Narm Test Specifications I. Mid Couns, Edu.&com.

Front 1

A. Provides interactive support and counseling and/or referral for the possibility of less-than-optimal pregnancy outcomes

Back 1

Support
- With any type of miscarriage, emotional support is critical at every phase. Local support groups or online.(Davis, 69)
- Grieving is essential part of recovery (Myles, 318)

Counseling
- regarding contraception
- resump. of sexual intercourse within 2-4 weeks
- future pregnancy couns (Varney 666)

Call midwife if:
- bleeding exceeds 500cc
- soaks a pad in an hour
- has chills or temp @ or >100.4*F
- passes clot >3 cm or size of 50 cent piece (Varney's 665)

Front 2

B. Provides education and counseling based on maternal and paternal health/reproductive family history and on-going risk assessment

Back 2

Determine, edu and couns concerning nml and abnml conditions of health hx

Paternal Hx
- Social, General health, medical, family, & conception

Maternal Hx
- All of the above and menstrual, OB history, physical and abdominal exams(Myles266-285)

Risk-assessment:
- Assess gathered info to determine appropriate type and pattern of prenatal care
- Identify predisposing or potential factors that may develop into problem, begin prevention early (Varney's 943)

Front 3

C. Facilitates the mother’s decision of where to give birth by exploring and explaining:
1. the advantages and the risks of different birth sites (3)

Back 3

Help mother facilitate choice by exploring her personal philosophy, care-providers philosophy, preferences regarding tech., mother's health, feelings about prev births, societal, family and financial considerations

1. Hospital
Risks:
-preg/birth considered medical condition/event
- increased infection rate
- decreased time for prenatals
- separation from baby or other family members(sometimes)
- not always cost effective

Benefits:
- Society's expected brith site
- Complex tech. on-site (and surgery)
- Medication for pain relief
- Manages complicated preg and birth
- Trip from home to birth-site

Birth-Center
Risks:
- No Complex tech on-site
- Meds for pain-relief not always available
- Does not manage complicated preg
- Transport nec. for high-tech interventions
- Trip from home to birth-site

Benefits:
- Preg and birth considered normal
- Decreased chance of infection
- extended prenatal times
- Edu. is core component
- Low-tech, high-touch enviro.
- Family friendly enviro. and no separation from baby
- Familiar, small intimate enviro.
- Cost effective

Home-birth has all of the same risks as birth-center except there are NO meds available for pain-relief

HB's also include similar benefits, except at home there is no need to take a trip to the birth-site and the enviro. is more familiar to client. (Varney's 940)

Front 4

C.2. the requirements of the birth sites AND
3. how to prepare, equip and supply the birth sites (3 sites)

Back 4

Hospital:
- basic health promotion (nutrition, rest, exercise, keep sched. appts etc.)
- tour the birth-site
- prepare/educate on breastfeeding and childbirth
- financial arrangement clear
- limited birth supllies nec.

Birth-Center
-Includes all of the above plus
- commonly a more determined understanding of her responsibilities and preparation
- arranging services for pediatric health care provider

Homebirth has the same requirements as the birth-center clients plus
- gathering more birth supplies for home-birth (Varneys 941-42)

Front 5

D. Educates the mother and her family/support unit to share responsibility for optimal pregnancy outcome

Back 5

-Suggest that the couple/support person takes childbirth edu together with the mother. Sibling prep. classes may also be helpful.
- Determine early who will be attending the birth and encourage mother to talk to those attending about specific roles (Davis, 13)
- Provide education, resources (books, videos, articles etc.), and opportunities to talk about the details of the birth and how they want it to occur. (Davis, 42, 50-54)

Front 6

E. Educates the mother concerning the natural physical and emotional processes of pregnancy, labor, birth and postpartum

Back 6

Offer education on and encourage furthered study at home surrounding the natural physical and emotional precesses of pregnancy, at each stage of pregnancy, and stages of labor and birth and postpartum period.

Front 7

F. Applies the principles of informed consent. (Define informed consent)

Back 7

Information regarding options for care/treatment (Myles)

verbal or written edu. about risks, benefits, & alternatives (interventions or treatments provided by midwife) to the midwife's plan of care. (NARM CIB)

Front 8

G. Communicates practice parameters and limits of practice. (Define practice parameters/scope of practice and practice guidelines)

Back 8

Scope of Pratice:
procedures, actions, or processes that are permitted for the licensed individual

Practice Guidelines/Protocols:
specific description protocols that reflect the care given by a midwife through-out preg, labor, birth, PP and NB care. Practice Guidelines should include an explanation of routine care and protocols for transports.

Front 9

H. Applies the principles of client confidentiality (define)

Back 9

Keeping private the information given (NARM CIB)

Confidentiality—to honor others’ privacy and keep personal interactions confidential (MANA Statement of Ethics)

Front 10

I. Provides individualized care (define)

Back 10

Providing care specific to the individual that will improve the health of the mother and baby.

