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Flashcards in OSCE Preparation Deck (40):
1

What 2 things should you undertake immediately when you suspect shoulder dystocia?

1. Call for help with emergency buzzer and request obstetrician, paediatrician and extra midwives
2. Explain to the woman and her partner what is happening

2

Following calling for help and explaining shoulder dystocia to mum and partner, what should you do next?

Put woman in to McRobers position:
Bed flat
Legs hyperflexed
Pillows behind mothers back removed
And apply gentle traction

3

During a shoulder dystocia emergency, how long should each manoeuvre be attempted for?

30-60 seconds

4

If McRoberts manoeuvre is unsuccessful during a shoulder dystocia, what should you attempt next?

Apply suprapubic pressure, CPR style, gentle rocking or continuous pressure over fetal back towards fetal chest for 30-60 seconds applying gentle traction

5

If suprapubic pressure is not successful during a shoulder dystocia, what should you consider?

An episiotomy

6

Following an episiotomy during a shoulder dystocia, what two things can be attempted next?

Either delivery of the posterior arm or internal rotational manoeuvres

7

How do you deliver the posterior arm during a shoulder dystocia?

Flex the posterior arm at the elbow, hold the baby's wrist, gently pull across chest and over face and deliver in a straight line then apply gentle traction to the head.

8

What are the three different ways to do an internal rotation manoeuvre?

1. Pressure on the front of the posterior shoulder and rotate in to oblique diameter
2. Pressure on the back of the posterior shoulder and rotate in to oblique diameter
3. Pressure on the back of the anterior shoulder and rotate in to the oblique diameter

9

During a shoulder dystocia, if McRoberts, suprapubic pressure and internal rotation manoeuvres or delivery of the posterior arm are all unsuccessful, what is the final manoeuvre that can be attempted?

Roll woman on to all 4's and attempt to deliver the posterior (closest to ceiling) shoulder first

10

You are providing midwifery care to Karis who is a para 1, 41 weeks gestation and is fully dilated and feeling an urge to push. The vertex slowly advances, crowns, but very soon begins to show signs of "turtle necking" and the shoulders fail to appear.
Detail your immediate midwifery management of the situation.

1. Call for help using emergency buzzer - ask for obstetrician, paediatrician, extra midwives (obstetric emergency team)

2. Explain to the woman and her partner what is happening

3. Demonstrate McRoberts position with bed flat, legs hyperflexed and pillows behind mothers back removed. Attempt manoeuvre for 30 - 60 seconds, applying gentle traction

(Manoeuvre is unsuccessful)

4. Perform suprapubic pressure CPR style. Gentle rocking or continuous pressure over fetal back towards fetal chest. Attempt for 30-60 seconds and apply gentle traction

5. Suprapubic pressure can be combined with McRoberts manoeuvre

(Manouvere is unsuccessful)

6. Consideration of episiotomy

7. Attempt internal rotation or delivery of posterior arm whilst continuing with McRoberts

8. To remove posterior arm, enter the vagina posteriorly, flex the arm at the elbow, hold the baby's wrist, sweep it across the chest and out in a straight line. Apply gentle traction

(Manoeuvre unsuccessful)

9. Attempt internal rotation. Apply pressure to the front of the posterior shoulder and rotate in to oblique diameter or rotate 180 degrees. Try gentle traction

(Manoeuvre unsuccessful)

10. Apply pressure on the back of the posterior shoulder and try to rotate in to oblique diameter

(Manoeuvre unsuccessful)

11. Try pressure on the back of the anterior shoulder to rotate in to oblique diameter

(Manoeuvre unsuccessful)

12. Roll patient on to all 4's position. Attempt to deliver the posterior shoulder (closest to ceiling) first with gentle traction

11

Sarah is a 26 year old who is pregnant with her second baby. She is now 38 weeks gestation and is currently in the delivery suite in established labour. Sarah has a breech presentation and has chosen to give birth vaginally. She is now in advanced second stage of labour with the breech slowly descending onto the perineum. The fetal legs are extended and appear to be causing a delay with decent. Explain the midwifery management of this assisted breech birth.

