prenatal care/normal pregnancy Flashcards
At what intervals do they perform a APGAR score?
at 1 and 5 minutes
What are the criteria in the APGAR score?
- Activity= 2 if moving
- Pulse = 2 if greater 100
- Grimace = 2 if pulls away/ sneeze
- Appearance = 2 if pink
- Respiration = 2 if crying
A score of _____ is good and a score of _______ requires resuscitation
- 6
2. 4
Macrosomia is what and associated with greater risk of what?
this is when the birth weight is greater than 90th percentile for gestational age/>4500g)
It is associated with shoulder dystocia
What does fetal attitude relate to to like what does it describe?
it is the relationship of fetal parts to one another
which is normal fully flexed or not flexed?
fully flexed
The relationship of fetal cephalocaudal axis (spinal column) to maternal cephalocaudal axis is called what?
The fetal lie
Out of longitudinal lie vs transverse lie vs oblique lie which are ideal and which aren’t
Longitudinal lie the others are non-ideal
What fetal presentation do you want for when giving birth?
Cephalic
What are the different types of breech presentations?
- Frank breech
- Complete breech
- Incomplete breech
- Shoulder breech
Describe the different kinds of breech?
- Frank- Hips flexed, knees extended, bottom presents
- Complete- hips and knee flexed, bottom presents
- Incomplete- one/both hips not completely flexed, feet present
- Shoulder- Transverse lie, shoulders present first
Does the prevalence of a breech increase or decrease with increasing gestational age?
decreases
How do you Dx breech presentation?
physical examination, with ultrasound confirmation, if the diagnosis is uncertain
How to tx a breech presentation?
External cephalic version
a 24-year-old G2P1 comes for her 13-week office visit she has a fundal height and an alpha-fetoprotein which are greater than expected for her due date. What is going on with this young gal?
Multiple gestations
How common is it to have twins?
in the US it is 1 out of every 80 births
What are the terms used to describe multiple births or the genetic relationships of their offspring.
Monozygotic (Identical) – multiple (typically two) fetuses produced by the splitting of a single zygote
Dizygotic (Fraternal) – multiple (typically two) fetuses produced by two zygotes
Polyzygotic – multiple fetuses produced by two or more zygotes
What are some clues that will make you think someone is having multiple children at one time?
- fundal height is usually greater than dates
- Extra fetal Heart tones
- Elevated maternal alpha-fetoprotein
Should prenatal visits happen more or less often with multiple gestations?
more often
what is the most common complication of multiple gestations?
spontaneous abortion and preterm birth
what are some other complications that occur at greter frequency with multiple gestations than regular ones?
preeclampsia and anemia
What are the three stages of labor?
- Uterine contractions
- Cervical changes
- Delivery of baby, placenta
Signs of false labor?
aka Braxton-Hicks contractions
irregular, intermittent contractions, no cervical changes, pain in abdomen, walking may decrease pain
Describe true labor?
Regular, increase in frequency, duration, intensity.
Produce cervical changes
Pain begins in lower back and radiates to abdomen and not relieved by walking
First stage of labor is last until the cervix is dilated to what size?
Till it is dilated to 10cm aka fully dilated
The first stage of labor is broken down into 3 more stages what are they?
- Early/latent
- Active
- Transition
Describe the early/latent phase of the first stage of labor?
- Last 8-12 hours
- Mild contractions 5-30 minutes
- Duration of contraction 30 seconds each
- Cervical dilation of 0-3cm
- Spontaneous ROM
Describe the active phase of first stage of labor?
- Last 3-5 hours
- Contractions every 3-5 minutes
- Duration of contractions are >/= to 1 minute
- Cervical dilation 3-7cm
- Effacement 80%
- Progressive fetal descent
Describe the transition Phase of the first stage of labor?
- Lasts 30minutes to 2 hours
- intense contractions every 1.5-2 minutes
- contractions last 60-90 seconds
- Cervical dilation 7-10cm
- Effacement 100%
So at what point does the second stage of labor begin?
When the cervix is dilated 10cm
Navigation of the child through the cervical canal is determined by what?
The three Ps
What are the three Ps of birth?
- Power
- Passenger
- Pelvis/passage
What are the different size/type of pelvises?
- Gynecoid- rounded pelvic inlet, midpelvis, outlet capacity adequate, this is optimal for vaginal delivery.
- Android- heart-shaped pelvic inlet; ↓midpelvis diameters, outlet capacity; associated with labor dystocia
- Anthropoid- oval shaped- favorable for vaginal delivery
- Platypelloid- oval shaped, decreased midpelvis diameters. Not favorable for vaginal delivery
What is the normal heart rate in a newborn?
120-160 beats per minute
Consistent decelerations after a contraction can indicate what?
fetal distress
When you perform internal fetal monitoring where is the electrode attached?
the infants head
What can variable decelerations be an indication for?
Cord compression, they can be considered benign if mild or moderate but if severe its worrisome
What is variable decelerations?
Rapid FHR drop with return to baseline
Describe early decelerations?
Mirror images of contractions- meaning the fetal head is compressed and is benign
A fetal acceleration is described as what?
increase of baseline 15 bpm for 15 seconds, this is a response to feta movement and is reassuring
What kind of fetal heart rate changes is always considered worrisome?
Late decelerations
What is a late deceleration?
FHR drop at the end of the contraction which implies uteroplacental insufficiency
How much larger does the uterus become in pregnancy?
20 times
What is the hegars sign?
Softening of uterine isthmus
What volume capacity does the uterus increase to during pregnancy?
10ml-5L
The cervix during pregnancy forms what to seal the endocervical canal?
Mucus plug
What color does the cervix turn?
Purplish blue because of increased vascularity
What is the Goodells sign?
Mild softening due to edema, hyperplasia
what hormones does the placenta release?
Estrogen, progesterone, relaxin, hcg
true or false; the placenta covers 50% of the uterine surface?
True
What is the function of the placenta ?
maternal-fetal organ for metabolic, nutrient exchange
What PH does the vagina become during pregnancy?
PH of 3.5-6 to protect agains bacterial infections
What are some changes that occur with the breasts during pregnancy?
- ↑ size, weight, nodularity, blood flow, vascular prominence
- Areola, nipples are a darker pigmentation due to ↑ melanocyte activity
- ↑ activity of Montgomery’s tubercles (sebaceous glands)
- Progesterone ↑ alveolar-lobular development; prevents milk production during pregnancy (inhibits prolactin)
- Estrogen ↑ growth of lactiferous ducts
- Secretion of colostrum begins week 16
How is the heart displaced during pregnancy?
displaced upward, forward slightly to left
Would you expect someone heart to increase or decrease during pregnancy? how much do you expect it to increase or decrease?
it should increase by about 15-20 beats/minute
Why does blood pressure decrease despite increased CO
this is because of progesterone induced vasodilation
By what percent do you expect stroke volume to increase to?
30%
Gravid uterus elevates pressure veins draining legs and pelvic organs. What can you anticipate happening because of this?
Varicose veins, hemorrhoids, dependent edema.
How much more blood volume do you get when pregnant?
1500ml
Why does your blood volume go up during pregnancy?
Related to sodium, water retention due to changes in osmoregulation, secretion of vasopressin by anterior pituitary, renin-angiotensin-aldosterone system (RAAS)
What effect does pregnancy have on blood?
increased RBC
Increased WBC
increased Clotting factors (fibrin, fibrinogen)
Plasma becomes greater than RBC volume causing hemodilation decreasing hematocrit (physiological anemia)
Pregnancy effect on urine?
↑ glomerular filtration rate (GFR)
40–50% by second trimester; ↑ urinary output (25%)
↑ size of kidneys (1–1.5 cm)
Dilation of urinary collecting system →physiologic hydronephrosis
Urinalysis
Glycosuria (due to ↑ glucose load), ↑ protein excretion (due to altered proximal tubule function + ↑ GFR)
What PE findings can you see on the skin during pregnancy?
Estrogen-induced vascular permeability →spider nevi, angiomas, palmar erythema
What does pregnancy do to the pituitary gland?
increase size of pituitary gland; mostly due to proliferation of lactotroph cells
Would you expect an increase or decrease with the parathyroid gland during pregnancy?
an increase to meet the calcium needs of developing fetal skeleton
What does pregnancy do to the adrenal gland?
physiological hypercortisolism
Describe physiological hypercortisolism
increase need for estrogen, cortisol which then increase glucocorticoids from adrenal gland, supports fetal somatic, reproductive growth
Does the thyroid stimulating hormone increase or decrease during pregnancy?
decrease
Does thyroid gland increase or decrease and what effect does that have?
It increases which causes an increase in total T3 and T4
where does progesterone come from during during first and second trimester of pregnancy? How bout during late second and third trimester?
- Corpus Luteum
2. Placenta
what is the recommended calorie increase for a pregnant woman?
300kcal/day with a total weight gain of 25-35 pounds
What is the breakdown of extra weight during pregnancy?
11 lb. (5 kg): placenta, amniotic fluid, fetus 2 lb. (0.9 kg): uterus 4 lb. (1.8 kg): ↑ blood volume 3 lb. (1.4 kg): breast tissue 5–10 lb. (2.3–4.5 kg): maternal reserves
What vitamins should every pregnant person be on?
600 mcg folic acid/day → RBC synthesis, placental/fetal growth, ↓ risk of neural tube defects
What are the nutritional needs during pregnancy?
600 mcg folic acid/day → RBC synthesis, placental/fetal growth, ↓ risk of neural tube defects
1,000–1,300 mg calcium/day supports pregnancy, lactation
60g protein daily supports tissue growth
27 mg iron/day supports ↑ RBCs
What is the recommended prenatal care schedule?
Monthly visits to a healthcare professional for weeks 4–28 of pregnancy
Visits twice monthly from 28 to 36 weeks
Weekly after week 36 (delivery at week 38–40)
Should all pregnant women receive a prenatal vitamin?
yes
What other supplements must pregnant women take?
- Folic acid supplementation (0.4–0.8 mg) prior to conception; 4 mg for secondary prevention
- Calcium: 1,000–1,300 mg/day; supplement may be beneficial for women with high risk for gestational hypertension
What is the recommended dose of iron in pregnant woman?
30mg/day if anemic
pregnant women in industrialized countries should take what kind of vitamin?
vitamin A but less than 5,000 IU/day
women with limited exposure to sunlight you should consider giving what?
Vitamin D
What should be done at first prenatal visit?
a full physical exam
After first prenatal exam what should be recorded at the following visits?
Weight: Total weight gain range (lb) should be 25–35 lb, except in obese women, for whom weight gain should be <15 lb.
BP
UA
Fundal height
What does the ACOG define hypertension in a pregnant woman?
BP >140 mm Hg systolic or >90 mm Hg diastolic
When should you expect to hear a fetal heart rate
at 12 weeks
When do you want to check for fetal position?
at 36 weeks
A woman thats pregnant and 35 or older should be offered what kind of test?
genetic testing for abnormalities
What is Naegeles rule and what is it used for?
its used to calculate due date and its 1’st day of last menstrual period + 7 days – 3 months + 1 year
When should your first visit be when pregnant?
6 weeks after LMP
At each pregnancy visit they will assess what?
Fetal heart tones, blood pressure, fundal height, fetal movement and urinalysis
Ultrasound should be able to detect fetal heart activity 1-2 weeks after 1st missed cycle (around 5-6 weeks)
What does a triple screen consist of?
AFP, HCG, Estriol
What does a quad scree consist of?
AFP, HCG, Estriol Inhibin A
When can you do Chronic villus sampling?
between 10-12 weeks
When can you perform an amniocentesis?
15-18 weeks (beginning of the second trimester) – especially for women over age 35 in the high-risk group
When do you want to do a 65 g 2-hour oral glucose test?
between weeks 26-28
When do you test for Group B strep?
between weeks 35-37
The first trimester from weeks 11-14 you can due what tests?
Ultrasound for nuchal translucency
PAPP-A and hCG
Increase levels are seen in chromosomal abnormalities
Low levels of PAPP-A can be associated with Down’s Syndrome
Cell free fetal DNA can be done around what week and what trisomies does it test for?
- 10 weeks
2. 13, 18, and 21
If you have positive tests from the Cell free DNA test what should you follow it up with?
CVS or amniocentesis
What does CVS test for?
Collect placental tissue to test for chromosomal and genetic abnormalities
increase in AFP with a quad screen means what?
neural tube or abdominal wall defects
if you have an increase in hCG and inhibin but decrease in AFP and estriol with a quad screen you should think what?
down syndrome
a decrease in AFP, hCG and estriol should make you think what?
Edwards syndrome
Visits during the first trimester weeks 1-12 should happen how often?
every 4 weeks
At every visit during the first trimester you should evaluate what?
weight gain / loss BP pedal edema fundal height urine dip for glycosuria and proteinuria trace glucose is normal due to ↑ GFR trace protein is not normal and should be evaluated
How often should visits be during the second trimester (weeks 13-26)?
still once a month
At 15-18 weeks what test should you offer?
offer triple marker screen (hCG, estriol, AFP)
used to detect neural tube defects or trisomies
At 16-20 weeks what test should you offer if person is older than 35 and history indicates it?
amniocentesis
at 17 weeks what should you document?
movement
at 24 weeks what test should you do?
glucose test
What are some routine 3rd trimester tests?
- UA
2. Blood glucose
At visits between the weeks 27-end you should ask about what?
vaginal bleeding
contractions
rupture of membranes
When if indicated should you give RhoGAM?
between weeks 28-30
Between the weeks 28-32 mothers with pre-gestational diabetes should undergo what?
twice weekly non-stress testing until deliery
between the weeks 36-40 what STIs should you check for?
chlamydia and gonorrhea
