NC Final Exam PDF

PART 1 Establishing a due date – LMP, conception history, physical exam, first trimester ultrasound - Dating ultrasound is the most accurate way of dating compared to LMP during the first and second trimesters - When performed with quality and precision, ultrasound alone is more accurate than a “cer...

PART 1 Establishing a due date – LMP, conception history, physical exam, first trimester ultrasound - Dating ultrasound is the most accurate way of dating compared to LMP during the first and second trimesters - When performed with quality and precision, ultrasound alone is more accurate than a “certain” menstrual date for determining gestational age in the first and second trimesters (≤ 23 weeks) in spontaneous conceptions, and it is the best method for estimating the delivery date. - First trimester crown rump length is the best parameter for determining GA - Barely any variation in biometric measurements (meaning genetics haven’t influence size yet) - Between the 12th-14th week CRL and biparietal diameter are similar in accuracy. CRL is recommended to be used up to 84mm and biparietal to be used for measurements >84mm - If there is more than one first trimester scan with a mean sac diameter or CRL, the EARLIEST ultrasound with a CRL of AT LEAST 7 weeks (10mm) should be used to determine GA. - Accurate plus or minus 1-3 days - Second/Third Trimester Ultrasound - Composite of BPD, head circumference, abdominal circumference and femur length - Less accurate because variation between babies due to genetics - Dates are accurate plus or minus two weeks so a lot less accurate than T1 ultrasound - If a second- or third-trimester scan is used to determine gestational age, a combination of multiple biometric parameters (biparietal diameter, head circumference, abdominal circumference, and femur length) should be used to determine gestational age, rather than a single parameter ○ When the assignment of gestational age is based on a third-trimester ultrasound, it is difficult to confirm an accurate due date. Follow-up of interval growth is suggested 2 to 3 weeks following the ultrasound - Naegele’s rule/LMP - For a 28-day cycle, add a year, subtract 3 months and add 7 days - For cycles greater than 28 days then you would do 7+ the days over 28. (ie 7+3 for a 31-day cycle) - For cycles less than 28 days you would subtract the days under 28 (ie 7-3 for a 25 day cycle) - Problems with LMP - Assumes 28-day menstrual cycle and ovulation at day 14 - Not all people have a 28-day cycle some people are irregular - Longer cycles push the EDB farther - - - - - Shorter cycles bring the EDB sooner Not all people have a 28-day cycle some people are irregular Not everyone can be certain of when they ovulate - Ovulation does not always happen at mid-cycle - Some women ovulate more than once a month - Also takes into account 2 weeks before ovulation before client is pregnant Conception history: - Using the believed conception date to estimate due date (ovulation and intercourse) - Difficult to be sure of exact ovulation date Physical exam: - Absence of menstruation - Palpate abdomen/SFH (usually palpable externally at 12 weeks) - Cervix bluish in colour - Fetal movements - Getting a heart rate Gravida (number of pregnancies regardless of the outcome including current, previous, still births, miscarriages, and abortions) Parity (number of pregnancies that have reached viability) - # pregnancies resulting in births after 20 weeks - Does not account for preterm or deaths Gravida and Para Terminology - Primigravida = first pregnancy - Multigravida = more than one pregnancy - Nullipara = never given birth after 20 weeks of gestation - Primapara = only given birth once after 20 weeks of gestation - Multipara = given birth at more more than once after 20 weeks of gestation Routine laboratory testing – CBC, group and screen, VDRL, hepatitis B screening, HIV CBC - Hemoglobin: anemia - Platelets: clotting - MCV: Size of red blood cells - Repeat hb and platelets at 24-28 weeks Ferritin - Iron stores - Repeat at 24-28 weeks ABO group and Rh factor - Blood type - Identify Rh- clients Antibody screen - Identify RBC antibodies in client that could attack RBC antigens of fetus resulting in hemolytic disease of the newborn (HDNB) Public health blood work - Rubella - HIV - Syphilis (VDRL) - Hep B - Chlamydia - Gonorrhea Urine C&S - Tests for bacteria Prenatal screening – multiple marker screening (eFTS, MSS), nuchal translucency ultrasound, anatomy scan, NIPT, CVS, amniocentesis - - eFTS (enhanced first trimester screen) - timing : 11 weeks 2days-13 weeks plus 3days - tests for Trisomy 18 (85% detection rate) and Trisomy 21 = downs syndrome (89% detection rate) - Can be ordered by midwives - Two step process that includes a blood draw and a U/S that looks at nuchal translucency (less than 3.5 mm) - Blood work: - Looks at maternal plasma protein - Pregnancy associated plasma protein (PAPP-A): ﹤0.35 - Low associated with small baby later on (IUGR) - Free beta hCG (viability of pregnancy): ﹤0.5 or ﹥5.0 - AFP (high = miscarriage, spina bifida, anencephaly, low = Trisomy 18 or 21): ﹤0.25 or ﹥2.0 - Placental growth factor (PLGF): ﹤0.3 - Potential relationship with gestational high blood pressure - DIA = ﹥3.0 - Ultrasound: - Nuchal Translucency (NT) = thickness (pocket of fluid) behind baby’s neck. Ideally less than 3.5mm - Not ideal for people with more than one baby - Vanishing twin - Low risk NIPT - Meaning of results - Screen negative = lower chance to have a baby with trisomy 21 and trisomy 18 but does not mean no chance - Screen positive (1/350 for trisomy 21 or 1/200 for trisomy 18) = higher chance to have a baby with trisomy 21 or trisomy 18 but does not mean that baby has any- more testing would be needed NT ultrasound alone - - - Nuchal translucency ultrasound OHIP funded Between 11w2d and 13w3d Can be ordered by midwives Can be performed with eFTS or alone Looks at: - Pocket of fluid behind babies head to determine likelihood of having a genetic condition or another health issue - Accurate due date - Number of babies expected - Heart and brain of baby - For who: - Those who chose eFTS - Those who chose NIPT - Expecting one baby but experienced vanishing twin - You do not want prenatal genetic testing - Meaning of results: - Normal NT= less than 3.5 mm - Increased NT= 3.5 mm or more MSS (Maternal serum screening) (aka second trimester screen) - For who: - Mostly for women who want genetic screening but missed the window for eFTS - Timing: 14+0-20+6 wks - Only blood work is done, no U/S - Screens for Trisomy 21 (87%) and Trisomy 18 - Looks at four markers - AFP – alpha-fetoprotein ( high = miscarriage or spina bifida, low = trisomy 21 or 18) - uE3 – estriol (low = trisomy 18/21 or pregnancy loss) - beta-hCG – (high = viable pregnancy): ﹥3.0 - DIA – inhibin A (released by the placenta): ﹥2.0 - Not recommended for: - More than one baby - Low risk NIPT or awaiting NIPT results - Meaning of results - Screen negative = lower chance to have a baby with trisomy 21 and trisomy 18 but does not mean no chance - Screen positive (1/350 for trisomy 21 or 1/200 for trisomy 18) = higher chance to have a baby with trisomy 21 or trisomy 18 but does not mean that baby has any- more testing would be needed 18-22 week ultrasound = Anatomy Scan - - Considered prenatal screening because it gives you more info about baby and it’s development - 18-22 weeks - OHIP funded - Can be ordered by midwives - Looks at: - Baby’s internal organs and structure development - Brain - Heart - Size of baby for gestational age ○ Position of baby ○ Activity of baby ○ Amount of fluid around baby ○ Location of placenta and umbilical cord ○ Cervix, uterus, ovaries, bladder ○ Sex of the baby depending on position (not really the focus) - Results: - Normal - the baby is the right size for its age. - the placenta has a normal size and is in the right location. - there is enough amniotic fluid surrounding the baby. - there are no differences in how the organs or structures of the baby are developing. These differences are sometimes called birth defects. - there are no other signs that increase the chance for the baby to have a chromosome difference. - Detection of soft markers - Soft markers are not birth defects, and do not usually in themselves cause health problems. Soft markers only raise the possibility that the baby might have a chromosome difference, such as trisomy 21, or another medical condition. It is important to remember that most babies with soft markers are born healthy. NIPS/T (non-invasive prenatal testing) - Not funded by OHIP unless - Age 40 at time of delivery - Abnormal eFTS - u/s showing abnormality - Previous child with abnormality (ie: trisomy 21 or 18) - Do not do efts if doing nips/t - NT greater or equal to 3.5 mm - Twin pregnancy - Timing: can be done as early as 9-10 weeks but recommended 11 weeks or greater for sufficient sample - Looks for: - Trisomy 21 (99%), 18 (96%), 13 (92%) - - - - - - Looks at placental DNA and chances for baby to have chromosomal differences - Triploidy - Fetal sex - Sex chromosome differences - Meaning of results: - Low risk = very low chance that baby has one of the trisomies - High risk = high chance baby has one of the conditions - Fail = for reasons outside our control – u/s before NIPT lowers chance of failed results - Usually a flag that something is going on Amniocentesis - Diagnostic testing - Same criteria as NIPS to be OHIP funded - After 15 weeks - 99% accurate - 1/800 chance of miscarriage or early delivery - For Who: - Positive eFTS/STS or Increased NT - High risk NIPT or Failed after two tries or more - Heart defect on u/s - Genetic condition running in family - Looks at amniotic fluid – testing DNA - Thin needle thorugh skin into amniotic fluid - Small amount of fluid is taken and tested - Fluid contains fetal DNA and can be tested for genetic conditions Chorionic Villus Sampling - Diagnostic - Least common - Between 11 and 14 weeks - OHIP Funded - 98% accuracy - 1/100 risk of miscarriage For Who: - Positive eFTS/STS or Increased NT - High risk NIPT or Failed - Heart defect on u/s - Genetic