Obs n Gynae Flashcards
define preterm labour
<37 weeks gestation
define prolonged labour
no definite time period
cervical dilatation <2 cm in 4 hours during active labour
describe the first stage of labour
onset to contractions to full dilatation
early latent phase = cervix becomes effaced, shortens and dilates up to 4 cm
active phase = 4 cm cervical dilatation to full dilatation (10 cm)
describe the 2nd stage of labour
full dilatation to delivery of fetus
passive stage = full dilatation prior to or in absence of persistent involuntary expulsive contractions
active stage = when baby is visible OR persistent involuntary expulsive contractions/active maternal effort with a finding of full dilatation
describe the 3rd stage of labour
delivery of fetus to delivery of placenta and membranes
how long can the 3rd stage of labour last
usually 5-10 minutes after delivery
> 30 minutes = abnormal
how long does labour normally last
first labour = average 8 hours
subsequent labours = average 5 hours
when is delay in labour diagnosed
nulliparous: active second stage has reached 2 hours
multiparous: active second stage has reached 1 hour
what is the difference between physiological and active management of the 3rd stage of labour
physiological: uterotonic drugs (oxytocin) are not used, cord not clamped until pulsations have ceased, placenta is delivered by maternal effort
active management: use of oxytocin before cord stops pulsating, bladder catheterisation, deferred clamping and cutting of the cord, controlled cord traction after signs of separation of the placenta
what are the signs that indicate separation of the placenta and membranes
uterus contracts, hardens and rises
umbilical cord lengthens permanently
gush of blood variable in amount
placenta and membranes appear at introitus
when should you change from physiological to active management of 3rd stage of labour
excessive bleeding or haemorrhage
failure to deliver placenta within 1 hour
patient’s desire to shorten 3rd stage
what are clinical signs of onset of labour
regular, painful contractions which increase in frequency and duration and produce progressive cervical dilatation
passage of blood-stained mucus from the cervix is associated with onset of labour nut not an indicator
rupture of membranes not always at start of labour
what is the definition of prelabour rupture of membranes
> 4 hours between rupture of membranes and onset of painful contractions
can be preterm or term
what are Braxton hicks contractions
non-labour contractions towards the end of gestation
which hormones are involved the initiation of labour
decreased progesterone
increased oestrogen and prostaglandin
oxytocin promotes PG release and initiates/sustains contractions
what are special features of uterine myocytes
contract and shorten, and return to precontraction length
contain ion channels that influence the influx of calcium ions into the myocytes and promote contraction of myometrial cells
affected directly by hormones such as relaxin, activin A (cAMP)
describe changes in the cervix leading up to labour
contains myocytes and fibroblasts
towards terms, there is a decrease in collagen (becomes softer and stretchy)
increased hyaluronic acid reduces the affinity of fibronectin for collagen and affinity of hyaluronic acid for water causes cervix to soften and stretch
what are the cardinal movements of labour
engagement descent flexion internal rotation extension external rotation expulsion
describe engagement (1st cardinal movement)
passage of widest diameter of the presenting part to a level below the plane of the pelvic inlet
engagement is measured in fifths (proportion of fatal head that is unpalpable)
describe descent (2nd cardinal movement)
downward movement of the presenting part through the pelvis
describe flexion (3rd cardinal movement)
flexion of the fatal head occurs passively as the head descends due to the shape of the bony pelvis and resistance by soft tissues
describe internal rotation (4th cardinal movement)
rotation of the presenting part from its original position (usually transverse with regard to the birth canal) to the anterior position as it passes through the pelvis
describe extension (5th cardinal movement)
occurs once the fetus has reached the introitus, and the base of occiput is in contact to the inferior margin of the pubic symphysis
describe external rotation/restitution (6th cardinal movement)
return of the fetal head to the correct anatomical position in relation to the fatal torso and shoulders
describe expulsion (7th cardinal movement)
delivery of rest of fetal body
what are causes of abnormal labour
malpresentation malposition too early (preterm <37 weeks) too late (post-term >42 weeks) too painful too quick (<2 hours) too long (failure to progress, obstruction) fetal distress
what is malpresentation
non-vertex presentation
vertex is bounded by the anterior and posterior fontanelles and the parietal eminences
involves breech presentation, transverse, shoulder/arm, face or brow presentation
what is malposition (labour)
occipitoposterior or occipitotransverse
what are the main causes of failure to progress
powers: inadequate contractions either in strength or frequency
passages: trauma, shape, cephalopelvic disproportion
passenger: big baby, malposition causing a relative cephalopelvic disproportion
what are potential complications of obstructed labour
sepsis: ascending genitourinary tract infection postpartum haemorrhage fistula formation fetal asphyxiation neonatal sepsis uterine rupture obstructed acute kidney injury
how is progress in labour assessed
how often should it be performed
vaginal examination every 4 hours
cervical dilatation
descent of presenting part
signs of obstruction (moulding, caput, anuria, haematuria, vulval oedema
what are the three main types of forceps
outlet forceps
mid-cavity/low-cavity forceps
rotational forceps
indications for outlet forceps
fetal scalp is visible without separating the labia
the fatal skull has reached the pelvic floor
sagittal suture is in the AP diameter or right or left occiput anterior or posterior position (not >45 degrees)
fatal head is at or on perineum
can be used for lift-out deliveries at c-section
indications of mid/low-cavity. forceps
when fatal head is 1/5 palpable abdominally
leading point of the skull is above station +2 but not above the ischial spines
rotation of <45 degrees
indications for rotational forceps
should be performed in theatre with effective regional anaesthesia
what are the indications for FORCEPS
fully dilated (10 cm)
occipitoposterior position
ruptured membranes
cephalic presentation
engaged presenting part (fetal head must not be palpable abdominally and must be below the ischial spines)
pain relief
sphincter (bladder) empty (catheterisation)
standard indications: failure to progress in 2nd stage, fatal distress, maternal exhaustion
what are the advantages of operative vaginal delivery over C-section
80% will have a spontaneous vertex delivery subsequently
reduced analgesic requirements
shorter hospital stay and quicker recovery
less physical restrictions on bonding with the baby
what are the advantages of c-section compared to operative vaginal delivery
avoids tears to perineum and therefore problems with long term urinary and faecal incontinence
no injury to cervix or high vaginal areas
less change of neonatal trauma
what are disadvantages of operative vaginal delivery compared to c-section
neonatal trauma
urinary symptoms if retention occurred around the time of delivery
high risk of postpartum haemorrhage
shoulder dystocia as the traction applied cases head to deflex and shoulders to abduct, widening their diameter
what types of neonatal trauma can occur as a result of operative vaginal delivery
intracranial haemorrhage
skull fracture
jaundice due to cephalohaematoma and caput succedaneum (ventouse)
facial nerve palsy
forceps leave mark on face
brachial plexus injury
disadvantages of c-section compared to operative vaginal delivery
haemorrhage/infection visceral injury VTE longer hospital stay risk of uterine rupture in future labours and placenta accreta in future pregnancy greater maternal mortality transient tachypnoea of newborn
advantages and disadvantages of ventouse delivery
less perineal trauma but more likely to fail than forceps
more likely to cause cephalohaematoma, chignon (swelling on baby’s heads) and retinal haemorrhage
contraindications to ventouse delivery
prematurity <34 weeks face presentation suspected fatal bleeding disorder eg haemophilia fetal predisposition to fracture maternal HIV or HepC
describe caput succedaneum in terms of onset, pathology, site, associated features and management
onset: present at birth
pathology: due to pressure of the presenting part against the cervix
site: tissue swelling that forms over the vertex and crosses suture lines
features: prolonged labour; soft puffy swelling; skin over swelling may look bruised; often with moulding
management: conservative, resolves in days
describe cephalohaematoma in terms of onset, pathology, site, associated features and management
onset: several hours after birth
pathology: subperiosteal haemorrhage due to prolonged second stage or instrumental delivery
site: forms below the first layer of periosteum, limited by suture lines
features: jaundice in newborn; often following operative delivery; swelling is firm with distinct margins; no skin discolouration; increases in size 12-24 hours after birth
management: conservative unless hyperbilirubinaemia in neonate, resolves over months
what is a chignon
temporary swelling after a ventouse suction cap has been used
2 hours - 2 weeks
describe subgleal haemorrhage in terms of onset, pathology, site, associated features and management
onset: at delivery and may progress rapidly
pathology: severing of the emissary veins that are located between the dural sinuses that cover the skull and scalp
site: forms above the periosteum, between the skull and the scalp aponeurosis; crosses the suture lines and covers a greater area than cephalohaematoma
features: delay in recognition may lead to neonatal encephalopathy, seizures, death; diffuse ill-defined swelling may shift when palpated and shift with reposition of the head; forceps/ventouse deliveries
management: resus and blood transfusions, assess for coagulopathies
what are the main diagnostic features of amniotic fluid embolism
occurs during or within 30 minutes of labour
respiratory distress, hypoxia, hypotension
after 30 minutes of physiological management of 3rd stage of labour and placenta still hasn’t been delivered
abs are stable and blood loss is minimal - what is the next best step
observe for 30 mins with IM syntocinon and breastfeeding
can wait up to 30 minutes total for physiological management of 3rd stage of labour
give syntocinon IM rather than In infusion
breastfeeding will stimulate spontaneous expulsion
29 yo primiparous women in prolonged labour following induction at 41 wks
6 cm dilated, fatal head is 1 cm above ischial spines
fetal heart rate is progressively dropping, <100 bpm, not recovered for more than 3 minutes
management?
category 1 C-section
fetal HR <100 bpm is a worrying sign
not fully dilated to instrumental delivery in theatre may not be advised
when is terbutaline given?
given in premature labour to reduce contractions
which of the following is not an indication for induction of labour?
prolonged pregnancy diabetes in pregnancy macrosomia pre-eclampsia at term IUGR
macrosomia
a baby born 4 hrs ago by forceps has a swelling in the parietal region which does not cross suture lines
what is it
cephalohaematoma
31 yo due to have induction of labour at 38 wks due to cholestasis of pregnancy
bishop’s score of 1 calculated with the station at -1 but her cervix is closed and firm
treatment?
vaginal prostaglandins (PGE2)
PGs will ripen the cervix and cause a dilation allowing ARM to occur later
what is syntometrine used for?
