Obs gyn important Flashcards
Physiological changes of pregnancy
Immune - not privileged, but trophoblast does not elicit allogeneic responses, no interface with maternal circulation immunogenically, thymus involutes in pregnancy, lymph nodes draining uterus enlarge
Cervix - reduction in collagen and accumulation of glycosaminoglycans and water, hypertrophies, more mucous, more vascularity
Vascular - hypertrophy of vessels, 50-500mL/min 10 weeks to term, invasion of spiral arterioles, 100-150 arterioles supply intervillous space (one per cotyledon)
Contractility - suppressed by progesterone, increased resting membrane potential, start by 7 weeks
CO - 40% increase 1st trimester, further increase after this, SV increases, HR increases
TPR - falls 4-6 weeks and halves by mid-pregnancy (allows BV to expand)
Arterial blood pressure - Sound 5 is for diastolic, MBP falls to mid-pregnancy, supine hypotension common in second half
Blood - Red cell mass increases by 20-30%, physiological anaemia
Respiratory - increase in minute ventilation, PaCO2 falls (right shift allows better unloading to foetus due to more 2,3DPG –> foetus is left shifted due to HBF), resp diseases usually not much effect on pregnancy
Renal function - GFR rises, some glycosuria and mild proteinuria common
Nutrients - Albumin falls, globulin rises, amino acids except alanine and glutamic acid decrease, HYPERLIPIDAEMIC, FFA (HPL)
Endocrine - placenta –> steroids betides and prostainoids, CRH and ACTH, Lowered oxytocin, GH, LH, FSH suppressed by placental gonadotrophin, pituitary gland grows, more prolactin, TFT’s increase, Aldosterone increases
Placental growth and development
Embryo –> morula –> blastocyst (formation of fluid filled cavity) –> penetrates endometrium by day 7 –> decidual reaction (syncytium phagocytksed by stromal cells) –> cytotrophoblast grow down to layers of decide and penetrate endometrial venules and capillaries –> forms intervillous space
2 arteries and one vein - high venous pressure preserves integrity of venous flow
Fetal cotyledon is functional unit
Angiotensin II important in regulating utter-placental blood flow
Placental transfer by simple diffusion, facilitated diffusion, active transport and pinocytosis
2x amount of glycogen in fetal liver - helps with birth
Insulin, glucagon, HPL, growth hormone - do not cross placenta (maternal Glucose levels major regulatory factor in placental)
Placenta makes –> BHCG, HPL, Progesterone, Oestrogens, Corticosteroids, CRH (last 4 are steroids, first two are protein)
Age, race, maternal height, weight and parity –> determine fetal birth weight
Fetal development
Ear by 10 weeks, inner by 24
Amniotic fluid sac as early as 7 days - turnover every 2-3 hours - sucked –> excreted in urine
1L by term
Oligo –> club foot, skull deformities, wry neck –> cord compression too
Poly –> unstable lie, cord proslapse/limbprolapse, abruption, PPH (over distension), discomfort and dyspnoea
Perinatal mortliaty
Australian 8.4/1000
Stillbirths - APH/IPH, IUGR, placental conditions, unexplained most common though
Neonatal - respiratory, congenital, neurological, extreme prematurity
Common causes of direct - sepsis, eclampsia, Thromboembolism, AFE, early pregnancy deaths
Indirect - cardiac, other indirect, neurological
Symptoms of pregnancy
N and V
Back pain - rule out peel, UTI, early labour - needs physiological and simple analgesics
Abdominal pain - suspect ectopic, miscarriage, gynae causes, UTI, surgical causes, later obstetric causes - otherwise common
Heartburn - rule out cardiac, pre-eclampsia, fatty liver –> conservative treatment, antacids and PPI if not working
Constpiation - due to progesterone –> fluid and dietary fibre
Frequency of urinartion
Snycope - progesterone + caval compression - exclude anaemia, hypoglycaemia, dehydration and arrhythmias - sit before standing enough hydration too
Lethargy
Varicosities - exclude DVT nd thrombophelbitis
