1
Q
What is itTPROM?
A
- term rupture of membranes prior to onset of regular uterine contractions
2
Q
Why does PROM happen?
A
- Etiology not well understood; result of normal pregnancy.
- Maybe be programmed weakening of membranes prior to labour, due to decrease collagen content
- Prostaglandins in amniotic fluid may also help body prepare for labour - i.e. cervical ripening
3
Q
Factors that may contribute to PROM?
A
- Infection, uterine stretching (ex: polyhydramnios, multip), cervical exams, cervical sweeps, low levels of fatty acids, vitamins C and E given together, environmental exposures (extreme weather, air pollution)
- Hx of PROM is strong predictor to PROM in subsequent pregnancies
4
Q
Target population of PROM?
A
- Occurs in 8-10% of term pregnancies
- 60-80% of those that experience PROM will go into spontaneous labour within 24hours
- SOGC indicates 55% within 24h, 95% within 72 hours
5
Q
Signs and Symptoms of PROM?
A
- Feeling internal pop followed by gush of fluid with continuous leaking
- Small amount of fluid loss may be harder to dx
- Ask clients: time of suspected rupture, colour, smell, amount of fluid, continuous leak, fetal movement
- Sterile spec exam: to observe pooling, fluid from cervix
- Nitrazine test: to confirm PROM by detecting alterations in vaginal pH levels
- Inaccurate if sexual intercourse in previous 24hours
- Ferning: smearing amniotic fluid on slide, observe under microscope for characteristic ferning pattern
6
Q
Prolonged PROM
A
- PROM > 18 hours prior to delivery
- Associated with chorioamniotitis, neonatal sepsis
- Clear documentation of time of rupture helps inform clinical decision making, reducing likelihood of introducing potential infection
7
Q
What is Prolonged ROM?
A
- Prolonged ROM with duration >18 hours prior to delivery
8
Q
Complications of prolonged ROM?
A
- Neonatal sepsis, EOGBS, maternal infection, chorioamnionitis, perineal infection
9
Q
Special mgmt of Prolonged ROM?
A
Maternal temp if greater than 18 hours
EFM for ROM greater than 24 hours?
10
Q
Expectant management for Term PROM GBS -
A
- In absence of risk factors, safe option
- Benefits: aligns with client values
- Risks: slight increased chance of infection (increased chance with increased number of VEs)
- Criteria: abn findings may change expectant to IOL
- Mec stained fluid; bad smelling fluid, active vag bleeding, fever >38, decreased FM
- Risk factors: VEs should be avoided until active labour or IOL;
- Frequent VEs, mec stained fluid, nullip, GBS pos status, active labour >6hours and no onset of labour after PROM >24hours
- Risk fx to NB: chorioamnionitis, GBS pos, frequent VEs, PROM >24 horus
- Timelines:
- up to 96 hours (AOM) of expectant management when GBS neg, no complications, no risk factors, no s/sx infection
- Monitoring:
- Client to inform care provider if risk fx present during PROM
- Daily in-person assessment to monitor VS, FHR, FM, fluid, wellbeing, IA
- Postpartum care: standard if NB appears well, client GBS neg
11
Q
IOL for term prom?
A
- Benefits: shorter onset of labour after PROM, reduced risk of infection, shorter hospital stay, less need for NB antibiotics, less risk for NB to go to NICU
- Risks: uterine tachysystole, may lead to cascade of interventions
12
Q
Term PROM for GBS pos?
A
- 15-40% of pregnant ppl are GBS pos
- 40-70% of babies born to GBS pos birther will be colonized if untreated
- 1-2% of colonized NB will develop infection if untreated
- 5% of NB who develop infection will die
- AOM: Offer choice b/w expectant management and immediate IOL if PROM <18h + no risk fx
If expectant management, offer:
- IAP in active labour
- IAP in latent phase
- IAP upon initiation of IOL
- AOM: Recommend IOL with oxytocin if PROM >18hrs - IAP should be offered upon initiation of IOL
- SOGC: recommend IOL for term clients :withi 24hrs of PROM to reduce NICU admins and maternal infection
- Expectant management has been linked to increase CS rates and prolong mat hospitalization
13
Q
Fx that contribute to onset of spontaneous labour
A
It is believed that the onset of spontaneous labour is initiated by the fetus -> cascade of positive feedback loops
14
Q
Fetus contributing to onset of labour?
