Pocket Tutor Obstetrics Jodi Keane, Manda Raz, Shavi Fernando
INDEX
ABCDEFGHIJKLMNOPQRSTUVWZ
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
Abdomen, examination of 66–67, 67
palpation 67
uterine size by gestational week 67
Abdominal pain 49
in early pregnancy 51
in late pregnancy 52
mild 49–50
non-obstetric and non-gynaecological causes 53
severe 50
Abdominal palpation 198
Abdominal wall, anterior 1
incisions 4, 4–5
muscles 1–3, 3
nerves 3
vessels 4
Abnormal fetal condition 197
Abnormal labour 197
Abscess
breast 228
epidural 231
Accelerations 171
Accoucheur 81, 82
Acute fatty liver of pregnancy (AFLP) 140, 142, 157–158
abdominal pain in 52
AFI see Amniotic fluid index (AFI)
AFLP see Acute fatty liver of pregnancy (AFLP)
Amniocentesis 44, 44
Amniotic fluid index (AFI) 34–35, 35, 72, 73
Ampicillin 126, 155
Anaemia 62
Anaesthetic assessment, antenatal 71
Analgesia, intrapartum 85–89
epidural anaesthesia 88
nitrous oxide and oxygen 88
non-pharmacological pain relief 86
opiate injection 88–89
perineal infiltration 87
pharmacological pain relief 86–89
production of pain and 86
pudendal block 87
spinal anaesthesia 87–88
Anencephaly 108
Aneuploidy 101 see also Congenital malformations
Aneuploidy screening 32, 38–39, 40
types of 39, 40
Angiotensin-converting enzyme inhibitors 162
Antenatal care 45
abdominal pain 49–50, 51, 52
breast fullness and tenderness 54
lower back pain 52–53
nausea and vomiting 46–49, 47, 50–51
peripheral oedema 54–55
predictive and proactive model 45, 45
sleep disturbance 55
trimesters of pregnancy 45, 46
vaginal discharge 54, 55
Antenatal counselling 106
Antenatal visit
first (see First antenatal visit)
follow-up (see Follow-up antenatal visits)
Antepartum haemorrhage 131–137
accidental causes 133, 133
examination 134–135
incidental causes 131, 132
investigations 135, 136
management 135–137
praevia causes 133, 133
speculum examination 135
types of morbidly adherent placenta 132
Anti-D prophylaxis 71
Arcuate line 2, 3
Artificial rupture of the membranes (ARM) 180–181, 182
Assessments, in pregnancy 25
Bishop's score 29, 29
engagement 27, 29
fetal heart rate 25
fetal lie 26, 28
fetal presentation 26–27
speculum examination 29–30, 30
symphysis-fundal height 26, 27
Asthma 161
Augmentation 177 see also Induction of labour
B
Baby blues 224
Balloon catheter insertion 180, 181
Beckwith-Wiedemann syndrome 119
Benzodiazepine, for alcohol misuse 64
Beta-human chorionic gonadotrophin (β-hCG) 17, 50
Betamethasone 126
Biophysical profile 37–38, 39
Birth defects see Congenital malformations
Bishop's score 29, 29, 72
Bivalve speculum 30, 30
Blood pressure, measurement of 65–66, 66
Blood tests, antenatal 32–33
anaemia 32
diabetes 33
infections, screening for 32–33
vitamin D deficiency 32
Body mass index (BMI) 65
Booking see First antenatal visit
Booking-in visit see First antenatal visit
Braxton Hicks contractions 75–77
Breast abscess 228
Breastfeeding 221–223
benefits of 222, 223
contraindications 222–223
difficulties 219–221
during pregnancy 54
management 222
unilateral mastalgia 219
Breech presentation 71, 121–124
external cephalic version for 122, 123
Buprenorphine, for opioid dependence 64
C
Caesarean section 194–195
risks of 195
Cardiac output, during pregnancy 16
Cardiotocography (CTG) 25, 30, 40–43, 72, 73, 85, 165, 197
abnormal cardiotocograph 40, 42
abnormal patterns 166–167
accelerations 171
baseline bradycardia 167–169, 168
baseline tachycardia 169, 170
cycling 42–43
deceleration 171–178
Dr-C-BraVADO (mnemonic) 40, 42
