Obstetrics

last menstrual period

number of times a woman has been pregnant, regardless of outcome

number of times a woman has had pregnancies that have carried over the threshold of viability [-24 weeks]

painful periods

pain during sex, can be superficial or deep

lateral = ovarian arteries from the abdominal aorta

medial = ascendary branch of uterine artery from the internal iliac artery

global term of all the structures that make up the external female genitalia

hypothalamus releases GnRH to the anterior pituitary gland which releases LH and FSH. These two stimulate the development of the folicles in the ovaries, the theca granulosa. This releases oestrogen which inhibits GnRH release.

promotes female secondary sexual characteristics:
breast tissue development, growth / development of female sex organs at puberty, blood vessel development in the uterus, development of the endometrium

provided by the corpus luteum after ovulation. It thickens / maintains endometrium, thickens cervical mucus and increases body temperature

12 weeks or less = 1st trimester
13 weeks to 27 weeks = 2nd trimester
28 weeks onwards = 3rd trimester

booking usually around less than 11 weeks. First scan is usally in first trimester, anomaly scan is offered routinely in 2nd trimester. Usually around 10 antenatal visits for 1st pregnancy and 7 for subsequent pregnanies

usually identifying risk factors, general information like diet, alcohol, smoking, folic acid, BP, urine dipstick, BMI

Also can do bloods for FBC, group save, rhesus status, haemoglobinopathies, hepatitis, HIV test offered.

Downs syndrome screening can also be around this time

offered but no compulsory. it is an invasive procedure so carries the risk of miscarriage

Combined test is the standard which involves an US [nuchal translucency meansurement] and maternal blood tests

offer tests include the triple test [b-hCG, alpha fetoprotein, serum oestriol] and the quadruple test which involves inhibin-A added on

if the score of the foetus having Downs is more than 1 in 150, then aminocentesis or chorionic villous sampling is offered.

Non-invasive prenatal testing is being offered more and more now

baby shows signs of alcohol withdrawal at birth [hypotonic, irritation, tremors].
Can lead to learning difficulties, microcephaly, growth retardation, cardiac malformations, short palebral fissures, epicanthic folds

whooping cough from 16 weeks gestation, influenza when available

live vaccines like MMR are avoided

increase in thyroxine binding globulin levels which leads to increase in total thyroxine.

Hypothyroidism untreated can lead to miscarriage, anaemia, pre-eclampsia, SGA. Levothyroxine is given

Hyperthyroidism untreated can lead to premature labour, foetal loss, maternal HF. Treat by propylthiouracil in 1st trimester, carbimazole in 2-3rd trimester. Aim is for free T4 levels to be kept in upper third of normal ranges

ideally, epilepsy should be controlled with a single anti-epileptic before becoming pregnant. Pregnancy can make seizure control worse. Avoid Sodium valproate [NTD risk] and phenytoin. 5mg folic acid daily to avoid NTD. Safer drugs are levetiracetam, lametrigine, carbamezepine

ideally, arthritis is well controlled for more than 3 months before pregnancy. usually sx of RA will improve during pregnancy and flare up after delivery.

hydroxychloroquine and sulfasalzine are safe. corticosteroids given for flare ups. Avoid methotrexate and advise to stop 6 months before conception.

NSAIDs block prostaglandins which are needed to maintain ductus arteriosus and stimulate uterine contractions. Uusally avoided unless very necessary and especially avoided in 3rd trimester as they can cause premature closure of ductus arteriosus and delay labour

used for HPTN, cardiac problems, migraine. Labetalol is the ideal one used to treat pre-eclampsia

can case FGR, hypoglycaemia / bradycardia in neonates

these can cross placenta and affect foetus kidneys, leads to less urine production. This can lead to miscarriage / foetal death, oligohydramnios, renal failure / hypotension in neonates, hypocalvaria [incomplete small bone formation]

can cause neonatal abstinence syndrome which leads to withdrawal sx in neonates after birth. Presents in 3-72hrs after birth with irritability, tachypnoea, high temperature and poor feeding

crosses placenta and is teratogenic in pregnancy. can cause foetal loss, congenital malformations and leading during pregnancy

mood stabiliser for bipolar px, mania or recurrent depression. avoided in pregnant women unless all other options have failed, and needs close monitoring of lithium levels every 4 weeks until 36 weeks where it is weekly. Avoided in breastfeeding and 1st trimester due to congential cardiac problems risk

these can cross the placenta. need to balance risks vs benefits. congenital heart defects if used in 1st trimester and risk of persistent pulmonary HPTN in neonates if used in 3rd trimester

if mother is rhesus D +ve = no Tx

if mother is rhesus D -ve, consider baby is +ve which can lead to antibodies formation. The 1st pregnancy will be fine but subsequent pregnancies will lead to haemolytic disease of the newborn

Needs early prophylaxis via anti-D injections usually at 28 weeks Gest and at birth if baby is +ve.

checks how much foetal blood has passed into mothers during a sensitisation event [antepartum haemorrhage, amniocentesis procedure, abdo trauma]. Assesses if further doses of anti-D are needed.

defined as a foetus below 10th centile for their gestational age. Severe is below 3rd centile

based on US using estimated foetal weight and foetal abdominal circumference. Customised growth charts are used to assess the size of the foetus which are based on the mother’s height, weight, parity, ethnicity

can be constitutionally small due to mother OR be due to FGR

Placenta mediated growth restriction: idiopathic, pre-eclampsia, maternal smoking / alcohol, malnutrition, infection

Non-placenta mediated growth restriction: genetic, structural, errors of metabolism

oligohydramnios, abnormal doppler, reduced foetal movements, abnormal CTGs

Short term: foetal death / stillbirth, birth asphyxia, neonatal hypothermia / hypoglycaemia

Longer term: CVS disease, T2DM, obesity, mood / behaviour problems

previous SGA, obesity, smoking, diabetes, HPTN, older than 35

multiple pregnancies, low PAPPA, antepartum haemorrhage, antiphospholipid syndrome

if below 10th centile, woman is booked for serial growth scans with umbilical artery doppler scan. They are also booked for this if they have 3 or more minor RFs, 1 or more major RFs OR issues measuring symphysis fundal height [obese / large fibroids]

more than 4.8kg at birth or higher than 90th centil during pregnancy

shoulder dystocia, failure to progress, perineal tears, Caesarean or instrumental delivery, PPH, uterine rupture

birth injury [foetal distress, hypoxia], neonatal hypoglycaemia, obesity in childhood, T2DM in adulthood

mono means identical twins, dizygotic means non-identical twins due to two different ovas being fertilised at the same time

just how many amniotic sacs there are

if they share one placenta or two separate placentas

this is seen in dichorionic diamniotic twins. The inter-twin membrane will be between the twins in a lamda shape

seen in monochorionic diamniotic twins. will see an abrupt membrane across the shared placenta

occurs when foetuses share a placenta. The connection of blood supples between the two foetuses may lead to one foetus receiving the majority of blood from the placenta whilst the other one is starved. The recipient foetus can become fluid overloaded, leading to HF and polyhydramnios. Donor foetus can have FGR, anaemia, olgohydramnios.

You will see a difference in the size of foetuses and px need to referred to tertiary specialist foetal medicine centre

essentially twin-twin transfusion syndrome but less acute. one foetus will be anaemic, the other is polycythaemic

additional monitoring for anaemia with FBC at booking clinic, 20 and 28 weeks.

Additional US needed as well. 2 weekly scans from 16 weeks onwards for monochorionic. 4 weekly scans from 20 weeks for dichorionic

offered between:

32-33+6 for uncomplicated monochorionic monoamniotic
36-36+6 for uncomplicated monochorionic diamniotic twins
37-37+6 for uncomplicated dichorionic diamniotic twins
Before 35+6 for triplets

waiting beyond these dates is associated with increased foetal death risk

monoamniotic = elective C section at 32-33+6

Diamniotic can try vaginal delivery IF first baby is cephalic. C section otherwise

usually caused by e.coli, others include klebsiella, enterococcus, pseudomonas aeruginosa

Management: 7 DAYS ABX
1st line: cefalexin / amoxicillin
2nd line: nitrofurantoin [avoid near term]
3rd line: Fosfomycin [used if allergic to 1st line or resistant]
4th line: trimethoprim [avoided in 1st trimester]
5th line: co-amoxiclav [can cause necrotising enterocolitis]

viral infection caused by togavirus. risk is highest in first 8-10 weeks. features in neonate include congenital deafness, cataracts, heart disease and learning disabilities. IgM antibodies will be raised in women recently exposed to virus. MMR vaccination is offered UNLESS during pregnancy where it is offered post-natally

caused by VZV. it is more dangerous in pregnancy because it can lead to fetal varicella syndrome and more severe cases in mother like varicella encephalitis. neonatal affects include FGR, microcephaly, learning disabilities, skin changes in specific dermatomes. Test for IgG in mother.

VZIG can be given as soon as possible if before 20 weeks gestation and not immune. If after 20 weeks, offer oral aciclovir days 7-14 after explosure

transmitted via unpasteurised dairy products, processed meats. Advise women to avoid eating these. Can lead to increased risk of miscarriage, foetal death, severe neonatal infection

spreads via infected urine, occurs due to CMV infection in mother during pregnancy. Can lead to FGR, microcephaly, learning disability, seizures, hearing / vision loss

cause is toxoplasma gondii parasite. spread via faeces of cats. Features include intracranial calcification, hydrocephalus, chorioretinitis

usually affects children and is self-limiting. Features include viral sx, “slapped cheeks” rash, reticular erythematous rash affecting trunk and limbs. Risk of miscarriage, severe fetal anaemia, Hydrops fetalis [fetal HF]. Investigate via IgM [acute] or IgG [chronic], supportive management

foetal anaemia caused by parovirus infection of erythroid progenitor cells in foetal bone marrow. Causes faulty RBCs to be formed which results in heart failure.

