Exam 2 Prenatal Care, labor, delivery, puerperium Flashcards
Elements of Preconception care
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
What immunizations are recommended for future mothers
- MMR, Varicella (these two CI in preg, need to prevent preg 1 mth after receiving)
- Hep B
- Flu
- Tdap
- +/- Pneumococcal
General recommendations for Preconception care
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
When should pt have 1st prenatal care visit
recommended in 1st trim by 10 wk gestation
PRENATAL CARE: 1st visit
Hx components
need full hx.. esp
- GYN hx: STIs PID, abn pap, procedures
- Planned/unplanned preg
- Domestic violence?
- Tobacco, ETOH, rec drug use
- Potential barriers to prenatal care
- 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
PRENATAL CARE: 1st visit
How do you determine EDD
Naegeles rule
add 7 d to LMP then subtract 3 mth
PRENATAL CARE: 1st visit
How do you classify deliveries from 37 wk gestation
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
PRENATAL CARE: 1st visit
PE
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
PRENATAL CARE: 1st visit
Routine Labs
CBC, blood type and Rh Antibody screen Rubella and varicella Syphilis testing HBsAG (even if vaccinated) HIV UA C&S TSH +/- CF carrier screening +/-
PRENATAL CARE: 1st visit
additional labs for women at risk
TB
HepC antibodies
Trich, Gonorrhea, HSV
HgbA1C
PRENATAL CARE: 1st visit
Ultrasound
confirm EDD*** crucial (LMP + 7d subtract 3 mth)
US: fetal cardiac motion as early as 5.5-6 wk
How are trimesters broken up?
1st: wk 1 to end of wk 12
2nd: wk 13 to end 26
3rd: wk27 to end of preg
How frequently should a preg women be seen
1st 28wk: monthly
28-36: q2wk
36+: weekly
How are fetal mvmt (aka QUICKENING) related to pregnancy hx? when should you begin to discuss KICK COUNTS
1st preg: first fetal mvmt @ 18-20wk
2nd+ preg: first fetal mvmt @ 16-18 wk
Kick counts: discuss in 3rd tri
PRENATAL CARE SUBSEQUENT VISITS
Hx, PE
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
What and when: Leopold maneuvers
PE in 3rd trimester
*4 different maneuvers to feel shape of fetus
PE in 3rd trimester should consist of
Leopold maneuvers
Cervical exam for: dilation, effacement, station, presenting part
will you marry me?
- clint
Routine screening labs during prenatal visits:
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)
OPTIONAL screening labs during prenatal visits
Down Syn: ACOG - ALL should be offered at screen NTD, Downs, trisomy 18
When would you consider the use of cell free fetal DNA
35+yo at delivery US indicates risk aneuploidy Prior preg with trisomy \+ test aneuploidy Parental robertsonian translocation
When do you receive OB UTZ
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?)
How should you counsel woman re wt gain for bmi
*note: only 7 lb of the wt gain is fat
BMI 30 = obese, should gain 11-20 lb
How should we counsel women re kcal intake needed (preg vs lactating)
nonpreg: 2200 kcal
Preg: 2500 kcal
Lactating: 2640 kcal
How should we counsel preg women re travel
yes, DVT is a worry but more concern over risk of complication and having to stay where she is for 10wk. Fly > drive
how should we be counseling pt in 2nd trimester
address indiv problem
discuss normal/abn labs
warn about preterm labor
discuss childbirth education
what counseling components should be included in 3rd trimester
- Hospital facilities
- Labor anesthesia
- Signs of labor
- Fetal Surveillance
- Post-dates counseling and induction
What are the tests for fetal well-being
*good if have GDM or preg HTN
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) -
Common complaints of preg include? what do we do to help?
*don’t need to know for test?
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
PROCESS OF LABOR
Define: Labor, effacement, dilation, presenting part, station
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
True labor vs False labor (braxton hicks contractions)
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
what components are included in labor and delivery eval
Rev hx & PE (ACOG antepartum record)
- brief hx, vitals, cervical exam
- status of membranes (has water broken!)
- fetal monitoring
What signs can help confirm or r/o suspected membrane rupture
- 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
Describe the 1st stage of labor
- 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
Describe the second stage of labor
begins: complete dilation
ends: delivery of infant
* *PUSHING phase
Describe third stage
Begins: delivery
ends: delivery of placenta
*want less than 30 min
What is friedman curve
lets us know if women is progressing appropriately
station, dilation, time
Progress of labor: 3 p’s
Power: uterine contractions
Passenger: want baby OA (face down)
Passage: Gynecoid pelvis best for labor and most common
Descibe adequate power in labor
- 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
How can we know how much the uterus is contracting?
- External tocodynamometry: freq and duration not intensity
- Internal tocodynamometry: measures freq, duration and intensity (IUPC = intrauterine pressure catheter)
* *probe that goes in, water has to be broken already
Baby size >4500g
macrosomic
How can the baby present
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)
Parts of bony pelvis include
Inlet, midpelvis, outlet
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
- Engagement: passage of widest diameter of the presenting part to level below pelvic inlet
- Flexion: head flexed, fetus present smallest diameter of its head
- Descent: greatest rate of descent during latter portions of 1st stage of labor and during 2nd stage of labor
- Internal rotation: rotate presenting part from original position (usu transverse) to AP position as it passes through pelvis
- Extension: once fetus descends to introitus, Head extends beneath maternal pubic symphysis and head delivers
- External rotation (restitution): head rotates 45 deg to line up w shoulders which are oblique in maternal pelvis
What occurs during third stage of labor
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
What can help with fetal monitoring
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
How should we assess heart rate variability (fetal monitoring)
*lets us know CNS functioning in tact
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
Do we want accelerations in fetal heart rate
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
How should we interpret decelerations in FHR
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
What options for labor pain relief are there
- 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)
what degrees of laceration are there
*only 4% get 3rd or 4th deg tear
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
when should we recommend induction of labor, and how do we know likelihood of success
*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
what ways can we induce labor
- stripping membrane (not used)
- Amniotomy
- PG gel
- OXYTOCIN*** most common but worry about uterine hyperstimulation
- Misoprostol (Cytotec)
what are complications of oxytocin
- Uterine hyperstimulation: >5 contractions q 10min
- Fetal distress or intolerance to labor: late decelerations of FHR
- Water intoxication caused by Antidiuretic properties of oxytocin
*monitor urinary output
What is Puerperium
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)
How do you manage Puerperium period
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
