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Obs and gynae - Set 1

Terms in this set (54)

Bodies responsible for setting rules governing clinical practice:
- Legislation:
~ Human Tissue Act 2004
~ Mental capacity Act 2005
- common law: caused by recent legal cases
- GMC regulations
- DOH
- BMA
- Royal collages

Fundamental rules to govern ethical choices in medicine:

Autonomy:
- the right for an individual to make his or her own choice

Beneficence:
- the principle of acting with the best interest of the other in mind

Non-maleficence:
- the principle that 'above all, do no harm' as stated in the Hippocratic oath

Equality/justice:
- concept that emphasises fairness and equality among individuals

Principles of valid consent:

1. patient must be competent to make the particular decision

The four elements of competent consent:
- outlined in the Mental Capacity Act 2005
- a patient is deemed to be competent to provide consent if they...
- understand information given to them (must present in a way appropriate for the patient to understand, e.g. if cannot read need to speak aloud)
- retain this information
- be able to weight up the pros and cons of the information and use this to make an informed decision
- communicate this decision (by any means e.g. blinking for yes)
- if one of these elements is missing then consent has not been adequately obtained
- people over 18 are deemed to have capacity unless proven otherwise

Consent in under 18s:
- see previous flashcard about Gillick ruling/Fraser guidelines

2. patient must have received sufficient information to make the decision

Information needed:
- the intended procedure
- the intended benefits
- alternative treatments
- risks:
~ serious risks
~ common risks
~ can use risk descriptors to help with this (see table in image)
- there procedures that may be involved

- if consent has to be taken during a painful labour, you must give the information between contractions

Explicit consent for medical students to be in room is needed for:
- during gynaecological and obstetric consultation
- in operating theatres as observers and assistants
- then performing clinical pelvic examination (this must be written consent if pelvic examination of an anaesthetised woman)

Information to give before conducting an intimate examination:
- explain to the patient why an examination is necessary and give the patient the opportunity to ask questions
- explain what the examination will involve in a way that the patient can understand, so that the patient knows what to expect (including pain and discomfort)
- ask patients permission before the examination and record that patient has given it
- offer a chaperone
- give patient privacy to dress and undress
- keep patient covered as much as possible to maintain dignity
- do not remove patient clothing unless they have asked you to or you have checked with them that they want help

Information to give during an intimate examination:
- explain what you are going to do before you do it
~ if its different to what you told them before, explain why and seek patients permission
- stop the examination if the patient asks you to
- keep discussion relevant and don't make unnecessary personal comments

Chaperones:
- need to always offer a chaperone and document the name of that person
- this offer should be made irrespective of sex
- offer should be documented even if patient declines (best practice may be to recommend a chaperone)

Who can a chaperone be?:
- should usually be a health professional
- chaperone should be sensitive and respect the patient's dignity and confidentiality
- they should reassure the patient if they show signs of distress and discomfort
- they should be familiar with the procedures involved in a routine initiate examination
- they should stay for the whole examination and be able to see what the doctor is doing, if practical
- they should be prepared to raise concerns if they are concerned about the doctor's behaviours or actions


3. patient must not be acting under duress, and there must be no coercion or deceit


Informed consent:
- a patient's agreement for a healthcare professional to provide care

Types of consent:

1. Oral:
- a form of valid consent
- however, it is best practice to obtain written consent for major procedures
- if it is only possible to obtain oral consent, it is good practice to make an entry in patient's notes to confirm advice was given and oral consent obtained
~ also include names and designations of any witnesses

2. Written:
- provides documentary evidence that the patient is willing to undergo the procedure
- cannot judge if patient is competent or if patient is acting under duress

3. Implicit consent:
- usually in an outpatient setting, consent is implied
- e.g. if a person rolls up their sleeve for blood pressure cuff it is implied that they consent to blood pressure being taken
Stillbirths:
- stillbirth rate is 5.7/1000 live births
- most common reason for stillbirth is unexplained (<2500g), then congenital malformations
- more than 50% of stillbirths are unexplained
- higher levels of stillbirths and neonatal deaths in lower birth weights and with smaller gestation
- extremes of maternal age (e.g. <20 or <40) have higher rates of stillbirth and neonatal deaths
- higher rates of both deaths in black and asian ethnicities than in white
- higher rates of both in higher levels of maternal deprivation

neo-natal deaths:
- top cause is immaturity (47.9% of neonatal deaths, 69% in multiple pregnancies)
- then congenial malformations, then intrapartum
- multiple births have 3x the rate of stillbirths and 7x the rate of neonatal deaths than single babies
~ a woman with a multiple pregnancy is 4x more likely to die

Congenital malformations:
- 8.2% of stillbirths have a CM
- 21.6% of neonatal deaths
- 30.7% of post neonatal deaths

Rates of maternal mortality:
- see graph for location
- UK rate = 11.39 per 100,000

Maternal suicide:
- 4% of suicides are in lone carers of children
- 22% are considered preventable
- 75% of mothers who die by suicide have factors that would have reduced risk
- half of suicides have a psychiatric history
- there are specialist perinatal mental health services
- 10% of new mothers develop depression, 1/3-1/2 of which are severe
- 2% are referred to psychiatric services and 0.2% have psychosis
- most common methods = hanging, jumping from height

Maternal drug use:
- 2-3% of children in the UK have a parent with drug or alcohol problems
- 26% of drug users die by suicide, 29% by accidental overdose, 37% due to medical conditions and 9% in RTAs/house fires
- there are specialist clinics for drug users - MDT approach including wider social and addiction services

Maternal abuse:
- 1 in 4 lifetime incidence of abuse
- 2 women and 2 children a week die as a result of family/partner abuse
- a woman is at higher risk when pregnant and when they leave their partner
- if the mother is abused, 70% of children are also abused
- all classes and races are at equal risk
- 21% of girls under 16 in UK experience sexual abuse in childhood

Maternal deaths due to medical condition: common conditions:
- thrombosis and thromboembolism
- haemorrhage
- early pregnancy deaths
- pre-eclampsia and eclampsia
- genital tract sepsis
- anaesthesia
- amniotic fluid embolism

how to manage high risk pregnancies:
- deliver high risk women in an appropriate place
- protocols
- training
- cancer = women have to make difficult choices and will need emotional support through this
Definition:
- any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality

Types of abuse:
- psychological
- physical
- sexual
- financial
- emotional
- HBV ('Honour' based violence or 'honour' crime is an act of violence explained by the abuser as being committed in order to protect or defend the 'honour' of the family/community. These crimes include: Domestic and Sexual Violence. Forced Marriage)
- FGM
- forced marriage

Epidemiology:
- 1 in 4 women and 1 in 6 men
- half of gay and bisexual men have experienced abuse
- 2-3 women are killed per week
- 1 man killed every 17 days
- risk increased with: teenagers, on disclosure, on leaving a partner and during pregnancy
- domestic abuse accounts for 18% of all violent crime in England and Wales
- women who've been abused present more frequently to hospital with chronic health complaints, unexplained pain and gynaecological problems
- higher levels of mental health issues, self harm, substance and alcohol misuse

Impact on children:
- increased risk of children developing physical and emotional health issues
- increased risk of abuse, injury and death
- nearly 75% of children considered at risk by social services live in a household with a parent experiencing abuse

Barriers to disclosing:
- shame
- fear
- not being believed
- what will happen to the children
- no support with previous disclosure
- who to trust
- language

How to ask the question to patients:
- Acknowledge = 'that bruise looks painful/sore"
- Contact = 'have you seen a doctor for that?"
- Enquire = 'can you tell me how you got that bruise?'

