prep for quiz 1 Flashcards
Guiding principles of Family-Centered Maternity and Newborn Care
- birth is a normal, healthy process
- every pregnancy and birth experience is unique
- maximize probability of a healthy woman giving birth to a healthy baby
- based on research evidence
- family-focused, culturally sensitive
- relationship between woman, family, and caregivers is one of mutual trust/respect
- language is important - avoid language like must, allowed, or permission (these are limiting phrases)
When does obstetrical care start?
ideally, when a women reaches child bearing age
hopefully before conception (about 3 months)
often when a women finds out she is pregnant
preconception phase
- before conception
- women of child bearing age (15-40+)
- preconception care ideally includes counselling for the couple
what percentage of pregnancies are unplanned?
50-75%
preconception care
- an opportunity to positively impact health of women and decrease risk factors impacting future pregnancy and fetus
- optimizing weight and nutrition, exercise
- decreasing modifiable risk factors like smoking, alcohol/drug use
- oral health (risk of preterm or small infant increases with peridontal disease)
- immunizations
- screening for communicable diseases/STIs
- controlling medical conditions
- genetic counselling
- spacing of childbearing and family planning
- screening for social risk factors, reducing stress, optimizing mental health
- folic acid and multivitamin with iron
ideally, how long should a woman wait between pregnancies?
1 year (which means 2 years between deliveries)
how long after discontinuing birth control should a woman wait before getting pregnant?
~ 3 months
how much folic acid should a woman intake daily during pregnancy?
0.4mg (400mcg) of folate daily
if pregnancy is high risk, may be advised to take up to 5mg daily
How much iron should a woman intake daily during pregnancy?
16-20mg of iron daily
How many more calories does a woman require daily during pregnancy?
200-300 calories
serious discomforts during pregnancy which warrant contacting health professional
- dizziness
- bleeding
- edema (some in legs not necessarily serious, but when all over, serious)
- abdominal pain
- severe headache
- severe nausea and vomiting
- UTI
- decreased fetal movement
- sudden gush of fluid
what are presumptive signs of pregnancy?
- they are SUBJECTIVE changes reported by a woman
- least reliable
- missed period (amenorrhea)
- hyperpigmentation of skin
- nausea
- weight gain
- breast enlargement/tenderness
- fatigue
- urinary frequency
- fetal movement felt by woman
what are probable signs of pregnancy?
- objective findings documented by an examiner
- strong indicator of pregnancy
- abdominal enlargement
- cervical changes (colour, softening)
- examiner feeling Braxton Hicks
- pregnancy test
- Hegar’s sign
- Chadwick’s sign
- Goodell’s sign
- Ballottement
What are positive signs of pregnancy?
- caused ONLY by pregnancy
- auscultation of the fetal heart rate using a Doppler
- palpation of fetal movement by a trained practitioner
- ultrasound
What is Hegar’s sign?
softening and compressibility of the lower uterine segment resulting in exaggerated uterine anteflexion during early months
- adds to urinary frequency
- occurs at 6-12 weeks
what is Chadwick’s sign?
- bluish colouration of cervix, vagina and labia as result of increased bloodflow
- occurs at 6-8 weeks
what is ballottement?
when examiner pushes against the cervix during an examination and feels rebound from the floating fetus
What is Goodell’s sign?
- softening of vaginal portion of cervix due to increased vasculation
- occurs at 5 weeks
What is Naegele’s rule?
- estimates expected date of confinement
- take 1st day of last menstral period
- add 1 year
- subtract 3 months
- add 7 days
When taking obstetrical history, what does G stand for?
Gravida
-the number of pregnancies (no matter how long)
When taking obstetrical history, what does P stand for?
1st P is para
-the number of pregnancies of viable age (>20weeks)
2nd P is preterm
-number of preterm births >20 weeks and <37 weeks
When taking obstetrical history, what does T stand for?
Term
-number of term births (>37 weeks)
When taking obstetrical history, what does A stand for?
Abortus
- number of births <20 weeks
- induced or spontaneous abortion
When taking obstetrical history, what does L stand for?
