Pregnancy and birth

Question 1

After 20 weeks gestation, hypotension may occur in the supine position because

Answer 1

the uterus can impede venous return through the inferior vena cava.

Question 2

To prevent supine hypotension …..

Answer 2

always tilt the patient 30 degrees (or more) to their left by placing a rolled towel or pillow under their right hip. If this cannot be achieved, manually displace the uterus to the left if feasible.

Question 3

what is considered early onset of labour

Answer 3

This is the onset of labour prior to 37 weeks of pregnancy.

Question 4

post birth treatment

Answer 4

• Ensure a warm environment and continue to keep the baby skin to skin with the mother provided neither requires immediate resuscitation. Place a hat on the baby if one is available and cover mother and baby with a warm blanket. Continually observe the baby’s activity and breathing.
• Clamp and cut the cord 5 cm from the baby 2-3 minutes after birth, unless this is required earlier to facilitate resuscitation.
• Administer 10 units of oxytocin IM into the mother’s lateral thigh. If multiple babies are present delay administration until after birth of the last baby. Routine administration of oxytocin is controversial, but appears to reduce the incidence of postpartum haemorrhage.
• Allow the placenta to deliver spontaneously, without applying traction, and document the time of placental birth. This usually occurs within 60 minutes. Place the placenta in a plastic bag.
• Following delivery of the placenta, feel for the uterus at approximately umbilical level and rub it using a circular motion until it feels firm.

Question 5

shoulder dystocia: Utilise the mnemonic HELPERR and move sequentially through the steps below if birth does not occur:

Answer 5

ū Help. Call for immediate help from an LMC, doctor or ICP.
ū Evaluate the need for episiotomy. This is not within delegated scopes of
practice and personnel must seek urgent clinical advice if this is thought to
be required.
ū Legs up. Ask the patient to grab her knees, pull them to her chest and push
as hard as she can with the next two contractions.
ū Pressure. With the legs still up (as above), place the heel of your hand
directly above the patient’s pubic bone and push slowly but firmly straight back toward the patient’s lower back. This is designed to reposition the baby’s shoulder, which is usually what is preventing delivery.
ū Enter manoeuvres. This refers to internal rotation manoeuvres that are not within delegated scopes of practice and personnel must seek urgent clinical advice if these are thought to be required.
ū Remove the posterior arm. Place the fingers of your hand into the posterior aspect of the vagina (adjacent to the anus), feel for the posterior arm and manipulate it until the arm is able to be pulled through the vagina.
ū Roll. Ask the patient to move on to her hands and knees and push as hard as she can with the next two contractions.

Question 6

If the cord is wrapped around the neck

Answer 6

• This is quite common and is not an emergency.
• If the cord is loose and is easy to slip over the baby’s head, then do so. If you cannot easily slip it over the head, allow birth to continue.

Question 7

Prolapsed umbilical cord

Answer 7

• This is when the umbilical cord appears in the vagina ahead of the baby.
• This is a life-threatening emergency for the baby. It risks the baby having poor blood supply from an obstructed cord and requires urgent delivery.
• Seek immediate help from an LMC if possible.
• Instruct the patient not to push.
• If possible position the mother tilted to the left with pillows/blankets under her pelvis, so that her head is below her pelvis. This is designed to take the weight of the baby off the cord and delay delivery until an LMC is available.
• Transport urgently to a hospital with obstetric facilities.
• Encourage delivery to occur if the baby appears at the vaginal opening or the patient wants to push.

Question 8

Breech delivery

Answer 8

• This is when the baby is coming out feet or buttocks first.
• This is a life-threatening emergency for the baby. It risks the baby having poor blood supply from an obstructed cord and requires urgent delivery.
• Seek immediate help from an LMC if possible.
• Instruct the patient not to push.
• If possible, position the mother tilted to the left with pillows/blankets under her pelvis, so that her head is below her pelvis. This is designed to take the weight of the baby off the cord and delay delivery until an LMC is available.
• Transport urgently to a hospital with obstetric facilities.
• Encourage delivery to occur if the baby appears at the vaginal opening or the patient wants to push.

Question 9

Retained placenta

Answer 9

• This is when the placenta has not been delivered within 60 minutes of the baby.
• Transport to a hospital with obstetric facilities without unnecessary delay and seek help from an LMC if possible.
• Gain IV access and be prepared to treat postpartum haemorrhage.

Question 10

Pre-eclampsia

Answer 10

• Pre-eclampsia is variable in both clinical presentation and severity, and can affect multiple organ systems. Signs and symptoms can include:
  ū Renal insufficiency. For example, a decreased glomerular filtration rate, proteinuria, increased serum creatinine and increased uric acid levels.
  ū Liver dysfunction. For example, nausea and vomiting and epigastric or abdominal pain.
  ū Cardiovascular dysfunction. For example, hypertension, haemolysis, vascular endothelial leak (causing oedema) and decreased plasma volume.
  ū Neurological symptoms. For example, headache, visual disturbance, hyperreflexia and cerebral haemorrhage.
• The aetiology of pre-eclampsia is not well understood, but is thought to be caused by poor placental implantation and/or abnormalities of placental vessels. This leads to placental hypoperfusion, a systemic inflammatory response, and foetal growth restriction.
• The diagnostic criteria for pre-eclampsia are:
  ū A systolic blood pressure of greater than 140 mmHg, and/or a diastolic blood pressure of greater than 90 mmHg, and
  ū More than 20 weeks gestation, and
  ū Proteinuria (protein in the urine).
• If pre-eclampsia is suspected, contact the LMC directly and arrange for urgent assessment to occur.
• Magnesium may have a role in the treatment of severe pre-eclampsia. Seek clinical advice.

Question 11

Eclampsia

Answer 11

• Eclampsia occurs when a patient with pre-eclampsia has one or more generalised seizures.
• These seizures are thought to occur as a result of acute severe intracranial hypertension, where the cerebrovascular autoregulatory mechanisms are unable to compensate.
• Eclampsia poses a significant threat to both the life of the baby and the life of the mother.
• Treat as per the ‘seizures’ section.
• Magnesium may have a role in the treatment of eclampsia. Seek clinical advice.
• Transport the patient to a hospital with obstetric and intensive care facilities, whenever feasible and safe.