Obs Flashcards

Question

Hyperthyroid in pregnancy Pre conception CI to pregnancy Antenatal care - meds + their risks

Answer 1

Mostly Graves - ANTI-TSH can cross placenta and may babies hyperythyoid Treatment: Block and replase Preconception - Radioiodine in last 6 months is a contraindication to pregnancy - Ideally well controlled TFTs - Stop Carbimazole (congenital defects in 1st trimester) - Propylthiouracil best in 1st trimester Antenatal care - Switch meds lol (Propylthiouracil hepatotoxic) BOTH MEDS CROSS PLACENTA AND CAN CAUSE FETAIL GOITRE AND HYPOTHYROID - lowest dose possible

Answer 2

Stages 1) Thyrotoxicosis ~ 3 months post-partum. Transient and subclinical - don't use antithyroids. Propanolol if needed for symptoms 2) Hypothyroid (for 20% lifelong). Treated with thyroxine 3) Normal function (but high recurrence rate in future pregnancies) TPO found in 90% of patients

Answer 3

Risk of congenital defects = 1-2% with epilepsy Taking AEDs = 3-4% AEDs also risk of SGA Lamotrigine best (lowest dose) NO SODIUM VALP 5mg folate 10mg OD Vit D from 36/40 20/10 anomaly scan - look at heart + NTDs >28/40: Serial growth scans if taking AEDs INTRAPARTUM CARE Delivery and timing not affected Must be LW Continue AEDs throughout Terminate seizures immediately with benzos Pain relief v important - all options, diamorph > pethidine No CI to IOL CTG not needed, but consider if high risk of seizure ``` POSTPARTUM CARE Continue AEDs but review in 10 days Higher risk of seizures post partum than in pregnancy but still low - avoid sleep deprivation, stress, pain - Don't bathe baby alone - Have support ``` Breastfeeding on AEDs = A OK

Answer 4

Sodium valproate - NTD | Phenytoin - Cleft palate

Answer 5

Pre-conception: BMI >30 should lose weight Obese = BMI >30 HIGH DOSE FOLIC ACID ``` Antenatal care: Booking: - BMI >40 - specialist care - Dietician - BMI >30: Screen for HTN ``` Aspirin 150mg from 12/40 if BMI >35 + one of - 1st pregnancy - Age >40 - FH of PET - Multiple pregancy Antenatal screening less accurate BMI >35 Serial US as SFH not accurate ``` RIsks of obesity in pregnancy Mother: - HTN complications - VTE - GDM - Thrombosis - Mental health ``` Baby - Miscarriage (1 in 4 chance) - national av = 20% - Stillbirth (1 in 100) - national av = 1 in 200 - Foetal macrosomia - NTD (double risk but still small)

Answer 6

Pre-existing HTN BP >/=140/90 pre pregnancy or <20 weeks - or already on anti HTN Pregnancy induced HTN BP >/=140/90 after 20 weeks - Either gestational HTN or pre-eclampsia

Answer 7

Falls in 2nd trimester (2ndary tofall in SVR) Normalises by term Protein excretion increased in pregnancy but in absence of renal disease is <0.3g/24h

Answer 8

``` Primary = Essential HTN Secondary = Chronic renal disorder, CV disease, Endocrine (primary aldosteronism, phaeo) ``` Risk of developing pre-eclampsia - 25% Investigations if HTN picked up <20/40 - THINK WHY - hx for Conn's, Cushing's, phaeo - Urinalysis (haem, proteinuria in renal disease) - Check renal function, calcium , urinary catecholamines if appropriate Management - Review anti HTN med - change ACEi to labetolol/nifedipine - Warn about PET signs - Growth scans and uterine artery dopplers - Low dose aspirin - Check BP and urine regularly Prediction of pre-eclampsia development - Bilateral notching and increased pulsatility index at 24/40

Answer 9

Risk of pre-eclampsia - 15% BUT risk actually relative to gestation. 40% if <30/40, 7% if >38/40 Usually resolves within 6 weeks of delivery but may pesist - Recurs often in subsequent pregnancies

Answer 10

Hypertension AND Proteinuria HTN >/=140/90 (2 readings 4 hrs apart) Proteinuria (>0.3g/34h or PCR >30) - send MSU. Don't repeat PCR

Answer 11

5mg Aspirin from 12 weeks if 1 of: - Pre-existing HTN - HTN in prev pregnancy - CKD - Autoimmune - SLE, Antiphospholipid - T1/T2 DM - SCD - PAPP-A <0.3 More than one of: - 1st pregnancy (2-3fold) - >40yo - Pregnancy interval >10y - BMI >35 at 1st visit - FH or PET - Multiple pregnancy

Answer 12

- Stems from placenta - incomplete trophoblastic invasion - Shearing forces -> exaggerated inflammatory response and endothelium damage 1) Increased vascular permeability - Oedema - Proteinuria 2) Vasoconstriction of vessels - HTN - Eclampsia - Liver damage 3) Clotting abnormalities (check platelets)

Answer 13

