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Phase 3B Bukky Olaitan and Rolla Ibrahim The Peer Teaching Society is not liable for false or misleading information…

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Presentation on theme: "Phase 3B Bukky Olaitan and Rolla Ibrahim The Peer Teaching Society is not liable for false or misleading information…"— Presentation transcript:

1 Phase 3B Bukky Olaitan and Rolla Ibrahim The Peer Teaching Society is not liable for false or misleading information…

2 Normal Labour Complications – Multiple Pregnancy – Abnormal fetal presentations Emergencies – Shoulder dystocia – Cord Prolapse – Amniotic Fluid embolism – Uterine Rupture Prematurity, postmaturity and puerperium The Peer Teaching Society is not liable for false or misleading information… Aims

3 Process whereby fetus and placenta are expelled from uterus. Normally between 37 and 42 weeks gestation When is diagnosis made? – Painful uterine contractions accompany dilatation and effacement of the cervix. 3 stages The Peer Teaching Society is not liable for false or misleading information… Normal Labour

4 Mechanical factors – Powers – degree of force expelling fetus – Passage – Dimension of pelvis and resistance of soft tissues – Passengers – Diameter of fetal head The Peer Teaching Society is not liable for false or misleading information… Labour - Anatomy

5 Uterine contractions Braxton Hicks occur after 30 th week and can be palpated. Causes cervical dilatation (1 st stage and then expulsion 2 nd and 3 rd stages) Effacement – Incorporation of cervix into lower uterine segment Poor uterine activity – Nulliparous – Induced labour The Peer Teaching Society is not liable for false or misleading information… Labour - Powers

6 What is: – Effacement? – Lie? – Presentation? – Station? – Attitude? – Rotation? The Peer Teaching Society is not liable for false or misleading information… Labour

7 Which three of the following are true? – A) The lie of the fetus describes the relationship of the fetus to the long axis of the uterus – B) Presentation refers to the part of the fetus that occupies the lower segment of the uterus or pelvis – C) Abnormal lie occurs in 1 in 200 births – D) Preterm labour is less commonly complicated by an abnormal lie than labour at full term – E) Unstable lie in nulliparous women is common – F) In an extended breech the feet are presenting A, B and C are true The Peer Teaching Society is not liable for false or misleading information… Labour

8 Bony Pelvis – Inlet – Mid cavity – Outlet Ischial spine – Used to assess descent (station) Soft Tissues – Cervical dilatation – Vagina and perineum need to be overcome in second stage The Peer Teaching Society is not liable for false or misleading information… Labour - passages

9 Regarding the normal bony pelvis: which three of the following are true? – A) The inlet of the pelvis is widest in its AP diameter at about 11cm – B) The mid-cavity is almost round, as the transverse and AP diameter are roughly similar – C) At the outlet, the AP diameter is about 12.5cm – D) Station 0 means the head is at the level of the ischial spines, approximately mid-cavity – E) Station is documented as +/-1, 2, 3; +2 means the head is 2cm above the spines – F) The coccyx may cause obstruction B, C and D The Peer Teaching Society is not liable for false or misleading information… Labour - passages

10 The Peer Teaching Society is not liable for false or misleading information… Labour - passages

11 Attitude and position of the fetal head: which four of the following are true? – A) Attitude is the degree of flexion of the head on the neck. The ideal attitude is maximal extension, keeping the head bowed. – B) Maximal flexion is called vertex presentation and the presenting diameter is 9.5 cm. – C) Extension of 90° results in brow presentation, and a much larger diameter of 13 cm. – D) 120° of extension from the vertex position results in face presentation. – E) The head must normally rotate 90° during labour. – F) The head usually delivers in the occipito-posterior position (OP). B,C, D and E The Peer Teaching Society is not liable for false or misleading information… Labour - Passenger

