Maternity / obstetrics

Question 1

1. The first stage of labour can be separated into early and active labour; what happens in early labour?
2. What do contractions in early labour look like?
3. How long does early labour last?
4. How much does the cervix dilate in early labour?

Answer 1

1. Cervix softens, thins and shortens in early labour.
2. Contractions are infrequent, irregular in duration and less intense than in active labour (i.e. patient able to talk).
3. Early labour typically lasts hours to days.
4. Cervis typically dilates up to 6cm in early labour.

Question 2

1. The first stage of labour can be separated into early and active labour; what happens in active labour?
2. What do contractions in active labour look like?
3. How long does active labour last?
4. How much does the cervix dilate in active labour?

Answer 2

1. Cervix dilates in active labour - approx 1cm per hour
2. Contractions are increasingly frequent, regular and stronger
3. Active labour typically lasts 4-8 hours or more.
4. Cervis typically dilates from approx. 4-10 cm in active labour

Question 3

1. The last part of active labour is the transition period; what happens in the transition?
2. What do contractions in active labour look like?
3. How long does active labour last?

Answer 3

1. Cervix dilates from approx 7-10cm
2. Contractions are frequent, regular and intense (i.e. patient typically unable to talk), typically lasting 60-90sec and occuring every few minutes. May also feel leg cramps, pressure in the back, nausea, and urge to push.
3. Transition labour typically lasts 15min-1hr

Question 4

What are the signs of imminent delivery?

Answer 4

• Appearance of presenting part at the vulva
• Spreading of the labia during contractions
• Involuntary pushing
• grunting
• vomiting
• “I can’t do this” and/or “don’t touch me”

Question 5

During the second stage of labour, when should mum push? When should she stop pushing?

Answer 5

Push during contractions until head reaches the point of no return. Then pant / “breathe the baby out”.

Question 6

What questions should be added to the patient assessment in pregnancy/birth?

Answer 6

• Number of previous pregnancies (gravida)
• Number of live births (parity)
• Number of miscarriages (M)
• Weeks gestation
• Number of babies
• Any complications in this/previous pregnancies
• Have you felt the baby move?
• Have your waters broken? What colour were they?
• Ante-natal care? Baby position?

Question 7

What are the colour variations of the amniotic fluid? What do each of these colours mean?

Answer 7

• Clear / tinted yellow- normal
• Green - merconium in fluid indicates baby distressed / breech presentation
• Greenish yellow - post term pregnancy
• Tobacco colour - intrauterine death of foetus
• Dark coloured or blood stained - concealed haemorrhage in abruptio placenta

Question 8

What are the signs of shoulder dystocia?
What maneouvres can be performed?

Answer 8

• Turtle-heading
• Failure to deliver head within next contraction

External maneouveres - McRoberts (knees to nipples) + supra-pubic pressure behind anterior shoulder

Internal (consult with on-call neonatologist via ECP) - deliver posterior arm, or woods screw to move posterior arm to be anterior

Question 9

What are the risk factors for shoulder dystocia?

Answer 9

• Previous shoulder dystocia
• Macrosomia (large foetus) > 4kg
• Maternal diabetes mellitus
• Maternal obestity (BMI>30)
• Older maternal age (>35yrs)
• Post-term pregnancy
• Excessive weight gain during pregnancy

Question 10

Within what time-frame should the newborn take its first breath?

Answer 10

Newborns should establish spontaneous effective respirations within 30 seconds; otherwise intervention is required

Question 11

What are the components of MRSOPA?

Answer 11

Mask adjustment - size and fit
Reposition head - neutral or slightly extended
Suction mouth then nose - only if airway compromised
Open mouth - lift jaw forward
Pressure increased if no chest rise - lock BVM blow off valve, max 3 breaths, release lock
Artificial airway - SGA (e.g. size 1 i-gel) early if ventilations are still ineffective

Question 12

In newborn resus, how many rounds of ventillation are given before CPR is considered?

Answer 12

2 rounds
* 1st round - cut cord if needed, ensure baby warm, head properly positioned
* 2nd round - MRSOPA

Ventillations provided with Room Air for first two rounds

Question 13

If the newborn has HR< 60 after two rounds of ventillation, what should be done?

Answer 13

Commence CPR 3:1
100% O2 (10L/min)
Pause for ventillations

Question 14

If the newborn has HR 60-< 100 after two rounds of ventillation, what should be done?

Answer 14

IPPV 40 – 60 per min
100% oxygen (10 L/min)
SpO2 monitoring (pre ductal - right hand)

Question 15

If the newborn has HR >100 after two rounds of ventillation but theres’ still
* ineffective breathing
* no cry
* poor muscle tone, or
* persistent cyanosis
what should be done?

Answer 15

oxygen therapy (10 L via tubing in vicinity of nose and mouth)
SpO2 monitoring (pre ductal - right hand)

Question 16

How much bleeding is to be expected during birth? What is the trigger for primary post-partum haemorrhage (PPH)?

Answer 16

Up to 300ml expected
Primary PPH: 500ml blood loss within the first 24hrs post-birth

Question 17

What are the 4 T’s to consider in primary PPH?

Answer 17

Tone (uternine tone - assess fundus / fundal massage)
Tissue - check placenta for retained products
Trauma - internal trauma
Thrombin - bleeding / clotting disorder

Question 18

What is secondary PPH?
What are the most common causes of secondary PPH?

Answer 18

Acute, excessive bleed between 24 hours and 12 weeks post birth

Causes:
* Diffuse uterine atony OR subinvolution of the placental site
* Retained products of conception
* Infection

Consideration should be given to the potential for sepsis and managed accordingly when indicated.

Question 19

What are the indications for fundal assessment?

Answer 19

Post-delivery (no massage until placenta delivered)
Patients with seconday PPH

Question 20

What are the priorities in post-partum haemorrhage?

Answer 20

• Early clinical support (ICP + EOC consult)
• Temperature management
• Prioritise early transport and minimise scene time where possible
• Assess fundus / fundal massage (if indicated)
• Assess external labia and perineum
• Encourage patient to empty bladder
• Facilitate skin to skin contact
• Large bore IV access x 2 above diaphragm if possible

Question 21

What are the indications for TxA in post-partum haemorrhage?

Answer 21

Pt>= 16yrs and PPH within 3hrs of injury or birth
(note: no BP / pulse requirement for TXA in PPH - trauma only)

For secondary PPH consult EOC clinician for SAAS Medical Practitioner advice on TXA

Question 22

How much TXA is administered in PPH? How is it administered?

Answer 22

TXA 1g/10ml
IV slow push over 2-3min

Question 23

How can the perineum be guarded / protected during birth?

Answer 23

Towel damped with warm water applied to perineum (softens skin)
Pressure applied to perineum with two fingers of dominant hand (pulling inwards)

Question 24

During the 3rd stage of labour, what are the signs of placental separation?

Answer 24

• The uterus rises in the abdomen, becomes firmer and globular
• Fresh show/trickle of blood
• Lengthening of the umbilical cord