Help: O+G, peads, anaesthetics Episiotomy Lithotomy - McRobert's - supine, nipples to knees Pressure - Rubins I - suprapubic pressure and push shoulder downwards Enter vagina - Rubins II + Woodscrew Remove post arm - splint humerus, sweep post arm across chest, grasp hand and pull to extension, may free posterior shoulder

1. Tone 2. Tissue 3. Trauma 4. Thrombin - coagulopathy

1. Uterus 1. No IUP 2. Gestational sac with no foetal pole 3. Extra-uterine pregnancy 2. Tube/Ovary 1. Complex extra-adnexal mass 2. Tubal ring sign 3. Haemosalpinx 3. Pelvis 1. Free fluid POD 2. Free fluid Morrison's pouch (higly likely)

O+G Flashcards by Sonal Shah

Cord Prolapse

OBS EMERGENCY

Def: ruptured membrane + cord infront/beside presenting part

Multiuparity
Pre-term labour
Multiple birth (esp 2nd twin)
Polyhydramnios
Malpresentation
Obstetric manipulation

Prevent cord compression
- Elevate presenting part
  - Deep Trendelenberg
  - Left lateral with 2 pillows
- Fill bladder
- Minimal cord handling
Calls to make
- Obs / Delivery suite
- Anaesthetics
- Paeds/NICU
Tocolyticcs to be considered
- Terbutaline 250mcg stat
- Nifedipine
- MGSO4

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Shoulder Dystocia

Help: O+G, peads, anaesthetics
Episiotomy
Lithotomy - McRobert’s - supine, nipples to knees
Pressure - Rubins I - suprapubic pressure and push shoulder downwards
Enter vagina - Rubins II + Woodscrew
Remove post arm - splint humerus, sweep post arm across chest, grasp hand and pull to extension, may free posterior shoulder

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McRobert’s Manoeuvre

Mother lies head down, supine in extreme lithotomy, hips hyperflexed w/ knees to nipples

+/- suprapubic pressure

Open pelvic inlet by : cephalic rotation of pubic symphysis, flattens lumbar lordosis and allows for passage of one shoulder at a time

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Wood’s Corkscrew Manoeuvre

The accoucheur places two fingers on the posterior aspect of the anterior shoulder of the fetus (internally) and two fingers on the anterior aspect of the posterior shoulder, then rotates the fetus forward through 180o so the posterior shoulder will now be anterior

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Gaskin Manoeuvre

Position mother onto all 4s

May allow posterior shoulder to descend

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Tocolytics Contraindications

Intrauterine Fetal Demise or lethal fetal anomaly
Fetal Compromise
1. Fetal Bradycardia
2. Fetal Tachycardia
Severe Eclampsia or Preeclampsia
Maternal bleeding + hemodynamic instability
Maternal cardiopulmonary symptoms (CP or SOB)
Chorioamnionitis
24 < gestation > 34 weeks

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Tocolytic Therapies

General Indications
a. Stops labour for 24-48 hours
b. Allow maternal transport and steroid

Considerations for Management
1. A = Antibiotics
a. Benpen 1.2g or CLindamycin 600mg
2. B = Betamethasone 11.4 mg IM BD for 48 hours
a. Reduces Foetal Resp Distress Syndrome - max effect 48 hours
3. CCB = Nifedipine
a. 20-30mg loading, then 10-20mg QID
b. NB high risk of maternal adverse events when combined with MGSO4
4. D = Magnesium (tocolysis + neurprotection)
a. 4g IV over 20 mins
b. 2g/hr IV infusion
5. Other tocolytic therapies
a. PGI - Indomethacin < 32/40 gestation
i. 50-100mg PO/PR
ii. Avoid > 48 hours (risk of oligohydramnios, premature closure ductus arteriosus)
iii. Not recommended > 32/40 due to DA constriction
b.Salbutamol / Terbutaline

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Placental abruption

25% APH

Most lifethreatening

Separation of placenta from uterus prior to second stage of labour

Concealed or Revealed

Painful PV bleeding

Clinical diagnosis + CTG

USS - placenta and abruption same echogenicity

RF - trauma, HTN, Pre-elampsia, Drugs - cocaine, amphetamine, Sudden reduction in uterine size (ROM with polyhydramnios, multiple births)

