1
Q
What are the 3 stages of labour?
A
- First stage: from the onset of labour until the cervix is fully dilated (10cm)
- Second stage: from full cervical dilation until the baby is delivered
- Third stage: after the baby is delivered until the delivery of the placenta
2
Q
Describe the first stage of labour
A
- Involves cervical dilation and effacement (thinning and shortening)
- Latent phase: from >4cm dilated, with irregular contractions, rate of around 0.5cm/hr
- Active phase: from 4-10cm, regular strong strong contractions, rate of around 1cm/hr
3
Q
Describe the second stage of labour
A
- Passive phase: full dilation without the urge to push
- Active phase: when mother is pushing with her contractions
- Success depends on 3 Ps: power (strength of uterine contractions), passenger (size, posture, lie, presentation of foetus), passage (size/shape of the pelvis)
4
Q
Describe the third stage of lanour
A
Delivery of the placenta, which can be…
- physiological: delivered by maternal effort, with no interventions (cord traction, medication)
- active management: assisted delivery of the placenta with IM oxytocin and umbilical cord traction, to reduce risk of bleeding
5
Q
How long is each stage of labour?
A
- First stage: nulliparous = 8-18 hours, multiparous = 5-12 hours
- Second stage: nulliparous = no more than 3 hours, multiparous = no more than 2 hours
- Third stage: often less than 10 minutes, no more than 30 minutes
6
Q
Describe the cardinal movements of labour?
A
- Engagement: baby enters pelvic inlet
- Descent: baby moves lower into pelvic cavity
- Flexion: foetal skull flexes (most favourable presentation due to smallest diameter)
- Internal rotation: contact with levator ani turns occiput anteriorly
- Extension: pubic symphysis acts as fulcrum so that foetal head extends and crowns
- Restitution/external rotation: head rotates so that shoulders are in AP direction
- Expulsion (delivery): external traction downwards to deliver anterior shoulder, then upwards to deliver posterior shoulder
7
Q
Describe the foetal lie, presentation, position, and station
A
- Lie: relationship between long axis of the foetus and the mother (longitudinal, transverse, oblique)
- Presentation: the foetal part that first enters the maternal pelvis (cephalic, breech, shoulder, face, brow)
- Position: orientation of the foetal head as it exits the birth canal (e.g. occipito-anterior = foetal occiput faces anteriorly)
- Station: relationship between lowest presenting part of baby and the mother’s ischial spines (- numbers for cm above ischial spines, + numbers for cm below)
8
Q
How is the onset of labour diagnosed?
A
- Regular, painful contractions
- Dilation and effacement of cervix on examination
- Rupture of membranes (not always)
- Cervical show (mucus plug)
9
Q
Describe the anatomy of the foetal skull
A
- 4 bones: occipital, temporal, parietal, frontal
- Anterior fontanel: frontal suture, coronal suture, sagittal suture (diamond shaped)
- Posterior fontanel: sagittal suture, lambdoid suture (triangle shape)
10
Q
What are the diameters of the foetal skull?
A
- Suboccipital bregmatic: well flexed, 9.5cm
- Occipital frontal: deflexed, 10.5cm
- Mento vertical: extended (brow), 13cm
- Submental bregmatic: hyperextended, 9.5cm
11
Q
Describe the pelvic inlet and outlet
A
Pelvic inlet:
- anterior border: pubic symphysis
- lateral border: iliopectineal line
- posterior border: sacral promontory
- widest diameter: lateral
Pelvic outlet:
- anterior border: pubic arch
- lateral border: ischial tuberosity
- posterior border: tip of coccyx
- widest diameter: anteroposterior
12
Q
Describe the pain pathway in labour
A
First stage:
- pain caused by lower uterine and cervical changes
- visceral afferent nerve fibres
- T10-L1
Second stage:
- pain caused from distention of the pelvic floor, vagina, perineum
- somatic nerve fibres, pelvic splanchnic and pudendal nerve
- S2-S4
13
Q
What are the non-pharmacological managements of pain in labour?
A
Water:
- helps concentration and relaxation
- works immediately
- make delivery harder for midwife
Sensory methods:
- positioning
- massage
- TENS machine
Phycological:
- relaxation/meditation
- hypnosis
- hypnobirthing
Complementary therapy:
- aromatherapy
- reflexology
- acupuncture
14
Q
What are the medical forms of pain relief used in labour?
A
Entonox
- oxygen + nitrous oxide
- pros: fast acting, doesn’t require foetal monitoring
- cons: can cause nausea and dizziness, effect wears off quickly
Opiates
- diamorphine, pethidine, remifentanil
- pros: still able to mobilise, doesn’t slow down labour, can help with anxiety, distress, and sleep
- cons: can cause nausea, vomiting, and respiratory distress for mother and baby
Epidural
- bupivacaine + fentanyl administered into epidural space of L3/4
- pros: total relief of pain in most case, patient can control top ups if needed
- cons: may have loss of mobility and bladder control, headache, hypotension, can slow down labour and need instrumental delivery
Spinal
- local anaesthetic injected into subarachnoid space into CSF between L3 and 4
- pros: effective total pain relief, suitable for C-section or instrumental delivery
- cons: complications of hypotension, only short lasting, loss of mobility
15
Q
What do CTGs monitor and how are they assessed?
A
CTGs monitor foetal heart rate and contractions of the uterus, assessed by Dr C BRAVADO…
- DR: Define Risk
- C: Contraction
- BRa: Baseline Rate
- V: Variability
- A: Acceleration
- D: Deceleration
- O: Overall
16
Q
What are the indications for continuous CTG monitoring?
A
- Sepsis
- Maternal tachycardia (>120)
- Pre-eclampsia (particularly >160/110)
- Fresh antepartum haemorrhage
- Delay in labour
- Disproportionate maternal pain
- Use of oxytocin
- Significant meconium
17
Q
How are contractions analysed on a CTG?
A
Used to gauge activity of labour based on the number of contractions in 10 minutes…
- too few = labour is not progressing
- too many = could indicate uterine hyperstimulation which leads to foetal compromise
18
Q
How is the baseline rate assessed in a CTG?
A
- Average foetal heart rate in 10 minute window
- Normal/reassuring: 110-160
- Non-reassuring: 100-109 or 161-180
- Abnormal: below 100 or above 180
19
Q
What are the causes of foetal tachycardia/bradycardia?
A
Tachycardia:
- foetal hypoxia
- chorioamnionitis
- hyperthyroidism
- foetal or maternal anaemia
- foetal tachyarrhythmia
Bradycardia:
- postdate gestation
- occiput posterior or transverse presentations
- prolonged cord compression
- cord prolapse
- epidural or spinal anaesthesia
- maternal seizures
- rapid foetal descent
20
Q
How is variability assessed on a CTG?
A
- Normal/reassuring: 5 - 25 (indicates a healthy foetus that adapts its heart rate in response to change in environment)
- Non-reassuring: less than 5 for 30-50 mins, more than 25 for 15-20 mins
- Abnormal: less than 5 for over 50 mins, more than 25 for over 25 mins
21
Q
What are the causes of reduced variability?
A
- Foetal sleeping (no longer than 40 mins)
- Foetal acidosis due to hypoxia
- Foetal tachycardia
- Drugs (opioids, benzodiazepines, magnesium sulphate)
- Prematurity (<28 weeks gestation)
- Congenital heart abnormalities
22
Q
Describe accelerations on a CTG
A
- Defined as an abrupt increase in the baseline foetal heart rate of greater than 15bpm for greater than 15 seconds
- Accelerations occurring alongside uterine contractions is a reassuring sign of a healthy foetus
- The absence of accelerations with an otherwise normal CTG is of uncertain significance
23
Q
How are decelerations assessed in a CTGs?
A
Define as abrupt decrease in the baseline foetal heart rate of greater than 15 bpm for greater than 15 seconds, categorised as…
- early: gradual dips and recoveries corresponding with uterine contractions, considered normal
- late: dips in heart rate after contractions, caused by foetal hypoxia due to excessive contractions or maternal hypotension/hypoxia, considered non-reassuring or abnormal
- variable: abrupt decelerations may be unrelated to contractions, indicates intermittent cord compression causing foetal hypoxia, classed as non-reassuring or abnormal, unless acceleration before and after (shouldering)
- prolonged: drops of more than 15bpm for longer than 2 minutes, indicates cord compression causing foetal hypoxia, considered abnormal
24
Q
What is a sinusoidal pattern on a CTG?
