Obstetrics Flashcards
1
Q
What is the average length of a normal pregnancy?
A
37-42w
2
Q
What does gravidity and parity mean?
A
Gravidity: total number of pregnancies
Parity: total number of pregnancies >24w
3
Q
What are the normal changes in pregnancy (cardiac)? (3)
A
Increase in cardiac output due to Increase in SV and HR BP first drops then rises Slight cardiomegaly Decrease in peripheral resistance Ejection systolic murmur Compression of IVC
4
Q
What are the normal changes in pregnancy (blood)? (2)
A
Dilutional anaemia: increase in plasma volume, decrease in Hb
Decreased albumin
Increased fibrinogen and clotting factors
5
Q
What are the normal changes in pregnancy (resp)? (3)
A
Increased tidal volume
Increased minute ventilation- but no increased RR
Some SOB
6
Q
What are the normal changes in pregnancy (endo)? (3)
A
Increased thyroid size and parathyroid
Increased basal metabolic rate
Increased prolactin through
7
Q
What are the normal changes in pregnancy (uterus)? (2)
A
Increased uterus size
Braxton Hick contractions
8
Q
What are the normal changes in pregnancy (gastro)? (3)
A
Constipation and haemorrhoids- due to reduced gastric emptying
GI reflux
Nausea and vomiting
Increased renal blood flow and GFR
9
Q
In normal pregnancy: what effects does the increased oestrogen production have on the breast and vagina? (3)
A
Increase in breast and nipple size
Vaginal hypertrophy
Increased discharge
10
Q
At what dates should the booking visit occur and what is done in it?
A
Before 12w- ideally 10w
FBC, blood group, HIV, serology for syphillis (VDRL), Hep B, rubella
11
Q
What supplement do pregnant women need to take and for how long for and what dose?
A
Folic acid from pre-conception to 12w gestation
Low risk: 0.5mg
High risk: 5mg (DM, obesity, PMH of spina bifida)
12
Q
When is the main ultrasound scan and what does it look for?
A
11-13+6 looking for:
- Dating: using crown rump length - estimate gestational age
- Nuchal translucency - for chromosomal abnormalities + beta-HCG, PAPP-A (pregnancy associated plasma protein A) (combined test)
- Viability of the pregnancy
- Presence of multiple pregancies
13
Q
What is involved in the combined and quadruple tests that can be offered to screen for chromosomal abnormalities e.g. Down’s, Patau’s, Edwards and at what times?
A
Combined test: between 11 + 13+6: NT + beta HCG + PAPP-A
Quadruple test if they have missed combined test at 18-20 weeks (2nd trimester): AFP + unconjugated estriol + inhibin A +beta HCG
14
Q
If the combined test is positive/baby is high risk for or chromosomal abnormalities e.g. Down’s, Patau’s, Edwards, what further two tests can be offered and when?
A
Chorionic villus sampling at 11-14w: safer than amnio
Amniocentesis at 15- 20w: risk of miscarriage, infection, pre-term labour
15
Q
What is the scan at 18-20 weeks looking at?
A
Anomaly scan: looking for foetal abnormalities like spina bifida or anencephaly.
16
Q
Rhesus haemolytic disease has occurred in this women’s pregnancy. Is she rhesus + or - and is the foetus rhesus + or -?
A
Foetus: rhesus + (DD/Dd)
Mother: rhesus - (dd)
Mother creates anti-D antibodies to foetus which cross placenta and destroy foetal RBCs (haemolytic anaemia )
17
Q
How can you prevent rhesus haemolytic disease from occurring?
A
Give anti-D to rhesus -ve mothers at 28w
18
Q
What are some maternal complications of multiple pregnancy? (3)
A
Polyhydramnios Pre-eclampsia APH and PPH Instrumental delivery Anaemia- increased iron and folate requirements Gestational Diabetes Placental abruption
19
Q
What are some foetal complications of multiple pregnancy? (3)
A
Foetal mortality
Growth restriction
Prematurity
Malformations
20
Q
What is the risk in monochorionic twins?
A
They share placenta: risk of foeti-foetal transfusion: blood flow doesn’t flow evenly between them
21
Q
What is the cause of polyhydramnios and what are some risk factors?
A
Due to increased foetal urination and decreased foetal swallowing
RF: multiple pregnancy, trisomy 18 & 21, diabetes, oesophageal atresia of foetus
22
Q
How is polyhydramnios treated?
