Obstetrics and Gynaecology Flashcards
What is the definition of term?
Term 37-40 weeks
Full term 40 weeks
Post term 40-42 weeks
Pre term <37 weeks
What are the causes of pre-term birth?
Iatrogenic causes - FGR, pre-eclampsia, etc
Spontaneous - ruptured membranes/spontaneous labour, recurrent in future pregnancies, can lead to pregnancy loss or neonatal death, preventable with interventions, modifiable outcomes (steroids, magnesium, place of birth)
What are the different stages of labour?
Labour - 1st Stage
Primigravida 8-18 Hours, multigravida 5-12 hours
Latent phase - a period of time, not necessarily continuous when -
There are painful contractions AND
There is some cervical change, including cervical effacement and dilation up to 4cm
Active phase/established
There are regular painful contractions AND
There is progressive cervical dilatation from 4cm
Labour - 2nd Stage
Passive 2nd stage - full dilatation of the cervix before/in the absence of involuntary expulsive contractions
Active 2nd stage - full dilatation and expulsive contractions/active maternal effort to delivery of the foetus
Labour - 3rd Stage
Time from birth of the baby to the expulsion of the placenta and membranes
What are the three P’s of pathological labour?
Passage
This relates to the shape of the pelvis
There can be racial differences in pelvic shapes and it can also be affected by previous pelvic fractures or pathology causing obstruction such as a large cervical fibroid or pelvic tumour
Powers
This relates to uterine contractions
Effective coordinated contractions are required to efface and then dilate the cervix and then allow expulsion of the foetus
Passenger
This relates to the foetus
Variables include the size of the foetus, what part of the foetus is presenting and what position the presenting part is in
Firstly the foetal head descends and flexes, then rotates through 90 degrees and then delivers by extension
This is to help facilitate the smallest diameters of the foetal head presenting to the largest diameters of the female pelvis
Describe how the foetus moves through he birth canal during a normal labour ?
Engagement
The foetal head engages in the pelvis in the transverse position often some weeks before labour starts
Descent and Flexion
The foetal head descends into the vagina through the dilated cervix during the second stage of labour
To aid delivery the foetal head flexes to present a smaller diameter to the true pelvis
Internal Rotation
As the foetus descends it rotates to an occipito-anterior position (OA)
Extension
As the foetal head hits the sacrum it climbs up the sacral curve by extension of the neck
Restitution
The foetal head (now external to the mother) returns to the transverse position in line with the foetal shoulders
External Rotation
The foetal shoulders corkscrew to come under the symphysis pubis and allow delivery of the torso
What are the options for pain relief in labour?
Maternal choice should always be paramount for analgesic choice
Coping strategies - breathing and relaxation techniques, massage techniques, water
Non-pharmacological analgesia - transcutaneous electrical nerve stimulation (TENS) - do not offer in established labour
Inhalational analgesia - Entonox (50:50 mix of O2 and NO)
Opioids - pethidine, diamorphine
Regional anaesthesia - epidural or combined spinal-epidural
What pharmacological or non-pharmacological agents could be used to induce labour?
Non-Pharmacological: Cervical dilatation - balloon catheter or osmotic dilators
Pharmacological: Prostaglandins
Artificial rupture of membranes (ARM)
Oxytocin infusion
What are the 2 different management options for the 3rd stage?
Active Management
Uterotonic drugs (oxytocin 10IU IM)
Deferring clamping and cutting the cord
Controlled cord traction (CCT) after signs of placental separation
Prolonged if >30 mins
Physiological Management
No uterotonic drugs
No clamping of the cord until pulsation has stopped
Delivery of the placenta by maternal effort
Prolonged is >60 mins
What is the APGAR score?
Forms an assessment of foetal neonatal wellbeing and scored from 0-10
A - Appearance:
0 = Blue all over
1 = Blue extremities
2 = No blue colouration
P - Pulse
0 = No pulse
1 = <100
2 = >100
G - Grimace
0 = No response to stimulation
1 = Grimace when stimulated
2 = Sneezing, coughing or pulling away when stimulated
A - Activity
0 = No movement
1 = Some movement
2 = Active movement
R - Respiration
0 = No breathing
1 = Weak, slow or irregular
2 = Strong
What is considered normal progress in the different stages of labour?
0.5cm per hour is the minimum acceptable progress
What are the complications of unrecognised slow progress?
Foetal acidemia, postpartum haemorrhage and uterine rupture
What are the complications of Caesarean section?
Intrapartum/postpartum haemorrhage (common)
Bladder injury and rarely bowel (rare)
Deep vein thrombosis (significantly increases risk)
Pain and reduced mobility
Infection - would or endometritis (common)
What are the complications of instrumental delivery?
Postpartum haemorrhage (common)
Perineal pain (common)
Infection (common)
Perineal injury - episiotomy (common) or anal sphincter (uncommon 2%)
Foetal injury - scalp or face (rarely serious)
What is the management of postpartum haemorrhage?
