Uterine Size and EDD Discrepancy

Study Group Module

Uterine Size and EDD Discrepancy National Midwifery Institute, Inc. Study Group Coursework Syllabus

Description: This module explores uterine size, fundal growth patterns, their normal variations, when to refer and its implications in midwifery practice. It includes recommended reading materials in print and online, and asks students to complete short answer questions for assessment, long answer questions for deeper reflection, and learning activities/projects to deepen your hands-on direct application of key concepts.

Learning Objectives: ● Review EDD calculations. ● Define IUGR, SGA and LGA. ● Identify the risks for IUGR or SGA babies, once they are born. ● Identify the risks for babies considered to be LGA. ● Understand the significance of polyhydramnios and oligohydramnios. ● Identify possible signs of twin pregnancy. ● Review possible signs of breech presentation in pregnancy. ● Understand why an abnormal fetal presentation can result in size/dates discrepancy. ● Review uterine abnormalities that can contribute to fetal position and size/dates discrepancy. ● Understand how fibroids may be affected during pregnancy and birth. ● Draft practice guidelines for responding to uterine size and EDD discrepancy.

Learning Activities: ● Research and read appropriate study sources, seeking out additional study sources where needed ● Complete short answer questions in attached module document for assessment ● Complete long answer questions for deeper reflection in attached module document for assessment ● Complete learning activities listed in attached module document for assessment ○ Draft practice guidelines for size/dates discrepancies ● Submit work to Study Group Course Coordinator ● Reflect on feedback from Study Group Course Coordinator and re-submit work as needed © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Uterine Size and EDD Discrepancy

Study Sources (print): The following texts are recommended for completion of this module. Use them to cross reference and build a more comprehensive understanding. Using keywords from the Learning Objectives, search the index. Read those pages listed, and read the chapter in which they are found. Establish a context for the information so that you understand how other topics are related. In addition, read the chapter headings in the Table of Contents, and flip through each text to familiarize yourself with the content of chapters. As you work through Study Group modules, you will eventually read each text in its entirety. ● Holistic Midwifery, Vol. I, II, Frye ● Varney’s Midwifery ● Myles Textbook for Midwives ● Human Labor and Birth, Oxorn and Foote

Study Sources (online): See NMI website Uterine Size and EDD Discrepancy module web resources section for current online study sources for this module.

Related Modules: ● Nutrition ● Placenta ● Gestational Diabetes ● Breech Birth ● Twins and Multiple Pregnancy ● Embryology and Fetal Development ● Physical Assessment of the Newborn

Submitting Module for Assessment: Study Group modules are accepted electronically in PDF format only. We encourage you to submit modules as you complete them throughout each quarter of enrollment.

Please e-mail your completed Study Group module to: Study Group Course Work Instructor [email protected]

Once your module has been emailed to us, you will receive an email confirmation that we have received it. Study Group modules are reviewed and returned in digital format as PDF documents. Modules can take up to 1 month from submission to be reviewed and returned to you. We will return your module as an e-mail attachment. Each module includes an Evaluation Sheet at the end of the pdf. The module’s page on the student portal also includes a link to a fillable online module evaluation sheet. Please take the time to fill out the module evaluation sheet and return it to us for each module, it helps us to improve our course work. © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Uterine Size and EDD Discrepancy

Please follow these formatting guidelines when submitting modules: ● Your first initial and last name in title of PDF, along with name of module. Example: “ERyanFirstStage.pdf” ● Title of module on the document’s front page ● Your name on the document’s front page ● Provide the text of each question, followed by a blank line and then your thoughtful answer (without the question, you have commentary without context) ● Blank line between the answer for a question and the next question: question, blank line, answer, blank line, question, blank line, answer… ● Please leave margin space for our comments! ● Don’t use script or cursive writing style text ● Font size not smaller than 12 ● Credit sources of direct quotes

Completion Requirements and Feedback: In order to complete this module for graduation purposes from National Midwifery Institute you must review all resources, complete the attached short answer questions for assessment, long answer questions for deeper reflection, and learning activities/projects, and submit them as detailed above. Upon return to you, your coursework may have feedback or ask for additional information or exploration on certain topics. Your work will be evaluated n the following Rubric (pasted below). You must achieve a minimum score of 7.5 in order to move on to your next module, though we encourage all students to strive for a 10.