A
- Hormones: Cortisol produced by fetal adrenal glands ->cervical ripening; DHEAS produced by placenta-> activates uterine activity
15
Q
Birther contributing to onset of labour?
A
- Hormones:
- cortisol-> reduces effects of progesterone
- progesterone-> low levels promote high estrogen
- estrogen-> cervical ripening+uterine activity
- prostaglandins->cervical ripening+contractions+oxytocin release
- oxytocin-> promotes onset spontaneous labour + cervical changes
- Inflammation-> membrane rupture; cervical ripening + contractions
- Corticotropin releasing hormone-> uterine activity + formation prostaglandins+inflammation
- Mechanical fx:
- Uterine ctx-> effacements+ dilation
16
Q
Physiological changes in early labour?
A
- Regular ctx with increasing intensity, duration, frequency - but may be disorganized and irregular for some
- Ctx ranging from mild to mod intensity, 15-20s to 30-40s, 10-20 min to 5-7 min
- Cause effacing, dilation up to 4 cm
- Descent of presenting part on cx
- Associated with easier lung expansion and increased stomach capacity for birther + increased urinary frequency
- May reduce observable fundal height
- Cervical changes -> bloody show, mucus plug expulsion
17
Q
What is Prolonged early labour?
A
- Latent phase lasting over 14 hours in multip/20h in nullip
18
Q
What is Prolonged early labour caused by?
A
- Unfavourable cx
- OP presentation
- Transverse lie
- Large baby
19
Q
Risks of prolonged early labour?
A
- Exhaustion
- Dehydration
20
Q
What is Prelabour/prodomal labour?
A
- Ctx do not cause significant cx changes
- Ctx change with activity, position, time of day; do not build in intensity; irregular pattern; can be intense/painful; may becoming challenging to cope with
21
Q
What does Early labour look like?
A
- Cx effacement
- Cx dilation 4-6cm
- Regular ctx which increase in frequency and intensity, do not dissipate
- Bloody show
- Variable length - several hours to > 24 hours
- Variability in client experience, perception, coping
- Biochemical changes: increased production of oxytocin, prostaglandins, other hormones
22
Q
What is involved in early labour assesment?
A
- Ctx frequency, strength, length
- Abdo palpation for fetal position
- Maternal VS
- FHR
- VE (dilation, station, membrane status)
- Maternal response to labour, including coping, fluid input/output
23
Q
- Non-pharmacological early labour support?
A
- Continuous support person
- Staying home; music; relaxed breathing; massage; counter pressure; TENS
- Use of water
- Intuitive movement, upright position; birth ball, etc
- Encourage rest, eating, hydration
- Emotional support and reassurance
- Fetal position impacts labour: encourage hands and knees; side-lying for OP
- Sterile water injections
24
Q
- Pharmacological early labour support?
A
- Acetaminophen + dimenhydrinate
- Morphine IM
- IV hydration (cases of severe nausea, vomiting)
25
What is non-pharm IOL?
- Cervical ripening to soften, dilate, shorten cx
- To initiate uterine ctx
26
What are some non pharm IOL options?
Castor Oil
Evening primrose oil
Nipple stim
Sexual intercourse
Acupuncture
Acupressure
Foley Cath
27
Research on castor oil?
- Not much research, no harm shown but uncertain effectiveness
- 60ml PO in water, juice, cocktail (including almond butter, apricot juice, alcohol)
- Can cause nausea, diarrhea, vomiting, dehydration, ctx without labour
28
Research on evening primrose oil?
- Possible cervical ripening effect when vaginal use
- 1000mg vaginal capsules daily starting at 38 wGA until delivery
- 500mg orally tid for 1 week beginning at 37w GA, then 500mg daily until delivery
- Can cause nausea, diarrhea, vomiting, PPROM, increase pregnancy length
29
Research on nipple stim for IOL?
- May increase oxytocin release
- Self-massage breasts 15-20min each side, tid; breast pump
30
Research on accupunture/accupressure for IOL?
- May be effective for cx ripening
31
Research on p & v sex for IOL?
- Physical stimulation of cx and increase release of oxytocin can induce labour; semen can stimulate cx ripening (prostaglandins)
- PROM: not recommended
32
7 cardinal movements?
Descent: Fetal head moving into pelvic inlet from station -5
Engagement: Fetal head reaches station 0 - spines. The widest part of the head passes through the pelvic inlet. Sagittal suture aligned in transverse diameter
Flexion: Fetal head flexes to accommodate curvature of sacrum - head meets resistance so fetal chin tucks towards chest
Rotation: Fetal head rotates internally to meet pelvic outlet shape. Shoulders start to rotate to align with head and to fit through pelvic outlet
Extension: fetal head moves past pubic bone to allow its delivery
Restitution: External rotation of the head to assume alignment with shoulders. Anterior shoulder delivery - shoulders continue to rotate in alignment with pelvic outlet for delivery
Expulsion: Delivery of anterior then posterior shoulders
33
What is Latent labour?
- Mechanical and hormonal changes that result in cx dilation up to 4 cm (nullip) 5 cm (multip), or 6cm according to ACOG
- Varies in length - few hours to over 24 hours
34
What is Active Labour?
- Contractions: regular, painful
- Cx changes: progressive-> from 4 (or 6)cm to fully effaced and dilated
- Progressive rate of dilation 0.5cm/hour (2cm over 4 hour period)
- Fetal descent: progressive descent of presenting part
- Birther behaviour: varying coping behaviour
35
Monitoring progress of labour birther?
- Birther
- wellbeing and coping
- Offering support/pain management
- Assessment:
- BP
- between ctx
- Every 4 hours
- HR
- May be elevated due to anxiety, pain, dehydration, hyperventilation
- Persistent tachycardia needs consult
- Every 4 hours
- Temperature
- 36.5-37.5
- Every 4 hours
36
Monitoring progress of labour fetus?
- Assessment
- FHR
- Baseline, rhythm, presence accels/decels
- IA - every 15-30 minutes or EFM-continuous
- Before and after medication admin
- Before and after AROM, SROM, VE, Epidural
37
Monitoring progress of labour?
- Abdominal palpation
- Initial assessment at onset of labour
- Used throughout first stage to assess ctx frequency, strength, duration, resting tone
- VE
- Cx position, consistency, effacement, dilation, presenting part position, presentation, station, membrane status
38
Documentation for birth?
● BC Perinatal Triage and Assessment Record (2)
○ Used for documenting all antepartum hospital visits and upon admission to hospital during labour
● Labour Partogram (3)
○ Used for documenting labour progress starting with admission for active labour
○ Used at home births and in hospital settings where paper charting is still used
● BC Labour and Birth Summary Record (4)
○ Can’t be completed until after the birth, but can be started during the first stage
● Electronic Health Record (5)
○ Different hospitals/health authorities use different softwares for record keeping during hospital births so local guidelines should always be checked
● BC Variance Record/Progress Notes (6)
○ Used for longer narrative notes throughout the intrapartum period
39
Fluid and nutrition guidelines for labour?
Low risk no restrictions
40
Documentation in labour output/input?
- Documentation of oral intake + voids/emesis for hydration status
41
Key factors that promote, protect, and support physiologic normal first stage?
