Flashcards in Mid Science Deck (229):
1
At what gestation do you anticipate
a woman will become nauseated and
what is the possible reason for this?
6-12-20 weeks
hCG increase,
Progesterone increase
decreased peristalsis
2
What element contributing to
conception is viable for 30- 80
hours?
Spermatozoa
3
List 5 common discomforts of
pregnancy and midwifery advice to
address these
N&V- small frequent healthy meals
Fatigue- rest when able
Constipation/ Haemorrhoids - A FEW
Heartburn- small meals avoid lying down after eating
Skin changes- sunscreen, moisturising
Dizziness- slow to stand, check iron, hydration, BP
4
What is the name given to the thick,
white mucousy discharge from a
woman's vagina during pregnancy?
Leucorrhoea
5
Name the seven most common
blood tests taken at the first
antenatal booking visit?
Blood Group, Rh factor, Antibodies,
Vit D, FBC, Rubella, Varicella, Hep B,
HIV,
6
What is the term that describes the
mother's first perception of fetal
movements?
Quickening
7
At what gestation are the trimesters
determined?
T1 = Wk 1 - 12
T2 = Wk 13- 27
T3 = Wk 28-42
8
What does the acronym EPDS stand
for and what does it assess?
Edinborough Postnatal Depression
Scale
Trick: it doesn't assess- it screens;)
9
Melanie is 29 years old,
At age 19, Melanie had a TOP at 6 weeks gestation.
At age 22, Melanie had a miscarriage at 12 weeks
At age 24, she had a stillborn baby at 22 weeks gestation at FSH born by Spontaneous labour and birth. Intact perineum. Autopsy: cause unknown, girl.
In 2011 Melanie had a liveborn girl Chloe at 41 + 3 weeks gestation at KEMH. Melanie was induced for post-dates. Intact perineum. Baby weighed 3,450g. Breastfeeding duration 6 months. Melanie is currently pregnant, with the due date 22 September 2017
by her 6 week U/S
G 5 P2 -1
10
What is the term for the ~butterfly
effect' or mask of pregnancy seen on
a woman's face during pregnancy?
Chloasma
11
What is the name of the brown
pigment line that appears in the
middle of a woman's abdomen
during her pregnancy?
Linea Nigra
12
At 24 weeks gestation where would
you expect to find the fundus?
Maternal Umbilicus
13
Why are the 28th and 34th weeks of
gestation important for a woman
who is Rhesus negative?
Recommended gestation for Anti-D
'prophylaxis'
14
PV, PR Screening for the presence of
which bacteria is offered to women
from 34 weeks gestation?
Group B Streptococcus
15
When is Term gestation?
40-42 weeks
RANZCOG - > 37 I 40
ACOG- 39/40- 40+6
RCOG 41 completed weeks
16
Name the seven bones that make up
the vault of the fetal skull.
Frontal x2
Parietal x2
Occipital
Temporal
17
Name the four sutures of the vault of
the fetal skull that are of importance in
midwifery care.
Frontal Suture
Coronal suture
Saggital Suture
Lambdoidal Suture
18
Name the 2 major fontanelles,
describe their shape and when each
of them closes.
Anterior fontanelle- diamond- 18- 24 months
Posterior fontanelle- triangle- 2 -3 months
19
Indicate the position of the fetus
when the occiput points to the right
S1 joint; and the saggital suture is in
the right oblique diameter of the
maternal pelvis
ROP
20
What is the word to describe the
movement of fetal bones that allows
the fetal head to reduce its
diameters.
Moulding
21
5 reasons to have a CTG antenatally
Reduced fetal movements
Over dates
Pain
To check for early labour
PROM
22
5 reasons to have a CTG intrapartum
High risk pregnancy
Epidural in place
Bleeding
SROM over 24 hours
Mech/ blood lycor
Prolongued second stage
23
How do you assess that someone is in labour?
-Assess the frequency, duration and strength of any contractions.
-Perform a vaginal examination. Note the following
The colour of the amniotic fluid if present., Cervical dilatation and effacement., Any caput or moulding present., Level and position of presenting part.
24
What is the definition of third stage and what are the recommendations
Third stage of labour: The part of labour from the birth of the baby until the placenta and foetal membranes are delivered
Active management of third stage should be recommended to all women as it shortens the third stage and reduces the risk of postpartum haemorrhage and the need for blood transfusion.
25
When do I know when to come into hospital?
Come into hospital if you have
- strong contractions 3- 4 in 10 mins
- waters have broken
- vaginal bleeding
- persistent abdominal pain
- Symptoms of high blood pressure
- Change in activity of your baby
26
How do you know shes in labour and what are you going to do.
- Persistent lower back pain or abdominal pain, with a pre-menstrual feeling and cramps.
- Painful contractions that occur at regular and increasingly shorter intervals, and become longer and stronger in intensity.
- Broken waters. Your membranes may rupture with a gush or a trickle of amniotic fluid. Either way, call your midwife or hospital to let them know.
- A brownish or blood-tinged mucus discharge (bloody show). If you pass the mucus plug that blocks the cervix, labour could be imminent, or it could be several days away. It's a sign that things are moving along.
- An upset tummy or loose bowels.
- A period of feeling very emotional or moody.
- Disrupted sleep.
get the mum to communicate with the ward so the midwife can assess how far along she is.
27
How do you know a woman is in second stage?
VE confirms full dilation of the woman's cervix
woman displays second stage behaviour such as moving around, unsettledness, feeling that they have to push, grunting noises, line that appears from the bottom upwards and woman is considered as fully, longer and stronger contractions with 1-2 mins apart, increased pressure in bottom, nausea and vomitting, early decels in a CTG stretching burning sensation in vagina,
28
What is active management of third stage
What is a physiological third stage? And what is normal.
Active management of the third stage is giving the woman a hormone, oxytocin (commonly known as Syntocinon® and Syntometrine®), after the baby is born, to assist in delivering the placenta. This hormone is the same hormone produced by the brain to get the uterus to contract in labour.
- the cord is cut and clamped and the delivery of the placenta is helped by pulling (often called traction) on the cord by the midwife or doctor.
29
what are the Personal Details needed for antenatal booking visit?
name, tel numbers, work, work place hazards, marital status, language spoken, religious or cultural needs, country of origin, ethnicity, smoker, drinker
30
what are the details required surrounding Medical / Surgical History?
gynaecological (last pap smear)
surgical
anaesthetic and reactions
mental health issues
Immunisations
Blood transfusions
known allergies
family history,
FGM
Dental care
31
Which screening tests are offered at booking visit?
Bloods – HB, Rhesus D Factor, FBC, Ferritin, Red-Cell Antibodies, Hep B, Hep C, HIV, STI’s, Rubella, Varicella
EPDS
Domestic violence screening
Ultrasounds – gestational age (dating scan), (Nuchal translucency screening), anatomy scan- location of placenta
Alcohol intake
smoking and nicotine
Drug intake
MSU sent and weekly urine Analysis for infection and proteinuria
32
Which baseline obs are done at booking visit?
BMI – weight and height
Maternal observations – BP, HR, Weight
Fundal height
Abdominal Palpation – not able to determine fetal position
Fetal heart rate
33
Which other appointments/referrals may be offered at a booking visit?
