Part 2 book “Midwifery & women’s health nurse practitioner certification review guide” has contents: Prenatal care and fetal assessment, intrapartum and postpartum, midwifery care of the newborn, professional issues, common health problems in primary care.
7 Prenatal Care and Fetal Assessment Jamille Nagtalon-Ramos Human Reproduction and Fertilization • Process of gametogenesis Definition—development of gametes; oogenesis or spermatogenesis Essential concepts a Oogenesis—developmental process by which the mature human ovum is formed; haploid number of chromosomes b Spermatogenesis—formation of mature functional spermatozoa; haploid number of chromosomes c Meiosis—a process of two successive cell divisions, producing cells, egg, or sperm, that contain half the number of chromosomes found in somatic cells d Mitosis—type of cell division of somatic cells in which each daughter cell contains the same number of chromosomes as the parent cell e Haploid number of chromosomes 23—possessing half the diploid or normal number of chromosomes, that is, 46, as found in somatic or body cells • Process of fertilization Definition—union of ovum and spermatozoan; usually occurs in fallopian tube within minutes or no more than a few hours of ovulation; most pregnancies occur when intercourse occurs within two days of ovulation Stages of development a Zygote—a diploid cell with 46 chromosomes that results from the fertilization of the ovum by a spermatozoan b Blastomeres—mitotic division of the zygote (cleavage) yields daughter cells called blastomeres c Morula—the solid ball of cells formed by 16 or so blastomeres; mulberry-like ball of cells that enters the uterine cavity three days after fertilization d Blastocyst—after the morula reaches the uterus, a fluid accumulates between blastomeres, converting the morula to a blastocyst; inner cell mass at one pole to become embryo; outer cell mass will be trophoblast e Embryo—stage in prenatal development between the fertilized ovum and the fetus (i.e., between second and eighth weeks inclusive) f Fetus—the developing conceptus after the embryonic stage g Conceptus—all tissue products of conception: embryo (fetus), fetal membranes, and placenta • Physiology of implantation of the blastocyst Definition—blastocyst adheres to the endometrial epithelium by gently eroding between the epithelial cells of the surface endometrium; invading trophoblasts burrow into the endometrium; the blastocyst becomes encased and covered over by the endometrium Implantation occurs six to seven days after fertilization and usually in the upper, posterior wall of the uterus Provides physiologic exchange between the maternal and embryonic environment prior to full placental function Development of the Placenta, Membranes, and Amniotic Fluid • Essential concepts Chorion—an extra-embryonic membrane that, in early development, forms the outer wall of the blastocyst; from it develops the chorionic villi, which establish an intimate connection with the endometrium, thus giving rise to the placenta Chorion frondosum—the outer surface of the chorion whose villi contact the decidua basalis; the placental portion of the chorion Chorion laeve—the smooth, nonvillous portion of the chorion Syncytiotrophoblast—outer layer of cells covering the chorionic villi of the placenta that are in contact with the maternal blood or decidua Cytotrophoblast—thin inner layer of the trophoblast composed of cuboidal cells Decidua capsularias—the part of the decidua that surrounds the chorionic sac 131 132 CHAPTER Prenatal Care and Fetal Assessment Decidua basalis—the part of the uterine decidua that unites with the chorion to form the placenta Decidua parientalis (vera)—the endometrium during pregnancy, except at the site of the implanted blastocyst Amnion—the innermost fetal membrane; a thin, transparent sac that holds the fetus suspended in the liquor amnii, or amniotic fluid; it grows rapidly at the expense of the extraembyrionic coelom and, by the end of the third month it fuses with the chorion, forming the amniochorionic sac, commonly called the bag of waters • Placenta—serves as fetal lungs, liver, and kidneys until birth, while growing and maintaining the conceptus in a balanced, healthy environment Anatomy a Trophoblasts b Chorionic villi c Intervillous spaces d Chorion e Amnion f Decidual plate Steroid and protein hormones—human trophoblasts produce more diverse steroid and protein hormones and in greater amounts than any endocrine tissue in all of mammalian physiology a Steroid hormones (1) Estradiol-17B—responsible for the growth of the uterus, fallopian tubes, vagina, and breast development (2) Estriol—an estrogen metabolite excreted by the placenta during pregnancy that is found in the urine of pregnant women (3) Progesterone—secreted by the corpus luteum; essential in preparing the uterus for implantation of the fertilized ovum and maintaining the pregnancy (4) Aldosterone—responsible for regulation of the body’s salt and water balance (5) Cortisol—plays a role in the metabolism of fats, glucose, and proteins b Protein and peptide hormones (1) Placental lactogen (hPL/HPL)—placental hormone that inhibits maternal insulin activity during pregnancy; decreases to undetectable levels soon after delivery of the placenta (2) Chorionic gonadotropin (hCG)—hormone secreted by the placenta to help maintain corpus luteum function and production of progesterone; levels found in serum and urine assays of pregnant women as early as a week after conception (3) Placental adrenocorticotropin hormone (ACTH)—the role of this hormone is related to the regulation of the secretion of glucocorticoids (4) Pro-opiomelanocortin—a precursor polypeptide (5) Chorionic thyrotropin—a type of hormone similar to thyroid-stimulating hormone (TSH) that has the ability to increase metabolism (6) Growth hormone variant—hormone plays a vital role in growth control (7) Parathyroid hormone-related protein (PTH-rP)—essential bone differentiation and formation and development of mammary gland (8) Calcitonin—hormone responsible for calcium balance (9) Relaxin—produced in placenta and corpus luteum and believed to help with relaxing the uterine myometrium during pregnancy c Hypothalamic-like releasing and inhibiting hormones (1) Thyrotropin-releasing hormone (TRH)—responsible for the regulation of TSH (2) Gonadotropin-releasing hormone (GnRH)—essential in controlling the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) (3) Corticotropin-releasing hormone (CRH)—works with vasopressin hormone to regulate the release of ACTH (4) Somatostatin—responsible for inhibiting the release of growth hormone, prolactin, and thyrotropin d Regulation of blood flow in the placenta; maternal blood traverses the placenta randomly without preformed channels and enters the intervillous spaces in spurts propelled by the maternal arterial pressure e The placental “barrier”—the placenta does not maintain absolute integrity between maternal and fetal circulations as indicated by the presence of fetal blood cells in maternal circulation and the development of erythroblastosis fetalis f Oxygen and glucose are transported across the placenta via facilitated diffusion • Umbilical cord Anatomy a Vessels—two arteries that carry fetal deoxygenated blood to the placenta, smaller in diameter than the vein; and one vein carrying oxygenated blood from the placenta to the fetus characterized by twisting or spiraling to minimize snarling b Measurements—0.8–2 cm in diameter; average length of 55 cm with range of 30–100 cm c Wharton’s jelly—extracellular matrix consisting of specialized connective tissue that serves as protection for the umbilical cord Abnormalities of length—positively influenced by amniotic fluid volume (AFV) and fetal mobility a Extremely short cord—associated with abruptio placentae or uterine inversion; the latter is rare b Abnormally long cord—associated with vascular occlusion by thrombi and true knots • Amniotic fluid Production—produced by amniotic epithelium; water transfers across amnion and through fetal skin; in second trimester fetus starts to swallow, urinate, and inspire amniotic fluid Volume maintenance—fetal swallowing seems to be a critical mechanism affecting fluid volume because polyhydramnios is consistently present when fetal swallowing is inhibited, but other factors, such as tracheoesophageal atresia, contribute to volume balance Polyhydramnios (also termed hydramnios)—an excess of amniotic fluid; amniotic fluid index (AFI) greater than or equal to 24 cm or a maximum deepest vertical pocket of equal to or greater than cm (ACOG, 2016b) a Incidence—about 1% of all pregnancies Diagnosis and Dating of Pregnancy b Etiology—50–60% are idiopathic; also associated with fetal anomalies, fetal infection, twin-to-twin transfusion syndrome, maternal diabetes (gestational and pregestational), isoimmunization, or multiple gestation c Signs and symptoms—uterine size larger than expected for gestational age (GA), difficulty auscultating fetal heart rate (FHR) and palpating fetal parts, mechanical pressure exerted by the large uterus (i.e., dyspnea, edema, heartburn, nausea) d Diagnosis (1) Physical findings—a fundal height measurement that is 3–4 cm greater than the normal height warrants an ultrasound to determine reason for enlarged uterus; palpation of fetal parts and auscultation of fetal heart beat may be difficult (2) Ultrasonography (USG)—an AFI measurement of > 24 cm confirms polyhydramnios diagnosis; USG may also identify associated fetal anomaly e Pregnancy outcome—hydramnios has been linked to fetal macrosomia; the greater the polyhydramnios, the higher the perinatal mortality; preterm labor increases; risk for postpartum hemorrhage (PPH) is higher given that the uterus is enlarged; increased risk for cord prolapse with rupture