Carpal tunnel - splints, severe steroid injections
SPD - due to relaxin - physiotherapy, support, analgesics
Breast tenderness and heainess
Foetal movements
Pica
Exam of pregnant woman
General, systemic and obstetric
Height weight and vitals
Thyroid status important and anaemia
Heart and lungs - benign flow murmurs, respiratory distress may occur
Head and neck - chloasma, look for pallor, dental hygiene
Breast - enlargement, vascularity, pigmentation of areolae,
Abdomen - striae gravidarum, hepatosplenomegaly, renal enlargement
UTERUS PALAPBE AT 12 weeks - 12 weeks above PS 24 weeks at umbilicus 36 at xiphisternum After 24 weeks number of weeks correlates to height above PS Girth 2.5 cm every week after 24 weeks
Limbs - oedema, varicose veins, increased lumbar lordosis may lead to back pain
Pelvic exam - speculum, cervix in later, VE contraindicated in later pregnancy until praevia excluded, plane of pelvic margins
Ischial spines - transverse
AP - least from inferior PS to coccyx (TRANSECTS LINE FROM ISCHIAL SPINES)
Should be gaining half a kilo a week after 18th week
ANTENATAL CARE
SEE handout from GP
Preconceptual - serology, influenza + pap smear, folic acid, iodine supplementation, change medications, nutritious diet and regular exercise, STOP ILLICIT
Smoking –> IUGR, lower crown-heel length
Alcohol –> FAS, growth retardation, structural defects, joint anomalies, cardiac
Ilicit –> IUGR, preterm, perinatal death
Cocaine –> cardiac arrhythmias, CNS damage, abruption
Amphetamine –» miscarriage, reterm, IUGR, abruption, fetal death and developmental abnormalities
Marjiuana can be teratogenic
Blood tests - Hb, B12, folate ABO antibodies Rubella and varicella Syphilis RPR, VDRL, FTA Hepatitis HIV GBS UTI OGTT - booking and 26-28
USS, CTFS/NIPT
No soft cheese, meats, salad bars, soft serve –> listeria
Protein 60-80 a day
Iron, calcium, iodine, magnesium, zinc, Vitamins A and B, B2, B5, ascorbic acid, folic acid
2000-2500kcalories a day
Exercise important, excessive exertion not good
Avoid coitus only if PPROM, APH, Placenta praaevia
Hygiene, brassiere
Lactation consultatnt
Motherrisk.org
NO NSAIDS
Hypertensive pregnancy disorders
0.3g/L OR 1g/L o random sample 2 or more occasions 6 hours apart
Pre-eclampsia –> abruption, convulsions, proteinuria, hypertension and oedema –> haemorrhage, renal and hepatic failure
- NEED SYSTEMIC MANIFESTATION
Vasoconstriction –> reduced utter-placental circulation –> DIC (slow, if fast –> HELLP) –> pro fibrin filtration –> reduced GFR –> sodium retention –> intracellular shifts of sodium –> vasoconstriction –> continues
ATERIOLAR VASOCONSTRICTION + DIC = PREECLAMPSIA
(MAP = CO x SVR) - loss of sensitivity to ATII and placental bed damage from vasoconstriction –> DIC
RF - genetic, autoimmune, thrombophilias, underlying CKD or essential hypertension, increased FFA’s, fetomaternal host response
Investigations - FBC, UEC, uric acid, LDH, Clotting studios, catecholamine, USS, CTG, Urinalysis Urine MCS
Give methyldopa, hydralazine, labetalol, prazosin, nifedipine
Give 2 doses IM betamethasone if severe enough when admitting as well
Prevention - aspirin, thrombophilia, calcium supplements
HEADACHE, RUQ pain, blurring of vision, sudden onset of vomiting, hyperactive reflexes, oedema - ALWAYS ASK ABOUT SEIZURES TOO
IOL - gestation over 37, uncontrollable BP, HELLP, deteriorating renal, eclampsia, APO, CTG compromise, reversal or end diastolic flow in umbilical artery, no fetal growth over 2 weeks, abruption
Leads to IUGR, Hypoxia, death
Maternal –> renal failure, hepatic failure, seizures, DIC< ARDS, cerebral infarction, heart failure,
Leads to infarction and abruption too
If seizure give MgSO4 and keep fluids up using CVO
IV hydralazine or labetalol if eclampsia too
APH
Placenta praaevia, placenta abruption, vasa praecvia, unexplained, infections of vagina, lesions of cervix
Praaevia - admit, IV, FBC and cross match, CTG, USS, anti-D
