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CSB339 > Postpartum emergencies, perinatal mental health, and birth and culture > Flashcards

Postpartum emergencies, perinatal mental health, and birth and culture Flashcards

1
Q

Outside obstetric emergencies, what is the most frequent cause of maternal death in Australia?

A

Trauma in pregnancy

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2
Q

What percentage of pregnant women suffer trauma?

A

7%

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3
Q

List some causes of trauma in pregnancy.

A
  • RTC’s
  • Falls
  • Penetrating trauma
  • Domestic violence
  • Assault
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4
Q

Name four examples of obstetric trauma.

A
  • Abruptio Placentae
  • Uterine rupture
  • Direct foetal injury
  • Disseminated intravascular coagulopathy (DIC)
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5
Q

What is Abruptio Placentae?

A

Complete or partial shearing of the placenta away from the wall of the uterus as a result of direct trauma.

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6
Q

What is the most common traumatic injury in pregnancy?

A

Abruptio Placentae.

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7
Q

True or false: abruptio placentae is a major emergency for both mother and baby.

A
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8
Q

Abruptio placentae occurs in ____% of minor trauma and ____% of major trauma.

A

5% and 65%

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9
Q

What are the signs and symptoms of abruptio placentae?

A
  • Constant pain
  • Rigid uterus
  • +/- contractions or tightenings
  • +/- PV bleeding
  • +/- haematoma
  • Reduced foetal movements
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10
Q

True or false: uterine rupture is potentially serious but not commonly fatal.

A

False: uterine rupture is a commonly fatal severe obstetric emergency.

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11
Q

What should raise suspicion of uterine rupture?

A
  • Significant mechanism
  • Hx of LUCSC/CICS
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12
Q

What are the signs and symptoms of uterine rupture?

A
  • Pain ++++
  • PV bleeding
  • Abdominal bruising
  • Absent foetal movements
  • DIC
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13
Q

Describe the management of domestic violence in pregnancy.

A
  • Recommend tx (though often refused/denied)
    • Check on baby
    • Maternal injuries
  • Mention supports available
    • Community support
    • Community housing
    • Emergency support
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14
Q

What is disseminated intravascular coagulopathy?

A

A disorder characterised by the pathological activation of coagulation resulting from the overstimulating of blood clotting mechanisms in response to disease, injury, infection, burns, and trauma.

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15
Q

List the additional considerations for resuscitation of obstetric pts.

A
  • Airway
    • Swollen mucous membranes
    • Large breasts and Gravid uterus
    • Difficult intubation
  • Breathing
    • Increased O2 demand
    • Heavier
    • Displaced diaphragm at term(difficult ventilation)
  • Circulation
    • Increased circulating blood volume
    • Tachycardia
    • Late signs of shock (suspect hypovolaemia before it becomes apparent)
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16
Q

List considerations for mx of the obstetric resus pt.

A
  • O2
    • Increased demand
    • Consider foetal compromise and affinity for O2
  • Large bore IVA
  • Tilt
    • Supine hypotensive syndrome
    • Lateral if possible
    • Wedge in absence of spinal injury
    • Secure to spine board and tilt this if c-spine consideration is in place
  • Consider tx destination
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17
Q

What is an amniotic embolism?

A

Entry of amniotic fluid into maternal circulation.

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18
Q

True or false: amniotic embolism is believed to be immune mediated and causes multisystem shutdown.

A
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19
Q

True or false: amniotic embolism is associated with poor survival and long term outcomes.

A
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20
Q

Amniotic embolism results in…

A

Rapid deterioration to cardiac arrest.

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21
Q

How is amniotic embolism diagnosed?

A

Exclusion, usually post mortem.

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22
Q

List the considerations for CPR in the pregnant pt.

A
  • Move Gravid uterus from IVC
    • Wedge R) hip
    • Manually displace uterus
  • Consider rapid tx during arrest
    • Peri-mortem EMCICS (EMLUSCS)
    • Best chance of saving both
    • 5 minute gold standard
    • Reported foetal survival 15-20 minutes after maternal death
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23
Q

With regard to CPR on a pregnant pt, what can be used when remembering to wedge the right or left hip?

