Obstetrics Flashcards
When should the booking visit occur? What is its purpose
At or before 10 weeks.
Needs of pregnancy assess and plan antenatal care (specific clinical, consent for antenatal screening)
When is the first ultrasound scan? What is its purpose?
10-14 weeks
Confirms pregnancy
Accurately dates it (gives EDD)
Identify multiple pregnancies
screens for chromosomal abnormality (nuchal translucency measurement)
How is foetal growth measured:
a) before 13+6 weeks
b) 14-20 weeks
what happens after 20 weeks
a) crown rump length (CRL)
b) head circumference
a) + b) can be plotted on standard foetal chart
Before 20 weeks growth is fairly standardised between pregnancies. After 20 weeks genes & environmental factors alter the rate.
Which ages are at higher risk of obstetric complications
<17 or >35
> 35= chromosomal abnormality
Which PMHx (not including obstetric) require additional care?
- Hypertension
- Diabetes
- Psychiatric disorders
- Epilepsy
- Recreational drugs use
- Thromboembolic disease
- Obesity
- Age >40
- Vulnerable women
- HIV/HEP B
Which Obstetric Hx requires additional care?
- Recurrent miscarriage
- Pre preterm birth
- Prv pre-eclampsia
- Prv c-section
- Prv puerperal psychosis
- Grand multip (>6)
- Still birth/neonatal death
- Baby with congenital abnormality
- Babe <2.5kg or >4.5kg
Gynae Hx in book visit
- Subfertilty? ↑ perinatal risk
- Assisted conception, higher risk multiple pregnancy
- Prev uterine surgery → elective CS
- Cervical smear Hx (should not occur if due during pregnancy, 12 week postpartum_
Book examination
General:
BMI, BP
Abdo exam: uterus palpable form 12 weeks, foetal heart can be oscillated with sonic aid.
What blood are taken at the booking visit?
FBC
Haemoglobinopathies
Blood group + antibody screen
Infection screening: HIV, Hep B, Syphilis
What should the FBC be? When is it repeated?
>
- 28 weeks
Which haemoglobinpathies are test for? Why?
sickle cell: carriers can test partner and prenatal diagnosis offered
thalassaemia:
Why ABO
What is the rhesus status used for
ABO- crossmatch in case of emergency
Resus negative are offered Anti-D prophylaxis to prevent rhesus D iso-immunisation & haemolytic disease of future feotus. Anti D given at 28 weeks, after any traumatising event (trauma, haemorrhage) and at delivery.
If baby is Rhesus positive give anti D within 72 hours
How to manage HIV in pregnancy
↓Risk of vertical transmission: – > antiretrovirals throughout pregnancy & up to 6 weeks for newborn
> C section delivery
> Avoidance of breastfeeding
Risk 30% → 1%
Higher risk of pre-eclampsia, stillbirth & IUGR
Do not write diagnosis in hand help notes
How to manage Hep B
Notifiable disease: contact HPA
Refer to hepatology
Neonatal immunisation: 5 dose treatment
Immunoglobulins for high risk
Complications of syphilis and treatment
miscarriage, severe congenital abnormality
Refer to GUM & prompt treatment with benzylpenicillin
Mother must receive treatment > 4 weeks before delivery otherwise baby must go under IV therapy
Chlamydia & gonorrhoea: prevalence in pregnancy, presentation and effects of each
5%, asymptomatic
Chlamydia: neonatal conjunctivitis (30%) & neonatal pneumonia (15%)
Gonorrhoea: postpartum endometriosis, chorioamnionitis, neonatal ophthalmia 40-50%
In the booking visit what health and promotion advice should be given? Include Drugs & Lifestyle advice
Folic Acid: 400 micrograms/day → 12 wks
Vit D: if BMI >3O, south asian or afrocaribbean
Iron supplements: not routine
Anti-epileptics: carbamazepine & lamatrigine are safest.
Diet: well balanced 2500 calories, no alcohol
Smoking: nicotine replacement
Infection advise: Listeriosis is avoid by only drinking pasteurised milk. Avoid soft or blue cheese & uncooked/partially cooked foods. Cook eggs & chicken thoroughly to avoid salmonella
What medication is recommended to those with pre-eclampsia in previous pregnancies?
Low dose aspirin (75mg)
If had 1 c-section for non-recurrent condition can your next delivery be vaginal?