management of postpartum haemorrhage
38 yo prim at 39+3 presents in spontaneous labour
she has only dilated 3 cm in last 6 hrs
she is now 6 cm dilated, CTG shows no fatal distress, uterine contractions are palpable but irregular and not very strong
management?
vaginal examination followed by amniotomy and reassess after
PV exam to assess dilatation, position and presentation of fetus
membranes are intact, so amniotomy is performed to accelerate progress of labour
CTG monitoring continued
what is the average rate of dilation in a primiparous woman
1 cm per hour
indications for induction of labour
prolonged pregnancy (>42 weeks) pre-eclampsia placental insufficiency and IUGR antepartum haemorrhage (includes abruption) Rh immunisation diabetes mellitus chronic renal disease
what does the bishop score measure
assessment of the cervix to predict outcome following induction
dilatation effacement station cervical consistency cervix position
a bishop score of ____ is strongly predictive of labour following induction
>6 = labour follows induction <5 = needs cervical ripening
what are the criteria of the Bishop’s score
dilatation: 0, 1-2, 3-4, 5+
effacement (?%): 0-30, 40-50, 60-70, 80-100
station: -3, -2, -1, >0
cervical consistency: firm, medium or soft
cervix position: posterior, middle, anterior
all criteria start at a score of 0 and up to a max of 3
what are mechanisms of induction of labour
stripping of membranes artificial rupture of membranes medical induction following amniotomy medical induction and cervical ripening mechanical cervical ripening
stripping of the membranes
requirements and hazards/precautions
requirements
aseptic conditions: finger is inserted into cervix and the fetal membranes are separated from the lower segment
hazards/precautions:
if 7 people have sweeps, only 1 will labour in 48 hours
artificial rupture of membranes (amniotomy)
requirements and hazards/precautions
requirements:
aseptic conditions to prevent infection
cervix should be soft, effaced and at least 2 cm dilated
head should be engaged in pelvis and should be presenting by the vertex
hazards/precautions:
cord prolapse, vasa praevia )make sure to assess the fetal membranes and make sure there are no pulsating vessels present before amniotomy)
need to monitor fetal heart rate on CTG
medical induction following amniotomy using synthetic oxytocin infusion (syntocinon)
requirements and hazards/precautions
requirements:
aseptic conditions to prevent infection
cervix should be soft, effaced and at least 2 cm dilated
head should be engaged in pelvis and should be presenting by the vertex
hazards/precautions:
uterine hyperstimulation (>5 contractions in 10 minutes); reduces uterine blood flow and results in fetal asphyxia
discontinue infusion if excessive uterine activity or signs of pathological fetal heart rate of concern
can cause uterine rupture, particularly if there is a uterine scar
medical induction of labour and cervical ripening by administration of PGE2
requirements and hazards/precautions
requirements:
method of choice when the membranes are intact or where the cervix is unsuitable for surgical induction
oral route: causes nausea and vomiting and not commonly used
pessaries: most commonly used; 3 mg doses if no response repeat after 6 hours
hazards/precautions:
PG contraindicated if previous uterine scar (risk of hyper stimulation and uterine rupture)
if hyperstimulation, remove pessary and use a bolus of short acting tocolytic eg terbutaline
what is mechanical cervical ripening
insertion of balloon catheter through the cervix which is used to distend the cervical canal over a 12 hour period and then removed to allow amniotomy
what is measure on a cartogram
fetal heart rate cervical dilatation duration of labour colour of liquor frequency and duration of contraction caput and moulding station/descent of the head maternal heart rate, BP and temperature
how is descent of fetal head/station measured
assessing the level of the presenting part in cm above or below the ischial spine and marked as +1/2/3 if below the spines and _1/2/3 if above the spines
pros and cons of narcotic analgesia in labour
pros:
suitable for women who can’t have regional analgesia eg women on anticonvulsants
remifentanil is ultra-short acting and is superior to pethidine
cons:
maternal: nausea and vomting (give anti-emetic too)
fetal: respiratory depression
pros and cons of inhalation analgesia (gas and air)
pros:
easy to administer
short-acting
cons:
may cause nausea
sometimes inadequate as labour progresses
contraindication to regional anaesthesia
maternal refusal coagpulopathy local or systemic infection uncorrected hypovolaemia inadequate or inexperiences staff/facilities
pros and cons of epidural anaesthesia
pros:
complete pain relief in majority
can be commenced at any time and does not increase risk of C-section
can be controlled by patient
can be topped up to allow operative deliveries
cons: may reduce desire to bear down in second stage of labour due to lack of sensation at the perineum and reduced uterine activity increased risk of a assisted delivery causes abnormal fetal HR hypotension accidental dural puncture postural headache high block which may cause resp depression in mother atonic bladder
describe how an epidural anaesthetic works
fine catheter placed into lumbar epidural space (L3-4) and a local anaesthetic agent such as bupivacaine is injected