A
Serial ultrasounds
Maternal steroids
May consider indomethacin or drainage
23
Q
What is the definition of small for gestational age and what are some risk factors (3)?
A
Symphysial fundal height <10th gentile for their gestational age. RF: maternal smoking, multiple pregnancy, maternal age >40, pre-eclampsia, previous SGA baby
24
Q
What are some risks of SGA baby?
A
Prematurity, foetal distress and meconium aspiration, foetal mortality (hypoxia), cerebral palsy
25
What is the definition of intrauterine growth restriction and what are some risk factors? (3)?
IUGR: estimated foetal weight <10th centile - slow growth.
RF: maternal smoking, alcohol & drugs, pre-eclampsia, maternal conditions eg. renal failure, IBD, CF, asthma , multiple pregnancy
26
What investigations are done in a foetus with IUGR?
```
Serial abdo circumference- SFH
Serial Ultrasound scans
CTG - assessment of cardiac oxygenation
Amniotic fluid index
Regular umbilical artery doppler- if reversed/absent end diastolic flow = may need C-section and steroids
```
27
What is the definition of small for dates?
Foetus with birth weight <10th centile on customised growth charts
28
What is the definition of large for dates and how is it measured?
Weight >90th gentile on customised growth chats
| Measure with SFH and serial US
29
What is the main risk factor for large for dates/foetal macrosmia and what is the main complication?
Gestational diabetes , polhydramnios
| Risk of shoulder dystocia- may need C section if baby >4.5kg
30
Heather is a 30 year old woman. She is currently experiencing lower abdominal pain and vaginal bleeding. Her last period was 14 weeks ago, and she had a positive pregnancy test 12 weeks ago. What is the diagnosis?
Miscarriage: loss of pregnancy <24w
31
What are the features of a threatened miscarriage? Is cervical os open or closed?
Mild painless bleeding, cervical os closed. 75% settle themselves.
32
What are the features of a inveitable miscarriage? Is cervical os open or closed?
About to miscarry- either after threatened or by itself. Heavier bleeding with clots. Cervical os is OPEN.
33
What are the features of a incomplete miscarriage? Is cervical os open or closed?
Most POC passed, some left in uterus. Cervical os is open. May need dilation and curettage.
34
What are the features of a complete miscarriage? Is cervical os open or closed?
All POC passed, US: empty cavity. May be bleeding and labour like cramps. cervical os is closed
35
What are the features of a missed miscarriage? Is cervical os open or closed?
Foetus has died but remains in uterus. TVUS: foetal pole large and no foetal heart activity. May have had a past bleed. Cervical os is closed.
36
What are the features of a septic miscarriage?
Infected contents of uterus- painful uterus, peritonism signs (swelling abdo, pain).
37
Heather is a 30 year old woman. She is currently experiencing lower abdominal pain and vaginal bleeding. Her last period was 14 weeks ago, and she had a positive pregnancy test 10 weeks ago.
Heather’s cervix is open and she is having an inevitable miscarriage.
Obs: BP 90/58, HR 105, RR 20, Temp: 36.9
What is your initial management?
ABCDE
| Profuse bleeding: IM ergometrine
38
What are the options for treatment of a miscarriage?
Expectant: wait 7-14 days for miscarriage to complete itself.
Medical management: if expectant doesn't work/pt preference: vaginal misoprostol
Surgical: suction/theatre if heavy bleeding, infection, severe pain. Give anti-D
39
Katrina was diagnosed with endometriosis. She underwent laparoscopy with surgical ablation and now takes ibuprofen for pain.
A year later, she presents to A&E with abdominal pain and some vaginal bleeding. She has vomited a few times. She is sexually active and her last period was 8 weeks ago.
What is the diagnosis?
Ectopic pregnancy
40
What is the most common site for implantation in ectopic pregnancy?
Ampulla of Fallopian tube
41
What are some risk factors for ectopic pregnancy?
PID, previous ectopic, endometriosis, surgery to tubes eg. tubal ligation, IVF, smoking
42
What are the symptoms of ectopic pregnancy?
Abdo pain- unilateral (LIF), colicky then constant
Dark PV bleeding
N&V
Syncope
Shoulder tip pain - bleeding irritates phrenic nerve
43
What are some signs of ectopic pregnancy?
