Phase 3A Stephen Lau & George Lam The Peer Teaching Society is not liable for false or misleading information…

Labour Abnormal Fetal Presentations Preterm Birth Postterm Birth Puerperium NOT Multiple Pregnancy The Peer Teaching Society is not liable for false or misleading information… Outline

G1P0 34+2/40 26 year old woman is experiencing contractions. They are decreasing in frequency and intensity. – List 3 Clinical Features of Labour – If this is not labour, what is it? The Peer Teaching Society is not liable for false or misleading information… Labour

G1P0 34+2/40 26 year old woman is experiencing contractions. They are decreasing in frequency and intensity. – List 3 Clinical Features of Labour – If this is not labour, what is it? Braxton-Hicks Contractions The Peer Teaching Society is not liable for false or misleading information… Labour

Same woman is now 39+1/40 and experiencing regular strong contractions. – What Are The 3 Stages of Labour? Describe Start/End Points of Each – Name 2 Maternal and 2 Fetal Parameters to be Monitored Initially and How Frequently The Peer Teaching Society is not liable for false or misleading information… Labour

Same woman is now 39+1/40 and experiencing regular strong contractions. – What Are The 3 Stages of Labour? Stage 1  Regular Contractions to Full Cervical Dilatation/Effacement Stage 2  Full Cervical Dilatation/Effacement to Delivery of Baby Stage 3  Delivery of Baby to Delivery of Placenta – Name 2 Maternal and 2 Fetal Parameters to be Monitored Initially and How Frequently Maternal Obs q2h Maternal Contractions q30 min Maternal Cervix q4h Fetal HR q15 min/After Contraction Fetal Station q4h Fetal Liquor on ROM The Peer Teaching Society is not liable for false or misleading information… Labour

The Peer Teaching Society is not liable for false or misleading information… Labour

You assess the woman’s cervix to be fully effaced. – What Are The 2 Phases of Stage 1 Called? – What Is The Cervical Dilatation Cut-Off Between Them? The Peer Teaching Society is not liable for false or misleading information… Labour

You assess the woman’s cervix to be fully effaced. – What Are The 2 Phases of Stage 1 Called? Latent Active – What Is The Cervical Dilatation Cut-Off Between Them? 4 cm (…6 cm) The Peer Teaching Society is not liable for false or misleading information… Labour

The woman’s cervix is now dilated 6 cm. – What is the minimum rate of cervical dilatation for nulliparous and multiparous women in the active phase? – Name 1 hormone involved in cervical ripening and where it’s synthesized – Name 1 hormone involved in promoting contractions and where it’s synthesized The Peer Teaching Society is not liable for false or misleading information… Labour

The woman’s cervix is now dilated 6 cm. – What is the minimum rate of cervical dilatation for nulliparous and multiparous women? Nullip  1 cm/h Multip  2 cm/h – Name 1 hormone involved in cervical ripening and where it’s synthesized Prostaglandins  Uterus Relaxin  Ovaries (CL) – Name 1 hormone involved in promoting contractions and where it’s synthesized Prostaglandins Oxytocin  Hypothalamus (to Post. Pituitary) Estrogen  Placenta The Peer Teaching Society is not liable for false or misleading information… Labour

The woman’s cervix is now dilated 10 cm and is feeling the urge to push. – How frequently do you monitor the baby’s HR now? – Fill in the blanks Engagement in ___ Position Descent ? Extension ? Expulsion The Peer Teaching Society is not liable for false or misleading information… Labour

The woman’s cervix is now dilated 10 cm and is feeling the urge to push. – How frequently do you monitor the baby’s HR now? q5 min – Fill in the blanks Engagement in OT Position Descent Flexion IR  OA Position Extension ER (Restitution)  OT Position Expulsion The Peer Teaching Society is not liable for false or misleading information… Labour

The baby is delivered and the umbilical cord is clamped. – What is the cut-off time before worrying about retained placenta? The Peer Teaching Society is not liable for false or misleading information… Labour

The baby is delivered and the umbilical cord is clamped. – What is the cut-off time before worrying about retained placenta? 30 min The Peer Teaching Society is not liable for false or misleading information… Labour

Summary – Labour Dx vs. Braxton-Hicks – Stage 1  Contractions to 10 cm Dilatation Monitoring Latent Phase  4 cm Active Phase – 1 cm/h (Nullip), 2 cm/h (Multip) – Hormones Involved – Stage 2  10 cm Dilatation to Baby Delivery Monitoring (FHR) 7-Step Process – Stage 3  Baby Delivery to Placental Delivery Prolonged After 30 min The Peer Teaching Society is not liable for false or misleading information… Labour

Define & Give Example – Lie – Presentation – Position – Engagement – Station The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Define – Lie  Fetal Long Axis WRT Maternal Long Axis E.g.) Longitudinal, Transverse, Oblique – Presentation  Fetal Lower Uterine Pole E.g.) Cephalic, Breech, Shoulder, Cord – Position  Leading Fetal Part WRT Transverse Plane E.g.) Occiput (OA, OT, OP, etc.), Chin (MA, MP), Sacrum – Engagement  Leading Fetal Part WRT Pelvic Inlet 0-1/5 (5/5 completely above pelvic brim) – Station  Leading Fetal Part WRT Ischial Spine +5 to -5 (+5 Outwards, -5 Inwards) The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Define & Give Example – Lie – Presentation – Position – Engagement “Engaged” = Station 0 = At Ischial Spine – Station The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

What is the ideal lie, presentation and position? The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

What is the ideal lie, presentation and position? – Longitudinal – Cephalic – OA The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Woman is pregnant. On examination, wide uterus and fetal head at mother’s left flank are appreciated. – Diagnosis? – Investigation? 2 Things on Ix? – 2 Management Options The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Woman is pregnant. On examination, wide uterus and fetal head at mother’s left flank are appreciated. – Diagnosis? Transverse Lie – Investigation? USS  Confirm Lie + ?Placenta Previa – 2 Management Options ECV + Normal Delivery C/S The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Diagnosis? – Investigation? The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Diagnosis? Breech – Investigation? USS The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Name 2 other types of breech presentation other than a frank breech presentation – Apart from traumatic injury, what is another important complication that can occur delivering The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Name 2 other types of breech presentation other than a frank breech presentation Frank  Flexed Thighs, Extended Legs Complete  Flexed Thighs, Flexed Legs Incomplete/Footling  Extended Thighs – Apart from traumatic injury, what is another important complication that can occur delivering Cord Prolapse The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards. – Name of the sign? – Diagnosis? – What Is It? – Management? The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards. – Name of the sign? Turtle Sign – Diagnosis? Shoulder Dystocia – What Is It? Anterior Shoulder Trapped Under Symphysis The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards. – Management Help Episiotomy Legs in MacRoberts (Knee to Chest) Pressure on Suprapubic Area Enter Pelvis – Rotational Manoeuvres – Remove Posterior Arm – Roll Pt on All Fours The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

Summary – Definitions – Transverse Lie – Breech Presentation – Shoulder Dystocia Didn’t Cover Brow/Face Presentation Didn’t Cover Malpositions (OP, OT) The Peer Teaching Society is not liable for false or misleading information… Abnormal Fetal Presentation

A 24 year old, G2P1 32+3/40 woman presents at A&E complaining of contractions. 1.How can we classify prematurity? 2.What are the clinical manifestations for preterm labour? The Peer Teaching Society is not liable for false or misleading information… Preterm Birth

A 24 year old, G2P1 32+3/40 woman presents at A&E complaining of contractions. 1.How can we classify prematurity? – Week of Pregnancy – Birth Weight of the Baby 2.What are the clinical manifestation of preterm labour? – Regular, painful contractions – Cervical Effacement/Dilation – Backache – Cervical Discharge The Peer Teaching Society is not liable for false or misleading information… Preterm Birth

Her previous pregnancy was delivered at 34 weeks. 1.What are the risk factors for preterm birth? 2.What is a biomarker for predicting preterm birth? The Peer Teaching Society is not liable for false or misleading information… Preterm Birth

Her previous pregnancy was delivered at 34 weeks. 1.What are the risk factors for preterm birth? – Infection – Reproductive History – Multifetal Gestation – Lifestyle Factors – Autoimmune Disease – Cervical Surgery – Uterine Malformations 2.What is a biomarker for predicting preterm birth? – Fetal fibronectin The Peer Teaching Society is not liable for false or misleading information… Preterm Birth

Your history and examination confirms that she is undergoing preterm labour. 1.What medicines should now be given to the patient? The Peer Teaching Society is not liable for false or misleading information… Preterm Birth

Your history and examination confirms that she is undergoing preterm labour. 1.What medicines should now be given to the patient? – Tocolytics Calcium Channel Blockers (nifedipine) NSAIDs (indomethicin) Beta adregenic receptor antagonists (salbutamol/ritodrine) – Steroids – Antibiotics – Magnesium Suphate The Peer Teaching Society is not liable for false or misleading information… Preterm Birth

