Breech

Risk factors (android, aneuploidy, ancepahlus, amniotic fluid)

- Compressive (tumors, fibroids, etc)
- Multi-gestation
- Multi-parity
- Aneuploidy
- Ancephaly
- Contracted pelvis
- Polyhydramnios
- Oligohydramnios

Mx:
- ECV is not a good idea in multi gestation (usu 1 in breech other not, so
ECV would just reverse that lol)
- If there is CI to vag delivery, ogc dont deliver

- Gest HTN doesnt necessarily lead to a big baby

- Gest HTN and GDM are both risk facs for pre-eclampsia

Pre-eclampsia

Risk Factors (5 Fs)

nulliparity
preeclampsia in a previous pregnancy
age >40 yr or <18 yr
FHx of preeclampsia
chronic HTN
chronic renal disease
antiphospholipid antibody syndrome or inherited thrombophilia
vascular or connective tissue disease
DM (pre-gestational and gestational)
high BMI
hydrops fetalis
 unexplained fetal growth restriction
abruptio placentae
there is a potential for further deterioration to severe preeclampsia as defined
above
the adverse conditions are many and include both maternal and fetal issues

Gest HTN
Ix:
- Urate!
- Routine bloods (fbc, u/e, lft)

- Hellp syndrome: hemolysis, low plts, elevated LFTs, e = edema (acute

pulm edema)

- Hydralazine,

Eclampsia
- Medical emergency!!
- C
o Confusion
o Convulsion (seizure)
- Mx: ABCD(elivery), recovery position, hydralazine, magnesium, labetalol,
delivery = definitive
- Hyper-reflexia = poor prognosis!

Mg toxicities:
- Hyporeflexia
Mg important for nerve and muscle function

IDA
- Folate folding NTD
- Daily folate = 0.5mg
 o Increase if: anti-epileptics, pregnancy, DM (why macrosomia)
o Preg: 5mg

DM
- Induce a little earlier as they have bigger baby

- Risk facs GDM:

o 5 Fs
- DM NTD
o Diabetes defects

GBS
- Risk facs:
o PROM
o Previous GBS infection
o Intra partum temp
o +ve GBS during current pregnancy
o GBS bacteriuria pyelo

Rx: GBS and broad spectrum antibiotics (if fever). PCN ofc (every strep)

Few PCNs: G

FUN: frequency, urgency, nocturia, fever

Pyelo: CVA tenderness, fever, flank pain

Ix:
- Urinalysis, urine C/S
- Recurrent infections cystoscopy (anatomical problems?)

Prognosis:

Mx:
- Uncomplicated UTI: 1st line amoxicillin
- Treat as(x) bacteriuria in pregnant ladies

Infections during pregnancy TORCH

- Toxo
o Avoid litter and listeriosis (uncooked everything. Raw stuff. Meats +
cheese)
 - Chicken pox
o Varicella think rubella you get cataracts and CNS defects in
both
Also, no Rx in varicella and rubella
Serology for Dx in both

- The other 2 which are similar are EBV and CMV

- Hs are also similar (HIV, HSV)
- Again, Dx is serology

- Syphilis and strep go to together

o Rx: PCN/ampicillin
- Breastmilk virus transfer

VTE
- Etio: preg = hypercoag state
- Placental blood clots miscarriage
- Ix: USS, DVT, CTPA, CXR

Mx:
- WARFARIN is CI in preg. HEPARANIZE! risk ofHIT!
Risk facs: 5 Fs

Mx: low dose aspirin + heparin

- Compression stockings, avoid sitting too long

Ntractions:
LABOR
Defn: dilatation + effacement + contractions
BISHOP score (>6 = favourable for delivery)
- ABCDEF
o 2 ABs: above, below (fetal station) and ant, post
o Consistency
 o Dilatation
o Effacement
- BH contractions = false
o Intensity + intervals dont increase in BH!
- True contractions should increase in intensity and intervals

Application = engagement

Fetus
- Occiput is for cephalic pres
- Sacrum is for breech (sacrum generally presents)
- Mentum for face presentation

Position:
- OA = safest
- OP can cause prolonged 2nd stage of labour
- OT = arrest of dilatation

APT: anterior, posterior

- Brow presentation dangerous head is extended. If extended and gets

caught, can damage the neck! Head should be flexed.

