exam 2 - prenatal Flashcards
A 20 yo G3 P0020 LMP 6 weeks ago presents for her first prenatal visit and states, “I didn’t plan to get pregnant now, but here I am, and I want to go ahead. I feel okay, but I get sick to my stomach a lot. And I have a million questions about everything!”
goals of prenatal care
Initial and repeat assessment of: gravid pt, fetus
screening for:
-Infectious diseases
-Genetic conditions
-Neoplastic conditions
-Hypertensive disorders of pregnancy
-Gestational diabetes mellitus
-Fetal well-being
-Intimate partner violence
-Toxic habits
-Depression
-Counseling pt and family:
-Course and conduct of prenatal care
-Warning signs of abortion, preterm labor, rupture of membranes, onset of labor
-Preparation for labor and delivery
-Work
-Preparation for the puerperium
-Breastfeeding
first visit: current and past OB hx
-LMP, prior hx of contraception
outcome of at least the last 5 pregnancies:
-Gestational age at delivery
-Route and type of delivery
-Gender assigned at birth
-Anesthesia
-Birth weight
-Complications of pts, if any
-Duration of breastfeeding, if any
-past gym hx- infertility, STIs, endometriosis, PCOS
-PMH
-surgical and hospitalization hx
-psychiatric hx
-genetics:
-father of fetus (FOF), if known
-inquire about any known or suspected congenital disorders
OB hx: past h/o Caesarean section
2 different approaches are most frequently used for incising the uterus during C/S
Low transverse incision (used for most C/S) =
- Reduced risk of uterine rupture if the patient has a trial of labor in a subsequent pregnancy
Classical incision:
- Primarily used in very preterm gestations
-Reduces risk of trauma to neonate at delivery
-If your patient has had a C/S with a previous pregnancy, obtain the operative note from that C/S to determine whether patient can have a trial of labor after Caesarean section (TOLAC)
types of uterine incisions for c-section
First visit: infectious diseases
-hx of tuberculosis (in pt or in any contacts)
-History of genital herpes simplex virus (in patient or partner) • Rash or viral illness since LMP
-Prior hx of neonate infected with Group B streptococcus
First visit: toxic habits, meds, and trauma/violence, genetics
-Toxic habits:
-Smoking or use of vaping devices
-Alcohol use
-Opiate use
-Marijuana use
-Other toxic habits
-Prescription medications (either as prescribed or those prescribed for others and used
by patient recreationally)
-History of trauma or violence
- genetics: include father of fetus (FOF), inquire about any known or suspected congenital ds
assessment of pelvis
-assessing the bony pelvis helps to determine if the pt is at risk of cephalopelvic disproportion
-> increase risk of operative delivery
-> Evaluate:
-pelvic inlet
-midpelvis
-pelvic outlet
First visit: immunizations
measuring fundal ht
-tape measure technique from symphysis pubis to the fundus uteri
duration of the trimesters
-First trimester: up to 14 weeks estimated gestational age (EGA)
-Second trimester: from 14 weeks, 1 day to 28 weeks EGA
-Third trimester: from 28 weeks, 1 day to term
-Full-term: after 37 completed weeks of gestation
determining estimated date of confinement (EDC) or estimated due date (EDD)
-based on LMP
-delivery may occur +- 2 weeks from EDC
-Naegele’s rule states that the EDC = LMP + 9 months + 7 days
-or, EDC=LMP - 3 months and 7 days
-however, most accurate method of estimating EDC up to 14 weeks gestational age (EGA) is by US exam***
US exam in pregnancy
-Highly accurate, noninvasive, and generally considered very safe in pregnancy
-Permits evaluation of fetal presentation, number of fetuses, fetal biometry, detection of fetal heart motion, amniotic fluid volume, placental location, survey of anatomy
Anatomic survey includes but is not limited to:
-4 chamber view of heart
-Neuroanatomy
-Facial anatomy
-Skeletal anatomy, incl. fingers and toes
-Stomach
-Kidneys and bladder
-Genitalia
patient LMP is jan 1. when is her EDD
-october 8
determination of gestational age: If the pt has not had an ultrasound that confirmed or changed the EDC before ___wks, the pt is considered to be _____ (well dated/not well dated)
