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Week 1 Flashcards

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1
Q

obstetric examination parts

A

1-Inspection from end of bed
–Expose maternal abdomen from symphysis publis to xiphoid
2-Vital Signs (temp, BP, pulse)
3-Cardiovascular
4-Respiratory
5-Neurological (If relevant to history)
6- Abdominal
—Palpation for lie and presentation, SFH measurement
7-Pelvic ( Sterile speculum vs digital vaginal)

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2
Q

Inspect the maternal abdomen for

A

Striae gravidarum (Stretch marks)
Linea nigra (midline hyperpigmentation)
Scars (i.e. appendicectomy, previous Caesarean Section…)
Tatoos, Piercings etc
Abdominal swelling or distended abdomen consistent with pregnancy

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3
Q

How to take BP in pregnant women

A

Blood pressure should be taken from the right arm with the patient lying in a semi recumbent position at an approximately 30 degree angle. Use large cuff for obese patients to ensure correct measurement.

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4
Q

the importance of urinalysis in pregnant women?

A

Proteinuria- diagnosis of Pre-eclampsia, renal disease
Haematuria- underlying renal disease, renal colic, UTI
Glycosuria – underlying diabetes, prompt GTT
Leucocytosis, Nitrates – diagnosis of UTI

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5
Q

NEUROLOGICAL examination ?

A
  • Examine reflexes and clonus in patients with Pre-eclampsia

- Fundi

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6
Q

position of abdominal palpation

A

Examined in the recumbent position, left lateral (to avoid compression of IVC)

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7
Q

what do we look in abdominal examination

A

1- SFHM

2- Lie and Presentation of the fetus

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8
Q

how to measure SFH

A

Symphyseal fundal height (SFH)
Using a tape-measure from the upper border of the Symphysis pubis to the fundus
Record measurements in cm
SFH in cm = weeks of gestation +/- 2cm

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9
Q

HOW do you locate the fundus

A
  • -Palpate down from the level of the Xiphoid with the ulnar border of your left hand until you reach the fundus of the uterus
  • -At umbilicus at 20 weeks
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10
Q

what is the lie? and are the different lies? who the lie examined

A

The ‘lie’ is the position of the fetus with respect to the longitudinal axis of the uterus

The lie must be either
longitudinal
Transverse/ Oblique.

Lateral palpation determines the lie of the fetus

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11
Q

what subjective assessment the abdominal palpation allows us to measure

A

The abdominal palpation allows a subjective assessment of fetal size and amniotic fluid volume

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12
Q

what is the lateral palpation

A

Place both hands flat on either side of the maternal abdomen

The fetus is then gently ballotted between the hands to determine the fetal lie and presentation

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13
Q

what is the 2 parts of presentation

A

1- which part is presented
- with the longitduenal lie, either cephalic or breech

2- proportion of fetal head passing the pelvic brim(inlet)

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14
Q

The proportion of the fetal head palpable within the abdomen compared with the proportion that has descended into the pelvis is described in fifths.

A

5/5: head is completely free and mobile within abdomen
4/5: head is beginning to enter the pelvic brim
3/5: most of head is within the pelvic brim
2/5: the widest diameter of the head has passed through
the pelvic brim
1/5: minimal portion of head palpable abdominally

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15
Q

head engagement?

A

The head is engaged when the widest part (biparietal diameter) has passed through the pelvic inlet.

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16
Q

what is the normal fetal heart rate, and how can we measured it

A

Fetal Heart (110- 160 bpm)
A Pinnard or Doppler can be used to detect the fetal heart
It is best heard over anterior shoulder of the fetus

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17
Q

lower limb examination

A

Oedema
Bilateral Pitting Oedema: very common in third trimester

Varicose veins

Evidence of deep vein thrombosis
Erythema
Pain
Swelling
Heat
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18
Q

indications for sterile speculum examinations

A

To confirm spontaneous rupture of membranes (in this case, amniotic fluid may be seen forming a pool in the posterior vaginal fornix)

To assess vaginal bleeding in pregnancy

To assess cervical dilatation in preterm labour

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19
Q

digital vaginal examination is indicated

A

confirm the diagnosis of labour
to assess cervical favourability for induction of labour
to assess the progress in labour

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20
Q

Bishop score

A

Position of the cervix (posterior/ mid-position/ anterior)
Consistency (firm/ medium/ soft)
Cervical Length or effacement (in cm or %)
Dilatation of the cervix in cm
Station of the fetal head in relation to the ischial spines

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21
Q

A transverse lie carries a risk of ?