fetal heart rate, baseline abnormal 165, 167–169
fetal heart rate variability, abnormal patterns of 169, 171
normal cardiotocograph 40, 41, 42
patterns 197
Cardiovascular disease, in pregnancy 161–162
congenital cardiac disease 162
ischaemic heart disease 162
Cardiovascular system, pregnancy-related changes to 14–16, 15
antenatal changes 15–16
electrocardiogram in pregnancy 15
intrapartum changes 16
normal findings on examination 14–15
postpartum changes 23
Carpal tunnel syndrome 54–55
Cell-free fetal DNA 39
Cervical cancer 62
Cervical insufficiency 62
Cervical ripening 177, 179–180, 180
balloon catheter insertion 180, 181
cervical membrane sweep 179
prostaglandins 179–180, 180
Cervical screening test 62
Childbirth, complications 197
Chorioamnionitis 124, 127, 154–155
abdominal pain in 52
Chorionic villus sampling (CVS) 43, 43
Chromosomal abnormalities 101 see also Congenital malformations; specific type
Comfort care 106
Congenital malformations 101–107
antenatal counselling 102
approach to 105
choices to parents in 104
Down syndrome 101, 104
Edwards syndrome 101, 103
investigations 101–103
management of high-risk aneuploidy 106, 106–107
Patau syndrome 101, 102
Turner's syndrome 101, 105
ultrasound 102–104
20-week scan 102
Conjoined twins 96
Consanguinity 63
Cord prolapse 204, 204–205
Counselling, at first antenatal visit 68–69
CTG see Cardiotocography (CTG)
Cystic hygroma 107
D
D-dimer 159
Decelerations 171–172
early 171, 172
late 177, 178
prolonged 173, 175, 176
variable 173, 174
Deep vein thrombosis 68, 233
Diabetes, in pregnancy 120–121, 149–153
complications 150, 151
diagnostic approach 150–152, 152
gestational 150, 152–153
insulin requirement during pregnancy 149
pre-existing 150, 153
Diet, during pregnancy 63
Dipstick urinalysis test 145
Dizygotic twins 93, 95, 95–96
Dopamine 18–19
Doppler assessment 35–36
ductus venosus 36
for fetal growth disorders 35, 109
middle cerebral artery 36, 38
umbilical artery 36, 37
uterine artery 35, 36
Down syndrome (trisomy 21) 39, 101, 104
Doxylamine 156
Ductus venosus Doppler 112, 115
Due date 60
Dysplasia 62
Dyspnoea, during pregnancy 21
E
Eclampsia 147–149
differential diagnoses 148
DRABC approach 148
postpartum care 149
Ectopic pregnancy, abdominal pain in 51
Edwards syndrome (trisomy 18) 39, 101, 103
Endocrine system, pregnancy-related changes to 16–19, 17, 19
glucose 18
lactation 18–19
pituitary hormones 18
thyroid hormone levels 17, 17
Endometritis, 228
Engagement, estimation of 27, 29
Epidural abscess 231
Episiotomy 82
Erythromycin 126
Essential hypertension 162
Examination 64–68
ABCD mnemonic 64–65
abdomen 66–67, 67
aims of, at first antenatal visit 65
cardiovascular and respiratory systems 66
general assessment 64–65
pelvis 67–68
vital signs 65, 66
Exercise, during pregnancy 63
F
Female reproductive system
anterior abdominal wall 1–5, 3, 4
internal structures of 1, 2
pelvic cavity 1, 2, 5–7
perineum 7–8, 8, 9
uterus 8–9, 9
Ferguson reflex 79
Fetal blood sampling 44
Fetal fibronectin 128
Fetal growth, disorders of 108
asymmetrical growth 110–111
Doppler assessment 111–115, 112–114
fetal biometry 109, 109–111, 110
intrauterine growth restriction 115–119
investigations 108–115
macrosomia 119–121
small-for-gestational-age fetus 115
Fetal growth, US assessments of 34
Fetal heart rate 67
assessment of 25
Fetal lie 26, 28
Fetal presentation 26–27
breech 27
cephalic 27
Fetal scalp lactate sampling 85
Fetoplacental circulation 10, 11
Fetus 12
head diameters 12, 13, 13
intrapartum monitoring 85
skull 12, 13