Cervical excitation
Pelvic tenderness
Hypotension , tachycardia
44
Katrina was diagnosed with endometriosis. She underwent laparoscopy with surgical ablation and now takes ibuprofen for pain.
A year later, she presents to A&E with abdominal pain and some vaginal bleeding. She has vomited a few times. She is sexually active and her last period was 8 weeks ago.
What investigations might you do?
Bloods- FBC, U&E, group and save, beta HCG (high)
Pregnancy test
TVUS - no intrauterine pregnancy
this is an ectopic
45
What are the options for treatment of ectopic pregnancy?
Expectant: mild symptoms, beta-HCG is low and falling. Do serial beta HCGs
Medical: methotrexate 1 dose. CI: live ectopic.
Surgical: symptoms, very high beta HCG. Laprascopic salpingectomy if other tube is healthy or salpingotomy if other tube is not healthy/retain fertility
46
What are some risk factors for hyperemesis gravidarum
RF: multiple pregnancy, molar pregnancy, previous hyperemesis gravidarum
47
A pregnant lady in her 14th week gestation presents complaining of severe nausea and vomiting. She says its been getting so bad she's unable to eat or drink anything at all. She says she's tried eating small amounts and tried having ginger but nothing has helped. She also describes feeling dizzy. On examination- she has dry mucous membranes, is hypotensive and has reduced skin turgor. How are you going to manage this?
Hospital admission for IV fluids - normal saline with potassium or hartmann's
Anti-emetics- promethazine/cyclizine
Thiamine replacement IV in hospital
This is hyperemesis gravid arum
48
What are the two types of gestational trophoblastic disease?
Molar pregnancy
| Choriocarcinoma
49
What happens in a molar pregnancy?
Abnormal fertilised egg implants in uterus. The cells proliferate without control and take over--> instead of foetus, get a mass of abnormal cells (trophoblast) which produce beta hCG as derived from chorion.
50
How do you investigate (what would you see) and treat molar pregnancy?
beta- HCG raised and US- snowstorm appearance of swollen villi and moles
Tissue is removed with gentle suction
51
How do you diagnose pre-eclampsia?
HTN: BP >140/90
Proteinuria: 0.3g/24h
52
What are some risk factors for pre-eclampsia?
Diabetes, previous pre-eclampsia, previous HTN, renal disease eg. CKD, FMH
53
What investigations do you want to do in a patient with pre-eclampsia?
Dipstick for proteinuria
FBC, U&E, LFTs, clotting
TVUS
54
How do you treat pre-eclampsia (mild, moderate, severe)?
Mild: regular blood tests- FBC, U&E, LFTs, foetal scans , regular BP
Moderate: treat if BP >150/100= labetalol
Severe: labetalol (2nd line=nifedipine), Mg sulphate as prophylaxis for pre-eclampsia
55
What can you give to patients with a high risk of pre-eclampsia eg. past history/FMH?
Aspirin from 12s
56
A lady comes in with known pre-eclampsia and has been monitored throughout with regular blood tests and blood pressure checks. Today she has come to A&E as she's got a very bad headache, feels drowsy, her vision has blurred and she's had 2 seizures where she has fallen to floor and her arms have gone stiff and shook. What's happened and how are you going to treat?
Eclampsia
| Magnesium sulfate IV
57
What does HELLP syndrome stand for and when does it occur?
Complication of pre-eclampsia
Haemolysis + elevated liver enzymes + low platelets
causes RUQ pain
58
How do you treat HELLP syndrome?
Deliver if >34 weeks
| Tranfuse Hb, platelets , FFP
59
What are the cut offs for gestational hypertension diagnosis? and how to treat?
BP >140/90
| lifestyle, if need meds: oral labetalol
60
What tests can be done to diagnose gestational diabetes?
Random fasting glucose >7
| 2 hour OGTT at 28w (if RF)= >8.5
61
What are some risk factors for gestational diabetes? What test will you do for those with risk factors?
```
FMH of GD
Previous GD in prev pregancy
Increased BMI
Ethnicity -SA, carribean
increasing age
```
OGTT at 28weeks
62
What are some foetal complications of gestational diabetes?
Macrosomia
Shoulder dystocia
Congenital abnormalities e.g.neural tube and cardiac
Post natal: hypoglycaemia (baby is accustomed to hyperglycaemia), jaundice
63
What are some maternal complications of gestational diabetes?
