Women's Health 3 Flashcards
(297 cards)
1
Q
Purposes of prenatal care
A
- patient education and reassurance
- patient comfor with provider of delivery services
- medical services: BP, detection of preeclampsia
2
Q
First visit should include (5)
A
- complete assessment
- gestational age assessment
- Pap smear, cultures
- prenatal panel
- discussion of breast feeding
3
Q
How long is the standard pregnancy?
A
40 weeks
4
Q
How many weeks is considered “term”?
A
37-40 weeks gestation
5
Q
How many weeks is “preterm”?
A
20-36+6 weeks
6
Q
How many weeks is considered abortion?
A
20 weeks
7
Q
What is happening when G does not = P?
A
patient is pregnant!
8
Q
Two most important genetic risk assessment factors for the patient
A
advanced maternal age (>35)
drug exposures
9
Q
What genetic RF should you think of in ethinic backgrounds (esp AA)
A
Sickle cell
10
Q
Recommended schedule for routine antepartum OB visits
A
Every 4 weeks until week 28
Every two weeks until 35-36 weeks
11
Q
Recommended schedule for postpartum OB visit
A
2-6 weeks after delivery
more frequent visits PRN
12
Q
4 parts of a gestational age assessment
A
- LMP
- Pelvic US (ideally in 1st trimester)
- Physical exam, fundal height
- Naegle’s rule
13
Q
What is the formula for Naegle’s Rule and what is it for?
A
Calculates the Estimated Date of Conception (EDC)
LMP + 7 days - 3 months +1 year
14
Q
How many week pregnancy is Naegle’s Rule based on?
A
40 weeks (10 months!)
15
Q
What’s a useful tool for determining Naegle’s Rule?
A
Pregnancy wheel
gives current gestational age
16
Q
The first trimester US takes what measurement?
A
Crown-Rump Length (CRL)
17
Q
What # weeks should the first OB visit happen?
A
8 weeks
18
Q
Do you need a Pap on the first OB visit?
A
only if patient is >21
19
Q
Name some things the prenatal panel contains
A
Blood type/screen CBC Hepatitis B surface antigen Syphilis Early 1-hour glucose tolerance test Rubella immunity status HIV Urine C&S B-hcG, P4 Hep C Igg Carrier testing for CF, Fragile X, SMA
20
Q
What is BhCG useful for?
A
Only establishing viability. It peaks at 10 weeks, then sharply declines and is back to baseline at about 15-17 weeks
21
Q
What type of fetal assessment happens at <12 weeks?
A
transvaginal US for “viability” or “dating”
22
Q
What type of fetal assessment happens at >8 weeks?
A
Fetal heart tones
23
Q
What type of fetal assessment happens at >16 weeks?
A
Fetal movement
24
Q
When assessing fundal height, when does the uterine fundus begin to grow out of the pelvis?
A
12 weeks
25
When assessing fundal height, when does the uterine fundus reach the umbillicus?
20 weeks
26
when measuring fundal height, when do the gestational weeks equal the measurement in cm?
beyond 20 weeks
27
When does the uterine fundus reach the xyphoid process?
36 weeks
28
When does genetic screening take place?
12 weeks
29
Does genetic screening detect neural tube defects?
no
| Ex: spinal bifida
30
GBS colonizes in the vaginal and rectal areas in what percent of women
30%
31
What happens to the baby if the mother is infected with GBS?
neonate may become infected during delivery >> fever, sepsis
32
When do you do a vaginal/rectal swab for GBS?
35 weeks
33
How is the fetal presentation classified?
the anatomical part of the fetus lying over the pelvic inlet: the presenting body part of the fetus
34
When the baby's head is presenting
Vertex presentation
35
When the baby's feet/bottom are presenting
Breach presentation
36
When the baby's shoulder is presenting
Shoulder presentation
37
What is fetal lie?
relation of the long axis of the fetus to that of the mother
38
What are the different fetal lies?
