NARM Study Cards NISM

Chicken Pox and pregnancy.

85-95% of expectant mothers are immune to chicken pox. However, 1 in 2000 non-immune women may develop chicken pox during pregnancy.If the infection occurs prior to 20 weeks gestation, there can be serious consequences to the fetus. The baby has a less than 1% chance of being born with congenital varicella syndrome. Defects include cataracts, chorioretinitis, limb hyperplasia, hydronephrosis, microcephaly, mental retardation, dermatome lesions and cutaneous scars. f the infection is at the time of birth the baby can contract chicken pox infection and must be treated to keep the infection mild. Without treatment 30% of babies will die. A blood test can determine immunity and, if performed before pregnancy, the woman can be vaccinated and advised to wait a month prior to becoming pregnant.If a pregnant woman who is not immune comes into contact with an infected person, an injection of VZIG can prevent infection or lessen the severity, and is safe for both mother and baby

Define the indications and related frequency of a biophysical profile (BPP).

A BPP is indicated when IUGR, oligohydramnios, insulin-dependent diabetes, multiple pregnancy, pre-eclampsia, postdatism, non-reactive I non-stress test, or a positive contraction stress test is known or 1 suspected. Insulin dependent diabetics and post date pregnancies require a testing frequency of twice weekly while the other indications require once weekly. If there is a change in maternal status a BPP may need to be repeated. BPP is usually started at the earliest gestational age that the health care practitioner would consider delivery if the BPP showed an acidemic fetus.If oligohydramnios is noted cord • compression is more likely to occur, therefore delivery is more likely to be recommended even though the rest of the BPP is within acceptable range. As the BPP score decreases the risk of complications increases. A score of 4/10 means that perinatal asphyxia has likely occurred and indicates a need for delivery. You must always consult with the physician whenever the scores are not reassuring.

Describe the purpose of the Pap smear.

A Pap smear is a diagnostic test in which cells from the cervix are obtained by gentle scraping and placed on a slide to be examined by a cytotechnologist. The test is a screen that describes and categorizes abnormal epithelial cells. On occasion other organisms are noted, such as Candida, Trichomonas, or cellular changes consistent with Herpes Simplex virus . None of these organisms is likely to need treatment and a Pap smear is not meant as a diagnostic tool for this ue.If, however, it is noted that bacteria that are morphologically consistent with Actinomyces spp, a followup should be done if the woman has or had an IUD. Actinomyces israelii has been found to cause pelvic inflammatory disease. Pap smears should be performed early in pregnancy since hormonal changes may precipitate abnormal cell growth. A second smear should be taken 6 weeks post-partum to check for any differences from early pregnancy.

Explain estimating or verifying EDD by assessing fundal height

A bimanual exam is used to assess the fundal height: 10 weeks: fundus is very slightly above the pubic bone 12 weeks: fundus is a few centimeters above the pubis 16 weeks : fundus is halfway between the pubic bone and the umbilicus 20 weeks: fundus is exactly at the umbilicus, whether single multiple fetuses, regardless of the size the fetus will attain by term. If the uterine size does not correlate to the EDD, the menstrual history should be reevaluated. Mothers may not have an accurate EDD if The cycle is irregular, They are breastfeeding and conceive prior to having a period They continue to have a period They are uncertain of their dates If the uterus does not seem large enough at the time of the second prenatal visit, a pregnancy test should be performed prior to continuing the exam.

Explain the elements and the premise of the biophysical profile.

A biophysical profile (BPP) consists of a non-stress test using .. electronic fetal monitoring, and an ultrasound measurement of the volume of amniotic fluid and fetal activity. When a fetus is fully oxygenated and neurologically intact it has characteristics of muscle tone, gross movement and respiratory activity which are observable on ultrasound and the non-stress test will be reactive. Amniotic fluid volume is considered to be a measure of fetal renal function.If the fetus becomes hypoxic the characteristics mentioned above are negatively impacted. There is hypotonia, fetal breathing and movement is absent, and the non-stress test is non-reactive . There is a decreased blood flow to the fetal kidneys which reduces the volume of amniotic fluid. This presents as oligohydramnios in the uterus. Fetuses with anomalies, especially of the central nervous system, respiratory system or genitourinary system may have decreased BPP scores characteristic of their specific anomalies.

Explain the advantages and disadvantages of birthing centers and home births.

A birthing center has many advantages of both a hospital and a home birth: • The care focuses on natural childbirth. • The mother is allowed to make most of the decisions in her care. • Some medical intervention can be done if needed • Transport is readily accomplished if attached to a hospital. Home birth advantages: • The mother remains in a relaxing and familiar place. • Very little intervention is planned. • The birth is allowed to occur at its own pace. Home birth disadvantages: • Emergency intervention can be delayed by transport if the hospital is not close by. • Homebirth requires more of a commitment to self reliance which may alarm a mother worried about the availability of medical care outside of the home birth attendant's purview, such as anesthesia, medical pain relief and other services available only through a medical center.

Describe the four types of breech presentations.

A breech presentation is one in which the fetus is longitudinal but not head down. Breech presentation types: • Frank breech: the fetus is flexed at the hips with the legs against the abdomen and the feet in front of the face. This includes nearly 70% of breech births and is very common in a primagravida. • Complete breech: the arms and legs are flexed and the fetus is sitting on the cervix. . • Footling breech: one or both feet are presenting through the cervix and into the birth canal. This breech position is very rare. • Knee breech : even more rare, the presenting part is one knee (through the cervix) or both knees, fetus is kneeling on the cervix . The fetus can assume six different positions within the uterus: left and right sacroposterior, left and right sacrolateral, and left and right sacroanterior .

Explain the significance of the family history and psychosocial history.

A complete family history can indicate a predisposition toward conditions that may impact the pregnancy such as a tendency towards I diabetes, hypertension, anemia, or other conditions requiring the ' attention of a specialist. Genetic issues may also be revealed such as the tendency for thalassemia, a condition more often seen in a particular ethnic group. An effective psychosocial history may be difficult to obtain, particularly as psychological issues are uncomfortable to confront. There are many different ways that pregnancy and motherhood can impact an individual. Some of these ways are revealed when the reasons for a home birth are discussed. The mother may be affected by: • Previous pregnancies, abortions, miscarriages, abusive relationships or the existence of previous children • Societal expectations of motherhood that seem unattainable or unwanted • 'unreasonable expectations of herself. Any psychological stress can create an issue with the pregnancy and birth if not addressed and resolved early.

Define "birth defect" and the four categories of birth defects.

A congenital, or birth, defect is an abnormality in the form, function, or structure of some part of the human body. These defects are categorized as chromosome and gene abnormalities, teratogen-caused abnormalities, abnormalities with multifactor causes, and abnormalities with unknown causes. In chromosome and gene abnormalities, a defect has occurred in the formation of the gametes or following fertilization; there will either be too little or too much chromosomal material. The clinical presentation depends on the specific abnormality of the chromosomal pattern. Teratogens are agents that increase the incidence of birth defects. The list of known and suspected teratogens continues to grow. Many are prescribed drugs. Others are environmental factors, infectious agents, and maternal disease. Abnormalities with multifactor causes are due to a genetic defect in conjunction with teratogenic effects. Abnormalities with unknown causes are responsible for about 80% of birth defects where no specific agent is known.

Describe elements of the obstetrical history that may negatively impact the current pregnancy.

A history of any obstetrical emergency such as placental abruption, fetal distress, postpartum hemorrhage, neonatal asphyxiation or shoulder dystocia and any transport to a hospital due to concerns during labor should be extensively documented and investigated. A history of childbirth losses also requires investigation as well as - discussion of the mother's emotional attitude toward the loss. If a desire from a previous birth experience has not been rilet, the mother also may feel a sense of loss for that issue.If the mother has lost a child within two years of the current pregnancy, counseling and investigation of the physical and psychological impact should take place.

Discuss the signs and symptoms of preterm labor.

A history of the woman's contractions should determine her perception of the duration, frequency, physical location, regularity, and progress to stronger, longer or more frequent. You should then palpate the contractions for intensity, duration and frequency. Perform electronic fetal monitoring and correlate all findings with the palpation results and the woman's perceptions. A very preterm fetus can reposition easily within the uterus and confound monitoring. Preterm labor is diagnosed when gestation is between 20 and 37 weeks, uterine contractions are 5 to 8 minutes apart or there are four contractions in twenty minutes or eight in sixty minutes, and: • the membranes are ruptured • OR membranes are intact and there is progressive cervical change • OR membranes are intact and the cervix is 2 cm dilated • OR membranes are intact and there is a positive fFN test.

Explain the characteristics and symptoms of a hydatidiform mole.

A hydatidiform mole is created by abnormal development of the chorionic villi which then fills the uterus with clear, spherical vesicles. The most common presentation is a complete mole; there is no fetus, instead the mole forms due to inactivation of the chromosomes of the ovum by an abnormal sperm. This occurs in 95% of all molar pregnancies. In the remaining 5%, a partial mole develops with some fetal tissue containing abnormal numbers of chromosomes. The fetus rarely survives. Molar pregnancy symptoms include: • Light brown bleeding that may last for weeks. • The uterus is unusually large for dates and feels woody or doughy to the touch. • Abnormally high hCG levels caused by the abnormal chorionic villi growth. • Hypertension and proteinuria due to liver stress. • Hyperemesis occurs in 25-35% of cases. Molar pregnancies usually spontaneously abort but surgical remov!ll may be required. Molar pregnancies can develop into invasive cancer 20% of the time.

Explain the need for appropriate facilities in a preterm birth.

A level III facility with a neonatal intensive care unit is urgently advised in a preterm birth. Neonatal mortality is significantly reduced when birth takes place at this type of facility as opposed to transporting the newborn there after the birth. Arrangements should be made for a pediatrician or neonatologist to be present at the birth. Consideration for the needs of the neonatal team must be made regarding any delay in clamping and cutting the umbilical cord. A reasonable compromise regarding cord clamping is to hold the baby in a warm blanket below the introitus for 30 to 45 seconds to speed transfusion from the placenta. In case of the need to wait for birth before transporting, arrangements for keeping the baby warm are paramount.

Discuss the importance of accurate and complete record-keeping.

A medical chart is a legal document. The chart must contain all records of assessments, procedures, recommendations, discussions with the patient and other care providers, and all observations during any examination and during the birthing process in case of lawsuit. For legal defensibility the records must be written on lined paper, all notes must be continuous with only the midwife's initials and time/date to interrupt the f low. Leave no empty space, or partially or completely empty lines. Blank areas can invalidate an entire chart by creating the possibility of recording after the original time and date stamped. If information must be crossed out, a single line plus the midwife's initials, date and reason for cross-out must be written in. No information should be obliterated in any way. In some instances, the mother's initials may also be required, such as when she declines a recommended procedure or when stating'understanding of the risks of a procedure. Accurate and complete charting is also helpful in establishing the midwife's professionalism.

Summarize the guidelines and philosophy of the Health Insurance Portability and Accountability Act (HIPAA) regarding the development of a written privacy policy.

A midwife legally: I • Must maintain the privacy of the client's healthcare information. Must provide clients with written notice about . I privacy policies and practices, and the client's rights I regarding personal information. · • May use the client's information for treatment, payment, I healthcare operations, to inform others in emergency treatment, when requir:ed by law, and if there is reasonable ! suspicion of abuse or neglect. The mother legally: • Must consent to disclosing information to family and friends, for marketing services, or for any other purpose. May revoke consent at any·time. • Has the right to copies of her own healthcare information and a list of times when the midwife has disclosed the information for purposes other than treatment, payment or healthcare operations. Has a right to ask for alternative methods of . communication to maintain confidentiality and/or to ask the midwife, in writing, to amend her privacy practice. 1 • May ask questions at any time about the practices. • Any complaints can be made to the midwife and to the U.S. Department of Health and Human Services.

Define postdate pregnancy.

A postdate pregnancy is one that has surpassed 294 days beyond the last accurately dated menstrual period or 280 days beyond the date of 1 ovulation or fertilization. There are several terms for a postdate I pregnancy: prolonged pregnancy, postterm pregnancy, and ' postmaturity.It is important to recognize that postdate pregnancy and I postmaturity syndrome are two separate conditions. Postdate pregnancy, even when called postmaturity, is a prenatal condition whereas postmaturity syndrome is a condition diagnosed in the infant upon neonatal examination. The percentage of postdate pregnancies is r 1% to 3% when the pregnancy is accurately dated and the menstrual 1 and ultrasound findings are consistent. In addition, the optimal range . of gestational ages for human gestation is not known. The definition of I postdates as pregnancies that persist 2 weeks past the estimated date of birth without labor is arbitrary.

Discuss the behavior typical of a sexual abuse survivor.

A sexual abuse survivor may have a history of chronic conditions of the reproductive organs and menstrual cycle such as severe PMS, vaginal infections, eating disorders, and/or painful intercourse.If she has been previously pregnant there may be a history of hyperemesis gravidarium, premature labor, or repeated abortion. During pelvic exams she may react in one of two ways: she may show intense emotion to any exam of a reproductive part such as a breast exam or a speculum exam. Vaginismus may occur. Conversely, she may have a dissociative reaction where she may offer completely free access to her body but her mind and emotions are completely divorced from the proceedings. During the birth process, the loss of control may be especially abhorrent. Caesarian sections are prevalent and breastfeeding can be extremely difficult. Many of these reactions are also seen in victims of rape.

Discuss some of the issues of pregnancy and single motherhood.

A single mother who chooses to give birth at home needs the self confidence and self-esteem to overcome the lack of a birth partner. Any concerns she has regarding parenting can be allayed by stressing her positive traits and skills. Plans should be discussed for baby care for the first few weeks post-partum, as well as any fears of the birth itself, sexuality during pregnancy and after birth, and future hopes for relationships as they are expressed by the mother. Each mother must be approached regarding these issues in accordance with their unique styles of intellectual, emotional and spiritual behavior. Development of depression should be noted. The mother's social life and emotional outlets should be considered; however, the midwife has a responsibility to other clients and should not allow a mother to become dependent on her for continuous emotional support.

Describe symptoms of genitourinary system defects.

A single umbilical artery in the umbilical cord or abnormal facies associated with Potter's Syndrome may be found at birth. These are usually the first symptoms observed in infants with genitourinary system defects. It should be noted whether urination occurs after birth. Observation should continue for 24 hours; if no urination occurs or urine is constantly dribbling, the infant should be referred to the 1 pediatrician. A constant, dribbling urine stream is indicative of nerve 1 damage as is seen in neural tube defects. A poor urine stream is seen I in lower urinary tract obstruction. Abnormalities include ambiguous I · genitalia, polycystic kidneys, hypospadias, cryptorchidism and posterior urethral valve(s).

Discuss the use of the speculum.

A speculum has two blades and a handle. It is inserted into the vagina and the two blades opened by use of a thumb-piece. Once opened, the intravaginal area and the cervix can be observed. There are several types of specula. The virginal speculum is the smallest and is meant for young girls and women with little coital experience. The Graves speculum, which has curved blades, comes in a standard size and a large size. The standard size is used for most women who are sexually active or who have borne at least one child. The large speculum is used for women with collapsing vaginal walls typically due to obesity or to grand multipara. The Pederson speculum is the same length as the Graves but the blades are narrower, flat, and best used for women who are sexually active but nulliparous ·or who have vaginas that are contracted by scarring, senescence, or radiation. Plastic specula are available.

Explain teratogenic substances and the effect of exposure during pregnancy

A teratogenic substance is one that causes congenital defects in the I unborn fetus. The Food and Drug Administration (FDA) maintains a list of categories sorting drugs according to their teratogenicity. Many are I drugs; an example is thalidomide, which caused infants to be born I with limb reductions. Maintaining access to this information is highly recommended for your reference . The type and severity of deformity I may depend upon the timing of the exposure during ges'tation. A thorough history that includes any medications the woman is taking or I handles should open a discussion of this issue and create awareness in \ the parents about examining all medications and other substances that are commonly taken or used in the home or at work.Ideally this discussion takes place prior to conception but in most cases must be addressed as soon as possible after conception.

Discuss important points of history of first trimester bleeding.

A thorough history can be an important tool in the differential diagnosis of vaginal bleeding .It should have: • confirmation of date of the LMP; • any contraceptive use prior to conception, especiallyIUD use; results of pregnancy tests; .. history of the bleeding: when it started, heaviness, color Qf , the blood and frequency of pad changes; : -- · · · · • pain or cramping, when it started and where it is located, severity and intensity; • possibility of recent UTI or STD; • changes in pregnancy symptoms; • whether recent intercourse has occurred.

Ex plain the use of the vacutainer type blood collection system.

A vacutainer type blood collection system consists of a .plastic sleeve with a narrow neck on one end to which a sterile, double ended blood collection needle can be affixed. The end of the needle protruding from the holder is a beveled sterile needle for insertion into a patient's vein. The other end of the needle is contained inside the vacutainer with a flexible rubber diaphragm covering it. The needle is inserted into the vein and a collection tube is gently inserted into the sleeve and pushed onto the inner end of the needle. The tube will automatically fill to the appropriate level. Once full the tube is withdrawn and additional tubes can be filled. Any tube with anticoagulant or other additive should be mixed immediately upon withdrawal from the vacutainer. Most vacutainers are meant for one time use and come with an automatic needle cover for disposal in the appropriate container.

Discuss nutrition for vegan mothers and mothers who prefer organic foods.

A vegan mother may have trouble ingesting enough B-12 which can cause serious anemia and neurological damage to the mother and the fetus. Supplemental B-12 in the active form of cyanocobalamin or hydroxocobalamin is the easiest remedy. Fermented soy products, shiitake mushrooms, seaweed, and spirulina have been offered as sources of B-12 but actually contain an analog of B-12 that can block the actual B-12 from being absorbed. Fortified soy products or fresh juices are good sources of B-12 as are sublingual tablets. Mothers who eat organic foods generally are healthier looking than those who eat more highly processed food. Quality in food choices counts as well as how the food is selected and when it is eaten. Mothers who do not have addictions to sugar, caffeine, alcohol, or marijuana can trust their instincts about food, even when it seems they are craving one food above others.

Describe a well-balanced pregnancy diet

A well balanced diet includes 'foods from all food groups in prescri!Ded amounts. This ensures proper nutrition by allowing the mother to obtain all required nutrients from food.If a mother takes in 80-100 grams of protein, salt to taste, and water to thirst, in addition to eating the appropriate amount of all food groups, she will be more likely to deliver a healthy baby with no nutritionally oriented birth defects. The mother should take in: • 2-3 servings of meat, fish, nuts, legumes, or tofu, • 2-3 servings of dairy, • 2 servings of green vegetables, • 1serving of yellow vegetables, · • 3 servings of fruit, • 3 servings of whole grains, • salt to taste, • 6-8 glasses of water each day. Pre-eclampsia can be prevented by eating at least 75 grams of protein a day. Adequate folic acid prevents neural tube defects such as spina bifida.

Discuss the use of the Amni-hook or Amnicot. ®

AROM or Artificial Rupture of the Membranes may be performed using this device, allowing labor to progress. To prevent cord prolapse, the baby's head should be low in the pelvic area, preferably zero (0) station or, in the event of a larger head, at -1 station. After putting on a sterile glove, sterile gel is placed on the fingers of the glove and the Amni-hook® or Amnicot® placed between the first two fingers with the tip protected. The mother is placed upright. At the end ef a contraction, the gloved fingers are placed inside the vaginal canal and the hook pushed into the membranes. The handle is pressed down to lift the tip of the hook and the fingers drawn out slowly .Immediately afterwards heart tones should be checked and charted. This process should not be performed too early or complications due to prolonged rupture of the membranes may occur.

Discuss abdominal breathing and panting techniques for use during labor.

Abdominal breathing can be taught to any mother with no prenatal breathing training. Abdominal breathing has two modes of action : performing controlled breathing will serve as a distraction from the pain of contractions and it helps lift the diaphragm off the uterus to relieve pressure and pain. Once transition is reached, however, the mother cannot continue abdominal breathing. At this point, some form of panting is required, either the pant-pant-blow rhythm, if possible, or panting "like a dog", whichever the mother is capable of. Panting is for those times when the mother is asked not to push. This includes when the cervix has not yet fully dilated, during delivery of the head between contractions, and if the cord is around the baby's neck and must be clamped and cut prior to delivery of the body . The best teaching method is to demonstrate and breath with the mother at each contraction.

Define abortion, spontaneous abortion, and threatened abortion.

Abortion is the termination of pregnancy with the expulsion of the products of conception prior to external fetal viability. This is an accepted definition to·20 weeks of gestation or 500 grams of fetal weight. Spontaneous abortion (SAB): Commonly known as a miscarriage, this 1 is an uninduced abortion, occurring naturally . The primary reason for ' this loss is genetic abnormality. Other causes are abnormal ' progesterone levels, thyroid conditions, uncontrolled diabetes, autoimmune disease, infection and uterine abnormalities. I Threatened abortion: This is a condition of vaginal bleeding during the first half of pregnancy. There may be cramping or lower backache.If ' both bleeding and pain are present, prognosis for the pregnancy is poor. A physical exam and evaluation of the serum BhCG and progesterone levels as well as ultrasound should be performed to determine the source of bleeding and treat it if possible.

Discuss achondoplasia and osteogenesis imperfecta .

Achondoplasia describes and infant with a disproportionately large ' head and short limbs. Cognitive development is not generally affected. I Most are new mutations with no previous family history. The infant [ may develop significant lordosis. [ Osteogenesis imperfecta is a defect in collagen production and results I in brittle bones. There are four types. Types IIthrough· v lead to multiple fractures of the skull, ribs and long bones in utero or during birth.In either case, the fetus may die. Genetic counseling is advised 1 prior to future pregnancies.

Discuss the use of acupuncture in pregnancy and childbirth.

Acupuncture is based on the principle of meridians, or energy lines, running through organs in the body. Stress causes obstructions on a meridian.If the point of the obstruction can be stimulated, by a needle or acupressure, the energies will be rebalanced. Other methods of stimulation are using suction cups to cover the point or by applying heat through the use of moxa sticks. Acupuncture has been used relieve pregnancy related nausea by using acupressure on a point on the wrist. For a more complete use of this treatment, a qualified traditional acupuncturist should be consulted. Acupuncture used in labor has been useful for pain relief, labor induction and acceleration of labor, as well as treatment for a retained placenta. Pain relief can take effect as quickly as 40 minutes and last as much as 6 hours with no drugs.

Discuss acyanotic cardiac defects.

Acyanotic defects include: • patent ductus arteriosus, • ventricular an atrial septa! defects, • coarctation of the aorta, and • hypoplastic left heart syndrome. There may be tachypnea, tachycardia, and incipient cyanosis after crying or feeding that will increase greatly once the ductus arteriosus closes with coarctation of the aorta or hypoplastic left heart syndrome. There may be heart murmurs and little or no femoral pulse. Prostaglandin stabilizes and maintains the infant until diagnosis. Coarctation of the aorta can be surgically repaired but hypoplastic left heart syndrome is more difficult to treat and does not have a good long term outcome . Patent ductus arteriosus, ventricular septal defects and atrial septal defects usually do not require surgery or other medical correction in infancy but monitoring should continue for cardiac problems later in life. While not every heart murmur is a harbinger of heart failure, any report of breathlessness or cyanosis should be referred for medical assistance as soon as possible.

Describe the elements of abusive relationships

Admission of any of these actions on the part of her partner may indicate abuse: • Fear of or threats by her partner, worries that her actions cause the abuse; • Being or nearly being grabbed, punched or physically harmed; • Hurting or threatening to hurt pets or committing property destruction; • Threatening home destruction or property confiscation • Denial of medication, medical care, or insistence on accompanying her to all medical exams; • Controlling all financial resources, refusal to pay bills; • Hiding important documents; • Threatening harm to or taking away existing children or threatening to harm himself or another loved one; • Denial of access to social outlets and communication with others; • Preventing her from going to work or school, or making her feel constantly watched; • Making her feel devalued or forcing her to hve sexual relations that are demeaning or damaging. If any one of the above conditions is true, the mother should be referred to the National Domestic Abuse Hotline (800) 799- SAVE or (800) 787-3224 (TDD).

Explain fetal alcohol syndrome.

Alcohol has been shown to directly impact fetal development.It is rare I that a specific teratogen is discovered and its effect defined so well.If the psychosocial markers for alcohol use are present fetal alcohol I syndrome and uterine growth restriction can result. When the infant is I born, there are a number of visible physical abnormalities: • · growth-restriction, I • low set ears, • small upturned nose, • thin upper lip, • flat facies, • close-set eyes with heavy epicanthic folds, • microcephaly. Some of the features will become more normal looking as the infant grows but the resultant mental retardation, microcephaly and small body size will still mark the child. The infant may have acute withdrawal symptoms and require therapy. The midwife should counsel and support the parents and refer them to appropriate medical help and social services.

Explain the following common issues of pregnancy: nausea and vomiting, breast changes, headache, and fatigue. Discuss the point, if any, at which they become medical problems of _ pregnancy.

All of these conditions are primarily attributed to hormonal changes. Nausea and vomiting affect approximately 50% of pregnancies. Small frequent meals are recommended to keep the blood sugar stable.It is thought that psychological and neurological adjustments may be the causes. A small percentage develops hyperemesis gravidarium in which vomiting becomes excessive and self-perpetuating which requires referral to a physician. During pregnancy the breasts become tender and slightly larger; the areola color deepens and the nipples enlarge. There are usually no serious issues. Headache is a common complaint during pregnancy. Fatigue, sinusitis and other issues may increase the frequency and severity of headaches.If the headaches occur in the third trimester along with increased blood pressure and/or proteinuria, refer for immediate medical attention. Fatigue occurs in the first and third trimesters and postnatally. It is caused by bodily changes, then to labor and il)fant care. There is usually no serious issue.

Discuss the uses of Motherwort tincture, Skullcap tincture, and Blessed Thistle tonic. ·

All of these herbs are said to keep the emotions calm during pregnancy. Motherwort tincture calms without causing sleepiness. Five drops in a small glass of water helps the emotions balance about 15 minutes after ingestion. This can be taken as often as every 2 hours. However, it may become psychologically habit forming. Skullcap tincture helps provide sleep. Up to 30 drops of a commercial tincture or 5 to 15 drops of fresh plant tincture 30 minutes before bed helps create a refreshing sleep. An infusion can help calm emotions. Two cups daily can be taken for several months. Blessed Thistle tonic, along with Burdock and Sarsaparilla tonics, can be used occasionally as an emotion calming agent. This can be substituted for daily Raspberry Leaf infusion.

Explain HIV screening of the expectant mother.

All women should be screened for HIV, in particular those who have ever shared a needle or had unprotected sexual relations. Testing can be performed anonymously. The ELISA test is most commonly used but has a false positive rate of about 10%. A second positive test is required to reflex to Western Blot, a more specific test. An untreated seropositive mother has a 25% risk of passing the infection to the baby: 5-10% prenatally, 20% during labor and birth, and 5-15% during breastfeeding. The mother must be fully informed of all risks, both of treatment and non treatment, and of related symptoms. The backup physician should be consulted regarding whether the midwife should continue primary care. Additionally, the midwife must define protocol for assisting anyone with a life-threatening, highly ·infectious disease since there is no immunization for HIV and, although Universal Precautions will be used, there is still a risk of infection to the health care worker .

Discuss maternal positioning during labor.

Allow the mother to assume the position she wishes if possible. It is likely that she will instinctively seek the position most suitable for her at a given point in labor. You can still offer support by suggesting positions that will alleviate pressure due to various fetal positions. Possibilities include supine with any or no incline, knee-chest, all-fours, lateral recumbent, sitting, standing, walking or squatting. Rotation of the fetus to an anterior position may be accomplished by the mother leaning forward, supported by a partner, table, birthing ball, or other support . The hands-and knees or knees-chest position may also accomplish this. Lateral recumbent positions can help rotate a fetus from an occipital posterior position. Once transition has occurred and second stage labor commences, you should be ready to assist with delivery from any position the mother may take be it hands-knees, squatting or any other position the mother feels is best.

Discuss the implications and management of an incompetent cervical OS;

An incompetent cervical os (incompetent cervix) is diagnosed when the cervix effaces and dilates in the second or early third trimester without pain. The symptoms often include vaginal bleeding, ruptured membranes, or pelvic pressure. Risk factors include a history of abortion at 14 or more weeks of gestation or cervical laceration after a vaginal or caesarian birth, extreme distension of the cervix during a prolonged second stage labor in a previous pregnancy, multiple elective abortions in the first or second trimester, exposure to DES, or extreme cervical conization.If the membranes are still intact and the cervix is in an appropriate condition, an incompetent cervix is often treated with cervical cerclage sometimes called a purse-string.

Discuss the risks associated with a true postdate pregnancy.

An increased risk of stillbirth has been found in postdate pregnancy which may be attributed to uteroplacental insufficiency. This eventually causes fetal hypoxia.In addition, amniotic fluid levels drop significantly in the final few weeks of gestation, increasing the risk of cord compression, especially during labor, as well as the risk of meconium aspiration pneumonia from inhalation of a viscous meconium stained fluid that is less dilute than usual owing to low fluid levels.In some postdate neonates there is a loss of subcutaneous fat as in postmaturity syndrome while others suffer macrosomia which can lead to cephalopelvic disproportion or shoulder dystocia. In many instances the true risk is during labor when the stresses to the fetus are significant and exacerbate any fetal compromise.

Explain blood type, Rh factors and their importance.

An individual's blood type and Rh factor is inherited from the parents. There are four blood types: A, B, AB and 0. Rh factor is an antigen that resides on the blood cell of Rh positive individuals. When the antigen is not present the individual is considered Rh negative. Knowledge of the maternal blood type and Rh factor is required in for blood transfusion. Additionally, if the mother is Rh negative, there is a possibility of isoimmunization occurring which can cause the baby to become anemic due to hemolytic disease of the newborn. This rarely occurs in first births but subsequent fetuses are at risk of this disease if the mother is not treated with Rhogam within 72 hours of giving birth to an Rh positive baby. ABO incompatibility can also cause some jaundice in the baby if a type 0 mother receives type A or B blood cells from the fetus due to a fetal/maternal cross bleed.

Discuss infant clothing and sleep positioning.

An infant is limited in ability to regulate body temperature.If overdressed and overheated the skin color will redden, the infant may become irritable, and the back of the neck will be very warm. Over time, an overly warm infant will appear lethargic. Nonrestrictive clothing near the face will cut cold winds. A good rule to follow is to clothe the infant in as many layers as adults plus one layer. Keep in mind that infants differ in their metabolisms just as adults and will feel the effects of the environment differently. An infant should be placed on its back to sleep to reduce the risk of SIDS (SuddenInfant Death Syndrome). Since the recommendation for this position was introduced in 1992 the deaths from SIDS have decreased significantly. Solt sleep surfaces, loose bedding, bed sharing, smoking by others in the home, overheating, and preterm birth all appear to increase the incidence of SIDS.

Outline the requirements of informed consent.

An informed consent document should be reviewed and signed by the midwife and the mother at the beginning their relationship .It details the essential issues about a home or birth center birth.It should include: • the advantages and disadvantages of the decision to be attended by a midwife, • the qualifications of the midwife, • the mother's consent to examination and treatment, • a summary of complications risked in childbirth, • a definition of common terms used. during the pregnancy and birth, • details of the emergency equipment provided by the · midwife and/or the birthing center, • ah agreement to any hospital transfer recommended by the professional judgment and at the discretion of the midwife. An informed consent should open discussions between the midwife and mother regarding the important issues of home childbirth without creating an adversarial or fearful atmosphere . t should be a springboard, not a substitute, for a nurturing, trusting relationship between mother and midwife.

Discuss the principle rules and steps in delivering a multiple birth.

An unexpected multiple birth must never be due to a failure by the attending midwife to diagnose multiple gestation during the prenatal period. Contact emergency services even though transport may not be possible before delivery. Limit medications during labor since the fetuses are likely preterm or small for gestational age and less able to withstand the effects. Prepare the mother as much as possible for medical management, including placing anIV and drawing blood for type and crossmatch. Deliver the first fetus according to its presentation and position. Quickly clamp and cut the cord to prevent the possibility of the other fetus( es) bleeding out through the cord. An ' assistant should maneuver the remaining fetus into position and place it into the true pelvis. Carefully monitor the remaining fetus' heart tones and watch the vagina for bleeding. The second fetus should deliver 3 to 15 minutes after the first. Once the remaining fetus is in place, rupture the membranes. If contractions do not continue, medication may be required to stimulate delivery.

Discuss anencephaly and microcephaly.

Anencephaly results when the cranial vault does not form.It is visible in ultrasound and very apparent at birth. Most fetuses with the defect do not survive to term but occasionally an infant is liveborn. The parents should be shown the infant, first with the back of the head wrapped and a sensitive, honest explanation of the deformity. They should then be shown the head because, while it is hard for parents to see their infant this way, it is helps them to accept the reality of what they are facing and keeps them from imagining anything worse . Microcephaly is a feature of fetal alcohol syndrome.It can also be seen I as a result of a prenatal infection, such as rubella, or as one of the defects in trisomic syndromes. The occipitofrontal circumference is I more than 2 standard deviations below normal for the gestational age. I Leaming difficulties, cerebral palsy and/or seizures will most likely result.

Explain the diagnosis and management of bleeding or spotting during pregnancy.

