Week 10-14 Flashcards
1
Q
Define: Pre-term birth
A
Labour that occurs after 20 weeks gestation and before 37 completed weeks gestation.
2
Q
What is the incidence of pre-term birth in Australia
A
8.2% in Australia
3
Q
In 2014 what was the % of pre-term births in NSW
A
7.7%
4
Q
When are most pre-term infants born
A
32-36 weeks
5
Q
What is the perinatal mortality rate for pre-term births
A
7.6 per 1000 births
6
Q
How does infection relate to pre-term birth
A
Inflammatory cytokines or bacterial endotoxins can stimulate prostaglandin release directly or indirectly by stimulating the release of corticotrophin-releasing hormone (CRH)
7
Q
What are the contributing risk factors for pre-term birth
A
- Past obstetric history: repeated pre-term birth, miscarriages or terminations
- Birth following ART and ovulation induction
- Birth among women >34 years
- Infection: bacterial vaginosis
- Demographic: social disadvantage
- Medical conditions: diabetes, high blood pressure
- Current pregnancy: placental abruption, pre-eclampsia
- Behavioural: stress, psychological issues
8
Q
What are the known causes of pre-term birth
A
- Infection and inflammation
- Multiple pregnancy (40-65% twins end in preterm birth).
- Medically assisted conception e.g. fertility drugs, IVF/GIFT (20% risk of preterm birth).
- PROM (25-30%).
- Short pregnancy interval.
- Polyhydramnios.
- ‘Incompetent’ weak cervix (35%).
- Premature separation of placenta.
- Excessive use of alcohol, smoking and narcotics in pregnancy.
- A genetic basis of preterm birth.
- APH.
- 50% have no obvious cause.
9
Q
Pre-term therapy
Explain: Tocolytic therapy
A
the attempt to stop or limit uterine contractions in preterm labour using drugs.
10
Q
Explain: Tocolysis
A
Betamimetics: e.g. I.V salbutamol, terbutaline, ritodrine are βeta-adrenergic agonists and relax smooth muscle cells in the uterus.
- side effects: rapid pulse, chest pain, headaches.
- Contraindicated in:cardiac disease. May delay labour by 48 hours, can be used on hospital transfer.
Calcium channel blockers: e.g. oral nifedipine reduce muscle contraction by controlling the influx of calcium across the plasma membrane.
11
Q
Explain: MgSO4
A
MgSO4 for neuroprotection of the preterm infant, to minimise the risk of cerebral palsy.
Indications:
Preterm fetus < 30 weeks gestation.
If preterm birth expected in <24 hours, treatment to commence as close as 4 hours before birth.
4g loading dose and titrated.
Used for singleton or twin pregnancies.
12
Q
What are the contraindications to treatment of premature labour
A
Contraindications to stopping a labour:
- Mature fetus >34 weeks.
- Fetal death.
- Fetal anomaly incompatible with life.
- SGA/IUGR related to unfavourable intrauterine environment.
- Other fetal compromise/fetal distress on admission.
- Active haemorrhage.
- Intra-amniotic infection/chorioamnionitis.
13
Q
Pre-term birth
What is the labour management for expectant delivery
A
(Tocolysis contra-indicated if cervix is dilated)
- Commence IMI steroids
- Have maternal and neonatal specialist’s notified and ready
- Conduct regular labour observations
- Monitor fetus
14
Q
Pre-term birth
What is the delivery management for pre-term birth
A
Be prepared for:
- rapid 2nd stage
- possible fetal distress
- neonatal resuscitation equipment/ ready for TF to NICU
- Contemporaneous documentation
15
Q
Pre-term birth
What is the subsequent midwifery care is a woman is admitted to the ward
A
- administer IV fluids, tocolytics, antibiotics and 2nd dose of steroids
- fetal welfare assessment
- discuss premature outcomes with parents
- maternal assessment (obs and abdominal palpations)
- r/v by specialist
16
Q
What is the midwifery care on admission to the BU for delivery
A
- take patient history
- prepare room (rests equipment ready)
- request additional personnel
- CTG monitoring
- type of birth
17
Q
Define: Premature rupture of membranes
A
Rupture of the amniotic sac prior to 37 weeks gestation
18
Q
Premature rupture of membranes
What are the maternal and fetal effects of PROM
A
Maternal
- 50% deliver within 1 week
- maternal sepsis
Fetal
- prematurity
- fetal infection (chorioamnionitis)
- fetal compromise
- developmental abnormalities
- possible TOP
19
Q
How is premature rupture of membranes diagnosed?
