HALO Term Test 2 - Birthing Complications Flashcards
Birthing complications make up ____% of all births.
3
What is a precipitous birth? What factors may contribute to having a preciptous birth?
Definition: an extremely rapid delivery. Baby is born in <3 hours of the start of regular contractions.
- more common in multips (given birth before) & in preemies (because they’re super small so very fast; but also likely pre-term babies will need resus when they come out)
- Constitutes up to 3% of all labour and births
Risks of having a precipitous birth
- perineal lacerations (vaginal tears)
- postpartum hemorrhaging
- neonatal resuscitation (likely need for suctioning because typically the vagina wants to stay closed and collapse on baby’s chest which squeezes fluids out of their lungs but in this case, there wasn’t enough time for that)
What S/S are you looking for that may indicate a precipitous birth?
- quickly progressing signs of second stage of labour
- Sudden, strong contractions very close together
- Pain that feels like one continuous contraction
- A sensation of pressure in the pelvis and a sudden urge to push
Management of precipitous birth
- Prepare and follow steps for uncomplicated birth
- Encourage mom to breath/pant (not push) during contractions
- Set equipment up quickly
- Call for second crew
- Attempt to control the head in a slow fashion (one hand on head, other on perineum for control)
- Mom in supine position, head raised, legs flexed and abducted at knees, hips (normal birthing position)
- One hand to guard perineum during crowning (place 2-3 fingers by the peritoneal space, this prevents tearing)
- Apply gentle counter pressure to vertex (baby’s head) when crowning to prevent rapid delivery of the head
How many degrees of vaginal tearing are there? Describe each degree of tear and what would be the appropriate treatment for such.
1) First degree tear: involves the first layer of tissue at the bottom of the vaginal canal. Treat with saline to cleanse the area multiple times a daily and will eventually adhere and self-heal (can be managed pre-hospital)
2) Second degree tear: Still somewhat superficial with some transverse ripping (skin and muscle layers), slightly bigger of a tear. There is a risk of ripping to the anus and requirement of stitches. Treatment can still be managed pre-hospital.
3) Third degree tear: tearing of the anal sphincter (skin and muscle layers & anal sphincter muscles affected). Treatment is hospitalization until mother heals to a 1st or 2nd degree tear
4) Fourth degree tear: tearing of the rectum (can be fatal). Treatment requires hospitalization and running a course of prophylactic antibiotics to prevent sepsis.
Note that anus and rectum are highly vascualr so lots of bleeding can occur here
Cephalic presentations are also know as __________ presentaitons and account for ___% of all births.
occiput (cephalic occiput anterior - aka head first)
97% of all births
What is the face up birth position?
What factors may contribute to this fetal presentation?
- aka persistent occiput posterior position
- normal in early labour (and then they would hopefully turn to normal cephalic position eventually)
- ~5.5% of deliveries
Factors:
- pelvic narrowing (naturally narrow pelvis or due to no pelvic dilation/widening)
- Malrotation (no restitution)
Potential complications and prognosis of a face up birth presentation
- can cause dystocia (labour stalling - taking the baby a long time to come out)
- often requires forceps delivery +/- manual rotation
- Pt is Code 4, CTAS 1 w/ high flow O2 to mom
- Prognosis for infant is excellent when performed by a skill clinician (doctor)
- increased maternal morbidity - can lead to ruptured uterus, hypotensive shock, fatal
What is labour dystocia and how would a paramedic manage a mother with this birthing presentation?
What factours may cause labour dystocia?
Definition: aka lack of progression. Slow, difficult labour
- happens when signs of imminent delivery are present but labour does not progress to delivery within 10 minutes
- The head is visible and the maneuver is done but baby still not coming out
- Various factors to contribute to this including primiparity (first birth), face- up presentation
Management:
- if birth doesn’t occur within 10 mins of initial assessment then consider transport, discourage mom from pushing/baering down during contractions
- Worried about baby and umbilical cord being compressed (deoxygenated and HR drops every time mother bears down)
What are the 4Ps?
factors that influence the delivery of the baby
1) Power: women’s push power i.e. strength of uterine contractions and mom’s expulsive efforts (increase push power/strength via encouragement)
2) Passenger: size of baby and their presentation
3) Passage: canal - is mom dilating? labour dystocia? You are considering maternal pelvis and tissue of the birth canal
4) Psyche: mental power to push & overall emotional state (anxious? is there adequate support from support system?)
