questions 4 Flashcards
what is normal discharge + cause
are different sorts of discharge and recommendations
Normal
clear or white, thin, not purulent
physiology
cervix makes more mucous (vagina doesn’t have glands)
increased PV dx- leucorrhoea - shedding of superficial mucosal cells
Grey / smelly- BV
Yellow- chlamydia
yellow/green + watery- gonorrhea
creamy / white/ itchy- thrush
frothy/ green/ yellow- trichomonias
what is not normal dx
white / itchy
grey / fishy- asymptomatic BV
yellow- may be chlamydia or gonorrhea (yellow green)
yellow / green/ frothy- trichomonias
pseudomonas
what is it
signs
rare bacterial infection
causes serious illness
spread via contact / food / water
151.A diaphragm prevents pregnancy by:
A A chemical discharge
B Stopping sperm from entering the vagina
C Stopping sperm from entering the cervical canal
D Chemical mechanisms
C Stopping sperm from entering the cervical canal
chlamydia
what is it
how is it transmitted
signs
risks in pregnancy
screening
how to test
what is it
bacterial infection
transmitted- Sexually transmitted or in pregnancy (not airborn / touching)
Signs
- usually asymptomatic. yellow dx, dysuria, pelvic pain, abnormal PV bleeding
risks
- miscarriage, preterm birth, ectopic birth, IUGR, vertical transmission
- Congenital conjunctivitis
screening
risk based- <25yrs
how to test
vulvo VAGINAL swab (self collected)
- first void urine
recommend partner gets treated too
recheck in 3mths
treatment-azithromycin
Treatment of a woman’s sexual partner(s) is indicated for all of the following infections EXCEPT: Choose one answer.
a. Bacterial vaginosis
b. Gonococcal cervicitis
c. Chlamydial infections
d. Trichomoniasis
BV - it’s not an STI, it’s caused by insufficient lactobacillus and excess anaerobic bacteria
bacterial vaginosis
cause
bacterial infection- due to reduction in lactobacillus
signs- grey/ fishy odour
risks- Preterm birth / ROM, SGA
screening- vaginal swab
CMV
what is it + type of transmission
symptoms
risks in pregnancy
screening
mgmt
viral infection (member of herpes family
usually chronic- becomes active when immunocompromised (pregnant)
type of transmission- bodily fluids (droplets, blood, breastmilk)
signs- flu like symptoms
risks
stillbirth, congenital abnormalities
vertical transmission
breastmilk
screening
risk based
mgmt
prevention- good hygeine
no treatment
TRANSFER
No treatment in pregnancy- give antivirals to neonate to reduce chane of serious problem
Syphilis
what is it + type of transmission
risks in pregnancy
screening
mgmt
bacterial infection - sexually transmitted (not via normal contact) + through placenta
risks
- transplacental transmission –> miscarriage/ congenital abnormality
- stillbirth
- VERY HIGH risk of vertical transmission
screening- Routinely (bloods).
mgmt- **consult **–> AB’s
- The neonate can contract congenital syphilis from his or her mother:
A At birth – If mum gets penicillin 4 weeks at least prior to birth, risk is minimal – followup and exam at birth
B During the fifth month of pregnancy
C During the second month of pregnancy
D During the seventh month of pregnancy
during 2nd mth (transplacental transmission)
HIV
what is it
transmission
risks in pregnancy
screening -what types and why do we screen
mgmt (referal, medication, birth type, what procedures to avoid, breastfeeidng considerations, skin to skin?)
what is it
virus
transmission
blood borne
most common presenting sign- recurrent thrush (candida)
risks in pregnancy
vertical transmission
Screening
routinely screen bloods
we screen to reduce risk oftransmission, and reduce disease progression for mum
mgmt
* TRANSFER
* Antivirals in pregnancy and given to neonate after birth (to reduce transmission)
* Caesarean section (if viral load not fully suppressed)
* AVOID invasive procedures- Amniocentesis, Fetal scalp electrode / blood monitoring, Episiotomy,
* beware increased risk of DM,
* breastfeeding- consider formula
* baby- Bathe baby immediately if viral load is high
- Which of the following statements best describes what is referred to as the “window phase†of human immunodeficiency virus infection (HIV)? Choose one answer.
a. The time between infection with HIV and the development of HIV viraemia.
b. The time between infection with HIV and the development of detectable levels of antibodies in the plasma.
c. The time between infection with HIV and the development of acquired immunodeficiency syndrome
d. The time between infection with HIV and the development of the first symptoms of infection.
b. The time between infection with HIV and the development of detectable levels of antibodies in the plasma.
Globally, by which mode of transmission have most women become infected with the human immunodeficiency virus (HIV)? Choose one answer.
a. Heterosexual transmission.
b. IV drug use.
c. Vertical transmission.
d. Blood transfusions.