A
NO vaginal examination
- sterile speculum
- amnicator test
- observe for labour signs
20
Q
What % of multiple pregnancies end in preterm delivery
A
15%
21
Q
What is the most common pregnancy complication relating to twins
A
Polyhydraminos- causing premature labour and prematurity
22
Q
Diagnosis of twins
How are twins diagnosed
A
Suspected
- IVF
- Severe hyperemesis
- increased pregnancy discomforts
- conditions (GDM, pre-eclampsia, LGA)
- polyhydraminos
Confirmation
- U/S examination
23
Q
Multiple pregnancies
What are the complications
A
- anaemia
- placenta previa
- polyhydraminos and preterm labour
- malpresentations
- pre-eclampsia and GDM
- PPH
- Growth restriction and IUD
24
Q
Define: PPH
A
Blood loss of 500ml or more during and after childbirth
25
Define: Severe PPH
A blood loss of 1000ml or more OR any amount of blood loss postpartum that causes haemodynamic compromise
26
Explain: Primary PPH
Occurs within the first 24hrs following birth
27
Explain: Secondary PPH
Occurs between 24hrs and 6 weeks postpartum
28
The incidence of PPH may be underestimated by up to what %
50% due to clinical difficulty in accurately estimating blood loss
29
Manual removal of the placenta at ELSCS and EmLSCS is associated
Increase in maternal blood loss and increased risk of infection
30
What are the 4 T's for most likely causes of PPH
Tone
Trauma
Tissue
Thrombin
31
4T's causes of PPH
Explain: Tone
- 70% of cases
- Examples: prolonged labour, multiple pregnancy, full bladder, polyhydraminos
- Obvious Signs: profuse bleeding and maternal collapse
- Subtle Signs: uterus large and soft, blood retained in the uterus
32
4T's causes of PPH
Explain: Trauma
- 20% of cases
- lacerations (cervix, vagina and perineum)
- episiotomy
- uterine rupture
- uterine inversion
33
4T's causes of PPH
Explain: Tissue
- 10% of cases
- retained products
- retained placenta or succenturiate lobe
34
4T's causes of PPH
Explain: Thrombin
- 1% of cases
- coagulation disorders acquired in pregnancy
- Idiopathic thrombocytopenia purpura
- thrombocytopenia with pre-eclampsia
- preeclampsia
- abruption
- severe infections
- amniotic fluid embolus
35
What is the Acute Management for PPH
- Summon help
- Rub up contraction
- Give an oxytocic
- Empty bladder
- Syntocinon infusion
36
What is the Prophylaxis management for PPH
- Avoid anaemia, dehydration, prolonged labour
- Empty bladder 2nd hrly
- Oxytocics for 3rd stage
- Check history: fibroids, anaemia, previous PPH
37
Explain: Drug therapy for PPH management
- Syntocinon: IM 10units
- Syntometrine: IM 1mL (2nd does within 2hrs if necessary)
- Ergometrine: IM 250mcg or IV 250mcg
- Prostin F2a: mix 5mg with 9mL N-saline
38
PPH management when placenta is undelivered or partially delivered
- attempt CCT
- Provide effective pain relief
- Perform procedure
- Oxytocic given post procedure
- Prophylactic antibiotics
39
If there is an Intractable PPH what is the management
- bi-manual compression
- balloon tamponade
- haemostatic brace suturing
- hysterectomy
40
What are the 4 degrees of shock
Compensation: 900mls, minimal symptoms
Mild Shock: 1200-1500mls, weakness, anxiety, tachycardia
Moderate Shock: 1800-2000mls, tachycardia, restlessness, cold/clammy skin, pallor
Severe Shock: 2400mls, collapse, depressed mental state, air hunger, Anura, circulatory arrest
41
PPH Resus steps
- Resus
- Cannulate
- collect bloods: FBC, cross match and haemoglobin
- Crystalloids: N Saline, Hartmann
- Blood
42
What are the causes of Uterine Inversion
- incorrect management of 3rd stage
- Short cord
- Precipitate labour and/or birth
- Manual removal
- Pathologically adherent placenta
- Spontaneous with no obvious cause
43
What are the 3 classifications of uterine Inversion
First degree: fundus reaches internal os
Second degree: the body of uterus is inverted to the internal os
Third degree: the uterus, cervix and vagina are inverted and visible
44
What is the management for Uterine inversion
- summon assistance
- Manual or surgical replacement
- If placenta still attached, leave there
- Correction of shock
- oxytocic once uterus in normal position
45
What are the 4 types of Perineal Trauma
1st degree- injury to perineal skin
