Newborn Assessment and Intrapartum Management

Posted on Oct 24, 2024 in Biology

Module 1: Newborn Assessment

APGAR – 5 Components

  • Colour
  • HR
  • Reflexes
  • Muscle Tone
  • Respirations

Reported

  • 1 minute
  • 5 minutes
  • (and) 5-minute intervals until 20 minutes – unless SCORE < 7

Physical Assessment

  • Cardio-Respiratory System
  • Head and Neck
  • Abdomen and Pelvis
  • Musculoskeletal System
  • Neurological System

Module 1: Physiological Birth Management

Labour (define): sequential pattern involving painful regular uterine contractions stimulating progressive dilation of the cervix with the descent of the fetus through vaginal birth of the baby and placenta.

The Myometrium

The muscular wall of the uterus

Stages of Labour

First Stage

Onset of strong regular painful contractions (dilation of the cervical opening – cervical Os)

Second Stage

Full dilation of the cervical os to birth the baby

Third Stage

Birth of the baby to delivery of the placenta and membrane

Module 2: Intrapartum Complications

Shoulder Dystocia (5-minute emergency)

Define: One or both shoulders stuck during vaginal delivery

Risk Factors (Antepartum)

  • Maternal obesity
  • Diabetes
  • Prolonged pregnancy
  • Male fetus
  • Previous shoulder dystocia
  • Advanced maternal age
  • Previous large baby

Risk Factors (During Labour)

  • Prolonged first stage
  • Prolonged second stage
  • Assisted delivery

Management

Recognised: After the head is birthed (head begins to burrow – turtle sign)

HELPERR

  1. Timed Emergency (START THE CLOCK)
  2. Call for HELP – time critical, and HAVE TWO PATIENTS to consider
  3. END PUSHING, EXPLAIN – further pushing CAN CAUSE IMPACTION
  4. LEGS McROBERS (30 SECONDS and then add)
  5. Suprapubic Pressure (30 SECONDS move to pulsing then add)
  6. Enter manoeuvres (internal rotation – 30 SECONDS then)
  7. Remove posterior arm (30 SECONDS) then
  8. Roll the woman to her hands and knees repeat internal manoeuvres

IF NOT SUCCESSFUL – OBSTETRIC EMERGENCY

  • Position Left Lateral
  • Administer Oxygen
  • Cannulate
  • Pre-notify receiving hospital

The McRoberts Manoeuvre (EFFECTIVE AS IT OPENS THE PELVIC INLET to increase pelvic diameter)

  1. Positioning (Lie FLAT on back)
  2. Bring knees to chest
  3. Delivery should begin as normal with application of gentle downward traction to deliver shoulder
  4. Attempt delivery using this technique for 30 SECONDS only

Suprapubic Pressure (Aim: Is to adduct and then displace the baby’s anterior shoulder)

  1. Keep mother in McRoberts position
  2. Move colleague to the side of the baby’s back
  3. Instruct colleague to place heel of hand two fingers above the symphysis pubis (behind baby’s shoulder) – Adopt the CPR position (with one or two hands)
  4. Inform colleague to apply moderate pressure on baby’s shoulders pushing down (to rotate and dislodge the shoulder)
  5. Apply gentle downward traction (to deliver shoulder)
  6. IF UNSUCCESSFUL, get colleague to apply suprapubic pressure by rocking gently and attempt to deliver the shoulder with gentle downwards traction

Rubin’s 2 Manoeuvres (Enter “the vagina” manoeuvres – internal rotation)

  1. Place two fingers on the back to front shoulder and push to rotate (ONLY 30 SECONDS)
  2. IF FAILS, try reversing the direction – apply pressure to posterior shoulder and rotate. This is called “WOOD SCREW MANOEUVER”
  3. IF FAILS, enter the vagina posteriorly and locate arm, flex the baby’s elbow and sweep the arm over the baby’s chest to remove. This is called “REVERSE WOOD SCREW MANOEUVER”. (ONLY 30 SECONDS)

DO NOT DO (Shoulder dystocia)

  1. Cut the cord – only means of fetal oxygenation – which can result in death
  2. Press on the uterine fundus – to help push the baby – can result in uterine rupture
  3. Pull / twist / bend infant’s neck – Can wedge shoulder in more

Face Presentations

  • Anterior face presentation (towards the symphysis pubis)
  • Posterior face presentation (towards the mother’s anus)

Oblique or Transverse Lie with Shoulder Presentation (OBSTETRIC EMERGENCY)

  • Birth not imminent
  • Transport without delay

IF IMMINENT BIRTH – Place mother on all fours

Module 2: The Premature Birth

Late preterm: 34-36 weeks

Moderately preterm: 32-34 weeks

Very preterm: < 32 weeks

Extremely preterm: 25 weeks

Cord Prolapse (OBSTETRIC EMERGENCY)

Define: Umbilical cord is out of the uterus with or before the presenting part of the baby

Cause: Diminished blood and oxygen supply

Risk Factors

  • Long umbilical cord
  • High presenting part
  • Prematurity
  • Low birth weight
  • Transverse or oblique lie

Management

  • Explain the situation
  • Position – knee to chest with buttocks raised
  • Insert two fingers into the vagina and lift the presenting part off the cord with upwards pressure (NEED TO MAINTAIN UNTIL DELIVERY AT HOSPITAL)
  • Administer oxygen (NRB – 10 lpm) – to maximise oxygenation to the fetus

Module 2: Other Birth Presentations

Breech Presentation

Define: Fetal buttock lies in the lower part of the uterus – Lying bottom first or feet first (“cephalic position”)

Risk Factors

Uterine
  • Multiparity
  • Uterine malformations
  • Placenta Praevia
Fetal
  • Prematurity
  • Twin pregnancy

OOH Diagnosis (Breech Birth)

  • On inspection: View of fetal buttocks, feet
  • Thick green meconium (often a diagnostic of breech birth)

Management – Breech Birth

  • Call for Backup
  • Prepare the area (Resus kit/ bluey)
  • Position – semi-recumbent position (butt near end of bed – legs up)

(OR) All fours leaning forward (avoid standing – can result in premature separation of the placenta)

  • MOST IMPORTANT RULE: “Hands off the breech“
  • Ensure mother Empties bladder before delivery

Delivery of Breech Baby

  1. Trunk rotation – ensure the baby’s back rotates anteriorly
  2. Leg delivery
    • Allow for spontaneous delivery
    • (IF NOT) Hold the buttocks over the iliac crest and rotate baby
  3. Umbilical Cord (DO NOT PULL IF VISIBLE)
  4. Shoulder and Arm Delivery
    • During contractions – scapulae and flexed arms should deliver naturally
    • Use Lovset Manoeuvre:
      • Hold baby’s thigh and gently lift towards the symphysis pubis
      • Rotate baby 180 degrees clockwise and release one shoulder
      • Run a finger from shoulder to elbow and deliver the arm across the body
      • Rotate baby 180 degrees to release second arm
  5. Head Descent (allow baby to hang and facilitate head flexion)
  6. Extended Head Delivery

    IF HEAD IS EXTENDED, perform Mauriceau-Smelli-Veit Manoeuvre

    1. Support baby’s body with legs straddling your arms
    2. Insert two fingers into the vagina
    3. Place hand over baby’s back with finger hooked on the shoulder and occiput
    4. Apply gentle traction and flexion simultaneously
  7. Final delivery and Newborn Care

Correction

  • Caesarean section
  • Manually turned (by obstetrician)

Module 2: Placenta Abruption

Define: The placenta separates from the inner wall of the uterus before birth.

Symptoms

  • Vaginal bleeding
  • Stomach and back pain

Risk Factors

  • Blunt trauma (car crash, fall, domestic violence)
  • Drugs (cocaine and methamphetamine)
  • Other (Multiple pregnancies and maternal age > 35)
  • Previous placental abruption

Supine Hypotensive Syndrome

Increased size of the uterus and baby can occlude the aorta and inferior vena cava – when a woman is supine.

