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What is Parturition?
- Parturition is the process of giving birth and consists of
- Rupture of the membranes
- Dilation of the cervix
- Contraction of the uterus
- Separation of the placenta
- Shrinking of the uterus
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How many stages of labor are there?
4, but 3 main that we worry about, and labor is actually one continuous event
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What is stage 1 of labor and delivery?
Onset of regular contractions to complete dilatation of the cervix.
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How long will stage 1 usually last?
7-18 hours
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What factors influence the duration of ALL stages?
- Multigravida vs. Primigravida
- Sedation
- Stress
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What is stage 2 of labor and delivery?
- Full dilatation and effacement of the cervix to delivery of the fetus
- Dilatation is the widening of the cervical opening. A 10 cm diameter cervical opening is considered fully dilated.
- Effacement is the stretching and thinning of the cervix. 100% effacement is when the cervix is not distinguishable from the uterus
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How long does stage 2 of labor and delivery last?
20 min to 1-2 hours
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What is stage 3 of labor and delivery?
- Delivery of the fetus to delivery of the placenta
- The fetus is in the head down position is the most common presentation. (Vertex position)
- There is also a fourth stage (not considered a major stage) where the uterus begins to shrink back to normal
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How long does stage 3 of labor and delivery last?
Lasts 3-4 minutes up to 45 minutes
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What is the most common process and presentation of the fetus?
- As the fetus begins down the birth canal, the head turns to a face down position for passage through the pelvis.
- Upon delivery of the head, the fetus rotates internally to ease passage of the shoulders through the pelvis.
- The upper shoulder delivers first, followed by the lower shoulder.
- After delivery of the shoulders, the rest of the body exits rather quickly.
- The umbilical cord is clamped and the baby begins life outside the uterus
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What is Tocolysis?
the process of stopping labor (drug induced)
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What are the different types of Pharmacologic Tocolysis?
- Beta adrenergics (terbutaline sulfate or ritodrine).
- - Relaxation of smooth muscle in the uterus
- Magnesium sulfate to decrease muscle contractility
- Indomethacin to inhibit prostoglandin synthesis.
- - Softens the cervix making it more susceptible to contraction
- Calcium channel blockers like nifedipine.
- - The uterus is a large muscle made up of thousands of muscle cells. When calcium enters these cells, the muscle contracts and tightens. When calcium flows back out of the cell, the muscle relaxes. Calcium channel blockers work by preventing calcium from moving into the muscle cells of the uterus, making it less able to contract.
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What are the different types of Non-Pharmacologic Tocolysis?
- Comprehensive accessible family planning.
- Risk assessment and counseling before conception.
- Risk assessment for prenatal patients.
- Patient education to identify signs of premature labor and when to seek help.
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What is Dystocia?
prolonged and difficult labor
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What are common causes of Dystocia?
- Dysfunction of the uterus.
- Cephalopelvic disproportion.
- Abnormal presentation.
- Hydrocephalus.
- Abnormality in size or shape of birth canal.
- Excessive fetal size.
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What is the Breech presentation?
- The most common of all abnormal presentations (3-5% of all births).
- Three varieties:
- - Complete breech. Feet , legs, and buttocks present together.
- - Incomplete or footling breech. One or both feet descend into the birth canal first.
- - Frank breech. The legs are flexed against the body with the feet near the face with the buttocks being the presenting part.
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What is Face Presentation?
Abnormal fetal presentation: The head enters the birth canal so the sutures cannot override each other and the head must pass at its full size
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What is Transverse lie?
Abnormal fetal presentation: The fetus is positioned perpendicular to the birth canal with the back or back shoulders being presented
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What is Prolapse of umbilical cord?
Abnormal fetal presentation: Prolapse is when the umbilical cord passes through the birth canal ahead of a body part crimping the cord
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What is Occult compression?
Abnormal fetal presentation: When the cord is compressed between the fetus and the wall of the birth canal
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What is Nuchal cord
Abnormal fetal presentation: Where the umbilical cord wraps around the fetus's neck
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What is placenta previa?
fetus implantation blocking cervix
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What is low implantation placenta previa?
