Pregnancy

Counselling

 * Folic acid: prevents neural tube defects
 * Folic acid 0.4mg/day.
 * Start taking 2-3 months prior to conception until breastfeeding complete
 * Higher doses may be required based on PMHx and medications (e.g. epilepsy, diabetes, obesity, family history of NTD)
 * Smoking, ETOH, recreational drug cessation
 * Cessation of current birth control
 * Optimize maternal medical conditions
 * Review medications and teratogenicity
 * Genetic screening if high risk groups
 * Review immunizations - MMRV, Hep B
 * Review previous pap and STI testing
 * Review diet: ensure iron (27 mg/day) and calcium adequate, caffeine < 300mg/day, <2 servicings of fish/week
 * Environmental counselling
 * Avoid cat litter (toxo)
 * Avoid soft cheeses and deli meats (listeria)
 * Avoid raw fish

GTPAL

 * Gravida = # pregnancies of any gestation
 * Term = # pregnancies >37 weeks
 * Preterm = # pregnancies < 37 weeks
 * Abortus = # pregnancies < 20 weeks (spontaneous or therapeutic)
 * Living = # live births

Dating the Pregnancy

 * Naegele's Rule: First day of LMP + 7 days - 3 months
 * Cycle length, regularity, use of contraception
 * 1st trimester ultrasound (preferred)

Initial Visit

 * WITHIN 12 weeks of LMP
 * Confirm pregnancy - urine dip
 * Confirm dates - LMP or order 1st trimester ultrasound
 * Review preconception counselling
 * Establish desirability of the pregnancy - counsel regarding options (termination, adoption)
 * Discuss risk of early trimester loss (20%)
 * Conduct history, physical and order initial blood work (see below) - this can be completed over a number of appointments
 * Discuss IPS screening

Initial Visit - History

 * Past Medical History
 * Surgical History (including cervix/uterine)
 * Medications
 * Allergies
 * Lifestyle History
 * smoking, ETOH, recreational drugs
 * Occupation
 * Partner involvement
 * Concerns - financial, violence, abuse, housing
 * Nutrition History
 * Family History
 * Obstetrical History
 * Date of delivery, place, gestation, type of delivery, sex, birthweight, hours of labour, complications in labour, complication of baby, breast fed
 * Gynecological history
 * Last pap
 * History of STIs
 * Contraception used
 * Cycle length and regularity
 * Current pregnancy
 * Bleeding
 * Nausea/Vomiting
 * Abdominal pain
 * Infections

Initial Visit: Physical Examination

 * Vitals
 * Weight
 * HEENT
 * CV/Resp/Abdo
 * GU: vulva, vagina, cervix, uterus size, +/- pap
 * MSK/ peripheral

Initial Visit: Investigations

 * Blood work:
 * CBC, type and screen
 * Rubella, syphilis screen, HIV, HBsAg (Hep B)
 * Consider: TSH, Hep C, toxoplasmosis, CMV, TB, parvovirus
 * Investigations:
 * Urine R +M, C+S
 * Chlamydia and Gonorrhea
 * Pap test

Prenatal Genetic Screening

 * IPS screening
 * IPS #1: GA 11-14 - nucal translucency ultrasound, BHCG, PAPP-A
 * IPS #2: GA 15-18 - alpha-fetoprotein, BHCG, estriol, inhibin A

Follow-up visits and Investigations

 * Visits q4 weeks until GA 28 weeks
 * Visits q2 weeks from GA 28-36 weeks
 * Visits q1weeks from GA 36 weeks - delivery
 * Each Visit:
 * Weight
 * BP and HR
 * Urine dip - protein, signs of infection
 * SFH (symphysis fundal height) > 12 weeks GA
 * Fetal heart rate (FHR) > 10-12 weeks GA
 * Position of fetus - third trimester
 * Patient concerns
 * Fetal movements, contractions, PV discharge, ROM
 * GA 28 weeks: Glucose Tolerance Test for Gestational DM. Repeat CBC, T+S (Rhogam if required)
 * GA 35-37 weeks: GBS screening

Exercise:

 * Okay for pre-pregnancy exercise regime as long as no contraindications (e.g. previa, heart d/o, PROM, HTN, incompetent cervix, IUGR, uncontrolled maternal disease)
 * Try to avoid becoming breathless, avoiding warm/humid environments, avoid breath holding, stay hydrated

Air travel
Weight gain Intercourse
 * Not recommended after 36 weeks GA
 * Dependent on airline policy therefore verify prior to booking
 * No concerns except if contraindications - premature rupture of membranes or placenta previa

