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Kuala Lumpur

Obstetric And Gynaecology

Home > Study Notes > Obstetric And Gynaecology
Published in: Medical
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This is a concise notes for OBGYN which will be helpful for the clinical students.

Meerashini N / Kedah

1 year of teaching experience

Qualification: Bachelor of medicine and Bachelor of surgery (MBBS)

Teaches: Mathematics, Science, Bahasa Tamil, Biology, Tamil, Medical

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  1. Preterm labour Causes of labour pain contractions of the muscles of the uterus and by pressure on the cervix Causes of preterm labour Idiopathic Infection Systemic infection Cervical weakness Poor social economic Malnutrition Uterinine and fetal abnormalities Drug abuse Antepartum haemorrhage Drug abuse History of preterm laour Over distntiion o Multiple pregnancy o Polyhydramnios Management 1. 2. 3. Give dexamethasone a. Corticosteroids can be give to enhance the lung maturation If patient in labour, >34w, let labour proceed. Aim for vaginal delivery unless contraindicated
  2. Full Blood Count(check total white blood cell) High vaginal swab ( to rule out BV infection) Urine analysis and microscopic examination ( to rule out UTI) Tocolytic drugs Salbutamol Nifedipine Indomethacin Pregnancy induced hypertension 1) 2) 3) 4) Possible causes of convulsion a. High blood pressure b. Proteinuria Investigation a. b. Maternal ii. iii. iv. Fetal ii. Full blood count ( check for haemolysis and reduced platelet count) Coagulation studies (if thrombocytopenia) BUSE and creatine clearance 1. Creatine clearance in severe renal impairment Liver function tests- serum transaminase, albumin C TG reactive Ultrasound (for IUGR) Complication a. b. Maternal Heart 1. High output failure 2. Pulmonary edema Placental abruption Haematology ii. iii. iv. v. vi. vii. Fetal ii. 1. Renal 1. 2. Liver 1. 2. Lung 1. CNS 1. 2. IUGR Thrombocytopenia Renal failure Nephrotic syndrome Infarction and rupture Congestion Aspiration pneumonia Eclampsia Cerebral haemorrhage Oligohydramnios Management of pregnancy induced hypertension a. Principle
  3. b. c. i. Control hypertension ii. Safely deliver the fetus iii. Prevent eclampsia For chronic hypertension and gestational hypertension i. Control it witht anti-hypertensive drugs if BP>150/100 ii. Treat as outpatient iii. Follow up 1. Maternal- BP, BUSE, urine protein, weight gain 2. Fetal- fundal height, FH, FKC, serial ultrasound to detect any superimposed PE 3. Can deliver as normal if no other complications For pre eclampsia best manage in hospital 5) Outline the principle of management of an eclampsia fit a. b. c. d. e. f. g. h. j. k. Call for help Left lateral positioning Secure airway, prevent patient injury Wait for convulsion to abate. If not, IV diazepam 10mg bolus Maximum oxygenation mask or intubation Catheterization for I/O chart Careful neurological examination Bishop Score Prophylactic anticonvulsant therapy to prevent subsequent seizure BP control Cervix favourable- Vaginal delivery Cervix unfavourable- LSCS Intrauterine growth restriction ( small gestational age) 1. 2. Causes of small gestational age a. b. c. d. e. f. g. h. j. Maternal weight less than 100 pounds Poor nutrition during pregnancy Birth defects or chromosomal abnormalities Use of drugs, cigarettes, and/or alcohol Pregnancy-induced hypertension (PIH) Placental abnormalities Umbilical cord abnormalities Multiple pregnancy Gestational diabetes in the mother Low levels of amniotic fluid or oligohydramnios Principal of management a. If gestational age is 34 weeks or greater, health care providers may recommend being induced for an early delivery. b. If gestational age is less than 34 weeks, health care providers will continue monitoring until 34 weeks or beyond. Fetal well-being and the amount of amniotic fluid will be monitored during this time. If either of these becomes a concern, then immediate delivery may be recommended. Depending on your health care provider, you will likely have appointments every 2 to 6 weeks until you deliver. If delivery is suggested prior to 34 weeks, your
