MCQ Flashcards
What are the most important individual factors that have an impact on human performance? (2)
Stress
Fatigue
Which of the following conditions could increase the risk of a woman developing sepsis? (3)
A- Woman had miscarriage in last 12 weeks
B- Women taking immunosuppressants for autoimmune disease
C- Women who have premature rupture of membranes
D- Women who are pregnant
B
C
D
Which blood test taken in the context of sepsis, should be interpreted with caution if woman has recently given birth?
Lactate
Which of the following are not causes of maternal collapse? (2)
A- Hirsutism
B- AFE
C- Sepsis
D- Skin rash
A
D
Which of the following actions are recommended in the A-E assessment of deteriorating woman?
A- Head tilt/chin lift, IV access, insert catheter with urometer
B- Left lateral, fluid bolus, give oxygen
C- Elevate legs, consider oral or IV glucose, assess medical needs
D- All of above
D- All of above
Placenta praevia is classified in… categories
4
Which one of the following actions should NOT be performed if a woman presents at 37/40 with a 40mls APH to MAU, unless placental site has been confirmed?
A- Speculum examination
B- VE
C- Presentation scan
D- All of above
B- VE
Which of the following are true about AFE? (2)
A- Fatality rate is 90%
B- Most women who die do so within 2 hrs of presentation
C- An ABG is the only test that can detect an amniotic fluid embolism
D- It rarely happens in 1st trimester
B- Most die within 2 hrs
D- Rarely happens in 1st trimester
Which of following about uterine inversion are FALSE?
A- Replacing uterus may always be done in theatre
B- Tocolysis might exacerbate atonic postpartum haemorrhage
C- Placenta should be removed whilst uterus is inverted outside of the vulva to aid visualisation
D- There is no need to X-match blood products
A- replacing uterus may always be done in theatre
C- placenta removed whilst uterus inverted
D- no need to X-match
What signs and symptoms would make you suspicious of uterine rupture when caring for a woman in labour having a VBAC?
Severe continuous abdominal pain
Slowing down of previously effective and regular contractions
Maternal tachycardia
Definition of placenta percreta
Penetrate through the myometrium, up to the serosa. Can potentially involve other organs
Which of the following are risk factors for a retained placenta? (2)
A- Cervical constriction ring, previous retained placenta
B- Premature birth or stillbirth
C- Maternal cardiac conditions
D- Maternal eczema
A- Cervical constriction ring, prev retained placenta
B- Premature birth or stillbirth
Which of the following are risk factors for uterine rupture?
A- Gestational diabetes
B- Use of prostaglandin in women having VBAC
C- Trauma to abdomen
D- None
B- Prostaglandin in VBAC
C- Trauma to abdomen
Which one of the following about retained placenta is FALSE?
A- Oxytocic agents should be injected in umbilical vein
B- Offer VE to assess need for manual removal
C- Assessing blood loss is always important
D- Always check placenta, membranes and cord following manual removal
A
During NLS, if after first round of inflation breaths the chest has not risen and heart rate is still slow, what should you consider next?
Inserting a Guedel airway
What is the approach to newborn resuscitation in order?
Dry and cover baby, assess situation, airway, breathing, chest compressions, (drugs)
How can a midwife facilitate breech birth? (2)
A- Clean away maternal faeces
B- Discourage epidural use
C- Encourage all-fours position
D- Apply FSE
B- Discourage epidural
C- All-fours position
During a breech birth when do you need to be more alert and potentially prepare to intervene?
A- Barrel-shaped stomach
B- Emerging body is white/blue mottled with long repurfusion time
C- No bulging of perineum after arms born
D- All of above
D
Incidence of congenital heart disease
Averages 8 per 1,000
(6-12 per 1,000 live births)
Of the 8/1000 with CHD, what percentage accounts for Critical congenital heart disease?
15-25%
Critical CHD
potentially life-threatening duct dependent conditions and those conditions that require procedures within first 28 days of life
Major serious CHD
those defects not classified as critical but requiring invasive intervention in the 1st year
Clinical risk factors for CHD
- 1st degree family hx
- Fetal trisomy 21
- Cardiac abnormality detected at anomaly scan
- Maternal exposure to viruses eg. rubella in early pregnancy
- Maternal T1 diabetes, epilepsy, SLE
- Antiepileptic and psychotrophic drug use in pregnancy
What leads to the first gasp of newborn?
Light
Sound
Touch
Gravity
Cooler temp
Cord clamping- increased co2 stimulates respiratory centre
Process of examination in NIPE:
History
Appearance of baby
Breathing
Pulses
Peripheral circulation- capillary refill
Auscultation of heart
Areas of Auscultation
- Aortic area
- Pulmonic area
- Tricuspid area
- Mitral area
- Coarctation area- midscapulae
Screen positives for critical major CHD
- tachypnoea at rest
- episodes of apnoea > 20 secs
- chest recession, nasal flaring
- central cyanosis
- visible heaves, thrills
- absent/weak femoral pulses
- cardiac murmur or extra heart sounds
Who is at risk of developing sepsis?
- impaired immune system
- gestational diabetes
- C section, forceps, removal of retained products of conception
- PROM
- close contact with group A strep eg. Scarlet fever
- continued vaginal bleeding
- Premature labour
- Invasive intrauterine procedure
- cervical suture
-breast abscess - wound haematoma
In how many cases is culture-positive sepsis observed?
30-40%
Signs and symptoms of Sepsis
- Widespread rash, sandpaper/ goose skin texture
- Fever
- D+V
- Abdo pain
- Wound infection
- Offensive vaginal discharge
- Tachypnoea RR>24
- Hypotension SBP<90
- Tachycardia
- Pyrexia >38
- Low sats
- Poor peripheral perfusion
- Pallor/grey
- Clamminess
- Low urine output
Often, what is the first sign that a patient is deteriorating?
Tachypnoea
Why does sepsis cause hypotension?
Vasodilation leads to absolute hypovolemia
If sepsis causes hypotension, what does the body do to compensate?
Compensatory tachycardia
Definition of maternal collapse
Severe respiratory or cardiocirculatory distress that may lead to a sudden change in level of consciousness or cardiac arrest if untreated
What 6 H’s are the cause of maternal collapse?
Head
Heart
Hypoxia
Haemorrhage
wHole body and Hazards
What signs trigger an emergency response for ABCN?
A- obstructed and noisy
B- resp rate <5 or >35
C- pulse <40 or >140, systolic BP <80 or >180
N- sudden decrease in level of consciousness, unresponsive or responsive to painful stimuli only, seizures
What is Amniotic Fluid Embolism?
Caused by amniotic fluid entering maternal circulation and triggers a serious reaction that includes cardiorespiratory collapse and/or coagulopathy
Initial onset of AFE is…
severe pulmonary hypertension
Risk factors for AFE
- IOL with prostaglandin
- Increased maternal age
- C section
- Vaginal instrumental
- placenta praevia
- multiple pregnancy
- atopy, or latex, medication or food allergy
What triad could suggest diagnosis of AFE?
Hypotension
Coagulopathy
Hypoxia
What is AFE always associated with a form of?
Disseminated intravascular coagulopathy (DIC)
…. as a presenting feature is recorded in 60-80% of registered cases of AFE
Cardiac arrest
When most commonly do women present with AFE?
in labour
What helpful investigations help diagnose AFE?
- X-ray showing diffuse opacity in lung fields
- Arterial blood gases
- Echocardiograms
- ECG
Define APH
bleeding from or in to the genital tract, occurring from 24 weeks and prior to birth
What is responsible for around 31% of APH?
Placenta praevia
Risk factors for placenta praevia
- previous CS
- prev TOP
- multiparity
- maternal age >40
- multiple pregnancy
- assisted conception
- smoking
- fibroids, uterine scar, endometriosis, prev MROP
What is classed as a low-lying placenta?
< 20 mm from the internal os
What gestation is the follow up USS for placenta praevia?
