Midterm Study Flashcards

Question

Describe the term antepartum

Answer 1

o Also called prenatal o Time between conception and onset of labour o Often used to describe the period during which a woman is pregnant

Answer 2

o Number of weeks of pregnancy since the first day of the last menstrual period

Answer 3

o First – first day of LMP through 12 completed weeks o Second – 13 weeks through 27 completed weeks o Third – 28 weeks through 40 completed weeks

Answer 4

o Pregnancy counts from the first day of the last menstrual period (LMP) o Gestation lasts for 40 weeks (10 lunar months) o The first 2 weeks of pregnancy correlate with development of the oocyte and endometrial lining

Answer 5

o Embryo count begins with oocyte fertilization (so different start dates) o Gestation lasts for 38 weeks

Answer 6

Beta-hCG, or b-hCG, or hCG o Production begins at implantation o Can be detected about 8-10 days after fertilization o Concentration peaks at 9-10 weeks o Declines to a stable level after 20 weeks Reduced levels indicate  Miscarriage  Abnormal gestation (i.e. Down’s syndrome) Higher levels indicate  Molar pregnancy  Multiple gestation

Answer 7

o Subjective changes reported by the patient o Symptoms can be caused by conditions other than pregnancy Examples include  Amenorrhea  Fatigue  Breast changes

Answer 8

o Objective changes assessed by an examiner o When combined with presumptive signs and symptoms, these changes strongly suggest pregnancy Examples: Hegar sign (softening of lower uterus) Ballottement (rebounding baby) Pregnancy tests or beta-hCG (could be molar)

Answer 9

o Objective signs assessed by an examiner that can be attributed ONLY to the presence of the fetus  Hearting fetal heart tones  Visualizing the fetus  Palpating fetal movements o HCG doubling every 48 hours (could argue that this is still presumptive lol), won’t be an exam question o Definitive signs that confirm pregnancy

Answer 10

First trimester o Uterine enlargement occurs due to  Increased vascularity and dilation of blood vessels  Hyperplasia  Hypertrophy o Week 7 – size of an egg o Week 10 – size of an orange o Week 12 – size of a grapefruit Second and third trimester o Uterine enlargement occurs due to pressure of the growing fetus

Answer 11

* Preconception – upside-down pear shape * Second trimester – spherical shape * Late pregnancy – ovid shape

Answer 12

Prelabour contractions (Braxton Hicks) o Intermittent, irregular, painless contractions that can be annoying o Facilitate uterine blood flow and promote oxygen delivery to fetus o Begins after 4th month until labour o Does not increase in intensity or duration and does not cause cervical dilation (this would be labour)

Answer 13

* More oxygen extracted from uterine blood during latter part of pregnancy * Uterine blood flow increase by 10 fold, and about 1/6 of total blood volume is within the uterine vascular system Factors that decrease uterine blood flow are o Low arterial pressure o Contractions of the uterus o Supine position Estrogen may stimulate an increase in uterine blood flow Doppler can be use to measure uterine blood flow especially in pregnancies at risk due to conditions associated with decreased placental perfusion including o Hypertension o Intrauterine growth restriction o Diabetes mellitus o Multiple gestation Ultrasound or fetal stethoscope may hear o Uterine souffle or bruit  Rushing or blowing sound of maternal blood flowing through uterine arteries to placenta  Synchronous with maternal pulse o Funic souffle  Fetal blood coursing through the umbilical cord  Synchronous with the fetal heart rate o Fetal heartbeat

Answer 14

* Responsive to hormones * Remains firm and closed to maintain pregnancy * Nullipara – rounded cervix * Previous vaginal birth – cervix is oval in the horizontal plan AT WEEK 6 Goodell sign * Softening of cervical tip Velvety appearance * Caused by proliferation at the external os (orifice) Increased friability (tendency to break apart) * Results in slight bleeding after vaginal exams or coitus

Answer 15

Fluttering fetal movements o Multiparous patient may feel it about week 14, nulliparous patient may not notice until 20 weeks o Gradually increases in intensity and frequency  Starts as subtle flutter that is very delicate  At end of pregnancy you can see it outside of abdomen o The week it starts may help date the gestation Affected by  Maternal obesity  Multiples (twins, triplets etc)  Fetal position

Answer 16

violet-bluish colour of vaginal mucosa and cervix Caused by the increased vascularity

Answer 17

Copious white/light grey mucoid discharge that smells faintly musty Cervical response to estrogen and progesterone The white is exfoliated vaginal epithelial cells caused by hyperplasia and is a normal finding

Answer 18

Aka the mucous plug o Caused by leukorrhea mucous filling the endocervical canal o Acts as a barrier against bacterial invasion

Answer 19

o Decreased anaerobic bacteria but increases in Lactobacillus o Decreases pH of vaginal secretions o Changes prevent ascending bacterial infections o May help establish gut microbiome of infant

Answer 20

They become enlarged due to  Increased vasculature  Hypertrophy of perineal body  Deposition of fat

Answer 21

Nullipara patients approximate and obscure the vaginal entrance Separation and gape may occur due to  Previous childbirth  Perineal or vaginal injury

Answer 22

Early gestation may have the following due to increased estrogen/progesterone levels: o Fullness o Heaviness o Heightened sensitivity (tingling to sharp pain) Blood vessels – dilate and become more visible Enlargement o Occurs during 2nd and 3rd trimester o Growth of mammary glands

Answer 23

o Production begins by the end of the first trimester due to prolactin o Secreted during the second trimester due to human placental lactogen o Lactation inhibited until progesterone decline after birth

Answer 24

o Also called stretch marks o Generally occur on abdomen, thighs, and breasts o May feel itchy o Colour darkens as patients skin darkens

Answer 25

o Proliferation of the lactiferous ducts and lobule-alveolar tissue o Result of high levels of luteal and placental hormones

Answer 26

o Primary areolae become more pigmented o Secondary pinkish areolae develop beyond the primary areolae o Nipples become more erect Montgomery tubercles – small bumps around the primary areolae  Caused by hypertrophy of sebaceous glands embedded there  Help secrete lubricating and anti-infective substances to protect the nipples and areolas during breastfeeding

Answer 27

* Glandular tissue displaces connective tissues so breasts become softer and looser

Answer 28

* Slight cardiac hypertrophy may occur but returns to normal size within 6 months of childbirth o Elevated upward and rotated forward to the left

Answer 29

o Apical pulse can shift up and out due to change in heart position o Audible splitting of S1 and S2 o S 3 o Systolic and diastolic murmur (best heard over left sternal border) o Generally returns to normal after birth

Answer 30

Heart rate o Begins to climb at 5 weeks and can reach a peak of 15-20 beats over normal Cardiac rhythm o Limited effects o May cause  Sinus dysrhythmia  PACs or PVCs o Close supervision should be made for those with pre-existing heart disease

Answer 31

* Increases by 1.2-1.5L above pregnancy level (40-50%) o Rapidly rises early and peaks around 28-34 weeks before stabilizing o Volumes are higher in multiple gestation

Answer 32

o Also called physiological anemia o RBCs only go up 17% though so lots of it is just plasma o Hemoglobin and hematocrit both decrease  Peaks during second trimester

Answer 33

o Total increases during second trimester, peaking in third o Mostly granulocytes

Answer 34

o Protective function to decrease chance of bleeding o Increases risk of thrombosis especially after C-section Caused by  Increase in clotting factors  Decrease in factors that inhibit coagulation  Depressed fibrinolytic activity

Answer 35

* Increases 30-50%, with half occurring by 8 weeks Results from o Increased stroke volume o Increased rate o Increased tissue oxygen demands

Answer 36

* Blood pressure remains stable or decreases slightly due to decreased systemic vascular resistance which is caused by o Vasodilatory effects of progesterone, prostaglandins, and relaxin o Uteroplacental vascular system holding a large percentage of blood volume Systolic pressure o Remains stable but can raise slightly during advanced pregnancy Diastolic pressure o Beings to decrease in first trimester until 28 weeks o After 28 weeks, gradually returns to pre-pregnancy level at term

Answer 37

o Also called vena cava syndrome o Systolic drop >30 mmHg when laying supine o Cause by compression of inferior vena cava by the baby

Answer 38

Maternal oxygen consumption increases by 20-40% during pregnancy Diaphragm pushed up as much as 4 cm by enlarging uterus o Less able to participate in breathing o Chest breathing becomes more predominant Lower ribs flare out and rib cage ligaments relax increasing chest expansion Upper respiratory tract becomes more vascular leading to o Increased nasal and sinus stuffiness o Epistaxis o Changes in the voice o Marked inflammatory response to even a mild upper respiratory tract infection o Swelling of tympanic membrane and eustachian tube leading to  Impaired hearing  Earaches  Sense of fullness in the ear Tidal volume increases by 40% Respiratory alkalosis occurs facilitating the transport of CO2

