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Obstetrics

Obstetrics is the surgical specialty dealing with the care of a woman and
her offspring during pregnancy, childbirth and the puerperium (the period
shortly after birth).

Antenatal care

In obstetric practice, the obstetrician will see a pregnant woman on a
regular basis as her pregnancy progresses. The exact schedule varies
depending on resources and risk factors, such as diabetes.

The main rationale for these visits is surveillance for diseases of
pregnancy which are detectable. Some examples are:

  1. pre-eclampsia. The blood-pressure and urine of a pregnant woman is
     checked at every opportunity to check for this
  2. placenta praevia. On ultrasound, the placenta is visible obstructing
     the birth canal
  3. abnormal presentation (late pregnancy only). The foetus may be
     feet-first (breech), side-on (transverse), or at an angle (oblique
     presentation)
  4. IUGR (Intrauterine Growth Restriction) , this is a general designation,
     where the foetus is too small for its age. Causes can be intrinsic (in
     the foetus) or extrinsic (usually placental problems)

Induction

An obstetrician may recommend a woman have her labour induced if it is felt
that continuation would be more dangerous to her, the foetus, or both.
Reasons to induce include:

  1. pre-eclampsia
  2. IUGR
  3. diabetes
  4. other general medical condition, such as renal disease

Induction usually occurs at 38 weeks gestation. At this age the foetal lung
is fully mature. Note that pre-eclampsia is a reason to induce earlier.

If a woman does not eventually labour by 41-42 weeks, induction is
performed, as the placenta becomes unstable after this date.

Induction is achieved by 3 methods:

  1. pessary of Prostin cream, prostaglandin E2
  2. surgical induction, by piercing the amniotic sac
  3. infusion of oxytocin

Labour

During labour itself, the obstetrician may be called on to do a number of things:

  1. monitor the progress of labour, by reviewing the nursing chart,
     performing vaginal examination, and assessing the trace produced by a
     foetal monitoring device (the cardiotocograph)
  2. accelerate the progress of labour by infusion of the hormone oxytocin
  3. provide pain relief, either by nitrous oxide, or opiates (epidurals are
     done by anaethestists)
  4. surgically assisting labour, by forceps or the Ventouse (a suction cap
     applied to the foetus' head)
  5. Caesarean section, if vaginal delivery is decided against or appears
     too difficult. Caesarean section can either be elective, that is,
     arranged before labour, or decided during labour as an alternative to
     hours of waiting. True "emergency" Cesarean sections (where minutes
     count) are a rarity.

Emergencies in obstetrics

Two main emergencies are eclampsia and ectopic pregnancy.

Ectopic pregnancy is when an embryo implants in the Fallopian tube or
(rarely) on the ovary or inside the peritoneal cavity. Tubal pregnancies are
very dangerous, as at about 4-10 weeks the tube bursts, causing massive
internal bleeding.

Ectopic pregnancy must be considered in any woman with abdominal pain who
has the slightest chance of being pregnant. Diagnosis is by a positive
pregnancy test and a uterus empty on ultrasound. Treatment is by
laparoscopy, and the tube is incised and excavated.

Pre-eclampsia is a disease caused by mysterious toxins secreted by the
placenta. These toxins act on the vascular endothelium, causing hypertension
and proteinuria. If severe, it progresses to fulminant pre-eclampsia, with
headaches and visual disturbances.

This is a prelude to eclampsia, where a convulsion occurs, which is often fatal.

The only treatment for eclampsia, or advancing pre-eclampsia is delivery,
either by induction or Caesarean section. Women can be stabilised
temporarily with magnesium sulphate. Delivery as early as 28 weeks is not unknown.

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