Normal-Childbearing-Blackmarket-Textbook (1).pdf

Normal Childbearing Winter 2016. Blackmarket demi-textbook. Learnin’! by the class of 2018 Table of Contents Prenatal Indications for Consultations and Transfer of Care (TOC) GTPAL/GP Common Discomforts in Pregnancy Respiratory Changes in Pregnancy Cardiovascular Changes in Pregnancy Normal Bleedi...

Normal Childbearing Winter 2016. Blackmarket demi-textbook. Learnin’! by the class of 2018 Table of Contents Prenatal Indications for Consultations and Transfer of Care (TOC) GTPAL/GP Common Discomforts in Pregnancy Respiratory Changes in Pregnancy Cardiovascular Changes in Pregnancy Normal Bleeding in Pregnancy Hb values and Blood volume Iron Supplementation Nausea/Diclectin Prenatal Vitamins Folic Acid Supplementation Nutrition and Exercise Symphysis-Fundal Height (SFH) Measurement Leopold’s Manoeuvres Routine Blood Work in Pregnancy Vaginal Laboratory Tests Urine Laboratory Tests Asymptomatic Bacteruria/UTIs. Gestational Diabetes Group B Streptococcus ABO/Rh and RHIG procedures Common Skin Conditions Dermatomes of Pregnancy Intrahepatic Cholestasis of Pregnancy Dating by LMP Post-dates and Prolonged Pregnancy Termination of Pregnancy Fetal Heart Auscultation Fetal Movement Counts Non-Stress Tests (NST) Biophysical Profiles (BPP) Uterine Artery Doppler Trimester One Ultrasound/Dating Ultrasound Trimester Two Ultrasound/Anatomy Scan First Trimester Screening (FTS) Integrated Prenatal Screening (IPS) Serum Integrated Prenatal Screening (SIPS) Maternal Serum Screening (MSS)/Quadruple Screen Chorionic Villus Sampling (CVS) Amniocentesis Teratogenic Exposure Smoking Alcohol 5 6 6 11 12 14 14 14 15 16 17 17 18 19 20 20 21 22 22 23 24 25 26 26 27 28 29 29 30 30 31 32 33 33 34 35 35 35 36 36 37 38 38 2 Parvovirus B19 Varicella-Zoster/VZIG Rubella Uterine Fibroids Pregnancy Induced Hypertension (PIH) Preeclampsia Intrapartum Initial Labour Assessment Preterm Labour (PTL) Phases of Labour Prelabour Rupture of Membranes (PROM) Meconium Stained Fluid Intermittent Auscultation (IA) Electronic Fetal Monitoring (EFM) Vaginal Exams in Labour (VE) Fetal Lie Fetal Presentation Fetal Attitude Fetal Position Fetal Engagement Cervical Ripening/Bishops Score Labour Augmentation Induction of Labour (IOL) Cervical Change in Labour Cardinal Movements Placental Location Occiput Posterior (OP) Position Premature Urge to Push Precipitous Labour Management of the 3rd Stage Uterine Involution Placental Examination Cord Blood Gases Perineal Lacerations Episiotomy Perineal Repair Levels of Hospital Care Homebirth Water Birth Vaginal Birth after Cesarean Section (VBAC) Non-Pharmacological Pain Relief Nitrous Oxide (N202) Pudendal Block 39 40 41 41 42 43 45 45 46 46 47 48 49 52 52 52 53 53 54 54 55 55 56 57 57 58 59 60 60 61 61 62 64 64 65 65 65 66 67 67 68 69 3 Narcotics Epidural Cesarean Section (C/S) Nutrition in Labour 69 70 71 71 Postpartum Normal Maternal Vitals Lochia Postpartum Hemorrhage (PPH) Perineal Healing Breastfeeding Engorgement Blocked Ducts Mastitis Contraception Postpartum Depression (PPD) PAP test 72 72 72 73 74 75 75 76 76 77 77 Newborn APGAR scores Newborn Transition Newborn Vitals Neonatal Resuscitation Respiratory Distress Transient tachypnea of the newborn Skin to Skin Newborn Exam Newborn Skull Gestational Age Assessment Murmurs Reflexes Red Reflex Hypoglycemia Jaundice Birthmarks Vitamin K Prophylaxis Erythromycin Eye Ointment Vernix Common Newborn Rashes Umbilical Cord Care Newborn Bathing Normal Output Tongue Ties 80 80 80 81 82 84 84 84 86 86 87 89 89 89 89 92 93 94 94 94 95 95 96 96 4 Newborn Screening (NSO) Normal Weight Loss and Gain Co-Sleeping SIDS Formula Feeding Regurgitation Heb B Immuniglobulin Thrush Rx Examples Prenatal Vitamins Dimenhydrinate Diphendydramine Hydrochloride Compression Stockings Diclectin Clotrimazole Macrobid TMP TMP/SMX Cephalexin Cloxacillin Clindamycin Amoxicillin-clavulanic acid Acetaminophen Ibuprofen Naproxen Acetyl-Salicylic Acid Domperidone APNO 96 97 99 99 100 100 100 101 102 5 Prenatal Indications for Consultation and TOC Consultation with a physician or other health care provider • Why: get advice and information on plan of care • Midwife still most responsible provider but may be transferred to consulting physician depending on outcome of consultation Transfer responsibility of woman and/or newborn’s primary care to a physician • Why: appropriate care is out of midwife’s scope • What: client remains primary decision-maker, midwife remains involved in care (i.e. supportive care) and may resume primary responsibility if condition for transfer is resolved Examples: Initial History and Physical Exam • Consult: history of: cervical cerclage, >1 T2 spontaneous abortion, ≥3 consecutive T1 spontaneous abortions, >1 preterm birth, preterm birth <34+0 in last pregnancy, >1 SGA infant, previous severe hypertension/preeclampsia/eclampsia/HELLP, previous neonatal mortality or stillbirth • Transfer: cardiac or renal disease, insulin-dependent diabetes mellitus, HIV positive Prenatal Care • Consult: twin, gestational hypertension, conditions unresponsive to treatment (i.e. anemia, UTI), asymptomatic placenta previa • Transfer: molar pregnancy, multiple pregnancy (not twins), severe hypertension/pre-eclampsia/eclampsia/HELLP, placental abruption or symptomatic previa Labour, Birth and Immediate Post Partum • Consult: PROM 34+0 to 36+6, twins, breech, hypertension, abnormal FHR pattern, retained placenta, 3rd or 4th degree laceration • Transfer: HIV positive, preterm labour <34+0, prolapsed or presenting cord, placental abruption, placenta previa, vasa previa, uterine rupture or inversion Post Partum • Consult: uterine prolapse, secondary postpartum hemorrhage, breast infection or UTI unresponsive to therapy, persistent bladder or rectal dysfunction • Transfer: postpartum eclampsia or psychosis Infant • Consult: 34+0-36+6 gestational age, suspected infection, in utero exposure to significant drugs/alcohol, prolonged PPV/resuscitation, feeding difficulties, doesn’t pass urine or meconium within 36 hours, jaundice within 24hrs, vomiting or diarrhea, persistent respiratory distress/cyanosis/pallor, fever, hypothermia, single umbilical artery, <5% in weight for gestational age, hypo-/hyper-glycemia, abnormal HR/pattern/murmur • Transfer: major congenital anomaly requiring immediate intervention 6 GTPAL/GP • G • T • P • A • L • • G P Gravida (number of pregnancies. incl. current) Term (number of births at >37 weeks) Preterm (number of births between 20 and 37 weeks) Abortuses (spontaneous or therapeutic abortions <20 weeks) Living (number of living offspring) Gravida (number of pregnancies. incl current) Parity (number of births) Common Discomforts of pregnancy Headaches Physiology: Increased vasodilation from progesterone causes • Increased pressure causing headaches • Increased dilation in nasal/sinus capillaries causing congestion Differential Diagnosis: PIH headaches, migraines. • Any history of migraines? • Any visual disturbances, epigastric pain, excessive swelling in hands or feet, rapid heartbeat, dizziness, nausea/vomiting? Non-Pharmacological Remedies • Headache diary, to help identify potential triggers and guide lifestyle changes if necessary. • Preventative measures: eating well, eating regularly, hydration, being well rested, exercising. • Relaxation techniques: massage, bath, warm bean