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PAR3031 - MATERNITY > Week 9 > Flashcards

Week 9 Flashcards

1
Q

what are the initial steps in the management of a neonate?

A

• Skin to skin straight after delivery
• Tum to tum –Neonate tummy to mums tummy
->allows for drainage of respiratory tract mucous
•Warm environment >25 degrees
•Warm towel –vigorous drying/wiping/stimulating of neonate while on mums tummy (usually for 1 minute)
•Allow neonate to take first big breath and cry
•Once dry –cover with warm towel (keep skin to skin)
•Hat on (in maternity kit) –keep warm

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2
Q

what are the benefit of skin to skin contact for the neonate?

A
  • improves mother child interaction at borth
  • decreases infant crying and calms breathing
  • improves neonatal temp, HR & Respiratory stability
  • Improves success and duration of breastfeeding
  • Increases neonatal blood glucose levels
  • Skin bacteria passed from mother to baby to help develop healthy skin flora and immune system
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3
Q

what are the 9 instinctive neonatal behavioural changes?

A 
Birth cry
Relaxation
Awakening
Activity
Crawling
Resting
Familiarisation
Sucking
Sleeping
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4
Q

What is the result of the 9 neonatal behavioural changes?

A
  • decrease circulating cortisol levels
  • increased oxytocin levels

resulting in calmer baby
relaxed mother
increased successful breastfeeding

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5
Q

What are the steps to cutting the cord?

A
  • If cord is wrapped tightly around neck and unable to loosen to loop over head then cut
  • If cord is loosely wrapped around neck during delivery then loop out and over
  • Once neonate delivered allow cord to stop pulsating
  • Mother may want cord attached (contact PIPER for advice)
  • Cord will stop pulsating about 1-2 minutes post delivery
  • No rush to clamp and cut!!
  • Using the clamps in the maternity pack: 1stclamp about 10cm from neonate and 2ndclamp 5 cm some that. Cut in between the 2 clamps.
  • Allow mothers partner to cut the cord (if they want) –scissors in the maternity pack
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6
Q

What does the APGAR Score stand for?

A 
Appearance (colour)
Pulse (HR)
Grimace
Activity (muscle tone)
Respiration
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7
Q

when is the apgar score assessed?

A

1 and 5 minutes

repeated every 5 mins until >7

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8
Q

what are the categories of appearance on the apgar table?

A 
0 = cyanosed
1 = partially pink
2 = pink
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9
Q

what are the categories of Pulse on the apgar table?

A 
0 = absent
1 = <100
2 = >100

Assessed suing stethoscope

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10
Q

what are the categories of Grimace on the apgar table?

A 
0 = no response
1 = Some response
2 = crying
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11
Q

what are the categories of Activity (muscle tone) on the apgar table?

A 
0 = Limp
1 = Some flexion
2 = Flexed arms and legs that resist extension
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12
Q

what are the categories of Respiratory effort on the apgar table?

A 
0 = apnoea
1 = all other types of respiratory effort
2 = breathing and crying lustily
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13
Q

what does the apgar score do?

A
  • Provides a retrospective summary of how the baby is transitioning to extra-uterine life
  • 5 minute score provides some value as a predictor of future morbidity and mortality
  • No value in immediate resuscitation decision making
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14
Q

Define the third stage of labour?

A
  • Interval from birth of baby until complete expulsion of the placenta and membranes
  • Can be anytime from 5 minutes post birth to 1 hour post birth
  • <30 mins is ideal
  • > 30 mins considered prolonged
  • Placenta begins separating with the contractions that ultimately deliver the neonate
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15
Q

WHat are the details of the placenta?

A

 Flattened discoid organ –continuous with chorion

 Maternal surface –red –attached to decidua

 Fetal surface –whitish -covered amnion with insertion of cord –blood vessels visible

 Embeds into the endometrium during pregnancy

 Supplies the foetus while in utero (nutrients, waste removal, oxygen etc)

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16
Q

What are the placental membranes?

A

 Amnion –foetal surface–produces prostaglandins–amniotic fluid

 Chorion –maternal surface –produces enzymes, prostaglandins, oxytocin and platelet-activating factor

 Grow to 28 weeks then stretch

 Contain amniotic fluid –up to 200ml

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17
Q

what is the umbillical cord?

A

 Attached to placental fetal surface

 2 umbilical arteries (deoxygenated away from foetus)

 1 umbilical vein (oxygenated blood towards foetus)
– Vessels longer than cord –loops –false knots

 Wharton’s jelly -mucoid connective tissue
 Normal length: 30-90cm

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18
Q

What is the physiological process occuring in the third phase of pregnancy?

A

 As baby born uterus retracts becoming smaller-Reducing size of placental site-Uterine volume reduces

 Contraction and retraction continues

 Placenta separates from decidua basalis

 Some blood forced into baby -if cord unclamped

 Placenta strips membranes of the wall of the uterus

 Placenta and membranes fall into the vagina ready for expulsion

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19
Q

What is the phsyiological process to control bleeding in the third phase of pregnancy?

