Week 3: Maternal adaptations, minor conditions during pregnancy and antenatal care. The Growing fetus & screening in pregnancy Flashcards
What are the key principles/rights for a women in a health assessment?
▪ Right to privacy & respect (of information and the setting she is in)
▪ Right to accurate explanations, informed decisions and the option of alternative treatments
▪ Right to decline (not refuse)
▪ Taking great history forms initial part of overall assessment
▪ Systematic (to ensure we don’t miss anything)
▪ Evidenced based
▪ Culturally safe
These underpin every action in midwifery
Briefly overview what a midwifes role is in antenatal care?
▪ Find out what is important to the woman
▪ Take an antenatal history and perform a physical assessment
▪ Education
▪ Health promotion
▪ Develop professional partnership with woman
▪ Assist with informed choices with evidence
based information
▪ Recognise complications & consult or refer
appropriately
▪ Document
What are the objectives for an initial or booking an appointment?
Prior to this they have only likley had a GP app
▪ Health assessment
▪ Baseline vital signs
▪ Identify risk-factors (medical/obstetric/social)
▪ Identify education needs
▪ Establishment of professional relationship
▪ Provide opportunities for questions
Why is communication so important in midwifery?
It is key in women centered care.
Birth verbal and non verbal communication can change how the women and her support people feel.
Do do this, midwifes;
▪ Language (use, non judgmental and women centred without any tone or bais)
▪ Privacy & Confidentiality
▪ Listening skills
– attentive
– non verbal responses & body language
– reflecting back key words
▪ Style
– conversational or a checklist approach
– Open-ended statements
▪ Accurate documentation & appropriate storage of notes
How can privacy be upheld?
▪ Privacy, avoid interruptions & distractions
(woman-centred care)
▪ Comfort (temp, seating, bed is at the right height)
▪ Noise levels
▪ safety- is someone near by for you and for the woman (you sit closer to the door)
▪ Equipment necessary
▪ Paperwork necessary
Explain the principles of disclosure during pregnancy care
Midwifery care is based on information sharing we as are experts in midwifery and the women is expert in her body and life.
▪ Partnership is about equality
▪ Sometimes it’s appropriate for the midwife to share
something of herself, others it is not as information
should be evidence based
▪ The midwife should not:
– hold themselves up as a role model
– impose values and cultural practices
– generalise her experiences to all women
– be judgmental
What is carried out in the initial assessment?
▪ Discuss pregnancy care options – models of care
▪ Assess comorbidities - referral
▪ Ultrasounds
▪ Previous pregnancy care – attended GP, pathology attended
▪ Identify pathology required
▪ Discuss mental health
▪ Discuss symptoms and common disorders of pregnancy
▪ Discuss other issues that may affect health and wellbeing during pregnancy
▪ e.g. smoking, alcohol, prescription and over-the-counter medicines,
nutritional supplements, domestic violence and oral health
▪ Ask about concerns
In the initial visit, what history and physical examinations should be undertaken?
Review history
▪ Health and maternity history and current wellbeing.
▪ Estimate due date (EDD)
▪ Review early ultrasound if available.
▪ Review results if screening tests have been performed
Perform examination – Full assessment including: ▪ Vital signs ▪ Body mass index (BMI) ▪ Weight ▪ Urine ▪ Psycho-social
What are the models of care? (Victoria)
A women can choose any model of care they are eligible for;
▪ Midwifery-led care (public hospital)
▪ Continuity of midwifery care program
– Team
– Caseload (allocated to 1 specific midwife and is on call when she has her baby)
– MGP (midwifery group practice)
▪ Private midwife (some do home birth, some not)
▪ Private midwife shared care
▪ Home-birth
▪ GP shared-care
▪ Obstetric-led care (public hospital)
▪ Private Obstetrician in a private hospital
What are some base line investigations that should be done early in pregnancy/at booking in?
