Download B2B OB review 2016 M Gomes

Back to Basics!
The essence of
OBSTETRICS
in two hours
Megan Arnold Gomes, MD, FRCSC
Susan Aubin MD, FRCSC
Department of Ob/Gyn
The Ottawa Hospital
Special Thanks to: Karine Lortie , MD, FRCSC
OVERVIEW
Introduction
•Early pregnancy
•Antenatal care
•Teratogens
•Fetal growth and wellbeing
•Medical complications
•Breech
•Multiple pregnancy
•Labour
•
INTRODUCTION
RISK SPECTRUM IN PREGNANCY
LOW RISK (75%):
normal obstetrics
MEDIUM RISK (20%):
pre-post dates
breech
twins
advanced maternal age, etc..
HIGH RISK (5%):
genetic disease
serious obstetric
maternal complications
RISK IN PREGNANCY
Definitions
Perinatal mortality rate
All stillbirths (intrauterine deaths) > 500 grams plus
all neonatal deaths per 1,000 total births
Neonatal death
Death of a live-born infant less than 7 days after birth
(early) or less than 28 days (late)
Live birth
An infant weighing 500 grams or more exhibiting any
sign of life after full expulsion, whether or not the cord
has been cut and whether or not the placenta is still in
place
PERINATAL MORTALITY RATE
ONTARIO:
5/1000
Developing:
100/1000
Perinatal mortality rate
All stillbirths (intrauterine deaths) > 500
grams plus all neonatal deaths per 1,000
total births
PERINATAL MORTALITY
Prematurity
•Congenital anomaly
•Sepsis
•Abruption
•Placental insufficiency
•Unexplained stillbirth
•Birth asphyxia
•Cord accident
•Other ie. isoimmunization
•
MATERNAL MORTALITY RATE
ONTARIO:
9.6/100 000
Developing:
1000/100 000
•
•
Maternal mortality rate
Number of maternal deaths resulting from
the reproductive process per 100,000
women of reproductive age (15-49 years)
MATERNAL MORTALITY
Direct Deaths
•Indirect deaths: < 42 days from delivery
•
Causes:
•Hypertensive disorders
•Pulmonary embolism
•Anesthesia
•Ectopic pregnancy
•Amniotic fluid embolus
•Hemorrhage
•Sepsis
EARLY PREGNANCY
EARLY PREGNANCY
Dating:
40 weeks from LMP
280 days, Naegle’s rule (+1 yr -3 months + 7 days)
Affected by cycle length
Hegar’s sign: softening of uterus
Chadwicks sign: blue discoloration of cervix
U/S Dating
SOGC Guideline 2014
- more accurate than patient recall
- T1 U/S most accurate CRL (3-8 days)
Hormones
BhCG:
A subunit similar to TSH, LH, FSH
Measurable 8 days post conception
Role: stimulate CL progesterone
100,000
Other use:
Zone 2000-6000
Level
doubling time 2 days
Mole
•Ectopic
•Ovarian cysts
•
5,000
8 days
8 weeks
16 weeks
Transvaginal U/S
BhCG (mIU/ml)
4-5 weeks - gest sac
1500-2400
5-6 weeks – fetal pole
> 5,000
6+ weeks – fetal heartbeats
>10,000
Other Placental Hormones
HPL =
human placental lactogen (growth hormone)
regulates maternal and fetal metabolism, fetal growth
Prolactin
regulates placental memb. fluid and electrolytes
Progesterone
modulates tubal motility, uterine bloodflow and relaxation
Estrogen
increases uterine bloodflow and regulates placental steroids
Maternal physiology
RBC and HR by 20%
plasma volume by 50%
GFR, CrCl (creatinine)
cardiac output (highest 1st hour after delivery)
SV
Placental flow: 750ml/min at term
ANTENATAL CARE
Antenatal care
Antepartum history:
Age, Gravidity/parity, gestational age
Prior pregnancy history
Medical, surgical history
Family, social history
Meds, allergies
Routine tests:
CBC (Hg), Type and Screen, prenatal antibodies (Rh)
VDRL, Rubella, Hep B, HIV
Urine culture
Pap smear, + vag swabs, cervical cultures
Offer IPS/MSS
Antenatal Care
Other testing:
Dating ultrasound, 18-20 weeks morphology ultrasound
Hb electrophoresis (Thalassemia, sickle cell, etc.)
