Basic ObstetricsDr Chris Harnden FRNZCGP

GP Blenheim GPEP2 FacilitatorPam Harnden

Self Employed LMC, Marlborough

Who Can Offer Lead Maternity Care?

• Specialist Obstetrician• Midwife• GP – Diploma Obstetrics• Shared Care options

Comparison of philosophy

Midwife• Holistic Approach• “Social Justice approach”• Work towards Self-health

and Self determination• Partnership Model• The woman ‘births’ her

baby

Medical• The mother reaches the end

of pregnancy as healthy or healthier than the outset

• That any physical or psychological defects are detected and treated

• That the mother is delivered of a healthy baby

First Antenatal Visit

• Confirmation of pregnancy• planned or unplanned• ?TOP• Assessment of pregnancy ‘risk’• Take full obstetric, medical & social history

(including assessment for domestic violence)

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Termination of Pregnancy• Reasons• Explain legal position• Discuss other options• Full hx / exam including hvs, chlamydia swabs, antenatal

bloods• Psych state• Info sheet, discuss procedure• Contraception• Follow up

Obstetric History

• Gravida, Para• Previous TOP/miscarriage• Complications of previous pregnancies• Previous congenital abnormalities

Medical History

• Current medical illnesses• Past medical Illnesses• Current medications, *folic acid• Allergies• Smoke/alcohol/drugs• Family history

Social history

• Support network• Work• Cultural Awareness

Assessment Family Violence

• Within the last year have you been hit, slapped or hurt in any way by your partner/ex partner

• Are you afraid of your partner/ ex partner• Are you safe to go home when you leave here• Would you like any assistance?• Screen when partners/family NOT present• (MOH guidelines 2007)

Physical Examination

• Ht/Wt BMI• CVS including BP• Abdominal Exam ?fundus ?FH• No evidence to support breast exam• No evidence to support V/E or smear taking• No evidence to support HVS• (Latter 2 increased risk of miscarriage &

infection ‘Cochrane review’)

Investigations

• Routine 1st A/N screen: FBC, Rubella, Bl Grp, antibody screen, Hep B, VDRL, HIV

• USS if unsure of dates• NT scan 11-13wks• Maternal Triple Test 15wks • MSSU chlamydia screening• Amniocentesis or cvs in high risk cases 1%

miscarriage risk

MSU

• Asymptomatic bacteriuria 2%-10% (NICE 2003) can cause pyleonephritis and preterm labour

• Urine dipstick unreliable only detects 50% of cases (NICE guidelines 2003)

Chlamydia Urine Screening should be offered to high risk women

• Under 25yrs• Unmarried women• History of STD• New/multiple partners• No history of barrier contraception• Women in communities with high rates1st trimester and 3rd trimester (Kirkham et al

2005)

Medications and Advice

• Folic Acid 0.8mg till 12wks• Morning Sickness• Contact if pain or bleeding• Discuss Lead Maternity Care options• LMC referral• Obstetric referral if risk identified

Further Tests

• 18-20wks Anomaly scan• 28wks- CBC, ?Ferritin if Hb < 10.5g/dL,

Antibodies, Anti D Rh neg (NICE 2003)• 34 wks ?kick chart (debateable point), 2nd dose

Anti D Rh neg (NICE 2003)• 36wks- CBC for those on iron, Antibodies Rh

neg, check presentation, ?ECV for breech, scan if placenta low lying

Schedule of Antenatal Visits

• Uncomplicated pregnancy 10 visits

• 1st-before 12wks• 14weeks• 20 weeks• 26wks• 30wks• 34wks

• 36wks• 38wks• 39wks• 40wks• 41wks CTG and refer for

obs consult

• (NICE guidelines 2003)

Complications of Early Pregnancy

Nausea and Vomiting• Nausea 70%-80% (Medalie 1957; Whitehead

1992; Gadsby 1993)• Vomiting 50% (Whitehead 1992; Gadsby

1993)• 17% just in the mornings• 13% beyond 20wks gestation• 35% lost time at work

Early pregnancy causes of nausea

• Rising HCG levels thought to stimulate thyroid activity. Goodwin et al (1992)