32 weeks
Signs and symptoms of placenta praevia
- out of blue- sometimes post coital
- bright red blood loss
- high presenting part or transverse lie
- recurrent spotting
- bleeding more common from 28-30 weeks due to formation of lower uterine segment
What are the 4 categories of placenta praevia?
- minor
- marginal
- partial
- complete
What is placental abruption?
premature separation of a normally positioned placenta occurring > 24/40
What is the cause of APH in 22% of women?
placental abruption
Risk factors for placental abruption
- PET/hypertension
- IUGR
- non-vertex presentations
- polyhydramnios
- low BMI
- abdo trauma
- following ECV
- PPROM
- intrauterine infection
- cocaine and amphetamines
Signs and symptoms of placental abruption
- loss dark red
- uterus enlarged and irritable
- abdomen hard, ‘woody’
- difficult to auscultate FH or determine fetal lie
- pathological CTG- fetal compromise
- maternal skin grey/pale, moist
- backache
What is Vasa praevia
fetal vessels run through the membranes across the internal os and in front of presenting part.
Associated with velamentous cord insertion or succenturiate lobes.
If APH settles and normally situated placenta…
- daily CTG
- stay in hospital until no APH for 24-48hrs
3 degrees of placental invasion:
- Accreta
- Increta
- Percreta
Placental accreta
placental villi adhere to the myometrium
placental increta
invade into >50% of myometrium
placental percreta
penetrate through the myometrium, up to the serosa. Can potentially invade organs eg. bladder
Risk factors for placental accreta spectrum
- uterine surgery
- repeated surgical TOPs
- age
- multiparity and assisted conception
At what gestation should elective delivery be for placenta accreta?
between 35-36 weeks with a course of steroids
What is classed as prolonged third stage with active management?
> 30 mins
What is classed as prolonged third stage with physiological management?
> 60 mins
What can a midwife do to help placenta separation?
- empty bladder
- skin to skin and BF to release oxytocin
- massage fundus
If woman is bleeding after MROP, what oxytocic agent is given?
30-40 IU oxytocin infusion
What are the 4 grades of uterine inversion?
- fundus inverts down to the cervical canal
- fundus inverts into the vagina
- fundus is visible at the introitus
- fundus below the level of the introitus
Risk factors for uterine inversion
- excessive traction on cord
- inappropriate fundal pressure
- short cord
- abnormally adherent placenta
- VBAC
- unicornuate uterus
- fetal macrosomia
- precipitate labour
Most common first sign of uterine inversion
sudden maternal shock or collapse
uterine inversion associated with vasovagal shock which is characterised by…
bradychardia
hypotension
What is the main complication with uterine inversion?
atonic postpartum haemorrhage
What is not a sign of sepsis?
Bradycardia
As a minimum, which physiological obs should be recorded at the initial assessment and as part of routine monitoring in critically ill and deteriorating patients?
Maternal pulse, respirations, systolic BP, level of consciousness, oxygen saturations, temperature
What is the cut off that would make you consider the lactate level abnormal?
> 2 mmol/L
What can be associated with an increased occurrence of placenta praevia?
Previous CS, multiple pregnancy, smoking, prev termination
Usual signs and symptoms of placenta abruption?
Constant and severe pain
Acute onset
What are potential complications of uterine inversion?
PPH
Neurogenic shock
What is neurogenic shock characterised by?
Bradycardia and hypotension
What 2 things are differential diagnoses for s&s of shock in labour?
Uterine rupture
AFE
What step should be done immediately before chest compressions in NLS?
30 seconds of ventilation breaths
During NLS ventilation breaths should be given at a rate of… per minute
30 bpm
Definition of primary PPH
The loss of 500mls or more of blood from the genital tract within the first 24 hrs of birth
A woman has lost over 1000mls of blood during PPH and he vital signs are still unstable. You’ve already given her 1.5L of Hartmann’s. What will you give her next?
1 unit of Red blood cells and 1 unit of Fresh Frozen Plasma
In the case of magnesium sulphate toxicity, what is the antidote?
Calcium Gluconate 1g IV
What does a lactate level > 4 mmol/l indicate?
tissue hypo perfusion
end-organ damage