of membranes; also associated with erythroblastosis f Management—treat only if symptomatic and if benefits outweigh risks; monitor with serial NST and BPP, typically starting at 34 weeks (1) Amniocentesis—to reduce fluid volume if polyhydramnios is severe (AFI > 35 cm); amniotic fluid can be tested for fetal lung maturity and can also be sent for chromosomal studies (2) Indomethacin—impairs production of lung liquid, increases fluid movement through fetal membranes, or decreases fetal urine production Oligohydramnios—decreased AFV, defined as an AFI of cm or less or a maximum deepest vertical pocket of fluid measuring less than cm a Conditions associated with oligohydramnios (1) Fetal—almost always present with fetal urinary tract obstruction or renal agenesis (a) Chromosomal abnormalities (b) Congenital anomalies (c) Growth restriction (d) Demise (e) Post-term pregnancy (f) Ruptured membranes; premature rupture of membranes (PROM) (2) Placental (a) Abruption (b) Twin-to-twin transfusion syndrome (3) Maternal (a) Uteroplacental insufficiency (b) Hypertensive disorders (chronic, gestational, superimposed) (c) Diabetes (4) Drugs (a) Prostaglandin synthesis inhibitors (b) Angiotensin-converting enzyme inhibitors (5) Idiopathic 133 b Prognosis (1) Early-onset diabetes has poor outcome, and risk of pulmonary hypoplasia is greatly increased; if due to early PROM, risk of stillbirth increased (2) Late pregnancy onset leads to more cesarean sections for fetal distress c Management (1) Sonographic evaluation for fetal anomalies and growth restriction (2) Amnioinfusion in the intrapartum period for the treatment of repetitive variable decelerations Embryonic and Fetal Development • Embryonic development—the period of organogenesis, which begins in the third week after fertilization and spans for eight weeks; this is around the time a woman may miss her next menstrual period and when pregnancy tests would turn positive by detecting human chorionic gonadotropin (hCG) However, serum and urine assays can detect hCG as early as a week after conception Fourth week—partitioning of heart begins; arm and leg buds form; amnion begins to unsheathe the body stalk that becomes the umbilical cord Sixth week—head is much larger than body; heart is completely formed; fingers and toes present All major organ systems are formed except for lungs • Fetal development—begins eight weeks after fertilization; 10 weeks after onset of last menstrual period (LMP) Twelve weeks—uterus palpable at the symphysis; fetus begins to make spontaneous movements Sixteen weeks—experienced observers can determine sex on ultrasound Twenty weeks—weighs 300 g; weight now begins to increase in a linear manner Twenty-four weeks—weighs 630 g; fat deposition begins; terminal sacs in the lungs still not completely formed Twenty-eight weeks—weighs 1,100 g; papillary membrane has just disappeared from the eyes; has 90% chance of survival if otherwise normal Thirty-two to thirty-six weeks—continues to increase weight as more subcutaneous fat accumulates Diagnosis and Dating of Pregnancy • Diagnosis Signs of pregnancy a Presumptive—subjective (what the woman reports) (1) Amenorrhea (2) Nausea and/or vomiting (3) Urinary frequency; nocturia (4) Fatigue (5) Breast tenderness, tingling, enlargement, and changes in color 134 CHAPTER Prenatal Care and Fetal Assessment (6) Vasomotor symptoms (7) Skin changes (8) Congestion of vaginal mucus (9) Maternal belief that she is pregnant b Presumptive—objective (physical examination) (1) Continuation of elevated basal body temperature (2) Chadwick’s sign (3) Appearance of Montgomery’s tubercles or follicles (4) Expression of colostrum (5) Breast changes c Probable (1) Enlargement of the abdomen (2) Enlargement of the uterus (3) Palpation of the fetal outline (4) Ballottement (5) Change in the shape of the uterus (6) Piskacek’s sign (7) Hegar’s sign (8) Goodell’s sign (9) Palpation of Braxton Hicks contractions (10) Positive pregnancy test d Positive (1) Fetal heart tones—heard with a fetoscope at approximately 18–20 weeks and/or by Doppler ultrasound as early as 10 weeks’ gestation (2) Sonographic evidence of pregnancy (3) Palpation of fetal movement Differential diagnosis a Pregnancy b Leiomyoma c Ovarian cyst d Pseudocyesis • Dating of pregnancy—determining estimated date delivery (EDD), estimated date of confinement (EDC), or estimated date of birth (EDB) Average duration of human pregnancy—280 days, 10 lunar months, calendar months Methods for determining EDD, EDC, EDB a Naegele’s rule—subtract three months, add seven days to the first day of the LMP, then add one year or add nine months and seven days to the first day of the LMP b Additional information is needed to set EDD more precisely, which can include (1) Complete menstrual history (2) Contraceptive history (3) Sexual history (4) Physical examination for signs and symptoms of pregnancy (5) Quickening—maternal perception of fetal movement, which usually occurs between 18 and 20 weeks for primiparas; earlier for multigravidas, at about 14–18 weeks USG for gestational age determination a Combination of measurements is more accurate than any one of the following measurements (1) Crown rump length (CRL) (2) Biparietal diameter (BPD) (3) Head circumference (HC) (4) Abdominal circumference (AC) (5) Femur length (FL) b Accuracy by trimester (1) First trimester—CRL is accurate to three to five days (2) Second trimester—BPD and FL are most accurate to within 7–10 days (3) Third trimester—after 26 weeks, all measurements are less accurate; variation in BPD and FL is 14–21 days Maternal Physiologic Adaptations to Pregnancy • Effects of pregnancy on the organs of reproduction and implications for clinical practice Uterus a Nonpregnant uterus is about 70 g with a 10-mL cavity b First trimester—at six weeks the uterus is soft, globular, and asymmetric (Piskacek’s sign); at 12 weeks, it is 8–10 cm and is rising out of the pelvis c Early second trimester—at 14 weeks, the uterus is one-quarter of the way to umbilicus; at 16 weeks, it is halfway to the umbilicus; at 20 weeks the fundus is approximately at the umbilicus d After 20 weeks, number of centimeters with tape measure equals number of weeks of gestation within cm e By term, the uterus weighs about 1,100 g with a 5-liter volume Cervix a Develops increased vascularity b Hegar’s sign is softening of the isthmus c Chadwick’s sign is bluish color of the cervix d Goodell’s sign is softening of the cervix e A thick mucus plug forms secondary to glandular proliferation Ovaries—corpus luteum a Anovulation secondary to hormonal interruption of the feedback loop b Corpus luteum persists under the influence of the hormone hCG until about 12 weeks c Corpus luteum is responsible for the secretion of progesterone to maintain the endometrium and pregnancy until the placenta takes over production d Ovaries also thought responsible for production of relaxin Vagina a Chadwick’s sign—bluish color b Thickening of vaginal mucosa c Increase in vaginal secretions d Some loosening of connective tissue in preparation for birth Breasts a Increase in size secondary to mammary hyperplasia b Areola becomes more deeply pigmented and increases in size c Colostrum may be expressed after the first several months of pregnancy d Montgomery’s follicles e Vascularity increases Maternal Physiologic Adaptations to Pregnancy Pelvis—four pelvic types a Anthropoid (1) 23.5% of white women and 50% of nonwhite women (2) Shape favors a posterior position of the fetus (3) Adequate for a vaginal birth due to large size b Android (1) Commonly known as a male pelvis (2) 32.5% of white women and 15.7% of nonwhite women (3) Heavy, heart-shaped pelvis leads to increased posterior positions, dystocia, operative births c Gynecoid (1) Commonly known as the female pelvis (2) 41% to 42% of women’s pelvis shapes (3) Good prognosis for vaginal birth d Platypelloid (1) Rare pelvic type (2) Occurs in less than 3% of women (3) Prognosis of vaginal delivery is poor secondary to short anterior-posterior (AP) diameter • Effect of pregnancy on major body systems, with related clinical implications and patient education needs Gastrointestinal a Mouth and pharynx (1) Gingivitis is common and may result in bleeding of gums (2) Increased salivation (3) Epulis (a focal swelling of gums) may develop and resolves after the birth (4) Pregnancy does not increase tooth decay b Esophagus (1) Decreased lower esophageal sphincter pressure and tone (2) Widening of hiatus with decreased tone (3) Heartburn is common c Stomach (1) Decreased gastric emptying time (2) Incompetence of pyloric sphincter (3) Decreased gastric acidity and histamine output d Large and small intestines (1) Decreased tone and motility (2) Altered enzymatic transport across villi, resulting in increased absorption of vitamins (3) Displacement of intestines, cecum, and appendix by the enlarging uterus e Gallbladder (1) Decreased tone (2) Decreased motility f Liver (1) Altered production of liver enzymes (2) Altered production of plasma proteins and serum lipids Genitourinary/renal a Dilation of renal calyces, pelvis, and ureters, resulting in increased risk of urinary tract infection (UTI) b Decreased bladder tone c Renal blood flow increases 35–60% d Decreased renal threshold for glucose, protein, water-soluble vitamins, calcium, and hydrogen ions 135 e Glomerular filtration rate increases 40–50% f All components of the renal-angiotensin-aldosterone system increase, resulting in retention of sodium and water, resistance of pressor effect of angiotensin II, and maintenance of normal blood pressure Musculoskeletal a Relaxin and progesterone affect cartilage and connective tissue (1) Results in a loosening of the sacroiliac joint and symphysis pubis (2) Encourages the development of the characteristic gait of