Prenatal care + Normal Pregnancy Flashcards
APGAR score
Activity (2=active movement)
Pulse (2= >100 BPM)
Grimace (2= pulls away, sneeze)
Appearance (2=pink)
Respiration (2=crying)
What is a good APGAR score vs a score that indicates resucitation?
- Score > 6 is good
- Score of 4 necessitates resuscitation
What is fetal attitude?
Fetal attitude: relationship of fetal parts to one another
- Full flexion (chin on chest; rounded back with flexed arms, legs); smallest diameter of head (suboccipitobregmatic diameter) presents at pelvic inlet
What is fetal lie?
Fetal lie: relationship of fetal cephalocaudal axis (spinal column) to maternal cephalocaudal axis
- Longitudinal (ideal): fetal spine lies along maternal
- Transverse: fetal spine perpendicular to maternal
- Oblique: fetus at slight angle
What is fetal presentation?
Fetal presentation: fetal/presenting part enters pelvic inlet first
Cephalic is ideal → Head first down pelvis
What are the various types of breech position?
Breech: head up; bottom, feet, knees present first
- Frank breech: hips flexed; knees extended; bottom presents
- Complete breech: hips, knees flexed; bottom presents
- Incomplete breech: one/both hips not completely flexed; feet present
- Shoulder: transverse lie; shoulders present first
Tx of breech baby?
TX: External cephalic version at or near term, followed by a trial of a vaginal delivery if the version is successful and planned cesarean delivery if breech presentation persists
a 24-year-old G2P1 comes for her 13-week office visit she has a fundal height and an alpha-fetoprotein which are greater than expected for her due date.
Multiple gestations, twins!
3 types of twins
- Monozygotic (Identical) – multiple (typically two) fetuses produced by the splitting of a single zygote
- Dizygotic (Fraternal) – multiple (typically two) fetuses produced by two zygotes
- Polyzygotic – multiple fetuses produced by two or more zygotes
How are twins diagnosed?
Often diagnosed at first screening ultrasound other clues include
- Fundal height is usually greater than dates
- Extra fetal heart tones
- Elevated maternal alpha-fetoprotein (AFP)
What are cervical changes seen prior to delivery
- Remodeling of cervix by enzymatic collagen dissolution, ↑ water content →softening, ↑ distensibility
- Cervical softening → expulsion of mucus plug → “bloody show” (pink-tinged mucus)
- Spontaneous rupture of amniotic membranes (ROM)
What is false labor?
- AKA Braxton-Hicks contractions
- True labor: regular, increase in frequency, duration, intensity; produce cervical changes (e.g. dilation/opening, effacement/getting thinner); pain begins in lower back, radiates to abdomen, not relieved by ambulation
- False labor: irregular, intermittent contractions; no cervical changes; pain in abdomen; walking may decrease pain
What is the first stage of labor?
FIRST STAGE OF LABOR ⇒ onset of labor to fully dilated (10 cm)
What happens in early latent stage of labor?
- 8–12 hours
- Mild contractions every 5–30 minutes
- Duration 30 seconds each
- Gradually increase in frequency, intensity, duration
- Cervical dilation 0–3 cm
- Effacement 0–30%
- Spontaneous ROM
What happens in active phase of labor?
- 3–5 hours
- Contractions every 3–5 minutes
- Duration ≥ 1 minute
- Cervical dilation 3–7 cm
- Effacement 80%
- Progressive fetal descent
What happens in transition phase of labor?
- 30 minutes–2 hours
- Intense contractions every 1.5–2 minutes
- Duration 60–90 seconds
- Cervical dilation 7–10cm
- Effacement 100%
The second stage of labor is considered when:
SECOND STAGE ⇒ fully dilated to the birth of the infant
- AKA pushing stage
- Begins with full dilation
- Navigation through maternal pelvis dictated by 3 Ps:
Power, passenger, passage
What happens in the “power stage” of the 2nd stage of labor?
