Maternal Assessments Flashcards
Rh negative
What is the normal blood pressure range?
90 to 140 systolic
60 to 90 diastolic
What blood pressure reading is consider hypertensive?
Above 140 systolic
What blood pressure reading is considered hypotensive?
Systolic below 90
Diastolic below 60
What is the normal temperature range?
36.5 - 37.5 degrees celsius
What is the normal expected respiration rate?
Between 10 and 20 respirations per minute
What are the symptoms of vaginal thrush in mamas?
- Itching
- Pain during urination
- Discharge; thick, odourless
- Swollen vagina
- Uncomfortable feeling when having sex
What increases the risk of developing candidiasis (vaginal thrush)?
- Wearing tight clothes
- Synthetic underwear
- Pregnant women
- Taking a course of antibiotics
What is the treatment and dose for vaginal thrush?
- Only treat woman if she is symptomatic
- Send vaginal swab for culture prior to commencing treatment to confirm organisms
- Clotrimazole 1% (35g) vaginal cream - insert 1 applicator full of cream into vagina (5g) once daily before bed for 6 days
- Micronazole Nitrate 2% (40g) vaginal cream- insert 1 applicator (5g) full once daily before bed for 6/7 days
- Consult with obstetrican if a woman has symptomatic recurrent thrush during pregnancy
What are the symptoms of thrush on nipples?
- Deep breast pain
- Stabbing pain or nipple pain that does not resolve after feeding
- Nipples are pink and shiny
What is the treatment and advice for thrush on nipples
- Topical anti-fungal cream
- Miconazole 2% cream applied after breastfeeding twice daily for 10 - 14 days
- Cream should be gently wiped off prior to breastfeeding
What is hyperemesis gravidarum?
- Severe and persistent vomiting that interferes with fluid intake and nutrition status that can result in dehydration, malnutrition, weight loss, fatigue and electrolyte and acid-base imbalance
What are the risk factors for hyperemesis gravidarum?
- Previous history of hyperemesis
- Multiple gestation due to increase hCG
- Molar pregnancy
- Preexisting diabetes
-Depression or psychiatric illness - Hyperthyroid disorder
- Peptic ulcer or other GI disorder
- Asthma
What is the pathophysiology of hyperemesis gravidarum?
- Serum hCG is higher = hCG stimulates secretory processes in the upper GI tract
- Increased oestrogen = decrease in intestinal motility and gastric
If a mama presents to you with severe nausea and vomiting, what assessments will you make?
Full maternal assessment - urinalysis, symptoms, severity, nutrition, how are they feeling
Obs - BP, P, T
Weight - compare to past/pre pregnancy
History of vomiting
Are they tolerating fluids - how much
Past history of hyperemesis
Ketones in urine = dehyrdated - how much urine are they passing, what colour/how concentrated?
Serum urea and electrolytes - FBC urgent
Assess risk/symptoms of preclampsia
Assess risk/symptoms of VTE
Are they dehydrated or malnourished = urgent referral to hospital
Do they need referral to GP for stomach bug?
What management should you do for a woman symptomatic of hyperemesis?
- Send for urgent referral at hospital for treatment of dehydration, malnutrition and electrolyte replacement in consultation with obstetrics
- Do not prescribe antiemetic of own accord. Consultation with obstetric team should be made before any medication prescribed.
How would you care for a woman symptomatic of hypermedia in the hospital?
- Full assessment and observations
- What are the current and local guidelines
- Weight - compare weights
- IV access
- Consider IV fluids after consultation
- Bloods and urine for MSU, FBC, ALT, AST, uric acid, electrolytes - sodium and potassium
- 2‐3L of IV fluid before maintenance fluids are commenced. The IV fluids are usually normal saline with added potassium complemented with daily electrolyte monitoring.
- 1L of normal saline daily for normal function, alongside oral fluids as tolerance increases.
- Whānau who are unable to keep anything down may also be given IV glucose, up to 150‐200g per day
What is first line antiemetic prescribed to woman with nausea and vomiting? What is the dose and frequency?
- Metoclopramide (Maxalon) 5 - 10mg IV, IM or PO 8 hourly for a maximum of 5 days
What adverse effects are associated with Metoclopramide?
- Generally avoid in first trimester due to risk of effects on mother and baby
- Risk of dystonic reactions in mother
What second line treatments can be prescribed for nausea and vomiting?
