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Obstetrics FOAMed

I gave up obstetrics last year and have moved to the head end (GP-anaesthetics). To be honest I have not seen a huge amount of new FOAMed material relevant to GP-obstetrics, but this may reflect my own cognitive bias.

Asking the question of a practicing obstetric colleague “what’s new in obstetrics?” was met with a wry smile and the comment “babies still get made in the same way and come out the same hole(s)”

If you have any relevant FOAMed for sharing amongst rural brethren, please let me know so can be posted here.

Two topics that I think still cause some controversy are those of timing of antibiotics pre-LSCS and dose of oxytocin to give at delivery.

Timing of antibiotic dosing for LSCS

Standard teaching used to be to wait until baby was delivered before giving maternal antibiotics during LSCS “in case of anaphylaxis”. Certainly this was still being promulgated when I was doing an anaesthetic refresher back in 2011. Yet this is surly muddled thinking – if we are giving antibiotics to prevent maternal infection post-op, it needs to be given before knife-to-skin. The concern has been not just anaphylaxis, but also neonatal necrotising enterocolitis. This does not appear to be borne out in studies and indeed perinatal guidelines indicate that antibiotics be given 30 mins before knife-to-skin. See this link for details.

Do you do this? Or does it depend on the obstetrician/anaesthetist/day of the week/whether you remember?

Use of a LSCS checklist may help.

Cephalosporins safe with penicillin allergy? Depends on side-chain

Leading on from this, would you give a cephalosporin to a patient noted to be ‘allergic to penicillin’? Some recent evidence that the oft-cited 10% cross-reactivity between pencillins and cephalosporins is a fallacy. Cephalosporins with a different side chain to beta-lactams appear safe (ceftriaxone OK, cefazolin/cephalothin/cephalexin maybe not). Read the evidence in this article and decide for yourself.

What dose of oxytocin?

“Is the synto in yet?” asks the obstetrician. “What dose do you want?” replies the obstetrician. Surely this could be decided beforehand, with an agreed escalation if there is abnormal bleeding…

The BJA suggests that TWO units of oxytocin is optimal. That’s from the anaesthetic end. What do the obstetrician’s think?

Of course if there is an ongoing PPH, follow accepted guidelines, backed up by evidence eg: BestBETS - a synto infusion is way to go…

Obstetric Nightmares

Dr Jo Deverill blogged this lovely piece on obstetric nightmares for the ED doc – relevant to GP-obstetricians as well!

Managing First Trimester Bleeding

Excellent podcast from BroomeDocs

Managing late pregnancy bleeding

Another great case from Dr Casey Parker and colleagues at BroomeDocs.com

http://broomedocs.com/2013/05/big-belly-baby-bleed/

Management of PCOS

Check out this useful presentation from Penny Wilson (@nomadicgp) on PCOS

Management of Dysmenorrhoea

Another useful presentation from Penny Wilson as part of the BroomeDocs podcast

The Pap Smear Podcast

BroomeDocs admits he is not much of a dab hand with the speculum – so goes in search of some top tips n tricks from colleagues – listen to “the Pap Smear Podcast


3 Comments

  1. mark raines says:

    What dose of oxytocin?

    I don’t recall ever asking for anything other an “oxytocin infusion 10 units per hours please kind anaesthetic person” at caesarean section.

  2. KIdocs.org says:

    …ah yes, but we give some synto with delivery of the head as a bolus…then an infusion.

    So – a bolus of 2 units? 3-5 units? 10 units?

    I given 2 for elective LSCS, 3 for emLSCS

    Then proceed to 10U/hr infusion…or do we even need to unless uterine atony and PPH?

  3. rain0021 says:

    Obstetric Nightmares!

    Obviously the producers of that BBC programme never read the ALSO manual!

    Let me be critical they were actors afterall………..

    - Sure they got help

    - 30 second blocks of interventions is recommended but they get excited affecting their temporal awareness

    - Those mother’s knees weren’t to nipples.

    - An episiotomy wound bloody difficult with a head in the way

    - There was too much camera jiggly to see if there was effective use of Rubin’s, Woods and reverse Woods but it did look like the second dud only had his fingers inside the vagina – you need the whole hand!

    - There was no Gaskin or onto all fours attempted

    - Clavicles fracture – well its on the list. I have seen a couple and the baby heals well

    - Zavanelli before symphysiotomy. In a remote setting I would do a symphysiotomy if all else failed knowing it would be at least 30 minutes before I could get to OT. I have to admit I have done neither. Should you do the Zavanelli in the birth room or the OT? If the baby is going to die from cord or neck compression then I think doing in the birth room buys time. Tocolysis (GTN, salbutamol) would be needed whilst awaiting your OT.

    I see however that maybe talking about a symphisiotomy may not be politically correct in Ireland at present.

    http://www.thejournal.ie/survivors-of-symphysiotomy/news/

    https://www.facebook.com/pages/SoS-Survivors-of-Symphysiotomy/173631906029192

    However, a Cochrane review is supportive depending on the environment and context

    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005299.pub3/full

    - I am absolutely certain that baby would not have cried 10 seconds after being delivered with a mask barely over its face!! from ALSO “a head-shoulder delivery interval threshold of seven minutes had a sensitivity and specificity of 67% and 74%, respectively, in predicting brain injury”

    Some thoughts Tim

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About

Http://about.me/timleeuwenburg

Http://about.me/timleeuwenburg

I am a Rural Doctor on Kangaroo Island, South Australia with interests in EM, Anaes & Trauma. Currently working with MedSTAR Retrieval, SA. Avid user & creator of #FOAMed; EMST & ATLS Director, Instruct on ETMcourse.com. My sites include KIdocs.org & RuralDoctors.Net, affiliated with smaccUs in Chicago 2015 Opinions expressed on these sites must not be used to make decisions about individual health related matters or clinical care as medical details vary from one case to another. Reader is responsible for checking information inc drug doses etc.

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