Management of Obstetrics and Gynaecology

Question 1

Obstetrics

Answer 1

The branch of medicine concerned with pregnancy, child birth and the post partum period

Question 2

Terminology

Answer 2

EDD/ EDB – Estimated Date Delivery/ Estimated Date Birth

LMP – Last Menstrual Period

SB – Still Birth

Primigravida – 1st Pregnancy

G/Gravida – pregnancy

P/Para/Parity – number of live births
Gestation – Length of pregnancy in weeks

37 - 42 weeks: Term

24 – 37 weeks: Pre-term

24 weeks or less: Miscarriage

VBAC: Vaginal Birth After C-Section

Meconium – First stool passed by baby

Question 3

Using the diagram, list and describe the anatomical and physiological changes that occur in the pregnant person

Answer 3

Lady diagram in folder on MT. Some points to include may be:
CVS:
- Increase in cardiac output by 20-30% in first 10 weeks
- Increase in maternal heart rate by 10-15bpm
- Decrease in systolic and diastolic BP of 10-15mmHg due to reduced peripheral resistance caused by increased progesterone levels
- Decrease in cardiac output of up to 40% when patient lying supine due to the weight of the uterus compressing the inferior vena cava
- Increase in blood volume due to haemodilution by around 45% occurs with a small increase in red blood cells. The disproportionate increase in blood plasma compared to red blood cell mass can lead to a ‘physiological anaemia’ from around 27 weeks gestation
- Due to increased blood volume, the pregnant female is more tolerant of severe blood loss at the expense of diverting blood away from the uterus and foetus

Resp:
Increase in rate and effort
Diaphragm flattens and becomes splinted
Increase in oxygen consumption/ requirements
Laryngeal oedema – consider securing airway quickly in pregnant female

GI:
Increased gastric acid (due to delayed emptying of the stomach caused by hormones)
Cardiac sphincter relaxes increasing likelihood of regurgitation/ vomiting
Nausea and vomiting can occur from 4-8 weeks gestation and continue to around 16 weeks. Some severe cases can last for longer and cause severe dehydration resulting in hospital admission (hyperemesis gravidum)

Urinary:
Increased frequency of urination

Other:
Increase in Relaxin hormone which leads to more lax joints – increased risk of strains/ sprains/ dislocations
Increased risk of falls due to changes in centre of gravity
Swelling to joints
Engorged breasts
Hair appears thicker due to decrease in hair loss during pregnancy
Nails appear stronger and less brittle
Possible appearance of stretch marks to skin

Question 4

Cardiovascular

Answer 4

Increase in cardiac output by 20-30% in first 10 weeks

• Increase in maternal heart rate by 10-15bpm
• Decrease in systolic and diastolic BP of 10-15mmHg due to reduced peripheral resistance caused by increased progesterone levels
• Decrease in cardiac output of up to 40% when patient lying supine due to the weight of the uterus compressing the inferior vena cava
• Increase in blood volume due to haemodilution by around 45% occurs with a small increase in red blood cells. The disproportionate increase in blood plasma compared to red blood cell mass can lead to a ‘physiological anaemia’ from around 27 weeks gestation
• Due to increased blood volume, the pregnant female is more tolerant of severe blood loss at the expense of diverting blood away from the uterus and foetus

Question 5

Respiratory

Answer 5

Increase in rate and effort
Diaphragm flattens and becomes splinted
Increase in oxygen consumption/ requirements
Laryngeal oedema – consider securing airway quickly in pregnant female

Question 6

1st Trimester

Answer 6

Starts: 1st day of last period
Ends: 12 weeks 6 days
Most crucial stages of development occur in this time frame
Foetal cells undergo differentiation
Female may not be aware she is pregnant until 4+ weeks
Most abortions occur within the first trimester.
Heart begins to beat around 6-8 weeks gestation and can be seen on ultrasound
Pregnant female may be unaware of pregnancy until missed period
Pregnant female may experience fatigue, nausea, vomiting during this time.