```
Pre-eclampsia (and risk of HELLP)
Birth trauma and instrumental delivery
Hypoglycaemia
Retinopathy
Post natal: increased risk of T2DM, hypoglycaemia
```
64
A pregnancy lady has an OGTT at 28 weeks due to having previous gestational diabetes in her last pregnancy. Her value comes back at 9 and her fasting plasma glucose is 7.5mmol/L. Foetal US has shown the baby to have a large head. What treatment are you going to offer?
Start insulin straight away as OGTT >8.5 and fasting plasma glucose >7 with foetal macrosmia.
65
What are the options for treatment of gestational diabetes?
First line: lifestyle- diet, exercise, weight loss
If >2 weeks and no change: insulin
Metformin only if CI to insulin
66
What are the TORCH infections?
Infections of foetus - toxoplasmosis, other- syphillis, varicella zoster, parvovirus B19, rubella, CMV and herpes
67
What complications to the foetus occur with CMV infection?
IGUR, hydrocephalus, motor and sensory impairment, deafness
68
How do you prevent herpes zoster infection travelling from mother to neonate?
Give baby varicella immune immunoglobulin (VIZG) at birth. C-section if within 6 weeks of onset.
69
What complications to the foetus occur with rubella infection?
Cataracts, deafness, cardiac disease, low IQ
70
How do you treat syphillis infection in mother/neonate?
IM Benzylpenicillin
71
What symptoms occur with toxoplasmosis infection?
Rash + sore throat + fever
72
How is vertical transmission of group B strep prevented in labour?
IV benzylpenicillin in labour
73
What are risk factors for group B strep sepsis? (2)
Prolonged rupture of membranes
Prematurity
Previous Group B strep infection
74
What foods can lead to listeria infection?
Soft cheeses, milk, pate
75
What foetal signs may occur with listeria infection?
respiratory distress, convulsions, premature labour
76
What are the signs of measles in neonate?
Generalised erythematous maculopapular rash, Koplik spots, conjunctivitis, cough
77
Can HIV positive mothers breastfeed?
No
78
What treatment should be started in a HIV positive mother?
HAART- highly active retroviral therapy from 28w till labour
79
Can a HIV positive mother have normal labour?
If viral load is <50 copies : yes
| If viral load >50: elective C section
80
What can be given to a newborn with a HIV positive mother?
Zidovudine or HAART
81
A pregnant lady comes in complaining of new onset calf pain. It started this morning in her left calf and has been getting worse. On examination the left calf looks red, hot, swollen and tender on palpation. She has no shortness of breath and chest pain at present. How will you investigate and treat?
```
DVT
Bloods: FBC, U&E, LFTs, clotting
D-dimer
Imaging: Duplex US scan of left leg
Treatment: LMWH eg. enoxaparin or dalteparin
```
82
A pregnant lady comes in complaining of new onset SOB and chest pain worse on breathing in. She also has noticed a new cough and has coughed up blood once. She has no leg tenderness or swelling of the legs at present. How will you investigate and treat?
```
PE
Bloods: FBC, U&E, LFTs, clotting
D-dimer
Imaging: 1. CXR, 2. VQ scan/ CTPA
Treatment: LMWH eg. enoxaparin or dalteparin
```
83
How long will you continue LMWH treatment in pregnancy for DVT/PE
Through pregnancy, stop it for labour and re-start after or change to warfarin after
84
What are the complications of uncontrolled severe asthma in a pregnant woman?
Preterm labour
| Foetal growth restriction
85
An indian origin pregnant woman comes to antenatal clinic with a worsening cough. She says its been ongoing for 6 weeks and has noticed herself coughing up blood a couple of times. She thinks she may have lost some weight even though she's been eating ok and is waking up in the night sweating frequently. What investigations are you going to do given the diagnosis?
```
TB:
Mantoux test (tuberculin skin test)
Sputum culture for acid fast bacilli (ZN stain)
Interferon gamma
CXR
```
86
How do you treat TB?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
+ Pyridoxine (reduce risk of peripheral neuropathy with isoniazid)
2 months all of them, 4 months just rifampin and isoniazid
87
A pregnant lady comes into clinic complaining of going to the toilet more often than usual. She has also noticed some burning on urination and this is not normal for her. She feels well otherwise and her obs are stable, What investigations are you going to do and how will you treat?