Uterus - tone increased, increased size

Supportive and resuscitative
- IVF / Blood
- Steroids if urgent deilvery
CTG
Conisder Anti-D
Emergent referral to O+G
Monitor for and reverse coagulopathy

Complications
* Preterm labour
* Foetal distress
* Maternal Haemorrhagic shock - APH and PPH
* Coagulopathy / DIC
* Amniotic Fluid Embolism

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Placenta Praevia

30% APH

Placenta implanting over internal os of cervix

Grade 1 - lower segment, not reaching os
Grade 2 - reaches margin of internal os
Grade 3 - partially covers internal os
Grade 4 - completely covers internal os

Also classified by adherance to uterus - accreta (superficial), increta ( into muscle), percreta (through muscle)

Painless PV bleeding

Mx
* Supportive and resuscitative
* IVF / Blood
* Steroids if urgent deilvery
* CTG
* Conisder Anti-D
* Emergent referral to O+G

Complications
* APH
* Foetal malpresentation
* IUGR
* PPROM

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Vasa Praevia

Rare (<0.3%)

Foetal blood vessels cross or run near internal os. Risk of rupture when supporting membranes rupture as they are not supported byy umbilical cord or placental tissue.

Mother fine

Foetal distress - decelrations on CTG
75% foetal mortality rate!

Mx
Immediate C- section

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Uterine Rupture

RF
Previous C-Section 40%, grand multip, small for dates
Trauma - forceps, shoulder dystocia
XS oxytocin

Clinical
Maternal shock
Abdominal Pain ++
Easily palpated foetal parts
Foetal distress or death
Possible decreased amplitude CTG

USS
ID protruding portion of amniotic sac
Endometrial or myometrial defect
Extra-uterine haematoma
Haemoperitoneum

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APH Mx considerations

Resus - Monitor / IV access x 2 / O2

Bloods - FBE, UEC, VBG, G+S, coags, Kleihauer

Consider activating MTP

Pain - ? Abruption ? labour

CTG

PV - contraindicated

Anti-D

Foetus

Steroids <34 weeks
MgSO4 < 30 weeks

Refer - O+G, Paed, anaesthetics, haem

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4 Ts

PPH - causes

Tone
Tissue
Trauma
Thrombin - coagulopathy

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Ectopic USS findings

Uterus
1. No IUP
2. Gestational sac with no foetal pole
3. Extra-uterine pregnancy
Tube/Ovary
1. Complex extra-adnexal mass
2. Tubal ring sign
3. Haemosalpinx
Pelvis
1. Free fluid POD
2. Free fluid Morrison’s pouch (higly likely)

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IUP pregnancy USS findings

0-4.3 weeks: no ultrasound findings
4.3-5.0 weeks:
- possible small gestational sac
- possible double decidual sac sign (DDSS)
- possible intradecidual sac sign (IDSS)
5.1-5.5 weeks:
- gestational sac should be visible by this time
5.5-6.0 weeks
- yolk sac should be visible by this time
- gestational sac should be ~6 mm in diameter
- double bleb sign (yolk sac + amnion
>6.0 weeks
- fetal pole may be identifiable on endovaginal ultrasound (1-2 mm)
- fetal heart rate (FHR) should be ~100-115 bpm
- gestational sac should be ~10 mm in diameter
6.5 weeks
- crown rump length (CRL) should be ~5 mm

Failed pregnancy
CRL 6-10mm and NO foetal activity
Gestational sac >20-25mm and no foetal pole

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PPH Mx

Study These Flashcards

Def:
* > 500mls post-delivery
- Primary = <24 hours post deivery
- Seconary = 24hrs to 12 weeks post delivery
* MAJOR > 1000mls

Mx
* MOVIE
* G+S
* MTP / correct coagulopathy
* Call O+G, OT, anaesthetics early
* Check for mulptiple pregnancy
* IDC to empty bladder

