1
Q
How much does blood volume increase during pregnancy?
A
30%
- To compensate for increased renal and uterine blood flow
- This allows to oxygenate/remove waste for fetus
- Increased volume also causes peripheral edema (due to higher pressure gradient)
2
Q
What supplement is recommended in pregnancy?
A
Iron
- To compensate for low hemoglobin
- Due to increased blood and plasma volume (anemia)
3
Q
When does blood pressure decrease during pregnancy? How much does it decrease by? And why does it decrease?
A
2nd Trimester (around 13-26 weeks)
- BP decreases by 10-15 mmHg (normally returns to normal by third trimester)
- As blood volume increases, blood vessels dilate in response.
- Hormonal changes (such as increased production of progesterone and estrogen) can also cause vasodilation
4
Q
How much does pulse rate increase during pregnancy, and when specifically does it increase?
A
Pulse rate increases 15-20 BPM above patient’s baseline in the THIRD TRIMESTER
5
Q
What should you encourage before and after delivery?
A
Peeing
- Empties bladder before delivery (uterus and baby put pressure on bladder > full bladder can make it harder for baby to descend)
- Prevents bladder distention (uterus continues to contract and shrink post-delivery > can cause bladder to become compressed and distended if full)
6
Q
Why is identifying the fundus important?
A
Allows us to estimate gestation based upon fundal height
7
Q
What is most common in the first 6-14 weeks of pregnancy?
A
Nausea/vomiting (morning sickness)
- Can occur during the entirety of pregnancy or not at all
8
Q
What is the medication commonly used for morning sickness classified as?
A
Antihistamines
- Crosses the blood brain barrier blocking H1 receptors (ex: Diclectin)
9
Q
As blood volume and HR increase, how does this impact Cardiac Output?
A
It increases it
- Specifically by 30% in the THIRD TRIMESTER
10
Q
What is Supine Hypotension Syndrome?
A
Compression of the inferior vena cava by the uterus
- Pregnant women >20 weeks have higher potential of this happening
- Compression of IVC causes decrease in preload
- Decrease in preload results in decreased cardiac output, which leads to hypotension and syncope
*Left lateral position limits compression and increases uterine blood flow. SUPER IMPORTANT IN CARDIAC ARREST
11
Q
How much does Functional Residual Capacity (volume left after normal exhalation) decrease by during pregnancy?
A
25%
- Can cause increased RR
- Can also be from enlarged uterus placing pressure on diaphragm
- Fetus also requires more O2
12
Q
What are considered Child Bearing Years?
A
14-50 years of age
13
Q
What does Primip mean?
A
Short for PRIMIPARA
- Means that patient has only had one birth/delivery (past 20 weeks)
14
Q
What does Multip mean?
A
Short for MULTIPARA
- Means that patient has had 2 or more deliveries (past 20 weeks)
15
Q
What is considered a Geriatric Pregnancy?
A
If a woman is aged 35+
16
Q
How many weeks/months is the FIRST TRIMESTER?
A
Week 1 - Week 12 (Approx. 3 months)
17
Q
How many weeks/months is the SECOND TRIMESTER?
A
Week 13 - Week 27 (Approx 4 - 6 months)
18
Q
How many weeks/months is the THIRD TRIMESTER?
A
Week 28 - Birth (usually around 40-42 weeks). Approx 7-9 months.
19
Q
- These contractions last approx 30-60 seconds
- Benign and painless
- Do not progress in regularity or severity
- Body’s way of “training” for delivery
What is this called?
A
Braxton Hicks Contractions
- Can occur as early as the 2nd trimester
- Increase in frequency 2-3 weeks before onset of labour
- Uterus undergoes effacement (thinning of cervix) and dilation
20
Q
During true/actual contractions, what will the abdomen feel like?
A
Rock hard
21
Q
What are the Stages of Labour?
A
- Late Pregnancy/ Pre-Labour
- Stage One: Early Labour + Active Labour
- Stage Two: Passive + Active Phase
- Third Stage
22
Q
What happens in Stage One: Early Labour + Active Labour?
A
- Begins with descent of infant - relieves pressure on upper abdomen but increases pressure in pelvis
- Contractions described as cramping, back pain, generalized abdo pain
- Mucus plug is expelled; “bloody show”
- Lasts 8-12 hours in first delivery, 6-8 or less thereafter
- 2 phases:
Latent (Dilation 3-4 cm)
Active (Dilation 5cm to 10cm)
23
Q
What happens in Stage Two: Passive + Active Phase?