12 Head is oblong in transverse section and bones not fused yet so moulding can occur. Attitude – Degree of flexion of head on neck (ideally maximal flexion – vertex presentation) – Extension/flexion Presentation – Part of fetus that occupies the lower segment or pelvis – head (cephalic) or breech The Peer Teaching Society is not liable for false or misleading information… Labour - Passenger

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

14 Presentation – Part of fetus that occupies the lower segment or pelvis – head (cephalic) or breech Position: Rotation – Degree of rotation of head on neck The Peer Teaching Society is not liable for false or misleading information… Labour -Passenger

15 Stages of Labour 1.Initiation to full cervical dilatation (10cm) Latent phase – Slow dilation up to 3cm Active phase – Up to full dilatationAvg 1cm/h (nulliparous), 2cm/hr (multiporous). 2.Full cervical dilatation to delivery of fetus Passive - full dilatation till head reaches pelvic floor, woman then feels desire to push Active – Mother pushing – Beware epidurals! 3.Delivery of fetus to delivery of placenta Traditional/expectant or active management Normally 15 mins <500mL blood loss normal The Peer Teaching Society is not liable for false or misleading information… Stages of Labour

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

17 Progress in labour: problems and their treatment: which two of the following are true? – A) The partogram aids identification of abnormal progress. – B) Cephalo-pelvic disproportion is the most common cause of slow progress in labour. – C) When hyperactive uterine contractions are associated with vaginal bleeding and fetal heart rate abnormalities, tocolysis should be given. – D) In a multiparous woman, if descent is poor in the second stage, an oxytocin infusion should be started and pushing delayed by up to 2 hours. – E) Epidural analgesia is associated with an increased risk of instrumental delivery. – F) Occipito-posterior position in the first stage of labour should be identified so that oxytocin can be given. A and E The Peer Teaching Society is not liable for false or misleading information… Management of Labour

18 General care – Physical health – Mental health Progress in labour – Partogram – records progress in dilatation of cervix (+/- descent of head) – Powers Inefficient uterine action Hyperactive uterine action The Peer Teaching Society is not liable for false or misleading information… Management of Labour

19 The Peer Teaching Society is not liable for false or misleading information… Management of Labour

20 Nulliparous – First stage Slow progress – Augmentation via ARM/amniotomy or artificial oxytocin. If no full dilatation after 12-16hr then C-section – Passive second stage Poor descent – oxytocin infusion – Active second stage If lasts longer than 1hr, spontaneous delivery unlikely due to maternal exhaustion, fetal hypoxia. – Episiotomy, ventouse or forceps. Multiparous – Unlikely to be problems with powers in first stage, more likely to be problems with fetal head. – Careful with augmentation with oxytocin. The Peer Teaching Society is not liable for false or misleading information… Management of Labour

21 Problems with Passage – Cephalo-pelvic disproportion – extremely rare – Pelvic variants and deformities The Peer Teaching Society is not liable for false or misleading information… Management of Labour

22 Care of fetus – Intrapartum problems – meconium aspiration, fetal blood loss, trauma, infection (Group B Strep) Fetal distress = hypoxia that might result in fetal damage or death if not reversed or fetus delivered urgently – Diagnosis – colour of meconium, fetal heart rate auscultation (every 15 mins in 1 st stage, every 5 mins in 2 nd stage), CTG, Fetal Ecg monitoring, Fetal blood (scalp) sampling The Peer Teaching Society is not liable for false or misleading information… Management of Labour

23 Dr C Bravado – Define Risk – Contractions per 10 mins (normal <5) – Baseline Rate – normal bpm Tachycardia – fever, fetal infection or hypoxia (in conjunction with other abnormalities) Steep, sustained deterioration in rate suggests acute fetal distress – Variability – Variation in fetal heart rate should be >5bpm Prolonged reduced variablity suggests hypoxia – Accelerations – With movements or contractions are reassuring! – Decelerations – Early, variable and late – Overall assessment The Peer Teaching Society is not liable for false or misleading information… CTG

