questions 3 Flashcards
1
Q
Definition of APH
A
Any bleeding
>20 wks
>before onset of labour
2
Q
fetal fibronectin
what is it
when do we test
indications
A
glycoprotein found at maternal-fetal membrane
normally found at low levels- higher levels may indicate increased risk of preterm labour
used bewteen 26-34wks
Indications
- intact membranes
- cervix <3cm
- only slight PV bleeding
- no cervical cerclage
- no sex / pelvic exam in last 24hrs
not appropriate if woman is asymptomatic (even if she is considered high risk)
3
Q
IOL contraindications
A
any maternal/fetal condition not to birth vaginally
malpresentation - transverse/ oblique
classical CS
Cord prolapse
Active herpes
placenta praevia
absolute cephalopelvic disproportion
invasive carcinoma of cervix
baby is severely compromised
relative CI’s
- FHR is non reassuring
- breech
- polyhydramnios
- not engaged
- severe hypertension
- maternal heart disease
4
Q
A
cord presentation:
- cord is inbetween leading part of fetus, and internal os AND membranes are intact
- diagnosis may be identified via VE and colour doppler studies
- high risk of cord prolapse, if membranes break
occult cord
- cord is alongside presenting part
- not identified via VE
Cord prolapse- overt
-Membranes ruptured +- cord descends past fetal presenting part, through cervix into vagina
- diagnosis
* -visual (seen in introitus)
* palpation in vagina
* Abnormal FHR
- high risk of fetal hypoxia
cord prolapse- occult
-membranes ruptured
-cord is trapped between presenting part and pelvis
diagnosis
* FHR change
* rarely seen / felt
5
Q
cord presentation / prolapse
risk factors
A
general
- multiparous
- small baby (preterm / SGA)
- abnormalities
- malpresentation (breech, transverse/ oblique /unstable)
- second twin
- polyhydramnios
- unengaged presenting part
- abnormal placenta (e.g. low lying)
intervention related
ARM
ECV / Vaginal manipulation of baby after ARM
6
Q
Referral for cord presentation + prolapse
A
Emergency
7
Q
cord prolapse - mgmt
A
1) change woman’s position (exaggerated SIMs)
2) call for help
3) confirm FHR viability
4) minimise compression bewteen fetal head and pelvis
* digital pressure via VE
* bladder fillling
5) Expedite birth (CS unless birth imminent)
give oxygen + IV line
consider tocolytics
*avoid handling cord / exposing cord to cool air to avoid vasospam of cord vessels
8
Q
Insulin mechanism
A
insulin unlocks glucose transporters (passive transport)
9
Q
for women already with diabetes and on insulin, what changes to diet can they expect
A
may become more restrictive
10
Q
what is HbA1c, when do you refer
A
universal sreening <20wks
looks at average glucose in blood over last 4-6wks
<40 “ NORMAL”–> polycose at 24-28 wks
41-50–> “prediabetic” clinic + OGTT at 24-28wks
>50- ->”probable diabetes”
11
Q
polycose test-
indication / normal results
A
for women with normal HbA1c
1hr 50g glucose
<7.8 NORMAL
>7.8 -11.0 -> do OGTT
»11.0–> refer to clinic
12
Q
OGTT
indication / what is it/diagnostic results
A
only for high risk women
- women with high polycost tet results
- hbA1c >40
diagnostic
- > 5.1 (fasting)
- >8.5 post prandil
13
Q
why do women with GDM have more UTI’s
A
glucose in urine ‘feeds’ bacteria
14
Q
hyperemesis gravidarum
* when is it most commonly occuring
* what is it
* what are causes
* mgmt
* risks if not treated
A
when
- usually from 6-20 wks
- what
persistent / vomiting - fluid + electrolyte depletion
- ketonuria
- nutritional deficiency
- rapid weight loss
causes
- multifaceted -
- `hcG- (higher risk for women with more hcg (e.g. molar + multiples)
psychological
gastric abnormalities (delayed emptying, reduced acid)
vestibular disorders
ANS changes
liver enzyme
high thyroxine
- no evidence that its sociioeconomic, racial, ethnic
- management
rest
avoid stimulating factors
antimetics (ginger, b6, metoclopramide, ondansetron if necessary)
IV fluids
electrolyte replacement
peripheral catheter/ nasal gastric tube
long term risks
- renal
- neurological - (thiamine deficiency–> wernicke’s encephalopathy- emergency)
- liver
15
Q
definitions + referrals
- chronic hypertension vs gestational hypertension
-
A
chronic
>140 / 90 (>2 readings (At least 4hrs apart))
>confirmed <20wks
>referral- CONSULT <16wks
gestational hypertension
>140/90
>20 wks gestation
>no features of PE
>BP returns to normal within 3mths of birth
>referral- CONSULT
16
Q
Mgmt of thin mec
A
no referral req
assess for fetal distress
more common in post dates / preterm
put on a pad and monitor ongoing loss
post partum-if resus required / APGAR <9 at 5mins- 4hourly obs for 24hrs
17
Q
referral guidelines for delay in 2nd stage
A
Consult
-primip- pushing for 2hrs with no progress