bags, acupuncture, aromatherapy • To relieve congestion: steam, neti pot (saline rinse), hydration, patience. Pharmacological Relief • Acetaminophen/Tylenol (Motherisk) • If congestion is unbearable, safe OTC antihistamines to use include: Claritin, Benadryl, Tylenol Dizziness/Fainting Physiology: Low blood sugar, low iron, low blood pressure– decrease in systemic vascular resistance decreases blood flow above the waist, causing lack of blood flow to the brain = dizziness. Differential Diagnosis: Anemia/ PIH • Feeling very tired lately? Out of breath? • Are you eating/drinking frequently enough? • Blurred vision with persistence dizziness may be associated with PIH. Non-Pharmacological Remedies (ø pharm tx) • Small frequent meals, ↑protein • Increasing dietary iron (iron supplementation 7 Increasing hydration Getting up slowly from sitting/lying down Strategies when feeling dizzy – deep breaths, sit down, head between knees if possible, Clinical Follow-up: • Blood work to check iron/sugar levels if symptoms persist • • • Heartburn Physiology: Progesterone relaxes cardiac sphincter, which results in acid reflux/esophageal irritation Non-Pharmacological Remedies • Small frequent meals – q90 minutes • No washing down food with water • Sleeping propped up in semi sitting position • Avoiding foods which decrease sphincter control – chocolate, caffeine etc. Pharmacological Relief • Antacids safe in pregnancy (Motherisk) o Proton Pump Inhibitors: Losec, Pantoloc, Tecta, Prevacid, Nexium, Pariet o Histamine antagonists: Tagamet, Zantac, Pepsid, Axid o Magnesium, calcium, aluminum based antacids – Tums, Rolaids, Maalox. *Antacids containing bicarbonate are contraindicated –acidosis, fluid overload. Back Pain Physiology • Loosening/shifting of the pelvic ligaments resulting from hormonal flux in pregnancy can be associated with back pain • Lordosis associated with change in center of gravity, and the weight of the uterus and baby at the front of the woman’s body can cause back pain. Non-Pharmacological Remedies • Warm baths (with or without Epsom salts) • Paying close attention to body mechanics when lifting, bending, doing regular activities • Chiropractic adjustments • Massage • Support belt Pharmacological Remedies • Tylenol/Acetaminophen Pelvic Pain Physiology: • The round ligament connects the uterus to the groin – ligaments are just a bit less flexible than muscles. The stretching of the round ligament as the uterus grows can be a cause of abdominal/hip pain. The effects of progesterone on the 8 ligaments of the pelvis can result in discomfort associated with the movement of the pubic symphysis and related structures. Non-Pharmacological Remedies: • Using a belt/scarf to provide support and stabilize the pubic symphysis • Changing positions slowly – sitting up, standing, twisting etc. Paying attention to body mechanics. • Stretching exercises if the pain is consistent – on hands and knees, lowering head to the floor and leaving bottom in the air (downwards dog position). Nausea/Vomiting Physiology: Progesterone slows the passing of food through the GI tract. Nausea from low blood sugar. Non-Pharmacological Remedies • Discontinuation of PNV if not well tolerated, break down supplements into individual pills etc. • Diet diary to identify trigger foods – avoiding spicy, acidic, greasy foods etc. • Ginger – Gingins, ginger tea, sips of ginger ale (beware the sugar) • Small frequent meals – eating something plain before you get out of bed, crackers or dry cereal. • Drinking ½ after eating, instead of simultaneously • Staying hydrated and well rested • No napping after meals Pharmacological Remedies • Gravol • Diclectin – Rx needed • Vitamin B6 – comes in diclectin too. Constipation Physiology: Decreased gut motility due to influence of progesterone Non-Pharmacological Remedies • ↑Hydration • Increase in dietary fibre • Regular exercise Pharmacological Remedies • Fibre supplementation – Metamucil • Adjusting iron supplementation – if taking pills, thinking about liquid iron/floradex (less GI effects) Swollen Feet/Ankles Physiology: Increased blood volume and vasodilation results in decreased venous blood return (esp. below the waist) results in edema in the tissues of the lower extremities. Differential Diagnosis: PIH/Pre-ecclampsia • Is the swelling accompanied by any other signs/symptoms of PIH? Non-Pharmacological Remedies 9 • • • Reduce sodium intake to reduce water retention Elevating feet Swimming can equalize pressure and redistribute water around the body Varicose Veins Physiology: Increased blood volume and vasodilation results in decreased venous blood return (esp. below the waist) which causes the pooling of blood in veins. Non-Pharmacological Remedies: • Avoiding standing/sitting with legs crossed • Elevate feet at the end of the day • Massage • Regular exercise • Reducing sodium intake • Support stockings – available below the knee, above the knee and full, to the waist – requires Rx Frequent Urination Physiology: • 1st Trimester – (as early as 5 weeks) a combination of the uterus expanding, but not yet out from under the pubic bone, compressing the bladder and hormonal changes that ↑GFR (↑blood flow through the kidneys = ↑urine production) • Relief often in the 2nd trimester • 3rd Trimester – displacement from uterus/baby, dilation of vessels, ↑GFR Differential Diagnosis: UTI • Hx of UTI? • Any pain/burning upon urination? Any blood? • Any abdominal or flank pain? • Any fever/ general unwellness? Relief? • When not accompanied by any signs of infection, frequent urination is normal and not harmful. • Remind women to continue to keep hydrated, despite frequent urination. Braxton Hicks Physiology: • Called “practice contractions” because it is suspected that they help to tone the uterine muscles and improve uterine blood flow (American Pregnancy Association) Differential Diagnosis: Preterm Labour • Investigating/outlining the difference between preterm labour and Braxton Hicks contractions can help to alleviate women’s anxiety about them. Braxton Hicks Preterm Labour • Tightening of uterine muscles – • Uterine cramping at the bottom often uncomfortable, but of the uterus, or along the lower 10 • • • sometimes painful Can respond to mat. or fetal movement Can become regular, but do not usually increase in length or strength “practice contractions” • • • back – akin to menstrual pain Independent of mat/fetal movement Come with increasing regularity, length and strength Not practice at all – may be accompanied by blood or fluid P.V. Non-Pharmacological Remedies • Take a warm bath • Relaxation – meditation etc. • Gravol to relax and get some sleep Trouble Sleeping Physiology: Hormone cycles during pregnancy affect the circadian rhythms. Frequently, women report trouble sleeping between the hours of 3-5am, when prolactin hormones spike. Non-Pharmacological Remedies • Acceptance of body’s current circadian cycle. It’s normal, counsel clients not to fight it, to try not to feel frustrated, resentful or dismayed about it. Accepting it can make a difference in mentality. • Compensate with naps if possible – don’t feel guilty about taking them! • Taking the time to do quiet things, relaxation, reading, yoga, meditating when awake in the night. Muscle Cramps Physiology: An involuntary contraction of the muscle resulting in sharp pain. Caused by dehydration, pregnancy-associated changes in