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Obstetrics and Gynaecology > Physiology > Flashcards

Physiology Flashcards

1
Q

Which event occurs 1 day after LH surge?

A

Ovulation

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2
Q

What is the site of ovulation?

A

Ovary

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3
Q

Where is the site of fertilisation?

A

Fallopian tube

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4
Q

At which day does the blastocyst enter the uterine cavity?

Where does this occur?

A

Day 3-5

Uterus

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5
Q

What day does implantation occur?

A

Day 6-7

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6
Q

Which day does hCG get released?

Where does this occur?

A

9-10

Trophoblastic cells

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7
Q

State the order of potency regarding stem cells.

A

Totipotent

Pluripotent

Multipotent

Omnipotent

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8
Q

What is puberty?

A

developmental phase between childhood and adulthood whereby functional maturation of reproductive glands and external genitalia mediated by changes in sex hormones (GnRH, FSH, LH)

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9
Q

What are the two stages of Female Puberty?

A

Adrenarche (6-8) - adrenal production

Menarche (10-16)

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10
Q

Describe adrenarche.

A

Process of adrenal gland secreting androgens (DHEA) which is pre-programmed with an unknown trigger. This occurs at age 6-8 years. Androgens stimulate a growth spurt. Breast development begins.

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11
Q

Describe Menarche.

A

Onset of menstrual cycle occurring aged 10-16, to produce mature ova and endometrium to potentially support a fertilised cell (zygote). The HPO axis begins: GnRH (Hyp.) released binds to Anterior Pituitary which releases FSH and LH, travelling in the blood. LSH binds to theca cells to produce androgens and oestrogen.

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12
Q

Where is GnRH released from?

A

Hypothalamus

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13
Q

What does GnRH cause and where?

A

Release of FSH and LH from the Anterior Pituitary

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14
Q

Where does LH bind to in the female body? What effect does it exert?

A

Theca cells

Production of testosterone
Release of ovum (ovulation)

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15
Q

State 3 female phenotypic changes.

A
  • Somatic growth
  • Pubic hair
  • Growth and maturation of reproductive tract
  • Fat deposition: breast, buttocks, thighs
  • Closure of epiphyseal plates: Stop growing

• Somatic growth occurs

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16
Q

At what age do males undergo puberty?

A

8-12 years old

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17
Q

Which cells to FSH bind to?

A

Sertoli

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18
Q

What effect does FSH have?

A

Spermatogenesis

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19
Q

What effect does LH have in males and where/

A

Binds Leydig cells to produce Testosterone

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20
Q

State 5 male phenotypic changes.

A
  • Somatic growth
  • Testicular enlargement
  • Pubic hair growth
  • Growth of larynx
  • Deepening voice
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21
Q

Define fertilisation.

A

Process of male + female gametes fusing ≈ zygote

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22
Q

Sperm cells attach to which part of the ovum?

A

Corona radiata, entering the zona pellucida

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23
Q

What cellular change occurs to reduce further sperm entry?

A

1º block: Egg depolarises

2º block: Zona pellucida changes

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24
Q

Which reaction allows entry of sperm cell to the zona pellucida?

A

Capacitance then Acrosome reaction (exocytic reaction of enzymes)

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25
Q

Outline cleavage and compaction.

A

Process of conceptus held in fallopian tube and zygote undergoes successive divisions to become a morula (16-cell)

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26
Q

Outline blastocyst formation.

A

Process of 16-cell morula becoming a blastocyst at days 3-5.

Blastocyst has ICM (embryo) and trophoblasts (placenta)

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27
Q

What process allows the blastocyst into the uterus?

A

Progesterone levels rise, with SMC and conceptus goes into uterus

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28
Q

What does the blastocyst do to avoid immune rejection?

A

Secretion of immunosuppressive agents and ßhCG

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29
Q

Which organ maintains secretion of progesterone until the placenta takes over?

A

Corpus luteum

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30
Q

When detecting ßhCG, which cell produce this?

A

Syncytiotrophoblasts at day 7-8

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31
Q

Describe implantation.

A

Blastocyst adheres to endometrium wall via:
Embryo hatching - lytic factors from endometrial cavity digest zona pellucida
Apposition - contact between blastocyst and endometrium epithelium form a crypt of endometrium
Adhesion - trophoblast and uterine epithelium bind via microvilli of trophoblast
Invasion - syncytiotrophoblasts flow into endometrium in decidualisation

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32
Q

What is decidualisation?