condition running in family Looks at placenta - Small piece of tissue is taken from placenta and genetic information is tested - Usually placenta has same genetic information as baby Statistics regarding detection rates of trisomies and screening methods - Detection rate (trisomy 21) Meaning, how many pregnancies where the baby really DOES have trisomy 21 will be flagged as screen positive (or high risk) by this test? - - - - eFTS = 89% MSS = 81% NIPT More than 99% (this test cost money if there is no indication, must do screening first to get coverage for this test) False positive rate (trisomy 21) Meaning, how many pregnancies will this test flag as screen positive (or high risk) but the baby does NOT really have trisomy 21? - eFTS = 7% - MSS = 5% - NIPT = 0.1% Detection rate (trisomy 18) Meaning, how many pregnancies where the baby really DOES have trisomy 18 will be flagged as screen positive (or high risk) by this test? - eFTS = 78% - MSS = 60% - NIPT = 95% False positive rate (trisomy 18) Meaning, how many pregnancies will this test flag as screen positive (or high risk) but the baby does NOT really have trisomy 18? - eFTS = 0.2% - MSS = 0.5% - NIPT = Less than 0.1% Counselling re: exposure safety in early pregnancy - Chance of miscarriage is higher earlier in pregnancy with exposures. After organogenesis then it is less likely that exposures pose risk to baby. - Less of a risk for teratogenic effects in the third trimester (infertility, intrauterine growth restriction, structural defects, and functional central nervous system abnormalities that may lead to fetal death) Over the counter medications – ibuprofen, acetaminophen, folic acid, vitamin supplements - Tylenol (Acetaminophen) - Nonopiod analgesic and antipyretic - Category B substance that is safe during pregnancy NSAID (iburpoen) - Usage after the 20th week gestation can cause premature closure of the ductucs arteirous and impact amniotic fluid levels Folic acid - Type of b vitamin that plays a role in preventing neural tube defects, heart defetcs and urinary tract anomalies etc - 0.4mg of folic acid daily Common discomforts of pregnancy Table in Comprehensive midwifery Pages 40-42 Nausea and vomiting of pregnancy – normal patterns, non-pharmacologic and pharmacologic management - Non-pharmacological methods: - Lifestyle changes: - Maintain hydration and electrolyte levels - Avoiding an empty stomach (small frequent meals) - Not mixing solids with liquids and avoiding very large and fatty meals - Allowing more time for food to digest prior to laying down - Appropriate sleep as fatigue heightens the symptoms of NVP - Discontinuing iron-containing PNV in early pregnancy if no history of past and present anemia and switch to a childrens chewable tablet and folic acid instead - Acupressure - Ginger (doses of 1000 mg/day have been seen to be effective with no negative outcomes) - Pharmacological - Vitamin B6 - Dose can be adjusted based on maternal weight and severity. Dose of 200 mg/day suggested 2007 motherrisk NVP alggorithim is the current recommended high dose. - Diclectin - Combination of an antihistamine (doxylamine) and vitamin B6 (pyridoxine). - Dose: 4 tabs daily 1 tab am, 1 tab midday, 2 tabs at bedtime Nutrition – pregnancy, postpartum - - Folic acid - Sources of natural folate are broccoli, spinach, peas, brussel sprouts, oranges, lentils. Multivitamin usage is recommended during pregnancy. A prenatal vitamin is recommended https://www.pregnancyinfo.ca/your-pregnancy/healthy-pregnancy/healthy-eating/ Iron intake to 27mg daily during the final six+ months of pregnancy to support an increase in red blood cells and fetal tissues. Fibre youll need 2-3g more of fibre in your diet for daily 28g to help with constipation omega-3 fatty acids, which are needed for fetal development, particularly eye and brain development. Food sources of each of the omega-3s are recommended compared to supplements. DHA, one of the three omegas that is found in fish, is the best source. Aim for 1.4g daily. Iodine (help synthesize thyroid hormone) need 250mcg daily Vitamin d- 2000iu last 6 month will enhance vit d in milk - During the second trimester you need around 340 extra calories Exercise in pregnancy ○ All women without contraindication should be physically active throughout pregnancy Promotes Shorter labour Promote SVD May help flip breech baby Maintaining a healthy weight during pregnancy Fewer c sections Fewer instances of urinary incontinence Reduces rates of depression ○ Don’t do anything that may put you at risk of falling/losing your balance ○ Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications (strong recommendation, moderate quality evidence). ○ Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged (strong recommendation, moderate quality evidence). ○ Pregnant women should incorporate a variety of aerobic exercise and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial (strong recommendation, high quality evidence). ○ Pelvic floor muscle training (e.g., Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction in proper technique is recommended to obtain optimal benefits (weak d recommendation, equality evidence). ○ Women with absolute contraindications may continue their usual activities of daily living but should not participate in more strenuous activities. Absolute contraindications to exercise are the following: Ruptured membranes Premature labour Unexplained persistent vaginal bleeding Placenta previa after 28 weeks’ gestation Preeclampsia Incompetent cervix Intrauterine growth restriction High-order multiple pregnancy (e.g., triplets) Uncontrolled type 1 diabetes Uncontrolled hypertension Uncontrolled thyroid disease Other serious cardiovascular, respiratory, or systemic disorder ○ Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider prior to participation. (may not fit the 150 minutes) Relative contraindications to exercise are the following: Recurrent pregnancy loss Gestational hypertension A history of spontaneous preterm birth Mild/moderate cardiovascular or respiratory disease Symptomatic anemia Malnutrition Eating disorder Twin pregnancy after the 28th week Other significant medical conditions Weight gain in pregnancy – normal patterns, monitoring PRE-PREGNANCY BMI RECOMMENDED RANGE TO TOTAL WEIGHT GAIN Ibs per week kg Ibs < 18.5 Underweight 1.0 12.5-18.0 28-40 18.5-24.9 Normal weight 1.0 11.5-16 25-35 25.0-29.9 Overweight 0.6 7.0-11.5 15-25 ≥ 30.0 Obese 0.5 5.0-9.0 11-20 Caring for uninsured clients - - Hospital costs - Uninsured clients are still required to pay for hospital stays, which generally range from $500-$3,000 per day. Midwives may try negotiating a reduced rate for hospital fees with your hospital administration or payment plans Consults & Diagnostic imaging (lab tests) The Ontario government provides funding to cover the cost of laboratory and consultation fees for uninsured clients who are residents of Ontario. The intention of the funding is to facilitate midwifery care for people living in Ontario, not for people visiting in order to have a baby with the plan of returning to their home country, who may be defined as a medical tourist. Uninsured midwifery clients are eligible for funding to cover pregnancy related third-party services for the full extent of their time in midwifery care - - Services covered: - Obstetrical referral/consultation/transfer (prenatal, intrapartum, postpartum) - Anesthetic referral/consultation - Surgical assist - Referrals to specialist physicians (e.g endocrinology, hematology, urology, cardiology) - Lab work (e.g. routine prenatal blood work, glucose testing, GBS) - Prenatal genetic testing (IPS/FTS) - Ultrasound Services that are NOT covered by this funding include: - NIPT (Non-Invasive Prenatal Testing) - Hospital stays & facility fees Ohip midwifery specific pot of money that is specific to midwifery clients that is used. As we are not funded by ohip we can look under people who are not covered by ohip (ministry of health and long term care). Liability concerns with taken medical tourists. Need to let TPA know that they are not insured and plan on staying in canada as a resident so then you have to go and send forms and say that you are getting paid by typical ohip rate by this organization. Use of language interpreters Vaccines during childbearing – Rubella, influenza, COVID - Unsafe vaccines in preg: Cannot give live attenuated vaccines in pregnancy, but recommend it for postpartum - HPV - MMR (rubella) - Varicella - Safe: - The hepatitis B vaccine is safe for pregnancy and should be offered to clients at high-risk (health care providers, individuals having sexual contact with an infected person, individuals with multiple sex partners, individuals with other STI, injection drug users, - TDaP (Pertussis) booster - Recommended to be able to give immunity to your child during pregnancy until they are able to get the vaccine themselves at 2 months - Flu vaccine - Normal fetal growth patterns and assessments, including SFH measurement SFH - Fetal size and growth are assessed by measuring fundal height - - The fundus is usually first palpable externally at 12 weeks’ gestation. It is then possible to estimate the approximate size of the fundus for each week of gestation, based on landmarks on the maternal torso, such as the pubic symphysis, the umbilicus, and the xiphisternum If the examiner finds that the fundus is larger than expected for the gestational age, an ultrasound examination may be useful to confirm the dating of the pregnancy and/or the presence of a single fetus. After 24 weeks’ gestation, a symphysis fundal height (SFH) measurement is an inexpensive and simple screening tool to assess fetal size and growth. In general, the measurement of the SFH in centimeters should be similar to the weeks of gestation plus or minus 2 cm. Since there can be great variability among examiners and variability due to the maternal BMI, the value of the measurement lies in graphing the trend over time to see the pattern and velocity of fetal growth. Changes in the velocity of growth, static growth, or growth beyond the 90th percentile or below the 10th