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BCM > Women's Health 3 > Flashcards

Women's Health 3 Flashcards

1
Q

Purposes of prenatal care

A
  1. patient education and reassurance
  2. patient comfor with provider of delivery services
  3. medical services: BP, detection of preeclampsia
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2
Q

First visit should include (5)

A
  • complete assessment
  • gestational age assessment
  • Pap smear, cultures
  • prenatal panel
  • discussion of breast feeding
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3
Q

How long is the standard pregnancy?

A

40 weeks

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4
Q

How many weeks is considered “term”?

A

37-40 weeks gestation

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5
Q

How many weeks is “preterm”?

A

20-36+6 weeks

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6
Q

How many weeks is considered abortion?

A

20 weeks

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7
Q

What is happening when G does not = P?

A

patient is pregnant!

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8
Q

Two most important genetic risk assessment factors for the patient

A

advanced maternal age (>35)

drug exposures

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9
Q

What genetic RF should you think of in ethinic backgrounds (esp AA)

A

Sickle cell

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10
Q

Recommended schedule for routine antepartum OB visits

A

Every 4 weeks until week 28

Every two weeks until 35-36 weeks

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11
Q

Recommended schedule for postpartum OB visit

A

2-6 weeks after delivery

more frequent visits PRN

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12
Q

4 parts of a gestational age assessment

A
  1. LMP
  2. Pelvic US (ideally in 1st trimester)
  3. Physical exam, fundal height
  4. Naegle’s rule
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13
Q

What is the formula for Naegle’s Rule and what is it for?

A

Calculates the Estimated Date of Conception (EDC)

LMP + 7 days - 3 months +1 year

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14
Q

How many week pregnancy is Naegle’s Rule based on?

A

40 weeks (10 months!)

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15
Q

What’s a useful tool for determining Naegle’s Rule?

A

Pregnancy wheel

gives current gestational age

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16
Q

The first trimester US takes what measurement?

A

Crown-Rump Length (CRL)

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17
Q

What # weeks should the first OB visit happen?

A

8 weeks

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18
Q

Do you need a Pap on the first OB visit?

A

only if patient is >21

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19
Q

Name some things the prenatal panel contains

A 
Blood type/screen
CBC
Hepatitis B surface antigen
Syphilis
Early 1-hour glucose tolerance test
Rubella immunity status
HIV
Urine C&S
B-hcG, P4
Hep C Igg
Carrier testing for CF, Fragile X, SMA
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20
Q

What is BhCG useful for?

A

Only establishing viability. It peaks at 10 weeks, then sharply declines and is back to baseline at about 15-17 weeks

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21
Q

What type of fetal assessment happens at <12 weeks?

A

transvaginal US for “viability” or “dating”

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22
Q

What type of fetal assessment happens at >8 weeks?

A

Fetal heart tones

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23
Q

What type of fetal assessment happens at >16 weeks?

A

Fetal movement

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24
Q

When assessing fundal height, when does the uterine fundus begin to grow out of the pelvis?

A

12 weeks

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25
Q

When assessing fundal height, when does the uterine fundus reach the umbillicus?

A

20 weeks

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26
Q

when measuring fundal height, when do the gestational weeks equal the measurement in cm?

A

beyond 20 weeks

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27
Q

When does the uterine fundus reach the xyphoid process?

A

36 weeks

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28
Q

When does genetic screening take place?

A

12 weeks

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29
Q

Does genetic screening detect neural tube defects?

A

no

Ex: spinal bifida

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30
Q

GBS colonizes in the vaginal and rectal areas in what percent of women

A

30%

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31
Q

What happens to the baby if the mother is infected with GBS?

A

neonate may become infected during delivery&raquo_space; fever, sepsis

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32
Q

When do you do a vaginal/rectal swab for GBS?

A

35 weeks

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33
Q

How is the fetal presentation classified?

A

the anatomical part of the fetus lying over the pelvic inlet: the presenting body part of the fetus

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34
Q

When the baby’s head is presenting

A

Vertex presentation

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35
Q

When the baby’s feet/bottom are presenting

A

Breach presentation

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36
Q

When the baby’s shoulder is presenting

A

Shoulder presentation

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37
Q

What is fetal lie?

A

relation of the long axis of the fetus to that of the mother

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38
Q

What are the different fetal lies?

A

Longitudinal
Oblique
Transverse

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39
Q

Common complaints in antepartum care

A 
N/V
Heartburn/reflux
Fatigue
Round ligament pain
Leg cramps, muscle pain
Low back pain
Dyspnea
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40
Q

What causes maternal N/V?

