Week 5: Third stage of labour and immediate care post birth Flashcards
Define the third stage of labour
period from the birth of the baby through to delivery of the placenta and membranes and ends with the control of bleeding
Describe some physiological changes that occur post-birth
- uterus reduces in size
- placenta site is now diminished by reduces uterus
- blood is forced back into the decidua basalis by this shrinking uterus.
- Simultaneously the oblique uterine muscle
fibers constrict clamping down on the blood
vessels so that they do not drain back into the
placenta
How does the placenta detach from the uterine wall?
- As uterus shrinks
- the pressure increases within the blood
vessels the vessels burst and blood tracks
between the decidua and placenta - The leakage of blood and the diminished
surface of the placental site results in the
placenta detaching from the uterine wall - Extra weight of placenta helps to strip membranes off uterine wall
- There is formation of retro placental clot may
aid complete separation
What is a retro placental clot?
Clot that forms over the site where the placenta has just detached from.
Formation of retro placental clot may
aid complete separation of placenta from uterus.
How does the body control bleeding after birth of the placental?
Living ligatures that surround the uterus.
- Oblique muscle fibres surrounding the blood vessels contract and seal off ends of maternal vessels
Pressure
- Further contractions causes opposing walls to exert pressure on placental site
Blood clotting
- Transitory activation of the coagulation system to
intensify clot formation
- Activation of fibrinolytic system so the placental
site is covered by fibrin mesh
Placenta descends into vagina expelled by maternal
effort
What are the two ways the third stage can be managed?
Physiological management (Expectant management)
Active management
Explain physiological management, when it is safest and what it look like.
No interventions
Safest when a physiological labour & birth has occurred
- of aiming for a physiological third stage, a physiological 1st and 2nd would need to have occurred.
• Informed consent (with risks of both)
Looks like
• No clamping of cord until stopped pulsating
• Initiation of breastfeeding to initiate contraction (oxytocin) + bonding and to meet babys needs
Explain the practice of lotus birth
The spiritual practice of Lotus birth: cord is not
clamped or cut. Placenta salted and wrapped with
baby.
Explain how the placenta can be assisted to be born both actively and physiologically and what should we do post expulsion.
- Expelled by maternal effort
Assisted by maternal positioning
e. g. squatting or sitting (toilet/ relaxes/familia), by utilising the forces of gravity, will aid expulsion
- woman will usually do what feels most comfortable
- Following birth of placenta palpate the fundus to ensure it is well contracted
- Monitor PV (per vaginal) bleeding
- Takes 15 – 60mins
Always have a uterotonic drawn up ready to be given if clinically needed.
Explain active management in the second stage of labour, why is it carried out, when it is safest and what 4 key pratice points it includes.
Active management involved interventions.
Goal of active management: prevent PPH
Purpose
- Helps prevent postpartum haemorrhage (blood loss
>500ml)
- Anticipated completion fo active management 30 minutes
Active management includes:
1. The use of a uterotonic agent
- Clamping and cutting of the umbilical cord within 2-3
minutes of birth - Controlled cord traction while ‘guarding the uterus’
- Uterine massage after the expulsion of the placenta
What amount of blood is considered a post partum haemorrhage?
Postpartum haemorrhage= blood loss > 500ml
Whar are uterotonic agents and what is their role? list some examples.
- artificial hormones that stimulate string contractions
e. g. (most common)
- syntocinon
- Ergometrine
- Syntometrine (combination of the above two)
What do you need to be aware of when using ergometrine? (uterotonic caution)
- it is associated with hypertension, nausea and vomiting.
History of pre eclampsia just go with syntocinon not syntometrine or ergometrine
Describe syntocinon. Its dose, mode of action, response time and length of action.
Dose: 10 IU IM
Mode of action: rapid uterine contraction by smooth muscle tissue contraction
Response time: 2-3 mins
Length of action: 15-30 mins
Describe syntometrine. Its dose, mode of action, response time and length of action.
Dose: 1ml IM
which contains 5 IU oxytocin (half dose) and 0.5mg ergometrine
Mode of action: combines the rapid uterine action of oxytocin/syntocinon, with the sustained uterotonic effects of ergometrine
Response time: 2-3 mins
(Oxytocin/Syntocinon acts in 2-3 mins)
(Ergometrine acts in 6-7 mins)
Length of action: 2-4 hours
Describe ergometrine. Its dose, mode of action, response time, length of action and a key practice point of when it is used.
Dose: 2.5mgs IM or IV (diluted)
Mode of action: Sustained uterotonic effect on
smooth muscle
Response time 6-7 mins if given IM
Length of action: 2 - 4 hours
Usually not the drug of choice in the
management of the third stage, more so in the
management of PPH.
Explain early cord clamping and the benefits it prevents.
clamping of the cord <1 minute following
the birth of the baby
- Reduces transfer of blood to baby
- Placenta does not reduce so much in size therefore…
- Delayed separation (thus increased risk of retained placenta)
• Reduced iron stores for the infant, and increased incidence of
hypotension and intraventricular haemorrhage
• Early umbilical cord clamping (less than 1 min after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation (WHO, 2012)
Explain delayed cord clamping and the benefits
Delayed cord clamping (performed approximately 1–3min after birth) for all births, while initiating
simultaneous essential neonatal care.