small-for-gestational-age 115
Fibroid degeneration, abdominal pain in 51
Finger-prick blood glucose test 151
First antenatal visit 55–57
counselling 68–69
early in pregnancy 56
general and obstetric examination 64–68
history taking 56–64
investigations 31–32, 68
lifestyle and dietary advice in 56
Folic acid supplementation 59, 68–69
Follow-up antenatal visits 69
aim of 69
fetal growth assessment 71
fetal monitoring 72
fetal presentation, assessment of 70–71
investigations 71
post-dates pregnancy 72–73
questions during 69–70
vaginal examination and cervical membrane sweep 71
visit schedule in uncomplicated pregnancies 70
Forcep delivery 187
Neville-Barnes forceps 189, 189
technique 192–194, 193
types of forceps 188–189, 189
Wrigley's forceps 189
G
Gastroenteritis 229–230
Gastrointestinal changes, in pregnancy 20–21
Gastro-oesophageal reflux 163–164
Genetic disorder 62–63
Gestational age, estimation of 58, 60
Gestational diabetes 18, 63, 150, 152–153
Gestational hypertension 142–143
Glucose tolerance test 150, 152, 152
Glycosuria 18
Graves speculum 30, 30
Group B Streptococcus (GBS), screening for 72
Gynaecological history 60–62
bleeding pattern and duration 61–62
cervical screening 62
irregular periods 61
menstruation 60
sexual history 62
H
Haematological changes, in pregnancy 21–22
Haematological disease 163
Haemorrhoids, during pregnancy 20
HELLP syndrome 144, 145
Hepatobiliary changes, in pregnancy 21
History taking 57–64
age and occupation 57–58
current pregnancy 58–59
family history 62–63
gynaecological history 60–62
key aims of 57
medical history 59
medication history 59–60
nutritional and physical health 63, 64
obstetric history 60, 61
rapport building and 57
social history 63–64
surgical history 59
Hydralazine 147
Hyperemesis gravidarum 47, 48, 155–157
medications 156
psychological support in 157
Hypertension 142, 143 see also Pre-eclampsia
antihypertensive medications for 146, 146
Hypertensive urgency 146–147, 147
Hyperthyroidism 160–161
Hypothyroidism 160–161
I
Induction of labour 71, 72, 77, 177, 179–185
abdominal examination 183
artificial rupture of the membranes 180–181, 182
cervical ripening 177, 179–180, 180
indications 179
intrapartum care 184–185
oxytocin infusion 181–182
procedure for 183–185
vaginal examination 183–184
Inferior vena cava filter 160
Inflammatory bowel disease 164
Instrumental delivery 185–194
classification 186–187
forceps 188–190, 189
FORCEPS mnemonic 185
indications 186
procedure 190–194, 192, 193
vacuum extractor 187, 188, 188
Integumentary changes, in pregnancy 22–23
Intermittent auscultation (IA) 85
Intrapartum fetal monitoring 85
cardiotocography 85
intermittent auscultation 85
Intrauterine growth restriction (IUGR) 101, 111, 115–119, 116, 162
asymmetrical 116
delivery 119
management 119
risk factors 118
symmetrical 116
types and causes 116, 117
Investigations, antenatal 30, 31–32
amniocentesis 44, 44
aneuploidy screening 38–39, 40
blood tests 32–33
cardiotocography 40–43, 41, 42
chorionic villus sampling 43, 43
fetal blood sampling 44
imaging 33–38
urine tests 33
Iodine, in pregnancy 59
Iron-deficiency anaemia 163
IUGR see Intrauterine growth restriction (IUGR)
J
Joel-Cohen incision 4
K
Kleihauer–Betke test 128
L
Labetalol 146, 147
Labour 75 see also Induction of labour
abdominal pain in 52
cardinal movements of 81–82
cord clamping 82–84
dystocia 197
first stage 77–79, 78
intrapartum analgesia 85–89
intrapartum monitoring 85
latent phase 75–77
monitoring during 75
peripartum and intrapartum cervical change 76