A

increased hCG/P4

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41
Q

What causes maternal Heartburn/GERD

A 
decreased GI motility 
increased stomach emptying time
reduced GE sphincter tone
increased intra-abdominal pressure
horizontal lie of the stomach as the uterus enlarges
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42
Q

What causes maternal dietary cravings?

A

PICA

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43
Q

What causes maternal constipation?

A

reduced GI motility

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44
Q

What causes maternal hemorrhoids?

A

elevated venous pressure
increased pelvic blood flow
pressure from constipation

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45
Q

Cardiac output increases _____% in the first 20 weeks of pregnancy

A

50%

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46
Q

What cardiac finding is normal in pregnancy, not normal otherwise

A

S3 gallop, systolic ejection murmur

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47
Q

IVC syndrome is common in pregnancy. What is it?

A

Compression of the IVC by gravid uterus. Causes dizziness, light-headedness, syncope

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48
Q

Hormonal changes cause what MSK change in mom?

A

SI joint relaxation

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49
Q

What causes maternal leg cramps?

A

electrolyte imbalances

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50
Q

What cause nasal “congestion” in pregnant women?

A

mucosal hyperemia

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51
Q

What causes maternal dyspnea?

A

diaphragmatic compression secondary to gravid uterus

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52
Q

What is centering pregnancy?

A

a model of group healthcare.

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53
Q

Three major components of centering pregnancy?

A
  1. assessment
  2. education
  3. support
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54
Q

Name a few CCs that can be the clinical presentation of pregnancy

A 
missed period
breast tenderness
nausea
fatigue
"purple cervix"
Softening and enlargement of the uterus
\+ hCG (home or office)
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55
Q

Name some early complications of pregnancy

A 
bleeding
pain/cramping
hyperemesis
change in bowel habits
social issues
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56
Q

Name some causes of first trimester bleeding

A 
abortion
ectopic pregnancy
Hydatidiform mole
cervical polyps
cervicitis
neoplasm
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57
Q

What percent of pregnancies result in spontaneous abortion?`

A

15-25% of all clinically recognized pregnancies, possibly as high as 50% of all

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58
Q

Most (80%) of miscarriages happen within how many weeks?

A

the first 12

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59
Q

The likelyhood of spontaneous abortion is lower once…

A

fetal heart activity is visualized on US

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60
Q

What are the percentages f recurrence associated with 1, 2, 3, and 4 prior losses?

A

1: 19%
2: 35%
3: 45%
4: 54%
(must be consecutive, live births start from the beginning)

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61
Q

Name 6 reasons etiologies of spontaneous abortion

A 
chromosome abnormalities!! (50-70%)
Endocrine abnormalities
Reproductive tract abnormalities
Immunologic
Infection
Idiopathic
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62
Q

Chromosome abnormalities are found in what percent of still births? and live births?

A

5% ; .6%

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63
Q

is alcohol associated with spontaneous abortion?

A

no, but it’s teratogenic

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64
Q

Is caffeine associated with spontaneous abortion?

A

possibly

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65
Q

Is trauma associated with spontaneous abortion?

A

no

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66
Q

Is radiation associated with spontaneous abortion?

A

Very much, if >10 rads

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67
Q

Is smoking associated with spontaneous abortion?

A

Yes, if moderate or more

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68
Q

Definition of spontaneous abortion

A

termination of pregnancy before 20 weeks

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69
Q

Most common etiology of spontaneous abortion

A

chromosome abnormalities

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70
Q

Definition of threatened abortion

A

vaginal bleeding in the first trimester, os is still closed, can see pregnancy on US, still have fetal heart tone

Pregnancy may be viable or abortion may follow

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71
Q

What is the most common cause of first trimester bleeding?

A

threatened abortion

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72
Q

POC in threatened abortion?

A

NO

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73
Q

cervical os is ____ in threatened abortion

A

closed

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74
Q

up to _____% of patients have threatened abortion, up to _____% of them miscarry

A

25%

50%

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75
Q

There is an increased risk of what with threatened abortion

A

PTD

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76
Q

Threatened abortion S/S

A

essential bleeding in first trimester; bloody vaginal discharge

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77
Q

Threatened abortion Tx

A

Supportive: rest, ER return precautions
Serial B-hCG to see if doubling
No medications helpful
EMOTIONAL SUPPORT

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78
Q

Incomplete abortion definition

A

in the process of aborting, but still have retained products, cervical os is open

pregnancy is not salvagable

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79
Q

POCs in incomplete abortion?

