Pregnancy Care Flashcards
Preconception History
Chronic diseases Medications known to be teratogens Reproductive history 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 a healthy baby
Minimize risk to mother
Early, accurate estimation of gestational age & due date
Identification of patient risk for complications & continuing risk assessment
Ongoing evaluation of health status of mother & baby
Patient education & communication
Preconception Interventions
Folic acid supplementation Glycemic control in women with DM Abstinence from alcohol & illicit & prescription drugs Smoking cessation UTD vaccinations Weight management (18-30) Absence from depression Teratogen avoidance Absence of STIs Planned pregnancy with early prenatal visit
Antepartum Care
Diagnosing pregnancy & determining gestational age
Monitoring the ongoing pregnancy with periodic exams & appropriate screening tests
Providing patient education that addresses all aspects of pregnancy
Preparing the patient & family for management during labor, delivery & postartum period
Detecting medical & psychosocial complications & instituting indicated interventions
Initiating Prenatal Care
Ideally prenatal care initiated in 1st trimester
Determining Gestational Age
IMPORTANT
Need to determine due date (EDC)
Usual Methods of Determining Gestational Age
History: date of LMP
Uterine size
Ultrasound (US)
Most Accurate Time Frame for Crown Rump Length
6-11 weeks
Most Accurate Time Frame for Biparietal Diameter
13-25 weeks
Most Accurate Time Frame for Femur Length
13-25 weeks
Assessment at First Prenatal Visit
Medical history Reproductive history Family history Genetic history Nutritional history Psychosocial history: domestic violence Contact information Prenatal menstrual history
Factors that Increase the Likelihood of Twins/Multiples
Advancing age Increased parity Family history from either parent Obese & tall women Fertility drugs
Risks of Multiple Gestations
Preterm birth can lead to bed rest early
Intrauterine growth retardation or unequal growth
Physical Exam at First Assessment of Pregnant Woman
Baseline BP Height & weight General PE Pay attention to oral hygiene Cardiac exam DTR's Breast exam Pelvic exam
Lab Tests for First Trimester
UA + pregnancy test + culture CBC Rubella immunity Varicella immunity Syphilis test Hepatitis B antigen test Blood type & Rh determination HIV Lipids, PPD, HgbA1C, thyroid testing, Hep C, Zika if indicated
Why obtain a urine culture?
Asymptomatic bacteriuria
Asymptomatic Bacteriuria
Associated with increased risk of preterm birth, low birth weight, & perinatal mortality
Need repeat after treatment
Treatment of Asymptomatic Bacteriuria in Pregnancy
Sulfisoxazole Amoxicillin Amoxicillin-clavulanate (Augmentin) Nitrofurantoin Cefpodoxime proxetil
Treatment of Acute Cystitis in Pregnancy
Augmentin
Nitrofurantoin
Cephalexin
Amoxacillin
Indications for Rhogam
At 28 weeks of gestation Spontaneous abortion, threatened abortion, induce abortion Invasive procedures Hydatidiform mole Fetal death in 2nd & 3rd trimester Blunt trauma to abdomen Antepartum hemorrhage in 2nd or 3rd trimester External cephalic version
First Trimester prenatal Genetic Screening
Define risk in low-risk population
Can assess for down syndrome, trisomy 18 & trisomy 13
Combination of what factors increases detection of down syndrome?
hCG level
Pregnancy associated plasma protein A (PAPP-A)
Nuchal transparency (NT)
Define Chorionic Villous Sampling
Get fetal DNA for testing for Down Syndrome & other abnormalities
Quadruple Screen in the Second Trimester Screening
Serum alpha-fetoprotein (AFP)
hCG
Unconjugated estrodiol
Inhibin A
Define Nuchal Translucency (NT) Measurement
Width of the translucent space at the back of the fetal neck determined by ultrasound
What defects can occur when maternal serum alpha fetal protein (MSAFP) is high?
Neural tube defects
Anencephaly
Multiple gestation
What defect can occur when MSAFP is low?
