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Flashcards in Complex Care Exam Deck (196):

What are the 4 types of malpresentation?

- Face
- Brow
- Breech
- Shoulder


What is the definition of the lie?

The relationship of the long axis of the fetus to the long axis of the uterus.
It can be longitudinal, transverse or oblique


What is the definition of the presentation?

The part of the fetus which enters the brim of the pelvis first and occupies the lower pole of the uterus.
It can be vertex, face, brow, breech or shoulder.


What is the definition of the position?

The relationship of the denominator to the 6 areas of the pelvic brim.
It can be ROA, ROP, ROL, LOA, LOP or LOL


How is the engagement of the head measured?

Measured by the amount of fetal skull (in fifths) palpated abdominally above the pelvic brim.


What is the definition of malposition of the occiput?

When the occiput occupies the posterior quadrant of the maternal pelvis


If the occiput is in the posterior quadrant of the pelvis, what is the:
- Presenting part
- Denominator
- Attitude
- Presenting diameter

- Presenting part : vertex
- Denominator : occiput
- Attitude : deflexed
- Presenting diameter : occipitofrontal 11.5cm


List 4 possible causes of malposition of the occiput

- Type of pelvis
- Flat sacrum
- Large or small fetus
- Anteriorally situated placenta


On inspection of the abdomen, what can suggest malposition of the occiput?

Saucer dip below umbilicus
Loss of fetal curvature - curve of back cannot be seen


On palpation of the abdomen, what can suggest malposition of the occiput?

Limbs will be easily palpable and back unable to be palpated
Head may be high and free


On auscultation of the fetal heart, what can suggest malposition of the occiput?

The FH can be heard midline under the umbilicus or in the flanks


What 4 signs during labour would suggest malposition of the occiput?

- Early SRM, prior to the onset of regular contractions
- Presenting part is high and held up at brim
- Presenting part is not well applied to the cervix
- On VE the anterior fontanelle is felt anteriorally


What 3 things will affect the outcome of an OP position?

- Shape of pelvis
- Size of fetal head
- Strength of uterine contractions


What are the 3 possible outcomes of an OP position?

- Long internal rotation
- Short internal rotation
- Deep transverse arrest


Describe a long internal rotation from an OP position

Occurs with good uterine contractions
The occiput rotates 3/8ths of a circle to an OA position and birth continues normally


Describe a short internal rotation from an OP position

Occurs when there is insufficient flexion of the head
Head rotates 1/8th of a circle and sinciput becomes the leading part
Baby is born face to pubes


Describe a deep transverse arrest

Head remains deflexed
Occipitofrontal diameter is caught above the ischial spines
During VE, diagnosed when able to palpate both fontanelles and saggital suture in transverse diameter


How should a deep transverse arrest be managed?

Using Kiellands forceps to rotate to OA position


List 10 possible effects that OP position might have on labour

- Prolonged latent phase
- Slow descent of fetal head
- Poorly effaced cervix causes incoordinate uterine action
- Early SRM - risk of infection and cord prolapse
- Severe backache
- Difficulty in micturition
- Dehydration and exhaustion - maternal ketoacidosis
- Fetal distress
- Operative intervention
- Maternal tissue trauma


List 7 points to consider in the care of a woman in labour whose baby is lying in the OP position

- Change positions, keep mobile, birthing pool
- Heat pads, massage, acupressure
- Hydration
- Pain relief
- Bladder care
- Documentation
- Position for second stage


List 3 maternal and 2 neonatal points to consider in the postnatal care following an OP delivery

- Pain relief for perineum
- Observe for infection
- Education on caring for perineum and hygiene

- Observe for caput, cephalhaematoma and note type of moulding
- Observe for signs of intracranial injury


Describe a face presentation

Face is directly over the internal os
The attitude of the head is complete extension
Occiput is in contact with the spine


When does primary face presentation develop?

Before the onset of labour


When does secondary face presentation develop?

After the onset of labour


List 2 potential causes of primary face presentation

- Anencephaly (absence of a large part of brain, skull and scalp)
- Fetal goitre (an enlargement of the thyroid gland in utero)


List 6 possible causes of secondary face presentation

- Deflexed OP position
- Contracted pelvis
- Lax uterus
- Polyhydramnios
- Multiple pregnancy
- Prematurity


What is the denominator of a face presentation?

The mentum (chin)


List 7 points in the management of a mento-anterior face presentation

- Notify obstetrician
- Check for cord prolapse once membranes have ruptured
- Monitor fetal and maternal wellbeing
- When face appears at vulva, hold back sinciput to allow chin to free
- Episiotomy and forceps may be necessary
- Monitor baby following delivery - facial bruising etc
- Reassurance for parents


Is vaginal delivery possible with a mento-posterior presentation?