-If the pt has not had an ultrasound that confirmed or changed the EDC before 22 weeks GA, the patient is considered to not have been well dated
scheduling of visits for uncomplicated pts
-From 6-28 weeks -Every 4 weeks
-From 28-36 weeks- Every 2 weeks
-From 36 weeks-delivery- Every week
-Complicated patients may be seen weekly or biweekly, depending on condition and need
at every prenatal visit, ask about
-any vaginal bleeding
-fetal movement (after quickening)
-at 20 weeks for primigravidas
-at 16 weeks for multiparas
-abdominal pain
-back pain
-any other problems
at every prenatal visit assess
-wt
-BP
-fundal ht
-fetal heart rate
-after 20 weeks, perform leopolds maneuvers -> NO NEED FOR PELVIC EXAM AFTER 20 WEEKS
-performance of intermittent auscultation by doppler stethoscope- at 10 weeks
recommended screening tests
other screening tests:
-anxiety
-depression and perinatal depression
-substance use
-alcohol use
-vaping
-interpersonal violence
-tobacco use
time-sensitive tests
-genetic testing- varies with GA
-first visit: schedule or perform OB sono for dating
-16-20wks: detailed anatomy scan (US)
-24-28 wks: glucose challenge test (GCT) for gestational diabetes mellitus, unless pt is known to have pregestational diabetes
glucose challenge test (GCT)
-50gm oral glucose drink is given
-pt may have fasted or not (doesnt matter)
-obtain 1 hour level in grey top tube
-normal: 130-140
-if pt has elevated GCT, administer 100gm, 3 hr oral glucose tolerance test (OGTT)
genital culture to r/o group B strep at _______ wks EGA
- at 35-37 weeks EGA
-GBS infection is the MC etiology of neonatal sepsis
-obtain by using culture swab and placing in vaginal introitus and then through anal sphincter
-not necessary if pt has urine culture + for GBS
-if pt has + GBS test, or if pt had GBS cultured in urine during pregnancy -> administer intrapartum IV penicillin G
repeat STI testing in 3rd trimester
-consider repeating GC/CT in 3rd trimester in pts testing positive in prenatal care
-consider repeat testing for RPR and HIV Ab in 3rd trimester in high risk pts
Rho (D) immune globulin for Rh negative pts at _____ wks GA
- at 28-30wks EGA
-10% of all humans are Rh negative (lack the Rh antigen)
-Fetal RBCs circulate in maternal blood to some extent
-If the father of fetus (FOF) is Rh positive and heterozygous, and the patient is Rh negative, there is a 50% chance the fetus is Rh positive
-If the FOF is Rh positive and homozygous, there is 100% chance the fetus is Rh positive
-The patient will produce antibodies to the fetus’s Rh antigen during this pregnancy
-The next Rh positive fetus born to this patient will be at risk of destruction of fetal RBCs due to formation of maternal antibodies
-May lead to fetal anemia, hydrops, hepatosplenomegaly, death
-If the patient is Rh negative and has no antibodies, repeat antibody screen and administer Rho(D) immune globulin (RhoGAM®) at 28-30 weeks EGA
-Rho(D) immune globulin administration will provide passive immunization and prevent most antibody formation for the remainder of the pregnancy
outcomes for Rh status of fetus with Rh+ father and Rh- mother
circumstances for administration of Rho(D) immune globulin in Rh negative, antibody negative pts
-Rho (D) immune globulin (RhoGAM®) is given IM at:
-28-30 weeks
-At time of amniocentesis or chorionic villus sampling
-Spontaneous loss or termination of pregnancy (VTOP, suction curettage, ectopic pregnancy)
-After obstetrical version or after abdominal trauma
counseling of prenatal pts: First appointment
First appointment:
-Ancillary testing: genetic testing, U/S, labs, etc.
-Medications
-Only prenatal vitamins
-All others require discussion first
-Intimate partner violence screen
-Avoidance of alcohol and recreational drugs, including marijuana and prescription drugs
-tobacco cessation if indicated
call if any:
-fevers
-vaginal bleeding
-pain
-severe N/V
-anything worrisome
referrals for prenatal pts
Refer to:
-Dentist
-Radiology, if needed, for ultrasound
-Genetic counselor, if indicated
-Dietician, if indicated
-Social work, if indicated
-Discuss with your patient your practice, scheduling of appointments, rotation among practitioners, delivery plans, etc.
