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Womens Health > Exam 2 Prenatal Care, labor, delivery, puerperium > Flashcards

Exam 2 Prenatal Care, labor, delivery, puerperium Flashcards

1
Q

Elements of Preconception care

A

BMI, age, Med hx, Medications, Repro hx, substance use, family hx, nutrition

Get complete PE, check for dental caries (linked with preterm labor)

Labs: routine HIV
Other if indicated: rubella titer, varicella titer, HepB SA, RPR, CBC, GC, CT, FBS, HepC ab, TB, CF carrier, Tay sachs

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2
Q

What immunizations are recommended for future mothers

A
  • MMR, Varicella (these two CI in preg, need to prevent preg 1 mth after receiving)
  • Hep B
  • Flu
  • Tdap
  • +/- Pneumococcal
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3
Q

General recommendations for Preconception care

A 
FOlic acid 0.4-0.8 mg qd but 4mg if +hx NTD
No ETOH or tobacco
Prevent HIV
Control med illnesses
Keep menstrual diary
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4
Q

When should pt have 1st prenatal care visit

A

recommended in 1st trim by 10 wk gestation

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5
Q

PRENATAL CARE: 1st visit

Hx components

A

need full hx.. esp

  1. GYN hx: STIs PID, abn pap, procedures
  2. Planned/unplanned preg
  3. Domestic violence?
  4. Tobacco, ETOH, rec drug use
  5. Potential barriers to prenatal care
  6. Inheritable dz

G-v, P-TPAL……..(g is gravida, P is para)
LMP (1st d last period)
EDC (est date of confinement)
EDD (conceived? LMP+7d - 3mth) - Naegele’s rule

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6
Q

PRENATAL CARE: 1st visit

How do you determine EDD

A

Naegeles rule

add 7 d to LMP then subtract 3 mth

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7
Q

PRENATAL CARE: 1st visit

How do you classify deliveries from 37 wk gestation

A

Early: 37 0/7 wk - 38 6/7 wk
Full: 39 0/7 wk - 40 6/7 wk
Late: 41 0/7 wk - 41 6/7 wk
Postterm: >42 0/7 wk

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8
Q

PRENATAL CARE: 1st visit

PE

A

Gen PE (BMI)
Pelvic exam
*uterine size/shape/adnexa
*Chadwick’s sign (blue/purple coloring of vagina/cervix)
*HEGARS sign: palpable softening of isthmus
*Clinical pelvimetry +/- (determine if >11.5cm)
*Specimen: pap (if due), CT swab, +/- GC swab

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9
Q

PRENATAL CARE: 1st visit

Routine Labs

A 
CBC, blood type and Rh
Antibody screen
Rubella and varicella
Syphilis testing
HBsAG (even if vaccinated)
HIV
UA C&S
TSH +/-
CF carrier screening +/-
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10
Q

PRENATAL CARE: 1st visit

additional labs for women at risk

A

TB
HepC antibodies
Trich, Gonorrhea, HSV
HgbA1C

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11
Q

PRENATAL CARE: 1st visit

Ultrasound

A

confirm EDD*** crucial (LMP + 7d subtract 3 mth)

US: fetal cardiac motion as early as 5.5-6 wk

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12
Q

How are trimesters broken up?

A

1st: wk 1 to end of wk 12
2nd: wk 13 to end 26
3rd: wk27 to end of preg

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13
Q

How frequently should a preg women be seen

A

1st 28wk: monthly
28-36: q2wk
36+: weekly

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14
Q

How are fetal mvmt (aka QUICKENING) related to pregnancy hx? when should you begin to discuss KICK COUNTS

A

1st preg: first fetal mvmt @ 18-20wk
2nd+ preg: first fetal mvmt @ 16-18 wk

Kick counts: discuss in 3rd tri

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15
Q

PRENATAL CARE SUBSEQUENT VISITS

Hx, PE

A

PE

  • BP
  • FHT fetal heart tones (10-12 wk w/ doppler, 120-160 bpm is WNL)
  • Fundal height (FH): 12 wk at pubic symphysis, 20 wk at umbilicus; add 1 cm for each wk after 20 wk (drops after 36-38)
  • Extremities
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16
Q

What and when: Leopold maneuvers

A

PE in 3rd trimester

*4 different maneuvers to feel shape of fetus

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17
Q

PE in 3rd trimester should consist of

A

Leopold maneuvers

Cervical exam for: dilation, effacement, station, presenting part

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18
Q

will you marry me?

A
  • clint
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19
Q

Routine screening labs during prenatal visits:

A

1) Urine: PRO and +/- sugar every visit
2) GDM screen at 24-28 wk (50 g 1 hr OGCT, if >130-140 f/u with 100g 3 hr OGTT)
3) CBC in early 3rd tri to assess anemia
4) Antibody screen in Rh negative women (completed during intial lab work, repeat early 3rd tri) - Rh neg gets rhogam at 28-30 wk
5) group b strep testing (swab both lower vagina and rectum at 35-37 wk; if + need intrapartum abx prophylaxis to preven neonatal GBS)

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20
Q

OPTIONAL screening labs during prenatal visits

A

Down Syn: ACOG - ALL should be offered at screen NTD, Downs, trisomy 18

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21
Q

When would you consider the use of cell free fetal DNA

A 
35+yo  at delivery
US indicates risk aneuploidy
Prior preg with trisomy
\+ test aneuploidy
Parental robertsonian translocation
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22
Q

When do you receive OB UTZ

A

1st tri:
Date, eval bleeding/pain, location of preg (ectopic), +/- 5-7 d

2nd trimester: (18-20 wk)
Fetal growth, fetal anatomy survey, placental location (done at 18-20 wks) +/- 10-14d
**Level 1 basic, Level II in depth
**may be able to determine gender

note: these are usually the only 2 US, but may have additional in third tri…

3rd tri: good w/in 3 wk: fetal growth, presentation, bleeding, Biophysical Profile (acidotic or hypoxic baby?)

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23
Q

How should you counsel woman re wt gain for bmi

*note: only 7 lb of the wt gain is fat

A

BMI 30 = obese, should gain 11-20 lb

24
Q

How should we counsel women re kcal intake needed (preg vs lactating)

A

nonpreg: 2200 kcal
Preg: 2500 kcal
Lactating: 2640 kcal

25
Q

How should we counsel preg women re travel

A

yes, DVT is a worry but more concern over risk of complication and having to stay where she is for 10wk. Fly > drive

26
Q

how should we be counseling pt in 2nd trimester

A

address indiv problem
discuss normal/abn labs
warn about preterm labor
discuss childbirth education

27
Q

what counseling components should be included in 3rd trimester

A
  1. Hospital facilities
  2. Labor anesthesia
  3. Signs of labor
  4. Fetal Surveillance
  5. Post-dates counseling and induction
28
Q

What are the tests for fetal well-being

*good if have GDM or preg HTN

A

Fetal mvmt or kick counts
Non-stress test (NST) - belt on belly to measure heart tracing to determine hypoxia
Contraction stress test (CST)
Biophysical Profile (BPP) -

29
Q

Common complaints of preg include? what do we do to help?

*don’t need to know for test?

A

NV:

  • unclear etiology;
  • rec small freq meals,
  • push fluid,
  • antiemetics (Promethazine, Meclizine, Reglan, Zofran, ginger, pyridoxine (vitB6)), IV hydration, steroids
  • **steroids only for severe hypermesis

Backache - mild
Varicosities
HA, Hemorrrhoids, Heartburn, PICA
fatigue, vag dc, constipation, urinary freq

30
Q

PROCESS OF LABOR

Define: Labor, effacement, dilation, presenting part, station

A

Labor: uterine activity that results in progressive dilation and effacement of the cervix

Effacement: thinning or shortening of length of cervix (normal length >2.5 cm)

Dilation: Diameter of cervical ox in cm
complete = 10cm dilation with 100% effacement

Presenting part: part of baby coming 1st through birth canal

Station: degree of descent of the presenting part in the birth canal in relationship to the ISCHIAL SPINE

31
Q

True labor vs False labor (braxton hicks contractions)

A

True: reg intervals, gradually increasing in freq and intensity, CERVICAL DIALTION, back and abd discomfort, no relief from sedation

False: irreg intervals and duration, intensity unchanged, no dilation, lower abd pain, relief with sedation

32
Q

what components are included in labor and delivery eval

A

Rev hx & PE (ACOG antepartum record)

  • brief hx, vitals, cervical exam
  • status of membranes (has water broken!)
  • fetal monitoring
33
Q

What signs can help confirm or r/o suspected membrane rupture

A
  • sterile speculum technique!!!
  • pooling of amniotic fluid in posterior fornix of vagina
  • direct visualization of fluid leakage through the cervix
    a) Nitrazine test; intact = pH 5-6, rupture = 6.5-8 BLUE
    b) “Fern test”: air dried sample of vaginal fluid under micro, looks like fern = + rupture
34
Q

Describe the 1st stage of labor

A
  • onset labor to full cervical dilation and effacement
  • subdivided into phases based on rate of cervical dilation
    a) latent: first reg contractions –> 3-4cm dilation; <0.5 cm/hr slow rate
    b) active: 1 cm/h, ends with complete dilation
    c) rates depend on parity
35
Q

Describe the second stage of labor

A

begins: complete dilation
ends: delivery of infant
* *PUSHING phase

36
Q

Describe third stage

A

Begins: delivery
ends: delivery of placenta

*want less than 30 min

37
Q

What is friedman curve

A

lets us know if women is progressing appropriately

station, dilation, time

38
Q

Progress of labor: 3 p’s

A

Power: uterine contractions
Passenger: want baby OA (face down)
Passage: Gynecoid pelvis best for labor and most common

39
Q

Descibe adequate power in labor

A
  • uterine contractions: 3-5 in 10min (30-60 sec long)
  • ^freq and strength due to PG E2 and F2alpha
  • ^ sensitivity of uterine m fibers to OXYTOCIN
40
Q

How can we know how much the uterus is contracting?

A
  1. External tocodynamometry: freq and duration not intensity
  2. Internal tocodynamometry: measures freq, duration and intensity (IUPC = intrauterine pressure catheter)
    * *probe that goes in, water has to be broken already
41
Q

Baby size >4500g

A

macrosomic

42
Q

How can the baby present

A

vertex
face
brow (shoulder)
Breech: frank, complete, footling (can do version to help spin baby, risk is placenta rupture)
Transverse Lie
Cmpd: 2 fetal parts (risk of anterior tears)

43
Q

Parts of bony pelvis include

A

Inlet, midpelvis, outlet

44
Q

what are the cardinal mvmts of labor (changes of position of fetus as it passes through birth canal due to asymmetry of in shape of fetal head and maternal pelvis)

E,F,D,IR,Ex,ER

A
  1. Engagement: passage of widest diameter of the presenting part to level below pelvic inlet
  2. Flexion: head flexed, fetus present smallest diameter of its head
  3. Descent: greatest rate of descent during latter portions of 1st stage of labor and during 2nd stage of labor
  4. Internal rotation: rotate presenting part from original position (usu transverse) to AP position as it passes through pelvis
  5. Extension: once fetus descends to introitus, Head extends beneath maternal pubic symphysis and head delivers
  6. External rotation (restitution): head rotates 45 deg to line up w shoulders which are oblique in maternal pelvis
45
Q

What occurs during third stage of labor

A

Uterus sig decreases in size
Want placenta out <30 min (otherwise need to manually remove bc risk DIC)
*uterus rises in abdomen
*globular configuration
*gush of blood and/or lengthening of umbilical cord

46
Q

What can help with fetal monitoring

A

Intermittent auscultation
Electronic fetal monitoring (ext US transducer on abd, Internal scalp eletrode ECG)

HR: 120-160
Tachy: 160-180 (intermittent is okay, but if consistent, worry about fever)
Brady <120: worry if consistent, that baby has heart block

47
Q

How should we assess heart rate variability (fetal monitoring)

*lets us know CNS functioning in tact

A

Fluctuation in FHR
short term: variation in amp beat to beat
AND
Long term: wavelike pattern changing every 4-6 cycles/min

D on example

48
Q

Do we want accelerations in fetal heart rate

A

yes: periodic increases 15 bpm above baseline 15 sec

these FHR accelerations let us know no hypoxemia or acidemia

want 2 accel. every 20 min

49
Q

How should we interpret decelerations in FHR

A

we worry about these

Early deceleration: mirrors shape of contraction, due to head compression, PHYSIOLOGIC

Variable: respect to timing of contraction, shape and severity, due to CORD compression - move mom to left side

Late: Fetal hypoxia, placental insufficiency, maternal hypoTN or hypoxia (*baby HR goes down after contraction) - need to intervene ASAP

50
Q

What options for labor pain relief are there

A
  • Psych: lamaze, relaxation techniques
  • Systemic: sedatives (vistaril), narcotics (demerol, stadol, nubain), dissociative drugs (ketamine - amnesia)
  • Paracervical block
  • pudendal block
  • *EPIDURAL (risk for maternal HypoTN, have IV)
51
Q

what degrees of laceration are there

*only 4% get 3rd or 4th deg tear

A

first: vaginal mucosa, not underlying tissue
Second: underlying SQ but not rectal sphincter/mucosa
Third: through rectal sphincter but not into rectal mucosa
Fourth: extends into rectal mucosa

most women who tear have posterior tear

52
Q

when should we recommend induction of labor, and how do we know likelihood of success

A

*recommend only if medically indicated
BISHOP score assess likelihood of successful induction
*9-13 pt = high likelihood of success
*0-4 is high likelihood of failed induction

53
Q

what ways can we induce labor

A
  1. stripping membrane (not used)
  2. Amniotomy
  3. PG gel
  4. OXYTOCIN*** most common but worry about uterine hyperstimulation
  5. Misoprostol (Cytotec)
54
Q

what are complications of oxytocin

A
  1. Uterine hyperstimulation: >5 contractions q 10min
  2. Fetal distress or intolerance to labor: late decelerations of FHR
  3. Water intoxication caused by Antidiuretic properties of oxytocin

*monitor urinary output

55
Q

What is Puerperium

A

period following delivery of baby and placenta to about 6 wk postpartum

Anatomic resolution

  • (1000g uterus to 50-100g)
  • lactating influenced by PRL, no ovulation 3 months!
  • non lactating: ovulation possible 6 wk pospartum
  • vagina: decreases in size but walls thin and can be dry till ovulation resumes (may need topical estrogen)
56
Q

How do you manage Puerperium period

A 
hospital: 1-2 d if vaginal, 2-4 if c/s
limit PA (wait till 4-6 wk at pospartum visit, familiy planing), Sexual activity, work

edu pros of breast feeding (colostrum 1st d, mature milk d 3-5)

psychosocial changes: postpartum blues vs pospartum depression

Womens Health (3 decks)

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