SPOPs Obstetrics Flashcards
3 Types of Placental Abruption
Marginal - an edge has detached
Central - centre has detached
Complete - whole placenta has detached
4 Primary Causes of PPH (4 Ts)
Tone - poor uterine tone (70%)
Trauma - tears of the vulva, vagina or cervix, or uterine rupture (20%)
Tissue - retained products (10%)
Thrombin - coagulopathy disorders (1%)
9 Stages of the Golden Hour
(4th Stage of Labour)
birth cry
relax
awake
activity
rest
crawling
(finding boob)
familirisation
sucking
sleeping
Active Management of Third Stage of Labour
(preferred)
skin to skin with mother
rapid assessment of bleeding with delivery
1 min APGAR
warming of baby
consent of mother for oxytocin
administer oxytocin
clamping and cutting the cord
early application of SPO2 monitor
5 min APGAR
Continued observation of bleeding and mother
After initial assessment, if newborn is crying and breathing…
Immediate skin to skin contact with mother (increases oxytocin production)
Immediately warm and baby with blanket and beanie
APGAR 1 minute and 5 minutes after delivery
All Fours Running Start Position Procedure
Flip into Gaskins
Lift leg for runing start
rotate foetus to oblique
remove posterior arm
Antepartum Haemorrhage (APH)
Any bleeding from the genital tract after 20 weeks of pregnancy and before labour onset
affects approx 2-5% of all pregnancies
Primary causes are placenta abruption (30%) and placenta praevia (20%)
Any APH needs to be taken seriously as a potential time critical situation
APGAR Activity Scoring
Active movement - 2
Arms, legs flexed - 1
No movement - 0
APGAR Appearance Scoring
Pink - 2
Blue extremities - 1
Pale or blue - 0
APGAR Grimace Scoring
Cries and pulls away - 2
Grimaces or weak cry - 1
No response to stimulation - 0
APGAR Pulse Scoring
> 100 bpm - 2
< 100 bpm - 1
No pulse - 0
APGAR Respiration Scoring
Strong cry - 2
Slow, irregular - 1
No breathing - 0
Benefits of Delayed Cord Clamping
Increase in blood volume of 80-100 mls and up to 300mls
Optimum iron scores at birth and higher scores at 3-6 months
Supports transition from fetal to neonatal circulation
Less risk of brain haemorrhage and ischeamic gut premature babies
Reduced risk of anaemia
Optimum transfer of antibodies and stem cells, boosting immunity
Birth of the Head Procedure
pant and small pushes with contractions as the baby’s head delivers
to control birth of the head, place flats of fingers against baby’s head to keep it flexed and prevent explosive delivery
once baby’s head delivers and mother ceases pushing, encourage mother to continue pushing with each contraction to deliver the shoulders
allow the baby’s head to turn spontaneously
Birth of the Shoulders and Body Procedure
Place a hand on each side of the fetal head
Wait for the next contraction and ask the mother to push gently with the next contraction
Apply slight downward traction to deliver anterior shoulder
Provide slight upward traction to deliver the posterior shoulder
Make sure you have a good grip and support on baby throughout the delivery
Blood Flow Through the Foramen Ovale
2/3 blood volume goes from RA to LA then to LV then to aorta
1/3 foetal blood goes to RV
Braxton Hicks Signs and Symptoms
feels like tightening or very mild cramping
no regular pattern
goes away with rest, hydration, position changes, and time
do not feel stronger over time
localized in the lower abdomen and groin
Breech Delivery Complications
Foetal distress/hypoxia
Failure to deliver
Pain
Prolapsed cord
Shoulder dystocia
Head entrapment
Meconium aspiration
PPH
Soft tissue injuries
Foetal Spleen/liver damage
(premature inspiration before head birthed)
Breech Delivery Occurance
3-4% of term deliveries
common before 35 - 36 weeks gestation
more common in nulliparous women
Breech Delivery Procedure
rapid recognition and call for backup
Prepare early for neonatal resuscitation
Hands off - Delivery should proceed spontaneously through gravity, maternal effort and uterine action
perform manoeuvres if complications or failure to deliver
Breech Delivery Risk Factors
Multiparity
Uterine malformations
Fibroids
Placenta Praevia
Prematurity
Macrosomia
Twin pregnancy
What is breech delivery?
the foetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first
Clamp and Cutting of Umbilical Cord
one-third of baby’s circulating blood contained within the placenta and umbilical cord
blood contains essential nutrients and stem cells
wait 3-5 minutes after birth or until cord has stopped pulsating
It will appear drained, limp and white in colour once stopped pulsating
Classification of Miscarriage
missed
threatened
inevitable
incomplete
complete
Complete Miscarriage
vaginal bleeding
closed cervical os
products of conception completely expelled
Complications of cord prolapse
hypoxia
asphyxiation
death
Confirming Shoulder Dystocia
baby is not delivered on the next contraction
appropriate traction fails to assist
process of delivery of the shoulders takes longer than 60 seconds.
Cord Prolapse Risk Factors
Fetal mal-presentation (breech, transverse, oblique and unstable lie)
Multiparity
Low birth weight (<2.5 kg)
Pre-term labour (<37/40)
Long umbilical cord
Unengaged presenting part
Low-lying placenta
Cord Prolapse Tx
If cord is pulsating - modified SIMS, get pt to attempt to place cord back in vagina
If cord not pulsating - knees to chest position, attempts made to push the presenting part off the cord
rapid transport
Current Pregnancy Hx Questions
Confirmation of pregnancy (intrauterine)
Gestation of pregnancy (how many weeks)
Singleton or multiple pregnancy
Antenatal care – scans, bloods etc
Any complications or concerns THIS pregnancy
Foetal movements
Degrees of Uterine Inversion
1st Degree
2nd Degree (incomplete) - funus reaches cervix
3rd degree (complete) - fundus passes through the cervix, but does not reach the vaginal opening
4th degree (prolapse) - fundus extends through the vaginal opening
What are the manoeuvres to deliver arms in breech delivery?
Loveset’s 1 Manouevre
Loveset’s 2 Manouevre
Loveset’s 3 Manouevre
Delivery of Legs in Breech Birth If Not Delivered Spontaneously
deliver one leg at a time
push behind knee to bend leg
grasp the ankle and deliver foot and leg
repeat for other leg
hold baby’s hip with thumbs on bums
Delivery of the Buttocks and Legs
tell mum she can push with contractions
let buttocks deliver until lower back and shoulders can be seen
gently hold buttocks in one hand (do not pull)
Delivery of the Placenta
assist mother to birth the placenta by her own efforts
encourage upright position, bearing down to expel the placenta OR
guard the uterus by placing one hand supra-pubically and apply steady controlled cord traction until the placenta is visible
support the birth of the placenta and membranes by gently twising to strengthen the placenta and limit the chance of retained products
do not apply increased traction if any resistanc is felt
place into clinical waste bag and take to hospital
Descent of the Placenta
After separation, the placenta moves down the birth canal and through the dilated cervix
Early Pregnancy PV Bleeding
20-40% will experience bleeding during first trimester
most bleeding in early pregnancy is benign and can be related to implantation
more sinister causes such as miscarriage (10–20% of clinical pregnancies) and ectopic pregnancy (1–2%) cannot be ruled out in the pre-hospital environment
Eclampsia
new onset of grand mal seizure activity and/or unexplained coma during pregnancy or post partum in a woman with signs or symptoms of preeclampsia
Eclampsia Management
Depending on the severity and gestation of the baby delivery may be considered
Manage symptomatically and take BP’s on every obstetric patient.