What types of presentation can brow presentations convert to?

- Face presentation by becoming fully extended
- Vertex presentation following flexion


What type of delivery will be required if a brow presentation persists?

Caesarean section


Describe a shoulder presentation

The long axis of the fetus lies across the long access of the uterus


List 7 pre-disposing causes of shoulder presentation

- Multiparity
- Lax abdominal and uterine contractions
- Placenta praevia
- Fibroids
- Polyhydramnios
- Prematurity
- Multiple pregnancy


On inspection of the abdomen, what would suggest a shoulder presentation?

Low fundus and wide uterus


On palpation of the abdomen, what would suggest shoulder presentation?

No fetal pole felt in fundus or pelvis and fetal head felt in left or right iliac fossa


During a VE, what would suggest a shoulder presentation?

Presenting part would be high and ill fitting
Scapula or ribs may be felt


What 2 options are available for shoulder presentation?

- Early cephalic version
- Caesarean section


List 4 possible complications of a shoulder presentation

- Prolapsed cord
- Prolapsed arm
- Caesarean section
- Obstructed labour/ruptured uterus


List 3 factors in pregnancy that significantly increases the risk for women with thrombophilia

- Increase in hypercoagulability
- Decreased venous return secondary to the compression of the pelvic veins
- Reduced vessel tone with venous pooling


What is thrombophilia?

Disorders of the haemostat if system that result in an increased risk of thrombosis


What prophylactic treatments should be given to women with thrombophilia?

Low molecular weight heparin, aspirin, TED stockings


Where do 85% of deep vein thrombosis occur in pregnant women and why?

In the left leg due to compression of the left iliac vein by the right iliac artery as they cross


List 6 possible symptoms of a DVT

- Pain in area of clot
- Unilateral and occasionally bilateral swelling
- Redness or discolouration
- Difficulty weight bearing on affected leg
- Low grade pyrexia
- Lower abdominal pain if the pelvic veins are affected


List 6 pieces of advice for pregnant women to reduce the risk of DVT

- Keep hydrated
- Remain as active as possible
- Avoid standing for long periods
- Elevate feet when sitting
- Leg care (massage gently with oil or cream)
- Avoid unnecessary long journeys by car, train or plane


What are the 3 possible side effects of heparin?

- Osteoporosis
- HIT (heparin induced thrombocytopenia) - low platelet count
- Cutaneous allergy


For labour, when and why should women stop their LMWH injections?

At the start of contractions.
This facilitates the use of an epidural and decreases the risk of PPH


Is breastfeeding safe for women on heparin or warfarin?



When should LMWH be restarted following delivery?

4 hours after removal of epidural catheter
2 hours after vaginal delivery with no epidural


When does the coagulation status return to pre-pregnancy levels?

6 weeks postpartum


List 3 typical symptoms of a pulmonary embolism

- Severe sudden onset of shortness of breath
- Sharp chest pain which is worse on inspiration
- Cough with blood


List 5 possible complications of a pulmonary embolism

- Cardiac arrest or sudden death
- Heart failure or shock
- Severe breathing difficulty
- Arrythmias
- Pleural effusion


What type of third stage management is recommended for women with thrombo-embolic disorders?

Active management


How many times more likely is a venous thromboembolism to occur in pregnancy?

10 times


At what stage of pregnancy and birth is a woman most likely to develop a VTE?



List 10 pre-existing risk factors for a VE in pregnancy

- Previous VTE
- Thrombophilia
- Age over 35
- BMI over 30
- Parity greater than 2
- Smoking
- Medical co-morbidities
- IV drug user
- Gross varicose veins
- Paraplegia


List 6 obstetric risk factors known to increase the risk of VTE

- Emergency c-section
- Instrumental delivery
- Pre-eclampsia
- Prolonged labour
- Blood loss of more than a litre
- Blood transfusion


What can be recommended to women during labour to reduce the risk of VTE and promote natural childbirth?

Mobilisation and avoidance of lithotomy


Describe a monozygotic pregnancy

Identical twins
Develop from one egg and one sperm
Will be the same sex and same genes
Can be different sizes


Describe a dizygotic pregnancy

Unidentical twins
Develop from two eggs and two sperm
Will be no more alike than normal brothers and sisters


Describe a dichorionic pregnancy

Two placentae
Two chorions
Two amnions
Twins can be mono or dizygotic


Describe a monochorionic pregnancy

One placenta
One chorion
Two amnions
Twins can only be monozygotic


What is the average gestation of a multiple pregnancy?

