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Y4 reproductive health > Normal pregnancy and labour > Flashcards

Normal pregnancy and labour Flashcards

1
Q

ANC visits

A

10 antenatal visits in the first pregnancy if uncomplicated

7 antenatal visits in subsequent pregnancies if uncomplicated

Women do not need to be seen by a consultant if a pregnancy is uncomplicated

All appointments - check BP, urine dipstick, assess maternal wellbeing & screen for domestic violence

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2
Q

Booking visit

A

Ideally < 10 weeks

General information eg. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes

BP, urine dipstick, check BMI

Booking bloods/urine

  • FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
  • hep B, syphilis
  • HIV
  • urine culture to detect asymptomatic bacteriuria
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3
Q

First trimester visits

A

Booking visit

10 - 13+6 weeks - early scan to confirm dates, exclude multiple pregnancy

11 - 13+6 weeks - Down’s syndrome screening including nuchal scan

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4
Q

Second trimester visits

A

16 weeks - information on the anomaly scan & blood results; if Hb < 11g/dl consider iron; routine care

18 - 20+6 weeks - anomaly scan

25 weeks (only if primip) - routine care (BP, urine dipstick, SFH)

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5
Q

Third trimester visits

A

28 weeks - routine care; second screen for anaemia & atypical red cell alloantibodies; first dose of anti-D prophylaxis

31 weeks (only if primip) - routine care

34 weeks - routine care; second dose of anti-D prophylaxis; info on labour & birth plan

36 weeks - routine care; check presentation (offer external cephalic version if indicated); info on breast feeding, vit K & baby blues

38 weeks - routine care

40 weeks (only if primip) - routine care; discussion about options for prolonged pregnancy

41 weeks - routine care; discuss labour plans & possibility of induction

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6
Q

ANC vitamins

A

Folic acid 400mcg should be given from before conception until 12 weeks

  • certain women may require higher doses

Vitamin D daily

Iron supplementation not offered routinely

Vitamin A supplementation might be teratogenic

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7
Q

ANC foetal growth

A

SFH measured at each antenatal appt after 24 weeks

Concerns → USS appt

  • multiple pregnancy
  • BMI > 35
  • large or multiple fibroids

Consider low dose aspirin at night from 12 weeks gestation → reduce incidence in those who are high risk of having a small for gestational age foetus

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8
Q

ANC alcohol

A

Advice is to exclude completely

High use may result in foetal alcohol syndrome

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9
Q

ANC smoking

A

Encourage smoking cessation & counsel about risks

NRT may be used if mothers’ wishes

Risks of smoking include low birthweight & preterm birth

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10
Q

ANC food-acquired infections

A

Listeriosis - avoid unpasteurised milk, ripened soft cheeses, pate or undercooked meat

Salmonella - avoid raw or partially cooked eggs and meat, especially poultry

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11
Q

ANC exercise

A

Strenuous exercise risk factor for small for gestational age babies

Encourage exercise at same level as pre-pregnancy if not vigorous/advise to start a gentle regular programme

Avoid contact or high risk sports & scuba diving

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12
Q

ANC travel

A

Women > 37 weeks with singleton pregnancy & no additional risk factors → avoid air travel

Women with uncomplicated, multiple pregnancies should avoid travel by air once > 32 weeks

Associated with increased risk of VTE

Correctly fitting compression stockings

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13
Q

ANC common problems

A

Reduced foetal movements - immediately contact maternity services if there is any concern about baby’s movements; no change to movements after 28 weeks gestation

  • unsure → lie on left side and focus on foetal movements for 2 hours → 10 or more is normal

N&V - normally starts between 4th and 7th week and should settle by week 20

  • if prolonged & severe → treatment for hyperemesis gravidarum

Heartburn - alleviate by sitting up after meals, reduce fat & space & eat smaller portions, gaviscon/PPI

Constipation - increased fibre & oral fluids; bran or wheat fibre supplements

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14
Q

Down’s syndrome antenatal testing

A

Combined test is now standard - nuchal translucency measurement + serum b-hCG + pregnancy-associated plasma protein A (PAPP-A)