Yes
Smoking in pregnancy increases risk of which conditions
IUGR, SGA, placental abruption, preterm labour, stillbirth, SIDS
When to treat anaemia. What with
Hb < 100 mg/dL
MCV < 80
iron supplements
For most women when is gestational diabetes test for?
What is the test?
Who is tested earlier? When are they tested?
26 week. GTT
BMI > 30 Prv GDM 1st degree with diabetes South asian or afro-carribean Prv baby's weight >4.5kg
16 weeks
What is the combined screening test? What does it involve? When is it done?
A scan & blood test performed @ 11-13 weeks.
Nuchal Scan: checks nuchal translucency. Tests for Downs (21), Edwards (18) & Patau’s (13)
Blood Tests:
PAPP-A: pregnancy associated plasma protein ↓ = chromosomal problem
HcG: ↑ in 1st & 2nd associated with downs, ↓ associated with Edwards & Pataus
How is the risk of Downs calculated & how is the risk given?
maternal age x risk ration form combined screening test
1 > 150
What is the combined screening tests sensitivity and specificity
85% & 2%
What two tests can be offered to confirm diagnosis of trisomy 21. When can they tested for each?
risks involved
Chorionic Villus Sampling (CVS): 11 weeks
Amniocentesis: 15 weeks
risks of miscarriage (1%, 0.8%)
When would you offer extra growth scans @ 30 & 36 weeks?
3 x low risk or 1 intermediate risk
What are low risk factors for FGR
Maternal age: Primip 35-39 years Multip > 40 Long pregnancy interval (>60 months) Previous PET
What are intermediate risk factors for FGR
IVF pregnancy Primip > 40 Current smoker Drug misuse PAPP-A <0.4MoM
What are the high risk factors for FGR
Prv stillbirth Renal impairment APLS Previous SGA baby on CGC Chronic hypertension Unexplained APH New hypertension in pregnancy
If high a patient is high risk for FGR. What additional care should they receive
Serial growth scans from 26 weeks
If a women present with reduced foetal movement. What questions would you like to ask.
- When did this start?
- Absence or reduction
- 1st occasion
Still birth risk evaluation: the number of presentations of RFM; any hypertensive disease of pregnancy, diabetes or poor past obstetric history; if the baby is small for gestational age (SGA); if there are issues with access to care.
Examination
Maternal Obsverations: Tolly + RR + urinalysis (pre-eclampsia)
Obstetric examination:
- measure size and plot
< 24 weeks hand held doppler (palpate mothers pulse to ensure its babies)
Investigations
CTG
USS
If there are no risk factors for stillbirth, the fetal heart is heard on auscultation, and examination is unremarkable, the woman can be reassured and advised to see her midwife within a week for further discussion.
What else should you inform the women.
reassure: 7/10 women will experience an episode of ↓ fetal movement. Only 3-5% have a re-occurance.
If second episode occurs: come back to MAC
General Health:, including smoking cessation and drug/alcohol reduction/cessation, should be given and also documented.
Ms Jones 26yr primid. Her routine abnormality scan has shown placenta praevia. Please explain the scan result including risk associated with this condition and how to manage it.
Introduction:
‘Do you know why you had the scan’
‘It has shown you have a condition called placenta praevia. Do you know what this means?)
Describe Placenta praevia:
- The placenta is the organ that allows blood to reach you baby so that it receives oxygen & nutrients
- Usually the placenta grows nr the top of your womb
- Your groin nr the bottom, so this can cover the entrance to the womb
- Sometimes the placenta moves up the womb & allow for a normal vaginal delivery but for 1/200 the placenta remains, at which point CS is often the safest method.
Impact on pregnancy:
- ‘You may have no symptoms at all’
- ‘As the placenta is covering the entrance to your womb, it may start to bleed’
- Advice: abstain from sex, ↑ risk of bleeding
- If this happens you will notice blood from vagina- like having a period - may be a small amount or large.
- If you bleed, you should come for an urgent assessment as you if you lose ↑ blood you & baby at risk
- If bleeding settles you could go home but if its significant or reoccurs we would get u to stay in hospital’
Delivery options
- Depends on if placenta moves: vaginally. If continues to block womb we would recommend planned CS at 39 weeks (safe)
- If b4 planned CS, a significant bleed occurred we would have to do an emergency CS
Management:
Re-arrange US @ 36 weeks to assess if placenta has moved away.
