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MDC 7180 Obstetrics & Gynecology: Important Topics

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Clerkship Cases

Abnormal labor management, abnormal labor management references for the mdc 7180 clerkship case., objectives:.

• Review common abnormal labor patterns.
• Discuss maternal and fetal complications of abnormal labor.
• Provide evidence-based management options for women with prolonged latent phase.
• Discuss key counseling points for intervention of prolonged latent phase.

References:

Abnormal Uterine Bleeding in Perimenopausal Women

Abnormal uterine bleeding in perimenopausal women references for the mdc 7180 clerkship case..

• Outline most common etiologies of abnormal uterine bleeding (AUB) in perimenopausal women and contrast this population to younger reproductive-aged women.
• Describe evaluation methods of AUB.
• Outline therapeutic options and counseling strategies associated with AUB.

Ectopic Pregnancy

Ectopic pregnancy references for the mdc 7180 clerkship case..

• Develop differential diagnosis for bleeding and pain in first trimester.
• Identify risk factors for ectopic pregnancy.
• Evaluate patient suspected of having ectopic pregnancy.
• Briefly review possible management options. (e.g., when is medical management to be considered; what are the types of surgical management and respective success rates; future fertility outcomes; etc.)

HIV in Pregnancy

Hiv in pregnancy references for the mdc 7180 clerkship case..

• Review epidemiology of HIV infection in pregnancy.
• Discuss potential impact on pregnancy outcomes.
• Outline strategies for antepartum, intrapartum and postpartum care of the HIV-infected woman and the neonate following delivery.

  Isoimmunization and it's Management in Pregnancy

Isoimmunization and it's management in pregnancy references for the mdc 7180 clerkship case..

• The role of RBC antigens.
• The clinical circumstances under which D isoimmunization is likely to occur.
• Discuss the use of immunoglobulin prophylaxis during pregnancy for the prevention of isoimmunization.
• Discuss the methods used to identify maternal isoimmunization and the severity of fetal involvement.

Lesbian, Bisexual, and Transgender Patients

Lesbian, bisexual, and transgender patients references for the mdc 7180 clerkship case..

• Identify health care disparities and barriers to care among lesbian, bisexual and transgender patients.
• Outline important health issues that lesbian and bisexual women and transgender individuals are at higher risk to develop.

• CDC - Lesbian, Gay, Bisexual, and Transgender Health Resources and information from the CDC on LGBT health topics

Management of Abnormal Cervical Cytology & Histology

Management of abnormal cervical cytology & histology references for the mdc 7180 clerkship case..

• Describe briefly the pathogenesis of cervical cancer and identify risk factors for cervical neoplasia and cancer.
• Describe the initial management of a patient with an abnormal Pap test.
• Describe management options (including counseling of risks/benefits) for women with cervical neoplasia.

Management of Preterm Labor / Premature Rupture of Membranes

Management of preterm labor / premature rupture of membranes references for the mdc 7180 clerkship case..

• Describe risk factors for preterm labor.
• Summarize history, physical findings, and diagnostic methods used to confirm rupture of membranes.
• Provide evidence-based management options for women of various preterm gestational ages.

Medical Complications in Pregnancy

Medical complications in pregnancy references for the mdc 7180 clerkship case..

• Recognize medical and surgical complications in pregnant women: cardiac disease, asthma, thyroid disease, anemia, diabetes, and urinary tract disorders.
• Discuss potential impact of above conditions on pregnant patients and on newborn/fetus.

Obstetric Analgesic and Anesthesia

Obstetric analgesic and anesthesia references for the mdc 7180 clerkship case..

• Explain anesthesia options in pregnancy.
• Explain indications, side effects, and contraindications to the anesthetic options in pregnancy.
• Explain effect of anesthetics on fetus and newborn.

Opioid Use in Pregnancy

Opioid use in pregnancy references for the mdc 7180 clerkship case..

• Explain opioid use in pregnancy.
• Understand incidence and epidemiology of opioid use in pregnancy.
• Explain how opioid dependence affects fetal outcomes.
• Explain treatment options and surveillance in pregnancy of opioid dependent mothers.

Preeclampsia and Eclampsia

Preeclampsia and eclampsia references for the mdc 7180 clerkship case..

• Define and classify hypertension in pregnancy.
• Enumerate the symptoms of preeclampsia-eclampsia syndrome.
• Summarize the physical findings of the preeclampsia-eclampsia syndrome.

  Premenstrual Syndrome and PMDD

Premenstrual syndrome and pmdd references for the mdc 7180 clerkship case..

• Identify criteria for making the diagnosis of PMS and PMDD.
• Describe treatment options (including complementary and alternative options) for PMS and PMDD.

Spontaneous Abortion

Spontaneous abortion references for the mdc 7180 clerkship case..

• Differentiate the types of spontaneous abortion: threatened, complete, incomplete.
• Discuss management options an outcomes for each of the above; compare expectant management to medical and surgical therapy.
• Identify the cause and complications of septic abortion.

  The Surgical Abdomen in the Pregnant Woman

The surgical abdomen in the pregnant woman references for the mdc 7180 clerkship case..

• Describe signs and symptoms of surgical abdomen in pregnancy.
• Enumerate most common conditions associated with surgical abdomen in pregnancy.
• Discuss potential impact of above condition on pregnant patients and on newborn/fetus.

Third Trimester Bleeding and Postpartum Hemorrhage

Third trimester bleeding and postpartum hemorrhage references for the mdc 7180 clerkship case..

• List causes of third trimester and postpartum bleeding.
• Differentiate the signs and symptoms of third trimester and postpartum bleeding.
• Describe the initial management of shock secondary to acute blood loss.
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History taking in obstetrics and obsterical examination

Published by Sharyl Harrison Modified over 6 years ago

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Presentation on theme: "History taking in obstetrics and obsterical examination"— Presentation transcript:

Obstetric Abdominal Palpation

HISTORY TAKING IN OBSTETRICS & GYNECOLOGY

HISTORY IN OB/GY AHMED ABDULWAHAB.

Periodic Woman Screening Sheet By Periodic Woman Screening Committee January 2010.