A
- FULL DILATION (10 cm): fetal head enters birth canal
- Urge to push or bear down is a HUGE indicator
- Heavy red show of blood
- Head (crowning) or other presenting part emerges
- Contractions are intense; 2-3 min intervals lasting 60-90 seconds
- Ends with delivery of infant
*500 mL of blood loss during labour
* Urination and BM may also occur during delivery
24
Q
What is imminent birth described as according to the ALS?
A
Crowning or other presenting part is visible OR:
- In primips, presenting part is visible during and between contractions. Contractions <2 mins apart. Maternal urge to push + bear down
-In multips, contractions are 5 mins apart or less + any other sign of second stage labour present.
25
What happens in the Third Stage?
- Begins with delivery of infant and ends with placental delivery
- Placenta takes 30-60 mins to deliver
26
What are some good hx gathering and assessment questions?
- Do you know your due date?
- Last menstrual period?
- Are you receiving prenatal care?
- How far apart are your contractions? How frequent are they? How long do they last?
- Have you given birth before? Any complications or regular deliveries?
- Any past medical hx? (diabetics = huge babies)
27
What happens in NORMAL LABOUR?
1) Descent - Fetus moves down towards pelvis
2) Flexion - Fetal chin to chest
3) Internal Rotation - Fetal occiput turns towards maternal pelvis
4) Extension - Birth with head facing down
5) Restitution - Baby's head rotates to side
6) Expulsion - Birth of baby
28
How do you deliver the placenta?
- Gush of blood (placenta will separate from uterine wall)
- May notice lengthening of cord or contractions afterwards
-Apply GENTLE controlled cord traction (CCT) & guard uterus with other hand (only after there is evidence of detachment)
- Encourage delivery and perform CCT if hemorrhage seems to be occuring
- Document time of delivery.
29
When the placenta is delivered, what should you do?
- Inspect it for wholeness
- Place in plastic bag from OBS kit: label with maternal patient's name, time of delivery
- Delivery of placenta should not delay transport considerations/initiation
30
What is the importance of cranial sutures?
To allow for flexibility during birth
- Cranial sutures also allow for reshaping of the fetus' head during delivery
- Complete fusion of cranial suture lines is ~18 months of age in child
31
What is Precipitous Labour?
Extreme rapid delivery:
- Delivery of baby within 3 hours of regular contractions
- More common with 2nd births "multips"
- Rapid labour may increase risk of perineal lacerations & postpartum hemorrhage due to uterine atony
32
What is uterine atony?
Medical condition: when uterus fails to contract properly after childbirth.
- Can lead to excessive bleeding and is a serious complication of childbirth.
- Most common cause of PPH (more than 500 ml of blood loss)
33
What are some things to be concerned about with Premature Births?
- Always at risk for hypothermia (true for all neonates)
- Usually requires resuscitation: poor lung compliance + no surfactant since alveoli are not fully formed
34
What are some malpresentations that will NOT deliver?
- Transverse lie
- Shoulder presentation
- Oblique lie
*In these scenarios, inspect perineum to rule out cord prolapse or limb presentation
35
What should you do with limb presentations?
- Do NOT push back in
- Discouraging patient from pushing - tell them to "pant" instead
- WRAP LIMB AND KEEP WARM
- Load and go babyyyy
36
Types of Breech Presentations?
- Frank Breech (most common): hips flexed and legs extended. Buttocks will present first
- Complete Breech: hips and knees are flexed. Buttocks and feet present together
- Footling Breech: One hip and knee flexes, other remains straight and enters birth canal first. Risk of cord prolapse is HIGH
*In all these scenarios, colour of amniotic fluid is important. Should be clear. If not, fetus may be in distress.
37
Should you attempt to deliver a baby if you see that they are in Frank Breech?
Yes
- Position patient, then tell them to push with contractions. HANDS OFF BREECH
- Once baby has been born to the umbilicus, you have 4 MINS TO DELIVER BABY COMPLETELY. Consider gentle release of legs if possible. HANDS OFF BREECH.
- Consider gentle release of arms at this point if possible. ALLOW GRAVITY TO BIRTH BABY. If hairline visible, do MSV
*Never touch cord in all circumstances
38
What is Placenta Previa?
When the placenta partially or completely covers the cervix
- Bleeding is bright red and PAINLESS
- Can occur when blastocyst implants too close to cervix
39
What is Placenta Abruptio?