11-13+6 weeks

Down’s syndrome - increased HCG, decreased PAPP-A, thickened nuchal translucency

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15
Q

Quadruple test

A

Women who book later in pregnancy, quadruple test should be offered between 15-20 weeks

  • AFP, unconjugated oestriol, HCG, inhibin A
  • AFP & oestriol are decreased
  • HCG & inhibin A are increased
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16
Q

Non-invasive prenatal screening test (NIPT)

A

Woman has ‘higher chance result’ → offered second screening test or a diagnostic test (amniocentesis, chorionic villus sampling)

Analyses small DNA fragments that circulate in the blood of a pregnant woman → early detection of certain chromosomal abnormalities

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17
Q

Anaemia in pregnancy

A

First trimester Hb < 110 g/l, second/third trimester Hb < 105 g/l or a postpartum Hb less than 100 g/l

Plasma volume & RBC mass increase during pregnancy, however plasma volume increases disproportionately → haemodilution effect

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18
Q

Anaemia in pregnancy risk factors

A

Haemoglobinopathies - thalassaemia, sickle cell disease

Increasing maternal age

Low socioeconomic status

Poor diet

Anaemia during previous pregnancy

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19
Q

Anaemia in pregnancy clinical features

A

Dizziness, fatigue, dyspnoea

Asymptomatic

Pallor, koilonychia & angular cheilitis

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20
Q

Anaemia in pregnancy ix

A

FBC

Serum ferritin - not routinely measured

Haemoglobinopathy screening should be considered in patients with confirmed anaemia & unknown haemoglobinopathy status

Serum folate

Haemoglobin electrophoresis - beta thalassaemia, sickle cell disease

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21
Q

Anaemia in pregnancy mx

A

IDA - oral iron

Folate deficiency - increased folate supplementation

Beta thalassaemia - folate & blood transfusions as required

Sickle cell disease - folate & iron supplementation

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22
Q

Endocrine system adaptations in pregnancy

A

Levels of progesterone and oestrogen increase

  • oestrogen is produced by the placenta
  • progesterone is produced by the corpus luteum & later by the placenta

Increase in oestrogen → increase in hepatic production of thyroid-binding globulin → more TSH released → free T3 and T4 levels remain unchanged but total T3 and T4 levels rise

Increase in human placental lactogen, prolactin & cortisol = anti-insulin hormones → increase in insulin resistance

Mother switches to alternative source of energy = lipids → increased likelihood of ketoacidosis

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23
Q

Cardiovascular system adaptations in pregnancy

A

Progesterone acts to decrease systemic vascular resistance in pregnancy → decreased in diastolic BP during first & second trimesters of pregnancy

In response, cardiac output increases by about 30-50%

RAAS activation → increase in sodium levels & water retention → total blood volume increases

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24
Q

Respiratory system adaptations in pregnancy

A

Increase in metabolic rate, results in increased demand for oxygen → TV and minute ventilation rate help mother meet these oxygen demands

Hyperventilation → increased CO2 production & increased respiratory drive caused by progesterone

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25
Q

GI system adaptions in pregnancy

A

Upward displacement of stomach → increase in intra-gastric pressure → predispose mother to reflux

Increase in progesterone → smooth muscle relaxation, with decreases gut motility → more time for nutrient absorption but can lead to constipation

Relaxation of gallbladder → biliary tract stasis → predisposes mother to gallstones

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26
Q

Urinary system adaptions in pregnancy

A

Increased CO → increase in renal plasma flow which increases GFR by ~50%

Progesterone relaxes ureter & muscles of bladder → predispose to urinary stasis causing infections

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27
Q

Haematological changes in pregnancy

A

Increase in fibrinogen & clotting factors in blood & decrease in fibrinolysis

Increase risk of thromboembolic disease

LMWH choice of drug if necessary to give mother an anticoagulant drug

Physiological dilutional anaemia → plasma volume increases significantly but red cell mass does not increase by as much

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28
Q

Normal labour

A

Physiological process by which a foetus is expelled from the uterus to the outside world

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29
Q

Braxton Hicks contractions

A

Throughout third trimester, involuntary contractions of the uterine smooth muscle begin to occur

Occur irregularly and are thought to be a form of ‘practice contraction’