Answer 39

Bladder symptoms early in pregnancy and again near term o Bladder irritability o Nocturia o Urinary frequency and urgency (without dysuria)

Answer 40

Changes  Ureter walls undergo hyperplasia, hypertrophy, and muscle tone relaxation  Ureters above the renal brim and the renal pelvis dilate  Ureters elongate, become tortuous, and form single or double curves Results  Larger volume of urine is held in renal pelvis and ureters and urine flow slows Consequences  Urinary stasis or stagnation can result in * Lag between urine formation and reaching the bladder affecting clearance test results * Increased risk of UTI o Higher sugar content and higher pH level don’t help this risk

Answer 41

Results in urethra that lengthens in response and can cause o Hyperemia of bladder and urethra due to pelvic congestion o Mucosa off bladder is easily traumatized resulting in bleeding o Bladder tone decreases increasing capacity o Bladder compressed by the uterus resulting in urge to void even if its mostly empty

Answer 42

GFR increases in early pregnancy resulting in o Increased creatinine clearance o Decreased serum creatinine, BUN, and uric acid levels Most efficient in side lying Supine position results in vena cava and aorta compression and kidney blood flow deceases

Answer 43

Tubular resorption of sodium increases

Answer 44

o Edema that occurs in the lower legs during later pregnancy o Does not require treatment o When patient is side lying, the pooled fluid will re-enter circulation

Answer 45

o May occur at varying times due to impaired glucose resorption o If noted, possibility of DM or gestational diabetes should be considered

Answer 46

o Increased excretion of protein and albumin after 20 weeks  Due to increased GFR and impaired proximal tubular function o There are abnormal levels, but the amount isn’t an indication of severity o If patient also has HTN, careful evaluation should occur

Answer 47

nipples, areolae, axillae, and vulva

Answer 48

o Blotchy, brownish hyperpigmentation of skin over cheeks, nose, forehead o Begins about week 6 and darkens gradually until term but usually fades after birth o More likely in those with dark complexions

Answer 49

o Pigmented line extending from symphysis pubis to the top of the fundus o With the first baby, it grows as the baby grows, subsequent pregnancies it just appears

Answer 50

o Also called vascular spiders o Tiny, star-shaped, lightly raised, pulsating end-arterioles o Appear on neck, thorax, face, and arms during months 2-5 and usually disappear a few months after birth

Answer 51

o Pinkish-red diffusely mottled or well-defined blotches over palmar surfaces that occurs during pregnancy

Answer 52

o Mild pruritic over abdomen that usually resolves after birth o Topical steroids and emollients may help with itching

Answer 53

o Also called pruritic urticarial papules and plaques of pregnancy (PUPPP) o Very itchy red bumps that appear over the abdomen and while it can cause significant discomfort, it is not associated with adverse outcomes for mom or baby o Occurs late in pregnancy and resolves after birth Less common but associated with  Increased weight gain during pregnancy  Multiple gestations  Hypertension  Induction of labour Usually treated with oral antihistamines and topical antipruritic and corticosteroid creams; severe cases may need oral steroids

Answer 54

o Can worsen during pregnancy (or be a new onset) o Accutane is a teratogen, so should be avoided

Answer 55

Increases due to  Increased blood supply to the skin  Increased metabolic rate

Answer 56

o Excessive growth of hair or growth in unusual places o Fine hair likely to disappear after pregnancy, but coarse hair does not usually

Answer 57

o Growth may be accelerated o Scalp hair loss slows during pregnancy o Increased hair loss may be noted after birth

Answer 58

o Growth may be accelerated o Thinning and softening of the nails may be noted

Answer 59

* Center of gravity shifts forward * Lordosis develops * Lower back pain occurs due to low spine stress * Pelvic relaxation * Abdominal wall stretches, losing muscle tone

Answer 60

o Accentuated by large breasts and stoop-shouldered stance o Compensatory exaggerated anterior flexion of the head develops to help maintain balance

Answer 61

o Permits enlargement of pelvis to facilitate birth o Considerable separation of symphysis pubis and instability of SI joints causes pain and difficulty walking o Waddling gate

Answer 62

 Rectus abdominis that separates in the third trimester  May persist even after birth as muscle regains tone

Answer 63

o Sensory changes in lower limbs due to compression of pelvic nerves and blood vessels o Pain caused by lordosis pulling or compressing nerves o Carpal tunnel syndrome o Acroesthesia (loss of sensation in the hands) o Tension headaches o Lightheadedness or syncope o Muscle cramps or tetany may be caused by hypocalcemia o Corneal thickening and decreased intraocular pressure occur during pregnancy and resolves shortly after birth

Answer 64

 Up to 80% experience it  Usually subsides at the end of the first trimester  Ranges from mild distaste for some foods to sever vomiting

Answer 65

 Occurs in 1% of pregnancies  Persistent vomiting leading to a weight loss of >5%  Associated with electrolyte imbalance and ketonuria  Intervention likely required

Answer 66

Gums o Hyperemia, spongy, and swollen o Bleed easier Epulis o Also called gingival granuloma gravidarum o Red, raised nodule on the gums that bleeds easily o May develop in third month and enlarge throughout pregnancy o Avoid trauma to area o Usually regresses after birth Increased risk for gingivitis and periodontitis o Periodontitis associated with poor pregnancy outcomes such as  Preterm birth  Low birth weight baby

Answer 67

Decreased tone and motility of smooth muscles, causing o Esophageal regurgitation o Slower stomach emptying o Reverse peristalsis Pyrosis o Heartburn or acid indigestion o May be as early as first trimester and intensify throughout pregnancy Hiatal hernia o Increased risk due to upward displacement caused by uterus o More common in multiparas and older or obese patients

Answer 68

 Smooth muscle relaxation and reduced peristalsis  Change in food intake and type of foods  Lack of fluids  Iron supplements  Decreased activity  Abdominal distension of the uterus  Displacement and compression of intestines by gravid uterus

Answer 69

Iron absorption in small intestines increases Microbiome changes o May protect the fetus and contribute to establishing the microbiome of the newborn Constipation Hemorrhoids o Swollen veins in the lower rectum (internal) or on the anus (external) o Common to develop in the third trimester and often resolve after birth o Can evert or bleeding during straining at stool from constipation

Answer 70

* Often distended due to decreased muscle tone * Slower emptying times results in thickening bile and possible stones

Answer 71

Hemodilution results in serum albumin and total protein levels to decrease ALP increases up to 4 times normal but other LFTs remain normal Intrahepatic cholestasis o Retention and accumulation of bile in the liver o May occur late in pregnancy due to placental steroids o May result in severe itching and possibly jaundice

Answer 72

o Pelvic heaviness or pressure o Round ligament tension o Flatulence o Distension o Bowel cramping o Uterine contractions Be alert because it may be caused by o Bowel obstruction o Inflammatory process

Answer 73

Because the appendix is displaced

Answer 74

* Produced by trophoblast tissue and eventually chorionic villi * Supports function of corpus luteum * Measuring levels can help in o Identifying a normal pregnancy o Pathologic pregnancy or pregnancy complications o Following an aborted pregnancy * Levels vary widely between women o Exponentially rise in first trimester and peaks at week 10

Answer 75

* Produced initially by corpus luteum and then by placenta * Inhibits FSH and LH * Helps establish placenta * Stimulates growth of blood vessels that supply the womb * Inhibits contraction of the uterus so it can grow with baby * Strengthens pelvic wall muscles for labour * Causes fat deposit in subQ tissues of maternal abdomen, back, and upper thighs * Decreases ability to utilize insulin

Answer 76

* Produced initially by corpus luteum and then by placenta * Inhibits FSH and LH * Helps uterus grow and maintain its lining * Helps fetal organ develop * Activates and regulates production of other hormones * Works with progesterone to stimulate breast growth and mild duct development * Causes fat deposit in subQ tissues of maternal abdomen, back, and upper thighs * Increases retention of sodium and water

Answer 77

* Produced by anterior pituitary gland * Main hormone needed to produce milk * Contributes to enlargement of the mammary glands and prepares them for milk production * Inhibits lactation during pregnancy

Answer 78

* Produced initially by corpus luteum and then by placenta * Inhibits uterus contraction to prevent premature birth * Vasodilates to increase blood flow to placenta and kidneys * Relaxes joints of pelvis * Softens and lengthens the cervix during birth

Answer 79

* Produced by posterior pituitary gland * Levels rise at start of labour stimulating uterine contractions * Triggers production of prostaglandins further increasing contractions * Can be used to induce labour * Stimulates milk ejection from breasts

Answer 80

* Previously called chorionic somatomammotropin * Produced by placenta * Acts as a growth hormone * Contributes to breast development * Decreases maternal metabolism of glucose * Increases the amount of fatty acids for metabolic needs

Answer 81

Accepting the pregnancy Identifying with the mother role Reordering personal relationships Establishing a relationship with the fetus Preparing for the birth

