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Obstetrics Flashcards

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1
Q

Why do you perform physical examination during pregnancy ?

A

Reveal risk factors for pregnancy complication.
Take blood pressure
Give an idea of the amount of amniotic fluid.
Estimate the growth of the fetus, monitor its heart sound,

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2
Q

What to you inspect in a pregnant uterus ?

A

Linea nigra or striae.
Pregnancy itch causing scratching
Scars
Abdominal swelling
Foetal movement

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3
Q

How do you percuss a pregnant uterus ?

A

Only from week 12 of gestation, to get an impression of uterus size.
Percuss median line from navel towards the pubic symphysis.
- uterus : dull to percussion

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4
Q

How do you palpate a pregnant uterus ?

A

Palpate fundal height : gives an idea of the amount of amniotic fluid and estimate foetal growth.
From 3rd trimester use Leopold maneuver.
Identify foetal movement and contraindication.

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5
Q

How to facilitate the palpation of a pregnant uterus ?

A

Empty the bladder.
Raise the knee slightly while supine to help relax the abdominal muscle

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6
Q

Why do you measure the fundal height ? What are factors influencing it ?

A

Help detection of growth disorder : successive measurement from 20-37 weeks.

Uniformity of measurement is influenced by : number of care provider doing it, measurement method used, position of mother, fullness of bladder.

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7
Q

Find fundal height by palpation ?

A

Using ulnar side of both hands, feel uterus border. Move from top to bottom until you find the fundus.
Use the pubic symphysis, navel and xiphoid process to assess the measurement.

Pubic symphysis = 12 weeks
-14
-16
-18
Navel = 20 weeks
-24
-28
-32
Xiphoid process = 36 weeks

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8
Q

Fundal height with tape ?

A

After 24 weeks.
Measure along the midline from upper border of symphysis to upper border of fundus.

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9
Q

Why do you use Leopold maneuver ?

A

From 28 weeks when the foetal body parts can be easily palpated.
Determine foetal position in relation to the mother’s back.
- where is the back of the foetus
- nature of presenting part
- extend of the descend

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10
Q

What is the first Leopold manoeuvre ?

A

To check the fundus and determine which body part is there.

  • on mother side facing her. Hands on both side of fundus upper pole, fingertips towards each other
  • gently palpate fetus
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11
Q

How to differentiate buttock and head ?

A

Buttock = rump : bumpy with hard and soft part

Head : hard, round and smooth

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12
Q

What is the second Leopold manœuvre ?

A

To locate the back of fœtus.

Hand on one side to maintain the uterus. Other hand on the other side palpating. Switch hands function.

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13
Q

How to recognise the back ?

A

Back side : even resistance over the entire surface
Belly side : irregular protrusion caused by arms and legs

In most case it is at the front left.
Doubts ? => apply pressure on the fundus to make the back bulge

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14
Q

What is the third Leopold manœuvre ?

A

To determine the nature and descend of the presenting part.

Hold presenting part between finger of dominant hand while the other holds the fundus. Move gently the presenting part back and forth.

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15
Q

What is the fourth Leopold manœuvre ?

A

To determine the nature and descend of the presenting part.

Toward the mother feet. Surround presenting part with both hands, fingers straight, side by side.
Move presenting part l/r. Palmar side of hands over the presenting part, follow the curve of the presenting part towards the pelvic inlet.

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16
Q

How can you know if the presenting part has descended properly ?

A

It will not respond to ballotement.
Press between the symphysis and the presenting part during exhalation => this won’t be possible.

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17
Q

Why do you listen to the fœtal heart sounds ?

A

First trimester : prove the pregnancy is viable. It has a strongly beneficial prognostic significance with regard to the risk of spontaneous abortion.

From the end of the second trimester : assess fœtus condition.

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18
Q

How do you listen to fœtal heart sound ?

A

In the absence of risk factors, using Doppler intermittently during labor.

Doppler can be used from 10 weeks : initially more audible on the midline above the symphysis. After 28 weeks, listen on the side of the baby’s back.

From 20-24 weeks : stethoscope can be used.

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19
Q

Normal heart rate of fœtus ?

A

Baseline heart rate : 110-160 bpm
- higher in early pregnancy

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20
Q

How do you do a Pap smear for a pregnant woman ?

A

Take the sample from the ectocervix. Otherwise it could disturb the cervical mucus barrier and the amniotic membrane could be torn.

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21
Q

What change in the result of a bimanual palpation of a pregnant woman ?