blood flow, overuse, nerve compression (sciatica) or lack of minerals. Non-Pharmacological Remedies • Stretch and/or massage the affected muscle • Heat/cold therapy for relief • Bath with or without Epsom salts • ↑hydration • Incorporating potassium rich foods in diet – bananas, kiwi, cantaloupe. Pharmacological Remedies • Supplemental potassium, magnesium. Carpal Tunnel Syndrome • Effects the narrow channel in the wrist on the palmar side, proximal to the hand. • Contains the median nerve which is covered by a sheath of tough connective tissue called the flexor retinaculum 11 • • • • The median nerve provides sensation to the palm and the palmar surface of the thumb. Compression of the median nerve may result in numbness or pain in these areas. Pregnant women are more susceptible to carpal tunnel syndrome because of fluid retention – especially in T3 – that leads to the compression of the median nerve. Usually resolves at the end of pregnancy but is likely to reoccur with subsequent pregnancy Elevation of the wrist and splinting to keep the wrist straight may help with symptoms. Respiratory Changes in Pregnancy • Tidal volume increases by about 200 ml, increasing vital capacity and decreasing residual volume. In later pregnancy, splinting of diaphragm may occur with some decrease in tidal volume • Respiratory rate does not alter significantly; increased oxygen consumption by approximately 20% • State of compensated respiratory alkalosis- arterial pCO2 drops, arterial pO2 remains unchanged and decrease in bicarbonate prevents pH change. Lower maternal pCO2 facilitates oxygen/carbon-dioxide transfer to/from fetus. • Many women complain of feeling short of breath in pregnancy without specific pathology; mechanism remains largely understood. • Hormonal changes to mucosa of respiratory tract lead to capillary engorgement and swelling of lining in nose, oropharynx, laryngopharynx and trachea. Symptoms of nasal congestion, voice change and upper respiratory tract infection may occur throughout gestation. Symptoms can worsen due to edema associated with pregnancy-induced hypertension (PIH) or preeclampsia. • Airway resistance is reduced, possibly due to progesterone-mediated relaxation of bronchial musculature • Upward displacement by uterus causes 4 cm elevation of diaphragm, but total lung capacity decreases only slightly because compensatory increases in diameters of chest, as well as flaring of ribs (brought on by hormonal changes that loosen ligaments) • During labour, oxygen consumption further increased (up to and over 60%) as result of exaggerated cardiac and respiratory work load. Cardiovascular Changes in Pregnancy • The heart is divided into four compartments: the right atrium, the right ventricle, the left atrium, and the left ventricle. • The left ventricular wall is thicker than the right ventricular wall. • The left ventricle is responsible for pumping blood into the systemic circulation, and the right ventricle is responsible for pumping blood into the pulmonary circulation. Blood leaves the heart through both the aorta and the 12 • • • • • • • • • pulmonary arteries. Blood enters the heart through the right and left pulmonary veins and the inferior and superior vena cava. The cardiac cycle consists of systole and diastole. Systole is the phase of myocardial contraction, whereas diastole is the period of dilation or rest between contractions. During diastole, the pressure in the heart is lower than in the aorta, and the initial backflow regurgitation of the blood closes the aortic valve. S1 is the first heart sound. It is heard during systole. The sound is made by the closing of the mitral and tricuspid valves. S2 is the second heart sound. It occurs during diastole. This sound represents the closure of both the aortic and pulmonary valves. During pregnancy, cardiac output is increased. A reduction of systemic vascular resistance leads to reduced systemic blood pressure. The heart is displaced laterally and to the left because of the growing uterus and displacement of the diaphragm. Blood volume increases by up to 50% due to increased sodium and water retention. An increase in plasma volume and red blood cell mass begins as early as the fourth week of pregnancy and peaks between the 28th and 34th week. The expansion of plasma volume is accompanied by a smaller increase in red cell volume. This discrepancy between the plasma volume and red cell volume results in a physiological anemia in pregnancy Mammary soufflé: Because of the increased blood volume and cardiac output, many pregnant women will develop a systolic murmur that will resolve shortly after they give birth. Varicose veins may develop as progesterone causes the blood vessels to relax and the growing uterus compresses veins running through the pelvic region, compromising venous return from the legs. Predisposition to varicose veins in pregnancy may be influenced by genetics, obesity, or previous damage to vessel walls. 13 Normal Bleeding in pregnancy • Implantation bleeding may happen when the fertilized egg attaches to the lining of the uterus. Occurs approximately 14 days after fertilization, around the time someone would expect their period. Usually lighter and shorter than a period. • During pregnancy, the cervix becomes increasingly vascularized as blood volume increases. Spotting is normal in pregnancy, especially after strenuous physical activity or intercourse. • Chadwick’s sign is a bluish discoloration of the cervix, vagina and labia that results from increased vascularization. It can be seen as early as 6-8 weeks after conception, and is considered an early sign of pregnancy Hb and Blood volume • The total blood volume increases during pregnancy by 30-50%. The timing of peak average is at 32 weeks and average amount of 5500 mL. This compares with the non-pregnant average blood volume of 4000mL. • Blood volume increase is essential in order to: o Meet the demands of the enlarged uterus with a significantly hypertrophied vascular system and provide extra blood for placenta perfusion o Supply extra metabolic needs of the fetus o Protect the woman and fetus against harmful effects of impaired fetus return o Provide extra perfusion of maternal organs o Counterbalance the effects of increased arterial and venous capacity o Safeguard against adverse effects of excessive maternal blood loss at birth • As blood volume increases, the production of red blood cell also increases by ~18%. This occurs due to increased levels of erythropoietin stimulation by maternal hormones and oxygen requirements of maternal and placental tissue, but does not follow in the same degree of quickness as volume, resulting in a state of “physiologic anemia” (low hematocrit and Hb). This trend can be seen most after 30 weeks when the plasma volume has plateaued. • WHO defines anemia as hB <110 g/l in T1 and T3 and <105 g/l in T2. • Many midwives will not recommend a home birth if Hb is <105 g/l. Being low in iron and Hb does not cause you to have a postpartum hemorrhage but it can worsen its impact and how your body deals with it. Iron Supplementation. • Most iron stores in the body are found in hB and myoglobin. hB carries oxygen in the blood. • Due to changes in plasma ratio, hB concentration in pregnancy averages 12.5 g/dL. hB is measured in routine CBCs. 14 • • • • • • • • • • Anemia in pregnancy is defined as hB levels