Flujo de Llegada de pasajeros Internacionales

Assessment of whether a woman is in labour is not always straightforward. A VE may help, but is con­

traindicated if there is painless loss of blood and/or it is known that the patient has a low­lying placenta;

potentially dangerous blood loss can occur if a VE disturbs a low­lying placenta.

Vaginal examination in labour should always be preceded by an abdominal examination as described above, together with observation of any contractions, their intensity, frequency, length of time and whether and how much pain they provoke. The VE aims to answer the questions listed in Box 5.7.

The Bishop score is an amalgam of the these findings (excepting the presenting part) at VE and is used to determine whether a woman is in labour. A low score is indicative of an ‘unfavourable cervix’ (firm, posterior, long, closed cervix with a high presenting part). In contrast, a ‘favourable cervix’ is one which is associated with an efficient labour – anterior (easy to reach), soft, open, thinned, with a low presenting part.

By repeating abdominal and vaginal examinations at intervals, the diagnosis and progression of labour can be ascertained. Vaginal examination is a potential introduction of infection and can be unpleasant and uncomfortable, so it is usual to not perform this more frequently than every 4 hours. Once labour is estab­

lished (i.e. the cervix is fully effaced and dilated at

Box 5.7 Reasons for vaginal examination in suspected or actual labour

■ Is the cervix anterior, mid position or posterior?

■ What is the consistency of the cervix – hard, firm or soft?

■ Is the cervix dilated?

■ Is the cervix effaced (thinned)?

■ What is the presenting part? Assuming a head/cephalic presentation, is the presenting part a vertex (posterior fontanelle palpable through the cervical os), a deflexed head (anterior fontanelle palpable) or, unusually, a brow (supraorbital ridges palpable) or face (mentum or chin)?

■ What is the station? The station is the relationship in centimetres between the dominator as above and the ischial spine of the pelvis and is measured in

centimetres above or below the spines – thus the depth of the presenting part is low when the tip of the presenting part is 2 or 3 cm below the spines.

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Cervical length can be measured, giving an indication of risk of possible late miscarriage or early premature labour. Fetal anatomy surveillance can be carried out using ultrasound from 18 weeks, and if indicated this can include fetal echocardiography. By 20 weeks, uterine and placental blood flow can be assessed in the form of a uterine artery Doppler test, which can help predict risk of fetal growth restriction and pre­

eclampsia. Ultrasound scans in the second and third trimester can be used to measure fetal growth velocity, amniotic fluid volumes, and Doppler examination of blood flow through fetal arteries can be used to ascertain fetal wellbeing.

In gynaecology, ultrasound is useful in the diagnosis of uterine and ovarian pathology and in the assessment of bladder function, by measuring residual urine volume and bladder neck activity. It is also helpful in the preoperative preparation for repair of anal sphincter damage.

Computed tomography and magnetic resonance imaging

Computed tomography (CT) scanning has proved less useful in gynaecology than was originally antici­

pated and is now used mainly for staging and follow­up of malignancies. Magnetic resonance imaging, where available, is a better option (see Fig. 5.9). It does not use ionizing radiation and is particularly good at staging gynaecological malignancies.

Hysterosalpingography

Imaging the uterine cavity and Fallopian tubes with X­ray hysterosalpingography (Fig. 5.16) has largely been replaced by the contemporary technique of hysterosonography (hysterosalpingo contrast sonog­

raphy, HyCoSy), in which the flow of saline or galactose microparticles through the tubes and uterus is visualized with a vaginal ultrasound probe, thereby avoiding exposure to radiation.

Endometrial sampling (biopsy)

Sampling of the endometrium is often diagnostically useful (Fig. 5.17). An adequate representative sample Figure 5.14 Ultrasound scan for early dating.

Figure 5.16 An abnormal X-ray hysterosalpingogram: uteri didelphys (double uterus).

Figure 5.15 An ultrasound image with shading which gives an impression of three dimensions. Its use scientifically is not yet determined, but patients love it for the view it gives of their babies.

Imaging

Ultrasound

Transabdominal ultrasound enables a wide field of view, greater depth of penetration and transducer movement. Transvaginal ultrasound, with higher frequency transducers, gives increased resolution and diagnostic power but over a more limited area. More recently, 3­D scanners have been introduced, and these give improved image quality.

