Normal Obstetrics Lecture

Pre-Pregnancy Care

Pre-Pregnancy Counselling
● All women of childbearing age with underlying medical conditions should be provided
with the opportunity to have counselling pre-pregnancy
● Pregnancy is a very risky time of a young woman’s life - increased risk of morbidity and
mortality
○ Best possible chance to minimise these risks for mother and baby
● Important to optimise underlying medical conditions e.g.
○ Diabetes mellitus
■ Tighter sugar control to help minimise risks to mum and baby
■ Do not want regular hypoglycaemic episodes
○ Epilepsy
■ Safe medication and minimal amount of medication
■ Shouldn’t come off this medication without appropriate intervention
○ Cardiac disease
○ Renal disease
○ Rheumatological disease
○ IBD
○ Haematological disorders
○ Alcohol and drugs/mental health disorders
○ For any woman: opportunity to discuss topics e.g. folic acid, risks of obesity,
healthy lifestyle, smoking

Antenatal Care
● Healthcare, support and interventions provided to a woman during her pregnancy
● Includes pre-pregnancy counselling and continues into the early neonatal period
● Objectives:
○ Promote and maintain physical, mental and social health of mother and
baby through education
○ Detect and manage complications
● Reassure about things that are normal and advise when things need further attention
Pregnancy Test
● Urine PT - can be done anytime after 1st day of missed period
● Measures BhCG (produced by trophoblasts of fertilised ovum) approx 6 days post
fertilisation
● BhCG detected in blood and urine after implantation, approx 12 days post
fertilisation

First Visit (Midwife/GP-led)

● <12th week of pregnancy
● Estimate due date - based on menstrual period dates
● Detailed history - provide risk assessment for pregnancy
● High risk or not? - only absolutely apparent once woman has delivered and is past the
neonatal period
● At each stage of pregnancy it is important to assess the risk

Dating USS (occurs between 11 and 14 weeks)

● Determine gestational age (measures CRL crown rump length - from top of baby to
bottom)
○ Accurately date a pregnancy
● Detect multiple pregnancies
● Measures nuchal translucency (NT) - fluid at the back of babies neck as part of
combined screening
● Between 11-14 weeks

Investigations
● At the booking visit
○ FBC - check not anaemic
○ ABO and Rhesus group
■ Rhesus negative – historically start Anti D at 28 weeks in case baby is
rhesus positive
■ Now able to look for foetal blood cells in maternal blood and tell if foetus
is rhesus negative or not so we can avoid having to give Anti D
○ Infection screen
■ Syphilis - treatment
■ Hepatitis B
■ HIV - treatment can help prevent transmission to baby
■ Immunisation in neonatal period- can help prevent transmission to baby
○ MSU - MC+S
■ Treat asymptomatic bacteriuria - proving to help prevent preterm delivery
■ Help prevent severe infections
 ■ If positive at booking, at every appointment do a MSU
○ Offer Down’s screening
■ Triple Test
■ Quad Test - if later on in pregnancy e.g. if woman did not know she was
pregnant
○ Consent for Mid T
■ 18-20 weeks for structural anomalies / placental site
○ None of these investigations are compulsory- strongly encourage all bar
Down’s Syndrome as this is her choice

At Each Visit
● Maternal BP and Urine
○ Checking for pre-eclampsia
● Fetal movements
○ Ask the woman - from third trimester
● Examination
○ Abdominal palpation third trimester- symphysio fundal height
○ Checking for foetal lie and presentation
● Additional
○ Some may need additional growth scans
○ OGTT - specific criteria to see if this is required
● At each visit, risk should be assessed to see if the requirement has changed

Follow-Up Visits
● Measure SFH from 24/26 weeks
○ Symphysio Fundal height
● Growth scans - for some women, regular growth scans are required
○ Previous SGA at birth - small for gestational age
○ Pre-eclampsia
○ Diabetes - pre-existing or gestational
○ SFH inaccurate e.g. BMI >35
○ SFH suggesting FGR - if SFH suggested that baby would be smaller than
expected

Antenatal Classes
● Largely virtual currently
● Discuss questions they may have around labour and birthing
○ Reviews labour and birth participant discussion, relaxation techniques
● Discuss breastfeeding
● Woman in labour who participated in classes feel less pain and use fewer analgesics
● Aim: woman centered
Obstetric History
● Age, Gestation, G/P (gravida - how many pregnancies they have had, parity- how many
births after 24 weeks gestation)
● Presentation Complaint
● PMHx
● Past Surgical History
○ Worry about back surgery - regional anaesthesia e.g. epidural or spinal
○ Extensive abdominal surgery - ?C-section → may be elective if have had lots of previous
abdominal surgery
● DHx
● SHx
● FHx - important for postnatal support
● Past Obstetric History
○ 3 normal pregnancies, well, NVD - very likely that the same thing will happen again
○ Type of delivery e.g. CS/instrumental
○ Antenatal, intrapartum and postnatal complications
○ Previous VTE event- may need to consider LMWH
○ Birth weight of previous baby i.e. LG/SGA - need to implement additional growth
scans
○ Live/NND
○ Other hospital - ?notes

Normal in Pregnancy - but still question...

