scope exam Flashcards

1
Q

What are the four things to cover in a booking appointment?

A
  • social history
  • obstetric history
  • current pregnancy
  • plan going forward
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2
Q

What are some relevant aspects of social history that would need to be ascertained

A
  • Smoker / drinker?
  • support network?
  • eligibility for maternity care
  • cultural needs
  • employment?
  • routine enquiry
  • travelled to other countries? (risk of TB?)
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3
Q

What are some relevant aspects of obstetric history that would need to be ascertained

A
  • is this first pregnancy?
  • how many pregnancies? any terminations or miscarriages?
  • how was last birth experience?
  • previous mode of birth?
  • any complications in last pregnancy, birth or postnatal? (for woman or baby)
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4
Q

What are some relevant aspects of the current pregnancy that would need to be ascertained (in a booking visit)

A
  • How has diet been? (if morning sickness, is she getting enough nutrients)
  • how has she been feeling in general? (headaches, swelling, visual disturbances? - if after 20 weeks)
  • getting enough iron?
  • taking iodine? (and folic acid in first trimester)
  • any bleeding?
  • feeling baby movements? (if later in pregnacy)
  • screenings? (blood, MSS1/2, anatomy scan, GDM?)
  • would she like to part-take in antenatal education?
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5
Q

What are birth place options of low risk pregnancy?

A
  • home
  • primary unit
  • hospital (secondary unit)
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6
Q

what are the benefits / risks (or cons) having a home birth?

A
  • own environment - more relaxed - increased endorphins - natural pain relief
  • more control of experience (no institutional rules)
  • have who ever you like present
  • no pharmaceutical pain medication (could be a con but increases chances of normal physiological birth)
  • having to transfer into hospital if anything deviates from normal (such as fetal or maternal distress, slow progress etc).
  • outcomes may be more adverse due to transfer time depending on where you live?
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7
Q

pros and cons of birthing at the primary unit

A
  • no pharmaceutical pain relief except for entonox (therefore increased chance of physiological birth)
  • usually birthing pools available that can be quickly filled
  • midwife led instead of doctor led - therefore protects normal birth
  • usually 1;1 postnatal care, double beds for partner to stay, pepi pods for baby.
  • may be restrictions of support people allowed
  • no epidural or opioid pain relief
  • long transfer - 1 hour - to secondary unit if anything is out of ordinary
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8
Q

pros and cons of birthing in the hospital

A
  • pain relief on hand when ever (epidural and opioid pain relief)
  • obstetricians on site majority of the time or on call to get there fast if needed - reduces adverse outcomes not having to wait.
  • increased exposure to interventions - increasing likely hood of non-physiological birth
  • institution rules may make you feel like you’re not in control
  • may be restrictions on support people allowed
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9
Q

what physical assessments are undertaken in a routine antenatal appointment? (provide rational)

A
  • urinalysis - for protein and glucose in urine ( glucose could be a marker for GDM, protein could be an indication of preeclampsia due to decreased kidney function)
  • blood pressure - normal range (100-139 mmHg (sys) / 40-89mmHg (dia) according to MEWS chart. if outside normal range or 20mmHg above booking blood pressure then this may be of concern - could indicate pre-eclampsia if after 20 / 40)
  • Abdominal palpation - fundus, fetal lie, position, presentation, engagement, fundal height (if after 26 weeks), fetal heart - rationale - monitor fetal wellbeing and growth of baby .
  • measure height and weight if in booking appointment to ascertain BMI and use in creating customised growth chart.
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10
Q

health information and eduction at a booking appointment?

A
  • discuss role and responsibilities of midwife, backup and how to contact
  • discuss logistics, frequency and location of visits
  • how to meet cultural needs of women
  • who will be involved? (partner/support person)
  • discuss place of birth options
  • community agencies
  • code of consumer rights
  • antenatal education
  • consent for student involvement
  • screening information offered in first trimester
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11
Q

What is involved in a labour assessment?