progress of normal labour 78
rule of three 75
second stage 79–84
stages of 77
stations of fetal descent 83, 84
third stage 84
three P's 6
vaginal examinations 78, 79
Lactation 18–19, 19
Laparoscopy incision 5
Last menstrual period (LMP) 60, 61
Leopold's manoeuvres 26, 28
Levator ani 7–8, 8
Levothyroxine 161
Lidocaine 87
Liver disease, in pregnancy 139–142
causes 141
Lower back pain 52–53
M
Macrosomia 119–121
Magnesium sulphate, for eclamptic seizure 148, 149
Malpresentation 121 see also Breech presentation
caesarean section 124
external cephalic version 122, 123
planned vaginal breech birth 124
types of 121, 122
Mask of pregnancy 22
Mastitis 226–227
Maternal age 58
Maternal sepsis 232–233
Maternity record 48
Medication history 59–60
Melasma 22
Meningomyelocele 108
Metformin, in pregnancy 152
Methyldopa 146
Metoclopramide 156
Middle cerebral artery Doppler 112, 114
Midline incisions 5
Midwife 56
Mini-Mental State Examination 220
Miscarriage, abdominal pain in 51
Model of care 56
Monozygotic twins 93, 95, 95
Multiparous uterus 182
Multiple pregnancy 91–93 see also Twin pregnancy
Multivitamin 156
Musculoskeletal changes, in pregnancy 22
N
Naegele's rule, for estimated date of birth 61
Nausea and vomiting 46–49, 50–51
differential diagnoses 47
Neural tube defects 108
Nifedipine 126, 146
Non-cephalic presentation see Malpresentation
Nuchal thickness
increased 107
normal 107
O
Obstetric examinations 64 see also Examination
Obstetrician 56
Ondansetron 156
Ovarian hyperstimulation syndrome, abdominal pain in 51
Ovarian torsion, abdominal pain in 51
Oxytocin infusion 181–182
P
Papanicolaou's test 62
Parasitic twins 96
Patau syndrome (trisomy 13) 39, 101, 102
Pederson speculum 30
Pelvic floor 7, 79
Pelvis 5
dimensions 6–7
examination of 67–68
greater bony pelvis 6
lesser bony pelvis 5–6, 6
Peptic ulcer disease 163–164
Perinatal depression 224–225
Perineal infiltration 87
Perineal tears, during childbirth 7
Perineum
anatomy of 7–8, 8
urogenital and anal triangles of 8, 9
Peripheral oedema 54–55
Pfannenstiel incision 4, 4
Physiological changes, in pregnancy 13–14, 45
cardiovascular changes 14–16, 15
endocrine changes 16–19, 17, 19
gastrointestinal changes 20–21
haematological changes 21–22
immunological changes 23
integumentary changes 22–23
musculoskeletal changes 22
normal values of physiological variables in pregnancy 14
respiratory changes 21, 22
urological changes 19–20
Physiological third stage 84
Pinard's manoeuvre 198
Placenta 9
changes after birth 10
decidua 10
early development and structure 10
fetoplacental circulation 10, 11
function of 9–10
Placenta accreta 132, 134
Placenta increta 132
Placental abruption, abdominal pain in 52
Placenta percreta 132
Placenta praevia 134
Pneumonia 230–231
risk factors 227
Polycystic ovarian syndrome 61
Polycythaemia 100
Post-dates pregnancy 72–73
Postpartum haemorrhage (PPH) 84, 182, 210–217
causes 212
classification 211–212
follow-up care for 216
management 212
medications 213
Postpartum pyrexia 226
Post-term pregnancy see Post-dates pregnancy
PPROM see Preterm prelabour rupture of membranes (PPROM)
Prednisolone 156
Pre-eclampsia 142–145, 143
abdominal pain in 52
defined 143
hypertension and 65, 142
screening for 60, 63
severe 144–145
Pregnancy
biological factor 223
emotional factor 223
gravidity and parity 60, 61
multivitamins 59
social factor 224
Prelabour rupture of membranes 79
Prenatal development 11
embryonic phase 11–12
fetal phase 12
stages of 12
Presentation 121 see also Malpresentation
Preterm labour 127–131