Abruption - associated with dietary deficiencies, folate deficiency, tobacco, hypertension, thrombophilia, IUGR, (not usually trauma)
- PAIN, bleeding, increased uterine activity, blood clot and increased tone
- use USS sometimes to differentiate from praevia but this is usually painful
- lie is usually longitudinal in this compared to mal in praevia
- Hb, IV, Transfuse, fluids, fetal condition, conservative management delivery by CS if 38 weeks and before if severe and persistent loss
- DDX acute hydramnios, perforated ulcer, volvulus of bowel, strangulated inguinal hernia
NOT ALLOWED TO USE EPIDURAL UNTIL CLOTTING SCREEN –> use opiates
Multiple pregnancy
Complications - n and V, anaemia, miscarriage, APH, pre-eclampsia, gestational HTN, eclampsia, IUGR, preterm labour
- IF MONOCHORIONIC - TTTS –> hydros fetalis, and cardiomegaly and polyhydramnios
Structural abnormalities increased
Antenatal supervision and USS to detect growth anomaly and TTTS
IUGR common, need to IOL
C section or vaginal
IV line needs to be in, epidural given if second twin complicated. - 30 minutes accepted between two deliveries –> C section
Obstruction and transverse –> C
Failure to descent with second twin breech –> guide foot and breech into pelvis (have to grasp foot with intact membranes to avoid cord prolapse)
IF placenta separates –> C section
EMCS - locked twins
Conjoined twins - C section
Higher perinatal mortality, often due to prematurity
Prolonged pregnancy
Postmaturity syndrome - dry skin, no fine hair, loss of subset fat, meconium staining of skin
–> mortality, distress, operative delivery, meconium aspiration
41+5 booking policy at most hospitals
<5cm AFI –> need to deliver
CTG and normal liquor –> doesn’t matter how you deliver
Breech
More irregular presenting part –> more risk of prolapsed cord or limb
Can deliver through incompletely dilated cervix as bitrochanteric less than biparietal
- ECV after 36
- –> DONT DO IF APH, abnormal CTG, placenta praevia, uterine scar or multiple pregnancy
- Give nifedipine or IM terbutaline
- stop if bradycardia and not past half way
Complications of eco - cord entanglement,abruption and ROM, persistent foetal bradycardia, 50% success, 1/200 emergency LSCS, abruption 0.1%, 3% revert
If 32-28 weeks or >4kg need to do C
VAGINAL:
Lift legs out –> once trunk out –> arms one at a time by sliding fingers over the shoulder and sweeping them downwards across fetal head (arm can be delivered by flexing at elbow and shoulders - Loveset’s manoeuvre - rotate body to do other arm) –> suspend trunk for 30 seconds –> grasp legs and swing upward through 180 degrees until can see mouth –> then do as normal
C section if <1.5 or >4
LCSC unless preterm
Unstable lie, transverse and shoulder presentation
May lead to prolapse of cord
No action until 37 unless labour starts
Look for USS to explain
39 weeks need to admit - in case SROM with prolapsed cord - allows for rapid C section
If any complicating - C section
If arrives in labour with shoulder presentation or prolapsed arm –> have to do C section (classical if arm wedged into pelvis)
Medical problems in pregnancy
Anaemia - physiological –> need more iron and folate
- Mainly affects mother, but can cause anaemia in child when born –> maternal mortality though
GDM - pregnancy is diabetogenic –> previous large infant, previous GDM, first degree with diabetes, obesity, ethnicity, macrosomia, unexpected perinatal death, PCOS< Polyhdramnois,
- Increases infections, polyhydramnios, macrosomia, increased risk of still birth, shoulder dystocia, instrumental, tears, IOL, C section - usually resolves
CHOLESTASIS
- Debilitating, prolongation on clotting, small stillbirth and preterm, high recurrence
- GIVE UDC, topical emollients, antihistamines, serial growth USS and CTG’s, OCP not to be used, oral vitamin K if clotting!!!!!!!
- Induce at 37, if unbearable for mother earlier
Fatty liver:
AFLP - variant of pre-eclampsia?