- Frequency, duration, intensity of uterine contractions
- Physiology of contractions
- Stimulation of uterine myometrium
- Alpha-receptors stimulate uterine contractions
- Numerous oxytocin receptors, mostly on uterine fundus
- Contraction steps
- Wave begins in fundus, proceeds downward to rest of uterus → muscle shortens in response to stimulus →increment (build up) → acme (peak) → decrement (gradual letting up) →relaxation → fetal descent, cervical effacement, dilation → amount of pressure exerted by uterine contractions (intrauterine pressure) measured in millimeters of mercury (mm Hg)
What happens in the “passenger stage” of the 2nd stage of labor?
Describes the fetal size, attitude, lie, presentation
What happens in the “passage stage” of the 2nd stage of labor?
Route through bony pelvis
- Size, type of pelvis
What are the size/types of pelvis’s?
- Gynecoid: rounded pelvic inlet, midpelvis, outlet capacity adequate; optimal for vaginal delivery
- Android: heart-shaped pelvic inlet; ↓midpelvis diameters, outlet capacity; associated with labor dystocia
- Anthropoid: oval-shaped pelvic inlet; midpelvis diameters, outlet capacity adequate; favorable for vaginal delivery
- Platypelloid: oval-shaped pelvic inlet, ↓ midpelvis diameters, outlet capacity adequate; not favorable for vaginal delivery
What are the cardinal movements of labor? (mechanisms of labor)
- Descent:: presenting part reaches pelvic inlet (engagement ) before onset of labor → degree of descent (fetal station), relationship of presenting part to maternal ischial spines → fetus moves from pelvic inlet (-5 station) down to ischial spines (0 station) to pelvic outlet (+4 station) to crowning at vaginal opening (+5 station)
- Flexion: fetal chin presses against chest, head meets resistance from pelvic floor
- Internal rotation: fetal shoulders internally rotate 45º; widest part of shoulders in line with widest part of pelvic inlet
- Extension: fetal head passes under symphysis pubis (+4 station), moves (+5 station), emerges from vagina
- Restitution (external rotation): head externally rotates as shoulders pass through pelvic outlet, under symphysis pubis, turns to align with back
- Expulsion: anterior shoulder slips under symphysis pubis, followed by posterior shoulder, rest of the body; marks end of second stage
What is the 3rd stage of labor?
Delivery of infant to delivery of placenta
Delivery of placenta, umbilical cord, fetal membranes; uterus contracts firmly, placenta begins to separate from uterine wall
What happens in the 4th stage of labor?
- Physiological adaptation to blood loss, initiation of uterine involution
What monitoring is done during labor?
- Heart rate and the pattern is an indicator of infant well-being
- Normal heart rate in newborn 120-160 beats per minute
- Consistent decelerations after a contraction can indicate fetal distress
- External fetal monitor – on the maternal abdomen
- Internal fetal monitor – electrode attached to the infants head
What are fetal HR accelerations?
- Accelerations: Increase of baseline 15 bpm for 15 seconds ⇒ Response to fetal movement ⇒ Reassuring
What are fetal HR early decelerations?
- Early decelerations: Mirror images of contractions ⇒ Fetal head compression ⇒ benign
What are fetal HR variable decelerations?
- Variable Decelerations: Rapid FHR drop with a return to baseline with variable shape ⇒ Cord compression ⇒ Benign if mild or moderate ⇒ worrisome if severe
What are fetal HR late decelerations?
- Late Decelerations:FHR drop at the end of the contraction ⇒ Uteroplacental insufficiency ⇒Always worrisome
What happens to the uterus during pregnancy?
- ↑ size, capacity due to hypertrophy, hyperplasia, mechanical stretching
- 20 times larger
- ↑ strength, distensibility, contractile proteins, number of mitochondria
- ↑ volume capacity (10 mL–5 L)
- Softening of uterine isthmus (Hegar’s sign)
What happens to the cervix during pregnancy?
- Formation of mucus plug; seals endocervical canal
- ↑ vascularity → purplish-blue color
- Mild softening due to edema, hyperplasia (Goodell’s sign); ↑ softening in third trimester
What is the function of the placenta?