Guides vitamin and other recommendation
▪ Blood group and antibody screen
▪ Full blood examination (FBE)
▪ Screening for haemoglobinopathies
– Hb electrophoresis, ferritin and DNA analysis (if indicated)
▪ Vitamin D screening (above 75)- sups and sunshine
▪ Diabetes testing
– All women have a random blood glucose (RBG) as a minimum
– Oral Glucose Tolerance Test (OGTT) is recommended at 26 – 28 weeks or earlier for women
with previous GDM or other risk factors (such as an elevated RBG.
▪ Screening for infections in pregnancy
– Rubella immunity
– Syphilis (TPHA)
– Hepatitis B surface antigen
– Hepatitis C antibodies
– HIV (Human Immunodeficiency Virus)
– Asymptomatic bacteruria - mid-stream urine for microscopy, culture and sensitivity
– ? Chlamydia
▪ Aneuploidy screening
▪ Early ultrasound for dating and to detect multiple pregnancies
What are some lifestyle consideration related information should be provided?
▪ Nutrition, diet, and discussion of a healthy weight gain according to initial BMI. (baby, BMI and stores intentionally put on by body is normal)
▪ Pregnancy multivitamin including folic acid and iodine supplementation.
▪ Smoking behaviour / cessation (offer contacts and information as appropriate).
▪ Low dose aspirin if moderate or high risk for pre-eclampsia and under 16 weeks gestation.
▪ Oral and dental health.
▪ Implications of recreational drug use and alcohol consumption.
▪ Vaccinations (pertussis/influenza/Covid19)
▪ Psychosocial assessment.
▪ Breastfeeding information.
What categories of information is involved in an antenatal history?
General ▪ Social ▪ Medical/surgical history ▪ Menstrual ▪ Obstetric history ▪ Family History ▪ Pregnancy progress
what general information is gathered in an antenatal history?
▪ Demographics- where r u having the baby and can u get there? ▪ Next of kin ▪ Model of care ▪ G.P. ▪ Exercise ▪ Diet ▪ Allergies
What medical information is gathered in an antenatal history?
Medical disorders – Diabetes, hypertension, asthma, epilepsy.. ▪ Operations / anesthetic complications ▪ Mental illness – Depression, anxiety ▪ Medications (GA) ▪ Gynecological – incontinence / bleeding / pap smear ▪ Allergies ▪ Blood Group
What social information is gathered in an antenatal history?
▪ Family supports / issues
▪ Special needs – young woman, illicit drug use
▪ Financial issues – unemployment, young woman
▪ Cultural background – specific needs
▪ Environmental factors – living conditions
▪ Teratogens – alcohol, smoking, illicit drugs
What family history is gathered in an antenatal history?
Those directly related to her or the baby father ▪ Previous fetal abnormalities – Down syndrome, hip dysplasia… ▪ Familial diseases on paternal side ▪ Familial diseases on maternal side
What obstetric history is gathered in an antenatal history?
Estimated date of birth ▪ Number of pregnancies (Gravidity/Gravida) ▪ Number of births (Parity/Para) ▪ Previous pregnancies - details ▪ Menstrual history ▪ Estimate date of birth ▪ Regular cycle ▪ Use of contraceptives ▪ IVF
Previous pregnancies
▪ Number of pregnancies = gravida
▪ Number of (viable) babies = para
▪ Date / gestation / place of birth
▪ Was the pregnancy normal?
▪ Was the labour spontaneous / induced / normal
▪ Interventions?
▪ Complications such as high blood pressure / bleeding /
tears / infection etc
▪ Was the baby born in good condition
▪ Baby details sex / weight / method of feeding / A&W now
▪ Miscarriages / Terminations of Pregnancy (TOP)
What does LUSC stand for?
Lower Uterine Section Caesarean Section
What does LNMP stand for?
Last Normal Menstrual Period
Para=
Para ~ number of viable births (>20 weeks)
What is a grand multi
someone who has had more than 5 babys.
What is occurred out at every antenatal app?
▪ Blood Pressure
– normal range 100/60 - 140/90mmHg
Expected to drop in early pregnancy as progesterone causes BP to drop- BP= really good way tp measure placental blood pressure. If womens BP is high their is likleyhood that placenta has high BP and therefore baby isn’t getting what it needs.