A
  • Contraction of oblique muscle fibres surrounding blood vessels
    –> sealing off ends of maternal vessels
  • Further contractions causes opposing uterine wall to thicken
    –> exerts pressure on placental site
  • Activation of coagulation & fibrinolytic systems
    –> Transitory but intensifies clot formation
    Physiology -Control of Bleeding
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20
Q

what are the signs of imminent 3rd stage pregnancy?

A

 Lengthening of the umbilical cord
 Gush (or trickle) of blood (30-60ml)
 Contraction/slight need to push (may or may not occur)
 Rising fundus
 Ballotable –firm ball type feel on palpation of uterus

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21
Q

what is the physiological management of the third stage of pregnancy?

A
  • Hands off” and non invasive method
  • Delivered by mums effort -placenta and membranes separate and delivery naturally without intervention
  • Physiological management of third stage can be changed to active management if a problem arises
  • In physiological third stage the uterus should not be externally stimulated by “fundal fiddling”
    –> may stimulate partial separation of the placenta.
    –> Can be difficult in pre-hospital context to check for bleeding

-May lead to heavier blood loss than active

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22
Q

what is the active management of the third stage of pregnancy?

A

 Not commonly practiced pre-hospitally
 Thought to reduce risk of PPH from 15% down to 5%
 Once commenced, active management can not be changed to physiological management
 Use of uterotonic drugs
 Elevating the fundus with a hand and simultaneously providing traction
 Controlled cord traction with mums contractions (effectively almost pulling the placenta out)
 We do not do this in AV

23
Q

What is the result of early cord clamping

A

 Prevents transfer of blood to baby
 Placenta does not reduce so much in size
 Delayed separation
 Active management of 3rd stage committed

24
Q

What is the result of delayed cord clamping

A

 Increased risk to babies iso-immunised or at risk of polycythaemia
 May assist establishment of pulmonary circulation
 Improves iron reserves in the preterm

25
Q

What is the pre-hospital management for phsyiological management of third stage of pregnancy?

A 
 May take 5 –60mins
 Clamp cord after pulsation ceases
 Placenta expelled by Maternal effort
–> Maternal positioning -? Utilize gravity
• e.g squatting or sitting
–> Initiation of breastfeeding
•release oxytocins
 Support Placenta as it delivers –may require a see-saw type manouevre to deliver (do not pull)
 Ensure uterus well contracted
–> Gentle palpation of fundus (avoid excessive touching)
–> Monitor PV bleeding –if increased
•Consider active management
26
Q

What do you do after the delivery of the placenta?

A

Immediately after delivery of the placenta

  • massage the fundus of the uterus through the woman’s abdomen until contracted

•Palpate for a contracted uterus every 15/60 &
-> repeat uterine massage for first 2 hours

• Ensure that the uterus does not relax after uterine massage

27
Q

What are the pre-hospital management steps after delivery of the placenta?

A

 Assess uterus contracted but don’t over handle
–> Beware of “fundal fiddling”

 Gentle visual inspection of genital tract –
–> Apply direct pressure to any tears

 Encourage passing urine before transport

 Encourage breastfeeding

 Transport all blood stained material & products in biohazard bag
–> Inspect placenta & membranes if desired

28
Q

What is placenta accreta?

A

– 75 % of abnormal implantation into muscle

– Placenta attached onto the myometrium but does not penetrate the muscle itself.

29
Q

What is placenta increta

A

– 17% of abnormal implantation into muscle

– Extends into the muscle itself

30
Q

what is Placenta percreta

A

– 5% of abnormal implantation into muscle

– Penetrates the entire muscle wall & other organs

31
Q

what is a succenturiate lobe?

A

where a small portion or lobe of placenta separated from the main body

32
Q

what is circumvallate placenta?

A

 The chorion is not attached to the edge of the placenta but to the fetal surface at some distance from the edge.
 Associated with prematurity, prenatal bleeding, abruption, multiparity & early fluid loss

33
Q

What is bipartite placenta?

A

divided into lobes

34
Q

what are the risks of a long umbilical cord?

A

 Risk of foetal entanglement & cord knots.

 risk of prolapse of the cord

35
Q

what are the risks of a short umbilical cord?

A

 prolonged second stage, cord rupture, uterine inversion & a difficult delivery.
 Can be associated Down syndrome, fetal malformation and malpresentation

36
Q

Define post partum haemorrhage?

A

 Blood loss of > 500mls from the birth canal from the end of second stage (neonatal delivery) to 24 hours post birth

37
Q

What are some risk factors for PPH?

A 
Large Baby
Polyhydramnious
Multiparity
Multiple gestation
Retained 3rdstage
Precipitate labour
Difficult labour
Prolonged labour
Full bladder
Infection –PROM
APH
Preeclampisa; HELLP
Drugs e.g.
–>MgSO4; nifidipine;
Operative delivery
–> Forceps; Vacum
38
Q

What are the 4 causes of PPH (4T’s)?