Any spotting or bleeding is cause for concern. If there is non-rhythmic pain, a tubal pregnancy may be suspected. Persistent bleeding implicates a missed abortion or (rarely) molar pregnancy. Other causes of: • severe cervicitis, • cervical lesions, • cervical polyps, • subchorionic bleeding, • post-coital bleeding • implantation spotting • fetal death of a twin without expulsion of the tissue Placental problems cause chronic bleeding late in pregnancy. Cervical bleeding is caused by infections, such as gonorrhea, chlamydia, Trichomonas, or cervical dysplasia. A herpes lesion or a vaginal yeast infection can cause the cervix to be friable. Treatment consists of rest. Sexual intercourse, insertion of anything into the vagina, or engaging in behavior that causes orgasm should not be attempted. Conilflue to monitor. If the bleeding worsens or is accompanied by pain, refer the mother to a physician.

Discuss the maternal physical changes during pregnancy and their relationship to joint pain, muscular strength and spinal straightness, symmetry and posture.

As estrogen, progesterone and relaxin affect the joints, pain may occur, particularly in the pelvic region. Maintaining good posture, even though the growth of the infant in the uterus places the body off balance, will help prevent or relieve some of the typical aches and pains of the skeletal system. I Exercise also benefits the joints, keeping them limber and less likely to ! stiffen. Various exercises, such as pelvic rocking and other centering ] activities, help keep the back muscles strong and improve the spinal alignment. Some joint pain may be alleviated by ensuring proper support when sitting or lying down. The side-lying position is best for pregnancy. Strengthening muscles such as the gluteals, abdominals, hamstrings, and upper back; and stretching others, such as the psoas, low back, and chest, can keep proper skeletal alignment more easily.

Discuss how to assist parents regarding fears of a negative birth experience due to pregnancy complications.

Ask .parents to tell you the worst of their fears regarding negative outcomes such as hospital transport or life threatening complications. This helps evaluate the parent's commitment to a home birth and also introduces the topic of complications and how they occur.It can then be emphasized that good prenatal care does much toward preventing many of the complications of labor and birth. This may impress upon them the importance of keeping appointments and informing you of any worrisome developments. Two of the most serious discussions are about hemorrhage and fetal distress. These topics should be discussed early in the pregnancy since there is no time to explain in such emergencies. The explanations should include possible causes of these issues, your procedures for handling them, your training, tools and techniques for stopping bleeds and resuscitating the baby.

Discuss the integration of the infant into the family

Assisting the integration of the newborn into the family is an important I part of aftercare. You should encourage the parent's attachment ] process as well as help any siblings learn about the new infant. The infant should remain with the mother as much as possible. The infant's name should be used anytime a parent interacts with the infant. Including the father in all discussions, decisions and care of the infant will draw the parents closer together in caring for the newborn and each other. Another point of integration is the education of the parents in feeding, bathing, clothing and diapering the infant. The operative word is "educate": you should not take over from the parents; you should encourage the parents to find the best way to do for themselves. You can also act as gatekeeper, minimizing the visitat ion of extended family and friends to help the bonding experience between mother and newborn.

Discuss asymptomatic bacteriuria and cystitis.

Asymptomatic bacteriuria has no associated symptoms and can progress into pyelonephritis with complications of pregnancy. Since up to 40% of untreated UTis can become pyelonephritis, identification and treatment are paramount concerns. Cystitis is a condition of inflammation of the bladder, typically caused by a bacterial infection. Symptoms include urinary urgency and frequency, dysuria, nocturia, suprapubic pain, and hematuria. Laboratory examination of the urine will show bacteriuria, increased white blood cells, red blood cells, and nitrites. It is not necessary to await identification of the specific pathogen to begin treatment. Prophylaxis can be changed upon identification if the current therapy proves to be inappropriate. Common antibiotics are sulfa drugs (Bactrim), nitrofurantoin (Macrodantin), cephalosporins, and ampicillin or amoxicillin. Sulfa d.rugs should not be used past 36 weeks, and nitrofurantoin should not be given to women with G6PD. f Group B Streptococcus is identified, treatment should be given prenatally and in labor.

Discuss backache, ligament pain and leg cramps during pregnancy.

Backache is common in all trimesters of pregnancy due to the growing uterus and its affect on the posture. Relaxin also impacts the ligaments creating backache. Using proper posture and lifting techniques and avoiding standing for long periods can decrease the discomfort. Pelvic tilts, walking, swimming and a supportive maternity girdle can also ease backache pain. Ligaments stretch under the influence of Relaxin. As the uterus grows and stretches the supporting ligaments, sharp spasms called ligament pain occur. Warm baths, massage, and avoiding stretching can relieve the symptoms. Leg cramps tend to occur during the third trimester. The cramping may be caused by lowered serum ionized calcium and increased phosphates. Leg stretches before bed and a decrease in the intake of milk, carbonated soft drinks and processed foods may decrease the frequency of cramps. When a cramp occurs, the mother should flex the foot in the opposite direction of the cramp.

Explain how Bacterial Vaginosis is diagnosed and treated.

Bacterial Vaginosis (BV) is a common vaginal infection. It is also known as gardnerella or hemophilus.It can cause chorioamnionitis, premature rupture of the membranes, and preterm labor when it presents during pregnancy. Indications include: • A fishy odor to the vaginal secretions, especially after sexual intimacy . • Thin, gray or white discharge that adheres to the vaginal walls. • Typically no vaginal irritation or itching. Diagnosis is made with the Whiff test in conjunction with the symptomology. A cotton swab saturated with vaginal discharge is touched to KOH (potassium hydroxide) solution. If a potent fishy odor, caused by amines, is released, the diagnosis is BV.Insert a garlic clove, peeled and without nicks, into the vagina to be changed three times a day, followed by five days of acidophilus treatment.If unresolved, medical treatment is indicated. The parents should abstain from sexual intimacy and the partner may need to be investigated as well.

Discuss bacterial infection of the newborn.

Bacterial infection of the newborn can be differentiated as early onset (birth to 6 days) and late onset (7 days to 3 months). The most common pathogens are Group B beta-hemolytic Streptococci and E. coli. Other common pathogens are Staphylococcus aureus and Streptococcus epidermidis, which tend to be nosocomial infections. Early onset bacterial infection can be severe. Symptoms include tachypnea, labored breathing, and poor color. Temperature instability and hypotension may be present.Immediately transport the newborn for emergency treatment. Late onset bacterial infection usually appears after the newborn has been discharged from daily care by a healthcare worker such as the midwife. Symptoms include lethargy, color changes, lack of sucking, transient apnea, and fever. In these instances, refer the newborn for medical treatment.

Describe basic suture principles.

Basic suture principles: • Close all lacerations in layers - muscle, fascia, skin. This will eliminate tension in a particular area. • Dead spaces between layers should be eliminated. f they are not, oozing can occur and a hematoma may form which is a risk for infection. • The suture should not be too tight or circulation will be impaired. Allowances must be made for the possibility of swelling. • Using too many stitches can also result in circulatory impairment. • Landmarks must be checked very carefully and repeatedly .If enough time has passed before the sutures are made swelling may confuse the issue. • Sutures should have greater depth than width. • Never clamp the suture with the needle holder because it may break at the site. • If possible, have an assistant handy to cut sutures as they are placed to prevent the person performing the suture from the need exchange instruments.

Discuss complications during birth of an infant who suffers from intrauterine growth restriction (IUGR).

Because a fetus suffering from IUGR has already been stressed from chronic hypoxia, the hypoxic environment during birth will make it more difficult to endure the transition to extrauterine life. Perform supportive care and close monitoring from the onset of labor. I After birth, quickly assess the fetus for visible abnormalities or I infection and determine the gestational age. Infant glycogen stores are ' extremely limited and the infant may suffer from immediate hypoglycemia and hypothermia . Encourage early feedings and screen the infant's blood sugar until it reaches at least 36 mg/di if the infant is asymptomatic and 45mg/dl if it is symptomatic. Frequent temperature assessments will be required as some infants will not be .able to stabilize without an external heat source. Save the placenta and cord blood for examination.

Discuss the reasons for determining the lie, presentation, position and variety of the fetus.

Before 20 weeks of gestation it is unlikely that the lie, presentation, position or variety of the fetus can be felt due to uterine size, toughness, and the high ratio of amniotic fluid to fetal mass in the amniotic sac. Not until the 35th week will any of these factors come into play. At this point, the fetus is generally settled into its intrapartal position although it is possible it may turn again. Perform Leopold's maneuvers of abdominal examination by palpation for the lie, presentation; position or variety. Malpresentation prior to 36 weeks is not significant. However, after 36 weeks, malpresentation may require intervention. The midwife should determine at the very beginning of labor whether the malpresentation still exists as part of management planning for this period.

Discuss the Beta-adrenergic drugs and magnesium sulfate as tocolytic drugs, including their effectiveness and side effects .

Beta-adrener:gic drugs (betamimetics or beta-sympathomimetics): These are the most commonly used drugs and include ritodrine, salbutamol, and terbutaline. Ritodrine has been found to be ineffective [ and its FDA approval for tocolysis may be reconsidered. These drugs [ typically have maternal side effects of tachycardia, pulmonary edema, markedly increased cardiac output, blood pressure effects, and increased blood sugar and insulin secretion. Typical feta.I side effects are tachycardia, hypoglycemia, and hyperinsulinism after birth. Efforts to maintain pregnancy after stopping preterm labor using beta adrenergic agonists has proven to be ineffective and is not recommended. Magnesium sulfate: This has not been evaluated as well as other tocolytic agents and it has some of the most serious side effects including maternal respiratory distress, cardiac arrest and death as well as an increase perinatal morbidity and mortality for the fetus. It is more effectively used for eclampsia.

Explain the elicitation of the biceps and triceps deep tendon reflexes.

Biceps reflex: The tendon of the biceps brachii in the bend of the elbow is struck. The patient's arm is flexed and rested on her lap or the examiner's arm. The elbow, arm and forearm should flex; the hand should supinate. · Triceps reflex: The tendon of the triceps brachii on the back of the upper arm above the elbow is struck. The patient's arm is flexed and the elbow held in the patient's opposing hand. The elbow and forearm should extend and the arm should adduct.

Discuss thyroid disorders and infectious diseases in pregnancy.

Both hyperthyroidism and hypothyroidism are associated with congenital fetal anomalies. Therefore it is important that the woman achieve and maintain euthyroid prior to and during the pregnancy. Refer the woman for medical consultation, especially regarding any medication requirements. Both propylthiouraci l and methimazole are FDA Category D pregnancy drugs and alternatives should be prescribed. The management plan should include assessment of thyroid levels. Many infectious diseases can be screened for and vaccinated against if immunity is not found. This is true of rubella, varicella, and hepatitis B which are common childhood vaccinations or are common infections in childhood. Positive titers for Toxoplasmosis and CMV show that there is minimal pregnancy risk while a negative titer shows non-immunity and e'ducation about avoidance can be offered. Testing for STD's including HIV can be performed. Negative results three months prior to preconception generally negate the need to repeat them after pregnancy begins.

Discuss emotional consequences and grieving process of a lost pregnancy.

Both parents must be counseled regarding the effect the loss of a baby will have on them. Grieving for the loss of a pregnancy is the same as grieving any other loss of a loved one. Most people pass through certain stages as they grieve, not always in the same order as another person. The stages are: • denial • anger (at the self, the spouse, or God for letting it happen) • guilt: (could it have been avoided by being more careful?) • depression • acceptance Men and women grieve differently. Women are generally more expressive about their grief and will look for support. Men more often grieve in solitude. Men also have a tendency toward problem solving and fact gathering, choosing not to participate in a support setting. Memorializing the baby, no matter what stage the loss occurred can serve as a way to gain closure.

Explain the elicitation of the brachioradialis, quadriceps, and gastrocnemius-soleus deep tendon reflexes.

Brachioradialis reflex: The radius is used to elicit this response rather than a tendon directly. The patient's arm is slightly flexed, the hand slightly bent at the wrist, and the arm rested on lap or abdomen. The elbow and forearm should flex. Quadriceps (knee-jerk) reflex: The patellar tendon below the patella is struck. The leg is flexed. The knee should extend and the leg should jerk. Gastrocnemius-soleus (ankle-jerk) reflex: The Achilles' tendon above the heel is struck. The leg is flexed at the knee and the foot is dorsiflexed. Plantar flexion of the foot at the ankle should be observed.

Discuss the impact of maternal nutrition on fetal brain and organ development.

Brain growth consists of hyperplasia and hypertrophy of cell growth. Malnutrition decreases both types of growth and can result in a smaller brain. Malnutrition during hyperplastic cellular growth causes irreversible damage because a reduced number of cells will be created. Improved nutrition during any phase of hypertrophy can increase cell size as needed and reverse any previous damage. Malnutrition retards other organ development as well. The fetal body and organs do not grow as large as when proper nutrition is maintained. This results in low birth weight infants who are small for gestational age. Perinatal mortality, mental retardation, cerebral palsy, visual, hearing and neurological defects, and poor perinatal growth and development all increase. Poor nutrition is often found in those who use tobacco, alcohol, caffeine, marijuana, cocaine or other illicit drugs. Multiple gestation, lactose intolerance, eating disorders, and strict vegetarianism can also cause malnutrition.

Describe normal variations in breast tissue during pregnancy.

Breast masses are more difficult to diagnose due to the changes in the breast during pregnancy. Normal variations in a pregnant woman include: • increase in size, possible tingling, tenderness • increased general coarse nodularity and lobularity • colostrum discharge as early as 6 weeks gestation • Montgomery's follicles • enlargement and increased erection of the nipples • broadening and increased pigmentation of the areola • dilated subcutaneous veins • vascular spiders on upper chest • striae of the breasts A supportive, well-fitted bra, gently cleaning dried colostrum from nipples, and assist everting flat or inverted nipples give comfort in pregnancy and postnatal breastfeeding. Colostrum expression is another presumptive sign of pregnancy.It also helps prove to an anxious mother that there is something to feed the newborn in her breasts if she is uncertain.

Discuss breastfeeding during pregnancy.

Breastfeeding during pregnancy is not harmful to the mother or the fetus.If the mother continues to breastfeed her child on demand, there will be no loss of milk. It has ben reported that the taste of the milk may change around the third or fourth month of pregnancy which may encourage some children to wean or nurse less.It is important to make certain that the child is receiving enough nourishment and not losing weight due to a decrease in breastmilk. There may be some discomfort when the nipples become sensitive. Once the baby is born, the mother can tandem nurse. Both the infant and the child can still breastfeed. Tandem nursing appears to deepen the relationship between the children and lessen the older child's feelings of isolation from his or her parents when the new baby arrives.

Describe the uses of bulb syringes, hemostats, and lancets.

Bulb syringe: used to suction the neonate's nose and mouth on the perineum or immediately after birth. Completely expel the air from 1 the bulb prior to insertion into the neonate's nose or mouth. Allow the I bulb to expand then withdraw and empty it by forcing air out of the I bulb again. Hemostats: a scissor-like device with locking clamps used to control I bleeding from a torn blood vessel by pinching the vessel closed I without damaging the tissues. Use them in clamping the umbilical cord I prior to cutting and in controlling bleeding while suturing lacerations. I Lancets: a sharp, pointed device used for punching a hole in the skin \ of the finger of an adult or the heel of a neonate to obtain blood for testing. Lancets can be either a flat, bladelike device with an arrow shaped tip or a needle-like tip mounted on a cylindrical plastic to be used manually or with a lancet device.

Explain the significance of CVAT (Costovertebral Angle Tenderness).

CVAT can be an indication of pyelonephritis, which is an inflammation of the kidney and renal pelvis, most typically due to a urinary tract infection traveling up from the bladder. The most common bacterial infection is due to E. coli. Treatment for pyelonephritis includesIV antibiotics.If successfulfy treated, there is no adverse effect to the pregnancy. Palpation for CVAT should be performed when assessing first trimester bleeding. The costovertebral angle is formed at the junction of the twelfth rib and the paravertebral muscles. Any pain in this area is typical of renal disease. CVAT is elicited during exam by lightly striking the woman's back, using the ulnar surface of the fist, from the midportion of the scapular area to the midportion of the buttock area. Ensure the CVA is struck on the way. Any report of pain during this exam should be investigated.

Discuss abnormalities of the skin: capillary malformations, capillary hemangiomata, and melanocytic nevi.

Capillary malformations and capillary hemangiomata are both vascular nevi and are defects in skin development. Capillary malformations affect the dermal capillaries. A common defect of this type is the "stork mark", usually on the back of the neck. These generally fade. A more obvious defect of this type is the port wine stain which affects mostly females.It does not fade but laser treatments and makeup can disguise it. Psychological support will be needed. Capillary hemangiomata arise after a few weeks and are typically red, raised lesions. They are most often seen in premature infants, more likely females. The lesions will increase for a time then regress until they disappear at age 5-6 years. Melanocytic (pigmented) nevi are brown, possibly hairy marks that may be raised or flat and vary in size. Because some of these result in malignancies, they are often surgically removed.

Discuss newborn heart abnormalities.

Cardiac problems in newborns appear similar to respiratory disease and sepsis. Most congenital defects are structural and impact the heart or the major cardiac vessels. Signs include: • Pallor, transient tachypnea, and central cyanosis. • Bounding or diminished pulses. • Variation of pulse intensity from upper to lower extremities. • Presence of a loud murmur at birth or a week or two later. Heart disease cyanosis is seen over the whole body differentiating congenital heart abnormalities from peripheral cyanosis of normal newborns. The most common defect is a ventricular septal defect. A large enough defect can degenerate into congestive heart failure.It is not a cyanotic defect and a murmur may not be heard for two or more weeks. Other concerns such as breastfeeding problems, failure to thrive, and tachypnea may point to this condition. Persistent pulmonary hypertension (formerly persistent fetal circulation) is another common defect. Immediately transport these newborns to a hospital. d outward into the interstitial space of the lung. With a large pneumothorax, there are diminished breath sounds on one side, cyanosis, and possibly overdistention of the chest. Meconium aspiration symptoms include uneven breath sounds, cyanosis, rales, ronchii, and a barrel chest.It can degenerate into I persistent pulmonary hypertension. I

Define cephalopelvic disproportion, cerclage, and disseminated intravascular coaguopathy (DIC)

Cephalopelvic disproportion is a disparity between the size of the mother's pelvis and the size of the fetal head. Cerclage is a non-absorbable suture inserted into the cervix to keep it closed in the case of incompetent cervix.Incompetent cervix may be caused by cone biopsy, trauma during a D&C or induced abortion.It can also be a congenital weakness of the cervix. DisseminatedIntravascular Coagulation (DIC):If abnormal blood clotting occurs in the blood vessels, the coagulation cascade is disrupted, clotting factors are used up and the blood loses the ability to clot, thereby causing severe hemorrhage.In pregnancy, this can occur if a miscarriage or stillbirth occurs and all products of conception are not expelled from the uterus within 3 to 4 weeks of the fetal death.

Describe preexisting conditions precluding at-home births.

Certain conditions, which should be made apparent when a medical history is taken, preclude an at-home birth as each can create serious consequences for the mother, the baby or both. • pre-existing diabetes or hypertension, thyroid disease (hyperthyroidism), chronic lung disease, • severe asthma, epilepsy, • clotting disorder, congenital heart disease, kidney disease Conditions occurring due to pregnancy contraindicating home births: • Rh negative mother with antibodies, • severe anemia that does not respond to treatment • acute viral infection such as rubella, cytomegalovirus, toxoplasmosis, chicken pox and herpes Other conditions precluding home births: • unresolved sexually tr:ansmitted disease, • malnourishment · • drug addiction or uses alcohol moderately to frequently • . smoking It is essential to have the consultation of peers or medical backup and availability of a comprehensive medical text to evaluate issues in the history.

Discuss buying and using herbs.

Certain herbs are contraindicated for use during pregnancy due to their harsh effect on certain organs. These include Goldenseal, Ephedra, Cotton root bark, Blue cohosh, Pennyroyal and Birthroot. Buy dried herbs that have the strongest scent and color of their particular species. Faded herbs have not been properly stored and may not maintain their effectiveness, like any other medication. An herbal tincture is a mixture of a fresh or dried herb in a liquid medium of alcohol or glycerin which extracts the effective portion of its chemicals. The mixture is strained and the resulting liquid stored for later use. Tinctures are administered by the dropperful. Knowledge of how the tincture was made aids proper usage. Those made from fresh, wild, or organically grown plants are best.

Explain the cervical exam.

Chadwick's sign in pregnancy is indicated by a bluish color of the cervix caused by increased vascularity. A non-pregnant cervix is pink. Growths, lesions, nodules, ulcerations, masses, polyps, erosions, and infected nabothian cysts are abnormal. Refer to physician. Cervicitis, an inflammation of the cervix, is typically caused by an irritation, injury, or infection. Cervicitis presents with hypertrophy, edema, discharge, and friability. Deviation of the uterus to one side can indicate pelvic masses or uterine adhesions. Eversion is caused by pressure on the vaginal fornices by the speculum and it should disappear if the speculum is moved back. Ectopy occurs in multiparous women or women using oral contraceptives. The size and shape of the os are impacted by childbirth.If lacerations of the os are extensive the cervix may be incompetent. Parity affects the patulousness of the cervix. The nulligravid cervix is closed. A multiparous cervix is open to a larger degree with each birth. Dilation can also be observed at this time.

Discuss important points of the office exam in diagnosing first trimester bleeding

Check the mother's blood pressure, temperature, pulse and respiration and repeat a pregnancy test to confirm pregnancy . The following should be performed: • palpation for pain/tenderness, fundal height and masses, rebound tenderness, CVA tenderness, bowel sounds; • a speculum exam for vaginitis, cervicitis, dilations of cervical os, presence in os of any unexpected condition; • a bimanual exam for uterine size, masses, cervical effacement or dilation; • auscultation of fetal heart tones; • a sonogram, a hemoglobin/hematocrit, and serial quantitative serum BhCG measurements or progesterone measurements.

Explain Chlamydia and its consequences to pregnancy.

Chlamydia is a common Sexually Transmitted Disease (STD) in the United States second in incidence only to Human Papilloma Virus (HPV). Women are often asymptomatic t;>ut chlamydia can cause: • Urinary tract infection • Infection of the amniotic sac and fluid. • Premature labor or premature rupture of the membranes (PROM) • Increased susceptibility to HIV • 70% chance of fetal infection upon delivery • Fetal conjunctivitis • Fetal pneumonia Gonorrhea is often seen in conjunction with chlamydia.If either one or both of these infections are present, both partners must be treated 1 and must use barrier-type birth control until the infection is resolved. Tetracycline may not be used because it causes discoloration of the fetal tooth enamel. Erythromycin is the antibiotic of choice.

Discuss choanal atresia and laryngeal stridor.

Choanal atresia is a narrowing of the nasal passages with a web of bone or tissue obstructing the nasopharynx. Typified by tachypnea and dyspnea, especially with a bilateral lesion, it is usually diagnosed when the infant is observed breathing by mouth and is unable to breastfeed without becoming cyanotic. Additionally, a nasal catheter cannot be inserted. A unilateral defect may not be noted until the infant feeds and cyanosis and respiratory difficulty occur. Laryngeal strider is a noise made on inspiration and becomes worse when crying. This is commonly caused by laryngomalacia from laxity of the laryngeal cartilage. This may take up to 2 years to disappear .If dyspnea or feeding problems also occur, a more severe condition may be present.

Discuss pregnancy in women with hypertension·, phenylketonuria, or advanced maternal age.

Chronic hypertension rarely impacts pregnancy as long as blood pressure is under control and the use of ACE inhibitors (FDA Pregnancy Category C) and angiotensin II receptor agonists (FDA Pregnancy Category D), is avoided. Counseling about the risk of preeclampsia and intrauterine growth restriction must be offered. Phenylketonurics should be counseled to return to dietary therapy prior to conception and strict maintenance of that diet throughout the pregnancy.If the dietary plan is not followed there is a substantial risk of mental retardation and microcephaly due to exposure in utero to high levels of phenylketones in the mother's system. Advanced maternal age is defined as delaying conception past the age of 35. There is an increased risk of genetic disorders, gestational diabetes, hypertension and other chronic conditions. Another issue is decreased fertility. You may wish to facilitate a discussion about the changes in lifestyle that occur with bearing and raising children.

Discuss cleft lip and cleft palate.

Cleft lip occurs in 1.3 per 1000 births.It may be unilateral or bilateral. Cleft palate is often found in conjunction with cleft lip. The cleft may be in the hard or soft palate, sometimes both. Sometimes the alveolar margins are impacted, sometimes it is the uvula.It is best to examine an infant for cleft palate with a good light rather than palpation. Breastfeeding is possible with unilateral cleft lip but in the case of cleft palate, an orthodontic plate will be necessary. Surgical intervention is not immediately needed. Depending on the physician and the parents, cleft lip may be repaired as early as 2 weeks. Some prefer to wait until 3-4 months in case other defects or concomitant medical conditions come to light. The parents should be referred to a support group to help with education about these defects.

Discuss midwifery management of preterm labor.

Closely conduct your management of preterm labor, and preterm labor that is progressing toward birth with the consulting physician. All treatment decisions work toward a viable infant with the least amount of morbidity.In impending birth, when preterm labor cannot be halted, every decision regarding treatment should avoid fetal asphyxia and trauma. If there is a history of preterm labor, perform increased monitoring starting at 24 weeks with visits every 2 weeks.Include a gentle cervical exam. Recommend a reduced workload and the use of condoms. If signs of infection appear, screen immediately. If the cervix begins to efface, or if preterm labor is halted, sexual contact should cease and visits become weekly. Give all instructions to the partner and family at each visit. If regular contractions begin or the cervix begins to dilate, immediately contact the consulting physician.

Discuss the complications and contraindications of external cephalic version (ECV).

Complications that can occur with ECV include separation of the placenta, rupture of the membranes, and knotting of the umbilical cord. With placental separation pain and bleeding may occur during or after the procedure. Rupture of the membranes can lead to a prolapsed cord since no fetal part is engaged in the pelvic brim. A knotted umbilical cord may be diagnosed if bradycardia suddenly presents and persists.It this occurs, the fetus is turned back to breech position and an emergency caesarian section if performed. A uterine scar from a previous caesarian section may be a contraindication to ECV for some woman. Absolute contraindications for ECV include a hydrocephaiic fetus, multiple pregnancy, oligohydramnios, preeclampsia, ruptured membranes, and any condition that requires the fetus to be delivered by caesarian section.

Discuss the impact on the fetus of gestational diabetes.

Complications to the fetus of uncontrolled diabetes include macrosomia, polyhydramnios, and pregnancy induced hypertension or preeclampsia. At each visit abdominal palpation should be performed. 1 If the fundal height is greater than expected for dates, polyhydramnios or macrosomia may be to blame. Ultrasound should be used to confirm fetal size and the amniotic fluid index. If both are normal, routine prenatal care continues. f, however, the fetus is large for dates or the , amniotic fluid index is abnormal, consult with a physician. I At 34 to 36 weeks, fetal movement counting should commence. If the fetus is the appropriate size, the amniotic fluid is at the appropriate levels, there is no hypertension and no history of stillbirth, the pregnancy can proceed until labor begins naturally. At 40 weeks a biophysical profile should be performed twice a week until birth.If, however, complications occur, or there is a history of stillbirth, labor should be induced at 40 weeks.

Explain compound presentation and its management.

Compound presentation means that a hand (most usually) presents alongside the head in the birth canal. This is called a "nuchal hand" or "nuchal arm". This is usually not diagnosed until the head is birthing depending on how far down the hand is.If the head and arm are not yet engaged, the Scott and Sutton's hip-twist movement may suffice to correct this presentation . Because the arm in addition to the head creates such a large circumference perinea! tearing is more likely.If the hip-twist does not resolve the issue, the baby's fingers should be pinched in an attempt to cause the hand to retract. If it does not, the arm should be extracted so the shoulders can be born.

Discuss causes and remedies for constipation in pregnancy.

Compression of the lower intestine due to the increasing weight and size of the uterus contributes to constipation.It is also possible that hormonal changes slow the motility of the intestinal tract causing increased water absorption from the contents of the gut, thereby causing constipation. Oral iron therapy can exacerbate the condition. Ingesting fiber and maintaining hydration, and getting the recommended exercise helps alleviate most problems of this sort.If additional fiber is needed, psyllium seed (the main ingredient of Metamucil) can be taken as a capsule or mixed into food with plenty of water to drink. Prune juice is also very effective. If constipation is not relieved, hemorrhoids may develop which can contribute to difficulties during birth. They can become very painful and may bleed. Avoidance of hemorrhoids should be the basic aim of constipation relief although a secondary effect is the comfort of the mother

Discuss congenital hyperplasia and intersex as causes of ambiguous genitalia.

Congenital adrenal hyperplasia is one cause of ambiguous genitalia. The adrenal gland overproduces androgens due to an enzyme deficiency. This problem may not be immediately apparent in male infants. The condition also causes loss of sodium from the body and concomitant imbalances in electrolytes and glucose as well as other blood chemistries. When internal reproductive organs do not match the appearance of the external reproductive organs it is called intersex. The identification of gender is performed by ultrasound examination of the internal organs but gender assignment is delayed for chromosomal studies, hormone assays, and determination of surgical intervention. It is extremely rare to see true hermaphroditism. Parents experience anxiety, being unable to tell others the gender of their infant nor to choose a name (although androgynous name choices may be made). Most commonly an infant with extremely ambiguous gender is raised as a female.

Discuss congenital cardiac defects.

Congenital cardiac defects·are the second most common abnormalities found. About 8 in 1000 live births have congenital heart disease and one-third of those will be symptomatic early in life. Chromosomal and gene defects account for 8% of these abnormalities, 2% are likely caused by teratogens. A single cause of the remaining 80% cannot be specified. Teratogenic damage of cardiac development usually occurs in weeks 3-6 of gestation. More and more cardiac defects are being found by ultrasound but most still depend on observation after birth to discover. Infants present with cardiac defects in two ways: cyanotic and acyanotic congenital heart disease. Cyanotic cardiac defects include (in order of frequency): transposition of the great vessels, pulmonary atresia, Fallot's tetralogy, tricuspid atresia, total anomalous pulmonary venous drainage, and univentricular/complex heart. Acyanotic cardiac defects include (in order of frequency): patent · ductus arteriosus, ventricular or atrial septa I defects, coarctation of the aorta, and hypoplastic left heart syndrome.

Discuss congenital viral and parasitic infections in the newborn.

Congenital viral and parasitic infections are acquired transplacentally and will have different symptoms than infections acquired during birth. Early jaund ice, hepatosplenomegaly, petechiae and palpable lymph nodes are some of the signs of this type of infection. The newborn may also be small for gestational age. Additional symptoms of congenital infection can include vesicles, rash, limb or cardiac defects, microcephaly, cataracts, or thrombocytopenia. Visibility of the symptoms or abnormalities depends upon timing·of exposure and severity of the infection. The cord blood should be tested forIgM, which signifies a viral infection, and cultured for virus identification. These newborns should be isolated from other newborns and pregnant women until the virus is identified. Some examples of this type of infection are Toxoplasmosis and Varicella (Herpes) Zoster.

Discuss constipation during pregnancy.

Constipation is a common issue during pregnancy.It can be avoided by maintaining proper hydration and eating a diet rich in fiber. Fiber can also help to resolve constipation once it begins.Intestinal motility is reduced in pregnancy allowing for greater water reabsorption from the gut, as well as intestinal compression and ingestion of iron supplements can be causes of constipation. Persistent constipation can ' lead to hemorrhoids which can in turn cause difficulties during birth. J You should be certain to monitor bowel habits during the course of the pregnancy and offer measures such as those above to alleviate the I · problem and manage it to avoid the bleeding and discomfort of 1 hemorrhoids.

Explain the appearance and treatment of cradle cap.

Cradle cap is an adherent, seborrheic exudate on the infant's scalp. The scalp has flaky, dry skin or thick, oily, yellowish scaling or crusting ' patches. This is a cosmetic issue.It is not an infection. There is very little agreement on what causes it. Massage the scalp with vegetable or olive oil and a soft brush then shampoo. Another method is application of natural oil to the scalp. Leave it in all night, and shampoo it away the next morning using a soft toothbrush. A very fine tooth comb will help remove the flakes from the hair. When this same condition is noted on the infant's eyebrows, ears, armpits or other folds it is called seborrheic dermatitis. More frequent shampoos, no more than two to three a week, can help clear the rash and prevent it in the future although once gone it rarely presents again prior to adolescence.

Discuss cryptorchidism and ambiguous genitalia.

Cryptorchidism is defined as undescended testes. Impacting male infants, this defect can be unilateral or bilateral with an occurrence rate of 1-2%. At birth the scrotal sac(s) will be empty. If the undescended testes are in the inguinal pouch it is possible to manipulate them into the scrotal pouch where it is likely they will continue to develop normally. If the testes are too high in the inguinal pouch to manipulate, they may be malformed. Regular examinations are advised.If the testis has not descended by 2 years of age, surgery may be needed. The appearance of ambiguous genitalia can be seen as any of the following: an enlarged clitoris or undescended testes, incompletely separated or poorly differentiated labia, a small hypoplastic penis, bifid 1 scrotum or chordee. There are many causes of ambiguous genitalia. , Refer such infants for expert medical assistance in clarification of gender.

Discuss cyanotic cardiac defects.

