Chantelle: Welcome to the third webinar in our new rural Health webinar series: Bubs in the Bush. This webinar will be presented by Dr Ross Wilson, Dr Ken Wanguhu and Dr Sarah Gleason. All three of our facilitators this evening are rural GP Obstetricians who also hold various roles in GP education. We're thrilled that they could join us this evening.
We'd like to start with an acknowledgement of country. RACGP would like to acknowledge the traditional owners of the land on which this event is being broadcast and we pay our respects to their Elders past and present.
RACGP Rural would also like to thank our sponsor access Telehealth. Access Telehealth provides GPs with free access to bulk billing specialists who conduct patient appointments via video. They manage the entire process via a secure software platform and have a wide range of specialists available. We greatly appreciate their support of this webinar series.
Finally, before we begin, there are a few housekeeping things to cover. Firstly just a few tips on how to use the webinar platform. You should all be able to see a control panel like the expanded image on the left of the screen. If you can only see a few icons like the image on the far left, please click on the red arrow to open the control panel. The control panel provides you with tools to select your audio options and it's also the place to ask questions during the webinar. Those of you who have logged in will be using the mic and speakers option as shown in the image on the screen. However, if you have any internet issues or slow connection, please switch to the telephone option and use the phone number and access codes to listen to the webinar through your phone. Doing this will reduce the bandwidth being used and provide clear audio.
We have everyone set on mute to ensure that learning will not be disturbed by background noise, but we encourage you to type your questions into the question log on the control panel and we'll endeavour to answer these questions towards the end of the webinar. Finally, this webinar has been accredited for two category two QI&CPD points. In order to gain these points you must be present for the duration of the webinar. We also ask that you complete the evaluation activity that will pop up at the conclusion of this webinar. I will now hand you over to our presenters for this evening.
Dr Ross Wilson: Good evening. This is Ross Wilson and we have Ken and Sarah.
Dr Ken Wanguhu: Hi.
Dr Sarah Gleeson: Hi everyone.
Dr Ross Wilson: This evening we’re going to try and cover a fairly broad spectrum of things from preconception care, to identification and management of the high-risk patient in the GP setting, basic principles of delivery and newborn assessment, and the essentials of postpartum care. Sarah, would you like to lead us off and some preconception care?
Dr Sarah Gleeson: Hi everyone. My name is Sarah Gleeson and I'm a rural GP Obstetrician working in Goondiwindi, a small rural town in Queensland, and preconception care is something that I'm very passionate about. I think it's a critically important part of primary care and probably one of the best spend of Public Health dollars, but probably ridiculously underfunded. Preconception consultations are a rare consultation in general practice, but are critically important. We really need to be offering these consultations to women that we are providing contraception to, especially if any of those women are considering pregnancy in the next 18 months.
As is probably obvious, we need to make sure that we've got the medical history and surgical history updated, and that their medication history is updated. Consider whether those medications can be used safely in pregnancy. Are their allergies accurately recorded? Check their blood pressure and their height and weight. What are they doing with smoking, alcohol and other drugs – check on that. Always ask about their current relationship history. Are they feeling safe and happy in their current relationship? Be mindful of any reproductive coercion from their partner. Children by Choice has an excellent document which talks about contraceptive use in situations of woman's reproductive coercion – so that's worth having a look at if you're interested. It’s also important to ask about current and historical contraceptive use so that you can make a plan going forward about what they would like to do in terms of trying to conceive. And obviously taking a menstrual history is important, to check for any underlying medical or gynaecological issues. STI screens and CST cervical screens are also critical – make sure they are up-to-date. It's also important to ask about a family history of chromosomal disorders or a family history of recurrent miscarriages and whether there might be any urgent undiagnosed conditions that may affect a pregnancy.
So continuing with preconception care, obviously there are a few medications that we are talking about – folate and iodine supplementation. It's important to double-check your doses. So, standard dose is 500 micrograms of folate, except if you have a high BMI. For BMI over 30 or a family history of spina bifida you need 500 milligrams – so that’s Megafol (that’s the brand name for that) and 150 micrograms of Iodine to be a minimum.
It is important to counsel your patients about smoking, alcohol and drugs cessation. Also to just to give them some basic education around the menstrual cycle and normal rates of fertility. My experience has been that even tertiary educated women have low levels of understanding of the menstrual cycle and their own anatomy, and that sometimes having a simple conversation with someone about when their optimal time is, usually when they are ovulating, can make a big difference to their chances of conceiving.
I have a mentality I talk to my patients about, about making sure they are aiming to be their fittest, healthiest self before they get pregnant. Talk about the importance of epigenetics. Explain to them the impact of maternal and paternal general health from the moment of conception and how crucial the time in-utero is. I often use the line about ‘giving your baby the best start’ as a motivational strategy. Is your patient overweight? Are they seeing a dietician? Have you had a chat about the importance of being at a healthy weight and being physically fit?
It's another time where you can consider AMH testing – Anti-Mullerian Hormone testing. This can give you an idea of a woman's ovarian reserve, and if they are considering pregnancy in the next 18 months, and certainly for anyone over 30, I am offering this routinely to most women. If this is low this will change your planning and advice to these women and you would refer them earlier to a specialist.
