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Indications for complete genetic eval
AMA, personal or family hx of defects, abnormal screening
indications for hcg
high: hydatidiform mole
low rising: ectopic pregnancy
dropping: loss or pregnancy greater than 12 weeks
what is included in first trimester screening
biochemical makers:
hcg,
PAPP-A, high in down's syndrome
NT screening: increase = fetal aneuoploidy, cardiac, others
what time frame is first trimester screening completed?
between 9 weeks and 13 weeks. NT can only be done between 11 weeks through the end of week 13
what is included in second trimester screening
AFP- yolk sac and fetus liver, increases to 20 weeks then declines
multiple marker screening (triple) - MSAFP (maternal AFP), hcg, unconjugated estriol
integrated screen: quad and NT
on a multiple marker screening an elevated hcg is indicative of
down syndrome
when is the multiple maker screen completed?
between 15 and 18 weeks and should be down with first trimester screens (combination is a integrated or sequential screening)
on a multiple marker screening an elevated AFP is indicative of
neural tube defect like spina bifida (associated with increased levels of actylcholinesterase in amniotic fluid, or omphalocele, or gastroschisis, or multiple gestation
what is added to Multiple marker screen to make it a quad?
inhibin - an elevated level is suggestive of down's syndrome
what is an elevated AFP indicated?
underestimation of gestational age, neural tube defects, renal anomalies, oligohydramnios, ectopic pregnancy, fetal maternal hemorrhage, underweight mother, black race, increased placenta size
what does a low AFP indicate?
down's syndrome
how do you test for neural tube defects?
amnio for AFP, acetylcholinesterase testing, karyotyping
When do you do a CVS?
between 8 and weeks, not after 10
what are some disadvantages for CVS
increased risk of pregnancy loss, oligohdraminios, ROM, subchorionic hematoma, limb reduction
What are indications for cordocentesis?
rapid DNA karyotyping of fetus, assessment and tx of Rh isoimmunization, measurement of blood gases for severe IUGR, fetal infection dx
What are some indications for BPP?
IUGR
postdates
Non reactive NST
multiple pregnancy
IDDM
What is tested on BPP
fetus oxygenated and neurologically intact,
movement, muscle tone, respiratory activity
what level on BPP is delivery indicated?
4/10
What can cause low amniotic fluid volume?
uteroplacental insufficiency, fetal hypoxia, fetal genitourinary or lung anomalies
What can cause a high amniotic fluid volume?
chromosomal abnormalites, structural anomalies, neural tube defect, CNS malformations, maternal DM, maternal substance abuse
what is doppler velocimetry
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
800mcg
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
intrahepatic choestasis
cause of varicose veins
progesterone relaxing smooth muscle, hindering venous return to throughout the body - 800 IU Vit E
Three layers of the uterus
external - longitudinal
internal- circular
middle - connective
what is a caruncle
hymenal skin tags that occur after birth
anemia definition
HCT- below 33
HBG- below 10
Weight gain
10 lbs by twenty weeks and 1 lb a week after that
What percentage of women bleed in first trimester
25%
What is a women at risk for with retained products of conception from missed abortion?
DIC
how many miscarriages before it is habitual?
>3
what is the time in weeks that an ectopic pregnancy is likely to rupture?
between 8-10
what puts a woman at increased risk for ectopic pregnancy
PID, severe GI upset, appendicitis
Two types of hydatidiform mole
complete - no fetus (abnormal sperm inactivating the chromosomes of the ovum)
partial - fetal tissue present - with abnormal numbers of chromosomes
What is a abnormal development of the chorionic villi?
molar pregnancy
What is a classic symptom of molar pregnancy
light brown bleeding
What age is more at risk for molar pregnancy?
over 40
some signs and symptoms of molar pregnancy
uterus is large for dates and feels woody hard or doughy to touch
abnormally high hCG
elevated hCG can lead to HTN and proteinuria
hyperemesis
is there pain with concealed placental abruption
yes - acute abdominal pain with a persistent location
Risks for placenta previa
previous uterine surgery
endometriosis
multiparity
pregnancies with short intervals between
maternal age over 35
4 types of placenta previa
total
partial
marginal
low lying placenta
should you do a vaginal exam with bleeding in late pregnancy?
