Obstetrics Flashcards
When is a booking visit done?
8-12 weeks (ideally <10 weeks)
What should you make sure to explore in booking visit?
- Has their doctor given them extra folic acid?
- RF for gestational diabetes
- RF for pre-eclampsia
- Mental health hx
- Domestic violence risk
Booking visit tests
- BP
- BMI
- Urine dipstick and MC&S
- Blood group
- Rhesus D status
- Anaemia, haemoglobinopathies, red cell alloantibodies
- Hep B, HIV, syphilis
(BP, BMI, urine dip at every appointment)
Booking visit supplementation
- Folic acid - 400ug (from pre-conception) until 12 weeks, or 5mg if high-risk
- Vitamin D - 10ug
IOL indications
- 41+ weeks gestation
- PROM
- Obstetric cholestasis
- Diabetic mother >38 weeks
- Pre-eclampsia
- Rhesus incompatibility
- RFM (careful consultant-led counselling)
- BISHOP =<6
Method of IOL
Antenatal ward under care of midwifes
Move to labour ward when in active labour
Membrane sweeping before induction (from 40 weeks) - releases prostaglandins
- Vaginal prostaglandin (tablet/gel 2 doses 6 hours apart, pessary 1 over 24 hours). Cervical ripening balloon can avoid uterine hyperstimulation.
- Amniotomy
- IV syntocinon (2 hours after rupture if labour has not ensued)
If failed, rest and attempt again or C-section
When is PPROM classed as PPROM?
24 to 36+6 weeks
PROM from 37 weeks
PPROM investigations
Admit to antenatal ward Bedside, bloods, imaging approach • Obs (focus on BP) • Abdo exam • Speculum: Pooling of clear fluid in posterior vaginal vault. If negative, ROM plus test (test for IGFBP1 or placental a-microglobulin1). If negative, FFN test. • CTG
- FBC, CRP, U&E (fluid loss), G+S, X-match
- Abdo USS
PPROM counselling
- High chance you will give birth in the next week
- Need to be admitted to keep an eye on your health and baby
- Keep baby in for as long as possible to help them grow and mature, but will balance this with risk of infection
- Neonatalogist will care when baby is born
- Taken to NICU if extra support is needed
PPROM management
- Antibiotics (oral erythromycin)
- Intense clinical surveillance for signs of chorioamnitis and pre-term labour (admit until 28 weeks, after which 2-3x week outpatient monitoring)
- IM steroids
- IV magnesium sulphate if birth expected next 24 hours
(no tocolytics due to risk of infection)
Should you induce labour after PROM?
0-24 hours expectant
Meconium or >24 hours induce straight away
Breech investigations
- Obs
- Urinalysis
- Abdo exam - lie and presentation
- USS - gestational age, presentation, placental position, amniotic fluid index
Breech management counselling
- External cephalic version at 36/37weeks
- Obstetrician will gently move baby by pressing hands on abdomen - head down for easier delivery
- Medication to relax uterus (tocolytics)
- Monitored with CTG
- USS to guide procedure and confirm
- Recommend elective CS if no ECV
- Vaginal breech delivery has 40% risk of emergency CS
VBAC counselling
• Can have VBAC if singleton pregnancy and 37 weeks or elective CS at 39 weeks
VBAC
• Maternal risk of uterine rupture, emergency CS, instrumental delivery
• Foetal risk of HIE
Elective CS
• Maternal risk of placenta praevia/accreta in future, adhesions, infection, clots (will give LMWH for 10 days after)
• Foetal risk of respiratory problems
HIV in pregnancy counselling
- Go to a joint HIV physician and obstetric clinic every 1-2 weeks
- Monitor CD4 baseline and delivery, and viral load every 2-4 weeks, 36 weeks, and delivery
- ART compliance
- Delivery options - <50: vaginal appropriate, >50 or hep C: elective CS at 38 weeks with IV zidovudine
- Don’t breastfeed
- Neonatal ART for 2-4 weeks and testing
Pre-eclampsia investigations
- Obs
- Examination - abdo, swelling, reflexes
- Fundoscopy for papilloedema
- Urine dipstick
- PCR if 1+ protein
- FBC, G+S, X-match
- LFTs for HELLP
- Creatinine for renal function
• CTG
Severe pre-eclampsia (>160/110) management
Admit to antenatal ward
• Oral labetalol/nifedipine
• BP monitor 4x a day whilst controlling it
• Can discharge when BP controlled
• Monitor bloods and BP 2x a week once discharged
- Aim for delivery 37 weeks
- If >37 weeks, aim for 24-48 hours
- IV magnesium sulphate if within birth 24 hours to prevent eclampsia
- Elective CS or IOL choice
- Deliver in labour ward
- Epidural anaesthesia can control BP
- Observe for 24 hours after delivery
- Continue meds if needed
- Follow-up with GP 2 weeks later if still on meds
Gestational diabetes management
Review with joint diabetes and antenatal clinic within a week
Fasting <7
- Changes in diet and exercise
- Targets not met after 1-2 weeks: metformin
- Add insulin or glibenclamide
> 7 or >6 with complications
Insulin
Birth no later than 40+6
Discontinue meds immediately after delivery
Fasting blood glucose 6-13 weeks postnatal
Gestational diabetes counselling
- Body can’t produce enough insulin to meet demands of carrying a baby
- Maternal risks: hypertensive disease, traumatic delivery
- Foetal risks: macrosomia, neonatal hypoglycaemia
- Discuss treatment options and monitor glucose (fasting, pre-meal, 1-hour post-meal, bedtime) *not injection regimen
- D and AN clinic every 2 weeks
- USS growth scans every 4 weeks between 28-36 weeks
- After birth, stop meds but follow-up if problems continue
Obstetric cholestasis investigations
Bedside and bloods approach
• Obs
• Inspection - jaundice, excoriation marks
• Examination - lie, presentation, SFH
- LFTs
- Bile acids
- PT
Obstetric cholestasis counselling
- Slow down of bile through the liver, build up, and leakage into bloodstream causing symptoms (unsure why - hormonal? genetic?)
