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Preconception Edit

Counselling Edit

  • Folic acid: prevents neural tube defects
    • Folic acid 0.4mg/day.
    • Start taking 2-3 months prior to conception until breastfeeding complete
    • Higher doses may be required based on PMHx and medications (e.g. epilepsy, diabetes, obesity, family history of NTD)
  • Smoking, ETOH, recreational drug cessation
  • Cessation of current birth control
  • Optimize maternal medical conditions
    • Review medications and teratogenicity
  • Genetic screening if high risk groups
  • Review immunizations - MMRV, Hep B
  • Review previous pap and STI testing
  • Review diet: ensure iron (27 mg/day) and calcium adequate, caffeine < 300mg/day, <2 servicings of fish/week
  • Environmental counselling
    • Avoid cat litter (toxo)
    • Avoid soft cheeses and deli meats (listeria)
    • Avoid raw fish

Prenatal Edit

GTPAL Edit

  • Gravida = # pregnancies of any gestation
  • Term = # pregnancies >37 weeks
  • Preterm = # pregnancies < 37 weeks
  • Abortus = # pregnancies < 20 weeks (spontaneous or therapeutic)
  • Living = # live births

Dating the Pregnancy Edit

  • Naegele's Rule: First day of LMP + 7 days - 3 months
  • Cycle length, regularity, use of contraception
  • 1st trimester ultrasound (preferred)

Initial Visit Edit

  • WITHIN 12 weeks of LMP
  • Confirm pregnancy - urine dip
  • Confirm dates - LMP or order 1st trimester ultrasound
  • Review preconception counselling
  • Establish desirability of the pregnancy - counsel regarding options (termination, adoption)
  • Discuss risk of early trimester loss (20%)
  • Conduct history, physical and order initial blood work (see below) - this can be completed over a number of appointments
  • Discuss IPS screening

Initial Visit - History Edit

  • Past Medical History
  • Surgical History (including cervix/uterine)
  • Medications
  • Allergies
  • Lifestyle History
    • smoking, ETOH, recreational drugs
    • Occupation
    • Partner involvement
    • Concerns - financial, violence, abuse, housing
  • Nutrition History
  • Family History
  • Obstetrical History
    • Date of delivery, place, gestation, type of delivery, sex, birthweight, hours of labour, complications in labour, complication of baby, breast fed
  • Gynecological history
    • Last pap
    • History of STIs
    • Contraception used
    • Cycle length and regularity
  • Current pregnancy
    • Bleeding
    • Nausea/Vomiting
    • Abdominal pain
    • Infections

Initial Visit: Physical ExaminationEdit

  • Vitals
  • Weight
  • HEENT
  • CV/Resp/Abdo
  • GU: vulva, vagina, cervix, uterus size, +/- pap
  • MSK/ peripheral

Initial Visit: Investigations Edit

  • Blood work:
    • CBC, type and screen
    • Rubella, syphilis screen, HIV, HBsAg (Hep B)
    • Consider: TSH, Hep C, toxoplasmosis, CMV, TB, parvovirus
  • Investigations:
    • Urine R +M, C+S
    • Chlamydia and Gonorrhea
    • Pap test

Prenatal Genetic Screening Edit

  • IPS screening
  • IPS #1: GA 11-14 - nucal translucency ultrasound, BHCG, PAPP-A
  • IPS #2: GA 15-18 - alpha-fetoprotein, BHCG, estriol, inhibin A

Follow-up visits and Investigations Edit

  • Visits q4 weeks until GA 28 weeks
  • Visits q2 weeks from GA 28-36 weeks
  • Visits q1weeks from GA 36 weeks - delivery
  • Each Visit:
    • Weight
    • BP and HR
    • Urine dip - protein, signs of infection
    • SFH (symphysis fundal height) > 12 weeks GA
    • Fetal heart rate (FHR) > 10-12 weeks GA
    • Position of fetus - third trimester
    • Patient concerns
    • Fetal movements, contractions, PV discharge, ROM
  • GA 28 weeks: Glucose Tolerance Test for Gestational DM. Repeat CBC, T+S (Rhogam if required)
  • GA 35-37 weeks: GBS screening


Counselling during Pregnancy Edit

Exercise: Edit

  • Okay for pre-pregnancy exercise regime as long as no contraindications (e.g. previa, heart d/o, PROM, HTN, incompetent cervix, IUGR, uncontrolled maternal disease)
  • Try to avoid becoming breathless, avoiding warm/humid environments, avoid breath holding, stay hydrated

Air travel Edit

  • Not recommended after 36 weeks GA
  • Dependent on airline policy therefore verify prior to booking

Weight gain

Pre-pregnancy BMI Recommended weight gain (kg) lbs
<18.5 12.5-18 kg 28-40 lbs
18.5-24.9 11.5-16 kg 25-35 lbs
25.0-29.9 7-11.5 kg 15-25lbs
>30 5.0-9 kg 11-20lbs

