NORMAL PREGNANCY Flashcards
PRECONCEPTION HISTORY
⦁ chronic diseases ⦁ meds known to be teratogens ⦁ reproductive hx ⦁ genetic conditions in the family ⦁ substance use ⦁ infectious diseases & vaccinations ⦁ folic acid intake & nutrition ⦁ environmental hazards & toxins ⦁ mental health & social health concerns
goals of prenatal care
- ensure birth of healthy baby with minimal risk to mom
- early, accurate estimation of gestational age
- identify if patient at risk for complications - continue risk assessment
- ongoing evaluation of health status of both mother & fetus
- patient education & communication
PRECONCEPTION INTERVENTIONS
⦁ folic acid supplements ⦁ glycemic control in women with DM ⦁ no alcohol, illicit or rx drugs ⦁ stop smoking ⦁ vaccinations up to date (live vaccines should be given 1 month or more prior to pregnancy ⦁ weight management (18 < BMI < 30) ⦁ no depression ⦁ avoid teratogens ⦁ no STIs ⦁ planned pregnancy with an early prenatal visit
antepartum care (before birth) includes
- diagnosing pregnancy & determining gestational age
- monitor pregnancy with periodic exams & appropriate screening tests
- provide patient education that addresses all aspects of pregnancy
- prepare pt & family for her management during labor, delivery & postpartum
- detect medical & psychosocial complications and institute indicated interventions
first trimester = _________ weeks
weeks 1-12
Naegele’s rule
add 7 days to LMP, then subtract 3 months = Naegele’s rule - to find out due date
ex: LMP was june 9th. 9 + 7 = june 16th - 3 months = march 16th is the due date
remember LMP = first day of last period
Usual methods to determining gestational age =
⦁ hx - use date of last menstrual period
⦁ uterine size - physical exam
⦁ ultrasound - measure “crown rump length” or biparietal diameter
what is used on ultrasound to determine gestational age
crown rump length
femur length
biparietal diameter
FIRST PRENATAL VISIT
- LOTS of info to collect/assess/review ⦁ medical hx ⦁ reproductive hx ⦁ family hx ⦁ genetic hx ⦁ nutritional hx ⦁ psychosocial hx - critical to screen for domestic violence (20% of women are physically abused when pregnant)
FACTORS THAT INCREASE THE LIKELIHOOD OF HAVING TWINS
- Factors that increase the likelihood of having twins
⦁ advancing age
⦁ increased parity (# of births)
⦁ fam hx from either parent
⦁ obese & tall women = greater chance of twins
⦁ use of fertility drugs
**Increased calories are needed for pregnant mother with multiple babies
RISKS OF MULTIPLE GESTATIONS (twins+)
- preterm birth - can lead to bed rest early in the pregnancy
- intrauterine growth retardation or unequal growth
PHYSICAL EXAM - 1ST PRENATAL VISIT
⦁ Baseline BP ⦁ Height & weight - calculate baseline BMI ⦁ general PE ⦁ pay attention to oral hygiene* ⦁ cardiac exam ⦁ DTRs** ⦁ breast exam ⦁ pelvic exam
after ______ weeks = can no longer use femur length & biparietal diameter to estimate gestational age
25
after 25 weeks, the baby’s growth is determined by genetics
what labs are done for first visit
- urine specimen for pregnancy test
- urine is checked EACH VISIT for glucose & protein
- 1st visit = both UA & urine culture are done
- CBC - to detect anemia & screen for thalassemia (iron overload)
- Rubella immunity & varicella immunity
- syphilis test
- HepBsAg - tests for chronic Hep B
other labs needed
- HIV
- Rhogam test
- lipids if indicated
- PPD if indicated
- Hbg A1C if indicated
- thyroid testing if indicated
- testing for other infections if indicated: Hep C, Zika
- 1st visit = both UA & urine________are done
culture
why is a urine culture obtained along with the UA in the 1st visit
o because asymptomatic bacteria occurs in 2-7% of pregnant women
⦁ will lead to a UTI in 30-40% if left untreated
⦁ is associated with increased risk of preterm birth, low birth weight & perinatal mortality
⦁ 2 consecutive specimens with same bacterial strain or 1 cath specimen with 1 isolated bacterial species = considered “positive” and requires treatment
⦁ need to repeat culture to know it is sterile after treatment; some repeat urine culture in each month of pregnancy
⦁ some providers choose to give suppressive therapy without pregnancy
TREATMENT OF ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMEN
WHICH ABX CLASS CAN YOU NOT GIVE?
TREATMENT OF ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMAN ⦁ sulfisoxazole ⦁ amoxicillin ⦁ augmentin ⦁ nitrofurantoin ⦁ cefpodoxime proxetil
which abx classes are NOT here? = FLUOROQUINOLONES - teratogenic
ACUTE CYSTITIS IN PREGNANCY
- complication in pregnancy; can lead to cystitis or pyelonephritis
- to diagnose = need UA & midstream urine culture to diagnose
- TX = Augmentin, nitrofurantoin, cephalexin.