A
- Similar pattern to sine wave with smooth regular waves up and down with an amplitude of 5-15bpm
- This is rare but very concerning sign of severe foetal compromise caused by hypoxia, anaemia, or haemorrhage
25
What are the different categories of the overall impression of a CTG?
- Normal: baseline = 110-160, variability = 5 to 25 bpm, decelerations = none, early, or variable with shouldering for less than 90 mins
- Suspicious: a single non-reassuring factor
- Pathological: two non-reassuring factors, or a single abnormal factor
- Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes
26
What is the rule of 3s for prolonged foetal bradycardia?
- 3 minutes: call for help
- 6 minutes: move to theatre
- 9 minutes: prepare for delivery
- 12 minutes: deliver the baby
27
How is gestational age and estimated date of delivery determined?
- Counted from the first day of the last menstrual period (LMP)
- Estimated date of delivery: 40 weeks gestation
- These are assessed more accurately after the booking scan and updated
28
Define gravidity and parity
- Gravidity: the number of times a women has been pregnant
- Parity: the number of times a women has given birth to a foetus older than 24 weeks (alive or stillbirth)
e.g.
- primigravida = woman in their first pregnancy
- multigravida = woman in their 2nd or more pregnancy
- nulliparous = woman who has never given birth
- primiparous = woman who has given birth once (or is currently in their first labour)
- multiparous = woman who was given birth 2 or more times
29
Describe the 3 trimesters
- First trimester: form the start of pregnancy until 12 weeks gestation
- Second trimester: from 13 weeks until 26 weeks gestation
- Third trimester: form 27 weeks gestation until birth
30
What happens at an antenatal booking clinic?
* between 8-12 weeks gestation, ideally before 10 weeks
- General pregnancy advice and education
- Check BP and BMI
- Booking bloods: FBC, blood group, rhesus status red cell alloantibodies, haemoglobinopathies
- Screening for hepatitis B, syphilis, HIV
- Urine dipstick and cultures (for asymptomatic bacteriuria)
- Risk assessment for other conditions (e.g. gestational diabetes, foetal growth restriction, pre-eclampsia, VTE)
31
What is the general lifestyle advice given in pregnancy?
- Folic acid 400mg (preconception until 12 weeks)
- Vitamin D supplements
- Don't drink alcohol (risk of foetal alcohol syndrome)
- Don't smoke
- Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
- Avoid undercooked or raw poultry or fish (risk of salmonella)
- Avoid excess vitamin A (e.g. supplements/liver)
- Continue moderate exercise but avoid contact sports
- Avoid flying after 37 weeks, or 32 if twins (risk of VTE)
32
When do antenatal scans take place and what do they involve?
- Dating scan: between 10 and 13+6 weeks, accurate gestational age, identifies multiple pregnancies
- Anomaly scan: between 18 and 20+6 weeks, identifies foetal anomalies (e.g. CHD)
- Extra scan for placenta praevia at 32 weeks (if identified on anomaly scan)
- Serial growth scans: e.g. every 2 weeks, if increased risk of foetal growth restriction
33
When do routine antenatal appointments take place and what do they involve?
- 25, 28, 31, 34, 36, 38 ,40, 41, 42 weeks
- Routine checks of BP and urine dipstick
- Measurement of symphysis-fundal height from 24 weeks
- Assessment of foetal presentation from 36 weeks
- Discuss plans for remainder of pregnancy and delivery (e.g. labour and birth plan, breastfeeding, vitamin K, baby blues, induction of labour)
* additional appointments offered if high risk/complicated
34
When are vaccines and other tests or management offered during antenatal care?
- Whooping cough vaccine from 16 weeks
- RSV vaccine from 28 weeks
- Flu vaccine when available in autumn or winter
- Screening for anaemia, and treatment if below 110 at 16 weeks, or 105 at 28 weeks
- Anti-D prophylaxis given at 28 and 34 weeks if mother is rhesus negative
- Oral glucose tolerance test: between 24 and 28 weeks, for those at risk of gestational diabetes
35
Describe the combined test for Down's syndrome screening
Performed between 11 and 14 weeks, combines results from ultrasound and blood tests...
- Ultrasound: nuchal translucency (>6cm = greater risk)
- Blood tests: beta-human chorionic gonadotrophin/bHCG (higher = greater risk), pregnancy associated plasma protein-A/PAPP-A (lower = greater risk)
36
Describe the triple/quadruple test for Down's syndrome screening
Preformed between 14 and 20 weeks...
- beta-human chorionic gonadotrophin/bHCG (higher = greater risk)
- alpha-fetoprotein/AFP (lower = greater risk)
- serum oestriol (lower = greater risk)
* quadruple test also includes inhibin-A (higher = greater risk)
37
How is Down's syndrome diagnosed antenatally?
- If screening tests give a high risk score (1 in 150), the woman is offered amniocentesis or chorionic villus sampling (CVS) to take a sample of foetal cells for karyotyping
- CVS is an ultrasound guided biopsy of placental tissue, usually done before 15 weeks
- Amniocentesis is an ultrasound guided aspiration of amniotic fluid, used later in pregnancy
38
Describe non-invasive prenatal testing (NIPT)
- The NIPT detects chromosomal abnormalities, such as Down's syndrome
- It analyses small fragments of foetal DNA which are derived from placental cells and circulate in the mother's blood
- It is likely to replace CVS/amniocentesis as it is non-invasive and has very high specificity and sensitivity
39
What are the screening results for congenital abnormalities (besides Down's syndrome)
- Trisomy 18 (Edward's syndrome) and trisomy 13 (Patau's syndrome) have increased nuchal translucency, low PAPP-A and bHCG
- Edward's syndrome: low AFP, oestriol, and bHCG, normal inhibin A
- Neural tube defects: high AFP, normal oestriol, bHCG, and inhibin A
40
Define pre-eclampsia
New onset of hypertension (over 140 systolic or 90 diastolic) after 20 weeks of pregnancy, and the coexistence of 1 or more of the following new-onset conditions:
- proteinuria
- renal insufficiency
- liver involvement (high ALT/AST +/- abdo pain)
- neurological complications (seizures, altered mental state, severe headache, clonus, stroke)
- haematological complications (low platelets, DIC, haemolysis)
- uteroplacental dysfunction (foetal growth restriction, abnormal umbilical artery, stillbirth)
41
Define gestational hypertension
Also known as pregnancy-induced hypertension, is new-onset hypertension occurring after 20 weeks gestation, without proteinuria
42
Define eclampsia
The occurrence of one or more seizures in woman with pre-eclampsia, which is an obstetric emergency, treated with IV magnesium sulphate
43
Define HELLP syndrome
Haemolysis, Elevated liver enzymes, and Low Platelets syndrome:
- a severe from of pre-eclampsia that is associated with high maternal and perinatal morbidity and mortality
44
What causes pre-eclampsia?
* exact mechanism is unclear, but thought to be due to poor placental perfusion:
- Trophoblast invasion of the endometrium by the placenta sends signals to the spiral arteries, causing them to remain dilated and unable to constrict, to reduce vascular resistance and increase blood flow
- In pre-eclampsia this remodelling is incomplete, causing a high vascular resistance with poor perfusion of the placenta
- Oxidative stress of the placenta causes the release of inflammatory chemicals into the circulation, leading to a systemic inflammatory response and endothelial cell dysfunction
45
What are the risk factors for pre-eclampsia?
High risk:
- hypertensive disease in previous pregnancy
- chronic kidney disease
- chronic hypertension
- diabetes (type 1 or 2)
- autoimmune disease (e.g. SLE, antiphospholipid syndrome)
Moderate risk:
- nulliparity (first pregnancy)
- aged 40 or older
- BMI of 35 or over at first visit
- family history of pre-eclampsia
- multiple pregnancy
- pregnancy interval of more than 10 years
46
When is prophylaxis for pre-eclampsia indicated?
- Women with 1 high risk factor or 2 or more moderate risk factors
- Aspirin 75mg a day, from 12 weeks gestation until birth
47
What are the symptoms of pre-eclampsia?
- Severe headaches (increasing frequency, unrelieved by regular analgesics)
- Visual problems (blurred vision, flashing lights, double vision)
- New persistent epigastric or RUQ pain
- Vomiting
- Breathlessness
- Sudden swelling of face, hands, or feet
- Reduced urine output
- On examination: papilloedema, brisk reflexes
48
What is the management of pre-eclampsia?
