Page 871 - TNFlipTest

Toronto Notes 2019 Normal Labour and Delivery
Management
• beforeinitiatingtreatment,obtainabaselineCBCincludingplateletsandaPTT
• unfractionatedheparin(preferred)
■ bolus of 5,000 IU followed by an infusion of ~30,000 IU/24h ■ measure aPTT 6 h after the bolus
■ maintain aPTT at a therapeutic level (1.5-2x normal)
■ repeat q24h once therapeutic
■ heparin-induced thrombocytopenia (HIT) uncommon (3%), but serious complication
■ LMWH can also be used in pregnancy (should be discontinued at least 24 hrs prior to delivery)
• warfariniscontraindicatedduringpregnancyduetoitspotentialteratogeniceffects
• compressionstockings
• poorevidencetosupportarecommendationfororagainstavoidanceofprolongedsitting
• VTEprophylaxis
■ women on long-term anticoagulation: full therapeutic anticoagulation throughout pregnancy and for 6-12 wk postpartum
■ women with a non-active PMHx of VTE: unfractionated heparin regimens suggested
■ insufficient evidence in pregnancy to recommend routine use of LMWH for all patients
■ current prophylaxis regimens for acquired thrombophilias (e.g. APS syndrome) include low dose
Aspirin® in conjunction with prophylactic heparin
Normal Labour and Delivery
Definition of Labour
• truelabour:regular,painfulcontractionsofincreasingintensityassociatedwithprogressivedilatation and effacement of cervix and descent of presenting part, or progression of station
■ preterm(≥20to≤36+6wkGA) ■ term(37-41+6wkGA)
■ postterm(≥42wkGA)
• falselabour(Braxton-Hickscontractions):irregularcontractions,withunchangedintensityandlong intervals, occur throughout pregnancy and not associated with any cervical dilatation, effacement, or descent
■ often relieved by rest or sedation
The Cervix
• seeBishopScore(Table21,OB37)
■ dilatation: latent phase (0-4 cm, variable time); active phase (4-10 cm)
■ effacement: thinning of the cervix by percentage or length of cervix (cm) ■ consistency: firm, medium, or soft
■ position: posterior, mid, or anterior
• other consideration:
■ application: contact between the cervix and presenting part (i.e. well or poorly applied)
The Fetus
• fetallie:orientationofthelongaxisofthefetuswithrespecttothelongaxisoftheuterus(longitudinal, transverse, oblique)
• fetal presentation: fetal body part closest to the birth canal
■ breech (complete, frank, incomplete) (see Figure 5, OB23)
■ cephalic (vertex/occiput, face, brow)
■ transverse (shoulder)
■ compound (fetal extremity prolapses along with presenting part)
■ all except vertex are considered malpresentations (see Obstetrical Complications, OB16)
• fetal position: position of presenting part of the fetus relative to the maternal pelvis
■ OA: most common presentation (“normal”) – left OA most common
■ OP: most rotate spontaneously to OA; may cause prolonged second stage of labour ■ OT: leads to arrest of dilatation
◆ normally, fetal head enters maternal pelvis and engages in OT position
◆ subsequently rotates to OA position (or OP in a small percentage of cases)
• attitude:flexion/extensionoffetalheadrelativetoshoulders
■ brow presentation: head partially extended (requires C/S) ■ face presentation: head fully extended
◆ mentum posterior always requires C/S, mentum anterior can deliver vaginally
• station:positionofpresentingbonypartrelativetoischialspines–determinedbyvaginalexam
■ at ischial spines = station 0 = engaged ■ –5 to –1 cm above ischial spines
■ +1 to +5 cm below ischial spines
Obstetrics OB31
Virchow’s Triad for VTE
• Hypercoagulable state • Stasis
• Endothelial damage
Maternal Triage Assessment
ID: Age, GPA, EDC, GA, GBS, Rh, Serology CC
HPI: 4 key questions:
• Contractions: Since when, how close (q x
min), how long (x s), how painful
• Bleeding: Since when, how much (pads), colour (pinky vs. brownish vs. bright red),
pain, last U/S, trauma/intercourse
• Fluid (ROM): Since when, large gush vs. trickle, soaked pants, clear vs. green vs.
red, continuous
• FM: As much as usual?, When last
movement?, Kick counts (lie still for 1-2 h, cold juice, feel FM – should have 6 movements in 2 h)
PregHx: Any complications (HTN, GDM, infections), IPS/FTS screening, last U/S (BPP score, growth/estimated fetal weight, position), last vaginal exam
POBHx: Every previous pregnancy and outcome: year, SVD/CS/miscarriage/abortion, baby size, length of labour, use of vacuum or forceps, complications
PMHx, Meds, Allergies, SHx
O/E: Maternal vitals, fetal heart tracing (baseline, variability, presence of accelerations/decelerations), Leopold’s, vaginal exam, U/S
Reference Point for Describing Fetal Position
• Occiput for cephalic presentation
• Sacrum for breech presentation
• Mentum for face presentation