Other topics in Obs Flashcards
VBAC indication
Offered in singleton preg of cehalic pres at 37+wk who have had single lower segment c-section
w or w/o Hx vaginal birth
Consider if 2+ lower segment c-sec
CIs to VBAC
Previous uterine rupture
classical c-sec scar
other CI e.g.major praevia
VBAC vs ERCS
VBAC has fewest Cx VBAC success rate = 75% Biggest risk of VBAC is emergency c-sec ERCS a/w placenta praevia/accreta and adhesions ERCS longer recovery ERCS risks bowel/bladder inj.
Best indicator of future successful vaginal delivery
Hx of vaginal delivery
Risks of VBAC
Emergency c-sec
uterine rupture 1:200 (1:100 if syntocinon).
39% req. instrumental
Higher risk w/post-dates, twins, macrosomia
infant: transient morbidity (can happen in ERCS to), still birth v small risk
Intrapartum Mx of VBAC
Electronic monitoring throughout
Induced/augmented labour increased risk
Induction with mechanical less likely to rupture scar and PGs
Planning ERCS
> 39w
proph. ABx
VTE proph.
Care of c-section scar
keep dry
remove sutures 5d
no heavy lifting 6w
no getting pregnant for 12-18m
PACES counselling of VBAC
option of VBAC or ERCS
VBAC risks: rupture, emergency c-sec, (75% success rate of VBAC)
ERCS risks: future preg. bleed, infection, clot
Multiple Pregnancy AN Care
Obstetric led care
Extra Scan for GA +anomalies+chorionicity
Epi of multiple pregnancy
1% natural conception
much higher with IVF
Chorionicity in multiple pregnancy
Detect at time of detecting multiple pregnancy
No. placental masses
Lamba and T sign
Assign left and right baby
Refer to senior USS if can’t be assessed
Manage as monochorionic until proven otherwise
If >14w use: membrane thickness, lamba sign, no, masses, and disconcordant foetal sex
General care for multiple pregnancy
Lifestyle: same as normal AN, risk of anaemia (FBC 20-24w)
Uncomplicated monochorionic diamniotic care
9+ appointments w/HCP
2+ w/ specialist obstetrician
Scan + appointment when CRL 45-84mm and then at:
16,18,20,22,24,28,32,34
Uncomplicated dichorionic
8+ appointments
2+ w/ specialist obstetrician
Scan+appointment CRL45-84 and then every 4wks from 20-36
Uncomplicated monochorionic triamniotic or dichorionic triamniotic
11+ appointments
2+ w/specialist obstetrician
Scan+appointment every 2wk from 14-34wk
Uncomplicated trichorionic triamniotic
7+ scans
2 apps w/ sp. obs
Scan+app every 4wk from 20-34
Summary of monitoring in mono/dichorionic
mono: 2wkly growth and doppler from 16w (refer foetal medcine)
di: 4wkly growth and doppler from 20w
Foetal complications of multiple pregnancy (T21)
Higher risk T21
Different screening (combined test, consider second trim. screen)
Caclulate risk per bayb in di risk per preg. in mono
Higher false positive rate in multiple preg
Invasive testing more likely
Cx of invasive tests more likely
Possibility of selective foetal reduction
Foetal Cx of multiple pregnancy (NOT T21)
Structural ab: as normal AN
TTTS: do not monitor in T1, start from wk16 on 2wkly basis, go to weekly if membrane folding or other signs
IUGR: do NOT use SFH, estimate weight discordance using 2+ biometric measures from 20w, difference >20% can be sign of IUGR
Maternal Cx of multiple pregnancy
Hypertension: - BP and proteinuria every visit Aspirin 75mg from 12w if any of: - First preg - 40+yo - Pregnancy interval >10y - BMI >35 at first visit - FHx pre-eclampsia
Higher Risk of Pre-term birth in multiple pregnancy
multiple preg have higher risk spontaneous birth do NOT use to determine risk: foetal fibronectin home uterine activity cervical length If inevitable give corticosteroids
Preventing preterm birth in multiple pregnancy
Do NOT use: Bed rest at home/hosp IM or vaginal progesterone Cerclage Oral tocolytics
Timing of birth in multiple pregnancy
60% of twin preg. will spontaneously birth before 37w
Continuing uncomp. preg >38w a/w risk (36 for triplets)
Offer continuous CTG
?elective birth
If not elective birth offer weekly apps w/sp. obs
Elective birth in multiple pregnancy indications
IF:
uncomplicated monochorionic twin (from 36w after CS)
Uncomplicated dichorionic twin (from 37w)
Uncomplicated triplet (from 35w after CS)
Vaginal birth possible in multiple pregnancy
first twin cephalic
5% risk of second twin needing C-sex
Aim for interval <30mins between twins
PACES Counselling of multiple pregnancy
RF: AMA, Hx, Assisted repro
Risks:
- mat: BP, hyperemesis, GDM
- Feo: monochorionicity, TTTS, defects, prematurity
Scans 2 or 4wkly
Del: 60% before 37w, vaginal if first twin ceph
Dx of Monochorionic twin pregnancy
All women w/twins offered USS 11-13+6 (CRL 45-84)
Determine chorionicity
Keep photographic record
Mono vs dichorionic risks
Higher rate of loss in mono (T2 particularly)
?higher risk neurodev. morbidity
Screening in monochorionic pregnancy
Triple test if 11-13+6 Quadruple after this Detailed USS at 18-20+6 USS every 2 weeks from wk16-del. - measure liqour (DVP) and UAPI Calculate EFW using biometrics
TTTS in monochorionic pregnancy
Advise mother to report sudden increase in abdo size or SOB
EFW differences may be TTTS
TAPS in monochorionic pregnancy
Screened following fetoscopic laser ablation for TTTS usinf serial MCA peak systolic velocity
Screening for selective growth restriction in monochorionic pregnancy
at each scan from 20w calc. EFW (2+ biometric)
>20% discordance = perinatal risk
UAD for progonsis and morbidity
Mx of TTTS in monochorionic preg
Refer FMU
<26w - fetoscopic laser ablation of vascular anastamoses
>26w delivery may be considered
Weekly USS
Del. 34-37w
Expectant Mx
? amnioreduction, septostomy, selective feticide
sGR Mx in monochorionic preg
Refer FMU
Selective reduction and option if done early
Surveillance scans every 2wks
Abnormal doppler waveforms indicator for delivery in some cases
Delivery in monochorionic pregnancy
Offer elective del from 36w after CS
MCMA twins high risk of death so c-sec between 32-34w
Breech Delivery frequency
3-5% at 37w
Breech at term women advice
Offer ECV
If ECV declined offer planned vaginal or C-sec (generally c-sec)
ECV?
