OB Test #1 Blueprint PDF

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OB/maternity...

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OB Test #1 Blueprint Remember that info from readings, power points, lecture, skills lab, handouts, assignments and clinical experiences are all reflected in this test. The blueprint is to help you focus your study. If you have questions or concerns, let me know!!

(2) Fertility health, Menstruation and Hormones-

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Estrogen and Progesterone levels need to ↑ in order to sustain a pregnancy Presumptive= Amenorrhea, Fatigue, Nausea/Vomiting, Breast changes, Frequent urination, Uterine enlargement. Probable = + Pregnancy test, ↑HCG= can be d/t hydatidid mole, choriocarcinoma, tumors, pelvic congestion Chadwick's sign= (Blue-purple change in color of the cervix) Goodell’s sign= (@ softening of a cervix) Heagar’s sign= ISTHMUS (softening and tender feeling of the upper part of cervix) Ballottement= Flutter, movement Braxton Hicks contractions- painless contractions in lower abdominal region Positive = Hear Fetal heartbeat, Fetal movement felt and or seen by examiner

(4?’s) Placenta and amniotic fluid –

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Umbilical Cord: 2 Arteries/ 1 Vein = AVA o Aetery takes AWAY carbon dioxide o Vein delivers oxygen to the baby BIGGER/THICKER o Covered in Whartons Jelly as protection o Delivers Oxygenation to baby and takes waste away Placenta- Organ that serves as the extracorporeal life-support system of the fetus. RESP=fetal lungs oxygenation, GI= NUTRITION, SKIN= HEAT, BARRIER against some dangerous substances. o Hormones- hCG, hPL-(only produced by the placenta), Progesterone, Estrogen. Placenta grows with the baby. o Placental hormonal increases in 12-14wks Amniotic Fluid- is the babies urine o 8 – 24CM NORMAL o Cushion for baby and cord o Prevents Adherence o Growth- stretches to allow o Fetal Movement- allows freedom of movement, which aids in MUSCULOSKELETAL DEVELOPMENT. o Lungs and GI- are allowed to grow/mature and their sensitive linings are kept moist by the surrounding amniotic fluid. o OLIGOHYDRAMNIOS (< 5 cm)

o Persistent decreased blood flow to fetal kidneys results in reduction of amniotic fluid production called /Smoker mom, not being oxygenated well, severely anemic o POLYHYDRAMNIOS (> 24 cm)  DM, Fetal malformation ex: Neural tube defects, obstruction of gastrointestinal tract or fetal hydrops results in increased amount of amniotic fluid called (3?’s) Pregnancy history and EDC

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UTERUSo Enlargement measured by fundal height o @12 week just above the symphysis pubis o @20 wks or less the fundus measure at U/U o Becomes an abdominal organ at 14weeks o Grows 1cm/wk

(11) Prenatal assessment

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During the initial visit, a comprehensive health history is obtained, including age, menstrual history, prior obstetric history, past medical and surgical history, psychological screening, family history, genetic screening, dietary habits, lifestyle and health practices, medication or drug use, and history of exposure to STIs

Barriers to PNC: lack of transportation, inconvenient clinic hours, cultural considerations, substance abuse Diagnostic tests•

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Ultrasound: outlines and identifies fetal and maternal structures. Assists to confirm gestational age and estimated date of delivery. May be done abdominally or transvaginal during pregnancy. Implementation: if the abdominal ultrasound is being performed, the woman usually needs to have a full bladder to obtain a better image of the fetus. Inform the client that the test presents no known risks to the client or fetus. Alpha-fetoprotein screening (AFP)16-18WKS: assesses the quantity of fetal serum proteins; if elevated, is associated with open neural tube and abdominal wall defects. Can detect spina bifida and Down syndrome. Implementation: explain that the level is determined by a single maternal blood sample drawn at 15 to 18 weeks of gestation. If the level is elevated and the gestation is less than 18 weeks, a second sample is drawn. An ultrasound is performed for elevated levels to rule out fetal abnormalities or multiple gestation. Chorionic villus sampling (CVS) 8-12WKS: aspiration of a small sample of chorionic villus tissue at 8 to 12 weeks’ gestation. Test is performed for the purpose of detecting genetic abnormalities; obtain informed consent. Implementation: instruct the client to drink water to fill the bladder before the procedure, to aid in positioning the uterus for catheter insertion. Lithotomy position. Instruct the client to report bleeding, infection, or leakage of fluid at the insertion site after the procedure. Rh-negative women may be given RhoGAM for risks related to the procedure.

