Obstetrics/Gynaecology (NEW) Flashcards
1
Q
Chlamydia trachomatis background
A
Epidemiology
- most common bacterial infection
- > more common in women
- risk factors
- > young adult (<25yrs)
- > new/multiple sex partner
- > partner with chlamydia
- > infrequent condom use
- > previous STD
- > urban
- coinfection common
- > gonorrhoea
- > trichomonas
- > m genitalium
Aetiology
- sexual transmission
- > cervix < - > urethra (approx 75% partners affected)
- > urethra < - > rectum (transmission rate much lower)
- infects
- > columnar epithelial cells cervix
- > urethra
- > bartholins glands
- > fallopian tubes
- > anus
- does not infect squamous cells of vagina
Pathophys
- structure
- > gram negative bacteria
- > obligate intracellular organism
- life cycle
- > spore like elementary body attaches to epithelium
- > enter and surround by vacuole (inclusion)
- > transforms to larger/metabolically active reticulate body
- > replicates over 3 days
- > transforms back into elementary bodies
- > cell rupture and spread
- incubation period up to 2 weeks
2
Q
chlamydia trachomatis syndromes
A
Women
- cervicitis
- > vast majority asymptomatic
- urethritis
- > 50% of infections
- PID and sequelae
- pregnancy
- > premature rupture of membranes
- > preterm birth
- > low birth weight
- > chorioamnionitis
Men
- urethritis
- epididymitis
- > unilateral pain/tenderness
- > hydrocele
- > swollen epididymis
Common to men and women
- conjunctivitis
- > by direct inoculation with genital secretions
- > erythematous injection of conjunctiva
- > non purulent
- reactive arthritis
- > acute onset several weeks post infection
- > asymmetric, oligoarticular
- > enthesitis
- > dactylitis
- > inflammatory lower back pain
- reiters syndrome (classic triad)
- > arthritis
- > conjunctivitis/uveitis
- > urethritis/cervicitis
- proctitis
- > pain
- > discharge
- > bleeding
- > tenesmus
- > constipation
3
Q
Miscarriage (<20 weeks) background
A
Epidemiology
- early pregnancy loss (first trimester)
- > 10% clinically recognisable pregnancies
- early second trimester loss (<20 weeks)
- > less than 1% of pregnancies
- almost half of parous women have EPL
Risk factors (ADIPOSE)
- Age
- > maternal
- > possible paternal
- Diabetes
- > euglycaemia risk is baseline
- Infection
- > CMV
- > syphilis
- > parvovirus B19
- Previous miscarriage
- > OR for 1 = 1.5
- > OR for 2 = 2.2
- Obesity
- Substances
- > medications
- > alcohol, smoking, cocaine
- Exposures
- > lead/arsenic
- > air pollution
- > radiation
Aetiologies
- chromosomal abnormalities
- > approx 3/4 of miscarriages
- uterine abnormalities
- > ashermans syndrome
- > fibroids
- > polyps
- direct trauma
- > violent
- > iatrogenic (chorionic villus sampling)
4
Q
Miscarriage (<20 weeks) evaluation
A
Hx
- confirm pregnancy
- > LMP
- > pregnancy test results
- bleeding
- > clots
- > tissue
- pain
- > cramping
- > shoulder tip
- loss of pregnancy symptoms
- syncope
- > hypovolaemia
- infection
- > fever
- > purulent discharge
- obstetric hx
- > previous pregnancies
- > previous miscarriages
- > assisted conception
- gynaecological hx
- > surgeries
- > significant conditions
- previous investigations
- > US
- > b HCG
Exam
- vitals
- > fever/tachycardia/hypotension = infection
- > tachycardia/hypotension = hypovolaemia
- > bradycardia/hypotension = tissue in cervical canal
- abdo
- > tenderness/guarding
- > distension
- > enlarged uterus
- speculum
- > bleeding from cervix
- > open os
- > tissue in cervical canal
- bimanual
- > cervical motion tenderness
- > uterine tenderness in infection
- > adnexal mass
Investigations
- b HCG
- > urine
- > serum