Longitudinal
Oblique
Transverse
39
Common complaints in antepartum care
```
N/V
Heartburn/reflux
Fatigue
Round ligament pain
Leg cramps, muscle pain
Low back pain
Dyspnea
```
40
What causes maternal N/V?
increased hCG/P4
41
What causes maternal Heartburn/GERD
```
decreased GI motility
increased stomach emptying time
reduced GE sphincter tone
increased intra-abdominal pressure
horizontal lie of the stomach as the uterus enlarges
```
42
What causes maternal dietary cravings?
PICA
43
What causes maternal constipation?
reduced GI motility
44
What causes maternal hemorrhoids?
elevated venous pressure
increased pelvic blood flow
pressure from constipation
45
Cardiac output increases _____% in the first 20 weeks of pregnancy
50%
46
What cardiac finding is normal in pregnancy, not normal otherwise
S3 gallop, systolic ejection murmur
47
IVC syndrome is common in pregnancy. What is it?
Compression of the IVC by gravid uterus. Causes dizziness, light-headedness, syncope
48
Hormonal changes cause what MSK change in mom?
SI joint relaxation
49
What causes maternal leg cramps?
electrolyte imbalances
50
What cause nasal "congestion" in pregnant women?
mucosal hyperemia
51
What causes maternal dyspnea?
diaphragmatic compression secondary to gravid uterus
52
What is centering pregnancy?
a model of group healthcare.
53
Three major components of centering pregnancy?
1. assessment
2. education
3. support
54
Name a few CCs that can be the clinical presentation of pregnancy
```
missed period
breast tenderness
nausea
fatigue
"purple cervix"
Softening and enlargement of the uterus
+ hCG (home or office)
```
55
Name some early complications of pregnancy
```
bleeding
pain/cramping
hyperemesis
change in bowel habits
social issues
```
56
Name some causes of first trimester bleeding
```
abortion
ectopic pregnancy
Hydatidiform mole
cervical polyps
cervicitis
neoplasm
```
57
What percent of pregnancies result in spontaneous abortion?`
15-25% of all clinically recognized pregnancies, possibly as high as 50% of all
58
Most (80%) of miscarriages happen within how many weeks?
the first 12
59
The likelyhood of spontaneous abortion is lower once...
fetal heart activity is visualized on US
60
What are the percentages f recurrence associated with 1, 2, 3, and 4 prior losses?
1: 19%
2: 35%
3: 45%
4: 54%
(must be consecutive, live births start from the beginning)
61
Name 6 reasons etiologies of spontaneous abortion
```
chromosome abnormalities!! (50-70%)
Endocrine abnormalities
Reproductive tract abnormalities
Immunologic
Infection
Idiopathic
```
62
Chromosome abnormalities are found in what percent of still births? and live births?
5% ; .6%
63
is alcohol associated with spontaneous abortion?
no, but it's teratogenic
64
Is caffeine associated with spontaneous abortion?
possibly
65
Is trauma associated with spontaneous abortion?
no
66
Is radiation associated with spontaneous abortion?
Very much, if >10 rads
67
Is smoking associated with spontaneous abortion?
Yes, if moderate or more
68
Definition of spontaneous abortion
termination of pregnancy before 20 weeks
69
Most common etiology of spontaneous abortion
chromosome abnormalities
70
Definition of threatened abortion
vaginal bleeding in the first trimester, os is still closed, can see pregnancy on US, still have fetal heart tone
Pregnancy may be viable or abortion may follow
71
What is the most common cause of first trimester bleeding?
threatened abortion
72
POC in threatened abortion?
NO
73
cervical os is ____ in threatened abortion
closed
74
up to _____% of patients have threatened abortion, up to _____% of them miscarry
25%
| 50%
75
There is an increased risk of what with threatened abortion
PTD
76
Threatened abortion S/S
essential bleeding in first trimester; bloody vaginal discharge
77
Threatened abortion Tx
Supportive: rest, ER return precautions
Serial B-hCG to see if doubling
No medications helpful
EMOTIONAL SUPPORT
78
Incomplete abortion definition
in the process of aborting, but still have retained products, cervical os is open
pregnancy is not salvagable
79
POCs in incomplete abortion?
