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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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notes	336
EMQ	1502
SBA	2115

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ESSAY 163 - PERINATAL COUNSELLING

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		Posted by Rani M. Tue Aug 2, 2005 04:54 am
Counselling of this woman should involve multidisciplinary input from neonatologist,anaesthetist,& her obstetrician & midwife. Preterm delivery can create considerable anxiety & distress,& therefore involvement of a psychological counsellor may be helpful. First of all her concern & questions if any should be answered & dealt with. Neonatologist inform her regarding neonatal implications,NICU admission,care & time required by parents.At 27 weeks survival of upto 70% is expected. She is informed regarding why C.S. is being done,that risk of continuing pregnancy at this stage are more than risk of prematurity. She is enquired regarding any previous surgeries &/or anaesthesia and any complications with them.History of any associated medical illness,UTI, & dentures is important. An appointment is arranged with anaesthetist to discuss type of anaesthesia,her wishes,& risks & adverse effects ( e.g. post dural puncture headache after regional anaesthesia).Advantage of epidural anaesthesia of continuing as post op analgesia through same catheter are discussed. She is informed regarding risks and complications which may arise intraoperative,post operative & short term & long term morbidity.It should include informing about risk of infections,wound hematoma,haemorrhage during operation & post op,venous thromboembolism,post op pain & hospital admission( usually 4-5 days) Woman need to be counselled regarding need for thromboprophylaxis according to her risk assessment based on evidence based guidelines and protocol. Informed consent is checked and confirmed.This should ideally be done by the person who is going to operate on her.Any objections/advanced directives related to blood and blood products are discussed. She is informed regarding operative difficulties in case of preterm prelabour C.S.,as lower segment may not be formed,modification of incision technique may be required like J shaped incision & therefore a senior obstetrician will either do the C.S. or directly supervise it. She is informed regarding future pregnancies,that,risk of lower segment scar rupture isless than 1% after one previous section.That 70% of woman may achieve vaginal birth following one previous lower segment C.S.If this will be her second C.S.,she is informed regarding need of elective C.S. in all future pregnancies.Need for hospital delivery in future pregnancies is discussed She is informed that safe interval between C.S. and future pregnancy is controversial but most will recommend an interval of 18 months & so adequate contraception is recommended for this period. Adequate time should be provided for indormation to be assimilated by her. after introducing new information, need to stop and ask her whether she understood the information provided.
		Posted by manjula C. Tue Aug 2, 2005 05:32 am
Severe growth retardation and its preterm delivery is a matter of deep concern to the couple.The woman should be counseled along with her partner .Counselling should involve the perinatologist and if necessary the clinical genetist if the etiology is a structural defect or a chromosomal anomaly. Ideally an appointment should be arranged with a neonatologist prior to the caesarean to counsel regarding the immediate and long term consequences of the growth retarded preterm baby. The woman needs counseling regarding both the fetus and caesarean procedure. Risks to the baby. The perinatal mortality and morbidity is increased in this situation of growth retardation at 27 wks of gestation.the woman is explained in detail about the etiological factor involved which could be more likely a chromosomal anomaly or an intrauterine infection of the fetus,CMV,RUBELLA,OR TOXOPLASMOS.The woman is explained about the survival rates at various birth weights and period of gestation in relation to ethnicity and race .However she should be told that the prognosis if the baby has chromosomal trisomy 18,the survival chances are poor.If ther e is a strong family history or previous baby being born as trisomy 21,she and her partner are suggested to undergo karyotyping to detect Robertsonian tranlocation,or mosaicism.If it is found to be positive then there is a high recurrene in the next baby. If the cause is detected to be intrauterine fetal infections the woman is explained about the permanent damage to certain organs because of it like,rubella infection with cardiac defects,hearing loss,and mental retardation as a result of microcephaly due to cmv.She should be told that though caesarean section has been decided the procedure by itself cannot gaurantee about the reduction in either the perinatal morbity or mortality. However, if she is tested negative for rubella IgG she should be adviced to receive the vaccine following delivery. The woman should be detailed about the immediate risks,like if left in utero there is a high likely chance of perinatal mortality.She should be told that the baby is likely to suffer the complications of prematurity like RDS,IVH,necrotizing entercolitis,infections and septicaemia.Other problems of growth retardation like hypoglycemia,hypothermia,hyperbilirubinemia,anaemia are more likely to manifest. Her doubts regarding the long tern outcomes has to be cleared,like slightly increased motor and neurodevelopmental delay,learning disability in schools needing special schools.The babies on the long run have showed increased likelihood of suffering from NIDDM,obesity,hypertension and cardiovascular disease. Lastly the woman should be explained about the need for an autopsy if there is an unfortunate event of perinatal death. Risks to the mother. The main risks to the mother will be the caesarean section.She should be detailed about the anaesthesia risk,likely chance of a wound extension due to illformed lower segment,risks of excessive blood loss and a probable chance of prolonged hospital stay . She should be given a chance to exress her concerns regarding the c.s and about her baby and her doubts cleared.
