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Phase 3a > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Antenatal - Booking visit; when, what, why?

A

When; 8-12 weeks (ideally before 10 weeks)

What;
- Bedside Ix; BP, Urinalysis + culture (r/o asymptomatic bacteruria as can cause pyelonephritis and preterm labour), BMI

  • Bloods; FBC (anaemia), Blood group, Rh status, Red cell alloantibodies (sickle cell for women at higher risk and thalassaemia for all), Hep B, syphilis, rubella, offer HIV test
  • Given green book for documenting the progress during the pregnancy
    (screening for Down’s - combined test - perfomed depending on gestational age from 11 weeks onwards)

Why; woman meets with a midwife to discuss all aspects of pregnancy (education, booking bloods, other physiological measures, risk assessment)

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2
Q

Antenatal - Folate supplementation; start, stop and doses in normal and high risk pregnancies?

A

Start - on conception or 1 month before conception in obesity or other high risk cases (risk of Neural Tube Defects)

Stop - 12 weeks

Dose:
*400mcg - normal pregnancy
*5mg - high risk pregnancy (obesity, smoking, FH)

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3
Q

Antenatal - Nuchal scan; when? 3 causes of increased nuchal translucency?

A

10 weeks

Causes:
- Down’s Syndrome
- Congenital Heart Disease
- Abdominal Wall Defects

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4
Q

Antenatal - Down’s findings in antenatal tests + definitive tests

A

10 weeks - increased nuchal translucency

11-13 weeks - Combined test:
- PAPP-A: ↓
- β-hCG: ↑

> 13 weeks - Quadruple test:
β-hCG: ↑
Inhibin-A: ↑
AFP: ↓
Oestriol (uE3): ↓

Definitive tests:
- Non-invasive prenatal testing (NIPT)
- CVS (< 15W)
- Amniocentesis (> 15W)

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5
Q

Antenatal - why might non-invasive prenatal testing (NIPT) be done?

A
  • Rh status of foetus
  • Down’s Syndrome screening; optional as parent may not want to know
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6
Q

Antenatal - routine care; begins when and what does it consist of?

A

Begins at 24 weeks

What:
- Symphysis-fundal height (SFH); to detect foetal intrauterine growth restriction
- BP; screen for pre-eclampsia
- Urinalysis; assess proteinuria as screen for pre-eclampsia

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7
Q

Antenatal - anti-D injections; why and when?

A

Why - in rhesus negative mother, if children are rhesus positive they express rhesus-D antigen. 1st pregnancy some foetal blood migrates into mother’s bloodstream and she begins to create antibodies to rhesus D antigen (sensitisation). Problem occurs in 2nd pregnancy onwards as rhesus-D antibodies can cross the placenta into the foetus attacking its red cells causing haemolysis -> haemolytic disease of the newborn

IM anti-D injections given to PREVENT sensitisation in rhesus-D negative women (no way to reverse sensitisation once it occurs); works by attaching to the rhesus-D antigens on the fetal red blood cells in the mothers circulation -> subsequently destroyed -> prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen

When:
- 28 weeks gestation
- Birth if baby’s blood group found to be rhesus-positive
*Also within 72 hours of sensitisation event eg antepartum haemorrhage, amniocentesis, abdo trauma

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8
Q

What are the 3 stages of labour (overview)?

A

First Stage - from labour onset (true contractions) to 10cm cervical dilation

Second Stage - from 10cm cervical dilatation until delivery of the baby

Third Stage - from delivery of the baby until delivery of placenta

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9
Q

First stage of labour features

A

Onset of labour (true contractions) to full cervical dilatation (10cm)

  • Cervical Dilation - cervix opens up from 0-10cm
  • Cervical Effacement/Ripening - cervix gets thinner/shorter
  • ‘Show’ - mucous plug in cervix (preventing bacteria entering uterus during pregnancy) falls out creating space for baby to pass through
  • 3 Phases of First Stage -
    1) Latent Phase - 0-3cm cervical dilation, progresses ~0.5cm/hour, irregular contractions
    2) Active Phase - 3-7cm cervical dilation, ~1cm/hour, regular contractions
    3) Transition Phase - 7-10cm cervical dilation, ~1cm/hour, strong + regular contractions
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10
Q

What are Braton-Hicks contractions?

