Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

RANZCOG guidelines > Obs > Flashcards

Obs Flashcards

1
Q

Services requirements for the provision of intrapartum care

A

Timely access to - obstetric, midwifery, neonatal / paediatric, anaesthetic, operating theatre, resuscitation services, ICU consultation, haematology, blood bank
Birth centres ideally placed within (or immediately adjacent to) an appropriately resourced 24h obstetric facility
If by virtue of remote location, on-site services cannot be provided, women should be informed of the limitations of services available and implications for intrapartum and postpartum care
- Formal systems must be in place to ensure safe and timely transfer if required

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

% of women developing peripartum complications requiring transfer in low risk population

A

Amongst women selected for low obstetric risk, ~25% will develop peripartum complications necessitating transfer to an obstetrician led services

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

RANZCOG recommended routine labour cares

A

VE is indicated for women admitted in apparent labour unless there are contraindications - Should be done within 4h to diagnose and assess the progress of labour.
Care is optimised where there is a 1:1 midwifery support in labour in collaborative service
Involve woman and her support person in management decisions
WHO recommends maternal observations be graphically displayed on a partogram to facilitate review of progress
HR, BP, RR, temp, contraction frequency, duration, intensity, abdominal palpation, VE findings, liquor colour / presence, FHR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Labour positioning

A

Women should be encouraged to ambulate freely according to comfort, where it does not compromise maternal and fetal observations in labour
- Cochrane 2013 - first stage of labour may be approx 1h 20m shorter for women who are upright or walk around (Better studies needed to validate these results)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Fluids and oral intake in labour

A

Some evidence that inadequate hydration may increase the length of labour and need for oxytocin augmentation
Encourage clear fluids and light diet in active phase of labour to minimise risk of aspiration pneumonitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Antibiotics in labour

A

For prevention of GBS
For women at risk of chorioamnionitis or where other bacterial infection is suspected - e.g. fever >38 on one occasion or >37.4 on two occasions
Women with cardiac lesions susceptible to infective endocarditis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Impact of ARM on labour

A

Evidence that routine ARM shortens labour is largely lacking (Cochrane review 2009)
Risk of infection increased following rupture of membranes
ARM provides useful information on fetal wellbeing (liquor volume and colour)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Relative contraindications of ARM

A

HBV, HCV, HSV and HIV infection
- In order to minimise the risks of ascending infection
- In developing countries where incidence of HIV is high, amniotomy is developed in labour to reduce vertical transmission rates
Presenting part high and mobile

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Monitoring labour progress

A

Most trials do 2 hourly cervical assessments
- Enables dystocia to be diagnosed and correctly early
- But added maternal discomfort of more frequent exams and potential for introducing infection
Compromise: 4 hourly VE
If full dilatation not clinically apparent after a woman is 9cm, further VE beneficial to confirm full dilatation or allow diagnosis of FTP if not fully
Second stage
- Reassessment at 2h in primigravida and 1h in multigravida

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Definition of failure to progress

1st stage
Before established labour

A

No upper limit to the length of the ‘latent phase’ can be defined
Not uncommon for labour to stop and start before finally established
Recurrent or prolonged episodes of spurious labour may contribute to a legitimate decision for IOL in some women

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Definition of failure to progress

1st stage
In established labour
- primigravida

A

10th centile for progress of cervical dilatation in labour is 0.9 cm/hour (primigravida)

Threshold at which slow cervical dilatation merits a recommendation for oxytocin:

  • Individualised with an informed discussion with the woman
  • Commonly 1cm/hr for most women in spontaneous labour
  • May be as high as 1cm / 2hr in women prioritising low intervention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Definition of failure to progress

1st stage
In established labour
- multigravida

A

10th centile for progress of cervical dilatation is 1.2cm/hr (multigravida)

Caution for augmentation as increased risk of uterine rupture compared to primigravida

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Definition of failure to progress

2nd stage

A

Progress in includes flexion, rotation and descent
Normal for primigravida = up to 2 hours
Normal for multigravida = up to 1 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

When to consider episiotomy

A

Episiotomy should be considered where there is a high likelihood of severe laceration

  • Soft tissue dystocia
  • Requirement to accelerate birth of a compromised fetus
  • Need to facilitate operative vaginal birth
  • History of FGM
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

When to recommend physiological third stage

A

“Expectant” or “physiological” management cannot be recommended on the basis of evidence and is associated with approximately a two-fold increase in the incidence of postpartum haemorrhage and an increased risk of blood transfusion when compared with active management

