Management Flashcards
1
Q
What is the treatment for a maternity patient with antepartum haemorrhage but no signs of altered perfusion?
A
- Place patient in the left lateral tilt position
- Transport to appropriate obstetric hospital
2
Q
What is the treatment for a maternity patient with antepartum haemorrhage with signs of altered perfusion?
A
- Place patient in the left lateral tilt position
- Transport to appropriate obstetric hospital
- Consider NS IV (max. 40mL/kg) titrated to response
- Consult for further fluid or if unavailable, NS IV 20mL/kg
- Manage pain as per pain relief guideline
3
Q
What should be assessed when suspecting APH?
A
- Perfusion status
- External bleeding
- Pt Hx
- Abdo pain
- > 20wks gestation
4
Q
What are signs and symptoms to look for with pre-eclampsia?
A
- Headache
- Agitation
- Visual disturbances (flashing lights, shimmering)
- Nausea and/or vomiting
- Heartburn/epigastric or abdo pain
- Hyper-reflexia
- Elevation of 20mmHg above normal
5
Q
hat is the most common cause of seizures in pregnancy?
A
- Pre-existing epilepsy
- Eclamptic seizures are generally new onset in the latter half of pregnancy
6
Q
What should be assessed when suspecting preeclampsia/eclampsia?
A
- Hypertension
- Pre-eclampsia S&S
- Seizure activity
- Gestation >20wks
7
Q
What is the treatment if significant hypertension is found?
A
- Basic care
- Left lateral tilt
8
Q
What qualifies as significant hypertension in a pregnant patient?
A
- SBP = 140-170
- DBP = 90-110
9
Q
What qualifies as severe hypertension in a pregnant patient?
A
- SBP > 170
- DBP > 110
10
Q
What is the treatment for eclampsia with seizure activity?
A
- Mx seizure as per guideline
- Left lateral tilt
- High flow O2
11
Q
What is the management post eclamptic seizure?
A
- Assess for aspiration and treat symptomatically
- Mx precipitous delivery as per normal birth guideline
- Mx placental abruption as per APH guideline
12
Q
What are the normal actions for birth of the foetal head?
A
- Encourage mother to push with each contraction
- If head is birthing too fast, ask mother to pant with an open mouth during contractions instead
- Place fingers on baby’s head to feel strength of decent of head
- Apply gentle pressure to the perineum to reduce risk of perineal tears
- Note the time once head is delivered
13
Q
Once the head is birthed, how should the umbilical cord be assessed?
A
- If cord is loose and wrapped around neck then slip over baby’s head with appropriate traction
- If tight then mother should be encouraged to push
- If baby still doesn’t descend and cord still not loosened - clamp and cut cord
14
Q
What are the normal actions for the birth of the shoulders and body?
A
- Hold baby’s head between hands and if required apply gentle downwards pressure to deliver the anterior shoulder
- Gentle upwards pressure may then be required to birth the posterior shoulder
- Body should follow quickly
- Support the baby
- Note time of birth
- Place baby skin to skin with mother to maintain warmth
- If body fails to deliver in <60secs after head then mx as per shoulder dystocia
15
Q
What is the appropriate action for cutting the cord?
A
- Wait for cord to stop pulsating (approx. 2mins)
- Apply first clamp 10cm from baby
- Second clamp 5cm from the first
- Cut between both clamps
16
Q
What are the normal actions for birth of the placenta?
A
- Allow placental separation to occur spontaneously (approx. 15-60mins)
- Position mother sitting or squatting to allow gravity to assist expulsion
- Breast feeding may assist separation or expulsion
- Allow placenta and membrane to be birthed by maternal effort
- Use two hands to support placenta using a see-saw motion
- Note time of delivery of placenta
- Inspect placenta and membranes for completeness
- Insepct that fundus is firm, contracted and central
17
Q
What are the signs that placenta is ready for birthing?
A
- Lengthening of cord
- Uterus becomes rounder, firmer, smaller
- Trickle or gush of blood from vagina
- Cramping/contractions return
18
Q
What are the 3 types of breech presentation as per AV CPGs?
A
- Frank/incomplete (knees extended)
- Complete (knees bent)
- Footling (foot presenting)
19
Q
What is the appropriate action if one foot, hand or arm is the presenting part?
A
- Do not attempt to deliver
- Tx urgently to n appropriate maternity service unit with notification
- Consult with PIPER for advice
20
Q
What are the most important aspects of breech delivery?
A
- Request urgent assistance (PIPER, MICA)
- Allow the birth to occur spontaneously where possible
- Position mother with buttocks to bed edge and legs supported
- HANDS OFF THE BREECH
21
Q
When should the Mauricea-Smellie-Veit Manoeuvre be used?
A
To deliver the baby’s head during breech presentation when the back is uppermost
22
Q
What action should be taken if legs have been delivered but back is not uppermost?
A
- Gently hold baby by placing thumbs on bony sacrum with fingers around thighs
- Do not squeeze abdo
- Rotate/turn baby uppermost between contractions taking care of baby’s spine
- Never pull the baby
23
Q
What action should be taken if legs do not spontaneously deliver during breech?
A
- Slip one hand along leg of baby lying anteriorly
- Place a finger behind the baby’s knee and deliver it by flexion and abduction
24
Q
When should Lovsett’s Manoueuvre by used?
A
Breech presentation and arms are not delivering spontaneously
25
What is involved in Lovsett's Manoeuvre?