Abdominal pain complicated 3 rd trimester pregnancy AUTHOR DR. PAULIN NG REVISED BY DR. WONG HO TUNG OCT, 2013 HKCEM College Tutorial.

History and Physical Examination Mike Clark, M.D..

Antenatal Check Up: Abdominal Examination

Special Tutorial Programme Professor Deirdre J Murphy Trinity College.

Post Partum Hemorrhage

Diagnosis of pregnancy

THE PREGNANCY EXPERIENCE.

The Female Physical Examination by Donald G. Hudson, D.O.,FACEP/ACOEP.

Examination of the obstetric patient

Gynecological history and Physical examination OB/GYN Hospital, Fudan University, Shanghai, China Lu Yuan.

Overview of Obs & Gynae.

Obstetric & Gynaecology History & Clinical Examination Hervinder Kaur Consultant Obstetrician & Gynaecologist, UHCW Obstetric & Gynaecology Lead for Warwick.

OBJECTIVE STRUCTURED CLINICAL EXAMINATION “OSCE”

A Healthy Pregnancy Mrs. Gudgeon. Early Signs of Pregnancy How does a woman know that she is pregnant? –A missed period –Fullness or minor aching abdomen.

Dr. ROZHAN YASSIN KHALIL FICOG,CABOG, HDOG, MBChB 2011.

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Obstetric Anesthesia: A Case Based and Visual Approach

Kumar, Nishant DA, DNB, MNAMS

Department of Anaesthesiology, Lady Hardinge Medical College and Associated Hospitals, Shaheed Bhagat Singh Marg, New Delhi, India, [email protected]

Anesthesiology practice in obstetrics is challenging. It is not 1 life or physiology that is to be understood and taken care of, but 2 that are entwined. The role of the anesthesiologist has expanded to include care during the entire perinatal period especially if there are postpartum complications.

Although there are many textbooks of obstetric anesthesia written by various authors, some of them well-renowned in the field, Obstetric Anesthesia: A Case Based and Visual Approach , edited by Thomas L. Archer, is a welcome and different approach to adult learning. Instead of lengthy theoretical discussions, the book presents an enhanced case-based approach. What makes it interesting are the real-life scenarios that the author has created, including a dialogue as it occurs between the patient and the doctor. Rather than a clinical case, one feels as if reading a narration, and the scene is vividly recreated right before the reader’s eyes. The dialogues between the patient, obstetrician, and the anesthesiologist lead us to the views and expectations of each from one another, which most books fail to address. Needless to say, this is the highlight of the book because at the end of the day, however well the job is done, it is only half done if the patient’s expectations/satisfaction has not been met! This book would be well received by residents, fellows who are preparing for their exit examinations, and practitioners of obstetric anesthesia as a practical refresher.

The book discusses 32 case scenarios, narrated much like a scene from a play, divided into 7 parts. Each case has emphasis points that are marked as (L- n ) at the end of the sentence. These are the learning points from the case. The entire discussion of the case hinges on these points referred to as lessons. Strategically placing these pointers helps the reader to clinically correlate the pathophysiology and treatment modalities with the patient's complaints and events occurring during the scenario.

The learning points are accompanied by simple colored line diagrams explaining the pathophysiology. The diagrams are attractive and easy to reproduce, and the imaginative use of emoticons makes them eye-catching and easy to understand. These would be a great help to students writing their examinations whence they can write a thousand words with a simple diagram.

Part I discusses the problems arising due to physiological changes of pregnancy and common interventions undertaken for cesarean delivery. Part II comprises 5–8 cases that discuss postpartum hemorrhage and uterine dehiscence leading to emergency cesarean under general anesthesia. Parts III and IV discuss more obstetric crises such as high spinal, prolapsed umbilical cord, vaginal delivery after an eclamptic seizure, general anesthesia in a septic patient for cesarean delivery, placenta previa and accreta for elective cesarean hysterectomy, and severe idiopathic pulmonary hypertension through cases 9–15.

Part V describes the do’s and don’ts for a successful neuraxial anesthetic, while part VII deals with anesthetic complications that are dreaded by the anesthesiologists.

In part VII, the author discusses an interesting theory: Cardiac output-guided resuscitation of the uterus, or as is described in the case, resuscitation of a lazy uterus. Nonprogress of labor is a nightmare for both the obstetrician and attending anesthesiologist. It is well known that the gravid uterus compresses on the inferior vena cava and thus decreases cardiac output. According to the author, maximizing the cardiac output simply by positioning the patient in a lateral position may increase the cardiac output, thus resuscitating a lazy uterus and thereby augment labor! An interesting theory indeed.

Overall, I found this book to be imaginative and covers almost all problems faced in obstetric anesthesia practice. It provides a good understanding of the physiological, clinical, and psychological aspects of labor and cesarean delivery, and the basic principles and techniques used to manage each. This reviewer focused on the eBook version, so I cannot speak to the aesthetics of the hard copy textbook. Starting to have a bit of grey hair, and though I would prefer a hard copy, most of my students carry an e-version for ease of access and ready availability. In the eBook version, the contents are hyperlinked, and a single click takes me to the desired case or lesson. Similarly, within the case, the lessons and figures are hyperlinked. So instead of scrolling through the entire chapter, all one has to do is simply click. Each case also has an icon on the right top corner at the beginning that would take to you an updated version. As I enjoyed the narrative cases while commuting to work on the metro rail, I thought, “Learning has not been so much fun in a long time!”

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An obstetric history involves asking questions relevant to a patient’s current and previous pregnancies . Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential.

Taking an obstetric history requires asking a lot of questions that are not part of the “standard” history taking format, therefore it’s important to understand what information you are expected to gather.

It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy).

• Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role .

Confirm the patient’s name and date of birth .

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

Key pregnancy details

It is useful to confirm the gestational age , gravidity and parity early on in the consultation, as this will assist you in determining which questions are most relevant and what conditions are most likely.

Gestational age, gravidity and parity should also be included at the beginning of your presentation of a patient’s history.

Gravidity (G)  is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).

Parity (P)  is the total number of times a woman has given birth to a child with a gestational age of 24 weeks or more, regardless of whether the child was born alive or not (stillbirth).