  4. health care provider may perform an amniocentesis to help evaluate fetal lung maturity Diabetes Mellitus in Pregnancy i. i. 1) 2) 3) 4) Risk factors a. b. Maternal i. ii. iii. v. vi. vii. Fetal i. ii. iii. iv. History of gestational Diabetes Family history of 1st relative with DM Obesity Age Recurrent vaginal candidiasis/ UTI Symptoms of DM Polyhydramnios History of baby >4kg History of unexplained IUD/ recurrent abortion History of congenital abnormality Multiple pregnancy/ Big baby Complications a. b. Maternal ii. iii. iv. v. vi. Fetal ii. iii. Nephropathy Retinoapathy Neuropathy Coronary artery disease Thromboembolic disease Hyperglycaemia/ hypoglycaemia/ ketoacidosis 1st trimester 1. Congenital abnormalities a. ASD, VSD b. Neural tube defect 2nd trimester 1. Macrosomia 2. Polyhydramnios After delivery 1. Respiratory distress syndrome 2. Hypoglycaemia How is screening for diabetes performed a. Early self-monitoring of blood glucose or a 2-hour 75g oral glucose tolerance test (OGTT) at 16-18 weeks to test for gestational diabetes if the woman has had gestational diabetes previously, followed by OGTT at 28 weeks if the first test is normal (since there is 2nd peak of beta-hCG about 26-32weeks) b. An OGTT to test for gestational diabetes at 24-28 weeks if the woman has any risk factors Antenatal care for diabetes
  5. a. b. c. d. e. f. g. h. j. k. After diagnosed, consult them lifestyle & diet changes Do blood sugar profile after 1-2 weeks Venous plasma sugar level was taken at pre-breakfast, pre-lunch, pre- dinner and before sleep If range between 4-7mmol/L, consider diet therapy If >7mmol/L or type 1 diabetes or u/s show fetal macrosomia, start insulin ( actrapid 4-6unit tds), admit patient for education of therapy Antenatal visit fortnightly till 32 weeks, weekly after 32 weeks. During check up, monitor BSP and detect any complications of DM developed For fetal, do ultrasound for: i. Early 11-14w- correct dating ii. Do a morphological scan during 2nd trimester. 1. (best during 18 to 22 weeks) iii. Serial scan for big baby, IUD, poly HBA1c should check for every trimester (especially 1st trimester). Should maintain between 4-7% To check risk of malformation Check for urinary tract infection and vaginal candidiasis Heart disease in Pregnancy a) b) c) Features of heart disease are relevant to pregnancy a. b. c. d. e. Total red cell volume Cardiac output Blood pressure Surgery before pregnancy Contraindication i. Elsemenger syndrome ii. Pulmonary hypertension iii. Marfan syndrome iv. Tight MS Fetal risk of maternal cardiac disease o Recurrence ( Congenital Heart Disease) o Maternal cyanosis ( Fetal Hypoxia) o Iatrogenic prematurity o Effects of maternal drugs ( teratogenic, Growth restriction, fetal loss) Principle of management a. Antenatal ii. iii. iv. v. vi. vii. Booking-all woman; routine CVS examination is essential Should continue medications Ensure regular attendance to clinic Adequate bed rest- lateral position Avoid additional stress Early detection of BP and treatment Hospital admission if symptomatic
  6. viii. ix. x. xi. xii. xiii. Anticoagulant- atrial fibrillation (Heparin drug of choice ) Antibiotic(rheumatic) Dental treatment- antibiotic cover (amoxycilin) Fetal monitoring IUGR, Premature labour- monitor with ultrasound Mode of delivery b. Intra-Partum ii. iii. iv. v. vi. vii. viii. Combined effort- cardiologist, O&G, anesethetists Adequate pain relief 1. Epidural- the best in many cases 2. Intramuscular( pethidine, rubain) Left lateral position Subacute bacteria endocarditis prophylaxis Careful iv fluid administration- pulmonary edema Intensive monitoring- BP, PP, RR Prop up ( Avoid lithotomy) Avoid symptometrine Antepartum Haemorrhage 1) 2) 3) 4) Definition a. Bleeding from genital tract after 24w of gestation Causes of bleeding a. b. Placental ii. iii. Local ii. Praevia Abruptio Vasa praevia Cervix erosion Vaginal laeceration Investigation a. b. Maternal ii. iii. iv. Fetal ii. FBC- Haemoglobin, platelet BUSE- electrolyte imbalance Coagulation profile Early speculum examination CTG reactive Ultrasound- localization of placenta Immediate management of antepartum haemorrhage a. b. c. d. Inform specialist oncall Rapid assessment of patient condition Resuscitation i. Maintain airway ii. Give oxygen (3L/min) iii. Set 2 large IV line, Hartmann solution, take blood, DIC&coagulation profile) Monitoring i. vital sign