- FBC
- blood group and antibodies
- > transfusion
- > sensitising event
- Coags
- Consider
- > MSU
- > STD
- Initial transvaginal ultrasound
- > IUP
- > ectopic pregnancy
- > absence of findings (PUL/complete miscarriage)
- > GTD
5
Q
Suspected miscarriage investigation pathway
A
Intrauterine pregnancy
- Confirmation
- > yolk sac/embryo within gestational sac in endometrial cavity
- Viable
- > fetal heart present
- Non viable incomplete miscarriage
- > loss of cardiac tones in confirmed intrauterine
- > MSD >25mm, no yolk sac/embryo
- > CRL >7mm w no cardiac tones
- Viability cannot be assess (MSD <25mm)
- > repeat TVU when MSD expected to be 25mm
- > assume MSD grows 1mm/day
Ectopic
- Confirmed
- > gestational sac with yolk sac/embryo at ectopic site
- > adnexal mass/empty uterus/free fluid
- > consider heterotopic
- Likely
- > pseudosac
- > complex extra ovarian adnexal mass
- > tubal donut sign
- > adnexa ring of fire sign on doppler
PUL
- DDx
- > early IUP/non viable IUP
- > ectopic
- b HCG >3500 w. no findings
- > almost certainly ectopic
- > proceed with treatment
- b HCG >2000 w. no findings
- > ectopic/multiple gestation
- > consider serum progesterone (low = non viable)
- > expectant treatment as ectopic justifiable
- > consider repeat TVU in 3 days (MSD visible at 3mm )
- b HCG <2000 w. no findings
- > repeat b HCGs over 48 hrs
- serial b HCGs
- > doubled = probably viable
- > falling = likely unviable (including aborted ectopic)
- > suboptimal rise (determined by initial level ) = ectopic or non viable IUP
6
Q
Miscarriage psych management
A
Breaking bad news
- setting
- > as soon as possible
- > ideally both parents present
- > offer and facilitate presence of support person
- > minimise waiting times
- > private, preferably away from maternity wards
- principles
- > provide as much information as possible
- > don’t speculate
- > talk about ‘baby’ or use name if given
Counselling
- principles
- > allow time for questions, grief and discussion
- > discuss potential experience of grief/depression
- memories
- > offer to provide momento (eg. US picture)
- > offer to see baby (prepare them for image)
- supports
- > discuss personal supports
- > mental health services
- > medicare pregnancy support counselling services
- consider
- > risk factors for psychological morbidity
- > suicide risk (leading cause of maternal mortality)
7
Q
Miscarriage general management
A
Disposal of fetal tissue
- if state requirements for birth registration met
- > death certificate
- > cremation or burial
- birth registration requirements not met
- > early pregnancy loss certificate can be provided
- > hospital cremation
- > private funeral director
- > burial on private property
Histopath
- products of conception sent to laboratory
- > confirm pregnancy
- > exclude ectopic
- > exclude GTD
- collection
- > during surgery/inpatient miscarriage
- > provide labelled specimen jar if expectant at home
Safety net
- seek emergency assistance
- > severe pain
- > shoulder tip pain
- > soaking more than 1 pad every hour
- > syncope
- > fever
- return of period
- > resolution of complications/completion of care
- ongoing bleeds (>2 weeks)
- > incomplete delivery
- > GTD
8
Q
Expectant management non-viable pregnancy
A
Indications
- > patient preference
- > incomplete miscarriage
Contraindications
- > later than first trimester
- > unstable
- > evidence of infection
- > high risk of haemorrhage or coagulopathy
- > suspected GTD
Risks
- > 20% unsuccessful
- > prolonged bleeding
- > high rate of unplanned admission
- > low and comparable infection rate (2-3%)
- > 2% risk of transfusion
Benefit
- > similar success rate as medical management
- > avoid medication/surgery
- > managed at home
Follow up with GP/EPAS
- > repeat b HCG in a week
- > US if b HCG decrease <90%
9
Q
Medical management non viable pregnancy
A
Indications
- > patient preference
- > incomplete miscarriage
Contraindications
- > later than first trimester
- > unstable
- > evidence of infection
- > high risk of haemorrhage or coagulopathy
- > prostaglandin allergy
Risks
- > heavier and prolonged bleeding than surgical
- > 20% unsuccessful
- > low and comparable infection rate (2-3%)
- > 1% risk of transfusion
Benefits
->faster process than expectant
Procedure
- > outpatient/day procedure
- > misoprostol per vagina single dose
- > analgesia and anti-emetics
Expect
- > bleeding within 24 hrs
- > bleeding heavier than menses
- > cramping pain
- > pain and bleeding gradual get worse
- > peaks for 2-4 hours
- > occasional bleeding/dull ache/cramping for 2 weeks
- > SE = diarrhoea and vomitting
Follow up with EPAS
- > b HCG day 1 and 8 (confirm levels falling)
- > US if b HCG decrease <90%
- > repeat dose after 2-7 days if no response
10
Q
surgical management non viable pregnancy
A
Indication
- first/early second trimester
- patient preference
- unstable/severe haemorrhage
- evidence of infection
- suspected GTD
- unsuccessful medical/expectant management
Contraindication
-no absolute
Risks
- standard procedure/anaesthesia risks
- low and comparable infection rate (2-3%)
- complications 1-2%
Benefits
- shorter time to completion
- lower rate unplanned hospital admissions
- lowest rate of blood transfusion
Procedure
- misoprostol PV 4hrs pre op
- dilation and curettage (suction recommended)
- general anaesthetic in OR
Follow up
- GP if ongoing concerns
- no b HCG or US
11
Q
Clinical manifestations and diagnosis pregnancy
A
Hallmarks signs/symptoms
- typical presentation
- > within 8 wks gestation
- > hx of sex without contraception
- common
- > amenorrhea
- > nausea +/- vomiting (until 10 weeks)
- > breast enlargement/tenderness
- > fatigue
- > urinary frequency
Additional hx
- Neuro
- > mood changes
- > difficulty sleeping
- > orthostatic presyncope
- > carpal tunnel
- Skin
- > hyperpigmentation
- > palmar erythema
- > spider angiomas
- Abdo
- > mild uterine cramping
- > adnexal discomfort
- > bloating
- > constipation
- > GORD
- > food cravings and aversions
- Genitourinary
- > bleeding
- > nocturia
- Resp
- > nasal congestion
- > SOB
Exam
- uterus above symphysis after 12 wks
- vulva/vaginal/cervix mucous
- > congested and bluish after 12 weeks
- breasts
- > areolar darkens
- > veins more visible
B HCG
- serum vs urine
- > serum much more sensitive and quantitative
- > urine rapid, cheap but quantitative
- serum
- > can detect 1-2 mili IU
- > level >5IU confirms pregnancy
- > earliest detected 2 weeks after first day LMP
- normal trajectory starts
- > double every 48hrs for first month
- > starts to decline after 10 weeks
- > plateaus for second and third trimester
TVU
- gestational sac
- > 4-5 weeks
- yolk sac
- > 5-6 weeks
- fetal pole w cardiac activity
- > 6 weeks
12
Q
Gonorrhoea background
A
Epidemiology
- approx 5/10,000 gen pop
- > 200 times more common in ATSI
- risk factors
- > ATSI
- > MSM
- > under 25yrs
- > new/multiple sex partners
- > partner with STD
- > inconsistent condom use
- > past STD
Aetiology
- penetrative sex
- > oral
- > vagina
- > rectum
- transmission rate
- > male to female = 60%
- > female to male = 25%
Pathophys
- attaches to mucosal epithelium
- chromosomal plasticity
- > evades immune system
- > high rate of antimicrobial resistance