Example of gravidity and parity calculation

A patient is currently 26 weeks pregnant and already has two children of her own. She reports having had a miscarriage at 10 weeks and a stillbirth at 28 weeks:

• G5 : The patient’s gravidity is 5 because she has had 5 pregnancies in total.
• P3 : The patient’s parity would be 3 because she has had 3 pregnancies which resulted in the birth of a child with a gestational age of greater than 24 weeks (one of which was a stillbirth).

How does parity work for twins?

A British Journal of Gynaecology study suggests that a mother who has carried twins to a viable gestational age (greater than 24+0 weeks) should be defined as P1 .

However, in clinical practice, only 20% of UK Obstetricians and Midwives follow this definition, with the remaining 80% referring to twin pregnancy as P2 .

As a result, you should be aware that in clinical practice, a mother who has carried twins to a viable gestational age will often be referred to as P2, but from an academic perspective, they would be deemed P1.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

• Demonstrating empathy in response to patient cues: both verbal and non-verbal.
• Active listening: through body language and your verbal responses to what the patient has said.
• An appropriate level of eye contact throughout the consultation.
• Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
• Making sure not to interrupt the patient throughout the consultation.
• Establishing rapport (e.g. asking the patient how they are and offering them a seat).
• Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
• Summarising at regular intervals.
• Presenting complaint

Use  open questioning  to explore the patient’s  presenting   complaint :

• “What’s brought you in to see me today?”
• “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to  expand  on their  presenting   complaint  if required:

• “Ok, can you tell me more about that?”
• “Can you explain what that pain was like?”

Open vs closed questions

History taking typically involves a combination of open and closed questions . Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

• History of presenting complaint

Once the patient has had time to communicate their presenting complaint, you should explore the issue with further open and closed questions.

The  SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Ask about the location of the symptom:

• “Where is the pain?”
• “Can you point to where you experience the pain?”

Clarify how and when the symptom developed:

• “Did the pain come on suddenly or gradually?”
• “When did the pain first start?”
• “How long have you been experiencing the pain?”

Ask about the specific characteristics of the symptom:

• “How would you describe the pain?”  (e.g. dull ache, throbbing, sharp)
• “Is the pain constant or does it come and go?”

Ask if the symptom moves anywhere else:

• “Does the pain spread elsewhere?”

Associated symptoms

Ask if there are other symptoms which are associated with the primary symptom:

• “Are there any other symptoms that seem associated with the pain?” (e.g. shortness of breath in pulmonary embolism)

Time course

Clarify how the symptom has changed over time :

• “How has the pain changed over time?”

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better :

• “Does anything make the pain worse?” (e.g. patients with symphysis pubis dysfunction may find going up or down the stairs makes things worse)
• “Does anything make the pain better?” (e.g. patients with gastro-oesophageal reflux may find that antacid medication helps with their symptoms)

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

• “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Obstetric symptoms

Once you have completed exploring the patient’s history of presenting complaint, you need to move on to more focused questioning relating to the  symptoms that may be relevant to pregnancy (if not already discussed). We have included a focused list of key symptoms to ask about when taking an obstetric history, followed by some background information on each, should you want to know a little more.

Summary of key obstetric symptoms

Key obstetric symptoms to ask about include:

• Nausea and vomiting : common in pregnancy and mild in most cases. Hyperemesis gravidarum represents a severe form of vomiting in pregnancy associated with electrolyte disturbance, weight loss and ketonuria.
• Reduced fetal movements : can be associated with fetal distress and absent fetal movements may indicate early fetal demise.
• Vaginal bleeding : causes include cervical bleeding (e.g. ectropium, cervical cancer ), placenta praevia and placental abruption (typically associated with abdominal pain).
• Abdominal pain : causes may include urinary tract infection, constipation, pelvic girdle pain and placental abruption.
• Vaginal discharge or loss of fluid : abnormal vaginal discharge may be caused by sexually transmitted infections such as gonorrhoea and the loss of fluid from the vagina indicates rupture of the amniotic membranes.
• Headache, visual disturbance, epigastric pain and oedema : these are typical clinical features of pre-eclampsia. Mild oedema is common and normal in the later stages of pregnancy.
• Pruritis : associated with obstetric cholestasis (typically affecting the palms and soles of the feet).
• Unilateral leg swelling : consider and rule out deep vein thrombosis .
• Chest pain and shortness of breath : pregnant women are at increased risk of developing pulmonary emboli.
• Systemic symptoms : fatigue (e.g. anaemia), fever (chorioamnionitis) and weight loss (e.g. hyperemesis gravidarum).

Nausea and vomiting

Nausea and vomiting are very common in pregnancy, but are typically mild, requiring only reassurance and basic hydration advice.

Nausea and vomiting typically begin between the fourth and seventh week  of gestation , then peak between the ninth and sixteenth week and resolve  by around the 20th week of pregnancy.

Persistent vomiting and severe nausea can progress to hyperemesis gravidarum . Hyperemesis gravidarum refers to persistent and severe vomiting leading to dehydration and electrolyte disturbance, weight loss and ketonuria. ¹

• Reduced fetal movements

Women typically start to feel fetal movements between 16 to 24 weeks gestation (primigravida women will often not feel fetal movements until after 20 weeks gestation). A mother will know what is the “usual” amount of fetal movements she experiences, therefore, if a reduction in fetal movements is reported, it should be taken very seriously .

Reduced fetal movements are associated with adverse pregnancy outcomes, including stillbirth , fetal growth restriction , placental insufficiency , and congenital malformations . ²

You should always ask about fetal movements once the patient is of the appropriate gestation to be able to feel them:

• “Have you noticed any change in the amount of your baby’s movement?”

Vaginal bleeding

Vaginal bleeding is an important symptom that can be relevant to a wide range of obstetric and gynaecological diseases.

It is important to ask about pain , associated trauma (including domestic violence), fever / malaise , recent ultrasound scan results (e.g. position of the placenta), cervical screening history , sexual history and past medical history to help narrow the differential diagnosis.

You should also ask about fatigue if anaemia is suspected and symptoms of hypovolaemic shock (e.g. pre-syncope/syncope).