Maternal Physiology

 * All physiology changes during pregnancy normally resolve by 6 weeks post-partum
 * Cardio: increase blood volume and cardiac output, HbG decrease (dilutional), lower BP, resting HR > 10bpm, decrease vascular resistance
 * Resp: increase tital volume,minute volumes,  pH (respiratory alkalosis) and oxygen use. No change in vital capacity or pO2
 * GI: constipation, delayed gastric motility, reflux, gallbladder disease
 * Renal: risk of UTI increases, decrease bladder capacity, decrease in serum Cr and Urea
 * Skin: melasma, linea nigra, spider angiomas
 * Endocrine: decrease response to insulin
 * Heme: hypercoaguable state
 * Extremities: leg swelling,varicose veins (legs, vulva), hemorrhoids
 * Other: dizzy lying flat (compression on IVC)

History/Physical

 * History: symptoms of blood loss (SOB/CP, presyncope/syncope), infectious symptoms, abdominal pain, amount of PV bleed +/- tissue
 * Physical: uterus size, cervix (open/closed)

Investigations

 * CBC, T+S (?need for rhogam), +/- coags, serum BhCG, Ultrasound (FHR, r/o ectopic)

Risk factors

 * Previous history, advanced maternal age, maternal medical conditions, history of therapeutic abortions, infections, IUD, uterine abnormalities, maternal medications, maternal substance use

Classification and Management

 * Threatened abortion: PV bleeding, +/- cramps. Cervix closed. U/S: +Fetal heart rate
 * Management: expectant
 * Inevitable abortion: PV bleeding + cramping, no tissue. Cervix open.
 * Expectant management +/- misoprostal or D/C
 * Incomplete abortion: PV bleeding + cramping +/- tissue. Cervix open. U/S: retained tissue
 * Expectant management +/- misoprostal or D/C
 * Complete abortion: PV bleeding, passage tissue + placenta. U/S: no retained tissue
 * Management: no treatment. Monitor
 * Missed abortion: fetal demise, no PV bleeding, cervix closed.
 * Management: Misoprostal, or D+C +/- oxytocin
 * Recurrent abortion: >3 consecutive
 * Septic abortion: SA with uterine infection (polymicrobial: gram + cocci, gram - bacillii).
 * Management: Rx broad spec Abx
 * All abortions: provide grief counseling, provide adequate resources

Differential

 * Vaginal trauma
 * Cervical/vaginal polyps, malignancy, friability
 * Infection
 * Molar pregnancy
 * Ectopic

Rule out Ectopic

 * Stable versus unstable
 * Unstable - ABC's and consult gyne
 * Stable
 * Determine BHCG
 * If < 1500 --> Repeat in 48 hours (should double every 48h in first 8 w GA, should double every 5 days between 8-10 weeks GA)
 * If > 1500 --> pelvic ultrasound to r/o ectopic
 * If > 6000 --> abdominal ultrasound to r/o ectopic

Complications in Pregnancy
Pregnancy Induced Hypertension (PIH)
 * Definitions: diastolic > 90 x 2 or >110 x 1, Severe > 160/110


 * ​Pre-existing HTN <20 weeks GA


 * ​with or without comorbid conditions
 * with preeclampsia: resistant HTN, new/worsening proteinuria or one or more adverse conditions*
 * Gestational HTN > 20 weeks GA


 * ​with or without comorbid conditions
 * with pre-eclampsia: new proteinuria or one or more adverse conditions *
 * severe pre-eclampsia: pre-eclampsia <34 weeks of age, heavy proteinuria (>3 grams/day)
 * Proteinuria > 300mg/day or >30mg/mmol urinary creatine on spot urine. (Suggestive if dipstick > 2+)
 * Eclampsia: pre-eclampsia + seizures (Tonic/clonic)
 * adverse conditions: HA, visual changes, RUQ pain, severe N/V, chest pain, dyspnea/pulmonary edema, eclampsia, placental abruption, elevated Cr, elevated LFTs with symptoms, decrease platelets, decrease albumin, oligohydramnios, IUGR, absent/reversed end diastolic flow in umbilical arteries, intrauterine fetal demise, DIC
 * HELLP: hemolysis (elevated bili, LDL, schistocytes on smear), Elevated liver enzymes, Low Platelets
 * Clinical: BP in both arms, HA, blurry vision, seizures, CHF, dyspnea, RUQ pain, N/V, oliguria, decrease fetal movement, symptoms of abruption, edema - non-dependent, clonus, hyperreflexia, weight gain, CVA (stroke)
 * Risk factors: etiology in unknown. Nulliparity, pre-existing HTN, vascular disorders,old >35, young <17, obesity, gestational diabetes, family history of preeclampsia, prior history, thrombotic disorders, multiple gestation
 * Complications:


 * ​maternal: seizure, thrombocytopenia, bleeding, DIC, HELLP, oliguria, pulmonary edema
 * fetus: abruption, IUGR, oligohydramnios, fetal hydrops, fetal demise
 * Investigations: urine dip (+/- 24 hour urine or spot urine Cr), CBC, lytes, BUN, Cr, LFTs, coags, bili, fibrinogen, albumin, biophysical profile, umbilical artery doppler
 * Management:


 *  Consult obstetrics 
 * ​Adjuncts: diet (low salt), stress reduction, anti-emetics, pain control, fetal monitoring
 * BP management: reduce risk of stroke. NO EFFECT on preventing seizures or fetal outcomes.