- > reinfection common
- incubation period
- > approx 3 days in men
- > longer in women
13
Q
Gonoccocal syndromes
A
Women
- cervicitis
- > most common
- > usually asymptomatic
- urethritis
- > almost always with cervicitis
- > usually asymptomatic
- PID and sequelae
- bartholinitis
- > with cervicitis
- > perilabial pain and discharge
- > oedematous/tender labia
- pregnancy
- > PPROM
- > premature delivery
- > low birth weight
- > chorioamnionitis
Men
- urethritis
- prostatitis
- > lower back pain
- > dysuria
- > frequency/urgency
- epididymitis/orchitis uncommon
Both
- proctitis
- > pain
- > discharge/bleeding
- > tenesmus/constipation
- pharyngitis
- > oral sex
- > pharyngitis
- > exudate
- > cervical lymphadenopathy
- conjunctivitis
- > by direct inoculation with anogenital secretions
- > hyperacute (symptoms within 12 hrs)
- > copious purulent discharge
- > red and irritated
- > chemosis/swollen eyelids
- > preauricular lymphadenopathy
- > sight threatening
- purulent arthritis (disseminated disease)
- > acute onset
- > distal/asymmetric/oligoarticular arthritis)
- > otherwise well
- arthritis-dermitis syndrome (disseminated disease)
- > several weeks post infection
- > flu like illness with fever
- > asymmetric, migratory polyarthritis
- > tenosynovitis
- > pustular/vesicular lesions on extremities
14
Q
Initial antenatal visit
A
Hx
- obstetric Hx
- edinburgh post natal depression scale
- genetic counselling
- > aneuploidy screening
- > carrier screening
Advice
- potential teratogens
- lifestyle
- > smoking, drinking, drugs
- > diet and supplements
- > exercise
- > general restrictions
- infection prevention
- > immunisation
- > precautions
- ongoing care
- > care team
- > frequency of visits
- > antenatal education courses available
Exam
- height, weight, BMI
- BP
- Uterine
- > size
- > consistency
- > position
Ultrasound
- confirm
- > pregnancy
- > number
- > location
- > cardiac tones
- GA
- morphological anomalies
- > poor sensitivity
Bloods
- FBC
- > haemoglobin (anaemia)
- > MCV (thalassaemia/iron deficiency)
- > platelets (thrombocytopenia)
- Blood group and antibodies
- MSU
- > dipstick for proteinuria
- > midstream culture
- Diabetes screening
- > random glucose
- > HbA1c if high risk
- Rubella
- > antibody titre
- Varicella
- > documented previous chickenpox/shingles
- > previous vaccination
- Syphilis
- > trepanemal assay
- Chlamydia/gonorrhoea
- > high risk
- > under 25
- HIV
- > EIA + western blot
- HBV
- > HBVsAg
Consider
- CMV
- > if contact with lots of children
- HCV
- > if high risk
- TSH
- > if high risk
- sickle cell and thalasaemia screeing
- > if high risk
Cervical screening
-if due
15
Q
Determining GA
A
Best estimates
- US is best estimate of EDD if
- > before 22 weeks
- > discrepancy with LMP larger than expected for GA
- most accurate estimate of EDD overall
- > CRL during first trimester
- accepted/unchanged EDD
- > earliest sonographic assessment made
Ultrasound
- indications
- > offered to all before 22 weeks
- > irregular periods
- > LMP unknown
- > conception with hormonal contraception
- > uterine size differs from LMP
- technique
- > TVU preferred during first trimester
- > TAU for remainder
- limitations
- > multiple gestation
- > morphology abnormalities
- initial scan in first trimester
- > use CRL
- initial scan in second/third trimester
- > BPD, HC, AC, FL
Clinical assessment
- Naegele’s rule
- > minus 3 months + 7 days
- > assumes 28 day period with fertilisation on 14th
- Uterine size (archaic)
- > 8 = plum/10 = orange/12 = grapefruit
- > above symphysis at 12/at umbilicus at 20
- > cm above umbilicus after 20
