Prenatal L&D Flashcards
What is fertilization and when does it occur?
- Egg moved fallopian tube by fimbriae, remains in ampulla for 24 hrs, destroyed if not fertilized
- occurs when viable sperm penetrate zona pellucida→ fertilized egg remain in fallopian tube for 72 hrs
What are 3 processes of implantation?
o Apposition→ blastocyte differentiates into embryo (inner cell mass) and placenta (trophectoderm) o Adhesion→ binds to endometrium o Invasion(migration) trophoblast cells invade endometrium, establish blood supply
What occurs in the first 7-9 weeks after fertilization?
Progesterone produced by corpus luteum
o If there is a corpus luteum cyst; leave it alone, they are common and the corpus leutem is providing stabilization of the pregnancy so mustn’t be disturbed
What happens to the HcG levels during pregnancy
o Amnt of hCG doubles every 2 days until 10 weeks
o If values are not doubling→ pregnancy could be compromised
o If you don’t have a good timing on the pregnancy it can be hard to interpret the hCG levels acutately
4 functions of the placenta?
• Exchange of oxygen and CO2, Waste removal, nutrients, produces hCG
What are some GI changes that can occur during pregnancy?
slowed gastric emptying=constipation
o Increased acidity, increased reflux
What are some renal changes that can occur during pregnancy
GFR increased by 50% because amnt of fluid sent to kidney has increased
o BUN & CR→ decrease d/t hemodilution
o Hydronephosis (swelling in urine d/t build up of urine) late in pregnancy and trace glucose in urine
What are some cardiac changes that can occur during pregnancy
o Blood volume incr. by 50% (if pt has valve problem you will hear murmur as preg. Progresses)
o HCT falls until wk 28 (d/t hemodilution)
o WBC increase (5,000- 12,000)
o In clotting factors (risk of DVT)
o 40% in CO, SV , decreased diastolic by 10mmHg
Gestation & Naegele’s Rule includes?
• Start of gestation is based on last normal menstrual period (LNMP), 2 wkes before ovulation
o Developmental/Fetal Age
o Menstrual Gestational Age→ calc. at 280 days/40 completed weeks
o Estimated Due Date
how to estimate due date
add 7 days to first day of last menstrual period, subtract 3 month, add 1 year (aka add 9 months
What is the development/ fetal age
age of conception calculated from time of implantation (4-6 days after ovulation is completed)
When is the first trimester? and what 2 phases occur during that time?
• Trimester 1: 1-12 weeks
o Embryonic
o Fetal Period
Embryonic phase
fertilization (2-10 wks), organogenesis—embryo most sensitive to teratogens
Fetal period is what?
8 wks after fertilization, or 10 wks after onset of last menstrual period
When are the second and third trimesters?
- Trimester 2: 13-27 weeks
* Trimester 3: 28-40 wks
What is the difference between a fetus and an embryo?
Embryo→ 1-8 wks
Fetus = after 8 weeks
What does fetal viability mean?
23 -24 weeks gestational age weight of 600 gm or more (600g=1.25 lbs)
What does term refer to in relation to pregnancy?
refers to 37 weeks or beyond
what does abortion mean?
elective or spontaneous
• Pregnancy loss
Less than 500 gm, Less than 20 week
What does preterm and premature refer to?
Preterm→ birth before 37 weeks
Premature→birth between 28 – 37 weeks, Weight 1000 - 2500 gm
What does post mature mean?
at or > 42 weeks → most are induced at this point
What does parity mean?
passing child through/actual births of over 20 wks gestational age, infants over 500g
What does gravity mean
of pregnancies, live or dead (elderly primigravida- 1st pregnancy > 35)
what is considered a low birth weight and macrosomia?
Low birth weight - full term but < 2500 gm
Macrosomia – large baby weighing > 4500 gm
What is the GPA system for birth?
- G-Gravida→ # of total pregnancies
- P-Para→ # of births (doesn’t matter how many children were born during the birth twins/triples =P1)
- A- Abortus→ nulligravita—no pregnancies, nullipara—no births
FPAL System (TPAL) for births
- F= full term births
- P= preterm births (<37 wks)
- A= abortions
- Living= living children
Preconception Counseling includes what? (3)
- Prenatal diagnosis & carrier screening, maternal age
- Immunizations→ rubella, tetanus, hepatits, chickenpox
- Meds, toxins, medically complicated pts, folic acid 400 microgram QD, multicitamin, calcium
- Estimated date of confinement→ accurate LMP, date of conception, early U/S
What are some symptoms of pregnancy? (7)
- Amenorrhea
- N/V→ 50% will have this in the first 2 weeks, often resolves 13-16 wks
- Hyperemesis gravidarum
- Breast changes
- Colostrum→1st milk prod by breast as early as 16 wks
- 2nd breast tissue→ across nipple line, or in axilla
- Skin changes
4 types of common skin changes found in pregnancy
o Chloasma→ rash on forehead/bridge of nose, after 16 wks
o Linea Nigra→ (line going from naval down)
o Striae→ often on breast and abd; collagen separation
o Spider Telangectasia→ palmar erythema
What are some breast changes seen in pregnancy?
tenderness, engorgement, periareolar venous prominences (montgomery’s tubericles)
What are some pelvic organ changes found in pregnancy
- Chadwick’s sign
- Hegar’s sign
- Leukorrhea
- Pelvic ligament laxity
- Abdominal enlargement
- Uterine contractions
What is chadwicks sign?
Congestion of the pelvic vasculature (bluish discoloration of vagina & cervix)
What is Hegar’s sign?
widening & softening of the body or isthmus of the uterus (6–8 weeks’ menstrual gestational age)
What is leukorrhea?
increase in vaginal discharge (epithelial cells&cervical mucous)
What are uterine contractions?
painless uterine contractions (Braxton Hick’s contractions/false labor), begin ~28 wks gestation, usually disappear with walking or exercise as opposed to true laborcontractions intensify
Abdominal enlargement
from 18 to 34 weeks good correlationbetween the uterine fundal height and gestational age
Pelvic ligament laxity
relaxation of the sacroiliac & especially pubic symphysis during pregnancy
What occurs on the first visit after postitive pregnancy test
o Complete PE, pelvic w/pap, STD and group be strep culture
o Bold type, HIV test, rubella titer, prenatal genetic testing (discuss—genetic/family dz, screening for spina bifida & trisomies)
What are 6 indications for genetic counseling?
o Advanced maternal age (over 35) advanced paternal age (over 50)
o Consanguinity (in reproducing with a relative)
o Prevous hx of child w/birth defects/genetic d/o, fam hx suggestive of genetic d/o
o High rsk ethnic groups
o Documented genetic alteration in fam member
o U/S or prenatal testing suggesting a genetic d/o
What are 4 methods of genetic testing?
o Advanced maternal age/previous child w/chromosome prob or IGD→ cytogenetics (amniocentesis)
o Biochemical d/o→ proteun assay, DNA dx
o Congenital abnormality→ U/S, fetal cytogenetics
o Screening for neural tube defects/trisomy→ maternal multiple marker screening/ U/S
What are 4 things that can occur if use of cocaine or meth during pregnancy
premature delivery, placental abruption, IUGR, irritability
What are 10 things that can occur if use of toluene during pregnancy
IUGR, micrcephaly, large anterior fontanelle, abnormal hair patterns, nail hypoplasia, renal anomalies, craniofacial abnormalities, postnatal growth deficiency, developmental delay
what occurs during prenatal visit?
weight, blood pressure, fetal heart, dipstick urine (glucose & protein), measure fundal height
What happens during first trimester visits?
o Listen for fetal heart (usually audible @ 10-12 wks) w/doptone
o Screening
• Free beta hCG, PAPP-A (preg associated protein A), U/S measure nuchal fold thickness (for downs)
o Address Hyperemesis Gravidum (is effects of estrogen)
How to date the uterus by size
- 8 weeks – lemon
- 10 weeks- orange
- 12 weeks- grapefruit
- 14 weeks- just above pubis
- 16 weeks- between pubis & umbilicus
- 20 weeks- at umbilicus
What happens during 15-20 weeks of pregnancy
fetal movements, triple screen (AFP, hCG, Estriol) esp if over 35
o Triple screen high levels→ spina bifida
o Triple screen low levels→ trisomy 21 and 18
What happens at 24-28 weeks of pregnancy
- 24-28 wks→ 1 hr glucose, 3 hr GTT if>140
* Birthing classes
What gets checked in the third trimester of pregnancy
- 1 hr HTT
- Rhogam is given
- Talk about child birth classes & plans (pediatricine, nusrsing,) maternity leave
- At 36 weeks→ weekly visits, group B strep culture, careful assessment
- Leopold Maneuvers→ if baby is mispresenting
What gets checked postpartum
visit 4-6 wks after delivery
• Pelvic exam (condition of vagina, cervix, pap smear
What are 3 types of baby breech?