Bedside: urine dipstick- leukocytes and protein, MSU send for MC&S
Bloods: FBC, U&Es!- creatinine, LFTs
Tx: nitrofurantoin (unless at term - then cefalexin)
88
A pregnant lady comes into clinic complaining of going to the toilet more often than usual. She has also noticed some burning on urination and this is not normal for her. She also is complaining of some pain in her abdomen that goes round to the back and has felt quite feverish later. On examination she is tachycardic and looks sweaty. What investigations are you going to do and how will you treat?
```
Admit - unwell.
Bedside: urine dipstick, MSU for MC&S
Bloods: FBC, U&Es- creatinine, eGFR, blood cultures
Imaging: may do renal US
Abx: IV cefuroxime
```
89
Can anti-epileptic drugs be continued in pregnancy and labour?
Not sodium valporate
Can continue carbemazepine and lamotrigine at lowest dose possible in preg and labour and post partum- increase back to usual dose
90
Why does obstetric cholestasis occur?
increased oestrogen reduce bile salt uptake by hepatocytes
91
What symptoms and what would you find on blood tests in a patient with obstetric cholestasis?
```
Intense pruritus (no rash) worse at night
Bloods: FBC, U&E, clotting, LFTs- cholestatic picture (ALP >ALT raised), raised bilirubin
```
92
How do you treat obstetric cholestasis?
Vitamin K
Ursodeoxycholic acid for itching
induce labour at 37-38w
93
What scale can be used to assess a patient for post-natal depression?
Edinburgh post natal depression scale
94
How do you treat post-natal depression?
CBT and interpersonal therapy
| If symptoms persist: sertraline
95
How do you treat post partum psychosis?
Need admission to hospital for specialist input
Therapy , reassurance
Antipsychotics- 2nd generation eg. risperidone and antidepressants
96
A pregnant lady of 26 weeks gestation has come in with vaginal bleeding to A&E. Her bleeding started an hour ago and has not stopped and is very heavy. How are you initially going to manage her?
ABCDE
Full set of observations
Cannulate- large bore, IV fluids, bloods- FBC, U&E, clotting, group and save
Consider ergometrine if bleeding heavy
Examination for cause eg. abdominal
TVUS eg. if cause is placenta praevia/abruption and then vaginal exam
CTG
97
Why do you never perform vaginal exam in patients with heavy PV bleeding after 24w?
If placenta praevia- it will cause massive bleeding! Need TVUS first
98
A 43 year old pregnant lady of 26 weeks gestation has come to A&E presenting with painless intermittent PV bleeding. She has no abdominal pain and denies any other symptoms at all. Her recent scan with the midwifes show her baby to be in a breech position. What is the likely diagnosis?
Placenta praevia- intermittent painless PV bleeding + abnormal lie of baby
RF: maternal age >40, prev C-section, multiparity, multiple pregnancy
99
What is the difference between major placenta praevia and minor?
Major: placenta is impacted in lower segment of uterus covering os
Minor : placenta impacted in lower segment of uterus NEAR os
100
What are some complications of placenta praaevia?
Major haemorrhage that can continue post partum
Transverse lie
Operational delivery/labour complications
Placenta accreta esp if prev C-section (placenta adheres to uterus)
101
After initial A-E assessment, how do you treat placenta praaevia? (delivery)
C-section if major
| Try for normal delivery with minor unless placenta impacted within 2cm of os
102
A pregnant lady of 26 weeks gestation comes in complaining of painful vaginal bleeding. It started this morning and hasn't stopped and is accompanied by abdominal pain. You do an abdominal examination and the uterus feels 'woody and hard'. Her obs show her to have a very low BP and very high RR and HR. Given the likely diagnosis, what is your initial management going to be?
```
Placental abruption
Management:
-Admit
-ABCDE
- Cannula- large bore, IVF
- Bloods- FBC, U&E, clotting, cross match
-Blood transfusion
- Analgesia
- Catheterise
-TVUS!!
-Foetal CTG
```
103
How would you decide whether a patient with placental abruption needs C-section or not?
Based on foetal distress: if foetal distress -C section. If not but >37w= induce with amniotomy.
104
What is the main complication with placental abruption in mother?
DIC !
105
What is vasa praevia and how does it cause foetal haemorrhage?
vasa praevia is when a foetal blood vessel runs in the membranes before presenting part and umbilical cord attaches to these membranes
Wen membranes rupture in labour, this foetal blood vessel ruptures causing foetal haemorrhage
106
A 26 week gestation pregnant woman has PV bleeding which is painless. When you ask her when it started she says it only started as soon as her water broke. CTG shows some foetal bradycardia but the mother is stable and well. What is the likely diagnosis?
