CP2 Final Flashcards
Referral guidelines- Polyhydramnios
9-11 cm deepest pocket measurement = “Mild polyhydramnios”–Consult
> 12cm = moderate - severe - Transfer
what are Causes of polyhydramnios
rapid / severe: congenital abnormality (Trisomy 21, 18,13) / gastro intestinal atresia/ hydrops fetalis
DM
twins
Fetal anaemia (Rh disease)
how do we identify polyhydramnios
> fundal height
-difficult to palpate limbs / spine
-difficult to auscultate
womanmay be complaining of ailments reflecting greater uterine volume (breathless, cramps, constipation, reflux, swollen genitals)
What are risks associated with polyhydramnios
usually mild to moderate - builds up slowly. can create some additional risks in L&B.
if sudden / rapid - may be indicating congenital issue.
Explain
Malpresentation
Cord prolapse (presenting part is less well applied)
Uterine Rupture
Preterm labour / pre labour rupture of membranes (irritated uterus)
placental abruption
PPH (over-distension leads to atony)
congenital abnormality
macrosomia
What is MW role to manage polyhydramnios
screening / diagnosis
screen for polyhydramnios with abdo palpation + fundal measurement
refer for USS to assess fluid levels
**information sharing **
- Explain polyhydramnios is common, usually doesn’t affect baby.
- small but serious risk of cahllenges in labour
-discuss Cord prolapse- what it is / risks / positions (knees to chest, head down)
Referral (Consult/ transfer)
(consider - GTT / anomaly scans / mum Rh-?
**Birth planning
**-plan to birth at tertiary unit
- what to do if SROM occurs- contact LMC immediately (do assessment timely to rule out cord prolapse / uterine rupture / confirm presentation
- positions if cord prolapse ofccurs
- - Cx - go to hospital early
Intrapartum
- caution with ARM- controlled conditions only
- EFM
- NICU notified
-regular palpation to check position
postpartum
- uterotonic (mgd 3rd stage)
VBAC- Referrals
Referral- All women with previous Caesarean section
VBAC - considerations
**benefits-
**1) avoid risks + complications associated with surgery (e.g. improved recovery/ reduced risk of infection / risk of placenta praevia / accreta/ hysterectomy/ risk of VTE, psychological benefits - for neonate- - risk of Transient tachyapnoea - microbe colonisation through vagina,
- breastfeeding initiation
**risks **
1) uterine rupture
increased (2-3x) risk of uterine rupture- overall risk low (ranges 0.3-1.5%) but can be serious
scar tissue has less collagen so less stretchy- skin around it can tear
can be asymptomactic (dehiscence) or symptomatic.
Symptomatic is emergency situation- interrupts blood flow to baby = asphyxia / PPH.
uterine rupture risk factors
- contraindicated- Classic caesarean + T shape incision/
- caution
- # of C sections
- time since surgery
- single double fold incision / wound healing
- IOL (esp misoprostil)
- BMI/ Age
2) Risk of emergency Caesarean section-
~3/10 women planning for VBAC have emergency Caesarean- this has greater risks than elective
VBAC booking visit- discussion
**understand obstetric history
**how many CS /VB’s?
when was the last CS? indication/ gestation / fetal position / progression of labour / type of incision / wound healing
Any other uterine surgery?
