Normal Pregnancy—Routine Prenatal Care, Labor, Delivery & Postpartum Care Flashcards
1
Q
Preconception History
9 things to ask about
A
- Chronic diseases**
- Medications known to be teratogens
- Reproductive history
- Genetic conditions in the family
- Substance use
- Infectious diseases and vaccinations
- Folic acid intake and nutrition
- Environmental hazards and toxins
- Mental health and social health concerns
2
Q
Goals of Prenatal (Antepartum) Care
5
A
- Ensure birth of a healthy baby w/ minimal risk to the mother
- Early, accurate estimation of gestational age
- Identification of the patient at risk for complications & continuing risk assessment
- Ongoing evaluation of the health status of both mother and fetus
- Patient education and communication
3
Q
Preconception Interventions
10
A
- Folic acid supplementation
- Glycemic control in women with diabetes
- Abstinence from alcohol and illicit and prescription drugs
- Smoking cessation
- Up date vaccinations—live vaccines should be administered 1 month or more prior to pregnancy
- Weight management (BMI >18 less than 30)
- Absence from depression
- Teratogen avoidance
- Absence of STI’s
- Planned pregnancy with an early prenatal visit
4
Q
Antepartum Care Includes:
5
A
- Diagnosing pregnancy & determining gestational age
- Monitoring the ongoing pregnancy w/ periodic exams & appropriate screening tests
- Providing patient education that addresses all aspects of pregnancy
- Preparing the patient and her family for her management during labor, deliver and postpartum period
- Detecting medical and psychosocial complications and instituting indicated interventions
5
Q
When in the first trimester?
A
weeks 1-12
6
Q
Initiating Prenatal Care
- Ideally prenatal care will be initiated in the what?
A
- first trimester
7
Q
- How do we deteremine the Gestational age?
2. Other usual methods of determining gestational age? 3
A
- Add 7 days to the LMP than subtract 3 months—Naegele’s rule
- Usual methods:
- History: using the date of the last menstrual period (LMP)
- Uterine size
- Ultrasound (US)
8
Q
The First Prenatal Visit
LOTS of information to collect/assess/review:
Such as?
6
A
- 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*)
9
Q
Factors that influence the likelihood of twins?
5
INCREASED _______ needed for pregnant mother with multiple babies
A
Factors that increase the likelihood:
- Advancing age
- Increased parity
- Family history from either parent
- Obese and tall women greater chance
- Fertility drugs
calories
10
Q
Risks of multiple gestations
2
A
- Preterm birth can lead to bed rest early in pregnancy
2. Intrauterine growth retardation or unequal growth
11
Q
Physical Exam
for pregnancy?
8
A
- Baseline BP
- Height and weight—calculate baseline BMI
- General PE
- Pay attention to oral hygiene**
- Cardiac exam
- DTRs
- Breast exam
- Pelvic exam
12
Q
Lab tests for pregnancy?
8
A
- Urine specimen for pregnancy test
- Urine is checked each visit for glucose and protein
- 1st visit UA and urine culture are done
- CBC: to detect anemia and screen for thalassemia
- Rubella immunity (if nonimmune counselled & immunized postpartum [PP]*)
- Varicella immunity (if nonimmune varicella vaccine PP)
- Syphilis test: mandated
- Hepatitis B antigen test [HepBsAg]
13
Q
Why Get a Urine Culture?
A
Asymptomatic bacteriuria: occurs in 2-7% pregnant women:
14
Q
Asymptomatic bacteriuria
1. Untreated—30-40% will get a what?
- preterm birth,
- low birth weight, and
- perinatal mortality
- What is considered is considered “positive” and requires treatment?
- Some providers choose to handle the risk of this how?
A
- UTI
- Associated w/ increased risk of what? 3
- 2 consecutive voided specimens w/ same bacterial strain or 1 cath specimen w/ 1 isolated bacterial species—
- Some providers choose to give suppressive therapy throughout pregnancy
15
Q
Why do you need to repeat the culture for asymptomatic bacteriuria?
A
Need to repeat culture to know it is sterile after treatment/some repeat urine culture each month of pregnancy
16
Q
Tx of Asymptomatic Bacteriuria
5
A
- Sulfisoxazole: 500 mg PO TID for 3-7 days
- Amoxicillin: 500 mg PO TID for 3-7 days
- Amoxicillin-clavulanate: 500 mg PO BID 3-7 days
- Nitrfurantoin: 50 mg PO QID for 7 days
- Cefpodoxime proxetil: 100 mg PO Q12 hrs for 3-7 days
17
Q
Acute Cystitis in Pregnancy
- Dx?
- Tx? 3
- What abx do you not use?
A
- UA and midstream urine culture for diagnosis
- Tx: empiric:
- Augmentin
- Nitrofurantoin
- Cephalexin - NO fluroquinolones!
18
Q
Pregnancy: And more lab tests…
What blood testing?
A
Blood type and Rh determination and antibody screen
19
Q
- Rh status necessary. Why?
- If mother is Rh neg another antibody screen is drawn at ___ wks if it is still negative then the Rh neg mother is given Rhogam
- What other circumstances is an Rh neg woman given Rhogham? 2
- If an Rh neg woman DOES get exposed to Rh pos blood from her baby she will produce antibodies against Rh pos blood in subsequent pregnancies causing what?
A
- if mother Rh neg then Anti-D immune globulin (Rhogam) is given whenever there is a risk of fetomaternal hemorrhage to prevent alloimmmunization
- 28
- Miscarriage,
- placenta rupture
- fetal hemolytic disease (fetalis hydrops)*
20
Q
Which test is routinely done unless patient refuses, retesting at 36 wks gestation in high risk patients or those who refused earlier is recommended?
A
HIV
21
Q
What labs may be indicated for pregnancy but are not always done?
5
A
- Lipids if indicated
- PPD if indicated
- Hgb A1C if indicated
- Thyroid testing if indicated
- Testing for other infections as indicated: Hep C, Zika
22
Q
First Trimester Prenatal Genetic Screening
- Purpose?
- Can assess for what? 3
A
- Purpose is to define the RISK of genetic disorders in a low-risk population
- Can assess for
- Down syndrome,
- Trisomy 18 and
- Trisomy 13
23
Q
First Trimester Prenatal Genetic Screening: Combining these markers yields an 82-87% Detection of Down Syndrome?
3
A
- hCG level
- Pregnancy associated plasma protein a (PAPP-A)
- Nuchal transparency (NT)
24
Q
Women found to have increased risk of aneuploidy with these tests should be offered what?
A
chorionic villous sampling**
25
1. What is chronic villous sampling?
2. Can be done how? 2
3. Should not be done before 10 weeks gestation because of what?
1. A procedure to get fetal DNA for testing for Down syndrome & other abnormalities
2. Can be done under US guidance through the vagina or by abdominal US
3. increased pregnancy loss**
26
Second Trimester Screening
1. May be used when?
2. Quadruple screen: ?
Using this combination improves the detection of Down syndrome to 80%
1. May be an option if a woman is seen later in pregnancy
2.
- Serum alpha-fetoprotein (AFP)
- hCG
- Unconjugated estrodiol
- Inhibin A
27
Integrated Screening
1. Uses both the first trimester and second trimester markers to do what?
2. Early amniocentesis (before 14 weeks of gestation) has what kind of risks? 2
3. Individuals who may be carriers can do what?
1. adjust a woman’s age-related risk of having a child’s with Down syndrome
2.
- high pregnancy loss and
- more amniotic fluid culture failures
3. undergo carrier testing
28
Maternal Serum Alpha Fetal Protein (MSAFP)
1. Measurement can be used to treat what?
2. MSAFP is high = ? 3
3. MSAFP is low = ?
1. Measurement can be used to detect abnormalities in the fetus**:
2.
- Neural tube defects: MSAFP is high
- Anencephaly: MSAFP is high
- Multiple gestation: MSAFP is high
3. Down Syndrome: MSAFP is low**
29
Amniocentesis—Indications
| 6
1. Prenatal genetic studies (most common)
2. Assessment of fetal lung maturity
3. Evaluation of the fetus for infection
4. Degree of hemolytic anemia
5. Evaluation of diagnosed neural tube defects
6. Therapeutic—removal of excess amniotic fluid
30
Amniocentis--Risks
| 3
1. Leakage of amniotic fluid
2. Fetal injury (rare)
3. Fetal loss: 1/300 to 1/500
31
1st Visit Prenatal Education
1. Prenatal visits every how often?
2. At each visit what should be checked? 6
3. Warning signs? 6
4. Avoid hot tubs and saunas—why?
1. 4 wks until 28wks then every 2wks until 34-36 wks then every wk
2.
- maternal weight,
- BP,
- uterine growth,
- urine dipstick,
- fetal activity and
- fetal heart rate
3.
- vaginal bleeding,
- cramping,
- fever,
- passing clots or tissue (save),
- dizziness,
- fainting or abdominal pain
4. maternal heat exposure during the first trimester has been associated w/ neural tube defects
32
Prenatal Education
1. Avoid substance use: such as? 4
2. Wear _______ at all times
3. Infection precautions: such as? 2
4. Exercise: how much?
5. Work: Ok unless what?
6. Sexual activity: OK unless what? 2
7. Travel: increased risk of what?
8. Medications: whats ok?
1.
- alcohol*,
- smoking**,
- illicit drugs,
- excessive caffeine
2. seatbelt
3.
- influenza,
- toxoplasmosis (cat feces)
4. moderate/30 minutes/AVOID strenuous exercise/Supine positions after 1st trimester and abdominal trauma
5. OK unless undue lifting or prolonged standing
6. OK unless
- risk of STI or
- vaginal bleeding/positions
7. increased risk DVT*/can fly* up to 36 weeks gestation if not high risk
8. acetaminophen OK should check on anything else including herbal preparations
33
Diet
1. What foods may be teratogenic? 3
2. Avoid what two things? 2
3. Can get listeria from what?
4. Fish—methylmercury exposure: avoid what?
5. Pregnancy increase daily calories by how much in each semester? (last two only)
6. Breastfeeding—increase calories by another _______ & add ______ mg Ca++/d
1.
- High dose iron,
- vitamin A,
- selenium may be teratogenic
2.
- No unpasteurized dairy products or
- fruit/vegetable juices
3. Can get listeria from processed deli meats (hot dogs, soft cheeses)
4.
- shark,
- mackeral,
- albacore tuna (canned light tuna OK)
5.
- 340—2nd trimester,
- 450—3rd trimester
6. 300-500, 1000
34
Common Symptoms of Pregnancy
| 11
1. Headaches: common in early pregnancy**
2. N/V: hyperemisis gravidum less than 2%
3. Heartburn: general maneuvers, may use tums
4. Constipation: can try stool softeners, add bulk, drink fluids
5. Fatigue
6. Back pain: later in pregnancy
7. Round ligament pain: as uterus grows; sharp groin pain--reassurance
8. Edema: fluid retention common but can be associated w/ HTN so need to evaluate
9. Hemorrhoids: sitz baths
10. mVaginal discharge is increased: check for infection if changes or is malodorous
11. Pica: inclination for nonnutritious substances such as clay or dirt it is often associated with anemia
35
Complications of the First Trimester
| Vaginal bleeding may be from what?6
1. Ectopic pregnancy
2. Threatened miscarriage
3. Inevitable miscarriage (Incomplete miscarriage and Complete miscarriage)
4. Vanishing twin
5. Vaginal tract bleeding
6. Implantation bleeding (diagnosis of exclusion)
36
Bleeding First Trimester
1. ______% of all pregnant women will have some bleeding during early pregnancy
2. About 1/3 of women have some degree of vaginal bleeding during when?
3. When pregnancy is complicated by vaginal bleeding before the 20th week it is termed a what?
4. 35-50% of these eventually result in what?
1. 30-40
2. first trimester
3. threatened abortion
4. loss of the pregnancy
37
Bleeding First Trimester
1. RULE OUT what?
2. Assess patient to make sure she is stable. How should we do this? 2
3. If patient is unstable— act how? 3
1. ectopic pregnancy!
2.
- ABCs
- Pay attention to cardiovascular status
3.
- presume ruptured ectopic and
- start fluids and
- get to OR ASAP!
38
Bleeding First Trimester
Patient stable: Manage how?
5
1. Get a history of the bleeding, if tissue or clots have been passed
2. Any pain or cramping
3. LMP
4. Any prenatal care
5. Blood type and Rh
39
Bleeding First Trimester
Exam?
6
1. Cardiovascular
Pelvic:
2. Pay attention to whether cervical os is open or closed
3. Is their blood in the vagina Tissue?
4. Any lesions or trauma?
5. Size of uterus consistent with gestation?
6. Consistency of uterus? Firm? Boggy?
40
Bleeding First Trimester
Imaging and Labs?
4
1. Pelvic US when suspect ectopic to see if free fluid
2. May follow with transvaginal US**
3. CBC with type and cross and Rh
4. Serum quantitative beta hCG
41
What weeks are second trimester?
Weeks 13-27
42
Second Trimester Evaluations
| 6
1. Fundus height
2. Fetal movement
3. Maternal BP and weight
4. Urine dip for glucose and protein
5. Documentation of fetal cardiac activity
6. Assessment of significant events:
43
Fundal height
1. At ____ weeks the uterus reaches the umbilicus and now the fundal height can be measured at each visit
2. Each week should equal _____ up until 36 wks
3. After that what happens?
1. 20
2. 1 cm
3. the baby drops down into the pelvis and is lower
44
Third trimester: Assessment of significant events? 4
1. Travel
2. Illness
3. Stressors
4. Infections
45
Complications 2nd Trimester
| 5
1. Premature labor
2. Vaginal bleeding:
3. Premature rupture of membranes
4. Hypertension in pregnancy
5. Preeclampsia**
46
What are common causes for vaginal bleeding in the 2nd trimester?
2
1. Placenta previa
| 2. Placental abruption
47
2nd Trimester Education
Moms are instructed on the signs & sx of preterm labor & premature rupture of membranes. What are these?
10
1. uterine contractions, low back pain, cramping, diarrhea
2. leakage or gush of fluid from the vagina (indicating?)
3. low pelvic pressure, or low back pain
4. Advised on selecting a newborn care provider
5. Lamaze or similar type class especially for first time parents
6. Tobacco cessation if still smoking
7. Depression counselling if appropriate
8. Asked about intimate partner violence
9. Postpartum family planning/tubal sterilization
10. Patient to lay on left lateral NOT flat on her back**
48
Third Trimester
| What weeks?
week 28-birth
49
From 28-36 weeks…
1. Visits are how often?
2. At each visit the abdomen is examined to determine what?
3. Usually by ___ wks. the fetus is in the position its going to stay in!
4. 4. Sometimes if a baby is breech the OB doc attempts to maneuver the fetus into the what?
1. Visits are now every 2 weeks
2. the position/presentation of the fetus using the maneuvers of Leopold
3. 36
4. cephalic position—external version**
50
28 Weeks More Tests!
| Which test at this date?
Time to screen for gestational diabetes:
51
Time to screen for gestational diabetes:
| 3
1. Random serum glucose > 200 mg/dL
2. Fasting serum glucose > 126 mg/dL
3. Glucose challenge test: 50-g oral glucose load given:
52
Glucose challenge test: 50-g oral glucose load given:
1. When is glucose measured after the 50-g oral glucose given?
2. Whats abnormal?
3. To confirm gestational diabetes do how many oral GTT?
1. 1 hour later serum glucose measured
2. Abnormal > 130
3. To confirm gestational diabetes do three hour oral GTT
53
Adverse outcomes associated w/ Gestational Diabetes Mellitus
6
Neonatal metabolic complications? 4
1. Preeclampsia
2. Polyhydramnios
3. Fetal macrosomia
4. Birth trauma
5. Operative delivery
6. Perinatal mortality
1. hypoglycemia,
2. hyperbilirubinemia,
3. hypocalcemia,
4. erthremia
54
If a Woman is Rh Negative
| at 28 weeks you should do what?
Rh antibody screen
Anti-D immune globulin (Rhogham) is given
55
32-36 weeks Screening Labs
| 4
1. CBC
2. US when indicated
3. HIV when indicated
4. Depression screening when indicated
56
35-37 week Labs
| 2
1, Group B strep
| 2. Resistance testing if penicillin allergic
57
```
1. Screening for Group B Strep
CDC recommends what?
2. How should we do this?
3. If they screen positive?
4. Tx?
```
1. CDC recommends universal screening for Group B Streptococcus at 35-37 wks gestation:
2. Swabs are done of the vagina and rectum
3. If positive for Group B strep—woman is treated prophylactically at time of labor and delivery
4. Tx w/ PCN, ampicillin, erythromycin or clindamycin
58
Women w/ GBS bacteriuria during the current pregnancy & women who have given birth to an infant w/ invasive GBS are not screened they are given what?
intrapartum antibiotic prophylaxis
59
3rd Trimester Education/Planning
| 11
1. Anesthesia/Birth plans
2. Labor signs*
3. Vaginal bleeding (Sign of?)
4. Signs & symptoms of preeclampsia (????)
5. Post-term counselling
6. Circumcision if a boy
7. Breastfeeding**
8. Postpartum depression
9. Intimate partner violence
10. Newborn education
11. Family medical leave or disability forms
60
Braxton Hicks Contractions
1. What are these?
2. How may they feel?
3. Do not result in a change in what?
4. What should we educate about this?
1. Commonly occur in the last 2-3 weeks of pregnancy—also referred to as “false labor”
2. May be regular and strong
3. DO NOT result in a change in the cervix!
- Therefore not active labor
4. Encourage the mother, do not treat carelessly or brush it off
61
Third Trimester:
When to come in!
4
1. Contractions every 5 minutes for 1 hour or very intense contractions
2. Mother getting very uncomfortable or feeling pressure in pelvis
3. Sudden gush or leaking of fluid from the vagina
4. Significant vaginal bleeding
Decreased fetal movement
62
Nonstress Test—Assessing fetal well-being
1. If a woman presents with decreased fetal movement and fetal heart tones are heard then the well-being of the fetus is evaluated with a what?
2. While the mother reclines—the fetal heart tones are recorded by a fetal heart monitor
They are recorded for _____ minutes
3. The mother presses a button when she detects what?
4. When is the test is reassuring and no intervention is needed at that time?
1. a nonstress test (usually after 28 wks)
2. 20-30
3. fetal movement
4. If the FHR accelerates AFTER movement for at least 3 episodes and there are no concerning decreased in heart rate
63
Complications of the 3rd Trimester
| 5
1. Preeclampsia/eclampsia
2. HELPP syndrome
3. Vaginal bleeding
4. Premature labor
5. Premature rupture of membranes
64
Biophysical Profile
| 5
1. Nonstress test
2. Fetal breathing movements (US)
3. Fetal movement (US)
4. Fetal tone (US)
5. Amniotic fluid volume (US)
65
Birth Plan:
Common topics?
4
1. Mobility, massage, music
2. Pain relief, medical procedures (monitoring, IV fluids, AROM**)
3. Positioning for pushing
4. Mother and baby together, breastfeeding within the 1st hr, rooming in*
66
What is the definition of labor?
Physiologic process by which regularly occurring, uncomfortable-to-painful uterine contractions result in progressive effacement and dilatation of the cervix
67
Onset
1. Increased synthesis of what?
2. which stimulates what?
3. An increase in what, which amplify the biologic effect from a given amount of oxytocin?
1. prostaglandins
2. uterine contractions and which may soften the cervix independent of uterine activity
3. myometrial oxytocin receptors
68
Exam for delivery
1. Determine presenting part: Whats preferable?
2. What are we looking for on digital exam of the cervix? 3
3. What is the fetal station?
1. (Head down preferably!)
2. Digital vaginal exam—cervix:
- Consistency—hard vs. soft
- Effacement—shortening of the cervical canal from 2 cm to paper thin
- Dilation—cervix opens from closed to 10 cm (fully dilated)
3. Fetal Station—position of the fetal head in the birth canal in relation to the ischial spines
69
What are the stages of labor?
| 4
1st Stage:
Latent, Active and Onset of labor
2nd Stage—Delivery of the infant
3rd Stage—Delivery of the placenta
4th Stage—Hour immediately after delivery
70
What makes up the first stage of labor?
| 3
1. Latent phase—cervical effacement and early dilatation
2. Active phase—begins when cervix is 3-4 cm dilated
3. Onset of contractions to complete dilatation and effacement of cervix
71
First Stage
1. Onset of Uterine contractions as percieved by what?
2. Ends with what?
3. Minimal dilation during active phase:
- Primiparous women?
- Multiparous women?
1. Onset of uterine contractions as perceived by the pregnant woman
2. Ends with complete dilatation of the cervix, which is 10 cm in diameter for a full-term infant
3.
- Primiparous women: 1 cm/hr
- Multiparous women: 1.2 cm/hr
72
EARLY LABOR
1. Typically contractions occur every how many min?
2. Last for how long?
3. Intensity?
1. Typically, contractions occur every 5 to 10 minutes (i.e., beginning of contraction to beginning of next contraction)
2. Last for 30 to 45 seconds
3. 20 to 30 mm Hg in intensity**
73
1. Contractions become more frequent—every____ min
2. Lasting _____ seconds
3. Intensity of _____ mm Hg
4. Can only measure intensity of contractions accurately with internal uterine monitor, why?
1. 2-3
2. 60-70
3. 40-60
4. external monitor does not accurately show actual pressure of contractions!
74
Management of 1st Stage
| 5
1. Ambulation if head engaged and intermittent fetal monitoring is done
2. If laying down—supine left lateral position (avoid supine hypotensive syndrome)
3. If membranes intact may bathe or shower
4. Hydration w/ IV fluids*
5. NPO except for ice chips
75
1. Continuous or intermittent monitoring of the fetal heart rate either with ? 2
Fetal Heart rate:
2. Range ?
3. Good ________, accelerations
4. Warning signs? 3
1.
- externally or
- with scalp electrode
2. 110-160
3. variability
4.
- late decelerations,
- bradycardia,
- decreased variability
76
Pain Control During Labor
1. During the first stage of labor pain results from what?
2. As the fetal head descends there is also what?
1. uterine contractions and dilation of the cervix
| 2. distension of the lower birth canal and perineum
77
Methods of anesthesia/analgesia:
| 5
1. Systemic narcotics—early in labor
2. Spinal anesthesia—single injection of anesthetic
3. Epidural block—infusion of local anesthetics or narcotics through a catheter into the epidural space***
4. Local block of the of anesthetic into the vagina or perineum
5. General anesthetic
78
2nd Stage Management
1. Begins with what?
2. Primgravida size: ?
3. Multigravida: ?
4. Fetal descent needs to be monitored carefully to evaluate progress of labor: Molding and formation of caput can create what?
1. Begins with complete dilatation of the cervix and ends with delivery of the baby—mother has urge to push:
2. Primgravida: 30 min-2 hrs
3. Multigravida: 5-30 min
4. false sense of fetal descent
79
1. The passage of the fetus through the pelvis is called what?
2. usually takes place in a predictable sequence based on what?
Power, Passenger, Passage
1. the mechanism of labor
| 2. the mechanics of force from above and resistance from below
80
Cardinal Movements of Labor (Stage 2)
| 7
1. Engagement
2. Flexion
3. Descent
4. Internal rotation
5. Extension
6. External rotation or restitution
7. Expulsion
81
The bony pelvis consists of four bones:
3
Baby’s head must go in an _____________ direction and then in an inferoanterior direction
1. Sacrum
2. Coccyx
3. Two innominate bones, each made of the fused pubis, ischium, and ilium
inferoposterior
82
1. Engagement: WHat is this?
| 2. The presenting part is palpated below the level of the what?
1. 1. Biparietal diameter, the widest transverse diameter of the fetal head, has passed the plane of the pelvic inlet
2. ischial spines
83
FLEXION
1. What is it?
2. What does it allow for?
1. As forces cause descent of the fetus through the pelvis, soft tissue and bony resistance is encountered
2. Allows the smaller diameters of the fetal head to present to the maternal pelvis
84
Descent
1. What is it?
2. The greatest rate of descent occurs during what? 2
1. Successful passage of the presenting part through the birth canal
2. The greatest rate of descent occurs during the
- latter portions of the first stage of labor and
- during the second stage of labor
85
Internal Rotation
1. Helps with what?
2. Most commonly rotates how?
1. Facilitates optimal diameters of the fetal head to the bony pelvis
2. Most commonly from transverse to either anterior or posterior
86
Extension
1. After further descent, the fetal head reaches the what?
2. To accommodate the upward curve of the birth canal the flexed head now does what?
1. introitus
| 2. extends
87
External Rotation
1. Occurs when?
2. The head rotates how relative to the shoulders ?
3. Known as _________ then there is rapid delivery of the body—expulsion
1. after the delivery of the head
2. “face forward”
3. “restitution”
88
Continuing the Delivery
1. Once the head is delivered what should happen?
2. Check for _______ umbilical cord
3. Deliver the what next? 3
4. Clamp and cut cord within what amount of time?
5. Place infant on mother's chest, if not in distress, then to do what?
1. oral cavity and nares are suctioned
2. nuchal
3. shoulders, trunk and legs
4. 15-20 sec
5. warm
89
3rd Stage
1. Begins with what and ends with what?
2. Obtain what while waiting?
3. While waiting for the placenta to deliver check for what?
4. Dont do what with the umbilical cord?
5. Once the placenta separates you can do what?
6. Usually give what after delivery of the placenta?
1. Begins with delivery of the baby and ends with delivery of the placenta and membranes
2. Obtain cord blood while waiting
3. While waiting for the placenta to deliver, check for lacerations (can take 2-30 min to deliver)
4. Don't pull on umbilical cord!!!
5. Once the placenta separates you can gently put traction on the cord, sometimes the mother will need to push; check the cord and placenta
6. Usually give oxytocin (Pitocin) IV after delivery of the placenta
90
STAGE 4
What are we watching for? 4
What are we monitoring specifically? 3
1. Close observation for postpartem hemorrhage:
2. Uterine relaxation***
3. Retained placental fragments
4. Cervical or vaginal lacerations
Monitor
1. pulse,
2. BP,
3. uterine blood loss
91
Newborn Care
| Apgar includes what? 5
1. Color
2. Heart rate
3. Reflex activity
4. Muscle tone
5. Respirations
92
Breastfeeding
1. Colostrum: [first 5 days]:
- What is there more of?
- What is there less of?
Milk production
2. You need adequate what? 5
3. Nipple Care? 2
```
1. Colostrum: [first 5 days]
More
-minerals,
-protein and
-IgG antibodies
```
Less
- fat and
- sugar
Milk production:
2. Adequate
- insulin,
- cortisol and
- thyroid hormone
- Adequate nutrients and
- fluids in mother’s diet
3. Nipple care:
- Wash with water and expose to air for 15-20 minutes after each feeding
- Lanolin or A & D ointment may be applied if tender
93
Induction of Labor
1. When can you induce a labor?
2. Cervical ripening may need to be done. How do we do this? 3
3. Pitocin drip to stimulate what?
1. Can be induced when the benefits to either the mother or the fetus outweigh those of continuing the pregnancy
2.
- Misoprostol and
- prostaglandin E2 can be administered intravaginally or intracervically
- Laminaria**—mechanical dilation of the cervix
3. uterine contractions**
94
1. What does VBAC stand for?
| 2. What does TOLAC stand for?
1. Vaginal birth after cesarean (VBAC)
| 2. Trial of labor after cesarean (TOLAC) preferred term
95
Breech presentation
1. What is it?
2. Generally known ahead of time automatic ________?
3. If you are faced with this most likely what will happen? 2
1. Bottom first
2. c-section
3. just deliver or will need expedient OB referral
96
Postpartum Care. Which weeks?
Puerperium—6-8 weeks following birth
97
Uterus
1. Involution of the uterus—normal size by what?
2. Lochia is what?
3. ____ at first
4. Rapidly decreases in amount over the first_____ days
5. May last for how long?
6. In women who breastfeed the lochia sometimes resolves more what?
1. 6 wks
2. The discharge from the uterus after birth as the dicidua differentiates into a superficial layer which sloughs off
3. Heavy
4. 2-3
5. several weeks
6. rapidly
98
Vagina
1. The vulvar and vaginal tissue return to normal over the first _________ days
2. If a woman had a what that can take 3-4 weeks to heal?
3. General “rule”—nothing in the vagina for ______ after delivery
1. several
2. episiotomy or tear
3. 4 weeks
99
Ovarian Function
1. In the nonlactating woman the average time to ovulation is how long?
2. In the lactating woman it is how long?
3. The likelihood of ovulation increases as what decreases?
Breastfeeding is NOT reliable contraception
1. 45 days
2. 189 days
3. frequency of breastfeeding decreases!
100
Variable decelerations are associated with what?
umbilical cord compression
101
Late decelerations are associated with what?
decreased oxygen to fetus
102
Sinusoidal pattern means what?
Baby is acidotic, VERY BAD