2nd degree- injury to perineum involving muscles
3rd degree- injury to perineum involving the anal sphincter complex
3a)- less than 50% of external anal sphincter (EAS) torn
3b)- more than 50% of EAS torn
3c)- both EAS and internal anal sphincter torn
4th degree- injury to perineum, anal sphincter complex (EAS and IAS), and epithelium
46
Define: Episiotomy
Is an incision made in the pelvic floor during childbirth to enlarge the vaginal orifice
47
What are the indications for Episiotomy
- fetal distress
- short, long or inelastic perineum
- shoulder dystocia
- fetal malposition
- instrumental or breech delivery
- previous pelvic floor surgery
48
What are the 2 types of Episiotomy
Midline: cut vertically from the fourchette down towards the anus
Mediolateral: starts in the midline at the fourchette but is directed diagonally outwards to avoid anal sphinter
49
When performing an episiotomy what 3 things are important
- Verbal consent
- Perineum MUST have local anaesthetic or a pudendal block
- must be made with a single cut beginning at the midline fourchette
50
How can woman avoid episiotomy/perineal trauma
- alternating positions
- physiological pushing and an upright position
- constant caring companion
- have previous trauma properly repaired
51
What are some 3rd Stage complications
- PPH
- Thrombophlebitis
- DVT
- Pulmonary embolus
- Puerperal infection (sepsis)
- Puerperal haematoma
- Breast problems: engorgement, mastitis, abscess
52
Define: Puerperal Infection
A temperature of 38 degreesC occuring on a single occasion OR of 37.5 degrees occuring on three or more successive occasions within 28 days of childbirth/abortion
53
What are the predisposing Intrapartum factors for Puerperal infection
- LSCS
- LSCS wound infection
- Prolonged ROM
- Chorioamnionitis
- Prolonged labour
- IDC (UTI risk)
- FSE
- Retained products
- Episiotomy, lacerations or haematoma
54
Puerperal infection
Explain: Endometritis
- most common cause of puerperal infection
- higher incidence in LSCS
- women with IDDM
- Signs: >38 degree temp, tachycardia, chills, anorexia, nausea, fatigue, pelvic pain, offensive lochia, uterine tenderness
- Investigations: blood cultures
- Treatment: antibiotics
55
What are common sources of pain in labour
- Uterine contractions
- Cervical dilation
- Back pain
- Emotional
- Psychological: anxiety, fear, current or past experiences
56
Define: Labour dystocia
an abnormal or difficult labour (8-11%)
57
What are the 3 P's associated with difficult labours
Powers- ineffective pattern of contractions
Passage- pelvis
Passenger- malposition/ malpresentation of the fetus
58
What are the possible causes of Labour dystocia
Classical causes: powers, passage and passenger
Other: dehydration, ketosis, psychological state (anxiety and fear)
59
What would cause you to suspect labour dystocia?
- A lack of progress in the rate of cervical dilatation.
- A lack of progress in fetal descent and expulsion.
- An alteration in the characteristics of uterine contractions.
- Most common cause of labour dystocia will be “abnormal uterine action”.
60
What may indicate ineffective uterine contraction
-Contractions do not effectively dilate the cervix
- Progress in labour is slow
- Length of labour is prolonged
- Contractions may be
Too weak or
Not working in harmony
61
Explain: Hypotonic uterine action
Two Types
Primary: occurs in early labour
Secondary: after a normal contraction pattern has been established (possibly after an epidural)
- Contractions: weak, short, inefficient
- Slow or no cevical dilation
- woman and fetus not distressed
62
Explain: Incoordinate uterine action
Two Types
Colicky uterus
Hypertonic lower uterine segment
- Polarity of uterus is reversed
- Cervix dilates slowly despite frequent painful contractions
- Linked to: malposition of the occiput and minor CPD
63
What is the management of incoodrdinate uterine action
- Identify cause and if possible, correct it
- Emotional support
- Avoid dehydration and ketosis
- Ensure bladder care
- Incoordinate uterine activity may be aggravated by the supine position. Encourage ambulating, positions which encourage gravity, warm baths
- Augmentation with Syntocinon?
