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29 Cards in this Set

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C. Offers alternative healthcare practices
(non-allopathic treatments) and modalities(list 15), and educates on the benefits
and contraindications:
1. herbs (beneficial herbs and Contraindicated herbs)
2. hydrotherapy (baths, compresses,
showers, etc.) (benefits and contraindications)
MODALITIES LIST:
- Acupressure (Shiatsu)
- Aromatherapy
- Acupuncture (Chinese Medicine)
- Bach Flower Remedy
- Craniosacral therapy
- Chiropractic Adjustment
- Hands-on energy healing (Reiki, theraputic touch, polarity, ortho-bionomy, kinesiology, crystals)
- Homeopathy
- Herbology
- Iridology
- Naturpoathic Medicine (variety of healing modalities)
- Osteopathy
- Reflexology/reflex zone therapy
- Massage
- Hypnotherapy/hypnosis
(Frye, 55-64) (Myles, 960-63)

HERBS:
- Beneficial herbs in preg:
Nettle, Dandelion, Red Raspberry leaf, Red clover, Lemon juice and water (specific herbal remedies for pregnancy discomforts and pains not listed here)

- Contraindicated herbs during preg:
Goldenseal, Ephedra, Cotton root bark, Blue cohosh. Peenyroyal, and Birthroot.

HYDROTHERAPY
Benefits:
- Baths and showers, reduce muscle tension, pain and anxiety dramatically for women (Simpkin 253) Lowers catechalomines, more rapid active labor progress.
- Hot compresses- increase local skin temp, circulation, and tissue metabolism, reduces muscle spasm and raises pain threshold
- Cold- helps musculoskeletal and joint pain, decreases muscle spasms, reduces sensations/pain, reduces temp and swelling

Contraindications:
- Shower- if balance or ability to stand is unreliable/unstable
- Bath immersion- before active labor is established, bleeding or fetal distress, when birth is imminent
- Heat- if woman does not desire, current fever, if their is apparent potential harm from heat
- Cold- If woman is feeling chilled, cultural, if it is causing irritation
(Simpkin 248-56)
E. Manages shock(define) by:
1. recognition of shock, or impending shock (list S/S, 7)
2. assessment of the cause of shock (List 5 types of shock and possible causes)
Shock- complex syndrome involving reduction of blood-flow to the tissues, may result in irreversible organ damage and progressive collapse of circulatory system. If left untreated will result in death.

S/S of shock:
- Elevated Pulse
- Low BP
- Paleness of skin, clammy, cold sweat
- Low body temp
- unresponsive/level of consciousness
- rapid shallow respirations
- Urine output decrease

Types/Causes of shock:
- Hypovolemic- result of a reduction in intravascular volume such as in severe obstetric hemorrhage
- Cardiogenic- impaired ability of heart to pump blood. May be seen following a pulmonay embolism or in women with cardiac defects.
- Neurogenic- results from an insult to the nervous system as in uterine inversion
- septic or toxic- occurs with severe generalized infection
- anaphylactic- may occur as the result of a severe allergy or drug reaction.
(Myles 640-43)
E. Manages shock by:
3. treatment of shock(9)
a) provide fluids orally (only in beginning stages, nothing orally in late stages of shock)
b) position mother flat, legs elevated 12 inches
c) administer oxygen
d) keep mother warm, avoid
overheating
e) administer/use non-allopathic remedies
f) encourage deep, calm, centered breathing
g) administer or refer for IV fluids
h) activate emergency medical services
i) prepare to transport
(from NARM Test Specifications)
F. Understands the benefits and risks and recommends the appropriate use of vitamin and mineral supplements including: (Prenatal Multi-Vitamin, Vitamin C, Vitamin E, Folic Acid, B-Complex, B-6, B-12, Iron, Calcium, Magnesium) (list fat vs. water-soluble)
Appropriate use(RDA), Benefits and Risks(with toxocity levels) of each:

Prenatal Multi-Vitamin:
-Taken as directed (usually one-a-day), can be taken before, during and after pregnancy.