- Delayed CC for approximately two minutes in
healthy term infants, will promote better iron
stores in infants in the longer term. - Delayed CC does not require delayed
administration of oxytocin in the active
management of the third stage of labour.
Define a retained placenta
If a placenta hasn’t been born within
Active management: 30mins after baby
Physiological: 60mins after baby
When should the uterotonic/oxytocic be administered?
when anterior shoulder shows or immediatley following the borth of the baby (within 1 minute)
- wait 2-3mins for ocytocic to have effect then cord can be reviewed for clamp and cut.
- clamp or cut cord
Whos role is the prep and administration of the uterotonic/oxytocics?
The secondary/receiving midwife.
Primary midwife/acousha
not their job
Explain the active management technique of CCT
Controlled cord traction
- place hand on abdomen to find fundus
- detect contractions and placental separation.
- gently but firmly pull on word in a downward motion
0 hold caord and apply tension then wait for next contraction to put on more tension.
- continually apply counter traction to the uterus with other hand.
When placenta separates
- mother will feel the urge to push again
- mother may feel same pain
- uterus begins to rise and involute
- small trickle of blood
List some signs the placenta has seperated and what can be done if none are observed?
- small trickle of blood
- mother will feel the urge to push again
- urterus contracting or rising up
- lengthening of the cord
If no signs of separation are observed
- gently begin gentle controlled cord traction in. a downwards motion whilst guarding the uterus.
What are key points of practice points for delayed cord camping?
- firm but cautious
- gentle
- clamp cord close to perineum
- hold cord and clamp in one hand
- use other hand to stabilise the uterus on abdomen ()this will also allow you to feel if it is not separated
What is the risk of controlled cord traction?
the risk is if the placenta is still attached we may cause the uterus to prolapse and come out the vagina.
- we must be honest with women either way and allow them to make the risk
What should CCT effort be stopped?
- if it doesn’t descend during 30-40 seconds
- if resistance is met
Describe the motion and hand placement when birthing the placenta
- downward traction until it is in the perineum
- then lift placenta up and continue traction
(think about the curve in the passage) - twist placenta to encapsulate all the membranes (non get stuck in uterus)
- the twist strengthens the membranes and creates a kind of rope- then we lift up and down to get out all membranes
Why is it important to get all membranes and part of the placenta out?
any left overs can cause
- bleeding
- infection
Describe the fundal rub that occurs directly after the birth of the placenta
- gently touch and palpate
- to ensure it has contracted
When is a uterine massage used?
when there is uncontrolled bleeding to cause a contraction
Estimate the amount of blood loss.
How frequently should a fundal rub be conducted?
Every 15 mins for 2 hrs
Ensure fundus does not become relaxed (soft) after you stop uterine massage
Explain the benefits and risks of active management
Reduces incidence of: – Blood loss – Postpartum haemorrhage – Prolonged third stage of labour – Maternal anaemia
Increases risk of
- maternal nausea, vomiting and raised blood pressure (when ergometrine preparations are used)
• There are no apparent clinical significant effects on
the baby
Explain the collection of blood, its use and how it is carried out.
Two clamps about 3cm apart to block blood in the cord to be used for a test.
Neccessary for
- Rh negative – Group / direct Coombes / Hb
- ensure correct tubes, labelling, pathology form, collect prior to checking placenta
- Cord pH - double clamp cord approximately 30cm
apart and collect blood using heparinised syringe and
needle
- Stem cell collection
- Cord Lactate
List some points of further care of the women post birth
- Examine genital tract for trauma
- suturing as necessary - Assess vital signs
- Assess condition of uterus
- contracted, central and below the umbilicus - Assess blood loss – measure if necessary
- Clean area and make woman comfortable
- Encourage breastfeeding
- Examine placenta and membranes
What should the genital tract be assessed for? What is a requirement for this type of check?
Perivulvar lacerations • First-degree tear • Second-degree tear • Third degree tear • Fourth-degree tear
Requirements include a new pair of sterile gloves (as
gloves will be contaminated from the birth), good lighting
and a perineal pad (combine)
Wat is a perivulvar lacertion?
- Lacerations near the clitoris or urethra are very vascular and require careful suturing
- Labial lacerations/grazes may not require suturing
Which muscles may be involved in a second-degree tear? and what is involved in a deep 2nd degree tear?
• Superficial transverse perineal muscle • Bulbospongiosus (bulbocarvenosus) • Central perineal body • Posterior margin of deep transverse perineal muscle and urogenital diaphragm
A deep 2nd degree tear can include:
• puborectalis muscle
• pubococcygeus muscle
Define a 3rd degree tear and What are the levels of a third degree tear?
Injury to perineum involving the anal sphincter complex:
Grade 3a tear: Less than 50% of external anal sphincter (EAS)
thickness torn
Grade 3b tear: More than 50% of EAS thickness torn
Grade 3c tear: Both external and internal anal sphincter torn
Define a fourth degree tear?
Injury to perineum involving the
external and internal anal sphincter complex and anorectal
mucosa.