Cyanotic cardiac defects include transposition of the great vessels, pulmonary atresia, Fallot's tetralogy, tricuspid atresia, total anomalous pulmonary venous drainage, and univentricular/complex heart.Infants with cardiac defects have persistent tachycardia, tachypnea and central cyanosis . Administration of 100% oxygen does not improve the condition and, in fact, may be detrimental since it may cause the ductus arteriosus to close. Treatment should be discontinued after 10 minutes with no improvement. Infants with transposition of the great vessels can be treated with surgery to correct the transposition in later weeks. Infants with pulmonary atresia are stabilized with prostaglandin therapy until surgical correction can be performed. Infants with tricuspid atresia usually have a ventricular septal defect or an atrial septal defect. Sometimes both are present allowing circulation to mix. Some infants do not show immediate cyanosis but become ill later, such as in the Tetralogy of Fallot. Illness occurs several weeks after birth and degenerates into cyanosis and heart failure .

Define cystocele, rectocele, and hematoma.

Cystocele: a swelling of the vaginal tissues at the opening of the vagina near the urethra. This is caused by weakening and straining of the muscles of the vaginal vault. Rectocele: a swelling of the vaginal tissues at the opening of the vagina near the perineum. This is caused by weakening or straining of the pelvic floor muscles. ·Hematoma: An asymmetrical, painful swelling of the perinea! area caused by soft tissue trauma in second stage labor and a tissue repair that has not contained or stopped bleeding vessels below the skin or mucosa! surfaces. The resultant pooling of blood can allow bacterial growth, infection and repair breakdown, and failure of the tissues to close. This may result in the need for reconstructive surgery.

Explain the consequences of cytomegalovirus (CMV) to the fetus.

Cytomegalovirus (CMV) is part of the herpesvirus group. A majority of people in the United States have been infected with no long term issues. This virus, which is inactive once the primary infection is over, is usually transmitted to the fetus prior to birth. However, if the primary infection occurs during pregnancy, the fetus may be at risk. Thirty percent will become infected. Less than fifteen percent are symptomatic ranging from jaundice and moderate enlargement of the liver and spleen to fatality. Most will survive but many will develop such abnormalities as hearing loss, mental retardation, and some blindness. Those who are asymptomatic may still develop some degree of these complications. The virus may not infect the infant until birth when genital secretions or breast milk may pass along the virus, but in these cases there is little to no illness demonstrated .

Discuss the decisions ·and arrangements to be made when managing preterm labor that is progressing to birth.

Decide the route of birth when fetal presentation and gestational age is determined. Choose analgesia and anesthesia based on the impact to the fetus: do not use narcotics, ataractics, and sedatives prior to delivery. When considering an episiotomy, consider the estimated fetal weight and the condition of the perineum. A pudenda! block or local infiltration is recommended unless the mother requires an epidural for comfort and control.In this case, preload the mother with crystalloid IV fluids to alleviate hypotension, although if betamimetics have been administered, consider the increased risk of pulmonary edema. Carefully monitor the fetus which cannot tolerate labor stress like a full term fetus. If a betamimetic drug is used or an intrauterine infection is present, observe for tachycardia. An internal electronic monitor may not be indicated due to skull bone density and structural differences of a preterm fetus.

Discuss the signs of multiple gestation.

Determine possible multiple gestation by: • Auscultation of more than one distinct heart tone • A history of ovulation-inducing drug treatments • Severe nausea and vomiting beyond that expected in typical morning sickness • Uterine size, fundal height, and abdominal girth that is large for dates, especially in the second trimester • A family history of twins • Discovery by palpation of three or more large body parts especially in the third trimester If there is a discrepancy between the estimated gestational age and the uterine size at the first prenatal visit, perform an ultrasound to date the pregnancy and show any multiple fetuses. The discrepancy may not be significant until the second or third prenatal visit if the mother began prenatal care very early in pregnancy.

Discuss estimating fetal weight

Determining the estimated fetal weight (EFW) deniands a great deal of practice and experience to become accurate enough for the measurement to be useful. There is no precise tool at this time to accurately measure the EFW for comparison. The EFW is important during the intrapartal period to determine adequacy of the maternal pelvis for the fetal size. Prenatally, the EFW is one of the 1 measurements used to determine gestational age and progressive fetal 1 growth. This method of estimating the fetal weight can be used in / conjunction with ultrasound to develop more accurate readings in the / field. Accuracy is best with the midrange of fetal size but becomes more inaccurate for smaller or larger fetuses. One way to practice and I become more accurate is by palpating as many mothers as possible in a labor and delivery unit and comparing the EFW with the actual birthweight of the baby.

Describe the appearance and management of diaper rash.

Diaper rash occurs when the skin becomes irritated by ammonia in urine and bacteria in stool. Simple diaper rash causes flat, reddened areas without involving the skin folds. Clean with mild soap and water or a commercial wipe. If possible expose the diaper area to the air and ensure frequent diaper changes. Clear the rash using a zinc oxide cream. Alternatively, use bag balm, or aloe vera gel and calendula cream. If there are erythematous confluent lesions, satellite lesions away from the p_erineum and anus, and skin fold involvement, it may indicate Candidiasis, a fungal infection caused by Candida a/bicans. Use an antifungal ointment such as nystatin, myconazole or clotrimazole. Hydrocortisone cream and tepid water rinses ease inflammation. If there is peeling skin, exudates or vesicles, there may be a secondary staph or strep infection. Herpes simplex or histiocytosis can cause a rash. Frequent diaper rashes may be caused by non hygienic practices.

Discuss the respiratory defects of diaphragmatic hrnia.

Diaphragmatic hernia refers to an abnormality of the diaphragm that allows herniation of the abdominal contents into the thoracic cavity. Lung development is impacted more or less depending on the size of the hernia and the gestational age when the hernia occurred. Most of these defects are found on the left side so heart sounds are displaced to the right. If not diagnosed prior to ·birth, the defect may be suspected if the infant is cyanotic and difficult to resuscitate. The diagnosis is confirmed with chest x-ray. This defect can be found on ultrasound, in which case a hospital birth is highly recommended.

Describe domestic violence and its affect on pregnancy.

Domestic violence is a pattern of behavior that includes threatened or actual violence committed by an intimate partner. It includes physical, emotional, or psychological abuse such as becoming detached or uncaring of loved ones. This behavior seeks to create power for the abusive individual by controlling another's life. The abuse can include personal humiliation, sexual degradation, social isolation and financial dependence upon the abuser. While the abuser may apologize later, the abuse continues. The mother may not interpret these actions as abuse and seek to justify the behavior. Certain cultural or religious backgrounds may play a role in the behavior of both partners. The violence may begin or become worse at pregnancy because it is viewed as a threat. Abuse may result in bleeding, miscarriage, vaginal and cervical infections, high blood pressure, premature labor and fetal distress. The mother may suffer from low weight gain and the fetus from low birth weight.

Explain the purpose of ophthalmic prophylaxis ointment for the newborn.

Due to the prevalence of chlamydia and its asymptomatic nature, and the severity of gonorrheal infection, the risk to the newborn's eyes is such that prophylactic treatment with 0.5% erythromycin ointment, or • other antibiotic, instilled into the eyes within a few hours of birth has been mandated by law in most states. Both pathogens may be transmitted to the newborn's eyes while passing through the birth canal. Gonorrhea can perforate the cornea and cause serious damage to the deeper eye structures. Chlamydia is a slightly milder infection but more common than gonorrheal infection. The mother may decline the prophylactic treatment in which case a waiver must be signed. The ointment is typically instilled from the inner to the outer canthus of each eye.Irrigation does not need to be performed afterwards. This prophylaxis should be delayed until after the first reactive period when the newborn must be able to see its parents.

Discuss causes and remedies for indigestion or heartburn during pregnancy.

During pregnancy the stomach and intestines are displaced by increasing uterine size, especially during the third trimester, causing gastric reflux.In addition, the gall bladder is not as efficient in pregnancy. Frequent small meals and digestive aids seem to be the most effective remedy. Limiting fat intake can decrease issues due to gall bladder insufficiency. Meals should be completed well before lying down at night as food in the stomach when the mother is supine exacerbates heartburn. Some effective digestive aids are Dandelion leaf or Red Raspberry leaf in herbal infusions or other ingestion method, and Slippery Elm lozenges, which work for extreme heartburn. Raw almonds, raw papaya, or papaya enzyme tablets can also help relieve heartburn and aid digestion

Explain the need for appropriate weight gain during pregnancy.

During the first visit, the mother's weight should be checked and charted along with her pre-pregnancy weight and a note of the total gain to date.If the mother's pre-pregnancy weight was appropriate for her frame and height, she should gain an average of one pound a week.It should be emphasized to her that an ample weight gain is required for fetal health and maternal endurance during pregnancy and labor. However, the weight gain should not be overdone as gaining too much weight can also cause complications, not only during pregnancy and childbirth but afterwards since the gained weight may be hard to lose. Generally, the following weight gain is accepted as appropriate: Underweight women should gain 27 to.40 pounds Normal weight women should gain 25 to 35 pounds Overweight women should gain 15 to 25 pounds Obese women should gain less than 15 pounds

Discuss the maternal psychological changes that occur during the second trimester.

During the second trimester, or "the period of radiant health", the mother feels good but is at her most introspective. This trimester is divided in to prequickening and postquickening. Quickening makes the pregnant woman the most aware she has been of her impending motherhood. Her primary adjustment is to discover her own mothering identity. Prior to quickening, sh will re-examine her relationship with her own mother and divine those qualities she will keep or reject. After quickening, the social circle of the mother changes to include more new mothers or others who are pregnant. Relationships change. Some grief is felt. The baby is now seen as a separate entity and the woman begins to focus on the baby instead of herself. In addition, her libido may increase as may her ability to feel sexual satisfaction.

Explain dyspareunia

Dyspareunia is defined as pain during sexual intercourse. The pain may be caused by pelvic/vaginal congestion from impaired circulation by uterine pressure. The abdominal enlargement may cause positional changes that are painful. Psychological causes may occur from misconceptions about sex during pregnancy and fear of harming the fetus. Positional changes may alleviate some issues due to an enlarged abdomen and ice may reduce congestion but cause its own discomfort. Discussion of any fears regarding sexual intercourse may alleviate psychological issues. Alternative sexual practices may be recommended.

Discuss edema and varicosities in pregnancy.

Edema is a common complaint in pregnancy. Edema of the ankles is a typical issue.It is often exacerbated by activity or hot weather. Edema of the upper shins, breastbone or sacrum is definitive for hemoconcentration. When coupled with proteinuria and/or hypertension it is indicative of preeclampsia and should be investigated and treated immediately. The degree of edema can be assessed by observing for pitting, or observing if an indentation in the edematous tissue remains. The degree of edema is rated by depression size: • +1 = 2mm • +2 = 4mm • +3 = 6mm • +4 = 8mm Any pitting of +2 or higher is indicative of preeclampsia. Varicosities tend to occur in pregnancy in those predisposed to them. They may be predictive of deep vein thrombosis. Varicosities can cause pain and reddened or white areas on the calf, secondary to deep vein thrombosis or phlebitis. Referral to a physician is recommended.

Discuss common environmental hazards to a safe pregnancy.

Environmental hazards are found at home and in the workplace and can cause conditions from premature labor to fetal death. Hazards are chemicals, heavy metals, temperature issues, radiation, infectious agents, and stress. Lead based paint is an environmental hazard that is a common public health issue. Lead exposure during pregnancy can cause miscarriage, low birth weight and developmental disorders. Lead exposure can also come from the workplace. Other environmental hazards include exposure to drugs such as cancer treatments, ethylene glycol ethers, and jobs that require heavy physical labor. Health care workers or animal workers are at particular risk of exposure to any number of infectious agents in the workplace . Most infections can be prevented by proper hand-washing or vaccination prior to pregnancy. A thorough history reveals most of the hazards the mother is exposed to and you should discuss the consequences of exposure to her and her fetus and how problems can be prevented.

Discuss the performance of newborn metabolic screening.

Every state in the United States requires newborn metabolic screening for congenital hypothyroidism and phenylketonuria. Beyond these two tests, each state may require additional screening tests. You must become familiar with the requirements of the state in which you practice. If the sample is taken before the infant has been feeding for at least 48 hours, the test will be invalid.In this case, a followup screening must be scheduled and collected, either by you or some other agency. In order to collect the sample appropriately, the instructions with the test must be read and followed.It is important to neither underfill nor overfill the testing areas with blood. The sample should be collected from the lateral underside of the infant's heel and placed on the sample areas according to the instructions for the test.

Discuss the reasons for examining the abdomen for scars/bruises, linea nigra, abdominal striae. Discuss the need for fetal heart tone (FHT) auscultation, and observation or palpation of fetal movement.

Examine the abdomen for scars and bruises to obtain information regarding the woman's health and potential problems. Scars and bruises on the abdomen should be satisfactorily explained by the mother. They may be evidence of physical abuse. In the case of scars, a caesarian scar is particularly important to note to determine if the mother is wishing to VBAC. Note any appendectomy scar so that any right side pain will not be misdiagnosed. The linea nigra and the abdominal striae are presumptive physical signs of pregnancy. The palpation of fetal movement and the presence of fetal heart tones are confirmatory signs of pregnancy. The typical fetal heart rate is 120-160 beats per minute. There is no predictive value in the heart rate for determining the gender of the fetus.

Explain the technique of self breast examination.

Examine the breasts in a mirror, first with arms down then with them up, to determine the normal look of the breasts and to check for: • dimpling, puckering, or bulging of the skin; • an inverted nipple or a nipple that has changed position; redness, soreness, rash or swelling. While at the mirror, squeeze each nipple gently to check for discharge of any color. Check the feel of the breasts first while supine then while upright, using the left hand to check the right breast and vice versa. Raise the opposing arm above the head. Examine the breast with the fingers together and flat, using a firm touch. Examine the entire breast including the nipple from collarbone to abdomen and cleavage to armpit using a pattern that covers the entire area. Palpate all tissue, from just under the skin down to the ribcage. The upright exam may more easily be performed in the shower on wet or soapy skin.

Discuss the role of nutrition and hydration in pregnancy-induced hypertension.

Exercise and nutrition, while important in general for pregnancy, can help alleviate pregnancy-induced hypertension. Aerobic exercise increases circulation and dilates blood vessels.If the mother's blood pressure rises to 140/90, rest should be recommended over exercise. Abnormal weight gain, which can be the result of poor nutritional habits, can exacerbate a tendency for high blood pressure but stressing the system. High quality protein, whole grains, and mineral rich vegetables and fruits should be consumed . Some foods are particularly suited to reduce blood pressure such as watermelon, cucumber, parsley, onion, and garlic. Salt intake should continue according to taste. The consumption of stimulants such as caffeine, nicotine, and cocaine can cause vasoconstriction and low birth weight and should be completely removed from the diet. Strong spices such as mustard, ginger, nutmeg and black pepper may also cause issues and should be reduced or avoided. Fluid intake should be increased.

Discuss external cephalic version.

External cephalic version (ECV) is a method of turning a breech to a cephalic presentation. Note: this procedure should only be performed by a skilled and experienced practitioner in a facility equipped for emergency delivery. This procedure should not be I attempted prior to 37 weeks gestation due to risk that the fetus will revert or that labor will begin. The amniotic fluid I volume, position and engagement of the fetus, and maternal parity all play a role in the success of this procedure. Ultrasound determines the ! placental position, and position and presentation of the fetus. With the I · woman in a supine position dislodge the breech from the pelvic brim towards an iliac fossa. With one hand on each end of the fetus, gently I force the fetus to perform a forward somersault into the cephalic position.If this is not possible, attempt a backward somersault. If the ' fetus will not easily turn, discontinue the ECV and try again in a few days.Immediately after the attempt auscultate the fetal heart tones and administer Rhogam if the mother is Rh negative mother, in case of placental separation.

Explain the condition "failure to thrive".

Failure to thrive is a condition where the infant cannot obtain, retain, or use enough calories needed to grow and are small when compared to age related norms. Either weight or length are lower than the third percentile or are decreased by more than two major percentiles from one measurement to the next.In the first year of life, failure to thrive is generally due to an organ system issue.Infections, intolerance to milk proteins, chronic illness, problems with the gastrointestinal system, such as chronic diarrhea or cystic fibrosis (which causes a malabsorption disorder), can all cause failure to thrive, as can physical and metabolic disorders. Occasionally, there may be a social factor. It is possible that parents who are worried about an overweight child will limit the infant's nutritional intake. Social issues can contribute to this condition, including poverty. Sadly, it can also be attributed to child abuse.

Discuss the implications of fetal bradycardia discovered during fetal heart rate auscultation.

Fetal bradycardia with a heart rate >80 bpm with appropriate variability rarely indicates acidemia. No variability with prolonged or late decelerations is typically found in hypoxia and metabolic acidosis. Sever hypoxia can present with a bradycardia with no variability and no return to baseline;"this condition worsens over time and may be seen immediately before intrauterine fetal death. With bradycardia only, at rates of 100-120 bpm, the following may be present: maternal hypothermia, administration of drugs such as propanolol, prolapsed cord or cord compression, cardiac abnormalities, vagal stimulation, or fetal hypoxemia or asphyxia. With rates of less than 110 bpm an immediate assessment should be performed for a prolapsed cord, expected time until delivery, duration of the bradycardia, the presence/absence of variabiiity, and late or prolonged decelerations. Sustained bradycardia with positive fetal movement is indicative of a complete or incomplete atrioventricular heart blockage.

Discuss the fetal kick count procedure.

Fetal movement is a reassuring symptom of a healthy pregnancy. Counting and recording the number of movements within a particular period of time each day can help determine if the number of movements is decreasing from a previously determined norm.If there is a significant decrease in movement, there is a high probability of a problem. If movement ceases, fetal death is a significant probability. Cigarette smoking can dramatically depress fetal activity . The methods used are not significant as long as accurate and precise results can be obtained. Count-to-ten method: One count session is performed at the same time each day . The time taken to reach lb movements is recorded. At least 10 movements should be felt in 10 hours. If there are fewer than 10 movements, if the time to reach 10 movements is increasing, or if no movement is felt within 10 hours, the woman should contact you.

Discuss the implications of fetal tachycardia discovered during fetal heart auscultation

Fetal tachycardia in conjunction with late decelerations or prolonged variable decelerations without variability indicates fetal hypoxia. Meconium may or may not be present.If the fetus is at term and the only issue is tachycardia, it is unlikely that the outcome will be I negatively impacted. A premature fetus or a post-term fetus, however, [ is not able to withstand the stresses of the underlying conditions as well as a term fetus. Tachycardia with no other fetal heiilrt rate I changes may indicate: hyperthyroidism, fetal anemia, maternal I dehydration, congenital anomalies, maternal hyperthermia, fetal hypoxia, administration of drugs such as beta-sympathomimetics, hypertension or asthma medications, and prematurity with gestational ; age less than 28 weeks. The cause of tachycardia must be identified and treated whenever possible and other tests of fetal well-being should be used such as scalp stimulation or scalp blood sampling.

Discuss the importance of determining fundal height and the two most accurate methods of measurement.

Fundal height is determined starting about 22 to 24 weeks of gestation ' and serves to measure progressive growth and size for dates. If the 1 height does not increase over a period of time perform an investigation into intrauterine growth restriction or fetal death. Inappropriate height 1 for dates also indicates problems. The least used and most accurate method after 22 to 2 weeks gestation uses calipers to measure the length between the superior border of the symphysis pubis and the top of the fundus. The second most accurate, and the most popular, method relies on a tape measure. The zero line of the tape is placed on the superior border of the symphysis pubis and the tape stretched along the midline of the abdomen to the top of the fundus. The number of centimeters should approximately equal the number of gestational weeks. All healthcare workers measuring the fundal height should notate the method used or try to standardize to one method.

Explain when genetic counseling should be recommended.

Genetic counseling should be recommended to those who: • have an inherited disorder or birth defect, • are pregnant or plan to become pregnant after the age of 35, • have existing offspring with a birth defect or other inherited disorder, • have lost babies in early infancy or had three or more miscarriages, • may be exposed to hazardous materials, • may have issues common to their ethnic group, • are couples who are first cousins or other close blood relative, or • are pregnant and whose ultrasounds or blood tests indicate an increased risk for birth defects. The family history and the parent's medical background are documented. Based upon this, blood tests, physical exams or amniocentesis may be recommended. The information is analyzed to explain the role of genetics in any condition discovered. Referral to a genetic counselor, resources, medical specialists, education specialists or support group is of enormous assistance in the parents' decision making process.

Discuss the possible causes and remedies for varicosities during pregnancy.

Genetic predisposition may play one role in the tendency of a woman to develop varicose veins during pregnancy. The pressure of the enlarged uterus on the pelvic veins when the mother is sitting or standing can create poor venous circulation and increase venous pressure on the legs. These can also impact the vena cava when she is lying down. Constrictive clothing can exacerbate the problem as can standing for long periods of time. Smooth muscle relaxation caused by progesterone adds to the issue as well by impacting the venous walls and valves. Remedies include the use of support hose, elasticized sport wraps, or elastic stockings. These should be applied to the legs after the legs have been elevated and also before rising from bed in the morning. Rest with the legs elevated throughout the day, decreased standing time, avoidance of crossing the legs and constrictive clothing will help mitigate the problem

Discuss gestational age equivalencies and the definition of a post date pregnancy.

Gestational age equivalencies refer to the various methods of dating a pregnancy. The most c;ommon method is the menstrual age. The pregnancy is dated in reference to the first day of the last normal menstrual period. The menstrual age, the gestational age and the fetal age are all identical. The average length of pregnancy is 280 days (40 weeks or 10 lunar months/9 calendar months). Conceptual age and ovulatory age are identical. The average length of pregnancy for the conceptual and ovulatory age is 266 days or 38 weeks (9 lunar/8 calendar months). The average gestational age of a pregnancy allows for estimated birth dates within a 4 week range, 2 weeks on either side of the estimated birth date. A post date pregnancy is considered to be any accurately dated pregnancy that is more than 294 days, more than 42 weeks, or more than 10 lunar months.

Discuss the importance of accurately dating a pregnancy.

Gestational age must be accurately assessed in order to determine the appropriate time for screening tests that are performed at specific times of the pregnancy . Without accurate dating the screening may be performed at an inappropriate time which in turn leads to misinterpretation of data, unnecessary treatment, or failure to treat when needed. Gestational age at birth is the best predictor of infant well-being and it is the best method for determining the timing of delivery. Accurate assessment of gestational age becomes more difficult as the pregnancy continues. There are various methods for obtaining enough data to make an accurate assessment, some of which depend upon the woman keeping accurate records in anticipation of conceiving. Since 70% of all conceptions are unexpected, these methods have the lowest compliance rate but one of the highest accuracy rates when used. Other methods depend on various screening or testing methods rather than record keeping.

Define gestational hypertension, its impact to the pregnancy, and its management.

Gestational hypertension, also known as pregnancy induced hypertension, is defined by blood pressure readings of 140/90 or above in repeated readings at least 6 hours apart to rule out readings affected by tension and emotional issues. Readings done with the mother on her left side are thought to be most accurate. Treatment to reduce this type of hypertension includes aerobic exercise, deep relaxation practice, elimination of stimulating foods and drinks and strong spices, a proper diet and herbal supplements, and counseling by a therapist.If readings of 160/100 or more occur, medical intervention is needed. If blood pressure suddenly increases near term with no other symptoms, it will likely resolve when labor begins. If all else shows readiness for labor, attempt inducing labor. f the blood pressure readings steadily rise during labor, preeclampsia or vascular damage may be beginning. Transport the mother to the hospital.

Explain the consequences of gonorrhea in pregnancy.

Gonorrhea is a sexually transmitted disease. Infected women are often asymptomatic but can exhibit pain and burning upon urination, increase vaginal discharge or bleeding or spotting. Male partners often exhibit discharge and pain and burning upon urination. Complications during pregnancy include: • Chorioamnionitis, • Premature rupture of the membranes, • Preterm labor, • Fetal blindness if antibiotic drops are not instilled into the eyes within 2 hours of birth, • Fetal joint infection or sepsis Gonorrhea is often seen in conjunction with Chlamydia.If either one or both of these infections are present, both partners must use barrier-type birth control until the infection is resolved.

Explain the consequences of Group B Streptococcus (GBS) to the infant during the birth process.

Group B Streptococcus can be found in the vagina or rectum of up to 30% of women, who are at no risk of harm from these bacteria . However, 5% of newborns can become infected during the birthing process. Premature infants are most at risk. Early onset GBS occurs within a few hours of birth. The first symptoms are often lethargy, fever, and difficulty feeding. This can lead to pneumonia, sepsis or meningitis. Late onset GBS occurs a few weeks to a few months after birth and about half the cases are passed from the mother. The I symptoms and illnesses are similar to those of early onset GBS but are usually less severe. Even with antibiotic treatment GBS, both early and I late onset, can be fatal. Survivors, especially of meningitis, may have I long term neurological damage such as seizures and hearing loss.

Describe the four pelvic types.

Gynecoid: Considered "ideal" for bearing children. The brim is rounded and the forepelvis is roomy. The ischial spines are blunt, sciatic notch rounded, and sub-pubic angle 90 degrees. The woman 's build and height is average. Smaller women may have a justo minor pelvis, exactly the same as gynecoid but with smaller measurements. Android : Least suited to childbearing. The brim is heart-shaped; the forepelvis is narrow . The .ischial spines are prominent and sub-pubic angle less than 90 degrees. The woman's build and height is short and heavy. Anthropoid : Typically no issues for delivery. The brim is long and oval, with the anter.oposterior diameter longer than the transverse. The ischial spines are not prominent, a very wide sciatic notch and sub-pubic angle. The woman's build is tall with narrow shoulders. Platypelloid: Typically no issues for delivery. The brim is kidney shaped; the pelvis flat . The anteroposterior diameter is decreased; the transverse increased. The ischial spines are blunt with a wide sub-pubic angle and sciatic notch.

Explain the diagnostic use of the H&H (hemoglobin/hematocrit), the complete blood count (CBC) and the blood glucose level.

H&H {Hemoglobin/Hematocrit): a screening test for anemia. Hemoglobin should be 11 g/dl or greater and the hematocrit 33% or greater. Low values impact the oxygen carrying capacity of the mother's circulatory system. Complete Blood Count {CBC): includes the hemoglobin and hematocrit. It also reports the number of red blood cells with their indices, the number of white blood cells with their type differential, and the number of platelets. A higher than normal white count may indicate the presence of an infection. Lower than normal platelet counts can result in bruising or extended bleeding. Blood glucose level: also called the blood sugar, this test screens for diabetes. A normal fasting glucose level is less than 99 mg/di. A higher reading indicates the possibility of gestational diabetes. A glucose tolerance test is then indicated.If gestational diabetes is diagnosed, closer monitoring of the mother's blood glucose is required.

Explain newborn hemorrhagic disease and differentiate between early and late onset.

Hemorrhagic Disease of the Newborn (HDN) occurs when there is a deficiency of Vitamin K. Symptoms of HDN are: • bruising, • bleeding from the umbilicus, nose, scalp, or puncture sites, gastrointestinal bleeding. HDN may be implicated by severe jaundice for more than 1week or persistent jaundice for more than 2 weeks. HDN occurs in three forms: • early (0 - 24 hours), • classic (1 - 7 days) • late (1-12 months with peak onset before 8 weeks). Early HDN is rare and impacts infants born to mothers who took warfarin, phenobarbital or phenytoin during pregnancy . Prevention is administration of Vitamin K in the last weeks of pregnancy. Classic HDN strikes infants with birth trauma, postnatal hypoxia, asphyxia, prematurity, antibiotic therapy disrupting normal gut flora, or poor enteral feeding. Late HDN occurs in breastfed infants or those with liver disease and Vitamin K absorption disruption in the bowel, as in cystic fibrosis. Injection of Vitamin K intramuscularly within the first hour of birth is preventative.

Explain Hepatitis B and risks to the mother and baby

Hepatitis B (HBV) can be transmitted through blood and through body fluids such as semen, saliva, or vaginal secretions. It is highly contagious and mothers who are Hepatitis B Surface Antigen (HbsAG) positive are highly likely to transmit the virus to the baby. The baby can then become a carrier and may pass the virus to their own children. Babies born to HbsAG positive mothers must be immunized within 12 hours of birth to avert this problem.If immunized, the baby can then be breastfed by the mother. Mothers with active HBV infections should be hospitalized and all family members screened. Active infection is characterized by nausea, vomiting, upper right quadrant abdominal pain, chills and fever. An HBV carrier may be asymptomatic and w ill be positive for Hepatitis B Core Antibody (HbcAB) .

Explain Hepatitis C and the risks to pregnancy.

Hepatitis C (HCV) is transmitted by blood and blood products and by sexual transmission. Symptoms of active infection are similar to Hepatitis B (nausea, vomiting, upper right quadrant abdominal pain, chills and fever), but 85% of cases become chronic. Transmission to the fetus occurs in about 5% of cases depending on the viral load of the. mother's bloodstream but breast milk is not impacted. About 20% of hepatitis cases in the United States are HCV. There is no immunization for this virus. A mother who tests positive for HCV should be referred to her backup physician and also counseled that she · may require liver function evaluation with blood tests and possibly a 1 liver biopsy. Treatment for HCV includes injections of alpha interferon and oral ribavirin (an antiviral). However, ribavirin is a teratogenic drug and this treatment is contraindicated in pregnancy.

Explain the benefits of the following herbs for pregnancy support: nettle leaf, dandelion leaf, red raspberry leaf, and red clover leaves and blossoms.

Herbal infusions are one method of ingesting herbs; one ounce of herb to one quart of boiling water is a general recipe for an infusion. Nettle leaf supports the kidneys, helps prevent leg cramps, and contains vitamins A, C, D and K. It is also a source of calcium, phosphorus, iron and sulfur. Dandelion leaf supports both the liver and the kidneys.It helps prevent preeclampsia and acts as a digestive aid. It is a source of vitamins A, B complex, C, and D. Red raspberry leaf is a uterine toner, a digestive aid and a remedy for morning sickness. Red clover leaves and blossoms are a source of calcium, magnesium and trace minerals. t supports the reproductive and endocrine system.

Discuss developmental hip dysplasia.

Hip dysplasia occurs most often in breech birth or oligohydramnios and more often in first pregnancies and in female infants. The left hip tends to be the one affected. The hip may be dislocated, easily dislocatable, or have subluxion at the joint. Only an experienced health care worker should perform the examination for this, using either Ortolani's test or Barlow's test. An ultrasound of the hips and a referral to an orthopedic specialist is recommended . Treatment is commonly performed by using a special splint or a harness.

Discuss the use of homeopathic remedies, herbs, acupuncture, reflexology, and aromatherapy for pain relief

Homeopathic Amica 200C alleviates irritation and reduces swelling in the cervix making contractions more effective and regular. Motherwort tincture provides pain relief when birth is not imminent and rest is needed. It creates a somewhat disconnected feeling to the uterus however, and may be contraindicated if labor is not yet regular. Skullcap tincture is a good overall pain reliever but has a sedative effect. Back, side, and uterine spasms may respond to a tincture of St. Joan's Wort which works well in combination with Skullcap. Other pain relief measures include acupuncture, reflexology, and aromatherapy. All should be given by trained personnel. Full body acupuncture is often used but ear lobe acupuncture may be sufficient and is easily learned. Aromatherapy uses essential oils for massage, in baths, or applied to mucus membranes. Reflexology, which involves pressure or massage on very specific areas of the feet, has been found to alleviate some pain issues in labor.

Discuss homeopathic or herbal treatment for maternal dehydration and vomiting during labor.

Homeopathic China, Carbo Veg, or Ustilago 200C will alleviate dehydration and exhaustion . It has been found that ice chips actually intensify the desire for liquids rather than relieving thirst and dehydration. Sips of water or other clear liquid with some sugar added for energy are better treatments for dehydration, dry mouth and throat, although unrestricted access to liquids would be best if possible. Herbs that have often been used to alleviate nausea and vomiting are peppermint, spearmint, or chamomile tea, and ginger capsules or tea. Nausea can also be relieved by pressure on the acupressure point PC-6 on the inner wrist. Nausea may be due to an empty stomach. Food restrictions may not be necessary in the first stage of labor. Light, non-constipating foods help supply energy for the later stages of labor

Explain the use of homeopathy in pregnancy and childbirth.

Homeopathy is considered an "energy" medicine. Small, highly diluted doses of substances are given that, at full strength, are causes of the symptom being treated. Homeopathy treats the whole person by considering the personality and the factors that make the symptoms change. It sees significance in even minor symptoms. Homeopathic remedies work by stimulating self healing rather than suppressing a symptom. Accurate advice should be obtained before attempting to use homeopathic remedies during pregnancy and childbirth. Two common remedies are Arnica and Pulsatilla. Arnica Montana is used to treat bruising, shock, and trauma.It is used as a tablet or cream. It should not be applied to an open wound. Pulsatilla is used to treat hemorrhoids, varicose veins, and heartburn.It has also been used for apprehension and slow labor progress with ineffective contractions, emotional distress, and fainting.

Describe Human Papilloma Virus (HPV) and its i:iossible consequences to a woman's health.