Intercourse

  • No concerns except if contraindications - premature rupture of membranes or placenta previa

Maternal PhysiologyEdit

  • All physiology changes during pregnancy normally resolve by 6 weeks post-partum
  • Cardio: increase blood volume and cardiac output, HbG decrease (dilutional), lower BP, resting HR > 10bpm, decrease vascular resistance
  • Resp: increase tital volume,minute volumes,  pH (respiratory alkalosis) and oxygen use. No change in vital capacity or pO2
  • GI: constipation, delayed gastric motility, reflux, gallbladder disease
  • Renal: risk of UTI increases, decrease bladder capacity, decrease in serum Cr and Urea
  • Skin: melasma, linea nigra, spider angiomas
  • Endocrine: decrease response to insulin
  • Heme: hypercoaguable state
  • Extremities: leg swelling,varicose veins (legs, vulva), hemorrhoids
  • Other: dizzy lying flat (compression on IVC)

Abortion (spontaneous) Edit

Pregnancy loss < 20 weeksEdit

History/PhysicalEdit

  • History: symptoms of blood loss (SOB/CP, presyncope/syncope), infectious symptoms, abdominal pain, amount of PV bleed +/- tissue
  • Physical: uterus size, cervix (open/closed)

InvestigationsEdit

  • CBC, T+S (?need for rhogam), +/- coags, serum BhCG, Ultrasound (FHR, r/o ectopic)

Risk factorsEdit

  • Previous history, advanced maternal age, maternal medical conditions, history of therapeutic abortions, infections, IUD, uterine abnormalities, maternal medications, maternal substance use

Classification and ManagementEdit

  • Threatened abortion: PV bleeding, +/- cramps. Cervix closed. U/S: +Fetal heart rate
    • Management: expectant
  • Inevitable abortion: PV bleeding + cramping, no tissue. Cervix open.
    • Expectant management +/- misoprostal or D/C
  • Incomplete abortion: PV bleeding + cramping +/- tissue. Cervix open. U/S: retained tissue
    • Expectant management +/- misoprostal or D/C
  • Complete abortion: PV bleeding, passage tissue + placenta. U/S: no retained tissue
    • Management: no treatment. Monitor
  • Missed abortion: fetal demise, no PV bleeding, cervix closed.
    • Management: Misoprostal, or D+C +/- oxytocin 
  • Recurrent abortion: >3 consecutive
  • Septic abortion: SA with uterine infection (polymicrobial: gram + cocci, gram - bacillii).
    • Management: Rx broad spec Abx
  • All abortions: provide grief counseling, provide adequate resources

DifferentialEdit

  • Vaginal trauma
  • Cervical/vaginal polyps, malignancy, friability
  • Infection
  • Molar pregnancy
  • Ectopic

Rule out EctopicEdit

  • Stable versus unstable
  • Unstable - ABC's and consult gyne
  • Stable
    • Determine BHCG
      • If < 1500 --> Repeat in 48 hours (should double every 48h in first 8 w GA, should double every 5 days between 8-10 weeks GA)
      • If > 1500 --> pelvic ultrasound to r/o ectopic
      • If > 6000 --> abdominal ultrasound to r/o ectopic

Complications in PregnancyEdit

Pregnancy Induced Hypertension (PIH)