percentile for gestational age should prompt further examination of fetal measurements with serial ultrasound biometry The SFH is measured by placing a measuring tape on the top of the pubic symphysis and measuring to the top of the fundus or measuring from the fundus down to the top of the pubic symphysis. The latte technique may be the most accurate, as it involves measuring from a non-fixed point to a fixed point. Other assessments: - Fetal kick count - Growth scan - Measurment of four fetal anatomical areas that when combined in a mathematical equation can estimate fetal growth at any gestational age ○ Four components measured after 14 weeks (32weeks) BPD, HC, AC, FL ○ Estimated fetal weight - Assessment of amniotic fluid - Amniotic fluid provides a supportive milieu for fetal development in the intrauterine environment. - Amniotic fluid is a balance between baby urinating and drinking - In cases of hypoxia, the baby’s brain prioritizes blood flow to other areas which reduces blood flow to the kidneys resulting in less urine being produced. This leads to less amniotic fluid being produced = oligohydramnios - Polyhydramnios when you have too much AF due to baby not swallowing enough. Rhesus negative clients – antibody testing, Rh immunoglobulin prophylaxis If you have Rh-negative blood and do not already have antibodies for Rh-factor, you will be given an injection of Rh immunoglobulin (also called RhoGAM, WinRho, or anti-D immunoglobulin) at about 28 weeks gestation. This prevents sensitization in 99% of women so that your body will not form antibodies to the baby’s Rh factor. An Rh immunoglobulin shot may be given if you have any vaginal bleeding during your pregnancy or if you require amniocentesis. You will also be given Rh immunoglobulin again within 72 hours after delivery if your baby is found to be Rh positive. Finally, if you are Rh negative, the baby’s father (if 100% confirmed) can be tested for his Rh status. If he is Rh negative then there is no need for you to receive treatment. Further, if a cell-free DNA test of your blood shows that your baby is also Rh-negative, you will not require treatment. ○ Problems can arise if the mother is Rh-negative, and the baby is Rh-positive. Because the mother does not have this particular protein in her body, her immune system will perceive it as a foreign and possibly harmful substance. Once she is exposed to Rh-positive blood (as fetal cells move through her system during pregnancy or at the delivery), her body will make antibodies that can ‘attack’ the Rh protein. She is then said to be ‘Rh-sensitized’. In most cases, this sensitization will not happen until delivery, in a first pregnancy. It is the subsequent pregnancies that are of concern. ○ The antibodies from an Rh-sensitized mother can cross the placenta and enter the fetal blood stream. These antibodies then destroy some of the baby’s blood cells and cause fetal anemia, which is called Rh disease. Since the job of red blood cells is to carry oxygen around the body, Rh disease is quite serious. Screening for asymptomatic bacteriuria in pregnancy Midstream urine to diagnose and test of cure after course of treatment Recurrent UTI – 2 in six months or 3 in a year All clients should be offered routine screening for ASB, essentially, a UTI without symptoms, by midstream urine in pregnancy, typically sampled between 12-16 weeks. Clients with ASB will have bacteria forming a UTI in their urine, however they will have none of the usual signs and symptoms of infection such as dysuria, urinary frequency, cloudy urine, hematuria or passing small amounts of urine. UTIs, both symptomatic and asymptomatic, are more common in pregnancy due to a greater propensity for urinary stasis due to dilation of the ureters and increased capacity of the bladder for holding urine. ○ Pregnant clients are at greater risk of a UTI becoming an ascending infection, such as pyelonephritis, involving the kidneys. Pyelonephritis is associated with low birth weight, preterm labour or preterm prelabour rupture of membranes. Diagnosis of ASB is confirmed with a urine culture of >100,000 colony forming units (CFU) of a single organism, typically E. coli (Figure 2-2). Treatment with an appropriate antibiotic should be initiated. This care pathway of screening and treatment of ASB reduces the risk of pyelonephritis and the risk of preterm birth and low birth weight.( GBS screening and prophylaxis - This screening is done between 35 to 37 weeks gestation and involves a swab test of the vagina and your rectum - 15 - 40% of all pregnant women are GBS positive 40 - 70% of positive mothers pass the bacteria onto their babies during the birthing process. 1- 2% of these babies will go on to develop a GBS infection 5% who develop the infection will die - A simple and painless test is done by inserting a Special Q-tip into a woman’s vagina and rectum. The Q-tip is then placed in a special solution to see if the bacteria grow. This is called doing a Culture. If bacteria grow, the woman is said to be positive. If no bacteria grow, the test is negative - GBS Positive = antibiotics via IV in labour to reduce the likelihood of transmission and reduces the risk of infection by - 65-86% swab is good for 5 weeks so testing between 35 to 37 weeks is ideal Studies show that it is not beneficial to give antibiotics during pregnancy, as in more than 65% of cases, the bacteria have time to re-grow before labour begins. Antibiotic options Pen G -> given q4h in active labour up to birth Cefazolin -> Intravenous cefazolin is recommended as the alternative for penicillin-allergic women who are at low risk for anaphylaxis (do not have a history of anaphylaxis, angioedema, respiratory distress, or significant urticaria Clindamycin->q8h Indicated for clients at high risk anaphylaxis reaction to Pen G Vancomycin -> Indicated for individuals who have an allergy to penicillin and the strain is resistant to clindamycin. (would need ob consult midwives can not order) - Antenatal fetal surveillance – fetal movement counting, NST, BPP FM/FKC - When? 24-28 weeks - if they perceive decreased fetal movement, such as going longer than a couple of hours without movement, or having minimal movement during a period of the day when the baby is typically active. NST - - BPP - Drink something cold and sit still with hands on abdomen Count 6 movements in 2 hours - Don’t have to be big huge kicks - shifts, turns, hits count - Hiccups don’t count The NST is based on the premise that the heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement external electronic fetal monitoring is used to infer adequate oxygenation status through expected neurological and cardiovascular reflex responses. Loss of reactivity is most commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidemia You want at least two accelerations in 20 minutes, no decels and no contractions - Baseline FHR 110-160 bpm Sometimes a button is provided so client can push when they perceive fetal movements For who: - (1) initial test in low-risk patients presenting with a concern (e.g., decreased FMs, fall or trauma, vaginal bleeding), - (2) high-risk patients requiring frequent fetal assessments - Ie: GDM, postdates, postterm, PROM Results: BPP is a widely used assessment tool that combines a 4- component sonographic assessment of fetal behaviours and amniotic fluid (Box), with or without an NST Components of fetal biophysical profile - Breathing movements: At least 1 episode continuing more than 30 seconds - Movements: At least 3 body or limb movements - - Tone: An episode of active extension with return to flexion of a limb or trunk, or Opening and closing of the hand - Amniotic fluid volume: a Single deepest pocket 2 cmx1 cm with no cord or fetal parts present Each component is counted as 2 points toward a total of 10 points, and interpretation depends on the score obtained (Table 2). If a score of 8 can be achieved with sonography an NST is not necessary BPP, q 2-3 days, starting around 41+0 weeks until birth or IOL. » If clients choose expectant management beyond 42 weeks, fetal surveillance may include US q 2-3 days, daily fetal movement counting and/or NST. Visit client at least twice a week starting during the 42nd week until labour. Postdates/prolonged pregnancy ○ Postdates: pregnancy is defined as lasting 40+0 weeks plus one or more days ○ Postterm: any pregnancy after 42+0 weeks ○ Contributing factors: Previous postterm pregnancy Parental or sibling history of postterm pregnancy Male fetal sex Higher body mass index (BMI) Advanced maternal age Lower parity Depression/anxiety ○ Risks of pregnancy past 41 weeks Meconium-stained amniotic fluid and risk of meconium aspiration syndrome Macrosomia/shoulder dystocia Stillbirth Caesarean section oligohydramnios In 2018-2019 for Ontario midwifery clients, 49% of term births occurred between 37 and 39 weeks, 31.2% during the 40th week, 18.4% during the 41st week and 1.3% at 42 weeks or more Prevention Accurate dating/confirmation of EDD using ultrasound Promoting spontaneous labour Stretch and sweep (between 38 and 41 weeks) Acupuncture ○ insertion of sterile needles into various points on the body to soften the cervix and induce uterine contractions Acupressure ○ application of manual pressure to points on the body as a natural method to initiate labour Primrose ○ natural method of cervical ripening, as the plant’s omega-6 essential fatty acids may affect the synthesis of prostaglandins and cytokines. The above support natural changes to cervix at the end of pregnancy rather than initiating labour Management of Postdates: ○ Expectant management: Choosing for labour to start in its own If you decide to wait for labour to start on its own, your midwife will offer to monitor your baby’s health, usually with an ultrasound. If they have concerns, they may recommend an induction. (AOM) Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume (JOGC) For those choosing expectant management, offer ultrasound twice weekly, starting between 41 and 42 weeks and continuing until birth to assess fetal well-being. For ultrasound assessments, BPP, AFI or maximum fluid pool depth can be used according to the care provider and community standards. In communities where ultrasound is unavailable, NST may be offered (AOM) ○ Induction Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section (sogc) For pregnancies at 41 weeks’ gestation, midwives should offer IOL between 41+0 and 42+0 weeks. Prior to 41 weeks, discuss the risks and benefits of IOL between 41 and 42 weeks. Offer clients with uncomplicated postdates pregnancies full support in choices that enable them to maximize their chances of spontaneous labour, including supporting their decision to choose expectant management up to and beyond 41+0 weeks’ gestation. ○ Choice of birthplace Having a postdates pregnancy doesn’t necessarily mean you can’t plan to give birth outside the hospital. There is little research to establish whether home birth is less safe than hospital birth for those whose pregnancies last longer than 40 weeks. Because some methods of induction (prostaglandin gel, oxytocin) are only provided in a hospital, undergoing induction of labour may limit your options for where you give birth. Babies born at 41 weeks and later are more likely to release meconium. If you are labouring out of hospital and your midwife notices meconium, they may advise a transfer to hospital First and second stage of labour – vital sign monitoring, bladder care, normal progress and assessment - - - Maternal vital signs - BP q4hours (should stay normal but elevation between 15 to 50 mm Hg may occur, over 140/90 mm Hg more frequent assessments and ob consult) - Heart rate q4hours (equal or under 100 bpm (60-100 bpm) is normal, increases because of anxiety or pain is normal) - Temperature q4hours - Can be elevated if client is dehydrated, has been in a warm birth tub for a long time or has had an epidural for a long time - More surveillance if client in a tub for a long time and if membranes have been ruptured for a prolonged period of time (longer than 18 to 24 hours). - 36.5 to 37.5 is normal - Over 37.5 abnormal – more checks and maybe other causes - More than 38 could be an infection, call for consult with OB Abdominal palpation - To assess contraction strength, duration and frequency and resting tone of uterus between contractions - To determine baby position and FHR Vaginal Examinations to assess progress - Every 4 hours with consent Bladder - Encourage client to empty every 2 hours or so - When epidural: empty using urinary catheter every two hours Fetal surveillance - Assessed regularly throughout labour - q15-30 minutes active first stage - q5 minutes second stage - Should be assessed between contractions for 60 seconds - Characteristics - Baseline FHR - Rhythm (regular or irregular) - Presence of accelerations - Presence of decelerations – variability and type of decel cannot be determine by IA**** Labour support – normal labour - Continuous support - Constant attendance - Comfort and reassurance - Positive encouragement - Assistance with position changes - Praises - Continuous support - Information about labour progress - Reducing painful stimuli: counter pressure, position changes - Activate peripheral sensory receptors: water, massage, acupressure, TENS, sterile water injections, aromatherapy - Distractions and focusing techniques – music and hypnosis Fetal health surveillance in labour – intermittent auscultation ○ Fetal surveillance Assessed regularly throughout labour q15-30 minutes active first stage q5 minutes second stage Should be assessed between contractions for 60 seconds Characteristics Baseline FHR Rhythm (regular or irregular) Presence of accelerations Presence of decelerations – variability and type of decel cannot be determine by IA**** Types Intermittent auscultation ○ Active first stage q15-30 minutes ○ Active second stage q5 minutes ○ IA between contractions ○ Make sure to listen right after a contraction ○ Make sure to look/listen to parent’s heart rate to make sure you’re actually listening to baby ○ Normal FHR Normal baseline rate between 110-160 bpm Rhythm (regular or irregular) Presence of accelerations Baseline is a specific number ○ Abnormal FHR Abnormal baseline FHR Tachycardia greater than 160 bpm Bradycardia less than 110 bpm Changes in baseline rate over time Presence of decelerations Induction of labour – physiologic methods, Bishop’s score ○ ○ ○ Cervical ripening Recommended when modified bishop score is less than 7 Use of Foley balloon catheters for first line cervical ripening whenever possible as they are safe and effective Cramping can be uncomfortable for some clients- ICD with client beforehand Balloon sits just above the cervix, immated the babys head and encourages prostaglandins Can use prostaglandin E1 or E2 vaginal gel or insert for safe and effective cervical ripening- Cervidil Contractions due to medical cervical ripening can be intense- ICD with client beforehand Repeat cervical ripening at a bishops score of 6 or less. A bishop of 7 or higher is when oxytocin can be used for induction This is nice and clear - 8 cm = good; 6 cm - not good - repeat. (kelly comment from tutorial) Oxytocin (*misoprostol)-dont spend a lot of time on misoprostol for the exam. IV drip (most commonly). Some clinics/hospitals do not have midwife control over oxytocin induction yet, meaning transfer of care to OB in such cases. Must be attached to EFM for Oxytocin induction; this may limit freedom of movement Contractions due to medical induction of labor can be intense- ICD with client beforehand 10-20IU considering that an average patient receiving oxytocin for induction will achieve adequate contractions when receiving between 8-12 milliunits per minute, a soft stop should be applied at 12 milliunits per minute to cue a thorough assessment by the administering healthcare provider before proceeding A hard stop would be at the maximum dose of the medication; which is 20 milliunits per minute Non-pharmacological/encouragement Stretch and sweep- using fingers to assess the cervix and stretch it open and sweep their fingers across the bag of waters Sweeping of the membranes has been found in numerous studies to reduce the length of pregnancy (2) The AOM recommends an offer of a sweep when appropriate, beginning between 38 and 41 weeks to reduce the rate of postterm pregnancy and the need for medical induction (2) The SOGC also recommends an offer of a membrane sweep commencing at 38 - 41 weeks following a discussion of risks and benefits (2) Theoretical risks of stretch and sweep include rupture of membranes, chorioamnionitis and bleeding from a previously undiagnosed placenta previa. However, trials have not shown an increase in these occurrences. Women may report discomfort or pain, bleeding, and contractions not leading to labour within 24 hours. (2) AROM: usually done to speed up labor/contractions rather than induce labor initially. Considered labor augmentation method as it can induce expulsion contractions Castor oil AOM does not provide clinical evidence towards the use of castor oil. Castor oil is widely regarded as a natural induction methodhistorical use of castor oil behind evidence towards midwifery usage Research shows that there is little evidence towards the success of castor oil inductions, although individual experience suggests otherwise. In theory, castor oil stimulates production of prostaglandins, leading to bowel and vagal nerve stimulation in hopes of starting uterine contractions ?? Why is there so little information on the science behind castor oil Research studies done in other cultures (ie. Egypt, Palestine) suggest castor oil use is valid form of labor induction Herbal remedies AOM in cpg guideline has said there is not enough research to show any benefit of using herbal remedies or things such as evening primrose oil, acupressure to induce labor. Cultural practices i.e. acupuncture. Research done in different cultures, very little research done in Western medicine Midwives brew Stone fruit juice, castor oil, i didn't get the rest Third stage of labour – normal progress, expectant and active management, placental exam ○ Expectant: Physiological Minimal intervention but stimulating the body’s response to release oxytocin Newborn placed skin to skin Skin to skin and stimulation of the mother’s breast during attempts to breastfeed trigger the release of oxytocin which promotes uterine contraction and placental separation When signs of separation are observed (gush, lengthening of the cord, parent has the urge to push) parent is encouraged to push that placenta out Upright maternal position (squatting or standing) will allow gravity to facilitate the expulsion of the placenta) ○ Active management Reduces severe PPH by Cervical ripening ○ https://www.jogc.com/article/S1701-2163(22)00732-0/abstract sogc guideline on cervical ripening ○ Recommended when modified bishop score is less than 7 ○ Use of Foley balloon catheters for first line cervical ripening whenever possible as they are safe and effective Cramping can be uncomfortable for some clients- ICD with client beforehand Balloon sits just above the cervix, immated the babys head and encourages prostaglandins Can use prostaglandin E1 or E2 vaginal gel or insert for safe and effective cervical ripening- Cervidil ○ Contractions due to medical cervical ripening can be intense- ICD with client beforehand ○ Repeat cervical ripening at a bishops score of 6 or less. A bishop of 7 or higher is when oxytocin can be used for induction ○ This is nice and clear - 8 cm = good; 6 cm - not good - repeat. (kelly comment from tutorial) Oxytocin (*misoprostol)-dont spend a lot of time on misoprostol for the exam. ○ IV drip (most commonly). Some clinics/hospitals do not have midwife control over oxytocin induction yet, meaning transfer of care to OB in such cases. ○ Must be attached to EFM for Oxytocin induction; this may limit freedom of movement ○ Contractions due to medical induction of labor can be intense- ICD with client beforehand ○ 10-20IU ○ Provincial maternal newborn https://www.pcmch.on.ca/wp-content/uploads/2022/02/Safe-Administration-of -Oxytocin-Guideline-Report-Jan2022.pdf considering that an average