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78 Cards in this Set

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A. Assess results of routine prenatal physical exams including ongoing assessment of:
1. maternal psycho-social, emotional health and well-being
If any psycho-social or emotional problems were discovered in the initial history taking visit, continually assess as to how she is coping, if she is receiving treatment (counseling, classes, natural or medical), if treatment is helping, and any other concerns as you are discussing the topic. Make sure to observe her expressions and try to read any untold emotions or feelings that she may not be expressing to you.

- Also continue observing for any newly occuring psychological issues throughout pregnancy, bearing in mind that the vast majority of emotional upsets in pregnancy result from hormonal changes. However, if an issue seems to be arising particularly in late pregnancy, pay close attention as they tend to get worse after birth if they occur in late pregnancy.

---Tip from Elizabeth Davis, " I have come to believe that the best way to promote a pregnant woman's well-being is to help her see weak or neglected aspects of herself in a positive light, so she will feel good about doing some work in these areas."
(Davis 88)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
2. signs and symptoms of infection
The symptoms of an infection depend on the type of disease. Some signs of infection affect the whole body generally, such as fatigue, loss of appetite, weight loss, fevers, night sweats, chills, aches and pains. Others are specific to individual body parts, such as skin rashes, coughing, or a runny nose.

The danger of microoganisms in pregnancy is 2-fold
1. direct effect it may have on mother
2. subsequent indirect effect on fetus
(Varneys and Wiki)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variations
and change in:
a) blood pressure (definie, ranges, and associted w? )
Blood pressure is the force exerted against the arterial walls when the heart pumps. (Heart contracting=systolic; refilling=diastolic) BP reading is a reflection of how hard the heart must work to adequately circulate the blood.

NML range: 89/59-139/89, cut-off pt-140/90 or 30/15 above baseline on two different occasions 6 hrs apart

Associated with:
- preclampsia,
- abruptio placenta, and
- convulsions
(non-pregnant--cerebral hemorrhage, cardiac arrest, headaches, visual problems, and underlying disease) In pregnancy there is generally a drop in BP in 2nd trimester and a rise in 3rd. (Frye 420-21)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variations
and change in (ranges and associated with?):
b) weight
- Weight gain during preg is caused by increased water retention due to hormones, increased fatty insulation deposited over the belly and backside, increased weight in breasts, increased blood volume, plus obvious weight of enlarged uterus, including amniotic fluid, placenta and fetus.
- Pre-pregnant weight is most significant to keep in mind while assessing weight gain throughout pregnancy. Assuming that her starting weight was normal for her height and frame, an average gain is about a pound per week (could be more or less for over or underweight woman--as rule of thumb, 10lbs by 20 wks and about a pound a week thereafter). Many women are sensitive about their changing figure and should be reminded and reasurred that an ample weight gainis both desirable and essential for the baby's health and their own endurance, particularly during labor and immediate PP.
- The value of routine weighing during antenatal visits has been questioned and in many areas has been abandoned as a form of antenatal screening for preeclampsia. However, wt. gain may be useful for monitoring the progression for preeclampsia in conjuction with other parameters.(Myles 403)

UNDERWEIGHT:
- Women underweight have little to no fat reserves to carry them through bouts of nausea or illness. Women with some extra pounds aren't at greater risk for problems as long as they keep a good diet throughout pregnancy.
- underweight women are at risk for anemia, preeclampsia, premature labor, prolonged labor, PP hemorrhage, poor recovery, and PPD. She must realize the importance of getting enough calories each day, discuss this thoroughly.
(Davis, 21, 67-68)
- Low-maternal weight seems to have more adverse effects upon the fetus than high-maternal weight. (Varneys 599)
- Eating disorders such as anorexia put the woman at higher risk for malnutrition and bulimia for hyperemesis gravidarium

OVERWEIGHT:
- If the woman seems to be gaining weight rapidly, double check her diet and see if she's made any deleterious changes, or is taking in excess sugar (signaling a need for more low-fat protein sources)
- obesity is associated with higher blood pressure readings (commonly from wrong cuff size)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variations
and change in (ranges and associated with?):
c) color of mucus membranes
NML during pregnancy: increases during beginning of pregnancy, then decreases until the end of pregnancy and is nml whitish colored discharge.

- blood-tinged mucus could indicate: the mucus plug(egg white and thick/clear could be part of plug), nml post-coidal bleeding, abnml bleeding from complications such as placenta abruption, , threatened miscarriage, placenta previa, etc.
- watery clear fluid leaking could indicate SROM
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variations
and change in (ranges and associated with?):
d) general reflexes
Hyperreflexes can occur in any woman whi is over excited, stressed or anxious during the exam and can be a benign finding. However, it can be a transitional sign indicating preeclampsia has progressed to a more serious stage. (Davis 77)(Frye 829)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variations and change in:
e) elimination/urination patterns
ELIMINATION:
Gastric emptying time and intestinal motility are decreased, which may cause increased bloating and constipation in some women.
Constipation can also be a result of preogesterone relaxing effect on smooth muscle.
- Loose bowels near term is NML
- continued constipation, diarrhea, pain with BM are abnml and need furthered investigation
URINATION:
- Frequency of urination is common during pregnancy (from weight of uterus)
- Slight urinary incontinence also occurs in some women near term.
(Frye, 193)
- (UTI's/infection) Progesterone relaxes the walls of the ureters and allows dilation and kinking. In some women this tends to the slowing down or stasis of urinary flow, making infection a greater possibility. (Myles 135)
- Any s/s extremely frequent irunation, infrequent/low amount of urine, blood in urine, or pain/burning with urination is ABNML and requires furthered investigation.
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variationsand change in:
f) sleep patterns
Sleep disturbances are a common complaint in pregnancy. Various hormonal and mechanical (growing uterus stretching and pulling muscles and ligaments, urine frequency) influences promote insomnia leading to disturbed sleep during pregnancy in most women. The worsens towards the end of pregnancy and continues to some extent for 3 mo's PP.
- Some studies show sleep loss on the last few weeks of pregnancy are associated with increased labor length and LSCS rates. (Myles 205)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
3. maternal health by tracking variations and change in:
g) energy levels
Pregnancy requires additional energy above that of normal levels

LOW NRG associated with:
- thyroid imbalance problems (hyperthyroidism, PP thyroidosis etc)
- fatigue can be a common discomfort of the first trimester (rest, good nutrition, and mild exercise help combat fatigue)
- combined with other issues such as nausea or dizziness beyond the 1st trimester could indicate anemia
- fatigue in conjuction with other symptoms could indicate an infection of some sort or another and should always be further investigated.

HIGH NRG women must be careful not to over-exert themselves in strenuous activities such as exercise, sports or other physical activities.
(Davis and Varneys-592)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
4. nutritional patterns (What is malnutrition and obesity associated with?)
Continued assessment of maternal nutritional intake should be a routine part of each prenatal visit if any signs of nurtitional deficiencies or issues come up, they should be further investigated.

-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).

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)

MALNUTRITION associated or correlated with:
- eating disorders (anorexia and bolemia)
- substance abuse
- debilitating illness
- IUGR
- prematurity or stillbirth
- maternal or fetal infection
- preeclampsia
- dysfunctional labor
- hemorrhage

OBESITY(preexisting with hx of medical problems) associated/correlated with:
- diabetes
- hypertension
- pyelonephritis
- uterine dysfunction
- hemorrhage
(Davis, 20)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
5. hemoglobin/hematocrit (associated with? treatment)
Routinely, an initial prenatal panel should be done which includes HGB and HCT. A 28 week CBC is also routinely done to reassess maternal blood condition.

--------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, polycythemia or dehydration.
(Frye Diagnostics, 102-103)

Many of these issues if caught early on can be treated naturally through diet, supplementation, exercise, etc. If a deficiency of some sort is causing the anemia, then supplementation (such as Floradix Herbs plus Iron for an iron deficiency anemia) can be recommended with continual assessment of the condition until it resolves.
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
6. glucose levels ( high and low associated with?)
HIGH blood-glucose/GD is associated with:
- macrosomia,
- polyhydramnios,
- hypertension and
- preeclampsia
- diabetes
(Varneys, 699)

LOW blood glucose/hypoglycemia is associated with:
- IUGR/SGA
- GD or diabetes
- Nausea
- Digestion issues
(Davis, 84)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
7. breast condition/implications for
breastfeeding
Examine and Ask Questions related to:
- any hx of injury or surgery (biopsy, reduction, augmentation etc) and consider the impact of trauma in the ducts and nerves in the assessment
- Signs of current inflammation, infection, or abscess should be noted and treated
- For inverted nipples, neither the wearing of hard plastic shells nor the performance of nipple exercises are more effective than natural softening effects of hormones of pregnancy in everting previously inverted nipples.
- Inverted nipples have been closely correlated with malnutrition and dehydration
- engorgement or fullness of the breast may also temporarily invert nipples (may be relieved by hand expressing, soaking breasts in luke-warm water, gentle pumping, cabbage leaves etc)
- unusually shaped or sized nipples are usually congenital, close follow-up may be needed to ensure adequate milk transfer
- any s/s of cancer noted should be promptly referred to physician.
(Varney's 1072-73)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
8. signs of abuse
Any of the s/s of abuse (previously stated in first section) that occur or a hx of abuse should be continually discussed in an appropraite manner. Continued education, referral to appropriate agencies/counseling/legal situation is also necessary.
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
9. urine for:
a) appearance: color, density, odor,
clarity
b) protein
c) glucose
d) ketones
e) PH
f) Leukocytes
g) Nitrites
h) blood
A) COLOR: NML-Pale yellow to Amber. Darker urine can indicate long period of time between voiding, dehydration, fever, or intake of iron salts. Foods, drugs, supplements and vaginal secretions can cause different colorations. Brown, black, or smoky are all abnml findings and should be furter investigated with a clean catch (also any other colors that are not correlated to a substance intake)

ODOR: Aromatic is NML. Strong ammonia could be high bacteria count if fresh, fecal-rectovaginal fistula, fishy-bladder infection or seafood meal, new mown hay-diabetes, foul-bacteria. (Firecracker-nitrites/UTI)

CLARITY: Cloudy could indicate mucous from vagina, proteinuria, or WBC's from infection (this also indicated from milky look in urine). Greenish or yellow foam when shaken is abnml could indicate bile pigments.

B) Protein: Neg-Tr is NML, +1- +2 could indicate concentrated urine, exercise, amniotic fluid, preeclampsia, kidney disease, diabetes, drugs, heart failure, Vit D, radiation.

C) Glucose: Neg - +2 could be NML. +2- +4 could indicate high glusoce levels, high sugar intake, Vit C intake, diabetes, preeclampsia, head or liver injury.

D) Ketones: Neg is NML. Tr - +2 indicates too long between meals, low calorie diet, excessive monitoring, --needs more food/fluids. +2 - +4 could indicate high blood ketones, dehyration, diabetes (immediate increase in food/fluids)

E) PH: 4/5-8 (average 5-6) is NML. Very acid is <6 could indicate high meat intake, diarrhea, dehydration, metabolic acidosis, fever, PKU, metal or alcohol poisoning. Alkaline >7 could indicate high veg. intake, excess vomiting, potassium depletion, hyperventilation, pyloric obstruction, chronic kidney failure.

F) Leukocytes: False positives frequently occur in pregnancy. Luekocytes in conjuction with nitrites (especially in a clean catch) can signify a UTI.

G) Nitrites: SAA

H) Blood: Blood in the urine can be nml, it can be contaminated from vag secretions (post-coidal bleeding). It could also be abnml and can be correlated with UTI or unrinary tract trauma, has been seen in women with kidney problems, hyperemesis, papilloma, hydronephrosis, heavy smokers and even significant hypertension. Rarely it could be from the obstetric complication placenta percreta and is therefore important to identify the cause of blood in the urine.
(Frye Diagnostics, 35-46, 88-91)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
10. fetal heart rate/tones auscultated with
fetascope or Doppler
- FHR should be heard by fetascope by 18-20 weeks and with the doppler by 10-14 weeks.
- NML range is 120-160, however early pregnancy it is considered NML up to 170 bpm (10-15 pts higher in early preg is NML until baby grows larger).
- Tachycardia is high FHR, above 160 bpm (marked tachy at or >180 bpm) and transient periods of acceleration can be NML. Sustained tachy is associated with: (maternal) dehydration, overheating(hot baths/exercise), oxygen deprivation, hemorrhage, fever, infection or hyperthyroidism; (fetal factors) anemia, blood loss, side effects of drugs
- Bradycardia is low FHR, below 120 (marked brady at or <100) sustained bradycardia is associated with: oxygen deprivation, umbilical cord compression/tanglement, fetal hypoxia, maternal drug intake, maternal hypothermia
(Frye, 987-88)
- Variability (a sign of nuerological health) should be documented by 28 weeks. The baseline rate should vary by at least 5 beats over a period of 1 min. Loss of this variability may indicate fetal compromise. If findings are questionable, contact back-up physician.
(Davis 30) (Myles 482)
- A Fetal Auscultated Acceleration Test can be done to assess and identify the baseline FHR and fetal reactivity through accelerations (of 2 beats per 5-second period) documented on the AAT graph. (Graph seen in Varneys 635-36)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
11. vaginal discharge or odor
- In preg an increased volume of vaginal secretions due to high levels of estrogen results in a thick, white discharge known as leukorrhea. (Myles 196)

Vaginal infections (causing discharge or odor):
- Monilia/Candida (yeast) characterized by a white, curd-like discharge and is common during preg.
Can lead to vaginitis (inflammation and discharge)and can exibit whitish or grayish patches or plaques which adhere to the vaginal wall and may bleed when scraped off
- Gardnerella (BV) causes a fishy odor and thin, gray or white discharge that tends to adhere to the vaginal walls. It can be transient, but has been associated with chorioamnionitis, premature ROM, and preterm labor.

- Trichomonas, characterized by a malordorous, highly irritating, yellow-green frothy discharge. It is assiciated with the same complications as BV. It also may lead to vaginitis (inflammation and discharge) which may cause red petichiae.
(Varneys 1182)(Davis 45)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
12. estimated due date based upon:
a) last menstrual period
b) last normal menstrual period
c) length of cycles
d) changes in mucus condition or
ovulation history
e) date of positive pregnancy test
f) date of implantation bleeding
g) quickening
h) fundal height
i) calendar date of conception/
unprotected intercourse
a) last menstrual period: Was the length, amount of flow, and timing NML? If not, how did it differ? Consider implantation and question any other forms of bleeding.
b) determine the last normal menstrual period

c) length of cycles: is it NML 28 days, longer or shorter? Is it regular?

d) changes in mucus condition or ovulation history: dates of ovulation if she kept record

e) date of positive pregnancy test

f) date of implantation bleeding

g) quickening: usually felt around 16-20 weeks

h) fundal height:
12wks- level of SP
16wks- 1/2 way between SP and navel
20wks- at navel
24wks- several cm above navel
(using soft measuring tape place one end at upper edge of pubic bone then stretch tape to highest pt of top of fundus. Give or take a few centimeters FH should match gestational age)

i) calendar date of conception/
unprotected intercourse, whether she was using contraceptives or not?

(Frye, 404, 362) (Davis, 28)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
13. assessment of fetal growth and wellbeing:
a) auscultation of fetal heart
- FHR should be heard by fetascope by 18-20 weeks and with the doppler by 10-14 weeks.
- NML range is 120-160, however early pregnancy it is considered NML up to 170 bpm (10-15 pts higher in early preg is NML until baby grows larger).
- Tachycardia is high FHR, above 160 bpm (marked tachy at or >180 bpm) and transient periods of acceleration can be NML. Sustained tachy is associated with: (maternal) dehydration, overheating(hot baths/exercise), oxygen deprivation, hemorrhage, fever, infection or hyperthyroidism; (fetal factors) anemia, blood loss, side effects of drugs
- Bradycardia is low FHR, below 120 (marked brady at or <100) sustained bradycardia is associated with: oxygen deprivation, umbilical cord compression/tanglement, fetal hypoxia, maternal drug intake, maternal hypothermia
(Frye, 987-88)
- Variability (a sign of nuerological health) should be documented by 28 weeks. The baseline rate should vary by at least 5 beats over a period of 1 min. Loss of this variability may indicate fetal compromise. If findings are questionable, contact back-up physician.
(Davis 30) (Myles 482)
- A Fetal Auscultated Acceleration Test can be done to assess and identify the baseline FHR and fetal reactivity through accelerations (of 2 beats per 5-second period) documented on the AAT graph. (Graph seen in Varneys 635-36)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
13. assessment of fetal growth and well-being:
b) correlation of weeks gestation to fundal height
Using soft measuring tape place one end at upper edge of pubic bone then stretch tape to highest pt of top of fundus. Give or take a few centimeters FH should match gestational age.
(Davis, 28)

- A 2cm leeway on either side of the week is considered NML (ie. 32wks 30-34cm would be NML)
- If FH is as much 4cm off from expected GA either way, this should alert midwife to possibilty of: SGA or LGA, abnml amniotic fluid volume, multiple gestation. Also re-evaluate the EDD, the mothers shape and size, her abdominal muscle tone, size of previous babies in relation to current, maternal nutrition and stress levels when the FH and GA does not seem to correlate.
- Sometimes FH measurement does not apply, with different nationalities, and pelvis types these measurements can be askewed.
(Frye 403-413)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
13. assessment of fetal growth and well-being:
c) fetal activity and responsiveness to
stimulation
Fetal activity is reassuring and marked decrease in movement fromo a fetus's usual pattern is cause for concern and cessation of movements os highly correlated with impending fetal death.

- Procedure: Ask woman to focus on fetal activity for an hour, preferably when she is resting, well fed, and hydrated. If she feels 3 movements (some some say 8-10/hr) on that hour, if she feels less than this then referral to a physician for NST or BPP should be made.

- Maternal perception of fetal movements can be diminished/affected by: polyhydramnios, oligohydramnios, anterior placenta, smoking cigarettes(only 2 per day show effects)
(Varneys 632-33)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
13. assessment of fetal growth and well-being:
d) fetal palpation for:
(1) fetal weight
(2) fetal size
(3) fetal lie
(4) degree of fetal head flexion
FETAL WT./SIZE: Assesment of fetal size is quite an art and art only since the scientific method of comparing your estimate to some objective measure is impossible during prenatal care. However, you can carefully assess the size of newborns of various weights and then transfer this knowledge to other babies still in urtero. Constantly be palpate women near term and then compare your last estimated fetal wt to actual size of NB.

3) FETAL LIE: the relationship of the fetal spine to the mothers long-axis/spine of body. It can be longitudinal, oblique, or transverse.

4) DEGREE OF FETAL HEAD FLEXION: Assessed by checking the Cephalic Prominence or Attitude and can be, well fexed, military, brow, or face.
(Frye, 400) (Davis, 28)
A. Assess results of routine prenatal physical
exams including ongoing assessment of:
14. clonus
If previously founded to be abnml it should have been referred to a physician. Continue to assess throughout pregnancy for the possibility of preeclampsia or hypertension. If seen in labor transport at first occurence.
(Davis 77, 154)
A. Assess results of routine prenatal physical exams including ongoing assessment of:
15. vital signs (list complications--for ea 4 vitals-- occuring from being outside of NML range)
Vitals that are borderline and/or outside of NML range require furthered investigation and possibly referral or transfer of care.

- BP--30/15 above or below baseline warrants investigation. Diastolic pressure assesses baseline intravascular tension, systolic pressure indicates cardiovascular tolerence for exertion.
----High BP ass. with: hypertension, preeclampsia, gestational diabetes, multiple gestation, nutritional defficiency(salt, calium, fliuds), IUGR, liver or kidney disease, hyperthyroidism, hydatidiform mole, CNS disorders (may be slightly elevated from tension, nervousness, or excitement. Always check cuff size)
----Low BP ass with: anemia, technical errors(size cuff), nausea, dizziness, fainting, visual disturbancces, breathlessness with exertion.
(Frye 1010-18)

- Pulse--normally 60-90 but can rise 10-15 points in pregnancy and still be normal. Irregularities such as a bounding, weak or thready pulse are not considered normal (Frye, 420)
----High (>100) Rate could indicate: anxiety, anemia, pain, infection, ketosis, or hemorrhage (Myles 486)
----Low Rate could indicate: congenital heart impairment, hypertension, hyperthyroidism, low thyroid

- RR-- 12-20 is NML, above or below is ABNML
---High er RR can be NML during pregnancy and goes away after dilevery it has been associated with: stress, anxiety, emotional upset, asthma, or lung cancer.

- Temp-- Axillary 96.6-98.6, Oral- 97.6-99.6
----High Temp ass. with: fever, infection/illness, maternal overheating(tub or shower), strenuous exercise, dehydration, advanced toxemia.
A. Assess results of routine prenatal physical exams including ongoing assessment of:
16. respiratory assessment
- RR-- 12-20 is NML, above or below is ABNML. Breathlessness is a NML finding in most preg women and may be due to lungs' slight displacement upwards, the growing uterus restricts free movement of the diaphragm.

- NML breath sounds have no definite pitch, they are quiet and easy. Note the rate, rhythm, depth and effort involved in breathing. The amount of air taken in with each breath should be consistent, and the chest should move symmetrically with expansion.
- Resp changes in pregnancy include a mild respiratory alkalosis which is NML (Myles 203)
---High er RR can be NML during pregnancy and goes away after dilevery it has been associated with: stress, anxiety, emotional upset, asthma, or lung cancer.
A. Assess results of routine prenatal physical exams including ongoing assessment of:
17. Edema
- Generalized edema prior to 24 wks gestation should be medically evaluated; edema occuring in later preg, rule out preeclampsia
- Swollen ankles can be NML in preg (as a result of impaired circulation) in the absence of hypertension or proteinuria
- Edema of the upper shins, breastbone, or sacrum can be a sign of preeclampsia (esp in conjunction with hypertension and proteinuria)
- Edema is also associated with deep vein thrombosis in pregnancy
(Davis, 16, 45, 76)
C. Provides prenatal education, counseling,
and recommendations for:
1. nutritional, and non-allopathic dietary
supplement support
NUTRITIONAL:
-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)

NON-ALLOPATHIC/ SUPPLEMENTAL:
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)
C. Provides prenatal education, counseling,
and recommendations for:
2. normal body changes in pregnancy
- The growing baby and enlarging uterus, with all of its accompanying discomforts and effects. Some of these effects include: abdominal and back aches and pains(round ligament), shortness of breath, frequent/changes in urination pattern, indigestion, hemorrhoids, sleep difficulties, itchy skin(from skin stretching), leg cramps, sciatica, varicose veins, stretch marks.

- Hormonal changes such as the smoth-mscule relaxing effect of progesterone and other hormones cause changes to the pregnant body. Some of which include: bleeding gums, breast soreness, gas, constipation, heartburn/indigestion, edema, fatigue, morning sickness, vaginal secretions and infection, varicose veins.

- Suppressed immune system can make women more susceptible to infections, colds/flus, runny nose/congestion during pregnancy.

