Obstetrics Flashcards
What is the definition of parity?
Refers to the pregnancies that resulted in delivery beyond 28weeks of gestation.
What is the definition of gravidity?
Refers to the number of pregnancies that a woman has had (to any stage)
What is an episiotomy?
An operation performed to enlarge the outlet to hasten birth of a distressed baby, for instrumental or breech delivery, to pre taste a premature head, and to try and prevent 3rd degree tears.
The tissues incised are vaginal epithelium, perineal skin, bulbocavernous muscles and superficial and deep transverse perineal muscles.
Describe Placental Abruption, its risk factors, symptoms, and management.
Accidental haemorrhage a form of anterpartum haemorrhage (APH). Part of the placenta becomes detached from the uterus. The outcome depends o the amount of blood loss and degree of separation.
Risk Factors: Pre-eclampsia, smoking, increased maternal age, thrombophilia, cocaine/amphetamine use, infection, multiple pregnancy. PROM.
Symptoms: Shock out of keeping with visible blood loss. Constant pain. Tender, tense uterus, normal lie and presentation, fetal heart absent/distressed, coagulation problem.
Management:
-admit, resuscitate, get help, deliver that baby
Describe Preterm rupture of membranes (PROM) and its management.
There are two foetal membranes, the amnion and chorion, which make up the amniotic sac. These may rupture and lead to spontaneous labour, waters breaking. If the membranes ruptured and 18hrs pass it is prolonged rupture of membranes. The mother may give a history of a popping sensation or a gush with continues watery liquid draining thereafter.
Management:
- admit do temperature, MSU and HVS, assess for causes e.g. Abruptions, twins, polyhydraminios.
- Give corticosteroids Betamethasone to help foetal surfactant production.
- In 80% membrane rupture induces labour. The problem with the remaining 20% is balancing advantages of remaining in utero I.e. Maturity and surfactant production) against the threat of infection which causes 20% of neonatal deaths after PROM.
- Prophylactic erythromycin 250mg/6h IV for 10 days or until delivery
- Monitor for signs of infection and treat if develops and expedite labour.
What is Cephalopelvic disproportion?
The appropriate label given if diameters are unfavourable, and/or the head is big. A clinically favourable pelvis is one where the sacral promontory cannot be felt, the ischial spines are not prominent, the supra public arch and base of supra sinuous ligaments both accept 2 fingers, and the inter tuberous diameter accepts 4 knuckle when the woman is examined.
What is dystocia?
Describes difficulty in labour implying problems with one or more of the three P’s:
- Passages, there may be soft tissue (e.g. Fibroid or cervical dystocia after cervical biopsy or genital mutilation) or bony obstruction
- Passenger, owing to a large baby, e.g. Impacted shoulders or an abnormal presentation.
- Propulsion, thanks to the uterine powers.
Describe Down’s Syndrome, it’s signs at birth, and associated problems.
Due to trisomy 21, and related to increased maternal age.
Signs at birth: flat facial profile, abundant neck skin, dysplastic ears, muscle hypotonia, and X-Ray evidence of a dysplastic pelvis, simian palmar crease, protruding tongue.
Associated Problems: Duodenal atresia, VSD, PDA, Low IQ, short stature, Alzheimers, Lung problems, hearing loss, leukaemia (AML),
Describe Pre-Eclampsia, it’s risk factors, symptoms, and management.
Pregnancy-induced hypertension with proteinuria, +/- oedema. Usually affecting pregnant woman from around 20 weeks. May develop into seizures (eclampsia) in 1% which can be life-threatening for baby (IUGR, Prematurity) and mother (Stroke, Eclampsia)
Risk factors:
- High risk: Diabetes, Hypertension, CKD, SLE, Antiphospholipid syndrome
- Medium Risk: FHx, 40+yrs, 1st pregnancy, pregnancy interval more than 10yr, BMI greater than 35, multiple pregnancy.
Symptoms: Asymptomatic (Raised BP, Proteinuria (more than 300mg in24hr urine or PCR greater than 30), raised serum urate, picked up on antenatal appointments), Other symptoms include headache (flashes floaters), chest or epigastric pain, vomiting, tachycardia, visual disturbances, shaking, hyperreflexia, irritability, facial oedema. HELLP syndrome due to loss of protein C+S in urine, DIC.
Management:
-if high risk or 2 medium risk 75mg Aspirin PO OD from 12th week
until delivery to prevent eclampsia.
-Admit if BP rises more than 30/20mmHg over booking BP, BP over 160/100mmHg, BP over 140/90mmHg and 1+ proteinuria, or there is IUGR.
-measure BP 2-4hourly and monitor FBC, U+E and LFTS beware DIC and HELLP syndrome.