Hydration, nutrition, and regular voiding: to provide energy for uterine contractions, making space for baby to move into pelvis
Ambulation/movement: can assist optimal position and engagement of baby; supportive for pain management and coping. Spinning babies, upright positions, frequent position changes
One to one care and support: leads to feelings of safety, promotes oxytocin release, reduces stress hormones. 3 Rs- relaxation, rhythm, ritual
Delayed admission to hospital: hospital admission can slow progress due to environment
Pain management/comfort measures: may mitigate action of stress hormones on uterine muscle. Counterpressure, double hip squeeze, heat and cold, hydrotherapy, TENS, sterile water injections, touch and massage, breathing exercises, acupuncture/acupressure, frequent position changes
Amniotomy/AROM: allows presenting part to apply greater pressure on cervix and lower uterine segment->stimulates oxytocin and prostaglandins. Risks: cord prolapse, infection
Nipple and clitoral stimulation: leads to oxytocin release
Psychosocial support: reduces stress hormones, promotes oxytocin release
42
How many people fear childbirth enough to lose sleep/have anxiety?
25%
43
What is heightened level of fear around birth associated with?
- C/S
- Epidural
- Neg experience of birth
- Neg feelings in the antenatal period
- Neg feelings in the initial pp period
- Reduced confidence and self-assurance as a parent
- Increased anxiety
- Labour progress can be impacted by birther’s psychological and emotional state, feelings of safety, feeling cared for in labour
44
Physiology of pain in labour
- Sensory nerves - nociceptors - stimulated by painful or unpleasant stimuli
- Signals travel along nerve fibres to spinal cord
- Spinal cord signals follow fast or slow pathway
- Fast nerve fibres associated with sharp pain
- Slow nerve fibres associated with dull pain
- Signals reach brain and are interpreted as pain
- Pain in labour can be experienced by multiple sources of stimuli
- Uterine contractility, cervical stretching, distension of pelvic floor muscles, pressure to bony pelvis and perineum
45
First stage non-pharmacological pain management?
- Continuous labour support, Hydrotherapy, Sterile water injections, Movement and positioning, Touch and massage, acupressure, acupuncture, TENS, hypnosis, aromatherapy, cold/hot, breathing techniques
46
What is transition?
period when active 1st stage of labour ends and beginning of 2nd stage begins; difficult to differentiate; may be characterized by a dip in contraction duration and interval length
47
What is latent 2nd stage of labour?
period of respite before onset of urge to push; pause in pushing efforts, despite continued contractions; ctx patterns change, ctx shorter, longer interval between; can last between 5min to 1 hour
48
What is active 2nd stage of labour?
period between full dilation and birth of baby-> fetal descent, regular ctx, expulsion of fetus
49
Pain management options for labour?
- Tylenol: effective for mild ctx in early labour; effective in early labour, dosage limited to 1g PO/Q4hrs, max 4g/Q24hrs
- Morphine+Gravol: effective for latent, early labour to reduce pain - works within 20-30 minutes for 4 hours; neonatal resus if precipitous birth to follow due to long half-life; side effects: nausea, vomiting dizziness (insert Gravol), Gravol ->drowsiness; Morphin 15-20mg IM Q4hrs; Gravol 25-50mg IM or IV Q4hrs, max 100 mg
- Nitrous Oxide: easy to use/discontinue; reduces intensity of experience; no adverse effects on NB; most effective in later first stage; needs filtration system; can cause dizziness/light-headedness
- Fentanyl IV: reduces pain, quick onset, short duration (45-60min); drowsiness, respiratory depression, nausea, itchy; IV admin or PCA pump
- Pre-admin: VS and sedation scale; VE within last hour (do not administer if birth expected in next 30 min)
- 0.5-1mcg/kg; max 50mcg per dose, max 4 doses per hour and 300mcg total; admin slowly over 1-3min during ctx; can repeat q10min
- Post-admin: monitor 02 sats for 10min after each dose; BP, HR, RR at 5 and 15 post dose, Q15min until 1 hour after last dose, q1h until 4 hours after last dose
- Naloxone should be readily available
- Pudendal block: local anesthetic injected into pudendal nerve in vagina; can be used in 2nd stage; often used for forceps/vacuum-assisted birth; rapid onset, local pain relief
- Epidural: neuraxial analgesia; mix of regional anesthetic and opioids
- Indications: client request, exhaustion, systemic diseases where stress may be dangerous, hypertension; breech, fetal anomalies, multiples, dystocia
- Contraindications: client lack of consent/refusal, systemic infection, local infection, coagulopathy, anesthetic allergy, increased intracranial pressure, lack of skilled practitioner
- Pre-admin: mat VS, FHR, emply bladder, place IV
- Post-admin: BP immediately after, q5min within 30min block to r/o hypotension, FHR q5min, bladder emptied regularly
50
Recognizing transition and 2nd stage of labour without VE?