ABCDE - call for help (2222)
Oxygen
Flatten bed
Uterine massage and bimanual compression
Observations - urine output, temperature, pulse, oxygen saturations
2x large bore IV cannulae
Bloods - FBC, U&E, LFT (preeclampsia), ABG
IV fluids - crystalloids (warmed if possible)
Consider blood transfusion - o negative if urgent or await type specific or crossmatched
Uterotonics - oxytocin bolus or infusion, ergometrine, carboprost (misoprostol)
Procoagulants - tranexamic acid (1g), clotting factors
Surgical procedures - B-Lynch sutures, Bakri balloon, hysterectomy
What are the risk factors for spontaneous pre-term birth?
Previous preterm birth
Uterine anomaly
Previous knife cone biopsy (and previous cervical cancer, likely HPV infection)
Previous early miscarriage (smaller effect size)
Smoking
Extremes of BMI
Extremes of maternal age
Inter-pregnancy interval under 18 months
Previous second stage Caesarean section (when 10cms dilated)
Previous mid-trimester loss (also known as ‘late miscarriage’ but this term is often not as acceptable to patients)
Previous surgical management of miscarriage or surgical termination of pregnancy
Socio-economic deprivation (and potentially pollution exposure)
What are the maternal complications of pre-eclampsia?
Abruption
Stroke
Seizure - eclampsia
Cerebral haemorrhage
Disseminated intravascular coagulopathy (DIC)
What are the foetal complications of pre-eclampsia?
Stillbirth
Iatrogenic preterm delivery
Foetal growth restriction
What are the long term risks of pre-eclampsia?
Persistent hypertension after pregnancy
Increased risk of later life hypertension and CVS disease
Recurrence in future pregnancies - aspirin can reduce risk
What blood tests are performed at 8-12 weeks?
FBC - to detect anaemia - should be repeated at 28 weeks in a singleton pregnancy
Blood group - to identify the blood group and Rhesus status to determine if anti-D may be required
Haemoglobinopathies - performed in conjunction with family origin questionnaire
Infection screen - HIV, Hep B, syphilis
Other blood tests may be performed depending on the patients PMH
What scans are performed in ante-natal care?
The dating scan
Performed between 8-14 weeks to date the pregnancy and produce the estimated date of delivery
If the first scan is performed as part of the combined test - it will be undertaken between 11.0 and 13+6 weeks
Looks for viability, confirm intrauterine pregnancy, estimated date of delivery (EDD) by measurement of the crown rump length (CRL) of the foetus, single/multiple pregnancies and neural tube defects
The anomaly scan
Performed between 18+0 and 20+6 weeks
The purpose of the scan is to identify foetal anomalies
This will allow parents to make reproductive choices, make preparation for treatment after delivery, plan delivery in a tertiary setting, identify if intrauterine procedures may be needed
Limitations to routine scanning include different conditions of foetus, maternal BMI and foetal position can also affect detection rates
The NHS foetal anomaly screening programme (FASP) identify the images that must be taken at an anomaly scan and provide data on the detection rates of different conditions
What supplements should be taken in pregnancy?
Folic acid is recommended for women planning to conceive and to be continued for the first 12 weeks of pregnancy to prevent neural tube defects - recommended dose is 400mcg
Women should be advised to take vitamin D supplements (10mcg) during pregnancy which can be found in most multi-vitamins - especially for women with darker skin and who have less exposure to sunlight
Iron is not recommended as routine in the pregnancy unless iron deficiency is suspected
Women should be advised that vitamin A should be avoided
How should nausea and vomiting be managed in pregnancy?
Nausea and vomiting are common in early pregnancy, symptoms usually subside by 16- 20 weeks
Dietary advice can be given
Non-pharmacological preparations - such as ginger
Antiemetics can be given - such as cyclizine and stemetil
In severe sickness (hyperemesis) hospital admission may be required for rehydration
In extreme situations when sickness is prolonged and does not respond to treatment, steroids can be considered as a dietary stimulant
How should heartburn be managed in pregnancy?
Heartburn is frequently experienced by pregnant women and can worsen with advanced gestation
Women should be given dietary and lifestyle advice to help with their symptoms
Antacid treatment can be instigated including: Gaviscon, Ranitidine or Omeprazole
What are the risks of obesity in pregnancy?
Increased risk of GDM – requires glucose tolerance test between 26-28 weeks
Should receive high dose folic acid in the 1st trimester (5mg)
Increased risk of pre-eclampsia - appropriate cuff size must be used to assess BP
Increased VTE risk
Consider serial scans due to inaccurate symphysial fundal height (SFH) with increased BMI
Consider intrapartum needs - foetal monitoring, IV access, increased risk postpartum haemorrhage (PPH), postnatal VTE risk