Answer 82

1 - I am pregnant 2 - I'm going to have a baby 3 - I'm going to be a mother

Answer 83

Accepting the pregnancy Identifying with the father role Reordering personal relationships Establishing a relationship with the fetus Preparing for the birth

Answer 84

1 - Announcement 2 - Moratorium (adjusts to reality, probably talks to their own dad) 3 - Focusing phase (usually last trimester and begins to actively become involved)

Answer 85

Germinal phase - conception to end of week 2 (embryology count) Embryonic phase - week 3 to the end of week 8 (embryology count) Fetal development - week 9 to end of pregnancy (embryology count)

Answer 86

* Conception until the end of week 2 (embryology counts) * Fertilized ovum divides and burrows into the uterus * Not susceptible to teratogenesis * Death of the embryo and spontaneous abortion are common

Answer 87

Embryonic phase Embryo is most susceptible to damage from external sources including o Teratogens (i.e. alcohol, medications) o Infections (i.e. rubella, cytomegalovirus) o Radiation o Nutritional deficiencies

Answer 88

Organogenesis Occurs during the embryonic phase begins in week 3 and continues until the end of week 8 (embryology counts)

Answer 89

o Neural tube defects o Heart defects o Limb abnormalities including missing parts of limbs/extremities o Cleft lip or cleft palate o Deafness o Ocular defects o Enamel hypoplasia (undeveloped tooth enamel) o Masculinization of female genitalia

Answer 90

* Weeks 3 to completion of week 8 (embryology counts) * Critical period of differentiation * By the end of embryo phase, it is starting to resemble a human being * Embryo is most susceptible to damage from external sources Organogenesis o Begins on day 17-19 until the end of week 8 o Starts with formation of the neural plate and continues until the end of the embryonic phase o Beginning development of the  Neural tube forms which then becomes the spinal cord  Brain  GI tract  Arm and leg buds appear and grow out from the body as they develop o Heart development  Complete at the end of embryonic phase  Fetal heart rate may

Answer 91

* Functional defects and minor anomalies may occur

Answer 92

o Sexual differentiation continues o Fetal heartbeat can be heard by the end of week 12 o Heartbeat is discernible by ultrasound o First movements begin at 12 weeks o Kidneys begin to produce urine

Answer 93

o Meconium in bowel o Musculoskeletal system has matured, most bones are distinct o Fetus makes active movement o Weight quadruples o Fetal heartrate is discernible with Doppler o Baby’s sex can be determined by ultrasound

Answer 94

o Fetal movement (quickening) detected by mother o Enamel on teeth is depositing o Bones ossifying o Brain grossly formed, spinal cord myelination begins o Vernix caseosa, a white, greasy film, covers the fetus o Eyebrows, eyelashes, and head hear develop

Answer 95

o Respiratory movements begin and alveoli are forming o Lungs begin to produce surfactant o Can hear o Eyelashes and eyebrows well formed o Fetus has a hand grasp and startle reflex o Skin is red and translucent

Answer 96

o Fetus about 15 inches or 28.1 cm long o Rapid brain development o Fetus can breathe, swallow, and regulate temperature o Eyelids reopen so they can now open and close o Fetus usually assumes head-down position (cephalic presentation) o Nervous system controls some functions o Fingerprints are set o Blood formation shifts from spleen to bone marrow

Answer 97

o Body fat rapidly increases o Lungs developed but immature o Rhythmic breathing movements o Fetus stores iron, calcium, and phosphorus o Increased CNS control over body functions

Answer 98

o Fetus is considered full term and fills the uterus o Maternal antibodies are transferred to the baby o Testes are in scrotum of male fetus o Small breast buds are present on both sexes o Lanugo begins to disappear o Body fat continues to increase o Fingernails reach the end of the fingertips

Answer 99

Circulation o Exchange metabolic and gaseous products between fetal and maternal circulatory systems Hormone production o Production of hormones necessary for fetal development and continuation of pregnancy

Answer 100

Trophoblast o Precursory cells of the placenta o First appear 4 days after fertilization o Initially appear as outer layer of blastocyst Upon implantation of the blastocyst into the maternal endometrium, trophoblasts continue to differentiate forming the inner and outer layers of the placenta (eventually the chorion and amnion)

Answer 101

2 arteries and 1 vein

Answer 102

Amnion of the placenta

Answer 103

o Thick gelatinous substances that surround the vessels in the umbilical cord o Prevents compression

Answer 104

pregnancy, or number or pregnancies including current one o Nulligravida – A person who is not and has not been pregnant o Primigravida – A person who is pregnant for the first time o Multigravida – A person who has had 2 or more pregnancies

Answer 105

Number of pregnancies that have surpassed 20 weeks gestation. Not affected by number of fetuses or if they are born alive or stillborn o Nullipara – A person who has not had a pregnancy > 20 weeks before o Primipara – One pregnancy that is > 20 weeks o Multipara – A person who has had 2 or more pregnancies > 20 weeks

Answer 106

Capacity to live outside the uterus, generally 22-25 weeks is the threshold

Answer 107

Term – A pregnancy between 37 weeks and 40 weeks + 6 days o Preterm – Pregnancy between 20 weeks and 36 weeks + 6 days o Late preterm – Pregnancy between 34 weeks and 36 weeks + 6 days o Early term – Pregnancy between 37 weeks and 38 weeks + 6 days o Full term – Pregnancy between 39 weeks and 40 weeks + 6 days o Late term – Pregnancy in week 41 o Post term – Pregnancy after 42 weeks

Answer 108

Review of symptoms and coping skills Estimated date of birth Environmental risks

Answer 109

Naegele’s rule  Subtract 3 months, add 7 days to LMP  This is what the wheel is based on  Just an estimate and could change with US Best practice is dated by ultrasound  Done at 18-22 weeks in anatomy scan  Can confirm EDB +/- 2 days

Answer 110

Menstrual history o Age at first menarche o Date of LMP Contraceptive history Infertility or gynecological conditions STI history o HIV, syphilis, gonorrhea, chlamydia – these are teratogenic Sexual history Last Papanicolaou (Pap) test and any results Past pregnancies (GTPAL) o Previous losses or multiple losses o Complications o Trauma from previous pregnancies/birth

Answer 111

o Physical or surgical procedures that can affect, or be affected by, pregnancy o Allergies, medication use, and immunization status o Previous or chronic medical conditions

Answer 112

o BMI o Nutritional advice should consider cultural influence o Obese patients should be aware of complications for themselves and fetus o History of bariatric surgery are at a nutritional risk o Maternal weight gain and fetal growth should be monitored  Special diet practices  Food allergies  Eating behaviours  Pica

Answer 113

* History of drug use and herbal preparation use * Family history * Social, experiential, and occupational history (like supports, perceptions, or activities) * Physical, sexual abuse and intimate partner violence

Answer 114

G – Gravidity o Number of all pregnancies including this one T – Term births o Births at >37 weeks gestation P – Preterm births o Births between 20 and 36 weeks + 6 days A – Abortions and miscarriages o Any abortions or spontaneous abortion before 20 weeks gestation L – Living children o Number of children currently alive the woman gave birth to

Answer 115

Gravida (number of pregnancies including this one) is 2 Para (number of pregnancies >20 weeks) is 0 Older style, less informative than GTPAL

Answer 116

ABO and Rh factor CBC, hemoglobin, WBC Rubella and varicella STIs (blood and vaginal/rectal smear) 1-hour glucose tolerance test

Answer 117

o Occurs when mothers blood type is Rh negative and her fetus’ blood type is Rh positive o Some of fetus’s blood passes into the mother’s blood stream and her body creates antibodies in response (alloimmunization) o First pregnancy is usually not affected as the exchange usually happens at the time of birth o In the next Rh-positive pregnancy, maternal antibodies attack fetal red blood cells resulting in lysis o Risk and severity of sensitization response increases with each subsequent pregnancy involving an Rh+ baby

Answer 118

o Prevention is the best treatment o Prophylactic RhIG is administered to Rh-negative (D-negative) pregnant patient  Destroys any fetal red blood cells in the maternal circulatory system before the immune system does so the mother does not produce antibodies  A dose of 300 mcg RhIG given at 26-30 weeks if mother is Rh negative and unsensitized o If baby is Rh positive, dose is repeated within 72 hours after birth o If mom refuses the shot, miscarriage in further pregnancies is common and mom should be aware as part of full consent

Answer 119

35-37 weeks gestation

Answer 120

First trimester o Same as nonpregnant Second trimester o Nonpregnant needs and an additional 340 kcal (calories) Third trimester o Nonpregnant needs and an additional 452 kcal

Answer 121

 Preterm birth  Small for gestational age baby  Spontaneous abortion  Intrauterine growth restriction (IUGR)