- Involuntary pushing
- Increased bloody show
- Passing stool
- engorgement/distension of vulva
- Anal dilation
- Fetal presenting part visible at introitus
- Increased rectal pressure
- Trembling/shivering
- Feeling sudden loss of control in transition
51
What is directed pushing?
- Birther told to hold breath and bare down, often with a count. At beginning of contraction to end of ctx
- Can occur while there is a true urge ot push/absence of urge to push
52
What is valsava pushing?
- Act of holding one’s breath and straining, closed glottis
53
Routine assessments, observations, record keeping during 2nd stage
Documentation:
- Time of full dilation
- Time active pushing started
- if/when IUPC or Foley was removed
- Ctx
- Time, frequency (in Q10min), intensity, duration, resting tone
FHR
- Rhythm, accels, decels, classification
Mat assessments
- VS: HR, BP, T, RR/02 sats
- Comfort measures
- activity/position
- Urine output/emesis
- Blood sugars - when appropriate
PV:
- Amniotic fuid
- blood/bloody show
Fetal presentation+descent
- Station in cm/time
Pain management
- Analgesia: time, type, initial dose, continuous infusion rate, time MD call/arrived, client sensory, motor, pain/sedation scale
- Medications
- Dose, route, etc
- IV oxy augment, time, amount per min
- Progress note
- Notes on assisted vaginal birth
- Forceps: time on/off, successful/unsuccessful
- Vacuum: Forceps: time on/off, successful/unsuccessful
- Additional comments
Birth:
- Time of birth of head
- Time of birth of baby
- Time STS initiated/d/c
- Uterotonics: type, time, dose, route
- DCC: y, n, time
54
When to call 2nd midwife for planned HB?
- Should be present at 2nd + 3rd stage of labour
- Should stay until client and baby are stable
55
Role of 2nd at planned HB
General
- Perform care within scope
- Support primary; support client
- Documentation; report any clinical findings to primary
Late 1st-2nd stage:
- Set up/check supplies, fx of equipment, meds
- FHR monitoring/documentation
- Mat VS/documentation
Birth
- warm/dry/stimulate baby
- Reposition head, clear airway
- Monitor NB
PP
- monitor/document maternal VS (BP, pulse), fundus, bleeding
Emergency
- 911
- Assist with NRP
- Assist with IV setup
- monitor/document NB and birther
- Assist with CPR
- Prepare for transport
56
Rationale for IA?
What is it? Component of FHS during labour, to assess how fetus is tolerating labour; FHR, strength, rhythm, accels/decels
How? Immediately following ctx, baseline 60 sec, then 30-60s; every 15-30 min in 1st stage; Q5min in 2nd stage
When? In absence of risk factors for adverse outcomes
Alternatives? EFM, Internal electronic fetal monitoring via fetal scalp electrode
Why? Associated with lower CS rates, operative birth; no sig diff in rates of NN or perinatal morbidity/mortality; 37+0 to 41+4
57
Nuchal cord?
1- Checking for presence of nuchal cord - no strong evidence
2- Risks of nuchal cord - 20-30% of all births; most are not emergencies
58
Mgmt of nuchal cord?