Front 11

J. Advocates for the mother during pregnancy, birth and postpartum.

Back 11

Advocacy is seen as speaking out on another's behalf. Sometimes, despite all efforts to support, encourage and inform, women may still be reluctant to act or speak up on their own, many midwives are finding they need to take on an advocacy role on their behalf. (NOT paternalism which is acting on anothers behalf)(Myles, 61)

Front 12

K. Provides culturally appropriate education,
counseling and/or referral to other health
care professionals, services, agencies for:
1. genetic counseling for at-risk mothers

Back 12

Mothers/Couples at-risk:
- age >35 yrs
- balanced chrom. rearrangement
- previous child with chrom. abnlties
- low MSAFP
Fam. History of birth defects:
- Cong. heart disease
- Neural tube defects
- Cleft lip/palate
- multiple cong abnlties
- mental retardation
- hx of mendelian genetic disorders (autosomal recessive and dominant disorders)--cystic fibroids, hemophilia A&B, Fragile X, Muscular dystrophies (Duschenne and Becker)--
Ethnicity:
- African--Sickle cell(US Blacks), Trait carriers
- Mediterranean/Indian--Beta-Thalassemia--
- Jewish--Tay-Sach's--

Edu. & Couns to offer:
- Sensitive/non-directive approach
- Education regarding different screenings, what is appropriate for that mothers history, and indications of results
- discuss false positives, false negatives, and range of options for follow-up (Varney's 625)
- determine mode of inheritance & risk of developing/transmitting the disorder
- diagnose problem and implications in relation to prognosis and poss. treat.
- discuss procedure-related risks with diagnostic measures
- discuss available choices/options
- support those involved to make informed choice
- make clear what constitutes 'high' or 'low' risk (Myles 179)
- understand and offer culturally/religiously sensitive education/couns on the above topics

When/Who to transfer:
- If a specific risk-factor is identified or parents have a serious concern, genetic screening is recommended(Varney's 89)
- up-to-date specialists who are compassionate and willing to spend time answering questions(Davis, 40)
- Screening should be offered to all women (Varnery's 625)

Front 13

K.1.a. What are the different genetic screenings (3) and diagnostic/Invasive tests (3) and what do they test for?
When are each of them performed?
What are the risks involved with each?

Back 13

1. AFP/MSAFP and Triple/Multiple Sceen(hCG, AFP and unconjugated estrogens) all from maternal serum screen for:
- Trisomies 16, 18(Edwards syndrome), 21(Down's)
- Nueral tube defects
- chrom abnlties/fetal aneuploidy(abnl # chroms) and more (Varney's627-29)

- this test done @ 15-20wks

- No risk of test itself, however because of false-positives it can lead to more invasive tests (US, AC, &CVS)

2. Nuchal Translucency Screening (NT) U/S screens for:
- trisomies 21, 18, & 13
- Turner Syndrome
- cardiac defects
- other anomalies

- done at 10-14 wks

- No risks with the actual U/S screen, however it may cause considerable anxiety in waiting for later screens. Also early identification of of chrom.abnlties may pose option to parents of terminating a pregnancy that may naturally miscarry. (Myles, 299)

3. Biochemical Markers to screen for Downs Syndrome
- hCG--10-22 wks (levels high)
- PAPP-A-- 10-14 wks (lower)
- uE3-- 14-22 wks (lower)
- AFP-- 15-20 wks (lower)
- Inhibin A-- 15-20 wks (higher)

- Risks similar to AFP screening
NOTE: Integrated screening combines biochem with NT

Diagnostic/Invasive Tests (Varneys 630-32; Myles, 303-05)-- All of these invasive tests require RhoGam for Rh- mothers following the procedure

4. Chorionic Villus Sampling (done either transcervically or transabdominally) is used as a diagnostic measure to identify genetic diseases affecting the fetus.

- done anytime after 10 wks

- Risks, higher miscarry rate than amnio
- Oligo, ROM, subchorionic hematoma have been reported as sequelae of CVS
- limb reduction reported in some early CVS (8-9 wks)

Advantages
- earliest definitive test for fetal chrom/genetic status
- opportunity to terminate preg (esp for those clients that are more willing to terminate)
- greater privacy for woman/family

5. Amniocentesis- removal of fluid from the uterine cavity (transabdominally) assesses for:
- genetic and biochem diagnosis
- fetal disease
- evaluation of fetal maturity

-performed at 15-16/18 wks (>15wks, previous to this time early amnio's are known to carry higher risks than CVS and even later amnio.)

Risks:
- 1% miscarriage rate
- 1% amnionitis rate

Advantges:
- provides more information
- less risks

6. Cordocentesis (AKA- Percutaneous umbilical blood sampling PUBS)-- most current direct method of sampling fetal blood, done transabdominally needle puncture of fetal cord(this method also used to transfuse or medicate baby). Test only indicated for few high-risk patients:
- need for karotyping of fetus by DNA
- assess & treatment of Rh issoimunization
- meas of cord blood gases for severe IUGR
- diag of fetal disease (cytomegalovirus, toxoplasmosis etc.)
- treatment of fetal disorders

- done in 2nd trimester

Risks:
- spontaneous abortion
- ROM
- preterm labor
- infection
- bleeding
- fetal trauma and
- isoimmunization

Referral is necessary for these invasive procedures.

Front 14

K. Culturally appropriate edu, couns, or referral for
2. abuse issues: including, emotional, physical and sexual

Back 14

1. Emotional abuse (Frye Vol 1, 300-311)
S/S:
- jealousy, controlling behavior, quick relationship invlolvement, unrealistic expectations, isolation, blaming, hypersensitivity, cruelty to animals or children, verbal abuse, rigid gender roles, low self-esteem/extremely apologetic, having little money available, having to ask permission to do things

Couns/Edu:
- kind non-invasive approach, LISTEN, don't withdraw
- validate clients perceptions
- once trust is established, negotiate, settle on agreement for care
- provide info on resources available to the woman
- discuss risk factors in staying in or leaving the abusive situation, with an emphasis on safety

When/who to refer:
- If any signs of emotional abuse occur counseling should be recommended