A

Final stage of implantation whereby syncitiotrophoblasts flow into the endometrium causing oedema and vascularisation

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33
Q

Outline the formation of the placenta.

A

Syncytiotrophoblast cells erode through endometrial capillaries which bleed into space to give primitive placental circulation.

Cytotrophoblasts proliferate to produce primary chorionic villi. Mesenchyme from extramebryonic coelom invades to produce secondary. Finally mesenchymal cells form foetal capillaries to form tertiary chorionic villus.

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34
Q

How many layers are produced through decidualisation. State them.

A

3, giving a specialised endometrium of pregnancy
• Decidua basalis = underneath implanting embryo
• Decidua capsularis = overlies embryo
• Decidua parietalis = covers remainder of uterine surface

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35
Q

Outline the maternal and foetal blood at the placenta.

A
  • 120 spiral arteries entering via uterus wall into intervillous space through pulsatile bursts
  • Blood flow towards chorionic plate for adequate for exchange
  • Blood drains through venous vessels in basal plate (no capillaries between arterioles and venules – placenta is essentially the capillary bed)
  • 2 umbilical arteries (deoxygenated blood) -> branch beneath amnion -> penetrate chorionic plate + branch in chorionic villi to form capillary network
  • 1 umbilical vein returns blood
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36
Q

Describe the blood-placental barrier in humans.

A

• Syncytiotrophoblasts regulate substance transport

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37
Q

State the main functions of the placenta.

A
  • Endocrine: Steroids + Proteins
  • Foetal lung: Gaseous exchange
  • Foetal gut: Supplies nutrients
  • Foetal kidney: Regulate fluid volume + Excretion
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38
Q

State the two main products of the placenta.

A
  • ßhCG: Syncytiotrophoblast cells produce under direction of progesterone and oestrogens
  • HCS1 + HCS2 (hPL): Polypeptide hormones related to GH and prolactin playing role in conversion of glucose to fatty acids and ketones + promote development of maternal mammary glands
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39
Q

Describe the effect foetal RBCs have on the O2 dissociation curve.

A

• HbF has 2 alpha and 2 gamma chains. Gamma chain has reduced 2,3-DPG affinity = higher O2 affinity -> dissociation curve shifts to left

Therefore at a lower ppO2, O2 saturation is higher

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40
Q

Describe how the following substances are transported across the placenta:

  • Glucose
  • Amino acids
  • FAs
  • Iron
A

GLUT1

AATs

FATP; pFABP

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41
Q

State 3 hormones the placenta produces

A
  • hCG
  • Oestrogens
  • Progesterone
  • hCS (hPL)
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42
Q

Which cells secrete hCG?

A

Syncytioblasts

Placenta (after 7 weeks)

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43
Q

What is the function of hCG?

A

• Prevent breakdown of corpus luteum at end of monthly female sexual cycle

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44
Q

By producing hCG, what do the syncytioblasts indirectly facilitate?

A

Production of hCG allows the maintenance of the corpus luteum which produces progesterone to prevent menstruation and help endometrium grow and store nutrients cf shed.

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45
Q

What are the functions of oestrogen generally?

A
  • Enlargement of uterus
  • Enlargement of breast ductal structure and growth
  • Enlargement of female external genitalia
  • Relax pelvic ligaments -> SI joint and pubic symphysis ≈ passage of foetus thorugh birth canal
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46
Q

How is oestrogen produced by the placenta?

A

Syncytioblasts do not produce oestrogen de novo. Adrenal glands produce DHEAS and 16-OH-DHEAS which is converted by trophoblasts into estradiol, estrone and estriol.

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47
Q

State the functions of progesterone.

A
  • Development of decidua -> nutrition
  • Reduced contractility of uterus ≈ reduce spontaneous abortion
  • Conceptus development prior to implantation ≈ secretions and dilatation of fallopian tubes
  • Aids oestrogen prepare breasts for lactation
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48
Q

Where is hCS produced?

A

• Protein hormone secreted by placenta at about 5th week of pregnancy

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49
Q

What is the highest amount of protein produced by the placenta?

A

hCS

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50
Q

What are the postulated functions of hCS?

A

• Partial development of breasts + lactation

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51
Q

During pregnancy, what is the output of the anterior pituitary like? State some hormones and which go up and which go down.

