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
3 FHT Categories
I - Normal baseline HR, normal variability, no late or variable decelerations, +/- presence of accelerations and early decelerations
II - inbetween
III - absent baseline variability + repeated late decelerations, variable decelerations, bradycardia or sinusoidal pattern
4 Fetal Movements for Delivery
1- Flex (tuck chin)
2- internal rotation (occipital toward pubic symphysis),
3- extend head (passes below pubic symphysis),
4- external rotation (to mom’s R or L side)
Anterior shoulder below pubic symphysis and posterior shoulder toward sacrum
- Use downward traction for anterior shoulder and upward traction for posterior shoulder
- Shoulder dystocia = EMER, anterior shoulder will not pass
Indications for C Section
Prior C section
Arrest of labor or descent
Fetal distress - need immediate delivery
Breech
Contraindications to Breast Feeding
HIV, miliary Tb, acute Hep B, Herpetic breast lesions, chemo, cocaine, heroine, PCP or alcohol use or nipple transplant
Types of Breast Milk
Colostrum (first day)
- yellow
- rich in IgA, AA, minerals, protein
Mature Milk (day 2 to 4) -fat, protein, carbs, vit, minerals and hormones
Postpartum Contraception
- Prog only pill if breastfeeding (combo dec lactation); can also use Depo-Provera
- IUD insertion (wait until 6 wks)
- Can refit diaphragm
- Lactation induced will last 6 mo if exclusively breastfeed and are ammenorheic whole time
Normal Postpartum Changes
- Dec uterus size
- 20 wk size (umbilicus) right after delivery
- 12 wk size (pubic symphysis) after 1 wk
- Normal size by 6 wk f/u
- Bleeding - brown/bloody lochia for 1 wk (decidua and epithelial cells) –> white/yellow lochia for 4-6 wks (more leuks)
4 T’s of Postpartum Hemorrhage
- Tone - uterine atony (70%)
- Trauma - uterine inversion, lacerations
- Tissue - retained placenta or membranes
- Thrombin - coagulopathy
Consider hemorrhage if loss > 500 mL
Early if in first 24 hrs
Tx of Postpartum Hemorrhage
- ABCs (2 IV’s)
- Oxytocin, misoprostol, carbopost, methylergonovine (not if HTN)
- Bimanual uterine compression
- Factors if coag
Causes of Postpartum Fever
- Endometritis - esp if foul smelling lochia and tenderness
- If vaginal - amp + gentamicin
- If C section - clindamycin and gentamicin to cover anaerobes
- UTI (cath)
- Mastitis - cont nursing, cover staph (cephalexin)
- Atelectasis, wound infection, embolic event if C section (like any surgery)
Postpartum Blues v. Depression v. Psychosis
- Blues = w/in first wk and usually gone by day 10
- Dep = w/in 4 wks; same criteria as MDD; first line are SSRIs (screen all women at 2 and 6 wk f/u)
- Psychosis = manic or delusional in days to wks after; HOSPITALIZE
