ALSO Asia Pacific Limited 2nd Edition 2013 PDF
Preview ALSO Asia Pacific Limited 2nd Edition 2013
Advanced Life Support in Obstetrics ALSO Asia Pacific Limited 2nd Edition 2013 ALSO Asia Pacific 2nd Edition (2013) 1 ALSO® Course Syllabus Advanced Life Support in Obstetrics (ALSO Asia Pacific Limited) 2nd Edition 2013 The ALSO® course originated in the USA in 1991, and the copyright is owned by the American Academy of Family Physicians (AAFP). The ALSO course has been adapted to meet the needs of thousands of practitioners across the world, from the UK to Haiti, Canada to Nepal. In January 2001, the first group of ALSO instructors for the region was trained in Canberra. Since then, over 100 courses have been held in Australia and New Zealand, teaching more than 6,000 maternity care professionals. ALSO Asia Pacific Ltd has also conducted ALSO courses in Fiji, Samoa and on the Thai‐Burmese border. The philosophy behind ALSO is that women and their families will benefit from the standardised, multidisciplinary approach to maternity care demonstrated during the course. The ALSO course is not aligned with any one professional institution, and is run in Australia by ALSO (Asia Pacific Ltd). ALSO Asia Pacific Ltd is a not‐for‐profit organisation. It is run by a seven‐person Board who are all volunteers. The members of the instructor Faculty are also all volunteers. The Board and the Faculty have assisted in updating the contents of this course. All maternity practitioners know that there are many safe and acceptable ways of dealing with different emergency situations. The procedures and approaches covered in the ALSO course are reasonable, consistent and evidence‐based and enable everyone to not only identify those at risk of obstetric emergencies but also to manage emergencies when they arise. The content of this course is a guide only. Practitioners should consider local governance and guidelines when incorporating the material into their professional practice. The course has been accredited for points for continuing professional development by the Royal Australian and New Zealand College of Obstetrician and Gynaecologists, the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the Australian College of Midwives. Completion of the ALSO course does not license participants to practice beyond the scope defined by their relevant registration boards and professional bodies. In 2006 the ALSO Asia Pacific manual was updated to create the first edited version of the ALSO Asia Pacific Manual. In 2012‐2013, a major revision of the manual and course materials was undertaken by a team including a Project Officer, the ALSO Asia Pacific Board and a number of the ALSO Asia Pacific Faculty. ALSO Asia Pacific 2nd Edition (2013) 2 Disclaimer The Board and Faculty of ALSO Asia Pacific have made considerable efforts to ensure that the content of the course is accurate and up to date. Users of the information presented in the course are strongly recommended to consult independent sources and local resources, for confirmation, particularly in regard to drug dosages. The Board and Faculty accept no responsibility for any inaccuracies, information perceived as misleading, or the outcomes of using any management strategies that are presented in the course. Working Party members who contributed to the Second Edition of the ALSO Asia Pacific Manual Name Discipline Qualifications (in alphabetical order) Andrew Bisits Obstetrician MBBS FRANZCOG Helen Cooke Midwife RM BHScMan MNRes Caroline Homer Midwife RM MMedSc(ClinEpi) MN PhD Moyra Lewis Midwife RM MMid James Lie GP Obstetrician MBBS FACRRM Teoni McHale Midwife RM RN MSc Kirsten Small Obstetrician and Project Officer MBBS FRANZCOG Anne Sneddon Obstetrician MBBS FRANZCOG Thank you to the ALSO Asia Pacific Faculty members who reviewed the whole manual: Alison Goodfellow RN RM BNurs MHlthMg Mark Marshall MBBS DRANZCOG FACRRM FRACGP Grad Dip Rural GP FARGP Fiona M Simpson RM CME Lucy Little MLM (Simulation & Technology) BSc (Hons) Midwifery, DipHE RN Editor Neil Clements ALSO Asia Pacific Board Anne Sneddon, Moyra Lewis, James Lie, Helen Cooke, Andrew Bisits, Patty Salisbury (2009 ‐ 2012), Kevin Stanton (from 2013), Caroline Homer ALSO Asia Pacific 2nd Edition (2013) 3 Contact details ALSO Asia Pacific Ltd, c/o Mayhem Corporation Pty Ltd ABN: 86 092 862 229 Address: Level 1, 4 ‐ 6 Park Lane, Caringbah NSW 2229 Phone: (02) 9531 5655 Fax: (02) 8209 4949 Recommended citation: ALSO Asia Pacific (2013) Advanced Life Support in Obstetrics Course Manual. 