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Associations of delayed cord clamping in preterm infants

A

reduced risk of requiring transfusion, infection, NEC, and intraventricular haemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Associations of delayed cord clamping in term infants

A

increased haematocrit and reduced iron deficiency at 3-6 months of age
However increased risk of polycythaemia and jaundice

No clear evidence to guide practitioners regarding DCC in term infants
Infants are most likely to benefit if maternal iron stores are low, or in infants who will be exclusively breast fed without iron supplementation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Positioning for delayed cord clamping

A

~75% of available placental blood for transfusion is achieved in the first minute

Transfer of blood from placenta to newborn is facilitated by the infant being held below the level of the in situ placenta

  • If infant 10cm above or below the placenta, transfusion is complete within 3 mins
  • If 40cm below, transfusion time is shortened to 1 min
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Routine newborn care

A
  • Assess immediately as to the need for resuscitation
  • Skin-to-skin should be facilitated providing there are no maternal or neonatal complications
  • Apgar scores at 1 and 5 mins of age
  • Regular neonatal obs - RR, HR, colour, tone, reflex irritability
  • Observe for signs of respiratory distress - grunting, nasal flaring, intercostal retraction, tachypnoea, cyanosis
  • IM vitamin K recommended
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Routine maternal postpartum care

A

Regular maternal obs (HR, BP, temp)
Palpation of the uterine fundus to exclude atony
Inspection of the perineum to exclude excessive PP blood loss or development of vulval haematoma

Debriefing opportunities should be provided following an adverse outcome or experience that did not meet the expectations of the woman or her partner

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Reasons for GDM screening

A

Evidence suggests benefit of reduced perinatal mortality in screening and treating GDM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

RANZCOG GDM screening recommendation

A

75g 2h OGTT at 26-28 weeks
Earlier if high risk, and repeat at 24-28/40 if negative

Fasting: >/= 5.1 mmol/l

1h: >/- 10.0 mmol/l
2h: >/= 8.5 mmol/l

Polycose not recommended

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

GDM risk factors

A

Pre-pregnancy BMI >30
Previous macrosomic baby (>4.5kg or >90th centile)
Previous GDM / hyperglycaemia in pregnancyFHx of diabetes (1st degree relative or sister with GDM)
Minority ethnic family origin with high prevalence of diabetes
- Asian, Indian, Aboriginal, Torres Strait Islander, Pacific Islander, Maori, Middle Eastern, non-white African
PCOS
Medications - corticosteroids, antipsychotics
Maternal age >40

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

ADIPS diabetes mellitus in pregnancy diagnosis

A

Fasting >/= 7.0 mmol/l

2h or random >/= 11.1mmol/l

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

BSL targets on treatment

A

Fasting: <5.0 mmol/L
2 hours after meals: <6.7 mmol/L
If >10% of readings above targets, then reassess treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Iodine supplementation recommendation

A

RDI if pregnant, planning a pregnancy, or breast feeding: 150 micrograms/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Definition of overt hypothyrodism

A

Overt hypothyroidism should be treated in pregnancy

  • TSH >reference range with decreased T4, OR
  • TSH >10mIU/L, irrespective of the level of FT4
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

RANZCOG recommendation for screening for hypothyroidism in pregnancy

A

No studies show thyroxine influences outcome
Routine screening and treatment not recommended

Test if symptoms of thyroid disease or personal Hx of thyroid disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Main cause of hypothyroidism in NZ and Au

A

Hashimoto’s thyroiditis

30
Q

Physiology of thyroid hormone production in pregnancy

A

Increase (2-fold) in serum thyroxine-binding globulin (TBG) –> increase in T4 and T3 but free T4 remains unchanged

Stimulation of the thyrotropin / TSH receptor by HCG
○ HCG has weak thyroid stimulating activity as structurally similar to TSH
○ Normal increase in HCG in early pregnancy may cause a small transient increase in free T4 with subsequent TSH suppression

T4 and T3 levels rise by approx 50% during the first half of pregnancy, plateau at 20/40, then new steady state is reach and overall production rate returns to prepregnancy rates
Fetus is reliant on transplacental transfer of maternal thyroid hormone (T4 and T3) until the fetal thyroid starts to become functional from 12/40

31
Q

Iodine state during pregnancy

A

Relative maternal iodine deficiency

  • 2-fold increase in renal loss (increased GFR + decreased reabsorption)
  • Active transport of iodine to fetus

Uptake of plasma iodide into the thyroid is increased 3-fold
Insufficient dietary iodine –> cellular hyperplasia and goitre