- > invalid with fibroids, obesity, twins, retroverted
16
Q
Aneuploidy screening
A
Combined first trimester screening
- timing
- > 11-13+6 weeks
- components
- > NT = >95th centile
- > PAPP-A = low
- > b HCG = high
- > maternal age
- > gestational age
- conditions tested (66% of all aneuploidies)
- > trisomy 21 (Down)
- > trisomy 13 (Patau)
- > trisomy 18 (Edwards)
- performance for 21
- > sensitivity = 85%
- > FPR = 5%
- soft markers increase sensitivity/specificity
- > nasal bone/DV waveform/tricuspid flow
- confounders
- > maternal weight
- > smoking
- > IVF
- report of results
- > risk of disease
Cell free DNA
- timing
- > from 10 weeks
- > consider as secondary screen
- components
- > maternal serum taken
- > fetal fraction and number of sequence specific chromosomes = presence of aneuploidy
- > offer early anatomy US @ 11-13 weeks
- conditions
- > autosomal trisomies (21/13/18)
- > sex chromosome aneuploidies
- > micro deletions (diGeorge) not recommended
- unable to provide a result in approx 5%
- > early GA
- > suboptimal collection
- > low FF in obese mothers/fetal karyotype/IVF
- private cost approx $400
- trisomy 21 performance
- > sensitivity = 99%
- > specificity = 99%
- > PPV = 90%
- causes of inaccuracies
- > placental mosaicism
- > maternal mosaicism
- > vanishing twin
- > copy number variants
- > maternal cancer
- report of results
- > positive/negative
- > high risk/low risk
Second trimester testing
- maternal serum screening (PPV = 3%)
- > at 15-20 weeks
- > maternal age
- > AFP
- > b HCG
- > UE3
- > Inhibin
- cfDNA (from 10 weeks)
17
Q
Initial antenatal genetic counselling
A
Discuss
- patient hx
- > concerns
- > family hx
- > risk factors
- genetic conditions
- > information on common genetic conditions
- > risks for pregnancy, baby and beyond
- > concept of phenotypic variability
- genetic testing
- > description of available tests
- > benefits and limitations of different tests
- > screening vs diagnosis
- > risk of unexpected findings without solutions
- > private costs
- implications
- > continue or terminate pregnancy
- > palliate baby with terminal illness
- > timing and restriction of abortion methods
- supports and further information
- > referral to genetic counselling
- > written information
- > support groups
Aneuploidies
- screening tests
- > combined first trimester screening
- > second trimester screening
- > cell free DNA
- diagnostic tests
- > amiocentesis
- > chorionic villus sampling
Carrier screening
- pre-conception screening preferred
- > pre-implantantion genetic testing etc
- monogenic diseases tested
- > fragile X
- > cystic fibrosis
- > spinal muscular atrophy
- > haemoglobinopathies
- most adults +ive for 3 severe recessive disorders
- > most are autosomal
- couples or sequential screening
- extended panel
- > offered to at risk groups
18
Q
Down syndrome prenatal diagnostic tests
A
Indications
- > patient preference (before screening)
- > postive genetic screen
Relative contraindication
- > alloimmunisation
- > HIV
- > Hep B/C
Amniocentesis
- timing
- > from 15 weeks gestation
- > before = high risk adverse outcomes
- procedure
- > withdraw amniotic fluid using needle
- > ultrasound guidance
- post procedure care
- > uterine cramping normal
- > spotting/amniotic fluid leak immediately after
- risks
- > rupture of membranes
- > indirect fetal injury (talipes/respiratory)
- > direct fetal injury (rare
- > fetal loss = 0.5% (1/200)
- > infection (rare)
Chorionic villus sampling
- timing
- > from 11 weeks
- > before = high risk complications
- procedure
- > tertiary institute
- > ultrasound guided