• Thyrotoxicosis. Chong and Johnston (1997)• Deficiency B6 and Zinc• Multiple pregnancy• Molar pregnancy• Hypogycaemia• Decreased serotonin levels

Psychosocial causes of nausea

• Stress• Anxiety• Fear• Unwanted/unplanned pregnancy• Relationship difficulties

Possible Treatments

• Acknowledge problem• Frequent small meals• Vit B6, ginger, acupuncture, acupressure• Medications (metoclopramide,

prochlorperazine) little is known of their teratogenic effects

Monitor

• Urine for Ketones• U&E for dehydration if severe vomiting

Refer and admit if signs of hyperemesis gravidarum

• Early scan to exclude molar pregnancy

Pain and Bleeding 1st trimester

• Bloods for HCG and progesterone levels• Scan • Anti D for Rh neg women• History and location of pain• Under 8wks possible ectopic

Complications of late pregnancy

• UTI/pyelonephritis – MSU – Antibiotics• Abdominal Pain ?muscular ?more serious• Bleeding- ?how much, ?placental position• Headaches - ?New, ?migraine, ?hormonal• Carpal Tunnel syndrome – due to fluid

retention• Anaemia

Hypertension in pregnancy

• Gestational Hypertension

• Pre eclampsia

• Eclampsia

Gestational Hypertension

• A blood pressure >140/90 mmHg after 20wks gestation (Brown et al., 2000)

May progress to pre eclampsia (Barton et al.,2001; Saudan et al., 1998)

Pre Eclampsia

• occurs 2-3% primigravida• Occurs 5-7% nulliparous

DefinitionGestational hypertension with proteinuria on

24hr urinary protein measurement (>0.3g/24hrs)

Eclampsia

DefinitionThe occurrence of one or more generalised

convulsions/coma in the setting of pre eclampsia, in the absence of other

neurological conditions.

Cholestasis

• Itching especially soles of feet and palms of hands

• Rash• Check Bilirubin

Gestational Diabetes

• 2%-9% pregnancies (NICE 2003) increasing due to maternal obesity

• RANZCOG recommend random fasting 50g glucose test at 28wks as initial screening - widely practised despite lack of evidence it prevents adverse outcomes

Turanga Kaupapa (Maori MW ass.)

Principles of Maori Childbirth should encompass• Whakapapa The wahine and her whanau is

acknowledged• Karakia The wahine and her whanau may use

karakia• Whanaungatanga The wahine and her whanau may involve others in her birthing

program

Turanga Kaupapa (2)

• Te Reo Maori The wahine and whanau may speak Te Reo Maori

• Mana The dignity of the wahine, whanau, midwife and doctors involved are maintained• Hau Ora The physical, spiritual and mental

wellbeing of the wahine and whanau is promoted and maintained at all times

Turanga Kaupapa (3)

• Tikanga Whenua maintains the continued relationship to land, life, nourishment and the

knowledge and support of kaumatua and whanau is available.

• Te Whare Tangata the wahine is acknowledged, protected, nurtured and respected as the Te Whare Tangata (the

house of the people)

Turanga Kaupapa (4)

• Mokopuna the mokopuna is unique, cared for and inherits the future, a healthy environment

and whanau• 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.

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Case 1

• Miss A• 17 yr old G1P0• 6 weeks since last period• fainted the previous day • spotting and mild l sided abdominal pain

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Case 1

• Miss A• 17 yr old G1P0• 6 weeks since last period• fainted the previous day • spotting and mild l sided abdominal pain

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Case 3

• Ms C• 26 yr old G4P1• 14 weeks since lmp• spotting with a few vague abdominal pains

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Case 4

• Mrs D• 35 yr old G7P5• unknown dates / felt movements for ages • no antenatal care • had some spotting last 2 d . None for 8 hrs • not contracting

References

• National Institute of Clinical Excellence UK 2003

• Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of systematic Reviews 2003, Issue 4

• MOH guidelines for Family violence• Denise Tiran, “Nausea and Vomiting in

Pregnancy An integrated approach to care”

References

• Fiona Lyall and Michael Belfort. Pre-eclampsia Etiology and Clinical Practice

• Debbie Holmes & Philip N Baker. Midwifery by Ten Teachers

• Pairman, Pincombe, Thorogood, Tracy. Midwifery Preparation for Practice