		Posted by Shakira B. Tue Aug 2, 2005 05:55 am
Preterm delivery causes anxiety and distress, so needs help from psychological counselor. Her care needs multidisciplinary involvement of obstetrician, neonatologist, anesthetist. Babies with normal anatomy born in good condition at 27 weeks are likely to survive in about 80% of cases if cared in a centre with modern neonatal facilities. Risks to the Mother:- CS is a major operation with risk of hemorrhage, wound infection, VTE. Antibiotics and thrombo prophylaxis given to reduce these risks. She must be counseled that CS is done as the risk of continuing pregnancy at this stage is more risky than the risk of PTL. Pre-op :- Her risks of any medical diseases are checked. An appointment with anesthetist to discuss type of anesthesia, her wishes, risk and adverse effects are discussed. Informed consent is checked and confirmed by the person who is operating. Any objections to blood / blood products are noted down. Intraoperative : - Difficulties may arise as lower segment is not formed, so ?J? shape incision and therefore senior obstetrician will do or supervise in operation. Her future pregnancy risk after one lower segment CS is 1% scar rupture incidence and 70-80%, chance of vaginal birth following 1 CS. She needs to be delivered in hospital in future. Risk to the Baby :- If there is opportunity to give betamethasone two doses at least 24 hours prior to babies delivery will reduce the risk of RDS by 50%. Baby may require stabilization at delivery by a pediatrician who will be present, and this may include intubation and ventilation if there is respiratory distress. Baby may require endotracheal surfactant which is given shortly after birth. Ventilation may be required for several days. Baby may require incubator car initially to maintain body temperature and may become jaundiced which will require phototherapy. Baby will be required to be tube fed once able to tolerate enteral feats, and mother may wish to express breast milk for him, otherwise he will receive formula milk. He is likely to start sucking feeds in about 4-5 weeks, and to go home after 6-10 weeks. Mother may have opportunity to care her baby as soon as he is stable. (Bathing, changing, tube feeding). Baby is at risk of complications such as acquired infection, persistent patent ductus arteriosus or necrotizing enterocolitis. He is at risk of periventricular leucomalacia. Long term he is at risk of nuerodevelopmental delay, cerebral palsy and deafness. Adequate time should be provided for indormation to be assimilated by her. after introducing new information, need to stop and ask her whether she understood the information provided.
		Posted by Mangala sundari R. Tue Aug 2, 2005 12:42 pm
The fetus by virtue of its prematurity and severe IUGR is at an increased risk of perinatal morbidity and mortality. The patient and the partner will be counselled about the possible causes so far assessed by the investigations and ultrasound and Doppler findings. The diagnosis of symmetrical IUGR is more in favour of infections like, herpes, syphilis, CMV, rubella, chickenpox or toxoplasmosis or chromosomal anomalies like trisomy 21, 18,13 or congenital anomalies. Ultrasound may show a normal amniotic fluid index with these fetuses. Asymmetrical IUGR, with oligohydramnios where the Ac is less than the BPD , the causes may be PPROM, , renal anomalies, small for gestational age as in preeclampsia, chronic hypertension or auto immune diseases..All anomalies may not be picked up and diagnosed by the ultrasongraphy. Asymmetrical IUGR babies carry a better prognosis than symmetrical IUGR babies. The baby needs to undergo investigations,for infectious screen, karyotyping, after birth to know the possible cause of IUGR. The baby may stay in SCBU for a long time for ventilation, undergo invasive investigations or nutrition and for weight gain.18 % of preterm babies are affected by GBS infection more so with preterm and PPROM. Being just above the borderline period of survival, the complications of prematurity , i.e RDS, intra ventricular hemorrhage, necrotising entrocolitis, retinopathy of prematurity, long term respiratory morbidity and neurodevelopmental delay. They may have learning difficulties when compared to their peers. Even if the pregnancy is left for conservative management, the likelihood of intrauterine asphyxia and death will be explained. The patients attitude towards the fetus is taken into consideration. The decision for termination and by elective LSCS will be explained to the patient since these babies do not tolerate the stress of induction or labour well due to the poor reserve. Elective procedure carries a better prognosis than the emergency for the availability of senior neonatologist and their team for care and also the morbidities are less with elective procedure. The morbidity associated with Lscs i.e.,,need for hospital stay, post op analgesia, wound infection, post op care, thrombo embolism, visceral injury will be explained. Regional and General anaesthesia complications will also be explained to her. . Senior Neonatologist will be involved in the discussion about the survival chances , and management . Honest discussion about the unit?s protocol and the statistics will be explained. Patient can have a visit to the neonatology unit .She will be given adequate time to discuss and make an informed choice and decision.
		Posted by Nitin P. Tue Aug 2, 2005 01:46 pm
Preterm delivery carries risk of short term and long term perinatal and maternal morbidity. Sever growth retardation further increases the risk. Perinatal mortality at this gestational age is 5-10%, though varying in different centres. The need for caesarean section is explained including the implications of continuing conservative management and inducing labour, which include high risk of intrapartum death. There is no good evidence that caesarean sections have a better outcome in preterms but it is difficult to conduct studies for such a management option. In event of trial of labour and fetal distress, an emergency section carries a higher risk than an elective section. She is explained that most babies will have a good outcome. The outcome also depends upon the cause of IUGR identified, poorer outcomes if congenital anomalies, chromosomal anomalies. She is explained the need for in utero transfer to a unit with onsite SCBU facilities as this has a better outcome for the baby than postnatal transfer. Neonatologist should be involved in counselling regards neonatal outcome. Visit to SCBU is arranged. Brief about handling new born is given. Neonatal outcomes differ in every unit and local figures are quoted. Immediate outcomes such as need for ventilation, surfactant, intravenous access, total parental nutrition, antibiotics, are explained. Complications such as hypoglycaemia, hypocalcaemia and hypothermia and sepsis are explained in language best understood. Short term complications include necrotising enterocolitis, respiratory distress syndrome, prolonged SCBU stay, prolonged O2 need and intraventricular haemorrhage. NEC may require surgery and this is explained. IVH has implications for long term prognosis. Long term comlications include milestone delay, need for special school, learning disabilities, epislepsy. These will have social and economic implications as care of such a child can be quite taxing. Communicaty care givers and GP are informed so that early identification and management of neonatal problems such as convulsions can be done. Implications of caesarean section at this gestational age include a higher risk of classical section or DeLee\'s incision, and hence important to have consultant presence. This has implications for future pregnancies including risk of placenta praevia, accreta and chances of vaginal birth. The type of skin incision, catheterisation, post operative recovery are explained. Risk of intrapartum haemorrhage, need for blood transfusion (0.4%) and bladder (0.1%), bowel injury are explained. Information is given regards anaesthesia and meeting is arranged with anaeshtetist if posssible. Advantages of breast feeding, though feeding not started immediately, are explained. These include less risk of NEC, better immunity and lesser skin eczema and wheezing. The risks of recurrence are discussed. These will depend upon the cause of the IUGR, for conditions such as severe preeclampsia is 10-15% and will differ for congenital anomalies, 3-5 % for cardiac anomalies. If a genetic syndrome or chromosomal anomaly is suspected, and confirmed after birth a meeting with a genetic counsellor is arranged for after the delivery. Information is given regards postnatal tests that might help in management of future pregnancies e.g. anti phopholipids in case of severe pre eclampsia. The counselling is done in a non-directive manner, at an appropriate place and time such that the patient is comfortable. Partner or relatives are allowed to be present only if wished so by the patient. It is good to have the patient\'s named midwife present at the counselling session as this reduces anxiety of the patient. The patient is encouraged to ask any question.
		Posted by Rani M. Wed Aug 3, 2005 11:25 pm
Dear Paul, Thanks for checking my answer. I now understand the basic flaw in my approach to this question. one thing I want to enquire ; Is there mark for checking informed consent . You didn\'t give me mark for that but gave Shakira one mark for the same. Also can you please tell us about EPICURE results .and also regarding survival rates at different gestation. I couldn\'t find it in the busyspr notes. Hoping for reply.
		Posted by manjula C. Thu Aug 4, 2005 07:52 am
Dear Paul, Thank you for correcting my answer for this essay,which highlighted the required points which i had omitted .But I am confused in the way the marks being alloted in certain areas ,which i had thought will be the answer,in case the question was regarding \"justify your management\" rather than for \'counselling\'.Like,taking or checking for informed consent,involvement of a senior obstetrician in c.s,discussing about the management of neonatal complications like use of surfactant,giving artificialfeeds or expressed breast milk. i hope you will clear my doubts regarding this. Thank you for your time.