some POC expelled, some still retained
80
Cervical os is ____ in incomplete abortion
DILATED
81
Incomplete abortion S/S
HEAVY bleeding
retained tissue
BOGGY uterus
82
Incomplete abortion Tx
may be allowed to finish
D&C in first, D&E after first
Pitocin
83
Inevitable abortion definition
pregnancy not salvageable, no POCs expelled yet
84
Cervical os is _____ in inevitable abortion
progressively dilating
+/- ROM
85
Inevitable abortion S/S
moderate bleeding >7 days
| cramping
86
Inevitable abortion Tx
Dilation and evacuation in 2nd trimester
| Suction curretage in 1st trimester
87
Missed abortion definition
vaginal bleeding, os is closed, US shows gestational sac, retained products, been in there for awhile. Body did not expel the fetus but there is no fetal heart tone
Fetal demise but still retained in uterus
88
POCs in missed abortion?
none expelled
89
Cervical os is ____ in missed abortion
closed
90
Missed abortion S/S
loss of pregnancy Sx
| maybe brown discharge
91
Missed abortion S/S
D&E (D&C if first trimester)
| Misoprostol
92
Complete abortion definition
complete passage of all products
93
POC in complete abortion?
all completely expelled
94
Cervical os is ____ in complete abortion
closed
95
Complete abortion S/S
pain, cramps, bleeding usually subsides
96
Septic abortion definition
the retained POC becomes infected, causes infection of the uterus and organs
97
POC in septic abortion?
some POC retained
98
Cervical os is ___ in septic abortion
closed
99
septic abortion S/S
```
cervical motion tenderness
Foul brownish disrcharge
fever, chills
uterine tenderness
spotting >> heavy bleed
```
100
When is RhoGam indicated in abortion Tx?
if Rh negative
101
Definition of elective abortion
termination of intact pregnancy before viability (usually surgical)
102
Describe medical regiment used for elective abortion (2)
Mifepristone >>> Misoprostol 24-72 hours after
OR
Methotrexate >>> Misoprostol 3-7 days later
103
Mifepristone MOA
anti-progestin
104
Methotrexate MOA
antimetabolit (folate antagonist)
105
Misoprostol MOA
prostaglandin that causes uterine contractions
106
Surgical elective abortion can be performed up to _____ weeks from LMP
24
107
what type of surgical elective abortion is used in weeks 4-12?
Dilation and currettage (including suction curettage)
D&C
108
What type of surgical elective abortion is used in weeks >12
dilation and evacuation
D&E
109
Definition of ectopic pregnancy
any pregnancy implanted outside the endometrial cavity
110
Most common place of ectopic pregnancy?
fallopian tubes, especially the ampulla
111
Ectopic pregnancy RFs
- Previous pelvic infection
- previous tubal surgery
- intrauterine device in place
- previous tubal pregnancy
ADHESIONS from surgery!
112
Ectopic pregnancy clinical triad:
1. unilateral pelvic/abdominal pain
2. vaginal bleeding
3. amenorrhea (pregnancy)
113
The ectopic pregnancy triad can also be seen with ___.
threatened abortion
| threatened more common than ectopic actually
114
ectopic pregnancy atypical S/S
vague Sx
menstrual irregularities
severe abdominal/shoulder pain
115
ruptured/rupturing ectopic pregnancy S/S
severe abdominal pain
dizziness
N/V
signs of shock (from hemorrhage): syncope, tachycardia, hypotension
116
ectopic pregnancy PE
cervical motion tenderness
| adnexal mass
117
Ectopic pregnancy Dx
1. SERIAL quantitative B-hCG
- normally doubles every 48 hours in first trimester
2. Transvaginal US
3. laparoscopy for direct visualization
118
What would you see on transvaginal US if there is an ectopic pregnancy
absence of gestational sac with B-hCG levels >2000 strongly suggest ectopic or nonviable intrauterine pregnancy`
119
Ectopic pregnancy Tx
- Surgical: laparascopy with salpingectomy or salpingotomy
| - Medical: methotrexate
120
When would you use surgical versus medical tx of ectopic pregnancy?