(The legs appear to be stuck)

1. Apply pressure behind the knee with the index finger (pressure on popliteal fossae)

(Trunk is now slowly descending until the scapulae are visible but the arms appear to be extended)

2. Begin Løveset's manoeuvre:

3. Place towel over baby's hips to keep warm

4. Gently hold baby over the pelvis and turn half circle in a clockwise direction keeping the back uppermost

5. The lateral arm is now the anterior arm and can be delivered under the pubic arch

6. Place two fingers on the upper part of the arm and draw it down over the chest as the elbow is flexed and sweep over the face

7. Turn the baby back a half circle keeping the back uppermost, and deliver the second arm in the same way simultaneously applying downward traction

8. It is important to avoid handling the umbilical cord

9. Allow the baby to hang until the nape of the neck is visible

(The head does not deliver spontaneously. Demonstrate the next stage of midwifery management)

10. Begin Mauriceau Smellie Veit manoeuvre

11. Support the baby's body with non-dominant arm

12. The first and third finger of the non-dominant hand should be placed on the baby's cheekbones with middle finger on the chin

13. With the dominant hand, apply first and third fingers to each shoulder and middle finger on the back of the occiput to flex the head

14. Apply gentle downward traction to deliver the head in a controlled manner

(Sarah has chosen an active management of third stage)

15. Withhold the administration of any oxytocic medication until after the birth of the baby's head

12

If the legs are extended during a vaginal breech delivery, what can be done to deliver the legs?

Popliteal pressure (index finger applying pressure behind the knee)

13

During a breech delivery, if the arms are extended, what manoeuvre can be done to deliver the arms?

Løveset's manoeuvre:
Place towel over baby to keep warm
Gently hold the baby's hips and rotate clockwise keeping the back uppermost
Lateral arm is now anterior and can be delivered under the public arch
Place two fingers on upper part of arm and draw it down over the chest, flexing the arm and sweeping over the face to deliver
Turn the baby back a half circle, keeping back uppermost and deliver the second arm in the same way, simultaneously applying downward traction
Take care to avoid handling the umbilical cord
Take hands off again and allow baby to hand until the nape of the neck is visible

14

During a breech delivery, if the head does not deliver spontaneously, what manoeuvre can be done?

Mauriceau Smellie Veit manoeuvre:
Support the baby on non-dominant arm with first and third fingers on baby's cheekbones and middle finger on the chin
With other hand, first and third fingers on each shoulder and middle finger on occiput to flex the head
Apply gentle downward traction to deliver the head in a controlled manner

15

If the woman has requested an active management of the third stage during a breech delivery, when should the oxytocics be administered?

After the birth of the baby's head

16

Stephanie has just given birth to a healthy baby girl weighing 4.55kg at home with you and your colleague. Following the active management of the third stage of labour, the placenta and membranes are delivered approximately 8 minutes following the birth of her baby. However, Stephanie continues to bleed heavily. Explain your immediate midwifery management of this.

1. Palpate the uterus

(Uterus is boggy)

2. Rub up a contraction to try and contract the uterus

(Uterus remains boggy. Blood loss approximately 800mls)

3. Request colleague to call ambulance control

4. Both me and my colleague must monitor and investigate, resuscitate and stop the bleeding

5. Request colleague to administer 2nd dose of oxytocic medication

(Uterus is still boggy)

6. Will continue to rub up a contraction and request colleague to check placenta for completeness

(Placenta is complete and uterus still boggy)

7. Will continue to rub up a contraction and request colleague to catheterise and empty the bladder

8. Request colleague to check for lacerations while catheterising

(No lacerations present, uterus is now contracted and bleeding is minimal)

9. Check maternal observations: temperature, pulse, blood pressure and respirations

10. Check fundus

11. Monitor PV blood loss

12. Resuscitate: consider inserting grey venflon

13. Commence IV Hartmann's infusion

14. Monitor and investigate: FBC, group and save, clotting screen

(If bleeding did not settle, can you explain bi-manual uterine compression?)

15. One hand inserted in to the vagina, locate anterior fornix of the cervix, make a fist. Other hand placed externally on the abdomen, locate the fundus and compress it against the internal fist

17

If you discover a woman is having a PPH, what is the first thing you should do?

Palpate the uterus and if boggy, try to rub up a contraction

18

During a PPH, if rubbing up a contraction does not stop the bleeding, what should you do next?

If in the hospital, call for emergency help using 4444 stating major obstetric haemorrhage emergency
If at home, call for an ambulance on 999

19

What should you do during a PPH once help has been called?

Monitor, investigate, resuscitate and stop the bleeding

20

During a PPH, what can be done after a contraction has been rubbed up and help has been called?

A second dose of oxytocic medication can be administered

21

During a PPH, if the uterus is still boggy after rubbing up a contraction and administering a second dose of oxytocic medication, what should you do next?

The placenta should be checked for completeness

22

During a PPH, if the placenta is complete and you have rubbed up contractions and administered a second dose of oxytocic medication, what should you try next?