  • Definitions: diastolic > 90 x 2 or >110 x 1, Severe > 160/110
    • ​Pre-existing HTN <20 weeks GA
      • ​with or without comorbid conditions
      • with preeclampsia: resistant HTN, new/worsening proteinuria or one or more adverse conditions*
    • Gestational HTN > 20 weeks GA
      • ​with or without comorbid conditions
      • with pre-eclampsia: new proteinuria or one or more adverse conditions *
      • severe pre-eclampsia: pre-eclampsia <34 weeks of age, heavy proteinuria (>3 grams/day)
    • Proteinuria > 300mg/day or >30mg/mmol urinary creatine on spot urine. (Suggestive if dipstick > 2+)
    • Eclampsia: pre-eclampsia + seizures (Tonic/clonic)
  • adverse conditions: HA, visual changes, RUQ pain, severe N/V, chest pain, dyspnea/pulmonary edema, eclampsia, placental abruption, elevated Cr, elevated LFTs with symptoms, decrease platelets, decrease albumin, oligohydramnios, IUGR, absent/reversed end diastolic flow in umbilical arteries, intrauterine fetal demise, DIC
    • HELLP: hemolysis (elevated bili, LDL, schistocytes on smear), Elevated liver enzymes, Low Platelets
  • Clinical: BP in both arms, HA, blurry vision, seizures, CHF, dyspnea, RUQ pain, N/V, oliguria, decrease fetal movement, symptoms of abruption, edema - non-dependent, clonus, hyperreflexia, weight gain, CVA (stroke)
  • Risk factors: etiology in unknown. Nulliparity, pre-existing HTN, vascular disorders,old >35, young <17, obesity, gestational diabetes, family history of preeclampsia, prior history, thrombotic disorders, multiple gestation
  • Complications: 
    • ​maternal: seizure, thrombocytopenia, bleeding, DIC, HELLP, oliguria, pulmonary edema
    • fetus: abruption, IUGR, oligohydramnios, fetal hydrops, fetal demise
  • Investigations: urine dip (+/- 24 hour urine or spot urine Cr), CBC, lytes, BUN, Cr, LFTs, coags, bili, fibrinogen, albumin, biophysical profile, umbilical artery doppler
  • Management:
    • Consult obstetrics
    • ​Adjuncts: diet (low salt), stress reduction, anti-emetics, pain control, fetal monitoring
    • BP management: reduce risk of stroke. NO EFFECT on preventing seizures or fetal outcomes.
      • ​Options labetalol, nifedipine, hydralazine, methyldopa
      • DO NOT USE: ACEI (renal failure, oligohydramnios, congenital anomalies), diuretics, nitroprusside (neonatal cyanide poisoning), atenolol
    • Seizure management: 50% ante-partum, 25% intra-partum, 25% early post-partum
      • Magnesium sulfate for prophylaxis (certain clinical criteria) and treatment.
        • Monitor for symptoms of toxicity: decrease deep tendon reflexes, oliguria, resp paralysis, heart block, cardiac arrest. If occurs stop MgSO4 and give calcium gluconate
    • HELLP: urgent delivery, blood products PRN, consultation to ICU for close monitoring
    • Delivery is the only cure for preeclampsia
  • Prevention:
    • ​Ensure adequate calcium, no ETOH/smoking, exercise, folic acid
    • In high risk women: calcium supplement >1 gram/day, +/- ASA, no ETOH, folic acid, avoid weight gain, rest in 3rd trimeter
  • Post-partum monitoring
    • ​Monitor BP at 3-6 days post-partum, and 6 weeks post-partum (Cr, lytes, fasting blood glucose, cholesterol)
    • Ensure resolution of end-organ damage
    • Continue anti-HTN PRN. Avoid NSAIDs. 

Gestational DiabetesEdit

  • Previous type 1 and type 2 diabetics should be referred to obstetrics for further evaluation. At risk for congential anomalies, spontaneous abortion, macrosomia, IUGR, polyhydramnios, stillbirth, maternal infections and retinopathy/nephropathy/neuropathy/CVD, maternal DKA in Type 1 DM
  • Gestational DM - tested at 28 weeks with glucose challenge (50 grams)
    • If < 7.7 = normal,  7.8-10.2 = OGTT, > 10.2 = GDM
  • Risk factors: previous GDM, family history of DM, previous macrosomia, previous stillbirth, obesity, advanced maternal age, polyhydramnios, PCOS, steroids, ethnicity
  • Complications: macrosomia (>4000grams), shoulder dystocia, increased c/s, brachial plexus injury, perinatal mortality, neonate metabolic d/o (hypoglycemia, hypocalcemia, hypoMg, hyperbilirubinemia, polycythemia), respiratory distress (insufficient surfactant), infections
  • Long term risk: 20% will develop Type 2 DM
  • Managment: diet/ exercise. If unable to control --> insulin. Monitor sugars. Target A1C < 6.0, fasting 3.8-5.2, post-prandial 5-6.6. 
  • Post-delivery: no insulin required. Repeat 75 gram OGGT at 6 weeks and 6 months
  • Refer to Obs +/- endocrine

Nausea ad VomitingEdit

  • Hyperemesis Gravida: persistent emesis resulting in wt loss >5% and electrolyte abnormalities
  • Important to r/o other etiology of vomiting: infection, multiples (>twins), molar pregnancy, substance use
  • Management
    • Encourage oral intake
    • Can try ginger, acupunture
    • Diclectin up to 10mg PO QID
    • If no benefit consider: gravol, promethazine, chlorpromazine, prochlorperazine, metoclopromide, ondansetron, methylprednisolone
    • If unstable, severe dehydration - Consider IV fluids and IV anti-nauseas

Rh NegativeEdit

  • Type and screen all pregnant women at first prenatal and at 28 weeks GA
  • Give rhogam to Rh negative women with PV bleeding, post-amniocentesis, at 28 weeks, 72 hours post delivery
  • Rhogam prevents isoimmunization and decreases risk in future pregnancies of hemolytic disease in the newborn