  7. ii. iii. iv. closed bladder drainage CTG Pad chart e. Find out causes of APH i. History ii. PE, fundal height, tenderness iii. Ultrasound iv. Speculum after exclude placenta praevia 5) 6) Maternal complication a. b. Placenta praevia i. Malpresentation ii. Obstructed labour iii. Maternal haemorrhage iv. Fetal hypoxia v. Preterm labour vi. IUGR Placenta abruptio i. Hypovolaemic shock ii. Post partum haemorrhage iii. Maternal haemorrhage iv. Acute renal failure Differences between placenta praevia and placenta abruptio Pain Uterus Fetal position Patients conditions Lie/Presentation of fetus CTG A/W pre-eclampsia DIC Precipitating factors Haemodynamic signs Placenta Praevia Painless Soft,non-tender Not engaged Malpresentation Usually normal Less distressed Abnormal Normal Less Later Post coital Hard Exercise Proportional Placenta abruptio Painful Tense and tender Irritable Hard to palpate fetal parts Normal Absent or abnormal More distressed Normal Abnormal Yes Sooner Trauma Massage Post coital Greater than observed blood loss Management of placenta praevia All patients with minor placenta praevia can be manage conservatively and treat as outpatients. Patient with major placenta praevia: o If no previous bleeding, careful counselling before contemplating outpatient care o If had previous bleeding,
  8. Should admitted and managed as inpatients from 34 weeks of gestation. Prolonged inpatient care can be associated with an increased risk of thromboembolism Thus, gentle mobility should encouraged together with the use of prophylactic thromboembolic stockings Prophylactic anticoagulation should be reserved for those at high risk of thromboembolism Educate patients No abdomen massage No coital Bed rest • Immediate admit if contraction Management of placenta abruptio Rapid assessment of maternal and fetal state o Blood taken for Hb, GXM and clotting screen o Analgesia to treat shock and pain o Blood transfusion to correct hypovolaemia Conservative treatment if o Marginal placental abruption & less bleed o Preterm o Mother and fetalnot compromised If severe, o o o Resuscitation Correct shock/DlC Monitor patient U/S vialability C TG- fetal distress Investigation- FBC. DIC profile, GXM Vaginal Examination- modified Bishop score Infection during pregnancy 1. 2. 3. Vaginitis Clinical sign a. b. c. d. e. f. Abnormal vaginal discharge Vulvar itch Odor Discomfort Burning with urination Painful intercourse Investigation a. Vaginal pH b. Whiff test (amine test) Saline and KOH wet mounts c. Microscopy d. DNA tests and cultures Postpartum haemorrhage
  9. 1. Immediate management of postpartum haemorrhage a. b. c. d. e. f. g. h. b. c. d. Call for help Maintain A,B, C Monitor vital signs Give oxygen at 6-8L/min Take blood for: i. FBC ii. GXM (MINIMUM 4 PACKED) iii. Coagulation profile Correct hypovolaemia/hypotension i. Set up at least 2 large bore IV line ii. Fluid resuscitation with crystalloids or colloids Catheterize the bladder& monitor I/O chart Look for cause of bleeding i. Palpate abdomen. If uterus is atonic, 1. 2. 3. 4. 5. Massage uterus to stimulate contraction Give ergometrine 0.5mg or 1M syntometrine Iml Start oxytocin infusion 40units in 500ml normal saline at 40 drops per min If uterus still fail to contract, give 1M carboprost 250mcg. This can repeated after 15min up to a max of 3 doses If still failed, do surgery i. Perform speculum examination to look for laeceration ii. Check placenta for completeness. If not complete, remove remaining placental tissue Transfuse blood if blood is ready If bleeding persists, do DIVC profile Give DIVC regime 2. 3. Causes of PPH a. b. c. d. e. Uterine atony Partial separation of placenta Retention of placental fragments Trauma Acute inversion of uterus If bleeding persist, it will cause a. b. c. d. e. f. g. shock need for transfusion and its attending complications adult respiratory distress syndrome renal failure following hypotension coagulopathy Sheehan syndrome (pituitary necrosis) loss of fertility following surgical intervention
  10. Breech delivery 1. Prerequisities a. b. c. d. e. Extended/Flexed No feto-pelvic disproportionate EFW
  11. iii. iv. v. Twin-twin transfusion syndrome Prematurity( Respiratory distress syndrome) Increase chances of congenital abnormalities b. Induction of labour Maternal ii. iii. iv. v. vii. viii. All physiological changes of pregnancy are exaggerated For pre-existing health problem, risk of morbidity increase High incidence of gestational hypertension Risk of operation delivery Anaemia APH PPI-I Thromboembolic dz 1. 2. Differences between induction and augmentation of labor Induction of labour: stimulating the uterus to begin labour. Augmentation of labour: stimulating the uterus during labour to increase the frequency, duration and strength of contractions Describe Bishop score Criteria Cervical dilatation