pregnancy b Lordosis Respiratory a Level of diaphragm rises about cm because of the increase in uterine size b Thoracic circumference increases by 5–6 cm and residual volume is decreased c A mild respiratory alkalosis occurs because of decreased PCO2 d Congestion of nasal tissues occurs e Respiratory rate changes very little, but the tidal volume, minute ventilatory, and minute oxygen uptake all increase appreciably f Some women experience a physiologic dyspnea due to the increased tidal volume and lower PCO2 Hematologic changes a Blood volume increases 30–50% from nonpregnant levels b Plasma volume expands, which results in a physiologic anemia c Hemoglobin averages 12.5 g/dL d Some require an additional gram of iron during pregnancy e Pregnancy can be considered a hypercoagulable state because fibrinogen (Factor I), and Factors VII–X all increase during pregnancy Cardiovascular system a Cardiac volume increases by about 10% and peaks at about 20 weeks b Resting pulse increases by 10–15 beats per minute, with the peak at 28 weeks c Slight cardiac shift (up and to the left) due to the enlarging uterus d Ninety percent of pregnant women develop a physiologic systolic heart murmur e May have exaggerated splitting of S1, audible third sound, or soft transient diastolic murmur f Cardiac output is increased g Diastolic blood pressure is lower in first two trimesters because of the development of new vascular beds and relaxation of peripheral tone by progesterone, which results in decreased flow resistance Integumentary system a Vascular changes (1) Palmar erythema (2) Spider angiomas (3) Varicose veins and hemorrhoids (4) Hyperpigmentation is believed to be related to estrogens and progesterone, which have a melanocyte-stimulating effect 136 CHAPTER Prenatal Care and Fetal Assessment (5) Chloasma, freckles, nevi, and recent scars may darken (6) Linea nigra (7) Increase in sweat/sebaceous activity (8) Change in connective tissues resulting in striae gravidarum b Hair growth (1) Estrogen increases the length of the anagen (growth) phase of the hair follicles (2) Mild hirsutism may develop in early pregnancy Endocrine a Pituitary (1) Prolactin levels are 10 times higher at term than in the nonpregnant state (2) Enlarges by more than 100% b Thyroid (1) Increases in size (about 13%) (2) Normal pregnant woman is euthyroid because of estrogen- induced increase in thyroxin-binding globulin (TBG) (3) TSH does not cross the placenta (4) Thyroid-stimulating immunoglobulins and TRH cross the placenta c Adrenal glands (1) Remain the same size; however, there is an increase in the zona fasciculata that produces glucocorticoid (2) Twofold increase in serum cortisol d Pancreas (1) Hypertrophy and hyperplasia of the B cells (2) Insulin resistance as a result of the placental hormones, especially hPL Metabolism a Weight gain during pregnancy (1) Recommended weight gain is 11–40 lb depending on prepregnancy body mass index (BMI) (2) Average weight gain is 28 lb—1.5 lb for placenta, lb for amniotic fluid, 2.5 lb for uterine growth, lb for increased blood volume, lb for increased breast tissue, 7.5 lb for the fetus, and the remainder for maternal fat deposits (3) Protein metabolism is increased (4) Fat deposit and storage are increased to prepare for breastfeeding (5) Carbohydrate metabolism is altered; blood glucose levels are 10–20% lower than prepregnant states Maternal Psychological/Social Changes in Pregnancy • Pregnancy is a time of many transitions; a woman is vulnerable; maternal moods may be labile • First trimester (1–13 weeks)—focus on physical changes and feelings Psychological responses a Ambivalence b Adjustment Prenatal anticipatory guidance a Normal changes of pregnancy (1) Increased pigmentation (2) Linea nigra (3) Striae gravidarum (4) Breast fullness (5) Urinary frequency (6) Nausea/vomiting (7) Fatigue b Calculate and explain EDD and comparison with uterine size c Client’s and healthcare provider’s expectations for visits d Importance of ongoing care in pregnancy to promote well-being and prevent and recognize problems e Rationale for vitamins and iron supplements f Resources available for education, emergency care, and so on g Discuss/review danger signs and symptoms • Second trimester (14–26 weeks)—more aware of the fetus as a person Psychological responses a Acceptance b Period of radiant health Prenatal anticipatory guidance a Avoid exposure to teratogenic agents (1) cytomegalovirus, herpes simplex rubella, syphilis, varicella, toxoplasma (2) hyperthermia (3) environmental chemicals such as herbicides and polychlorinated biphenyl (PCB) (4) recreational drugs (5) if medication required in pregnancy (over-the-counter, herbal, or prescription), lowest possible dose should be considered, and minimizing first trimester exposure b Fetal growth, movement, and fetal heart tones (FHTs) c Personal hygiene, brassieres, vaginal discharge, and so on d Infant feeding—breast and/or bottle e Avoidance and alleviation of backache, constipation, hemorrhoids, leg aches, varicosities, edema, and round ligament pain f Nutritional needs, diet, and weight gain g Discuss/review danger signs and symptoms • Third trimester First part (27–36 weeks)—concerned with baby’s needs a Psychological responses (1) Introversion (2) Period of watchful waiting b Prenatal anticipatory guidance (1) Fetal growth and well-being (2) Review hygiene, clothing, body mechanics and posture, positions of comfort (3) Physical and emotional changes (4) Sexual needs/intercourse (5) Alleviation of backache, Braxton Hicks contractions, dyspnea, round ligament pain, leg aches, or edema (6) Confirm infant feeding plans and discuss preparation for breastfeeding (7) Preparation for baby supplies and help at home (8) Prenatal classes/approach (9) Involvement of significant other Antepartum Visit (10) Review danger signs at each visit (11) Provide contraceptive counseling (12) If planning tubal ligation, prepare papers if required c Women anticipate birth and infant care (1) Discuss fetal movement (2) Personal hygiene needs/concerns, alleviation of discomforts of pregnancy (3) Discuss recognition of Braxton Hicks and prodromal contractions and differentiation from true labor (4) Discuss labor, contractions, and labor progress and expectations of labor (5) Breathing and relaxation techniques; labor support options (6) Provisions for needs of other children, sibling issues, and care of children during hospital stay (7) Review signs of labor (8) Continue discussion of relaxation and breathing techniques; latent labor coping skills (9) Final home preparations (10) Discuss procedures particular to home/birthing center (BC), hospital—analgesia, IVs, examinations, labor care, birthing plans, postpartum care, and supplies needed (11) Confirm plans for transport to the hospital, who to call, and where to go; hospitalization and process of admission (12) Consider birth control/family planning needs (13) Discuss emergency arrangements in the event of danger signs, PROM, bleeding, severe headache, pain, and so on • Risk factors for psychological well-being Limited support network High levels of stress Psychological and mental health issues Problem pregnancies Overview of Antepartum Care • Purpose and objectives of antepartum care—to differentiate normal and pathologic maternal-fetal alterations throughout pregnancy by employing maternal-fetal assessment methods, techniques, and parameters appropriate to the antepartum period, specifically Perinatal period—from the end of 22 weeks (154 days) gestational age up to seven days after birth; also defined as births weighing 500 g or more and ending at 28 completed days after birth Fetal death—spontaneous intrauterine death of a fetus at any time during the pregnancy; also referred to as stillbirth if it occurs after 20 weeks or more Stillbirth rate (fetal death rate)—the ratio of fetal deaths divided by the sum of births (including live births and fetal deaths) in any given year Neonatal death—early neonatal death is death during the first seven days after birth; late neonatal death is death between and 28 days Neonatal mortality rate—the number of neonates dying before reaching 28 days of age per 1,000 live births in a given year 10 Perinatal mortality—refers to the number of stillbirths and deaths in the first week of life 11 Perinatal mortality rate—the number of stillbirths and perinatal deaths (in the first week of life) per 1,000 total births 12 Infant mortality—death of an infant in the first 12 months of life 13 Infant mortality rate—number of infant deaths (in the first 12 months of life) per 1,000 live births 14 Maternal morbidity—illness or disease associated with childbearing 15 Maternal mortality ratio—number of maternal deaths that result from the reproductive process/100,000 live births 16 Abortus—fetus or embryo removed or expelled from the uterus during the first half of gestation (20 weeks or less), weighing less than 500 g 17 Late preterm infant (34 0/7–36 6/7 weeks of gestation) 18 Early term infant—(37 0/7–38 6/7 weeks of gestation) 19 Term infant—infant born after 37 completed weeks of gestation up until 42 completed weeks of gestations (260–294 days) 20 Post-term infant—infant born any time after completion of the 42nd week beginning with day 295 21 Direct maternal death—death of the mother resulting from obstetric complications of pregnancy, labor, or the puerperium; and from interventions, omissions, incorrect treatment, or a chain of events resulting from any of these factors Application of the management process, including components of history and physical examination at initial and interval visits Antepartum Visit Critical evaluation of indications and techniques for the application of therapeutics during the antepartum period • Terminology that describes women and their