Vaginal discharge

All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking an obstetric history.

You should ask the patient if they have noticed any changes to the following characteristics of their vaginal discharge :

• Colour (e.g. green, yellow or blood-stained would suggest infection)
• Consistency (e.g. thickened or watery)
• Smell (e.g. fish-like smell in bacterial vaginosis)

Urinary symptoms

Urinary tract infections are common in pregnancy and need to be treated promptly. Untreated urinary tract infections in pregnancy have been associated with increased risk of fetal death, developmental delay and cerebral palsy .

Common symptoms of urinary tract infections include:

• Dysuria: pain whilst passing urine.
• Frequency: increased frequency of passing urine.
• Urgency: a sudden need to pass urine, with no earlier warning.

Headache, visual changes, epigastric pain, oedema

Pre-eclampsia is a relatively common condition in pregnancy which is characterised by maternal hypertension, proteinuria, oedema, fetal intrauterine growth restriction and premature birth. The condition can be life-threatening for the mother and the fetus. As a result, it is essential to ask about symptoms of pre-eclampsia as part of every patient review during pregnancy.

The key symptoms to ask about include:

• Headache (typically severe and frontal)
• Swelling of the hands, feet and face (oedema)
• Pain in the upper part of the abdomen (epigastric tenderness)
• Visual disturbance (blurring of vision or flashing lights)

Other symptoms

Fever is important to ask about when considering infectious pathology (e.g. urinary tract infections, cervical infections, chorioamnionitis).

Fatigue  is a non-specific symptom, but its presence may indicate anaemia or other systemic pathology.

Weight loss is a symptom of hyperemesis gravidarum and other significant conditions (e.g. malignancy, anorexia nervosa).

Pruritis in the context of pregnancy is suggestive of obstetric cholestasis (it typically affects the palms and soles of the feet).

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas , concerns and expectations  (often referred to as ICE ) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues . This will help ensure your consultation is more natural , patient-centred and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Explore the patient’s ideas about the current issue:

• “What do you think the problem is?”
• “What are your thoughts about what is happening?”
• “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Explore the patient’s current concerns :

• “Is there anything, in particular, that’s worrying you?”
• “What’s your number one concern regarding this problem at the moment?”
• “What’s the worst thing you were thinking it might be?”

E xpectations

Ask what the patient hopes to gain from the consultation:

• “What were you hoping I’d be able to do for you today?”
• “What would ideally need to happen for you to feel today’s consultation was a success?”
• “What do you think might be the best plan of action?”
• Summarising

Summarise  what the patient has told you about their  presenting complaint . This allows you to  check your understanding of the patient’s history and provides an opportunity for the patient to correct  any  inaccurate information .

Once you have  summarised , ask the patient if there’s anything else that you’ve  overlooked . Continue to  periodically summarise  as you move through the rest of the history.

• Signposting

Signposting , in a history taking context, involves explicitly stating  what you have discussed so far  and  what you plan to discuss next . Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare  for what is coming next.

Signposting examples

Explain what you have covered so far : “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next : “Next I’d like to quickly screen for any other symptoms and then talk about your current pregnancy.”

• Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

• Systemic : fatigue (e.g. anaemia), fever (e.g. chorioamnionitis, urinary tract infection), weight loss (e.g. hyperemesis gravidarum)
• Respiratory : dyspnoea (e.g. pulmonary embolism, anaemia), chest pain (e.g. pulmonary embolism)
• Gastrointestinal : abdominal pain (e.g. placental abruption), vomiting (e.g. hyperemesis gravidarum)
• Genitourinary : urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)
• Neurological : visual changes, motor or sensory disturbances, headache (e.g. pre-eclampsia)
• Musculoskeletal : pelvic pain (e.g. symphysis pubis dysfunction)
• Dermatological : rashes, skin lesions, linea nigra
• Current pregnancy

Clarify the current gestational age of the pregnancy (e.g. 26 weeks and 5 days would be written as “26+5”).

Accurate estimation of gestation and estimated date of delivery (EDD) is performed using an ultrasound scan to measure the crown-rump length .

Scan results

Women are offered an ultrasound scan to check for fetal anomalies between 18+0 and 20+6 weeks . You should ask about the results of the scan (or check the medical records if the patient is unsure). The key findings to note include:

• Growth of the fetus: clarify if it was within normal limits for the current gestation.
• Placental position: if embedded in the lower third of the uterine cavity there is an increased risk of placenta praevia.
• Fetal anomalies: note any abnormalities identified.

There are several types of screening that women are offered during pregnancy:

• Down’s syndrome screening
• Rhesus status and the presence of any antibodies
• Hepatitis B, HIV and syphilis.

You should clarify if the patient has opted for screening and if so, what the results were.

Other details of the pregnancy

• Check if this is a singleton or multiple gestation .
• Clarify if the patient took folic acid prior to conception and during the first trimester.
• Explore the planned mode of delivery   (e.g. vaginal or Caesarean section ).
• Ask about any medical illness during pregnancy (clarify what type of illness and if the patient is still receiving any treatment).

Immunisation history

Check the patient is currently up to date with their vaccinations including:

• Flu vaccination
• Whooping cough vaccination
• Hepatitis B vaccination (if at risk)

Mental health history

Pregnancy can have a significant impact on maternal mental health , therefore it is essential that patients are screened for symptoms suggestive of psychiatric illness (e.g. depression, bipolar disorder, schizophrenia).

Ask about previous mental health diagnoses and any current thoughts of self-harm  and/or  suicide if relevant.

• Previous obstetric history

It is important to ask about a woman’s previous obstetric history, as this may help inform the assessment of risk in the current pregnancy and have implications for the mode of delivery.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Term pregnancies (>24 weeks)

Gestation at delivery :

• Previous pre-term labour increases the risk of pre-term labour in later pregnancies.

Birth weight :

• A high birth weight in previous pregnancies raises the possibility of previous gestational diabetes.
• A low birth weight (small for gestational age) in a previous pregnancy increases the risk of a further small for gestational age baby.

