Alice Graham

FY1

OBSTETRICS FOR

FINALS

Learning outcomes

1. Basic clinical skills – history, examination, investigations…

2. Ethics and legal issues

3. Clinical governance

4. Clinical pharmacology and therapeutics

5. Antenatal care in low-risk pregnancy, recognition of high-risk

and abnormal pregnancy and appropriate modifications to

antenatal care. Importance of preconception case.

6. Maternal medicine – effect of pre-existing medical conditions

on pregnancy and effect of pregnancy on these conditions

7. Management of labour and delivery

8. Postpartum problems.

Outline

Antenatal care

Antenatal schedule

Maternal screening

Foetal screening

Pregnancy Antepartum Haemorrhage

Gestational diabetes

Preeclampsia

Labour and

delivery

Premature rupture

membranes

Obstructed labour

Post-partum haemorrhage

Case study

Amy

32 years old

G3 P1+1

BMI 30, hypothyroidism

Antenatal care - questions

1.What dose of folic acid should Amy take and for how long?

2.How many antenatal visits would a multiparous expect to have?

3.What routine tests would be carried out at antenatal visits?

1.How would Amy’s baby be screened for Down’s syndrome?

1. Schedule of antenatal care

8-12

• Booking appointment

• Screening and dating

16 • Review results of screening

18-20

• Anomaly scan

• Nulliparous – extra visit @ 25/40

28

• Second screening, antiD prophylaxis

• Nulliparous – extra visit @ 31/40

34

• 2nd antiD prophylaxis

• Labour planning

36 • Assess foetal presentation

38 • Nulliparous –extra visit @ 40/40

>41 • Weekly from 41/40

ANTENATAL CARE

2. Maternal screening in pregnancy

Blood tests

• Hb

• Blood group

• Syphilis, rubella

• HIV, HepB

Urine

• Bacteriuria

• Protein

• Glycosuria

Examination

• BP

• Fundal height

• 36/40 lie and presentation

ANTENATAL CARE

3. Foetal screening in pregnancy

• Ultrasound – ‘soft signs’

• AFP

• Amniocentesis

• Chorionic Villus Biopsy

ANTENATAL CARE

3. Foetal screening in pregnancy

ANTENATAL CARE

Down’s syndrome

Combined test

10+3 to 13+6 weeks

Nuchal translucency Free B-HCG Pregnancy

associated plasma protein

Woman’s age

Integrated test

Combined test 1st trimester

AND Quadruple test in 2nd

trimester

Quadruple test

15 to 20 weeks

Maternal AFP Unconjugated estriol

Free/total BHCG Inhibin A

Woman’s age

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

Pregnancy - questions

1. How do we differentiate between placental abruption

and placenta praevia?

2. What complications are associated with gestational

diabetes?

3. What are the symptoms of pre-eclampsia?

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

20/40 – antepartum haemorrhage

1. Antepartum Haemorrhage

Genital tract bleeding from 24weeks

abruption

• Constant pain and tender uterus

• Normal lie and presentation

• Foetal heart absent or distressed

• Shock proportionate to visible blood loss

praevia

• No pain, abdomen non-tender

• Abnormal lie/presentation

• Foetal heart normal

• Shock disproportionate

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

20/40 – small haemorrhage – simple ectropion

28/40 – fasting glucose = 6.5mmol/l

2. Gestational Diabetes

Fasting glucose >5.6mmol/l

2hour OGTT >7.8mmol/l

PREGNANCY

Maternal complications

• Instrumental delivery

• Long term diabetes

• Pre-eclampsia

Foetal complications

• Macrosomia

• Growth restriction

• Metabolic abnormalities

• Premature birth

• Miscarriage

• Still birth

• Childhood/adult obesity

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

20/40 – small haemorrhage – simple ectropion

28/40 – gestational diabetes

36/40 – proteinuria 2+

3. Pre-eclampsia

Pregnancy-induced hypertension and proteinuria

Symptoms:

•Flu – headache, vomiting, tachycardia

•Neuro – visual disturbance, hyper-reflexia, seizures

•Organ failure – liver, renal, cardiac

PREGNANCY

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

Small antepartum haemorrhage,

gestational diabetes, pre-eclampsia

Things are about to get scary…

Normal Labour

3rd stage - placental

2nd stage - expulsive

1st stage - dilatation

Latent phase Active Phase

LABOUR AND DELIVERY

Labour and Delivery

1. How do we manage PROM?

2. What are the types of operative delivery?

3. What are the risk factors for PPH?

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

gestational diabetes, pre-eclampsia

Things are about to get scary…

Admitted to hospital due to pre-eclampsia

at 36/40.

Waters break in car ride to hospital.

1. Premature rupture of membranes

Rupture of membranes before 37+6 weeks

Benefits of remaining in utero

Vs

Risk of infection

LABOUR AND DELIVERY

CTG

D

R

C

B

R

A

V

A

D

O LABOUR AND DELIVERY

Define risk

Contractions

Baseline rate

Variability

Acceleration

Decelerations

Overall Impression

CTG

LABOUR AND DELIVERY

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

gestational diabetes, pre-eclampsia

Things are about to get scary…

PROM.

Amy starts to have contractions

2. Operative delivery

LABOUR AND DELIVERY

1

2

3

Perineal tears

LABOUR AND DELIVERY

Case study

Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

gestational diabetes, pre-eclampsia

Things are about to get scary…

PROM.

Amy starts to have contractions

Baby delivered using forceps.

Placenta delivered. 2nd degree tear.

Amy starts to lose a lot of blood…

3. Post partum Haemorrhage

Loss of >500mls of blood in first 24hours after delivery

LABOUR AND DELIVERY

Antenatal

• Previous PPH

• BMI>35

• Maternal anaemia

• Antepartum haemorrhage

• Multiparity

• Maternal age >35

• Uterine malformation

• Placental abnormalities

Labour

• Prolonged labour

• Induction

• Oxytocin use

• Operative birth

Case study Amy, 32 years old

Para 1+1, Gravida 3

BMI 30, hypothyroidism

gestational diabetes, pre-eclampsia

Things are about to get scary…

PROM.

Baby delivered using forceps.

Placenta delivered. 2nd degree perineal tear.

Amy starts to lose a lot of blood…

Bleeding controlled with suturing of laceration.

Amy stabilised and remains in hospital for 1 week.

Mum and baby well on discharge. THE END

Outline

Antenatal care

Antenatal schedule

Maternal screening

Foetal screening

Pregnancy Hyperemesis Gravidarum

Gestational diabetes

Preeclampsia

Labour and

delivery

Premature rupture

membranes

Obstructed labour

Post-partum haemorrhage

Alice Graham

FY1

OBSTETRICS FOR

FINALS