Human Papilloma Virus (HPV) is the most common sexually transmitted disease although it can also be contracted without sexual contact.It is possible for a mother to be unaware of the infection because there may be no outward signs of infection at all. HPV can be seen as condyloma accuminata, or visible genital warts, as well as flat lesions that are less visible. The warts can be treated topically but there is no cure for HPV. Some genotypes of HPV may be precursors to \ abnormal cell growth that can develop into cervical cancer . When HPV \ is diagnosed, it is recommended that pap smears be taken every 6 months to aid in early cancer diagnosis. HPV infection can be passed to \ the infant during birth. Genital warts may enlarge during pregnancy. Some treatments may harm the fetus in utero and must be avoided during pregnancy.

Discuss the role of hydration and alcohol consumption or administration in preventing or stopping preterm labor.

Hydration is often regarded as a method of stopping preterm labor based on the assumption that preterm labor can begin due to dehydration. However, this has not been shown to be the case, although the recommendation still appears in many texts. Using hydration to attempt to delay birth can increase the risk of pulmonary edema if tocolytic therapy is later used and so can delay the prompt administration of tocolysis when it is needed. The risk of pulmonary edema can be reduced by hydrating intravenously with a hypotonic solution such as 5% dextrose in water or 5% dextrose in 0.25% normal saline. Prior to the availability of today's tocolytic drugs, alcohol was used to slow or stop preterm labor. It can be given intravenously but oral administration may be effective enough. The equivalent of two shots of strong spirits daily may stall preterm labor.

Discuss hydrocephalus and spina bifida.

Hydrocephalus is caused by a blockage in the circulation and absorption of the CSF in the lateral brain ventricles which swell and compress the brain tissue around them. Characteristics are large tense anterior fontanelle, splayed skull sutures, increased occipitofrontal circumference, "sun-setting" eyes, and irritability or abnormal movements.It can be managed with a ventriculoperitoneal shunt. Spina bifida aperta is caused by failure of the vertebral column to fuse. The area has no skin covering resulting in a meningocele or myelomeningocele. The lesions may rupture and expose the neural tissue. This often occurs at the lumbosacral area but can be anywhere on the vertebral column. An encephalocele is a myelomeningocele at the base of the skull and may contain brain tissue. At birth cover open lesions should with a non-adherent bandage and the take care not to damage the sac. Transport the infant. Spina bifida occulta is a minor defect with no spinal cord involvement.

Discuss hydrotherapy and visualization during labor.

Hydrotherapy, or immersion in water, can relieve muscle spasms and the effects of gravity on the woman's body decreasing the stress on the pelvis. There is little evidence in the literature of increased risk with hydrotherapy. The use of warm water to sooth tight muscles and uncomfortable joints can decrease reliance on analgesics. Labor progresses more efficiently and quickly when the mother is relaxed, thereby negating use of labor augmentation drugs. The .mother's birth experience is also more positive. The temperature of the water should not be above normal body temperature. This avoids increasing fetal temperature and heart rate. Continuous soaking can slow labor somewhat so the length of the bath should be monitored and bathing delayed until labor is well established. Visualization is the practice of visualizing a soothing place or a smooth birth. It is often taught in conjunction with muscle relaxation techniques to help the mother achieve a positive birth experience.

Discuss the management of pregnancy induced hypertension.

Hypertension is managed according to its severity. Close monitoring is required in the event it progresses into preeclampsia. Rest, appropriate nutrition, and adequate hydration are required. The weight will be monitored along with other parameters. The blood pressure is monitored at home on a daily basis, and every 4 hours if the mother is an inpatient. A daily abdominal exam is performed to identify any tenderness that could signal placental abruption or HELLP syndrome. A biophysical profile is performed to assess fetal well being. A complete blood count (CBC), coagulation profile, electrolytes, " BUN, creatinine, albumin and liver function tests are performed. In severe preeclampsia the blood tests may be repeated every 12 to 24 hours. Certain drugs, such as methyldopa, atenolol, labetalol, and nifedipine may be prescribed as a short term prophylaxis. Some antithrombolytic agents are also prescribed to prevent DIC and other conditions found in preeclampsia.

Explain hypoglycemia of the newborn.

Hypoglycemia refers to abnormally low blood sugar. A blood glucose level should be taken via heel stick. Normal levels for a newborn are 50-60 mg/ml. Leyels below 30 mg/ml require immediate intervention. At risk are infants that are: • large or small for gestational age, • premature, • postmature, • born of diabetic mothers • hypoxic or depressed at birth. and they will exhibit: • apathy, • irregular respiration, • hypothermia, • refusal to nurse • a high pitched cry. If the level is 45 mg/ml or above, the baby should be nursed as often as possible and given water with molasses every few hours (1 teaspoon per cup). The central nervous system can sustain damage if blood glucose levels are too low. The newborn may require more aggressive treatment.

Discuss the management of a pregnancy that occurs when anIUD is in place.

If a woman who has an IUD becomes pregnant there is a significant ri_sk of intrauterin. infection, placenta previa, premature tabor, spontaneous abortion, and spontaneous septic abortion, anc:l ectopic pregnancy.If the strings of the IUD are not observed at the cervical os or accessible in the cervical canal, use ultrasound to locate the position of the IUD.If theIUD car:i.not be found, it is possible it was expelled and arrangements for prenatal care or a therapeutic abortion can be made according to the woman's decision about maintaiping the pregnancy. If theIUD is found but inaccessible for refiiloval, a therapeutic abortion should be discussed since the risk of septic abortion in the second . trimester is significant and life-threatening to the mothi=r.- Ttie IUD should be removed in any case. Even if therapeutic abortion has been chosen, removal of the IUD decreases the risk of a spontaneous septic abortion prior to therapeutic abortion.

Explain fetal scalp stimulation.

If assessment of fetal well-being does not give a reassuring result, the fetal scalp can be stimulated in an attempt to increase the heart rate. The fetal scalp can be massaged through the dilated cervix with a finger for 15 seconds.If this does not create the desired response, an Allis clamp may be used to pinch the scalp. The fetal heart rate should accelerate for at least. 15 seconds. If electronic fetal monitoring or auscultation is being performed at the time of a pelvic exam, any acceleration during the exam should be recorded as a reassuring sign of wellness. Another method of stimulating the fetal heart rate is through vibroacoustic stimulation. The result is typically a startle, activity, and FHR accelerations. However, if fetus is startled from a sleep state to an awake state tachycardia may result. The fetus must be monitored until a normal baseline heart rate is established.

Explain the signs and categorization of intrauterine growth restriction.

If the birthweight of a newborn is below the 10th percentile for gestational age, it is considered to be small for gestational age (SGA). The majority have an underlying cause for intrauterine growth restriction (IUGR). Other signs ofIUGR are subcutaneous tissue wasting, prominent eyes and firm skulls. There may be compensatory polycythemia . There are two categories of IUGR. Symmetrical IUGR includes infants who were affected early in gestation. They will have both reduced cranial circumference and reduced birthweight. Symmetrical IUGR can be caused by · chromosomal anomalies, exposure to drugs or other teratogens , or perinatal infections. Asymmetrical IUGR includes infants who were affected late in gestation, usually the third trimester. The birth weight is below the 10th percentile but the cranial circumference is above the 10th percentile.It is usually due decreased placental blood flow or oxygenation of the fetus.

Describe the signs of placental separation in third stage labor.

If the cord has been cut, the clamp can be observed to move downward as the placenta detaches in the third stage of labor. Cord blood, if needed, must be collected before separation occurs. Excessive bleeding should be noted as there should be minimal blood loss until placental separation. In rare cases, the placenta only separates in the center with outer margins attached. The uterus grows larger and blood filled; the mother can go into shock. Guarding the uterus, with a hand resting on the fundus as soon as birth occurs and leaving it there until placental delivery helps rule out such a separation. The fundus should not be prodded or massaged as this could cause partial separation and hemorrhage.

Explain the use and insertion of a urinary catheter, including reasons for catheterization in pregnancy or childbirth.

If the mother's bladder has become distended in second stage labor because she has been unable to empty it naturally, you may need to catheterize to empty it, preferably before the baby's head enters the true pelvis. Consider the following: whether the bladder is distended, whether the mother has urinated in the past 2 hours, • whether the risk of a bladder infection is greater than the need to empty the bladder, whether a complication is expected. A full bladder can cause discomfort or even become traumatized, especially if a labor complication ensues such as shoulder dystocia, which requires an empty bladder to manage. When the catheter is inserted at this point, the urethra is displaced by the fetal head and also conforms to the head's contours. The catheter must be guided in the direction of the urethra to avoid traumatizing the urethral wall.

Discuss non-allopathic remedies for slowing or halting preterm labor.

If there is a predisposition towards the condition, consumption of oily fish or fish oil capsules, or supplemental magnesium may help prevent preterm labor. Magnesium supplementation can be used up to 37 weeks gestation; if preterm labor begins, the dosage can be increased and a deep warm bath may help stall labor. Care should be taken with magnesium since it can cause diarrhea. Homeopathic Mag Phos 30C may be effective at a rate of 7 pellets per 4 oz of hot, but not boiling, water. The solution is sipped until gone and the contractions should slow or stop within the hour. Postural tilting several times daily has occasionally stopped preterm labor, perhaps by taking the weight of the fetus off the cervix.If contractions do not slow or if they begin to accelerate notify the consulting physician.

Explain the diagnosis of preterm labor.

Immediately assess a woman who appears to be in preterm labor and notify the consulting physician if assessment shows preterm labor. Take a history that includes: • the present signs and symptoms; • any sign of urinary tract infection, STDs, vaginitis, cervicitis, viral or bacterial infection; • signs of premature rupture of the membranes (PROM). Include a physical exam: • vitals; • evaluation of gestational age, contractions, FHT, CVA tenderness, low back or suprapubic pain; • palpation for multiple gestation, position, presentation, and estimated fetal weight. Pelvic exam: • assess vaginitis or cervicitis, • STDs, • bloody show, • meconium, • PROM, • cervical changes, • station If PROM is diagnosed, a digital exam is contraindicated. Laboratory tests should include urine microscopy, urine culture, wet mount for bacterial vaginosis and trichomonas, cultures for Group B Streptococcus, genital lesions, gonorrhea, chlamydia, CBC, fern test, and nitrazine test.

Describe the causes, symptoms and treatment for shock.

In childbirth, shock is most often caused by blood loss, which is also known as hypovolemic shock. Another possibility is septic shock. The symptoms of shock are: • cool, clammy skin, • weak and rapid pulse, • dull eyes, • faintness, • weakness, • confusion. Occasionally, the mother will lose consciousness. Any delay in treating shock can result in multisystem organ failure and death. You must quickly determine the cause of the blood loss, make an effort to contain it, and stabilize the mother.In the meantime, the mother should be positioned flat on her back with her feet elevated. She should be kept warm without overheating, oxygen and fluids should be administered, and she should be encouraged to breathe deeply and calmly. Emergency medical services should be notified and the mother prepared for transport to a medical facility.

Explain face presentation and its management

In face presentation, the deflexed head is evident during prenatal palpation unless the baby is posterior. If it is discovered before the head is fixed into the pelvis, an attempt should be made to secure flexion. Face presentation can be caused by inlet CPD (cephalopelvic distortion) or a cord around the neck which will tighten and deflex the head it descends. Fetal heart tones must be monitored closely and the birth should not be rushed. Face presentation occurs in 4% of births and can cause a serious obstruction requiring transport to a hospital prior to delivery. The baby must be born chin up to prevent the brow from becoming lodged in the symphysis . This presentation causes extra strain on the perineum and tearing may be unavoidable. The baby will receive more fluids than usual into the nose during birth, requiring more suction and possibly resuscitation . The bruising and swelling can be treated with arnica and Vitamin K.

Discuss the indications for labor induction in a postdate pregnancy.

In most cases, it is best to allow labor to begin spontaneously as long as there are no complications arising. However, in some cases, there is j ustification for inducing labor. The following issues may indicate a need to induce labor: • A low biophysical profile score which translates into a nonreassuring test result for the fetus. • Preeclampsia that progressively worsens at term. • Oligohydramnios • Insulin dependent diabetes • History of previous stillbirth at term • Intrauterine growth restriction. It may also be justified in the case of a woman with a history of rapid labor who has an effaced cervix at 4 cm dilation who may go into labor , away from medical assistance. Being tired of pregnancy and the attendant discomfort or feeling as though waiting is causing family difficulty is not a justification for induction, but rather a need for more I support.

Discuss contraindications to home birth besides pre-existing conditions such as diabetes.

In some instances there is no contraindication to a home birth, only the realization that the relationship between an you and a pregnant woman or her partner may not feel comfortable. Simply refer the mother to another midwife.In other situations, problems may not be evident until the first visit. This can include a contracted or abnormal pelvis, essential hypertension or extreme obesity . Psychological reasons play a role. There may be indications of irresponsibility, hostile reactions to suggestions for improved health, or rigidity in thinking processes. Smoking, drinking, or drug use that is not adjusted or eliminated in favor of the pregnancy or a poor diet may also be signs of unwillingness to adapt to pregnancy or work with you. If other behaviors or conditions become apparent that make you uncertain of the advisability of a home birth, consult experienced peers for assistance.

Discuss any changes in bowel or urination habits commonly caused by pregnancy.

In the first trimester, the weight and shape of the uterus changes to increase pressure on the bladder, causing the feeling of urgency to urinate. in the third trimester, because the engaging part of the fetus has descended and the enlarged uterus crowds the other organs, the bladder loses the room to expand and the need to urinate more frequently occurs.In addition, when edema occurs, the fluid drains during the night and increases the need to urinate during the night, interrupting sleep. Education is the only remedy to this issue, teaching causes and suggesting limiting fluids directly before bedtime. Constipation may develop during pregnancy. Peristalsis is slowed during the third trimester by progesterone. The increasing size of the uterus may also compress the bowel and limit peristaltic movement. Adequate fluids, rest and fiber, and mild laxative foods such as prunes and warm liquids, with the addition of gentle exercise can keep the bowel moving and regular.

Explain Vasa Previa presentation

In vasa previa presentations, the placental or cord vessels present over the cervical os.It is a very rare occurrence that can happen with a velamentous cord insertion or if the vessels emerge beyond the edge of the placenta, running through membranes immediately above the cervix to an accessory succenturiate lob of placental tissue. This condition may be diagnosed if a pulse is felt near the cervix prior to labor or may remain undetected until early labor.If the membrane ruptures near where the vessels run, the mother can hemorrhage and the baby will die. If bleeding is noted after membrane rupture, the mother should be administered oxygen and transported to the hospital. The backup physician must be consulted anytime a presenting part cannot be identified or that may be abnormal.

Define inevitable abortion and incomplete abortion.

Inevitable abortion: A spontaneous abortion (SAB) is highly'\likely to occur and cannot be stopped. Beyond bleeding and lower back or abdominal pain, there is also cervical dilation and/or rupture of the membranes. In the first trimester, the woman may be assisted by a physician to hasten the abortion with a suction D&C or she may wait for the abortion at home while monitoring for infection, heavy bleeding, or clots larger than 3 cm. Once she aborts she should contact the midwife. f there is a history of repeated SAB, the products of conception should be saved for genetic studies and confirmation of a complete abortion and intrauterine pregnancy. Incomplete abortion: An SAB occurs without expelling the placenta along with the fetus. This may result in bleeding, possibly heavy, and infection, especially in the second trimester. Referral to the consulting physician is required to manage the infection and evacuate the retained placenta.

Discuss infant safety in the home and car.

Infant safety in the home begins from birth. The earliest risks are falling or getting stuck between crib bars. Used equipment and supplies should be inspected for reliability and to insure there are no I1 spaces where the infant's head can be stuck. Crib slats can be no more than two and three-eighths (2 3/8) inches apart. The mattress should I fit tightly. The crib should be free of soft bedding and toys that could I suffocate the infant. A child car safety seat is mandated in many states for transporting I infants and young children. Newborn infants must be placed facing I backwards in the back seat of the car. An extremely small infant may I I , not safely fit into a regular infant car seat so different seats should be I tried until a good fit is found. A car seat that is also a free standing infant carrier is a good safety feature because it can be used in the house decreasing the chance of falling.

Discuss the practice of infant bathing and umbilical care.

Infants do not require daily baths. The face, head and the diaper area require cleaning with mild soap whenever they become soiled. The area should be thoroughly dried afterwards. A full bath may be given once the umbilicus has fallen off whenever the parent can commit sufficient time for a relaxed experience. All materials must be at the tub-side and the infant should never be left unattended in the water. The care of the umbilicus begins immediately after birth. Typical practice is to lightly wipe the umbilicus with alcohol or hydrogen peroxide at each diaper change until the umbilicus falls off. The diaper should not cover the umbilicus. Some references state that the disinfection step is not required. The baby s'hould be observed for oozing at the umbilicus and red streaks on the abdomen near the naval requiring medical attention.

Discuss meconium aspiration in the newborn.

Infants with moderate to heavy meconium at birth may develop respiratory problems.If lung obstruction is heard or the baby's respiration is too rapid, the baby should be observed for other signs of respiratory distress syndrome: • nasal flaring, • grunting upon exhalation, • retractions of the chest and abdomen, • cyanosis. If any of these signs are observed, blow-by oxygen should be administered and the baby immediately transported to the hospital with notification of pediatric support. f none of these signs is observed, the baby's breathing may be made easier by using steam to loosen any congestion. In addition, apply percussion using two or three fingertips to tap sharply in each lung quadrant while the baby rests on your lap head down. If the congestion remains unresolved, the pediatrician should be notified. Otherwise, the baby may be observed overnight by the parents for further problems.

Discuss the signs and symptoms of infection.

Infections are caused by pathogenic microorganisms such as bacteria, viruses, fungi, parasites, protozoans, and rickettsia.Infection during pregnancy can directly impact the mother and directly and indirectly impact the fetus. Systemic infections can cause chills, sweats, fever, malaise, and sometimes headache, muscle or joint pain, or changes in mental status. Localized infections can cause tissue swelling and redness, tenderness, heat, and loss of function. The fetus is indirectly impacted when the mother is too ill to take in proper nutrition or maintain proper hydration. The fetus can be directly impacted by certain infections that cause congenital abnormalities. Infections must be differentially diagnosed to determine appropriate treatment. Due to increasing numbers of drug resistant bacteria any bacterial pathogen may require additional study to determine an effective antibiotic. Prescribing antibiotics for a viral infection is ineffective, may be detrimental to the patient, and may increase antibiotic resistance of bacteria that are also present.

Discuss methods for stress reduction for a working mother.

Interview the mother to determine her ability, methods, and time for rest and relaxation during pregnancy. Non-allopathic treatments using Vitamins B and C, calcium, protein and trace minerals, as well as herbal tinctures of hawthorn, passionflower, or hops can help ease chronic stress that can be the proximal cause of night-time pain and insomnia. Chiropractic treatments, massage, deep relaxation and aerobic exercise also help with stress. Advocate resting as soon as work is done, enlisting significant others and family members for support. Quitting work one to two weeks prior to the EDD is essential to prevent an overdue birth. Enough time must be taken from work after the birth to establish bonding, milk supply and a routine. Support ' of a post-partum doula or other helper and from associations such as the La Leche League will increase the success of th first few weeks.If the mother is a student, discuss a reasonable schedule of classes and homework to enable both the mother and baby to be adequately cared 1 for.

Explain the practice and purpose of Kegel exercises.

Kegel exercises, also called pelvic floor exercises, help to strengthen the pelvic floor muscles and maintain urethral and anal sphincter function before and after birth. It also builds awareness of the muscles and the ability to manipulate them to ease some aspects of giving birth. Typically, the bladder is emptied. The pelvic floor muscles are tightened and held for about 10 seconds, then released for 10 seconds. The exercise is repeated up to 10 times. The exercises are performed three times a day. The proper performance of these exercises is important but difficult to discern. The thighs or abdomen may be tightened in error. Awareness of the various muscles within the peritoneal area must be taught in order to avoid these errors. One method of teaching the proper way of doing Kegels is to have the woman sit on the toilet, begin to urinate, and then stop the flow.

Discuss the different maneuvers in delivering a breech

Learn methods of breech delivery as well as possible in the event of unexpected breech delivery where transport or caesarian is not possible. • Pinard maneuver: for delivering a frank breech. t is a method of manipulating the legs of the fetus. The hips are deflexed, the legs are brought down one at a time and the frank breech is changed into a footling. Use this maneuver when delivery has stalled due to a splinting effect of the fetal legs. • Mauriceau-Smellie-Veit maneuver: for keeping the head flexed once the shoulders are delivered . Place one hand is placed into the vagina to hold the infant's face; the index finger goes into the mouth and the back of the finger is pressed against the maxilla. This is not to provide traction. The rest of the hand supports the head. Place the other hand at the back of the neck with one finger hooked over each shoulder to provide traction .

Explain Leopold's Maneuvers 1and 2.

Leopold's Maneuvers indicate fetal lie, presentation, position or variety.It is typically performed at or around 36 weeks. There are four maneuvers starting from the top of the fundus. The palmar flat of the fingers are used for palpating and just enough pressure is used to obtain accurate readings. The first three maneuvers are performed while standing to one side of the mother and facing her head. In the first maneuver, the top of the fundus is palpated with one hand on either side of the fundus. This maneuver identifies whether the lie is longitudinal or transverse and whether the fetus is in breech. The second maneuver is midway between the fundus and symphysis pubis. The area from the abdominal midline to the lateral side and from the symphysis pubis to the fundus is palpated by holding the fetus to one side and palpating with the other, then reversing. This will indicate the variety and the position: anterior, posterior, or lateral.

Explain Leopold's Maneuvers 3 and 4.

Leopold's Maneuvers indicate fetal lie, presentation, position or variety.It is typically performed at or around 36 weeks. There are four maneuvers starting from the top of the fundus. The palmar flat of the fingers are used for palpating and just enough pressure is used to obtain accurate readings. The first three maneuvers are performed while standing to one side of the mother and facing her head. The third maneuver consists of grasping the lower abdomen immediately above the symphysis pubis between the thumb and middle finger of one hand. Findings from the first and third maneuvers should be compared to make a definitive determination of the lie and presentation . The fourth maneuver is done facing the mother's feet. The bottom of the fundus is palpated with both hands. This will determine presentation and engagement.

Describe the use of lidocaine.

Lidocaine is a local anesthetic used when suturing a laceration. Lidocaine spray or gel is administered directly to the laceration then subcutaneous injections of 1% or 2% lidocaine are administered into the edges of the laceration. Wipe the top of the lidocaine bottle with alcohol. • Draw 5-10 cc's of air into the syringe and inject it into the bottle · Draw 5-10 cc's of lidocaine into the syringe. Only 1cc is administered in each location. The injections start at the top of the tear and descend. Do not insert the needle to the hilt. Slowly inject the medication, pulling back on the plunger at each injection site to ensure it has not entered a blood vessel. Wait for the anesthetic to take effect.It may not completely anesthetize the tissue; the mother will feel pressure and pulling but it should not be painful. Lidocaine is also used for pudenda! block.

Discuss the examination of the lymph glands. .

Lymph glands in the neck, chest and under the arms are checked for swelling. This is often done as part of the breast exam. The supraclavicular and infraclavicular regions are palpated for the subclavian nodes. The anterior axilla area is palpated for the pectoral nodes while the posterior axilla area is palpated for the subscapular nodes. The middle of the axilla area contains the central axillary nodes and the upper arm has the lateral brachia! nodes. Any palpable node is cause for concern and should be referred to a physician for investigation. Occasionally infections distal to nodes can cause enlargements of those nodes.If palpable nodes are found in the axilla area, the fingers and hand of that side should be examined for abrasions and cuts around the cuticles and fingernails. Consultation with a physician to confirm this diagnosis is required.

Discuss the management of gestational diabetes.

Maintaining an appropriate level of glucose in the bloodstream is the goal of diabetes management. Most mothers can manage diabetes with diet and exercise while others require the assistance of insulin injections. Nutritional therapy begins with a nutritionist or other professional in diabetic management. Education includes determining food exchanges, types of acceptable foods, determining an appropriate number of calories to ingest and in what forms, and meal planning. Additionally, the mother is counseled in monitoring her blood sugar with the finger-stick method and a commercial glucometer although office visit glucose monitoring can be made available if the woman cannot perform the monitoring herself. Fasting blood sugar should be less than 95 mg/di, 1 hour postprandial blood sugars should be less than 140 mg/di and 2 hour postprandial blood sugar should be less than 120 mg/di. The frequency of monitoring should be determined by the mother and the health care worker to maintain consistent glucose values .

Define malrotation/volvulus, meconium ileus, Hirschsprurig's disease, and pyloric stenosis .

Malrotation (volvulus) is a defect of the small intestine in which incomplete rotation has occurred causing obstruction. Bilious vomiting and abdominal distention are common. Bile stained vomiting requires emergency medical treatment. Surgical correction is required. Meconium ileus is seen in cystic fibrosis . The meconium is extremely viscous and often causes an obstruction resulting in abdominal distension and bile-stained vomiting. A definitive diagnosis is made via a sweat test at 4-6 weeks. Hirschsprung's disease is a defect where the large intestine has a section that is aganglionic; peristalsis is lacking and obstructions, abdominal distension and bile-stained vomit ocur. A rectal biopsy confirms the diagnosis and the intestine is usually surgically resected. Pyloric stenosis is caused by a genetic defect causing hypertrophy of the pyloric sphincter muscles. Typically, the defect is suspected when projectile vomiting occurs at 6 weeks or earlier.It pfedominates in boys and is corrected with surgery.

Discuss contraception issues in post-partum parents.

Many common contraceptive methods are not suitable for a nursing mother. • IUD can cause chronic bleeding and low grade infection. • Basal body temperature and cervical mucus may not stabilize for some time after the birth and during nursing. • Estrogen/progesterone birth control pills can cause milk production to slow or stop while progesterone-only mini-pills are not as effective for birth control. • Norplant and Depo-Provera can cause heavy bleeding and may delay the start of menstruation when stopped. Barrier methods have the fewest side effects and are most effective for post-partum couples. These include condoms, diaphragms, and cervical caps. Some couples dislike the implied separation of barrier devices and may have the urge to conceive again, albeit subconsciously, and be less than diligent with the device. The couple must consider these issues and come to terms with them prior to resuming intimacy.

Discuss diagnosis and treatment of infection in the newborn.

Many early signs of infection are difficult to differentiate from other conditions. An infection may be due to prolonged membrane rupture prior to birth, chorioamnionitis, or infection of the amniotic fluid. It can be diagnosed by abnormal body temperature, urine and stool output. Diagnostic symptoms also include vomiting, lethargy, poor intake of nutrition, hypoxia, acidosis, dehydration, starvation, or central nervous system conditions that require investigation by a neurodevelopmental specialist. A diagnosis of infection can be confirmed by a performing a complete blood count and culturing urine, meconium, nasal, umbilical, pustule, vesicle, amniotic fluid, placental tissue, cord blood or throat secretions . Additional testing includes MRI, CT scan, che.st X-rays, or CSF examination through lumbar puncture.

Discuss post traumatic stress disorder (PTSD) resulting from the birth experience.

Many women who have a traumatic birthing experience can overcome any trauma that may have occurred during the birth such as the effects of pain, the experience of an operative birth rather than a natural one, or a suboptimal emotional experience because of disrespectful or indifferent treatment by staff. Others may not be able to overcome these experiences and suffer flashbacks and nightmares along with other issues related to PTSD. Unlike postpartum depression it is not physiologically based, but directly linked to the trauma, fear, and stress of childbirth. At this time, there is no standard treatment for this issue although it has been thought that a brief intervention in which the immediate symptoms of obstetric distress are treated. You can assist by encouraging the mother to talk about her experiences and fears and by reassuring the mother that nightmares can simply be a way to express fear and anxiety.

Discuss the generally accepted frequency of vital signs, dipstick urinalysis, and observation of food and fluid intake/output during the first stage of labor.

Maternal blood press\.]re is usually checked every hour, while the temperature, pulse and respirations are checked every 2 to 4 hours if the temperature is normal and the membranes are intact. Once the membranes have ruptured, temperature, pulse, and respirations are checked every 1 to 2 hours. Each time te mother passes urine duringlabor, it should be tested by dipstick for ketones indicating exhaustion or distress and proteins indicating preeclampsia. The labor record should also be updated with fluid intake, urinary output, and any emesis in general so that dehydration and ketosis can L>e (!voided.

Explain blood pressure norms and the significance of abnormal values.

Maternal blood pressure should be checked and charted at each visit. The systolic reading (first number) indicates the pressure in the arteries when the heart is actively pumping and indicates the cardiovascular tolerance for exertion. The diastolic reading (second number) is the pressure when the heart is at rest and indicates baseline intravascular tension. Normal blood pressure during pregnancy is in the range of 90/50 to 140/90. In pregnancy, blood pressure may be somewhat elevated due to tension or excitement. However, blood pressure higher than 130/80 may indicate undiagnosed essential hypertension. A steady increase from the baseline may indicate the need for stress reduction techniques. f edema or proteinuria accompanies the increase in blood pressure, preeclampsia may be indicated requiring immediate referral to the consulting physician.

Discuss some effective techniques for preserving an intact perineum during birth.

Maternal self-control is the best way to preserve the perineum no matter the method used. Warm compresses applied to the perineum increase circulation in the local area and relax the muscles, decreasing the risk of tearing. Prenatal digital stretching, while not proven to be protective of the perineum, can familiarize the mother with the sensation of pressure in that area, relieving anxiety about tearing or episiotomy. Perinea! support can be performed by placing the thumb and the middle finger in the left and right groin leaving a slight gap between the hand and the perineum.Inward pressure is applied with the finger and thumb to increase the flexibility of the perineum without blocking the head. A third technique, which is mandatory in lithotomy and dorsal birth positions to prevent tearing, is to control the fetal head by applying pressure against it to keep it flexed then allowing gradual extension as the perineum stretches.

Describe the symptoms and treatment of an amniotic fluid embolism.

Maternal symptoms are : • extreme shortness of breath, gasping, hypoxia • significant decrease in blood pressure • depressed cardiac function • seizures • DIC (Q.isseminated ntravascular _coagulation) Typically occurring during hard labor, it is caused when amniotic fluid or fetal cells enter the mother's bloodstream . Although this is a rare complication maternal mortality rate is 60-80%. The mother must be transported to a hospital immediately.If the baby is delivered within 15 minutes of embolic occurrence, there is a 67% chance of intact survival of the baby. Maternal management includes treatment for shock, CPR with oxygen, and anIV. If the birth is complete, bimanual compression helps prevent bleed-out. The mother should then be transported to the hospital. At this time there is no known cause of amniotic fluid embolism although it is thought that abortion, amniocentesis, amnioinfusion, or hyperstimulation of the uterus with an oxytocic may cause this complication.

Explain the uses of methergine, pitocin, Vitamin K.

Methergine: an ergot derivative used to control uterine bleedif\g after delivery.It is offered as an oral medication or as an intramuscular injection and can be given when bleeding occurs or as a preventative. It promotes uterine contraction. Pitocin (Oxytocin): similar to methergine and is given for the same condition. Pitocin causes uterine contractions which can help staunch or stop postpartum bleeding. Both methergine and pitocin are used when the placenta must be manually removed or when it properly separates but maternal bleeding does not cease. Vitamin K: administered routinely to newborns to prevent hemorrhage. Vitamin K activates precursor proteins that in turn make blood clotting proteins.Injected Vitamin K stimulates clotting.It can also be found in alfalfa tablets which an expectant mother can take regularly in the last weeks of pregnancy to facilitate clotting after giving birth.

Describe the type of care typically given by midwives.

Midwives are often involved with their clients from the early part of pregnancy and offer continuous prenatal care. This affords them a chance to know their client exceptionally well and to intuit how the birth will go. Midwives tend to do extensive prenatal assessments which results in a more relaxed and predictable birth. Midwives see mothers as unique individuals who all have different needs during their pregnancy. This gives him or her the information to assist each mother with the best practices for that mother. This also gives an advantage to the midwife at the time of labor and delivery. By knowing the mother so well, he or she can more reliably tell whether all is going as it should, more so than if she was unfamiliar with the mother.

Discuss the use of osteopathy, chiropractic and reflexology treatment in pregnancy.

Midwives typically do not practice osteopathy or chiropractic but may make a referral to a practitioner. Both practices rebalance the neuromusculoskeletal system to align the body. The difference is osteopathy looks at mobility in joints where chiropractic treats the relative position of joints. While both practices have been used to treat symptoms of heartburn, nausea and constipation, they more olten deal with structural symptoms such as backaches and sciatica. These practices can also be used in labor. Some osteopaths specialize in craniosacral therapy which treats infants with excessive head molding after instrument deliveries. Reflexology uses very precise manipulation of the feet to treat general physiological discomfort and labor pain. Constipation, headaches, anxiety, sciatica and migraines are eased using reflexology. Some research has shown an easier labor for women regularly treated with reflexology than in the average population. There are some contraindications and possible rnmplications if used inappropriately.

Explain migraines.

Migraines tend to be seen in adolescents, early adulthood, through middle age. They are often unilateral, severe and cause throbbing pain, nausea and vomiting, and sensitivity to light or noise. Prior to the migraine striking, there are often recognizable symptoms of its approach which can last for days prior to the migraine (prodromes). The most common symptoms are light and noise sensitivity, irritability, [ mood changes, drowsiness, and increased thirst and hunger. Some 1 may experience aura an hour prior to the migraine. Migraines may be avoided by changes of lifestyle and avoiding known causes of the I migraines. Severity and frequency determine medication type and 1 frequency. Mild, infrequent migraines may only need NSAIDs, acetaminophen or aspirin. Tryptans, tricyclic antidepressants, and ergotamine preparations may be used for more severe attacks although these are contraindicated for pregnancy. Pregnancy can cause migraines in those who never suffered them before. Menstrual migraines may be controlled by stabilizing the estrogen levels with birth control pills.

