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NSW Ambulance Graduate Intern > Maternal Emergencies > Flashcards

Maternal Emergencies Flashcards

1
Q

What are some of the maternal complications of shoulder dystocia?

A

PPH
soft tissue injury (to genitalia)
pelvic and femoral nerve damage
psychological trauma

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2
Q

What are some of the baby’s complications of shoulder dystocia?

A

trapped cord = hypoxic ischemic encephalopathy
foetal pH drops 0.04 per minute
brachial plexus injury
humerus fracture

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3
Q

What are the risk factors for shoulder dystocia?

A

previous shoulder dystocia
macrosomia >4.5kg and small stature/small pelvis
diabetes
induction of labour
BMI >30 or >20kg pregnancy weight gain

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4
Q

What are the signs of shoulder dystocia?

A

failure to birth within 60 seconds of the head
turtle sign
incomplete restitution

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5
Q

What is the management for shoulder dystocia?

A

Backup
McRoberts and Gaskin manoeuvres
supra pubic pressure
urgent transport with McRoberts and supra pubic pressure
prepare for newborn resuscitation
perinatal advice line 1300 362 500

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6
Q

What is the McRobert’s manoeuvre for shoulder dystocia?

A

supine with knees to ears
gentle downwards traction on foetal head

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7
Q

What is the Gaskin manoeuvre for shoulder dystocia?

A

All fours position
gentle downwards traction on foetal head

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8
Q

How do you do supra pubic pressure for shoulder dystocia?

A

30 sec constant downwards pressure then if unsuccessful 20 seconds rocking pressure (withheld during maternal pushing)

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9
Q

How do you transport a Pt with shoulder dystocia?

A
  • Pt can walk with lunging steps to stretcher - prepare to catch baby
  • continue mcroberts with suprabuic pressure and 30 degree left lateral tilt
  • alternate between constant and rocking pressure
  • Pass code 3 to ED “I have a shoulder dystocia that has not been born with McRoberts, Gaskin or Supra pubic pressure”
  • Consider urgent clinical advice through TPN Tier 6 Hospital - Protocol R49
  • Urgent transport
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10
Q

What timeframe should the baby be delivered in with shoulder dystocia?

A

4 - 6 minutes

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11
Q

What are the steps in the 3rd stage of labour (Delivery of the newborn to the delivery of the placenta)?

A
  • Administer IM oxytocin while waiting for cord to stop pulsating
  • Observe for signs of placental separation
  • Encourage the woman to push
  • When placenta is visualised outside the perineum, place it between both hands and gently ‘see-saw’ the placenta and membranes up and down
  • When placenta is delivered, place in a zip lock bag and take to hospital and note time of delivery
  • Check fundus – place hand at the level of the umbilicus and palpate abdomen to assess tone and position of fundus
  • Estimate blood loss
  • Cover vulva with a peri pad
  • Replace soiled blueys and linen
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12
Q

What are the steps in the fundal massage?

A

Place one hand at level of symphysis pubis (pubic bone)
* Place other hand at top of fundus, (normally at height of umbilicus, however may be higher if fundus is not contracted), positioning uterus between your hands
* Firmly massage fundus with uppermost hand whilst keeping lower hand still. Advise this may be very uncomfortable for the woman
* Massage fundus in a downward & inward direction
* The uterus should contract & become firm
* When performing fundal massage it is normal for blood to be expelled from the vagina. Bleeding should cease when uterus is well contracted

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13
Q

When do you assess APGAR?

A

1 and 5 minutes

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14
Q

APGAR Appearance Scoring

A

Pink - 2

Blue extremities - 1

Pale or blue - 0

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15
Q

APGAR Pulse Scoring

A

> 100 bpm - 2

< 100 bpm - 1

No pulse - 0

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16
Q

APGAR Grimace Scoring

A

Cries and pulls away - 2

Grimaces or weak cry - 1

No response to stimulation - 0

17
Q

APGAR Activity Scoring

A

Active movement - 2

Arms, legs flexed - 1

No movement - 0

18
Q

APGAR Respiration Scoring

A

Strong cry - 2

Slow, irregular - 1

No breathing - 0

19
Q

What are the steps in newborn resuscitation?

A
  • Position supine with head in a neutral position
  • Consider 2cm padding under shoulders to aid in correct alignment due to baby’s large occiput
  • Only suction when visual signs of obstruction are present (meconium, blood, mucous or vernix)
  • Consider OPA/ NPA
  • Ventilate at 40/min
  • Reassess after 30 seconds
  • Continue ventilations whilst heart rate is <100/min
20
Q

What are the steps in newborn CPR if heart rate is <60bpm?

A
  • Compression ventilation ratio 3:1
  • Two thumb method preferred. Place thumbs over sternum at nipple line
  • Reassess after 30 seconds
  • If HR > 100, RR>40 and good tone provide post resuscitation care and complete physiological observations every 5 minutes
  • Ensure the newborn is kept warm
21
Q

What are the three types of breech?

A
  • Frank (feet at head)
  • Complete Breech (bottom first)
  • Footling (foot first)
22
Q

What is the procedure for breech birth?

