Week 9 Flashcards
what are the initial steps in the management of a neonate?
• 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
what are the benefit of skin to skin contact for the neonate?
- 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
what are the 9 instinctive neonatal behavioural changes?
Birth cry Relaxation Awakening Activity Crawling Resting Familiarisation Sucking Sleeping
What is the result of the 9 neonatal behavioural changes?
- decrease circulating cortisol levels
- increased oxytocin levels
resulting in calmer baby
relaxed mother
increased successful breastfeeding
What are the steps to cutting the cord?
- 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
What does the APGAR Score stand for?
Appearance (colour) Pulse (HR) Grimace Activity (muscle tone) Respiration
when is the apgar score assessed?
1 and 5 minutes
repeated every 5 mins until >7
what are the categories of appearance on the apgar table?
0 = cyanosed 1 = partially pink 2 = pink
what are the categories of Pulse on the apgar table?
0 = absent 1 = <100 2 = >100
Assessed suing stethoscope
what are the categories of Grimace on the apgar table?
0 = no response 1 = Some response 2 = crying
what are the categories of Activity (muscle tone) on the apgar table?
0 = Limp 1 = Some flexion 2 = Flexed arms and legs that resist extension
what are the categories of Respiratory effort on the apgar table?
0 = apnoea 1 = all other types of respiratory effort 2 = breathing and crying lustily
what does the apgar score do?
- 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
Define the third stage of labour?
- 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
WHat are the details of the placenta?
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)
What are the placental membranes?
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
what is the umbillical cord?
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
What is the physiological process occuring in the third phase of pregnancy?
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
What is the phsyiological process to control bleeding in the third phase of pregnancy?
- 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
what are the signs of imminent 3rd stage pregnancy?
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
what is the physiological management of the third stage of pregnancy?
- 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
what is the active management of the third stage of pregnancy?
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
What is the result of early cord clamping
Prevents transfer of blood to baby
Placenta does not reduce so much in size
Delayed separation
Active management of 3rd stage committed
What is the result of delayed cord clamping
Increased risk to babies iso-immunised or at risk of polycythaemia
May assist establishment of pulmonary circulation
Improves iron reserves in the preterm
What is the pre-hospital management for phsyiological management of third stage of pregnancy?
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
What do you do after the delivery of the placenta?
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
What are the pre-hospital management steps after delivery of the placenta?
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
What is placenta accreta?
– 75 % of abnormal implantation into muscle
– Placenta attached onto the myometrium but does not penetrate the muscle itself.
What is placenta increta
– 17% of abnormal implantation into muscle
– Extends into the muscle itself
what is Placenta percreta
– 5% of abnormal implantation into muscle
– Penetrates the entire muscle wall & other organs
what is a succenturiate lobe?
where a small portion or lobe of placenta separated from the main body
what is circumvallate placenta?
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
What is bipartite placenta?
divided into lobes
what are the risks of a long umbilical cord?
Risk of foetal entanglement & cord knots.
risk of prolapse of the cord
what are the risks of a short umbilical cord?
prolonged second stage, cord rupture, uterine inversion & a difficult delivery.
Can be associated Down syndrome, fetal malformation and malpresentation
Define post partum haemorrhage?
Blood loss of > 500mls from the birth canal from the end of second stage (neonatal delivery) to 24 hours post birth
What are some risk factors for PPH?
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
What are the 4 causes of PPH (4T’s)?
Thrombin Tissue Tone Trauma Other
What are the general signs of PPH
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)
What is the pre-hospital management for PPH?
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;
WHat is the cornerstone of mamagement with PPH?
PIPER/MICA/Consult Reducing anxiety –> Rest & Reassure woman & partner Restoring fluid volume & Oxygen capacity of blood –> IV therapy & Oxygen Find & treat cause(s) –> 4 “T’s” –> Other
What is the pre-hospital management for PPH caused by Tone
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
WHat do you do if fundal massage unsuccessful?
External aortic compression
What is the pre-hospital management for PPH caused by Tissue & trauma
Deliver placenta if still insitu– –Active management • Signsof separation & descent • Using controlled cord traction • Service dependent
If placenta delivered
– Check placenta & membranes complete
– Retained placenta/tissue?
? Genital tract tears
–Direct pressure
WHat is the management for PPH caused by tissue and trauma?
- 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)
What is the pre-hospital management for PPH caused by Thrombin
<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
What is the last resort for managing a PPH if all else fails?
Aortic Occlusion –Last Resort
If all else fails:
Rarely used in hospital but may be in pre-hospital
Reduces blood flow to uterus
What is disseminated intravascular coagulation (DIC)?
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
What is a secondary PPH?
Abnormal bleeding from 24 hours to 6 weeks post delivery (>500ml)
Most common 7-14 days post partum
What are the main causes of secondary PPH?
Infection
Retained products of conception (placenta)
What are some risk factors for secondary PPH?
- endometriosis
- retained products of conception
- Lower genital tract trauma
- placental abnormalities
- uterine abnormalities
- choriocarcinoma
- C-section wound injury
- Bleeding disorders
What is normal blood loss in pregnancy?
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
What is the paramedic management of secondary PPH
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
