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Obstetrics Simulation Workshop - Student Handout, Exams of Obstetrics

History of the Labouring Obstetrical Patient o GTPAL o Gestational age o Degree of prenatal care (e.g., IPS, MSSS, ultrasounds, last medical appointment).

Typology: Exams

2022/2023

Uploaded on 02/28/2023

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Intro to Obstetrics: Simulation Workshop - Student Handout
History of the Labouring Obstetrical Patient
o GTPAL
o Gestational age
o Degree of prenatal care (e.g., IPS, MSSS, ultrasounds, last medical appointment)
o Infection status (e.g., GBS, HIV)
o Medical conditions associated with pregnancy (e.g., gestational diabetes, pre -eclampsia)
o Fetal well-being (e.g., fetal movement)
o Current vaginal bleeding or leaking fluid from vagina
o Onset and frequency of contractions (if present)
o Past medical history
o Current medications
o Allergies
o Distance from home to hospital
Physical Exam of the Labouring Obstetrical Patient
o Vitals
o Speculum exam for presence of fluid
o Cervical assessment:
Dilation
Effacement
Fetal station
Consistency
Position
o Assessment of fetal well-being
Fetal tracing
Definition of Labour
Labour is defined as uterine contractions producing cervical changes and is divided into four stages:
o First stage
Onset of true labour to complete dilation of the cervix
Includes latent and active phase
Latent: early cervical effacement and dilation (usually considered up to 3-4 cm)
Active: more rapid cervical dilation (~1cm/hour)
o Second stage
Full dilation (10 cm) to delivery of the fetus
o Third stage
Delivery of fetus to delivery of the placenta
Generally occurs 2-10 minutes after the birth of the baby
o Fourth stage
Variability in the definition (6 hours to 6 week postpartum)
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Intro to Obstetrics: Simulation Workshop - Student Handout

History of the Labouring Obstetrical Patient

o GTPAL o Gestational age o Degree of prenatal care (e.g., IPS, MSSS, ultrasounds, last medical appointment) o Infection status (e.g., GBS, HIV) o Medical conditions associated with pregnancy (e.g., gestational diabetes, pre-eclampsia) o Fetal well-being (e.g., fetal movement) o Current vaginal bleeding or leaking fluid from vagina o Onset and frequency of contractions (if present) o Past medical history o Current medications o Allergies o Distance from home to hospital

Physical Exam of the Labouring Obstetrical Patient

o Vitals o Speculum exam for presence of fluid o Cervical assessment:  Dilation  Effacement  Fetal station  Consistency  Position o Assessment of fetal well-being  Fetal tracing

Definition of Labour

Labour is defined as uterine contractions producing cervical changes and is divided into four stages:

o First stage  Onset of true labour to complete dilation of the cervix  Includes latent and active phase  Latent: early cervical effacement and dilation (usually considered up to 3-4 cm)  Active: more rapid cervical dilation (~1cm/hour) o Second stage  Full dilation (10 cm) to delivery of the fetus o Third stage  Delivery of fetus to delivery of the placenta  Generally occurs 2-10 minutes after the birth of the baby o Fourth stage  Variability in the definition (6 hours to 6 week postpartum)

Management of Labour

o First stage  Maternal ambulation or if lying, lateral recumbent position  CBC, Hgb, blood group, Rh type, HBV status, urinalysis  Maternal vitals q1-2 hours  Assess need for analgesia  Fetal monitoring (active phase) q30 minutes (uncomplicated pregnancy) or q15 minutes (obstetric risk factors)  Monitor uterine contraction q30 minutes (uncomplicated) or continuously (complicated)  Vaginal exams q2 hours (active phase) o Second stage  Avoidance of supine position  Encourage mother to bear down with each contraction  Fetal monitoring q15 minutes (uncomplicated pregnancy) or continuously or q5 minutes (obstetrical risk factors)  Vaginal exam q30 minutes to monitor fetal descent  Put on gloves and set up tray  Modified Ritgen’s maneuver or manual perineal support  After delivery of the head, clear airway and check for nuchal cord  Delivery of anterior shoulder (administer oxytocin)  Delivery of posterior shoulder  Place baby on to mum’s belly (and then into infant warmer)  Clamp and cut cord and take cord samples o Third stage  Placental separation occurs within 5-30 minutes  Avoid fundal massage  Inspect for signs of placental separation (fresh blood from vagina, umbilical cord lengthening, fundal rising, uterus feels firm) before applying traction on cord  Deliver placenta and inspect for abnormalities/ensure completeness  Examine mum for lacerations (and repair if necessary) o Fourth stage  Monitoring for BP, HR, and blood loss