``` Asymptomatic Headache Visual disturbance N/V Epigastric pain Drowsy (late sign) Signs: HTN, Oedema, Epigastric pain, Hyperreflexia*, Clonus * ``` ``` Urine PCR Creatinine, Urea LFTs Albumin (low) Thrombocytopenia ```

Answer 14

Mild: Proteinuria and mild/mod HTN - 140-149/90-99 Moderate Proteinuria and severe HTN with no maternal complications - 150-159/100-109 Severe: 1 of the 3 met: 1) HTN >/= 140/90 with proteinuria (>/=0.3g/24h) AND 1 of - Headache, visual disturbance, epigastric pain - Clonus (3 or more beats) - Platelets <100, ALT >50 2) Severe HTN (systolic >/=170 or diastolic >/=110) wiith proteinuria (>/= 0.3mg/24h or 2+ on dipstick) 3) Eclampsia

Answer 15

Mother: - Cerebral oedema - cortical blindness, seizure, visusal loss - Eclampsia - Cerebrovascular haemorrhage (if BP control poor) - Pulmonary oedema, ARDS - HELLP + DIC - Liver failure, rupture - Renal failure Fetal - IUGR - Pre-term delivery (10% of total) - Placental abruption (5% still births)

Answer 16

BP AIM = <150/80-100 Treat HTN Regular fetal surveillance - growth, liquor, UA flow Steroids for lung maturity if delivery <34/40 Do not deliver unless mother stable Inpatient care as can deteriorate rapidly - consultant led ANTIHYPERTENSIVES Labetolol [1st line]. - CI: Asthma - SE: maternal bradycardia/tired Nifedipine [1st line] - CI: Aortic stenosis - SEs: headache, flushing, peripheral oedema, hypotension when used with MgSO2, interference with labour Methyldopa [1st line] - CI: Depression, Liver disease, Acute porphyria - SE: Lethargy and dizzy Hydralazine [2nd line] - SE: Tachycardia, flushing Amlodipine [3rd line] - If nifedipine not tolerated or poor compliance with BDS/TDS regimen Doxazocin [3rd line]

Answer 17

- Uncontrollable BP - Rapidly worsening biochem/haem (plt <100, coagulopathy, deteriorating liver/renal function) - Eclampsia or other crisis - Maternal symptoms - Fetal distress, severe IUGR, reversed UA EDF STABILISE MUM FIRST

Answer 18

Continuous CTG Blood pressure regularly (continuous if severe) Analgesia - Plt must be >100 for epidural (>80 ok if clotting and LFTs ok) Do not fluid overload Recommend operative birth in 2nd stage if severe HTN IM/IV oxytocin for 3rd stage - AVOID ERGOMETRINE

Answer 19

PET protocol, consider delivery - HDU transfer unless in active labour - Stop any anticoagulation - Inform LW/Obs, anaesthetis, neonatal team - Documentation on MEOWS/HDU - BP every 15mins - Careful fluid balance - PET bloods AIM BP <150/100, diastolic >80 - Nifedipine - Labetolol - Hydralazine - crystlloid fluid at same time to prevent sudden hypotension (NOT if pulmonary oedema) Fluid balance - Catheter - Fluid restrict to <85/h - if albumin <20, free PO fluids ok - If UO >50ml/h free PO fluids ok MgSO4 = Seizure prophylaxis Post-natally: - HDU for 24h (BP, symptoms and fluid balance) - LMWH within 6 h - BP often peaks day 3-6 postpartum - Aften a spontaneous diuresis after oliguria - don't treat aggressivey - Avoid NSAIDs - Switch anti-HTN to oral and continue for 6 weeks then review at GPPr