Define missed abortion and habitual abortion.

Missed abortion: The fetus dies but the products of conception are not expelled for 2 or more weeks. There is a normal early pregnancy but without accompanying signs of pregnancy. There may be vaginal spotting or bleeding or lower abdominal or back pain at fetal death. The fundal height no longer increases and will decrease somewhat. Mammary changes will reverse. The woman will lose weight and no fetal heart tones will be present. Amenorrhea is present. An ultrasound , should be obtained to confirm fetal death. There is a high possibility of 1 DIC occurring. Refer to a physician. Habitual abortion: This term is used if three or more consecutive pregnancies have terminated in spontaneous abortion. The woman should receive followup care throughout the grieving process, including counseling about contraception and sexual intercourse. Future pregnancy counseling should be given including genetic counseling, an endocrinology study, and examination to rule out developmental abnormalities of the genital tract.

Discuss Morning Sickness and methods to reduce symptoms.

Morning sickness is caused by elevated estrogen and hCG levels. It is most likely to occur when the stomach is empty but may also occur due to cooking odors. Stress can cause morning sickness to worsen, making emotional support networks and stress reduction essential. In addition, 50mg of Vitamin B-6 at bedtime and midday can also lessen the feelings of nausea. Other ways to reduce the queasy feeling are to eat crackers or plain yogurt when rising in the morning and to drink ginger or raspberry leaf tea. Small meals and keeping food in the stomach may help since morning sickness can be caused by low blood sugar. If vomiting occurs, ground ginger capsules with meals and daily contact with the midwife is advisable, even if only by phone.In the event hyperemesis grav idarium develops severe hydration may result, requiring an immediate visit to the consulting physician.

Define central nervous system defects.

Most central nervous system defects are due to a failure of the neural tube to fuse shut, leading to openings in the covering of the spinal cord, or failure of the cranial vault to develop. Central nervous system defects can be prevented by appropriate supplements of folic acid during preconception and pregnancy. These abnormalities are more often discovered prenatally with today's technology, such as detailed ultrasound screening, and parents may choose to terminate the pregnancy when severe neural tube defects are identified. This has led to fewer infants born with these defects. Central nervous system defects include anencephaly, spina bifida aperta, spina bifida occulta, hydrocephalus , and microcephaly.

Discuss the prevention of infection in the newborn.

Most methods of prevention are common sense. Anyone touching the newborn should have clean hands. Frequent washing with soap and running water is best but if this is unavailable or time is of the essence, alcohol based hand wash solutions can be substituted. Wearing gloves decreases the chance of infection further. Breastfeeding, avoiding breakage of the newborn skin and mucous membranes, and continuing education regarding prevention will help reduce infections. Visitors who have infections or have been exposed to a contagious infection should not be allowed to visit the baby or the mother.If, in spite of all measures, an infection is discovered, early diagnosis and treatment will limit the course of infection and the damage .it can cause.

Discuss the use of Pulsitilla, moxibustion, and other methods for turning a breech presentation.

Moxibustion originated in China. A stick of dried mugwort is used as a heat source over the Bladder 67 acupuncture point (the lower outer corner of the small toe). The theory of moxibustion is that adrenocortical output is stimulated and increases the release of lactogens. This, in turn, increases myometrial sensitivity and contractility. The fetal heart rate and fetal movements increase and the fetus turns cephalic on its own. One study showed a success rate of 66% to 87%, a higher success rate than external version. Moxibustion should be performed on both feet two to three times daily until version occurs. It is most effective when the mother is on a slant board. Homeopathic Pulsitilla 30C can be taken several times a day and may help turn a breech. Swimming or performing handstands while immersed in water may also cause a fetus to turn from a breech presentation.

Compare Naegele's Rule and Nichol's Rule for calculating the estimated due (or birth) date (EDD or EBD

Naegele's Rule calculates the EDD by counting back three months from the last menstrual period (LMP) and adding one week. This calculates 10 lunar months or 40 weeks. Note that Mittendorf's study showed the average length of gestation was 41 weeks and 1day. . Nichol's Rule calculates the EDD in the following way: First time mothers with 28 day cycles: LMP + 12 months - 2 months, 14 days = EDD Second time or more mothers with 28 day cycles: LMP + 2 months - 2 months, 18 days = EDD Cycle time > 28 days: EDD + (days in cycle - 28 days) = EDD Cycle time < 28 days: EDD - (28 days - days in cycle) = EDD The previous menstrual period (PMP) should also be recorded.If the interval between the PMP and the LMP is considerably shorter than the mother's average cycle length (less than three weeks) it is probable that the LMP was implantation bleeding rather than a true period. The EDD should be recalculated accordingly

Define feeding, urination, and stool patterns for the newborn including frequency, color and quantity as appropriate.

Newborn feeding patterns are seen in the eagerness for feeding, coordination ·of sucking and swallowing, and reflexes during feeding. The newborn clenches its fists, places them under its chin, and wriggle its toes. The sucking is interrupted by rest periods which occur more frequently as the feeding session continues. Most newborns feed 8 to 12 times a day and feeding sessions occur in clusters. Abnormal feeding reflexes can be signs of cerebral damage, a congenital abnormality, or illness. Note the frequency of stool and urine passage.If no stoolis being passed, evaluate for infection, gastrointestinal tract abnormalities, or metabolic errors. Loose stools may indicate sensitivity to glucose. Constipation may be relieved by giving water between feedings. Pale stools may indicate biliary atresia.If -little or no urine is being passed, breastfeeding may not be occurring as expected. Very dark urine may be seen in jaundiced newborns.

Discuss the appearance of the newborn's skin and cord.

Newborn skin shows its hydration level. Dry looking skin indicates a dehydrated state. Discuss feeding habits to determine the frequency and volume of feeding. Dehydration should only ensue if the newborn I is not feeding adequately or if the newborn spends time in a hot environment in which case some water can be offered to offset any sweating. Inspect the skin for rashes;septic spots, and abrasions. The folds and between the fingers especially need attention.'The umbilicus should not show r.ed streaks on the belly near the cord and the cord itself should not be oozing or giving off an odor. Refer any septic spots, red streaks or cord problems to the pediatrician.

Discuss immunity and modes of infection in the newborn.

Newborns lack the immune system to fight off most infections once the innate immunity has been breeched. Infection can be passed from an individual's hands, from within the birth canal, or through the placenta. Preterm newborns are more vulnerable than term newborns because maternalIgG transfer may not yet have occurred. Innate immunity does not require previous contact with a pathogen and is the first defense against infection. It is conveyed through barriers or chemicals. In humans, this means intact skin and mucous membranes, gastric acid and digestive enzymes. A newborn's skin is easily irritated and broken, and normal flora has not yet colonized the gut and developed the acid and enzymes. Acquired immunity develops as the body is exposed to pathogens . This type of immunity can be passed in some measure by breastfeeding and placental IgG transfer, but a majority of this immunity is developed with time and exposure.

Explain the use of nitrazine paper and of the Delee® device.

Nitrazine paper: a blue-green paper test strip used for measuring pH. Impregnated with a specific dye, it is used to test the pH of vaginal secretions. Vaginal fluid is very acidic. If a neutral pH is found, amniotic fluid is present indicating ruptured membranes. Delee® {tube/mouth suction device): A Delee device is a cup with a lid into which two small openings have been placed. Small pieces of tubing are attached, one to each opening. One piece of tubing is placed in the practitioner's mouth and the other piece of tubing is placed in the baby's mouth or nose. The practitioner applies gentle suction to her mouth tubing which then draws any matter from the baby's mouth or nose into the cup. This method of suctioning has fallen out of favor due to the small chance that infected blood or body fluid could reach the practitioner's mouth.

Discuss the signs and symptoms of anemia.

Normal hemoglobin in a menstruating woman is 12.0 g/dl and in a pregnant woman is 11.0 g/dl due to an incre1Jse in plasma rather than a decrease in red blood cells. A complete blood count (CBC) will help differentiate the cause of any anemia. A hemoglobin level below 10.0 g/dl is cause for concern. Signs of significant anemia: • pallor, • jaundice, • tachypnea or dyspnea on exertion, • splenomegaly, • tachycardia or flow murmur, • orthostatic hypotension, • peripheral edema, • smooth and sore tongue, • pale mucus membranes and nail beds. Symptoms : • poor appetite or changes in food preferences, • changes in mood, • changes in sleep habits, • pica, • malaise, • headaches, • weakness, • dizziness, • fatigue, • drowsiness. 95% of pregnancy related anemia is iron de.ficiency anemia, but a history of any hematologic abnormalities should be investigated.

Describe the physical assessments required in early labor.

Notes should be taken regarding how labor started and its progress. Between contractions: • the mother's urine should be checked for ketones; • her blood pressure, pulse and temperature taken; • the baby should be palpated for position and dcescent. During and immediately after contractions, fetal heart tones should be taken to assess fetal response. The uterus may also be palpated to gauge the intensity of the contraction. Vaginal exams should be done sparingly at this time of labor and should have maternal consent. The exam should start as a contraction ends. The dilation should be gauged in centimeters, and the quality and placement of the cervical os should be noted. Most importantly, estimates should be taken of effacement, station of the head, and how evenly the head fills the pelvic cavity. Findings should be interpreted depending on the rapidity of labor and the mother's response to the labor.

Explain performance of a breast exam by a health care practitioner.

Observe the breasts with arms by sides, arms raised overhead, and with hands pressed against hips or palms pressed together under the chin. Observe the breasts while the client is bent forward from the hips with arms extended toward the examiner. Next palpate the supraclavicular and infraclavicular regions for the subclavian nodes; palpate the axilla; inspect the nipple epithelium. Lastly, palpate the breasts on a supine client. Refer all abnormal findings to a physician: • asymmetry in breast contour, • retraction signs, • nipple deviation or retraction, • shrunken breast, • edema, • dilated subcutaneous veins, • redness or heat in non postpartal breasts, • ulcerations, • excessive breast elevation and asymmetry with contracted pectoral muscles • palpable nodes, • erosion, • ulceration, • thickening, • roughness, redness, or crusting of the nipples (in a non-breastfeeding woman), • coarse, granular nodularity in a localized area, • loss of elasticity of the tissue or nipple with increased firmness or thickening of skin, • any mass

Explain the use of the Denver IIdevelopmental screening test.

Of the developmental screening tests available, the Denver II is the most accurate in early infanthood.It compares the infant's skills with the skill sets of a composite group of 2000 infants of the same age. It does not measure intelligence or motor skills so much as it identifies where an infant lays on a continuum of developmental issues. Typically, if an infant is unable to perform a skill that 90% of others in the age group can, that skill is noted for further investigation. However, it is not a diagnostic tool, it is a screen for early identification of children at risk of delayed development. By 8 weeks of age, babies who were born at term should have reached the developmental levels in all four areas tested: personal-social skills, fine motor movements, language, and gross motor capabilities. Any findings of significant difference should be placed in context with other 1 information such as previous developmental patterns and degree of delay.

Discuss oligohydramnios

Oligohydramnios is a condition in which there is a lower than normal volume of amniotic fluid. This increases the likelihood of cord compression, fetal distress and hypoxia during labor. Prior to labor this condition significantly increases the chances of fetal mortality due to the increased incidence of intrauterine growth restriction, post maturity syndrome, and congenital anomalies.It can be diagnosed by demonstrating a tightly packed fetus within the uterus and a fundal height that is small for dates. Although amniotic fluid can be increased by hydrating the mother or, more rarely, replacing fluid volume with sterile saline, it is best to quickly diagnose the cause of the condition and treat it. If intrauterine growth restriction is determined a hospital birth is recommended.

Explain the use of a tub bath during active labor.

Once active labor has begun, there is no reason an ambulatory mother cannot relax in a tub of warm water . This is a very relaxing comfort measure. The water must be deep enough to cover the abdomen creating a buoyancy and hydrotherapeutic lift to relieve pressure. A Jacuzzi or tub designed for labor and birth are excellent ways to provide this if available. Relaxation can help the cervix dilate more rapidly and effectively. However, after about 2 hours, contractions may begin to stall. At that time the mother should leave the tub to stimulate further labor. f the birth partner wishes to be involved .and has not yet found a way, sharing the bath can be an intimate and supportive activity.

Explain post partum depression.

One in five mothers develop depression or anxiety up to a year after the birth of a baby. Half show at least two signs of clinical depression including: • loss·of interest or pleasure in life, • low energy , • sleep problems, • increased crying or tearfulness, • feelings of worthlessness, hopelessness, guilt, restlessness, irritability or anxiety, • sudden weight loss or gain, • thoughts about self harm, • worry about hurting the baby. These feelings are caused by hormonal shifts and maternal emotions regarding the baby, the birth experience and the maternal role. Depression may not begin until a baby is weaned and menses returns. A woman with a personal or family history of depression or bipolar illness, or other issues in her life may be more prone to developing post partum depression . You should immediately refer her to the appropriate health care professional if you observe these symptoms.

Discuss the symptoms and general causes of vaginal bleeding during the first trimester.

One-third of women experiencing first trimester bleeding may be suffering symptoms of abortion. Demise of a twin without expelling products of conception can cause vaginal bleeding. Other causes of first trimester bleeding include: • ectopic pregnancy, • cervical lesions or polyps, • post-coital bleeding, implantation spotting, • severe cervicitis, • subchorionic bleed. ' Any bleeding during the first trimester may endanger the mother or fetus and must be investigated. If the bleeding is light and there is no attendant low abdominal or back pain, the woman should observe precautionary instructions: bodily rest, pelvic rest, avoid orgasm, and notify you of any increase in vaginal bleeding., lower abdominal cramps or backache, pelvic pain, a gush of fluid or fever. Bodily rest does not ·mean bed rest, only an awareness of symptoms. Sexual intercourse or insertion of any object into the vagina should be avoided except a progesterone suppository if being used.

Explain the sequelae of infant thrush.

Oral or perinea! thrush, caused by the yeast Candida albicans, can develop into more serious forms. Cutaneous candidiasis is a form in which a moist papular or vesicular rash occurs, most commonly on the axillae, umbilicus, or perineum.It is managed by keeping the areas clean and dry, and applying topical antifungals such as nystatin. More seriously, disseminated candidiasis can develop in very low birth weight infants. This is a systemic infection that can cause osteomyelitis, meningitis, endocarditis, pneumonia, and pyelonephritis I' among other illnesses. Oral flucytosine and intravenous Amphotericin B is required for treatment. These infants often have a history of ' exposure to systemic steroids, catecholamine infusions, and antibiotics, especially cephalosporins. While this is a situation in which the infant is already receiving medical treatment, awareness is essential for all infants who may become immunocompromised

Discuss the types of considerations parents should make regarding a home birth.

Parents should discuss several factors before determining whether to have a home birth, above and beyond any pre-existing medical risks that may rule out a home birth from the beginning. The following issues can be discussed privately before meeting with you again: • the reasons and perceived benefits for having the baby at home, • the perception of your duties • the possible reactions to a hospital birth if one is required due to complications, • an enumeration of the risks and complications of birth that are known to the parents, • how any permanent disability or death of mother or baby will affect the parents. The answers to these issues may illuminate any incompatibilities with your style of practice and the parent's commitment to a home birth. Any reluctance on the part of the mother to discuss these issues is likely an indication of lack of commitment to a home birth.

Discuss Parvovirus B19 (Fifth Disease, ErythemaInfectiosum) and pregnancy.

Parvovirus is transmitted by respiratory secretion and percutaneous exposure to infected blood or blood products. It is a common virus in school aged children.If infection occurs during pregnancy, ;W-30% of fetuses will become infected. Of those fetuses, some will develop aplastic anemia or nonimmune hydrops.In rare cases, the infection is fatal. Infection in the first half of pregnancy results in the most serious infections. If a pregnant woman is exposed, serumIgM and IgG should be tested for immunity. Negative results should trigger a repeat test three to four weeks later. With seroconversion the fetus must be monitored on a weekly basis for fetal hydrops, placentomegaly, and fetal growth restriction. Referral to a physician is advised.

Discuss pelvimetry.

Pelvimetry is the practice of manually measuring internal structures of the pelvis during a pelvic exam to assess possible issues with birthing. All measurements are in centimeters. First, the depth of the sacral curve is measured. It is found by locating the coccyx and tracing the sacral curve up toward the sacral promontory. Here the size of the pelvic inlet is assessed. Upon reaching the sacral promontory the diagonal conjugate is measured. From this measurement is extracted the obstetric conjugate, the inlet , . dimension the fetus must move through. A measurement of 10.5 cm 1 or greater is adequate. The contour of, and distance between, the ischial spines is measured next. The amount of sharpness and protrusion is noted then the distance between the spines, called the interspinous diameter, is measured. 10.5 cm is adequate. The angle or , width of the pubic arch is assessed next followed by the outlet dimension, or intertuberous diameter. An adequate measurement is 8.5 cm or greater.

Discuss pemphigoid gestationis (herpes gestationis).

Pemphigoid gestationis is a skin condition that is of unknown etiology but may begin with a maternal autoimmune response to paternal antigens that is prolonged by pregnancy hormones. It typically begins in the second trimester and can extend to the postpartum period. The primary complaint is generalized itching and burning of the skin and an · erythematous rash. The rash begins on the abdomen and spreads to the rest of the trunk and to the extremities. Blisters develop that can subsequently become infected. Once the diagnosis is confirmed by skin biopsy, topical or oral steroids may be prescribed. Labor is often induced in the 37th week due to placental insufficiency and growth restriction. The baby may be born with a slight rash. The mother's lesions will heal aner birth but may take several years with periodic resurgence at menstruation, ovulation, or when taking oral birth control medication.It may also recur in future pregnancies, especially those with the same partner.

Discuss the influence the following may have on the pregnancy and birth outcome: personal information, demographics, personal history, including religion, occupation, education, marital status, economic status, changes in health or behavior and the woman 's evaluation ot her health and nutrition.

Personal information is the beginning of the medical record, identifying an individual. • Demographics can give clues to potential age or ethnically related complication. • Information regarding religion can identify cultural or religious needs. • The mother's occupation determines when she stops working.If she is in a physically demanding job she will likely need to stop earlier than if she has a desk job. Her.occupation may increase her environmental exposure to toxins. • Marital and economic status can reveal stressors if the mother is single, estranged, or financially insecure. • Educational level determines what level to communicate on. A lack of education may lead to misunderstandings and inadvertent non compliance. • Any changes in heaJth or behavior can be cause for concern if it is a degradation of health or abnormal behavior. A woman's I evaluation of her own health and' nutrition are valuable markers of commitment to the pregnancy and of her awareness of her health I and diet.

Differentiate between physiological jaundice and pathological jaundice.

Physiological jaundice is a non-threatening condition caused by the release of bilirubin during the breakdown of excess red cells in newborn circulation . Bilirubin gives a characteristic yellow tinge to the skin and is seen by the second or third day of life. Other types of physiological jaundice are: • breast milk jaundice: a hormone in the breast milk interferes with the newborn's ability to eliminate bilirubin, • ABO incompatibility: Maternal Type 0 blood transfers to a baby with blood-type A or B. Maternal red cells breakdown creates excess bilirubin. Pathological jaund ice may be caused by: • liver disease, • an obstructed bile duct, • infection, • Rh hemolytic disease. Unlike physiological jaundice, pathological jaundice usually : • presents within the first 24 hours of life, • , Bilirubin levets are much higher • If bilirubin levels are not decreased quickly, kernicterus can result. Another name for jaundice is hyperbilirubinemia . Any jaundice on the first day should be referred to the pediatrician .

Explain polycythemia in the newborn.

Polycythemia is defined as a hematocrit greater than 70%, venous . I This can occur due to twin-to-twin transfusion in utero or a large placental transfusion. The latter can be caused by holding the newborn , below the level of the placenta after birth or by delayed placental clamping. Other risk factors for polycythemia are being small for gestational age, being borne of a diabetic mother, having neonatal hypothyroidism, or having Down syndrome. Sequelae to polycythemia are hypoglycemia due to the increased number of red cells consuming glucose, apnea, respiratory distress, cardiac failure, or necrotizing enterocolitis. The newborn may also present with jitteriness, irritability, convulsions or a neurological disorder. Treatment is reserved for those exhibiting symptoms. In these cases, a partial exchange using plasma or plasma expanders is performed to reduce the red cell load. Refer a polycythemic newborn to a pediatrician immediately.

Explain polydactyly and syndactyly.

Polydactyly and syndactyly are both musculoskeletal defects in the structure of the fingers or toes. Polydactyly is defined as extra digits and syndactyly refers to webbing between the digits, possibly complete fusion . The fingers and toes should be carefully counted and separated during the birth examination. Polydactyly may result in one or more fully formed extra digits or there may only be extra tissue attached by a pedicle. Syndactyly usually affects the hands.It can occur independently or as part of a syndrome. Surgical procedures are available for both of these issues.It is common to have family history of these types of defects.

Explain polyhydramnios.

Polyhydramnios is a condition of excess amniotic fluid most commonly occurring with multiple pregnancies, Rh incompatibility, or diabetes. Fetal anomalies may also engender polyhydramnios, I especially atresia of the esophagus, hydrocephaly, anencephaly or I spina bifida . Generally there will be an elevated fundal height at 28 weeks with a steady increase in height as the pregnancy progresses.It I may be difficult to palpate the baby and the heart tones' may be muffled. In order to differentiate polyhydramnios from a thick uterine wall check for fluid thrill by placing a hand on either side of the uterus. A positive thrill indicating polyhydramnios is found when a vibration is felt on one side of the uterus when it is tapped on the opposite side. Ultrasound monitoring should be performed to determine the cause. Uterine dysfunction, placental abruption and post partum hemorrhage may take place during labor due to uterine hyperdistension. Excess fluid can also cause fetal malpresentation and cord prolapse. A hospital birth is recommended. ·

Describe the indications for and use of a bag and mask resuscitator.

Positive pressure ventilation using a resuscitation bag and mask is indicated when the newborn does not exhibit spontaneous, regular respirations or if the color is dusky after the newborn has been positioned on its back with the neck slightly extended and tactile stimulation has been ineffective. Flow-inflating bags use compressed oxygen to inflate and can deliver different pressures and concentrations of oxygen. This type should be adjusted to 5 cm H20 with a peak pressure of 30-40 cm H20 to avoid damage to newborn lungs. Self-inflating bags deliver a peak pressure of 30-40 cm H20 after which extra pressure is wasted to free air. They will not deliver high concentrations of oxygen unless a closed-ended reservoir is attached. This bag type should be used to deliver room air to a newborn if there is no source of compressed oxygen.

Discuss posterior urethral valve(s), polycystic kidneys, and hypospadias

Posterior urethral valve(s) defects affect male infants. Urine is prevented from flowing normally out of the body due to valves occurring in the posterior urethra. This in turn causes bladder distension, back pressure on the ureters and the kidneys, and concluding in hydronephrosis. This abnormality may be diagnosed and treated within the uterus; otherwise early diagnosis and treatment postnatally is urgent although severe renal damage may have already occurred. Surgical and other treatments are available. Polycystic kidneys can cause birthing problems because the infant's abdomen is larger in circumference tha_n a normal infant. The kidneys are palpable and confirmation is done via ultrasound and radiological exam. The most common outcome is renal failure. Hypospadias is also a defect of the male genitourinary system.It results in the urethral opening being placed elsewhere on the penis than the tip, as far back as the perineum. This defect is typically associated with chordee. Surgical intervention may be necessary to allow normal urination and sexual function.

Discuss Potter syndrome, Turner syndrome, and Klinefelter syndrome.

Potter syndrome is a fatal condition generally resulting in stillbirth or death soon after birth. It is caused by compressive effects of oligohydramnios either in renal agenesis or severe hypoplasia. Severe - asphyxiation at birth is common due to lung hypoplasia. The face is flattened, with low set ears, antimongoloid slant to the eyes with heavy epicanthic folds and a beaked nose. Turner syndrome, or XO, is a genetic abnormality where only one sex chromosome exists, always an X. The missing chromosome is designated 0. The infant is female with a short, webbed neck, edematous feet, and widely spaced nipples, underdeveloped genitalia, and reproductive organs that do not mature. Puberty will not occur, and often is the time diagnosis. Mental development is typically normal but congenital cardiac defects may be present. Klinefelter syndrome, or XXY, is the presence of an extra female chromosome.It only affects males and is also not typically diagnosed until the absence of puberty.

Explain pre-eclampsia.

Pre-eclampsia occurs in about 5% of pregnancies and tends to start between 20 weeks of gestation and the first week after birth. Symptoms include: • Increased blood pressure, Proteinuria • Persistent headaches, Blurred vision or sensitivity to light • Abdominal pain Pre-eclampsia can lead to placental abruption and can affect the mother's liver, kidneys and brain. It is a leading cause of fetal complicat ions including low birth weight, premature birth, and stillbirth. Mothers at risk for preeclampsia include those who have or develop: • Chronic hypertension, High blood pressure during a previous pregnancy, Obesity prior to pregnancy, • An age under 20 years or over 40 years, • Pregnancy with multiple fetuses, Diabetes, • Kidney disease, Rheumatoid arthritis, Lupus, Scleroderma There is no cure except to have the baby. Those exhibiting signs of pre-eclampsia must be monitored closely to prevent fetal or maternal damage or death. A home birth is not recommended.

Discuss the management of pregnancy in a diabetic mother.

Preconception counseling should be undertaken for· diabetic women. Persistent high blood sugar during the first 6 weeks of pregnancy can increase the risk of major congenital abnormalities and/or low birthweight. Educate such women about these risks and create a management plan that includes focusing on maintaining blood sugar level control.If the woman is diet controlled or on oral medication, she , may be required to use insulin during the pregnancy. She should be referred to either an obstetrician who specializes in high risk pregnancies or an endocrinologist to help manage the diabetes during her pregnancy. Perform a health assessment focusing on conditions that are high risk in diabetics such as diabetic retinopathy, nephropathy, coronary artery disease (CAD), and hypertension. A history of gestational diabetes in previous pregnancies can increase the risk for developing it in future pregnancies. A management plan that includes a good diet and exercise may reduce the risk of gestational diabetes and/or its complications.

Discuss the midwife's role in child protective procedures.

Pregnancy and the birth of a child are stressful times for a woman and her partner or family. You are in an excellent position to observe the family dynamic and honestly discuss ways to cope with this stress, in part to decrease the possibility of child abuse. You are also in a position to observe whether a child may need protection because earlier intervention did not prevent the abuse from occurring. It is essential to keep excellent records of any suspected abusive behavior or signs of abuse and any attempted intervention and communication to other professionals or services regarding the family. Abuse includes physical abuse, sexual abuse, emotional abuse, and neglect. You must be fully cognizant of the child protection laws and services in your area.

Discuss any changes in sleep patterns caused by pregnancy.

Pregnancy increases the demands on the body and adequate rest is required whenever possible to maintain the health and energy of the mother. Women who may never have napped prior to pregnancy may now find themselves in need of at least one nap during the day of about 30 to 60 minutes. As the pregnancy progresses, it may become more difficult to obtain uninterrupted sleep due to the need to urinate during the night due to bladder constriction and edematous fluid drain and other discomforts. The distension and weight of the uterus, the activity of the fetus, muscular aches due to the pregnancy may all combine to disrupt or inhibit sleep. Remedies include warm baths, a warm drink such as milk prior to bed, and techniques of relaxation may all help, if not ensure a good night's sleep, at least make getting more sleep easier.

Define the nutritional purpose of each of the following: Prenatal Multi Vitamin, Vitamin C, Vitamin E, Folic Acid, B-Complex, B-6, B-12, Iron, Calcium, Magnesium.

Prenatal Multivitamin: Contains appropriate levels of the vitamins most needed in pregnancy including increased folic acid and iron. Vitamin C: Functions as a preventive antioxidant, often given to ward off infection. Vitamin E: Functions as a non-specific chain breaking antioxidant. Has also been used to relieve varicose veins. Folic Acid: Prevents megaloblastic anemia in adults and neural tube defects in the fetus. B-6: Functions as a coenzyme in the metabolism of amino acids and glycogen. May also reduce morning sickness. B-12:. Reduces the occurrence of central nervous system damage in the newborn from a deficiency of B-12. Iron: A component of hemoglobin which is used for oxygen transport in the red blood cell. Pregnancy creates an increased need for iron as well as other vitamins and minerals. Calcium: Functions in blood clotting, muscle contraction, nerve tr.ansmission, and bone and tooth formation. May relieve pregnancy based hypertension. Magnesium: Helps prevent preterm labor and stops preterm labor if it occurs.

Define preterm labor and its role in prenatal management.

Pretem labor is considered to be labor commencing after 20 weeks and before 37 weeks gestation. Signs and symptoms of preterm labor should be part of prenatal education commencing at 20 weeks gestation.If there is a single previous preterm labor or birth you should: • Screen monthly for bacteriuria; • Treat vaginal or cervical infections; • counsel about stress, nutrition, cigarette, alcohol or drug abuse; • reiterate the signs and symptoms of preterm labor. With two or more previous preterm events, or with multiple gestation but no signs of preterm labor, you should also: • perform a vaginal exam every 2 vyeeks from 24 weeks gestation onwards to check for cervical changes; • counsel for workload reduction; • recommend condom use; • counsel avoidance of nipple stimulation

Summarize the causes of preterm labor.

Preterm labor can be caused by a variety of issues.In most cases, however, the cause remains unknown. The following conditions can result in or contribute to preterm labor: • Vaginal or urinary tract infectic;m progressing into chorioamnionitis and premature rupture of the membranes • Incompetent cervix • Polyhydramnios • Malnutrition and/or dehydration • Chronic gum disease in the second trimester • Uterine abnormalities • Multiple pregnancy • Improper implantation of the placenta • Not enough time between pregnancies • Fetal death Extreme or chronic stress, emotional or physical • Substance abuse The primary issue is the maturity of the fetal lungs.If development is incomplete, respiratory distress syndrome with retractions, nasal flaring, tachypnea, cyanosis, and grunting on expiration will result.

Differentiate between primary apnea and secondary apnea of the newborn and their treatments.

Primary apnea and secondary apnea are the two categories of neonatal depression. Primary apnea is a condition in which the infant has not been hypoxic for long, but is already attempting to breathe more rapidly in utero to compensate. Stimulation, blow-by oxygen, or a few breaths of mouth to mouth resuscitation should revive this infant. Secondary apnea is a condition in an infant who has been hypoxic for much longer than above and making a second attempt in utero to breathe more rapidly without succeeding in restoring oxygen levels. This infant will not attempt to breathe again on its own. Immediate ventilation is required via mouth-to-mouth or bag-mask to reverse acidosis caused by hypoxia. The baby's color, muscle tone, and respiratory effort guide the choice of resuscitation technique. The baby is suctioned, then warmed and stimulated by massaging it from the base of the spine up the back. The mother's voice may encourage a rise in oxygen level.

Discuss the decision-making process in offering tocolytic therapy.

Prior to tocolytic therapy, it must be decided whether it is best to attempt to stop labor or allow it to continue to birth. The uterine environment must be assessed to determine if it is better for the fetus to remain in utero or if the environment has degenerated to the point where it is better to try to care for the preterm fetus in an intensive care unit with all that this implies to the future development of the baby. Also the side effects and risk of complications to the mother must be kept in mind. Another factor to consider is the time needed to reach an appropriate tertiary care facility or to begin corticosteroid administration for fetal lung maturity issues. If tocolytic therapy is administered, the woman will require increased support, not only due to the emotional issues of preterm labor but also due to physical side effects and complications from the therapy.

Categorize and explain newborn reflexes.

Proprioceptive reflexes include the gross motor reflexes such as the Moro reflex .It is symmetrical and can be elicited for the first 2 months. Asymmetry can be caused by fracture of the clavicle or humerus, or brachia! plexus palsy. Reflex absence may be due to brain 1 damage or immaturity . Mental retardation can cause the reflex to 1 persist past 4 months. 1 I Exteroceptive reflexes include rooting, grasping, plantar, anal wink, I eye reflexes, stepping, and superficial abdominal reflexes. They can be elicited when the infant is in the alert state. Asymmetry, accentuation, I or absence of any of these reflexes should be noted and the infant I referred to a pediatrician. Many abnormities in these reflexes can be caused by prematurity or some form of brain damage. Parents should be instructed in these reflexes to reassure them of their infant's normality and to observe for problems.

Discuss prostaglandin synthesis inhibitors, calcium channel blockers and oxytocin agonists as tocolytic agents including their effectiveness and side effects.

Prostaglandin synthesis inhibitors: The most commonly used of these drugs isIndomethacin. They are more effective than other agents at inhibiting uterine contractions. They also have fewer of the severe side effects of betamimetics. These are better choices for women with heart disease, hyperthyroidism, or diabetes but routine use is not encouraged. Calcium channel blockers_;_ These include nifedipine and nicardepine. There are fewer side effects than betamimetics and magnesium sulfate, and there is little to no adverse effect on fetal outcome. They also postpone birth longer and are as effective as betamimetics and magnesium sulfate in inhibiting uterine contractions and delaying birth making them preferable to betamimetics as tocolytics . · Oxytocin agonists: These are relatively new agents which include atosiban. They appear to have fewer maternal side effects and equal effectiveness in tocolysis but carry greater fetal risk. More extensive study is needed to determine usefulness.