Living
- number of living children
- **this is confusing as it doesn’t only refer to live births so if a child passes later in life, still would decrease number of L - not really obstetrical hx in some ways
When taking obstetrical history, how are twins or multiples accounted for?
count as a single pregnancy, but as 2 infants!
G or P is a single pregnancy while T/P/A/L for each infant
What does primipara, primigravida, primip or nullip refer to?
a woman who is pregnant but has never given birth
what does multigravida, multipara or multip mean refer to?
when a woman has had multiple pregnancies and deliveries (at least one)
What is the most accurate way to estimate expected date of confinement?
an early ultrasound - generally befor 12 weeks
How many trimesters are there?
3
What is the duration of the 1st trimester?
0-13 weeks
what is the duration (week number to week number) of the 2nd trimester?
14-27 weeks
what is the duration week # to week #) of the 3rd trimester?
28-40 weeks (+/- 2 weeks)
how long is the post-partum period?
6 weeks
how long is the preconception period?
12 weeks
how long after delivery do hormones return to normal?
6 weeks
though in breastfeeding women may still be altered
What are the cardiovascular changes that accompany pregnancy?
- blood volume increases 1500mL
- cardiac output increases 40-50%
- peripheral vasodilation occurs to maintain normal blood pressure
- physiological anemia may occur as RBC increase but hemoglobin does not always rise as well
- increase in clotting factors and fibrinogen (hypercoagulable state increases risk for thrombus formation)
- supine hypotension
what is supine hypotension syndrome?
also called aortic cable syndrome
- occurs when inferior vena cava is compressed by weight of fetus keeping blood from returning to heart
- the decrease in venous return can cause bradycardia
- symptoms mimic hypovolemic shock
- reduced blood flow to placenta causes fetal hypoxia and distress as well as bradycardia
what kind of lying position should be avoided by pregnant women and why?
supine position should be avoided because of supine hypotension syndrome which affects 10% of pregnancies
-compression of the inferior vena cava reduces blood flow to placenta and fetus
what is the optimal lying position during pregnancy and why?
left lateral is optimal as it optimizes blood flow to placenta, fetus and kindeys
What are respiratory changes that occur during pregnancy?
- increased oxygen consumption (15-20%)
- increased tidal volume
- minimal change to respiratory rate
- displacement of diaphragm as pregnancy progressing leading thoracic breathing and mild shortness of breath
How does the uterus change during pregnancy?
- enlarges to hold a volume of 15-20 litres
- around 12 weeks rises out of pelvis
- wall thin, but strengthened with fibrous tissue
- 20-25% of CO goes to uterous
how does the cervix change during pregnancy?
- softens and becomes bluish in colour
- mucus plug forms to protect the fetus
what changes occur in the ovaries during pregnancy?
- normal function ceases (no eggs released)
- corpus luteum secretes progesterone
- placenta produces progesterone by 6-7th week and corpus luteum regresses
what changes occur in breasts during pregnancy?
- enlarge and become tender
- areola darkens
- tubercles of Montgomery enlarge and secrete a substance to maintain areolar suppleness
- colostrum may leak from nipples
what hematological changes occur in pregnancy?
- blood volume increases by 40-50%
- plasma volume increases by 1200-1600mL
- RBCs increase by 450mL (25-33%)
- Physiologic anemia results as hemoglobin concentration drops up to 2mg/dL
- iron deficiency anemia considered when hemoglobin drops to 10.5mg/Dl or less
- increase in clotting factors
What GI changes occur during pregnancy?
- increased hCG causes altered carbohydrate metabolism
- changes in taste/smell
- progesterone causes decreased muscle tone in smooth muscles (like intestines and uterus) decreasing peristalsis and delaying stomach emptying
- morning sickness may occur
what changes to musculoskeletal system occur during pregnancy?