Fetus and fully breastfed infant are dependent on maternal iodine for thyroid hormone synthesis

32
Q

Risks of overt hypothyroidism

A
  • Miscarriage
  • PET
  • Abruption
  • PPH
  • Anaemia
  • Low birth weight
  • Prematurity
  • Perinatal mortality
  • Stillbirth
  • Impaired neurological development
  • Low offspring IQ

Adequately treated hypothyroidism is not a/w any adverse maternal, fetal or neonatal complications

33
Q

Pregnancy outcomes with subclinical hypothyroidism

A

Results for large cohorts and meta-analyses have not been consistent in demonstrating an association between SCH and adverse pregnancy outcomes

High quality prospective RCTs involving >100,000 women have not demonstrated any maternal or neonatal benefits from treatment of SCH with thyroxine

Associated with childhood developmental delay has not been confirmed in prospective cohort data

34
Q

Incidence of obesity / overweight

A

~50% of women who become pregnant are either overweight or obese

35
Q

Increased antenatal risks for obese women

normal BMI vs. BMI >40

A 
Miscarriage
GDM (1% vs. 7%)
Fetal congenital abnormalities - E.g. increased risk of NTD - recommend high dose folate 5mg/day
Stillbirth (perinatal death - 0.7% vs. 2%)
PET (if BMI >35)
HTN in pregnancy (2% vs. 10%)
Thromboembolism (risk of PET > DVT)
Abnormalities in fetal growth
Obstructive sleep apnoea 
Preterm birth (7% vs. 11%)
Maternal death
36
Q

Increased intrapartum risks for obese women

A 
IOL, prolonged labour and failure to progress
Rate of instrumental delivery 
Failed instrumental delivery
Shoulder dystocia
Caesarean section (33% vs. 52%)
Difficulties with fetal heart rate monitoring 
PPH
Peripartum death
37
Q

Increased anaesthetic risks for obese women

A

Difficulties with labour analgesia
Use of GA
Difficultly maintaining an adequate airway, failed intubation
Increased risk of need for ICU care post-op

38
Q

Increased postpartum risks for obese women

A 
Delayed wound healing and infection
Thromboembolic disease
Greater likelihood of needing support with breastfeeding establishment and continuation
Postnatal depression
Long term neonatal consequences
- Neonatal body composition
- Infant weight gain
- Obesity
39
Q

BMI definition and WHO categorisation

A

Weight in kg / square of height in metres

Underweight 	<18.5
Normal	18.5 - 24.99
Overweight	25 - 29.99
Obese class 1	30 - 34.99
Obese class 2	35 - 39.99
Obese class 3	>40
40
Q

Fetal / neonatal risks with obesity

normal BMI vs. BMI >40

A 
Neonatal mechanism ventilation (5 vs. 10%)
PTB (7 vs. 11%)
Macrosomia (11 vs. 21%)
SGA customised (11 vs. 19%)
LGA customised (11 vs. 16%)
41
Q

Obesity - prepregnancy management

A

Weight management strategies:
- Dietary modification - consider referral to dietician
- Exercise
Discuss impact of obesity on fertility and pregnancy outcomes
Modest gain of 1-2 BMI units between pregnancies may increase the risk of gestational HTN, macrosomia, GDM
Medications or surgery for weight management are not recommended around the time of conception or during pregnancy

Advise supplement containing folate (high dose 5mg/day) and 150mcg iodine pre-conception
Address psychosocial concerns
Offer contraception to allow time for weight optimisation

42
Q

Prior bariatric surgery

A

Require closer monitoring of their nutritional status and fetal growth
Current evidence suggests a positive outcome in reduction of maternal risks during pregnancy, such as GDM, but with an increase risk of FGR and stillbirth
Pre-pregnancy counselling
- Should be on lifelong vitamin supplementation
- Referral to dietician, especially if malabsorptive surgery - may require additional supplementation during pregnancy - vitamin B12, iron, folate, vitamin D, calcium
- Avoid pregnancy for 12-24 months after surgery and during the initial weight loss phase

43
Q

Weight loss between pregnancies:

A 
Reduces the risk of:
	○ Stillbirth
	○ Hypertensive complications
	○ Fetal macrosomia
Increases the chances of successful VBAC
44
Q

Recommended weight gain in pregnancy

A

Underweight - 12.5 to 18kg

Normal weight - 11.5 to 16kg

Overweight - 6.8 to 11.3kg

Obese (includes all classes) - 5 to 9.1kg

45
Q

Recommended weight gain for multiples

A

Normal weight 17 to 25kg
Overweight 14 to 23 kg
Obese (includes all classes) 11 to 19 kg