Try catheterising and emptying the bladder and check for any perineal lacerations at the same time

23

Once bleeding has been stabilised following a PPH, what three things should you do first?

-Maternal observations: temperature, pulse, BP, respirations
-Check fundus
-Monitor PV blood loss

24

Following a PPH, after the fundus has been checked and maternal observations documented, what should you do next?

Insert a grey venflon, take bloods (FBC, group and save, clotting screen) and commence IV Hartmann's infusion

25

If bleeding did not settle during a PPH, what manoeuvre could be attempted?

Bi-manual uterine compression

26

Describe bi-manual uterine compression

One hand inserted in to the vagina, locate anterior fornix of the cervix and make a fist. Other hand placed externally on the abdomen. This hand then locates the fundus and compresses it against the internal fist

27

You and your colleague are on call in the community and are attending a home birth for Claire who is a primigravida, 39 weeks gestation. Claire has been well throughout her pregnancy. Claire has just given birth at home to a baby boy. His tone appears to be floppy and he is gasping. Explain your immediate midwifery management of this situation.

1. Ask the other midwife or the birth partner to call 999 and inform the local unit

2. Dry the baby, remove any wet towels, cover with dry towels and put a hat on the baby

3. Start the clock or note the time

4. Assess the tone, colour, breathing and heart rate. Breathing should be assessed by observing chest movement. Heart rate is best judged using a stethoscope

(The baby is not breathing)

5. Open the airway, placing baby on its back with the head in the neutral position

6. Give 5 inflation breaths using the bag and mask

7. Ensure mask is correct size: should cover nose and mouth but not encroach over the chin or the eyes

8. Using air, 5 inflation breaths with pressures 30cm water for 3 seconds. The first 2-3 breaths will replace fluid with air so chest wall movement may not be evident until 4-5th breath

(Chest is not moving)

9. Re-check head position. Possibly request help to maintain head position

10. Repeat 5 inflation breaths

(How would you know if inflation breaths were successful?)

11. Check for response - would see an increase in heart rate or spontaneous breathing

(Chest is moving but heart rate is not detectable or less than 60 bpm)

12. Find imaginary line between the nipples and either grip either side of the chest and compress the chest using thumbs OR use two fingers and compress the chest by about a third

13. Begin 3 chest compressions to 1 breath (ask for help with mask if required)

28

If a baby is delivered and is floppy and gasping, what should be your immediate actions?

Call for help:
999 if in the community or emergency buzzer if in hospital
Dry the baby, remove wet towels, cover with dry towels and put a hat on the baby
Start the clock or note the time

29

When a baby is born not breathing, what should be done once the baby has been dried and the clock has been started?

Assess the tone, colour, breathing (observe chest movement) and heart rate (best to use a stethoscope)

30

Once you've confirmed a baby is not breathing (by observing chest movement) what should you do next?

Open the airway by placing baby on its back with the head in the neutral position

31

In neonatal resuscitation, what should be done once the head is in a neutral position?

5 inflation breaths ensuring the mask is covering the nose and mouth but not encroaching over the chin or eyes

32

Describe the 5 inflation breaths and what you will see with regards to chest movement in neonatal resuscitation

With pressures 30cm water for 3 seconds.
Chest wall movement might not be evident until 4-5th breath as the first 2-3 breaths will replace fluid with air

33

During neonatal resuscitation, if the chest is not moving during inflation breaths, what should you do?

Recheck the head position and consider asking for help in maintaining the airway.
Then repeat 5 inflation breaths

34

In neonatal resuscitation, what signs would indicate that the inflation breaths were successful?

You would see an increase in heart rate or spontaneous breathing would occur

35

In neonatal resuscitation, if the baby is breathing but the heart rate is still less than 60bpm, what should you do?

Begin chest compressions (3 compressions to 1 breath)

36

Describe the two ways to do chest compressions on a neonate

Find the imaginary line between the nipples and halfway between them, either:
Grip the chest with both hands and use both thumbs to compress
OR
Use index and middle finger to compress
Compress the chest about one third

37

In neonatal resuscitation, what 4 things would you ideally need to know before beginning resuscitation?

- Gestation
- Type of delivery
- Maternal sedation
- Known complications

38

In neonatal resuscitation, when using a bag and mask, what should you do before beginning resuscitation?

Ensure the valve works by occluding the outflow and watching for the valve moving

39

In neonatal resuscitation, at what heart rate would you begin chest compressions?

60bpm or less

40

Should neonatal CPR begin with compressions or ventilation?

One ventilation breath followed by three chest compressions