Provimi i Shtetit - Mami cheat sheet

Naegele's rule: EDD = LMP + 280 days (adjust for cycle length; if cycles >28 days, add the difference).

Recommended antenatal visit schedule (WHO 2016): 8 contacts - first before 12 weeks, then at 20, 26, 30, 34, 36, 38, and 40 weeks.

Gravida = number of pregnancies including current; Para = number of births after 20 weeks (or ≥500 g).

Fundal height in cm ≈ gestational age in weeks from 20–36 weeks; discordance >3 cm warrants evaluation.

First-trimester labs: CBC, blood group and Rh, antibody screen, HIV, syphilis (RPR/VDRL), HBsAg, rubella immunity, urinalysis, Pap if due.

Folic acid 400 mcg daily preconception through first trimester reduces neural tube defects; 4–5 mg for prior NTD-affected pregnancy.

RhD immunoglobulin 300 mcg (1500 IU) at 28 weeks and within 72 hours postpartum if mother Rh-negative and infant Rh-positive.

Normal fetal heart rate baseline: 110–160 bpm; presence of accelerations and variability indicates reassuring status.

Danger signs requiring immediate referral: vaginal bleeding, severe headache/blurred vision, fever, reduced fetal movements, leaking fluid, severe abdominal pain.

First stage: latent phase 0–5 cm (may last up to 20 h nullipara, 14 h multipara); active phase ≥5 cm with regular contractions.

Active first stage progress: cervical dilation ≥1 cm/hour; arrest = no dilation for ≥2 hours despite adequate contractions.

Second stage: nullipara up to 3 hours, multipara up to 2 hours (with or without epidural per ACOG; add 1 h for epidural).

Partograph: plot cervical dilation, descent, contractions, FHR, and maternal vitals; action line triggers reassessment/referral.

FHR auscultation: every 30 min in active first stage, every 15 min in second stage (every 5 min if risk factors).

Cardiotocography categories: Category I (normal) = baseline 110–160, moderate variability, no late/variable decels; Category III = absent variability with recurrent late/variable decels or bradycardia.

Adequate uterine contractions: 3–5 in 10 minutes, lasting 45–60 seconds, firm on palpation.

Active management of third stage: uterotonic (oxytocin 10 IU IM), controlled cord traction, uterine massage - reduces postpartum hemorrhage.

Delayed cord clamping ≥1 minute improves neonatal iron stores; dry and stimulate newborn immediately, then assess Apgar at 1 and 5 minutes.

Postpartum hemorrhage definition: blood loss ≥500 mL after vaginal birth or ≥1000 mL after cesarean, or any loss causing hemodynamic instability.

Uterine atony is the most common cause of PPH; management: uterine massage, oxytocin 10 IU IM/IV, then carboprost 250 mcg IM (contraindicated in asthma), misoprostol 800 mcg sublingual, tranexamic acid 1 g IV within 3 h.

Bimanual uterine massage/compression and balloon tamponade are mechanical measures for atony; laparotomy if refractory.

Lochia: rubra (days 1–3, red), serosa (days 4–10, pink/brown), alba (after day 10, white/yellow).

Postpartum fever ≥38.0°C on two occasions ≥24 h apart after first 24 h suggests endometritis; treat with IV clindamycin + gentamicin.

Newborn transition: first period of reactivity (0–30 min), sleep, second period (2–8 h); normal respiratory rate 40–60/min, heart rate 120–160 bpm.

Newborn thermoregulation: dry immediately, skin-to-skin, hat; avoid bathing before 24 h; target axillary temperature 36.5–37.5°C.

Breastfeeding initiation within 1 hour; colostrum provides immunoglobulins; feed on demand ≥8–12 times/24 h.

Postpartum depression screening: Edinburgh Postnatal Depression Scale (EPDS) ≥10 or positive question 10 requires further assessment.

Preeclampsia: BP ≥140/90 mmHg on two occasions ≥4 h apart after 20 weeks plus proteinuria ≥300 mg/24 h or end-organ dysfunction; severe features: BP ≥160/110, platelets <100,000, AST/ALT >2× normal, creatinine >1.1 mg/dL, pulmonary edema, visual/cerebral symptoms.

Magnesium sulfate for eclampsia prophylaxis in severe preeclampsia: 4–6 g IV loading over 20 min, then 1–2 g/h; monitor reflexes, respirations, urine output; antidote calcium gluconate 1 g IV.