- There are also NML resp, cardiovascular(blood volume increases dramatically) and temperature (increases) changes that occur in pregnancy.
C. Provides prenatal education, counseling,
and recommendations for:
3. weight gain in pregnancy
- Pre-pregnant weight is most significant to keep in mind while assessing weight gain throughout pregnancy. Women underweight have little to no fat reserves to carry them through bouts of nausea or illness. Women with some extra pounds aren't at greater risk for problems as long as they keep a good diet throughout pregnancy.
- Low-maternal weight seems to have more adverse effects upon the fetus than high-maternal weight. (Varneys 599)
- Assuming that her starting weight was normal for her height and frame, an average gain is about a pound per week (could be more or less for over or underweight woman--as rule of thumb, 10lbs by 20 wks and about a pound a week thereafter). Many women are sensitive about their changing figure and should be reminded and reasurred that an ample weight gainis both desirable and essential for the baby's health and their own endurance, particularly during labor and immediate PP.
- Weight gain during preg is caused by increased water retention due to hormones, increased fatty insulation deposited over the belly and backside, increased weight in breasts, increased blood volume, plus obvious weight of enlarged uterus, including amniotic fluid, placenta and fetus.
- Eating disorders such as anorexia put the woman at higher risk for malnutrition and bulimia for hyperemesis gravidarium
- If the woman seems to be gaining weight rapidly, double check her diet and see if she's made any deleterious changes, or is taking in excess sugar (signaling a need for more low-fat protein sources)
- underweight women are at risk for anemia, preeclampsia, premature labor, prolonged labor, PP hemorrhage, poor recovery, and PPD. She must realize the importance of getting enough calories each day, discuss this thoroughly.
(Davis, 21, 67-68)
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
a) sleep difficulties
Can come from multiple causes, mostly involving emotional and mental concerns, anxieties, etc. During pregnancy your growing baby, fetal movements, and even hypoglycemia can also cause discomfort while sleeping.

RECOMMENDATIONS:
-Reduce your activity level before going to bed (after dinner try to avoid anything
stimulating, like exercising, watching TV, getting on the computer etc.)
-Take warm baths, read a book, meditate or pray, and do other calming activities
-Eat a snack and keep one near the bed, drink warm non-stimulating herbal tea (Kava Kava)
-Aconite, Calms Forte (homeopathic remedies)
-Sleep with extra pillows (between knees and
supporting your belly)
-Use progressive relaxation techniques and aromatherapy with essential oils
-Make sure all of the lights are off, this releases sleep-inducing hormones
-Stay away from caffeine and sugars
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
b) nausea/vomiting
EDU/COUNSELLING
Is mostly due to natural hormonal changes of pregnancy and hypoglycemia. Some scientists believe that this occurs from the bodies
immune system defending the vulnerable baby from dangerous toxins.

RECOMMENDATIONS:
- Console the woman--Take solace in knowing that this is a good sign that your baby is growing well and that your
pregnancy will continue successfully! Keep in mind that it will most likely end in the 2nd trimester.--
- Apply ice cold washcloth to eyes when nauseous
- Acupressure on the wrists, between the two tendons (sea bands)
- Drink plenty of fluids-preferably water or juice, if water makes you sick add Emergen-c (no more than 2-3 per day) or other healthy
tastes
- Eat small, frequent,(about 5-6 per day) non-greasy meals with little odor (i.e.: crackers-
preferably whole grain, fresh fruits, especially melons, power shakes (fruit smoothies-green drink if possible), piece of toast or snack just before getting out of bed in morning, just before bed at night, and possibly even in the middle of the night
- Ginger- fresh, ginger-ale, tea, capsules
- Peppermint oil or tea, Chamomile tea
- Extra vitamin E
- Extra rest, reduce stress, cut back on vigorous exercise
- Vitamin B6 (A large banana provides almost an entire milligram of this B vitamin. B6 also helps with mood swings.)
- For a new mother a nap every day is important, your body is doing so much work,
a nap and a walk out in the sun, daily, will allow this growth to happen more naturally and comfortably.
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
c) fatigue
COUNS/EDU
Is common in early and late pregnancy. The reasons for this are not fully known, the heightened levels of progesterone may have a sleep-inducing effect.

RECOMMENDATIONS:
- Try to nap (even multiple times) each day and take it easy in general
- Mild nutrition, good nutrition and ample water help to combat fatigue
- If the fatigue persists or increases you could contact your midwife
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
d) inflammation of the sciatic nerve
COUNS/EDU:
The sciatic nerve runs through the hip joint and can get irritated during pregnancy because the pelvic joints move due to hormones and the growing uterus.

RECOMMENDATIONS:
-Walking, swimming and yoga
-Chiropractic adjustments
-Massage lower back with essential oils (peppermint, wintergreen, etc.)
-St. John's Wort tincture (5-25 drops) has helped some women
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
e) breast tenderness
COUNS/EDU:
This is a normal physiological change that happens in the first trimester of pregnancy as your breasts increase in size they become tender.

RECOMMENDATIONS:
-Where a well fitted and supportive bra (with no under-wire and cotton to breathe)
-Put warm pack on breasts and warm bath
-Vitamin E oil on your nipples (not when breastfeeding)
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
f) skin itchiness
COUNS/EDU:
this can be a result of the stretching skin during pregnancy, this can worsen if the skin is dry. It could possibly come from recent changes in soaps or laundry products.

RECOMMENDATIONS:
-Soothe skin with oils (particularly wheat germ, sesame, almond, and safflower)
-Add more unrefined olive oil to the diet and vitamin A and D rich foods
-Get more sunshine and drink lots of water to flush out toxins
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
g) vaginal yeast infections
COUNS/EDU
- discharge increases as pregnancy advances and due to pregnancy hormones, vaginal yeast is more prone to grow.
- Monilia/Candida (yeast) characterized by a white, curd-like discharge and is common during preg.
Can lead to vaginitis (inflammation and discharge)and can exibit whitish or grayish patches or plaques which adhere to the vaginal wall and may bleed when scraped off

RECOMMENDATION:
-Bathe and shower regularly with non-irritating soap, clean outer vagina often
-Wear cotton underwear (try and avoid tight clothing)
-Avoid bubble baths, bath oils and salts, perfumes, feminine hygiene products
-Use only unscented, non-deodorant panty liners
-Add more probiotics, to your diet (acidolphilus, yogurt, raw milk)
-Sit tailor fashion to allow more air to the vaginal area
-Pelvic exercises to increase circulation
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
h) bacterial vaginosis
COUNS/EDU:
- discharge increases as pregnancy advances and due to pregnancy hormones, vaginal yeast is more prone to grow.
- Gardnerella (BV) causes a fishy odor and thin, gray or white discharge that tends to adhere to the vaginal walls. It can be transient, but has been associated with chorioamnionitis, premature ROM, and preterm labor.

RECOMMENDATIONS:
-Bathe and shower regularly with non-irritating soap, clean outer vagina often
-Wear cotton underwear (try and avoid tight clothing)
-Avoid bubble baths, bath oils and salts, perfumes, feminine hygiene products
-Use only unscented, non-deodorant panty liners
-Add more probiotics, to your diet (acidolphilus, yogurt, raw milk)
-Sit tailor fashion to allow more air to the vaginal area
-Pelvic exercises to increase circulation
-Antibiotic treatment of bacterial vaginosis necessary
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
i) symptoms of anemia
Symptoms of Anemia:
- fatigue
- rapid pulse
- shortness of breath
- headache
- Dizziness
- Pale skin
- Leg cramps
- Insomnia

RECOMMENDATIONS:
- Iron supplementation (Floradix), if it is iron-deficiency anemia
- dark leafy-greens and other iron-rich foods in diet
- adequate rest, fluid intake, nutrition and exercise
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
j) indigestion/heartburn
COUNS/EDU:
Indegestion is when the reflux of gastric acid comes in contact with the esophagus and causes burning in the chest. This occurs in pregnancy from the increased muscle relaxing hormone, which relaxes the cardiac sphincter of the stomach and from the enlarging uterus pushing the stomach upward.

RECOMMENDATIONS:
-Chew and eat slowly and eat frequent small meals
-Sit up and/or walk after meals, maintain good posture and raise arms over you head to make more room for your stomach
-Zypan (Standard Process)
-Apple Cider Vinegar (1TBL in 8-10oz liquid)
-Avoid spicy foods or foods that cause indigestion (greasy, junk foods)
-Avoid drinking with meals as this tends to inhibit gastric juices
-Mineral Goat Whey Powder (Mt. Capra)
-Slippery Elm
-Eat yogurt, honey, raw almonds, and papaya (Papaya Chewables)
-Drink Alfalfa, Chamomile, and Catnip tea
-Tums are bad calcium and not recommended
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
k) constipation
COUNS/EDU:
Constipation can occur in pregnancy due to the muscle relaxing hormones released, which slow the peristaltic actions of the gastrointestinal tract (this enhances absorption, which means that what you eat and drink stays in your system longer and has an intensified effect on your body).

RECOMMENDATIONS:
-Drink more water, eat more fresh fruit, roughage and fiber (hot whole grain cereal)
-Exercise with moderation (walk or swim daily)
-Warm pregnancy tea, prune juice
-Avoid laxatives, never hold back bowel movements
-Stop or decrease taking all vitamin supplements and antacid preparations
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
l) hemorrhoids
COUNS/EDU:
are swollen veins in the lower rectum and anus, they can come from increased pressure from the uterus on the hemorrhoidal veins and lack of circulation or from other issues.

RECOMMENDATIONS:
-Avoiding constipation with plenty of fluids and fiber in the diet
-Avoid straining during a bowel movements (feet on a stool) try to keep BM's regular
-Do pelvic rocks, Kegels (perineal tightening exercises)
-Sitz bath daily, the warm water not only soothes the pain, but also increases circulation (herbs in water: Witch Hazel, White Oak Bark, Chamomile, Epsom Salt)
-Tuck the hemorrhoid back into the rectum with a lubricated finger for instant relief
-Ice bag for reduction or compresses with some of the herbs mentioned above
-Rest, with your hips elevated on a pillow
-If hemorrhoids worsen, referral to a doctor may become necessary
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
m) carpal tunnel syndrome
COUNS/EDU:
The median nerve runs from the forearm to the hand. Weight gain and edema during pregnancy can reduced the narrow passage for this nerve which can cause tingling, pain numbness, and stiffness in the fingers.

RECOMMENDATIONS:
-Skullcap infusion and B6 has shown to relieve this
-Regular exercise helps move fluids around
-Acupuncture can also be helpful
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
n) round ligament pain
COUNS/EDU:
Round ligament pain can occur due to the enlarging uterus, circulatory changes, fetal movement, and muscle relaxing hormones.

RECOMMENDATIONS:
-Pregnancy exercises and moderate stretching can be a preventative measure for this problem (pelvic tilt)
-Bend towards the pain to allow the muscle to relax, breathe slowly and relax
-Support abdomen and knees with a pillow when lying on side
-Apply hot pack to the painful area (take warm bath)
-Avoid sudden changes of position and prolonged standing
-St. John's Wort (tincture or tea)is said to relieve spasms
-If stomach tightens more than 6 times an hour, notify your midwife
-Lemon grass oil and lavender oil
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
o) headache
COUNS/EDU:
Headaches in pregnancy are mostly caused by hypoglycemia and dehydration.

RECOMMENDATIONS:
-Drink a glass of water every 2-3 hours at least and eat small frequent meals
-Put a cool rag on your forehead, use cold and warm packs, take a bath
-Sleep and rest
-Breathe...fresh air if at all possible
-Possibly see a chiropractor or get a massage
-Take Tylenol as directed, if the headaches persists. Do not take aspirin or ibuprofen products (Motrin, Advil, Bayer, Nuprin, and Medipren)
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
p) leg cramps
COUNS/EDU:
Leg cramps can come from a lack of minerals, dehydration, excess lactic acid and a lack of circulation to the legs from the growing uterus.

RECOMMENDATIONS:
-Increase water and mineral intake to prevent cramps (calcium, phosphate, magnesium, potassium, sodium(sea salt), celery, seaweed, and lots of raw veggies)
-Straighten your leg and flex your foot to immediately alleviate cramp
-Sleep or sit with legs slightly elevated
-Exercising daily to improve circulation (pelvic rocks and daily walks)
-Do not stand or sit in one place for too long
-Warm bath or hot packs
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
q) backache
COUNS/EDU:
Leg cramps can come from a lack of minerals, dehydration, excess lactic acid and a lack of circulation to the legs from the growing uterus.

RECOMMENDATIONS:
-Increase water and mineral intake to prevent cramps (calcium, phosphate, magnesium, potassium, sodium(sea salt), celery, seaweed, and lots of raw veggies)
-Straighten your leg and flex your foot to immediately alleviate cramp
-Sleep or sit with legs slightly elevated
-Exercising daily to improve circulation (pelvic rocks and daily walks)
-Do not stand or sit in one place for too long
-Warm bath or hot packs
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
r) varicose veins
COUNS/EDU:
Varicose veins are swollen blood vessels with weakened valves, these are more common in pregnancy due to the expanding blood volume, muscle relaxing hormones, and limited circulation from enlarged uterine pressure.

RECOMMENDATIONS:
-Support hose can be worn from the beginning of pregnancy if veins are visible, they should be put on when legs are elevated, avoid restrictive clothing
-Elevate legs above heart several times a day and rest (put feet up on couch)
-Avoid long periods of standing or sitting with your feet below your waist
-Increase vitamin E and C intake
-Do not cross your legs try and avoid anything that restricts circulation
-Maintain good posture, exercise, do pelvic exercises each day to increase circulation
-Avoid heavy lifting and constipation
-Witch Hazel infusion can be applied to the veins with a rag
-Hot and cold compresses on the veins
-An abdominal support or girdle may be helpful
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
s) sexual changes
COUNS/EDU:
The growing uterus and changing hormones during pregnancy causes different desires and physical changes effecting sexual intimacy.

RECOMMENDATIONS:
- Explain physical and emotional changes trimester by trimester (1st- may be honeymoon-like intimacy and tenderness, fatigue and nausea may interfere. 2nd- mother may focus intently on new moving fetus, generally high levels of estrogen, prog, and oxytocin, plus pelvic circulation serve to boost desire. 3rd- as birth approaches mother may withdraw and focus on impending labor. She needs her partner to be deeply connected to her and baby.)
- suggest various sex positions as pregnancy advances
- other adaptions (such as lubrication) as pregnancy moves forward
(Davis 97-98)
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
t) emotional changes
COUNS/EDU:
The vast majority of emotional upsets in pregnancy result from hormonal changes.

RECOMMENDATIONS:
- Reassure her that her emotions are very connected to the hormones she is experienceing during pregnancy.
- as the midwife we can help the woman see weak or neglected aspects of herself in a positive light, so the woman will feel good about doing some work in these areas.
- referral to counseling may become necessary and possibly a screening out of your primary care.
C. Provides prenatal education, counseling,
and recommendations for:
4. common complaints of pregnancy:
COUNS/EDU:
Edema is caused by normal pregnancy changes, including hormonal changes, increased blood volume and venous pressure, and impaired venous circulation.

RECOMMENDATIONS:
-Change position, walk (try and not stand or sit in one position for too long)
-Elevate legs periodically throughout the day and rest
-Avoid tight or restrictive clothing
-Be conscious of your eating and drinking habits as always (drink lots and eat easily digested proteins)
C. Provides prenatal education, counseling,
and recommendations for:
3 Physical preparation:
a) preparation of the perineum
b) physical activities for labor
preparation (e.g., movement and exercise)
A) PREP of PERINEUM:
- 5 minute session of perineal stretching, starting 6 weeks before the due date has been a factor in preventing tears (Frye 480)
- The purpose is to encourage elasticity and help the mother learn to relax and feel comfortable with the sensations of stretching and burning which occur as the head distends the perineum.

PHYSICAL ACTIVITIES for LABOR PREP:
- daily exercise
- pelvic floor exercises should continue through the last six weeks as well, so that elasticity is encouraged.
D. Recognizes and responds to potential
prenatal complications/variations by
identifying/assessing:
1. antepartum bleeding
a) first trimester
b) second trimester
1ST & 2ND TRIMESTER BLEEDING:
- vaginal bleeding occurs in up to 25% of pregnancies prior to 20 wks of those only one-third of women with painless vag bleeding have symptoms of impending abortion.

POSSIBLE CAUSES of vaginal bleeding:
- miscarriage(info on card I.A.)
- ectopic pregnancy(s/s- pelvic pain, sometimes vaginal bleeding--advanced may show shock and shoulder pain--immediate transport necessary)
- severe cervicitis(inflammation of cervix usually caused by infection(eg. trich, chlamydia, gonorrhea etc.)--inspection of type of infection and treatment of that specific infection)
- cervical lesions(associated with STI's, cause and treatment should be implemented)
- cervical polyps
- postcoidal bleeding(benign)
- implantation bleeding(benign)
- subchorionic bleeding(can be a cause of bleeding without termination of pregnancy)
- demise of fetal twin(may cause bleeding w/out any products of conception)
RARELY: hydatidiform mole or cervical malignancy
D. Recognizes and responds to potential
prenatal complications/variations by
identifying/assessing:
1. antepartum bleeding
c) third trimester
Risks of 3rd trimester bleeding:
- Fetal: mortality and morbidity increased, stillbirth, neonatal death, hypoxia(from premature placental separation), neurologic damage
- Maternal: if severe-- shock, DIC, death or permanent illness.

CAUSES:
- local lesions of genital tract
- placenta previa(transport if excess bleeding is present)
- placental abruption(transport immediately)
-"Unclassified Bleeding": Marginal, show, cervicitis, trauma, vulvovaginal varicosities, genital tumors or infections, hematuria(RBC in urine could be benign, UTI, Kidney stones, or tumor), vasa previa(fetal vessels crossing or coming in close proximity to inner cervical os), other
(Myles 336-345)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
2. identifying pregnancy-induced hypertension
3. assessing, educating and counseling for pregnancy-induced hypertension with:
2. Define/IDENTIFY:
Pregnancy-Induced or Gestational Hypertension is the development of hypertension at or after 20 weeks gestation where the blood rises above 140/90, on at least 2 occasions, no more than one week apart. The BP returns to NML 12 weeks PP with Gestational Hypertension, therefore final determination cannot occur until this time. (with no other signs of preeclampsia. Chronic refers to high BP before 20 wks).
(Myles 398)(Varney's 706)

S/S(above) or at greater risk:
- previous hypertension, gestational or chronic, renal disease or liver-related disease
- Fam Hx of hypertension
- Over-weight
- Nulliparity (this is questionable, according to Dr. Brewer)
- Multiple Gestation
- Advanced maternal age (>40)

Associated With: IUGR, preeclampsia, later development of chronic hypertension, placental abruption, premature delivery, gestational diabetes, multiple gestation, nutritional defficiency(salt, calium, fliuds), liver or kidney disease, hyperthyroidism, hydatidiform mole, CNS disorders (may be slightly elevated from tension, nervousness, or excitement. Always check cuff size)

3. Assessing, Educating, Counseling:
Counseling-- May be first step if you are caring for a woman so tense that she can hardly take responsibility for herself. Helping her get to the roots of her anxiety, release tension, and finding new enjoyment in the pregnancy.

EDU/ASSESS--
a) nutritional/hydration assessment:
Improper eating and abnml weight gain place stress on the system; encourage the woman to eat plenty of high-quality protien, whole-grains, and lots of mineral-rich fresh fruits and vegetables. Salt is a necessary nutrient and should be used to taste with a healthy diet. Increase of fluids is crucial. All stimulants should be cut out of diet completely, such as: coffee, black tea, some carbonated beverages, chocolate, nicotine and cocaine. Strong spices (black pepper, mustard, ginger and nutmeg should also be avoided)

b) administration of calcium/
magnesium supplement: Increase of calcium, magnesium, and potassium intake is also very important

c) stress assessment and management:
Deep relaxation goes hand in hand with exercise. Relaxation practice can help relive tension in the voluntary muscles, which in turn reduces tension in the involuntary system it can also contribute to emotional stability.

d) non-allopathic remedies:
- Herbs: hops, skullcap, passionflower, hawthorn, chamomile (listed in order of potency) can help induce relaxation and lower systolic pressure. Elevated diastolic pressure can be helped with cayenne pepper which helps mimic exercise by causing vasodilation and stimulating the heart.
- Chinese herbs and accupuncture may also be helpful

e) continual monitoring for signs and symptoms
of increased severity (s/s listed above) Family should also be aware of s/s (esp of preeclampsia and elcampsia)

f) increased frequency of maternal assessment:
Increase in frequency of prenatal visits (twice weekly if indicated) to assess symptoms

g) hydrotherapy:
Heat relieves muscles spasms and if voluntary muscles can be relaxed then it may also relax involuntary muscles.
(Myles 500) (Davis 74-75)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
a) pre-eclampsia (Define, Risk Factors, S/S, Associated with, assess and referral)
Define Preeclampsia:
refers to a condition that usually occurs after 20 weeks gestation, resulting from contracted blood volume and liver malfunction. It includes the presence of hypertension and proteinuria, with or without the existence of edema.

Risk Factors:
- Previous hypertension, gestational or chronic
- Previous pregestational diabetes mellitus
- Previous renal disease
- Previous liver-related disease
-Family hx of preeclampsia or eclampsia
- Hx of illicit drug or oral contraceptive use
- Over-weigh
- Nulliparity (this is questionable, according to Dr. Brewer)
- Multiple Gestation
- Advanced maternal age (>40)
- Trophoblastic disease (rare cancer in womb)
- New sexual partner multipara at increased risk
- African-American or Asian ethnicity
- Maternal age <16
- Digestive or eating disorders

S/S:
- 2 consecutive readings taken at least 6 hours apart of >140/90 or an increase of 30 mm Hg systolic or 15 mm Hg diastolic over the client's lowest baseline blood pressure.
- proteinuria(+1 on dipstick)
- edema-pitting of +2 (4mm) or greater
- Frequent headaches, dizziness, feeling faint, black-outs, (indicative of hypoglycemia) or even the more severe headaches and visual disturbances from nerve irritation that comes in a result of hypertension, vasoconstriction, and excessive swelling.
- A plateau in fetal growth, SGA and possibly leading to IUGR (from poor placental function)
- hyperreflexia
- a stedy or rising HGB or HCT
- Nausea, tiredness, insomnia and general malaise/unwell feeling (can develop from liver damage and chronic hypoglycemia)
- liver enzymes elevated (could indicate HELLP)
- Poor appetite
- Poor weight gain, especially in a previously thin/underweight woman

Associated with:
reduced uterine blood-flow, leading to IUGR, premature delivery and fetal distress in labor, there is also a higher risk of (roughly 8%) placental abruption. May lead to severe maternal complications, including eclamptic seizures, intracerebral hemorrhage, pulmonary edema, acute renal failure, DIC, HELLP syndrome. (Davis, pp.77) (Medscape)

ASSESS:
- The back-up physician should be consulted and recommendation/treatment should be discussed with continued collaboration of care as long as the mother stays low-risk according to your state laws.
- First of foremost, the diet should be reviewed and necessary changes made.
- Make sure that she is getting adequate proteins, sea salt intake and nutrient-rich calories for her activity/stress level. (Furthered info can be found in nutrition hand out) A minimum of 80-90 g of protein per day should be adequate.
- Ample amounts of water are also essential (8-10 glasses per day or more if indicated)
- Complex carbohydrates, fresh fruits and veggies, and high-fiber foods are also recommended
- Assess/discuss the possibility of psychological issues that may prevent the mother from eating or feeling good about eating (i.e. emotionally unsure/unstable about pregnancy, hx of eating disorder)
- Assess absorption of nutrients in diet (is there presence of indigestion, allergies, diarrhea, or other digestive issues?)
- Assist the woman in using her resources, (food stamps, WIC etc.) if needed, to get the food she needs
- Modified bedrest is standard of care (increased or decreased according to the severeness of condition and gestational age) NOTE: Exercise and relaxation are strongly recommended by Frye and Davis.
- Increase in frequency of prenatal visits (twice weekly if indicated) to assess symptoms
- Family should be educated of s/s of preeclampsia and report to the midwife if s/s worsen (including but not limited to, severe headaches, epigastric pain, visual disturbances, decreased urine output, extreme nervous irritability, or decreased fetal movement)
- Varney's Midwifery states that the only cure for preeclampsia is delivery of the baby, this is clearly a controversial topic, but valid information.

REFERRAL:
If any of her S/S worsen and go out of the range which you and the back-up physician set-up as apart of her care plan she should be immeditely referred and possibly transported.
(Davis and Frye)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
b) gestational diabetes (Define, Risk Factors, S/S, Associated risks, assess and referral)
DEFINE GD:
Gestational diabetes (GD) occurs when the pregnant woman's body does not process and use sugars correctly. The pregnant woman's pancreas cannot produce enough insulin to compensate for the increased resistance (mainly from HPL) during pregnancy. This usually occurs around the 26th-28th week of pregnancy or so, when 4 of the 5 most potent diabetogenic hormones peak. The pancreas is not able to keep up with the heightened demands of insulin.

RISK FACTORS:
- Previous GD or abnormal blood sugars
- Diabetes in first-degree relatives
- High-risk ethnicity (Women of Hispanic, African, Native American, South or East Asian, Hindu, Pacific Islands, or Indigenous Australian)
- PCOS
- Over-weight, marked obesity, especially in abdominal region
- History or presence of polyhydramnios
- Recurrent Glucosuria
Prior birth of truly macrosomic baby (>4500g)
- Women over age 35
- Previous unexplained stillbirth, anomaly, or >2 previous SAB's

S/S:
- Sudden strong hunger
- Nausea
- Repeated bladder or vaginal infections
- Dizziness
- Feeling shaky
- Feelings of constantly being sick
- Colds
- Fatigue
- Headaches
- Sweating
- Weakness
- Predisposing

ASS. RISKS:
- LGA/macrosomia (prolonged labor and shoulder dystocia)
- RDS in baby hypoglycemia and/or hypocalcaemia
Mother
- preeclampsia,
- polyhydramnios
- PP hemorrhage

ASSESS/EDU:
- 1 hr 50g glucose tolerance test (with option of 50g liquid juice, meal or sugar drink)Furthered diagnostic testing(3 hr GTT) suggested at >130-140mg/dl (considered diagnostic if >200mg/dl) (Davis 73 and Frye)
- Nutritional counseling and specific food planning including adding protein, quantities of complex carbohydrates high in fiber, calories, fruits, vegetables (whole foods) and possibly supplementing into her plan. -- Eliminate refined foods and sugars. See nutrition hand-out for more info.
- Keep a daily food record to review at prenatal visits.
- Get adequate exercise, three times per week at 20 minutes per session is optimal. See exercise hand-out for specifics.
- Monitoring blood sugar levels at home 4x/day, upon waking before breakfast, and 2 hours after each meal. Strive to keep levels below 95 before breakfast and below 120 two hrs after meals.
- Observe urinalysis for persistent glucose and ketones.
- Start recording movement (“kick”) counts at 34-36 weeks, continuing until birth. -- Do fetal auscultated heart graph in office, if indicated.

REFER:
If blood glucose levels do not stay within normal limits after 1-2 weeks of treatment, consult/refer to physician for insulin therapy. Mother will have to be risked out of care at this point.
(Davis, Frye and Varneys)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
c) urinary tract infection (Define, Risk Factors, S/S, Associated risks, assess and referral)
DEFINE UTI:
Due to hydronephrosis that normally occurs during pregnancy, urinary stasis can result, a condition that makes an excellent medium for bacterial growth. Bacteria frequently ascend from the closely placed vagina and rectum and from the kidneys.

RISK FACTORS:
- previous hx (should be screened throughout preg for UTI)
- sickle cell trait
- sickle cell anemia
- diabetes
S/S:
- stinging, urgency, pain after urination, these characteristic signs may be absent during pregnancy due to progesterone's softening effect on urethra.
- findings of blood or nitrites on urine dipstick
- presence of +4 or more bacteria on a urinalysis (obtain culture do determine what type of bacteria)
- when bacteria count on clean catch reaches 100,000 treatment is most often recommended. (Varney 681)
(Davis 17, 21, 38)

ASSOCIATED RISKS:
- low birth wt.
- hypertension
- preeclampsia
- maternal anemia
- pyelonephritis
- premature labor

ASSESS:
- If UTI is present, consult physician and create a care-plan. Treatment is necessary (Uva ursi, cranberry juice, garlic etc.) and reassessment until all s/s of infection have deceased.
(Fyre 1056) (Varney 681-83)

REFERRAL:
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
d) fetus small for gestational age
e) intrauterine growth retardation (Define, Causes, S/S, Associated risks, assess and referral)
Definition SGA:
When baby's birthweight dips below the 10th percentile (population norms) on a standard growth chart, they can grow either symmetrically (length wt. and head circumference values that are proportionate) or asymmetrically (only one or two of the parameters of wt. head circ or length fall within 10th centile).
NOTE: At least half of SGA babies in Britain have no known etiology. They are proportionately small babies, are usually healthy, should be treated accordingly and do not need overzealous labeling which may lead to unwarranted wasteful and potentially harmful interventions.

Definition IUGR:
Failure of NML fetal growth
caused by multiple adverse effects on the fetus. All IUGR babies are at some risk for PP complications. (Frye Vol 2, 597) (Myles 820)

Causes of SGA:
miscalculated dates, fetus transverse or low-lying, hereditary predisposition and IUGR.

Causes of IUGR:
Maternal- Gest Hypertension, preeclamsia, chronic hypertension, diabetes, malnutrition, substance abuse, anemia, renal disease, irradiadtion, prolonged pregnancy, chronic stress and overwork.
Fetal- multiple gestation, chromosomal/genetic abnmlty, intrauterine infection(TORCH etc).
Placenta- abruption, previa, chorioamnionitis, abnl cord insertion, single UC artery.

S/S:
- head circ, length, and wt are either all reduced (symmetric), or some are reduced (Asymmetric) for GA.
- Symmetric growth babies are generally vigorous and less likely to be hypoglycemic or polycythemic, they may suffer from major congenital abnlties.
- Asymmetric growth- abdomen looks sunken in, hypoglycemia is more common, skin is loose, vernix reduced or absent, skin appears pale, dry, coarse and possibly mec stained, they may be hyperactive and hungry with a lusty cry. (Myles 821)

Associated risks:
hypoglycemia, polycythemia, hyperactive, congenital/genetic abnlties, hypothermia

ASSESS/Referral:
- For s/s of growth restriction during pregnancy, FH may be NML to 24 wks then fall behind this average with consistent, but slightly less increments of growth.
- With even minor degrees of IUGR, non-stress testing. AFI assessment (BPP?), and having the mother start charting/doing movement/kick- counts at 34 weeks is recommended.
- An U/S diagnosis of IUGR requires consultation with physician, most situations ca collaborative midwifery management is appropriate. Attempt to determine cause of IUGR and antepartal fetal testing.
- Any undergrowth will benefit from excellent maternal nurtition, reduction in workload and stress. Nutritional assessment and counseling are critical, as is cessation of smoking and any other substance abuse.
- If significant IUGR persists throughout pregnancy despite every attempt to remedy, hospital birth is advisable.
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
f) thrombophlebitis (Define, Risk Factors, S/S, Associated risks, assess and referral)
DEFINE:
The inflammation of either a superficial or a deep leg vein.

Risk Factors:
- varicosities
- genetically susceptible to vein wall relaxation and venous stasis

Superficial S/S and Assess:
- pain, with heat, tenderness and reddness at site of inflammation
- a positive Homan's sign (gently press on straight leg knee with foot dorsi-flexed, pain=positive test result)

Deep S/S and Assess:
- high fever, severe pain, edema and tenderness along entire length of leg

Refer:
With either condition immediate contact of physician is necessary. Meanwhile, have the mother stay in bed and keep the affected leg elevated. And hands off the leg--DO NOT massage.

NOTE: Should a clot lodge in her lungs, the life threatening condition of pulmonary embolism will result. characterized by chest pain, shortness of breath, rapid resps, and elevated pulse.
- If any of these develop, immediately give mom oxygen and call the paramedics.
(Davis 208) (Varneys 1097)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
g) oligohydramnios (Define, Risk Factors, S/S, Associated risks, assess and referral)
Define Oligo.:
An abnmly small amount of amniotic fluid. (NML amount is 800 mL by term--higher just before that up to 1000)

S/S:
- mother may notice a reduction in fetal movements
- upon palpation the uterus is small and compact and fetal parts are easily felt.
- :molding" of uterus around fetus
- fetus is tightly compacted
- FH lags in measurement
- continuity of care enables midwife to notice small fluctions in amniotic fluid volume

Associated Risks:
- IUGR, postmaturity syndrome, congenital anomalies, cord compression, fetal distress/hypoxia during labor, renal agenesis, Potter's syndrome, pulmonary hypoplasia, fetal abnlty, placental-insufficiency, hypoplastic lung disease, compression deformaties, prolonged pregnancy
- make sure it is not preterm pre-labor ROM

ASSESS/Refer:
- If oligohydramnios seems to be presenting itself, aside from advising increased water intake, this is a sign that something is amiss and it must be identified. Contacting back-up physician is important for determining etiology and care-plan and setting up U/S to detect amniotic fluid volume and possible etiology
- Conservative management includes bedrest, hydration, good nutrition, monitoring of fetal well-being (fetal movement counts, NST BPP, doppler fetal aus. graph), regular U/S measurement of AFV, amniofusion, and induction and delivery.
- intrapartum amniofusion (saline lactated Ringer's or 5% glusoce) can reduce cesarean rates and the incidence of variable decelerations during labor and improved neonatal outcome for structurally NML babies.
- If at hospital epidural may be helpful as contractions are often unusually painful with oligo.
- continuous FHR monitoring during labor is desirable
(Varneys 694-95)(Myles353-54) (Davis 78-79)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
4. identifying and consulting,
collaborating or referring for:
h) polyhydramnios (Define, Risk Factors, S/S, Associated risks, assess and referral)
Define Polyhy.:
An excessive amount of amniotic fluid volume. It occurs in fewer than 1% of all pregnancies.

Risk factors:
- Multiple Gestation
- Rh incompatibility
- diabetes
- fetal anomalies

S/S:
- elevation in FH(around 28 wks) with a steady increase in weeks that follow
- difficulty palpating baby
- FHT will bwe difficult to hear
- check for fluid thrill (place a hand on ea side of uterus, and if a tap from one sends a vibration to the other, the test is positive)
- indegestion, heartburn and constipation
- edema, varicosities of vulva and lower limbs

Associated Risks:
- fetal malpresentation
- cord prolapse
- prelabor ROM premature also
- preterm labor
- hospital birth (likely unless condition is borderline)
- unterine dysfunction
- placental abruption
- PP hemorrhage
- overdistension of the uterus
- preeclampsia

ASSESS/Refer:
- the aim of managing this condition is to relieve maternal symptoms and optimize the length of gestation, prolonging it is safe. Adequate rest (feet elevated), heartburn remedies (smaller meals, digestive enzymes etc.)
- the cause and condition should be determined if possible, an U/S in indicated to confirm diagnosis and determine abnlties of fetus or placenta
- when polyhy. is diagnosed, consultation with physician is indicated
- emotional support particularly if fetal anomalies are present
- If you are comanaging a woman with polyhy, check her cervix weekly to look for changes that might portend premature labor
(Davis 77-8) (Varneys 694) (Myles 351-53)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
5. breech presentations:
a) identifying breech presentation (Define, Risk factors, S/S, Associated Risks
Define Breech:
Is an unusual presentation but it should not be considered abnl as the fetus lies longitudinally with the buttocks in the lower pole of the uterus. The pressenting diameter is the bitrochanteric and the denominator the sacrum. This presentation occurs in approx 3% of preg at term.
4 Types of breech:
1. Frank breech--breech presents with the hips flexed and legs extended on abdomen (70% this way)
2. Complete breech-- hips and knees both flexed and feet tucked in beside the buttocks, fetal attitude is one of complete flexion
3. Footling breech--(rare) One or both feet present because neither hips nor knees are fully flexed
4. Knee presentation-- (very rare) One or both hips are extended, with the knees flexed.

Risk Factors/Causes:
- Preterm labor
- Multiple preg
- Polyhydramnios
- Hydrocephaly
- Uterine abnlties
- placenta previa

S/S:
- mother may complain of something hard and uncomfortable under her ribs
- Upon palpation the lie is longitudinal with a soft presentation, the head can usually be felt in the fundus, as a round hard mass, moving independently of the back by balloting with one hand.
- Upon auscultatiion the FHT's will be heard most clearly above the umbilicus
- U/S scan
- vaginal exam-- the breech feels soft and irregular with no sutures palpable (fresh mec from the anus may be visible)

Associated Risks:
- CPD (cephalopelvic disproportion)
- fetal hypoxia
- Cord prolapse
Risks of Spontaneous Breech:
- rapid head decompression causing intracranial hemorrhage
- head getting stuck in a partially dilated cervix
- injuries to internal organs
- impaired placental circulation developing during labor
- baby aspirating before born
- extended arms (breech version of shoulder dystocia)
- Increased fetal morbidity and mortality rate
- risk of cesarean birth/surgical/assisted birth
(Frye 801-17) (Myles587-92) (Davis 80-81)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
5. breech presentations:
b) turning breech presentation with:
(1) alternative positions (tilt board, exercises, etc.)
(2) referral for external version
(3) non-allopathic methods
(moxibustion, homeopathic)
1) Alternative Positions:
- Postural tilting (with tilt board or otherwise tilting hips 12 in. above head) 3 x per day for 20 mins.(Empty bladder 1st) She can also do deep relaxation in this position visualizing her baby turning while asking baby to do so. If she feels a large movement she should come in right away to be checked by midwife.
- doing somersaults or handstands in a pool
- doing elephant walking
- placing headphones low on uterus and playing music(baby may turn toward light)
- shining a flashlight low in the uterus or between her legs (baby may turn toward the light)
- placing a bag of frozen vegetables on the backside of the baby's head (baby may turn away from the cold).
- partner talking to baby low on her belly, asking the baby to turn
- rebozo (mother on knees and elbows, rebozo around her bumb where buttocks and thighs meet, stand at her head and sharply pull rebozo from side to side, 1, 2, 3, 4, 5, pause and repeat for a few minutes, daily)
- referral for external version (or of there is a very experienced midwife and it is within your state laws, one midwife can listen to FHT's continuously as the other attempts a gentle external version. Full disclosure of risks to parents including cord entanglement and placental disruption, either of which may lead to fetal death. Also an anterior placenta make an external more difficult and dangerous. Doing the version around 32 risks might lower some of these risks)
(Frye 806-808) (Davis 81)

C) NON-Allopathic methods
- Moxibustion- Moxa is a roll of tightly compacted mugwort used in traditional chinese medicine and is most effeectively done on a slant board.
(Davis 49)
- Homeopathic: Pulsitilla 30C taken several times/day
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
5. breech presentations:
c) management strategies for
unexpected breech delivery
Assisting Breech Birth (Davis 162)
1. Warm up the room (baby's body will be exposed to air for extended period of time)
2. Have mother in upright position. (Standing, standing squat, or sitting on a birth stool or at the edge of the bed will work well also.
3. The mother must not push until the body is born. (she may bring the baby down before the cervix is dilated enough for the head to emerge)
4. Once baby has birthed to the umbilicus and the legs are out, check for tension on the cord (NOTE: this is NOT up to date, U.C. should not be touched at all if possible, as it begins the vasoconstriction process of the cord vessel), try to handle cord as little as possible.
5. Unless room is very warm, wrap the baby's body in 2 warmed blankets (NOTE: this is also not up to date, again as little touching of the baby as possible is encouraged so as to not cause the baby's reflex of arms to go up inside birth canal or to deflex)
6. If breech is frank or complete and delivery of the body is arrested, nudge the legs to the antero-posterior position. (Extract one leg by splinting it and bringing it across the body, if necessary.)
7. After delivery of shoulders, make sure the baby is OA. If you must rotate the baby, grasp at the hipbones only, as undue pressure on internal organs could cause serious danger.
8. Allow the baby to hang until the naoe of the neck appears (or jaw line, depending on whether you are in front or in back of the mother), then support the body and slowly ease the head out. This promotes flexion and protects the head from being born too quickly, which can cause an abrupt and potentially traumatic change in intercranial pressure.
9. Remember that babies born breech more often need extra suction, stimulation, or blow-by oxygen to help them get started.

NOTE: many of these maneuvers can be modified if the baby is born in water, alleviates the concern about keeping the cord and the body warm to delay breathing until the head is born.
(Davis 162)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
6. multiple gestation:
a) identifying multiple (Define, Risk factors, S/S, Associated Risks)
b) management strategies for
unexpected multiple births
A) Define:
The Development of more than one fetus in utero at the same time. Monozygotic twins aka identical twins, develop from the fusion of one egg and one sperm, which after fertilization splits into two. Dizygotic or fraternal twins represent two eggs, two sperm, thus two pregnancies occuring at the same time. Dizigotic twins have separate placentas and separate amniotic sacs,this type counts for 60-75% of twins.(This type is more safe for home-birth)

Risk Factors:
- previous multiple gestation
- family hx of multiple gestation

S/S:
- FH greater than GA
- abundance of fetal parts upon palpation
- twins are not usually detected with auscultation until 28-32 weeks of two different FHT's. (If you note a 10-15 pt. difference in rhythms with distinct patterns of variablility, you have almostcertainly identical twins.
- confirmed with U/S

Associated Risks:
- Anemia
- polyhydramnios
- cord prolapse
- hypoxia
- placental abruption
- PP hemorrhage
- overdistended uterus
- heightened pressure can cause varicose veins, edema, and backache
- NML pregnancy discomforts can all be heightened from extra enlargened uterus and hormones, amniotic fluid can also double the NML pregnancy.
(Myles 433-39)(Davis 78-79)

B) Management Strategies:
- setting up for a multiple birth requires double of all of your nml supplies, including labeling (a/b or 1/2) of as many umbilical clamps as could possibly needed. Also setting up for and laying out equipment for the possible complications of labor/birth such as resuscitation equipment, PP hemorrhage supplies etc.
- Upon arrival the position of each baby should be noted and a mark made with waterproof markers (1/2) for the position where FHT's are heard for each.
* both babies vertex is most favorable/safe
* when first twin is vertex and 2nd breech fetal outcomes are not better with surgical delivery
* when first twin is not vertex medical opinion favors surgical birth and complications may increase, parents need to be aware of breech complications and informed consent signed would be prudent (possibilty of rare but disastrous locked twin with this situation, this is why many advise transport)
*If first baby is oblique or transverse, transport is safest option
- 1st stage of labor chould progress as a single pregnancy would, there is an increased risk of dysfunctional labor from over-distension of the uterus
- careful assessment of both babies should take place throughout labor, the markers may help to identify FHT's but they will move as labor progresses. It may be helpful for 2 midwives to listen at same time. If fetal comprimise occurs during labor transport is necessary
- the mother should be encouraged to be in the most comfortable position as possible for labor and to use whatever relaxation techniques she finds helpful
- If the 1st baby is breech mother should push as she feels, and the birth should proceed just like a singlton birth
- Upright positions tend to keep the 2nd baby in a longitudinal lie and descending with help of gravity.
- leave a nuchal cord intact at all cost, unless you are sure the babies are in separate bags
- once first baby is born, have the other midwife palpate the 2nd baby to determine position and to help guide it down into the pelvis (if she is behind the mother and the mother leans back into her this is easier to do)
- It is generally considered advisable to clamp the cord immediately after birth of first twin due to risk of twin-to-twin transfusion. (NOTE: TTS can be diagnosed in pregnancy by U/S. S/S of TTS in babies include donor twin as smaller, anemic, dehydrated, and recipient as polycythemic, redness high blood pressure(hydrops). Ass. risks include CNS abnlties, kidney and skin problems and limb defects)
However, studies on this topic along with what we know about placenta-to-newborn transfusion in single births, suggest that leaving the cords intact until they both stop pulsing in the center (or at navel base) ,ay allow such twins to equiliberate there blood volumes. As long as each baby looks nml and both babies are about the same size leaving the cord in place in a nuetral position to placenta (at or just above) to minimize dramatic blood volume shifts.
*However, if TTS is suspected get the first baby into placenta-nuetral position and clamp cords immediately as each is born.
- If all goes NML with the first birth, the baby should be placed skin-to-skin and begin nursing asap to help instigate UC's for subsequent birth.
- Close FHR monitoring of baby still in utero after first birth
- One cord (or labelled cord) can be placed on 1st twin at time of cutting and 2 on the second twin (or 2nd labelled clamp)
NOTE: One advantage of immediate cord clamping is that it keeps the placenta engorged with fetal blood, so it will go through little or no reduction in size. However, this is not reason enough to deprive first twin of her placental transfusion or to risk imbalanced blood supply to either baby.
- Talk to babies as the first one comes out, let it know that their sibling is still on its way and that they are doing well. Comfort it and help parents to do same.
- Bleeding between babies may occur, if you are unsure of origin of bledding AND it continues without stop--more than 1/2 cup--(and second birth is not imminent), if maternal vessel has been torn and will not stop bleeding, or if (rare) edge of low-lying placenta slipped over the internal os creating a placenta previa for second baby, then an immedite transport to the hospital is necessary, with careful and continuous monitoring of FHT.
- If the 1st babies card breaks you must clamp the babies cord stump at umbilicus and find the other end of the cord (usually up in vagina) and clamp it to prevent 2nd twin from hemorrhaging.
- The birth of the placenta should not be encouraged until both babies are out. If first placenta comes out, it can cause some complications and second birth should proceed promptly
- If abruption of 2nd baby's placenta occurs, this puts the 2nd baby in grave danger. Check FHR, if baby is already in distress, get her out as fast as possible. A version and extraction is easier with second twin. Don a sterile glove, reach up inside, rupture the membranes, determine position (do internal version is baby is oblique or transerse), extract if baby is breech and have mother push and do fundal pressure if baby is vertex. If the baby is high and there are no UC's, bleeding is light and you are near a hospital, transport.
- Once the 2nd baby's position is determined, if it is transverse or oblique lie, an external version is recommended and if the baby will not rotate, transport is necessary. A longitudinal lie is essential for birth of 2nd twin.
- Continue assessing FHR, transport if it is low or questionable, while giving oxygen to mother
- Time resting phase between babies is a topic of great controversy. This is commonly rushed in medical model for fear of risk of placental abruption, hypoxia and death. These risks are primarily associated with early placental separation, cord prolapse, nonvertex presentation and ill-advised maneuvers performed by nervous practitioner. Studies show that there can be a space from a few minutes to as long as 44 days between babies with an average of 30-40 mins. Midwives average have observed to be about an hour to an hour and a half. Time between babies is not critical as long as FHR is nml, there is no bleeding, and mother is doing well. Greatest risk being intrauterine infection with lengthy time between babies.
- Widely recommended to AROM second baby, however, keeping membranes reduces risk of cord prolapse and degree of abrupt uterine size reduction, minimizing chance that placenta from 1st baby will detach.
- How long labor takes after resumption of labor begins depends on cervix, how much it has closed. usually redilation doesn't take long.
- Birth of subsequent should be managed the same as a single birth, it will most likely be increasingly efficient.
- Birth of the placentas is most cases comes after both of the babies have been born. Birth of placenta in multiple birth may take longer, because uterus is lager and must gather itself to trigger separation and release of entire placental mass, making for a long resting phase after birth.
- The tremendous psychic and physical sheft after birth puts the mother at greater risk for blood volume comprimise, if not true shock. Expect more bleeding than usual, with larger placental site and increased blood volume for 2 babies. Have uterine-stimulating herbs and pharmaceuticals on hand and any other emergency equioment for hemorrhage and shock on-hand. Keep a close eye on the mother after birth. Have enough midwives and skilled attendants at birth to handle each of the babies and mother and possible complications that may occur with each of them.