Heterosexual transmission
influenza
risks in pregnancy
recommendations
preterm irht, SGA, perinatal death
flu vaccine anytime in pregnancy
hepatitis B
what is it/ how is it transmitted
risk in pregnancy
Screening
mgmt
what is it
viral infection -causes liver disease
most people have ‘acute’ illness, then develop immunity
some people have chronic hep b (carriers )
transmission
bodily fluids (inl. blood /breastmilk)
risk in pregnancy
Risk of transmission during birth (either Vaginal or CS)
low risk in pregnancy (hep b doesn’t usaully cross placenta)
screening
universal screening (bloods) to check for presence of antigen
Lfts- indicates liver damage
mgmt
* Mum take antivirals during pregnancy to reduce risk of transmission
* avoid invasive interventions (ARM, FSE, forceps)
* wash baby before Vit K
* give baby immunoglobulin (passive, artificial) + vaccination (active) <24hrs after birth
* give baby normal hep b vaccinations (6wks etc)
* can breastfeed (unless nipples cracked etc)
133.Peda asks about Hepatitis B. The midwifes best response would be to tell her that:
A It is hard to catch
B It is caught by unsanitary conditions
C Good handwashing will keep the incidence down
D The baby is not at risk
C Good handwashing will keep the incidence down
herpes (HSV)
what is it
transmission
risk in pregnancy
screening
mgmt
what is it
* viral infection- can be on mouth or genitals
* 1st exposure has highest viral load, usually then chronic with flare up when immuno compromised
* viral load can be repressed by antivirals (but no vaccine)
transmission
direct contact
risk in pregnancy
vertical transmission- esp if mum has contracts HSV in late pregnancy
symptoms
mum- varying- may have sores around genitals, various other symptoms
baby- fluid filled blisters on skin, eye infection
screening
ask women about HPV
if woman is symptomatic, can do a swab
mgmt
antivirals
consider CS if lesions are present during labour
avoid invasive procedures (forceps, FSE)
monitoring in labour- how often
1st stage-20-30mins
2nd- after each cx / 5mins
What is mechanism of labour for baby in Anterior position
Descent
flexion (enter brim transverse 11cm)
internal rotation (12cm)
crowning
extension (Anterior posterior diameter) - sinciput, face and chin sweep perineum
restitution (head returns to correct alignment with shoulders )
shoulders internally rotate (to fit AP diameter of outlet)
head externally rotates (head move stowards woman’s thigh)
shoulder released (usually anterior)
laternal flexion
what is definition of presentation
the part of the baby in the pelvic brim (cephalic/ breech / shoulder )
what is definition of presenting part (list for each presentation)
part of body that lies closest to cervix
(cephalic- vertex, brow, face)
(breech- (frank- legs extended), complete (feet tucked to bottom), footling)
what is definition of “lie”
relationship of mum’s back to baby
longittudinal
transverse
obligue
what is definition of attitude
Relationship of fetal head and limbs to its body
fully flexed / deflexed/ partially or completely extended
what is definition of denominater
landmark on presenting part, describes degree of rotation
vertex- occiput
buttock- sacrum
face- metum
Describe vertex presenting part
what is denominator
what are types of flexion and circumferences?
denominator- occiput
Fully flexed Vertex -Suboccipital bregmatic diameter (9.5)
partially deflexed- suboccipital frontal (10.5)
deflexed vertex- occipitalfrontal (11.5)
Describe face presentation
what is denominator
what are types of flexion and circumferences?
what position does menum need to be in, to birth
denominator- mentum
Extended- submentum bregmatic 9.5
partially extended- submentum vertical 10.5
mentum needs to be anterior (if posterior, it gets stuck at sacrum)
Describe brow presentation
what is denominator
what is diameter
denominator- glabella
mentovertical - 13.5cm
Station
Definition and classification
Relationship to presenting part and ischial spines
+1 = going past spines (below spines)
-1 = above spines
Descent
Definition and how to classify
How much of baby’s head is palpable (above brim)
5/5 = all palpable
0/5 = not in brim at all
which diameter is optimal)
suboccipital- bregmatic (9.5cm)
ARM
what are contraindications
not well engaged
not vertex presentation (risk of cord prolapse)
presentation unknown / unstable
dilation <4cm
HIV/ Herpes
placenta praevia
- A platypelloid pelvis is: Choose one answer.
a. A normal pelvis with a heart shaped inlet.
b. An apelike pelvis with an oval inlet.
c. A typical female pelvis with a rounded inlet.
d. A flat female pelvis with a transverse oval inlet.
flat - transverse oval inlet
183.The widest anterior-posterior diameter in which of the following types of pelvis?
A Android
B Anthropoid
C Gynaecoid
D Platypelloid
anthropoid
android pelvis
describe shape
heart shaped- smaller inlet, prominent ischial spines, subpubic arch <90degeres.
least suitable
progesterone only pill
mechanism contraindications when can you take it after birth
mechanism
block passage of sperm by thickening cervical mucous and decreasing endometrial receptivitiy
suppress ovulation
All tablets contain hormones
absolute contraindication
current breast cancer
how to take it
commence at any time, but use other contraception for first 7 days
combined oral contraception pill
mechanism
contraindications
mechanism
main action- blocks ovulation (by suppressing FSH/ LH)
Also impedes sperm penetration (thickens mucous / thins endometrium)
All women Avoid for 3wks post partum (risk of blood clots)
breastfeeding women avoid for first 6 wks (as it can inhibit lactogenesis II)
CONTRAINDICATIONS
- Blood clot issues
- personal hx of breast cancer/known genetic mutations
-increases risk of stroke- should be avoided by women with risk factors ( smoking / >35yo / migraine with aura
Contraceptive Implant
what is it
what is mechanism of action
when can you start?
hormonal side effects / BF safe?
contraindications
what is it-
“Jadelle”
2 Rods SC Implanted into upper arm
lasts for 1-5 years
what is mechanism of action-
rod releases progestogen
primary - thins endometrium / affects cervical mucous
secondary - inhibit ovulation through suppressing LH surge
when can you start?
immediately postpartum
side effects
variable/ unpredictable bleeding
headache, acne, weight gain, mood changes
rapidly reversible
BF
minute amounts ingested via breastmilk
contraindications-
anti-epileptic meds, St johns wart, Antivirals for TB + HIV
Combined contraceptive
what is it
what is mechanism of action
side effects
when can you start?
