Lorna's Review Flashcards
(107 cards)
1
Q
What is Naegele’s rule?
A
3 months back + a week
2
Q
What is BPD?
A
Biparietal Diameter (one parietal bone to the other)
3
Q
What are pregnancy exercise recommendations?
A
Normal and healthy to exercise, but don’t start a new sport (especially contact)
4
Q
When is GDM screen done
A
24-28 weeks
5
Q
What is recommended options for GDM screening w low risk?
A
Glucose challenge screen: 50 g 1 hour no fasting
Glucose diagnosis test: 75 g fasting plus 1 hour and 2 hours
6
Q
What do you do at every antenatal visit (9)?
A
GA
BP
Urine (if indicated)
Wt
Fundal height
Fetal Heart rate
Fetal monitoring
Presentation
Position
7
Q
What do you check in fetal heart rate?
A
Strength, rhythm, rate (110-160)
8
Q
What is normal/abnormal in intermittent oscillation?
A
Normal: Regular rate and rhythm & 110-160
Abnormal: deceleration
9
Q
What does an acel mean in intermittent oscillation?
A
Shows fetal well being but not required for ‘normal’
10
Q
What hormones effect nausea/vomiting?
A
We think hCG, progesterone, and estrogen
11
Q
What hormone causes heartburn?
A
Progesterone and pressure from growing uterus
12
Q
What hormones cause vaginal discharge?
A
The ‘hormones of pregnancy’ :|
13
Q
What is GBS?
A
Group B streptococcus
14
Q
Why are we interested in GBS?
A
Leading cause of morbidity death of nb due to infection, via early onset GBS disease
15
Q
How many birthers are GBS colonized?
A
35%
16
Q
Of those colonized birthers, how many nb are colonized with GBS?
A
50%
17
Q
Of those colonized newborns, how many develop early onset GBS disease?
A
1-2%
18
Q
What is the risk of ANY bb having early onset GBS disease?
A
0.2%
19
Q
When is the GBS swab done?
A
35-37 weeks
20
Q
What is an alternative for GBS beyond taking ABX if screen positive (6)?
A
Only take ABX if you have one of these criteria met:
1) Birther GBS positive again at term
2) Preterm birth
3) ROM 18 hours before birth
4) Maternal fever/suspected infection in labour
5) Previous bb with GBS disease
6) GBS in maternal urine during pregnancy
21
Q
What are active labour contractions like?
A
Stronger, longer, more frequent, and will be regular/more organized over time
22
Q
What is in Bishop’s score (5)?
A
- Dilation (1-10)
- Effacement (thinning of cervix % or cm (3-5 cm before birth))
- (Fetal) Station
- Cervical consistency (soft, medium, hard)
- Position of cervix (Posterior, anterior, midline)
23
Q
What is active mgmt?
A
1) Oxytocin (def)
2) Controlled cord traction (sometimes)
3) Fundal massage (sometimes)
24
Q
What dose of oxy is given in active mgmt?
A
10 units IM or 5 units IV
25
What does expectant management of the third stage look like (7)?
* No uterotonic is given
* No clamping or controlled cord traction
* No fundus fiddling
* Must be patient and not interfere
* Placenta comes with bearing down & gravity
* 3rd stage usually = 15 min
Retained placenta @ 60 minutes
26
What is 'normal' physiological time limit of 3rd stage?
15 mins - one hour
27
What is normal time of 3rd stage in active mgmt?
5-30 mins
28
What is normal blood loss in third stage?
less than 500 mL
29
What is definition of PPH?
Any blood loss resulting in hemodynamic instability and/or more than 500 mL of blood
30
Describe the mechanism for placental separation (7)?
1) Uterine muscle retracts during labour
2) At the onset of 3rd stage the placental site has diminished in area by 75%
3) W this retraction placenta becomes compressed
4) Blood in intervillous pace is forced back into decidua
5) Oblique muscle fibres compress blood vessels/they tense/become congested
6) With the next contraction veins burst, small amount of blood seeps into decidua nd placental surface
7) This pressure helps strip the placenta from it's attachment to uterus
31
What happens during 3rd stage retraction (4)?
1) Oblique fibres shorten clamping blood vessels
2) Septa torn, separation begins
3) Veins in spongy layer of decidua become tense and burst
Villi collapse as blood is released
32
What happens during 3rd stage separation (3)?
1) Living ligatures retract to seal off blood vessels
2) Blood vessels collapse
Blood tracks between placenta and decidua completing separation
33
What are the features of the shiny shultz (6)?