Ruptured vasa praevia - painless PV bleeding at ROM (spontaneous- water breaking or amniotomy)
107
How do you treat ruptured vasa praevia ?
C-section
108
What occurs in placenta accreta, increta and percreta and how are they treated if diagnose before birth?
Accreta: abnormal adherence of placenta to uterus
Increta: infiltration of myometrium
Percreta: infiltration through uterus into other structures eg. bowel/ bladder
Tx is with C-section and hysterectomy if diagnosed before birth on USS
109
What happens in the first stage of labour?
Latent: cervix dilates 0-3cm. Irregular contractions every 5-10mins
Active: cervix dilates 3-10cm (full dilation) at 1cm per hour. Regular contractions.
110
What happens in the 2nd stage of labour?
Lasts from full cervical dilation to birth
Get descent, flexion and internal rotation as well as extension- can see head
Passive: head reaches pelvic floor, woman has uncontrollable desire to push.
Active: mother is pushing
111
What happens in 3rd stage of labour?
Delivery of the placenta.
| Active management here: oxytocin, early cord clamping and controlled cord traction to reduce PPH risk
112
What are the 7 steps the foetus goes through to be delivered?
```
Engagement as head enters pelvis
Descent
Flexion - for easy passage into pelvis
Internal rotation - head rotates in 90 degrees so face faces sacrum
Extension
External rotation/restitution
Expulsion
```
113
What are some indications for induction of labour?
Prolonged pregnancy- 12 days post due date
Baby growth problems eg. IUGR, APH
Maternal medication conditions e.g. pre-eclampsia, gestational diabetes
114
What are some contraindications for induction of labour?
Malpresenation
| Foetal distress
115
What score can be used to decide if induction of labour is needed? What value is the cut off?
Bishop's score
| Score <5= labour is unlikely to progress on it's own and likely needs induction
116
What are the options for induction of labour?
Membrane sweep
1. Vaginal prostaglandin gel/pessary - max 2 doses
2. Amniotomy (ARM) +/-oxytocin (start 2 hours after if no success with amniotomy)
Can use oxytocin alone if SROM
117
What are some complications of induction of labour?
```
Infection
Foetal distress
Increased risk of instrumental delivery/CS
Prematurity
PPH
```
118
What are some side effects/complications from using an epidural in labour?
```
Longer labour
Increased risk of instrumental delivery
Loss of bladder control
HYPOTENSION
Foetal tachycardia
```
119
What are some risk factors for abnormal foetal presentations?
```
Prematurity
Large baby
Uterine problems eg. fibroids
Maternal smoking
Multiple pregnancy
Polhydramnios/oligohydramios
2nd baby
```
120
A 28 week gestation pregnant woman comes to clinic and a foetal US has shown her baby is breech. What do you tell her?
Just to wait and see until 36w- it might turn by itself
121
A 38 week gestation pregnant woman comes to clinic and a foetal US has shown her baby is breech. What do you do?
External cephalic version- try and turn the breech if waters broken.
If this doesn't work: C-section or vaginal delivery- but increased risk of birth trauma
122
What is an occiput-posterior foetal malpresentation ? and how might you treat?
Baby is back to back so can't feel it's back
| Tx: rotational forceps to OA
123
What is an occiput-transverse foetal malpresentation? What can you feel? And how might you treat it?
Foetal head is lying on side - can palpate the sutures and fontanelle
Tx: ventouse to rotate
124
What happens in a brow presentation? What can you feel? How do you treat?
Full extension or flexion of neck (usually chin tucked, neck slightly extended). Can feel anterior fontanelle, supraorbital ridge and nose. C-section
125
What happens in a face presentation? What can you feel? How do you treat?
Full extension of neck. Mouth, nose and eyes are palpable. Likely need C-section.
126
What are some indications for instrumental delivery?
```
Prolonged 2nd stage
Maternal exhaustion
Maternal conditions preventing proper pushing eg. cardiac , paraplegia
Suspected foetal distress
Breech delivery
```
127
What are the complications of forceps delivery?
Maternal mainly- genital tract trauma eg. vaginal tears. Can get rotational or non-rotational forceps.
128
What are the complications of ventouse delivery?
