Mark K lecture 10 + some 11 (maternity)

Due date calculation

First day of last menstrual period + 7 days - 3 months + due date

how to calculate ideal weight gain in pregnancy

• Ideal in all = gest wk - 9

• Further assessment when more or less than 2 lbs of ideal gain

Fundus (when is palpable)

• Top part of uterus

• Not palpable until wk 12, then assess at 13

Viability dates

• Start at 20-22 wks gestation

  • 22: date of viability USUALLY

Using fundus on when to give priority to baby or mother

• First or second trimester (fundus below umbilicus)

  • Mother

• Third or when fundus above umbilicus

  • Baby

Positive signs of pregnancy

• Fetal skeleton on X-ray

• Fetal presence on U/S

• FHR auscultation (8-12 wks)

• Quickening: 16-20 wks

• All urine and blood test are positive signs of pregnancy

Different correct answers for when FHR is heard

• When should you do it by: 12 wks

• When do you first: 8 wks

• When is it most likely (or first) to hear: 10 wks

Different correct answers for when quickening is felt

• Should by: 20

• Most likely: 18

• First: 16

Home pregnancy tests

Hormone levels can skew tests → probable

One other probable or presumptive

• Chadwick and then Goodell then Hegar

  • Chadwick: cervical color change to cyanosis

  • Goodell: cervical softening

  • Hegar: uterine softening

Patient teaching in pregnancy (general)

• Hemoglobin will fall (normal)

• Should visit once a month until wk 28

  • Once Q 2 wks until 36 wks → then every week until 42 (c-section or other maneuvers)

  • Recurring visits reduces infant mortality

Hemoglobin levels in each trimester

• Not perg: 12-16

• 1st tri: 11

• 2nd: 10.5

• 3rd: 10

First trimester issues

• Morning sickness

  • Dry carbs for before you get out of bed

• Urinary incontinence (also in 3rd)

  • Not 2nd tri bc it’s abd pregnancy and uterine in 1st and 3rd

  • Void Q2H

2nd and 3rd trimester problems and teaching

• Difficulty breathing

  • Tripod pos

• Back pain

  • Pelvic exercises

Fetal station

• Relationship of presenting part to mom’s ischial spine

  • Narrowest part of the pelvis

  • Negative station means above tight squeeze (ischial spine)

  • Positive is below

Fetal lie

• Spinal relations between mom and baby

  • Best: vertical

  • Bad: transverse (trouble)

Fetal presentation

• Part of baby that enters canal first

• Best and most common: ROA and LOA

Stage 1 Phase 1 of labor (measurements and other name)

• Latent

  • Dilate 0-4 cm

  • Contractions

    • Freq q5-30 mins apart

    • Duration: 15-30s

    • Mild

Stage 1 Phase 2 of labor (measurements and other name)

• Active

  • Dilate: 5-7 cm

  • Contraction frequency

    • q3-5 mins apart

    • Duration: 30-60s

    • Moderate

Stage 1 Phase 3 of labor

• Transition

  • Dilate: 8-10 cm

  • Contraction

    • frequency: q2-3 mins apart

    • Duration 60-90s

    • Strong

Cut-off numbers in labor (serve as a basis for…)

• Basis for uterine tetany, hyperstimulation, pitocin overload

  • Contractions no longer than 90s

  • Lasting < 2 mins apart

Terms of labor

• Frequency: beginning of one contraction up to beginning of another

• Duration: beginning and end of one contraction

• Intensity: contraction strength

  • Palpate w/ one hand over fundus w/ pads of fingers

Stage 2 of labor (checklist)

• Delivery of baby

• Process

  • Deliver head out

  • Suction mouth THEN nose

  • Check nuchal cord (if wrapped around neck)

  • Deliver rest of baby

  • Must have ID band before leaving delivery

Stage 3 of labor

• Delivery of Placenta

  • Uterine contractions: pushes placenta

  • Check vessels in cord (AVA: 2 arteries and 1 vein)

Stage 4 of Labor

• Recovery

  • For 2 hrs right after placenta pushed

  • Uterine contractions: stop bleeding

4 things to do 4x an hour in the 4th stage

• VS and S/S of shock

• Fundus check

• Check perineal pads

• Roll her over (to check pads)

Fundus check in 4th stage of labor

• Boggy: massage

• Displaced: cath

Why roll over in 4th stage

• Check bleeding underneath

• Pad sometimes won’t catch blood underneath

Fundus assessment in postpartum

Ideally firm; if boggy → massage until firm

Lochia in postpartum

• Vaginal drainage

  • Rubra: red

  • Serosa: pink

  • (Jessica) Alba: white

  • Usual amt: 4-6 pads

Checkin extremities in thrombophlebitis

• Thrombophlebitis

  • Bilat calf circumference measurement

Painful back labor

• Baby is in occi posterior = oh pain

  • 1. Position: knee chest

  • 2. Push

  • Low priority

Prolapsed cord

• Emergency

• When cord comes out first

• 1. Push head back up

• 2. Position knee chest

Intervention for other complications (when in doubt…)

• LION

  • Lie left side

  • Increase IV

  • Oxygenate

  • Notify physician

  • PIT

    • If pitocin is running in a crisis; stop it before lying

Pain meds in labor

Do not give for a woman in labor if baby is likely to be born when med peaks

Good fetal tracings

• High baseline variability

  • Document

Tracings that require LION

• Low FHR (<110)

• Low baseline variability (same FHR regardless of contraction)

• Late deceleration (FHR slows near end of contraction)

Very bad fetal tracing

• Variable Decels

  • Prolapsed cord

  • Push then position

OK fetal tracings

• High FHR (>160)

  • Document and take mom’s temp

  • Nothing wrong w baby

VEAL CHOP

• Variable

  • Cord compression

• Early decels

  • Head compression

• Acceleration

  • Ok

• Late decels

  • Placental insufficiency

Fine vs dangerous: caput succedaneum vs cephalohematoma

• Caput succedaneum

  • Crosses sutures

  • Caput symmetrical

• Cephalohematoma

Terbutaline

Tocolytic: stops labor

• Causes maternal tachycardia

Mag sulfate

Tocolytic: stops labor

• ↓ HR, BP, reflexes, RR, LOC

• Parameters

  • 12 resps/min (notify if lower)

  • + 2 reflexes (slow mag if lower and admin if higher)

Oxytocics (what drugs)

• Pitocin

  • Uterine hyperstimulation: contractions

    • Longer than 90s and closer than 2 mins

• Methergine

  • ↑ BP

Betamethasone

• Fetal lung maturing med

• Steroid

  • Given to mother

  • IM

  • Before baby is born

Survanta

• Fetal lung maturing med

• Surfactant

  • Given to baby

  • Transtracheal

  • After baby is born