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Kick counts (fetal movement counting)Low Risk @34-36/ High Risk @ 26 wks: 6x/Hr-mother sits quietly or lies down on the left side for 1 hour after meals and counts fetal kicks for 30 minutes. Instruct the client to notify the physician or health care provider if there are fewer than 3 kicks in 1 hour. Amniocentesis 14WKS: aspiration of amniotic fluid done from 14 weeks of pregnancy or thereafter. Performed to determine genetic disorders, sex of the fetus, and fetal lung maturity. Risks: maternal hemorrhage, infection, Rh isoimmunization, abruptio placentae, amniotic fluid emboli. Implementation: obtain informed consent, instruct the client to empty the bladder before the procedure, prepare the client for the ultrasound, which is performed to locate the placenta, obtain baseline vital signs and fetal heart rate (FHR), and monitor every 15 minutes, place the client in the supine position, instruct the client to notify the physician or health care provider if chills, fever, leakage of fluid at the needle insertion site, decreased fetal movement, or uterine contractions occur. Fern test@37wks: a microscopic slide test to determine the presence of amniotic fluid leakage. By use of sterile technique, a specimen is obtained from the external os of the cervix and vaginal pool. Fluid is examined on a slide under a microscope. A fernlike pattern occurring from the salts of amniotic fluid indicates the presence of amniotic fluid. Implementation: place the client in the dorsal lithotomy position. Instruct the client to cough to cause the fluid to leak from the uterus if the membranes are ruptured. Nitrazine test: use of a nitrazine test strip to detect the presence of amniotic fluid in vaginal secretions. Vaginal secretions have a pH of 4.5 to 5.5 and do not affect the yellow Nitrazine strip. Amniotic fluid has a pH of 7.0 to 7.5 and turns the yellow Nitrazine strip or swab blue. Implementation: place the client in the dorsal lithotomy position. Touch the test tape to the fluid. Assess the test tape for a blue-green, blue-gray, or deep blue color, which indicates that the membranes are probably ruptured. Nonstress test (NST) 28WKS: performed to assess placental function and oxygenation. Determines fetal well-being. Evaluates fetal heart rate (FHR) in response to fetal movement. Implementation: external ultrasound transducer and the tocodynamometer (toco) are applied to the mother, and a tracing of at least 20 minutes’ duration is obtained so that the FHR and the uterine activity can be observed. Obtain baseline blood pressure (BP) and monitor BP frequently. Place the mother in the left lateral position to avoid vena cava compression. The mother may be asked to press a button every time she feels a fetal movement, the monitor records a mark at each point of fetal movement, which is used as a reference point to assess FHR response. Results:  Reactive Nonstress Test (Normal/Negative) indicates a healthy fetus. Two or more FHR accelerations of at least 15 beats per minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period.  Nonreactive Nonstress Test (Abnormal): no accelerations or accelerations of less than 15 beats per minute or lasting less than 15 seconds in duration for a 40minute observation.  Unsatisfactory: cannot be interpreted because of the poor quality of the FHR tracing. 

DONE Q3-4 days

DM

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PIH

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 IUGR  Maternal trauma  Decreased FM  Chronic maternal disease  Oligohydramnios  Rh isoimmune disease BPP- Development of fetal behaviors is predictable and correlates with CNS development  2 components NST/US  Order of development:  Muscle Tone- loss of tone means no breathing or movement  Movement- if baby is not moving baby is hypoxic, conserving energy  Breathing movements- baby is NOT actually breathing, breath movements SCORING  NST = Reactive or Nonreactive,  BREATHING= 30 seconds of cont movement is +2pts/ 3 FM is +2/ 0-2 FM’s = 0,  TONE=1extension and flexion is +2 / No evidence of tone  AFI- withing normal range or not 8-24cm  (2pt’s) Each category 8/8-Normal 6- Equivocal 6. Fix it or deliver  Loss of tone = Acidotic Hypoxic, Minimal/Absent variability  Can’t have no tone and have movement Modified BPP  NST-Assesses acute fetal acid-base status 