3 stages of labour (1,2,3: 1 day, 2hrs, 30 min respectively):

1) Latent, active. Active = accelerated dilatation
2) Full dilatation to delivery of bub
3) Birth to placental birthing
a. Uterine fundus changing shape and rising upwards
b. Oxytocin helps clamp uterine blood vessels and can reduce risk of
PPH

Placental separation signs [normal] red, rise, round, :

- Blood (gush of blood)
- Cord (lengthening of cord)
- Fundus (fundus rises)
- Globular (uterus becomes globular)
4th stage labour:
- Monitor comps
- Repair lacerations

CARDINAL MOVTS
- DEFINE
o Descent
o Engagement
o Flexion
o Internal rotn
o Extension, External rotation, Expulsion
Marriage analogy: descent down the aisle, engaged, lower your head to
pray,

Analgesia
- Analgesia alleviates pain
o Oxytocin = positive environ = quicker delivery

Pain relief techniques

- Reduce painful stimuli
- Non-pharm: superficial heat + cold, TENS, aromatherapy, immersion in
water
o As: aromatherapy, attention/distraction, audio, acupuncture, abdo
compression
Pharm (NOP)
- N2O gas
- Narcotics
- Pudendal n block
- Epidural is gold standard

Fetal monitoring

Vag exam
o Engagement, effacement
o BISHOP score
o Bony pelvis, size + shape

Fetal scalp sampling

Approach to the Management of

Abnormal FHR (e.g. late decels)
POISON ER
Position (left lateral decubitus position) eases IVC compression
O2 (100% by mask)
IV fluids (corrects maternal hypotension)
Fetal Scalp stimulation
Fetal Scalp electrode
Fetal Scalp pH
Stop Oxytocin
Notify MD
Vaginal Exam to rule out cord prolapse
Rule out fever, dehydration, drug effects,
prematurity
If above fails, consider C/S

- Position
- Oxytocin
- Scalp stimulation
- Scalp PH
- IV = IV fluids
Poison, position
If all else fails, c section

Meconium monitor

Monitor if:
- Prol labor
- Meconium
- Aspirations

Late decal
Cord compression

Fetal arrhythmias are worrying!

Factors alter HR (AEIOU):

- Arryhtmia
- Anaemia
- Electorlytes
- Infections
- O2, opiates
- Umbilical cord compression

Induction of labor
- BISHOP score needs to be used
 Pre-requisites ofr IOL
- C/S possible
- Maternal: ripe cervix
- Cervix >6
- Cephalic (wouldnt induce breech)
- Membrane status
- Fetal well being

Induction indicated when risks of continuin preg outweigh benefits

Mum >40yrs induce

Fetus >40 weeks induce

Meconium in amniotic fluid

- 10%

Etiology
- Cord compression
- Low O2

Features
- Dark/green/black = low APGAR

Rx (met call, monitor, meconium):

- Calls peds team
- Close monitor FHR for signs of fetal distress
- Nasal suction for meconium aspiration

4 Ps of dystocia:
o Power (contractions)
o Passenger (fetal position, anomalies)
o Pelvis
o Psyche (hormones)

Mx:
- Dystocia mainly due to CPD
o Exclude that
o If CPD excluded, can give IV oxytocin
- Dx/defn: No descent/dilatation >2hrs
Dystocia comps
- Maternal stress
- Maternal Infection
 - PPH HoTN

https://nf.aafp.org/Shop/advanced-life-support-in-obstetrics/helperr-poster-
shoulder-dystocia

Dystocia
- Bs, ds, ps

Shoulder dystocia
- Px:
o Turtle sign: head delivered but retracts aginst inf portion of pubic
symphysis
- Comp (Bs: brain, bone, brachial, breadth )
o Erbs palsy (waiters tip sign walking past asking for a tip)
o Brain damage, brachial plexus damage, breakage of bones, breadth
of shoulders
Zavanelli maneuver: replacement of fetus into uterine cavity and emergent C/S

Umbilical Cord Prolapse

Definition
descent of the cord to a level adjacent to or below the presenting part, causing cord compression
between presenting part and pelvis

- Prolapse causes pressure between presenting part and pelvis

Risk facs Ps
- PROM
- Premature
- Polyhydramnios
- Pelvis disproportion
- Prolonged labour
Presentation:
- Visible cord
- FHR changes (fetal brady, decels or both)
Rx:
- Emergency C/S
- O2 to mum, monitor FHR
- Alleviate pressure on presenting part of cord by elevating fetal head with a
pelvic exam
- Pressure, position (knees to chest), roll them over
Uterine rupture:o
 - Etio: scar, multiparity, power (oxytocin)
o Power (oxytocin)
o Previous scar VBAC
o Procedure (Previous intrauterine manipulation)
o MultiParity

Px:

- Prolong fetal brady

- Painful! vaginal bleeding
- Intra-abdominal haemorrhage (uterus is a vascular organ, hence lots of
bleeding)

Risk facs:
- Previous scar
- Procedures (Previous intrauterine manipulation)
- Placenta accreta
- multiParity
- Power (oxytocin)
Treatment
- Rule out pl abruption
- PGE2, protracted labor
- Maternal stabilization
Comps
- Maternal mortality
- Maternal haemorrhage
- DIC
- Shock
- Fetal distress fetal 50% ( fetal 50)