Placenta implants low near cervix instead of fundus
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What is partial placenta previa?
Placenta partially blocks cervix
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What is total placenta previa?
Placenta completely blocks cervix
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What is Abruptio Placentae?
- Premature separation from the uterine wall.
- May be partial or complete separation
- There is always hemorrhage associated with abruptio placentae
- - Vaginal bleeding may or may not be visible.
- - External hemorrhage. Visible bleeding.
- - Concealed hemorrhage. No visible bleeding
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What are Indications for cesarean deliveries?
- Prior cesarean delivery.
- Dystocia.
- Breech presentation.
- Fetal (or maternal) distress.
- Multiple gestations
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Why are multiple gestations high risk pregnancies?
- Higher incidence of premature labor and delivery
- Increased risk of congenital defects
- Higher incidence of bacterial infections
- Intra-uterine growth retardation (IUGR)
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What 3 factors come into play at birth for transition to respiration?
- Asphyxia
- - Increased PaCO2, decreased PaO2, and decreased pH.
- - Stimulate the respiratory chemoreceptors, which stimulates gasping breathing
- Thoracic recoil
- - The thorax is compressed when passing the birth canal and on exiting the chest recoils outward drawing air into the chest
- Environmental changes
- - As the fetus exits it leaves a warm dark environment into one that is bright, loud, and cold.
- - This, in turn, stimulates a cry reflex
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How much cmH2O can be required to iniciate our first breath?
-100 cmH2O
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The presence of __________ overcomes the surface tension forces, once the newborn begins normal breathing.
surfactant
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What is the importance of FRC?
re-inflation of the lungs easier with each passing breath
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What closes ductus venosus and ductus arteriosus?
first breath to increase PO2, which then decreases prostoglandin synthesis
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What factors cause the change from fetal to adult circulation?
- Alteration of circulatory pressures.
- Closure of fetal shunts.
- Clamping of the umbilical cord
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What percent of new borns require some assistance, and what percent require major resuscitation to survive?
10%; 1%
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What is a normal transition from intrauterine life to extrauterine life?
- Alveolar fluid is absorbed into lung tissue and replaced by air.
- Umbilical arteries and veins are clamped, removing the low resistance placental circuit and increasing systemic blood pressure.
- Blood vessels in lung tissue dilate, increasing pulmonary blood flow.
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What can go wrong with transition from intrauterine life to extrauterine life?
- Lack of ventilation of the newborn�s lungs results in sustained constriction of the pulmonary arterioles, preventing systemic arterial blood from being oxygenated
- Prolonged lack of adequate perfusion and oxygenation to the baby�s organs can lead to brain damage, damage to other organs, or death
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What are signs of a compromised newborn?
- Poor muscle tone
- Depressed respiratory drive
- Bradycardia
- Low blood pressure
- Tachypnea
- Cyanosis
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Why and how does prematurity affect the need for resuscitation?
- Possible surfactant deficiency
- Decreased drive to breathe
- Rapid heat loss, poor temperature control
- Possible infection
- Susceptible to brain hemorrhage
- Susceptible to hypovolemia secondary to blood loss
- Weak muscles make spontaneous breathing difficult
- Immature tissues may be damaged by excessive oxygen
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Define and describe primary vs. secondary apnea and how to treat each.
- Primary Apnea: When a fetus/newborn FIRST becomes deprived of oxygen (Asphyxia), an initial period of attempted rapid breathing is followed by primary apnea and dropping heart rate that will improve with tactile stimulation
- Secondary Apnea: If oxygen deprivation (Asphyxia) continues, secondary apnea occurs, accompanied by a continued fall in heart rate and blood pressure
- Secondary apnea cannot be reversed with stimulation; assisted ventilation must be provided
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What does effective positive-pressure ventilation during secondary apnea usually result it?
Rapid improvement of heart rate
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What are resuscitation risk factors? (most of the time which can be anticipated by identifying the presence of risk factors associated with the need for neonatal resuscitation)
- Socioeconomic factors
- Demographic factors
- Medical factors
- - Obstetric history
- - Maternal history
- - Current obstetric status
- - Habits
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NRP divides resuscitation risk factors into what and what? (be familiarized, don't need to memorize)
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What are the equipment necessary for resuscitation?
