Obstetrics Flashcards
Full term
over 37 weeks
Pre-term
24-37 weeks
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Vaginal discharge of mucous and blood
Spontaneous rupture of membranes
Gush of pink or clear fluid. Can occur from onset of labour until baby is born.
Meconium stained amniotic fluid
Greenish/brown stained amniotic fluid
First stage labour
Onset of regular painful contractions to full cervical dilation.
Contractions every 2-20 mins, 20-60 seconds duration)
Second stage labour
Full cervical dilation to birth of baby
Typical duration primipara 1-2hours, Multipara 15-45mins
Imminent birth presentation:
Crowning Rectal pressure Anal pouting/bulging perineum Mother states "i'm going to have the baby" Pushing and grunting Strong urge to push
Precipitate birth
Unusually rapid labour (less than 4 hours) with extremely quick birth.. Rapid change in pressure can cause cerebral irritation.
Hx of previous pregnancies
Number of pregnancies
Prior ceasareans
Complications
Length of previous labours
Hx of current pregnancy
How many weeks gestation Single or multiple Have membranes ruptured? colour of amniotic fluid Contractions? frequency or duration Do you have urge to push? Have you felt fetal movements? Hospital interventions? Do you anticipate any problems? Antenatal care? Current complaints: pain, bleeding, BP
Normal HR in pregnancy
80-110
Normal RR in pregnancy
14-19 breaths/min at term
Antepartum Haemorrhage definition
Vaginal bleeding after 20 weeks gestation
Causes of antepartum haemorrhage
Placenta praevia
Placental abruption
Placenta praevia definition
Placenta implants close to or covering the cervix, bleeding occurs as the lower section of the uterus extends and produces shearing forces.
Placental abruption definition
Bleeding from separation of a normally situated placenta, should be considered in any pregnant woman with abdo pain with or without bleeding.
Mx of APH
No signs of altered perfusion: L) lateral tilt and tx
Signs of altered perfusion: L) lateral tilt, tx, pain relief, hypovolaemia
Pre-eclampsia definition
Pregnancy induced HT beyond 140/90 that occurs usually over 32 weeks gestation in association with generalised oedema and proteinuria
Signs and symptoms of pre-eclampsia
Headache Cerebral irritability Visual disturbances Nausea and/or vomiting Heartburn/epigastic pain Hyper-reflexia HT
Patho of pre-eclampsia
Substances from placenta can cause endothelial dysfunction in maternal blood vessels of susceptible women
Mx of pre-eclampsia
HR SBP over 170 or DBP over 110 with S+S: consult with PIPER
seizure: mx as per seizures, L) lateral tilt, O2
Post seizure: assess for aspiration, normal birth, APH
Normal birth - birth of head
- as head advances encourage mother to push with contractions
- if too fast ask mother to pant instead
- place fingers on baby’s head to feel strength of descent
- apply gentle pressure to perineum to reduce risk of tears
- if preciptuous, apple gentle backward and downward pressure to controll sudden expulsion of head
- not time of delivery
Normal birth - umbilical cord check
- check for cord around neck
- if loose, slip over baby’s head
- if right. urge mother to push
- if baby doesn’t descend, clamp and cut cord
Normal birth- birth of shoulders and body
- hold baby’s head between hands and if required apply gentle downward pressure to deliver anterior shoulder
- apply gentle downward pressure to assist birth of posterior shoulder
- support baby, note time of birth
- place baby skin to skin with mother to maintain warmth
- if baby fails to deliver in less than 60 ecs after head mx as shoulder dystocia
- gently palpate abdo following delivery to ensure no second baby
Normal birth - clamping and cutting the cord
- umbilical cord should not be routinely cut, wrap placenta while still attached to baby
- only cut when necessary to facilitate resus or safe extrication post birth
- clamp 10cm from baby, and another one 5cm from first
Normal birth - birthing placenta
- allow separation (15mins to 1hour)
- position mother sitting or squatting to assist or breastfeeding may assist
- do not pull wait for signs of separation
- placenta and membranes are birthed by maternal effort
- use 2 hands to support and remove placenta using a twisting ‘see-saw’ motion to ease out slowly
- note time of delivery
- place in a container and transfer
- ensure fundus is firm, contracted and central
Signs of placental separation
- lengthening of cord
- uterus becomes rounded, firmer, smaller
- trickles or gush of blood
- cramping/contractions return
Breech - one foot, hand or arm presenting
Do not attempt to deliver
Tx and consult with PIPER
Breech imminent - buttocks or both feet presenting
Mx as normal birth except: request assistance, prepare equipment, provide warm environment, analgesia, allow spontaneous birth, position mother with buttocks on edge of bed and legs supported, do not touch baby
Breech imminent - buttocks first, back up - delivery of body/legs