Surgical: ruptured or unstable
Medical: unruptured or stable
121
Methotrexate MOA in ectopic pregnancy
destroys trophoblastic tissue (disrupts cell multiplication)
122
Indications for methotrexate in ectopic pregnancy (4)
- hemodynamically stable
- early gestation (<4cm)
- B-hCG <5,000
- no fetal tones
123
CI for methotrexate in ectopic pregnancy
- ruptured ectopic
- history of TB
- B-hCG >5,000
- fetal heart tones present
124
Do you give RhoGAM in ectopic pregnancy?
Yes, if mom is Rh negative
125
What is hydatidiform mole?
"molar pregnancy"
a type of gestational trophoblastic neoplasia
Partial mole= identifiable fetal structures
Complete mole= NO identifiable fetal structures
126
Molar pregnancy S/S
Exaggerated pregnancy symptoms
Threatened abortion Sx
Uterus larger than expected
127
Molar pregnancy Dx
US: "snowstorm appearance"
128
Molar pregnancy Tx
Definitive: prompt evacuation of uterine contents, hysterectomy if no wish for future children
129
In clinic, you'll probably see more ____ pregnancy, complications. In ER, you'll probably see more ____ pregnancy complications.
late; early
130
Women are how many times as likely to be diagnosed with clinical depression?
twice
131
When does depression most commonly happen in women?
during childbearing years (25-44)
132
How many women will be dx with depression in their lifetime?
1/8
133
Do depressed women seek treatment?
less than 1/2 do
134
Do more men or women get diagnosed with bipolar?
equal
135
___ times as many women as men experience rapid cycling of bipolar disease
3x
136
What does research show about women with bipolar?
they have more depressive and mixed episodes than men
137
Premenstrual syndrome definition
a cluster or general pattern of physical, emotional, and behavioral symptoms with cyclical occurence during the LUTEAL phase of the menstrual cycle
138
when does PMS occur?
in the LUTEAL phase
1-2 weeks before menses
Remits with onset of menses
139
How many women experience PMS?
50-80% of women of reproductive age
140
What is premenstrual dysphoric disorder?
severe PMS with functional impairment
141
PMS physical S/S
```
bloating
breast swelling and pain
HA
bowel habit changes
fatigue
muscle/joint pain
```
142
PMS emotional S/S
```
depression
hostility
irritability
libido changes
aggressiveness
```
143
PMS behavioral S/S
food cravings
poor concentration
noise sensitivity
loss of motor senses
144
Most common Sx of PMDD
irritability
145
DSM-V criteria for PMDD
A. 5 or more Sx in most menstrual cycles in the past year
B. One or more of the following: affective libility, irritability or increased interpersonal conflict, depressed mood or hopelessness or self-depricating thoughts, and anxiety
C. One or more of the following: decreased interest in usual activities, difficulty concentrating, decreased energy, change in appetite, hypersomnia or insomnia, feeling overwhelmed or out of control, physical symptoms
D. Clinically significant distress
E. not an exacerbation of another disorder
F. Prosective daily fatings during 2 symptomatic cycles
G. NOT due to substance use or another med
146
PMS Dx
- Sx initiate during the luteal phase (1-2 weeks before menstruation)
- relieved with 2-3 days of the onset of menses
- at least 7 Sx-free days during the follicular phase
147
PMDD Dx
Daily charting of Sx for 2 months
148
T/F: women with or vulnerable to PMDD have abnormal hormone levels
FALSE. Research shows women vulnerable to PMDD do NOT have abnormal levels of hormones, they have a particular SENSITIVITY to normal cyclical hormonal changes
149
PMDD pharmacologic Tx
SSRIs are first line
Other options: OCPs containing drospirenone, GnRH agonists (leuprolide), Danazol (a synthetic androgen)
150
How long does it take for SSRIs to work for PMDD?
a few days, FAST!
