PACES obstetrics Flashcards
P-PROM RFs
smokers
STI
previous P-ROM
mutliple pregnancy
PACES P-PROM counselling…explain
- need for admission
- risks (infection when can cause damage to the baby)
- risks of prematurity (ideally like to keep baby inside for as long as possible but this has to be balanced with infection risk)
- importance of close monitoring (CTG, maternal infections)
- role of antenatal steroids
- likelihood of delivery
Breech RFs
uterine malformation fibroids placenta praevia poly/oligohydramnios foetal anomaly (chromosomal disorders) prematurity
Breech counselling
- explain what breech means
- offer ECV and explain risks (50% success rate, placental abruption, foetal distress, requiring emergency CS)
- explain benefits of vaginal (if successful, fewest complications, 40% risk of needing emergency CS)
- explain benefits of CS (small reduction in perinatal mortality, implications on future pregnancy = praevia, VBAC, uterine rupture)
VBAC PACES couselling
- options: ERCS or VBAC
- VBAC (uterine rupture risk of 1/200, 75% success rate, others need emergency CS)
- ERCS (implications on future pregnancies, uterine rupture/abruption)
HIV counselling
- need to be seen at a joint HIV physician and obstetric clinic every 1-2 weeks
- need to monitor viral load every 2-4 weeks, 36 weeks and delivery
- stress important of good compliance with ART
- discuss options for delivery (depending on viral load at 36 weeks)
- advise not to breastfeed
- neonatal treatment with ART for 2-4 weeks and testing for HIV transmission
Pre-eclampsia RFs
- previous HTN disease in pregnancy
- mutliple pregnancy
- DM
- kidney disease
- 1st pregnancy
- obseity
- > 35y or <20y
- FH
- PCOS
- IVF
Counselling of Pre-eclampsia
- admission is needed (at leas until BP controlled)
- explain early delivery and risks (early delivery, reduced placental function, IUGR, risks to mother)
- treatment = labetalol
- BP monitored closely with regular blood tests (2/ week) and foetal surveillance (every 2 weeks)
- early delivery before 37 weeks may be needed
- 15% risk of recurrence
GDM RFs
- age
- FH
- obesity
- multiple pregnancy
- Asian background
GDM counselling
- diabetes that occurs in pregnancy because body isn’t able to produce enough insulin to meet demands of carrying a baby
- Maternal risks: HTN disease, traumatic delivery, stillbirth
- Foetal risk: macroscomia, neotnatal hypoglycaemia, congenital abnormalities
- treatment options: CDE, metformin, insulin
- importance of good glycaemia control
- explain to monitor blood glucose using glucometer
- need to be seen at joint diabetes and antenatal clinic within 1 week and every 2 weeks thereafter
- US growth scans every 4 weeks from 28-36 weeks
- medication stopped at delivery but followed by GP
OC RFs
- personal/family Hx of OC
- history of liver disease
- multiple pregnancy
OC counselling
- explain diagnosis and risks (still birth and premature birth)
- need for early delivery (37 weeks)
- regular monitoring and weekly LFTs
- pay close attention to foetal movements
- symptomatic treatment with ursodeoxycholic acid, emollients, Vit K
- high recurrence rate (up to 90%)
Placenta Praevia RFs
previous placenta praevia multiple pregnancy previous CS smoking and drug use advanced maternal age
counselling if placenta praevia presenting with asymptomatic low-lying/placenta
- importance of the finding (increases risk of bleeding)
- 90% of placentas will move away from os
- rescan at 32 weeks and go from there
- advise to avoid having sex
counselling if placenta praevia presenting with symptomatic placeta praevia (with bleeding)
- admit until bleeding has stopped and for further 48 hours
- importance of findings and foetus needs to be monitored
- prompt delivery needs to be discussed (based on gestation)
- risks of delivery: major blood loss, may require blood transfusion, may require hysterectomy
- Anti-D
important to ask about previous pregnancies
how born and WHY
what to do if the situation is an emergency
ABCDE
alert seniors
Hyperemesis Gravidarum counselling
- unlikely to harm the baby but if you lose a lot of weight, baby can be smaller than expected
- condition usually resolves after 14 weeks, hopefully treatment we will give you can help reduce symptoms
when to do CTG
if come with problems and in third trimester
Tests in PROM
- IGF binding protein 1
- placental alpha-microglobulin 1 test
- TVUSS can be used to assess cervical length and determine likelihood of birth in 48 hours
what to monitor in eclampsia?