-If BP over 160/100mmHg use labetalol (or Methyldopa, nifedipine)
-If signs of severe pre-eclampsia, e.g. BP greater than 160/100mmHg with proteinuria or greater than 140/90mmHg plus proteinuria plus one of the following: Seizures, Headache or epigastric pain, thrombocytopenia, Visual disturbance, Papilloedema, raised ALT, clonus, Liver tenderness. Use prophylactic magnesium, IV labetalol/hydralazine (require CTG monitoring) and delivery is the only cure. Continue to monitor post delivery.
-treat eclampsia with magnesium sulfate.
What are the WETFAG calculations?
Weight in Kg: 0-12 months = (0.5 X age in months) + 4, 1-5years (2 X get in years) + 8, 6-12 years = (3 X age in years) + 7
Electricity for a DC shock: 4J per Kg
Tracheal tube: Internal diameter mm = (age/4)+4 prepare one size above and below
Fluid Bolus: 20ml/kg of Normal saline
Adrenaline: 0.1ml/kg of 1:10000 solution
Glucose: 0.5ml/kg of 10% glucose.
Describe Intrahepatic Cholestasis of Pregnancy, its symptoms, tests and management.
Symptoms: Jaundice, pruritis especially of palms and soles in the second half of pregnancy. There is risk of preterm labour, foetal distress, and stillbirth so monitor foetal wellbeing.
Tests: liver transaminase are mildly raised in 60%, and bilirubin raised in 25%. Exclude viral hepatitis.
Management:
- deliver baby if Bile acid greater than 40.
- offer delivery at 37weeks.
- Vitamin K 10mg/d PO to mother and 1mg IM at birth.
- Ursodeoxycholic acid reduces prutitis and abnormal LFTs.
- Symptoms resolve within days of delivery, LFTs normalise after 10days.
- it is a contraindication to oestrogen containing contraceptive pills.
Describe HELLP syndrome, its symptoms, and management.
Triad of haemolysis, elevated liver enzymes and low platelet count. Risk is higher in pre-eclampsia.
Symptoms: Upper abdominal pain, malaise, vomting, headache, jaundice, microangiopathic haemolytic anaemia, DIC, raised LDH, raised ALT.
Management:
- admit, get expert help
- deliver if severe.
What is the bishop score?
Used to help assess whether induction of labour will be required. A score of less than 5 indicates labour is unlikely to start without induction and a score over 9 indicates that labour will most likely commence spontaneously.
Cervical Position: posterior = 0 , intermediate =1, anterior =2
Cervical consistency: firm = 0, intermediate = 1 , soft = 2
Cervical effacement:0-30% = 0, 40-50%=1, 60-70% = 2 80% =3
Station of head (cm above ischial spines): -3 = 0, -2 = 1, -1-0=2, 1-2 = 3
Cervical dilation: 0cm = 0, 1-cm = 1, 2-3cm =2, more than 3 = 3
Describe Shoulder Dystocia, it’s risk factor, and management.
Also known as impacted shoulders, this is the inability to deliver the shoulders after the head has been delivered. The danger is death from asphyxia as the cord is usually compressed at the pelvic inlet.
Risk factors: previous shoulder dystocia, macrosmia, raised BMI, induction of labour, slow first or second stage, increased abdominal circumference is good marker for large shoulders.
Management:
- HELPERR
- Help, call for help SOAPS = Senior Midwife, Obstetrician, Anaethetist, Porter, Scribe
- Evaluate for an episiotomy, if to attempt manoeuvres
- Legs, McRoberts position (hyperflexion of legs to abdomen)
- Pressure, suprapubic pressure.
- Enter, wood screw and reverse woodscrew
- Remove the posterior arm in attempt to delivery the posterior shoulder first.
- Roll the mother over to attempt manoeuvres again on all fours. Each manoeuvres should be attempted for 20-30 seconds.
- If these measure fail emergency C-section or deliberate fracture of anterior clavicle should be considered
- If fails anaesthetise, disengage baby and emergency CS
Describe Cord Prolapse and its management.
This is the descent of the cord through the cervix, either alongside or in front of the next presenting part in the presence of ruptured membranes. It is an emergency because cord compression causes foetal asphyxia. The problem is obvious if the cord is at the introitus, but the only sign may be foetal bradycardia or variable foetal heart rate decelerations, always for a vaginal examine in this context to exclude prolapsed cord.
Management:
- get help, activate alarms, tell labour ward
- displace the presenting part by putting a hand in the vagina, push it back up towards mothers head during contractions.
- use gravity, get woman on all fours.
- infuse 500ml into bladder
- tocolysis reduces contractions and helps bradycardia.
- consider Caesarian.
What is the puerperium?
The 6 weeks after delivery in which the body returns to a pre-pregnancy state.
Describe Antepartum Haemorrhage, it’s causes, presentation, investigations, and management.
Defined as bleeding from the birth canal after the 24th week of pregnancy. It can occur at any time until the second stage of labour is complete, which marks the boundary of postpartum haemorrhage. Bleeding before 24 weeks is miscarriage.