Contraindications
what is it
oestrogen + progesterone pill
take within 24hrs of each other
what is mechanism of action
inhibits LH/ FSH
inhibit endometrium dev
side effects
oestrogen- Increased risk of VTE
disrupts lactogenesis III
Weight gain / acne /mood
increases risk of stroke
when can you start?
not breastfeeding -3 wks post partum ( avoid risk of VTE)
Breastfeeding- 6wks post partum but ideally wait for 6mths
impact on breastmilk
minute amount of hormone in breastmilk- but viewed as safe overall
Contraindications
breast cancer (family hx of certain genetic mutations that increase risk of breast cancer)
known genetic mutations
family hx of VTE (not ok if you have thrombophlebitis)
risk factors for stroke (BMI>30, >35 years, >smoking )
>diabetes / Hypertension
>taking medications that induce CYP3A4 liver system (reduce efficacy of contraceptive)
when do you need to start using contraception
21days postpartum
what is lactational amenorrhoea?
what are hormones involved
how effective?
what are requirements for this
contraception via breastfeeding
prolactin inhibits GnRH –> FSH/LH
98% effective
3 Criteria must be met
<6mths
exclusively/ near fully BF (no long intervals (<4hrs during day, <6hrs night)
no period
effectiveness reduced with expressing
progestogen only pill
what is it
what is mechanism of action
when can you start?
Contraindications
what is it
Progesterone only
everyday -take within 3hr window (no inactive day)- if you miss a 3hr window, wait 48hrs
what is mechanism of action
* primary- block passage of sperm through thickening mucous + decreasing endometrial rceptivity
* varying effect on ovulation
when can you start?- anytime post partum
effect on Breastfeeding
doesn’t seem to reduce volume
minute amounts pass through breastmilk
Contraindications
current breast cancer (but ok if you are old / smoking/ clotting risk)
if mum is taking medication that affects CYP3A4 liver system (antiepileptics, TB/HIV antivirals, st johns wort)
medical assessment req if hypertensive, cancers, previous ectopic pregnancy, cysts,)
Injectable contraction
what is it
what is mechanism of action
side effects
when can you start?
Contraindications
what is it
aka depo provera
3mth injection
medroxyprogesterone (doesn’t contain oestrogen)
what is mechanism of action
primary- suppress ovulation (suppress FSH/ LH)
Secondary- thickens mucous / thins endometrium
side effects
can take 1 year to return of fertilty
reduced bone density
variable effect on bleeding
when can you start?
Anytime post partum- but bleeding may be heavier in first 6wks
no evidence it affects breast milk
Which of the following would preclude midwifery prescribing of the combined oral hormonal contraception? Choose one answer.
a. History of irregular menstrual periods
b. History of frequent headaches.
c. Presence or history of thrombophlebitis.
d. Smoking by women over the age of 35.
d. Smoking by women over the age of 35.
152.After the birth of a baby, contraception is best used:
A 3 months postnatally
B After weaning occurs
C When the bleeding stops
D After the first period
when bleeding stops
Which of the following is NOT a predisposing risk factor for an ectopic pregnancy? Choose one answer.
a. Intrauterine contraceptive devices
b. Two or more induced abortions
c. Bilateral tubal ligation
d. Pelvic infections
2 or more induced abortions
149.A young teenage woman said that her sister had problems with “the pillâ€. This was most likely
caused by:
A Increased progesterone
B Increased oestrogen
C Decreased progesterone
D Decreased oestrogen
increased oestrogen
151.A diaphragm prevents pregnancy by:
A A chemical discharge
B Stopping sperm from entering the vagina
C Stopping sperm from entering the cervical canal
D Chemical mechanisms
C Stopping sperm from entering the cervical canal
150.The best description of how an IUCD works is by:
A Stopping sperm from implanting
B Stopping ovulation from occurring
C Creating a hostile environment for sperm and for implantation
D Prevents sperm from entering the vagina
C Creating a hostile environment for sperm and for implantation
bladder care (intrapartum and postnatal)
what are the concerns- what causes this?
risk factors
post birth monitoring
issues
bladder overdistension –> urinary retention –> PPH + long term damage
- risk factors
- extensive tear / episiotomy/ prolonged 2nd stage / regional anaesthesia, instrumental, operative birth
monitoring
intrapartum- PU 4hourly / empty bladder if assisted birth
post partum
* - monitor timing and vol of PU- should PU <6hrs, >200ml. after PU, bladder should feel empty, and flow and vol feel normal
* if IDC- keep in-situ for >6hrs
use fluid balance chart
228.Rico and Elena Nenitez arrive at the labour and delivery suite. This is their first baby, and they
have completed a prepared childbirth class. During the admission procedures, the midwife
continues to observe Elena for manifestations of anxiety. Which of the following statements best
describes the relationship between anxiety and labour?