- Cord reduction: if cord is loose, provider can slip over head before shoulders are born
- Birthing through the cord: if cord is too tight for reduction, but has some ability to move slip it over the shoulders as newborn is born so babe is born through the cord
- Somersault maneuver: if cord too tight but still has some mobility, use a hand to flex baby’s head to one side of the birther’s thigh and the other hand somersaults the baby’s body over the perineum to reduce tension on cord; shoulders should be supported to emerge slowly without manipulating the cord; once baby is fully born, cord is unwrapped, regular cord management can occur
- Clamp and cut: if cord is too tight for any of the above maneuvers, clamp and cut cord at baby’s neck before birth of body
- Cutting cord before birth is associated with number of risks: hypovolemia, anemia, shock, hypoxic ischemic encephalopathy, rarely cerebral palsy; additional risk if cord cut before shoulders are born due to shoulder dystocia
59
Waterbirth eligibility?
- Low risk, uncomplicated pregnancy - 37+GA
- Cephalic presentation
- Ability to enter, exit tub
- Active labour >4cm
- N VS, N FHS
60
Waterbirth exclusion (BCW)?
- Reduced mobility, pre-preg BMI >35
- Epidural; opioids within 3 hours
- Maternal infection (respiratory, gastro, blood-borne)
- Colonized with abx-resistant organisms (ARO - ex: MRSA, VRE, CPO, MDRO)
- Skin lesions suggestive of VZH/HSV, active skin/soft tissue infection
- Suspected cases of ARO, other communicable diseases
- No agreement from care attendants/providers
- Atypical or abnormal FHR
*GBS+ or ROM do not exclude
61
Must have for waterbirth at BCW?
- Clear amniotic fluid
- Absence of obs risk
- No opioid analgesia in last 6 hours
- No medications during pregnancy or labour that may impact NB respiratory effort (ex: SSRIs)
62
Temp of birth pool?
- Water temp: 36.6-37.5, not exceed 38
BUT IRL feel with your hand
- Assess birther temp every 30 min
- If above 37.5 on 2 occasions, must exit water
63
2nd stage in water?
- Avoid touching head of baby - await restitution and birth of body
- If fetal head is exposed to air, ensure birther remains OUT of water for birth
64
APGARs for waterbirth?
- 1 min APGARS starts when NB is exposed to air
65
3rd stage for water?
- Encourage birther to get out of tub for delivery of placenta
- Do not clamp/cut cord under water
- If cord snaps during birth, a peds must assess bb
66
Benefits of water birth?
- Mat satisfaction; lower perceived pain; lower rates of intrapartum analgesia (opioids, epidurals); shorter duration of labour, reduces risks of tx from planned HB to hospital; lower risk 2nd degree tears but no diff in 3-4 degree tears; lower episiotomy rate; more hands off/less intervention; possibility gentler experience for NB; lower rate PPH
67
Risks of waterbirth?
- -0.4% vs 0.1% risk of cord avulsion
- Use of water immersion in early labour may slow progress and reduce strength of ctx
- With improper care
- NB aspiration
- Mat temp instability
- Injury manouveuring in and out of water
- NB temp instability
- Infection
- delayed/missed response to PPH
- Suturing complications
68
- Cervadil vaginal insert?
- Contains 10mg prostaglandin which slowly releases
- Manually placed in post fornix
- Monitor FHR 1-2h, then can be outpatient
- Insertion can be repeated every 6 hours if labour not started, or left in place for 12-24 hours and then removed with the string
- Remove earlier if labour begins or if hyperstimulation of uterus; non-reassuring FHR, remove cervadil and administer tocolytic agent
69
- Intracervical/vaginal PGE2 gel
- Intracervical Prepidil contains 0.5mg prostaglandin; Intravaginal Prostin contains 1mg prostaglandin
- Prefilled syringes; Prepidil into cervical canal; Prostin into post fornix
- Must follow local protocols
- Either inpatient only with EFM
- Outpatient after satisfactory EMF 1-2 hours
- Leave for 12 hours, or remove if ctx become greater than 5/10, if uterine hyperstimulation leads to non-reassuring FHR-> remove and administer tocolytic
- Prostin may be repeated at does of 1-2mg/6hours, max 3 times
70
MCAF ICD?