Will need intrauterine blood transufions and can lead to maternal pre-eclampsia-like syndrome [triad of hydrops fetalis, placental oedema and oedema in mother]

at booking clinic and 28 weeks gestation

Plasma volume increases during pregnancy which results in a reduction in haemoglobin concentration. Important to optimise the Tx so that the woman has reasonable reserves in case there is significant blood loss during delivery.

Haemoglobin concentration, MCV looked at, haemoglobinopathy screening offered as well for thalassaemia and sickle cell disease

Cut off is below 110 Hb. Give Ferrous sulphate 200mg 3 times a day. Intramuscular hydroxycobalamin injection for low B12 levels

smoking, parity of 3 or above, age over 35, BMI over 30, reduced mobility, multiple pregnancy, pre-eclampsia, immobility, FHx, thrombophilia, IVF pregnancy

increase in factors 7,8,10, fibrinogen

decrease in protein S

Uterus presses on IVC leading to venous stasis

28 weeks if there are 3 RFs

1st trimester if there are 4 or more RFs

there are many other situations as well like if they have had a previous VTE, hosital admission and surgical procedures

Depends on policy and protocol but usually a LMWH unless contraindicated and continued until 6 weeks postnatally. Prophylaxis is temporarily stopped when women goes into labour and is started immediately after delivery [except in PPH, spina anaesthesia and epidurals].

If CI to LMWH = use mechanical prophylaxis like intermittent pneumatic compressions or anti-embolic compression stockings

diabetes triggered by pregnancy due to a decrease in insulin sensitivity during pregnancy, resolves after birth.

Usually leads to macrosomia which increases risk of shoulder dystocia OR T2DM longer term

previous gestational diabetes, BMI over 30, ethnicity, FHx of diabetes, previous macrosomic baby

OGTT for all pregnant women with RFs at 24-28 weeks. Diagnosed as higher than 5.6 fasting glucose and 7.8 2hr post glucose levels

Education about condition, how to monitor and track blood sugar levels.

If fasting glucose is below 7, diet and exercise escalating to metformin and insulin

If fasting is above 7, insulin straight away

Glibenclamide is used if patients refuse insulin or are unable to tolerate metformin

the reduction in outflow of bile acids from the liver with the condition resolving after the delivery of the baby. Usually develops in the 3rd trimester

pruritus of the hands / soles of feet, fatigue, dark urine, pale / greasy stools, jaundice. NO RASH INVOLVED

monitor LFTs during and after pregnancy. Ursodeoxycholic acid is the primary Tx. Emollients can be used for itching and water soluble vitamin K for prothrombin time

usually occurs in 3rd trimester.
Long-chain-3-hydroxyacyl-CoA dehydrogenase [LCHAD] deficiency [autosomal recessive] is the most common cause. LCHAD is a important enzyme to break down fatty acids for fuel. A deficiency leads to a build up of fatty acids within the liver leading to acute hepatitis

obstetric emergency so it needs prompt admission and delivery of baby. most px will recover after delivery. There is a chance of acute liver failure which can lead to liver transplant consideration

when the placenta is attached in the lower portion of the uterus, lower than the presenting part of the uterus which can lead to blocking the internal cervical OS. One of the causes of antepartum haemorrhage

previous C-sections [embryo more likely to embed into scar], previous placenta praevia, older maternal age, maternal smoking, structural uterine abnormalities, assissted reproduction

usually ASx, may present with painless vaginal bleeding in pregnancy, no pain, uterus is not tender, foetal heart normal

20 week anomaly scan used to assess the position of the placenta and diagnose placenta praevia.

Do not do a digital vaginal exam before a transvaginal US as it may provoke a severe haemorrhage

if diagnosed before 20 weeks, repeat scan at 32 weeks. If present again, repeat scan at 36 weeks.

Plan delivery at 36-37 weeks. C-section is required with different incisions maybe being done.

When the foetal blood vessels are placed over the internal cervical OS leading to them being prone to bleeding when membranes are ruptured. This can be caused by Velamentous umbilical cord [where the umbilical cord inserts into the chorioamniotic membranes, leaving the foetal vessels unprotected] OR an Accessory lobe of the placenta

low lying placenta, IVF pregnancy, multiple pregnancy

diagnosed via US but this isnt reliable. Uusally presents with antepartum haemorrhage around 2nd / 3rd trimester with fetal bradycardia being seen.

