ObsGyn

AIM

- Hx + exam
- Antenatal care
- Common obstetric problems
- Common gynae disorders
- Epidemiology, stats
- Mortality + morbidity in obstetrics
- Knowledge of operative gynae

LMP 1st day of LMP

Naegeles Formula = LMP + 9months + 7 days

* if cycle > or < 28 have to adjust
* if recently stopped OCP, < useful

Term = 40 wks, 37-42 THUS preterm <37 , posterm >42

Parity = no of times a woman has delivered a POTENTIALLY VIABLE babies (>24 wks)

Gravidity = no of times woman has been pregnant

Stillbirth = child shows no sign of life when expelled from mother after 24wks @ 500g

Neonatal death (NND) = liveborn who dies w/in 28 days of birth *early NND : w/in 1st wk of life

Perinatal mortality rate = No. of stillbirths + early NND

Maternal death = death occurring in a/w pregnancy, childbirth or during 6 wks of puerperium (late
death : 6 wks to 1 yr UK)

*direct maternal death = death due to direct result of obs complication / intervention

*indirect maternal death = underlying maternal dx exacerbated by pregnancy

*fortuitous maternal death = causes unrelated to pregnancy (inc violent deaths + suicide)

# most common cause = PE , HTN disorders , haemorrhage , anaesthesia , abortion , sepsis , ectopic,
amniotic fluid embolism

Pregnancy tests
*hCG secreted by placenta when egg fertilised.

Urinary hCG
(> effective 1 wk after missed period)

Serum hCG
(can determine results earlier, qualitative OR quantitative, > accurate 1 wk after ovulation)

MODE OF DELIVERY
 - Normal (NVD, SVD)
- Instrumental / assisted (ventouse, forceps)
- Vaginal breech delivery
- C-section
o Elective
o Emergency
o Classical (midline incision on uterus longitudinal axis + abdomen sikit, skang byk
LSCS)
o Hysterotomy (incision in the uterus aka of uterus itself, kdg dlm c-sxn, kdg abortion,
etc)

Figure 1: Neville Barnes Obstetric Forceps

HX + EXAM

@ OBS

Personal details name, age, occupation, Gx Px, gestation

Presenting what ? referral ? how long ?
complaint HxPC :- nature ? duration ? ix + tx (timeline) ?
how affect (inc psychosocial) ? cause @ risk factor ?

Hx of current LMP, EDD

pregnancy Complications ? planned ?
Tests (booking scan (10-12), dating scan (8-14), anomaly scan(20))
Fetal movements ?

Past Obs Hx Any pregnancies before (inc miscarriage)

Type of delivery + how many wks gestation
Complications (of baby or mother, ante, intra, post) ?
Gender ? Age ? Health ? Wt ? of baby

Past Gynae Hx Menses : cycle? regular? length? heavy?

Gynae surgery / tx hx
Cervical smear ?
Contraception ? Difficulty conceiving ?

Others Past medical + surgical hx

Medications (before pregnant, time pregnant, masuk hospital, supplements)
Family hx
 (pregnancy [twin, PET, HTN, DM, VTE] @ fetal [NTD, CF, cardiac defect])
Social hx (smoke, alcohol, occupation, relationship, living status, support)
Systems review
# common complications : bleeding , UTI , anaemia , HTN, DM , tired , dehydration , sickness , etc
# fetal movements : 1st pregnancy > 20 wks , multi > 16 wks)

General examination General appearance ? Vitals (iMEWS)?

Abdominal examination
*exposed from xiphisterum
to pubic symphysis
*ask if any pain
Wt ? Height ?
Systemic exam (breast, bmi, respi, cvs, legs) ?
Inspect Distended ?
Linea nigra , striae gravidarum , everted umbilicus
, scars , fetal movements
Palpate 1. 4 palpate (check tenderness)
2. SFH
*fundus guna ulnar border of L hand
* 24 wks ~ gestation 2 cm
3. Leopolds manoeuvre , pelvic grip , pawliks grip
(satu tgn fixed satu tgn gerak atas ke bawah)
(comment on lie , presentation , engagement ,
liquor vol)

Auscultate Guna Pinards stethoscope (24 wks) / Doppler (12)

Listen over ant shoulder , ideally a minute
FHR ~ 110-160
# avoid fully flat (baring semi-prone @ L lat tilt) to avoid aortocaval compression

# iMEWS
- 1 yellow : repeat obs 30-60 mins
- 2 yellow @ 1 red : call obs to review , repeat obs in 30 mins
- >2 yellow @ 1 red : immediate review , repeat obs in 15 mins

# rough fundal landmarks : 12 (pubic symphysis) , 20 (umbilicus) , 36 (xiphoid process)

Presentation (cephalic, breech, shoulder, face, brow)

*Breech : complete (hips + knees F) // frank (hips F, knees E) // footling (hips + knees E)

Lie (longitudinal, oblique, transverse)

Engagement : fetal head engaged WHEN max diameter have passed thru pelvic inlet
*(fifths palpable) , 2/5 = engaged
*usually 37 wks (nulli) , multi often not engaged
#Post-natal hx