Answer 122

* Intrauterine growth restriction (IUGR) * Macrosomia o Much larger than average baby o Difficult to deliver due to fetopelvic disproportion  Capacity for woman’s pelvis is insufficient for the safe vaginal delivery of the baby * Operative vaginal birth (i.e. forceps) * Emergency Caesarean birth * Postpartum hemorrhage * Wound, genital tract, or urinary tract infection * Birth trauma * Late fetal death * Pre-eclampsia * Gestational diabetes

Answer 123

Classified as an eating disorder and may be caused by delusions o We may need to look into their mental health Consumption of nonfood substances or excessive amounts of foodstuffs low in nutritional value, can be toxic Associated with mineral deficiency (low iron) May include o Excessive ice chewing o Eating backing soda, laundry detergent etc. May cause o Nutritional food displaced from diet o Interference with absorption May result in nutritional deficits in mom and baby

Answer 124

* Consider low-iron prenatal vitamins * Small frequent meals * Try not to mix food and drinks * Do not skip meals * Eat pregnancy-safe foods that are appealing o Try salty and tart foods * Aoid strong odours * Avoid sudden movements * Get fresh air, use an exhaust fan when cooking * Eat room temp or cool foods that have little to no smell * Try candies, gummies or lozenges for metallic taste in the mouth * Avoid brushing teeth immediately after eating

Answer 125

o Proper hand hygiene and wiping pattern o Soft, absorbent toilet paper o Avoid bubble bath or bath oils o Cotton underwear o Adequate fluid intake o Not holding urine o Cranberry capsules

Answer 126

* Distance from pubic bone to top of the uterus * Helps determine gestational age and fetus position

Answer 127

* After week 20, fundal height in cm is approximately the same as the number of weeks of gestation, +/- 2 weeks (mother’s bladder should be empty) o Week 12-14 – fundus palpable above the symphysis pubis o Week 20-22 – fundus at umbilicus o Week 36 – fundus at xiphoid process

Answer 128

slight decrease in fundal height o Result of fetus descending into pelvis o Usually occurs after 36 weeks, provider may order tests to rule out other causes o Nullipara – occurs anytime in 4 weeks before labour onset o Multipara – occurs at start of labour

Answer 129

o Use a disposable paper tape o Palpate pubis symphysis and place the 0 there o Measure to the top of the uterus and document results

Answer 130

* Petite mother * Strong maternal abdominal muscles * Oligohydramnios (not enough amniotic fluid) * Fetus has dropped into the pelvis * Intrauterine growth restrictions (IUGR)

Answer 131

* Incorrect due date * Uterine fibroids * BMI > 25 * Carrying multiples * Polyhydramnios (excessive amniotic fluid) * Breech positioning * Fetal macrosomia (large baby, may be caused by gestational diabetes)

Answer 132

Systematic way of palpating the maternal abdomen to determine o Number of fetuses o Fetal presentation, fetal lie, and fetal attitude o Degree of descent of the presenting part into the pelvis o Point of maximal intensity of the fetal heart rate on the mothers abdomen 1 - determine the fetal part in the fundus 2 - determine where the fetal back is located 3 - determine presenting part over inlet to pelvis 4 - Determine if head is flexed/extended and engaged/free-floating

Answer 133

The presenting part Cephalic - head first Breech - butt or feet first Shoulder - rare but shoulder first

Answer 134

General flexion Describes the position of specific parts of the fetus’s body Optimal attitude allows for the smallest biparietal diameter to enter the pelvic inlet o Chin tucked to the chest o Arms and legs drawn into the center of the chest If the fetal head is abnormally flexed or extended the presenting head diameter may exceed the maternal pelvis leading to prolonged labour and interventions May be described as o Occiput/Vertex o Sinciput/Military o Brow/face

Answer 135

* Poorly controlled diabetes mellitus * Fetal-maternal hemorrhage * Fetal congenital anomalies including o Gi obstruction o CNS abnormalities * Genetic disorders * Twin-twin transfusion syndrome

Answer 136

Maternal Factors * Hypertensive disorders * Pregestational diabetes * Cyanotic heart disease * Autoimmune disease * Restrictive pulmonary disease * Multifetal gestation * Malabsorption disease/malnutrition * Living at high altitude * Tobacco or substance use Fetal Factors * Genetic disorders * Teratogenic exposure * Fetal infection

Answer 137

* Renal agenesis (Potter syndrome) * Premature rupture of membranes * Prolonged pregnancy * Uteroplacental insufficiency * Severe intrauterine growth-restriction (IUGR) * Maternal hypertensive disorders * Maternal dehydration/hypovolemia

Answer 138

* Advanced maternal age * Paternal chromosomal rearrangements * Previous pregnancy with autosomal trisomy * Abnormal ultrasound findings during the current pregnancy including o Fetal structural anomalies o IUGR o Amniotic fluid volume abnormalities * Increased risk as calculated from noninvasive screening results including o Nuchal translucency o Maternal serum analytes

Answer 139

Nulligravida

Answer 140

Primigravida

Answer 141

Multigravida

Answer 142

Between 22-25 weeks gestation

Answer 143

Human chorionic gonadotropin

Answer 144

Presumptive changes

Answer 145

Probable changes

Answer 146

Positive changes

Answer 147

400 mcg 3 months before until 6 months post partum

Answer 148

Braxton Hicks

Answer 149

Quickening

Answer 150

Supine hypotensive syndrome

Answer 151

- onset of regular contractions - 10

Answer 152

Lightening Lower body ache Bloody show Spontaneous rupture of membranes Cervical changes (early dilation and effacement as well as ripening where the cervix softens) Surge of energy (nesting)

Answer 153

110-160 bpm

Answer 154

All increase

Answer 155

The tone of the uterus between contractions Should be soft to allow for improved blood flow to the fetus If it is hard on palpation between contractions, the baby may not be getting adequate oxygen

Answer 156

Fetal station Ischial spines

Answer 157

Effacement cm

Answer 158

right occipital anterior

Answer 159

Baby is born Dilation Effacement Birth off the baby

Answer 160

Ferguson's reflex (urge to push or defecate) Shaking extremities Sudden appearance of sweat on the upper lip Episode of vomiting Increased bloody show___ Increased restlessness Involuntary bearing down

Answer 161

Birth of the baby Delivery of placenta Separation Firmly contracting uterus Globe Rush of blood Umbilical cord

Answer 162

4th stage of labour

Answer 163

uterine atony postpartum hemorrhage

Answer 164

Afterpains

Answer 165

Thrombus or thrombophlebitis Heat, tenderness, redness

Answer 166

Rhogam IM injection 72 hours

Answer 167

Baseline fetal heart rate

Answer 168

Absent variability

Answer 169

Minimal variabiliity

Answer 170

bradycardia

Answer 171

prolonged deceleration

Answer 172

periodic changes

Answer 173

tachycardia

Answer 174

variability

Answer 175

early deceleration Considered normal and benign

Answer 176

late deceleration Lowest point occurs after the peak of the contraction and baseline rate is not usually regained until the uterine contraction is over

Answer 177

Variable deceleration Result of umbilical cord compression

Answer 178

Acceleration

Answer 179

episodic changes

Answer 180

Relation of the long axis (spine) of the fetus to the long axis (spine) of the mother Longitudinal o Ideal lie o Spines line up vertically with fetal head in down in the birth canal Transverse o Fetus is sideways or horizontal across the uterus o Not compatible with a vaginal birth Oblique o Usually converts to longitudinal or transverse lie during labour

Answer 181

We use a 3 letter abbreviation used to describe the fetal position First letter denotes the side of the mothers pelvis the presenting part is located in o R – right o L – left Second letter is the presenting part of the fetus o O – occiput o S – sacrum o M – mentum o Sc – scapula Third letter represents the location of the presenting part in relation to the maternal pelvis o A – anterior o P – posterior o T – transverse

Answer 182

Fetal position as some presentations have different diameters which may prevent natural labour ROA is the most optimal

Answer 183

12 weeks gestation

Answer 184

Point of maximal intensity (PMI) is heard through the fetal back...use Leopolds to figure out where that is?