● Highest risk time of a young woman’s life (even though it is a normal physiological
process)
● Varicose veins
● Carpal tunnel
● N+V - severe requiring rehydration and anti-emetics? Or tolerating well
● Back pain - severe or milder MSK within normal limits?
● Braxton Hicks
● Oedema - is it slight oedema or is it a dramatic sudden change hinting at pre-eclampsia?
● Reflux
● Skin changes

Symptoms of Pathology
● Hyperemesis - very dehydrated, risk of VTE as a result
● IUGR - scanning regime helps to identify this and deliver if needs be
● Pre-eclampsia - checking BP and urine for proteins
○ Can occur anytime from 20th week of pregnancy
○ New onset HTN or proteinuria - big spectrum
○ Important for women to be aware of the symptoms: Headache, epigastric pain,
sudden increase in oedema, visual changes
● VTE - assess at every encounter particularly at booking and hospital admission
 ● Diabetes
● Obstetric Cholestasis - sever intractable itching, associated with an increased risk of
stillbirth
● Psychological sequelae - antenatal depression, underlying mental health conditions

Labour: Assessment of Progress

First Stage
● From onset of labour (painful, regular contractions) to full dilatation (10cm cervical
dilatation)
Second Stage
● Full dilation to delivery of baby
Third Stage
● From delivery of baby to complete expulsion of placenta and membranes

Progress of Labour
● The 3 Ps
○ POWER
■ 1st stage - contractions
■ 2nd stage - contractions + maternal effort (pushing)
○ PASSENGER
■ Flexion and rotation
○ PASSAGE - birth canal itself
■ Pelvis
■ Cervix
■ Perineum
● Cervical changes
○ Nulliparous - never had a baby before
○ Multiparus - have had a baby before
○ Effacement - thinning out of the cervix
○ Child before - multip’s os - cervix is
slightly already open and slightly
shorter
■ Effacement and dilatation can
happen all at once
■ Slightly different process due
to previous delivery
Progress of Labour
● Full dilatation = 10cm
● First Stage
○ Latent phase - irregular
contractions
○ Active phase - right up to full
dilatation
■ If very prolonged - may
be a warning that full
dilatation may not be
reached, or NVD may not
be possible
● Second stage
● Third stage
● Progress of labour will give you a clue as
to how the delivery will be

Presenting Part
● Part of the baby that presents to the maternal pelvis
● Shoulder - unable to deliver vaginally - VERY IMPORTANT TO DETECT → need a C-section
● Face - can deliver vaginally depending on chin position
● Brow - widest diameter of baby head is trying to fit through birth canal → NVD is not possible

Cephalic
Attitude
● For cephalic presentation ONLY
○ Head can be flexed -
narrowest diameter trying to
fit through birth canal
○ Head can be deflexed
● 13.5cm - widest part of baby’s head
● Normal attitude is flexed (A and D)

Station – how far down babies head is

● The relationship between the lowest point of the presenting part and the maternal ischial
spines (can only determine where these spines are vaginally)
● Assessed by vaginal examination to monitor descent
○ Labour is an active, dynamic process so have to
monitor and assess where the baby is - then we can
tell how the progress of the delivery is going
● Need to do Abdominal palpation alongside vaginal
examination - during birthing process, bones are not fused in
babies head
○ Babies head can be effectively become moulded into shape
(as bones overlap) - think that the bottom edge of the head is
lower down than it actually is → why it is important to do an
abdominal palpation also
● How far down the birth canal baby is

Mechanism of Labour
● Descent
● Flexion
● Internal rotation - head rotates on pelvic floor
● Extension - the occiput escapes from underneath the symphysis pubis which acts as a
fulcrum
● Restitution - shoulder drops into right position
● Delivery of anterior shoulder
● Delivery of body
Labour: Intrapartum Assessment of Mother and
Fetus and Intrapartum Analgesia