37 weeks


List 4 effects that a multiple pregnancy can have on the pregnancy

- Exacerbation of common disorders such as sickness, nausea and heartburn
- Iron and folic acid deficiency anaemia
- Polyhydramnios
- Pressure symptoms such as impaired venous return, backache and indigestion


Which antenatal screening test is not recommended in a multiple pregnancy?

Chorionic villus sampling


Why should monozygotic twins have an ECG at approximately 24 weeks?

There is a higher risk of cardiac abnormalities


Why are monochorionic pregnancies scanned every 2 weeks from diagnosis?

To check growth and signs of twin-to-twin transfusion syndrome


From what gestation and then how often should dichorionic pregnancies be scanned?

From 20 weeks they should be scanned every 4 weeks


At what gestation is a multiple pregnancy usually induced?

38 weeks


Who should be informed and when, when a multiple pregnancy lady is in labour?

Neonatal unit should be advised when the woman is in established labour.
Paediatric team should be summoned when the birth is imminent


Describe the management of the birth of a twin pregnancy

- If first twin is vertex presentation, birth can proceed same as singleton pregnancy
- Following the birth of the first twin, baby and cord should be immediately labelled "twin 1"
- Twin 1 can be put to the breast for feeding and to help stimulate further contractions
- The abdomen should then be palpated to determine the lie, presentation and position of twin 2
- If longitudinal, VE to confirm presentation. If not, ECV can be attempted
- Fundal pressure can be used to engage the head
- Birth of twin 2 should ideally be complete within 45 minutes of twin 1 delivery but can be longer if no signs of fetal distress
- Oxytocic drugs given at delivery of anterior shoulder of twin 2
- Baby and cord labelled "twin 2"
- Once oxytocics working, controlled cord traction to both cords simultaneously


What postnatal advice should be given to new parents of twins or triplets?

They should be encouraged to treat each baby as an individual and spend time interacting with each separately to aid development of speech and social skills.
They may bond with one baby more quickly which is normal so reassurance should be given.
Encouragement of the father to be involved in the care and suggest extra help for the first few days


List 11 complications associated with multiple pregnancies

- Polyhydramnios
- Twin-to-twin transfusion syndrome
- Fetal abnormality
- Conjoined twins
- Malpresentations
- Cord prolapse
- Prolonged labour
- Locked twins
- Premature expulsion of placenta
- Postpartum haemorrhage


What is the definition of shoulder dystocia and what happens?

Failure of the shoulders to traverse the pelvis spontaneously after birth of the head.
The anterior shoulder becomes trapped behind the symphysis pubis while the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory


List 9 antenatal risk factors of shoulder dystocia

- Previous birth with shoulder dystocia
- Previous macrosomic fetus
- Maternal birthweight greater than 4000g
- Diabetes and gestational diabetes
- Obesity greater than 90kg
- Post-dates
- Pelvic abnormality
- Advanced maternal age
- Higher parity


List 6 intrapartum risk factors for shoulder dystocia

- Oxytocin augmentation
- Prolonged labour
- Prolonged second stage
- Macrosomia
- Arrest or failure of descent
- Need for assisted delivery


List 2 warning signs of shoulder dystocia

- "Turtle-necking"
- Failure of restitution and descent of shoulders


What 3 things are the various manoeuvres to assist shoulder dystocia, designed to do?

- Increase functional size of the pelvis
- Decrease bisacromial diameter
- Change relationship between bisacromial diameter and pelvis


What are the 8 important things that should be documented during a shoulder dystocia?

- Time of delivery of the head
- Time appropriate assistance was called
- Who arrived and when
- Which manoeuvres were tried, when, by who and for how long
- Episiotomy
- Number of times traction was tried
- Time of delivery of shoulders
- Apgar score


List 7 possible adverse maternal outcomes of a shoulder dystocia

- Cervical, vaginal or perineal lacerations
- Bladder injury
- Uterine rupture
- Separation of the symphysis pubis
- Postpartum haemorrhage
- Vaginal infections


List 4 possible adverse fetal outcomes of a shoulder dystocia

- Brachial plexus injury
- Erb's palsy
- Phrenic nerve injury
- Birth asphyxia


What is the definition of a breech presentation?