Intrauterine Growth RestrictionEdit

  • Defintion: fetal birth weight < 10% for GA or U/S measurements < 2 standard deviations because of pathological process. Do not rely on symphysis fundal height
  • Classifcation:
    • Symmetric: both head and abdomen small (usually early in pregnancy secondary to infection, congential or chromasomal anomalies
    • Assymetric: head in spared (usually later in pregnancy, better prognosis)
  • Etiology:
    • Maternal: poor intake, substance use, maternal medical disease
    • Placental: insufficiency (maternal medical conditions), aburption, previa, infarct
    • Fetal: TORCH infections (toxoplasmosis, other (syphillis, varicella, TV) rubella, CMV, Herpes), chromasomal abnormalities, congenital anomalies
  • Diagnosis: suspect if low SFH (>3 cm difference), ultrasound
  • Managment: preconception counselling, improve nutrition, stop substance use, antenatal monitoring (non-stress test, biophysical profiles, doppler flow of umbilical artery)
  • Consult: Obstetrics +/- maternal high risk
  • Neonatal complications: metabolic (hypoCa, low glucose, polycythemia, thrombocytopenia), hypoxia, prematurity

PolyhydramniosEdit

  • > 1.5 L of amniotic fluid between 32-36 weeks
  • Associated with neural tube defects, GI obstruction, maternal diabetes
  • Risk of pre-term labor
  • Usually resolves but requires referral to obstetrics

OligohydramniosEdit

  • <0.5L of amniotic fluid between 32-36 weeks
  • Secondary to renal agenesis, or rupture of membranes
  • Refer to obstetrics

Decreased Fetal MovementsEdit

  • After 26 weeks should have >6 movements in 2 hours
  • If less than 6 movements --> drink juice, go to quiet room, count
  • If still < 6 movements go to ED for non-stress test +/- biophysical profile

BreechEdit

  • Abnormal fetal lie - presenting part either feet/buttocks
  • Rule out cord prolapse and ultrasound to confirm
  • Refer to obsetrics for either external cephalic version or C/S

InfectionsEdit

  • TORCH: toxoplasmosis, other (syphillis, varicella, TB), rubella, CMV, Herpes
  • GBS Bacteruria - requires prophylactic antibiotics at delivery regardless of GBS swab (vaginal/rectal) therefore no need to repeat
  • Varicella:
    • Most individuals immune through exposure history or immunization
    • Transmission: droplet. Infectious 48 hours prior to rash until vesicles crusted over. Incubation 10-21 days
    • Clinical: fever, malaise, pruritic maculopapular rash -->vesicular -->crusts
    • Diagnosis: clinical. Serology (IgM + within 3 days)
    • Complications:
      • Mother:  pneumonia (medical emergency) Rx - supportive care + high dose acyclovir
      • Fetus: congenital varicella syndrome (infection in T1/T2 - limb/muscle hypoplasia, corticoatropy, seizures, chorioretinitis, microcephaly, IUGR). Assess with fetal U/S + referral to maternal high risk
      • Newborn: risk if mom develops symptoms from 5 days prior to delivery to 2d post delivery. Symptoms: rash, fever +/- dissemination (encephalitis, pneumonia, hepatitis). Consider VZIG +/- acyclovir
    • Prevention: VZIG up to 96 hours after exposure for mothers. Encourage immunization prior to pregnancy > 4weeks. NO IMMUNIZATION during pregnancy.
  • Genital Herpes:
    • Classification: primary episode (more severe), non-primary first episode, recurrent
    • Most viral shedding occurs during active lesions + 14 days post. Can have asymptomatic shedding.
    • Diagnosis: clinical, viral culture from vesicular fluid, serologic assays
    • Transmission: congenital, neonatal (during the delivery - skin, CNS disease, disseminated)
    • Treatment in pregnancy: anti-viral from 36 weeks + to decrease outbreaks and need for C-section
      • C/S indicated if first episode of genital herpes, prodromal symptoms at delivery
  • Parvovirus B19 - erythema infectiosum - fifth disease
    • clinical: slapped cheek, fever, arthralgias
    • Fetus: hydrops fetalis (aplastic anemia--> CHF-->hydrops)
    • Refer to high risk
  • Rubella
    • Clinical: often asymptomatic, rash face-->trunk/extremities, fever, conjunctivitis, sore throat, polyarthritis
    • Transmission: T1 (highest) and highest rate of congenital malformations
    • Complications fetus: deafness/ VSD, retinopathy, cataracts, MR, DM, cataracts, thyroiditis
    • Diagnosis: 4x rise in IgG or +'ve IgM
    • Mngt: supportive management. Suggest immunization > 4 weeks prior to pregnancy, NO IMMUNIZATION in pregnancy. 
    • Immunization post partum
  • Hep B
    • Transmission: often occurs during delivery. 
    • Post-natally babies receive HGIB and Hep B vaccine
  • HIV
    • Evaluate for opportunitic infections, immunizations status, other STIs
    • Refer to high risk 
    • Change medications to most efficacious that is safe in pregnancy (decrease risk of vertical transmission) - HAART. Monitor plasma viral load and drug toxicities. If elevated C=section
    • Neonates: receive 6 weeks of zidovudine
    • Breastfeeding: contraindicated
    • If HIV positive and wishing to receive refer to fertility specialist for options

ImmunizationsEdit

  • Avoid life viruses if trying to conceive x 4 weeks and while pregnant ( MMRV, polio, yellow fever)
  • Inactivated or killed are safe in pregnany (Hep A/B, influenza, diphtheria, meningococcus, polio-inactivated)
  • Breast feeding woman can receive any immunization (live, killed, inactive)