46
Q

Timing of birth in obese women

A
  • No universal consensus
  • Observational data comparing outcomes before and after a protocol of delivery by 40/40 found a significant reduction in the risk of CS for obese women
47
Q

Intrapartum management obese women

A

IV line on admission to labour ward
May need to confirm presentation with USS
Awareness of increased risk of shoulder dystocia and PPH
Operating theatre staff need to be altered regarding increased weight (usually >120kg)
To ensure adequate staffing and equipment available

48
Q

Postpartum management obese women

A

Use of Rh(D) immunoglobulin
- Some evidence to suggest IM anti-D may be associated with increased risk of lack of effect in patients with a BMI >30 - however insufficient evidence to support a change in practice
Breastfeeding support
- Obesity is associated with lower rates of breastfeeding initiation and maintenance
- Breastfeeding has been associated with postpartum weight loss
Consider VTE prophylaxis
Weight management postpartum

49
Q

Benefits of exercise during pregnancy

A

Physical benefits - fitness, prevention of excessive weight gain, lifelong benefits (reduced CVD, T2DM, some cancers)
Psychological wellbeing - reduced Sx of depression
No evidence detrimental to fetus or woman
Regular exercise during pregnancy has been a/w shorter and less complicated labour, and fewer neonatal complications (but inconclusive evidence)

50
Q

Advice for Women with a high level of fitness doing regular vigorous exercise

A

No evidence of harm to pregnancy provided they adjust routine based on changes in comfort and tolerance
Athletes should be wary of excessive exertion - fetal wellbeing may be compromised about a certain (high) threshold of intensity - transient FHR decels and alterations in umbilical and uterine artery dopplers immediately post-exercise
Not known if these transient changes impact neonatal outcomes
Attention to adequate nutrition, hydration and avoiding overheating
Pregnancy is not a time for serious competition or aiming to reach peak lifetime fitness

51
Q

Intensity of exercise recommendations in pregnancy

A 
Pregnancy-specific heart rate zones equivalent to 60-80% of max aerobic capacity have been recommended for normal-weight women
<20y - 140-155bpm 
20-29y - 135-150bpm
30-39y - 130-145bpm
>40y - 125-140bpm

If inactive overweight and obese, may be too high therefore aim for targets of 102-124bpm (if 20-29y) or 101-120bpm (if 30-39y)
Intensity considered moderate if can comfortably hold a conservation
Vigorous if need to pause for breath during conversation

52
Q

General exercise advice for adults, apply to pregnancy

A

Active on most, preferably all days each week
Aim for 150-300 mins of moderate intensity exercise each week or 75-150 mins of vigorous exercise each week, or combination
Plus muscle strengthening exercises >2 days per week
Avoid prolonged sitting

53
Q

Contraindications to exercise, irrespective of pregnancy

A

CVD
Poorly controlled asthma
Poorly controlled diabetes
Bone or joint problems

54
Q

Additional medical and obstetric issues in pregnancy that may preclude exercise (but no literature, therefore individualise recommendation)

A 
Persistent bleeding
Placenta praevia 
PET
PIH
Indicators of increased risk of PTL - multiple pregnancy, rupture membranes, premature contractions, shortened cervical length
FGR
Poorly controlled thyroid disease 
Anaemia
55
Q

Physiological changes of pregnancy that have implications on exercise

A

Increase in body weight - increased loading at the joints
Change in weight distribution - altered centre of gravity
Increase in ligament laxity - may have implications for the risk of injury
Decrease in BP
Increase in resting and submaximal HR
Increase in metabolic rate - avoid exercising at high temperatures and humidity
Enlarged uterus - improves venous return
Growing fetus
Weakened pelvic floor

56
Q

Incidence of smoking in pregnancy

A

Australia: 1 in 10
NZ: 1 in 8
44% of Aboriginal and Torres Strait Islander
22% of Maori women
Smokers in pregnancy more likely to be younger and live in areas of SE disadvantage

3.8-fold increase in smoking cessation rate when compared to non-pregnant women

Of women who cease smoking during pregnancy, 50-70% will resume in the year PP

57
Q

Pathogenesis of smoking and pregnancy outcomes

A

Smoking potentially disrupts the implantation process and interfering with the transformation of the uterine spiral arteries
Studies show thickening of the villous membrane of the placenta in smokers, lessening the ability of the placenta to function
Nicotine also impairs amnio acid transport across the placenta

58
Q

Obstetric complications of smoking in pregnancy

A

Miscarriage
Ectopic pregnancy
Preterm labour and premature rupture of membranes – two-fold increase in the risk of preterm birth with smoking
Placental abruption – Two-fold increase in the risk
Placenta praevia – Relative risk 1.36
Pre-eclampsia – Of pregnancies that are complicated by severe pre-eclampsia, smoking is associated with increased rates of perinatal mortality, placental abruption and small for gestational age infants
Thrombotic risk
Anaesthetic risks and respiratory complications

59
Q

Fetal complications of maternal smoking

A

Low birth weight (less than 2500g at birth)
Fetal anomalies
Perinatal death

60
Q

Child and adult complications of maternal smoking

A 
Sudden unexpected death in infancy syndrome (SUDI)
Respiratory disease
ENT and other infections
Childhood cancers
Nicotine dependence
61
Q

Non-obstetric risks of smoking

A

increased rates of all- cause mortality, lung cancer, cervical pre-invasive disease and cancer, vulval cancer, bladder cancer, oropharyngeal cancer, breast cancer, cardiovascular disease, thromboembolic disease, chronic respiratory disease, reduced fertility, premature menopause and osteoporosis

62
Q

NRT and pregnancy

A

NRT may be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking
Intermittent-use forms (such as gum or spray) are preferred over continuous-delivery nicotine (patches)

63
Q

Options for testing for inherited conditions

A
  1. Having child and testing after birth
  2. Conceiving naturally and having diagnostic testing during pregnancy (amniocentesis or CVS)
  3. IVF and testing embryos by preimplantation genetic diagnosis
  4. Using donor sperm, egg or embryo from unaffected individuals
  5. Adoption
  6. Not having children
64
Q

If of Eastern European (Ashkenazi) Jewish descent, offer screening for:

A
  • Tay Sachs disease
    • Niemann Pick disease type A
    • Fanconi anaemic group C
    • Familial dysautonomia
    • Bloom syndrome
    • Canavan disease
      Mucolipidosis type IV
65
Q

Genetic carrier screening

  • CF
  • Spinal muscular atrophy
  • Fragile X syndrome

Carrier frequency, frequency affected
Main clinical features

A

Cystic fibrosis
- 1 in 35
- 1 in 4925
Recurrent lung infections, malabsorption, shortened life span

Spinal muscular atrophy

  • 1 in 50
  • 1 in 9917
  • Severe muscle weakness, death usually during childhood

Fragile X syndrome

  • 1 in 332
  • 1 in 7143
  • Intellectual disability, autism

Australian study found that approximately 1 in 20 individuals accessing self-funded carrier screening were carriers of cystic fibrosis, spinal muscular atrophy and/or fragile X syndrome

66
Q

three most common inherited genetic conditions for which prenatal diagnosis is currently performed:

A

thalassaemia
cystic fibrosis
fragile X syndrome.

67
Q

Folic acid supplementation

A

Folic acid for a minimum of 1 month pre-conception and for first 3 months of pregnancy
- At least 0.4mg daily

If increased risk of NTD (anti-convulsant medication, pre-pregnancy diabetes, previous child or family history of NTD, BMI >35) –> 5mg daily

68
Q

Luteal phase support for IVF

A

Luteal phase support with synthetic progestogens should be provided in IVF

- Associated with an improved live birth rate
- Better results obtained with synthetic progestogens than micronized progesterone 
- No evidence to favour a specific route or duration of administration
69
Q

Progesterone in early pregnancy

A

No evidence to suggest that giving progesterone supplementation to otherwise healthy women in the first trimester reduces the risk of spontaneous miscarriage

Progestogen supplementation until the second trimester in women presenting with threatened miscarriage may reduce the rate of spontaneous miscarriage
- Current evidence limited by methodological inconsistencies

Routine use of progestogens in those with recurrent spontaneous miscarriage does not improve pregnancy outcomes

Luteal phase support with synthetic progestogens should be provided in IVF

70
Q

Progesterone use for recurrent spontaneous miscarriage

A

Routine use of progestogens in those with recurrent spontaneous miscarriage does not improve pregnancy outcomes
- PROMISE trial - no difference in the rate of miscarriage in women using vaginal micronized progesterone compared to placebo
- Significant heterogeneity in the clinical trials of progestogens
○ Possibility of a benefit cannot be excluded

RANZCOG guidelines (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions