phase 3a stephen lau & george lam the peer teaching society is not liable for false or...

Phase 3A

Stephen Lau & George Lam

Obstetrics

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

• Labour• Abnormal Fetal Presentations• Preterm Birth• Postterm Birth• Puerperium

• NOT Multiple Pregnancy

Outline

• G1P0 34+2/40 26 year old woman is experiencing contractions. They are decreasing in frequency and intensity.– List 3 Clinical Features of Labour– If this is not labour, what is it?

Labour

• G1P0 34+2/40 26 year old woman is experiencing contractions. They are decreasing in frequency and intensity.– List 3 Clinical Features of Labour

– If this is not labour, what is it?• Braxton-Hicks Contractions

Labour

• Same woman is now 39+1/40 and experiencing regular strong contractions.– What Are The 3 Stages of Labour?

• Describe Start/End Points of Each

– Name 2 Maternal and 2 Fetal Parameters to be Monitored Initially and How Frequently

Labour

• Same woman is now 39+1/40 and experiencing regular strong contractions.– What Are The 3 Stages of Labour?

• Stage 1 Regular Contractions to Full Cervical Dilatation/Effacement• Stage 2 Full Cervical Dilatation/Effacement to Delivery of Baby• Stage 3 Delivery of Baby to Delivery of Placenta

– Name 2 Maternal and 2 Fetal Parameters to be Monitored Initially and How Frequently

• Maternal Obs q2h• Maternal Contractions q30 min• Maternal Cervix q4h• Fetal HR q15 min/After Contraction• Fetal Station q4h• Fetal Liquor on ROM

Labour

• You assess the woman’s cervix to be fully effaced. – What Are The 2 Phases of Stage 1 Called?– What Is The Cervical Dilatation Cut-Off Between

Labour

• You assess the woman’s cervix to be fully effaced. – What Are The 2 Phases of Stage 1 Called?

• Latent• Active

– What Is The Cervical Dilatation Cut-Off Between Them?

• 4 cm (…6 cm)

Labour

• The woman’s cervix is now dilated 6 cm.– What is the minimum rate of cervical dilatation for

nulliparous and multiparous women in the active phase?

– Name 1 hormone involved in cervical ripening and where it’s synthesized

– Name 1 hormone involved in promoting contractions and where it’s synthesized

Labour

• The woman’s cervix is now dilated 6 cm.– What is the minimum rate of cervical dilatation for nulliparous and

multiparous women?• Nullip 1 cm/h• Multip 2 cm/h

– Name 1 hormone involved in cervical ripening and where it’s synthesized

• Prostaglandins Uterus• Relaxin Ovaries (CL)

– Name 1 hormone involved in promoting contractions and where it’s synthesized

• Prostaglandins• Oxytocin Hypothalamus (to Post. Pituitary)• Estrogen Placenta

Labour

• The woman’s cervix is now dilated 10 cm and is feeling the urge to push. – How frequently do you monitor the baby’s HR now?– Fill in the blanks

• Engagement in ___ Position• Descent• ?• ?• Extension• ?• Expulsion

Labour

• The woman’s cervix is now dilated 10 cm and is feeling the urge to push. – How frequently do you monitor the baby’s HR now?

• q5 min– Fill in the blanks

• Engagement in OT Position• Descent• Flexion• IR OA Position• Extension• ER (Restitution) OT Position• Expulsion

Labour

• The baby is delivered and the umbilical cord is clamped. – What is the cut-off time before worrying about

retained placenta?

Labour

• The baby is delivered and the umbilical cord is clamped. – What is the cut-off time before worrying about

retained placenta?• 30 min

Labour

• Summary– Labour Dx vs. Braxton-Hicks– Stage 1 Contractions to 10 cm Dilatation

• Monitoring• Latent Phase 4 cm• Active Phase

– 1 cm/h (Nullip), 2 cm/h (Multip)– Hormones Involved

– Stage 2 10 cm Dilatation to Baby Delivery• Monitoring (FHR)• 7-Step Process

– Stage 3 Baby Delivery to Placental Delivery• Prolonged After 30 min

Labour

• Define & Give Example– Lie– Presentation– Position– Engagement– Station

Abnormal Fetal Presentation

• Define– Lie Fetal Long Axis WRT Maternal Long Axis

• E.g.) Longitudinal, Transverse, Oblique

– Presentation Fetal Part @ Lower Uterine Pole• E.g.) Cephalic, Breech, Shoulder, Cord