When the fetal buttocks lie in the lowermost part of the uterus


List 16 possible causes of breech presentation

- Pre-term
- Uterine abnormalities
- Pelvis shape
- Tight or lax abdominal muscles
- Placenta praevia
- Uterine fibroids and tumours
- Polyhydramnios
- Oligohydramnios
- Multiple pregnancy
- Grand multiparty
- Fetal death
- Short cord
- Impaired growth
- Emotional factors
- Fetal abnormalities affecting head


List the 4 types of breech presentation and describe them

- Flexed/complete: baby sitting crossed legged
- Extended/frank: Baby's feet up by head
- Knee: One of baby's legs underneath as if kneeling
- Footling: One of baby's feet over the cervix


What are the 4 points to consider when trying to diagnose a breech presentation?

- History
- Inspection
- Palpation
- Auscultation


What points in the mothers medical history should you consider when trying to diagnose breech presentation?

Listen to the mother for complaints of discomfort under the ribs and kicks low down.
Previous breech delivery also increases risk


What points in the inspection of the mother should you consider when trying to diagnose breech presentation?

Visualisation of movements, kicking seen at the umbilicus or lower


What points in the palpation of the mothers abdomen should you consider when trying to diagnose breech presentation?

A soft, wider presenting part
Head felt in upper pole


What points in the auscultation of the fetal heart should you consider when trying to diagnose breech presentation?

The FH will be heard above the umbilicus but this is not reliable for diagnosis on its own


What is the only way to diagnose a breech presentation?

An ultrasound scan after 36 weeks and a VE in labour


Describe 5 things to be felt on a VE to diagnose breech presentation

- Soft and irregular shape
- No sutures or fontanelles felt
- Fetal anus felt
- Meconium on glove, fresh
- Genitalia felt (more obvious on boys)


What is the denominator in a breech presentation?

The sacrum


What are the 6 breech positions?

Left: - sacroanterior
- sacrolateral
- sacroposterior
Right: - sacroanterior
- sacrolateral
- sacroposterior


What advice can midwives give to women to try and turn a breech presentation?

- Ask the woman to lie on her back, hips slightly elevated, hips and knees flexed and roll from side to side through 180 degrees. This should be done 3 times a day
- Ask the woman to lie face down with her knees to her chest. This should be done for 15 minutes, every 2 hours, for 5 days


List 4 risks of an ECV

- Cord knotting
- Separation of placenta
- Rupture of membranes
- Fetal distress


List 10 contraindications for an ECV

- Uterine scar
- Pre-eclampsia or eclampsia
- Multiple pregnancy
- Oligohydramnios
- Rupture of membranes
- Hydrocephaly
- Any condition requiring c/s delivery
- Compromised fetus
- Antepartum haemorrhage
- Pre-term labour


List 6 things to consider during the first stage of a breech delivery

- Differs very little from a normal labour
- Inform senior midwife, obstetrician and anaesthetist
- Potential risk of cord prolapse
- Leave membranes intact until breech is at the spines
- Maternal and fetal observations vitally important
- Avoid fetal blood sampling from buttocks


Describe the 6 points in the Liverpool technique for breech delivery

- Assisted breech delivery
- Forceps to assist coming head
- Body hangs until nape of neck is visible
- Assistant holds baby's feet up in arch
- Forceps used to slowly deliver the head
- Aim to prevent head from sudden compression at birth


List 6 potential complications of a breech delivery

- Cord compression or cord prolapse
- Intra-cranial haemorrhage
- Nerve palsy
- Fractures
- Meconium aspiration
- Maternal trauma


What is hypovolaemic shock?

The most common type of shock which results from a loss of fluid such as blood


What is the medical definition of shock?

When the metabolic needs of the cells are not being met because of inadequate blood flow. This causes tissue hypoxia with the accumulation of waste products.


Describe the aetiology of hypovolaemic shock

- Blood volume is decreased by 15-20%
- Cardiac output falls because of low blood volume
- The drop in cardiac output leads to hypotension
- Reduced BP then leads to a decrease in tissue perfusion
- This results in impaired cellular metabolism


List 3 possible obstetric causes of hypovolaemic shock

- Severe obstetric haemorrhage
- Ruptured ectopic pregnancy
- Coagulopathy problems


What is cardiogenic shock?

Occurs in acute heart disease when the damaged heart muscle cannot maintain an adequate cardiac output


What is septic shock?

Caused by severe infections that release toxins in to the blood which triggers an uncontrolled inflammatory response.
This can result in multiple organ failure, vasodilation leading to hypotension and poor tissue perfusion


What is neurogenic shock?

Also known as vasogenic shock, it is caused by acute pain, severe emotional experience or spinal cord damage.
This results in excessive parasympathetic activity or decreased sympathetic activity which in turn reduces the heart rate and cardiac output.