Causes:
- Idiopathic
- placenta praevia
- placental abruption
- uterine rupture
- vasa praevia
- infection
Presentation: bleeding which may be accompanied by pain (suggestive of abruption) or be painless (suggesting praevia). There may also be malpresentation of failure to engage with placenta praevia. Mother may show signs of hypovoleaemia shock if bleeding is severe.
Investigations: no vaginal examination until placenta praevia is excluded by ultrasound. FBC and Group and save, clotting studies if platelet count abnormal. Crossmatch 4 units and check U+Es and LFTs.
Management:
- admit to hospital, ABCDE
- investigate and treat cause.
What are the stages of normal labour?
Usually spontaneous and occurs between 37 and 42 weeks. Can be split into 3 stages.
The first stage consists of the Latent phase and Active phase. It lasts from the onset of true labour to full cervical dilatation. Signs of true labour include, painful rhythmic uterine contractions, beginning of dilatation of cervix, show (leakage of mucus plug), and rupture of the membranes. During the Latent phase the cervic is gradually pulled up so that is one with the lower segment of the uterus a process known as effacement. During the active phase describes dilatation of the cervix.
The second stage involves expulsion of the foetus. It lasts from full dilatation of the cervic (10cm) to the birth of the baby. The baby becomes visible and expulsive contractions begin. Baby’s head is flexed and descends into pelvic cavity in left occiput anterior position. Head then rotates to face the sacrum due to a guttering effect of the pelvic floor muscles. Head is born by extension during crowning. Restitution occurs after the head is born head turns laterally and the shoulders rotate internally to be born.
The third stage involves the separation and expulsion of the placenta and membranes and the control of maternal bleeding. Uterus contracts as placenta sloughs to prevent bleeding and products can pass passively. Signs of separation include cord lengthening followed by a gush of blood (retro placental haemorrhage) followed by contraction of the uterus (felt as globular mass) usually takes less than 1h. Examine the placenta to check it is complete, looking for complete puzzle effect (cotyledons), both membranes, if any vessels on the membranes look for suceenturate lobes.
Describe the timeline of appointments in routine antenatal care, and briefly describe the tests and screening offered.
Nulliparous women receive 11 appointments and Multips have 8. All appointments should include measuring BP and testing urine for proteinuria.
Booking (10wks): Folic acid + Vitamin D, lifestyle advice, medication review/advice, mental health screen, nutrition (no uncooked meat or fish, raw egg, unpasteurised milk or soft cheese, pate, more than two portions of oily fish, unwashed fruit of vegetables). Offer screening bloods for anaemia red cell allo-antibodies, Hep B, HIV, Rubella, Syphilis, Chlamydia, sickle cell and thalassaemia, screening for gestational diabetes in women with risk factors. Also discuss down’s screening.
11-13+6wks: Dating Scan + Combined test (Down’s)
16wks: review previous results. Quadruple test for down’s if missed Combined window
18-20wks: Ultrasound Anomaly Scan, Quadruple test for down’s if missed Combined window
25wks (Nulliparous only): Routine
28wks: Bloods for Hb, Antibodies and Glucose. Anti-D if Rh-ve, pertussis vaccination.
31wks (Nulliparous only): review of screening tests.
34wks: Repeat Hb, second dose Anti-D review of tests.
36wks: information given regarding breast-feeding, care of new baby, postnatal depression, vitamin K
38wks: routine
40wks (Nulliparous only): routine
41wks: Offer membrane sweep and discuss induction of labour
Describe Post-Partum Haemorrhage, it’s causes, risk factors, and management.
Blood loss of more than 500mls in first 24hr after delivery. More than 1.5L becomes Major Obstetric haemorrhage.
Causes (4T’s):
- Tone I.e. Uterine Atony (90%),
- Trauma to genital tract
- Tissue I.e. Retained products or clots
- Thrombin I.e. clotting disorders pre-existing or acquired
Risk Factors: previous PPH or retained placenta, BMI over 35, Maternal Hb less than 85 at onset of labour, antepartum haemorrhage, multiparty over 4, maternal age over 35, fibroids, polyhydraminos, twins, macrosomia, placental abruption, placenta praevia, pre-eclampsia, infection
Management:
- ABCDE
- bimanual uterine compression
- Oxytocin 5-10u slowly IV
- if uterine Atony is cause Carboprost (Haemabate) IM, Ergometrine.
- if fails, balloon tamponade, B-Lynch suture +/- uterine artery ligation.
- if severe uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure.
Describe Down’s Syndrome antenatal testing.
Combined test is standard performed at 11-13+6 wks. It entails a nuchal translucency measurement + b-HCG (Raised in Down’s)+ Pregnancy associated plasma protein A (PAPP-A) (reduced in Down’s)
If women book later in pregnancy or change mind etc quadruple test can be offered between 15-20wks. It entails alpha-fetoprotein (Reduced in Down’s), Unconjugated oestriol (Reduced in Down’s), b-HCG (Raised in Down’s), and inhibin A (Raised in Down’s)