pregnancies (King, Brucker, Kriebs, & Fahey, 2015) Incorporation of current evidence and research in the care of women and families during the antepartum period • Definition of the essential concepts (Centers for Disease Control and Prevention [CDC], 2016) Fertility rate—number of live births/1,000 females 15–44 years of age Birth rate—number of births divided by total population in the given year(s) Live birth—birth of an infant, no matter the age of gestation, showing any signs of life (e.g., spontaneous breathing, beating of the heart, pulsation of the cord, movement of voluntary muscles) Neonatal period—28 completed days after birth 137 Gravida—the number of times a woman has been pregnant Para—refers to the number of pregnancies carried to the 20th week of gestation or the delivery of an infant weighing more than 500 g, no matter the outcome Nulligravida—a woman who has never been pregnant Nullipara—a woman who has not carried a baby to 500 g or 20 weeks Primigravida—a woman who is pregnant for the first time Primipara—a woman who has carried a pregnancy past the 20th week of gestation or who is currently pregnant for the first time and is carrying past the 20th week Multigravida—a woman pregnant two or more times 138 CHAPTER Prenatal Care and Fetal Assessment Multipara—a woman who has carried two or more pregnancies past the 20th week of gestation or who has delivered an infant weighing more than 500 g more than once Grand multipara—has given birth seven times or more 10 TPAL numerical description of parity—four-digit system that counts all fetuses/babies born rather than pregnancies carried to viability T = term babies (37 weeks or 2500 g) P = premature babies (20–36 weeks; 500–2499 g) A = abortions (any fetus born < 20 weeks and 500 g) L = current living children • Components of the antepartum visit (initial and return) The Pregnant Patient’s Bill of Rights Complete history a Menstrual history b Contraceptive history c Obstetric history, including quickening d Medical-surgical history e Sexual history f History or current physical, sexual, emotional abuse g Medicines and/or complementary alternative medicines and therapies h Family history i Genetic risk j Health habits k Environmental exposures l Social history m Exercise and nutrition history n Immunizations Physical examination a Height, weight, and vital signs b Complete physical examination c Abdominal examination (1) Fundal height—measured in centimeters, from pubic symphysis to the fundus of the uterus (2) Leopold’s maneuvers—four abdominal palpation maneuvers used to determine the following fetal characteristics (a) Lie (b) Presentation (c) Position (d) Attitude (e) Variety (f) Estimated fetal weight (3) Fetal heart tones—auscultation of presence and pattern of FHR (4) Bimanual examination—performed in the first trimester to determine uterine size and thus estimate gestational age (5) Clinical pelvimetry—measurement of the features of the bony pelvis with the examiner’s hand d The pelvis (only the true pelvis is of significance)—true pelvis is bony canal through which the fetus passes and that lies below the pelvic brim (linea terminalis) (1) Three planes of obstetric significance—inlet, midplane, and outlet (2) Critical diameters for evaluation of pelvic adequacy (a) Inlet—AP, transverse (b) Midplane—AP, transverse, posterior sagittal (c) Outlet—AP, transverse, posterior sagittal (3) Assessing and measuring the pelvis—clinical pelvimetry (a) Diagonal conjugate—extends from middle of sacral promontory to middle of lower margin of symphysis pubis; only AP diameter that can be measured clinically; should be more than 11.5 cm (b) Pubic arch—formed by the descending rami of pubic bones and inferior margin of symphysis pubis; angle should be at least 90 degrees (c) Interspinous diameter—distance between the ischial spines, normally measures 10 cm, is smallest diameter of the pelvis and defines the midplane (d) Ischial spines—may be prominent, encroaching, or blunt; assess the sidewalls and the sacrum; best if blunt (e) Sacrosciatic notch—note shape and width in fingerbreadths (f) Sidewalls—sidewalls extend from the upper anterior angle of the sacrosciatic notch to the ischial tuberosities and are assessed as straight, convergent, or divergent; should be straight (g) Sacrum—assess the inclination of the sacrum, the length, and the curvature; curved is best (h) Intertuberous diameter—distance between the ischial tuberosities, about 11 cm Laboratory studies used in the provision of antepartum care a Initial visit (1) Blood type, Rh factor, antibody screen, complete blood count (CBC), rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL), rubella titer, hepatitis B surface antigen (HBsAg), urine culture/screen (2) HIV testing should be recommended to all pregnant women with option to decline testing (3) Gonorrhea (GC), chlamydia (CT), and wet-mount tests (also called a vaginal smear or a wet prep), TSH, Hgb A1C, as indicated by history and physical examination findings (4) Pap test per routine recommendations (5) Positive purified protein derivative (PPD) skin test, hemoglobin (Hgb) electrophoresis, genetic screening tests as indicated by history and risk factors b Prenatal genetic screening tests (American College of Obstetricians and Gynecologists, 2016a) (1) Two main types of prenatal genetic tests (a) Prenatal screening tests—tests that provide the risk for certain genetic disorders such as aneuploidy (a condition wherein the infant has a missing or has an extra chromosome) (b) Prenatal diagnostic tests—confirmatory tests using cells from the fetus or placenta (2) Different types of prenatal screening tests (a) Carrier screening—serologic or tissue testing performed before or during the pregnancy, on the mother and/or father, to determine if they carry specific genetic illnesses (b) Prenatal genetic screening—serologic testing combined with ultrasonography performed during pregnancy to screen for aneuploidy and spine and brain defects Antepartum Visit (3) First-trimester screening—performed between 10 and 13 weeks; by combining serologic testing for pregnancy-associated plasma protein (PAPP-A) and hCG, an ultrasound exam to measure nuchal translucency, along with the mother’s age, a risk for trisomy 18 and 21 is calculated (4) Second-trimester screening (also known as quad or quadruple screen)—serologic blood test performed between 15 and 22 weeks to detect neural tube defects and trisomy 18 and 21; serologic testing measuring maternal serum alphafetoprotein (MSAFP), estriol, inhibin A, and hCG; in addition to the blood test, an ultrasound exam is performed between 18 and 20 weeks to determine if there are anatomical fetal defects, specifically of the brain, spine, face, abdomen, heart, and limbs (5) Combined first- and second-trimester screening—results of first- and second-trimester screening are combined to increase accuracy of detecting trisomy 21 (6) Cell-free DNA testing—serologic screening test on mother analyzes the small amount of DNA that is released from the placenta into the bloodstream of the mother; screens for aneuploidy (trisomy 13, 18, 21) and problems with sex chromosomes; this screening test can be performed as early as 10 weeks, and results may take up to one week; positive cell-free DNA results need to be followed by a diagnostic test (chorionic villus sampling (CVS) or amniocentesis) (7) Prenatal screen test results (a) Positive screening test—indicates that the fetus has an increased risk for aneuploidy than the general population; this is only a screening and is not diagnostic; positive result does not mean that the fetus definitely has the disorder (b) Negative screening test—indicates that the fetus has a lower risk for aneuploidy than the general population compared to the general population; however, this is only a screening, so the possibility that the fetus definitely has the disorder is not completely ruled out c Ultrasound (1) Fetal cardiac activity (2) Fetal presentation (3) Placental position (4) Fetal number (5) Fetal biometry (6) Fetal number (7) Anatomic survey (8) Specialized examination, as indicated (a) Targeted/detailed anatomic survey (b) Doppler flow (c) Biophysical profile (BPP) (d) Fetal echocardiography (9) As an adjunct to diagnostic testing d Gestational diabetes screening at 24–28 weeks—see the section on diabetes in “Medical Complications” later in this chapter e Repeat antibody screen at 26–28 weeks for Rh-negative mother f Repeat CBC/hematocrit (Hct), VDRL/RPR, CT, GC, HIV, HBsAg as indicated by history, physical examination findings, and risk factors in third trimester 139 g Group B streptococcus (GBS) screening at 35–37 weeks— vaginal introitus and rectal specimens h Some other laboratory studies that might be indicated include (1) Amniocentesis or CVS (2) Tay-Sachs screening (3) Maternal/paternal chromosomal studies (4) Chest radiographs (5) Blood chemistry (basic or comprehensive metabolic panel) (6) Thyroid studies (7) Toxoplasmosis testing (8) Cytomegalovirus (CMV) (9) Herpes simplex virus (HSV) cultures or antibody testing (10) Antinuclear antibody (ANA) (11) Antiphospholipid antibodies (12) Serum iron studies (13) Blood glucose studies (three-hour glucose tolerance test [GTT], fasting blood sugar [FBS], two-hour postprandial, and hemoglobin A1c) Subsequent (interval) prenatal visits—frequency of a Every weeks to 28 or 32 weeks b From 28 or 32 weeks to 36 weeks every weeks c Weekly visits from 36 weeks to 41 weeks d Some prefer biweekly visits 41 weeks to delivery e Schedule more frequent visits as appropriate; some providers recommend fewer prenatal visits if there are no problems Content of prenatal revisits a History b Physical examination—blood pressure, urine dipstick, weight, FHT, fundal height c Anticipatory management d Anticipatory guidance e