Vitamin K Deficient Bleeding (VKDB)
Information in this self-learning package regarding signs and symptoms of VKDB, diagnosis, risk factors and treatment.
It is imperative we educate our clients about the importance of the neonate receiving Vitamin K. Since
the introduction of Vitamin K injections to the neonate, incidences of VKDB have decreased
dramatically.
Check with your educator or designate for access to sign-in sheets if required.
Post Quiz
- Name three reasons why Vitamin K is deficient in the neonate.
- At what age is the neonate able to use the vitamin K in breast milk?
- What dosage/route of Vitamin K should be given?
- Name three signs & symptoms of VKDB
- Name three risk factors associated with VKDB.
- Why is it so important that neonates receive Vitamin K prophylaxis?
Vacuum Assisted Delivery
Objectives for this package – you will:
be able to define indications, prerequisites and contraindications to a vacuum assisted birth
be able to identify proper technique for the procedure
be able to list the risks/complications to the procedure
know what to do if the vacuum attempt fails
be able to appropriately document a vacuum assisted delivery
Check with your educator or designate for access to sign-in sheets if required.
Critical Thinking
- What constitutes inadequate progress?
Answer
Nulliparous women – No progress made in second stage for two hours (without regional analgesia) or three hours (with regional analgesia)
Multiparous – No progress made in the second stage for one hour (without regional analgesia) or two hours (with regional analgesia)
*If progress is being made, then the length of time is flexible
- Why would a vacuum delivery predispose a fetus to jaundice?
Answer
A cephalohematoma is a complication of a vacuum delivery. Any bleeding can cause jaundice in the newborn. Jaundice is caused by the breakdown of red blood cells in the neonate. This breakdown increases when there is a sequestering of blood within a closed space, such as a cephalohematoma.
- How can you tell the difference between a cephalohematoma and a subgaleal hematoma?
Answer
A cephalohematoma will not cross the suture line. It rarely increases in size after birth and is a fluctuant mass. It usually resolves spontaneously and is self limiting.
A subgaleal hematoma will cross the suture lines and feel firm and fluctuant. It may shift with movement and continues to expand post delivery. The neonate may exhibit symptoms of pallor and tachycardia due to blood loss. Blood loss from these hemorrhages can be extensive and life threatening. The hemorrhage can extend from the brow to the nuchal ridge and from ear to ear in severe cases. Common contributing factors include excessive attempts and high pelvic station/CPD.
- Which is the most serious complication?
Answer
A subgaleal hematoma can cause the neonate to bleed to death (a loss of 50 – 100 mLs can be fatal to a neonate as it is 20 – 40% of their blood volume).
- How do you maintain situational awareness?
Answer
Maintain verbal communication – communicate verbally in regards to the number of application, how many pop offs have occurred, the pressure used with each application, the length of time involved (e.g. Vacuum on at 12:10, pressure at 450 mm Hg. Pop off #1 at 12:11.
Vacuum reapplied at 12:12, pressure at 470 mm HG. Pop off #2 at 12:14, head descending well (if not moving may state the station instead as to not worry the client), at 4 minutes since initial application etc…)
- Why might a newborn not adequately feed after a vacuum delivery?
Answer
A newborn may not adequately feed for several reasons. Initially, the newborn may have trouble establishing a coordinated suck due to the discomfort from the delivery and cerebral irritation. (If you had a bad headache, would you be able to suck a thick milkshake through a straw?). Later, issues such as jaundice or a hemorrhage might cause lethargy.
Post self-learning Quiz
- Name three requirements that have to be met in order to proceed with a vacuum delivery attempt.
Answer
Any of the following: Full dilation, ROM, Empty bladder, maternal ability to push, fetus is engaged, informed consent, estimated. Fetal weight of less than 4000 gram, vertex presentation, no brow or face presentation, experienced operator, known position of the fetus, no suspicion of CPD, adequate pelvis, adequate staff, awareness of policies/guidelines, back up plan.
- Name three indications to proceed with a vacuum delivery attempt
Answer
Any of the following: Abnormal FHR or fetal compromise, maternal exhaustion, inability to push effectively, prolonged second stage, inadequate uterine activity, maternal conditions that inhibit her from pushing, inadequate pushing in the second stage.