Level 1 Level 2 Level 3 Level 3 Student (0 Points) (1 Point) (1.5 points) (2 points) Exceeds Score Not Adequate Developing Meets Basic Expectations Adequacy Expectations

Completion of -Module not -Major -All aspects of -All aspects of module module completed Elements of module elements present and prompts and module are elements answered completely elements missing present, with some minor questions unanswered or missing

Study Group Module: Uterine Size and EDD Discrepancy

Level 1 Level 2 Level 3 Level 3 Student (0 Points) (1 Point) (1.5 points) (2 points) Exceeds Score Not Adequate Developing Meets Basic Expectations Adequacy Expectations

Demonstrates - Lack of - Responses - Responses - Responses are clear, Comprehensi comprehension are unclear are clear and well written, and and do not reflect basic reflect in-depth on of module reflect basic comprehension comprehension of content and comprehension of module module content and concepts of module content and concepts. Added concepts concepts subpoints and additional reflections demonstrate a deeper knowledge and curiosity. Analysis - Key terms not -Inaccurate -Accurate - Accurate definitions defined definitions of definitions of of key items key items key items -Strong connections -Limited -Connections made between connections made between evidence, subtopics made between evidence, and clinical experience evidence, subtopics and subtopics and clinical clinical experience - experience Incorporation of original ideas and incorporates some clinical experience in responses where possible Evidence - No research -Research not -Research is -Research is abundant evidence used used present but -Research is -Research not limited compelling and clearly -Research relevant to connected to presented is communities served questions weak or not by midwives asked in relevant to module communities served by midwives Engagement -Evident study -Evident study -Evident that -Evident that study with Learning sources were sources were study sources sources were fully not utilized partially utilized were fully utilized and Resources utilized independent research was undertaken -Full incorporation of original ideas, personal analysis and incorporates relevant clinical experience in all areas possible

Skills © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Uterine Size and EDD Discrepancy

Following are excerpts from the NMI forms for assessment of midwifery skills, which include all skills identified and required by NARM. Review the following skills and consider how they each relate to the content of this module. If you are currently working with a preceptor, take this opportunity to focus on these areas. During Supervised Primary Care you will formally evaluate these skills together using the NMI forms Form 52 - Assessment of Student’s Midwifery Skills and Form 53 - Student Self-Assessment of Midwifery Skills. 1. Midwifery Counseling, Education and Communication: A. Provides interactive support and counseling and/or referral services to the mother regarding her relationships with her significant others and other health care providers B. Provides education, support, counseling and/or referral for the possibility of less-than- optimal pregnancy outcomes C. Provides education and counseling based on maternal health/reproductive/family history and on-going risk assessment D. Facilitates the mother's decision of where to give birth 1. The advantages and the risks of different birth sites 2. The requirements of the birth site 3. How to prepare, equip and supply birth site E. Educates the mother and her family/support unit to share responsibility for optimal pregnancy outcome F. Educates the mother concerning the natural physical and emotional processes of pregnancy, labor, birth and postpartum G. Applies the principles of informed consent H. Provides individualized care I. Advocates for the mother during pregnancy, birth and postpartum J. Provides education, counseling and/or referral, where appropriate for: 3. Prenatal testing 4. Diet, nutrition and supplements 5. Effects of smoking, drugs and alcohol use 8. Complications 9. Environmental risk factors 2. General Health care Skills: D. Demonstrates the use of instruments and equipment including: 10. Gestation calculation wheel/calendar 22. Tape measure L. Refers for performance of ultrasounds N. Refers for performance of biophysical profile 3. Maternal Health Assessment: C. Estimates due date based upon: 5. Date of positive pregnancy test 6. Date of implantation bleeding/cramping/pelvic congestion 7. Changes in the cervix 8. Changes in the uterus 9. Auscultation of the fetal heart 10. Date mother reported quickening 11. Measurement of fundal height 12. Palpation of body parts 13. Calendar date of conception or unprotected intercourse D. Assesses fetal weight, size, lie, or lightening E. Assesses correlation of weeks gestation to fundal height F. Performs routine prenatal physical exams, including ongoing assessment of: 1. Maternal psychosocial, emotional health and well-being 2. Maternal physical health and well-being, by tracking variations and