Discuss the purpose of monitoring the urine for protein, glucose, and ketones.

Proteinuria in conjunction with gestational hypertension is a hallmark of preeclampsia.It can also occur due to renal damage suffered in acute pyelonephritis . There are no observable physical anomalies indicating early preeclampsia, the blood pressure and urine must be routinely monitored. Acute pyelonephritis presents with many other physical symptoms, including fever, hematuria, myalgia, cystitis, and CVA tenderness. The urine is routinely screened for glucose and ketones to monitor for symptoms of diabetes . Glucose is spilled into the urine when lack or ineffectiveness of insulin causes the cells of the body to be unable to up glucose to use for energy . The excess glucose is cleared throug h the kidneys and excreted in the urine. Ketones are metabolic breakdown products of fat and protein which the cells use for energy in place of the unavailable glucose. Ketones cause acidosis which, in the extreme stages of diabetes, can cause coma and death.

Explain Pruritis (Skin Itchiness) and methods of treatment in pregnancy.

Pruritis may manifest due to a compromised liver from liver disease, excessive alcohol or recreational drugs, or prolonged use of other medications. It occurs in 3-14% of mothers. Liver tonics of dandelion root and yellow dock root can be effective in reducing the itch. Beets, dark greens, lemon juice and olive oil have liver-cleansing properties as are choline-rich foods like egg yolk, wheat germ, and brewer's yeast . Topical treatments can include plain yogurt rubbed into the skin or oatmeal baths.Itchiness in the palms of the hands or soles of the feet can indicate intrahepatic cholestasis. While this is rare in the general population, it is common in women of Chilean, Mediterranean, , or Scandinavian descent. A consult with a backup physician is advisable to determine the need for a liver profile.

Explain psychological screening out.

Psychological screening out occurs when a client has emotional issues that preclude the probability of a successful home birth outcome. Before deciding to withdraw from the case, discuss the situation with the mother's backup physician so he or she understands any problems that may occur during the birth process. Also discuss the situation with midwife peers to avoid rumors and learn more regarding this type of client. Refer the mother to a recommended care giver who is more able to handle her case. Be firm with the decision to screen out. Avoid the temptation to accept the case later if the situation becomes better.It may not be due to improvement in the mother's basic issue. The decision to screen out will not allow the type of involvement you want but the alternative at best may be an unhappy birth situation and at worst a malpractice proceeding.

Discuss acute pyelonephritis.

Pyelonephritis is an inflammation of the kidney(s), typically due to a bacterial infection.It is the most common non-obstetrical complication resulting in hospitalization for pregnant women. Complications : • preterm labor and delivery, • acute respiratory distress syndrome, • septic shock, • hemolysis leading to anemia. Causes: • ureter compression by the uterus at the pelvic brim, • decreased bladder tone, • dilation of the renal pelves, • urinary stasis. Symptoms: • fever, • chills, • suprapubic or lumbar pain, • CVA tenderness, • hematuria, • myalgia, • dysuria, • nausea and vomiting, • a history of asymptomatic bacteriuria or cystitis • Urinary frequency and urgency Laboratory results include bacteriuria, hematuria, pyuria, and proteinuria, and an increased white count with a left shift. Refer to the consulting physician. Pyelonephritis requiresIV therapy for dehydration and electrolyte imbalance. Antibiotic suppressive therapy is usually maintained until delivery

Discuss ROS of the cardiorespiratory system.

ROS for the cardiorespiratory system includes dyspnea, orthopnea, tachypnea, wheezing, cough, pleurisy, sputum production, cyanosis, dependent edema, night sweats, palpitations, hemoptysis, chest pain, strider, history of respiratory infections, contact with tuberculosis, results and date of latest chest x-ray, known abnormalities of the heart rate or rhythm, history of rheumatic heart disease, anemia, ' hypertension, and coronary artery disease (CAD). Dyspnea is a lack of air resulting in labored or difficult breathing. Breathing may be audible with retracted intercostal spaces, and cyanosis. Orthopnea is labored breathing while supine. Tachypnea is abnormally rapid respiration. Pleurisy is the inflammation of the pleura and can be primary or secondary; unilateral, bilateral or local; acute or chronic, fibrinous, serofibrinous, or purulent. Hemoptysis is the expulsion or .expectoration of blood from the larynx, trachea, bronchi or lungs. Small amounts may occur in several illnesses that may irritate these areas. Strider is a high-pitched sound occurring on inspirations indicating an upper airway obstruction.

Explain ROS for the eyes during a physical exam.

ROS for the eyes should include a discussion of any blurring of vision, scotomata, diplopia, spots before the eyes, flashing lights, pressure or pain, injuries, diseases or conditions, photophobia, discharge, redness, burning, lacrimation, the presence of corrective lenses, and the patient's own evaluation of her visual health. Other observations include whether the eyelids are abnormally closed, edematous, have signs of infection, masses, lesions, ptosis, matting in or .absence of eyelashes, involuntary eye movements, observation of the lacrimal ducts for infection or tenderness, the color of the sclera and lower conjunctiva I sac, any abrasions or opacities of the lens or cornea, strabismus, parallel movement, papillary reaction to light, protrusion of the eyeball, the size, shape and equal appearance of the eyes. It also includes an ophthalmoscope exam for red reflex, optic disc, any hemorrhage, papilledema, retinal vessels, macula and fovea.

Discuss ROS and examination of the head during a physical exam

ROS for the head includes determination of the incidence of headaches: • location, duration, time of day of occurrence, • type of pain, frequency, • any known causes, any medications or other remedies taken and the effectiveness, • other symptoms associated with them. ROS also includes dizziness, syncope, and sinusitis. Other observations include: • the size, shape, contour and symmetry of the head, • the facial symmetry, • the location of the facial structures, • facial tenderness over the sinuses, • involuntary movements. Syncope can be vasovagal, cardiogenic (often from arrhythmias), orthostatic, and neurogenic. It may also be due to certain medications. The most common types of headaches are migraines and tension headaches. Sinusitis is often caused by a bacterial infection in the sinus due to sinus blockage and subsequent inability to drain. Common bacterial causes are Staphylococcus sp., especiaNy S. aureus, and Hemophilus influenzae.

Explain ROS for the mouth.

ROS for the mouth includes toothaches , bleeding, lesions, pain, or edema of the gums, lips, mouth, or tongue, extractions and dentures, and difficulty with swallowing or chewing. Other observations include breath odor, color and symmetry of lips and tongue, whether the palate is intact, the color of the mucus membrane and gum, and any signs of infection. Dental work should be completed prior to conception, especially if it involves radiation exposure, sedation, gum surgery, or anesthesia. Significant periodontal disease can cause premature labor and birth.If gums are manipulated during pregnancy, bleeding is increased due to the increased vascularity caused by the pregnancy. Between pregnancy and any time spent breastfeeding, there may be significant delay in dental care if it is not performed prior to conception.

Discuss observations of skin and hair during a physical exam.

ROS includes an exam of the skin for pruritis, rashes, moles, lesions, tendency towards bruising, hirsutism and the type of skin: oily or dry.It includes and exam of the hair for hair loss, reasons for wearing a wig, whether there is a scalp infection, dandruff or lice, and the type: oily or dry. Document and investigate abnormal temperature, color (pallor, cyanosis, pigmentation, and jaundice), moles, scars, turgor, rashes, lesions, bruises, tumors, and patterns of injury on the skin. Examine the hair and scalp for bald spots, lumps, hair · pattern, and infections. The skin and hair can indicate variety of conditions: • hypothyroidism causes dry skin and hair; • a pattern of injury may indicate domestic violence, abuse, a balance problem, or self-mutilation • changes in moles over time in the size, shape, or color of the mole can indicate melanoma • cyanosis indicates a respiratory or cardiac problem • jaundice may indicate a liver condition.

Discuss newborn Respiratory Distress Syndrome (RDS).

Respiratory Distress Syndrome (RDS) is a medical ·emergency requiring hospital care. RDS occurs in premature infants who have little or no surfactant in the lungs. RDS is caused in term infants by pneumothorax, aspiration of meconium, pneumonia, and TIN. A pneumothorax is the rupture of alveoli by air being pushed outward into the interstitial space of the lung. With a large pneumothorax, there are diminished breath sounds on one side, cyanosis, and possibly overdistention of the chest. Meconium aspiration symptoms include uneven breath sounds, cyanosis, rales, ronchii, and a barrel chest.It can degenerate into I persistent pulmonary hypertension. I Pneumonia can be differentiated from meconium aspiration by the I presence of hypothermia, color changes, and apnea. Pneumonia can I be caused by a variety of pathogens and the intensity of the infection varies.

Explain the use of Rhogam.

Rhogam is a plasma product given to RH negative mothers to prevent alloimmunization of their Rh positive newborn. Rhogam is specific for the D antibody, which a mother who is Rh negative will create whenever a fetal-maternal bleed has occurred. Since it is impossible to 1 tell every such circumstance, Rhogam is given in every situation where the Rh negative mother has borne an Rh positive child; or if an Rh negative woman miscarries or has an abortion. Other procedures whic may prompt the injection of Rhogam are chorionic villus sampling, amniocentesis, caesarian section, and any other procedure that could cause fetal-maternal transplacental hemorrhage (TPH). Rhogam suppresses the mother's production of antibodies in response to the Rh positive antigen from the baby. These antibodies can cause hemolytic disease of the newborn in subsequent pregnancies with an Rh positive fetus.

Explain sciatica and its treatment in pregnancy.

Sciatica is a pain that runs along the sciatic nerve, a large nerve extending from the lower back and down the back of each leg. The pain is felt in the buttocks and leg and becomes worse when sitting. Sometimes the leg or foot can become weak or numb. The pain can be constant on one side of the buttocks and tile pain may become shooting when attempting to stand. Often it only affects one side of the lower body. Pregnancy is only one cause of sciatica.·It may result from the pressure of the uterus on the sciatic nerve or from muscular tension or vertebral compression from the extra weigh and posture changes in pregnancy. Treatment aims to relieve pressure and inflammation. Medications such as non-steroidal anti-inflammatories are used to relieve inflammation while physical therapy can relieve both inflammation and pressure.

Define scotomata, diplopia, photophobia, lacrimation, and strabismus.

Scotomata: an island like blind spot in the visual field. There are many different types of scotomata: annular, absolute, arcuate, central, centrocecal, color, eclipse, flittering, negative, peripheral, physiological, positive, relative, ring, and scintillating. Diplopia: double vision, or, more formally, two images of an object seen at the same time. There are several types of diplopia: binocular, crossed, homonymous, monocular, uncrossed, and vertical. Photophobia: also called photodysphoria, this is an intolerance, or sensitivity, to light. Lacrimation: the secretion of tears. It may become excessive . Strabismus: an optical disorder where the optic axes cannot be directed to the same object: t is commonly called crossed eyes. There are several types: unilateral, alternating, constant, and periodic.

Explain breast self-examination.

Self breast examination and its importance should be taught at the time of the breast exam. Education should include an assessment of the knowledge already possessed by the mother and whether she performs self breast examination on a regular basis. If the mother does not know how to perform the exam, the following elements should be covered: • why regular self-exams are important, • to perform the exam every month 24-48 hours after the end of a menstrual period, • positions in front of the mirror for visual inspection and what look foG . • the supine position with shoulder lifted on a pillow for palpation including exam with the arm raised and lowered, • proper palpation technique and what to look for, • the normal structure is of the breast area. If the mother states she performs the self exam already, ask her tQ.demonstrate it for you.If she does not or will not perform the exam, try to find out why.

Discuss foot and leg exercises.

Since circulation is not as efficient in pregnancy, especially venous return, cramping, varicose veins, and edema can occur easily. Circulation can be improved by moving the feet and legs on a regular basis, avoiding standing or crossing the legs, and by putting the feet up several times a day. The mother should sit with the legs supported. The ankles are bent and stretched at least 12 times. Both feet are circled at the ankle at least 20 times each direction. Then both knees are braced and held for a count of 4. The legs are then relaxed. This final exercise should be repeated 12 times. For the most effectiveness, these exercises should be done before getting up from bed, at night just before bed and several times a day.

Explain the appropriate use of single dose ampules and multidose vials of injectable medication.

Single dose ampules of medication may be liquid or freeze dried. Reconstitute freeze dried medication with the accompanying liquid. Break the vial away from your face.If reconstitution is needed, draw up the required amount of liquid with a sterile syringe needle. After reconstitution use a new sterile needle to draw up the medication for injection. f the medication is already liquid, use a sterile needle and syringe to draw up the appropriate amount of medication and inject it into the patient. Multidose vials may come liquid or dried. Use the same technique as above for reconstitution. Discard reconstituted medication vials alter the expiry in certain number of hours. Multidose medication that comes as a liquid may be used until the expiry date as long as it is stored according to the manufacturer's instructions. Each time the multidose vial is used, wipe the diaphragm on the bottle with 70% alcohol. Use a sterile syringe needle each time the vial is entered.

Discuss infant skin care and choice of diaper.

Skin care is of most concern in the diaper area. Diaper rash can be prevented by regular diaper changes and thorough cleaning with mild soap and water or a commercial wipe. Barrier creams containing zinc oxide may stop early diaper rash. Otherwise, routine use of oils, powders or lotions is neither needed nor preventative. Parents must determine the choice of diaper themselves. Some opt for disposable diapers for the convenience. Others oppose them for environmental reasons although commercial diaper services can also pose environmental issues because of bleach use and pollution caused by the delivery trucks.If the parents decide to wash the diapers at home, the diapers must be presoaked in bleach and detergent and then washed twice in hot water to ensure absolute cleanliness. The rinse water should move freely around the diapers so overloading must be avoided.

Recommend remedies for sleep difficultie

Sleeping difficulties due to pregnancy can be relieved by several methods: • Deep relaxation and healthy exercise during the day will create proper physical conditions for sleep. • A silken eye pillow filled with flax seed and lavender may help. • Stronger remedies can be used if needed; half a dropperful of Skullcap tincture or Valerian tincture may be beneficial. • In the last trimester, half a dropperful of Hops tincture can help. • If anxiety and worry are keeping sleep at bay, homeopathic Aconite 30C can be an effective calming agent but should only be used during episodes of anxiety. • Lemon balm and oats/oat straw have been found to be calming as well.

Explain the effects of smoking both prenatally and postnatally.

Smoking during pregnancy can increase the risk of prematurity, low birth weight, and stillbirth. At birth and throughout the first year, the infant has a higher risk of having respiratory problems, asthma, and otitis. media.It has been shown that women who smoke 20 or more cigarettes are 15 times more likely to lose the infant to SuddenInfant Death Syndrome (SIDS) than a non-smoker. Other complications are spontaneous abortion, placental abruption, and placenta previa. Breastfeeding is still recommended even though nicotine is passed in breastmilk, as the benefits of breastmilk outweigh the risk of nicotine ingestion. Counsel the mother about these complications and urge her to stop smoking or to decrease the number of cigarettes she smokes each day. Refer her to a specialist or group that can help her stop. At this time, nicotine replacement therapy during pregnancy is controversial.

Discuss the challenges of societal perception of .motherhood.

Society may see the birth of an infant as the culmination of a woman's reason for being. While there is no financial gain, her status is raised 1 and her femininity is proven. However, if the mother herself feels less , than completely ecstatic about motherhood and her baby, she is 1 unlikely to admit it because she thinks that society would then see her 1 as a "bad" mother. The emotional distress is internalized, creating I stress and loss of sleep, which in turn erodes the ability to cGpe with I the new lifestyle.In rare extremes, the mother may suffer severe psychological trauma and endanger herself or her children. With a I mobile society, it is less likely the new mother has family available to help She becomes isolated and unsure of her success in her new role.

Discuss alternative remedies for colic.

Some alternative or homeopathic remedies for colic include crushed fennel or caraway seed tea, light pressure and warm compresses on the infant's belly, massaging clockwise around the umbilicus, or bringing the infant's feet to its ears several times . Chamomilla, Nux Vomica, and Mag Phos have also been used. An adjustment by a chiropractor with infant expertise may help. A simple exercise to try is to place the infant on its back and grasp the feet. The feet and legs are brought up as in a diaper change but the lift is slowly continued until the infant is hanging upside down. The infant may rotate in place. When it seems to be settled in one place, the move is reversed until the infant is on its back again. This exercise can be done daily.

Discuss the effectiveness of bed rest for preterm labor.

Studies have shown that placing a mother on prolonged bed rest does not prevent preterm labor. It may, in fact, be deleterious because the lack of activity can decrease the muscle strength required for birth and postpartum.It can also increase the risk of clots in the veins of the legs. However, if a mother presents with signs and symptoms of preterm labor, bed rest should be prescribed until it is determined whether the criteria for preterm labor has been met. The mother should be placed in the lateral, or side-lying, position with external FHT and uterine contractility monitoring.If the membranes are still intact, vaginal exams to monitor for cervical changes may be performed, preferably by the same examiner each time.

Discuss the vital signs and what any variations may indicate.

Take vital signs at every visit, including baseline readings at the first physical exam. Vital signs include temperature, pulse, respirations, and blood pressure. Height is taken at the first physical exam but is rarely checked again. Assume the woman is in a relaxed state and has not exerted herself in the past few minutes.Increased temperature indicates infection although it may also be a symptom of dehydration. The source of any infection should be investigated.Increased pulse rate may be due to anxiety or exertion, or it may be a sign of infection, dehydration or shock. An increased respiratory rate can also be due to anxiety,shock or infection. If accompanied by coughing or wheezing, asthma or respiratory infection may be to blame. Increased or decreased blood pressure can indicate a hypertensive disorder of pregnancy or shock, in that order.

Explain talipes.

Talipes is commonly known as clubfoot. Talipes equinovarus, TEV, is a defect in which the ankle is plantarflexed, or bent downwards, and the front part of the foot turns inwards. This form of talipes is likely to occur along with spina bifida defects. Talipes calcaneovalgus is where the ankle is dorsiflexed, or bent upwards, and the front part of the foot is turned outwards. Both of these types of defects occur most often due to crowded conditions in utero as in multiple pregnancies, oligohydramnios, or a macrosomic fetus. Talipes is more common in males than females and sometimes there is a family history of the condition. Mild forms can be corrected with exercise and manipulation while severe forms may need surgery, splinting, and/or manipulation. Early treatment is highly recommended .

discuss the examination and findings of deep tendon, or stretch, reflexes; include clonus.

Tapping a tendon briskly can cause a brief muscle stretch. Baseline reflexes are needed to compare for changes in future reflex exams.If the reflexes are hyperactive, there may be a disease of the upper motor neuron or pyramidal tract. Some diseases can cause hypoactive reflexes. Reflexes are evaluated according to a scale from zero to 4+ with zero meaning the reflex was absent and 4+ indicating hyperactivity . Reflexes at either extreme, zero or 4+ are abnormal and the patient should be referred to a physician. Reflexes should be symmetrical from one side to the other. Clonus is rapid, repetitive, rhythmical, involuntary contraction and relaxation of a muscle when it is sharply stretched and the stretch is maintained in either flexion or extension.It is only present when there is central nervous system disease.It is typical of upper motor neuron disease. Check for clonus If hyperreflexia is found.

Explain the "elevator" pelvic floor exercise.

Tearing and lacerations may be decreased or prevented if the mother has vaginal muscle control . The "elevator" exercise teaches this control. The pelvic floor muscles pull up as if they were part of an 1 elevator. The elevator stops at the first, second, third, fourth, and fifth [ floors. At each point hold the pelvic muscles momentarily. Once the "fifth floor" is reached, hold the muscles 30 seconds and descend the elevator, pausing at each floor and stopping at the "sub-basement" where birth takes place. Another exercise to teach muscle control strengthens the bulbocavernosus muscle by making snapping movements low in the vagina near the introitus. An alternate approach is to contract first the bulbocavernosus muscle, then the transverse perinea! muscle, then the vaginal canal, and finally the levator ani. Once all the layers are contracted, the muscles are held briefly and then released in the opposite order.

Define the appropriate parameters for newborn·temperature, heart rate, respiration, circumference of the head, length, and weight gain.

Temperature: 36.5 - 37.5 C (96.8 - 97.7 F) at birth. The flexed posture of the newborn helps maintain body temperature. Unstable temperature may indicate infection. Heart rate: 120 - 160 beats per minute. There are fluctuations with respiration and activity. Respiration: 30 -60 breaths per minute. The newborn is an obligatory nose breather and has periods of apnea for 10 - 15 seconds. There should be no nasal flaring, grunting, sternal or subcostal recession during respiration. Head circumference: 31 - 38 cm occipital/frontal circumference. Length: average 19 % inches in the United States and shows fairly steady growth over the first year, adding half again the original newborn length. Appropriate weight gain: one ounce a day for the first three months. Initially the newborn may lose up to 10% of the original weight but will gain it back within 2 weeks, a little longer for breastfed babies. Within the first year the weight triples.

Explain tension headaches.

Tension headaches can be chronic or episodic. They tend to begin in early adulthood and are more common in women than men. Episodic headaches are rarely reported for treatment. Chronic headaches may last for hours with a high frequency. While women with chronic headaches suffer diminished function . They are also more likely to have mood disorders or anxiety. Lifestyle changes that include relaxation techniques and stress reduction plus validation of the issue can help decrease the severity of these headaches. Medications such as acetaminophen or NSAIDs may be ineffective. A combination of 400 mg ibuprofen and 200 mg caffeine has proven more effective than either alone. A combination of behavioral therapy for stress management and tricyclic antidepressants also proved more effective than either alone.

Discuss the Auscultation Acceleration Test for fetal heart rate assessment.

The Auscultation Acceleration Test is a !ow-tech alternative to a non-stress test. The 6-minute auscultatio . acceleration test is used to predict both reactive and non-reactive NST results .It is best used at 34 weeks gestation in a singleton pregnancy. An Allen fetoscope is used to auscultate the fetal heart rate for 6 minutes, counting the rate during alternating 5 second intervals. The results are graphed on a chart. The baseline fetal heart rate (FHR) is determined and any accelerations are identified by comparison to the baseline FHR. An acceleration is defined as any time the FHR is up by two beats per 5 second period. Only one acceleration during the 6 minutes is needed to indicate reactivity. Test results are used the same as non-stress test results. A reactive test is a positive indicator of fetal well-being . A non reactive test is considered a non-reassuring result, especially if a previous test showed reactivity.

Summarize the practice of Universal Precautions that are relevant to midwife care.

The Centers for Disease Control and Prevention have set out precautions to be followed by health care workers during interactions with all clients regardless of blood-borne infection status. These Universal Precautions are set out in a CDC document entitled "Recommendations for Prevention of HIV Transmission in Health-Care Settings". For midwives, the following precautions are relevant: * Use barrier precautions (gloves, waterproof gowns or aprons, protective eyewear, and mouthpieces for resuscitation) to prevent skin and mucus membrane exposure to blood, amniotic fluid, vaginal secretions, seminal fluid, and breast milk. * Use gloves for blood and culture collection, vaginal exams, assisting delivery, handling the newborn prior to its cleaning and handling soiled under-pads, clothing or bed linens. * Immediately wash hands and skin if they become contaminated and consult a health care professional. * Dispose of all used sharp instruments and needles in a puncture resistant container. Never recap or excessively handle such items.

Explain the FDA labeling criteria for potential teratogenic activity in medications that may be prescribed during pregnancy.

The FDA has five labeling categories for medications that may fJe used during pregnancy. These categories attempt to identify the risk to the fetus from specific drugs. The FDA categories and their definitions are as follows: A Failure to demonstrate a risk to the fetus in the first trimester through human studies, risk of fetal harm remote. B Animal studies show no risk to the fetus or do show risk but studies in pregnant women show no risk. C Animal studies show the drug to be teratogenic to animal fetus, but no human studies or no animal or human studies performed. D Positive evidence of teratogenicity but beneficial for certain reasons that may make drug use acceptable. X Definite serious teratogen as demonstrated by fetal abnormalities found during studies or fetal risk demonstrated based on human experience, or both. Risk outweighs any benefit. Decisions on the use of a specific drug should be made by the mother in conjunction with the midwife and the physician.

Discuss the purpose and the results of a Pap smear and gynecological culture.

The Pap smear is the standard method of detecting cervical cancer. Cells from the endocervical region of the cervix are collected and processed. The slide is examined for abnormal signs. The report may include observations of various organisms such as Trichomonas or Candida and cellular changes due to inflammation or the presence of an IUD. Any abnormalities of the squamous and glandular cells and indications of carcinoma are reported. Any abnormal-appear ing cervix, dysplasia , or cancer, ASC, repeated ASC, ACG, multiple unexplained inflammations, Pap smear reporting HPV infection history of intrauterine diethystilbesterol (DES) exposure should be referred for colposcopy. The gynecological culture is a method of diagnosing gonorrhea and Chlamydia. Gonorrheal infection during pregnancy has been linked to spontaneous abortion, very low birthweight, chorioamnionitis, postpartum endometritis, pelvic sepsis, and premature rupture of the membranes. Chlamydia in pregnancy has been linked to amnionitis and postpartum endometritis. Both infectious agents can infect the newborn as it transits the birth canal.

Explain the advantages and disadvantages of hospital birth.

The advantages of a hospital birth are : • Quick access to emergency care during birth. • Availability of a "birthing room" as opposed to a "hospital room". • Access to educational opportunities about childbirth and childcare. • Access to a number of caregivers and healthcare workers such as trained anesthesiolog ists to administer any desired medications or meet other needs. The disadvantages are that of a "managed birth" in which : • The hospital staff may take responsibility for decision making away from the mother. • The same room may not be used for the entire process of labor, delivery and recovery. • The hospital may feel uncomfortable to the mother. • A mother with a normal birth and healthy baby must then go home shortly afterwards, without allowing time to adjust to or recover from the birth.

Discuss the requirements of the birth environment.

The birth environment must be conducive to a relaxed labor.If you find this is not the case, you should assist the mother in making it so. Tell any family or friends the birth may be some time away. Only the birth team should be left and should sent elsewhere to give the mother some time alone or asked to cook for after the birth if needed. Once active labor has begun, you can ensure the mother has the setting needed to labor effectively. This may mean complete prlvacy, even from the birth attendant, and low light. You should not disturb her and should make certain others do the same. The partner may feel the need to assist; if so, the parents should be left alone to work things out and any interruptions should be minimal. Give plenty of warning and allow them to dictate when someone can enter the area.

List the items to be assembled by the birth family in preparation for a home birth.

The birth family should gather items specified by the midwife by 36 weeks. Supplies include: • plastic covers to protect furniture and floors from blood and body fluids, • extra pillows, • nutrition for the mother during labor, • clean towels and washcloths, • antiseptic solution, • flashlight; mirror, bulb syringe, 2 quart bowl, • heating pad, thermometer, measuring tape, • newborn receiving and clothing supplies, • squeeze bottle, • pads and underpads, underwear, • alcohol and cotton balls, • large garbage bags, Ziploc freezer bags, • hydrogen peroxide for blood stains. • emergency plan, • a list of phone numbers to be posted by the phone and in the mother's chart. In case of transport the fuel the car; test the route to the hospital; complete and chart hospital admission forms . The home should be reasonably clean and all participants educated for the arrival of the new family member.

Discuss the implications of breast condition in breastfeeding.

The breast size does not indicate ability to produce sufficient breastmilk. Gigantomastia and micromastia may indicate underlying issues and can contraindicate the ability to breastfeed. Trauma to the chest and/or breast may affect nipple patency or the ability to produce breastmilk. Biopsy, surgery, or injury to the breast may impact the nerve tissue and/or the ducts and decrease the ability to breastfeed. Classification of inverted nipples: • Grade 1- easily pulled out, • Grade 2 - can be pulled out but will not remain everted • Grade 3 - may not pull out It has not been shown that any method of everting the nipples is effective, including the wearing of breast shells. If the nipple does not pull out into the baby's mouth during feeding, there will be a lack of stimulation to produce more milk and continue lactating.In these cases, the infant can become malnourished and dehydrated.

Discuss cervical and vaginal causes of bleeding.

The cervix is extremely vascular in the first trimester. Any inflammation of the tissue can cause bleeding. It is important to examine for the source of the bleeding. If the blood is coming from within the uterus, a sonogram and bloodwork for BhCG and progesterone should be obtained. If the blood is from the cervix itself, it is rarely implicated in pregnancy loss but must still be treated. Infection is a primary cause of cervical bleeding, such as gonorrhea, chlamydia , or trichomonas . Cervical dysplasia may also be at fault. Herpes lesions, yeast infections, polyps, and bacterial vaginosis can also cause cervical bleeding as can sexual intercourse due to increased cervical vascularity.If there is a concern about ectopic pregnancy, a history of repeated miscarriage, or a non-reassuring bimanual exam perform an ultrasound exam.

Discuss protocol regarding stillbirth and neonatal death.

The coroner must be notified of any stillborn weighing 500 grams or more. An autopsy is at the discretion of the coroner.If it can established that the baby has been dead for a period of time, the autopsy may be optional. The coroner releases the body to the funeral home chosen by the parents and signs the death certificate. The midwife should plan to spend time with the parents for the first weeks. After allowing time for grieving, the parents should be encouraged to prepare a memorial such as a chronicle of the birth and death, or a scrapbook. The basic phases of grieving should be discussed with the parents and the appropriate referrals to support groups and· written materials on speaking to children and siblings about death should be given.

Explain the effects of drug abuse/use during pregnancy.

The effects of illegal drug use/at_)use during pregnancy are many and varied. First and foremost, there is a high likelihood that the infant will go through withdrawal either during labor or after birth. The length of withdrawal depends upon the drug or drugs used by the mother as each drug has a different half-life. Additional problems include placental abruption, fetal distress during labor, intrauterine growth restriction and stillbirth. The mother is also less likely to obtain regular prenatal care or neonatal followup. She is unlikely to disclose her drug use to her medical care workers. Due to the typical lifestyle of a drug user, there is a greater risk of infectious disease such as Hepatitis B and C and/or HIV and the attendant complications of those diseases, as well as having poor housing, possibly other children with problems, and a lifestyle not conducive to raising a child.

Discuss the maternal psychological changes that occur during the first trimester.

The emotions and psychological balance of a pregnant woman are very changeable. She can be very sensitive, introspective, vulnerable and dependent. The first trimester is known as the "period of adjustment"; the mother must accept that she is pregnant. Most will be disappointed, anxious, depressed and/or unhappy about the pregnancy, no matter h6w prepared they were to become pregnant. You must discuss these feelings and their ubiquitousness. These feelings often persist until the pregnancy is accepted. Most mothers want to wait until this trimester ends to notify others of the pregnancy. Many mothers also begin to think about weight gain at this time, either as a happy confirmation of pregnancy or another element to hide from others. The mother often wants repeated evidence of the pregnancy Divulge the pelvic findings; it will be appreciated. She, and her partner 1 if possible, should be counseled that her libido may decrease during · this time

Discuss the examination of the external genitalia, vagina, cervix, perineum, and anus during the pelvic exam.

The external genitalia, or vulva, are examined p.rior to the pelvic and speculum exams . The mons is ob$erved for hair growth pattern and pediculosus. The labia majora and perineum are checked for swelling, edema, cysts, inflammation, dermatitis, irritation, discoloration, tenderness, lesions, vesicles, ulcerations, crusting, or condylomata. Investigate and refer to a physician. Varicosities and episiotomy or perinea! laceration scars should be considered when creating the birth plan. The labia minora is checked for inflammation, irritation, discoloration, herpetic vesicles, chancre, fistulas or fissures which must be referred to a physician. The clitoris is checked for adhesions and enlargement; the urethral orifice is checked for irritation or dilation (possible repeated UTis or insertion of foreign objects), and for growths or fistulas, all to be referred to a physician. The vaginal introitus is also inspected for all of the above problems and physician consultations sought for abnormal growths, fistulas, fissures, and uterine prolapse

Discuss the anatomy of the organs and muscle structures making up the female reproductive system.

The female reproductive system consists of the pelvic floor, vulva, vagina, uterus, Fallopian tubes, and ovaries. The pelvic floor supports the abdominal and pelvic organs. The muscles control urination and defecation and gives slight control to the passage of the fetus.It includes the perinea! body: the muscle and tissue between the vagina and the rectum. The vulva includes all external genital organs: the mons pubis, labia majora, labia minora, clitoris, vestibule, urethral orifice, vaginal orifice, and Bartholin's glands. The vagina excretes menstrual flow, encloses the penis, receives sperm, a.nd forms an opening for the fetus. Posterior to the vagina lays the pouch of Douglas, rectum and perinea! body. Superiorly lies the uterus; and inferiorly lies the external genitalia. The uterus holds the fetus. The Fallopian tubes push the ovum toward the uterus, receive the sperm, and allow fertilization. The ovaries produce ova, estrogen and progesterone.

Discuss the management of an unexpected breech delivery.

The fetal position may be incorrectly interpreted during palpation or the fetus may turn breech at the last moment. * Make the room extremely warm. * Place the mother in an upright position *Instruct the mother not to push until the body is born *Once the fetal umbilicus and legs are out ensure there is no tension in the cord; do not handle the cord * Wrap the body and umbilical cord in warmed receiving blankets to delay onset of respiration *If a frank or complete breech becomes arrested while birthing the body, gently place the legs into an antero-posterior position so the body can descend. * Once the shoulders are delivered, place the infant into an occipital anterior position using the hips to guide the body. * The baby should be allowed to hang until the nape or jaw line is visible. * Administer additional support after the head is born to stimulate respiration

Discuss the use of the fetoscope and dopplar for monitoring the fetal tones and heart rate.