Define a first degree tear
Injury to perineal skin and/or
vaginal mucosa.
Define a second degree tear
Injury to perineum involving
perineal muscles but not involving the anal
sphincter.
Describe the placenta and its key components including the fetal and maternal sides.
Flattened discoid (round coon shaped) organ - continuous with chorion
Maternal surface
– red
– attached to decidua
Fetal surface
– whitish
– covered with amnion with insertion of cord
– blood vessels visible
Cotyledons separated by sulci (furrows)
Lobules – villi
Describe each of the membranes their key features and functions
Amnion
– fetal surface
– produces prostaglandins
– amniotic fluid (liquor amnii)
Chorion
– maternal surface
– produces enzymes, prostaglandins, oxytocin and platelet-activating factor
• Grow to 28 weeks then stretch
• Contain amniotic fluid
- Increases up to 700-1000ml by 37 weeks then decreases
Which membrane produces prostaglandins, enzymes, oxytocin, amniotic fluid and platelet-activating factors?
Amnion
– fetal surface
– produces prostaglandins
– amniotic fluid (liquor amnii)
Chorion
– maternal surface
– produces enzymes, prostaglandins, oxytocin and platelet-activating facto
Describe the key components of the umbilical cord.
Attached to placental fetal surface
• 2 umbilical arteries
• 1 umbilical vein
• Wharton’s jelly - mucoid connective tissue
• Spiralled vessels longer than cord – loops – false knots
List all the factors that should be assessed in the umbilical cord
- length
- Insertion – central, eccentric, battledore or velamentous
- number of vessels – 2 arteries and 1 vein
- Thromboses
- Knots
- Presence of Wharton’s jelly
What complications can arise if Wharton’s jelly is absent or only in a small amount?
- prone cord compression
- absence of Whartons jelly is usually associated with fetal death
- ## if cord is twisted or knotted it is more likley to tighten where there is low whartons jelly due to low resistance.
Describe some abnormalities of the umbilical cord
Long
- Increased risk of fetal entanglement and cord knots.
When prolapse of the cord is more liable to occur.
Short
- Can cause prolonged second stage, cord rupture, uterine
inversion and a difficult delivery.
- Can be associated Down syndrome, fetal malformation and malpresentation.
Two vessels
The absence of a vessel may be associated with kidney
abnormalities such as the absence of a kidney
What is the normal length of an umbilical cord?
Normal cord length is about 40-70 cm
What is a true knot often associated?
How often are they found?
active fetal movements
1% of pregnancies
Result in fetal death in 6% of the pregnancies with a true knot
How do you examine the membranes?
Hold the placenta up by the cord and allow the
membranes to hang.
Examine:
- Complete / Incomplete
(ragged membranes are
incomplete)
- Lay the placenta down and tear the membranes.
Examine:
• 2 layers, amnion (fetal surface) and chorion (maternal surface)
• Vessels running through the membrane
How do you example the placenta?
- no missing parts on endges
- all vessels end smoothly on edge (if not this may indicate another part that has been left behind)
- Completeness – complete / incomplete
- Missing cotyledons
- Vessels finishing at edge of placenta or in membrane
– may indicate possible lobe left insitu - Infarcts
– Death of cotyledons/lobules
• Calcification
– White, gritty
• Other abnormalities such as tumours and nodules
Why might tissue be retained in the uterus?
What can these findings indicate? and what can be done about this?
- Incomplete separation
- Abnormal location of the placenta
- Abnormal placental implantation
- Abnormal placenta
Numerous common and uncommon findings of the
placenta, umbilical cord and membranes are associated
with abnormal fetal development and perinatal morbidity.
• The placenta should be submitted for pathologic
evaluation if an abnormality is detected or certain
indications are present
List 3 abnormal placental implantations
Placenta accreta
Placenta increta
Placenta percreta
Define placenta accreta.
Placenta implants onto the myometrium but does not penetrate the
muscle itself. This is the most common form of the condition and
accounts for around 75–78% of all cases of abnormal implantation.
Define placenta increta.
occurs when the placenta extends into the muscle of the uterine wall
and happens in around 17% of all cases.
Define placenta percreta.
the worst form of the condition and occurring in 5–7% of cases, is
when the placenta penetrates the entire uterine wall. This variant can
lead to the placenta attaching to other organs such as the bladder
Explain the placental abnormality succenturiate lobe
- Succenturiate lobe is a small portion or lobe of placenta
separated from the main body - Attached to the main placenta by blood vessels which cross
the intervening membrane, these vessels run from the edge of
the placenta.
Explain the placental abnormality circumvallate placenta
- The chorion is not attached to the edge of the placenta but to
the fetal surface at some distance from the edge - This condition can be associated with prematurity, prenatal
bleeding, abruption, multiparity and early fluid loss
Explain the placental abnormality: bipartite placenta
the placenta is divided into two lobes
Explain the placental abnormality: battledore placenta
Cord is attached to the margin of the placenta
Explain the placental abnormality: eccentric insertion
Cord is attached to one side (off centre) of the placenta
Explain the placental abnormality: velamentous insertion
- The vessels of the cord break up and run into the membranes before reaching the placenta.
