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

3. INTRODUCTION

4. RISK SPECTRUM IN PREGNANCY
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

7. PERINATAL MORTALITY RATE
ONTARIO: 5/1000
Developing: 100/1000

8. MATERNAL MORTALITY Direct Deaths
Indirect deaths: < 42 days from delivery
Causes:
Hypertensive disorders
Pulmonary embolism
Anesthesia
Ectopic pregnancy
Amniotic fluid embolus
Hemorrhage
Sepsis

9. MATERNAL MORTALITY RATE
ONTARIO: 5/
Developing: 1000/

11. EARLY PREGNANCY

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

16. ANTENATAL CARE

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

28. TERATOGENS

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.

36. FETAL GROWTH AND WELL-BEING

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

45. BPD AC

46. BPD AC

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

49. IMMEDIATE NEONATAL MORBIDITY IN IUGR
Birth asphyxia
Meconium aspiration
Hypoglycemia
Hypocalcemia
Hypothermia
Polycythemia, hyperviscosity
Thrombocytopenia
Pulmonary hemorrhage
Malformations
Sepsis

50. CAUSES OF FETAL OVERGROWTH
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

52. EVALUATION OF WELL-BEING

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

60. NORMAL TRACE

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

67. MEDICAL COMPLICATIONS

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

70. ORAL GLUCOSE TOLERANCE TEST (OGTT)
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

76. HYPERTENSION

77. HYPERTENSION IN PREGNANCY
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

86. BREECH

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

88. MANAGEMENT OF BREECH PRESENTATION
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

91. MULTIPLE PREGNANCY

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

98. LABOR

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