Health education and counseling f Appropriate screening • Prenatal risk factors History a Genetic factors (1) Maternal age at or older than 35 years (2) Previous child with a chromosome abnormality (3) Family history of birth defects or mental retardation (4) Ethnic/racial origins (a) African—sickle cell disease (b) Mediterranean or East Asian—B thalassemia (c) Jewish—Tay-Sachs disease b Multiple pregnancy losses/previous stillbirth c Psychological/mental health disorders d History of intrauterine growth restriction (IUGR) e Preterm birth(s) Current pregnancy a Abnormal multiple marker screening b Exposure to possible teratogens (1) Radiation (2) Alcohol/medications/other substances (3) Occupational exposures 140 CHAPTER Prenatal Care and Fetal Assessment (4) Infections (a) Toxoplasmosis (b) Rubella (c) CMV (d) Syphilis (e) Zika c IUGR d Oligohydramnios/polyhydramnios e Diabetes (1) Pregestational (2) Gestational (a) Diet-controlled (b) Medication-controlled (by insulin or oral medications) f Hypertension (1) Chronic (2) Gestational g Preeclampsia/eclampsia h Multiple gestation i PROM j Post dates k Decreased fetal movement l Rh isoimmunization Common Discomforts of Pregnancy and Comfort Measures • Nausea and vomiting of pregnancy (NVP, most common in first trimester) (American College of Obstetricians and Gynecologists, 2015) Nausea and vomiting—50% of pregnant women; nausea only, 25%; unaffected, 25% NVP is different from hyperemesis gravidarum (HG), which happens much less frequently, at approximately 0.3–3% of pregnancies a HG is a diagnosis of exclusion when other causes of nausea and vomiting have been explored b Documented weight loss from prepregnancy weight is seen with HG c Signs of acute starvation such as presence of ketones in the urine d Abnormal bloodwork may also include a shift in electrolyte, thyroid, and liver enzymes Nonpharmacologic therapies for NVP a Prevention—women who were taking multivitamins at the time of conception are less likely in need of treatment for vomiting; recommend for women of reproductive age to take prenatal vitamins three months prior to conceiving to reduce likelihood and intensity of NVP b Avoid triggers such as odors that provoke symptoms c Small, frequent meals every one to two hours d Avoid spicy or fatty foods; eat bland or dry foods; eat foods that are high in protein e Try to eat something like crackers or toast before getting up and out of bed f Discontinue prenatal vitamins with iron until nausea and vomiting resolved, but continue folic acid g Acupressure, acupuncture, or acustimulation at the P6 (or Neiguan)—conflicting evidence for this therapy Pharmacologic treatments for NVP a Ginger g per day in divided doses b Pyridoxine (vitamin B6) 10–25 mg quid or tid orally; maximum dose of 200 mg/day c Diclegis (approved by the FDA in 2013) combined pyridoxine 10 mg and doxylamine 10 mg orally; two tablets for moderate NVP before bedtime; for severe NVP, four tablets, one tablet in the morning, one in the afternoon, and two at bedtime d Metoclopramide to 10 mg g q6–8h orally e Promethazine 25 mg q4h per rectal suppository f Ondansetron—although use of this drug is increasing, evidence is limited on its safety or efficacy; risk vs benefit should be weighed with each case • Breast tenderness Good support brassiere Careful lovemaking Reassurance that it will soon pass • Backache Consider other differential diagnoses for musculoskeletal strain, sciatica, sacroiliac joint problem, preterm labor, UTI Nonpathologic—related to normal changes in pregnancy a Massage b Application of ice or heat c Hydrotherapy d Pelvic rock e Good body mechanics f Pillow in lumbar area when sitting or between legs when lying on side g Pregnancy support harness or girdle h Good support brassiere i Supportive low-heeled shoes Sacroiliac joint problems a Teach appropriate exercises b Nonelastic sacroiliac belt c Trochanteric belt worn below the abdomen at the femoral heads to increase joint stability • Fatigue Reassurance that this is a normal first-trimester problem and will pass Mild exercise and good nutrition Decrease activities and plan rest periods Decrease fluid intake in evening to decrease nocturia • Heartburn Small, frequent meals Decrease amount of fluids taken with meals; drink fluids between meals Papaya (may recommend fresh, dried, juice, or enzymes) Elevate head of bed 10–30 degrees Slippery elm bark throat lozenges Antacids Proton pump inhibitors and H2 blockers—Pregnancy Category B Index hormonal therapy (HT), 77, 285 assessment and education prior to initiation of, 78 indications for, 77 management of bleeding, 79 regimen options, 78–79 side effects of, 79 hormones, effect of, 37–38 HPV See human papillomavirus HSIL See high-grade squamous intraepithelial lesion HSV See herpes simplex virus HT See hormonal therapy human immunodeficiency virus (HIV), 159–160, 228 CDC, 18–19 infection, 269–272 risk assessment, screening, 44, 76, 81 tests, 18–19 human papillomavirus (HPV), 152 and cervical cancer, 96 immunizations, 20 tests, 41 human reproduction and fertilization, 131 humerus, fracture of, 228 hydatidiform mole, 149 hydrocephalus, 229 hydroxychloroquine, 273, 274 hygiene, 204 hyperandrogenism, 89 hyperbilirubinemia, 220, 229 hyperplasia in breast, defined, 120 hyperprolactinemia, 93 hypertension, 238–241 hypertensive disorders, 156–157 hyperthyroidism, 163, 279–280 hypoactive sexual desire disorder, 117 hypoglycemia, 214–215 hypoplasia, 119 hypospadias, 230 hypothalamic-like releasing and inhibiting hormones, 132 hypothyroidism, 281 hysterosalpingogram, 118 I IBS See irritable bowel syndrome IC See interstitial cystitis ICSI See intracytoplasmic sperm injection IDM See infants of diabetic mothers Illicit drugs, 146 IM See infectious mononucleosis immediate newborn transition, management of, 196 immune system, newborn’s, 216 immunizations, 19–20, 76, 205 recommendations hepatitis B, 219 newborn care, 219 immunologic disorders HIV infection, 269–272 RA, 273–275 SLE, 272–273 immunometric assay, 42 implantation of blastocyst, 131 in Vitro fertilization (IVF), 118 inborn errors of metabolism, 231 “incident to” services, Medicare reimbursement for, 324 incompetent cervix, 150 incomplete abortion, 148 incontinence, urinary, 110–111 independent and collaborative care management, 323 inevitable abortion, 148 infant mortality rate, 137 infant–parent attachment, 22 infants of diabetic mothers (IDM), 227 infectious disease tests, 15–16 infectious mononucleosis (IM), 252 infertility, 118–119 infliximab, 274 influenza, 144 immunizations, 19 informed consent, 328 infrequent menstrual bleeding, 90 inhaled corticosteroids, 248t inhaled short acting B2-agonists, 248t inherited anemias, 164 inhibin B, 74 insomnia in pregnancy, 141 inspection technique of examination, insulin, 277 integrated delivery systems, 325–326 integumentary system, pregnancy changes, 135–136 intentional infliction of emotional distress in tort law, defined, 326 intentional tort, defined, 326 intermittent asthma, 254, 255 internal hemorrhoids, 259 internal pelvic structures, 37–38 internal rotation movement of labor, 191 interstitial cystitis (IC), 111–112 interstitial leiomyomata uteri, 94 intimate partner abuse, 147–148 intra-articular injection, 284 intracytoplasmic sperm injection (ICSI), 119 intraductal papilloma, 121 intraligamentous leiomyomata uteri, 94 intrapartum period delivery management, 193–195 diagnostic studies/lab tests, 186 first stage of labor, 188–191 immediate newborn transition, management of, 196 initial assessment, 183–184 management and teaching, 186–187 maternal response to baby, assessment of, 203–204 mechanisms of labor, 187–188 second stage of labor, 192–193 special considerations and deviations from normal, 196–201 third stage of labor, management of, 195–196 intrauterine contraception (IUC), 45–47, 204, 272 initiation of, 62 intrauterine contraceptives, 62 intrauterine growth restriction (IUGR), 153–154 intrauterine pressure catheter (IUPC), 188 intravenous access methods, intrapartum, 186 involutional pain, 205 iron-deficiency anemia, 164, 267–269 iron requirements (nonpregnant women), 17 irritable bowel syndrome (IBS), 260–261 irritant contact dermatitis, 293 irving procedure, 61 ischemic heart disease, 239 isochromosomes, defined, 151 339 itraconazole, 295 IUC See intrauterine contraception IUGR See intrauterine growth restriction IUPC See intrauterine pressure catheter IVF See in Vitro fertilization J Jarisch-Herxheimer reaction, 152 jaundice, 219, 224–225, 229 justice as ethical principle, 326 K karyotype, 21 kernicterus, 229 keyed response, Klumpke paralysis, 228 knee presentation, 199 L labia, 75 labia majora, 36 labia minora, 36 labor curve, partographs of, 189 labor support and roles, 191 LACE See Licensure, Accreditation, Certification, and Education lacerations, 193 lactation, 202 immunizations during, 20 lactational amenorrhea method (LAM), 59–60, 62 lactobacilli, BV and loss of, 99 LAIV See live attenuated influenza vaccine LAM See lactational amenorrhea method lanugo, 222 laparoscopy, 43 large for gestational age (LGA), 154 infants, 227 latent labor, defined, 188 latent TB infection (LTBI), 255 law, defined, 326 LBP See low back pain LDL See low-density lipoproteins lecithin/sphingomyelin ratio (L/S) fetal lung maturity, 146 leflunomide, 274 leg cramps in pregnancy, 141 legal and ethical issues consensus model, 321–322 coworker incompetence issue, 326 ethical principles, 326 HIPAA, 326–327 liabilities and concerns, 326–327 leiomyomata uteri, 94–95 Leopold’s maneuver, 200 leukorrhea in pregnancy, 141 leukotriene modifiers, 248t levonorgestrel, 204 levonorgestrel Intrauterine Systems (LNG IUS), 45, 62 levothyroxine, 281 LGA See large for gestational age LGV See lymphogranuloma venereum licensure, 322 Licensure, Accreditation, Certification, and