- increase in abdominal size and decrease in muscle tone
- exaggerated lumbosacral cure
- compression of lumbar nerve roots may cause low back pain
- increased mobility of pelvic joints
- stretching of rectus abdominis
- muscle cramps
what is diastasis recti?
when abdominal muscles separate, which can be caused by pregnancy
what examination technique is used before auscultation of the fetal heart rate?
Leopold’s maneuvers
-allows location of baby to be identified
what does the 1st leopold’s maneuver identify?
the part of the fetus in the upper-pole of the fundus (place hand at top of fundus)
what does the 2nd leopold’s maneuver identify?
to location of the fetal back and extremities (place one hand on side of women’s abdomen, and stabilized, then use other to palpate on opposite side - the switch - trying to identify where back and extremities are)
what does the 3rd leopold’s maneuver identify?
the presenting part in the pelvis and engagement (use hand just above pelvic bone to palpate - trying to identify what is presenting)
what does the 4th leopold’s maneuver identify
the attitude or degree of flexion of the presenting part
why are ultrasounds routinely recommended?
- they confirm pregnancy and EDC
- can identify the number of fetuses
- show size for gestational age
- show how fetus’s internal organs are developing
- show placental position and size
- allow inspection of ovaries, uterus, and fallopian tubes
- check for signs of possible genetic problems
What is a biophysical profile?
- an examination done via ultrasound that examines: fetal movement, respirations, heart rate, muscle tone, movement, and the amount of fluid around the baby
- basically gives insight into fetal well-being and if baby is better off inside or outside of the uterus
what is prenatal serum screening?
-blood test women can take to determine the risk of carrying an infant with trisomy (down syndrome, edwards syndrome) or an open neural tube defect
What is nuchal translucency?
- a collection of fluid under the skin at the back of a fetus’ neck
- can be checked by ultrasound during 11-14 weeks by measuring thickness of nuchal translucency combined with maternal age risk of chromosomal abnormality can be calculated
Why and when is amniocentesis used for testing
- in 2nd trimester to test genetics around 15-16 weeks
- in 3rd trimester around 35 weeks to measure fetal maturity by testing lecithin/sphingomyelin ratio and phosphatidylglycerol (present if baby is close to term)
what are the risks of amniocentesis?
-it is an invasive procedure that can cause pre-term labour and infection
what is the L/S ratio?
- lecithin/sphingomyelin ratio
- these are 2 components of surficant which line alveoli of lungs and reduce surface tension when infant exhales
- should be in 2:1 ratio around 35 weeks and indicate baby is close to term
what is PG?
- phosphatidylglycerol
- appears around 35 weeks
- can be measured by amniocentesis and indicates baby is close to term
what is GBS screening for?
for group B streptococcus
- done in 3rd trimester between 35-37 weeks
- it is a common bacteria found in vagina, rectum, or urinary bladder of 15-40% of women
what is GBS disease?
- caused by fetus being exposed to group b streptococcus
- can cause respiratory issues
- later on can cause meningitis-type symptoms
what are the risks for GBS infection in baby?
- preterm labour before 37 weeks gestation
- term rupture of membranes greater than 18 hours
- unexplained, mild fever during labour
- previous baby with GBS infection
- previous or present GBS bacteriuria
what is fetal fibronectin?
- glycoprotein released in response to inflammation or separation of amniotic membranes
- found in cervico-vagina secretions untill 22 weeks gestations and then again near time of labour
what is fetal fibronectin test used for?
- a negative result after 22 weeks indicates pregnancy is 98% likely to continue for another 2 week
- positive test between 24 and 34 weeks indicates increased risk of preterm delivery
what is a simple way to assess fetal well-being?
fetal movement
what are the 6 Ps?
passage passenger powers position psychology people
what is meant by the p - passage?
it is the ability of the pelvis and cervix to accommodate passage of fetus
what shapes of pelvis are optimal for vaginal delivery?
gynecoid and anthropod
what are the four classic pelvis shapes?