frank breach= (legs up, feet by ears)
single footling breech= (one foot down straight, one foot up)
complete breech= (both legs up but bent at the knees, with ankles crossed)
What are 4 causes of breech position?
o Uterine problems→ biconrnuate or septate uterus, contracted pelvis
o Pelvic tumors obstructing canal
o Abnormal placenta
o Multiparity→ each twin prevents the other from turning
What are some congenital malformations due to the breech position
hip dislocation, hydrocephalus, anencephalus, familial dysautonomia, spina bifida, memingomyelocele
External Cephalic Version
done in the hospital next to an OR
• Done at 36-37 weeks
• Non stress test before (measure the HR of fetus in response to the perceived movements by mother), monitor throughout
• Tocolytic(Terbutaline) given before
• U/S, stop if sounds of fetal distress somersault fetus in direction of the head (head first)
How does external cephalic version work best?
pt has had previous term birth, complete breech, normal fluid levels, not macrosomic (big baby)
What are some contraindications for external cephalic version
o Ruptured membranes, previous uterine scar, low amniotic fluid, multiple fetuses, uterine anomaly, fetal chin not tucked, birth defect, placenta is low lying or previa (would separate placenta from the uterine wall),
what are some complications for external cephalic version?
o Fetal distress, reuptured membranes, abruption, cord prolapse (every time there is a contraction the flow will stop to the cord), fetal heart decelerations
What happens during labor?
What is labor measured by?
- Oxytocin receptors increase, fetal size, prostaglandins, ruptures membranes, CRH→ produced by placenta, elevated levels present before labor
- Labor is measured by → cervical dilation, cervical effacement/thinning, station (position relative to the ischeal spine)
What is enffacement
thinning/flattening of cervix, measured in % compared to normal uneffaced cervix
Cervical dilation
from 0-12, usually occurs with effacement, faster w/previous birthsm first stage of labor ends with full dilation
How to measure cervial dilation?
o 1cm= 1 finger width o 2cm= very loose 1 finger but thight 2 fingers o 3 cm= 2 fingers side by side o 6 cm= 3 fingers side by side o 10 cm= no palpable cervix
What is station?
decent of presenting part (usually head) in relation to ischial spine
Station is measured how?
o At spine=0 o Above spine= (-) 1,2,3 o Below spine= (+) 1,2,3 o Each station presents 2cm distance • Station -1→ 2cm above spines • Station +2→ 4cm below spine
What is the first stage of labor?
onset of labor to full dilation of cervix
• Latent & active
How long does the first stage last?
- For first child (primipara)→ lasts 6-18 hrs & dilation at 1.2cm/hr
- For next children (multiparas)→ lasts 2-10 hrs & dilation is 1.5cm/hr
- Check cervix Q2 hrs, check fetal HR Q30 mins
What is the latent phase of first stage of labor?
longest, dilation is only 2-3 cm
What is the active phase of the first stage of labor?
rapid dilation to 10cm dilation, some desent of vertex, frequent fetal monitoring, intense contractions, epidural, still 1.2cm/hr for primapara and 1.5cm/hr for multiparas
Therapeutic rupture of fetal membrane
increase risk cord prolapse, may provide info on volume of amniotic fluid or meconium, increases uterine contractility
What is the second stage of labor
full dilation to the actual delivery
• Descent of presenting part in relation to ischial spines
• Active stage of labor→ pt actively bearing down, constant fetal monitoring
• Max duration→ 2 -3 hrs
How does the baby navigate through the pelvis?
cardinal movements
cardinal movements
• Head into lower pelvis→ flex head (head now in presenting position)
• Neonate descends through pelvis
• Internal rotation of vertex to go past lateral ischail spines
• Extends head to pass beneath maternal symphysis
• External rotation of head after delivery to facilitate delivery of shoulder
Determining position of vertex
how to tell if head is facing forward
• Posterior fontanelle is triangular & easy to palpate w/head flexed
• Position is indicated by position of occiput
What is the third stage of labor?
delivery of infant to delivery of placenta
• Once cord is clamped & cut, placenta will separate, don’t pull cord it may avulse placenta
• Inspect vagina, cervix, perineum
• Inspect placenta to assure its complete
What are 5 things that should be done during a normal vaginal birth?
