Comprehensive Guide to Prenatal Care and Multiple Gestations

School

Brooklyn College, CUNY**We aren't endorsed by this school

Course

MEDICINE PA1

Subject

Nursing

Date

Dec 12, 2024

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Uploaded by israt095

Prenatal Care and Pregnancy EOR Study Guide APGAR Scoring-Done at 1 and 5 minutes after birth and repeated at 10 minutes if abnormal 0 points 1 points 2 points Appearance (skin color changes)Blue-grey, pale all overAcrocyanosis (body is pink, blue extremities)Pink baby with no cyanosis Pulse 0 bpm <100 bpm >100 bpm Grimace (reflex irritability) No response Grimaces feebly Pulls away, sneezes, coughs Activity (muscle tone) None Some flexion Flexes arms and legs,resists extension Respiration Absent Weak, irregularStrong, crying Scoring-<3 is critically low, need resuscitation 4-6 is low >7 is normal Fetal Position-Fetal Size- Low Birth Weight- <2,500 g (5.5 lbs) Intrauterine Growth Restriction-<10%. Risk factors: maternal HTN, renal disease, lung disease, smoking, malnutrition. Macrosomia->4,500 g (at risk for shoulder dystocia) Large for GA->90% Fetal Altitude- Relationship of fetal parts to one another. Fetal Lie- Relation of fetal cephalocaudal axis (spinal cord) to the maternal spinal cord. Longitudinal- Along maternal line, this is ideal Transverse-Perpendicular to maternal line

Oblique-Slight angle Presentation- Presenting part: determined by Leopold’s maneuvers. Cephalic- Head first oVertex-Head completely flexed onto chest and occiput is presented oBrow-Fetal head partially extended, sinciput is presented oFace-Fetal head hyperextended, fetal face is presented Breech- Bottom, feet, knees first oFrank Breech-Hips flexed, knees extended, bottom presents oComplete Breech-Hips, knees flexed, bottom presents oIncomplete Breech-One or both hips not completely flexed, feet present oShoulder-Transverse lie, shoulder presents first Position- Relation of the fetal presenting part to the right or left side of the maternal pelvis.

Multiple Gestations-A pregnancy with two or more fetuses. Incidence is 1 in 80. Classification-Dizygotic Twins (Fraternal)- Two separate ova are fertilized by two separate sperms Monozygotic Twins (Identical)-Twins from the division of the ovum after conception Polyzygotic-Multiple fetuses produced by two or more zygotes Diamniotic/Dichorionic-Division of conceptus occurs within 3 days of fertilization, each fetus surrounded by amnion and chorion Diamniotic/Monochorionic-Division occurs between 4thand 8thday. Each fetus surrounded by amnion but a single chorion. Monoamniotic/Monochorionic-Division occurs between days 9 and 12. Twins share a common sac. There is a risk of entanglement of umbilical cords and fetal death. C-sectionat 32 weeks. Chorion-The outermost membrane surrounding an embryo that contributes to the formation of the placenta. Forms prior to the amnion Amnion-Innermost membrane that encloses the embryo Discordant Growth-15-25% reduction in the estimated fetal weight of the smallest fetuscompared to the largest Risks- All multiple gestations are considered high risk pregnancies Perinatal mortality Preterm labor and delivery: twins are usually delivered at 35 weeks. With each extra fetus, gestation is decreased by 2-3 weeks. Hyperemesis, anemia, preeclampsia, postpartum hemorrhageNeonatal death Multifetal Pregnancy Reduction- First or second trimester termination of one or more fetuses to increase the chance of survival of the remaining fetusesTwin-Twin Transfusion Syndrome-An anastomosis takes place, and an unequal sharing occurs between fetuses. Monochorionic diamniotic babies. Death of One Fetus- No consensus on surveillance and management once demise has occurred. Diagnosis- Often diagnosed at first screening ultrasound Extra fetal heart tones Elevated maternal alpha-fetoprotein Antenatal Management-With multifetal gestations, micronutrient requirements will be increased due to the nature of supporting multiple fetuses Patient should be cautioned about the signs and symptoms of preterm labor Ultrasounds should be performed every 4-6 weeks beginning at 20 weeks Intrapartum Management- Labor and C-section usually schedule because fetal demise increases after 39 weeks. If the first twin is in normal cephalic position, can do a vaginal delivery.