A

Wedge the right hip - ‘women are always right’.

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24
Q

Describe some aspects of normal bleeding in the post partum period.

A
  • Lochia
  • Heavy loss for the first few days after birth
  • Also common for blood loss to increase after breast feeding
  • Passing some clots is normal
  • Duration of blood loss is variable
    • Often ceases after 2 to 3 weeks but can continue (though diminishing) for 6 weeks
  • Changing sanitary pads frequently (full pads 2+ times an hour) is excessive blood loss.
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25
Q

What is lochia?

A

Vaginal discharge after giving birth containing blood, mucous, and uterine tissue that typically continues from 4 to 6 weeks after birth.

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26
Q

What is involution of the uterus?

A

The process by which the uterus returns to its usual pre-pregnancy state.

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27
Q

How long before the uterus is usually no longer an abdominal organ post-birth?

A

10 days

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28
Q

Describe the common presentations and causes of PP infection.

A
  • ? retained products
    • Increased blood loss
    • Uterine tenderness
    • Pyrexia
    • Tachycardia
  • LUSCS wound infection
    • Wound breakdown
    • Discharge
    • Odour
    • Pain
    • Cellulitis
  • Breast infection (mastitis)
    • Pyrexia
    • Pain
    • Flu-like symptoms
  • Perineal suture infection
  • Endometritis
  • UTI
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29
Q

What is mastitis, and what is it caused by?

A

Inflammatory condition of the breast often accompanied by infection; caused by breast engorgement, milk stasis, and bacteria entering via cracked nipple.

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30
Q

Describe the common presentation of mastitis.

A
  • Often synonymous with oversupply or poor attachment
  • Hx of engorgement or blocked duct
  • Flu-like symptoms
  • Pyrexia
  • Painful and reddened +/- hot area on breast
  • Hardened breasts
  • Fever
  • Tachycardia
  • Abcess and/or sepsis if left untreated
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31
Q

Describe the mx of mastitis.

A
  • Antibiotics
  • Drainage of abcess
  • Tx baby to hospital - feeding is essential
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32
Q

What will most women experience with regard to perineal care PP?

A
  • Pain
  • Swelling
  • Tenderness
  • Dependent on degree on perineal trauma
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33
Q

Severe perineal trauma can have long term deficits; give three examples.

A
  • Discomfort for 12 months
  • Sexual dysfunction
  • Faecal incontinence
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34
Q

Describe the paramedic mx of perineal tears PP.

A
  • Examination is not necessary
  • Query signs of infection
    • Increased or unrelieved pain
    • Odour
  • Analgesia
  • Antipyretic
  • Tx for antibiotics
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35
Q

Describe aspects of care after LUSCS.

A
  • Wound care
  • Possible perineal care if failed instrumental birth
  • Reduced lifting capabilities
  • Uterine rupture
  • Scar dehiscence
  • Infection
    • Hygiene important
    • Obsesity is a huge risk factor
36
Q

List the signs of wound breakdown/complication.

A
  • Fever
  • Haematoma/redness
  • Increased pain
  • Separation of wound edges
  • Purulent discharge
  • Odour
37
Q

Describe the mx of LUSCS wound breakdown.

A
  • Tx for investigation
  • Swabs
  • Antibiotics
  • Debriding
  • Sutures
38
Q

What is the definition of primary PPH?

A

Bleeding from the vagina which exceeds 500mL for SVB up to 24 hours after birth.

39
Q

What is the definition of secondary PPH?

A

Excessive bleeding from the vagina 24 hours and 6 weeks weeks after birth (>1 pad/hour)

40
Q

True or false: PPH is the most common obstetric emergency.

A
41
Q

When is the highest risk of PPH?

A

After the third stage.

42
Q

What are the risk factors for PPH?

A
  • Expedited birth
  • Obstructed or prolonged labour
  • Shoulder dystocia
  • Hx of PPH
  • Multiples
  • LGA
  • Grand Multis
  • Low Hb
  • Low platelet count
  • Directed pushing
  • Perineal trauma
43
Q

What things should be checked when assessing primary PPH?