access birth notes
mum’s BMI/ age
**identify risk factors / contraindications
offer referral- explained informed consent
Uterine Rupture- managing risk
Assess risk factors
Tertiary setting + CTG
monitoring
-CTG - decels
previously regular contractions - slow
sharp continuos pain
tachycardia, reduced BP
vaginal bleeding –> haemorrhage / collapse
IOL definition
intervention to bring about onset of labour, with plan to birth baby
what are indications for IOL
Post dates (>42 weeks)
IUGR
PROM >24hrs before birth
PROM and GBS risk factor
PE (affecting maternal / fetal wellbeing)
Placental abruption
congenital abnormalities
what are contraindications for IOL
Malpresentation (breech / transverse)
VBAC (foleys only)
placenta praevia
Classical C section
previus uterine rupture
low lying placenta (no foleys)
what is MW’s role if woman is post dates
- accurate dating (LMP/ dating scan)
- Discuss perspectives about post dates
* risk of fetal death after 41 weeks increases (but this is still very low 0.16%-0.22%) - Discuss options of IOL (41-42 wks)
explain methods
explain monitoring (CTG, 2hrly VE’s in established labour)
* explain benefits and risks
* alternatives- additional monitoring (CTG + USS - note- no evidence) / Do nothing - Offer referral (<42wks)
- 3 way conversation-ask questions, discuss options, monitoring recommendations (CTG, 2hrly VE’s) - if woman consents to IOL- explain process, discuss challenge, recommend strategies, explain role of Core MW/ obstetric team / when LMC will support
what are the risks of IOL
- unsuccessful - exhausting / C section
- Uterine hypercontractility- FHR distress
- > Epidural (stronger cx / lack of beta endorphins / mobiliy)
- PPH - (Esp ARM + Oxytocin)
- Assisted birth
- Cord prolapse (with ROM- esp ARM)
- Uterine rupture **
what is MW’s role to support woman having IOL
Information (options, risks) + full informed consent
Bishops score to assess cervical ripeness ( effacement, dilation, position changes of cervix, station of presenting part,
Asses effects of medication (VE / EFM) - titrateto cervical / uterine changes, monitor for hypertonicity
ARM- assess for cord prolapse / contraindicated if high presenting part
Environment- quiet, supportive, (promote oxytocin)
describe misoprostil method of induction
Medical
**1. misoprostil (oral)
**synthetic prostaglandin given to ripen cervix
Dosage- 8x 25mg oral solution. wait 8hrs. 8 x 25mcg
Benefit- helps ripen cervix (increased effectivness of IOL)
monitoring - - 2hrly VE’s - CTG
cautions-
*hypersensitivity to misoprostil
*Abnormal distress
previous uterine surgery (C section)
>3 parity
>IUGR / Oligohydramnios
proces:
1st dose- 20min CTG before/ 40min CTG after
subsequent- 20min CTG before. once woman is contracting strongly, wait 1hr then do VE
continue misoprostil until woman is fully effaced / 3-4cm dilated
Site IV line –>ARM
Epidural - Risks
Progress to instrumenta birth (slowed contractions / difficulty pushing baby/ fetal distress)
adverse affects (itchy/ headache / nausea)
neurological injury /nerve damage
fetal bradycardia (from maternal Cardiovascular system toxicity - bradycardia/ hypotension / arrhythmia / cardiac arrest )
may not work
infection (urinary / meningitis)
MW management of woman with epidural
before siting epidural
immediately after sited
ongoing care
post partum
Before epidural
* ensure informed consent
* Site IV line, take CBC, G&H bloods
* empty bladder / site Foleys IDC
* put up normal saline Fluids to avoid risk of hypotension
**immedaitely After epidural sited
**monitor mum and baby’s response to epidural -
1)maternal bradycardia / hypotension- ( sign of CVS toxicity)
2) fetal bradycardia/ distress- ( sign baby is not coping with reduced blood supply )
3) respiratory depression (sign paralysis is affecting lungs )
epidural ongoing
- support adverse affects (nausea/vomiting / headache/ itchy) and offer care (e.g. anti-emetic)
- ask mum about senseations
- - explain CTG results
- palpate uterus to feel strength of contractions / position / descent of baby
- repositioning woman to support baby rotation + use props (peanut ball)
- stimulate muscles / ciruclation- massage / robozo/ pressure points
**Passive descent
**-wait one hour after dilation
-consider reducing epidural rate if woman wants to feel urge to push
-deflate IDC to avoid damage to urethra
Post partum
- removeal of epidural cathether (after suturing / completed by certified MW)
- support mobilising (Ensure epidural block is even)
- keep IDC in situ for 6hrs after epidural removed. TOV (2x 200ml - first in first 6 hrs) - checking woman is able to prdouce normal urine volume/ fully empty bladder
- obs
why do women get more UTI’s in pregnancy
glycosuria
weakened immune system
presssure of uterus on bladder- full empyting difficult
hygeine more difficult
progesterone relaxes ureters - stasis
What are types of UTi’s- what is MW’s role to manage these ?
**Booking visit
**screen women for renal condition / hx of recurrent UTIs.
Information sharing -
- UTI’s in pregnancy / risks / prevention/ signs/ management/ urine dipstick screening
- asymptomatic bacteriruria - normal gut bacteria in urine- undetected, it can progress to cystitis (bladder infection_ or pyeloneprhitis
* - Offer MSU / treat with AB’s
**treating woman for UTI (cystitis (in bladder/ lower UTI)
**-MSU shows elevated bacteria / white blood cells
symptoms- dysuria, frequency, urgency, lower back pain
Risk- SGA/ Preterm birth/ pyelonephritis
Treat wiht AB’s and do MSU 1 week later
Recurrent infection- Refer for consult (may be offered low dose AB for remainder of pregnancy)
**treating woman for pyelonephritis
**-infection ascended up to kidney.
- increased risk in pregnancy (urinary stasis, reduced ureter tone, urinary reflex)
- additional symptoms (fever, pain, nausea, cloudy smelly urine) - potentially life threatening
- Higher risk of preterm labour / renal failure
May require Hospitalisation - IV AB’s
Pre labour rupture of membranes
risks / MW assessments / referrals
PROM
~70% of women have spontaneous labour within 24hrs
Risks
-maternal / neonatl infection rates are increased with longer interval from ROM to delivery mec in liquor (fetal distress)
- polyhydramnios - cord prolapse
MW assessments
Liquor- colour / amount/ smell (Offensive?) / timing - put on a pad
maternal - obs (Fever?) (i.e. caused by infection / chorioamnionitis)
fetal-movements, palpation (position, descent), uterine tenderness, FHR auscultation,
speculum (if concern about cord prolapse)
No VE
Consider GBS risk factors (preterm, GBS positive swab, GBS bacteriuria, PROM>24hrs pyrexic)
**referrals
**PROM with GBS risk factor + unwell– CONSULT - broad spectrum AB’s
PROM with GBS risk factor + well - GBS prophylactics (IV) + IOL
PROM with no GBS risk factors- wait for labour. if reach 24hrs, then CONSULT- GBS prophylactics + IOL
moderate / thick mec- Consult + expedite IOL
Pre-eclampsia
(risk factors, pathophysiology, outcomes + risks, Diagnostic, MW asessment + actions)
Diagnostic
hypertension (140/90) 2 consecutive readings, 4hrs apart
AND 1 other
- proteinurea
- sign of organ dysfunction
- uteroplacental insufficiency
Risk factors
Autoimmune - antiphospholipid syndrome, donated oocyte
medical conditions- Chronic hypertension, DM, renal condition
maternal demographic- age >40, BMI >35, primip, family hx PE,
pathophysiology
trophoblastic invastion + spiral artery remodelling insufficeint
tissue hypoxia–> placental ischaemia
release of inflammation that causes:
-vasoconstriction (BP)
- endothelial damage (leak protein + oedema)
- platelet aggregation
outcomes + risks
* elevated BP–> stroke, pulmonary hypertension, IUGR, Stillbirth, preterm labour, placental abruption
* proteinurea –> renal failure
* liver dysfunction–> liver enzymes
* neurological damage- severe headaches/ visual disturbances/ clonus/ seizures (Eclampsia)
oedema
* platelet aggregation (HELLP + DIC)
GDM Screening / dates
rationale for screening
- pregnancy hromones can change insulin resistance, causing BGL to increase (diabetes)
-unstable BGL’s dangerous for mum and baby
-GDM is often hard to identify without screening
through screening / diagnosis, we can treat GDM and reduce associated risks
- there is also high risk of developing DM T2 with GDM diagnosis, so screning / idnetifying earlier enables you to introduce longer term liefstyle changes
Screening
booking -HbA1c-
assess glycated Hb (3mth average BGL’s)
refer for clinic >40 mmol/ mol)
Antenatal- urinalysis
24-28 weeks
rationale to retest
- insulin resistance can increase in first trimester and then decrease from ~24wks
- (due to pregnancy hormones from placenta (oestrogen/ HPl/ cortisol)
- thus important to recheck for GDM at 24 weeks
- 2 options
polycose screen (non-fasting)
for women with low risk / low HbA1c (47 mmol/ mol)
drink 50g glucose drink- wait 1hr. test BGL.
>7.8 mmol/ L- do GTT
Glucose Tolerance test (diagnostic)
for women with higher risk
fast 8hrs, take bloods. drink 75g glucose. take bloods again.
if fasting >5.5 mmol / L or 2 hr post prandil >7.8 mmol/ L - refer to clinic.
Explain Clinic
multidisciplinary support- obstetric, specialist MW, dietician- refer for other support as required.
treatment- diet first. metformin, insulin (injections)
PE -Midwifery actions
MW assessments for PET
- Screen for Famly Hx/ related medical condition at booking
- recommend BP assessment every appointment + urinalysis
- fundal height measurement (28 weeks) and plot of customised GROW chart- refer for USS if meet conditions
- explain PE and signs of PE at every appointment - ask about them.
- if BP elevated,
- recommend MAU to do full PET assessment- (bloods- FBC (platelets), Lft, Rnl, ALT, AST), MSU + PCR, and
Referral- Transfer
recommendations-
- Antihypertensives ( labetalol/ Nifidipine)
- USS
- consider timing of birth (gestation vs risk to mum + baby)
- consider corticosteroids (>34wks) + magnesium sulphate (<30wks)
Predisposing factors for PPH
Antenatal
Hx of PPH
LGA (>4KG)
Placenta praevia / accreta
Hypertension (PIH/ PE)
Obesity
high parity
bleeding disorders
Labour
IOL / Augmentation
shoulder dystocia
long 1st stage (>24hrs ) / Delay in 2nd stage
precipitous labour
instrumental delivery/ C section
retained placenta
lacerations
What is definition of PPH
excess bleeding that causes mum to become symptomatic
* faint / lightheaded / dizzy
* sweating
* agitation / confusion
* pallor, cold peripheries, goose bumps
* tachycardic (sometimes bradycardic) / hypotension
~ >500ML after birth that is uncontrolled
- Explain Uterine rupture
2 types
asymptomatic- dehiscence
symptomatic- acute emergency. interrupts blood flow to baby - asphyxia / PPH
scar tissue has less collagen so less stretchy- skin around it can tear
uterine rupture contraindications - Classic caesarean + T shape incision
cautions \+3 C sections --Contraindicated high presenting part (above -2 stations) - single double fold incision / wound healing - time since surgery - IOL (no misoprostil) - BMI/ Age
VBAC
monitoring/ intervention intrapartum
**signs of Uterine rupture **
- strongest indicator is abnormal FHR
vaginal bleeding
disturbance in uterine contractions
pain
preparation
antenatal- birth plan agreeing monitoring / threshold for intervention
birth at tertiary unit
notify obstetric / NICU
EFM + uterine contractions
avoid misoprostil
- IV line / access
- bloods taken (G+H, CBC, order cross match)
- consider no epidural (masks pain)
- monitor bleeding
g2p1 in labour at primary unit
ROM when woman is in transition
moderately thick mec in liqur.
what factors do you need to cosnider to provide relevant into
what do you do if she stays at primary unit
Explain presence of moderate/ thick mec may be associated with fetal distress- important to birth baby quickly and provide support.
Recommendation is consult / transfer to hospital - woman can decline
Considerations
- How far away is the hospital
- How close to birthing is she (VE - dilation / obstetric history / other indicators of close to birth)
MW actions
- Increase FHR auscultation
- Notify 2nd midwife / seek help from other midwives
- consult/Notify obstetric+ NICU
- Prepare for Resus
- Postpartum- observe for signs of RDS. Consider transfer baby to hospital
what are benefits /risks of C section
maternal risks
venous thrombosis
wound infection/ prolonged healing
damage to nearby organs (e.g. bladder nipped)
haemorrhage
risk for future pregnancy (development of scar tissue = adhesions = risk of placenta praevia, accreta, hysterectomy, uterine scar rupture)
neonatal
trauma from C section (cut)
transient tachyapnoea
reduced establishment breastfeeding
long term risks (asthma, juvenile arthritis, connective tissue disorders, immune disorders)
IUGR - definition
customised EFW <3rd centile
or 2 or more
* 1. <10th
* 1. slowing >30 centiles from 28wks
* 1. abnormal dopplers
What is process of IOL
**Pre IOL assessment
**1. - check informed consent
2. take hx (gestation / indication /
3.Maternal Assessments
* obs (confirm normal readings and get baseline)
* urinalysis (if mum has DM / hypertension)
* palpation (confirm presentation + engagement)
* assess cervical ripeness (bishops score >6)
4) Fetal assessments
CTG - normal
what is the bishops score
5 things- cervix length, consitency, dilation, position, level
need score of at least 6 to start ARM/ oxytocin
Describe stretch and sweep
- digitally separate fetal membrane from lower uterine segment- during VE
- ~39-40 wks
aim to release prostaglandins encouraging onset of labour
evidence- (1/8 women avoid IOL) - risks- discomfort, bleeding, irregular contractions
what is uterine hyperstimulation
explain the management (with / without fetal distres)
definition
>5 x contraction / 10mins
>OR cx lasting >2mins
with / without effect on FHR
**Causes **
Can occur during misoprostol + oxytocin
management
* maintain EFM throughout
* if on oxytocin- consider reducing / stop (Depending on FHR)
* Obstetric review (urgency depends on FHR abnormality)
* * if FHR abnormal
* left lateral (optimise blood to baby)
* IV fluids
* consider tocolysis + fetal scalp lactate
describe foleys method of induction
Mechanical
**3) Transcervical cathether ( foleys )
**IDC placed in cervix, balloon inflated (40-60ml water)
effect
directly dilates canal
OR indirectly mimics fetal head pressure on cervix (releasing prostaglandins / oxytocin)
indications
particularly unfavourable cervix- step before oral misoprostil (but will likely require oxytocin)
VBAC
outpatient management
cautions
low lying placenta / APH / infection >24hrs
process
12- 24hrs- if unable to do ARM, then consider Miso (unless contraindicated)
May be able to go home - contact / transfer back if (catheter falls out / regular painful cx/ ROM/ reduced movements / fresh vaginal bleeding)
describe oxytocin method of indication
10 IU / 500mls
indications
speed up CX - once sufficient cervical ripening + ARM
caution
- VBAC / >4 parity
Risks
more painful + restricted mobility = increased need for epidural
CVS disturbance- bradycardia / tachycardia
GI - nausea / vomiting
headache
monitoring
* 1 to 1 MW care
* titrate oxytocin via pump to achieve 3-4 cx /10mins
monitor for hyperstimulation / fHR distress
* maternal obs (temp, BP, pulse, vaginal loss, fluid balance (risk of water intoxication with prolonged infusion)
describe ARM method of induction
*indications
to speed up labour (with or without Oxytocin)
to reduce risk of infection
used after sufficient cervical ripening (bishops score >7- generally fully effaced and / or > 3-4cm depending on parity)
cautions
**cord prolapse- **high presenting head
HIV / HEP B+C - obstetric review
**process **
sit IV
VE before / after- check for possible cord presentation
EFM immediately after
document liquor color / consistency
mobilisation to promote cx
start oxytocin - immediately (primip)/ 1hr if regular cx haven’t started (multiparous)
what is cervical cause of APH?
1) Cervical + genital tract
not related to pregnancy- rarely affects baby
cervical pathology (polyps, lesions, carcinoma, ectropion, vaginal / vulval varicosities)
trauma
List 6 differences between presentation of placenta abruption vs placenta praevia
- pain- placenta abruption (constant abdo pain) / praevia (painless bleeding, but may have painful cx)
- haemodynamic compromise-abrutpion- significant bleeding may be concealed / praevia- degree of shock aligns to visible blood
- uterus- abruption- tender and tense /(previa (non tender)
- fetal - praevia- may have abnormal presentation / lie
- fetal condition- abruption- non-reassuring/ praevia- usually reassuring
- complication- abruption- DIC / praevia- secondary (larger) bleed
describe anatomy of spinal + Epidural
spinal- injection pass through epidural / dura/ arachnoid space. much stronger. instant but shorter lived
Epidural- inject / catheter outside dura mater- takes 10mins. local anaesthetic blocks SNS, fentanyl crosses dura and enters spinal cord
risks of epidural
assisted birth
urinary retention
hypotension, fever, motor blockage
longer 2nd stage
oxytocin
based on evidence- risk of assisted delivery + C section not increaesd
(but increase likelihood of oxytocin, which is associated with assisted/ C section)
complete loss of mobility
describe pathophysiology of DIC
1) primary pathophysiology (placental abruption/ PPH/ sepsis) causes endothelial damage
2) endothelial damage causes thromboplastin release which stimulates clotting, + anti-clotting mechanisms
3) microclots form in vessels, occluding blood flow and causing ischaemic damage
4) causes further endothelial damage–> release of more thromboplastin/ anticlotting mechanisms
6) more clots form- vicious positive cycle until clotting factors + platelets depleted
6) uncontrolled bleeding (internal / external/ )–> can lead to hypovolaemia/ shock
7) multiple organ failure
What are causes of obstructed labour
pelvis shape
macrosomia
fetal position /presentation
fibroids
Signs of obstructed labour
slow progress (descent/ cervical change) inspite of good cx
retraction ring- dangerous
haematuria
early ROM
risks of multiples
miscarriage
anaemia
abnormal amniotic fluid
TTT transfusion syndrome
PIH/ GDM
C section
PPH
Ectopic pregnancy- Risk factors
Pelvic infection leading to scarring / damage to tubes
previous ectopic pregnancy
STDs
TOP
Endometriosis
ectopic symptoms/ diagnosis
normal signs
but may not experience amenorrhea
pain
empty uterus
low hcg levels
tubal rupture- sharp sudden intense abdominal pain / haemodynamic shock
breech- signs of good progress
cleavage
abdo crunches
pulsating cord
tummy to mummy (anterior)
rapid progress
breech- types
frank (legs head)
complete (yoga)
what does CTG with late decels look like
repeititve
>15 sec drop, lasting >15 sec
trough of decel is 15sec after peak of contraction
what are risk factors for oligohydramnios
PE/ Hypertension/ IUGR
CVS/ Amnioentesis
Congenital abnormality
what are complications associated with oligohydramnios
lung development
skeletal deform
fetal demise
cord compression
amniotic band syndrome
placenta praevia risk factors
Hx C section
multiparous
fibroids
smoking
multiples
obstetric cholestasis- pathophysiology
liver
build up of bile due to hormones (oestrogen increases bile production / progesterone causes it to be stored)
bile into circulation- itchy
obstetric cholestasis- risks
preterm labour / fetal distress / stillbirth
obstetric cholestasis- presentation
itchy
jaundice
RUQ pain
increaesd bile acid
obstetric cholestasis- causes
hormonal
genetics
environment (winter/)
ethnicity
multiples
age (older)
when does Amniotic fluid vol peak vs term
37 wks peak (700-1l)
40- (600ml)
Functions of amniotif fluid
lung
protection
mobility
temp
infection barrier