Answer 20

15% but depends on gestation when obtained - higher recurrence if earlier 3-4X risk HTN in later life 2 x IHD and CVD

Answer 21

MgSO4 Loading dose 4g, then infusion 1g/h - Maintain fro 24 hours after delivery/last seizure whichever last If recurrent seizures - Further dose of 2g over 15 mins or increase infusion to 1.5/2g per hour ECG monitoring during and 1hr after loading RR, O2 sats, deep tendon reflex monitoring ``` MgSO4 overdose - Motor paralysis - Absent reflexes - Resp depression - Cardiac arrhythmia If confirmed - stop MgSo4 and give antidote (10% 10ml calcium gluconate over 10mins) ```

Answer 22

Fetal HB present at 4-5 weeks - Seen on US a week later Pregnancy tissue should be identifiable on scan from bHCG >1000 - be suspicious of ectopic if it is not

Answer 23

Previous baby with early- or late-onset GBS disease Preterm labour regardless of their GBS status (<37) women with a pyrexia during labour (>38ºC) Rupture of membrane >24h before delivery +ve test/UTI with GBS earlier in pregnancy Risk of GBS infection to neonate – Sepsis – pneumonia – meningitis Explanation – bacteria found in the vagina of one in for pregnant women, in most cases it goes no son causes no symptoms or long-term problems – but then sometimes with certain risk factors that can cause an infection in the baby so you want to try and avoid that

Answer 24

Down's syndrome congenital heart defects abdominal wall defects

Answer 25

1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery 2: Correct, to avoid compression 3: The patient is advised to go onto all fours 4: The cord should not be pushed back into the uterus 5: Immediate Caesarean section is the delivery method of choice

Answer 26

Bradycardia or a single prolonged deceleration with baseline below 100/min for >3 minutes

Answer 27

Heart rate - >180 BPM or <100 BPM Variability - Less than 5 for over 90 minutes Decelerations - Non-reassuring variable decelerations for over 30 minutes since starting conservative measures to improve occuring with over 50% of contractions OR late decelerations present for over 30 minutes not improving with conservative measures occurring with over 50% of contractions OR bradycardia or a single prolonged deceleration lasting 3 minutes or more.

Answer 28

MCDA from 36 DCDA from 37 NO LATER THAN 38 Monozygotic: - 3x risk of congenital abnormalities Monochorionic - Increased risk. - 3-5 x increased risk of perinatal loss

Answer 29

AC, HC, FL SGA based on AC or EFW < 10th centile - need serial growth scans and UA Doppler Delivery by 37 weeks usually

Answer 30

GDM by 40 weeks T1/2 between 37+0 and 38+ 6

Answer 31

LMP: Subtract 3 months and add 1yr 7 days - Extra if >28 days - Obstetric wheel in practice If recently stopped COCP, more difficult to ell USS: 11-13+6 --> more accurate – Measurement to see our L between 9 to 14 weeks – HC between 14 to 20 weeks if no early scan and LMP unknown – little use beyond 20 weeks

Answer 32

Before 10 weeks – Clinical history and information – Alcohol, drugs and smoking cessation advice – medication optimisation Meds – routine 0.4 mg folic acid – Vitamin d (Particularly S Asian and African Caribbean women or women with BMI greater than 30) – iron supplements if needed Lifestyle – diet – 2500 cal – avoid alcohol completely – smoking for Seshan advice – coitus okay if no placenta previa or rupture of membranes – Pelvic floor exercises – Exercise it is advised (avoid contact sports) – avoid the following foods: on pasteurised milk/soft/blue cheese, pâté (including vegetable), uncooked food in, liver and liver products ``` Booking BMI Booking blood pressure Urine dip and culture Advise STI screen Booking bloods: – FBC – HB electrophoresis – blood-group/recent status – randomBlood glucose – HBV – HIV – syphilis – Rubella immunity (vaccine postnatal) ```

Answer 33

Sickle-cell disease People have attacks of severe pain and get serious, life-threatening infections – if we pick it up early they can receive early treatment to prevent serious illness and allow them to live a healthy life

Answer 34

With specialist care you can greatly reduce the chance of passing on HIV to baby – medications and planned care for birth, not breastfeeding et cetera

Answer 35

Specialist team to look after maternal health before and after birth Vaccinations for baby at 24 hours, four weeks, eight weeks, 12 weeks, 16 weeks, one year

Answer 36

``` Booking 16/40 18-20/40 28/40: OGTT if needed, FBC, G&S, Anti-D 34/40 36/40 38/40 ``` Extra for nullips 25/40 31/40 40/40

Answer 37

Done between 18 to 21/40 This is an exam scan which looks for some physical abnormality by looking at babies bone, brain, heart, spinal-cord, face, kidneys and abdomen But we cannot find everything that me wrong ``` 1.And then carefully to To.open spina bifida 3.palate 4.diaphragmatic hernia 5.gastroschisis 6.3 7.bilateral renal a Genesis 8.XO follows 9.Lateral skeletal dysplasia 10.Edwards 11. Patau ```

Answer 38

``` 10 to 13+6/40 – gestation and EDD – CRL – single/multiple – Nuchal translucency ```

Answer 39

``` At 24-28/40 if any risk factprs Age >40 BMI >30 PCOS Previous macrosomic baby FH of diabetes Previous hx of GDM ``` If GDM in previous pregnancy, OGT offered earlier (just after booking visit) and again at 24-28/40 if it was normal Otherwise any point in pregnancy when glycosuria 2+

Answer 40

Gestational diabetes occurs when enough insulin (hormone that controls glucose levels in the blood) is not being produced to meet its extra needs in pregnancy. This results in high blood sugar levels. Most women with just gestational diabetes go and have a healthy pregnancy and a healthy baby. However occasionally there may be complications. These include: [1] Baby being big, which can cause difficulties during birth [2] After the baby is born, his/her blood sugar levels can become too low and baby may need need specialist care [3] Your blood pressure may be raised during pregnancy. The risk of all complications to you and the baby can be reduced by controlling blood sugat levels. Going forward: 1) Going to refer you to a special clinic (obstetrician, specialist diabetic nurse, specialist diabetic midwife, dietician) where you will go within a week. We’ll see them once every couple of weeks to review how you getting on. They will help you to learn how to monitor your blood sugar levels, give me targets for blood sugar levels and may suggest treatment either by diet changes or some medication. +/- aspirin 2) You will also have some more scans in your pregnancy to monitor babies well-being and growth. 4 weekly from 28/40 3) Where are you planning on giving birth? Labour ward because extra care may be needed for you and baby - hourly glucose capillary test (use dextrose/insulin to keep between 4-7) There is also a chance that we may have to do a C section if baby is too big to deliver naturally There is also a very small risk that I have to tell you about. In GDM, there is a small chance of baby dying in the womb. That’s why we're going to monitor you very carefully and we need you to come in if you noticed any changes in babies movements. Please don’t worry I know that’s a lot of information. We’re all here to support you and I’ll give you some information to take home and read in your own time bring back any questions or worries that you have. Are there any that I can address now? Postnatal - will need to get blood sugar checked by GP 6 weeks after birth to see if it has resolved. Likely to occur in future pregnancies

Answer 41

Refer directly to HIV/ Obs Med Order CD4 counts and viral loads ``` Other tests to do Varicella Zoster Hep C Measles Toxoplasmosis She should be screened for genital infections (at booking an again at 28 weeks) ``` VACCINATIONS Hepatitis B and pneumococcal vaccination is recommended for all individuals who are HIV positive and can be safely administered in pregnancy. Influenza and pertussis vaccination can also be safely administered in pregnancy. ``` Anti-retroviral therapy 1. Zidovudine monotherapy: - Commenced by 24 weeks in women with good maternal health - Taken orally and IV during delivery - VL load < 100000 HIV RNA copies/mL + CD4 >350 - Willing to deliver by caesarean section - Delivery by elective caesarean section at 38 weeks to prevent labour and/or ruptured membranes - NO known teratogenic effects ``` 2. Combination HAART - Effects of teratogenicity not fully known - Alternative to zidovudine - Falling maternal health – commence as soon as possible - If on HART and plasma viral load <50 can attempt vaginal delivery - Associated with Pre-Term delivery Delivery Women should have elective C section at 38 weeks to prevent ROM: - - exception: Vaginal delivery can be considered in women taking HAART with a VL<50 copies at 36 weeks BUT avoid ARM, invasive fetal monitoring (scalp electrode) or instrumental delivery

Answer 42

MDT APPROACH: HIV specialist, obstetrician, specialist midwife, paediatrician Psychosocial support Perinatal mental health assessment Consider testing of other children Not to Breastfeed (oral dose of cabergoline to suppress lactation) Guidance About Contraception MMR and varicella vaccinations may be indicated HIV +ve women are recommended to have annual cervical screening All neonates should be treated with anti-retroviral therapy within 4 hours of birth. ● Most neonates should be treated with ZDV monotherapy but those at high risk of HIV infection should be treated with HAART. ● Prophylaxis against PCP is recommended only for neonates at high risk of HIV infection. ● Infants should be tested for HIV DNA and RNA at 1 day, 6 weeks and 12 weeks of age. If all these tests are negative and the baby is not being breastfed, the parents can be informed that the child is not HIV-infected. A confirmatory HIV antibody test is performed at 18 months of age.

Answer 43

Risk low so inform Episodes usually resole in 7-10 days without need for antiretrovoiral treatment Continue plans for vaginal delivery Consider suppressive aciclovir from 36 weeks

Answer 44

1st/2nd trimester – no risk of spontaneous miscarriage – immediate acyclovir PO 400 MGTDS for five days – paracetamol plus topical lidocaine gel for symptom relief –Refer for gum review and take swabs and DPC are – inform up Obstetrician – Daily suppressive acyclovir from 36 weeks Third trimester – immediate acyclovir PO 400 MGTDS and continue until delivery – Recommend C-section to all, especially within six weeks of delivery (41% risk of neonatal herpes if vaginal) – do specific antibody testing for HSV-1 and HSV-2 to assess if the first episode of repeat episode to guide delivery plans

Answer 45

C-section To mother who acquired infection in the trimester – Conservative as risk slow – no active treatment for baby – good hand hygiene for pet parents – safety netting: come back if concerns about babies skin, eyes, mucus membranes, lethargy, poor feeding SVB When infection was an acquired within six weeks for delivery – high risk so take swabs of baby skin, conjunct either, or a pharynx and rectum for herpes simplex PCR – give IV acyclovir until active infection is ruled – Infection control for mum and baby – breastfeeding recommended electricians are on nipple – same safety netting

Answer 46

Down’s syndrome is caused by the presence of an extra chromosome in the body’s cells. In the majority of cases, Down’s syndrome is not an inherited condition. It usually occurs because of a chance happening at the time of conception. Everyone with Down’s syndrome will have some degree of learning disability. Certain physical characteristics are more common among people with Down’s syndrome, and they can be more prone to certain medical conditions. However, the most important thing to remember is that everyone with Down’s syndrome is an individual, with their own strengths and weaknesses and personality traits that make them who they are. Ultimately patient’s choice, tell them about support/info available: ARC: helpline available on weekdays Down syndrome association: lots of info and support SOFT UK: For support with Patau/Edward Risk with age 20: 1/1,500 30: 1/800 35: 1/270 40: 1/85 45: 1/50

Answer 47

Between 11-14 weeks. US (nuchal thickness), maternal age, bloods (HCG + PAPP-A) If 15-20: Triple/quadruple tests: Same but hormones tested are HCG, Estriol, alpha fetoprotein, (Inhibin) Down’s: HCG high, Inhibin high, others low Edward/Patau: Low everything Result of screen is high chance or low chance (cut off = 1/150). Determines whether NHS will offer diagnostic testing

Answer 48

CVS (11-14 weeks) Fine need to pass through the abdominal wall or cervix and centre – 2% miss carriage rate – "some of the cells from the placenta (the organ links mothers blood supply with babies) is removed for testing. As it is carried out earlier you have more time to consider the results Amniocentesis (15-20/40 but can be later) – And ultrasound guidance, fine-needle to attend sample of amniotic fluid – enables prenatal diagnosis of chromosome of Amatis, infections, inherited disorders – 1% risk of miscarriage , If the tests are positive – some women choose to continue with the pregnancy and prefer prepare for a child with condition – others decide they don't want to continue with the pregnancy and have a termination – lots of support and guidance is available ARC: helpline available on weekdays Down syndrome association: lots of info and support SOFT UK: For support with Patau/Edward

Answer 49

ANTENATAL Materna - Miscarriage - HTN - Anaemia - Placenta praevia - GDM - Pre-term delivery fetal - Congenital abnormalities - IUGR - Still birth - TTTS - Malpresentation INTRAPARTUM - Cord prolapse - Increased risk of fetal distress: C-section + instrumental - Abruption - Cord entanglement POSTPARTUM - Prematurity - Perinatal loss - PPH - HTN

Answer 50

Obstetric led care. Same as singleton: OGTT, BP + urine dip + Aneuploidy screen Lower threshold for iron - THINK STEROID: 60% deliver before 37/40 GROWTH SCANS - Anomaly scan needs 1hr - IUGR monitorying (>25% difference in size is an indicator) - Monitor for comps from intertwin vascular anastamoses - MC: 2 weekly from 16 weeks - DC: 4 weekly from 20 weeks REDUCE PET RISK - Aspirin from 12/40 if one other factor

Answer 51

- SFH, abdo papation, FH auscultation - BP and Urine dip - TORCH screen CONSULTANT led antenatal clinic - Growth scans - Ultrasound umilical artery dopplers = diagnostic of FGR Management - IF V BAD ON CTG/Doppler - deliver? - Serial growth scans and dopplers - Close fetal surveillance: RFM?, consider CTGs - Delivery (usually by 37 weeks but consultant call), Mode dependent on fetal condition, needs CTG - Steroids <36 weeks gestation

Answer 52

``` Prematurity + associations – H I E – NEC – underseas – ROP – prolonged intense of cast day ``` Other early – hypoglycaemia – hypothermia – FTT Later ``` – FTT – learning difficulties – short stature – three will palsy – Barker's hypothesis ```

Answer 53

<5th centile for AFI ``` Causes [1] Too little production - Renal agenesis - Multicystic kidneys - Urinary tract abnormalities - FGR/placental insufficiency - Maternal drugs e.g. NSAIDs - Viral infections (can also cause polyhydramnios_ ``` [2] Post-dates pregancy [3] Leakage - PPROM - do speculum Assessment - SFH, speculum - US: assess liquor, structural abnormalities, measure fetal size (doppler if FGR) - Karyotyping IF appropriate

Answer 54

Causes - Hx of macrosomic babies - Maternal BMI >/= 35 - Maternal diabetes - Male babies - Genetic disorders e.g Beckwith Weidemen syndrome Diagnosis - USS - HC, AC, FL - Serial measurements to follow growth ``` COMPLICATIONS Mother/labour - Pre-term - Labour arrest - Operative vagina delivery - C-section - Perineal tears - PPH - Uterine rupture ``` Baby - Shoulder dystocia - Asphyxia - Hypoglycaemia - RDS (suppressed surfactant production) - Polycthaemia - neonatal jaundica - Increased risk of admission NO need for further scans

Answer 55

AFI above 95th centla AFI = measure of maximum cord free vertical pocket of fluid in 4 quadrants of the uterus and adding them together Causes [1] Maternal - Diabetes - Lithium [2] Placental - Chorioangioma [3] Fetal - Swallowing problems: Oesophageal atresia, CNS abnormalities, diaphragmatic hernia, duodenal atresia - Anaemia - Fetal hydrops - TTTS - Increased lung secretions Management: generally nil If severe consider - Amnioreduction (but infection and placental abruption) - Indomethacin (enhances water retention = reduced fetal UO)

Answer 56

24h national domestic violence helpline - Can arrange safe housing and plans to leave Women's aid/women's refuge can support you Plans for follow up - Domestic abuse support worker - Lead midwife for safeguarding - Card - Consider child protection referral If you are at immediate risk, please call 999!