151
When should you start to consider another option if the SSRI isn't working a for a patient's PMDD?
after 3 menstrual cycles with no improvement
152
PMDD non-pharmacologic Tx
- Lifestyle Mods: exercise, sleep, decreased caffeine, decreased EtOH/tobacco
- Nutritional supplements: Ca, Vit B6
- Herbal supplements: no evidence for this
153
2 keys for follow up for PMDD
1. continue daily charting after Dx to determine Tx effectiveness
2. Tx for at least 12 months to cover relapse
154
T/F: the pregnant state is protective for mood disorders
False
155
Theory behind hormones and mood of postpartum depression
Theory: some women are more sensitive to changes in hormone levels >> increased susceptibility for mood disorders via NT changes
156
What hormone changes happen with delivery?
plummeting of both estradiol and progestin
157
Spectrum of postpartum mood changes
```
Postpartum blues
>>
Postpartum depression
>>
Postpartum psychosis
```
158
What dose the following describe: mother is tearful, irritable, and anxious about the new responsibilities of being a mother, but experience SOME joy, sleeps when the baby sleeps, and eats well
Sx DO NOT impair the woman's ability to care for herself or baby
Baby blues
159
Onset of baby blues
about 3 days after delivery, usually resolves by 2 weeks postpartum
160
Baby blues Tx
support and reassurance
161
What is one of the most common complications of childbirth?
Postpartum depression
162
Postpartum depression Dx
Same DSM-V criteria as MDD (SIGECAPS), but onset of episode within 4 weeks postpartum
163
What does the following describe: mom has guilt, appetite change, agitation, anxiety, cannot sleep even when baby is sleeping, has obsession and compulsions about the baby
Postpartum depression
164
PPD screening
Edinburgh postnatal depression scale (EPDS)
10 item self report scale
Score of 10-12 is positive
If positive, conduct a brief clinical interview to establish the Dx of depression
165
PPD RF
- previous episode of depression
- Severe PMS
- anxiety during pregnancy
- depression during pregnancy, particularly 3rd trimester
- prior episode of PPD
- FHx of depression/anxiety/bipolar
- Poor marital support
- Trauma
- isolation of mother
- increased life stressors
- prefectionism
- work/financial pressures
- lack of maternal self-care
166
Most important RF for PPD
prior episode of PPD
167
Three components of PPD recovery
1. medical intervention
2. social support
3. psychotherapeutic intervention
168
Moms MUST get uninterupted sleep for at least ____ hours _____ nights per week
4-6 hours; 2 nights/week
169
PPD pharmacologic Tx
SSRIs first line
170
PPD prophylactic Rx
for high risk women, no longer than 17 weeks
171
Untreated PPD may lead to the following problems: (4)
- interrupted bonding with baby
- contributes to family/marital discord
- can lead to psychosis, SI, tragedies
- interferes with the normal child development
172
Children who grew up with a mother who suffered from depression have shown an increased incidence of:
- childhood psychiatric disturbances
- behavior problems
- poor social functioning
- impaired cognitive and language development
173
In normal interactions, mothers and infants engage in _____ mismatching states which leads to trust in the partner and sense of mastery ("we can overcome problems").
Depressed mothers find it difficult to read and respond to infants' communications, leading to larger and longer mismatches and less likelihood of _____ repair
repairing; repair
174
What commonly occurs with PPD
Postpartum OCD
175
what happens in POCD
intrusive thoughts or images of harming baby or something harmful happening
176
Are women with POCD more likely to harm their infant?
NO
177
Explain how a mom with POCD might act
Obsessive thoughts about harm coming to the infant causes them to avoid holding the baby on staircases, bathing the baby, the kitchen area, leaving the house, etc
178
Important note about women with POCD
These Sx cause shame and embarrassment, women don't volunteer this info unless you ask!!
179
What is described by the following: mom has anxiety and agitation, disorganized behavior, confusion, delusions about infant, voices in her head, hallucinations, and thoughts about hurting herself or baby
postpartum psychosis
180
When does postpartum onset? what about recurrence?
onset is rapid- within 3 days to one week
| Recurrence rate is extremely high!
181
Patients with preexisting Dx of ____ have a 20% increased risk for developing postpartum psychosis
bipolar
182
Postpartum psychosis Tx
ANTIPSYCHOTICS AND HOSPITALIZATION
PSYCHIATRIC EMERGENCY!!
Risk of suicide and infanticide!!
183
General rules of treating depression during pregnancy
discuss psychotropic meds and pregnancy when you first prescribe meds for women during their childbearing years
ABRUPT cessation of psyciatric meds during pregnancy makes relapse more likely
184
What is first line Tx for depression during pregnancy
SSRIs
185
Any risks for fetus with SSRI?
no risk of malformations
| no evidence of being teratogenic
186
Other Tx options for depression during pregnancy
psychotherapy
ECT
Omega-3s
Bright light therapy
187
General principals for breastfeeding while on meds (for mom)
breastfeeding not always safe
SLEEP is very important
188
General principals for breastfeeding while on meds (for baby)
- BBB is porous
- liver enzymes not fully developed
- kidneys partially functioning
189
Breastfeeding while on SSRIs: drug exposure to infant is ___
low
190
Normal pregnancy is an average of ___ weeks from the first day of the LMP to the estimated date of delivery
40
191
Definition of early term
37 0/7 - 38 6/7 weeks
192
Definition of full term
39 0/7 - 40 6/7 weeks
193
Definition of late term
41 0/7 - 41 6/7 weeks
194
Definition of post term
42 weeks and beyond
195
What term has the lowest incidence of adverse neonatal outcomes?
full term
196
What are the four warnings of labor?
- the 5-1-1 rule
- spontaneous rupture of membranes
- vaginal bleeding
- decreased fetal movement
197
What is the 5-1-1 rule of labor?
Contractions occur...
- every 5 minutes (are painful)
- last at least 1 minute each
- go on for at least 1 hour
198
How many fetal movements should there be at term?
about 10 discrete movements per hour
199
Explain dilation/effacement/station on cervical exam when a patient is admitted to labor and delivery
Dilation: the opening of the cervix, ranges from 0-10
Effacement: rough estimate of the shortening of the cervix
Station: fetal head location in the maternal pelvis
200
The reference point for "station" is what?
the ischial spines
201
what is 0 station
baby's biparietal diameter is AT the level of the ischial spines
202
what is minus station?
baby's biparietal diameter is ABOVE the ischial spines
203
what is plus station?
baby's biparietal diameter is BELOW the ischial spines
204
There is an increased risk of what in spontaneous rupture of membranes?
infection
205
What is the first stage of labor?
from onset of labor >> complete cervical dilation (10cm)
206
What is the second stage of labor?
from complete cervical dilation >> delivery of the infant
207
What is the third stage of labor?
from delivery of the infant >> delivery of placenta
208
What is happening in the latent phase of the first stage of labor?
cervix effacement with gradual cervical dilation
209
What is happening in the active phase of the first stage of labor?
rapid cervical dilation, usually beginning at 3-4 cm
210
What is happening in the passive phase of the second phase of labor?
complete cervical dilation to active maternal expulsive efforts
211
What is happening in the active phase of the second phase of labor
from active maternal expulsive efforts to delivery of the fetus
212
What are the three signs of placental separation in the third stage of labor?
1. gush of blood
2. lengthening of the umbilical cord
3. anterior-cephalad movement of the uterine fundus (becomes globular and firmer after the placenta detaches
213
what is the biggest difference in labor from nulliparas to multiparas women
second stage of labor lasts about 33 minutes in first labor, but only 8.5 minutes in subsequent labors
214
describe pain in the first stage of labor
diffuse, visceral, not well localized
215
describe pain in the second stage of labor
pudendal nerve and the anterior divisions of S2-S4 are stimulated by distention of vagina/pelvic floor/perineum
somatic pain, better localized
216
biggest problem with systemic analgesia as pain management in labor
it crosses the placenta
it also doesn't really work as well
217
Best part of neuroaxial (regional) analgesia for pain management in labor
pain relief with minimal maternal and neonatal adverse affects
218
What women are more likely to elect regional anesthesia?
higher education levels
caucasian
early presentation for prenatal care
219
what is the apgar score for?
assessing clinical status of newborn
220
5 components of the apgar score
1. color
2. HR
3. reflexes
4. muscle tone
5. respiration
221
when do you report the apgar score?
1 and 5 minutes after delivery
222
Describe the apgar scores and what they'd mean
1-10 total, assigned 0-2 points in each section
7-10 is reassuring
4-6 is moderately abnormal
0-3 is nonspecific sign of illness
223
When would you repeat apgar scores
if score <7, repeat at 5 minute intervals up to 20 minutes
224
When would a baby get a +2 for on the HR section of the apgar?
HR >100
225
When would a baby get a +2 for color on the apgar score?
pink baby (no cyanosis)
226
When would a baby get a +1 on for color on the apgar?
acrocyanosis: body is pink, extremities are blue
227
What's a normal baseline fetal heart tone?
110-160
228
What are we looking for when monitoring fetal heart tones?
baseline, long and short term variability, accelerations and decelerations
229
Two types of fetal monitoring
- External: US
| - Internal: same tech as EKG measures R-R interval. Allows for better quality tracing with more continuity
230
Fetal heart tones are always discussed in increments of ____.
5
231
What is short term variability in fetal heart tones?
beat to beat irregularity in the HR, represents the push-pull effect of sympathetic and parasympathetic nerve input
232
What is the dominant nerve of short term variability?
vagus
233
What is long term variability of fetal heart tones?
the waviness of the tracing. Accelerations.
234
What is a reactive long-term variability?
2 accelerations every 20 minutes
235
Why is variability important?
it's a marker of fetal well-being.
236
When a fetus is alert and active, the variability is _____. When a fetus is obtunded, variability is _____.
normal or increased; reduced
237
Name some things that would decrease variability
anything that depresses or reduces brain function!!
```
sleeping baby
drugs
fetal anomalies
neuro insult
immature CNS
fetal tachy
fetal sepsis
```
238
what causes variable decelerations?
compression of the umbilical cord
239
classic shape of variable decelerations
V
240
What are early decelerations caused by?
head compression
241
usual shape of early decelerations
U
242
What are late decelerations and what is their shape?
begin after onset of contraction; U
243
What types of decelerations are worrisome
Late, if repetitive
244
Describe the predictive value of apgar score
1 min 0-3: natta
5 min 0-3: correlates with neonatal mortality in large populations but does not predict individual future neurologic dysfunction
245
A low 5 minute apgar score confers an increased relative risk of what?
Cerebral palsy
246
Why does postpartum hemorrhage happen?
failure of uterus to contract after expulsion of contents
247
How much blood flows through the placenta at term?
600 mL/min
248
RF for postpartum hemorrhage
```
Overdistention of uterus (mult gestations, macrosomia)
oxytocin-stimulated labor
Uterine relaxants
Amnionitis
manual extraction of placenta
```
249
Post partum hemorrhage Tx
Uterine massage
Uterotonics
Surgery
250
Recommended time frame for umbilical cord clamping
30-60 seconds
251
What does umbilical cord clamping do for term infants?
increases hemoglobin levels at birth
| improves iron stores in first months of life
252
Name a few things umbilical cord clamping does for preterm infants
- improved transitional circulation
- better establishment of RBC volume
- decreased need for blood transfusion
- lower incidence of necrotizing enterocolitis and intraventricular hemorrhage
253
When does the postpartum visit usually happen?
4-6 weeks after delivery
254
Topics to be addressed in the post partum visit
```
mood and emotional well being
feeding
sexuality, birth control
sleep and fatigue
physical recovery
chronic disease mgmt
health maintenance
```
255
What percent of women do not attend a postpartum visit?
40%
256
Nickname for postpartum care
"fourth trimester"
257
How many lobes are in one mature mammary gland? what are lobes separated by?
15-25; fat
258
Each lobe is made up of several ___, and those are made up of large numbers of ______.
lobules; alveoli
259
what do the alveolar secretory epithelium synthesize?
milk constituents
260
What are the ducts that open separately on the nipple?
lactiferous ducts
261
What is the other name for stage 1 of lactation?
mammogenesis
262
WHen does stage 1 (mammogenesis) of lactation occur?
conception to mid-pregnancy
263
What is happening in mammogenesis?
- increased proportion of glandular tissue
- increased size of breasts
- darkening and prominent veins
- milk secretion inhibited by the high levels of progesterone and estrogen
264
What is the other name of the second stage of lactation and when does it occur?
lactogenesis I: mid pregnancy to 2 days postpartum
lactogenesis II: 3-8 days postpartum
265
What is happening in lactogenesis I?