- Name three absolute contraindications to a vacuum delivery.
Answer
Any of the following: incomplete dilation of the cervix (except in extreme circumstances), intact membranes, breech or face/ brow presentation, fetus not engaged, known bleeding disorders in the neonate, operator inexperience, inability to assess fetal station/position, evidence of CPD,
- What should you prepare for in the immediate postpartum period in regards to the maternal care? Newborn Care?
Answer
Maternal – You should prepare for a PPH
Newborn – You should prepare for a neonatal resuscitation
- What do you need to assess post delivery on the newborn and why?
Answer
Newborn assessment should include head to toe assessment with careful consideration given to the scalp (formation/injuries), observe for brachial plexus injury, hemorrhages (retinal/subgaleal), cephalohematomas, VS, HC, Umbilical cord gases.
- How frequently do you assess the newborn?
Answer
Assess the newborn (VS and HC) as per routine (at birth and q 1 hour x 3), then q 3 hours until 24 hr of age, then q shift x 48 hours. Assessments also need to include colour, scalp, activity level, feeding patterns.
- A G1P0 has been pushing for 2 hours. The fetus has been moved down to +2 station. The client is tired and demanding that you ‘just pull it out’. Her pushing is ineffective as she is uncontrolled and yelling with the contractions. The fetal heart rate post contraction is 70 bpm and then recovers to baseline. Variability is unknown as you are auscultating. Is this a case for a vacuum delivery? Why or why not?
Answer
No. The first action attempted would be to help the client gain control and push effectively. Good progress has been made and the FHR is recovering from the contractions/pushing. Should the FHR worsen then a vacuum might be considered.
- You have been pushing with a client for over 2 ½ hours. You check to see the descent of the fetus and find that an anterior lip is present, station is -1. The client is exhausted and the fetal heart rate is atypical. The MD wants to do a vacuum, as she is a multip he feels he can get the fetus past the cervix. What do you do? Why?
Answer
You would need to advocate for the client against a vacuum attempt. The client needs to have a C/S given the fetal heart rate/fetal station. If the fetal heart rate recovers when the client is no longer actively pushing, then you may be able to wait awhile, possibly try syntocinon, to see if the cervix completely dilates and the fetus descends.
- A G4P3 client comes in and is complaining of decreased fetal movement all day. C/S coverage is not available. When you check the heart rate, it is at 60 bpm and not recovering. PV is 8 cms and the client is a multip. The FHR does not increase with any intrauterine resuscitation techniques. What should you do? Why?
Answer
A vacuum attempt might be warranted in this situation, given that the decreased fetal movement has been occurring all day and you do not know how long the FHR has been low. The choice is between maternal trauma (e.g. cervical tear) and possible fetal demise as a C/S is unavailable.
Supplementation for term newborn
Supplemental feedings provided in place of breastfeeding. This may include expressed breastmilk or banked breastmilk and/or breastmilk substitutes/formula. Exclusive breastfeeding is recommended for the first 6 months. Supplemental feeding should not be given to breastfed infants unless there is a medical indication for such
feedings.
Check with your educator or designate for access to sign-in sheets if required.
Skin-to-Skin
Immediate mother-infant contact after birth is firmly established as an evidence-based practice that supports breastfeeding and the physical and developmental transition of the infant to extra-uterine life. The Baby friendly Initiative (BFI) lists this practice as a recommended standard of immediate post-delivery care.
Check with your educator or designate for access to sign-in sheets if required.
Newborn Assessment
Routine physical assessment of the newborn is an important skill for maternity nurses. Initial examination should be carried out before 24 hours of age.
6 Rights of Medication Administration
For all clinical staff who are responsible for administration of medication. How to avoid medication errors… the 6 rights and link to associated policy.
Intrauterine Pressure Catheter and Amnioinfusion
Access the module for IUPC and amnioinfusion.
Induction of Labour
Access the module for induction/augmentation of labour with Oxytocin. Practice quiz below.
Quiz
- If the FHR has been normal upon auscultation, you only need to apply the EFM at the time you begin the oxytocin induction. True or False
Answer
True
- ) It may take ____ to ____ minutes to see a response once the oxytocin is adjusted down or off due to tachysystole (half life of oxytocin).