adding an opioid to the local anaesthetic reduces dose requirements to spare motor function of the lower limbs and reduced complications eg hypotension and abnormal fetal HR
describe a pudendal nerve block
injection of local anaesthetic around the pudendal nerve at the level of the ischial spine
pros and cons of pudendal nerve block
pros:
used in operative vaginal delivery
cons:
risk of haemorrhage from pudendal artery
risk of lignocaine toxicity if inadvertent intravascular injection
can be ineffective
describe a spinal anaesthetic
catheter is placed at L3-4 and inserted into the subarachnoid space where anaesthetic agent is injected
pros and cons of spinal anaesthesia
pros:
commonly used for operative delivery
cons:
not used in pain control because of superior safety of epidural and its ability to top up with doses or as continuous infusion to get pain relief over a long period of time
maternal indication for continuous electronic fetal monitoring
gestation <37 weeks or >42 weeks
induced labour
administration of oxytocin
ante/intrapartum haemorrhage
maternal illness
pre-eclampsia
previous uterine scar (C-section or myomectomy)
contractions >5 in 10 mins or lasting >90 seconds
during/following insertion of epidural block
maternal request
fetal indication for continuous electronic fetal monitoring
abnormal doppler artery velocimetry
known or suspected IUGR
oligohydramnios or polyhydramnios
malpresentation
meconium stained liquor
multiple pregnancy
suspected small for gestational age or macrosomia
reduced fetal movements in the last 24 hours reported by mother
two vessel cord
prolonged ROM >24 hours unless delivery imminent
rise in baseline, repeated decelerations or slow to recover decelerations or overshoots
fetal structural abnormalities
which mnemonic is useful while interpreting CTGs and what does it stand for
DR BRAVADO
Define Risk: why are they on CTG (pre-eclampsia, antepartum haemorrhage, maternal obesity, DM, HTN etc)
Contractions: normal = 3-5 contractions/10 minutes
Baseline RAte: fetal HR 110-160 bpm
Variability: good 5-25 bpm, reduced <5 bpm,
Accelerations: rise in fetal HR of at least 15 bpm for 15 seconds (fetal movement), occur with contractions, at least 2 every 15 mins
Decelerations: reductions of 15 bpm for 15 secs, generally abnormal, early or late in relation to contractions (late decelerations are worse)
Overall impression: reassuring or not, BE AWARE of terminal bradycardia (<100 bpm for 10 mins) and terminal decelerations (HR drops and doesn’t recover for 3 mins)
describe a normal CTG in terms of baseline, variability and decelerations
baseline: 100-160
variability: 5 or more accelerations
decelerations: none of early
describe a non-reassuring/suspicious CTG in terms of baseline, variability and decelerations
baseline: 161-180
variability: <5 accelerations for 30-90 minutes
decelerations: variable decelerations dropping <60 bpm, recovering in <60 secs, present for over 90 minutes, occurring with >50% of contractions
OR
variable decelerations dropping >60 bpm, recovers in >60 secs, present for up to 30 minutes, occurring with >50% of contractions
OR
late decelerations present up to 30 minutes, occurring with 50% of contractions
describe an abnormal/pathological CTG in terms of baseline, variability and decelerations
baseline: >180 or <100 bpm, sinusoidal pattern
variability: <5 for >90 minutes
decelerations: non-reassuring variable decelerations still observed 30 mins after conservative management
OR
late decelerations present over 30 mins, do not improve with conservative measures, with >50% of contractions
OR
bradycardia or single prolonged deceleration lasting >3 mins
definition and management of normal CTG
baseline, variability and decelerations all normal
Continue CTG and normal care
definition and management of non-reassuring CTG
1 non-reassuring features and 2 normal features
inform senior, move to left lateral position, encourage fluids (IV or oral), stop oxytocin, consider tocolysis
definition and management of abnormal CTG
1 abnormal feature or 2 non-reassuring features
inform senior, start conservative measures, offer fetal blood sampling
exclude factors indicating need for immediate delivery (cord prolapse, uterine rupture, hyperstimulation, abruption)
treat dehydration, hyperstimulation, hypotension and change position
definition and management of pathological CTG
bradycardia or a single prolonged deceleration with baseline <100 bpm for >3 minutes
inform senior, start conservative measures, make preparations for urgent birth (c-section)
early decelerations
definition, cause and management
drop in fetal HR of >15 bpm for >15 min that occurs at the beginning of the contraction with the lowest point occurring at the peak of the contraction and recovery when contraction stops
often due to head compression during a contraction and increased vagal tone, occurs in late first and second stage of labour
physiological management
late decelerations
definition, cause and management
occurs well after contraction is established and does not return to normal baseline rate until at least 20 seconds after contraction is completed
due to placental insufficiency and may indicate fetal hypoxia (maternal hypotension, pre-eclampsia, uterine hyperstimulation)
call senior help, get fetal blood sample to check for hypoxia, may need to expedite delivery
reduced variability
definition and cause
variability of <5 bpm for >40 minutes OR more than 25 bpm 15-25 minutes
fetal sleeping (<40 mins), fetal acidosis and hypoxia, fetal tachycardia, drugs, prematurity, congenital heart problems
variable decelerations
definition, cause and management
vary in timing and amplitude and may not have a relationship to uterine contractions
cord compression
change position of mother, increase monitoring
what makes a variably deceleration more concerning
shoulders of deceleration are accelerations before and after a deceleration: indicate the fetus is not yet hypoxic and is adapting to the reduced blood flow
variable decelerations without shoulders suggest that the fetus is hypoxic
sinusoidal pattern (CTG) definition, cause and management
smooth irregular wave-like pattern, no beat-to-beat variability, stable baseline of 120-160 bpm
severe fetal hypoxia, fetal anaemia, fetal/maternal haemoarhage
urgent C-section
how often is fetal heart rate monitored in the first and second stage of labour
1st stage: every 15 mins for a period of 1 minute soon after a contraction
2nd stage: every 5 mins or after every other contraction for 1 minute
how is a fetal blood sample taken
amnioscope used to obtain blood from fetal scalp
cervix must be at least 3 cm dilated to allow insertion
what is the normal fetal pH
7.25-7.35
what does management of fatal distress involve
changing maternal position
maternal assessment (pulse, BP, abdomen palpation, PV)
IV fluids
stopping contraction (stop/reduce syntocinon or start terbutaline)
scalp stimulation during PV (should have an acceleration)
fetal blood sampling
operative delivery
what is maternal collapse
acute event involving the cardiorespiratory systems and/or brain resulting in reduced or absent conscious level
what are the 4H’s of maternal collapse
hypovolaemia: bleeding, relative hypovolaemia of dense spinal block, septic or neurogenic shock
hypoxia: peripartum cardiomyopathy, MI, aortic dissection, large vessel aneurysms
hypo/hypoerkalaemia (and other electrolytes)
hypothermia
what are the 4T’s of maternal collapse
thromboembolism: amniotic fluid embolism, PE, air embolus, MI
toxicity: local anaesthetic magnesium
tension pneumothorax
tamponade (cardiac)
how does amniotic fluid embolism cause maternal collapse
amniotic fluid enters the maternal circulation and triggers a syndrome similar to anaphylaxis and septic shock
if the woman survives the amniotic fluid embolism what is she at risk of developing
disseminated intravascular coagulopathy
which dietary supplements are recommended during gestation
folic acid 400 mcg from before conception to 12 weeks (reduce neural tube defects)
up to 5 mg if DM, anti-epileptics, BMI >30, previous neural tube dect
10 mg vitamin D, through pregnancy + breastfeeding
250-300 extra calories
what is the guidance for smoking and drinking during pregnancy
drinking: no safe limit (risk of fetal alcohol syndrome)
smoking: avoid, increased risk of miscarriage, low birth weight, prematurity
side effects of cocaine, amphetamines and ecstasy in pregnancy
maternal: hypersensitive disorders including pre-eclampsia, placental abrupt, death via stroke and arrhythmias
fetal: prematurity, neonatal abstinence syndrome, teratogenicity, IUGR, preterm labour, miscarriage, developmental delay, sudden infant death syndrome, withdrawal
side effects of opiates in pregnancy
risk of neonatal abstinence syndrome, IUGR, SIDS, stillbirth, maternal deaths
side effects of cannabis in pregnancy
cognitive defects, miscarriage, fetal growth restrictions
side effects of nicotine in pregnancy
increased risk of miscarriage
increased risk of preterm labour and IUGR
increased risk of still birth, SIDS
side effects of alcohol in pregnancy
fetal alcohol syndrome (smooth philtre, thin vermillion, small palpebral fissures)
IUGR and postnatal restricted growth
learning difficulties
risk of miscarriage
withdrawal
Wernicke’s encephalopathy and Korsakoff’s syndrome
microcephaly
how is substance abuse managed in pregnancy
consider methadone programme (avoid chaotic lifestyle)
child protection and social work referral
smear history (put measures in place to ensure the woman gets involved with a screening programme)
breastfeeding education (HIV+ should bottle feed)
labour plan regarding analgesia and labour ward delivery
early IV access
postnatal contraception plan (ASAP)
when does a booking visit take place and what does it consist of
10-12 weeks by community midwife
History: medical, drug, social and family, LMP, planned pregnancy, ethnicity of parents
obstetric history: previous pregnancy, mode of delivery, previous miscarriages/terminations
Ix: mother’s blood group, Hb levels, haemoglobinopathies, blood borne infections (HIV/AIDs, syphilis, hep B/C)
when does the anomaly scan take place and which conditions does it screen for
18-20+6 weeks
anencephaly, open Spina Bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious cardiac anomalies, bilateral renal genesis, skeletal dysplasia, trisomy 18/13
when is the first stage of Down’s syndrome testing and what does it consist of
11-13+6 weeks
combined test = blood test and US
US: nuchal translucency >3.5 mm
bloods: serum PAPP-A, AFP, beta-hCG (down’s = low PAPP-A and aFP, high beta-hCG)
what is the 2nd stage of Down’s syndrome testing andwhe does it take place
15-16 weeks
quadruple test = blood test checking aFP, inhibin, estriol and total hCG
how many routine midwife appointments with nulliparous and multiparous women have during pregnancy
nulli: 10
multi: 7
women with pre-existing diabetes or gestational diabetes are offered extra monitoring during pregnancy - why?
monitor fetal growth and amniotic fluid volume
increased risk of stillbirth, congenital malformation and polyhydramnios
how does exposure to Rh antigen expose future pregnancies to risk of haemolytic disease on newborn
when mothers are first exposed to the RH antigen, they form IgM antibodies that are too big to cross the placenta and harm the current fetus
in futur pregnancies when the mother is exposed to the same antigen from the foetus’s red cells, the body forms IgG antibodies which are smaller and can cross the placenta to harm the fetus
how does anti-D work?
removed the rhesus positive blood cells from mother’s circulation before antibodies are formed
who is anti-D given to
Rh negative mothers who have been exposed to a sensitising event
should be given within 72 hours of the event
prophylactic anti-D given at 28 weeks to cover silent sensitising events, regardless of other sensitising events
what is a sensitising event (in the context of anti-D)
placental abruption any abdominal trauma amniocentesis or CVS external cephalic version IU surgery/transfusion fetal death vaginal bleeding from 12 weeks surgical management of miscarriage at <12 weeks evacuation of retained products of conception and molar pregnancy termination of pregnancy ectopic pregnancy delivery (baby is Rh+)
what should always be undertaken before vaginal examination
abdominal examination
what equipment is needed to perform a bimanual examination
apron alcohol hand rub sterile gloves lubricant eg aqua gel towel or sheet to cover the woman inco pad
PV examination: inspection
inspect the clitoris (size, trauma, ulcers)
external urethral meatus (discharge, prolapse) and 2 para urethral glands at the 3 and 9 o’clock position
remnants of the hymenal ring
vaginal canal (mucosa for colour, texture and rugosity)
vaginal discharge (colour, texture and odour)
older women: ask to cough to demonstrate urinary incontinence or utero-vaginal prolapse
what do you assess the cervix for in PV examination
cervical os: open/closed
length of cervix
directed posteriorly (anteverted) or anteriorly
consistency (usually firm when normal but hard in fibrosis/cancer and soft in pregnancy)
cervical excitation tenderness: gently move the cervix from side to side simultaneously assessing the patient’s face to ascertain if painful (positive in PID or ectopic pregnancy)
how to assess the uterus in bimanual examination
vaginal fingers are pushed on or behind the cervix to elevate the uterus upwards and towards the anterior abdominal wall and the left hand is placed suprapubically to palpate the uterus between the two hands
size, shape, consistency, position, tenderness, mobility
how to assess the adnexa in bimanual examination
vaginal fingers are moved to one of the lateral fornices with the abdominal hand moving into the corresponding iliac fossa
presence of ovary/Fallopian tube, adnexal masses, size, shape, tenderness
what is shoulder dystocia
when the baby’s head has been born but one of the shoulders becomes tuck behind the mother’s pubic bone, delaying the birth of the baby’s body
how to manage shoulder dystocia (emergency situation)
stop pushing
reposition into all fours position to increase pelvic diameter
OR
lie the woman on her back with her legs pushed outwards and up towards her chest (McRoberts manoeuvre)
ideally have two helpers to abduct each knee to the woman’s chest
press on the abdomen just above the pubic bone in an attempt to dislodge the fetal shoulder
what is the definition of post part haemorrhage
loss of >500 ml of blood from the genital tract within 24 hours of the birth of a baby
indications for examination of pregnant abdomen
at each antenatal assessment from 24 wks to assess growth
prior to auscultation fo fetal heart and use of CTG (to work out where to listen)
prior to vaginal examination
during labour
which gestational ages are associate with the following fundal heights:
pubic symphysis
umbilicus
xiphoid process of the sternum
pubic symphysis: 12 weeks
umbilicus: 20 weeks
xiphoid process: 36 weeks
what is the relationship between the SFH and gestational age
gestational age +/- 2 cm
where should you place the stethoscope to listen to the fetal heart rate
between the shoulders
which swabs are used for; trichomonas vaginalis bacterial vaginosis chlamydia gonorrhoea
TV and BV: blue swab, vaginal
chlam and gon: orange swab, vulvovaginal
management of miscarriage
expectant: up to 14 days
medical: misoprostol
surgical: evacuation of uterus (manual vacuum or electric vacuum)
when to give anti-D in case of miscarriage
Rh negative AND >12 weeks or <12 weeks and surgical management
where is most common site of ectopic pregnancy
tubes
risk factors for ectopics
smoking, PID, previous ectopic, previous tubal surgery
investigation of suspected ectopic pregnancy
check HCG 48 hours apart if stable or cannot see pregnancy (PUL)
if >63% rise, likely IUP and offer USS (if HCG >1500)
if >50% drop, likely a failing pregnancy and check urine pregnancy test in 14 days
when is expectant management of ectopic appropriate
HCG <1500 and dropping
no significant pain
empty uterus
mass <35 mm and no FH (unruptured)
medical management of ectopic
when/what
best if HCG <3000 but up to 5000
methotrexate
side effects of methotrexate management of ectopic
bloating and flatulence
transient elevation of LFTs
stomatitis
presentation of molar pregnancy
irregular bleeding
hyperemesis
hyperthyroidism
what is a complete molar pregnancy
duplication of haploid sperm following fertilisation of an empty ovum
no fetal tissue
USS snowstorm appearance/IU cystic mass
management of complete molar pregnancy
surgical evacuation
15% chance of chemo
what are the risks of molar pregnancy
becomes invasive and potentially cancer-y
what is a partial molar pregnancy
triploid = 2 sets of paternal genes and 1 set of maternal
might be fetal tissue
management of partial molar pregnancy
medical management if large fetal tissue
or surgical
0.5% chance of chemo
what is the guidance for future pregnancies after molar pregnancy
no pregnancy for 6 months
or 1 year if chemo
fibroids are most common in pre- or post menopausal women
pre menopausal
IU masses in post-menopausal women are cancer until proven otherwise
symptoms of fibroids
none (50% incidental finding) HMB dysmenorrhoea pressure effects (frequency, hydronephrosis if compress ureters) infertility
what further medical complications can be caused by fibroids
anaemia if heavy bleeding
degeneration (pain)
torsion if pedunculated
infection
management of fibroids <3 cm
Mirena 1st line tranexamic acid and NSAIDs other contraception (COCP, POP) if submucosal can have transcervical resection endometrial ablation hysterectomy
management of fibroids >3 cm
tranexamic acid and NSAIDs Mirena coil/COCP/POP uterine artery embolisation myomectomy hysterectomy GnRH analogues (switch off hormone production from ovaries, 3 months pre-op)
tumour marker of ovarian cancer
Ca125
what is a complex ovarian cyst
multiloculated
has solid parts in it
in any way suspicious of cancer
what is an RMI (risk of malignancy index) in ovarian cancer
USS features x menopausal status x ca123
<200 low risk (repeat in USS 3 months or benign surgery)
>200 refer to gynae onc MDT and CT chest abdo pelvis
who is offered cervical screening
25-64 year olds
what is tested in cervical screening
HPV
if negative - recall in 5 years
if positive do cytology
cytology
if negative HPV in 12 months
if positive colposcopy
when would you diagnose someone with the menopause
cessation of menstruation for >1 year
risks of HRT
VTE: increased with oral, no increase with transdermal
stroke: increased with oral, not with transdermal
CVS: if <60 no increase
BrCa: increased, no increase if oestrogen only
osteoporosis: reduced risk
when to give combined or oestrogen only HRT
if no uterus = oestrogen only
if uterus = combined (oestrogen and progesterone)
what are the two main diagnostic tests available to high risk pregnancies
chorionic villous sampling and amniocentesis
what is NIPT
non-invasive prenatal testing
analyses cell-free DNA in the mother’s blood from the fetus
better sensitivity and specificity than 1st trimester DS screening
risk factors for multiple pregnancy
assisted conception eg clomid, IVF ethnicity (African) family history on maternal side increased maternal age increased parity tall women > short women
define zygosity and chorionicity
monozygotic: splitting of a single fertilised egg
dizygotic: fertilisation of 2 ova by 2 sperm
dichorionic: 2 placentas, always dichorionic diamniotic
monochorionic: 1 placenta, may be mono- or diamniotic
how is chorionicity determined
USS, at booking scan
DCDA: lambda sign
MCDA: T-sign
how does management differ between DC and MC twins
MC twins need 2 weekly USS to pick up early signs of Twin-Twin transfusion syndrome
signs and symptoms of multiple pregnancy
exaggerated pregnancy symptoms (eg hyperemesis gravid arum)
high AFP
large for dates uterus
multiple fetal poles
fetal complications of multiple pregnancy
congenital anomalies IU death (single and both) preterm birth growth restriction (equal, discordant) cerebral palsy TTTS (monochorionic pregnancies)
maternal complications of multiple pregnancy
hyperemesis gravidarum anaemia pre-eclampsia GDM antepartum haemorrhage (abruption, praaevia) preterm labour c-section
describe antenatal management of multiple pregnancy
consultant led care
antenatal clinic every 2 weeks if MC and 4 weeks if DC
iron and folic acid supplements
low dose aspirin to prevent HTN
USS from 16th week with deep vertical pool, bladder and umbilical artery assessment
anomaly scan 18-20 weeks
what is TTS
disproportionate blood supply to foetuses in MC pregnancies
one twin has reduced blood supply leading to decreased urine output, anaemia and oligohydramnios while the other twin has increased urinary output, polyhydramnios, polycythaemia and eventually heart failure
management of TTS
fetoscopic laser ablation before 26 weeks
after 26 weeks amnioreduction/septostomy and aim to deliver at 34-36 weeks
timing of delivery in DCDA and MCDA twins
DCDA 37-38 weeks
MCDA 36+0 with steroids
mode of delivery of multiple pregnancies
triplets c-section
MCMA: c-section
one cephalic twin: aim for vaginal but may need to with to CS
labour management of multiple pregnancy
epidural to facilitate operative delivery
continuous use of CTG for both
syntocinon after twin 1 to maintain contractions
USS to confirm presentation
intertwine delivery time <30 mins
what are the different types of breech presentation
complete breech: legs folded with the leet level with the bottom