TONE
* Deliver placenta - controlled cord contraction
* In/out IDC to empty bladder
* Uterine massage / bimanual uterine compression
* Bakri balloon w/ 500ml saline
* Manual aortic compression
* Drugs
* Syntocin 5-10 units IV/IM + 40 units over 4 hrs infusion 500ml saline
* Ergometrine 0.25mg up to 1mg IV - ONLY if placenta delivered

TRAUMA
* Inspect - trauma, lacerations and repair
* Vaginal vault packing with adrenaline soaked gauze

TISSUE
* Remove placenta and RPOC

THROMBIN
* TXA 1g IV
* Early replacement of platelets / clotting factors

Pregnancy Physiology

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Cardiovascular

1st tirmester
- SVR decreased
- CO begins to rise
2nd trimester
- CO continues to increase
3rd trimester
- CO peaks
- Inc HR

Respiratory

Chest wall - Diaphragm moves up 4cm but excursion increased by 2cm
Lung volumes - decreased FRC 20%
Ventilation - resting minute ventilation inc by 25% due to inc VT 40%
Gas exchange
- inc alveolar ventilation → dec PaCO2 (27-32) → resp alkalosis
- Compensatory renal excretion of bicarbonate so pH slightly alkalotic 7.40-7.45
O2 consumption - inc 20-40% due to myocardial and renal O2 demand
Upper Resp tract - inc oedema

Renal

Blood

NEEDS FINISHING

Pre-eclampsia risk factors

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Age > 40 or young
FHx

Obstetric Hx
* Previous PET Hx
* Previous gestational HTN
* Multiple pregnancy
* Primagravida

Pre-existing conditions
* Chronic HTN
* CRF
* DM
* APL syndrome
* BMI > 35 at booking

Pre-eclampsia Mx

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HTN + proteinuria + end organ dysfunction

BP 140/90 - mild

BP 160/110 - severe

Clinical features

Neuro - headache, drowsy, Hyper-reflexia

Vision - blurred, visual scotoma

Hepatic dysfunction - RUQ pain

Resus, left lateral

Bloods

CTG

MgSO4

BP control

IV labetolol or hydralazine

Urgent O+G referral for delivery

Pre-eclampsia complications

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Eclampsia

Hypertensive crisis

SAH or ICH

Renal

ARF
Oliguria

Haematological

DIC
HELLP syndrome

Resp

Foetal

FDIU
Placental aburption / infarct
Growth retardation

Anti - D recommendations

RANZCOG

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AbN Uterine Bleeding - Chronic

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Progestins
a. Norethisterone 5-10mg PO TDS for 1/52 then 5mg TDS for 2/52
Anti-fibrinolytic agents
a. TXA PO 1g TDS 3-5d, then 500mg TDS
Anti-PG
a. Ibuprofen
b. Naproxen 250mg 3-4 x daily
c. Mefanamic acid 500mg PO TDS
COCP
a. Oestrogen containing (35 mcg) BD up to 7 days
IUD - Mirena

AbN Uterine Bleeding - Acute Severe

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MOVIE
Inspect cervix for products + remove
Uterine compression - Foley
Vaginal packing
a. Bakri Balloon
b. Adrenline soaked gauze
Pharmacological
a. Pregnant - syntocinon/ ergometrine
b. Non-pregnant - premarin (conj oestrogen) 25mg IV

NB Avoid oestrogen containing products:
- Thromboembolic events
- Active liver disease
- Pregnancy
- Smokers
- Oestrogen dependent tumours

Pre-Term Labour

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A - Antibiotics Benpen 1.2g
Betamethasone 11.4g
Calcium antagonist - Nifedipine 20mg (up to 3 doses q30min)
D = MgSO4 IV 4g loading - neuroprotection for foetus

Rubin's Manoeuvre

Hand is inserted into the anterior vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest. This rotates the shoulders forward into the more favourable oblique diameter Then attempt deilvery