Eclampsia Risk Factors
Prior preeclampsia
Multiparity
Hypertension
Pre-existing diabetes
BMI >30
Pre-existing kidney disease
Ectopic Pregnancy
fertilised ovum implants at a site other than the endometrial lining of the uterus
most commonly in the fallopian tube
Estimated to occur in 1-2% of all pregnancies
as the embryo continues to grow it will rupture around 5-7 weeks when the fallopian tube cannot stretch to accommodate the growth
a ruptured ectopic pregnancy is a true obstetric emergency
95% in the fallopian tube but can also be seen in the ovary and abdominal cavity
Ectopic Pregnancy Management
treat symptoms
if ruptured - Pt has uncontolled haemorage so monitor fluids
consider analgesia
antiemetic
IV fluid
transport
If shocked - manage as per CPG: hypovalemic shock
3 objectives of shoulder dystocia emergency manoeuvres
Increase the functional size of the bony pelvis
Change the relationship of the bisoacromial diameter within the bony pelvis by rotating the foetus into the wider oblique diameter
Decrease the bisacromial diameter of the foetus
Expected SPO2 Values After Birth
1 minute - 68%
3 minutes - 1%
6 minutes - 94%
10 minutes - 97%
Expulsion of the placenta
The placenta is completely expelled from the birth canal
end of the third stage of labour
the muscles of the uterus continue to contract and compress the torn blood vessels to combine with blood clotting stops the postpartum bleeding
First Line External Manoeuvres for Shoulder Dystocia
McRoberts Manoeuvre
Supra-pubic pressure
(combine with McRoberts)
Gaskins Manoeuvre
(reposition to all fours)
First stage of labour established (active) phase process
When cervix dilates to at least 4cm
Regular contractions continue to dilate the cervix
3-4 contractions in 10minute period
Contractions longer in length, more intense
(oxytocin)
Mum more internally focused
(can’t talk - need to concentrate on body)
First stage of labour latent phase process
Begins when the cervix starts to soften up and thin out (effacement and dilation)
can last for hours/days
Minor discomfort and niggles
No regularity at this point
tends to be longer in the first pregnancy (6-10 hours to days)
First stage of labour transition phase:
Cervix dilates from 7-8cm through till 10cm
Contractions most powerful and intense
spontaneously releases noradrenaline triggering expulsive contractions
often the crisis point for a labouring woman
(feels out of control, can’t go on etc - triggered by noradrenaline)
Contractions at their longest (60-70 seconds), strongest and closest together (<2 minutes)
First Trimester
1st day of last menstrual period
cessation of menses
find out pregnant around 4-5 week mark after last menstrual period (LMP)
HCG building up and beginning to cause symptoms of:
breast changes
nausea and vomiting
fatigue
Foetal circulatory systems uses shunts for…
to direct blood that needs to be oxygenated
bypasses liver and lungs which are not fully developed
Foetal Complications of Shoulder Dystocia
brachial plexus injury (4-40%)
humerous and clavicle fractures (10%)
hypoxic brain injury (0.5-23%)
foetal death (0.4%)
Foetal Development First Trimester
Weeks 10-12
end of week 10 embryo is now called a foetus
arms and legs grow longer and start to move
face becomes well-formed
baby is 3 inches long
Foetal Development First Trimester
Weeks 1 - 2
not acutally pregnant - calculation date
body preparing for pregnancy
fertilisation occurs around 2 week mark
Foetal Development First Trimester
Weeks 3-4
Zygote divides to form a blastocyst ( hollow ball of cells)
cells arrange into 2 groups (inner - baby, outer - tissues to nourish and protect baby)
blastocyst moves into the uterus and hatches through the outer layer
inner layer implants into the uterine wall
water-tight sac forms around the embryo gradually filling with amniotic fluid to cushion growing embryo
Foetal Development First Trimester
Weeks 5-6
Embryonic period
Major organs start to grow (brain, spinal cord, heart)
heart begins to beat
placenta starts providing nutrients
bones and muscles begin to grow
embryo starts to look more human
Foetal Development Second Trimester
hair beginning to form
nervous system is starting to function
baby beginning to swallow and takes in small gulps of amniotic fluid
genitalia fully developed
fingers and toes are well developed
lanugo and vernix covering baby
baby is now moving freely and developing muscles
Foetal Development Third Trimester
foetus can now see and hear
all systems continue to mature
covered in vernix
fatten up
skull bones stay soft to make it easier to pass through birth canal
Foetal manoeuvring during labour
anteriposterior plane into the transverse plane
Fourth Stage of Labour
Beginning of the post partum period and the first hour after birth
The ‘golden hour’ where the female body stabilises and the baby is adjusting to life outside the womb
The tone of the uterus is re-established as the uterus contracts again assisting to expel any remaining contents
Encourage skin-to-skin contact and bonding
Encourage breast feeding
Gaskins Manoeuvre Procedure
reposition Pt to all fours
(can be time consuming and difficult)
GDM Management
50% require insulin
Oral hypoglycemics often used in conjunction with insulin if necessary
diet, lifestyle and regular glucose monitoring
GDM Risk Factors
Obesity
Family history
Aboriginal and Torres Straight Islander
Previous GDM
Maternal age >25 years
Gestational Diabetes
Defined as any degree of glucose intolerance with first recognition during pregnancy
affects 8-10% of pregnancies in Australia
50% will require treatment with insulin
mostly asymptomatic and diagnosed during routine GTT test between 24-28 weeks
generally self resolves once the pregnancy is completed, although 50% will develop TD2M in later life
Gestational Diabetes (GDM) Pathophysiology
pregnancy hormones affect the body’s uptake of glucose
Oestrogen and human placental lactogen can block insulin and/or make it less effective from being utilised by the cells (insulin resistance)
Usually begins around 20-24 weeks
pancreas does not make enough insulin to overcome the insulin resistance
Gestational Hypertension
Development of hypertension in the second half of pregnancy without other effects on kidneys or other organs
Gravida
number of pregnancies
Gravidity and Parity: 3 previous births and currently pregnant
G4 P3
Gravidity and Parity:
3 previous births and currently pregnant
G4 P3
Gravidity and Parity: currently pregnant and has previously delivered twins at term
G2 P1
Gravidity and Parity:
currently pregnant and has previously delivered twins at term
G2 P1
Gravidity and Parity: currently pregnant, has a 3 year old and has previously miscarried at 8 weeks
G3 P1
Gravidity and Parity:
currently pregnant, has a 3 year old and has previously miscarried at 8 weeks
G3 P1
Gravidity and Parity: first time pregnancy
G1 P0
Gravidity and Parity:
first time pregnancy
G1 P0
Gravidity and Parity:
Patient is not pregnant, had one previous delivery
G1:P1
Gravidity and Parity:A woman who has 2 living children and is currently pregnant
G3:P2
Gravidity and Parity Patient is currently pregnant and has had twins delivered in the previous pregnancy
G2:P1
Gravidity and Parity:
Patient is currently pregnant and has had twins delivered in the previous pregnancy
G2:P1
Gravidity and Parity Patient is currently pregnant, had one previous miscarriage and one previous delivery
G3:P1
HELLP Presentation
non-specific symptoms
general malaise
fatigue
right upper quadrant or epigastric pain
nausea and/or vomiting
jaundice
visual disturbance
HELLP Syndrome
rare, life-threatening liver disorder thought to be a type of severe preeclampsia
characterized by:
Haemolysis (destruction of RBC’s)
Elevated liver enzymes
Low platelet count
Occurs in the later part of pregnancy and sometimes after birth
Not all woman who develop preeclampsia develop HELLP
Hyperemesis Gravidarum Management
Positioning
Anti-emetic
IV fluids
Glucose (If hypoglycemic)
Emotional support and care
Hyperemesis Gravidarum Signs and Symptoms
Weight loss
dehydration
constipation
headache/migraines
food aversions
excessive salivation
exhaustion
low BP
tachycardic
dizziness
syncopal
How do we do tactile stimulation?