A Increased utilisation of glucose store, caused by stress and anxiety, decrease the availability of
glucose to the contracting uterus
B Peripheral vasoconstriction, caused by norepinephrine, decreases the blood supply to the
contracting uterus
C Anxiety, fear and labour pain result in catecholamine release, which can ultimately result in
myometrical dysfunction and ineffectual labour
D Epinephrine inhibits myometrical activity, and, therefore, uterine contractility
D Epinephrine inhibits myometrical activity, and, therefore, uterine contractility
- The clinical manifestations of a localised infection of a episiotomy would include:
A Approximation of skin edges of the episiotomy
B Patient complaint of severe discomfort in the perineum and an oral temperature of 99.8ºF
(37.7ºC)
C Reddened, bruised tissue
D Reddened, odematous tissue with yellowish discharge
D Reddened, odematous tissue with yellowish discharge
which muscles are cut with episiotomy
superficial- bulbocavonosus, transverse perinei
deep- pubococcygeus, illiooccygeus
NOT- ischiococcygeus
describe a mediolateral episiotomy
60degrees
(between anus + ischial tuberosity)
compard with midline- more pain + bleeding, but less likely to cause 3rd degree tear
what is difference between episiotomy and tear
tear tears between muscles/ fibres/nerves (natural pathway)
epis cuts across muscles / fibres/ nerves (maybe why more painful and associatd iwth more issues)
Which of the following agents is unlikely to be used to treat post-partum haemorrhage when the placenta has not been retained? Choose one answer.
a. Oxytocin
b. Carboprost trometamol
c. Nifedipine
d. Ergotomine malate
nifidipine
- What is the most serious sign of pre-eclampsia? Choose one answer.
a. hypertension
b. proteinuria
c. occult oedema
d. excessive weight gain
proteinuria
classification of perineal tear
1st- perineal skin + vaginal mucosa
2nd- perineal muscle
3rd
a- <50% eas
b- >50% eas
c- IAS
4th - EAS+ IAS + ano-rectal mucosa
what suturing technique is recommended
continuous non locked
- Antepartum haemorrhage is defined as bleeding from the genital tract occuring:
A In late pregnancy
B After the 28th week of gestation
C Before the onset of labour
D All of the above
all of above
- The amount of blood which constitutes an antepartum haemorrhage is:
A 20mls
B 60mls
C 45mls
D 15mls
20ml
- Beverley Smith a primigravida at 29 weeks, presents at delivery suite with a history of one episode of painless vaginal bleeding. Ultrasound scanning reveals placenta previa with the placenta reaching the cervical os edge. Which type of placenta previa is Beverley presenting with?
A Type I
B Type II
C Type III
D Type IV
type II
what are types of placenta praevia
Grade I : The lower edge of the placenta is inside the lower uterine segment
Grade II : The lower edge of the placenta reaches the internal os
Grade III : The placenta partially covers the cervix
Grade IV : The placenta completely cover
“Major”- the placenta fully or partially covers cervix (Grade 3-4)
“Minor” (aka low lying/ marginal)- placenta edge is <20mm from cervix
- Beverley has placenta parevia (type 2) nad has a bleed is admitted to the antenatal ward for observation and bed rest. Increased activities may be permitted after no vaginal bleeding for:
A 24 hours
B 36 hours
C 48 hours
D 12 hours
24hrs
- Suzie is diagnosed as having a multiple pregnancy. Ultrasound confirms twins. Multiple pregnancy may be suspected if:
A Foetal limbs are felt on both sides of the abdominal midline
B The uterus appears round, tense and tender
C There is excessive foetal movement
D The uterus appears too large for the estimated age of gestation
uterus appears too large
- To ensure both heart rates are heard the midwife must be able to:
A Hear a FH on different quadrants of the maternal abdomen
B Hear one FH louder than the other
C Hear two FH with two separate machines
D All of the above
all of the above
- Suzie asks about the likelihood of having binovular twins. The incidence:
A Remains unchanged throughout the reproductive life
B Increases with age
C Decreased with age
D Is not affected by age
increases with age
- A monozygotic twin pregnancy is associated with:
A Increased risk of foetal abnormalities
B Increased maternal age
C Family history of twins
D Use of fertility drugs
Increased risk of abnormalities
- To establish a diagnosis of preterm labour you will need to do:
A A vaginal examination
B Blood sugars
C An abdominal palpation
D FH Ausculation
VE
- Cindy Lund is a 17 year old primipara who goes into labour at 34 weeks gestation. She progresses to a normal vaginal birth. INITIAL management of Cindy’s baby after birth is ONE of the following:
A Blood gas determination
B Administration of sodium bicarbonate to correct potential metabolic acidosis
C Administration of epinephrine to correct potential metabolic acidosis
D Quick and effective drying of the baby
just dry and stimulate
- In the first few days of life in which of the following do premature infants MOST often experience difficulty:
A Poor sucking reflex
B Overdeveloped Moro reflex
C Reduced renal funtion
D Delay is passing meconium
poor sucking reflex
- When assessing the foetal condition during labour which of the following will you as the midwife be MOST interested in observing about the FH:
A The rate
B The rhythm
C The location
D All of the above
all of the above
- Janet a primip is 8 weeks pregnant and books into your local maternity unit. She expresses a desire to go home soon after her baby is born. You know Janet is Rhesus positive. This means Janet has:
A An antibody carried on maternal red blood cells
B An antigen carried on maternal red blood cells
C An antibody carried on maternal white blood cells