64
Explain: Hypertonic uterine action
- usually occurs with the use of prostaglandins
- Pain out of proportion to contractions and cervical dilation
- Seen in multiparous women with precipitate labour (<2 hours) and those with c.p.d.
- May result in uterine rupture, perineal trauma and PPH
65
What is the management of Hypertonic uterine action
- Determine cause
- Early recognition
- Timely preparation for birth under controlled conditions
- Properly administered analgesia
66
Explain: Cervical dystocia
- Oedematous anterior lip of cervix.
- Rigid cervix: uterus contracts normally but the cervix fails to dilate. Woman may have a history of cervical stenosis from previous cervical surgery or congenital abnormality of the cervix
67
Explain: Pelvic dystocia
Contractures of the pelvic diameters reducing the capacity of the inlet, cavity and the outlet.
- common cause of obstructed labour
68
Explain: Soft tissue dytocia
Obstruction of the birth passage by an anatomic abnormality other than the bony pelvis
Causes
- Pelvic mass - fibroids located in the LUS or on the cervix can prevent fetal head descent.
- Ovarian tumours or rare tumours of the bony pelvis may also prevent the head from entering the pelvis
69
What are the fetal causes of labour dystocia
- Anomalies e.g. hydrocephalus, conjoined twins
- Disproportion
- Malposition
- Malpresentation
70
Define: Malpositions
‘Refers to a position of the fetus in the uterus which will not aid normal progress in labour.
71
Define: Malpresentations
‘when the fetal head is not over the cervix; the breech, brow, shoulder or face may be found instead.’
72
Possible causes of brow presentations
- multiparity,
- placenta previa,
- uterine anomaly,
- polyhydramnios,
- prematurity,
- multiple births and
- macrosomia.
73
Possible causes of Shoulder presentation
- lax multiparous uterus,
- placenta previa,
- fetal anomaly,
- polyhydramnios and
- uterine malformation
74
Possible causes of Breech presentation
Restricted space: e.g. primigravidae, bicornuate uterus, fibroids, placenta previa, contracted pelvis, multiple pregnancy.
Excessive uterine space e.g. grand multiparity, polyhydramnios
Fetal causes e.g. hydrocephaly, preterm labour, congenital anomalies.
75
What are contraindications for an ECV
- Uterine scar
- Hypertension
- Oligohydramnios
- H/O premature labour
- Multiple pregnancy
- Hydrocephalic fetus
76
Define: IOL
Is any attempt to initiate uterine contractions before their spontaneous onset to facilitate a vaginal delivery
77
Define: Augmentation
Is any attempt to stimulate uterine contractions during the course of labour to facilitate a vaginal delivery
78
What is the incidence of IOL/Augmented labours
↑29.6% of NSW confinements were induced or augmented with oxytocins and/or prostaglandins in 2014.