Fat people and multiple and first pregnancy
- N, V abdominal pain, malaise, jaundice, hypoglycaemia, can have maternal death due to encephalopathy haemorrhage, fetal mortality,
NEED TO GIVE MDT supportive, dialysis may be necessary after delivery
Infections
Varicella - congenital is eye defects, limb, neurological –> USS
Parvovirus - fever rash and arthropathy in mother, anaemia, heart failure or miscarriage in kid - analgesics, contact avoidance, in utero blood transfusions
Influenza - preterm, stillbirth, death, give oseltamivir and rest support, immunisation
HIV - HAART, miscarriage, IUGR, prematurity, stillbirth (if advanced)< C section usually, but can do vaginal if viral load is normal, NO breastfeeding (screen from birth - 12 weeks) and HAART for child
Hepatitis - No impact on pregnancy, sometimes preterm labour –> Mainly want to reduce vertical transmission, avoid use of instruments, give immunoglobulin and vaccination at birth
TB - streptomycin gives ototoxicity, need to give therapy, rarely crosses placenta
Malaria - IUGR, preterm, congenital, death
Acute peel - asymptomatic needs to be treated (pyuria)
VTE - need to give compression stockings, heparin, no OCP later on if conrfirmed diagnosis
Pre-existing medical conditions
Renal - pre-eclampsia, IUGR, preterm, C section
- Give aspirin, BP, renal function, UTI, prophylactic heparin if proteinuria, prophylactic antiobtics if multiple UTI, genetic counselling of PCKD, if calculi- longer antibiotics
Diabetes
- need more insulin, reduced signs of hypoglycaemia, complications accelerated, pre-eclampsia, preterm, polyhydramnios, instrumental delivery, IUGR, need to go to nursery, jaundice for child after, miscarriage, fetal abnormality
- change meds, MDT, tight parameters, control BP, ophthalmic assessment due to retinopathy
Thyroid
- Oestrogen increases thyroid
- need more in hypothyroid –> abortion, pre-eclampsia, HTN, PPH, LBW, IQ, cretin, monitor, and iodine adequate
- hyper –> don’t need as much as pregnancy needs more thyroxine –> augur, pre-eclampsia, prematurity, still births, thryotoxicosis
Obesity
- Miscarriage, congenital, pre-eclampsia, GDM, PPH, IOL, instrumental, C section, tears, VTE, Macrosomia, stillbirth, nurses, childhood diabetes, obesity for child, need more folic acid, OGTT
Thrombophilia - need to give LMHX, aspirin, heparin
- Pre-Eclampsia, abruption, IGUR, miscarriage (antiphospholipid especially),
Epilepsy - minimal - abnormalities, may need vitamin K, counselling, no stopping abruptly, breastfeeding safe
Headache - usually drop - no prophylaxis as vasoconstrictive
Autoimmune - some effect placental function, some like crohn’s improve due to altered
Haemoglobinpathies - N, V, anaemia, infection, need to give folic acid, aspirin, prophylactic antibiotics, avoid dehydration, VTE prophylaxis
Congenital abnormlaities
In over 50%, 70% miscarriages, 15% of deaths
Neural tube defects - anencephaly, microcephaly, spina video, 1/200 risk, normal intelligence, need folic and,
Heart - IUGR< oligohydramnios, defects
Defects of abdominal wall - exompahlos has a sac, gastroschisis doesn’t
Downs syndrome most common chromosomal
Risks - age, drugs, previous history, maternal disease, persistent breech, vaginal bleeding, abnormal AFI, abnormal foetal movements, IUGR
First USS - 11-13+6 - CRL, NT
20 week USS - Anatomical survey
CTFS - 9-13+6 or NIPT ANYtime
Second - 14+2-20 weeks not as sensitive
Counselling should be good
Amniocentesis of CVS sampling has risks - can terminate if they so choose, surveillance, some things can be treated
Screening not always works
AFI must be 2-8 single deepest pocket or at least 8 overall
FHR, breathing, movements, tone, normal foetus sleeps up to 40 so monitor for that long
Stages of labour
First early latent up to 3cm, active phase 3cm-10
Second fully dilated to delivery
Third - placenta and membranes
Regular - painful contractions that increase in frequency and duration, radiate down,
CRH –> more prostaglandins and oestrogen and less progesterone
Collagen breakdown due to leucocyte inflation
Latent is 6-8 in nulliparous, 4-6 in multiparous, - ACTIVE SHOULD BE 1cm per hour at least from 3-4 to full dilation
No progress with brow –> C SECTION
If lags more than 2 hours behind in active latent phase - if CPD excluded –> augment with oxytocin
Keep adequately hydrated, only light amount of food
NORMAL labour
Descent –> flexion due to sloping pelvic floor –> internal rotation –>extension just before delivery after through pelvis –> crowning –> restitution (head rotates back in line –> external rotation (shoulders rotate into AP position head rotates too to face thigh) –> delivery of shoulders and trunk –> third stage usually use synto –> need to massage uterine fundus and twist the cord which should continue to lengthen as it all comes out with the placenta (if this takes longer than 30 this is retained placenta )
When pressure exceeds 25mmHg –> pain
Encourage empty bowels and bladder early in labour
Exam - full exam - including urine
Vaginal exam only after cleansing using aseptic technique - BISHOPS SCORE - presentation, membranes, assessment of station, assessment of bony pelvis and outlet
NEED TO GIVE ADEQUATE ANALGESIA
Observe the cartogram —> early evidence of obstructed labour
Pain relief in labour
Discuss in antenatal
Narcotic, inhalatational, non pharmacological - heat packs, water, TENS, acupuncture, sterile water, aromatherapy, massage and relaxation, birth ball
Regional - not allowed to if coagulopathy, local or systemic infection, hypovolaemia, inadequate staff
- GIVE WITH ANTIEMETIC, naloxone, oxygen prescription ready
- Obs, DVT, IDC
- Post dural headache, N+V, nerve pain, not working, hypotension etc.