Down syndrome
Indications for Amniocentesis
Prenatal genetic studies
Assessment of fetal lung maturity
Evaluation of fetus for infection
Degree of hemolytic anemia
Evaluation of diagnosed neural tube defects
Therapeutic: removal of excess amniotic fluid
Risks of Amniocentesis
Leakage of amniotic fluid Fetal injury (rare)
1st Visit Prenatal Education
At each visit maternal weight, BP, uterine growth, urine dipstick, fetal activity, & fetal HR
Every 4 weeks until 28 weeks; every 2 weeks until 34-36 weeks; every week until term
How to reach provider after business hours
Avoid hot tubs & saunas
Avoid substance use
Wear seatbelt
Infection precautions
Exercise: moderate, 30 minutes
Work: okay unless excessive lifting or standing
Sexual activity: risk of STI or vaginal bleeding
Travel: increased risk of DVT
Medications: check with provider
Weight gain counseling
Breast Feeding
Childbirth classes/hospital facilities
Diet
Education on Warning Signs of 1st Visit Prenatal Education
Vaginal bleeding Cramping Fever Passing clots or tissue (save) Dizziness Fainting or abdominal pain
Diet During Pregnancy
High dose iron, vitamin A, selenium may be teratogenic
Fully cooked meats, fish, poultry, & eggs
Unpasteurized dairy products or fruit/vegetable juices
Can get listeria from processed deli meats
Fish
Increased daily calories
Breastfeeding
Common Symptoms of Pregnancy
Headaches N/V Heartburn Constipation Fatigue Back pain Round ligament pain: sharp groin pain Edema Hemorrhoids Increased vaginal discharge Pica
Define Pica
Inclination for non-nutritious substances such as clay or dirt is is often associated with anemia
Complications of the First Trimester
Vaginal bleeding
Types of Vaginal Bleeding in the First Trimester
Ectopic pregnancy Threatened miscarriage Inevitable miscarriage: incomplete/complete Vanishing twin Vaginal tract bleeding Implantation bleeding
What needs to be ruled out with first trimester bleeding?
Ectopic pregnancy
Unstable Patient with Bleeding in First Trimester
Check ABCs
Pay attention to CV status
Start fluids
Get to OR
Stable Patient with Bleeding in First Trimester
History of bleeding Pain or cramping LMP Any prenatal care Blood type & Rh
Evaluation of First Trimester Bleeding
Pelvic US
Transvaginal US
CBC with type & cross & Rh
Serum quantitatve beta hCG
Second Trimester Evaluations
Fundal height Fetal movement Maternal BP & weight Urine dip for glucose & protein Documentation of fetal cardiac activity Assessment of significant events: travel, illness, stressors, infections, abuse
Fundal Height at 20 weeks, up to 36 weeks, & later
20 weeks: uterus reaches umbilicus
36 weeks: grows up to 1 cm/week after 20 weeks
Then baby drops into pelvis
Fetal Movement
Begin to feel fetus & 18-29 weeks
Ask about fetal movement
Decreased movement: have mother come in
Complications of 2nd Trimester
Premature labor Vaginal bleeding: placenta previa, placental abruption Premature rupture of membranes HTN in pregnancy Pre-eclampsia
Signs & Symptoms of Preterm Labor & Premature Rupture of Membranes
Uterine contractions, low back pain, cramping, diarrhea
Leakage or gushing of fluid from vagina
Low pelvic pressure, low back pain
Advised on selecting newborn care provider
Lamaze or similar type class especially for 1st time parents
Tobacco cessation if still smoking
Depression counseling if appropriate
Asked about intimate partner violence
Postpartum family planning/tubal sterilization
Patient to lay on left lateral side
Third Trimester
28-36 weeks
Abdomen examined to determine of position
Tests at 28 Weeks
Random glucose >200 Fasting glucose >126 Glucose challenge test: abnormal >130 after 1 hour Glucose tolerance test Rhogham if Rh Negative
Adverse Outcomes Associated with Gestational Diabetes Mellitus
Pre-eclampsia Polyhydramnios Fetal macrosomia Birth trauma Operative delievery Perinatal mortality
Neonatal Metabolic Complications
Hypoglycemia
Hyperbilirubinemia
Hypocalcemia
Erythremia
32-36 Week Screening Labs
CBC
US when indicated
HIV when indicated
Depression screening when indicated
35-37 Week Labs
Group B strep (anal/vaginal swab)
Resistance testing if penicillin allergic
3rd Trimester Education/Planning
Anesthesia/birth plans Labor signs Vaginal bleeding Signs & symptoms of pre-eclampsia Post-term counseling Circumcision Breastfeeding Postpartum depression Intimate partner violence Newborn education Family medical leave or disability forms
Braxton Hicks Contractions
Commonly last 2-3 weeks of pregnancy
Regular & strong
Don’t result in change in cervix
Not active labor
When to come into the hospital?