Heartrate of all fetuses monitored closely. As long as the second twin is monitored, there is no urgency in delivering the second twin. Second Twin- If the second twin is cephalic, can continue with vaginal delivery. If the second twin is in any other position, an external cephalic version or breech extraction canbe performed or a C-section. Complications- MC complications are spontaneous abortion and preterm birth Prolapsed umbilical cord Overdistended uterus postpartum Postpartum hemorrhage Labor and Delivery-Labor- Regular and increasing uterine contractions lead to cervical changes Premonitory Signs- Remodeling of the cervix by enzymatic collagen dissolutionCervical softening and expulsion of mucus plug Spontaneous rupture of amniotic membranes False Labor- Braxton-Hicks contractions. Irregular, intermittent contraction without cervical changes. Evaluation for Labor- Contractions every 5 minutes for at least 1 hour Sudden gush of fluid or continuous leakage Significant vaginal bleeding Significant decrease in fetal movement Pain Control- Epidural Block- Infusion of local anesthetic into the epidural space and allows for longer duration of labor analgesiaSpinal- Single injection that provides pain relief for 2 hours Local Block- Puedendal block to block the nerves to just the perineum/vagina General Anesthesia- Used for C-sectionLabor Induction- Indicated for preeclampsia, PROM, diabetes mellitus, placental abruption, oligohydramnios, postdates. Bishop Score- Score under 3 means that they will need cervical ripening or a C-section

Cervical Ripening- Done if the cervix is unfavorable for induction. Misoprostol- 25 mcg intravaginally to ripen the cervix and induce labor oCI- women with history of C-section or previous uterine surgery due to small increased risk of uterine rupture Dinoprostone- AKA cervidil. Put 10 mg transversely in the posteropr fornix of the vagina and remove after 12 hours. Preps the cervix by softening it. Releases over a 12-hour period. Laminaria- Rods made from seaweed are inserted in the cervical os Foley Catheter- Place 30 mL foley catheter in cervical canalMembrane Manipulation- Stripping of the amniotic membranesOxytocin Administration- Lower and less frequent doses are associated with better outcomes and less risk of uterine hyperstimulation. Stages of Labor-The trigger for the onset of labor is unknown. Onset of labor is when uterine contractions occur with or without rupture of membranes. First Stage- Onset of labor to 10 cmSecond Stage-Complete dilation to deliveryThird Stage-Delivery of infant to delivery of placenta Fourth Stage-Immediate postpartum period

First Stage- Onset of the latent phase with minimal cervical dilation (<5 cm) through the active phase with more dilation. During the active stage, dilate about 1.5 cm per hour. Ends with complete cervical dilation of 10 cm. Early/Latent- Mild contractions, cervix is 0-3 cm dilated, effaced 0-30%, lasts 8-12 hoursActive Phase- Contractions every 3-5 minutes and last at least 1 minute each, cervix dilated to 3-7 cm, effacement 80%. Lasts 3-5 hours. Transition Phase- Intense contractions every 2 minutes, cervix dilates to 10 cm and effacement 100%. Lasts 30 minutes-2 hours. Adequate Contractions- Every 2-3 minutes, lasting 40-60 secs. MVU >200. Managing First Stage- oSterile vaginal exams: look for station, dilation, and effacementoUrge to push may indicate significant descentoSignificant FHR decelerations may indicate umbilical cord prolapse, meaning delivery will happen very soon oPlacement of intrauterine pressure catheter or fetal scalp monitor oDetermine presence or absence of meconium Second Stage- Begins with complete cervical dilation and ends with delivery. “Pushing stage”. 50 minutes for nulliparous, 20 minutes for multiparous. Consider assistive devices if this stage lasts >2 hours. Passive Phase- Complete cervical dilation to active maternal expulsive efforts. Active Phase- Active expulsive efforts oDirect Pushing- Take deep breath, fill lungs and release. Then another deep breath in and hold. oPhysiologic Pushing-As mother feels the urge to bear down, open glottis, multiple pushes per contraction Management of Second Stage- oAs the fetal head crowns, extend the fetal head to decrease likelihood of lacerationoRitgen Maneuver- Place one hand over the vertex and use the other to place pressure on the perineum and fetal chin