▪ FH and /or movements (once they start= they should not stop! if they arent getting enough blood they will stop extra expendature= stop moving limbs)
▪ normal FH range 110 – 160 bpm
▪ Abdominal examination
– normal growth – after 20 weeks 1cm per wk
– presentation
▪ Urine dipstick – if indicated
▪ ? Weight
▪ Assessment of emotional wellbeing
▪ Provide relevant appointment information depending on gestation
▪ Allow time for questions/discussion
What are some normal discomforts during pregnancy?
▪ Reassurance of normal physiological changes
▪ Identify and offer strategies to manage normal discomforts
associated with healthy pregnancy
Discomforts: – Nausea & vomiting – Backache – Tiredness – Leg cramps – Heartburn – Headache – Constipation – Hemorrhoids – Varicose veins – Vaginal discharge – Emotional instability
What are some key points of education for a women at the booking in app?
▪ Plans for birth – Discuss :
– when to phone
– when to present
– what to expect in labour
▪ Postnatal period – expectations of length of stay – child safety – social support at home – need for 6 week check / contraception – support peoples visiting hours
▪ Breastfeeding
▪ Red Nose (formerly SIDS)
▪ Social – family violence / community supports
What are some education that we can provide them to allow them to prepare for both and post natal period?
Hospital Services ▪ Social worker ▪ Physiotherapist ▪ Dietician ▪ Specialised clinics – endocrinology / thalassemia
Community Services ▪ Maternal and Child Health Center's ▪ Australian Breastfeeding Association ▪ PANDA ▪ Beyond Blue
Explain antenatal documentation
Hand held record: – VMR (Victorian maternity Record) - important if she is admitted interstate for decreased fetal movements for those health care practitioners to know what up with her ▪ BOS database ▪ Medical record ▪ Referrals ▪ Pathology requests
What are some signs and symptoms of pregnancy?
Presumptive=
Are subjective changes that a woman experiences, diagnosis cannot be made as they are unreliable
e.g.
- amenorrhea (missed period)
- Nausea and vomiting
- Fatigue
These could be prelated ot many other things
Probable=
Signs are objective findings that can be
documented by an examiner and are related primarily to
physical changes to reproductive organs. Positive diagnosis
Cannot be made on these as they may have other causes
e.g.
- uterine/abdomen enlargement
- breast enlargement
- softening of cervix
- colour changes of mucous membrane from pink to blush pink
Positive= Signs are those caused only by pregnancy e.g. - urine test (HCG) - Blood test (HCG) - Heart beat - U/s
How do u calculate EDC?
First day of last menstral period - 3 months + 1 year and 7 days= EDC
Naegles Rule
▪ 9 months + 7 days from last normal menstrual period
▪ OR add 280 days
▪ Assumes conception occurs day 14 in a 28 day cycle
& the LMP was true
▪ +/- the deviation from the 28 day cycle
Explain the difference between a screening test and a diagnostic test
Screening
– Aims to identify those at increased risk of a certain
problem
– Screening tests do NOT diagnose problem
– low or high result
– Eg of screening: Maternal serum screening is a blood test available to pregnant women who want to know about their chance of having a baby with a chromosome
condition, such as Down syndrome.
NIPT, CMSS
Diagnostic
If screening test positive the woman is recommended to
have a further diagnostic test for a definitive diagnosis
– Eg of diagnostic test: amniocentesis or CVS
What are some potential benefits and harms of screening tests?
Benefits ▪ Targeted monitoring ▪ Improves outcomes ▪ Increases choice ▪ Time to plan care ▪ Reassurance following low-risk result
Harms • Anxiety through false positives • Errors can occur • Failure to detect + result • Unwanted incidental findings
Explain Maternal Serum Screening: Combined First Trimester Screening Test
▪ Provides an estimate (low to high) of the chance that a
pregnancy is affected by a chromosome condition, such as Down syndrome.
▪ Blood test between 9+0 and 13+6 to measure two
chemicals called PAPP-A and free beta hCG (if also looking at screening for early onset preeclampsia (PE) this is done between 11+0 and 13+6)
▪ In addition an U/S between 12-13 weeks gestation -
Measures crown/rump length (CRL), nuchal translucency (NT) and nasal bone in some cases
Explain Second Trimester Maternal Serum Screening (2TMSS)
▪ is a single blood test, that is performed between 14-20
weeks gestation (best between 15-17 weeks). This test measures four chemicals: alpha-feto protein, unconjugated
oestriol, free beta hCG and dimeric inhibin A.
▪ The results of these two tests are combined with maternal age, weight and gestation to provide an estimate of the chance a pregnancy is affected by a chromosome condition, such as Down syndrome as well as neural tube defects like spina bifida.
Explain Non Invasive Prenatal Test (NIPT)
▪ Can be performed as early as 10 weeks
▪ A blood test from
the woman
▪ Millions of DNA fragments are analysed and fetal DNA is separated from maternal and the pairs of chromosomes are counted
▪ Results reported are low probability (expected number of chromosomes counted) or high probability (too many or
too few chromosomes identified)
What are some examples of other antenatal tests
• Mid Stream Urine (MSU) • Blood Pressure • Measure symphysis - fundal height(SFH) • Fetal heart (FH) rate, movements, position • Group B Streptoccocus – vaginal swab approx. 36/40 • Cardiotocography (CTG) • Amniotic Fluid Index
Explain some antenatal diagnostic tests
▪ Chorionic Villus Sampling (risk of miscarriage 1:100)- takes a piece of placenta
▪ Amniocentesis (risk of miscarriage 1:200)- takes piece of amniotic fluid
– genetic abnormalities
▪ Ultrasound
– physical abnormalities e.g. short limp, missing kidney
▪ Bloods
– Raised Liver Function Tests (LFTs) – pre-eclampsia
▪ Urinalysis – culture
– Urinary tract infection
Explain ultrasound as a screening tool
Used as both screening and diagnostic tool
▪ Confirmation of pregnancy / Dating
▪ Nuchal translucency for Downs syndrome
▪ Fetal anomalies
▪ 18-20 weeks – routine
▪ Assessment growth (single scans wont help but serial scans will)
▪ With external cephalic version (ECV)
▪ Amniotic Fluid Index (AFI)
▪ estimate of the amount of amniotic fluid & is an index for the fetal well-being. Normal; 5-25cm
▪ AFI < 5 is considered as oligohydramnios
▪ AFI > 25 is considered as polyhydramnios
What are the pregnancy specific normal vital signs of a mother and baby?
Materinal HR: 60- 100 bpm BP: 100/60- 140/90 Temp: 36-37.3 degrees celsius Resp: 12-2- breaths/min
Baby
FHR= 110-160 BPM - pinnard, doppler or CTG
Explain an abdominal palpation
Aims
▪ Observe signs of pregnancy (another way to confirm pregnancy)
▪ Assess baby’s lie, presentation & position
▪ Assess size & growth of baby
▪ Assess deviations from normal
3 stages
- Inspection
- Palpation
- Auscultation
Explain some key pratice points of an abdominal palpation
▪ Ensure woman is comfortable ▪ Ensure privacy ▪ Encourage her to empty bladder ▪ Explain procedure and ask permission to touch ▪ Consent ▪ Clean hands ▪ Equipment – Doppler or pinard stethoscope, tape measure
What is involved in inspection?
▪ Shape
▪ Skin colour (rash, bruises)
▪ Markings
– Striae gravidarum (stretch marks), linea nigra
(verticle pigmented line appearing on the
abdomen) and scars
What is check in an abdo palp?
- lie (longitudinal, oblique, transverse)
- presentation (what part of fetus is at pelvic brim e.g. cephalic, sacral, solder?)
- Dominator/presenting part
If head is presenting, what part of head? (Vertex, breech, face, brow, shoulder acromion process or dorsum) - Position (relationship between presenting part and pelvis)
- Attitude of head= degree of flexion or extension of the head or neck (determines which part will present in labour)
Explain the attitude of head in labour
Determines which diameters will present in labour
A) Well flexed: Vertex presentation (SOB 9.5cm and
biparietal 9.5cm diameters)
B) Incomplete flexed : Occipitofrontal (OF) 11.5cm
C) Partial extension: Brow presentation (mento-vertical diameter 13.5cm)
D) Complete extension: face presentation
(submento-bregmatic diameter 9.5cm)
What are the 4 manouvers of an abdo palp?
- be systematic
Manoeuvre 1 – Fundal palpation
• Presence of head or breech
Manoeuvre 2 – Lateral palpation
• Locate fetal back
Manoeuvre 3 –Pawliks grip or Deep pelvic palpation
• Assess size, flexion & mobility of head
Manoeuvre 4 –Pelivc palpation
• Identify pole of the fetus in pelvis & determine engagement
What causes minor disorders in pregnancy?
▪ Hormonal changes (as baby grows, organs have to shut in abdomen)
▪ Accommodation changes
▪ Metabolic changes
▪ Postural changes (core is being challeneged)
Explain morning sickness/nausea and vomiting
- occurs in 50% of women
Cause is not fully understood, however connections with the pregnancy hormone HCG has been made.
1% or less are diagnosed with hyperemesis gravidarum.
What are some clinical history question that should be asked?
Clinical history:
▪ Medical history, gestations, pattern of N&V, dietary and
fluid intake, & what exacerbates it or improves it
▪ Exclude other medical conditions (gastro-intestinal,
renal, endocrine, or allergies)
▪ Assess for signs of dehydration – vital signs, Urine sample (head ache, muscle pain, tachycardia)
Explain some non-pharmacological measures for Nausea and vomiting?
▪ Small frequent
▪ meals/snacks
▪ Eat before getting up
▪ Avoid an empty stomach, or a very full stomach (mixing solids and liquids), rich, fatty, or spicy foods
▪ Take more liquids than solids to prevent dehydration, consider ice chips/icy poles, watermelon to avoid to much in stomach
▪ avoid mixing liquids and solids
▪ Ginger extract (though evidence is inconsistent) do not exceed 1g per day
▪ Acupressure
Explain some pharmacological measures for Nausea and vomiting?
▪ Pyridoxine (vitamin B6) or combination of B6 with
doxylamine (brand name Restavit) an antihistamine
If that is ineffective, then antiemetics such as:
▪ Penothiazine
▪ Metroclompramide
▪ Ondansetron (for prolonged and intractable symptoms such as
in the case of hyperemesis gravidarum)
(All medications carry some risk, it is a matter of weighing up risk vs benefit)
Explain Hyperemesis Gravidarum
▪ Severe, constant nausea and vomiting in pregnancy
Characterised by; - persistent vomiting - weight loss more than 5%, - ketonuria - electrolyte imbalances and dehydration
Specific Management
– Replace fluids – IV therapy (will need hospital
admission) maybe picc line if they are on fluid long term
– Bloods – U&E, FBE
– Antiemetics
– Review by dietician
Explain Gastro-intestinal reflux (heartburn)
Cause
Clinical history
Management
Pharmacology
Cause:
▪ Elevated levels of progesterone relaxes lower
oesophageal sphincter allowing gastric reflux
▪ Also may affect gut motility and slow gastric emptying
▪ Occurs in two thirds of women in third trimester
Clinical history
▪ Take a history, exclude differential diagnosis e.g.
preeclampsia (BP)- women may feel pain n right upper ribs with PE
Gastroesophageal reflux disease (GERD) is reported in up to 80%
pregnancies
Management
▪ Small meals, avoid eating and drinking at the same time to reduce stomach volume = makes sure there is enough acid to digest the food
▪ Decrease fat in diet, increase protein
▪ Avoid gastric irritants such as coffee, chocolate, citrus juice, tomatoes,
fizzy drinks, spicy food, alcohol (which should be avoided in pregnancy
anyway)
▪ Avoid eating late or within 3 hours of going to bed so it doesn’t settle and rise when you sleep
▪ Sleep semi-recumbent or right side
Pharmacological
▪ Antacids (used by 30-50% of women in pregnancy)
▪ Ranitidine 150mg bd is effective at treating oesophageal reflux
Explain constipation in pregnancy
Cause
Implications
Clinical history
- Progesterone enhances smooth muscle relaxation which reduces peristalsis and intestinal motility, enhances sodium and water absorption in the colon leading to smaller stools with lower water content
- its it due to a pregnancy supplement? iron can cause this
- Bowel displaced by growing uterus
- Can affect up to 40% women in pregnancy
Implications:
▪ Straining can lead to pudendal nerve damage which
impairs the supportive function of the pelvic floor
muscles. This can be a contributing factor in developing
utero-vaginal prolapse
Clinical history:
▪ Diagnosis is made when there is <3 passing of stools
per week, hard stools, and/or difficulty passing stools
Management
- increase fibre intake
- psyllium husk (metamusal)
- increase fluid intake >2L per day
- avoid caffeine
- pharmacology treatment
- promote light physical activity
- suposotories
Explain anemia
Cause
- considered normal to have some level of anemia during pregnancy
- it D is necessary for absorption
- Calcium will take precedence for absorption so don’t have it an hour on either side of iron.
Due to: ▪ Circulating blood/plasma volume ↑’s 50% - more plasma (more dilute) ▪ Red blood cells ↑18% ▪ Considered normal – unless physiologically compromised
Treatment
▪ Diet- green leafy vegetables, red meat
▪ Iron supplements e.g. Ferrograd
Explain Varicosities- Leg & vulval
Cause
▪ Progesterone relaxes smooth muscle
▪ Increasing weight & pelvic congestion
Management
▪ Leg exercises
▪ Raising legs when able
▪ Support stockings/compression underwear
▪ May need to apply ice pack for pain
▪ Reassure will reduce/cease a few months after baby is
born
Explain Back aches/pelvic girdle pain
- 45-50% of women experience pregnancy related back pain or
pelvic girdle pain, - more than 80% of these women
experiencing difficulties with daily living
Cause
▪ Progesterone (& relaxin hormone later) muscle relaxant
▪ Change in center of gravity occurs any time but usually in 3rd trimester
▪ Weight of growing uterus
Management
▪ Educate regarding posture and exercises (avoid doing sit up motions and rather role)
▪ Refer to physiotherapist
▪ Massage/Osteo/Chiro/Body-workers
Explain Leg cramps/restless leg syndrome
Usually occurs at night, may affect up to 30% of women.
Cause
▪ Unclear, although slowed venous return due to increased intra abdominal pressure, progesterone decreasing the tone
in venous musculature and nutritional deficiencies (due to the fetal demands).
▪ The pain and cramps felt is a build up of lactic and pyruvic acid, leading to involuntary muscle contraction
▪ magnesium loss due to baby taking it
▪ relaxing of muscles
▪ reduces blood pressure
Management:
▪ Exclude other possible causes of leg cramps
▪ Massage, walking, stretching
▪ Warm bath before bed, stretch before bed
▪ Drink adequate fluids
▪ Magnesium lactate or citrate supplement
Explain Vaginal discharge during pregnancy
Leucorrhoea:
Increase in benign, odourless, white vaginal discharge
Cause
-due to high levels of oestrogen resulting in
shedding of superficial mucosal cells leading to increased discharge.
Increasing acidity which protects against some
pathogens increases a woman’s risk for Candida Albicans and trichomonas vaginalis.
- ensure membranes haven’t ruptured
Management – Exclude infections e.g. thrush – Exclude ROM – Wash with water – Reassure normal
Explain Carpal Tunnel Syndrome
Cause
▪ Oedema and pressure on the median nerve causing
paraesthesias and swelling, pain and impairing motor
function
Management ▪ Avoid prolonged extreme flexion/extension or vibration (driving, power tools, lawn mower) ▪ Raising hand on 1-2 pillows at night ▪ Splinting hand at night ▪ Exercises before getting out of bed ▪ Physiotherapy ▪ Usually resolves within 2 weeks of birth
What is the ABO system?
Describes 4 blood groups by their negative or positive presence of antigens.