A
  • Increased production of ACTH, TSH, PL

* Reduced production of FSH and LH

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52
Q

Which of the following go up or down during pregnancy:

  • Glucocorticoids
  • Aldosterone
  • Thyroid hormone (T3/T4)
  • PTH
  • Relaxin
A

All increased

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53
Q

Which placental hormone increases thyroxine production?

A

hCG

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54
Q

Which hormone induces secretion of relaxin?

A

hCG

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55
Q

Which two effects does relaxin have?

A

Vasodilation

Ligament laxity

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56
Q

State which of the following metabolic and nutritional changes increase or decrease in pregnancy and how:

  • Metabolism
  • Nutrition
A

• BMR increases in latter half of pregnancy

  • Require store prior to last 2 months of pregnancy when foetus requires however reserve required
  • If not adequate reserve, nutritional deficiencies may occur: Ca, PO4, Fe, Vitamins DEAK
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57
Q

Describe the changes in maternal circulatory system in pregnancy.

A
  • Blood flow through placenta + maternal cardiac output increased: Increased metabolism and blood flowing in maternal circulation increases cardiac output h/e falls in last 8 weeks of pregnancy
  • Maternal blood volume increases during pregnancy: fluid retention (aldosterone + renal mechanisms) + hemopoiesis ≈ increased blood volume
  • Maternal respiration increases during pregnancy: Increased oxygen requirement to meet increased BMR thus minute ventilation increases
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58
Q

What happens to maternal blood volume during pregnancy and why?

A

• Maternal blood volume increases during pregnancy: fluid retention (aldosterone + renal mechanisms) + hemopoiesis ≈ increased blood volume

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59
Q

What happens to maternal respiration during pregnancy and why?

A

• Maternal respiration increases during pregnancy: Increased oxygen requirement to meet increased BMR thus minute ventilation increases

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60
Q

Which three factors cause an increase in respiration rate during pregnancy?

A

Increased CO2 demands
Progesterone (sensitivity)
Foetus mechanical pressure upwards in abdominopelvic cavity

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61
Q

Outline the changes in kidney function during pregnancy?

Why is this?

A

• Urine output increased: Increased fluid intake + excretory

  • Reabsorption increased: Sodium, chloride and water reabsorbed by steroid hormones of placenta and adrenal cortex
  • Renal blood flow and GFR increased due to vasodilation (relaxin + progesterone)
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62
Q

Define Sex.

A

physical, biological appearance determined by anatomy, as a result of interactions of chromosomes and hormones

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63
Q

Does Sex equal Gender?

A

Sex ≠ Gender

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64
Q

State the two primitive duct systems all embryos have.

A

Wolffian (male) + Mullerian ducts (female)

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65
Q

In males, which primitive duct predominated?

A

Wolffian

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66
Q

In females, which primitive duct predominated?

A

Mullerian

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67
Q

Outline the process of male sex differentiation in utero.

A

Sex determining region of Y (SRY) chromosome codes testis determining factor (TDF) which causes differentiation of gonads to testes.

Testes secrete MIF and T which causes Wolffian ducts into reproductive tract whilst degenerating mullerian ducts.

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68
Q

Outline the process of female sex differentiation in utero.

A

No SRY chromosome thus no TDF which results in ovaries. No Testes production of T or MIF thus Mullerian ducts develop into female reproductive tract whilst degeneration of Wolffian ducts occurs

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69
Q

What is the standard EDD from last LMP?

A

40/40

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70
Q

Why may actual foetal age be EDD - 14 days?

A

• Ovulation will not be known thus actual foetal age can be EDD - 14 days (assuming 28 day cycle)

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71
Q

What is the week range for a delivery at term?

A

37-42

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72
Q

What is a pre-term birth?

A

< 37 weeks

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73
Q

What is a post-term birth?

A

> 42 weeks

74
Q

Outline the trimester ranges.

A

1/3 = 0-12

2/3 = 13-27

3/3 = 28-40

75
Q

When does organogenesis begin?

A

8 weeks - 12 weeks (1/3)

76
Q

Outline processes which maintain the pregnancy state.

A
  • Uterine quiescence: gap junctions downregulated + OTr downregulated + relaxin
  • Anatomical arrangement of cervix: collagen fibres > smooth muscle + GAG ground substance (glue)
  • Amnion + chorion membranes intact: Low level PG biosynthesis
77
Q

State 3 processes which occur in preparation for parturition.