D An antigen carried on maternal white blood cells
AN ANTIGEN CARRIED ON MATERNAL RBC’S
- Janet IS RH NEG reaches term and had a normal vaginal birth. Which of the following cord blood tests will be ordered:
A Direct coombs and serum bilirubin
B ABO Group and RH Factor
C HB
D All of the above
ALL
dat- presence of maternal AB’s on neonatal RBC’s
- A direct coombs investigation tests for:
A Cystic fibrosis
B Spina Bifida
C Maternal antibodies
D Kleihauer
maternal antibodies
- The following combination most likely to result in Rhesus sensitization is:
A O/Rh negative mother and O/Rh positive father
B O/Rh positive mother and O/Rh positive father
C B/Rh negative mother and B/Rh negative father
D B/Rh positive mother and O/Rh negative father
mum is neg
dad is pos
- Should antibodies be formed, Jills baby is at risk of developing which of the following:
A Phenylkentonuria
B Haemolytic disease of the newborn
C Physiological jaundice
D Hypoglycaemia
haemolytic disease of nb
- Cindy had an epidural during her labour. When giving an epidural the anaethetist will inject the anaesthetic solution between:
A The arachnoid mater and pia mater
B The cauda equina and the cerebrospinal space
C The duramater and the ligamentum flavum
D The pudendal nerve and the uterine plexus
dura mater and ligamentum
- Should Cindy suddenly become hypotensive following administration of an epidural anaesthetic which is the BEST course of action:
A Turn the woman on her left side, give vasopressor, increase IV fluids
B Increase IV fluids, give vasopressor, turn woman on her right side
C Turn woman on her left side, increase IV fluids, administer O2 via a facemask
D Give vasopressor, decrease IV fluids, turn woman on her left side
i bp> 90-
left lateral, fluids, consult anaethetist (he may consider vasopressor- (ephedrine)
if BP <90,
then stop epidural, commence oxygen
if not breathinng- commence CPR
how do we calculate infant mortality rate
Death of baby from birth to 1year
/ 1000 live births
how do we calculate stillbirth rate
# death of baby born dead, before 20wks, or <400g
/ total births (live + stillbirth)
how do we calculate neonatal death rate
of live babies that die <28days / 1000 total live births
- Perinatal death is composed of STILLBIRTHS and NEONATAL deaths calculated per 1000 total births as:
A First day deaths
B First week deaths
C First month deaths
D Infant deaths
infant deaths
what is the perinatal death rate
# stillbirths (>20wks / >400g) + neonatal deaths (born alive, but die <28days )
/ 1000 live + stillbirths
- Physiological jaundice in the newborn may be caused by ONE of the following:
A Haemolytic disease of the newborn
B Accumulation of bilirubin with breakdown of Hb
C Sulphonamide drugs
D Large doses (>5mgs) of Konakion IM
accumultation of bilirubin with breakdown of hb
- Pathalogical Jaundice is a failure of bilirubin to be conjugated. WHICH of the following enzymes is necessary for conjugation of bilirubin:
A Alpha amylase
B Glucuronyl transferase
C Tryspin
D Protinase
glucuronyl transferase
- Tiny white spots across a newborns nose are called:
A Mongolian spots
B Haemangioma
C Milia
D Erythema toxicum
milia
- A newborn’s ability to maintain a stable temperature is influenced by WHICH of the following:
A Sweating and shivering mechanisms
B Size of body surface in relation to body mass
C Amounts of subcutaneious layer
D All of the above
all of the above
(although babis have a decreased ability to shiver / sweat)
- A neonate born to a drug dependent mother is MOST likely to exhibit which ONE of the following EARLY signs of drug effect:
A Dry skin
B Fever
C High pitched cry
D Restlessness
high pitched cry
neonatal abstinance- signs and symptoms of withdrawal
most common- tremors, irritability, hyperactivity, vomiting, high pitched cry
many- respiratory distress, fever, diarrhoea, sweating
few- convusions
recurrent sneezing / yawning should raise possibility that baby is withdrawing
fetal alcohol syndrome
what is it
features
rx
guidance to whanau re. alcohol
alcohol passes through placenta in same amount as plasma level, however it stays in baby’s system for longer, as baby takes longer to digest it
what is it
neurodevelopmental disorder caused by alcohol exposure before birth- complex physical, behavioural, learning and intellectual prblems
NOT every baby exposed to alcohol is diagnosed
features
small eye openings
thin upper lip
flat midface
smooth philtrum
low birth weight
diagnosis - at least 3/10 CNS conditions
rx
neurological or facial features + known /suspected AN drinking
advice
stop alcohol if you are trying to get pregnant/ could be pregannt
- Bettina, at term with ruptured membranes for 36 hours, is induced and delivers a healthy daughter. Within 24 hours of birth Bettinas baby manifests a temp of 38 degrees. Which of the following tests will take PRIORITY in the care of a newborn with a raised temp:
A Blood glucose test
B Ear, nose and throat swabs
C Lumbar puncture
D Blood cultures
blood cultures (sepsis)
describe the bracht manouvre
indication
for breech birth, when normal physiology is progressing- HANDS OFF
LOUWEN Manouvre
indication
“Side to side” manouvre to disimpact shoulders during Breech birth- “1st sign of dystocia”
indication
descent halts BEFORE Nipple line, and baby is sacro-oblique
manouvre-
grasp shouders, thumbs into vagina
turn baby to sacroanterior position- then wait
LOVESET Manouvre
indication
indication
breech birth
woman is supine and progress halts at Umbicus and arms extended
aim- help free arms
process
hold baby at pelvis
lift trunk anterior to cause lateral flexion
rotate 180, keeping back anterior- release posterior arm
rotate 180 in reverse direction, to deliver anterior arm
mauriceau smellie manouvre
breech
aim- to maintain flexion of baby’s head as it births