delivery 130
fetal fibronectin test 128
medications for management in 129, 129
prognosis 130, 130–131
twin pregnancy 98
Preterm prelabour rupture of membranes (PPROM) 124–127
delivery 127
medications for management 126, 126
Primigravid uterus 182
Prochlorperazine 156
Promethazine 156
Prostaglandins, for cervical ripening 179–180, 180
Proteinuria 142, 145
Psychiatric illness 224
Pudendal block 87
Pulmonary embolism 158–160, 233
Pulmonary oedema, in pregnancy 16
Pyelonephritis 229
Pushing 81
Pyelonephritis 20, 33
Pyramidalis muscle 2–3
Pyridoxine (vitamin B6) 156
Q
Quadruplets 93
Quickening 69
R
Ranitidine 156
Rectus abdominis 1–2, 3
Relaxin 22
Renal disease, in pregnancy 162–163
Respiratory changes, in pregnancy 21, 22
Respiratory disease 161
Respiratory distress syndrome 130
Retained products of conception 10
Ruptured ovarian cyst, abdominal pain in 51
S
Sciatica 53
Sexually transmitted infections 62
Sheehan's syndrome 18
Shoulder dystocia 120, 205–208, 206
management of 207–208
risk factors 207
Shouldering 173
Show 54, 69, 75
Sickle cell disease 163
Sleep disturbance, during pregnancy 55
Small-for-gestational-age (SGA) fetus 115
Speculum examination 29–30, 30
Spinal anaesthesia 87–88
Stretch marks 22–23
Substance misuse, in pregnancy 63–64
Suckling 18–19
Surgical history 59
Symphysis-fundal height 26, 27, 67, 108
T
Terbutaline 176
Thalassaemia 163
Thiamine (vitamin B1) supplementation 64, 155, 156
Thyroid dysfunction, during pregnancy 160–161
Thyroid function test 220
Thyroid-stimulating hormone (TSH) 17
Triplets 93
TTTS see Twin-to-twin transfusion syndrome (TTTS)
Turner's syndrome 101, 105
Twin anaemia polycythaemia sequence 100–101
Twin pregnancy 93
amnionicity 94, 94
chorionicity 93, 94, 96
conjoined twins 96
descriptive terms for 94
dizygotic twins 95, 95–96
fetal complications, risk of 97–98, 98
maternal complications, risk of 97, 97–98
monozygotic twins 95, 95
parasitic twins 96
preterm labour 98
T sign 96
twin anaemia polycythaemia sequence 100–101
twin reversed arterial perfusion 96
twin-to-twin transfusion syndrome 98–100, 99
zygosity 93, 94
Twin reversed arterial perfusion (TRAP) 96
Twin-to-twin transfusion syndrome (TTTS) 98–100
fetal outcomes 100
Quintero's stage 99
Type 1 diabetes mellitus 150
U
Ultrasound, antenatal 33–38, 61, 72, 96
advantages 34
amniotic fluid index 34–35, 35
biophysical profile 37–38, 39
congenital malformations 102–104
Doppler assessment 35–36, 36, 37, 38
indications 33–34
US dating scan 34
Umbilical arteries 10, 11
Umbilical artery Doppler 111–113
absent end-diastolic flow 113
decrease in diastolic flow 113
reversed end-diastolic flow 114
systolic to diastolic flow (SD ratio) 113
Umbilical cord 10
clamping 82–84
Umbilical vein 10, 11
Unilateral mastalgia 219
Urinary stasis 20
Urinary tract infections 229
Urinary urgency 20
Urine tests 33
Urological changes, in pregnancy 19–20
bladder function 20
renal function 20
Uterine artery Doppler 111, 112
Uterine inversion 208–210, 209
Uterine rupture, abdominal pain in 52
Uterotonic agent/oxytocic 83
Uterus 8
anatomy of 8, 9
blood supply to 9
relations of 8
V
Vacuum-assisted delivery 187, 188
advantages and disadvantages 188
technique 191–192, 192
Vaginal breech birth
contraindication 199
fetal injury 200–201
risks 199
Vaginal discharge 54
show 54
types indicating infection 55
watery 54
Vanishing twin syndrome 97
Varicose veins 68
Venous thromboembolism 158–160
Virchow's triad 158
Vitamin D, in pregnancy 59
W
Warm compresses 81
Weight gain, recommended, in pregnancy 64
Wernicke's encephalopathy 155
Womb mates 95
Z
Zero station 83, 84
×
Chapter Notes

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Obstetrics
Obstetrics
Jodi Keane BPhysio (Hons) MBBS (Hons) FRANZCOG Consultant Obstetrician and Gynaecologist Monash Health Assessment Coordinator (Women's Health) Monash University Victoria, Australia Manda Raz MBBS (Hons) Resident Medical Officer Monash Health Victoria, Australia Shavi Fernando MBBS (Hons) BMedSc (Hons) FRANZCOG PhD Consultant Obstetrician and Gynaecologist Monash Health Director of Undergraduate Curriculum (Women's Health) School of Clinical Sciences Curriculum and Assessment Lead (Women's Health) Monash University Victoria, Australia
© 2020 Jaypee Brothers Medical Publishers
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The rights of Jodi Keane, Manda Raz and Shavi Fernando to be identified as the authors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
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9781909836747
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Preface
Obstetrics is a unique medical field, encompassing a time of personal significance and vulnerability for the mother in one of the most intimate experiences of her life. Furthermore, the special circumstances posed by caring for two interdependent beings create challenges that are also unique. All of this occurs in a time of wider social change, where care is focusing on shared decision making and adopting a ‘women-centered’ focus, rather than seeing mothers as ‘patients with a disease’.
Pocket Tutor Obstetrics provides a concise but comprehensive guide to the subject. A first principle chapter recaps key anatomy and physiology. Clinical essentials and normal pregnancy chapters cover the relevant history-taking, examination techniques and management options available during pregnancy, while subsequent chapters cover possible complications for the mother and baby. Throughout the book we have included practical tips, clinical images and diagrams to clarify concepts aid your learning.
We hope Pocket Tutor Obstetrics provides you with a solid grounding on the journey to becoming a compassionate and competent practitioner. Whether you are a medical student or a junior doctor, Pocket Tutor Obstetrics is your portable guide to understanding concepts, passing exams and performing clinical tasks during your obstetrics term.
Jodi Keane, Manda Raz,
Shavi Fernando
July 2019
Acknowledgements
Thanks to my co-authors, colleagues, trusty laptop, excessive amounts of caffeine and a study door which closes in the face of children's television shows. The book would have been impossible without the support of my phenomenal family, Sir Chas and three patient children, Lily, Gemma and Rosie, to whom I owe more than I can ever express. They are now all in a real book.
JK
Thanks to my co-authors, mentors, colleagues and patients, who inspire me to pursue excellence.
MR
Thanks to my co-authors for their hard work and persistence. Thanks to my wife Sharmayne, daughter Ellara, and son Arlen who have allowed me extra time on top of a busy schedule to complete this book.
SF
The authors jointly thank Tom Banister-Fletcher and Richard Furn for their guidance, patience and for making this book possible, as well as Finland Tan and Aidan Kashyap for their proofreading and invaluable comments. We would also like to thank Lesleigh Baker and Mark Beaves and the Monash Health Fetal Monitoring Unit for providing clinical images.
JK, MR, SF