A
  • Braxton-Hicks contractions (false labour)
  • Cervical softening: PG + relaxin
  • Relaxation of pelvic bones: Relaxin
  • Foetus drops: Head is engaged with cervix
78
Q

Outline the triggers for labour

A
  • Oestrogen (drives CRH and ACTH and cortisol production)
  • Oxytocin (sensitivity increased -> OTr)
  • Cortisol (+ Pulmonary surfactant)
79
Q

Which two hormones drive labour?

A

Oestrogen

Oxytocin

80
Q

Outline the importance of cortisol in parturition.

A

Cortisol binds to foetal lungs increasing pulmonary surfactant protein in amniotic fluid which increases macrophages secreting IL-1ß.

The IL-1ß causes positive feedback to increase Our in the myometrium and increase responsiveness to OT

IL-1ß also causes increased PGE2 and cervical softening

81
Q

Outline the importance of oestrogen in labour.

A

Oestrogen drives increased CRH then ACTH and cortisol and DHEA production.

Increased cortisol drives foetal lung maturation.

DHEA production increases oestrogen production (via chemical change), increases gap junction upregulation and increases Our in myometrium.

82
Q

State the 3 stages of pregnancy.

A

1) Stage 1: Cervical dilatation: Latent + Active Phase
i) Latent Phase: Painful contractions + Cervical ripening + Dilation 3-4cm
ii) Active phase: Increased contractions + Descent + Cervical dilation (10cm)
2) Stage 2: Delivery of baby (Fully dilated cervix to Birth = 30-90 minutes)
3) Stage 3: Delivery of placenta and membranes (expulsion of placenta and membranes taking an hour)

83
Q

Describe the Fergusson reflex.

What stage of labour does this occur in?

A

Uterine contractions push against the cervix which stimulates OT secretion from the Posterior Pituitary to increase OT and PGE2 which is positive feedback

Active stage of pregnancy - stage 1

84
Q

What is postpartum involution?

A

shrinkage of uterus to pre-pregnancy size = 4-6 weeks

85
Q

In the Fergusson reflex, which hormone secretion is being increased?

A

OT

86
Q

In the non-pregnant state, why do breasts not fully develop milk production?

A

DA (PIH) dominates which inhibits PL release from the posterior pituitary

87
Q

Outline the glandular structure of the breast.

A

Lobule bears alveoli which produce milk.

Alveoli produce milk and epithelial cells secrete into the lumen of alveoli. These are drained by a lactiferous due which converge at the lactiferous sinus onto the nipple.

The alveoli are surrounded by adipose tissue and supported by CT stroma and pectoral fascia

88
Q

Describe the perfusion of the breast

A

Perfused by Internal Thoracic Artery, Lateral Thoracic Artery and Thoracoacromial branches

89
Q

Describe the route of lymphatic drainage of the breast.

A

Axillary lymph nodes (anterior + lateral + posterior) to central to apical. From this, supraclavicular nodes drain into the subclavian and lymphatic trunk.

These drain into the R or L venous angle.

90
Q

During pregnancy, what are the roles of the following hormones regarding breast development:

  • Oestrogen
  • Prolactin
  • hCS
A

Oestrogen (duct development)
Progesterone (lobule formation)
hCS (enzymes for milk production)
Prolactin (synthesis of enzymes for milk production; milk production post-partum)

91
Q

What two main processes are involved in lactation?

A
  • Milk production

* Milk ejection reflex

92
Q

Which two cell types are involved in milk production and ejection?

A
  • Acini (Secretory alveoli)

* Contractile myo-epithelial cells

93
Q

Outline the route of milk production in the breast.

A

Milk secreted by myoepithelial cells into lactiferous ducts which drain alveoli into lactiferous sinus and out via nipple.

94
Q

Outline the suckling reflex.

A

Surge of prolactin due to suckling which travels afferently to posterior pituitary which stimulates OT (milk ejection) and PL (milk production)

95
Q

Differentiate the difference in colostrum vs mature milk.

A
  • Colostrum: Low calories, higher proteins, more fat-soluble vitamins (DEAK), more micronutrients Zn + Na, greater immunoglobulins (IgG and IgA)
  • Mature milk (14-21 days): higher calories, higher carbohydrates, lower protein, lower in micronutrients, lower in immunoglobulins and lower in fat-soluble vitamins
96
Q

What are the key differences between colostrum and mature milk?