* Separation occurs centrally first
* Large retroplacental clot formed
* Aids separation by exerting pressure at midpoint and helps strip adherent lateral borders and peel membranes off wall
* The clot formed will become enclosed in sac
* Placenta is born shiny fetal side first
Associated with more complete shearing & less fluid blood loss
34
What are the features of the Dirty Duncan (6)?
* Placenta detaches unevenly at one of lateral borders
* Blood escapes so that separation is unaided by retroplacental clot
* Placenta descends, slipping sideways
* Is born maternal surface first
* Takes longer
Associated with ragged, incomplete expulsion and higher fluid blood loss
35
How much blood perfuses the uterus (LOL)?
500-800 mL/min
36
What is the leading cause of death following birth around the world?
Hemorrhage
37
How is the uterine site clamped naturally (5)?
Living ligatures!
* Uterine oblique muscles retract
* The blood vessels are intertwined among these muscle fibres
* The retracted muscle fibres are thicker and put pressure on the torn vessels
* They thus act like “clamps”
The muscle fibres are dense in the upper segment of the uterus: different muscle fibres in the lower segment.
38
How is clot formed in 3rd stage (4)?
* Activation of the coagulation and fibrinolytic systems occurs during and immediately following placental separation.
* Clot formation is intensified
* Following separation, the placental site is rapidly covered by a fibrin mesh
This uses up 5-10th of circulating fibrin
39
How is uterine tone enhanced after birth?
* Breastfeeding and skin to skin
* Causes Oxytocin to be released from posterior pituitary - uterus contract
40
What is central cord insertion?
In the middle of the placenta
41
What is eccentric cord insertion?
Offset from the middle of the placenta
42
What is battledore cord insertion?
Edge of the placenta
43
What is velamentous cord insertion?
Not directly inserted into the placenta (blood vessels of the cord run through the membrane bw the cord and the placenta)
44
What is the amnion?
Inner membrane that surrounds the amniotic cavity
45
What is the chorion?
Outer membrane that covers the amion
46
What should you look for with uterine tone (3)?
* Firm or Boggy
* Massage as indicated for bleeding, tone or retained clots
* Measured in fingerbreadths above, below or @ umbilicus
Ensure bleeding is controlled / Clots expressed
47
WHERE do you expect the uterus after a birth?
Firm, central, 1FBU
48
What are signs of placental separation (3)?
Cord lengthening, small blood loss (may be larger than with AMTSL), uterus contracts (firm globular on palpation at the umbilicus)
49
What are some things 'to do' in physiological management of third stage (3)?
Wait for signs of placental separation
Encourage bearing down w contractions and if needed upright position
After placenta out, gently assess uterine tone (only massage if uterus boggy/bleeding)
50
What do you do with cord in PMTSL?
Leave unclamped till last pulsation has ceased or after birth of placenta
51
When should you change from PMTSL to AMTSL (3)?
On request, bleeding, retained placenta
52
What is the new AMTSL (7)?
1. Body of baby is born, gives Uterotonic > notes time of birth of head, waits for next contraction and
2. Notes time of birth of baby.
3. Baby skin to skin, dried, airway open
4. Controlled cord traction is controversial
a. with physiological cord clamping,
b. with uterine contraction,
c. with counter-traction
5. Assess uterine fundus tone, only massage if indicated
6. 3rd stage usually = 5 min
Retained placenta @ 30 minutes
53
What is Fahy’s Holistic Psychophysiological approach to Third Stage (10)?
* Pregnancy labour and birth have been normal
* The person feels safe, secure, cared about and trusting that their privacy is respected.
* Immediate sustained skin-to-skin + kept warm;
* Midwife gently encourages the focus on baby whilst maintaining awareness that the placenta is yet to be born;
* Support people ensure all interactions remain focused on the dyad;
* There is ‘self-attachment’ breastfeeding;
* Midwife unobtrusively observes for signs of separation of the placenta;
* No fundal meddling or massage;
* Placenta is birthed entirely by pushing effort and gravity.
* Gently check fundus frequently for 1 h post-placental birth to ensure contraction and haemostasis.
(IF ANY PART IS MISSING THAN AMTSL)
54
When should controlled cord traction NEVER be used?
In the absence of a well contracted uterus following the admin of uterotonic
55
Who does SOGC recommend get cord blood sampling?
All births
56
When risk factors are present why is it recommended to get arterial and venous blood cord sampling?
Shows the status of placenta (venous) and baby (arterial)
57
What does arterial blood show you in cord blood sampling?
Baby
58
What does venous blood show you in cord blood sampling?