- Vitamin C(water soluble)- 80mg, helps with tissue formation, health of cennective and vascular tissue, increases iron absorption, maintains collagen, helps resist infection. Essentially non-toxic

- Vitamin E (fat-soluble)- 10IU, tissue growth, cell wall integrity, RBC integrity, protects fat-soluble vitamins protects RBC's, inhibits coagulation of blood by preventing clots. Essentially non-toxic

- Folic Acid- 1-2mg, increased mtabolic demand in preg, prevention of mageloblastic anemia, RBC formation, metabolism, coenzyme in nucleic acid. Risk of NOT taking folic acid (low amounts) is neural tube defects in fetus. No known toxicity level.

- B-Complex (water soluble)-
B-6- 2.6mg, Coenzyme in metabolism of amino acids, fat and glycogen, aids in formation of antibodies. Toxic risk of sensory neuropathy.
B-12- 4mcgCoenzyme in protein metabolism, prevents megaloblastic anemia. No known toxicity

- Iron- 18+mg, Makes hemoglobin(increased need in preg), fetal iron storage, blood loss PP. Excessive intake may be toxic, could cause gastrointestinal distress.

- Calcium-1200mg, Essential in blood clotting, muscle contraction, nerve transmission, bone and tooth formation,
Excessive intake may cause leg cramps, kidney stones, hypercalcemia, renal insufficiency.

- Magnesium- 450mg, Acts as catalyst in untilization of carbs, fats, proteins, calcium, and phosphorus. Coenzyme in energy and protein metabolism, enzyme activator, tissue growth, cell metab, muscle action. High amounts may be toxic in people with kidney malfunction.

FAT-SOLUBLE Vitamins-- A, D, E, K

WATER-SOLUBLE Vitamins-- B, C

(Vitamins A (reproduction, embryonic development, vision and immunity), D (bone formation and maintainence) and K (coenzyme for proteins involved with blood clotting and bone) are also helpful during pregnancy)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
1. Lidocaine/xylocaine for suturing
BENEFITS:
Fast acting, local anesthesia, has no effect on uterus or contractions, poses minimal potential danger to mother.

RISKS:
Primary disadvantage is that it distorts the tissue, making tissue approximation and judgement of tightness of the sutures more difficult.

ADMINISTRATION:
Always rule out allergy to lidocaine first.
Injected by sterile technique with 22-gauge, 11/2-inch attached to 10mL syringe. 1% lidocaine, 10mg/mL is to be injected around the edges of the wound, waiting a few minutes for the medication to take effect.
(Varney's 1235-40) (Davis 73-76)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
2. medical oxygen
BENEFITS:
- oxygenates the body orally
- Short-term inhilation of pure oxygen via face mask, acts as an analgesic, relieving muscle tension, as well as pain and nausea. It can calm down a nervous or fearful mother and give a boost of energy, it can also help revive her if she is woozy from blood loss. (Frye vol 2, 841)

RISKS:
- breathing nothing but pure oxygen may produce coughing, chest pain, paresthesias(numb/tingling extremeties), nausea, vomitting, fatigue, and malaise within 6-24hrs.
- Infants given 35-40% oxygen or above for prolonged periods may suffer permanent visual impairment or blindness.

ADMINISTRATION:
Adults- oxygen is delivered by nasal cannula or face mask, connected by a tube to the oxygen carrying device(tank)
Baby/Resuscitation- delivered by a cushioned or non-cushioned mask connected to a self-inflating or flow-inflating mask that connects to tubes and oxygen device.

- Avoid carbon dioxide build up by always starting with at least 6 1/min of flow when using any type of mask
(Frye, Vol 2, 839-57)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
3. methergine
BENEFITS:
- To help contract the uterus and causes vasoconstriction in the case of PP hemorrhage and uterine atony. (acts directly on smooth muscle of uterus and stimulates a sustained tetanic contraction)

RISKS:
- May cause BP increase
- Contraindicated for women with impaired liver or kidney function, heart or vascular disease, sepsis, severe hypertension, preeclampsia, eclampsia, or Hx of PPD.

ADMINISTRATION:
- 0.2 mg by mouth, every 4 hours for 6 doses, is prescribed when mother has had significant uterine atony (PP hemorrhage) after giving birth. It is also prepared in IM or IV injection form. Never administer methergene before the placenta has been delivered.
(Frye Vol2, 807-809)(Varney, 926, 1055)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
4. prescriptive ophthalmic ointment
BENEFITS:
- Eye prophylaxis against infections caused by gonorrhea and chlamydia

RISKS:
- antibiotic
- short-term blurred vision just after administration

ADMINISTRATION:
- 0.5% erythromycin ointment, spread from newborns inner to outer canthus of each eye.
- Eye care should be deferred until after 1st period of reactivity (1st half hr), when the alert NB is searching for parents faces.
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
5. Pitocin® for postpartum hemorrhage
BENEFITS:
- stimulates intermittent contractions (primarily on the fundus)
- little to no effect on blood pressure
RISKS:
- reactions to oxytocin-based drugs are extgremely rare
- side effects include occaional nausea & vomiting

ADMINISTRATION:
- IM injection of 10 units postpartum is the standard single starting dose. It should take effect in 3-7 mins and last 30-60 mins.
(Varney's 926-27)(Frye Vol 2, 804-06)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
6. RhoGam
BENEFITS:
- a fractionated plasma product that supresses the mothers production of antibodies in response to receipt of the Rh-positive antigen.
- reduces risk of alloimmunization to 1-2%.

RISKS:
- it is a blood product (even though it is highly fractionated plasma derivation) and carries theoretical risks of transmission of viruses such as HIV, hepatitis and Creutzfeldt-Jakob disease.

ADMINISTRATION:
- 300ug within in 72 hrs PP is sufficient to treat a fetal-maternal bleed cotaining 15mL of RBC's or 30 mL of whole blood. (Varneys1054-55)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
7. Vitamin K:
a) oral
b) IM
BENEFITS:
- prevents hemorrhagic disease of NB (Vitamin K deficiency bleeding-VKDB)

RISKS:
- not protecting against NB hemorrhagic disease if not taken

ADMINISTRATION:
- 1mg IM in NB thigh
- 2.0mg orally given on the 1st and 7th days of life, then again at 1 month and monthly thereafter until solid food is introduced to the infant
(Varneys 978)(Myles 867-69)
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
8. antibiotics for Group B Strep
BENEFITS:
- prophylaxis against GBS, for women who are infected and to help protect newborn against infection

RISKS:
- Potential risks from antiobiotic use (yeast, Frye's Diagnostic book days, " Babies exposed to antibiotics at birth may never develop the same degree of flora health and integrity as a baby born to a mother with intact microbial ecology.
- possible allergy to medicine

ADMINISTRATION:
- Penicillin 5 units via IV initially, then 2.5 units IV every 4 hrs until birth
- If allergic, Ampicillin next best, 2g via IV initially and 1g IV every 4 hrs until birth
G. Demonstrates knowledge of the benefits and risks and appropriate administration of
9. IV fluids
BENEFITS:
- lifeline for fliud and medications
- means of maintaining maternal hydration

RISKS:
- pain of prick, a bother, and restrictions, such as movement and being connected to an immovable device(unless it has wheels)
- fluid overload
- systemic infection of procedure itself

ADMINISTRATION:
- administration of IV fluids and medicine depends upon your state laws/what is allowed in your scope of practice and the condition of the woman you are caring for.
- Usual IV solution for a woman in labor, as said in Varney's (762), consists of 1000aa given at 125cc/hr
(Varney's 761-63)
(Frye Vol 2, 858-59,
H. Demonstrates knowledge of benefits/risks of ultrasounds:
1. provides counseling regarding ultrasound
2. makes appropriate referrals for ultrasound(when)
BENEFITS:
- enables assessment and monitoring of many aspects of the pregnancy (fetal and placental positioning in utero)
- pregnancy complications such as oligo/polyhydramnios, placental problems(previa/abruption), vaginal bleeding of unknown etiology, pelvic mass, uterine abnlty, locate an IUD, manual removal of placenta, during external version(and many other special procedures),
- screen and diagnose for fetal abnormalties
- 1st trimester to establish- viable and intruterine pregnancy, gestational age, fetal number, fetal abnlties
- 2nd and 3rd trimester- anomalies, placental location, AFI, fetal growth, confirming fetal presentation/lie and biophysical profile.
(Myles 297-302)

RISKS:
- false sense of fetal well-being and false-positive diagnoses
- overreliance on technology
- US has been used since the 1950's and any major adverse effects would have been present by now. However, modern machines have higher resolutions and indications for US have greatly increased, therefore levels of exposure to US have increased and there is little research into the effects. US should be used with respect and only when there is good indication.
Overuse:
- significant risk of fetal growth restriction (Davis 30)
- neither fetal nor maternal outcomes are improved by routine use

COUNSELING:
- explain and discuss the findings, and implications in a gentle way

REFERRAL:
- because of the disadvanteages and risks above mentioned midwives must have an in-depth knowledge of the indications for US and the true value and limitations of this imaging technology. (Varney646-47)
I. Demonstrates knowledge of benefits(5 things tests for)/risks of biophysical profile
1. provides counseling
2. makes appropriate referrals
BENEFITS:
- evaluates the fetus by both electronic fetal monitoring and US.
-----5 Variables in test
1.Fetal HR reactivity- 2 episodes accel for 15 sec or more
2. Breathing movement- one episode 20 duration
3. AFV- 1 pocket 2cm or higher
4. Movement- +2 movements in 30 min
5. Tone- Ext and flexion

RISKS:
- false-positives or negatives

COUNSELING:
- Score of 8/10 means the fetus in nonasphyxiated and fetus should do well for the next week. Less could mean complications.

REFERRAL:
- Indications for BPP:
IUGR, oligohydramnios, preeclampsia, postdates, multiple pregnancy or nonreactive NST or positive CST.
- Generally done weekly begun at the earliest point at which delivery is likely (considered by clinician)
(Varney's 642-44)
J. Demonstrates knowledge of how and when to use instruments and equipment including:
8. scissors (all kinds)Epis., Suture, Umbilical cord
EPISIOTOMY:
Indications: Need to cut is rare, depends more upon baby's condition rather than perineal tissue.
- If baby appears seriously comprimised and birth would occur very soon after.
- If perineum is so tight and unyielding that maternal attempts to push are causing excessive exhaustion and worsening fetal response (and position changes is not working)

How/when to cut:
Preferrably using flat/guarded/blunt-tipped scissors
- Protect the presenting part by inserting 2 fingers between peri and baby
- The cut should be timed to avoid lacerations (too late) and unecessary blood loss (too soon). Peri should be bulging, approx. 3-cm diameter of presenting part should be seen between UC's, and deliver of presenting part should be expected within next 2-4 UC's.
- Scissors should be held at midline, perpendicular to the skin surface and cut at a very slight angle to one side (essentially an off-center midline cut to try and avoid extension into rectal sphincter)--other possible cuts are midline or mediolateral.
- One episiotomy should be large enough to not have to make another cut
(Frye Vol 2, 483)(Varney's 1279-80)

SUTURE:
- A separate pair of scissors with sharp/sharp tips, used for cutting suture material precisely.(Davis, 173) With strict adherence to aseptic technique.