A

Occasional irregular contractions of the uterus

Often felt during 2nd/3rd trimester

Can experience temporary/irregular tightening or milf abdo cramping

NOT TRUE CONTRACTIONS - don’t signify start of labour
* Don’t progress or become regular

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11
Q

How can Braxton-Hicks contractions be reduced?

A

Staying hydrated and relaxing

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12
Q

What are the signs of labour (4)?

A

1) Show - mucous plug from cervix

2) Rupture of membranes - waters breaking

3) Regular, painful contractions - true contractions

4) Dilating cervix on examination

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13
Q

How to distinguish between latent first stage and established first stage of labour?

A

Latent first stage is when there are both:
1) Painful contractions
2) Changes to the cervix, with effacement and dilation up to 4cm

Established first stage of labour is when there are both:
1) Regular, painful contractions
2) Dilatation of the cervix from 4cm onwards

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14
Q

Definitions - ROM, SROM, PROM (x2), P-PROM

A

Rupture of Membranes (ROM); amniotic sac has ruptured

Spontaneous Rupture of Membranes (SROM); amniotic sac has ruptured

Prelabour Rupture of Membranes (PROM) - amniotic sac has ruptured before the onset of labour

Prolonged rupture of membranes (also PROM) - The amniotic sac ruptures more than 18 hours before delivery

Preterm prelabour rupture of membranes (P‑PROM) - The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm)

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15
Q

Prematurity - definition, viability, resuscitation considerations

A

Definition - birth before 37 weeks gestation (more premature = worse outcomes)

Non-viable if below 23 weeks gestation

Resuscitation -
* Born 23-24 weeks, not considered if not showing signs of life
(If born at 23 weeks - 10% chance of survival)
* ≥ 24 increased chance of survival so full resus offered

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16
Q

Classification of prematurity

A

Extreme preterm - <28 weeks

Very preterm - 28-32 weeks

Moderate to late preterm - 32-37 weeks

17
Q

Prophylaxis of Preterm Labour - methods

A

Vaginal Progesterone - via gel or pessary
* Progesterone has role in maintaining pregnancy/preventing labour
* It decreases myometrial activity and prevents cervical remodelling in preparation of delivery
* Offered to women if cervical length <25mm on vaginal US between 16-24 weeks gestation

Cervical Cerclage - stitch in cervix supporting it and keeping it closed and removed when in labour/reaches term
* Spinal or GA needed
* Offered to women with cervical length <25mm on vaginal US between 16-24 weeks gestation + have had previous premature birth/cervical trauma (colposcopy and cone biopsy)

18
Q

What is rescue cervical cerclage?

A

Offered to women between 16 and 27+6 weeks gestation if cervical dilation WITHOUT ROM - prevents progression and premature delivery

19
Q

P-PROM - definition, diagnosis and management

A

Definition - amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation)

Diagnosis -
* Speculum exam; reveals pooling of amniotic fluid in vagina (no further tests required)
If diagnosis in doubt then:
* Insulin-like growth factor binding protein 1 (IGFBP-1); high conc in amniotic fluid, test vaginal fluid
* Placental alpha-microglobin-1 (PAMG-1); similar alternative to IGFBP-1

Management -
* Prophylactic Abx; to prevent chorioamnionitis - erythromycin 250mg QDS for 10 days or until labour established if within 10 days
*Induction of labour may be offered from 34 weeks

20
Q

Preterm Labour w/ intact membranes - features + diagnosis

A

Features - regular, painful contraction + cervical dilatation WITHOUT ROM

Diagnosis - Speculum exam;
* <30 weeks - clinical assessment alone
* >30 weeks - transaginal US to measure cervical length; if <15mm management can be offered (labour unlikely if >15 mm)
* Fetal fibronectin - alternative test to vaginal ultrasound, -ve if <50ng/mL so preterm labour unlikely
(Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour)

21
Q

Preterm Labour w/ intact membranes - management

A
  • Fetal Monitoring - CTG or intermittent auscultation
  • Tocolysis w/ nifedipine
  • Maternal corticosteroids - offered <35 weeks to reduce neonatal morbidity and mortality
  • IV MgSO4 - offeref <34 weeks gestation for fetal neuroprotection
  • Delayed cord clamping/cord milking - increase circulating blood volume and Hb in baby at birth
22
Q