2.Physical/domestic violence:
- S/S--same as emotional s/s with addition of:
- self-harm
- eating disorders
- mental illness (symptoms of depression, or talks of suicide/has signs of self-harm/mutilation)
- bruises, black eyes or any other physical signs of abuse OR attempts to cover up bruises or injuries with clothes, make-up etc.
- making unrealistic explanations for injuries (tripped, fell etc)
- substance abuse problems
- past batterings
- refers to them as having a temper, but does not disclose further information
- abuser threats of violence
- abuser breaking or striking objects
- abuser uses of any force during argument

Couns/Edu-- Same as emotional abuse with the addition of:
- fully apprise of legal situation
- educate on stats and facts (23% of preg women are battered, battering may be initiated or intensified during pregnancy and postpartum)
- discuss and plan a time (realistically) for mother to get to ssupport groups and other local resource help centers
- disuss/educate components of emergency plan of action


When/who to refer:
- by now she should already have been seeing proffesional help (counseling)
- effective strategies must be in place such as multi-agency support services
- Know your state laws, many states are obligated to report evidence of physical abuse to local authorities, and abuser will be arrested

3.Sexual Abuse/Rape
Possible Physical S/S:
- extreme PMS
- chronic pelvic pain
- constipation
- vaginal infection
- pain with intercourse
- intense reaction to physical/well-woman exams, blood draws
- eating disorders (poss hx of habitual abortion, hyperemesis gravidum)

Other behaviors/characteristics S/S:
(many similar to above emotiona/physical s/s plus following)
- often needy, controlling and angry
- dissociative disorder
- attachment disorders
- overwilling to expose genitals, opposite of protective
- PTSD
- Obesity
- Migraines or severe head aches
- may develop multiple personality disorder esp w/hx of prolonged sexual abuse
- deeply estranged from family
- unkept personal appearance
- over-controlling or chaotic surroundings/habits
- shows no trust or personal boundaries
- exaggerated anger
- inability to appreciate other or blindy adores others
- most abuse victims have tremendous fear of losing contol
- sexual addiction or issues (inability to acheive orgasm)

- 2nd stage characteristics may be particularly terrifying from vaginal triggers to previous violation. Fear of "ripping apart/in half" is common.
- Inability to breastfeed or deal with normal behaviors of baby during nursing

Couns/Edu:
- same as physical couns/edu, again with devoted efforts to make create a safe and healing environment for victim

When/who to refer:
-similar to physical abuse, client should be receiving counseling and may need to involve local authorities

(Davis, 99-102)(Varney's 611)(Myles, 682)

Front 15

K. Provide culturally app. edu, couns, and/or referral for
3. prenatal testing and lab work(what each tests for, normal ranges, and when to refer)

Back 15

~Initial Prenatal

Blood type and factor: identifies the blood group/type (ABO) and Rh factor status.
- Blood type: O+ is most common then A+, B+, AB+; next is O-, A-, B- and AB-. O- is universal doner, AB is universal receiver, AB+ is universal plasma doner.
- Rh factor is an antigen present on the blood cell and can be either + or - it is clinically important if the woman is Rh-negative, she is at greater risk for isoimmunization and requires Rhogam during pregnancy and postpartum.

Antibody: to detect red cell antibodies (anti-D as well as other antibodies)
- Normal antibody will be negative
- If anti-D antibodies are present an automatic titer will usually be done. A titer greater than 1:4 is considered to be Rh(D)-sensitized and referral for medical management is indicated for any woman who is Rh-sensitized and fetus is Rh-positive.

CBC: Hemogram includes, RBC count, WBC count, hemo, hemat, RBC indices and platelet count. A CBC includes a hemogram plus a differential WBC.

--------HGB: nml values are 10-14 during preg, should not be <10 in 3rd trimester. Drops 2 pts from 6 wks to 28 wks, hemodilution. Normal HGB=33% of Hct.
Low could indicate iron def, hemorrhage, aplastic or sickle cell, thalassemia, or leukemia
----------Hct: 30/31-36%(up to 48% if not pregnant). Drops as blood volume expands, with low-point at 28-30wks.
Low Hct indicates iron def. or other microcytic anemia, and/or hemorrhage(PP).
High Hct could indicate macrocytic anemia (esp if hct/hgb ratio is off), contracted blood volume, impending toxemia, polycuthemia or dehydration.
----------RBC: Total # of erythrocytes ina given volume of blood
NML range- 3.4-5.0
Low-iron-def.
High- dehydration, high-altitude, lung disease, polycythemia
---------MCH: (Mean corpuscular hemoglobin) average concentration of hemoblobin in a RBC
NML range- 26-34
Low- microcytic anemia (iron)
High- macrocytic anemia, protein malabsorption
-----------MCV: (Mean corpuscular volume) the size of the individual RBC.
NML range- 82-98
Low- Iron-def, chronic bleeding
High- Low folate or B12 intake or absorption, acute blood loss or liver disease (alcoholism, hemolysis, hyperthyroid)
-----------MCHC: (mean corp hemo concentration) concentration of hemo in an average RBC.
NML range- 31-37
Low- Iron-def, Macrocytic anemia, thalassemia
High- Spherocytosis
----------Platelet Count:
NML range- 100/140-400
Low-(<50) hemorrhage, vit B def., (cancer, anaphylactic shock, spleen disease, thrombocytopenia
High-(200-500) may be NML w/PP hemorrhage, polycythemia, sicle cell anemia
--------WBC: Total number of all types of WBC's (leukocytes)
NML range- 9,000-16,000 (up to 25/30,000 closer to birth)
High- 20=slight, 30=mod, 50=very high. indicates infection, can also signify some drugs, necrosis, cancer, occult disease.

