Obstetric Monitoring Flashcards
How many antenatal appointments should a nulliparous woman have?
10
How many antenatal appointments should a multiparous woman have?
7
What is routinely done at all appointments?
Plot symphysis fundal height
Measure BP
Urine dip - proteinuria
What should pregnant women be informed about at first contact with a healthcare professional?
Folic acid supplementation
Food and nutrition
Lifestyle advice
Antenatal screening information
What folic acid supplementation should pregnant women take?
400 micrograms per day before pregnancy and for first 12 weeks
5mg if BMI >30
Folic acid reduce neural tube defects
What food and nutrition advice should pregnant women be given?
How to avoid food poisoning:
Listeria - only pasteurised or UHT milk, avoid soft cheese
Salmonella - avoid raw/partially cooked eggs and meat
Avoid vit A - found in eating liver products
Supplement vit D
What lifestyle advice are pregnant women given?
Risks of smoking, alcohol and recreational drugs
Avoid long haul flights
Seatbelt above and below bump when in car
When should booking for pregnancy be done?
Within first 10 weeks
What happens at the booking appointment?
Inform about baby development
Reiterate diet, lifestyle, nutrition etc.
Exercise - pelvic floor
Reiterate screening and book these
Discuss place of birth
Pregnancy care pathway
Breastfeeding workshops and information
Antenatal classes
Discuss mental health
Measure BMI, BP, urine dip, urine culture
Bloods - infection screen, Hb, blood group, haemoglobinopathies
What appointments do all women have?
16 weeks 18-20 weeks 28 weeks 34 weeks 36 weeks 38 weeks 41 weeks
What happens are the 16 week appointment?
Review and discuss screening
What happens are the 18-20 week appointment?
Fetal anomaly scan - if woman chooses
What happens are the 28 week appointment?
Second haematological condition screening
What happens are the 34 week appointment?
Prepare for labour
Help recognise active labour
What happens are the 36 week appointment?
Check presentation and offer ECV (external cephalic version) if necessary Information about: Breastfeeding Labour Vit K prophylaxis Baby blues
What happens are the 38 week appointment?
Options for managing prolonged pregnancy
What happens are the 41 week appointment?
Membrane sweep and induction of labour
What additional appointments do nulliparous women have?
25, 31 and 40 week routine care appointments
When is a gestational age assessment made?
USS between 10+0 and 13+6 weeks
Measure crown rump length - if >84cm then use head circumference
What are the benefits of antenatal screening?
Choice of termination
Time to prepare for disabilities - costs and treatments
Birth in specialist setting
Intra-uterine therapy
What are the limitations of antenatal screening?
Detection rates vary - anomaly, fetal position, woman BMI
May lead to tough decisions - further tests and termination
Emotional turmoil - false negative/positive
What diagnostic tests are done in antenatal screening?
Chorionic villus sampling
Amniocentesis
What happens in chorionic villus sampling and when?
Fine needle take sample of tissue from placenta - tested
11-14 weeks
What risks are associated with chorionic villus sampling?
Miscarriage
Rhesus sensitisation
Uterine infection
What happens in amniocentesis and when?
Fine needle passed through mothers abdomen into uterus to collect sample of amniotic fluid
Fluid contain baby’s cells which can be tested
Done after 15 weeks
What risks are associated with amniocentesis?
Miscarriage
Rhesus sensitisation
Uterine infection
Club foot if done <15 weeks
What haematological conditions are screened for antenatally?
Anaemia
Blood group and rhesus D status
Atypical red-cell alloantibodies
When are haematological conditions screened for antenatally?
Booking and 28 weeks
What is the risks and outcomes of finding anaemia on antenatal screening?
Trial oral iron supplements
Risk - low birth weight, preterm
What is the risks and outcomes of finding blood group and rhesus D status on antenatal screening?
Anti-D prophylaxis to all rhesus -ve women who aren’t sensitised at 28-34 weeks
Risk of haemolytic disease of newborn
What is the risks and outcomes of finding atypical red cell alloantibodies on antenatal screening?
Refer to specialist care
Risk of haemolytic disease of newborn
What fetal abnormalities are screened antenatally?
Haemoglobinopathies
Fetal anomaly
Down’s, Edward’s and Patau’s syndrome
When and how are haemoglobinopathies screened?
By 10 weeks
Blood test if area of high prevalence, questionnaire if low prevalence
Dad need blood test if mum carrier, if both carriers then diagnostic testing req.