Social worker
Physiotherapist
Dietitian
Spec obs
Antenatal classes
Welfare officer
GP
other hospital dependent on co-morbidities.
34
What are the visiting schedules for a pregnant woman?
Traditional:
8 weeks (booking visit) then 4 weekly - 12 weeks -16 weeks - 20 weeks -24 weeks - 28 weeks
Then 2 weekly from 28 weeks -30 weeks -32 weeks 36 weeks -
Then weekly from 36 weeks -37 weeks -38 weeks -39 weeks -40 weeks -41 weeks
35
what are foods to avoid in pregnancy
Soft, blue, goats, sheeps, unpasteurised cheeses
Pates (and liver in large quantities)
Uncooked / cold / smoked seafood
Raw eggs (home made mayo / chocolate mousse / coleslaw)
Soft serve ice-cream/thick shakes
Cold deli meats (such as diced chicken, salami, ham)
36
what are the minor discomforts of pregnancy
Morning sickness
Constipation
Haemorrhoids
Varicose veins
Backache
Heartburn
Cramps
Tiredness
37
What is the management of nausea and vomiting
dry biscuits
fizzy drinks
ginger
acupressure
small meals simple carbs
38
what is the management of constipation
increase fluids
increase exercise
increase fibre - bran cereals, and vegetables
39
what is the management for haemorrhoids
increase fluids
increase exercise
increase fibre - bran cereals, and vegetables
Proctosedyl ointment for 7 days treatment
Pelvic floor exercises
Avoid straining on the toilet
Ice packs (10 mins in one hour)
40
what is the management for varicose veins
Keep legs elevated
Leg exercises
Support tights: (from chemist or possible refer to physio for measurement)
41
what is the management for vaginal varicose veins
Support
Pelvic floor exercises
Rest
42
what is the management for lower back pain
Low shoes
Use legs rather than back to lift
Avoid lifting, pushing, pulling as much as possible
Don’t slouch, lean
Roll onto side to sit up
Refer to physio
43
What is the management for reflux
Avoid fatty, spicy foods and caffeine
Drink yoghurt, coconut milk, cold milk.
Avoid tobacco and alcohol
Eat smaller meals slowly
Antacids: Gaviscon, Gastrogel
44
What is the management for leg cramps
Pull toes up to chin
Take a Magnesium supplement
Increase sodium intake (slightly)
45
What should be done at the 16 week appointment
Fundal height – clinical estimation
Fetal heart rate (if woman agrees)
BP and urinalysis
Invite women to discuss concerns/issues since last visit, offer verbal and written information
Review, discuss, record test results
Assess EPDS
If indicated, arrange follow-up investigations, referrals, reassess plan of care
Measure BP, weight if influences management, test urine for protein for women at high risk of pre-eclampsia
Offer fetal anomaly ultrasound scan for between 18-20 weeks
46
What should be done at the 24 week appointment
Invite women to discuss concerns/issues since last visit, offer verbal and written information, including
antenatal education
Offer screening for anaemia, blood group and antibodies
Discuss fetal movements (timing, normal patterns of behaviour)
Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of pre-eclampsia
47
What should be completed between 18-20 weeks
If the woman chooses, a morphology ultrasound scan should be performed. If the placenta is found to
extend across the internal cervical os, another scan at 32 weeks should be offered
Offer diabetes screening between 24- 28 week
48
What should be completed between 32 weeks
Invite women to discuss concerns/issues since last visit, offer verbal and written information, infant
feeding including breastfeeding and skin-to-skin
Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of preeclampsia,
discuss fetal movements
Review, discuss and record test results
Reassess plan of care; identify women who require additional care
49
What should be completed at antenatal appointment at 28 weeks
8 Invite women to discuss concerns/issues since last visit, offer verbal and written information, including
antenatal classes, infant feeding including breastfeeding and skin-to-skin
Offer Anti-D to rhesus negative women, investigate Hb less than 10.5g/100ml & consider iron
supplements, if indicated
Offer screening for anaemia, blood group and antibodies (if there was no 25 week visit)
Reassess EPDS at 28-30 weeks
Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of
pre-eclampsia, discuss fetal movements (timing, normal patterns of behaviour)
Measure BMI if this is likely to influence clinical management
50
What should be completed at antenatal appointment at 34 weeks
Invite women to discuss concerns/issues since last visit, offer verbal and written information, including
labour & birth, birth plan, recognising active labour, coping with labour, breast feeding (including skinto-skin)
or formula feeding if chosen
Discuss and provide written information on Group B strep and the screening test at 36 weeks
Discuss repeat full blood picture and Rhesus screening test at 36 weeks
Offer 2nd Anti-D to Rhesus negative women
Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of preeclampsia,
discuss fetal movements
Offer Ultrasound Scan to women if morphology scan suggested repeat to assess location of placenta
Reassess plan of care; identify women who require additional care
51
What should be completed at antenatal appointment at 36 weeks
nvite women to discuss concerns/issues since last visit
Offer verbal and written information, including care of the new baby, infant feeding, including
breastfeeding, safe sleeping, newborn screening tests and vitamin K prophylaxis, the postnatal period
including distress; provide an opportunity to discuss issues and ask questions; offer ongoing support
Offer Group B strep screening test
Measure symphysis-fundal height, BP, weight, test urine for protein for women at high risk of
pre-eclampsia, discuss fetal movements
Check position of baby, for women with breech presentation, discuss options and offer external cephalic
version (ECV)
Review ultrasound scan report if performed at last visit
52
What should be completed at antenatal appointment at 38 weeks
Review screening /diagnostic test results undertaken at 36 weeks and develop plan of care if required
Invite women to discuss concerns/issues since last visit, offer verbal and written information, including
normal length of pregnancy (two weeks before or after expected due date), onset of labour, any fears/
worries; provide an opportunity to discuss issues and ask questions
Measure and plot symphysis-fundal height, BP, weight, test urine for protein for women at high risk of
pre-eclampsia, discuss fetal movements
53
What should be completed at antenatal appointment at 40 weeks
For women having their first baby
Invite women to discuss concerns/issues since last visit, offer verbal and written information, including
options for prolonged pregnancy; provide an opportunity to discuss issues and ask questions
Measure symphysis-fundal height BP, weight, test urine for protein for women at high risk of preeclampsia,
discuss fetal movements
54
What should be completed at antenatal appointment at 41 weeks
Invite women to discuss concerns/issues since last visit , offer information, including further discussion
about options for prolonged pregnancy; provide an opportunity to discuss issues and ask questions
Measure symphysis-fundal height BP, weight, test urine for protein for women at high risk of preeclampsia,
discuss fetal movements
Offer membrane sweep, induction of labour
Advise to be vigilant of a reduction in fetal movements
55
What is the definition of the first stage of labour:
From the onset of regular purposeful contractions
(which cause cervical changes) until full
dilatation of the cervix.
56
What are the Signs of Impending Labour
Nesting
withdrawal
Mucous show
Need to feel safe
Braxton hicks
57
What is the latent first stage of labour
up to 4cm dilatation
58
What is the active first stage of labour
from 4 cm to fully
59
What starts labour?
drop in progesterone production by placenta so higher ratio of oestrogen to progesterone
Oestregen-increases myometrial sensitivity, promotes prostaglandins synthesis which promotes the release of oxytocin.
