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_  C/S requirements #Obs__shift

_ Drainage of liquor #Obs__shift

= Pre_term labour: _Intrauterine infection + bleeding are major risk factors =Detailed hx ( frequency of contractions & duration/ rupture of membrane/ past hx of preterm delivery or vaginal bleeding/ hx of UTI ) = Examination : - General ex ( pulse/ BP / temp " evidence of infection ") _obs ex ( fetus lie ,  contractions frequency &duration  ,amount of liquor...) _sterile speculum examination = Full investigations =Treatment: according to the pt condition A_ Expediting labour: ( In Severe bleeding ,  Intrauterine infection "maternal pyrexia & tender uterus " , fetal distress or death) B_ Observation: ( If 36w or more / membrane rupture + pt receive steroids /active labour) C_ Tocolytic therapy +Steroids: *The objective of drugs to lengthen gestation until the pt receive steroids for lung maturity * Drugs ( nifedipine "1st line "/ Indomethacin "2nd line ") + dexamethasone * Tocolytic therapy should be stopped when active labour confirmed  / delivery should be attended by the nursery staff #Obs__shift

=  Diagnosis of labour: _  painfull regular uterine contractions _ Progressive cervical dilataion ± membrane rupture = Management: A_ Detailed hx " pain onset,  frequency & duration " /passage of show /rupture of membrane  / past obs hx B_Examination  "general + obs ex" + PV " cx affecemant & dilatation " C_ Full investigations D_ Treatment: _ if the diagnosis of active labour is not confirmed " cx < 4cm " repeat the assessment after 4 hrs _ if  the diagnosis of active labour confirmed "cx > 4cm " admitted to labour room,  follow up using patrogram *Labour room: _ 2 IV lines _ Follow up ( PR / BP / FHS every 15 min at first stage& every 5 min at secondstage/ Uterine contractions every 30 min/ cx dilatation) and record at patrogram _ oxytocin ± Ergometrine should be given after anterior shoulder delivery _ After delivery every pt should be monitored for 2 hrs + discharge card " write briefly about labour events,   the medication that received by the pt and last vitals & discharge on..." #Obs__shift

_ Hepatitis B+v mother: #Obs__shift

= Antepartum Hemorrhage: _ Vaginal bleeding "after 24 w" of pregnancy _ causes: placental abruption/placenta previa/vasa previa/local cervical causes "polyps , erosion,  ulceration,  malignancy.." = placental abruption: _ Symptoms: *painfull Vaginal bleeding  usually the blood is dark in color " maybe preceded by hx of trauma " _ O/E : * tachycardic or even shocked pt * Abdominal examination: - Tender,  rigid abdomen - difficult to feel the fetal parts - decrease fatal movement and FHS = Placenta previa: _ symptoms: * painless vaginal bleeding and recurrent  , usually  the blood is fresh " no hx of trauma " - O/E: *Abdominal examination: -The abdomen is soft  , not tender - fetal parts are palpated ± abnoraml lie - PV is contraindicated in PP = Management: A_  Take  detailed hx + " hx of trauma/ drug abuse / color and amount of bleeding " to assess the severity " B _ General ex "PR , BP , pallor..." + abdominal examination/ don't do pv unless U/S is done C_ Investigations: _ CBC    _blood group &cross matching _ U/S to differentiate between AP & PP and mange accordingly : *Features of AP at U/S (normal placental position,  retroplacental bleeding) * Features of PP ( abnoraml situated placenta either covering internal os "PP major " or partially cover the internal os " PP minor " D_ Anti-D should be given for Rh _ve pt E _ Treatment : = AP : *If small AP + no featl distress ( close monitoring) * If moderate maternal &fatal distress ( consider AROM + induction of labour ± blood transfusion) * In sever cases consider C/S = PP : * if samll amount of bleeding ( close monitoring of the pt and elective C/S at term) * In massive bleeding ( emergency C/S) *Expectant management ( if the pt close to term , admit to the hospital,  close follow up/ when to end expectant management?? " sever bleeding,  severe maternal & fetal distress,  labour pain " #Obs__shift