What is anaphylactic shock?

A severe allergic response.
Vasodilation occurs because of the release of histamine and bradykinin. This then leads to pooling and hypotension.
Bronchoconstriction leads to respiratory difficulty and hypoxia


What is compensated shock?

A decrease in blood volume triggers stimulation of baroreceptors which results in vasoconstriction which in turn increases BP.
A decrease in blood volume also stimulates the sympathetic nervous system which increases heart rate.
Chemical compensation then causes a decrease in oxygen and an increase in carbon dioxide. This then signals an increase in respirations which can lead to hyperventilation resulting in confusion and restlessness.


List 6 minimal symptoms of compensated shock

- Subtle colour change
- Skin temperature change
- Slight increase in heart rate
- Nausea
- Thirst
- Reduced urine output


What is uncompensated shock?

Leads from compensated shock with cardiac depression.
Hypoxia will ensue which will result in cellular metabolism switching to anaerobic respiration.
This results in the accumulation of lactic acid and a resulting metabolic acidosis.
Capillaries will become more permeable which will result in leakage in to the tissue
Accumulation of waste products will cause vasodilation and a reduction in BP
Reduction in BP reduces blood supply to the heart preventing it from supplying the brain with O2 causing brain damage and eventually death


List 7 symptoms of uncompensated shock

- Low BP
- Raised pulse
- Pulmonary oedema
- Peripheral oedema
- Decreased urinary output
- Altered level of consciousness
- Cold, pale skin


List the 9 points in the midwifery management of shock

- Summon help
- Initial assessment (ABC) and treatment
- Determine cause of shock and treat
- Site two large venflons and take emergency bloods (FBC, group and save, cross match and clotting screen)
- Observations
- Administer facial oxygen and pulse oximeter
- Commence IV fluids
- Catheterise with hourly urine volumes
- Transfer to HDU


What is disseminated intravascular coagulation?

A secondary blood disorder characterised by inappropriate, accelerated systemic activation of the clotting cascade simultaneously causing thrombosis and haemorrhage


Describe the aetiology of DIC

Haemorrhage leads to increased clotting.
This leads to fibrin clots which in turn leads to organ damage and fibrinolysis.
This then creates fibrin degradation products which in turn leads to further haemorrhage.


List 7 signs and symptoms of DIC

- Frank bleeding
- Bleeding from mucus membranes, IV sites and surgical incisions
- Frank blood in stools
- Frank haematemesis
- Haematuria
- Vaginal bleeding
- Abnormal bruising


List 9 points in the midwifery management of DIC

- Site two grey venflons and take FBC and clotting screens. Check blood levels every 1-2 hours
- Monitor vital signs and record on MEWS chart
- Strict monitoring of fluid balance
- Care of wound site if C/S. Monitor fluid loss from wound
- Vigilantly monitor vaginal bleeding due to increased risk of haemorrhage
- Monitor pain and administer analgesia as required
- Assist with personal hygiene and breastfeeding
- Support for family if baby in neonatal
- Record accurately events detailing all midwifery care in accordance with the midwives rules and standards


What is the definition of antepartum haemorrhage?

Bleeding from the genital tract after 24 weeks gestation and before birth


What are the 3 main causes of antepartum haemorrhage?

- Placenta praevia
- Placental abruption
- Ruptured vasa praevia


List 14 risk factors for placental abruption

- Hypertensive disease
- Short umbilical cord
- Smoking
- Previous abruption
- Multiparity
- Advance maternal age
- Multiple birth
- Polyhydramnios
- Accidental or deliberate trauma
- Illegal drug use
- Folic acid deficiency
- Metabolic abnormalities


List 5 signs and symptoms of placental abruption

- Dark vaginal bleeding
- Shock - pale, clammy, tachycardia, hypotensive
- Hard and tender uterus
- Abdominal pain - back pain, increasing abdominal girth
- Fetal distress


List 5 potential maternal complications of placental abruption

- Postpartum haemorrhage caused by coagulation problems
- Renal failure
- Pituitary necrosis
- Anaemia


List 4 potential fetal complications of placental abruption

- Prematurity
- Growth restriction
- Still birth
- Fetal hypoxia


What is the classification of mild placental abruption?

Blood loss: slight, may be entirely concealed
Abdominal pain/ uterus consistency: slight pain/ not tender
Shock: not evident
Fetus: not in distress


What is the classification of moderate placental abruption?