Responding to a disclosure:
- prioritise the safety of survivor and children
- acknowledge, believe and support the victim
- be honest about what you can keep confidential
- contact the domestic abuse link for advice/support and information sharing
- provide helpline numbers/cards
- think about if it is safe for lady to go home

Sharing information:
- share concerns with manager, colleagues and safeguarding team
- share relevant information with external agencies
- information about an abused child can be shared without consent if it protects child/public interest
- explain why and to whom you're disclosing to if appropriate

Support and advice:
- a domestic abuse nurse
- safeguarding adult/children's teams
- Women's aid
- Respect
- police 101 or 999 if in immediate danger
1. Introductions/consent and explanation:

2. Inspection:
- DO NOT LIE SUPINE = can lead to lightheadedness/passing out
- inspect for scars, fatal movements, symmetry and cutaneous markers of pregnancy:
~ linea nigra (darker pigmented line along midline - normal sign pregnancy)
~ striae gravidarum (stretch marks in pregnancy - normal sign)

2. Palpation:
- assess pain/tenderness over the uterus
- measure the symphysial-fundal height (SFH)
~ a measurement from the symphysis pubis to the fundus of the uterus
~ approx. equivalent to the gestational weeks +/-2cm (e.g. 28 weeks = 28cm - see pic)
~ crude measurement of foetal growth over time (plot over time on growth chart)

Palpate the foetus:
- need to use 2 hands to palpate the foetus as the foetus is in a sack of water so will bob away

~ lie of foetus
A. longituditional lie (see next flashcard for image)
B. transverse lie (at 90 degrees to mother)
C. oblique lie (on a diagonal)

~ presentation of foetus
- the anatomical part of the foetus that is leading/nearest the pelvic inlet of the mother
- cephalic = head first
- breech =bottom first
- shoulder and cord presentations (rare)

~ assess the engagement of the foetus (may be difficult if under 34 weeks!)
- the foetus is engaged if the widest part of the fetal head has passed through the pelvic inlet
- it is determined by the amount of the head we can feel in the maternal abdomen
- divided into fifths: 5/5, 4/5,3/5 = not engaged, 2/5,1/5,0/5 = engaged


3. Auscultate the foetal heartbeat
- auscultate the foetal heartbeat
- normal range is 110-160 beats per minute (100 may be normal if towards term)
- heartbeat is higher in preterm, getting lower towards term
- need to locate the foetal back on examination as you need to auscultate over the foetal anterior shoulder
For any gynaecological exam:
- start with abdominal palpation to assess for any masses or pain
- requires verbal instructions about exam, why it is needed and consent from patient
- ask for a chaperone

Patient positioning:
- undress clothing from the waist down including underclothes
- cover yourself with a sheet and lay flat on bed if able to do so
- bend your knees with feet together, drawing them up towards your bottom and let your legs flop to the side

Speculum examination:

Firstly examine the external genitalia/vulva

Terminology:
- Vulva = the externally visible female genitalia including the mons pubis, labia majora and minora and clitoris
- Vaginal introitus = the opening of the vagina visualised by separating the labia

Look for:
- problems with skin around genitalia
- scars from previous operations
- abnormal discharge or bleeding
- any visible prolapses

Then insert the speculum to visualise the cervix and upper vagina

Types of speculum:
1. Cusco speculum = a bivalve speculum used for inspecting the cervix, taking smears and swabs
~ can be metal or plastic, use same technique for both

2. Sim's speculum:
- used to assess vaginal wall prolapse

Taking swabs:
- take swabs from vagina and cervix to check for vaginal examinations and STIs
- traditionally 'triple swabs':
~ black charcoal high vaginal swab (taken from posterior fornix vagina, for candida, trichomonad, bacterial vaginosis)
~ black charcoal endo cervical swab (for gonorrhoea)
~ pink coloured NAAT swab (endo cervical, for chalmydia and gonorrhoea)

- now can test for gonorrhoea and chlamydia using a self administered low vaginal swab ('double swab' = replaces the 2 swabs for STIs, taken before speculum is inserted)

endocervical swabs = swab the pinpoint on the cervix
What is antenatal care?:
- care provided during pregnancy
- multidisciplinary approach
- allows opportunity for screening, education or treatment

How is it delivered?:
- consultant led with shared care
- community led
- input from: midwives (hospital/community), obstetricians, GPs
- takes place in GP surgery, hospital and patient's home

Classic timeline of antenatal care:
- before 10 weeks: booking visit with midwife
- 11-14/40: dating scan
- 18-20+6/40: anomaly ('detailed') scan
- later appointments depend on risk factors
- nulliparous women (first baby) = 10-12 midwife appointments:
~ every 4 weeks from 20/40
~ every 2 weeks from 28/40
~ weekly from 36/40
- parous women = 7 appointments

The booking visit:
- full history from patient
- relevant examination
- height/weight (calculate BMI)
- BP
- urine dip +/- MSU
- offer screening
- purpose of visit = identify risk factors, offer screening, arrange early ultrasound, give information, plan antenatal care

Identifying medical risk factors:
- any pre-existing medical conditions
- any psychiatric disorders requiring treatment
- any infections (especially HIV, hepatitis B/C)
- include current medications (?safety in pregnancy)
- family history of conditions
- BMI >30 or <18
- age >40

Identifying obstetric risk factors:
- small (<2.5kg) or large (>4.5kg) previous babies
- previous still births or neonatal deaths
- any preterm births
- any previous pre-eclampsia, hypertension or gestational diabetes
- history of recurrent miscarriage
- previous uterine surgery
- previous grand multiparty (>para 4)

Identifying social risk factors:
- housing
- support? domestic violence
- any smoking/alcohol/drug use
- any previous social care environment (patient or children)
- thought of school?

Advice to give women in booking visit:
- specific to gestation
- healthy lifestyle advice:
~ food safety in pregnancy
~ dental care
~ exercise
~ folic acid
~ vaccinations
- anti-D status
- advice on breastfeeding

Planning antenatal care timeline:
- frequency of visits and investigations depend on risk factors
- booking history is vital
- clear documentation in handheld notes

Follow up visits:
- to confirm maternal wellbeing
- to confirm fetal wellbeing
- identification of complications:
~ BP check/urine dip
~ ask about symptoms
~ symphysis-fundal height
- screening
- information
Twins:
- dizygotic twins (different eggs) = 80% of twins
~ dizygotic twins are dichorionic and diamniotic
- monozygotic twins (one egg and one sperm) = 20% of twins
~ can be monochorionic and mono amniotic (MC/MA)
~ or can be monochorionic and diamniotic (MC/DA)

Predisposing factors to dizygotic twins:
- mutliparity
- older age
- fertility treatments
- ovarian hyper stimulation without IVF (very high chance multiple birth)
- ovulation induction

Maternal physiological changes in multiple births:
- increase in weight and CO
- plasma volume is increased by an additional 500ml
- there is exaggerated haemodilution and anaemia
- there is increased AFP level, tidal volume and GFR

Use of USS in multiple pregnancy:
- to confirm the pregnancy
- to confirm the viability of the fetus
- to look for chorionicity
- to look for fetal abnormalities
- to look for twin/twin transfusion
- to look for placental localisation
- for fatal growth monitoring for IUGR
- to assess the amniotic fluid volume
- to assess the presentation and lie of the foetus

Fetal complications in multiple pregnancies:
- increased risk of miscarriage
- premature rate is high (80%)
- twin-twin transfusion syndrome
- placental insufficiency
- IUGR
- structural anomalies
- interuterine death of one foetus
- asphyxia and stillbirth

Maternal complications in multiple births:

During pregnancy:
- anaemia
- pre-eclampsia (25%)
- hydramnios(10%)
- antepartum haemorrage
- malpresentation
- preterm labour (50%)
- mechanical distress

During labour:
- early rupture of membranes and core prolapse
- prolonged labour
- bleeding
- postpartum haemorrhage
- increased operative intervention

Management of multiple pregnancies:
- consultant led MDT care
- identify the type of twin
- screen in first trimester for twins
- counselling about the risk and complications
- need regular USS
- encourage to take vitamins and iron supplements
- encourage to attend twin birth antenatal classes
- discuss the timing and mode of delivery with the mother

Common lie and presentation baby:
- most common lie = longitudinal
- most common presentation = both vertex (50%)
~ first vertex and second breech = 30%
~ first breech and second vertex = 10%
~ both breech = 10%


Patient explanation of labour with multiple births:

Once your first baby is born, your midwife or doctor will check the position of your second twin by feeling your tummy and doing a vaginal examination, or an ultrasound scan.