Causes

  • Fetal hypoxia
  • Decreased uterine blood flow
  • Maternal hypotension
  • Reduced venous return

Module 2: Trauma in Pregnancy (Part 1)

Trauma Considerations

First Stage (Trauma)

Treated as any other trauma (obvious additional awareness to radiation)

2nd and 3rd Stage (Trauma)

Airway Considerations
  • Difficult airway: enlarged breasts
  • Laryngeal oedema: consider bougie use
  • Increased aspiration risk: early NGT to empty stomach
Breathing Considerations
  • Increase in oxygen demand: always supply oxygen – to avoid hypoxia
  • Chest drain placed higher – as diaphragm is elevated (3rd or 4th intercostal space)
  • Decreased thoracic compliance due to breast tissue/ large abdomen – makes BVM more difficult
Circulation Considerations
  • Increased HR (by 10-20 at term)
  • Lowered BP (by 10-15 mmHg in 2nd trimester)
  • Increased cardiac output
  • Increased blood volume
Abdominal Considerations
  • Delayed gastric emptying – early gastric decompression with NGT
  • Bladder becomes an intra-abdominal organ after 1st trimester
  • Other abdominal organs displaced by the uterus
Musculoskeletal Considerations
  • Increased joint laxity (due to progesterone)
  • Pelvic binders – DON’T FIT
  • Consider significant injury to fetus if pelvic fracture detected (OR) suspected
Social Considerations
  • Domestic and sexual abuse
  • Trauma – caused by postnatal depression, postpartum psychosis
  • Transport: To obstetric teams and social work
Fetal Considerations
  • Amniotic fluid embolism
  • Placental abruption
  • Uterine rupture
  • Uterine vessel damage
  • Premature labour

Module 2: Trauma in Pregnancy (Part 2)

Abdominal Considerations

  • Delayed gastric emptying – early gastric decompression with NGT
  • Bladder becomes an intra-abdominal organ after 1st trimester
  • Other abdominal organs displaced by the uterus

Musculoskeletal Considerations

  • Increased joint laxity (due to progesterone)
  • Pelvic binders – DON’T FIT
  • Consider significant injury to fetus if pelvic fracture detected (OR) suspected

Social Considerations

  • Domestic and sexual abuse
  • Trauma – caused by postnatal depression, postpartum psychosis
  • Transport: To obstetric teams and social work

Fetal Considerations

  • Amniotic fluid embolism
  • Placental abruption
  • Uterine rupture
  • Uterine vessel damage
  • Premature labour

Module 2: Maternal Collapse

Maternal Collapse: An acute event involving the cardiorespiratory system and CNS at any stage in pregnancy.

Possible Causes of Cardiac Arrest

  • Haemorrhage
  • Pre-eclampsia / eclampsia
  • Amniotic fluid embolism
  • Pulmonary embolism

Management

  1. Follow ABCDE and high-quality CPR approach (H’s and T’s)
  2. Cardiac Arrest consider:
    • Left lateral tilt (wedge under R buttock – 15-degree tilt)
    • Manual displacement of the uterus

Note:

  • Hypoxia occurs quickly and potential aspiration (due to normal physiology changes associated with pregnancy)
  • Experts: Obstetric and neonatal assistance
  • Effective resuscitation of the mother is best for baby
  • Perimortem caesarean

Module 2: Postpartum Haemorrhage

Define (PPH): Estimated blood loss of 500ml or greater

  • Can have 500 – 1000 ml loss without clinical signs of compromise

Primary PPH: Occurs in the First 24 hours

Secondary PPH: Occurs 24 hours post-delivery and up to 6 weeks

Causes (PPH)

  1. Tone (70%) – Uterine atony (lack of muscle tone)
  2. Trauma (20%) – Genital laceration, haematoma or inverted/ruptured uterus
  3. Tissue (10%) – Retained placenta or placental products (blood clots)
  4. Thrombin (1%) – Coagulation disorder