 * ​Options labetalol, nifedipine, hydralazine, methyldopa
 * DO NOT USE: ACEI (renal failure, oligohydramnios, congenital anomalies), diuretics, nitroprusside (neonatal cyanide poisoning), atenolol
 * Seizure management: 50% ante-partum, 25% intra-partum, 25% early post-partum
 * Magnesium sulfate for prophylaxis (certain clinical criteria) and treatment.
 * Monitor for symptoms of toxicity: decrease deep tendon reflexes, oliguria, resp paralysis, heart block, cardiac arrest. If occurs stop MgSO4 and give calcium gluconate
 * HELLP: urgent delivery, blood products PRN, consultation to ICU for close monitoring
 * Delivery is the only cure for preeclampsia
 * Prevention:


 * ​Ensure adequate calcium, no ETOH/smoking, exercise, folic acid
 * In high risk women: calcium supplement >1 gram/day, +/- ASA, no ETOH, folic acid, avoid weight gain, rest in 3rd trimeter
 * Post-partum monitoring


 * ​Monitor BP at 3-6 days post-partum, and 6 weeks post-partum (Cr, lytes, fasting blood glucose, cholesterol)
 * Ensure resolution of end-organ damage
 * Continue anti-HTN PRN. Avoid NSAIDs.

Gestational Diabetes

 * Previous type 1 and type 2 diabetics should be referred to obstetrics for further evaluation. At risk for congential anomalies, spontaneous abortion, macrosomia, IUGR, polyhydramnios, stillbirth, maternal infections and retinopathy/nephropathy/neuropathy/CVD, maternal DKA in Type 1 DM
 * Gestational DM - tested at 28 weeks with glucose challenge (50 grams)
 * If < 7.7 = normal,  7.8-10.2 = OGTT, > 10.2 = GDM
 * Risk factors: previous GDM, family history of DM, previous macrosomia, previous stillbirth, obesity, advanced maternal age, polyhydramnios, PCOS, steroids, ethnicity
 * Complications: macrosomia (>4000grams), shoulder dystocia, increased c/s, brachial plexus injury, perinatal mortality, neonate metabolic d/o (hypoglycemia, hypocalcemia, hypoMg, hyperbilirubinemia, polycythemia), respiratory distress (insufficient surfactant), infections
 * Long term risk: 20% will develop Type 2 DM
 * Managment: diet/ exercise. If unable to control --> insulin. Monitor sugars. Target A1C < 6.0, fasting 3.8-5.2, post-prandial 5-6.6.
 * Post-delivery: no insulin required. Repeat 75 gram OGGT at 6 weeks and 6 months
 * Refer to Obs +/- endocrine

Nausea ad Vomiting

 * Hyperemesis Gravida: persistent emesis resulting in wt loss >5% and electrolyte abnormalities
 * Important to r/o other etiology of vomiting: infection, multiples (>twins), molar pregnancy, substance use
 * Management
 * Encourage oral intake
 * Can try ginger, acupunture
 * Diclectin up to 10mg PO QID
 * If no benefit consider: gravol, promethazine, chlorpromazine, prochlorperazine, metoclopromide, ondansetron, methylprednisolone
 * If unstable, severe dehydration - Consider IV fluids and IV anti-nauseas

Rh Negative

 * Type and screen all pregnant women at first prenatal and at 28 weeks GA
 * Give rhogam to Rh negative women with PV bleeding, post-amniocentesis, at 28 weeks, 72 hours post delivery
 * Rhogam prevents isoimmunization and decreases risk in future pregnancies of hemolytic disease in the newborn

