fetal umbilical arteries, velocity of flow through the fetal umbilical arteries to the plactenta IUGR -> vessels narrow -> increase in ratio between systolic and diastolic
What are some high risk factors in pregnancy?
Diabetes thyroid disease active TB chronic lung disease severe asthma epilepsy clotting abnormalities Rh with antibodies severe anemia acute viral infections congenital heart disease renal disease extreme obesity
What is naegeles rule?
LNMP + 7 days - 3 months, majority of women delivery within 10-14 days, longer cycles, add the number of days to the due date and opposite for shorter periods
What should be included in the medical history?
obstetrical hx - including history of abortion, previous c-section Gyn hx - fibroids, surgeries contraceptive history - (IUD may have led to anemia or scarring of uterus). PID, Family history - HTN, DM, CA
what is the deal with Toxoplasmosis
causes severe neurological damage to the fetus, but only if contracted after 10 weeks (uncooked meats and cat feces)
why is pyelonephritis so risky in pregnancy
can cause premature labor
What is included in first visit?
establish due date weight urine BP pulse temp DTRs - to establish baseline breast exam pelvic assessment (may be postponed) fundal height perform uterine/ fetal palpation FHTs
What do you need to assess on initial pelvic assessment
cervix - consistency, length, patency and position bimanual exam - size of uterus pelvic pelvimetry
5 steps of pelvimetry
assess the depth of the sacral curve assess the size of pelvic inlet assess diagonal conjugate/assess obstetrical conjugate assess contour of, and distance between, the ischial spines/interspinous diameter assess angle, width of pubic arch (done on outside)
iron should be dosed below
100mg/d recommend 75 mg per day
how much folic acid should a pregnant women take
how much protein? how much water
80g of protein two quarts of water
What lab work is needed
CBC - hbg, hct VDLR/RPR Hep B HIV rubella titer blood type with Rh UA
What causes morning sickness
elevated estrogen and hCG
doses of B6 for morning sickness
50 mg BID
what is happening with itchy palms and soles
cause of varicose veins
progesterone relaxing smooth muscle, hindering venous return to throughout the body - 800 IU Vit E
what are some underlying conditions of oligohydramnios?
IUGR, postmaturity syndrome, congenital anomalies
what is TTTS
Twin to twin transfusion syndrome -the "donor" baby is at risk for growth restriction and other complications
What are some signs of RDS (respiratory distress syndrome)
cyanosis, tachypnea, grunting, retractions, nasal flaring - all due to insufficient surfactant
Causes of premature labor
vaginal or urinary infection - chorioamnionitis PROM incompetent cervix polyhydramnios multiples uterine abnormalities faulty implantation of the placenta substance abuse short interval between pregnancies malnutrition fetal death extreme or chronic stress
When do you suspect IUGR
when normal growth occurs up to 24 weeks and then drops off
Causes of IUGR
malnutrition, anemia, chronic HTN, substance abuse, fetal malformation or infection, abnormalities of placenta or cord, prolonged pregnancy, chronic stress
blood glucose below what, is an indication to call physician
What blood issue does IUGR put the baby at risk for?
polycythemia - then jaundice
Causes of LGA
miscalculated dates, molar, diabetes, twins, polyhydramnios, maternal obesity, hereditary predisposition for big babies, fetal anomalies, baby high in fundus due to placenta previa or abnormal muscle tone, fibroids, postmaturity
ways to assess fetal well-being in post dates period
fetal kick counts ( every day for an hour), NST BPP
provide oral fluids position mother flat with legs elevated administer O2 Keep mother warm, avoid overheating administer non-allopathic remedies encourage deep, calm, centered breathing administer or refer for IV fluids activate EMS prepare to transport
What should you look for in the urine of a woman who may have exhaustion in labor
what can you give a woman with ruptured membranes to decrease chances of infection?
fluid - she will continue to make fluid to flush the vaginal area Vitamin C (250 mg q 2 hours)
When does implantation bleeding occur?