- Monitoring (foetal + maternal): blood pressure, FBC, U&Es, LFTs, foetal growth scans, dopplers/CTGs
- VTE prophylaxis: low-molecular weight heparin
- Antihypertensives: labetalol
- Delivery: only definitive cure, decision made on individual basis
Severe cases:
- Aggressive BP control (e.g. IV hydralazine)
- Fluid restriction
- IV magnesium sulphate (during labour and 24 hours after, to prevent seizures)
49
What anti-hypertensives are commonly used in pregnancy, and what are their side effects?
- Labetalol: beta-blocker, avoid in asthma or diabetes, SE = postural hypotension, fatigue, n/v, epigastric pain
- Nifedipine: calcium-channel blocker, SE = peripheral oedema, dizziness, headache
- Methyldopa: alpha-agonist, SE = drowsiness, headache, oedema, bradycardia, postural hypotension, hepatotoxicity, GI upset
** ACEi/ARBs and thiazides are contra-indicated in pregnancy
50
What are the complications of pre-eclampsia?
Maternal:
- eclampsia
- HELLP syndrome
- organ damage (cardiac, liver, kidneys)
- intracerebral haemorrhage/stroke
- placental abruption
Foetal:
- prematurity
- intrauterine growth restriction
- stillbirth
51
What are the causes of antepartum haemorrhage?
* 40% are unidentifiable cause
- Low lying placenta/placenta praevia
- Vasa praevia
- Placental abruption
- Infection
- Trauma (including domestic violence)
52
What is the general management of antepartum haemorrhage?
- Estimate blood loss: minor (<50ml), major (50-1000ml), massive (>1000 and/or shock)
- Identify cause: e.g. urgent USS to exclude placenta praevia
- Resuscitation and stabilisation of mother, including blood transfusion if needed (before any decision about baby)
- Do not perform a vaginal examination as this may induce torrential bleeding of placenta praevia
- Foetal monitoring and urgent delivery if foetal distress/compromise
53
Define placenta praevia
When the placenta has implanted into the lower segment of the uterus, and is covering the os completely or partial (partial praevia)
* low lying placenta is in the lower segment but at least 0.5cm from the os
54
What are the risk factors for placenta praevia?
- High parity
- Maternal age >40
- Multiple pregnancy
- Previous placenta praevia
- Previous C section
- Smoking and cocaine use
- Deficiency in endometrium (e.g. endometriosis, fibroids, previous curettage or C section)
- Assisted conception
55
What are the clinical features of placenta praevia?
- May present with painless vaginal bleeding (antepartum haemorrhage), varying from spotting to life-threatening
- May be found incidentally, diagnosed at 20 week USS, repeat scan at 32 and 36 weeks to confirm placenta remains low lying
- Usually no indication of foetal distress unless complications occur
56
What is the management of placenta praevia?
- Advise patient on risks (to present if pain/bleeding, avoid sexual intercourse)
- TVUS at 32 and 36 weeks
- Antenatal corticosteroid therapy between 34 and 36 weeks (due to risk of preterm delivery)
- Anti-D given to rhesus -ve women with bleeding
- Elective C-section around 36/37 weeks if asymptomatic, or earlier if bleeding (to reduce risk of spontaneous labour and bleeding)
- Management of any haemorrhage before/after delivery (e.g. blood transfusions, intrauterine balloon, uterine artery occlusion, emergency hysterectomy)
57
What are the complications of placenta praevia?
- Antepartum haemorrhage (causing maternal anaemia)
- Preterm birth and prematurity
- Emergency C-section
- Emergency hysterectomy
- Stillbirth
58
Define vasa praevia
Foetal vessels coursing through the membranes over the internal cervical, unprotected by placental tissue or the umbilical cord, and prone to bleeding when the membranes rupture
59
What are the clinical features of vasa praevia?
- Asymptomatic until membranes rupture (may be diagnosed on prenatal ultrasound or MRI)
- Painless vaginal bleeding (often sudden and heavy)
- Abnormal foetal heart rate (most commonly bradycardia)
- Foetal anaemia (due to chronic slow leakage from the vasa praevia)
- Foetal distress or death
60
What is the management of vasa praevia?
- Prenatal screening for those at risk (low-lying placenta, multiple pregnancies, IVF)
- Elective C-section at 34-36 weeks, with corticosteroids given from 32 weeks (prevents onset of labour and vessel rupture)
- Emergency C-section if membranes rupture or bleeding occurs
- Neonatal and maternal resuscitation
- Anti D to rhesus -ve women
61
Define placental abruption
Premature separation of the placenta from the uterine wall, partially or completely (before or during labour), due to compromise of the vascular structures, causing significant bleeding, classed as concealed (os remains closed, blocked by baby) or revealed (bleeding seen externally)
62
What are the risk factors for placental abruption?
- Previous placental abruption
- Pre-eclampsia
- Trauma (including domestic violence)
- Multiple pregnancies
- High parity
- Increased maternal age
- Smoking or alcohol
- Cocaine or amphetamine use
- Chorioamnionitis
63
What are the clinical features of placental abruption?
- Vaginal bleeding (severity ranging from none to life-threatening haemorrhage)
- Abdominal pain (sudden onset, severe, continuous)
- Hard/"woody" uterus on palpation
- Maternal shock (hypotension, tachycardia)
- Foetal distress (abnormal CTG)
64
What is the management of placental abruption?
- Initial resuscitation (fluids, analgesia, transfusion)
- UUS will rule out placenta praevia, but cannot diagnose abruption
- Delivery of baby (emergency C-section if maternal or foetal compromise, induced vaginal delivery if only minor bleeding)
- Active management of third stage of labour (high risk of postpartum haemorrhage)
- Antenatal corticosteroids form 24 to 24 weeks
- Anti-D for rhesus -ve mothers with bleeding
65
Define hyperemesis gravidarum
Severe and prolonged nausea and vomiting of pregnancy (usually starts between weeks 4-7, peaks at 9 weeks, settles by 20 weeks), leading to weight loss (more than 5% of pre-pregnancy weight), and dehydration, electrolyte imbalances
66
What is the pathophysiology and risk factors for hyperemesis gravidarum?
- Rapidly increasing levels of bHCG released by the placenta, which stimulates the chemoreceptors of the brainstem to trigger the vomiting centre of the brain
- Hence, multiple pregnancy and trophoblastic disease are risk factors (as well as nulliparity, and obesity)
67
What are the investigations for hyperemesis gravidarum?
- FBC (anaemia, infection)
- U&Es (hypokalaemia, hyponatraemia, renal function)
- Blood glucose (exclude DKA if diabetic)
- Urine dipstick (quantify ketonuria)
- Mid-stream urine (rule out UTI)
- USS (confirm viability and gestation, rule out multiple pregnancy and trophoblastic disease)
68
What is the management for hyperemesis gravidarum?
- Mild: managed in community, oral antiemetics, hydration, ginger
- Moderate: managed in day care, IV fluids and antiemetics
- Severe: managed as inpatient, IV fluids and antiemetics, electrolyte monitoring
Pharmacology…
- 1st line antiemetics: cyclizine/promethazine, or prochlorperazine
- 2nd line antiemetics: metoclopramide (no longer than 5 days due to EPSEs), ondansetron (small risk of cleft palate/lip)
- thiamine: to prevent neurological complications (Wernicke’s encephalopathy) of vitamin depletion
- ranitidine/omeprazole if having acid reflux
69
Define obstetric cholestasis
A multifactorial intrahepatic disorder usually developing in the third trimester of pregnancy, due to reduced outflow of bile acids from the liver thought to be caused by high levels of oestrogen and progesterone
70
What are the risk factors for obstetric cholestasis?
- Past history (recur more severely in 50%)
- Family history
- Multiple pregnancy
- Presence of gallstones
- Hepatitis C
71
What are the clinical features of obstetric cholestasis?
- Generalised intense pruritis (most common on palms and soles, and worse at night)
- Right upper quadrant pain
- Dark urine and pale stools
- Nausea, anorexia, fatigue
- Jaundice
72
What are the investigations needed for cholestasis?
- Total serum bile acid: cut-off value of 10, taken weekly to monitor after diagnosis
- LFTs: deranged (mainly ALT/AST)
- Clotting: raised PT
* US and CTG are not helpful to predict outcomes
73
What is the management for obstetric cholestasis?