A

Cervix becomes soft, tender and engorged with blood vessel at an early stage of pregnancy.

Asymmetrical uterus in the first 12 weeks.
- size not pregnant : 8 cm

Extra-uterine pregnancy : tenderness moving the cervix side to side

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22
Q

When do you do the internal pelvic examination ?

A

Early because in the late pregnancy, the head or buttock are too deeply descended for a reliable examination.
- very important to perform for future management in nulliparous woman with breech position child

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23
Q

How do you insert the finger in an internal pelvic exam ?

A

Insert behind the symphysis.
- feel for irregularities on the ridge of the symphysis
- feel for the linea terminalis with both fingers following the edge of the pelvic brim from symphysis to sacral promontory

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24
Q

How do you determine the diagonal conjugate ?

A

Radial side of index against symphysis lower edge.
Localise sacral promontory with middle finger (normally out of reach). If it can be reached : place other hand on the symphysis against the external finger.
Remember the marking point and measure the distance.

To calculate true conjugate substract 1.5 cm.

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25
Q

What is the diagonal conjugate ?

A

Distance from lower edge of symphysis to sacral promontory.

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26
Q

What do you do in a internal pelvic exam ?

A

Insert examining finger.
Determine the diagonal conjugate.
Feel the along sacrum from promontory to coccyx
- sacrum should be biconcave without ridge
- coccyx should point inwards
Determine if the ischial spine is too inward.
Determine the width of the pubic arch.
Remove finger and make a fist.
Measure distance between the ischial tuberosity : 9-10 cm

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27
Q

How do you measure the width of the pubic arch ?

A

Place index and middle finger next to each other in the angle of the arch. The width is normal if the angle is 90°.

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28
Q

What do you look for in a pregnancy blood test ?

A

Blood group and rhesus factor : if negative, measure antibody titre an repeat at 30 weeks

Irregular erythrocytes antibodies.
Syphilis response
TPHA : treponema pallidum hæmagglutination assay
Rubella titre
Haemoglobin level
Hepatitis B surface antigen
Infection to HIV

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29
Q

What does the level of haemoglobin tell you in a pregnant woman ?

A

Increased : gestational hypertension/pre-eclampsia
- due to plasma extravasation blood becomes thicker

If level was normal for the first test and its a single pregnancy with mother having a varied diet, the level doesn’t need to be checked until 32 weeks

30
Q

What do you look at in a urine test of a pregnant woman ?

A

Proteins :
- contamination by vaginal discharge
- UTI
- gestational hypertension/pre-eclampsia
- pre-existing or coincidental vascular or renal abnormalities

Glucose :
- after breakfast urine
- gestational diabetes

31
Q

What do you ask about in the initial history taking of a pregnant woman ?

A

Personal data
Physiological symptom or complaints
Course of previous pregnancy and childbirth :
- numbers of pregnancy/birth/abortion
- course of previous pregnancy, birth and postnatal period
Genital tract function and contraception
Medical data concerning past/current disease, the operation and treatment
Family history
Psychosocial history
Lifestyle habits

32
Q

What do you do during a regular check up for pregnancy ?

A

Frequency increase with the pregnancy. To facilitate optimal condition and detect potential risk and adjustment management.

Compare with previous check up.
Brief history taking covering the period since consultation.
Physical examination

33
Q

What is the physical examination of a regular check up in pregnancy ?

A

General inspection
Blood pressure : systolic should remains unchanged but diastolic often fall during the second trimester (by 10-15 mmHg) then rise to normal level. Shouldn’t be higher than 140/90
Weight : first trimester has low weight gain, it is more pronounced in the second.
External obstetrics examination
Inspection
Palpation
Auscultation of fœtal heartbeat
Laboratory test

34
Q

What are the abnormality in weight gain in pregnancy ?

A

Excessive weight gain in the second half => interstitial fluid accumulation
Low weight gain or loss => foetal growth retardation

35
Q

What is parturition ?

A

= Labor

Begins with uterine contraction (fetus : 37-42 weeks)
End with placenta delivery

Duration : 12-18h for the first time and 6-9h for subsequent pregnancy

36
Q

What trigger true contraction ?

A

Bloody show : plug of mucus fall out of the cervix.
Water breaking : amniotic sac ruptures

37
Q

Characteristics of true contraction ?

A

Progress in frequency, intensity and duration.
Feels like a wave build up to a peak intensity then gradually decrease.
The thick tissue of the cervix : effaces (get thinner) and dilates (open up)

38
Q

What are the stages of the first part of labor ?