- Hold baby by sacrum and turn 90 degrees in between contractions to anterior-posterior
- Insert finger into brachial plexus and sweep arm down over the baby's chest
- Turn baby 180 degrees and repeat for other arm
- Turn baby back to back upper most orientation
- Do not pull or apply traction
26
What should be assessed when determining if shoulder dystocia is the cause?
- Normal birthing procedure fails to accomplish delivery
- Prolonged head-to-body delivery time (>60secs)
- Difficulty with birth of face and chin
- Baby's head retracts against perineum (turtle sign)
- Failure of baby's head to restitute
- Failure of shoulders to descend
- Difficulty reaching neck when attempting to check for cord around neck
- Baby's head colour turns purple then black
27
What is the first line of mx if there is prolonged head to body delivery time?
- Note time of birth of head
- Request urgent assistance
- Position mother with buttocks at bed edge
- Apply gentle downward traction to deliver anterior shoulder
28
What is the first manoeuvre to be attempted for shoulder dystocia?
McRobert's manoeuvre (knees to nipples)
- Place mother in a recumbent position
- Hips to edge of bed enabling better access for gentle downward traction
- Assist mother to grasp her knees and pull her knees/thighs back as afar as possible onto her abdomen
29
If McRobert's position alone does not deliver then shoulder then what is the next step?
Suprapubic pressure while in McRobert's
- Hands in CPR position behind symphysis pubis at 45 degrees along baby's back
- Apply 30secs firm downward pressure then 30secs rocking motion to get shoulder out from under rim
30
If McRobert's and suprapubic pressure do not work for shoulder dystocia, what is the next step?
Gaskin manoeuvre (all fours)
- Rotate mother to all fours
- Hold baby's head and apply gentle downward traction (attempting to dis-impact and deliver the posterior shoulder
31
If all management strategies fail to deliver a baby with shoulder dystocia what is the next step?
- Consult with PIPER regarding when to abandon manoeuvre and tx
- If unable to consult, tx with notification
- Tx in McRobert's position with 30 degree left lateral tilt
32
What are the 4 Ts of PPPH?
- Tone
- Trauma
- Tissue
- Thrombin
33
What risk factors increase the likelihood of PPPH?
- Multiple pregnancy
- Multiple births (>4)
- PHx of PPH
- Hx of APH
- Large baby
34
What is the definition of PPPH?
Blood loss >500mL in first 24hr following birth
35
What is the definition of SPPH?
Blood loss >500mL which occurs more than 24hrs after birth and up to 6wks after
36
What should be assessed when considering PPH?
- Fundal tone
- Visible blood loss
- Perineal/vaginal laceration
37
What is the treatment for PPH if fundus is firm?
- High flow O2
- Analgesia if req'd
- Mx and visible lacerations with dressing and firm pressure
If BP <90
-- consider IV NS max 40mL/kg
38
What is the treatment for PPH if fundus is NOT firm?
- Massage fundus until firm and blood loss reduces but only if placenta is delivered
- - Cupped hand, firm pressure in circular motion
39
What is the treatment if fundus remains not firm after fundal massage?
- Misoprostol 800mcg Oral
MICA
- Oxytocin 10IU IM
- - Repeat @ 5/60 if bleeding continues
40
What is the last resort for treatment of PPPH?
External abdominal aortic compression
- Locate point of compression just above the umbilicus and slightly to the left
- Apply downward pressure with a closed first directly through abdominal wall
- Effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied
41
What is the definition of miscarriage?
- Unexpected loss of a pregnancy prior to 20wks gestation
| - Infant delivered >/= 20wks with no signs of life is regarded as stillborn
42
What are typical signs of miscarriage?
- Abdominal or pelvic pain/cramping
- Pain may radiate to lower back, buttocks or genitals
- Vaginal bleeding may be present (range from spotting the life threatening)
43
What are the two major things to assess immediately with each newborn?
- Breathing
| - Muscle tone
44
If breathing adequately and good muscle tone what is the management of a newborn?
- Continue to dry (especially the head)
- Maintain warm (skin-skin, blankets, hat)
- Monitor HR (auscultation), breathing, tone and colour
45
Where should you Tx a newborn of >36wks, uncomplicated and stable vital signs?
- Appropriate maternity service (e.g. pre-booked hospital)
46
Where should you Tx a newborn of 32-36wks and stable vital signs?
- Level 2 hospital (paediatrician and midwife on site 24/7) in consultation with PIPER
47
Where should you Tx a newborn of <36wks or unstable vital signs?
- Tertiary centre in consultation with PIPER
48
What is the most important thing in newborn resus?
Effective ventilations
49
What is the initial Mx for a newborn which is apnoeic or gasping or no muscle tone?
- Stimulate by drying (no more than 30secs)
- maintain warmth
- Place supine with head/neck in neutral position
- Suction only if airway obstruction is suspected
50
What is the Mx if newborn remains HR <100 and/or apnoeic or gasping?
- IPPV @ 40-60/min on room air
- Pulse oximetry
- ECG monitoring
- Reassess after 30secs
51
What is the Mx if after IPPV for 30secs the HR <60?
- CPR @ 3:1 with oxygen (5L/min)
52
What is the Mx if after IPPV for 30secs the HR 60-100?
- IPPV @ 40-60/min
- Ensure adequate mask seal, airway position and increase ventilation pressure
- If no increase in heart rate IPPV with oxygen 5L/min
53
What is the Mx if after IPPV for 30secs the HR >100 but SpO2 <90%?
Breathing laboured
- IPPV @ 40-60/min
- Titrate O2 (1-5L/min)
Breathing normally
- Maintain warmth
- Titrate O2 1-2L/min via nasal cannula