A

A transverse lie carries a risk of cord prolapse in the event that the membranes rupture.

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22
Q

effacement meaning

A

With regard to the cervix: it shortens in preparation for labour, this is referred to as ‘effacement’

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23
Q

incision used in Caesarean section

A

Pfannenstiel incision leaves transverse scar

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24
Q

is the murmur normal in pregnancy

A

physiological murmur is normal

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25
for who PRECONCEPTION CARE is offered
General considerations:GP Medical disorders: GP/HOSPITAL Physician and obstetric: Medications should be reviewed An obstetric complication in a prior pregnancy, or a gynaecology condition - Her Gynaecologist - congenital malformation --> specialist in fetal medicine or a geneticiss
26
``` GENERAL PRECONCEPTION COUNSELLING where it took place what history is taken what examinations are performed what standard and targeted tests are done ```
Usually takes place at the GP surgery Review family history, gynaecological history, medical history Clinical examination to exclude cardiovascular, respiratory, renal, neurological disease Standard:Cervical Smear if due, Rubella Immunity, Varicella Zoster Immunity Targeted: e.g.Thyroid panel if history of thyroid dysfunction or if clinical indication, Hepatitis screen if at risk (may require immunization)
27
5 other things the GP need to do
Preconception folic acid : 400mcg orally daily for 3 months prior to conception and continue up until 12 weeks Smoking Cessation Alcohol Recreational Drug Use Dietary advice
28
EXAMPLES OF MEDICAL DISORDERS PARTICULARLY RELEVANT TO PREGNANCY
Diabetes Epilepsy Cardiac Disease: pregnancy may be particularly hazardous in some conditions, eg pulmonary hypertension (30% maternal mortality) ``` Rheumatology: SLE, rheumatoid arthritis Renal Disease Infections: HIV, Hepatitis Respiratory (e.g. cystic fibrosis) Gastrointestinal: Crohn’s, Ulcerative Coliti ```
29
who responsible for prenatal care and who initiate it
Commonly delivered through a ‘Combined Care’ system with GP, Obstetrician, and midwifery care Care is initiated by GP who confirms the pregnancy and writes to the hospital to request a registration or ‘booking’ appointment at the hospital.
30
what the booking visit involves ?
Involves a discussion with the midwife, followed by history-taking and examination by the Obstetrician Obstetrician performs a risk assessment to determine the degree of pregnancy risk (low- or high-risk) Taking into account the patients views, a decision is made on the type of antenatal care appropriate: - Midwifery-led care - Combined care with GP + Hospital - High Risk consultant-led care
31
BOOKING VISIT EXAMINATION
Baseline BP/ urinalysis/ BMI Cardiovasculal Breast examination Abdominal examination is effectively replaced by ultrasound Pelvic examination/ speculum: only in specific circumstances (e.g. bleeding)
32
BOOKING VISIT ULTRASOUND | when is the first and second one, and what each one assess?
Early Ultrasound examination at 8-14 weeks 1-Confirms ongoing intrauterine pregnancy 2-Determines gestational age 3-Detects multiple gestation 18-22 weeks: women usually scheduled for a detailed ultrasound to confirm fetal anatomic normality
33
how many visits to GP/Hospital the pregnant need to attend
10 | 12 -> 16 --> 20 >24>28>30>32>34>36>41
34
ADDITIONAL CARE REQUIRED DURING
Medical Problems Problems in previous pregnancy: Women with complications arising in index pregnancy; e
35
ADDITIONAL CARE REQUIRED DURING | medical problems example
``` Cardiac Renal Dibaetes HIV EPILEPSY Psychiatric disorder ```
36
ADDITIONAL CARE REQUIRED DURING | Problems in previous pregnancy:
Preterm labour Severe PET/ HELLP Rhesus Isoimmunisation or other red cell antibodies that may pose a risk for haemolytic disease of the newborn Still birth/ Neonatal death Previous small for gestational age infant (<5th centile) Previous large for gestational age infant (>95th centile) Baby with a congenital anomaly/ genetic disorder Puerperal Psychosis