A
  • admission and ID on arrival at unit
  • history - pregnancy, relevant medical Hy and allergies
  • history of contractions and SROM? colour of liquor?
  • abdominal palpation - ascertain lie, position and decent, auscultate FHR post contraction. (110-160bpm norm range)
  • assess PV loss regularly. blood? liquor? mucus?
  • assess nature of contractions every hour - length, strength, frequency ;10min, maternal response
  • baseline maternal obs: pulse 1hrly, BP - 4hrly, temp, O2 sats, resps (document on MEWS)
  • review birth plan with woman
  • abdo palp 4 hrly
  • VE 4 hrly if consent or more frequently if indicated - to assess cervical dilation, effacement, length, decent of baby’s head and confirm position.
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12
Q

what are the benefits of water immersion in labour and what would be considered contraindications for it?

A
  • natural pain relief owing to reduced anxiety and adrenalin. increased endorphins, natural pain relief and enhances flow of oxytocin - could result in a faster, more manageable labour.
    -reduces likelihood for needing other methods of pain relief.
  • bouyancy and increased mobility
  • provides protective and secure birthing space
  • contraindications: epidural, recent administration of opioid, feeling faint, if continuous fetal monitor was required and couldnt get a good trace of FHR in water, maternal temp more than 37.5, thick meconium in liqour.
  • would need to get out of pool if active management of the third stage is required
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13
Q

what is neagales rule?

A

first day of LMP, minus 3 months, plus 7 days. (add any days for a longer cycle e.g. if they have a 30 day cycle instead of 28, add an extra 2 days to the date).

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14
Q

what would you share with a woman about when to make contact in labour and how will she know t is time to go to the primary unit?

A

regular contractions - 3:10 minutes lasting 45-60 seconds each.
could contact before this if requiring more support or can let me know if suspected in early labour and its not night time.
contact any time day or night if waters break and liqour is green, black or brown. Or if actively bleeding.
contact if fetal movements reduce
ensure she has the right contact information for me and the backup midwife

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15
Q

benefits of upright positions in labour

A

Upright positions in labour can be a great way to distract from the pain and to move according to body’s needs
gravity can assist with descent and reduce risk of an instrumental birth

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16
Q

Aspects to include in a birth plan

A
  • cultural considerations (whenua, clamp or tie, support people)
  • active or physiological third stage
  • pain relief
  • positions
  • vitamin K
  • skin to skin?
  • how will baby be fed?
17
Q

what is screened and or assessed at booking? and rationale

A

Booking bloods?
- blood group, rhesus factor, antibodies (to prevent haemolytic diseases of the newborn)
- complete blood count (Hb, haematocrit, white blood cells, platelets) - indications of anemia, infection and clotting abilities
- serology for: hep B, syphillis, rubella - as untreated can cause adverse outcomes for baby
- HIV status - so that can be treated to reduce transmission to baby.
- Glycated Hb (HbA1C) - between 20-40mmol/mol. above can indicate pre-existing diabetes or marker for developing GDM

MSU - rule out any underlying UTI, detect protein or glucose in urine. protein can be an indication of poor kidney function. glucose and indicator of excess glucose in blood - may be diabetic.

vaginal swab if indicated - for STIs such as chlamydia if suspected - so that treatment can be established and reduced the likely hood for poor pregnancy outcomes.

18
Q

dietary / lifestyle recommendations in pregnancy?

A
  • whole foods, meat, vegetables and fruit
  • foods high in iron, folate and vit b12: red meat, leafy green veges, pulses, legumes
  • everything in moderations
  • 30 min of exercise per day to maintain fitness and reduce liklihood of developing GDM(light to moderate - some thing manageable for your body- dont introduce any thing too new or extreme). Walking is fine.
19
Q

food safety and other cautions in pregnancy:

A

-listeria - be wary of deli foods/salads, cold rice in sushi, soft serve icecreams
-uncooked meat and seafood
- high mercury fish
- no safe recommended amount of alcohol
- smoking not recommended - refer to cessation services if neccesary
- toxoplasmosis - found in cat faeces, can cause adverse fetal/neonatal outcomes. avoid if possible otherwise use gloves and practice adequate hand hygiene if cleaning out litter trays.

20
Q

what are the normal ranges for maternal baseline obs and for FHR?

A

Maternal obs (as per mews charts)
BP: 100-139mmhg / 40-89mmhg
Pulse: 60-100bpm
temp: 36.0 - 37.9degrees C
resp: 10-20 rpm
O2 sats: 95-100%

Fetal heart rate: 110-160bpm

21
Q

indications for VE:

A

{only done if consent from woman}
- slow progress of labour: such as diminishing frequency or strength of contractions
- before interventions: epidural or opioid to ensure birth is not imminent - opioid crosses and can make transition to extrauterine life harder if administered too close to birth.
- maternal request
- confirm presenting part (how flexed is head)
- offered as assessment of labour progress as per institution guidelines

22
Q

Signs of transition:

A

bloody show (cervical blood vessels) - normal
rhomus of michaelus
purple line
“i cant” statements
vomiting
pressure in bottom
change in maternal vocal sounds

23
Q

positive signs of second stage progress

A

anal dilation
involuntary evacuation of rectum
vertex (or presenting part) becoming visible
thinning of the perineum

24
Q

preparations for imminent birth:

A

delivery pack - including clamp or tie, scissors, receptacle for placenta
uterotonics on hand and/or drawn up
warm towels for baby
sterile gloves
resuscitaire / oxygen set up and ready to go

25
Q

midwifery responsibilities in minutes following birth:

A
  • facilitating skin to skin immediately or as early as possible
  • cover baby with warm towel
  • rub baby with towel to stimulate if not immediately crying
  • watch and wait - assess baby apgars at 1 and 5 minutes of birth (colour, tone, resps, heart, grimmace)
  • observe maternal wellbeing - watch for excessive bleeding or if she feels faint
26
Q

signs the placenta is ready to birth

A

lengthening of the cord
separation bleed
bulging at vulva

27
Q

assessments and observations in immediate postpartum period

A
  • breastfeeding assessing and assisting if required
  • perineal assessment and sutured if indicated
  • assessment of blood loss - treat pph if required
  • maternal obs - ensure stable - no signs of haemmorage such as weak pulse, low BP
  • examine whenua to check complete
  • pain relief as indicated for mama
  • bladder care if required - insert IDC
  • assess uterine tone - palpate fundus - should be firm and central at about the umbilicus. If not involuted then diagnose cause (tone, trauma, tissue, thrombin)
  • support skin to skin and oxytocin release.
28
Q

Midwifery assessments and discussions 24 hrs post birth:

A

full postnatal assessment of mum:
- mental and emotional wellbeing
- any sleep?
- appetite (food and fluid intake)
- Breasts / nipples
- uterus - involution
- lochia - how heavy (filling a pad every hour? smell offensive?)
- bowel and bladder function? haemorrhoids? sting to pee?
- perineum or genital tract trauma? how is it feeling? is it malodorous?
(visual check with consent)
- legs - assess for DVT due to hypercoagulabilty - encourage mobilisation

baby:
ouput - at least 1x PU and 1x BM
check umbilicus - ensure intact and healing - no signs of infection
settling ok?
signs of jaundice
any concerns?

discussions:
- breastfeeding assessment - plan made if required
- when to contact me or go to emergency (causes for concern):
—heavy bleeding - 1 pad per hour or more or clot size of a golf ball or bigger
—fever / unwell with painful or odorous perineum or bleeding, painful hot breasts
— any concerns about baby - feels hot, no wet nappies in 24 hours, lethargic and not feeding.

29
Q

perineal care?

A

look at it
note if malodorous, red / swollen, hot or painful, pus/yellow/green discharge, gaping holes
contact me if any of these concerns
take regular paracetamol and ibuprofen for comfort
can expect it to be uncomfortable for coming weeks but will gradually get better

30
Q

advice around resuming sexual activity:

A
  • only when you feel ready and comfortable to do so
  • use lubrication if required as hormonal changes in the postnatal period can cause a dry vagina
  • be aware that she may not know when her fertility resumes so contraception may be a good idea if not planning to get pregnant again immediately.
31
Q

questions and assessments about postpartum emotional state?

A

can you tell me how you have been feeling the past week emotionally?
have you been eating and drinking well?
have you got whanau around supporting regularly?
Do you leave the house or go for walks with baby?
Are you enjoying your baby?