Normal Pregnancy Flashcards
(52 cards)
1
Q
What constitute Low Risk Midwifery led care during pregnancy?
A
- Booking appointment – before 12+6 weeks gestation
- Dating Scan – 12 weeks gestation
- 16 week appointment
- 20 week gestation – anomaly scan
- 25 week gestation – nulliparous
- 28 week gestation – start fundal height measurement
- 31 week gestation
- 34 week gestation
- 36 week gestation
- 38 week gestation
- 40 week gestation – primips only – offer membrane sweep
- 41 week gestation – offer membrane sweep and consider planning induction of labour
2
Q
Antenatal growth scans - how are scans differentiated from fundal height measurements?
A
X fundal height measurement
o scan measurement
3
Q
High Risk ANC pathway: Maternal characteristics
A
BMI > 30 kg/m2 BMI<18 KG/m2 Smoking Age> 40 Teenage mothers
4
Q
High Risk ANC pathway: Past medical History
A
- Cardiac disease
- Renal Disease
- Endocrine disease, Diabetes
- HIV
- Hematological disease
- Autoimmune disorders
- Epilepsy requiring treatment
- Severe asthma
- Recreational drugs
5
Q
High Risk ANC pathway: Obstetrics Issues
A
- Recurrent miscarriage
- Preterm birth
- Eclampsia, preeclampsia
- HELLP
- RH isoimmunization
- Significant blood group antibodies
- APH, PPH on 2 occasions
- > 6 pregnancies
- Stillbirth/neonatal death
- SGA < 5TH centile
- LFGA < 5 th centile
- Birth weight <2.5 kg,>4.5 kg
- Fetal congenital anomaly: structural, chromosomes
6
Q
widest diameter of pelvis
A
inlet - transverse is widest
outlet - anterior posterior is widest
7
Q
Shape of fontanelles on infant
A
- Anterior fontanelle-bregma (diamond)
- Posterior fontanelle- Occiput (triangle)
- Area between the two- vertex
8
Q
Mechanical Factors of labour- 3 Ps
A
- Power ( force expelling fetus: uterine contractions)
* Passage : Pelvic dimensions, Soft tissue resistance • Passenger ( diameters of fetal head)
9
Q
Important factors on Power in mechanism of labour
A
- In established labour contraction for 45-60 seonds every 2-4 minutes.
- This leads to cervical effacement and dilatation aided by pressure of head
- Poor contractions common in nulliparous and induced labours but rare in multiparous.
10
Q
Mechanism of labour: Passage Bony pelvis
A
3 planes
• Inlet: Transverse 13cm wider that AP 11 cm
• Mid-cavity: Round ( Transverse and AP similar)
• Outlet : AP AP 12.5 > Transverse 11 cm
• Ischial spine is the palpable landmark to assess descent
• Station 0 : Head at level of spines.
11
Q
Mechanism of labour: Passage: Soft tissue
A
- Cervix: Dilatation depends on contractions, Pressure of fetal head on cervix
- Vagina ( tear, episiotomy)
12
Q
Mechanism of labour steps
A
Engagement – Head enters the pelvis in occipito transverse postion
Descent of flexed head
at ischael spines internal rotation to AP
delivery by extension of head
shoulders turn to AP
Restitution - Head rotates back to 90 degrees to the same position in which it entered the inlet to enable delivery of shoulders
delivery by lateral flexion
13
Q
Mechanism of labour: Passenger factors
A
- Presentation: Cephalic/Breech ( part of the fetus that occupies the lower segment)
- Presenting part: Lowest part of fetus palpable on vaginal examination
- Attitude of head describes the degree of flexion- vertex/brow/face
14
Q
Fetal skull - what is Atitude of fetus
A
Attitude is degree of flexion of the head on the neck.
Maximum flextion- vertex presentation
- Vertex: Presenting diameter 9.5 cm
- Brow: 90 degree extension Presenting diameter 13 CM • Face: further 30 degree extension
- Extension makes the fetal presenting diameter larger
15
Q
Movements of the head in labour
A
- Engagement ( head enters pelvis) in occipito-transverse as it is oblong and transverse diameter of pelvis is longer
- Descentandflexion
- Internal Rotation 90 degrees to occipito-anterior OA
- Descent
- Extension to deliver
- Restitution and delivery of shoulders
16
Q
Signs of placental separation
A
gush fresh blood
cord lengthening
17
Q
First stage of labour
A
Average 8 hours nulliparous, 5hours multiparous Latent ,4m, active 4-10 cm
Cervix dilates
Head remains flexed during descent
90 degree rotation from OT to OA
18
Q
Second stage of labour
A
Contractions continue, Full dilatation to delivery Head descends, flexes and rotation completed
Pushing starts when head reaches levator ani (active second stage)
Delivery: Head extends as it delivers over the perineum
Head restitutes, rotating back to transverse before shoulders deliver.