SEE THE other flashcard set it outlines this perfectly
Foetal monitoring
What does meconium do –> airway obstruction, chemical irritation, inflammation, infection, surfactant inactivation
Maternal - C section, pre-eclampsia, post-term, PROM, induced, diabetes, APH, maternal medical disease
Fetal - IUGR, Prematurity, Oligo, abnormal doppler, multiple meconium stained liquor, breech presentation
HR and meconium suggests distress, or less movements - can get foetal acid balance from scalp incision
Preterm delivery
OVER 20 or under 37
Can be threatened
Risk factors - ethnicity, age, anxiety, depression, stress, smoking, low socio-economic, high or low BMI, PTD, shortened cervix, genital tract infections, UTI, bleeding, assisted reproducers, uterine abnormality, PPROM, previous surgery cercix, poly/oligo, multiple gestation, chronic and acute medical conditions
Cramping lower back pain, regular uterine activity, pressure sensation - PV loss sometimes
GBS sometimes release prostaglandins from phospholipase which release arachinooidonic acid
Death causes - -Death, RDS, NEC, haemorrhage (periventricular)
Complications - jaundice, hypoglycaemia, hypothermia,, pulmonary dysplasia, neurodvelopmetnal delay
Normal exam - check for GBS, check FFN, high vaginal swab checks FFN and MCS)
Measure cervical length
NNPV from FFN is so high, don’t do if cercix is dilated more than 3, ruptured membranes, presence of soaps etc., placenta praceia or abruption
If less than 34 weeks use tocolysis and steroid load –> increase risk of infection, bleeding, death, lethal foetal abnormality, foetal compromiser, abruption
Tocolytics
DONT USE TOCOLYTICS IF MEMBRANES ARE RUPTURED
TVCL <25mm consider interventions
Types are beta agonist such as salbutamol, terbutaline - palpitations, tremor, pulmonary oedema, GIVE with dextrose - need to monitor vitals and urine
Prostaglandin synthesise inhibitors such as indomethacin - may cause in utero closure of DA - can cause oligo, renal after resistance and pulmonary artery too
Calcium antagonists –> headaches, achy, palpitations,dizziness, heartburn, consptiation, oedema
CORTICOSTEROIDS - reduces hyaline disease, IVH, NEC, - dexamethasone is given by IM on two occasions 12 hourly 12 mg
MGSO4 - low NNT but given anyway reduces cerebral palsy
NO INHIBITION OF LABOUR after 34
IF FHR abnormal, antepartum bleed or infection –> deliver
If membranes not ruptured no infection signs can inhibit
IV Abs for GBS prevention
<26 weeks not allowed to do C section
Progesterone sometimes helps? not advised but may be used in future
Cervical cerclage if greater than or equal to two losses
PPROM
Factors associated - infection, dilatation of cervix, intra-amniotic fluid pressure
Long term drainage of amniotic fluid may result in fetal pulmonary hypoplasia
Management - US, speculum, oxytocin, antibiotics, if not infected you give erythromycin
Maternal uterus - TENDER< PURULENT DYSCHARGE, TACHYCARDIA, PYREXIA, CRP
If at term need to induce, otherwise conservative
- Risk of infection, abruption, cord prolapse, pulmonary hyperplasia or stillbirth –> no sex, no bath, no swimming
IOL
At 40+10 in QLD - reduces perinatal mortality, less meconium aspiration, look at doppelers and AFI!!!!
