Antepartum Care Flashcards
1
Q
Define: live birth
A
- Irrespective of length of gestation, a birth where there is any sign of life (ie heart beat, umbilical cord pulsation, movement of voluntary muscles). Even if umbilical cord hasn’t been cut.
2
Q
Define: stillbirth/fetal death
A
- Fetal loss after 20 completed weeks or 400 g.
- No signs of life after extraction
3
Q
Define: perinatal period
A
- 28 weeks gestation to <7 days post-birth
4
Q
Define: neonate
A
- within 28 days of life
5
Q
Define: infant death
A
- within 1st year of life
6
Q
Define: gravida
A
- Gravida – the total number of times a person has been pregnant , regardless of the outcome. Current pregnancy counts.
- Nulligravida – never been pregnant
- Primigravida – first pregnancy
7
Q
Define: parity
A
- Parity – # of times a woman has given birth to a fetus > 20 weeks gestation (viable or not), multiple gestation counts as 1 birth
- Nulliparity – never been pregnant beyond 20 weeks
- Primiparity – 1 pregnancy beyond 20 weeks. Has given birth once (possibly to twins, etc)
- Multiparity – 2 or more pregnancies beyond 20 weeks. Has given birth more than once
8
Q
Decode GTPAL
A
- G = gravida
- Para split into 4 categories:
- Term – births after 37 weeks
- Preterm – births between 20 – 37 weeks
- Abortions – miscarriage/abortion before 20 weeks
- Living – number of children living
9
Q
Name some Healthy People 2020 goals
A
- Reduce rate of fetal and infant deaths
- Reduce rate of maternal mortality by 10% (currently 12.6/1,000)
- Reduce maternal illness and complications due to pregnancy (complications during hospitalized L&D) currently 31.1%
- Reduce cesarean birth among low-risk women (full-term, singleton, vertex)
- Reduce low birth weight and very low birth weight
- Reduce preterm births
- Increase proportion of women who receive early and adequate PNC
- Increased abstinence of cigarettes, alcohol, and illicit drugs among pregnant women
- Increase proportion of mothers who achieve recommended weight gain during pregncy
- Increase proportion of women of childbearing potential having:
- at least 400 mcg folic acid from fortified foods or dietary supplements
- adequate RBC folate concentrations
- Increased proportion of women who had preconception care and followed advice.
- Increased number of women who took folic acid/MV supplement and didn’t smoke or drink before pregnancy and had a healthy weight
- Increase number of women who use good birth control post partum
- Reduce post partum smoking relapse
- Increase number of women attending post partum visit
- Reduce number of women with PPD
- Increase number of babies put back-to-sleep
- Increase breastfeeing: even, through 6 months, through 1 year, exclusively breastfed x 3 months/x 6 month
- Increase employee lactation programs
- Reduce formula in first 2 days of life
- Increase number of women giving birth at facilities that promote breastfeeding
- Reduce FAS
10
Q
Leading causes of mortality in US in pregnant people
A
- Cardiovascular (15.5%)
- Non-cardiovascular (14.5%)
- Infection/sepsis (12.7%)
- Hemorrhage (11.4%)
- Cardiomyopathy (11%)
- PE (9.2%)
- Hypertensive disorders (7.4%)
- CVA (6.6%)
- Amniotic fluid embolism (5.5%)
- Anesthesia complications (0.2%)
- Unknown 6.1%
11
Q
Components of an inital visit:
Health Assessment
A
- Pregnancy dating (LMP/menstrual assessment)
- Pregnancy history: GTPAL, operative procedures (ie cesarian) and indication, other labor/pregnancy complications, history of infertility treatments, circumstances of prior loss (GA, what precipitated it, evaluations like genetic testing/autopsy)
-
Medical history: may need to consult/co-manage/refer if preexisting diabetes, HTN, or other condition associated with poor maternal or fetal outcome
- ***MEDICATIONS: make sure they are safe for pregnancy
- ***ALLERGIES: document
- Infection history: Assess for childhood illnesses, need for immunizations
- Family history: evaluate for high risk for maternal complications (like GDM) or genetic issues
- Sexual history: evaluate risk for STIs (partners, practices, protection, previous hx of STI)
- Nutritional history: identify any dietary deficiencies that can benefit from intervention
- Psychosocial history: life, work, financial concerns, stress, social support
12
Q
Components of an inital visit:
Physical Exam
A
- Height/weight
- BP, HR, RR
- Pelvic exam: uterine size. Clinical pelvimetry not super accurate (according to Jordan)
- Auscultation of fetal heart tones (if at least 11-12 weeks)
- Fundal height (if >20 weeks)
13
Q
Components of an inital visit:
Labs
A
- Hgb/Hct/MCV (CBC)
- Blood type & Rh
- Rubella/Varicella titer if unknown immunity
- TB, GC/CT/RPR/HIV/HbsAg
- Urine: dip for protein/glucose, culture.