In obstetrics, the integrity, location and the number of gestation sacs can be viewed in early pregnancy.

By 11 to13 weeks, mono­ or dichorionicity, nuchal translucency, nasal bone development and gross fetal abnormality can be detected (Figs 5.14 and 5.15).

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bladder volume are recorded. Electromyographic (EMG) activity in the external urethral sphincter and/or real­time ultrasound assessment of bladder neck activity and descent may provide further informa­

tion. In stress incontinence, urinary flow commences at low bladder pressures because of sphincter incompetence; in urge incontinence, urinary flow develops at low bladder volumes because of unin­

hibited detrusor activity. Reflux and overflow also show as urethral leakage. Incontinence can also result from a defect in the anatomical integrity of the urinary tract, such as a congenital abnormality or fistula.

Viewing the interior of the bladder by cystoscopy gives information about its condition and allows biopsy of the mucosa or the removal of foreign bodies.

Figure 5.17 An endometrial biopsy curette, a pipette cell sampler and fixing medium.

Figure 5.18 Hysteroscopic view of an intrauterine device in situ.

Figure 5.19 Hysteroscopic view of submucosal fibroids.

of endometrium can be obtained using a Vibra or Pipelle sampling system in the outpatient setting.

The definitive assessment of the endometrium is usually by hysteroscopy and directed biopsy. With current miniature fibreoptic systems, this can be done under local analgesia in an outpatient setting.

Colposcopy

Colposcopy permits visualization of the cervix, the vaginal vault (vaginoscopy) or vulva (vulvoscopy) with an illuminated binocular microscope to detect precancerous abnormalities of the epithelium. It can be undertaken on an outpatient basis, by accessing the cervix with a speculum, treating it first with acetic acid then with Lugol’s iodine. This aqueous solution of iodine and potassium iodide causes the cervix and the normal mucous membrane, which contain glycogen, to stain dark brown. Those areas of abnormality that fail to take up the stain can then be identified (Schiller’s test). The whole cervix is viewed through a colposcope, which gives binocular magnification, to identify the degree, site and extent of the cervical pathology.

Hysteroscopy

In this technique, the cavity of the uterus is viewed using small­diameter fibreoptic instruments (Fig.

5.18). Diagnostic hysteroscopy using a 4­mm hys­

teroscope can be performed as both an inpatient and an outpatient procedure for disorders such as abnormal bleeding and subfertility. This technique can also be adapted with larger hysteroscopes to be used operatively for the resection of uterine adhesions, polyps, septae, submucous fibroids (Fig. 5.19) and endometrium.

Cystoscopy and cystometry

The pressure/volume relationships of bladder filling, detrusor and sphincter activity and urethral flow rate can be assessed with a cystometrogram. The bladder is catheterized and slowly filled with sterile saline.

The volume and pressure at which bladder filling is perceived, and at which a desire to micturate is felt, are noted. The urinary flow rate and postmicturition

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a predictable way with gestation. For example, at 16 weeks’ gestation, increased levels of AFP suggest fetal spina bifida or anencephaly. However, similar levels can be caused by several other conditions, including threatened miscarriage, multiple pregnancy and exomphalos. Decreased levels are associated with Down’s syndrome. A computed risk of Down’s syndrome can be produced from maternal weight, gestation, parity and race, measured against βhCG and unconjugated oestriol, and the results matched against ultrasound findings. The ‘integrated test’ for Down’s syndrome predicts a risk ratio that depends on such a comparison. Alternatively the ‘combined test’ uses the same information plus fetal nuchal translucency at 11 to 13 weeks’ gestation.

Late pregnancy

Fetal health in labour can be estimated by checking for the presence of meconium, the responsiveness of the fetal heart rate and by counting fetal movements.

In addition to these simple clinical tests, fetal pH measured on a scalp blood sample can be used to detect acidosis and is particularly useful if labour is prolonged, complicated or known to be high risk.

Once the membranes are ruptured, the fetal scalp is displayed using an amnioscope and a small sample of capillary blood obtained from a puncture site. If the pH of the sample is below 7.2 then delivery is an urgent priority.