Macrosomia - at 38+0 if >3.5kg at 36, 3.7 at 37, 3.9 at 38
Cholestasis - stillbirth can do it at 37 and 37+6 -
Advanced maternal age offer between 39 and 40
ALSO DO FOR APH, pre-eclampsia, DM, Chronic renal disease
CAN DO Dinoprostone (CANNOT USE THIS IF PREVIOUS C SECTION)
- <7 bishops, following balloon catheter
- not allowed - when hypersensitivity, ruptured membranes, >4 parity, previous uterine, undiagnosed PV bleeding, abnormal CTG
- Take out pessary when contractions or ruptured membranes or fetal distress or adverse effects
- wait 6 hours for gel, 12 hours for pessary to reassess
- after this have to ARM –> if this does not work then have to use gel max 3 doses or max one pessary –> reassess in 6 hours
- if still doesn’t work use balloon catheter
BALLOON
- Not allowed if membranes ruptured, bleeding, simaltenaous use of prostate, low lying placenta, polyhydramnios, abnormal FHR
- Relative is APH, lower infection, fetal head not engaged
- inflate balloon –> check vitals, engagement, loss vaginally, if no ROM 12 hours after insertion –> take it out before 18 hours ARM –> if this doesn’t work reconsider dinoprostone or catheter –:> IF TI TODES WORK –> reduce balloon volume if still in, offer anagesia, ongoing labour care
Oxytocin and ARM -
- relatively contraindicated if weird presentation or not engaged
- need to do examination after complete ARM and one before
- continue of all good and give oxytocin, CTG if abnormalities or consult obstetrician if not good and/or abnormalities
COMPLICATIONS OF INDUCTION
Tachyststrole or htypertonus, uterine htyperstimulation –> asyphisa
- Cant have less than 2 minutes between a contraction or have it last longer than a minute –> NEED TO DISCONTINUE/ REDUCE
- Continuous CTG
- VE
- If persists need to give terbutaline
- Prolapsed cord
- Infection - terminate unless delivery imminent
- PPH
Problems with labour
Precipitate - PPH and maternal morbidity, usually due to hypwerstinulation –> sometimes rupture of uterus
Delay - consider CPD, usually inefficient uterine activity
Insufficient uterine activity - usually hypotonic, can be hypertonic and asymmetrical
- Once CPD ruled out, give [ain relief, fluids, use snyto, fir hypertonic only low dose (if this doesn’t work C section)
Constriction ring dystocia can be reversed by use of beta-sympathomimetic agents, or ether or halothane anaesthesia
CPD - head too big for pelvis, pelvis tooo small for head or mix of both
- Careful monitoring
- if distress to either party, no descent, no dilatation over 4-6 hours —-> C section
- multiparous women at risk of uterine rupture
Cord presentation and cord prolapse
- Any condition that displaces the head or presenting part away from the cervix
- UNLESS DELIVERY IMMINENT place in DOGGY STYLE POSITION, or buttocks elevated by pillows
- Filling bladder may help too
- Give tocolytic
- -> C section unless filly dilated
Tears
Perineal injury - 1 is laceration to vagina and perineum only - no suture, 2 is involves posterior vaginal wall and underlying perineal muscles BUT NOT sphincter - suture, 3 is involving sphincter complex - surgery under GA or spinal, 4 involves anorectal mucosa as well - same as 3
3-4 –> anal incompetence, perineal discomfort, dyspareunia, rectovaginal fistulas 3a <50%, 3b>50% ES, 3c both ES and IS
RISK FACTORS FOR TEARS - large baby, first vaginal, instrument, oP, prolonged, augmented, epidural, shoulder, episiotomy midline, previous anal sphincter, infibulation of genitalia
JNEED TO GIVE Broad spectrum antibiotics, physiological, stool softners
Follow up at 6 weeks - need to offer C section at subsequent deliveries
Malpresenation
95% vertex
Face - if slow C section, mentoposterior needs to be rotated with forceps so some just do c section in this case as well
Brow - mentovertical diameter is 13 - C section
OP - most correct –> need fluid, pain, oxytocin, instrument
- PERFORM C SECTION if no completely dilated or head not engaged
Deep transverse - OT or OP –> arrested labour –> C section or instrument
Instrumental Delivery
Forceps and vacuum
Indications - delay, foetal distress, maternal exhaustion, clinical factors (resistance of floor, inefficient contractions, poor maternal effort, malposition, CPD, epidural analgesia)
NEED TO HAVE - fully dilated, vertex, head engaged, known position, empty bladder, adequate analgesia
OUTLET, LOW, MID PELVIC
CANNOT DO IF STATION < +2
Forceps -
neville barnes and simpsons - when no anterior rotation of head required
- blades suit pelvis, sagittal suture perpendicular to shank, occiput 3-4cm above the shank and one finger space between head of bladder and head on either side
- intermittent traction
Vacuum - anterior cups, posterior cups
- applied at flexion point
USE KJellands when you need to rotate - OP and OT
If not working C section
C section
Indications - distress, abnormal progress, IUGR, malpresentation, placenta praevia or severe APH, previous C section, severe pre-eclampsia or other disorders, cord presentation and prolapse, miscellaneous common conditions
Risks - GA, spinal or epidural, primary and secondary haemorrhage, wound, cannulas, UTI, pneumonia and endometritis, adhesions, infertility, foetal laceration, PE
Benefits - 40% get tears in birth, avoids risk of emergency C section which has higher risks than normal
Faster recovery with vaginal, increased bonding
RISK OF PLACENTA ACCRETA and praevia increase after each C section
COMPLCIATIONS - haemorrhage, injury to bladder, ureters, wound infection, uterine infection, PE, DVT, Secondary PPH
VBAC
VBAC - rupture of scar –> 1/200, 1/100 with oxytocin –> if it does rupture 1/10 need hysterectomy, 1/20 stillbirth or morbidity to the child
Death is 2-4/10,000 in VBAC
60-80% success rates 2-5/10 require repeat C section,
- especially if young, not fat, prior CS not related to arrest, dilated on admission, not big baby
2/1000 need blood transfusion
CONTRA - classical scar, preference, previous uterine surgery/hyesterectomy, previous rupture, needs induction and has unfavourable cervix, unusual pelvic shape, transverse position, not equipped for emergency C section, medical condition, other contraindications
- generally don’t recommend if past dystocia, mother overweight, older, VBAC2, IOL, no past vaginal birth
VBAC HAS LOWER complications (infection and bleeding), no risks of surgery, shorter hospital stay and quicker recovery, lower DVT, more bonding, lower maternal morbidity
Signs of scar dehysicanece - distress, tachycardia of mum, vaginal bleeding, cessation of contraction, Kehr’s sign, FOETAL BRADY
Planned VBAC < Elective C section
BUT EMERGENCY C SECTION has more risks than all
ECS - maternal mortality is higher, still quite low, increased risk of placenta praevia and accrete in future pregnancy –> blood loss mortality and hysterectomy, infection
NEED TO GROUP AND HOLD< CROSS MATCH, notify other staff, NEED to be cannulated, need continuous monitoring
Shoulder dystocia
When shoulder doesn’t deliver after head
ASK FOR HELP –> put mother fully recumbent (McRoberts manoeuvre) –> SUprapubic pressure on anterior shoulder –> Episiotomy –> Woods corkscrew (insert hand and rotate shoulders) –> pull posterior arm across chest –> Break clavicle –> Zavenelli (put back in and C section)
PPH
Tone, tissue, trauma, thrombin
500 or 1000 if c
Secondary is after puerperium up to 6 weeks
Tone - overdistention, prolonged, instrumental, APH, multiparty, multiple fibroids, uterine abnormalities, GA
Trauma - STI, episiotomy, lacerations to anywhere, uterine rupture, haemoatoma
Tissue - retained tissue
Thrombin - acquired - Sepsis DIC HELLP
Chorioamniotis also risk of PPH
UPTO 2L crystalloid, 1.5L colloid max allowed - want to give RBC
Complications - Hypovolaemic shock, renal failure, hepatic failure, DIC, ARDS, Death, SHEEHAN
Secondary - placental tissue, infection, trophoblastic disease
Complications of pregnancy - other
Haematoma - superficial or deep
Drain superficial,
deep occurs with instrumental delivery - excision and drainage for this as well and pack vagina, IDC, antibiotics
Uterine inversion - leave placenta attached to uterus - rhesus and push fundus back in -0-> take to theatre if not GA and push back with uterus relaxatns
Perineal wound break down - regular cleaning, if not decried –> repair again
- ANTIBIOTICS THE WHOLE TIME
AFE - shock - head clinician should organise
Post partum issues
Milk from 14 days, 6-13 mix, before then still colostrum
Initial sucking 2-3 minutes each side
Skin to skin contact etc important for healthy flora
Wash nipples and breasts use aqueous based emollients to soften
If express milk 2-4 degrees for 3-5 days or frozen for upto 3 months
Complications - Infection, UTI, wound infection, mastitis, VTE, incontinence, anal sphincter dysfunction, breakdown of ep[isiotomy wound
Endometritis - GBS, GAS
UTI
Mastitis - S aureus, epidermis, GAS, GBS, GFS
- oral abs
- IV for abscess - I + D sometimes
Other infections - must consider other sources - spies, pneumonia, influenza, bacterial endometrial, meningitis
VTE - heparin and warfarin can be used
Anaemia
Collapse - Haemorrhage most common cause Cardiac Sepsis Drug toxicity Eclampsia Anaphylaxis Metabolic hypoxia -----> ABC - -------HYPOVOLEMIA,Hypoxia,HYPO/HYPERKALEMIA,HYPOTHERMIA ------Thrombo, Toxicity, Tension pneumothorax, Tamponade
Post natal period
Examine - Edinburgh PSD Discharge 3 days usually early ambulation, episiotomy repair, bladder 4-6 hours post delivery, bowel, pain, immunisation, endometritis check for it, no sex/swimming for 6 weeks, advise of signs of infection when to return GP follow up
Psychiatric disorders of chidlbirth
50% recurrence if past
SSRI, SNRI (no pulmonary hypertension), TCA (jitters, hypoglycaemia etc) not good
NO CLOZAPINE
Can use atypical higher risk of GDM
Lithium - abstain,
Highest risk is valproate of anti epileptics - use lamotrigine if possible - NT, delay, retarded kids basically
Screen antenatally
Post natal screen - lots of people have blues
Psychosis post partum - risk factors if previous or family history
- Admit with baby - give meds, may use ECT, high risk of recurrence
- sometimes start lithium or antipsychotircs soon after
Postnatal depression -
Give antidepressant in severe, mild to moderate try without medication just psychotherapy
BREASTFEEDING
can use vslropaite and carbamazepine, no benzes, no lithium, no antipsychotics, avoid SSRI until >3 months, can use TCA
EOGBSD
PPROM give erythromycin 250mg 6 hourly 10 days OR amoxicillin IV 6 hourly 48 hours THEN amoxy 6 hourly for 7 days PLUS erythymcin same as above for 7 days
Intrapartum - benzylpenicillin IV then infusion - Lincomycin or cephazolin if allergic
No routine screening
- risk factors prolonged ROM, PPROM, previous, GBS in current or bacteriuria with it
NOT REQUIRED FOR C SECTION
If pyrexia 24 hours within birth need to notify paeds and use broad spectrum
Ectopic
Past tubal Past ectopic Infertility PID Previous miscaerriage Current or past smoker
ERxpectgent if HCG <1500 - cant have sex or pelvic exam
Medical - methotrexate <5000 (IV if >3000 otherwise IM)
- cant give if non-compliant
- FBC, UEC and LFT normal range
- avoid sunlight and folic acid food, no pelvic exam and sex
- nausea, tiredness, bowel habit altered and mouth ulcers from method
Surgery every other
DELAY OPREGNANCY FOR EVERYONE - FOLLOW UP USS TO SEE IF MASS GONE
Non viable
Exepectant - followup 7-10 days, repeat USS if needed and repeat BCHG
Medical - give misoprostol pCV Orlando or sublingual - not allowed if infection, medical contraindications, allergy, IUD,
IF Haemo unstable have to do surgical, or if GTD, infected POC
- Prime with misoprostol , don’t need to follow up generally
Safety net
IF GTD need to do bhcg until negative for 3 weeks for partial, same for complete then monthly for 6 months after 3rd negative result,
- After 6 months free can try for conception
Recurrent loss
Age, anatomy, endocrine, genetic, choromsotmal, antiphospholipid, infection, thormobphilia
HAVE TO DO FBC, ELFT, Homocysteine, MTHFR, antiphospholipid, TFT, insulin, glucose, POC, parental chromosomes, USS, sperm, ACA and LA, karyotype, TORCH, Kleihaauer, autopsy, pictures, metabolic things, SEE OSCE Investigate cord and placenta Cultures Chomosomal analysis from biupsy Histopathology of placenta Post mortem, surface swabs
VTE
LMWH or stockings
NEED TO DO THORMOBOPHILIA SCREEN IF ANY ONE HAS VTE
Antiphospholipid APC resistance Protein C Protein C AT III Prothrombin gene Factor V leiden
Complications of prematurity
Ards, retinopathy, PDA< bronchopulmonary dysplasia, late onset sepsis, NEC, hypothermia, hypoglycaemia, jaundice, infection, respiratory complications, chronic lung disease, PDA, anaemia and retinopathy
Longer term - hospitalisation, long term neurodevelopment impairment, chronic health problems
NEC - Football sign, Rigler sign, Falciform
Endometriosis
White, Family, age, nullipartiy, mullein anomalies, low BMI, autoimmune, smoking
Risks of surgery - infection, bleeding, adhesions, damage to other structures, excess tissue remove
PALMCOIEN
Polyps Adenomyosis Leiomyomata Malignancy and hyperplasia Coagulopathies Ovalatory dysfunction Endometrial Iatrogenic Not yet classified
Anaemia, thyroid and pelvic exam
Alternatives to HRT
Tibolone, SERMs, Clonidine, SSRI’s and SNRI’s, Gabapentin, NO EVIDENCE FOR HERBAL