below 11.0 g/dL In most cases, the placenta ensures that the fetus is receiving adequate iron regardless of maternal anemia. Severe anemia may increase the risk of preterm birth and low birth-weight infants. RDA for iron in pregnancy = 27mg. rec. daily supplement containing 16-20 mg of iron. PNV are often adequate. Heme iron is the most bioavailable. Found in meat, poultry and fish. Non-heme iron is most abundant in our diets. Found in eggs, green leafy veg, nuts, black strap molasses, etc. Polyphenols from tea and coffee, and calcium at the levels found in dairy products can inhibit the uptake of non-heme iron, while vitamin C can increase its absorption. Additional supplementation may be required if hB counts are low or symptoms of anemia are present (fatigue, pale skin, dizziness). Adverse effects include GI reactions - constipation, dark stools, nausea, vomiting, cramping, diarrhea, or heartburn. May cause staining of teeth. Palafer: Rapid release iron supplementation binds to ferritin carrier protein and increases serum iron levels replacing iron found in hemoglobin and enzymes. Onset of action: 3-10 days, with peak effect showing hB increase in 2-4 weeks. Dose: 100-200 mg elemental iron PO BID Feramax: polysaccharide iron complex is absorbed at pH of 4.o or lower and closely resembles the body’s carrier protein ferritin, increasing its bioavailability. The elemental iron contained in the supplement increases serum iron levels replaces iron found in hemoglobin and enzymes. Onset of action: 3-10 days, with peak effect showing hB increase in 2-4 weeks. Dose: 150mg of elemental iron PO QD. Venofer: Onset of action: 5-10 days, with peak effect showing hemoglobin value increase within 2-4 weeks. Metabolism: dissociated into iron and sucrose by the reticuloendothelial system. Dose: 200 mg elemental iron IV =, administered on 5 different occasions over a 14 day period. Total cumulative dose: 1000mg in 14 days. Nausea and Diclectin • Nausea and vomiting affects 50-90% of women in pregnancy. • First trimester nausea usually resolves around week 12. • The most severe form of NVP is commonly referred to as hyperemesis gravidarum (HG) (occurs in 1% of pregnancies). HG, defined as persistent vomiting that leads to weight loss greater than 5% of pre-pregnancy weight, with associated electrolyte imbalance and ketonuria • Pathogenesis of NVP is poorly understood and etiology likely multifactorial • No evidence to prove effectiveness of dietary changes on relieving NVP symptoms • No evidence that short-term dietary deficiencies during early weeks of preg will have long-term consequences on pregnancy outcome 15 • • • • • NVP thought to be related to the exponential increase in beta-hcg until 20 wks and resolves when hcg plateaus. Use of vitamin supplements encouraged even if woman unable to tolerate PNV, important to maintain folic acid until neural tube closes Sleep requirements increase in early preg, fatigue seems to exacerbate NVP – women should be encouraged to increase their rest, esp when symptomatic Women may take 50 – 100 mg dimenhydrinate (gravol) PO q4-6 hours. May help with fatigue. If nausea and vomiting is severe, gravol is available as a PR suppository. Doxylamine succinate-pyridoxine hydrochloride (Diclectin) o doxylamine succinate (10mg) (histamine) + pyridoxine hydrochloride (10mg) (form of vit B6) o anti-nauseant/anti-emetic o DOSE: 20 mg tablets po; one tab in morning, one midday and two at bedtime (max dose 8/day) o Take the dose regimented because the goal is to elevate the background level at all times, most women are most nauseated in the AM which is why 2 pills taken in the evening is recommended o Peak serum is 2-3 hr, acts for 4-6 hrs o Weaning: go slow! Take away the afternoon dose first (keeping 1 pill in the AM and 2 pills in the PM), then take away one of the evening pills, then take away morning pill, then take evening one every other night, then nothing. Many women have to go back on. Prenatal Vitamins • Recommended that women take a prenatal vitamin (PNV) 3 months before conception, throughout pregnancy, until cessation of breastfeeding. • Folic Acid: >0.4mg for the prevention of NTD and encouragement of healthy cell division. • Vit B12: >2.6 IU for the prevention of anemia/deficiency. Important component if taking folic acid as deficiency can be masked. • Ca: >150 mg for bone growth • Fe: > 27 mg for the prevention of anemia and encouragement of efficient oxygenation. • I: >150 mcg aids in thyroid/brain development. • Vit B6: >1.9 mg helps with morning sickness • Omega 3 FA: if not sufficient in diet for the promotion of brain development • Vitamin D: > 600 IU. Not always included in PNV but very important supplementation. Promotion of Ca uptake and bone development. Studies linking Vit D deficiency and MS later in life. Maternal benefits such as prevention of osteoporosis post-menopause. • Pregvit contains 1.1 mg of folic acid. Pregvit Folic 5 contains 5 mg of folic acid. 16 Folic Acid Supplementation • A water soluble vitamin • Benefits: plays a role in preventing neural tube defects as well as other folic-acid sensitive anomalies such as heart defects, urinary tract anomalies, oral facial clefts, and limb defects. Other possible benefits include a reduction in ovarian cancer and decreased incidence of preeclampsia. Possible reduce incidence of autism. Highest benefit is before conception • Risks: High dose (5 mg) may be associated with increased incidence of asthma and increased incidence of lip and tongue ties, but evidence is poor. • Recommendations from 2015 SOGC guideline: o Low Risk à no maternal or paternal personal or family history of health risks for folic acid-sensitive birth defects o Moderate risk à Maternal or paternal personal or family history any of the following folate sensitive congenital anomalies: cardiac, limb, cleft palate, urinary tract, or congenital hydrocephaly Maternal or paternal first or second degree relative with a NTD Maternal type I or II diabetes and RBC folate < 906 Maternal teratogenic medications that inhibit folate including: anticonvulsants, metformin, methotrexate, sulfasalazine, triamterene, trimethoprim, and cholestryamine Maternal GI malabsorption conditions including: Crohn’s or Celiac disease, gastric bypass surgery, liver disease, kidney dialysis, alcohol overuse o High risk à maternal or paternal personal NTD history or NTD in previous pregnancy Risk Category Low Moderate High 3 months preconception – 12 wks 0.4 mg 1.0 mg 4.0 mg >12 wks until 4- 6 wks postpartum and throughout breastfeeding 0.4 mg 0.4 – 1.0 mg 0.4 – 1.0 mg Nutrition, Exercise, and Healthy Weight Gain. • Energy requirements only increase by ~ 20% in pregnancy. (~350 Kcal/day) • Iron requirements increase due to increased blood volume and fetal needs, especially in trimester 3. • Calcium intake should be 1000 mg/day • Protein intake should be 60-80 g/day • Maintaining an active lifestyle in pregnancy is beneficial, within the comfort level of the client. Continuing with preferred methods of exercise is fine as long as it remains comfortable. It is not recommended to introduce new high 17 • • • • • impact exercise in pregnancy. Low impact exercises that may be introduced include swimming, prenatal yoga, and walking. Physiological changes in pregnancy and the growth of baby account for a large proportion of gestational weight gain. The mother will gain up to 8 lbs in extra blood volume, 7 lbs in extra breast tissue and fat stores, 2 lbs of uterine muscle, and 2 lbs of amniotic fluid, plus the weight of the baby averaging between 6 and 9 lbs. This accounts for approx. 