place finger on chin, place other hand on baby’s back with finger pushing on occiput ot keep flexion
kristellir manouvre
“suprapubic pressure” (e.g. shoulder dystocia / sometimes breech to maintain occipital flexion)
frank nudge
indication- breech- when head isn’t coming
push down over clavicles to encourage flexion
use palms to help round shoulders
- What is the incidence of breech presentation at term:
A 3%
B 10%
C 8%
D 5%
0.03
- In a frank breech presentation it is ESSENTIAL to determine by vaginal examination:
A If the presenting part is well applied
B Whether the cord is palpable
C The station of the presenting part
D The degree of flexion of the presenting part
whether cord is palpable
what is a complete breech position
buttocks are presenting, but feeet / knees are flexed and near buttocks
what is a frank breech position
hips flexed, legs extended
buttocks presenting
describe mechanism of labour for RSA
lie
Presentation
presenting part
attitude
denominator
position
lie- longitudinal
presentaiton- breech
presenting part- right buttock
attitude fully flexed
denominator- sacrum
position RSA
what are complications of breech birth
preterm birth
cord prolapse
erbs palsy (damage to brachial plexus)
fracture of clavicle / humerus/ femur
dislocation of hips / shoulders
bruising - esp to male genitalia
hip dysplasia
- Trudy presents at 36 weeks in established labour. She is unbooked. Which of the following would be indicative of breech presentation:
A Deeply engaged presenting part
B FH heard high on abdomen
C A regular mass in the lower pole
D A regular mass in the upper pole
FHR heard high
- The baby lies in the LSA position. During the breech mechanism when the buttocks complete internal rotation the bi-trochanteric diameter is in the:
A AP diameter of the brim
B AP diameter of the outlet
C Transverse diameter of the brim’
D Transverse diameter of the outlet
transverse diameter of outlet
- Following delivery of the buttocks and legs the shoulders are in the:
A Oblique diameter of the brim
B Transverse diameter of the brim
C Oblique diameter of the cavity
D Transverse diameter of the outlet
B- transverse diameter of brim
what is dosage of TXA
1g/10ml IV (1m/ min)
how does TXA work?
reduces bleeding by stopping breakdown of fibrinogen + fibrin (by plasmin)
morbidity sig reduced if given early
- Vaginal bleeding due to placenta previa is initiated by:
A Vaso constriction of vessels leading to the placenta
B A sudden increase in maternal blood pressure
C Blood seeping between foetal membranes and uterine wall
D Tearing of anchoring villi as the lower segment forms
tearing
how should Anti D immunolobulin be stored
if any delay, store in blood / vaccine fridge (2-8degrees)
not a domestic fridge, as temp too variable
what is deep transverse arrest?
what are indications?
when widest part of fetal head is blocked at ischial spines
indications
- fetal head is not descending past ischial spines
- extensive moulding / caput succedaneum
- primip- contractions are irregular / hypotonic
- sagittal suture is at transverse diameter in pelvis
describe physiology of asthma
inflammation of airway wall
bronchoconstrction- tightening of mucles constricts airway
increased mucous
what is maternal sepsis?
what are causes
risk factors
Signs
mgmt
body’s abnormal response to infection causing organ dysfunction.
woman that is pregant / has been pregnant
Causes
usually bacterial (Group A strep, GBS, eColi)
viral (herpes, CMV)
**Risk factors
**continued bleeding / offensive dx / wound infection
invasive procedures (CS, forceps, catheter, cervical sutures)
pyelonephritis
PROM
GDM
immuno compromised
Signs
* extreme temp (<36 >38)
* altered mental state
* hypotension
* tachyapnoea (>25rpm)
* tachycardic (>100bpm)
* sudden pain
* nausea / vomiting
in pregnant women- may also be abdo pain / offensive dx/ abnormal FHR
Mgmt
prompt response important- clinical deterioration can be rapid
Take 3
- blood cultures (before giving AB’s)
- lactates
- urine
-
Give 3
- empirical AB’s
- fluid
- oxygen
consider
- thromboprophylaxis
- delivery of baby / POC
Full exam required to identify possible cause / severity of sepsis
define 3rd stage
is from birth of baby to when bleeding is under control
What is NB resus
assess breathing / tone
Dry / stimulate
lie Flat / open airway
5 inflation breaths (3 sec)
30 sec of ventilation (40-60rpm - i.e. ~1 sec / breath)
check HR- >100 Ok
if <100, continue ventilation for 30 sec recheck
if HR<60bpm, start chest compressions
3 compressions: 1 resp
Give adrenaline if not responding to chest compressions
what do you do if a woman tests positive for chlamydia
prescribe woman AB’s (Remember it is our job to prescribe)
Azithromycin
recommend her partner get AB’s from GP
what is screeen for chlamydia
vulvaginal swab ( urine test is for men only)
ondansetron
indication
anti-emetic (nausea + vomiting in pregnancy)
avoid in Trimester 1- cleft palate
amount
4-8mg (max 16mg daily)
omeprazole
indication
- proton pump inhibitor
- reflux / indigestion / used in theatre to avoid mendelson’s syndrome)
calcium or magnesium based antacids- are they recommended? how do they work
recommended (e.g mylanta tablets)- they neutralise stomach acids
high dose aluminium containing antacids- are they recommended? what are effects
high dose aluminium containing antacids
side effects- constipation and altered GI motility
alginic acid- what does it do
forms viscous cohesive foam
prevents reflux by increasing adherence of mucous
simethicone- indication / effects
diseperses and prevents formation of gas in GI tract
relieves flatulence
what is homan’s sign
homan’s sign- pain behind knee after foot dorsiflexed/ Knee bent- clinical sign of DVT
Heparin
what is indication?