Do not attempt to pull baby out
Encourage other to push
Feet and legs should spring free
Await further descent
Keep body warm by wrapping with towel or bubble wrap
Body will descend to clavicles and arms should swing free, let baby hang until nape of neck visible
Assist with birth of head using modified Mauriceau Smellie Veit Maneuvre
Breech - buttocks first back up, delivery of head
- index finger and ring finger of non-dominant hand on baby’s shoulders and middle finger on occiput
- place dominant hand under baby to support body, with ring and index fingers on baby’s cheekbones
- slowly lift the baby straight up in a circle onto mother’s abdo
- an assistant can aid flexion by putting pressure behind pubic bone
Breech - buttocks first back not uppermost
Baby’s back needs to be up
If legs delivered and back not up, gently hold baby by placing thumbs on bony sacrum with fingers around thighs
-do not squeeze abdo
-rotate baby uppermost between contraction
-never pull baby
Breech - buttocks first legs don’t birth
If extended, slip one hand along the leg of the baby lying anteriorly, place a finger behind the baby’s knee and deliver it by flexion and abduction
Breech - buttocks first arms don’t birth Lovsett’s Manouvre
- hold baby by sacrum
- turn baby 90 degrees so that one shoulder is in the antero-posterior diameter
- insert finger into brachial plexus and sweep arm down over baby’s chest
- turn baby 180 degrees so that opposite shoulder is antero-posterior diameter
- repeat finger manoeuvre
- turn baby 90 degrees so back is uppermost
- await descent
Preterm labour definition
Uterine contraction at 20-37 weeks gestation
Preterm labour management
Birth no imminent less than 34 weeks: consult for GTN patch applied to abdo
Another patch can be applied after 1 hour if contractions persist (max 20mg/24hr)
Cord Prolapse definition
Umbilical cord visible at vulva with ruptured membrane. Associated with unstable lie or malpresentation.
Cord Prolapse Management if birth not imminent - Mx of mother
Position pt semi-prone with hips elevated over folded towels
Provide explanation and reassurance
High flow O2
Cord Prolapse
Management if birth not imminent -Mx of cord
Minimise cord handling
Keep cord warm and moist. Use 2 fingers to gently place cord in vagina.
If unsuccessful cover with warm saline packs (if possible)
Cord prolapse
Management if birth not imminent - mx presenting part
If pressure on the cord by presenting part, insert fingers into vagina and push the presenting part away from cord
Maintain pressure until birth commences or advised to release
Cord prolapse management if birth commencing
Instruct mother to push
Assist in delivery
Prepare for newborn resus
Shoulder Dystocia definition
Difficult delivery due to baby’s shoulders becoming wedged behind the mother’s pubic bone
Signs and symptoms of Shoulder Dystocia
Prolonged head-body delivery time (over 60secs)
Difficulty with birth of face/chin
Baby’s head retracts against perineum
Failure to restitute
Failure for shoulders to descend
Difficulty reaching neck when attempting to check cord
Baby’s head turns blue/black
Shoulder Dystocia -prolonged head to body delivery time
Note time of birth of head
Request urgent assistance
Explain to mother and encourage her to push
Position mother with buttocks on edge of bed
Apply gentle downward traction to deliver anterior shoulder
Shoulder Dystocia - unable to birth shoulder
Alternate shoulders - if no response after 30-60secs:
Hyperflexion of maternal hips (McRoberts Manourvre) - knees to nipples
Shoulder Dystocia - McRoberts maneuvre unsuccessful after 30-60s
Surapubic pressure whilst in McRoberts - apply 30secs firm downward pressure then 30 sec rocking motion
If no success after 30-60secs: All fours (Gaskin) manouvre - hold baby’s head and apply gentle downward traction attempting to disimpact and deliver the posterior shoulder
Post-partum haemorrhage definition
Haemorrhage from birth canal in excess of 500ml during 1st 24 hours after birth
Causes of PPH
Tone (uterine atony)
Trauma (to genital structures)
Tissue (retention of membranes or placenta)
Thrombin (coagulopathy)
PPH mx - fundus firm
- high flow 02
- analgesia
- perfusion as per hypovolaemia
- mx visible laceration with dressing and firm pressure
PPH mx - fundus not form
- avoid fundal massage prior to placental delivery and continue checking for PV bleeding and observing vital signs
- massage fundus until firm and blood loss reduces, use a cupped hand and apply firm pressure in a circular motion
- encourage mother to empty bladder if possible
- encourage baby to suckle breast
- if remains not firm: Misoprostol 800mcg oral
PPH mx - intractable haemorrhage
-perform external abdo aortic compression:
locate point of compression just above the umbilicus to the left
apply downward pressure with a closed fist through the abdo wall
effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied
