Maternity Flashcards
You are called to a 26 year old female who has recently missed her last menstrual cycle, she complains of pain in the lower abdomen, pelvic area and back.
She feels slightly faint so you lay her down to maintain blood pressure, she has a history of Pelvic inflammatory disease.
What is your diagnosis?
Ectopic Pregnancy - Pregnancy not implanted into the uterus. Effects 1 in 80 pregnancies and is responsible for 13% of pregnancy related deaths.
What physiological changes occur within pregnancy?
Increased cardiac output by 20-30% within the first 10 weeks.
Increase in the average maternal heart rate by 10-15 beats per minute.
A decrease in the systolic and diastolic blood pressure by an average of 10-15mmHg.
Slight increase in breathing rate due to diaphragm compression.
What is the assessment for a normal delivery?
Assessment - ABCDE, note period of gestation.
Assess - for show, waters broken, contractions, bleeding (If none are present then discuss management with maternity unit)
If any of those are present:
Assess for contraction interval
The urge to push or bear down
Crowning/ top of baby’s head.
What is the management for imminent birth within the community?
Prepare incontinent pads, maternity pack, towels, heat.
Encourage mother to take entonox (be very cautious with morphine and only give in exceptional circumstances).
As the baby’s head is delivering, help the mother to AVOID Pushing by getting her to pant.
Check the umbilical cord, if wrapped around baby’s neck then try to loop it over, but it will still delivery the baby.
When baby is born, dry the baby and wrap in a clean dry towel, place onto mothers chest immediately.
Assess the baby for breathing, if the baby is crying then it has a clear airway. If baby is not breathing then confirm that airway is open (refer to newborn life support)
Once baby is breathing, cyanosis will gradually improve over serveral minutes, if not give oxygen near the baby’s mouth with low flow.
Wait until the cord has stopped pulsating and apply two cord clamps 3 cms apart and about 15cms away from the umbilicus. Cut the cord between the two clamps. Place baby on its mother where she can breast feed if she wants to.
Get the mother to adopt a squatting position. Do not pull the cord. Put the placenta into a plastic bag for inspection from midwife or doctor. Assess the amount of blood loss (shouldn’t exceed 200-300ml) conduct full set of obs)
What is your management for Pre-term delivery?
Assess the period of gestation
If <22 weeks: transport to nearest gynaecology unit
22-37 weeks: every effort should be made to take patient to a consultant led unit without delay.
If birth is imminent, request a midwife and an additional ambulance.
If baby is born, immediately take to nearest ED or obstetric unit. Mother is to follow to the same hospital
If a patient is having a seizure whilst pregnant what is your management?
Same as normal seizures, assess A and B and refer to convulsion guidelines.
What is your management for a prolapsed umbilical cord?
The decent of the umbilical cord into the lower uterine segment. This is a time critical emergency
Use 2 fingers to replace the cord into the vagina. Make 1 attempt only to replace the cord. Handle to cord as little as possible to prevent spasm.
If it is not possible to replace the cord, use dry padding to prevent further prolapse and position the patient on her side with padding under her hips.
Administer entonox to prevent the urge to push and pre-alert the maternity unit or ED. Blue light into hospital
What defines post partum haemorrhage and what is your management?
Primary PPH: 500mls or more over 24 hours
Massive PPH: blood loss of 50% of the blood volume within 3 hours.
If the placenta has delivered:
Palpate the abdomen and feel for top of the uterus usually at the level of the umbilicus and massage gently in a circular motion using a cupped hand.
Offer entonox as uterine contraction can be uncomfortable.
Administer misoprostol under the guidelines.
Gain IV access and administer fluid replacement. Check for tears at vaginal entrance and apply gauze direct to stop the bleeding
What is your management for placental abruption?
Patient will have severe abdominal/back/epigastric pain and may not present with bleeding (concealed abruption)
Assess A and B. Once established the patient is pregnant, convey without delay to consultant led unit.
Insert a large bore cannula and give fluid therapy if required. Encourage the mother to lie in a comfortable position, pre-alert.
What is your management for multiple births?
If delivery is not in progress, convey to nearest consultant led unit.
If delivery is in progress, request back up and midwife and follow the normal delivery management.
Once the first baby has been born transfer mother and baby to nearest maternity unit, if birth of the second baby occurs on route, pull over and request a second crew to take the second child
What is your management for a breech birth?
If delivery is not in progress, transport to the booked obstetric unit without delay and constantly reassess.
Is it is progress then get mother to sit over the edge of the sofa, don’t touch the baby or umbilical cord until the body is free of the birth canal and the nape of the neck is visible. Only exception is when the baby’s back rotates to face the mothers anus. The umbilicus should always face the anus.
Don’t clamp or cut the cord until the head is free of the birth canal. Once the body of the baby is born gently lift the baby by its feet to facilitate the delivery of the head.
Once baby is delivered, treat for a normal delivery.
What is your management for a shoulder dystocia?
Do not cut the cord until baby’s head is delivered
Do not press of the uterine fundus
First attempt McRoberts manoeuvre
The attempt suprapubic pressure
If no success encourage the mother to empty her bowels and as the assistant to apply intermittent pressure on the shoulder, encourage mother to push through next 2 contraction.
If no luck after 2 contractions then position the mother on all 4s as the mother contracts, apply gentle traction to the baby’s head (both out and downwards) try twice before undertake a time critical transfer to consultant led unit, give high levels of o2 and pre-alert.
You deliver a baby at home, what reasons should the baby be conveyed to hospital?
Required resuscitation Birth asphyxia (APGAR below 5) Meconium staining or aspiration Baby of a diabetic mother Small for dates/ growth retarded baby Prematurity (gestation <36 weeks) Any baby that required naloxone at birth Major congenital abnormalities, even if baby appears well at birth Red flags suggesting a high risk of early onset neonatal bacterial infection.
What are the red flags that suggest a high risk of early onset neonatal bacterial infection?
Systemic antibiotic treatment given to the mother for confirmed or suspected invasive bacteria
Seizures in the baby
Signs of shock in the baby
Need for mechanical ventilation in a term baby
Suspected or confirmed infection in a co-twin
What is the APGAR score and what is the scoring?
The APGAR score is used to assess the condition of the baby after birth. APGAR stands for:
Appearance
0 - blue or pale all over
1 - blue at extremities, body pink
2 - body and extremities pink
Pulse
0 - absent
1 - <100
2 - > 100
Grimace
0 - no response to stimulation
1 - grimace/ feeble cry when stimulated
2 - cry or pull away when stimulated
Activity
0 - none
1 - some flexion
2 - flexed arms and legs that resist extension
Respiration
0 - absent
1 - weak, irregular, gasping
2 - strong, lusty cry