Special PopulationsEdit

  • Consider early referral to Obs for patients with epilepsy or obesity

Delivery Edit

Stages of Labour Edit

  • First phase:
    • Latent: 3-4cm dilation + contractions
    • Active: >3-4 cm dilation in nulliparous. >4-5cm parous woman
  • Second phase:
    • Passive: full dilation without pushing
    • Active: full dilation with pushing to delivery of baby
  • Third Phase: immediately after delivery of baby to delivery of placenta
  • Fourth Phase: after delivery of placenta to one hour post partum
Nulliparous Multiparous
Latent phase:

Mean (time)

Longest normal

6.4 hours

20.1 hours

4.8 hours

13.6 hours

Active phase:

Mean (time)

Longest normal

3.0 cm/hour

1.2cm/hour

5.7cm/hour

1.5cm/hour

Second stage:

Mean (time)

Longest normal

1.1 hours

2.9 hours

0.4 hours

1.1 hours

Dystocia Edit

Definition: Edit

  • Active labour: greater than 4 hours of <0.5cm per hour or no dilatation in two hours
  • Active second stage:
    • Nulliparous: no progress for 3 hours with epidural or 2 hours without epidural
    • Multiparous: no progress for 2 hours with epidural or 1 hour without epidural
    • One hour with no descent with active pushing

Etiology of Dystocia: 4 P's Edit

  • Power: contractions, maternal effort
    • Adequate contractions last 60seconds every 2-3 minutes
    • Management: oxytocin
  • Passenger: position, attitude, size, cephalopelvic disproportion
  • Passage: pelvic structure, soft tissue factors (full bladder/rectum)
    • Management: empty bladder/rectum, reposition patient
  • Psyche: pain, anxiety
    • Management: analgesia

Management of Dystocia: Edit

  • Prevention: admit only patients in active labour, monitor closely, analgesics PRN, augmentation as necessary
  • Ensure adequate hydration
  • Consider empty bladder/bowel
  • Consider therapeutic rest and analgesia for fatigue
  • Consider augmentation:
    • Amniotomy
    • Oxytocin: low dose protocol 1-2mU/minute (increase by 1-2mU/30minutes)
      • high dose: 2-4 mU/minute
  • Assisted Vaginal delivery
  • C-Section


Induction/Augmentation of Labour: Edit

Definitions:

  • Induction: artificial initiation of labour
  • Augmentation: enhancement of contractions for patient already in labour
  • Cervical ripening: soften, dilate cervix to increase likelihood of vaginal delivery

Risks of induction: Edit

  1. Increase risk of operative delivery and C/S in nulliparous
  2. Uterine tachysystole with fetal compromise (uterine hyperstimulation)
  3. Risk of uterine rupture
  4. Increased risk of chorioamnionitis
  5. Cord Prolapse with ARM (artificial rupture of membranes)
  6. Failure to achieve labour

Indications for induction: Edit

  1. Risk of continuing pregnancy > risk of induction
  2. Severe pre-eclampsia/eclampsia
  3. Significant maternal disease not responding to treatment
  4. Stable but significant antepartum hemorrhage
  5. Chorioamniotitis
  6. Suspected fetal compromise
  7. Term PROM with GBS colonization (GBS+)
  8. Post-dates 41+3
  9. Twins >38 weeks
  10. IUGR (intra-uterine growth restriction)
  11. IUFD (intra-uterine fetal demise

Contraindications of induction: Edit

  1. Placenta previa or vasa previa
  2. Abnormal fetal lie or presentation
  3. Prior classical or inverted T uterine incision
  4. Significant prior uterine surgery
  5. Active genital herpes
  6. Pelvic structural deformities
  7. Invasive cervical carcinoma
  8. Previous uterine rupture
  9. Suspected fetal macrosomia
  10. Convenience

Pre-Induction Criteria: Edit

  • Predictors of successful induction include Bishops score >6 and parity
  • Predictors of induction failure include BMI >40, age >35, estimated fetal weight >4 kg, DM
Score 0 1 2 3
Dilation Closed 1-2 3-4 >5
Length >4 3-4 1-2 0
Consistency Firm Medium Soft -
Position Posterior Midline Anterior -
Station -3 -2 -1, 0 +1,+2

Cervical ripening - unfavorable cervix: Edit

  1. Mechanical: balloon catheter
    1. Sterile technique: No 14-18 foley with 30 cc balloon
    2. Insert past internal os. Inflate to 30-60cc
    3. Reduced risk of tachysystole, C/Section
    4. Increased risk of maternal infection
  2. Prostaglandins PGE2
    1. Options:
      1. Prostin 1-2mg into Posterior fornix
      2. Cervidil 10mg into Posterior fornix
      3. Can repeat after application x 1
    2. Monitor FHR before and after application (1-2 hours)
    3. Risk: rupture, infection, tachysystole, vaginal irritation
    4. NO CERVICAL PREPARATIONS in PROM
  3. Prostaglandins PGEI
    1. Misoprostal 50 ug oral or 25 ug transmucal (vagina)
    2. Oxytocin should not be given w/in 4 hours of last dose
    3. Side-effects: N/V/D, uterine tachysystole
    4. Monitor FHR before and after application (30+minutes)

