ob exam 1

AWHONN

discusses women’s health as health + illness issues unique or more prevalent in women

regionalization

coordinate cooperative system of maternal + perinatal care w/in geographic area

level 1 care

basic, no complications UNEVENTFUL

level 2 care

some cases

level 2E care

some cases + special care nursery

level 3 care

ALL CASES, special care nursery + NICU

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PERINATAL CENTERS

birth rate

\# of live births in 1 year/1000 people in population

infant mortality rate

\# of deaths of infants under 1 yr/1000 live births in population

fetal death

death in uterus at 20 weeks+ gestation

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still birth

neonate death rate #

\# of deaths of infants

perinatal death rate

\# of neonatal + fetal deaths/1000 liver births

fertility rate

\# of live births/1000 women of childbearing age (15-44)

maternal mortality rate

\# of maternal deaths from births, complications, childbirth, puerperium during first 42 days after termination of pregnancy/100,000 live births

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hemorrhage, hypertension, infections, accidents don’t count

healthy people goal

improve health + wellbeing of women, infants, children, families, and eliminate health disparities

first visit patient history assessment

\-past medical history

\-current medical history

\-gynecologic history

\-social history

\-religious/cultural history

nagele’s rule

calculates due date

gravida

pregnancy

para

pregnancy delivered past 20 weeks

term births

births (38-42 weeks gestation)

preterm births

births (20-37 6/7)

abortion

pregnancy ends before 20 weeks gestationl

living children

children alive

first visit physical exam

\-baseline vital signs

\-pelvic exam

* pelvic adequacy

\-vaginal exam

uterine enlargement

\-fetal assessment

* fetal heart tones (after 12 weeks)
* ultrasoun
* is there baby, is it alive?

first visit lab work

\-H+H, CBC

\-ABO, Rh type screen

\-VDRL/RPR

\-rubella

\-hep b surface antigen

\-HIV

\-urinalysis

\-gonorrhea/chlamydia cultures

\-pap smear (before preg)

\-sickle cells for clients of African descent

prenatal teaching first trimester

\-prenatal visit schedule

\-dietary needs/restrictions

\-hygiene

\-activity

TRIMESTER SPECIFIC

first 28 weeks

every 4 weeks (once/month)

until 36 weeks

every 2 weeks (twice/month)

after 36 weeks until delivery

weekly

prenatal checkups

\-maternal vital signs

\-maternal weight

\-fetal heart rate

\-fundal height measurement

\-urine dip (protein, glucose, ketones)

\-ultrasound/vaginal exam maybe

total weight gian

25-35 lbs

weight gain first trimester

3\.5-5 lbs

weight gain last two trimesters

1 lb/week

additional calories needed

300 daily

fluid

8-10 glasses/day

first trimester

12 weeks

dietary no’s

\-fish

\-raw eggs/meats

\-listeria

\-nicotine, alcohol, drugs

\-artificial sweeteners

\-caffeine

hygiene

inc vaginal discharge (leukorrhea)

* soap and water

inc sweating

* bathe more frequently

bathing/shower safety

* sitting is good
* no hot tub

activity and safety

\-exercise is beneficial

* depends on normal activity
* pelvic tilt, kegels

\-shifting center of gravity

* inc risk for falls

\-adequate rest and sleep

* inc risk for DVTs

\-employment

\-travel

\-pets

* no cat boxes or dirt in yard= toxoplasmosis

2nd trimester weeks

13-28 weeks

2nd trimester pregnancy changes

\-what discomforts

\-usually feel best during this trimester

2nd trimester nutrition assessment

1 lb/week or 4 lbs/month

2nd trimester screening

quad screening 15-20 weeks for fetal neural tube defect, down’s syndrome, multiple gestation

danger signs of pregnancy

\-vaginal bleeding

\-persistent vomiting

\-chills/fever

\-fluid from vagina

\-chest pain

\-abdominal pain: ripping or tearing sensation

\-s/s of PIH

\-changes/lack of fetal movement

s/s oh pregnancy induced hypertension (PIH)

blurred vision, severe headaches,

3rd trimester

week 28-

3rd trimester pregnancy changes

\-dyspnea

\-backaches

\-frequent urination (head on bladder)

\-pyrosis

\-swelling of hands + feet

\-braxton hicks contractions

\-inc weight gain, 35 lbs

\-fatigue

3rd trimester safety

weekly exams starting 35 weeks

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monitor for PIH

3rd trimester prep for childbirth

\-childbirth prep classes

\-s/s of labor

\-braxton hicks bs true labor

\-when to call MD/go to doctor

3rd trimester screening testts

1 hr GTT

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GBBS vaginal culture

1 hr GTT

24-28 weeks for gestational DM

GBBS

group b beta strep that can be transmitted to baby, need antibiotics

maternal and fetal blood can intermingle when

\-trauma

\-post amniocentesis (placenta damaged)

\-post abortion/miscarriage

\-after delivery when placenta separates

rh sensitization

mom produces rh antibodies that are bad for next pregnancies

rhogam

immune globulin

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\-suppresses immune response

\-blood product, get from blood bank

\-deep IM injection

\-causes soreness at injection site

\-risks bloodborne pathogens

indirect coombs

done on mom’s blood, detects antibodies to other blood types

direct coombs

done on baby’s blood

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looks for antibodies piggybacked onto baby RBC