what is antidote
aka clexane
indication- DVT risk (anticoagulant)
antidote- protamine sulphate
- You explain to Kate that she needs to be admitted to hospital for further tests and delivery of her baby. A blood screen indicates a raised uric acid and a scan shows reduced liquor volume. The obstetrician now consulted has recommended an induction of labour. Contra indications for induction of labour include all of the following EXCEPT:
A Cephalopelvic disproportion
B Malpresentation
C Fetal distress
D Prematurity
prematurity
when does the morula enter the uterine cavity
day 4-5
when is the embryonic period/ organogenesis
wk 3-8
when is a fetus capable of survival (in NICU)
Maybe possible from 22-26wks (although <24 wks baby is usually neurologically impaired)
what are signs of congenital heart disease
pulse oximetry
cyanosis
respiratory distress
heart failure
what are most common congenital heart disease
- transposition of the great arteries (mixing of 2 separate circulations pulmonary + central)
- tetralogy of fallot- large ventricular septal defect
what period is most sensitive period for teratogens?
3-8wks
what is supine hypotension
when woman lies supine, and pregnant uterus compresses the inferior vena cava
what are legislative requirements re. miscarraige
<20wks / <400g
no birth / death registration.
baby can be cremated (anywhere) or buried- if baby is being buried at cemetery- MW writes a letter to confirm it is a MC
What are legislative requireemnts for termination
W
if >20wks
birth must be registered with medical certificate re. cause of death.
if baby is born alive, Notification of birth + registration is req
what are requirements for stillbirth
Notification to BDM by hospital /MW (within 5 days)
medical certifiate re. cause of death must be completed (by MW or Doctor)
parents must register birth (and acknowlege stillbirth)
if medical certificate is not issued, then coroner’s order is required (and don’t need to register birth)
what are requirements for neontal death
MW notifies BDM of birth
after death, MW or doctor issues ‘medical certificate of cause of death’ + parents register birth, and parents or their representative (MW or funeral director) register death - within 3 working days after disposing of body
IF medical certificate is not issued, then Coroner is involved
what is a postmortem
legal requirement when requested by coroner, because a medical practitioner can’t certify cause of death
wernicke’s encephalopahty
neurological- emergency
caused by thiamine deficiency
associated with Hyperemesis
what are changes to abortion legislation
women can self refer to abortion services provider (any age)
Abortion is decriminalised
a wider range of health practitioners can provide abortion
* appropriately trained MW’s can provide early medical abortion services in community
abortion can be performed anywhere (not just licensed premise)
MW must report each abortion to MoH
MW’s have right to decline care, but must ensure whanau can access closest provider, and info is shared without bias.
Abortion
-what can MW’s currently do
what are recommendations for USS / Contraception
reporting
MW’s currently have education to provide “early medical abortion”
28-70 days ( 10 weeks) after LMP
use mifipristone (anti-progesterone) + misoprostol (prostaglandin)
usually occurs at whanau’s home
important to discuss contracteption
Routine USS not necessary
reporting: MW needs to report to MoH every abortion they provide, as well as an annual report
NOT:
- early surgical abortion
- any 2nd trimester abortion
threatened miscarriage
signs
implications
assessment
signs
self limiting bleeding
maybe back / abdo pain
cervix closed
normal uterus (soft/ not tender / normal size)
implications
may become an inevitable miscarriage
bleeding may be caused by other reasons
assessment
bloods- hcg
USS
inevitable miscarriage
signs
implications
assessment
signs
cardinal sign- cervix is open (baby may still be alive)
may have- more severe/ persistent bleeding / contractions
impliations: miscarriage may be complete, or incomplete
what is management of molar pregnancy
need to remove all tissue- usually suction, then regular bloods to check hcg is normal before conceiving again
avoid hormonal contraception
what are signs of ectopic pregnancy
initially
- normal symptoms of pregnancy
non-specific signs develop *** Always consider possibility of ectopic pregnancy for woman with abdominal pain, until proven otherwise **
- similar to threatened miscarraige- lower abdo pain preceding bleeding
- may also have referred pain / lateral pain
-
immediately prior to rupture
increasing abdo pain
rigidity / rebound tenderness
abdo tenderness
pv bleeding
Deteriorates quickly
signs of shock (tachycardic, hypotensive, confused, pallor, cold clammy, fait)
What is cervical erosion
pregnancy hormones cause columnar cells on cervix to proliferate
these cells secrete a lot of mucous (= PV dx) and can rupture ( = bleeding) - esp after sex
what is definition of APH
- incidental
- accidental
- inevitable
- extraplacental
Any bleeding >20 weeks, before onset of labour
- incidental- localised bleeding (polyps, vaginitis)
- accidental- placenta is normally situated but separting (placental abruption (~50%)
- inevitable- placenta is abnormally situated (placenta praevia , accreta, increta, percreta)
- extraplacental (bicorneate uterus, uterine rupture)
what is a couvelaire uterus
severe concealed placental abruption
blood can’t escape- uterus becomes swollen and engorged
high risk of PPH
Corticosteroids
indication
What gestation
what is it
indication
risk of preterm labour
reduce risk of RDS (stimulate dev of surfactant)
when
24-34+6wks
> > betamethasone 11.4 mg 24hrs apart
DIC- what coag studies results indicate DIC
Fibrinogen normally increases, so normal / low fibrinogen levels and prolonged prothrombin time suggest DIC
when do you give mag sulphate for neuroprotection
<30wks
what is sheehan’s syndrome
anterior pituitary necrosis
a rare complication following massive bleeding
symptoms- amenorrhoea, failure to lactate, coarse hair and skin, feeling cold, genital atrophy
what is placenta acreta
placenta attaches too deeply into uterine wall
define placenta
- accreta
- increta
- percreta
what are these caused by / associated with
accreta-placenta attaches firmly into uternine wall
increta- placenta attaches into uterine muscle, but not through it
percreta- placenta grows through uterus- into nearby organs
causes
- uterine surgery / scar tissue
maternal age
complications
- PPH
what is velamentous cord
when the cord has attached to membranes rather than placenta
(associated with vasa praevia)
premature separation of (normally situated) placenta from myometrium
what is definition of placenta praevia?