  12. Additional treatment depends on why your labor is going slowly. If the baby is already in the birth canal, the doctor or midwife may use special tools called forceps or a vacuum device to help pull the baby out through the vagina. If your doctor feels like you need more or stronger contractions, you may receive Pitocin (oxytocin). This medicine speeds up contractions and makes them stronger. If after your doctor feels like you are contracting enough and the labor is still stalled, you may need a C-section. If the baby is too big, or the medicine does not speed up delivery, you will need a C-section. Occipito-posterior position 1. 2. Definition: a. The OP position (occiput posterior fetal position) is when the back of baby's head is against the mother's back. The posterior baby's back is often extended straight, even arched, along the mother's spine. Mechanism and management of OP a. b. c. d. e. f. g. Descent Engagement Internal Rotation Continue descent and delivery Crowning of head Restitution External rotation Pregnancy sign and symptoms Symptoms Sign - amenorrhea -morning sickness -increase micturition -breast discomfort -fatique -breast enlarge -prominent Montgomery gland -nipple hyperpigmented -suprapubic pulge in pelvis Anaemia in Prgnancy Symptoms Shortness of breath Weak and lethargy
  13. Palpitation Headache Indigestion Symptom of CCF Blurring of vision Investigations Hb screening-booking, 32w, 36w (RCOG recommended screen at booking & 28w) MCV volume (mean cell volume) o If
  14. Pelvic type known Membrane rupture Patient adequate anaesthesia Adequate facilities Operator fully experience Amniocentesis Definition: removal of fluid containing cells and biochemical products of fetal origin form amniotic cavity Indication Prenatal o o Chromosome analysis Advance maternal age Previous fetal aneuploidy Parenteral balanced translocation DNA Biochemistry Enzyme assay Metabolic analysis Alpha fetoprotein Fetal infection Cytomegalovirus Toxoplasmosis Fetal welfare o o o o Maternal RBC alloimmunization Spectophotometry of amniotic fluid as indirect measurement of the level of bilirubin Lung maturity L:S ratio Chorioamnionitis Diagnosis+ identify causative agent and sensitivity Obstetrics cholestasis Check for meconium staining ( Intrahepatic cholestasis a/w meconium stained and IUD) Method of amniocentesis Approach consideration After appropriate consent has been obtained, the patient is placed on an examination bed in the dorsal lithotomy position. If the patient cannot tolerate that position, the head of the bed may be raised for patient comfort. A bedside ultrasound is done to demonstrate fetal number, placental location, fetal heart tones, and amniotic fluid location. At that moment, the recommendation is that the clinician generate a plan in which a straight needle can be inserted from the maternal skin to a sizeable pocket of amniotic fluid while avoiding the fetus and umbilical cord. In the case of multiples,
  15. pay careful attention to the existence of different gestational sacs and the location of placental membranes. If the flow of amniotic fluid stops when aspirating with a syringe, or if the amniotic fluid turns bloody, re-evaluation of the needle tip location should occur by ultrasound. The clinician may change the position of the needle accordingly. Approach Some clinicians may mark the area they intend to insert the amniocentesis needle with a surgical pen if a free-hand technique is to be used. The ultrasound transducer is removed and covered with a sterile glove or plastic wrap, and the patient's skin is prepared with an antiseptic solution and draped with sterile towels. Using sterile gloves and maintaining sterile techniques, the clinician places the ultrasound transducer, now covered with a sterile glove, on the patient's skin surface. Sterile gel or antiseptic solution may be used to help with the sound transmission from the transducer. The clinician may choose to use a needle guide to help with the needle