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Highyield obstetrics Takinganobstetrichistory • G – number ofpregnancies • Currentpregnancy: • Scanresults, screening e.g. down’ssyndrome,single/multiple, • P – number oftimesshe gave birth> 24 weeks illnesses, complications, folic acid, vaccines etc • Key obstetric symptoms? • Mentalhealth • Nausea and vomiting • Reducedfetal movements • Previous pregnanciesand deliveries: • C-sections, complications • Vaginal bleeding • Abdominal pain • Any miscarriages,abortions, still births, ectopic? • Uptodate withcervicalscreening? • Vaginal discharge/fluid loss • Any gynae conditionsortreatments? • Headaches, vision changes, epigastric pain, oedema • PMH, DH, allergies, FH, Social • Pruritus • Unilateralleg swelling,chestpain,SOB • Ifthere is time ask ifthey feel safe at home – domesticabuse • Urinarysymptoms • Systemic symptoms e.g. fatigue, fever, weight loss • ICE WEEKS PURPOSE <10 weeks Bookingvisit: 1. Advice –folic acid,vitaminD, avoidsmoking, alcohol and vitaminAsupplementsetc. 2. Baseline–BP,urine dip,BMI 3. Bloods –FBC,bloodgroup,rhesusstatus, haemoglobinopathies,hep B,syphilis,HIV 4. urineculture–asymptomatic bacteriuria 10-14 weeks Datingscan –gestationalage,excludemultiplepregnancy Down syndrome combinedtest –nuchal translucency (thick),b-HCG(high),PAPP-A(low) Antenatalcare -Edward (18)andpatau (13)aresimilarbut hCGis lower. 15–20 weeks Quadrupletest fordown’ssyndrome -AFP (low), oestriol (low), hCG(high),inhibinA(high) 20 weeks Anomalyscan 28 weeks Screenforanaemiaand alloantibodies First doseofanti-D prophylaxisifrhesusnegative 34 weeks Seconddose of anti-D prophylaxis Discusslabourand birthplan 36 weeks Checkpresentation –offerECV ifnecessary 40+ weeks Discussoptionsforprolongedpregnancy/induction Diabetespre-conceptioncounselling General advice: • high BMI – loseweight, eat healthy, exercise • manage chronic conditions e.g. diabetes ideallybefore getting pregnant • retinopathy screening before and at 28 weeks. 5mg folic acid before and to 12 weeks pregnant • stop contraindicated medications e.g. diabetic meds but insulin and metformin,ACE/ARBs, NSAIDs,teratogenic Who needs 5mg folicacid? • Epileptic medication, diabetes, highBMI Encourage vitamin Dsupplements and iron rich foods Avoid vitamin A supplements Avoid unpasteurized dairyand undercooked poultry Gestationaldiabetes • Insulinbecomes lesssensitiveduring pregnancy, usually Management: resolvesafter birth - > 7 or>6 with macrosmia - startinsulin+/- metformin • Risk factors: • Previous GD - < 7– exerciseanddiet for 1-2 weeks → metformin→ insulin • FH ofdiabetes - 4 weekly USStomonitor fetalgrowth • Previous big baby > 4.5kg • High BMI> 30 - advise against a home birth • Ifatrisk, screenat24-28weeks withOGTT Complications: macrosmia → shoulder dystocia • Diagnosis– 5,6,7,8 • Fasting > 5.6 Neonatal hypoglycaemia • 2 hour glucose> 7.8 Ectopicpregnancy • Implantedoutside ofthe uterus • Investigations • pregnancy test • Typicalhistory ofa late period(6-8 weeks), constant lower abdominal pain, vaginal bleeding • transvaginal USS • hCG • Peritonism– shoulder tippainandpainon • management: • urination/defecation • Expectant • Medical - MTX • surgical • O/E • abdominal tenderness • cervicalexcitation/motion tenderness • adnexalmass (NOT recommended to check dueto risk of rupturing it) Hyperemesisgravidarum • RegularN/V is commonandusuallyresolves by 20 weeks • Management: • HG isworse. Severe persistent N/Vwhichcanlead to: • Admit if severe • Dehydration, >5% weightlosssince pregnancy, electrolyte • IV fluids– saline and KCL disturbance • VTEprophylaxis– LMWH + TEDstockings • Alsocheckfor ketonuria • Anti-emeticsPCOM – prochlorperazine, cyclizine, ondansetron, • PUQEscore > 12 = severe, <7 = mild metoclopramide • thiamine topreventWernicke's Pre-eclampsia • Thoughttobe duetoabnormalblood vesselsinthe minimum 75mgaspirindaily from 12 weeksuntil birth placenta whichcauseshighblood pressure and toprevent pre-eclampsia reduced perfusionoforgans • Management: • NewonsetBP >140/90 after20 weeksof pregnancy • Ifsuspected,emergency secondarycareassessment AND 1+of: • >160/110–admit andobserve • Proteinuria • Giveoral labetalol (or nifedipine ifasthmatic) • Otherorganinvolvement e.g.renalinsufficiency,liver, • Definitive management isdeliveringthebaby neurological etc • Preventeclampsiawithmagnesium sulfate oncedecisionto • Riskfactors: deliverhas beenmadeand fluidrestrict to preventoverload • HTN,previouspre-eclampsia,diabetes,CKD,>40 y/o, BMI > 35etc • CheckLFT forHELLP syndrome • Commoncommsstation –lady doesn’t want to be • Symptoms: admittedeventhough she hasBP >160/110 and • headache,vision disturbances,epigastric pain,N/V,oedema, symptomsof pre-eclampsia.Must inform about riskof reducedUO,briskreflexes deathifleft untreated. • Ifthey have 1highriskor2 moderateriskfactors–take HELLP • Complicationof pre-eclampsia and • Symptoms: eclampsia • N/V • 20% ofpeoplewith severepre- • RUQ pain eclampsia develop HELLP • Lethargy • Haemolysis Treatment –delivery the baby! • Elevated Liver enzymes • Lowplatelets Breechbaby • Baby usuallykicksitselfspontaneouslyintocephalicpresentationby 36 • Management: weeks • 36weeks+offerECVtomanually turnbaby • 50%success rate • Riskfactors: • Givetocolyticslike terbutaline • Riskofplacental abruption. • Uterine malformation,fibroids • Placenta previa • Poly/oligohydramnios • Ifstillbreech,discussbirthingoptionwith mum,includingplanned sectionvsbreechvaginal delivery • Chromosomal disorders • Prematurity • ContraindicationstoECV: • Where c-sectionisrequirede.g.placenta previa • Complications –cordprolapse,failuretoprogress,birthinjuries, • Antepartumhemorrhageinthe last 7days instrument use,emergency c-section • Abnormal CTG • Majoruterine abnormalities • Rupturedmembranes • Multiple pregnancy Vaginaldeliveryvsc-section • c-sectionfor breechdeliveryhas areducedperinatal mortalityandearly neonatalmorbiditycompared to planned vaginalbirth • There isnoevidence thatthelong-termhealthof abreechbabyisinfluenced byhow itisborn • Pros andconsofboth? VBAC • Plannedvbacis appropriateforwomen 37weeks+ whohavehada single previousc-section as 75%ofthese womenhave a successfulvaginaldelivery • Contraindication –classicalc-sectionscarorprevious uterine rupture • Advantage:shorterrecoverytimeandhospital stay,nomajorsurgery,subsequentdeliveries more likelytobe successfulvaginally • Disadvantage:scar/uterine rupture –requires continuousCTGmonitoring • Having another c-sectioninstead? • Disadvantage:More difficult, adhesions, placenta attaching in the wrong position, vaginal deliveries become riskier,general operation risks – bleeding, damage, infection • Advantage – avoids risk of rupture Birthoptions • Take a fullhistory -previousbirths,current pregnancy,co- Usuallyforpainmanagement orfailure toprogress morbidities/riskfactorsand importantlyICEto findout the patient’swishes–painmanagement, personalpreference, • Hospital births: whotheywant tobethere etc • Advantage–epidural forpain,emergencyequipment and doctorsreadilyavailable • Homebirth: • Disadvantage –lesspersonal • Forlow-riskpregnancies • Homeshould be of adequatesize,heating,lighting and hygiene.Accesstotelephoneincase of emergencies. Careravailable forotherchildren. • Midwife led birthingcenter • Advantage–more comfortable,likely know their • Contraindicated –breech,HTN,Hx of antepartum midwife