A

Posture standing, squatting or kneeling where possible
* Hands off/eyes on
* Note time breech is visualised
* Ensure foetal spine stays opposite to woman’s spine (foetal nose to woman’s bottom)
* If the spines aren’t opposite, careful rotation of the foetus must be undertaken:
* thumbs on bum & gently rotate the foetus to ensure spines are opposite and do not pull the foetus
* Support may be given by placing hands gently around the foetus’ chest and under the buttocks
* Allow the foetus to ‘hang’ and continue to birth slowly until nape of neck is visualised
* Ask the woman to pant (not push) to facilitate slow, controlled birth of head
* Allow head to birth slowly
* Note time of birth

23
Q

When do you do an assisted shoulders manoeuvre in a breech birth?

A

If no descent or progress is seen and shoulders are still in vagina after 2 contractions (approx. 90 secs)

24
Q

What are the assisted shoulder manoeuvre steps in a breech birth?

A

Anterior arm release:
* During a contraction, encourage the woman to push and gently rotate the foetus on its side
* Apply gentle traction towards the woman’s back to birth the anterior shoulder and arm

Posterior arm release:
* Gently traction the foetus towards the woman’s abdomen to allow its other arm to birth
* Rotate the foetus back into the spines opposite position and remove your hands
* Allow the foetus to “hang” whilst awaiting the birth of the head

25
Q

When do you use the Assisted Head Manoeuvre (Adapted Mauriceau Smellie-Viet Manoeurve) in breech birth?

A

If the head is not easily born within 2 contractions (approx. 90 secs) with good maternal effort

26
Q

What are the steps in the assisted head manoeuvre?

A

Rest the foetus on your non-dominant forearm ensuring umbilical cord is not compressed
* Place other hand on foetus’ back
* Slide your middle finger towards the nape of the foetus’ neck
* Place your middle finger on the foetus’ occiput
* With next contraction encourage the woman to push and provide downwards pressure on the occiput
* Observe for the foetal face
* When the foetus’ face is visible, place your index and middle fingers of non-dominant hand gently on the foetus’ cheek bones, being careful to avoid the eyes and mouth
As the foetus’ face delivers, ask the woman to stop pushing and to start panting to allow the head to come out slowly
* Gently guide the face out of the vagina
* As head is born through this flexing motion, lift (not pull) the foetus upwards and place newborn on the woman’s abdomen

27
Q

What are the signs of shoulder dystocia?

A

failure to birth within 60 seconds of the head
turtle sign
incomplete restitution

28
Q

What is the management for shoulder dystocia?

A

Backup
McRoberts and Gaskin manoeuvres
supra pubic pressure
urgent transport with McRoberts and supra pubic pressure
prepare for newborn resuscitation
perinatal advice line 1300 362 500

29
Q

What is the McRobert’s manoeuvre for shoulder dystocia?

A

supine with knees to ears
gentle downwards traction on foetal head

30
Q

What is the Gaskin manoeuvre for shoulder dystocia?

A

All fours position
gentle downwards traction on foetal head

31
Q

How do you do supra pubic pressure for shoulder dystocia?

A

30 sec constant downwards pressure then if unsuccessful 20 seconds rocking pressure (withheld during maternal pushing)

32
Q

How do you transport a Pt with shoulder dystocia?

A
  • Pt can walk with lunging steps to stretcher - prepare to catch baby
  • continue mcroberts with suprabuic pressure and 30 degree left lateral tilt
  • alternate between constant and rocking pressure
  • Pass code 3 to ED “I have a shoulder dystocia that has not been born with McRoberts, Gaskin or Supra pubic pressure”
  • Consider urgent clinical advice through TPN Tier 6 Hospital - Protocol R49
  • Urgent transport
33
Q

What timeframe should the baby be delivered in with shoulder dystocia?

A

4 - 6 minutes

34
Q

When do you commence newborn CPR?

A
  • Commence BVM if any one or more of following are present:
    • Heart rate <100
    • Apnoea or gasping respirations
    • RR < 40
    • Hypotonia
35
Q

What are the steps in delivering a baby?

A
  • have neonateal resus equipment ready
  • request backup
  • obtain info re gestation, parity, complications, previous births etc
  • visually assess for presenting part when pushing
  • allow head to deliver slowly, asking mum to pant
  • support head and gently use index finger to check for nuchal cord
  • use clean gause to remove any blood or membrane off face if required
  • check for restitution
  • support each side of head (covering ears)
  • guide foetus head towards mums back
  • take weight of baby as it is birthed
  • note time of birth
  • assess APGAR
36
Q

What are the steps in the care of the newborn?

A

Dry and provide tactile stimulation to the newborn
* Maintain skin to skin contact to prevent hypothermia
* Cover exposed parts of the newborn with dry bunny rugs, leave only face visible
* Cover head with beanie
* Gently feel base of cord for pulsations (pulsations should cease 3-5 minutes post birth)
* Once cord stops pulsating, apply 1st clamp 10cm from the newborn’s abdomen
* Prior to applying second clamp, milk cord by holding the first applied clamp with one hand and gently squeezing cord away from newborn
* 2nd clamp should be applied 5cm from the first clamp (15cm from the newborn)
* Cut between 1st and 2nd clamps
* Apply 3rd clamp on cord near the perineum

NSW Ambulance Graduate Intern (18 decks)

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