A

Differ in:

  • Calories (low colostrum)
  • Protein (high colostrum)
  • Micronutrients (colostrum higher in minerals)
  • Vitamins (higher in colostrum)
  • Immunoglobulins (IgG and IgA)
97
Q

Which immunoglobulin is highest in breast milk?

A

IgA

98
Q

Describe the process of weaning and its regime.

A

process of breastfeeding recommended for 6 months exclusively then continue with solid food until 2 years

99
Q

List 5 risks of breastfeeding.

A
  • Reduces infection risk
  • Reduces SIDS risk
  • Reduces childhood leukaemia risk
  • Reduced T2DM
  • Reduced obesity risk
  • Reduced risk of breast Ca
  • Reduced ovarian Ca
  • Reduced OP
  • Reduced CVD
  • Economic
  • Social
100
Q

Define a foetal lie

A

longitudinal axis relation of foetus and uterus – usually longitudinal but may be transverse or oblique

101
Q

Define the foetal position

A

Position: Relationship between denominator and mother’s pelvis

102
Q

Define the presentation.

A

Portion of foetus felt on vaginal examination

103
Q

Define the vertex of a foetus in pregnancy.

A

• Vertex: Area bounded by anterior fontanelle, posterior fontanelle and biparietal eminences

104
Q

Define the occiput.

A

• Occiput: area below the posterior fontanelle

105
Q

Define the sinciput.

A

• Sinciput: Area anterior to anterior fontanelle

106
Q

Define labour.

A

onset of regular uterine activity associated with dilatation and effacement (thinning) of cervix and descent of presenting part through the cervix

107
Q

Outline the 3 stages of pregnancy.

A

1) Onset of labour until cervix fully dilated (latent + established)
- Latent: Painful contractions where some cervical effacement and dilatation < 4cm
- Established: Painful contractions and cervical dilatation from 4cm

2) Cervical dilatation -> Head delivered
3) Delivery of head -> placenta and membranes

108
Q

What is a Partogram?

A

Graphical display of intrapartum information assessing: power, passenger and passage

109
Q

What are the 3Ps of a Partogram?

A
  • Power: Freq. + Duration of Contractions
  • Passenger: FHR + Position/ Station/ Moulding/ Caput
  • Passage: Effacement + Dilation of Cervix
110
Q

Give 3 indications for induction of labour and augmentation of labour.

A
  • Prolonged pregnancy: 42/52
  • Maternal DM
  • Multiparity
  • Pre-labour ROM
  • SGA/IUGR/Placental insufficiency
  • Hypertensive disorders
  • Maternal medical disorders
  • Maternal age
  • Reduced foetal movements
  • Maternal requests
111
Q

What are the main forms of induction of labour?

A

Pharmacological: PGE2 or Syntocinon

Mechanical: Membrane sweep; Amniotomy; Balloon

112
Q

State the form of administration of PGE2 in induction.

A

PV (Gel/Tablet/Pessary)

113
Q

How does PGE2 analogues mediate the induction of labour?

A

Ripens the cervix and strengthens uterine contractions

114
Q

What is the risk of administering PGE2 analogues in induction of labour.

A

Hyperstimulation

115
Q

How does syntocinon mediate its effects in induction of labour?

A

Stimulate uterine contractions

116
Q

State the form of administration of Syntocinon in induction.

A

IV infusion/dose titration to achieve contractions 4:10

117
Q

Describe 2 forms of mechanical forms during induction of labour.

A

Membrane sweep

Amniotomy

Balloon dilation

118
Q

Which adjunct is used for amniotomy?

A

Syntocinon

119
Q

Which classification system is used in labour to check cervix progression?

A

Bishop’s Cervical Scoring System

120
Q

What are the complications of induction of labour?

A
  • Failure/repeat courses
  • Uterine hyperstimulation (1-5%)
  • Labour experience: examinations, discomfort, analgesic requirements, assisted vaginal deliveries (AVD)
  • Increased obstetric intervention
  • Uterine rupture
121
Q

In the event of uterine hyperstimulation, what class of drugs may be given? Give an example.

A

Tocolytics

Terbutaline - ß2-agonist causing dilation

122
Q

What is the general process of treating pain?

A

Prevent
Recognise
Assess
Treat

123
Q

Outline non-pharmacological methods of pain relief in labour.