Third Stage- Begins after delivery of the fetus and ends with delivery of the placenta. May see gush of blood, uterus rises, lengthening of the umbilical cord. Managing Third Stage- Avoid excessive pulling when delivering the placenta. Examine placenta for completeness and look for 2 arteries and 1 vein. Excessive blood loss is a sign of uterine atony. Three classic signs of placental separation:oUterus rises in abdomenoGush of blood oLengthening of the umbilical cord After the placenta is removed, palpate the uterus to ensure it has decreased in sizeFourth Stage- Begins after delivery of the placenta and ends after 2-4 hours postpartum.Management of Fourth Stage- oFirst hour after delivery has the greatest likelihood for complications. Monitor uterine size, tone, and blood loss Risk Factors- Rapid labor, protracted labor, large uterus, infectionoVital signs every 15 minutes for the first hour Cardinal Movements of Labor-Engagement- The widest diameter of the fetal presenting part passes below the plane of the pelvic inlet (0 STN). Descent- Descending through the maternal pelvis Flexion- The fetal head flexes onto the chest due to resistance from the pelvic tissues. This allows from the smallest part of the fetal head to pass through. Internal Rotation- Fetal head rotates from transverse position to occiput anterior or occiput posteriorExtension- The head rotates at the maternal introitus and extends around the symphysis pubis External Rotation- AKA restitution. The fetal head returns to transverse to deliver the shoulders Expulsion- controlled delivery of the rest of the baby Monitoring During Labor- ACOG Recommendation- Every 30 minutes during the first stage and every 15 minutes during the second stage. With Risk Factors:Every 15 minutes during first stage, every 5 minutes during second stage Fetal Heart Rate- Best indicator of fetal wellbeing. Normal is 120-160 bpmConsistent decelerations associated with fetal distress Physiology of Pregnancy- Cardiovascular- The earliest changes in maternal physiology are cardiovascular to improve fetal oxygenation.

Heart Position- Heart is displaced upward/left and horizontally due to diaphragmatic elevationCardiac Output- Increases to 50%. 1/5thof CO goes to the uterus. Blood Pressure- Diastolic decreases by 10 mmHg Pulse-Increases by 10-18 bpm Inferior Vena Cava Syndrome-Pregnant women may have symptoms of hypotension when laying supine due to ineffective shunting via paravertebral circulation due to the pregnant uterus blocking the IVCPhysical Exam-oIncreased 2ndheart sound with inspiration oDistended neck veins oSystolic ejection murmur oS3 gallop Respiratory- Diaphragmatic Position- Elevates 4 cm Oxygen Consumption-Increases by 50 mL oxygen per minute (20% above nonpregnantlevels)Tidal Volume-Increased by 30-40% Compensated respiratory alkalosisDyspnea is common due to low arterial PCO2 Hematologic- Increase in plasma volume (1500 mL), red cell volume, and coagulation factors Iron is actively transported to the fetus regardless of stores, often leading to iron deficiency anemia (60 mg of iron needed daily) Increased oxygen delivery to the lungs and increased Hg in blood leads to increased oxygen carrying capacity Bohr Effect- Shift in maternal oxygen dissociation curve to the left. Maternal Hg affinityfor oxygen increases. Risk of thromboembolism doubles and causes a hypercoagulable state Increases fibrinogen levels Renal-Increased activity to maintain balance. Enlargement and dilation of the kidneys and urinary collecting system Increased renal plasma flow, increased GFR by 50% Glucosuria is a common finding Urinary frequency due to compression on the bladder Decreased creatinine and BUN Gastrointestinal- GI smooth muscle relaxation from progesterone and estrogen relaxes lower esophageal sphincter tone, leading to GERD Decreased GI motility and peristalsis may lead to N/V Reduced gallbladder contractility leads to increased risk of cholelithiasisHemorrhoids are common