Cyclizine, Ondansetron, Prochlorperazine
What is the the first line treatment for nausea and vomiting intrapartum and its dose?
Metroclopramide hydrochloride 10mg/2ml injection. IV dose given as slow bolus over at least 3 minutes
What are the symptoms of heart burn?
- Burning pain in the middle of chest
- Sharp pain in chest
What is the pathophysiology of heartburn?
Caused by a reduction in the oesophageal sphincter pressure and an increase in gastric emptying during pregnancy causing regurgitation of acidic gastric content into the oesophagus
What assessments should you make when diagnosing heartburn?
- Assess for symptoms of PET as they have similar symptoms (BP, urinalysis, blurred vision, epigastric pain, headaches, oedema, reflexes)
- Pain: where does the pain occur, where is the plan, what does the pain feel like, what relieves the pain, is the pain recurrent or persistent
- What is her diet/eating habits e.g. spicy food, lying down after eating
- FBC, ferritin, antibodies, LFTs, renal function, MSU
- Fetal assessment - FHR, fetal movements, fundal height, palpation
What non medical treatment advice can you give for heartburn?
- Avoid coffee and caffeine products
- Avoid spicy food
- Avoid heavy meals but eat regularly
- Sit in upright position after meals to avoid reflux
- If symptoms occur at night = raise your bed by 10cm
What kind of medical treatment can a midwife prescribe for heartburn?
Antacids
What are antacids?
Type of medications that neutralise stomach acids to provide fast relief but do not heal existing esophageal damage
Why can persistent heartburn be a problem?
Can cause damage to the esophagus over time
What type of antacid medications can a midwife prescribe?
Mylanta (aluminum hydroxide), Eno, Quick-eye, Gaviscon
If antacids are not helping heartburn for a mama, what should the midwife do?
Refer to GP
What does Mylanta effect the absorption of and what advice would you give to account for this?
Affects the absorption of iron, advise to take iron supplements and malanga two hours apart
How do H2 receptor blockers work?
Reduce the production of stomach acid. Are slower acting than antacids but provide longer term symptom relief. Doctor prescribed
How do proton pump inhibitors work?
They block stomach acid production and help heal the oesophagus
What is the normal range of haemoglobin?
100 - 145 g/L
Serum ferritin normal range?
30 - 170umol/L
What is anaemia diagnosed as
Hb <100 g/L
What is iron deficiency anaemia defined as?
Hb <100g/L and Fe <15umol/L
Why is anaemia concerning in pregnancy?
Is concerning in anticipation of birth where there is blood loss and there are no hb reserves if anaemic. Low hb also compromised oxygen delivery to the tissues potentially causing hypoxia
Why does iron requirements increase in pregnancy?
There is an increase in maternal and fetal RBC production and demand increases as foetus requires more iron for growth drawing from maternal stores
Who are at risk of low iron/anaemia?
- Maori
- Indians
- Pacific women
- Vegetarians/Vegans
- Previous history of anaemia
- 1 year pregnancy interval
- Mulitparity
- Teen mums
- Anaemic pre pregnancy
- Previous APH / PPH
What are symptoms of iron deficiency anaemia?
Fatigue / tiredness
Shortness of breath
Pale
Dizziness
Headaches
Lethargy
Pallor
Palpitations
Breathlessness
What are the maternal consequences of IDA?
Increased risk of infections (UTI’s)
Fainting
Depression
Reduced mental and physical performance
Increased risk of PPH
Affect choice of birth place?
May require IV access in labour
What are the consequences of maternal IDA for the baby?
SGA
Preterm birth
Low iron stores first 3 months
Impaired psychomotor and mental development
What non-medication advice can you give women to increase iron stores?
Eat iron rich food - spinach, red meat, oysters, capsicum, pulses, molasses, red beans, tofu, wok chow, chickpeas
Limit caffeine intake as can inhibit iron absorption
Drink or eat food high in vitamin c as it aids iron absorption
When should you check ferritin and hb in pregnancy?
At booking
26 - 28 weeks
36 weeks
4 weeks after commencing iron therapy
What is the treatment plan for hb >100 and fe >30
No iron supplementation needed
Continue iron rich diet
Recheck bloods at 26 - 28 weeks
What is the treatment plan for hb <100 and fe >30?
Diagnosis as anaemic (hb <90 = consultation if treatment not working). Low dose iron therapy.
What is the treatment plan for hb >100 and fe <30?