- stimulation of milk synthesis by prolactin
| - milk secretion still inhibited
266
What is happening in lactogenesis II?
- reduction of progesterone allows for production and secretion of large amounts of milk
267
What is the other name for Stage three of lactation and when does it occur?
galactopoiesis; 9 days postpartum until involution (stage 4)
268
what is happening during galactopoiesis?
- maintenance of milk secretion controlled by hormones
| - breast size diminishes between 6-9 months, production continues as long as baby sucks
269
What is the other name for the 4th stage of lactation, when does it occur?
involution, begins about 40 days after last breastfeed
270
What is happening during involution?
- loss of the secretory function of milk
| - epithelial cells no longer needed and are removed by apoptosis and replaced with adipose tissue
271
Describe the physiology of breastfeeding
1. baby sucks, no milk released
2. receptors on nipple sense pressure from sucking, send sensory impulses transmitted to the hypothalamus
3. nerve signals in hypothalamus stimulate release of oxytocin from posterior pituitary gland and prolactin from the lactotrophs
4. oxytcin released into blood, acts on myoepithelial cells causing them to contract. Increase in pressure in alveoli causes the milk to be ejected in the ducts
5. 30 seconds to 1 min later, baby is still sucking on the nipple, milk is ejected
272
When do prolactin levels rise?
5th week of pregnancy
273
what does prolactin increase do?
causes mammary ducts to mature and alveoli to differentiate into secretory cells
274
What acute effect does prolactin have?
causes mammary glands to secrete milk into the alveoli
275
When does oxytocin surge?
with suckling, crying baby
276
What inhibits oxytocin?
stress
277
What effect does oxytocin have?
causes milk ejection
278
what is colostrum?
thick, yellow, high in protein/Ab/vits/minerals type of milk that develops during pregnancy and lasts until a few days after baby is born
279
what is transitional milk?
white, high fat/calories/protein/lactose/vits milk that replaces colostrum 2 days after birth
280
what is mature milk?
replaces transitional milk 10-15 days after birth
foremlik or hindmilk
281
Foremilk vs Hindmilk
foremilk: bluish in color, more water content
hindmilk: more white, higher fat content, essential to baby's growth/nutrition
282
Why are the first 2-4 weeks of breastfeeding the hardest?
```
exhaustion (they eat so freakin much)
latching problems
lazy/sleepy eaters
discomfort
milk supply vs demand
baby blues
```
283
3 nursing positions
cradle
football
lying down
284
How to latch
bring baby to the breast not breast to baby!!!
| nose in line with nipple, brush nipple from nose to upper lip, put areola and nipple into mouth
285
Breastfeeding recommendations
- exclusive BF for first 6 months
- intro of complementary solid foods with continued BF until 12 months (mom's milk looses iron, need iron from solid food)
- continue BF until "mutually agreeable" time between mom and baby
286
Benefits of BF
```
involution of mom's uterus
bonding
decreased cancer and T2DM risk in mom
decreased infant mortality
decreased risks in baby for diarrhea, resp illness, obesity, OM, DM
save money
portable
good nutrition for baby
```
287
2 main problems in BF
engorgement
| plugged milk ducts
288
Plugged milk duct Tx
moist heat prior to feeding
| massage during feeding
289
Presentation of mastitis
single area of localized warmth, TTP, edema, erythema in one breast >10 days after delivery
Flu-like Sx: fever, fatigue, N/V, HA
290
Mastitis Tx
Keflex for 10-14 days (not excreted in breast milk)
continue to nurse
Analgesics
291
what can happen if there is failure of mastitis to improve after 48-72 hours?
breast abscess
292
Breast abscess Tx
surgical drainage
Incision corresponding to skin lines (cosmetic)
pack resulting cavity with gauze
293
what percent of women will elect to never BF for varying reasons?
20%
294
How to make more milk?
feed the baby!
| supply and demand
295
how long to see a change in supply?
24-48 hours
296
Name some common Rx contraindicated during lactation
```
acebutolol
aspirin
antihistamines
bromocriptine
ergotamine
lithium
phenobarbitol
primidone
sulfasalazine
```
297
Alternatives to BR
formula
| pumping