Rubella: Measures the rubella antibody titer.
>1:10=immunity
<1:10=non-immune
>1:64= indicates present disease

RPR/VDRL: Screening for syphilis, these are nontreponemal serological tests, which demonstrate the presence of reagin in serum
Negative or non-reactive indicates no current disease
Postive or Reactive results indicate need for treponemal testing (usually FTA-ABS), if this test is positive, treatment is recommended. (Varneys 451)

Hep B: Surface antigen (HBsAg) screening is offered to help with early intervention in PP period to decrease risk of mother-to-baby transmission.
Negative-indicates no current disease
Positive- indicates present disease (Varney's 179-80)

(HIV and MSAFP should be offered (not required) to all)

-PAP: (Papanicolaou) Done during speculum exam to test for HPV, epithelial cell abnormalties, and other organisms.
Results:
Negative for intraepithelial lesion or malignancy
Epithilial cell abnlties
Other (Varney's 419)

Urinalysis: for protein, glucose, and routine microscopic examination
NML ranges:
Negative/None or very little of these should be present in the urine (to rule out proteinuria)
Urine culture- >100,000 indicates infection (to rule out asymptomatic bacteruria)

- GC/Chlamydia Specimens: to rule out gonorrhea or chlamydia, can be done with urine or from speculum exam.
--------Gonorrhea specimen/culture
NML ranges
Negative or no Neisseria gonorrhoeae seen- indicates no current infection
Positive- indicates presence of infection
--------Chlamydia
Negative or
Positive

~Other Prenatal labwork:

Glucose Screen: 1 hr GTT done around 28 wks gestation to screen for gestational diabetes
Cut-point >190mg/dL, furthered testing suggested at >130-140mg/dl

GBS: Done at the end of pregnancy (around 35-36weeks) to test for the presence of group-beta strep in vaginal flora.
Results
Positive or
Negative

Sickle cell/Thallasemias: Done with hemogram (above)

Varicella (chickenpox): Highly contagious viral infection caused from a form of herpesvirus. Do screening IF woman has not had disease or vaccine.
NML ranges:
>1:4=(beyond 8 months of age) immunity
<1:4= no immunity
A 4-fold increase or greater in titer indicates current infection (Frye, 564-567)

Tuberculin: skin test, screening only done for high-risk populations (immunosuppression, immigrant from Asia, Africa, Latin America, crowded living conditions, recent contact with TB patient, etc.)
Lab results:
Reaction=presence of hardened area at injection site (skin lesion)
Non-reactive=absence of hardened area (Frye, 827-32)

(Varney's 583-91)(Myles 273-75)

Front 16

K. Provide culturally appropriate edu, couns, and/or referral for
4. diet, nutrition and supplements (general info & when/who to refer)

Back 16

Diet/Nutrition
-Edu/Couns:
Base your diet recommendation on the mother's food and fluid intake record (have a comprehensive reference of composition of foods on hand to aid in understanding amounts of nutrients in foods). The cardinal rule for nutritional counseling is to always begin with praising the positive. (Davis, 32-33)
Explain that there are 5 main classes of nutrients (carbohydrates, fats, proteins, vitamins and minerals) and that we need a balance of these nutrients, including water, for good health. We should obtain these micro and macronutrients through a variety of foods rather than nutritional supplements. (Varney's 99-105)
Key minimums for prenatal diet, above and beyond a good-quality, well-balanced diet are as folllows. Daily:
-3000 calories
-80 g protein
-at least 2 qts water or more
Assess and educate the specialized needs for nutrients in other types of diets. (vegetarian, vegan etc)

-Referral:
If obtaining food is a problem refer mother to public assistance ( be knowledgeable of social services available in your area, ie. WIC, food stamps etc).
If s/s of an eating disorder are evident, discuss and refer to the appropriate professional (counselor, nutritionist etc)

Supplements:
Supplements should be supplemental! Food comes first, encourage good-quality, organic, chelated brands whenever possible.
Recommendations:
-1200 mg calcium
-Vit E, Vit C, folic acid and iron (Davis, 32)

Front 17

K. Provides culturally appropriate education,
counseling and/or referral
5. effects of smoking, drugs and alcohol use

Back 17

Smoking (tobacco use)
Couns/Edu:
-cigarette smoke contains 68,000 toxins (including nicotine, hydrogen cyanide, heavy metals) all of which readily gain access to mothers circulation and cross placenta.(Frye, 266-71)
-associated risks include IUGR, low birth weight, miscarriage, congenital heart disease, fetal hypoxia in labor, decrease fetal breathing movements, increased fetal and neonatal death, SIDS, placenta abruption, placenta previa, bleeding, premature rupture of membranes, constricts blood vessels which contributes to hypertension, elevates stress hormones in mother and baby, slows transmission of nuerologic signals, childhood cancer increased.
-Counseling regarding helps on how to quit, when to quit, commitment to quit, honest evaluation of how much she is smoking, evaluate support system, make realistic goals, have mother research and bring information to you on effects of smoking so she clearly understands.

If she will not quit, you must decide if you are willing to work with her and delineate exact boundaries (ie. onle 5 icg/day, or only smoke 1/2 of each cig) and requirements for excellent nutrition. Referral to a counselor or another health-care provider for maternity care may be necessary.