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30
Q

Cervical ripening

A

Softening of the cervix that occurs before labour

Occurs in response to oestrogen, relaxin and prostaglandins (synthesis increases in 3rd trimester due to increased oestrogen:progesterone)

Ripening involves:

  • reduction in collagen
  • increase in glycosaminoglycans
  • increase in hyaluronic acid
  • reduced aggregation of collagen fibres

Means cervix offers less resistance to presenting part of fetus during labour

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31
Q

Myometrial excitability

A

Relative decrease in progesterone in relation to oestrogen that occurs towards the end of pregnancy helps to facilitate an increase in the excitability of the uterine musculature

Mechanical stretching of the uterus also helps to increase contractility → foetus grows, contractility of muscle increases

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32
Q

Role of oxytocin in labour

A

Responsible for initiating uterine contractions

36 weeks, under influence of oestrogen, increase in number of oxytocin receptors present with the myometrium → uterus begins to respond to pulsatile release of oxytocin from the posterior pituitary gland

Ferguson reflex → positive feedback loop → contractions lead to more oxytocin being released leading to stronger contractions

33
Q

First stage of labour

A

Results in the creation of the birth canal and lasts from the beginning of labour until the cervix is fully dilated (~10cm)

Contractions will occur every 2-3 minutes, foetal membranes rupture if haven’t already

Latent phase → slow cervical dilatation over several hours which lasts until the cervix has reached 4cm

Active phase → faster rate of cervical dilatation until 10cm reached; phase should normally last longer than 16 hours

34
Q

Second stage of labour

A

Lasts from full dilatation of the cervix until the foetus has been expelled

Passive stage - lasts until the head of the foetus reaches the pelvic floor; rotation and flexion of the head are completed in this stage; few minutes

Active stage - pressure of the foetal head on the pelvic floor results in an urge to ‘bear down’ → woman pushes in conjunction with her contractions in order to expel the foetus

  • 40 mins in nulliparous women, 20 minutes in multiparous women, > 1 hour = spontaneous labour becomes unlikely
35
Q

Delivery

A

Once head reaches perineum → extends in order to come up and out of pelvis

Following delivery of head → rotated by 90 degrees to assist with shoulders

Anterior shoulder delivers first, body flexes laterally and anteriorly to help deliver the posterior shoulder

Once shoulder have been delivered → rest of body follows

36
Q

Third stage of labour

A

Follows delivery and lasts until the placenta has been delivered

Uterine muscle fibres contract to compress the blood vessels supplying the placenta → shears away from the uterine wall

Typically lasts 15 minutes & up to 500ml blood loss

Normal mechanisms to control bleeding:

  • contraction of the uterus constricts blood vessels in the myometrium
  • pressure exerted on placental site once it has been delivered by uterus
  • normal blood clotting mechanism
37
Q

FGM

A

Refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons

38
Q

FGM classification

A

1 - partial/total removal of the clitoris and/or the prepuce

2 - partial/total removal of the clitoris and labia minora, with or without excision of the labia majora

3 - narrowing of the vaginal orifice with creation of covering seal by cutting & appositioning the labia minora and/or labia majora, with or without excision of the clitoris

4 - all other harmful procedures to female genitalia for non-medical purposes e.g. pricking, piercing, incising, scraping & cauterisation

39
Q

Naegele’s rule

A

Begin on the first day of the LMP, subtract 3 months, add 7 days, and then add 1 year

40
Q

Factors that affect accurate dating

A

Length of menstrual cycle

Date of last period may be incorrect - may think implantation bleeding is LMP

41
Q

Pelvic girdle dysfunction

A

Pain in the front and/or back of the pelvis, which may affect other areas such as the hips or thighs

Usually caused by the joints moving unevenly, which can lead to the pelvic girdle becoming less stable & painful

42
Q

Pelvic girdle dysfunction mx

A

Physiotherapy - exercises, avoid triggers, manual therapy

Can still have normal vaginal birth

Usually improves after birth

43
Q

Failure to progress

A

Refers to when labour is not developing at a satisfactory rate

44
Q

Delay in first stage of labour

A

Less than 2cm of cervical dilatation in 4 hours

Slowing of progress in a multiparous women

45
Q

Delay in the second stage of labour

A

Active second stage lasts over:

