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Year 4 - Obs and Gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What happens at a booking visit and when is it?

A

8 - 12 weeks (ideally < 10 weeks)

Booking visit – with midwife. Give info on how baby develops during pregnancy

  • general information e.g. diet, alcohol, smoking, folic acid 400mg, vitamin D, antenatal classes, pelvic floor exercises, discuss mental health classes
  • Risk assessment
  • BP, urine dipstick, check BMI

Booking bloods/urine

  • FBC (anaemia/ low platelets), blood group, rhesus status, red cell alloantibodies, haemoglobinopathies (sick cell + thalassaemia)
  • Infection: hepatitis B, syphilis, HIV
  • Urine culture (mid-stream urine specimen) to detect asymptomatic bacteriuria. Urine: Glycosuria, proteinuria, haematuria

Risk assessment

  • Gestational diabetes (book oral glucose tolerance test)
  • Fetal growth restriction (book additional growth scans)
  • Venous thromboembolism (provide prophylactic LMWH if high risk)
  • Pre-eclampsia (provide aspirin if high risk

No evidence that routine screening for GBS, toxoplasmosis, CMV, chlamydia, hep C or asymptomatic BV beneficial

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2
Q

What different DS testing occurs and when is it?

A

11 - 13+6 weeks

DS (+Edwards T18, Patau’s T21) screening including nuchal scan

  • Nuchal translucency scan - Down syndrome
  • Preferred: Combined – USS nuchal translucency measurement + blood test (↑HCG, ↓PAPP-A)
  • NIPT: not offered by NHS routinely

If women book later in pregnancy

  • Triple test: AFP, unconjugated oestriol, HCG
  • Quadruple test: as above + inhibin-A
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3
Q

When is a fetal anomaly scan and what does it look at?

A

Fetal Anomaly scan: USS – limitations: depends on BMI + baby position

  • Dating scan
  • CRL used unless beyond >84mm. Then HC used
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4
Q

When is anti-D prophylaxis given? What else occurs then?

A

28 weeks then 34 weeks

  • Routine care: BP, urine dipstick, FSH
  • Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
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5
Q

What conditions are screened for during pregnancy?

A
  • Anaemia
  • Bacteriuria
  • Blood group, Rhesus status and anti-red cell antibodies
  • Down’s syndrome
  • Fetal anomalies
  • Hepatitis B
  • HIV
  • Neural tube defects
  • Risk factors for pre-eclampsia
  • Syphilis

The following should be offered depending on the history:

  • Placenta praevia
  • Psychiatric illness
  • Sickle cell disease
  • Tay-Sachs disease
  • Thalassaemia
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6
Q

Routine use of USS after 24 wks of gestation unsupported and only offered in specific circumstances such as?

A
  • Low lying placenta at 20 wks - rescan at 32 weeks
  • Suspected small for date on clinical examination/ customised growth charts
  • Suspected malpresentation of clinical examination
  • Women who decline IOL from 42weeks should be offered USS estimation of maximum amniotic pool depth
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7
Q

What are some of the Normal variant screening in pregnancy (previously soft markers?

A
  • nuchal fold >6 mm
  • Ventriculomegaly>10mm
  • Echogenic bowel
  • Renal pelvic dilatation
  • Biometry <5th centile on national charts
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8
Q

What invasive procedures are offered for screening?

A

Amniocentesis - 15 weeks

Chorion villus sampling - 10 weeks

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9
Q

When is amniocentesis used and how?

A

after 15 weeks under USS guidance

  • 15-20ml of aspirated using 22G needle
  • Culture of amino types, harvesting and banding
  • Risk of miscarriage is 1% preterm delivery, chronic liquor leak
  • Assessment of fetal karyotype - maternal age, high risk for Down’s syndrome, USS findings, parental translocation, maternal request, measurement of AFP and ACHE assessment of congenital néphroses, virology screen

‣ PPROM to rule out chorioamnionitis

‣ OD 450 haemolytic disease

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10
Q

What are some RFs for breech presentation?

A
  • uterine malformations, fibroids
  • placenta praevia
  • polyhydramnios or oligohydramnios
  • fetal abnormality (e.g. CNS malformation, chromosomal disorders)
  • prematurity (due to increased incidence earlier in gestation)
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11
Q

How is chorionic villus sampling carried out and for what?