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

25 Fetal Distress Management – Level 1: Intermittent auscultation of fetal heart, if abnormal or indicated proceed to – Level 2: continuous CTG If sustained bradycardia deliver If other abnormalities attempt to correct, if fails proceed to – Level 3: Fetal blood sampling. If abnormal – Level 4: Delivery by quickest route The Peer Teaching Society is not liable for false or misleading information… Management of labour

26 Pain relief in labour – Non medical – Entonox (nitrous oxide and oxygen) – Systemic opiates IM Can be PCA Antiemetics needed Epidural anaesthesia (pros and cons) The Peer Teaching Society is not liable for false or misleading information… Management of Labour

27 First degree: Injury to skin only Second degree: Involving perineal muscles but not anal sphincter Episiotomy: Equivalent to second degree, may extend to 3 rd /4 th Third Degree: Involving anal sphincter – 3a: <50% external anal sphincter torn – 3b: >50% external anal sphincter torn – 3c: Internal anal spincter also involved Fourth Degree: Involving anal sphincter and anal epithelium 1 st and 2 nd can be sutured using local anaesthetic, 3 rd /4 th requires epidural or spinal and physiotherapy. The Peer Teaching Society is not liable for false or misleading information… Perineal Trauma

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

29 Which of the following does NOT increase your risk of multiple pregnancies – FHx of monozygotic twins – Increased maternal age – Induced ovulation – IVF – Japanese Women Ans: Family history of monozygotic twins Its family history of dizygotic twins The Peer Teaching Society is not liable for false or misleading information… Question 1

30 Incidence – Twins 3/200 Triplets 1/10’000 Predisposing factors – FH of dizygotic twins – Increased maternal age – Induced ovulation, IVF – Race – Japanese and Nigerian Yoruba women The Peer Teaching Society is not liable for false or misleading information… Multiple Gestation

31 ‘Chorionic’  Placenta ‘Amnionic’  Amniotic sac Dizygotic/Faternal twins – 2/3rds of twins – Derived from 2 different eggs  2 different zygotes Monozygotic twins – 1/250 – Occur at constant rate worldwide – Derived from 1 separate egg The Peer Teaching Society is not liable for false or misleading information… Termanology

32 Name the following The Peer Teaching Society is not liable for false or misleading information… Question 2 ANS: Monoamniotic Monochorionic

33 Name the following The Peer Teaching Society is not liable for false or misleading information… Question 3 ANS: Diamnionic Dichorionic

34 Dichorionic twins – Thick chorionic intertwin septum – Separated on either side by a thin layer of amnion Monochorionic twins – Thin midline septum The Peer Teaching Society is not liable for false or misleading information… Multiple Pregnancies

35 Puking Pallor (anemia) Pre-elampsia Pressure – compressive symptoms Preterm Labor, Prolonged Rupture of membranes, Premature Prolonged rupture of membranes Polyhydramnios The Peer Teaching Society is not liable for false or misleading information… Complications: the P’s Cord Prolapse Prematurity Mal Presentation Perinatal Morbidity and mortality Parental distress Postpartum despression

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

37 How often do you ultrasound multiple pregnancies? – Monthly from presentation – Monthly from 20 weeks – Biweekly from 20 weeks – Monthly from 28 weeks – Weekly during last trimester Ans: Monthly during 20 weeks The Peer Teaching Society is not liable for false or misleading information… Question 4

38 When would you offer an elective birth? – 39 weeks – 42 weeks – 37 weeks – 35 weeks Ans: 37 weeks The Peer Teaching Society is not liable for false or misleading information… Question 5

39 Ultrasound – 11 to 13+6wks – Viability, chorionicity, nuchal translucency, malformation FBCat weeks Monthly US from 20 weeks Refer if – Discordant growth of >25% – Fetal anomaly – Monochronionic Monoamniotic The Peer Teaching Society is not liable for false or misleading information… Management