- This can be very dangerous if the unprotected blood vessels
should lie near the internal os (condition is called vasa previa).
Explain the placental abnormality: infarcts
- Usually seen as white fibrous tissue, they may be seen
occasionally in any placenta but they are often associated
with pre eclampsia. - They are caused by localized death of placenta tissue due
to interference with the blood supply.
Explain the placental abnormality: calcification
- Seen as small grayish- white patches seen on the maternal
side of the placenta, these are deposits of lime salts. - Calcification is a sign of placental ageing. There can be
considerable calcification before there’s really any compromise
to the baby. - Women with hypertension or women who smoke generally
have calcified placenta’s.
Which stage of labour poses the highest risk of morality and morbidity for women and why?
the third stage due to PPH
- PPH is the leading cause of death in low income countries
What is normal blood loss after birth? and what is considered a PPH?
Normal blood loss after birth is less than 500ml over the first 24 hours, blood loss beyond that is referred to as postpartum haemorrhage or PPH.
What are the two forms of PPH?
Primary - occurring within the first 24 hours
Secondary - occurring beyond 24 hours and up to six weeks postpartum
What factors reduce a womans risk of a PPH?
- high income country dwelling (due to;)
- overall improved rate of maternal health
- lower rates of anemia
infectious diseases
What does oxytocin do in the third stage of labour?
if in sufficient amounts;
- results in uterine contractions
- the separation of the placenta from the uterine wall
- the birth of the placenta
- birth of membranes
- the control of uterine bleeding
What does oxytocin produced physiologically/naturally do?
compared to synthetic oxytocin?
enables;
- bonding
- breastfeeding
- postnatal recovery
- pain management
synthetic oxytocin may only deliver uterine contraction.
What factors increase a womans risk of a PPH?
- low-income nations
- induced labour
- operative birth
- past history of PPH
What is the role of the midwife in the third stage of labour?
- inform women of risks + benefits
- inform women of options when it comes to the management of the third stage of labour.
- facilitate informed decision making. The midwife is informed within a philosophy of promoting physiological labour and birth which is safest for the woman and the baby
- Midwifery practice aims to avoid interventions unless medically indicated, where potential benefits of such actions outweigh potential risks
- The management of the third stage of labour is a vital time for midwives to facilitate informed decision-making, as there are distinct options, with evidence-based risks and benefits, which should be presented to the woman.
- It is the role of the care recipient, after receiving all necessary information, to choose whether they wish to have this intervention or not
Why is it important to inspect the membranes and placenta?
As abnormalities may indicate retained products of conception or abnormalities of the preganacy that may indicate concerns for the neonate.
These can cause PPH, infection etc
What does RPOC
Retained produce of conception
What should be included in the examination fo the placenta and membrane?
Umbilical cord
length, insertion, thromboses, knots, and the presence of Wharton’s jelly
Vessels: 2 umbilical arteries and 1 umbilical vein (Remember: A-V-A = Ava) (Or 2 Arms 1 Vagina - iykyk)
Cord Insertion: Central, eccentric, battledore or velamentous
Membranes
Amnion (fetal surface) and Chorion (maternal surface)
Complete / Incomplete (ragged membranes are incomplete)
Vessels finishing at edge of placenta or in membrane; may indicate lobe left insitu
Placenta
Maternal surface; red, attached to decidua
Fetal surface; whitish, covered with amnion with insertion of cord, blood vessels visible
Complete/ incomplete placenta (missing cotyledons)
The presence of accessory lobes, placental infarcts, haemorrhage, tumours and nodules should be noted
Infarcts - Death of cotyledons/lobules that appear like white patches
Calcification (maternal side) that feels gritty
Explain the significance of burying the placenta in first national cultures.
Reasons are diverse
Some beliefs are
- considered dangerous to men so it is burried and not discussed when men are around.
- to others it is conisdered the baby’s soul map which must be burried for them to receive ancestor guidance when older
- other cultures it is believed the placenta should be buried inside or near a boab tree.
- some cultures believe it should be buried and covered in fire.
The view that the placenta is sacred and that placental rituals are important to the future wellbeing of the family is common.
Describe lotus birth
when the umbilical cord remains attached to the baby for 3 - 10 days, until the cord naturally dries up and detaches from the baby.
The placenta is wrapped in cloth and coated with salt and some lavender oil. This is to create a transition for the baby to slowly detach from the mothers body.
Describe the practice of eating the placenta
- this has been done for thousands of years.
- It is thought to play a significant role in celebrating the birth
- believed to help assist with the recovery of the woman as placenta is thought to be packed full of nutrition.
Describe the practice of placenta encapsulation
ingesting the placenta after it has been steamed, dehydrated, ground, and placed into capsules. Traditionally, this is taken by the mother and is believed to impart numerous health benefits, including assisting with avoiding postpartum depression.
Describe the practice of burying the placenta
Countless cultures around the world have ceremonially handled the placenta because to them, it is a pure symbol of spirit, life and individuality. For this reason, several cultures tend to bury the placenta instead of just disposing of it.