- Suction NOSE when head is out
- Check nuchal cord & lift over head
- Pull down to deliver anterior shoulder
- Pull up to deliver posterior shoulder
- Dry& stimulate baby, clamp and cut umbilical cord
What is the umbilibal cord made of?
o 2 arteries, 1 central vein
o 24% have nuchal cord (when cord is wrapped around neck)
What are obstetrics lacerations
- 1st degree→ superficial
- 2nd degree→ into sub mucosa
- 3rd degree→ through anal sphincter
- 4th degree→ through rectum
What are 4 causes for the baby to stop progressing?
- Baby→ not vertex, not LOA, no internal rotation
- Pelvis→ narrow pubic arch, narrow spines
- Propulsion→ adequate contractions, strength, duration, frequency
- Arrest of labor/dilation (50% have cephalopelvic disproportion/head is too big)
How would a stop in progression be managed?
o Oxytocin, rupturing membranes
What are 4 reasons to induce labor
• Post dates, prevent macrosomia, heart dz, convenience
What are 2 methods for induction?
o Oxytocin
• Contra indicated if→low lying placenta, placenta previa, not vertex, multiples, fetal distress, undiagnosed 3rd trimester bleeding, oligiohydraminios, previous c section
o Cervical ripening→ Misoprostol (PGE1), dinoprostone (PGE2), relaxin, laminara
What are some phases that would be considered too long
- Prolonged Latent→ 20 hrs for nulli, 14 for multi
- Protracted active phase dilatation→ less than 1cm/hr nulli, less than 2cm/hr multi
- Arrest of dilatation→ no dilatation for more than 2 hrs
- Arrest of descent→ no change in station for 2 hrs or more
What are some indications of c-section?
• Cephalopelvic disproportion, fetal distress, breech/abnormal presentation, multiple pregnanices, previous c section, placenta previa, cord prolapse, active herpes, breech
Vaginal Birth after C-section
- Increased risk to mother & baby, increased morbidity
- Requirements for VBAC→ normal vertex low transverse uterine scar, full consent of pt, IV typed & crossed, available OR, no Pitocin
What is done during a c-section
- Anesthesia→ epidural or spinal
- External incision→ vertical or low transverse
- Internal incision→ vertical or low transverse
What 2 things can be used during vaginal births?
- Vacuum→ less likely to cause maternal injury, cephalohempatoma more common, more low 5 min Apgar scores with cavuum, don’t need to know orientation, no need for anesthesia
- Forceps→ used infetal distress, maternal exhaustion, prolonged second stage, cant have cephalopelvic disproportion
How is the baby monitored?
- Monitor heart & uterus, uterine contraction can show if fetus is compromised
- Baseline fetal heart rate→ 120-160 and vary 10-15 bpm
Spontaneous Rupture of Membranes—SROM
- Risk of infection when ruptures, minimize exams to decrease infection risk
- Test for rupture using ph paper→ because amniotic fluid is basic and turns paper blue
3 stages of pain relief
- 1st stage→ breathing, ambulation, narcotics
- 2nd stage→ epidural
- 3rd stage→ spinal, local
postpartum lactation
o (+) Helps contract uterus, convenient, cheap, good nutrition, less PPD
o (-) interferes w/wok, uncomfortable, unable to measure intake, cant take meds
o Without breast feeding→ engorgement, hard tender breasts, mild fever
Postpartum sex, metabolic changes, depression
• Metabolic changes
o Slow return to normal over 6 wks, 1st menses at 6 wks
• Sex→ usualy desire after 6 weeks, can take 12
• Depression→sleep deprivation/hormonal
Masitis postpartum
o Infection of breast
o Fever, flu sx, wedge shaped erythematous area, axillary nodes enlarged, nipple cracking
o Tx→ abx, warm compress, pump&dump, monitor for abscess
endometritis postpartum
infection of endometrium
o Fever, tender utuerus, malodorous lochia, bleeding
o Tx→ abx
