Births Flashcards
Uncomplicated childbirth
Spontaneous vaginal birth in vertex position between 37 and 42+0 weeks gestation
Precipitous birth
Birth of a newborn within less than 3 hours of commencement of regular contractions.
Primips
Presenting part visible during and between contractions, bearing down, strong contractions 2-3 min apart
Multips
Strong contractions 5 min apart or less, urge to push, bloody show.
Imminent delivery
Presenting part visible at the perineum. Primips Multips Offer calm reassurance to pt and family Optimize safety, ease of access, mobility
Mechanisms of labour’s and birth
Decent - fetus moves down
Flexion - fetal chin to chest
Internal rotation - back of fetal head turns to front of pelvis
Extension - birth of head
Restitution - baby’s head rotates to the side
Expulsion - birth
Preparing for delivery
- Assist patient to firm flat surface
- Pt Supine, head raised, legs flexed, adducted at hips and knees, perineum visible
- Provide warmth and privacy
- Wash hands, put on sterile gloves, place sheet and sterile drape under buttocks
- Ensure adequate lighting
What do you do during crowning?
Guard the perineum
Prevent rapid delivery of head
Encourage pt to pant
Once head born, assess for nuchal cord
What do you do during normal birth?
Await restitution after birth of head
Next contraction deliver anterior shoulder, then posterior shoulder and rest of body
Provide warmth, skin to skin, dry and stimulate baby, assess transition
Where do you clamp the cord?
Approx. 15cm from newborns abdomen, place 2 clamps a few cm apart, cut between
How long do you wait before clamping and cutting the cord?
2-3 min or once cord stops pulsing.
How long after birth of baby before placenta delivers?
5-30 min after birth
What are signs of placental separation?
Sudden small gush/trickle of blood from vagina
Umbilical cord lengthening
Uterine contraction
What do you do during delivery of placenta?
Guard the uterus
Apply gentle downward controlled cord traction
Inspect placenta for completeness, bag/label and bring to hospital
What do you do after placenta is delivered?
Perform external uterine massage to minimize bleeding as required, uterus should feel firm and central
Check fundus and bleeding every 5 min in first 15 min
What do you do with baby after birth?
Provide warmth, skin to skin, dry and stimulate baby, assess transition
Baby APGAR at 1 and 5 min
Check vitals
Shoulder distocia
The inability of the fetal shoulders to deliver spontaneously or in response to gentle lateral Flexion on the head, impaction of anterior shoulder against the symphysis pubis or sacral promontory of the pelvis
When does critical irreversible hypoxic injury occur?
8 min after birth of baby’s head
What does ALARM stand for?
A - ask for help, 2 ppl
L - lift legs, hyperflex thighs (McRoberts maneouvre)
A - adduct shoulder = apply suprapubic pressure
R - roll over (Gaskin maneouvre)
M - manual delivery of posterior arm (if visible at perineum)
How many times can you go through alarm?
2, partners switching to apply the suprapubic pressure
How do you perform McRoberts maneouvre?
Lie pt flat and huperflex pt thighs onto the abdomen, simulating a squatting position - best done by 2 individuals
Why use McRoberts maneouvre?
Aids delivery by straightening the sacrum relative to the lumbar spine
Removes the sacral promontory as an obstacle, creating room for descent
Impacts the angle of the symphysis pubis superiorly, increasing the bispinous diameter.
How do you perform suprapubic pressure?
Place heel of hand above the public symphysis and press the fetal anterior shoulder directly down.
When the pt pushes, apply lateral Flexion to the fetal head to deliver the anterior shoulder.
Why do you apply suprapubic pressure?
Dislodged and adducts the anterior shoulder towards the fetal chest, allowing the shoulders to enter the pelvis in an oblique diameter.
Reduces fetal bisacromial diameter by changing the shoulders drop a position of abduction to adduction
How do you perform the Gaskin maneouvre?
Assist the pt onto hands and knees.
Attempt manual removal of posterior arm if visible at perineum - lateral Flexion follows the pelvic anatomy of pt.
Why do we perform the Gaskin maneouvre?
Position change may dislodge anterior shoulder and may increase pelvic diameter, permitting movement of impacted shoulder.
Signs of shoulder dystocia..
Turtle sign
Cyanosis of the fetal head
Restitution rarely takes place spontaneously
Expulsive effort and gentle lateral flexion of the head fails to deliver the shoulders.
What is breech birth?
The fetus is in a longitudinal lie with the buttocks as the presenting part entering the pelvis
Signs of imminent breech?
Fresh passing of dark meconium at perineum
Breech (buttocks), leg or foot visible protruding from vagina
Presenting part descending/emerging more with each contraction
What are precipitous birth considerations?
Assist pt into anti-gravity position Reassure pt baby is coming Encourage pt to pant (not push) Guard the perineum Control the delivery of the head Be prepared to stimulate the baby and manage potential increased risk of postpartum bleeding
Prepare for breech delivery by…
Positioning pt upright, at the edge of a firm surface Hands off (don't pull), allow gravity to encourage fetal descent and flexion
1st steps of breech delivery…
Position pt
Breathe with contractions
HANDS OFF THE BREECH
2nd steps of breech delivery…
Baby born to umbilicus
Note time: 4min to deliver baby from here
Consider gentle release of LEGS if possible
HANDS OFF BREECH
3rd steps of breech delivery…
Consider gentle release of arms if possible
ALLOW GRAVITY TO BIRTH BABY
Hairline visible
Mariceau-Smellie-Veit manoeuvre
What are the placement/steps for Mauriceau-smellie-veit manoeuvre?
Support baby with forearm, palm supports chest
Fingers on malar bones
Apply suprapubic pressure to promote flexion
Place dominant hand over baby’s back: 2 fingers over shoulders and middle finger on occiput to maintain flexion
When nap is visible, lift body to pivot head around public bone and allow face to be born
What are multiple gestation pregnancies at higher risk for?
Preterm delivery Congenital anomalies Low birth weight Hypertensive disorders (pre-eclampsia) Postpartum hemorrhage
How do you identify a twin/multiple pregnancy after the birth of the first baby?
Smaller than expected first baby
Pts fundus remains high
Fetal parts can be palpated in utero
Cannot know if the placenta(e) are connected or separate, so what do you do?
Immediately clamp the cord of the first baby
Do not let the cord pulse and drain as this may cause exsanguination of the second twin
What are considerations for transport with twin/multiple births?
Optimal length in time b/w the births of twin A and twin B has not been established
Safe transport after the first twin may be possible depending on the circumstance of labour and distance to hospital
After the first baby is born, 80% of the time there is a 20-30 min delay prior to the birth of the second baby
Management of a twin/multiple birth…
Inform pt/family and other paramedic
Evaluate and provide immediate newborn care to first baby
Visualize perineum to rule out bleeding, cord prolapse or presenting limb
Urgent transport unless second birth is imminent
What do you do if twin birth is imminent?
Proceed with delivery of twin B in vertex or breech presentation
Identify twin B by placing two clamps on cord before cutting
Placental delivery - deliver placenta(e) together by guarding uterus and applying controlled cord traction or both cords together
What are immediate postpartum considerations?
Be prepared to resuscitate; twins are at higher risk of preterm delivery, congenital anomalies and low birth weight. Risk of postpartum hemorrhage is increased Once placenta(e) are delivered perform external uterine massage to minimize bleeding
What is prematurity?
A baby born prior to completion of the 37th week of gestation.
Preterm considerations….
Gentle handling
Provide warmth by skin to skin with warm blankets and baby hat, use of heat source, increasing ambient temp, limit exposure to cold air
Manage airway
If extremely preterm, consider wrapping newborn in emergency blanket along with warmed blankets
Signs of malprentation…
Unusually wide or asymmetrical abdomen
Low fundal height
Pt reports fetal head felt on one side of abdomen.
What are different types of malpresentaion?
Transverse lie
Shoulder presentation
Unstable lie
Describe transverse lie..
Fetus lies horizontally, ballotable head felt on one side.
Describe shoulder presentation..
Shoulder is the presenting part
Describe unstable lie..
If lie varies after 36 weeks, changing from longitudinal to oblique or transverse b/w one clinical exam to the next
What is cord prolapse?
Cord lies alongside, or in front of the presenting fetal part after the membranes have rupture, and may prolapse into or beyond the vagina.
Considerations for cord prolapse.
Imminent birth with cord prolapse is RARE but more likely in multips; explain urgency or cord prolapse and need for c-section.
Management of cord prolapse.
Move the pt into the knee-chest position
Manually elevate presenting part
Gently cradle cord in hand, replace cord in vagina while inserting fingers into vagina and applying manual digital pressure to presenting part, elevating fetus off the cord
In order to apply sufficient force, you may need to place your hand in the vagina
Rapid load and go
Transport in exaggerated Sims position
Maintain digital elevation until TOC in hospital
Call ahead to hospital
What is postpartum hemorrhage?
Any amount of blood loss that causes the pt to exhibit signs and symptoms of shock. >500ml blood loss after basically birth
What is the initial management of postpartum hemorrhage?
Communicate- inform pt and other paramedic of excessive blood loss
Resuscitate- initiate Resuscitative measures (consider IV start, O2 therapy), monitor vitals, uterine tone, bleeding, pt alertness
Arrest the bleeding- identify cause and treat blood loss. Consider 4 T’s; Tone, tissue, trauma, theombin
When do you avoid massaging the uterus?
When the placenta remains undelivered.
How do you attempt to deliver the placenta?
Guard the uterus
Controlled cord traction
Patient effort during a contraction.
If placenta is not delivered and pt is not stable you should…
Ensure resuscitative measures in place - IV and fluids running, high flow O2, encourage patient to void.
Urgent transport and consider external biannual compression on route until TOC