Endocrine- Thyroid- Euthyroid state despite changes including gland enlargement and transient rise in T4. Parathyroid-Increased to meet calcium needs of baby Pituitary-Increased size leads to increased risk of postpartum infarction (Sheehan syndrome) Metabolism- Carbohydrates- Reduced tissue response to insulin (from hPL) leads to postprandial hyperglycemia. Maternal hypoglycemia can occur when fasting due to fetal consumption of glucose stores. Lipids- Increased lipids, lipoproteins, and apolipoproteins. Protein- 50% of additional protein intake required Musculoskeletal- Lumbar lordosis Change of center of gravity Progesterone activity leads to laxity of the ligaments and can increase risk of falls Diastasis recti due to separation of abdominal rectus muscles Skin- Spider angiomata Palmar erythema Hyperpigmentation due to increased melanocyte-stimulating hormoneLinea nigra on stomach Reproductive- Uterus- Increased size (20 times larger)Cervix- Increased vascularity and softeningVagina- Leukorrhea (increased vaginal discharge) with pH of 3.5-6 to protect from bacterial infections Breasts- Secretion of colostrum (thick, yellow discharge) from nipple begins at 16 weeksNutrition- Recommended increased 300 calories per day with weight gain of 25-35 pounds. 600 mcg folic acid per day 1,000 mg calcium per day 60 g of protein per day 27 mg iron per day Prenatal Diagnosis and Care-Diagnosis of Pregnancy- Presumptive Signs- Physiologic changes that the patient notices. Ex: absence of menses,breast fullness, fatigue, nauseaProbable Signs-Physical exam findings noted by the examiner.

oLadin’s Sign- Uterus softening at 6 weeks oHegar’s Sign- Uterine isthmus softening after 6-8 weeks oGoodell’s Sign- Cervical softening due to increased vascularization at 4-5 weeks oChadwick’s Sign- Bluish coloration of the cervix and vulva at 8-12 weeks Positive Manifestations-Diagnostic findings. oSerum HCG- Serum quantitative can detect after 5 days of conception. Should double every 1.5-2 days oUrine HCG- Can detect 14 days after conception, best if first-morning void oIncreased serum progesterone oFetal heart tones at 10-12 weeks oPelvic ultrasound detects fetus at 5-6 weeks GPA Classification-Gravida- # of times pregnant Para- # of births >20 weeks (multiple gestations count as 1)Term- # of births after 37 weeks Preterm- # of births 20-36 weeks Abortion- # of pregnancy losses/births before 20 weeks Living- Living children Established Estimated Delivery Date- Naegele’s Rule (LMP-3 months plus 7 days) Routine Antepartum Visits-4-28 weeks- Every 4 weeks 28-36 weeks- Every 2 weeks After 36 weeks-Weekly At every visit: check BP, weight, fetal heart tones, palpation of uterine fundus, leopold maneuvers, UA to look for protein, glucose and ketones. First Trimester Screening/Tests- First trimester is weeks 1-12. Initial visit is usually 6 weeks after LMP. Maternal Blood Screening- All pregnant women should receive HIV screening Down Syndrome- oIncreased beta-HCG oLow PAPP-AoHigh inhibin A may indicate chromosomal abnormality oNuchal translucency on ultrasound at 10-13 weeksCell Free Fetal DNA-at 10 weeks. Screens for trisomies. Not invasive and is sensitive. A positive result needs a amniocentesis or chorionic villus sampling. Ultrasound- Fetal heart tones heard at 10-12 weeks by Doppler.