Using a soft towel place hands either side of newborn’s trunk and utilise a brief rubbing motion for a period of no more than 10 seconds
How do we assess HR in a newborn?
Determined via auscultation (prefered) or palpation of the umbilical cord if it is still pulsating
How long should shoulder dystocia manouvres be attempted for before moving on to next manoeuvre?
30 seconds
How much blood loss after delivery is normal?
<500 mL
How to Actively Control Newborn’s Temperature
Consider warm environment
Consider placing newborn into a plastic bag with head exposed
Use external heat sources to warm environment
How to Do Fundal Massage
Place one hand just above pubic symphysis and the other hand at the top of the fundas. With the top hand gentle massage in a circular motion until it firms up
Neonate Suctioning Notes
wipe face and nose area first
if suctioning required, suction mouth before nose with head in neutral position
Hx taking prior to delivery
Confirm gestation
How far apart are contractions? Length? Transport?
Where is the pain?
Have your membranes ruptured? If so, details.
How many babies? Chance of twins?
Antenatal care?
Complications so far? Previous pregnancies?
Head engaged? Normal cephalic or breech?
Parity / Gravidity?
If newborn’s HR is <60 bpm after 30 seconds of resuscitation…
Rapidly clamp and cut cord and move newborn to a flat, hard surface away from mum
Commence CPR at a rate of 3:1
(90 compressions:30 ventilations per minute)
Apply defibrillator pads
If newborn’s HR is >100 bpm after 30 seconds of resuscitation…
Manage as per normal cephalic delivery
Wrap and keep the newborn warm and encourage skin to skin contact
Ensure continued close management of newborn – HR, tone, breathing
If HR >100bpm but has central cyanosis at 10 minutes post birth commence oxygen 2 L/pm through nasal prongs until centrally pink
If newborn’s HR is between 60-100 bpm after 30 seconds of resuscitation…
Continue IPPV with supplementary O2 at 15 L/min
REASSESS after every 30 seconds and manage appropriately depending on HR range
If PPH not controlled…
Manage the cause(s) of the haemorrhage (4T’s)
prioritise interventions according to the likely aetiology and if possible should be performed simultaneously by different members of the paramedic team
If providing CPR to a newborn, when do we cut the cord?
When the heart rate is less than 60 bpm
If tactile stimulation and/or suctioning isn’t effective, immediately assess the newborn’s…
TONE – ability to flex and move limbs - floppy newborn with poor tone is more likely to need active resuscitation
BREATHING – crying and breathing? May initially pause breathing and then establish regular breaths. Chest recession or retraction, expiratory grunting and nasal flaring may indicate respiratory distress.
HEART RATE – should be 130bpm (110-160 range), anything above 100 initially acceptable
Implication of Immature Cilia in the Airways
poor secretion (bacteria and bugs) clearance
Incomplete Miscarriage
vaginal bleeding and cramping
dilated cervical os
some products of conception expelled
Inevitable Miscarriage
vaginal bleeding and cramping
rupture of membranes
dilated cervical os
products of cenception may seen or felt at or above cervical os
nothing can be done - make feel comfortable
Initial Bradycardia (<100 bpm) Management
IPPV with ROOM AIR at a rate of 40-60/min
Reassess after 30 seconds
Manage the baby at this point in between mums legs with placenta still pulsating
Key Investigations First Trimester
Dating scan approx. 7 – 8 weeks to confirm intrauterine implantation
12-week nuchal translucency scan and blood test (extremely accurate non-invasive screening test to identify fetuses at risk of down syndrome and other chromosomal and structural abnormalities) optional
harmony blood test – DNA blood based screening test for abnormalities optional
Key Investigations Second Trimester
Morphology scan (18-22 weeks) - complex in-depth scan of entire foetus, position of placenta, umbilical cord, amniotic fluid around baby, uterus and cervix
Key Investigations Third Trimester
often no scans during this period
further ultrasound if any growth or position concerns
antenatal visits will increase closer to term
Labour Room Tips
keep labour room nice, dark and quiet to help with delivery
makes it safe calm and quiet to help with melatonin production
List some pertinent information that we need to gather from our antenatal hx taking
gravidity and parity
gestation
antenatal care
complications
foetal movements (regular and similar to normal?)
