Prenatal Care/Normal Pregnancy Flashcards
1
Q
APGAR score
A
2
Q
fetal position
A
- the orientation of the fetus in the womb, identified by the location of the presenting part of the fetus relative to the pelvis of the mother
- LOA (vertex position): occiput against the buttocks, facing anteriorly, toward the left (most common position and lie)
- ROA: occiput faces anteriorly and toward R
- LOP: posteriorly, toward L
- ROP: posteriorly, toward R
- LOT: occiput faces L
- ROT: occiput faces R
3
Q
Multiple Gestation
A
- Etiology: routine US screeing, then again at 18-20wks
- Sxs: earlier and more severe pressure in pelvis, nausea, backache, varicosities, constipation, hemorrhoids, abd distention, and difficulty breathing
- uterus larger than expected (>4cm for dates), excessive maternal weight gain, polyhydramnios
- Dx: MSAFP elevated, US (outline or ballottement of more than 1 fetus, multiplicity of small parts, fetal heart tones (recording of different fetal rates simultaneously, varying by 8 bpm), Hgb/Hct and RBC reduced compared to blood volume, tidal volume increased
- Tx: increase iron and Ca supplement, high protein, more weight gain, tocolytics to suppress PTL and extend gestation 48h so effects of steroids realixed, admit first sign of labor or PTL
- Complications: morbid course of pregnancy, maternal anemia, UTI, preeclampsia, eclampsia, hemorrhage, uterine atony, higher rates of GDM and hypoglycemia, operative intervention more likely
4
Q
First stage of labor
A
- Latent Phase: begins when mom feels reg contractions, ends with 3-5cm dilation
- Active Phase: begins with CERVICAL dilation of 3-5cm
- at 9cm - very active/fast - monitor and augment with oxytocin
- ends with complete dilation (10cm)
- Protraction - not changing at rate we expect (nulliparous = <2cm/h dilation or <1cm/h descent) (multiparous = <1.5cm/h dilation or <2cm/h descent)
- arrest of dilation = no cervical change over 2h
- arrest of descent = no fetal descent over 1h
- Management: Oxytocin unless large baby, monitor fetus q2-4h
5
Q
Second Stage of labor
A
- interval between full cervical dilation and delivery of the infant
- measured by descent, flexion, and rotation of presenting part
- median duration = 30min - 3hr, highly variable (epidural = 1 additional hr)
- begin pushing (dorsal lithotomy)
6
Q
Fourth stage of labor
A
- postpartum hemorrhage most likely to occur
- check maternal BP and pulse immediately after delivery and q15m during this time
7
Q
Mechanism of delivery
A
- in the vertex position, includes engagement, flexion, descent, internal rotation, extension, external rotation, and expulsion
- engagement: head enters superior strait in occiput transverse position
- flexion: good flexion noted in most cases, aids engagement and descent
- descent: depends on pelvic architecture and cephalopelvic relationships. descent is usually slowly progressive
- internal rotation: during descent, head rotates so that sagittal suture occupies the anteroposterior diameter of the pelvis
- extension: follows distention of perineum by vertex, head stems beneath symphysis, extension is complete with delivery of the head
- crowning: when largest diameter of fetal head is encircled by vulvar ring
- external rotation: after delivery, head rotates to position it originally occupied at engagement. Next, shoulders rotate anteroposteriorly for delivery. Then, head swings back to its position at birth
8
Q
changes and monitoring during
A
- 6-12 gestational weeks: Uterine size and growth determined by pelvic examination, fetal heart tones 10-12 wks, UA, randome glucose, CBC, tests for: syphylis, rubella, varicella immunity, blood group, Rh, anti-Rho, HBsAg, HIV
- GC and Chlamydia test and pap, test for sickle cell in black women
- fetal aneuploidy testing for all women before 20wks
- high risk for aneuploidy: noninvasive testing with cell-free fetal DNA from moms blood (screens for trisomy 13, 18, 21)
- CVS can be performed 11-13wk
- 12 wks: uterus palpable above pubic symphysis, fetus begins to move
- 14 wks: GENDER
- 16 wks: eye mvmnts, quad screen and amnio
- 20 wks: midpnt of preg
- 24 wks: lungs almost fully developed, US exam, pt instructed about signs/sxs PROM
- 28 wks: GLUCOSE TOLERANCE TEST, CBC, syphilis and HIV, fetal position, kick counts
- 36 wks: repeat syphilis and HIV tests, culture for gonorrhea/Chlamydia
- 35-37 wks: prenatal culture - screen for GBS
- 41 wks: cervical exam for prob of successful induction of labor, induction undertaken if cervix favorable
9
Q
Induction and Augmentation of labor
A
- induction: process of initiating labor by artificial means
- Bishop method: pelvic scoring
- common indications for induction:
- maternal: preeclampsia, DM, heart dz
- fetal: prolonged preg, Rh incompatibility, chorioamnionitis, PROM, placental insuff., suspected IUGR, fetal abnl
- augmentation: artificial stimulation of labor that has begun naturally
10
Q
maternal physiology during pregnancy: things that increase
A
- Increase: blood volume, iron utilization, leukocytosis (last trim.), thrombocytosis (clotting factors), plasma volume (increased red cell mass), estrogen production (by placenta) - RAAS, increased aldo, increased Na reabs. and H2O retent., PRL, progesterone (dec. GI mot.)
- CO, SV, HR, venous pressure in lower extrem, renal blood flow,
- TV, insp capacity, minute vent.
- Gastrin
- hyperpig (linea nigra, melasma), spider angiomas, palmar erythema, cutis marmorata, hemorrhoids, thickening of hair
11
Q
maternal physiology during pregnancy: things that decrease
A
- systemic arterial pressure (nadir 24-28wks), periph vascular resistance, blood viscosity, exp reserve and residual volume, esophageal peristalsis, emptying of gallbladder
12
Q
other physiologic changes during pregnancy
A
- respiratory alkalosis: compensated with metabolic acidosis
- chadwick sign: vaginal mucosa appears dark bluish red and congested
- hegar sign: 6-8 wks of menstrual age, firm cervix contrasts with softer fundus and compressible interposed softened isthmus
- increased pigmentation, abdominal striae
- syncytiotrophoblast produces hCG that increases exponentially during first trimester following implantation (doubling time of hCG = 1.4 - 2 days)
- hCG reaches peak levels 60-70d and then decreases - plateau reached at 16wks
- intradecidual sign: anechoic center surrounded by single echogenic rim
- double decidual sign: two concentric echogenic rings surrounded by gestational sac
- visualization of yolk sac
- CRL is predictive of gest. age until 12wks
- quickening: 18-20wks
13
Q
Third stage of labor
A
- period between delivery of the infant and delivery of the placenta
- do not exert excess traction on umbilical cord (may cause uterine inversion) - can cause maternal mortality
- retained placenta: does not deliver >30 min after delivery, still bleeding
- Placenta accreta - placenta growts through the uterus d/t absence of decidua
- RF = prior C-section, hx retained placenta, preterm delivery, age 35+, parity >5, labor induction (extended)
- place sterile gloved hand into uterine cavity and manually remove placenta from uterus within 30min, DO NOT SEDATE
14
Q
intrauterine pregnancy signs/sxs, dx, tx
A
- signs/sxs: breast enlargement/engorgement and colostrum, vaginal cyanosis, cervical softening (7wks), enlargement and softening of corpus (>8wk), abdominal enlargement (16wk), palpable uterine fundus above pubic symphysis (12-15wk), FHT (10-12wk)
- the following are NOT diagnostic: amenorrhea, N/V, breast tenderness, urinary frequency/urgency, “quickening”, weight gain
- dx: UPT, B-hCG double q48h, peak at 50-70d, fall in 2-3 timesters, progesterone remains stable during first trimester (best indicator of viable preg >25ng/mL)
- tx: prenatal vits or folic acid (0.4-0.8mg unless prior kid with NTD then 4mg 1 mo prior to conception)
15
Q
hyperemesis gravidarum
A
- unexplained intractable N/V/retching beginning in first trimester, peaks during 8-12wk
- MC in young mothers and pts w/ hx of motion sickness, migraines, N/V associated with OCPs
- signs/sxs: severe intractable N/V during preg, weight loss >5%, starts during 3-5wk
- dehydration, ptyalism
- complications: wernicke encephalopathy, ATN, central pontine myelinolysis, Mallory-Weiss tear, pneumomediastinum, splenic avulsion
- dx: hypokalemia, alkalosis, UA: ketonuria, TFTs: elevated T3, elevated LFTs, bili, amylase, lipase
- tx: supportive (hydration, vit supp, acupuncture, hypnotherapy, avoid triggers, herbal teas, vitB, ginger), >50% resolve by 16wk, 80% by 20wk