A
  • Maternal support: 1:1 care in labour
  • Birthing pools
  • Other: Breathing + relaxation
124
Q

Outline pharmacological methods of pain relief in labour

A

Entonox (O2:NO = 50:50)

Diamorphine (5-10mg)

Remifentanil

Epidural

Spinal block

General Anaesthetic

125
Q

Which three forms of anaesthetic may be given in pregnancy.

Outline the benefits and drawbacks

A

Epidural (epidural space)
+ Efficacious cf parenteral opioids
+ Reversible with Naloxone
+ No increase in LUSCS (C/s?)

  • Prolonged second stage: increase AVD
Spinal block (subarachnoid space)
\+ Lasts longer cf epidural (2-4 hours)
\+ Reversible with Naloxone
  • Longer-lasting

General anaesthetic
+ ‘Complete pain relief’

  • Higher risk: tissue oedema (more problems associated), reduced GI tone, increased IA pressure, delayed GI emptying (regurgitation and asphyxiation) + increased GI acidity (regurgitation)
126
Q

Give 3 ways you may assess foetal wellbeing.

A

Pinard stethoscope
CTG
Foetal blood sample

127
Q

State 3 factors determining FHR.

A
  • Gestation: younger = faster
  • Drugs: Impact rate and variability e.g. Mg = less variability
  • Pyrexia
  • Cerebral activity
  • Hypoxia
  • Cord compression
  • Blood pressure
  • Blood-gas concentration
128
Q

What is a CTG?

A

investigation recording foetal heartbeat and uterine contractions during pregnancy

129
Q

What systematic way is used to interpret a CTG?

A

Dr C BRAVADO

  • Dr – Determine Risk:
  • C – Contractions
  • Bra – Baseline Rate -> 110-160bpm
  • V – Variability -> 5-25bpm
  • A – Accelerations
  • D – Decelerations -> none or early + no concerning characteristics for 90 minutes
  • O – Overall assessment
130
Q

State 5 indications for continuous CTG monitoring in labour?

A
  • Maternal tachycardia
  • Maternal pyrexia
  • Suspected chorioamnionitis/sepsis
  • Presence of significant meconium
  • Fresh vaginal bleeding
  • Hypertension/Proteinuria
  • Confirmed delay in labour (1st or 2nd stage)
  • Hypertonus or tachysystole
  • Oxytocin use
  • Reported pain out-with the normal
  • Preterm
  • Multiple pregnancy
131
Q

Outline how foetal blood sampling is conducted and why?

A

• Fetal scalp capillary sample -> assess acidaemia (pH > 7.25 = reassuring; pH < 7.20 = non-reassuring/immediate delivery)

132
Q

What defines the foetal skull diameter?

A

Distance between occipitus and anterior fontanelle

133
Q

During normal vaginal delivery, describe the movements the foetus makes accompanied by the pelvis in order to assist delivery.

A
  • Pelvic inlet widest in transverse diameter -> often baby descends in L or R occipitolateral position
  • Neck flexes so presenting diameter is suboccipitobregmatic (face)
  • Internal rotation of head = occipitoanterior position
  • Head delivers by extension + shoulders rotate into AP diameter of pelvis
  • Anterior shoulder delivered by lateral flexion downward pressure on baby’s head
  • Posterior shoulder delivered by lateral flexion upwards
134
Q

What is malpresentation?

A

non-vertex presentation

135
Q

Describe the various forms of malpresentation.

A
  • Face
  • Brow
  • Breech (extended/flexed/footed)
  • Transverse
136
Q

Which three variations of breech presentation exist?

A

Extended - legs extended upwards
Flexed - legs flexed
Footed - feet are engaged

137
Q

State the key indications for assisted vaginal delivery.

A
  • Failure to progress into active 2nd stage of labour
  • Maternal exhaustion
  • Pathological CTG
  • Abnormal FBS
  • Prophylactic shortening of 2nd stage: hypertensive crisis/ cardiac disease/ cerebrovascular disease
138
Q

Outline the criteria for assisted vaginal delivery.

A
  • Consent
  • Analgesia
  • Empty bladder
  • Abdominal palpation: head engaged 0/5 palpable
  • Vaginal examination: cervix fully dilated (10cm), membranes rupture, presenting part at/below ischial spines
  • Position of fetal head (OA/OP)

Note: If not OA, rehires rotational delivery via manual/ventouse/forceps

139
Q

What are the two main forms of AVD?

A

Ventouse

Forceps

140
Q

Evaluate the benefits and risks of the forms of assisted vaginal delivery.