The fetoscope is a device used to monitor fetal heart tones and rate. The Allen fetoscope depends on bone conduction of the fetal heart sounds to the user's cranium.It produces muffled sounds of the fetal heart.It is difficult or impossible to hear the fetal heart with a fetoscope during a contraction. Close proximity to the mother's abdomen is required and positioning may cause problems with accuracy. The dopplar is now more commonly used due to increased accuracy and precision.It creates an electronic sound using ultrasound waves based on the movement of the fetal heart. The act of listening for the fetal heart tone in this manner is called auscultation. Intermittent auscultation is used not only to assess the heart rate but to note any variations beat-to-beat and to note any unexpected decelerations.

Explain the purpose'of a well-child visit during postpartum.

The first postpartum visit generally takes place when the infant is 10 to 14 days old and includes reviewing the family history taken to this point. Observe the family interacting with the baby and ask questions about their adjustments, recording the results in the chart. Further history is taken on the newborn, including feeding, bowel, bladder, alertness and crying habits and any concerns noted. The infant's length, weight and head circumference measurements are repeated. The weight should now be back to the birthweight. A physical exam of the baby is performed to ensure continued health and to find any later presenting conditions. f a metabolic screen was taken before the baby was nursing for a full 48 hours, it must be repeated. Offer guidance to the parents and any siblings regarding expectations of the next 6 to 8 weeks when another visit will be scheduled. Finally, tell the parents how to obtain emergency assistance.

Describe elements of the gynecological history that may negatively impact the current pregnancy.

The following conditions may negatively impact the current pregnancy: • A history of fibroids reduces the intrauterine space or disrupts placental implantation. Fibroids tend to increase greatly in size during pregnancy. They also increase the chance of postpartum hemorrhage. An ultrasound should be performed to learn the size and location of these benign uterine masses. • Cone biopsies can cause scarring that reduces dilation. • Cervical cauterization and cryosurgery may cause scarring. • LEEP laser surgery may be implicated in cases of incompetent cervix and premature labor. Cervical changes may need to be monitored throughout the pregnancy and the mother educated about signs of premature labor. • A contraceptive history of UD use may cause anemia due to excess menstruation • Pelvic inflammatory disease and IUD use can cause scarring of the uterine lining and result in ectopic pregnancy, irregular implantation of the placenta and third stage hemorrhage. • The cervical os may be scarred. • Oral contraceptive use can cause a folic acid deficiency .

Define the elements to be included in a complete physical exam.

The following elements comprise a thorough physic::al exam: general appearance and condition of skin • baseline weight and height • vital signs • examine (HEENT) including the hair and scalp • examine lymph glands of the upper body • assess the breasts and the mother's knowledge of and compliance with self-breast examination techniques I • examine the torso and extremities for abrasions, bruising, unusual I growths, or moles • baseline reflexes auscultate heart and lungs • palpate the abdomen noting any scarring • internal pelvic landmarks and measurements • assess Pap smear and gynecological culture results • bimanually determine uterine and ovarian size • assess vulva, vagina, cervix, perineum, and anus • assess kidney pain or CVAT results • assess joint pain, muscular strength, spinal straightness, symmetry, and posture • assess the vascular system including indications of edema, varicosities or thrombophlebitis

Discuss methods of dating pregnancies and their accuracy.

The following methods have been used to date pregnancies: • Basal body temperature charting: coital record, ovulation record and temperature elevations with menstrual history. • Accuracy: +/- 2 to 5 days and depends on record keeping capability. • First trimester ultrasound: range of accuracy of +/- 3 to 5 days. t Accuracy: depends on gestational age, sonographer's skill, fetal position, and available technology. • Serum BhCG of less than 10,000, using two values obtained 1 week apart and rising appropriately. • Accuracy +/- 3 to 5 days. • Last accurately recorded normal, regular menstrual period that is consistent with a first trimester exam. t Accuracy +/- 1to 2 weeks. • Second trimester ultrasound . • Accuracy +/- 1to 2 weeks depending on the requirements for accurate ultrasound. • Third trimester ultrasound. + Accuracy +/- 2 to 3 weeks, depending on the ultrasound conditions. • • Physical exam after 20 weeks. • Accuracy +/- 2 to 3 weeks.

Discuss the risk of uterine rupture during VBAC

The greatest risk of uterine rupture during VBAC is when the previous caesarian section was performed via a vertical incision of the upper contractile uterine segment. Catastrophic uterine rupture may well result, in which the old incision opens completely, the fetal membranes rupture, part or all of fetus extrudes into the peritoneal cavity, and there is significant hemorrhage. If the caesarian was performed prior to 28 weeks gestation, especially without labor, it indicates the corpus muscular mass was likely incised regardless of type of incision; the risk of rupture in this case may be significant enough to deny a trial of labor. Labor induction increases the risk of uterine rupture, especially if prostaglandins are used. Risk of rupture may be related to the previous incision closure. A greater risk is found in single layer of continuous running stitch as opposed to a double layer of interrupted sutures. This information may 1 not be available in the medical record.

Describe the contents of the basic suture kit.

The kit must contain: • Two (2) needle holders. Five-inch Baumgartners are recommended. These have small, serrated tips that hold the needle without slipping. Hemostats should not be used as needle holders because of the difficulty in suturing well. • One (1) tissue forceps is needed, either Semkin-Taylor or Addsons, to hold and lift tissue; thumb forceps or dressing forceps are not suitable. The tissue forceps will not pinch or destroy membranes when used. Two or three (2-3) mosquito hemostats should be included to control small bleeding vessels and never used for anything else. • One (1) pair of scissors to be used only for cutting suture material and are very sharp. These scissors should not be used during delivery or to cut the cord. • Four-by-four gauze pads or sponges, • Betadine solution • suture material All equipment should be kept sterile until the moment for use.

Discuss fundal height measurement using a method of gross approximations based on expected fundal height plus gestational age and a secondary method of tape measurement.

The least accurate method is measured with the examiner's fingerbreadths and depends on the position of fundal height in relation to the symphysis pubis, umbilicus, and tip of the xyphoid process at various weeks of gestation. It can be a rough guide when calipers or measuring tapes are not available. Another method uses a tape measure with the zero line on the superior border of the symphysis pubis. Hold the tape between the index and middle finger with the edge of the little finger on the top of the fundus. The measurement is the number of centimeters where the tape meets the fingers plus additional centimeters depending on the fundal relationship to the umbilicus.

Discuss some commonly used techniques that are ineffective in preserving an intact perineum during birth.

The least effective techniques massage or place pressure on the perineum prior to crowning. In some instances, the technique creates conditions favorable to a tear or laceration. This includes "ironing out" the perineum by sweeping the fingers from side to side within the vaginal vault using pressure on the posterior vaginal wall ahead of the crown. This may bruise the tissue which then may tear. Perinea! massage with warmed oils or lubricants is thought to increase circulation and relax the perineum, but creates a tendency to lacerate. A third technique supports the perineum at the time of birth by bracing the perinea! body with the hand, but this tends to block the fetal head from descending properly and can force the tissue from the midline, both conditions may cause tearing. The ironing and massaging techniques are also known to be irritating and distracting to some women.

Discuss the influence of the menstrual history and sexual history on prenatal care.Include the impact of risky sexual or personal behavior on the pregnancy and the fetus.

The menstrual history includes the cycle length and the normal volume of menstrual flow. A cycle length that is longer or shorter than the average of 28 days can impact the estimated due date. If the mother states that her periods are normally heavier than the last menstrual period before pregnancy it could mean the conception took place as much as a month earlier than originally believed and the LMP was implantation bleeding. Risky sexual behavior exposes the mother to sexually transmitted disease and if the behavior is still taking place it exposes an issue with the mother's commitment to the pregnancy and birth. Counseling and education may help the mother change this behavior. This is also true of other personal risk such as smoking or taking illegal drugs and sharing needles, thereby risking exposure to blood borne diseases.

Describe the laboratory tests routinely ordered for all pregnant women.

The menu of tests ordered for pregnant women can vary depending upon the policies of each facility. Some testing also varies with gestational age. You can be expected to collect blood and pap specimens during the first visit and exam.In general, the following tests are performed: • Pap smear • Gonococcal and Chlamydia samples (collected with the Pap smear) • Blood Type and Rh factor with antibody screen/antibody titer • Sickle cell screening ' • Tuberculin test in high risk groups • VDRL, RPR, or other syphilis serology test • Hepatitis B surface antigen • Rubella titer • Varicella antibody screen • Hemoglobin and hematocrit • Urinalysis • Diabetes screening (28 weeks) • Group B Strep colonization (35-37 wees) All women should be offered HIV testing and alpha-feto protein or triple screen testing at 15 to 18 weeks.

Discuss the gastrointestinal defects of gastroschisis and exomphalos.

The most common abnormalities of the gastrointestinal system are atresias, gastroschisis, and exomphalos, all requiring surgical correction . Many are diagnosed prenatally via ultrasound. Gastroschisis is a defect of the abdominal wall with extrusion of the bowel which is not covered by peritoneal sac. There is a high risk of injury and infection. Exomphalos or oomphalocele is defined by protrusion of the bowel or other viscera through the umbilicus and covered by a sac. Other abnormalities often present in tandem which could delay surgery to enclose the viscera. In both gastroschisis and exomphalos, cover the herniated contents with clean cellophane wrap or warm sterile saline gauze to protect the organs and to delay fluid and heat loss. Aspirate the stomach contents. Immediately transfer to the hospital.

Discuss assisting a birth with previously unknown fetal anomalies.

The most common anomaly is a heart defect presenting as cyanosis and respiratory distress. Heart defects and spina bifida require immediate newborn transportation and pediatric consultation. Most other anomalies do not require immediate treatment but should be seen as soon as possible to determine the extent of the anomaly. · Fetal anomalies can be genetic or caused by viruses, chemicals, pharmaceuticals, radiation, or street drugs. If the anomalies are so severe that they are incompatible with life, follow the parents' lead regarding transport but you are obligated to give life support and call emergency services if the baby seems viable.

Discuss glucose disorders in the newborn.

The most common glucose disorder is hypoglycemia of the newborn, a reaction to the prenatal environment. It is defined as a blood glucose level of 45 mg/di or lower. Symptoms include: • lethargy, • poor feeding, • seizures, • hypothermia, • high-pitched cry, irregular respirations-, • decreased consciousness level. Premature infants, infants of diabetic mothers, sick infants (i.e. septic), and infants with inborn errors of metabolism are at higher risk of neurological damage. Treat these infants promptly. If the blood glucose is close to 45 mg/di encourage the mother to breastfeed as often as possible and afterwards give the infant water with molasses at a rate of 1teaspoon of molasses per cup of.water.If the glucose level does not rise, medical intervention is required. Hyperglycemia .is less severe than hypoglycemia and usually presents in premature and severely growth restricted infants. Generally, no treatment is needed unless there is excess loss of glucose in the urine, causing osmotic diuresis.

Discuss causes of headaches.

The most common headaches are migraines and tension headaches. Less common are headaches caused by: • infections, • cerebrovascular events, • meningitis, • tumors, • glaucoma, • dental issues, • overuse of medication, • arteriovenous abnormalities. Immediately refer any sudden, severe headache that persists despite remedies to a neurologist.If the patient is over 40 and the headache is a new complaint, it may be due to a tumor and she should be referred to a physician. If it is referred to as the worst headache the patient ever had, there is the possibility of hemorrhage into the brain and the patient should be immediately eyaluated by a physician. A thorough history to investigate headache issues should include a full description of the headache, frequency and onset, location, precipitating factors if known, family trends, menstrual history, and any other conditions such as neck stiffness, visual complaints, and head trauma.

Discuss a history of previous abortion in conjunction with having a home birth.

The mother must be ready to discuss the abortion in order for you to obtain accurate information without causing her undue emotional distress. The method of abortion is important to note as each method holds risks for the future ability to become pregnant and to carry a baby to term. Dilation and curettage involves scraping of the endometrium which may cause scarring, creating a risk of interference ' with placental implantation. Suction is less damaging to the endometrial lining. A thorough discussion should be made of the decision to abort as well as the emotional impact of the abortion itself. Many women feel the same great sense of loss women who have ex perienced repeated miscarriage.

Explain maternal recovery from labor and delivery.

The mother requires 10 full days of absolute rest. She should sleep l and eat whenever her body tells her she must. She should not become r stressed as that will release adrenaline which interferes with the : oxytocin release needed for uterine involution. The mother should also I be encouraged to walk several times daily, even if the distance is short I to stimulate circulation and prevent tl:irombophlebitis. A jug of water 1 should be at hand at all times to replenish liquids lost by nursing. Her room should be comfortably warm with any baby or personal needs close by. She may need help with a shower. The mother should be relaxed and happy; if she is not, the reason must be found and corrected. The mother should be allowed to talk to you about the birth if she wishes. Remain receptive.

Explain the signs and management of early labor.

The mother should be well educated in the signs of early labor. The most obvious signs of impending labor are the "show", pink tinged vaginal mucus; spontaneous rupture of the membranes, commonly called the breaking of the water; or regular contractions, no more than 20 minutes apart. The mother should call you as soon as she thinks labor has started so you can make preparations. The mother should be taught the difference between "show" and excess bleeding that could indicate placental complications. Counseling about membrane rupture should include monitoring for bacter'ial infection, meconium passage, and the need to get rest while she is still able. When true contractions begin, it can be suggested that the mother get some light walking exercise, and she should be counseled to continue to eat and to sleep whenever possible.

Discuss partner and sibling preparation for participating in the birth.

The mother's partner may need time to determine his or her role in the birth, or may be completely ready and willing to do whatever is needed or wanted. For some couples the act of the partner "catching" the baby is the most cherished wish of the pregnancy. You are responsible for ensuring the partner's education with appropriate reading materials, discussing the birth process, and depicting the sensual side of it. Use a model pelvis and doll for practice ahead of the actual birth. You must ensure the partner understands the emotional needs of the mother and to take all cues from the mother regarding the process. Give siblings age appropriate books and show videos of the birthing process to give them a sense of what to expect. An adult companion for the sibling(s) should be present at the time of birth to care for them in the event they are overwhelmed by the birth.

Discuss the significance of color in the mucus membranes.

The mucus membranes are found in the nose, mouth, eyes, and other internal areas that can be exposed to the environment. Mucus formed within the membranes and nonpathogenic organisms form another level of resistance to infection of the body. Examination of the mucus membranes should note: • degree of moisture, • hyperemia, • pallor, • cyanosis, pigmentation, lesions • hemorrhage. Anemias will cause pallor; temporary pallor can be caused by shock, vasomotor spasm, or severe hemorrhage. Pallor occurring in [ alternation with flushing indicates aortic regurgitation. Hyperemia, or I excessive redness, is caused by different pathologies depending on the tissue. Redness in the mouth can be due to tooth decay, stomatitis or I trauma. Redness in the nose can be caused by ulceration, 1 inflammation, or rhinitis. Dry membranes indicate fever, chronic ] gastritis, liver disturbances, shock, prostration, fatigue, dehydration, and use of certain drugs.

Discuss pigmentation changes of the skin in pregnancy.

The nipple and primary areola darken in the third month of gestation. Secondary areolae, linea nigra and abdominal striae appear. Striae is also seen on extremely large breasts and sometimes the buttocks and upper thighs. Chloasma, or mask of pregnancy, may appear. Pigment changes may be caused by estrogen or progesterone stimulating the melanocytes of the skin: The linea nigra·appears as a dark line from the umbilicus to the symphysis pubis at the abdominal midline. Nipple pigmentation varies with complexion; blondes have pink nipples and brunettes have brown nipples. Chloasma is most prevalently seen in brunettes. Sometimes pigment changes will not be seen in pregnancy and occasionally certain pigment changes can be seen in non-pregnant women taking hormones or who may have tumors in other areas.

Discuss the need for well-baby care after the immediate postpartum has passed.

The parents are expected to be solely responsible for the infant once the immediate postpartum time has passed. Often, within a week, friends and family who gathered to help with the birth are no longer available. However, the parents are just beginning to realize the reality of life with a newborn, even if this is not a first child. There are still many skills to be learned at a time when rest is at a premium. Assistance from a professional who can educate them ahd watch them practice these skills is invaluable. The midwife, who has become especially well known and accepted by the parents, will be in a position to immediately answer any questions the parents have in a way that 1 helps them most. Additionally, the midwife is able to watch the infant while it is still adapting to extra-uterine life. He or she may observe 1 conditions or diseases that may escape the notice of the parents

Explain the planning and preparation required of participants besides the midwife in the mother's birth.

The participants should continuously commit to any plans of care made for a home birth. All should be counseled regarding their responsibilities to maintain communication with the midwife including any life changes. Everyone involved must avail themselves of the reading material and educational classes that will assist them in a homebirth. Preparation must be made for breastfeeding, payment of any related fees, and relaying insurance information. Siblings and other participants must be educated about the experience to come and their responsibilities in it. All baby clothing, supplies and equipment must be obtained over the course of the pregnancy. Arrangements for other issues such as pet care and visits to care providers must be made and followed. Any supplies needed for emergency transport must be ready, including fuel for the transport car and a sure route to the hospital.

Explain pelvic inclination and the axis of the pelvic canal.

The pelvis is on an incline when the female is standing erect. The line between the sacral promontory and the top ofthe symphysis pubis forms a 60 degree angle with the floor. A line from the center of the sacrum and the center of the symphysis pubis forms a 30 degree angle with the floor. At the outlet, the angle of inclination is 15 degrees. In a recumbent position, these angles would be formed with a vertical surface rather than the floor; you should be cognizant of this when performing an abdominal examination. The curve of Carus is formed when a curved line is imagined exactly half-way between the anterior pelvic wall and the posterior pelvic canal. Familiarity is required of this structure when examining the vagina and when assisting in birth.

Discuss the general performance of a physical exam.

The physical exam can be a way of gaining trust with the new client and to check for underlying conditions that may impact pregnancy. A physical exam typically includes a "review of systems" (ROS) which is a structured investigation of past or current symptoms or complaints. ROS during the physical exam eliminates repetition but can cause information to become disconnected. Immediately prior to the exam thoroughly wash and warm your hands. Keep nails trimmed to avoid scratching the client. Touch to the client gently but firmly to avoid tickling and communicate respect for the client's body. Explain each touch first. Minimize the need for movement by the client. The exam should proceed the same way for every client to avoid missing anything and should proceed from head to toe. Communicate all findings to the client whether normal, abnormal or in need of confirmation by another examiner such as a physician.

Give an overview of the physiology of the female reproductive system with and without occurrence of pregnancy.

The pituitary releases GnRH and the anterior pituitary releases FSH and LH. FSH influences follicles within the ovaries to enlarge and estrogen levels increase. LH is produced a few days after FSH' when · both levels peak, the follicle ruptures and ovulation occurs. Estrogen levels increase causing FSH production to stop. Progesterone levels rise and cause FSH and LH levels to fall.If the released ovum is not fertilized, it degenerates in 14 days and the cycle begins again. The ovum moves along the Fallopian tubes. It can be fertilized by only a single sperm. The gametes merge to convert the ovum into a zygote. Once the zygote reaches the uterus in the form of a blastocyst, the outer layer becomes the placenta and chorion, and the inner portion becomes the fetus, amnion and umbilical cord. The blastocyst adheres to the uterine wall and is embedded into the endometrium (implantation). The zygote becomes an embryo until 8 weeks post conception when it becomes a fetus.

discuss herbal remedies for gestational hypertension.

The regular ingestion of Raspberry leaf or Nettle infusions help prevent hypertension. When hypertension occurs, hops, skullcap, passionflower, hawthorn, and chamomile all induce relaxation and reduce systolic pressure. Diastolic pressure can be reduced through the use of cayenne pepper, which acts as a vasodilator and cardiac stimulant. Hops is the most potent of the listed herbs and can be taken nightly as a tea in the last months of pregnancy; but it is contraindicated for regular use throughout pregnancy or for use in the first trimester. Skullcap can be taken as an infusion once or twice daily . Passionflower can be taken in capsule form, 2 to 4 capsules daily, or in tincture at the rate of 15 drops three times daily. Hawthorn is a strong vasodilator that works cumulatively. A cold infusion taken in sips at the rate of one cup daily, or 15 drops of the tincture two to three times a day is recommended.

Discuss the role of calcium and magnesium in hypertension treatment.

The role of calcium in controlling hypertension has not been satisfactorily proven or explained. While studies have shown magnesium and phosphorus intake can impact blood pressure, calcium has not been shown to have the same effect. However, since calcium intake is usually below the recommended levels, ensuring adequate intake during pregnancy is not harmful. Calcium uptake by the body requires adequate magnesium, phosphorus, and Vitamins A, C, and D. The best nutritional sources for calcium are in fish and dairy products. Salmon, sardines, mackerel, seaweed (kelp), sesame salt, tahini, and dark leafy vegetables such as turnip tops, kale and beet greens are all good sources of calcium in food. Nettle and Raspberry leaf infusions both carry calcium and the supporting vitamins and minerals .Many wild greens such as Lamb's Quarters, Mallow, Galinsoga, Shepherd's Purse, Knotweed, Bidens, Amaranth, and Dandelion leaves are good sources of calcium

Explain the Rubella antibody titer and the consequences of rubella in pregnancy.

The rubella antibody titer indicates the level of immunity that the mother has to German measles (Rubella). A titer greater than 1:10 indicates a prior infection or vaccination conferring immunity to rubella. An unusually high titer, greater than 1:64, may indicate a recent or current infection. Anything less than 1:10 is low and the mother may not have immunity. In this instance, the mother must be immunized after the current pregnancy and three months prior to becoming pregnant again. Vaccination while pregnant is contraindicated because the vaccine is a live attenuated virus that may impact the fetus.In the meantime, the mother must avoid infection since rubella infection during pregnancy can cause fetal cardiac defects, cataracts, and deafness in 20% of infants. It can also cause miscarriage, stillbirth, and fetal anomalies .Intrauterine and postnatal growth retardation may also occur.

Explain the newborn's sensory capabilities.

The sensory capabilities for a term newborn are: • ability to visually fix and track objects. • a strong preference for stripes or patterns, and black, white, and strong colors. • At two weeks an infant can mimic human facial expressions. • Discrimination of taste and odor, preferring its own mother's scent and the taste of sweet liquids. • Localization of sound and discrimination between sounds, showing a preference for human voices over synthesized sounds and picking out its mother's voice from others. • By one month this preference evolves into preferring sound patterns similar to speech. Many of the exteroceptive reflexes are related to touch. These reflexes are often survival mechanisms meant to help the infant obtain nutrients and remain safe from danger.Infants also enjoy being touched, especially skin to skin contact

Discuss the maternal psychological changes that occur during the third trimester.

The third trimester is the "time of watchful waiting;,. The mother becomes anxious both for the baby's arrival and worried about premature labor. Visible preparation begins, including choosing names, preparing the baby's room, and receiving gifts. Now is the time of fear about death and abnormalities, and pain during childbirth. The mother may worry that she won't recognize labor or that the baby is unable to come through the birth canal. The mother may grieve the loss of attention as well as the closeness of the baby once it is born. There is also physical discomfort affecting her emotions, feeling fat or awkward. The mother's partner should be made aware that loving, non-sexual contact is needed to emotionally support her.

Discuss the examination of the thyroid and any related conditions

The thyroid is part of ROS of the neck. Abnormal symptoms include: enlasgement, excessive sweating, dry skin or hair, fatigue or excessive energy . Common laboratory tests for diagnosis of thyroid disease are TSH, Free T4 and Serum T3. Total T4 is not as significant. Hyperthyroidism means TSH is low or absent and T3 and Free T4 are increased. Grave's Disease, an autoimmune disease, is the most common type. The thyroid is enlarged and tender with optical symptoms. Another less common cause of hyperthyroidism is high hCG in hydatidiform moles. Treatment alterations during pregnancy keep Free T4 levels in the high-normal range. In hypothyroidism TSH is elevated, most commonly due to Hashimoto's thyroiditis, an autoimmune disease. Postpartum thyroiditis presents as hyperthyroidism first, then hypothyroidism. Recovery is spontaneous but may recur in future pregnancies and may increase the risk of thyroid disease in the future. L-Thyroxine is the typical medical treatment.

Discuss the changes in the serum glucose, hemoglobin and hematocrit over the course of the pregnancy

The total blood volume in a singleton pregnancy can increase between 30% and 50% with increases above 50% in multiple gestation. The majority of the volume increase is an increase in the plasma volume which causes a hemodilution effect. This in turn causes the hematocrit to decrease as the ratio of red blood cells to plasma changes. The most significant decrease in hematocrit occurs between weeks 24 and 32. After 32 weeks the hemodilution effect stabilizes. Unless the mother is diabetic in any form, the normal serum glucose levels of a pregnant woman will not differ from a non-pregnant one. Gestational diabetes will cause the serum glucose to remain elevated longer than normal and may cause the levels to become more elevated than normal when ingesting a standard load of glucose

Explain the transverses exercise and pelvic tilting or rocking.

The transverse exercise tones the deep transverse abdominal muscles and helps prevent backache due to poor posture. Sit or kneel on hands and knees with a level spine. Breathe in then release. Pull in the lower part of the abdomen below the umbilicus without moving the spine and continue to breathing normally. Hold the muscles for 10 seconds then gently relax. Repeat up to 10 times. The pelvic tilt or rocking exercise is performed in a half-sitting position with plenty of support from pillows. Bend the knees and place the feet flat on the floor. Place one hand under the small of the back and the other on the abdomen. Tighten the abdominal and the buttocks and press the small of the back into the floor. Breathe normally. Hold this position for 10 seconds and release. Repeat up to 10 times.

Discuss the structure of the true pelvis as it relates to the practice of midwifery.

The true pelvis is the bony opening through which the fetus passes during birth. It is formed by a brim, a cavity and an outlet. Fixed points on the pelvic brim are landmarks. Beginning from the posterior the landmarks are as follows: • sacral promontory, • sacral ala or wing, • sacroiliac joint, • iliopectineal line, • iliopectineal eminence, • superior ramus of the pubic bone, • upper inner border of the body of the pubic bone, and • the upper inner border of the symphysis pubis. Three diameters of the brim are measured. One, the obstetrical conjugate, is about 11 cm from the sacral promontory to the posterior border of the upper surface of the symphysis pubis. This is the space through which the fetal head must pass. The obstetrical outlet portion of the pelvic outlet is formed by the narrow pelvic strait and the anatomical outlet. The anteroposterior diameter, a line from the lower border of the symphysis pubis to the sacrococcygeal joint measuring 13 cm, indicates the available space during delivery.

Discuss uterine abnormalities.

The uterus can be malformed due to the failure of the MOllerien ducts to fuse correctly . This can result in several abnormalities: a double uterus with a double vagina, a double uterus with a single vagina, a bicornate uterus, and other deformities depending on where the fusion fails. The difficulty in pregnancy depends on the severity of the abnormal ity. If the uterus can still stretch to accommodate a full size fetus, the pregnancy may not be endangered. If it cannot, premature labor, abnorma l lie of the fetus, and abortion may result.In the case of a double uterus, the fetus takes up one horn while the other remains empty. The empty horn enlarges under hormonal influence and can obstruct the birth canal.In this case, a caesaria!l section will be required.

Describe a normal uterus, lochia and perineum at the first day post partum examination.

The uterus is below the mother's umbilicus and feels firm, not tender. Massage it to remove any clots and place the mother upright briefly before checking the flow of lochia. At this time lochia rubra, or red-brown flow, appears like a heavy period. The odor is fleshy and similar to menstrual blood. The perineum should no longer be swollen.If swelling is apparent, alternating warm and cool compresses and rinsing the perineum twice a day with warm water and Betadine may help decrease swelling.If the swelling is increased and pain is evident, a hematoma may be indicated. At this time, the vaginal canal is checked for hematoma, cystocele and rectocele. Areas with stitches are pulling together and are clean and dry with no sign of infection. Ask mother about pain with urination and whether a bowel movement has yet occurred.

Discuss the examination of the uterus and ovaries during a pelvic exam.

The uterus is palpated bimanually. One hand is placed on the abdomen I between the umbilicus and the symphysis pubis. Two vaginal finges should be placed to either side of the cervix, pressed on top of it and the cervix pushed downwards with the backs of the fingers. The tips of the fingers are pushed upwards to feel the shape, size and contour of the uterus. A multiparous uterus is larger than a nulliparous uterus. An enlarged uterus can indicate pregnancy or tumors. Normal nulliparous size is 5 .5 to 8 cm long, 3.5 cm wide, and 2 to 2.5 cm thick. A multiparous uterus is slightly larger. The ovaries are also palpated at this time. Normal ovaries during childbearing years are 2.5 to 5 cm long, 1.5 to 3 cm wide; and 0.5 to 1.5 cm thick. After menopause ovarian size decreases significantly.

Discuss the sleep-wake states of a newborn.

The waking states include: crying, much motor activity, alert, and drowsy. Newborns spend 15% of daytime hours in the alert state. Crying communicates a need to be fed, held, stimulated to suck, or to sleep. Rarely, it is for pain. The sleep states include active (light) sleep and deep sleep.In light sleep, respiratory rates may vary, there are frequent motor movements and the infant can startle easily.In the deep sleep state there are few motor movements and respiration is deep and regular. Healthy newborns spend up to 60% of their time sleeping, mostly in short naps. Over the first month, many changes take place: the infant begins to spend more time in deep sleep as opposed to light sleep and in the waking states there is an increase in the alert state. There is higher alertness to the world around her even while crying.

Describe turning a breech presentation prior to labor by using alternative maternal positions.

There are several methods: Postural tilting: The mother must empty her bladder and lie down with hips elevated three times a day for 20 minutes. Somersaults in a swimming pool. Elephant walking, with the mother walking on hands and feet. A baby may be turned by placing a rebozo, or large shawl, at the juncture of the mother's thighs and hips while the she is on knees and elbows. The midwife then takes the ends of the rebozo and stands at the mother's head and alternates pulling each end forward, creating a rocking motion. This should be performed for several minutes. Other alternatives, while not strictly _ postural, may suffice: playing music through headphones low on the mother's uterus, speaking to the baby from low on the uterus, shining a light into the vagina from between the legs or placing a bag of frozen vegetables near the baby's head all may cause the head to turn downward.

Discuss methods of avoiding post-partum hemorrhage.

There are three elements to avoiding post-partum hemorrhage: • Good nutrition and supplements, • Familiarity with the mother, • Delivery of the placenta without urgency. With proper nutrition the mother will maintain hemostasis more readily. Certain supplements such as liquid chlorophyll, red raspberry and nettles or tincture of nettles, yellowdock, alfalfa and red raspberry as well as multivitamins can keep nutritional levels at optimum. Delivery of the placenta should not be rushed but taken in its own time so that the intervillous spaces can contract and control blood flow. Familiarity with the mother allows you to be aware of the mother's diet and previous birth experiences.It also means that aU recent lab results have been obtained and checked, especially the hemoglobin, hematocrit, and platelet count.

Discuss·the structure of the female pelvic bones and ligaments.

There are three pelvic bones: the innominate (hip) bones (2), the sacrum (1) and the coccyx (1). The innominate bones are composed of the ilium, the ischium, and the pubic bone. The ischium contains an inward projection called the ischial spine. The station of the fetal head is estimated in relation to this spine during labor. There are four pelvic joints: the symphysis pubis (1), the sacroiliac joints (2) and the sacrococcygeal joint (1). During pregnancy, the ligaments soften due to estrogenic activity and move to make room for the fetal head during birth. The symphysis pubis may separate before birth, causing discomfort while walking. The pelvic joints are held together by the interpubic ligaments at the symphysis pubis, the sacroiliac ligaments and the sacrococcygeal ligaments. Two other important ligaments are the sacrotuberous ligament and the sacrospinous ligament which cross the sciatic notch and form the posterior wall of the pelvic outlet.

Discuss the types of uterine rupture and signs and symptoms of dramatic catastrophic uterine rupture.

There are two types of uterine rupture. • Catastrophic uterine rupture involves the old incision separating completely. The fetal membranes rupture; part, -0r all, of the fetus extrudes into the peritoneal cavity; and hemorrhage is significant. The first sign of catastrophic rupture is fetal bradycardia; any change in FHT, especially recurrent late decelerations and which are not relieved by any action, may indicate a rupture is imminent. The most serious sign is recurrent late decelerations followed by prolonged decelerations and terminal bradycardia. In dramatic rupture, the mother feels a sharp, shooting abdominal pain at the peak of a contraction. The presenting part is now movable, a loss of station or repositioning is apparent, fetal parts are easily palpated, fetal movements are violent and then cease, the contracted uterus is felt beside the fetus. Maternal shock may occur. • Atraumatic dehiscence is where the old scar does not separate along the entire length, the fetal membranes do not rupture, the fetus does not extrude into the peritoneal cavity, and there is little to no bleeding

Explain the causes and treatment of colic.

