Hope this helps to guide you through the course somehow. I find it quite useful and helps me a lot during my posting as a medical student in the hospital.

notes:

This is not my own link. I copy and paste it here from a websites called HOUSE OFFICER WORKSHOP MALAYSIA to share with you all. You can directly go to the websites and download other books here.

Day 1 : The Clinical Long Case in O&G ward, 3 May 2017

I slept at 4 am last night. So tiring and I need to be at hospital by 8 am. Another 1 and half hour. *Sigh*

When I arrive at the labour room, Mdm Wee is waiting for us. Hahaha, I'm so nervous and scared. Remember Prof. Che Anuar ? the one that I told before? Hahaha, I got him as for my long case examiner. Actually, we already knew most of the cases in the hospital that time. Surprisingly the cases that we thought the least probability to come out, were the one that was chose by Dr. Poh for the long case exam. Got patient with multinodular goitre and gestational diabetes during pregnancy. Then one of my friend got monochorionic diamniotic twin with chronic hypertension ! We never had the experiences to palpate the twin. And the twin was one with the cephalic presentation and another one was with breech.

There was also a pregnant lady with asthma. Need to focus on her antenatal care and also the management outline for asthma patient in pregnancy, The pathophysiology of asthma is very important and it was taught to us so many time in our previous posting. 



I'm getting nervous and more nervous. I am the second last candidate for the long case. I'm the 21 of 23 students. hahaha, I have waited from 8 am till 11.10 am for my turn to examine the patient. 

What happened was, we shared patients for our long case exam. So, the patient has been examined by another student before me. The patient that time was so anxious and tired. She was in pain as she claimed she has been administered with progestin vaginally to induce labour that morning.

She refused to continue the examination, and I'm so done. Terkebil kebil aku berdiri tepi cardiac table tu tengok dia strongly refuse to continue the session. Then I tried to persuade her. She said she want to take bath. So yeaaaa, tinggallah aku kat situ sadly, alone and jotted down all important things from her pink book (Antenatal Check Up Book). 

Luckily Dr. Poh ada and pujuk patient to cooperate. Thank you Dr. Poh !! I managed to finish my history taking and physical examinations. My patient was in pain so I couldn't perform any examination in front of Prof Anuar, but luckily I had examine her before that. Now I'm afraid of how he will evaluate me without physical examination. My history taking alone is not sufficient. I just hope he will consider and let me pass this time. I really hope so. 

HISTORY TAKING

Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby. The most important causes of APH are placenta praevia and placental abruption, although these are not the most common. APH complicates 3–5% of pregnancies and is a leading cause of perinatal and maternal mortality worldwide. Up to one-fifth of very preterm babies are born in association with APH, and the known association of APH with cerebral palsy can be explained by preterm delivery.

Obstetric haemorrhage remains one of the major causes of maternal death in developing countries and is the cause of up to 50% of the estimated 500 000 maternal deaths that occur globally each year. Obstetric haemorrhage encompasses both antepartum and postpartum bleeding.



There are no consistent definitions of the severity of APH. It is recognised that the amount of blood lost is often underestimated and that the amount of blood coming from the introitus may not represent the total blood lost (for example in a concealed placental abruption). It is important therefore, when estimating the blood loss, to assess for signs of clinical shock. The presence of fetal compromise or fetal demise is an important indicator of volume depletion.

For the purposes of this guideline, the following definitions have been used: 

1. Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection Minor haemorrhage – blood loss less than 50 ml that has settled
2. Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock 
3. Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock

Recurrent APH is the term used when there are episodes of APH on more than one occasion

The role of clinical assessment in women presenting with APH is first to establish whether urgent intervention is required to manage maternal or fetal compromise. The process of triage includes history taking to assess coexisting symptoms such as pain, an assessment of the extent of vaginal bleeding, the cardiovascular condition of the mother, and an assessment of fetal well being. 

Women presenting with a major or massive haemorrhage that is persisting or if the woman is unable to provide a history due to a compromised clinical state, an acute appraisal of maternal well being should be performed and resuscitation started immediately. The mother is the priority in these situations and should be stabilised prior to establishing the fetal condition. If there is no maternal compromise a full history should be taken.

● The clinical history should determine whether there is pain associated with the haemorrhage. Placental abruption should be considered when the pain is continuous. Labour should be considered if the pain is intermittent. 

● Risk factors for abruption and placenta praevia should be identified. 

● The woman should be asked about her awareness of fetal movements and attempts should be made to auscultate the fetal heart. 

● If the APH is associated with spontaneous or iatrogenic rupture of the fetal membranes, bleeding from a ruptured vasa praevia should be considered. 

● Previous cervical smear history may be useful in order to assess the possibility of a neoplastic lesion of the cervix as the cause of bleeding. 