6-12 days after ovulation
when does quickening occur?
around 18 weeks
fundal height standard measurements
12 weeks - level of symphysis pubis 16 weeks - 1/2 between pubis and umbilicus 20 weeks - 1 finger below umbilicus 36-38 weeks - 2-3 fingers below xiphoid process
What is the BP changes that are indicative of pregnancy induced hypertension
usually develops post 28 weeks systolic by 30, diastolic rise by 15, medical intervention needed at 160/100
what is variable decelerations (type III)?
dips in FHTs well below 80 and above 160 during a contractions - caused by cord entanglement or cord compression, the degree of which varies according to the strength of a contraction and the resulting tension or pressure exerted on the cord - change maternal position
what is late deceleration (type II)
dip in FHTs late in contraction, placental insufficiency or maternal ketoacidosis - not enough oxygen reaching the baby,
how dilated does a cervix need to be to determine position
which fontanelle is smaller
posterior and triangular and the size of a fingernail
what shape is the anterior fontanelle
diamond, size of a thumbnail
what can the mother do before entering second stage do decrease chances of PPH
what are early decelerations (type I) a sign of
head compression, FHTs return to normal by the end of the contraction
how long is second stage when it becomes prolonged
at what FHT rate does birth need to happen ASAP
when the head is visible what is a good way to determine if baby is getting adequate oxygen
press the baby's scalp white/blue is bad
is suction on the perineum considered mandatory if the baby has passed meconium
yes it is standard of care
Why do you not want to massage or rub a uterus with a placenta still in it?
is can result in partial separation or hemorrhage
what is considered guarding a uterus according to heart and hands
place a hand on fundus of uterus immediately post delivery and leave it there until delivery of placenta - to prevent concealed hemorrhage
What is it called when the vessels are suspended in membrane alone (without wharton's jelly) occurs right near insertion?
velamentous cord insertion
what is an extra lobe like piece of placenta called
what is a birth red tone to the baby's skin a sign of
polycythemia - usually a sign of prematurity
what is lanugo
fine hair covering the body
two colorings that are abnormal at birth and require immediate transfer
jaundice and circumoral cyanosis
What does a cephalhematoma look like
abnormal, lumplike swelling confined to a particular area of the head and does not cross suture lines, it is internal bleeding between the scalp and the skull
at what level should the ears be in relation to the corner of the eye of a newborn
top of ear equal with corner of eye, lower ears are a sign of kidney problems or other anomalies
what is the concern if the newborn's femoral pulses are not symmetrical
congenital heart defect
what should a babies toes do with a babinski reflex
How to do you diagnose clinical exhaustion
ketonuria, elevated temperature and elevated pulse
what is fetal overlap
when the fetal head bulges over the pubic bone
What is inlet disproportion
arrest of labor at 6cm dilation, lack of descent past -3 or -2 station, asynclitism, and cervix not well applied to the head
What is midpelvic disproportion
the head generally engages without trouble, dilation proceeds normally, but second stage is prolonged
what is deep transverse arrest
the head gets wedged behind the ischial spines and cannot rotate to the antero-posterior position
what is out outlet disproportion
prolonged second stage, but more commonly affects the perineal phase, causing severe early decels or bradycardia, delayed delivery and tears of the bulbocavernous muscle or perineum
Cord nipping is?
