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Fetal Surveillance Mnenonic
DR C BRAVADO
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Shoulder Dystocia Mnemonic
HELPERR
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Mnemonic for Causes of PPH
- 4 T's
- Tone (Uterine atony)
- Trauma (Cervical or vaginal)
- Tissue (Retained placenta)
- Thrombin (Coagulopathy)
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Approach to Mgmt of Massive PPH
- Head
- Arms
- Uterus (start at uterus)
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Mnemonic for Forceps Application
ABCDEFGHIJ
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Mnemonic for Vacuum Application
ABCDEFGHIJ
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DR C BRAVADO
- DR - define risk
- C - contractions
- BRa - baseline rate - Normal 110-160
- Variability
- Accelerations
- Decelerations
- Overall
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What does DR stand for in DR C BRAVADO?
Define Risk - high or low
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What is C in DR C BRAVADO?
C is Contractions - comment on frequency, etc
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What is BRa in DR C BRAVADO?
Baseline RAte - bradycardia, normal 110-160 or tacky
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What is V in DR C BRAVADO?
Variability - at least 10-15 bpm (persistent, reduced variability is a particularly ominous sign)
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What is A in DR C BRAVADO?
Accelerations - present or absent (at least 15bpm rise from baseline lasting at least 15 seconds)
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What is DR C BRa V A in DR C BRAVADO?
- DR - define risk
- C - contractions
- BRa - Baseline Rate
- V - Variability
- A - Accelerations
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What is remaining D and O in DR C BRAVADO?
- Decelerations - early, variable or late
- Overall - assess as reassuring or nonreassuring and plan
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What is criteria for intermittent Auscultation?
- Healthy women with uncomplicated pregnancy
- During active labour, should occur after a contraction x 1 min q15min in 1st stage and q5min in 2nd stage
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What are things that would require change to continuous auscultation?
If NST/auscultation is non-reassuring - bradycardia, tackycardia, decelerations or other intrapartum risk factors develop
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Normal baseline rate?
110-160
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Normal variability
At least 10-15 bpm
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Normal Accelerations
at least ≥15 beat rise x ≥15 seconds
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Normal decelerations
Earlys are okay
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Overall assessment
Reassuring vs Non-Reassuring
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What are causes of early decelerations?
Head compression
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What is the intervention for early decelerations?
None
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What is the causes of variable decelerations?
Cord compression
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What is the intervention for variable decelerations?
Amnioinfusion, reposition mother
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How do you do an amnioinfusion for variable decels?
Infuse 250-500cc warm saline through intra-uterine pressure catheter and follow with 50-60cc/h drip
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What is the cause of late decelerations?
Uteroplacental insufficiency
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Intervention for late decelerations?
Stop oxytocin, give oxygen
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What is the Mnemonic for Shoulder Dystocia?
HELPERR
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What is each stand for in HELPERR?
- H - call for Help
- E - Evaluate for Episiotomy
- L - Legs - mcroberts maneuver
- P - external Pressure
- E - Enter: rotational maneuvers
- R - Remove posterior arm
- R - Roll patient to her hands and knees
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What is H-E-L of HELPERR?
- H - Help - call for HELP
- E - Evaluate for Episiotomy
- L - Legs - McRoberts (knees to chest with supraopubic pressure)
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What is P-E-R-R of HELPERR?
- P - Pressure - External Pressure (suprapubic pressure)
- E - Enter - rotational maneuvers
- R - Remove - remove posterior arm
- R - Roll onto hand and knees
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What is HELPERR (1 word for each)?
- Help
- Eval/Episiotomy
- Legs
- Pressure
- Enter
- Remove
- Roll
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How to do McRoberts Maneuver for Shoulder Dystocia?
Legs - knees to chest and combine with Pressure - suprapubic pressure
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3 different 'Enter' maneuvers?
- Rubin II
- Rubin II + Wood's Screw
- Reverse Wood's Screw
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How to remove the posterior arm?