Induction with favorable cervix: Edit

  1. Amniotomy:
    1. Should be used in conjunction with oxytocin
    2. Creates commitment to delivery - ensure proper fetal presentation
    3. Risk of cord prolapse and infection
    4. After amniotomy: note amount, color of amniotic fluid, assess FHR, ensure no cord prolapse and head well applied
  2. Oxytocin:
    1. Causes myometrial smooth muscle contraction
    2. First line in PROM
    3. Risks: hypotension, fetal compromise, hyperstimulation of uterus, uterine rupture, water intoxication, postpartum hemorrhage

Treatment of tachysystole Edit

  • Definition: > 5 contractions in 10 minutes, Ctx >90 seconds, or less than 30 seconds between Ctx
  • D/C oxytocin
  • Maternal position change, oxygen, IV fluids
  • Pelvic examination for dilation and r/o prolapse
  • +/- scalp electrode
  • Possible tocolytic - IV nitroglycerine
  • Immediate preparation for delivery if abnormal FHR


Fetal Heart Rate Monitoring Edit

  • Normal: external dobbler or fetal scalp monitor.
    • Baseline: 120-160 with moderate variability. No decelerations
    • >2 accelerations in 20 minutes. Accelerations > 15bpm, greater >15secs. 
  • Early decelerations: head compression. Benign
  • Variable decelerations: cord compression. 
  • Late decelerations: uteroplacental insufficiency. Initial management: change position, 100% O2, hold oxytocin, IV fluids +/- immediate delivery

SEE google documents (ALARM):[http:// https://drive.google.com/drive/folders/0B2fXzHCO6AYSOS1FNF9aQmZaX3c https://drive.google.com/drive/folders/0B2fXzHCO6AYSOS1FNF9aQmZaX3c]

Edit

Assisted Vaginal Deliveries Edit

Vacuum Delivery: Edit

  • Indications: atypical or abnormal FHR, medical d/o to avoid valsalva, inadequate progress in labour, lack of maternal expulsive effort, >2+ station, proper position OA
  • Risks: lacerations, fetal scalp trauma, cephalohematoma, subgaleal hemorrahge, intracranial hemorrhage, hyperbilirubinemia, retinal hemorrhage
  • Contraindications: non-cephalic, fetal position not OA, any contraindication to vaginal delivery, <GA 34, need for rotation
  • Pre-requisites:
    • A - address patient, obtain consent, anesthesia, assistance (neonatal team/obs)
    • B - bladder empty
    • C- cervix full dilated, membranes ruptured
    • D - Determine position, station, and pelvic adequacy
    • E - Equipment, ongoing fetal/maternal monitoring
    • F - Fontanelle - ensure maternal tissue out of the way
    • G- Gentle traction (100mmHG initially). Pull with Ctx. Increase to 600mmHG
    • H - Halt - no progress with 3 tractions, pop-offs x 3, >20 minutes
      • pop-offs etiology: poor seal,improper traction angle, impingement of maternal tissue, excessive traction force (unrecognized CPD, presentation not OA)
    • I - Incision - consider episiotomu
    • J - Jaw - remove vacuum when jaw is reached

Forceps Delivery: Edit

  • Risks: higher risk maternal injury, fetal facial nerve palsies, fetal ocular injuries
  • Indications: same as vacuum delivery + sub-optimal station or presentation of presenting part
  • Contraindications: same as vacuum deliveries
  • Pre-requisites: same as vacuum deliveries

Vaginal Birth After C-SectionEdit

  • VBAC - icnrease risk of uterine rupture and failure for SVD
  • Contraindications: history of uterine rupture, > 1 C/S, classical c/s, multiples (twins+), placenta previa, macrosomia, within 18-24 months of last C/S
  • Consult obstetrics for review

Antepartum Hemorrhages Edit

Placental abruption

  • Premature separation of the placenta from the uterine wall (incidence 1%)
  • Classifcation: concealed (80%) - no bleeding, revealed (20%)
  • Risk factors: previous, advanced maternal age, trauma, HTN, cocaine/substance use, uterine anomalies, vascular disease, multiparity, PPROM, rapid decompression of distended uterus (twins, polyhydramnios)
  • Clinical: PV bleeding, abdominal pain, anemia, fetal distress, hypertonic tender uterus
  • Diagnosis: clinical, U/S to r/o previa. CBC, coags, fibrinogen, T + S
  • Complications:
    • Maternal: DIC, anemia, hypovolemic shock, mortality
    • Fetus: hypoxia, prematurity, neurological complications. fetal demise
  • Mngt: stabilize, rhogam, delivery w/ either c/s or vaginal pending fetus/maternal stability. May also trial conservative management