Intrauterine Growth Restriction

 * Defintion: fetal birth weight < 10% for GA or U/S measurements < 2 standard deviations because of pathological process. Do not rely on symphysis fundal height
 * Classifcation:
 * Symmetric: both head and abdomen small (usually early in pregnancy secondary to infection, congential or chromasomal anomalies
 * Assymetric: head in spared (usually later in pregnancy, better prognosis)
 * Etiology:
 * Maternal: poor intake, substance use, maternal medical disease
 * Placental: insufficiency (maternal medical conditions), aburption, previa, infarct
 * Fetal: TORCH infections (toxoplasmosis, other (syphillis, varicella, TV) rubella, CMV, Herpes), chromasomal abnormalities, congenital anomalies
 * Diagnosis: suspect if low SFH (>3 cm difference), ultrasound
 * Managment: preconception counselling, improve nutrition, stop substance use, antenatal monitoring (non-stress test, biophysical profiles, doppler flow of umbilical artery)
 * Consult: Obstetrics +/- maternal high risk
 * Neonatal complications: metabolic (hypoCa, low glucose, polycythemia, thrombocytopenia), hypoxia, prematurity

Polyhydramnios

 * > 1.5 L of amniotic fluid between 32-36 weeks
 * Associated with neural tube defects, GI obstruction, maternal diabetes
 * Risk of pre-term labor
 * Usually resolves but requires referral to obstetrics

Oligohydramnios

 * <0.5L of amniotic fluid between 32-36 weeks
 * Secondary to renal agenesis, or rupture of membranes
 * Refer to obstetrics

Decreased Fetal Movements

 * After 26 weeks should have >6 movements in 2 hours
 * If less than 6 movements --> drink juice, go to quiet room, count
 * If still < 6 movements go to ED for non-stress test +/- biophysical profile

Breech

 * Abnormal fetal lie - presenting part either feet/buttocks
 * Rule out cord prolapse and ultrasound to confirm
 * Refer to obsetrics for either external cephalic version or C/S

Infections

 * TORCH: t oxoplasmosis, other (syphillis, varicella, TB), rubella, CMV, Herpes
 * GBS Bacteruria - requires prophylactic antibiotics at delivery regardless of GBS swab (vaginal/rectal) therefore no need to repeat
 * Varicella:
 * Most individuals immune through exposure history or immunization
 * Transmission: droplet. Infectious 48 hours prior to rash until vesicles crusted over. Incubation 10-21 days
 * Clinical: fever, malaise, pruritic maculopapular rash -->vesicular -->crusts
 * Diagnosis: clinical. Serology (IgM + within 3 days)
 * Complications:
 * Mother:  pneumonia (medical emergency) Rx - supportive care + high dose acyclovir
 * Fetus: congenital varicella syndrome (infection in T1/T2 - limb/muscle hypoplasia, corticoatropy, seizures, chorioretinitis, microcephaly, IUGR). Assess with fetal U/S + referral to maternal high risk
 * Newborn: risk if mom develops symptoms from 5 days prior to delivery to 2d post delivery. Symptoms: rash, fever +/- dissemination (encephalitis, pneumonia, hepatitis). Consider VZIG +/- acyclovir
 * Prevention: VZIG up to 96 hours after exposure for mothers. Encourage immunization prior to pregnancy > 4weeks. NO IMMUNIZATION during pregnancy.
 * Genital Herpes:
 * Classification: primary episode (more severe), non-primary first episode, recurrent
 * Most viral shedding occurs during active lesions + 14 days post. Can have asymptomatic shedding.
 * Diagnosis: clinical, viral culture from vesicular fluid, serologic assays
 * Transmission: congenital, neonatal (during the delivery - skin, CNS disease, disseminated)
 * Treatment in pregnancy: anti-viral from 36 weeks + to decrease outbreaks and need for C-section
 * C/S indicated if first episode of genital herpes, prodromal symptoms at delivery
 * Parvovirus B19 - erythema infectiosum - fifth disease
 * clinical: slapped cheek, fever, arthralgias
 * Fetus: hydrops fetalis (aplastic anemia--> CHF-->hydrops)
 * Refer to high risk
 * Rubella
 * Clinical: often asymptomatic, rash face-->trunk/extremities, fever, conjunctivitis, sore throat, polyarthritis
 * Transmission: T1 (highest) and highest rate of congenital malformations
 * Complications fetus: deafness/ VSD, retinopathy, cataracts, MR, DM, cataracts, thyroiditis
 * Diagnosis: 4x rise in IgG or +'ve IgM
 * Mngt: supportive management. Suggest immunization > 4 weeks prior to pregnancy, NO IMMUNIZATION in pregnancy.
 * Immunization post partum
 * Hep B
 * Transmission: often occurs during delivery.
 * Post-natally babies receive HGIB and Hep B vaccine
 * HIV
 * Evaluate for opportunitic infections, immunizations status, other STIs
 * Refer to high risk
 * Change medications to most efficacious that is safe in pregnancy (decrease risk of vertical transmission) - HAART. Monitor plasma viral load and drug toxicities. If elevated C=section
 * Neonates: receive 6 weeks of zidovudine
 * Breastfeeding: contraindicated
 * If HIV positive and wishing to receive refer to fertility specialist for options