- multip- pushing for 1hr with no progress
18
Q
Mendelson’s syndrome
A
aspiration pneumonia that can occur in CS- hence avoid eating before surgery
- OMEPRAZOLE given to reduce acidity in stomach
19
Q
Placenta praevia- types
A
type 1 - placenta is mostly in upper segment
type 2- partially in lower segment (minor)
type 3- partially covers internal os
Type 4- completely covers internal os (major)
20
Q
when can women with placenta praevia birth vaginally
A
if inferior edge of placenta is >2cm from internal os
21
Q
signs of possible placenta praevia
A
- painless / unprovoked vaginal bleeding >20wks
- high presenting part
- abnormal lie
- (irrespective of previous imaging results)
TV USS is safe with placenta praevia
22
Q
What is AN mmgt of placenta praevia if no bleeding / placenta reaches edge
A
- explain that is bleeding / contractions start- go to hospital immediately
- check for anemia
- avoid sex / digital exams/ speculum (unless we are sure about placenta location)
recheck placenta location at 32 wks
>32wks- transfer
23
Q
uterine hypertonus / hypersystole- definition
A
contractions >2min duration OR <60sec break in between
FHR normal
24
Q
uterine tachysystole- definition
A
> 5 contractions :10mins
FHR normal
25
uterine hyperstimulation- definition
abnormal FHR
hypersystole /hypertonus OR tachysystole
26
sinusoidal pattern
what does it look like?
what is it associated with
smooth undulating pattern, 2-5cycles / min, NO baseline variability / acceperations
associated with severe hypoxia
27
what is a complicated decel
decels that vary in shape, duration, intensity
associated with cord compression
rising baseline/ fetal tachycardia
rduced variability
slow return to baseline
large drop (>60bpm or to 60bpm, or lasting >60sec)
presence of overshoot (baby is compensating for hypotension)
28
what are recommendations for third stage during water birth
## Footnote
r
routinely try to have physiological 3rd stage- don't clamp cord beforehand
can stay in pool to birth placenta
29
what is on MEWs chart
resps-
oxygen- room air
oxygen sat-
heart rate:
BP
TEMP
Level of consciousness-
pain score- rest/ movement
resps- 10-20
oxygen- room air (yes / no)
oxygen sat- >95%
heart rate: 60-100
BP: 140/90
TEMP- 36-38
Level of consciousness- normal / abnormal
pain score- 0-10
30
what is MCNZ's role with cultural competence
* cultural competence is integrated into competencies for entry
* competencies require MW to apply principles of cultural safety to mw partnership
* integrate turanga kaupapa within partnership and practice
31
how does MCNZ discuss tiriti
founding document
basis of the 'bicultural relationship btwn Maori + other NZer's
32
what is cultural competence
ability to interact respectfully and effectively with people with background different from yours
more than awareness / sensitivity to others culture
1) recognising impact of your culture and beliefs on MW practice
2) being able to acknowledge / incorporate each woman's culture into provision of individualised care
having knowledge, skills, attitude to understand effects of power within healthcare relationship
applies frameworks of partnership, cultural safety and turanga kaupapa
33
what is cultural safety
effective MW care of woman by MW's who have undertaken process of self reflection
unsafe cultural practice- any action that demeans or disempowers the cultural identity and wellbeing of an individual
34
who are nga maia
national organisation of maori MW's and whanau
formed 1993
key obj- to protect Maori childbrit hknowledge and practice
charitable trust
35
what is turanga kaupapa
guidelines on cultural values of maori
developed by Nga maia
about cultural competence and respect
formally adopted by MCNZ and NZCOM
provide cultural guidelines for MW practice to ensure cultural requirements are met for maori during pregnancy + childbirth
36
what is meaning of whakapapa
geneology
whanau + wahine are acknowledged
helps to place maori in among their ancestors / lands / tribes
37
what is principle of karakia
whanau + wahine may use karakia
for many maori- karakia is an essential element in protectign wairua (spirit), hinengarao (pscyological, tinana (physical) + wellbeing
offer patient+whanau/ allow time for karakia
38
what is principle of whanauungatanga
relationship / sense of connection
wahine and whanau can involve others in her brithing program
39
what is principle of te reo maori
wahine and her whanau may speak te reo maori
## Footnote
mana
40
what is the principle of mana
the digntiy of the wahine, her whanau, the MW and others involved is maintained
41
what is the principle of tikanga whenua
maintains the continuous relationship to land life and nourishment