I’ll just mention now that there is a very useful website by GPs very passionate about antenatal and postnatal care called Maternity Matters. Dr Wendy Burton has put together this website and it has some excellent checklists that are open for use, especially a preconception checklist and a pregnancy history checklist as well as some really useful videos and YouTube videos about summaries of first trimester screening and basic prenatal testing. Next slide.
When we talk about risk factors, these are things that we can monitor, modify or treat. Primips are those in their first pregnancy and multips are those in a second or subsequent pregnancy. Ideally we identify risk factors prior to conception if we can and optimize them if possible, or within those first trimester first visits. It's really important to weigh every pregnant lady. Get their height and get an accurate BMI. Ask about their history of recurrent miscarriage. It is really crucial to take an obstetric history. This takes time – it’s often time we open don't have but this is a really important consultation. So managing these risk factors well in the first and second trimesters have seen positive impacts on pregnancy outcomes and on general maternal health. Did your patient have preeclampsia in a previous pregnancy? Does she need calcium prior to 16 weeks? Did her mother or sister have preeclampsia or severe postpartum haemorrhage? Has your patient had recurrent miscarriages in the past? Was this investigated? Is there undiagnosed Thrombophilia that could affect this pregnancy? Did your patient have threatened or actual preterm labour in a previous pregnancy? Have you arranged for the cervical links to be checked? Does she require progesterone histories prior to 16 weeks? Did she have an untreated STI that might have contributed to that or a low level bacterial vaginosis infection that wasn't treated?
Sometimes I find that trying to address all this in two consultations is pretty overwhelming and if this is stretching your knowledge or your comfort level it's important to just ask your friendly local GP Obs or your local Obstetrician for some advice. And also consult your state-based maternity guidelines or RANZCOG guidelines.
So, let’s look at our clinical case. Lucy is a 22 year old primip who presents to you for an initial pregnancy check at about eight weeks. It’s important with all women presenting to you that you need to clarify whether this is a wanted pregnancy or not. It is important to ask how they feel about being pregnant. Obviously it's important to clarify the first day of their last normal menstrual period and, if you haven't done already, conduct a thorough history and examination, which must include height, weight and blood pressure. Be sure to ask about the past medical, surgical and obstetric history like we alluded to before. Also check or recheck their cervical screening status, current smoking patterns, alcohol use, drugs, current mental health conditions or background of mental health conditions, and check about their relationship safety and whether there has been any domestic violence in this or previous relationships, and whether they've had any cervical procedures in the past that may put them at risk of pre-term labour.
Once that's been done, then we can organize our routine antenatal testing. Now most of you would have an auto-fill or list that you pre-populated that you use. It’s important to mention that I don't think there is ever a need for a routine quantitative HCG so we do not need to be checking that. What I do think needs to be checked routinely is iron levels. So don’t forget to check them for all pregnancies. In our service we recheck these at 28 weeks and at 36 weeks. So far we've probably found that about 50% of our antenatal patient base was iron deficient. If you manage that appropriately throughout the pregnancy, you know then that that decreases the severity of postpartum haemorrhages and need for transfusion postpartum, so it’s a very worthwhile and safe intervention. Dating scans these days is routine practice and I would encourage you all to do that to clarify the location of the pregnancy, whether it is a single or multiple pregnancy, and whether there’s any other gynaecological issues that may have yet been undiagnosed. Next slide please.
So additional testing – and we could spend the whole day talking about these extra testing, but it’s worth just mentioning them so they're on your radar. And I always mention this to patients after their dating scan and that's all been confirmed to be okay. So aneuploidy screening which is available currently in Australia either as a combined first trimester screening which is Medicare funded (that you should all know about, which involves blood tests and ultrasounds check) versus your more expensive but more accurate NIPT, non-invasive prenatal testing, which goes under a variety of brand names. It's also worth being aware that there is options to screen for preeclampsia and IUGR in that pregnancy. It's usually performed by your local private or public MFM unit and involves private pathology bloods plus an extra ultrasound measurement that is routinely taken around the 12-week mark. This can make a big difference for woman who obviously had an episode of preeclampsia and can let us manage the pregnancy safely. It may change our management such as adding some aspirin and some calcium if they're confirmed to be at higher risk of preeclampsia again, or for far more close foetal monitoring if we’ve identified that their baby is at risk of growth restriction.
It is important to screen women for gestational diabetes if they are high risk. There are different state by state guidelines but certainly if we’ve got a high BMI or a family history of gestational diabetes then these women do need an initial screening and then another one at 26 to 28 weeks.
Carrier screening is also available now as a private service. It is important to try to mention this obviously at the preconception appointment, but it is important to make parents aware that this is available in that first trimester, especially if there's a family history of such conditions that will change the decision made about that pregnancy.
This is also the time to consider your referrals. So do they need to see the dietitian now? Have they had an untreated postnatal depression or anxiety problem from their previous pregnancy? Do they need to see a psychiatrist to clarify the safest and best medication options for them this pregnancy. Have you identified some risk factors that you need to consult your local GP Obstetrician or Obstetrician or Obstetric Physician to get some advice on? Next slide please.
So, Lucy returns to your clinic at 32 weeks with some ankle oedema. Her blood pressure is severely elevated with a trace of proteinuria. What do you do? It is important to understand your local pathways and where you can refer women for urgent care. So this is an obstetric emergency and this needs to be seen promptly. So you need to refer to your local Centre of Excellence, wherever that is, for urgent admission and management of blood pressure. Lucy needs to make sure that she has some foetal monitoring performed and pathology taken as well to see whether she is developing preeclampsia. Growth scan is also important, also check AFI and Dopplers, with hypertension we have a concern about placental disruption.