Question 7

2nd trimester

Answer 7

Starts: 13 weeks

Ends: 25 weeks 6 days

The uterus begins to expand and can be palpated above the pelvic rim

The fundus can be palpated at the umbilicus around 20- 22 weeks gestation
Amniocentesis is usually performed where required between 14-16 weeks
Any nausea and vomiting may be starting to ease
The fetus starts to develop bone structure
Fundal height is a way of measuring babys growth and development.

Amniocentesis is a medical procedure used primarily in prenatal diagnosis of chromosomal abnormalities and fetal infections, as well as for sex determination

Question 8

Stage 1 Labour

Answer 8

LASTS AROUND 8 - 10 HOURS, BUT IS LONGER IN PRIMIGRAVIDAE
SHOW
REGULAR CONTRACTIONS BECOMING MORE FREQUENT
RUPTURE OF THE MEMBRANES (BREAKING OF THE WATERS )
LONGEST PART OF THE LABOUR

Question 9

Stage 1 Labour

Answer 9

ABCDE primary survey
Ascertain gestation and review the notes
Assess for ‘bloody show’, ruptured membranes, contractions and/or bleeding
Visual inspection of vaginal entrance if contractions are at 1-2 minute intervals OR there is an urge to push
If contractions within 1-2 mins or urge to push/ crowning/ breech presentation then remain on scene and request midwife. Prepare for birth of baby

Question 10

Stage 2 Labour – Full dilation of the cervix until birt

Answer 10

RUPTURE   OF   THE   MEMBRANES   UNLESS   THEY  WERE  RUPTURED  IN  FIRST   STAGE
CHANGES   IN   CONTRACTIONS 
MOTHER  BEARS   DOWN
CROWNING
POSSIBLE  BOWEL   MOVEMENT
DELIVERY   OF   BABY

Question 11

Stage 3 Labour – Birth of the placenta and membranes

Answer 11

LENGTHENING OF CORD
RETURN OF PAINS
URGE TO BEAR DOWN
A SMALL GUSH OF BLOOD ( 200 - 300 mls )
EXPULSION OF THE PLACENTA
THIS SHOULD BE WITHIN 15 MINUTES OF BIRTH OF THE BABY

Question 12

APH - Miscarriage

Answer 12

Bleeding resulting in the loss of a pregnancy at 24 weeks gestation or less
Most common within the first 12 weeks (commonly 6-14 weeks)

Question 13

Miscarriage

Risk Factors:

Answer 13

Previous Hx miscarriage
Previously identified potential miscarriage at scan
Smoking
Obesity

Question 14

Miscarriage

Risk Symptoms

Answer 14

Bleeding: light or heavy, often with clots or tissue
Pain: central, crampy, suprapubic, backache
Pregnancy symptoms subsiding
Signs of cervical shock due to retained tissue in the cervix (hypotension, bradycardia)

Question 15

Management of Fetal Tissue

Answer 15

Fetal tissue may resemble blood stained tissue or may present as a discernible baby with placenta attached

Discuss the preferences about management of the fetal tissue or ‘her baby’ with the woman
If the tissue is difficult to identify, transport to hospital
Where the baby is noticeably developed and small, wrap the baby within a towel and ask the mother if she wishes to hold the baby during transport
Where the mother does not wish to see or hold the tissue or baby, wrap sensitively and convey to hospital
Document how the fetal tissue/ baby was conveyed and hand over to the midwife or nurse at transfer of care

Question 16

APH - Ectopic/ Ruptured Ectopic Pregnancy
Refers to the development of an embryo or foetus outside of the uterus. Most occur within the fallopian tubes. Ruptured ectopic pregnancies are fatal for both mother and foetus.
risk factors

Answer 16

Previous ectopic pregnancy
Previous tubal surgery
Abnormal anatomy
Repeated elective abortions
Intra uterine contraceptive device
Pelvic inflammatory disease

Question 17

APH - Ectopic/ Ruptured Ectopic Pregnancy Symptoms:

Answer 17

Acute severe abdominal pain
Unexplained fainting
Shoulder tip pain
Unusual bowel symptoms
*Acute lower abdominal pain*
*Slight bleeding or brownish vaginal discharge*
*Signs of blood loss within the abdomen*

