Normal Pregnancy—Routine Prenatal Care, Labor, Delivery & Postpartum Care Flashcards
Preconception History
9 things to ask about
- 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
Goals of Prenatal (Antepartum) Care
5
- 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
Preconception Interventions
10
- 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
Antepartum Care Includes:
5
- 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
When in the first trimester?
weeks 1-12
Initiating Prenatal Care
- Ideally prenatal care will be initiated in the what?
- first trimester
- How do we deteremine the Gestational age?
2. Other usual methods of determining gestational age? 3
- 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)
The First Prenatal Visit
LOTS of information to collect/assess/review:
Such as?
6
- 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 influence the likelihood of twins?
5
INCREASED _______ needed for pregnant mother with multiple babies
Factors that increase the likelihood:
- Advancing age
- Increased parity
- Family history from either parent
- Obese and tall women greater chance
- Fertility drugs
calories
Risks of multiple gestations
2
- Preterm birth can lead to bed rest early in pregnancy
2. Intrauterine growth retardation or unequal growth
Physical Exam
for pregnancy?
8
- Baseline BP
- Height and weight—calculate baseline BMI
- General PE
- Pay attention to oral hygiene**
- Cardiac exam
- DTRs
- Breast exam
- Pelvic exam
Lab tests for pregnancy?
8
- 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]
Why Get a Urine Culture?
Asymptomatic bacteriuria: occurs in 2-7% pregnant women:
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?
- 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
Why do you need to repeat the culture for asymptomatic bacteriuria?
Need to repeat culture to know it is sterile after treatment/some repeat urine culture each month of pregnancy
Tx of Asymptomatic Bacteriuria
5
- 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
Acute Cystitis in Pregnancy
- Dx?
- Tx? 3
- What abx do you not use?
- UA and midstream urine culture for diagnosis
- Tx: empiric:
- Augmentin
- Nitrofurantoin
- Cephalexin - NO fluroquinolones!
Pregnancy: And more lab tests…
What blood testing?
Blood type and Rh determination and antibody screen
- 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?
- 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)*
Which test is routinely done unless patient refuses, retesting at 36 wks gestation in high risk patients or those who refused earlier is recommended?
HIV
What labs may be indicated for pregnancy but are not always done?
5
- Lipids if indicated
- PPD if indicated
- Hgb A1C if indicated
- Thyroid testing if indicated
- Testing for other infections as indicated: Hep C, Zika
First Trimester Prenatal Genetic Screening
- Purpose?
- Can assess for what? 3
- Purpose is to define the RISK of genetic disorders in a low-risk population
- Can assess for
- Down syndrome,
- Trisomy 18 and
- Trisomy 13
First Trimester Prenatal Genetic Screening: Combining these markers yields an 82-87% Detection of Down Syndrome?
3
- hCG level
- Pregnancy associated plasma protein a (PAPP-A)
- Nuchal transparency (NT)
Women found to have increased risk of aneuploidy with these tests should be offered what?
chorionic villous sampling**
- What is chronic villous sampling?
- Can be done how? 2
- Should not be done before 10 weeks gestation because of what?
- A procedure to get fetal DNA for testing for Down syndrome & other abnormalities
- Can be done under US guidance through the vagina or by abdominal US
- increased pregnancy loss**
Second Trimester Screening
- May be used when?
- Quadruple screen: ?
Using this combination improves the detection of Down syndrome to 80%
- May be an option if a woman is seen later in pregnancy
- Serum alpha-fetoprotein (AFP)
- hCG
- Unconjugated estrodiol
- Inhibin A
Integrated Screening
1. Uses both the first trimester and second trimester markers to do what?
- Early amniocentesis (before 14 weeks of gestation) has what kind of risks? 2
- Individuals who may be carriers can do what?
- adjust a woman’s age-related risk of having a child’s with Down syndrome
- high pregnancy loss and
- more amniotic fluid culture failures
- undergo carrier testing
Maternal Serum Alpha Fetal Protein (MSAFP)
1. Measurement can be used to treat what?
- MSAFP is high = ? 3
- MSAFP is low = ?
