Obstetrics and neonates Flashcards
What do dark green stains/streaks mean in a pregnant person’s broken water?
Meconium in the amniotic fluid
What are the dangers of meconium in the amniotic fluid?
The neonate can aspirate on it if stressed and gasping whilst still in the womb
What questions are important to ask with labour patients?
Has she got notes to hand?
Gestation
Parity/gravida
Any risk factors?
Complications with pregnancy so far?
Multiple pregnancy (Twins,triplets etc.)?
Spontaneous rupture of membranes (SROM)? -Were they stained?
Contractions - frequency, duration?
Bleeding?
Pain?
Foetal movement?
What is gravida?
Number of times a woman has been pregnant, including current pregnancy and regardless of any past outcomes (miscarriage, stillbirth, termination etc.)
What is parity?
Number of live childbirths a woman has had
What are the 3 stages of labour?
Stage 1: Regular uterine contractions increasing in length and frequency causing cervical effacement and dilation from 0cm-10cm
Stage 2: Delivery of the baby
Stage 3: Placenta delivery
What are Braxton Hicks?
False labour pains when the womb contracts and relaxes, usualling during the second and third trimester, uncomfortable but not usually painful. Braxton Hicks do not cause the cervix to dilate.
What are you looking for upon inspection during labour?
Bleeding
Head or breech presentation
Prolapsed loop of cord
Perineum bulge with each contraction
Environment
What is the second stage of labour and its signs?
Full dilation to delivery of baby:
Contractions become more expulsive in nature
Women may have a strong urge to push
The vertex (head) may be visible at the introitus
Dilation of the anus due to the engagement of the baby’s head
Head, body then full delivery of baby
How should you prepare the birth environment?
Clean towels/incontenance pads
WARMTH - close windows, heating, warm blankets etc.
What should you recomend during head delivery?
Panting over pushing hard
Why should you usually delay umbilical cord cutting?
Leaving the umbilical cord intact until it has ceased pulsating will help the baby gradually adapt to extrauterine life and ensure it has optimum blood volume for full lung expansion
Why do neonates lose heat easily?
A high surface area to volume ratio and a metabolic response to cooling that involves chemical (non shivering) thermogenesis.
What is the physiology of the neonate thermogenesis response?
Norepinephrine is discharged into brown fat in the nape of the neck, between the scapulae, and around the kidneys and adrenals.
There is lipolysis and oxidation. This produces heat locally, that is then circulated.
What is the danger of the neonate thermogenesis response?
It is a diversion of calories to produce heat which can impair growth.
Metabolic rate and oxygen consumption is increased 2-3x.
May also result in tissue hypoxia and neurologic damage in neonates with respiratory issues.
Activation of glycogen stores can cause transient hyperglycemia. Persistent hypothermia can result in hypoglycaemia and metabolic acidosis and increases the risk of late-onset sepsis and mortality.
What are the increased mortality rates associated with neonate hypothermia?
For each 1 degree decrease in temperature below 36.5 degress there is an associated increase in mortality of 28% in an otherwise healthy baby
What maneuvre can you use to maintain body heat in premature neonates?
Place the baby wet in a polyethene bag along with blankets and hat
What are the benefits of skin to skin?
Regulates baby’s heart rate, breathing and temperature
Stimulates release of hormones – oxytocin
Helps provide protection against infection
What is the AGPAR assessment for neonates?
Appearance
Grimace
Pulse
Activity
Respiration
How can you assess neonate heart rate in very noisy or cold environments?
Palpating the umbilical cord (if HR >100)
When is the AGPAR assessment performed with neonates?
At one minute after birth then five minute intervals
When might you not delay cord clamping?
Problems with mother: e.g. Bleeding, placenta issues (abruption, praevia etc.)
Problems with the cord e.g. bleeding so blood not reaching baby anyway.
Problems with baby e.g. resus needed
What is placental abruption?
A serious condition in which the placenta separates from the wall of the uterus before birth
What is placenta praevia?
When the placenta lies very low in the uterus, covering all or part of the cervix.
How far away from the baby should you cut the cord?
15cm
How long can placenta delivery last without active management?
Up to one hour
What are the signs of impending placenta delivery?
Contractions return
Cord lengthens
Urge to push
Sometimes small gush of blood
Why is it important to keep the placenta?
It must be examined by a midwife
What are the risks associated with placenta praevia?
Cervix dilation can cause placenta rupture and massive bleeding and damage. Almost all patients require C-section.
What are the benefits of immediate breastfeeding after birth?
It can encourage delivery of the placenta
It induces oxytocin release
It helps bonding with mother and baby
It is a great source of energy for the newborn - promotes adequate thermogenesis
What is placenta accreta?
A serious condition in which the placenta grows too deeply into the uterine wall, causing difficulty separating and likely to cause haemorrhage
What is the difference between placenta accreta, placenta increta and placenta percreta?