Placental previa

  • abnormal placental location near or covering cervical os (low lying - within 2 cm of internal os)
  • Risk factors: multiparity, previous previa, multiple gestations, advanced maternal age, smoking, uterine scarring
  • Diagnosis: ultrasound
  • Clinical course: 90% resolve by third trimester. Need f/u U/S at 30-32 weeks.
  • Clinical symptoms: painless PV bleeding, uterus soft/non-tender
  • Complications:
    • Maternal: shock, DIC, mortality, placenta accreta/increta/percreta
    • Fetal: preterm delivery, IUGR, malpresentation, congenital anomalies, vasa previa
  • Management: stable --> conservative with bed rest. Unstable --> Emergency c-section
  • Delivery: C- Section ONLY

Vasa Previa

  • Bleeding from baby (rare. Occurs with velamentous cord insertion_
  • Clinical: small amounts of bleeding with fetal distress
  • Diagnosis: clinical. Apt test (differentiate maternal versus fetal blood)
  • Management: poor fetal prognosis. Immediate delivery by C- Section

Uterine rupture

  • Clinical: acute onset abdo pain, uterine hypertonic, abN FHR, PV bleeding, palpable fetal limbs, high lying fetus
  • Risks: prior surgery (esp classical incision), oxytocin, grand multip, Previous uterine manipulation
  • Complications: maternal and fetus mortality, DIC, shock, amniotic fluid embolism

Other etiology of bleeding 

  • cervial, vaginal polyps, cancer, trauma
  • other sites: baldder bowel
  • Bleeding d/o

PROM Edit

  • History: gush of fluid
  • Physical: sterile spec r/o cord prolapse. No bimanual examination. Assess for pooling, ferning on microscopy, nitrazine blue
  • Management: if GBS negative - expectant x 24 hours then induction. If GBS positive - admit + induction

Preterm Labour Edit

  • Definition: regular contraction + cervical changes between 20-37 weeks
  • Investigations: fetal fibronectin, U/S for cervical lenght, urine R+M, C+S
  • Management: bed rest, counselling, steroids IM x 2, +/- tocolytics, +/- magnesium sulfate if < 32weeks GA for neuroprotection

Umbilical cord prolapseEdit

  • Definition: descent of umbilical cord through cervix alongside (occult) or past presenting part (overt) in presence of ROM
  • Risk factors:
    • malpresentation, polyhydramnios, preterm, grand multiparity >5, male gender, pelvic tumors, placenta previa or low lying placenta, multiples, PROM, cephalopelvic disproportion, iatrogenic (Amniotomy/scalp electrode placement/IU pressure catheter insertion/ attempted external cephalic version/manual rotation of fetal head)
  • Diagnosis:
    • Visualize/palpate cord
    • Sudden FHR deceleration with ROM
  • Management:
    • Call for HELP
    • Elevate presenting part (until delivery)
    • Trendelenburg position
    • If delayed C/S inflate bladder and clamp foley 

Shoulder dystocia Edit

  • Clinical: turtle sign, head tight against perineum, spontaneous restitution does not occur
  • Risk factors: 50% - no risk factors
    • macrosomnia, maternal DM, GA>42, multiparity, previous shoulder dystocia, previous macrosomnia infant, excessive weight gain in pregnancy, prolonged labour, epidural, labour induction, operative vaginal delivery
  • Morbidity and mortality:
    • Fetal: hypoxia, birth injuries (brachial plexus injury, clavicle #), death
    • Maternal: PPH, uterine rupture, 4th degree tears
  • Management: ALARMER
    • AVOID 4 P's: push, pull, panic, pivot
    • A- Ask for help
    • L - lift/hyperflex legs (McRobert's maneuver)
    • A- anterior shoulder disimpaction (suprapubic pressure). NO FUNDAL PRESSURE
    • R - rotation of posterior shoulder (Woodscrew's maneuver)
    • M - Manual removal of posterior arm
    • E - episiotomy
    • R - roll over onto all fours
    • Other options: deliberate # clavicle, symphysiotomy, zavenelli maneuver (replace baby into uterus then c/s)

Post-partum Edit

Retained PlacentaEdit

  • Undelivered placenta > 30 minutes post infant delivery (failure to deliver versus abnormal implantation)
  • Risk of post-partum hemorrhage and infection
  • Management: stabilize - blood products PRN, explore uterus - firm traction on umbilical cord with suprapubic pressure + oxytocin --> no success attempt manual removal --> no success D+C

Post-partum Hemorrhage: Edit

Definition:

  • >500 cc blood loss vaginal delivery
  • >1000 cc blood loss C-section
  • Primary: within 24 hours
  • Secondary: late > 24 hours. Often caused by retained products of conception