5% of pregnancies are delivered after term 1.What is the upper limit of time for a pregnancy? 2.What are the strongest risk factors for a postterm birth? The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

5% of pregnancies are delivered after term 1.What is the upper limit of time for a pregnancy? – 42+6 weeks 2.What are the strongest risk factors for a postterm birth? – Previous postterm birth – Nulliparity – Obesity – Male Foetus – Older maternal age – Maternal or Paternal history of postterm birth The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

A 26 year old woman, G1P0 with a 41+1 week pregnancy of a single male foetus wants have a home birth. The foetus is in a cephalic, left occiput anterior position. 1.Will you let this woman give birth at home? Explain your answer The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

Liz, 26 year old woman, G1P0 with a 41+1 week pregnancy of a single male foetus wants have a home birth. The foetus is in a cephalic, left occiput anterior position. 1.Will you let this woman give birth at home? Explain your answer – No, pregnancies past the 41 st week should be induced. The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

1.What are the dangers of a postterm pregnancy? The Peer Teaching Society is not liable for false or misleading information… Postterm Birth MotherChild

1.What are the dangers of a postterm pregnancy? The Peer Teaching Society is not liable for false or misleading information… Postterm Birth MotherChild Postpartum HaemmorhageMacrosomia 3/4 th degree perineal tearsFetal Dysmaturity Syndrome Failed InductionPerinatal Mortality

Liz arrives at the maternity unit in hospital. 1.How is labor iatrogenically induced? 2.Cervical status is important for predicting success of induction. What scoring system is used for assessing cervical status? The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

Liz arrives at the maternity unit in hospital. 1.How is labor iatrogenically induced? – Oxytocin IV – Amniotomy – PGE1/PGE2 The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

2. Cervical status is important for predicting success of induction. What scoring system is used for assessing cervical status? The Peer Teaching Society is not liable for false or misleading information… Postterm Birth

What changes can you expect in the postpartum period in the following areas? 1.Uterus 2.Cervix 3.Vagina/Vulva 4.Reproductive Hormones 5.Breasts The Peer Teaching Society is not liable for false or misleading information… The Puerperium

What changes can you expect in the postpartum period in the following areas? 1.Uterus – Uterine involution and Lochia 2.Cervix – Contraction of the cervix. External os never fully recpovers. 3.Vagina/Vulva – Contracts but not to its nulligravid size 4.Reproductive Hormones – Beta HCG returns to normal levels in 12 days. 70% menstruate by week 12 postartum 5.Breasts – Swelling of the breasts and milk production The Peer Teaching Society is not liable for false or misleading information… The Puerperium

1.The observations show Liz has a temperature of 38 C. Are you worried? 2.What other routine procedures should be done for Liz after birth? The Peer Teaching Society is not liable for false or misleading information… The Puerperium

1.The observations show Liz has a temperature of 38 C. Are you worried? – No, only after the first 24 hours. Most common is cause is infection. 2.What other routine procedures should be done for Liz after birth? – Counselling/Practical help with breastfeeding – HR/BP/RR/Temp monitoring. – Examine for signs of bleeding – Distended bladder examination – Examine for perineal damage The Peer Teaching Society is not liable for false or misleading information… The Puerperium

Liz bled a lot during the birth. The nurse tells you she bled 800mls of blood. 1.What is the definition of primary postpartum haemorrhage in a vaginal delivery? What about after Caesarean section? 2.What are the causes of postpartum haemorrhage? The Peer Teaching Society is not liable for false or misleading information… The Puerperium

Liz bled a lot during the birth. The nurse tells you she bled 800mls of blood. 1.What is the definition of primary postpartum haemorrhage in a vaginal delivery? What about after Caesarean section? – >500ml blood loss, >1000ml in C - Section 2.What are the causes of postpartum haemorrhage? – Retained Placenta – Uterine atony – Trauma to uterus and vaginal tract – Clotting abnormalities The Peer Teaching Society is not liable for false or misleading information… The Puerperium

Venous thrombosis is 21 – 84x more common in women postpartum. – Risk assess and treat with stockings and LMWH Urinary Retention Urinary/Fecal Incontinence. Haemorrhoids Varicose Veins Postpartum Depression – 10% of women The Peer Teaching Society is not liable for false or misleading information… The Puerperium