Obstetrics Peer Teaching Flashcards
What tests are done at a pregnant woman’s first visit?
urine sample, haemaglobin, blood group
syphilis and rubella serology
HIV screening
What is the 11-13 weeks scan for?
How many fetuses, nuchal translucency, dating scan
What is the 20 week scan for?
fetal anomaly
What is checked at 36 and 37 weeks?
Lie and presentation of the baby
Head engaged at 37 weeks
What are the “latent” and “established” phases of the 1st stage of labour
Latent: dilated <4cm
Established: dilated >4cm and contractions
What are the “active” and “passive” phases of 2nd stage of labour?
Passive = fully dilated, not pushing Active = pushing
How long does the first stage of labor take?
Nulliparous: 8-12
Multiparous: 5-12
How long does the 2nd stage take?
Nulliparous: 3 hours
Multiparous: 2 hours
What is pre-eclampsia?
Hypertension and proteinuria in pregnancy
What are the symptoms of pre-eclampsia?
Shakinf, flu-like symptoms, visual changes and hyperreflexia
What is the cure for pre-eclampsia?
Delivery
How to prevent pre-eclampsia from becoming eclampsia?
Magnesium sulfate, MgSO4
Wha tis the pathophysiology of pre-eclampsia?
Failure of spiral arteries to embed properly into the trophoblast, causing an ncrease ion blood pressure to compensate
When should someone with pre-eclampsia be admitted?
BP 160/100
When should someone with pre-eclampsia be admitted if there is proteinurea or IUGR?
140/90 BP
If a pregnant woman is in shock but there appears to be little blood loss what is the diagnosis?
Concealed placental abruption
When would you feel a “woody” uterus?
Placental abruption
What is placenta praevia?
Placenta lies on the lower segment of the uterus
What are the symptoms of placentsa praevia?
Abnormal lie of fetus, painless bleeding
What should you not do if you suspect placenta praevia? Why?
A vaginal examination, because of the risk of beeding
What effects would maternal rubella infection have on the developing fetus?
- Deafness
- Cataracts
- Cardiac abnormalities
What effects would maternal cytomegalovirus infection have on the developing fetus?
cognitive impairment
How should a pregnant woman avoid listeria infection
Avoid soft cheese`
How should you initially manage a 28 week premature delivery?
Wrap in plastic and put under heat lamp, don’t dry
Delay cord cutting for 3 minutes.
What constitutes as a delay in 2st stage of labour?
<2cm/hr dilation in 4 hours
What treatment should you use in delayed labor?
Oxytocin
What is delayed 2nd labour?
When delivery isn’t imminent after 2 hours of pushing in a nulliparous woman and 1 hour for a parous woman
What should you do if there is a delay in 2nd stage?
a. Amniotomy
b. forceps
c. c-section
How should a diabetic woman trying for a baby be managed?
5mg folic acid preconception
Control diabetes
When should you deliver a baby in a maternal diabetic?
38 Weeks
What is the medical treatment for pre-eclampsia where the BP is >150/100
oral labetalol
What does blood pressure do in normal pregnancy?
Falls initially until 20-24 weeks then returns to pre pregnancy levels by term
What counts as hypertension in pregnancy?
140/90 OR 30 increase in systolic and 15 increase in diastolic
Give 3 high-risk factors for pre-eclampsia
CKD
SLE
Diabetes
previous pre-eclampsia
What is pre-eclampsia?
Hypertension + proteinuria >0.3g/day
What is HELLP syndrome?
Haemolysis, elevated liver enzymes, low platelets
Give 3 things that can be caused by pre-eclampsia?
IUGR, prematurity
kidney failure
placental abruption
What are features of severe pre-eclampsia?
170/110
headache/visual disturbance
papilloedema
When would you deliver in pre-eclampsia?
if mild, 37 weeks
If moderate/severe: 34-36 weeks
If there is maternal complications always deliver
What is eclampsia?
Pre-eclampsia + seizures
What is the treatment for eclampsia?
Magnesium sulfate
How should MgSO4 be administered?
4g IV bolus over 5/10 minutes followed by an infusion of 1g/hr
How long should MgSO4 treatment last?
24 hours after last seizure or delivery, whichever is last
What is the most common pathogen in the mother causing neonatal sepsis/
Group B strep
What are risk factors for developing neonatal sepsis?
Prolonged rpture of membranes
sibling with group B strep infection
maternal pyrexia
What prophylaxis is given for group B strep?
Benzylpenicillin
Name 4 causes of antepartum haemorrhage
placenta praevia
placental abruption
uterine abruption
vasa praevia
What is the classis symptom of placenta praevia?
Painless vaginal bleeding
What is a major placenta praevie?
where the placenta covers the os - type 3 and 4
What is the managements of placenta praevia?
anti-D if rhesus -ve, c section at 39 weeks, steroids if <34 weeks gestation
Should you be worried if the placenta is low lying at 20 weeks?
No - At 20 weeks placenta is low-lying in most pregnancies but appears to move upwards with time as the formation of the lower segment of the uterus occurs in the third trimester
What are some risk factors for placental abruption?
