Term
| what is the ob continuum of care? |
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Definition
| the spectrum from preconception counseling to post partum care |
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Term
| what does the initial ob visit consist of? when does this usually occur? |
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Definition
| verification of the pregnancy and clinical dating - which usually occurs around the 8th wk of pregnancy. |
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Term
| what is the avg duration of pregnancy/gestation? |
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Definition
| 280 days or 40 wks or 10 mos from FDLMP. gestational period is *based on menstrual, not conceptual wks. pregnancy is said to be 9 mos, but this is b/c 1 month of "conception" is subtracted. |
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Term
| what does clinical dating consist of? |
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Definition
| naegele's rule, fetal heart tones, palpation of the uterine fundus, and ultrasonographic dating. |
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Term
| what characterizes naegele's rule? |
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Definition
| naegele's rule is the *most reliable method of clinical dating. and it states that the EDD (est. date of delivery) = (last menstrual period - 3 mos) + 1 wk [this date is of the next year]. |
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Term
| how can fetal heart tones be used for clinical dating? |
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Definition
| fetal heart tones can confirm gestational age w/a doppler by 11-12 wks if mom has unreliable LMP. |
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Term
| how can palpation of the uterine fundus be used for clinical dating? |
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Definition
| palpation of the uterine fundus first appears at *20 weeks - but this doesn't apply if twins+. |
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Term
| how can ultrasonographic dating be used for clinical dating? |
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Definition
| ultrasonographic dating, which is most reliable *between 7-11 weeks and 6 days can be used if the mother has an unreliable LMP. if the mother does have an unreliable LMP, the rule for using US is as follows: for each trimester you get a week of leeway before you take the ultrasound due date. so if the EDDs are off by more than one week in the first trimester, more than 2 weeks in the second, or 3 weeks in the third trimester, then the US due date is taken, otherwise you stick with the LMP. |
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Term
| what is the crown-rump length (CRL)? |
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Definition
| what you measure on the fetus to determine mom’s gestational age |
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Term
| how many more calories do pregnant women require vs non-pregnant? how does this translate to wt? |
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Definition
| 15% more kilocalories or *300-500 cal. if the pt has an avg BMI, this translates to *25-35 lbs. (3-6 lbs are gained in the 1st trimester, and .5-1 lb per week for the 2nd and 3rd trimesters) |
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Term
| increased maternal dietary requirements are adequately supplied by a balanced diet, except for what? why? how is this addressed? |
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Definition
| iron - which is deficient due to expanding blood volume. so encourage consumption of red meats, eggs, dried beans, leafy green vegetables, and whole grain enriched cereals. PO iron supplementation is also available if the *mother’s Hgb is at or below 10 at her 1st prenatal visit*. (colace is then co-administered to fight constipation). |
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Term
| what is the prenatal Ca++ requirement? |
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Definition
| 1200 mg/day (as long as not lactose intolerant - this should be covered in balanced diet) |
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Term
| what methods are used to prevent morning sickness (n/v) during the first trimester of pregnancy? |
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Definition
| avoidance of greasy/spicy food and maintaining a small amount of food in the stomach at all times (even @ night). |
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Term
| what is hyperemesis gravidarum? |
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Definition
| severe n/v which requires pharmacologic intervention to prevent dehydration/wt loss |
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Term
| what exercise is recommended for pregnant women? |
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Definition
| mild to moderate exercise routines are encouraged - but be careful in activities where a pt is shifting her weight (fall risk). scuba diving = contraindicated due to deoxygenation. |
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Term
| what are important prenatal labs? |
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Definition
| pap smear, DNA probes for gonorrhea/chlamydia, determination of specific pelvis shape, blood type, antibodies screen, Rh type, CBC (esp Hgb), rubella titers (confirm immunity), VDRL/RPR (syphilis), hep B surface Ag, HIV, Hgb electrophoresis (r/o sickle cells), and urine cx + sensitivity. |
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Term
| what are important educational topics for a pregnant pt? |
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Definition
| helping the pt w/planning: birth plans, daycare/school plans, is the father involved? breastfeeding, and birth control after delivery |
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Term
| when is the first trimester sequential screen? what does this include? |
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Definition
| 11-14 wks, and this includes: maternal age, nuchal translucency (measurement of the posterior neck on US), maternal serum free beta hCG, and pregnancy associated plasma protein-A (PAP-A) |
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Term
| what is the detection rate for down syndrome at the first trimester sequential screen? trisomy 18? open neural tube defects? |
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Definition
| 78% for downs. 95% for trisomy 18. this however does not screen for open neural tube defects. |
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Term