Chicken pox, parvovirus, TSH
28 weeks glucose screening test
GBS at 35-37 weeks
Genetic testing:
CVS, Amniocentesis (offer at age 40), NIPT
Scheduled visits:
0-28 weeks: q4 weeks
28-36 weeks: q2 weeks
36+ weeks: q1 week
Antenatal follow up visits
Symphysis-Fundal Height (SFH) (cm):
(+ 2cm # of weeks), Sensitivity of 60%
12 weeks: symphysis pubis
20 weeks: umbilicus
36 weeks: xiphisternum
Presentation – T3 (Leopold’s)
Symptoms, fetal movement
+ urine dip: glucose, protein
Blood pressure, maternal weight
MATERNAL WEIGHT GAIN
Weeks
0 - 20
21 - 28
29 - 40
Average
BMI before pregnancy
>18.5
18.5 and 24.5
25 and 29.9
>30
Weight Gain
4 kg
4 kg
4 kg
12 kg
Recommended weight gain
12.5 - 18 kg (28 to 40 lb)
11.5 - 16 kg (25 to 35 lb)
7 - 11.5 kg (15 to 25 lb)
At least 7 kg (15 lb)
Genetic testing
IPS:
First Trimester screening (10+6 – 13+6 weeks)
• Nuchal translucency
• PAPP-A, (BhCG)
Second Trimester screening (15-20 weeks)
• BhCG, estriol, AFP, Inhibin A
87% detection rate, 2% false positive rate
MSS: (Quad test)
15-20 weeks
BhCG, estriol, AFP, Inhibin A
77% detection rate, 5% false positive rate
IPS vs MSS Detection rate
NT
Suchet I, Tam W. The ultrasound of life. Interactive fetal ultrasound teaching program on DVD,
4th Edition, 2004.
Screening patterns
Down’s syndrome: low PAPP-A, AFP, estriol,
Trisomy 18: low
high BhCG
PAPP-A, AFP, BhCG, estriol, Inhibin A, high NT
Trisomy 13: high AFP, low BhCG/estriol
NTD: high AFP
Low estriol – associated with many congenital anomalies
TERATOGENS


Any agent that acts during embryonic or fetal
development to provoke permanent
alterations to form or function.
Eg. Chemical, virus, environmental agent,
physical factors

















Alcohol
ACE-I, ARB
Aminopterin
Androgens
Bexarotene
Carbamazepine
Chloramphenicol
Cocaine
Corticosteroids
Cyclophosphamide
Danazol
DES
Efavirenz
Isotretinoin
Leflunomide
Lithium
Methimazole


















Methyl Mercury
Methotrexate
Misoprostol
Mycophenolate
Paroxetine
Phenobarbital
Phenytoin
Radioactive Iodine
Ribavirin
Streptomycin
Tamoxifen
Tetracycline
Thalidomide
Tobacco
Toluene
Tretinoin
Valproate
Warfarin
Category
Description
A
Adequate well-controlled studies in pregnant women have not shown an
increased risk of fetal anomalies Eg PNV, Levothyroxine
B
Animal studies have not demonstrated fetal risks but no controlled
studies in pregnant women have been reported OR animal studies have
shown an adverse effect that was not confirmed in controlled studies in
women in the 1st trimester Eg. Penicillin
C
Studies in animals have revealed adverse effects in the fetus but no
controlled studies have been reported
OR studies in women and animals are not available
Eg. Beta blocker, CCB, 2/3 medications
D
Positive evidence of human fetal risk exists but the benefits for use in
pregnant women may be acceptable despite the risk
Eg. Lithium, systemic corticosteroids
X
Contraindicated in pregnancy
Studies in animals or humans have demonstrated fetal anomalies or fetal
risks clearly outweigh any possible benefits
Eg. Methotrexate, Warfarin
FETAL GROWTH AND WELL-BEING
Dating Scan
Transvaginal Ultrasound
T1 Crown Rump Length (CRL) best parameter for
determining GA
Must be at least 7 wks GA (or CRL 10mm)
5 + 0 wks - Empty gestational sac
6 + 0 wks - Gestational sac and yolk sac + heart beat
8 + 0 wks - Embryo with separate amniotic sac +yolk sac.