A
  • Check/massage fundus
  • Check placenta (unless there are large portions missing - usually a secondary PPH)
  • Check perinuem. If there is good uterine tone, placenta is intact and nil evidence of clotting disorders - you will need to inspect vagina and cervix.
  • Thrombin - are there any clots?
44
Q

Describe the mx of PPH.

A
  • Ensure basic cares (no raising of legs)
  • CCP/HARU backup
  • Fundal massage
  • Encourage urination (emesis bag is useful)
  • Expel clots from introitus
  • Administer oxytocin (if haven’t already)
  • External aortic compression
  • Bi-manual compression
45
Q

Describe the process of fundal massage.

A
  • 1 or 2 handed technique
  • Between umbilicus and pubic symphysis
  • Checking for uterine tone
    • Contracted uterus feels like a ‘rubber ball’
    • If not contracted will feel ‘boggy’
46
Q

What is a first line rx for PPH?

A

Fundal massage.

47
Q

When is external aortic compression applied for PPH?

A

Significant and rapid blood loss with symptomatic woman.

48
Q

Describe the application of external aortic compression for PPH.

A
  • Direct pressure with fist on abdominal aorta
  • Maternal L) at the level of the umbilicus
    • Uterine artery is below this
  • Direct presssure perpendicular to the spine
  • Feel for femoral pulse to check effectiveness
  • Note: this will be painful.
49
Q

What is bimanual compression?

A

Application of direct pressure to the placental bed.

50
Q

Describe the process of bimanual compression.

A
  • Insert open-palmed hand
  • Make fist once able to feel the uterus
  • With the other hand, find the fundus/uterus and bring it down towards your closed fist
  • Apply direct pressure in order to stem bleeding from placental bed
51
Q

True or false: suicide rates in women are dropping, except in the perinatal period.

A
52
Q

Is there an increased incidence of perinatal anxiety disorders in higher risk or complicated pregnancies?

A
53
Q

Antenatal anxiety increases the likelihood of what mental health condition?

A

Postnatal depression.

54
Q

Describe the paramedic mx of perinatal anxiety disorders.

A
  • Assessment of the anxious pt
  • Assess likelihood of self harm
  • Encourage tx to appropriate maternity and mental health facility
55
Q

Antenatal depression is dx after…

A

One or more episodes of depression with no mixed, manic, or hypomanic episodes.

56
Q

How much does risk of depression increase during pregnancy?

A

Two-fold; there is speculation of hormone correlation.

57
Q

List some associations and features of antenatal depression.

A
  • Features
    • Poor sleep and fatigue
    • Focus on pregnancy concerns
    • Anxiety or OCD symptoms possible
    • Increased reporting of poor appetite/nausea/vomiting
  • Associations
    • Substance abuse
    • Smoking
    • Stress
    • Low socioeconomic status
    • Hx of major depressive disorder
    • Predictor of postnatal depression
    • Higher rates of placental anomalies, preterm birth, MC, low birthweight, SGA
58
Q

What are used to mx antenatal depression?

A

SSRI’s

59
Q

What is the only screening tool for antenatal depression?

A

EPDS

60
Q

Describe the paramedic mx of antenatal depression.

A
  • Focused assessment
  • Care assessment and reassurance
  • Tx to appropriate facility
61
Q

Describe the ‘baby blues’.

A
  • Women are often elated or ‘feel high’ immediately after birth
  • Low mood 3-5 days PP
  • 50-80% experience characteristic tearfulness, anxiety, and irritability
62
Q

What is thought to be the cause of ‘baby blues’?

A

A rapid drop in oestrogen and changes in electrolytes, serotonin, and dopamine.

63
Q

How long do the ‘baby blues’ generally last?

A

Usually short term; 24-48 hours. If longer, may progress to postnatal depression.

64
Q

True or false: PND can occur in both mothers and fathers.

A
65
Q

What is the incidence of PND in mothers?

A

10-15%

66
Q

What is the incidence of PND in fathers?

A

0.5%

67
Q

When does PND usually begin?

A

1 to 2 months after giving birth.

68
Q

List symptoms characteristic of PND.