2nd Edition. ALSO Asia Pacific Ltd, Sydney. Revision endorsed by the ALSO Asia Pacific Board 13 March 2013 Minor alterations made as a result of small errors and inconsistancies being corrected since initial publication. Current version: 15 September 2013 ALSO Asia Pacific 2nd Edition (2013) 4 ADVANCED LIFE SUPPORT IN OBSTETRICS COURSE SATURDAY TIMETABLE TIME LECTURES/WORKSTATIONS ALLOTTED TIME 7:30 – 8:00 Registration 30 minutes 8:00 – 8:15 Welcome 15 Minutes Course Introduction & Layout Instructors’ Introduction 8:15 – 8:35 Safety in Maternity Care 20 minutes 8:35 – 9:50 WORKSTATIONS 1 75 minutes Fetal Monitoring – Group A & B Red Group Assisted Vaginal Birth Blue Group Maternity Cases A – Group 1 & 2 Yellow Group 9:50 – 10:10 Labour Dystocia 20 minutes 10:10 – 10:30 MORNING TEA 20 minutes 10:30 – 11:45 WORKSTATIONS 1 75 minutes Fetal Monitoring – Group A & B Yellow Group Assisted Vaginal Birth Red Group Maternity Cases A – Group 1 & 2 Blue Group 11:45 – 1:00 WORKSTATIONS 1 75 minutes Fetal Monitoring – Group A & B Blue Group Assisted Vaginal Birth Yellow Group Maternity Cases A – Group 1 & 2 Red Group 1:00 – 1:50 LUNCH 50 minutes 1:50 – 2:55 WORKSTATIONS 2 65 minutes PPH & Maternal Resuscitation Red Group Shoulder Dystocia Blue Group Maternity Cases B – Group 1 & 2 Yellow Group 2:55 – 4:00 WORKSTATIONS 2 65 minutes PPH & Maternal Resuscitation Yellow Group Shoulder Dystocia Red Group Maternity Cases B – Group 1 & 2 Blue Group 4:00 – 4:20 AFTERNOON TEA 20 minutes 4:20 – 5:25 WORKSTATIONS 2 65 minutes PPH & Maternal Resuscitation Blue Group Shoulder Dystocia Yellow Group Maternity Cases B – Group 1 & 2 Red Group 5:25 – 5:30 Assemble in main lecture room 5 minutes All participants & 7:00 – 10:30 Course Dinner Instructors ALSO Asia Pacific 2nd Edition (2013) 5 ADVANCED LIFE SUPPORT IN OBSTETRICS COURSE SUNDAY TIMETABLE TIME LECTURES/WORKSTATIONS ALLOTTED TIME 8:00 – 8:05 Housekeeping & Announcements 5 minutes 8:05 – 9:05 WORKSTATIONS 3 60 minutes Neonatal Resuscitation Red Group Malpresentation Blue Group Maternity Cases C – Group 1 & 2 Yellow Group 9:05 – 10.05 WORKSTATIONS 3 60 minutes Neonatal Resuscitation Yellow Group Malpresentation Red Group Maternity Cases C – Group 1 & 2 Blue Group 10.05 – 10.25 MORNING TEA 20 minutes 10.25 – 11.25 WORKSTATIONS 3 60 minutes Neonatal Resuscitation Blue Group Malpresentation Yellow Group Maternity Cases C – Group 1 & 2 Red Group 11:25 – 11:45 Birth Crisis 20 minutes 11:45 – 12.30 WORKSTATION REVIEW SESSION 60 minutes Shoulder Dystocia Participants self–select and practice Assisted Vaginal Birth those subjects they feel Malpresentations the need to Neonatal Resuscitation revise/practice 12.30 – 1:00 LUNCH 30 minutes 1:00 – 3.30 WRITTEN EXAM 60 minutes for the Written exam and 15 minutes per participant for the PRACTICAL EXAMINATION Practical exam 3.00 – 4.00 AFTERNOON TEA 60 minutes On Completion Assemble in area advised away from the exam room to allow Wait for all to finish exam all to finish the exam in a quiet atmosphere. Approx 4:00 Debriefing & Examination Results Questions and discussion 30 minutes about the Course. ALSO Asia Pacific 2nd Edition (2013) 6 Advanced Life Support in Obstetrics® ALSO Asia Pacific Limited 2nd Edition 2013 Introduction A. First Trimester Pregnancy Complications B. Medical Complications of Pregnancy C. Vaginal Bleeding in Late Pregnancy D. Preterm Birth E. Intrapartum Fetal Monitoring F. Labour Dystocia G. Malpresentations, Malpositions and Multiple Gestation H. Assisted Vaginal Birth I. Shoulder Dystocia J. Postpartum Haemorrhage K. Maternal Resuscitation and Trauma L. Safety in Maternity Care, including working with Aboriginal and Torres Strait Islander Women M. Severe Perineal Trauma N. Diagnostic Ultrasound in Labour and Birth O. Neonatal Resuscitation P. Caesarean Section Q. Birth Crisis ALSO Asia Pacific 2nd Edition (2013) 7 ALSO Asia Pacific 2nd Edition (2013) 8 A: First Trimester Pregnancy Complications Original chapter by Mark Deutchman, MD, Steve Eisinger, MD, Mike Kelber, MD Revised in 2013 for ALSO Asia Pacific by Kirsten Small, MBBS, FRANZCOG and Anne Sneddon MBBS FRANCOG Objectives At the end of this chapter participants will be able to: 1. relate ßhCG levels to the progression of normal and abnormal pregnancy in the first trimester 2. describe the diagnostic capabilities and limitations of ultrasonography in the first trimester of pregnancy 3. describe the pathophysiology, diagnosis and management of miscarriage 4. describe the pathophysiology, diagnosis and management of ectopic pregnancy 5. describe the pathophysiology, diagnosis and management of gestational trophoblastic disease 6. describe the spectrum of psychological reactions to early pregnancy loss, and early interventions that may reduce long-term sequelae. Introduction Complications of the first trimester of pregnancy are common. 