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Flashcards in Midwifery Deck (60):
1

Describe photos - month of pregnancy + anatomical changes

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  • a) non pregnant
  • b) 5th month
  • c) 9th month
  • d) prior to birth

many organs compressed (bladder, lungs, etc) - not always externally visible, but felt by pregnant women. 

2

how is corpus luteum maintained? 

 

production of hcg by trophoblasts. CL continues to produce progesterone, which maintains the uterine lining for implantation. AFter 6-10w post fertilization, placenta takes over. 

Placenta produces estrogen and hcg and hpl, which stimulates breast development

 

Blackburn (2013) Maternal, Fetal, & Neonatal Physiology

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3

How is pregnancy dated?

first day of LMP + 7 - 3mths +1year

40 weeks from first date of LMP

4

hcg, estrogen, progesterone levels

hcg peaks at 11-12 w, whereas estrogen and progesterone continue to rise until term and birth

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5

Hematologic & Hemostatic changes - blood volume

  • Hypervolemia: BV ↑ 30-45%
  • Plasma volume
    • ↑ starts 6-8 wks
    • Peaks 28-32 wk
    • 75% of total BV ↑ due to plasma
  • RBCs
    • ↑ 20-30%
    • Lags behind plasma
  • Hemodilution, physiologic anemia

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6

Hematologic & Hemostatic changes: WBCs 

 

  • —WBC volume ↑ 8%, up to 15,000/mm3

 

 

7

Hematologic & Hemostatic changes: PLTs

  • —Platelets largely unchanged
    • Mild-moderate thrombocytopenia
       

8

Hematologic & Hemostatic changes: coagulation

 

  • Hypercoagulable state
  • Starts 11-15 weeks
  • Clotting Factors
    • Increase: I, VII, VIII (increase then decrease), IX, XII, von willebrand.
    • decrease: XI, and VIII later in pregnancy (to about 50% of nonpregnant)

9

normal labs in pregnancy

different from nonpregnant and may change throughout pregnancy

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10

normal labs in pregnancy 2

same idea - may be different from nonpregnant

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11

Anemia in pregnancy - risks

  • Yes - blood loss in birth, etc
  • —Lab values differ from non-pregnant
  • —Risk for iron-deficiency anemia
  • —↑ Risk for thromboembolic disorders
    • Increases further with age, parity, C/S
  • Increase in coagulopathies (PIH - disrupts clotting)

*iron supplements w/vit c. Warn about dark stool & constipation

12

Cardiovascular changes : position of <3

  • starts at 3-4w, plateaus 2nd or early 3rd T
  • Diaphragm elevates --> —Heart displaced to left, rotated (apex displaced laterally)
  • most women tolerate changes unless CV dz
     

13

Cardiovascular changes: CO & systemic vascular resistance

—Cardiac Output

◦↑ 30-50%
◦50% of that ↑ by 8 weeks GA
◦↑ HR 10-20 BPM

—↓ Systemic vascular resistance (--> inc BF to uterus)
 

most women tolerate well

14

Cardiovascular changes: skin

—↑ Skin perfusion (d/t vasodilitation)

15

CV changes: RAAS

 

 

  • —Renin-angiotensin-aldosterone (all components increase)
    • ◦Enhanced sodium and water retention
    • help maintain BP

16

CV changes: vessels

  • —↑ Vascular distensibility
  • —Aorto-caval compression (increases venous pressure in lower extremities - leakage from vasculature)
  • —Decreased baroreflex (impaired BP regulation - difficulty responding to OH and blood loss)
  • —BP decreases

17

Cardiac exam on pregnant women: what might you see?

 

  • Jugular venous distension
  • Split S1, sometimes split S2
  • 3rd sound audible at times
  • SEM along LSB (92-95% of women) >grade 2 or thrill must be evaluated
  • Soft, transient diastolic (20% of women)
  • ↑ Mammary blood flow, veins dilate
  • Mammary souffle (14% of women)
  • —MVP common – may ↓ murmur
     

18

BP in pregnancy: worried about low or high?

both

19

BP in pregnancy - normal changes

 

  • Lowest second trimester: lowest 24-32 weeks, returns to nonpregnant values near term
  • Measurement changes

20

BP in pregnancy - what compounds effects?

physiologic but can be compounded by other pregnancy changes

  • Positional effects
    • –Supine hypotensive syndrome (uterus compress great vessels)
    • –Orthostatic hypotension (perhaps d/t decreased baroreflex sensitivity)
  • Other hypotensive effects (heat, long hot showers, etc.)
  • Hypertensive disorders of pregnancy