- Suction equipment
- - Bulb suction device (blue bulb suction thingy)
- - Oral suction device (large bore suction catheter, 5, 6, 8, or 10 French)
- - Meconium aspirator (if indicated)
- - Feeding tube (if long term resuscitation is necessary)
- Bag-mask for PPV
- - O2 flow meter
- - Flow inflating bag or Neo Puff (self inflating bag for back up)
- - Appropriate sized mask
- Intubation equipment
- - Laryngoscope with appropriate blades( size 00, 0, or 1)
- -- Make sure it works and have back ups
- - Appropriate sized ET tube
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What are some advantages and disadvantages of Flow Inflating Resuscitation Bags?
- - Advantages:
- Delivers 21% to 100% oxygen, depending on the source
- Easy to assess seal on the baby�s face
- Can be used to give free-flow oxygen through the mask
- - Disadvantages:
- Requires a compressed gas source
- Requires a tight face-mask seal to remain inflated
- Requires a gas source to inflate. If empty, looks like deflated balloon
- Usually does not have a safety pop-off valve
- Uses a flow-control valve to regulate pressure/inflation
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What are some advantages and disadvantages of Self Inflating Resuscitation Bags?
- - Advantages:
- Always refills after being squeezed and
- Is always inflated
- Pressure release (pop-off) valve makes over-inflation less likely
- - Disadvantages:
- Bag will work without a gas source; ensure that oxygen is connected
- Requires tight face-mask seal to inflate the lungs
- Requires oxygen reservoir to provide high concentration of oxygen
- Cannot give free-flow oxygen through the mask
- Cannot be used for CPAP. No PEEP without special valve
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What are some advantages and disadvantages of Neo Puff (T-Piece Resuscitator)?
- - Advantages:
- Consistent delivery of pressure
- Reliable control of peak inspiratory and positive end-expiratory pressure
- Reliable delivery of 100% oxygen
- No fatigue from bagging
- - Disadvantages:
- Requires compressed gas source
- Must have tight face-mask seal to inflate lungs
- Compliance of the lung cannot be �felt�
- Requires pressure to be set prior to use
- Changing pressures during use is more difficult
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Always have a what as a back-up when resuscitating a neonate?
Self-inflating bag
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What is the importance of having a tight seal for resuscitation?
- required for flow-inflating bag to inflate
- required to inflate lungs when self-inflating bag squeezed
- required to inflate lungs when PEEP cap occluded using the T-piece resuscitator
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How do you determine appropriate size of mask?
- Mask should cover:
- Tip of Chin
- Mouth
- Nose
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How do you fix an inadequate seal on a face mask?
- Reapply maskto face and lift jaw forward
- Use light downward pressure
- May gently squeeze mandible up toward mask
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How do you fix a blocked airway?
- Reposition the head
- Check for secretions; suction if present
- Ventilate with the newborn�s mouth slightly open
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How do you fix a situation where there is not enough pressure?
- Increase pressure until there is a perceptible chest movement
- Consider endotracheal intubation
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What range of breaths should be given when giving rescue breaths to a new born?
40-60 bpm
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Is it good or bad if the baby appears to be receiving deep breaths?
- bad;
- Too much pressure is being used
- Danger of producing a pneumothorax
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When should an orgastric tube be put in place?
to relieve gastric distention
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What is gastric distention?
- Elevated diaphragm, preventing full lung expansion
- Causes regurgitation and aspiration
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What is the process for inserting an orogastric tube?
- Equipment: 8F feeding tube, 20-mL syringe
- Measure the length from the bridge of the nose to the ear lobe and then to half way between the zyphoid process and the umbilicus
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What are the steps involved for "provider response for resuscitation"?
- 1st steps:
- 1. term gestation?
- 2. clear amniotic fluid?
- 3. breathing or crying?
- 4. good muscle tone?
- if no for any of these then 2nd step.
