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Back to Basics! The essence of OBSTETRICS in one hour

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1 Back to Basics! The essence of OBSTETRICS in one hour
Karine J. Lortie , MD, FRCSC Assistant Professor Department of Ob/Gyn The Ottawa Hospital/University of Ottawa

2 Fetal growth and wellbeing Medical complications Breech
OVERVIEW Introduction Early pregnancy Antenatal care Teratogens  Fetal growth and wellbeing Medical complications Breech Multiple pregnancy Labour This is the first page


LOW RISK (75%): normal obstetrics MEDIUM RISK (20%): pre-post dates breech twins maternal age, etc.. HIGH RISK (5%): genetic disease serious obstetric maternal complications

5 RISK IN PREGNANCY Definition of Outcome Measures
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 I9NSER MM

6 PERINATAL MORTALITY Prematurity Congenital anomaly Sepsis Abruption
Placental insuffienciency Unexplained stillbirth Birth asphyxia Cord accident Other ie. isoimmunization

ONTARIO: 5/1000 Developing: 100/1000

Indirect deaths: < 42 days from delivery Causes: Hypertensive disorders Pulmonary embolism Anesthesia Ectopic pregnancy Amniotic fluid embolus Hemorrhage Sepsis

ONTARIO: 5/ Developing: 1000/



12 EARLY PREGNANCY Dating: Hegar’s sign: soft uterus
40 weeks from LMP 280 days, Naegle’s rule (-3 months + 7 days) Affected by cycle length Hegar’s sign: soft uterus Chadwicks sign: blue cervix

13 Hormones BhCG: Others use: Zone 2000-6000 Mole Ectopic Ovarian cysts
A subunit similar to TSH, LH, FSH Measurable 8 days post conception Role: stimulate CL progesterone 8 days 8 weeks 16 weeks 5,000 Level 100,000 doubling time 2 days Others use: Zone Mole Ectopic Ovarian cysts

14 Other placental hormones
HPL = human placental lactogen (growth hormone) prolactin progesterone estrogen

15 Which of the following statements best describes the foramen ovale:
It shunts blood from right to left 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


17 Maternal physiology RBC
plasma volume by 50%, GFR, CrCl (creatinine), glucosuria cardiac output (highest 1st hour after delivery) HR by 20% SV Placental flow: 750ml/min at term

18 Antenatal care Antepartum history: Routine tests:
age: >40 offer amniocentesis Parity/gravidity Medical, surgical history Family, social history Meds, allergies Routine tests: CBC (Hg), Type and Screen, prenatal antibodies VDRL, Rubella, Hep B, HIV Urine culture Pap smear, + vag swabs, cervical cultures Offer IPS GBS swab at 35 weeks

19 Antenatal Care Optional testing: Genetic testing: Scheduled visits:
Dating ultrasound, 18 weeks morphology ultrasound Hb electrophoresis (Thalassemia, sickle cell, etc.) Chicken pox, parvovirus, TSH 28 weeks glucose screening test Genetic testing: CVS Amniocentesis Scheduled visits: 0-28 weeks: q4 weeks 28-36 weeks: q2 weeks 36+ weeks: q1 week

20 Scheduled visits SFH (cm): (+ 2 # of weeks) presentation
Sensitivity of 60% 12 weeks: symphysis pubis 20 weeks: umbilicus 36 weeks: siphisternum presentation Symptoms, fetal movement + urine dip: glucose, protein Blood pressure, maternal weight

21 MATERNAL WEIGHT wks gain 0 - 20 4 kg 21 - 28 4 kg 29 - 40 4 kg
Average kg Underweight: lbs Normal BMI: lbs Overweight: less than 25 lbs

22 Genetic testing IPS: MSS:
First Trimester screening (10.6 – 13.6 weeks) Nuchal translucency PAPP-A, BhCG Second Trimester screening (15-16 weeks) BhCG, estriol, AFP 94% detection rate MSS: 15-19 weeks 70% detection rate

23 IPS vs MSS Detection rate

24 NT Suchet I, Tam W. The ultrasound of life. Interactive fetal ultrasound teaching program on DVD, 4th Edition, 2004.

25 Screening patterns Down’s syndrome: low AFP/estriol, high BhCG
Trisomy 18: low AFP, BhCG, estriol Trisomy 13: high AFP, low BhCG/estriol NTD: high AFP

26 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

27 Appropriate screening tests in an early, uncomplicated pregnancy include all of the following except: a) repeat BhCG b) hemoglobin c) syphilis serology d) Cervical cytology e) Blood type and Rh factor





32 I Q F G H J K L M N O P R S T



35 Risk Classification System for Drug Use in Pregnancy
Category Description A Taken by a large number of pregnant women. No increase in malformation. B Taken by only a limited number of pregnant women and women of childbearing age. No increase in malformation. Studies in animals wither show no increase or are inadequate. C Have caused or may be suspected of causing harmful effects on the human foetus or neonate without causing malformations. These effects may be reversible. D Have caused an increased incidence of human foetal malformations or irreversible damage. X Drugs that have such a high risk of causing permanent damage to the foetus that they should not be used in pregnancy.