NO FLUOROQUINOLONES! = teratogenic - can cause cartilage deformities
Rhogam given at
28 weeks
- important to know blood type if transfusions are needed
- Rh status - if mother is Rh negative = give Rhogam - whenever there is a risk of fetomaternal hemorrhage to prevent allimmunization
- if mother is Rh negative, another antibody screen is drawn at 28 weeks; if still negative, then mother is given Rhogam at 28 weeks
- if Rh negative woman is exposed to Rh positive blood from her baby, she will produce antibodies against Rh positive blood in subsequent pregnancies, causing fetal hemolytic disease (fetalis hydrops)
instances in which rhogam is given
- 28 weeks gestation
- abortion
- ectopic pregnancy
- invasive procedures
- hydatidiform mole
- fetal death in 2nd or 3rd trimester
- blunt trauma to abdomen
- antepartum hemorrhage in 2nd or 3rd trimester (placenta previa or abruption)
- external cephalic version
markers that can detect for down syndrome
⦁ hCG level
⦁ PAPP-A = pregnancy associated plasma protein
⦁ nuchal transparency (NT)
- Women found to have increased risk of aneuploidy with these tests should be offered chorionic villous sampling
chorionic villous sampling should NOT be done before _______ weeks
10
increased risk of pregnancy loss
what is chorionic villous sampling
procedurer to get fetal DNA to test for down syndrome and other abnormalities; done under ultrasound guidance through vagina or by abdominal US
- do NOT do before 10 weeks - increased risk of pregnancy loss
screening options for down syndrome
1) nuchal translucency - width of translucent space at back of fetal neck - ultrasound
2) combined test = 1st trimester; sonographic measurements, maternal serum mmts, hcg, PAPP-A, along with maternal age
3) Triple test = 2nd trimester = AFP, estriol, hcg with maternal age
4) Quadruple test = 2nd trimester = AFP, estriol, hcg and inhibin A with maternal age
5) Integrated test = combination of tests from 1st & 2nd trimester into single test
which condition is MSAFP low
down syndrome
MATERNAL SERUM ALPHA FETAL PROTEIN (MSAFP)
- can be used to detect abnormalities in fetus
⦁ neural tube defects = MSAFP is high
⦁ ***DOWN SYNDROME = MSAFP IS LOW
⦁ Anencephaly = MSAFP is high
⦁ multiple gestation = MSAFP is high
INDICATIONS FOR AMNIOCENTESIS
- prenatal genetic studies = Most common **
- assessment of fetal lung maturity
- evaluation of fetus for infection
- degree of hemolytic anemia
- evaluation of diagnosed neural tube defects
- therapeutic - to remove excess amniotic fluid
MOST COMMON INDICATION FOR AMNIOCENTESIS
PRENATAL GENETIC STUDIES
risks of amniocentesis
⦁ leakage of amniotic fluid
⦁ fetal injury (rare)
⦁ fetal loss - 1/300 - 1/500
prenatal visit schedule
every 4 weeks until 28 weeks
every 2 weeks from 28 weeks - 34/36 weeks
then weekly until delivery
what is checked at each prenatal visit
maternal weight, BP, uterine growth, urine dipstick, fetal activity & fetal HR
warning signs to educate patient about
vaginal bleeding cramping fever passing clots or tissue dizziness fainting abdominal pain
Avoid hot tubs and saunas—maternal heat exposure during the first trimester has been associated w/
neural tube defects
EDUCATION FOR 1ST TRIMESTER
- need prenatal visits every 4 weeks until 28 weeks, then every 2 weeks until 34-36 weeks, then weekly
- at each visit = maternal weight, BP, uterine growth, urine dipstick, fetal activity & fetal HR
- educate pt on how to reach provider after business hours
- WARNING SIGNS = vaginal bleeding, cramping, fever, passing clots or tissue, dizziness, fainting, or abdominal pain
- Avoid hot tubs and saunas—maternal heat exposure during the first trimester has been associated w/ neural tube defects
- avoid substance abuse - alcohol, smoking, illicit drugs, excessive caffeine
- wear seatbelt at all times
- infection precautions: influenza & toxoplasmosis (cat feces)
- exercise = moderate (30 min/day) - avoid strenuous exercise. avoid supine positions after 1st trimester
- work is ok unless lifting or prolonged standing
- sex is ok unless risk of STI or vaginal bleeding
- travel = increased risk of DVT; can fly up to 36 weeks if not high risk