37
ADDITIONAL CARE REQUIRED DURING PREGNANCY: | Women with complications arising in index pregnancy
Multiple gestation Rhesus Isoimmunisation or other blood group antibodies Small for gestational age fetus, or ultrasound evidence of uteroplacental insufficiency Large for gestational age fetus Suspected or confirmed fetal congenital anomaly (structural or chromosomal) Placenta Praevia Women who are particularly vulnerable or lack social support
38
Labour Diagnosis
Diagnosis: ‘Progressive effacement and dilatation of the cervix in the presence of uterine contractions
39
Effacement ?
Effacement occurs when the entire length of the cervical canal has been taken up into the lower segment of the uterus. In a Primigravid patient, dilatation will not begin until full effacement is complete
40
which additional 2 evidence that pregnant in labour? | providing ---?
A ‘show’ (blood-stained mucous discharge) or spontaneous rupture of membranes (SROM) provide further evidence that a woman is in labour provided she is experiencing regular uterine contractions.
41
what are the 3 stages of Labour
First stage: From establishment of labour until full dilatation. Second stage: Full dilatation to delivery of the fetus. Third stage: Delivery of the placenta
42
Labour assessment general maternal fetal
Standard procedures: General examination, assessment of uterine contractions and fetal wellbeing. FBC, blood type and Rh status. Partogram. Minimal vaginal examinations following initial assessment ``` Fetal assessment: Amniotic fluid (volume & colour). Fetal heart rate monitoring: continuous vs intermittent. ``` Maternal assessment: BP / HR / temp charting Uterine contractions
43
what factors the progression of first stage depend on? and how it is recorded what is the average of cervical dilatation
Progress is measured in terms of dilatation of the cervix and descent of the presenting part. Progress is recorded by means of a partogram. The average rate of cervical dilatation in primigravidae is 1cm per hour. and 1-2 cm in multigravida
44
how the Descent of the fetal head is measured in labour
Abdominal examination. If only 2-fifths --> Engagement Vaginal examination, the ‘station’ of the fetal head with respect to the ischial spines is recorded --> + 5 head crowning
45
Progress in second stage is measured in terms of ?
Progress is measured in terms of descent and rotation of the fetal head on vaginal examination.
46
what is the 2 phases of second stage of labour?
Passive phase: From full dilatation until the head reaches the pelvic floor. Active phase: When fetal head reaches pelvic floor. Usually associated with strong desire to push.
47
MECHANISM OF LABOUR?
Engagement Flexion Descent Internal rotation: form occiptiotransverse to occipitoanterior Extension (as the head delivers). External rotation (back to transverse position, allows rotation of shoulders to anteroposterior position.) Expulsion
48
Signs of placental separation in third stage of labour
Lengthening of umbilical cord Gush of blood per vaginam ‘Rising up’ of the fundus
49
how is third stage of labour is managed?
The third stage of labour is actively managed to minimise the risk of postpartum haemorrhage. Active management involves administration of Syntocinon (oxytocin) or Syntometrine (oxytocin and ergometrine) and delivery of the placenta via controlled cord traction. The uterine fundus is rubbed up to ensure that it is well contracted and the placenta is examined to ensure that it is complete
50
what is Episiotomy ?
An episiotomy is a surgical procedure in which the perineum is cut with a scissors with the intention of widening the soft tissue diameter of the introitus in order to prevent a severe perineal tear or accelerate delivery.
51
indications of Episiotomy ?
There is little evidence to support routine use of episiotomy. Indications include: A rigid perineum, if it is felt that a perineal tear is imminent and shoulder dystocia.
52
PERINEAL TEARS Degrees