- Pap if due
- Hemoglobin electrophoresis and Cystic fibrosis (if not previously done)
- HA1C/Thyroid/Lead/HCV if at increased risk for each, respectively
- History of aneuploidy: CVS or amniocentesis
14
Q
Components of an return visit:
Health Assessment
A
- Maternal perception of fetal movement
- Signs/symptoms of common pregnancy problems
- Premature labor
- Vaginal bleeding, Leaking of amniotic fluid
- Changes in lifestyle, exposures, illnesses.
- Assess for violence, substance use, depression prn
15
Q
Components of an return visit:
Physical Exam
A
- BP
- Weight
- Fundal height
- FHR assessment with Doppler
- Leopold’s maneuvers (3rd trimester)
- No routine cervical check until 41 weeks
16
Q
Components of a return visit
Labs and Ultrasound
A
- 16 - 20 weeks: Quad/penta screen
- 18 - 20 weeks: Dating and anatomy ultrasound
- 24 – 28 weeks: Glucose tolerance, repeat H/H, Ab screen if Rh negative
- 35 – 37 weeks: GBS screen
- 3rd trimester: rescreen GC/CT/HIV/RPR if at increased risk
17
Q
Appropriate spacing of visits:
A
- q month up to 28 weeks
- q 2 weeks until 36 weeks
- q week until 40
- then twice a week until delivery?
18
Q
Presumptive signs of pregnancy
A
Presumptive signs: subjective signs noticed by mother
- Amenorrhea
- Breast changes
- Skin changes
- Chloasma – face darkening
- Pigmentation changes in breasts, axilla, genitals, linea alba → linea negra
- Striae on breasts, abdomen, maybe thighs/buttocks
- Skin vasculature changes → spiders and palmar erythema
- Vaginal symptoms
- leukorrhea – increased vaginal discharge (odorless, nonirritating)
- Subjective sensations – ie nausea/vomiting, urinary frequency, fatigue
- Quickening – usually first felt sometime between 15 – 22 weeks
19
Q
Probable signs of pregnancy
A
Probable signs: objective signs noticed by provider
- Enlargement of abdomen – uterus generally not palpable in abdomen until 12 weeks
- Vaginal changes
- Chadwick’s sign – bluish color eventually spreads to all of vaginal mucosa (as early as 6 weeks gestation)
- Cervical changes – also becomes bluish in color
- Goodell’s sign – softening of the cervix
- Uterine changes
- Hegar’s sign – LUS so soft it can be compressed during a bimanual (?)
- Ballottement of the fetus (palpation technique to feel something floating in the body, ie a fetus or floating kidney)
- BBT elevation – progesterone makes temp go up
- Endocrine pregnancy tests
20
Q
Positive signs of pregnancy
A
- Identification of fetal heart activity
- Doppler placement during early pregnancy: in center of abdomen slightly above symphysis pubis
- Should be heard by Doppler by 12 weeks (can as early as 10) and by ultrasound as early as 6 weeks. Not until 15-22 weeks by fetoscope
- Detection of fetus/embryo by ultrasound or xray
- Gestational sac detectable by 4 weeks
- Embryo detectable by 6 weeks
- Detection of fetal movement by the examiner – usually not until 2nd half of pregnancy
21
Q
Naegele’s rule
A
EDD = LMP + 7 days – 3 months
- Add 1 year if LMP not in 1st 3 months of year
- Careful with months that have 30 vs 31 days.
- 90% of women with known LMP will deliver by 41 wks.
- Assumes a 28 day cycle.
22
Q
What is the fetal lie?
A
- Lie: relationship of fetal spine to the maternal spine (longitudinal, transverse, oblique)
23
Q
What is the fetal presentation?