previous pregnancies
previous losses
Loveset’s 1 Manoeuvre Procedure
hold baby by hips and turn 180o keeping the back uppermost and applying downward traction so that the posterior arm becomes anterior
place one or two fingers on upper part of the arm and draw arm down over the chest as the elbow is flexed and sweeping hand over face
Loveset’s 2 Manouevre Procedure
to deliver second arm, rotate baby back 180o, keeping the back uppermost and applying downard traction
Loveset’s 3 Manoeuvre Procedure
hold and lift baby up by the ankles
move baby’s chest towards mums inner leg, posterior shoulder should deliver
free the hand and arm
lay baby back down by the ankles, anterior shoulder should deliver
macrosomia
big baby due to gestational diabetes
Management of PPROM and PROM
Term patients: proceed to delivery with prophylactic antibiotics
Pre-term: antibiotics, corticosteroids and expectant management
Management of PV Bleed
Treat symptomatically: You may need to manage:
Hypovoleamia
Pain
Nausea
Hypotension
Reassurance
Management of Uterine Rupture
Position to avoid aortocaval compression (left lateral)
If trauma related, manage as per trauma in pregnancy
If evidence of shock, manage as per hypovolaemic shock
IV access
Analgesia
Assist patient to attain position of comfort
Transport and pre-notify as appropriate
Maternal Complications of Shoulder Dystocia
PPH
vaginal lacerations and tears
uterine rupture
psychological trauma
McRoberts Manoeuvre Procedure
knees to nipples position
primary officer - hand on head with gentle downward traction
second officer - assist with movement and/or apply supra pubic pressure
What is miscarriage?
spontaneous loss ofpregnancy before 20 weeks gestation and/or foetal weight less than 400g
Approx 1 in 4 pregnancies will end in miscarriage before 10 weeks
Any PV bleeding in 1st and 2nd trimester should be considered a threatened or actual miscarriage until proven otherwise
Miscarriage Management
Reassurance and emotional support
Estimate blood loss on scene
Retain any products of conception
Consider:
IV access and fluid
Positioning
Pain relief
Antiemetic
Miscarriage Pt Presentation
abdominal pain
PV bleeding (may not)
nausea
vomiting
hypotensive
tachycardic
missed miscarriage
no vaginal bleeding
closed cervical os
no foetal cardiac activity or emply sac
usually found at scan
Morning Sickness Management
empathy and reassurance
antiemetic
postural positioning
IV fluid replacement
MSV (adapted Mauriceau-Smellie-Veit) Manoeuvre Procedure
lay baby face down with length of body over your hand am arm and place first and second fingers either side of the nose
flex the head
use other hand to hood the baby’s shoulders with index and ring fingers with middle finger on baby’s occiput
gently flex baby’s head towards chest until the hairline is visible
pull gently to deliver head
raise baby until mouth and nose are free
place baby on mum’s abdomen
Neonatal Resuscitation Guidelines
<20 weeks gestation Resuscitation is futile
>23 weeks Newborn considered viable
Some pre-term infants <20 weeks may show signs of life but resuscitation is futile
If there is any uncertainty resuscitation measures should be commenced
Newborn Care Immediately After Delivery
Clean the newborn’s mouth and nose of visible blood and mucous with a clean cloth
- If airway obstruction identified, gentle suction the mouth followed by nares
Thoroughly dry the newborn
Within first 30 seconds assess the newborn’s:
- Tone
- Breathing status
- HR
Newborn Chest Compressions
Compress over lower sternum
Two thumb technique
A half second pause after 3 compressions for ventilation
Newborn Ventilations
Head in neutral position
1 breath after every 3 compressions
Approx 30 breathes per minute
Non-Ruptured Ectopic Pregnancy Signs and Symptoms
Hx amenorrhoea (at least one missed period)
Abnormal vaginal bleeding
Pelvic and/or abdominal pain
Nausea
Pre-syncopal symptoms
Normal Cephalic Birth
Spontaneous in onset
Considered low risk at the start of labour
Remains low risk throughout labour and birth
The newborn is born sponataneously, in vertex position
37-42 weeks gestation
After delivery mother and baby are in good condition
Normal pregnancy duration
37 - 42 weeks
Nuchal Cord 3 Management Options
Cord Reduction
slip cord over baby’s head
Through Cord
slip over baby’s shoulder as baby is born
Somersault Manouvre
As shoulders are deliver flex baby’s head towards mothers thigh
As the baby’s body delivers gently flex the torso of the baby to ensure the cord remains intact
Nuchal Cord Birth
15-34% of births and most will deliver without incident
Risk of hypoxia;
Avoid early clamping and cutting of the cord prior to delivery
Obstetric Hx Questions
Number of past pregnancies (gravidity)
Number of past deliveries (parity)
Previous complications
Miscarriages/terminations
Previous pregnancies – length, delivery
Obstetric Pt Hx Taking
determine quickly if presenting complaint is obstetric related
Per Vaginal Bleeding: How long, how much, what colour (frank blood or dark blood), presence of clots
Per Vaginal Discharge: Colour, consistency, odour, duration
Abdominal Pain: Location, duration, severity, radiation, exacerbation, score
Urinary symptoms: Frequency, dysuria, odour, colour.
Nausea and vomiting: Onset, frequency, contents, blood, current fluid status
Headache: visual disturbance, fast
Once Delivery is Complete
Place baby directly on mother’s chest (postural drainage)
Observe for breathing, crying, tone
If sufficient – warm baby rapidly with blanket, beanie
Remember you now have 2 patients
Paramedic Management of Pre-Term Labour
Manage symptoms
Be wary of pain relief, especially narcotics given the risk of delivering a premature baby
Position comfortably, reassurance, be calm
Rapid transport to hospital as tocolysis and steroids are definitive management
pre-notify birth suite
Prepare for neonatal delivery – premature babies have immature respiratory system development, so may require significant assistance if born pre-hospital
Parity
number of babies born at or > 20 weeks, pre-term <37 weeks, post-term >42 weeks
perinatal anxiety and depression risk factors
Hx of depression, anciety, OCD
pregnancy or delivery complications, infertility, mascarriage or infant loss
abrupt discontinuation of breastfeeding
thyroid imbalance, diabetes, endocrine disorders
PMS
Hx of abuse
lack of support form family and friends
financial stress or poverty
unwanted or unplanned pregnancy
Pertinent questions for the pt in labour
confirm gestation
any complications
antenatal care
when did contractions start?
how often are they coming?
where is the pain with your contractions?
have your membranes ruptured? If so, what colour?
Previous deliveries
when was your last appointment and is the baby engaged?
Pertinent questions relating to PV bleeding in pregnancy
How long have you had it?
How much is there?
How often do you have to change a pad
what colour is it?
what preceded it (coitus, nothing, strenuous exercise)?
Have you had bleeding like this before?
Does it have any odour?
Are there any clots in it?