when the cord is periodically pinched between the head and pelvic bones, causing variable decelerations in the Fetal Heart Rate
What can cord nipping lead to in second stage
what is an occult cord prolapse
it is when the cord is low enough in the pelvis to be increasingly compressed by the head as it descends, but not low enough to be at the os of the vagina
what are some associations with complete cord prolapse
polyhydramnios, multiple pregnancy, breech or compound presentation and transverse lie
When does a woman push during a breech delivery
not until the body is born
What are the two principle causes of intrapartum bleeding
placenta previa and placenta abruption
definition of third stage bleeding
loss of 500cc of blood after the birth of the baby
what actions should you take with partial placenta separation
immediately give the mother tincture of angelica, begin vigorous nipple stimulation, administer 10 to 20 units of pitocin by IM injection
Why do you not need to worry about pitocin closing the cevical os before the placenta is delivered
because it only contracts the longitudinal fibers of the uterus, not the circular ones
what can you inject into a cut cord to encourage placental seperation
10 units of pitocin mixed with 10 units of saline
How soon can you administer pitocin to attempt to get a placenta out after the initial dose
does methergine close the cervical os
what is fourth stage hemorrhage
blood loss of 500cc or more after the placenta is delivered but within 24 hours of birth
what is the major cause of 4th stage hemorrhage
what is one of the first things you should check with a fourth stage hemorrhage
a full bladder then sequestered clots
what is the difference between placenta accreta and percreta
accreta - placenta implants on myometrium percreta - placenta invades the myometrium (occurs after cesarean)
what are the two categories of neonatal depression
primary apnea - describes the baby that has not been hypoxic for long, but has made gasping/respiratory efforts while in utero secondary apnea - baby has dad a greater degree of apnea, and has made a second round of gasping/respiratory efforts - will not try again, needs ventiliation
baby with apgar at 6 needs?
suction, warmth, and stimmulation via immediate firm massage
if a an apgar is less than 7 how often do you do apgar scores after that
every 5 minutes until two in a row are 8 or higher
When doing CPR when do you stop doing chest compression
when the heart rate reaches 60 bpm
at what weight does a stillborn baby need to be in, that a coroner must be notified
non-threatening condition caused by a hormone in the mother's milk that can interfere with the baby's ability to process bilirubin - manifests after the milk comes in
What is the cause of pathological jaundice
liver disease, an obstructed bile duct, infection, or Rh hemolytic disease - manifests within the first 24 hours
what is kernicterus
high levels of bilirubin that baby is unable to eliminate that seep into the basal ganglia of the brain
signs of kernicterus?
lethargy and a high pitched cry
how much sunlight exposure should jaundice babies have
30 min BID, with eyes covered
what is the primary danger of a vaginal hematoma?
infection - pooled blood readily permits bacteria
what are symptoms of a uterine infection?
fever over 101 degrees elevated pulse pelvic pain subinvolution of the uterus
what are some other names for a uterine infection?
puerperal infection endometritus
what are some risk factors for a uterine infection
anemia compromised immune system PROM numerous vaginal exams in labor manual rotation or other manipulations of the baby during labor maternal exhaustion delayed placenta delivery hemorrhage uterine exploration Postpartum dehydration improper perineal hygiene
what is thrombophlebitis?
inflammation of either a superficial or deep vein (usually in the leg)
superficial thrombophlebitis will present?
leg pain, with heat tenderness and redness at the site of inflammation
deep thrombophlebitis will present as?
high fever, severe pain, edema, and tenderness along the entire length of the leg
how does mastitis occur?
milk is left pooled in the sacs, particularly if a residual amount remains timer after time and bacteria enter through the nipple
what are some physiologic causes of Post partum blues
anemia malnutrition - poor diet
when does PPD usually set in?
10 days after birth or later
When PPD is also characterized by fatigue, what might be the problem?
what are 4 categories for PPD?
psychiatric factors demographic factors relationship factors cultural factors
what is postpartum psychosis
an extreme form of PPD, characterized by manic or depressive episodes of confusion or disorientation, delusional thinking, and suicidal or infanticidal behaviors
What are some indications for RhoGAM?
delivery of an Rh positive baby to an Rh neg mother (within 72 hours) antepartum prophylaxis at 26-28 weeks antepartum fetal-maternal hemorrhage as a result of placenta previa, amniocentesis, CVX, pecutaneous umbilical sampling actual or threatened pregnancy loss at any stage of gestation ectopic pregnancy
When do you use 300ug of RhoGAM
for antenatal and postnatal use, second or third trimester pregnancy terminations or transplacental hemorrhage
When do you use MICRhoGAM 50ug?
for use immediately after first trimester pregnancy termination
Is amniotic fluid more or less alkaline than vaginal fluid
more alkaline - normal vaginal fluid is 4.5 -5.5 and amniotic fluid is 7.0-7.5
what fluid can give a false positive on nitrazine paper (positive being ROM)
blood - it's pH is close to amniotic fluid semen - also has a higher pH than the vagina