- Topical emollients (relieves itching)
- Antihistamines (e.g. chlorphenamine, helps with sleep)
- Ursodeoxycholic acid (unlicensed in pregnancy, little evidence)
- Vitamin K (if prolonged prothrombin time)
- Induction of labour (early if bile acids are very high)
- Follow up 6 weeks postnatal to ensure liver function returns to normal
74
Describe acute fatty liver of pregnancy
- Rare complications occurring in the third trimester or early postpartum
- High risk in first pregnancy, older maternal age, multiple pregnancy
- Genetic factors causing an inability to break down fatty acids in the placenta, causing an accumulation in the hepatocytes
- Clinical features: malaise, nausea, vomiting, abdominal pain, jaundice, hepatomegaly, encephalopathy, coagulopathy, organ failure, foetal distress, premature birth, stillbirth
- Management: delivery of the baby (usually resolves), supportive care and treatment of complications (e.g. dialysis, liver transplant)
75
What is the cause of anaemia during pregnancy?
Disproportionate increase of plasma volume and red blood cell mass, leading to an overall decrease of haemoglobin concentration due to a haemodilution effect
76
What are the risk factors for anaemia during pregnancy?
- Haemoglobinopathies (thalassaemia, sickle cell disease)
- Increased maternal age
- Anaemia during previous pregnancies
- Poor diet
- Low socioeconomic status
77
How is anaemia in pregnancy identified?
- Symptoms: fatigue, SOB, pallor, dizziness
- Screening at booking clinic (should be >110), and at 28 weeks (should be >105, postpartum should be >100)
- Assess MCV: low = iron deficiency, normal = physiological (due to increased plasma volume), high = low B12 or folate
- Screening for haemoglobinopathies (thalassaemia and sickle cell)
78
What is the management of anaemia in pregnancy?
- Iron replacement (e.g. ferrous sulphate 200mg OD)
- B12 replacement (PO or IM)
- Folate replacement (increase from usual 400mcg to 5mg daily)
79
Describe VTE in pregnancy
- Pregnancy is a hypercoagulable state due to increased production of clotting factors
- Stasis also occurs due to haemodynamic changes causing decreased flow velocity, and increased progesterone leading to reduced venous tone
- There is an increased risk of thrombus formation, manifesting as a DVT or PE
80
What are the risk factors for VTE during pregnancy?
Pre-existing factors:
- age > 35
- BMI > 30
- parity > 3
- smoking
- varicose veins
- co-morbidities (e.g. cancer, thrombophilia)
- family history of unprovoked VTE
Obstetric factors:
- multiple pregnancy
- pre-eclampsia
- prolonged labour
- stillbirth
- preterm birth
- PPH
- use of IVF
Transient factors:
- surgical procedure
- dehydration (e.g. hyperemesis)
- ovarian hyperstimulation syndrome
- admission or immobility
- systemic infection
- long distance travel
81
How are VTEs managed in pregnancy?
- VTE risk assessed at booking clinic
- Non-pharmacological prophylaxis with mobilisation, hydration, and compression stockings
- Antenatal prophylaxis with LMWH given to those at risk (at 28 weeks or immediately if very high risk)
- Postnatal prophylaxis with LMWH for 10 days if low risk, or 6 weeks if high risk
- Immediate investigation (doppler/CTPA) and management (LMWH) of suspected VTE
82
Describe the pathophysiology of diabetes in pregnancy
- Pregnancy is a state of physiological insulin resistance and relative glucose intolerance
- Glucose handling is altered, causing decreased fasting levels and increased levels following a meal
- The glucose tolerance decreases with increasing gestation after the first trimester, due to anti-insulin hormones secreted by the placenta
83
What are the risk factors for gestational diabetes?
- BMI > 30
- Age > 40
- Black/Asian ethnicity
- Previous gestational diabetes
- 1st degree relative with diabetes
- PCOS
- Previous macrosomia baby (>4.5kg)
- Previous unexplained stillbirth
- Persistent glycosuria
- Polyhydramnios
84
What are the clinical features and complications of gestational diabetes?
Maternal:
- often asymptomatic, but may have diabetic symptoms (polyuria, polydipsia, fatigue)
- increased risk of pre-eclampsia
- worsening of pre-existing ischaemic heart disease
- complications of neuropathy, nephropathy, retinopathy, more prone to infections, more likely to need c-section/instrumental delivery
Foetal:
- macrosomia (leading to complicated delivery, shoulder dystocia, trauma)
- organomegaly (particularly cardiomegaly)
- polyhydramnios
- increased rates of preterm delivery
- hypoglycaemia after delivery
85
Describe the screening for gestational diabetes?
- Screened at 24-48 weeks if at risk, or earlier if previous gestational diabetes
- Also screened at any time if suggestive features (persistent glycosuria, large for dates, polyhydramnios)
- Oral Glucose Tolerance Test (OGTT) involves measuring fasting glucose, then having 75mg glucose drink and measuring glucose after 2 hours
Positive results:
- fasting glucose > 5.6mmol/L
- 2 hrs postprandial > 7.8mmol/L
86
What is the diabetes management of gestational diabetes?
- MDT approach (obstetrician, specialist midwife, dietician)
- Lifestyle advice: diet and exercise (may be sufficient alone)
- Metformin if still raised after 2 weeks of lifestyle changes
- Insulin if still raised, or if fasting glucose >7, or fasting glucose >6 + macrosomia
- Glibenclamide (sulfonylurea) if metformin is not tolerated or insufficient and insulin is declined
- Education about self monitoring blood glucose (targets: fasting <5.3, 1 hour post-meal <7.8, 2 hours post-meal <6.4)
87
What is the obstetric management of gestational diabetes?
- Monitoring for pre-eclampsia
- Regular foetal growth scans (usually 28, 32, and 36 weeks)
- Delivery by induction or C section by 40+6 for uncomplicated GDM, or 37/38 for complicated GDM
- Intrapartum foetal monitoring, hourly blood glucose monitoring, insulin infusion if needed
88
What is the postnatal management of gestational diabetes?
Maternal:
- stop medication
- healthy lifestyle advice
- contraception
- HbA1c monitoring
Foetal:
- close monitoring for neonatal hypoglycaemia
- assess for cardiomyopathy and congenital heart diseases
- assess for jaundice
89
What are the effects of pregnancy on pre-existing diabetes?
- Increased insulin dose requirements, particularly in 3rd trimester (T2DM often started on insulin)
- Risk of development or progression of retinopathy, and worsening of nephropathy
- Hypoglycaemia with relative hypo unawareness
- Diabetic ketoacidosis (risk in hyperemesis, infection, steroid therapy)
90
What is the diabetes management of pre-existing diabetes in pregnancy?
- Treatment with metformin and/or insulin (stop all other oral medications)
- Close monitoring of blood glucose (e.g. continuous glucose monitoring)
- Hypoglycaemia education and treatment
- Ketone monitoring
- Retinal screening (1st trimester, repeated in 3rd trimester if normal)
- Control of existing hypertension
91
What is the obstetric management of pre-existing diabetes in pregnancy?
- 5mg folic acid from preconception to 12 weeks gestation
- Aspirin 75mg once daily from 12 weeks until delivery (prevents pre-eclampsia)
- Foetal growth scan at 28, 32, and 36 weeks
- Delivery at 37/38 weeks by induction or C-section (sometimes before 37 weeks if complications)
- Intrapartum hourly blood glucose and sliding-scale insulin infusion if needed
92
Describe the risks of obesity in pregnancy
- Maternal: higher risk of VTE, pre-eclampsia, diabetes, caesarean section, PPH
- Foetal: higher rate of macrosomia, congenital abnormalities, perinatal mortality, and childhood obesity and metabolic syndrome
- Management: preconceptual weight loss, but weight maintenance during pregnancy, screening for GDM, close blood pressure surveillance, anaesthetic risk assessment, VTE prophylaxis
93
Describe asymptomatic bacteriuria
- The presence of bacteria in the urine without symptoms of infection
- Screened for at booking and throughout pregnancy with urine MC&S
- Requires treatment due to risk of lower and upper urinary tract infections which may lead to preterm birth
94
What are the common causes of UTI in pregnancy?
- Escherichia coli
- Klebsiella pneumoniae
- Enterococcus
- Group B streptococcus
95
What is the management of UTI in pregnancy?