Amniotic fluid embolus

- Defn: amniotic fluid debris in maternal circulation triggering an anaphylactoid
immunologic response
o Anaphylaxis is therefore a d/dx

Risk Factors (abruptions and abortions)

placental abruption
rapid labour
multiparity
uterine rupture
uterine manipulation

Leading cause of death in induced abortion

Mx:
- ABC
- ICU
Chorioamnionitis
Definition
infection of the chorion, amnion, and amniotic fluid typically due to ascending infection by
organisms
of normal vaginal flora

etio:
- GBS
- Ascending from vagina

Rx:
- Ampicillin
- Clindamycin

Comps:
- Infant meningitis, pelvic abscess, wound infection, bacteraemia of
mother/fetus

Osces at a glance obs hx:

- Name
- Age consent
- Current gest
- Gravidity
- Parity
- PC
o Pain
o Bleeding
o ROM
o Socrates
- Current pregnancy
o LNMP
o Movements, membranes, Menopausal bleeding
o Nausea
o Oedema (pre-eclampsia sign)
o Pain (dysmenorrhoea, dyspareunia), PV bleeding + discharge, Pre-
eclampsia s(x)
- PMH
o hyperT, HTN, thromboembolic disease, T1/2DM, Teratogens
- bleeding
o inter-menstrual
o menorrhagia
o post-coital
 o post-menopausal

Ps: PV bleeding, discharge,

Ix:

Obs hx:
- Gravida, Terminations, Power, Abortions, Live births
Children
- Age
- Number
- Abnormalities
- Birth wt
- Count
- Comps
- Deliveries

Gyne Hx:
- 3 Cs: cycle, contraception, cervical smear
- Explode every s(x)!
- LMNOP
o Bleeding, discharge, pain

Obs exam:
- Chaperone!
- Dignity
- Communicate
- Exposure
o Below breasts, above pubis
- Position
o As flat as possible for abdomen
- General
o Oedema
o BP: semi-recumbent @ 45
- Inspect
o Shape
o Size
o Scars
o Striae
o Everted umbilicus
- Palp (Leopolds: sternum, symphysis, side, cephalic)
o Determine fundal ht
o Establish the lie (transverse, or horizontal)
o Then establish presentation

- Obs exam

Bimanual
 - Always use lubricant!
- Insert 2 fingers into vagina
- Palp uterus, cervix or adnexae
- Wipe off lube
- Offer to redress
Gyne hx:
- Movements, LMNP, membrane, menstrual cycles prior to preg,
movements, nausea
- Prolapse, Dyspareunia
- Sexual Hx: Partners, previous STI, previous preg, protection, practices
- O = operations
- Pain, purulence, Pee (urinary s(x)), previous Ix, past gyne hx, pap smear:
- past obstetric hx (cover present hx to some extent)
o GPP, wt, delivery, Hs
o ABCD: age, BMI, comps, delivery
- R+S: results and screening tests
- Ts (PMH): thromboembolic disease, HTN, hyperT
- v, w: vaginal delivery, weights (birth wt of other kids)
- Y: years (how old is pt?)
- menstrual (3 Cs): cycle (and symptoms in relation to cycle), cervical,
sexual Hx

Gyne exam:

WINNER/ICE

- Intro, consent, chaperone, expose, position,

- Inspect: ABCD (alert, orientated, body habitus, colour, distress) size,
shape, symmetry, scars, striae
- CVS:
- Breast exam: lymph nodes is SPECIAL (lateral, supraclavicular,
infraclavicular, central, pectoral)
- Palp: symphysis, sternum
- Abdo exam:
- Establish position (lie) and presentation
o Use a sonographic doppler

- Bimanual
- Lubrication always used! 2 fingers

Engagement: The sensation that a pregnant woman feels when the

lowermost part of the fetus descends and is engaged in the mother's
pelvis, an event that typically occurs 2 to 3 weeks before labor begins.

Speculum exam:
o Inspect
o Insert
 o Speculum
o Swab/smear

Sims speculum:
- Visualise prolapse

CI to digital vag exam (2 Ps PROM, pl praevia):

- Placenta praevia!!! (why? Infections! [and bleeding])
- PROM (again infections!!)

Station 226: spontaneous miscarriage

Hx hints:
- Shoulder tip pain (diap irritation)
- LNMP, vag bleeding
- Planned pregnancy?
- Preg test?
- PID/IUCD/fertility (obviously these are risk factors!)
- How much pain? Contractions? Post-coital bleeding?

Exam hints:
- Open os (inevitable miscarriage os finally opens)
- Signs of shock
- Pyrexial
- Abdo tenderness
- Speculum exam

Station 227: recurrent miscarriage. Aetiologies of reccurent preg loss.

- Arcuate, bicornuate, didelphic
- In utero DES exposure is the risk factor
Ashermanns syn: adhesions and/or fibrosis of the endometrium (risk fac: D+C)