- gynecoid
- android
- anthropod
- platypelloid
what is meant by the p - passenger
the fetus, membrane and placenta are all “passengers”
what is moulding?
when the cranial bones overlap under pressure of the powers of labour and demands of unyielding pelvis
what are the fontanels?
the soft spots on an infants head
there is an anterior and posterior fontanel
what is meant by the p - position
-the position of the fetus and the maternal position(s)
what are the attributes that make up fetal position?
Lie Attitude Presentation Position Station Engagement
what does lie refer to when discussing fetal position?
- the relationship of the fetal cephalocaudal axis (spine) to maternal cephalocaudal axis
- longitudinal means the spines line up, transverse means right to left lie, oblique is angled
what is the optimal fetal lie for delivery?
longitudinal
what does attitude refer to when discussing fetal position?
- the relationship of fetal parts to one another
- includes degree of flexion of the head (can be extended, brow, or flexed)
what does presentation refer to when discussing fetal position?
- is a combination of lie, attitude, and what body part enters passage first
- can be cephalic, breech, shoulder, or compound
what types of cephalic presentations are there?
- vertex, brow, face, chin
- cephalic is head down
what kinds of breech presentations are there?
- breech is buttocks down
- complete (bum down)
- frank (bum down but legs straight up with feet by face)
- incomplete - footling, meaning a foot or both feet down first
what is position related to fetal position discussing?
-the position of the fetus relative to the pelvis
-refers to direction facing
R - right
L - left
O - occiput
S - sacral (bum)
M - mentum (face first)
A - anterior
P - posterior
T- Traverse
what is meant when discussion station?
- it is the relationship of the presenting part of the fetus to the imaginary line drawn between ischial spines of maternal pelvis
- 0 is engaged
- positive mens baby is further through pelvis
what is meant by engagement?
the largest portion of the presenting part reaches the pelvic inlet
what is meant by the P - powers?
- the powers that lead to delivery
- primary power is uterine muscular contractions
- secondary power is abdominal muscles pushing during second stage of labour
How are contractions assessed?
frequency (interval) duration (length) intensity (strength) resting tone (the breaks - should be 20mmHg)
how is frequency of a contraction measured?
from the onset of one to the onset of the next contraction
how is the duration of a contraction measured?
from start to end of one contraction
how can intensity of a contraction be assessed?
- by palpation
- by interuterine pressure catheter
(Contraction can be assessed with to competed, but not intensity)
what does progesterone cause?
-relaxation of smooth muscle
what does estrogen cause?
-stimulation of uterine muscle contraction
what do prostaglandins cause?
-cervical ripening and dilation
what is meant by the p - psychosocial
-psychosocial considerations like understanding/prep for childbirth, history, experiences, present emotional status, beliefs, values, age, general wellness
what is meant by the p - people?
-the support people, the healthcare providers, the type of support
what are premonitory signs of labour?
- lightening
- braxton hicks contractions
- increase in vaginal mucus
- cervical ripening
- bloody show
- rupture of membrane
- sudden burst of energy/nesting
- diarrhea, indigestion, nausea, vomiting
what is meant by lightening?
-the fetus descends into the pelvic inlet
what are the stages of labour?
there are four: 1st- zero to 10cm dilation 2nd- from full dilation to delivery 3rd- delivery of placenta 4th- recovery and stabilization
what are the phases in the first stage of labour?
phase 1: early or latent (0-3cm dilation)
phase 2: active phase (4-7cm dilation)
phase 3: transition (8-10cm)
what happens in the early or latent phase of labour?
dilation from 0-3cm
- regular, mild contractions start and increase in intensity (5-10min apart)
- cervical effacement and dilation begins
what happens in the active phase of labour?
- cervix dilates from 4-7cm
- contractions increase in intensity, duration, and frequency (2-3 min apart)
- fetus begins to descend into pelvis
what happens in the transition phase of labour?
- cervix dilates from 8-10cm
- contractions increase in intensity, duration, and frequency (1.5-2min apart)
- cervix thins and stretches
- fetus descends rapidly into birth passage
- may experience rectal pressure
- nausea and vomiting
- diaphoresis
- increased bloody show
what is a uterotonic and when is it given?