If your second baby is in a good position to be born, the waters surrounding him will be broken. Your second baby should be born very soon after the first, because your cervix is already fully dilated. If your contractions stop after your first twin is born, hormones are added to the drip to restart them.

You'll usually be recommended to have a managed third stage. This is when the placenta is delivered with the help of a hormone injection, instead of a natural delivery. This is because there is an increased risk of bleeding when the placenta is larger, and the uterus (womb) will have been stretched by two babies.

Triplets/quads:
- perinatal loss is increased due to prematurity (average time of delivery for quads is 30-31 weeks)
- selective reduction = if there are 4 or more foetuses, selective reduction leaving 2 foetuses behind is done t improve outcome
~ this is done by intracardiac injection of potassium chloride between 11-13 weeks
- selective termination = of a foetus with structural or genetic abnormalities may be done in a chorionic multiple pregnancy in the second trimester
Epidemiology:
- cardiac disease is the biggest cause of maternal death 2013-15
- 2 pregnant women per 100,000 died from heart disease
- cardiac deaths are increasing = due to older mothers, increasing obesity, better cardiac data and better recognition of cardiac pathology
- complicates 1% of pregnancies

Maternal adaptions during pregnancy:

Why are adaptions required?:
- foetus increases oxygen requirements
- enlarging uterus and breasts also increase oxygen requirements
- increase in maternal work due to 10-14kg weight gain

Physiological changes:
- increased preload
- physiological anaemia
- increased cardiac output
- fall in systemic vascular resistance mid-pregnancy
- colloid oncotic pressure falls

Changes during stages of labour:

First stage:
- cardiac output increases 15-30%
- supine position reduces cardiac output
- sympathetic response to anxiety and pain

Second stage:
- cardiac output increases up to 50%
- blood pressure increases with pushing
- venous return decreases with pushing

Third stage:
- up to 1L of blood returns to circulation
- cardiac output increases by 60-80%

Postnatal:
- cardiac output returns to pre labour levels by around 1 hour after birth
- reversion of pregnancy changes over 6 weeks, but can persist for up to a year

Diagnosing cardiac issues in pregnancy:
- cardiac symptoms are common in pregnancy, particularly:
~ fatigue
~ fainting
~ palpitations
~ breathlessness

- however, cardiac pain can present differently in pregnancy. RED FLAGS ARE:
~ Chest, back, epigastric pain
~ wheeze
~ persistent breathlessness when lying flat is NOT NORMAL in pregnancy - can suggest cardiac cause
~ severe chest pain spreading to arms = cardiac
~ always investigate: raised resp rate, persistent tachycardia, orthopnoea

- congenital heart problems are more commonly seen, but women are more likely to die from acquired heart disease in pregnancy

Antenatal care of women with cardiac disease:
- MDT approach
- baseline heart assessment and ongoing surveillance
- review medications
- consider performing growth scans
- have a low threshold for other investigations
~ do not deny investigations just because they are pregnant
- individualise care = disease specific

Mode of delivery for those with cardiac conditions:
- vaginal birth generally has a reduced risk of blood loss, VTE and infections compared to C-sections
- haemodynamic changes are more rapid at C-section
- vaginal birth recommended unless there are obstetric reasons for C-section

modifications for delivery:
- minimise cardiovascular stress
- continuous fetal monitoring
- positioning

Role of epidurals:
- GIVE EARLY EPIDURAL
- can assist in pain control, reducing maternal tachycardia and aids BP management
- can also help to avoid further increases in CO associated contractions
- can reduce the need for spinal/GA if operative delivery required
- facilitates a limited 2nd stage

Management of second stage:
- try and keep it short as puts pressure on mother's heart
- occasionally may need diuretics at delivery

Management of third stage:
- syntocinon (which helps uterus to contract to deliver placenta)
~ can cause tachycardia and hypotension
~ give as a slow IV infusion instead of bolus dose to minimise effects

- ergometrine can cause hypertension (via vasoconstriction) and coronary artery vasospasm

- most partum haemorrhage is potentially more problematic
Definition:
AFTER 20 WEEKS (Bar if hydatidiform mole)
- caused by pregnancy
- cured by delivery of the placenta
- an endothelial cell disorder
- an excessive inflammatory response to pregnancy

Features:
- hypertension
- proteinuria
- oedema
- multiorgan involvement
- fetal compromise
- maternal morbidity and death

Risk factors:
- extremes of reproductive age
- socioeconomic status
- ethnicity
- genetic factors
- multiple pregnancies
- primigravida
- assisted contraception
- previous pre-eclampsia
- obesity
- chronic renal disease
- chronic hypertension
- DM and connective tissue diseases
- certain thrombophillia

Pathophysiological mechanisms in pre-eclampsia:
- the placenta's role in late pregnancy is to provide a systemic inflammatory response that activate clotting pathways and the complement system

Abnormal placentation:
- failure of the trophoblast cells to invade myometrium of the maternal uterus
- this means the maternal spiral arteries continue to have thick muscular walls
- reduced maternal perfusion of placenta and possible vasospasm
- placental damage leading to increased apoptosis (cell death)
- release of circulating factors or placental syncytial fragments
- endothelial cell dysfunction
- exaggerated maternal immune response
- foetus = IUGR and hypoxia

Maternal endothelial cell dysfunction:
- causes 3 effects:

1. tissue oedema:
- due to increased permeability of endothelial cells (as they don't work properly)
- fluid leaks out of vascular tree causing oedema

2. hypertension:
- dysfunctional endothelial cells lead to altered production of vasodilator substances
- there is also disturbed control of vascular tone by endothelial cells which causes vasospasm
~ both of these lead to hypertension

3. Clotting dysfunction:
- abnormal endothelial cells produce abnormal levels do procoagulants
- these cause activation and clumping of platelets
- can lead to DIC

Organ hypoperfusion:
- the vasoconstriction caused by abnormal endothelial cells leads to underperfusion/focal ischaemia in:
~ kidneys
~ liver
~ brain

Plasma volume loss:
- the intravascular compartment becomes constricted and underfilled due to the considerable tissue oedema (from leaking endothelial cells)
- low intravascular volume contributes to poor organ perfusion including of the foetus/placenta

Complications of pre-eclampsia:

Maternal:
- Haematological: thrombocytopenia, DIC, haemolysis, HELLP, thromboembolism
- Cardiovascular: severe hypertension, LVF, pulmonary oedema
- Respiratory: laryngeal oedema, ARDS
- Neurological: eclamptic seizures, retinal detachment, cortical blindness, intracerebral or subarachnoid haemorrhage
- Renal: oliguria, renal failure (cortical or tubular necrosis)
- Hepatic: hepatocellular dysfunction, ischaemic pain, sub capsular haemorrhage, liver rupture

Fetal:
- asymmetrical IUGR (abdominal circumference falls much faster than head circumference)
- intrauterine hypoxia
- prematurity
- abruption
- stillbirth/interuterine death
- hypertension/IHD/metabolic disease in later life ("fetal programming")

Monitoring of patients with pre-eclampsia:

Maternal monitoring:
- BP 4-6 hourly
- urinalysis +/- quantify proteinuria (PCR, 24 hour collection)
- monitor symptoms and signs
- blood tests
- fluid balance

