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Case 14 > Pregnancy, labour, delivery and postnatal care > Flashcards

Pregnancy, labour, delivery and postnatal care Flashcards

1
Q

how many antenatal care appointments will a typical nulliparous woman with an uncomplicated pregnancy have?

A

usually 10

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2
Q

In an uncomplicated pregnancy how many appointments will a parous woman have?

A

7

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3
Q

how do you measure symphysis fundal height?

A

from the pubic bone to the top on the uterus

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4
Q

when should screening for sickle cell disease and thalassaemia occur?

A

before 10 weeks pregnant

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5
Q

when are ultrasound scans typically done?

A

8-14 weeks- dating scan

18-20 weeks- ultrasound scan for structural abnormalities

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6
Q

what are the typical screening tests done during pregnancy?

A

bloods- blood group, rhesus D status, anaemia, haemoglobinopathies, red-cell alloantibodies, hep B, HIV, syphilis
screening for downs syndrome- bloods and ultrasound for nuchal thickness at 11-13weeks.
ultrasound screening for structural abnormalities- 18-20weeks

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7
Q

what are the investigations used to assess male and female fertility?

A

female- bloods (progesterone, oestrogen, testosterone, FSH, LH, AMH), pelvic ultrasound, tubal patency (hysterosalpingogram, laparoscopy)
male- semen analysis (sperm count/ concentration, motility, morphology)

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8
Q

when is intrauterine insemination used?

A

when there is an issue with intercourse e.g. disability
when donor sperm is used
when sprm washing is utilised e.g. man is HIV positive
social, cultural, religious objections to IVF

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9
Q

what are the steps in IVF?

A

down regulation- GnRH agonist to shut down normal hormone production
ovarian stimulation- FSH given
egg collection, insemination with sperm sample, embryos transferred to uterus

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10
Q

what are some of the emotional issues associates with sub-fertility and assisted conception?

A

impact on individual- isolation/lack of support, feelings of grief/loss, feelings of inadequacy
impact on relationships- power balance, lack of intimacy, diminished self esteem, sexual issues

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11
Q

what are techniques used to assist pregnancy in mitochondrial disease?

A

egg donation- egg from donor, sperm from partner, embryo transferred to mother
pre-implantation diagnosis- eggs from mother fertilised and tested for level of mutation within each embryo, embryo with lowest level of mutation implanted
pronuclear transfer- the pronucleus (genetic material) from an egg from the mother is removed and transferred into a donor egg which has had its pronucleus removed

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12
Q

how do the levels of progesterone and oestrogen contribute to the initiation of labour?

A

during pregnancy progesterone promotes quiescence of the uterus by decreasing gap junctions and prostaglandin synthesis. towards the end of pregnancy progesterone levels decrease .
at the end of pregnancy oestrogen levels increase which promotes uterine excitation by increasing gap junctions, prostaglandin synthesis, and local oxytocin production

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13
Q

what are the 3 stages of labour?

A

1st stage- 3cm to full dilation, 2 phases: latent stage (irregular contractions) and active stage (regular contractions)
2nd stage- full dilation to delivery of baby, 2 phases: passive phase (baby moves down through pelvis), active phase (woman is pushing)
3rd stage- delivery of placenta and membranes, can either be physiological or assisted (oxytocin injection)

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14
Q

what is descent of the baby head measured in relation to?

A

the ischial spines

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15
Q

what is a partogram?

A

a graph which can be used to assess the progress of labour. it depicts cervical dilatation agains time.

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16
Q

what is the definition if preterm labour?

A

labour between 24 and 37 weeks of pregnancy

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17
Q

what are risk factors for preterm labour?

A

smoking, extremes of maternal age, cervical surgery, infection, multiple pregnancy, uterine abnormalities, fibroids

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18
Q

define non-progressive labour

A

non progressive labour occurs when labour slows and delays the delivery of the baby

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19
Q

what are the complications associated with assisted vaginal delivery?

A

trauma- vaginal lacerations, damage to rectum/anal sphincter
haemorrhage
infection
urinary retention/bladder damage

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20
Q

what are the complications associated with c-section?

A

haemorrhage, infection, DVT/pulmoary embolism, damage to other organs, future pregnancy risk (scarred uterus)

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21
Q

what hormones promote uterine quiescence?

A

progesterone and hCG

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22
Q

what promotes uterine contractility?

A

Connexion 43 (Cx43), prostaglandins and oestrogen

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23
Q

how does Cx43 promote uterine excitation?

A

Cx43 is a gap junction protein which facilitates electrical connections between cells

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24
Q

how to prostaglandins promote uterine excitation?

A

they facilitate depolarisation of myocytes

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25
Q

how does hCG promote uterine quiescence?

A

it causes an increase in cyclic AMP which inhibits uterine contractility bu preventing calcium mobilisation and myosin light chain kinase activity

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26
Q

what is cervical effacement?

A

the cervix shortens and thins out before dilation occurs

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27
Q

what causes effacement and dilation?

A

towards the end of pregnancy cervical collagen fibres become more soluble and lose organisation, the cervix takes on water, and releases prostaglandins. pressure on the cervix increases leading to effacement and dilation

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28
Q

how is delivery date estimated?

A

pregnancy wheel- 40 weeks from 1st day of last menstrual period
ultrasound- more accurate, crown-rump length determines weeks of gestation and can be used to calculate EDD. should be done before 13 weeks

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29
Q

define stillbirth, perinatal mortality, neonatal and infant death

A

stillbirth- death of a baby before or during birth after 24 weeks of gestation
perinatal mortality- timber of stillbirths plus early neonatal deaths (<7 days)
neonatal death- death of a baby within 28 days of life
infant death- death of children under the age of 1 year

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30
Q

what are the risk factors for stillbirth?

A

IUGR, obesity, smoking, mother >40, infection, pre-eclampsia, multiple pregnancy (monochorionic), chronic diseases, substance abuse

31
Q

what are the risk factors for neonatal death?

A

preterm birth, congenital abnormalities, obstetric complications, extremes of maternal age, obesity, infection

32
Q

when should weaning begin?

A

around 6 months

33
Q

what are some benefits of breastfeeding?

A

ideal combination of nutrients
contains protective factors such as immunoglobulins
can protect against things such as gastroenteritis, ear infection,respiratory infection
decreased risk of breast cancer in mother
improved maternal-infant attachment

34
Q

what factors can influence maternal choice in feeding decisions?

A

age, cultural factors, education, support, return to work, concern about milk supply

35
Q

what is the process of transition in the newborn?

A

transition is a process of physiological change in the newborn that beings before delivery which prepares the infant for the switch from placental support to extrauterine self maintenance.

36
Q

what are the changes that occur to prepare the foetus for birth?

A

surfactant production- from 34 weeks
storage of glycogen in liver
producing catecholamines
depositing brown fat

37
Q

how is respiration initiated after birth?

A

umbilical cord clamping increases blood co2 and decreases blood pH. this stimulates aortic and carotid chemoreceptors to imitate respiration. during vaginal birth compression of the chest forces fluid out of the lungs, once the chest is delivered it re-expands drawing air into the lungs- lungs inflate. this causes decreased resistance to blood flow through pulmonary arteries so pulmonary circulation is established.

38
Q

which 3 cardiac shunts close after birth?

A

ductus arteriosus, ductus venous, foramen ovale

39
Q

what are the signs and symptoms of pregnancy?

A

amenorrhoea, nausea, breast tenderness enlargement, fatigue, frequent urination, changes to taste, smell and cravings

40
Q

how does a pregnancy test work?

A

urine is placed on the sample are of a pregnancy test. if the urine contains hCG it will bind to free antibodies in the reaction zone. these antibodies bound to hCG will then bind to immobile antibodies in the test zone which activates an enzyme producing a colour change. in the control zone excess mobile antibodies bine producing a second line. 1 line- not pregnant, 2 lines- pregnant

41
Q

what cell produces hCG?

A

syncytiotrophoblasts

42
Q

what is the function of human placental lactogen?

A

it supports foetal nutrition by decreasing maternal insulin sensitivity and decreases maternal glucose utilisation leading to an increase in blood glucose available to the foetus. it also increases the release of free FAs

43
Q

what is the function of relaxin?

A

relaxes maternal structures in preparation for birth- rupture of foetal membranes, softening of cervix and ligaments

44
Q

what physiological changes occur in the mother during pregnancy?

A

weight gain
uterus- increase in volume, weight and blood supply
cervix- increased secretions, canal fills with mucus plug, increased elasticity
breast- proliferation of ducts, lobules and alveoli
blood- increased BV, RBCs, decreased albumin
immunological- decreased lymphocyte function and cell mediated immunity
cardiac- hypertrophy, increased CO
respiratory- increased O2 consumption
renal- increased RBF, GFR, urinary output

45
Q

why does foetal haemoglobin have a higher affinity for oxygen than adult haemoglobin?

A

due to that absence of 2,3-diphosphoglycerate. it means that foetal haemoglobin can extract oxygen from maternal blood even at the lower pO2- born effect- right shift

46
Q

how is glucose transferred to the foetus?

A

by facilitated diffusion via the GLUT1 carrier protein

47
Q

how are fats transferred to the foetus?

A

fats are broken down and transported- e.g. as free FAs bound to albumin

48
Q

how are amino acids transferred to the foetus?

A

requires active transport- foetal concentration of AA> than maternal. transported via secondary active transport with sodium

49
Q

how do molecules with high molecular mass cross the placenta?

A

pinocytosis- important for immunoglobulins

50
Q

how is CO2 and urea removed from the foetal blood?

A

simple diffusion

51
Q

how does the foetus excrete bilirubin?

