Obstetrics Flashcards
Four types of breech birth
- Complete Breech where hips and knees are flexed so foetus is sitting cross legged
- Frank Breech: legs flexed at the hip and buttocks presents first
- Kneeling breech
- Footling breech
Signs of imminent delivery of birth
- Increasing frequency of contractions with urge to push
- Membrane rupture
- Primal instinct
- Bulging perineum
- Appearance of presenting part
Complications of breech delivery
- Fetal distress and hypoxia
- prolapsed cord
- Head entrapement
- Meconium aspiration
- Inversion of uterus
- PPH
Birthing manoeuvres: Breech Birth
- Delivery of the buttocks and legs:
- Ask mother to push with contractions once but has entered vagina and let them delivery until shoulder blades are seen.
- If legs do not delivery spontaneously, delivery on leg at a time but grabbing ankle.
- Hold baby by the hips with thumbs on the buttocks - Delivery of the arms (if stretched out):
- Lovset’s Manoeuvre: Apply dry cloth wrapped around bab ‘s pelvis; hold baby by hips and turn 180 degrees, applying downwards pressures that the arm can dislodge anteriorly.
- Assist by placing 1-2 fingers on the upper part of arm; draw arm down and over the chest
- Rotate baby back 180 degrees to deliver second arm. - Delivery of the head:
- Mauriceau Smellie Veit manoeuvre: place baby face down with length of body over hand and arm. Place 1st and 2nd fingers on baby’s cheek bones and flex head.
- Use other hand to support occiput and back.
- pull gentley to delivery head
Care of the newly delivery baby
- Clean newborns mouth and nose of mucous, blood or meconium.
- If obstruction, gently suction the mouth and nasal flares.
- Use a dry towel to immediently and thoroughly dry baby, stimulating also.
- Within 30seconds: assess HR (stethoscope) and breathing status.
- IF HR <100, apply SpO2 monitoring to R) finger and commence resuscitation.
- Skin to skin and promote breastfeeding
- Apply SpO2 monitoring R) hand. SpO2 85-90% after 10mins.
- 1 min: APGRA
- 5 mins: APGAR
- Keep tab ywarm
When to commence resuscitation for newborns
- HR <100
- Reduced muscle tone
- Slow or irregular respirations
_ Centrally pale or cyanosed or CPO2 <60%
Newborn cord clamping
- Delay cord clamping and cutting 3-5 mins following birth
- Always gain permission
- Clamp at 10, 15 and 20cm and cut between the 15 and 20cm
New born resuscitation: assessment for resuscitation
- Observe colour and tone: limp muscle tone and minimal activity
- Breathing adequacy: recession, retraction, or irregular respirations
- HR: auscultate for 6 seconds.
Newborn resuscitation procedure
- Preterm: wrap in glad wrap (don’t dry)
- Blanket and beanie.
1. Airway: Supine with 1cm pad under shoulder blades
2. Breathing: If inadequate breathing, IPPV at a rate of 40-60 breaths/min - SpO2 R) hand
- Assess every 30 seconds
3. Circulation: <60bpm commence compressions
If HR >100bpm, stop resuscitation
Primary PPH
> 500mL blood loss in the first 24 hours following delivery.
Secondary PPH
Abnormal or excessive blood loss from birth canal 24hours to 12 weeks postpartum.
Excessive bleeding considered more than one heavily soaked pad per hour.
Risk factors of PPH
- Previous Hx of PPH
- Anaemia
- > 35 YO
- Multiparty
- Prior uterine surgery
- Preeclampsia and HELLP syndrome
- Obesity
- Uterine anomolies
- Abnormal placenta
- Prolonged second or third stage
- Large baby
- Infection or rupture of membranes
- Cesarean
- Manual removal of placenta
Causes of PPH (4 T’2)
Tone - inability for uterus to contract
Tauma - cervical and genital tract damage during delivery
Thrombin - Coagulation disorder
Tissue - retained products
PPH Management
- PPH identified
- Placenta birthed? if no, manage third stage of labour; if yes, commence fundal massage until firm and central.
- Empty bladder and breast feed
- If bleeding hasn’t stopped, manage cause of haemorrhage:
- continue fundus massage and administer oxytocin
- Assess for tears and apply compression
- Aortic compression
- Bimanual compression
Pre-eclampsia definition
high blood pressure, protein in the urine and severe swelling.Occurs during pregnancy after 20 weeks gestation and up to one month post partum.