COMPLICATIONS of multiple gestation include:
- Obstruction of descent due to fetal positioning (Collision, impaction, compaction, and interlocking)
- Monoamniotic gestation (occurs 1 in every 100 monozygotic twins, cord entaglement or pertially or total unseparation of cords may occur, anastomoses leading to possible DIC, greater incedence of interlocking)
- Extremely delayedinterdelivery periods (linked to preterm delivery or very rare superfetation--two babies conceived at different times, infection is a problem and placenta problems)
- Fetal defects and anomalies
- death of one baby
- PP observance of a single surviving twin
(Frye Vol.2, 976-89)(Myles, 440-45)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
7. occiput posterior position:
a) identification
b) prevention
c) techniques to encourage rotation
A) IDENTIFY: Posterior (when the occipital bone of fetus is in the posterior region of the pelvis) babies are more challenging to palpate; there are lots of small parts and little more than an edge of the back, but you may find a shoulder just above the pubic bone that will tell you more conclusively which side the baby is on.
- mother may comment she is feeling a lot of movement in the front, all hands and feet
- mother may complain of urinary frequency (babies forehead on bladder)
- FHT's may be difficult to hear or be faint

B) PREVENT:
- doing pelvic rocks (10 mins, 6-8 times daily as technique if posterior baby has already been detected) mother rock/crawling on feet, exeggerated cleaning the floor movements
- regular exercise gets joints of pelvis moving nd encourages anterior rotation
- avoid sitting in scrunched up psotions with knees higher than hips. Upright, forward leaning postures, with hips higher than knees are recommended

C) TECHNIQUES TO ENCOURAGE ROTATION:
- Baby's back may be on side mother always sleeps on, encourage her to switch positions at night
- have mother straddle a padded chair and facing it, lean forward and pusch her bottom to the edge of the seat and to relax in this postion 4-6 times daily for 20 mins
- lie on slant board several times daily 15-30 mins
- Have mother wrap warm wool shawl around her esp in winter
- visualize beby turning and talk to baby encouraging this
- chiropractic adjustment can help align subtle pelvic misalignments could be a contributing factor
- homeopathic pulsatilla 30C or 200C
(Davis 30)(Frye 19-20)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
8. vaginal birth after cesarean (VBAC):
a) identifying VBACs by history and physical
b)indications/ contraindications for out-of-hospital births
A) identifying VBACs by history: ask woman to bring her previous medical records, have her ask for complete chart, not just a summary. Overview the reasons for the surgery, the type of incision (lower uterine segment/horizontal is safest) made and any attendant complications. Was there any infection following birth? How was nutrition after the surgery?

Physical: How does the scar look? Is it tender? The scar on the abdominal skin does not determine the scar on the uterus.

B) INDICATIONS:
- To gain empowerment, healing, and confidence that she can fulfill her desires of giving birth naturally
- emotional healing from previous birth
- a wonderful and spiritual experience to bring her family, including the newborn baby, together in a strong and powerful way, by taking initiative, being informed and prepared for whatever outcome may come
- A healthy mother, who is aware of good nutrition and practices it before and throughout pregnancy (nutrition and eliminating any harmful substances/habits)
- reasons such as failure to progress, no urge to push, cord prolapse, placenta previa, placental abruption, breech, posterior presentation, CPD, and twins are not necessarily repeating complications (some weren't even complications in the first place like posterior or breech) and are NOT necessarily contraindicated for VBAC.
- a low uterine segment incision
- established that the presenting part can flex addquately to pass through the pelvis
- progress of labor is sufficient, observed ny descent and dilation
- neither multiple gestation nor breech appear to increase the risk of scar separation

CONTRAINDICATIONS for
out-of-hospital births:
- anything other than a lower uterine segment incision from previous c-section (some scars pose more risk than others however the highest of any of these risks is only 5%). Women with upreight T, J-shaped, or classical incisions, or those who have experienced a previous rupture should have a hospital birth
- Studies indicate that multiple surgical births does not increase the risk of rupture, it does however, increase the risk of placental problems
- uterine scarring that makes it unsafe for the woman to carry to term for great risk of uterine rupture
- if the reasoning for previous c-section was for a physical deformity
- reasons such as failure to progress, no urge to push, cord prolapse, placenta previa, placental abruption, breech, posterior presentation, CPD, and twins are not necessarily repeating complications (some weren't even complications in the first place like posterior or breech) and are NOT necessarily contraindicated for VBAC.

NOTE: Henco Goer found the rupture rate to be .3%, the possibility for other unforseen events necissitating transport such as intrapartum hemorrhage, fetal distress, or cord prolapse is about 7.2%, roughly 10 times the rate of rupture during labor. This must be taken into into context with overall risks inherent in birth. Compared to the great multiple risks inherent in C-section, VBAC seems a very sane choice.
(Frye 915-26)(Myles 617-18)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
8. vaginal birth after cesarean (VBAC):
c) management strategies for VBAC
d) recognizes signs, symptoms of uterine rupture and knows emergency treatment
MANAGEMENT STRATEGIES for VBAC:
- Veterans of cesarean birth may benefit from mind-body therapies to regain a sense of confindencein themselves and their body for a VBAC.
- Listen to the woman's previous birth experience intently. This gives you an opportunity to see her psychological and emotional patterns in high relief and hopefully she can become more conscious of them as a result. Support women to view their birth as a growing experience.
- Note that just making an effort to seek out a care provider that will encourage them to belive in themselves is for many women a major breakthrough.
- Suggest prenatally that the woman do daily affirmations (of her own or help her form them/give her some to start, pg 919 of Frye has good ones) and visualizations of vaginal birth done on a daily basis with specific emphasis on seeing themselves moving past the point where they had surgery before, will help them contradict their negative belief patterns.
- Good nutrition as well as avoiding harmful substances/habits can help the woman to not only feel empowered, but to increase her chances greatly of having a VBAC this time around, by decreasing other possible complications with good nutrition.
- Locating the placenta (with auscultating or U/S--U/S may be comforting to mother?) to make sure it is in a higher position will reduce risk of placenta previa. (Increases risk when it is low-lying)
- Often the most difficult point in labor is getting past the point when she previously had surgery. The biggest contribution the midwife can offer to the VBAC is her belief in labor, her faith that the woman has the strength to birth naturally, and her patience.
- working with these women on issues of fear and pain, of birth and of losing control is important.
- during labor watch for s/s of uterine rupture and other possible complications/risks of VBAC (ie. placental issues) and transport at first sign.

D)S/S of UTERINE RUPTURE:
- abdominal pain in lower abdomen(over previous scar site)
- abnlties of FHR
- vaginal bleeding (might not be seen until later)
- maternal tachy
- maternal drop in BP
- maternal rapid RR
- poor labor progress
(Myles 635)(Frye Vol 2, 1135-39)

NOTE: differential diagnosis may include: abruption, previa, amniotic fluid embolism(no bleeding), hematoma of broad ligament, abdominal pregnancy.
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
9. identifying (Define, Risk factors, S/S, Associated Risks)and dealing with pre-term labor with:
a) referral
b) consults for preterm labor
DEFINE Preterm:
- Defined as labor (UC's causing cervical change &/or ruptured membranes) starting before term gestation (20-37wks).

RISK FACTORS:
- Previous preterm labor or birth (20-40% chance with one previous preterm, risk increases with each preterm birth)
- Multiple Gestation (10% of all preterm births)
- Low socioeconomic status
- Non-white race
- Poor nutrition (low weight gain)
- One or more second trimester miscarriages, multiple abortions
- Short interval between pregnancies, 3-9 mo's
- Substance abuse/addiction (alcohol, nicotine, street drugs, especially cocaine)
- Inadequate prenatal care
- Uterine anomalies
- Incompetent cervix, previous cervical surgeries
- DES exposure in utero
- UTI
- Genital tract infections: GBS, Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella, Gonorrhea, Chlamydia, Trichomonas
- Premature rupture of membranes
- Chorioamnionitis, polyhydramnios
- Physical injury, trauma or severe physical violence during pregnancy
- Placenta abruption or previa
- Fetal death
- Stress, high blood-pressure, diabetes

S/S:
- Painful Cramps in abdominal/UC's in rhythmic pattern
- Intensified dull low backache
- Suprapubic and/or pelvic pressure or pain
- Loose bowels or diarrhea
- Vaginal bleeding or spotting
- Change in vaginal discharge (thinner, thicker, bloody, brown, colorless, watery)
- Premature rupture of membranes

ASS. RISKS:
- RDS
- Vag infections
- Chorioamniotnitis
- incompetent cervix
- uterine distortion/fibroids,
- cervical inflammation (infections, bacteria etc),
- hormonal changes,
- maternal inflammation (UTI),
- uteroplacental insufficiency (hypertension, diabetes, substance abuse).