insertion toward a clear pocket of amniotic fluid. Alternatively, the clinician may use the free-hand technique, by lining up the center of the transducer with the amniotic fluid pocket from where the sample is obtained. A 20-gauge to 22-gauge spinal needle with adequate length is placed in one side of the transducer at an angle almost parallel to the transducer. The clinician inserts the needle under direct ultrasound visualization until the tip of the needle is at the center of an amniotic fluid pocket. The clinician removes the guide of the needle and places a syringe on top of it, making sure the needle does not move during that step. Aspirating and discarding the first 2-4 mL of amniotic fluid (because it may be contaminated with maternal cells) is recommended. Removal After the syringe is full, or when the total amount of fluid needed is obtained, the syringe can be removed from the needle, and the amniotic fluid can be poured into containers depending on the test desired, or continued to be drained if the purpose is to decrease amniotic fluid volume in cases of polyhydramnios. When all the fluid that is desired has been obtained, the needle is pulled out in a rapid way to reduce discomfort, and fetal heart tones are assessed again at this time. Staging of Labour 1st stage Early Labor Phase —The time of the onset of labor until the cervix is dilated to 3 cm. Active Labor Phase — Continues from 3 cm. until the cervix is dilated to 7 cm. • Transition Phase — Continues from 7 cm. until the cervix is fully dilated to 10 cm. 2nd stage The second stage of labor begins when the cervix is completely dilated (open), and ends with the birth of your baby.
  16. Contractions push the baby down the birth canal, and you may feel intense pressure, similar to an urge to have a bowel movement. 3rd stage The third stage is the delivery of the placenta and is the shortest stage. Management of 3rd stage of labour For active management, Administer 5-10 IU of oxytocin by intramuscular injection with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is clamped and cut. (Use oxytocin as it is associated with fewer side effects than oxytocin plus ergometrine.) After administering oxytocin, Clamp And Cut The Cord (Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heartbeat below 60 beats/minute that is not getting faster.) Apply Controlled cord traction [after signs of placental separation ] [CCT applied only when there is a strong uterine contraction] Dysfunctional labour 4 most common causes of dysnfunctional labour Power: Dysfunctional uterine activity: 75% (Steer et al, 1985) Malfunction in the myogenic, neurogenic, or hormonal mechanisms of uterine activity. Passenger: Malpresentation, malposition, fetal anomalies Passages: -Uterine malformation, pelvic tumors, uterine over distension, cervical stenosis from previous surgery —CPD Extrinsic factors: Patient not in labor, sedation, anxiety, anesthesia, supine position, unripe cervix, chorioamnionitis How will you induce labour in this patient Treatment: Artificial rupture of membrane Oxytocin augmentation Caesarean section Oxytocin augmentation If uterine contraction is not adequate 2 hours after the membrane ruptured, start oxytocin augmentation Commencing oxytocin augmentation 1) 2) 3) Ensure that the patient is well hydrated and the bladder is empty Prescribe antibiotic by 6 hourly intravenous infusion, 12 hours after rupture of membranes if delivery is not imminent Monitor the Fetal heart rate closely, ideally with scalp electrode continuous electronic foetal monitoring
  17. 4) 5) 6) 7) 8) 9) Group and save 2 units of packed cells Commence oxytocin infusion 10 U syntocinon diluted into 500mls NS (20mU/ml), titration every 30 minutes Carry out a review VE 2 hours after a strong contraction pattern has been achieved, and thereafter a 4-hourly VE. Usually after 4 hours of strong contraction, the outcome will be known, either the patient have delivered vaginally or she will shortly deliver In the absence of progress in cervical dilation, caesarean section has become indicated Booking What screening is performed on the booking blood Blood group Rhesus Haemoglobin level What is the purpose of routine ultrasound scan -11-14 weeks for carrect dating -20-24 weeks to detect any congenital abnormality

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