| what is nuchal translucency? how should the fetus be positioned for US imaging of this? when does this need to be performed? what does normal thickness of the nuchal lucency depend on? |
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Definition
| the sonographic appearance of a collection of fluid under the skin, behind the fetal neck in the first trimester of the pregnancy (this is important to distinguish from the underlying amnionic membrane). in fetuses with chromosomal abnormalities, cardiac defects and many genetic syndromes, the NT thickness is increased (most often down syndrome). the fetus has to be in the sagittal section and the fetal head must be in a neutral position. *this is only useful if done at 11-14 weeks* - b/c this is when the fetal lymphatic system is developing and the peripheral resistance of the placenta is high. the normal thickness of the nuchal lucency depend on the CRL (crown-rump length). |
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Term
| why is nuchal translucency not accurate after 11-14 wks? |
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Definition
| at that point, the lymphatic system of the fetus is fully developed and is able to drain away the excess fluid and the changes in placental circulation lead to a drop in peripheral resistance and any abnormalities in the fetus that would cause an increased amount of fluid are able to be drained/accommodated by the fetus and can go undetected by nuchal screening. |
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Term
| what is the second semester quad screening? |
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Definition
| this is performed at 15-20 wks and determines the risk for down syndrome, trisomy 18, and open neural tube defects - this is *mainly for if mom missed the sequential screen* (nuchal translucency etc). the second semester quad screening quantifies the maternal AFP, free beta hCG, unconjugated estriol (E3), and dimeric inhibin A. |
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Term
| what needs to be done if the mother has an elevated AFP? |
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Definition
| a diagnostic US to determine gestational age, detect multiple pregnancies, visualize the placenta, and detect any fetal anomalies. if AFP is up and twins are detected - this is normal, but if AFP is up and she has a single baby- you need to zoom in and look for any anatomical defects. |
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Term
| what anomalies is elevated AFP associated with? |
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Definition
| open neural tube defects, multiple pregnancies, abdominal wall defects, teratomas (hair and teeth), IUGR (intra-uterine growth restriction), and fetal death |
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Term
| when is the first US for a mother who did not have an earlier US for gestational dating? what is the purpose of this US? |
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Definition
| @ 20 wks (between 18-22) - the purpose of which is to look for *genetic abnormalities and *fluid volume. by this time, *organogenesis is complete, structures are large enough for accurate assessment, and *ossification of the bony structures is not yet complete. this is also the time when *sex determination is the easiest. @ 20 wks, *adequate time is available for further workup of any anomalies detected, while still allowing the option of terminating the pregnancy. also, this is when the *baby's size is assessed and IUGR can be r/o (*IUGR is considered when estimated fetal weight is below the 10th percentile for gestational age). |
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Term
| what is usually the reason for a small baby? |
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Definition
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Term
| what is checked at monthly visits (after 20 wks)? |
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Definition
| BP, wt, fundal height, fetal heart tones, fetal movement, urine, r/o preeclampsia, and contractions. |
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Term
| what characterizes monthly evaluations of BP? |
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Definition
| r/o HTN, may be heading towards PIH (pregnancy induced HTN)and ultimately preeclampsia. |
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Term
| what characterizes monthly evaluations of wt? |
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Definition
| make sure the mother is gaining wt appropriately |
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Term
| what characterizes monthly evaluations of fundal height? |
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Definition
| measure from pubic symphysis to the fundus - pt should be gaining 1 cm per wk after 20 wks i.e. 25 cm @ 25 wks (but 2 cm off in either direction is ok). |
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Term
| what characterizes monthly evaluations of fetal heart tones? |
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Definition
| use a doppler to make sure the baby’s heart rate is between 110-160 bpm and is staying nice and rapid with some accelerations (r/o decelerations). |
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Term
| what characterizes monthly evaluations of fetal movement? |
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Definition
| if the mom has never been pregnant before - she doesn’t normally feel anything until about 18-20 weeks - but if she has been pregnant before she may feel it earlier (16-18 wks). |
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Term
| what characterizes monthly evaluations of urine? |
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Definition
| testing for protein (watch along w/high BP/HTN) and glucose (esp if she is having frequency/thirst - test for DM) |
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Term
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Definition
| a syndrome defined by HTN and proteinuria that also may be associated with a myriad other signs and symptoms, such as edema, visual disturbances, headache, and epigastric pain. lab abnormalities may include hemolysis, elevated liver enzymes, and low platelet counts (HELLP syndrome). proteinuria may or may not be present in patients with HELLP syndrome. proteinuria is defined as the presence of 0.3 g or more of protein in a 24-hour urine specimen. this finding usually correlates with a finding of 1+ or greater but should be confirmed using a random urine dipstick evaluation and a 24-hour or "timed" collection. |
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Term
| what characterizes monthly evaluations of preeclampsia potential? |
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Definition