25% of women report vaginal bleeding in the first trimester of pregnancy [1]. 8 to 15% of recognised pregnancies miscarry, with the majority of these losses occurring in the first trimester [2, 3]. In addition to miscarriage, bleeding in the first trimester can herald ectopic pregnancy, trophoblastic disease and non-obstetric conditions such as cervical bleeding from polyps, a friable cervix, trauma or cervical cancer. This chapter reviews the normal progress of the first trimester of pregnancy as revealed by laboratory and sonographic findings, and then explains the diagnosis and management of miscarriage, ectopic pregnancy and trophoblastic disease. Laboratory parameters of normal first trimester Pregnancy can be confirmed by the presence of the beta subunit of the human chorionic gonadotropin (ßhCG) molecule in either urine or serum. Serum quantitative ßhCG levels rise rapidly in the first trimester of normally progressing pregnancies and are therefore correlated to gestational A: First Trimester Pregnancy Complications 1 age [4]. At least two measurements of ßhCG taken two to three days apart can help determine if a pregnancy is progressing normally. Quantitative ßhCG usually doubles every two to three days during weeks four to eight in normal early pregnancy. Falling or plateauing levels are suggestive (though not conclusive) of impending poor outcome but do not distinguish between spontaneous miscarriage and ectopic pregnancy. Multiple pregnancy produces higher levels of ßhCG for the same gestational age, and some researchers have noted higher ßhCG levels in pregnancies conceived with the use of Assisted Reproductive Technology (ART) [5]. The addition of ultrasound examination to ßhCG determination gives the most information about the status of the pregnancy. Improvements in ultrasound technology, and the use of transvaginal ultrasound scanning has enabled visualisation of the gestational sac at levels now around 1,500 MIU/mL [6]. There is substantial variability between quantitative ßhCG levels from one occasion to the next, and particularly from one laboratory to the next. Using the same laboratory when serial levels are being monitored is therefore advisable [7]. Progesterone levels can also help predict pregnancy outcome in the first eight weeks of gestation although are not commonly used. In contrast to ßhCG levels which rise rapidly in the early stages of normal pregnancy, serum progesterone levels remain relatively constant during the first nine to 10 weeks of gestation [8]. Unlike ßhCG, a single progesterone level in early pregnancy helps predict outcome. Progesterone levels less than 45 nmol/L are more likely to be associated with a nonviable pregnancy, but higher levels do not exclude ectopic pregnancy [9, 10]. In areas where ultrasound is not readily available and the turnaround time for ßhCG makes serial testing impractical, a serum progesterone level may provide reassurance that the pregnancy is proceeding normally. Ultrasonography in early pregnancy Routine ultrasound in early pregnancy enables more accurate gestational age assessment (thereby reducing the incidence of labour induction for post-dates), earlier detection of multiple pregnancies and earlier detection of fetal malformations [11]. First trimester ultrasonography is most useful when done in combination with knowledge of the woman’s history, physical examination and serum ßhCG. Availability of both transabdominal and transvaginal ultrasounds provides the greatest opportunity to make a definitive diagnosis for the woman. Chapter N: Diagnostic Ultrasound in Labour and Birth describes the technique of transvaginal scanning. Sonographic findings of normal pregnancy Between the fifth and seventh menstrual weeks of pregnancy, transvaginal ultrasound scanning will reveal the gestational sac, yolk sac and embryo in that order. At a ßhCG level of > 1,500 mIU/ml a transvaginal scan will demonstrate an intrauterine gestation sac in 91% of women [12]. When first visible during the fifth week, the gestational sac appears empty. Some features of early, normal gestational sacs are: 1. round shape 2. location in uterine fundus 3. echogenic ‘ring’ surrounding the sac. During the sixth menstrual week the yolk sac appears. It is an echogenic, round structure within the gestational sac. Since the yolk sac is a fetal structure, its appearance confirms intrauterine pregnancy A: First Trimester Pregnancy Complications 2
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