Management of Shoulder Dystocia*

o McRobert’s maneuver (may be done in conjunction with suprapubic pressure)  Flexion of maternal legs against abdomen o Suprapubic pressure o Wood’s/corkscrew maneuver  Apply pressure to scapula of posterior shoulder to try to rotate it into the anterior position o Insert hand into vagina, grasp posterior arm and move it across the chest (results in delivery of posterior shoulder and displacement of anterior shoulder from behind pubic symphysis)  May result in fractured humerus o Fracture of one or both clavicles o Zavanelli maneuver  Push fetal head back into vagina and prepare for c/s (may require uterine relaxant)

*Note these are listed in the order that they should be attempted

Indications for Operative Vaginal Delivery and Caesarean Section

Pharmacologic Options

Fetal Surveillance

Baseline Assessment

o Rate  Normal (120-160 bpm) o Variability  Short-term (beat-to-beat) is normally 5-25 bpm  Long-term variability is 3-10 cycles/minute

Advantages Disadvantages

Systemic analgesia

Parenteral agents

Patient controlled opioid (e.g., Remifentanil PCA)

Less variable plasma concentration Superior pain relief with dose maternal respiratory depression placental transfer of drug Higher patient satisfaction

Specialized equipment Opioid side effects Small doses are not always effective Risks to fetus/neonate are unclear

Opioid adjuncts (e.g., barbiturates, BZDs)

Rarely used due availability of safer alternatives

Intermittent bolus parenteral opioid (e.g., meperidine, morphine, tramadol, fentanyl)

Simple Quick onset No specialized equipment or personnel

Maternal side effects (e.g., Nx, dysphoria, respiratory depression, drowsiness, delayed gastric emptying) Fetal side effects (e.g., decreased FHR variability, respiratory depression)

Inhalational agents

Nitrous oxide Negligible neonatal effect No effect on uterine activity

Requires maternal cooperation

Volatile anesthetic agents (e.g., isoflurane, sevoflurane)

Not used clinically at present

Regional analgesics

Epidural analgesia

Most effective analgesia Higher patient satisfaction Allows conversion to c/s if necessary

Contraindicated if:  Increased ICP  Active neurological disorder  Infection at site of injection/systemic infection  Frank coagulopathy Complications:  Hypotension  Extensive motor block  Slowed labour progress  Fetal effects  Post-dural puncture headache (PDPH) Spinal analgesia

Combined spinal-epidural analgesia

Rapid onset with good sacral analgesia Delayed verification of functioning epidural catheter Higher incidence of pruritus Possible higher risk of fetal bradycardia Risk of PDPH Limited analgesia duration (in single-shot spinal)

Paracervical block Rarely used due to risk of uteroplacental perfusion Lumbar sympathetic block Pudendal nerve block (S2-S4) Frequent failure with risk of direct fetal trauma Perineal infiltration Rapid onset Incomplete epidural analgesia

Fetal Heart Rate Patterns

Description Fetal distress? Potential Explanation Intervention Accelerations FHR in response to contraction

No Physiologic response None needed

Early deceleration

FHR with lowest point at peak of the contraction

No Seen when fetal head engaged (head compression)

None needed

Late deceleration

FHR with lowest point after peak of contraction

Yes Uteroplacental insufficiency Fetal hypoxia Fetal metabolic acidosis Low arterial pH

Change maternal position (supine  lateral) Maternal oxygen Discontinue oxytocin IV tocolytic c/s Variable deceleration

FHR with variable onset

Yes Umbilical cord compression Change maternal position 100% oxygen to mother Trendelenberg position Discontinue oxytocin IV tocolytics Amnio-infusion with normal saline Assisted vaginal delivery or c/s Decreased beat- to-beat variability

<5 bpm Possibly Fetal acidosis Quiet sleep state Maternal sedation (drugs)

Acoustic stimulation to differentiate between sleep state and something more concerning

Augmentation of Labour

o Artificial stimulation of labour o Artificial rupture of membranes (ARM), which may be done in conjunction with IV oxytocin infusion o Complications of oxytocin augmentation include:  Hyperstimulation causing fetal distress as a result of ischemia  May lead to uterine rupture  Antidiuretic effect of oxytocin may lead to severe water intoxication  Uterine muscle fatigue and post-delivery uterine atony (more commonly seen with prolonged oxytocin use)

References

Chen, Y. A., & Tran, C. (Eds.). (2011). Toronto notes: Comprehensive medical reference & review for MCCQE I & USMLE II. Toronto, ON: McGraw Hill Professional

Hacker, N. F., Gambone, J. C., Hobel, C. J. (2010). Essentials of obstetrics and gynecology (5th^ ed.). Philadelphia, PA: Saundiers Elseviers.

Wong, C. (2009). Advances in labor analgesia. International Journal of Women’s Health, 1 , 139-154.