What is it? Occurs when fetus defecates into amniotic flulid. Fresh - green, old- yellow
Incidence: 10-20% of all births; dependent on clinical picture, GA, obs risks
Relevance: associated with neonatal complications - meconium aspiration syndrome->5-20% of MSAF->3-5% BB affected will die; if MSAF 0.06% chance of baby dying
Risk factors that may lead to MSAF:
- Postterm pregnancy/GA->rates increase as GA increases (can reach 27% at 42wGA)
- Prolonged labour
- Fetal hypoxia
- Clinical chorioamnionitis
- Fetal growth restriction
- Preeclampsia
- Oligoydramnios
- Vaginal breech delivery
- Maternal use of drugs (cocaine, castor oil, bowel purgatives)
- Herbal substances (isihlambezo)
- Cholestasis
Fetal implications
- Neonatal hypoxic-ischemic
- Encephalopathy
- Neonatal sepsis
- Neonatal seizures
- MAS
- Higher incidence in postdates
Management
- SOGC: no suctioning
- ACOG: if meconium present and NB depressed, intubation and suction
- FHS Intrapartum Consensus Guideline 13: indication for EFM
71
Midwife’s responsibility when tx from HB to hospital
- Must have transport plan in place with hospital that serves community; hospital privileges
- Communication: ensure hospital has up-to-date records for client; notify hospital when person goes into labour
- 23% clients require transfer to hospital: 45% nullip; 14% multip
- Decision to transfer, timing of transfer, mode of transfer need to be taken into account
- Distance to hospital
- Staffing conditions
- Mode of transport available
- Weather and traffic conditions
- Possible social implications of transfer
- Transfer procedure
- Documentation
- Communicate recommendation with client, level of urgency
- Inform referral hospital of incoming transfer
- Use clinical judgement- same/separate vehicles
- Bring documentation/appropriate assessment tools
- Privileges- midwife will remain MRP
72
Positive ortalani sign?
Positive ortalani sign- audible clicking or clunking noise when femoral head goes back into acetabulum. Requires further investigation
73
Best swaddling practice?
- No straightening/constraining infant’s hips
- Provide room for infant to bend legs
74
Active management 3rd stage?
- Active management reduces PPH by up to 40% and severe PPH by 60-70%
- Only step in active management: administration of uterotonic
- Immediately after birth of NB
- Oxytocin 10iu IM; 20iu diluted in 30ml saline via umbilical vein for placental separation; rapid infusion rate 1iu/min for 4 min followed by 7.5-15 iu/h or 3iu IV rapid injection
- Carbetocin 100mcg IM or 100mg IV infused over 30-60s; more expensive but more effective; first line for c/s
- Ergometrine/ergonovine 0.2-0.25mg IM; 02mg diluted in 30ml saline via UV for placental separation; increased side effects like nausea, vomiting when compared to oxytocin; contraindication with hypertension
75
Supporting NB transition/ assesments?
- Initial period of reactivity -> 1st hour after birth, assessments eerie q15-30min
- Period of inactivity-> 2-3 hours after birth, assessments every 30-60 min
- Second period of reactivity-> 4-6 hours after birth, final transitional assessment occurs in this period
- Assessments:
- CVS: delayed cc, appearance->acrocyanosis in first 24-48hours, central not ok; HR
- Respiratory: stimulate for crying/breathing response; observe breathing, listen lungs, encourage sts
- Thermoregulation: dry, sts, covering with warm blankets; monitor temp
- Metabolic: encourage sts, feeding <1hour; s/sx hypoglycemia
76
What is Respiratory acidosis?
when CO2 not removed rapidly enough by placenta. Initiation of lung resps corrects condition quickly. Expected at normal birth. Can be caused by temporary cord compression, maternal hypotension/hypovolemia, hypertonus of uterus, short interval placental abruption
- Arterial blood gases: low pH; high pCO2; normal HCO3; normal base deficit
77
What is Metabolic acidosis?
pH imbalance; H+ increases but not enough buffer to neutralize acid. True metabolic acidosis often indication resuscitation/stabilization after birth
- Arterial blood gases: low pH; normal pCO2; low HCO3; high base deficit
78
What is mixed acidosis?
both impaired CO2 exchange AND where perfusion has been compromises (as in metabolic acidosis). NB require immediate care
- Arterial blood gases: low pH; high pCO2; low HCO3; high base deficit
Arterial blood reflect fetal status; Venous blood reflect placental status
79
What is APGAR looking at?