– Position Leading Fetal Part WRT Transverse Plane• E.g.) Occiput (OA, OT, OP, etc.), Chin (MA, MP), Sacrum

– Engagement Leading Fetal Part WRT Pelvic Inlet• 0-1/5 (5/5 completely above pelvic brim)

– Station Leading Fetal Part WRT Ischial Spine• +5 to -5 (+5 Outwards, -5 Inwards)

• Define & Give Example– Lie– Presentation– Position– Engagement

• “Engaged” = Station 0 = At Ischial Spine

– Station

• What is the ideal lie, presentation and position?

• What is the ideal lie, presentation and position?– Longitudinal– Cephalic– OA

• Woman is pregnant. On examination, wide uterus and fetal head at mother’s left flank are appreciated. – Diagnosis?– Investigation?

• 2 Things on Ix?

– 2 Management Options

• Woman is pregnant. On examination, wide uterus and fetal head at mother’s left flank are appreciated. – Diagnosis?

• Transverse Lie

– Investigation?• USS Confirm Lie + ?Placenta Previa

– 2 Management Options• ECV + Normal Delivery• C/S

• Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Diagnosis?– Investigation?

• Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Diagnosis?

• Breech

– Investigation?• USS

• Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Name 2 other types of breech presentation other

than a frank breech presentation– Apart from traumatic injury, what is another

important complication that can occur delivering

• Woman is pregnant. On examination, subcostal tenderness and presenting part is softer than expected. – Name 2 other types of breech presentation other than a

frank breech presentation• Frank Flexed Thighs, Extended Legs• Complete Flexed Thighs, Flexed Legs• Incomplete/Footling Extended Thighs

– Apart from traumatic injury, what is another important complication that can occur delivering

• Cord Prolapse

• A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards.– Name of the sign?– Diagnosis?– What Is It?– Management?

• A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards.– Name of the sign?

• Turtle Sign

– Diagnosis?• Shoulder Dystocia

– What Is It?• Anterior Shoulder Trapped Under Symphysis

• A 30 year old G3P0+2 with PMH of DM and BMI of 35. After the head is delivered, the baby retracts backwards.– Management

• Help• Episiotomy• Legs in MacRoberts (Knee to Chest)• Pressure on Suprapubic Area• Enter Pelvis

– Rotational Manoeuvres– Remove Posterior Arm– Roll Pt on All Fours

• Summary– Definitions– Transverse Lie– Breech Presentation– Shoulder Dystocia

• Didn’t Cover Brow/Face Presentation• Didn’t Cover Malpositions (OP, OT)

• A 24 year old, G2P1 32+3/40 woman presents at A&E complaining of contractions.

1. How can we classify prematurity?

2. What are the clinical manifestations for preterm labour?

Preterm Birth

• A 24 year old, G2P1 32+3/40 woman presents at A&E complaining of contractions.

1. How can we classify prematurity?– Week of Pregnancy– Birth Weight of the Baby

2. What are the clinical manifestation of preterm labour?– Regular, painful contractions– Cervical Effacement/Dilation– Backache– Cervical Discharge

Preterm Birth

• Her previous pregnancy was delivered at 34 weeks.

1. What are the risk factors for preterm birth?

2. What is a biomarker for predicting preterm birth?

Preterm Birth

• Her previous pregnancy was delivered at 34 weeks.

1. What are the risk factors for preterm birth?– Infection– Reproductive History– Multifetal Gestation– Lifestyle Factors– Autoimmune Disease – Cervical Surgery– Uterine Malformations

2. What is a biomarker for predicting preterm birth?– Fetal fibronectin

Preterm Birth

• Your history and examination confirms that she is undergoing preterm labour.

1. What medicines should now be given to the patient?

Preterm Birth

• Your history and examination confirms that she is undergoing preterm labour.