At this point as well, after she's left your room, and after your heart rate has returned to normal, add her past medical history on a note somewhere very obvious that for future pregnancies to consider aspirin – for subsequent pregnancies we might be able to reduce the chance of this happening again.
That's me. Thank you.
Dr Ross Wilson: Thanks, Sarah. So, Lucy is now at 38 weeks and she presents in early labour. Her blood pressure is being controlled with Labetalol and she comes in asking for some analgesia and there are a number of options available. There's the non-pharmacological, the pharmacological, and if you like the slightly more invasive, the epidural or spinal anaesthetic. So let's deal with a few of the non-pharmacological. And probably the ones that have the best track record in this respect are the presence of a significant other. It doesn't need to be a husband or partner, it can be a mother or close relative, even a close friend, but it's been shown that a significant other reduces pain by 30% and the labour length by around about the same 30%. So a significant other in the room is important. Some people these days are employing a doula to assist them – if there's been a relationship established along those lines, continue it and support it.
The other non-pharmacological things like meditation, hypnosis, and biofeedback techniques haven't got such strong evidence, but they work for a good number of pregnant women and I certainly wouldn't dismiss them out of hand.
Sterile injections of saline in the lumbar region – whilst they’re popular in some areas with midwives, they haven’t a strong evidence base. But, again, don’t deny anything that the patient has faith in – it will reduce the need for other analgesia.
If we move to pharmacological techniques, then we're starting to talk about the use of narcotic analgesics. These days morphine is the medication of choice – usually subcutaneous or administered IV if it's necessary. But keep the doses low, and go slow. The effect is very apparent and if necessary can be readily reversed with Naloxone. Some people now are trying, if they've got the equipment, using remidentanyl through a pump – small doses, it is a very short acting analgesic, can be used for each contraction. You need special pump mechanisms to deliver the doses and you need very close and constant monitoring, particularly of any respiratory depression which may occur.
The gold standard, if you like, of pain relief where labour is concerned is the lumbar epidural and I think most of us these days have access to that. There's very few centres that don't and a good experienced GP or consultant anaesthetist can provide you with an epidural which may allow the patient to walk and move around – the so called walking epidural if you like. Or if the patient is in quite a degree of distress, a more solid block, a more dense block, may be necessary. Towards the end of labour, if you're fairly confident of a delivery, a simple spinal anaesthetic, which is quicker onset and often more easily placed than an epidural, may save your bacon at those later stages and provide you with good conditions for delivery and an analgesic which lasts up to three or four hours. So don't be afraid further on and in the labour to facilitate things with a spinal anaesthetic. Often at delivery itself one can get good control of outlet pain, that is perineal and vaginal pain, with a well-placed pudendal block. I think it's a technique that most people can quite simply learn – if you can find the ischial spine in the pelvis by palpation vaginally, then you're probably sensible enough to administer a dental anaesthetic. It's a technique which is easily learned and very applicable for low pain during the actual delivery phase.
I guess the thing then to decide is, this girl is going to need delivery fairly promptly and it may be a good idea to have an itinerary which includes the ability to allow you to use your forceps or vacuum so that the girl’s not pushing for terribly long or even move to the sometimes necessary caesarean – and I'll throw to Ken for some hits and tips about how to manage a caesarean.
Dr Ken Wanguhu: Hi. As you heard, my name is Ken and I'm a GP obstetrician and anaesthetist in the Riverlands of South Australia. So obviously it's a bit hard to do a presentation on delivery or caesarean section on a webinar, but I will try my best.
I guess the start is starting off just with the basics. The initial question is when would you be looking at doing a vacuum or forceps delivery? As a GP I honestly think that indications, for all of us, the indications are fairly simple – it's foetal or maternal distress. So you want to if the mother is unable to push and you want to hurry things along to either help mum or baby.
I have really very few rules about it, but I think the important things when I'm assessing is to make sure that there is no head above the pelvis – so when I do examine I do not feel head above the pelvis, when I do an internal examination the head is at or below the spine. And then when I do that assessment, I get the lady to push gently and see whether there is with a contraction and check that there is dissent. There is no signs of CPD, excessive moulding or caput that would that would make it difficult. The single most important thing regardless of what instrument you're going to use is knowing the position. If you cannot assess the baby and the position of the head, you should not put an instrument on the baby's head. So that's really, really important because you do need to be able to identify where your instrument is going to go. Nowadays, most of us will have ultrasound and you can just plonk an ultrasound on their tummy to confirm what you're feeling.
Very, very important that we discuss concerns because if you don't explain properly or the patient's not willing to have the instrumental delivery, then you can’t – no really does mean no in this case. Adequate analgesia is important, which we've heard about, and people ask what instrument you should use and I say use your favourite instrument. Use what you know best. Know your toys. The other question with instrumental deliveries is, as you know, you do have a higher success rate with the forceps, so if you fail with vacuum should you go on to the forceps? My advice is you've got to have a really, really good reason to do that. The risk of a trauma increases quite a lot if you use both instruments and I can tell you the coroner does not take kindly to it and there have been a few reports of foetal trauma – so do think twice about that. I'd be very, very careful.
The vacuum that I use is the Kiwi Omni Cup and this is a very simple system where you have a cup and the pump all-in-one and it comes in a sterile pack. It’s not very expensive but while I haven't seen it, I am told there is a new one that's a bit bigger so gives you better suction and so less trauma and there is a one that's more flat that makes it easier if you're using it during a caesarean section. I haven't used any of those but I imagine they'll be very similar sort of philosophy.
You want to understand the flexion point and it's going around the posterior fontanelle. So when you apply traction you will actually cause flexion – when you apply traction, you'll cause flexion and therefore present before the vertex which is the smallest part. So that really is what you want to do and the Kiwi cup has markings on it which will determine whether you’re anterior or posterior – if you’re very posterior it will give you a guide as to whether you applied the cap in the right place, but this is only a guide – you've got to be able to feel it and also make sure that you haven't caught any maternal tissue. Generally the vacuum is kinder to mum, but you get less traction, but it has a higher risk of the bleeds so you do need to be very aware of that. My rules with a cup is three pulls – in three pulls if the bub is not out then you're out, and if you slip twice you’re also out.
Forceps - You can see on that slide there the outlet forceps, the mid-cavity and the rotation forceps. My belief is that the high and rotation forceps are going to be used less and less – there is obviously medical legal issues and it's just we are getting less and less training in this and we are using them less and less so it becomes a self-fulfilling prophecy in my opinion that we are going to get less experience and therefore more afraid to use them and they are just falling out of favour. However, the Wrigley’s there on the left is very easy to use, applied correctly. Test your faucets before you try and put them in and then left along the patient's leg and it's fairly easy. I also use that in caesarean section if I have even the slightest problem with getting the baby out or where I have made on purpose a very small incision for cosmetic reasons. So that makes life a lot easier. Next slide.
If I do a rotation, the Kiwi cup actually does a rotation quite well, so if I want to turn my occiput posterior head I use a Kiwi cup, it works quite well, but again it's about training and adequate supervision.
So with a caesarean section, the really important thing is consent. I think this is quite easy for us as GP Obstetricians because generally we will know our patients quite well, we'll have been there with them through a good part of a labour so we will hopefully have spoken to them even before the labor what the options are and we will have the rapport already. So we already know what the indications are, when we are going to stop, and which we are going to go – so that puts us in a really good, much easier, place.
I suggest disimpaction and on the right there the photo shows a fetal pillow. If you haven't seen one, please do look for one. It's basically an elastic balloon that you place posteriorly and right between the coccyx and the baby and inflate about a 180ml with a 60ml syringe that you can see there – 180mls of sterile normal saline and that disimpacts the head. So if you've got a full dilatation, head is firmly attached, all of us who've done a section know how difficult that can be to get that head disimpacted and the old, other way is to get someone to go down vaginally and push the head up. This works a lot better and I think it's a lot less traumatic and it just makes it so much easier.
Other things I would suggest is when opening, please do take your time. Unless it is severe foetal distress you have lots of time to open the skin. Control the bleeding – be meticulous with that. The rectus sheath is a layer that is actually quite limiting, so open that as widely as you can. I find skin is generally quite surprisingly elastic, so that doesn't worry me too much. So a big opening, opening up widely on the inside is probably more important than a big wide incision on the skin. Great respect for tissue is basic for all of us I think. I always try and open the peritoneum as far as proximal ah superior as possible because your risk of injuring gut and blood actually I think that is a lot lower. And if you can try and get to a clear path of peritoneum where you can see what lies behind their bit peritoneum and open it bluntly rather than sharp. Plan your incision. There's no hurry. Make sure you mobilize the bladder as far as you can. Try and go to the superior aspect of the thin membrane as part of the uterus. Obviously closing it in two layers with interlocking. I think evidence shows one layer is that the risk of ruptures increases and if you struggle with controlling hemostasis or closing or if you've got a tear that goes too far south, do deliver the uterus, but please do remember to tell the anaesthetists that's what you're doing because they do get a bit surprised with the bradycardia that often follows so do warn the guy on the other side of the blood-brain barrier. Next slide and Ross.
Dr Ross Wilson: Thanks Ken. Now Lucy manages to deliver but with a bit of a severe blood loss and when you are doing the whole thing you actually did try forceps before you moved to the caesarean. Lucy appears shocked and your anaesthetist friend says it's not just the spinal anaesthetic that's been used and you're obviously faced with a postpartum haemorrhage.
There's a little poem that I use quite frequently to get myself out of trouble. It's just: A B C’s, two IVs an IDC and remember the 4 Ts. So, the initial resuscitation is obviously airway, breathing, circulation. Nobody works without oxygen, particularly women who've just had an operative procedure. Two large-bore intravenous cannulas – get yourself good access. Don't flood them with crystalloids – all you'll be doing is turning what blood they have into pink lemonade and disturbing the coagulation factors as well. The 4 Ts are the crucial thing, and they're obviously tone, tissue, trauma, and thrombin.
Starting with tone, just massage the uterus, even with the abdomen closed – firm uterine massage or even use of bi-manual compression will often induce a degree of tone. During the procedure your anaesthetist mate has probably used an oxytocic of some sort (the common one is syntocinon), and at this stage, if they've had an initial dose, it may well be worthwhile commencing a syntocinon infusion if that's not already done. 40 units in a litre of fluid over four hours is a probably a good idea. You can vary the volumes but around 40 units over four hours is a good dose to start with. There are various other things you can use if you like and we can move to ergometrine if she's not had hypertension. The one warning is that it's very emetogenic, so if you're going to use ergometrine please have a vomit bag some somewhere handy. If you are going to use one of the prostaglandins (and some are used intramyometrially and some are used intravenpusly), remember they have potentially potent side effects and people who've had asthma in particular in the past will experience quite severe bronchospasm, which is very disturbing. The other is the use of misoprostol, popular in some areas and administered either orally or rectally. It gives you late onset, but prolonged uterine contraction, which is very useful and about 800 mg is probably sufficient for the task.
Tissue. Make sure that you've got all the placenta. Make sure that you've got all the membrane. And get somebody to countercheck them with you because the Eye of Faith often leads us to believe that we've got it all when really we've left a cotyledon or two inside the uterus. An empty contracted uterus doesn't bleed. So look for the bits of tissue.
Trauma. Well, we've said that she already has the episiotomy, you've tried forceps, so close that, but in closing it make sure you haven't done any trauma further up the genital tract. Cervixes tear very easily particularly in the use of forceps. They're not kind on cervixes, which have become softened through the labour process.
Posterior vaginal tears. If this has been an OP labor and the head has been coming down well posteriorly in the pelvis, it's not uncommon to have a posterior vaginal wall tear, and unless you look you won't find.
And lastly thrombin. One not to be missed. One of my most memorable postpartum haemorrhages was a girl who'd actually taken it upon herself to be swallowing 12 fish oil tablets a day for the entire duration of the pregnancy and managed to lose over two and a half litres purely and simply due to the anticoagulant effect of the fish oil – so something not to be missed. If the blood that is pooling is clotting, you can be fairly sure. But in any event send blood off at the onset and make sure that you include coagulation studies in that.
So you've got the physical compression of the uterus, you've got the use of the oxytocic of one sort of the other, check for the important tissue that may be missing, look for signs of trauma, and remember thrombin – a small component, but one worthwhile remembering.
Anyhow, Lucy seems to do well and your attentions turn to Bob. Sarah, did you want to talk about neonatal resus or should I?
Dr Sarah Gleeson: I’ll let you do that Ross.
Dr Ross Wilson: Okay, first thing, if this baby comes out somewhat, as we call it, ‘flat’, the first thing to remember is that you are not alone in the world. Ask for help. Get as many people around as you can. You're going to need somebody to maintain observations of mother, maintain observations of her vaginal loss, her general physical condition and continue to make manage that post-partum haemorrhage.
The principles of neonatal resuscitation are simple. Babies need oxygen. Now, it's generally delivered as 21% these days – the old days of delivering 100% oxygen to babies immediately at birth are well past. We are looking after baby’s cerebral circulation and ocular circulation in particular so they need 21%. Babies generally have a healthy heart, but if you can't deliver oxygen to them, they're in strife. So the aim is to get the baby pink and that's by just airway manoeuvres, remembering that the neonatal head is large, very floppy, if you like – their muscle tone is not good, and it's easy to occlude a neonatal airway. So neutral position – the old ‘sniffing the air position’ as it’s described – is important. Don’t kink the head forward or back. Don't extend it too far. The trachea is easily compressed against the spinal column.
You need to keep them moist. You may need to include some intravenous or intraosseous fluids as part of your resuscitation. Babies lose heat very, very quickly. They've got a large surface area for their body weight and convection from that in a cold labour suite, maternity suite, is very, very common, and studies show that they will drop degrees in temperature extremely quickly and that complicates the hypoxia that may be there as a result of their birth. The other thing you need to ensure is that the babies remain with a good blood glucose. They need that for their circulation. They need that for the metabolism. So we're going to have to keep them pink, wet, warm, and sweet.
Airway management is crucial, and using either the NeoPuff, which is the common device on most Resuscitaires now or the good old fashion bag valve mask with the appropriate size facial mask is easily the best way to ensure that there's good oxygenation.
You may need access to veins. They are extremely small, they are extremely fragile, and in a neonate they are easily missed. On several occasions I have found that the intraosseous root is probably the most appropriate and it buys you time, allows you to get some fluid in, and it allows you to at least get an idea of hemoglobin from that tiny bone marrow specimen. And remember, don't put it through an i-STAT. If you’re in a unit that has an i-STAT stay well away from it with that sample that you take from the bone marrow through the intraosseous needle. Intraosseous is now a lot easier – we are now not based entirely with the Cook needle, which is the one that works as a corkscrew into the bone, we've got the EZ-IO which is a little Black & Decker, if you like, to gain access. Make sure you secure the intraosseous well. It's only good for 24 hours at best until you can get time to get intravenous access if you need it, but it's often a life saver.
The last and most final access is obviously an umbilical vein, and I think unless you've done a couple of them it can be an extremely difficult and messy procedure for some people. So at least have a practice and probably the easiest way to practice is to get the midwives to cut you off a length of cord from a normal delivery and go and practice with whatever device you've got for gaining umbilical access and it doesn't take a lot of practice but it's worthwhile doing several times yourself before you try it in anger.
We then sort of have bub recovering which they always do – they’re wonderful little robust animals – and it's worth at that point in time for reassurance for yourself and for the parents to do a quick top to toe examination of the child while you're there. Remember they have to stay warm. Keep them under the radiant heat of the Resuscitaire, wrap them well – bubble wrap is often a good way of wrapping them and you can easily obtain good supplies of bubble wrap (at least in New South Wales) from being sweet with your local post office who will wrap parcels in bubble wrap and are only too happy to part with it if they think of saving a baby's life. So, wrap the baby, keep it warm, and start up the top and work your way south, covering everything as you go. It doesn't need to be a real in-depth examination, but it's most reassuring for yourself, and for the parents in particular, because they've been through a difficult delivery, bub has obviously been through a bit of resuscitation, and to tell them that their baby looks absolutely A1 is one of the most reassuring things you can do for a parent.
The specifics you really need to look at are the heart, the hips, the eyes, and if it's male obviously, the testes. The idea is also, if you've got it available, before the baby leaves the hospital, at least do a pulse oximetry. Good oximetry prior to discharge eliminates 99.9% of any of the congenital heart lesions – even if you can't hear the murmur, if the oximetry is below 90, in an otherwise well-looking baby, you can be sure that that part is going to need checking further on, or at least the lungs are going to need further checking as well. So don't be hesitant – just pop a pulse oximeter on and just make sure you've got to figure probably better than 92.
So, back to mum, and Sarah would you like to take us through mum examination?
Dr Sarah Gleeson: Sure Ross. So it's important for us to be just as thorough with mum. Just because she's had the baby doesn't mean she's out of danger and there's plenty of postpartum complications that can occur – and the list there (all the B’s) is a good way to remember to make sure that we look at all parts of mum, not forgetting all her other usual vital organs so we can make sure that she hasn't developed any complications. So making sure they don't have any headaches, that their blood pressure is okay. Did they have an epidural and do they have a headache related to that? By day four their breasts are expected to get full and tender and the milk coming in – make sure they've got some support from their midwife or lactation consultant in the hospital. Check the fundus every day, make sure it is firm and central. One thing we’re realising now is we want to train postpartum bladder function as well (so there is another B to add to that list) and ensuring that there's been adequate voiding and, if not, being very proactive about insertions and catheters and referrals to physios to ensure good bladder and pelvic floor function. Get onto that early and we can get far better outcomes for our mums.
It is important to keep a close eye on blood pressure and obviously to keep an eye on the connection between mum and baby. Some women can develop a postpartum psychosis very early in their postnatal period so just to see if there's any red flags that are jumping out in relation to that. I do a fair bit of in-hospital postpartum care, but I also see a lot of women for their postnatal checks and, Chantelle if you want to click to the next slide…
So you’ll be familiar with doing a six-week checks. We routinely do 5 to 10 day checks, which I would strongly encourage you to do. I think there's lots of early problems that can spread out at that mark, rather than waiting to see them at the six week mark when the wheels might have fallen off – breast feeding, baby settling and maternal mental health. There's an auto fill which you should see there in the handouts section. This is an auto-fill that I've created and modified over the years and use in my practice and most of my colleagues use – and you’re very welcome to use that and modify that for your own use in practice and make your own autofill. I think it's important to make sure that all the things listed in that document are addressed. Clarify whether this was a natural or IVF conception, what the mode of delivery was, and whether there was any complications, how the mother has recovered from that physically and mentally, specifically listing patient’s concerns and ask them early about the things they’re worried about for them, and then specifically asking them what they might be worried about for the baby. It is important to take a good breast feeding history – I think this is something that unfortunately is poorly taught in general practice. If you want some good online education the Possums online service, which is run by Dr Pamela Douglas, is excellent and it's got some great breastfeeding education.
So it's important to ask how they're feeding their baby. What is the condition of their breasts and nipples? Have they got lumpy, sore breasts? Have they got cracked nipples? Are they bleeding? What's the baby's attachment like? Is it painful to feed or are they having a nice relaxed feed? Are they getting a letdown? Is the baby milk drunk after feeding? It is important to check about what the maternal perception of their milk supply is and whether their breasts feel full initially before a feed. Certainly whether the baby is milk drunk is a nice indicator that the baby is getting enough milk.
Always ask about sleeping and whether they are getting as much as they can. Everyone's always tired. It's always a red flag if someone is tired but can’t get to sleep – you need to worry about postnatal depression and anxiety. It is always important to ask what their supports at home are like and see how things are going. And specifically ask about their mood and how they're enjoying their role as parent. And it is crucial at each postnatal visit to do a postnatal depression score and record that in your notes. It is also crucial to do a domestic violence screen. It is difficult sometimes when partners are in the space and you might have to find a moment when you can catch mum on her own to make sure she feels safe at home and everything is okay. It is also important to talk about drug and alcohol use since the baby has been born.
Obviously then you need to go through and check whether they had any perineal injury, whether that needs to be reviewed, or if they had a caesarean wound that needs checking. Ask about lochia, their PV loss. Whether they're back having intercourse yet and whether that has been problematic for them. And it's really important to ask about their bladder and bowel function and whether they've been doing any pelvic floor exercises and, if they haven't, to strongly encourage them to do that.
