Cardiotocography

• Diabetes is estimated to affect almost 1 million Australians aged 25 and over.
• 30% of Indigenous Australians and Torres Strait Islanders have diabetes.
• 7% of non-indigenous people have diabetes.
• 194 million people worldwide have diabetes.
• 333 million people may have diabetes by 2025.
• The annual cost to the Australian nation for diabetes exceeds $1.2 billion.
• The annual cost for each individual with type II diabetes without
  complications is $4,025.
• The annual cost for a diabetic with macro-vascular or micro-vascular
  complications is $9,645.

Prostaglandins are synthetic hormones (or medications), usually in the form of a gel or a vaginal pessary, that are commonly used to ripen the cervix or induce labour.

The prostaglandin gel, or pessary, is placed behind the woman’s cervix in her vagina, by the health care worker during a vaginal examination. After the prostaglandins are inserted, the woman is usually requested by the caregiver to stay in bed for about 40 minutes, to one hour, afterwards. This enables the absorption of the prostaglandins. In addition, the baby’s heart rate is usually monitored for this time with a CTG machine. Prostaglandins have the potential to overstimulate the woman’s uterus, (causing it to contract too much). The baby can react to this by becoming distressed, due to a reduced oxygen supply.

If after 6 to 8 hours the woman is not in labour, the health care worker will check her cervix by performing another vaginal examination, to make a decision about ‘the next step’. These could include:

• If the cervix is unchanged, then a 2nd dose of prostaglandin will usually be inserted. Again, the woman needs to be in bed, and the baby is monitored for about 40 minutes to an hour or so
• If the cervix is ripe, and slightly dilated, the waters may be broken by the health care worker. Removing the amniotic fluid can encourage the baby to move further down onto the cervix, hopefully stimulating contractions
• If breaking the waters is unsuccessful, then an oxytocin drip would be needed, in the delivery suite

The Bishop’s score is used to assess the ripeness of the woman’s cervix, before deciding if the prostaglandins are appropriate to give. If the score is more than 7 or 8, the prostaglandins would not be given, rather IV oxytocin and/or breaking the waters would be considered as an alternative.

Thermoregulation:

• Core body temperature is a reflection of the balance between heat gain and heat loss by the body. Metabolic processes produce heat, which must be dissipated.
• The hypothalamus is the thermal control centre for the body, receives information from peripheral and central thermoreceptors, and compares that information with its temperature set point.
• Heat loss occurs through transfer of body core heat to the surface through the circulation. Heat is lost from the skin through radiation, conduction, convection, and evaporation.
• An increase in core temperature is effected by vasoconstriction and shivering, and a decrease in temperature by vasodilation and sweating.

Immunization prevents an estimated 2.5 million deaths every year

Immunization prevents deaths every year in all age groups from diphtheria, tetanus, pertussis (whooping cough), and measles. It is one of the most successful and cost-effective public health interventions.

More children than ever are being reached with immunization

In 2010, an estimated 109 million children under the age of one were vaccinated with three doses of diphtheria-tetanus-pertussis (DTP3) vaccine. These children are protected against infectious diseases that can have serious consequences like illness, disability or death.

An estimated 19.3 million children under the age of one did not receive DTP3 vaccine

Seventy percent of these children live in ten countries, and more than half of them live in WHO’s Africa and South-East Asia regions.

Over 1 million infants and young children die every year from pneumococcal disease and rotavirus diarrhoea

A large number of these deaths can be prevented through vaccination.

Public-private partnerships facilitate the development and introduction of vaccines

For example, a new vaccine which prevents the primary cause of epidemic meningitis in sub-Saharan Africa, meningococcal A, MenAfriVac, was introduced in Burkina Faso, Mali and Niger last year. At the end of 2011. Cameroon, Chad and Nigeria are vaccinating more than 22 million individuals with the vaccine which has the potential to eliminate the leading cause of meningitis epidemics in Africa.

The supply of influenza vaccines has been significantly expanded

The expansion has been possible as a result of WHO supporting the efforts of vaccine manufacturers to produce and license influenza vaccines in 11 developing countries.

Global measles mortality has declined by 78%

Global measles mortality has been reduced from an estimated 733 000 deaths in 2000 to 164 000 deaths in 2008, thanks to intensified vaccination campaigns.