Fetal body movements visible, heart rate 175 bpm.
T2 Morphology scan
Transabdominal Ultrasound
18- 20 weeks
BPD
HC
AC
Femur length
Detailed assessment of fetal morphology
spine, head, face, heart, abdomen, limbs
Anomalies: U/S 18-20 wks
Spina Bifida
•Anencephaly
•Cardiac- ASD, VSD, hypoplastic
•Renal
•Diaphragmatic hernia
•Limbs
•Facial- cleft lip/palate
•Chromosomal
•
Late > 20 weeks
•Renal
•Microcephaly
•Hydrocephalus
•Ureteral valves
Info from U/S
Morphology
•Estimated fetal weight
•Amniotic Fluid Volume
•
No. of fetuses
•Twins – type, growth discordance
•
Behavioral states (BPP)
•
Presentation
•
Placentation (previa)
•
Interventions
Amniocentesis
•
Chorionic villus sampling
•
Cordocentesis, transfusion
•
Paracentesis
•
Shunts: bladder, ascites, kidney, head
•
Fetal reduction
•
DEFINITION OF SGA + IUGR
Small-for-gestational age (SGA)
th centile on ultrasound
•EFW < 10
•Pathology vs lower end of normal
•Intrauterine growth restriction (IUGR)
•EFW < 10th centile on ultrasound
•AND due to pathologic process has not
Obtained biologically determined growth potential
Approx. 4-7% of infants
•
CAUSES OF IUGR
•Maternal:
Malnutrition
Drugs
Substance Abuse
Diseases
Infections
•Fetal:
Chromosomal Abnormality
Congenital Abnormality
Multiple Gestation
Congenital Infection
CAUSES OF IUGR
Placental:
Perfusion Abnormalities:
•Abnormal Cord Insertion
•Abruption
•Circumvallate placentation
•Placental Hemangioma
•Placental Infections
•Twin to Twin Transfusion
IMMEDIATE NEONATAL MORBIDITY IN IUGR
Birth asphyxia
•Meconium aspiration
•Hypoglycemia
•Hypocalcemia
•Hypothermia
•Polycythemia, hyperviscosity
•Thrombocytopenia
•Pulmonary hemorrhage
•Malformations
•Sepsis
•
FETAL MACROSOMIA
No precise definition agreed upon by authorities
th %ile = 4000g at 39 wks
•>90
• 4000g – 4500g (ACOG
•
Factors Associated with Macrosomia:
•Maternal diabetes
•Maternal obesity
•Excessive maternal weight gain
•Postterm gestation
•Multiparity
•Previous macrosomic infacnt
•Racial and ethnic factors
•Advancing maternal age
EVALUATION OF
WELL-BEING
FETAL ACTIVITY
Kick counts:
Fetal movements perceived after 24 wks
in a constant fashion
•Daily monitoring at 26-32 wks with risk factors
•Healthy pregnancy
•aware of fetal movement
•kick counts only if decreased movement
•
6 movements / 2 hours*
•Women concentrating on movements
in a reclined (not supine position)
•
BIOPHYSICAL PROFILE
Graded (0 or 2 pts; max 10)
•NST (normal)
•Movement
•Tone
•AFI (amniotic fluid volume)
•Breathing (30 seconds)
•
DOPPLER
What is it?
•Uteroplacental waveforms
•Umbilical artery
•Carotid artery
•Middle Cerebral Artery
•
CARDIOTOCOGRAPHY
Maybe as good as BPP
1. Non-stress test:
movement
uterine activity
Oxytocin infusion
2. Stress tests:
nipple stimulation
Features of the normal CTG:
•rate 110-160 bpm
•BTB variation 5-15 bpm
•Accelerations present (2)
•No decelerations (early, variable, late)
Which fetus to assess?