Drugs(Frye, 282-90)
Couns/Edu:
- Over-the-Counter drugs can cause an array of issues from decreased liver to kidney function to PP hemorrhage, increased birth defects, stillbirth, and other issues.
Inquire as to whether she is willing to substitute for holistic remedies instead (herbal, homeopathic etc.). If symptoms are severe consider referral for an evaluation of the condition by a specialist. (ref. to an OB, CNM or Naturopath may be appropriate)
- Recreational Drugs
There are many different kinds of recreational drugs, all of which have negative effects on maternal/fetal health in some way. Generally IUGR, fetal hypoxia, RDS, malnutrition, preeclampsia, infection, dysfunctional labor and hemorrhage are common effects of drug abuse. More specifically Amphetamines and Cocaine cause similar problems effecting the heart, brain/head/body size and defects and withdrawal syndrome. (exencphaly, macrocephaly, seizures, accute heart attack etc.) PCP is associated with infants with extreme sensitivity, tremulousness, increased muscle tone & even darting eyes. LSD can cause paranoia, tachy HR, abnml heart rhythms. Heroin causes menses, fertility and bleeding complications. It crosses the placenta rapidly, maternal/fetal withdrawal, risk of intrauterine demise, and SIDS. (Hyperactivity, RDS, fever, diuresis, convulsions and diarrhea characterize withdrawal in NB)
- Prescription drugs virtually all reach the fetus with the exception of pituitary & thyroid hormones, insulin, catecholamines and heparin. Have a Physician's Desk Reference (PDR) on hand to look up any drug and it's overall effects and possible implications for pregnancy.

- Referral: It is recommended to involve other specialist/counseling whenever an addiction is suspected. If abuse or children being exposed are involved then it is recommended to get local authorities involved.

Alcohol (Frye 274-76)
Couns/Edu:
Dangers include fetal alcohol syndrome (can cause mental retardation, anomaly, impaired eyesight, behavioral problems, and stillbirth), miscarriage, low-birth-weight babies, infant mortality, and learning disabilities.
No amount of alcohol consumption during pregnancy has been proven safe.

Referral:
Counseling can be helpful in case of addiction, referral to another care-provider may be necessary.
(Davis, 20)

Front 18

K. Provides culturally appropriate education,
counseling and/or referral
6. social risk factors

Back 18

Risk Factors
- Malnutrition(could be related to substance abuse, debilitating disease, eating disorders, or financial struggle) Dangers: IUGR, preeclampsia, infection, premature, stillbirth, & hemorrhage.
- Drug, Alcohol, or Tobacco abuse (dangers included in K.5. flashcard)
- Heavy caffeine use (10+ cups/day) Dangers: fetal malformation, heart defects, reproductive problems.
- Occupational Hazards: position (standing, sitting), strain (eye, muscle), ventilation, exposure to toxic chemicals
- Environmental hazards: air, water, sewage, lack of window screens, open fireplace , lead paint
- Childhood physical/mental/sexual abuse
- Domestic violence/ battering/rape/isolation: historical, current; safety
- Medications: prescription and non-prescription
- Sleep patterns, exercise, & leisure activity
- Religious beliefs effecting health-care (ie. Jehovah's Witness- refuse transfusion of blood products, including Rhogam)
- Microwave use
- Pets: bird & cat feces can carry toxoplasmosis
(Davis, 20)(Frye, 561-64) (Varney's 37)

Women should be advised to avoid or to appropriately use or be educated about these social factors.

Consultation/Referral is recommended if any of these social factors develop into a serious compication or s/s of a complication are present.

Front 19

K. Provides culturally appropriate education,
counseling and/or referral
7. situations requiring an immediate call to the midwife

Back 19

- Leaking of Fluid
- Vaginal Bleeding
- Persistent or Severe vomiting or you are unable to keep food or drink down for 24 hours.
- Initial outbreak of blisters in the perineal or anal area during the 1st trimester
- Severe pelvic, abdominal, or midback pain
- After 26-28 Weeks-Decreased Fetal Movement (Your baby moves less than usual)
- Menstrual-like cramps more than 4-6 times an hour sometimes combined with
bloody discharge can be a sign of premature labor.
- Severe Abdominal Pain
- Significant Generalized
- Swelling
- Persistent or Severe
- Headaches after 25 weeks.
- Fever of 101 F or Higher
- Urgency or Burning With
- Urination
- Signs of labor (UC's 5 min apart and strengthening, bloody show, ROM)
(Davis, 104)

Front 20

K. Provides culturally appropriate education,
counseling and/or referral
8. sexually transmitted diseases/infections (12) and safer sex practices

Back 20

Educate, recognize and diagnose the following as appropriate:
1. Trichomoniasis
2. Candida
3. Bacterial Vaginosis (BV)
4. Chlamydia
5. Gonorrhea
6. Group B-Strep (GBS)
7. Syphilis
8. HPV, Genital Warts
9. Hepatitis B Virus
10. Hepatitis C Virus
11. Herpes
12.Human Immunodeficiency Virus (HIV)

Be aware of the broad range of psychological and social respones to STI's. Good communication skills are essential, those who are at risk need to be approached in a sensitive, tactful, and non-judgemental manner.

Condoms are considered the only safe barrier method of contraception to prevent against STD's.