Describe the practice of burying the placenta in Maori culture
In Maori culture the placenta is placed in a prepared receptacle and buried in a particular location. This practice originates from the traditional cultural belief that the placenta should be retrieved after death to ensure physical integrity in the next life.
Why is it considered the birth of the mother and baby?
It is such as pivotal moment in ones life but spiritually, emotionally, physically, socially etc
We must respect this and
Describe some of the responsibilities of the midwife when caring for a women post birth
- Assess blood loss and inspect perineum
- Observations of woman
- Initial care and assessment of baby including APGARs
- Ensure comfort of the woman while maintaining skin to skin
- Support the first breast feed if breast feeding
- Examine placenta and membranes
- Tidy room and clean up body fluids
- Documentation
- Be aware of policies and protocols including OH&S
How often would a womens ‘observations’ be taken post birth? and what observations should be taken?
Every 15mins for the first hour
- maternal temp, HR, RR and BP
- palpate fundus and assess vaginal blood loss while doing this + check pad
(a big gush may indicate poor prevention of bleeding) - following the baseline observations, continue according to hospital guidelines and AS CLINICALLY NECCESSARY
What is the ok temperature range for a women in the first hour post birth?
36-73.5
What are some physical assessments on the women post-birth
Involution= uterus returning to non-pregnant state
- Immediately after childbirth, the uterus rapidly contracts & the fundus can be palpated midway between the umbilicus
and symphysis pubis
Fundus
- Well contracted (not boggy)
- Central (not to one side, this may be due to full bladder)
- Below or at the umbilicus (not above the umbilicus)
When can the fundus be palpated at which stages post birth?
At the end of the third stage: fundus central & ~ 2 cm below umbilicus.
Within 12 hours the fundus may be at the umbilicus or approximately 1 cm above the umbilicus
The fundus descends 1 to 2 cm every 24 hours
Immediately following birth, what are some crucial practices the midwife must complete?
assess blood loss
- measure clots in jug
- weigh pads (compare wet with dry pads)
- estimate loss on sheets
normal loss in vaginal brths is <500mls
After this period, vaginal loss is reffered to a lochia
What is lochia
blood that comes out after the birth of the baby. (kinda after the initial/immediate birth)
What occurs to initiate breathing for the baby
- compression of chest walls during birth recoils when the chest is no longer compressed
- chemoreceptors are stimulated by the reduced oxygen and increase in Co2 in the blood.
- sensory stimulation on skin causes resp effort- e.g. touch, pressure, cold (cold air across the face)
- stimulation of senses also initiate breathing. e.g. bright lights and noise
Describe the immediate care of a new born in the first 5 mins
- Note time / start Apgar clock
- Baby is placed on mothers chest, skin to skin this helps regulate;
- babys temp
- resp rate
- gets amniotic fluid on mothers chest which the baby will recognise and feel comfortable with. - Assist transition to extrauterine life (if this is delayed we can dry baby/tactile stimulation to attempt to initiate breathing.
- Assess transition to extrauterine life
– Is baby breathing or crying
– Is there tone (holding legs and arms + not floppy) - Call for more help if resuscitation is required
- If baby is in good condition leave skin to skin (everything we do can happen around skin to skin)
- Assess 1 minute Apgar score
- Keep warm
- Clamp cord 2-3cm from umbilicus
- Attach name bands to baby (must have mothers name)
- Assess 5 min Apgar score
What is the APGAR? who developed it? what does/when is it measure?
Developed by Virginia Apgar in 1950’s
- Assesses how the baby is adapting to extra-uterine life
- It does not act a cue to indicate the need for resuscitation.
- Baby assessed @ 1 & 5 minutes (& more if necessary)
How does we know a baby requires resus?
not with an APGAR
- if a baby is floppy, blue etc we could already know.
Remember that this does not act a cue to indicate the need
for resuscitation. This is a snapshot assessment of the
condition of the infant at the time
What are the 5 points in the AGAR assessment?
5 variables assessed – Appearance (colour) – Pulse (heart rate) – Grimace (response to stimuli) – Activity (muscle tone) – Respiratory effort
What is the most common APGAR score of 1 and 5 mins and why?
9 and 9
- usually a babys extremities wont perfuse until 24hrs post birth
What does an APGAR or 7-10 4-6 <3 mean?
Apgar score 7-10 = good condition
Apgar score 4 - 6 =moderate depression
Apgar score ≤3 = severe depression
What should the midwife do to assist in new born care?
Encourage breastfeed
o Skin to skin time
o teach bearst feeding and babys ques
- Temperature / heart rate / respirations
- Hourly for 4 hours, then if any clinical concerns four
hourly/AC
- Weight (average 3.5kg)
- Length (average 50 cm)
- Head circumference (average 35 cm)
- Initial newborn examination (visual)
o cleft pallet
- First bath (initial cleanse) - Usually the next day, promote
skin to skin and thermoregulation
o wait for baby to absorb vernex and natural flora
o recommend to dry in between any rolls and arm pits - Konakion (Vitamin K) and Hepatitis B IM injections
DOCUMENT all findings
When is the best time for a babys first feed and why?