and the knowledge and support of kauatua (elderly) and whanau is available
whenua "LAND"/ "Placenta"
'tikanga'= guiding principles
42
what is the principle of te whare tangata
"the house of humanity" (womans womb)
the wahine is acknowledged, protected, nurtured and respected as te whare tangata
43
what is the principle of mokopuna
"grandchild / great neice or nephew"
symbolizes the continuation of whakapapa (geneology)
the mokopuna is unique, cared for, and inherits teh future, a healthy environment, wai u and whanau
44
what is the principle of manaakitanga
the MW is a key person with a clear role and share with the wahine and whanua the goal of a healthy safe birthing outcome
45
what is the principle of hau ora
the physical, spiritual, emotional and mental wellbeing of teh wahine and her whanau is promoted and maintaiend
46
ergometrine
dose, contraindication
dose: 5IU oxytocin, 500mcg (0.5mg) ergometrine
CI:
not routine drug
hypertension- has vasoconstrictor effect that can result in vasospasm
47
Folic acid dose + indications
(0.8mg) 800mcg- routine
5mg- high risk
* hx of previous NTD
* on insulin treatment for diabetes
* Taking anticonvulsants (epilepsy)
48
iodine dose
150 mcg
(iodine requirements increase in pregnancy- deficiency can negatively affect maternal / infant thyroid function + fetal cog dev)
49
what impacts with iron absorption
improves absorption
- vit C
- soaking legumes / roasting nuts
inhibits absorption
-calcium
zinc
tannins in teas /red wine
cigarette smoke
50
what can midwives prescribe in labour
opioids
tramadol
51
what is max dose of lidocaine
1% 20ml
52
morphine
dose
10mg dose IM
30-60mins time to peak effect
53
morphine
effects
contraindications
effects
reduced FHR variability
maternal + neonatal CNS depression
reudced oxytocin release
reduced uterine contractions
CI
<2hrs from expected birth
previous opioid allergy / anaphylaxis
Severe asthma/ obstructive airway / respiratory depression
premature baby
54
what medication is prescribed for increased risk of PET
Aspirin 100mg + calcium
12-16wks - 36wks
55
mag sulphate toxicity
signs
antidote + action
Assessment
loss of deep tendon reflexes (patellar) - Note- loss of patellar reflex PRECEDES respiratory depression
signs of respiratory depression - Call for Urgent - stop mg sulphate, give calcium glucomate (prevents ca deficiency)
BP, pulse, resp rate
Drowsy / loss of consciousness
Urine output mesaurement / 4hourly testing - -monitor for Risk of pulmonary oedema
temperature
Continurous FHR
If signs of respiratory depression or low urinary output (<100/4hrs)
STop mag sulphate
give calcium glucomate- prevents calcium deficiency
56
what is effect of mag sulphate
calcium antagonist- blocks calcium channels
= neuroprotection for baby
= reduces seizures
57
Syntocin IM
dose + time to effect
10 IU
2-4MINS time to effect
58
What is dose of vit D
Colecalciferol
10-20mcg (400-800units) daily
59
Nifidipine
indication
how does it work
Effect-
calcium channel blocker
indication-
tocolytic to slow/stop preterm labour <34wks
anti-hypertensive
60
Salbutamol
indication
how does it work
indication- tocolyse preterm labour + asthma
stimulates beta adrenreceptors = relaxes smooth muscle
61
warfarin
effect
use in pregnancy
antagonist
Anticoagulant
not recommended in pregnancy where possible, especially in T1 - birth defects + bleeding problems (vitamin k deficiency bleeding)
better to replace with enoxaparin (heparin)
antagonist- Vitamin K
62
what are MW responsibilities under OT act
MW must provide info if request is made by CE of OT/ constable
- OT act overrides privacy act- MW can disclose confidential info and be free from civil/disciplinary proceeding
(unless info is protected by legal professional privileges)
63
what are legal requirements to bury stillborn
>20wks / 400g
legally required to register birth, bury or cremate them in a registered place
death must be registerd within 3days of burial/cremation
if baby is <20wks /400g, you are not legally required to bury baby, you may bury in a place of your own choice - ensure it's at least 1m deep
64
what is early + late neonatal death
early- baby that shows signs of life at birth, then dies before 7 days post birth
late- baby that shows signs of life at birth, then dies before 28days post birth
65
what is requirement for notice of birth
required for stillbirth +live birth
completed by hospital / MW (homebirths)
must complete <5 working days of birth
includes-baby sex, date of birth, place of birth, stillborn (Y/N), weight, gestation
mum's contact details
66
what are MW responsibilities re. alcohol in pregnancy
MW's required to
* ask all pregnant women about alcohol consumption
* advise women of potential risks
* recommend women stop drinking alcohol
* offer primary referral + early referral for baby PN if FASD is concern
67
what are legal requirements to bury stillborn
>20wks / 400g
legally required to register birth, bury or cremate them in a registered place
death must be registerd within 3days of burial/cremation
if baby is <20wks /400g, you are not legally required to bury baby, you may bury in a place of your own choice - ensure it's at least 1m deep
68
what are requirements for 'notice of birth'
for All births (including stillborn)
completed by hospital or MW, within 5working days
includes
-mum's contact details
gestation length
weight + ethnicity
69
what are requirements for birth registration
for all births (incl. stillborn)
completed by biological parents (and adopted if relevant)- ideally within 2mths
includes
- child details- name + sex + live/stillborn + place of birth / ethnicity/
- mum +DAD name, - address, date of birth, ethnicity,
- Parent's relationship
- live /stillborn
- gender
70
what should MW write in prescriptions
client
Title, full name (incl. middle name), residential address (NOT PO box), DOB if <13yrs
prescriber
full name, full street address / postal address of place of work, phone number, designation, APC #, signature, date
medication info
name (use generic name), form(tablet), strength
dose, freq, route
quantitiy dispensed
# of repeats
71
what are MW's requirements if they suspect another MW has health issue?
mandatory obligation to report concern to MCNZ
72
Abortion changes
which acts changed
criminal act
HPCAA
Abortion act
HDC Act
73
adoption
what is process
who are 'statutory agents'
birth- birth parent completes birth registration
birth-12days- biological parents are guardians
>12days- biological parent can sign consent
>6mths- interim order - trial period for adopting parents
~12mths- final adoption order- family court makes decision. adopted parent can register birth (@nd time)
74
read over health information privacy code
collecting info
- when you can collect (lawful reason)
- directly from the person
- tell the person about purpose
- women can ask to correct information they think is inaccurate
- used for the purpose it was originally collected
- people have right to access info
-health professional must keep info safe adn secure--> MW must tell person + privacy commissioner if there is confidentiality breech
- info should be kept confidential
- treated as sensitive
- don't keep info for longer than needed (!o years)
- dispose of info securely
75
how long does MW need to keep health care record
## Footnote
1
10 years from last time the NW provided care
MW doesn't need to offer record back to client after 10years
76
list the 10 HDC rights
health providers have 'duties'- and must tell people about their rights and enable them to use them
1) treated with respect- privacy/ cultural needs
2) fair treatment- no discrimination for age /gender/ race
3) dignitiy and independnece
4) appropriate standards -meet professional standards
5) effective communication- interpretor avaialable if needed
6) information- explanation of condtion, options, involvement in teaching, results of tests, right to written info
7) choice and consent- if you are unable to give consent, services are given 'in your best interest'. consent in writing. you can ask to change providers + decide whether body parts are used/stored
8) support- support person can accompany you (as long as its safe and doesn't affect other people's rights)
9) teaching and research- same rights apply
10) compaints taken seriously- you can makea complaint- providers must resolve your complaint farly + quickly
77
2nd MW fee + sec 88
available to provide relief / support to LMC MW when providing primary care in any setting
reasons
- MW is tired due to excessive work (long labour/ 2 labours in a row)
- MW becomes unwell / has an unanticipated personal crisisi
- 2nd MW at homebirth
- MW requires support from a colleague to provide safe care
requirements
-2ND MW claims the fee
-must stay >90mins
-can't be used instead of a handover to core staff
78
What is minimum # of PN visits
7 (5 at home)
79
what are timeframes for submitting claims
MoH pays electronic claims <10 working days
10% deduction if claims are submitted >6mths after service are completed
No claim paid if claims submitted >12mths after
80
# mc
what is diagoxin
medication used for heart failure
keep taking it in pregnancy if benefit>risks
81
what are symptoms of molar pregnancy
bleeding / dark brown dx
severe morning sickness
abnormal uterus size (too small/ large )
elevated hcg
abdo pain
early pre-eclampsia (<20 wks)
82
what are types of molar pregnancy, and causes?