19
Q
Third stage of labour
A
average 15 minutes, Placenta delivered by controlled cord traction to prevent uterine inversion
Physiological management or Active management (to reduce blood loss in women at risk of PPH - overstretched uterus such as twins, polyhydramnos)
20
Q
How long is postnatal period?
A
up to 6 weeks
still at risk of DVT, PE, eclampsia, infection
21
Q
Lochia
A
discharge from the uterus may be blood stained for 4
weeks later on it is yellow or white
22
Q
Cardiovascular changes in puerperium
A
- BP usually normal in 6 weeks
* Cardiac output and plasma volume returns prepregnant level with in a week
23
Q
Postnatal review history
A
- Privacy
- Mother and baby should be together
- Early mobilization
- Check blood loss
- Pain
- Bladder –passing urine
- Bowel – opened or not
- Lochia
- Diet
- Mobility
- Breast feeding/bottle feeding/both
- Mood-normal/low/elevated
- Postnatal debrief about delivery events
- Fasting blood sugar in 6 weeks for gestational diabetics
24
Q
Postnatal review-examination
A
- Vitals
- Abdominal palpation- uterus
- Examine calves-DVT
- Episiotomy /caesarean scar
- Risk score all women according to RCOG guidelines for risk for DVT and start appropriate prophylactic treatment
- Breast for mastitis
- Chest/throat
- Uterine tenderness
- LSCS wound
- Look for signs of DVT • Dip urine
- Take vaginal swab
- Lochia-foul smelling • Perineal wound
25
Postnatal Advise
* Contraception advise • Perineal care
* Pelvic floor exercises Post
```
LSCS-
• Wound care
• No heavy lifting for 6 weeks
• Future pregnancies-VBAC
• Driving as per insurer terms
• Delay pregnancy for at least 12months
```
26
Postnatal review: Women with third/forth degree perineal tears
* Perineal care/hygiene
* Laxatives
* Antibiotics
* Analgesia
* Review in 6 weeks
27
Colostrum
yellow fluid containing fat laden cells, proteins including immunoglobulin A and minerals – passed first 3 days
28
Advantages of breast feeding
* Protection against infection
* Bonding
* Protect mother against cancer
* Cost saving
* Combined pills supress lactation/ hence progesterone only pill is safer
29
Lactation is dependent on which hormones?
* Prolactin from anterior pituitary stimulates milk secretion
* Oxytocin from posterior pituitary stimulates ejection in response to suckling
30
Approach to Postpartum pyrexia
* Maternal fever ≥38°C in the first 14 days • Genital tract sepsis
* Group A streptococcus, Staphylococcus, E. Coli. • Urinary tract infection (10%)
* Chest infection/pharyngitis
* Infection at IV (intravenous) sites
* Mastitis
* Perineal infection
* Wound infection after LSCS
* Infection of epidural site
* Deep Vein thrombosis –low grade pyrexia
31
Definition of Postpartum pyrexia
Maternal fever ≥38°C in the first 14 days
32
Postnatal Red flag’ signs and symptoms
* pyrexia more than 38°C
* sustained tachycardia more than 90 beats/minute
* breathlessness (respiratory rate more than 20 breaths/minute; a serious symptom)
* abdominal or chest pain
* diarrhoea and/or vomiting
* uterine or renal angle pain and tenderness
* woman is generally unwell or seems unduly anxious or distressed.
33
Common organisms –puerperal sepsis
* GAS, also known as - Group A Streptococcus pyogenes • Escherichia coli
* Staphylococcus aureus
* Streptococcus pneumoniae
* methicillin-resistant S. aureus(MRSA), • Clostridium septicum
* Morganella morganii
34
Managing Hypotension Bacterial Sepsis following Pregnancy
* In the event of hypotension and/or a serum lactate greater than 4 mmol/l: Deliver an initial minimum 20 ml/kg of crystalloid
* Apply vasopressors for hypotension In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or serum lactate greater than 4 mmol/l:
* Achieve a central venous pressure of ≥8 mmHg
35
Antibiotics for Bacterial Sepsis following Pregnancy
* Co-amoxiclav
* Metronidazole
* Gentamycin
* Clindamycin
* Tazocin (Piperacillin/Tazobactam)
* Discuss with microbiology consultant on call about treatment
36
Postnatal Psychiatric problems
* Postnatal blues -50%- need support and reassurance
* Postnatal depression affects -10% of women
* Puerperal psychosis- 0.2% of women, around 4th day
37
Postnatal Urinary problems
Retention of urine- is common after delivery
• Bladder scan to check for residual urine
• Cather for 24 hrs
Urinary infection in 10%
Incontinence in 20% women
Usually improve with pelvic floor exercise
Vaginal haematoma –severe pain and needs drainage under general anaesthesia
Constipation in 20% women Incontinence of faeces in 4% , transient
38
what is the NIPT test?