- RF of FHx, previous Hx, multiple pregnancy
• Offer IOL at 37 weeks and deliver on labour ward with continue CTG monitoring, due to risk of stillbirth
- Weekly LFTs and bile acid levels
- Wear cool, loose clothing
- Pay attention to foetal movements
- Symptomatic treatment: ice packs, emollients, ursodeoxycholic acid
• High recurrence rate
Placenta praevia / abruption investigations
Beside, bloods, imaging approach • Obs • Abdo exam (if tense, worried about abruption) • Pelvic exam but not digital • CTG
- FBC, blood type, X-match for 4 units of packed RBCs
- Kleihauer test (abruption)
• Abdominal USS with colour flow Doppler analysis
Asymptomatic placenta praevia management
- Avoid sex
- Rescan at 32 weeks
- If still low-lying/praevia, rescan at 36 weeks
- If still low-lying/praevia, elective CS within next couple of weeks
Symptomatic placenta praevia management
Admit and involve the MDT - call for senior obstetrician, call 2222 for major obstetric haemorrhage protocol
ABCDE • Gain IV access • Bloods if haven't done that yet as acute • Give anti-D in Rh-negative women • Continuous fetal monitoring
- Haem unstable/foetal distress: deliver
- Stable: steroids and discharge after 48 hours of observation with no bleeding
Placental abruption management
Admit and involve the MDT - call for senior obstetrician, call 2222 for major obstetric haemorrhage protocol
ABCDE • Gain IV access • Bloods if haven't done that yet as acute • Give anti-D in Rh-negative women • Continuous fetal monitoring
- Haem unstable/foetal distress- deliver
- Stable: <37 - steroids, admit to antenatal ward, discharge with weekly serial growth scans, >37 - IOL
VTE/PE investigations
Beside, bloods, imaging approach
• Obs
• Examination - cardio, resp, preg abdo
• FBC, ABG, coagulation screen
- DVT: Compression duplex USS - if positive start treatment
- PE and no DVT: V/Q lung scan or CTPA
VTE/PE management
Admit if PE. Involve the MDT - senior obstetrician, radiologists, anaesthetists, midwives.
- SC LMWH immediately
- Titrate to booking weight and use throughout pregnancy until 3 months postpartum
- Teach how to use injections daily
- Stop 24 hours before delivery or once in labour
Postpartum haemorrhage investigations/management
- Abdo exam
- Vaginal exam (speculum)
I would like to involve the MDT by calling for help for the senior obstetrician, anaesthetist, senior midwife and porter. I’d pull the alarm behind the hospital bed and call 2222 for Major Obstetric Haemorrhage Protocol.
An ABCDE investigative approach would then be started concurrently with management. Would ensure:
• O2 by mask
• 2x 14 gauge peripheral cannulae
• Cross-match 6 units of bluid and inform the haem team
• Foley catheter into bladder and fluid balance chart
• Blood transfusion
• Anti-D if rhesus negative
Mechanically: • Bimanual compression • Intrauterine balloon tamponade • MROP • Clamp ligation of uterine or internal iliac arteries • Surgical repair for trauma
Medically:
- IV syntometrine or IV syntocinon (if HTN/asthma)
- IM carboprost (increases uterine tone)
- IV tranexamic acid
ABx for secondary PPH (>24 hours after birth) e.g. endometritis
Hysterectomy if severe uncontrolled haemorrhage (2 seniors to make decision)
SGA/IUGR investigations
- Obs
- Abdo exam - SFH, lie
- Urine dip
- Doppler
- CTG
IUGR management
Monitoring
• Serial growth scans every 2 weeks
• Doppler USS 2x a week
• Advise mother to monitor foetal movements
Delivery
• Aim for 37 weeks
• Immediate delivery if abnormal CTG + RFM, or abnormal doppler
Shoulder dystocia management
Obstetric emergency - call for senior obstetric help and neonatal paediatric team.
Tell mother to stop pushing.
- McRobert’s manoeuvre: flexion and abduction of hips
- Suprapubic pressure to improve manoeuvre
- Internal rotation (consider episiotomy)
- Rubins manoeuvre: pressure on anterior aspect of baby’s shoulder
- Wood’s screw manoeuvre: insert other hand on posterior aspect of shoulder to aid (4) for 180-degree rotation - Deliver posterior arm
- Change position to all fours
- Foetal cleidotomy, maternal symphisiotomy, or Zavanelli followed by C-section