A

10 weeks, USS guided, trans abdominal/ trans cervical. Risk of miscarriage. Results in 7 days

  • Uses: to assess fetal karyotype and achieve a rapid result.
  • Assessment of genetic abnormalities: CF, thalassaemia major, detection of viral DNA maternal sérosités conversion CMV
  • Cordocentesis
  • Fetoscopy
  • Fetal skin biopsy
  • Aspiration of fluid filled fetal cavities
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12
Q

What are some of the important terms in labour?

A
  • Labour - progressive effacement and dilatation of the cervix in the presence of regular uterine contractions
  • Delivery - expulsion of the fetus and placenta
  • Show - cervical mucus plus
  • SROM - spontaneous rupture of membranes, can precede labour
  • ARM – artificial rupture of membranes
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13
Q

What are the three factors that affect labour?

A

Passage

  • Pelvis: >11cm pelvis inlet. 12cm mid cavity. 10-11.5cm pelvic outlet
  • Soft tissues: lower uterine segment, cervix, vagina, vulva, pelvic floor, perineum

Powers

  • There is fundal dominance of contractions
  • Contractions are rhythmic and occur ever 3-4 mins in early labour and every 2-3 minutes in advanced labour

Passenger

  • Lie: oblique and transverse lies
  • Presentation: part of the fetus lowermost in the uterus (céphalique, vertex, brow, face, breech, shoulder)
  • Denominator: part of the fetus used as a reference point to describe position in the maternal pelvis (occiputs, mentum, sacrum, acromion)

Position: relation of the fetal denominator to the maternal pelvis

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14
Q

What is the normal mechanism of labour?

A
  • Engagement
  • Flexion
  • Descent
  • Internal rotation – contractions bringing the head down
  • Extension
  • External rotation
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15
Q

What monitoring goes on labour?

A
  • FHR monitored every 15min (or continuously via CTG)
  • Contractions assessed every 30min
  • Maternal pulse rate assessed every 60min
  • Every 4H: Maternal BP and temp, VE, maternal urine (for ketones and protein)
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16
Q

What are the different stages of labour?

A
  • Stage 1: from the onset of true labour to when the cervix is fully dilated (8-18h primip and 5-12 multip)
    • Latent phase = 0-3 cm dilation, normally takes 6 hours – painful, irregular contractions and cervix effaces then dilates
    • Active phase = 3-10 cm dilation, normally 1cm/hr (regular contractions)
  • stage 2: from full dilation to delivery of the fetus
    • Passive: complete cervical dilatation but no pushing
    • Active: refers to the active process of maternal pushing (valsava) (usually 3h)
      • less painful than 1st (pushing masks pain)
      • lasts approximately 1 hours
      • If longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section
      • episiotomy may be necessary following crowning
      • Associated with transient fetal bradycardia
  • stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
    • At uterus contract to a 24 week size post birth, the placenta separates from the uterus through the spongy layer of decidua basalis
    • It then buckles and a small amount of retroplacental haemorrhage takes place
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17
Q

What are some of the common problems in labour?

A
  1. Failure to progress (delay in first or second stage)
  2. Malpresentation/ malposition
  3. Breach, transverse, oblique
  4. Suspected fetal compromise (fetal distress) – problems with fetal HR
  5. Vaginal birth after C section -
  6. Operative delivery – vaginal or abdominal
  7. Shoulder dystopia
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18
Q

What are some of the causes of failure to progress?

A
  • Fetal malposition/malpresentation
  • Cephalopelvic disproportion (relative, absolute)
  • Obstructed Labour – e.g. haematuria, cervix becomes swollen and oedematous
  • Maternal Exhaustion
  • Mx: oxytocin
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19
Q

What problems arise from malrotation/ malpresentation?

A
  • Malrotation: OP position – baby looking up. Changes how head presses on cervix
  • Malpresentation:
    • Face – when baby heais fully extended. Cannot come out vaginalis if chin is at the back.
    • Brow – when head becomes more and more extended
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20
Q

What are of the complications of breech pregnancy?

A
  • Intracranial haemorrhage, internal injuries, cord prolapse, trapped after coming head
  • Higher incidence of fetal abnormality and neuro developmental problems regardless of mode of delivery
  • Mx: ECV at 36 weeks, if still breech:
    • Elective c section; Vaginal breech delivery
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21
Q

What indicates suspected fetal compromise?