Answer
6 to 8
- ) A Bishop score of 7 is adequate to start an oxytocin induction. True or False
Answer
False
- Many of the medications given in labour are compatible with oxytocin. A port line may be used as long as long as the line is clearly marked as oxytocin. True or False
Answer
False
- The PCP leaves an order to start the oxytocin as per protocol. You mix 30 units Syntocinon in 500 mLs N/S. The patient is a grandmultip. The infusion should be started at ____ mU/min, which equals _____ mLs/hr. You will adjust the rate by _____ mU/min (= to _____ mLs/hr) every _____minutes until the contractions are adequate.
Answer
The PCP leaves an order to start the oxytocin as per protocol. You mix 30 units Syntocinon in 500 mLs N/S. The patient is a grandmultip. The infusion should be started at .3 mU/min, which equals .3 mLs/hr. You will adjust the rate by 1 mU/min (= to 1 mLs/hr) every 30 minutes until the contractions are adequate.
- Before starting the infusion, what risks should the PCP discuss with the patient?
Answer
Failed induction resulting in C/S, chance of operative vaginal delivery, tachysystole, with and without
FHR changes, chorioamnionitis, prolapsed cord with ARM, preterm infant being delivered if dates are
off, uterine rupture & water intoxication.
- The labour floor is really busy and you cannot find a nurse to do your independent double nurse check when mixing the syntocinon. You feel it is OK to mix and infuse the medication as the drug monograph states a double check is only required when possible. True or False
Answer
False
- It takes _______ to _____ minutes to achieve a uterine steady state with oxytocin.
Answer
30 to 40
- A patient had her cervidil removed at 1200. It is now 1220 and the PCP wants the oxytocin initiated. What is the period of time that must lapse between cervidil removal and initiation of the infusion?
Answer
30 minutes
- A patient is having contractions every 2-3 minutes, lasting 20 seconds, palpating mild. Do you increase the oxytocin? Why or why not?
Answer
As they contractions are only lasting 20 seconds, the rate may be turned up (ineffective contractions) as
long as the FHR is normal and there is adequate resting tone between contractions. However, it is also
OK to wait to see if the contractions lengthen and if not, turn the rate up at the next 30 minute mark.
- Written consent by the patient is required to initiate an induction. True or False
Answer
True
- During an induction/augmentation, BP must be monitored every _____ and pulse every _____.
Answer
During an induction/augmentation, BP must be monitored every hour and pulse ever 15 minutes.
- An accurate I&O is not necessary until the patient has been on oxytocin for greater than 24 hours as this is when water intoxication may occur. True or False
Answer
False
- After initiating an oxytocin infusion, the patient is able to ambulate once…
Answer
…. the rate of infusion has been constant for 1 hour and the FHR is normal
- A patient is on 20 mu/min of oxytocin, with contractions every 2-3 minutes, lasting 60 seconds, palpating moderate. SROM occurs. Should the oxytocin be turned down? Why or why not?
Answer
Consideration should be given to decreasing the rate of infusion as the patient has adequate
contractions. A ROM generally will cause an increase in contractions. If the patient does not have
adequate contractions, the rate may be left as is. Monitor the contractions carefully to ensure
tachysystole does not occur.
- When the patient is ambulating in the halls, you can document on the labour record that she is ambulating as a reason why the FHR/Contraction pattern was not checked. True or False
Answer
False
- The most common sign of a uterine rupture is ____________, followed by….
Answer
The most common sign of a uterine rupture is Abnormal FHR, followed by… Abnormal uterine pain, vaginal bleeding or hematuria, elevated presentation of fetal presentation upon PV, easier abdominal palpation of fetal part.
- What important safety feature should you inform your patient about regarding the oxytocin infusion on the pump?
Answer
That the oxytocin line should never be disconnected from the pump before being disconnected from her, unless she has already delivered her baby.
Orientation | Obstetrical-Emergency Department
Please select the video below that pertains to the current topic in your self-learn education package (NOTE: do not watch the videos at the same time because there is a short quiz to be taken after each video in the self-learn package). After each video is complete, please return to your internet browser page (tab at the top of your page) to complete your self-learn package questions and to continue the education.
Imminent Delivery in the Emergency Department
Five Minute Vaginal Delivery
Neonatal Resuscitation