Answer 185

Point of maximal intensity (where we heart the FHR best) Continues to be heard lower on the abdomen and moves closer to the midline

Answer 186

Above the umbilicus

Answer 187

Minimal or absent FHR

Answer 188

Rate < 110 bpm although 110-119 is usually not a sign of compromise in the absence of other concerning symptoms Etiology o Heart block o Occiput posterior or transverse position o Serious fetal compromise

Answer 189

Rate > 160 bpm o Good variability of tachycardia is not a sign of fetal distress Etiology o Maternal fever o Fetal hypoxia o Fetal anemia o Amnionitis o Fetal tachyarrhythmia  Usually >200 with abrupt onset and little to no variability o SVT (200-400) o Fetal heart failure o Drugs  Beta sympathomimetics  Vistaril  Phenothiazines o Rebound  Transient tachycardia following a deceleration accompanied by decreased variability

Answer 190

Should be counted with mother in a reclined position Should feel at least 6 distinctive fetal movements in 2 hours If mom is walking, she may feel rebounding and not actual movements Babies can sleep, if this is suspected, have mom get up and move around, drink some juice, etc. to wake the baby up and then sit down to try again

Answer 191

If mom is walking, she may feel rebounding and not actual movements Babies can sleep, if this is suspected, have mom get up and move around, drink some juice, etc. to wake the baby up and then sit down to try again

Answer 192

Decreased placental perfusion Fetal acidemia

Answer 193

A non invasive test that is done during the 3rd trimester Measures FHR in response to fetal movement Indicated when there has been decreased fetal movement, advanced maternal age, gestational HTN, or post maturity

Answer 194

Baseline 110-160 bpm Accelerations o 2 accelerations with an increase of ≥15 bpm, lasting at least 15 second o Indicates fetal movement Variability o 6-25 bpm (moderate) o Absent or minimal is ≤ 5 bpm for < 40 min Decelerations o None or occasional variable <30 seconds

Answer 195

* High frequency sound waves deflect off tissues showing structures of various densities * Visualizes fetus * Allows fetal growth monitoring * No known side effects * Common methods o Transabdominal o Transvaginal

Answer 196

* Part of enhanced first-trimester screening (eFTS) * Screen for trisomy’s 13, 18, and 21 * Done between weeks 11-14 * US scans the translucent area on the back of the fetal neck measuring the diameter of the area

Answer 197

Generally, not offered unless o Noninvasive screening test positive o Maternal age at birth is ≥ 40 y/o Procedure that obtains a sample of amniotic fluid Genetic testing o Amniotic fluid contains fetal cells that can be used to test for fetal abnormalities Fetal lung maturity o Can be determined in 3rd trimester

Answer 198

First stage – Dilation and Effacement Second stage – Delivery of Fetus Third stage – Delivery of Placenta Fourth stage – Recovery

Answer 199

7 movements Allow for the baby to move through the birth canal Movements are: - Engagement - Descent - Flexion - Internal rotation - Extension - Restitution/external rotation - Expulsion MEMORY TRICK: Every Day Fetuses Incur Eviction Requests Early

Answer 200

* Also called “dropping” * Uterus drops into the true pelvis * Nulliparous parents o Noticeable change up to 4 weeks before end of term o More frequently 38-40 weeks * Multiparous parents o Tend to not drop until true labour is already in progress * Results o Parent can breathe easier o Pressure on bladder increases so urinary frequency occurs

Answer 201

* Low back and sacroiliac distress * Caused by pelvic joint relaxation o Also called laxity o More movement in areas that usually don’t move o Occurs between the two parts of the symphysis pubis * May identify Braxton Hicks contractions

Answer 202

Spontaneous rupture of membranes * Also called “water breaking” * This is the rupture of the amniotic sac * Only occurs about 8% of the time * High break results in a trickle of fluid * Low break results in a gush of fluid

Answer 203

Softening of the cervix that occurs before labour begins

Answer 204

Early labour o 0-3 cm dilated o Lots of effacement Active labour o 4-10 cm dilated

Answer 205

Increased risk of infection Managed by o Prophylactic antibiotics given o If no labour after 18 hours, induction may occur

Answer 206

Cervical, uterine, and pituitary gland changes

Answer 207

Increased estrogen, oxytocin, and prostaglandins * Prostaglandins are in semen so it will encourage cervical patients (sex also increases uterine contractions) Decreasing progesterone * Progesterone decreases myometrial irritability Result in progressive uterine distension and increasing intrauterine pressure associated with increased myometrial irritability Cause regular and rhythmic uterine contractions

Answer 208

Risk of massive cervical tear

Answer 209

o Nulliparous are about 1 cm per hour o Multiparous can happen much faster

Answer 210

o Time labour started o Frequency of contraction o Pain location and intensity o Vaginal discharge (bloody show) we use COAT o Have membranes ruptured? If so, when?

Answer 211

Vaginal exam - dilation - SROM Fetal assessment - heart rate - Leopold maneuver

Answer 212

Once we determine they are in active labour and we are keeping them

Answer 213

o Identifies any risk factors we need to take into consideration o Determine what the mother wants in terms of experience, pain management etc.

Answer 214

Done by palpation at the fundus Frequency o Time (minutes) from the beginning of one contraction to the beginning of the next o Generally the number of contractions in 10 min increments Intensity o Strength of a contraction at its peak o Described as mild, moderate, strong Duration o Time (seconds) of one contraction from start to stop Resting tone o Tension of uterine muscles between contractions  Mild – slightly tense fundus – feels like tip of nose  Moderate – firm fundus – feels like chin  Strong – rigid fundus – feels like forehead o Should be mild to moderate o If it is strong, it can impact fetal perfusion and lead to fetal hypoxia  Baby usually grabs blood flow during the resting period  It’s why tachysystole is so bad o This can only be done by palpation

Answer 215

Only a thin ridge of the cervix is felt

Answer 216

Cannot be felt anymore

Answer 217

 C – colour  O – odour  A – amount  T – time

Answer 218

Red or green/brown

Answer 219

A possible tear in the umbilical cord

Answer 220

meconium, or "mec" o Green/brown staining, it looks like pea soup o First stool from baby that has built up while in the womb o Should not be expelled until after birth o If it occurs during labour, it is an indication of fetal distress o If they inhale it, it can result in pneumonia o Respiratory will need to be called down to aggressively suction them before they take their first breath

Answer 221

o Will show intensity of the contraction o Mild, moderate, strong o If it is not strong, there will not be enough push down on the presenting part to get the dilation and effacement that we need

Answer 222

This can only be done by palpation Tension of uterine muscles between contractions  Mild – slightly tense fundus – feels like tip of nose  Moderate – firm fundus – feels like chin  Strong – rigid fundus – feels like forehead Should be mild to moderate If it is strong, it can impact fetal perfusion and lead to fetal hypoxia  Baby usually grabs blood flow during the resting period  It’s why tachysystole is so bad

Answer 223

latent - 6-8 hours active 3-6 hours

Answer 224

Latent Strength - mild to moderate Rhythm - irregular Frequency - 5-30 min apart Duration - 30-45 seconds Active Strength - moderate to very strong Rhythm - more regular Frequency - 2-5 min apart Duration - 40-90 seconds

Answer 225

Latent Nulliparous: 0 Multiparous: -2cm to 0 Active Nulliparous: +1 to +3 cm Multiparous: +1 to +3 cm

Answer 226

Latent Brownish discharge, mucous plug, or pale pink mucous Scant amount Active Pink-to-bloody mucus Scant to copious amounts

Answer 227

Latent * Excited * Thoughts center on self, labour and baby * May be talkative or silent, calm or tense * Some apprehension * Alert, follows directions readily, open to instructions Active * Becomes more serious, apprehensive * More doubtful of pain control * Desires companionship and encouragement * Attention more inner directed * Fatigue evidenced * Malar (cheeks) flush * Some difficulty following directions * Amnesia between contractions * Writhing with contractions * Nausea and vomiting, especially if hyperventilating * Hyperesthesia * Perspiration on forehead and upper lip * Shaking tremor of thighs * Feeling of need to defecate, pressure on anus

Answer 228

Urine  Encourage voiding  Avoid distended bladder as it can result in bladder rupture Stool * Over 70% of moms will have a bowel movement during labour o Labour is a clean process, not a sterile process o Just clean it up quickly and perform perineal care * Suppositories and enemas NOT RECOMMENDED Prophylactic enemas can result in contractions that are too strong

Answer 229

o Encourage and support movement and changing positions  Walking  Swaying hips  Shower or bath  Sitting on exercise balls Obviously unless an epidural was given as they will be confined to the bed after

Answer 230

Benefits o Gravity helps o Stronger but more efficient contractions helping with dilation and effacement o Improved cardiac output Includes walking, sitting, kneeling, squatting A very deep squat is actually the best position for labour  The bottom of the bed actually comes away and there is a bar that can be hooked in that mom can hang off to sit in this position

Answer 231

o On hands and knees o Used to relieve back pain o Can also increase blood flow to baby in the case of decelerations

Answer 232

o Very effective for pain o Unfortunately patients are bed bound after this o Try to encourage movement even in the bed and don’t lay on the back o High correlation for c-section in nulliparous patient

Answer 233

 Describes the degree of descent of the presenting part through the birth canal  The line between the ischial spines is considered 0  1 cm above the spines is -1, 1 cm below the spines is +1

Answer 234

o Indicates the largest transverse diameter of the presenting part has passed through the pelvic brim inlet into the true pelvis o Usually corresponds with station 0 o Nulliparas – occurs in the weeks prior to labour o Multiparas – may occur before or during labour

Answer 235

Engagement, or fetal station 0 We will go forward with a normal vaginal birth after this

Answer 236

Passenger (fetus/placenta) Passageway (birth canal) Powers of contraction Position (of labouring mother) Physiological adaptations

Answer 237

* Place of birth * Preparation * Presence of continuous labour support * Type of provider * Nursing care * Procedure

Answer 238

* Size of the head * Presentation – the presenting part * Lie – direction of baby * Attitude – angle of the face in the pelvis * Position

Answer 239

Bony pelvis o True pelvis  Portion that is involved in childbirth  If we know the baby is too big for the pelvis, a recommendation may be given for an elective c-section Soft tissues o Includes  Lower uterine segment  Pelvic floor muscles  Vagina  Introitus o Labour changes uterus  Bottom becomes thin and muscular  Top is thick and muscular o Contractions push fetus against the cervix o Considerations for scar tissue etc.