- Admission to hospital if suspected pyelonephritis or sepsis
- Urine MS&C
- Antibiotics for 7 days: nitrofurantoin (not in third trimester, risk of neonatal haemolysis), or amoxicillin/cefalexin
- Avoid trimethoprim in first trimester (folate antagonist so causes neural tube defects)
96
Describe hypothyroidism in pregnancy
- If hypothyroidism is untreated or under-treated during pregnancy, it can lead to miscarriage, anaemia, pre-eclampsia, and small for gestational age
- The dose of levothyroxine needs to be increased by 30-50%, as it will cross the placenta and be used by the foetus
97
Describe epilepsy in pregnancy
- Epilepsy increases the risk of neural tube defects, so women are advised to take 5mg folic acid from before conception
- Pregnancy may worsen seizure control due to changes in hormones, medication, and sleep, but are not harmful to the pregnancy other than physical injuries
- Medication should be monotherapy with levetiracetam, lamotrigine, or carbamazepine
- Sodium valproate is avoided due to risk of neural tube defects, and phenytoin is avoided due to risk of cleft lip/palate
98
Describe the use of antidepressants during pregnancy
- SSRIs can cross the placenta, and my have risks to the foetus
- First-trimester use has links with congenital heart defects (paroxetine has stronger risks of congenital malformations)
- Third-trimester use has links with persistent pulmonary hypertension for the neonate
- The risks need to balanced against the benefits, as the risks of untreated depression can be significant
99
Describe the risks of varicella zoster virus infection in pregnancy
- VZV infection in pregnancy can lead to more sever illness for the mother (varicella pneumonitis, hepatitis, encephalitis)
- The foetus can be affected if infected in early pregnancy, with scarring, eye defects, limb hypoplasia, and neurological defects, or severe neonatal varicella if infected around delivery
100
How is exposure or infection with varicella zoster virus in pregnancy managed?
- If a mother has already had chicken pox or the vaccine, they are immune and protected
- If there is any doubt of immunity, IgG levels should be tested (positive = immune)
- A pregnant woman who is not immune (-ve IgG levels) should be treated with prophylactic antivirals, or IV varicella immunoglobulins, given between day 7 and 14 post exposure
- Mothers who develop chicken pox >20 weeks gestation should be treated with oral acyclovir within 24 hours of onset of the rash (used with caution <20 weeks)
101
Describe rubella infection in pregnancy
- Infection with rubella during the first 20 weeks of pregnancy can cause congenital rubella syndrome (deafness, cataracts, congenital heart disease, learning disability)
- Women planning to become pregnant should ensure they've had the MMR vaccine, as it cannot be given during pregnancy as it's a live vaccine
102
Describe parvovirus B19 infection during pregnancy
- Infection with parvovirus B19 in the first and second trimesters can cause miscarriage, still birth, severe foetal anaemia, hydrops fetalis
- If suspected, the woman should be tested for IgM (recent acute infection) and IgG (long term immunity from previous infection)
- Treatment is supportive, but the foetus is monitored for complications and given intrauterine transfusions if needed
103
Describe HIV and pregnancy
- The aim of management is to treat HIV positive women during pregnancy, to reduce harm and prevent vertical transmission
- Mothers are offered antiretroviral therapy, as well as neonates if mothers viral load is high
- Mode of delivery should be C-section of viral load is high, and babies shouldn't be breastfed
104
Describe chlamydia in pregnancy
- Chlamydia during pregnancy can ascend from the vagina and cause chorioamnionitis, which can lead to early rupture of membranes and premature delivery
- If a baby is born vaginally while mother has an active infection of chlamydia, neonatal complications include conjunctivitis and pneumonia
105
Describe group B streptococcus infection in pregnancy
- GBS is colonised in the vagina or rectum of 25% of pregnant women
- Usually causes no symptoms but can cause sepsis, pneumonia, or meningitis in the neonate
- Screened for with vaginal and rectal swabs at 35-37 weeks
- Neonatal infection can be prevented with high dose IV penicillin during labour
106
What are the risk factors for group B streptococcus infection in neonates?
- Positive GBS swab in the mother
- UTI caused by GBS in this pregnancy
- GBS infection in previous baby
- Prematurity <37 weeks
- Rupture of membranes >24 hours before delivery
- Pyrexia during labour
107
What are the risks of smoking in pregnancy?
- Miscarriage
- Pre-term labour
- Stillbirth
- Intrauterine growth restriction
- Sudden infant death
108
What are the risks of alcohol in pregnancy?
Foetal alcohol syndrome:
- learning difficulties
- facial characteristics (smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly)
- intrauterine or postnatal growth restriction
109
What are the risks of illicit drugs in pregnancy?
- Cannabis: similar to tobacco (miscarriage, still birth, IUGR)
- Cocaine: pre-eclampsia, placental abruption, prematurity, neonatal abstinence syndrome
- Opioids: growth restriction, placental abruption, prematurity, neonatal respiratory depression or opioid withdrawal
- Amphetamines: congenital defects, pre-eclampsia, placental abruption, prematurity, neonatal withdrawal
110
What is the management of substance abuse in pregnancy?
- Early identification and support
- Multi-disciplinary approach: specialist midwife, safeguarding, addiction services, obstetrics, paediatrician
- Additional growth scans and antenatal appointments
111
Define rhesus haemolytic disease
- If the mother is rhesus-D negative, and the baby is rhesus-D positive the mother will mount an immune response to create anti-D antibodies (due to a sensitising event where maternal and foetal blood are mixed)
- In subsequent pregnancies large numbers of rhesus-D antibodies will be created and cause immune haemolysis of rhesus-D positive foetal/neonatal red blood cells
- If mild this leads to neonatal jaundice, or if more severe foetal or neonatal haemolytic anaemia and death
112
What are potential sensitising events in pregnancy?
An event which can cause a foetomaternal haemorrhage and can result in a pregnant woman becoming sensitised (making an antibody)…
- termination of pregnancy
- evacuation of products of conception
- miscarriage or threatened miscarriage >12 weeks
- ectopic pregnancy
- antepartum vaginal bleeding
- intrauterine death and stillbirth
- invasive uterine procedure (e.g. amniocentesis)
- external cephalic version
- abdominal trauma
- delivery
113
How is rhesus disease prevented in pregnancy?
- Anti-D is given to the mother to destroy any rhesus D antigens, stopping her creating maternal antibodies and preventing an immune response
- Antenatal anti-D should be given to all rhesus negative mothers if the foetus is rhesus positive or unknown at 28 and 34 weeks
- Also given to these women within 72 hours of any sensitising event including delivery
114
What is the Kleihauer test?
- Used to screen maternal blood for the presence of foetal red blood cells
- Quantifies the severity of foetomaternal haemorrhage after any sensitising event after 20 weeks, to calculate the dose of anti-D needed
115
What are the different types of multiple pregnancies?
- Monozygotic: identical, develops from single ovum which divided into two/more embryos
- Dizygotic: non-identical, two/more ova fertilised at the same time
- Monoamniotic/chorionic: single amniotic sac and/or placenta
- Diamniotic/chorionic: separate amniotic sacs and/or placentas
* diamniotic dichorionic is most ideal, each foetus has their own nutrient supply
* monoamniotic monochorionic is the most risky, higher chances of complications
116
What are the complications of multiple pregnancies?
- Maternal: increased risk of gestational diabetes, pre-eclampsia, anaemia, hyperemesis gravidarum, instrumental/c-section delivery, PPH
- All multiples: increased risk of foetal growth restriction, preterm delivery, miscarriage, congenital abnormalities, malpresentation
- Monochorionic (shared placenta): twin-twin transfusion syndrome (unequal blood distribution, with one twin depleted and one overloaded), anaemia-polycythaemia sequence, co-twin death
117
What is the management of multiple pregnancies?
- Early diagnosis and identification of chronicity
- Increased surveillance for pre-eclampsia, diabetes, anaemia
- Serial USS, especially for twin-twin transfusion or IUGR
- Delivery at 36-37 weeks if uncomplicated (earlier if monochorionic monoamniotic, or triplets, with antenatal corticosteroids)
- Elective C-section if first twin is not cephalic
118
Describe reduced foetal movements
- Foetal movement are typically felt from 20 weeks onwards, and mothers will recognise a pattern to these movements
- Reduced foetal movements can represent foetal distress as a method of compensation in response to hypoxia
- Reduced foetal movement can indicate a risk of placental insufficiency, growth restriction, of stillbirth
- Assessment includes handheld Doppler, ultrasounds, and CTG monitoring is over 28 weeks
119
What are the risk factors for reduced foetal movements?
- Posture: foetal movement are less noticeable when sitting or standing up
- Distraction: movements are less prominent if focussed or concentrating
- Placental position: anterior placentas may reduce awareness of movements
- Foetal position: anterior foetal positions may reduce awareness of movements
- Foetal size: movements are more likely to be reduced if the foetus is small for gestational age
- Amniotic fluid volume: both increased and decreased fluid volumes can reduce foetal movements
- Body habitus: obese patients are less likely to feel prominent movements
- Medication: alcohol and sedatives can temporarily reduce movements
120
Define small for gestational age
A foetus that measures below the 10th centile for their gestational age when considering their estimated foetal weight and abdominal circumference, categorised as...