Mode of delivery :

• Spontaneous vaginal delivery
• Assisted vaginal delivery (e.g. forceps)
• Caesarean section (will have implications for the choice of future mode of delivery)

Complications :

• Antenatal period: pre-eclampsia, gestational diabetes, gestational hypertension, placenta praevia and shoulder dystocia.
• Postnatal period: post-partum haemorrhage, perineal/rectal tears during delivery and retained products of conception.

Assisted reproduction :

• Clarify if IVF or other assisted reproductive techniques were used for any previous pregnancies.

As stated below, asking about stillbirths need to be done in a sensitive manner.

A  stillbirth  is when a baby is born dead after 24 completed weeks of pregnancy.

Sensitivity clarify the gestation of the stillbirth if this is not already documented.

Other pregnancies (<24 weeks)

Questions about miscarriage, terminations and ectopic pregnancies need to be asked in a sensitive manner in a private setting. It can be very difficult for women to discuss these topics. These questions should only be asked when relevant and by a person who is competent to do so.

Miscarriage

A  miscarriage  is the loss of a pregnancy before 24 weeks gestation.

Gestation :

• Clarify the trimester at which the miscarriage occurred (miscarriage is most common in the first trimester).

Other details :

• Clarify if medical or surgical management was required for the miscarriage and if any cause was identified for the miscarriage (e.g. genetic syndromes).

Termination of pregnancy

Termination of pregnancy  is the medical process of ending a pregnancy  so it doesn’t result in the birth of a baby. The pregnancy is ended either by taking medications or having a minor surgical procedure.

Clarify the gestation at which the termination of pregnancy was performed and the method of management (e.g. medical or surgical).

Ectopic pregnancy

An  ectopic pregnancy  is when a fertilised egg implants itself outside of the uterus , usually in one of the fallopian tubes.

Clarify the site of the ectopic pregnancy and how it was managed (e.g. expectant, medical, surgical).

• Gynaecological history

Cervical screening :

• Confirm the date and result of the last cervical screening test.
• Ask if the patient received any treatment if the cervical screening test was abnormal and check that follow up is in place.

Previous gynaecological conditions and treatments :

• Sexually transmitted infections
• Endometriosis
• Bartholin’s cyst
• Cervical ectropion
• Malignancy (e.g. cervical, endometrial, ovarian)

Past medical history

A patient’s past medical history is particularly relevant during pregnancy, as some medical conditions may worsen during pregnancy and/or have implications for the developing fetus.

Ask if the patient has any medical conditions :  

• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how   well   controlled  the disease is and what  treatment(s)  the patient is receiving. It is also important to ask about any  complications  associated with the condition including  hospital   admissions .

Ask the patient if they’ve previously undergone any surgery or procedures in the past such as:

• Abdominal or pelvic surgery: may influence decisions regarding delivery due to the presence of scar tissue and adhesions.
• Previous Caesarean section : increased risk of uterine rupture in subsequent pregnancies.
• Loop excision of the transitional zone (LETZ): increased risk of cervical incompetence.

It’s essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced.

Medical conditions which are particularly important to be aware of during pregnancy

Diabetes (type 1 or 2) : blood glucose control can deteriorate significantly during pregnancy resulting in poor maternal health and fetal complications (e.g. macrosomia).

Hypothyroidism : untreated or undertreated hypothyroidism can result in congenital hypothyroidism with significant neurodevelopmental impact.

Epilepsy : seizures during pregnancy pose a risk to both the mother and fetus (e.g. miscarriage) and many anti-epileptic drugs are teratogenic.

Previous venous thromboembolism (VTE) : pregnancy is a pro-thrombotic state, therefore, women who have previously developed a venous thromboembolism are at significantly increased risk of developing further VTEs without prophylactic treatment (e.g. low molecular weight heparin).

Blood-borne viruses :  HIV , hepatitis B, hepatitis C pose a risk to the fetus during childbirth (vertical transmission).

Genetic disease : it is important to identify any genetic diseases (e.g. cystic fibrosis, sickle-cell disease, thalassaemia) carried by both the mother and father as this may influence the management of the patient and their pregnancy (e.g. arranging input from the paediatric team immediately after delivery).

• Drug history

It is essential to gain an accurate overview of the medications the patient is currently and has previously taken during the pregnancy. The first trimester is when the fetus is most at risk of teratogenicity from drugs, as this is when organogenesis occurs.

Prescribed medications

Clarify the prescribed medications the patient has been taking since falling pregnant, noting which they are still taking and which they have now stopped (including drug name, dose and route).

• “Are you currently taking any prescribed medications or over-the-counter treatments?”
• “Have you stopped taking any prescribed medication since you became pregnant?”

Ask if the patient was using contraception prior to becoming pregnant and if so, clarify what method of contraception was being used. Check the patient has stopped their contraception or had their contraceptive device removed (e.g. coil, implant).

If the patient is taking prescribed or over the counter medications, document the medication name , dose , frequency , form and route .

Ask the patient if they’re currently experiencing any side effects from their medication:

• “Have you noticed any side effects from the medication you currently take?”

Teratogenic drugs

Some examples of drugs that are known to be teratogenic include:

• ACE inhibitors
• Sodium valproate
• Methotrexate
• Trimethoprim

Medications frequently used during pregnancy

Some medications are commonly used in pregnancy to both reduce the risk of fetal malformations and treat the symptoms of pregnancy.

Some examples of medications commonly used in pregnancy include:

• Folic acid (400μg): recommended daily for the first trimester of pregnancy to reduce the risk of neural tube defects in the developing fetus.
• Oral iron: frequently used in pregnancy to treat anaemia.
• Antiemetics: frequently used in pregnancy to manage nausea and vomiting (e.g. hyperemesis gravidarum).
• Antacids: frequently used to manage gastro-oesophageal reflux symptoms during pregnancy.
• Family history

Taking a brief family history can help to further assess the risk of adverse outcomes to the mother and fetus during pregnancy. This can also help inform discussions with parents about the risk of their child having a specific genetic disease (e.g. cystic fibrosis).