27 lbs of healthy pregnancy weight gain. Calculating BMI = weight in Kg / height in meters (squared). Horribly flawed as it does not take into consideration metabolic health or muscle mass. The above chart is a guideline only. Women with higher BMIs may lose weight in pregnancy due to healthier living and maintain a perfectly healthy pregnancy. Women with hx of eating disorders- may be beneficial to abstain from tracking weight throughout pregnancy and focus on healthy lifestyle. Symphysis-Fundal Height (SFH) Measurement • Measurement that tracks fetal growth by measuring from the symphysis pubis to the fundus. • Commonly used after 20 weeks gestation, when the fundus has reached the umbilicus. • With normal fetal growth, the SFH will correspond to the gestational age +/2 cm. • Useful as a “rule of thumb” estimation tool. Subject to baby’s position, maternal anatomy, and practitioner variability. • Best used to track growth progress along a growth curve over a pregnancy by charting SFH progress. If growth by SFH falls off the growth curve, or is plotting between below the 10th % or above the 90th %, further investigation (U/S) may be warranted. 18 Leopold Manoeuvres. • • • • • • • • • Fundal Palp. (helps to determine lie and presentation) – determines presence of bum (breech) or head in the fundus. Sometimes bum feels firm, but it is not as hard, smooth or well-applied as a head. Head with have increased blottability compared to the sacrum. Lateral palp. (used to locate fetal back to determine position) both hands placed on either side at the level of the umbilicus; back = continuous, smooth, resistant mass from breech to neck, and the other side, limbs are small parts that slip about under examining fingers Pelvic palp. used to identify the presentation / pole of the fetus in the pelvis woman should bend her knees slightly to relax abdominal muscles and also suggest steady breathing – sighing out slowly may help with relaxation. The sides of the uterus below the umbilicus are grasped with fingers pointing downwards and inwards. If the head is presenting, a hard mass with a distinctive round smooth surface will be felt – use this opportunity to determine how much of the fetal head is palpable above the pelvic brim to determine engagement – if not engaged PP will move freely above pelvic brim Pawlicks Maneuver (used to judge size, flexion and mobility of the head) 19 Routine Blood Work in Pregnancy: • Initial: CBC, ABO and Rh investigation, Abs. PH blood work – Rubella, Syphilis, HIV, Hep B. • T3 (28 weeks): Repeat CBC for hB levels, Abs. • Additional blood work based on risk factors: 8-20 weeks – hB electrophoresis (thalassemia, sickle cell), Purified protein derivative, tay sachs, hep c. Repeat CBC for hB and ferritin levels as indicated. • 24-28 weeks – 50g OGCT, 70g OGTT. Vaginal Laboratory Tests Bacterial vaginosis (BV) • • • • • • • In symptomatic pregnant women, testing for and treatment of BV is recommended for symptom resolution. Treatment with either oral or vaginal antibiotics is acceptable for achieving a cure in pregnant women with symptomatic bacterial vaginosis who are at low risk of adverse obstetric outcomes. Asymptomatic women and women without any risk factors for preterm birth should not undergo routine screening for or treatment for BV. Women who are at increased risk for PTL may benefit from routine screening. BV is associated with PTL, PPROM, chorio, post c section deliveries, subclinical PID. Treatment 1st line: Metronidazole 500 mg BID PO x 7 days. Testing for cure should be repeated one month after treatment to ensure that the cure was achieved. Diagnosis of BV is made of ¾ of the following signs if present: an adherent and homogenous vaginal discharge, vaginal pH > 4.5, detection of cue cells on saline wet mount and an amine odour after the addition of potassium Testing: swabbed for in the posterior vaginal wall Complaints: discharge, bad odour after intercourse. Discharge: thin, homogenous. Colour: white or gray. Odour: fishy. Yeast • It affects 75% of women at least once. Topical and per vaginum (recommended in pregnancy) and oral antifungal azole medication are equally effective. Boric acid has been associate with a greater than 2-fold increased risk of birth defects when used during the first 4 months of pregnancy and should thus be avoided during this time. Recurrent vulvovaginal candidiasis is defined at 4 or more episodes a year. • Complaints: discharge, burning, itching, erythema and edema. External dysuria and dyspareunia may also occur. Discharge: cottage cheese, white. Odour: absent • Diagnosis requires a pelvic examination. The combination of thick white discharge and vulvar pruritis is neither sensitive nor specific on its own for diagnosis. When there is evidence of complicated VVC, collection of vaginal fluid for culture and yeast speciation may help to direct therapy because there is an increased likelihood of non-albicans strains in such cases. • Risk factors: sexual activity, recent antibiotic use, pregnancy, immunosuppression from such conditions such as poorly controlled HIV or diabetes. STI: Chlamydia and Gonorrhea: • Universal screening is recommended (urine sample or swab in cervical os), but some clinicians only elect to screen those at risk. CDC recommendation: First prenatal visit: Screen all pregnant women <25 years of age and older pregnant 20 • • • • • • women at increased risk for infection. Third trimester: Rescreen if <25 years of age or at continued high risk. Risk Factors: New or multiple sex partners, sex partner with concurrent partners, sex partner who has a sexually-transmitted disease (STD). Pregnant women found to have chlamydial infection should have a test-of-cure three to four weeks after treatment and then be retested within three months. Women who have chlamydia during pregnancy tend to have higher rates of infection of the amniotic sac and fluid, PTL, and PPROM. Some studies have linked chlamydia to an increased risk of miscarriage, although other studies have found no connection. Up to half of babies born vaginally to mothers with untreated chlamydia (and even some babies born by c-section) will contract the infection. Between 25 to 50 percent of these babies will develop an eye infection (conjunctivitis) a few days to a few weeks after birth. And 5 to 30 percent of babies who contract chlamydia during delivery develop pneumonia a few weeks to several months after birth. Erythromycin eye ointment, is mandated by the Health Care Consent Act to give babies and was created at a time when chlamydia and gonorrhea could not be tested or screened for. Research shows that this drug has high resistance and would not even be the drug of choice for these diseases if baby became sick with them. Urine Laboratory Tests • C&S: Culture tests for bacteria, indicative of urinary tract infection. • Urinalysis: Testing for red blood cells (for urinary tract disease), white blood cells (urinary tract infection), and glucose (high levels indicate diabetes mellitus). Amount of protein also measured as high protein levels in urine may be sign of preeclampsia. • Pregnancy Test: Measures hormone, human