The presentation of cervical cancer in pregnancy depends on the stage at diagnosis and lesion size; most women with International Federation of Gynecology and Obstetrics (FIGO) stage I cancer are asymptomatic; symptomatic pregnant women usually present with APH (mostly postcoital) or vaginal discharge. 

In a Swedish population study, the incidence of cervical cancer was 7.5 cases per 100 000 deliveries; in over half of these cases, the women had an abnormal cervical smear history.

Examination of the woman should be performed to assess the amount and cause of APH. The basic principles of resuscitation should be adhered to in all women presenting with collapse or major haemorrhage. 

The primary survey should follow the structured approach of airway (A), breathing (B) and circulation (C). Following initial assessment and commencement of resuscitation, causes for haemorrhage or collapse should be sought. 

All women presenting with APH should have their pulse and blood pressure recorded.

Abdominal palpation The woman should be assessed for tenderness or signs of an acute abdomen. The tense or ‘woody’ feel to the uterus on abdominal palpation indicates a significant abruption. Abdominal palpation may also reveal uterine contractions. A soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.

A speculum examination can be useful to identify cervical dilatation or visualise a lower genital tract cause for the APH. In a prospective observational study of 564 women presenting with APH, 521 (92.4%) underwent an admission speculum examination; 389 women (69%) had a normal cervix, 120 (21%) had cervical ectropion and 12 (2%) had a dilated cervix. If the woman presents with a clinically suspicious cervix she should be referred for colposcopic evaluation 

Digital vaginal examination

If placenta praevia is a possible diagnosis (for example, a previous scan shows a low placenta, there is a high presenting part on abdominal examination or the bleed has been painless), digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia. Digital vaginal examination can provide information on cervical dilatation if APH is associated with pain or uterine activity.

Investigations should be performed to assess the extent and physiological consequences of the APH. The maternal investigations performed will depend on the amount of bleeding. 

The Kleihauer test should be performed in rhesus D (RhD)-negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D immunoglobulin (anti-D Ig) required. The Kleihauer test is not a sensitive test for diagnosing abruption. 

Ultrasound can be used to diagnose placenta praevia but does not exclude abruption. Placental abruption is a clinical diagnosis and there are no sensitive or reliable diagnostic tests available. Ultrasound has limited sensitivity in the identification of retroplacental haemorrhage.

In cases of major or massive haemorrhage, blood should be analysed for full blood count and coagulation screen and 4 units of blood cross-matched. Urea, electrolytes and liver function tests should be assayed. The initial haemoglobin may not reflect the amount of blood lost and therefore clinical judgement should be used when initiating and calculating the blood transfusion required. In such circumstances a point of care test (‘bedside test’) to assess haemoglobin may be useful. 

The platelet count, if low, may indicate a consumptive process seen in relation to significant abruption; this may be associated with a coagulopathy. In minor haemorrhage, a full blood count and group and save should be performed. 

A coagulation screen is not indicated unless the platelet count is abnormal. In all women who are RhD-negative, a Kleihauer test should be performed to quantify FMH to gauge the dose of anti-D Ig required.

The Kleihauer test is not a sensitive test for diagnosing placental abruption.

Women presenting with APH should have an ultrasound scan performed to confirm or exclude placenta praevia if the placental site is not already known. Ultrasound scanning is well established in determining placental location and in the diagnosis of placenta praevia.

The sensitivity of ultrasound for the detection of retroplacental clot (abruption) is poor. Glantz and colleagues reported the sensitivity, specificity, and positive and negative predictive values of ultrasonography for placental abruption to be 24%, 96%, 88% and 53% respectively. Thus, ultrasonography will fail to detect three-quarters of cases of abruption. However, when the ultrasound suggests an abruption, the likelihood that there is an abruption is high. 

An assessment of the fetal heart rate should be performed, usually with a cardiotocograph (CTG) in women presenting with APH once the mother is stable or resuscitation has commenced, to aid decision making on the mode of delivery. Whenever possible, CTG monitoring should be performed where knowledge of fetal condition will influence the timing and mode of delivery. 

Ultrasound should be carried out to establish fetal heart pulsation if fetal viability cannot be detected using external auscultation. APH, particularly major haemorrhage and that associated with placental abruption, can result in fetal hypoxia and abnormalities of the fetal heart rate pattern. If the fetal heart rate cannot be heard on auscultation, then an ultrasound scan should be performed to exclude an intrauterine fetal death. 

Ultrasound imaging can be technically difficult, particularly in the presence of maternal obesity, abdominal scars and oligohydramnios, but views can often be augmented with colour Doppler. Guidance directly relevant to monitoring the fetal heart rate at the extreme of viability can be reasonably extrapolated from advice on the management of women in extremely preterm labour (less than 26+0 weeks) from the British Association of Perinatal Medicine. 

The results of this working group suggest ‘If active obstetric intervention in the interests of the fetus is not planned, for example at gestations less than 26+0 weeks, continuous monitoring of the fetal heart rate is not advised. There is a lack of published evidence regarding the role and usefulness of fetal heart-rate monitoring in women presenting with APH. In one study, the fetal heart-rate pattern (CTG) was abnormal in 69% of women presenting with placental abruption. Whilst conservative (expectant) management appears to be safe in preterm pregnancies with placental abruption and a normal CTG, an abnormal CTG is associated with poor fetal outcome and delivery should be expedited to save the fetus.

Clinical judgement is required in these circumstances since women presenting with bleeding that may indicate a catastrophic event such as placental abruption, constitute a group where the fetus is more likely to be exposed to severe hypoxia and acidaemia. In such circumstances, the CTG can reasonably be expected to be informative.

When should women with APH be delivered and what mode of delivery should be employed in women whose pregnancies have been complicated by APH? 

If fetal death is diagnosed, vaginal birth is the recommended mode of delivery for most women (provided the maternal condition is satisfactory), but caesarean birth will need to be considered for some. 

If the fetus is compromised, a caesarean section is the appropriate method of delivery with concurrent resuscitation of the mother. 

Women with APH and associated maternal and/or fetal compromise are required to be delivered immediately. The optimum timing of delivery of women presenting with unexplained APH and no associated maternal and/or fetal compromise is not established. 

A senior obstetrician should be involved in determining the timing and mode of birth of these women. In women with APH secondary to placenta praevia, intrapartum management is described in Green-top Guideline No. 27

APH associated with maternal or fetal compromise is an obstetric emergency. Management should include maternal resuscitation and delivery of the fetus to control the bleeding. Delivery in this situation will usually be by caesarean section, unless the woman is in established labour. Similarly, if there is evidence of fetal distress, resuscitation of the mother should commence and arrangements made to deliver the baby by caesarean section once the woman is stabilised.

Definition

• Placenta previa is a condition wherein the placenta of a pregnant woman is implanted abnormally in the uterus. It accounts for the most incidents of bleeding in the third trimester of pregnancy.

Pathophysiology

• The placenta implants on the lower part of the uterus.
• The lower uterine segment separates from the upper segment as the cervix starts to dilate.
• The placenta is unable to stretch and accommodate the shape of the cervix, resulting in bleeding.

• Low lying placenta. The placenta implants in the lower portion instead of the upper portion of the uterus.
• Marginal implantation. The placenta’s edge is nearing the cervical os.
• Partial placenta previa. A portion of the cervical os is already covered by the placenta.
• Total placenta previa. The placenta occludes the entire cervical os.

Signs and Symptoms

• Bright red bleeding. When the placenta is unable to stretch to accommodate the shape of the cervix, bleeding will occur suddenly that could frighten the woman.
• Painless. Bleeding in placenta previa is not painless and may also stop as abruptly as it had begun.

Diagnostic Tests

• Ultrasound. Early detection of placenta previa is always possible through ultrasonography. It is the most common and initial diagnostic test that could confirm the diagnosis.

Medical Management

• Intravenous therapy. This would be prescribed by the physician to replace the blood that was lost during bleeding.
• Avoid vaginal examinations. This may initiate hemorrhage that is fatal for both the mother and the baby.
• Attach external monitoring equipment. To monitor the uterine contractions and record fetal heart sounds, an external equipment is preferred than the internal monitoring equipment.

Surgical Management

• Cesarean delivery. Although the best way to deliver a baby is through normal delivery, if the placenta has obstructed more than 30% of the cervical os it would be hard for the fetus to get past the placenta through normal delivery. Cesarean birth is then recommended by the physician.

Nursing Assessment

• Assess baseline vital signs especially the blood pressure. The physician would order monitoring of the blood pressure every 5-15 minutes.
• Assess fetal heart sounds to monitor the wellbeing of the fetus.
• Monitor uterine contractions to establish the progress of labor of the mother.
• Weigh perineal pads used during bleeding to calculate the amount of blood lost.
• Assist the woman in a side lying position when bleeding occurs.

Nursing Interventions

• Assess fetal heart sounds so the mother would be aware of the health of her baby.
• Allow the mother to vent out her feelings to lessen her emotional stress.
• Assess any bleeding or spotting that might occur to give adequate measures.
• Answer the mother’s questions honestly to establish a trusting environment.
• Include the mother in the planning of the care plan for both the mother and the baby.

Vaginal bleeding during pregnancy first trimester can be caused by various factors. Nearly 20 to 30% of pregnancies will be affected with bleeding during this phase.