Look out for bleeding
Confirm rhesus status- if neg tell them they will need injection if they bleed
- leaflet
37 weeks diagnosed with frank breach presentation 1st preg. Explain ECV and delivery if ECV is unsuccessful.
- What is breech
‘We have done an US to see how baby is position in the womb, your baby is in the breech position”
- 3-4% of term pregnancies are breeched
- It means you abut bottom is at the exit of the womb. This means if you were to give birth vaginally your baby would come out bottom first which could place them at higher risk of complications than if they were head first.
What has caused the breech?
Patient explanation & answers
No cause is identified in most cases. It may be associated with certain conditions (which prevents engagement of the head)
- Twins
- Polyhydramnios or Oligohydramnios
- Uterine fibroids
- Placenta praevia
- Pelvic tumour
- Pelvic deformity
How do you manage breech?
‘A procedure called external cephalic version’ at 36 weeks may put baby back into normal position’
‘This involves the obstetrician attempting to rotate the baby in your womb, but putting their hands on your tummy. They may give you some medication to relax your womb’
‘This procedure ↓ need for CS. The immediate success is around 50% but in around 10% the baby subsequently turns back into breech position
‘Risks: small risk or umbilical cord entanglement, placental abruption (premature separation of placenta from womb) or induction of labour. Although risks are small- procedure is done when there is access to operating theatre
- As risk of ECV are lower than that of CS, 34 advise to try that first.
- If ECV is unsuccessful or there is good reason not to do it -> elective CS
Vaginal breech delivery
‘Labour is potential more hazardous’ (cord prolapse, foetal hypoxia)
‘Each case can be judged individually, in some cases it may be reasonable to go ahead with a vaginal delivery provided certain criteria are met.
- Skilled attendant
- Anaesthetic & neonatal personnel available
- Patient selection
- not footling breech
- estimated weight is <4.0kg
- Head not hyperextened
- No maternal or foetal complications
- No PTE
- Willing mother who is aware of complications
- Access to operating theatre
Intrapartum care:
- Adequate progress
- continous monitoring
- No foetal distress
Mrs Taylor at term with 1st child. Baby is breeched and she is considering an elective CS. Explain risk & benefit.
1 Why is it being done
You baby is breeched, if you were to deliver vaginally with its feet/bottom coming out first it makes the delivery more technically difficult and increases the risk to baby’s health. A CS would be a safer option for the baby, but it has its own risks.
How will it be done?
- It is surgical procedure that involves making a cut along the bikini line and bringing the baby out through that cut. Then we sew everything back together.
- We will use a spinal or epidural painkiller, which will numb your lower half or your body. You should not feel any pain but you may feeling some pushing & pulling
- Before we start the operation, we also need to empty your bladder with a catheter.
- You will be awake for the procedure and we will put up a screen so you cannot see the actual operation
- Once your baby is born, there will be a paediatrician (childs doctor) contactable. After the baby has been checked over, it is possible to hold your baby while the rest of the operation is finished.
There will be many ppl in the operating theatre- an anaesthetist, obstetrician, midwives, and theatre staff. Your partner can also be in the theatre.
Once the baby is born we will give you a drug to contract your womb and reduce bleeding, as well as antibiotics to reduce the risk of infection.
Risks to mother
- During operation
Bleeding:
Everyone will lose blood to some extend during the procedure. Depending on the amount of blood lost we can give iron tablets or a blood transfusion. There are also surgical techniques to stop bleeding. However (5/1000) these measures are not enough removing the womb is the only option to stop the bleeding. This is a last resort.
Damage to surrounding organs (1:1000)
Damage can occur to the bladder or bowel if damage occurs this can usually be fixed during the operation
Risk to mother
After operation
Increased risk of blood clots. To reduce the risk blood thinning tablets is given, early mobilisation and special stockings are recommended
Increased risk of infection so antibiotic are give
You bowels might not work properly for a while
Post operative pain (painkillers)
Future pregnancies
70% of women in future pregnancies can give birth vaginally. However there is increased risk of tear of the womb, still births and placenta acreta (womb sticks to uterine wall for a longer time than normal after delivery)
Risks to baby
Cuts to baby skin (1:1000)
Breathing difficulties can occur, normally minor.