A blood pressure check and a weight check is really important yet again. Obviously, there are also the usual things about asking about whether they are up-to-date with their pap smears, what other contraceptive options they’re considered, and just triple-checking about their rubella status, whether they’ve had their Pertussis immunisations, and their blood group. These are just some basic things that I cover at a 5 to 10 day check or six week check.
Now that auto-fill is also stuff that we talk about at our baby check and again just to clarify and recap for the mum as well everything that's happened and whether there are any issues that need to be assessed. So whether the neonatal exam done in hospital was normal, have they had their neonatal screening test done, have they had their hearing test done, have they had their hepatitis B shot and vitamin K. There are examinations like Ross alluded to that should be done before the six week mark. And if you're not sure, get a college to come and have a look or examine the baby as well, or talk to your friendly paediatrician if you need some advice. It is important to get a good handle on weighing babies and handling babies and as you do more it becomes easier.
I think it's always crucial to again just re-clarify about the way the baby is feeding and if their development is appropriate. Have they had lots of wet and dirty nappies, and even questions like did it have some curds in their stool because that'll let us know that there is enough fat in that breast milk that’s getting though the baby’s gut that there’s some left over. And just checking again on their weight percentile to make sure that they are an appropriate weight.
Obviously another thing to check at the time is the interaction between mother and baby and whether there is an appropriate reaction and what their connection is there, and mum’s overall general demeanour and mental health.
So that auto-fill is there so please feel free to use that. I forgot to mention earlier that we also have a letter that we provide patients once we have clarified that they have a wanted pregnancy which summarises all the current guidelines and information we want to make sure that all of our patients receive so that we’re being consistent in our practice, and we would be very happy to share that with the attendees from today as well. We would just appreciate that our service is referenced in that document. What is the next slide Chantelle?
Chantelle: We’re up to questions. So I know Ken has been going through and writing some answers down, but what else have we got Ken?
Dr Ken Wanguhu: Yes. I have answered a few questions, but I think what I'll do is I will try and answer the simple questions and give the more difficult question to Sarah and Ross. We'll start with you Sarah. The first question is what dose of iodine and folate do you give in early pregnancy, for how long, and what for?
Dr Sarah Gleeson: Ideally, women need to be taking those medications or supplements one month prior to conception and ideally for that first trimester and need 150 micrograms of iodine and 500 micrograms of folate unless their BMI is over 30 or they have a family history of spina bifida, in which case they need 5 milligrams of folic acid and the brand of that product is Megafol.
Dr Ken Wanguhu: Thank you. The other question was that you have found out someone has Hep C when you've done the antenatal screening and how would you manage this? I'll say what I would do and Sarah can add to this. I would actually order a Hepatitis C RNA PCR which actually confirms active disease and, from there, I would then be speaking to the liver specialist down at one of the tertiary hospitals to advise me on how to progress from there – Sarah and Ross?
Dr Sarah Gleeson: The only other thing I would add is that there is a really excellent document – the Australian Society for Infectious Diseases has got superb flow charts for management of infectious diseases in pregnancy. I like it because it is idiot proof and I can follow it. I'd strongly recommend everyone having a look at that because that gives you a step-by-step guide on which test you need to do and can also give you some early information to provide to mum to allay concerns about actual transmission risk – that’s something that they’ll often be most worried about. I'm yet to find someone who's got hep C and that it's the first time they've heard that, but I'm sure people around the country might need to bring people their first diagnosis.
Dr Ken Wanguhu: Yes, then and as a nice segue from that, Sarah and Ross and I as well, if we could just provide at least of a references and web pages that we are referring to and the books we are referring to and maybe Chantelle can send them to all the attendees because that's been a question that's been asked.
Chantelle: Yes, we can email that.
Dr Ken Wanguhu: Thank you very much Chantelle. There's also a question about whether dating is routine per RANZCOG and RACGP, and my answer to that is yes, it still is routinely recommended in South Australia but I'm not talking about the whole country, I'm talking about South Australia. I don't know what the rules are in Queensland and New South Wales.
Dr Ross Wilson: Guidelines, but not demanded in New South Wales. Certainly worth doing because you quite often get some surprises as far as menstrual dates are concerned. I thought men were the only ones who had no brains, but sometimes it gets the point, but I think we're all a bit dumb when it comes to dating things.
Dr Ken Wanguhu: Not routine but recommended I think is the best answer. And the best option for gestational diabetes screening in women who have a history of sleeve gastrectomy? Just talking about references in South Australia, we have the perinatal guidelines. If you google PPG SA, you will get the perinatal guidelines and they actually do cover this quite well. You can use, in late pregnancy, HbA1c and a HbA1c of greater than 6.5 would be diagnostic, but you can also just use home testing and I think the number is 5.7 (I'm not sure, don't take that take that under notice) and you can, for patients who've had that gastrectomy, sleeve gastrectomy, you can use finger prick testing – so just capillary testing – and that is also acceptable. For people who have just had a balloon, you can still do GTT.
Could I ask that as I do the next question, Chantelle can you go back to the slides that Sarah talked about that covered the prenatal testing because there have been a few questions about that. So the questions are around what is SMA, which is spinal muscular atrophy, and there have been a few questions about screening. So I was wondering whether you could just discuss what's available in prenatal screening please Sarah, and whether there are times when we can do pre conception screening for hemoglobinopathies for selected patients.