complete
1 sperm fertilising 1 egg that has no maternal genetic material = normal placenta forms
46 chromosomes (all paternal)
incomplete
2 sperm fertilising 1 egg = 69 chromosomes (triploid)
83
definition- Meninogomyelocoele
spina bifida
caused by lack of folic acids / exposure to virus
84
what do elevated ALT/ AST indicate
PET
HELLP
Hyperemesis gravidarum
acute fatty liver
85
what is Anti D dose
625 IU
86
kleihauer test
purpose, when is it done
maternal blood test- checking# of fetal cells in maternal blood (indicates blood has mixed)
indication
>20 wks
>possible
post birth ( if mum is Rh- and baby is Rh+)
87
what is purpose of direct coombs test
check level maternal antibodies in cord blood
88
when do you give Anti D
how long can anti-d be left out of fridge
within 72hrs of confirming potential isoimmunising event
4hrs out of fridge
89
what is Anti D recommendation for Rh- women <12 wks
dose 250 IU prophylaxis (single pregnancy)
indications
termination
miscarriage / ectopic/ molar pregnancy
CVS
uterine bleeding - heavy / repeated or associated iwth abdo pain
don't do kleihauer
90
what is anti-d recommendation for Rh - women >12wks
**2 routine prophylactic doses
**- 28 wks +34 wks
- 625IU
**
Additional dose with isommunising events **
625 IU prophylactic , within 72hrs (<10 days may give some benefit)
>20wks- kleihauer( to assess whether more anti-D should be given)
isoimmunising events
Ectopic pregnancy / molar pregnancy miscarriage/ threatened miscarriage/ stillbirth
APH
ECV /CVS/ amniocentesis
TOP
Abdo trauma
blood transfusion
91
what is diet req of vegetarian
often harder to get source of iron, calcium, B12
92
what does Fe refer to
iron stores
93
# F
what is iron deficiency / IDA
Iron deficiency: Ferritin <30
IDA: Ferritin <30, Hb <110/ 105
94
what do you do if Hb is ok, but ferritin low?
"iron deficiency"
prescribe 100-200mg iron
recheck at 26-28wks
95
What is referral for iron deficiency
hb<90
or not responding to treatment
96
what are the WHO 10 steps to breastfeeding
1) comply with marketing code and ahve a written feeding policy communicated to staff/parents
2) staff training / education
3) discuss importance of BF with pregnant whanau
4) facilitate skin to skin
5) support whanau to start/ maintain BF
6) don't provide other fluid unless clinically indicated
7) practice rooming in
8) support mother to recognise baby's cues for feeding
9) counsel whanau on use/risks of feeding bottle/ pacifiers
10)dx - refer whanau to communit yresources
97
Composition of colostrum vs breastmilk
## Footnote
c
colostrum
- more protein, Sodium, minerals, Mg, Cl, immunoglobulins
- less lactose, carbohydrate, fat, vitamins
mature milk
-90% water
-more lactose (draws water in), protien, carbohydrate, fat, vitamins, minerals)
98
signs of good latch
99
referral for breast abscess/ infection not settling with AB's
consult
100
what AB do you use for mastitis?
