O&G - Shanaye's Deck Flashcards
History qns to ask at 1st antenatal visit
- current pregnancy: planned or unplanned, wishes to proceed. LMP
- medical: pmhx, medicines, family hx, cervical smears, immunisation
- Obstetric: previous experience of pregnancy and birth
- SNAP + drug use
- expectations, social support, culture and spirituality, concerns, knowledge, breastfeeding and infant feeding options
- Previous mental health disorders
- Edinburgh Postnatal Depression Scale
Clinical assessment tasks to perform on first antenatal visit.
- Discuss conception and date of LMP
- Measure ht and wt
- Measure BP
- Test for proteinuria
Screening tests at first antenatal visit.
- Blood group and antibodies
- HIV, hepatitis B (and C if necessary), rubella, syphilis, chlamydia, gonorrhoea
- FBC, U+Es, LFTs
- Urine MCS
- Offer chromosomal abnormality screening to be carried out between 11 and 14 weeks of pregnancy
RF for breech birth
Maternal: - Nulliparity - Previous breech birth - Uterine anomaly - Placental abnormalities - Oligohydramnios - Polyhydramnios - Multiple pregnancy - Grand multi Fetal - Short umbilical cord - Prematurity - Fetal abnormality - Poor fetal growth
Features of breech presentation on examination
- Presenting part feels irregular and a hard, round, ballotable head is found in the fundus
- Fetal heart sounds are heard high in the abdomen
- Thick, formed meconium may be present once the membranes are ruptured
Clinical approach to suspected breech at or beyond 37wks
USS
- Confirm type of breech
- Estimate fetal weight
- Exclude hyperextension of the fetal head (if hyperextended need C-section)
- Exclude placenta praevia
- Assess fetal morphology
When to offer external cephalic version (ECV)
Success rate of ECV
At 36-37wks. All women with uncomplicated breech presentation at or near term unless contraindications exist.
40% for nulliparous, 60% for multiparous with trained operator
Contraindications to ECV
- APH in current preg.
- Ruptured membranes
- Multiple pregnancy
- severe fetal abnormality
- Caesar necessary for other indications
- Poor fetal growth
- Significant HTN or pre-eclampsia
- Uterine anomaly
- Cord around fetal neck
- Abnormal CTG
- Hyperextension of the head
- Previous CS (relative contraindication)
RARE: uterine rupture
Procedure for ECV
Confirm breech presentation with no contraindications to ECV and gain consent.
Record pulse and BP and obtain CTG
Perform ECV
Monitor CTG for 30mins after and use USS to confirm success.
If unsuccessful, consider salbutamol tocolysis and repeat
Give anti-D to Rh -ve woman
Management of breech delivery
- Book LSCS after 38.5wks or planned vaginal delivery if appropriate
If vaginal delivery: - No pushing until full dilatation and breech descended to pelvic floor
- If delivery not imminent after 60mins of pushing - CS
- Episiotomy generally advised
- Intervene and use manoeuvres where necessary
Criteria recommended for a planned vaginal breech term birth.
- Consent and counselling about risks and outcomes of vaginal vs LUSCS
- Appropriate experienced personnel available
- Clinically adequate pelvis
- No growth restriction or macrosomia
- No footling or kneeling breech (only frank or complete)
- Fetus has a flexed head
- Theatre facilities available for LUSCS if required
- No previous c-section
- No fetal anomaly
- No fetal or maternal compromise
How to deliver a breech baby vaginally if no complications present
Allow spontaneous delivery to the level of the umbilicus. Correct position to sacro-anterior if necessary
- Deliver the legs by abduction of the thigh and flexion of the fetal knee
- Allow fetus to hang from vulva until scapula is seen
- Encourage woman to push to deliver shoulders and arms
- Delivery of rest of body to level of fetal mouth over next 1-2 contractions
- Delivery of head with forceps or Mauriceau-Smellie-Veit manoeuvre +/- bracht manouvre
What to do if arms don’t deliver spontaneously in breech presentation?
Lovset’s manoeuvre
- Grasp baby’s thighs with thumbs on sacrum and gently pull downwards and turn baby through 180 degrees until posterior arm is anterior and released
- Elbow appears under pubic symphysis and can be delivered by sweeping across the fetal body
- Repeat in reverse to deliver other arm
Management of cord presentation/prolapse.
Call for help -obstetrician, anaesthetist, paediatrician Expedite delivery If cord pulsating: - Immediate caesarean - Reduce risk of cord compression with maternal position (place woman in deep knee/chest position or on L side with head down, legs up) and manual elevation of the cord - Consider tocolysis - Consider bladder filling - Minimalise handling of the cord
If in 2nd stage of labour:
- Prepare for immediate delivery using vacuum or instrumental
Take cord blood gases immediately after delivery.
If cord not pulsating confirm fetal death
Risk factors for cord prolapse
- Breech and other malpresentations
- Multiple gestation
- Preterm labour, low birth weight
- Transverse, oblique and unstable lie
- High head at onset of labour
- Grand multi
- Polyhydramnios
- Abnormal placentations
- Fetal congenital abnormalities
- Abnormally long umbilical cord
What to do if a woman presents with suspected pre-term labour?
Hx - assess for signs and sx (pelvic pressure, cramping, back pain, vaginal loss, uterine activity)
O/E - vital signs, abdo palp, CTG, speculum examination to identify ROM and take high vaginal swab and low vaginal/anorectal GBS swab. Check for fFN Assess cervical dilatation
US
Labs - send high vaginal swab and low vaginal swab for MCS and MSU for MCS
When to admit woman with suspected pre-term labour?
Consider admission if any of the following
- fFN . 50ng/ml
- Cervical dilatation
- Cervical change over 2-4 hrs
- ROM
- Contractions regular and painful
- Further obs or Ix indicated
- Other maternal or fetal concerns
Management for a woman in pre-term labour.
- Transfer to tertiary centre equipped with NICU
- Give corticosteroids if <35+0 wks (2 doses of IM betamethasone 24hrs apart), if risk of PTB ongoing, repeat in 7 days
- Give tocolysis: Nifedipine 20mg oral, if contractions persist repeat after 30mins and again after another 30mins if still persisting. Give maintenance therapy every 6hrs for 48hrs.
- If established labour give GBS prophylaxis
- If chorioamnionitis give amoxycillin + gentamicin + metronidazole
- If no labour and no chorioamnionitis with intact membranes –> cease ABs
- If PPROM then convert to erythromycin
Give Mag Sulf if 24-30wks with labour established or birth imminent. - Prepare for birth
Maternal characteristics associated with preterm birth
Age of mother (<18 or >35) Ethnicity (African, South asian, ATSI) Smoking Psychological stress Late/no antenatal care Low SES High or low BMI
Medical and pregnancy conditions associated with pre-term birth.
Presence of fetal fibrinonectin Short cervical length (<25mm) Previous PTB and no of PTBs Genital tract infections (bacterial vaginosis doubles risk) UTI/pyelonephritis Assisted reproduction PPROM Surgical procedures on the cervix Uterine anomalies Poly/oligohydramnios Multiple gestation Chronic medical conditions Acute medical conditions (APH, preeclampsia)
Contraindications to tocolysis
In-utero fetal death Lethal fetal anomalies suspected fetal compromise maternal bleeding with haemodynamic instability severe preeclampsia placental abruptions chorioamnionitis
Signs of chorioamnionitis
Fever >38 Tachycardia Fetal tachycardia > 160 Uterine tenderness Offensive smelling vaginal discharge Increased WCC Elevated CRP
Components of a normal CTG
Baseline FHR 110-160
Baseline variability 5-25
Accelerations- 15 beats above baseline, lasting 15 seconds
No deceleration
Causes of fetal bradycardia
Low inherent rate (post-term) Drugs Maternal hypothermia Fetal heart conduction defect Maternal hypotension Prolonged cord compression Hypoxia