UMBILICAL CORD CUTTING:
- Acheived by dividing the umbilical cord between 2 clamps (or other clampind devices, sterile bands, string etc.) approx. 8-10cm(3-4 in.) from umbilicus, then cut between the clamps. You can also aid the father in cutting the cord.
O. Evaluates laboratory and medical records:
1. hematocrit/hemoglobin
(NML values for each trimester of pregnancy and non-pregnant)
Hemoglobin levels at different trimesters/PP(Hb):
1st- 12-13
2nd- 10-11 (2 pt drop nml around 28 wks)
3rd- 12-13 (or back to initial healthy level at beg. of preg)
Non-preg- 11.5-16.5
NOTE: over 8,000 ft altitude may see slight to no drop in Hb
(Frye, Diagnostic 258-60)

Hematocrit:
1st- 36-48%
2nd- 30-36%
(Frye, Diagnostic, 102)
Non-pregnant- 35-47%
(Myles, 200)
O. Evaluates laboratory and medical records:
2. blood sugar (glucose)
(1OGTT, 3OGTT, & Fasting)
1OGTT:
- furthered diagnostic testing (3 hr GTT) suggested at >130-140mg/dl (this test is considered diagnostic IF the value is >200)

3OGTT: diagnostic 100gm glucose drink
-NML is less than 140 mg/dL, above indicates GD

FASTING:
- NML 60-100mg/dL
- diagnostic if levels are >126 (NOTE: also dignostic if non-fasting levels are >200)
O. Evaluates laboratory and medical records:
3. HIV
HIV:
- Standard HIV testing is to run the ELISA (enzyme-linked immunosorbent assay) and repeat if positive.
- If it is positive a Western blot test should be done to confirm HIV ( for this to be positive, antibodies to 2 or more protein "bands" found in HIV must be present)
(Varney's 166-68)
O. Evaluates laboratory and medical records:
4. Hepatitis B and C
HEPATITIS B:
- HbsAG (hepatitis B surface antigen) results as negative or positive. This will usually appear in the infected person's blood 1-10wks after acute exposure and will stay until about 4-6 months after infection; at which point hepatitis B surface antibody will be present and will confer lifeling immunity.

HEPATITIS C:
- If HCV antibody screen is positive RIBA(recombinant immunoblot assay aka "Western Blot") is used to confirm the result
(Varney's 179-82)
O. Evaluates laboratory and medical records:
5. Rubella
Rubella:
Titre of--
>/= to 1:10= immunity
<1:10= not immune (a blood specimen should be obtained for serologic testing and physician consulted)
>1:64= current infection
O. Evaluates laboratory and medical records:
6. Syphilis (VDRL or RPR)
Screening follows a 2-step process:
1st- the nontreponemal serologic tests, which demonstrate the presence of reagin in serum (most common are VDRL--Venereal Disease Research Laboratory or RPR--rapid plasma reagin) If these are positive (reactive) treponemal testing should be done.
- Treponemal testing, usually the FTA-ABS (flourescent treponemal antibody absorbed), if this comes out positive, the woman should be treated. (Varney's 450-51)
O. Evaluates laboratory and medical records:
7. Group B Strep
Standard screening for vaginal/rectal GBS colinization at 35-37 wks gestation, specimen collected by a swab. This comes out as positive or negative. (Varney 583)
O. Evaluates laboratory and medical records:
8. Gonorrhea Culture
specimen taken from urine or from speculum exam

NML ranges
Negative or no Neisseria gonorrhoeae seen- indicates no current infection

Positive- indicates presence of infection
O. Evaluates laboratory and medical records:
9. complete Blood Count
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.
O. Evaluates laboratory and medical records:
10. blood type and Rh factors
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.
O. Evaluates laboratory and medical records:
11. Rh antibodies
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.
O. Evaluates laboratory and medical records:
12. chlamydia
- Chlamydia Specimens: to rule out chlamydia, can be done with urine or from speculum exam.

- Test results can come out as either positive or negative.
O. Evaluates laboratory and medical records:
13. PAP test
-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)