prescribe only if primary response is not working
- fluoxicillin 500mg 6hrly - empty stomach, v. effective narrow spectrum
- Erythromycin if penicillin allergy
101
management of breast engorgement
REST
ICE
ANTI-INFLAMMATORY- IBUROPROGEN
Compression
102
what is maternal diet advice when breastfeeding
wide variety of food
need to eat more
don't cut out foods
103
what screening is particularly important for women of increased maternal age
chromosomal abnormality screening
104
what is timing for MSS1
Bloods- 9-13+6
scan- 11-13+6
105
interlocked twins
rare obstetric complication with multiple pregnancy
2 fetuses become "interlockedd" during presentation before birth - leading breech, 2nd is vertex
requires CS
106
twin twin transfusion
* MZ twins only (identical twins that have potential to share placenta)
* blood from one twin is transfused to the other twin, via blood vessels in shared plancenta
107
monozygotic AND dizygotic twins
- type
- genetic similarity
- physiology
- incidence / causes
monozygotic
* - type: identical twins (always same sex)
* - genetic similarity - always same sex. genetically identitical- very similar physical+psychological
* - physiology-1 sperm + 1 ovum (uniovular). developing embryo splits into 2 in first 2 weeks
* - incidence / causes- unknown cause
dizygotic
type- fraternal twins (can be same or different sex)
- genetic similarity- 50%
- physiology- 2 different sperm fertilise 2 ovum (binovular) = 2 zygotes. separate membranes cords.
- incidence / causes: familial, maternal age, parity
108
Describe characteristics of MCDA vs MCMA
what type of twin has this
Both
ONLY monozygotic-timing- >9 days after conception- egg splits after amniotic sac has begun to form
MCDA
1 CHORION (share placenta)
2 AMNION (separate amniotic sac)
MCMA
1 choirion
1 amnion (sitting next to each other)
109
Describe characteristics of DCDA
which types of twins have this
Dizygotic Only + 30% of monozygotic (egg splits <3days)
2 Chorion ( placenta may be fused or separate)
2 amnion
110
after delivery of first twin- what's next action for 2nd twin
check position
111
guthrie test
when do we do it
what is it for
asap >24hrs (<72hrs)
screens for rare, usually inherited disorders
112
where is prolactin stored
anterior PG
113
Where is oxytocin stored/released
posterior PG
114
which hormone reduces digestive system muscle activity
progesterone
115
describe role of myelinated and non-myelinated pain receptors in labour
related to gate control theory of pain
myelinated- faster transmission- touch / pressure/ pain
non-myelinated- (C fibres)- slow transmission- activated by pain
TENS activates myelinated, blocking non-myelinated
116
what is purpose of red eye reflex
detect congenital cataracts - via confirming presence of retina+ clarity of lens
117
which umbilical vessel carries most oxygenated blood to baby
umbilical vein
118
when must the hearing test be completed by
before 1mth old
119
what is true about screening for Developmental dysplasia of hips
orthopedic Referral
be gentle
no nappy
baby must be calm
120
cephaehaematoma vs caput succedaneum
cause-
when does it appear
mgmt
cephahaematoma
* bleeding UNDER periosoteum
* doesn't cross suture lines
12-72hrs
may worry parents but generally doesn't require treatment
caput
- oedema ABOVE periosteum
- crosses suture lines
- appears during labour
121
describe moro reflex
arm extends out and returns to chest
122
what do you do if baby has sticky eye
- usually caused by inflamed tear duct
- regularly cleanse eye
- few drops of breastmilk
- if infection suspected- take swab for cultures + sensitivities
consider possibility of chlamydia (usally with pneumonia- 1-3wks)
123
what happens to strawberry mark in future
grows
124
what are strawberry naevus
develop after birth - grow fast in first few months, then stop.
caused by overgrowth of cells
usually shrink over few years
125
how do you sterilise a bottle?