Vaginal examination during labour may show pulsating fetal vessels through dilated cervix.

for ASx women, elective C-section planned for 34-36 weeks with corticosteroids from 32 weeks to mature the fetal lungs

antepartum haemorrhage = emergency c sections

when the placenta separates from the wall of the uterus during pregnancy. Bleeding can occur in this space which leads to antepartum haemorrhage

ABRUPTION: abruption previously, blood pressure, rupture membranes [premature / prolonged], uterine injury, polyhydramnios, twins, infection, older age, narcotic use [cocaine]

sudden onset severe abdominal pain that is continuous. vaginal bleeding and shock sx will be seen. Fetal distress seen on CTG.

Woody abdomen on palaption

obstetric emergency. ABCDE management, if fetus is alive and in distress = emergency c section.

If there is no distress, when monitor closely and if past 36 weeks, consider a vaginal birth

when the placenta implants deeper than the endometrium, making it difficult to separate the placenta after delivery of the baby.

layers: endo then myometrium and then perimetrium

attaches deeply into myometrium

invades past perimetrium, potentially into other organs likebladder

previous incidence, previous endometrial curettage procedures, previous c section, multigravida, increased maternal age, placenta praevia

very ambiguous sx, diagnosed on antenatal US scans particularly in women with previous incidence or C-section. It is a cause of PPH and MRI scans can help aid assessment of depth / width of invasion

specialist MDT approach. options include hysterectomy with placenta still in uterus [recommended]. Uterus preserving surgery with resection is also an option or expectant management [leaving placenta to be resorbed over time] which has the risk of infection

new onset of BP of 140 / 90 or higher after 20 weeks gestation AND 1 or more of:
proteinuria,
other organ involvement [renal insufficiency, neurological, haematological]

High BP that exists before 20 weeks gestation and is long-standing. Therefore not caused by dysfunction in placenta and so is no classed as pre-eclampsia

HPTN occuring after 20 weeks gestation without proteinuria

pre-eclampsia but with seizures

Lacunae [pools of blood] are formed from spinal arteries when they break down which reduces the vascular resistance of the maternal blood flow from the uterine arteries to the veins. If the formation of lacunae is inadequate, pre-eclampsia is formed due to the high vascular resistance in the spiral arteries and poor perfusion of the placenta.

headache
visual disturbance / papilloedema
HPTN + proteinuria
RUQ / epigastric pain
hyperreflexia
low platelet / abnormal LFTs
HELLP syndrome

can lead to eclampsia, foetal complications, haemorrhage, cardiac failure

Aspirin 75-150mg daily from 12 weeks until birth if px has RFs. Close monitoring and scoring systems used to see if escalation is needed.

Labetalol is first line, Nifedipine is 2nd line, methyldopa is 3rd line.

IV hydralazine and magnesium sulphate can be given in severe cases or when seizures occur

After birth, Enalapril is first line, Nifedipine is 1st line Black African

BP of 140 / 90 or higher + proteinuria or organ dysfunction or placental dysfunction

Placental growth factor can also be tested around 20-35 weeks where low levels are seen in pre-eclampsia

used for seizures associated to eclampsia. Given as an IV bolus of 4g over 5-10 mins and continue treatment for up to 24hrs after last seizure / delivery

Need to monitor urine output, reflexes, RR and oxygen sats as overdose can lead to respiratory depression.

Reversed by calcium gluconate

follows on from severe pre-eclampsia

Haemolysis + Elevated Liver enzymes + Low Platelets

will see n / v, RUQ pain, lethargy. Resolves with delivery of baby

when the presenting part of the fetus is the legs / bottom

complete breech: legs fully flexed
Frank breech: legs extended
footling breech: foot is the presenting part

uterine malformations / fibroids, placenta praevia, poly / oligohydramnios, fetal abnormalities, prematurity

if before 36 weeks usually resolves spontaneously.

External cephalic version: used at 36 weeks for nulliparous or after 37 weeks for multiparous, to manually move fetus from breech to cephalic [50% success]. Usaully given tocolysis like terbutaline to relax uterus

If ECV fails, woman can choose between vaginal delivery [safer for mother but needs experienced nurses and doctors] or C-section [safer for baby]

when caesarean is required, antepartum haemorrhage in last 7 days, abnormal CTG, major uterine abnormalitiy, rupture of membrane, multiple pregnancy

birth of dead fetus after 24 weeks gestation

unexplained [50%], pre-eclampsia, placental abruption, vasa praevia, cord prolapse, obstetric cholestasis, diabetes, thyroid disease, infection, congenital / genetic abnormalities

FGR, smoking, alcohol, increased maternal age, maternal obesity, twins, sleeping on back

reduced fetal movements, abdominal pain, vaginal bleeding

After 20 weeks gestation, the uterus can compress the IVC and aorta when the woman lies down. This leads to reduced cardiac output / hypotension which can lead to cardiac arrest.