Gestational diabetes screening: 50 g glucose challenge at 24–28 weeks; diagnostic 75 g OGTT (fasting ≥92, 1 h ≥180, 2 h ≥153 mg/dL; any one value abnormal).

Placenta previa: painless vaginal bleeding after 20 weeks; avoid digital vaginal exam; confirm by ultrasound; cesarean delivery for complete previa.

Placental abruption: painful vaginal bleeding, tense uterus, fetal distress; risk factors hypertension, trauma, cocaine, prior abruption.

Preterm labor: regular contractions with cervical change before 37 weeks; tocolysis (nifedipine) for 48 h to allow corticosteroids (betamethasone 12 mg IM ×2, 24 h apart) and magnesium sulfate for neuroprotection <32 weeks.

Rh alloimmunization prevention: RhIG for Rh-negative unsensitized women at 28 weeks, after amniocentesis, and within 72 h of delivery of Rh-positive infant.

Shoulder dystocia maneuvers: McRoberts, suprapubic pressure, internal rotation (Rubin II/Woods), delivery of posterior arm, Gaskin; avoid fundal pressure.

Postpartum hemorrhage emergency: call for help, assess ABC, fundal massage, IV access, crystalloid, oxytocin 10 IU IM/IV, tranexamic acid 1 g IV, blood products; monitor vital signs every 5–15 min.

Uterine inversion: do not remove placenta before replacement; replace manually (Johnson maneuver) with tocolysis/uterine relaxation; resuscitate concurrently.

Shoulder dystocia: recognize after head delivery with turtle sign; McRoberts + suprapubic pressure first; document times and maneuvers; examine newborn for brachial plexus injury.

Cord prolapse: call for help, knee-chest or Trendelenburg, elevate presenting part manually, fill bladder 500–700 mL if needed, immediate cesarean.

Eclamptic seizure: protect airway, left lateral position, magnesium sulfate 4–6 g IV loading, then 1–2 g/h; control BP with labetalol/hydralazine; delivery after stabilization.

Maternal cardiac arrest: start CPR, left uterine displacement, continuous manual fundal displacement; perimortem cesarean within 4–5 minutes if no ROSC.

Newborn resuscitation: warm, dry, stimulate; if apneic or HR <100, positive pressure ventilation with room air (21% O2) at 40–60 breaths/min; chest compressions if HR <60 after 30 s effective ventilation (3:1 ratio).

Anaphylaxis: epinephrine 0.3–0.5 mg IM (1:1000) in anterolateral thigh, repeat every 5–15 min; oxygen, IV fluids, antihistamine/corticosteroid adjuncts.

Sepsis in pregnancy: maternal early warning signs (fever, tachycardia, hypotension, altered mental status); obtain cultures, start broad-spectrum antibiotics within 1 hour, fluid resuscitation.

Combined oral contraceptives: take daily; missed pill rules - if one pill missed, take ASAP and continue; if ≥2 missed, use backup for 7 days and consider emergency contraception.

Emergency contraception: levonorgestrel 1.5 mg within 72 h (efficacy declines with time); ulipristal 30 mg within 120 h; copper IUD within 5 days is most effective.

Contraindications to combined hormonal contraceptives (WHO MEC category 4): smoking ≥15 cigarettes/day at age ≥35, hypertension ≥160/100, history of DVT/PE, migraine with aura, breast cancer, severe liver disease.

Depot medroxyprogesterone acetate (DMPA) 150 mg IM every 12 weeks; may cause delayed return to fertility (up to 10 months) and bone mineral density loss; not first-line for adolescents per some guidelines.

Copper IUD: effective up to 10–12 years; increases menstrual bleeding and cramping; emergency contraception within 5 days.

Lactational amenorrhea method (LAM): requires exclusive breastfeeding, amenorrhea, and <6 months postpartum; 98% effective when criteria met.

STI screening in pregnancy: HIV, syphilis, hepatitis B at first visit; repeat HIV and syphilis in third trimester if high risk; chlamydia/gonorrhea for women <25 or risk factors.

Syphilis in pregnancy: benzathine penicillin G 2.4 million units IM is the only proven fetal treatment; penicillin allergy requires desensitization.

HIV in pregnancy: antiretroviral therapy for all; viral load monitoring; cesarean if VL >1000 copies/mL near delivery; avoid breastfeeding if safe replacement feeding feasible.

