Midwifery NMC OSCE Questions and Answers

Midwifery NMC OSCE Questions and Answers What are the risk factors for sepsis in a pregnant person that are features of the woman? - obesity - impaired glucose tolerance/DM - impaired immunity - anaemia or sickle cell disease - poor socio-economic groups - black or minority ethnic group origin - hx of pelvic infection or vaginal discharge - hx of GBS - IV drug misuse - woman whos language is a barrier to receiving care Risk factors for development of infection and sepsis related to pregnancy and childbirth - septic miscarriage or termination of pregnancy - cervical cerclage - prolonged SROM - amniocentesis and other invasive procedures Risk factors for development of infection and sepsis related to labour and puerperium - IOL - preterm birth - C/S - instrumental vaginal delivery - prolonged ROM or chorioamnionitis - prolonged labour w/ more than 5 vaginal examinations - retained products of conception - UTI's/catheteriizations - Mastitis - GAS infection among the family Steps in assessing sepsis A- Airway (if the patient can talk, their airway is patent) B- Breathing (SPO2 &RR; Inspect, palpate, auscultate ) * intervene & investigate as needed, i.e. apply O2, etc. C- Circulation (Pulse, BP, Cap refill, extremity temp/edema/pain, oral temp,) I&I's : fluid balance sheet start, more blood work, catheter, x2 large bore IV's & start fluid, BW) *want to start IV antiobiotics after BW &w/i 1hr of suspected sepsis D- AVPU, neuro signs, Blood glucose, review pt's meds E- Head to toe, try to identify source of infection, review everything thats done Sepsis 6 protocol 1. oxygen 2. blood cultures 3. give IV antibiotics 4. Give IV fluids and monitor response 5. Measure lactate levels 6. Measure urine output What are the investigations for sepsis - blood culture - serum lactate - FBC and CRP - Renal and liver function tests - Coagulation screen, - Samples and swabs taken as indicated by clinical suspicion of the focus of infection - imaging- chest X-ray, Pelvic USS, CT scan Maternal Red Flags of Sepsis - responds only to voice or pain/unresponsive - acute confusion - systolic BP 90mmHg - HR 130 bpm - RR 25 pm - Needs O2 to keep SpO2 92% - non-blanching rash, mottled/ashen/cyanotic - has not passed urine in last 18hours What do you do if a maternal red flag for sepsis is present in the community? - call 999, arrange blue light transfer - if available give O2 to keep O2 above 94% - Cannulate if skills & competencies allow - consider IV fluids - inform family - ensure crew pre-alerted as "red flag sepsis" What do you do if a maternal amber flag presesnt in the community? - same day assessment by GP/team leader - Is urgent hospital referral required? - agree and document ongoing management plan including observations frequency, planned second reveiw as agreed with GP/team leader) - Monitor urine output - consider life threatening sepsis mimics e.g. PE Management of antepartum haemorrhage APH Airway, is it patent? position appropriately Breathing, monitor resps, attach pulse ox, give O2 Circulation, cannulate x2 large bore, take group and screen, commence fluids, monitor pulse and BP, ask for 2 units RBC the following blood tests should be taken as part of the management of primary pph STAT - cbc - LFTS - lytes and creatinine - coag studies - group and screen and a cross match what are the medications that you can use for a PPH oxytocin 5iu over 2min direct IV oxytocin 40 iu/500mL isotonic crystalloid @ 125mL/hr carboprost 0.25mg IM q15min up to 8x (Asthma!!) ergometrine 0.5mg slow IV or IM (HTN!!) misoprostol 800mg sublingually or per rectum TXA acid bolus 1-2g What should you chart with a PPH - staff in attendance and time they arrived - sequence of events - time of admin of drugs and amount - the time of surgical intervention, where relevant - the condition and overall assessment of the mother throughout the different steps - identification and timing of the fluid and blood products given What is ABCDE Airway Breathing Circulation Disability (lvl of consiousness) Expose and examine At each level, if something is identified it needs to be treated! Structured midwifery assessment of a woman - a wuick review of airway and breathing - a check for contraction of the uterus postnatally - review of any significant pain - assessment of the womans current condition by performing a physical examination -review of the womans history and assessment of any risk factors - traditional head to toe including fetus/newborn once any lifethreatening problems have been address useful questions about pain -describe the pain. Is it sharp, dull, aching, hot, tight? - is it constant or intermittent? - where is it? Put a finger where the pain is worst. Does the pain go anywhere? - Does anything bring on the pain? - Does anything help the pain? Have you taken anything? What can we learn from the 'A' part of ABCDE "How are you?" When a woman answers this questions we can determine airway patency, neurological status (&th4 ok circulation), reasonable respiratory effort, pain level. Does her repsonse indicate any level of confusion or neurological impairment? What can we learn from the 'B' part of ABCDE a change in respiratory status is a sensitive indicator of deteriorating illness a midwife should asses - for signs of increased resp effort (use of accessory muscles, difficulty completing scentences, wheezing, etc - ++++++ important to assess and record the respiratory rate - a rate over 20 breaths is cause for concern - a rate over 30 is a sign of significant pathology necessitating immediate action - apply a pulse ox (always state if she is on oxygen or RA) - ABGs may be taken here What can we learn from the 'C' part of ABCDE Circulation - pulse rate - BP - and assessment of perfusion provide vital initial info - Note general appearance (is she pale? sweaty? etc) - if irregular pulse should do an ECG - measuring urine output What can we learn from the 'D; part of ABCDE ' Disability' - AVPU/consciousness (if reduced move to glascow coma scale) - check blood sugar AVPU classification A: alert B: responds to voice C: responds only to painful stimuli U: unresponsive to all stimuli What can we learn from the 'E' part of ABCDE? 