Intro to Obstetrics Flashcards
Define the following terms: stillbirth IUFD neonatal death term preterm post-term
Birth: complete extraction or expulsion of a fetus from the mother
Stillbirth: no signs of life at birth > 20wks, doesn’t happen anymore.
Intrauterine Fetal Demise (IUFD): No cardiac activity in a fetus > 20 weeks
Neonatal death: death before 28 days of life
Term: 37-42 weeks (260-294 days)
Preterm: 37 completed weeks (before 259th day)
Post-term: 42 weeks and beyond (>295d)
define the following terms:
gravidity or gravid
parous or parity
Gravidity or Gravid
=Pregnant
Parous or Parity
=Delivered
Define the following terms: nulligravid primagravid primapara primip
Nulligravid: woman who is not now or ever been pregnant
Primagravid: pregnant with first pregnancy
Primapara: woman who has delivered once past the state of viability
“Primip”: short for Primapara. It is NOT a woman who is pregnant for the first time
Define the following terms: multipara nullipara parturient puerpera
Multipara: woman who has delivered 2 or more past the state of viability
Nullipara: never completed a pregnancy beyond 20 weeks
Parturient: woman who is in labor
Puerpera: woman who has just delivered
Describe the TPAL nomenclature:
T= term P= preterm birth A= abs, sab, or ectopics L= living children
What does the TPAL system not take into account?
- Route of delivery
- Distinction between spontaneous abortion, elective termination, or ectopic
- Twin deliveries with death of a child
What are presumptives that a woman may be pregnant versus probables?
Presumptives: Nausea and/or vomiting Fatigue Disturbance in urination Amenorrhea Breast changes Discolored cervical epithelium Increased skin pigmentation
Probables: Enlargement of abdomen Change in uterine size/shape Change in cervix Braxton Hicks contractions Physical outline of fetus \+ hCG test
Why is an hCG test only a probable that a woman may be pregnant? what do you need to confirm?
Definitive evidence of pregnancy:
FHTs identified
Fetal movement noted by examiner
Ultrasonographic or x-ray confirmation
What is the most important aspect of obstetrical care?
the assignment of an accurate EDD because every management care decision is based on this date
What are three dating parameters?
- history
- exam
- u/s
What are two components of the history that allow for dating?
- naegele’s rule
2. quickening
What is naegele’s rule?
from the FDLMP, add 7 days, and subtract 3 months to calculate the EDC
What is quickening?
in the prima gravid patient, fetal movement is usually noted at 20 weeks. In the primarparous patient, this occurs at 18 weeks.
What components are including in the exam for dating of the fetus?
- uterine size- 1st trimester
- fundal height
- fetal heart tones
What components are including in the U/S for dating of the fetus?
- first trimester (plus/minus 7 days)
- second trimester (plus/minus 14 days)
- third trimester (plus/minus 3 weeks)
Can an U/S be used to assign the EDD in the 3rd trimester?
No, it is not accurate
What should be included at the initial pre-natal visit?
- Risk assessment to include genetic, medical, obstetrical and psychosocial factors
- Physical examination
- Charting – ACOG record
- Laboratory tests
- Assignment of due date
- Patient education
What labs are indicated at the initial visit?
Hemoglobin Urinalysis Urine culture Blood group Rh Antibody screen Rubella status Varicella Syphilis screen Pap smear if >/= 21 HBsAg testing HIV Drug screen* GC/Chlamydia* Cystic fibrosis screen* **if indicated
How often should ever visit take place?
What should happen at every visit?
Visit intervals: every 4 weeks until 28, then q 2 wk until 36 wk, then weekly
Each visit: BP, wt, +/-UA, Fundal ht, FHT, FM, PTL risks, symptoms and focused assessment
What screenings should take place during pregnancy
11w0d – 13w6d: First trimester screen
15-20w6d weeks: MSAFP with quad screen
24-28 weeks: screen for gestational diabetes mellitus, give anti-D immune globulin
35-37 weeks: screen for GBS
What is aneuploidy screening?
screening for fetal chromosome abnormalities
1. first trimester screen (11w-13w6d)
Nuchal translucency
PAPP A (pregnancy associated plasma protein-A)
Free ß-hCG
2. second trimester screen (quad screen) AFP (alpha-fetoprotein) hCG Inhibin-A Estriol (E3)
There is now new non invasive prenatal testing that uses cell free fetal DNA from mom’s blood. Can be tested 10 weeks after gestation. However, it is only being used for high risk populations at this time.
what is the fundal height?
is a measure of the size of the uterus used to assess fetal growth and development during pregnancy. It is measured from the top of the mother’s uterus to the top of the mother’s pubic bone in centimeters. Fundal height roughly corresponds to gestational age in weeks between 16 to 36 weeks for a vertex fetus.
Record at every visit.
Fundus usually measures 20 cm at 20 weeks to the umbilicus. One cm /week until 36-37 weeks. 4 cm discrepancy is significant.
What are the general recommendations at the initial visit?
Active lifestyle Sexual activity permissible 25-35# weight gain for normal BMI Nutritious diet No ETOH/smoking/drugs Avoid cat litter box Wear lap/safety belt Discussion of first trimester screening
How does respirations change during pregnancy?
Chest diameter ↑ by 2 cms Chest circumference ↑ by 5 cms Diaphragmatic excursion ↑ by 4 cms RR-no change 30-40% ↑ in tidal volume Expiratory reserve volume- decreases
Is respiratory alkalosis normal in pregnancy?
yes
What cardiac changes are normal in pregnancy?
Hypervolemia (increases by about 50%)
Heart rate- 12-18 bpm increase
Stroke volume- 10-30% increase
Cardiac Output - therefore 33-45% increase
Increased split S1-S2, systolic ejection murmur heard 90% of the time.
What renal changes occur in pregnancy?
Kidneys enlarge 1 cm 2° to ↑ renal vascular volume and interstitial volume
Right-sided ureteral dilation 2° to effects of progesterone and uterine effects
***GFR and RPF (renal plasma flow) increases by up to 50%
Creatinine = .3-.7 mg/dL. Glycosuria during pregnancy is not necessarily abnormal. It is the result of increased GFR and impaired tubular reabsorpative capacity. There is NO increase in proteinuria due to pregnancy (normal - 100-300mg;/24hours). There is an increase in urinary frequency and total daily output.
What GI changes occur in pregnancy?
- increased appetite
- delayed gastric emptying and transit times = constipation
- due to mechanical obstruction from uterus, decreased motility from progesterone, and increased water absorption. - cholelithiasis: Impaired gallbladder contractions (progesterone) –>stasis and with ↑ cholesterol (estrogen)–> stone formation
- LFT: increased alkaline phosphatase due to placenta, decreased serum albumin
What blood changes happen in pregnancy?
Pregnancy is a hypercoagulable state and in the normal pregnancy, the coagulation cascade is in an activated state.
All clotting factors are increased except factor XI and factor XIII. Normal fibrinogen in a non-gravid woman is 150-250 mg/dL. In pregnancy the normal value is 300-600 mg/dL.
What is involved in the fetal assessment?
Fetal Kick Counting Non-stress test Ultrasound: -Biophysical profile -Modified BPP
How does the NST work?
The primary goal of the test is to measure the heart rate of the fetus in response to its own movements. Healthy babies will respond with an increased heart rate during times of movement, and the heart rate will decrease at rest. The concept behind a non-stress test is that adequate oxygen is required for fetal activity and heart rate to be within normal ranges. When oxygen levels are low, the fetus may not respond normally. Low oxygen levels can often be caused by problems with the placenta or umbilical cord. NSTs are generally performed after 28 weeks of gestation. Before 28 weeks, the fetus is not developed enough to respond to the test protocol. The test involves attaching one belt to the mother’s abdomen to measure fetal heart rate and another belt to measure contractions. Movement, heart rate and “reactivity” of heart rate to movement is measured for 20-30 minutes. If the baby does not move, it does not necessarily indicate that there is a problem; the baby could just be asleep. A nurse may use a small “buzzer” to wake the baby for the remainder of the test.
What is the biophysical profile?
The biophysical profile is a method of fetal assessment that utilizes both the NST and ultrasound.Each component is scored as either 0 or 2 points.
What is fetal monitoring?
Fetal monitoring is comprised of uterine contraction assessment and fetal heart rate assessment.
How do you assess contractions?
using an external tocodynomomter or IUPC
How do you assess FHR?
External transducer-usn doppler
Internal monitoring or scalp lead
Rate: 110 bpm – 160 bpm Variability: Absent Minimal (0 – 5 bpm) Moderate (6 – 25 bpm) Marked (>25 bpm)
What may be the cause of decelerations of HR?
Early: head compression
Variable: cord compression
Late: utero-placental insufficiency
what is amniorrhexis:
rupture of the amniotic sac
How do you diagnose amniorrhexis?
Pooling: noted at time of sterile speculum examination
Nitrazine: pH of vaginal fluid
Ferning: dried microscope slide of vaginal fluid
History: not helpful
How is labor defined?
Labor is defined as cervical effacement and dilation in the presence of uterine contractions.
What are the 3 stages of labor?
1st Stage of Labor
Latent phase
Active phase
2nd Stage of Labor
complete dilation to fetal expulsion
3rd Stage of Labor
delivery of fetus until delivery of placenta
How is abnormal labor defined?
come back to me
How do we define induction of labor?
To achieve a vaginal delivery by stimulating the onset of uterine contractions before the spontaneous onset of labor at 39 weeks or beyond unless fetal lung maturity has been determined.
What are the indications for induction of labor?
Chorioamnionitis Fetal demise Hypertension Preeclampsia/eclampsia PROM Post-dates IUGR
What are the contraindications for induction of labor?
Vasaprevia Placenta previa-complete Transverse lie Umbilical cord prolapse Prior uterine surgery above lower uterine segment Active herpes infection
What are some of the different methods for induction of labor?
Mechanical -foley bulb -laminaria Amniotomy Oxytocin PGE1 -misoprostol (cytotec) PGE2 -dinoprostone (cervidil)
what needs to be considered when referring to the undelivered fetus and whether or not vaginal delivery is appropriate?
LIE PRESENTATION POSITION
the fetal lie is the relation of the fetus to the long axis of the mother. It is either longitudinal, oblique, or transverse.
most are longitudinal
What is cephalic presentation? what are the 3 types of cephalic?
cephalic is coming on face first.
vertex (most are vertex)
face
brow
what is breech?
face not first.
- frank - thighs flexed, legs extended
- complete: thigh flexed, legs flexed (indian style)
- footlin/incomplete: one or both fee or knees are lowermost.
what are the tree types of vaginal deliveries?
SVD =spontaneous vaginal delivery
Assisted vaginal delivery=use of forceps or vacuum assisted
Breech vaginal delivery= rarely done, most go to c-section
During the active phase of delivery, what will the fetus do?
During the active phase of labor the fetus will usually progress through 7 cardinal movements prior to a vaginal delivery.
Engagement, flexion, descent, internal rotation, extension, external rotation, restitution
what are some indication for c-section?
Maternal indications:
- abnormal labor
- hemorrhage
- contracted pelvis
- prior c-section
Fetal Indications
- abnormal presentation
- fetal distress
- multiple gestation
- fetal macrosomia
describe the incision for c-section
classic = vertical ltcs= transverse
What tools are involved in an assisted vaginal delivery?
- forceps
2. vacuum (don’t use for baby less than 37 weeks or under 2500g)
What is a VBAC?
vaginal birth after cesarean.
Can get if
- one prior LTCS
- two prior LTCS and SVD
- adequate pelvis
- no other uterine scars
- physician immediately available throughout active labor or crew and anesthesia is available.
What are some of the hypertensive disorders of pregnancy?
- chronic hypertension
- bp >140/90 before 20 weeks or has been on bp meds in the past - gestational hypertension
- bp>140/90 after 20 weeks - Preeclampsia
- proteinuria >300 mg/24hrs
- bp>140/90 on 2 readings 6 hours apart
- after 20 weeks
What are some risks associated with multiple gestations?
- hyperemesis
- abortion
- gestational HTN and preeclampsia
- gestational diabetes
- anemia
- preterm labor
- umilical cord prolapse
- discordant growth
- operative delivery
- fetal complications
- congential malformations
- IUGR
What is the Rh factor?
The Rh factor is a type of protein on the surface of red blood cells. Most people who have the Rh factor are Rh-positive. Those who do not have the Rh factor are Rh-negative.If your blood lacks the Rh antigen, it is called Rh-negative. If it has the antigen, it is called Rh-positive.When the mother is Rh-negative and the father is Rh-positive, the fetus can inherit the Rh factor from the father. This makes the fetus Rh-positive too. Problems can arise when the fetus’s blood has the Rh factor and the mother’s blood does not. If you are Rh-negative, you may develop antibodies to an Rh-positive baby. If a small amount of the baby’s blood mixes with your blood, which often happens, your body may respond as if it were allergic to the baby. Your body may make antibodies to the Rh antigens in the baby’s blood. This means you have become sensitized and your antibodies can cross the placenta and attack your baby’s blood. They break down the fetus’s red blood cells and produce anemia (the blood has a low number of red blood cells). This condition is called hemolytic disease or hemolytic anemia. It can become severe enough to cause serious illness, brain damage, or even death in the fetus or newborn.
When is RhIG used?
RhIg is used during pregnancy and after delivery.
If a woman with Rh-negative blood has not been sensitized, her doctor may suggest that she receive RhIg around the 28th week of pregnancy to prevent sensitization for the rest of pregnancy.
If the baby is born with Rh-positive blood, the mother should be given another dose of RhIg to prevent her from making antibodies to the Rh-positive cells she may have received from their baby before and during delivery.
The treatment of RhIg is only good for the pregnancy in which it is given. Each pregnancy and delivery of an Rh-positive child requires repeat doses of RhIg.
Rh-negative women should also receive treatment after any miscarriage, ectopic pregnancy, or induced abortion to prevent any chance of the woman developing antibodies that would attack a future Rh-positive baby.
What is IUGR?
Intrauterine Growth Restriction.
An EFW at or below the 10th percentile for that gestational age is consistent with IUGR and close scrutiny is warranted.
Serial estimations of fetal weights and NST should be performed. If there is no growth over a 2-4 week period, consideration of delivery would be prudent.
Increased risks of: Stillbirth FHR abnormalities in labor Meconium passage and aspiration Hypothermia
What causes IUGR?
Smoking Low pre-pregnancy weight Poor wt gain Age 35 Diabetes Chronic renal dx SLE Heart dx Sickle cell dx Hypertension Thrombophilia Rx Multiple gestation Anomalies Infections Cytomegalovirus Toxoplasmosis Syphilis Placental
How do we define pre-term labor?
Preterm labor is defined as regular contractions associated with cervical change before 37 weeks.
Risk factors: Smoking Vaginal bleeding in pregnancy Age <17 [RR]=1.75 African-American [RR]=3.3 Low pre-pregnancy wt History of prior preterm birth Uterine or fetal anomalies Multiple gestations
What is gestational diabetes? How is it diagnosed?
Screening consists of a 50 gm glucose load and a RBS 1 hour later. If the value is >140 mg/dL, a 3 hr GTT should follow.
Fasting 105 95 1 hour 190 180 2 hour 165 155 3 hour 145 140 **GDM is diagnosed if two or more of the values are elevated
When should GBS be screened for? How is it treated?
All women should be screened at 35-37 weeks. If GBS is confirmed, antibiotics (penicillin) should be administered while in labor.
What is shoulder dystocia?
Shoulder dystocia is the entrapment of the anterior shoulder beneath the maternal symphysis pubis.Failure to deliver the baby can result in long-term neurological deficit or demise.
What is the leading cause of maternal mortality?
The leading cause of maternal mortality is embolic events from either a thrombus or amniotic fluid.