  • 2 hours in a nulliparous woman
  • 1 hour in a multiparous woman

Interventions:

  • changing positions
  • encouragement
  • analgesia
  • oxytocin
  • episiotomy
  • instrumental delivery
  • c-section
46
Q

Failure to progress mx

A

Amniotomy (ARM) for women with intact membranes

Oxytocin infusion - first line to stimulate uterine contractions during labour

Instrumental delivery

C-section

47
Q

Retained products of conception

A

Pregnancy-related tissue remain in the uterus after delivery

Can also occur after miscarriage or termination of pregnancy

48
Q

Retained products of conception clinical features

A

Vaginal bleeding that gets heavier/does not improve with time

Abnormal vaginal discharge

Lower abdominal or pelvic pain

Fever (if infection occurs)

Diagnosis made by USS

49
Q

Retained products of conception mx

A

Surgical removal - evacuation of retained products of conception

  • cervix widened, retained products are manually removed through the cervix using vacuum aspiration & curettage
  • complications - endometritis & Asherman’s syndrome
50
Q

Asherman’s syndrome

A

Adhesions form within the uterus

Endometrial curettage can damage the basal layer of the endometrium

Damaged tissue may heal abnormally, creating scar tissue connecting areas of the uterus that are generally not connected → can lead to infertility

51
Q

Cardiotocography

A

Used to measure the fetal heart rate and the contractions of the uterus

Can help guide decision making and delivery

52
Q

Cardiotocography procedure

A

Two transducers are placed on the abdomen to get the CTG readout:

  • one above the fetal heart → uses Doppler US
  • one near the fundus of the uterus to monitor the uterine contractions → assess tension in the uterine wall
53
Q

Indications for continuous CTG

A

Sepsis

Maternal tachycardia (> 120)

Significant meconium

Pre-eclampsia

Fresh antepartum haemorrhage

Delay in labour

Use of oxytocin

Disproportionate maternal pain

54
Q

CTG decelerations

A

Concerning finding

Fetal HR drops in response to hypoxia

  • early decelerations - gradual dips and recoveries in HR that correspond with uterine contractions; normal → caused by uterus compressing the head of the fetus, stimulating the vagus nerve, slowing the HR
  • late decelerations - gradual falls in HR that starts after the uterine contraction has already begun → caused by hypoxia
  • variable decelerations - abrupt decelerations that may be unrelated to uterine contractions; intermittent compression of the umbilical cord
  • prolonged decelerations - last between 2 and 10 mins with a drop of more than 15bpm, indicates compression of the umbilical cord, causing fetal hypoxia
55
Q

CTG mx

A

Escalating to a senior midwife and obstetrician

Further assessment for possible causes - uterine hyperstimulation, maternal hypotension & cord prolapse

Conservative interventions - repositioning the mother or giving IV fluids for hypotension

Fetal scalp stimulation - acceleration in response reassuring sign

Fetal scalp blood sampling - test for fetal acidosis

Delivery of baby - instrumental or emergency CS

56
Q

DR C BRaVADO

A

Assess features of a CTG in a structured way

DR - define risk

C - contractions

BRa - baseline rate

V - variability

A - accelerations

D - decelerations

O - overall impression

57
Q

Perineal tears

A

Occurs where the external vaginal opening is too narrow to accommodate the baby

58
Q

Perineal tears classification

A

First degree - injury limited to the frenulum of the labia minora and superficial skin

Second degree - including the perineal muscles, but not affecting the anal sphincter

Third degree - including the anal sphincter, but not affecting the rectal mucosa

Fourth degree - including rectal mucosa

59
Q

Perineal tears mx

A

Sutures

Broad-spectrum abx to reduce the risk of infection

Laxatives to reduce the risk of constipation

Physiotherapy

Follow-up

Elective CS in subsequent pregnancies

60
Q

Perineal tears complications

A

Short-term: pain, infection, bleeding, wound dehiscence or wound breakdown

Long-term: urinary incontinence, anal incontinence & altered bowel habit, fistula, sexual dysfunction & painful sex, mental health consequences