patient receiving oxytocin for induction will achieve adequate contractions when receiving between 8-12 milliunits per minute, a soft stop should be applied at 12 milliunits per minute to cue a thorough assessment by the administering healthcare provider before proceeding A hard stop would be at the maximum dose of the medication; which is 20 milliunits per minute Non-pharmacological/encouragement ○ Stretch and sweep- using fingers to assess the cervix and stretch it open and sweep their fingers across the bag of waters ○ ○ ○ Sweeping of the membranes has been found in numerous studies to reduce the length of pregnancy (2) The AOM recommends an offer of a sweep when appropriate, beginning between 38 and 41 weeks to reduce the rate of postterm pregnancy and the need for medical induction (2) The SOGC also recommends an offer of a membrane sweep commencing at 38 - 41 weeks following a discussion of risks and benefits (2) Theoretical risks of stretch and sweep include rupture of membranes, chorioamnionitis and bleeding from a previously undiagnosed placenta previa. However, trials have not shown an increase in these occurrences. Women may report discomfort or pain, bleeding, and contractions not leading to labour within 24 hours. (2) AROM: usually done to speed up labor/contractions rather than induce labor initially. Considered labor augmentation method as it can induce expulsion contractions Castor oil AOM does not provide clinical evidence towards the use of castor oil. Castor oil is widely regarded as a natural induction method- historical use of castor oil behind evidence towards midwifery usage Research shows that there is little evidence towards the success of castor oil inductions, although individual experience suggests otherwise. In theory, castor oil stimulates production of prostaglandins, leading to bowel and vagal nerve stimulation in hopes of starting uterine contractions ?? Why is there so little information on the science behind castor oil Research studies done in other cultures (ie. Egypt, Palestine) suggest castor oil use is valid form of labor induction Cochrane review: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003099.p ub2/full?highlightAbstract=caster%7Coil%7Ccastor Meta-analysis, peer-reviewed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9240406/ Herbal remedies AOM in cpg guideline has said there is not enough research to show any benefit of using herbal remedies or things such as evening primrose oil, acupressure to induce labor. Cultural practices i.e. acupuncture. Research done in different cultures, very little research done in Western medicine ○ Midwives brew Stone fruit juice, castor oil, i didn't get the rest 60-70% Reduction of PPH of up to 40% Higher risk of hypertension, vomiting and after pains Reduction in the use of therapeutic uterotonics, maternal blood transfusion, maternal anemia, and lower mean blood loss. Administration of a uterotonic agent (ie. Oxytocin) 10 IU of IM or 20IU in IV Slow push for active management as a prevention In response to active PPH rapid injection Controlled cord traction to deliver the placenta Support and guard uterus Uterine massage after delivery of the placenta Most common cause of PPH is uterine atony Immediate postpartum care – monitoring, normal newborn transition Parent: - Vitals (pulse, BP) - q15 mins for the first hour then every q1hr - Temp - q1hr - Bleeding - q15 minutes for the first hour then q1hr - Uterus - q15 minutes for the first hour then q1hr - Involution - Firm and central Newborn: - Newborn exam - Vitals (temp, HR, RR) - q1hr Vitamin K prophylaxis - Given at 1-2 hours of life 1mg intramuscularly in vastus lateralis OR 2mg orally, repeat at 2-4 weeks and 6-8 weeks VKDB: neonatal intracranial hemorrhage Eye prophylaxis - Erythromycin eye ointment once baby is born 0.5cm ribbon in each conjunctival sac - - To protect against the devastating effects of neonatal ophthalmia (NO) (conjunctivitis) that can lead to blindness. Neonatal ophthalmia caused by untreated chlamydia and gonorrhea during pregnancy. STIs transmitted to baby during delivery Introduced in the 1800s when we didn’t have the technology to test for STIs or have antibiotics to treat them. Government mandated practice to prevent neonatal ophthalmia in neonates. Research evidence states that the erythromycin is not effective in treating NO caused by chlamydia or gonorrhea (CPS and AOM against universal administration of EEO) - Failure rate 7-19% in gonococcal NO - Failure rate of 23-32% in chlamydial NO - Most cases of NO are caused by chlamydia and not gonorrhea - Erythromycin is resistant to gonorrhea in 23% of cases - Erythromycin does not prevent the transmission of chlamydia or gonorrhea to baby - If NO is confirmed baby will be treated with a different eye ointment given systemically Pros: - No long term effect to baby if ointment is given and no infection is present - Quick, easy, and painless Cons: - Temporary cloudiness and irritation of the newborns eyes Alternatives - Screening every pregnant person during pregnancy and treating if there is an infection Infant feeding – body feeding initiation and support, formula feeding, assessment of input and output, a. b. c. d. e. f. g. h. i. Immediate skin to skin Discussion c-hold or u-hold Difference between colostrum and breast milk i. Colostrum is sticky and takes more effort for them to get out ii. Milk is easier and you’ll get the suck suck swallow Suck, suck, swallow Entire areola in the mouth not just the nipple Nutritive suck vs a comfort suck Hunger cues Peeing is a sign that baby is hydrated a. Engorgement i. Usually day 3 to day 5 ii. Should pass in 24 to 48 hours if properly managed iii. Cold compress after a feed iv. Hot compress before and during a feed v. Massaging breasts in the shower vi. Pain killers i. Infant feeding a. Newborns feed frequently, approximately 8-12 times in a 24-hour period b. For the first few days of life, the baby may still be sleepy and the parents may need to wake the baby to feed frequently - Or undress baby/make baby uncomfortable so he is alert enough to feed c. The parents may also need to stimulate the baby when they are at the breast to encourage active sucking. d. Stimulating the baby to suck can be done by stroking the hands, feed or head of the infant. e. When the mother’s milk supply is established, the amount of milk and the increased caloric intake provides more energy for the newborn and they will often begin to wake and initiate feeds on their own a. Output (stool and urinary output in the infant is a direct reflection of the adequacy of nutritional input) (PAGE 418) i. Within the first 24 hours of life it is important for the newborn to void and stool at least once to ensure that both the urinary and gastrointestinal systems are functioning ii. Day 1 – Day 3 2-3 stools per day Meconium – thick, sticky, black to dark green Wet diapers = how old baby is iii. Day 2 – Day 5 2-3 stools per day Transitional: more liquidy, less sticky, green to brown in colour iv. Day 3-6 weeks 1 per week to 8 per day Breastfed stools – liquid, soft, yellow, visible seeds/milk curds normal patterns of weight loss, common challenges and management Yall i’m freestyling this one… loool thats okay:) - Day 3 is the baby’s lowest weight because usually parent’s milk comes in between Days 3-5 Baby should have gained back weight by day 5 - And should continue to gain consistently 0.5 - 1 ounce a day until back to birth weight (two weeks usually) If no weight gain: - Either a transfer issue or a supply issue - - - Watch a feed - Ask how often baby feeds per day and how long baby feeds for should be 8-12 feeds (q2-3 hours until reaches birth weight than on demand) 15-20 minutes - Ask about output - Check positioning of baby (emphasis on skin to skin) - Check latch (correct if needed) and what baby does at the breast - Offer different positions for chest feeding (football, cross-cradle, cradle etc.) - Educate parent on sucking vs swallowing - Check baby’s mouth for tongue tie Ask parent to pump after a feed and see how much breast milk is left - If small volume (10-15 ml) could be a sign of low milk supply - Herbs can help increase - Domperidone - If large volume (50-60 ml) could be a transfer issue with baby - Breast compressions when feeding - Tongue tie Introduce feeding plan - Top ops after feeds either by EBM or formula - Pumping to stimulate breasts and make milk (but don’t overdo it) In cases of weight loss: - Can supplement with formula after a feed or formula feed and supplement with breast milk Ontario newborn screening (including CCHD) - - A public health system offered to all newborn infants used as an early detection tool for early treatment of serious, but rare diseases and conditions that affects 350 out of 143,000 (0.24%) newborns born each year. Dried blood spot (DBS) screens for 29 diseases and conditions that can be grouped int o6 categories: metabolic diseases, endocrine diseases, sickle cell disease, cystic fibrosis, severe combined immunity deficiency, and spinal muscular atrophy - 24-48 hours - Heel prick for capillary blood - The results of this analysis will either come back as unsatisfactory, negative, or positive CCHD - CCHD refers to conditions where a baby’s heart or major blood vessels around the heart have not formed properly. They are called critical because they require surgery or intervention in the first year of life to ensure healthy outcomes for the baby - Pulse oximetry screening (POS) is the most effective device for detecting CCHD, the most common congenital anomaly amongst newborns - - 24-36 hours pulse oximeter on the right hand and either foot of the newborn to measure the oxygen levels of arterial blood being transported from the most oxygenated to least oxygenated point in the body - done at the bedside and results are available right away - > 95% and less than a 3% difference between both readings negative result = low risk positive result = high risk which would require follow up and referral for testing at the nearest regional treatment centre in order to make a diagnosis Newborn screening is highly recommended by