| from 20 weeks on, look for symptoms involving headaches, spots in vision/cloudy vision (scotoma), epigastric or RUQ pain, and non-dependent edema (frank swelling in the hands, arms, face, thighs) |
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Term
| what characterizes monthly evaluations of contractions? |
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Definition
| differentiate between braxton hicks or actual contraction (if she is near term) |
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Term
| what does vaginal bleeding (not spotting) raise a red flag for? |
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Definition
| the pt may be near a missed abortion, threatened abortion, placenta previa (placenta over the cervix), or low-lying placenta |
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Term
| what might a feeling of having "peed" her pants in a pregnant pt indicate? |
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Definition
| the baby's water bag may have broken |
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Term
| what characterizes pain/pressure during pregnancy? |
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Definition
| this is normal during pregnancy and if she has pain on one or both sides right along the inguinal ligament, this is round ligament (what holds the uterus up) pain - this is also normal and the body should accommodate. |
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Term
| what are the symptoms of labor? |
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Definition
| contractions, bleeding, leakage of fluid |
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Term
| what labs need to be performed at 24-28 wks? |
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Definition
| blood type, *Rh type, antibody screen, CBC (make sure Hgb not 10 or lower), VDRL/RPR (syphilis), and gestational DM screening w/non-fasting 50g glucola (doesn't matter if she has DM or not and this is a screening, not dx test). |
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Term
| why is determining the Rh type for pregnant pts important? when are RhoGAM injections administered? |
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Definition
| if the mother is Rh (-), then she needs to be injected w/RhoGAM any time she bleeds during pregnancy. RhoGAM is an anti-Rh Ab that seeks/destroys any Rh (+) blood cells that may have moved from fetal circulation into maternal circulation. otherwise, rhesus disease, a hemolytic disease of the newborn where the mom's immune system attacks the baby's RBCs can occur. *if the mother is Rh (-), she gets RhoGAM at 24-28 wks, and *if the baby is Rh (+), she gets RhoGAM again postpartum to protect the next pregnancy (2nd injection unnecessary if baby is also determined to be Rh (-)). |
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Term
| what characterizes the 36 wk visit? |
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Definition
| repeat previous tests including pelvic exam, DNA probe for gonorrhea/chlamydia, swab for group B strep (if positive, will require antibx - prevents neonatal sepsis), optional cervical exam to check dilation (will prob be tight), check for HSV lesions (if visible, vaginal birth = not possible) and administer HSV suppressive therapy if (+), establish labor precautions (if contractions are 2x/10 min and *strong*, if there is a giant gush of fluid, if there is vaginal bleeding, and if the baby has stopped moving -> mother needs to see her OB/gyn), and planned mode of delivery (C-section if: HSV (+), baby is breech, past due date, or elective). |
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Term
| what are amniocentesis and chorionic villous sampling (CVS)? |
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Definition
| special procedures that allow for collection of fetal cells for karyotyping or other genetic evaluation - are invasive and require needle bx. |
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Term
| what characterizes amniocentesis? |
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Definition
| this is done for genetic reasons at 16 wks or later at ~35-37 wks to determine fetal lung maturity (FLM). a high lecithin/sphingomyelin ratio (L/S) or high phosphatidylglycerol (PG) indicate good FLM and the baby should be able to breath on its own if delivered early. |
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Term
| what characterizes chorionic villous sampling (CVS)? |
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Definition
| this is done earlier ~10-12 wks |
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Term
| what can be done if there is a discrepancy between baby size and gestation dates? what is likely if the baby is smaller than the avg for its gestational stage? |
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Definition
| US for interval growth. if the baby is smaller than it should be for its gestational stage - this is a likely sign of placental insufficiency. |
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Term
| what can a doppler flow study of the umbilical artery of the baby tell you? |
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Definition
| if the fetus has an *elevated systolic to diastolic ratio (blood has to work hard to get to the baby) OR if there is *absent/reversed end diasolic flow |
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Term
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Definition
| this is "extra monitoring" and can be started after 24-26 wks. there are 2 ways of doing this: 1) the mother lies still on one side for an hour and if 4 kicks are felt, she is fine, if not she should see her dr. 2) first thing in the morning, she determines how long it takes to get to 10 kicks and if it takes 3 hrs +, she should see her dr. |
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Term
| what is the non-stress test (NST)? |
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Definition
| this is done in the hospital w/2 monitors: a US fetal heart rate monitor and a tocometer to measure uterine contractions. fetal accelerations are measured, which are *15 beats above baseline that last for 15 seconds*. if the mom is past 32 wks, 2 of these fetal accelerations *w/in 20 min* are considered a *reactive strip* - which is a good sign. if the mother is less than 32 weeks, 10 beats above baseline and 10 sec long is considered a fetal accelerations and 2 of these w/in 20 min is also considered a good prognostic sign (highly predictive for low risk of fetal mortality in the next 3-4 days). |
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Term
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Definition