Immunizations

 * Avoid life viruses if trying to conceive x 4 weeks and while pregnant ( MMRV, polio, yellow fever)
 * Inactivated or killed are safe in pregnany (Hep A/B, influenza, diphtheria, meningococcus, polio-inactivated)
 * Breast feeding woman can receive any immunization (live, killed, inactive)

Special Populations

 * Consider early referral to Obs for patients with epilepsy or obesity

Stages of Labour

 * First phase:
 * Latent: 3-4cm dilation + contractions
 * Active: >3-4 cm dilation in nulliparous. >4-5cm parous woman
 * Second phase:
 * Passive: full dilation without pushing
 * Active: full dilation with pushing to delivery of baby
 * Third Phase: immediately after delivery of baby to delivery of placenta
 * Fourth Phase: after delivery of placenta to one hour post partum

Definition:

 * Active labour: greater than 4 hours of <0.5cm per hour or no dilatation in two hours
 * Active second stage:
 * Nulliparous: no progress for 3 hours with epidural or 2 hours without epidural
 * Multiparous: no progress for 2 hours with epidural or 1 hour without epidural
 * One hour with no descent with active pushing

Etiology of Dystocia: 4 P's

 * Power: contractions, maternal effort
 * Adequate contractions last 60seconds every 2-3 minutes
 * Management: oxytocin
 * Passenger: position, attitude, size, cephalopelvic disproportion
 * Passage: pelvic structure, soft tissue factors (full bladder/rectum)
 * Management: empty bladder/rectum, reposition patient
 * Psyche: pain, anxiety
 * Management: analgesia

Management of Dystocia:

 * Prevention: admit only patients in active labour, monitor closely, analgesics PRN, augmentation as necessary
 * Ensure adequate hydration
 * Consider empty bladder/bowel
 * Consider therapeutic rest and analgesia for fatigue
 * Consider augmentation:
 * Amniotomy
 * Oxytocin: low dose protocol 1-2mU/minute (increase by 1-2mU/30minutes)
 * high dose: 2-4 mU/minute
 * Assisted Vaginal delivery
 * C-Section

Induction/Augmentation of Labour:
Definitions:
 * Induction: artificial initiation of labour
 * Augmentation: enhancement of contractions for patient already in labour
 * Cervical ripening: soften, dilate cervix to increase likelihood of vaginal delivery

Risks of induction:

 * 1) Increase risk of operative delivery and C/S in nulliparous
 * 2) Uterine tachysystole with fetal compromise (uterine hyperstimulation)
 * 3) Risk of uterine rupture
 * 4) Increased risk of chorioamnionitis
 * 5) Cord Prolapse with ARM (artificial rupture of membranes)
 * 6) Failure to achieve labour

Indications for induction:

 * 1) Risk of continuing pregnancy > risk of induction
 * 2) Severe pre-eclampsia/eclampsia
 * 3) Significant maternal disease not responding to treatment
 * 4) Stable but significant antepartum hemorrhage
 * 5) Chorioamniotitis
 * 6) Suspected fetal compromise
 * 7) Term PROM with GBS colonization (GBS+)
 * 8) Post-dates 41+3
 * 9) Twins >38 weeks
 * 10) IUGR (intra-uterine growth restriction)
 * 11) IUFD (intra-uterine fetal demise

Contraindications of induction:

 * 1) Placenta previa or vasa previa
 * 2) Abnormal fetal lie or presentation
 * 3) Prior classical or inverted T uterine incision
 * 4) Significant prior uterine surgery
 * 5) Active genital herpes
 * 6) Pelvic structural deformities
 * 7) Invasive cervical carcinoma
 * 8) Previous uterine rupture
 * 9) Suspected fetal macrosomia
 * 10) Convenience

Pre-Induction Criteria:

 * Predictors of successful induction include Bishops score >6 and parity
 * Predictors of induction failure include BMI >40, age >35, estimated fetal weight >4 kg, DM

Cervical ripening - unfavorable cervix:

 * 1) Mechanical: balloon catheter
 * 2) Sterile technique: No 14-18 foley with 30 cc balloon
 * 3) Insert past internal os. Inflate to 30-60cc
 * 4) Reduced risk of tachysystole, C/Section
 * 5) Increased risk of maternal infection
 * 6) Prostaglandins PGE2
 * 7) Options:
 * 8) Prostin 1-2mg into Posterior fornix
 * 9) Cervidil 10mg into Posterior fornix
 * 10) Can repeat after application x 1
 * 11) Monitor FHR before and after application (1-2 hours)
 * 12) Risk: rupture, infection, tachysystole, vaginal irritation
 * 13) NO CERVICAL PREPARATIONS in PROM
 * 14) Prostaglandins PGEI
 * 15) Misoprostal 50 ug oral or 25 ug transmucal (vagina)
 * 16) Oxytocin should not be given w/in 4 hours of last dose
 * 17) Side-effects: N/V/D, uterine tachysystole
 * 18) Monitor FHR before and after application (30+minutes)