chorion gonadotropin (HCG), produced by the body during pregnancy; appears in blood and urine in pregnant women as early as 10 days after conception. Qualitative: measuring whether HCG hormone is present vs. Quantitative: measuring how much HCG present. (HCG can also be measured via blood testing). • Routine Dipstick Test: Protein: high levels in urine are warning sign - may indicate kidney damage or disease, or transient elevation due to infection, medication, emotional or physical stress. Additional tests to further assess: 24-hour urine protein test, full urinalysis, urine culture. Particular concern is pre-eclampsia, disorder characterized by high blood pressure and large amounts of protein in urine that effects approximately 8% of all pregnancies. In later pregnancy, it is normal to see trace amount of protein in the urine due to increased vaginal discharge. Glucose: may be indication of undiagnosed diabetes already present in mother or gestational diabetes, however this screen has a very high false positive rate. Positive urine test for glucose may be followed by confirmatory blood glucose test. 21 Asymptomatic Bacteruria and UTIs. • UTIs common in pregnant women; defined as either a lower tract (acute cystitis) or upper tract (acute pyelonephritis) infection • Incidence of bacteriuria in pregnant women approximately the same as that in non-pregnant women, however, recurrent bacteruria is more common during pregnancy. Asymptomatic bacteriuria occurs in 2-7% of pregnant women • Incidence of pyelonephritis higher than in general population, like as result of physiologic changes in urinary tract during pregnancy • Typically occurs during early pregnancy; factors leading to higher risk of this include: prior urinary tract infection, pre-existing diabetes mellitus, increased parity, and low socioeconomic status • If not treated, 30-40% of pregnant women with asymptomatic bacteriuria will develop UTI, including pyelonephritis. Risk reduced by 70-80% if issue is eradicated. Gestational Diabetes (note – SOGC guideline from 2002). • Affects 1-14% of pregnant women • Delayed glucose uptake normal in pregnancy; problematic if not regulated • Purpose of testing: reduction of birth trauma and possible neonatal metabolic disorders • Low risk: < 25 years old, Caucasian, BMI <= 27, no history or family history of GDM/DM, no history of GDM-associated adverse outcomes • High risk: history of GDM, family history of DM, history of macrosomia, unexplained stillbirth, neonatal hypoglycemia/hypocalcemia/hyperbilirubinemia, advanced maternal age, obesity, glycosuria, polyhydramnios • SOGC recommendation: routine screening at 24-28 weeks unless low-risk o If at high risk of GDM, OGTT asap in pregnancy (repeat at 24 weeks if negative) o Option to initially to OGTT at 24 weeks (woman’s choice), but results have stricter guidelines • OGCT: 50g screening test – measure glucose levels 1 hour after consumption • OGTT: 75g diagnostic test – 12 hours of fasting; fasting levels measured, and 1 and 2 hours after consumption • Management: o Regular glucose testing o Nutrition counselling o Insulin therapy if unresponsive to nutrition therapy (TOC) o Closely monitor in labour (keep between 4-7mmol/L) and breastfeed immediately after – to minimize risk of neonatal hypoglycemia Screen at 6-12 weeks PP to identify if persistent glucose intolerance 22 Group B Strep • Gram positive, aerobic, B-hemolytic streptococci. Transient part of normal flora. Approximately 10-35% of women will screen positive for colonization. • If mother is GBS positive, there is a 50% chance that baby will be colonized vaginal tract. If colonized, there is a 0.5% chance (1/200) that baby will develop GBS disease of the newborn (EOGBSD). EOGBSD is the leading cause of morbidity and mortality of newborns in North America. Early onset occurs before 7 days old. Late onset occurs between 7 days and 7 months of age. 90% of cases happen in the first 24 hours of life. EOGBSD can lead to sepsis, pneumonia, and meningitis, bacteremia, among other infections. • GBS colonization may increase risk of preterm labour, premature rupture of membranes, urinary tract infections, and chorioamnionitis. • Signs and symptoms of a GBS infected baby: Apnea, lethargy / irritability, poor feeding, temperature instability, poor peripheral perfusion, respiratory distress. tachycardia. • The risk of GBS disease increases from 1/200 to 1/25 if additional risk factors are present, such as: maternal fever in labour, previous child with GBS disease, chorioamnionitis, prolonged rupture of membranes (>18 hours), GBS bacteriuria in pregnancy, SGA or IUGR, or preterm birth. • It is important to note that babies of GBS negative mothers may still develop sepsis. Routine thorough monitoring of newborn vitals is important for all babies. • Swab is offered to all women between 35-37 weeks. Swab is indicative of status for 5 weeks. 13% false positive rate. If GBS bacteriuria is present in pregnancy, women will be considered GBS positive for the remainder of their pregnancy due to high colony counts. 23 • • Standard treatment: IV antibiotics at the start of active labour or once membranes have ruptured. 5 million IU Penicillin G (first line) loading dose. 2.5 million IU subsequent doses. Q4 hours. Client is considered treated if they receive at least 1 4h dose. Decreases vaginal bacteria count and crosses the placenta to prophylactically treat baby. Second line abx include ampicillin, cefazolin, clindamycin, and vancomycin. Some women will choose to treat based on risk factors rather than opt for antibiotics in labour based solely on GBS status. ABO/Rh and RHIG procedures • Rhesus factor (Rh), also known as D-antigen, is an antigen present on red blood cells of the majority of individuals. • Hemolytic disease of the fetus/newborn is caused by Rhesus blood group incompatibility between mother and baby, specifically, when the mother’s blood cells are D-negative (without the antigen) and the baby’s blood calls are D-positive (with the antigen). • In pregnancy the placenta prevents mixing of maternal and fetal blood cells. During parturition, especially during separation of the placenta, fetomaternal hemorrhage and exposure of fetal blood cells (and therefore antigens) to maternal plasma may occur. When maternal red blood cells lack the Dantigen and are then exposed to it for the first time, the maternal immune system will recognize it as a foreign body and make antibodies. In subsequent pregnancies anti-D antibodies are still in circulation and are small enough to cross the placenta. • D-negative status is influenced by race; 15% of Caucasian, 3-5% of African and 1% of the Asian population is D-negative. Without treatment, a Dnegative mother with a D-positive baby has a 12-16% chance of isoimmunisation for subsequent pregnancies. • Any traumatic event such as abdominal trauma, amniocentesis, threatened miscarriage or other antepartum bleeding can lead to antepartum sensitization. It is recommended that an Anti-D Ig (RhIG/Rhogam – a sterilized blood product) be given at the 28th week of gestation to prevent antepartum maternal exposure to D-antigens. Without treatment the risk of antepartum exposure is 1.6-1.9%, which is decreased to 0.2% with administration of Anti-D Ig • Anti D Ig side effects: Local swelling at the injection site, headache or chills are the most common side effects. Rarely hypersensitive urticarial reactions or anaphylaxis may occur if administration is intravenous. No severe reactions occur when treatment is given intramuscularly. • Rhesus factor incompatibility as well as ABO incompatibility (with O type mothers and A, B, or AB fetuses) are risk factors for hyperbilirubinemia o ABO is milder than Rh incompatibility • The kleihauer-betke test measures the amount of fetal Hb transferred to the maternal blood system. This test can be used if there is suspected fetal- 24 • maternal transfer of blood to determine if Rh sensitivity to fetal blood has occurred during pregnancy. The direct coombs test is a fetal blood test that measures the presence of foreign antibodies on fetal RBC, causing hemolysis and increasing jaundice. • Common skin conditions Skin Lesions Macule - small, flat and circumscribed (eg. freckle or flat mole) Papule - small, solid, elevated, and circumscribed; smaller than 1 cm (eg. mole or wart) Nevus - congenital discolouration of circumscribed area, due to pigmentation (eg. birthmark or mole) Wheal - superficial, raised, irregular area of localized edema (eg. mosquito bite, urticaria (like hives) ) Vesicle - elevated cavity containing clear fluid; smaller than 1 cm (eg. blister, chickenpox, shingles) Bulla - big vesicle; larger than 1 cm (eg. burn, friction blister) Pustule - small elevation of the skin containing fluid (eg. impetigo, acne) 25 Keloid - hypertrophic scar (elevated scar tissue) Petechia - small, purplish, hemorrhagic spot on the skin; an example of a type of macule Skin Changes in Pregnancy Linea nigra – brown hyperpigmented line appearing in the midline of the abdomen in pregnancy, due to an increased production of melanin Chloasma – pigmented discoloration appearing over eyes and nose in pregnancy, due to increased production of melanin; aka ‘mask of pregnancy’. Can also occur when OCP’s are taken Spider veins & varicose veins common because of pressure changes in the circulatory. Stretch Marks – small discolored lines of visible changes to the connective tissue as it becomes fragile and stretched over the growing abdomen, hips, thighs and buttocks in pregnancy. At beginning may have red or pink color but will fade to silvery over time. Montgomery tubercles – small raised areas of darkened skin on the areola of the breast during pregnancy Dermatomes of Pregnancy • Skin disorders that are limited to pregnant and puerperal women. • Pemphigoid gestationitis: 1/1700 to 1/50,000 pregnancies. Pruritus may precede onset of visible skin lesions, which erupt during the second or third trimester or postpartum. The rash typically begins on the trunk as urticarial plaques or papules surrounding the umbilicus. Lesions may be seen on the palms and soles, but rarely on the face or mucous membranes. The eruption spreads rapidly and forms bullae. 75 percent of patients flare postpartum and at least 25 percent subsequently flare with use of oral contraceptive pills or during menses. Most cases spontaneously resolve in the weeks to months following delivery. The disease usually recurs with subsequent pregnancies and is often worse. Differential diagnosis — Pemphigoid gestationis can PUPPP, especially in the early stages of disease. PUPPP often begins in striae, while pemphigoid gestationis is periumbilical. Two skin biopsies should be obtained to make the diagnosis of pemphigoid gestationis. The goal of treatment is relief of symptoms: topical corticosteroids and oral antihistamines. Mild placental insufficiency may result from an immune response between placental antigens and the antibodies targeted against the 26 • • skin antigen. Increased risk of IUGR and premature birth. Antepartum fetal assessment is recommended. Pruritic urticarial papules and plaques of pregnancy (PUPPPs): most common specific dermatosis of pregnancy. 1/160 to 1/300 pregnancies. Most common in nulliparous women or multiple gestation pregnancies. Typically presents as erythematous papules within striae on the abdomen, and can spread to the extremities. The face, palms, and soles are usually spared. PUPPP usually begins late in the third trimester (mean onset 35 weeks), but may develop postpartum. Generally resolves around 4 weeks postpartum, although may last longer. Cause of PUPPP is unknown, but it may be caused by circulating fetal antigens and/or excess stretching of the skin causing damage to connective tissue and increased inflammatory response to circulating hormones and fetal antigens. — PUPPP poses no increased risk of fetal or maternal morbidity. The goal of treatment is relief of symptoms: topical corticosteroids and oral antihistamines. There are no biochemical markers associated with PUPPPs, therefore no skin biopsy is required for diagnosis. Atopic eruption of pregnancy: eczema, prurigo, pruritic folliculitis. The goal of treatment is relief of symptoms: topical corticosteroids and oral antihistamines. Intrahepatic Cholestasis of Pregnancy • Most common pregnancy related liver disorder. Occurs most often in trimesters 2 or 3. • Associated with abnormally elevated serum bile acid levels. Hepatic aminotransferase levels may also be mildly increased. • Bile acids deposited in the skin cause intense pruritus. Symptoms often begin in the palms and soles of the feet, and are often worse at night • Multifactorial disorder with genetic, hormonal, and environmental contributors. Sensitivity to estrogen may be a factor. • Generally no primary skin lesions. • IOL at term may be recommended due to increased risk of fetal morbidity and mortality. Amniocentesis results may indicate earlier IOL with presence of meconium regardless of fetal lung maturity. Only cure is delivery of baby. • Consult for diagnosis/treatment. TOC may be considered based on clinical picture. Dating by LMP • The first day of the LMP can be used if no ultrasounds have been done and menstrual history is strong. • Naegel’s rule: subtract 3 months, and add a week. This is for a normal 28 day cycle. If a woman has a longer or shorter cycle, the rule will have to be adjusted. • Menstrual dating underestimates ultrasound-based EDD by average of 2-3 days. 27 • 45% of pregnant women are uncertain of menstrual dates. Strong menstrual history includes: § woman has been tracking her menstrual periods § menstrual periods are regular § ovulation and fertilization happen at the midpoint of the cycle § oral contraceptives have not been used for 3 months prior to conception. Post-dates and prolonged pregnancy • Postdates – pregnancy beyond 40 weeks gestation • Prolonged or postterm – pregnancy lasting 42 weeks or more, thought to occur in 6-8% of pregnancies • Active management – induction of labour between 41-42 weeks • Expectant management – waiting until 42 weeks or beyond for labour to commence naturally • Causes: Incorrect dating, physiologic maturity of fetus is not reached until 42 weeks, maturity is reached but labour does not commence. • Women at increased risk: high BMI, male fetus, previous or family history of postdates pregnancy, and primips Increases risk of: • Meconium stained amniotic fluid and meconium aspiration syndrome • Stillbirth and perinatal mortality or morbidity – evidence is low. • Macrosomia and shoulder dystocia • Instrumental and operative deliveries • Risks are higher for SGA babies Gestation Risk of perinatal death 40+0 2.72/1000 41+0 1.18/1000 42+0 