urine output reflexes RR Oxygen sat LFTs and plt
pathophysiology of GD
- placenta produces substaicnes that have anti-oestrogen effect
= increased insulin resistance = hyperglycaemia - maternal glucose crosses placenta = foetal hyperglycaemia
- foetal pancreas starts producing high levels of insulin = foetal hypoglycaemia
target levels for glucose in GDM
fasting < 5.3
2 hour post meal < 6.4
chance of successful VBAC after 1 previous CS
70%
what is the multiple pregnancy support group>
TAMBA (twin and multiple birth association)
MCDA sign and when split
T-sign
conceptus split 4-8 days
OC features of history and care
jaundice
ask about urine and poo
consultant led care
F/U after delivery to ensure LFTs returned to normal
physiological skin changes
linea nigra
striae gravidarum
striae albicans
SGA PACES counselling
- may be a sign your placenta is getting a little bit tired and not being able to feed the baby as well as it did before
- we would like to keep an eye on growth of baby by scanning your regularly now
- serial growth scans, CTG and doppler US every 2 weeks
- ask mum to pay attention to foetal movements
important question to ask in ROM
fever
if discharging with ROM, what safety net?
call midwife if:
- raised temp
- any fluid discharge/bleeding from vagina
- reduction in foetal movements
Couselling features in PPROM
balancing risks of prematurity with risks of infection
early delivery likely to be necessary
come in x2/ week for CTG and obs
consider delivery at 34 weeks
questions to ask in pre-eclampsia
- headaches
- epigastric pain
- visual disturbances
- oedema (feel more swollen recently)
- N/V
- previous BP before and during pregnancy
- previous urine dipstick results
investigations to do in pre-eclampsia
- full CV and abdo exam
- examine legs and reflexes
- feel for liquor volume, SFH
- FBC, U&Es, uric acid, LFTs, Albumin, clotting screen
- USS
antenatal management plan for patient with pre-eclampsia
- keep inpt
- BP every 4 hours
- urinalysis daily
- 3x week FBC, U&Es, LFTs
- FUSS and CTG regularly
- Labetaolol
intrapartum management of pre-eclampsia
IV labetaolol
continous fetal monitoring on CTG
postnatal management
discharged to primary care if no symptoms of pre-eclampsia
BP 149/99 or lower
blood tests stable and improving
individual care plan, GP to check BP in community
how to manage woman at risk of pre-eclampsia?
- healthy lifestyle
- refer for consultant led care at booking
- aspirin 75mg daily from 12 weeks
- urine and BP at every visit
- safety net to seek urgent help if signs of pre-eclampsia
explaining pre-eclampsia to a patient
Pre-eclampsia is a complication of pregnancy that causes you to have high blood pressure and protein in your urine. It can make you unwell and can affect your baby’s growth and wellbeing.
prolonged first stage of labour management
- As membranes are not ruptured, offer ARM
- Consider augmentation with oxytocin
- Ongoing obstetric review every 15-30 mins
- Consider instrumental delivery (if criteria for instrumental delivery are met)
- Diligent observation of the CTG trace in case emergency C-section is ne
causes of prolonged labour
Malposition
Epidural analgesia
Obstructed labour (e.g. CPD)
propess vs prostin
Propess (24 hours)
Prostin (can be given 6 hourly)