Blood loss: up to 1 litre of blood loss (25% placenta separated)
Abdominal pain/ uterus consistency: tender and firm
Shock: may have some signs
Fetus: signs of fetal distress


What is the classification of severe placental abruption?

Blood loss: 2 or more litres of blood loss (50%+ placenta separated)
Abdominal pain/ uterus consistency: severe pain and solid
Shock: severe shock and risk of coagulation defects
Fetus: likely that fetus will be dead


Describe the management of mild placental abruption

Determine placental site using ultrasound scan and administer anti-D if woman is rhesus negative.
If less than 34 weeks, steroid can be given for lung maturation. Observation over a few days and then home if no further bleeding.
If 37 weeks or more then consider IOL


Describe the management of moderate placental abruption

Observation and documentation of maternal pulse, BP and blood loss.
Stabilise the mother first and treat for shock.
Analgesia if required
If baby is alive or showing signs of distress then consider c/s


Describe the management of severe placental abruption

If fetus is alive then c/s ASAP. If dead then vaginal delivery
Monitor vital signs and treat shock
Accurate fluid balance with indwelling catheter
Oxytocic drugs in third stage
Good communication skills


What is placenta praevia?

A placenta that is partially or wholly implanted in the lower uterine segment on either the anterior or posterior wall


List 7 risk factors for placenta praevia

- Previous c/s
- Uterine surgery
- Multiparity
- Maternal age
- Smoking
- Multiple gestation
- Placental abnormality


List 6 signs and symptoms of placenta praevia

- Painless bleeding usually after 32 weeks
- Bleeding after sexual intercourse
- Malpresentation of fetus
- Non engagement of presenting part
- Difficulty in identifying fetal parts on palpation
- Loud maternal pulse below umbilicus


List 5 potential maternal complication of a placenta praevia

- Severe haemorrhage
- Collapse
- Hysterectomy
- Death
- Future placental complications


List 3 potential fetal complications of placenta praevia

- Prematurity
- Fetal compromise
- Fetal death


Describe the management of placenta praevia

Management is conservative.
Monitor blood loss and fetal wellbeing and administer anti-D for rhesus negative women
Dexamethasone for surfactant production and lung maturity
Aim to deliver around 38 weeks
If placental edge less than 2cm from internal os or bleeding past 38 weeks then delivery by c/s recommended


What is vasa praevia?

When the fetal blood vessels on the placenta run through the membranes in front of the cervical os
If diagnosed then delivery should be by c/s


What does the abbreviation HELLP stand for?

Elevated Liver enzymes
Low Platelets


Describe the pathology of HELLP syndrome

Regarded as a variant of pre-eclampsia/eclampsia.
Similar pathology to DIC but usually clotting times are normal


List 7 signs and symptoms of haemolysis

- Anaemia
- Fatigue
- Pallor
- Anorexia
- Weakness
- Dyspnoea
- Possibly jaundice


What are the 3 signs and symptoms of elevated liver enzymes?

- Right upper quadrant pain
- Jaundice
- Hepatic failure


Why is HELLP syndrome difficult to diagnose?

Due to the vague nature of the symptoms


List 9 signs and symptoms of HELLP syndrome

- Right upper quadrant pain
- Nausea and vomiting
- Headache
- Visual changes
- Bleeding
- Jaundice
- Diarrhoea
- Weakness
- Fatigue


What is polyhydramnios?

Excessive amniotic fluid in the amniotic sac surrounding the fetus


List 4 functions of amniotic fluid

- Allows for growth and movement of the fetus
- Maintains a constant temperature for the fetus
- Equalises pressure and protects from injury
- Allows lung development


List 7 signs and symptoms of chronic polyhydramnios

- Gradual accumulation of fluid so not usually detected before 32 weeks
- Uterus larger than expected for dates
- Abdomen tense and shiny
- Fluid thrill detected
- Marked striae gravidarum
- Difficult to feel fetal parts
- Pressure symptoms exaggerated


List 8 possible effects of polyhydramnios

- Pressure symptoms (shortness of breath and oedema in legs)
- Unstable lie
- Malpresentation
- Pre-term labour
- Cord prolapse
- Inefficient uterine action resulting in prolonged labour
- Placental abruption


Describe the management of mild, asymptomatic polyhydramnios

- Advise mother to get plenty of rest at home
- Advise to be aware for membrane rupture and call triage immediately
- Good antenatal care, monitor maternal and fetal condition


Describe the management of symptomatic polyhydramnios

- Advice on relieving pressure symptoms
- Monitor maternal and fetal conditions
- Induction of labour possible if longitudinal lie
- Baby checked for oesophageal atresia
- Be alert for PPH
- Syntocinon continued after delivery


What is oligohydramnios?

Abnormally small amounts of amniotic fluid (500mls or less)


Name two things that are thought to cause oligohydramnios

- Placental failure
- Malformations of the renal tract


List 3 clinical signs of oligohydramnios

- Fundal height less than gestational age
- Fetal parts easily palpated
- Reduced fetal movement


Describe 3 stages of management of oligohydramnios

- Ultrasound scan to diagnose
- Labour may be induced because of placental insufficiency
- Adequate pain relief and fetal monitoring


What is cord prolapse?

When a loop of cord lies below presenting part when the membranes are intact and then prolapses once membranes rupture


What is an occult cord prolapse?

When the cord is alongside the presenting part


What is a frank cord prolapse?

When the cord escapes through the cervix


What procedure can increase the risk of cord prolapse by up to 50%?



List 3 signs and symptoms of cord prolapse

- Visible cord at vulva
- Cord felt on VE
- Fetal bradycardia / prolonged late deceleration following ROM


List 7 possible complications of a cord prolapse

- Perinatal mortality
- Hypoxia from compression
- Cooling or drying of cord causing spasm leading to decreased blood supply
- Operative delivery
- Haemorrhage
- Sepsis
- Psychological trauma


List 10 points to consider in the management of cord prolapse

- Call for help
- Maintain pressure on presenting part
- Remain calm
- Position mother on back, knees to chest and bum raised
- Replace cord in to vagina if slight prolapse
- Delay delivery by filling the bladder
- Urgent delivery
- Prepare for transfer to theatre
- Be prepared for resuscitation
- Documentation


In the case of critical care, what 10 things should be checked in the head to toe assessment?

- Level of consciousness
- Colour
- Respiratory rate
- Temperature
- Clammy to touch
- Blood pressure and pulse
- Oxygen saturation
- Urinary output
- Reflexes
- Blood loss


Name and describe the 3 layers of the uterus

- Perimetrium (external epithelial layer)
- Myometrium (muscular layer)
- Endometrium/Decidua (mucous lining of the uterus)


What is the definition of a retained placenta?

When the placenta remains undelivered following 30-60 minutes after birth


List 6 predisposing factors to a retained placenta

- Previous history of retained placenta
- Inadequate uterine contraction and retraction
- Third stage mismanagement
- Uterine abnormality (previous section scar)
- Preterm labour
- High parity


List 8 points in the hospital management of a retained placenta

- Attempt to deliver the placenta
- Administer oxytocic drugs with consent
- Empty the bladder using a bedpan if possible to change maternal position and utilise gravity
- Put the baby to the breast
- Encourage maternal pushing and effort (no controlled cord traction at this time)
- Observations
- IV access and bloods
- Prepare woman for theatre for manual removal of placenta


List 8 points in the home management of a retained placenta

- Attempt to deliver the placenta
- Administer oxytocic drugs with consent
- Empty the bladder
- Put the baby to the breast
- Encourage maternal pushing and effort
- Observations
- Contact ambulance control and receiving unit
- If the maternal condition worsens and heavy bleeding persists it is expected that a midwife must carry out a manual removal of placenta when no doctor is available


Describe the three different degrees of uterine inversion

First degree - fundus becomes inverted but does not pass through the cervix
Second degree - the inverted fundus protrudes through the cervix
Third degree - complete inversion of the uterus which appears outside the vulva


List 4 possible causes of uterine inversion

- Mismanagement of third stage
- Short cord
- Manual removal of placenta
- Precipitate delivery


List 12 points in the management of uterine inversion

- Call for help - obstetric emergency
- Woman will be experiencing severe pain, shock and potential haemorrhage
- Basic resuscitation
- IV access x2
- Bloods - cross match
- IV fluids
- Observations
- Facial oxygen
- Elevate end of bed and lower head of bed
- Analgesia
- Prepare for theatre
- Attempt to reposition uterus if possible


List 2 points in the management of uterine inversion at home

- Treat maternal shock
- Try to reposition uterus, if unsuccessful, wrap in sterile gauze swabs which have been soaked in warm water, wrap in a plastic bag followed by a towel. Get to hospital ASAP!


What is the definition and classifications of a postpartum haemorrhage?

Excessive bleeding from the genital tract within the first 24 hours following delivery.
Minor - 500-1000mls
Major - > 1000mls
Severe - > 2000mls


What are the four causes of PPH?