		Posted by hassan M. Sat Aug 6, 2005 05:06 am
Sever Intra uterine growth restriction at 27 weeks is associated with increased neonatal morbidity and mortality estimated birth weight will be around I kg at this gestational age for normal fetuses but for severIUGR it will be even less.Patient and her partner should be counceled in view of the results of available investigations which will give us an idea about the possible cause of IUGR ie chromosomal anomalies,viral infections,placental insufficiency ,thrombophilia and sever preclampsia .Councelling is done in liaison with senior neonatologist,anesthetist and senior obstetrician ideallythe one who will be performing the surgery.. Patient is informed that Cs is the best mode of delivey for severly compromised fetus who may not be able to survive the normal labour and at 27 weeks she is less likely to respond to IOL due to poor cervical ripening .Continuation of pregnancy may result in IUFD .She should be informed about the possibility of chromosomal and congenital anomalies which were not diagnosed earlier on uss and may be there at delivery.Patient should be given betamethasone 12 mg b d to decrease the severity of NEC,ARDS and IVH.Instead of receiving the steroids severity of the risk associated with prematurity can not be predicted at the time of delivery. long term out come of these babies such as delayed mile stones ,Low IQ,cataract ,deafness are possible .Ethical dilemmas about decession to resuscitate baby may arise if weight is lower then 500 gms .In these cases parents wishes should be documented in notes. Parent should be allowed to visit NICu to have an idea about the baby on a ventilator .Duration of stay in NICU may be as long as 8 to 10 weeks. Premature neonates have higher risk of neonatal jaundice and may need photo therapy .Breast milk can be expressed and brought to NICU to be fed with NG tube to baby .If mother is not able to do so due to difficulty in coming to hospital daily it can be stored in freezer for 24 to 36 hours otherwise suppression of lactation is adviced with bromocryptin or cabergoline.Investigations are carried out on in NICU for baby to find out the possible cause of IUGR as it would be a guide in management of future pregnancies. Mother is informed about LSCS incission which would be dee Lees or Pfannenstil .There may be a need of Inverted T ,or J shaped incessiion on uterus to deliver the baby .Clssical CS may be needed as lower segment will be not formed at this gest age. She would have a catheter and Iv line on waking up from anesthesia .If she had GA breathing exercises and chest physiotherapy will be given to her to prevent chest infection due to secretions.She will have thromboprophylaxis s/c to prevent post op DVT and risk of pulmonary embolisam. IV antibiotics will be given to prevent post op endometrites and wound infections.She would out of bed and mobilized within 24 hours and would be able to go and visit the baby in NICU.In case she received epidural she might feel headache on waking up in case of a dural tap .For GA she would be kept NPO for 6 to 8 hours pre op.If she has bleeding intra operatively she might need blood transfusion .Her views regarding blood transfusion should be mentioned eg Jeehova witness and consent should be duely signed with consent of LSCS and anesthesia .Conscent should be explained and signed with the help of interperator in case of language barrier.As patient will have scar on uterus she should be informed about the risk of scar rupture in next pregnancy as 1%for lscs and 40% for classical lscs.However if this lscs was with out any complication and if next pregnancy is normal she has a good chance to have a normal delivey.
		Posted by A H. Sun Aug 7, 2005 07:48 am
A decision to deliver a fetus at 27 weeks gestation means that there is a high risk of fetal demise if the pregnancy is allowed to continue. The mother and her partner will have many questions and anxieties. An understanding attitude and enough time and privacy to address all their concerns must be provided. She will be reassured that this is the best choice for the baby at this time. She will be advised that fetal lung maturity will be enhanced by the administration of maternal steroids and suitable arrangement made for expert neonatal care in a neonatal intensive care unit. Surfactant administration after delivery will further improve lung function. I will also advise her that Caesarean Section at this time may necessitate a classical or modified classical incision or a J- or U-shaped incision. This is associated with increased blood loss. However, arrangements for the consultant anaesthetist and senior obstetrician to perform or supervise anaethesia and the operation will be made. If the above incision becomes necessary, I would explain to her the implications for a future pregnancy, especially ruptured uterus, if labour is allowed to take place. She will be advised that the baby will most likely not withstand the stress of labour .If this is her first pregnancy, induction of labour is likely to be a prolonged process and failure of induction is quite possible. Both these situations will then necessitate an emergency Caesarean Section at a time when all senior personnel may not be available. There is also increased maternal morbidity as well as a worse prognosis for the baby. It will thus be better for a planned delivery by elective caesarean Section. She will be advised that although the baby may gain normal weight in the neonatal period, there is an increased risk of hypertension, ischaemic heart disease and atheromatous vascular disease in later life. I will arrange a consultation with neonatologist to discuss risks and prognosis for the baby. She will be encouraged to visit the neonatal unit and view premature babies being ventilated in order to prepare her to deal with her situation. Arrangement with the anaesthetist will also be made to discuss type of anaethesia employed for surgery. I will also advise and arrange for a visit with a haemotologist or physician after the puerperiun. This is to identify with factors for IUGR especially thrombophilias, if the cause of IUGR was not established or if it was not pregnancy related, for example, pre-eclampsia. She will be advised that the risk of severe morbidity and even mortality is high even though the baby is delivered. However, if all facilities and expert personnel are involved in her management she will feel reassured that her baby’s best interest is being pursued at this time.