40 What is the commonest complication of multiple pregnancy – Down’s syndrome – Prematurity – Prolapsed cord – IUGR – Miscarriage Ans: prematurity The Peer Teaching Society is not liable for false or misleading information… Question 6

41 10% monochorionic twins Concern if >30% discordance in estimated fetal weight Etiology – Arterial blood flow form donor goes through placenta to vein of recepient The Peer Teaching Society is not liable for false or misleading information… Twin-Twin Transfusion

42 Donor Twin IUGR Oligohydramnios Hypovolemia Hypotension Anemia Recipient Polyhydramnios Hypertension Polycythemia Oedema Kernicterus in neonatal period CHF The Peer Teaching Society is not liable for false or misleading information… Complications

43 Doppler analysis flow for diagnosis Therapeutic amniocentesis to decrease polyhydramnios for recipient Intra-uterine blood transfusion if needed Laprascopic occlusion of placental vessels The Peer Teaching Society is not liable for false or misleading information… Management

44 Shoulder dystocia: which three of the following are true? – A The obstruction is at the pelvic outlet. – B The incidence is about 1 in 200 deliveries. – C Can be prevented in the majority of cases. – D Maternal diabetes is a risk factor. – E The most effective treatment is strong, sustained traction on the neck. – F Many affected babies are of normal birth weight. B, D and F The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

45 Shoulder Dystocia – Failure of shoulder to deliver – 1 in 200 deliveries – Can cause: Erb’s palsy (Brachial plexus damage), or clavicle or humerus fracture – Risk factors – Large baby, previous socal dystocia, increased maternal BMI, labour induction – Management – Rapid and skilled intervention The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

46 Shoulder Dystocia The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

47 Cord prolapse: which three of the following are true? – A Cord prolapse occurs when the cord is felt through intact membranes. – B Occurs in 1 in 5000 deliveries. – C Risk factors include preterm labour, breech presentation, abnormal lie and twin pregnancy. – D More than half occur at artificial amniotomy. – E Initial management is to elevate the presenting part to prevent cord compression, followed by expedited delivery. – F Is a common cause of intrapartum stillbirth. C,D and E The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

48 Cord Prolapse – Umbilical cord descends below presenting part – 1 in 500 deliveries – Can cause compression or spasm of cord => hypoxia – Risk Factors – preterm labour, breech presentation, polyhydroamnios, abnormal lie, twin pregnancy – Mx – prevent compression of cord. C-section The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

49 Amniotic fluid embolus: which four of the following are true? – A It can present with sudden dyspnoea, hypoxia or hypotension. – B Occurs in 1 in pregnancies and as such is not a significant cause of mortality. – C Disseminated intravascular coagulation, pulmonary oedeema and adult respiratory distress syndrome (ARDS) develop rapidly in those who survive the initial 30 minutes. – D Once the patient is stabilized a hysterectomy is normally performed. – E It can occur at any time during pregnancy. – F It is a cause of postpartum haemorrhage. A, C, E and F The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

50 Amniotic Fluid Embolism – Liquor enters maternal circulation => anaphylaxis with sudden dyspnoea, hypoxia and hypotension, often accompanied by seizures and cardiac arrest. – Causes DIC, pulmonary oedema and ARDS – Rare but high mortality rate – Usually occurs when membranes rupture, can happen at labour, C-section or TOP – DDx – Eclampsia – Mx – Resuscitation and supportive treatment O2, Fluid, bloods (clotting, FBC, electrolytes, cross-match), blood and FFP. ICU The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

51 Uterine Rupture – 1 in 1500 pregnancies – Causes: de novo, old scar (e.g C-section) – Signs: fetal heart rate abnormalities, constant lower abdo pain, vaginal bleeding, cessation of contractions, maternal collapse – Fetus extruded, bleeding, acute fetal hypoxia, massive internal maternal haemorrhage – Risk Factors: labours with scarred uterus: classical c-section or deep myomectomy, neglected obstructed labout (developing countries) – Mx – Maternal resuscitation, urgent laparotomy for delivery of fetus – High recurrence rate in subsequent pregnancies. The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

52 Uterine Inversion – Fundus inverts into uterine cavity – From traction on placenta – 1 in deliveries – Mx: GA, replacement with hydrostatic pressure, several litres warm saline Epileptiform seizures – Maternal epilepsy or eclampsia or hypoxia – Clear airway, give O2, diazepam if epilepsy, MgSO4 if ecmlapsia Local anaesthetic toxicity Massive antepartum Haemorrhage Massive Postpartum Haemorrhage Pulmonary embolus The Peer Teaching Society is not liable for false or misleading information… Obstetric Emergencies

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

54 What is the difference between induction and augmentation? Induction – artificial initiation of labour Augmentation – promotes contractions when spontaneous contractions are inadequate The Peer Teaching Society is not liable for false or misleading information… Question 1

55 What is a ‘ripe’ cervix? Soft, short, thin, anterior cervix with open OS The Peer Teaching Society is not liable for false or misleading information… Question 2

56 Prerequisites Capability for CS if necessary Fetal – Cephalic lie – Normal fetal heart tracing Maternal – Soft, short, thin, anterior cervix with open os – If not ripe  prostaglandin vaginal insert, gel, or Foley catheter The Peer Teaching Society is not liable for false or misleading information… Induction of Labour

57 What are the 5 cervical characteristics of the Bishop Score? – Effacement – Position – Consistency – Dilation – Fetal lie The Peer Teaching Society is not liable for false or misleading information… Question 3

58 Post-date pregnancy  >41wks Fetal factors – Fetal demise, IUGR – Any suspecion of fetal jeopardy Maternal-fetal factors – Premature rupture of membranes, isoimmunization, chorioamnionitis Maternal factors – Significant medical problem – HTN, eclampsia, renal disease – Sigificant antepartum hemorrhage The Peer Teaching Society is not liable for false or misleading information… Indications

59 Which of the following is NOT a contraindication for induction of labour? – Cephalopelvic disproportion – Fetal distress – Cord presentation – Breech presentation – Pelvic tumour Ans: Breech presentation Also contraindicated: placenta praevia, previous repair to cervix The Peer Teaching Society is not liable for false or misleading information… Question 4

60 Failed induction – 15% Uterine hyperstimulation – 1-5% Iatrogenic prematurity Infection Bleeding Cord prolapse e.g. high head at amniotomy CS 22% Instrumental delivery 15% Uterine rupture - rare The Peer Teaching Society is not liable for false or misleading information… Complications

61 Cervical ripening – Must be done first if Bishop’s score <6 – Intravaginal prostaglandin – Foley catheter – manual dilation Induction – Amniotomy  rupture of membrane – Monitor fetal heart rate – Oxytocin IV with 5% dextrose If cervix dilated 5cm, more sensitive Start with 1-4MU/min, increase every 30mins The Peer Teaching Society is not liable for false or misleading information… Methods

62 When is misoprostol used? – NICE – after intrauterine death Why? – Route and dose for labour induction with a live fetus are not known and there are concerns regarding hyperstimulation The Peer Teaching Society is not liable for false or misleading information… Question 5

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

64 You see a pregnant woman at 14 weeks gestation. She has a history of preterm pregnancy at 33 weeks. You perform a vaginal swab and its positive for bacterial vaginosis, but she is asymptomatic. What is the appropriate management? – Oral metronidazole – Vaginal clindamycin – No treatment, she’s asymptomatic – Oral tinidazole – IV ceftriaxone Ans: Oral metronidazole. Significant link between BV and preterm labour. Possible links to miscarriages, low birth weight, and PROM. Clindamycin cream avoided during 2 nd half of pregnancy  premature birth. Metronidazole contraindicated in first trimester. The Peer Teaching Society is not liable for false or misleading information… Question 1