A

some POC expelled, some still retained

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80
Q

Cervical os is ____ in incomplete abortion

A

DILATED

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81
Q

Incomplete abortion S/S

A

HEAVY bleeding
retained tissue
BOGGY uterus

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82
Q

Incomplete abortion Tx

A

may be allowed to finish
D&C in first, D&E after first
Pitocin

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83
Q

Inevitable abortion definition

A

pregnancy not salvageable, no POCs expelled yet

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84
Q

Cervical os is _____ in inevitable abortion

A

progressively dilating

+/- ROM

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85
Q

Inevitable abortion S/S

A

moderate bleeding >7 days

cramping

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86
Q

Inevitable abortion Tx

A

Dilation and evacuation in 2nd trimester

Suction curretage in 1st trimester

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87
Q

Missed abortion definition

A

vaginal bleeding, os is closed, US shows gestational sac, retained products, been in there for awhile. Body did not expel the fetus but there is no fetal heart tone

Fetal demise but still retained in uterus

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88
Q

POCs in missed abortion?

A

none expelled

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89
Q

Cervical os is ____ in missed abortion

A

closed

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90
Q

Missed abortion S/S

A

loss of pregnancy Sx

maybe brown discharge

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91
Q

Missed abortion S/S

A

D&E (D&C if first trimester)

Misoprostol

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92
Q

Complete abortion definition

A

complete passage of all products

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93
Q

POC in complete abortion?

A

all completely expelled

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94
Q

Cervical os is ____ in complete abortion

A

closed

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95
Q

Complete abortion S/S

A

pain, cramps, bleeding usually subsides

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96
Q

Septic abortion definition

A

the retained POC becomes infected, causes infection of the uterus and organs

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97
Q

POC in septic abortion?

A

some POC retained

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98
Q

Cervical os is ___ in septic abortion

A

closed

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99
Q

septic abortion S/S

A 
cervical motion tenderness
Foul brownish disrcharge
fever, chills
uterine tenderness
spotting >> heavy bleed
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100
Q

When is RhoGam indicated in abortion Tx?

A

if Rh negative

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101
Q

Definition of elective abortion

A

termination of intact pregnancy before viability (usually surgical)

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102
Q

Describe medical regiment used for elective abortion (2)

A

Mifepristone&raquo_space;> Misoprostol 24-72 hours after
OR
Methotrexate&raquo_space;> Misoprostol 3-7 days later

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103
Q

Mifepristone MOA

A

anti-progestin

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104
Q

Methotrexate MOA

A

antimetabolit (folate antagonist)

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105
Q

Misoprostol MOA

A

prostaglandin that causes uterine contractions

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106
Q

Surgical elective abortion can be performed up to _____ weeks from LMP

A

24

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107
Q

what type of surgical elective abortion is used in weeks 4-12?

A

Dilation and currettage (including suction curettage)

D&C

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108
Q

What type of surgical elective abortion is used in weeks >12

A

dilation and evacuation

D&E

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109
Q

Definition of ectopic pregnancy

A

any pregnancy implanted outside the endometrial cavity

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110
Q

Most common place of ectopic pregnancy?

A

fallopian tubes, especially the ampulla

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111
Q

Ectopic pregnancy RFs

A
  • Previous pelvic infection
  • previous tubal surgery
  • intrauterine device in place
  • previous tubal pregnancy

ADHESIONS from surgery!

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112
Q

Ectopic pregnancy clinical triad:

A
  1. unilateral pelvic/abdominal pain
  2. vaginal bleeding
  3. amenorrhea (pregnancy)
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113
Q

The ectopic pregnancy triad can also be seen with ___.

A

threatened abortion

threatened more common than ectopic actually

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114
Q

ectopic pregnancy atypical S/S

A

vague Sx
menstrual irregularities
severe abdominal/shoulder pain

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115
Q

ruptured/rupturing ectopic pregnancy S/S

A

severe abdominal pain
dizziness
N/V
signs of shock (from hemorrhage): syncope, tachycardia, hypotension

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116
Q

ectopic pregnancy PE

A

cervical motion tenderness

adnexal mass

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117
Q

Ectopic pregnancy Dx

A
  1. SERIAL quantitative B-hCG
    - normally doubles every 48 hours in first trimester
  2. Transvaginal US
  3. laparoscopy for direct visualization
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118
Q

What would you see on transvaginal US if there is an ectopic pregnancy

A

absence of gestational sac with B-hCG levels >2000 strongly suggest ectopic or nonviable intrauterine pregnancy`

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119
Q

Ectopic pregnancy Tx

A
  • Surgical: laparascopy with salpingectomy or salpingotomy

- Medical: methotrexate

120
Q

When would you use surgical versus medical tx of ectopic pregnancy?

A

Surgical: ruptured or unstable

Medical: unruptured or stable

121
Q

Methotrexate MOA in ectopic pregnancy

A

destroys trophoblastic tissue (disrupts cell multiplication)

122
Q

Indications for methotrexate in ectopic pregnancy (4)

A
  • hemodynamically stable
  • early gestation (<4cm)
  • B-hCG <5,000
  • no fetal tones
123
Q

CI for methotrexate in ectopic pregnancy

A
  • ruptured ectopic
  • history of TB
  • B-hCG >5,000
  • fetal heart tones present
124
Q

Do you give RhoGAM in ectopic pregnancy?

A

Yes, if mom is Rh negative

125
Q

What is hydatidiform mole?

A

“molar pregnancy”
a type of gestational trophoblastic neoplasia
Partial mole= identifiable fetal structures
Complete mole= NO identifiable fetal structures

126
Q

Molar pregnancy S/S

A

Exaggerated pregnancy symptoms
Threatened abortion Sx
Uterus larger than expected

127
Q

Molar pregnancy Dx

A

US: “snowstorm appearance”

128
Q

Molar pregnancy Tx

A

Definitive: prompt evacuation of uterine contents, hysterectomy if no wish for future children

129
Q

In clinic, you’ll probably see more ____ pregnancy, complications. In ER, you’ll probably see more ____ pregnancy complications.

A

late; early

130
Q

Women are how many times as likely to be diagnosed with clinical depression?

A

twice

131
Q

When does depression most commonly happen in women?

A

during childbearing years (25-44)

132
Q

How many women will be dx with depression in their lifetime?

A

1/8

133
Q

Do depressed women seek treatment?

A

less than 1/2 do

134
Q

Do more men or women get diagnosed with bipolar?

A

equal

135
Q

___ times as many women as men experience rapid cycling of bipolar disease

A

3x

136
Q

What does research show about women with bipolar?

A

they have more depressive and mixed episodes than men

137
Q

Premenstrual syndrome definition

A

a cluster or general pattern of physical, emotional, and behavioral symptoms with cyclical occurence during the LUTEAL phase of the menstrual cycle

138
Q

when does PMS occur?

A

in the LUTEAL phase
1-2 weeks before menses
Remits with onset of menses

139
Q

How many women experience PMS?

A

50-80% of women of reproductive age

140
Q

What is premenstrual dysphoric disorder?

A

severe PMS with functional impairment

141
Q

PMS physical S/S

A 
bloating
breast swelling and pain
HA
bowel habit changes
fatigue
muscle/joint pain
142
Q

PMS emotional S/S

A 
depression
hostility
irritability
libido changes
aggressiveness
143
Q

PMS behavioral S/S

A

food cravings
poor concentration
noise sensitivity
loss of motor senses

144
Q

Most common Sx of PMDD

A

irritability

145
Q

DSM-V criteria for PMDD

A

A. 5 or more Sx in most menstrual cycles in the past year
B. One or more of the following: affective libility, irritability or increased interpersonal conflict, depressed mood or hopelessness or self-depricating thoughts, and anxiety
C. One or more of the following: decreased interest in usual activities, difficulty concentrating, decreased energy, change in appetite, hypersomnia or insomnia, feeling overwhelmed or out of control, physical symptoms
D. Clinically significant distress
E. not an exacerbation of another disorder
F. Prosective daily fatings during 2 symptomatic cycles
G. NOT due to substance use or another med

146
Q

PMS Dx

A
  • Sx initiate during the luteal phase (1-2 weeks before menstruation)
  • relieved with 2-3 days of the onset of menses
  • at least 7 Sx-free days during the follicular phase
147
Q

PMDD Dx

A

Daily charting of Sx for 2 months

148
Q

T/F: women with or vulnerable to PMDD have abnormal hormone levels

A

FALSE. Research shows women vulnerable to PMDD do NOT have abnormal levels of hormones, they have a particular SENSITIVITY to normal cyclical hormonal changes

149
Q

PMDD pharmacologic Tx

A

SSRIs are first line

Other options: OCPs containing drospirenone, GnRH agonists (leuprolide), Danazol (a synthetic androgen)

150
Q

How long does it take for SSRIs to work for PMDD?

A

a few days, FAST!

151
Q

When should you start to consider another option if the SSRI isn’t working a for a patient’s PMDD?

A

after 3 menstrual cycles with no improvement

152
Q

PMDD non-pharmacologic Tx

A
  • Lifestyle Mods: exercise, sleep, decreased caffeine, decreased EtOH/tobacco
  • Nutritional supplements: Ca, Vit B6
  • Herbal supplements: no evidence for this
153
Q

2 keys for follow up for PMDD

A
  1. continue daily charting after Dx to determine Tx effectiveness
  2. Tx for at least 12 months to cover relapse
154
Q

T/F: the pregnant state is protective for mood disorders

A

False

155
Q

Theory behind hormones and mood of postpartum depression

A

Theory: some women are more sensitive to changes in hormone levels&raquo_space; increased susceptibility for mood disorders via NT changes

156
Q

What hormone changes happen with delivery?

A

plummeting of both estradiol and progestin

157
Q

Spectrum of postpartum mood changes

A 
Postpartum blues
>>
Postpartum depression
>>
Postpartum psychosis
158
Q

What dose the following describe: mother is tearful, irritable, and anxious about the new responsibilities of being a mother, but experience SOME joy, sleeps when the baby sleeps, and eats well
Sx DO NOT impair the woman’s ability to care for herself or baby

A

Baby blues

159
Q

Onset of baby blues

A

about 3 days after delivery, usually resolves by 2 weeks postpartum

160
Q

Baby blues Tx

A

support and reassurance

161
Q

What is one of the most common complications of childbirth?

A

Postpartum depression

162
Q

Postpartum depression Dx

A

Same DSM-V criteria as MDD (SIGECAPS), but onset of episode within 4 weeks postpartum

163
Q

What does the following describe: mom has guilt, appetite change, agitation, anxiety, cannot sleep even when baby is sleeping, has obsession and compulsions about the baby

A

Postpartum depression

164
Q

PPD screening

A

Edinburgh postnatal depression scale (EPDS)

10 item self report scale
Score of 10-12 is positive
If positive, conduct a brief clinical interview to establish the Dx of depression

165
Q

PPD RF

A
  • previous episode of depression
  • Severe PMS
  • anxiety during pregnancy
  • depression during pregnancy, particularly 3rd trimester
  • prior episode of PPD
  • FHx of depression/anxiety/bipolar
  • Poor marital support
  • Trauma
  • isolation of mother
  • increased life stressors
  • prefectionism
  • work/financial pressures
  • lack of maternal self-care
166
Q

Most important RF for PPD

A

prior episode of PPD

167
Q

Three components of PPD recovery

A
  1. medical intervention
  2. social support
  3. psychotherapeutic intervention
168
Q

Moms MUST get uninterupted sleep for at least ____ hours _____ nights per week

A

4-6 hours; 2 nights/week

169
Q

PPD pharmacologic Tx

A

SSRIs first line

170
Q

PPD prophylactic Rx

A

for high risk women, no longer than 17 weeks

171
Q

Untreated PPD may lead to the following problems: (4)

A
  • interrupted bonding with baby
  • contributes to family/marital discord
  • can lead to psychosis, SI, tragedies
  • interferes with the normal child development
172
Q

Children who grew up with a mother who suffered from depression have shown an increased incidence of:

A
  • childhood psychiatric disturbances
  • behavior problems
  • poor social functioning
  • impaired cognitive and language development
173
Q

In normal interactions, mothers and infants engage in _____ mismatching states which leads to trust in the partner and sense of mastery (“we can overcome problems”).
Depressed mothers find it difficult to read and respond to infants’ communications, leading to larger and longer mismatches and less likelihood of _____ repair

A

repairing; repair

174
Q

What commonly occurs with PPD

A

Postpartum OCD

175
Q

what happens in POCD

A

intrusive thoughts or images of harming baby or something harmful happening

176
Q

Are women with POCD more likely to harm their infant?

A

NO

177
Q

Explain how a mom with POCD might act

A

Obsessive thoughts about harm coming to the infant causes them to avoid holding the baby on staircases, bathing the baby, the kitchen area, leaving the house, etc

178
Q

Important note about women with POCD

A

These Sx cause shame and embarrassment, women don’t volunteer this info unless you ask!!

179
Q

What is described by the following: mom has anxiety and agitation, disorganized behavior, confusion, delusions about infant, voices in her head, hallucinations, and thoughts about hurting herself or baby

A

postpartum psychosis

180
Q

When does postpartum onset? what about recurrence?

A

onset is rapid- within 3 days to one week

Recurrence rate is extremely high!

181
Q

Patients with preexisting Dx of ____ have a 20% increased risk for developing postpartum psychosis

A

bipolar

182
Q

Postpartum psychosis Tx

A

ANTIPSYCHOTICS AND HOSPITALIZATION

PSYCHIATRIC EMERGENCY!!

Risk of suicide and infanticide!!

183
Q

General rules of treating depression during pregnancy

A

discuss psychotropic meds and pregnancy when you first prescribe meds for women during their childbearing years

ABRUPT cessation of psyciatric meds during pregnancy makes relapse more likely

184
Q

What is first line Tx for depression during pregnancy

A

SSRIs

185
Q

Any risks for fetus with SSRI?

A

no risk of malformations

no evidence of being teratogenic

186
Q

Other Tx options for depression during pregnancy

A

psychotherapy
ECT
Omega-3s
Bright light therapy

187
Q

General principals for breastfeeding while on meds (for mom)

A

breastfeeding not always safe

SLEEP is very important

188
Q

General principals for breastfeeding while on meds (for baby)

A
  • BBB is porous
  • liver enzymes not fully developed
  • kidneys partially functioning
189
Q

Breastfeeding while on SSRIs: drug exposure to infant is ___

A

low

190
Q

Normal pregnancy is an average of ___ weeks from the first day of the LMP to the estimated date of delivery

A

40

191
Q

Definition of early term

A

37 0/7 - 38 6/7 weeks

192
Q

Definition of full term

A

39 0/7 - 40 6/7 weeks

193
Q

Definition of late term

A

41 0/7 - 41 6/7 weeks

194
Q

Definition of post term

A

42 weeks and beyond

195
Q

What term has the lowest incidence of adverse neonatal outcomes?

A

full term

196
Q

What are the four warnings of labor?

A
  • the 5-1-1 rule
  • spontaneous rupture of membranes
  • vaginal bleeding
  • decreased fetal movement
197
Q

What is the 5-1-1 rule of labor?

A

Contractions occur…

  • every 5 minutes (are painful)
  • last at least 1 minute each
  • go on for at least 1 hour
198
Q

How many fetal movements should there be at term?

A

about 10 discrete movements per hour

199
Q

Explain dilation/effacement/station on cervical exam when a patient is admitted to labor and delivery

A

Dilation: the opening of the cervix, ranges from 0-10

Effacement: rough estimate of the shortening of the cervix

Station: fetal head location in the maternal pelvis

200
Q

The reference point for “station” is what?

A

the ischial spines

201
Q

what is 0 station

A

baby’s biparietal diameter is AT the level of the ischial spines

202
Q

what is minus station?

A

baby’s biparietal diameter is ABOVE the ischial spines

203
Q

what is plus station?

A

baby’s biparietal diameter is BELOW the ischial spines

204
Q

There is an increased risk of what in spontaneous rupture of membranes?

A

infection

205
Q

What is the first stage of labor?

A

from onset of labor&raquo_space; complete cervical dilation (10cm)

206
Q

What is the second stage of labor?

A

from complete cervical dilation&raquo_space; delivery of the infant

207
Q

What is the third stage of labor?

A

from delivery of the infant&raquo_space; delivery of placenta

208
Q

What is happening in the latent phase of the first stage of labor?

A

cervix effacement with gradual cervical dilation

209
Q

What is happening in the active phase of the first stage of labor?

A

rapid cervical dilation, usually beginning at 3-4 cm

210
Q

What is happening in the passive phase of the second phase of labor?

A

complete cervical dilation to active maternal expulsive efforts

211
Q

What is happening in the active phase of the second phase of labor

A

from active maternal expulsive efforts to delivery of the fetus

212
Q

What are the three signs of placental separation in the third stage of labor?

A
  1. gush of blood
  2. lengthening of the umbilical cord
  3. anterior-cephalad movement of the uterine fundus (becomes globular and firmer after the placenta detaches
213
Q

what is the biggest difference in labor from nulliparas to multiparas women

A

second stage of labor lasts about 33 minutes in first labor, but only 8.5 minutes in subsequent labors

214
Q

describe pain in the first stage of labor

A

diffuse, visceral, not well localized

215
Q

describe pain in the second stage of labor

A

pudendal nerve and the anterior divisions of S2-S4 are stimulated by distention of vagina/pelvic floor/perineum

somatic pain, better localized

216
Q

biggest problem with systemic analgesia as pain management in labor

A

it crosses the placenta

it also doesn’t really work as well

217
Q

Best part of neuroaxial (regional) analgesia for pain management in labor

A

pain relief with minimal maternal and neonatal adverse affects

218
Q

What women are more likely to elect regional anesthesia?

A

higher education levels
caucasian
early presentation for prenatal care

219
Q

what is the apgar score for?

A

assessing clinical status of newborn

220
Q

5 components of the apgar score

A
  1. color
  2. HR
  3. reflexes
  4. muscle tone
  5. respiration
221
Q

when do you report the apgar score?

A

1 and 5 minutes after delivery

222
Q

Describe the apgar scores and what they’d mean

A

1-10 total, assigned 0-2 points in each section

7-10 is reassuring
4-6 is moderately abnormal
0-3 is nonspecific sign of illness

223
Q

When would you repeat apgar scores

A

if score <7, repeat at 5 minute intervals up to 20 minutes

224
Q

When would a baby get a +2 for on the HR section of the apgar?

A

HR >100

225
Q

When would a baby get a +2 for color on the apgar score?

A

pink baby (no cyanosis)

226
Q

When would a baby get a +1 on for color on the apgar?

A

acrocyanosis: body is pink, extremities are blue

227
Q

What’s a normal baseline fetal heart tone?

A

110-160

228
Q

What are we looking for when monitoring fetal heart tones?

A

baseline, long and short term variability, accelerations and decelerations

229
Q

Two types of fetal monitoring

A
  • External: US

- Internal: same tech as EKG measures R-R interval. Allows for better quality tracing with more continuity

230
Q

Fetal heart tones are always discussed in increments of ____.

A

5

231
Q

What is short term variability in fetal heart tones?

A

beat to beat irregularity in the HR, represents the push-pull effect of sympathetic and parasympathetic nerve input

232
Q

What is the dominant nerve of short term variability?

A

vagus

233
Q

What is long term variability of fetal heart tones?

A

the waviness of the tracing. Accelerations.

234
Q

What is a reactive long-term variability?

A

2 accelerations every 20 minutes

235
Q

Why is variability important?

A

it’s a marker of fetal well-being.

236
Q

When a fetus is alert and active, the variability is _____. When a fetus is obtunded, variability is _____.

A

normal or increased; reduced

237
Q

Name some things that would decrease variability

A

anything that depresses or reduces brain function!!

sleeping baby
drugs
fetal anomalies
neuro insult
immature CNS
fetal tachy
fetal sepsis
238
Q

what causes variable decelerations?

A

compression of the umbilical cord

239
Q

classic shape of variable decelerations

A

V

240
Q

What are early decelerations caused by?

A

head compression

241
Q

usual shape of early decelerations

A

U

242
Q

What are late decelerations and what is their shape?

A

begin after onset of contraction; U

243
Q

What types of decelerations are worrisome

A

Late, if repetitive

244
Q

Describe the predictive value of apgar score

A

1 min 0-3: natta
5 min 0-3: correlates with neonatal mortality in large populations but does not predict individual future neurologic dysfunction

245
Q

A low 5 minute apgar score confers an increased relative risk of what?

A

Cerebral palsy

246
Q

Why does postpartum hemorrhage happen?

A

failure of uterus to contract after expulsion of contents

247
Q

How much blood flows through the placenta at term?

A

600 mL/min

248
Q

RF for postpartum hemorrhage

A 
Overdistention of uterus (mult gestations, macrosomia)
oxytocin-stimulated labor
Uterine relaxants
Amnionitis
manual extraction of placenta
249
Q

Post partum hemorrhage Tx

A

Uterine massage
Uterotonics
Surgery

250
Q

Recommended time frame for umbilical cord clamping

A

30-60 seconds

251
Q

What does umbilical cord clamping do for term infants?

A

increases hemoglobin levels at birth

improves iron stores in first months of life

252
Q

Name a few things umbilical cord clamping does for preterm infants

A
  • improved transitional circulation
  • better establishment of RBC volume
  • decreased need for blood transfusion
  • lower incidence of necrotizing enterocolitis and intraventricular hemorrhage
253
Q

When does the postpartum visit usually happen?

A

4-6 weeks after delivery

254
Q

Topics to be addressed in the post partum visit

A 
mood and emotional well being
feeding
sexuality, birth control
sleep and fatigue
physical recovery
chronic disease mgmt
health maintenance
255
Q

What percent of women do not attend a postpartum visit?

A

40%

256
Q

Nickname for postpartum care

A

“fourth trimester”

257
Q

How many lobes are in one mature mammary gland? what are lobes separated by?

A

15-25; fat

258
Q

Each lobe is made up of several ___, and those are made up of large numbers of ______.

A

lobules; alveoli

259
Q

what do the alveolar secretory epithelium synthesize?

A

milk constituents

260
Q

What are the ducts that open separately on the nipple?

A

lactiferous ducts

261
Q

What is the other name for stage 1 of lactation?

A

mammogenesis

262
Q

WHen does stage 1 (mammogenesis) of lactation occur?

A

conception to mid-pregnancy

263
Q

What is happening in mammogenesis?

A
  • increased proportion of glandular tissue
  • increased size of breasts
  • darkening and prominent veins
  • milk secretion inhibited by the high levels of progesterone and estrogen
264
Q

What is the other name of the second stage of lactation and when does it occur?

A

lactogenesis I: mid pregnancy to 2 days postpartum

lactogenesis II: 3-8 days postpartum

265
Q

What is happening in lactogenesis I?

A
  • stimulation of milk synthesis by prolactin

- milk secretion still inhibited

266
Q

What is happening in lactogenesis II?

A
  • reduction of progesterone allows for production and secretion of large amounts of milk
267
Q

What is the other name for Stage three of lactation and when does it occur?

A

galactopoiesis; 9 days postpartum until involution (stage 4)

268
Q

what is happening during galactopoiesis?

A
  • maintenance of milk secretion controlled by hormones

- breast size diminishes between 6-9 months, production continues as long as baby sucks

269
Q

What is the other name for the 4th stage of lactation, when does it occur?

A

involution, begins about 40 days after last breastfeed

270
Q

What is happening during involution?

A
  • loss of the secretory function of milk

- epithelial cells no longer needed and are removed by apoptosis and replaced with adipose tissue

271
Q

Describe the physiology of breastfeeding

A
  1. baby sucks, no milk released
  2. receptors on nipple sense pressure from sucking, send sensory impulses transmitted to the hypothalamus
  3. nerve signals in hypothalamus stimulate release of oxytocin from posterior pituitary gland and prolactin from the lactotrophs
  4. oxytcin released into blood, acts on myoepithelial cells causing them to contract. Increase in pressure in alveoli causes the milk to be ejected in the ducts
  5. 30 seconds to 1 min later, baby is still sucking on the nipple, milk is ejected
272
Q

When do prolactin levels rise?

A

5th week of pregnancy

273
Q

what does prolactin increase do?

A

causes mammary ducts to mature and alveoli to differentiate into secretory cells

274
Q

What acute effect does prolactin have?

A

causes mammary glands to secrete milk into the alveoli

275
Q

When does oxytocin surge?

A

with suckling, crying baby

276
Q

What inhibits oxytocin?

A

stress

277
Q

What effect does oxytocin have?

A

causes milk ejection

278
Q

what is colostrum?

A

thick, yellow, high in protein/Ab/vits/minerals type of milk that develops during pregnancy and lasts until a few days after baby is born

279
Q

what is transitional milk?

A

white, high fat/calories/protein/lactose/vits milk that replaces colostrum 2 days after birth

280
Q

what is mature milk?

A

replaces transitional milk 10-15 days after birth

foremlik or hindmilk

281
Q

Foremilk vs Hindmilk

A

foremilk: bluish in color, more water content
hindmilk: more white, higher fat content, essential to baby’s growth/nutrition

282
Q

Why are the first 2-4 weeks of breastfeeding the hardest?

A 
exhaustion (they eat so freakin much)
latching problems
lazy/sleepy eaters
discomfort
milk supply vs demand
baby blues
283
Q

3 nursing positions

A

cradle
football
lying down

284
Q

How to latch

A

bring baby to the breast not breast to baby!!!

nose in line with nipple, brush nipple from nose to upper lip, put areola and nipple into mouth

285
Q

Breastfeeding recommendations

A
  • exclusive BF for first 6 months
  • intro of complementary solid foods with continued BF until 12 months (mom’s milk looses iron, need iron from solid food)
  • continue BF until “mutually agreeable” time between mom and baby
286
Q

Benefits of BF

A 
involution of mom's uterus
bonding
decreased cancer and T2DM risk in mom
decreased infant mortality
decreased risks in baby for diarrhea, resp illness, obesity, OM, DM
save money
portable
good nutrition for baby
287
Q

2 main problems in BF

A

engorgement

plugged milk ducts

288
Q

Plugged milk duct Tx

A

moist heat prior to feeding

massage during feeding

289
Q

Presentation of mastitis

A

single area of localized warmth, TTP, edema, erythema in one breast >10 days after delivery

Flu-like Sx: fever, fatigue, N/V, HA

290
Q

Mastitis Tx

A

Keflex for 10-14 days (not excreted in breast milk)
continue to nurse
Analgesics

291
Q

what can happen if there is failure of mastitis to improve after 48-72 hours?

A

breast abscess

292
Q

Breast abscess Tx

A

surgical drainage
Incision corresponding to skin lines (cosmetic)
pack resulting cavity with gauze

293
Q

what percent of women will elect to never BF for varying reasons?

A

20%

294
Q

How to make more milk?

A

feed the baby!

supply and demand

295
Q

how long to see a change in supply?

A

24-48 hours

296
Q

Name some common Rx contraindicated during lactation

A 
acebutolol
aspirin
antihistamines
bromocriptine
ergotamine
lithium
phenobarbitol
primidone
sulfasalazine
297
Q

Alternatives to BR

A

formula

pumping

BCM (8 decks)

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