In an ectopic pregnancy, the fertilized egg implants outside the uterus, that is usually in the fallopian tube. You will usually notice cramping and a sharp pain in the lower abdominal region accompanied by dizziness, weakness and nausea. It can be life threatening to mother and requires immediate medical attention. Statistically, only 3% of pregnancies experience it.

Signs of Ectopic Pregnancies:

Women are at a higher risk if they have had:

Molar pregnancy is a rare condition that results when the placenta becomes a cystic mass from a malformed embryo. This is a type of tumor that occurs because of pregnancy hormones and is not life threatening at all. It happens within a few weeks of conception. In some cases, it can turn out to be abnormal and can spread throughout the body, the condition being diagnosed as gestational trophoblastic disease. You can observe vaginal bleeding within few weeks of conception if you happen to suffer from molar pregnancy.

Signs of a Molar Pregnancy:

One of the major concerns with bleeding during first trimester of pregnancy is that it can be a miscarriage as well. It is common to occur during the initial 12 weeks of pregnancy. If bleeding accompanies symptoms like cramping, lower abdominal pain and passage of tissue through the vagina, then there is a higher chance of miscarrying the baby. About 50% pregnant women who experience the symptoms along with vaginal bleeding, miscarry a baby.

The common cause of bleeding during late pregnancy is due to placenta problems. Also, abnormal cervix or vagina can cause bleeding.

This is the most common cause of bleeding during late pregnancy. In this condition, the placenta that usually connects the fetus to the womb will cover a part of the cervical opening. As a result, bleeding takes place. Later in pregnancy, the cervix becomes thin and dilates to prepare for labor. At this stage, the placenta stretches and ruptures causing heavy bleeding. The risk factors for this placenta previa condition include prior placenta previa, multiple pregnancies and prior cesarean delivery.

6. Uterine Rupture:

7. Fetal Vesssel Rupture:

8. Pre-term Labor:

• Vaginal discharge (watery, mucus, or bloody)
• Pelvic or lower abdominal pressure
• Low, dull backache
• Stomach cramps, with or without diarrhea
• Regular contractions or uterine tightening

• Injury to vagina or cervical region

• Cancer

• Polyps

• Varicose veins (abnormal veins with full of twists and turns)

HOW TO DIAGNOSE

Lab Test

Imaging

Reference

Mom Junction Web

American Pregnancy Association

Topic : Postpartum Care by Association of Professors of Gynecology and Obstetrics (APGO)

Postpartum Maternal Physical Assessment Summary- BUBBLE HE

Breasts:

Uterus (Fundus):

Bladder:

Bowel:

Lochia:

• Persistent red lochia suggested delay involution that is usually associated with infections or retained piece of placenta tissue.
• Offensive lochia, which may be accompanied by pyrexia and a tender uterus, suggests infections and should be treated with broad spectrum antibiotics.
• Retained placental tissue is associated with increased red blood cell loss and blood clots, and this may be suspected if the placenta and membranes were incomplete at delivery. Management includes uses of antibiotics and evacuation of retained products under regional or general anaesthesia. 

Episiotomy 

Homan’s Sign-for DVT

Emotional State:

At my postpartum placement, one of the nurses gave us a very helpful handout on what to look for specifically in cesarean and vaginal deliveries postpartum.  Again, the Disclaimer is that these were tips she found useful in assessing her patients, do not use this information to guide your practice, checking college standards and organizational regulations is imperative to good practice. 

Vaginal Birth Assessment

1. VS: on admission; 1hr post 1st set of vitals; q4hrs for the next 48 hrs; qshift until d/c; within 2hrs of d/c
2. Urine Output: d/c foley catheter 12 hrs post opt unless ordered; output for first 2 voids should match ~30ml/hr; if no void within 6-8 hrs post foley removal then do I/O catheter
3. IV: assess for complications such as infiltration, fluid overload; d/c 24hrs or when stable VS

1. Check: GBS, Bloodtype, HepB, HIV and Rubella status of mother and baby
2. VS: on admission; qshift (if GBS+ive then q4h)
3. Head to Toe: on admission; qshift; the mother is a great resource wen you are doing vital assessments or when you are getting blood samples for the heel prick.  Have the mother hold the baby skin-skin or breast feed the baby when you assess, they cry less and will make the assessment go faster. 
4. Blood Work: GBS+ive babies need cbc and blood culture 4hrs after birth; bilirubine and newborn screen with heel prick is done after 24hrs for Vaginal births and 48hrs for Cesarean sections
5. Breastfeeding: skin-skin as much as possible; breask feed 12-3 hrs or when baby shows feeding cues.

Core module 12: Postpartum problems (the puerperium)