| another extra monitoring test, which is a rough index of fetal amniotic fluid which in general reflects fetal perfusion and if decreased, raises suspicion as to whether there may be placental insufficiency. *a normal test is an AFI greater than 5 and up to 20 cm.* it is measured by using US to probe each abdominal quadrant and adding up each of the deepest pockets w/o cord (*US probe needs to be held completely parallel to the floor). |
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Term
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Definition
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Term
| what does it mean if a pts AFI drops after 36 weeks? |
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Definition
| this is normal, part of birth prep |
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Term
| if a pt is past term (40 wks), what does the AFI have to be at least to remain pregnant? |
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Definition
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Term
| what is the biophysical profile (BPP)? |
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Definition
| a special US test for mothers w/complaints or failed other tests such as NST. the BPP has 5 parameters: *NST, *fetal breathing movements, *fetal activity/gross body movements, *fetal muscle tone, and *qualitative AFI. each normal test result is 2 points and abnormal tests are 0 points. the BPP also has to be carried out in 30 min. |
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Term
| what characterizes the fetal breathing movements portion of the BPP? |
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Definition
| fetal lungs are observed for inhalation/exhalation on US, which should happen 6x during 30 min (most reassuring), but if this *happens once - 2 BPP points. |
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Term
| what characterizes the fetal activity/gross body movements portion of the BPP? |
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Definition
| the fetus is observed for moving its hand all the way across the field or kicking. 2 of these movements = 2 BPP points. |
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Term
| what characterizes the fetal muscle tone portion of the BPP? |
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Definition
| active bending/straightening of the limb or trunk is observed in the fetus (open or close hand, extend arm, etc). if they do this 1x = 2 BPP points. |
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Term
| what characterizes the qualitative AFI portion of the BPP? |
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Definition
| if the pt has at least one vertical pocket greater than 2 cm = 2 BPP points |
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Term
| how are BPP scores interpreted? |
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Definition
| a BPP of 8-10 is reassuring, a BPP of 6 is ok if everything else is ok (vitals, no vaginal bleeding, etc.), and if the BPP is < 6 = baby needs to be delivered immediately. |
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Term
| what is the modified BPP? |
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Definition
| just NST and AFI - done only in the third trimester |
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Term
| what does in-hospital postpartum care consist of? |
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Definition
| vital signs monitoring, pain management, and watching for post-partum hemorrhage/endometriosis/breast engorgement. post-c section pts get extra attention as this is major abdominal sx. |
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Term
| what are important educational issues to be covered postpartum? |
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Definition
| parental education, maternal self-care, appropriate sexual and physical activity (pelvic rest - no sex for 6 wks and nothing lifted over 10lbs), contraceptive counseling and infant nutrition. *discharge instructions for mom include: pain control, pain to expect from perineum and uterine cramping, especially with breast feeding - which the pt may not know how to do OR that breast feeding releases oxytocin = contractions/some blood, but any blood should not be heavier than a period, should not have an odor… should not have firm/swollen breasts…. call with any temps > 101.4 (febrile response to all the milk production). if the mom is breast feeding: needs to do so every 3-4 hrs, if not - needs to wear tight fitting bras. |
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Term
| what vaccinations should be offered in the peripartum period? |
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Definition
| rubella (if she is not immune or equivocal she gets an MMR before she leaves), RhoGAM (if mom is Rh (-) and baby is Rh(+)), and gardasil (protects against HPV 6,11,16,18) |
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Term
| when is a vaginal delivery pt stable for discharge? |
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Definition
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Term
| when is a C-section pt stable for discharge? |
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Definition
| 24-96 hours (most leave on day 3) |
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Term
| what pts need to come back in for outpatient post-partum care 1-2 wks later? |
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Definition
| if there were any complications. if C-section w/staples: 1 wk ,if C-section w/dissolving sutures: 2 wks. if the mother had a high risk pregnancy: HTN, DM, or bleeding issues - check kidneys. |
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Term
| when is the standard of care outpatient post partum care dr visit for all pregnancies? what happens then? |
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Definition
| 6 weeks. breast feeding is discussed, if still occurring - need to continue prenatal vitamins/iron and be on a safe BC (depo provera, progesterone only pill, IUD, and tubal ligation). another pelvic exam for episiotomy pts. pap smear if needed. BP/blood sugar monitoring (determine if gestational HTN/DM). and every pt gets the edinburgh depression scale - *post partum blues last 2 wks*, *if it continues past that - post-partum depression* - get mom to psychological services. |
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Term
| what is the difference between post partum blues and post partum depression? (*exam question*) |
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Definition
| *post partum blues last 2 weeks. post partum depression is continuous.* |
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