A
  • Non-reassuring CTG: high sensitivity but low specificity
    • Baseline tachycardia/ bradycardia
    • Reduced baseline variability
    • Absence of acceleration (non reactive)
    • Presence of decelerations
  • Passage of meconium
  • Confirm by fetal acid base status
  • Eliminate the need for the FBS
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22
Q

What are some of the causes of suspected fetal compromise?

A
  • Uterine hyperstimulation
  • Maternal Hypotension – can cause fetal distress. Also epidural
  • IUGR – poor fetal tolerance of labour
  • Cord compression
  • Infection
  • Maternal disease
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23
Q

How is suspected fetal compromise mx’d?

A
  • Rectify reversible causes e.g. maternal hypotension
  • Left lateral position
  • Stop oxytocin
  • Confirm compromise by blood sampling where possible
  • Deliver by speediest route if unable to correct or if significant acidosis
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24
Q

How is VBAC mxd?

A
  • Do not use oxytocin/ prostaglandins to induce labours. Usual manual induction
  • Risks: Emergency C section in labour
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25
Q

What are the CI, precautions and risks ax’d with VBAC?

A
  • CI: previous uterine rupture or classical caesarean scar
  • Precautions: IV access, G+S, continuous fetal monitoring. Avoid prolonged labour.
  • Risks: Emergency C section in labour
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26
Q

What are some indications for operative delivery?

A
  • Failure to progress to 2nd stage
  • Fetal distress in 2nd stage
  • Maternal reasons
27
Q

What are some Pre-requisites for operative (instrumental) delivery?

A
  • trained operator, full dilation, absent membrane, cephalic presentation, clearly defined position, presenting part engaged, no evidence of CPD, adequate analgesia, empty bladder
28
Q

What are some complications of operative/ instrumental delivery?

A
  • failure
  • Fetal trauma
  • maternal trauma
  • PPH
  • urinary retention
  • cephalohaematoma: oedema following forceps delivery
29
Q

What are some indications for C section?

A
  • absolute cephalopelvic disproportion
  • placenta praevia grades 3/4
  • pre-eclampsia
  • post-maturity
  • IUGR
  • fetal distress in labour/prolapsed cord
  • failure of labour to progress
  • malpresentations: brow
  • placental abruption: only if fetal distress; if dead deliver vaginally
  • vaginal infection e.g. active herpes
  • cervical cancer (disseminates cancer cells)
30
Q

What are some complications of C section?

A
  • Infection
  • haemorrhage
  • bladder bowel injury
  • thromboembolic disease
  • requirement for blood transfusion
  • TTN
  • fetal trauma
31
Q

What is shoulder dystocia?

A
  • Complication of vaginal cephalic delivery.
  • It entails inability to deliver the body of the fetus using gentle traction, the head having already been delivered
32
Q

Who is at risk from shoulder dystocia?

A
  • macrosomic baby
  • diabetic mother
  • using rotational instrument
  • high maternal BMI
  • prolonged labour
33
Q

What are some of the complications of shoulder dystocia?

A
  • Fetal death
  • Asphyxia with resulting hypoxic damage
  • Birth trauma (Erb’s palsy, fractured bones, brachial plexus injury)
  • Maternal trauma: soft tissue, psychological
34
Q

How is shoulder dystocia managed?

A
  • McRoberts position: entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen. This rotation increases the relative anterior-posterior angle
  • Supra public pressure – press on the side that the back is on
  • Obstetric maneovres – wood screw – try and spin the baby around.
  • Consider episiotomy. No oxytocin
35
Q

How can a CTG be improved?

A
  • Terbutaline
  • Fetal scalp stimulation
36
Q

What are some causes/ RFs for reduced fetal movements?

A
  • Posture: positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
  • Distraction: Awareness of fetal movements can be distractable
  • Placental position: Patient with anterior placentas prior to 28 weeks gestation
  • Medication: alcohol and sedative medications (opiates or benzos)
  • Fetal position: Anterior fetal position means movements are less noticeable
  • Obese patients
  • Amniotic fluid volume: oligohydramnios and polyhydramnios
  • Fetal size: SGA fetus
37
Q

How are reduced FM Ixd?

A

Ix: handheld doppler.

  • 28 weeks: handheld doppler.
    • No HB? -> USS immediately
    • If fetal HB - CTG
38
Q

What are indications for Induction of Labour?