A

Ventous
+ Less maternal injury risk
+ Less use of RA
+ Less post-op pain

  • Less likely to result in successful vaginal delivery
  • Cephalohaematoma (subperiosteal blood collection within suture lines)
  • Subgaleal haematoma (subperiosteal blood collection crossing suture lines)

Forceps
+ Less likely to get intracranial injuries (cephalohaematoma/subgaleal haematoma)
+ higher % of successful vaginal delivery
+ Shorter time

  • More likely to injure the mother - perineal and vulval tear
141
Q

What is a complication of AVD?

State 2

A

Unintended consequence due to assisted vaginal delivery to either mother or baby

Shoulder dystocia

Subgaleal haematoma

Cephaloheamatoma

Facial palsy

Perineal tears

142
Q

Describe a shoulder dystocia.

A

impaction of anterior shoulder behind symphysis pubis

143
Q

State 3 RFs for shoulder dystocia.

A
  • Macrosomia
  • DM
  • Post-term
  • Obesity
  • Multiparous
  • AVD
  • Prolonged 1st/2nd stage
144
Q

State the potential foetal complications which may occur in shoulder dystocia.

A
  • Hypoxia: trapped umbilical cord, pH drop, mortality (5-7% risk)
  • Cerebral palsy
  • Nerve damage: Excessive downward traction
145
Q

A woman is experiencing a particularly challenging labour. There is a potential risk of a shoulder dystocia.

How would you manage this?

A 
Management: HELPERR
•	Help
•	Episiotomy
•	Legs to McRoberts
•	Pressure
•	Enter manoeuvres
•	Remove posterior arm
•	Roll over
146
Q

Outline the categories of perineal tear.

A
  • 1st Degree: Injury to skin ± vaginal mucosa
  • 2nd Degree: Injury to perineum involving muscles, not sphincter
  • 3rd degree: Injury to perineum involving anal sphincter
  • 4th Degree: Injury to perineum involving anal sphincter complex (EAS + IAS) + anorectal mucosa
147
Q

How do you manage a perineal tear?

A
  • Surgical management

* Physiotherapy

148
Q

State 5 indications for a caesarean section.

A
  • Malpresentation: Breech
  • PMHx Cesarean
  • Severe growth restriction/placental insufficiency
  • Placenta praevia
  • Suspected fetal compromise
  • Failure to progress in labour
  • Unsuccessful AVD
  • Maternal request
  • POH
  • Twins
149
Q

Outline the key categories for caesarean section need.

A
  • 1: Requiring immediate delivery
  • 2: Requiring urgent delivery
  • 3: Requiring early delivery
  • 4: Elective
150
Q

Outline the process of a first breath.

A

Detachment from placenta causes a reduction in oxygen supply this hypercapnia and hypoxia drive to respiratory control centre in the Medulla. This drives the expansion of the lungs which is aided by a slight negative pressure (-25mmHg) present to oppose the foetal pulmonary surfactant.

151
Q

State the causes of hypoxia during delivery.

A 
Cord compression
Placental abruption 
Premature placental separation
Excessive uterine contraction
Excessive anaesthesia
152
Q

Which cells secrete pulmonary surfactant?

A

Type 2 pneumocytes

153
Q

Which drug can be given to increase lung development in pre-term (<37 weeks) babies?

A

Steroids - bethametasone

154
Q

State the main foetal variations in circulation.

A

Foramen ovale
Ductus arteriosus
Ductus venosus

155
Q

What is the ductus venosus a conduit between?

A

Umbilical vein and IVC

156
Q

What is the foramen ovale a conduit between?

A

RA and LA

157
Q

What is the ductus arteriosus a conduit between?

A

Aorta and pulmonary artery

158
Q

Outline how the foramen ovale is closed.

A

LA p > RA p due to ∆ in pulmonary resistance and systemic vascular resistance ≈ close septum over opening

159
Q

Outline how the ductus arteriosus is closed.

A

• Closure of Ductus Arteriosus: Functional closure of ductus arteriosus as increased oxygenation of blood through ductus + PGE2 reduced (less vasodilation) + aortic pressure increases (due to systemic vascular resistance increasing) + venous pressure decreases (due to pulmonary pressure reducing) + fibrous tissue grows into lumen

160
Q

Should the ductus arteriosus remain patent, what type of murmur is heard.

A

Continuous machinery murmur

161
Q

How is a patent ductus arteriosus treated.