1. What medicines should now be given to the patient?– Tocolytics

• Calcium Channel Blockers (nifedipine)• NSAIDs (indomethicin)• Beta adregenic receptor antagonists (salbutamol/ritodrine)

– Steroids– Antibiotics– Magnesium Suphate

Preterm Birth

• 5% of pregnancies are delivered after term

1. What is the upper limit of time for a pregnancy?

2. What are the strongest risk factors for a postterm birth?

Postterm Birth

• 5% of pregnancies are delivered after term

1. What is the upper limit of time for a pregnancy?– 42+6 weeks

2. What are the strongest risk factors for a postterm birth?– Previous postterm birth– Nulliparity– Obesity– Male Foetus– Older maternal age– Maternal or Paternal history of postterm birth

Postterm Birth

A 26 year old woman, G1P0 with a 41+1 week pregnancy of a single male foetus wants have a home birth. The foetus is in a cephalic, left occiput anterior position.

1. Will you let this woman give birth at home? Explain your answer

Postterm Birth

Liz, 26 year old woman, G1P0 with a 41+1 week pregnancy of a single male foetus wants have a home birth. The foetus is in a cephalic, left occiput anterior position.

1. Will you let this woman give birth at home? Explain your answer– No, pregnancies past the 41st week should be induced.

Postterm Birth

1. What are the dangers of a postterm pregnancy?

Postterm Birth

Mother Child

1. What are the dangers of a postterm pregnancy?

Postterm Birth

Mother Child

Postpartum Haemmorhage Macrosomia

3/4th degree perineal tears Fetal Dysmaturity Syndrome

Failed Induction Perinatal Mortality

Liz arrives at the maternity unit in hospital.

1. How is labor iatrogenically induced?

2. Cervical status is important for predicting success of induction. What scoring system is used for assessing cervical status?

Postterm Birth

Liz arrives at the maternity unit in hospital.

1. How is labor iatrogenically induced?– Oxytocin IV– Amniotomy– PGE1/PGE2

Postterm Birth

2. Cervical status is important for predicting success of induction. What scoring system is used for assessing cervical status?

Postterm Birth

What changes can you expect in the postpartum period in the following areas?

1. Uterus2. Cervix3. Vagina/Vulva4. Reproductive Hormones5. Breasts

The Puerperium

What changes can you expect in the postpartum period in the following areas?

1. Uterus– Uterine involution and Lochia

2. Cervix– Contraction of the cervix. External os never fully recpovers.

3. Vagina/Vulva– Contracts but not to its nulligravid size

4. Reproductive Hormones– Beta HCG returns to normal levels in 12 days. 70% menstruate by week 12

postartum

5. Breasts– Swelling of the breasts and milk production

The Puerperium

1. The observations show Liz has a temperature of 38 C. Are you worried?

2. What other routine procedures should be done for Liz after birth?

The Puerperium

1. The observations show Liz has a temperature of 38 C. Are you worried?

– No, only after the first 24 hours. Most common is cause is infection.

2. What other routine procedures should be done for Liz after birth?

– Counselling/Practical help with breastfeeding– HR/BP/RR/Temp monitoring.– Examine for signs of bleeding – Distended bladder examination– Examine for perineal damage

The Puerperium

Liz bled a lot during the birth. The nurse tells you she bled 800mls of blood.

1. What is the definition of primary postpartum haemorrhage in a vaginal delivery? What about after Caesarean section?

2. What are the causes of postpartum haemorrhage?

The Puerperium

Liz bled a lot during the birth. The nurse tells you she bled 800mls of blood.

1. What is the definition of primary postpartum haemorrhage in a vaginal delivery? What about after Caesarean section?

– >500ml blood loss, >1000ml in C - Section

2. What are the causes of postpartum haemorrhage? – Retained Placenta– Uterine atony– Trauma to uterus and vaginal tract– Clotting abnormalities

The Puerperium

• Venous thrombosis is 21 – 84x more common in women postpartum.– Risk assess and treat with stockings and LMWH

• Urinary Retention• Urinary/Fecal Incontinence.• Haemorrhoids• Varicose Veins• Postpartum Depression – 10% of women

The Puerperium

phase 3a stephen lau & george lam the peer teaching society is not liable for false or...

romthe peer teaching

regular contractions

cervical ripening

cervical dilatation

stages of labour

regular strong contractions

year old woman

fetal parameters

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