1)HR
2)Resp effort
3) Reflex response
4) Muscle tone
5) Colour
80
What are heart murmers?
result of turbulent blood flow in the chambers of the heart; often sound like low pitched humming sounds and are a longer duration than other sounds; can be normal adaptation to extrauterine life
81
What should you identify w heart murmer?
timing, location, intensity, radiation, quality, pitch
82
What is a systolic murmur?
when heart contracts (following closure mitral and tricuspid valves just after S1)
83
What is a diastolic murmur?
when heart relaxes and chambers fill with blood (following closure aortic and pulmonary valves just after S2)
84
What is nb benign murmer like?
- Can be present without other s/sx
- Common in first 24-48 hours
- All NB murmurs require ongoing monitoring and further evaluation, including pulse O2 and/or consult
- Usually grade1/2 with normal ECG/CXR
- Usually systolic
- Early soft mid-systolic ejection murmur-> especially occurs in premies; usually grade 1-2; can arise within first few weeks but goes away at 3-6 mo
- Systolic ejection murmur-> grade 1-2, heard along mid/upper sternal border; not common immediately after birth but can occur several hours later and last few days/weeks
- Continuous systolic murmur->15% of NB; grade 1-2; along left sternal border; usually first 8-24 hours; heard during systole and diastole
85
Pathological murmurs?
- Distinct from physiological murmurs
- Some aren’t triggered until day 3 or until 1-6weeks; others do not occur until older child
- Some infants have serious congenital heart disease without murmur
86
Delayed CC
Benefits:
- Increases RBCs and Hgb
- Improves iron stores
- Increase blood volume
- Improves transitional circulation
- Decreases need for transfusion
- Does not increase risks PPH
87
Risks of DCC?
Possibly jaundice
88
Contraindications to DCC?
- Fetal hydrops
- Need for immediate maternal/fetal resuscitation (unless ability to do so cord intact)
- Disrupted utero-placental circulation (bleeding vasa previa)
- Twin-to-twin transfusion syndrome or twin anemia polycythemia sequence
89
Maintaining perineal integrity
- Warm compresses during second stage
- Slow down delivery of fetal head/prevent rapid expulsion
- Frequent position changes to support fetal descent and rotation
- Side lying position for second stage/upright/hands-knees
90
- What is not recommended for perineal integrity?
- Intrapartum perineal massage
- Manually stretching perineum in 2nd stage
- Directed pushing/closed glottis pushing- unless clinically necessary or requested by birthing person
- Routine episiotomy
91
How do nb lose heat?
- Convection: body surface to cooler air
- Conduction: body surface to cooler surface
- Radiation: heat lost into air
- Evaporation: heat lost to moisture on skin
92
Nb adaptations to thermoregulate?
- Peripheral vasoconstriction
- Burning brown fat stores to increase metabolic rate
- Muscle activity
MIDW 230
flashcards
Decks in class (13)
# Cards
-
CBL 1_PROM and Early Labour66
-
CBL 2_Active Labour and Non-Pharmacological Pain Management69
-
CBL 3_Second Stage Management, Nuchal Cord55
-
CBL 4_Pharmacological Pain Management and Induction of Labour77
-
CBL 5_Waterbirth, Precipitous Birth, Newborn Dermatitis46
-
CBL 6_Meconium, Home Birth Transfer, Newborn Hips26
-
CBL 7_Third Stage Management, Placentas, Newborn Innocent Heart Murmur37
-
CBL 8_Perineal health, Newborn transient tachypnea & hypothermia57
-
CBL 9_Cesarean Birth, PostOp recovery, Sexual Health34
-
201_Postdates and Third Stage25
-
201_GBS screening and prophylaxis_prepping for birth26
-
201_Newborn_first 24 hours and adaptations and discomfort of pp_safe sleep18
-
MISC92