at what age do you do this for
1min in a pot
6mths
126
Shoulder dystocia-
definition
Definition
A birth that requires additional manoeuvres to release the shoulders after
* head has been born
* AND routine axial traction has failed
127
shoulder dystocia- describe the cause
disproportion between
-bisacromial diameter of fetus (width of shoulders)
Anterio posterior diameter of pelvic INLET
Shoulder is impacted
- usually anterior shoulder is impacted behind Symphysis pubis
- occasionally posterior shoulder is impacted against sacral promontory
128
Clinical signs of shoulder dystocia
* prolonged 2nd stage
* slow descent of fetal head
* slow extension of head with chin remaining tight against perineum
* absence of restitution
129
# ```
```
what is referral for shoulder dystocia
Emergency
130
Describe process to respond to Shoulder dystocia
What are key considerations if shoulder dystocia has been diagnosed
1) CALL FOR HELP (always first) - Emergency
- discourage pushing
- avoid excessive traction
- prepare for emergenices: NB resus + PPH
2) POSITION- McRoberts ( to increase functional size of bony pelvis + dislodge shoulder)
3) Suprapubic Pressure (to reduce bisacromial diameter, move shoulder into wide oblique diameter)
4) Internal manouvres
(change relationship of bisacromial diameter + bony pelvis) - posterior arm removal / auxillary traction
131
McRoberts manouvre
indication
purpose
describe position
indication-
- shoulder dystocia- first position change - resolves up to 40%
position-
- Completely Flat (no pillows under head / back)
- knees to shoulders /nipples
purpose
flatten lumbosacral spine
raise the symphysis pubis
-
132
Suprapubic Pressure
indication
purpose
describe position
indication-
shoulder dystocia- after + with McRoberts
purpose-
put pressure on posterior aspect of impacted shoulder
* to ADDUCT shoulders- and thus reduce the bisacromial diameter of fetus (width of shoulders)
* to encourage rotation of anterior fetal shoulder into wider oblique diameter
position
- stand SAME Side as fetal back
- apply pressure ABOVE symphysis pubis
- CPR hands- rocking or constant pressure
- simultaneously, another MW can apply gentle axial traction
133
PV internal manoeuvres
indication
purpose
describe
indication
Shoulder dystocia
- use after trying position + suprapubic pressure
purpose
change relationship of bisacromial diameter (shouder width) with bony pelvis (i.e. rotate)
Describe
- communicate + get consent
- try internal rotation (two fingers) --> wood screw (2 hands, 2 fingers)--> delivery of posterior arm (whole hand)
134
PV internal manoeuvre- remove posterior arm
indication
shoulder dystocia
try these if internal rotation / wood screw manouvres haven't worked
purpose
reduce bisacromial diameter (by width of arm)
description
insert whole hand posterior to baby
try to find hand and grasp out- may need to push down on cubital cossa (elbow) to flex, encouraging arm to sweep over baby's chest
p. 953
remember- discourage pushing, and never grasp / pull fetal head
135
PV internal manouvre- internal rotation
purpose
shoulder dystocia
comes after position + suprapubic pressure
try this internal manouvre first
description
insert 2 fingers
apply pressure to anterior fetal shoulder (adduction) to encourate rotation into oblique plain / under symphysis
remember- discourage pushing, and never grasp / pull fetal head
136
PV internal manouvre- wood screw manoeuvre
purpose
shoulder dystocia
comes after position / suprapubic pressure
try after internal rotation manouvre
description
ONLY manouvre with 2 hands
2 fingers of each hand-
involves internal rotation (pressure on anterior fetal shoulder , as well as on anterior aspect of posterior shoulder too)
137
Anthropoid pelvis-
describe shape
what is it associated with?
shape- oval with longest anterior posterior diameter. larger pelvis generally
posterior position
138
61. It is believed that the exaggerated lithotomy position (McRoberts manoeuvre) facilitates delivery of the foetal shoulders through which of the following mechanisms? Choose one answer.
a. Rotating the symphysis pubis to free the impacted shoulder
b. Increasing the room for the attendant to deliver the shoulders
c. Increasing the length of the anteroposterior pelvic diameter
d. Producing rotation of the shoulders into an oblique diameter
a. Rotating the symphysis pubis to free the impacted shoulder
139
62. Which of the following is NOT an appropriate procedure to manage a shoulder dystocia? Choose one answer.
a. Fundal pressure
b. Episiotomy
c. Manual rotation of the shoulders
d. Supra-pubic pressure
fundal pressure
140
what is brandt andrews manouvre
CCT
141
toxoplasmosis- how to avoid
don't touch cat faeces
142
what does HELLP stand for
haemolysis (destruction of RBC's)
elevated liver
low platelets
143
what is vit k dose
kanokian
0.1ml 1mg IM
0.2ml 2mg Oral x3
144
what are signs of VKDB
bruising- esp head and face
Bleeding - nose / umbilicus
pale
whites of eyes are yellow
blood in stool
vomiting blood
irritable /seizures / sleepy
145
Which of the following best describes the reasoning behind administering vitamin K to newborns? Choose one answer.