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 AFI- Assesses for chronic fetal stress  Assesses acute and chronic fetal well-being  Better predictive value than NST alone  Faster to perform than full BPP PUBS @  Percutaneous Umbilical blood sampling- US guided and aid in prenatal dx of inherited blood disorders, detection of infection, Acid/ Base status of IUGR fetus  To assess and treat isoimmunization and thrombocytopenia  Can precisely identify fetal blood type and RBC count  Allows for transfusion earlier than through intraperitoneal route  Complications  Hemorrhage  Cord Laceration

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Preterm Labor/ PROM Infection**

Contraction stress test: assesses placental oxygenation and function. Determines fetal ability to tolerate labor and determines fetal well-being. Fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. Performed if the nonstress test is abnormal. Implementation: the external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal BP readings are done, and the mother is monitored closely while increasing doses of oxytocin are given.  Results: Negative contraction stress test: represented by no late or variable decelerations of the FHR  Positive contraction stress test abnormal): represented by late or variable decelerations of the FHR with 50% or more of the contractions in the absence of hyperstimulation of the uterus. • Equivocal: contains decelerations but with less than 50% of the contractions, or the uterine activity shows a hyper stimulated uterus. • Unsatisfactory: adequate uterine contractions cannot be achieved, or the FHR tracing is not of sufficient quality for adequate interpretation. • Screening for gestational diabetes24-28wks: the screening test used most often in North America consists of a 50 g oral glucose load, followed 1 hour later by a plasma glucose determination. Screening should be performed at 24-28 weeks of gestation. It is not necessary that the woman be fasting. A glucose value of 140 mg/dl is considered a positive screen and should be followed by a 3-hour oral glucose tolerance test. The 3hour OGTT is administered after an overnight fast and at least 3 days of unrestricted diet and physical activity. The woman is instructed to avoid caffeine because it tends to increase glucose levels, and to abstain from smoking for 12 hours before and during the test. A fasting blood glucose level is drawn before giving a 100 g glucose load. Blood glucose levels are then drawn 1, 2, and 3 hours later. The woman is diagnosed with gestational diabetes if two or more values are met or exceeded. • GBS 35-36WKS Monitoring and Screenings

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Monthly until 28wks, Q2 wks until 36wks, QWeekly until delivery CBC or H&H BMP or CMP Blood type & Rh- If mom is Rh- incompatibility, GIVE RhoGAM(28wks), if don’t know blood type after birth if baby is Rh+ mom gets RhoGAM within 72hrs Antibody screen HbA1C (diabetics) TORCH  Toxoplasmosis  Other (HepA/HepB)  Rubella  Cytomegalovirus- Prevention WASH HANDS Herpes

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RPR (Syphilis) TSH UA UDS Pap GC, chlamydia HIV: opt-out prn

(10?’s) Normal changes of pregnancy (maternal and fetal), and fetal positions Maternal Changes: •

Hematologic: WBC monitor for levels above 15K for infection during pregnancy, Postpartum diuresis causes concentration of clotting factors: increased risk of DVT

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Respiratory: Diameter of Thoracic increases 4-6cm

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Changes in the respiratory center result in a lowered threshold for CO2; progesterone/estrogen are presumed to be responsible for the increased sensitivity of the resp center to CO2.

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As pregnancy progresses, breathing changes from abdominal to thoracic and it is less possible for the diaphragm to descend with inspiration

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Increase in blood flow to nose, pharynx, larynx, trachea, bronchi. Can cause chronic nasal stuffiness, nosebleeds, sense of fullness in ears and impaired hearing.

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Increased tidal volume 30-40% (volume of gas moved into or out of the resp tract with each breath).

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The pregnant woman will develop respiratory acidosis and metabolic acidosis more rapidly than a woman in the non-pregnant state.

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The pregnant woman is in a normal state of respiratory alkalosis and metabolic acidosis

Renal •

Urinary Stasis increases risk of UTI- Glucose excretion increases by 10-100x= frequent glycosuria. SO: glycosuria in pregnancy not necessarily significant for DM, urine glucose testing can’t accurately monitor the pt with DM, glycosuria predisposes woman to UTI’s

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Increased Pyelonephritis

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Esophageal sphincter displaced GI contents enter esophagus (Acid reflux)

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Displaced intestines- delayed gastric emptying

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Gastric Acid secretion ↑ in 3rd trimester

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Delays in gastric emptying

GI

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Integ •

Linea Nigra- Line down the belly hormones

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Striae- Stretch marks, can be genetic

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Chloasma- darkened patches on the face (go away after pregnancy)

