Mother & Child In Immediate Post-Partum Period

Question 1

What is the Apgar score?

Answer 1

A quick and replicable test with 5 categories that determines physical condition and health of the newborn and whether the baby needs help or resuscitating:

1 min score = how baby tolerated birth process
5 min score = how baby is doing outside of uterus

Normal = ~7-9/10 
Abnormal = < 7/10

Question 2

What are the 5 categories of the Apgar score?

Answer 2

Appearance (skin colour/cyanosis)
Pulse rate (>100bpm)
Grimace (reflex irritability)
Activity (muscle tone)
Respiratory effort 

For each one you score 0, 1 or 2 so MAX = 10/10

Question 3

Why do babies very rarely score 10 out of 10 in the Apgar Score?

Answer 3

Because babies often come out looking slightly off in colour e.g. jaundice or cyanosed

Question 4

Why is routine suctioning of the newborns oral and nasal passages now not recommended?

Answer 4

As baby is capable of clearing fairly large amounts of lung fluid naturally

Question 5

What would you do if there was suspicion that the baby had aspirated a lot of amniotic fluid?

Answer 5

If they are grunting or breathing funny as a result of liquid in their airways, you would want to suction the newborn and also put them on a continuous positive airway pressure (CPAP) machine

Question 6

What is neonatal respiratory distress?

Answer 6

Condition affecting 7% of all term newborns where there is commonly transient tachypnea triggered by excessive lung fluid and recognized as one or more signs of increased breathing i.e. tachypnea (>60bpm), nasal flaring and grunting - NOT the same as respiratory distress syndrome in premature babies

Question 7

What is the normal respiration rate for a newborn baby?

Answer 7

30-50bpm

Question 8

What might you do if there is suspicion of respiratory distress in a newborn?

Answer 8

ABGs

Question 9

What is skin-to-skin contact and why is it important?

Answer 9

When a baby is placed in contact with mother or partners skin and dried with pre-warmed towels undisturbed for 1 hour to help the baby regulate temperature (lose heat dramatically after birth), breathing, HR and possibly blood sugar - also has +ve effects on initiation/duration of breastfeeding (dont ask about before contact and encourage initiation in 1st hour)

Question 10

According to the evidence based guidelines, how should a baby be treated immediately after birth?

Answer 10

Kindness and respect of the newborn baby should involve gentle handling and avoidance of excessive noise

Question 11

What is moulding?

Answer 11

Overlapping of the bones of the foetal skull that self resolves quickly in the first 24-48 hours as a result of compression on cervix for e.g. in an OP position

Question 12

What is caput?

Answer 12

Characteristic change in apparent shape of the foetal head due to subcutaneous collection of fluid with poorly defined margins (often crossing suture lines) caused by pressure on presenting part of head during birth that self-resolves in first 24-36 hours

Question 13

What is cephalohaematoma?

Answer 13

Subperiosteal haemorrhage bound by periosteum so swelling does not cross suture lines (in contract to caput succedaneum) often associated with instrumental delivery - may take longer to resolve (no. of weeks) and cause jaundice so bilirubin should be monitored

Question 14

What is plagiocephaly?

Answer 14

A type of flat head syndrome where the head is flattened on one side causing it to look asymmetrical; ears may be misaligned and head looks like parallelogram when seen from above with the forehead/face bulging a little on flat side

Question 15

Why can flat head syndrome occur?

Answer 15

Bones of the foetal skull in utero and very early life are relatively soft and malleable so can be shaped by restriction or positioning

Question 16

What is brachycephaly?

Answer 16

A type of flat head syndrome where the back of the head becomes flattened causing the head to widen and forehead to bulge out - more common in premature babies and since ‘back to sleep’ campaign

Question 17

What is the Back To Sleep campaign?

Answer 17

Encouragement of parents to get infants to sleep on their backs (supine position) to reduce risk of sudden infant death syndrome (SIDS)

Question 18

How can you help mums to breastfeed?

Answer 18

Offer skilled breastfeeding support including advice on positioning, attachment and ways to prevent concerns

Question 19

What are the first 2 examinations of the newborn?

Answer 19

1. Initial exam at birth and within the first couple of hours composed of a general exam recorded in the hospital postnatal notes
2. Newborn and Infant Physical Exam (NIPE) within 72 hours including more detailed checks and recorded in the red book (Personal Child Health Record (PCHR))

Question 20

What should the initial examination of the newborn include (don’t list all)?