Placenta
59
What are the 4 Ps?
Powers, Passage, Passenger, Psyche
60
What is Powers?
The contractions: strength, length, and frequency
61
What is passage?
The pelvis: shape, size, angles, pelvic floor, perineum
62
What is the passenger?
The fetus: size, position, and attitude
63
What is the psyche?
Beliefs, history, wishes, capacity, coping
64
What is lie?
Relationship of the long axis of the fetus to the long axis of the uterus
65
What is longitudinal lie?
Fetus runs parallel w length of uterus
66
What is transverse lie?
Fetus is perpendicular w length of uterus
67
What is oblique lie?
Fetus lies on a diagonal
68
What is presentation?
The part of the fetus that lies over the pelvic brim
69
What are the presentation options?
Cephalic, breech, shoulder
70
What is attitude?
The relationship of the head of the fetus to their trunk
71
What are the options of fetal attitude?
Flexed (head tucked into the chest aka flexion)
Unflexed (varying degrees all the way to face presentation)
72
What is the denominator?
The landmark of the presenting part that is used to describe position.
73
What are the denominator options (5)?
Occiput (cephalic vertex)
Sinciput (cephalic brow)
Mentum (cephalic face)
Sacrum (Breech)
Acromion (shoulder)
74
What is position?
Relationship bw denominator and the landmark points on the pelvic brim
75
What are the possible possible positions for fetus with vertex in longitudal lie (8)?
R or L ( right or left side maternal pelvis)
Anterior (baby's back toward birther belly - back toward anterior)
Posterior (baby's back toward birther spine - back toward posterior)
OA (occiput anterior)
LOA (left occiput anterior)
LOT (
LOP
OP
ROA
ROT
ROP
Posterior (back of pelvis)
Anterior (front of pelvis)
76
Describe elements of Powers : Uterus (4)?
§ Most powerful muscle in the body
– 500 - 800 mL of blood / min to uterus at term
§ Contracts from 6 weeks gestation
Braxton Hicks contractions felt by 28 – 32 weeks
77
Describe elements of Powers: Uterine Contractions (4)?
§ Start in the fundus near one of the cornua and spread across and downwards
§ Lasts longest in the fundus where it is also most intense
§ Peak reached simultaneously over whole uterus
Fades from all parts together
78
Describe elements of Powers: Amniotic Sac (3)?
§ Intact membranes create equalized pressure throughout the uterus and over the fetal body called “general fluid pressure”
§ Preserving membrane integrity optimizes the oxygen supply to the fetus and helps to prevent infection
§ Hydrostatic action of membranes helps to effectively dilate the cervix
79
Describe elements of the passenger (2)?
* The fetal skull is capable of moulding to fit through the maternal pelvis
Fetal lie, presentation, position and attitude contribute to the fit as well.
80
What are the cardinal movements in order (8)?
* Engagement
* Descent
* Flexion
* Internal rotation of the head
* Extension of the head
* Restitution- internal shoulder rotation and external head rotation
* Expulsion
ED FIERE
81
Describe the cardinal movements in groups?
1. Head floating before engagement
2. Engagement, Descent, Flexion
3. Further descent, Internal rotation
4. Complete rotation, beginning Extension
5. Complete extension
6. Restitution , External Rotation
Delivery of anterior shoulder, delivery of posterior shoulder (Lateral flexion)
82
What is descent (4) in cardinal movement?
* The downward pressure of the uterine contractions along with the force of gravity encourage the descent of the fetus into the pelvis
* In a Nullip, this may occur prior to labour
* In a primipara and multipara this usually happens in labour
Upright positions and mobility can aid in the descent of the fetus into the pelvis
83
What is engagement (5) in cardinal movement?
* Widest part of the presenting part has passed through the brim of the pelvis – in cephalic presentations this is the bi-parietal diameter
* > 36 weeks in primigravida
* May not occur until labour in a multipara
* Head not engaged: more than half of head palpable above pelvic brim, head is movable (ballotable)
Head engaged: only 2/5 palpable, head not mobile
84
What is flexion in cardinal movement(2)?
* As the fetus descends, the chin tucks into the chest and the arms cross. This is further increased when the head meets the resistance of the pelvic floor
Upright positions and mobility in general can encourage descent and flexion of the fetus.
85
What is internal rotation in cardinal movement (3)?
* As the occiput reaches the pelvic floor, the resistance of the muscles encourage a 45 degree rotation. The head emerges in the longest diameter of the pelvis (the anteroposterior diameter)
* By this time, the woman is usually fully dilated and depending on the station of the head, may or may not have an urge to push
Upright positions, squatting, hands+knees can help to bring the baby down.