A

Indomethacin - NSAID thus reduces PGE2 to help close

162
Q

Describe the changes in blood volume for the foetus after birth.

A

Isovolumic: Increased Hct but fluid lost into tissue space - increases with age

163
Q

Describe the changes in CO in a newborn foetus.

A

High - 500mL/min

164
Q

Describe the blood count differences between a foetus and an adult.

A

Higher WBC

Higher RBC (hypoxic stimulus) - stabilises at 4.75million/cm3 as drive reduced

165
Q

Outline the key differences between a newborn foetus and an adult regarding ventilation.

A

Foetus RR = 40 cf adult RR = 12-16

Tidal air = 15mL

Minute ventilation = 640mL/min thus 2x cf adult

166
Q

What is the risk of fluid and acid-base changes in a neonate and why?

A

• Acidosis and dehydration/overhydration %: Increased fluid intake and excretion + BMR high creating acid + incomplete kidney development

167
Q

Why may jaundice be present in a newborn? Explain.

A

Physiological jaundice occurs due to bilirubin rising (from increase in erythrocytes) and inability of immature foetal liver to conjugate bilirubin with glucuronic acid thus physiological hyperbilirubinaemia.

168
Q

Outline the process of Erythroblastosis foetalis.

How do you manage this?

A

Rh incompatibility occurs if baby inherits Rh positive RBC and mother is Rh negative. Mother detects foetal blood as foreign thus antibodies destroy foetal red blood cells and bilirubin is elevated in the neonate.

Manage with Anti-D

169
Q

With an immature liver, which changes might you expect in a newborn infant?

A
  • Hypoproteinaemia: Hepatic protein synthesis is low thus [plasma] reduces -> hypoproteinaemia
  • Reduced glucose: Impaired gluconeogenesis function thus blood glucose level falls to half
  • Reduced coagulation: Liver of neonate forms too little clotting factors
170
Q

Describe the important thermoregulatory differences in the neonate.

A

BMR is high

Heat rapidly lost (high SA:V ratio)
Poor thermoregulatory mechanisms
High BAT - thermogenesis

171
Q

Why may a neonate lose weight initially? Describe the processes involved.

A

Pre-partum, energy derived from glucose in maternal blood.

Post-partum, glucose supplied by immature liver and muscle glycogen. These stores are used up thus falling blood glucose.

Impaired gluconeogenesis due to immature liver thus catabolic process of lipolysis and proteinolysis to drive Kreb’s Cycle for ATP.

Weight loss occurs

Nutrients acquired from high-strength colostrum 2-3 days following

172
Q

Which micronutrients are key yet difficult to absorb in the neonate?

A

Vitamin D - high requirement and poor GI absorption thus lower intake

Iron - depleted hepatic iron stores

Vitamin C - not stored well

173
Q

What is the main form of immunity provided from the mother to the neonate in the 1st month?

A

Humoral immunity

Gamma globulins decrease

Alpha globulins present in breast milk

174
Q

What age do gamma globulins begin to increase in the neonate?

A

12-20 months

175
Q

State the key roles of microbiology.

A
  • Diagnostic tests
  • Interpretation of results + clinical consultations
  • Treatment advice
  • Infection control
176
Q

Outline ways a microbiologist may make a diagnosis.

A

• Direct examination: Smear + Microscopy
• Culture: Culture diagnosis
• Serology: Agglutination + Precipitation + Complement fixation + Virus neutralisation
+ ELISA + RIA + Immunofluorescence
• Molecular: DNA hybridisation + PCR + LCR + Automated DNA amplification + Real time PCR

177
Q

Weigh up the benefits and costs of direct examination vs microscopy.

A 
Direct Examination
•	Smear diagnosis
\+ Rapid
\+ Simple 
\+ Cheap
  • Not very sensitive
  • Not very specific
  • Requires expertise

• Microscopy
+ Variety of types
+ Quick

  • Requires expertise
  • May require preparation
178
Q

Give 3 examples of specimens you can acquire.

A
  • MSU
  • Pus or swab wound
  • CSF or blood
  • Serology
  • Sputum
  • Lavage
179
Q

Describe the difference between sensitivity and specificity.

A
  • Sensitivity = ability to detect all of true positive (SnOUT)
  • Specificity = ability to detect all true negatives (SpIN)
180
Q

Describe what is meant by normal flora.

A

flora everywhere including commensal and opportunistic pathogens

Obstetrics and Gynaecology (8 decks)

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