HELLP Syndrome

Haemolysis + Elelvated LIver enzymes + Low Platelets MAHA leads to liver damage 1% of pregnancies, mortality 1-2% Typically 28-36/40, but can be earlier or even post partum Considered to be severe form of pre-eclampsia Risk of hepatic rupture Symptoms HA N/V Malaise Visual distrubance RUQ pain Exam HTN RUQ Jaundice, ascites Proteinuria Ix MAHA - Bloods film schistocytes PLT < Br > 20 AST > 2x upper limiti normal Coags - 40% dvp DIC Mx As per pre-eclampsia - HTN Mx - Seizure Mx w/ MgSO4 Supportive - PLT transfusion - PRBC - Bethmethasone 11.4 g IM ICU / O+G / Paeds referral Prognosis 1-2% mortality Prematurity 70% require pre-term delivery IUGR Complications DIC, ICH, Placental abruption + spontaneous hepatic or splenic hemorrhage. Hepatic hemorrhage can progress to hepatic rupture - asoc with 50% maternal + foetal mortality.

Diagnosing Preterm Rupture of Membranes

Rubin's I

An assistant applies pressure above the symphysis pubis in a downward and lateral motion over the fetal shoulder to attempt to release the anterior shoulder from the pubic bone. A rocking action can also be applied with this manoeuvre.

Rubin's II

The accoucheur places two fingers on the anterior shoulder of the fetus (internally) and pushes in a forward and downward direction to attempt to disimpact the anterior shoulder from the pubic bone.

HTN in Pregnancy

Vaginal Breech Delivery

Lithotomy Evaluate- ROM / prolapsed cord. If the cord is presenting with the breech, pull out a 10–15 cm loop to provide room to work. Consider episiotomy Allow the delivery to happen spontaneously Support the fetus’s body after the umbilicus appears (Wrapping a towel around the fetus provides for better traction after the legs deliver) Pull out the 10–15 cm loop of umbilical cord after the umbilicus delivers if not yet already done. Keep the fetal sacrum anterior with the fetal face and abdomen away from the symphysis. Encourage the mother to bear down strongly until the scapulae are visible. Sweep the flexed arms across the chest to deliver each. Rotate the body to deliver the arms, each from an anterior position. Perform the Mauriceau-Smellie-Veit maneuver to deliver the head once the fetal chin is at the pelvic inlet. The provider’s arm is placed under the fetus with the middle fingers on the fetal maxilla and the fetal legs straddling the forearm. The maxillary fingers plus occipital pressure with the other hand promote head flexion and descent as the body is slightly elevated [22]. The fetus should be delivered well within 10 minutes, as the umbilical cord will be compressed during delivery causing acidosis.

Methotrexate in Ectopic

Indications: Asymptomatic Highly compliant HCG < 3500 (inc risk of failure HCG > 5000) Tubal size < 3cm No FHB on USS No medical CI (allergy, hepatic/renal impairment Willing to use contraception for next 3 months

RF PPH

# H Foetal Radiation

CTG

[https://geekymedics.com/how-to-read-a-ctg/](http://) Approach to CTGs Dr - Define risk C - Contractions BRA - Baseline Rate V - Variability A - Accelerations D - Decelerations O - Overall Impression Define Risk Maternal and obstetric as well as social complications Contractions Should be 2 in 10 mins Baseline Rate FHR should be 110-160 Fetal tachycardia causes include fetal hypoxia, chorioamnionitis, hyperthyroidism, fetal or maternal anaemia, fetal tachyarrhythmia Fetal bradycardia causes include prolonged cord compression, cord prolapse, epidural and spinal anaesthesia, maternal seizures, rapid fetal descent Variability Should be 5-25 beats per minute Categorised as reassuring, non-reassuring or abnormal Abnormal < 5 bpm for more than 50 minutes > 25 bpm for more than 25 minutes sinusoidal Causes Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause) Fetal acidosis (due to hypoxia): more likely if late decelerations are also present Fetal tachycardia Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate Prematurity: variability is reduced at earlier gestation (<28 weeks) Congenital heart abnormalities Accelerations Increase in FHR >15bpm for more than 15seconds = Reassuring Decelerations Decrease in FHR < 15 bpm for > 15 seconds Early, variable and late, prolonged and sinosoidal Late = BAD Begins at peak of uterine contraction and ends after contraction finished Sign of decreased uterin blood flow - Maternal hypotension - Pre-eclampsia - Uterine hyperstimulation Overall Impressison Reassuring, vs suspicious vs abnormal

O+G Flashcards

(35 cards)