=Specific Treatment: = complete miscarriage: Hx :of Vaginal bleeding +pain " then pain subsided " PV: Closed os U/S : showed empty uterus _ Nothing to be done,  repeat U/S after 2w  ±antibiotics = Incomplete miscarriage: Hx :of Vaginal bleeding +pain PV: opened os U/S : non viable fetal products are found at the uterus _ Treatment: there is many options according to pt condition & stability * Expectant management: give the pt chance of 2w for spontaneous expulsion of products if failed go for other option * Medical treatment: using misoprostol "sublingual or per vagina" *الجرعة تختلف حسب بروتوكول المستشفى * Surgery "Evacuation " In sever cases of bleeding and hemodynamic unstable pt = Threatened miscarriage: Hx :minimum Vaginal bleeding &pain PV: opened os U/S :  viable fetus _ Treatment: duphaston tabs = Inevitable miscarriage: Hx : Sever vaginal bleeding &pain PV: opened os U/S :  at the beginning fetal pole , activity and heart beats are  present then stopped _ Treatment: * Medical or surgical  according to pt condition & hemodynamic stability = Missed miscarriage: _Hx : cessation of pregnancy symptoms/ No Abdominal pain or Vaginal bleeding _PV: Closed os _U/S :  Gestational sac >25mm and no fetal heart activity/ GA should be >6 w to diagnose missed miscarriage/ if <6w called " blighted ovum" _ Treatment: *Expectant Give the pt chance of 2w for spontaneous expulsion / 2w for follow up if nothing changed prepares for Evacuation = Septic miscarriage: _Hx : Vaginal bleeding + Abdominal pain & features of sepsis "Fever , malaise,  rigor and offensive Vaginal discharge " _ Investigations: * Routine + blood culture + high vagina swab _Treatment: * IV fluids *Antipyretic *IV antibiotics " ceftrixone + metronidazole " * surgical evacuaion #Obs__shift

= Miscarriage: = Symptoms: _Vaginal bleeding "before 24w" * ممكن العيانة ماتكون عارفة نفسها pregnant في الحالة دي نطلب beta HCG _ Abdominal pain ±  expulsion of products =  Approach: _ Take good and detailed hx: (Gravity & parity/ previous scar / LMP and GA = important for the mode of treatment...) _ Assess severity of bleeding from  hx + Check PR /BP _ Do PV " to assess open or closed os" = investigations : _ CBC          _UG _viral screening   _blood group & cross matching _obstetrical U/S to  determine the type of Miscarriage and mode of treatment accordingly "write brief hx at the request " = Treatment:  " General/ specific " A_ General : *Resuscitation " IV lines + IV fluids "& prepare blood for sever cases B_ Specific Treatment: *بيختلف العلاج حسب نوع ال Miscarriage بيتشابهو كلهم ف ال presentation  لكن بنميز بينهم عن طريق ال  PV& U/S #Obs__shift

= Bleeding during pregnancy: * من الحاجات الشائعة جدا وبتلاقينا كتير في الطوارئ  taking proper hx + making good examination and early resuscitation save pt life *حسب ال Gestational age نفكر في ال differential diagnosis  اذا كان after 24 w نفكر في أسباب ال APH واذا قبل كدة نفكر في أسباب Bleeding in early pregnancy =causes: _Bleeding in early pregnancy "Miscarriage/ Ectopic pregnancy / Gestational trophoblastic disease/cervical erosion , polyp...." _APH " placenta previa,  placental abruption, vasa previa " #Obs__shift

= Hypertensive disorder during pregnancy: 3_ Eclampsia: The pt present with convulsions =Management: _ABC نضع العيانة في Lt lateral position to maintain airway patancy _ 2 IV lines _Investigation " CBC , RFT+e , LFT+e , blood group and cross marching " _loading doe of Mg sulphate then maintaince _ Call for help + inform ICU _ close monitoring "PR, RR , BP , UOP , CTG " _ Termination 4to 6 hrs following control of pt condition #Obs__shift