Physiologicial Management of the Third Stage
Women who don’t consent and/or prefer physiological management must birth the placenta unaided, by maternal force
Big focus on increasing the women’s natural oxytocin production
Skin to skin contact, encourage breast feeding
Continue to monitor for signs of placental delivery
Placenta Previa Signs and Symptoms
Painless bleeding usually in third trimester (>28 weeks)
Bright red blood
No pain, other than that associated with contractions
A soft, non-tender uterus
Significant blood loss, which may lead to hypovolemic shock
Placenta Previa Tx
left lateral positioning
IV access
antiemetic
analgesia
IV fluid as required
rapid transport
Placental Abruption Tx
Left lateral positioning
IV access
antiemetic
analgesia
IV fluid as required
rapid transport
Positive Hormonal Feedback Loop of Childbirth
head of baby pushes against cervix
nerve impulses from cervix transmitted to brain
brain stimulates pituitary gland to secrete oxytocin
oxytocin carried in bloodstream to uterus
oxytocin stimulates uterine contractons and pushes baby towards cervix
PPH Management if Oxytocin Unsuccessful
Consider:
Tranexamic acid (TXA)
Sodium Chloride
Packed RBC’s
External aortic compression (Last resort)
Bimanual compression (Last resort)
PPROM and PROM Causes
Previous PROM or PPROM
Short cervical length
Second and third trimester bleeding
Low socioeconomic status
Smoking and drug use
sometimes no cause identified
PPROM and PROM Paramedic Considerations
Reassurance
Position left lateral – this allows for fluid to accumulate for hospital to get a sample and gives consideration to hind/fore water scenario
Pre-Eclampsia
severe form of gestational hypertension
serious and only occurs after 20 weeks or up to 6 weeks after delivery
includes hypertension accompanied by one or more signs of organ dysfunctionon:
renal impairment
proteinuria
elevated liver enzymes
neurological complications
pulmonary oedema
foetal growth restriction (FGR)
haematological complications
Pre-Eclampsia Signs and Symptoms
headache blurred vision flashing lights scotoma right upper quadrant pain (epigastric) oliguria
Pre-Hospital Birth Preparation
early call for backup to get extra hands and resources on deck
set up maternity kit and get neonatal resuscitation gear primed and ready in case needed
let mum adopt a position of comfort
reassure and communicate with mother and partner
Pre-Hospital Implications of RDS
More likely with premature delivery
Must be considered in any premature baby
Many have long-lasting effects and respiratory issues
Important to ask about RDS if bub born prematurely
Pre-Term Labour
when regular contractions result in the opening of the cervix after 20 weeks gestation and before 37 weeks gestation
Pre-Term Labour Sub Categories
Early preterm <34 weeks
Very preterm 28-32 weeks
Extremely preterm <28 weeks
earliest gestation survival age 24 weeks gestation
Pregnancy Duration
37 - 42 weeks
approx 280 days in total
calculated from first day of last period
Pregnancy Trimesters
first trimester = 1-13 weeks gestation
second trimester = 14-27 weeks gestation
third trimester = 28-40 weeks gestation
Premature Rupture of Membranes (PROM)
rupture of gestational membranes prior to the onset of labour post 37 weeks gestation
Preterm Premature Rupture of Membranes (PPROM)
membrane rupture before 37 weeks gestation
PV Bleed 1st Trimester
postcoital
cervicitis
cervical polyps
infection
implantation
spontaneous abortion
ectopic pregnancy
PV Bleed 2nd Trimester
infection
incompetent cervix
malfomation of the uterus
cysts
molar pregnancy
PV Bleed 3rd Trimester
placenta praevia
placental abruption
preterm labour
bloody show
First things to do when you recognise shoulder dystocia
stop maternal pushing effort
call for CCP backup
Rapid initial newborn assessment of breathing consists of…
Is the baby crying and breathing?
Newborns may initially pause breathing and then establish regular breathes;
Respiratory distress is indicated by:
- chest recession or retraction
- expiratory grunting
- nasal flaring
Rapid initial newborn assessment of heart rate consists of…
the most important indicator for resuscitation
should be 130bpm (110-160 range)
Rapid initial newborn assessment of tone consists of…
Assessing baby’s ability to flex and move limbs
A floppy newborn with poor tone is more likely to need active resuscitation
Restitution
the baby’s head turning spontaneously
Reverse Wood Screw (reverse posterior shoulder rotation) Procedure
one hand on posterior aspect of the posterior shoulder and attempt to rotate shoulder 180o in opposite direction
Risk Factors for Primary PPH
Uterine atony
Increased maternal age (tone)
Obesity (tone)
History of previous PPH (tone)
Multiple pregnancy (tone)
Precipitate labour (trauma/tone)
Prolonged labour (tone)
Risk Factors for Secondary PPH
infection
retained piece of placenta or membrane
Risk Factors for Shoulder Dystocia
Macrosomia
Maternal obesity
Gestational diabetes
Prolonged second stage of labour
Previous hx of shoulder dystocia and/or large foetus
Risk Factors for Uterine Atony
Overdistention of the uterus caused from:
Multiparity (tone)
Macrosomia (tone)
Polyhydraminos (tone)
(too much amniotic fluid around baby)
Risk factors for uterine inversion
over-aggressive management of the third stage of labour (excessive fundal massage and cord traction prior to placental separation)
relaxed uterus
lower uterine segment and cervix
short umbilical cord
antepartum use of magnesium or oxytocin
Risks Associated wit Pre-Term Labour
perinatal mortality
long term neurological disability
admission to NICU
prolonged hospital stays and readmission to hospitals
increased risk of chronic lung disease
Significant association between preterm birth and:
Social disadvantage
Previous preterm birth
Pre-existing GD
Cervix insufficiencies
Current urogenitial infections
Smoking and alcohol consumption
Room Air Versus Oxygen for Newborns?
first 30 seconds of IPPV should be with room air only
excess oxygen can be toxic as it leads to free radical formation and issues with lungs, eyes, brain and other organs
quicker time to first breath compared with high flow oxygen
Rubins II (internal anterior shoulder displacement) Procedure
apply pressure to the posterior aspect of the anterior shoulder
attempt to push the shoulder towards the chest of the fetus
Ruptured Ectopic Pregnancy Signs and Symptoms
Syncope
Shock
Acute pelvic and/or abdominal pain
Shoulder tip pain (Kehr’s sign), caused by free blood irritating the diaphragm when supine
Abdominal distention
Rebound tenderness and/or guarding
Scoring System for APGAR
0 – 3 - severe distress, immediate management is required
4 - 7 - moderate distress, baby may require some additional assistance
7 - 10 - little difficulty in adjusting to extrauterine life
Second Line Manoeuvres for Shoulder Dystocia
Rubins II - internal anterior shoulder displacement
Wood Screw - internal anterior and posterior shoulder rotation
Reverse Wood Screw - reverse posterior shoulder rotation
All fours running start position - to deliver posterior arm
Second Stage of Labour Process
Begins when the cervix is fully dilated (10cm)
Ends with the birth of the baby
During this stage the baby’s head navigates down the vagina and crowns
The mother will instinctively feel like bearing down
Encourage her to push with contractions
Monitor the perineum
Second Trimester Maternal Changes
many woman start to feel energised
nausea often settles
uterus continues to grow
aches and pains from uterine ligaments stretching
weight gain
Separation of the Placenta
The placenta separates from the wall of uterus
blood from the tiny vessels in the placental bed begins to clot between the placentaand the muscular wall of the uterus (the myometrium)
Shoulder Dystocia Definition
vaginal cephalic delivery requiring additional obstetric manoeuvres to deliver foetus after head delivery and general downward traction has failed
Shoulder Dystocia Description
the anterior shoulder becoming impacted behind the pubic symphysis after delivery of the head
less frequently, the posterior shoulder impacting against the sacral promontory
Signs and Symptoms of Labour
Cramping
Dirrahoea
(rectum is pelvic muscle that loosens up prior to delivery)
Nesting
Lightening
(able to breathe easier as baby has shifted into pelvis)
Membrane rupture
(may/may not indicate labour, colour/stain can indicate baby stress)
Signs and Symptoms of PPH
PV bleeding greater than 500 mls after vaginal delivery or 1000 mls after c section
Placenta may or may not have delivered
Poor fundal tone
Signs of shock may or may not be present
Signs and symptoms of uterine rupture?