the Canadian Paediatric Society (CPS) for any newborn 34+7 weeks gestations CMO recommended standards of care for routine newborn screening, including CCHD Jaundice – physiologic jaundice, assessment, bilirubin screening and routine follow up - - - - Most newborns born at term, about 60%, will develop some level of jaundice in the first days of life. Jaundice, the visible yellowing of the skin and whites of the newborn’s eyes, occurs when there is excessive bilirubin pigment in the bloodstream, called hyperbilirubinemia. Bilirubin is produced during the breakdown of red blood cells. Newborns have an excess number of red blood cells in the days following birth because when they were in utero they produced special neonatal red blood cells, but then following birth, they begin to make normal ‘adult’ red blood cells. In addition, their livers isn’t as functional as adults so it takes them more time to clear out the bilirubin therefore there is an accumulation of bilirubin that occurs giving the yellow tint to their skin. Effects of high levels of bilirubin include: ○ Bilirubin toxicity affecting the brain (acute bilirubin encephalopathy) ○ Dark urine ○ Lethargy ○ Poor suck ○ Hypotonia Jaundice that presents in the first 24 hours of life is more likely to be pathological and requires further testing and evaluation of the cause. Normal, physiologic jaundice usually begins after 24 hours of age and peaks around day three or day four of life. - It first appears on the face and then moves down the chest and trunk. - Yellowing of the sclera is a later sign of jaundice. - However, the clinical appearance of the baby as mild to severely yellow is not adequate for diagnosing levels of hyperbilirubinemia Babies who are high risk for hyperbilirubinemia are: - preterm, of an East Asian or Mediterranean descent - significantly bruised following birth, not feeding well, born to a family with a history of previous children with significant hyperbilirubinemia requiring treatment, or - who are born to mothers with O blood type are at greater likelihood to develop severe hyperbilirubinemia. - The goal of screening newborns for the total serum bilirubin (TSB) levels is to identify and predict those infants who are at greatest risk of developing significant hyperbilirubinemia. - A capillary heel blood sample collected between 24 and 72 hours of age, and reviewed based on the age of the infant at the time of the sample (timed TSB measurement) can be used to predict if a subsequent TSB will be above the 95th percentile - Alternatively the TcB can be used to assess bilirubin levels - Light flashed at the chest three times - Visual and risk factor assessment - Less accurate - Overestimation amongst infants of darker skin tones - May be inaccurate during/after phototherapy - Should be used as a screening tool - TCB make sure to know unit of measurement!!! - In canada - ɥmol/L - If high, try TSB because the TSB is the gold standard - TCB on day three because that’s when most start - If you see jaundice before day 3 to the serum test!!!! - Results from TSB and TcB plotted on a nomogram to determine risk of progression to severe hyperbilirubinemia (340umol/L) Result category Action required High Repeat TSB in 4-24 hours High intermediate Repeat TSB in 24 hours Low intermediate Follow-up assessment within 48 hours Low Follow-up assessment within 2-3 days Jaundice education Lethargic Doesn’t want to feed, reduced sucking and regression in feeding High pitched cry Tired Red Crystal in urine. Dark urine PART 2 (AFTER MIDTERM) Routine laboratory testing in pregnancy – chlamydia and gonorrhea screening, cervical screening **these are the most common STI’s atm - anyone with risk factors should be rescreened each trimester** ○ Syphilis Screening @ initial visit (8-12 weeks or the earliest point that the client comes into care) Blood sample for Venereal Disease Research Laboratory (VDRL) screen, for syphilis. A positive VDRL requires follow up with a treponema-specific test. Fetus risks: congenital abnormalities, preterm birth, stillbirth, and active infection at birth for the neonate. Mother: painless sore, or cancre, at the site of infection, which may be internal and therefore go unnoticed. The infection can be transmitted across the placenta or at the time of birth. Antibiotic treatment in pregnancy should be tailored to the gestational age and appears to reduce the rate of transmission, significantly ○ Gonorrhea Due to the risks to the newborn, and the chance of asymptomatic infection, it is recommended that all pregnant clients be screened for gonorrhea Symptoms of gonorrhea: vaginal discharge, dysuria, abnormal vaginal bleeding, lower pelvic pain and dyspareunia (difficult or painful sex) Screening for gonorrhea can be carried out by cervical/vaginal swab, if a pelvic examination is indicated, or through non-invasive urine-based testing. This infection can cause endometritis for the mother and eye infection or sepsis for the newborn. Antibiotic treatment of known infections is recommended in pregnancy. Clients should be advised to abstain from sexual intercourse until treatment is complete. Sexual partners should also be tested and, if required, treated to prevent reinfection. Repeat testing can be done if there is continued risk of infection. ○ Chlamydia Often asymptomatic Symptoms in birth person include: vaginal discharge, dysuria, dyspareunia, and abdominal pain Screening for chlamydia can be carried out by cervical/vaginal swab or through non-invasive urine-based testing. If an infection is present, antibiotic treatment is recommended. Sexual partners should also be tested and treated to prevent recurrent infection. Repeat testing can be done if there is continued risk of infection. Mothers with chlamydia infection during pregnancy should be made aware that there is a 50% rate of transmission to babies born vaginally. Chlamydia in newborn = conjunctivitis and pneumonia. ○ Cervical Screening Reduce deaths related to invasive cervical cancer The Papanicolaou method of cervical screening, or Pap smear, looks for pre-cancerous and cancerous cells from the cervical transformation zone, which comprised of outer squamous cervical cells and inner glandular endocervical cells. Screening results are presented in categories. The most common findings are: Negative Atypical squamous cells of undetermined significance (ASCUS) Low-grade squamous intraepithelial lesion (LSIL)¬ High-grade squamous intraepithelial lesion (HSIL) The Canadian Task Force on Preventative Health Care recommends initiating cervical screening after 21 years of age. From age 21 to 69 routine screening is recommended every three years unless findings warrant more frequent screens. After 70 years of age, if routine screening has been maintained with no abnormal results in the last three screens then no further Pap tests are recommended. During pregnancy, clients should be screened based on these same timing recommendations, thus, a Pap-smear is not required in the antenatal or postnatal period unless the client is otherwise due for her regular three year screening. Glucose screening in pregnancy – ICD and routine screening ○ What is GDM and lifestyle management of GDM? ○ Modifications in diet and exercise ○ Self-monitoring of glucose ○ Insulin (TOC) ○ associated with perinatal complications such as shoulder dystocia, birth trauma, neonatal hypoglycemia, increased risk of operative birth and preeclampsia Midwifery management: Referral to diabetes clinic/dietician Serial ultrasounds q4 weeks starting at 28 weeks Weekly monitoring starting at 36 weeks NST or BPP, Growth U/S (can alternate each week) EFM during labour Early induction Between 38 and 40 weeks Glucose monitoring during labour q1hr recommended maternal blood glucose between 4.0 and 7.0 mmol/L Glucose protocol after birth At 2 hours then q 4 hours Must be over 2.6 mmol/L Postpartum OGTT between 6 weeks and 6 months Risk factors for developing gestational diabetes ○ Age > 35 ○ BMI > 30 ○ Previous baby > 4500g ○ Previous GDM ○ Family history of first degree relative with diabetes ○ Ethnic background with high prevalence of diabetes Indigenous, Hispanic, Asian, South Asian, African/Black ○ When high risk factors present early screening is recommended (20 weeks) then repeat at 24-28 weeks When to screen for GDM? ○ Between 24 and 28 weeks Closer to 26 weeks is best ○ Universal screening is best How to screen for GDM? ○ OGCT (preferred step 1) 50g of glucose Non fasting One blood test one hour later ○ OGTT (preferred step 2) 75g of glucose Fasting Three blood tests At fasting At one hour At two hours What are the normal values? ○ OGCT Less than 7.8 mmol/L If value is between 7.8 and 11 -> OGTT test needs to be done If value is greater than 11.0 then automatic GDM diagnosis ○ OGTT (if above OGCT between 7.8-11) If 1 values if met or exceeded FPG ≥5.3 mmol/L 1-h PG ≥10.6 mmol/L 2-h PG ≥9.0 mmol/L ○ OGTT without doing OGCT (1 step approach) FPG ≥5.1 mmol/L 1-h PG ≥10.0 mmol/L 2-h PG ≥8.5 mmol/L ○ Glucose monitoring after diagnosis Antenatal perform self-monitoring of blood glucose before (fasting) and after meals (postprandially, PP) [Grade B, Level 2] and should strive for target glucose values of: ○ Fasting < 5.3 mmol/L [Grade B, Level 2] ○ 1hPP < 7.8 mmol/L [Grade B, Level 2] ○ 2hPP < 6.7 mmol/L [Grade B, Level 2] Intrapartum ○ Testing blood glucose every hour ○ Recommended maternal blood glucose between 4.0 and 7.0 mmol/L Delivery ○ Newborn glucose protocol testing at 2 hours post birth ○ Value should be at least 2.6 mmol/L Anemia in pregnancy – physiologic anemia, iron deficiency anemia ○ Defined as reduced capacity for transport of oxygen in the blood, as demonstrated by lower than normal values of hemoglobin or ferritin. The volume of fluid in maternal circulation increases by a total of 40%; beginning at 6 weeks gestation and plateauing around 32 weeks. The increased volume of fluid has a dilution effect on hemoglobin levels, which decreases the blood’s capacity to carry oxygen, drop for drop. ○ Iron deficiency anemia occurs when red blood cell production is inadequate due to insufficient dietary intake and absorption of iron. It can also be caused by excessive blood loss (e.g., following postpartum hemorrhage). Iron deficiency is the most common cause of anemia worldwide. (3,4) Iron deficiency anemia, by definition, responds to treatment with iron. ○ Iron plays many important roles in your health. You need iron to make hemoglobin, a part of red blood cells that carries oxygen throughout the body. When you have iron deficiency anemia, you don’t have enough iron to make hemoglobin, so your body starts to make smaller and fewer red blood cells. Less hemoglobin and fewer red blood cells also means your cells can’t get the oxygen they need. ○ What components of a CBC indicate anemia and what are normal and abnormal values ○ Hemoglobin st 1 trimester: level below 110g/L 2 nd trimester: level below 105 g/L rd 3 trimester: level below 110 g/L ○ Ferritin low : 15-30 ug/L ○ Low hematocrit: st 1 trimester: less than 33% 2 nd trimester: less than 32% rd 3 trimester: less than 33% ○ Low MCV: smaller RBCs Under 80? Signs & Symptoms of anemia ○ Feeling weak and/or getting tired more easily ○ Feeling dizzy or faint ○ Feeling especially grumpy or cranky ○ Having headaches ○ Having trouble focusing or concentrating ○ Heart palpitations while exercising ○ Pale skin tone ○ Treatment of anemia (ex. Iron supplementation) Iron supplementation ○ 100 to 200 mg of elemental iron taken daily Best practice is 200 mg Fe every second day (for example feramax) to allow time for the iron to be absorbed by the body) ○ 50 to 80 mg per day of elemental iron may result in less gastrointestinal discomfort and may be adequate treatment. ○ A variety of oral iron preparations are currently available in Canada, including ferrous sulfate, ferrous gluconate, ferrous fumarate and iron-polysaccharide complexes ○ Best absorbed on an empty stomach ○ Administration of 200 mg of vitamin C for every 30 mg of iron may increase iron absorption by 10%. Avoid caffeine and calcium within 2 hours of taking ○ Side-effects: Nausea Vomiting Dyspepsia constipation and diarrhea and are generally dose-dependent. Side-effects tend to subside with continued use though compliance is often a significant barrier to treatment ○ If gastrointestinal upset is a concern, iron may be taken with or just after meals at doses < 100 mg and gradually increased after 4 to 5 day Increasing dietary iron ○ Dark green leafy greens ○ Cooking meals in a cast iron pan is an easy way to boost the iron content in your food. ○ When eating an iron-rich meal, avoid high-calcium foods. Calcium makes it harder for your body to absorb iron. ○ Add foods with vitamin C to your iron rich meal to help your body absorb iron. Tomatoes, strawberries, or orange slices can be added to a salad or eaten for dessert ○ Almond butter ○ Tofu ○ If you eat meat, darker meats like beef, duck, moose, venison and lamb have the most iron. Organ meats like liver ○ Legumes such as lentils, lima, soy, kidney, pinto and black beans are all rich in iron Intravenous iron therapy ○ may be considered if anemia is identified in the third trimester or oral therapy fails to improve the condition ○ If anemia persists after two weeks of oral iron treatment with good compliance, there are concerns about malabsorption of oral iron, or there is a requirement for fast iron repletion ○ IV iron therapy produces a greater and more immediate increase in hemoglobin levels compared to oral iron supplementation and without the side-effects of oral iron or the risks associated with blood transfusion. ○ Currently, iron dextran, iron sucrose and sodium ferric acid gluconate are the most commonly used IV preparations in Canada. ○ The costs associated with hospital visits (including physician and hospital fees as well as travel, parking and childcare costs) may present a barrier to accessing IV iron for some midwifery clients. Blood transfusion ○ RARE and based on symptoms ○ Clients with hemoglobin < 70 g/L and symptoms of anemia that include tachycardia (pulse >90 bpm), shortness of breath, dizzy/fainting spells, and/or chest pain should receive transfusion. How to manage anemia in pregnancy (ex. Retest CBC) ○ Following completion of two weeks of oral iron therapy, some authors suggest reassessing hemoglobin levels to test therapeutic response with an expected increase in hemoglobin of ≥ 10 to 30g/L or the client presents with a hemoglobin < 70 g/L at any time, physician consultation should be initiated to rule out other types of anemia. ○ Iron therapy should be continued for three to six months even if symptoms of anemia are resolved. ○ Both hemoglobin and ferritin levels may be tested following a three-month course of oral iron treatment to ensure iron stores are replete ○ Intravenous iron therapy may be considered if anemia is identified in the third trimester or oral therapy fails to improve the condition. Risk factors: ○ A vegetarian or vegan diet may put you at higher risk for anemia because the iron found in vegetarian food sources is non-heme iron and is harder for the body to absorb. ○ Vitamin D deficiency may also increase the risk of anemia since vitamin D plays an important role in iron absorption. Your body produces vitamin D when your bare skin is exposed to sunlight. Anyone who keeps their skin mostly covered may be at higher risk of vitamin D deficiency. Because of our long winters, this can include most people who live in Canada! ○ A multiple pregnancy (twins or triplets) may put you at higher risk for anemia because the demands for iron are even higher than during a pregnancy with one baby. ○ It can take up to 18 months for the body to fully recover from a pregnancy, so two (or more) pregnancies less than a year apart can make it hard to maintain good iron stores. ○ People who have very heavy menstrual periods often have low iron because they lose a lot of blood every month. If you had heavy periods before becoming pregnant, you may be at higher risk of becoming anemic during pregnancy. ○ If you are anemic during pregnancy you are also more likely to be anemic postpartum. ○ If you have a postpartum hemorrhage (losing too much blood after birth), you may be at higher risk for becoming anemic. Considerations for labour and delivery regarding anemia ○ Anemia in pregnancy is associated with an increased risk of: low birth weight infant, PTB small for gestational age infant, and increases the client’s vulnerability to severe infection postpartum. ○ If you are anemic during pregnancy you are also more likely to be anemic postpartum. Vaccinations during childbearing – Tdap, Hepatitis B ○ Tdap Tdap vaccination should be offered to all pregnant people in every pregnancy, regardless of previous Tdap vaccination history, as a means of protecting the infant from pertussis ○ The National Advisory Council on Immunizations (NACI) recommends vaccination between 27 and 32 weeks (3); the SOGC recommends Tdap between 21 and 32 weeks Tdap can be offered at any prenatal appointment; after 13 weeks based on available data; however, immunization between 27 and 32 weeks of gestation maximizes passive antibody transfer to the infant. One must keep in mind that a systematic delay of vaccination may lead to missed opportunities among women who deliver preterm, so immunization as early as 21 weeks (usually after the routine anatomical ultrasound) is encouraged. Maternal vaccination after 32 weeks or in the postpartum period still confers some protection to the infant and should be recommended if a dose of Tdap has not yet been provided during the pregnancy ○ Tdap vaccination in pregnancy is generally not covered by OHIP and is outside midwifery's scope of practice, necessitating a referral to a physician. The cost is covered by OHIP only when a client has not received a Tdap vaccine as an adult ○ The WHO has promoted maternal vaccination with Tdap as the most cost effective strategy for preventing pertussis in infants too young to be vaccinated. ○ Hepatitis B: The SOGC (2018) recommends that pregnant people at high risk for acquiring hepatitis B infection during pregnancy be offered recombinant hepatitis B vaccine series and hepatitis B immune globulin (HBIG) , which is not contraindicated in pregnancy. Pregnant people at high risk are: those with more than one sex partner within the last six months those being evaluated or treated for an STI those with recent or current injection drug use those having exposure to a partner with a known hepatitis B infection health care workers household contacts of hepatitis B-infected individuals Acute maternal hepatitis B infection during pregnancy poses a high risk of mother-to-child transmission (up to 60% in the third trimester). These infants have a 70% to 90% risk of chronic hepatitis B infection. Immunization of susceptible pregnant women is highly immunogenic (84%– 100%) and effective to confer anti-HBs to the newborn (60%–100%). Hepatitis B is not transmitted across the placenta, but is transmitted through maternal bodily fluids at the time of birth In midwifery scope of practice Screening in first trimester Smoking in pregnancy ○ Smoking during pregnancy is associated with complications for mother and baby including, gestational hypertensive disorders, low birth weight, growth restriction, and preterm labour. ○ Effects on the growing fetus While you are still pregnant, you are more likely to miscarry if you smoke to go into labour too early your water is more likely to break too soon. Your baby is more likely to be born small. After delivery, babies whose mother’s smoked during pregnancy are more likely to have Sudden Infant Death Syndrome (SIDS) ○ Carbon monoxide from smoking binds to the fetal blood cells more strongly than oxygen decreasing how much oxygen is delivered to baby therefore affecting the ability of baby to grown and thrive. ○ Effects on lactation Both smoking and exposure to secondhand smoke appear to have an impact on the hormones related to breastfeeding, oxytocin and prolactin. This may cause a reduction in milk supply and may also reduce the fat level in the milk. Smoking during pregnancy can affect a baby’s ability to suck well in the first few weeks of life. If your