There does not seem to be any agreement on what causes colic or even if such a condition actually exists.Infant colic is defined as crying and screaming for three to four hours at a time on a daily basis. This behavior peaks between three weeks and three months of age and then gradually subsides. There is no conclusive evidence that colic is caused by the mother's diet.It is possible that products containing cow's milk whey may cause gastrointestinal distress. It is also possible that the infant is very sensitive and is overreacting to its environment. There is no treatment but there are some recommendations for soothing the infant: try to feed the infant, swaddle it, give it a pacifier, talk to it face-to-face with a low, rhythmic voice, using different holds, reduce stimulation in the room, walk with the baby, or take it outside for a walk or car ride.

Discuss limb reduction defects.

There has been no success in finding any singular cause of limb reduction defects. These defects can be due to arrested development, as in the absence of part or all of an appendage, or longitudinal arrest of the limb as in fingers or a hand appearing at the end of a severely foreshortened arm.In the latter case, thalidomide has been identified as a major teratogen causing this issue. Cases of a particular type of defect may be clustered in a geographical area but even then a cause may not be found. Supportive care, not only of the infant, but of the parents, is of the most importance. The infant can be fitted with prostheses and may benefit from corrective surgery. Most will adapt to their defect and to any treatment. Refer parents to support groups where available.

Explain the conditions in which parents should immediately call the midwife.

These are emergencies. Parents should be instructed to call the midwife must be called at once if they observe: • Vaginal bleeding indicating possible miscarriag, spontaneous abortion, or a molar or ectopic pregnancy. In later trimesters, placenta previa, placental abruption, or a ruptured cervical polyp may be indicated. • Blisters breaking out in the perinea! or anal area indicating herpesvirus. • Severe pelvic or abdominal pain indicating a tubal pregnancy or placental abruption depending on the trimester. • Persistent, severe pain in the mid-back indicating pyelonephritis or kidney infection. • Swollen hands and face, severe headaches, blurry vision, or pain under the ribcage indicating pre-eclampsia. • A gush of fluid in the first or second trimester indicating a miscarriage. • Premature delivery in the late second or early third trimester indicating a miscarriage. • Regular uterine contractions before 37 weeks indicating impending premature birth. • Cessation of fetal movement indicating fetal demise.

Discuss the management of third stage hemorrhage.

Third stage hemorrhage is caused by partial placental separation which in turn is often caused by uterine massage prior to placental delivery. While the placenta may become partially separate during delivery, the condition is usually short lived, but separation due to medical mismanagement almost always causes hemorrhage. If hemorrhaging in the third stage occurs, someone other than the midwife should immediately call the consulting physician and emergency services. Thoroughly massage the uterus to try to complete the placental separation. Place anIV with Ringer's Lactate and draw blood for a type a.nd crossmatch . Watch the mother and manage signs of shock. Catheterize her · unless her bladder is known to be empty . Manually separate and deliver the placenta if it has not already been. lf you are unable to do so and emergency services have not yet arrived, an oxytocin solution that causes intermittent contractions should be given to contract the uterus and cervix ONLYIF ABSOLUTELY NECESSARY.

Define Pierre Robin Syndrome.

This is a group of three defects of the mouth including hypoplasia of the lower jaw (micrognathia), abnormal attachment of the muscles controlling the tongue, and a central cleft palate. The abnormally attached muscles of the tongue allow it to fall back into the throat and occlude the airway. Feeding is extremely difficult. The infant must breastfed in a prone position and be put to sleep on its stomach to keep the airway clear. Aspiration is highly likely. Equipment for medical intervention must be nearby at all times. A long hospitalization is likely until the mandible has developed enough for the parents to take the infant home.

Discuss the gastrointestinal defects of atresias.

Three common atresias are esophageal, duodenal,' and rectal (accompanied by an imperforate anus). Esophageal atresia occurs when the canalization of the esophagus is incomplete early in pregnancy and impacts the tracheo-esophageal fistula. Commonly, the upper esophagus ends in a blind upper pouch and the lower esophagus attaches to the trachea. This often happens with polyhydramnios. Duodenal atresia is the most common site for atresia defects. Persistent vomiting in the first 24 - 36 hours after birth will be the first , problem seen. This defect is often seen with others; 30% occur in 1 infants with Down Syndrome.Imperforate anus will be apparent upon close examination of the infant. Rectal atresia will be signaled by the non-passage of meconium. All infants with these defects should be referred for surgical correction.

Explain thrombophlebitis .

Thrombophlebitis is an inflammation of a leg vein. Those with varicose veins are at higher risk than those without. Superficial thrombophlebitis presents with leg pain, heat, tenderness and redness at the inflamed area. Confirmation of superficial thrombophlebitis can be done by checking for Homan's sign. Thrombophlebitis is superficial if there is pain in the mother's calf when the affected leg is straight and the foot flexed. I • Deep thrombophlebitis is indicated if there is a high fever, severe pain, edema and tenderness along the entire leg. For either problem, the mother should be on bed rest with her leg elevated . Her leg should not be manipulated in any way. If a clot becomes dislodged from her leg and lodges in the lungs, pulmonary edema may result; oxygen must be administered and emergency services notified.

Explain the cause and treatment of thrush

Thrush is caused by the yeast Candida albicans.In infant thrush, the infection appears as adherent, white, plaque-like clumps on · the tongue, gums and hard palate; or ·as a red rash on the infant's perineum. The infant may develop thrush from birth, after administration of antibiotics, and from caregivers' hands or feeding equipment. Treat with applications of acidophilus solution three times a day by swab if the thrush is not interfering with nursing .It may take several weeks to subside. Gentian violet may also be used for infant thrush. Thrush can spread from infant to mother, or it can develop on the breasts if the mother has frequent yeast infections.If only one nipple is infected, prevent spread to the other by careful hygiene. Symptoms include an acute onset of sharp, stabbing pain at the nipple during breastfeeding, burning, or itching. Refer the mother and her baby to a physician for appropriate treatment..

Explain tocolytic therapy.

Tocolytic therapy is the administration of certain agents that inhibit uterine contractions. THESE DRUGS ARE EXTREMELY TOXIC AND MAY PRODUCE DANGEROUS SIDE EFFECTS II\! MOTHER AND FETUS. An early and accurate diagnosis of preterm labor is required. In general, only mothers who are dilated to at least 4 centimeters and are less than 34 weeks gestation are potential candidates for this treatment because it has not been shown to be effective enough to overcome the risk of side effects when used between 34 and 37 weeks, although it may be used under certain conditions. Tocolysis may only prolong pregnancy for 24 to 48 hours, although prolongation of 3 to 7 days has been obtained. When labor has been halted for at least 24 hours corticosteroids can be given which will reduce neonatal mortality, respiratory distress syndrome, and intraventricular hemorrhage in the newborn.

Explain the impact of toxoplasmosis to pregnancy and how to avoid it.

Toxoplasmosis is a protozoan infection.If contracted after the tenth week of gestation it can cause congenital anomalies, the most severe of which are: • anencephaly, • hydrocephalus, • microcephaly, • intracranial calcifications. Many babies do not show symptoms at the time of birth. The condition can continue to cause symptoms throughout childhood such as seizures or mental retardation. Toxoplasmosis can be contracted through raw or undercooked meat that has been infected, or by exposure to cat feces or contaminated soil. The best way to avoid it is to avoid eating raw or undercooked meat, especially pork, and to refrain from emptying a cat's litter box or coming into contact with a cat's feces in any other way. You should take a careful history in order to uncover any way in which the mother may be put at risk of this or other illnesses. Infection can be prevented through education and counseling.

Explain transient tachypnea of the newborn (TIN).

Transient tachypnea of the newborn TTN) is a temporary condition in which the newborn has abnormally rapid breathing. This occurs in 1-2% of newborns. TTN is also called "wet lungs" or type II respiratory distress syfi\drome. Infants born to mothers who smoked during pregnancy or had diabetes and infants small for their gestational age are at higher risk for this condition. Normal newborn breathing rates are 40-60 breaths per minute. TTN may increase these rates to 120 breaths per minute. TTN is caused by delayed absorption of fetal lung fluid and is a condition that will often resolve itself within 24-72 hours. However, if it is accompanied by respiratory distress syndrome, meconium aspiration, sepsis or any sign of respiratory problems the baby must see the pediatrician immediately. Once TIN resolves, the infant is at no higher risk of other respiratory illness than any other newborn.

Discuss Trisomy 18 and Trisomy 13.

Trisomy 18, in which the 18th chromosome is tripled, presents physically with a small head, a flattened forehead, receding chin, low-set and malformed ears, and often a cleft palate. The sternum is generally short, the fingers may overlap and the feet have the rocker bottom appearance typical of the syndrome. Cardiovascular and gastrointestinal defects are common. These infants rarely live out the first year. Trisomy 13, also known as Patau syndrome, has a tripled 13th chromosome. These infants are also short-lived, rarely living beyond the age of 3. Physical manifestations are as follows : • small stature with microcephaly; • limb defects; • midline facial defects such as clelt lip and cleft palate; • brain, renal, and cardiac defects.

Discuss Trisomy 21 (Down Syndrome).

Trisomy 21, or Down syndrome, is so-called because the 21st chromosome is tripled. The risk of Down syndrome increases with the age of the mother. The syndrome can be definitively diagnosed with amniocentesis prenatally but the extent of mental retardation cannot be determined. There are many physical features that may be present in the infant such as widely set, obliquely slanted eyes, a small nose, a rough thick tongue, a small head with flat occiput, broatl, squat hands with stubby fingers and incurving small finger, simian crease and generalized hypotonia. Not all features are present in every Down's infant. Do not make a statement based on observations of these features however suggest the possibility to the parents and consent obtained for testing. Down's infants also have higher incidence of cardiac abnormalities, leukemia, and hypothyroidism. Mental retardation is also present with typicalIQs of 40-80. Genetic counseling should be offered for future pregnancy risk.

Discuss the risks of multiple gestation and a first step toward management.

Twin pregnancy is at higher risk than singleton for a number of complications: • malpresentation, • gestational diabetes, • placenta previa, • stillbirth, • fetal abnormalities, • early pregnancy loss, • IUGR, • premature labor and birth, • preeclampsia, • dysfunctional labor. Managing multiples requires exceptional support from a consulting physician. You should expect a hospital birth. Higher order multiples require physician management (triplets and higher). Determine placental placement and chorionicity of twinning by ultrasound for risk identification and management. Chorionicity refers to whether the twins are monozygotic (from the splitting of a single embryo) or dizygotic (from the fertilization and implantation of two ova). Amnionicity indicates whether a single amniotic sac is being shared by the fetuses (monochorionic) or whether two separate amniotic sacs are present (dichorionic). In the case of dichorionicity, there may be a single fused placenta with two cords or two separate placentas.

Discuss the condition and management of membranes presenting at birth.

Typically, if the membranes are bulging from the vagina they are ruptured by the descent oMhe head and the waters flow out ahead of the baby. Occasionally the rupture-occurs higher up and the membranes envelop the face as it is born, called "delivery in the caul". This is a breathing obstruction that must be corrected immediately. A finger must be hooked into the membrane below the chin and the membrane peeled away. This issue can be avoided if the midwife and mother both agree to artificially rupture the membrane if it presents in this manner. Cultural sensitivity must be used as this condition is seen in some cultures as "good luck". The midwife should have a good sense of how the family sees such a presentation.

Describe the risks of ultrasound.

Ultrasound imaging: • Can give a false sense of wellness of the fetus, • Can give a false positive indications of abnormal conditions Ubiquitous use can cause an over-reliance on technology and an increase in health care costs. Randomized controlled studies have shown that, for a woman with no risk factors and a normal pregnancy, routine use of ultrasound made no difference in the outcome of the pregnancy as opposed to routine care and screening with manual methods by the health care practitioner . The quality of the information from the ultrasound can differ depending upon the expertise of the operator. A general ultrasonographer in a general radiology department may not as readily identify key components and anomalies as an ultrasonographer who routinely performs only pregnancy related scans and/or specializes in ultrasound for woman with risks to their pregnancy. The National Institutes of Health have published a listing of indications for obstetrical ultrasound.

Describe the benefits of ultrasounds.

Ultrasound imaging: • improves gestational age assessment with uncertain dates, • identifies fetal anomalies, assesses fetal growth, and accurately identifies fetal demise, placental location, fetal position, and fetal number. • Amniotic fluid anomalies and pelvic masses are readily identified. • Gestational age assessment determines the course of ongoing management of prenatal care. • Identification of fetal anomalies by ultrasound can be done early enough in the pregnancy to allow the mother to terminate the pregnancy if she desires or to plan to care for a baby with abnormalities. Conditions may be identified that can be corrected by intrauterine treatment or surgery. • Some studies of ultrasound show that alcohol and tobacco use decrease when ultrasound is performed. Ultrasound is best used in cases where the mother has risk factors that may decrease the chances of an optimal pregnancy outcome. The NationalInstitute of Health has published a listing of indications for obstetrical ultrasound.

Describe methods of identifying a fetus in breech presentation prior to labor.

Ultrasound is the best method of identifying a breech presentation. It provides a clear picture of the position and presentation of the fetus at any given time. Palpation may be used to identify a breech although with difficulty in a primagravida with firm abdominal muscles. Palpation shows a longitudinal lie with a soft presentation. The head can be felt in the fundus and is easily movable unless it is a frank breech and the legs do not allow the head to move as fr.eely. Auscultation of the fetal heart tones are typically heard above the umbilicus in a breech unless the hips have engaged in the pelvic brim. In that case, the heart tones will be lower. X-ray is almost never used to identify breech presentation due to the risk to the fetus but it can provide pelvimetric measurements while showing the presentation .

Discuss weight gain issues for pregnancy women.

Underweight women may gain more weight during pregnancy while overweight women should gain less. By 20 weeks approximately 10 pounds should be gained with one pound a week after that. f more weight is gained than expected and it is not due to a growth spurt of the fetus, the mother may have changed her dietary habits due to unsound nutritional information. Sometimes there is a perceived need to watch weight because of a partner's attitude or simply physical discomfort with extra food intake. Nutritional information, patient urging to eat healthy foods for the baby's sake, and working with the mother to find alternatives to favorite but unhealthy foods may put her back on track. An outline of poor consequences if this plan is not followed may increase cooperation. Pregnancy may cause eating disorders to recur and a history of eating disorders may require the services of a specialist.

Explain the use of compresses in preventing perinea! tears.

Unless the birth is in water, one technique for preventing tears in the perineum is application of hot compresses. Such compresses stimulate blood circulation. They also relieve some of the burning felt by the mother when the perineum is stretched to its fullest. In . addition to these, the compress promotes relaxation which in turn helps the mother to continue the birth process more easily . To make the compresses, sterile gauze pads or clean washcloths are soaked in hot water with an antiseptic agent added. The pad is pressed onto the perineum and is most useful if the perineum begins to blanch.If the pressure of the descending head causes the mother to pass fecal matter, it should be wiped away with a tissue.If the compress becomes contaminated, it should be exchanged for a clean one.

Discuss urinary tract infections during pregnancy.

Urinary tract infections are common during pregnancy because urinary stasis occurs due to normal hydronephrosis, creating a breeding ground for bacteria. Urinary tract infections during pregnancy are associated with preterm labor, low birth weight, hypertension , preeclampsia, pyelonephritis and maternal anemia without prompt identification and treatment. Those who have sickle cell trait or anemia, diabetes, or a history of UTI are at higher risk of developing infections. The most common bacteria implicated in UTI is E. coli which is part of the normal flora of the intestinal tract but can be pathogenic elsewhere. Other UTI causing bacteria are Klebsiella, Proteus, Pseudomonas aeruginosa, and beta-hemolytic Streptococcus. Treatment consists of prescribing the appropriate antibiotic. UTI during pregnancy often lacks symptoms; it is recommended that screening of the urine be performed at the first prenatal visit. The presence of more than 100,000 bacteria of the same species per milliliter of urine indicates infection.

Discuss the reliability of fundal measurement, quickening, and "20 week uterus at the umbilicus" methods of determining gestational age.

Uterine size correlates with gestational age but measurement of the fundus is not a reliable method of measuring uterine size. Factors that can cause discrepancies in a fundal size assessment: • bladder distension , • position of the fetus, • the length of the cervix, • maternal build, • fibroids, • uterine abnormalities, • placental location, • amniotic fluid volume, • retroflex ion or retroversion of the fetus, • placental location, • examiner experience, • foreknowledge of the last menstrual period. The assessment is typically most accurate between 20 and 30 weeks gestation with a margin of error of up to 3 weeks. Quickening and using the time of uterus at the umbilicus as a benchmark for 20 weeks gestation have significantly wide margins of error as do using signs and symptoms of pregnancy or the date on first noting fetal heart tones by ultrasound or fetoscope.

Discuss the factors that indicate a high rate of success for VBAC.

VBAC may be more successful with: • a previous history of VBAC, • spontaneous labor with normal progression, and • non-repetition of the reason for the previous caesarian section , such as a breech presentation or preeclampsia. In some instances, a trial of labor may end in a repeat caesarian section if the same reasons for the previous caesarian occur such as: • failure to progress or cephalopelvic disproportion, • the need to induce or augment labor, • no prior vaginal delivery, • more than one previous caesarian section, a non-reassuring fetal heart tone early in labor. The operative report and record of the previous labor and surgery should be obtained prior to discussing the possibility of VBAC. The mother will not have the necessary medical information. Placement of the abdominal incision does not indicate the placement of the uterine incision.

Discuss Vaginal Birth After Caesarian Section (VBAC).

Vaginal birth after C-section (VBAC) is a controversial subject. In 2004, the American College of Obstetrics and Gynecology released a statement "strongly advising" women and birth centers against attempting VBACs in birth centers because the health risks were too great and recommended all VBACs take place in a hospital. It concluded that women with a previous C-section were at increased risk for complications compared to those with no C-section history. The American Academy of Family Physicians released recommendations in 2005 stating women with a single previous caesarian delivery with a low transverse incision should be offered a trial of labor and not restricted to facilities with surgical teams present due to lack of evidence of improved outcomes. However, some hospitals will not offer VBAC services. You should be aware of the situation in your community and about the complete VBAC recommendations so your can fully inform clients who desire VBAC about the choices and risks in labor and delivery.

Discuss the risks of excess Vitamin A, Vitamin C, Calcium, and Iron.

Vitamin A is a teratogen in large doses which can cause birth defects. It can also affect the maternal liver. Vitamin C can cause increased absorption of iron which in turn causes problems when taken in excess. Excess calcium can affect kidney function and cause kidney stones as well as decrease absorption of iron, zinc and magnesium. Excess iron can also decrease absorption of zinc as well as copper and calcium. It becomes evident that maintaining the appropriate levels of vitamins and minerals is a balancing act. f there is excess of one, another is usually impacted in some way, often to decrease absorption of that nutrient.It is prudent to take into consideration the diet, including any herbs or other supplements being ingested, before administering any additional vitamin or mineral supplementation.

Discuss midwifery support of the parents after the birth of an infant with fetal anomalies.

When a baby is born with anomalies, the parents will still bond with the baby, often only noticing the beauty of the other features. You should remain present until the anomaly is noted.If the parents seem to be in denial of the anomaly, it should be pointed out without extended discussion. If a severely deformed infant is rejected by the mother, you can encourage her to bond by helping her to see the perfect features the baby does have. You should stay in·close contact with the parents for several months, assisting them by referring them to resources for information and support. TheInternet is a valuable tool.

Explain the contraceptive effect of breastfeeding.

When a mother is breastfeeding it is thought that gonadotrophin release is inhibited, especially luteinizing hormone (LH) which then inhibits ovulation. The start of ovulation in a breastfeeding mother varies depending upon the breastfeeding pattern she follows. The return of ovulation depends on nursing frequency, intensity, and duration including night feedings and the advent of solid food. The Lactation Amenorrhea Method (LAM) combines the lack of menstruation experienced after birth with full time breastfeeding to act as a form of family planning during the first six months postpartum. In other words, as long as the mother is not yet menstruating and is exclusively breastfeeding an infant that is 6 months old or younger, there is only a 2% chance that she will become pregnant. Once the infant is older than 6 months, the chances of pregnancy begin to increase.

Discuss the role of the midwife when upsetting information must be shared with the mother.

When given the time to plan, you should determine the best way to give the news to each individual. Enough time should be allotted for the mother to absorb the information and ask questions if desired. Any other person or group the mother wants there should be brought in. All of the information regarding any problematic report should be readily available and the main points determined. Above all, honesty is required. No part of the information should be withheld. In addition, all the support you can give should be offered including personal time with the mother as well as referrals to any support groups or specialists . The news should be given as clearly and as simply as possible. The parents should be given time alone in a private room of your practice unless they wish to leave.

Discuss the timing of attempts to conceive in conjunction with the use of birth control pills, injections or implants, and for those with irregular cycles.

With birth control pills, the recommendation is to delay attempts to become pregnant until the first menstrual cycle has occurred signaling the likelihood that ovulation has resumed:If long term hormonal birth control has been used, such as Depo Provera or implants, it may take several months for regular cycles and ovulation to resume. A barrier method of birth control should be used until this occurs in order to accurately date the pregnancy. There is no issue of harm to the fetus by these birth control methods. Encourage the woman to keep a menstrual calendar. If irregular cycles are an issue, basal body temperature charting or ovulation predictor kits are useful since predicting ovulation based on menses and subsequently dating the pregnancy are difficult in this case.If, after 12 months of unprotected sex, pregnancy has not occurred, referral to a fertility specialist may be in order.

Explain the challenges of working with a sexually abused mother.

Women who have been sexually abused can be controlling, needy, or angry.In some instances, there may be no way t.o avoid accusations of wrongdoing as any action can becoro exaggerated in an abused person's mind. There are some guidelines for working with mothers with thes.e issues. The , midwife should not withdraw from any confrontation created by the mother. She should rei;nain and actively listen. The mother's perceptions should be validated even if inaccurate or exaggerated. This diffuses anger and increases the chances of · gaining and establishing trus.t. At that point, disagreements may. be settled. The midwife must also educate these mothers about their legal situation . Depending on the location, healthcare workers may be obligated by law to report evidence of violence to the authorities which can have an emotional impact on the mother. If the mother remains with the abuser, the midwife must determine a safe way of. caring for her.

Discuss the management of preconception care for women on medication for chronic health issues.

Women who have epilepsy, chronic hypertension, psychoses, malaria and some other conditions are usually managing the illness using a medication that is teratogenic to a fetus. You must work with the client's physician who is treating the illness to try to find alternatives for the medications and to determine the risk to the fetus in the event the client has already conceived. No .client should discontinue any prescribed treatment for such disorders without a. physician's guidance.In addition to these conditions and the known teratogenic nature of many of the medications used to treat them, the teratogenicity of all medications taken during pregnancy must be assessed, whether the medication is prescription or over the counter (OTC). The risk/benefit ratio of medication use during pregnancy should be discussed prior to conception whenever possible.

Discuss the problems of cardiac disease in relation to pregnancy.

Women with cardiac disease should be strongly urged to consult both a cardiologist and obstetrician when planning or managing a pregnancy. The cardiac condition must be thoroughly assessed and the parents educated about the risks involved. The risk is based on: the cardiac lesion, the baseline functional compromise, and the possibilities of complications during pregnancy. Genetic counseling may also be indicated if a condition is the result of inherited heart disease. A decision to terminate the pregnancy to save the mother's life may be required. The following cardiac diseases are examples of those carrying a serious risk of maternal mortality during pregnancy : • Pulmonary hypertension • Dilated cardiomyopathy • Marfan's syndrome • Any uncorrectable cardiac lesion in classesIII or V refractory to medical management . The woman must anticipate multiple office and hospital visits and close management during the pregnancy. Child care, workplace issues, and insurance should all be taken into consideration in the management plan.

Discuss yeast infections in pregnancy .

Yeast infections, also called monilia, are common during pregnancy.It causes a white, curdish discharge with a yeasty odor. Yeast is part of the normal flora of the vagina that overgrows due to the higher alkalinity of the vaginal secretions during pregnancy and the associated increase in progesterone levels .It can increase the risk of newborn thrush if present at birth. Yeast overgrowth can be controlled with the insertion of vaginal sponges (boiled to remove mineral deposits) or cotton tampons which have been soaked in acidophilus culture solution . The lightly squeezed, saturated sponge or tampon is inserted into the vagina and changed every three hours. Cotton underwear should be worn.

Discuss the management of couples who are estranged.

You must assert your role as practitioner for the mother. You should not get caught up in the couple's problems. They may need referral to a specialist for counseling. They must be advised of the consequences to the birth if they are still indecisive about their relationship.It is to be hoped that the decision to remain together or to part will come early enough in the pregnancy to stabilize the mother's life. The mother must feel supported by her labor partner and may elect another in the life partner's place if support is lacking.If the life partner will be taking part, you should do everything to facilitate involvement . The mother should be counseled as a single mother in the event the partnership dissolves. This is also true of a mother presenting with a new partner. The couple may not truly be prepared to be parents together even with appropriate conseling.

Discuss the management of candidates for VBAC.

You must have thorough knowledge about the local legal policies of your community. A thorough history and review of previous medical records is essential for determining whether to attempt VBAC.If the previous caesarian section was via vertical incision in the contractile uterine segment, there is a high risk of uterine rupture. Repeat caesarian without trial of labor is indicated. In most other cases, a trial of labor may be indicated if the pregnancy and labor are otherwise normal. Prenatal management includes referral to a VBAC course or support group and additional support for those without complete familial support for their decision. During labor, management is the same as normal labor except for increased frequency of fetal heart tone auscultation since the typical first indication of uterine rupture is fetal bradycardia. Check FHR every 15 minutes in the first stage and every 5 minutes in the second. Use labor augmentation cautiously. There is an increased possibility of the placenta implanting over the uterine scar and resulting in placenta accreta.

Discuss the emotional support of the mother in preterm labor.

You must help the mother allay her fears and anxieties since emotional stress can be a causative agent of preterm labor. An empathetic approach devoid of false reassurances is the best route to take. You can attempt to make the mother feel she has some control over the situation and can positively contribute to its treatment. Trust the mother's suspicions and her reports of any important changes; remain available by phone.If preterm birth does occur, the mother may face separation from the infant although the current trend in "kangaroo care" alleviates this by involving the mother in the care of the infant early and often. The mother may grieve for the loss of the home birth experience and you may be the only person able to listen and give support. At the appropriate time refer the parents to a support organization for parents with premature infants.

Discuss the role of the midwife in advocating for the mother.

Your primary role is one of education and support. f the opportunit ies are taken to educate the mother of her options and ensure they are clearly understood, the mother is then empowered to control her own pregnancy. Advocacy is defined as speaking for someone; in other words, ensuring that person's wishes are executed. In the medical establishment paternalism is still the norm and pregnancy is still treated as a medical issue. This leads health care workers to feel they must determine what is best no matter what the mother wants. Certainly, in medical emergencies, the medical staff must provide the correct care; however, during normal pregnancy and childbirth, the mother's choice should hold paramount.If she is not in a position to insist, you must advocate for her. This means the mother's wishes are known to you and you uphold the trust of the relationship by ensuring the wishes are followed.

Discuss the midwife's role in providing information for the continued care and wellness of mother and baby

Your strength is your experience of normal pregnancy and birth. Due to the relationship built between yourself and the mother, you are in the best position to offer referrals for ongoing support and care. As you have been throughout the pregnancy, you should provide information best suited to each individual mother regarding medical and social services within your mutual community. Not only must you acquire and continue to update medical knowledge to successfully and safely assist in pregnancy and childbirth, you must acquire and update j knowledge of the community within which you work and develop j contacts within that community for services your clients may need. Prior to birth you ascertained the existence or type of support the j mother had during pregnancy and for the birth. After the final postpartum visit, you must determine a strategy and referral list for I that mother and her entire family, including the newest member.

Discuss conditions that may cause a fetus to be small for the gestational age (small for dates).

a fetus considered small for dates in the first half of pregnancy is often the result of inaccurate dating. Other causes in early pregnancy: • missed abortion, • ectopic pregnancy, • a small maternal frame • inaccurate first measurement • fetal or chromosomal abnormality, • placental pathology, • fetal death, • oligohydramnios, • fetal infection, • insufficient intrauterine growth due to maternal illness. Causes in later pregnancy: • intrauterine growth retardation, • fetal death, • oligohydramnios, • poor maternal weight gain, • transverse or oblique lie, • genetically small infant that is normally grown Perform an ultrasound to confirm the abdominal examination findings and for differential diagnosis. f needed, give nutritional counseling and assistance to stop smoking and manage any other substance abuse issue.It may be necessary to minimize time in the workplace and reduce stress .If IUGR is diagnosed, contact the consulting physician.

Explain the location of the fetal heart tones on the mother's abdomen as a characteristic of the fetal presentation and position.

fetal heart tones should be audible by 20 weeks gestation. The abdomen should be palpated for the presentation, position, lie, and variety prior to auscultation of the fetal heart tones. In order to clearly hear the tones, the position of the convex portion of the fetus must be ; known in relation to the anterior uterine wall. Once found the position of the heart tones can also confirm the previously determined lie, position and presentation. In a cephalic presentation the fetal heart tones can be heard midway between the umbilicus and the level of anterior superior iliac spine.In a breech presentation with anterior variety, fetal heart tones are heard level with or above the umbilicus. With a breech in transverse variety, the heart tone is near the abdominal midline. With a breech in posterior variety, the heart tones are heard in the flank area or near the midline on the opposite side of the abdomen.

Discuss hydrotherapy.

hydrotherapy means, literally, water therapy. Water is used to deliver heat or cold to various areas of the body requiring analgesia or other treatment. In pregnancy, full immersion in a hot bath is not advisable due to possible danger to the fetus. Brief tepid baths are appropriate. Additionally, warm and cold compresses placed on affected body parts can increase circulation and analgesia. Hydrotherapy can increase the rate of healing and relaxation of aching muscles or bruising and sore tissues from birth.

Explain nutritional counseling methods.

if the diet history shows a lack of true nutritional elements, begin with praise for any positives of the diet. Suggestions for improvement should be based on the mother's own preferences. A diet that seems lacking in variety may signify a lack of resources to secure better nourishment; she should be referred to public assistance. Qualification for assistance may require a letter from you verifying the pregnancy and stating the risks of inadequate weight gain. She should then be taught to create meals from her own best choices of foods. Do not attempt to replace core foods or ingredients with healthier selections if they are part of an ethnic or regional dietary preference. Other sources 1 for deficiencies can be found. This is also true of preferences for sweets or other treats. Unrealistic recommendations may cause the mother to become non-compliant and incommunicative about her eating habits. This will hinder any investigation into later concerns or complications.

Discuss the signs and symptoms of quiet catastrophic uterine rupture. Discuss the treatment of uterine rupture.

in quiet uterine rupture, there may or may not be maternal vomiting; there may be increased abdominal tenderness, hypotonic uterine contractions, severe suprapubic pain, lack of labor progress from the time of rupture, and maternal syncope. Later hematuria, slight pain, vaginal bleeding, and shock will occur. Contractions may be ineffective or cease and fetal heart tones are not evident. All of these signs may also be seen in placental abruption. Bleeding into the peritoneum may cause the diaphragm to become irritated and pain to be felt in the chest in imitation of amniotic fluid or pulmonary embolism. Emergency services and the consulting physician should be notified immediately and two IV routes placed, one for blood transfusion and one for electroiyte solution. Oxygen must be administered and transport obtained. It is likely a hysterectomy will result.

Discuss circumcision as a routine procedure.

ircumcision has become a controversial procedure. Education regarding the procedure and its aftermath is essential to make an informed decision for the male infant.In some cultures circumcision is part of religious or family tradition . There is also some evidence that a circumcised penis is more easily cleaned, reducing the incidence of urinary tract infections, cancer and sexually transmitted diseases. However, these potential medical benefits are not significant enough to advocate the procedure for all male infants. If it is to be performed, the American Academy of Pediatrics recommends analgesia via a dorsal nerve block or anesthetic cream pricur to surgery.If the decision is made not to circumcise, the parents must be educated in the appearance, development and care of an uncircumcised penis.

Discuss methods of prenatal counseling.

many mothers have common fears regarding pregnancy and birth. You ' should both sympathize with her and help her resolve her own problems. The midwifery model of care defines counseling in terms of friendship and reassurance. Techniques such as mirroring, pacing, active listening, and positive reinforcement are all excellent ways to connect with the mother and work with her to resolve any issues. These techniques help identify the emotional tendencies of an individual and allow you to customize your communication. This personal approach is the opposite of the detachment of most medical models of care. This type of counseling should encourage the mother to accept the responsibility for her own fears and reactions. You should be aware of the boundaries of client privacy and pacing to prevent a codependent relationship and loss of objectivity.

Define and discuss the management of a postdate pregnancy .

· A postdate pregnancy is one which has surpassed 42 weeks. There may be a family history of postdate infants, no reason and no abnormal findings, or the mother may not yet be ready for the pregnancy to end. While the fetus may continue to grow, the risk of cephalopelvic disproportion or shoulder dystocia increases. The mother may decrease her fluid and food intake in an effort to keep the fetal size down and risk fetal weight loss, cord compression from oligohydramnios, fetal distress or stillbirth (all included in fetal postmaturity syndrome). If there are no mitigating factors other than postdatism, practice watchful waiting. Assessments to monitor fetal health include fetal kick-counts, a non-stress test, and serial ultrasounds to check amniotic fluid volume. If no abnormality is found, home-based induction can be attempted, especially if the fetus is becoming large or if the head is well into the pelvis. Or waiting can be continued.