Contractions every 5 minutes for an hour
Mother getting very uncomfortable or feeling pressure in pelvis
Sudden gush or leaking of fluid from vagina
Significant vaginal bleeding
Decreased fetal movement
Complications of 3rd Trimester
Pre-eclampsia/eclampsia HELPP syndrome Vaginal bleeding Premature labor Premature rupture of membranes
Biophysical Profile
Non-stress test Fetal breathing movements (US) Fetal movement (US) Fetal tone (US) Amniotic fluid volume (US)
Common Topics of Birth Plan
Mobility, massage, music Pain relief, medical procedures Positioning for pushing Mother & baby together Breastfeeding in first hour Rooming in
Define Labor
Physiologic process by which regularly occurring uncomfortable-to-painful uterine contractions result n progressive effacement & dilation of the cervix
Permits passage through the birth control
Increased synthesis of prostaglandins: stimulate contractions, soften cervix
Increase in myometrial oxytocin receptors: amplify biologic effect from oxytocin
Exam for delivery
Determine presenting part
Digital vaginal exam
Fetal station
Parts of the Digital Vaginal Exam
Consistency of cervix: hard vs. soft
Effacement: shortening of cervical canal to paper thin
Dilation
Define Fetal Station
Position of fetal head in the birth canal in relation to the ischial spines
Stages of Labor
1st Stage: leading up to delivery
2nd Stage: delivery of the infant
3rd Stage: delivery of the placenta
4th Stage: hour immediately after delivery
1st Stage of Labor
Latent phase: cervical effacement & early dilation
Active phase: begins when cervix is 3-4 cm dilated
Onset of contractions to complete dilation & effacement
Minimal Dilation During Active Phase
Primiparous: 1 cm/hr
Multiparous: 1.2 cm/hr
Not progressing need to evaluate
Early Labor Contractions
Every 5-10 minutes
last for 30-45 seconds
Late Labor Contractions
Every 2-3 minutes
Lasting 60-70 seconds
Management of 1st Stage
Ambulation if head engaged Left lateral position Membranes intact: bathe or shower Hydration with IV fluids NPO except for ice chips
Fetal Monitoring
Continuous or intermittent monitoring of fetal HR
Warning Signs of Fetal HR
Late decelerations
Bradycardia
Decreased variability
Pain Control During Labor
Systemic narcotics: early Spinal anesthesia Epidural block Local block of vagina or perineum General anestetic
2nd Stage Management
Begins with complete dilation of cervix & ends with delivery of baby
Fetus needs to be monitored carefully
Crucial Items for Delivery
Power
Passenger
Passage
Cardinal Movements of Labor
Engagement Flexion Descent Internal rotation Extension External rotation or restitution Expulsion
Define Engagement
Biparietal diameter has passed the plane of the pelvic inlet
Define Flexion
Forces cause descent of the fetus through the pelvis, soft tissue, & bony resistance is encountered
Define Descent
Successful passage of the presenting part through the birth canal
Define Internal Rotation
Facilitates optimal diameters of the fetal head to the bony pelvis
Define Extension
Fetal head reaches introitus
Flexed head now extends
Define External Rotation
Occurs after delivery of the head
Head rotates “face forward” relative to shoulders
Define Expulsion
Rapid delivery of the body
Continued Delivery
Suction oral cavity & nares Check nuchal umbilical cord Deliver the shoulders, trunk & legs Clamp & cut cord Place infant on mom's chest
3rd Stage
Obtain cord blood Check for lacerations Don't pull on cord Delivery placenta Check cord & placenta Give oxytocin after delivery of placenta
Stage 4
Uterine relaxation
Retained placental fragments
Cervical or vaginal lacerations
Monitor pulse, BP, uterine blood loss
Breastfeeding: Colostrum
Minerals, protein, & IgG antibodies
less fat & sugar
Breastfeeding: Milk Production
Adequate insulin, cortisol, & thyroid hormone
Adequate nutrients & fluids in mother’s diet
Breastfeeding: Nipple Care
Wash with water
Expose to air for 15-20 minutes
after feeding
Lanolin or A&D ointment
Induction of Labor
When benefits of induction outweigh those of continuing the pregnancy
Cervical Ripening for Induction of Labor
Misoprostol
Prostaglandin E2
Laminaria: mechanical dilation
What medication stimulates uterine contractions?
Pitocin
Involution of the Uterus occurs by what week post partum?
6 weeks
Define Lochia
Discharge from the uterus after birth as the diced differentiates into a superficial layer which sloughs off
Lochia PostPartum
Heavy at first
Rapid decreases in first 2-3 days
May last for several weeks
Breastfeeding: may occur more rapidly
How long does it take the vulvar & vaginal tissue return to normal?
First several days
General Rule for the Vagina
Nothing in the vagina for 4 weeks
Ovarian Function PostPartum
Non-lactating woman: ovulate ~45 days
Lactating: 189 days
