Basic obstetrics
The aim of obstetrics is to
monitor and promote foetal and maternal well-being during pregnancy and labour,
and to identify and manage high risk pregnancies or complications. In the UK
most women choose to deliver in hospital, although planned home deliveries are
on the increase. Depending on local provision women may also choose to deliver
in a birthing centre, community midwifery unit, or midwife-led unit attached to
an obstetric centre.
All ‘high-risk’ deliveries should
be in a consultant-led obstetric unit, and clear protocols should be in place
for the transfer in of women from outly-ing centres if problems arise during
labour.
In the UK, care is usually shared
among GP, community midwife, and ob-stetrician.
·
First
antenatal (‘booking’) visit usually occurs at 10–12wks gestation when
significant risk factors should be identified.
·
Foetal
US is usually performed to determine gestational age.
Women are assessed every few weeks
to monitor:
·
general
health;
·
haemoglobin
(Hb);
·
BP,
urine glucose and albumin;
·
foetal
growth, movements, HR, and lie (liquor volume).
Maternal testing is offered for:
·
Blood
group and antibodies (iso-immune haemolytic disease);
·
Serology
for syphilis, rubella, hepatitis B, and human immunodeficiency virus (HIV);
·
Urine
for protein, glucose, and bacteria.
Blood tests are also offered at
17–18wks to screen for chromosomal dis-orders and structural anomalies.
Controversy exists as to what is most cost-effective and they may include:
·
α-fetoprotein
(AFP);
·
Human
chorionic gonadotrophin (hCG);
·
Oestriol
(combined with above 2 tests = ‘triple test’);
·
Triple
test plus inhibin (‘quadruple test’);
·
Quadruple
test plus pregnancy-associated protein-A (PrAP-A) ± US nuchal thickness.
A detailed foetal US looking for
abnormalities is usually done at 718wks.
Chorionic villus biopsy (>10wks
gestation) or amniocentesis (usually at 15–16wks) is offered for chromosomal, enzymatic,
or gene probe analy-sis, if screening tests show high risk of serious problems
(also if maternal age >35yrs, previously abnormal baby, +ve family history).
Both diagnostic tests carry a risk of miscarriage (71%, slightly higher with
cardiovascular system (CVS)).
Indicated when delivery is safer
for either mother or baby than to remain in
utero. Method: use prostaglandin (PO or vaginally, per vagina (PV)) or amniotomy.
Occurs >37wks and should result
in delivery within 24hr of starting.
·1st
stage: from the onset of
labour to full cervical dilatation. Once cervix
is 3cm dilated should then be at least 1cm/hr.
·2nd
stage: time from fully
dilated cervix to birth. Normal duration is
45–120min in a primiparous woman; 15–45min if multiparous. Active pushing
during the second stage should not usually exceed 60–90min.
·3rd
stage: time from birth to
placental delivery.
Intrapartum foetal heart
monitoring detects signs of foetal compromise:
·In established low-risk labour
intermittent auscultation (by Doppler USS,
or Pinard stethoscope) should be undertaken for 1min after contractions, at
least every 15min in the first stage and every 5min in the second stage.
·Continuous electronic foetal
monitoring (cardiotocogram) should be undertaken in high risk pregnancies and
when:
· abnormal foetal HR detected;
· meconium staining of liquor or
bleeding in labour;
· maternal pyrexia;
· oxytocin use;
· maternal request.
·Foetal blood sampling is indicated
if foetal distress suspected.
Majority of term infants are
delivered by normal vaginal delivery. Indications for caesarean section (CS)
include:
·maternal ill health;
·acute foetal distress;
·antepartum haemorrhage (APH);
·placenta praevia;
·umbilical cord prolapsed;
·failure to progress;
·failed induction;
·previous CS;
·foetal malpresentation (including
breech);
·multiple pregnancy;
·pregnancy-induced hypertension;
·maternal HIV or HSV;
·evidence of ongoing foetal
compromise, e.g. severe IUGR.
Instrumental delivery (forceps or
vacuum extraction) may be indicated when there is:
·prolonged 2nd stage;
·malpresentation, e.g. breech
delivery or occipital-posterior;
·foetal distress.
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