86
What is extension in cardinal movement (7)?
* The head extends when it comes under the pubic arch and no longer recedes between contractions
* The widest transverse diameter of the head is born
* Birther usually spontaneously pushing and introverted in her behaviour.
* Slowing the crowning process may prevent or decrease perineal tearing
* Through the process of extension, the bregma, forehead, face and chin will pass over the perineum and the head will be born
* Woman may still be actively pushing or slowly breathing the head out
Perineal support may help to prevent tearing as the head is born
87
What is restitution in cardinal movement (3)?
* The head will turn in the direction of the back, righting itself with the shoulders. The shoulders then rotate to the anteroposterior diameter of the pelvis Rotation follows the same direction as restitution.
* Allow time for restitution. No need to do anything but to wait for the next contraction to deliver the body.
Rushing restitution may cause “shoulder dystocia”
88
What is internal rotation of shoulders in cardinal movement (1)?
* The external manifestation of internal rotation of the shoulders is the head turning with the shoulders after restitution.
89
What is lateral flexion in cardinal movement (3)?
In the supine or semi recumbent positions, the anterior shoulder will be born first (under the pubic arch)
* In a hands+knees position, the posterior shoulder may be born first (over the perineum)
If assisting the delivery, following the natural curve of the flexion is important
90
What should you observe in 4th stage (1st hour)?
* Parent and Infant hemodynamic status
* Vital Signs
* Involution/ Blood Loss
* Bladder
* Perineum – repair as indicated
* Inspect Placenta
* Comfort & Nutrition & Pain Management
* Parental/ Infant Dyad – StS & Breastfeeding
Documentation / PSBC Forms/ Hospital record / Vital Statistics
91
What are some things newborn screen screens for (6)?
1) Metabolic disorders
a. Amino acid disorders
b. Fatty acid oxidation disorders
c. Organic acid disorders
2) Endocrine disorders
3) Hemoglobinopathies
4) Spinal muscular Atrophy
5) Severe Combined immunodeficiencies
Cystic Fibrosis
92
What the the stages of third stage (3)?
1) Latent phase
2) Placental Separation
Expulsion
93
Regular newborn vitals?
HR: 110-160 bpm
RR: 40-60 breaths per minute
Temp: 36.5-37.5 (Axilla temp)
94
Fundal height?
top of pubic symphysis to top of fundus in cm, after 24 wks similar to wks GA +/- 2cm. Palpable just above pubic bone at 12w, measures to umbilicus at 20w.
95
Adult vitals?
- HR: 60-100 bpm
- RR: 12-20
- Temp: 36-37.5 C (oral)
- BP: 90-140 / 60-90
96
Duration of pregnancy?
first day of LMP + 280, or 266 days from ovulation
97
Which is which: vein vs artery
artery = away from the baby; 2 arteries
vein = towards the baby; 1 vein
98
· Why might someone choose a homebirth (5)?
- more control over birth process & environment
- family members & kids can be involved in a more natural way
- desire to avoid medical interventions
- more comfortable at home, less inhibited
- for low risk clients, home is as safe as hospital and associated with lower rates of interventions
99
What are the components of a vaginal exam that you are always looking for
- Bishop’s score: “everything you need to think of for a VE”
o 1. Dilation (0-10 cm)
o 2. Effacement (thinned out %, normally 3-5 cm thick)
o 3. (Fetal) Station (-3, -2, -1, 0, +1, +2)
o 4. Cervical consistency (firm, medium, soft)
o 5. Cervical position (anterior, mid, posterior)
- fetal presentation & position
100
What is the "typical" dilation?
0.5 cm/hr
101
· Baby blues vs PPD?
baby blues – onset usually around day 3-4 (when milk comes in), rapidly changing hormonal levels, self-resolving in 1-2 weeks
- PPD – still around at 2wks pp, weeping, not re-engaging in usual activity, lack of personal care, fatigue & trouble sleeping, trouble concentrating
102
ICD template?
- what is it
- why is it an option, what are the impacts
- what are the options/choices/do nothing
- what are the risks/benefits of each choice
- what is recommended
- BRAIN acronym: Benefits, Risks, Alternatives, Intuition, Nothing/Need time
103
Initial Health Hx?
- obstetric
- medical
- genetic
- infectious disease
- psychosocial
- family
104
Pregnancy blood volume?
Increases
105
Pregnancy Heart Rate?
Increases
106
Pregnancy Stroke volume?
Increases
107
Pregnancy blood pressure?
Decreases