- constitutionally small (small but expected, matching maternal/family patterns, growing appropriately)
- intrauterine/foetal growth restriction (IUGR, foetus not growing as expected due to pathology
* low birth weight < 2.5kg
121
What are some causes of intrauterine growth restriction?
Placental:
- idiopathic
- pre-eclampsia
- maternal smoking and alcohol
- anaemia
- malnutrition
- infection
- chronic health conditions
Non-placental:
- genetic abnormalities
- structural abnormalities
- foetal infection
- errors of metabolism
122
What are the risk factors for small for gestational age pregnancies?
- Previous SGA baby
- Obesity
- Smoking
- Chronic health conditions (e.g. diabetes, renal disease)
- Hypertension (existing or pre-eclampsia)
- Older maternal age
- Multiple pregnancy
- Low PAPP-A)
- Antepartum haemorrhage
- Antiphospholipid syndrome
- Extreme exercise
123
What is the monitoring/management of small for gestational age pregnancies?
- Low risk women have their symphysis fundal height monitored, and booked for serial growth scans and umbilical artery dopplers if concerned
- High risk women are monitored with serial ultrasound scans to assess foetal weight, abdominal circumference, umbilical artery blood flow, and amniotic fluid volume
- When SGA is identified, the cause may be investigated with BP monitoring, detailed foetal anatomy scans, karyotyping, infection screens
- Early delivery is indicated if growth becomes static, or abnormal Doppler results are seen (absent or reversed end-diastolic flow)
124
What are the complication of small for gestational age pregnancies?
- Intrauterine death or stillbirth
- Neonatal hypothermia
- Neonatal hypoglycaemia
- Birth asphyxia
- Long term risk for cardiovascular disease, type 2 diabetes, obesity, and behavioural problems
125
Define large for gestational age
Also known as macrosomia, when the estimated foetal weight is above the 90th centile, or the babies weight is >4.5 kg
126
What are the causes of macrosomia?
- Constitutional
- Maternal diabetes
- Previous macrosomia
- Maternal obesity or rapid weight gain
- Prolonged pregnancy
- Male baby
127
What are the complications of macrosomia?
- Shoulder dystocia
- Birth injuries (Erbs palsy, clavicular fracture, foetal distress, hypoxia)
- Failure to progress in labour
- Neonatal hypoglycaemia
- Perineal tears
- Instrumental delivery or C-section
- Postpartum haemorrhage
- Uterine rupture
- Obesity and type 2 diabetes later in life
128
What is the management of macrosomia?
- Ultrasound monitoring of foetal weight and amniotic fluid volume
- Screen for gestational diabetes with oral glucose tolerance test
- Consider risk of shoulder dystocia (consultant lead unit, access to theatre, early decision for C-section, active management of third stage)
129
Describe oligohydramnios
- Low levels of amniotic fluid
- Causes: PPROM, placental insufficiency (causing poor perfusion to foetal kidneys and reduced urine output), foetal renal abnormalities (renal agenesis, obstructive uropathy), prolonged pregnancy, twin-twin transfusion syndrome, maternal dehydration
- Management: monitored with foetal growth scans, amniotic fluid volume, umbilical artery dopplers, with early delivery if concerned
- Complications: Potter's sequence (renal agenesis causes oligohydramnios, which leads to pulmonary hypoplasia
130
Describe polyhydramnios
- Large levels of amniotic fluid
- Causes: idiopathic, impaired foetal swallowing (oesophageal atresia, CNS abnormalities), maternal diabetes, foetal anaemia, foetal hydrops
- Management: antenatal corticosteroids (preterm labour is common), early delivery if foetal distress, amnioreduction if severe maternal symptoms
131
Describe foetal hydrops
- Abnormal fluid accumulation within foetal compartments (e.g. abdominal, pleural)
- Causes: anaemia, haemolysis (rhesus disease), chromosomal/structural abnormalities, cardiac abnormalities, twin-twin transfusion
- Management: detailed scans including echo, intrauterine transfusion to treat anaemia, preterm delivery with corticosteroid, termination of pregnancy (many causes are not curable)
132
Define stillbirth
Birth of a dead foetus after 24 weeks gestation, as a result of intrauterine foetal death
133
What are the causes of intrauterine death?
- Unexplained (around 50%)
- Pre-eclampsia
- Placental abruption
- Vasa praevia
- Cord prolapse
- Obstetric cholestasis
- Diabetes
- Thyroid disease
- Infections (e.g. rubella, parvovirus B19)
- Genetic/congenital abnormalities
134
What are the risk factors for intrauterine death?
- Foetal growth restriction
- Smoking
- Alcohol
- Increased maternal age
- Maternal obesity
- Multiple pregnancy
135
What is the management of intrauterine death?
- Diagnosed with ultrasound to confirm loss of foetal heartbeat
- Anti-D prophylaxis for rhesus-D negative mothers
- Vaginal delivery with induction of labour or expectant management (or C-section if immediate delivery is needed)
- Dopamine agonists (e.g. cabergoline) to supress lactation
- Testing to determine cause (e.g. genetic testing of foetus and placenta, post-mortem, testing of mother for associated conditions)
- Psychological support to mother and families
- Close monitoring of future pregnancies
136
What are the indications for induction of labour?
- Prolonged gestation (after 40 weeks)
- Prelabour rupture of membranes (if labour doesn't start with 24 hours, may be delayed if premature)
- Maternal health problems (e.g. pre-eclampsia, diabetes, cholestasis)
- Foetal growth restriction (to reduce foetal compromise)
- Intrauterine foetal death
137
What are the contraindications of induction of labour?
Absolute:
- cephalopelvic disproportion
- major placenta praevia
- vasa praevia
- cord prolapse
- transverse lie
- previous classical C section
- active primary genital herpes
Relative contraindication:
- breech presentation
- triplet or higher pregnancy
- 2 or more previous low transverse C sections
138
Describe the Bishop score
- Assesses ripeness of cervix, determined by dilation, effacement, consistency, and position of the cervix, and station of the baby
- A score of 8 or more means that the cervix is ripe, and predicts a high chance of spontaneous labour or good response to induction methods
- A score below 5 means that labour is unlikely to start without induction
139
Describe membrane sweep for induction of labour
- Classified as adjunct of IOL, increases that likelihood of spontaneous delivery, reduces need for formal induction
- Finger inserted through cervix and rotated against membranes to separate chorionic membrane form decidua
- Helps to release natural prostaglandins and start labour usually within 48 hours
- Usually offered at 40/41 gestation, or before pre-term IOL
140
Describe vaginal prostaglandins for induction of labour?
- Vaginal prostaglandin E2 (dinoprostone) is the first line choice, given as a gel, tablet, or pessary
- Prostaglandins act to ripen the cervix, and also have a role in contractions of the uterus
141
Describe cervical ripening balloon for induction of labour
- Mechanical induction using balloon catheter inserted into the vagina above and below the cervix
- Internal pressure increases prostaglandins and oxytocin to ripen cervix and induce labour
- Used as an alternative to vaginal prostaglandins if they woman is at risk of hyperstimulation (e.g. previous C-section) or where vaginal prostaglandins have failed
142
Describe amniotomy for induction of labour
- Forewaters are ruptured with an amnihook (artificial rupture of membranes, ARM), only after cervix is ripe
- This process releases prostaglandins to start labour
- Oxytocin infusion (syntocinon) usually started within 2 hours, if labour hasn’t started
- This method is usually used for higher Bishop scores (i.e. the cervix is almost ripe), or to progress labour after other methods
143
Describe oral medications used for induction of labour
Misoprostol (prostaglandin E1) and mifepristone (anti-progesterone) are used to induce labour where intrauterine foetal death has occurred
144
What are the complications of induction of labour?
- Failure of induction: may need C section
- Uterine hyperstimulation
- Cord prolapse: can occur if head is high
- Infection: as more frequent vaginal exams
- Pain: more painful than spontaneous labour
- Uterine rupture: higher risk if previous C section
145
Describe uterine hyperstimulation
- Defined as uterine contractions lasting more than 2 minutes, or more than 5 contractions in 10 minutes
- Can lead to foetal compromise with hypoxia and acidosis, emergency C-section, uterine rupture
- Managed by removing any induction agents, and giving a tocolytic (terbutaline)
146
What are the indications for an instrumental delivery?