Answer 240

Involuntary or primary powers o Responsible for effacement and dilation Voluntary or secondary powers o Begin after cervix has dilated o Typically mom is at +1 or +2 fetal station o We coordinate it with contractions o Bearing down

Answer 241

o Urge to push or feeling need to have a bowel movement o If mom doesn’t have this (i.e. epidural), sometimes doc will touch with a finger to show mom where to focus the pressure to

Answer 242

Should be monitored 110-160 bpm o Progressively decreases as the fetus matures closer to term Temporary accelerations and slight decelerations are expected in response to o Fetal movement o Vaginal examination o Fundal pressure o Uterine contractions o Abdominal palpation o Fetal head compression

Answer 243

o Maternal position o Contractions o BP o Umbilical cord flow

Answer 244

Chemoreceptors stimulated in aorta and carotid artery to prepare fetus for initiating respirations resulting in * Clearing of fetal lung fluid * Decrease in o Fetal oxygen pressure o Arterial pH o Bicarbonate levels * Increase in arterial carbon dioxide pressure Fetal respiratory movements decrease during labour

Answer 245

Heart rate increases o Returns to pre-labour baseline within 1 hour after birth Cardiac output increases o Can be up to 51% above pre-labour baseline o Peaks 10-30 minutes after birth o Returns to pre-labour baseline within an hour Changes in BP can be observed Discourage woman from holder her breath during second stage

Answer 246

Greater oxygen consumption increases respiratory rate o Consumption doubles in second stage Hyperventilation can cause o Alkalosis o Hypoxia o Hypocapnia Anxiety can increase oxygen intake

Answer 247

Spontaneous voiding difficulty due to o Edema caused by pressure from presenting part o Discomfort o Analgesia o Embarrassment Proteinuria up to +1 is normal due to muscle tissue breakdown caused by physical work of labour

Answer 248

* Stretching of tissues in area of vaginal introitus (entrance to vagina) * Regardless, minute tears in skin around vagina introitus occur * Temperature may rise but should resolve quickly after birth

Answer 249

* Fatigue due to increased muscle activity * Pelvic joint relaxation causes back pain * Cramps o Leg cramps may be caused by patients pointing toes during contractions

Answer 250

Endorphins raise pain threshold and produce sedation o Physiological anesthesia of perineal tissues caused by presenting part pressure decreases perception of pain Changes in behaviour o May start euphoric and become more serious later o Amnesia between contractions during second state o Elation and fatigue after giving birth

Answer 251

* Motility and absorption is deceased * Nausea and vomiting of any undigested food consumed prior to labour onset * Nausea and belching may occur as a response to full cervical dilation * Diarrhea may occur at onset of labour * Hard impacted stool may be in rectum that will often pass during pushing

Answer 252

Hormone changes during labour o Increased estrogen, prostaglandins and oxytocin o Decreased progesterone Metabolism increases Blood sugar may decrease o Carefully monitor diabetic patients

Answer 253

Associated with poor pregnancy outcomes Present in 10-30% of healthy pregnancies Risk factors for neonatal infection o Mother testing positive for GBS o Prolonged rupture of membranes > 18 hours o Interpartum maternal fever To help reduce risk, IV antibiotics should be given after admission

Answer 254

o Should be done intermittently for healthy term women o Measured along with uterine activity (for context) o Assessed 15-30 minutes o Assess before and after ROM, and medical interventions

Answer 255

o Recommended when there is a high risk for adverse outcomes o False belief that EFM can prevent negative outcomes o Meant to assess fetal oxygenation continuously

Answer 256

Device placed internally in the uterus, membranes must already be ruptured Not interrupted by fetal movement

Answer 257

FHR > 160 Early sign of hypoxia Can occur with o Maternal fever (most common) o Maternal or fetal infection o Maternal hyperthyroidism o Fetal anemia o Medications

Answer 258

FHR < 110 bpm Confirm the maternal heart rate is different Bradycardia is not the same as prolonged decelerations Can be caused by o Fetal cardiac problems o Infection o Maternal hypoglycemia o Maternal hypothermia

Answer 259

Fluctuations in the baseline FHR that are determined in a 10 min segment Does NOT include accelerations and decelerations May be o Absent: 0-2 bpm o Minimal: ≤ 5 bpm o Moderate: 6-25 bpm (this is considered normal) o Marked: > 25 bpm

Answer 260

o Apparent and abrupt increase in FHR above the baseline o At least 15 bpm o Lasts 15 sec or more o Could be in association with fetal movement o Considered an indication of fetal health

Answer 261

 Considered normal  Caused by transient fetal head compression  Onset to lowest point is ≥30 sec  Mirrors moms contractions  Take the top of moms contractions and it is the same place as the babies deceleration  This is good because this means that baby is coming down the birth canal

Answer 262

In relation to the timing of the contraction

Answer 263

 Associated with contractions and begins after contractions start  Onset to lowest point is ≥ 30 sec and well after the peak of contraction  Have a long slow U shape to them  Persistent and repetitive decelerations are a concern when they are uncorrectable  Caused by uteroplacental insufficiency

Answer 264

 Most common type  Onset to lowest point is < 30 sec so abrupt, leaving a distinct V shape rather than the U shape of late decelerations  FHR decreases at least 15 sec but less than 2 min  Occur during or between contractions  Cause by umbilical cord compression  Could cause fetal hypoxia

Answer 265

At least 15 bpm below baseline and lasting >2 min but <10 min When decelerations last > 10 min it is considered a baseline change Causes include * Prolonged fetal hypoxia * Prolonged or extreme uteroplacental insufficiency * Prolonged cord compression, prolapse, or entanglement * Maternal hypotension * Cervical exam * Uterine tachysystole or rupture

Answer 266

Placenta previa Breech position

Answer 267

Nulliparous  Latent >20 hours  Active <1.2 cm/h cervical dilation Multiparous  Latent >14 hours  Active < 1.5 cm/h cervical dilation

Answer 268

About 1 cm per hour

Answer 269

Vernix caseosa  Is the waxy substance baby’s are covered in  Babies shed this as they come close to term  Premie babies are covered in it  Overdue babies are wrinkly because they don’t have it any more to protect them

Answer 270

<500 mL blood loss

Answer 271

Urge to push/defecate Crowning

Answer 272

3 characteristics pregnant women use to cope well Relaxation o Relaxing between contractions o Later they may have a hard time so even just move or vocalize Rhythm o Use of rhythm Ritual o Repeated use of personally meaningful rhythmic activities with every contraction

Answer 273

Baby is the top, mom is on the bottom

Answer 274

VEAL CHOP - Variable-----------Cord compression - Early ---------------Head compression - Accelerations----Ok - Late ----------------Placental insufficiency

Answer 275

Predominantly visceral pain over lower portion of the abdomen Caused by o Dilation of the cervix o Pressure on adjacent structures o Hypoxia of uterine muscles during contractions o Stretching of lower uterine segment Referred pain from the uterus may radiate to o Abdominal wall o Lumbosacral area of the back o Iliac crests o Gluteal area o Thighs

Answer 276

* Scarred cervix * Fatigue * Interval and duration of contractions * Fetal size and position * Rapidity of fetal descent * Maternal position

Answer 277

Nulliparous patients o Greater pain during early latent labour (dilation <4 cm)  Due to reproductive tract structures are less supple Multiparous patients o Greater pain during active labour  May be due to increased speed of fetal descent

Answer 278

Excessive FEAR and anxiety associated with increased pain in labour Causes catecholamine secretion increasing stimuli to brain from pelvis The result is  Increased muscle tension  Decreased effectiveness of uterine contractions  Increase in experience of discomfort  Further increases fear and anxiety making a positive feedback loop  Slowed labour progression (Catecholamine inhibits oxytocin secretion)

Answer 279

- physiological - sensory - affective (FEAR!) - cognitive (education) - behavioural - sociocultural factors - supportive care

Answer 280

It is recommended that all women in active labour have continuous 1-1 labour support May be a trained person (doula) or a friend or family member of the woman’s choice (even if they have no childbirth experience) Includes continuous presence, emotional support, comfort measures, advocacy, information, and advice Benefits o Increased likelihood of vaginal delivery o Decreased risk of c-section o Reduced use of epidural analgesia o Increased Apgar score o Increased maternal satisfaction