As a health-care provider you must define your protocols, according to your scope of practice and state laws. Consultation/referral or co-management can be recommended if there is an initial break-out during pregnancy, or active lesions/disease are not treated by the time of birth.
(Davis, 36-39) (Myles, 415-31)

Front 21

K. Provides culturally appropriate education,
counseling and/or referral
11. environmental risk factors

Back 21

The workplace, radiation, street drugs and pharmaceuticals are some of the places/things teratogenic chemicals can be found in.
- 25 known teratogenic chemicals (lead is common, chemicals seen in solvents for resins, dyes, polymers etc, cleansing agents, paints, perfumes even some water (flouride) and certain foods contain teratogenic substances and more)
- Common occupations where chemical exposure might occur:
Textile operatives (sewers & stitchers)
RN's, aides, orderlies (dental hygeinists, lab workers)
Electronic assemblers
Farm workers
Hairdressers & cosmetologist
Launderers/maids
Photographic processors
Plastic fabricators
Domestic workers
Transportation operators
Painters/letterers/printing
Plastic workers

(Frye, 292-94)
Mold
alcohol, caffeine tobacco
vaccines and infections
(OTIS)

Front 22

K. Cult. appropriate edu, counseling&/or referral for
12. newborn care including normal/abnormal newborn activity, responses, vital signs, appearance, behavior, etc.
(Varney's 975)

Back 22

- NB activity:
NML- Sleep States(deep or light), Awake States (quiet alert, active alert, crying, drowsiness and motor activity) Healthy NB's spend up to 60% of their time sleeping. With experience you can start differentiating the cry and identify the need (most common hunger, also can be thirst, pain, general discomfort)

ABNML- Preterm infants may struggle with quiet alert stage and become hyperalert

- Vital signs:
NML ranges- Breathing, 40-60/min irregular & fast or slow deep then shallow.
Temp, axill. 97.7-99.5*F skin temp slightly lower than core, best way to ensure warmth is keeping baby close to mom, skin-to-skin.
Heart Rate- 120-160 bpm, may vary with sleep or crying 100-180

ABNML-
Above or below any of the above nml ranges. Breathing- flared nostrils, grunting or retractions. Temp- cyanotic/blue hands/feet or body. HR- irregular sounds or rhythm.

- Appearance/Behavior/Responses:
NML-
Bowel Movements- Meconium is passed w/in 1st 24hrs and up to 72 hrs. Then 3-5 days transitional stool occurs, after the milk comes in stool is bright yellow and occurs 1-4 or more times per day.
Voiding- first should occur before 24 hrs after that at least 4-6 or more wet diapers per day and clear or pale yellow
Breastfeed- on-demand and at least every 2-3 or 4 hrs, wake if not occuring this often, burp after each feeding.
Skin Care/Cord care- Skin may be peeling at first you can give bath and rub a non-chemical/organic based oil into baby's skin. Do not immerse baby fully in water until cord falls off. Before then check and if necessary clean umbilical cord daily.

ABNML-
If more than 2 days go by without a BM contact pediatrician.
Urine-excessively above or below nml range in amount or color
Breastfeeding- if time lapsed is greater than 4-6 hrs or BM is greenish color indicating lack of adequate nutrition.
Skin/cord- excessive peeling or rashing on skin, red, inflamation, foul smell around the cord stump, call midwife.
(Varney's 981)

Front 23

K. Cult. appropriate edu, counseling&/or referral for
13. postpartum care concerning complications and self-care

Back 23

Nutrition- Women should be encouraged to continue much of the same nutrition they had in pregnancy, they should maintain a balanced fluid intake and increase their caloric intake particularly in fresh foods. (Myles 659)

Perineal Care- Expect to be sore for the first few days and experience pain in those days if perineal trauma occured. Rinse peri with water after each urination or BM. Sitz baths can also be very helpful for healing.

Breastfeeding/Breast-care- Forming a good relationship and foundation with breastfeeding early is helpful. Breast-feeding often and on-demand (every 2-3hrs) is important taking good care of your nipples that they don't get too dried or cracked. Many breastfeeding problems can come from an incorrect/assymetric latch.

Rest- is most critical after the birth for healing. Make this clear to the mother and her support team so that this can become a reality.

Hygeine- tub bath or shower as preferred, stiz bath herbs could be helpful for healing also.

Urination/Bowel Movements- minor disorders of urinary and bowel function are common in the first few days. (continence, constipation etc) If these problems persist contact your midwife.

After Pains- Tylenol or Ibuprofen are appropriate anelgesia for afterpains if they are of discomfort to the mother and she desires such. (Myles 660)

Sexual Activity- Sexual adjustment is required, open communication is necessary for this. Physiologically healing must take place before penetration can occur and the mother must also feel comfortable with this, again open communication is necessary.

Front 24

K. Provides culturally appropriate education,
counseling and/or referral
14. contraception (Separate into hormonal and non-horm/barrier, define each, failure rates and considerations/contraindications)

Back 24

HORMONAL
Combined Hormonal Pill- Work primarily by preventing ovulation, menstruation of women on the pill is a pseudomenstration, which is produced by the administration and then withdrawal of the hormonal drugs. Failure rates 0-0.1% with perfect use and 5% with typical use. Contraindications include:
Pregnancy, Thrombophlebitis, Thromboembolic disease or hx of, cerebrovascular accident/disease, liver damage or tumor, Carcinoma of breast, undiagnosed abnnml vag. bleeding, Classic migraine headaches, smoking after age 35, diabetes (hypertension, cardiac, renal or gallbladder disease, lupus or sickle-cell anemia).

Emergence Contraception- (morning after pill) if initiated in first 72 hrs after unprotected sex reduces risk of pregnancy 60-75%, lower if taken in 1st 12 hrs.

Injectables- inhibits ovulation and can inhibit sperm pentrating cervical mucous. Failure rate- 0.1 for perfect use and 0.2 for typical use.