A 
Thrombin
Tissue
Tone
Trauma
Other
39
Q

What are the general signs of PPH

A

Often asymptomatic initially but:
 Enlarged uterus that feels “boggy”
+/-Visible bleeding
–>?uterus or ? tears or ? both
Restlessness; Pallor
Tachycardia or increase in HR by 20bpm
Hypotension or drop in systolic by 20mmHg
Vital signs not reflective of blood loss
Maternal collapse -late sign (compensate well)

40
Q

What is the pre-hospital management for PPH?

A

 Position –Autoinfuse if uterus is contracted but
–> Blood may pool in uterus -excerbating condition
• Elevate feet on pillows but keep pelvis flat

 Monitor 5/60
–> Fundus; vital signs; conscious state & blood loss

 X 2 14G -16G cannula
–> IV therapy –Crystalloids initially
–> N/Saline/ Hartmanns -infuse rapidly

Notify & transport to nearest obstetric facility;

41
Q

WHat is the cornerstone of mamagement with PPH?

A 
PIPER/MICA/Consult
Reducing anxiety
–> Rest &amp; Reassure woman &amp; partner
Restoring fluid volume &amp; Oxygen capacity of blood
–> IV therapy &amp; Oxygen
Find &amp; treat cause(s)
–> 4 “T’s”
–> Other
42
Q

What is the pre-hospital management for PPH caused by Tone

A

 Check uterus contracted if not
–> Apply gentle fundal massage
•Use cupped hand
•Apply circular motion

 Encourage mother to empty bladder –Up to toilet

 Encourage baby to suckle breast
–> Releases Oxytocin

Beware massaging a contracted uterus
–Can cause atony

 Give uterotonic drugs
– Misoprostol 800mg Oral
– Syntonion10iu IM
– *Varies by service
– Repeat after 5 minutes if bleeding continues

Check for second twin
–Before administration
–Confirm antenatal care & one baby on U/sound
•If not consult

43
Q

WHat do you do if fundal massage unsuccessful?

A

External aortic compression

44
Q

What is the pre-hospital management for PPH caused by Tissue & trauma

A 
 Deliver placenta if still insitu–
–Active management
• Signsof separation &amp; descent
• Using controlled cord traction
• Service dependent

 If placenta delivered
– Check placenta & membranes complete
– Retained placenta/tissue?

 ? Genital tract tears
–Direct pressure

45
Q

WHat is the management for PPH caused by tissue and trauma?

A
  • PIPER
  • Rest and Reassurance
  • Explain to mum what’s happening
  • Visual inspection of vagina and perineum for tears/trauma
  • Normal trauma management to stem bleeding-pressure-dressings
  • Pain relief
  • IV –fluids (service dependent)
46
Q

What is the pre-hospital management for PPH caused by Thrombin

A

 <1% of all PPH
 Load and go
 Caused by clotting disorders
– Disseminated Intravascular dissemination
•Prolonged prothrombin time; activated partial thromboplastin & thrombin time

– Thrombocytopenia
•Platelets are consumed

47
Q

What is the last resort for managing a PPH if all else fails?

A

Aortic Occlusion –Last Resort

 If all else fails:
 Rarely used in hospital but may be in pre-hospital
 Reduces blood flow to uterus

48
Q

What is disseminated intravascular coagulation (DIC)?

A

 Abnormal stimulation of the clotting mechanism
– Causes excessive clotting -leadsto Ischemia
– At the same time there’s excessive bleeding (a paradoxical reaction)

 Complication of pre-exisitingproblem:
–missed abortion, abruptio placentae; amniotic fluid embolus; severe pre-eclampsia, haemorrhage & foetal death in utero

49
Q

What is a secondary PPH?

A

 Abnormal bleeding from 24 hours to 6 weeks post delivery (>500ml)

 Most common 7-14 days post partum

50
Q

What are the main causes of secondary PPH?

A

 Infection

 Retained products of conception (placenta)

51
Q

What are some risk factors for secondary PPH?

A
  • endometriosis
  • retained products of conception
  • Lower genital tract trauma
  • placental abnormalities
  • uterine abnormalities
  • choriocarcinoma
  • C-section wound injury
  • Bleeding disorders
52
Q

What is normal blood loss in pregnancy?

A

Small amounts of loss (not excessive –no specific amount)
Lochia Rubra
•1-3 days
•red blood loss

Lochia Serosa
•4-10 days
•Lighter red to brown loss

Lochia Alba
•11-21 days
•Light brown to clear

53
Q

What is the paramedic management of secondary PPH

A

 History
–Days postpartum; placenta complete; ?offensive lochia;

Rest & Reassure

Pain relief –where required

Oxygen -where required

Vital signs
–Especially HR; BP and temp –may be retained placenta leading to infection

Monitor ABC’s & blood loss

IV therapy –Normal Saline
–Administer fluids (service dependent)

Stop bleeding if able
–If fundus palpable –fundal massage
–If fundus not palpable –misoprostol (service dependent); stimulate nipple; syntocin(service dependent)
–? Laceration site breakdown
•Direct pressure

Analgesia if required
Nil orally until hospital to find cause
Transport & Notify hospital

PAR3031 - MATERNITY (11 decks)

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