Fetal monitoring:
- movements
- USS of size and growth
- umbilical artery doppler for blood flow (see picture)
- liquor volumes
- biophysical tests
- CTG (>26 weeks)

Management of pre-eclampsia:

Maintenance tablets:
- Methyldopa
- Labetalol
- nifedipine (slow release)
- prazocin/doxazocin
- atenolol

NOT ACE-Is OR DIURETICS

Emergency BP control:
- hydralazine
- labetolol
- nifedipine (slow release)

Indications for delivery:
- HTN uncontrolled despite maximal hypertensives
- eclampsia
- renal, hepatic or coagulation impairment
- pulmonary oedema
- fetal distress
- milder pre-eclampsia at term

~ consider steroids if pre-term
~ mode of delivery dependent on severity, gestation and previous obstetric history
Classification:
- overweight = 25-29.9
- obesity I = 30-34.9
- obesity II = 35-39.9
- obesity III = 40+

Epidemiology:
- 21% of women were obese at booking in 2015
- 8.7/10,000 mothers have BMI >50
- 33% of women who died as mothers have BMI >30

Obesity and pregnancy antenatal risks:
- 1st trimester miscarriage
- recurrent miscarriage
- fetal anomaly
- UTI
- hypertension and pre-eclampisa
- gestational diabetes
- macrosomia
- increased minor complications
- 22% of women with BMI >35 have at least one comorbidity (DM, HTN, CVD, sleep apnoea, VTE)

Modifications to antenatal care:
- consultant led care
- weight management advice
- use of the correct blood pressure cuff
- assess co-existing conditions

Preconceptual counselling:
- weight loss
- appropriate contraception
- assessment of other medical problems
- 5mg folic acid
- ?low dose aspirin

Early pregnancy:
- high dose folic acid (5mg)
- 10mcg of vitamin D
- ?75mg of aspirin from 12 weeks (for ?pre-eclampsia)
- may have some difficulties with dating

Management plan:
- glucose tolerance test
- referral to a dietician
- risk assess for VTE prophylaxis
- possible increased visits in 3rd trimester
- avoid unnecessary inductions
- may need multiple USS to discover presentation and growth

Risks of pregnancy in obese people:

Intrapartum risks:
- dysfunctional labour
- induction of labour (unsucessful)
- shoulder dystocia
- 3rd and 4th degree tear

anaesthetic risks:
- failed epidurals
- aspiration during general anaesthesia
- difficulty with intubation
- respiratory complications
- difficulties with IV access

Neonatal risks:
- lower Apgar scores
- increased likelihood of admission to NICU
- increased stillbirth and neonatal death

Postpartum risks:
- PPH
- VTE
- endometriosis
- wound infection and dehiscence (edges of wound don't meet)
- longer hospital stays
- problems with breast feeding

Intrapartum care:
- MDT
- fetal monitoring (discuss early use of FSE)
- consider early epidural
- regular ranitidine
- early IV access

Considerations for C-section:
- table weight limits
- anaesthetics = see 'risks' above
- loss of normal anatomical landmarks
- problems with access and retractions of pannus
- longer instruments needed
- suture materials

Postpartum care:
- VTE prophylaxis = if BMI >40, offer regardless of mode of delivery
- careful surveillance for infection
- watch pressure areas
- breastfeeding support
- advice on weight reduction
- opportunity for pre-conceptual counselling
Epilepsy:
- prevalence 0.5-1% (most common neurological condition in pregnancy)
- 2500 babies born to women with epilepsy each year
- 14 women died in birth (or 6 weeks after) from epilepsy

Questions to ask in epilepsy history:
- when was epilepsy diagnosed
- is it idiopathic or secondary to other causes e.g. tumour, following hydrocephalus surgery
- seizure type and control
- medications
- is the woman on folic acid?
- has woman had pre-pregnancy counselling

Commonly used anti-epileptic drugs in pregnancy:
- lamotrigine
- levetiracetam
- carbamazepine +/- clobazam
- clonazepam

Counselling for anti-epileptic drugs:
- the risk of congenital abnormalities in the foetus is dependant on the type, number and dose of AEDs
- some AEDs have adverse impact on long-term neurodevelopment of the newborn
- switching AEDs can be associated with increased seizure frequency (so caution in pregnancy)
- counselling points:
~ AVOID VALPROATE UNLESS NO ALTERNATIVES
~ avoid poly pharmacy if possible
~ use lowest possible dose of appropriate AEDs
~ use high dose folic acid

AEDs and congenital malformations:
- background risk of congenital malformations = 2.2%
- risk of congenital malformations in women with epilepsy without AEDs = 2.8%
- risk of congenital malformations in women with epilepsy on AEDs = 6.1% (dependent on the type, number and dose)
~ <300mg of lamotrigine = 2 in 100
~ <400mg of carbamazepine = 3.4 in 100
~ sodium valproate = 6.7 in 100
~ levetiracetam = 0.7 in 100
~ AED polytherapy = 16.8 in 100

- most common major congenital malformations associated with AEDs:
~ NTDs
~ congenital heart disorders
~ urinary tract and skeletal abnormalities
~ cleft palate
~ with sodium valproate: NTDs, facial clefts, hypospadias
~ phenobarbital and phenytoin: cardiac malformations
~ phenytoin and carbamazepine: cleft palate

AEDs and neurodevelopment:
- in utero exposure to sodium valproate = increased rates of childhood autism
- in utero exposure to carbamazepine and lamotrigine = DOES NOT effect neurodevelopment of the offspring
- very little evidence for levetiracetam and phenytoin

Effects of epilepsy on pregnancy:
- seizure frequency: 1/3 improve, 1/3 stay same, 1/3 worsens
- cause of maternal death: sudden death from epilepsy followed by drowning
- IUGR risk with recurrent tonic clonic seizures
- risk maternal injury
- risk of congenital malformations

Antenatal care for epileptic women:
- MDT (obstetricians and neurologists/epilepsy specialist nurse)
- discuss the effects of epilepsy and AEDs on pregnancy including the risk of discontinuing meds
- aim to be seizure free: assess risk factors for seizures (like sleep deprivation and stress), adherence to meds and frequency
- continue AEDs (lowest effective dose of an appropriate AED) and increase high dose folic acid
- ??monitor serum AED levels (still debated)
- detailed USS performed in line with the national Health Service fetal anomaly screening programme standards
- serial growth scans in third trimester

Intrapartum care for epileptic women:
- epilepsy on its own is NOT INDICATION for c-section unless having recurrent seizures
- hospital delivery in consultant led unit
- continue AEDs during labour
- pool birth not recommended but may be offered with specialist input if seizure free for a significant period
- adequate analgesia and appropriate care in labour provided to stop risk factors for seizures (such as insomnia, stress and dehydration)
- avoid pethidine as it increases seizure frequency

Postpartum care for epileptic women:
- continue AEDs: adjust dose if necessary (sometimes dose of lamotrigine is increased in pregnancy)
- support mothers to ensure risk factors for seizures like sleep deprivation are minimised
- encourage breastfeeding (caution lamotrigine)
- contraception advice
- arrange follow up in neurology clinic before discharge
- safety strategies such as: nursing baby on the floor, using very shallow baby baths, laying baby down if unaccompanied and aura

Contraception for women with epilepsy:
- offer all methods of contraception to women taking non enzyme inducing AEDs
- copper IUD is the preferred choice for emergency contraception for women taking enzyme inducing AEDs
- women taking lamotrigine mono therapy and COCP/oestrogen containing contraceptives need to be informed that lamotrigine levels may fall causing increased risk of seizures
- IUD/IUS/injections can be used in those with enzyme inducing AEDs (no risk of falling levels AEDs)
Normal changes to carbohydrate metabolism in pregnancy:
- foetus and placenta uses glucose = lowers fasting glucose levels
- there is a higher level of insulin resistance due to hormones:
~ HPL from the placenta
~ oestrogen
~ progesterone
~ cortisol
- diabetes develops if the pancreas is unable to provide sufficient insulin to prevent hyperglycaemia

effect of pregnancy on diabetes:
- change in eating pattern (hyperemesis)
- increase in insulin dose needed from 18-28 weeks (increase in insulin requirement by 40% in third trimester)
- need tight HbA1C control
- increased risk severe hypoglycaemia
- risk of deteriorating retinopathy and nephropathy
- lower renal threshold for glycosuria


