What are the fundamentals of learning basic obstetrics?

Fundamentals of Basic Obstetrics

Learning basic obstetrics requires mastering key physiological changes during pregnancy, understanding risk assessment, developing procedural skills for normal and complicated deliveries, and implementing evidence-based preventive care.

Physiological Changes in Pregnancy

• Pregnancy causes significant anatomical and physiological adaptations affecting multiple maternal organ systems, including cardiovascular, respiratory, and endocrine systems 1, 2
• The mucosa of the upper respiratory tract becomes more vascular and edematous during pregnancy, leading to increased risk of airway bleeding and swelling, resulting in progressively increasing Mallampati scores as pregnancy progresses 1
• Decreased functional residual capacity and increased oxygen requirements accelerate the onset of desaturation during apnea, particularly problematic in obese parturients 1
• Progesterone reduces lower esophageal sphincter tone, resulting in gastric reflux, while painful labor and opioid administration delay gastric emptying 1
• These physiological changes create unique challenges for airway management during obstetric emergencies 1

Risk Assessment and Care Levels

• Maternal cases should be categorized according to a four-level maternal care classification system: basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV) 2
• Every pregnant woman should undergo comprehensive airway assessment to predict possible difficulties with tracheal intubation, mask ventilation, or supraglottic airway device insertion 1
• Women predicted to have significant airway difficulties should be referred antenatally for formulation of a specific anesthetic and obstetric management plan 1
• Risk assessment should include evaluation of pre-existing medical conditions, obstetric history, and current pregnancy complications 2

Procedural Skills and Emergency Management

• Mastery of airway management techniques is essential, as the majority of obstetric difficult and failed intubations occur during emergencies and outside regular hours 1
• Practitioners should develop a preformulated strategy for managing difficult intubations, including the use of laryngeal mask airways or other supraglottic airway devices when tracheal intubation fails 1
• In cases of cardiac arrest during labor and delivery, standard resuscitative measures should be initiated with uterine displacement (usually left displacement) maintained 1
• If maternal circulation is not restored within 4 minutes of cardiac arrest, cesarean delivery should be performed by the obstetrics team 1

Preventive Care and Patient Education

• Antacid prophylaxis is crucial before surgical procedures, with recommendations for non-particulate antacids, H₂ receptor antagonists, and/or metoclopramide 1
• Patient education about obstetric danger signs is essential, as awareness is the first step in accepting appropriate and timely referral to obstetric care 3
• Studies show low levels of knowledge about obstetric danger signs among women in some regions, with only 31.9% knowing at least three key danger signs during pregnancy 3
• Antenatal care attendance significantly improves knowledge of obstetric danger signs, with women who attend ANC being 2.56 times more likely to recognize danger signs during pregnancy 3

Documentation and Communication

• Comprehensive documentation is essential for all levels of obstetric care, with increasing detail required for higher-risk pregnancies 2
• Documentation should include demographic information, comprehensive medical history, obstetric history, and current pregnancy details 2
• For high-risk cases, documentation of multidisciplinary planning involving obstetrics, anesthesiology, and relevant subspecialties is crucial 2
• Clear communication between team members is vital, especially during emergencies when time pressure may affect preparation, planning, and performance 1

Evolving Practice and Training

• There has been a decline in obstetric general anesthetics in developed countries as regional anesthesia has become more popular, resulting in reduced training opportunities 1
• Trainees may begin obstetric on-call duties without having performed or observed a general anesthetic in an obstetric patient 1
• The concept of obstetric medicine has re-emerged in recent decades as maternal morbidity and mortality increasingly stem from pre-existing medical disorders and preventable medical complications of pregnancy 4
• Understanding the anatomical changes during pregnancy is essential for performing procedures such as episiotomies and repairing perineal lacerations 5, 6

Infection Control and Prevention

• Infectious agents are associated with a wide range of obstetric complications affecting the placenta, membranes, and fetus 7
• Two major infection mechanisms are associated with significant perinatal morbidity: ascending genital tract infections (bacterial) and hematogenous spread of maternal systemic infections 7
• Specific preventive measures should be implemented for infections like toxoplasmosis, including avoiding undercooked meat, unpasteurized milk, and contact with cat feces 1

Human factors play a significant role in decision-making, task management, and communication during critical obstetric situations, with fixation error being a specific concern during airway emergencies 1. Mastering these fundamentals will provide a solid foundation for obstetric practice and improve maternal and fetal outcomes.