Risk Factors (PPH)

  • Multiparity
  • Multiple pregnancies
  • Anaemia
  • Prolonged labour
  • Obesity
  • Placenta abruption

Management (PPH)

If Placenta Is Still In Situ/Retained

  1. Fundal rub – help with separation (cupping hand over uterus and massaging clockwise)
  2. Empty bladder – go to toilet (full bladder can impede uterine contraction and retraction)
  3. Attempt to deliver the placenta
    1. Support the Uterus
      • Place one hand above the symphysis pubis.
      • Apply firm but gentle pressure to push the uterus upward, preventing inversion.
    2. Manage the Umbilical Cord
      • Use the other hand to wrap fingers or a clamp around the umbilical cord.
      • Apply gentle downward traction until the placenta is visible at the vulva.
      • Once visible, switch to upward traction to extract the placenta.
    3. Handle the Placenta
      • Gently twist the placenta in an up-and-down motion to braid the trailing membranes.
      • Ensure to keep the placenta for examination at the hospital.
    4. If the Placenta Cannot Be Delivered:
      • Manual removal by an obstetrician under anesthesia will be necessary.
      • Continue with the above management steps, consult an obstetric unit + initiating emergency extrication + transport.
  4. Assess for other sites of possible bleeding – e.g., Lacerations/tears to vulva or perineum
  5. Breast Feed – Will stimulate the release of natural oxytocin and stimulate uterine contractions.
  6. Manage altered perfusion / hypovolemic shock – Fluid resuscitation
  7. Urgently transport to hospital

If Placenta Expelled/Removed

  1. Fundal rubbing – IF EFFECTIVE – BLEEDING WILL EASE AND UTERUS WILL BECOME FIRM
  2. If not already, get mother to empty bladder
  3. Assess for other sites of possible bleeding – e.g., Lacerations/tears to vulva or perineum
  4. Breast Feed – Will stimulate the release of natural oxytocin and stimulate uterine contractions.
  5. Manage altered perfusion / hypovolemic shock – Fluid resuscitation
  6. IF HAEMORRHAGE CONTINUES, then the uterus or abdominal aorta may need to be manually compressed

Internal Bimanual Compression

  1. Make a fist with one hand and place it into the vagina
  2. Push your fist upwards
  3. Dip down behind the uterus and pull it upwards toward the symphysis pubis
  4. Push the hands together and compress the uterus and placental site. (maintain until uterus contracts – to hospital)

Abdominal Aortic Compression (Reduce blood flow to uterus)

  1. Place fist above the fundus and below the level of the renal arteries.
  2. Apply direct pressure downwards towards the spine to compress the aorta

EFFECTIVE: Measured by palpating for the absence of femoral pulses.

Massive Obstetric Haemorrhage

Define: Massive “> 1500 ml” or BP of < 80 mmHg

Management

  1. Establish IV access x2 large bore cannula
  2. Treat hypovolemic shock
  3. Pre-notify hospital
  4. Blood transfusion

Amniotic Fluid Embolism

Define: Amniotic fluid entering the bloodstream of the mother

After 1 hour of onset: Death

Causes: Maternal cardio-respiratory collapse

Symptoms

  • Restlessness, numbness, tingling, agitation

Management

  1. Normal cardiac arrest management

Management (Haemorrhage)

Oxytocins / Application of uterotonic agents to manage haemorrhage

Assessment and Management / Uterine inversion/ Retained placenta

Massive Obstetric Haemorrhage

Define: Massive “> 1500 ml” or BP of < 80 mmHg

Management

  1. Establish IV access x2 large bore cannula
  2. Treat hypovolemic shock
  3. Pre-notify hospital
  4. Blood transfusion

Amniotic Fluid Embolism

Define: Amniotic fluid entering the bloodstream of the mother

After 1 hour of onset: Death

Causes: Maternal cardio-respiratory collapse

Symptoms

  • Restlessness, numbness, tingling, agitation

Management

  1. Normal cardiac arrest management

Uterine Atony

  • Inadequate contractions leading to soft, boggy uterus (most common cause of postpartum haemorrhage)