Placenta accreta – The placenta attaches itself too deeply and too firmly into the uterus
Placenta increta – The placenta attaches itself even more deeply into the muscle wall of the uterus.
Placenta percreta – The placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder.
What is vasa praevia?
Unprotected blood vessels from the umbilical cord travelling across the opening of the cervix
What is the time frame for post-partum haemorrhage?
24 hours
What is a massive obstetric haemorrhage?
Obstetric haemorrhage is classified as antepartum (APH) or postpartum (PPH) of more than 1.5L of blood loss
What is the difference between primary and secondary post-partum haemorrhage?
Primary is within 24 hours of birth, secondary is after 24 hours and up to 6 weeks after birth
What is the first stage of labour broken down into and what are the qualities of each?
When would comfort care be prioritised for pre term babies?
Obvious miscarriage
Below 22 weeks gestation
OR
Unknown gestation and eyes fused
When would care be survival focused for pre-term babies?
Above 22 weeks gestation
OR
Unknown gestation and unfused eyes
What are features of comfort care of the pre-term delivery?
Call the baby a baby
Don’t try to make things better e.g. “at least..”
Don’t guess the sex of the baby
Explain “Even with the best care in the world your baby has been born too early and will not survive”
Don’t be afraid to say you don’t know - do not guess - say ‘I don’t know but I will take you to someone who can answer your questions’
Wrap the baby in a blanket or cuddle pocket - no clinical waste bags/vomit bowls etc.
Have someone hold the baby
How much bleeding is normal during pregnancy?
Ideally none, apart from some spotting or bloody show. Bleeding during pregnancy is relatively common and does not always mean there’s a problem - but it can be a dangerous sign.
Therfore, any maternal bleeding should always be assessed by a midwife/GP/obstetrician
When do spotting bloody show occur?
Spotting (light bleeding) often happens around the time mum’s period would have been due. Cervical changes caused by pregnancy can sometimes cause bleeding, for example after sex.
Bloody show is a plug of bloody mucus usually released in later pregnancy anytime from a few days before contractions start and to during labour.
What are the key differences in presentation between a revealed and a concealed placental abruption?
Both will have constant abdominal pain.
Revealed will have blood gushing out.
Concealed will have a few drops of fresh blood
What should a history of placental abruption include?
History of:
- Placental location in scans
- Previous abruptions
- Smoking
- Cocaine use
- Abdominal trauma
What are the signs and symptoms of placental abruption?
Abdominal pain (usually constant)
Abdominal/uterine tenderness
Signs of shock (hypotension/tachycardia/clamminess etc.)
Vaginal bleeding (not always present)
- quantity and characteristics of blood should be noted as well as presence of clots
What history is most common on placenta accreta spectrum (PAS)?
- Previous C-section (main risk factor)
- Other uterine procedures
- Advanced maternal age
- Multiple parity
Although rare PAS can occur in nullpariois women with no prior uterine surgery
Which condition is present in 80% of placenta accreta spectrum (PAS) cases?
Placenta praevia
How is placenta accreta diagnosed?
With imaging
What are the signs and symptoms of placenta accreta spectrum?
Often it is asymptomatic antenatally. Occasionally bleeding in the later stages of pregnancy is noted.
PAS can cause MoH and PPH with no prior symptoms
Over 20 weeks of gestation how much bleeding is cause for concern?
Any, especially if accompanied by pain.
During pregnancy how much pain is cause for concern?
Any that is moderate or severe
OR
is mild and doesn’t go away with changing position, resting for 30-60 minutes or passing wind/opening bowels
What are the most common cause of mild stomach pain during pregnancy?
Ligament/growing pain
Constipation
Trapped wind
What are the features of pre-eclampsia?
20+ weeks gestation
Hypertension
Headache (frontal and persistent)
Blurred vision/visual disturbances
Epigastric pain
Nausea and vomiting
Proteinuria
What type of seizures does eclampsia usually present as?
Normally tonic-clonic. Short lasting but recurrent with minimal recovery
What are the signs and symptoms of maternal inferior vena cava syndrome?
Initial tachycardia and late bradycardia
Diaphoresis
Nausea
Vomiting
Pallor
Weakness
Lightheadedness
Dizziness
What CPR changes are there to maternal patients?
Difficult airway management due to oedema and additional breast tissue.
Higher risk of regurgitation and aspiration
Difficult ventilation - higher airway pressure and quick desaturation
Chest compressions 2-3cm higher
Manual uterine displacement
IV/IO access above diaphragm
Move to hospital after 5mins without ROSC
What is term for a baby?
37 weeks
How long after birth should the placenta pass?
20 minutes, at this point it is considered a retained placenta and an urgent transfer is required
What are the 4 T