When and how are fetal anomalies screened?
Between 18+0 and 20+6 weeks
Scan with echo - 4 chamber view, open spina bifida, diaphragmatic hernia, cleft lip, gastroschisis, bilateral renal agenesis, cardiac abnormalities
When and how are down’s, patau’s and Edward’s syndrome screened?
By 13+6 weeks
Combined test - Nuchal translucency, B-HCG and plasma protein A
Serum screening used if large BMI stop nuchal translucency or booking late
If chance <1/150 then low risk and no further tests, if >1/150 then further testing
How are infections screened antenatally?
Blood test at booking
What infections are screened for antenatally?
HIV
Hep B
Syphilis
What is the outcome of finding an infection on screening?
HIV - specialist care and treatment, birth plan to avoid transmission, avoid breast feeding
Hep B - B vaccinations given to baby between birth and 1 year
Syphilis - Specialist team - Abx, Baby need blood test and poss Abx at birth
What is Naegele’s rule?
Rule to calculate delivery day
Date of first day of LMP
+ 7 days
- 3 months
+ 1 year
Where can women give birth?
Midwifery led unit
Home
Obstetric unit
When is giving birth in a midwifery led unit particularly suitable?
Low risk pregnancy as rate of interventions lower and outcome is same as obstetric unit
What is the outcome for the baby if a woman chooses to give birth at home?
Small increase risk of adverse outcome
When should birth be planned in an obstetric unit?
Higher rate of interventions
Conditions that place pregnancy as high risk
What interventions can be done in birth?
Instrumental vaginal birth
C section
Episiotomy
What conditions can place a pregnancy as high risk?
Cardiac disease Hypertension Haemoglobinopathies VTE Hyperthyroidism Diabetes Infections - Hep, HIV Abnormal renal function Epilepsy Previous/current pregnancy complication
What observations of the woman are done on initial assessment of labour?
Review antenatal notes
Ask about contractions - length, frequency, strength
Ask about pain relief
Review obs - pulse, BP, temperature, urinalysis
Record vaginal loss (if any)
What observations of the unborn baby are done on initial assessment of labour?
Ask about baby movements in last 24hr
Palpate woman’s abdomen - fundal height, baby lie, presentation, position, engagement
Auscultate fetal heart rate
When can you offer vaginal examination in assessment of labour?
Uncertainty about whether woman is in established labour
Woman appear in established labour
What maternal red flags in labour would require transfer to an obstetric unit?
Pulse >120 on 2 occasions, 30 mins apart BP >160/110 OR >140/90 on 2 occasions 30 mins apart 2+ protein on urinalysis and BP >140/90 Temp >38 or >37.5 on 2 occasions 1hr apart Vaginal blood loss Presence of significant meconium Pain different from normal contraction Delay in 1st or 2nd stage labour Request of regional anaesthesia
What fetal red flags in labour would require transfer to an obstetric unit?
Abnormal presentation - inc. cord presentation
Transverse or oblique lie
High or free floating head in nulliparous woman
Suspected fetal growth restriction or macrosomia
Suspected anyhydramnios or polyhydramnios
Fetal HR <110 or >160
Deceleration in fetal heart rate heard
What non pharmacological pain relief is considered in labour?
Breathing exercises
Immersion in water
Massage
What pharmacological pain relief options are there for labour?
Entonox
IV/IM opioids
Regional anaesthesia
What is entonox? What are its advantages and disadvantages?
Mix of O2 and NO
Under patient control, act quickly and wear off quickly
Can cause nausea and light-headedness
What opioids are used in labour?
Pethidine
Diamorphine
Others
What are the ads and disads of opioid pain relief in labour?
Effective within 15 mins
Debate of effectiveness
SE for mum and resp depression and drowsiness in fetus
Cant use birthing pool for 2 hrs after administration
What regional anaesthesia can be used in labour?
Bupivicaine and fentanyl given either epidural or combined spinal epidural
What are the ads and disads of regional anaesthesia?
Most effective pain relief for labour, can avoid greater analgesia or GA if instrumental or C section needed
Dizziness, shivering, hypotension
Increased rate of operative vaginal delivery
Have to be in obstetric unit with CTG monitoring
Associated with longer 2nd stage of labour
What happens following full cervical dilatation in a woman with an epidural?
Delay pushing for 1 hour