Answer 20

Assess physiological adaptation into extra-uterine life by looking at:

• Appearance inc. colour, tone
• Palpate bony structures of spine and integrity of skin
• Note colour and texture of skin
• Note cry sound
• Note weight
• Check CNS by assessing tone, behaviour, movements and posture (elicit reflexes if concerned)
• Head (inc. fontanelles), face, nose, mouth (inc. palate), ears and general symmetry of head and facial features noting head circumference
• Neck and clavicles, limbs, hands, feet and digits assessing proportions and symmetry
• HR
• Breathing by checking effort, rate and sounds
• Check shape of abdomen and umbilical cord
• Check completeness of genitalia and anus

Question 21

What should the Newborn and Infant Physical Exam (NIPE) consist of?

Answer 21

1. Heart: check position, rate, rhythm and sounds, murmurs and femoral pulse volume
2. Eye examination: check opacities and red reflex
3. Testes examination: check for patency and undescended testes in male
4. Hip examination (some children more likely to have developmental hip dysplasia): check symmetry of limbs and skin folds; perform Barlow and Ortolani’s manoeuvres
5. Abdomen: palpate to identify any organomegaly

Question 22

What should you ensure when you are carrying out the initial examination of the newborn?

Answer 22

Carry out in mothers/fathers presence after obtaining consent accompanied by a comprehensive explanation of the procedure, reason for it and afterwards explain and record findings

Question 23

What are the guidelines regarding vitamin K administration?

Answer 23

Vitamin K administration requires informed consent as well as explanation and education regarding deficiency bleeding and its signs/symptoms - baby finds it difficult to clot after delivery as its hard work so this can help

Question 24

What should be carried out in the immediate post-partum period to the mum?

Answer 24

Vital signs
Bladder/bowels
Perineum/lochia/sutures
Fundus
Breasts
Vital signs
BP (pulse esp.)

Question 25

What are some examples of serious postnatal problems that can occur in the mum?

Answer 25

PPH
VTE
Anaemia
Postpartum psychosis (2-3 days after birth) which can lead to suicide or infanticide

Question 26

What are some risk factors for primary post-partum haemorrhage (PPH) before the birth?

Answer 26

Previous PPH in pregnancy
BMI > 35
4 or > babies previously
Carrying twins/triplets
South Asian 
Placental praevia
Placenta abruption
Pre-eclampsia/HBP
Anaemia

Question 27

What are some risk factors for primary post-partum haemorrhage (PPH) in labour?

Answer 27

Caesarean section
Labour induction
Retained placenta
Episiotomy 
Forceps/ventouse delivery
>12 hrs labour
Big baby >4kg/9lbs
1st baby >40 years old

Question 28

What anatomical changes occur to the mum after birth?

Answer 28

• Uterus involutes from 1kg to 100g becoming a pelvic organ within 10 days with PA reducing by 1 finger-breadth each day
• CVS reverts to normal in 2 weeks
• Vaginal wall is initially swollen and bluish but regains tone although fragile for 1-2 weeks
• Perineal oedema may persist for few days
• Cervix is firm and internal os closes by day 3 whilst external os closes at week 3
• Lochia is red on days 1-3 (blood and trophoblastic tissue remnants), yellow by day 10 and white white until 6 weeks

Question 29

What is lochia?

Answer 29

Vaginal discharge containing endometrial slough (endometrium repairing and involuting), RBC and WBC

Question 30

List a few common puerperal problems that occur to the mum after giving birth.

Answer 30

1. Mastitis via S.Aureus infection treated with Flucloxacillin and Analgesia
2. Perineum episiotomy/tear which can cause pain/infection so should be repaired
3. Micturition retention due to pudendal n. bruising so may want to catheterize - 50% develop stress urinary incontinence so pelvic floor exercises should be encouraged
4. Bowel problems e.g. constipation (stool softeners) and haemorrhoids causing pain (ice pack/anusol)
5. Backache: in 25% of women so give analgesia, support when sitting, physioT and gentle exercise e.g. swimming
6. Psychological problems: blues (temp. sad/emotional) and 10% get PND within 1 year so give ADs

Question 31

What is the puerperal period?

Answer 31

Period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition