Week 8

Question 1

what are some examples of Malpresentations of a baby in utero?

Answer 1

Breech (we went through this last week)
Occipito-posterior position
Face presentation
Brow presentation
Transverse or oblique lie

Question 2

What is the occipitoposterior position (OP)

Answer 2

Babies back to maternal back

Question 3

What is the presentation of the occipitoposterior position (OP)

Answer 3

• As per normal labour
• May feel need to push earlier
• Foetal head is only delivered once face is cleared of symphysis pubis
• Can lead to extensive perineal tearing
• Painful ++

Question 4

What are the risk factors for the occipitoposterior position (OP)

Answer 4

mum sitting hip below knee

Question 5

How do you manage the the occipitoposterior position (OP)

Answer 5

Spontaneous rotation occurs 90-95% of the time

- manage as per normal labour

Question 6

What is Face Presentation?

Answer 6

• Complete or hyperextension of the foetus’ neck

- Face is presenting part

Question 7

What are the risk factors for Face Presentation?

Answer 7

• Macrosomicfoetus
• Contracted pelvis
• Umbilical cord wrapped around the neck a few times
• OP position
• Large neck due to cystic hygroma

Question 8

What is the presentation of Face Presentation of baby in utero?

Answer 8

• Face in the introitus
• Will be bruised and oedematous (prepare mum)
• can be confused with a breech pattern

Question 9

How do you manage a face presentation?

Answer 9

Mentoanterior:

• deliver as per normal
• Prepare for extensive perineal tearing and trauma
• Prepare for haemorrhage
• Prepare for resus of neonate

Mentoposterior:

• Can’t be delivered vaginally
• Needs c-section
• Rapid transport

Question 10

What is mentoanterior and mentoposterio in face presentation?

Answer 10

Mentoanterior - chin anterior

Mentoposterior - chin posterior

Question 11

what is brow presentation of the baby during labour?

Answer 11

Less “extreme” extension of neck compared to face presentation

Question 12

How do you manage a brow presentation?

Answer 12

May move to a face presentation (unlikely)
Cannot be delivered vaginally –needs a C-section
Management: Rapid transport (consult with PIPER)

Question 13

What is Transverse or oblique lie (shoulder presentation)

Answer 13

Long axis of mum and foetus are at right angles

The baby is sideways

Question 14

What are the risk factors for Transverse or oblique lie (shoulder presentation)

Answer 14

• Lax uterine muscles
• Placenta praevia
• Preterm foetus
• Twins +
• Grand multiparity

Question 15

How does Transverse or oblique lie (shoulder presentation) present?

Answer 15

• shoulder

- cord prolapse

Question 16

What are some possible complications of Transverse or oblique lie (shoulder presentation)

Answer 16

can lead to uterine rupture

Question 17

What is a cord prolapse

Answer 17

• The cord lies ahead of the presenting part
• Can be occultor overt
• Can compromise foetalcirculation-hypoxia-brain injury-death

Question 18

What are the causes/risk factors of cord prolapse?

Answer 18

 Multiparity
 High head
 Prematurity
 Malpresentations
 Polyhydramnious
 Low birth weight
 Placenta praevia
 Pelvic tumours
 Foetalcongenital abnormalities

Question 19

How do you manage a cord prolapse on scene before transport (delivery not imminent)?

Answer 19

If delivery not imminent:

• Position in all fours with head to floor immediately
  - >Genu-pectoral position
• When ready -walk patient to stretcher or put patient straight on stretcher avoid carry chair
• Administer oxygen –time critical

Question 20

How do you transport a cord prolapse patient (delivery not imminent)?

Answer 20

Exaggerated Sims position
–For transport
–Ensure patient is well secured

Question 21

What is the overall management plan for a cord prolapse patient (delivery not imminent)?

Answer 21

 Document time of cord prolapse
 Transport in exaggerated SIMs position
 Oxygen high flow
 PIPER and MICA
 Rapid transport with pre-alert
 Pain relief if required
 Cord Management:-Insert cord into vagina using fingers only & try not to touch further-Keep cord warm and moist
 If presenting part compressing cord
     – Insert fingers into vagina & hold/push presenting part off cord
 Mum will require urgent c-section

Question 22

What is the overall management plan for a cord prolapse patient (DELIVERY IMMINENT- OMGGGGG)?

Answer 22

 PIPER
 MICA
 Ask mother to push through contractions –need to deliver foetusASAP
 Give pain relief
 Assist delivery as per normal keep an eye on cord and compression
 Neonate will most likely require resus –prepare
 Rest and reassure mum ++

Question 23

What are the risk factors of twins?

Answer 23

 In vitro fertilisation/assisted fertility
 Previous history of twins+
 Familial history
 Multiparity
 Maternal age >45

Question 24

What are some complications associated with twins?

Answer 24

Prematuriy
Foetal growth restriction (FGR)
Cerebral palsy
Still birth
Antepartum and postpartum haemorrhage
Thromboembolic disease

Question 25

How to manage delivery of twins?

Answer 25

``` Transport if able-if not: Call for back up, MICA, PIPER Notify hospital Oxygen for 2ndtwin  ``` ``` If in imminent delivery - –deliver first twin as singleton –Identify neonate as first twin  Clamp cord in two places & cut cord Do not attempt to deliver placenta Do not allow the placental end to bleed –the second twin may be attached ``` ``` Transport to hospital if able –before second delivery Deliver 2ndbaby as singleton Cut cord & clamp Prepare to resuscitate Identify as second twin –Identify cord clamps Check for third foetus Check for PPH ```

Question 26

What do you do after the delivery of both twins in the management of this patient?

Answer 26

``` Attempt to transport Allow 3rdstage to remain in-utero –Beware of risk of hemorrhage Check fundus is firm & remains so –Blood loss minimal ``` ``` Only if bleeding or “boggy fundus” –Deliver 3rdstage with cord traction –Give oxytocic if available •Syntocinonor Mysoprostyl Keep fundus firm & central ```

Question 27

What is pre-term labour?

Answer 27

Labour prior to 37 weeks. | Very premmy = <28 weeks

Question 28

How can preterm labour present?

Answer 28

Mother will complain of labour –regular contractions (may or may not have pain) –cramp like period pain or backache. •Manage as per labour

Question 29

What are the causes of preterm labour?

Answer 29

- Infection - > Haematogenous - > Latrogenic - Stress - > Maternal - > foetal - Multiple pregnancy - Uterine distension - Placental abruption - Cervical weakness

Question 30

What are the risk factors for pre-term labour?

Answer 30

``` Previous premature delivery Twins+ Smoker Low SES Previous cervical incompetence Known SROM in current pregnancy Environmental stress Alcohol and drug use Poor nutrition Interestingly…. Marital status ```

Question 31

How to you manage a preterm labour in pre-hospital environment (delivery not imminent)?

Answer 31

``` Reassure mother PIPER & MICA Good obstetric history Pain relief Mother in lateral position if transporting ``` If >34 weeks (AV) –basic care If <34 weeks gestation (in AV) consult to give GTN via 50mg patch on abdomen Notify hospital -Transport ?NICU –Dependent on gestation

Question 32

How to you manage a preterm labour in pre-hospital environment (DELIVERY IS imminent GAHHHH)?

Answer 32

``` Back up –second crew + MICA + PIPER Prepare for delivery Prepare for resuscitation Risk of cord prolapse Breech presentation common prior to 34 weeks Keep neonate warm –If very prem. place baby in baking bag –Wrap head Observe ABC’s refer neonatal resus lecture ```

Question 33

What is PROM (premature rupture of membranes)

Answer 33

``` Occurs in approx. 2% of all pregnancies 50% will deliver within 1 week & 75% within 2 weeks May occur during the ante-natal period –Prior to the commencement of labour –At any gestation ``` History of gush of fluid –May be sudden → forewaters – May be slow → hindwater

Question 34

What are some complications of PROM?

Answer 34

Can progress to delivery of prem. infant Infection risk Prolapsed cord

Question 35

How do you manage PROM?

Answer 35

- PIPER - Not in labour –> R&R +++; Oxygen; pain relief is not usually required - Transport

Question 36

What is an Episiotomy?

Answer 36

Episiotomy –surgical incision of perineum to aid vaginal birth

Question 37

What is an instrumental delivery?

Answer 37

Forceps - Indicated when there is foetal or maternal distress or issues associated with the 5 P’s - C/I in patients whose cervix isn’t fully dilated-Large metal forceps are placed inside the vagina on either side of the foetus’ head - Traction is applied with each contraction to effectively pull the foetus out (normally within 3 pulls)

Question 38

What are the risks of operative (instrument) delivery

Answer 38

- High risk of trauma to mum and foetus | - High risk of haemorrhage due to tearing (even in the presence of episiotomy)

Question 39

What is a caesarean section?

Answer 39

Incision through mums abdo(laparotomy) and uterus (hysterotomy)

Question 40

What are the indications for a C section

Answer 40

Indications - Previous c-section - Immediate life threat - Elective - Failure to progress in Labour - Malpresentation

Question 41

What are some complications of c sections?

Answer 41

``` Haemorrhage Infection UTI Transient tachypnoea is neonate Organ damage (bowel/bladder) VTE Psychological ```