5.23/1000 Prevention: • First trimester dating ultrasound – improves dating accuracy • Stretch and sweeps starting between 38 and 41 weeks – treating 8 women will prevent 1 induction Guidelines: • SOGC – recommends women be offered induction at 41-42 weeks • AOM – recommends ICD for both active and expectant management • If choosing expectant management monitoring of fetal well-being is recommended by both SOGC and AOM o Biophysical profile and amniotic fluid index (via ultrasound) offered twice weekly starting at 41 weeks 28 • o Fetal movement counting and non-stress tests are also often recommended but there is little evidence to support their use CMO does not recommend homebirth after 43 weeks Termination of pregnancy • Abortuses including first trimester abortions (complete, incomplete and therapeutic), early second trimester abortions prior to 20 weeks, ectopic pregnancies, and molar pregnancies are recorded under A in GTPAL. Using the term “abortion” when referring to a miscarriage can have a negative connotation. Language is important. • Reasons for termination may include: lack of partner support, having to raise other children, financial situation, lack of social support, health problems, pregnancy caused by incest or rape, fetal abnormalities, feeling unready to have or care for a child, • If a client has experienced previous therapeutic abortions, inquire about any complications from the procedure. • Surgical: D&C or vacuum evacuation • Medical: uterotonic agents such as misoprostol • Studies have shown that there is no increased risk for ectopic pregnancy, spontaneous abortion, low birth weight, or preterm birth in the first pregnancy after a first trimester medical or surgical abortion. • If the woman is Rh negative she needs to receive RgIG after a spontaneous or therapeutic abortion. 120mg if less than 12 weeks gestation, 300mg if greater than 12 weeks gestation. • If a previous termination is for a fetal anomaly then there seems to be more support in the medical community regarding counselling. Women who are terminating for a medical reason are more supported than women who are terminated for a psycho-social or financial reason Fetal Heart Auscultation • Assessment of fetal heart rate (FHR) can be done once the uterus is palpable above the symphysis pubis. • Normal FHR is between 110-160 bpm. FHR should be counted over a full 60 seconds. Consideration should be given to any accelerations and decelerations. • FHR is best heard over the shoulder or back, so abdominal palpation prior to auscultation is helpful. • FHR is strongly influenced by cycles of movement and rest. • A handheld doppler device is commonly used in prenatal appointments. • Fetoscope or pinard horn can be used aswell. These methods are especially helpful for confirmation of fetal position by location of heart sounds (i.e. helping to identify a breech lie). 29 Fetal movement counts • Decreased placental perfusion and fetal academia and acidosis associated with decreased fetal movements • In high-risk pregnancies, risk for adverse outcomes in women with decreased fetal movements increase: mortality, IUGR, Apgar <7 at 5 minutes, need for emergency delivery. • Daily monitoring of fetal movements starting at 26-32 weeks should be done in all pregnancies with risk factors for adverse perinatal outcome • Routine formal fetal movement counts are not recommended for low risk pregnancies. Healthy pregnant women without risk factors for averse perinatal outcomes should be made aware of the significance of fetal movements in third trimester and asked to perform fetal movement count if they perceive decreases movements • Women who do not perceive six movements in two hours require further antenatal testing and should contact their caregivers or hospital as soon as possible • Women who report decrease fetal movements (<6 distinct movements in 2 hours) should have complete evaluation of maternal and fetal status, including non-stress test and/or biophysical profile. An anatomical scan to rule out fetal malformation should be done, if one has not already been done. • If the non-stress test is normal and there are no risk factors: the women should continue with daily fetal movement counting. • If the Non-stress test is normal and risk factors or clinical suspicion of intrauterine growth restriction/oligohydraminos is identified: u/s BPP and AFV index should be done within 24 hours. The woman should continue with daily fetal movement counting Non-stress test is atypical/abnormal: further testing (BPP and/or contraction stress test and assessment of amniotic fluid volume) should be performed as soon as possible Non-Stress Test • Done when the uterus is relaxed, (fetus is not exposed to the “stress” of uterine ctx) • Client should be reclining or lying in left lateral position, with an empty bladder. • *Recording should last at least 20 minutes. • No evidence found to indicate non-stress tests are effective in monitoring postdates pregnancies (low sensitivity/positive predictive value (AOM) • In most cases a normal NST is predictive of good perinatal outcome for one week (providing the maternal-fetal condition remains stable) …except women with insulin dependent diabetes or postdates pregnancy, in which case NSTs are recommended at least twice weekly. 30 Biophysical Prophile (BPP) • The BPP is an evaluation of current fetal well-being. It is performed over 30 minutes and assesses fetal behaviour by observing: o fetal breathing movement o body movement o tone o amniotic fluid volume • Scoring o Each of these individual ultrasound assessed variables is scored 0 (if absent) or 2 (if present) and summed for a maximum score of 8. NST can be done after ultrasound to bring total to 10 o A score of 10 or 8 (including 2 for fluid present) is considered normal o 6 is considered equivocal o 4 or less is abnormal. o Reassessment of a patient with an equivocal result, 6 of 10 [with normal fluid], will be reassuring in 75% of cases. • The BPP identifies less than a 2 cm by 2 cm pocket of amniotic fluid as oligohydramnios. o There are two other commonly used techniques for quasi-quantitative evaluation of amniotic fluid volume. Neither better at determining true AFV. § maximal vertical pocket depth • 2 to 8 cm as normal • 1 to 2 cm as marginal • < 1 cm as decreased • > 8 cm as increased § AFI - attempts to assess amniotic fluid volume more broadly by 31 • summing the deepest vertical pocket of fluid in the four quadrants of the uterus. • uses the 5th and 95th percentiles for gestational age to signify oligohydramnios and polyhydramnios respectively. § There is evidence from recent RCTs that use of AFI, rather than pocket size, increases intervention frequency without improving outcomes. This is despite a well-conducted blinded prospective cohort that found AFI as a more sensitive, but still poor, predictor of adverse pregnancy outcome. A systematic review of four RCTs using the BPP for fetal assessment in highrisk pregnancies concluded that there is not enough evidence to clearly inform providers’ care decisions. Retrospective and prospective reports of large cohorts indicate that lower BPP score is associated with more frequent fetal acidosis, perinatal morbidity and mortality, and cerebral palsy. This level II evidence is the basis of BPP use for assessment of antenatal health surveillance. It should be acknowledged that