Education (LACE) model, 322 lichen planus, 112 lichen sclerosus, 112 lichen simplex chronicus, 112 linear model, female sexual response, 41 lipid profile, 15 340 Index lipid screening, 76, 82 lipids, 18 listeria, 227 live attenuated influenza vaccine (LAIV), 19 live birth, 137 liver enzymes, 16 LNG IUS See levonorgestrel Intrauterine Systems lobes, breast, defined, 36 lobules, breast, defined, 36 local anesthesia, 192 lochia, physiologic and anatomic changes, 202 long-acting inhaled B2-agonists, 248t long-acting nitrates for angina, 245 long-acting reversible method, 62 low back pain (LBP), 281–283 low-density lipoproteins (LDL), 15, 243 low-dose vaginal estrogen, 79 low-grade squamous intraepithelial lesion (LSIL), 114 lower respiratory disorders asthma, 253–255 community-acquired pneumonia, 252–253 TB, 255–257 LSIL See low-grade squamous intraepithelial lesion LTBI See latent TB infection lubiprostone for IBS treatment, 261 lumbosacral spine, radiograph of, 282 lumbosacral strain, 282 lung cancer screening, 19 luteal phase of ovarian cycle, 38 luteinizing hormone, 38 lymphatics, 37 breast, 36 lymphogranuloma venereum (LGV), 108 M macrocytic anemia, 267 macrosomia, 154 magnesium sulfate (MgSO4), 157, 197–198 major depressive disorder (MDD), 298–300 male condom, fertility control, 56 male factor leading to infertility, 118 male-focused reproductive health assessment, 13 male genitalia, 222 male sterilization, fertility control, 61–62 malformation, fetal, defined, 150 malignant melanoma (MM), 9, 165, 294 malignant tumors, gynecological, 94–99 malpractice, defined, 326 malpresentations, 156 mammary duct ectasia, 121 mammogram, 18, 43 mammography, 40, 76, 81, 165 managed care organization (MCO), 324 marijuana abuse, 229 mast cell stabilizers, 246, 247t, 248t maternal morbidity, defined, 137 maternal mortality ratio, 137 maternal response baby, assessment of, 203–204 maternal–infant bonding and attachment, 203 Mauriceau-Smellie-Veit maneuver, 200 McBurney’s point, 261 MCH See mean corpuscular hemoglobin MCHC See mean corpuscular hemoglobin concentration MCO See managed care organization MCQs See multiple-choice questions McRobert’s maneuver, 199 MCV See mean corpuscular volume MDD See major depressive disorder mean corpuscular hemoglobin (MCH), 14 mean corpuscular hemoglobin concentration (MCHC), 14 mean corpuscular volume (MCV), 14 meconium aspiration, 218, 227 median episiotomy, 193 repair, mechanisms of, 193 medical complications, newborn care, 226 mediolateral episiotomy, 193 megaloblastic anemia, 164 meiosis, 131 membranes, development of, 131–133 Mendelian (single-gene) disorders, 151 meningocele, 229 meningococcal disease, immunizations, 20 menopause, 74–76 menorrhagia, 90 menstrual cycle, 38, 39f, 75 menstrual history, menstruation, 37, 38 disorders of, 87–93 mental status, physical exam, 12 metabolic diseases, heterozygous group of, 275 metabolic disorders, 288 metabolic syndrome, 275 metabolic system, newborn assessment, 223 metabolism body processes drugs, pharmacology, 28 inborn errors of, 231 methotrexate, 63, 275 plus misoprostol, 63 methylergonovine, 195 methylxanthines, 248t metronidazole, 30, 100, 101 microcytic anemia, 267 midtrimester spontaneous abortion, 149 midwifery ACNM, 319, 323 credentialing, 323 hospital privileges, 323 independent and collaborative care management, 323 prescriptive authority, 322–323 standards of practice, 323 mifepristone plus misoprostol, 63 migraine, 288 headache, 288 mild acne, 293 mild persistent asthma, 254, 255 Mini Mental Status Examination (MMSE), 81 misoprostol, 196 misoprostol—prostaglandin analog, 63 mitosis, 131 MM See malignant melanoma MMSE See Mini Mental Status Examination moderate acne, 293 moderate persistent asthma, 254, 255 molluscum contagiosum, 105–106 monozygotic multiples, 155 monozygotic twins, 200 mons pubis, 36 montelukast, 246, 248t Montgomery’s glands, 36 mood changes and menopause, 75 MORAL model of ethical decision making, 326 moro reflex, 222 morula, 131 Müllerian abnormalities, 119 multigravida, defined, 137 multipara, defined, 138 multiple-choice questions (MCQs), components of, multiple gestation, 155–156 multiple marker screening, 139 Murphy’s sign, 265 musculoskeletal anomalies, 230 musculoskeletal disorders fibromyalgia, 286–287 LBP, 281–283 osteoarthritis, 283–284 osteoporosis, 284–286 strains/sprains, 287 musculoskeletal system newborn, physical examination, 221 older adults, 80 physical exam, 11 pregnancy changes, 135 myelomeningocele, 229 myoclonic seizure, 291 myoma, 94–95 N NAAT See nucleic acid amplification test Naegele’s rule for pregnancy dating, 134 naltrexone, 303 nasal corticosteroids, 247t National Association of Nurse Practitioners in Women’s Health (NPWH), 319 National Certification Corporation (NCC), 1, National Institute on Drug Abuse (NIDA), 303 National Osteoporosis Foundation (2013), 17 National Provider Identifier (NPI) number, 324 nausea and vomiting of pregnancy, 140 NCC See National Certification Corporation needle aspiration, 165 negligence tort, 326 Neisseria gonorrhoeae (GC), 44, 103, 227, 251 neonatal death, 137 neonatal fractures, 228 neonatal infection, 227–228 neonatal morbidity, danger signs of, 226 neonatal mortality rate, 137 neonatal period, 137 neonatal resuscitation, 217 neoplasms/tumors, gynecological, 94–99 neoplastic disease, 165 neurologic disorders headaches, 288–291 seizure disorders, 291–292 neurologic examination, 222 neurologic system older adults, 80 physical exam, 11–12 neurosyphilis, 106 New Ballard scales, 221 newborn assessment, 221–223 newborn care bonding with parent, 217–218 circumcision of, 224 common variations from normal newborn findings, 224–226 deviations from normal, 226–231 discharge planning, 219–220 feeding patterns, 218 first weeks, primary care of, 223–224 in first few days of life, 218–219 in first hours after birth, 217–218 immediate care and assessment, 216–217 Index newborn assessment, 221–223 transition to extrauterine life, 214–215, 217 nicotine replacement therapy, 20 nicotinic acid drugs, 244 NIDA See National Institute on Drug Abuse nifedipine, 197 nipples, breast, 36 nitrazine test, 197 nitroglycerine, sublingual, 245 no-scalpel vasectomy, 61 non-neoplastic disorders, of vulvar epithelium, 112 non-nutritive sucking, 224 nonbiologic disease-modifying antirheumatic drugs (DMARDs), 275 noncoital pain, 117 noncontact sexual abuse, 301–302 nongestational trophoblastic disease, 99 nongynecological diagnostic studies/ laboratory tests, 13–16 nongynecological disorders/problems cardiovascular disorders, 238–246 dermatologic disorders, 292–296 endocrine disorders, 275–281 eye, ear, nose, and throat disorders, 246–252, 247t–248t gastrointestinal disorders, 257–266 immunologic disorders, 269–275 lower respiratory disorders, 252–257 musculoskeletal disorders, 281–287 psychosocial issues, 297–304 respiratory system, 247t–248t noninflammatory joint diseases, 283 nonlinear model, female sexual response, 41 nonmaleficence, as ethical principle, 326 nonsteroidal anti-inflammatory drugs (NSAIDs), 275, 284 dysmenorrhea, 89 endometriosis, 92 nonstress test (NST), 145 nontreponemal tests, 44 nonvascular intracranial disorders, 288 normal postpartum, 201–203 normocytic anemia, 267 nose, physical exam, 10 NP See nurse practitioner NPI See National Provider Identifier NPWH See National Association of Nurse Practitioners in Women’s Health NSAIDs See nonsteroidal anti-inflammatory drugs NST See nonstress test nucleic acid amplification test (NAAT), 43–44 nulligravida, defined, 137 nullipara, defined, 137 nurse practice acts, 322 nurse practitioner (NP) certification, 319 nurse practice acts, 322 nutrition, 186 general health promotion, 16–17 during pregnancy, 141–142 NuvaRing, 52 O OBRA See Omnibus Budget Reconciliation Act obsessive-compulsive disorder (OCD), 297 obstetric care, careful supervision of, 273 obstetric history, obstetrical complications abuse, 146–147 birth defects/anomalies, 151, 226 ectopic pregnancy, 149 first-trimester bleeding, 148 and gravidity/parity status, 183 hydatidiform mole, 149 hypertensive disorders, 156–157 inevitable/incomplete abortion, 149 LGA/macrosomia, 154 malpresentations, 156 multiple gestation, 155–156 post-term pregnancy, 157 preterm birth, 154–155 second-trimester bleeding, 149–150 SGA/IUGR, 153–154 spontaneous abortion, 148 STIs, 151–153 third-trimester bleeding, 150 threatened abortion/disappearing twin, 148 obstetrics, ultrasound in, 144 obstructed lacrimal ducts, 225 obturator sign, 261 occiput anterior (OA) position, 191 occiput posterior (OP) position, 191 occlusion, methods of, 61 occurrence liability insurance, 327 OCD See Obsessive-compulsive disorder OCT See oxytocin challenge test Office for Civil Rights, 327 OGTT See oral glucose tolerance test OLD-CARTS mnemonic, for health history, older adults, well-woman care, 80–81 oligo-ovulation, 91 oligohydramnios, 133 oligomenorrhea, 90 Omnibus Budget Reconciliation Act (OBRA) (1989), 325 omphalocele, 230 one-step approach, diabetes, 162 oogenesis, 131 ophthalmoscopic examination, 10 opiate abuse, 229 oral antifungals, 295 oral contraceptives, 272, 293 oral corticosteroids, 248t oral glucose tolerance test (OGTT), 14 oral hypoglycemic agents, 277 oral medications, 278t, 293 orgasmic disorder, 117 ospemifine, 79 osteoarthritis, 283–284 osteoporosis, 284–286 otoscopic examination, 10 outpatient vs admission management decision, 186 ovarian carcinoma, 97–98 ovarian cycle, 38 ovarian cysts, 95–96 ovaries, 37 physiologic adaptations in pregnancy, 134 ovulation, 38 fertility awareness method, 59 ovulatory dysfunction leading to infertility, 118 oxybutynin, 32 oxytocin, 158, 195 oxytocin challenge test (OCT), 145 P pain management, during labor and delivery, 189 painful bladder syndrome, 111–112 PAINS warning signs for IUC problems, 47 341 palmar grasp, 222 