The Partogram
● How often are contractions - regular, strong, too many
● Important to monitor fluid input and output
● HR- any evidence of foetal distress
● Liquor - what is the colour of the fluid around the baby? Is it clear, is there meconium,
bleeding
● Is the baby descending through the birth canal

MATERNAL FETAL
Cervical changes Heart rate
Contractions Liquor
Observations (HR, BP, Temp, Descent
Urine)
Drugs & fluids Position (of presenting part)
Analgesia
● The partogram is a snapshot of all of these things
● Maternal and foetal observations
● Make sure labour is progressing as it should be
● Monitor normality but to check for any signs of
abnormality which could result in maternal or foetal
compromise
Foetal Monitoring in Labour
● Low risk pregnancy - intermittent auscultation with a sonocade
● High risk pregnancy - CTG (cardiotocography)
○ Abdomial monitor to monitor babiea HR
○ OR Foetal scalp electrode once waters have broken - monitor baby’s HR directly
■ Useful if high BMI, highly active woman and it is difficult to monitor babies
HR

● CTG
○ Dr C Bravado mnemomic
○ Foetal HR, variability of HR, accelerations or decelerations, monitor contractions
○ By palpation, can tell how strong contractions are (not by CTG)
○ From CTG, can tell how OFTEN contractions are and regularity

Indications for Operative Delivery

● Delay in 1st/2nd stage
○ prolonged 1st (require C-section) or 2nd stage (may be able to do instrumental
delivery)
● Suspected fetal distress
● Breech (after-coming head) - may need to use forceps
● Multiple pregnancies - may require operative delivery
● Severe FGR
● Maternal conditions (HIV, ITP, pre-eclampsia/eclampsia) - will increase risk of needing
operative delivery

Operative Delivery
Vaginal
● Vetouse (Kiwi) - suction cup which fits onto baby head to guide baby out of birth canal
● Neville-Barnes forceps - non-rotational
● Kielland’s forceps - rotational
● C-section

Analgesia - no right or wrong pain relief

● None
○ Support
○ Confidence
● TENS
● Parenteral Narcotics
○ Sedative effects for mum/baby
● Epidural
 ○ Affects labour progress?
○ Predisposes to intervention?
○ Potentially increases the risk of rotational delivery
Summary
● The majority of pregnancies are normal and require no intervention
● AN care identifies those few that require care and:
○ Prepares for delivery
○ Allows identification of problems in labour
○ Improves overall outcome
Puerperium

● Management of 3rd stage - delivery of baby to expulsion of placenta and membranes

● Passive vs Active
○ CCT - controlled cord traction - cord is clamped and cut (often delay cord
clamping to give baby benefit of receiving blood cells through cord)
○ Uterotonic - IM injection after baby is delivered
■ Syntocinon 10 units IM
○ Cord clamping and cutting
● Helps to reduce blood loss in third stage
● Women may opt to have a PASSIVE third stage

Postpartum Issues
● Establishing breastfeeding
○ Mastitis - aware of signs and symptoms and what to do
● PPH - may be immediately after delivery (atonic uterus that doesn’t contract or placenta
that is retained) or may be delayed PPH (largely due to infection, retained placental
tissue)
● Pre-eclampsia - largely a condition at antenatal time (can get it postnatally)
● Wound infections - perineum or C-section site
● VTE - all should be risk assessed
● Baby blues/ depression/ psychosis
Benefits of Breastfeeding

MOTHER BABY

Free Availability

Reduced risk of breast/ovarian ca Temperature

Uses 500 calories/day Less diarrhoea/vomiting/constipation

Mother-baby bond Fewer chest/ear infections

 Exclusive breastfeeding delays periods Less likely to develop obesity/Type 2
diabetes

Less chance of developing eczema

Family Planning - opportunity to discuss contraception

Some need to wait for a time following delivery
● Barrier methods
○ Don’t interfere with lactation
○ Femcap (cervical cap) - wait 10 weeks before use
● Pill
○ COCP - wait 6 weeks at least if breastfeeding - 3 weeks at least if not and VTE
assess POP
○ Increases risk of VTE, breastfeeding or not
● IUCD/IUS
○ Immediately / within 48 hours or wait 4 weeks
● Depo
○ Anytime after if not exclusively breast-feeding
○ 6 weeks after if exclusively breastfeeding
● Implanon
○ Can be immediately post delivery
● Sterilisation
○ At CS - has to be extensible discussed prior to CS → ideally months before, thoroughly
discussed
○ Vasectomy - failure rate is much less than female sterilisation
○ Filshie clips 3 months postnatal laparoscopic - risk of ectopic pregnancy
● Emergency Contraception
○ IUD/ Levonorgestrel