- 2nd steps:
- 1. provide warmth
- 2. position, clear airways* (as necessary)
- 3. Dry, stimulate, reposition
- 3rd steps:
- 1. Evaluate respirations, heart rate, and color
- 4th steps:
- Cyanotic = give supplemental oxygen
- Apneic or HR <100 = provide positive pressure ventilation
- if HR <60 continue to step 5
- 5th step:
- Administer epinephrine
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For all new borns, what should be done?
- Provide warmth
- - Thermal Regulation
- Position head and clear airway as necessary
- Dry and stimulate the baby to breathe
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What does any resuscitation begin with?
- The ABC's:
- Airway
- - Position the infant
- - M before N � Suction the mouth then the nose
- Breathing
- - Stimulate
- - PPV if necessary (Using Bag-Mask or Neo Puff)
- Circulation
- - Chest compressions
- - Medications
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What is central cyanosis and is it good or bad?
baby is blue throughout; bad
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What is acrocyanosis and is it good or bad?
peripheral (hands and feet) cyanosis; its ok
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How many compressions should be performed per each breath?
3 compressions per each breath; 90 compressions per min and 30 breaths per min
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How do you determine proper tube size?
- Below 28 weeks, below 1,000 g = 2.5 mm
- 28-34 weeks, 1,000-2,000 = 3.0 mm
- 34-38 weeks, 2,000-3,000 = 3.5 mm
- Above 38, above 3,000 = 3.5-4.0mm
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What are the proper sizes for laryngoscope blades?
- No. 0 for preterm newborns
- No. 1 for term newborns
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How do we determine length of ETT tube?
- <1 kg = 6 cm
- 1 kg = 7 cm
- 2 kg = 8 cm
- 3 kg = 9 cm
- 4 kg = 10 cm
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How often is APGAR score assessed?
1 minute of life, 5 minutes of age, and every 5 minutes there after
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What is a perfect APGAR score?
8-10
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What is excellent APGAR score?
7-10
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What is fair APGAR score?
4-6
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What is a poor APGAR score?
0-3
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What are abnormal APGAR scores directly linked to?
the degree of and the time of severe anoxia
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How do we determine APGAR score?
- Heart rate: absent=0, below 100 bpm=1, above 100 bpm=2
- Respiratory effort: absent=0, weak irregular or gasping=1, good or crying=2
- Muscle tone: Flaccid=0, some flexion of arms and legs=1, well flexed, or active movements of extremities=2
- Reflex/Irritability: No response=0, grimace or weak cry=1, good cry=2
- Color: blue all over or pale=0, body pink hands and feet blue=1, pink all over=2
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If HR <60 despite effective PPV with coordinated chest compressions, you administer what?
- epinephrine as you continue assisted ventilation and chest compressions
- At this point the patient must be intubated if you have not done so already
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What two primary medications do we use during a neonatal resuscitation?
- Epinephrine (Increase cardiac contraction)
- Volume Expanders (Treatment of Hypovolemia)
- - Normal Saline (recommended)
- - Ringer�s Lactate (acceptable)
- - O negative blood (acceptable)
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What is recommended dose of Epinephrine?
0.1 to 0.3 mL/kg of 1:10,000 solution (consider 0.3 to 1 mL/kg if giving endotracheally)
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What is the recommended route for administering epinephrine?
Intravenously (consider endotracheal route while intravenous access being obtained)
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What is the recommended rate of administraion of epinephrine?
Rapidly-as quickly as possible
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What is the recommended dose for Volume expanders (NS, Ringer's lactate, or Rh-negative blood)?
10 mL/kg
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What is the recommended route for Volume expanders (NS, Ringer's lactate, or Rh-negative blood)?
Umbilical vein
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What is the recommended rate for delivery of Volume expanders (NS, Ringer's lactate, or Rh-negative blood)?
over 5 to 10 minutes
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How do we insert Umbilical Venous Catheters (UVC)?
3.5F or 5F catheter, sterile technique
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How do we draw blood from the Umbilical Venous Catheter (UVC)?
- It is just like drawing from an arterial line
- We only draw enough to run the sample
- We always give the blood back
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