Etiology: 4 T's Edit

  1. TONE (#1 cause)- uterine atony or distended bladder
    1. Overdistention - polyhydramnio, multiples, macrosomia
    2. Uterine muscle exhaustion - rapid labour, prolonged labour, high parity, oxytocin use, induction
    3. Intra-amniotic infection - prolonged ROM, fever
    4. Anatomic abnormalities of uterus: fibroids, uterine anomalies
    5. Uterine relaxing agents: tocolytics, anesthetics
    6. Bladder distention
  2. Trauma - laceration, rupture, inversion, hematoma
  3. Tissue -retained placenta/clots
  4. Thrombin - congenital or acquired coagulopathy
    1. acquired: ITP, DIC, abruption, amniotic fluid embolism, gestational HTN

Prevention: Edit

  • Oxytocin at delivery
    • 10 units IM at delivery of anterior shoulder
    • 20-40 units in 1000ml normal saline at 100-150cc/hour
  • Gentle cord traction with suprapubic support of uterus
  • Delayed cord clamping

Management: Edit

  • ABCs + monitor vitals
  • IV fluids
  • CBC, crossmatch, caogs
  • If uterus boggy:
    • External uterine massage
    • Oxytocin
      • 5 units IV push
      • 20-40 units in 1 L NS wide open
      • 10 units IM
    • Bimanual massage - assess for retained products
    • Empty bladder
    • Hemabate/carboprost
      • 250uG IM q15 minutes (Max 8 doses)
      • Contraindication: asthma
    • Carbetocin
    • Misoprostal(cytotec)
      • 200mcg oral + 400mcg S/L
      • 800 - 100mcg rectal
      • SL quicker but rectal lasts longer
    • Ergonovine
      • 0.2 -0.25 mg IM q 2-4 hours
      • 0.125 mg IV q 2-4 hours
      • Contraindication: hypertension disorders, HIV drugs. Risk of stroke
  • If uterus firm:
    • explore lower genital tract
    • Ensure adequate analgesia
    • Repair lacerations
    • Evaluate for acquired coagulopathy and correct for FFP/platelets/pRBCs
  • Other therapies:
    • tamponade, emergency embolization, emergency laparotomy, emergency hysterectomy

Post-partum Fever Edit

  • THINK W's
  • Wind (atelectasis, pneumonia), water (UTI), wound (C/S, episiotomy site), womb (endometritis, retained products of conception), walking (DVT, pelvic thrombophlebitis), breast (mastitis, engorgement)
  • Investigations: pending history. If endometritis suspected - blood, genital cultures, ultrasound for retained products of conception
  • Mngt: pending etiology. Endometritis - clinda + gentamycin

Post-partum check-up Edit

  • Give Rhogam 300ug IM within 72 hours of delivery if infant is Rh positive
  • Give MMR 0.5ml IM to rubella nonimmune
  • Contraception: non-breastfeeding- OCP within 3 weeks postpartum.
  • if breastfeeding: IUD or mini pill at 6 weeks post-partum. Or OCP at 3 months/introduction to supplemental feeding

REMEMBER the B's

  • Brains (blues, depression, psychosis)
  • Breasts (breastfeeding, pain)
  • Blood pressure
  • Bladder/bowel function
  • Bleeding (PV - color, smell, amount)
  • Baby (concerns, feeding, bonding, support at home)

Physical exam:

  • Immediate post-partum: Vitals, symptoms of anemia, abdomen, C/S - incision (ask about calf swelling, CP/SOB)
  • 6 weeks post-partum: pelvic exam +/- pap

Post-partum Depression Edit

Post-partum BluesEdit

  • 85% of mothers, onset day 3-10, lasts < 2 weeks. No treatment required.
  • Symptoms: emotional labiality, flat affect, irritable, poor concentration

Post-partum DepressionEdit

  • Major depressive episode occuring within 4weeks- 6 months of delivery
  • 10% of mothers, 50% reoccurrence
  • Treatment: SSRIs (avoid fluoxetine), Behavior activation strategies, CBT

Post-partum PsychosisEdit

  • Rare. Risk of harm to both mother and baby
  • +/- involuntary form 1, consult psychiatry

Breast feeding Edit

  • Benefits: contains essential nutrients in proper %, bonding, antibodies/immune benefits, cost effective
  • Information to mother:
    • colostrum< 72 hours (yellow/thick---> white breast milk)
    • important for mother to obtain balanced diet and enough calories as breastfeeding burns calories
    • Breastfeed every 2-3 hours or whenever baby is hungry. Feed them as long as they want alternating breasts
    • Breastfeeding well: hear sucking noise, breasts do not hurt after BF, full breast-->empty feeling after feeds, baby appears content
  • If exclusively breastfeeding: need to add Vitamin D 400IU daily
  • Screen for poor latch, poor production, poor let-down
  • Consider referral to lactation consultation
  • Could consider domperidone if poor supply
  • Breast feeding resources: http://www.rourkebabyrecord.ca/parents/?t=1

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