Question 18

APH - Placenta Praevia

Answer 18

The placenta develops low in the uterus causing a partial or complete covering of the internal opening of the cervix
This usually presents at 24-32 weeks with small episodes of painless bleeding

This condition can lead to severe haemorrhage during the pregnancy or when labour begins

The baby may need to be delivered via caesarean section

Question 19

APH – Placenta Praevia

Signs and Symptoms

Answer 19

Hypovolaemia

Soft, non tender abdomen

Small episodes of painless bleeding

Bright red blood present

Question 20

Placental Abruption Signs and Symptoms

Answer 20

Signs and Symptoms

Dark red vaginal bleeding

Severe/ sudden/ continuous abdominal pain

Severe/ sudden/ continuous back pain

Tender abdomen

Rigid abdomen
Absent foetal heart sounds

Reduced/ no foetal movements

Signs of shock

Associated with disseminated intravascular coagulation (DIC) which can lead to increased bleeding

Question 21

Management of APH

Answer 21

Assess the patient and the scene on approach
Undertake a ABCDEF primary survey
If time critical features are present, correct ABC and transport to the nearest receiving unit
Monitor SpO2 and maintain 94-98% saturation range
Take full history including fetal movements, blood loss etc.
Consider Paramedic for fluid resuscitation
If >20 weeks gestation, ensure the uterus is displaced; manual displacement, left lateral tilt or full lateral positio

Question 22

Pre-eclampsia

Answer 22

Usually occurs between 22- 28 weeks gestation
It is a placental disorder associated with proteinuria
Diagnosis is made in the presence of; BP  140/90 mmHg, oedema and protein detected in urine
Can be Mild, Moderate, Severe

Question 23

Pre-eclampsia Signs and Symptoms

Answer 23

Signs and Symptoms
Hypertension
Headache
Visual disturbances
Epigastric pain
Right sided upper abdo pain
Muscle twitch/ tremor
Nausea
Vomiting
Confusion
Rapid oedema progression

Question 24

Pre-eclampsia Management

Answer 24

Primary ABCDEF survey

If time critical correct A and B problems and immediately transfer to nearest receiving unit

Monitor Sp02, BP and Blood Glucose

Pre alert and consider paramedic assistance

Question 25

Eclampsia

Answer 25

Generalised tonic/clonic convulsions that occur usually after 24 weeks of pregnancy
Convulsions are usually self limiting but severe and repetitive
Hypoxia caused by the convulsion can lead to fetal compromise or death

Question 26

Eclampsia Management:

Answer 26

Management:
ABCDEF Primary survey – correct A and B and rapidly transfer
Monitor SpO2
Place patient in full lateral position to protect airway (recovery position NOT left lateral tilt)
Call paramedic back up (do not delay on scene)
Pre alert stating obstetric emergency of eclampsia
It does not matter if the patient has a history of epilepsy – if they are 24 weeks or more gestation and experience a tonic/clonic convulsion then it is to be treated as eclampsia until proven otherwise unless there is no history of hypertension or pre-eclampsia and BP is normal

Eclampsia is the cause of 2% maternal mortality in the UK and is the most dangerous complication of pregnancy.

Question 27

Modifications for Maternal Resuscitation

Answer 27

Start resuscitation as per JRCALC guidelines

Manual displacement of the uterus to the maternal left – LONG BOARD WILL NOT ACHIEVE THE REQUIRED LEFT LATERAL TILT

Hand position should be 2-3cm higher on the sternum in gestations >28 weeks

Electrode pads can be placed in antero-posterior position or bi-axillary if large breasts interfere with normal placement

Question 28

Breech Delivery

Answer 28

It is important to note that any presentation other than head, feet or buttocks must be immediately transferred

The video demonstrates management of a Breech that is in line with current JRCalc teachings. Stop video at 3mins