- causes uterus to contract
- given after shoulder is delivered to prevent post-partum hemmorhage
What kind of standard questions should be asked when a woman arrives on a delivery unit?
- when are you due?
- any contractions?
- any rupture of membranes or bleeding
- allergies
- what pregnancy is this for you?
- is the baby active
- any complications in pregnancy?
- anything else to know?
when a woman arrives in active labour to the labour unit, when should fetal assessment be done?
before admission is done - can usually be done simply with a doppler
what should be assessed during the baseline assessment after admission of a labouring woman?
- FHR
- BP
- temp, RR, pulse
- contractions
- cervix
- membranes
- any anomalies
- assess urine
- LMP and EDC
how can contractions be assess electronically?
- tocometer
- intrauterine pressure catheter
what is dilation?
-opening of the cervix
what is effacement?
the thinning of the cervix
-may occur before labour in primi or multinip or during labour in multi
when assessing rupturing of membranes, what possible findings are there?
intact ruptured (ROM) -spontaneous -artificial -premature -preterm premature
what should be assessed with amniotic membranes?
if it is ruptured or not fluid FHR check for cord prolapse infection
what should be assessed about amniotic fluid?
time (want to know the 18-24 window after rupture)
amount (normally between 800-1000mL at term)
colour - normally clear. Green may indicate meconium. Fresh bright red blood is NOT normal but some streaks or brownish/pinkish is normal
Odor - distinct earthy smell
what is meant by “ferning positive”
when a sample of cervical mucus is examined under a microscope a ferning shape/image is evidence of amniotic fluid
what is a nitrazine swab?
checks for amniotic fluid
yellow is negative
blue is positive
what are the two major methods of fetal heart monitoring?
intermittent auscultation
electronic fetal monitoring
what is a normal fetal heart rate?
110-160
are accelerations of FHR normal?
yes
are decelerations of FHR normal?
no. if noted, monitor should be put on for further examination
how often should a fetal heart rate be taken during the first stage of labour?
Q15min if things are normal
how often should fetal heart rate be taken during the second stage of labour?
Q5min during pushing
how can the fetal heart rate be assessed for accelerations/decelerations?
take FHR for 1 minute in 15 second intervals. compare the intervals
what is happening when early decelerations occur?
early decelerations are associated with uterine contractions and are caused by head compression
-these aren’t abnormal and dont usually require an intervention
what is happening when variable decelerations occur?
usually caused by cord compression
- visually apparent, abrupt
- not associated with a contraction
- drops more than 15 below baseline, generally more than 15 seconds
what is happening when prolonged decelerations occur?
- indicate a profound change in fetal environment
- more than 2 but less than 10 minutes
what is happening when late decelerations occur?
-uteroplacental insufficiency
-gradual drop in fetal HR
OMINUS & always atypical
-associated with a contraction, but happening after. It shows fetus isn’t mounting good response to contractions
What may affect fetal heart rate in short term?
Sleeping
20min or less
What are ideal position of fetus to deliver?
LOA or ROA
when does the anterior fontanelle typically close?
18 months
when does the posterior fontanelle typically close?
2-3 months
When an abnormal fetal heart rate is seen on a monitoring strip, what should the nurse do?
Maternal repositioning (repeated) Decrease or discontinue oxytocin Correct hypotension, if present Oxygen Administer IV fluids as needed Nitroglycerine if uterine hyperstimulation and bradycardia(Sublingual. Relaxes smooth muscle – uterus and cardia are smooth) Vaginal exam – assess progress and rule out prolapse Support/explain Notify document
what are normal newborn vital signs?
temperature: 36.5-37.5
HR 110-160
RR 30-60
BP 50-75/30-46
what are symptoms of neonatal respiratory distress?
- tachypnea
- apnea
- cyanosis
- grunting/cooing
- nasal flaring
- retractions or indrawing
- poor feeding
- accessory muscle use
what is the first breath of a newborn triggered by?
- it is an inspiratory gasp
- triggered by pressure changes and increased PCO2, decrease in pH and PO2
