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)