Study Group Module: Uterine Size and EDD Discrepancy

changes in: a) color of mucous membranes, b) General reflexes, c)Elimination/urination patterns, d) Sleep patterns, e) Patterns of sexuality, f)Movement, gait and energy level 3. Nutritional patterns 4. Vital signs 5. Weight 6. Hemoglobin and hematocrit 7. Glucose level 8. Urine for: a) Appearance, b) Protein, c) Albumin, d) Glucose, e) Ketones, f) pH, g) Leukocytes, h) Nitrites, i) Blood 9. Breast condition 10. Costovertebral angle tenderness (CVAT) 11.Deep tendon reflexes (DTR) of the knee 12. Signs of clonus 13. Fundal height measured with: a) Finger breadths b) Tape measure 14. Evaluation of estimated time of delivery 15. Fetal activity and responsiveness to stimulation 16. Fetal heart rate/tones auscultated with: a) Fetascope b) Doppler 17. Fetal position, presentation, lie, and the volume of amniotic fluid 18. Fetal weight 19. Signs of edema 20. Vaginal discharge or odor 21. Signs of abuse including: a) Maternal substance abuse b) Emotional/physical/sexual abuse to the mother G. Evaluates laboratory and medical records from other practitioners H. Obtains assistance evaluating laboratory and medical records from other practitioners

K. Recognizes and responds to potential prenatal complications by: 5. Identifying breech presentations 6. Turning breech presentations with: a) Alternative positions (tilt boards, exercises), b) non-allopathic methods 7. Identifying multiple gestation pregnancies

Study Group Module: Uterine Size and EDD Discrepancy

Uterine Size and EDD Discrepancy National Midwifery Institute, Inc. Study Group Coursework Short Answer Questions

Short Answer Questions: 1. List the common methods used to establish a baby’s expected due date.

2. Describe in detail how to calculate a due date based on LMP or known conception date. How do you adjust for longer and shorter cycles?

3. Compare the accuracy of a well-calculated due date based on LMP and a first trimester ultrasound given EDD.

4. Discuss measurements of uterine size a. do you measure uterine size before 20 weeks? How? b. do you measure uterine size after 20 weeks? How? Describe in detail. c. given how many weeks gestation you predict someone to be, how many centimeters do you expect their uterus to measure?

5. If there is a discrepancy between measured uterine size and expected size based of gestation/EDD, and the uterus is measuring larger than expected, what might be the most common explanations? a. at any gestation © National Midwifery Institute, Inc. Revised 2018

Study Group Module: Uterine Size and EDD Discrepancy

b. in the first 20 weeks of a pregnancy c. in the second 20+ weeks of a pregnancy

6. If there is a discrepancy between measured uterine size and expected size based of gestation/EDD, and the uterus is measuring smaller than expected, what might be the most common explanations? d. at any gestation e. in the first 20 weeks of a pregnancy f. in the second 20+ weeks of a pregnancy

7. Which possible explanations are due to midwife-related factors?

8. Which possible explanations are due to maternal/parental/uterine factors?

9. Which possible explanations are due to fetal-related factors?

10. Which possible explanations are due to placenta-related factors?

11. Define the following terms: a. small-for-gestational age (SGA) b. intrauterine growth restriction (IUGR) c. large-for-gestational-age (LGA) d. macrosomia