79
What is the criteria for induction
- An engaged presenting part
- No previous classic uterine incision
- No fetopelvic disproportion
- No non-reassuring fetal heart rate patterns
- No major bleeding from an abruptio placentae
- No placenta praevia or vasa praevia
- No active herpes
80
Methods of induction include:
MEDICAL
Oxytocin
Prostaglandins, prostaglandin analogues
Amniotomy/Artificial rupture of membranes (ARM)
Digital stretching of the cervix, ‘sweeping and stripping’ of the membranes
Mechanical cervical dilators e.g. laminaria
Extra amniotic balloon catheters
```
NON-MEDICAL
Herbs, egg, blue and black cohosh tinctures,
Raspberry leaf
Cod liver oil
Acupuncture, homeopathy
Nipple stimulation, sexual intercourse
```
81
How is the medical method of IOL chosen
by using a Bishop Score
82
Explain: Bishop Score
A score is ascertained by performing a vaginal examination and assigning points to five sets of parameters
- Parameters: dilatation; length of cervix; station; consistency; position
- Bishop’s score <6 requires cervical ripening
- Scores >9 indicate induction favourability
83
Whats are the Advantages and Risks of performing and ARM
Advantages:
- Decreases the length of some labours,
- allows assessment of the colour of the amniotic fluid,
- allows for internal fetal and uterine monitoring
Risks:
- Can increase pain and
- lead to further intervention,
- variable decelerations,
- cord prolapse,
- vasa previa cases,
- infection
84
Explain: Prostaglandin use (route, dose, care)
Route of administration Prostaglandin (PGE2): Prostin gel
Intravaginal (posterior fornix)
Dosage: 1-2mg, can be repeated 6 hourly, maximum 3 doses
Midwifery care:
- Check dates, note prior Bishop’s score, explain procedure, allay anxiety,
- abdominal palpation,
- pre and post CTG, woman to remain supine for 30-60 minutes post administration,
- assess for hyperstimulation, observe other side effects e.g. diarrhoea, ambulate after 60 mins, after 6 hours re-assess Bishop’s score
85
What are the Advantages and Risks of Prostaglandins
Advantages
- Enhanced cervical ripening
- Decreased use of oxytocin
- Decreased oxytocin induction time
- Reduced amount of oxytocin used
- Decreased caesarean section rate
Risks
- Uterine hyperstimulation -uterine rupture
- Non reassuring FHR pattern changes
- Gastrointestinal side effects
86
Explain: Mechanical cervical ripening
Various methods used, however all stimulate the release of prostaglandins due to mechanical pressure
87
What are mechanical methods of cervical ripening
- Balloon catheters now back in practice. E.g. Foley’s, Bard
- Natural dilator e.g. laminaria rods
- Synthetic dilator
88
What are the risks of mechanical cervical ripening methods
Infection
PROM
Haemorrhage
89
Explain: Syntocinon
Oxytocin promotes the contraction of the uterine smooth muscle, synthetic form is Syntocinon.
- Administered when cervix is ‘favourable.’
Administration:
- Intravenously via infusion pump
- ‘Piggy backed’ to the main intravenous line
- Prepared in an isotonic solution e.g. Hartmann’s solution
90
How do drugs affect people
```
Mood
Behaviour
Violence
Health: physical and mental
Social
Financial
Family dysfunction
Society: health costs, crime
Death
```
91
What are the common referrals used when women have been using substances in pregnancy
- Medical teams e.g. infectious diseases
- DUPS/CUPS team
- Social worker, Safestart guidelines
- Psychiatry
- Neonatalogist
- Child protection team in hospital/LHD
- Mandatory DOCS referral
92
What are the general care principles of drug dependent women
- Multidisciplinary approach
- Vertical transmission of blood-borne viruses e.g. Hep B, Hep C, HIV
- Mental health issues: pre-existing, new diagnosis
- Confidentiality issues
- Pregnancy care facilities and support e.g. late to book-in
- Child protection obligations
- Staff opinions and reactions
- Contraception
93
What types of drugs are used in pregnancy
- Tobacco: cigarettes, cannabis
- Alcohol, caffeine
- Opioids: heroin, methadone, morphine, pethidine, oxycodone, buprenorphine
- Naltrexone
- Cocaine
- Benzodiazepines
- Amphetamines, ICE
- Prescription & OTC drugs
- Inhalants
94
What complications are associated with smoking in pregnancy
low birth weight,
preterm birth,
SGA
perinatal death
95
What percentage of teenage and ATSI mothers smoked on pregnancy
Teenage mothers: 42.0% reported smoking during pregnancy.
| ATSI mothers: 52.2% reported smoking during pregnancy.
96
What type of interventions are available to assist mothers in reducing/stop smoking in pregnancy
- ‘Quit for New Life Program’ is a smoking cessation program aimed at quitting/reducing
- Training for staff re: interventions to encourage women to stop smoking.
- Nicotine replacement therapy= nicotine patches
97
Can alcohol consumption in pregnancy cross the placenta?
Yes
98
What are the complications of alcohol in pregnancy
It can cause:
- bleeding,
- miscarriage,
- stillbirth and
- premature birth.
99
What are the facial characteristics of Fetal Alcohol Syndrome
- small head
- low nasal bridge
- short eyelid opening
- epicanthal folds
- flat midface
- short nose
- smooth philtrum (space betwwen nose and upper lip)
- thin upper lip
- underdeveloped jaw
100
What are the effects of long term/heavy caffeine consumption
Woman
- dependence and withdrawal
- osteoporosis
- high BP
- heart disease
- heartburn
- severe insomnia
- infertility
Pregnancy
- increased risk of miscarriage,
- difficult birth and
- delivery of low-weight babies.