- Prolonged labour and failure to progress (e.g. 2nd stage >2 hours for nulliparous, >1 hours for multiparous)
- Maternal exhaustion
- Maternal medical condition which limits prolonged pushing or exertion (e.g. intracranial pathologies, severe cardiac disease or hypertension)
- Foetal distress
147
What are the pre-requisites for instrumental delivery?
- Fully dilated
- Ruptured membranes
- Cephalic position
- Defined foetal position
- Empty bladder
- Adequate pain relief
- Adequate maternal pelvis
- Foetal head engaged (station = 0 or below)
- No increased risk of coagulopathies
148
Describe a ventouse delivery and its complications
- Cup attached to foetal head via vacuum, over flexion point (midline, 3cm anterior to posterior fontanelle)
- Traction applied perpendicular to cup during uterine contractions
- Associated with more foetal complications particularly cephalohaematomas, or rarely subgaleal or intracranial haemorrhage
- Less maternal complications, but can cause perineal tears and PPH
149
Describe a forceps delivery
- Double bladed instrument, which can be rotational or non-rotational
- Grip the head on either side, and traction is used to pull the head from the vagina
- Associated with higher risk of maternal complications, including perineal tears, PPH, obturator or femoral nerve injury
- Lower risk of foetal complications, but can cause facial nerve palsy and bruising, and rarely fat necrosis, skull fractures, and intracranial haemorrhage
150
What are the risk factors for perineal tears?
- Nulliparity
- Large babies (over 4kg)
- Shoulder dystocia
- Occipital-posterior position
- Instrumental deliveries
- Very fast or short labours
151
What are the different types of perineal tear?
- First degree: involving superficial perineal skin only
- Second degree: perineal skin and muscles torn
- Third degree: perineal skin, muscles, and anal sphincter are torn (a: <50% of external, b: >50% of external, c: both internal and external)
- Fourth degree: perineal skin and muscles, and anal sphincter and mucosa are torn
152
What is the management of perineal tears?
- First degree: heal without treatment
- Second degree: require sutures to repair muscle, can be done on the ward by midwife or clinician
- Third and fourth: require specialist repair in theatre
- Reduce risk of complications with broad spectrum antibiotics, laxatives, physiotherapy, C-section in subsequent pregnancies if severe
153
What are the complications of perineal tears?
Short term:
- pain
- bleeding
- infection
- wound breakdown
Long term:
- urinary incontinence
- altered bowel habits including incontinence
- fistula between vagina and bowel
- sexual dysfunction and dyspareunia
- psychological effects
154
Describe prolonged pregnancy and its risks
- More than 42 weeks gestation
- Common with previous prolonged pregnancies, and nulliparity
- Increased risk of stillbirth, neonatal illness, meconium passage, foetal distress, delivery complications due to increased size
155
What is the management of prolonged pregnancies?
- Cervical sweep usually at 40-41 weeks may help labour start spontaneously
- Induction between 41-42 weeks is favoured, despite risk of failure to establish labour
- If patient prefers to wait, offer daily CTGs and deliver by emergency C-section is abnormal
156
Define preterm delivery
- Delivery occurring between 24 an 37 weeks gestation
- At 32 weeks of before is considered very preterm, and under 28 weeks is extreme prematurity
- Before 24 weeks is considered miscarriage, but some foetuses survive from 23 weeks
- Can be spontaneous or iatrogenic
157
What are the risk factors for spontaneous preterm labour?
- Previous history
- Extremes of maternal age
- Short interpregnancy interval
- Maternal medical disease (e.g. renal failure, diabetes, thyroid disease)
- Pregnancy complications (e.g. pre-eclampsia, IUGR)
- Infections during pregnancy (STIs, UTIs, BV)
- Previous cervical surgery
- Multiple pregnancy
- Congenital foetal abnormalities
- Antepartum haemorrhage
158
What are some methods of prevention of preterm labour?
Cervical cerclage:
- suture in the cervix to strengthen and keep it closed
- offered between 16 and 24 weeks if cervix is <25mm on TVUS, or as a rescue even when cervix is dilated
Progesterone supplements:
- pessary from early pregnancy in women at high risk
- prevents cervical softening
Treatment of polyhydramnios:
- reduction of amniotic fluid levels by needle aspiration
- NSAIDs will reduce foetal urine output
159
What is the management of spontaneous preterm labour?
- Maternal and foetal assessment (e.g. cervical examination, CTG, mothers vitals)
- Fibronectin testing (raised result indicates increased risk of delivery)
- Assess PROM by testing any pooled vaginal fluids (amnisure)
- Steroids: given between 24 and 34 weeks to promote foetal pulmonary maturity, two doses given 24 hours apart
- Tocolysis: nifedipine or oxytocin receptor antagonists given to delay labour (not stop it), only used short term
- Detection and prevention of infection: antibiotics if indicated, to reduce maternal and neonatal risks
- Magnesium sulphate: neuroprotective to prevent cerebral palsy, requires monitoring as toxic in overdose
- Neonatal care: consider transfer to department with appropriate NICU, with paediatric follow up
160
What are the complications of spontaneous preterm labour?
Foetal:
- need for neonatal intensive care
- perinatal mortality
- cerebral palsy
- respiratory distress syndrome
- chronic lung diseases
- cognitive development problems
- retinopathy of prematurity
- necrotising enterocolitis
- hearing problems
Maternal:
- infection
- need for C section
- psychological
161
What are the indications for pre-term delivery?
Placental complications:
- placenta praevia
- prior classical c section
- previous uterine rupture
- suspected accreta, increta, or percreta
Foetal complications:
- oligohydramnios
- growth restriction (decreased expected foetal weight and/or abnormal umbilical artery doppler)
- multiple gestations
- autoimmunisation
Maternal complications:
- hypertension/pre-eclampsia/HELLP
- poorly controlled diabetes
- HIV
- obstetric cholestasis
- P-PROM
162
Define the types of rupture of membranes
Definitions:
- SROM = spontaneous rupture of membranes
- ARM = artificial rupture of membranes
- PROM = prelabour rupture of membranes OR prolonged rupture of membranes (>18 hours before delivery)
- P-PROM = preterm prelabour rupture of membranes (>37w gestation)
163
How is preterm/prelabour rupture of membranes diagnosed?
- Examine with speculum for pooling of amniotic fluid in vaginal vault
- Visible fluid confirms rupture of membranes
- If no fluid seen, test for placental alpha microglobulin-1 protein (amnisure) or insulin-like growth factor binding protein-1
164
What is the management of pre-term/prelabour rupture of membranes?
- Admission for observation and monitoring
- Prophylactic antibiotics (erythromycin) to prevent chorioamnionitis
- Induction of labour
165
Describe cord prolapse
- Occurs after rupturing of the membrane if cord presents first, or alongside presenting part
- Is an obstetric emergency as it causes compression or vasospasm of the exposed cord and significant risk of foetal morbidity and mortality from hypoxia
166
What are the risk factors for cord prolapse?
- Premature rupture of membranes
- Polyhydramnios
- Long umbilical cord
- Non-cephalic presentation (particularly transverse or oblique lie, or breech)
- Multiparity
- Multiple pregnancy
- Low birth weight and prematurity
- Induction of labour
167
What is the management of a cord prolapse?
- Confirm cord prolapse with examination
- Trendelenburg position (knee-chest position, feet higher than head), or left lateral lie
- Continuous CTG
- Infuse fluid into bladder via catheter
- Manually alleviate pressure on cord
- Keep cord warm and wet, minimise handling as this causes vasospasm
- Tocolytics (terbutaline) to minimise contractions
- Emergency C section as soon as possible
168
Define shoulder dystocia
An obstetric emergency due to failure of the anterior shoulder to pass under the symphysis pubis after delivery of the foetal head
169
What are the risk factors for shoulder dystocia?
- Macrosomia
- Maternal diabetes
- Previous shoulder dystocia
- Disproportion between mother and foetus
- Induction of labour
- Prolonged pregnancy
- Maternal obesity
- Prolonged 1st or 2nd stage of labour
- Instrumental delivery
170
What is the management of shoulder dystocia?