Tocolysis - definition, medications, indications

A

Definition - use of medications to stop uterine contractions

Meds -
* Nifedipine (CCB) - 1st line
* Atosiban - oxytocin receptor antagonist to be used if nifedipine contraindicated

Indications -
* 24 - 33+6 weeks in preterm labour to delay delivery and buy time for fetal development, maternal steroids or transfer to specialist unit (eg NICU)
* Short term measure (<48 hours)

23
Q

Antental steroids - use and indications

A

Helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery

Used in women with suspected preterm labour of babies <36 weeks gestation
* Eg two doses of intramuscular betamethasone, 24 hours apart

24
Q

IV MgSO4 - use, indications, considerations

A

Use - helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy

Indications - given within 24 hours of delivery of preterm babies of <34 weeks gestation
* It is given as a bolus, followed by an infusion for up to 24 hours or until birth

Considerations - Mg toxicity; close monitoring at least 4 hourly. Monitor obs as well as tendon reflexes (patellar mostly)

25
Q

Key signs of Mg toxicity

A

Reduced respiratory rate
Reduced blood pressure
Absent reflexes

26
Q

Induction of labour - definition and indications

A

Definitions - use of medications to stimulate onset of labour

Indications - if patient goes over due date. Offered between 41-42 weeks. Also if beneficial to start labour early:
* Prelabour rupture of membranes
* Fetal growth restriction
* Pre-eclampsia
* Obstetric cholestasis
* Existing diabetes
* Intrauterine fetal death

27
Q

Bishop Score - purpose, assessment + scores, results

A

Purpose - used to determine whether to induce labour, scored 0-13

Assessment - 5 criteria;
* Fetal Station (0-3)
* Cervical position (0-2)
* Cervical dilatation (0-3)
* Cervical effacement (0-3)
* Cervical consistancy (0-2)

Results -
* ≥8 successful induction of labour
* <8 suggests cervical ripening may be required to prepare the cervix

28
Q

Induction of labour - options

A

Membrane Sweep - finger inserted into cervix to stimulate it/begin labour
* Can be done in clinic
* Should produce labour onset within 48 hours
* Not a full method of inducing so is more of an assistance
* Used from 40 weeks in women over their EDD

Vaginal Prostaglanding E2 (dinoprostone)
* Inserting gel, tablet (Prostin), or pessary (Propess) into the vagina
* Pessary like a tampon that releases local prostaglandins over 24 hours
* Stimulates the cervix/uterus
* Done in hospital setting so the woman can be monitored before being allowed home to await full onset of labour

Cervical Ripening Balloon (CRB)
* Inserted into cervix/gently inflated to dilate cervix
* Used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3)

Artifical Rupture of Membranes + Oxytocin Infusion
* Would only be used where there are reasons not to use vaginal prostaglandins
* It can be used to progress the induction of labour after vaginal prostaglandins have been used

If fetal death has occurred; Oral Mifepristone (anti-progesterone) + misoprostol

29
Q

Induction of labour - required monitoring

A

Cardiotocography (CTG) - assess fetal heart rate and uterine contractions before AND during labour

Bishop score - before AND during induction of labour to monitor progress

30
Q

Induction of labour - ongoing management required if slow/no progress

A
  • Further vaginal prostaglandins
  • Artificial rupture of membranes and oxytocin infusion
  • Cervical ripening balloon (CRB)
  • Elective caesarean section
31
Q

Induction of labour - how long until most women give birth induction started

A

Most women will give birth within 24 hours of the start of induction of labour

32
Q

What is the main complication of induction of labour w/ vaginal prostaglandins?

A

Uterine hyperstimulation

33
Q

Uterine hyperstimulation - definition + criteria, complications and management

A

Definition - contraction of the uterus is prolonged and frequent, causing fetal distress and compromise

Criteria - two criteria often given are:
* Individual uterine contractions lasting more than 2 minutes in duration
* More than five uterine contractions every 10 minutes

Complications -
* Fetal compromise, with hypoxia and acidosis
* Emergency caesarean section
* Uterine rupture

Management -
* Removing the vaginal prostaglandins, or stopping the oxytocin infusion
* Tocolysis with terbutaline

Phase 3a (7 decks)

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