101
Explain: Heroin use in pregnancy
- Heroin and other opioids are depressant drugs that slow down the CNS.
- Heroin use has been associated with an increased risk of miscarriage and premature birth, SGA and may be prone to illness. The substances that are cut with heroin may also cause problems during the pregnancy and affect the developing fetus.
- Heroin can pass through the placenta to the fetus, and cause heroin withdrawal, known as Neonatal Abstinence Syndrome (NAS).
102
What are the common treatments for heroin dependence
Buprenorphine (Subutex).
Methadone (if using buprenorphine, the transfer to methadone can occur rapidly).
Naltrexone (if using buprenorphine, the transfer to naltrexone can take place within 3–5 days).
103
What is the management of Neonatal Abstinence Syndrome (NAS)
NAS occurs in newborns going through withdrawal as a result of the mother’s dependence on drugs during pregnancy.
- NAS is characterised by signs and symptoms of central nervous system hyperirritability, gastrointestinal dysfunction and respiratory distress, and by vague autonomic symptoms that include yawning, sneezing, mottling and fever.
- Usually begins within 72 hours, but may appear up to two weeks after birth.
- Pharmacological management is often required for babies affected by NAS and includes morphine and phenobarbitone.
104
Whats is the Management of Substance use in pregnancy
1. Treatment of withdrawal, including pharmacotherapy if appropriate.
2. Provision of information about substance use, and encouragement to participate in decisions about care.
3. Involvement of the partner, family, the extended family and community according to the woman’s preference and available supports.
4. Medical, mental health, psychosocial, pregnancy, and drug and alcohol management, and care of co-morbidities.
5. Pre-birth child protection notification to be made if appropriate
6. Links to community or Indigenous health, mental health, drug and alcohol support services, midwifery and or neonatal nursing services, outreach services, general practitioner or Flying Doctor services should be established and maintained.
7. Pre- birth liaison with paediatric colleagues to provide early counselling for parents of possible outcomes for baby.
8. Management of Neonatal Abstinence Syndrome is provided if this occurs.
9. Information, counselling and support are provided to minimise the incidence of relapse.
10. Appropriate follow-up arrangements are made for both mother and baby.
105
What is the Management of APH
- Assessment of general condition
- General appearance. Signs of shock?
- Vital signs
- Blood loss: Colour? Amount? Onset?
- History: any predisposing factors?
- Palpation: guarding/tense?
- Assess fetal condition
- NO VE. Speculum and ultrasound to confirm diagnosis
- Pain relief
- Reassurance and explanation
- IV access, group and cross match
- Subsequent management depends on degree of blood loss and maternal and fetal condition
- DOCUMENTATION ☺
106
Define: Preterm labour
as regular uterine contractions that cause progressive dilation of the cervix after 20 weeks of gestation and before 36 completed weeks
107
What 4 factors are propsed to inlfuence the risk of spontaneous preterm uterine contractions and cervical changes
- altered uterine and cervical factors,
- placental ischemia;
- inflammation,
- stress
108
Bacterial infections account for what % of preterm births
25% to 40%
109
Give examples: of the 4 predisposing risk factors for preterm labour
Altered uterine and cervical factors: Multip, polyhydraminos, trauma, cervical injury, smoking
Placental Ischemia: diabetes, hypertension, obesity, anemia, cardiovascular disease, renal disease
Inflammation: bacterial infections in genital tract, gonorrhea or chlamydia
Stress: high stress, DV, single marital status, long work hours, strenuous work
110
Explain: Oestrogen
- produced by the corpus luteum
- produced for first 2-4wks
- placenta then takes over production
111
Explain: Progesterone
- produced by the corpus luteum
- produced for the first 4 to 6 weeks
then produced by fetal syncytiotrophoblasts until 32-34wks gestation
112
Side effects for the neonate as a result of preterm labour/birth
- Respiratory distress syndrome
- Intraventricular or pulmonary hemorrhage
- Patent ductus arteriosus
- Necrotizing enterocolitis •
- Retinopathy •
- Hyperbilirubinemia •
- Increased susceptibility to infections •
- Anemia •
- Ineffective temperature regulatory mechanism •
- Developmental delay •
- Chronic lung disease •
- Later in life, increased risk for type 2 diabetes mellitus
113
Case:
Liz is admitted to the postnatal ward following a
prolonged augmented labour and the birth of a 4.5kg
baby girl after a 3 hour second stage.
