated in-utero –Flecainide /Digoxin
List types of chest defects screened for in pregnancy
- Diaphragmatic hernia- herniation of abdominal contents into chest-60% with isolated defects survive
- In-utero tracheal occlusion FETO
- Pleural effusions-in-utero shunting useful
- Congenitalcysticadenomatousmalformation(CCAM)-many regress and prognosis usually good
What sign is there to indicate Gastrointestinal defects of the foetus?
• Oesophageal atresia & Tracheo-oesophageal fistula: • Polyhydramnios present, stomach small
What condition is the ‘double bubble’ sign on ct a sign of?
Duodenal atresia
• Classic “double bubble” sign , dilated upper duodenum- associated with Down syndrome
What test results would be expected in a trisomy 21 (Down’s syndrome) pregnancy?
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