Small for gestational age, postdates
Maternal hypertension, diabetes
Antepartum hemorrhage
Decreased FM
The “high risk” pregnancy
Etc…
WHY FETAL ASSESSMENT?
1.To prevent damage (asphyxia)
2. To deter unnecessary intervention (prematurity,
operative deliveries)
WHAT IS IT LOOKING FOR?
Fetal hypoxia before asphyxia
•
Signs of placental failure:
•
Poor fetal growth
•Decr. FM
•Decr. AFI
•Atypical, abnormal NST
•
How to test?
•
Fetal scalp pH sampling
•Normal >7.25
•Borderline >7.21-7.25 (repeat sampling in ½ hour)
•Abnormal <7.20 (deliver)
•Fetal scalp stimulation
•
Criteria for asphyxia
(hypoxic acidemia)
umbilical cord arterial pH < 7.0
•
base deficit > 16
•
Apgar score 0-3 for >5 minutes
•
neonatal neurologic sequelae (e.g. seizures, hypotonia,
•
coma)
evidence of multiorgan system dysfunction in the
•
immediate neonatal period
NORMAL TRACE
Early decels
Late
Decels
Late decelerations
Variable
Decels
Variable decals
ced variability
Reduced Variability
Tachycardia
MEDICAL
COMPLICATIONS
NAUSEA AND VOMITING
Morning sickness: 50%
•Hyperemesis gravidarum: 1%
Treatment
•Diclectin (10 mg doxylamine succinate with vit B6)
•Rest
•Avoid triggers
•Admit if severe (i.e. dehydration, electrolytes
imbalance)
•TSH, LFT
•IV
•Dietitian consult
•Psychology
•
Gestational Diabetes
Diabetes 1%
GDM: 3-5%
Screening: 50g GTT
•<7.8 = normal
•7.8 – 11.0 do 75 g 2 hr OGTT
•> 11.0 = GDM
Risks factors:
•Previous stillbirth
•Previous LGA
•FHx
•Previous GDM
•Age >35 yrs
•PCOS








Macrosomia
Shoulder dystocia and nerve injury
Neonatal hypoglycemia
Preterm delivery
Hyperbilirubinemia
Caesarian section
Offspring obesity (?)
Offspring diabetes (?)
Rhesus Isoimmunization
Incidence:
•7% african-american
•13% caucasion
IgG anti-D in Rh –ve sensitized women
Complications:
•fetal anemia
•heart failure
•Hydrops fetalis
•Born with jaundice
In-Utero Dx: Amniocentesis, Cordo, Doppler
Prophylaxis: WinRho @ 28 wks + postpartum (newborn Rh
status)
Antepartum hemorrhage (>20 wks)
Placental abruption: concealed, revealed
•Signs: vaginal bleeding, pain, fetal distress
•Causes:
PIH (DIC)
Cocaine
SLE
Smoking
Trauma
Previous abruption
Abnormal placentation: previa, vasa previa
•Signs: painless vaginal bleeding
PPH
Causes (4T):
Uterine aTony:
•Overdistended Uterus (Twins, macrosomia,
Poly)
•Uterine muscle fatigue (prolonged or
precipitous labor, multiparity, operative delivery)
Tissue (Retained products)
•Infection
Trauma (laceration, uterine rupture)
Thrombin (coagulopathy)
PPH Treatment
Conservative:
Deliver the placental
Bimanual compression
Uterine packing
IV, X-match, blood bank (PRBC, FFP, …)
Medical:
Ergot
Hemabate
Oxytocin
Cytotec
Cyklokapron
PPH Treatment
Surgical:
•Repair the tear
•D&C (explore the uterus)
•Ligate internal iliacs
•UAE
•Uterine Compression sutures (B-Lynch suture)
•Bakri balloon
•Hysterectomy
HYPERTENSION
HYPERTENSION
Leading cause of maternal death and perinatal
mortality/morbidity
•
BP monitoring is major activity of antenatal care
•
Affects up to 10 % of all pregnancies
•
TERMINOLOGY
Gestational Hypertension (> 20 wks)
with preeclampsia
with comorbid conditions
Pre-existing Hypertension (< 20 wks)
with preeclampsia
with comorbid conditions
ABNORMAL VALUES? (depends on who…)
>140 / 90 two readings
PROTEINURIA
>0.3 g/day (mild); >5 g/day (severe)
protein to creatinine ratio > 20
Classification (it changes all the time…)
Preeclampsia:
• Gestational hypertension with one or more of the
following:
•new proteinuria, or
•one or more adverse conditions or
•one or more severe complications.