First line:
- McRoberts position (knees up): increases angle of pelvis and allows successful delivery
- suprapubic pressure (pressure behind anterior shoulder to disimpact from maternal symphysis)
Second line (after episiotomy):
- internal rotational manoeuvres
- removal of posterior arm
Third line (rarely used):
- fracture of the foetal clavicle
- symphysiotomy (cutting pubis symphysis)
- Zavanelli manoeuvre (push head back inside and deliver by C section)
Post delivery:
- PR exam to exclude 3rd degree tear
- physiotherapist review of pelvic floor weakness
- paediatric review for complications
171
What are the complications of shoulder dystocia?
Maternal:
- PPH
- extensive vaginal tear
- psychological
Foetal:
- hypoxia (seizures, cerebral palsy)
- injury to brachial plexus causing Erb's palsy
- humeral fracture
172
What are the indications for an elective C-section?
- Maternal choice
- Previous C-section
- Symptomatic after previous perineal tears
- Placenta praevia
- Malpresentation (e.g. breech, brow)
- Multiple pregnancy
- IUGR
- Uncontrolled HIV
- Cervical cancer
- Active vaginal herpes
173
What are the 4 categories of C-section?
- Category 1: within 30 minutes (immediate threat to life of mother or baby)
- Category 2: within 75 minutes (compromise of mother or baby, but no imminent threat to life)
- Category 3: within 24 hours (mother and baby are stable, e.g. failed induction)
- Category 4: elective (planned from clinic)
174
What are the risks associated with C-section?
Maternal:
- abdominal and wound discomfort
- haemorrhage
- infection (wound, endometritis, UTI)
- emergency hysterectomy
- thromboembolism
- bladder or ureter injury
- bowel ileus or adhesions
- risk of placenta praevia/accreta, uterine rupture, or need for C-section in future pregnancies
- death
Foetal:
- lacerations
- increased risk of transient tachypnoea of the newborn
175
Describe a VBAC
- Vaginal birth after C-section is successful in around 75% of people, after individual assessment
- Contraindications: previous uterine rupture, classical C-section scar, placenta praevia
176
What are the common causes of maternal sepsis?
- Chorioamnionitis: infection of membranes and amniotic fluid, presenting with abdominal pain, vaginal discharge, and septic features
- Urinary tract infections: a more rare cause of sepsis, presenting with dysuria, urinary frequency, suprapubic or loin pain, and septic features
177
What are the risk factors for maternal sepsis?
- Obesity
- Diabetes
- Impaired immunity
- Anaemia
- History of pelvic infection (including group B Strep)
- Amniocentesis and other invasive procedures
- Cervical cerclage
- Prolonged rupture of membranes
- Close contact with group A strep infections
178
What is the management of maternal sepsis?
- Identification and recognition with maternal early obstetric warning system (MEOWS)
- Sepsis 6 (give IV antibiotics, fluids, and O2 as required, take blood culture and lactate, monitor urine output)
- Investigate cause (e.g. urine dipstick and culture, swabs of throat, vagina, wound, lumbar puncture for meningitis/encephalitis)
- Continuous maternal and foetal monitoring
- Emergency C-section if foetal distress
179
Describe amniotic fluid embolism
- Amniotic fluid or fat cells enter the mothers bloodstream, causing a systemic immune reaction similar to anaphylaxis
- Usually occurring during labour or immediate post-partum, with increased risk in increased maternal age, IOL, C-section, multiple pregnancy
- Presentation: chills, shivering, shortness of breath, cough, hypoxia, shock, hypotension, confusion, seizures, arrythmia, MI
- Management: supportive care in ITU
180
Describe uterine rupture
- Rupture of the myometrium (partial) and uterine serosa (complete), causing significant bleeding and high morbidity for mother and baby
- Risk factors: previous C-section with VBAC, IOL, use of oxytocin, increased BMI, high parity
- Presentation: abnormal CGT, ceasing of contractions, vaginal bleeding, abdominal pain, shock
- Management: resuscitation, transfusion, emergency C-section, repair or removal of uterus
181
Describe uterine inversion
- An obstetric emergency, where the fundus of the uterus descends into the vagina (partial) or all the way to the introitus (complete)
- May be as a result of pulling too hard on the umbilical cord, and can cause severe PPH and maternal shock
- Management: pushing inverted uterus back into position, or filling to uterus with fluid to inflate it back into position, or surgical correction
182
Define post partum haemorrhage
- Primary: within 24 hours
- Secondary: after 24 hours up to 12 weeks
- Minor: 500-1000 mls
- Major: >1000 mls
183
What are the causes of primary post partum haemorrhage?
4 Ts…
- Tissue: retained placenta
- Tone: uterine atony (abnormal contraction following delivery)
- Trauma: perineal or uterine (due to instrumental delivery, episiotomy, C section)
- Thrombin: clotting disorders, DIC, placental abruption
Others...
- uterine infection (secondary PPH)
- placenta accreta
- trophoblastic disease
184
What are the risk factors for post partum haemorrhage?
- Previous PPH
- Multiple pregnancy
- Macrosomia
- Obesity
- Very fast or failure to progress in labour
- Prolonged third stage
- Pre-eclampsia
- Placenta accreta
- Instrumental/C-section delivery
- Episiotomy or perineal tear
185
What is the management of primary post partum haemorrhage?
Mechanical:
- uterine massage (stimulates contractions)
- catheterisation (full bladder prevents contractions)
Medications:
- sytocinon (synthetic oxytocin to stimulate contraction)
- ergometrine (directly stimulates uterine muscle to contract, CI in hypertension)
- carboprost (prostaglandin analogue, to stimulate contractions, CI in asthma)
- tranexamic acid (antifibrinolytic to reduce bleeding)
Surgery:
- balloon tamponade
- haemostatic B-Lynch suture
- uterine or internal iliac artery ligation
- hysterectomy
186
What is the management of secondary postpartum haemorrhage?
- Ultrasound to rule out retained placenta
- Endocervical and high vaginal swabs (likely infectious cause)
- Management: surgical evacuation of retained POC, antibiotics for infection
187
Describe routine postnatal care
- Analgesia as required
- Help with establishing feeding
- VTE risk assessment
- Monitoring for PPH, sepsis, hypertension
- FBC (Hb <100 treated with oral iron, Hb <90 treated with IV iron, Hb <70 treated with blood transfusion)
- Anti-D for rhesus D -ve mothers
- Routine baby checks
- Routine follow up with midwife/GP (wellbeing, menstruation, pelvic floor, scar healing, contraception, breastfeeding, vaccines)
188
What are some common breastfeeding problems?
- Nipple pain (may be caused by a poor latch)
- Blocked ducts (treated by continuing feeding, or breast massage)
- Nipple candidiasis (treated with miconazole cream for the nipple and nystatin for the baby)
- Infrequent feeds or low supply (only concerning if poor infant wight gain)
- Engorgement (causes breast pain often before feeding and relieved by expression of milk, can lead to blocked ducts or mastitis
189
Describe contraception in the postpartum period
- Fertility can return after 21 days postpartum
- Lactational amenorrhoea is 98% effective for up to 6 months if continually breastfeeding and having no periods
- The progesterone-only pill and implant can be started any time after childbirth and are safe in breastfeeding
- The combined pill is contraindicated before 6 weeks if breastfeeding, and should be avoided for up to 6 weeks if not breastfeeding
- An IUD/IUS can be inserted either within 48 hours of birth, or more than 4 weeks after birth
190
Describe baby blues
- Very common, seen in first week after birth, due to significant hormone changes, fatigue, recovery from birth, and sleep deprivation
- Presentation: anxiety, tearfulness, irritability
- Management: reassurance, support, usually resolves with no treatment within 2 weeks
191
Describe postnatal depression
- Affects around 10% of women between 1 and 3 months postpartum
- Presentation: similar to depression outside of pregnancy, low mood, anhedonia, low energy
- Management: moderate cases require CBT and SSRIs (paroxetine is safest in breastfeeding), may need specialist input if severe
192
Describe puerperal psychosis
- Rare condition, with onset 2-3 weeks after birth
- Presentation: delusions, hallucinations, severe mood swings, confusion
- Management: admission to mother and baby unit, psychiatric medications, CBT, ECT
193
Describe postpartum thyroiditis
- Changes in thyroid function within 12 months of birth, typically following the pattern of thyrotoxicosis, then hypothyroidism (but not always)
- Signs of thyrotoxicosis are anxiety, heat intolerance, tachycardia, weight loss, loose stools, and signs of hypothyroidism are weight gain, dry skin, hair loss, low mood, constipation, abnormal periods
- Management: testing thyroid function, symptomatic control of thyrotoxicosis (propranolol), and treating hypothyroidism with levothyroxine
UKMLA
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