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What is pre-term labour?
Birth before the completion of 37 weeks
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How should you manage a pre-term birth?
Ascertain the period of gestation
– <20 weeks gestation transfer mother to the nearest Emergency Department with an Obstetric unit on site
– >20 -37 completed weeks gestation, transfer mother to the nearest Obstetric department or ED with Obstetric unit on site
• Reassess the mother constantly en route
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If a pre-term baby is birthed before hospital hat should you do?
If baby is birthed:-
• Ensure additional resources have been requested via EOC
• Keep baby WARM – priority with preterm newborn
• Convey mother and baby to NEAREST Obstetric Unit (or ED) with pre- alert to ensure midwifery / neonatal team mobilised
• If baby and mother need to be separated (clinical need), convey to same location ensuring ID bracelets on both
• If still on scene when baby is born, use additional ambulance to convey baby IMMEDIATELY to the NEAREST appropriate unit
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What is a prolapsed umbilical cord?
The descent of the umbilical cord into the lower uterine segment before the presenting part of the fetus, ruptured membranes
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What are the risk factors for a prolapsed umbilical cord?
Risk factors
– Multiparity – presenting part may not be engaged
– Pre-term < 37 weeks – size of fetus allows cord to prolapse
– Breech presentation – especially complete / footling due to ill fitting of the presenting parts and proximity of umbilicus to buttocks
– Multiple births – especially second twin
– Polyhydramnios – excess membranes; allows cord to be swept down
– Unengaged presenting part – allows for cord to fall past
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How do you manage a prolapsed umbilical cord?
- Rapid <c> A B C D E assessment
– Ask / assist the woman to adopt the ‘knee to chest’ position until ambulance ready
– Protect cord with dry dressing / underwear. HANDS OFF CORD
– Walk to the ambulance – NO CARRY CHAIR – In ambulance, adopt exaggerated left lateral position (Sim’s)
– PRE-ALERT TO NEAREST OBSTETRIC UNIT
– Ongoing assessment and monitoring
– Reassurance
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What is a breech birth?
Breech is a malpresentation as the presenting part at the introitus is not the vertex of the head
• A longitudinal lie where the fetal buttocks or feet are presenting part
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What is a Frank Breech?
Most common (65%), where the baby's hip joints are flexed and knee joints extended.
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What are incomplete breeches?
Around 25% are incomplete, and will not deliver - need a rapid transport to Obstetric Unit.
Can be a Footling breech (foot first - hip extended on one side) or Kneeling breech (knee first - hip extended, knee flexed on one side)
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What are the breech risk factors?
Risk Factors
- • Prematurity (incidence 20% at 28wks)
- • Previous breech
- • Low lying placenta/ praevia
- • Pelvic masses/ abnormally shaped uterus
- • Twins or other multiples
- • Polyhydramnios/oligohydramnios
- • Fetal abnormalities
- • Grand multiparity
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What's the likelihood of a breech presentation in an early birth?
20% at 28 weeks
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What are breech signs and symptoms?
Signs & Symptoms:
• You may see the feet or buttocks at the introitus
• The genitals may look bruised and swollen
• Meconium may be visible
• Labour will progress as normal
• Cord prolapse is more common with breech presentation
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When can you stay and deliver a breech birth?
No red flags and buttocks first presentation.
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What is Shoulder Dystocia?
Shoulder dystocia is a vaginal, head-first delivery that requires additional manoeuvres to deliver due to baby’s shoulder impacting on the maternal pelvis
Delay between the delivery of the head and body is greater than 60 seconds
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Risk factors for shoulder dystocia?
Risk Factors
- • Previous shoulder dystocia
- • Big baby > 4 kg
- • Maternal diabetes
- • Induction of labour
- • Prolonged labour
- • Prolonged second stage
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Signs and Symptoms for Shoulder Dystocia?
Signs & Symptoms
• Arrest of spontaneous delivery
• Head remaining tightly applied to the vulva or retracting “turtle- neck”
• Fetal head not turning easily
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What is Post Partum Haemorrhage?
Most common cause of obstetric haemorrhage immediately after delivery due to uterine atony
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How much blood loss is there with primary PPH?
Primary PPH = loss of ≥ 500mls within 24 hours of delivery
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How much blood loss is there with massive PPH?
Massive PPH = loss of 50% of mothers blood volume within 3 hours of delivery
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How much blood loss is there with secondary PPH?
Secondary PPH = abnormal or excessive bleeding from the birth canal between 24hrs and 12 weeks postnatally
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Risk factors for Pot Partum Haemorrhage?
Risk Factors:
• Previous Ante-Partum Haemorrhage/Post-Partum Haemorrhage
• Long labour (>12hrs)
• Anything that increases the size of the uterus e.g. multiple pregnancy, large baby, excess amniotic fluid
• Advancing maternal age (>40yrs)
• Obesity
• Multiparity greater than 5 deliveries
• Uterine fibroids
• Partial separation of the placenta / placenta accreta
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Primary Causes for Post Partum Haemorrhage?
Primary Causes
• Tone - Uterine atony
• Trauma - Vaginal tear
• Tissue - Retained placenta
• Thrombin - Clotting problems
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How do you manage PPH if there is vaginal trauma?
<c>ABCDEFG rapid assessment
Vaginal trauma
• Apply direct external pressure using pad / dressing to tears
• Pre-alert to Nearest Obstetric Unit
• If Paramedic also on scene - IV access and fluids as per JRCALC en route (to maintain SBP>90mmHg
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How do you manage PPH if there is tone problem?
If Placenta has delivered – Uterine massage and offer Entonox as can become painful
– Pre-alert to Nearest Obstetric Unit
If Placenta NOT delivered – DO NOT perform uterine massage*, may cause further haemorrhage
– Pre-alert to nearest Obstetric Unit stating PPH
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