Initial alert period for babies often followed by sleepy
period for up to 24 hours
Initial alert period for babies often followed by sleepy period for up to 24 hours
A baby will then likely go a long time (6hrs) before next feed
How can you assist a women to breastfeed and what are some recommendations?
- Builds mother’s confidence
– Gives baby the anti-infective benefits of colostrum immediately
– Colonises baby with maternal normal flora
– Stimulates baby’s gut
– May reduce B/F problems later
– Enhance the bonding between mother & baby
– May assist to imprint suckling action
What are the three key assessment
- Immediately post birth – attended by the midwife while in birth suite (attended by Dr if complicated birth)
Check for any anbormalities- celft pallet?
- abnormal genitalior?
- Daily examination – attended each day by the midwife to assess normal progress
- skin colour
- waking at normal intervals (2-4hrs)
- feeding at regular intervals (8-12 times in 24hrs)
- meconium poo
- Baby examination prior to discharge – attended by a Dr or accredited midwife prior to discharge
- confirm nromabity
- systematic approach and assess every part
- Confirm normality / detect deviations
- Systematic approach using
o auscultation, palpation & inspection
- Baby undressed
What needs to occur in a new born examination?
- Parents consent
- Wash hands + gloves
- Good lighting/ warm baby so we can see and so baby is warm
Equipment:
- ? Overhead heater
- scales
- tape measure
- Clothes, blankets, nappy & hat
- vital signs equipment
- bring in any equipment
List the components of a physical assessment?
Identification bands X 2
Vital Signs
– Temperature NR 36.5 -37.5 degrees Celsius
– HR 110 - 160 at birth, however reduces over time
– Respirations NR 30 - 60 rpm
– BP not done unless indicated in special care nursery (SCN)/neonatal intensive
care (NICU)
Weight - approximately 3.5kgs (3500 grams)
Length - approximately 50 cms
Head circumference - approximately 35cms
General observation of normality
Head to toe examination for normality (as per the following slide)
How much weight will a baby lose within 24-48 hours of birth?
On average 5-7 %
Beyond 10% loss of birth weight is abnormal and needs to be investigated.
What do you check for in a new born physical assessment?
Head – both fontanelles, Sutures all present, abnormalities such as squishy bruises, caput succedaneum or cephalhaematoma etc.
Face – note symmetry, skin rashes, pustules, peeling, eyes, ears hat are open and symmetrical, nose is patent,
mouth- lips and tongue not tied, complete pallet- soft and hard, not teeth that need referring
Neck – note skin colour, excessive folds, or abnormalities (skin tag)
Chest – note nipples, symmetry, respirations (any rib retracttion?), listen to heart
Abdomen – distended? umbilicus- any ooze?
Legs – note symmetry, count digits, talipes (turned in feet), hips- don’t click
Arms – note symmetry, count digits, hard creases (babies with down syndrome ten to only have 2 creases)
Back – note spine (straight?), dimples at the base of the spine, tufts of hair, Mongolian blue spot
Skin – abnormalities such as bruising or marks, dry skin, lanugo (hair), vernix
What is the rough shape of each fontanelle?
Anterior= triangle
Posterior- diamond
What is a regular temperature for a neonate?
Why is temp such an important vital sign for neonates?
Healthy neonate body temperature
o 36.5 -37.5 degrees Celsius
- Rapid change in environment at birth can cause extreme and life-threatening fluctuations.
- Babies don’t shiver reaction
- Non shivering thermogenesis (metabolism of brown fat)
- Heat generated from the metabolism of brown fat
- Sufficient stores of brown fat to last 2-4 days
- Cold stress leads to the metabolism of brown fat resulting in increased O2 demands and caloric consumption therefore can lead to hypoglycaemia & respiratory distress
SKIN TO SKIN COMBATS THIS HEAT LOSS
t’s important to keep baby warm!
What is the rough intrauterine temp?
37.5
What is a baby way of thermoregulation.
Non-shivering thermogenesis= metabolism of brown fat
- this increases oxygen demands
- increased calorie consumption
- this leads to hypoglycemic stress
- During pregnancy thermoregulatory processes are supressed in the fetus and must be activated once the baby is born
- Stimulation of cutaneous cold receptors, spinal cord and hypothalamic thermal receptors at birth activate the sympathetic nervous system
- This seads to increased metabolic rate, O2 consumption and heat production (thus maintaining temp)
- Clamping and cutting of the cord removes the placental factors that suppress non-shivering thermogenesis and
starts the metabolism of brown fat stores (assists in heat production)
How do babys lose heat? and at what rate?
Convection: drafts
Conduction: touch cold surfaces
Radiation: near cold surfaces
Evaporation: water loss from skin, resps, urine, faces
RAPIDLY
- approx 0.2-2 degree per minute
How do babys generate heat?
– Increased metabolic activity (having food in their tummy)
Babys can increase heir metabolic rate by up to 200-300% when they are trying to get warm.
– Non shivering thermogenesis: metabolism of brown fat
– Physical activity; crying, restlessness
SKIN to SKIN is most efficient
How and where do you take a babys temp?
Surface: axilla, skin (for head or under arm depending on thermometer)
Core: tympanic membrane
What is the normal HR of a neonate?