footling breech: on or both feet point down so will emerge first
frank breech: feet are up at the baby’s head so bottom emerges first
what is external cephalic version
attempting to manually turn the fetus into a cephalic presentation
50% successful
what is prolonged pregnancy
> 42 weeks
risks of prolonged pregnancy
stillbrith
meconium aspiration
respiratory distress
when should induction be offered in prolonged pregnancy
21-42 weeks
role of USS in early pregnancy
assessment of viability IU or ectopic date pregnancy using CR L determine chorionicity off Down syndrome screening
role of USS in 2nd trim
fetal anomaly scans
placental site
screen maternal uterine artery resistance
role of USS in 3rd trim
monitor fetal growth (abdominal circumference, head circumference, femur length - calculate EFW)
fetal hypoxia
anaemia
how can USS assess for fetal anaemia/hypoxia
umbilical artery increases its resistance in fetal hypoxia and middle cerebral artery decreases resistance
MCA shows increased peak systolic volume in anaemia
how many USS does an uncomplicated pregnancy get
2: booking and anomaly scan
risk factors for maternal morbidity and mortality
black/asian ethnicity age >40 deprivation VTE mental health issues
define still birth
baby born with no signs of life at or after 28 weeks gestation
major causes of stillbirth
labour complications post-term pregnancy maternal infections eg malaria, HIV maternal disorders eg DM, HTN fetal growth restriction congenital abnormalities
what are the features of gestational HTN
develops after 20 weeks gestation, no proteinuria or oedema
systolic >140 or diastolic >90
or increase above booking readings of >30 or >15
what ar the features of pre-eclampsia
after 20 weeks gestation, HTN with proteinuria (>0.3 g/24 hours)
complications of pre-eclampsia
fetal prematurity and IUGR eclampsia haemorrhage due to placental abruption cardiac failure stroke VTE DIC and HELLP pulmonary oedema multi-organ failure
investigations for PET
BP
urinalysis (protein)
Hb, PLT, U&Es, coag screen, rate
management of pre-existing HTN
switch from ACEI (teratogenic) to labetalol, nifedipine, methyldopa
consider patient’s allergies and PMH
management of pregnancy induced HTN (if <20 weeks)
labetalol
nifedipine
methyldopa
hydralazine
management of PET >20 weeks
labetalol, nifedipine, methyldopa, hydralazine
IV MgSulphate
definitive treatment is delivery of baby
steroids if early delivery
secondary preventions in women with history of PET or risk factors for PET
low dose aspirin started at 12 weeks
increased surveillance for signs and symptoms of PET
regular growth scans
risk factors for GDM
previous GDM obesity BMI >30 Fix of a first degree relative with GDM ethnicity (SE asian, Middle Eastern, black Caribbean) previous big baby
signs of GDM
polyhydramnios
glycosuria
complications of GDM
overgrowth of insulin sensitive tissues and macrosomia
shoulder dystocia and vaginal trauma
assisted delivery/c-section
hyperaemic state in utero (risk of stillbirth)
short term metabolic complications (fetal hypoglycaemia post-delivery)
long term risk of obesity, insulin resistance and diabetes in baby
complications of pre-exisiting diabetes in pregnancy
congenital anomalies (increased risk of NTD and cardiac anomalies) miscarriage (<24 weeks) IU death (>24 weeks)
pre-pregnancy counselling in T1DM or T2DM
HbA1c monitoring: aim for 48 avoid pregnancy if >86 stop embryopathic medication determine micro-microvascular complications high dose folic acid low dose aspirin from 12 weeks
when to deliver in GDM
metformin: 39-40 weeks
diet controlled: 40-41
insulin: 38 weeks
describe screening and diagnosis of GDM
assess risk factors at booking
previous gestational diabetes
blood glucose monitoring and OGTT in 1st trim (if normal repeat at 24-28 weeks)
fasting: >5.1
2 hour: >8.5
blood sugar targets in pregnancy
fasting: 3.5 - 5.5
1 hours post-meal: <7.8
which medications can be used to control GDM if diet and exercise fail
metformin
insulin
postnatal care in GDM
increased risk of T2DM
fasting BG measured 6-8 weeks
if results suggest T2DM, OGTT at 6 weeks
annual screening for diabetes by GP
aetiology of PROM
infection
cervical incompetence
over-distension of uterus
vascular causes eg placental abruption
risk factors for PROM
previous pre-term labour multiple pregnancy smoking uterine anomalies parity ethnicity poor socioeconomic status drugs (esp cocaine)
what are the complications of PROM
neonatal mortality and morbidity (prematurity, sepsis, pulmonary hypoplasia)
chorioamnionitis
how to diagnose PPROM
maternal history followed by sterile speculum examination (pooling of blood in posterior vaginal fornix)
USS: oligohydramnios
avoid digital vaginal examination due to risk of infection, unless suspicion woman may be in labour
management of PROM
monitor for signs of chorioamnionitis (maternal pyrexia, tachycardia, leucocytosis, uterine tenderness, discharge, fetal tachycardia)
Abx to prevent ascending infection (erythromycin)
tocolytics (nifedipine if 26-33+6)
maternal steroids
magnesium sulphate
causes of fetal anaemia
Rh antibodies parvovirus CMV syphilis toxoplasmosis Hb-opathies feto-maternal haemorrhage MC tiwn complications
what is hydrops fetalis
abnormal accumulation of fluid in 2 r more compartments and manifests as ascites, plural effusion, skin oedema, pericardial effusion