Manage via notifying women to lie on their left side to position the uterus away from the IVC

15 degree tilt to LHS for CPR to avoid compression of IVC.
Early intubation to protect airway as well as early oxygen
Aggressive fluid resuscitation
Delivery of the baby after 4 mins and within 5 mins of starting CPR via C-section, with it being performed at the site of arrest.

foetal distress, as a method of fetal compensation to chronic hypoxia

the first onset of fetal movements at around 18-20 weeks. Fetal movements should be established by 24 weeks gestation with multiparous women usually experiencing them sooner

before 24 weeks = hand held doppler, if not felt then refer to maternal fetal medicine unit

24-28weeks: hand held doppler

after 28 weeks: hand held doppler but if no fetal heartbeat, then immediate US offered

the spontaneous loss of pregnancy before 24 weeks gestation. Around 30% of pregnancies.

usually before 12 weeks, placenta expelled with fetus

around 12-24 weeks, parts of placenta remain in uterus therefore requires vaginal misoprostol OR surgical management

vaginal bleeding with closed cervix and fetus is alive

no sx, but fetus is dead

vaginal bleeding that ranges from spotted to heavy
lower abdominal cramping pain
vaginal fluid / tissue discharge
loss of pregnancy sx [no nausea, breast tenderness]
LBP

any haemodynamic instability: emergency admission

if just bleeding w/ no pain and less than 6 weeks: repeat pregnancy test after a week, if -ve = miscarriage

otherwise: refer to early pregnancy assessment unit

usually clinical diagnosis and transvaginal US [looking for mean gestational sac diameter, foetal pole and heartbeat], alongside a beta-hCG test for pregnancy status

Expectant: waiting for spontaneous miscarriage, escalates to medical / surgical management if there is any sign of haemorrhage or infection

Medical: Oral mifeprisone to induce uterine contractions. 48hrs later, misoprostol. Pregnancy test 3 weeks later

Surgical: vacuum aspiration in theatre under LA / GA

3 or more, warrants investigations

causes include: antiphospholipid syndrome, endocrine disorders, uterine abnormalities, smoking, parental chromosomal abnormalities

24 weeks along with specific criteria AND 2 registered medical practitioners that agree. Must be carried out by a registered medical practitioner in an NHS hospital

Can be performed after 24 weeks IF:
Continuing the pregnancy is a risk to life of the woman, termination will prevent “grave permanenent injury” to the physical / mental health of the woman or if there is “substantial risk” that the child will suffer physical / abnormalities.

Mifepristone and Misoprostol [given 48hrs later]. Mimics a miscarriage. Can be done at home and a pregnancy test 2 weeks later is needed for confirmation

Vacuum aspiration, dilation / evacuation.

severe form of n / v that is a common sx of pregnancy.

multiple pregnancies, molar pregnancies, nulliparity, obesity, FHx of n / v

Smoking REDUCES the incidence of hyperemesis

Protracted n / v AND:
more than 5% weight loss compared to before pregnancy AND dehydration AND electrolyte imbalance

Quantified by pregnancy-unique quantification of emesis [PUQE]. more than 12 is severe out of 15. less than 7 is mild

conservative: avoid triggers, rest, eat plain food, wrist acupressure

First line: antihistamines [oral cyclisine], phenothiazines [prochlorperazine]

Second line: ondansetron [cleft lip risk if used in 1st trimester], domperidone / metaclopramide [extrapyramidal SEs, so dont use for longer than 5 days ]

Hydatidiform mole which is a tumour that grows like a pregnancy in the uterus. Can be complete [where two sperm cells fertilise an empty ovum which leads to sperms cells to combine and divide, no fetal material] or partial [two sperms fertilise a normal ovum, new cells has 3 sets of chromosomes, can contain fetal material]

can experience: worse morning sickness, vaginal bleeding, uterus size is greater than expected gestational age, abnormally high hCG, thyrotoxicosis

Snow storm appearance on pelvic US

a life threatning medical emergency usually a result of an ascending bacterial infection of the amniotic fluid / placenta. RF is preterm ROM

Needs prompt delivery of fetus and administration of IV ABx

400mcg of folic acid until 12th week of pregnancy

Higher risk px need 5mg folic acid before conception until 12th week [BMI over 30]

MORE: Metabolic disease, Obesity, Relative / FHx of NTDs, Epilepsy

+ Sickle cell / thalassaemia

presence of lower than normal volume of amniotic fluid in the uterus

Uteroplacental insufficiency, fetal urinary system abnormalities, premature ROM, post term gestation, chromosomal abnormalities, maternal use of ACEi and prostaglandin inhibitors

usually will see reduced fetal growth and development

can lead to Potter’s syndrome: clubbed feet, facial deformity, congenital hip dysplasia