Eclampsia:
Convulsion during pregnancy or within 7 days to 6
weeks of delivery
Not caused by epilepsy
Risk factors
Primigravida or new partner
Age, race, Low social class, obesity
Underlying/chronic hypertensive
disorder 20 %
diabetes 50 %
Twins (mono) 30 %
Hydatidiform mole
Previous gestational hypertension 30 %
Severe Preeclampsia:
Severe preeclampsia is defined as preeclampsia with
one or more severe complications
•Eclampsia
•Stroke, TIA
•Uncontrolled severe HTN
•Pulmonary edema
•MI
•AKI
•Placental abruption
•Stillbirth
Management
MILD:
monitor, deliver near term
SEVERE:
stabilize and deliver, MgSO4
MOTHER:
•Labwork: CBC, LFT, uric acid, BUN, Cr,
protein/creatinine ratio or 24 hour urine total
protein, LDH,
•Symptoms: IV, BP meds, +/-Magnesium sulfate
BABY :
•BPP, NST
•Ultrasound: growth, doppler
•Celestone
ANTIHYPERTENSIVES
Short or long-term:
•Methyl dopa
•Labetolol
•Nifedipine
•
Acute:
•Labetolol
•Nifedipine
•Hydralazine
•
ANTICONVULSANTS
Prophylaxis and treatment:
•Magnesium sulphate
•
ECLAMPSIA
Rx:
•Control airway
•Stop convulsion
•reduce BP
•MgSO4
•Deliver (C. Section?)
•watch postnatally
BREECH
ETIOLOGY OF BREECH PRESENTATION
prematurity
•Fetal abnormality
•Multiple pregnancy
•polyhydramnios
•Placenta previa
•Uterine abnormality
•
TYPES OF BREECH PRESENTATION
Extended (frank)
Flexed (complete)
incomplete
footling
MANAGEMENT OF BREECH PRESENTATION
If diagnosed >34 weeks, options:
•External cephalic version
•Trial of labor with vaginal delivery
•caesarean
•
Criteria for TOL:
•At 37+ weeks:
•Estimated fetal weight 2.5-4 kg
•Frank or complete breech presentation
•clinical pelvimetry adequate
•Fetal abnormality excluded
•No serious medical or obstetric complications
TRANSVERSE LIE
Incidence: 1:200 at term
•Risk factors:
•Multigravidae
•Placental previa
•Fibroids
•Polyhydramnios
•Multiple pregnancy
•Contracted pelvis
•Fetal abnormality
•Uterine abnormality
•
Management:
•Ultrasound, version attempt
•Cesarean if not resolved
•
MULTIPLE
PREGNANCY
Twins
Incidence:
•1:80 (triplets 1:802)
•1:320 MZ twins worldwide
•
Etiology:
•Population based
•Age
•Parity
•Previous twins
•Heredity
•
Twins
Diagnosis:
LGA
u/s: lambda sign
Increased AFP
Management:
Rest
Serial u/s
Assess presentation
+ IOL @ 38 wks
Placentation
Zygosity:
Diamniotic/Dichorionic
Separate amnion and chorion (Separate
placentas and sacs)
Diamnionic/Monochorionic, and
Monoamnionic
Presentation:
Vx/Vx: 45%, Vx/BR: 25%
Br/Vx: 10%, Br/Br: 10%
Placentation
DIZYGOTIC
DAY
23 %
0-3
Totally separate
75 %
4-7
Separate fetuses & amnion
single chorion with vascular
connections
1%
7 - 11
Monoamniotic & monochorionic
1%
11+
conjoined twins
Hazards of multiple pregnancy
Increased risk pre-eclampsia (X3)
•pressure symptoms
•anemia
•
Abortion (disappearing sac)
•Prematurity (approx. 30% deliver < 37/40 )
•Polyhydramnios
•twin-twin transfusion
•Placenta previa
•APH/PPH
•Malpresentation
•cord entanglement
•
LABOR
What is Labor ?