Previous abruption Smoking IUGR pre eclampsia pre-existing hypertension
A patient presents with painful bleeding, a woody hard uterus, and appears to be shocked - what is the diagnosis?
Placental abruption
What maternal investigations need to be performed in suspected placental abruption?
FBC, Coag screem cross-match, U&E, urine output
What is the management for placental abruption?
anti-D, steroids if <34 weeks, C/S if fetal distress, induce labout >37 weeks
Blood transfusion if necessary
What are the cardinal movements of labour?
Engagement. Descent. Flexion. Internal rotation. Extension. External rotation/restitution. Expulsion.
- Describe engagement
Head enters pelvis in occipito-transverse position.
OR
Widest part of the presenting part becomes level with the pelvic inlet
- Describe descent
Passage of the widest presenting part through the pelvis
- Describe flexion
Fetal head flexes as it is pushed downwards
- Describe internal rotation
Head rotates 45 degrees
- Describe extension
Fetal head faces the sacrum, occiput in contact with the symphisis pubis
- Describe restitution/external rotation
Fetal head turns to be in line with its torse so shoulders can be delivered
- Describe expulsion
Delivery of the fetal body
What are the 3 Ps?
Mechanical factors determining the progress of labour: passenger, passage and power i.e. width of head, pelvis and strength of contractions
What is the management of failre to progreess in labour in the first stage of a nulliparous woman?
amniotomy then oxytocin then c-section
Management for failure to progress in passive 2nd stage?
2 hour wait before pushing, give oxytocin
Management for failure to progress in active 2nd stage?
episiotimy if head is against the perineum, ventouse if not
What can obstruct the passage of the fetus during delivery?
cephalo-pelvic disproportion
pelvic mass e.g. fibroid
abnormal pelvic architecture e.g. poorly healed pelvic fracture
What is the OP position? What are the features?
Occiputo-posterior “back to back”
- back ache
- more painful and longer labour
- early desire to push
What is the OT position?
Occipito-transverse
Incomplete internal rotation
Ventouse needed
What is the brow position?
Fetal head extended, large presenting diameter - nose and anterior fontanelle may be palpable
What is the management of brow position?
C-section
What are the factors that determine the bishop score?
Cervical dilation, effacement, and consistency
Position of the fetus and station of the fetal head
What does a bishop score of <6 mean?
Unlikely to go into spontaneous labour, not suitable for induction
What does a bishop score of >8 mean?
Likely to go into spontaneous labour, suitable for inductinop
What is the first line induction of labour?
Membrane sweep - separate the membranes away from the cervix manually
What is the 2nd line induction of labour?
Prostaglandin gel vaginally 2mg, 2 doses maximum
What is the 3rd line induction of labour?
Amniotomy + oxytocin 2 hours later if still not progressing
Give some fetal indications for induction of labout?
post term pregnancy, IUGR
Gice some materno-fetal indication for induction of labour?
Diabetes, pre-eclampsia
What are the maternal complications of shoulder dystocia?
perineal tears, PPH, urethral and bladder injuries
What are the fetal complications of shoulder dystocia?
Erb’s palsy - brachial plexus injury
Hypoxic ischaemic encephalopathy
What are risk factors for shoulder dystocia?
Diabetes, high maternal BMI, macrosomia
What manouvre should be used in shoulder dystocia? Describe it.
McRoberts manouvre - flex thighs towards abdomen
Apply suprapubic pressure
What is the management for cord prolapse?
Delivery
When is the cord more likely to prolapse?
When the fetal head is not engaged in the pelvis
What are risk factors for cord prolapse?
Polyhydramnios
Multiple pregnancy
Low lying placenta
Abnormal lie
What is a risk factor for uterine rupture?
Previous c-section (or traumatic injury)
Shock, severe abdominal pain which persists between contractions, vaginal bleeding and CTG abnormalities during labour indicate what?
Uterine rupture
What might you see on CTG in uterine rupture?
Fetal Bradycardia
How does amniotic fluid embolism present?
like a PE, with collapse
How is fetal distressed measured?
fetal blood gas, CTG, fetal ECG
What is fetal distress?
Hypoxia which may cause damage or death to the fetus if left unresolved.
How do you interpret a CTG?
Dr C Brvado
DR - Define Risk
Contractions - how many in 10 minutes? More than 5 is hyperstimulation
Baseline Rate - 110-160
Accelerations in fetal heart rate with movement or contractions are reassuring
Decelerations
Overall assessment
What do early, variable and late decelerations indicate?
Early - benign
Variable - cord compression
Late - persist after contractions, suggesting fetal hypoxia
What is the first line management of primary PPH?
IV syntocinon followed by 0.5mg ergometrine
What are the risk factors for PPH?
polyhydramnios, pre eclmapsia, prolonged labour, macrosomia, previous PPH
What is the most common cause of PPH?
Uterine atony
What are the causes of secondary PPH?
endometritis, retained placental tissue
What is the scoring system for post natal depression?
Edinburgh scale