- Mother
o Delivery : gestation, mode, labour, analgesia
o Puerperium : BUBBLES
o Contraception
 o Home circumstances
- Baby
o Name, gender, wt,
o APGAR score, cord pH
o Feeding , vit K

Position (OP, OA, OT, etc)

LABOUR

Definition (ada 2 benda) = (1) progressive dilatation of cervix in the presence of (2) regular uterine
contractions

Stages

1st : onset to full Regular contractions, ROM

(10cm) dilation Maternal + fetal monitoring
- BP, pulse, temp, contractions
- FHR, abdominal exam
- Cervical dilation (VE)
Measure the dilatation using partogram
Has latent + active phase
Latent phase = smpai 3 cm for several hrs
Active phase = normal 1cm/hr , klu multi kadang 2cm/hr
Problems
- No progress
SO artificial ROM or syntocinon infusion
- Unsatisfactory
SO simple measures (position, epidural) @ FBS @ delivery (CS if
still in first stage)
 2nd : full dilation til Passive phase 1 hr, descent of fetal head on to perineum
fetus delivery Active phase pushing (klu first time 1hr, klu multi 30 mins)

Problems
- Unsatisfactory monitoring
- Failure to progress
o Either passenger OR power OR passage
o Malrotation , maternal exhaustion, cephalopelvic
disproportion (baby too big)
- Need to curtail 2nd stage (spinal tap, CVS dx)
SO : assisted delivery
= kena ada reason, consent, analgesia, position of fetal head, empty
bladder
HOW ?
- Rotation IF head OT/OP (guna Ventouse @ Kiellands forceps)
- No rotation IF OA (Neville Barnes forceps @ Ventouse @ Wrigleys)

3rd : fetus delivery til Kena active mx to < haemorrhage

complete delivery of - Give oxytocin bolus injection AT delivery of ant shoulder
placenta - Delivery : controlled cord traction
CCT = guna cara bawah ni
- Brandt-Andrews manoeuvre to prevent uterine inversion

Signs of uterine inversion ?

- Lengthening of cord
- Gush of blood
- Reduction of fundus
Problems
- Retained placenta
# VE in labor
- Cek (5) dilatation , consistency , position, length, station
- Station : descent of fetal presenting part in pelvis (ischial spines = zero station) -3 to +1

# CTG (cardiotocography) = record FHR + uterine contractions

 - Normal intrapartum CTG ~ 110-160
- Variability
- Acceleration = peak must be 15 bpm and must last 15 s from onset to return to baseline
- Deceleration

= variable dece : irregular, happen when babys umbilical cord is temporarily compressed,
abrupt decresed in FHR <10 mins, most common
The umbilical cord consists of two small, thick-walled arteries and one large, thin-walled vein. The
arteries transport deoxygenated blood and waste products away from the fetus back to the placenta.
The vein transports oxygenated blood and nutrients from the placenta into the fetal circulation. When
umbilical cord perfusion is decreased due to mechanical compression, the thin-walled vein becomes
occluded first. Blood no longer can return from the placenta to the fetal circulation but still can exit the
fetus via the unimpeded umbilical arteries. The decreased venous return to the heart precipitates a
transient reflex tachycardia that is seen as the initial, anterior shoulder in the classic variable
deceleration. If the pressure on the cord becomes greater, the small, thick-walled umbilical arteries also
become compressed. The result of this arterial compression is a rapid increase in fetal blood pressure
that activates a fetal baroreceptor-reflex response. Vagal stimulation occurs, and the FHR decreases
abruptly. Once compression of the umbilical cord is relieved, the higher elastic arteries open first, but
the umbilical vein still may be compressed. A transient tachycardia (posterior shoulder) may occur. As
perfusion in the umbilical vein resumes, the blood pressure normalizes and the FHR returns to baseline

If lama sgt, blh jdi resp acidosis memula then jdi metabolic acidosis

= early dece : transient decrease in FHR w/ nadir 30s coincides w/ onset of uterine
contraction, caused by fetal head compression during uterine contraction SO vagal
stimulation (reflex) , sometimes describes as shallow dece (xturun > 20bpm), uniform in
appearance

= late dece : transient decrease in FHR occurring at / after peak of uterine contraction ,
resulting from fetal hypoxia, gradual, nadir 5 to 30 bpm, shallow + uniform shape

#FBS @ cordocentesis @ percutaneous umbilical cord blood sampling

(advised in the presence of patho FHR trace unless evidence of acute compromise)

- Indications
o Pathological CTG in labour (cervix >3cm)
o Suspected acidosis in labour (cervix >3cm)
- Pre-requisites = consent, confirm position + dilatation of cervix + station
- Result interpretation

7.25 Normal result, repeat after 1 hr if CTG remains same

*klu sama gak, further samples deferred unless makin teruk
7.21 7.24 Borderline , repeat after 30 mins
7.20 Abnormal , consider delivery asap
* take into acc previous pH measurement, rate of progress in labour, clinical features woman + baby
* if indicated BUT xleh obtained + xde improvement in CTG trace, advise woman suruh bersalin
cepat (expedite)

- Contraindication
o Maternal infection (HIV, herpes, hepatitis)
o Fetal bleeding disorders
o Premature (<34 wks)
o Acute fetal compromise