Informed consent requires capacity, disclosure of risks/benefits/alternatives, and voluntariness; document discussion.

Confidentiality: disclose health information only with patient consent or as required by law (e.g., reportable communicable diseases, child abuse).

Mandatory reporting: suspected child abuse/neglect, domestic violence (per jurisdiction), and certain communicable diseases (e.g., HIV per local law).

Scope of practice: midwives provide care for normal pregnancy, birth, postpartum, and newborn; refer or consult for complications beyond scope.

Professional boundaries: avoid dual relationships; maintain patient dignity and privacy; cultural safety and non-discrimination.

Documentation standards: contemporaneous, accurate, legible, signed, dated; errors corrected with single line, initial, and date - no obliteration.

Duty of care and negligence elements: duty, breach, causation, damages; midwife held to standard of a reasonably competent midwife.

Advocacy: support patient's informed choice, including right to refuse interventions; escalate concerns through chain of command.

Legal frameworks: licensure/registration, continuing education requirements, and mandatory reporting of impaired colleagues.

Five rights: right patient, right drug, right dose, right route, right time; add documentation and reason.

Oxytocin: IV infusion 10–20 IU in 1 L crystalloid; titrate to contractions; risk of hyperstimulation and hyponatremia with high-volume IV.

Magnesium sulfate toxicity signs: loss of deep tendon reflexes, respiratory depression (<12/min), oliguria; stop infusion and give calcium gluconate 1 g IV.

Methylergonovine 0.2 mg IM: contraindicated in hypertension/preeclampsia; causes vasoconstriction.

Carboprost (PGF2α) 250 mcg IM: contraindicated in asthma; may cause diarrhea, fever, hypertension.

Betamethasone 12 mg IM ×2 24 h apart for fetal lung maturity between 24–34 weeks (and up to 36 weeks per some guidelines).

Labetalol for hypertension in pregnancy: start 100–200 mg PO BID or 20 mg IV; avoid in asthma, bradycardia, heart block.

Hydralazine IV 5–10 mg every 20–40 min for severe hypertension; risk of reflex tachycardia and headache.

Medication safety in lactation: check compatibility (e.g., avoid codeine due to CYP2D6 ultrarapid metabolism risk in neonates).

WHO five moments for hand hygiene: before patient contact, before aseptic task, after body fluid exposure, after patient contact, after touching surroundings.

Hand hygiene with alcohol-based rub for 20–30 seconds; soap and water for 40–60 seconds when hands visibly soiled or after C. difficile exposure.

Sterile technique for invasive procedures (e.g., catheterization, episiotomy repair, cord cutting); use single-use sterile gloves.

Safe motherhood: clean delivery kit (soap, clean gloves, sterile blade, cord ties, clean cloth), clean hands, clean perineum, clean surface.

Active third-stage management reduces PPH; ensure uterotonic storage per cold chain (oxytocin 2–8°C).

Sharps safety: do not recap needles; dispose in puncture-proof container; report needlestick immediately and follow post-exposure prophylaxis protocol.

Isolation precautions: contact for MRSA/ESBL, droplet for influenza/pertussis, airborne for TB (N95 mask, negative pressure).

Maternal sepsis prevention: screen for group B strep 36–37 weeks; intrapartum penicillin for carriers; treat chorioamnionitis with broad-spectrum antibiotics.

Waste segregation: infectious waste (yellow), sharps (puncture-proof), general waste; follow local regulations.

Teach-back method: ask patient to explain in own words; confirms understanding and corrects misconceptions.

Motivational interviewing principles: open-ended questions, affirmations, reflective listening, summarizing (OARS).

Shared decision-making: present options, discuss benefits/risks, elicit patient values, reach agreement.

Health literacy: use plain language, limit to 3–5 key points, use visual aids, avoid jargon.

Cultural competence: assess beliefs, language, and decision-making preferences; use trained interpreter, not family members.

Breaking bad news (SPIKES): Setting, Perception, Invitation, Knowledge, Emotions, Strategy/summary.

Counseling on breastfeeding: skin-to-skin, feeding cues, correct latch, frequency; address common concerns (engorgement, sore nipples).

Perinatal mental health communication: screen with EPDS, ask directly about thoughts of self-harm, provide resources and follow-up.

Documentation of counseling: record topics discussed, patient response, and plan; include interpreter use if applicable.