Obstetric Presentations Flashcards
What is an antepartum haemorrhage?
Bleeding from birth canal >24 weeks
How common is an antepartum haemorrhage?
3-5% of all pregnancies
What would you ask about in the history of an antepartum haemorrhage?
How much blood What colour Provoked? - post coital Have waters broken? Any pain Foetal movements Risk factors - smoking, drugs, domestic abuse
What would you look for on examination in a patient with an antepartum haemorrhage?
General appearance - pallor, cap refill Tender abdomen? Uterus feel tense and woody? (placental abruption) Palpable contractions Lie of foetus CTG - >26 weeks
What are some causes of an antepartum haemorrhage?
Infections - candida, vaginosis, chlamydia Vasa praevia Uterine rupture Placenta praevia Placental abruption Benign or malignant lesions Domestic violence
What triad does vasa praevia present with?
Vaginal bleeding
Membrane rupture
Foetal compromise
What is uterine rupture usually associated with?
Hx of previous C Section or uterine surgery
Why should vaginal examination for suspected antepartum haemorrhage not be carried out in primary care?
Women with placenta praevia may haemorrhage
What is the immediate management in suspected antepartum haemorrhage?
Admit to hospital for assessment and management
Resus
Mothers life take priority!
Urgent delivery of baby if foetal distress
If Rhesus -ve - Kleihauer test and prophylactic anti-D
What is Kleihauer-Betke’s test?
Blood test to calculate amount of fetal Hb that has crossed to maternal blood stream
What investigations should be ordered for a patient with a suspected antepartum haemorrhage?
Depend on presentation
Can include - FBC, platelet, G&S, clotting, USS, foetal monitoring
What should you do once you rule out placenta praevia?
Cusco speculum examination
Digital vaginal exam
Swabs - exclude infection
What complications are associated with an antepartum haemorrhage?
Premature labour DIC AKI Placenta accreta Foetal hypoxia and death
What features, if accompanying abdominal pain, require urgent midwife assessment?
Bleeding or spotting Regular cramping or tightening Vaginal discharge that is unusual Lower back pain Pain or burning on urination Pain is severe or doesn't go away after 30-60 mins of rest
What are the common causes of abdominal pain in pregnancy?
Constipation
Trapped wind
Growing pain of ligaments
How is abdominal pain in pregnancy complicated?
Visceral displacement and absence of peritoneal signs - lifting of abdominal wall
What history would make you worry about an ectopic pregnancy?
History of 6-8 weeks amenorrhoea
Lower abdominal pain +- shoulder tip pain
Later - vaginal bleeding
What is the vaginal bleeding seen in an ectopic pregnancy like?
Less than normal period
Can be dark brown
What history may indicate a threatened miscarriage?
Painless vaginal bleeding <24 weeks
Typically at 6-9 weeks
What history may indicate a missed miscarriage?
Light vaginal bleeding/discharge
Symptoms of pregnancy which disappear
What history would indicate a patient is going into labour?
Regular tightening of the abdomen
What history would make you worry about placental abruption?
Shock out of keeping with visible loss Constant pain Tense, tender uterus Fetal heart - absent/distressed Coagulation problems
What history would make you think a patient has symphysis pubis dysfunction?
Pain over pubic symphysis
Radiate to groin and medial aspects of thighs
Waddling gait
What symptoms are indicative of pre-eclampsia?
Epigastric pain
Severe headache - often frontal
Swelling of hands, feet and face
What symptom is indicative of HELLP syndrome?
RUQ pain
What history may suggest uterine rupture?
Abdominal pain and shock in labour or the third trimester
How would appendicitis present in pregnancy?
RLQ in 1st trimester
Umbilical pain in 2nd trimester
RUQ pain - 3rd trimester
When should women feel fetal movements by?
24 weeks
When do women normally feel fetal movements by?
18-20 weeks
Some women feel as early as 16 weeks
How often do women normally feel fetal movements and how do they progress?
16-45 movements per hour
<75 mins between movements
Diurnal changes - peak movement afternoon/evening
Movements increase upto 32 weeks then plateau
What should happen if no movements are felt by 24 weeks?
Refer to fetal medicine for investigation of possible neuromuscular disorder
What are the possible causes of reduced fetal movements?
Stillbirth and fetal compromise
Anterior placenta - decrease women’s perception of movement prior to 28 weeks
Sedating drugs that cross placenta - alcohol and opiates
Cigarette smoking
Corticosteroids - fetal lung development
Major fetal malformations
What is the general management of reduced fetal movements?
Assess risk factors for still birth
Auscultate fetal HR
CTG
Can do: USS, obstetrician review
SEE NOTES FOR FULL GUIDANCE
What should women be advised to do if they suspect reduced fetal movements?
Lie on left side and focus on movements for 2 hours
If <10 in 2 hours then contact midwife or maternity unit immediately
What risk factors are associated with stillbirth?
Multiple consultations for reduced fetal movements Hypertension Growth restriction Diabetes Extremes of maternal age Primiparity Smoking Placental insufficiency Congenital malformation Obesity Ethnicity - higher if black or asian Poor past obstetric Hx Genetic factors Can't access care