37 Dating Scan Gestational sac: 5wks Fetal pole: 6wks Fetal heart: 7 wks
Limb buds: 8 wks crown rump length

38 Morphology scan weeks BPD HC AC Femur length

39 Info from U/S Estimated fetal weight Twins discordance
Behavioral states (BPP) Presentation Placenta (previa)

40 Anomalies: ultrasound 18 - 20 weeks
Spina Bifida Anencephaly Cardiac Renal Diaphragmatic hernia Limbs Facial Chromosomal Late > 20 weeks Renal Microcephaly Hydrocephalus Ureteral valves

41 Interventions amniocentesis, l/s ratio (lung maturity) cvs
cordocentesis, transfusion paracentesis Shunts: bladder, ascites, kidney, head Liver biopsy, skin Fetal reduction

42 DEFINITION OF I.U.G.R < than 2500 grams
< than 5th centile for GA Approx. 4-7% of infants





47 CAUSES OF IUGR Maternal: Fetal: Malnutrition Drugs Substance Abuse
Diseases Infections Fetal: Chromosomal Abnormality Congenital Abnormality Multiple Gestation Congenital Infection

48 CAUSES OF IUGR Placental: Perfusion Abnormalities:
Abnormal Cord Insertion Abruption Circumvallate placentation Placental Hemangioma Placental Infections Twin to Twin Transfusion

Birth asphyxia Meconium aspiration Hypoglycemia Hypocalcemia Hypothermia Polycythemia, hyperviscosity Thrombocytopenia Pulmonary hemorrhage Malformations Sepsis

Maternal diabetes Maternal obesity Excessive maternal weight gain

51 The perinatal mortality rate is defined as:
The number of neonatal deaths that occur per 1000 live births The number of stillbirths that occur per 1000 births The number of fetal deaths within the first week after birth The number of stillbirths and neonatal deaths in the first week of life per 1000 live births d


53 BIOPHYSICAL PROFILE DOPPLER Graded (0 or 2 pts; max 10) NST (normal)
Movement (2) Tone (2) AFI (amniotic fluid volume) Breathing (30 seconds) DOPPLER What is it? Uteroplacental waveforms Umbilical artery Carotid artery Descending aorta

54 FETAL ACTIVITY Kick counts: “count to ten “ chart towards term
10 movements in 2 hours over 12 hours

55 CARDIOTOCOGRAPHY Maybe as good as BPP movement Non-stress test:
uterine activity Oxytocin infusion 2. Stress tests: nipple stimulation Features of the normal CTG: rate bpm BTB variation bpm Accelerations present (2) No decelerations (early, variable, late)

56 Which fetus to assess? Small for gestational age, postdates
Maternal hypertension, diabetes Antepartum hemorrhage Decreased FM The “high risk”pregnancy Etc…

57 WHY FETAL ASSESSMENT? 1. ? To prevent damage (asphyxia)
2. ? To deter unnecessary intervention (prematurity, operative deliveries)

58 WHAT IS IT LOOKING FOR? Fetal hypoxia before asphyxia How to test?
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 > (repeat sampling in ½ hour) Abnormal <7.20 (deliver)

59 Criterias 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


61 Early decels

62 Late Decels

63 Variable Decels

64 Reduced Variability

65 Tachycardia

66 Characteristics or associated findings with late decelerations include all of the following except:
They may be seen in patients with pre-eclampsia They may be associated with respiratory alkalosis They are associated with a decreased uteroplacental blood flow They often are accompanied by decreased PO2 They usually are accompanied by an increased PCO2


68 NAUSEA AND VOMITING Morning sickness: 50% Hyperemesis gravidarum: 1%
Tx: 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

69 DIABETES Incidence: 1% GDM: 3-5% Risks factors: Screening: 50g GTT
If > 7.8 do 75 g 2 hr OGTT > 10.3 GDM Risks factors: Previous stillbirth Previous LGA FHx Persistent glycosuria

Criteria (ADA): Fasting > 5.3 1 hour > 10.0 2 hour > 8.6 2 of the 3 values met or exceeded = GDM 1 of the values failed = impaired glucose tolerance Risks: Anomalies Infection Pre-eclampsia Macrosomia Polyhydramnios IUFD shoulder dystocia