Answer 281

Cardiac output o Increases with pain from contractions and anxiety Blood pressure o Increases during contractions and may increase with pain Respiratory system o Oxygen demand and consumption increases o Respiration and pulse increase with pain Musculoskeletal system o Decreased oxygen supply to muscles increases pain Immune system o Increase in WBC Blood values o Maternal BGL decreases

Answer 282

* Patients should not eat solid foots once in established labour due to decreased gastric emptying * Clear liquids are emptied much faster * Low risk patients o Evidence says allowing them to eat during labour may shorten length of labour and does not increase obstetrical risk

Answer 283

Maternal ambulation and position change o Upright and gravity enhancing positions o Rhythmic motion o Change position frequently Distraction may employ gate-control theory of pain so try o Cutaneous stimulation strategies o Sensory stimulation strategies o Cognitive strategies

Answer 284

 Counterpressure  Effleurage (light massage)  Therapeutic touch and massage  Walking  Rocking  Changing positions  Application of heat or cold  TENS machine  Acupressure/acupuncture  Hydrotherapy (showers, bath)  Intradermal water block

Answer 285

 Aromatherapy  Breathing techniques  Music  Imagery  Use of focal points

Answer 286

 Childbirth education  Relaxation  Hypnosis  Biofeedback

Answer 287

* Cross the placenta * Rapid onset with short duration * Administer only once labour is well established Includes o Fentanyl o Sufentanil o Morphine Side effects include o Decreased uterine contractions o Nasua and vomiting o Respiratory depression o Maternal and neonatal CNS depression

Answer 288

* Self-administered via a demand valve * Can be used in combination with other forms of pain relief * Results in a sense of euphoria and decreased anxiety * Begin inhaling 30 seconds prior to contractions to achieve peak with contraction peak Benefits o Safe for baby and does not accumulate in fetal tissues o Does not affect uterine activity o Rapid onset, fast clearance Side effects o Nausea and vomiting

Answer 289

* Anesthetic or opioid injected into the epidural space o Drug type, amount and combination result in varying degrees of motor impairment o A combination of both is often used to achieve desired pain relief but retaining the largest degree of motor function o Goal is to provide sufficient anaesthesia with as little blockage to the sensory and motor nerves as possible

Answer 290

o Considered to be the most effective and flexible method of pain management for labour o Promotes good relaxation o Mother remains fully awake, and airway reflexes remain intact o Mom is more comfortable and remains able to participate in the birth o Does not delay gastric emptying o Motor paralysis is mild

Answer 291

o Delayed or arrested progress in labour, irrespective of causes o Epidural can provide benefits for this if they require augmentation Although epidurals can prolong labour if administered before the labour is will established

Answer 292

o May prolong labour if administered before labour is well established o May interfere with mobility (walking during first stage) Maternal * Hypotension o Can result in decreased uteroplacental perfusion and reduced oxygen delivery to the fetus * Nausea, vomiting * Fever * Pruritis o Common with opioids * Intravascular injection * Respiratory depression * Post partum urinary retention and stress incontinence o May be related to the epidural or catheterization done in labour o May be related to use of forceps or vacuums used during labour Fetus  Fetal distress secondary to maternal hypotension

Answer 293

 Longer second-stage labour  Fetal malposition  Use of oxytocin  Forceps or vacuum assisted birth

Answer 294

* Systemic analgesia o Opioid agonist analgesics o Opioid agonist-antagonist analgesics * Epidural (block) analgesia * Combined spinal-epidural (CSE) analgesia * Nitrous oxide

Answer 295

* Nerve block analgesia/anesthesia * Local infiltration anesthesia * Pudendal block * Epidural (block) analgesia and anesthesia * Spinal (block) anesthesia * Nitrous oxide

Answer 296

* Spinal (block) anesthesia * Epidural (block) anesthesia * General anesthesia

Answer 297

* Monitor the status of the patient receiving regional anaesthesia, the fetus, and the progression of labour * Replace empty infusion syringes or bags with the same medication and concentration * Stope the infusion if there is a safety concern or the patient has given birth * Remove the catheter if properly educated to do so * Initiate emergency measures if the need arises * Communicate clinical assessments and changes in patient status to obstetrical and anaesthesia care providers * Alter rate of medication infusion and administer bolus doses as ordered

Answer 298

Passive phase o Baby making the cardinal movements to get into place o It’s a holding pattern for mom o Don’t have mom push until she has an urge to push  Tricky with an epidural as this sensation may not exist Active pushing (descent) phase

Answer 299

* Begins with full cervical dilation and complete effacement and ends with baby’s birth

Answer 300

Can range from 2 hours to 30 minutes Factors that affect length include * Epidural anaesthesia (reduces urge to bear down and limits ability to get into an upright position to push) * Patients age * BMI * Emotional state (FEAR is the biggest issue!) * Adequacy of support (Someone who is experienced and supportive is really helpful here) * Level of fatigue * Fetus: cephalopelvic disproportion due to head size, position, and presentation

Answer 301

o Very fast <3 hours from onset of regular contractions o If they have a history of it they are likely to have that happen again

Answer 302

Nulliparous o ≥3 hours with no regional anaesthesia o ≥4 hours with regional anaesthesia Multiparous o ≥2 hours with no regional anaesthesia o ≥3 hours with regional anaesthesia

Answer 303

If epidural is in place o More drugs given through it for pain relief for the c-section o Partner is allowed to be in the room If no epidural is in place o General anesthesia is provided o Anesthesiologist has to control the airway so the partner has no room to be there

Answer 304

Ferguson’s reflex o Urge to push or feeling need to have a bowel movement o If mom doesn’t have this, sometimes doc will touch with a finger to show mom where to focus the pressure to Shaking of extremities Sudden appearance of sweat on the upper lip Episode of vomiting o We discourage heavy eating because it will come back up o Fight or flight, don’t got enough time for it Increased bloody show Increased restlessness, may verbalize they can’t continue etc. Involuntary bearing-down efforts

Answer 305

* Occurs when the top of the head no longer regresses between contractions * The widest part of the head distends the vulva just before birth +4 station they will still be sliding back and forth o We don’t want to have mom push at +4 too much as it can cause significant tearing o It is very painful o We can have mom pant, because she can’t pant and push at the same time +5 station they are staying there between contractions o Ready to push when mom is

Answer 306

Mom every 5-30 min o BP, pulse, respirations Fetus every 5 min o Heart rate and pattern Labour progression every 10-15 min o Vaginal show o Signs of fetal descent o Changes in maternal appearance, mood, affect, energy level o Condition of support person o Contraction and bearing down effort

Answer 307

* Help patient to rest in a position of comfort * Encourage relaxation to conserve energy * Promote progress of fetal descent and onset of urge to bear down by encouraging position changes, pelvic rock, ambulation, and showering

Answer 308

* Help patient change position and encourage spontaneous bearing-down efforts * Help patient to relax and conserve energy between contractions * Provide comfort and pain-relief measures as needed * Cleanse perineum promptly if fecal material is expelled * Coach patient to pant during contractions and to gently push between contractions when the head is emerging * Provide emotional support, encouragement, and positive reinforcement of efforts * Keep patient informed regarding progress * Create a calm and quiet environment * Offer mirror to watch birth or encourage patient to feel top of fetal head as they are pushing

Answer 309

* Vaginal and urethral lacerations * Cervical injuries

Answer 310

Fear is one of the biggest barrier to natural childbirth Fear and anxiety can increase risk of perineal trauma

Answer 311

* Baby’s face is up * Baby’s shoulder is stuck * Breech delivery that gets a little hung up * Very large baby * Using forceps or assistive use devices * History of cephalopelvic disproportion * Parity o Nulliparous are likely to have a longer second stage increasing swelling in the perineal area increasing risk of tear o Multiparous are more likely to have a precipitous delivery which doesn't allow time for the introitus to stretch on it's own * Maternal position o Upright allows for gradual stretching from downward pressure o Supine or side lying for the majority of second stage doesn’t allow for this * Emotional response o Fear and anxiety can increase risk * Previous tears o 3rd and 4th degree tears previous can tear down the same line (c-section may be offered in these more severe cases)

Answer 312

* Perineal massage with lubricant o Can be done after 34 weeks o Pushing down on the bottom of the vaginal opening * Warm compress * Kegel exercises * Knowing the risk factors * Mother in upright position in second stage

Answer 313

First degree o Extends through the skin Second degree o Extends through the muscles of the perineal body Third degree o Continues through the anal sphincter muscle o Can happen with the use of forceps or pushing at only +4 o Repairs are significant with multiple layers involved o If not repaired correctly, they may end up with fistulas which can result in massive side effects including sepsis o May require a pudenda block Fourth degree o Involves the anterior rectal wall o Can happen with the use of forceps or pushing at only +4 o Repairs are significant with multiple layers involved o If not repaired correctly, they may end up with fistulas which can result in massive side effects including sepsis o May require a pudenda block