palpation technique of examination, pancreatitis, 265 panic disorder, 297 Pap test, 18, 41, 115 Actinomyces-like organisms on, 47 para, defined, 137 parathyroid hormone (PTH), 286 parathyroid hormone-related protein (PTH-rP), 132 parenting education, 22 parity, 8, 183 partial breech extraction, 199 passageway, in labor, 187 passenger, in labor, 187 patent urachus, 230 pathologic jaundice, 220 PCOS See polycystic ovarian syndrome PCR See polymerase chain reaction PE See pulmonary embolus pediatric follow-up care, arranging, 220 pedunculated leiomyomata uteri, 94 pelvic examination, 76, 81, 185 physical exam, 12–13 pelvic floor muscles, 37 pelvic floor musculature, 193 pelvic inflammatory disease (PID), 108–109 pelvic musculature, 36–37 pelvic relaxation disorders, 113 pelvic ultrasound, 42–43 pelvis and pelvic abnormalities/pathologies musculature of, 196 physiologic adaptations in pregnancy, 135 penicillin allergy, 152 peptic ulcer disease (PUD), 262–263 peptide hormones, 132 per member per month (PMPM) costs, 325 percussion technique of examination, percutaneous umbilical blood sampling (PUBS), 146 perennial vs seasonal allergies, 246 perimenopause, 74, 90 perinatal mortality rate, 137 perinatal period, 137 perineal integrity, factors interfering with, 193 perineal muscles, 36 perineal pain, 205 perineum, 36, 204 episiotomy decision during delivery, 192 musculature, 193 repairing lacerations in, 193–194 peripheral blood smear, 14 peripheral vascular system, older adults, 80 PERRLA See Pupils Equal, Round, React to Light, and Accommodate “petit mal” seizure, 291 pharmacokinetic, 29 pharmacology, principles of adverse reactions, 29 body processes drugs, 28–29 client education, 30 drug action on living tissue, 29 drug contraindications, 29–30 drug interactions, 29 drug review, 30–33 drug therapy, benefits and risks, 30 pharyngitis, 251–252 phenylketonuria, 231 PHI See protected health information phosphatidylglycerol (PG) fetal lung maturity, 163 phototherapy, 229 342 Index physical activity, 17 physical examination general health, 9–13 male-focused reproductive health assessment, 13 newborn care, 221 pelvic, 12–13, 185 physician role in labor and delivery, 187 physiologic jaundice, 220 PID See pelvic inflammatory disease pituitary adenoma, 93 placenta, 132 delivery of, 195 development of, 131–133 placenta accreta, 201 placenta increta, 201 placenta percreta, 201 placenta previa, 150, 198 placental abruption, 150, 198–199 placental adrenocorticotropin hormone (ACTH), 132 placental anomalies, 150 placental barrier, 28 affecting drug distribution, 28 placental lactogen, 132 plasma protein binding, 28 platelet count, 14 platypelloid pelvic type, 135, 185 plexus injuries, 228 PLISSIT model, 118 PMDD See premenstrual dysphoric disorder PMPM See per member per month PMS See premenstrual syndrome pneumococcal vaccine, 82 pneumococcus, immunizations, 19 pneumonia, 220, 252 point-of-service plan (POS), 325 polycystic ovarian syndrome (PCOS), 91–92 polyhydramnios, 133 polymerase chain reaction (PCR), 44 polypeptide hormones, 38 polyploidy, defined, 151 pomeroy procedure, 61 POPs See progestin-only pills POS See point-of-service plan position of fetus at delivery, 185 post-traumatic stress disorder (PTSD), 297, 301 postabortion health assessment, complications, 63 postmenopause, 74 postpartal discomforts, 205 postpartum blues and depression, 203 postpartum contraception, 62 postpartum period, management plan for, 204–205 postterm infants, 227 defined, 137 post-term pregnancy, 157 power of contractile efforts, in labor, 187 PPD See purified protein derivative PPIs See proton pump inhibitors practice tests, pre-abortion health assessment, 63 preconception care, 21–22 prediabetes, 276 preeclampsia, 156 pregnancy See also antepartum care chlamydia’s risks to, 102 diagnosis and dating of, 133–134 discomforts and remedies, 140–142 embryonic and fetal development, 133 family support role, 142–143 FDA risk factor categories for drugs in, 144 fertilization process, 131 immunizations during, 20 IUC, 47 medical complications, 158–166 nutrition during, 141–142 obstetrical complications, 146–147 pharmacologic considerations, 144 physiologic adaptations, maternal, 134–136 psychosocial changes, 136–137 teaching and counseling, 143–144 test, 42 premature birth, definitions, 196 premature ejaculation, 117 premature labor, definitions, 196 premature menopause, 74 premenstrual dysphoric disorder (PMDD), 88 premenstrual syndrome (PMS), 87–88 prenatal care and fetal assessment embryonic and fetal development, 133 human reproduction and fertilization, 131 placenta, membranes, and amniotic fluid development, 131–133 pregnancy See pregnancy prescriptive authority, 322–323 presentation, fetal, 185, 192 PRESIDE See Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking presyncopal episodes, 141 preterm birth, 154–155 preterm infants, 226 defined, 137 primary infection, HSV, 104 primigravida, defined, 137 primipara, defined, 137 pritchard procedure, 61 privacy rule, HIPAA, 326 pro-opiomelanocortin, 132 problem-oriented medical record, 8–9 prodrugs, 28 professional issues advanced practice registered nurse (APRN), 318–320 professional components of, 322–325 ethical and legal issues and principles, 326–327 evidence-based practice, 327–328 healthcare delivery systems, 325–326 trends and issues, 320–322 professional organizations, 324 progesterone, 38, 77, 132 progestin, 77 progestin-only contraceptive methods, initiation of, 62 progestin-only implant—etonogestrel (Nexplanon), 48 progestin-only injectable contraception, 53–55 progestin-only methods, 62 progestin-only pills (POPs), fertility control, 52–53 prolactin, 38 proliferative phase of uterine cycle, 38 prolonged menstrual bleeding, 90–91 prostaglandin inhibitors, 158 prostaglandin synthetase inhibitors, 89 prostaglandins, 38 protected health information (PHI), 327 protein hormones, 132 proton pump inhibitors (PPIs), 262–263, 266 protozoal infections, 227–228 psoas sign, 261 psyche principle in labor, 187 psychosis, postpartum, 203 psychosocial issues anxiety, 297–298 attachment, infant–parent, 218 cultural health history, 7–8 domestic violence/intimate partner violence, 300 eating disorders, 301–302 MDD, 298–300 and newborn assessment, 214–215 newborn’s psychological tasks, 224 sexual violence, 301 sociodemographics for intrapartum prognosis, 183 stress, 297 substance use disorders (SUDs), 302–304 PTH See parathyroid hormone PTSD See post-traumatic stress disorder puberty, 37 pubococcygeus, 193 PUBS See percutaneous umbilical blood sampling PUD See peptic ulcer disease pulmonary embolus (PE), 242 pulmonary hypoplasia/agenesis, 229 pulmonic stenosis, 230 Pupils Equal, Round, React to Light, and Accommodate (PERRLA), 10 purified protein derivative (PPD), 16 push/expulsive phase of labor, 188 pyelonephritis, 109, 158, 159 pyloric stenosis, 230 Q qualitative amniotic fluid volume (AFV), 146 question format, R RA See rheumatoid arthritis Race and ethnicity status, intrapartum considerations, 183 radioactive iodine (RAI) scan, 280 therapy, 280 RAI See radioactive iodine rape, defined, 301 rape trauma syndrome, 301 RBCs See red blood cells recitation, active study techniques, rectocele, 114 rectovaginal examination, 13 recurrent HSV syndrome, 104 red blood cells (RBCs), 13, 215 referral, defined, 323 refusal of treatment, right of patient to, 326 regional anesthesia, 192 regulation of behavior, newborn capabilities, 223–224 regurgitation, 225 newborn’s tendency toward, 216 relaxin, 132 renal insufficiency, 156 renal system newborn in transition, 216 normal postpartum, physiologic and anatomic changes, 202 pregnancy changes, 135 respiration of newborn during transition, 214 respiratory anomalies, 229 respiratory system disorders of, 247t–248t newborn, 214, 226 physical exam, 10 pregnancy changes, 135 Index restitution of labor, 191 resuscitation of newborn, 217 retained placenta, 201 retinoic acid derivatives, 293 Rh isoimmunization, 163 rheumatoid arthritis (RA), 273–275 Rhus plant antigens, 293 RIA See serum hCG radioimmunoassay right occiput posterior (ROP) position, 191 ring chromosome, defined, 151 Rinne test, 10 Rome criteria for IBS, 260 round ligament pain during pregnancy, 141 routine suctioning, of nasal and oral passages, 194 Rovsing’s sign, 261 rubella, 15, 144, 160–161, 228 immunizations, 19 rubra, stages of discharge, 202 S safety education, 21 saline laxatives, 258 Sanovsky’s protocol, 145 SBP See systolic blood pressure SCC See squamous cell carcinoma school of fish pattern, 107 Schultz mechanism for placental delivery, 195 screening asymptomatic adults, 276 seasonal vs perennial allergies, 246 second period of reactivity, newborn’s, 217 second stage of labor (pushing), 188, 192–193 second trimester bleeding in, 149–150 psychosocial changes, 134, 136 screening, 139 secondary headaches, 288 secretory phase of uterine cycle, 38 sedatives for labor pain management, 187 seizure disorders, 291–292 selective estrogen-receptor modulators (SERMs), 77 selective serotonin reuptake inhibitors (SSRIs), 79, 291, 298, 300 self-assessment, 1t self-belief, sensitized pregnancy, 164 sensory capabilities, 223 sensory function, 12 sepsis, 220, 227 sequence abnormalities, fetal, 150 SERMs See selective estrogen-receptor modulators serosa, stages of discharge, 202 serotonin-norepinephrine reuptake inhibitors (SNRIs), 287, 299 serum creatinine, 15 serum hCG radioimmunoassay (RIA), 42 serum hormonal levels, 42 17β-estradiol, 77 severe acne, 293 severe persistent asthma, 254, 255 sex-linked genetic abnormalities, 151 sexual assault, 301 sexual dysfunction, 117–118 sexual history, sexual interest/arousal disorder, 117 sexual orientation, 41 sexual violence, 300–301 sexuality, 21, 41, 143 sexually transmitted infections (STIs), 101–109 anogenital warts, 102–103 chancroid, 107–108 