Obstetrics

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grignoter
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175716
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Obstetrics
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2013-03-16 12:16:24
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obstetrics gynaecology medicine
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obstetrics gynaecology medicine
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  1. Bishop's Score Factors
    • Cervical position (posterior, intermediate, anterior)
    • Consistency (firm, intermediate, soft)
    • Effacement (<30%, <50%, <80%, >80%)
    • Dilation (<1cm, 1 - 2cm, 3 - 4cm, >5cm)
    • Station (-3, -2, -1 or 0, 1 or 2)

    • Modified score:
    • + 1 for pre-eclampsia or each previous vaginal delivery
    • - 1 for post-dates, nulliparous, PPROM
  2. Bishop's Score Predictions
    • < 5 = induction likely
    • < 6 require cervical ripening
    • >8 = likely to acheive vaginal birth
    • > 9 likely to labour spontaneously
    • maximum 13
  3. Stages of Labour
    • 1. onset of regular painful contractions
    •      latent phase <4cm
    •      established phase >4cm dilated

    2. full dilation to delivery of the baby

    3. delivery of the baby to delivery of the placenta
  4. 1st Stage of Labour
  5. Term
    37 completed weeks - 42 completed weeks

    • < 37 weeks counts as premature
    • > 42 weeks may require induction
  6. Latent Phase of Labour
    From 0 - 4cm dilation of the cervix

    May last 2 - 3d in primiparous women or 8h in multiparous
  7. Station (of Presenting Part)
    • -3 = 3cm above spines
    • -2
    • -1
    • 0 = ischial spines = halfway point
    • 1 = 1cm below
    • 2
    • 3 = scalp/PP at perineum
  8. Second Stage of Labour
    Dilation to delivery

    • 1 hour passive descent
    • 2 hours or 1 hour of pushing (nulliparous or multiparous)
  9. CardioTocoGraph Reporting
    • Dr - define risk
    • C - contractions
    • BR - baseline rate
    • A - accelerations >15bpm for >15s
    • VA - variation >5
    • D - deccelerations
    • O - overview
  10. Physiology of the Onset of Labour
    • Inflammatory response:
    • - increased PG and oxytocin receptors on uterus
    • - decreased progesterone
  11. Symptoms of Labour
    • strong regular contractions (> 2:10)
    • rupture of membranes (confirmed by staff)
    • operculum "show" (mucus plug that drops out as cervix dilates and mucus thins)
  12. Spontaneous Rupture of Membranes
    if no contractions, wait up to 48h then induce labour
  13. Lochia
    vaginal discharge post-partum (may last 4 - 6 weeks) = blood, mucus and placental tissue

    • 3 stages:
    • 1. rubra/cruenta = red, 3 - 5 days
    • 2. serosa = thin, brown/pink, exudate + RBC, WBC, mucus. Persisting for weeks suggests late PPH
    • 3. alba/purulenta = white or yellow, 2 - 6 weeks, fewer RBC, mainly WBC, epithelium, cholesterol, fat, mucus. More than 6 weeks may suggest genital lesion.


    • Offensive odour = infection
    • Lochiostasis/lochioschesis = lochia retained in uterus
    • Lochiometra = distension of uterus
    • Lochiorrhea = excessive flow, may be infection
  14. Amniotomy
    = artificial rupture of membranes
  15. Anomaly scan
    20 week detailed scan of fetal anomaly

    Each organ, limb deformities, liquor volume, position of placenta

    Abdo circumference checking size of liver - 1st sign of starvation/IUGR is decreased AC:HC
  16. Antepartum Haemorrhage
    bleeding after 24 weeks
  17. Apgar Score
    Appearance (blue or pale all over / acrocyanosis, blue extremities and pink middle / pink all over)

    Pulse rate (absent / less than 100 / 100 or more)

    Grimace (no response to stimulation / grimace or feeble cry / cry and pull away)