21

aortocaval compression relief, image

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22

Clinical implications of CV changes in pregnancy: multiple pregnancies 


—even greater increase in CO, stroke volume
increase in HR, anemia, PIH, MVP (tend to be asymptomatic)
 

23

Clinical implications to increased skin perfusion

  • —Vascular spiders, palmar erythema
  • —Nasal hyperemia: congestion
  •  

24

Exercise in pregnancy

  • shorter labors, fewer perinatal complications, inhibits clot formation, varicosities, weight gain
  • ◦30” daily 2-3x/wk
  • ◦Aerobic walking, stretching, biking, weights
  • ◦Benefits swimming
  • ◦Cautions:
    • no lifting >25lbs,
    • balance (biking in 3rd T),
    • redistributes blood to skin and muscles, so may cause dizziness;
    • high heat (hyperthermia can be teratogenic, so also stay away from saunas & hottubs),
    • avoid jumping, deep flexion of joints, blunt abdominal trauma, aortocaval compression (supine)

25

Respiratory: anatomical changes

  • ◦Position of diaphragm shifts
  • ◦↑ Subcostal angle
  • ◦↑ Chest diameter & circumferences
  • ◦ Hyperemia oro- & nasopharynx

probably due to relaxation of ligaments btwn rib cage and sternum
 

26

Respiratory: physiologic changes

 

  • ◦Progesterone respiratory stimulant
    • ◦Chronic mild hyperventilation (increased alveolar O2, drop in arterial CO2)
      • ◦Favors transfer CO2  fetus → mom 

27

Progesterone & PGs in respiration

  • prog: decrease airway resistance up to 50%
  • both relax smooth muscles of resp tract - reduced WOB

28

O2 consumption in pregnancy

O2 consumption increases d/t metabolic demands of mother, placenta, fetus, and lung capacity changes

29

Which of the following increase during pregnancy?

Respiratory rate (RR)

Vital capacity (VC)

Inspiratory capacity (IC)

Tidal volume (TV)

Inspiratory reserve volume (IRV)

Functional residual capacity (FRC)

Expiratory reserve volume (ERV)

Residual volume (RV)

Total lung capacity (TLC)

Inspiratory capacity, tidal volume, 

30

Which of the following decrease during pregnancy?

Respiratory rate (RR)

Vital capacity (VC)

Inspiratory capacity (IC)

Tidal volume (TV)

Inspiratory reserve volume (IRV)

Functional residual capacity (FRC)

Expiratory reserve volume (ERV)

Residual volume (RV)

Total lung capacity (TLC)

FRC, ERV, RV, TLC

31

Which of the following stay the same during pregnancy?

Respiratory rate (RR)

Vital capacity (VC)

Inspiratory capacity (IC)

Tidal volume (TV)

Inspiratory reserve volume (IRV)

Functional residual capacity (FRC)

Expiratory reserve volume (ERV)

Residual volume (RV)

Total lung capacity (TLC)

RR, VC, IRV

32

Physiologic dyspnea

Result of anatomic & physiologic changes

(60-70% women)
◦1st trimester start, max 28-31 weeks
◦At rest or with mild exertion

r/o pathology then reassure

33

URIs & rhinitis

  • d/t capillary engorgement and hyperperfusion, hyperemia of oro and nasopharynx, along w/smooth muscle relaxation
  • ◦Immune system changes 
  • ◦↑ susceptibility to pneumonia - if they do get URI
    tolerate coughs longer, but if febrile & productive cough, recognize may be more serious

34

Asthma in pregnancy

—(8% women)

better, worse, or unchanged

inhaled steroids first line

35

Kidney size in pregnancy

—Kidneys enlarge about 1 cm

growth d/t increased renal vasculature, IS volume, dilation of pelvis, renal calyces, and ureters

 

36

Effect of progesterone & PGs on kidneys

  • Progesterone leads to:
    • —↓ Bladder tone, ↑ capacity (maybe - but compression decreases later
  • —Hypomotility, ↓ peristalsis ureters (PG mediated)

37

Changes to ureters in pregnancy

  • —Ureters longer, tortuous, displaced (leads to stasis, interferes w/glomerular filtration)
  • —also ↑ Hydronephrosis and hydroureter

38

Physiologic Renal and Fluid homeostasis changes 

 

  • —Na+ retention
  • —↑ Extracellular volume
  • —GFR↑ 40-60%
    • ◦Starts 4-6 wk, peaks 9-16 wk
    • ◦Maintained until term
  • —↑ Reabsorption, secretion solutes (glc, AAs, protein)
  • —Renin-angiotensin-aldosterone altered (maintain homeostasis, may play role in PIH)
     

39

Clinical implications of kidney changes

 

  • —↑ Frequency (60% of women)
  • —Nocturia
  • —Incontinence (30-50% of women) (24% of these have continued sx 1yr post-partum)
  • —Dependent edema (more in obese, large babies)
  • —↑ UTIs, pyelonephritis
    • —Urine testing
    • —Renal testing
       

40

Maternal GI & hepatic changes

 

  • —Mouth; gum tissue friable w/bleeding, saliva more acidic, more plaque, etc --> more gingivitis. No evidence for >caries
  • —Esophagus↓ sphincter tone, motility, pressure
  • —Stomach ↓ tone, motility, emptying (may help w/nutrient absorption). Increased risk GERD. N/V etiology unknown.
  • —Intestines ↓ tone, motility, ↑H2O absorption
  • —Liver enzymes altered
    estrogen appetite suppressant, prog - appetite stimulant

41

Clinical implications of GI and hepatic changes

 

  • —Gingivitis (30-80% women), ptyalism, caries
    • increased preterm, SGA
  • —Heartburn  - pyrosis (80% of women) (H2 antagonists if necessary Class B, PPIs if more severe - class C)
  • —NVP
    • ◦Nausea (70-90% of women)
      • ◦Vomiting (30-45% of women with nausea)
      • hcg levels may be involved
      • assoc w/better pregnancy outcomes
    • ​◦Hyperemesis (<1% of women)
  • —Food cravings/aversion (esp meat, poultry, eggs)
  • —Pica -consumption of nonnutritive substances. Starch, ice, dirt (cultural). Concerns over whether safe
     

42

Constipation, bloating, flatulence in pregnancy


—Acute abdomen differential dx

  • ◦Obstetrical causes - enlarged uterus (pressure), contractions, ligament pain, prone to pulling abdominal muscles
  • ◦Non-obstetrical causes, including appendicitis, UTI
     

43

appendix in pregnancy

displaced upward and laterally to right. 2nd trimester - above iliac crest

44

weight gain recommendations

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45

how many calories per day

extra 350-450 kcal, depends on weight

 

46

Mortality rates & weight gain

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47

Skin in pregnancy

 

  • —Hemangiomas, varicosities
  • —Pruritis (abdomen or generalized. Can be sign of intrahepatic cholestasis, but probably not)
  • —Vasomotor instability
  • —Hair growth mild hirsutism
  • —Hyper-pigmentation (91% of women) (estrogen, prog)
    • ◦Areolar, genitalia, axillae, linea nigra
    • ◦Freckles, nevi, scars
    • ◦Melasma (chloasma)
  • —Striae gravidarum
    hair loss postpartally

48

melasma/chloasma

mask of pregnancy. 

Recommendation: avoid sun, use sunscreen. usually fades significantly to completely

49

Striae Gravidarum

stretch marks. 50 - 80% of women. Probably secondary to estrogen, relaxin, adrenocorticoids; irregular pink or purple and become silvery white

more frequent in younger, obese, larger babies. Tends to be familial. Can itch. can be on breasts.

50

Musculoskeletal changes 

 

  • —Joint mobility increased
  • —Progressive lordosis
  • —Stretching ligaments
  • —Stretching abdominal muscles 
  • —Diastasis recti - separation of abdominal muscles. PP ab exercises
  • —Flexion neck & slumping shoulders (can lead to nerve compression)
  • —Balance
     

51

Clinical implications of MS changes

 

  • —Joint laxity, SP separation
  • —Low back pain (45-50% of women): combo of hormonal and mechanical factors
    • —Lumbar lordosis: shifts center of gravity antiororly - strain. Teach pelvic tilt.
    • sciatica d/t nerve compression
  • —Abdominal pain
  • —Carpal tunnel: pressure on median and ulnar nerves d/t anterior neck flexion, edema, etc
  • —Leg cramps: pressure or electrolytes 
  • —Falls
  • —Headaches
     

52

Immune system & pregnancy

 

  • Suppression - may help to not reject fetus, but can have implications for maternal health
  • Activation - can lead to spontaneous abortion
     

53

Eyes and pregnancy

increased Intraocular pressure - don't get new contact lenses

54

Sleep

difficult to fall asleep by 12w. Less efficient sleep. 

55

CNS effects

reduced attention/memory, continues postpartum

perhaps d/t sleep? 

56

Emotional lability & pregnancy

sleep deprivation, discomforts, hormonal changes, role changes, financial & social changes

57

significance of facial edema after 20w gestation

investigate preeclampsia

58

preeclampsia

SBP >140 or DBP >90 after 20w, w/proteinuria

59

significant thyroid enlargement: normal or abnormal

abnormal

(some enlargement is physiologic)

60

When does mom feel fetal movement

18-24 w