baby is not sucking well, this may also impact your milk supply. This does not mean that you should not breastfeed your baby. It just means that you might want to take extra care to have a plentiful milk supply. You can do this by feeding often and making sure that your baby has an effective latch Mothers who use tobacco or e-cigarettes should be encouraged to quit; regardless, breastfeeding provides numerous health benefits and breast milk remains the recommended food for an infant. ○ How to manage and counsel regarding secondhand smoke The midwife should offer assistance for smoking cessation or reduction during pregnancy. Nicotine replacement therapy, including use of nicotine patches is safe. Stress and anxiety may be triggers for smoking, and therefore helping clients to develop alternate coping strategies through a personalized, supportive approach will be a key component in helping them achieve smoking cessation or reduction. Current evidence suggests that a combination of support groups with nicotine replacement therapy will provide the best chance of success for quitting. Pregnancy and lactation as two ideal times to promote tobacco and smoking cessation. ○ To minimize exposure to the infant, mothers and others who smoke should: not smoke near the infant. smoke outside. have smoke-free rules for the car and home. change clothes and wash hands after smoking and prior to handling the infant. Switch to e-cigarettes, nicotine gum or another nicotine replacement product. Smoke fewer cigarettes per day. If possible, quit smoking. Nurse your baby first and smoke immediately after. Then, if possible, wait two to three hours before nursing again. After smoking a cigarette, it takes 95 minutes for half of the nicotine in your system to be eliminated. If your baby wakes to feed in that 2 to 3-hour window, breastfeed, of course. Smoke outside or in a separate room. Change your clothes before handling your baby. (This is important for your partner to do too.) Home birth ○ Eligibility for client No pre-existing disease T1 diabetes, heart disease, etc No diseases occuring because of pregnancy Preeclampsia GDM with insulin Gestational hypertension No IUGR No macrosomia No active genital herpes No placenta previa/placental abruption Singleton fetus Cephalic presentation 37+1 and less than 42 weeks No more than one previous c-section Spontaneous or induced labour Hemoglobin over 100 ○ Eligibility for home: Distance for midwives Distance to hospital if transfer is needed OB unit or where MW has privileges Small or cluttered homes cause limitations for midwife to setup Difficulty for EMS to find home Children and someone to watch them during the birth and if TOC occurs Parking Staircase for EMS Narrow, steep or winding staircases impede emergency transfer ○ What to have NRP area: Good working surface area If no bureau that is wide enough, correct height – portable table (ask during HV at 37 weeks) Shoulder roll for baby Baby Stethoscope T piece hooked up Tank ready to turn on Laerdal Suction set up, plugged in when possible. LMA Timer O2 sat monitor with tape Towels/ blankets close by but not on work surface Cutting Board to sit 10 Lb baby Add to HB kit: Orogastric tube & syringe (zip lock) Extras (nice to have out but in precipitous birth not necessary) Heating pad inside the towels or on the NRP area, turned on Pair of gloves for 2nd RM out on NRP area Maternal supplies: Tray w/ birth instruments, oxytocin drawn up. Dopler & gel BP cuff/ stethoscope ○ Reasons to move into the hospital Abnormal FHR Meconium stained fluid Wanting pain relief (epidural) Oxytocin augmentation needed Dystocia in the 1st or 2nd stage Intrapartum hemorrhage Cord prolapse Fever (suspected chorioamnionitis) PPH Retained placenta Uteine rupture Abnormal newborn transition to extrauterine life Water birth ○ Guildeline for water immersion in labour and birth https://midwives.mb.ca/document/5756/guideline-for-water-immersion-in-l abour-and-birth.pdf Temp should not exceed 37.7 degrees Recommended Birth Pools and Components Portable pools designed and manufactured for use as birth pools for which the manufacturer has provided cleaning and disinfecting instructions. These pools should be used with liners. Single-use disposable pools. Pools with removable jets and a pipeless system. The pool should be deep enough for water immersion. Pools Not Recommended Pools/tubs with piped recirculating water systems of any type that have heaters, jets and/or overflow drains that cannot be easily cleaned. These features may harbor biofilms. ○ Examples include Spa-in-a-Box, Soft Tub, and jetted tubs in client’s homes. Client’s home baths are not recommended due to the presence of recirculating and heating systems in the tub as a place where biofilm develops If the client’s home bath is used for water labor or water birth, clean and disinfect the tub. A pool liner is highly recommended. Depth and Temperature of Water In order to facilitate the physiological response to water immersion and protect the infant from being born in the air and resubmerging into water, the water must completely cover the mother’s abdomen, but not reach to the level of her neck. The temperature of the water must be comfortable for the mother and below 100.4° F (38°C). This temperature is important to prevent maternal and fetal hyperthermia. The water temperature should be assessed before entry to the tub and after adding water and documented in the chart. Want the temperature to stay at maternal body temp There needs to be enough space around the pool so your midwife can reach you and baby from multiple angles benefits : Non-pharmacological method of pain relief Provides buoyancy which supports movement Creates a relaxing environment which supports the physiological process of labour Increases client ability to cope with pain Increases client satisfaction of birth experience Decreases use of analgesia Decreases labour augmentation rate Decreases operative birth rate Reduces risk of 3rd or 4th degree perineal tearing Risks Risks of infection and temperature control issues for both the client and the baby are directly related to cleaning/hygiene protocols and/or improper management of temperature control of the water Can cause prolonged labour if entering water before active labour is established Maternal dehydration Blood loss estimation and assessment may be more difficult in water CONTRAINDICATIONS FOR WATER IMMERSION IN LABOUR AND BIRTH Intrapartum hemorrhage Abnormal or atypical fetal heart rate Use of fetal scalp clip Gestation of less than 37 weeks Maternal temperature of 37.5°C or higher Presence of maternal infection transmitted through fluid or blood, such as Hepatitis B or C, or HIV The baby has known defects involving the vagus nerve, such as cardiac disorders or defects of the larynx, respiratory or abdominal organs Epidural Narcotic sedation within 2 hours Client unable to get in or out of the pool independently ○ Levels of hospitals ○ Level 1 GA ≥ 36 weeks and 0 days Provides planned neonatal services to low risk newborns at ≥36 weeks in a mother/baby dyad care model; including minor transient conditions related to physiological adaptation. Provides postnatal care of newborns including education and support for parenting, bonding, feeding and lactation. Documented process in place for consultation and referral to higher level of care Low risk ○ Level 1a GA ≥ 36 weeks and 0 days Singleton pregnancies with cephalic presentation. Low risk pregnancies. Caesarean section may not be available. Birthing person should be informed that in the case a caesarean section is required, they may have to be transferred to a centre that can perform this procedure. Assesses available resources and completes consultation prior to use of oxytocin for augmentation and induction. Labour analgesia (example: PCA narcotics or nitrous oxide) a. Electronic Fetal Monitoring b. Outlet vacuum assisted vaginal delivery c. Administration of blood products d. Designated Level 1 for neonatal care ○ Level 1b GA ≥ 36 weeks and 0 days Singleton pregnancies. Low risk pregnancies. Hospital can provide caesarean section which would allow for a planned birth for a person who may be 1) requiring induction of labour and 2) at a higher risk for caesarean section. Labour analgesia (example: PCA narcotics or nitrous oxide) Electronic Fetal Monitoring Outlet vacuum assisted vaginal delivery Administration of blood products Augmentation and Induction of Labour Caesarean Section D&C Designated Level 1 for neonatal care ○ Level 2a GA ≥ 34 weeks and 0 days and a birth weight of > 1800 grams Singleton pregnancies. Uncomplicated dichorionic twin pregnancies. For a twin pregnancy and gestational age that is < 36 weeks and 0 days, consider consultation and transfer. Low-risk pregnancies. Moderate-risk pregnancies can be considered with appropriate consultation. Labour analgesia (example: PCA narcotics or nitrous oxide) Regional anaesthesia Electronic Fetal Monitoring Outlet vacuum assisted vaginal delivery Administration of blood products Augmentation and Induction of Labour Caesarean Section D&C Designated Level 2a or higher Neonatal Intensive Care Unit ○ Level 2b ≥ 32 weeks and 0 days and a birth weight of > 1500 grams Singleton pregnancies. Uncomplicated dichorionic twin pregnancies. For a twin pregnancy and gestational age that is < 34 weeks and 0 days, consider consultation and transfer. Low-risk pregnancies. Moderate-risk pregnancies can be considered with appropriate consultation. Labour analgesia (example: PCA narcotics or nitrous oxide) Electronic Fetal Monitoring Outlet vacuum assisted vaginal delivery Administration of blood products Augmentation and Induction of Labour Caesarean Section D&C Regional anaesthesia Designated Level 2b or higher Neonatal Intensive Care Unit ○ Level 2c ≥ 30 weeks and 0 days and a birth weight of > 1200 grams Singleton pregnancies. Low and moderate risk pregnancies. Uncomplicated dichorionic or monochorionic twin pregnancies. For a twin pregnancy and gestational age that is 95% in the right hand or foot AND there is a 3% difference between the hand and foot. A result of