External cephalic version
50-60% success rate
risks: distress needing emergency c-sec or labour
CI: c-section to be performed, APH last 7d, abnormal CTG, uterine anomaly, ROM, multiple preg
C-section for breech at term
benefits: small reduction in perinatal mortality, planned vaginal higher risk of low apgar and early morbidity but late outcomes same
Risks: small risk of Cx (less than emergency c-sec which happens in 40% of breech PVD), increases risk in future pregnancy
Antenatal assessment of Breech delivery
Suggestive of high risk vaginal birth:
- hyperextended neck, high/low EFW, footling presentation, AN compromise
Women near or in active 2nd stage should not be routinely offered c-section
Induction not generally recommended (augmentation using oxytocin possible)
Continuous foetal monitoring
Breech Delivery itself:
V. dangerous if footling Hands off approach (ideally baby will deliver itself) Manoeuvres Forceps Make sure theatre ready (bloods e,g G+S X-Match)
Summary of breech delivery
<36w: many will turn spontaneously 36w ECV (37 for multip)
PACES Counselling of Breench Delivery
RF: uterine malf., fibroids, praevia, poly/oligohydramnios
Dx: feet down
Offer ECV
Vaginal vs C-section
Unstable lie
RF: Multip, praevia, uterine anomalies, polyhydramnios, multiple pregnacny
Risks: cord presentation or prolapse, uterine rupture
USS to conform
80% revert to longitudinal before labour
If mechanical eg praevia LSCS
Admit >37w
consider ECV ARM LSCS
Mastitis in pregnancy
Ix: clinical, consider USS, aspiration, cytology
Encourage continue bf
Treating mastitis in pregnancy
If systemically unwell, nipple fissure, if Sx not improved after 12-24h
Fluclox 10-14 (clindamycin if allergic)
Continue bf in treatment
Breast abscess Mx
Surgery
IV/PO ABx (fluclox, cefalexin, doxy, clindamycin) non b-lactam if MRSA
Nipple thrush in pregnancy Mx
Clinical fx: pain in both nipples after feed, pain up to 1hr, creamy spots in baby mouth
Mx: miconazole topical oral nystatin for bby
High dose folic acid in pregnancy
5mg Previous child w NTD DM AED Obesity HIV taking co-trimox sickle cell disease
Perineal tear
1st deg: superficial damage no muscle
2nd deg: perineal muscle not anal sphincter
3rd deg: involving anal sphincter complex (E/IAS)
3a: <50% EAS, b: >50% EAS, c:IAS tear
4th deg: sphincter complex and rectal mucosa
Edinburgh post-natal depression scale
10-items max score 30
how mother has felt in the last week
>13 suggests depressive illness
Mx: sertraline and paroxetine for bf
Bf CI drugs
ABx: cipro, tetracycline, chloramphenicol, sulphonamides Psych: Li, benzos Aspirin Carbimazole MTX Sulphonylureas Cytotoxics Amiodarione
Req. for Instrumental delivery
Fully dilated cervix
OA (OP possible w/some forceps +ventouse)
Ruptured membranes
Cephalic presenation
Engaged presenting part
Pain relief
Sphincter (bladder empty req. cath usually)
Preparing for an elective C-section
around 39w Pre-ass w/midwife: blood: G+S MRSA swabs Ranitidine night before and morning of operation Fast 8 hours before c-section
AN corticosteroids how are they given?
2x12mg IM betamethasone
24hrs apart
benefit window from 24hr after first dose to 7d
Pregnancy and flying
Most airlines say no after 37w (32 for twins)
Discuss w GP
Reduce VTE risk by hydration and activity
Depression in pregnancy
Discuss concerns
Mild to mod: refer for facilitated self help
Mild w/Hx of severe: consider Mx (SSRI, SNRI, TCA)
Mod-Sev: CBT, consider TCA, SSRI, SNRI,
If therapy req. refer urgently
If a woman decides to stop taking her pre-existing meds ask why and offer alternatives
Post natal: treat as normal pop. offer sertaline/paroxtine