Answer 57

Presentation of the buttocks 3% of term pregnancies Term babies that are breech have worse outcomes than cephalic, irrespective of mode of delivery Risk factors Maternal: Fibroids, congenital uterine abnormalities, surgery Fetal: Oligohydramnios/polyhydramnios, multiple pregnancy, prematurity, placenta praevia Management [1] External cephalic version we can try turning the baby to head first position - external cephalic version. Gentle pressure is applied on your abdomen which helps the baby to turn a somersault in the womb to lie head first to increase likelihood of vaginal birth - Successful in ½ Baby’s heart rate will be monitored b/f and after; USS confirms which way baby is lying; Mother given injection to relax uterus: Terbutaline = b2 agonist. will rescan after. Give anti-D if Rh-ve. Can attempt again ``` Generally safe and doesn’t cause labour to begin. Like any medical procedures, complications can sometimes occur. - 1/200 (0.5%) babies need to be delivered by emergency c-s ``` Can’t do it: CI for vaginal delivery, Abn CTG, Womb abnormalities, ROM, twins, PV bleed in prev 7 days SAFETY NET. USS after for DDH If ECV is unsuccessful + depending on your situation, your choices may include a:  Caesarean delivery – this is a surgical operation where a cut is made in your abdomen and your baby is delivered through that cut o Safer for the baby around the time of birth. o Slightly higher risk for you, compared with the risk of having a vaginal breech birth.  Vaginal breech birth. o In some circumstances, you may need an emergency caesarean delivery during labour. o Forceps may be used to assist the baby to be born o See C/I and advise against if they exist