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positive=antibodies break down rbc risk for jaundice w inc bilirubin

admission assessment

\-review of prenatal records

* complications, due date

\-medications/allergies

\-last meal

\-s/s labor

\-status of amniotic membranes

\-vaginal discharge/bleeding

\-birth plans

labor systemic changes: cardiovascular

inc blood pressure

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inc cardiac output

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supine hypotension

inferior vena cava syndrome

\-pressure on IVC from lying on back

\-turn to side

\-dec CO

* dizziness
* diaphoresis

labor systemic changes: respiratory

inc oxygen consumption

* inc metabolism

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inc respiratory rate

* paced breathing

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possible hyperventilation

* respiratory alkalosis
* dizziness + tingling
* breathe in paper bag, need CO2

labor systemic changes: renal

difficulty voiding

* dec sensation

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proteinuria

labor systemic changes: musculoskeletal

\-diaphoresis

\-fatigue

\-backache

\-joint pain

\-leg cramps

* frog legs, stretch them out

labor systemic changes: neurologic

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\-endorphins

* inc pain threshold

\-perineal pressure

* dec perineal sensation
* pressure on nerve endings, dont feel it
* can tear or episiotomy

labor systemic changes: GI

\-dehydration

* IV, minimal for venous access in case

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\-dec motility

* peristalsis stops

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\-slowed absorption

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\-N/V

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\-rectal pressure

* need to poop? NOPE ITS BABY

NSD

natural unassisted vaginal delivery

why induce labor

doesnt happen, DM, past due, placenta ages

placenta age span

40 weeks

bishop score

prelabor scoring system that predicts

prepidil + cervidil gel

syringe that ripens cervix

cytotec

orally or up cervix

pitocin

oxytocin IV drip titrate 1 mLunit/min

induction warning signs

\-happens every less than 2 min

\-lasts longer than 90 sec

\-above 90 mmhg on IUPC

\-uterine resting tone greater than 20 mmhg

\-fetal heart rate variations

if hyperstimulation occurs

stops medication ASAP

operative vaginal delivery- forceps or vacuum

2+ station or lower, can see head

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indications:

maternal exhaustion

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maternal contraindications to pushing

operative vaginal delivery- forceps complications

\-fetal ecchymosis, caput succedaneum, cephalohematoma, facial nerve damage, birth canal trauma

fetal ecchymosis

forcep mark

caput succedaneum

edema to scalp

cephalohematoma

hematoma to cranial bone

facial nerve damage

placed incorrectly on face (perm/temp)

birth canal trauma

extensive tears (perm/temp)

operative vaginal delivery: vacuum complications

\-scalp trauma

\-birth canal trauma

\-pop offs

scalp trauma

edema, skin removed

pop offs

suction pop offs, negative pressure leaves mark

pfannenstiel c section

bikini cut

vertical c section

up + down

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emergency, obese, appendage to abdomen, had vertical before

LCT uterine incision

like bikini cut on uterus

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ONLY ONE THAT CAN HAVE VAGINAL DELIVERY

low vertical uterine incision

low up + down

classical uterine incision

up + down

VBAC: risk for uterine rupture

\-only 1 previous c-section

\-LCT uterine incision

\-adequate pelvis

\-monitor FHR

\-no augmentation

\-physician

\-willing consent for c-section in case of complications

delivery complications

\-date/time

\-type

\-incisions/lacerations/repairs

\-gender/weight of infant

\-apgar scores

\-time of placental delivery/assessment

\-estimated blood loss

\-total length of labor (stages + phases)

premonitory signs of labor

PRIOR TO LABOR OR >10 DAYS BEFORE LABOR STARTS

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\-lightening (baby drops, descends to pelvis)

\-cervical changes

* soft
* dilation/effacement (opens + thins)
* mucus plug sheds (mucusy discharge)
* bloody show (not a lot)

\-braxton hicks contractions

* prep contractions, will get more frequent

\-sudden burst of energy

\-rupture of membranes

* can be first indicator

true labor

\-regular contractions

\-back to front

\-inc intensity + frequency

\-cervix dilates + effaces

\-walking inc intensity of contractions

false labor

\-irregular contractions

\-lower abdomen + groin

\-don’t inc intensity + frequency

\-doesn’t dilate + efface

\-walking relieves intensity of contractions

rupture of membranes

complete ROM

* come to hospital ASAP

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leaking bag of water

* will reproduce fluid

nitrazine test

pH of fluid

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yellow= acidic urine

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blue= alkaline amniotic fluid

fern test

amniotic fluid under microscope looks like fern tree

amnisure

strip that detects amniotic fluid, expensive

amniotic fluid functions

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\-buoyancy, floating

\-cushions

\-protects umbilical cord

\-sterile environment

* pushed to side as baby grows

\-thermoregulation

when water breaks

assess

* check FHR ASAP
* check for cord prolapse, pelvic exam

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document

* color of amniotic fluid (clear or meconium stained fluid)
* date/time (want to deliver w/in 24 hrs)
* method of rupture (SROM, AROM)

meconium stained amniotic fluid

fetal distress in utero

* rectal sphincter relaxes
* brown, green or thick fluid

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risk for aspiration at birth

* suction mouth/nose w/ bulb syringe
* may need to deep suction