counseling of prenatal pts in 2nd and 3rd trimester
-Childbirth education classes (~32 wks)
-Warning signs of preterm labor and labor
-Birth plan
-Umbilical cord banking for stem cells, if desired
-Rupture of membranes
-Preparation for neonate
-Car seat (babies dont leave the hospital w/o car seat)
-Desire for circumcision, if fetus is male
counseling of prenatal pts in 2nd and 3rd trimester: contraception
-ideally wait 3 years after c-section
-vaginally- 18 months -> increased mortality
May use:
-Lactational amenorrhea method (may be effective for up to 6 months)
-Any progestin-only system
-Subdermal contraceptive implant (Nexplanon)
-Progestin-containing intrauterine device (levonorgestrel IUD systems)
-Progestin-only pills
-Depot medroxyprogesterone acetate (Depo-Provera)
-Copper T380A IUD
-Sterilization
-Condoms
-Other non-hormonal methods
-you dont use estrogen bc it influences milk production and pregnancy is a high coagulable state
true labor: what type of contractions and what may occur
contractions:
-Develop a regular pattern, coming closer together
-Last between 30-90 sec
-Do not vary with rest
-Are usually felt in abdomen and lower back
may occur:
-rupture of membranes
-bloody show - less than a period (from stretching of cervix)
- call if you are in doubt!
false labor: “contractions” and what may occur/not occur
contractions:
-Are irregular- every 4, then stop, then every 20 etc.
-Vary in length and in intensity
-May vary with rest or activity
-Are generally felt in lower abdomen and groin
typically:
-rupture of membranes usually does not occur
-no bloody show
-but call if you are in doubt!
exercise recs
-It is best for patients to obtain 30’ of moderate exercise all or most days of week
-If patient was already exercising prior to pregnancy, the patient may continue in same activity
Patients should avoid:
-Contact sports
-Sky diving
-Activities that put one at high risk of a fall
-“Hot” yoga or “hot” Pilates
-Scuba diving
-Maintaining prolonged supine position
-Exposure to steam room, sauna or hot tub for lengthy periods of time
-Sports or exercise performed at high altitude if patient is not accustomed to the altitude
consumption of fish and use of herbal products
-Avoid >1 serving (6 oz)/week of albacore tuna OR >12 oz of fish and shellfish varieties low in Hg++
-Avoid black cohosh, blue cohosh, echinacea, willow bark, valerian, ginseng, pennyroyal
infectious disease risks in pregnancy
risk of toxoplasmosis:
-Avoidance of exposure to cat litter (patient does not have to give cat away; just have someone else empty box or change litter)
-Avoid poorly cooked meat, esp. lamb
risk of listeria:
-avoid cold cuts, sliced cheese
weight gain and nutrition: prenatal vitamins and breastfeeding
-Nutritional assessment with BMI can be useful
Rx prenatal vitamins (PNV):
-Iron 27 mg per day is the only mineral supplement that is needed
-Refer eligible patients to Women, Infants and Children (WIC) Federal Supplemental food program, food stamps, Aid for Families and Dependent Children (AFDC)
Breastfeeding:
-Generally preferred; few contraindications based on maternal infection (HIV, TB, etc.) and use of various medications
-Breastfeeding is recommended by WHO, AAP
-Lactation consultant present in all hospitals with Labor and Delivery unit in NYS
other issues: sex, travel
sex is generally acceptable if pts has no:
-placenta preaevia- placenta is between the fetus and cervix -> going to need a c-section
-no h/o preterm labor
-no h/o rupture of membranes (breaking of water)
travel:
-most airlines will not permit pregnant pts to fly after 36wks
-Permitted before that if pt has uncomplicated pregnancy
-Aisle seat is best to promote walking during flight- every hour
-May need letter from prenatal practitioner
-Carry obstetrical records if traveling far from home
-Walk every 1-2 hrs during travel to avoid VTE
employment
-The patient may work until onset of labor, barring complications or very strenuous work (should be avoided)
-The U.S. Supreme Court decision in Young v UPS (2014) stated that employers “must treat women (sic) affected by pregnancy…the same for all employment-related purposes…as other persons not so affected but similar in their ability or inability to work.”
-Usually, most postpartum patients return to work 4-6 weeks after delivery
-!!23% of postpartum patients return to work within 10 days postpartum
-22% return to work between 10-40 days postpartum
-!!!United States is the only industrialized nation that does not provide paid leave for new parents
which best identifies the potential risk of eating sliced cheese in pregnancy
-listeria infection!!
-microcephaly
-toxoplasmosis
-symmetric intrauterine growth restriction