What is shoulder dystocia?
% of occurrence?
What risk factors are associated with this birthing complication?
Definition: Occurs when fetal anterior shoulder becomes impacted against mother’s symphysis pubis or fetal posterior shoulder becomes impacted on sacrum.
- Reuslts in inability of fetal shoulders to deliver spontaneously or in response to gentle flexion of the head
- Occurs in up to 3% of all vaginal deliveries
Increased risk with:
- prior shoulder dystocia
- poorly controlled diabetes
- maternal obesity
- macrosomia (>10 lbs)
- postdated pregnancies (up to 42 weeks - bb too big)
- Small mothers (small hips)
Complications of shoulder dystocia
- Clavical fracture
- Humeral fracture
- Brachial plexus palsy - irreversible damage & arm does not grow properly along with a loss of adequate/normal fine and gross motor movements in that arm)
- hypoxia/asphyxia
- death
- postpartum hemorrhage (PPH)
- vaginal lacerations
- uterine rupture
How to identify shoulder dystocia
- fetal head emerging slowly, chin havin difficulty sliding over perineum (prolonged head to body delivery time - >2 mins)
- “Turtle sign” - once crowning, chin and head retract against perineum
- Cyanosis of the fetal head
- Restitution rarely takes place spontaneously
- Failure to deliver shoulders despite good expulsive effort with contraction from mom and gentle lateral flexion from paramedics
How to manage birth with suspected shoulder dystocia?
1) If the head delivers, just allow restitution and next contractions however, if clear signs of shoulder dystocia are present, begin maneuvers
2) lay patient on edge of firm flat surface and position them supine (i.e. floor)
3) DO NOT direct pt to push outside of a contraction to allow restitution of the head
4) Abduct patient’s legs at the knees
5) McRobert’s Maneuver: use 2-3 ppl to help lift the pt’s legs and hyperflex legs towards the abdomen/shoulders (increases pelvic diameter)
6) Provide gentle but firm downward pressure above the pt’s symphysis pubis during contractions only
7) Apply lateral traction to the fetal head while pt psuhes
8) Only do McRobert’s 2 times and if the birth does not occur after the 2nd attempt - LOAD and GO
When is Mc Roberts Maneuver done and why does it work?
done during shoulder dsytocia and works because it flattens/opens the pelvic girdle
True or false
During the McRoberts Maneuver, you should only bring the knees to the chest during contractions, bringing them down between them.
True
At which point (timeframe) is critical hypoxic injury most likely to begin?
Irreverible at 8 minutes after birth of the baby head
What is the goal of applying suprapubic pressure and how should the technique be modified if you are unable to determine the orientation of the fetus’ head?
- Goal is to adduct the anterio shoulder decreasing the shoulder to shoulder dimension allowing passage through the pelvis
- If you don’t know which position the fetus is facing, the best method is to just apply DIRECT DOWNWARD suprapubic pressure
What is the Gaskin maneuver and what is it used for?
- used for shoulder dystocia, may disimpact the shoulders (this position allows for easier access to posterior shoulder for rotational maneuvers or removal of posterior arm)
- Flip FLOP:
- F: on all Fours
- L: Lift leg into a running start
- O: Rotate the shoulder into the Oblique diameter of the pelvis
- P: Remove Posterior arm (gently sweep one arm out and then hopefully like a superman)
What is breech birth?
Baby is delivered feet or buttocks first
What are the 3 types of breech birth?
What potential complications may occur with delivering breech?
1) Complete - cross-legged (ideal presentations - paramedics can deliver this with assistance to the legs)
2) Incomplete/Footling - When one of the knees are bent and foot and bottom are closest to the birth canal (find the other leg and pull it out)
3) Frank - when the baby’s bottom is down but legs are straight up with his feet near the head. We can deliver this but will cause trauma to the mother and baby.
- assist legs to come out straight and then deliver once both legs are out
- Can risk joint issues, hip and femure fracture
- may see umbilical cord during delivery that is compressed
Complications of breech birth
1) Cord prolapse -drying of cord can lead to vasospasm, compression, tearing and exsanguination (needs to be wrapped in wet warm sterile gauze and 2 fingers in the vagene to push sides of vaginal canal to release pressure)
2) Placental abruption/premature separation
3) Hypoxia/asphyxia - hypoxic brain injuries
4) Damage to the internal organs
5) Humerus/clavicle/femur/spine fractures or hip dislocation
6) Head and neck trauma - most fatal is internal decapitation; intracranial hemorrhage, fetal head entrapment, SCI injuries
7) Postpartum hemorrhage
What are the appropriate steps for a breech delivery?
1) Advise mom to not push unless it’s imminent
2) If Imminent birth, position patient in upright supported position with buttocks at edge of bed/table (place feet on chairs or have people holding legs) - we need gravity!
3) Don’t touch the baby much as to avoid vasospasm of cord which could cause baby to take a deep breath while baby’s head is still in uterus)
4) Allow gravity to birth the baby UNTIL the umbilicus - initially have hands off an encourage the mom to push with contractions
5) Avoid cord handling unnecessarily to prevent constriction of cord due to spasm
6) Consider gentle release of legs PRN - then hands off again
7) Document time of birth of umbilicus - ideally within 4 minutes baby is born
8) Consider gentle release of legs PRN - then hands off again
9) Once arms are delivered, allow descent of the head through the pelvis. Head will spontaneously rotate to face mom’s back with fetal back uppermost
10) Once back has rotated, allow gravity to encourage baby to descend so head comes down onto pelvis floor and flexion of the head is encouraged
11) Do not rush this stage of birth! Can cause head to extend (and then internal decapitation)
12) Wait until hairline is visible below pubic arch (may take 1-2 min)
What maneuver do you use for breech births and when would you use it?
Maneuver: Mauriceau-Smellie-Veit (MSV)
- maneuver used to aid flexion of the head and used when head does not deliver within ~3 minutes of the body
1) Non-dominant hands support baby with forearm on chest, two fingers on malar bones
2) Dominant hand 2 fingers hooked over shoulders and middle finger pushing on occiput
3) Using fingers on malar bones and finger on occiput to create neck flexion while supporting the spine
4) Scissoring - Guide baby downwards until nape of neck (occiput) is visible, promote flexion guiding the baby upwards to expose the face. Whe nose is visible/felt, deliver the head in a slow and controlled fashion up and out of vagina
5) Prepare for neonatal resuscitation
If the head does not deliver in a breech delivery, what should be done?
Rapid transport and keep vaginal airway open for infant enroute, O2 for mother.
In a breech birth, how long should it take to birth from the point the umbilicus is visible?
What should be done if it doesn’t deliver within that time frame?
4 minutes
Keep vaginal airway open for the infant en route, O2 for mother
In a breech delivery, how should the arms and legs be release if they don’t deliver spontaneously?
- legs and arms will often deliver spontaneously or with gentle release
- Legs: press back of knee to bend the leg and grab ankle and deliver the foot (repeat if needed)
- Arms: hand or elbow is visible on fetal chest (gently sweep in and out)
Do we deliver limb presentation?
What do we do with the limbs?
no, unless it’s two legs
Leave limb outside the vagina - wrap limb in blanket (you an try to gently reach in and feel for other foot and try and guide it out but doe not force it. If it doesn’t come then it doesn’t come).
Management of limb presentation
(Mother positioning and transporting decision)
- Position mother on L side to take pressure off aorta and increase circulation
- Fetal position for mom with hips and knees flexed OR supine with hips /butt elevated and knees/hips partially flexed (takes pressure off presenting part)
- Administer O2 and rapid transport (Code 4 CTAS 1)
- Strongly discourage pushing with contractions
- Prepare for delivery, neonatal resus
What position shall the paramedics position mom to be in for umbilical cord prolapse?
- knee-chest position or extended SIMS position
- assist mother onto her L lateral side with chest flat on the floor
- R knee brought up to the chest & supported with pillows/blankets
- L arm lies along her back
- Hips and buttocks supported with pillows and blankets - slightly elevated to relieve pressure on umbilical cord