Some important medical conditions to ask about include:

• Inherited genetic conditions : such as cystic fibrosis and sickle cell disease.
• Type 2 diabetes : if first-degree relatives are affected there is an increased risk of gestational diabetes.
• Pre-eclampsia : most relevant if maternal mother or sister is affected as this is associated with an increased risk of developing pre-eclampsia.
• Social history

Understanding the social context of a patient is absolutely key to building a complete picture of their health. Social factors have a significant influence on a patient’s pregnancy.

General social context

Explore the patient’s general social context including:

• the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
• who else the patient lives with and their personal support network
• what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)

Record the patient’s smoking history , including the type and amount of tobacco used.

Offer smoking cessation services (see our smoking cessation guide for more details).

Smoking increases the risk of a small for gestational age baby.

Record the frequency , type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Excess alcohol use during pregnancy can result in conditions such as fetal alcohol syndrome .

Recreational drug use

It is important to ask about recreational drug use , as these can have significant consequences on the mother and developing fetus (e.g. cocaine use increases the risk of placental abruption).

If recreational drug use is identified, patients can be offered input from drug cessation services .

Diet and weight

Ask if the patient what their diet looks like on an average day .

Ask about the patient’s current weight (obesity significantly increases the risk of venous thromboembolism, pre-eclampsia and gestational diabetes during pregnancy).

Ask about the patient’s current occupation and if there are plans in place for maternity leave.

Domestic abuse

It is important to privately ask all pregnant women if they are a victim of domestic abuse to provide an opportunity for them to seek help.

• Closing the consultation

Summarise  the  key   points back to the patient.

Ask the patient if they have any  questions  or  concerns that have not been addressed.

Thank the patient  for their time.

Dispose of PPE appropriately and wash your hands .

Dr Venkatesh Subramanian

Obstetrics & Gynaecology Registrar in London

• NICE. Clinical Knowledge Summary. Nausea/vomiting in pregnancy. Published: June 2017. Available from: [ LINK ].
• BMJ. Reduced fetal movements.  2018 ;  360. Published March 2018. Available from: [ LINK ] 
• MBRRACE-UK. Saving Lives, Improving Mother’s Care. Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009. Available from: [ LINK ].

• Wash your hands and don PPE if appropriate
• Introduce yourself to the patient including your name and role
• Confirm the patient's name and date of birth
• Explain that you'd like to take a history from the patient
• Gain consent to proceed with taking a history
• Confirm gestational age, gravidity and parity early on in the consultation
• Use open questioning to explore the patient’s presenting complaint
• Site: ask where the symptom is (if relevant)
• Onset: clarify when the symptom first started and if it the onset was sudden or gradual
• Character: ask the patient to describe how the symptom feels
• Radiation: ask if the symptom moves anywhere else
• Associated symptoms: ask if there are any other associated symptoms
• Time course: ask how the symptom has changed over time
• Exacerbating or relieving factors: ask if anything makes the symptom worse or better
• Severity: ask how severe the symptom is on a scale of 0-10
• Screen for other key obstetric symptoms (e.g. nausea, vomiting, reduced fetal movements, vaginal bleeding, abdominal pain, vaginal discharge or fluid loss, headaches, visual disturbance, epigastric pain, oedema, pruritis, unilateral leg swelling, chest pain, shortness of breath, fatigue, fever, weight loss)
• Explore the patient's ideas, concerns and expectations
• Summarise the patient’s presenting complaint
• Screen for relevant symptoms in other body systems
• Clarify the current gestational age of the pregnancy (if not done already)
• Ask about recent scan results
• Ask about screening
• Ask about immunisations
• Ask about maternal mental health
• Clarify other details of the current pregnancy (e.g. singleton vs multiple gestation, use of folic acid, mode of delivery, medical illness during pregnancy)
• Clarify the patient’s gravidity and parity (if not done already)
• For term pregnancies (>24 weeks) clarify: gestation at delivery, birth weight, mode of delivery, complications, stillbirths, use of assisted reproductive techniques
• Ask sensitively about miscarriages, termination of pregnancy and ectopic pregnancy
• Ask about recent and previous cervical screening results
• Ask about previous gynaecological conditions and treatments
• Past medical history
• Ask if the patient has any medical conditions
• Ask the patient if they've previously undergone any surgery or procedures
• Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance
• Ask if the patient is currently taking any prescribed medications or over-the-counter remedies
• Ask if the patient was using contraception prior to falling pregnant and if this has stopped/removed (e.g. coil, implant)
• Ask if there is any family history of genetic conditions, type 2 diabetes or pre-eclampsia
• Explore the patient’s general social context (accommodation, who the patient lives with, support)
• Take a smoking history
• Take an alcohol history
• Ask about recreational drug use
• Ask about diet, weight and occupation
• Ask about domestic abuse
• Summarise the salient points of the history back to the patient and ask if they feel anything has been missed
• Thank the patient for their time
• Dispose of PPE appropriately and wash your hands
• Key communication skills
• Active listening

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Oxford Case Histories in Obstetric Medicine

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Obstetric Medicine provides the reader with 55 cases of different clinical presentations in obstetric medicine. Each case is presented with a background to the subject area, a summary of the history, and examination findings, and relevant investigation results. This is followed by several questions on clinically important aspects of the case with answers and detailed discussion, particularly of the differential management options. Each topic is mapped on to both the curriculum for physicians undertaking obstetric medicine, and for obstetric trainees studying for membership exams, the Advance Training Skills Module in maternal medicine, and speciality training in maternal and fetal medicine. Providing an ideal self-assessment tool, this new title is of interest to all doctors working in obstetrics, midwives, physicians who may encounter pregnant women in their clinical practice, and students revising for exams.

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• Mammary Glands
• Fallopian Tubes
• Supporting Ligaments
• Reproductive System
• Gametogenesis
• Placental Development
• Maternal Adaptations
• Menstrual Cycle
• Antenatal Care
• Small for Gestational Age
• Large for Gestational Age
• RBC Isoimmunisation
• Prematurity
• Prolonged Pregnancy
• Multiple Pregnancy
• Miscarriage
• Recurrent Miscarriage
• Ectopic Pregnancy
• Hyperemesis Gravidarum
• Gestational Trophoblastic Disease
• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
• Oligohydramnios
• Polyhydramnios
• Placenta Praevia
• Placental Abruption
• Pre-Eclampsia
• Gestational Diabetes
• Headaches in Pregnancy
• Haematological
• Obstetric Cholestasis
• Thyroid Disease in Pregnancy
• Epilepsy in Pregnancy
• Induction of Labour
• Operative Vaginal Delivery
• Prelabour Rupture of Membranes
• Caesarean Section
• Shoulder Dystocia
• Cord Prolapse
• Uterine Rupture
• Amniotic Fluid Embolism
• Primary PPH
• Secondary PPH
• Psychiatric Disease
• Postpartum Contraception
• Breastfeeding Problems
• Primary Dysmenorrhoea
• Amenorrhoea and Oligomenorrhoea
• Heavy Menstrual Bleeding
• Endometriosis
• Endometrial Cancer
• Adenomyosis
• Cervical Polyps
• Cervical Ectropion
• Cervical Intraepithelial Neoplasia + Cervical Screening
• Cervical Cancer
• Polycystic Ovary Syndrome (PCOS)
• Ovarian Cysts & Tumours
• Urinary Incontinence
• Genitourinary Prolapses
• Bartholin's Cyst
• Lichen Sclerosus
• Vulval Carcinoma
• Introduction to Infertility
• Female Factor Infertility
• Male Factor Infertility
• Female Genital Mutilation
• Barrier Contraception
• Combined Hormonal
• Progesterone Only Hormonal
• Intrauterine System & Device
• Emergency Contraception
• Pelvic Inflammatory Disease
• Genital Warts
• Genital Herpes
• Trichomonas Vaginalis
• Bacterial Vaginosis
• Vulvovaginal Candidiasis
• Obstetric History
• Gynaecological History
• Sexual History

Obstetric Examination

• Speculum Examination
• Bimanual Examination
• Amniocentesis
• Chorionic Villus Sampling
• Hysterectomy
• Endometrial Ablation
• Tension-Free Vaginal Tape
• Contraceptive Implant
• Fitting an IUS or IUD

Original Author(s): Minesh Mistry Last updated: 12th November 2018 Revisions: 7

• 1 Introduction
• 2 Preparation
• 3 General Inspection
• 4 Abdominal Inspection
• 5.1 Fundal Height
• 5.3 Presentation
• 5.4 Liquor Volume
• 5.5 Engagement
• 6 Fetal Auscultation
• 7 Completing the Examination

The obstetric examination is a type of abdominal examination performed in pregnancy.

It is unique in the fact that the clinician is simultaneously trying to assess the health of two individuals – the mother and the fetus.

In this article, we shall look at how to perform an obstetric examination in an OSCE-style setting.

Introduction

• Introduce yourself to the patient
• Wash your hands
• Explain to the patient what the examination involves and why it is necessary
• Obtain verbal consent

Preparation

• In the UK, this is performed at the booking appointment, and is not routinely recommended at subsequent visits
• Patient should have an empty bladder
• Cover above and below where appropriate
• Ask the patient to lie in the supine position with the head of the bed raised to 15 degrees
• Prepare your equipment: measuring tape, pinnard stethoscope or doppler transducer, ultrasound gel

General Inspection

• General wellbeing – at ease or distressed by physical pain.
• Hands – palpate the radial pulse.
• Head and neck – melasma, conjunctival pallor, jaundice, oedema.
• Legs and feet – calf swelling, oedema and varicose veins.

Abdominal Inspection

In the obstetric examination, inspect the abdomen for:

• Distension compatible with pregnancy
• Fetal movement (>24 weeks)
• Surgical scars – previous Caesarean section, laproscopic port scars
• Skin changes indicative of pregnancy – linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum (‘stretch marks’), striae albicans (old, silvery-white striae)

Fig 1 – Skin changes in pregnancy. A) Linea nigra. B) Striae gravidarum and albicans.

Ask the patient to comment on any tenderness and observe her facial and verbal responses throughout. Note any guarding.

Fundal Height

• Use the medial edge of the left hand to press down at the xiphisternum, working downwards to locate the fundus.
• Measure from here to the pubic symphysis in both cm and inches. Turn the measuring tape so that the numbers face the abdomen (to avoid bias in your measurements).
• Uterus should be palpable after 12 weeks, near the umbilicus at 20 weeks and near the xiphisternum at 36 weeks (these measurements are often slightly different if the woman is tall or short).
• The distance should be similar to gestational age in weeks (+/- 2 cm).
• Facing the patient’s head, place hands on either side of the top of the uterus and gently apply pressure
• Move the hands and palpate down the abdomen
• One side will feel fuller and firmer – this is the back. Fetal limbs may be palpable on the opposing side

Fig 2 – Assessing fetal lie and presentation.

Presentation

• Palpate the lower uterus (below the umbilicus) to find the presenting part.
• Firm and round signifies cephalic, soft and/or non-round suggests breech. If breech presentation is suspected, the fetal head can be often be palpated in the upper uterus.
• Ballot head by pushing it gently from one side to the other.

Liquor Volume

• Palpate and ballot fluid to approximate volume to determine if there is oligohydraminos/polyhydramnios
• When assessing the lie, only feeling fetal parts on deep palpation suggests large amounts of fluid
• Fetal engagement refers to whether the presenting part has entered the bony pelvis
• Note how much of the head is palpable – if the entire head is palpable, the fetus is unengaged.
• Engagement is measured in 1/5s

Fig 3 – Assessing fetal engagement.