Chorionic Villus Sampling- Performed at 10-13 weeks, identifies chromosomal abnormalaties. Offered to women who have had a previous child with chromosomal abnormality, maternal age >35, abnormal screening tests/ultrasound, prior pregnancy loss. Advantage- Allows for decision-making if an abnormality is found. Disadvantage-Increases risk of spontaneous abortion, alloimmunization, infectionSecond Trimester Screening/Tests- Second trimester is weeks 13-27 Triple Screening- Done at 15-20 weeks. Measures AFP, HCG, and estradiol Trisomy 21- oLow estradiol oLow AFP oHigh HCG Neural Tube Defects- High AFP Trisomy 18-Low AFP, estradiol, and HCG Ultrasound- Anatomy survey at 18-22 weeks for all pregnancies. Used to check amniotic fluids level, fetal viability, nuchal transparency (for chromosomal abnormalities) and growth. Oligohydramnios- Amniotic fluid index <5 cm in the second or third trimester that can lead to underdevelopment lung tissue and fetal death. oEtiology-MCC is rupture of membranesAlso fetal urinary tract abnormalities Placental insufficiency (preeclampsia, HTN) Fundal Height- Assessment of uterus size. From 20-36 weeks, the cm in fundal height = gestational age 12 weeks- Pubic symphysis 20 weeks- Umbilicus 36 weeks-Xiphoid process Amniocentesis- Performed at 15-18 weeks gestation. A sample of amniotic fluid is removed andsampled. Recommended for women >35 years old or at risk for chromosomal disorders. Gestational Diabetes- Screen at 24-28 weeks. See “gestational diabetes” in OB/GYN EOR study guide Repeat Test- If result is >140. Must fast for 8 hours. If two or more abnormal results, they have gestational diabetes. 1 hour <190 2 hour <165 3 hour <145 Third Trimester Screening/Tests- Week 28-birth. Ask about vaginal bleeding, contractions, rupture of membranes.

Rhogam- Repeat antibody titers in unsensitized Rh negative mothers. If still negative, give Rhogam at 28 weeks and then 72 hours after childbirth GBBS- Screen for group B beta strep at 32-37 weeks via vaginal-rectal culture. If positive, give prophylactic IV PCN during labor. Vaginal Exam- Typically starts at 36 weeks. Effacement- Shortening of the cervical canal expressed in percent of thinning. Station- Level of the presenting part in the birth canal in relation to the ischial spines. oNegative Station- Above the ischial spine o0 Station- Level of ischial spine oPositive Station- Below ischial spine Dilation- o1-2 cm- About the diameter of 1-2 fingers o3-4 cm- About 2 fingers Antepartum Patient Education- Exercise- Up to 30 minutes of moderate exercise per day is allowed if there are no complications. Avoid supine exercises after first trimester Do not sit in sauna/hot tub after exercise CI to exercise- oCervical insufficiency oPersistent bleeding oPremature labor oRuptured membranes oPreeclampsia/gestational HTN Teratogens- Medications- There are more but these are commonly seen oACE and ARBs oCarbamazepine oCyclophosphamides oDanazol oEthanol oFluoroquinolones oIsotretinoin oLithium oMethimazole oMethotrexate oMisprostol oParoxetineoPhenytoin oRadioactive iodine

oTamoxifen oTetracycline oTretinoin oValproic acid oWarfarinMercury- oTuna oShark oKing mackerel oSwordfish oSafe fish- Carp, snapper, cod, salmon, lobster, shrimp- eat 1-2 times a week max Common Issues-Headache- May take acetaminophen N/V- Take pyridoxine with doxylamine. Diclegis for serious cases. GERD-Antacids Constipation-Docusate, psyllium, increase fiber Leg Cramps-Calcium and potassium supplemtns