Obs Emergencies, IPV, Perinatal Loss Flashcards
GBV and IPV rates _______ during pregnancy
Increase
___ of women >16 reported at least 1 incident of physical/sexual assault
51%
______ of women had been abused by their intimate partners
25%
Of Canadian women who reported being abused by their partner in pregnancy, 40% stated violence _________ during the pregnancy
Began
Indigenous females in Canada have been shown to have ______ the odds of being a victim of IPV (generally)I
4-5x
Impact of Domestic Violence on Pregnancy
§ Delayed/less PN care
§ Stress/depression
§ Financial effects
§ Inadequate weight gain
§ Substance use/abuse
§ Physical and sexual health complaints
Impact of domestic violence on fetus
Direct physical trauma causing injury or miscarriage
Negative effects of behaviours
Preterm labour/birth
Low birthweight/SGA
Impact of domestic violence on postnatal period
- Decreased likelihood of breastfeeding
- Maternal mental health issues associated with difficulties in parenting and mother-child bonding
- Increased risk of aggression, emotional disorders, and hyperactivity in the child
- Increased risk of child abuse, associated with risk-taking behaviours in adolescence and adulthood
Studies have found insufficient evidence that recommend ____ or _____ “routine” screening.
Providers should include queries about violence in the assessment of new patients at annual visits as part of prenatal care.
for or against
Several validated screening tools exist; however, the ___________________ and how questions are asked seem more important than the screening tool.
nature of the clinician–patient relationship
Ensure you have __________ with the client in case they need to speak in confidence
* In ______ or _______
time alone
shower/bathroom
Dystocia
Something not going as planned; difficult labour
What dystocias exist with powers/uterine contractions?
Hypotonic Contractions
Hypertonic Contraction
Arrested Labour (complete cessation)
Precipitious Labour (<3hr)
Risks associated with Precipitious labour
pelvic injury, trauma risk for fetus, doesn’t allow full dilation, potential for rupture and intracranial hemorrhage/hypoxia to fetus
Any presentation other than ______ or slight variation in fetal position or size increases probability of ________
occiput anterior
dystocia
What problems with the passenger cause dystocia?
Persistent Occiput Anterior
Cephalopelvic Disproportion
Breech
Shoulder Dystocia
Cord Prolapse
Breech presentation is associated with:
multiple gestation, grand parity, previa, hydramnios, preterm, uterine abnormalities
Breech presentation is most common in _____. Why?
Preterm
Lots of room to move around, nothing stressing fetus to get into that position
Frank Breech
50-70%
Feet up by ears
Footling Breech
Foot presents first
10-30%
Require C/S
Complete breech
Head up top in fundus
5-10%
Diagnosis of Breech
- maternal perception
- leopolds
- FH
- Vag exam
- Ultrasound
- Passage of Thick Meconium
Maternal Perception of Breech presentation
- In cephalic/head down most movement is felt up top where feet are
- If felt in lower abdomen, likely breech
Leopolds Maneuver of Breech Presentation
- hard, ballotable part (head) in uterine fundus (top)
FH of Breech Presentation
auscutated above umbilicus
* pre-term or small fetus - may still be below umbilicus.
Vag exam of breech presentation
Not palpating fontanelles
Why is passage of meconium a diagnostic factor of breech?
If getting contractions on torso
Fetal risks associated with breech
- cord prolapse
- traumatic injury
- preterm breech leading to entrapment
Cord Prolapse as a risk for breech
more likely with ROM
r/t softer bum/ not hard head on cervix – cord has higher likelihood/easier for slipping down
Traumatic injury as risk for breech
to the aftercoming head can cause
- intracranial hemorrhage
- anoxia
- congenital dislocated hips because they are used to that position
How does entrapment happen in preterm breech?
Preterm breech – footling & body may deliver before full dilatation entrapment
Criteria for vaginal delivery of breech (6)
- uncomplicated
- term,
- frank or complete breech,
- singleton,
- > 2500 and <4000g
- with flexed head
When is external cephalic version done?