Loss of intrauterine pressure or cessation of contractions
Abnormal labour or failure to progress
Severe localised abdominal pain
Shoulder tip pain or suprapubic pain
Vaginal bleeding
Maternal hypovolaemic shock
Difficulty palpating the uterus
Easily palpable fetal parts
Signs of Imminent Delivery
Strong pressure in the lower back or perineum
Bulging of the perineum
Crowning of fetal head
Need to bear down or defecate
Rupture of membranes
Increase in bloody show as capillary in cervix rupture
Nausea and vomiting
The mother may verbalise ‘I can’t do this anymore’ she feels like she has lost control
Contractions: 1-2 minutes apart, Regular, Lasting 45 to 60 seconds
Six Key Hormones in Pregnancy
HCG
progesterone
oestrogen
prolactin
relaxin
oxytocin
Step by step management of normal cephalic delivery
Early call for backup
early set up of equipment
Delivery of the head: use one or two fingers lightly touching the occiput to prevent rapid expulsion of the head
Hands off and let baby restitute naturally
Check for nuchal cord
Delivery of the body: One hand lightly holding either side of the head, apply slight downward traction to deliver the anterior shoulder and slight upward traction to deliver the posterior shoulder
Once the bay is delivered: quickly assess tone, crying and anything in the mouth or nose
Skin to Skin contact with mother
Steps to success with Shoulder Dystocia manoeuvres
correct hand position
knowing sacral hollow
tuck thumb into palm
Steps when breech is identified
Hands off - use gravity and encourage maternal effort
Deliver legs if they don’t deliver on their own
Lovesets 1
Lovesets 2
Lovesets 3
MSV
Steps when shoulder dystocia is identified
tell mum to stop pushing
McRoberts manoeuvre (knees to chest) with suprapubic pressure
All fours in running start position with Rubins II
Wood Screw
Reverse Wood Screw
Suction neonate only if…
obvious signs of obstruction and secretions stop spontaneous breathing (meconium, blood clots, mucous, vernix or if baby birthed through meconium stained amniotic fluid)
Supra-Pubic Pressure Procedure
combine with McRoberts
place hands immediately superior to pubic symphysis
apply pressure to the posterior aspect of the impacted foetal shoulder in a rocking or continuous motion
Symptoms of perinatal depression (postnatal depression) and anxiety
fellings of guilt, shame or hopelessness
feelings of anger, rage, irritability or scary and unwanted throughts
lack of interest in baby or difficulty bonding
loss of interest, joy or pleasure in things used to enjoy
disturbance of sleep and appetite
crying and sadness, constant worry or racing thoughts
physical symptoms like dizziness, hot flashes and nausea
possible thoughts of harming the baby or yourself
Symptoms of Shoulder Dystocia
Prolonged or difficult birth of the face and chin
The head is birthed but remains tightly applied to the vulva
Turtle sign
No restitution of the head
The body is not delivered within 60 seconds of the head
The 2 classifications of PPH
Primary – within the first 24 hours after birth with haemorrhage amount >500ml (vaginal), >1000ml (caesarean), or enough to cause deterioration of the mother’s condition
Secondary – after first 24 hours and up to 12 weeks after birth with haemorrhage amount >500ml or enough to cause deterioration of the mother’s condition
The 4 Types of Breech Presentation
frank breech
complete breech
complete footling
incomplete footling
Third Trimester Maternal Changes
fatigue
dyspnoea
increase in urine frequency
braxton Hicks
trouble Sleeping
starts to position itself ready for birth
Threatened Miscarriage
vaginal bleeding and cramping
cervix closed and soft
foetal cardiac activity
pregnancy going on as normal
To spontaneously deliver the placenta and featal membranes the…
cervix must remain open and there needs to be good uterine contraction
Treatment of Poor Uterine Tone in PPH
fundal massage
Oxytocin (subsequent dosing and commencement of infusion)
Treatment of PPH if Placenta Has Been Birthed
Commence fundal massage until firm and central
Encourage birthing parent to empty bladder
Treatment of PPH if Placenta Has Not Been Birthed
Actively manage the third stage of labour:
oxytocin
skin to skin contact
breast feeding
urinate
True Labour Signs and Contractions
Intense, stops you in your tracks
Regular, gets closer over time
Nothing makes them stop
Feel stronger and more painful over time
Starts at the back and moves to the abdomen
Tx of Retained Products in PPH
Continue fundal masage to expel retained products
transport to nearest facility with surgical capabilities
Tx of Trauma in PPH (perineum or vaginal lcerations)
control external haemorrhage
Uterine Inversion Management
Protect any exposed uterus with a moist sterile drape
Assist the women to achieve a position of comfort
Analgesia
Consider if postpartum haemorrhage
IV access
IV fluids
Transport and pre-notify as appropriate
NOTE: high risk for infection, aseptic technique and infection control measures must be used
Weight Gain During Pregnancy
can affect both maternal and fetal health and development
recommended weight gain depends on pre-pregnancy weight
11.5kg to 16kg is recommended for those in healthy weight range
What are baby blues?
symptoms three to five days after birth, such as mood swings, teariness, feeling overwhelmed and/or anxious
generally subside after a few days to weeks
What are the 3 foetal shunts?
Ductus Venosus - bypasses the liver and into inferior vena cava
Foramen Ovale - bypasses pulmonary circulation
Ductus Arteriorsus - shunts blood away from lungs into the aorta to feed lower extremities
What are the 3 key assessments of the newborn that we need to complete immediately?
colour/tone
breathing/crying
heart rate
What are the 3 stages of labour?
first stage
body preparing for birth
Gradual effacement and dilation of the cervix through regular contractions up to 10cm dilation
second stage
The period from full dilation of the cervix (10cm) until the birth of the baby
third stage
From the birth of the baby until the delivery of the placenta
What are we assessing with each part of the APGAR?