A

the foetus does not have glucuronic acid and so cannot conjugate bilirubin. so the unconjugated bilirubin is transferred to the maternal system and is conjugated and excreted

52
Q

why does physiological jaundice occur in newborns and how is it treated?

A

their hepatic enzymes are immature and so cannot conjugate bilirubin effectively enough. it usually resolves by 2 weeks but can be treated with blue light phototherapy which converts the unconjugated bilirubin into a soluble form

53
Q

what is placental insufficiency?

A

when the placenta cannot provide enough oxygen and nutrients to support the growing foetus. it is the most common cause of foetal growth restriction and can cause foetal death in severe cases

54
Q

what is placental abruption?

A

premature separation of the placenta. associated with maternal health (smoking, folate), and trauma

55
Q

what is placenta previa?

A

implantation occurs in lower uterine segment, can block internal os of cervix

56
Q

what is placenta accreta?

A

implantation occurs deep in the uterine wall in the myometrium

57
Q

how is placental insufficiency screened for?

A

symphysis fundal height- check for IUGR
if concerns about growth identified: ultrasound assessment of growth, uterine artery doppler- assesses blood flow and indicates resistance within placenta, assessment of foetal wellbeing.

58
Q

what are some complications that can occur during the antenatal period?

A 
hyperemesis- sever nausea/vomiting
anaemia 
pyelonephritis- kidney infection 
gestational diabetes 
pre-eclampsia/ eclampsia- seizures, stroke, renal/liver failure, disseminated intravascular coagulation 
haemorrhage
59
Q

what are some maternal complications that can occur during birth?

A

haemorrhage, amniotic fluid embolism, operative delivery, anaesthetic risk, tearing

60
Q

what are some postnatal complications that can occur?

A

anaemia, VTE, puerperal sepsis, mastitis, perineal breakdown/haematoma, haemorrhage due to retained placenta, postnatal depression/ psychosis

61
Q

what is the puerperium?

A

the time from the third stage of labour until the changes of pregnancy revert to the non pregnant state. usually 6 weeks postpartum.

62
Q

what is uterine involution?

A

the process where the uterus returns to its pre pregnancy state. it is a process of autolysis- excess protein in uterine muscle is broken down and excreted. breastfeeding helps

63
Q

what is lochia?

A

lochia is the vaginal discharge after pregnancy.

64
Q

what are the 3 types of lochia?

A

rubra- dark red period like loss, till day 5-7
serosa- lighter in amount and colour (red, brown), till day 10-14
alba- clear/light yellow, till day 14-21

65
Q

what are the hormonal changes during lactation?

A

suckling stimulates nerves in nipples and this sends signals to inhibit the release of PRL release inhibiting hormone, causing prolactin release from the anterior pituitra, allowing the secretion of milk. oxytocin release from the posterior pituitary is responsible for stimulating myoepithelial cells around the glands of the nipples to promote milk ejection.
gonadotrophin release is inhibited- anovulation

66
Q

what is the purpose of the 6-8 week baby and mother check?

A

to screen for abnormalities, monitor development, check mothers recovery, provide support to parents and encourage health promotion (immunisations, SIDS etc.)

67
Q

what is mamogenesis and what hormones are involved?

A

this is the growth and development of the breast. it is mediated by oestrogen, progesterone, human placental lactogen and prolactin

68
Q

what is lactogenesis and its stages?

A

lactogenesis is the functional changes that occur for milk secretion.
stage 1- secretory differentiation: glands become sufficiently differentiated and begin to secrete colostrum, from mid pregnancy to a few days after birth. triggered by reduction in oestrogen
stage 2- secretory activation: onset of mature milk secretion, 3-8days after birth, triggered by drop in progesterone after delivery of placenta

69
Q

what is galactopoesis and galactokinesis?

A

galactopoesis is the maintenance of milk production. it is under autocrine control- production of milk is dependant on regular removal of milk
galactokinesis is the process of milk ejection. this remains under endocrine control- oxytocin

70
Q

what are the features of candidal infection of the nipple?

A

candidal infection- infection of candida albicans fungus, can be due to cracked nipples. presents with pain persisting between feeds, itchy red flaky rash on areola, tender
treatment- antifungal cream

71
Q

what is breast engorgement?

A

swollen, hard, painful breasts due to inadequate removal of milk. can lead to a blocked milk duct which can present with a small, tender lump in the breast. management- improve milk removal

72
Q

what are the features of mastitis?

A

inflammation of breast usually due to milk stasis. usually occurs in first 2-3 weeks after birth, most common cause- staph aureus. presents with fever, systemically unwell, tender firm red area of breast, severe pain
treatment- improve milk removal, if no improvement antibiotics

73
Q

what are the feature of a breast abscess?

A

develops if mastitis is untreated. localised collection of pus. presents with painful swelling in breast which feels fluid filled, may have discolouration over the area
management- incision and drainage plus antibiotics

Case 14 (4 decks)

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