US will show reduced amniotic fluid index of single deepest pocket

depends on cause and GA

can rehydrate mother, amnio infusion or escalate to delivery via IOL or c section

too much fluid in the uterus

excess production: maternal DM, fetal renal disorders / anaemia, twin to twin transfusion syndrome

Insufficient removal: esophageal / duodenal atresia, diaphragmatic hernia, anencephaly, chromosomal disorders

will see a tense / large uterus that is unusual for GA

difficulty feeling fetal parts on palpation

the onset of REGULAR and PAINFUL contractions associated with cervical dilation and descent of the descending part

regular and painful uterine contractions
show / shedding of mucous plug
ROM
dilation of cervix

occasional IRREGULAR contractions of the uterus, usually in 2nd or 3rd trimester. there also may be irregular cramping of the abdomen

latent phase: 0-3 dilation
active phase: 3-7cm
transition: 7-10cm

cervical dilation AND effacement

from 10cm dilation to delivery of the baby.
3Ps: POWER, PASSENGER, PASSAGE

delivery of the placenta afterwards: can be physiological or active [midwife / doctor assists taking the placenta out]. If there is haemorrhage or 60 mins delay, proceed with active management via giving IM oxytocin

FHR monitored every 15 mins
contractions every 30 mins
maternal pulse rate every 60 mins

maternal BP / temp and vaginal examination and maternal urine every 4 hrs

prelabour ROM, FGR, pre-eclampsia, obstetric cholestasis, existing diabetes, stillbirths

determines whether we should induce labour yet. Score up to 13. Score of 7 or more means there is a high chance of spontaenous labour. If 5 or less, not ready to do IOL

assessment based on: cervical position [anterior is 2], cervical consistency [soft is 2], cervical effacement [60% is 2, 80% is 3], cervical dilation [3-4cm is 2, more than 5cm is 3], fetal station [-1,0 is 2 points, +1 and +2 is 3 points]

If score is 6 or less, vaginal prostaglandins or oral misoprostol

If bishop score is above 6, amniotomy and an IV oxytocin

Assissting IOL method. Used from 40 weeks gestation to attempt to initiate labour via inserting a finger into the cervix to separate the chorionic membrane from the decidua to initiate labour

E2 [dinoprostone] can be inserted as a gel, tablet, pessary [propess] into vagina, to stimulate the cervix and uterine contractions

silicone balloon inserted into cervix and gently inflated to dilate the cervix,

Usually used in cases of women where previously prostaglandins have failed

Oxytocin infusion to IOL. Only used if there are reasons not to use vaginal prostaglandins

When contractions of uterus are prolonged, causing fetal distress, in response to vaginal prostaglandins.

Classified as individual contractions being longer than 2 mins and more than 5 contractions every 5 mins

Manage via removing vaginal prostalandin and possible giving tocolysis like terbutaline

stimulates smooth muscle contraction via alpha adrenergic, dopaminergic, serotonergic receptors. Used in 3rd stage of labour or to prevent PPH

SEs: HPTN, diarrhoea, vomiting, angina, coronary artery spasm

CI: eclampsia px, caution in px with HPTN

paracetamol is used often. Codeine may be added for extra, avoid NSAIDs

Gas mixture of 50% nitrous oxide and 50% oxygen. User controlled pain control

SEs: lightheadedness, nausea, sleepiness

Opiod medication to help with anxiety and distress. Can cause drowsiness / nausea in mother AND respiratory depression in neonates

Needs anaesthetic input and safety management in case of adverse effects

Naloxone for respiratory depression, atropine for bradycardia SEs

catheter into epidural space to insert levobupivacaine

SEs: headache after insertion, hypotension, motor weakness in legs [URGENT review as catheter may be incorrectly sited into subarachnoid space], nerve damage, prolonged 2nd stage, increased probability of instrumental delivery

When labour is not developing at a satisfactory rate, more likely in nulliparous women.

There is less than 2cm cervical dilation in 4 hours

leads to increased risk to foetus / mother

is used to monitor women in 1st stage using all kinds of data like cervical dilation, contractions, fetal HR, maternal pulse / BP / temp / urine output

Has two lines of alert and action, if these cross each other then amniotomy is considered

when active pushing lasts over 2hrs in nulliparous and 1hr in multiparous

more than 30mins with active management, more than 60 mins with physiological management

refers to vaginal delivery assissted by either a ventouse suction cup or forceps

co-amoxiclav is given after to reduce risk of maternal infection

failure to progress, foetal distress, maternal exhaustion, control of head in various fetal positions

PPH, episiotomy, perineal tears, anal sphincter injury, incontinence of the bladder / bowel, nerve injury [obturator / femoral n]

cephalohaematoma [collection of blood between the skull and periosteum] with ventouse

facial nerve palsy with forceps

suction cup on a cord, goes on the babies head and traction is applied to pull baby out of vagina

