Basic Obstetrics

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A review of basic obstetrics in New Zealand for the College of GP`s

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Basic Obstetrics

  1. 1. Basic Obstetrics Dr Chris Harnden FRNZCGP GP Blenheim GPEP2 Facilitator Pam Harnden Self Employed LMC, Marlborough
  2. 2. Who Can Offer Lead Maternity Care? <ul><li>Specialist Obstetrician </li></ul><ul><li>Midwife </li></ul><ul><li>GP – Diploma Obstetrics </li></ul><ul><li>Shared Care options </li></ul>
  3. 3. Comparison of philosophy <ul><li>Midwife </li></ul><ul><li>Holistic Approach </li></ul><ul><li>“ Social Justice approach” </li></ul><ul><li>Work towards Self-health and Self determination </li></ul><ul><li>Partnership Model </li></ul><ul><li>The woman ‘births’ her baby </li></ul><ul><li>Medical </li></ul><ul><li>The mother reaches the end of pregnancy as healthy or healthier than the outset </li></ul><ul><li>That any physical or psychological defects are detected and treated </li></ul><ul><li>That the mother is delivered of a healthy baby </li></ul>
  4. 4. First Antenatal Visit <ul><li>Confirmation of pregnancy </li></ul><ul><li>planned or unplanned </li></ul><ul><li>?TOP </li></ul><ul><li>Assessment of pregnancy ‘risk’ </li></ul><ul><li>Take full obstetric, medical & social history (including assessment for domestic violence) </li></ul>
  5. 5. Termination of Pregnancy <ul><li>Reasons </li></ul><ul><li>Explain legal position </li></ul><ul><li>Discuss other options </li></ul><ul><li>Full hx / exam including hvs, chlamydia swabs, antenatal bloods </li></ul><ul><li>Psych state </li></ul><ul><li>Info sheet, discuss procedure </li></ul><ul><li>Contraception </li></ul><ul><li>Follow up </li></ul>07/06/09
  6. 6. Obstetric History <ul><li>Gravida, Para </li></ul><ul><li>Previous TOP/miscarriage </li></ul><ul><li>Complications of previous pregnancies </li></ul><ul><li>Previous congenital abnormalities </li></ul>
  7. 7. Medical History <ul><li>Current medical illnesses </li></ul><ul><li>Past medical Illnesses </li></ul><ul><li>Current medications, *folic acid </li></ul><ul><li>Allergies </li></ul><ul><li>Smoke/alcohol/drugs </li></ul><ul><li>Family history </li></ul>
  8. 8. Social history <ul><li>Support network </li></ul><ul><li>Work </li></ul><ul><li>Cultural Awareness </li></ul>
  9. 9. Assessment Family Violence <ul><li>Within the last year have you been hit, slapped or hurt in any way by your partner/ex partner </li></ul><ul><li>Are you afraid of your partner/ ex partner </li></ul><ul><li>Are you safe to go home when you leave here </li></ul><ul><li>Would you like any assistance? </li></ul><ul><li>Screen when partners/family NOT present </li></ul><ul><li>(MOH guidelines 2007) </li></ul>
  10. 10. Physical Examination <ul><li>Ht/Wt BMI </li></ul><ul><li>CVS including BP </li></ul><ul><li>Abdominal Exam ?fundus ?FH </li></ul><ul><li>No evidence to support breast exam </li></ul><ul><li>No evidence to support V/E or smear taking </li></ul><ul><li>No evidence to support HVS </li></ul><ul><li>(Latter 2 increased risk of miscarriage & infection ‘Cochrane review’) </li></ul>
  11. 11. Investigations <ul><li>Routine 1 st A/N screen: FBC, Rubella, Bl Grp, antibody screen, Hep B, VDRL, HIV </li></ul><ul><li>USS if unsure of dates </li></ul><ul><li>NT scan 11-13wks </li></ul><ul><li>Maternal Triple Test 15wks </li></ul><ul><li>MSSU chlamydia screening </li></ul><ul><li>Amniocentesis or cvs in high risk cases 1% miscarriage risk </li></ul>
  12. 12. MSU <ul><li>Asymptomatic bacteriuria 2%-10% (NICE 2003) can cause pyleonephritis and preterm labour </li></ul><ul><li>Urine dipstick unreliable only detects 50% of cases (NICE guidelines 2003) </li></ul>