Foetal mainly eg. chignon - little swelling on scalp that should disappear, cephalohaemoatoma , retinal haemorrahges
129
What are some indications for C-section?
```
Previous vertical C-section
Foetal compromise eg. cord prolapse
Prolonged labour
Malpresentation
Pelvic deformity
```
130
What type of breech presentation is most common and which type is most associated with cord prolapse?
Extended: hips flexed, knees extended. most common.
| Footling- legs underneath bum - one leg hangs down. cord prolapse
131
Which type of C-section is associated with less bleeding and adhesions? lower segment CS or classic SC?
LSCS- transverse incision
| Classic - only if huge fibroids/extreme prematurity.
132
A woman has just given birth to a lovely baby boy. The boy is fit and healthy and she will be taken to recovery once the placenta has been delivered. However it's been 80 mins now and the placenta has yet to be delivered. What are you going to do?
Retained placenta is an emergency!
| Treat with IM syntocinin to stimulate uterine contractions. Or manually remove it.
133
What is the most common cause of retained placenta?
Uterine atony
134
A woman in her 35th week gestation (3rd trimester) presents to A&E with severe abdominal pain and PV bleeding. She is tachycardic and hypotensive. CTG is showing foetal distress. You find out her last 3 children were C-sections. What could be the diagnosis?
Uterine rupture!
135
What is the most common cause of uterine rupture?
Due to dehiscence of C-section scar--> maternal haemorrhage and foetal distress as it is forced out the rupture
136
How do you treat uterine rupture?
```
ABCDE
IV fluids
O2
Analgesia
Bloods- FBC, U&E, clotting, cross match
Transfuse
DELIVER BABY= C-Section
If rupture is small - repair
If big - in cervix/vagina= hysterectomy
```
137
What happens in cord prolapse?
Cord descends below the presenting part --> vasospasms-->foetal hypoxia --> damage (Cerebral palsy) or death
138
What are risk factors for cord prolapse?
Anything that stops engagement of head:
- Prematurity
- Breech
- Abnormal foetal lie
- Polyhydramnios
- Praevia
- Second twin
139
How do you manage cord prolapse definitively? And what can you do to manage to vasospasm of cord?
Usually need C-section or instrumental vaginal delivery (only if fully dilated at 10cm)
If cord is below level of Introits: push it back in with finger
If above: leave it alone
Give terbutaline or nifedipine - reduces contractions
140
What are some complications of shoulder dystocia- foetal and maternal?
Foetal: hypoxia and asyphxia, Erb's palsy C5, C6, C7--> waiter's tip presentation, hypoxic ischaemic encephalopathy ,fractured clavicle
Maternal: bladder/ureter rupture, PPH, perineal tears
141
How would you manage shoulder dystocia?
McRoberts manœuvre to increase angle of pelvis, apply suprapubic pressure to try displace shoulder.
If fails: episiotomy + internal manoeuvres eg. Woodscrew manoevouer
142
Uterine inversion is a rare obstetric emergency where the uterus fundus collapses into the endometrial cavity turning it inside out. If you did see it- how might the mother present and how would you treat?
Mother presents with shock and haemorrahge
| Tx: 1. push fundus up manually with terbutaline to relax the uterus. 2. infuse warm saline into the vagina.
143
What happens in amniotic fluid embolism?
A rare birth complication where foetal cells/amniotic fluid enter mother's blood stream and there is an anaphylaxis reaction to it
144
How does a patient present with an amniotic fluid embolism?
Maternal chest pain, SOB, resiratory distress, tachycardia, hypoxia, palpitations
145
How do you treat an amniotic fluid embolism?
```
ABCDE
Oxygen
IV fluids
Analgesia
Bloods- FBC, U&E, clotting, cross match
Correct clotting abnormalities - get DIC picture so need FFP/blood
DELIVERY OF BABY - C/S
```
146
Before what week is a baby classed as premature and what complications are associated with prematurity?
<37w
Associated: developmental delay, cerebral palsy, visual problems, infections of placenta/cord, infections of foetus, genital infections eg. UTI of mum
147
What tests can be done to predict risk of prematurity?
Foetal fibronectin test- if found in vaginal fluid- likely premature
148
What treatment can be offered to help reduce complications associated with prematurity?
IV benzyl penicillin - reduce risk of infection
| Steroids eg. betamethasone and nifedipine- reduce risk of RDS
149
After what week is baby classed as 'postmature' and what complications are associated with post-maturity?