A
  • prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
  • prelabour premature rupture of the membranes, where labour does not start
  • diabetic mother > 38 weeks
  • pre-eclampsia
  • rhesus incompatibility
  • Bishops score
    • Score of < 5 indicates that labour is unlikely to start without induction
    • Score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
39
Q

What is bishop score?

A
  • Score of < 5 indicates that labour is unlikely to start without induction
  • Score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
40
Q

What methods are used for IOL?

A
  • Membrane sweep: passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
  • Vaginal prostaglandin E2(PGE2): insertion of gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour
  • Maternal oxytocin infusion: causes artificial ROM. Used when reason to not use vaginal prostins.
  • Amniotomy (‘breaking of waters’)
  • Cervical ripening balloon: passed through endocervical gland to gentle dilate cervix
  • Oral mifepristone (anti-progesterone) plus misoprostol are used to induce labour where intrauterine fetal death has occurred.
41
Q

What are the complications of IOL?

A

Uterine hyperstimulation – prolonged and frequent uterine contractions – ‘tachysystole’

  • Consequences: intermittent interruption of blood flow to the intervillous space over time ->
    • Fetal hypoxemia and acidemia
    • Uterine rupture (rare)
  • Mx: removal of vaginal prostaglandins, stop oxytocin infusion, tocolysis with terbutaline
42
Q

What is the puerperium?

A
  • Definition: time from delivery until the anatomical and physiological changes of pregnancy have resolved
  • Roughly 6 weeks
  • Period of manor physical, social and emotional change and adaptation
43
Q

What physiological changes go through in pueruium?

A
  • Lochia and uterine involution – bleeding in the discharge
  • Lactation
  • Menstruation and resumption of ovulation
44
Q

What is lochia?

A
  • Lochia: bleeding after delivery of baby in placenta.
  • Endometrial slough of red and white cells: Mix of blood, tissue and mucus
  • Blood for first few days
  • Serosanguinous for up to 7-10 days
  • Clear for 6 weeks
45
Q

What happens in uterine involution?

A
  • From 1kg to 100g
  • Felt at the umbilicus after delivery
  • Becomes a pelvic organ by 10 days – due to contractility of uterus
  • Cervix firms at 3 days and closed Os by 3 weeks
46
Q

What happens in lactation in the puerperium period?

A
  • Oestrogen stimulates duct growth
  • Progesterone stimulates alveolar growth
  • Placental lactogen affects growth of epithelium in alveoli
  • Colostrum – sero sanguinous – for first 3 days
  • Followed by establishment of milk secretion
  • Continued lactation depending on suckling
47
Q

When does menstruation resume in lactating and non lactating women?

A

Non-lactating women:

  1. Resumption of menstruation after 8 weeks
  2. First ovulation approx 10 weeks
  3. About 40% of first cycles are ovulatory – so address contraception in timely manner

Lactating women:

  1. If for <1 month: menstruation resumes in approx 10 weeks
  2. If breast feeding after the first month: average interval to first ovulation is 16 weeks (6 months?)
  3. Breast feeding does not secure contraception beyond the 9th week post partum (up to 6months)
48
Q

What information should be discussed at discharge?

A
  • Inform GP and arrange for midwife and health visit: 6-8 weeks post natal examination
  • Anti D – if indicated
  • Discuss contraception + breast feeding
  • Perineal care and post-natal exercise, pelvic floor exercise
  • Vaginal loss, Hb check
  • At post-natal visit in 6 weeks: discuss problems and assessment of fecal and urinary incontinence
49
Q

What things should be ixd prior to discharge?

A
  • Observation of vital signs: temp, BP, HR, pulse, SATS, RR
    • Pyrexia in first 14 days: full assessment (sepsis), MSU, high vaginal swabs, blood sputum
      • Unknown cause: cefalexin 500mg/8h and metronidazole 400mg/8h
    • Breast infection: flucloxacillin (2nd clarithromycin); encourage breast feeding
  • Uterine size and involution
  • Lochia/ discharge – if still persistently red -> ?uterine involution/ 2o PPH
  • Abdo would
  • Perineum and para vaginal tissue
  • Breast
  • Lower limbs DVT
  • Enquire about bladder function + bowel function
50
Q

What methods of contraception are available in the puerperium period?