Option if patient does not want C/S
Baby is manually turned externally
Best 34-37 weeks (risk baby flips himself back) or after 37 weeks (inducing)
In external cephalic version, fetus cannot be
Engaged
What medication is given prior to external cephalic version
Tocolytic to relax uterus (if done preterm)
Risk for external cephalic version
Nuchal cord
Indications for a C/S (10)
- non reassuring FHR
- herpes
- multiple gestation (>3)
- cord prolapse
- pelvic size
- lack of progression/failed induction
- maternal infection/severe disease
- previa
- vertical C/S incision
- fetal anomalies in size
Intra-operative C/S risks
- aspiration
- difficult airway management
- PPH (>1000 mls)
Post op C/S risks
- Endometritis/Infection
- Hemorrhage
- Poor bladder emptying
- Paralytic ileus (rare)
- Thrombophlebitis
use of ranitidine or sodium citrate pre C/S
Patient’s may not have been NPO if urgent but need to decrease acidity of gastric acid
TOLAC depends on what 2 things
- Indication and type of 1st section
- Maternal health
Most common risks for TOLAC
Hemorrhage
Uterine rupture - Complete separation of the myometrium with/without extrusion of fetal parts into the maternal peritoneal cavity
Infant death or neurological complications
5 Key Management pieces for TOLAC
- continuous EFM
- contraction monitoring
- Avoid oxytocin (rupture)
- Avoid cervical ripening methods (rupture)
- c/s available
Uterine rupture
Most serious complication of TOLAC
Complete separation of the myometrium with/ without extrusion of fetal parts into the maternal peritoneal cavity usually at scar
Signs of Uterine Rupture
- First sign: abnormal FHR (specifically if patient has epidural)
- vaginal bleeding/hematuria
- maternal hypovolemic shock
- Abdominal palpation of fetal parts
- unexpected elevation of presenting part
- chest/shoulder pain/sudden SOB (bleeding into cavity displacing organs)
How can operative vaginal birth be prevented?
Support through early labour
- mobility
- position changes
- rest
- bladder empty
- well hydrated/nourished
Indications for operative vaginal birth
Any need to expedite 2nd stage
- FHR indications
- maternal exhaustion/inability to push
- lack of rotation of fetal head/largest diameter won’t line up
- maternal CAD
Important considerations in operative vaginal birth?
- Completely dilated / membranes ruptured
- Empty bladder
- Fetal position known / adequate pelvis
- Analgesia if able
- What is the plan if it doesn’t work?
§ OR availability
When can you expect progression using vacuum?
Suction applied to fetal head (occiput – not over fontanelles)
Pull with contractions
Should be progressive descent with first two pulls (with contractions – should only be 3 pulls)
Common newborn vacuum complications
Bruising, laceration, edema (caput)
Uncommon operative vaginal birth complications for newborn (7)
- Retinal hemorrhages
- Nerve injury
- Cephalhematoma (vacuum)
- Cerebral hemorrhage
- Skull fracture (forceps)
- Intracranial bleeding
- Subgaleal hemorrhage (vacuum)
What should you be assessing a newborn for after use of operative vaginal delivery tools?
hyperbilirubinemia
- Extra blood and RBC destruction
- Already at risk – given extra load r/t bruising/hemorrhage
Complications of operative vaginal delivery for labouring client
- Genital tract trauma
- Increased bleeding
- Risk for PPH
- Bruising and edema
- ? Shoulder dystocia
- Without descent in first couple pulls, shoulder dystocia could be cause
Shoulder dystocia definition
Anterior shoulder impacts against maternal symphysis pubis.
- Fetal shoulders do not deliver spontaneously
- Failure to deliver with expulsive effort & usual maneuvers
Major risk factors for Shoulder Dystocia
- maternal obesity/diabetes
- macrosomic infant
Interventions for Shoulder Dystocia
A - ask for help
L - lift/hyperflex legs with stools (McRoberts)
A - anterior should disimpaction (suprapubic pressure)
R - rotate posterior shoulder
M - manual removal/delivery of posterior arm
E - episiotomy
R - roll over onto all 4’s
McRobert’s Manoevre
Lift / hyperflex legs with stools
Pelvis tilts, orienting symphysis more horizontally to facilitate shoulder delivery
Suprapubic pressure
NOT fundal pressure
Lateral pressure above symphysis in direction of fetal nose to bring shoulders closer together
Protect your back (foot stool and get on bed)
Support/inform patient and support person
Complications of Shoulder Dystocia to client
§ Episiotomy
§ Extended Lacerations
§ Hematomas
§ Uterine atony
§ Hemorrhage
§ Bladder Injury
§ Rectal Injury
Fetal complications of shoulder dystocia
§ Fracture of clavicle or humerus
§ Brachial plexus injury or spinal nerve damage
§ Erb’s palsy
§ Asphyxia
§ Death
How is cord prolapse detected?
Sudden, severe, variable decelerations or no fetal heart
Feel or see cord
* Or not…. May not have protruded all the way out of vagina
Causes/Increase Risk for Cord Prolapse
- polyhydraminos
- long cord
- malpresentation
- PROM
- amniotomy before engaged vertex
Why is polyhydraminos a risk for cord prolapse?
Fetus and cord floating around, come down together and cord wins
Why is malpresentation a risk for cord prolapse?
Head isn’t blocking opening
What precaution is taken to assure cord prolapse isn’t occuring and why?
Immediately after ROM - displacement of fluid - CHECK FHR - if normal lack of risk of prolapse
Why is cord prolapse bad/emergency
Cord = only way baby gets oxygen - prolapse completely cuts of oxygen source
Management of cord prolapse
Keeping pressure off of cord!
- trendelnburg/knee to chest position
- keep gloved hand in vagina to prevent compression
- decrease contractions (C/S coming - don’t need)
- warm, wet sterile cloth if outside vagina
- only VD if fully dilated (often C/S)