60
What can happen to Blood pressure in labour
Rises during contractions (systolic 10 – 20 mm Hg, diastolic 5 – 10 mm Hg)
Further exacerbated by pain, fear, apprehension
Can be lowered by lying on side
61
What can happen to metabolism in labour
Carbohydrate metabolism rises due to anxiety and increased skeletal muscle activity
Leads to increase in vital signs, cardiac output and fluid loss
62
What can happen to temperature in labour
Slightly elevated is normal, reflecting increased metabolism
Any significant or prolonged elevation may be due to dehydration or infection
63
What happens to maternal pulse in labour
Slightly higher than average during labour
More marked elevation with contractions
64
What happens to respiratory rate in labour
Slightly elevated
Exacerbated by excitement, pain, apprehension, breathing techniques (prevent hyperventilation)
65
Renal implications in labour
Increased cardiac output leads to higher glomerular filtration rate and increased urine output
Slight proteinuria common
66
Gastrointestinal implications in labour
Reduced gastric motility and absorption
Delayed gastric emptying of food (not fluids)
Nausea and vomiting common
67
Haematological implications in labour
Decreased blood coagulation time
Increased white cell count
Reduced blood glucose level
68
What is the effect of oxytocin in pregnancy and birth
Uterine contractions
Pressure of baby on cervix
Distension of pelvic floor muscles
Stretching of perineum
Oxytocin receptors increase in number as gestation increases
69
What are the triggers for oxytocin release
Stimulation of clitoris
Distension of the vagina
Pressure on the cervix
Distension of pelvic floor muscles
Stretching of the perineum
Nipple stimulation
70
What are inhibitors of oxytocin release
Fear and anxiety
Anaesthesia
Exogenous oxytocin
Episiotomy
Separation of mother and baby
71
What are the effects of adrenaline in pregnancy and birth
Inhibits oxytocin production and release
Reduces blood flow to uterine muscle which results in increased pain
Pause in cervical dilatation
Raised BP
Panic behaviours
72
What do you need to know when a woman enters the labour ward
Record medical/social/obstetric history/allergies
Frequency and duration of contractions
Are the membranes ruptured?
How is the woman coping?
Is there a birth plan or obstetric plan?
Group B strep status
Blood group
73
What are the regular observations that need to be done for a woman in labour?
As per policy
Temp 4/24 if membranes intact, 2/24 if ruptured and 1/24 if febrile
Pulse 4/24 in latent phase and 30 minutely in active
BP 4/24 in latent phase and 2/24 in active labour
Resps on admission and as per policy
Amniotic fluid if ruptured 2/24 in early labour, 30 minutely in active labour
Bladder: U/A on admission, regular bladder emptying (2/24 and measure in active labour)
Diet as appropriate
Fetal heart rate: 15-30 minutely. Also fetal movements, though these may be reduced
74
What is the normal fetal HR
110-160
75
What are signs of transition
Any or all of the following:
Belief she can’t carry on
Panic
Fearfulness (sometimes of death)
Disorientation
Nausea
Uncontrollable shivering
Demands for pain relief
Shouting and screaming
Slowing contractions
Heaving ‘show’
A period of dozing
Variable urge to bare down or push
76
Define latent second stage of labour
Cervix found to be fully dilated prior to involuntary expulsive contractions. Fetal head descends and rotates through pelvis
77
Define active second stage of labour
Fetal head visible -expulsive contractions occurring with signs of full dilatation
Active maternal effort at full dilatation in the absence of expulsive contractions
78
What are the expulsive signs of labour
Urge to push:
“Grunting” noises
Urge to poo
Perineal bulging and thinning
Anal “flowering”: pouting and dilating
Vagina gapes, and eventually the presenting part is visible
Rhombus of Michaelis: Rounding of the lower back
Discomfort under the ribs (anecdotal)
79
How do you prepare the room for delivery?
Warm linen/towels for the baby where possible
Check and set up the newborn resuscitation equipment
Prepare and check any medications that will be given at the birth
PPE
Birth pack on trolley
80
What items should be available on the birth trolley?
Gloves
Plastic apron
Forceps for clamping the cord
Scissors for cutting the cord
Scissors for an episiotomy
A plastic cord clamp
Gauze swabs
Plastic bowls
Linen
Cord blood collection bottle and heparinised syringes and needles for cord gas collection if needed
Syringe and needle for oxytocic
Oxytocic: As per hospital policy
(10ml syringe and 20ml lignocaine 1% under trolley)
(If membranes not ruptured amnihook under trolley)
81
when to do obs in second stage?
As per hospital protocol
BP 1/24 | Maternal HR ½ hourly | Temp 2/24
Regularly empty bladder
Amniotic fluid: colour and odour
Contractions ½ hourly
Vaginal exams: PRN
Fetal heart rate (FHR) every 5 minutes, during and at least 30 seconds after a contraction
FHR monitoring if complicated birth, epidural or more than 1 hour active pushing with birth not imminent
82
When should you coach pushing in second stage?
Only coach pushing if:
Difficulty with effective pushing- epidural
Prolonged second stage
Non-reassuring fetal heart rate
83
What is the approximate time of first and second stage for a primigravida?
1st stage 12-14 hours
2nd stage 60 minutes
84
What is the approximate time of first and second stage for a multigravida?
1st stage 6-10 hours
2nd stage 30 minutes
85
What is the role of the placenta
The placenta sustains life delivering oxygenated blood, filtering fetal waste and carrying the -O2 back to maternal circulation for oxygenation via the umbilical cord.
86
What does the umbilical cord comprise of
Two umbilical arteries which convey deoxygenated blood to the maternal circulation.
One Umbilical Vein which conveys oxygenated blood from the mother to the baby.
Wharton’s Jelly –a tenacious jelly-like substance which cushions the umbilical vessels.
87
What are the two names given to the way the placenta is delivered
Shiny Schultz
Dirty Duncan
88
Describe active management of third stage
Give Syntometrine1 amp (primips) or Syntocinon10iu (multips) after birth of the anterior shoulder (Refer Policy)
Clamp and cut the cord.
Wait for signs of separation of the placenta:
-hand on the fundus to feel for contraction; fundus becomes hard and narrow
-trickle of blood vaginally
-lengthening of the cord
89
What do you do in an active third stage
Guard the uterus by placing hand above symphysispubis
Apply traction to the cord down towards the sacrum
When placenta is seen at introitus lift cord upwards.
•As widest diameter of placenta fills the vaginal entrance place hand below to catch placenta.
•If membranes are trailing rotate the placenta continually until membranes fall out.
•Check fundusand lochia.
90
What is involved in a physiological third stage
Delayed clamping and cutting of the umbilical cord to allow continued pulsation
Encourage baby to suck at breast to stimulate release of natural oxytocin
Encourage upright maternal posture and maternal effort to aid expulsion
Once placenta is visible at the vulva, the midwife may assist by lifting cord and collecting placenta
Controlled cord traction is NOT performed as this could lead to uterine inversion
91
What does APGAR stand for
Activity
Pulse
Grimace
Appearance
Respirations
92
When examining the placenta what are you looking for
Observe any malodour , healthy placenta almost odourless, feint alkaline smell.
Inspect membranes for completeness either complete or ragged.
Strip the amnion back from chorion to examine presence of both membranes -
Fetal surface examined –shiny, healthy, cord insertion site, no irregularities.
Maternal surface examined to ensure all lobes are present & for any abnormalities.
Cord examined for number of cord vessels, Whartons jelly, length & for any abnormalities
93
Define primary PPH
>500 ml blood loss or any blood loss sufficient to cause haemodynamic instability in 1st 24 hours after birth
Some say >1000ml (C/S)
Massive obstetric haemorrhage= >1500-2000 mls
94
Define secondary PPH
Abnormal/excessive bleeding 24/24 –6 weeks after birth
95
What are some of the antenatal PPH risk factors
Pre-eclampsia
Prev Hx PPH/retained placenta/MROP
Previous caesarean section
Grand multip>P4
Prolonged labour
Rapid or incoordinated labour
Anaemia
Over-distended uterus
Multiple pregnancy
polyhydramnios
APH (abruption)
Coagulation disorders
Uterine disorders
96
What are some of the intrapartum PPH risk factors
Dystocia
Prolonged third stage
Episiotomy
Lacerations -cervical -vaginal -perineal
Assisted delivery -forceps =vacuum
Induced/ augmented labour
Retained products -Cotyledon -Succenturiate lobe -Membranes
Uterine rupture or inversion
97
How can we prevent a PPH
Treat anaemiaantenatally
•Avoid episiotomy
•Be prepared if risk factors present
•Have a plan for 3rdstage (? high risk)
•Actively manage third stage of labour
•Re-examine woman frequently after birth
98
What are the benefits of skin to skin for the neonate
Greater respiratory, temperature and Glucose stability
Causes release of Oxytocin
Decreases sensation of pain/ distress
Assists to identify maternal odour
Assists colonisation with maternal flora
99
What are the benefits of skin to skin for the mother
Increases release of Oxytocin
Hormone of bonding and attachment
Assists with Uterine Involution
Works synergistically with Endorphins
Cements feelings of love and nurture
Increased confidence with parenting
Longer breastfeeding rates
100
What are the initial postnatal observations for mum
Fundal height
•Lochia every 15 minutes initially
•BP •P •RR •Perineum 30 mins for 1st hour
Hourly for 2nd hour then
Four hourly
•Temp –once or hourly
30 mins for 1st hour
Hourly for 2nd hour then
Four hourly
101
What are the initial postnatal observations for baby
Respirations (30 –60)
•Colour (pink)
•Airway patent
Within the 1sthour
•Temp (36.5 –37.4)
•Heart Rate
•SaO2 on R wrist
•Tone
102
What should be done after birth
Repairing the perineum
Feeding the baby
Food and drink
Shower
Bladder Care
Hygiene and Comfort
Obs
Practical support
103
Responsibilities to the neonate straight after birth
Skin to skin
Breast feed
Cephalocaudal examination
Weight
Length
Head circumference
Vitamin K
104
Some considerations after birth
Epidural removal
Suture technique
Shoulder dystocia form
IVI removal and fluid balance
Drug chart: ?antibiotics, analgesia
105
What documentation must be completed after birth
Fill in/sign the Medicare/ government financial benefits (Family Tax Benefit A & B, Maternity Payment (must be done within 26 weeks of birth).
Fill in the birth register
Fill in/sign the birth registration form
Enter STORK into computer
106
On postnatal ward what are the assessments required
Vital signs (temp, pulse, BP)
Uterine involution
Lochia
Perineum and vulva
Urinary elimination
Bowel elimination
Breast care
Legs
Haemorrhoids
Other…epidural site, iron levels, pelvis stability, physio needs
107
What is Involution?
Involution is the process by which the uterus returns to its normal size, tone and position. The ovaries and uterine tubes become pelvic organs again
108
How do you check the fundus postnatally?
Procedure:
Empty bladder
Gently palpate uterine fundus
Were membranes and placenta complete?
Educate woman (and family) on what to expect
Considerable variability has been found in the pattern of uterine involution experienced by women who have had a normal puerperium
109
What is normal involution?
Fundal height reducing daily by about 1 cm and is firm and central (and not palpable by day 10)
Lochia reducing and changing (rubra, serosa, alba)
Involution pains reducing and gone by day 3
No offensive discharge or pyrexia
110
Describe the different types of lochia
Discharge classified according to its appearance & contents
lochia rubra(red)
lochia serosa (pink)
lochia alba (white)
111
What is lochia and what is considered normal postnatally
Discharge heavier following rest periods due to pooling of lochia in the vagina
Amount may be increased due to exertion or breastfeeding
Type, amount & consistency of lochia reflects progress of placental site healing
112
Describe lochia rubra
Occurs first 2 -3 days
Dark/bright red in colour
Composition of blood -epithelial cells, erythrocytes, leukocytes, shreds of decidua, & occasionally fetalmeconium, lanugo & vernixcaseosa
A few SMALL clots considered normal
113
Describe lochia serosa
From about the third to tenth day
Pinkish to brownish colour
Composed of serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucous, numerous micro-organisms
114
Describe lochia alba
Gradual decrease in blood cell component to creamy yellowish discharge
Continues from about 10 days to up to 6 weeks
Composed of leukocytes, decidualcells, epithelial cells, fat, cervical mucous, cholesterol crystals & bacteria
When lochia stops cervix is closed
115
How to care for the perinium postnatally
•Diclofenac suppository after suturing
•Keep it clean and dry
•Crushed ice for 10 minutes 2 hourly
•2 baths or showers a day
•Pelvic floor exercises
•Rest
•Physiotherapy for particularly swollen perinea
•Salt baths are not proven to be beneficial
•Manual support when bowels open
116
How to care for haemorrhoids postnatally
Fibre rich diet
Increased fluids
Ice
Pelvic floor exercises
Anusol
Scheriproct/Proctosedyl
117
Bladder care postnatally
Physiological diuresis
Bladder tone returns to normal in first week
Risk of Urinary Tract Infection (UTI) Assessment
Should void within 4-6 hours of birth
Normal: Sensation Flow Volume
Two consecutive voids 150-600mL
Is woman experiencing any pain or discomfort
118
Bowel care postnatally
Ask woman if she is experiencing any discomfort
Discuss any concerns
Medications
Diet
Aperients
119
When is Anti D Given and why
Routine antenatal anti-D immunoglobulin prophylaxis (28 & 34wks)
Again within 72hrs of birth (after cord blood sent & maternal kliehauer sent following birth) if baby is Rh-pos or antibodies are detected in maternal blood. Or after any other sensitising event
This destroys any fetal cells in the mothers blood before her immune system produces antibodies
120
When and why is MMR given ?
Sero-negative for Rubella should be offered a MMR vaccination following birth and before discharge
Rubella during pregnancy associated with high risk of congenital abnormalities (Rubella Syndrome)
Probability of further pregnancy within the first 30 days postnatal is small therefore appropriate time to immunise
121
When and why is ADCEL given ?
Increase in whooping cough incidents in newborn infants and children
Contracted through an adult source
Program commenced to re-immunise adult population for whooping cough
122
Reproduction advise to be given
Return of menstruation by 6 weeks in the non-lactating woman
Lactating woman unpredictable
Ovulation may be delayed for 10 -12 weeks
Progesterone Only Pill (POP)
Implanonimplant
“You are never 100% safe”
123
What postnatal care is required for cesarean birth
Access to call bell
More frequent observations
Wound checking: Dressing in situ for 48 hours
Suture/staple/drain removal
No fundal checking
Deep breathing exercises
IV therapy?
TEDS
IDC care
Epidural care
More assistance with baby care and feeding
Early ambulation and falls prevention (check legs before ambulating)
Education: reason for C/S, future pregnancies, lifting and driving
124
Care of the neonate on the ward
Rooming in
Vital signs –GBS?/ IVABs in labour/ CS
Hygiene
◦nappy changing
◦Bathing
◦Umbilical cord care
Responding to Baby
125
What are the postpartum blues?
‘Normal’ condition in response to changing maternal hormonal levels
Tearful, sensitive about comments relating to baby or themselves
Occurs in first few days after birth ~ often around days 2-4
Treatment ~ support, reassurance & adequate sleep
126
What is postpartum psychosis
Incidence 1 :500 women
Occurs in first 4 weeks following birth
Syndrome characterized by delusions, being out of touch with reality, manic & depressed phases, paranoid, suicidal thoughts
Psychiatric emergency often requiring psychiatric hospitalization ~ ‘mother and baby unit’
Treatment ~ psychological therapies and medications including antipsychotics and mood stabilizers
127
What is postpartum depression?
Incidence 1:6 women
Increased risk for women with a previous history of depression or antenatal depression
Can start at birth or in the first few months post birth
Can be mild or severe
Feelings of inadequacy/unable to cope on more than half the days of the week
Tearfulness, irritability sleeplessness, low energy, suicidal thoughts
Treatment ~ as per depression
128
What do women need to know before going home
Visiting Midwifery Service
Contraception?
Community resources
Support groups
Child Health Nurse
Postnatal 6 week check
129
How often should you listen to the fetal heart rate in labour
15-30 mins for 1 min evey 5 mins in second stage
130
What do you listen for in fetal heartrate when using intermittent auscultation?
Baseline rate
•Variability
•Periodic changes (accelerations and decelerations)
131
What is considered good variability in fetal heart rate?
If the doptone has a counter watch the rate per minute change. If there’s a difference of 5 beats over the 30 secs it demonstrates good variability
132
Why do we listen to FHR during a contraction
One of the goals of listening throughout the contraction and for a brief time after the contraction resolves is to identify variable and late decelerations of the FHR
133
what are the risk factors for changing to CTG monitoring
significant meconium-stained liquor,
•abnormal FHR detected by intermittent auscultation (less than 110 beats per minute [bpm]; greater than 160 bpm; any decelerations after a contraction)
•maternal pyrexia (defined as 38.0 °C once or 37.5 °C on two occasions 2 hours apart)
•fresh bleeding developing in labour
•oxytocinuse for augmentation
•the woman’s request
•ACTIVITY………….
134
What are the reasons to use CTG monitoring in labour
IUGR
•Previous abnormal antenatal CTG,
•oligohydramnios,
•polyhydramnios
•Pre-eclampsia
•Antepartum or intrapartum haemorrhage
•Prolonged rupture of membranes
•Chorioamnionitis
•Prolonged pregnancy greater than 42 weeks
•Multiple pregnancy
•Breech presentation
•Diabetes –women on insulin, fetus is macrosomic or diabetes poorly controlled
•Prior uterine scar or previous Caesarean section
•Current or previous obstetric or medical condition which may pose a significant risk of fetal compromise
IOL with prostaglandins /oxytocin
• Abnormal auscultation –baseline less than 110, greater than 160 or decelerations
• Oxytocin augmentation
• Epidural
• Abnormal vaginal bleeding in labour
• Maternal pyrexia of 38°C or more
• Meconium or blood stained liquor
• Absent liquor
• Active first stage of labour greater than 12 hours (ie regular uterine activity, cervix 4 cm or more dilated)
• Active second stage (ie pushing) of greater than one hour when birth is not imminent
• Pre-term labour less than 37 completed weeks
135
What is neuraxial blockade?
the administration of analgesics into the spinal/epidural space. This gives a powerful analgesic effect.
136
What are women’s expectations around pain in
labour?
What are women’s expectations around pain in
labour?
• Background
• Peer influences
• Culture
• Geography
• Availability
137
How does an epidural work?
They work by blocking pain fibres as
they enter the spinal cord
• By directly blocking the pain fibres
epidurals can selectively block pain
transmission
• Selectively blocking pain fibres
decreases side effects
138
What is the Anatomy of the vertebrae
cervical x 7
thoracic x 12
Lumber x 5
Sacral x 5
coccygeal x 4
139
What is the Anatomy of the spinal ligaments
Supraspinous -strong and fibrous - thickest in lumbar region
• Interspinous - thin membranous - thickest in lumbar region
• Ligamentum flavum - the yellow ligament -comprises of elastic fibres - connects adjacent laminae of
vertabrae
• Longitudinal ligaments - the anterior and postierior
longitudinal ligaments bind the vertebral bodies together
140
What are the meninges
3 connective tissue layers that run around the spinal cord and brain offering protection and containing CSF.
141
What is the dura mater
the outermost layer - tough fibrous membrane continuous with the cerebral dura.
142
what is the arachnoid mater
the middle of the three coverings of the brain and spinal cord. It is a delicate non vascular layer of the meninges
143
what is the pia mater
delicate highly vascular membrane surrounding the spinal cord and brain
144
What are the spaces called in the meninges
epidural space, subdural space, subarachnoid space.
145
How many pairs of spinal nerves are there?
31 pairs of spinal nerves
attached by anterior and
posterior roots. These join and
exit the spine to form peripheral
nerves which supply a ‘segment’
of the body, known as
dermatomes.
146
How many types of spinal nerves are there
3 types of nerves:
• Sensory
• Motor
• Autonomic (sympathetic)
147
What are sensory nerves responsible for
carry messages of touch, pressure, temperature and pain to the spinal cord
148
What are motor nerves responsible for
they carry messages to the muscles
149
What are autonomic nerves responsible for?
maintain venous and arterial tone
regulates autonomic tone - gastrointestinal, GIT and endocrine
150
What are the reasons for checking dermatomes
Unilateral block (only covering one side)
High block (above T4)
Low block (not covering incision/contractions)
Adequate block but still experiencing pain (requires larger opioid doses)
151
When to check dermatomes?
Prior to giving a bolus containing local anaesthetic and 20 minutes following the bolus
Prior to leaving the recovery room in theatre
Prior to increasing an epidural infusion rate containing local anaesthetic and 20
minutes following the increase
Poor pain control
If you suspect the block may be high
Three times in 24 hours (at the beginning of each shift)
Only when local anaesthetic is used
152
How to calculate Bromage score
1. sustains leg raise
2. can hip flex easily
3. can hip flex but overcome by gravity or pressure
4. can hip flex cant sustain flexion against gravity
5. cannot hip flex
153
what is Melatonin?
Endogenous Produced by the body
Concentrations peak during labour
Works synergistically with Oxytocin
Levels become increasingly higher towards the end of pregnancy
Post pregnancy levels return to normal
Facilitates rhythmical labour patterns
Peak concentrations at second stage
Affected by blue lights
Modulates other hormones Scavengers Free Radicals
Concentrations peak at night
154
what is Prostaglandin
Enhances the immune system
Is produced and affects tissues locally
Synthetic versions used to ripen cervix for labour
Appreciable amounts of this hormone found in Semen
Release is affected by Epidural Analgesia
155
What are Catecholamines
(Adrenaline/ Nor Adrenaline)
Secreted by the body in response to painful stimulus
Released by the Adrenal glands in response to SNS stimulation
Release of this hormone will inhibit production and release of oxytocin
Release will reduce blood flow to uterine muscles which can result in increased pain in labour
Fight or Flight Hormones divert blood flow to large muscle groups
Causes a raise in BP, Pulse
156
What is Prolactin
Neuroprotective mechanisms in Fetal Brains
Fathers and expectant fathers have higher levels of this hormone than celibate males
Responsible for Lactogenesis
Levels of this hormone naturally peak at night
Levels peak 1 -2 hours after birth
Increases REM sleep
Increase in apetite
Alteration of sleep wake cycle
157
What are Beta-Endorphins
Endogenous
Produces feelings of pleasure and joy
Similar molecular structure to Morphine. (translation means endogenous Morphine)
Can cause an altered state of consciousness
Release is stimulated by activation of Parasympathetic NS
‘Rest and Digest’
Works Synergistically with Oxytocin
158
Nitrous oxide and oxygen (N2O &O2) how does it work?
Acts by limiting the
neuronal and synaptic
transmission within the
central nervous system
thereby in hi biting pain
pathways in ~ brain
159
When should you seek help in pregnancy?
Abdominal pain or sudden onset of back pain
Baby is moving less than usual
Fainting
Fever
If your 'waters' (liquor) break;
watery vaginal discharge
Urinary problems, including frequency or burning
when passing urine
Blurred vision
If you think labour has started
Vaginal bleeding
Swelling in your hands, feet and face first thing in the
morning
Unusual headaches [severe/persistent]
Constant itching
Uncontrollable vomiting or diarrhoea, severe nausea
You are worried
160
When is discharge postnatally after SVD
Discharge home after a vaginal birth is usually within 4 - 24 hours after birth
161
When is discharge postnatally after cesarean section
Discharge home after a vaginal birth is usually within 4 - 24 hours after birth
162
How would you manage a lady with perineal trauma postnatally
Simple oral analgesia (paracetamol) +/-NSAID (if appropriate)
Cold compresses 10 mins every 2 hours
Positioning
Hygiene avoid soaps/ perfumed products/ cotton underwear
Wash and pat dry
Change pad every 3 hours or as necessary
Wipe from front to back after toileting
Good bowel habits
Consider Physio referral
Teach PFE’s
163
which opioids can be given in labour?
Morphine
Tramadol
Fentanyl
164
What are the side effects of opiods
Respiratory depression
Drowsiness. dizziness
Sedation
Mood changes
Euphoria
Dysphoria
Mental clouding
Headache
Nausea & vomiting
Bradycardia and EEG changes.
165
What effects does morphine have on the fetus
Morphine acts as a vasoconstrictor of
the placental vasculature
•Morphine significantly lowered the
APGAR score
•Placental retention of morphine
prolongs fetal exposure to morphine
•Reduced FHR variability and acid-base
•Risk of respiratory depression and
drowsiness
•Decreased success with
breastfeeding
166
What are the midwifery responsibilities when giving an opioid medication in labour
Informed consent required (side effects, risks and benefits to woman and baby)
Due consideration for potential risks and progress of labour (VE prior to administration may
be indicated)
Women should not enter water (birthing pool or bath) within 2 hrs of opioid administration
Caution in preterm labour- foetal metabolism
Any contraindications or allergies?
Ensure availability of opioid antagonist {Naloxone)
Consider anti-emetic
Follow institution guidelines reschedule 8 medications
Record and document maternal (and fetal) observations. e.g.
RR hourly
BP hourly
Urinary output(? Retention)
167
what are the pharmacological interventions for pain in labour
Nitrous oxide and oxygen can be an effective analgesic for labouring women
particularly in early labour
Opioids in labour can provide relatively adequate analgesia but knowledge
of side effects and risks are important
Epidural analgesia can provide excellent pain relief for labouring women and
may increase their satisfaction with their birth experience
Epidurals can increase the chances of interventions and
instrumental/operative births
168
In which clinical situations would an episiotomy be performed?
To Speed Up a Prolonged Labor when there is fetal distress
During Assisted Vaginal Delivery
Breech Presentation and use of forceps
Delivery of Large Babies - shoulder dystocia
Patients with Previous Pelvic Surgery - FGM, previous episiotomy
Abnormal Position of the Baby's Head - face presentation
Delivery of Twins
169
Describe the rationale(s) for the timing of an episiotomy.
The perinium should be bulging and the baby iminent within 2-4 contractions as this reduces risk of lacerations and unnecessary blood loss
170
What are the possible short term and long term problems that may be associated with episiotomy?
urinary incontinence, anal incontinence, sexual dysfunction
Short-term side effects include pain and swelling of the episiotomy site. Over the long term, an episiotomy can contribute to a condition called dysparunia, or painful intercourse, as well as pelvic floor weakness, which can lead to difficulty controlling your urine or stool.
171
what is the role of a child health nurse
•care for Babies and young children up to the age of
4 years.
• assess baby and child health development
• provide ongoing support for families
• Growth and nutrition guidance
• act as a link between hospitals and the community
• working with family GPs and other health professionals
• Education is provided to help parents understand their baby and have realistic expectations
172
How is the role of the father viewed
Breadwinner, protector, discipline
Support Mum during pregnancy
The “fun” parent – play and humour
Less competent parent – around the house
Main focus on Mum by parenting services
173
Why Engage Fathers?
Coparenting - Focus on the Mother and Father
Parenting Relationship
The need of children to be stimulated, pushed
and encouraged to take risks is as great as
their need for stability and security. (father role)
Children need to learn to deal with unexpected
events
Expectant fathers who have a strong desire to participate in their partner’s pregnancy can be left
disillusioned when they are not acknowledged by health professionals
174
What are dads expectations of the birth
emotionally connected to their child.
To feel involved and useful at the birth.
Practical information on caring for a newborn.
Encourage and acknowledge role as Dad
More information about changes after birth.
Strategies to help with changes in relationship after birth
175
What might be barriers to Dads engaging in
family support services?
Help seeking behaviour
Conflict with work.
Dads perceptions of the service – For Mums?
Previous negative experiences.
Staff attitudes
Staff inexperienced working with men
176
What are the three types of immunity?
Anatomical (saliva, cilia)
•Innate (acute inflammation)
•Adaptive (production of antibodies or specific cells recognise and destroy pathogens)
177
What is herd immunity?
The proportion of people in a community with immunity to a specificinfectious disease.
•Decision to vaccination affects everyone
178
Why immunise
immunisation is second only to clean water as the public health intervention with the greatest global impact.
•Immunisation is one of the most successful and cost effective health interventions ever
179
What is the Midwives role in immunisation?
Antenatal vaccines added to schedule
•Midwife may be first health professional to discuss vaccination with new parents
•Birth dose Hep B administered by Midwives in hospital
•Health providers have great impact on client’s decision making
180
If planning a pregnancy what immunisations should you have?
Should be fully immunised against:
–Varicella (chickenpox)
–Measles, mumps and rubella
–Hepatitis B
–Influenza
–Pneumococcal
181
Which immunisations should a pregnant woman have?
Influenza:
Recommended for all women at any stage Particularly those in 2nd or 3rd trimester during flu season
Pertussis:
Recommended for all women Single dose
During 3rd trimester (28-32 weeks)
182
Why should women have the influenza jab in pregnancy?
•Higher risk of serious complications
–Pneumonia and cardiopulmonary events
–All trimesters, but particularly later in pregnancy
•Depressed cell-mediated immunity
–Less able to clear influenza infection
•Reduced tidal volume and increased cardiac output
–Less able to handle cardiopulmonary stress of respiratory infections
183
Why is pertusis given in pregnancy?
Pertussis can be very serious (potentially lethal) in young babies under 6 months of age
–90% of hospital admission for pertussis are in infants <6 months
184
How does maternal vaccination protect the unborn baby?
Passive Immunity
•Antibodies travel across the placenta from the mother’s blood to the growing baby’s blood
•While babies’ immune system is developing, they are protected by antibodies from their mother
•Babies may not be fully protected by vaccines until 6 months
185
When are pregnancy vaccines given?
•Influenza:
–Seasonal influenza vaccine can be given in any trimester of pregnancy.
–Preference near when flu is circulating in community, but should be provided throughout season.
•Pertussis:
–Pertussis vaccine is recommended as a single dose during the third trimester of each pregnancy.
–The optimal time for vaccination is between 28 and 32 weeks gestation, but the vaccine can be given at any time during the third trimester up to delivery.
–Recommended every pregnancy to provide maximal protection to infant –this includes pregnancies which are closely spaced.
186
Which vaccines are given after pregnancy?
MMR and varicella if found to be low during pregnancy
187
On admission to labour ward what should be discussed?
Positioning for labour and birth
• The role and responsibility of the care providers
• Who will be present for the birth?
• Eating and drinking during labour
• The use of cameras and video recordings
• The use of music or other therapies
• The use of and availability of pain relieving methods
• The use of intermittent and electronic fetal heart rate monitoring
• The use of any intervention in the labour and birth process
• Care during the actual birth of the baby – including care of the perineum, the use of an oxytocic
for the third stage, cutting the cord
• What will happen to the baby after the birth?
188
What are non pharmacological interventions for pain in labour?
• Water immersion
• TENS
• Complementary therapies
• One-to-one support
• Breathing and distraction techniques
189
What are the circulatory changes in the newborn at birth?
The shunting mechanisms of the fetal circulation begin to change as the baby is born and the low pressure placental circulation begins to shut down.
As the newborn takes it’s first few breaths, the high vascular resistance of the pulmonary
vessels falls, allowing blood flow to the lungs to increase. The shunting of blood through the ductus
arteriosus continues to occur for a few hours following birth but as pulmonary pressures increase and
stabilise in the first few days of life, and placental prostaglandin levels fall, the shunting of blood
gradually decreases and the duct closes.
190
What are the essential components to transition to extra-uterine life?
• Circulatory adaptation
• Pulmonary adaptation
• Thermal adaptation
• Endocrine adaptation
• metabolic adaptation
191
Describe circulatory changes in the newborn
Closure of the occurs soon after
birth, permanent closure may take a couple of months.
•Clamping of the cord equalizes pressure in the
right and left chambers of the heart
• Increase in blood supply to the pulmonary
circulation
• Functional and then permanent closure of the
shunting mechanisms ( Ductus Venosus, Ductus Arteriosus, Foramen Ovale)
• Umbilical vein and arteries occlude
• Direction and pressures of blood flow and heart
workload alter to resemble that of the
permanent human circulatory system
192
What are the stimuli to start breathing at birth
• Squeezing and recoil of the thorax
• Catecholamine release
• Rise in the partial pressure of carbon dioxide and a ‘physiological asphyxia’ of a fall in the blood pH which stimulate the respiratory centre
• Replacement of fluid with air in lungs
• Fall in environmental temperature
• Tactile and sensory stimulation
• Clamping and cutting of the umbilical cord
• Reflexes – Heads paradoxical reflex, Hering Breuer reflex
193
What are the pulmonary changes at birth
•0 Infant is squeezed through the birth canal
• Physiological asphyxia stimulates gasping on
release from birth canal
• Lung fluid is squeezed out and chest wall
recoils
• Release of surfactant
• Air replaces lung fluid
• Heads paradoxical reflex - air entering
bronchi stimulates reflex gasping
• Hering Breuer reflex – stretch receptors
operate and infant exhales
194
Explain thermoregulation in the newborn infant
Heat production in the newborn occurs via a process of non-shivering thermogenesis which is
characterised by:
• The metabolism of brown fat (in the upper spine, clavicles and the mediastinum), adipose tissue
deposits that are unique to newborn infants
• An increase in the metabolic rate
195
How can the midwife ensure thermoregulation at birth
Ensure the environment is warm (at least 20 degrees) and free of draughts
• Encourage immediate and close skin to skin contact between mother and newborn at birth – or
dad if mother is unable to hold baby
• Perform any resuscitation or examination of the newborn under the warmth of a radiant heat
source
• Encourage early initiation of infant feeding
• Ensure the baby is dry and adequately covered - consider covering the head of the baby initially
(beware of overheating though)
• Whenever possible, use prewarmed towels, clothes and wrappings for the baby
• Delay bathing the baby until the temperature is stable
196
what are the gastrointestinal changes in the newborn
Reflexes enable baby to suck and feed
Co-ordination of suck, swallow and breathe quickly learned
Meconium passed until day 3
Colonisation of GIT with normal gut flora days 3 – 7
Production of Vitamin K dependent clotting factors
Initial weight loss generally regained by end of second week
Limited gastric capacity – 20 - 30 ml initially
197
What are the hepatic changes in the newborn?
Utilisation of stored glycogen to
maintain blood glucose levels within 2.5 – 7 mmol/L
Closure of ductus venosus to allow
increase blood flow to liver
Blood cells formed in bone marrow
Slow metabolism of drugs
198
What are the renal changes in the newborn?
Initial low level of renal function at birth:
o Low glomerular filtration rate
o Limited anti-diuretic hormone
o Low renal threshold leads to loss
of amino acids and bicarbonate
Newborn adapts quickly
199
what are the physiological changes a newborn makes to extrauterine life?
adjusting to and maintaining respiration
adjusting to circulatory changes
regulating temperature
ingesting and digesting nutrients
eliminating waste and regulating weight
200
what are the behaviourl changes a newborn makes to extrauterine life?
self regulating waking and patterns of sleep
processing multiple stimuli
establish a relationship with care givers in the environment
201
what is expected from a neonate in the first thirty minutes of birth?
increased heart rate irregular, amount of breaths,
some crackles on auscultation and signs of WOB
202
what is expected from 60 -100 minutes of birth in the neonate?
period of decreased responsiveness
HR regular
No WOB
RR around 60
pink in colour.
203
what is expected from 2 - 8 hours post birth in the neonate?
tachycardia
tachypnea
mech passed
increased muscle tone
changes in skin colour
mucus production.
204
What are the four ways a newborn can lose temperature to the environment
Conduction
Radiation,
Convection
Evaporation
205
What should you note prior to examining the newborn?
• Maternal details – including health history, social situation and family history
• Obstetric history – previous pregnancy, birth and newborn details
• Antenatal history for this pregnancy
• Details of the labour and birth
• Details of the immediate post-birth period – including Apgar scores and any resuscitation
measures or other interventions
206
When looking at general appearance of a neonate in the cephlacordal what should be considered
• Breathing pattern and rate – are there any signs of respiratory difficulty?
• Muscle activity – any tremors, jitteriness, seizures?
• Muscle tone – poor tone (‘floppy’) or marked tone/flexion.
• Body proportions and symmetry of movements.
• Any obvious malformations or dysmorphic features?
• Colour – mottled, pale, plethoric, cyanosed, jaundiced.
• Skin/integument – vernix or lanugo, meconium, birthmarks, petechiae, oedema.
• Cry – vigorous, weak, high-pitched.
• Indicators of prematurity (refer to your textbook for the Ballard Scale)
207
When looking at the Head/Skull of a neonate in the cephlacordal what should be considered
•Size and shape – presence of moulding.
• Suture lines, fontanelles.
• Caput succedaneum, chignon, cephalhaematoma, or other lesions/trauma.
• Hair.
208
When looking at the Facial Features of a neonate in the cephlacordal what should be considered
•Proportions and symmetry.
• Ears – position, structure, cartilage, skin tags.
• Eyes – number, size, iris, pupil, lids, discharge, red reflex.
• Mouth – size, shape, lips, palate, tongue, teeth.
• Nose – position, nostrils, bridge, septum, milia.
209
When looking at the musculoskeletal system of a neonate in the cephlacordal what should be considered
• Neck – movement, tumours, hairline, webbing.
• Clavicle.
• Spine – shape, dimples, hair, tumours.
• Sacrum, coccyx.
• Limbs – number, length, proportions, fractures, creases.
• Digits – number, length, proportions, shape, webbing, palmar creases,
fractures.
• Hips – Barlow, Ortolani tests for congenital dislocation of the hip.
• Feet – talipes.
210
When looking at the respiratory system of a neonate in the cephlacordal what should be considered
• Symmetry and chest appearance – nipple position.
• Hyperinflation, structural deformity.
• Respiratory difficulty - sternal or rib recession, tachypnoea, nasal flaring, expiratory grunt, cyanosis.
211
When looking at the cardiovascular system of a neonate in the cephlacordal what should be considered
• Colour, perfusion.
• Heart rate.
• Irregularities or murmurs.
• Pulses
212
When looking at the abdomen of a neonate in the cephlacordal what should be considered
• Any distension.
• Bladder distension.
• Localised bulging or palpable masses.
• Tenderness.
213
When looking at the umbilicus of a neonate in the cephlacordal what should be considered
• Cord – 2 arteries, 1 vein.
• Cord clamp secure.
• Structure – any hernia or abnormality of the midline
214
When looking at the Genitourinary system of a neonate in the cephlacordal what should be considered
• Identification of sex of baby – male, female, indeterminate/ambiguous.
• Abnormalities of genitalia.
• Anus – patent, passing meconium.
• Urinary output.
215
When looking at the neurological system of a neonate in the cephlacordal what should be considered
• Symmetry of movement.
• Muscle tone, presence of seizures.
• Sleeping, waking, crying behaviours.
• Reflexes – Grasp, Rooting, Sucking, Moro, Step, Babinski.
216
What does the Gutherie test explore?
• Phenylketonuria (PKU)
• Galactosemia
• Congenital hypothyroidism
• Cystic fibrosis
• Amino acid disorders
• Fatty acid oxidation disorders
• Organic acid disorders
217
What should midwives ensure new mothers know about when discharging them.
• The physical care of the newborn – bathing, changing nappies, dressing, care of the umbilical cord, eye care, skin care.
• Expected patterns of weight gain.
• Normal expected newborn behaviours – including elimination patterns, sleeping and settling patterns, crying.
• Feeding – this will be covered separately in another module of this unit.
• Safety – this includes information regarding SIDS.
• Signs of illness in the newborn.
• Visiting midwife (where available) – role and contact details.
• Ongoing care schedules and contact details – child health nurse, general practitioner, other
community resources.
• Advice regarding the Australian immunisation schedule
218
What are the SUDI risk factors for an infant under 4 months of age
Low birth weight
Prematurity
Health problems
Tobacco smoke exposure
Cough/cold medicines
Decreased tone/reflexes
Lethargy
219
What are the parental SUDI risk factors when caring for an infant under 4 months of age
Either parent/carer smoking
Extreme tiredness
Obesity
Medications (alter consciousness)
Conditions affecting mobility and sensory awareness
Conditions causing temporary loss of consciousness
Drug and alcohol use
220
What are the environmental SUDI risk factors when caring for an infant under 4 months of age
Prone/side sleep position
Unsafe sleep environment:
multiple bed sharers
co-sleeping
soft or sagging sleep surface
Environmental tobacco smoke
Other children/pets
221
What is physiological jaundice
A visible yellow discolouration of the skin of an otherwise healthy newborn
• Occurs due to the increased level of haemolysis in the newborn of red blood cells, and the reabsorption of bilirubin into the enterohepatic re-circulation as a
result of decreased gut motility.
• May be worsened by such problems as bruising and polycythaemia, where there are extra red blood cells to be haemolysed.
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What are the six key messages to reinforce safe infant sleeping are adapted from SIDS and KIDS WA:
1. Sleep baby on back*
2. Keep baby’s head and face uncovered
3. Keep baby smoke free before and after birth
4. Safe sleeping environment night and day
5. Sleep baby in a safe cot in parent’s room
6. Breastfeed baby**
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Define SIDS
Sudden Infant Death Syndrome (SIDS) is defined
as the sudden and unexpected death of an
infant less than one year of age during their
sleep that remains unexplained after a thorough
investigation.
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What is considered as an unsafe sleep surface
is NOT firm (i.e. soft or sagging such as mattresses, pillows, waterbeds, sheepskins, a couch, or beanbag)
is tilted, dirty or damaged
the mattress and/or bed sheets are incorrectly fitted (e.g. mattress/bed sheets are the wrong size for cot,
portacot or bassinet)
has or creates gaps where baby can become trapped (e.g. couch or mattress against a wall)
risk of infant falling and causing injury
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Define ‘Breast Milk’ jaundice
• Breastfed babies receive a decreased volume of milk through the bowel in the early days of life, resulting in an increase in reabsorption of bilirubin through the entero-hepatic circulation
• There is also a theory that inhibitory substances present in breast milk prolong jaundice in breastfed babies
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How does the midwife decide if it is physiological jaundice over pathological jaundice?
• Gestation of the baby at birth
• The maternal blood group and presence of antibodies or other risk factors
• Any other factors, such as bruising or cephalhaematoma (that would lead to greater haemolysis of red blood cells)
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If a baby has jaundice up to the head what recommendations should the midwife make?
• Encourage frequent feeding - 8-9 breastfeeds in 24 hours is optimal or increase number of formula feeds if artificially feeding
• Monitor the infants input and output
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When is phototherapy used
A midwife checks SBR and age of infant and then
if Age of baby in hours Consider phototherapy if
SBR level at or above
25 – 48 hours 170 m mol/L
49 – 72 hours 260 m mol/L
More than 72 hours 290 m mol/L
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