(: work)
Regular painful uterine contractions
accompanied by progressive effacement and
dilatation of the cervix.
Timing of Labor
40 weeks (280 days)
4-8% deliver on E.D.D.
7% premature <37 weeks
10% post-mature >42 weeks
Stages of Labor
1st stage:
Onset to ‘full dilatation
Latent and active
2nd stage: Full dilatation to delivery of baby
3rd stage:
Delivery of placenta
4th stage:
Placenta to 6 wks PP
Signs of Onset of Labor
“Show”
•
Rupture of membranes
•
Contractions
•
Detection of ruptured membranes
Nitrazine Test:
•Alkaline pH of fluid turns blue
•
Ferning:
•High Na+ content causes “ferning” on air
dried slide
•
Ferning
Cord prolapse
Only with ruptured membranes
Incidence: 1/300
Risk factors:
80% happen in multigravida
Malpresentation:
Transverse lie
Breech
High head
Twins
Prematurity
OB interference: forcep, arm
Cord prolapse
Diagnosis:
•Ultrasound
•Pelvic exam in labour (e.g. after ROM)
•FHR abnormality
•
Treatment:
•Don’t panic
•Push up presenting part
•Sims position or knee/chest
•Cesarean (forceps if fully)
•
Table 30-1. Characteristics of Labor Nulliparas and Multiparas*
Characteristic
Nulliparas
All patients
Ideal Labor
Duration of first stage
(hr)
Latent phase
6.4(±5.1)
Active phase
4.6(±3.6)
Total
11.0(±8.7)
Maximum rate of
descent (cm/hr)
3.3(±2.3)
Duration of second
stage (hr)
1.1(±0.8)
Multiparas
All patients
Ideal labor
6.1 (±4.0)
3.4(±1.5)
9.5(±5.5)
4.8 (±4.9)
2.4(±2.2)
7.2(±7.1)
4.5 (±4.2)
2.1 (±2.0)
6.6(±6.2)
3.6(±1.9)
6.6(±4.0)
7.0(±3.2)
0.76(±0.5)
0.39(±0.3)
0.32(±0.3)
* All values given are ± SD.
(Data from Friedman EA: Labor: Clinical Evaluation and Management. 2nd ed. New York,
Appleton-Century-Crofts, 1978).
Cesarean Section
Indications
Failure to progress (Dystocia)
Repeat (Failed VBAC)
Fetal Distress
Breech Presentation
Placenta Previa
Cord prolapse
Abruption
Diabetes
Fetal Reasons (e.g. prevent infection)
Social...
Preterm labor
Incidence: 7% <37 wks
Major cause of perinatal morbidity
Overall recurrence risk of 30%
Risk factors:
Previous PTD
Smoking
Low income
Cervical surgery
Uterine anomaly
Multiple pregnancy
Preterm labor
Treatment:
Rest
Steroids (for fetal lung maturity)
Tocolytics?
PPROM:
antibiotic protocol (IV/PO
ampicillin(amoxil)/erythromycin)
Prevention:
Ultrasound cervical length?
Fetal fibronectin (predictor?)
Amniotic Fluid
Mainly fetal urine
•Some from extraplacental membranes
•12 wks:
50 mls
•24 wks:
500 mls
•36 wks:
1,000 mls
•
Oligohydramnios:
•Reduced AFI on u/s: <5cm
•SFH: small for dates; baby easy to feel
•Causes:
•Placental insufficiency, PPROM
•Urinary tract dysplasia
•Diagnosis:
•Ultrasound
•Treatment:
•Intensive monitoring, Early delivery
•
Polyhydramnios
Definition:
•An excess of liquor to such a degree that it is
likely to influence the course or management of
pregnancy.