Induction with favorable cervix:

 * 1) Amniotomy:
 * 2) Should be used in conjunction with oxytocin
 * 3) Creates commitment to delivery - ensure proper fetal presentation
 * 4) Risk of cord prolapse and infection
 * 5) After amniotomy: note amount, color of amniotic fluid, assess FHR, ensure no cord prolapse and head well applied
 * 6) Oxytocin:
 * 7) Causes myometrial smooth muscle contraction
 * 8) First line in PROM
 * 9) Risks: hypotension, fetal compromise, hyperstimulation of uterus, uterine rupture, water intoxication, postpartum hemorrhage

Treatment of tachysystole

 * Definition: > 5 contractions in 10 minutes, Ctx >90 seconds, or less than 30 seconds between Ctx
 * D/C oxytocin
 * Maternal position change, oxygen, IV fluids
 * Pelvic examination for dilation and r/o prolapse
 * +/- scalp electrode
 * Possible tocolytic - IV nitroglycerine
 * Immediate preparation for delivery if abnormal FHR

Fetal Heart Rate Monitoring

 * Normal: external dobbler or fetal scalp monitor.

SEE google documents (ALARM):[http:// https://drive.google.com/drive/folders/0B2fXzHCO6AYSOS1FNF9aQmZaX3c https://drive.google.com/drive/folders/0B2fXzHCO6AYSOS1FNF9aQmZaX3c] 
 * Baseline: 120-160 with moderate variability. No decelerations
 * >2 accelerations in 20 minutes. Accelerations > 15bpm, greater >15secs.
 * Early decelerations: head compression. Benign
 * Variable decelerations: cord compression.
 * Late decelerations: uteroplacental insufficiency. Initial management: change position, 100% O2, hold oxytocin, IV fluids +/- immediate delivery

Vacuum Delivery:

 * Indications: atypical or abnormal FHR, medical d/o to avoid valsalva, inadequate progress in labour, lack of maternal expulsive effort, >2+ station, proper position OA
 * Risks: lacerations, fetal scalp trauma, cephalohematoma, subgaleal hemorrahge, intracranial hemorrhage, hyperbilirubinemia, retinal hemorrhage
 * Contraindications: non-cephalic, fetal position not OA, any contraindication to vaginal delivery, 20 minutes
 * pop-offs etiology: poor seal,improper traction angle, impingement of maternal tissue, excessive traction force (unrecognized CPD, presentation not OA)
 * I - Incision - consider episiotomu
 * J - Jaw - remove vacuum when jaw is reached

Forceps Delivery:

 * Risks: higher risk maternal injury, fetal facial nerve palsies, fetal ocular injuries
 * Indications: same as vacuum delivery + sub-optimal station or presentation of presenting part
 * Contraindications: same as vacuum deliveries
 * Pre-requisites: same as vacuum deliveries

Vaginal Birth After C-Section

 * VBAC - icnrease risk of uterine rupture and failure for SVD
 * Contraindications: history of uterine rupture, > 1 C/S, classical c/s, multiples (twins+), placenta previa, macrosomia, within 18-24 months of last C/S
 * Consult obstetrics for review

Antepartum Hemorrhages
Placental abruption
 * Premature separation of the placenta from the uterine wall (incidence 1%)
 * Classifcation: concealed (80%) - no bleeding, revealed (20%)
 * Risk factors: previous, advanced maternal age, trauma, HTN, cocaine/substance use, uterine anomalies, vascular disease, multiparity, PPROM, rapid decompression of distended uterus (twins, polyhydramnios)
 * Clinical: PV bleeding, abdominal pain, anemia, fetal distress, hypertonic tender uterus
 * Diagnosis: clinical, U/S to r/o previa. CBC, coags, fibrinogen, T + S
 * Complications:
 * Maternal: DIC, anemia, hypovolemic shock, mortality
 * Fetus: hypoxia, prematurity, neurological complications. fetal demise
 * Mngt: stabilize, rhogam, delivery w/ either c/s or vaginal pending fetus/maternal stability. May also trial conservative management