2 curved metal pieces around babies head to apply traction to delivery baby. Bruises can form which mostly resolve spontaneously, fat necrosis is a very rare complication

umbilical cord descends below presenting part of the foetus and through the cervix, after ROM

significant danger of presenting part compressing the cord, leading to fetal hypoxia

when fetus is in abnormal lie after 37 weeks AND artificial ROM

fetal distress signs on CTG and vaginal examination to see prolapsed umbilical cord

Emergency C section. Cord should be kept warm and wet + minimal handling [risk of vasospasm] whilst waiting for delivery

obstetric emergency where the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered. Often caused by macrosomia secondary to gestational diabetes

Difficulty delivering face / head + obstruction in delivering shoulders

Failure of restitution where the head remains face downwards and does not turn sideways as expected

Turtle neck sign [retraction of head back into vagina]

fetal macrosomia, high maternal BMI, DM, prolonged labour

Emergency: needs senior involvement ASAP

needs additional manoeuvres like McRoberts or episiotomy or apply pressure to the anterior shoulder through the abdomen to encourage it under the pubic symphysis

flexion + abduction of maternal hips, bringing thighs to abdomen to increase the relative anterior-posterior angle of the pelvis

Rubins involves reaching into vagina to put pressure on posterior aspect of anterior shoulder. Woods screw is then to push the top shoulder forwards through the abdomen to try and delivery the baby

occurs when external vaginal OS is too narrow to accommodate the baby, leading to the tearing of skin / tissues as babys head passes

nulliparity, macrosomia, shoulder dystocia, Asian, occipito-posterior position, instrumental delivery

1st degree: limited to frenulum of labia minora and superficial skin, no repair needed

2nd degree: involves perineal muscles but not anal sphincter, needs suturing on ward

3rd degree: involves anal sphincter BUT NOT rectal mucosa, needs surgery

Urinary incontinence, Anal incontinence, fistula between vagina / bowel, sexual dysfunction / dyspareunia, psychological / mental health consequence

used in anticipation of needing additional room for delivery of the baby, used with LA

45 degree cut, down and laterally to avoid anal sphincter

reduces risk of perineal tears

Involves massaging skin / tissue between vagina and anus. Done from 34 weeks onwards to stretch / prepare tissues for delivery

previous c section, placenta praevia, vasa praevia, breech, multiple pregnancy, cervical cancer, uncontrolled HIV infection

Pfannenstiel incision [2 fingers above public symphysis]

Joel Cohen incision [recommended]

vertical incision is in only very rare cases

previous uterine rupture, vertical incision C section scar, other usual CI to vaginal delivery like placenta praevia

amnitoic fluid passes into mothers blood, usually around labour / delivery. Amniotic fluid contains fetal tissue which can trigger the mothers immune system causing a systemic anaphylactic reaction [mortality 20%]

increased maternal age, IOL, C-section, multiple pregnancy

when myometrium ruptures either completely [uterine contents released into peritoneal cavity] OR incomplete [uterine intact, perimetrium surrounds uterus].

Leads to lots of bleeding

previous C section scar is a source of weakness, VBAC, previous uterine surgery, high BMI, high parity, older age

Acutely unwell mother and abnormal CTG

Abdo pain, vaginal bleeding, ceasing of uterine contractions, hypotension, tachycardia, collapse

obstetric emergency, A2E with emergency C-section, stop bleeding and repair / remove uterus

when the fundus of the uterus drops down through the uterine cavity and cervix, flipping the uterus inside out

May be a result of pulling too hard on umbilical cord during active management of 3rd stage of labour

usually with PPH so shock and collapse. Incomplete inversion can be felt with manual vaginal examination. Complete inversion, the uterus may be seen at introitus

Johnson manoeuvre: manual push fundus back into correct posn and hold it there for several minutes + oxytocin to stimulate tension

Hydrostatic methods via filling the vagina with fluid to inflate the uterus back [requires a tight seal, may be difficult to do practically]

Laparotomy of abdomen to reutrn uterus to normal position

before 37 weeks is premature. before 28 weeks is extreme, 29-32 is very preterm, 32-37 is moderate preterm

babies considered non-viable before 23 weeks so no resuscitation is considered

amniotic sac ruptured before labour

rupture before 37 weeks gestation and labour

amniotic sac ruptures more than 18hrs before delivery

Vaginal progesterone to maintain pregnancy and prevent labour

Cervical cerclage is to stitch the cervix and keep it closed.

Both given around 16-24 weeks gestation and cervical length less than 25mm

usually speculum will show pooling of amniotic fluid in posterior vaginal wall.