'Exposure' - traditional head to toe, may help identify source of blood loss, source of infection, etc Midwifery antenatal assessment steps - review medical, obstetric, family and current pregnancy history, EDC, &GA - review general physical and psychological wellbeing - perform abdominal palpation, including symphysis funal height easurement; enquire regardign fetal movements and FH auscultation or CTG - examine legs (swelling, pain) - Enquire regarding any concerns, (pain, urine, PV loss, headaches, visual disturbances, skin disorders) - Test BP and urine - review any test results Taking history questions How are you? What made you come to the hospital today? Are you worried about anything? How long have you been unwell? Do you have any pre=existing illnesses? Are you taking any medication? Do you have any allergies? Have you taken anything since you became unwell? Have you been in contact with anyone with an infective illness? Have you got any pain? Is the baby moving? When should the NIPE be performed? w/i 72hrs of birth by a qualified practitioner caput succedaneum is a diffuse subcutaneous fluid collection w/ poorly definded margins (often crossing suture lines) caused by pressure on the presenting part of the head during delivery, does not cause complications and resolves over the first few days cephalhaematoma subperiosteal haemorrhage which may increase in size after birth, bound by the periosteum therefore does not cross suture lines, subgaleal haemorrhages occur between the aponeurosis of the scalp and periosteum and form a large, fluctuant collection which crosses sutures lines Postive screen for the testes on the NIPE necesitate Babies with screen positive findings of bilateral undescended testes following NIPE newborn examination should be seen for assessment by a senior paediatrician within 24 hours of the examination to rule out metabolic and disorders of sex development conditions. Babies with screen positive findings of unilateral undescended testis following NIPE newborn examination should be reviewed by the GP during the NIPE infant examination at 6 to 8 weeks of age. Four areas to auscultate heart sounds for NIPE Mitral valve- 5intercostal space midclavicular line (apex) Tricuspid valve- 4-5 intercostal space lower sternal edge pulmonary valve- 2nd intercostal space- left sternal edge aortic valve- second intercostal space right sternal edge NIPE info is recorded in S4N (NIPE newborn screening examination) or GP IT system (NIPE infant screening examination) baby's clinical notes baby's PCHR local clinical data collection system (where appropriate) Risk factors for other eye or visual problems -a first-degree relative with an ocular condition which was congenital or developed in early childhood, for example aniridia (absent iris), coloboma (malformation of the eye) or retinoblastoma (malignant retinal tumour) childhood -prematurity -genetic syndromes, such as trisomy 21, associated with eye and vision disorders -extensive port wine stain involving the eyelids, which can cause glaucoma -maternal exposure to viruses during pregnancy, including rubella and cytomegalovirus -neurodevelopmental conditions or sensorineural hearing loss (deafness caused by abnormal nerve function in the inner ear) Parents should be advised to contact their midwife, GP or health visitor whenever they have any concerns about their baby's eyes or visual behaviour, including: inability of their baby to fully open their eyes or if eyelid opening appears asymmetrical apparent deterioration of visual interest a wobbling of the eyes a consistent eye misalignment an abnormal appearance of the eyes a white reflex, consistently seen on flash photography asymmetry of the red reflex, consistently seen on flash photography Babies with screen positive eye results following the NIPE newborn screening examination should be urgently referred via the NIPE pathway to an ophthalmologist within 2 weeks of the screening examination. However, if there are significant concerns at the time of the NIPE newborn screening examination, discussion with the ophthalmology service before the baby's discharge home should be considered. Risk factors for CHD include: family history of CHD (first-degree relative) fetal trisomy 21 or other trisomy diagnosed (these babies have high risk of cardiac defects and require continued surveillance) cardiac abnormality suspected from the antenatal scan maternal exposure to viruses, for example, rubella during early pregnancy maternal conditions, such as diabetes (type 1), epilepsy, systemic lupus erythematosis (SLE) teratogenic drugs taken during pregnancy Parents should be asked if their baby: (heart exam) ever gets breathless or changes colour at rest or while feeding is not