Maternal Blood test
• Diagnostic test: NIPT -free fetal DNA 99% accurate Results take > 1 week & expensive , not routine now
• NIPT used as near 100% sensitivity • Positive NIPT-needs invasive testing
Free fetal DNA
39
outline Ultrasound as a diagnostic test in pregnancy
* Anomaly scan ~ 20 weeks
* 25% identified earlier
* Cardiac – may remain undiagnosed even at 20 weeks • Some develop later gestation
40
Outline Amniocentesis
* Removal of amniotic fluid using fine gauge ultrasound needle under US guidance
* Performed after 15 weeks
* Used of chromosomal abnormalities, infections(CMV, Toxo)
* Inherited disorders(Sickle cell, thallasemia & CF)
* 1% chance of miscarriage
41
Outline Chorionic villus sampling
* Biopsy of trophoblast by fine needle through cervix or abdomen from 11 weeks
* Higher risk of miscarriage
* Earlier identification of abnormalities • Can offer TOP
42
How are samples from amnio and CV sampling tested?
• FISH(Fluorescence insitu hybridization) & PCR –result <48 hrs • Karyotyping-inspection of chromosomes by looking through
microscope
• Microarray-CGH-Comparative genomic hybridization techniques-closer or magnified inspection of chromosomes- smaller deletions or abnormalities
43
What is PGD (Pre-implantation genetic diagnosis)?
* Requires IVF
* Selection before implantation
* Expensive
* Ethical dilemmas
* Used in X linked ,trisomies & AD /AR conditions
44
What is Down syndrome due to?
* Trisomy 21
| * Most common Non disjunction or balanced translocation(6%) • Features: mental handicap, facies, 50% cardiac disease
45
Risk factors for Down syndrome
* Maternal age
* Previous affected baby
* Balanced parental translocation
* Thick NT
* Structural abnormalities
* Absent or short nasal bone#
* Tricuspid regurgitation
* Severe FGR
* Low PAPP-A, High HcG, Low AFP, low estriol ,high inhibin
46
Screening for chromosomal abnormalities
* All pregnant women offered
* DS 75% sensitivity , 3% False positive
* 1 in < 150 high risk
* NIPT 1 in <1000
* Combined test: Maternal age , NT ,PAPPa & hcG
* Performance enhanced by presence or absence of nasal bone & TR
47
What is the rate of Structural abnormalities-CNS screened for in pregnancy?
* 1 in 200 pregnancies
* Spina bifida , anencephaly, ventriculomegaly
* Preconception folic acid 400mcg reduces NTD risk • Recurrence in 1 inn 10 pregnancies
* Higher dose 5mg reduces recurrence
48
What risk factors are there for fatal Cardiac defects
• 1% pregnancies
Cardiac defects
• Common in maternal diabetes, congenital cardiac defects, on antiepileptic drugs ,previous offspring affected 3%,other chromosomal defects & structural abnormalities
• 50% can be associated with high NT
• Less than 1/3 diagnosed prenatally
• Most are non lethal/Correctable after birth
• Arrthymias can be treated in-utero –Flecainide /Digoxin
49
List types of chest defects screened for in pregnancy
* Diaphragmatic hernia- herniation of abdominal contents into chest-60% with isolated defects survive
* In-utero tracheal occlusion FETO
* Pleural effusions-in-utero shunting useful
* Congenitalcysticadenomatousmalformation(CCAM)-many regress and prognosis usually good
50
What sign is there to indicate Gastrointestinal defects of the foetus?
• Oesophageal atresia & Tracheo-oesophageal fistula: • Polyhydramnios present, stomach small
51
What condition is the 'double bubble' sign on ct a sign of?
Duodenal atresia
| • Classic “double bubble” sign , dilated upper duodenum- associated with Down syndrome
52
What test results would be expected in a trisomy 21 (Down's syndrome) pregnancy?
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