Pre-eclampsia diagnosis
SBP >140mmHg AND/OR
DBP >90mmHg plus one or more of:
- Neurological problems
- Proteinuria
- renal insufficiency
- Liver disease
- Haematological disturbances
- Foetal growth restriction
Health consequences of pre-eclampsia and eclampsia
Placental abruption
DIC
Cerebral haemorrhage
Hepatic failure
Acute renal failure
HELLP Syndrome definition
Hemolysis, elevated liver enzyme’s and low platelets
- Severe variant of pre-eclampsia
Risk factors of pre-eclampsia
First pregnancy
Hx pre eclampsia
Gestational HTN
Increased maternal age
Renal disease
Diabetes
Obesity
Family Hx
Multiple babies
Pre-eclampsia clinical features
- Neurological: Headache, visual disturbances, seizure, hyperreflexia, clonus, dizziness
- Resp: acute pulmonary oedema
- CVS: HTN, oedema
- GIT: Epigastric pain, RUQ tenderness, N/v
- Jaundice
Pre-eclampsia management
- Identified pre-eclampsia: SBP >140; DBP >90; peripheral/generalised oedema; GIT disturbance.
- Lateral position to avoid hypotension.
- High flow O2
- Dark and cal envonrment
Eclampsia management
- Lateral position and maintain airway
- ICP back up
- High flow O2
- If delay in MgSO4, administration of midaz
- MgSO4 infusion (ICP only)
Trimester periods
Trimester 1: 1-12 weeks: Growing uterus is protected by bony pelvis
Trimester 2: 13-28 - Fondus is the height of the umbilicus
Trimester 3: 29-40 - fondus is the height of the ziphoid process
Cardiovascular changes in pregnancy
- Increase HR due to increase blood volume & O2 demand
- Increased SV
- Plasma volume increases by the 10th week
- Increased CO
- Decrease in BP 2nd trimester
- Hypercoaguluable state
Respiratory changes in pregnancy
- Dyspnoea due to diaphragm being pushed upwards
- Increased O2 requirements
- Increased tidal volume and RR
Renal & GIT changes in pregnancy
- Increased GFR by week 28
- Increased urinary frequency due to compression of bladder
- more UTI susceptibility
- Displacement of organs and peristalsis is slower
Three stages of labour
First stage: Dilation of cervix begins with regular painful contractions.
Second stage: Expulsion of foetus from full cervical dilation to complete birth of baby (recognised by transition to primal instinct)
Third stage: Separation and expulsion of placenta and membranes.
Obstetrics history
Number of pregnancies
Hx of labours/durations/gestationla outcomes
previous full-time or pre?
When did contractions being
Frequency and duration of contractions
Membrane rupture?
What position in last scan
Multiple babies?
Antenatal issues?
Preterm baby
<37 weeks
What stimulates the neonate to breathe?
- Fall in blood pH; when cord is clamped, lower O2 and increases CO2, detected by chemoreceptors and stimulating the respiratory centre
- Sensory and tactile stimuli
- Temperature changes from internal to external environment
- Chest wall compression during birth expels fluid and creates a negative pressure
APGAR
- Appearance: 0 - cyanosis/pallor; 1 - blue extremities, pink body; 2 - normal colour
- Pulse: 0 - absent; 1 - <100 BPM; 2 - >100bpm
- Grimace: 0 - no response; 1 - minimal reflex response; 2 - cry or responds to reflex.
- Activity: 0 - flaccid; 1- minimal flection of extremities; 2-good, active motion
- RR: 0 - Absent; 1 - slow, irregular or weak cry; 2 - good, vigorous cry
What causes a low APGAR score?
- Foetal distress due to hypoxia before delivery
- Maternal anaesthetic or analgesia
- Preterm infant
- Difficult or traumatic delivery
- Excessive suctioning
- Severe respiratory distress
HOW SHOULD YOU STIMULATE RESPIRATION IMMEDIATELY AFTER BIRTH?
Dried with a warm towel and rubbing newborn to stimulate breathing. Stimulation alone will normally start breathing in most cases.