Can test IGF binding protein 1 levels in vaginal fluid which is usually high in amniotic fluid OR PAMG-1 [placental alpha microglobulin-1] is an alternative

Contractions: 4-5 in labour is normal
Baseline Rate: 110-160
Variability: 5-25 is normal
Accelerations of more than 15bpm for more than 15 seconds is healthy
Decelerations of more than 15 bpm for more than 15 seconds are always PATHOLOGICAL

3 mins: call for help
6 mins: prepare theatre
9mins: prepare for delivery
12 mins: delivery by 15 mins

occurs in women who are breastfeeding, may not return to regular menstrual periods for 6 months or longer.

98% effective as contraception

not considered fertile until 21 days after giving birth. After this, they need contraception. POP or implant are considered safe

UKMEC4: if breastfeeding for less than 6 weeks post partum OR within first 21 days due to increased risk of VTE

UKMEC2: 6weeks to 6 months breast feeding post partum

within 48hrs of birth or more than 4 weeks after birth is UKMEC 1

between this time period is UKMEC3

increased risk of preterm birth, low birthweight, SGA babies

inflammation of the endometrium, usually caused by infection travelling from vagina upwards. Occurs most commonaly after C-section

If endometritis occurs unrelated to pregnancy and delivery, then its pelvic inflammatory disease

presents shortly after birth with:

Foul smelling discharge / lochia, bleeding heavier or does not improve over time, lower abdominal pain, fever, sepsis

vaginal swabs, urine culture and sensitivities, US considered to rule out retained products of conception

SEPSIS 6 and clindamycin / gentamicin

if milder, use community ABx like co-amoxiclav

pregnancy related tissue remain in uterus after delivery. Can also occur after miscarriage / abortions.

Diagnosis is made by US

vaginal bleeding that gets heavier and does not improve over time, abnormal vaginal discharge, lower abdominal pain, fever

Surgery to evacuate the retained products of conception under GA, via vacuum aspiration and curettage

px who have poor adherence to oral iron Tx, fail to respond / cannot tolerate oral iron or cannot absorb iron

CI in people with active infecctions as pathogen feeds on iron, worsening infections

used to assess how mother has felt over past week as a screening tool for postnatal depression. Score of 30, more than 10 indicates postnatal depression

mood swings, low mood, anxiety, irritability, tearfulness

hormonal changes, recovery after birth, fatigue / sleep deprivation, responsibility of caring for neonate, established feeding, life events

usually mild sx that resolve within 2 weeks of delivery. Only needs reassurance and support

low mood, anhedonia, low energy

must last for longer than 2 weeks for diagnosis

mild cases: support, self help, follow up with GP

moderate: SSRIs and CBT

severe: specialist psychiatry services

onset of 2-3 weeks after delivery with:

delusions, hallucinations, depression, mania, confusion, thought disorder

urgent assessment and input from specialist mental health services. Admit to mother / baby unit, CBT, Meds, Electroconvulsive therapy

inflammation of breast tissue, sometimes associated with infection

caused by obstruction in ducts and accumulation of milk OR infection entering from nipple into ducts

breast pain / tenderness, erythema, local warmth / tenderness, nipple discharge, fever

Duct blockage: conservative with regular milk feeds, breast massage, simple analgesia

Infections: first line is flucloxacillin, if allergic then erythromycin. Send samples for culture and sensitivites

usually occurs after a course of ABx, leading to recurrent mastitis as the cracked skin on nipple is an entrance for infection.

sore nipples after feeding, nipple tenderness / pruritus, cracked / flaky areola, sx in baby [oral thrush in baby]

topical miconazole 2% after every breastfeed

give baby miconazole gel / nystatin

rare PPH complications where the drop in circulating blood volume leads to avascular necrosis of anterior pituitary gland. This is due to the ant pit gland only having the hypothalamo-hypophyseal portal system for blood supply

decreased lactation [prolactin loss], amenorrhoea, adrenal crisis, hypothyroidism

specialist endocrinologist needed, hormone replacement therapy for all of the hormones affected

usually occurs in first few days after delivery with pain being worse before a feed. The milk doesnt flow well leading to the infant having difficulties suckling. Hand expression of milk may help

intermittent pain, during and after feeding. Blanching of the nipple seen followed by cyanosis and erythema.

Advise px to have minimal exposure to cold, use heat packs, avoid caffeine, can use nifedipine

prematurity, prolonged ROM, previous sibling GBS infection, maternal pyrexia

offer intrapartum ABx prophylaxis which is benzylpenicillin

Complication of pelvic inflammatory disease where perihepatitis occurs in 10% of cases. Characterised by RUQ pain and can be confused with cholecystitis

10 days oral erythromycin

10% threshold in the first week of life. NICE recommends an “expert” review of feeding if this occurs via midwife-led breastfeeding clinics AND monitoring of weight until weight gain is satisfactory

Hypertensive disease in a previous pregnancy
CKD
Autoimmune disease
T1 / 2DM
Chronic HPTN

First pregnancy
40yrs or over
pregnancy interval of more than 10yrs
BMI > 35
FHx of pre-eclampsia
Multiple pregnancy