Polio incidence has been reduced by 99%

Since 1988, polio incidence has fallen by 99%, from more than 350 000 cases to 1410 cases in 2010. Only four countries remain endemic – Afghanistan, India, Nigeria and Pakistan – down from more than 125 countries in 1988.

Annual deaths from neonatal tetanus have fallen

Neonatal tetanus deaths have declined to an estimated 59 000, down from 790 000 deaths in 1988.

Immunization provides an opportunity to deliver other life-saving measures

Immunization not only protects children from vaccine-preventable diseases. It also serves as an opportunity to deliver other life-saving measures, such as vitamin A supplements to prevent malnutrition, insecticide-treated nets for protection against malaria and deworming medicine for intestinal worms. In addition, the benefits of immunization are increasingly being extended across the life course to include adolescents and adults, providing protection against life-threatening diseases such as influenza, meningitis, and cancers that occur in adulthood.

Cholestasis of pregnancy

The liver produces approximately 600mL-1200mL of yellow/green bile daily. Bile contains: water, bile salts, bilirubin, cholesterol, and certain byproducts of metabolism. Bile salts serve an important function in digestion- they aid in emulsifying dietary fats.

Cholestasis is a decrease in bile flow. As a result, the materials normally transferred to the bile (bilirubin, cholesterol and bile salts) will accumulate in the blood. Itching is the most common presenting symptom in a person with cholestasis, it is thought that an elevation in plasma bile acids cause this. A characteristic lab finding in cholestasis is an elevated serum alkaline phosphate level.

I was able to watch an ultrasound-guided aspiration of a fluid accumulation in a patients left hip post-total hip replacement. The technician explained the ultrasound both to me and the patient while it was being conducted, as well as pointing things out (like blood vessels dodged, local anaesthetic being injected, the needle used to aspirate and the fluid sac itself). After 50ml of fluid was taken and sent off to pathology it was decided that the poor patient would be sent back to theatre for a washout of the hip.

I was able to practice plenty of VAC therapy dressings while out on prac (although I was lucky and didn’t have stoma’s to dodge like in the photo)… One of the patients had a pig membrane stitched in to his abdo wall, one had an amputated big toe and one was an oozey hernia repair that had dehisced and gone wrong. Although VAC therapy dressings can be tricky I’ll always put my hand up because I know below the foam there’s going to be a decent wound to learn from underneath!

Placement for conducting an ECG:

• Blue dot- V1 which is placed in the 4th intercostal space on the patients right
• Yellow dot- V2 which is placed in the 4th intercostal space on the patients left
• Red dot- V3 which is simply placed in the middle of V2 and V4
• Green dot- V4 which is placed in the 5th intercostal space on the patients left midclavicular line
• Pink dot- V5 which is simply placed in the middle of V4 and V6
• Purple dot- V6 which is placed in the 6th intercostal space on the patients left midaxillary line

And of course, the limb leads which are placed on both the left and right arms and legs (avoiding bony prominences)

While I was out on prac I had an opportunity to watch an echocardiogram. The patient actually had some thickened valves, bicuspid valves where tricuspid valves should be, some narrowed arteries and a dialated aorta and as a result wasn’t suitable to go to theatre like planned. Although it was a bummer for them it was a good learning experience for me because I was told what is and isn’t normal, what manifestations I might see if there were abnormalities and how they would go about treating them. Basically- you want to learn cardiac, watch an echocardiogram.

Little sentences scribbled on the back of my notepad during my recent block of clinical prac:

• Antacids containing aluminium or magnesium affect the absorption of other drug and therefore should be administered 1-2 hours apart from other drugs
• Consuming large amounts of Vitamin K (eg green leafy vegetables) will alter a patients INR result
• Antiemetics may mask signs of overdose of toxic drugs or may even obscure diagnosis of underlying diseases
• PICC (as in PICC line) stands for peripherally inserted central catheter
• Should not administer Metformin if patient is known for diabetic ketoacidosis

Cirrhosis of the liver is characterized by widespread nodules in the liver combined with fibrosis. The fibrosis and nodule formation causes distortion of the normal liver architecture which interferes with blood flow through the liver. Cirrhosis can also lead to an inability of the liver to perform its biochemical functions.

“The five P’s that affect labour and birth”…

Power- the power of the contractions and the mothers pushing efforts

Psyc- the psychological state of the mother will affect the physical

Passage- the pelvis and birth canal allowing for expulsion

Passanger- the positioning and size of the foetus

Placenta- normal attachment and expulsion