Appearance - colour
Pulse - heart rate
Grimace - response to stimulus
Activity - tone and motion
Respiration - crying/breathing
What are braxton hicks contractions
Normal, non dangerous practice contractions of the uterine muscles which happen in the weeks to months before birth
Most commonly in third trimester, but anytime after 20 weeks
Painless, yet uncomfortable
perinatal anxiety and depression - What can we do to educate?
Share information about perinatal mental health issues and the effectiveness of early intervention
Speak about it, ask every patient antenatally and post-natally how they are?
perinatal anxiety and depression - What can we do to empower (support them to seek help)?
Explore what has worked in the past
Speak about referral options and seek pts input
Encourage pts to be persistent and that there are numerous options
What does APGAR stand for?
Appearance
Pulse
Grimace
Activity
Respiration
What happens to foetal circulation after birth?
With the first breathes, the lungs begin to expand causing:
- lung alveoli cleared of fluid
- BP increases
- significant reduction in pulmonary pressure
These changes reduce the pressure and stimulate shunts to close
Transition to newborn circulation completed
what is the foramen ovale?
a small hole located in the septum of the atria that closes shortly after birth
What is cord prolapse?
the umbilical cord presents in front of the foetus resulting in the cord prolapsing through the cervix into the vagina
occurs in 0.6% (approx 1 in 200)
What is effacement:
The shortening and ‘thinning out’ or ‘ripening’ of the cervix
The cervix shortens from approx 3.5 - 4cm during pregnancy
Measured by percentage
What is external aortic compression?
The manual compression of the abdominal aorta against the vertebral column to restrict uterine blood flow
What is fundal massage?
external manual stimulation of a boggy postpartum uterus to increase uterine tone, express clots and reduce haemorrhage
What is gravidity?
the number of times a female has been pregnant (regardless of the outcome)
What is grief?
a reaction to different types of loss
What is labour?
Regular and coordinated muscular contractions of the uterus
Gradual effacement and dilation of the cervix
What is our focus in the initial stages of breech management?
hands off - let gravity do the work
What is our initial management if the newborn presents flat?
tactile stimulation (often all that is needed)
What is parity?
the total number of times a female has given birth to a child greater than 24 weeks or more gestation, regardless of whether the child was born alive or not.
What is Patent Formaen Ovale?
when the foramen ovale doesn’t close after birth
What is perinatal depression (postnatal depression) and anxiety?
any mental health condition affecting the mood, behaviour, wellbeing and or daily function of an expecting or new parent
What is perinatal OCD?
an anxiety disorder characterized by recurrent, unwelcomed thoughts, images, ideas and doubts
What is placenta previa?
an abnormally implanted placenta in the lower part of the uterus that is either partially or fully covering the cervical os making vaginal delivery difficult
What is placental abruption?
bleeding as a result of premature separation of a normally situated placenta from the uterine wall before the birth of the baby
What is placental abruption?
bleeding as a result of premature separation of a normally situated placenta from the uterine wall before the birth of the baby
What is post partum haemorrhage?
Excessive bleeding from or into the genital tract after the birth of a baby/ies
What is post partum phychosis?
rare mental illness that starts soon after childbirth. of loss of reality, delusions, hallucinations, disorientation, agitation, insomnia
What is the key indicator of resuscitation in neonates?
heart rate
What is the main reason that newbons will require resuscitation?
hypoxia - they haven’t initiated their breathing mechanics
What is the management of a newborn if tactile stimulation is not successful and heart rate is less than 100?
IPPV room air for 30 seconds - 40-60 breaths per minute for 30 seconds
IPPV with oxygen for 30 seconds - 40-60 breaths per minute for 30 seconds
What is the management of newborn heart rate greater than 100 breaths per minute?
manage as per normal cephalic delivery
What is the management of newborn heart rate between 60 - 100 breaths per minute?
IPPV with oxygen (46-60 breathe per minute) for 30 seconds then reassess
What is the management of newborn heart rate between 60 - 100 breaths per minute after initial IPPV on room air?
IPPV with oxygen (46-60 breathe per minute) for 30 seconds then reassess
What is the most common cause of uterine rupture?
Dehiscence (splitting or bursting) of a caesarean section scar, with rupture more frequent in obstructed labour
What is the most common form of obstetric haemorrhage and leading cause of maternal morbidity and mortality?
PPH
What is the procedure to deliver the head in a breech birth?
MSV (adapted Mauriceau-Smellie-Veit) Manoeuvre
What is the ratio for CPR in a newborn?
3:1
What is the structure of antenatal hx taking?
presenting complaint
current pregnancy
obstetric history
What is uterine atony?
a failure of the uterine myometrial fibres to contract and retract for any reason causing continuation of bleeding
What is uterine inversion?
rare, but potentially life-threatening obstetric condition where the uterus collapses in on itself
What is uterine rupture?
the tearing of the uterine wall during pregnancy or birth
(very rare but one of the most lifethreatening obstetric emergencies)
What is Dilation
The opening up of the cervix
measured in cms
What percentage of babies required some form of active resuscitation?
5%
What should we communicate with the mother instantly when we identify shoulder dystocia?
Stop pushing as this may further impact the baby
What time do we have to safely deliver the baby if breech presentation occurs?
4 minutes
When cord is not pulsating during cord prolapse.
Ask the mum to assume the knee-chest position
Carefully attempt to push the presenting part off the cord
When do foetus start producing surfactant?
around 28 weeks
When pulsting cord is evident during cord prolapse
Assist the mother into exaggerated SIMS position (left lateral tilt)
Ask mother to gently push the cord back into the vagina (using a dry pad)
When do we initiate newborn resuscitation?
if the newborn has poor tone and/or is floppy
Where do defibrillation pads go on the newborn?
anterior and posterior
Where do we hold the baby to assist during a breech delivery?
thumbs on bums (to avoid the abdominal organs)
Where does blood collect in a placental abruption?
rapidly passes through the placental implantation site and either collects inside the reproductive tract or expelled vaginally
Where to Clamp and Cut Cord
Clamp - 10, 15 and 20 cm
Cut - between 15 and 20 cm
Why de we do tactile stimulation?
to initiate breathing on the 15% of newborns who don’t spontaneously breathe on their own - successful in 5-10%
Why does SD occur?
biasacromial diameter of the foetus is too wide for the pelvic inlet and they don’t enter in the transverse diameter
Why is oxytocin given post delivery?
to speed up the delivery of the placenta and reduce the risk of post partum haemorrhage (PPH)
Wood Screw (internal anterior and posterior shoulder rotation) Procedure
apply pressure to the posterior aspect of the anterior shoulder
second hand locates anterior aspect of posterior shoulder and applies pressures
What are we more likely to see in pregnant patients due to cardiovascular changes during pregnancy?
dizziness
lightheadedness
syncopal episodes
palpitations
mumurs
patient positioning after 20 weeks gestation
What are we more likely to see in pregnant patients due to respiratory changes during pregnancy?
increased RR
increased WOB
oedmatous airways lead to more difficult airway management and intubation
What are we more likely to see in pregnant patients due to haematological changes during pregnancy?