Dr Sarah Gleeson: That’s a good question. So there's a number of private pathology labs like we discussed earlier that are offering preconception carrier screening. You can do carrier screening at any time but obviously having this done prior to pregnancy is preferable. So these are people who have a family history of one of these conditions, or maybe for a higher risk antenatal patient – perhaps an older mother who is considering going down the IVF pathway and wants to know and get a level of reassurance. It obviously can be done once someone is pregnant and that might change their decision making about whether they have an amniocentesis or other further diagnostic testing during pregnancy that may or may not affect their decision making around whether or not they will continue with that pregnancy. This is a private pathology service and my understandings of cost are somewhere in the vicinity of one hundred dollars per person. So the mother would usually be screened, if she's negative then there's no need to screen the partner; if the mother was positive to one of those conditions then the partner will also be screened. In terms of the hemoglobinopathies, I haven't yet come across the situation in the preconception setting, but it’s rare in the patient base we care for, so I might flick bask to Ken and Ross to see if they have more experience in that area.
Dr Ross Wilson: As far as prenatal testing, very few couples, unless they're going strong family history, are requesting it because of the costs. I think in the last 10 years I’ve probably only had two or three couples who requested prenatal testing. There's a lot of increasing interest in non-invasive testing during pregnancy and the cost of between four and six hundred dollars, depending on how extensively you want to test, doesn't seem to deter too many people. There is some argument now as to whether just the screening for the trisomies and sex are the ones that we should be doing and whether we encourage people asking for things like the micro deletions to be more anxious and there's a few false positive test with the micro deletion test and you then obviously need to progress to amniocentesis which has obviously a far higher risk rate of miscarriage. So I think you've got to choose your patient carefully, you've got to counsel well, and you've got to be prepared to provide access to genetic counselling of a fairly sophisticated nature if you're going to do extensive ‘intro’ natal testing if you like.
Dr Ken Wanguhu: Good. There was a question about the biophysical profile, specifically what is AFI – and that's amniotic fluid index, and basically when you do an ultrasound and testing foetal well-being, divide the uterus, the abdomen, into four quarters, assess deepest pool of amniotic fluid, measure the depth in centimeters, note coordinates, and normal is 8-18, ah 1 of 5 is also good, and that is part of it. It’s also combined as you saw in Sarah's presentation with the dopplers, and this is the measuring flow through the uterine arteries which tells us about implantation from the mother’s side – how healthy the placenta is on the mother's side and you're looking at flow and diastole and if you've got a negative flow, that’s a baby that's not doing very well. You also look at the baby's middle cerebral artery flow, which tells you whether the baby is in distress and therefore favouring flow to the brain and basically like all of us will do essential diverting flow to the essential organs which are the brain and the heart. So that's all part of that screening. Sarah, this was your topic – I don't know whether you'd like to add anything else?
Dr Sarah Gleeson: I think that covers all of that Ken, and I would just echo Ross’s comments about how it's just so important to make sure that women who decide to go ahead with either combined first trimester screening and/or other testing that they have had pre-test counseling and to ask them what they would do if they had a high chance result and to consider what they would do in that scenario, otherwise, yes, you can cause a lot of unnecessary anxiety. And it's important to remind women that while it is a test that is taken up by, in my experience probably 95% of the people that I look after, it's certainly not a mandatory test and they can opt to not to have it.
Dr Ken Wanguhu: And the other question, again Sarah to you, was when should aspirin and calcium be started and stopped in pregnancy for a lady at high risk of preeclampsia?
Dr Sarah Gleeson: Normally, we recommend it be started before 16 weeks ideally, so I would still, myself, usually be touching base with one of the obstetric positions or MFM specialists just to triple check that they're a good candidate for that, and then usually the aspirin is ceased even just a couple of weeks before term, depending on the unit (because different units will do different things). But usually to at least 37 weeks.
Chantelle: Okay. Well, unfortunately we have run out of time. So was there anything that any of our presenters today wanted to leave our participants with? Any final messages?
Dr Sarah Gleeson: I just think it's important for all GPs, whether you’ve got a special skill in Obstetrics or not, to be really passionate about antenatal care. You know, it’s looking after half of our population at some point, and I think that opportunity to participate in really excellent preconception care is just a really excellent spend of your time and public health dollars. So get passionate about it and get your women fit and healthy before they get pregnant.
Dr Ross Wilson: My message would be that obstetrics is one of the areas of greatest joy in general practice, both the antenatal, intrapartum, and postpartum care. So enjoy it yourselves and enjoy it for your patient.
Dr Ken Wanguhu: I don't think I can add anything. That said, I do enjoy it. It can be a bit scary at times, but you do find there's lots of supports and do not be afraid to seek help, even with what you consider to be fairly basic stuff. Ask, and talk to your colleagues, there is always someone that is willing to help.
There have been a lot of really good questions that we've not got into so I think we will be trying to answer them and send them out in an email – I will ask Chantelle to send out an email with answers to these questions next week. Thank you.
Chantelle: Well, thank you Dr Ross Wilson, Dr Ken Wanguhu and Dr Sarah Gleason and thank you to all of our attendees for joining us this evening. Just a reminder to complete the evaluation form that will pop up in a new window in just a moment once this webinar session closes. It'll take no more than a minute to complete. And also certificates of attendance will become available on your QI& CPD statements within the next few days, but for any non RACGP members who would like a certificate of attendance, please email email@example.com. Thank you and good night.