A
  • Low mood
  • Constant tearfulness
  • Distress
  • Anxiety
  • Lethargy
  • Irritability
  • Insomnia
  • Appetite changes
  • Disinterest in daily activities
  • Thoughts of self harm
  • Thoughts of infant harm
  • Difficulty with self care
  • Feelings of guilt
69
Q

Is PND a major depressive illness?

A
70
Q

What is the incidence of postnatal psychosis?

A

~1-2 in 1000 deliveries

71
Q

When can symptoms of postnatal psychosis occur?

A

As early as 48-72 hours PP up to 1 year PP.

72
Q

When do most episodes of postnatal psychosis develop?

A

Within the first two weeks after delivery.

73
Q

What is the infanticide and suicide rate for postpartum psychosis?

A

5%

74
Q

True or false: postpartum psychosis isn’t always a psychiatric emergency.

A
75
Q

Why might a woman with postnatal psychosis not present with typical psychotic symptoms?

A

She may be urgently trying to cover up her distress and return to the care of her baby.

76
Q

List some possible presentations of postnatal psychosis.

A
  • Severe/acute anxiety
  • Psychotic symptoms
    • Talking in a strange manner
    • Hearing or seeing things others cannot
    • Suspicious of others trying to harm her or her baby
    • Decreased need for sleep or food
    • Hyperactive with racing thoughts/behaviours
    • Delusions (may take many forms)
    • Irrational thinking and impaired judgement for herself and baby
77
Q

Describe the paramedic mx of perinatal mental health.

A
  • Rest and reassurance
  • Mental health disorders at this time are common, but not normal.
  • Encourage to seek help
  • Careful risk assessment
  • Encourage tx when risk of self harm is suspected
  • EEA may be considered in event of refusal
  • Consider baby in mx
78
Q

List some barriers to birthing in a multicultural society.

A
  • Limited understanding of complications of pregnancy causing stress and anxiety
  • Stress related to poor communication skills
  • Gender of health practitioners
  • Inability to comply with cultural or religious practices (e.g. specific dietary requirements)
  • Unaware of some health services that assist pregnant women
  • Australia’s C-section rate is ~33% (much higher than other countries) - this can create issues with women who see them as weakness or a burden postpartum
79
Q

List some features of western birth culture.

A
  • Medicalised birth
  • Highly managed
  • Mostly English-speaking
  • Physician-led, midwifery-lead, or mixed models of care
  • Pain should be ‘fixed or stopped’
80
Q

What are some influences of western religion on birth culture?

A
  • Hands-on physical and emotional support from birth partner
  • Post-birth rituals
    • Baptism
    • Circumcision
81
Q

List some features of modern Australian birth culture.

A
  • Concept of birth rituals is ‘strange’
  • Current antenatal care is a type of ritual
  • Hands on physical and emotional support from birth partner
  • Increased trend in respect for ‘birth as normal’
    • Home birth
    • Unassisted birth
    • Doula guided
82
Q

List some features of Middle Eastern and Mediterranean birth culture.

A
  • Express emotion
  • Cry and scream uncontrollably
    • Does not equate to wanting pain relief
  • Medical model
  • No family present, labour on their own
  • No VBAC
  • Confined to bed for labour
  • 95% occur in hospital
83
Q

List some features of birth culture of African nations.

A
  • Various cultural and tribal influences
  • Medical model in developed areas, however C-section is perceived as failure by the mother
  • Gives birth alone a few hundred metres from the tribe
  • Traditional birth attendants are common
  • High incidence of sequelae after birth
  • Rituals
    • Face fears by watching a birth first
    • Biting the cord and mother must bury placenta
84
Q

What is female genital mutilation?

A

A procedure in which all or part of the external genitalia are cut off for reasons that do not have a medical purpose.

85
Q

List some forms of female genital mutilation.

A
  • Male and female circumcision
  • Female removal of labia, clitoris, and vulva - “pureness”
  • May require surgery to remove scar tissue to facilitate birth
    • Illegal in Australia to re-infibrillate
  • Causes menstrual disorders, psychological trauma, HIV, hepatitis, and other infections

CSB339 (7 decks)

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