Module 3: Newborn Stabilisation

Newborn: infant in the first 24 hours after birth

Preterm: Infant born before 37 weeks gestation

Birth Transition

  • Disruption of fetal-placental circulation
  • Lungs transitioning from fluid-filled to air-filled
  • Increased pulmonary blood flow
  • Closure of intracardiac and extracardiac shunts

Thermoregulation

Newborns lose heat rapidly – critical to maintain normothermia – to prevent hypoxia

Warm Chain

  1. Warm delivery room
  2. Immediate drying DO NOT DRY – PRETERM > PLACE IN BAG
  3. Skin-to-skin contact (consider plastic/insulated bag/ cling film)
  4. Breastfeeding
  5. Bathing and weighing postponed
  6. Appropriate clothing/bedding
  7. Mother and baby together
  8. Warm transportation (at least 26 degrees)
  9. Warm resuscitation

Four Ways Body Heat Can Be Lost

  1. Convection
  2. Evaporation
  3. Radiation
  4. Conduction

Airway Opening

Common causes – tongue falling back or overextension of the head and neck

Head and Neck Position

  1. Lay supine
  2. 2 cm Pad (under shoulders)

Chin Support

  1. Neutral Head positioning
  2. Chin-lift and head-tilt

Jaw Thrust

  1. Jaw thrust (If above methods don’t work then)

Suctioning

  • Use a 14g catheter – low pressure

Compressions

  1. Two thumbs or two fingers Bottom 1/3 of sternum – one-third of the chest

< 24 hours old – ratio 1:3 (compressions to ventilations)

Infant and Children patient – ratio 15:2 (compressions to ventilations) Shock 4 joules per kg

>1 years old – ratio 30:2 (compressions to ventilation)

Module 3: The Unwell Newborn

Questions on the baby’s feeding habits are one reliable measure of a newborn’s well-being.

Red Flags of a Baby Feeling Unwell

  1. Abnormal breathing/distressed breathing
  2. Not feeding or poor feeding
  3. Urine output decreased / few wet nappies
  4. Not alert or difficult to wake
  5. Fever and non-blanching rash
  6. Fever > 38C
  7. Mottled skin colour
  8. A caregiver’s gut instinct

Non-blanching rash test: Press a glass firmly on the skin. Non-blanching if the rash stays visible.

Module 3: The Child at Risk

Maltreatment: The abuse or neglect of a child under 18 y.o. (Emotional, sexual, physical and neglect)

Mandatory Reporting – Report suspected cases of child abuse and neglect.

Paramedics have an ethical obligation to report

Module 3: Loss and Grief

Loss before 20 weeks doesn’t need to be registered

SIDS: Sudden Infant Death Syndrome (sudden death of a baby < 1 y.o. Cause: Unknown

GRIEF

Read the scene, resuscitate where appropriate

Explain – in empathic “passed on”

Slow down – Death notification and loss of grief shouldn’t be rushed

Police may attend – paramedics aren’t likely to confirm the cause of death

Everybody says goodbye – Let everyone say farewell as per family’s wishes

Compassion, show care

Tell the truth / Not silence is important (Normally bad news is delivered by a senior compassionate paramedic) /Consider clinical debrief

FUNDAS RUB

To encourage the uterus to contract and prevent haemorrhage

OXYTOCIN

After the placenta is delivered, massage the fundus to encourage uterine contractions and minimise excessive bleeding. Administer 10 IU of oxytocin intramuscularly to improve uterine tone further and reduce the risk of haemorrhage.

CORD Clamping

  • Wait 2-3 minutes or until the cord stops pulsating
  • Close to the navel
  • Once pulsations have stopped, clamp the cord by placing a clamp approximately 8-10 inches from the baby. Place a second clamp approximately 2 inches from the first, then cut the cord between the clamps. Do not cut or clamp a cord that is still pulsating. Apply one clamp or tie about 10 inches from the baby.