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  ABNORMAL PRESENTATION BREECH PRESENTATION   A 25 yo primigravida with breech presentation at 32 weeks of gestation came to GP clinic. Task:  take history, ask examination finding, explain management. Causes Mother -   Polyhydramnion (abnormal liquor volume) -   Contracted pelvis (abnormality of maternal pelvis) -   Placenta previa -   Fibroid -   Multigravida -   Bicornuate uterus Fetus -   IUGR (Intra Uterine Growth Restriction) -   Prematurity -   Short umbilical cord -   Baby’s abnormalities -   Fetal death (intra uterine fetal death) -   Twins Hx: Is this a planned pregnancy? Congratulation How’s the pregnancy so far? Regular antenatal check up? !  US (number of fetus, placenta), sweet test, blood group Is your baby kicking well? Do you have any headache, blurring of vision, dizziness, leg swelling? Do you have any significant medical condition in the past? HPT, DM, thyroid, liver disease? Any vaginal bleeding/discharge, water leaking, tummy pain? FHx of breech presentation or miscarriage Medication O/E: GA; VS; Brief check of heart and lungs; Leg oedema or not Abdomen: Fundal height; Tenderness; FHS; Presentation !  breech (bell shaped at fundus) Pelvic exam only inspection Ix:  Urine dipstick; BSL Explanation:  From Hx and examination, I discovered your baby’s position is so called breech presentation.  Normally baby’s head is down and buttock is up. But in your case, your baby’s buttock is down, head is up. The good news is your baby is all right and there is a chance your baby will change to normal position. I’d like to order US to confirm: -   type of breech -   fetal well being -    baby’s size and neck extension (CI for NVD) -    placental position 1  ABNORMAL PRESENTATION (For water breaks ! need to exclude cord prolapse.) <37 week, if not in labour: -   frequent follow-up -   Reassure that the baby might change to normal position <37 week, if in labour (regular contractions/any complications): -   Refer for Elective CS  as baby is premature (cause haemorrhage of the brain) -   If in labour + baby death !  Vaginal delivery >37 week but <38week -   external cephalic rotation !  done in hospital by experienced obstetrician because it can lead to labour. (CI !  previous CS, severe eclampsia, placenta previa...) Risk: Placenta separation, bleeding, entanglement of the cord, PROM !  premature labor, fetal-maternal haemolysis (give anti-D before the procedure) >38week -   Elective LSCS (lower segment caesarean section) is safe for the baby; vaginal delivery is  possible but more risky which can cause perinatal morbidity and mortality. Types of breech: 1.   Frank or extended (hips flexed, knees extended) !  can try normal delivery 2.   Complete or flexed (hips flexed, knees flexed) !  can try normal delivery 3.   Footling or incomplete (one or both hips extended with a foot presenting) !  CS Risks of vaginal delivery: -   Injury to baby ! Fractured limbs (clavicular, femur, humerus fracture) -   ICH (intracranial haemorrhage) -   Death of baby -   Cord prolapse -   Prolonged labour -   Obstructed labour -    Nerve injury in the baby (Erb’s palsy !  brachial plexus; Facial palsy !  facial nerve). Erb’s palsy !  paralysis of the arm caused by injury to the upper group of the arm’s main nerves !  C5-C6 !  depends on the nature of damage, can resolve on its own over a  period of months, necessitate rehabilitative therapy, or require surgery. Risk of CS !  bleeding, infection, DVT, injury Indication for CS:  Fetal distress; Abnormal CTG; Poor prognosis When is NSVD (normal spontaneous vaginal delivery) possible: -   Imminent labour -   Must be in tertiary hospital (obstetrician consultant) -    No absolute contraindication Main concern  is cord prolapse , if you have water leakage, tummy pain, bleeding, go to ED immediately.  ABNORMAL PRESENTATION TRANSVERSE LIE A 38-week multigravida, lives 80 km from tertiary hospital. You’re a HMO in rural hospital. You found that her baby is transverse lie. Task:  take relevant history, ask examination finding, and explain management. Hx:  Your baby’s position is different from normal. I’d like to ask you a few Qs. How’s your pregnancy so far? Have you done a regular antenatal check up? 18 weeks US, 26 weeks sweet test? Are you aware of your blood group? Is your baby kicking well? Signs of labour  ! Any tummy pain; Water leakage; vaginal bleeding How many children do you have? ! 2 Any complication during the previous pregnancies? How were the delivery? How’s your general health? SADMA O/E: GA; VS; Quick system review Abdominal examination: fundal height; presentation/lie; tenderness; FHS PV Ix:  Urine dipstick; BSL Explanation: I found your baby is in a different position we called “transverse lie”. It’s quite a common condition. (draw and show) One reason is small pelvis, but in your case, it’s unlikely because you have 2 previous NVD; the other reason is lower position of placenta (Placenta previa), previous pregnancy can cause it which can prevent baby from normal position. We need to r/o it by US. The 3 rd  reason is  b/o too much fluid in the womb; and the 4 th  reason is relatively large uterus, after previous  pregnancy; this is most likely in your case. 5 th  reason !  small baby. We’re far away from tertiary hospital and you’re already term. I’d like you to get admitted in the hospital as you need obstetrician’s assessment. Need to exclude placenta previa by US. Risk: Rupture of membrane !  can cause cord prolapse that can compromise your baby. Let me reassure you that you’ll be monitored closely to try to avoid this condition. I’ll call the tertiary hospital and arrange to transfer you (mode of transfer !  air ambulance). They may try gentle rotation of the baby to normal position (Eexternal cephalic version) !  >38 wk low amount of amniotic fluid. If successful, we can go for NVD. If it’s not successful, you have to go for a CS. You’ll be under supervision and obstetrician will decide mode of delivery according to your condition and wish. 2  ABNORMAL PRESENTATION Right Occipito-Posterior Delivery   A 19 yo primigravida, started labour and presented to a birth centre at 2 am by dilated cervix 4 cm but poorly progressed & very painful. She was given 300 mg of pethidine and after 4 hours the progress is still poor. The doctor diagnosed her with right occiput posterior. Task:  manage the case include counselling the patient and explain her condition. How to Understand Cephalic Fetal Positions Fetal position refers to the way that the baby is lying inside the womb. Doctors and midwives can determine fetal position by palpating your stomach with their hands. If the baby's position is questionable at the time of birth, it can be confirmed through an ultrasound. The bones of the fetal scalp are soft and meet at suture lines. Over the forehead, where the  bones meet, is a gap, called the anterior fontanel, or soft spot. This will close as the baby grows during the 1st year of life, but at birth, it is open. The anterior fontanel is an obstetrical landmark because of its' distinctive diamond shape. Early in labor, it is usually difficult to feel the anterior fontanel. After the patient is nearly completely dilated, it becomes easier to feel the fontanel. The occiput of the baby has a similar obstetric landmark, the posterior fontanel. This junction of suture lines in a Y shape that is very different from the anterior fontanel. Occiput Anterior Occiput Anterior (OA) means that the occiput is lying against the center of the abdomen and the face is looking directly towards the back. This is the optimal position for birth.   Occiput anterior is usually the easiest position for the fetal head to traverse the maternal  pelvis. Shown here is the direct OA position. While some fetuses deliver in this position, others deliver slightly rotated clockwise (Left Occiput Anterior) or counterclockwise (Right Occiput Anterior). Either way, the fetus is still considered to be an anterior position. Left Occiput Anterior (LOA) The occiput is facing the lower left abdomen and the face is looking towards the right  buttocks. 3
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