Maternal Care Flashcards
Folic Acid Suggestions
400-800 mu grams / day
1 mg / day if DM or epilepsy
4 mg / day if have prior child w/ neural tube defect
Pre-conception Genetic Screening
Blacks - sickle cell
French Canadian and A Jewish - Tay sachs
SE Asia and Middle East - thalassemia
Caucasian and A Jewish - CF
How much radiation to cause damage to fetus?
5 rads
Gestational Age Confirmation
Naegel’s rule = first day of LMP - 3 months + 7 days
Use US to confirm if … date uncertain, LMP was abnormal or irregular, if bleeding since LMP, if on oral contraceptive in last yr
Accurate to 1 wk in 1st trimester, 2 wks in 2nd, 3 wks in 3rd
US not indicated if no complications
Initial Prenatal Labs and Tests (11)
Blood type
Rh status - if neg for Rh antibodies then give RhoGAM at 28 wks or if any trauma/complications/bleed/procedures and after delivery if baby found to be Rh+
rubella status - if not immune then advise caution and give live vaccine after delivery (same strategy if seronegative to varicella)
HIV - ELISA then W blot; if pos give antiretrovirals in 2nd trimester, C section, IV zidovudine in labor
HBs antigen - check LFTs and give baby HBIG and vaccine
RPR or VLDR (syphilis) - if < 1 yr then 1 IM dose PCN, if > 1 yr then 3 IM doses PCN
urinalysis/urine cx - asymptomatic bacteria in urine can cause pyelonephritis in pregnancy so treat w/ abx then recheck urine
Pap smear - only dealt w/ during pregnancy if invasive cancer cervical swab (chlamydia and gonorrhea) -
Gonorrhea - can cause preterm labor/ blindness, give 1 dose IM ceftriaxone
Chlamydia - blindness/pneumonia, give azithromycin X1 or amox X 7 days
CBC - if mild anemia try iron, if moderate give ferritin and do Hb electrophoresis (thalassemia?)
Prenatal Apt Schedule + What Happens at Ea
Schedule - 1st visit at 8-10 wks Every 4 wks until 28 wks Every 2 wks from 28-36 wks Every wk from 36 on
Ea apt - fetal height, fundal meas, heartbeat w/ Doppler after 10 wks, mom’s BP and wt, UA to look for protein, glucose or infection
Genetic Screening
1st trimester - nuchal translucency +/- hCG and PAPP-A)
-If pos then inc risk NOT dx, offer karyotype, additional US, CVS or 2nd trimester screen
2nd trimester - QUAD (more sensitive than triple screen) - AFP, hCG, unconjugated estriol and inhibit-A
Amniocentesis - 15 wks, .5% chance spont abortion, only if some risk
CVS - 10 to 12 wks, 1-1.5% risk spont abortion
Vaccines in Preg
Flu
Tdap at 27-36 wks in all
NO varicella, rubella or live intranasal flu
Gestational DM
screen in all @ 24 wks
1 hr glucose challenge
If pos … 3 hr glucose tolerance test (gives 100 g after overnight fast then meas at fast and 1, 2, 3 hr) … if 2/4 pos then diagnosed
Screen for DM Type 2 postpartum
GBS
-vagino-rectal swab at 35-37 wks - if colonized get IV abx during labor or ruptured membranes
Indications for Tx - pos screen, hx past infant w/ GBS, bacteria in urine at any point in pregnancy, if unknown status w/ preterm labor, amniotic rupture > 18 hrs, intrapartum fever or + nuclei acid amp for GBS
Tx = Give IV PCN (or amox)
- If intolerance to PCN give cefazolin
- If true allergy to PCN give erythromycin/clindamycin if susceptible, if not susceptible give vancomycin
Post Term v Pre Term Def
Late term from 41 wks 0 days to 41 wks 6 days
Post term if beyond 42 wks
Pre term if b/f 37 wks
Stages of Labor
1- onset to complete cervix dilation (10 cm)
- Latent
- Active - once 3-4 cm, max rate of dilation )avg rate is 1.2 or 1.5 cm / hr dep on first baby or not)
2- Complete dilation to delivery of fetus
< 2 hrs if first baby
< 1 hr if prior baby
3- Delivery of placenta and membranes
Should be < 30 min
Signs of Rupture of Mem
-Fluid from cervical os
-Amniotic fluid pooling in posterior vagina (pH > 6.5 on -Nitrazine or ferning of fluid on microscope)
False pos -semen, blood, vaginitis
Fetal Monitoring (decelerations and accelerations)
- Extrinsic Doppler or fetal scalp electrode
- Auscultate every 30 min in stage 1 and every 15 min in stage 2 (every 15 and 5 if high risk pregnancy)
Baseline: 110-160
Want variability in HR (means autonomic NS is working)
-Fetal accelerations (15 beats for 15 sec) - means likely not acidosis (GOOD)
- Early deceleration - from compression of fetal head leading to dec vagal tone; okay
- Late deceleration - gradual dec after peak contraction due to placental insufficiency (epidural causing hypotension, oxytocin uterus hyperstimulation, maternal HTN/DM/placental abruption)
- Variable deceleration - from umbilical cord compression not associated w/ hypoxemia
Causes of Dec Variability in Fetal HR
Dec if sleep cycle, CNS depressants, congenital neuro problem, premature, fetal acidemia