Normal 110-160 bpm
- Tachycardia HR >160/min
- Bradycardia HR <110/min
Palpate umbilical cord immediately following birth or Apex beat (auscultation using stethoscope)
- Document
What is the normal RR of a neonate?
Babies are nose breathers
- Normal rate – 30-60 rpm
- Irregular respirations
– 10 -15 secs. of apnoea within normal range
– Should not have nasal flare, grunting, or sternal/rib retraction
Ensure they have no signs of resp distress
To measuring baby’s respiration rate
– gain consent from mother
– Calm, expose chest & abdomen
– Listen & count for 1 minute
- Document
What is Pulse oximetry? and what does it measure?
Measures pre-ductal arterial oxygen saturation (blood
supplying major organs)
- Place sensor on the right hand or wrist in the immediate period (may use foot for long term Rx)
What is the target pre ductal SpO2 after birth?
Targeted pre-ductal SpO2 after birth 1 min 60 – 70% 2 mins 65 – 85% 3 mins 70 – 90% 4 mins 75 – 90% 5 mins 80 – 90% 10 mins 85 – 90%
- remember it takes 3 to 10 mins to get to 90% oxygenation
What check one resp related check must baby have before going home?
an O2 sat
+ 95%
What chart do we document neonatal findings on in vic?
Victor chart
What is vernix? and what is its role?
- help baby transition to extrauterine life
- absorbs into babies skin over first few hours of life
- cheese, white substance that has not smell
- coats whole baby while inutero
What is lanugo?
Small/fine hair that covers baby
- to keep warm and assist with the transition to extra uterine life.
Define molding? how long doe sit take to return to normal?
When the sutures allow for bones to cross over each other during birth to ensure the babys head is small and shaped well enough to get though the birth canal.
- The head shape usually returns to normal after 24hrs
Define and describe caput succedaneum? how does it occur?
- Localised soft tissue oedema with poorly defined outline
Cause: pressure of head
against cervix. Potentially if the baby was crowning or on cervix for a longer period of time e.g. prolonged 2nd stage
- Present at birth
- Does not increase in size
- Swelling crosses suture lines
- Disappears after birth within hours to a few days
- Complications rare
Define and describe caput cephalhematoma? how does it occur? What can it be associated with?
Soft, fluctuant, localised swelling with clearly defined outline
• Caused by subperiosteal
haemorrhage
• Appears after birth
• Increases in size for 2-3 days
• Swelling does not cross suture lines
• Disappears from several weeks to even months after birth
• Associated complications include; clotting disorders, skull fracture, intercranial bleeding, jaundice
Describe the differences between caput succedaneum and a cephalhematoma and how they can be identified?
Caput is swelling that does not have a defined edge where as cephalhematoma does.
Caput can cross mid line of skull and is big bit of swelling
Cephalhematoma is in periosteum and so it is contained between suture lines and fontanelles.
Describe facial brusing and why it can be confused with poor oxygenation.
Occurs due to trauma in the birth canal.
It can often be confused with poor oxygenations, however if you
- expose baby and look at its chest
- look if extremities are perfused and are pink
you can assume that it is facial brusing.
A new born has circular lines on its cheeks. What is the likely cause of these?
forceps from birth
What is normal and abnoral to see in an umbilical cord stub as it dry and falls off.
Normal
- little bit of blood
- dryness
- white after it has fallen off
Abnormal
- puss
- redness
- odour
What is a Mongolian blue spot?
Patch of blue-black colour
distributed over sacral regions
tends to go away
Infants of African or
Asian descent.
Note and explain to parents what it is to ensure they don’t become concerned
What process should you follow when giving medications after birth?
Gain informed consent from parents (therefore you need to inform parents prior to asking consent)
Document decision either way
- medication chart / Birthing Outcomes System BOS
- Child heath record
- pathway
what 2 immunisations are offered to new borns in Vic?
Vit K
Hep B
What is Vit K and why is it offered? Do these levels change? and what can be done about this?
New borns have reduced levels vitamin K dependant clotting factors.
This is due to;
- poor transport of Vit K by the placenta
- lack of intestinal colonisation by bacteria that normally synthesise Vit K
Colostrum is very high in Vit K (this may be bodys natural way of solving this problem)
- The low levels decrease even more in the first few days after birth as the Vitamin K they acquire from the mother is metabolised quickly
- Because low Vitamin K levels can lead to a bleeding tendency in some babies, prophylactic Konakion (Vitamin K) is recommended
e. g. Cephalhematoma
What is vitamin K Deficiency Bleeding (VKDB)
- AlKA haemorrhagic disease of the newborn
- Involves bleeding from the gastrointestinal tract, the cord, puncture sites
- Although most newborns do not need Vit K at birth,
Vitamin K Deficiency Bleeding often occurs in newborns with no specific risk factors - Risk factors include bruising (from an instrumental birth)
and prematurity are at higher risk
Explain the provision of Vit K including the dose.
Konakion (Vitamin K)
- 1mg IMI x 1 OR 2mg oral x 3
- Prophylaxis recommended in Australia
- Document medication chart / child health record /
pathway - IMI are given to newborns in their thigh muscle
- given with 25 gauge
Explain the use of hepatitis B.