71 Rhesus isoimmunization
Incidence: 7% african-american 13% caucasion IgG anti-D in Rh –ve sensitized women Can cause: fetal anemia heart failure Hydrops fetalis Born with jaundice In-Utero Dx: Amniocentesis, Cordo, Doppler Prophylaxis: 28 wks + postpartum (newborn Rh status)

72 Antepartum hemorrage (>20 wks)
Causes: Placental abruption: concealed, revealed Signs: vaginal bleeding, pain, fetal distress PIH (DIC) Cocaine SLE Smoking Trauma Previous abruption Abnormal placentation: previa, vasa previa Signs: painless vaginal bleeding

73 PPH Causes (4T): Uterine aTony: Twins long labor Etc…
Tissue (Retained products) Infection Trauma (tears) Thrombin: Congenital Disorders APH

74 PPH Treatment Conservative: Deliver the placental Bimanual compression
Uterine packing IV, xmatch, blood bank (PRBC, FFP, …) Medical: Ergot Hemabate Oxytocin cytotec

75 PPH Treatment 3. Surgical: Repair the tear D&C (explore the uterus)
Ligate internal iliacs UAE B-Lynch suture Bachrey balloon Hysterectomy


Leading cause of maternal death and perinatal mortality/morbidity BP monitoring is major activity of antenatal care Affects up to 10 % of all pregnancies

78 >0.3 g/day (mild); >5 g/day (severe)
TERMINOLOGY wks 75 70 40 dbs ABNORMAL VALUES? (depends on who…) >140 / 90 DBP > 90 two readings Systolic rise >30 or diastolic >15 PROTEINURIA >0.3 g/day (mild); >5 g/day (severe)

79 Classification (it changes all the time…)
Primary Diagnosis Definition of preeclampsia Pre-existing hypertension With comorbid conditions With preeclampsia (after 20 wks GA) Gestational hypertension Resistant HTN, or new or worsening ptnuria, or one/more adverse conditions New proteinuria, or one/more adverse conditions † Severe preeclampsia corresponds to preeclampsia: with onset before 34 weeks’ gestation, with heavy proteinuria (3–5 g/d according to other international guidelines), or with one or more adverse conditions. ‡Comorbid conditions, such as type I or II diabetes mellitus, renal disease, or an indication for antihypertensive therapy outside pregnancy. §Other adverse conditions consist of maternal symptoms (persistent or new/unusual headache, visual disturbances, persistent abdominal or right upper quadrant pain, severe nausea or vomiting, chest pain or dyspnea), maternal signs of end-organ dysfunction (eclampsia, severe hypertension, pulmonary edema, or suspected placental abruption), abnormal maternal laboratory testing (elevated serum creatinine [according to local laboratory criteria]; elevated AST, ALT or LDH [according to local laboratory criteria] with symptoms; platelet count <100x109/L; or serum albumin < 20 g/L), or fetal morbidity (oligohydramnios, intrauterine growth restriction, absent or reversed end-diastolic flow in the umbilical artery by Doppler velocimetry, or intrauterine fetal death). Eclampsia: Convulsion during pregnancy or within 7 days to 6 weeks of delivery Not caused by epilepsy

80 Risk factors Primigravida or new partner Age, race Low social class
Familial trend ?single gene Underlying hypertensive disorder 20 % diabetes 50 % Twins (mono) 30 % Hydatidiform mole Previous gestational hypertension 30 %

81 DBP> 110 with proteinuria (3-5g/d) Symptoms:
Severe: DBP> 110 with proteinuria (3-5g/d) Symptoms: Headache Scotomas Epigastric pain/RUQ Vomiting Hyperreflexia

82 head ache

83 Management MILD: monitor, deliver near term
SEVERE: stabilize and deliver MOTHER: Labwork: CBC, LFT, uric acid, BUN, Cr, Albumin/creatinine ratio or 24 hour urine total protein, LDH, INR/PTT Symptoms: IV, meds, …. BABY : BPP Ultrasound: growth, doppler NST Celestone, …

84 ANTIHYPERTENSIVES ANTICONVULSANTS Short or long-term: Methyl dopa
Labetolol Nifedipine Acute: Hydralazine ANTICONVULSANTS Prophylaxis and treatment: Magnesium sulphate

85 ECLAMPSIA Rx: Control airway Stop convulsion reduce BP
Deliver (C. Section?) watch post natally


prematurity Fetal abnormality Multiple pregnancy polyhydramnios Placenta previa Uterine abnormality TYPES OF BREECH PRESENTATION Extended (frank) Flexed (complete) incomplete footling