•>20 cm
•
Diagnosis:
•SFH increased: large for dates
•Tense and uncomfortable
•Fluid thrill
•Difficult to feel fetus
•
Polyhydramnios:Etiology
Maternal:
Multip
Diabetes, Hypertensive disorders
Infection: toxoplasmosis, CMV
Fetal:
Macrosomia
Anencephaly, hydrocephaly
Gut atresia
Multiple pregnancy
CAN’T SWALLOW (diaphragmatic hernia,
mediastinal tumor)
HYDROPS FETALIS (Rh incompatibility, infection,
heart disease, thalassemia major, etc.)
Dystocia
Definition:
Abnormal progression of labour in the
ACTIVE Phase
Cervical dilatation of <0.5 cm/hr
over a 4 hr period
arrest of progress in the ACTIVE
phase either in the first or second
stage of labour
Failure of descent of presenting
part (less than 1cm/hr in 2nd stage)
CAUSES OF DYSTOCIA
Power
Uncoordinated uterine action
Dysfunctional Labour
Passenger Cephalo-pelvic disproportion
Relative disproportion
Massive baby! (macrosomia)
Passages
Diameters (pelvic anatomy)
Dystocia
Risk Factors:
age
Parity
Infection
Epidural
Position in labor
Induction
Macrosomia
cervix
Initial Management of Dystocia
A. Attention to:
Comfort
wellbeing
hydration
B. Amniotomy
C. Oxytocin if A+B fail
D. Wait long enough to see a response
Oxytocin Augmentation
Dosage:
•Depends on your hospital protocol
•Initial dose: 1 to 2 mu/min
•Rate increased by 1 to 2 mu/min every 30 min
until contractions are considered adequate
and cervical dilation achieved
•Clinical response usually seen at 8-10 mu/min
•Accelerated protocol (2-4mu/min)
•
Reduction of Risk of Dystocia
Avoid induction for fetal macrosomia
Avoid oxytocin use with unfavourable cervix
Avoid admission to Labour and Delivery at <4cm
dilation
“Management” of epidural at full dilatation
Avoid immediate pushing after full dilatation
Supportive strategies
Cervical evaluation for ripening prior to booking
induction
Obstetrical triage
Continuous professional support in active labour
Mobilization of women in active labour
Minimization of motor blockage with epidural
Use of amniotomy and oxytocin prior to C/S for
dystocia
Cesarean Section for Dystocia
Timing of procedure
Latent phase
Active phase
Second stage
Rate
41%
38%
21%
Source: Stewart CMAJ 1990:142; 459-463
The perinatal mortality rate is defined as:
The number of neonatal deaths that occur per 1000 live
births
a)
a)
The number of stillbirths that occur per 1000 births
The number of fetal deaths within the first week after
birth
a)
The number of stillbirths and neonatal deaths in the first
week of life per 1000 births
a)
Good Luck!
All of the following factors are associated with
an increased risk of perinatal morbidity except:
a)
low socioeconomic status
b)
low maternal age
c)
heavy cigarette smoking
d)
alcohol abuse
e)
exercise
Appropriate management for slow labour (dystocia)
associated with an occiput posterior presentation
during the first ACTIVE stage of labour would include:
a)
immediate cesarean section
b)
forceps
c)
augmentation with oxytocin
d)
external cephalic version
e)
fetal blood sampling
Which of the following statements best
describes the foramen ovale:
It shunts blood from left to right
It connects the pulmonary artery with the aorta
It shunts deoxygenated blood into the left atrium
It is an extra cardiac shunt
It is functional after birth
Appropriate screening tests in an early,
uncomplicated pregnancy include all of the
following except:
a)
b)
c)
d)
e)
repeat BhCG
hemoglobin
syphilis serology
Cervical cytology
Blood type and Rh factor
Characteristics or associated findings with late
decelerations include all of the following except:
a)
They may be seen in patients with pre-eclampsia
a)
They may be associated with respiratory alkalosis
They are associated with a decreased uteroplacental blood
flow
a)
a)
They often are accompanied by decreased PO2
a)
They usually are accompanied by an increased PCO2
A complete breech presentation is best
described by which of the following
statements:
The legs and thighs of the fetus are flexed.
The legs are extended and the thighs are flexed.
The arms, legs, and thighs are completely flexed.
The legs and thighs are extended.
None of the above