- > transabdominal/transcervical approach
- > placental tissue aspirated into syringe
- > mild pain
- post procedure care
- > no exercise or sex 24hrs
- > some light spotting is normal
- risks
- > fetal loss approx 1% (1/100)
- > transverse limb reduction defects
- > sampling failure
- > vaginal bleeding
- > infection (rare)
Assessment of sample
- extremely low false negative rate
- > variants of unknown significance in 5%
- methods
- conventional karyotyping
- FISH
- chromosomal microarray
19
Q
Diet advice initial antenatal visit
A
Diet
- opportunity for intervention
- > importance of well balanced diet
- > referral to dietician/written information
- caloric intake
- > no need for increase in first trimester
- > increase is only small in second/third trimester
- > eating for two is misnomer
- avoid
- > raw/smoked meats/fish (listeria/toxoplasmosis)
- > soft cheeses/pate (listeria)
- > unpasteurised milk/cheese (brucellosis)
- > large predatory fish (mercury)
- > high caffeine intake
- > sugar sweetened beverages (childhood obesity)
- > artificial sweeteners appear safe
- vegetarian
- > balanced diet probably ok
- > supplement vitamin D/E and iron
- vegan
- > also deficient in calcium, B12, omega 3 fatty acids
- low carbohydrate
- > deficient in folate
Supplements
- multivitamin
- > may not be needed in well nourished mothers
- > prudent to presribe empirically
- goals
- > iron 30mg
- > calcium 1000mg
- > vitamin D 600IU
- > folic acid 0.4-0.8mg (increase with gestation)
- iodine
- > adequate intake avoids hypothyroidism
- > 250mcg recommended
- > may be replete is consuming fortified foods (eg salt)
- > excess intake can cause fetal goiter
- vitamin A
- > main concern is excess intake (teratogenic)
- > avoid supplements containing >1500mcg
20
Q
Lifestyle advice initial antenatal visit
A
Substance use
- Alcohol
- > FASD = neurodevelopmental/ID/craniofacial
- > possibly preterm/LBW/IUGR
- > consider withdrawal and thiamine
- Smoking
- > approx 1.5 x miscarriage/still birth/SIDs
- > approx 3x PPROM/preterm/LBW/abruption
- Cannabis
- > approx 3x perinatal morbidity/mortality
- > risk of preterm/low birth weight
- > long term neurodevelopment delay/ADHD
- Amphetamines
- > approx 3x fetal/neonatal death and preterm
- > many other obstetric complications
- Cocaine
- > approx 3x preterm and LBW
- > placental abruption
- Opioid
- > broad range of obstetric/neonatal complications
- > heroin = Rh/HIV/IE/Hep B/C risk
- > methadone substitution recommended
Exercise
- standard exercise prescription
- > controls gestational weight gain
- > less lower back pain
- > potential reduction pre-eclampsia/GD
- small risk
- > trauma leading to abruption
- caution
- > high intensity for long duration
- > high level in IUGR/threatened pre term
Infection control
- Influenza vaccine
- > at any stage if during winter
- DPT booster
- > in third trimester
- STDs
- > advise barrier method if high risk
- CMV and parvovirus
- > good hand hygiene
- > caution around children
- Varicella
- > pre conception vaccination
- > IvIg available if unvaccinated exposure
21
Q
Labour protraction/arrest background
A
Epidemiology
-approx 20% labours
Aetiology
- risk factors
- > highest risk in nullips
- > abnormal pregnancy/fetal abnormality
- > short stature/obesity/macrosomia/post term
- > neuraxial anaesthesia
Pathophys
- hypocontractile uterus
- > diagnoses by palpation/tocodynamometry
- > weak/infrequent (<3-4/10)/short (<50seconds)
- cephalo-pelvic disproportion
- > usually due to malposition (extension/OP/OT)
- > floating head at 7cm
- non occiput anterior positioning