If diagnosed >34 weeks, options: External cephalic version Trial of labor with vaginal delivery caesarean Criteria for TOL: At weeks: Estimated fetal weight kg Frank or complete breech presentation clinical pelvimetry adequate Fetal abnormality excluded No serious medical or obstetric complications

89 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

90 TRANSVERSE LIE Incidence: 1:200 at term Risk factors: Multigravidae Placental previa Fibroids Polyhydramnios Multiple pregnancy Contracted pelvis Fetal abnormality Uterine abnormality Management: Ultrasound Cesarean if doesn’t turn


92 Twins Incidence: 1:80 (triplets 1:802) 1:320 uniovular twins worldwide
superfecundation superfetation Etiology: Population based Age Parity Previous binovular twins Heredity

93 Twins Diagnosis: Management: LGA u/s: lambda sign Increased AFP Rest
Serial u/s Assess presentation + 38 wks

94 Placentation Dizygotic: Presentation: Separate amnion and chorion
Separate placentas Presentation: Vx/Vx: 45% Vx/BR: 25% Br/Vx: 10% Br/Br: 10% Etc…..

95 Placentation DIZYGOTIC DAY 23 % 0 - 3 Totally separate
75 % Separate fetuses & amnion single chorion with vascular connections 1% Monoamniotic & monochorionic <1 % conjoined twins

96 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

97 cy cy


99 What is Labor ? (: work) Regular painful uterine contractions accompanied by progressive effacement and dilatation of the cervix.

100 Timing of Labor 40 weeks 8% deliver on E.D.C.
7% premature <37 weeks 10% post-mature >42 weeks

101 Signs of Onset of Labour
“Show” Rupture of membranes Contractions

102 Detection of ruptured membranes
Nitrazine Test: Alkaline pH of fluid turns blue Ferning: High Na+ content causes “ferning” on air dried slide

103 Ferning

104 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

105 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)

106 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





111 Table 30-1. Characteristics of Labor Nulliparas and Multiparas*
Characteristic All patients Ideal Labor All patients Ideal labor Duration of first stage (hr) Latent phase 6.4(±5.1) 6.1 (±4.0) 4.8 (±4.9) 4.5 (±4.2) Active phase 4.6(±3.6) 3.4(±1.5) 2.4(±2.2) 2.1 (±2.0) Total (±8.7) 9.5(±5.5) 7.2(±7.1) 6.6(±6.2) Maximum rate of descent (cm/hr) 3.3(±2.3) 3.6(±1.9) 6.6(±4.0) 7.0(±3.2) Duration of second stage (hr) 1.1(±0.8) (±0.5) (±0.3) (±0.3) * All values given are ± SD. (Data from Friedman EA: Labor: Clinical Evaluation and Management. 2nd ed. New York, Appleton-Century-Crofts, 1978).





116 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...

117 Premature 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

118 Premature labor Treatment: Prevention: Rest
Steroids (for fetal lung maturity) Tocolytics? PPROM: Mercer protocol (IV/PO ampicillin(amoxil)/erythromycin) Prevention: Ultrasound cervical length? Fetal fibronectin (predictor?)

119 Amniotic Fluid Mainly fetal urine Some from extraplacental membranes
12 wks: 50 mls 24 wks: mls 36 wks: 1,000 mls Oligohydramnios: Reduced AFI on u/s: <5cm SFH: small for dates; baby easy to feel Causes: Placental insufficiency Urinary tract dysplasia Diagnosis: Ultrasound Treatment: Intensive monitoring Early delivery

120 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

121 Polyhydramnios: Etiology
Maternal: Multip Diabetes GHTN 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.)

122 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 Friedman’s curve



125 CAUSES OF DYSTOCIA Power Uncoordinated uterine action
Dysfunctional Labour Passenger Cephalo-pelvic disproportion Relative disproportion Massive baby! (macrosomia) Passages Diameters (pelvic anatomy)

126 Dystocia Risk Factors: age Parity Infection Epidural Position in labor
Induction Macrosomia cervix

127 Initial measure to treat dystocia
A. Attention to: Comfort wellbeing hydration B. Amniotomy C. Oxytocin if A+B fail D. Wait long enough to see a response

128 Oxytocin usage 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 dilatation achieved Clinical response usually seen at dose levels of 8-10 mu/min

129 Reduction of risk of dystocia
Avoid induction for large fetal weight Avoid oxytocin use with unfavourable cervix Avoid admission to Labour and Delivery at <4cm dilatation “Management” of epidural at full dilatation Avoid immediate pushing after full dilatation


131 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

132 Cesarean section for dystocia
Timing of procedure Rate Latent phase 41% Active phase 38% Second stage 21% Source: Stewart CMAJ 1990:142;

133 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


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