First degree: --Injury to the vaginal epithelium & vulval skin only. ``` Second degree (equivalent to episiotomy): --Injury to the perineal muscles, but not the anal sphincter. ``` Third degree: --Injury to the perineum involving the anal sphincter. Fourth degree: --Injury involving anal sphincter and rectal mucosa.
53
Modes of Analgesia in Labour
``` TENS machine: Simple analgesia- Paracetamol Opiods: --IM Pethidine --Morphone PCA --Fentanyl PCA --Remifentanil PCA Epidural Combined Spinal-epidural ```
54
define normal labor
Beginning from 37- 42 weeks, progressing at an acceptable rate and resulting in the spontaneous vaginal delivery(SVD) of a live neonate in good condition in the occipitoanterior position
55
Fetal skull Diameter
Biparietal diameter 9.5 cm. Between parietal eminences The greatest transverse diameter Suboccipitobregmatic 9.5 cm. Middle of the bregma (forehead) to undersurface of the occipital bone at the neck. The presenting diameter of the well flexed head in labour Occipitofrontal 11.5 cm Root of the nose to the most prominent point of the occiput A deflexed head presents with this diameter Mentovertical 13 cm Chin to most prominent point of the occiput The presenting diameter in brow presentation The largest diameter of the fetal head Submentobregmatic 9.5 cm Chin to middle of bregma The presenting diameter in face presentation
56
Abnormal labour
Abnormal Progress in Labour Abnormal Cardiotocograph(CTG) in Labour
57
Prolonged Labour
Prolonged Labour refers to prolongation of the first stage of labour Prolonged labour is often defined as >12 hours from onset of labour until delivery in a primigravid
58
Causes of Prolonged Labour
The Powers’ inefficient uterine action ‘The Passages’ maternal pelvic abnormalities ‘The Passenger’ fetal macrosomia or malpresentation
59
what define Efficient and inefficient Uterine Contractions
Efficient Uterine Contractions: --are regular contractions, lasting 60-80 seconds and have frequency of up to 7 in 15 minutes Inefficient Uterine Contractions: --Contractions are not strong enough or are in-coordinate (irregular) Commonest cause of failure to progress in labour in primigravid patients is inefficient uterine action
60
how to manage inefficient uterine contractions | when it is dangerous
Oxytocin Aim to achieve 7 contractions in 15 minutes Important to monitor fetal heart rate when using oxytocin Caution with the use of oxytocin in a multigravida A multigravid woman is less likely to have inefficient uterine action If not progressing, it is essential to out rule a malposition or malpresentation The use of oxytocin in these circumstances can result in uterine rupture
61
Cephalopelvic Disproportion causes
- Pelvis is too small or may be abnormally shaped - Fetus is large – macrosomia, hydrocephalus - Malpresentation of the fetal head means that a larger diameter is presenting to the pelvis eg. OP position – this is ‘relative’ CPD
62
Diagnosis of prolonged labour
Firstly: Is there uncertainty about the timing of the onset of labour? Next: Review the history Assess the contractions – fequency and strength Review the CTG Perform abdominal and vaginal examinations before making any decisions
63
Indications for Delivery by Caesarean Section in prolonged labour
Suspected Fetal compromise Arrest in cervical dilatation despite good contractions (with or without use of oxytocin) Cephalopelvic disproportion
64
what is the consequneces of OP presentation
Prolonged first stage of labour: corrected by oxytocin The second stage is also prolonged If rotation is incomplete then deep transverse arrest results = The fetal head has descended to the level of the ischial spines and the sagittal suture lies in the transverse position Management: Delivery by caesarean section Rotational Instrumental Delivery
65
Types of Malpresentation
Face (abnormal cephalic) Brow (abnormal cephalic) Breech Arm/shoulder (with a transverse or oblique lie
66
``` Face Presentation the cause the incidence the presenting diameter 2 types ```
The head is fully extended Occurs in 1 in 2000 labours The widest diameter is the submentobregmatic diameter at 9.5cm May be mentoanterior or mentoposterior

OBS/GYN (3 decks)

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