Partial/full detachment of placenta at 20 weeks.
- Significant bleeding
- Severe abdominal pain; tearing pain
- Risk factors: trauma, previous c-section, pre-eclampsia/eclampsia, age of 35 years
- SECOND/THIRD TRIMESTER COMPLICATION
40
What is Placenta Accreta?
When the placenta grows too deeply into the wall of the uterus
41
When should you assume Pre-Eclampsia in patients?
- >20 weeks gestation
- BP >140/90 (severe pre-eclampsia has a diastolic value of >110)
- Generalized edema
- c/o of headache, nausea, abdominal pain (with or without vomiting), blurred vision, fatigue, rapid weight gain
42
What is Pre-Eclampsia?
Pregnancy complication that typically develops after 20 weeks of gestation
- Characterized by high BP (>140/90)
- Proteinuria (protein in the urine)
* Proteins are big and shouldn't be in urine. This is due to osmotic pressure
43
A pregnant woman is having a seizure. Immediately, what should the first thing be in your mind?
Eclampsia.
- Treat how you would normal seizures (maintain ABC's: consider airway, O2)
- Only exception is to position left lateral
44
What is Gestational Diabetes?
Type of diabetes that develops during pregnancy.
- Typically develops in second or third trimester; goes away after baby is born
- Women who develop GD are at increased risk of developing Type 2 Diabetes later on in life
- BIG BABIES: be mindful of breech/shoulder dystocia with these patients
45
What is a Spontaneous Abortion (Miscarriage)?
Loss of pregnancy without outside intervention before 20 weeks gestation
- Often presents with light bleeding; possibly some clots
- Cramping and lasts for approx. 1 week
46
What is Gestational Trophoblastic Disease?
When abnormal cells or tumour develops in uterus from cells that would normally develop placenta
- Mostly benign but can be malignant
- Risk factors: maternal age <20 or >35, previous spontaneous abortion, molar pregnancy
47
What is Dysmenorrhea?
Pain during menstruation
- Very common
- Can be secondary to other factors such as endometriosis, pelvic infections, and fibroid tumours
48
What is Endometriosis?
When endometrium tissue grows abnormally
- Normally, endometrium (lining of the uterus) grows and sheds each month
- In endometriosis, tissue similar to lining of uterus grows on other areas such as ovaries, fallopian tubes, or other organs in pelvic area
49
S&S of Endometriosis?
- Dysmenorrhea
- Lower back and pelvic pain
- Pain during intercourse or after
- Painful bowel movements or pain when urinating
- Infertility
50
What is Disseminated Intravascular Coagulation (DIC)?
Serious medical condition that affects the body's ability to control blood clotting
- Body normally forms blood clots to stop bleeding during injuries
- In DIC, body forms too many blood clots throughout the body
- These blood clots can block blood flow to important organs; leads to organ damage and failure
*Body depletes platelets and coagulation factors, leading to thrombolysis and massive bleeding
51
Stages of Shock?
Stage 1 (Compensated or Nonprogressive)
- Vasoconstriction, tachycardia, tachypnea occurs to retain fluid, along with renal
- This is due to blood shunting to core; pt may appear cyanosed with cool skin, poor cap refill
- Anaerobic metabolism begins, producing lactate and H+ ions (start of acidosis)
Stage 2 (Decompensated or pressive)
- Compensation is failing.
- Hypotension due to vasodilation, which decreases cardiac output.
- Possibility of decreased LOA here
Stage 3 (Irreversible)
- End of organ dysfunction and death
52
What is a thready pulse?
A pulse that's longer instead of one quick beat. This is bad LOL.
53
What is a Uterine Rupture?
Spontaneous or traumatic rupture of uterine wall.
- Fetus can be expelled into peritoneal cavity.
- For this reason, limbs/head of fetus may be able to be palpated outside uterus
- May result from old scar openings (c-section) and trauma to uterus
- High fetal mortality: 50-75%
54
What are Ovarian Cysts?
Fluid filled sacs on ovaries
- As sacs grow and stretch, pain and discomfort results
- Eventually ruptures, which can cause serious hemorrhage
- C/O: unilateral lower abdominal pain, sudden and sharp
55
What is one of the most dangerous FIRST TRIMESTER complications, occurly most often at 6 weeks?
Ectopic Pregnancy
56
What is the clinical triad of ECTOPIC PREGNANCY?
- Pain
- Amenorrhea (lack of menstruation)
- Vaginal bleeding
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