no never - could be a placenta previa
what are some consequences of gestational diabetes
macrosomia
fetal respiratory distress- due to increased insulin interrupts production of surfactant
pre-eclampsia
polyhydramnios
greater risk for PPH
newborn at risk for hypoglycemia/hypocalcemia
To diagnosis essential HTN, what are the parameters for BP readings
two elevated readings 6 hours apart
what is a consequence of gestational HTN
prolonged HTN can lead to IUGR- secondary to vasoconstriction and decreased O2 getting to fetus
increased risk for placental abruption
preeclampsia and eclampsia
signs and symptoms of preeclampsia
occurring after 26 weeks
hemoconcentration, hypertension, generalized edema, sudden and excessive weight gain, protein in urine
What may be the first sign of preeclampsia
hemoconcentration seen by an abnormally high HCT
pitting edema grading
+1 = 2mm depression
+2 = 4mm depression
+3 = 6 mm depression
+4 = 8 mm depression
(greater than +2 is sign of preeclampsia)
6 symptoms of preeclampsia
severe HA
epigastric pain
visual disturbances
decreased urine output
extreme nervous irritability
decrease in fetal movement
Causes of polyhydramnios
multiples
Rh incompatibility
diabetes
fetal anomalies (esophageal atresia, hydrocephaly, anencephaly or spina bifida)
what is the classic sign of polyhydramnios?
fluid thrill (like for ascites)
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
45
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
what is evaluated in BPP
fetal muscle tone, breathing movements
amniotic fluid volume and NST results
what level on BPP is delivery indicated?
less than 7 (heart and hands)
What do you do to manage shock?
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
ketones
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
recommended weight gain according to BMI
<19.8 = 28-40 lb
19.8 to 26 = 25-35 lb
>26 = 15-25 lb
causes of first trimester bleeding
ectopic, severe cervicitis, cervical lesions, cervical polyp, postcoital bleeding, implantation, subchorionic blood, demise of a twin, rarely h. mole
Causes of second trimester bleeding
ruptured cervical polyp, placental abruption, placenta previa
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
6cm
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
urinate
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
2 hours
at what FHT rate does birth need to happen ASAP
60 bpm
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
succenturiate lobe
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
fan out
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
cord compression
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
three main causes of third stage bleeding
partial placenta separation, cervical lacerations, vaginal tears
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
8 minutes
does methergine close the cervical os
yes
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
uterine atony
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
500g + (the coroner signs the death certificate)
things to address at PP visits
nipples/breastfeeding
uterus involution
lochia
perinuem healing
mother temp/pulse/BP
baby's cord stump
baby's color, skin consistency
baby's elimination patterns/nursing patterns
What do you need to address at the last visit
the uterus
the cervix - PAP smear
internal muscle tone
lacerations or episiotomy
abdominal muscle tone
breasts - tenderness and lumps
hemoglobin/hematocrit
diet
adjustment to parenting
baby hypoglycemia is at what level
50 - 60 is normal, anything below 30 is serious
What babies are at risk for hypoglycemia
LGA
SGA
premature
postmature
babies of diabetic mothers
what are some symptoms of hypoglycemia
apathy, irregular respirations, inability to regulate body temperature, refusal to nurse, irritability, and tremors
treatment suggestion for baby at glucose of 45
nurse as often as possible and water with a little molasses (1 tsp/cup)
flaring, grunting and retractions are signs of
respiratory distress syndrome
what is the cause of transient tachypnea
delayed absorption of fetal lung fluid
what is associated with transient tachypnea
respiratory distress syndrome
meconium aspiration
sepsis
how do septic babies present?
lethargy, irritability, jitteriness, fever, dehydration
when does physiologic jaundice manifest
second or third day
can ABO incompatibility cause jaundice?
yes, similar to the way Rh sensitization does
what is breast milk jaundice
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?
postpartum thyroiditis
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