    Activity (no muscle tone / some flexion / flexed limbs resist extension)

    Respiration (absent / weak, irregular gasps / strong lusty cry)
  18. Chorionic Villous Sampling
    placental sample taken before 16 weeks for chromosomal analysis
  19. Combined Test
    • serum screening triple test (14 - 18 weeks) = alpha-fetoprotein, HCG, unconjugated oestrogen
    • +
    • nuchal translucency (11  -13 weeks)

    for Down's syndrome
  20. Dating Scan
    • Ultrasound to date the pregnancy around 12 weeks
    • Also look for location of embryo, number, viability (double check with HCG > 1000)

    Foetal heart is visible on scan from 5/40
  21. Eclampsia
    fitting due to raised blood pressure, proteinuria and elevated liver enzymes
  22. External Cephalic Version
    when breech is turned to cephalic
  23. Foetus
    from 12 weeks
  24. Trimester
    • 1 = 0 - 12 weeks
    • 2 = 13 - 28 weeks
    • 3 = 29 weeks +
  25. HELLP
    • Haemolysis
    • Elevated Liver Enzymes
    • Low Platelets

    may develop from pre-eclampsia?
  26. Kleuhauer
    blood test to find amount of fetal blood cells in the maternal blood
  27. MROP
    manual removal of retained placenta - under anaesthetic in theatre
  28. Placenta Acreta
    morbid attachment of the placenta to the uterus, particularly where there is uterine scar tissue
  29. Symphysis Pubis Dysfunction
    pelvic pain during pregnancy
  30. Booking
    Ideally 8 - 12 weeks
  31. Postnatal period
    0 - 28 days

    Health visitor takes over care after 28 days until school age.
  32. Foetal Scanning
    • 12 weeks - dating, location, number, viability
    • 2nd scan screening?
    • 20 - anomaly
    • 4th scan of foetal well-being iff problems in previous scans
  33. Perineal Injuries
    1st degree = vaginal mucosa only

    2nd degree = subcutaneous

    3rd degree = into external anal sphincter

    4th degree = through EAS into rectal mucosa
  34. Types of Episiotomy
    • Mediolateral = 45 degrees to posterior forchette on one side
    • - less trauma, less blood loss, less infection, worse pain

    • Midline = vertical from posterior forchette towards rectum
    • - hastens delivery, severe trauma involving EAS
  35. Episiotomy
    a surgical incision made in the perineum to facilitate delivery

    > 30% vaginal deliveries

    preparation for operative delivery, shoulder dystocia

    no benefit to the mother
  36. Indications for Operative Delivery
    • Maternal:
    • - exhaustion
    • - inadequate expulsion (spinal cord injury, neuromuscular disorder)
    • - avoiding expulsive effort (cardiac disease, cerebrovascular disease)

    • Foetal:
    • - foetal distess/non-reassuring CTG

    • Other:
    • - prolonged second stage
    •      > 3 hours in nulliparous with analgaesia
    •      > 2 hours in nulliparous women without
    •      > 2 hours in parous with analgesia
    •      > 1 hour in parous without
  37. Requirements for Operative Delivery
    • Maternal:
    • - analgesia
    • - consent
    • - lithotomy position
    • - empty bladder
    • - adequate pelvimetry

    • Foetal:
    • - engaged vertex presentation
    • - station > +2
    • - known foetal position and attitude, caput and moulding

    • Uteroplacental:
    • - fully dilated
    • - ruptured membranes
    • - r/o placenta previa

    • Other:
    • - experienced operator
    • - capability for EmCS if needed
  38. Contraindications for Operative Delivery
    • Relative:
    • prematurity
    • fetal macrosomia
    • suspected fetal coagulation disorder
  39. Complications of Operative Delivery
    • Maternal:
    • - perineal injury - especially rotational forceps, not really increased in ventouse

    • Foetal:
    • - forceps
    •       - facial bruising or laceration
    •       - facial nerve palsy
    •       - skull fractures
    •       - cervical spine injury
    •       - intracranial hamorrhage
    • - ventouse:
    •      - caphalohaematoma (scalp bleeding)
    •      - scalp lacerations
    •      - possibly intracerebral haemorrhage?
  40. Brow Presentation
    occipitomental or mentovertical

    extended head

    13cm diameter

    • AF is anterior/central
    • PF is very anterior
  41. Face Presentation
    submentobregmatic

    • hyperextended head
    • 9.5cm

    AF very anterior or no fontanelles
  42. Deflexed Vertex Presentation
    • occipitofrontal
    • deflexed or partially extended head

    11.5cm

    • central AF
    • very anterior PF
  43. Vertex Presentation
    • suboccipitobregmatic
    • well-flexed head

    9.5cm

    • central or anterior PF
    • very posterior AF
  44. Partially Deflexed Vertex Presentation
    • suboccipitofrontal
    • may associated with OP

    10 - 10.5cm

    • PF anterior
    • AF posterior
  45. Cardinal Movements in Labour
    1. Engagement - the widest diameter passes the pelvic inlet (biparietal 9.5cm in vertex presentation) - usually by 36/40

    2. Descent

    3. Flexion

    4. Internal rotation - presenting part moves from transverse to AP, asynclitic then even

    5. Extension (of head over symphysis pubis)

    6. Restitution (extenal rotation of the head to match the torso)

    7. Expulsion - anterior shoulder over symphysis, then posterior shoulder, then body
  46. Semen Analysis - Normal Results 
    (WHO)
    • Volume > 2ml
    • pH > 7.2
    • concentration >20million per ml
    • total > 40 million per ejaculate
    • motility >50% a or b
    • morphology > 30% normal forms
  47. PCOS
    - Rotterdam Criteria (2003)
    2 out of 3 of:

    1. oligo or anovulation

    2. clinical or biochemical increased androgens

    3. USS polycystic ovaries: 12+ follicles of 2 - 9mm each OR >10cm cubed overall volume

    • AND
    • r/o Congenital Adrenal Hyperplasia, androgen-secreting tumour, Cushing's
  48. Fibroids
    • Presentation: menorrhagia, subfertility
    •     if large: peripheral oedema (obstructed venous return), urinary incontinence (compression)

    Risk Factors: Afro-Carribean, overweight, forties, fertile
  49. Ectopic Pregnancy Presentation
    • PV bleeding
    • abdominal pain
    • missed periods/positive pregnancy test
    • painful dysuria and painful BO
    • shoulder tip pain (blood under diaphragm)
  50. Presentation of Endometriosis
    • - menorrhagia
    • - dysmennorhoea
    • - dyspareunia
    • - chronic pelvic pain (adhesions)
    • - nulliparity (infertility or abstinence due to pain)
    • - cyclical haematuria
    • - haemoptysis
    • - painful, cyclical expanding masses in a pelvic scar
  51. Arias-Stella phenomenon/reaction
    benign change in endometrium associated with presence of chorionic tissue.

    Cells appear malignant but aren't. Characterised by nuclear enlargement, +/- irregular nuclear membrane, granular chromatin, centronuclear vacuolisation, pseudonuclear inclusions
  52. Vasa Previa
    • vessels coming from cord travel away from the placenta in the membranes and overlie internal os
    • risk of tear during dilation
    • 1 in 3000
    • clinical diagnosis
    • high foetal mortality (it is foetal blood being lost)
    • low maternal risk
  53. Symptoms of Vasa Previa
    abnormal CTG + <500ml painless PV bleeding
  54. Management of Vasa Previa
    • immediate CS
    • foetal transfusion
  55. Routine Indications for Caesarian Section
    • HIV (NB. not HBV/HCV alone)
    • primary genital HSV in 3rd trimester
    • placenta previa major
    • twins with first twin breech
    • singleton breech at term where ECV failed or contraindicated

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