Implants (not used in US, lowest failure rate)

Intavaginal ring(NuvaRing)- supress ovulation with lower hormonal doses (no need to go through digestion). Inserted into vagina for 1st 3 wks of cycle last week is free of use. Failure rates 1-2 woman out of 100

Contraceptive Patch- failure rate 0.7-0.88%

IUD- (chemical and non-chemical) Primarily prevents fertilization, usually by changing intrauterine fluids or mucous. Failure rates, Copper- .6-.8%, Levonorgestrel-releasing .1%
Contraindications include:
Pregnancy, PID or hx of, Cervical/Uterine Carcinoma, Uterine Cavity Abnormalties, Copper allergy, High risk for STD, Hx of ectopic preg, Acute cervicitis or vaginitis, Increase susceptibility to infection (HIV/AIDS, caner), Current IUD that has not been removed, Acute liver diseas or tumor, Carcinoma of breast, deep vein thrombosis/pulmonary embolism, Migraine headahces.

NONHORMONAL/Barrier methods
Spermicide- inactivates sperm, not recommended for long-term use for its toxic nature as it can damage the vaginal epithelium. Failure rates 6% with perfect use and 26% typical use.

Condoms- borth protect against STD's. Complaints of less spontaneity with both.
Male- catches semen during ejaculation an prevents any exposure to the vagina. Failure rates- 3% perfect use 14% typical use
Female- similar to male condom, but bigger with 2 rings on either end, one end is closed. Insert the closed end into the vagina for protection against semen. Failure rates 5% perfect use and 21% typical use.

Diaphragms- barrier between sperm and ovum, thick latex with flexible metal ring, fits around cervix resting on bladder. Usually used along with spermicide. Instrruction from care-provider on how to fit an place diaphragm. Failure rates 6% perfect and 20% typical use. Contraindications:
Severe Uterine prolapse, severe cystocele, severe anteversion or retroversion of uterus, fitulas, known allergy to rubber or spermicides, severe UTI's.

Cervical Caps- latex rubber cervical cap that fits snuggly over cervix also holds spermicide like the diaphragm. Has lower incedence of UTI's than diaphragm. Fitting and instructions are also recommended from care-provider for cap. Common complaint is increased vaginal discharge. Failure rates- Parous women perfect 26-40% typical and Nulliparous 9-20%. Contraindications include:
Abnml PAP, Known or suspected uterine/cervical malignancy, Hx of TSS, Current vag or cerv infection, allergy to latex or spermicides.

FemCap is similar to the cervical cap and is made of nonallergic silicone rubber.

Periodic Abstinence, perfect and typical rates
Calender/rhythm, 9%, 25%
Ovulation Method (based on recognition of changes in cervical mucous), 3%, 25%
Symptothermal (combines all s/s of impending ovulation), 2%, 25%
Postovulation, 1%, 25%
Lactation Amenorrhea Method (LAM), ovulation inhibited by high levels of naturally occuring prolactin during first 6 months of lactation. 98% protection rate. Guidelines are 1. baby must be less than 6 mo's old, 2. woman has no vag. bleeding after 56 days PP, 3. Exclusive breastfeeding, no other source of nourishment for baby.

Surgical methods
Female sterilization has failure rate of .5%
Male sterilization failure rate of .10% perfect and .15% typical use

Front 25

K. Provides culturally appropriate education,
counseling and/or referral
15. female reproductive anatomy and physiology (list all of external pelvic floor anatomy,(15) internal reproductive female organs(14), list all pelvic muscles (6/9), pelvic bones/cartilage(12), 4 pelvic types, explain changes that occur and any implications of A&P to preg and birth)

Back 25

External Pelvic Floor (top to bottom):
Mons Veneris
Labia Majora
Labia Minora
Clitoral hood/prepuce
Clitorus
Frenulum
Vestibule of vulva
Urethral orifice
Paraurethral Glands & ducts
Vaginal Opening
Bartholin's duct
Hymen
Fourchette
Perineum
Anus

Internal Female Reproductive Organs:
Symphysis Pubis
Bladder
Ureter
Uterine Artery
Vagina
Fornix, posterior and anterior
Cervix, inner and outer os
Uterus, isthmus, corpus and fundus
Fallopian Tubes, interstitial area, isthmus, ampulla, infundibulum, and fimbriae
Ovary, ovarian follicles
Broad ligament
Rectum
Anus
Sacrum

Pelvic Muscles:
Superficial- Ischiocavernosus, Bulbocavernosus,
External anal sphincter, Anococygeal body
Deep-
Levator Ani (Pubococcygeus, iliococcygeus, Ischiococcygeus)
Deep transverse perineal muscle

Pelvic bones/Cartilage:
-Sacral Promontory
-Sacrum (sacrococcygeal joint)
-Coccyx
-Illium (Innominate bone consists of illium, ischium, tuberosities and pubis)
-Sacrosciatic notch
-Ischial Spine
-Ischium
-Ischial Tuberosity
-Pubis
-Symphysis Pubis
-Acetabulum
-Obterator Foramen

4 Pelvic Types:
-Gynecoid- round shape, most common in european descent, most conducive to childbearing
-Android- male pelvis, heart-shaped, encroaching spines, narrow arch, deep transverse arrest is seen.
-Anthropoid- anterio-posterior oval, most common in black descent, posterior babies common
-Platypeloid- kidney shaped(transverse oval), most rare and least likely to have vaginal birth

--Muscles and ligaments may feel sore or tender from the stretching, growth, and hormonal influence. The growing uterus, and effects of progestrone (relaxing smooth muscle)on muscles and ligaments can cause other discomforts including frequent urination, constipation, indigestion/heartburn. Be careful with exercise and stretching as everything is lossening up and preparing for birth the effects of hormones can cause injuries.