- Develops where embryo attaches to uterine wall
- Expands to cover 50% internal uterine surface
- Functions as maternal-fetal organ for metabolic, nutrient exchange
- Secretes estrogen, progesterone, relaxin, hCG
What happens to the vagina during pregnancy?
- ↑ vascularity → bluish-purple color
- Loosening of connective tissue → ↑ distensibility
-
Leukorrhea
- pH of 3.5–6.0 → protects against bacterial infections
What happens to the heart in pregnancy?
- Mild hypertrophy
- S2, S3 more easily auscultated, split exaggerated
- Heart displaced upward, forward, slightly to left
- ↑ heart rate by 15–20 beats/minute
- Stroke volume ↑ 30%, cardiac output (CO) ↑ 30-50% (by term); ↓ blood pressure (BP) despite ↑ CO due to progesterone-induced vasodilation; BP = CO × systemic vascular resistance (SVR)
- Supine hypotensive syndrome caused by gravid uterus pressing on inferior vena cava (left lateral recumbent position optimal for CO, uterine perfusion)
- Gravid uterus elevates pressure veins draining legs, pelvic organs → slowed venous return, dependent edema, varicose veins, hemorrhoid
What happens to blood in pregnancy?
-
↑ blood volume (approx. 1500 mL)
- Related to sodium, water retention due to changes in osmoregulation, secretion of vasopressin by anterior pituitary, renin-angiotensin-aldosterone system (RAAS)
- ↑ total red blood cell (RBC) volume (approx. 30%), with iron supplementation
- ↑ volume, oxygen-carrying capacity needed for ↑ basal metabolic rate (BMR), needs of uterine-placental unit (offsets blood loss at delivery)
- Plasma > RBC volume → hemodilution, ↓ hematocrit (physiologic anemia)
- ↑ white blood cell (WBC) count (approx. 5,000–12,000/mm3)
- ↑ clotting factors (fibrin, fibrinogen): hypercoagulable state of pregnancy
What happens to respiratory system in pregnancy?
- ↑ oxygen consumption, subcostal angle, anteroposterior diameter, tidal volume (30–50%), minute ventilatory volume, minute oxygen uptake
- Gravid uterus places upward pressure on diaphragm → elevates approx. 4 cm
- Hyperventilation → mild respiratory alkalosis (renal compensation → maternal blood pH 7.40–7.45)
- Nasal congestion, epistaxis due to estrogen-induced edema
What happens to GI system during pregnancy?
- Gums bleed easily due to estrogen-induced hyperemia, friability
- Progesterone-induced smooth muscle relaxation, delayed gastric emptying, ↓ peristalsis → nausea, vomiting (AKA “morning sickness” ); constipation; heartburn (pyrosis), esophageal reflux; intrahepatic cholestasis of pregnancy due to ↓ gallbladder emptying time → ↑ risk of cholelithiasis
- ↑ saliva production (ptyalism)
What happens to the kidneys during pregnancy?
- ↑ glomerular filtration rate (GFR)
- 40–50% by second trimester; ↑ urinary output (25%)
- ↑ size of kidneys (1–1.5 cm)
- Dilation of urinary collecting system →physiologic hydronephrosis
- Urinalysis
- Glycosuria (due to ↑ glucose load), ↑ protein excretion (due to altered proximal tubule function + ↑ GFR)
What are the recommended nutritional needs of pregnancy?
- Recommendation of additional 300 kcal/day, weight gain of 25–35 pounds (11.5–16 kg)
- 11 lb. (5 kg): placenta, amniotic fluid, fetus
- 2 lb. (0.9 kg): uterus
- 4 lb. (1.8 kg): ↑ blood volume
- 3 lb. (1.4 kg): breast tissue
- 5–10 lb. (2.3–4.5 kg): maternal reserves
- 600 mcg folic acid/day → RBC synthesis, placental/fetal growth, ↓ risk of neural tube defects
- 1,000–1,300 mg calcium/day supports pregnancy, lactation
- 60g protein daily supports tissue growth
- 27 mg iron/day supports ↑ RBCs
What is the appointment intervals for pregnant patients?
- Monthly visits to a healthcare professional for weeks 4–28 of pregnancy
- Visits twice monthly from 28 to 36 weeks
- Weekly after week 36 (delivery at week 38–40)
What are the vitamin recommendations for pregnant patients?
- All pregnant women should receive a prenatal vitamin.
- Folic acid supplementation (0.4–0.8 mg) prior to conception; 4 mg for secondary prevention
- Calcium: 1,000–1,300 mg/day; supplement may be beneficial for women with high risk for gestational hypertension or communities with low dietary calcium intake.
- Iron: Screen for anemia (Hgb/Hct) and treat if necessary. Recommend 30 mg/day of iron in pregnant women.
- Vitamin A: Pregnant women in industrialized countries should limit to <5,000 IU/day.
- Vitamin D: Consider supplementation in women with limited exposure to sunlight.
What is the ACOG definition of hypertension
ACOG defines hypertension as BP >140 mm Hg systolic or >90 mm Hg diastolic
When is fetal HR audible?
- Fetal heart rate: usually audible by 12 weeks’ GA with a Doppler instrument
When is fetal position palpable?
- Fetal position by abdominal palpation at 36 weeks
How do you calculate Nageles rule?
- What was the first day of bleeding? = 1’st day of the last menstrual period
- 1’st day of last menstrual period + 7 days – 3 months + 1 year
When should the first initial OB appt be?
6 weeks after LMP
What is the triple screen and quad screening that can be performed?
- Triple screen: AFP, HCG, Estriol
- Quad Screen: AFP, HCG, Estriol, Inhibin A
When would you perform an amnio?
- Amniocentesis: between 15-18 weeks (beginning of the second trimester) – especially for women over age 35 in the high-risk group
When is the 2-hour oral glucose test performed?
75 g 2-hour oral glucose tolerance test at 26-28 weeks
When is Group B strep test be performed?
- Group B strep test between 35-37
What would you estimate gestational age if baby is at pubic symphysis?
12 weeks
What would you estimate gestational age if baby is Midway from symphysis to umbilicus?
16 weeks
What would you estimate gestational age if baby is at umbilicus
20 weeks
What would you estimate gestational age if baby is above pubic symphysis?
20-36 weeks
Height (in cm) above pubic symphysis correlates with weeks of gestation
What happens in the first trimester screening at 11-14 weeks?
- Ultrasound for nuchal translucency
- PAPP-A and hCG
- ↑ levels are seen in chromosomal abnormalities
- Low levels of PAPP-A can be associated with Down’s Syndrome
Cell free fetal DNA occurs at 10 weeks and includes what?
- Analyze fetal DNA in maternal blood
- Screens for trisomies of 13, 18, and 21
- Positive test results should be followed by CVS or amniocentesis
Quadruple screen occurs at 16-18 weeks and includes
- AFP, hCG, estriol, inhibin
- ↑ AFP = neural tube or abdominal wall defects
- ↑ hCG and inhibin and ↓ AFP and estriol = Down syndrome
- ↓ AFP, hCG, and estriol = Edwards syndrome
Second trimester appts are every 4 weeks and include what screenings?
-
15-18 weeks
- offer triple marker screen (hCG, estriol, AFP)
- used to detect neural tube defects or trisomies
- offer triple marker screen (hCG, estriol, AFP)
-
16-20 weeks
- amniocentesis if > 35 years old or history indicates
-
17 weeks
- document movement
-
24 weeks
- glucose screening
- 25 -28 weeks
- repeat Hct
When would a pregnant patient start coming in every 2 weeks?
week 28, then every two weeks, then every week after 36
When would RhoGAM be given if indicated?
28-30 weeks
Mothers with pre-gestational diabetes should undergo twice weekly non stress testing until delivery
Weeks 28-32
When would cervical chlamydia and gonorrhea cultures if indicated
36-40 weeks