- meds: acetaminophen is ok, check everything else, including herbals
- weight gain counseling = 20-25 lbs, sometimes much more
- breastfeeding
- childbirth classes / hospital facilities
- Diet = fully cook all meats/eggs. no unpasteurized dairy products or juice. can get listeria from processed deli meats. risk of methylmercury exposure from fish. Avoid high iron, vitamin A and selenium - teratogenic
- increase daily calories by 340 calories in 2nd trimester, and 450 calories in 3rd
- breastfeeding = increase calories by another 300-500 and add 1000mg Calcium
COMMON SYMPTOMS OF PREGNANCY
⦁ Headaches: common in early pregnancy**
⦁ N/V: hyperemisis gravidum <2%
⦁ Heartburn: general maneuvers, may use tums
⦁ Constipation: can try stool softeners, add bulk, drink fluids
⦁ Fatigue
⦁ Back pain: later in pregnancy
⦁ Round ligament pain: as uterus grows; sharp groin pain–reassurance
⦁ edema
⦁ hemorrhoids
⦁ increased vaginal discharge (check for infxn if changes or malodorous)
⦁ Pica = cravings for clay or dirt = associated with anemia
what is pica? what is it associated with
cravings for clay or dirt = associated with anemia
complications of 1st trimester
⦁ ectopic pregnancy
⦁ threatened miscarriage
⦁ inevitable miscarriage (incomplete or complete miscarriage)
⦁ vanishing twin
⦁ vaginal tract bleeding
⦁ implantation bleeding (dx of exclusion)
bleeding in 1st trimester
- many women will have some vaginal bleeding in 1st trimester during early pregnancy.
When pregnancy is complicated by vaginal bleeding before the 20th week = termed THREATENED ABORTION.
35-50% of threatened abortions eventually result in loss of pregnancy
- Need to rule out ectopic pregnancy
- assess patient - ensure that she’s stable (ABCs, CV status)
- if pt unstable = presume ruptured ectopic & start fluids and get to OR asap!
vaginal bleeding in 1st trimester = need to rule out
ectopic pregnancy
Do a ________ (imaging) if you suspect ectopic pregnancy
pelvic ultrasound
second trimester = _______ weeks
13-27
third trimester
28 weeks +
2nd trimester education
- educate on signs/symptoms of preterm labor & premature rupture of membranes
⦁ uterine contractions, low back pain, cramping, diarrhea
⦁ leakage/gush of fluid from vagina (premature rupture)
⦁ slow pelvic pressure or low back pain - advise them on selecting newborn provider
- lamaze classes - for 1st time parents especially
- tobacco cessation if still smoking
- depression counseling if needed
- ask about intimate partner violence
- postpartum family planning / tubal steriliation
- lay on left lateral, NOT FLAT ON HER BACK**
potential complications of 2nd trimester
- premature labor
- vaginal bleeding (placenta previa, placental abruption)
- premature rupture of membranes
- HTN in pregnancy
- preeclampsia**
2nd trimester = - educate on signs/symptoms of preterm labor & premature rupture of membranes
⦁ uterine contractions, low back pain, cramping, diarrhea
⦁ leakage/gush of fluid from vagina (premature rupture)
⦁ slow pelvic pressure or low back pain
screening for gestational diabetes at
28 weeks
test for gestational diabetes: procedure & values
- screening for gestational diabetes
⦁ random serum glucose > 200
⦁ fasting serum glucose > 126
⦁ glucose challenge test = give 50g oral glucose load. measure serum glucose in 1hr. Abnormal = serum glucose > 130. To confirm gestational DM = do 3 hr oral GTT
adverse outcomes of gestational DM
⦁ preeclampsia ⦁ polyhydramnios ⦁ fetal macrosomia ⦁ birth trauma ⦁ operative delivery ⦁ perinatal mortality
Neonatal metabolic complications = hypoglycemia, hyperbilirubinemia, hypocalcemia
screening labs at 32-36
⦁ CBC
⦁ US when indicated
⦁ HIV when indicated
⦁ depression when indicated
screening labs at 35-37 weeks
⦁ Group B strep
⦁ resistance testing if allergic to PCN
Braxton hicks = not active labor, because there is no
cervical change
nonstress test is done when
use nonstress test if woman presents with decreased fetal movement & heart tones
- record fetal heart tones when mother reclines in left lateral position; record for 20-30 minutes. When mother detects fetal movement = presses a button
when are there are no concerns; no intervention needed at the time for a nonstress test?
If fetal heart rate accelerates AFTER movement for at least 3 episodes = there are no concerns; no intervention needed at the time
what is labor
Physiologic process by which regularly occurring, uncomfortable-to-painful uterine contractions result in progressive effacement and dilatation of the cervix
This thinning out and dilatation permits passage of the fetus from the uterus through the birth canal, resulting in delivery
what is effacement
cervical thinning
- during labor, there is increased synthesis of ________ which stimulate uterine contractions and which may soften the cervix independent of uterine activity
An increase in myometrial ________ receptors, which amplify the biologic effect from a given amount of _________
prostaglandins,
oxytocin
oxytocin
fully dilated = ___ cm
10
position of fetal head in birth canal in relation to ischial spines
fetal station
2nd stage
delivery of infant
3rd stage
delivery of placenta
4th stage
hour after delivery
1st stage
⦁ Latent phase = cervical effacement & early dilation
⦁ active phase = begins when cervix = 3-4cm dilated
⦁ onset of contractions to complete dilatation & effacement of cervix
- The onset of uterine contractions as perceived by pregnant woman
- ends with complete dilatation of the cervix (10cm)
Minimal dilatation during active phase
⦁ primiparous woman = 1cm/hr
⦁ multiparous woman = 1.2 cm/hr
⦁ if not progressing = need to evaluate
stages of labor
1st stage
⦁ Latent phase = cervical effacement & early dilation
⦁ active phase = begins when cervix = 3-4cm dilated
⦁ onset of contractions to complete dilatation & effacement of cervix
o 2nd stage = delivery of infant
o 3rd stage = delivery of placenta
o 4th stage = hour immediately after delivery
contractions are measured from the
beginning of the first contraction to the beginning of the next contraction
- normally, contractions = every 5-10 minutes (the beginning of a contraction to the beginning of the next contraction)
⦁ last for 30-45 seconds
⦁ 20-30 mmHg in intensity
then, contractions become more frequent
every 2-3 minutes
⦁ last 60-70 seconds
⦁ intensity of 40-60 mmHg
can only measure the intensity of contractions accurately with an
internal uterine monitor
the external monitor doesn’t accurately show actual pressure of contractions
MANAGEMENT OF THE 1ST STAGE
- ambulation if head engaged & intermittent fetal monitoring is done
- if laying down = lay supine on left lateral position - avoid supine (hypotensive syndrome)
- if membranes are intact = may still bathe/shower
- hydrate with fluids***
- NPO except for ice chips
may still bathe/shower during 1st stage if
membranes are still intact
FETAL HEART MONITORING DURING 1ST STAGE
- continuous or intermittent monitoring of fetal heart rate - either externally or with scalp electrode
⦁ FHR = 110-160
⦁ good variability, accelerations
⦁ warning signs = late decelerations, bradycardia, decreased variability
variable decelerations associated with
umbilical cord compression
late decelerations means
decreased oxygen to fetus
PAIN DURING LABOR IS FROM
- during 1st stage of labor, pain results from uterine contractions & dilation of cervix
- as fetal head descends, there is also distention of the lower birth canal & perineum
METHODS OF ANESTHESIA/ANELGESIA
- systemic narcotics - early in labor
- spinal anesthesia = single injection of anesthetic
- epidural block = infusion of local anesthetics or narcotics through catheter into epidural space
- local block of anesthetic into vagina or perineum
- general anesthetic
2nd stage begins with _________ and ends with __________
- begins with complete dilation of cervix, ends with delivery of baby; mother has urge to push
⦁ primigravida = 30 min - 2 hrs
⦁ multigravida = 5-30 min
fetal descent needs to be monitored carefully to evaluate progress of labor because
molding & formation of caput can create a false sense of fetal descent
3 Ps to the baby getting out
power
passenger
passage
descent
successful passage of presenting part through birth canal
**the greatest rate of descent = occurs during latter portions of 1st stage of labor & during 2nd stage of labor
stage 4 = closely monitor for
postpartum hemorrhage
⦁ uterine relaxation**
⦁ retained placental fragments
⦁ cervical or vaginal lacerations
⦁ monitor pulse, BP, and uterine blood loss
usually give _________ after the delivery of the placenta
oxytocin (Pitocin) IV
Induction of labor
- give ________ & ________ for cervix
- give _________ drip to start uterine contractions
misoprostol & Prostaglandin E2
Pitocin drip
born sunny side up =
face up
most common major operation performed in the US
C-section
breech =
bottom first
- generally known ahead of time - can schedule automatic C-section
- if you are unknowingly faced with this - most likely baby will just deliver, or will need OB referral
involution of the uterus occurs by
6 weeks - back to normal size
Lochia
discharge from the uterus after birth, as the decidua differentiates into a superficial layer and sloughs off
- discharge is heavy at first, then rapidly decreases in amount over the first 2-3 days;
may last several weeks
Lochia sometimes resolves more rapidly in women who
breastfeed
general rule = nothing in vagina for __________ after delivery
4 weeks
- the likelihood of ovulation ____________ as frequency of breastfeeding decreases
increases
- in nonlactating woman; average time to ovulation = 45 days
- in lactating woman = 189 days