- > length of labour/caesarian risk correlates with rotation
- > often start OT/OP and rotate
- bandl’s ring
- > rare complication of second stage
- > hourglass contracture between upper/lower uterus
- neuraxial anaesthesia
- > does not impact on first stage
- > longer second stage/more oxytocin and instrumentation
22
Q
Evaluation and management prolonged labour
A
Review 3 P’s
- Power
- > uterine contractility
- > maternal effort
- Passenger
- > presentation/position
- > physical abnormalities
- Passageway
- > history of pelvic trauma etc
- > maternal size, known anatomical abnormalities
Additional signs
- CTG
- > baseline/variability/accelerations/decelerations
- liquor
- > clear = reassuring
- > bloody = normal if clears
- > meconium stained = mature or distressed baby
- obstructive signs
- > caput
- > moulding (significant override of sutures)
- > haematuria (irritation of bladder)
Latent first stage protraction
- definition
- > no accepted threshold
- > can be many hours or days
- management
- > counselling on normality/reduce anxiety
- > therapeutic rest if tired (morphine <20mg)
- > oxytocin if ready
- > neuraxial anaesthesia
Active first stage protraction
- definition
- > dilating <1cm/hr after 6cm
- > more than 7hrs for 4 to 5cm
- > more than 4hrs for 5 to 6cm
- high dose oxytocin (vs low dose)
- > increased tachysystole (avoid in VBAC)
- > decreased caesarian/increased vaginal delivery
- > similar maternal/neonatal outcomes
- amniotomy
- > chemical stimulation/mechanical advantage
- > contraindicated when not engaged (cord prolapse)
- > best evidence when combined with oxytocin
Active first stage arrest
- definition
- > 6cm with ruptured membranes plus
- > no change >4hrs with good contractions
- > no change >6hrs with inadequate contractions
- management
- > caesarian section
Second stage
- failure to progress
- > 2hrs for nulip (95th = 3.5hrs)
- > 1hr for multip (95th = 2hrs)
- > longer for neuraxial anaesthesia
- consider oxytocin after 60-90mins
- consider passive decent
- > one hour without pushing if high station
- consider manual rotation manoeuvres
- consider operative delivery
- > fetal/maternal demise with high change of success
- consider need for caesarian
- > failure to progress
- > denies or contraindication for operative delivery
23
Q
management first stage labour
A
Initial assessment
- review
- > pregnancy/complications/fetal wellbeing
- > routine bloods/Rh/GBS/STDs
- vitals
- > BP/HR/temp
- > frequency/quality/duration contractions
- > fetal heart rate
- abdo
- > lie (longitudinal/transverse/oblique)
- > presentation (cephalic/breech)
- digital exam
- > baseline cervix status (dilation and effacement)
- > integrity of membranes
- > presence of bleeding
- > position (occiput position)
- > > station (-5 to +5/ischial spines = 0)
- investigations
- > UA for protein (pre-eclampsia) if membranes intact
General management
- fluid and foods
- > avoid foods where possible
- > clear fluids improve outcome (consider anaesthetic risk)
- > consider dextrose/fluid infusion
- infection prophylaxis
- > GBS
- > no need for empiric antibiotics
- positioning and activity
- > no evidence for any preference
- > move and position as comfortable
- pain control
- >
- fetal heart rate monitoring (low risk)
- > consider 30 mins external continuous upon admission
- > intermittent auscultation preferred
- > every 30 mins during active first stage
- > every 15 mins second stage
- > intermittent auscultation
- fetal heart rate monitoring (high risk)
- > continuous external from admission
- additional monitoring
- > external tocodynamometry
- > cervical progress every 4 hrs