a. Because the trauma of birth quickly exhausts the available clotting factors in the newborn’s reserve.
b. Because the newborn gut, where vitamin K is synthesised, is immature.
c. Because vitamin K protects against bacterial colonisation of the newborn’s gut.
d. Because the newborn liver, where clotting factors are manufactured, is immature.
b. Because the newborn gut, where vitamin K is synthesised, is immature.
146
what is lactose
main carbohydrate in breastmilk- slowly broken down to gluocse/ galactose
147
what is the initial oxygen level for resus
## Footnote
2
0.21
148
what are risks to formula feeding
obesity
DM
149
Cholestasis
signs / assessment
cause
risks in pregnacy
mgmt
signs
- pruritus in absence of skin rash
- AND abnormal Lft +/or raised bile acids
- both have no alternative cause + resolve after delivery
may also have - pale stools/ dark urine/ possible jaundice
cause
multifactorial- genetic, environmental, increased oestrogen
Risks
preterm birth, stillbirth, meconium
Assessment
- inspect skin- ensure it's not ezema, PUPP
- bloods- ALT AST, bilirubin, bile salts
mgmt
close monitoring
IOL
recheck LFT's 10 days post partum (LFTs normally increase in first 10 days)
150
feeding multiples- esp if twin has dropped 8%
body should be able to produce double breastmilk
may be easier to breastfeed together (1 breast helps other breast let down) or separately (less awkward)
<10% is normal weight loss.
check latch / skin to skin / maybe increase
151
listeria
what is it
symptoms
AN risks
what can it pass through
key safety messages
symptoms
non-specific- usually asymptomatic- accurate diagnosis difficult. minor illness in pregancy doesn't warrant AB's for listeria
may develop 2mths after expsoure
Risks to baby
PPROM, fetal distress, PTL, chorioamnionitis, placental abruption, fetal demise, sepsis, stillbirth
can pass Pass through placenta / vagina
safety
- cook food well, eat steaming hot
-avoid high risk foods (Raw eggs, unpasteurised cheese, unhomogenised milk, uncooked seafood, meat)
152
Rubella
what is it
screening
mgmt
what is it**
Virus - passes to baby invitro.
if contracted in Trimester 1, ** can cause congenital Rubella syndrome (blindness, heart, stillbirth(
screening
- universal screening- check bloods (gold/ red) for presence of antibodies (10 indicates immunity)
If NOT immune-
- avoid contact with people at risk of rubella (flu like symptoms, rash)
- have vaccination post birth (NO VACCINE IN PREGNANCY)
- if suspected rubella contraction- **CONSULT**
153
what are the types of immunity
1) innate
** (what you are born with- e.g. skin)
2) **Acquired (What you develop in your lief)
i) Active
(your body developed immunity in response to something)
* ` Natural - body developed immunity in response to infection (e.g. chicken
pox)
* Artificial- body developed immunity in response to vaccine (Covid/ Rubella)
ii) Passive (body developed immunity after receiving antibodies from something)
* Natural- antibodies received from mother(e.g. breastmilk, placenta)
* Artifical- Antibodies recived from a medicine- e.g. Anti D immunoglobulin
154
158. What type of immunity is transferred from mother to child by IgA immunoglobulins? Choose one answer.
a. acquired passive
b. natural active
c. acquired active
d. natural passive
Passive (body received the AB's, rather than making them)
natural (from mum, rather than medicine)
155
how do we grade deep tendon reflexes
4+ "hyperactive" (with/without clonus)-- clonus can indicate increased risk of convulsions
2 Average
1 Diminished
0 no response- NOT normal
156
When should urgent Antihypertensive treatment be commenced
160/110
157
why is fluid balance so importnat for severe PET
Excessive fluid administration can cause pulmonary oedema
fluids must be tightly controlled during labour + postpartum - 1st wk is very critical