Breech Delivery Demonstration
Encourage woman to the edge of the bed or sofa or onto all fours
Ensure the fetal back always faces the mothers abdomen throughout the delivery. IF IT DOES NOT: Gently hold the bony pelvis with your fingers and rotate until the fetal back is facing the maternal abdomen
Allow the breech to descend spontaneously hands off approach
The baby’s arms and legs will deliver spontaneously
Once the nape of the neck is visible, support baby on your forearm with one finger on the back of baby’s head and two fingers on the cheeks
In this position, gently lift the baby upwards to facilitate the delivery of the head

If there is a delay in delivery, the following techniques can be used:
Legs – gently apply pressure behind the baby’s knee in an upward direction – this will flex the leg and allow it to deliver. Repeat on both sides if required
Arms – holding the bony pelvis, gently rotate the baby through 90 degrees to birth one arm and then rotate back to centre and then 90 degrees in the opposite direction to birth the next arm
Head – support the head ONLY when the nape of the neck can be seen and gently lift upwards to deliver the baby

Question 29

Shoulder Dystocia – ‘a bony problem’ Request Help

Answer 29

Identified by a ‘turtle neck’ head bobbing from delivery. If on back bring; legs to McRoberts supported either side by persons, suprapubic pressure continuous, rocking, axial traction
Rotate to all fours, squat
If on all fours – racing start, squat down, rotate back to McRoberts

Question 30

Cord prolapse

Answer 30

Time Critical for Unborn Baby
Use a dry pad or sanitary towel to gently place the cord against the woman’s vagina (once only) and apply underwear over
Walk the woman to the ambulance quickly, do not use a carry chair
Position mother to relieve pressure of presenting part on the cord:
Position 1 (waiting for transport): mother to adopt knee to chest position with buttocks in the air
Position 2 (during transport): mother to lie on her side with lowest hip elevated using cushions/ blankets/ pillows – exaggerated Sim’s position
Provide pre-alert stating ‘cord prolapse’

Question 31

Post partum haemorrhage

Answer 31

The most common cause of PPH is uterine atony

Primary PPH – blood loss of 500ml or more within 24hours of birth
Massive PPH – 50% loss of blood volume within 3 hour of birth

Question 32

PPH Management – Placenta Delivered

Answer 32

Palpate the abdomen feeling for the top of the uterus (fundus) – this is usually found around the umbilicus

Using a cupped hand, firmly massage the fundus in a circular
motion – this should stimulate a contraction

Call Paramedic back up for tranexamic acid

Undertake time-critical transfer to appropriate destination with
pre alert

Offer Entonox as this procedure can be uncomfortable
DO NOT massage the uterus

Consider Paramedic back up to administer Tranexamic Acid

Rapid transfer to nearest appropriate destination with pre-alert stating ‘PPH undelivered placenta’

If the placenta delivers – assess blood loss and consider uterine massage at this point

If any vaginal tears are present, apply direct pressure using gauze

Question 33

PINK HEALTHY BABY

Answer 33

A healthy baby (Pink) will:
Be born BLUE but will ‘pink up’ rapidly
Have good tone
Cry within a few seconds
Have a good heart rate (120-150) within a few minutes.
(Resuscitation Council (UK) Newborn Life Support 2010)

Question 34

A LSS HEALTHY BABY (BLUE) – PRIMARY APNOEA

Answer 34

Born blue
BM Less than 2.5mmol/l 
Less tone
May have a slow heart rate (<100)
May not establish adequate breathing by 90-120 seconds after birth.

Question 35

WHITE BABY

Answer 35

An ill baby (white) – terminal apnoea

Born pale and floppy

Not breathing

Slow, very slow or undetectable heart rate (<60)

Question 36

white baby resus numbers

Answer 36

60 sec warm dry baby
5 inflation breaths
 change position if you don't get good inflations
after 5 inflation breaths check HEART RATE 
RR below 60 
15 ventilation in 30 sec 
reassess HR if below 60 
CPR 3-1 reassess 30secs 
5cycles of 3.1

Question 37

three colour babies

Answer 37

PINK HEALTHY BABY
A LSS HEALTHY BABY (BLUE) – PRIMARY APNOEA
white baby resus numbers