Pregnancy Additional Info Flashcards
1
Q
menstrual cycle
define these words:
* menarche
* menses
* perimenopause
* menopause
A
- Menarche: 1st mensturual period (starting on avg at 12 yrs)
- Menses: monthly cycles of menstruation
- Perimenopause: interval of menstural irregularities leading up to total cessation of cycles
- Menopause: cessation of menses for 12+ months (avg age = 51 yrs)
2
Q
menstrual cycle
effects of progesterone on reproductive organs
A
- Stabilizes and causes maturation of endometrium for implantation
- increases Endometrial secretions/ thickness
- Lobular breast development
- elev Body temperature
3
Q
Menstrual cycle
what is corpus luteum
A
forms from cells of the ovarian follicle wall after an ovum is released during ovulation; serves as a temporary endocrine gland during the latter half of the menstrual cycle and into early pregnancy
4
Q
menstrual cycle
purpose of follicular phase
A
- Grow the endometrial layer of the uterus (increased number of stroma and glands, increasing depth of the spiral arteries that supply the endometrium)
- Create an environment that is friendly and helpful to possible incoming sperm (creation of channels within the cervix, allowing for sperm entry)
- develop a primordial follicle (a primordial follicle matures into the Graafian follicle that is ready for ovulation)
5
Q
Menstural Cycle
- amenorrhea
- menorrhagia
- metrorrhagia
- menometrorrhagia
- dysmenorrhea
- oligomenorrhea
- polymenorrhea
A
- Amenorrhea: absence of menses due to hypothalamic, pituitary, ovarian, uterine, or vaginal cuases; can be primary (no menarche by age 15) or secondary (absence for 3+ mo w/ previously normal cycle)
- Menorrhagia: regular menstrual interval w/ excessive eflow (>80mL for 7+ d)
- Metorrhagia: irregular uterine bleeding between menstural periods or at irregular intervals
- Menometrorrhagia: menorrhagia (heavy menstrualflow(> 80 mL for > 7 days) with metrorrhagia (menses at irregular intervals)
- Dysmenorrhea: recurrent abdominalpainassociated with menstruation
- Oligomenorrhea: menstrual interval > 35 days
- Polymenorrhea: menstrual interval < 21 days
6
Q
Pregnancy Diagnosis
pregnancy terminology (g/p/a system)
A
Gravidity (G)
* The number of times a woman has been pregnant
* Gravidity = Parity + Abortion
Parity (P)
* The total number of pregnancies reaching the age of viability regardless of the outcome (live birth, stillborn,cesarean delivery, etc.)
* Viability: ability to survive or live successfully; ≥ 24 weeks
Abortion (A)
* Number of lost pregnancies prior to the age of viability
* Includes both spontaneous abortions (miscarriages) and elective abortions (induced terminations of pregnancy)
7
Q
Pregnancy Diagnosis
what does G3P2A1 mean
A
- G3: 3 pregnancies
- P2: 2 pregnancies carried after viability
- A1: one loss of pregnancy prior to viability
8
Q
Pregnancy Diangosis
pregnancy terminology: LMP, gestational age, EDD
A
- Last menstrual period (LMP): 1st day of woman’s most recent period
- Gestational age (weeks, days): age of pregnancy calculated from LMP
- Estimated date of delivery (EDD): also known as the estimated date of confinement (EDC); Date when a pregnant woman is expected to give birth, Usually determined during the first prenatal visit, ~4–5% of women give birth on their EDD
9
Q
pregnancy diagnosis
duration: classify terming + trimester
A
- Counted by completed weeks + completed days of the current week since the LMP
Duration of normal pregnancy:
* Full-term pregnancy: 37–42 weeks
* Preterm pregnancy: < 37 weeks
* Post-term pregnancy: > 42 weeks
Classified into trimesters:
* 1st trimester: first day of LMP to 13 weeks, 6 days
* 2nd trimester: 14 weeks, 0 days to 27 weeks, 6 days
* 3rd trimester: 28 weeks, 0 days to 40 weeks, 6 days
10
Q
Pregnancy diagnosis
gestations vs embryonic age
A
- Gestational age: time that has passed since the onset of the last menstruation, which generally or as standard occurs 2 weeks before the actual fertilization
- Embryonic age: measures the actual age of the embryo or fetus from the time of fertilization
11
Q
Pregnancy Diagnosis
US 1st trimester findings
A
Presence of a gestational sac:
* 1st visible finding of pregnancy is seen around 4.5–5 weeks
* Ahypoechoiccircle within the uterine cavity, surrounded byhyperechoicendometrium
* Should be visible in theuterusif quantitative serum β-hCG is >2,000 mIU/mL
Presence of a yolk sac:
* A thinhyperechoicring within the gestational sac
* 1st visible around 5–6weeks and disappears around 10 weeks
Presence of a fetal pole with a heartbeat:
* visible around 5.5–6weeks
12
Q
Pregnancy Diagnosis
establishing the EDD
A
Calculating the EDD from the LMP:
* The date that falls exactly 40 weeks after the LMP
* Calculated by adding 9 months + 7 days to the LMP or subtracting 3 months from the LMP and adding 7 days
Dating by ultrasound:
* Measure the crown-rump length and compare to an established table
* Ultrasound dating is most accurate in the 1st trimester before genetic variation and the effects of intrauterine environment begin to have greater effects on fetal growth
- Calculating the EDD from the LMP is themost accuratemethod to date a pregnancyifthat EDD is consistent with the dates obtained from the ultrasound
- If the LMP is unknown, a 1st-trimester ultrasound is the next most accurate way to date a pregnancy
13
Q
Pre-Natal Care
genital herpe management
A
- Receive antiviral prophylaxis with acyclovir 400 mg PO TID starting around 36 weeks gestational age
- Be evaluated specifically for any signs of active lesions (including on the cervix) at the onset of labor
- Active lesions at the time of labor are a relative contraindication to vaginal delivery
14
Q
A
15
Q
Pre-Natal Care
types of US screenings in pregnancy
A
- Viability US: Ultrasound at 8-12 weeks, first scan to determine the heart rate, placenta location, identify # of embryos
- Nuchal Translucency (NT): 11-14 weeks. Measures fluid behind the fetus neck. Can identify certain birth defects, including cardiac and risk for Down Syndrome.
- Anatomy US: 16-20 weeks. Check the entire anatomy of fetus, all organ development
16
Q
Pre-Natal Care
US- cervical length, growth US
A
- Cervical Length: Measure length of cervix starting at 16 weeks, only indicated for those at risk of cervical shortening or cervical incompetence. (< 2.5 cm = short cervix)
- Growth US: Measure areas of the body to determine estimated fetal weight. Occurs at anatomy scan and every 4-8 weeks depending on maternal conditions
17
Q
Pre-Natal Care
Fundal Height- location/measurement by age
A
- 12 weeks at pubic symphysis
- 16 weeks midway between pubic symphysis and umbilicus
- 20 weeks at umbilicus
- 20-36 weeks height in cm=gestational age
- After 36 weeks fetus descends into pelvis
18
Q
Pre-Natal Care
Leopold’s Maneuver
A
- performed after 20 wks
- Determines fetal position, done near end of pregnancy
- What is at the fundus
- Where is fetal back and small parts
- What is the presenting part
- Where is the cephalic prominence
19
Q
Pre-Natal Care
Folate + Folic Acid in Pregnancy
A
- Folate (Vitamin B9) naturally occurs in foods: beef, liver, leafy greens, peas, beans, eggs, milk
- Folic Acid: Synthetic form of folate
- Most important during the first trimester during organogenesis
Pregnancy Recommendations:
* Universal prophylaxis: 0.4mg (400mcg) once daily, Recommended to start at minimum 1 month before conception to help prevent neural tube defects
* High dose prophylaxis: 1-4mg, Recommended for individuals who are at higher risk of having fetal neural tube defects
20
Q
Pre-Natal Care
recommended preg wt gain
A
- Twins: 15-20 kg
- BMI < 18.5: 12-17 kg
- BMI 18.5-24.9: 11-15 kg
- BMI 25-29.9: 6-11 kg
- BMI > 30: 6 kg
21
Q
Pre-Natal Care
why to avoid smoking/EtOH in pregnancy
A
Smoking
* Increases risk of low birth weight and fetal growth restriction
* Increased risk of preterm labor and perinatal death
* Carbon monoxide > vasoconstriction of the fetal vessels in the placenta > decreased placental perfusion
Alcohol
* Fetal alcohol syndrome (FAS) birth defect syndrome
* Structural malformations (predominantly facial) (Microcephaly, short palpebral fissures, flat midface, underdeveloped philtrum, thin upper lip, low nasal bridge, epicanthal folds, minor ear anomalies, small teeth with faulty enamel, foreshortened nose, micrognathia)
* Growth restriction
* Neurologic abnormalities including mental retardation
* Alcohol consumption during pregnancy generally >3oz/day, no lower limit
22
Q
Pre-Natal Care
genetic carrier screening
A
- Blood or saliva testing prior to pregnancy for pregnant patient and partner. Checks for any autosomal recessive inherited disorders
Single Gene Autosomal recessive disorders
* Able to test based on ethnicity that is most often affected, however these disorders are not restricted to these groups
* Common: Tay Sachs (Eastern/Central European Jewish, French Canadian, Cajun), Fragile X, Cystic Fibrosis, Sickle Cell Disease (African descent)
Benefits:
* Preconception identification of carriers of genetic disorders provides an opportunity for education regarding their risk of having an affected offspring, its prognosis, and their reproductive options.
* Patient can consult with genetic counselor
23
Q
Pre-Natal Care
old pre-natal genetic testing
going out of use…
A
- sequential screen labs
- Triple screen (1st trimester): NT, bHCG, PAPP-A
- Quad screen (2nd trimester): AFP, bHCG, Estriol, Inhibin A
- Alpha fetoprotein: increased result suggests spina bifida, decreased result suggests trisomy 21 (Down Ayndrome)
- Down syndrome marker results: bHCG high, Inhibin A high, Estriol low, AFP low
- PAPPA-A: pregnancy associated plasma protein, key regulator of insulin-like growth factor essential for normal fetal development. Low PAPP-A indicative of placental insufficiency (increased risk of preterm delivery, fetal growth restriction, stillbirth and hypertensive disorders)
24
Q
Pre-Natal Care
New Prenatal testing
A
Non-Invasive
* Non-Invasive Prenatal Testing (NIPT) (Screening Test)
* cfDNA: Small amount of cell-free DNA released from placenta into the pregnant woman’s bloodstream.
* test at 10-14 wks pregnancy for Trisomy 13, 18, 21, and sex chromosomes
* results return as “low risk” or “high risk”; detection rate > 98%
Invasive
* Chorionic Villi Sampling (CVS): Needle aspiration procedure, small amount of cells taken from the placenta; performed at 10-12 wks
* Amniocentesis: Needle aspiration procedure, cells taken from the amniotic sac; performed 16+ wks
25
# Pre-Natal Care
things for providers to do at each visit 12-24 wks
* monthly visits
* maternal vital signs (BP, wt), feta heart rate, fundal height
* HPI: vaginal bleeding, fluid loss, contractions, fetal movement
Special Tests
* 12-16 wks: serum MSAFP
* 20+ wks: anatomy scan
26
# Pre-Natal Care
common 2nd trimester issues/complaints
* Round ligament pain: Stretching, frequent position change, sleeping with a pillow between legs)
* UTI’s: Dilated urinary tract increases risk, asymptomatic bacteriuria is treated if >100,000 CFUs
* Yeast infections: immunosuppression, treat with Terconazole suppositories
* Constipation: Colace 100mg BID, educate on increased fruits/vegetables, water, fiber-rich foods; if necessary, consider Miralax)
* Iron-deficiency anemia: Ferrous sulfate with vitamin C supplementation
27
# Pre-Natal Care
Non-Stress Test
* Test for fetal well-being (Assess response of FHR to periods of fetal movement)
* Most commonly performed antenatal testing
* Low risk pregnancy- performed weekly after 40 weeks
* High risk pregnancy: performed in the the late third trimester weekly/ biweekly
Describe
* An evaluation of the FHR pattern in the absence of regular uterine contractions to determine fetal oxygenation, neurologic, and cardiac function
* Based on premise that the normal fetus moves at various intervals; CNS and myocardium respond to FM with acceleration of FHR
* Acceleration is a sign of fetal well-being
Interpret Fetal Heart Monitoring
* NST reactive: two accelerations in FHR in a 20 minute period
28
# Rh Alloimmunization
Rh Factor- what is it
* Inherited lipoprotein on the surface of RBCs
* Several Rh antigens, Rh (D)
* Presence of Rh (D) is Rh +; Absence of Rh is Rh-
29
# Rh Alloimmunization
Rh (D) neg vs pos
* if mother & father are Rh (D) pos, baby will be pos. (no intervention required)
* if mother & father are Rh (D) neg, baby will be neg. (no intervention required)
* if mother is negative & father is positive, fetus could be negative or positive so RhoGam protocol should be initiated.
30
# Rh Alloimmunization
first pregnancy vs second pregnancy
FIRST PREGNANCY
* if the mother is Rh neg and baby is Rh pos, there is Rh incompatibility and the mother will create anti-Rh antibodies
SECOND PREGNANCY
* mother's IgG anti-Rh antibodies will travel through the placenta and attack the baby if the baby is Rh Pos
* this leads to fetal hemolytic anemia or hydrops fetalis
31
# Rh Alloimmuniztion
Alloimmunization
* An immune response when exposed to foreign antigens which stimulates production of immunoglobulin G (IgG) antibodies
* Maternal Alloimmunization: reserved for Rh neg mother exposed to Rh pos fetal blood
* Antibody response develops slowly – not detectable serologically until 5-15 weeks after exposure. Primary immune response depends on several factors besides the volume of fetal blood the mother is exposed to frequency of Fetomaternal bleeding and abo compatibility
* exposure can occur due to miscarriage, therapeutic termination, ectopic pregnancy, antenatal bleeding, abd trauma; can do CVS, amniocentesis, ECV
32
# Rh Alloimmunization
when to screen?
* first prenatal visit, all pregnant women should be screened for ABO blood group + Rh antigen
* common practice to just test the mother and give all Rh(D) negative mothers Rhogam prophylais
33
# Rh Alloimmuniztion
Preventing Alloimmunization
Anti-D Immunoglobulin (RhoGam) Injection
* Administered to women exposed or at high risk of being exposed to Rh (D) + RBCs
* Suppresses immune response and antibody formation
* Protect against maternal alloimmunization from 15mL of fetal RBCs/ 30mL of fetal whole blood
* Dose: 300 µg IM injection
RhoGam Admin Protocol
* 28 weeks: Administer to all patients, if Rh negative
* 40 weeks: If more than 12 weeks have elapsed since Rhogam administration, administer again
* Postpartum: If infant Rh (D) +; Recommend 72 hours after delivery, however shown to be effective up to 28 days after delivery
* Fetomaternal bleeding: As little as 0.1 ml of Rh+ cells can cause sensitization !
34
# Rh Alloimmuniztion
Evaluating Fetomaternal Hemorrhage
* Rosette Test: sensitive, qualitative test = can detect >2mL fetal whole blood in maternal circulation; if pos do KB
* Kleihauer-Betke (KB): measure amount of fetal hemoglobin txfr to maternal bloodstream & aid in determination of # of vials of RhoGam needed; 1 vial = 300mcg which protects against 30 mL of fetal blood
35
# Fetal Monitoring
Antepartum Testing- screening vs diagnostic
* Screening: non-invasive tests, maternal blood work, imaging
* Diagnostic: invasive testing that involves obtaining sample of material from inside the uterus containing fetal DNA (CVS at 10-13 wks or amniocentesis 15-20 wks)
36
# Fetal Monitoring
Antepartum Monitoring- describe
* monitoring when not in labor
* Cardiotocography = Electronic fetal monitoring
* Non-stress test (NST)
* Contraction stress test (CST)
* Biophysical Profile (BPP)
37
# Fetal Monitoring
Antepartum Monitoring- describe
* monitoring when not in labor
* Cardiotocography = Electronic fetal monitoring
* Non-stress test (NST)
* Contraction stress test (CST)
* Biophysical Profile (BPP)
38
# Fetal Monitoring
Indications for Antepartum Monitoring
| Maternal vs Fetal
Maternal Indications
* Preterm labor, preterm prelabor rupture of membranes (PPROM)
* Prior fetal demise
* Pre-existing or gestational diabetes
* Chronic or pregnancy-induced hypertension (gestational HTN or preeclampsia)
* Rh Alloimmunization
* Other pre-existing medical conditions - SLE, cyanotic heart disease, sickle cell anemia
Fetal Indications
* Multiple gestations (twins, triplets, etc)
* Post-dates pregnancy (40+ weeks)
* Fetal growth restriction
* Oligohydramnios
* Decreased fetal movement (detected by mother)
39
# Fetal Monitoring
Electronic Fetal Monitoring- describe
* Cardiotocography
* Monitors fetal heart rate on one graph, and contractions (toco) on second graph over time
* Provides data on how fetus is responding to intrauterine event
* External monitoring: Doppler ultrasound on the maternal abdomen; Picks up artifact, movement. Difficult in abdominally obese patients. Need physical transducer on abdomen at all times.
* Internal monitoring: Fetal scalp electrode; More invasive, need to feel fetal scalp transcervically in order to place.
40
# Fetal Monitoring
why use EFM?
* For antenatal monitoring, EFM can give an idea of fetal well-being
* During labor uterine contractions cause interruptions in fetal oxygenation, so EFM helps providers decide when to intervene (offer resuscitation or c-section, etc)
* Identification of FHR changes potentially associated with inadequate fetal oxygenation may enable timely intervention to reduce the likelihood of hypoxic injury or death.
41
# Fetal Monitoring
when to use EFM?
* Upon admission to L&D, monitor patient 20-30 minutes
* Monitor FHR at least every 30 minutes in first stage active labor
* Monitor FHR at least every 15 minutes in the second stage
* Either continuous or intermittent monitoring acceptable for uncomplicated pregnancies.
* Always continuously monitor high risk patients!
42
# Fetal Monitoring
factors making it high risk
* pitocin for induction/augmentation
* HTN
* suspected chorio
* sepsis
* vag bleeding
* meconium
* febrile
* pre-eclampsia
43
# Fetal Monitoring
EFM Definitions
* NST
* Labor
* **NST**: usually in outpatient/triage setting, at least 20 minute strip, classified as REACTIVE or NON-REACTIVE
* **Labor**: Continuous strip, interpret tracing as Category I, II, or III
44
# Fetal Monitoring
EFM- Baseline
* mean FHR rounded to increments of 5 bpm during 10 min segment
* normal is 110-160
45
# Fetal Monitoring
causes of brady and tachy cardia
Causes of bradycardia:
* beta-blocker therapy
* hypothermia
* hypoglycemia
* hypothyroidism
* fetal heart block or interruption of fetal oxygenation
Causes of tachycardia:
* maternal fever
* infection
* medications
* hyperthyroidism
* elevated catecholamines
* fetal anemia, arrhythmia
46
# Fetal Monitoring
EFM Monitoring- Variability
* Fluctuations in the baseline that are irregular in amplitude and frequency.
* Resembles the variation from baseline, measured from highest to lowest FHR
Evaluating
* Absent: No variation in baseline, undetectable
* Minimal: < 5bpm
* Moderate: 6-25bpm
* Marked: >25bpm
47
# Fetal Monitoring
EFM Monitoring- Accelerations
* A visually apparent abrupt increase (onset to peak less than 30 seconds) in the FHR
* Definition is based on gestational age
* reassuring, because usually based on fetal movement
Assessing
* < 32 weeks: Increase in 10bpm in at least 10 seconds
* >32 weeks: Increase in 15bpm in at least 15 seconds
* **Total acceleration should last less than 2 minutes!**
48
# Fetal Monitoring
EFM Monitoring- Prolonged Accelerations/Decelerations
* Accel or decel lasts >2 minutes
* If a FHR pattern lasts more than 10 minutes, it is a change in baseline
* Requires new interpretation
49
# Fetal Monitoring
EFM Monitoring- Early Decelerations
* Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction.
* Gradual: Lasts >30 seconds from onset to nadir
* **Nadir of FHR align with contraction peak**
* clinically benign (nonpathologic)→ head compression
* No intervention needed
50
# Fetal Monitoring
EFM Monitoring- Variable Decelerations
* Visually apparent abrupt decrease in FHR.
Rhythm Strip
* Onset to nadir < 30 seconds
* Usually steep deceleration, >15bpm decrease in FHR
If due to Umbilical cord compression:
* Resuscitation measures
* Reposition patient to left-lateral side
* Consider amnioinfusion (after membranes are ruptured, provider can place an intrauterine catheter that will infuse fluid back to the uterus and cushion the umbilical cord)
51
# Fetal Monitoring
EFM Monitoring- Late Decelerations
* Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction.
* Gradual: Lasts >30 seconds from onset to nadir
* Nadir of FHR begins after contraction peak
Cause/Tx
* Hypoxemia and placental hypoperfusion
* Always requires intervention
52
# Fetal Monitoring
Physiology of Late Decelerations
* Uterus contracts → compression of maternal uterine blood vessels → decreased placental perfusion
* Decrease in delivery of oxygenated blood to placenta → decreased diffusion of oxygenated blood to fetus
* Autonomic response triggers vasoconstriction and blood shunting → parasympathetic reflex to decrease HR & CO.
53
# Fetal Monitoring
Causes of Late Decels
* Post-epidural hypotension
* Uterine tachysystole
* Maternal hypoxia, vasculopathy
* Placental disorders
54
# Fetal Monitoring
Management of Late Decels
* move mom on side
* O2 (if > 95%, O2 wont help)
* stop pitocin
* IV fluids
* terbutaline
* umbilical cord prolapse assesment
* open OR/page labor response
55
# Fetal Monitoring
EFM- Sinusoidal Pattern
* Visually apparent, smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5 minute which persists for 20 min or more.
* FETAL ANEMIA
56
# Fetal Monitoring
intrauterine monitoring
* Normal uterine activity: 5 or less contractions in 10 minutes
* Tachysystole: >5 contractions in 10 minutes
* Also characterised by strength (mild/moderate/strong)
56
# Fetal Monitoring
Classifying Decels
* Intermittent: occur w/ less than half of uterine contractions
* recurrent: occur with more than half of uterine contractions
57
# Fetal Monitoring
mneomnic for heart rate pattern vs cause
* V: variable decelerations --> C: cord compression/prolapse
* E: early decels --> H: head compression
* A: accelerations --> O: okay
* L: late decels --> P: placental insufficiency
| VEAL CHOP
58
58
# Fetal Monitoring
NST
* Use the electronic fetal monitoring system for a minimum of 20 minutes to assess fetal well-being
* Done outpatient in clinic/office, or in triage to discharge a patient home safely
* Usually performed at viability ~24 weeks
* Keep in mind the definition of accelerations and decelerations goes from 10bpm to 15bpm at 32weeks
* Either REACTIVE or NON-REACTIVE
59
# Fetal Monitoring
Reactive NST
* Normal baseline 110-160bpm
* Moderate variability
* 2 or more accelerations in 20 minute tracing strip
* A reassuring pattern predicts a low likelihood of fetal demise due to hypoxic injury over next few days
* Management - observation
60
# Fetal Monitoring
Non-Reactive NST
* Not achieving 2 or more accelerations in 20 minutes
* Any decelerations
* Any variability other than moderate
* A non-reassuring pattern would indicate that provider is unable to rule out fetal demise due to hypoxic injury over next few days
Management
* Further monitoring required: Normal baseline, moderate variability, no decelerations, but no accels = monitor for a few hours. Maybe baby was in a sleep cycle
* Depending on gestational age & severity of non-reassuring NST, immediate delivery may be considered
* Bradycardia with absent variability and full term = immediate cesarean delivery
61
# Fetal Monitoring
Contraction Stress Test
* An NST where contractions are present (testing the fetus ability to withstand stress)
* Either patient is spontaneously contracting, or a dose of pitocin is given to induce contractions
RESULTS:
* Negative CST: No significant decels, Reassuring result
* Positive CST: Late decels >50% of the time; Non-reassuring result = intervene
* Equivocal: Presence of late decels < 50% of the time, or inadequate contractions to assess
62
# Fetal Monitoring
Biophysical Profile
* Non-invasive test to assess fetal well-being
* Performed after 28 weeks
2 parts
1. NST (assessing the fetal heart rate)
2. Ultrasound to evaluate several things:
* Fetal movement
* Fetal tone
* Fetal breathing
* Amniotic fluid index
63
# Fetal Monitoring
Scoring of BPP
* Scored out of 10 points, but each component is either 0 or 2 points
* Fetal movement: 3+ discrete body or limb movements
* Fetal tone: 1+ episode of fetal extremity (arm, hand, etc) flexing and extending
* Fetal breathing: 1+ breathing episode lasting >30 seconds (can include hiccups)
* Amniotic fluid volume: single deepest pocket >2x2cm
64
# Fetal Monitoring
EFM in labor- 3 tiered system
* Created to identify fetal distress
* Helps determine if a fetal heart tracing is reassuring or non-reassuring
* Normal, suspicious, or pathologic
65
# Fetal Monitoring
EFM - Category I
* Baseline: 110-160 bmp
* Variability: moderate
* late/variable decels: absent
* early decels: present or absent
* accelerations: present or absence
Interpretation
* healthy & reassuring
* allows for intermittent monitoring
* low risk for development of fetal acidemia
* no indications to change current intrapartum management
66
# Fetal Monitoring
EFM - Category II
* anything not categorized as I or III
67
# Fetal Monitoring
EFM - Category III
* absent baseline FHR variability w/ recurrent late decels, receurrent variable decels, or bradycardia
* sinusoidal pattern
Interpretation
* not reassuring; increased risk fetal hypoxic acidemia which can cause cerebral palsy or neonatal encephalopathy
* scalp stimulation: if no acceleration, 50% have acidemia
* DELIVER ASAP (decision to devliery < 30 min)
68
# Fetal Monitoring
what can affect EFM
Maternal
* meds
* physiology
* comorbid
Fetal
* cardiac arrhythmias
* neuro injury
69
# Fetal Monitoring
causes of fetal brady/prolonged decels vs fetal tachy vs minimal variability w/out decels
Causes of Fetal Brady/Prolonged Decels
* Placenta abruption
* Umbilical Cord Prolapse
* Uterine Rupture
* Tachysystole
Causes Fetal Tachycardia
* Infection (chorioamnioitis)
* Meds (Stimulants, beta-agonists)
* Hyperthyroidism
* Fetal tachyarrhythmias
Causes of Minimal Variability w/ out Decels
* sleep
* CNS depressants (magnesium, opioids)
70
# Fetal Monitoring
Additional Management + Interventions
| 2
Tocolysis
* Attempt to relax uterus, stop contraction to restore fetal oxygenation
* Terbutaline 0.25mg OR Nitroglycerin
* Smooth muscle relaxant
Amnioinfusion
* Infusion of saline through intrauterine pressure catheter
* due to manage variable or late decelerations
71
# Fetal Monitoring
what is a tectonic contraction
Sustained muscle contraction for abnormally long time - need to break cycle to reperfuse baby
72
# Practice Q
definition of uterine tachysystole?
greater than 5 contractions in 10 min
73
# Labor & Delivery
Role of progesterone and estrogen in labor
* **Progesterone**: function is to support/stabilize the endometrium in an environment that is conducive to fetal survival and to suppress contractility in uterine smooth muscle.
* **Estrogen**: functions are to stimulate growth of the myometrium and antagonize the myometrial-suppressive activity of progesterone, also used to stimulate the development to the mammary glands.
74
# Labor & Deliver
Role of beta-hCG in labor
produced by fetal trophoblast cells, binds to LH receptors on the cells of the corpus luteum, which prevents luteal regression, also is the signal for maternal recognition of pregnancy.
75
# Labor & Delivery
role of prostaglandins in labor
* Paracrine/autocrine hormones
* Concentration of prostaglandins in amniotic fluid and maternal circulation are increased during parturition
* Help in the onset of synchronous uterine contractions, cervical ripening, and increase myometrial sensitivity to oxytocin and increase oxytocin receptor concentrations
76
# Labor & Deliver
role of relaxin and prolactin in labor
* **Relaxin**: Causes relaxation of pelvic ligaments, mostly at the end of gestation to prepare body for delivery.
* **Prolactin**: stimulates the mammary gland development and milk production. Also provides positive feedback for when a woman is lactating to act as a somewhat natural form of birth control.
77
# Labor & Delivery
role of oxytocin in labor
* Peptide hormone synthesized by hypothalamus and released from posterior pituitary
* Also produced by the placenta
* Release of oxytocin > forceful contractions
* Most potent endogenous uterotonic
* Circulating levels of oxytocin don’t change during pregnancy, however myometrial receptor concentrations increase in pregnancy and in labor
78
# Labor & Delivery
4 phases of labor
1. uterine quiescence
2. cerival softening
3. preparation for labor
4. labor
79
# Labor & Deliver
describe uterine quiescence phase of labor
* Makes up 95% of pregnancy
* Uterine smooth muscle tranquility while maintaining cervical structure and integrity
* Uterine size increases, uterine vascularity increases
* Myometrial contractions which do not cause cervical change (braxton hicks)
80
# Labor & Deliver
describe cervical softening phase of labor
* Non pregnant women = cervix closed and firm
* End of pregnancy = cervix distentable and soft
* Tissue remodeling to soften the cervix: Increased vascularity, cellular hypertrophy, and collagen changes to alter strength and flexibility
Cervix function in pregnancy:
* Maintain barrier of lower vaginal tract and upper internal tract from infection
* Maintain cervical competence despite increasing uterine size
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# Labor & Deliver
describe preparation for labor + actual labor phases
PREPARATION FOR LABOR
* Progression of uterine changes during the last 6-8 weeks (uterine activation)
* Myometrium prepares for labor contractions
* Oxytocin receptors and prostaglandin receptors increase
* Cervical ripening (Additional cervical remodeling)
LABOR
* Uterine contractions that cause cervical dilation and change
* Contractions of sufficient frequency and intensity
* Divided into three stages
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# Labor & Delivery
describe Braxton Hicks Contractions
* False labor pains
* Do not cause cervix to dilate or efface
* Usually irregular in duration and intensity (lasting < 30 seconds up to 2 minutes)
* Described as strong menstrual cramps
* Can start around 6 weeks of gestation, but usually are not felt until 2nd or 3rd trimester
* Body’s way of preparing for labor
* Can be caused by: Increased physical activity, full bladder, dehydration, after intercourse, and near the end of pregnancy
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# Labor & Delivery
when should mom's seek immediate attention?
* Contractions becoming more frequent and intense (every 5 minutes or more, severe pain, not able to speak full sentences during contractions)
* Vaginal bleeding
* Leakage of fluid
* Decreased fetal movement
84
# Labor & Delivery
define labor
regular painful uterine contractions that cause cervical dilation and effacement
85
# Labor & Deliver
Cardinal Movements of Labor + Describe
| ED FIRE REX
ED FIRE REX
* **Engagement**: presenting parts enters the pelvis (can happen even 2 weeks before delivery)
* **Descent**: fetus sitting on top of cervix, starts earlier in first pregnancies, later in multiparous patients
* **Flexion**: Tucking of the fetal head into the chest to make the smallest presenting part in the pelvis
* **Internal Rotation**: sagittal suture is parallel to the AP diameter of the pelvis
* **Extension**: as vertex passes beyond the pubic symphysis
* External rotation (**Restitution**): Head is outside of the vagina, rotates at the level of perineum after delivery
* **Expulsion**: delivery of anterior shoulder followed by posterior shoulder
**between extension and restitution you have crowning of the fetal head at the vaginal introitus**
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# Labor & Delivery
describe types of pelvises
* Gynecoid- >50% females, round, wide pelvis and pubic arch (ideal for vaginal birth)
* Android- heart shaped, narrow (more common in men)
* Platypelloid- 2-5%, narrow anterior posterior diameter, wide transverse diameter
* Anthropoid- 25% females,wide anterior posterior diameter, narrow transverse diameter
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# Labor & Delivery
differentiating latent and active labor
LATENT
* Mucus plug / Bloody show: Extrusion of mucus and blood that filled the cervical canal
* Slow cervical dilation to 5cm dilated
* Less than 1cm per hour
* Painful irregular contractions
ACTIVE:
* Rapid cervical change
* Painful regular contractions
* Cervical dilation 1cm per hour
* Spontaneous rupture of membranes
Duration
* Nulliparous: avg 10-14 hrs
* Multiparous: age 5-7 hrs
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# Labor & Delivery
Components of cervical exam
Dilation
* How open the cervix is related to the internal cervical os
* Based on digital hand exam 0-10cm
Effacement
* Percent of cervix shortened
* Subjective based on examiner
* Normal cervix about 4cm > 2cm felt = 50% effaced
Station
* Relation of the fetal presenting part to the ischial spine (-5 to +5)
* Most descended part of the fetus at ischial spine = 0 station
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# Labor & Delivery
Bishop Score
* Effacement
* Dilation
* Station
* Cervical position: In relation to the patient; Posterior / Mid position / Anterior; In labor the cervical position usually advances from posterior to anterior
* Cervical consistency; firm, medium, soft; In labor the cervix usually softens
| score >8 favorable for vaginal delivery
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# Labor & Delivery
spontaneous rupture of membranes
* SROM
* Check the color
* Clear/yellow - generally ok
* Green - meconium = first bowel movement of fetus; Dark green and thick amniotic fluid can be a sign of distress from the baby
* Red - blood-tinged could be mixed with blood from cervical stretching; Bright red blood could be a sign of placental abruption
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# Labor & Delivery
Fetal Orientation in Utero
* Lie: relationship between longitudinal axis of baby with respect to uterus and patients body; Longitudinal, transverse, oblique
* Presentation: Fetal presenting part in the pelvis; Cephalic, breech, compound
* Position: Relationship and orientation of the presenting fetal part in the pelvis; LOA / ROA / LOP / ROP / LOT /ROT
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# Labor & Delivery
Fetal Positioning & Leopold's Maneuver
Positioning
* breech
* transverse
* vertex
Leopold's Maneuver
* 4 distinct maneuvers to palpate the maternal abdomen and determine fetal position and size
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# Labor & Delivery
describe breech positioning
* Buttocks or lower extremities presenting part
* 3-4% term pregnancies
Frank
* Flexing both hips and legs straight near face (Frank = Face)
Complete Breech
* Fetus sitting in flexion both hips, both legs flexed (tucked)
Incomplete Breech
* Combination of one or both hips extended
* Footling - one leg extended
* Double footling - both legs extended
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# Labor & Delivery
Delivery of Fetus + Placenta
Fetus
* Fetal head restitution
* Check for nuchal cord
* Deliver anterior shoulder with gentle traction (too much --> brachial plexus injury or shoulder dystocia)
* Guide fetus posterior >> anterior
PLACENTA
* Up to a 30-minute delay in delivery of placenta is normal
* Signs of placental separation: Fresh show of blood, Lengthening of umbilical cord, Uterus becomes firm and globular
* Placenta delivery: gentle traction on the cord → apply suprapubic pressure important to prevent uterine prolapse or inversion
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# Labor & Delivery
APGAR score
* Test performed on baby 1 to 5 minutes after birth- in rare cases it can also be done 10 minutes after birth
* Tests: Heart rate, lung maturity, muscle tone and movement, skin color/oxygenation, reflex responses
* All categories range from 0-2 (APGAR score of 10 being the highest!)
* 0-6 points = distress & 7-10 points = normal
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# Labor & Delivery
what does APGAR evaluate
* Appearance (skin color)
* Pulse (heart rate)
* Grimace (reflex irritability)
* Activity (tone)
* Respirations
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# Labor & Delivery
Labor Augmentation
**Use of oxytocin and/or amniotomy to stimulate uterine contractions if adequate cervical changes do not occur with spontaneous labor**
Amniotomy:
* Artificial rupture of membranes (AROM)
* Healthcare provider breaks water bag for patient
* Helps with active management of labor
* Releases prostaglandins, can cause an increase in uterine contractions and fetal head descent
* Risks: Cord prolapse, infections
* Contraindications: Malpresentation, maternal infections, fetal head station too high
Oxytocin
* Natural oxytocin is a polypeptide hormone produced by the hypothalamus and secreted from posterior pituitary
* Pitocin = synthetic drug form
* Dose ranges from 2-40 mU/min
* Uterus contracts in response to high levels of oxytocin
* Pitocin can be given to patients to increase frequency and strength of contractions in labor
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# Labor & Delivery
Labor Induction via cervical ripening
* Mechanical: Intracervical balloon
**MEDS**
Misoprostol (cytotec)
* Synthetic Prostaglandin E analog
* 25mcg tablet placed into the posterior vaginal fornix at base of cervix
* Causes cervical softening and ripening, also may induce some uterine contractions
* Start oxytocin induction (earliest) 4hrs after initial insertion
Dinoprostone (cervidil)
* 10mg vaginal insert, sustained release lasts 12hrs
* Start oxytocin induction 30-60 minutes after removal
| + amniotomy + oxytocin
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# Labor & Delivery
Operative Vaginal Delivery
* Use of a device to help guide fetus out of the vaginal canal and achieve vaginal delivery
* Benefits: Can perform quickly if fetal distress, avoid cesarean section
* Risks: Maternal perineal and vaginal lacerations, potential newborn injuries (nerve palsy, skull fracture, intracranial hematoma)
* Indications: Prolonged second stage of labor (N >3-4hrs pushing, M >2-3hr pushing). It also shortens second pushing stage of labor (for maternal benefit)
* Contraindications: Fetal head not engaged in pelvis, fetal bone disorders
* **Forceps OR Vacuum**
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# Labor & Delivery
rupture of membranes
| PROM vs PPROM vs SROM vs AROM
GENERAL
* Amniotic water sac breaking
* Can occur before the onset of labor or throughout the labor process
PROM
* Prelabor rupture of membranes
* Rupture of fetal amniotic membranes after 37 weeks (full term) and prior to the onset of labor
* 8-10% pregnancies
PPROM
* Preterm prelabor rupture of membranes
* Rupture of fetal amniotic membranes before 37 weeks (preterm) and prior to the onset of labor
* 2-4% of pregnancies
SROM
* Spontaneous rupture of membranes
* Rupture of fetal membranes after 37 weeks (full term) and during labor
AROM
* Assisted/Artificial rupture of membranes
* Amniotic fluid sac is ruptured by a medical provider during labor induction/ augmentation
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# Labor & Delivery
Maternal PROM/PPROM risk factors
* Preterm prelabor rupture of membranes (PPROM) in a prior pregnancy (recurrence risk is 16%–32% as compared with 4% in women with a prior uncomplicated term delivery)
* Antepartum vaginal bleeding
* Chronic steroid therapy
* Collagen vascular disorders (such as Ehlers-Danlos syndrome, systemic lupus erythematosus)
* Direct abdominal trauma
* Preterm labor
* Cigarette smoking
* Illicit drugs (cocaine)
* Anemia
* Low body mass index (BMI < 19.8 kg/m2)
* Nutritional deficiencies of copper and ascorbic acid
* Low socioeconomic status
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# Labor & Delivery
PROM/PPROM uteroplacental factors
* Uterine anomalies (such as uterine septum)
* Placental abruption (may account for 10%–15% of preterm PROM)
* Advanced cervical dilatation (cervical insufficiency)
* Prior cervical conization
* Cervical shortening in the 2nd trimester (< 2.5 cm)
* Uterine overdistention (polyhydramnios, multiple pregnancy)
* Intra-amniotic infection (chorioamnionitis)
* Multiple bimanual vaginal examinations (but not sterile speculum or transvaginal ultrasound examinations)
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# Labor & Delivery
multipe gestations- risks
*Almost all obstetric complications have increased risk and prevalence with multiple fetal gestations!
104
# Labor & Delivery
epidemiology of twin pregnancies
* 1-3% of births in US
* 97.5% of all multi-fetal gestations in the US
* 70% dizygotic, 30% monozygotic
105
# Labor & Delivery
Multiple Gestations- MCMA vs DCDA vs MCDA
Monochorionic Monoamniotic Twins (MCMA)
* One placenta, one amniotic sac
* Shared fetoplacental circulation
* Increased risk of pregnancy complications, cord entanglement and conjoined twins
Dichorionic Diamniotic Twins (DCDA)
* Two placentas, two amniotic sacs
* Can visualize the intertwin membrane on ultrasound
* Most common type of twins!
Monochorionic Diamniotic Twins (MCDA)
* One placenta, two membranes
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# Pre-Term Labor
Risk Factors
* Historical: person hx PTB, 2nd trimester abortion, hx cervical surgeries
* Obstetric: multiple gestations, polyhydraminos, IVF, PPROM, pos FFN
* Infectious: STIs, systemic infections, bacteriuria, periodontal disease, Malaria
* Placental: previa, abruption
* Fetal: anomoly, growth restriction
* Structural: uterine anomaly, short cervix, advanced cervical dilation, abd surgery
* Maternal: chronic medical illness (HTN, CKD, T1DM, autoimmune, anxiety, depression), extreme age (very young or very old), non-Hispanic black race, low maternal education
* Heme: vaginal bleeding, severe anemias
* Social: no partner, low SES, stressors, no pre-natal care
* Toxin: substance use (cocaine, alcohol), tobacco use (dose dependent)
* Behavioral: short interpregnancy interval, occupational physical activity
* Genetic: PTB susceptbility genes, hx of 1st deg relative with PTB
* Nutritional: poor nutrition, low BMI
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# Pre Term Labor
use of fetal fibronectin testing
* Extracellular matrix protein present at the decidual-chorionic interface
* Any disruption of this interface due to subclinical infection or inflammation, abruption, or uterine contractions releases fFN into cervicovaginal secretions, which is the basis for its use as a marker for predicting preterm labor/birth
* FFN only collect if patient between 24 - 34wk GA!
Positive result
* increased risk of PTB within 7 days
* however, many false positives
Negative result
* Good negative predictive value! If negative, highly unlikely patient will go into preterm labor within 7-10 days
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# Pre Term Labor
use of Tocolysis
Reduces strength & frequency of uterine contractions
* Not indicated before fetal viability (24 weeks)
* Upper limit of use generally 34 weeks
* Not indicated for CTX without cervical change
Contraindications
* IUFD
* Non-reassuring fetal status
* Severe preeclampsia
* Hemorrhage with hemodynamic instability
* Chorioamnionitis
* Maternal medical contraindications (agent-specific)
**Tocolytics should be discontinued after 48 hours**
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# Pre Term Labor
describe use of corticosteroids
Fetal Lung Maturity
* Betamethasone (and Dexamethasone) has been shown to improve fetal lung maturity and reduce neonatal respiratory distress syndrome (RDS) and mortality in offspring. Subsequent trials have shown that ACS also improves circulatory stability in preterm neonates, resulting in lower rates of intraventricular hemorrhage and necrotizing enterocolitis compared with unexposed preterm neonates.
Surfactant Effects
* increase surfactant & promote growth of T1 & T2 pneumocytes
* Improved lung compliance & volume
* Improved gas exchange
* Increased surfactant production
* Induction of enzymes/receptors to enhance absorption of lung fluid
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# Cesarean Sections
why TOLAC vs repeat CS
Common reasons patients choose TOLAC include…
* Future pregnancy plans since multiple cesarean births increase the risk for placenta previa and accreta spectrum
* Family obligations that make a speedy return to normal activities postpartum desirable
* Desire to experience labor and vaginal birth
* Desire for their partners' greater involvement in labor and birth
Common reasons patients choose repeat CS include…
* Scheduling convenience
* Ease of arranging a procedure for permanent contraception at the time of birth
* Fear of failed trial of labor and emergency cesarean birth
* Avoidance of labor pain and labor in general
* Hospital policies restricting access to TOLAC
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# Postpartum Hemorrhage
effects of different blood products
| pRBCs, PLTs, FFPs, cryoprecipitate
* **PRBC**: one pack=250cc, increases Hb by 1mg/dL or HCT by 3%
* **PLT**: 1 unit= 6 packs, increase PLT by 25-50k, give if PLT drops by 25k
* **FFP**: 1u=200-250mL, usually 2-4u per infusion. Indicated with bleeding and abnormal coagulation (INR>1.5)
* **Cryoprecipitate**: 1u=15-20mL, usually in pools of 6 units. Dose: 1-1.5u/10kg body weight. Increases fibrinogen by 30-60mg/dL per 6 units. Indicated when fibrinogen < 100 (DIC).
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# Lactation
role of prolactin & oxytocin in lactation
Prolactin
* Polypeptide hormone synthesizes by lactotrophic cells in anterior pituitary
* Structurally similar to GnRH and placental lactogen
* Both positive and negative feedback loops
* Stimulates mammary gland ductal growth and epithelial cell proliferation > induces milk synthesis
* Increases with suckling of nipple
Oxytocin
* Involved in the milk ejection and letdown
* Nipple stimulation > hypothalamus trigger of oxytocin > contractiile myoepithelial cells, forcing milk into thr ducts and out through the nipple
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# Lactation
benefits of breast milk
* Ideal nutrition for infants with vitamins, proteins and fats that are usually more easily digested than formula
* Contains antibodies from mother that help fight off viruses and bacteria
* Breast milk contains IgA, WBCs, whey protein (lysozyme and lactoferrin) and oligosaccharides
* Reduces newborn risk of allergies, asthma, ear infections, respiratory illness, and risk of diabetes and obesity
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# Pregnancy loss
etiologies of spontaneous abortion
Maternal
* Medical Conditions: Antiphospholipid syndrome
* Infections: CMV, Parvovirus B19, Toxoplasmosis, Chlamydia trachomatis
* Anatomic Abnormalities: Congenital uterine anomalies, Intrauterine adhesions
* Drug use (cocaine)
* Cigarette smoking
Fetal
* Chromosomal abnormalities (most common cause): Turner syndrome (45,X, or 45, XO), Autosomal trisomies (Down Syndrome - Trisomy 21)
* Congenital abnormalities
Paternal
* increased paternal age
* paternal chromosomal abnormalities
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# Ectopic Pregnancies
Fallopian Tube Anatomy
Function:
* Transport ova from the ovaries to the uterus.
Size:
* 10 to 12 cm in length
Regions:
* Divided into 4 regions:
* Interstitial (embodied in muscular wall of uterus)
* Isthmus (narrow portion)
* Ampulla (gradually wider, lateral portion)
* Infundibulum (fimbriated end)
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