65 The following is NOT a risk factor for preterm labour – Untreated bacteriuria – Previous abdominal surgery – Single pregnancy – Polyhdramnios – Fetal hydrops Ans: Single pregnancy The Peer Teaching Society is not liable for false or misleading information… Question 2

66 Labour occurring between 20 to 37 weeks gestation Etiology Idiopathic – 40% Maternal-fetal – PPROM, polyhydramnios, multiple pregnancies, Placenta previa or abruption, placental insufficiency Fetal – chromosomal abnormalities – Fetal hydrops  abnormal build of fluid in 2 or more body areas  sign of underlying disease The Peer Teaching Society is not liable for false or misleading information… Prematurity

67 Maternal causes Infection – recurrent pyelonephritis, untreated bacteriuria, chorioamnionitis Infection Genital infection – BV associated with 2X increase risk Illness – HTM, DM, chronic illness Previous obs/gyn or abdo surgery Social factors – Smoking, alcohol, drugs, stress, poor nutirion The Peer Teaching Society is not liable for false or misleading information… Prematurity

68 What is the most important risk factor for preterm labour? – Bacterial vaginosis – Fetal fibronectin – Previous pre-term labour – Cervical length Ans: Previous preterm labour All of these are risk factors, but the most important one is previous Fetal fibronectin – glycoprotein in amniotic fluid. Fx – maintain chorionic-decidual interfase. If present in high amounts and short cervix, pre-term labour likely The Peer Teaching Society is not liable for false or misleading information… Question 3

69 Initial – Hydration, bedrest. Avoid repeated pelvic exam – increased risk of infection – Ultrasound – GA, position, placenta, estimate weight Suppress labour  Tocolysis – Prostaglandin synthesis inhibitors  indomethacin – Calcium channel blockers  Nifedipine – Requirements Preterm labour Live, immature fetus, intact membranes, cervical dilatation <4cm The Peer Teaching Society is not liable for false or misleading information… Management

70 Which of the following is NOT an absolute contraindication for tocolytics? – Fetal death – Chorioamnionitis – Pre-eclampsia – Maternal condition close to death Ans: Pre-eclampsia Absolute CIs as above Relative: pre-eclampsia, placenta previa, cervix >4cm, pulmonary oedema, fluid overload The Peer Teaching Society is not liable for false or misleading information… Question 4

71 Why would a corticosteroid be used in preterm birth? To help fetal surfactant production Which one? Betamethasone or Dexamethasone The Peer Teaching Society is not liable for false or misleading information… Question 5

72 28-34 wks  reduce risk of RDS 24-28wks  reduces severity of RDS, overall mortality and rate if IVH Help close patent ductuses and protect periventricular malacia, which can cause cerebral palsy Caution: – Systemic infection – TB maternal sepsis, chorioamnionitis – Diabetic The Peer Teaching Society is not liable for false or misleading information… Glucocorticoid

73 Cervcical sutures at the internal OS. Usually at the end of the first trimester and removed in the third trimester Indications – Cervical incompetence Diagnosis – Obstetric hx – silent cervical dilation – Ability of cervix to hold inflated Foley during hysterosonogram The Peer Teaching Society is not liable for false or misleading information… Cervical cerclage

74 Premature rupture of membranes Rupture of membranes prior to labour at any GA Prolonged ROM >24hrs elapsed between ROM and onset of labour Preterm ROM ROM before 37wks PPROM Rupture of membranes before 37wks AND prior onset of labour The Peer Teaching Society is not liable for false or misleading information… Question 6 – Definitions!

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

76 The Peer Teaching Society is not liable for false or misleading information… Question 1

77 Frank breech - 60% – Most common breech presentation to be delivered vaginally Complete breech – 10% Footling breech – 30% The Peer Teaching Society is not liable for false or misleading information… Breech

78 Bukky: Rolla: The Peer Teaching Society is not liable for false or misleading information… Thank you!


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