Tone - atomic uterus
Trauma - cervical/vaginal lacerations
Tissue - retained placental tissue
Thrombin - coagulopathies


List 12 antenatal risk factors for PPH

- Pre-eclampsia (coagulation problems)
- Nulliparity (no obstetric history)
- Previous PPH
- Previous section
- Multiple pregnancy
- High parity
- Fibroids (interferes with contraction of the uterus)
- Maternal anaemia
- Infection
- Coagulation problems
- BMI >35


List 11 intrapartum risk factors for PPH

- Multiple pregnancy
- Polyhydramnios
- Fetal macrosomia
- Prolonged labour (use of oxytocics to augment)
- General anaesthesia
- Ketoacidosis
- Mismanagement of third stage
- Prolonged third stage (over 30 minutes)
- Retained placenta
- Uterine inversion
- Coagulation problems


List 6 ways to prevent/anticipate a PPH

- Booking interview (establish if at high risk)
- Treat any anaemia
- Avoid routine episiotomy
- Actively manage third stage
- Correct management of third stage
- Re-examine after delivery


List 5 points in the management of PPH

- Stop the bleeding
- Resuscitate
- Monitor
- Investigate
- Communication


What signs and symptoms can you expect with a 500-1000mls PPH?

Normal BP
Compensated shock


What signs and symptoms can you expect with a 1000-1500mls PPH?

Mild shock


What signs and symptoms can you expect with a 1500-2000mls PPH?

Rapid weak pulse (>110bpm)
Cold clammy skin
Poor urinary output
Moderate shock


What signs and symptoms can you expect with a 2000-3000mls PPH?

Cold clammy skin
Peripheral cyanosis
Severe shock


List 6 points in the resuscitation of a woman following a PPH

- Secure airway/breathing (oxygen mask at 15 litres)
- Fluid balance (2 litres Hartmanns's, 1.5 litres colloid)
- Blood transfusion (O negative or cross matched blood)
- Blood products (FFP, platelets, cryoprecipitate, factor VIIa)
- Keep woman warm
- Beware of haemodilation and fluid overload


List 6 points for monitoring following a PPH

- Continuous pulse and BP
- Pulse oximetry / ECG
- Position flat
- Foley catheter, measure hourly urine output
- Clinical observation of bleeding and other signs of shock
- Documentation on MEWS chart


What is the definition of an amniotic fluid embolism?

When amniotic fluid, fetal cells, hair or other debris enter the maternal circulation


What are the 4 respiratory symptoms of an amniotic fluid embolism?

- Cyanosis
- Chest pain
- Dyspnoea
- Bloodstained frothy sputum


What are the 2 cardiovascular symptoms of an amniotic fluid embolism?

- Hypotension
- Cardiac arrest


What is a haematological symptom of an amniotic fluid embolism?



What is a neurological symptom of an amniotic fluid embolism?



List 7 points in the management of an amniotic fluid embolism

- Call for medical assistance
- Commence CPR
- Administer high concentration of oxygen
- Observations
- IV infusion commenced
- Central venous pressure line
- Delivery must be swift - probably section


What is the normal respiration rate of a newborn?

30-50 breaths a minute


What is the normal breathing rate of a neonate immediately following birth and up to 2 hours later?

60-70 breaths a minute


Describe 5 signs and symptoms of respiratory distress syndrome in a neonate

- Respiratory rate greater than 60 breaths a minute
- Chest recession
- Grunting
- Nasal flaring
- Central cyanosis


What are the 4 mechanisms of heat loss in the neonate?

- Conduction
- Convection
- Evaporation
- Radiation


Describe the conduction mechanism of heat loss in the neonate

Direct heat loss from the skin to cooler objects with which it is in contact with


Describe the convection mechanism of heat loss in the neonate

Heat lost through a current of moving air and is transferred from the baby's warm skin to cool air


Describe the evaporation mechanism of heat loss in the neonate

Transfer of heat to a drier atmosphere. Moist baby exposed to room temperature - there is a conversion of liquid to vapour


Describe the radiation mechanism of heat loss in the neonate

Transfer of heat from the baby's warm skin to cooler objects with which it is NOT in contact with


What is the normal temperature range in a neonate?

36.5 to 37.7 degrees Celsius


What are the 4 reasons that premature infants are at more risk of hypothermia?

- High surface area to body weight ratio
- Low levels of subcutaneous fat so less insulation capacity
- Low levels of brown fat stores
- High rate of transepidermal water loss


List 6 ways in which we can prevent heat loss in the neonate

- Keep delivery room warm and draft free
- Dry and re wrap in warm towels
- Put a hat on
- Skin to skin contact
- Use of polythene bag/wrap
- Heated cot