A

Early / latent stage : can last up to 20h
Active stage

39
Q

What are the characteristics of the early first stage of delivery ?

A

Irregular contraction every 5-30min that last 30s
- dilatation : 0-3 cm
- effacement : 30%

THEN

Regular contraction every 3-5min that last 1 min
- dilatation : 3-6 cm
- effacement : 80%

40
Q

What are the characteristics of the active first stage ?

A

Very intense contraction : 60-90s every 30 to 120s
- dilatation : 6-10 cm
- effacement : 100%

Rupture of the amniotic sac (if isn’t already done)

41
Q

What main factors influence the second stage of labor ?

A

Power : force of uterine contraction
Passenger : foetus and their unfused skull (head as large as possible while being safe
Passage : route through bony pelvis

42
Q

Characteristics of the fetus influencing the passage ?

A

Foetal size (head)

Foetal attitude : flexion of the body

Foetal lie : position in the uterus
- longitudinal is preferred

Foetal presentation :
- cephalic : head fist
- breech : bottom first
- shoulder first

43
Q

What are the different foetal attitude ?

A

Fully flexed (normal) : chin on chest, rounded back, flexed arm and leg

Not completely flexed : more difficult to go through the passage

44
Q

What are the cardinal movements ?

A

Mechanism of labor : foetus makes several movements to be able ton pass

-descend : from station -5 to 0 (engagement)
- flexion : chin against chest, resistance from pelvis
-internal rotation : 45° so widest part are aligned
- extension : of the head after it passes the symphysis (station +4) and emerge from the vagina
- restitution : rotate under symphysis pubic
- expulsion : one shoulder after another

45
Q

What do you check when a pregnant comes because she think she’s in labor ?

A

Vital signs
Leopold manoeuver :
- fundal height, growth, descend
Vaginal examination :
- state of membrane, presentation of the head
- foetal descend, rotation
- consistency, effacement and position of cervix

46
Q

What are the objectives in the management of the first stage ?

A

= dilatation

Determine the start of labor.
Observe progress of dilation, its end and detect in time problems.
Assess state of foetus.

47
Q

What can you use to monitor in foetal condition during parturition ?

A

Heart sounds : 120-160 bpm
- deceleration after contraction
- acceleration foetal rate : foetal distress

Presence of meconium in amniotic fluid : foetal bowel movement

Green leakage when breaking of membrane during dilatation : intra-uterine asphyxia

48
Q

What is the physical examination of a woman coming for parturition ?

A

Assess general condition :
- tired, anxious, tense
- pulse rate, blood pressure, t°
- cyanosis, anemia, oedema

Inspection of abdomen : curvature and visible contraction
- measure contraction activity : intensity, duration, time in between

Determine presentation : longitudinal, transverse, presentation of head

Determine the position

49
Q

Longitudinal presentation characteristics ?

A

Vertex : head first
- more stable because the smooth rounded scalp fits in the pelvis brim

Breech : buttock first
- fits less well and foetus could push its feet against the brim

50
Q

Transverse position characteristics ?

A

Common in the early stage of pregnancy because there’s a lot of space
Vaginal birth impossible without correction

51
Q

What are the type of head presentation ?

A

Degree of flexion of the head.
- flexed presentation : head bent forward
- extended presentation : head bent backward

52
Q

What are the kind of flexed presentation of the head ?

A

Occiput :
- chin on chest & almost max flexion
- back of head near pelvis axis
- most prevalent and favorable

Sinciput = forehead :
- less flexed
- forehead near the pelvic axis
- less favorable, still allow natural birth

53
Q

What are the kind of extended presentation of the head ?

A

Brow = fronto (F)
- brow in the pelvic axis
- normally not possible for full term

Facial = mento (M)
- hyperextended
- face in the pelvic axis
- vaginal birth possible if the chin rotate forward on its axis towards pubic symphysis

54
Q

How do you determine the position of the foetus ?

A

Give the reference point based on the presenting part and the direction in the pelvis in which it is oriented.

55
Q

What are the different reference point to determine the position of the foetus ?

