2: OBSTETRICS

Published on 27/05/2015 by admin

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Last modified 27/05/2015

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CHAPTER 2 OBSTETRICS

Preconceptual counselling
Booking visit
Subsequent antenatal visits
Prenatal screening and diagnosis
Bleeding in early pregnancy (<14 weeks)
Bleeding in later pregnancy
Nausea and vomiting
Heartburn
Swollen ankles
Varicose veins
Glycosuria
Proteinuria
Anaemia
Rhesus-negative mothers
Pre-eclampsia
Abnormal lie
High head
Back pain
Postpartum bleeding
Postpartum pyrexia
Postnatal depression
Postnatal check
Breast-feeding

PRECONCEPTUAL COUNSELLING

Preconceptual counselling ensures that the woman is fully informed about measures which may be taken to protect herself and the developing foetus during any future pregnancy.

Assessment

History.

Ask about:

• past medical and obstetric history, family history and social problems
• present contraception.

Examination

• Check the pre-pregnancy blood pressure.
• Perform a cervical smear, if due.

Investigations

• Rubella antibodies should be checked before the first pregnancy. If the woman is non-immune she should be vaccinated and should avoid conception for 1 month.
• If the woman has had a previous large baby (>4.5 kg), consider performing a fasting blood glucose and a modified GTT.
• Arrange haemoglobin electrophoresis to exclude thalassaemia trait in those from southern Europe, the Indian subcontinent and the Far East, and sickle cell trait in Afro-Caribbeans. All pregnant women and partners of carriers should be offered screening. Refer couples who are both heterozygous.

Management

Advice

Smoking and alcohol.

Women should be advised to stop smoking and to reduce their alcohol intake to a minimum.

Diet and nutrition

• Advise a well-balanced diet.
• Advise a diet rich in folic acid (green vegetables, bread, potatoes, fruit and fortified cereals). Advise all women to take supplements of folic acid, 400 mg per day, from before conception to 12 weeks of gestation. This may reduce the risk of neural tube defects. (Folic acid can be prescribed on FP10 or bought OTC.)
• To minimise the risk of listeriosis, avoid unpasteurised soft cheeses, cooked chilled foods, prepacked salads and pâtés.
• To minimise the risk of toxoplasmosis, avoid undercooked meat, wash all vegetables and fruit prior to consumption, and avoid handling soil or cat faeces.
• Avoid high vitamin A intake.
• Avoid peanuts.
• Advise a high-calcium diet or calcium supplements for women who may require it, e.g. grand multiparous women or those who are socially deprived.

Contraception.

If oral contraception or an IUCD is being used, one natural period without contraception should ideally be allowed before conception.

Referral

Obstetric problems

• Previous miscarriages: if the woman has had three or more miscarriages, refer for assessment of, e.g. cervical incompetence (which tends to cause mid-trimester miscarriages) or chromosomal abnormalities.
• Previous still births, foetal abnormalities or a family history of foetal abnormalities: refer for genetic counselling where this is likely to be beneficial. Advise, where appropriate, on antenatal screening and diagnosis. If the patient has a previous history or family history of a neural tube defect, advise her to take folic acid 5 mg daily from 1 month prior to stopping contraception to 12 weeks of gestation.

Medical problems

• Hypertension: refer for assessment. Methyldopa and some beta blockers, e.g. propranolol, are known to be safe and effective in pregnancy.
• Diabetes: refer for assessment. Perinatal mortality is around 10%, even with excellent control of blood sugar, which is crucial. The incidence of congenital abnormalities can be significantly reduced by good blood sugar control both before and during pregnancy. HbA1c levels should be checked before stopping contraception.
• Epilepsy: refer for assessment. Congenital abnormalities are more than twice as common as usual. All anticonvulsants increase the incidence of foetal abnormalities to varying degrees, and this has to be assessed against the risk of untreated epilepsy and convulsions during pregnancy.

BOOKING VISIT

The booking visit is ideally between 8 and 14 weeks, and usually requires a 20–30 minute appointment.

Diagnosis

Pregnancy can be confirmed by home or laboratory testing of an early morning urine specimen taken after a missed period, measuring urinary HCG.

Tip

A diagnosis of pregnancy can usually be made on the history alone.

History.

Ask about:

• LMP (and degree of certainty of that date), and calculate EDD
• age, occupation, race of both patient and partner (if appropriate), medical and obstetric problems (see p. 23), socioeconomic background, family history, alcohol, smoking and dental hygiene.

Examination

• BP
• weight
• heart
• lungs
• legs (for varicose veins)
• abdomen.

Vaginal examination is unnecessary.

Investigations

• Urine: check for protein and sugar and send an MSU.
• Bloods:

– Hb
– ABO and rhesus groups and antibodies
– VDRL and hepatitis B status
– HIV status (this is now routinely checked with patient consent)
– rubella antibodies
– consider testing for haemoglobinopathies (see p. 22)
– arrange serum AFP and a ‘triple test’/integrated test if required at appropriate times (see p. 26).

• Ultrasound scan (see p. 26): consider

– a dating scan at 7–11 weeks
– a nuchal scan at 10–13 weeks
– an anomaly scan at 18–20 weeks.

Management

After assessing risk factors, discuss the most appropriate form of antenatal and intrapartum care. The usual options are ‘shared care’ (the patient’s care is shared between hospital doctors and GPs/midwives, and the mother is delivered by the hospital team) and community care (involving the GP and the community midwives with delivery in hospital, community units or at home). Arrangements and criteria for low-risk community units will vary according to the locality. Refer as appropriate.

Advice

• Discuss diet (see p. 22).
• Discuss prenatal screening and diagnosis (see p. 25), as appropriate.
• Discuss the woman’s concerns and expectations with regard to the pregnancy and delivery.

Administration

• Complete form FW8. This authorises free prescriptions and dental care throughout the pregnancy and for 12 months after delivery.
• Complete the relevant maternity hospital registration form.

SUBSEQUENT ANTENATAL VISITS

Follow-up intervals vary. Normal multigravidae require at least six antenatal check-ups at 12, 16, 22, 30, 36 and 40 weeks. In addition, normal primigravidae require check-ups at 26, 34, 38 and 41 weeks.

History.

Ask about:

• general health
• gestation.

Examination

• Blood pressure.
• Look for oedema.
• Fundal height.
• Foetal presentation (from 32 weeks).
• Foetal movements/foetal heart (Doppler, e.g. Sonicaid, can detect the foetal heart from 12 weeks of gestation).

Investigations

• Urinalysis for protein and sugar.
• At 28 and 34 weeks re-check Hb and ABO and rhesus groups.
• Prenatal screening (see below), as appropriate.

Administration

Complete form Mat B1 at 26 weeks, if appropriate.

PRENATAL SCREENING AND DIAGNOSIS

SCREENING TESTS

All women may be offered ultrasound, serum AFP and the triple test or integrated test as part of routine screening. Discussion of the pros and cons of these tests must take account of the patient’s feelings regarding termination of pregnancy. False-positive results can cause considerable unnecessary anxiety. Diagnostic tests are necessary to confirm a positive screening test.

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