61
Q

Episiotomy

A

Obstetrician or midwife cuts the perineum before the baby is delivered

Done in anticipation of needing additional room for delivery of the baby

62
Q

Perineal massage

A

Method for reducing the risk of perineal tears

Involves massaging the skin and tissues between the vagina and anus

Done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery

63
Q

Breastfeeding

A

Recommended for the first 6 months of life, with introduction of solid food around this time & continued breastfeeding up to 2 years of age or longer

64
Q

Breastfeeding maternal benefits

A

Lowers risk of:

  • breast cancer
  • ovarian cancer
  • osteoporosis
  • CVD
  • obesity
65
Q

Breastfeeding foetal benefits

A

Reduces risk of:

  • infections
  • D&V
  • SIDS
  • obesity
  • CVD in adulthood
66
Q

Gas and air (entonox)

A

Used during contractions for short term pain relief

Woman takes deep breaths using a mouthpiece at the start of a contraction, the stops using it as the contraction eases

Can cause lightheadedness, nausea or sleepiness

67
Q

IM pethidine or diamorphine

A

Opioid medications usually given by IM

May help with anxiety and distress

May cause drowsiness or nausea in the mother & can cause respiratory depression in the neonate if given too close to birth

68
Q

Patient controlled analgesia

A

Patient controlled IV remifentanil

Requires careful monitoring

Access to naloxone for respiratory depression & atropine for bradycardia

69
Q

Epidural

A

Inserting a small tube into the epidural space in the lower back

Local anaesthetic medications are infused through the catheter into the epidural space → surrounding tissues & spinal cord

Offers good pain relief during labour

Adverse effects:

  • headache
  • hypotension
  • motor weakness in the legs
  • nerve damage
  • prolonged second stage
  • increase probability of instrumental delivery

Urgent anaesthetic r/w if motor weakness → catheter may be in the subarachnoid space

70
Q

PPROM & PROM

A

PROM - rupture of fetal membranes at least one hour prior to the onset of labour, at > 37 weeks gestation

P-PROM - rupture of fetal membranes occurring <37 weeks gestation

71
Q

PPROM & PROM aetiology & pathophysiology

A

Combination of factors can lead to the early weakening & rupture of fetal membranes:

  • early activation of normal physiological processes
  • infection
  • genetic predisposition
72
Q

PPROM & PROM risk factors

A

Smoking (< 28 weeks gestation)

Previous PROM/pre-term delivery

Vaginal bleeding during pregnancy

Lower genital tract infection

Invasive procedures eg. amniocentesis

Polyhydramnios

Multiple pregnancy

Cervical insufficiency

73
Q

PPROM & PROM clinical features

A

Hx of ‘broken waters’

Gradual leakage of watery fluid from vagina

Damp underwear/pad

Change in the colour/consistency of vaginal discharge

O/E - speculum: pooling of fluid in the posterior vaginal fornix; lack of normal vaginal discharge

74
Q

PPROM & PROM ix

A

Actim-PROM - swab test looking for IGFBP-1 in vaginal samples (100-1000x conc in amniotic fluid)

Amnisure - looks for placental alpha microglobulin (found in large concentrations in amniotic fluid)

USS - not routine

High vaginal swab - GBS

75
Q

PPROM & PROM > 36 weeks mx

A

Monitor for signs of clinical chorioamnionitis

Clindamycin/penicillin during labour if GBS

Watch & wait for 24 hours/consider IOL

IOL & delivery recommended if > 24 hours

76
Q

PPROM & PROM 34 - 36 weeks mx

A

Monitor for signs of clinical chorioamnionitis & advise patient to avoid sexual intercourse

Prophylactic erythromycin for 10 days

Clindamycin/penicillin during labour if GBS isolated

Corticosteroids if between 34 and 34+6 weeks gestation

IOL & delivery recommended

77
Q

PPROM & PROM 24 - 33 weeks mx

A

Monitor for signs of clinical chorioamnionitis

Advise patient to avoid sexual intercourse

Prophylactic erythromycin for 10 days

Corticosteroids

Aim expectant mx until 34 weeks

78
Q

PPROM & PROM complications

A

Chorioamnionitis

Oligohydramnios

Neonatal death - prematurity, sepsis & pulmonary hypoplasia

Placental abruption

Umbilical cord prolapse

Y4 reproductive health (11 decks)

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