- Follow the posterior arm to the elbow
- Flex arm at elbow
- Sweep forearm across chest without pulling directly on hand
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Mgmt of Massive PPH - how to organize the team
- Helper 1 @ Head
- Helper 2 and 3 @ Arms
- Leader at Uterus (start here)
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What does Uterus person do PPH?
- Start here - call for help
- massage uterus to stimulate contraction
- Coordinate helper 1 to head and helpers 2 and 3 to arms
- If bladder full or palpable - empty with catheter
- If atony persists - bimanual compression
- Review 4 T's of PPH
- Move to surgery if bleeding persists
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What does helper 1 @ head do for PPH?
- Check airway
- Check breathing
- Admin O2
- Lie flat
- Not time of relevant events
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What do helpers 2 and 3 do at arms for PPH?
- Check pulse and bp
- Large bore IV x 2
- Check blood counts, clotting and crossmatch 4-6 units
- Fluid resuscitation PRN w 2L crystalloid
- Drugs admin
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What drugs can be administered for PPH?
- Oxytocin/Syntocinon
- Methylergonovine/Ergometrine (if avail)
- Prostaglandin F2alpha (consider surgery if >2 doses needed)
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PPH - Manual maneuvers for uterine atony?
- Bimanual massage and compression
- Intramyometrial prostaglandin injection
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PPH - Manual maneuvers for retained placenta
- Manual extraction
- Exploration for fragments
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PPH - Manual maneuvers for uterine inversion
- Recogion
- Replacement (push back with hand)
- Restitution (ensure fundus is restored)
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Doses of Meds for PPH due to Atony
- 1) Oxytocin/Syntocinon - 10U IV or IM. 10-40U in 1L NS @ 250cc/h
- 2) Methylergonovine 0.2mg IM or Ergometrine 0.5mg IM
- 3) Prostaglandin F2alpha 0.25mg IM or intramyometrial (repeat q15 min up to 8 doses but consider surgery after 2 doses)
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What percentage of PPH are caused by each of the 4 T's
- Tone - 70% of cases
- Trauma - 20% of cases
- Tissue - 10% of cases
- Coagulopathy - 1%
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Mnemonic for Forceps application
- A - address the patient, ask for help, anesthesia adequate?
- B - bladder empty?
- C - cervix must be completely dilated
- D - determine position of head - think of shoulder dystocia
- E - Equipment ready
- F - Forceps ready
- G - Gentle traction
- H - Handle elevated to follow the j shaped pelvic curve
- I - Incision - evaluate for a possible episiotomy when the perineum distends
- J - Remove forceps when Jaw is reachable
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A to C of mnemonic for Forceps use
- A - address the patient, ask for help, anesthesia adequate?
- B - bladder empty?
- C - cervix must be completely dilated
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D to F of mnemonic for Forceps use
- D - determine position of head - think of shoulder dystocia
- E - Equipment ready
- F - Forceps ready
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G to J of Forceps mnemonic
- G - Gentle traction
- H - Handle elevated to follow the j shaped pelvic curve
- I - Evaluate for Incision for a possible episiotomy when the perineum distends
- J - Remove forceps when Jaw is reachable
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Mnemonic for Vacuum Application
ABCDEFGHIJ - all except E, F, G, H are the same
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Whole mnemonic for Vacuum use?
- A - address the patient, ask for help, anesthesia adequate?
- B - bladder empty?
- C - cervix must be completely dilated
- D - determine position of head - think of shoulder dystocia
- E - Equipment ready, extractor ready
- F - place cup in proper relation to Fontanelles on Flexion point
- G - Gentle traction following pelvic curve, rising as head crowns
- H - Halt traction b/w contractions, Halt procedure if cup disengages 3 times, halt if no progress in 3 pulls, halt after 20 min of use (be prepared to abandon and go to C/S)
- I - Incision - evaluate for a possible episiotomy when the head is crowning
- J - Remove vacuum when Jaw is reachable
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