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Phase 3B Bukky Olaitan and Rolla Ibrahim

Obstetrics II. Phase 3B Bukky Olaitan and Rolla Ibrahim. The Peer Teaching Society is not liable for false or misleading information…. Aims. Normal Labour Complications Multiple Pregnancy Abnormal fetal presentations Emergencies Shoulder dystocia Cord Prolapse Amniotic Fluid embolism

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Phase 3B Bukky Olaitan and Rolla Ibrahim

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

  2. Aims • 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…

  3. Normal Labour • 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…

  4. Labour - Anatomy • 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…

  5. Labour - Powers • Uterine contractions • Braxton Hicks occur after 30th week and can be palpated. • Causes cervical dilatation (1st stage and then expulsion 2nd and 3rd 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…

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

  7. Labour • 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…

  8. Labour - passages • 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…

  9. Labour - passages • 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…

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

  11. Labour - Passenger • 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…

  12. Labour - Passenger • 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…

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

  14. Labour -Passenger • 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…

  15. Stages of Labour • Stages of Labour • 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). • 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! • 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…

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

  17. Management of Labour • 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…

  18. Management of Labour • 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…

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

  20. Management of Labour • 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…

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

  22. Management of Labour • 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 1st stage, every 5 mins in 2nd stage), CTG, Fetal Ecg monitoring, Fetal blood (scalp) sampling The Peer Teaching Society is not liable for false or misleading information…

  23. CTG • Dr C Bravado • Define Risk • Contractions per 10 mins (normal <5) • Baseline Rate – normal 110-160 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…

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

  25. Management of labour • 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…

  26. Management of Labour • 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…

  27. Perineal Trauma • First degree: Injury to skin only • Second degree: Involving perineal muscles but not anal sphincter • Episiotomy: Equivalent to second degree, may extend to 3rd/4th • 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 • 1st and 2nd can be sutured using local anaesthetic, 3rd/4th requires epidural or spinal and physiotherapy. The Peer Teaching Society is not liable for false or misleading information…

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

  29. Question 1 • 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…

  30. Multiple Gestation • 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…

  31. Termanology • ‘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…

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

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

  34. Multiple Pregnancies • 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…

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

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

  37. Question 4 • 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…

  38. Question 5 • 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…

  39. Management • Ultrasound • 11 to 13+6wks • Viability, chorionicity, nuchal translucency, malformation • FBCat 20-24 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…

  40. Question 6 • 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…

  41. Twin-Twin Transfusion • 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…

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

  43. Management • 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…

  44. Obstetric Emergencies • 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…

  45. Obstetric Emergencies • 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…

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

  47. Obstetric Emergencies • 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…

  48. Obstetric Emergencies • 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…

  49. Obstetric Emergencies • 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 80 000 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…

  50. Obstetric Emergencies • 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…

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