Musculoskeletal •

Center of gravity shifts from buttocks to abdomen req realignment of spinal curve

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Lordosis- curvature of cervicodorsal region

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Rectus abdominus separation

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Separation of symphysis pubis

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Ligaments- causes lower back pain, inguinal area can cause pain (2nd trimester going into 3rd)

Neuro •

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Numbness and tingling

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Carpal tunnel

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Muscle cramps d/t hypocalcemia, dehydration (CMP)- electrolytes look to tx for infection #1 reason for Preterm Labor ↑ HR 10-15 BPM (14wks) Darkening of the nipples, areolas,axillae, vulva by 16th wk Maternal uterus is considered an internal organ @14wk

3rd Trimester 27-40 3rd trimester: return to first trimester levels WBC: 10,500 LABOR: 20,000-30,000 Blood Volume- ↑30-50% (peaks at 32-34wks), protective mechanism

Fetal Changes: Embryonic Day 14Fertilization occurs in ampullary portion of fallopian tubezygote

1st trimester 1-13 2nd Trimester 14-26 Week 3 13-16WK  Hair develops on  Beginning head-lanugo development  Skin is almost of brain, transparent spinal cord,  Bones become and heart harder  Beginning  Head still dominant development  Fetus makes active of GI tract movement/  Neural tubes detected by mother form becomes

3rd Trimester 27-40 WK 25-28  15 inches in length  Rapid brain development  Eyelids open and close  Nervous system controls some function  Fingerprints are set  Blood formation shifts from spleen to bone marrow  Assumes head-down

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Weeks 1-5 Ovarian phase

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spinal cord Legs and arm buds appear and grow out from body

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Brain differentiates Limb buds grow and develop more Stomach, pancreas, liver begin to form

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Heart beats at regular rhythm Beginning structures of eyes and ears Cranial nerves are visible Muscles innervated Straightening of trunk Nipples and hair follicles form Arms/legs move – toes and elbows are visible Diaphragm forms Heartbeat can be heard Mouth/lips and early tooth bud’s form

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Sucking motions are made with mouth Amniotic fluid is swallowed Fingernails/toenails are present Weight quadruples

WK 17-20  Rapid brain growth  Heart tones can be heard with stethoscope  Kidneys excrete urine in amniotic fluid  Vernix caseosawhite grease film covers fetus  Eyebrows / head hair appears  Brown fat deposited to help maintain temperature  Muscles are well developed

position

Wk 29-32

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Rapid increase in body fat Increase CNS control over body function Rhythmic breathing movements occur Lungs are not fully mature Fetus stores: Iron/calcium/phosphoru s

Weeks 610 Embryonic phase

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Rotation of intestines Facial features continue to develop Heart development is complete Starts to look like a human

WK9-12  Sexual differentiation continues  Buds for all 20 temporary teeth laid down  Digestive system shows activity  Head is nearly half the size of the fetus  Face/neck are well formed  Urogenital tract completes development  RBCs produced by the liver  Urine is produced and excreted  Fetal gender can be determined by week 12  Limbs are long and thin, digits are well formed

WK 21-24  Eyebrows/eyelashes are well formed  Has hand grasp and startle reflex  Alveoli forming in lungs  Body is lean/ well proportioned  Skin is translucent and red in color  Lungs begin to produce surfactant

Wk 33-38

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Testes are in scrotum of male fetus Lanugo starts to disappear Increase in body fat Fingernails reach the end of fingertips Small breast buds are present on both sexes Mother supplies fetus with antibodies against disease Fetus considered full term at 38w Fetus fill uterus

(9) Fetal monitoring, placement, interpretation, pathophysiology, interventions

(4) Diabetes-

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Screen at 24-28 wks with 1 hr GTT if average risk A1- GDM; abnormal GTT; normal fasting glucose = Tx Diet controlled A2- GDM; abnormal GTT; ↑ fasting glucose = Diet, oral meds and insulin (insulin is preferred)

GDM- Gestational Diabetes- nondiabetic prior to pregnancy, pregnancy induced diabetes. 

Normal HgB A1C- 4.4-6.4%. GTT: 1hr

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A fasting plasma glucose level >126 mg/dl (7.0 mmol/l) or a casual plasma glucose >200 mg/dl (11.1 mmol/l) meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day, and precludes the need for any glucose challenge.

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Higher sugars are higher risk of congenital Malformations

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@20wks -All Placental hormones are Insulin Antagonists (S...