Answer 58

``` More room for turning - Polyhydramnios, high parity Turn prevented - Uterine abnormalities, twin pregnancy Conditions preventing engagement - Praevia, pelvic tumours, uterine abnormalities ``` Complications - Won't be able to deliver if head/breech doesn't enter pelvis - Umbilical cord prolapse --> uterine rupture Management ONLY MATTERS AT 37 weeks/ LABOUR - Admit at 37/40 in case ROM - Don't do ECV as usually turns back - If spontaneous version and stays for 48h can discharge - Persistently abnormal lie --> c-section

Answer 59

Fetal - prolonged pregnancy - Suspected IUGR or compromise - APH - PROM after 24h Materno-fetal - Pre-eclampsia - Maternal disease e.g. diabetes Maternal indications - IUD - Social reasons ``` CONTRAINDICATIONS Absolure: - Fetal compromise (abnormal CTG) - Abnormal lie - Placenta praevia - Pelvic obstruction - C-section in past (usually if >1) ```

Answer 60

Why - Problems that arise can increase risk to mu or baby - Most commo reasons: late (placenta becomes less efficient so safer to deliver), IUGR, PROM, APH, Complicaed pregnancy What happens [1] MEMBRANE SWEEP - Separate membranes that surround baby from the neck of your womb. Is a vaginal examination and sweep finger around cervix to free up the hormone that promotes labour. May cause some discomfort but will not harm baby [2] IOL Prostaglandin. In natural labour, pregnancy hormone prepares cervic for labour by making it softer and opening it. Can give you that hormon - Propess pessary - slow release. No more uncomfortable than VE itself. Will monit HR of baby for 20mins before and 1hr after. MW check every 4 hours and remove after 24h/ready for labour - Prostin gel - can give 3 doses at 6hrly intervals Breaking your waters = ARM - Once cervix ripe, transfer to LW to stimulate labour. Membrane enclosing the fluid around baby broken by a small hook inserted into neck of the womb (no more uncomfortable than VE) Syntocinon drip - If labour not started within 2h of ARM - Similar to hormone that stimulates contractions - Will monitor your contractions and baby's HR continuously to ensure not too many and distress - Tocolytics if bad - Will be given pain relief

Answer 61

In the room your baby is protected in what essentially a sack Of amniotic fluid otherwise known as waters. Normally your waters break During labour or close to labour and this can help the process of labour along. However if this occurs early, before 37 weeks (in 2%) , there are some complications we need to be careful about. [1] Zach back to the barrier between the environment and the baby so if this fire is lost there is a chance of infection which can cause distress to the baby and make you a little bit ill [2] There is also the chance that you are going to leave early you will go into labour early: most women go into labour within a week after breaking waters. This means the baby can be born early and that in its self is associated Going forward there are few things we going to do to minimise any problems 1) Will admit you for at least 48 hours to monitor 2) You'll need 10 days of antibiotics 3) Will give you steroid injections, this will be to 24 to 48 hours to help the development of babies lungs in case you do delivery 4) You may need some medicine to stop your contractions if you need to be transferred to a specialist specialist baby unit if all is well after that you might be able to go home but you will have to watch out for signs of infection: your temperature, changes in the fluid colour (use pads not tampons), avoid intercourse

Answer 62

So your waters break, this is also called rupturing of membranes because it is a break in the sack that surrounds baby and the fluid is the amniotic fluid that you refer to his waters. This commonly happens during labour but it can't happen earlier and if it is 24 hours before labour starts and there are some small risks to you and baby. Good thing is that you close to your due date anyway to baby should be fully developed and healthy, Which is the important thing Occurs in 10-15%. 60% go into labour within 24h Management – Check line presentation – fetal oscitation and CTG – If I'm clear history common speculum cooling test (fluid draining into posterior vaginal fornix) - uneccesary If amniotic fluid seen training from vagina – POC tests e.g. actim PROM if diagnosis not clear OPTIONS [1] Await spontaneous onset of labour - Admit - Wait 24h and then induce - Regular monitoring of pulse, temp, fetal HR - Presence of meconium --> immediate IOL - After 18-24h antibiotics against GBS ``` [2] Expedited IOL Indications - Significant meconium/blood stained liqor - Known GBS +ve - Diabetes (any) - Evidence of maternal/fetal infection - RFM ``` Induction is with oxytocin

Answer 63

2nd stage of labour - Think is she stable? Is there a valid indication to intervene MATERNAL INDICATION - Inadequate progress: Lack of progress for 1 hr (2 if nullips) - -> 2h (3hr if nullips) if regional - Maternal fatigue/exhaustion FETAL INDICATION - Malposition of the fetal head e.g. OT and OP. - Suspeced fetal compromise in 2nd stage (pathological ctg or abnormal FBS) - CLinical concern e.g significant APH ``` CONTRAINDICATIONS – Lack of engagement of fetal head – incompletely dilated cervix in Singelton – to Cavallo pelvic disproportion – breach and face presentation – preterm for volunteers (<34/40) ``` In generak - Ventouse = lower maternal comps - Forceps = lower fetal comps

Answer 64

BASED ON EXPERIENCE AND TRAINING Ventouse more likely to be: - Fail to achieve VD - Cephalohematoma - Associated with retinal haemorrhage Ventouse less likely to be associated with - Maternal regional/GA - Signifocant perineal trauma Equally associated with c-section and low 5 min APGAR score

Answer 65

PREP – Two weeks before: routine MRSA screen (no soap) – five days before: ANC Bloods to test iron and safe course matching – night before ranitidine – don't eat anything after 2 am, only clear fluids DURING – You'll be awake but then a part of your body will be numb So you won't feel pain – screen replaced across your body can't see what's been done, doctors and nurses will keep you informed – a drip will be put into a blood vessel in your arm before the anaesthetic and catheter will be in set into your bladder to keep empty – When the anaesthetic is working a cut 10 to 20 cm is made across your lower tummy and womb – You may feel some tugging – Will see baby as soon as they are delivered, will be dried, quickly examined and given to you for skin to skin. During this time you'll be stitched. – Whole operation takes 40 to 50 minutes – very safe but like any surgery there is a small and AFTER – And Kirstie mobile – physio advice – should be drinking normally buy 24 hours – sanger him the day after, most within 23 days – with the midwife and health visitor at home – LMWH considered