12. What are your concerns when anticipating the birth of an SGA baby?

13. Define symmetrical and asymmetrical IUGR.

14. How is IUGR confirmed prenatally?

15. List 5 possible causes of IUGR.

16. What is the management of a pregnancy diagnosed as IUGR?

17. Describe how you might identify IUGR based on baby’s appearance after birth.

18. What are the risks for a baby considered to be LGA?

19. Reflect on how an LGA suspicion might affect your informed choice discussion around gestational diabetes.

Study Group Module: Uterine Size and EDD Discrepancy

20. Describe the role of nutrition in SGA, LGA, and IUGR.

21. Describe which infections may cause growth restrictions. If you work outside North America, be sure to include relevant “tropical” diseases as applicable to your area.

22. Reflect on oligohydramnios and polyhydramnios below. a. what may oligohydramnios indicate? b. what may polyhydramnios indicate? c. how are oligohydramnios or polyhydramnios diagnosed?

23. When is an ultrasound indicated to assess the following: a. fetal size b. amniotic fluid volume c. fetal lie d. number of fetuses

24. Discuss the accuracy of ultrasound in estimating fetal weights accurately in the first, second, and third trimesters.

25. Discuss the accuracy of ultrasound in estimating an amniotic fluid index (AFI) in the first, second, and third trimesters. What are normal ranges of AFI? What findings would concern you?

26. How may abnormal fetal lie contribute to a size/dates discrepancy?

27. Describe the possible signs of twin or multiple pregnancy.

28. What uterine abnormalities can contribute to size/dates discrepancy and fetal position?

29. How may fibroids be affected during pregnancy?

30. If you detect an SGA, LGA, or IUGR baby, do you change the frequency or type of fetal monitoring done in pregnancy?

31. What can decreased fetal movement indicate?

32. Discuss the role of non-stress tests (NSTs) in fetal monitoring: a. when is an NST indicated for an SGA, LGA, or IUGR baby? b. if a non-stress is non-reactive, when do you repeat the NST? c. when do you transport for a nonreactive NST?

Study Group Module: Uterine Size and EDD Discrepancy

Continued……

Uterine Size and EDD Discrepancy National Midwifery Institute, Inc. Study Group Coursework Long Answer Questions for Deeper Reflection

Questions Requiring Longer, More Thoughtful Answers: (number continued from previous section). 33. Your client has been diagnosed with IUGR and this has been confirmed by ultrasound and consultation with your local OB/GYN. Your recent nonstress tests appear normal and reactive, and your client is within two weeks of her due date when labor begins spontaneously. Why is hospital birth indicated?

Study Group Module: Uterine Size and EDD Discrepancy

34. Your client is 36 weeks pregnant. Her fundal height has been within normal range. Her baby was head down at your last visit. Today when you palpate her baby’s position, she flinches a little on her left side, under her ribs. She says that she’s really tender there, so you don’t press very hard there. When you measure her fundal height, you find it measures 33 cm. What would you do now?

35. Your client is pretty sure about their dates. Their measurements, and your presumed gestational age, are listed below: 12 weeks : 1 finger above pubic bone 16 weeks : 3 fingers below umbilicus 20 weeks : at umbilicus, 20cm 24 weeks: 24cm 28 weeks: 25cm What would you do next? Describe your course to follow through to the conclusion that there is IUGR, and your course should IUGR be ruled out.

36. Your client has a pre-pregnancy BMI of 38, and distinguishing a fundus and fetal parts on palpation is difficult. How do you continue to assess uterine size and evaluate dates, while providing adequate informed choice and sensitive midwifery care?

Continued…….

Uterine Size and EDD Discrepancy National Midwifery Institute, Inc. Study Group Coursework Projects/Learning Activities

Projects(send completed projects with the rest of your course work for this module) (number continued from previous section).

Study Group Module: Uterine Size and EDD Discrepancy

37. Draft practice guidelines for size/dates discrepancies in your own practice. Include reference to your schedule of visits, medical consultation and screening. Submit this draft along with this module, and include it later in your Practice Guidelines projects (in the Charting and Practice Guidelines Module.)