Used to prevent Hepatitis B
- is an infection of the liver and is contracted by coming in contact with an infected persons bodily fluids
- People with hepatitis B may not appear sick, and if they are infected they can often recover from the infection.
However, some people (particularly children) may have no symptoms but carry the virus in their blood and are infectious to others (and they can become sick much later
in life)
- The vaccine works by causing the body to produce its own protection by making antibodies against hep B
Explain the Hep B shot given in Aus including the dose.
Hepatitis B Vaccine
- Universal program Australia commenced the year 2000
Paediatric dose 0.5 ml IM
- If mother a carrier then the infant will require Hepatitis B
immunoglobulin (HBIG) in addition - Birth dose preferably within 24 hours
- followed by primary course of combined
immunisations- exceptions are babies <32 weeks/2000g
Document on medication chart / child health record /
consent form / pathway
Need three doses to be fully immunised
List some key parts of documentation for birth.
During labour;
- take contemporary notes via the partogram / progress notes
e. g. liquor, VE, stations
Meds in medication chart
- Computer – BOS (birthing outcome systems)
Birth notification to local council
Birth register
- says this is a legal and official documentation
- access for birth certificate
- Registration/Centrelink documentation (for the woman)
Postnatal maternal pathway
- feeding output
- bleeding
- fetal bowels
- emotional wellbeing
Neonatal pathway
o ? Medications
o Victor chart
o Green book
List some universal precaution that are carried out during birth
Asepsis – sterile packs
- suturing
- catheterisation
- injections
Hand washing / alcohol hand rinse
- at the 5 moments
- Sterile Gloves / clean gloves
- Aprons / sterile gowns
- Goggles
- Appropriate disposal
- drapes / sheets into linen skip, may need to be inside plastic bag (so cleaners know how heavy the contents will be)
Disposal rubbish
- clean – white/black bag
- contaminated – yellow bag
- Sharps container
- Pathology specimens
What helps the uterus to contract post birth?
- breast feeding
- skin on skin
What can be done if there is concerns that the uterus is not contracted and PPH is at risk?
If there is concern regarding the contraction of the uterus a contraction can be induced by a “fundal rub” (or “fundal massage”) where a midwife or obstetrician presses down onto the fundus.
Alternatively, if there is an excess of bleeding (PPH) a uterotonic drug may be required.
What are some key practice points post birth to increase maternal emotional wellbeing?
- Congratulate the woman!
- Reassure the woman that she and the baby are well
- Keep the woman and baby together - skin to skin - for as long as possible
- Encourage and facilitate involvement of the other parent of family members
- Many women commence shivering immediately after birth, so it is important to keep her warm e.g. giving her a pre-warmed blanket
- Wrap both woman and baby in the blanket
- Encourage and support the woman to breast feed.
- Allow the woman and baby to bond - this is quiet time following birth to facilitate the rapid process of attachment for parents and baby Offer food and fluids
- Assist the woman with her first shower and void (although in some cultures showers are not taken for some days post-birth, therefore ask the woman what she would like)
- When the woman is stable, transfer to the postnatal ward (If she is in hospital)
How does the babys respiratory system adjust to extrauterine life.
- the fetus practices breathing movements within its thorax while in-utero.
- the first breath requires most effort as it has to push out left over fluid.
- surfactant in the alveoli reduces surface tension allowing the alveoli to remain open.
- Whilst establishing breathing, the baby experiences periodic respirations, this is normal.
Prior to birth the lungs are full of fluid however as the fetus passes though the pelvis some of this is squeezed out of the alveoli from the compression of the chest wall.
Why is the first breath the one that requires the most energy and what stimulates it?
because of the effects of intra-alveolar fluid.
Subsequent breaths are easier due to the tension-easing effects of surfactant (a phospholipid substance produced in adequate amounts the last trimester).
Stimuli thought to play a part in initiating breathing are:
- Compression of the chest wall during birth followed by the recoil immediately following
- Chemoreceptor stimulation due to the reduction in oxygen (the hypoxic state a fetus is in from labour) and the increase in carbon dioxide (hypercapnoea) in the blood which stimulate the respiratory centre in the brain.
- Sensory stimulation on the skin such as touch, pressure, cold air
- Stimulation of the senses generally; light & noise
What is a normal resp rate of a new born?
Once established, the respiratory rate of a newborn is 40-60 breaths per minute.
What events causes a baby to have lower brown fat stores?
long labour
What effect does skin on skin have on the mother when the baby is cold?
She will elevate her basal metabolic rate in order to produce heat to warm the baby. This will bring the baby rapidly to its desired temperature and then her BMR will slow. This demonstrates yet another aspect of the symbiosis of the mother-infant interaction.
Define milia
Distended sebaceous glands often seen over the nose.
Define erythema toxicum
White papules on erythematous base.
Occurs in 50% of newborns and no treatment is required.
white little pimples
Define Acrocyanosis
Peripheral cyanosis of the hands and feet. Common in the first 24 hours after birth.
Please note: central cyanosis is not normal and requires immediate attention