Congenital malformations with DM:
- hyperglycaemia causes teratogenic effects in early pregnancy (<7 weeks )
~ women with GDM are NOT at risk
- common malformations:
~ CNS = 4x increase in NTDs
~ Cardiac = 3x increase
- rate of major malformations are between 6-10% (varies with HbA1C)
- avoid/delay pregnancy if HbA1C is >10% (>86mmol/mol)

Sacral agenesis:
- <1:1000 pregnancies
- abnormal fetal development of the lower spine
~ due to a disturbance in mesoderm migration between 3rd-7th week of gestation
- variable severity
- associated with smaller lower extremities and paralysis
- bowel/bladder control is usually affected
- aetiology:
~ diabetes
~ inadequate folic acid intake
~ genetic = Currarino syndrome

Antenatal care of diabetic women:

Lifestyle advice:
- refer to DAFNE programme for carbohydrate counting
- have regular meals and snacks including late night supper
- target 1 hour post prandial glucose and <7.8mmol (strongly associated with birth weight)
- eat low GI sources of carbs = improve maternal sensitivity to insulin
- recommend exercise for effects on glucose metabolism and reduces weight gain

Medication:
- regular capillary blood glucose tests
~ 7 point profile
~ if T1: libra device

- insulin regimen:
~ mix of long and short acting insulin
~ basal:bolus regimens
~ bolus for melas
~ insulin pump can be given in some cases

- NOT METFORMIN (T2DM or GDM only)

Disorders of fetal growth:

Macrosomia:
- birth weight over 4kg or >90th centile
- measured from abdominal circumference rather than head circumference
- complicates 10-40% of DM pregnancies
~ can occur in all types of DM
~ related to blood glucose control
- macrocosmic foetuses at risk of sudden IUFD and birth trauma

Growth restriction (IUGR):
- occurs with a baby fails to reach its genetic growth potential
- defined as: birth weight less than the 5th centile or <250g
- can occur in women with long standing diabetes or macro-vascular disease

Fetal risk of diabetes:
- miscarriage
- congenital abnormalities (poorly controlled DM in early pregnancy)
- pre-term labour
- polyhydraminos (25%)
- macrosomia (25-40%)
- IUGR
- stillbirth

Management of delivery:

Timing of delivery:
- aim to redice incidence of macrosomia and stillbirth
- NICE recommends:
~ after 37 weeks T1+T2
~ 40+6 for uncomplicated GDM
~ induction of labour only unless Caesarean section nindicated
~ prostaglandin induction of labour
~ monitor with 7 point profile whilst eating and drinking and normal insulin levels
~ following rupture of membranes = hourly glucose monitoring and if BM >7 = start insulin/dextrose sliding scale

Established labour:
- continuous electronic fetal monitoring recommended as increased incidence of fetal distress in labour
- possibility of operative intervention (keep starved whilst in active labour)
- hourly BM
- insulin sliding scale if BM 4-7mmol/l
- fluid balance

Steroid use:
- for fetal lung maturity
- 2 doses of 12mg dexamethasone or betamethasone at 2 hour intervals
- steroids have anti insulin actions - possibility of hyperglycaemia
- careful monitoring of capillary glucose for 24 hours after each steroid dose
- still give regular metformin/insulin
- BM 1 hourly (if >8, give insulin sliding scale)

Postnatal care:
- insulin requirement falls quickly after delivery of placenta (return to pre-pregnancy levels by 24 hours)
- stop all hypoglycaemics (metformin or insulin) in GDM
~ return to pre-pregnancy medication levels in T1 or T2
- less tight glycemic control is acceptable
- encourage breast feeding but give awareness of hypoglycaemia
- risk of neonatal hypoglycaemia = feed early, check capillary BM, keep in hospital for at least 24 hours
- for GDM confirm resolution at 13 weeks (HbA1C, fasting glucose or GTT)
- contraception: avoid COCP if breast feeding or vascular complications (POP safe)

Neonatal complications of maternal diabetes:
- respiratory distress syndrome
~ more common due to increased insulin causing suppression of surfactant production
- polycythemia
- hyperbilirubinaemia and jaundice
- hypoglycaemia
- hypocalcaemia
- hypomagnesaemia
- hypothermia
- cardiomegaly
- birth trauma = shoulder dystocia, fractures, Erb's palsy, asphyxia
- delayed gastric emptying leading to feeding difficulties

Maternal complications of DM in pregnancy:
- hypos
- UTI
- recurrent candidiasis
- pregnancy induced HTN or pre-eclampsia
- pre-term labour
- obstructed labour
- operative deliveries (caesarean and assisted vaginal deliveries)
- delayed wound healing and infections
- increased retinopathy
- increased nephropathy
- cardiac disease

Pre-pregnancy counselling for a diabetic woman:
- aim for planned pregnancy
- offer counselling to all women with DM of reproductive age
- aim for normoglycaemia:
~ <5.5mmol pre meal
~ <7.8mmol 1 hour post prandial
~ HbA1C <6.1%

- assessment of severity of diabetes:
~ HTN
~ retinopathy and retinal assessment
~ nephropathy (U&E, urinalysis, urinary PCR, 24 hour for protein, CrCl)
~ neuropathy = clinical assessment
~ cardiac disease signs

- review meds (stops teratogenic drugs and review oral hypoglycaemics/insulin)

- education:
~ DAFNE
~ importance of tight control
~ risks of hypoglycaemia and loss awareness in pregnancy

- general health:
~ stop smoking
~ optimise weight = aim for BMI <27

- start on 5mg folic acid
- importance of effective contraception until good control achieved

Antenatal care of DM:
- MDT care (DM doctor, obstetrician, diabetic specialist nurse, dietician, specialist midwife)
- dietician review
- dating/viability scan (increased risk miscarriage)
- folic acid until 12 weeks
- aspirin 12 weeks - delivery
- aim first trimester downs combined test
- anomaly scan (increased risk of congenital anomalies)
- surveillance of BP/urine/fetal growth (4 weekly starting at 26-28 weeks)
- advise hospital birth
- aim for vaginal delivery after 37 weeks (but over 41 weeks if GDM)

Diabetic emergencies:

Hypoglycaemia:
- most common at 8-16 week gestation (associated with the vomiting and reduced intake)
- loss of warning signs from early pregnancy
- may be confused/aggressive
- check BMs regularly (<4mmol/l)
- give oral lucozade/hypostop
- other treatments: IV glucose, IM glucagon

DKA:
- check blood/urine glucose and ketones
- bloods: glucose, U&Es, bicarbonate, FBC, blood gases_
- screen for infection (especially URTI/UTI)
- check fluid balance (need dehydration and insulin/dextrose sliding scale - accurately record)

Screening for GDM:

risk factors:
- BMI >30
- previous macrocosmic baby weighing 4.5kg or above
- previous gestational diabetes
- first degree relative with DM
- family origin with high prevalence of DM (S. Asian, black carribean, middle eastern)

- selective screening misses 30% of cases
- test = 2hour 75g oral glucose tolerance rest
- WHO fasting >6.9mmol, 2 hour >7.7mmol
Fetal positions in labour:
- see picture
- OA = occipito-anterior
- LOA/ROA - Right/Left occipto-anterior
- OP - Occipto-posterior
- LOP/ROP - occipito-posterior
- LOT/ROT - Left/Right occipito-transverse

Why can examination in labour be difficult:
- moulding = the overlapping of the fetal parietal bones in order to fit through the maternal pelvis
- caput succedaneum = swelling on the fetal scalp caused by pressure of the fetal head on the dilating cervix

Risk of hypoxia:
- during contractions, the blood flow to the fetus is diminished significantly.
- In normal labour with a normal fetus, relaxation of the the uterus in between contractions allows the fetus to recover from this hypoxic stress.
- If there are too many contractions or the contractions are too long, the fetus may not be able to recover and this can lead to hypoxic injury if left untreated.