A
  • Barrier
  • IUCP
  • Tubal ligation: mini lap, lap – consider at C section
  • Hormonal: mini/ pill/ depot injections
    • POP/depot/ contraceptive implant: start any time post partum unless >x21 days for which you need 2 days other contraception
    • COCP: reduces breast milk, excreted in milk,
      • If not breast feeding: start COP 3 weeks post-partum - increased risk of thrombosis if started earlier
      • Need contraception for the first 7 days
51
Q

What are the benefits of breastfeeding>

A
  • Newborn:
    • Easily digested nutrients
    • Antibodies: reduced risk of gastroenteritis, respiratory infection, otitis media, NEC (lysozyme, lactoferrin, IgA)
    • Avoid milk allergies
    • Good source of nutrition except Vit C, D and iron
    • Cannot overfeed
    • Reduced risk of hypocalcaemia
  • To mother: Bonding, improved uterine involution, reduced risk of breast cancer, safe and cheap
52
Q

What are some of the difficulties associated with breastfeding?

A
  • Nipple inversion: correct by Waller shields in late pregnancy
  • Maternal fatigue
  • Emotional stress: due to sleep deprivation
53
Q

What medications are CI in breastfeeding?

A
  • antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • psychiatric drugs: lithium, benzodiazepines
  • aspirin
  • carbimazole
  • methotrexate
  • sulfonylureas
  • cytotoxic drugs
  • amiodarone
54
Q

What mastitis and how does it present?

A
  • Sx: fever, chills, malaise, pain, erythema, tenderness may induration, tender axillary lymphadenopathy, milk may be purulent
  • Two types:
    1. Acute intra mammary mastitis: secondary to engorgement, empty breast, cold compresses, abx prophylactically
    2. Infective mastitis: secondary to staph aureus. Periareolar induration, axillary lymphadenopathy. Penicillin G resistent in 90% of cases
      • Mx: Continue breast feeding; Drain existing breast abscesses. Flucloxacillin
55
Q

What methods can be used to suppress lactation?

A
  • Firm supporting bra, analgesia, +/- ice packs
  • No milk expression or nipple stimulation
  • Bromocriptine: not routinely used
56
Q

What are the common complications of the puerperium?

A
  • Puerperal pyrexia
  • Secondary PPH
  • Thromboembolic disease
  • Mood changes, postnatal depression
  • Urinary or faecal Incontinence
57
Q

What is Puerperal pyrexia (sepsis) and how is its mxd?

A
  • Definition: temp of 38 on any occasion in 6 wks after delivery
  • Commonest organisms: Group A. B haemolytic strep, E.Coli, Staph. A
  • Causes: UTI, endometritis, breast engagement (infective mastitis), chest infections or thrombosis (DVT)
  • Ix: sepsis 6 pathway, MSU, HVS, blood cultures, sputum if indicated, USS, VQ etc
  • Mx: Unknown cause: cefalexin 500mg/8h and metronidazole 400mg/8h
    • IV broad spectrum abx: piperacillin-tazobactam in 1h
58
Q

What is 2ndary PPH?

A
  • Definition: bleeding after 1st 24h (usually days 5-12)
  • Causes: retained products, or blood clots, infection, incomplete uterine involution
  • Management: conservative, abx, evacuating under GA – obstetric emergency, USS to look for retained products
59
Q

what is urinary incontinence in the peurperium period and how is it mxd?

A
  • Transient urinary retention relative common post partum
  • Due to physiological effects of pregnancy, pain etc
  • Mx: pelvic floor exercises, catheterisation and prophylactic abx
  • Usually resolves spontaneous
60
Q

what is faecal incontinence in the peurperium period and how is it mxd?

A
  • Due to damage of perineum
  • Strong association with child birth, particularly forceps delivery but not C section
61
Q

What are the RFs for placental abruption?

A

ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking

62
Q

What screening tools are used for dx post partum depression?

A
  • GAD-2
  • Edinburgh postnatal depression scale EPDS(14-15) – assesses how mother has felt this last week
63
Q

What is neonatal abstinence syndrome?

A

caused by SSRI anti depressants taken during pregnancy

  • Presentation: first few days after birth, sx: irritability and poor feeding.
  • Mx: Neonates are monitored for this post delivery. Supportive mx

Year 4 - Obs and Gynae (7 decks)

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