Front 26

K. Provides culturally appropriate education,
counseling and/or referral
16. monthly breast self examination techniques

Back 26

Emphasize the importance of monthly self-exam of breasts, along with routine exam by clinician. Often this teaching can be incorporated into the exam you give to the woman, instead of setting a different time to teach.Simple instruction pamphlets can be found from American Cancer Society.
Begin by asking the woman if she already performs SBE and to demonstrate if so. Also ask about the frequency of exams and educate where necessary.
Give following info when educating for SBE:
-Explain importance of monthly SBE and that early cancer identification can most often be cured.
- Reminder that not all lumps mean cancer but should be diagnosed quickly.
- Explain when to do exam, monthly a day or 2 after menstruation
- Positions for inspection in mirror (hands above head, hands on hips, bend at the hips, hands at your side)
- What she is looking for (creases, lumps, indents, any changes in breasts)
- Supine position for palpation and placing small pillow under the shoulder of the arm being raised/breast being examined.
- Proper palpation technique of covering every square inch of breast and axillae.
- What to look for during palpation, lumps, especially hard fixed lumps, bumps, any changes from previous exam.
- Explaining anatomical structures that may be encountered, such as ribs, inframammary, and her NML breast tissue.
(Varney 1144)

Front 27

K. Provides culturally appropriate education,
counseling and/or referral
17. implications for the nursing mother

Back 27

Prenatally discuss infant feeding options, ask questions and help her prepare for her desired feeding. Discourage vigorous nipple preparation/scrubbing with loofah, washcloth or other harmful substances, it can cause UC's (esp. discourage for those pron to preterm labor).
Discuss the importance of the initial latch in the first hour immediate PP and instruct/show how to breastfeed. Discuss benefits and management of breastfeeding exclusively for the first 6 mo's-1 yr, encourage breastfeeding on-demand. Discourage the following: bottlefeeding unless medically indicated, artificial teats, nipple shield, pacifiers, giving food or drink other than breastmilk.

Front 28

K. Provides culturally appropriate education,
counseling and/or referral
18. the practice of Kegel exercises

Back 28

Explain how to do Kegel exercises of contracting and releasing the pelvic floor and internal muscles. This and other exercises performed regularly during pregnancy can provide relief of discomfort during pregnancy and preparation for labor.

Front 29

K. Provides culturally appropriate education,
counseling and/or referral
19. risks to fetal health, including:
a) TORCH viruses (toxoplasmosis,
rubella, cytomegalovirus, herpes,
other--Varicella, parvo, Syphilis and HIV)
Below risks were previously mentioned in other card...
b) environmental hazards
c) teratogenic substances

Back 29

A)TORCH
Toxoplasmosis- infection, can be contracted through exposure to cat feces, infected soil and infected or undercooked (particularly pork). Can cause severe congenital malformations if mother aquires infection in pregnancy (esp late 1st trimester), it crosses placenta to fetus. Many infants don't demonstrate symptoms at time of birth, but later in childhood. Seizures, motor and cognitive deficits, and mental retardation. Most severe cases have nuerologic anomalies such as anencephaly, hydrocephalus, microcephaly, & intracranial calcifications.

Rubella- virus (German Measles) Most important consequences are miscarriage, stillbirths, fetal anomolies, and theraputic abortions. If woman contracts rubella in 1st trimester approx. 52% chance that baby will be born with Congenital rubella syndrome(CRS). Most common malformations associated with CRS are cataracts, cardiac defects, and deafness. Also IUGR and postnatal growth retardation are frequent. Infection after 20 wks gest. rarely causes defects.

Cytomegalovirus (CMV)- apart of the herpes simplex virus types 1 and 2 (ie. mono and epstein-barr). Mostly spread (among healthy individuals) within households and among young children in day care centers and classroom. Encourage mother to maintain excellent hand-washing technique to diminish likelihood of infection. Greater risk of congenital CMV if primary infection occurs in during fetus. Complications to fetus of congenital CMV include: Generalized infection, liver or spleen enlargement (to fatal illness), hearing damage/loss, vision impairment, and varying degrees of mental retardation.
(Varney's 674-78)

Herpes simplex-1- Neonatal herpes is a severe systemic viral infection with high morbidity and mortality. This can occur if the mother acquires a primary during late preg and baby is born before development of maternal antibodies develop. Primary infection occuring in early preg can lead to congenital HSV infection which although rare can cause severe congenital abnlties. HSV transmitted to the baby during delivery may result in neonatal death, severe CNS, or ocular damage. Baby can also contract HSV.(Varney's 453)

OTHER:
Varicella- Highly contagious viral infection from a herpesvirus. The earlier the mother has varicella in preg the greater the risk of congenital varicella syndrome. Between 25-40% of fetuses exposed to varicella in utero will get this syndrome. It is associated with cataracts, chorioretinitis, limb hypoplasia, hydronephrosis, microcephaly, mental retardation, lesions and scars. Maternal varicella occuring 6 days prior to 2 days after delivery can be passed to the NB. Without passive immunity from mother, the infant can become seriously ill and 5% will die when infected this way.
Parvovirus B19-Rash all over body, virus passed through respiratory secretions, also blood or blood products. Infection in preg has 20-30% placental transfer rate. Fetuses affected will experience aplasctic anemia, nonimmune hydrops, and rarely death. (Varneys 678-81)
Syphilis-WHO figures estimate that maternal syphilis adversely affects 1 million preg/yr. 460K result in abortion or perinatal death, 270K babies born with congenital syphilis, and 270K babies born premature or with low birth weight. Congenital syphilis is associated with serious neurological, developmental and musculoskeletal sequelae and prognosis is considered poor if symptoms occur in 1st wk of life.
HIV- the incidence of HIV infection through vertical transmission increases during pregnancy and breastfeeding (millions of babies worldwide are primarily infected this way). HIV in preg is associated with increase in stillbirth, preterm delivery, and IUGR. (Myles 422-28)