Fetal Auscultation

• Hand-held Doppler machine >16 weeks (trying before this gestation often leads to anxiety if the heart cannot be auscultated).
• Pinard stethoscope over the anterior shoulder >28 weeks
• Feel the mother’s pulse at the same time
• Should be 110-160bpm (>24 weeks)

Completing the Examination

• Palpate the ankles for oedema and test for hyperreflexia (pre-eclampsia)
• Thank the patient and allow them to dress in private
• Summarise findings
• Blood pressure
• Urine dipstick
• Hands - palpate the radial pulse.
• Skin changes indicative of pregnancy - linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum ('stretch marks'), striae albicans (old, silvery-white striae)
• One side will feel fuller and firmer - this is the back. Fetal limbs may be palpable on the opposing side

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OBSTETRIC EMERGENCIES

Nov 01, 2011

750 likes | 2.82k Views

Overview:. Obstetric emergencies - cause damage and death to mothers and babies. They require quick, decisive and effective action from the staff immediately available. In the UK, the maternal mortality rate is around 11.4 per 100,000.Worldwide, the situation is much worse, with around 600,000 maternal deaths reported each year.The causes of maternal death:Embolism (Thrombotic

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1. OBSTETRIC EMERGENCIES Dr. Ahmed Al Harbi Obstetrics/Gynecology Consultant

3. Definition of Obstetric Emergencies: An emergency is an occurrence of serious and dangerous nature, developing suddenly and unexpectedly, demanding immediate attention.

4. Obstetric emergencies related directly to pregnancy include, for instance: Pre-eclampsia Eclampsia Antepartum Haemorrhage Postpartum Haemorrhage Amniotic Fluid Embolism Congenital Heart Disease Epilepsy

5. Principles Of Managing Obstetric Emergencies

6. Management: If breathing spontaneously : She must be moved to the left lateral position; aspiration of stomach. If there is no spontaneous respiration : Check the circulation at the carotid or femural pulse prior to chest compression if necessary. Artificial respiration is required if managing a case alone. Obtain as much help as is possible immediately. Summon the cardiac arrest team immediately.

7. Obstetric Haemorrhage Any blood loss from the vagina greater than a show during pregnancy Or excessive blood loss after delivery.

8. Managing severe haemorrhage Call For Help: Senior Obstetrician Anaesthetist Notify blood bank and consult haematologist.

9. Pulmonary Embolism (PE) Occurs in association with approximately 3:1000 pregnancies. Two thirds of cases of puerperium.

10. Diagnosis of Pulmonary Embolism: Symptoms Acute Breathlessness Pleuritic Chest Pain Haemoptysis

11. Signs Tachycardia Cyanosis Hypotension May be Confusion (hypoxia)

12. Investigations Reduced oxygen tension in arterial blood Electrocardiogram lead 3 Large Q waves, inverted T waves Chest X-ray Ventilation perfusion scan

13. Clinical Presentation Of Amniotic Fluid Embolism

14. Symptoms Sudden severe chest pain Dyspnea

15. Signs Hypotension Tachycardia Pulmonary Oedema Peripheral Shutdown Haemorrhage due to coagolation failure May be seizure seccondary to hypoxia or cardiac arrest.

16. Investigations Electrocardiogram � right ventricular strain Abnormal coagolation screen Reduced oxygen tension in arterial blood

17. Treatment Urgent resuscitation and circulatory support Intubation and 100% oxygen Treat the coagolupathy agressively Correct acidosis Dopamine and steroids may be useful Transfer to intensive care unit

18. Hypertensive Disorders: Pre-eclampsia Is a disease of pregnancy characterized by a blood pressure of 140/90 mmHg or more on two separate occasions after the 20th weekof pregnancy in a previously normotensive woman. Accompanied by significant proteinuria (>300mg in 24 hours) Eclampsia A same condition that has proceeded to the presence of convulsions. Imminent Eclampsia or Fulminating Pre-eclampsia The transitional condition characterized by increasing symptoms & signs.

19. Incidence & Epidemiology: Eclampsia Relatively rare in the UK, occurring in approximately 1:2000 pregnancies. It may occur Antepartum � 40% Intrapartum � 20% Postpartum � 40% Severe Pre-eclampsia A blood pressure of 160/110 mmHg or more.

20. Symtoms Of Severe Pre-Eclampsia Frontal Headache Visual Disturbance Epigastric Pain General Malaise & Nausea Restlessness

21. Signs Of Severe Pre-Eclampsia Agitation Hyper-Reflexia Facial & Peripheral Oedema Right Upper Quadrant Tenderness Poor Urine Output

22. Treatment Of Eclampsia: Turn the woman onto her side with her head down Ensure the airway is protected Give oxygen Give a 5g bolus of magnesium sulphate intravenously over a few minutes. Progress to stabilizing the woman�s condition The mother�s condition needs to be stabilized urgently, before considering delivery in antenatal cases

23. Senior obstetric and anaesthetic staff must be involved Antihypertensive Hydralazine Labetalol Anticonvulsants Magnesium Sulfate Fluid Balance ? To avoid pulmonary and cerebral oedema, Central Venous Pressure (CVP) INPUT & OUTPUT

24. Indications For Urgent Delivery Blood pressure persistently at 160/100 mmHg or more with significant proteinuria Elevated liver enzymes Low platelet count Eclamptic Fit Anuria Significant foetal distress

25. HELLP Syndrome H - Haemolysis E - Elevated L - Liver Enzymes L - Low P - Platelets ? 5 to 10% of cases of severe pre-eclampsia ? May be associated with dissaminated intravascular coagulation, placental abruption & foetal death.

26. Hypertensive Disorders Fulminating pre-eclampsia & eclampsia are dangerous Recognize women at risk Manage minor hypertensive problems to prevent progression In the serious case: Prevent or control convulsion Bring down the blood pressure Minimize or avoid organ damage Control coagulopathy Avoid fluid overload Deliver a healthy baby safely

27. The Collapse Obstetric Patient Complete or partial loss of consciousness is very uncommon in pregnancy

28. Causes Of Loss Of Consciousness Simple Faint Epileptic Fit Hypoglycaemia Profound Hypoxia Intracerebral Bleeding Cerebral Infarction Cardiac Arrhythmia Or Myocardial Infarction

29. Pulmonary Embolism Anaphylaxis Septic Shock Anaesthetic Problems Major Haemorrhage Eclampsia Amniotic Fluid Embolus Uterine Inversion

30. Basic Life Support Skills Shake & Shout Airway Breathing Circulation Look for hypovolaemia (Tachycardia, Pallor) Aggressive Fluid Replacement Stop Haemorrhage Stabilize and seek a cause Senior multi-disciplinary assistance throughout

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