Discuss dietary awareness and probable need for low dose iron supplementation soon/maintenance dose commenced
Recheck bloods at 26 - 28 weeks
What is the treatment plan for hb >100 and fe <15
Low dose iron supplementation 1x Ferrotab (Ferrous fumarate 200mg tab). Assess after 4 weeks therapy, if ferritin hasn’t improved and developed anaemia = high dose iron therapy
What is the treatment plan for hb <100 and fe <15
Diagnose with IDA
Commence high dose iron supplementation 2x Ferrotab (200mg) OR 1x Ferrogradumet (ferrous sulphate controlled release 325mg) + advice on how to avoid constipation
Referral for IV iron therapy (hb <70g/L or not successful in taking iron tabs)
What is the management plan for hb <90 and not responding to treatment?
Refer to obstetric team
Consider iron infusion - requires consult
What is ABO incompatibility?
When the fetal blood type is different to the mothers blood type causing the maternal immune system to make antibodies against the babies RBCs. Only happens when mother is blood type O.
What is isoimmunisation?
a process in which an individual develops antibodies to the blood/tissues of another individual
What is an antigen?
foreign substance that enters your body. It allows your body to create a defense against future invaders
What are antibodies?
Circulate in your body once created to identify, attack and destroy the same type of antigens if they enter the body again
What is rh incompatibility?
Occurs when mother is rh negative and baby is rh postitive causing the maternal immune system in a sensitising event to form antibodies that will attack the baby RBCs
What does rh negative mean?
That the RBCS do not have the rh protein and that the immune system will form antibodies against RBCs that do have the protein as then body will identify them as foreign
Why is Rh positive not concerning in pregnancy?
Because Rh positive blood types have the rh protein meaning that if the baby has the rh protein they will not identify it as foreign because they already have the protein
Why is Rh negative blood type concerning in pregnancy?
Because if the baby is rh positive the maternal rbcs will identify the rh protein that the baby carries as foreign and form rh antibodies to attack them. This should only happen if there is blood mixing which can happen at a sensitising event like birth. If blood mixing occurs at birth this can create problems for subsequent pregnancies as the mother will form rh antibodies and attack future babies RBCs if they are rh positive
How do we try and prevent antibodies attacking the baby rbcs?
Prophylactic anti d imuunoglobulin
What is Anti D immunoglobulin?
It is a blood product that contains rhD antibodies that will circulate in the maternal blood and destroy rbcs that have rh antibodies
What is the recommended injection schedule for anti D?
At 28 weeks, 34 weeks, postpartum (within 72 hours), and at any sensitising event
What is a sensitising event?
An event where blood mixing can occur e.g. Amniocentesis
Late miscarriage >12 weeks
Abdominal trauma
Birth
Termination of pregnancy
Spontaneous miscarriage
Ectopic pregnancy
Molar pregnancy - tumor that develops in the uterus as a result of a non-viable pregnancy
ECV - done at term (from 37 weeks), trying to turn breech baby in utero
Bleeding during pregnancy/APH
Intrauterine death or stillbirth
Abdominal trauma
What is the recommended anti d dose for woman that are up to 12 weeks pregnant?
250 IU IM for single pregnancy
625 IU IM for multiple pregnancy
What is the recommended anti d dose for woman in their 2nd and 3rd trimesters
625 IU IM
What test should be performed on rh negative woman >20 weeks gestation after a sensitising event?
A kleihauer test
What is a kleihauer test and how does it affect anti D?
A kleihauer test is a test performed on the mother to determine if there is fetal blood in the maternal circulation. A negative test result means that no fetal blood has entered the maternal circulation but does not remove the need for anti d. A positive test can indicate that an increased dose of anti d is indicated. More than two vials of anti d must be discussed with a transfusion medicine specialist.
When should a kleihauer test be done in rh negative women?
After a sensitising event if the woman is >20 weeks gestation and after birth
What test should be done on the baby of a rh negative mother?
A Direct Coombs test with blood (5ml) taken from the cord
What is a direct Coombs test?
The direct Coombs test is used to detect antibodies that are stuck to the surface of red blood cells.
If a direct Coombs test from a baby with an rh negative mother is anomalous what should you do?
Treat as Rh positive until confirmed
Mina platelet count is 80 x 109/L (Normal is 150 - 450 x 109/L). The best way to administer Anti-D postpartum is:
By Intravenous route.
If the baby’s blood group shows the anomalous result for RhD should we regard the result as RhD negative or positive?
RhD Positive until confirmed.