CONSULT/REFER:
- If preterm labor is suspected, moniter mother carefully from 24 weeks gest on, schedule visits every 2 weeks and getly check the cervix at each visit. Contact physician to determine care plan.
- If cervix begins to dilate, immediately contact physician
(Davis 82-3)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
c) treats for preterm labor:
- Contact back-up physician if s/s of preterm labor are present
(1) increase of fluids, drink herbal teas and try to eliminate any stress
(2) non-allopathic remedies
(3) discussion of the mother’s fears-emotional support, the psychological consideration of the mother and father is of utmost importance as this is an extremely disturbing condition for parents.
(4) consumption of an alcoholic beverage- if the mother has no hx of alcoholism, then suggesting a few stiff drinks when UC's are mild and cervix is only minimally changed can help. Alcohol inhibits oxytocin and relaxes the uteus, before tocolytic drugs were developed, alcohol was given IV for premature labor.
(5) evaluation of urinary tract
infection- screen (for any vaginal infection) at the first sign of infection and treat
(6) evaluation of other maternal infection- again screen and treat at the first sign of infection
(7) bed rest in the side-lying or lateral position for women with s/s of preterm labor, without such, but with predisposing and possibility of preterm labor, ease on work-load, more rest and arrange for someone to help with children and household work is recommended.
(8) pelvic rest, exercises(including no sexual intercourse) If her cervix begins to efface all sexual activity needs to be curtailed and before this time condoms should be used to protect from STD's and prostiglandin's in semen
(9) no breast stimulation (including nursing)

NOTE: do all you can to prevent preterm labor but learn all you can about support orginazations in your area for parents with premies. Know that apart from woerries of the baby, the mother may also grieve the loss of her homebirth and may need to process that with you.
(Davis 82-83)(Varyneys 858-60)(Myles 355)
10. assessing and evaluating a post-date pregnancy by monitoring/assessing:
a) fetal movement, growth, and heart tone variability (done routinely at prenatal a fetal auscultated graph can be a very helpful tool in assessing fetal well-being)
b) estimated due date calculation (check with U/S if necessary)
c) previous birth patterns
d) amniotic fluid volume (by palpation and BPP)
e) maternal tracking of fetal movement
f) consultation or referral for(at 40-42 weeks+):
(1) ultrasound
(2) non-stress test
(3) biophysical profile
11. treating a post-date pregnancy by stimulating the onset of labor
a) sexual/nipple stimulation
b) assessment of emotional blockage and/or fears(ask mother if she feels ready to give birth and these problems will generally come out and can then be discussed)
c) stripping membranes
d) cervical massage
e) castor oil induction
f) non-allopathic therapies (cramp bark, black and blue cohosh, evening primrose oil, homeopathic cimicifuga or caulophylum)
g) physical activity
h) repositioning a posterior baby( Upon vaginal exam you should feel the anterior fontanelle near the pubic bone. 1. slightly disengage--dislodge ant. font. from the plane in the pelvis where it is lodged, by spreading your fingers to either side of the sagittal suture and push upward on the parietal bones--flexion and rotation may occur with this alone. 2. Exert steady even pressure on the bony edge of ant. font. and rotate it to transverse position. 3. Now flex the head by pushing the font. toward the side of the vaginal wall, quickly reach for the posterior fontanelle, secure an edge and complete the rotation to anterior. (an assistant can help externally by grasping the baby's shoulder and backside and pushing it to the anterior position. The mother can slowly roll over in the direction you are turning the baby at the same time--immediately check FHT's)
i) refer for chiropractic adjustment
j) refer for acupuncture
(Davis, 49, 151)
12. identifying and referring for:
a) tubal pregnancy(s/s ass.risks of each)
b) molar pregnancy
c) ectopic pregnancy
All of the following can cause vaginal bleeding, but don't always cause vaginal bleeding.

A) Tubal preg. S/S: pelvic pain(consistent and more intesne than cramping), spot bleeding-sometimes brown, If rupture occurs pain is severe and sharp with shoulder pain, syncope and shock (far beyond expectation for her blood loss)

Ass. Risks: PID(main cause), scar tissue, STD's, infection following abortion, IUD's,

B) Molar (extremely rare 1 per 1,500-2,000, abnl growth of chorionic villi which form membranes and placenta--no fetus with complete mole, partial contains fetal tissues-- clear, grape-like vesicles. Caused by abnml sperm inactivating chrom's of ovum) S/S: light brown bleeding (persisting weeks or months--rarely past 1st trimester), uterus large for dates and is woody hard or doughy to the touch, abnmly high hCG levels--possibly leading to hypertension and proteinuria.

NOTE: the mole almost always aborts on itslef only occasionally surgically removed.

C) Ectopic (occurs 1 in 100 pregs, when implantation outside of the uterus, tubes, cervix, abdominal etc., 95% are tubal) S/S: similar to tubal pregnancy with localized pain where implantation occured

Ass risks: (also similar to tubal preg) sterilization, PID, sub-fertility

Refer: If a mother calls with these s/s immediately have her call ambulance and notify her physician
Always attend to the mothers emotional recovery after any of these events.
12. identifying and referring for:
d) placental abruption(define, causes, s/s, ass risks, refer)
DEFINE: premature separation of the placenta. 3 types of separation.
1. Marginal (edge only) causing vag bleeding
2. Concealed (central separation w/margins still attached) bleeding concealed
3. Complete (total sep.)

CAUSES:
- preeclampsia, direct trauma to abdomen(car accident, deliberate abuse), polyhydramnions, cocaine/cigarette smoking, uterine infection, umbilical cord or uterus problems (tangled cord or over-worked uterus?? ie. prolonged transition)

S/S:
- bright red vag bleeding (not with concealed)
- acute pain
- tachy pulse
- low BP
- uterus is woody hard and tender to touch

Ass. Risks/Causes: hypertension, cord entanglement, physical trauma, IUGR, preterm birth, high pariety, previous c-section, cigarette smoking, cocaine, multiple gestation

Refer: Immediately transport to hospital while simultaneously treating for shock (feet elevated, head down, admin O2, warm body with blankets)
(Davis 70-72)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
12. identifying and referring for:
e) placenta previa (define, s/s, ass risks, refer)
DEFINE:
When the placenta is implanted partially or wholly in the lower uterine segment (1 in 250 with primip, 1 in 90 multigrav).
There are 4 types:
1. total previa (placenta completely cover os)
2. partial (os is partially covered)
3. marginal (os marginally covered)
4. low-lying placenta (placenta close to the placenta but does not actually reach it)

Risk Factors: previous uterine surgeries, endometritis, multiparity, short intervals between pregnancies, maternal age >35

S/S:
- repeated episodes of light bleeding or heavy spotting, with NO report of abdominal pain (severe hemorrhage occurs most frequently after 34th week)
- upon palpation of abdomen the lie of fetus may be oblique or transverse, fetal head my be high/above pelvis, uterine consistency is NML and no pain is felt by mother during palpation
- low or cessation of fetal movement may occur with severe fetal hypoxia (some midwives say that excessive fetal movement is an indicator of fetal hypoxia)
- with slight hemorrhage vitals may not change, with sever there will by low BP, rapid pulse and RR, mothers color may be pale and skin cold and most. Syncope may occur with severe bleeding.

ASS. Risks:
- Maternal shock
- anesthetic or surgical complications
- placenta accreta (15% of previa have this)
- air embolism, an occasional occurrence when sinuses in placental bed are broken
- PP hemorrhage (also 3rd stage hemorrage)
- maternal death (very rare in developed world)
- fetal hypoxia and its sequele due to placental separation
- fetal death depending on gestation and amount of blood loss

NOTE: NEVER do a vaginal exam when there is bleeding in late preg (with previa it could cause torrential hemorrhage)

REFER:
-total and partial previa require c-section delivery
- marginal may have a TOL, and depending on maternal blood-loss may also necessitate a cesarean
- Low-lying, vaginal delivery is more likey, maternal blood loss must be carefully monitored, this also heightens the risk for PP 3rd stage hemorrhage. Transport is necessary when s/s occur and condition does not improve.
(Davis 72) (Myles 337-41)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
13. identifying premature rupture of membranes
(define, s/s, ass risks)
DEFINE: ROM prior to labor(36-37weeks gest). Incedence of PROM (premature rup of mem.) at term is 8-10% and most women will labor spontaneously within 24 hrs with this condition.

(Preterm PROM is when ROM occurs before 37 weeks without the onset of spontaneous UC's and that results in cervical dilation. It occurs in 2% of pregnancies and is associated with increased complications such as preterm laborm, placental abruption, cervical incompetence, vag colinization with potentially pathogenic micro-organisms(GBS?), chorioamnionitis, oligo., psychosocial problems(relating to fetal-wellbeing), cord prolapse, malpresentation, primary antepartum hemorrhage.)

S/S:
- leaking fluid-- either a large gush with continued leaking or it may only be small continuous discharge (clear, cloudy, yellow, or green) and a feeling of moistness in panties (with no UC's or cervical dilation)
- inability to control leakage with kegels (differentiate from urinary incontinence)
- ask when last sexual intercourse occured to rule out semen being expelled from amniotic fluid
- upon abdominal palpation check for amniotic fluid volume, molding of ab. wall around fetus, and decreased balootability, these all indicate frank rupture, but will not be seen in leaking fluid.
- Upon speculum exam, look for signs of fluid around genitalia, visualize cervix for flow of fluid from os and pooling of fluid on vaginal vault. If no fluid is seen have the woman bear down and gently life the presenting part externally and observe for any leaking fluid from a high leak. Observe fluid for any lanugo or vernix, observe cervix for dilation, prolapsed cord or any fetal extremeties/parts.
- Positive ferning test with microscope (caused by sodium chloride and protein in amniotic fluid)
- Positive nitrazine paper test: this mustard-gold pH-sensitive paper will turn dark blue in the presence of alkaline amniotic fluid (cervical mucus, blood, urine, semen, glove powder and vag discharge from a vag infection (eg. trich), can also cause alkaline pH. For this reason fern test is more accurate)
- U/S checking for oligo. may be helpful if other techniques are not showing a clear picture

ASS. Risks:
- intruterine infection (Chorioamnionitis)
- fetal malpresentation
- multiple gestation
- veg/cervical infection(BV, Trich, STDs, GBS)
- umbilical cord compression
- prolapsed cord
- oligohydrmanios
(Varneys 863-63) (Myles 354-55, 480)
14. managing premature rupture of membranes in a FULL-TERM pregnancy:
If the woman is not in labor and wishes to stay home until spontaneous labor occurs this is appropriate if:
- she has no compounding medical or obstetrical risk factors including malpresentation, or unengaged cephalic presentation
- she must understand how to take and read her temperature and pulse every 4 hrs (including at night)
- understand and be able to implement restrictions regarding pelvic rest (no sexual intercourse, no douches, no vaginal therapeutics)
- have immediate telephone and access to transportation
- someone to support her, do cleaning and run errands
- have her evaluate for uterine tenderness daily
- fetal movement should be charted and BPP with NON-stress test according to protocol (

a) monitor fetal heart tones and movement
b) minimize internal vaginal
examinations
c) reinforce appropriate hygiene techniques
d) continual monitoring of vital signs for signs of infection
e) encourage increased fluid intake
f) support nutritional/non-allopathic treatment: magnesium supplement throughout pregnancy, deep soaking in tub, homeopathic Mag Phos 30C
g) stimulate labor (cramp bark, black and blue cohosh, evening primrose oil, homeopathic cimicifuga or caulophylum)
h) consult for prolonged rupture of membranes and discuss care-plan
i) review Group B Strep status and inform of options.
If positive she has the option of trying to treat it prenatally (naturally with garlic or other suppositories, vaginal microbial creams, hibiclense wash etc.) or intrapartal treatment with IV antibiotics.
(Davis 49)(Varneys 865-67)
D. Recognizes and responds to potential prenatal complications/variations by
identifying/assessing:
15. consult and refer for premature rupture of membranes in PRE-TERM pregnancy
16. establishes and follows emergency contingency plans for mother/baby
- If regular contractions begin to occur or the cervix begins to dilate (or preterm PROM occurs) before term(37 wks), physician must be immediately be contacting and care plan made, most likely transport to the hospital

EMERGENCY CARE PLAN:
- tranpsort to the hospital, if this is not possible, emergency care plan considerations are as follows:
- Kangaroo care (skin-to-skin) is critical when far from hospital
- FHT's should be monitored more frquently as the preterm fetus is less tolerant of stress during labor
- abnml presentation and cord prolapse are risks for the smaller fetus and should be kept in mind
- left-lateral or waterbirth are good position options for birth
- more babies will present breech and risks to preterm baby that presents breech are increased
- leave cord intact
- do not use postural drainage (could cause bleeding in brain)
- if NRP is nec, be careful and gentle to not get carried away with PPV as their lungs are smaller and more fragile
- keep baby warm
- encourage nursing
- vigilant PP care esp for s/s of RDS in first 12-24 hrs and infection (temp done at least 3 times daily for first 7 days)
- educate and arrange for PP support tothe extent possible depending on your equipment and human resources
(Frye VOl 2, 990-93)