chlamydia, 102–103 Chlamydia trachomatis, 43–44 condyloma acuminata, 44, 102–103 genital herpes simplex, 44 genital warts, 44 gonorrhea, 103–104 hepatitis B (HBV), 44 HPV, 152 HSV, 44, 104–105, 152 LGV, 108 molluscum contagiosum, 105–106 Neisseria gonorrhoeae, 44 in newborns, 224 PID, 108–109 during pregnancy, 151–153 screening/diagnostic tests for, 43–44 syphilis, 44, 106–107, 151–153 Treponema pallidum, 44 trichomoniasis, 44 SGA See small for gestational age shingles (herpes zoster), 161 shoulder dystocia, 199 shoulder presentation, 156 sickle cell anemia, 267–269 sickle cell hemoglobinopathies, 164 sickle cell screening, 16 SIDS See sudden infant death syndrome silastic band and occluded sterilization, 61 sildenafil, 117 single-gene (Mendelian) disorders, 151 sinuses, physical exam, 10 sinusitis, 250 skin cancer, 294–295 lesion characteristics, menopause, 75 older adults, 80 rash during pregnancy, 141 SLE See systemic lupus erythematosus sleeping patterns in newborn, 223 small for gestational age (SGA), 153–154, 196 infants, 226 smoking, 147 smoking cessation, 20 SNRIs See serotonin-norepinephrine reuptake inhibitors SOAP format for medical record, social phobia, 297 socioeconomic status, intrapartum considerations, 183 somatostatin, 132 spermatogenesis, 131 spermicides, 204, 272 spina bifida occulta, 229 sponge, contraceptive, 58–59 spontaneous abortion, 148 spontaneous vaginal breech delivery, 199 squamous cell abnormalities, 114 squamous cell carcinoma (SCC), 294 SSRIs See selective serotonin reuptake inhibitors stages of labor, 188 standard days fertility awareness methods, 59 standardized test taking, rules of, 4–5 standards of practice, 323 Staphylococcus aureus, 115 statins, 244 sterilization methods, 62 steroid hormones, 132 stillbirth, 152 rate, 137 343 STIs See sexually transmitted infections stool for occult blood, 16 stool softeners, 260 stooling/voiding, newborn care, 218 strains/sprains, 287 STRAW reproductive-aging continuum, 74 stress diagnosis and management, 297 vs urge incontinence, 110 studying, business of, 2–3 subclinical hypothyroidism, treatment of, 281 sublingual nitroglycerine, 245 submucosal leiomyomata uteri, 94 subserosal leiomyomata uteri, 94 substance abuse, 302–304 substance dependence, 302 substance use disorders (SUDs), 302–304 succenturiate lobe, 196 suctioning, 195 sudden infant death syndrome (SIDS), 231 SUDs See substance use disorders sulfamethoxazole, 250 sulfasalazine, 274 superficial fungal infection, 295 surgical methods, abortion, 63 surgical repair, 229 suture material, 194 sympto-thermal fertility awareness methods, 59 synclitism vs asynclitism, 187 syncytiotrophoblast, 131 syndrome abnormalities, fetal, 150 synthetic estrogen, 77 syphilis, 106–107, 151–152, 220, 227 screening/diagnostic tests for, 44 systemic lupus erythematosus (SLE), 272–273 systolic blood pressure (SBP), 238 T T-score, 44 tadalafil, 117 talipes equinovarus, 230 tamoxifen, 33 tanner stages, 37 target organ damage (TOD), 238 TB See tuberculosis TCAs See tricyclic antidepressants TCE See total cutaneous examination tension headache, 288 teratogens, 144 terbinafine, 295 term birth, definitions, 196 term infant, defined, 137 test-taking strategies/techniques, 1–5 tetanus, 144 tetanus, diphtheria, and acellular pertussis (Td/Tdap), 76, 82 immunizations, 19 vaccination, 144 thelarche, 37 therapeutic effect, 29 thermoregulation of newborn during transition, 214–215 thiazide-type diuretics, 239 third stage of labor, 195–196 third trimester bleeding in, 150 psychosocial changes, 134, 136–137 threatened abortion, 148 thrombocytopenia, 156 344 Index thromboembolic disease, 241–243 thromboembolic disorders, 78 thrush, 225 thyroid disease, 163 thyroid function, 15, 18 thyroid-stimulating hormone (TSH), 15 thyroiditis, 279 management of, 280 thyrotoxicosis, 163 thyrotropin-releasing hormone (TRH), 132 tinea/dermatophytosis, 295 tinidazole, 101 tissue biopsy, 165 tissue culture, 44 TIV See trivalent inactivated influenza vaccine TM See tympanic membrane tocolysis, 197 tocolytic drugs, 155 TOD See target organ damage tonic-clonic seizures, 292 tonic neck response, 222 topical antibiotics, 293 topical antifungals, 295 topical corticosteroids, 246, 247t, 294 tort law, defined, 326 total breech extraction, 199 total cutaneous examination (TCE), 295 total palsy in newborns, 228 total thyroxine (T4), 15 toxic adenoma/solitary autonomous nodule, 279 toxic multinodular goiter, 279 toxic shock syndrome (TSS), 115–116 toxoplasmosis, 160, 227 TPAL description for parity, 184 tracheoesophageal fistula, 230 tramadol, 287 transabdominal occlusion method, 61 transcervical occlusion procedure, 61 transdermal contraceptive system, 51 transgender, 41 transitional period for newborn, 217 transposition of great vessels, 230 transvaginal ultrasound, 144 traveler’s diarrhea, 259 Treponema pallidum, 106 screening/diagnostic tests for, 44 treponemal tests, 44 TRH See thyrotropin-releasing hormone Trichomonas vaginalis, 115 trichomoniasis, 100–101, 153 screening/diagnostic tests for, 44 tricuspid atresia, 230 tricyclic antidepressants (TCAs), 260–261, 291, 299 triglycerides, 243 triple screen test, 176 trisomies 13 and 18, 231 trisomy 21 (Down syndrome), 151 trivalent inactivated influenza vaccine (TIV), 144 truncus arteriosus, 230 TSH See thyroid-stimulating hormone TSS See toxic shock syndrome tubal ligation, 204 tuberculosis (TB), 15, 18, 161, 227, 255–257 tumors/neoplasms, gynecological, 94–99 Turner’s syndrome, 119–120 TWEAK screening tool for drinking problem, 147 twin gestation, 200–201 two-step approach, diabetes, 162 Chapter opener image: © Kristin/Shutterstock tympanic membrane (TM), 250 type diabetes mellitus, 278t type-specific serologic tests, 44 U ultrasonography (USG) amniotic fluid, 133 for gestational age determination, 134 ultrasound, 144, 197 umbilical cord, 132 prolapse, 198 United States Preventive Service Task Force (USPSTF), 17, 76, 81 unresponsive sleep, newborn’s initial period of, 217 unsensitized pregnancy, 163–164 urethritis, 109 urethrocele, 114 urge vs stress incontinence, 110 urinalysis, 14, 197 urinary excretion, 28 urinary frequency in pregnancy, 141 urinary incontinence, 110–111 urinary tract, 75 urinary tract infections (UTIs), 109–110, 158–159 disorders of, 109–112 urine hCG tests, 42 urogenital triangle, 193 U.S Department of Health and Human Services (USDHHS), 17 USDHHS See U.S Department of Health and Human Services USPSTF See United States Preventive Service Task Force uterine body, 37 uterine cycle, 38 uterine prolapse, 114 uterus, 37 physiologic adaptations in pregnancy, 134 physiologic and anatomic changes, 202 UTIs See urinary tract infections V vaccinations, during pregnancy, 144 vacuum aspiration (first trimester), 63 vagina, 37, 75, 202 examinations during first stage of labor, 188 physiologic adaptations in pregnancy, 134 vaginal carcinoma, 98 vaginal infections, 99–101 vaginal spermicides, 55–56 vaginismus, 117 vardenafil, 117 varenicline tablets, 21 varicella, 144 immunizations, 19–20 varicella-zoster (VZV), 161 varicosities in pregnancy, 141 vas deferens, 61 vascular disorders, 288 vasomotor symptoms (VMS), 77–79 VAW See violence against women velamentous cord insertion, in placenta, 196 venous thrombi, 242 venous thromboembolism (VTE), 62 veracity, as ethical principle, 326 vertebral fracture assessment (VFA), 285 vertex presentation, 192 vestibule, 36 vestibulitis, 112 VFA See vertebral fracture assessment vicryl, 194 violence against women (VAW), 147 viral conjunctivitis, 246 viral hepatitis, 263–265 viral infections, 227–228 virchow’s triad, 242 vision, physical exam, 10, 18 visualization, active study techniques, vital signs, monitoring during labor, 192, 203 vitamin B12 deficiency anemia, 267–269 vitamin K for newborn, 219 VMS See vasomotor symptoms voiding/stooling, newborn care, 218 VTE See venous thromboembolism vulva, 36 vulvar biopsy, 42 vulvar carcinoma, 98–99 vulvar dermatoses, 112–113 vulvodynia, 112–113 vulvovaginal candidiasis (VVC), 101, 153 VVC See vulvovaginal candidiasis VZV See varicella-zoster W waist circumference, WBCs See white blood cells Weber test, 10 weight gain in pregnancy, 136, 141 weight loss, normal postpartum, 202 well-child visits in first weeks of life, 223 well-woman care: menopause and beyond genitourinary syndrome of menopause (GSM), 79–80 menopause, 74–76 older adults, 80–81 pharmacologic considerations for elderly patients, 82 vasomotor symptoms (VMS), 77–79 visit age 65 and beyond, 81–82 visit ages 40 to 64, 76 well-woman visit age 65 and beyond, 81–82 ages 40 to 64, 76 older adults, 80–81 reproductive years, 39–40 wet mounts, 41 WHIMS See Women’s Health Initiative Memory Study white blood cells (WBCs), 14, 216 WHNP See women’s health nurse practitioner withdrawal contraceptive method, 60 withdrawal of treatment, right of patient, 326 Women’s Health Initiative Memory Study (WHIMS), 75 women’s health nurse practitioner (WHNP), 319 Wood’s screw maneuver, 199 X X-linked dominant inheritance, 22t X-linked recessive inheritance, 22t Z Z-score, 44 Zavanelli maneuver, 199 ZIFT See zygote intrafallopian transfer zoster (shingles), immunizations, 20 zygote, 131 zygote intrafallopian transfer (ZIFT), 118 ... alive and well The four-digit descriptor of this history is: a 0 121 b 022 1 c 20 21 d 22 01 22 A patient comes in for her first antepartal visit When asked the date of her last menstrual period, she... born at 36 weeks, and one born at 41 weeks Both infants are living Her parity is: a 20 22 b 21 22 c 121 2 d 1 122 97 The pelvic planes of obstetric significance are the: a inlet, midplane, and outlet... vaginal delivery at 34 weeks; two living children; now 28 weeks pregnant Her gravity and parity are: a G5 P1 122 b G5 P 022 2 c G3 P20 02 d G3 P21 12 Questions 117 Which of the following tests is diagnostic