  13. 13. Chlamydia Urine Screening should be offered to high risk women <ul><li>Under 25yrs </li></ul><ul><li>Unmarried women </li></ul><ul><li>History of STD </li></ul><ul><li>New/multiple partners </li></ul><ul><li>No history of barrier contraception </li></ul><ul><li>Women in communities with high rates </li></ul><ul><li>1 st trimester and 3 rd trimester (Kirkham et al 2005) </li></ul>
  14. 14. Medications and Advice <ul><li>Folic Acid 0.8mg till 12wks </li></ul><ul><li>Morning Sickness </li></ul><ul><li>Contact if pain or bleeding </li></ul><ul><li>Discuss Lead Maternity Care options </li></ul><ul><li>LMC referral </li></ul><ul><li>Obstetric referral if risk identified </li></ul>
  15. 15. Further Tests <ul><li>18-20wks Anomaly scan </li></ul><ul><li>28wks - CBC, ?Ferritin if Hb < 10.5g/dL, Antibodies, Anti D Rh neg (NICE 2003) </li></ul><ul><li>34 wks ?kick chart (debateable point), 2 nd dose Anti D Rh neg (NICE 2003) </li></ul><ul><li>36wks - CBC for those on iron, Antibodies Rh neg, check presentation, ?ECV for breech, scan if placenta low lying </li></ul>
  16. 16. Schedule of Antenatal Visits <ul><li>Uncomplicated pregnancy 10 visits </li></ul><ul><li>1 st -before 12wks </li></ul><ul><li>14weeks </li></ul><ul><li>20 weeks </li></ul><ul><li>26wks </li></ul><ul><li>30wks </li></ul><ul><li>34wks </li></ul><ul><li>36wks </li></ul><ul><li>38wks </li></ul><ul><li>39wks </li></ul><ul><li>40wks </li></ul><ul><li>41wks CTG and refer for obs consult </li></ul><ul><li>(NICE guidelines 2003) </li></ul>
  17. 17. Complications of Early Pregnancy <ul><li>Nausea and Vomiting </li></ul><ul><li>Nausea 70%-80% (Medalie 1957; Whitehead 1992; Gadsby 1993) </li></ul><ul><li>Vomiting 50% (Whitehead 1992; Gadsby 1993) </li></ul><ul><li>17% just in the mornings </li></ul><ul><li>13% beyond 20wks gestation </li></ul><ul><li>35% lost time at work </li></ul>
  18. 18. Early pregnancy causes of nausea <ul><li>Rising HCG levels thought to stimulate thyroid activity. Goodwin et al (1992) </li></ul><ul><li>Thyrotoxicosis. Chong and Johnston (1997) </li></ul><ul><li>Deficiency B6 and Zinc </li></ul><ul><li>Multiple pregnancy </li></ul><ul><li>Molar pregnancy </li></ul><ul><li>Hypogycaemia </li></ul><ul><li>Decreased serotonin levels </li></ul>
  19. 19. Psychosocial causes of nausea <ul><li>Stress </li></ul><ul><li>Anxiety </li></ul><ul><li>Fear </li></ul><ul><li>Unwanted/unplanned pregnancy </li></ul><ul><li>Relationship difficulties </li></ul>
  20. 20. Possible Treatments <ul><li>Acknowledge problem </li></ul><ul><li>Frequent small meals </li></ul><ul><li>Vit B6, ginger, acupuncture, acupressure </li></ul><ul><li>Medications (metoclopramide, prochlorperazine) little is known of their teratogenic effects </li></ul>
  21. 21. Monitor <ul><li>Urine for Ketones </li></ul><ul><li>U&E for dehydration if severe vomiting </li></ul><ul><li>Refer and admit if signs of hyperemesis gravidarum </li></ul><ul><li>Early scan to exclude molar pregnancy </li></ul>
  22. 22. Pain and Bleeding 1 st trimester <ul><li>Bloods for HCG and progesterone levels </li></ul><ul><li>Scan </li></ul><ul><li>Anti D for Rh neg women </li></ul><ul><li>History and location of pain </li></ul><ul><li>Under 8wks possible ectopic </li></ul>
  23. 23. Complications of late pregnancy <ul><li>UTI/pyelonephritis – MSU – Antibiotics </li></ul><ul><li>Abdominal Pain ?muscular ?more serious </li></ul><ul><li>Bleeding - ?how much, ?placental position </li></ul><ul><li>Headaches - ?New, ?migraine, ?hormonal </li></ul><ul><li>Carpal Tunnel syndrome – due to fluid retention </li></ul><ul><li>Anaemia </li></ul>
  24. 24. Hypertension in pregnancy <ul><li>Gestational Hypertension </li></ul><ul><li>Pre eclampsia </li></ul><ul><li>Eclampsia </li></ul>
  25. 25. Gestational Hypertension <ul><li>A blood pressure >140/90 mmHg after 20wks gestation (Brown et al., 2000) </li></ul><ul><li>May progress to pre eclampsia (Barton et al.,2001; Saudan et al., 1998) </li></ul>
