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OBSTETRICS

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OBSTETRICS

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  1. OBSTETRICS

  2. Placenta- HCG (doubles every 48hrs untill 12 wks),

  3. Antenatal care • +ve pregnancy test- Attend GP • Referred for booking at hospital. • Booking USS scan to date pregnancy. • Full Hx and booking bloods. • Identify LOW risk (Community/Green) or HIGH risk (Consultant/Red).

  4. Booking Investigations • FBC (Rpt 28 wks and term) • Blood group and abs. (rpt 28wks if Rh –ve) • Rubella status • HEP B/C, HIV. If no Hx chicken pox do Varicella. • Dip urine • OGTT, Haemaglobinopathy screen.

  5. Each visit. • BP • Dip urine • Fundal height (1 cm/week) • Fetal heart with Doptone. • Palpate abdomen for presentation/station.

  6. Screening • CUBS -11-13 wks • 16 wks – AFP/HCG • Gives risk for trisomy 21/ spina bifida. Not definitive. (DS↓ , SB↑ ) If > 1in 250, referred for counselling. • 20 wks anomaly scan. Structural abnormalities. • CVS (9-11 wks)/ Amniocentisis (>15 wks). Karyotype. 1% risk of miscarriage.

  7. Labour • Prim- 12-24 hrs • Multi- 6-12 hrs • Can start with Show, SRM or regular painful contractions. • Classified ‘labour’ when >3 cm dilated- effaced.

  8. Stages in Labour • Stage I- Onset of labour to full dilatation. • Stage II- Full dilatation to delivery of baby (<3hrs in prim, <2hrs in Multi) • Stage III- Birth of baby to delivery of placenta. (<1hr) • Can be active – Syntocinon/Syntometrine. • Physiological.

  9. Partogram

  10. Progress • Monitor FH • Contractions- 3-5 good contraction in 10 mins. • Examine for Cx dilatation/ station/ position every 4hrs.

  11. Presentation

  12. Station

  13. Position • Related to OCCIPUT (posterior fontanelle) Symphysis Pubis Direct L R ANTERIOR Left Right TRANSVERSE TRANSVERSE POSTERIOR L R Direct Sacrum

  14. Analgesia in labour • Breathing/ TENS/ Bath/ Co-codamol • Entonox (Nitrous oxide/ oxygen) • Morphine- can cause neonatal resp depression. • Epidural- L3/4 ( Needs IV fluids, Catheter, Continuous CTG) • Can be topped up if needs LUSCS.

  15. Types of delivery • SVD • Assisted delivery- Forceps/ Ventouse. • LUSCS- Emergency/ Elective

  16. Emergencies • Malpresentation- Breech, face, Brow, compound- Needs LUSCS. • Cord prolapse- Cord comes out with fluid. Elevate presenting part- Crash LUSCS. • Shoulder dystocia- Head delivered. Shoulders stuck. Manoeuvres to try disimpact.

  17. The puerperium • 6 wks post natal • Uterus shrinks- Lochia produced. • PPH (secondary) • DVT/PE • Haemarrhoids/ Constipation • Post natal depression.

  18. Breast feeding. • Oestrogen and Progesterone stimulate breast proliferation. • Prolactin stimulates milk production and descent into alveoli. • Oxytocin stimulates milk ejection. • First thick yellow fluid- Colostrum. • Maintained by suckling.

  19. Breast feeding

  20. Breast feeding • Skin to skin contact/ Bonding • Receives all required nutrients. • Passive immunity of antibodies. • Cant breast feed with certain medications or if HIV +ve.

  21. Complications • Cracked nipples • Mastitis • Milk stasis • Poor supply- Domperidone.

  22. POST PARTUM HAEMORRHAGE

  23. PPH • >500mls blood loss PV. • Primary or secondary. • Secondary- endometritis/RPOC

  24. Primary PPH • Emergency • ABC • A- talk to pt • B- facial O2 • C- IV Access (2 large venflons) FBC, Coag, X-match IV fluids

  25. Causes • T- Tone • T- Tissue • T- Trauma • T- Thrombin

  26. Tone • Atonic uterus 90% • Catheterise • Bimanual compression • IM syntocinon 10iu • IM ergometrine 500mcg • IV Syntocinon infusion 40iu • IM Haemabate (PGF2 ) 250mcg

  27. Bimanual compression

  28. Tissue • Check placenta. • Manual removal.

  29. Trauma • Genital tract trauma. • Repair.

  30. Thrombin • Chase Coag result. • Contact haematology. • Watch for signs of DIC.

  31. ANTE PARTUM HAEMORRHAGE

  32. APH • Bleeding from the genital tract after 24 wks gest. • 2-5% of pregnancies. • Important cause of maternal and fetal morbidity and mortality. • Don’t forget Anti D in Rh-ve women

  33. Causes • Placenta praevia • Placental abruption • Show • Local causes • Vasapraevia

  34. Placenta praevia • Placenta develops in lower uterine segment. 0.5% of all pregnancies. • Risk factors- increased age -multiparous - prev LUSCS - Smoking - prev history - mulitple pregnancy

  35. Classification

  36. Presentation • 20 wk USS (97% will migrate) • Painless vaginal bleeding- unprovoked • Post coital bleeding. • Malpresentation • Massive haemorrhage may follow warning bleed.

  37. Diagnosis • VE/ Speculum should not be carried out if PP suspected. • USS (TV scan best) • MRI scanning can detect accreta.

  38. Management (Major) • If asymptomatic- admit from 35-36wks. • Large cannula, G&S. • Delivery at 37-38wks by LUSCS. • Best to have blood and interventional radiology ready. • If haemorrhage- ABC, stabilise mother then emergency LUSCS.

  39. Placental Abruption • Bleeding following separation of normally sited placenta. 0.5-1.5% of all pregnancies. • Risk factors- Increased age - Multiparous - Smoking - Recreational drug use - Abdominal trauma.

  40. Classification Revealed/ Concealed

  41. Presentation • PV bleeding- Ammount may not correlate with significance of haemorrhage. • Abdo pain/ tension. • Shock/ collapse. • Fetal distress.

  42. Diagnosis • Usually clinical • USS (only if mother and baby stable)

  43. Management • ABC • Resuscitation • Delivery if required. • Increased risk of PPH • Watch for signs of DIC.

  44. MISCARRIAGE

  45. Miscarriage • 15 % of all confirmed pregnancies. • Threatened • Inevitable • Complete/Incomplete • Missed • Recurrent • Molar

  46. Threatened miscarriage • PV bleeding +/- abdo pain • Mild • Os closed • USS confirms viable pregnancy. • May lead on to miscarriage.

  47. Inevitable miscarriage • Heavy PV bleeding and pain • Open cervix • Products in canal.

  48. Complete/ Incomplete • Complete- products passed and uterus empty • Incomplete- Not all products passed but no FH on USS and PV bleeding.

  49. Missed miscarriage • Pregnancy Loss with no sx. • Can be picked up at booking scan. • Pregnancy sx usually gone away

  50. Management • Expectant- Await body to pass pregnancy • Surgical- Evac • Medical- Mifepristone and Misoprostil