- Measurement can be used to detect abnormalities in the fetus**:
- Neural tube defects: MSAFP is high
- Anencephaly: MSAFP is high
- Multiple gestation: MSAFP is high
- Down Syndrome: MSAFP is low**
Amniocentesis—Indications
6
- Prenatal genetic studies (most common)
- Assessment of fetal lung maturity
- Evaluation of the fetus for infection
- Degree of hemolytic anemia
- Evaluation of diagnosed neural tube defects
- Therapeutic—removal of excess amniotic fluid
Amniocentis–Risks
3
- Leakage of amniotic fluid
- Fetal injury (rare)
- Fetal loss: 1/300 to 1/500
1st Visit Prenatal Education
1. Prenatal visits every how often?
- At each visit what should be checked? 6
- Warning signs? 6
- Avoid hot tubs and saunas—why?
- 4 wks until 28wks then every 2wks until 34-36 wks then every wk
- maternal weight,
- BP,
- uterine growth,
- urine dipstick,
- fetal activity and
- fetal heart rate
- vaginal bleeding,
- cramping,
- fever,
- passing clots or tissue (save),
- dizziness,
- fainting or abdominal pain
- maternal heat exposure during the first trimester has been associated w/ neural tube defects
Prenatal Education
- Avoid substance use: such as? 4
- Wear _______ at all times
- Infection precautions: such as? 2
- Exercise: how much?
- Work: Ok unless what?
- Sexual activity: OK unless what? 2
- Travel: increased risk of what?
- Medications: whats ok?
- alcohol*,
- smoking**,
- illicit drugs,
- excessive caffeine
- seatbelt
- influenza,
- toxoplasmosis (cat feces)
- moderate/30 minutes/AVOID strenuous exercise/Supine positions after 1st trimester and abdominal trauma
- OK unless undue lifting or prolonged standing
- OK unless
- risk of STI or
- vaginal bleeding/positions - increased risk DVT/can fly up to 36 weeks gestation if not high risk
- acetaminophen OK should check on anything else including herbal preparations
Diet
1. What foods may be teratogenic? 3
- Avoid what two things? 2
- Can get listeria from what?
- Fish—methylmercury exposure: avoid what?
- Pregnancy increase daily calories by how much in each semester? (last two only)
- Breastfeeding—increase calories by another _______ & add ______ mg Ca++/d
- High dose iron,
- vitamin A,
- selenium may be teratogenic
- No unpasteurized dairy products or
- fruit/vegetable juices
- Can get listeria from processed deli meats (hot dogs, soft cheeses)
4.
- shark,
- mackeral,
- albacore tuna (canned light tuna OK)
- 340—2nd trimester,
- 450—3rd trimester
- 300-500, 1000
Common Symptoms of Pregnancy
11
- Headaches: common in early pregnancy**
- N/V: hyperemisis gravidum less than 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: fluid retention common but can be associated w/ HTN so need to evaluate
- Hemorrhoids: sitz baths
- mVaginal discharge is increased: check for infection if changes or is malodorous
- Pica: inclination for nonnutritious substances such as clay or dirt it is often associated with anemia
Complications of the First Trimester
Vaginal bleeding may be from what?6
- Ectopic pregnancy
- Threatened miscarriage
- Inevitable miscarriage (Incomplete miscarriage and Complete miscarriage)
- Vanishing twin
- Vaginal tract bleeding
- Implantation bleeding (diagnosis of exclusion)
Bleeding First Trimester
1. ______% of all pregnant women will have some bleeding during early pregnancy
- About 1/3 of women have some degree of vaginal bleeding during when?
- When pregnancy is complicated by vaginal bleeding before the 20th week it is termed a what?
- 35-50% of these eventually result in what?
- 30-40
- first trimester
- threatened abortion
- loss of the pregnancy
Bleeding First Trimester
1. RULE OUT what?
- Assess patient to make sure she is stable. How should we do this? 2
- If patient is unstable— act how? 3
- ectopic pregnancy!
- ABCs
- Pay attention to cardiovascular status
- presume ruptured ectopic and
- start fluids and
- get to OR ASAP!
Bleeding First Trimester
Patient stable: Manage how?
5
- Get a history of the bleeding, if tissue or clots have been passed
- Any pain or cramping
- LMP
- Any prenatal care
- Blood type and Rh
Bleeding First Trimester
Exam?
6
- Cardiovascular
Pelvic:
2. Pay attention to whether cervical os is open or closed
- Is their blood in the vagina Tissue?
- Any lesions or trauma?
- Size of uterus consistent with gestation?
- Consistency of uterus? Firm? Boggy?
Bleeding First Trimester
Imaging and Labs?
4
- Pelvic US when suspect ectopic to see if free fluid
- May follow with transvaginal US**
- CBC with type and cross and Rh
- Serum quantitative beta hCG