Stages of labour:

First stage:
- from contractions until the cervix is fully dilated
- can be subdivided into latent and active first stage

Latent first stage:
- can vary in length
- contractions can be regular or irregular but are classically short
- cervix effaces and dilates from 0 - 3/4cm
- long latent phase is more common in primiparous women (multparous women often have a naturally dilated cervix)

Active first stage:
- when cervix is 3-4cm dilated and there are strong regular contractions (3-4 every 10 mins)
- expect a primiparous woman to dilate 0.5cm/hour and a multiparous 1cm per hour
- progress recorded on a partogram

Second stage:
- full cervical dilation - deilvery
- in women with epidural or do not feel a strong desire to push = can give a passive hour of descent where the woman does not push
- active pushing should only be encouraged for 2 hours with primiparous women and 1 hour for multiparous women
~ after this, should consider speeding up delivery

Third stage:
- delivery of baby - delivery of placenta
- This stage can be viewed as physiological when the umbilical cord is left unclamped until it has stopped pulsating and uterotonic medication is not given. Putting the baby to the mothers breast will help release natural oxytocin to separate the placenta and aid its delivery. In physiological 3rd stage, it should not last longer than 1 hour.
- active management of this stage = give uterotonic medication like oxytocin (syntocinon) or combination medications such as syntometrine (oxytocin and ergometrine - NOT WITH HTN) are given to help shorten this phase
~ sometimes controlled traction on the cord is used to speed up delivery (pulling on the cord). MUST also push on the fundus of uterus to prevent uterine inversion
~ active management of third stage should not last longer than 30 mins
~ active management reduces blood loss and the need for transfusion but the medications can induce N+V
~ prolonged 3rd stage = prompts diagnosis of retained placenta (need to be manually evacuated under spinal or general anaesthetic)

Other considerations in the third stage:
- delated cord clamping = delaying clamping the cord by 1-5 minutes can increase blood flow to baby and prevent anaemia
- skin to skin ASAP
- Promote early feeding is encouraged
- administration of IM vit K due to risk of haemorrhage
- awareness of PPH risks and caution

Fetal movement during labour and birth:
- start of labour = fatal head above the pelvis
- as labour progresses = metal head engages (widest part of the foetal head descends through the pelvic inlet)
~ at this point baby usually in the occipito-trasnvwerse position (head facing sideways)
- contractions cause the foetus to further descend and progressive flexion of the fatal head occurs
- In the mid-pelvis, the fetal head undergoes internal rotation so normally the fetus is now in the occipito-anterior position (OA) and is looking towards the maternal back
- The fetal head extends and at complete extension the fetal head is delivered. You see externally, the baby looking towards the mothers back
- Restitution is the process by which the shoulders come into alignment with the head and externally we see this as the babies head turning to look at the mothers leg (which could be the right or left).
- The anterior shoulder comes underneath the pubic symphysis and is delivered. The posterior shoulder soon follows and with the remainder of the body delivery of the fetus is complete.

Treating common abnormal labour issues:

Failure of cervix to dilate/baby to descend:
- problem with contractions
- common in primigravida women where uterine contractions may not be well co-ordinated
- this can be worsened by exhaustion/dehydration
- treat = rehydrate mother and give an oxytocin augmentation (provided fatal monitoring was normal)
~ can also artificially rupture membranes
~ if in second stage of labour and contractions wane = consider assisted vaginal delivery (only if fatal head is below ischial spines however)

Can feel the orbital ridges:
- it indicates brow presentation
- incompatible with vaginal delivery so need caesarean

Cephalopelvic disproportion:
- baby and pelvis do not fit together
- may require C-section
MATERNAL WELLBEING:
- all women have regular obs
- measure contractions, cervical dilation and fatal heart rate
- recorded on a partogram by the midwife
- cervical dilation measured by 4 hourly vaginal exams


FETAL WELLBEING:

Intermittent Auscultation:
- the monitoring of the fatal heart beat during a low risk labour
~ low risk labour = >37 weeks, single foetus in cephalic presentation with no antenatal or intrapartum problems
- listen via a Pinnard or a doppler
- The fetal heart beat is listened to for a minute after a contraction to detect rate (in beats per minute) and presence of accelerations or decelerations
~ abnormal = change to continuous monitoring
~ important to listen after a contraction as decelerations after a contraction may be a sign of fatal hypoxia
- first stage of labour = listen every 15 mins
- second stage = listen every 5 minutes
- In a healthy women with a healthy fetus in normal labour, IA has been proven to reduce the risk of intervention to the mother without increasing the risk of harm to the fetus.

Continuous fetal monitoring:
- usually performed using a CTG (cardiotocography)
- This monitors the fetal heart rate and uterine activity at the same time allowing the interpretation of abnormalities of the fetal heart beat in relation to the timing of contractions

Indications: maternal =
~ mod-severe HTN or pre-eclampisa
~ recurrent antepartum haemorrhage or fresh vaginal bleeding develops in labour
~ mother has antenatal problems such as DM or pre-eclampsia
~ IOL or oxytocin use
~ regional anaesthesia
~ presence of significant meconium
~ suspected chorioamnionitis or sepsis, temperature over 38
~ prolonged first or second stage of labour

Indications: fetal =
~ woman <37 weeks
~ foetus is not cephalic
~ multiple pregnancy
~ oligohydraminos
~ fetal growth restriction
~ abnormal doppler
~ abnormal fatal heart rate on auscultation
-

Intepretation of the traces:
- DR - Define risk; including but not limited to, gestation, antenatal or intrapartum concerns, previous obstetric problems e.g. Vaginal Birth After Caesarean (VBAC)
- C - Contractions; normally counted as the number of contractions in 10 minutes
- Br - Baseline heart rate; the average rate accross a representative portion of the trace (normal 100-160)
- A - Accelerations; increase from baseline rate of >15beats or >15seconds, a marker of fetal health
- Va - Variability; the change in fetal heart rate across a representative minute away from accelerations or decelerations, should be at least 5 beats.
- D - Decelerations; decrease from baseline rate of >15beats for >15seconds, can be further defined according to relationship to contractions
~ Early decelerations - occur at the same time as contractions and 'mirror' them
~ Variable decelerations - vary in shape, depth and duration, occur during the contraction and may persist after the contraction. They are a marker of cord compression and in most instances do not cause hypoxia but can
~ Late decelerations - occur after the contraction has finished, they are a marker of fetal hypoxia and placental insufficiency
O - Overall; is the CTG either Normal, non-reassuring or abnormal.

