Obs+Gynae Flashcards
Management of Shoulder Dystocia
Call for help
Evaluate for episiotomy
McRoberts manoeuvre - bending maternal thighs on abdomen
Pressure on posterior aspect of fatal shoulder
Enter manoeuvres to internal rotation of fatal shoulders
Roll patient fours
Last resort: Clavicular #, symphoysiotomy, GA + Zavanelli
Management of Cord Prolapse
Trendelenburg position - manually elevate the fatal head and urgent C section (instrumental vaginal delivery can be done if fully dilated and head low in pelvis)
Tocolysis may be used
If cord is below Introits - keep warm and moist and do not push back in
PPH Management
Initial management: Get senior help + activate Major Haem Protocol. A-E approach (flat if poss, protect airway, 2x large cannula). Rapid infusion of fluids.
STOP THE BLEED: bimanual compression - empty bladder - IM Sent - Ergometrine .5mg - Syntometrin infusion - Caboprost IM (CI in asthma) - Carboprost myometrium injection - Misoprostol 100mg
Surgical: Balloon tamponade - compression sutures - uterine artery ligation
If uterine rupture or placenta acreta: Hysterectomy!
Management of Breech Presentation
25% of pregnancies are breech at 28 weeks but most resolve spontaneously!
ECV offered at 36 weeks if still breech (60% effective) CI: if going for C-section, APH in <7days, worrying CTG, Major uterine abnormality (fibroids) Multiple pregnancy or PROM
If unsuccessful: planned vaginal delivery or C-Section
Managing OP poisiton
Most cannot deliver vaginally as the position of baby’s head circumference. Typically presents with delay in 2nd stage.
10% begin OP but 3/4 of these will resolve to an OA position during labour.
Kielland’s Rotational forceps can be used if: prolonged labour and 1/5th below spines!
What are the indications fo IOL?
Pregnancy that is >42 weeks (most common reason, risk of: still birth, meconium passage, placental insufficiency)
PROM beyond 34 weeks
Maternal health concerns (HTN, pre-eclampsia, GDM, APH)
Fetal concerns (IUGR, Placental insufficiency)
What are the Contraindications to being induced?
Cephalopelvic disproportions BREECH Fetal distress Placenta Praevia Cord presentation
What are the complications of IOL?
Uterine rupture
Overstimulating the uterus (excess contractions, fatal hypoxia, abnormal CTG)
Cord prolapse (if ARM’d if the head is high)
Need for analgesia
Longer duration of labour
No association with increased risk of C-section
What is the management of Prolonged labour?
1st stage: Augmentation with oxytocin (careful in twins and no more than 4-5:10 contractions)
Artificial ROM
2nd stage: Artifical rupture of membranes
Augmentation with oxytocin (after obstetric review)
Instrumental delivery [must be 10cm dilated, head below the spines, analgesia]
3rd stage: oxytocin with cord traction
Pre-eclampsia management?
[75mg of aspirin given from 12w gestation if deemed at high risk: HTN in previous pregnancy, CKD, autoimmune, diabetes]
If presenting with pre-eclamisa: HTN + Oedema + proteinuria (300mg/24hrs)
Tight HTN control with oral or IV labetalol / nifedipine
MgSO4 given as seizure prophylaxis
Steroids given for lung maturation <34 weeks
Delivery definitive treatment
Management of Pre-term labour
<37 weeks (affects around 6% of pregnancies)
RF: multiple preg, infection, cervical incompetence, uterine abnormalities, smoking and PROM.
Admit with senior review 2x doses of IM steroids 12 hrs apart Tocolysis (CI: choreoamnitis, foetal death, thyroid disease, cardiac disease) Antibiotics MgSO4 (to reduce cerebral palsy risk)
Management of PROM?
Admit for 48-72hrs observation Steroid administration Erythromycin 250mg QDS for 10d Regular CTG monitoring 4hrl temps Can be managed as an outpatient after initial monitoring - but must do daily temp with aim to delivery @~34 weeks (trade off between chorioamniitis + RDSS)
Ectopic pregnancy management:
Expectant: <30mm, enraptured, asymptomatic, no FHR (good if another viable pregnancy in womb), B-HCG<200
Closely monitor over 48 hours, intervene if becomes symptomatic or increasing b-HCG.
Medical Mx: <35mm, no pain, no FHR, serum HCG<1500. Give methotrexate (as long as patient willing and able to attend follow-up)
Surgical: >35mm, ruptured, pain, visible FHR, bHCG>1500, compatible with other uterine pregnancy
Salpingectomy vs Salpingotomy (1in5 need rather treatment with methotrexate as not that effective)
Management of hyperemesis?
Triad of: >5% pre-pregnancy weight loss, dehydration and electrolyte imbalance.
Inv: Bloods, Urine dip (ketones indicate extremem dehydration, USS (to rule out molar/multiple pregnancies)
Admit for observation Adequate hydration, nutrition and rest 1st line: cyclizine Metacloperamide Ginger and acupuncture! If severe: steroids and TPN!
NICE guidelines on endometriosis?
10% of women have some degree of endometriosis!
1st line: NSAIDs + paracetamol
COCP or Progestrones can be tried
If not management by this, REFER
GnRH analogues induce ‘pseudomenopause’
Surgery: Laparoscopic excision and laser