- Four hours post
birth Liz rings the bell to report a torrential vaginal blood
loss.
What is:
Condition
Cause/Why
Management
Condition: Primary PPH
Cause: tonic uterus
Why: prolonged labour, 3hr second stage and 4.5kg baby
Managment:
- Rub up her fundus-make sure it becomes hard,
- observe for any additional blood loss,
- call for help!,
- give some form of oxytocic (syntocinon),
- fluids,
cannula, bloods- group and hold/cross match
114
Case:
Diana has been admitted to the postnatal ward and has
been identified as having an increased risk for embolus
formation.
- What predisposing factors could have increased this
risk?
- how you would reduce the risk of embolus
formation
- How would Diana present if a DVT of the leg or
pulmonary embolus developed?
- Management
Predisposing factors: High BMI, GDM, LSCS, pregnancy, medical history- previous embolism, blood clotting condition, preeclampsia, high parity, epidural (immobilisation)
Reduce risk: encourage mobilisation, use of teds, calf air compressors
Presentation:
Leg- hot, red, varicose veins prominent, pain, swollen
Pulmonary- pain on breathing, shortness of breath
Management: Celxane injections, mobilisation
115
Kate now a P1 had a normal vaginal birth with
the assistance of an episiotomy. Sixteen hours
post delivery Kate is complaining of severe
discomfort in her rectum and vagina,
accompanied by a pulse rate of 110bpm.
What is:
Happening
Management
Happening: Haematoma recto-vaginal (bleeding collection near episiotomy site- perhaps area between vagina and rectum)
Management: Pain relief, view the area, go to theatre to have area drained, ice-packs
116
Case:
Charlotte a 26y.o P1 had an emergency LSCS at 36 weeks
for fetal distress and prolonged rupture of membranes.
- Charlotte is now Day 3 postnatal and complains of feeling
hot, lethargic and has uterine pain.
- Obs Temp is 38.5, Pulse 108, Respirations 32 and
BP 120/70.
What is:
Happening
Management
Happening: infection (puerperal sepsis)
Management: Start on sepsis pathway-
- call for help,
- cannulate and take blood cultures to determine type of infection,
- do a high vaginal swab (spec),
- IV antibiotics,
- fluids,
- check fundus,
- MSU,
- pain relief
- documentation
117
Case:
Rona a P0 requires an emergency LSCS this afternoon for fulminating
pre-eclampsia at 32 weeks.
- Prior to delivery her B.P has been
stabilised and MgSO₄ is being given.
- The anaesthetist is deciding on
the mode of anaesthetic.
- Her bloods taken this morning showed a
platelet count of 78, her coagulation studies show increased
prothrombin time, increased partial thromboplastin time and
decreased fibrinogen, and her liver and renal function tests have both
deteriorated from two days ago.
What is:
- likely management and considerations for Rona at delivery
- What postnatal outcomes and considerations would you need to
be aware of
- What postnatal complications is Rona at risk of
She's had preeclampsia (Her potential problem would be a Thrombin cause PPH)
Likely considerations: Anaesthetic would be a general anaesthetic, call for help, possible bleeding during procedure, have bloods done- Group and hold, cross-match, eclamptic fit,
Postnatal considerations/outcomes: Doing regular obs, IDC, facilitating feeds with baby
Postnatal risks: Possible secondary PPH, blood pressure, urine output, DVT, pulmonary embolus, fitting
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Case:
Anna is a P1 and is going home on Day 3 after a
precipitous vaginal birth in which she sustained a
3rd degree tear. Anna has been very upset about her
birth and states she is traumatised from the
delivery.
What:
- would be incorporated into her discharge plan
- short and long term implications of severe perineal trauma
Incorporated into discharge plan: Social work follow up, gynaecological referral, physiotherapy referral?, debrief with her about the birth
Short and long term implications: Pain & discomfort, postnatal depression,decline in sexual health (pain, psychological trauma, loss of libido)