hemorrhage,VBAC,othercomplications • Disadvantage -no epidural,mayneed tobe • Advantages:familiarenvironment,withfamily transferredto hospital if highrisk • Disadvantage –no epidural,hemorrhage management,transfertime tohospital incase of emergency • 25%offirst timebirthsneedtransfertohospital Shoulder dystocia • Baby’sheadisdeliveredbutthe body is stuckbecause the anterior • Applypressureto thesuprapubicregiontopushthe anterior shoulder shoulder is lodgedbehind the pubic symphysis down • This is anemergency whichcanlead tomaternal and fetal death • Rubin's maneuver– reach into vaginaandhelpmove the anterior shoulder • Risk: • Macrosmia–associatedwithdiabetes • Woodscrew– during rubinsmanouverreachthe other handintothe • HighBMI vagina and putpressureon the posterior shoulder • Diabetes • Longlabor • Zavenelli – pushbaby’s headbackintothe vagina todoanemergency section • Turtle-neck sign andfailure ofrestitution – baby’s facestays downwards and doesn’tturnsideways • Complications: Management: • Fetal hypoxia – cerebralpalsy • Brachialplexus injuryand erb’s palsy • emergency – involveseniors • Perineal tears • McRoberts maneuver – flex andabduct themum’ships andbring thighstoabdomen • Post partum hemorrhage smallforgestationalage • Lessthan10 centileforgestationalage • Monitoring: • basedonestimatedfetal weightand fetal abdominal • symphysisfundal heightcheckedat everyappointment from24weeks circumference onwardsplottedon customizedchart.Ifit islessthan10 centile,do • Plottedoncustomizedgrowthchart serial growthscansand umbilical artery doppler • Lowbirthweight =<2.5kg • iftheyhave SGA checkamnioticfluidvolume, umbilical artery pulsatility index,estimatedfetal weightandabdominal circumference forgrowth • Causes: velocity • Constitutionallysmall–Family history • Fetal growthrestriction(IUGR) –small duetopathology reducing • Increase frequencyofUSS if there are concerns e.g.reducedflowthrough amount ofnutrientsandoxygendeliveredtobaby e.g.smoking, umbilical artery pre-eclampsia,alcohol,anaemia,infection,errorsin metabolism • Othersignsof SGA:Reducedamniotic fluid,lessfetalmovements, abnormalCTGanddopplerstudies • Complications ofSGA:stillbirth,asphyxia at birth,neonatalhypothermia andhypoglycemia • Increasedriskofobesity, T2D, HTN,cardiovasculardisease Placentapraevia • Placentais low lyingin thelower portion oftheuterus over the internal os,lower than the presentingpartof thefetus • Painlessantepartumhemorrhage • Risks:still birth,emergency c-section/hysterectomy,antepartumhemorrhage • Riskfactors:c-section, previousprevia,smoking,old,IVF, fibroids • Usuallypickedup on 20-weekscan → repeat TVUSS at32 weeks and 36 weeksif still present. Discuss plans for delivery – steroidsat34-36weeks.Planned section 36-37weeksto reduced risk of spontaneous delivery • Emergency section may beneededif they haveantenatal bleeding or premature labor Post partumhaemorrhage • >500ml aftervaginal delivery • Bloods –FBC,U&E,clotting,groupand save,cross match4 units • >1000ml inc-section • PrimaryPPH=within 24hrs of birth • Lie flat,keep warm,catheterize • Rubthefundusoftheuterus • Secondaryis24hrs–12 weeksaftere.g.retained placenta orinfection • Medication:Oxytocin,ergometrine,carboprost, • Causes: misoprostol • Surgery: intrauterine balloon,b-lynchsuture,uterine • Uterine atony,trauma e.g.perinealtear,tissuee.g. artery ligation,hysterectomy retained placenta,thrombin–bleedingdisorder • Prevention:treat anemia,give birthwithempty bladder,activemanagementof3 stageoflabor,IV • SecondaryPPH tranexamic acid inc-sectionif higherrisk • DoUSSforretainedproductsandendocervical swab and Management: highvaginal for infection • Surgicalevacuationor ABX • Obstetric emergency