1. 2017/2018

2. Obstetrics Phase 3A Revision Session Jennifer McMurran 08/10/2018
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3. Overview Normal Pregnancy and Labour Pregnancy Labour Complications
Pre-eclampsia
Bleeding
Infection
Premature labour
Prolonged labour
Maternal Medical Conditions
Diabetes
Post-natal depression
Chronic infections
From the UoS Women’s Health Handbook
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4. Normal Pregnancy Timeline:
<12 weeks – 1st visit weeks – Scan >14 weeks – CXR if TB risk
18-20 weeks – Scan
36 weeks – Check lie and presentation
37 weeks – Head engaged
What do you do at the first visit? 1st visit: MSU, Hb, group, serology (syphilis & rubella), HIV test
What is the week scan for? dates, multiple pregnancies, nuchal translucency
What is the week scan for? Anomaly scan
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5. Normal Labour 1st stage 2nd Stage
- Latent – cervix effaces and dilates <4cm
- Established – contractions, dilatation > 4cm
2nd Stage
- Passive – complete dilatation, no pushing
- Active – pushing
How many weeks? 37 – 42 weeks, spontaneous delivery within 24hrs
What is the ‘show’? cervical mucus plug and blood
What is the ‘waters breaking? Membranes rupture Which position for 2nd stage? encourage comfortable not supine. How long do the stages of labour take? 1st stage: 8-18hrs primip, 5-12hs multip. 2nd stage: 3hrs primip, 2 hrs multip.
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6. Pre-eclampsia Pregnancy-induced hypertension with proteinuria
Flu-like symptoms, visual changes, shaking, hyperreflexia, may be asymptomatic
Only cure = delivery (usually resolves within 10 days of delivery)
What is the Pathophysiology? in placenta: spiral arteries don’t properly invade trophoblast => BP increases to compensate
What week does pre-eclampsia start from? after 20 weeks
How is pre-eclamspia prevented (e.g. HTN, CKD, DM, SLE)? aspirin from 12th week until delivery
When to admit? BP 30/20 over booking, 160/100, or 140/90 with proteinuria or growth restriction How is eclampsia risk decreased in pre-eclampsia? MgSO4 (can be toxic to fetus in too high doses)
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7. Bleeding in Pregnancy
Abruption – part of placenta detaches. Disproportionate shock for blood seen, pain, ‘woody’ uterus.
Placenta Praevia – placenta in lower uterine segment. Painless, lie/presentation may be abnormal.
Why avoid vaginal examination? Can get catastrophic bleeding from placenta praevia
Management: admit, emergency management- if bleeding severe, deliver, otherwise establish diagnosis, keep PP in until delivery, abruption depends on severity and other factors. Risk of PPH in both abruption and placenta praevia.
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8. Infection in Pregnancy
Rubella – Cataracts, deafness, cardiac lesions.
CMV – Cognitive effects
Toxoplasmosis – Intracranial calcification, hydrocephalus
HIV – transmission risk
Syphilis – rhinitis, rash, hepatosplenomegaly
Listeria – fetal distress, respiratory distress, convulsions
How is rubella picked up? Routine antenatal screening What are the TORCH infections? Toxoplasmosis, Other (syphilis, varicella-zoster, parovirus B19), Rubella, CMV, Herpes
What is the treatment for syphilis? Procaine penicillin IM 3 weeks What should pregnant women avoid eating to reduce listeria risk? Soft cheeses
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9. Premature Labour Born before 37 +6 weeks
Delivery <28 weeks: Room temp 36’, wrapped in plastic without drying, placed under heat
>28 weeks: dry towels
3-min delay cutting cord
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10. Prolonged Labour
Delay in 1st stage: <2cm/hr dilatation in 4hrs, continuous fetal heart monitoring, consider oxytocin
Delay in 2nd stage: Delivery not imminent within 1hr of active 2nd stage (multip) or 2hrs (primip) => call relevant obstetrician, Amniotomy, Consider instrumental/c-section
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11. Maternal Diabetes 5mg Folic acid preconception
Tight diabetes control around conception
Compensatory fetal hyperinsulinaemia => fetal growth
Elective delivery at 38 weeks
Avoid acidosis in labour
Encourage breastfeeding
Give a risk of macrosomia during labour- Shoulder dystocia.
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12. Post-natal Depression
Usually resolves in about 6 months – however important to manage as risks for patient and baby.
Pre-empt - antenatal clinic
MDT
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13. Maternal Chronic Infections
HIV
Offer testing
Maternal antiretrovirals
Avoid fetal blood sampling/ scalp elctrodes
Can have vaginal delivery if low viral load otherwise elective c-section
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14. Reference Oxford Handbook of Clinical Specialities 9th Edition
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