A

Vertex
- flexed => small fontanel
- extended => chin

Breech => sacrum

Transverse => back or head

56
Q

Did parturition already start ?
(Sign 1 : Contraction)

A

Regular powerful contraction that increase in intensity.
- at least 1h of contraction every 4-8 minutes => it has started
- irregular contraction occur frequently in the 3rd trimester

Palpation to observe contraction
- duration and frequency
- observe progress of dilatation as sign of effective contraction

57
Q

Did parturition already started ?
(Sign 2 : bloody show)

A

Losing a plug of vaginal mucus mixed with blood
- mucus originates from the endocervical crypts
- blood loss caused by the membrane detaching from the cervix during dilatation

58
Q

Did parturition already start ?
(Sign 3 : water breaking)

A

Membrane are tearing. Happen at the end of the dilatation phase but may happen before dilatation contraction start and amniotic fluid leaks out.
- perceived as involuntary urine loss
- amniotic fluid recognised as sweet smelly and with vernix flakes

59
Q

What internal examination do you do during parturition ?

A

Cleaning the vulva :
- cotton ball with disinfectant
- clean around vulva and labia majora
- wipe once ventrally to dorsally with each cotton
- spread labia minora with thumb and index at the height of the vagina. Repeat procedure

Digital vaginal examination : gain impression of the dilatation and engagement progression, position of child and accessibility.

60
Q

What should you look at during parturition in the digital vaginal examination?

A

CDMSPL :
- Cervical effacement : shorter, softer and open cervix. Merge with lowest uterine segment
- Dilatation : use outer side of 2 finger estimate the opening size
- Membranes : is the amniotic sac still present, is the membrane still taut => functional
- Station : determine the relation between presenting foetal part and maternal pelvis
- Presentation : deepest part of presenting part
- Lie and attitude of foetus

61
Q

What should you beware of during a digital vaginal examination during parturition ?

A

Not during contraction : except to assess the functionality of membrane.

Contraindicated in case of clear red vaginal blood loss or amniotic fluid loss without contraction activity.

62
Q

How do you do a digital vaginal examination ?

A

Clean hands, sterile gloves.
Clean vulva, spread labia minora with thumb & index, insert fingers and support fundus.
Stable posture, relaxed wrist and horizontal forearm
Note :
- CDMSPL
- pain, prolapse limbs or umbilical cord, soft tissue of birth canal / pelvic floor / rectum

Remove examining finger and check gloves for blood, méconium, mucus, flakes of vernix in amniotic fluid

63
Q

What are the objectives in the management of the second stage ?

A

Establish start of delivery.
Assess condition of foetus, ensure its passage appropriately.
Detect any complication and treat these early.

64
Q

What do you do if the delivery becomes too long ?

A

The child can become distressed therefore medical intervention is needed.
Either :
- applying pressure
- episiotomy
- forceps extraction
- Caesarian section

65
Q

When do you know you can expect the birth of the head ?

A

When it is crowning : scalp remains visible and no longer sinks back.

Before it is only appearing : part of the scalp becomes visible during contraction then sinks back.

66
Q

What is the procedure once the newborn is delivered ?

A

Note time of birth
Drain nose, mouth, throat
Determine APGAR score after 1 min then 5min
Clamp umbilical cord
Hand child to mother
Perform checks up on mother : fundal height, strength of contraction, vaginal blood loss, tears
Supervise placental birth

67
Q

What is the cause of a too high fundal height after birth ?

A

Unrecognised multiple pregnancy or intrauterine blood loss.

68
Q

How do you clear the throat, nose and mouth of a newborn ?

A

To reduce the risk of pneumonia in 15s.

Mucus suction device : broad piece in your mouth, small suction in child’s mouth with little finger.
Pull tube backward while sucking.
Repeat in the nostrils.

69
Q

How do you use the Apgar score ?

A

Heart rate : more / less than 100 Bpm OR absent
- stethoscope at the heart of umbilical cord

Breathing : regular more than 30/min and good crying OR weak, gasping OR absent

Skin color : entirely pink OR pink with peripheral cyanosis OR blue/pale
- extremities remains blue because of blood stasis due to flexed position
- white asphyxia : too little circulating volume, oxygen administration has little effect

Muscle tone : good OR reduced OR complete hypotonia
- reduced : easier to extend than flex
- flaccid child : do not move

Response to stimuli : retraction, grimace, crying OR moderate response OR no response

70
Q

When do you tie the umbilical cord ?

A

If in good condition : can be delayed
If poor condition : as quickly as possible
- if child hasn’t cried yet, stroke umbilical cord towards the child so they can receive more blood.

71
Q

What do you check in the mother after foetus birth ?

A

Important uterine contraction : stop blood loss and release placenta
If fundal height doesn’t increase and the uterus is well contracted : placental birth isn’t urgent
Blood loss is normal for less than 500 mL

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