feeding well or ever too tired to feed, quiet, lethargic, or has poor muscle tone dextrocardia heart displaced to the right Signs and symptoms that suggest critical or major congenital heart abnormality tachypnoea at rest episodes of apnoea lasting 20s or associated with colour change intercostal, sub-costal, sternal or supra-sternal recession, nasal flaring central cyanosis visible pulsations over the precordium, heaves, thrills absent or weak femoral pulses presence of cardiac murmurs/extra heart sounds Significant murmurs loud heard over a wide area have a harsh rather than soft quality associated with other abnormal findings NIPE hip risk factors— NIPE hip clinical examination + Hip Ultrasound First degree family history of hip problems in early life Breech presentation at or after 36 completed weeks of pregnancy, irrespective of presentation at birth or mode of delivery (i.e. includes breech babies who have had a successful external cephalic version ECV) Breech presentation at the time of birth between 28 weeks gestation and term Multiple pregnancy where any of the NIPE hip risk factors listed above is present. All babies from that pregnancy should have a hip ultrasound. Barlow manoeuvre is used to screen for dislocatable hip— aims to dislocate hip posteriorly. barlow maneuvre is positive if if femur heads slips out of posterior rim of hip joint (thus confirming the hip is dislocatable and has instability) Ortolani manoeuvre is used to screen for a dislocated hip— aims to relocate a posteriorly dislocated hip. Screen negative newborn examination but positive NIPE hip risk factors— hip ultrasound by 6 weeks of age. Screen positive newborn examination — (hip) hip ultrasound within 2 weeks of age Screen positive results for hips are: - difference in leg lengthknees at different levels when hips and knees are bilaterally flexed (positive Galeazzi sign) - restricted unilateral limitation of hip abduction (with a difference of 20 degrees or more between hips) -gross bilateral limitation of hip abduction (loss of 30 degrees abduction or more) - palpable 'clunk' when undertaking the Ortolani manoeuvre - from 2018, asymmetrical skin creases has been removed from the list of screen positive criteria. Cryptorchidism undescended or absent testicles Clinical risk factors for cryptorchidism a first-degree family history of cryptorchidism (baby's father or sibling) low birth weight small size for gestational age or preterm birth steps in each part of the NIPE sections 1. - why is it important to identify 2, Establish history - establish mothers medical, recent obstetrical history including medicatioins - family history - how was the baby postnatally? - identify any risk factors - identify any parental concerns 2. Inspect, Auscultate, palpate 3. determine +/- and relay results & plan How to conduct the barlow examination adduct the hip by bringin the thigh towards midline then apply gentle posterior pressure to the knee Orlatani maneuver how to flex infants knees to 90 degree position then abduct the legs by folding the thigh outwards Undetected unstable hips with delayed treatment may result in the need for complex surgery and/or long-term complications such as: impaired mobility and pain osteoarthritis of the hip and back Management of CLICKY HIPS Isolated clicks without any other relevant clinical findings should not be classified as screen positive and do not require referral for ultrasound.Confirmation of the screening outcome by an experienced clinician should be sought if the examiner is unsure,After a second opinion and if a screening outcome is still unclear, an ultrasound scan at 6 weeks of age may be considered. This would be a local clinical referral and not part of the national NIPE screening pathway. Parents should be advised to contact their healthcare professional at any time if they have any concerns about their baby's hip(s). They should observe if: one leg cannot be moved out sideways as far as the other when changing the baby's nappy one leg seems to be longer than the other one leg drags when their baby starts crawling their child walks with a limp or has a 'waddling' gait when they start walking Where testes are felt bilaterally but high in the inguinal canal, this should be managed as screen positive What does hitting the emergency buzzer mean for a shoulder dystocia? I am going to immediately use the emergency buzzer and declare the obstetrical emergency, clearly stating 'Shoulder Dystocia'. It is important to promptly call for help and clearly declare the emergency to other healthcare team members to ensure the woman receives safe, timely and appropriate care for the situation. By calling this emergency buzzer I am notifying others of what is going on, and that I want a senior obstetrician, anesthetist, senior midwife and pediatrician, as well as some extra midwives to help me What do I need done/monitored during a shoulder dystocia? One person will need to monitor moms vital signs. This is important as recording maternal observations establishes her condition and monitors her for shock One person will need to chart/scribe times or maneuvers, arrivals of staff, vital sign times, etc One person will need to start a pre-operative checklist incase we need to go to the OR Scribe, I need you to note that the head delivered at this time, and it is facing ______, the Anterior shoulder at the time of the dystocia is _______ first line shoulder dystocia maneuvers mcroberts suprapubic pressure