Pts can loose considerable amount of blood prior to displaying classic signs of shock
low RBC can contribute to SOB
fatigue
What are we more likely to see in pregnant patients due to muskuloskeletal changes during pregnancy?
changes in gait
pelvic girdle disease
sprains and strains
niggling pelvic girdle pain
What are we more likely to see in pregnant patients due to gastrointestinal changes during pregnancy?
constipation
reflux
heartburn
What are we more likely to see in pregnant patients due to renal changes during pregnancy?
Increased risk of pyelonephritis
UTI’s
increased frequency of urine
What should we do regarding the normal physiological changes in a pregnant patient?
have an awareness of the normal changes
How can grief affect people?
Emotionally
In our cognition or thoughts
Physically
Behaviourally
Socially
Professsionally
Spiritually
Philosophically
Pre-Eclampsia Statistics
affects 5-7% of all pregnant woman
responsible for 70,000 maternal deaths and 500,000 fetal deaths
worldwide every year
Pre-hospital birth is more likely in…
precipitate labour (<3 hrs)
younger mothers (<18)
multiparous mothers
mothers from low socioeconomic areas (less likely for antenatal cares)
Statisitcs on Shoulder Dystocia
1-3% of deliveries
Likelihood increases with fetal size:
- 1% for babies <4kg
- 5% for babies between 4-4.5kg
- 10% for babies >4.5kg
What is the average foetal bisacromial angle?
12-15 cm
What is the transverse width of the pelvis?
13.5 cm
What is the oblique width of the pelvis?
12.75 cm
What is the anteroposterior width of the pelvis?
11 cm
How to Build Trust
Be kind and warm
Compassion and empathy
Acknowledge the change that comes with new parenthood
Listen
Let them know they can be honest and open
What can we say to build trust?
How are you going with it all?
Becoming a parent is a big change, how are you going with it all?
Are you getting enough sleep?
perinatal anxiety and depression - How to Validate
Active listening
Reflect back in your own words
Avoid reassurance before validation
Be ok with silence (let them gather their thoughts)
perinatal anxiety and depression - What can we say to validate?
It sounds like things are really tough
You’re dealing with a lot of worry and I can see it’s making it really hard to sleep
perinatal anxiety and depression - How can we explore (assess the risk)?
Ask open ended questions
Non judgemental
Be curious about their journey
Stop and listen
perinatal anxiety and depression - What can we say to explore (assess the risk)?
When you say it’s all too much, have you thought about harming yourself?
What goes through your mind when your baby is constantly crying and won’t settle?
perinatal anxiety and depression - What can we say to empower (support them to seek help)?
What do you think will be most helpful to you right now?
Have you ever spoken to anyone about this before?
Do you have a good GP you can chat to about your mental health?
perinatal anxiety and depression - What can we say to educate?
It is commonplace to be experiencing these feelings with the stage you are at.
This can happen to anyone, and there is lots of support and help available.
perinatal anxiety and depression - What does PANDA do?
provide risk assessment, telecounselling, peer support, service navigation and care coordination to people affected by perinatal mental health concerns during the transition to parenthood.
Provide secondary consultations to health professionals supporting individuals and families during the perinatal period
What is culture?
values and way of life that they have grown up with that guide decisions and actions
Examples of Cultural Approaches to Pregnancy and Labour
say yes in order to please HCPs, even if they do not understand
prefer all female attendance at birth
a period of confinement after delivery
Australia’s culture challenges include:
Indigenous mothers suffer three times mortality rate
Premature and low birthweight babies doubled
factors affecting babies in utero and in early life have an effect on long-term health
Key aims of the National Maternity Services Plan 2010
Develop and expand culturally competent maternity care for ATSI people
Research international evidence-based examples of Birthing on Country programs to inform the development and implementation of a national Birthing on Country service delivery model
improve health outcomes for ATSI mothers and babies.
What is birthing on country?
an Aboriginal mother giving birth to her child on the lands of ancestors, ensuring a spiritual connection to the land for her baby
Cultural Considerations for Paramedics
try and respect cultural needs and provide a positive health care experience
lack of awareness and understanding of culturally competent care can affect future medical decisions of women and their families
Body Language Tips for Paediatric Patients
Get down to their level
Always make eye contact when talking to the patient.
Smile. Small mannerisms go a long way.
Emotional development at 3 months
Stops crying when picked up
Emotional development at 6 months
enjoys being played with and laughs
Emotional development at 9 months
Stiffens body when annoyed and shows fear of strangers
Emotional development at 12 months
Egocentric and very dependent on familiar adults
Emotional development at 2 years
Consistently demands attention and has tantrums when frustrated
Emotional development at 3 years
Becomes less egocentric and shows feeling and concern for others
Emotional development at 4 years
Very affectionate to people they see often
Emotional development at 5 years
Comforts playmates in distress and will respond to reasoning
Pain managment and cultureal considerations
differences exist between interpretation and experience of pain across different cultures
have an understanding of cultural differences and practices in response to pain
there is no one right way to deal with the pain of labour, and that pain is a personal experience
How to build rapport with paediatric patients
Make conversation about topics other than their condition.
Simple questions: how old they are what school they go to teddy's name something in their room
Get down on their level
Make eye contact
Physical development during infancy
3 months - child begins sitting without support
6 months - begins crawling and standing with assistance
9 months - begins standing on own and walking with assistance
Physical development during early childhood
12 months - can stand and may start to take first steps
15 months - begin to walk unassisted
18 months - able to begin stacking bricks
Physical development during childhood
2 years - can run and walk down steps 2 feet at a time
3 years - able to catch objects and hold a pencil to draw
4-5 years - can clib, skip, hop and colour in neatly
Pain Definition
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
Types of play at different paediatric ages
Unoccupied - 0-3 months
Solitary 0-2
Spectator/onlooker behaviour - 2 years
Parallel play - 2+ years
Associate play - 3-4 years
Cooperative play - 4+ years
What is solitary play?
child plays alone and not interest in playing with others yet
What is spectator/onlooker behaviour?
child watches and observes other children playing but will not play with them
What is parallel play?
child plays alongside or near to others, but not with them
What is associate play?
child starts to interect with others during play, without much cooperation being required
What is cooperative play?
child plays with others and has interests in both the activity and other children
What is unoccupied play?
baby making movements with their arms, legs, hands, feet, learning about and discovering “” how their body moves