Answer 314

3rd and 4th degree

Answer 315

Third decree includes the anal sphincter and fourth involves the anterior rectal wall o Can happen with the use of forceps or pushing at only +4 o Repairs are significant with multiple layers involved o If not repaired correctly, they may end up with fistulas which can result in massive side effects including sepsis o May require a pudenda block

Answer 316

Pudendal nerve provides most of the movement and sensations for the pelvic region including the external genitals and anus. 3rd and 4th degree tears may need a pudenda block for pain relief and tear repair unless a spinal block/epidural block are already in place

Answer 317

At the Alex * 3rd and 4th degree tears automatically referred * They do Kegel exercises to increase muscle strength to the area as part of physio

Answer 318

Surgical incision of the perineum to enlarge the outlet o Conversation about cut vs tear o Routine are no longer recommended Procedure o We go medio-lateral now rather than midline  This way if there is tearing beyond the cut, it doesn’t involve the anal area

Answer 319

o Bleeding o Infection o Painful intercourse o Injury to anal sphincter and rectum o Scarring o Urinary incontinence o Prolonged recovery time

Answer 320

Perineal pain is the primary cause of pain o Distension of vagina and perineum Stretch receptors o Located on the pelvic floor o Stimulates release of oxytocin from the posterior pituitary gland resulting in more intense contractions o This is where Ferguson’s reflex comes from Pressure on adjacent structures Hypoxia of contracting uterine muscles

Answer 321

Labour o Contractions o Fetal response (FHR q5min when pushing) o Amniotic fluid Labour progress * Assessing progress of labour q 10-15 min o Vaginal show o Signs of fetal descent o Bulging o Crowning

Answer 322

Maternal coping o Mood o Affect o Energy level o Pain management Partner's coping

Answer 323

o Squatting works best to bring baby down and stretch the perineal area o On all 4s is best to help get baby shift position o Supine position is the worst position  Prolongs second stage  Increases need for assistive devices  May be the only position in a epidural

Answer 324

Encourage to push as she feels like pushing o Instinctive spontaneous pushing Encourage open glottis bearing down o Preferred method o Maternal grunting or groaning when pushing o Allows air to be released while pushing o Helps maintain adequate oxygen levels for mom and baby o About 5 pushes of about 5 seconds long per contraction

Answer 325

o These are the old hold the breath and push for 10 seconds o Directed, closed glottis pushing o While still widely used, it can trigger Valsalva manoeuvre due to the increase in thoracic pressure Adverse effects  Fetal hypoxia and subsequent acidosis  Increased risk of pelvic floor damage  Increased risk of perineal trauma

Answer 326

* Lasts from birth of the baby until the placenta is expelled * Generally occurs within 15 minutes of the birth of the baby

Answer 327

Retained placenta Interventions to hasten its separation and expulsing are usually instituted at this point and they include: * Gentle cord traction * Manual removal o Someone reaches in and gently pulling the placenta off the uterine wall o Is only done if they have an epidural * Surgical o D&C to remove the placenta

Answer 328

* Firmly contracting fundus * Change in the uterus from a discoid to a globular oval shape as the placenta moves into the lower uterine segment * Sudden gush of dark blood from the introitus o Normal and not a concern as long as it’s associated with the placenta releasing * Apparent lengthening of the umbilical cord as the placenta descends to the introitus * Vaginal fullness (the placenta) noted on vaginal examination or of fetal membranes at the introitus

Answer 329

Passive management o Wait for signs the placenta has separated spontaneously o Monitors for spontaneous expulsion o May involve gravity or nipple stimulation to facilitate expulsion o Quiet, relaxed environment supports skin-to-skin contact o Promotes endogenous oxytocin release o No oxytocin is given

Answer 330

within 30 seconds Delayed is 1-3 minutes

Answer 331

Active management o Decreases rates of PPH due to uterine atony o Oxytocin is given after birth anterior shoulder o Clamp and cut cord within 3 minutes of birth o Gently controlling cord traction following uterine contraction and separation of the placenta

Answer 332

* Assist patient to bear down to facilitate expulsion * Administer oxytocin as ordered to ensure adequate contraction of the uterus to prevent hemorrhage * Provide nonpharmacological and pharmacological comfort and pain-relief measures * Perform hygienic cleansing measures * Keep patient informed of progress of placental separation and expulsion and perineal repair, if appropriate * Explain the purpose of medications administered * Introduce parents to their baby and facilitate the attachment process by delaying eye prophylaxis and other tasks like weighing and measuring the baby * Cover parent and baby together for skin-to-skin contact * Provide private time for parents to bond with their new baby * Encourage breastfeeding when newborn shows signs of interest

Answer 333

Active management of third stage of labour o Reduces risk of PPH and should be offered and recommended to all women IM Oxytocin o 10 IU o IM is best for low-risk deliveries o Should be administered after delivery of fetuses anterior shoulder IV Oxytocin o Used if IM is not indicated o 20-40 IU in 1000 mL infusion at 150 mL per hour If the uterus is boggy, perform fundal massage If hemorrhage continues, it is likely due to retained products

Answer 334

Occurs before placenta separates from maternal uterus Used for o ABG and VBG o Blood type, especially if mother is Rh negative

Answer 335

“Shiny side” o Fetal side presents o Grey and shiny in appearance o Occurs when placenta separates form the inside to the outside margins “Dirty side” o Maternal side presents o Surface is rough and red o Occurs when placenta separates from the outside margins inward  It basically rolls up and presents sideways, maternal side first

Answer 336

* 1-2 hours after birth (sometimes 4 hours depending on source) * Immediate care of mother and newborn Monitor mother for o Hemorrhage o Bladder distension o Venous thrombosis

Answer 337

Every 15 min o BP returns to pre-labour values o Pulse will be lower than during labour

Answer 338

Every 4 hours o May increase minimally in first 24 hours  Due to increased work of effort during prolonged labour  Exacerbated by dehydration o As long as it goes back to normal after 24 hours it is considered normal

Answer 339

Assess for tone (firmness) by palpating the fundus o Bogy - Uterus is soft (uterine atony)  Massage to express retained clots Height measured in cm from the umbilicus  Above the umbilicus is a positive value, below is negative  Decreases 1 cm per day, about 7-10 days is back in the pelvis Should be midline  If it is up and right it means bladder is distended * This prevents proper uterus contractions to bring it back to a small size and the uterus will continue to bleed

Answer 340

* Measure % of pooling of blood under the buttocks * Inspect bloody vaginal discharge * Monitor for clots (size and consistency) * Chart amount (scant, minimal, moderate, heavy) * Chart colour (red, pink, white)

Answer 341

Normal  < 1 cm  Gelatinous feel Retained product signs  > 1 cm  Fleshy feel

Answer 342

o Turn mom onto her side to ensure that we are seeing any blood that is pooling at her bottom and missing the pad o Normal < 500mL Scant - <2.5 cm stain Light - 2.5-10 cm stain (may see this with c-sections) Moderate - 10-15 cm stain (normal for first 1-2 hours) Heavy - full pad saturated in 1 hour (should not happen) While many start as moderate for the first few hours, they should continue to decrease in amount after that

Answer 343

o When mom is discharged, we have her monitor the bleeding for the next 3-4 weeks and it should be decreasing over time  If there is a saturation of a pad <1 hour they need to come in right away

Answer 344

 Dark red discharge  From birth to 3-4 days post-partum  Flow in amounts like a heavy menstrual period  May have small clots  Odour should be fleshy, like menstrual blood

Answer 345

 Pinkish-brownish discharge  From 4 days to 12-14 days post-partum  Flow is moderate to small amount

Answer 346

 Yellowish white discharge  From 12 days to 3 weeks postpartum  Gradually disappearing scant creamy whitish discharge

Answer 347

May increase amount or change the colour i.e. serosa back to rubra

Answer 348

Steps: * Wash with warm water, dry well, and apply sanitary pad * Provide ice pack against perineum to promote comfort and decrease swelling * When assessing the perineum, have the woman lie on her side Laceration/episiotomy repair evaluation: GRACED with a new baby G - Goose egg - Hematoma  Causes lots of discomfort  Suspect it even if you can’t see it  Usually caused by a vessel that was missed in a repair  May need a repair R - Redness A - Approximation C - Contusion E - Edema D - Discharge Also look for hemorrhoids

Answer 349

Assess firmness of uterine fundus then observe and palpate bladder o Noted as suprapubic rounded bulge o Fluctuates like a water-filled balloon o Dull to percussion Often associated with uterus that is o Boggy o Well above the umbilicus o Deviated to the patient’s right side o This actually prevents the uterus contractions we need to stop the hemorrhaging Management * Assist patient to void spontaneously o Measure amount of urine collected * Catheterize as necessary * Reassess after voiding/catheterization o Ensure bladder is not palpable and fundus is firm and midline

Midterm Study Flashcards

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