Placental previa
 * abnormal placental location near or covering cervical os (low lying - within 2 cm of internal os)
 * Risk factors: multiparity, previous previa, multiple gestations, advanced maternal age, smoking, uterine scarring
 * Diagnosis: ultrasound
 * Clinical course: 90% resolve by third trimester. Need f/u U/S at 30-32 weeks.
 * Clinical symptoms: painless PV bleeding, uterus soft/non-tender
 * Complications:
 * Maternal: shock, DIC, mortality, placenta accreta/increta/percreta
 * Fetal: preterm delivery, IUGR, malpresentation, congenital anomalies, vasa previa
 * Management: stable --> conservative with bed rest. Unstable --> Emergency c-section
 * Delivery: C- Section ONLY

Vasa Previa
 * Bleeding from baby (rare. Occurs with velamentous cord insertion_
 * Clinical: small amounts of bleeding with fetal distress
 * Diagnosis: clinical. Apt test (differentiate maternal versus fetal blood)
 * Management: poor fetal prognosis. Immediate delivery by C- Section

Uterine rupture Other etiology of bleeding
 * Clinical: acute onset abdo pain, uterine hypertonic, abN FHR, PV bleeding, palpable fetal limbs, high lying fetus
 * Risks: prior surgery (esp classical incision), oxytocin, grand multip, Previous uterine manipulation
 * Complications: maternal and fetus mortality, DIC, shock, amniotic fluid embolism
 * cervial, vaginal polyps, cancer, trauma
 * other sites: baldder bowel
 * Bleeding d/o

PROM

 * History: gush of fluid
 * Physical: sterile spec r/o cord prolapse. No bimanual examination. Assess for pooling, ferning on microscopy, nitrazine blue
 * Management: if GBS negative - expectant x 24 hours then induction. If GBS positive - admit + induction

Preterm Labour

 * Definition: regular contraction + cervical changes between 20-37 weeks
 * Investigations: fetal fibronectin, U/S for cervical lenght, urine R+M, C+S
 * Management: bed rest, counselling, steroids IM x 2, +/- tocolytics, +/- magnesium sulfate if < 32weeks GA for neuroprotection

Umbilical cord prolapse

 * Definition: descent of umbilical cord through cervix alongside (occult) or past presenting part (overt) in presence of ROM


 * Risk factors:
 * malpresentation, polyhydramnios, preterm, grand multiparity >5, male gender, pelvic tumors, placenta previa or low lying placenta, multiples, PROM, cephalopelvic disproportion, iatrogenic (Amniotomy/scalp electrode placement/IU pressure catheter insertion/ attempted external cephalic version/manual rotation of fetal head)
 * Diagnosis:
 * Visualize/palpate cord
 * Sudden FHR deceleration with ROM
 * Management:
 * Call for HELP
 * Elevate presenting part (until delivery)
 * Trendelenburg position
 * If delayed C/S inflate bladder and clamp foley

Shoulder dystocia

 * Clinical: turtle sign, head tight against perineum, spontaneous restitution does not occur
 * Risk factors: 50% - no risk factors
 * macrosomnia, maternal DM, GA>42, multiparity, previous shoulder dystocia, previous macrosomnia infant, excessive weight gain in pregnancy, prolonged labour, epidural, labour induction, operative vaginal delivery
 * Morbidity and mortality:
 * Fetal: hypoxia, birth injuries (brachial plexus injury, clavicle #), death
 * Maternal: PPH, uterine rupture, 4th degree tears


 * Management: ALARMER
 * AVOID 4 P's: push, pull, panic, pivot
 * A- Ask for help
 * L - lift/hyperflex legs (McRobert's maneuver)
 * A- anterior shoulder disimpaction (suprapubic pressure). NO FUNDAL PRESSURE
 * R - rotation of posterior shoulder (Woodscrew's maneuver)
 * M - Manual removal of posterior arm
 * E - episiotomy
 * R - roll over onto all fours
 * Other options: deliberate # clavicle, symphysiotomy, zavenelli maneuver (replace baby into uterus then c/s)

Retained Placenta

 * Undelivered placenta > 30 minutes post infant delivery (failure to deliver versus abnormal implantation)
 * Risk of post-partum hemorrhage and infection
 * Management: stabilize - blood products PRN, explore uterus - firm traction on umbilical cord with suprapubic pressure + oxytocin --> no success attempt manual removal --> no success D+C

Post-partum Hemorrhage:
Definition:
 * >500 cc blood loss vaginal delivery
 * >1000 cc blood loss C-section
 * Primary: within 24 hours
 * Secondary: late > 24 hours. Often caused by retained products of conception