>42w
Associated: neonatal death, instrumental delivery, foetal distress, maternal death, placental insufficient, meconium aspiration syndrome
150
How do you manage post-maturity?
Induction! - membrane sweep, prostaglandin gel/pessary, oxytocin if SROM, amniotomy +/-oxytocin
151
What are the two methods of foetal monitoring?
Intermittent asuculatiation via US doppler
| CTG continuous monitoring
152
What does the Dr stand for in Dr C Brvado in CTG foetal monitoring?
Dr- define Risk factors eg. prematurity, post-maturity, induction , C-section, pre-eclampsia
153
What does the C stand for in Dr C Brvado in CTG foetal monitoring?
Contractions- Hyperstimulation is over 5 contractions in 10 mins
154
What does the Br stand for in Dr C Brvado in CTG foetal monitoring?
Baseline rate: normal is 100-160
Bradycardic: <100 associated with hypoxia
Tachycardia >160- associated with maternal pyrexia, hypoxia
155
What does the V stand for in Dr C Brvado in CTG foetal monitoring?
Variation. Decreased variations (<5bpm): foetal hypoxia (>40min of decreased variability), foetus sleeping (<40 min of decreased variation).
156
What does the A stand for in Dr C Brvado in CTG foetal monitoring?
Accelerations: accelerations in foetal heart rate with movement or contractions is reassuring.
157
What does the D stand for in Dr C Brvado in CTG foetal monitoring?
Decelerations: decelerations early with contractions = normal. decelerations with contractions = can be associated with cord compression. decelerations AFTER contractions= foetal hypoxia!
158
What does the O stand for in Dr C Brvado in CTG foetal monitoring?
Overall assessment
159
How do you grade perineal tears?
1st degree: perineal skin and vaginal epithelium
2nd degree: perineal skin and muscles
3rd degree: perineal skin and muscles AND anal sphincter
4th degree: skin, muscles, anal sphincter and rectum epithelium
160
A woman has just given birth to a lovely baby girl. However 2 hours after she is still bleeding and has lost about 800ml of blood now. What is the likely diagnosis and how are you going to treat initially?
Primary PPH- loss of >500ml of blood in 24h
Treat:
ABCDE
IV fluids, oxygen, bloods- FBC, U&E, clotting, cross match
Blood transfusion if needed
Compression of uterus manually to stimulate contractions to stop bleeding
IV syntocinon/IV or IM ergometrine
Remove any retained products of conception
161
What are the surgical options to treat PPH?
B Lynch compression sutures for c-section
Rusch balloon- inflate balloon to create pressure on uterus - for vaginal
Internal iliac/uterine artery ligation
162
What are the causes of primary PPH?
```
4 T's
Tone- uterine atony from prolonged labour, multiparty
Trauma- perineal tears/episiotomy
Tissue- retained products of conception
Thrombin - clotting disorders eg. DIC
```
163
A woman comes into clinic having given birth 2 weeks ago. She is describing heavy PV bleeding that started once she got home (2 days after giving birth). She also is describing some fevers and some abdominal pain. What is the likely diagnosis?
Secondary PPH likely due to endometritis from retained products of conception.
164
What investigations would you do in a patient with secondary PPH?
Bedside: urinalysis, vaginal swabs
Bloods: FBC, U&E, clotting, group and save, blood cutures
Imaging: ULTRASOUND to look for retained products of conception
165
How would you treat secondary PPH due to retained products of conception causing endometritis?
Antibiotics
| Remove retained POC
166
What happens with the uterus size and uterus discharge in the 6 weeks following birth (puerperium)?
Uterus size decreases
Discharge:
Lochia rubra- red discharge (blood) till day 3, then lochia serosa (yellow), then lochia alba (white)
Only US if lochia persists >6w
167
What happens with the breasts/lactation in the 6 weeks following birth (puerperium)?
Breasts produce colostrum from last trimester to day 3-yellow fluid with fat, protein, minerals
At day 3- start producing milk.
168
What hormones control production and ejection of breastmilk?
Production : prolactin from anterior pituitary
| Ejection: oxytocin from posterior pituitary
169
How do you reduce the risk of postnatal DVT/PE?
Encourage early mobilisation and hydration
| Prophylactic LMWH
170
What is the peak time for 'baby blues'?
3-7 days following birth. doesnt last longer.