Baseline FHR normal values:
- 110-160 reassuring
- <100 or >180 abnormal

Causes fetal tachycardia:
- increased fetal activity
- prematurity
- fetal anaemia
- maternal tachycardia, pyrexia or dehydration
- fetal compromise

Bradycardia:
- fetal heart block (SLE)
- maternal hypotension
- maternal vagal stimulation
- fetal compromise

Variability:
- the variation in small baseline heart rate spikes
- reassuring = 5 or more beats (normal variability represents the normal fatal autonomic system)
- non-reassuring = <5 for 30-50 minutes or >25 for 15 to 25 minutes
- abnormal = <5 for more than 50 minutes or >25 for more than 25 minutes or a sinusoidal patten (looking like a saw tooth baseline rather than a smooth wave)

Causes reduced variability:
- fetal sleep
- prematurity (<32 weeks)
- medications = opioids, beta blockers, magnesium

Accelerations:
- increase in baseline FHR of at least 15bpm, lasting at least 15 seconds
- presence of accelerations is a sign that the unborn baby is healthy
- absence of accelerations = in an otherwise abnormal trace is of little significance

Decelerations:
- decrease in baseline FHR of at least 15bpm, lasting for at least 15 seconds
- describing decelerations:
~ duration of the individual decelerations
~ their timing in relation to the peaks of contractions and whether or not the FHR returns to normal
~ how long have they been present for
~ whether they occur with over 50% of contractions
- early decelerations = head compression
- variable decelerations = cord compression
- later decelerations = placental insufficiency

reassuring:
- no decelerations
- or variable decelerations with no concerning characteristics for less than 90 mins

Non-Reassuring:
- variable decelerations with no concerning characteristics for over 90mins
- variable decelerations with any concerning characteristics in up to 50% of contractions for 30 mins or more
- variable decelerations with any concerning characteristics in 50% or over contractions for less thann 30 mins
- late decelerations in over 50% of contractions for under 30 mins with no maternal or clinical risk factors such as vaginal bleeding and significant meconium

Abnormal:
- variable decelerations with any concerning characteristics in over 50% of contractions for less than 30 mins
- late decelerations for 30 mins
- bradycardia or a single prolonged deceleration lasting 3 minutes or more


MANAGEMENT OF CTG TRACES:

Normal:
- continue CTG and normal care
- if only on CTG due to abnormality on intermittent auscultation, discontinue after 20 mins

Suspicious:
- 1 non-reassuring and 2 normal features
- increased risk of fetal acidosis
- correct any possible underlying causes: change position, IV fluids, treat pyrexia and hyper stimulation
- inform seniors

pathological:
- 1 abnormal feature OR 2 non-reassuring features
- more likely fetal acidosis
- think about causes, exclude acute events, inform seniors
- fetal scalp stimulation
- fasting blood sample
- expedite birth if FBS cannot be obtained

Need for urgent intervention:
- BRADYCARDIA OR SINGLE PROLONGED DECELERATION FOR 3 MINUTES +
- very likely to be associated with fetal acidosis
- make preparations for urgent birth and expedite birth if persists for 9 minutes

PICTURE = classic CTG trace. Top = fatal heart rate, bottom = contractions
Arterial line:
- an arterial catheter over a needle which is inserted into an artery
- the radial artery is used - most accessible and has the best collateral circulation
~ can also use axilliary, femoral, brachial and pedal arteries

indications:
- for rapid moment to moment BP changes
- for alterations in oxygen, fluid volume, tissue perfusion
- for frequent blood sampling
- for circulatory therapies (pre-eclampsia)
- if cannot obtain indirect BP (due to obesity)

Complications:
- uncommon
- prolonged shock
- high dose vasopressors
- prolonged cannulation

Monitoring with transducers:
- transducers enable the pressure readings from invasive monitoring to be displayed on a monitor
- need to continuously flush the cannula with saline to maintain patency
- see a clear sharp upstroke with a peak for systolic pressure and an end diastolic pressure

complications:
- distal ischaemia in 0.1% of cases (thrombosis in cannula or artery)
- accidental drug injection into arterial line
- misleading results and failure of equipment
- infection
- fetal haemorrhage from dislodged line

CVP/PIC line:
- a catheter is passed via the subclavian or jugular vein into the SVC to determine the venous return and intravascular volume of the right atrium

Purpose:
- to serve as a guide of fluid balance
- to estimate the circulating blood volume
- determine the function of the left side of the heart
- to assist in monitoring circulatory failure
- for circulatory failure

Advantages of the right internal jugular:
- consistent, predictable anatomical location
- readily identifiable landmarks
- short course straight to SVC
- high success rate (90-99%)

PIC line:
- peripherally inserted into upper arm
- long flexible tube inserted into upper arm
- tip in SVC

CVP line:
- 3 or 4 lumen catheters (distal, medial, proximal)
- distal used to connect to transducer
- reflects the pressure at junction of of vena cava and RA
- CVP. provides estimate of intravascular blood volume and RV preload
~ high CVP = hypervolaemia, heart failure
~ low CVP = hypovolaemia
- trends in CVP more useful

Complications:
- unintended carotid artery puncture (3-9%)
~ usually benign, put firm pressure for 10 minutes
- trauma to vessel
- loss of guide wire
- arrhythmias, heart block
- venous air embolism
- nerve injury
- infection
- pneumothorax
- mediastinal emphysema
- thrombosis
- cardiac perforation
- haemorrhage
- haematoma and airway compromise
Epidemiology:
- rate of up to 20-25% in UK (some countries have higher rates)

Types of C-section:
- skin incision is always the same (lower transverse incision)
- types of uterine incision can vary:

Lower segment Caesarean section (LSCS):
- left hand pic
- most commonly performed caesarean
- The 'lower segment' of the uterus develops as the pregnancy progresses, such that it may not be present in a very preterm uterus (<28 weeks).
- The incision is transverse within the lower segment of the uterus.
- This type is associated with the lowest risk of scar dehiscence (separation) in furture pregnancies

Classical caesarean section:
- rarely performed
- may be performed if baby is <28 weeks, making LSCS impossible or high risk for damaging the foetus
- It may also be performed for placenta praevia/accreta where we do not want to disturb the placental site in the lower segment to avoid excessive bleeding
- associated with higher rate of scar dehiscence so women are recommended to have another caesarean section with future pregnancies

T or J incision:
- less common
- often starts as LSCS but incision is extended when the delivery is found to be difficult
- This could occur for caesarean section at full dilatation or delivery for fetal malposition.
- This type of incision is also associated with a higher rate of scar dehiscence/uterine rupture and so repeat caesarean is offered in subsequent pregnancies.

Benefits of C-section:
- lower risk of uterine scar rupture (only a risk if woman spontaneously goes into labour before agreed C-section date)
- lower risk of perineal trauma (no chance)
- option for sterilisation at same time (Bilateral tubal ligation/clipping can be performed at the same time as the caesarean if future fertility is not required)
- able to plan a known delivery date (date not guaranteed though!)
- Lower risk of hypoxic ischaemic encephalopathy/death in the baby (The risk of this in elective caesarean section is <0.01% compared to 0.08% in the VBAC group)

Risks of C-section:
- longer recovery (expect to be in hospital for at least 2 days)
- likely to need a repeat caesarean in all future pregnancies
~ multiple caesareans are associated with: adhesions, visceral damage, hysterectomy, blood transfusion and abnormal placentation including placenta praevia
- increased risk of maternal death
- higher risk of transient respiratory morbidity (This risk is higher when the baby is delivered via caesarean, approximately 4-5% (2-3% when delivered vaginally). The risk is higher if the caesarean is done earlier so most elective caesareans are done around 39 weeks.)
What is a VBAC?:
- VBAC is applied to a woman attempting vaginal delivery if she has ever had a caesarean in the past. Planned VBAC is a suitable option for the majority of women.
- main risk = uterine scar dehiscence/uterine rupture
~ The average risk of this in women with one previous, uncomplicated lower segment caesarean section is about 0.5% (1:200). This risk is higher in complicated uterine scars such as classical incision, T or J incision.
- overal success of VBAC is 75% but can very based on many factors
- women who have had a C-section are referred to the hospital for consultation about their previous experiences and a discussion about options for birth

Benefits of VBAC:
- quicker recovery time
- shorter hospital stay
- increases the likelihood of future vaginal birth
- decreased risk of transient breathing difficulties in baby (higher in elective caesarean)

Risks of VBAC:
- higher risk of uterine scar rupture/scar dihiscence
- higher risk of perineal trauma including third degree tear
- higher risk of hypoxic ischaemic encephalopathy/delivery related perineal death in baby

Factors that increase success in VBAC:
- previous C-section was needed only for presentation rather than slow progress of labour/fetal distress
- previous successful vaginal birth
- maternal age <40

Contrindications VBAC:
- a patient who requires a caesarean or another reason e.g. placenta praevia
- previous classical uterine incision
- previous uterine rupture

Reasons for caution:
- 2 or more LSCS
- uterine incisions other than the lower segment
- need for induction of labour (using PGs and oxytocin can increase the rate of uterine rupture)

Classic management plan for woman undergoing VBAC:
- no need for routine epidural unless woman requests
- all women need IV access and blood sent to lab for group and save (in case need emergency caesarean section)
- The fetus should have continuous monitoring in labour with CTG (Abnormalities with the CTG are often the 1st sign of uterine rupture)
- recommend deliver in hospital (can be one to one with midwife if all is going well - pool birth is not recommended but can be discussed on an individual basis)
- woman will need regular vaginal examinations once in established labour to check progress (especially if previous C section was due to failure to progress in labour)
~ will have early discussion about need for C section/risks of augmentation labour

Making the decision:
- information given in clinic regarding risks, benefits of each
- can give women until around 36 weeks to decide
- PROVIDE INFO LEAFLET
Types of breech presentation:
- Frank/extended breech = The hips are flexed and knees extended in a frank or extended breech. This is the most common form of breech presentation (see left hand picture)
- flexed/complete breech = hips and knees are flexed. least common (middle pic)
- Footling breech = one or both feet present lower than the breech (bottom) itself. associated with highest rate of cord prolapse (right hand pic)

Factors increasing the chance of breech presentation:
- placenta praevia:
~ placenta is low lying in the uterine cavity so baby cannot position normally within the cavity
- urine cavity abnormalities (uterine septum, bicornate uterus or unicorn ate uterus)
- multiple pregnancy
- preterm baby
- oligo or polyhydraminos

Management of breech at term:

1. ECV:
- external cephalic version
- turning the baby from breech to cephalic to aim to allow vaginal birth
- 1 or sometimes 2 operators check the fetal heart beat, lie and position of the fetus using ultrasound guidance.
- usually performed between 36-37 weeks
- overall success rate is 50-60%
- The procedure can be done in the early stages of labour provided the membranes are intact but this may be associated with lower success rates

Contraindications:
- multiple pregnancy
- fetal distress or abnormal CTG
- recent antepartum haemorrhage or active vaginal bleeding
- other contraindication to vaginal birth
- ruptured membranes
- major uterine anomaly e.g. bicornate uterus
- lack of consent

- major risk is failure of procedure. Bleeding or fatal distress requiring emergency caesarean are rare

Process:
- the baby is shifted up by the doctor so it is out of the maternal pelvis
- the baby is then encouraged to do a forward roll by the doctor moving the baby
- check heartbeat before, during and after the procedure

2. Caesarean section:
- if ECV is not appropriate or the mother declines ECV

Maternal risks:
- bleeding (may require a transfusion)
- infection (wound, chest or urinary)
- damage to other abdominal organs (bowel, bladder or ureters)
- DVT/PE
- increasing risk of placental problems in future pregnancies
- risk of uterine rupture with repeated C-sections - leading to hysterectomy

Fetal risks:
- accidental cut to baby during delivery
- breathing problems occasionally requiring breathing help

3. Vaginal breech delivery:
- option for some women
- risks:
~ reduced amount of skilled operators around with training in breech delivery and complications
~ increased perinatal mortality and early neonatal morbidity compared with caesarean birth
~ rare = obstructed delivery of the head
- Not offered when:
~ other indication for Caesarean section including fatal distress
~ footling breech
~ large or growth restricted baby

Stages of vaginal breech delivery:
- normal effacement and 10cm dilation
- breech enters pelvis in sacrotransverse position and descends to vagina
- DO NOT touch baby so don't set off startle reflex (which could lead to nuchal arms causing complicated delivery)
- crowning and delivery of the buttocks first
- keep the baby's back anterior to pubis
- legs deliver spontaneously (can put finger behind knee to cause flexion but don't do this if dont need to)
- then head may deliver naturally or may need operator to manoeuvre it
- placenta delivers as normal
Obstetric haemorrhage:
- accounts for 25-30% of all maternal deaths worldwide
- in 70% of these deaths, substandard care is a feature

Definition:
- significant blood loss = >1000ml
- major blood loss = >2500ml
- blood loss can be difficult to quantify due to amniotic fluid and physiological adaptions of pregnancy altering blood volume
- 2 types: antepartum and postpartum haemorrhage

Antepartum haemorrhage:
- after 24 weeks gestation
- occurs in 2-5% of all pregnancies beyond 24 weeks

Causes:
- placental abruption = premature separation of a normally sited placenta (most common cause of DIC in pregnancy)
- uterine rupture = tearing of uterine wall in pregnancy/delivery
- placenta praevia = placenta totally or partially inserted in lower uterine segment

General management of haemorrhage:
- MDT apporoach
- restoration of blood volume
- correction of defective coagulation
- remedy of underlying cause
- continued vigilance (recognise signs and symptoms of intra-abdominal bleeding)

Transfusion:
- components (British committee for Standards in Haematology guidelines):
~ Hb <8g/dl
~ Platelets <75x10^6
~ PT/APTT ratio >1.5
~ fibrinogen <1g

Options for stopping bleeding (medical):

Oxytocin:
- agent of choice
- 5 units IV
- causes vasodilation (hypotension) and reflex tachycardia

Carbocetin

Ergometrine:
- 125mcg - 500mcg IV or IM
- causes nausea and vomiting
- contraindicated in hypertensive patients (causes hypertension, coronary spasm, ischaemic pain)

Carboprost :
- a type of prostaglandin (F2 alpha)
- 250mcg doses IM
- can cause hypertension and bronchospasm

Misoprostol:
- synthetic prostaglandin E1 analogue
- can increase uterine tone in 3 minutes

Surgical options:
- bimanual compression
- uterine balloon tamponade
- compression sutures
~ appose the anterior and posterior walls of the uterus
~ use a variety of sutures (B-Lynch, Hayman's horizontal brace suture, Cho's multiple square technique)
~ issues = pyometria, uterine necrosis, intrauterine bands and abdominal adhesions
- arterial ligation
- aortic clamping
- hysterectomy/subtotal hysterectomy

Other options:
1. cell salvage
- blood suctioned form surgical site through heparinised tubing
- passes via a filter into reservoir bowl and then centrifugal bowl
- RBCs are cleaned and pure RBCs are retranfused into person

2. interventional radiology
~ >90% success rate
- used prophylactically in anticipated large blood loss e.g. placenta praaevia or accreta
- or in emergency where there is localised arterial bleeding
- place vascular sheaths in both femoral arteries, to internal iliac arteries to uterine arteries
- balloon occlusion of internal iliac arteries can stem flow until the uterine arteries are embolised
- however, need expert

3. methotrexate:
~ used for conservative treatment of placenta accrete
~ given IM
~ outpatient monitoring of bHCG and ultrasound

4. haemostatic agents
~ tranexamic acid = antifibrinolytic
~ consider in cases where blood loss is major and ongoing
~ 1g slow IV bolus and 1g after 4 hours

5. Factor V11a:
- licensed for haematological disorders
- increasing use in obstetrics but no consensus on dose or timing
- factor works at the site of vascular injury, where tissue factor is expressed and platelets aggregate
- enhances localised thrombin generation and the formation of a stable clot
- does not work unless there is a good enough circulation to deliver fibrinogen and platelets to the site of bleeding
- can be life saving and avoid hysterectomy (indicated to preserve fertility)

6. Fresh frozen plasma:
- includes all coagulation factors
- dose: 12-15ml/kg (4u)
- aim for PT and APTT <1.5x normal

7. Platelets