  26. 26. Pre Eclampsia <ul><li>occurs 2-3% primigravida </li></ul><ul><li>Occurs 5-7% nulliparous </li></ul><ul><li>Definition </li></ul><ul><li>Gestational hypertension with proteinuria on 24hr urinary protein measurement (>0.3g/24hrs) </li></ul>
  27. 27. Eclampsia <ul><li>Definition </li></ul><ul><li>The occurrence of one or more generalised convulsions/coma in the setting of pre eclampsia, in the absence of other neurological conditions. </li></ul>
  28. 28. Cholestasis <ul><li>Itching especially soles of feet and palms of hands </li></ul><ul><li>Rash </li></ul><ul><li>Check Bilirubin </li></ul>
  29. 29. Gestational Diabetes <ul><li>2%-9% pregnancies (NICE 2003) increasing due to maternal obesity </li></ul><ul><li>RANZCOG recommend random fasting 50g glucose test at 28wks as initial screening - widely practised despite lack of evidence it prevents adverse outcomes </li></ul>
  30. 30. Turanga Kaupapa (Maori MW ass.) <ul><li>Principles of Maori Childbirth should encompass </li></ul><ul><li>Whakapapa The wahine and her whanau is acknowledged </li></ul><ul><li>Karakia The wahine and her whanau may use karakia </li></ul><ul><li>Whanaungatanga The wahine and her whanau may involve others in her birthing program </li></ul>
  31. 31. Turanga Kaupapa (2) <ul><li>Te Reo Maori The wahine and whanau may speak Te Reo Maori </li></ul><ul><li>Mana The dignity of the wahine, whanau, midwife and doctors involved are maintained </li></ul><ul><li>Hau Ora The physical, spiritual and mental wellbeing of the wahine and whanau is promoted and maintained at all times </li></ul>
  32. 32. Turanga Kaupapa (3) <ul><li>Tikanga Whenua maintains the continued relationship to land, life, nourishment and the knowledge and support of kaumatua and whanau is available. </li></ul><ul><li>Te Whare Tangata the wahine is acknowledged, protected, nurtured and respected as the Te Whare Tangata (the house of the people) </li></ul>
  33. 33. Turanga Kaupapa (4) <ul><li>Mokopuna the mokopuna is unique, cared for and inherits the future, a healthy environment and whanau </li></ul><ul><li>Manaakitanga the midwife is a key person with a clear role and shares with the wahine and her whanau the goal of a safe, healthy birthing outcome. </li></ul>
  34. 34. Case 1 <ul><li>Miss A </li></ul><ul><li>17 yr old G1P0 </li></ul><ul><li>6 weeks since last period </li></ul><ul><li>fainted the previous day </li></ul><ul><li>spotting and mild l sided abdominal pain </li></ul>07/06/09
  35. 35. Case 1 <ul><li>Miss A </li></ul><ul><li>17 yr old G1P0 </li></ul><ul><li>6 weeks since last period </li></ul><ul><li>fainted the previous day </li></ul><ul><li>spotting and mild l sided abdominal pain </li></ul>07/06/09
  36. 36. Case 3 <ul><li>Ms C </li></ul><ul><li>26 yr old G4P1 </li></ul><ul><li>14 weeks since lmp </li></ul><ul><li>spotting with a few vague abdominal pains </li></ul>07/06/09
  37. 37. Case 4 <ul><li>Mrs D </li></ul><ul><li>35 yr old G7P5 </li></ul><ul><li>unknown dates / felt movements for ages </li></ul><ul><li>no antenatal care </li></ul><ul><li>had some spotting last 2 d . None for 8 hrs </li></ul><ul><li>not contracting </li></ul>07/06/09
  38. 38. References <ul><li>National Institute of Clinical Excellence UK 2003 </li></ul><ul><li>Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of systematic Reviews 2003, Issue 4 </li></ul><ul><li>MOH guidelines for Family violence </li></ul><ul><li>Denise Tiran, “Nausea and Vomiting in Pregnancy An integrated approach to care” </li></ul>
  39. 39. References <ul><li>Fiona Lyall and Michael Belfort. Pre-eclampsia Etiology and Clinical Practice </li></ul><ul><li>Debbie Holmes & Philip N Baker. Midwifery by Ten Teachers </li></ul><ul><li>Pairman, Pincombe, Thorogood, Tracy. Midwifery Preparation for Practice </li></ul>

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