what distance is CS recommended
when placenta is partially/wholly in lower uterine segment
CS recommended when placenta tip is <20mm from internal os
what is definition of vasa praevia
what is it associated with
what is presentation + Mgmt
when umbilical vessels are unprotected and travel across os
associated with placenta praevia / velementous cord / succenturate lobe
presentation- profuse bleeding after VE / ARM - EMERGENCY- requires immediate CS
what is Polycythemia
too many RBC’s
Graves disease
hyperthyroidism
hyperthyroid
signs
risks
mgmt in pregnancy
signs
raised metabolic rate
weight loss
heat intolerance
fatigue
rapid irregular HR / Palpitations/ hypertension
goitre
Risks
thyorid storm (severe thyrotoxicosis)
Mgmt T1/ BF- PTU T2/T3- Carbimazole No surgery / radioactive iodine in pregnancy Rx CONSULT
hypothyroid
diagnosis
signs
risks
mgmt / rx
Diagnosis - increased TSH/ reduced T4
Signs
low metabolic rate
cosntipation
feel cold
lethargy
oedema
thick/ dry skin
Risks
GDM / PE/ Preterm / infertility/ miscarriage
mgmt
Thyroxine (pregnancy + BF)
What is most common rheumatic valvular lesion in preganncy
mitral stenosis - esp left sided
Rheumatic heart disease
cause / LMC role
cause
GBS–> acute rheumatic fever –> rheumatic heart disease –> damage to heart valaves (esp mitral stenosis)
Risk in pregnancy
heart failure- -Pregnancy is often the time that valvular heart disease is identified (pregnancy puts extra pressure on CVS)
if woman is high risk population, Always rx for ECG if they ahve a heart murmor
what are L&B and postpartum recommendations for someone with heart disease
l&b
epidural
3rd stage
continuous oxygen
use of diuretics
instrumental delivery (shorten 2nd stage)
postpartum
Rest
continously monitor for at least 72hrs
how do we calculate EDD
+ 280 Day
+ 7 days + 9mths
+ 7days -3mths
remember knuckles- from Jan 31st onwards
G’s
P’s
G’s (# of pregnancies, multiples = 1)
P’s (# of births (includes live + stillborn). Multiples - 1. Stillborn = -1.
what is primagravida vs primiparous vs nulliparous woman
primagravida- first pregnancy
nulliparous- woman hasn’t given birth before
primiparous- woman who has given birth once (so shouldn’t be used until woman has actually delivered baby)
what uter
what uterotonic can MW prescrbe
oxytocin + syntometrine
NOT
Misoprostil (can give at primary unit after discussion with obstetric reg)
carboprost (only at hospital)
what does HPCAA act enusre
protect public
by promoting mechanisms to ensure health practitioners are competent
set up MCNZ (regulatory bodies) to provide regulatory frameworks (have legislative power)
Hormone HPL
where is it secreted from
when does it start / peak
role
human placental lactogen
secreted from placenta
from 5-10days post implantation, peaks right before birth
Role
- growth hormone (breast dev / fetal dev)
- changes maternal metabolism ( insulin atagonist= increased BGL) / mobilise maternal lipid stores/ accelerate Amino acid to fetus)
which opioid is contraindicated with entonox
fentanyl
hypotension after epidural
definition
monitoring
management
definition: systolic <90-100, or 20-30% drop from baseline
monitoring: every 5min for 20mins, then hourly
mgmt:
- left lateral position
- fluids
- vassopressor (e.g. ephedrine drug that causes vasoconstriction = increase BP)
what
what drug do we give for hypotension AFTER EPIDURAL
ephidrine
Norepinephrine as second choice
what is definition of GDM
Any DM first diagnosed in pregnancy
What is glucagon
hormone that increases BGL
(Promotes breakdown of glycogen / lipids)
labetalol
mechanism
indication
beta blocker
anti-hypertensive
hydralazine
mechanism
indicator
vasodilator
anti-hypertensive
What is definition of ectopic pregnancy
blastocyst implants somewhere other than endometrial lining