A
- Part of the fetus presenting at pelvic inlet (96% cephalic)
- Cephalic presentations:
- Vertex – head tucked
- Sinciput (median vertex) – head not completely tucked
- Face – head somewhat extended
- Brow – head very extended
- Breech presentations:
- Complete – legs crossed
- Incomplete – one leg crossed, one extended
- Frank – both legs extended
- Footling – leg presenting first (single or double)
24
Q
What is the fetal position?
A
Relation of presenting part to the left or right of maternal pelvis. Occiput is the reference (ie LOP, ROP)
25
What is the ***fetal variety?***
Relationship of presenting part to anterior, posterior, or transverse part of the maternal pelvis
26
What is the **_fetal attitude_**?
Position of the head with regards to the fetal spinal column. Flexion or extension
* vertex, sinciput, face/brow
27
Expected uterine size by weeks: 1st trimester
* 4-5 weeks = pear
* 6 weeks = juice orange
* 8 weeks = naval orange
* 12 weeks = grapefruit
28
Location of fundus by weeks: after 1st trimester
* 12 weeks – symphysis pubis
* 16 weeks – halfway between symphysis pubis and umbilicus
* 20 weeks – umbilicus
* 28 weeks – halfway between umbilicus and xyphoid process
* 36 weeks – xiphoid process
29
Guidelines for safe exercise
* General
* Avoid exercising while fasting or in hot/humid conditions
* Adequate hydration (monitor urine color)
* Exercise in loose, comfortable clothing (heat/sweat dissipation)
* Movements
* Avoid jumpy/jerky movements that could result in abdominal trauma, also no horseback riding or skiing
* Strength training: keep weight light (don’t want to overload joints) and preferably use resistance bands (so free weights don’t hit stomach)
* Avoid walking lunges (risk of groin strain)
* Avoid supine position after 16-20 weeks
* Avoid valsalva maneuver
* Exertion
* Listen to your body
* “Talk test” should be able to comfortably carry on a conversation during exercise, if not, intensity is too high
* Heart rate monitors: guidelines different by age and fitness
* Borg Rating of Perceived Exertion (scale of 1 – 20), don’t go over 14 (aim for 12 – 14).
* **_Warning signs to stop exercising while pregnant_**: bleeding, dyspnea prior to exertion, dizziness, headaches, chest pain, muscle weakness, calf pain/swelling of unknown origin, PTL, decreased fetal movement, ruptured membranes
30
Recommended physical activity/exercise
* 30 minutes or more of moderate intensity exercise most days recommended (same as non-pregnancy)
* If not used to exercise, start walking 10 min at moderate intensity 4-5x/week, work up to 30 min at least 4x/week
* Low-impact aerobics (ie group fitness classes), swimming/water aerobics (esp good if submerged to chest → improves venous return, decreases lower back pain, etc)
* HIIT training good. More time spent at high intensity, the shorter interval needed for good effect
31
Describe treatment modalities for musculoskeletal discomforts during pregnancy, including alternative and complementary therapies.
* Kegels
* Pelvic tilts
* Swimming/aquatic therapy
* Chiropractic
* Short term acetaminophen
32
Review the CDC recommendations for immunizations in pregnancy
* MMR vaccine: live vaccines contraindicated during pregnancy. Need to wait 4 weeks after to get pregnant
* TDAP and flu (if in season) recommended during pregnancy
* Other inactivated or toxoid as indicated
33
Define: **birth rate**
* The number of live births in a defined administrative jurisdiction, in a calendar year divided by the midyear population of the jurisdiction, with the customary multiplier of 1,000 to produce a whole number rather than a decimal or fraction
34
Define: **fertility** **rate**
* A measure of the fertility of a population using the annual number of live births as the numerator and the number of women in the reproductive age group (15–44 or 15–45 years) as the denominator.
35
Define: **early neonatal death vs late neonatal death**
* early - first week
* late - second, third, and fourth weeks
36
Define: **maternal mortality rate/ratio**
* Rate:
* # of maternal deaths / # women of reproductive age
* Ratio:
* # of maternal deaths / # live births
37
Define: **low/very low/extremely low birthweight**
* Low = \< 2500g
* Very low = \< 1500g
* Extremely low \< 1000g