Etiology: 4 T's

 * 1) TONE (#1 cause)- uterine atony or distended bladder
 * 2) Overdistention - polyhydramnio, multiples, macrosomia
 * 3) Uterine muscle exhaustion - rapid labour, prolonged labour, high parity, oxytocin use, induction
 * 4) Intra-amniotic infection - prolonged ROM, fever
 * 5) Anatomic abnormalities of uterus: fibroids, uterine anomalies
 * 6) Uterine relaxing agents: tocolytics, anesthetics
 * 7) Bladder distention
 * 8) Trauma - laceration, rupture, inversion, hematoma
 * 9) Tissue -retained placenta/clots
 * 10) Thrombin - congenital or acquired coagulopathy
 * 11) acquired: ITP, DIC, abruption, amniotic fluid embolism, gestational HTN

Prevention:

 * Oxytocin at delivery
 * 10 units IM at delivery of anterior shoulder
 * 20-40 units in 1000ml normal saline at 100-150cc/hour
 * Gentle cord traction with suprapubic support of uterus
 * Delayed cord clamping

Management:

 * ABCs + monitor vitals
 * IV fluids
 * CBC, crossmatch, caogs
 * If uterus boggy:
 * External uterine massage
 * Oxytocin
 * 5 units IV push
 * 20-40 units in 1 L NS wide open
 * 10 units IM
 * Bimanual massage - assess for retained products
 * Empty bladder
 * Hemabate/carboprost
 * 250uG IM q15 minutes (Max 8 doses)
 * Contraindication: asthma
 * Carbetocin
 * Misoprostal(cytotec)
 * 200mcg oral + 400mcg S/L
 * 800 - 100mcg rectal
 * SL quicker but rectal lasts longer
 * Ergonovine
 * 0.2 -0.25 mg IM q 2-4 hours
 * 0.125 mg IV q 2-4 hours
 * Contraindication: hypertension disorders, HIV drugs. Risk of stroke
 * If uterus firm:
 * explore lower genital tract
 * Ensure adequate analgesia
 * Repair lacerations
 * Evaluate for acquired coagulopathy and correct for FFP/platelets/pRBCs
 * Other therapies:
 * tamponade, emergency embolization, emergency laparotomy, emergency hysterectomy

Post-partum Fever

 * THINK W's
 * Wind (atelectasis, pneumonia), water (UTI), wound (C/S, episiotomy site), womb (endometritis, retained products of conception), walking (DVT, pelvic thrombophlebitis), breast (mastitis, engorgement)
 * Investigations: pending history. If endometritis suspected - blood, genital cultures, ultrasound for retained products of conception
 * Mngt: pending etiology. Endometritis - clinda + gentamycin

Post-partum check-up

 * Give Rhogam 300ug IM within 72 hours of delivery if infant is Rh positive


 * Give MMR 0.5ml IM to rubella nonimmune


 * Contraception: non-breastfeeding- OCP within 3 weeks postpartum.


 * if breastfeeding: IUD or mini pill at 6 weeks post-partum. Or OCP at 3 months/introduction to supplemental feeding

REMEMBER the B's Physical exam:
 * Brains (blues, depression, psychosis)
 * Breasts (breastfeeding, pain)
 * Blood pressure
 * Bladder/bowel function
 * Bleeding (PV - color, smell, amount)
 * Baby (concerns, feeding, bonding, support at home)


 * Immediate post-partum: Vitals, symptoms of anemia, abdomen, C/S - incision (ask about calf swelling, CP/SOB)


 * 6 weeks post-partum: pelvic exam +/- pap

Post-partum Blues

 * 85% of mothers, onset day 3-10, lasts < 2 weeks. No treatment required.
 * Symptoms: emotional labiality, flat affect, irritable, poor concentration

Post-partum Depression

 * Major depressive episode occuring within 4weeks- 6 months of delivery
 * 10% of mothers, 50% reoccurrence
 * Treatment: SSRIs (avoid fluoxetine), Behavior activation strategies, CBT

Post-partum Psychosis

 * Rare. Risk of harm to both mother and baby
 * +/- involuntary form 1, consult psychiatry

Breast feeding

 * Benefits: contains essential nutrients in proper %, bonding, antibodies/immune benefits, cost effective
 * Information to mother:
 * colostrum< 72 hours (yellow/thick---> white breast milk)
 * important for mother to obtain balanced diet and enough calories as breastfeeding burns calories
 * Breastfeed every 2-3 hours or whenever baby is hungry. Feed them as long as they want alternating breasts
 * Breastfeeding well: hear sucking noise, breasts do not hurt after BF, full breast-->empty feeling after feeds, baby appears content
 * If exclusively breastfeeding: need to add Vitamin D 400IU daily
 * Screen for poor latch, poor production, poor let-down
 * Consider referral to lactation consultation
 * Could consider domperidone if poor supply
 * Breast feeding resources: http://www.rourkebabyrecord.ca/parents/?t=1