OB Antepartum aclift

A woman who is or has been pregnant

the umber of pregnancies that reached viability

A woman who is pregnant for the first time

Woman who has delivered one viable fetus

Pregnant woman who has been pregnant before

Woman who has delivered more than one viable fetus

Woman who has never been pregnant

Woman who has not carried a fetus to variability

Gravida - # of total pregnancies

Para - # of pregnancies that reached viability

• T --> Term Pregnancies
• P --> Preterm deliveries (20-37 wks)
• A --> Abortions (< 20 wks)
• L --> Number of Living Children

• G   4
• T    1
• P    1
• A   1
• L   2

• 1st date of LMP
• Subtract 3 months
• Add 7 days

• First date of LMP
• Add 9 months (usual time for baby to grow)
• Add 7 days (babies are usually a week late)

Those that suggest but do not positively indicate pregnancy (subjective signs)

• Amenorrhea: absence of menstruation
• Nausea/vomiting: due to metabolic and hormonal changes
• Breast changes: enlargement, tingling, increased sensation to touch, darkening of nipples and areola
• Urinary frequency: due to pressure on bladder from uterine enlargement
• Fatigue: due to increased metabolism
• Quickening: fluttering sensation when fetus moves (16-20 weeks gestation)

Strong indicators of pregnancy, short of confirmation (objective signs). Two or more are highly suggestive of pregnancy. Detected at about 12th week.

Pigmentation changes: linea nigra, chloasma (mask of pregnancy)

Abdominal enlargement: as uterus rises out of the pelvis (after 12 weeks)

Chadwick’s Sign: purplish color of cervix

Hegar’s Sign: softening of the lower uterus

• Ballottement: detection of fetus floating in
• amniotic fluid

Braxton Hicks contractions: irregular, painless uterine contractions

Goodell’s Sign: softening of a normally-firm cervix

• Positive pregnancy test: Maternal blood or urine test for human chorionic gonadotropin (hCG). (Testing one week after a missed period
• usually provides more accurate information)

absolute confirmation of pregnancy

Detection of fetal heart tones

Palpation of fetal movement

Ultrasonic evidence of a fetus

butterfly shaped rash (mask of pregnancy)

purplish color of the cervix (increase in estrogen)

Softening of the lower uterus

Detection of a fetus floating in amniotic fluid

irregular, painless uterine contractions

Softening of normally-firm cervix (progestrone)

Maternal blood or urine test for human chorionic gonadotropin (hCG)

Testing one week after a missed period usually provides more accurate information

Increasing vascularity

Slowing everything down.

A molar pregnancy

Benign proliferating growth of the trophoblast in which the chorionic villi develop into edematous, cystic, vascular transparent vesicles that hang in grapelike clusters without a viable fetus. Although hCG is produced, this is a nonviable pregnancy

• 1st trimester
•        First day of LMP to week 13

• 2nd trimester
•        14 weeks to 27 weeks

• 3rd trimester
•        28 weeks to 40 weeks

Full term pregnancy 37-42

• A --> perfectly fine
• B --> pretty benign
• C --> could be harm (must weigh risk vs benefit)

• D --> Tetrogenic
• X --> Tetrogenic = never ever give

Week 2-8

• CBC (H&H, platelets, WBC)
• Serology/VDRL/RPR --> syphilis
• STD screening --> chlamydia, gonorrhea, herpes
• Pap smear --> cervical cancer screening
• Antibody tiders for rubella and Hep B
• ABO/Rh typing
• Plasma Glucose --> diabetes
• Urinalysis --> UTI?
• TB screening
• TORCH screening
• Alpha-fetoprotein (AFP) --> fetal liver
• Group B strep
• HIV --> with permission

Mother is Rh negative and fetus is Rh positve

Baby's Rh+ blood enters mom's circulation, and mom's body perceives this foreign blood type as harmful. She makes Rh antibodies in response

Current baby not effected... next pregnancy is!!

Treatment: 300 mcg IM or IV at 28 weeks, and 72 hours after birth (if baby is Rh+)

RhoGam is also given after abortion, ectopic pregnancy, and amniocentesis as in each case blood could be exchanged and trigger Rh sensitization response.

YES!!

It is a blood product

More common than Rh incompatibility but less serious

• Mom --> O
• Baby --> A, B or AB

Antibodies will cause red blood cell breakdown in fetus

• Causes: hyperbilirubinemia
• Treatment: phototherapy

• T  --> Toxoplasmosis
• O  --> Other **
• R  --> Rubella
• C  --> Cytomegalovirus
• H  --> Herpes

** gonorrhea, syphilis, varicella, hep B, Group B strep, HIV

• Congenital Heart defects
• Physical fetal anomalies
• Intrauterine growth restriction (IUGR)
• Mental retardation
• Encephalitis
• Hydrocephalus
• Blindness
• Deafness

• TORCH infections place both mother and baby in jeopardy due to the associated complications
• All torch infections can cross the placenta
• Prenatal complications include premature labor and premature rupture of membranes
• Prenatal screening important since many infections are asymptomatic

Streptococcus (Group B) is a frequent cause of sepsis in the mother/neonate

Transplacentally

At birth

Breast milk --> absolutely no breast feeding!!

• Oral AZT --> pregnancy
• IV AZT --> during labor

Reduce invasive procedures (AROM, fetal scalp electrodes, IUPCs)

Bathe baby as soon as possible after delivery. If baby is unstable, wash injection sites with soap and water, then clean with alcohol

Delay injections, heel-sticks until after bath

Medical personnel --> should wear eye shields, gowns, masks, and double glove during the birth

Usually not harmful to mother but can cause serious complications if transferred to infant

Vaginal/rectal area swabbed

Screened at 35-37 weeks (pathogen comes and goes)

If positive --> mother is treated with IV antibiotics while in labor. Must have 2 separate doses administered at least 4 hours before birth to be considered treated.

Substance produced by the fetal liver

• Elevated --> may be neural tube defects
• Decreased --> may be down syndrome

Abnormal levels will necessitate further testing. Amniotic fluid will be assessed --> more accurate

May be elevated when there are twins.. triplets!

• Pregnant woman are more abused than general population
• Most likely related to the partner feeling a sense of lack of power/control
• Essential to screen throughout the entire pregnancy

• 1) “In your current relationship, do you feel safe?”  
• 2) “Within the last 6 months have you been hit, slapped, kicked, or punched?” 
• 3) “Do you fear for your own safety or the safety of your children?”

• ETOH
• Tobacco
• Marijuana
• Cocaine
• Amphetamines
• Heroin
• Other perscribed or ilicit drugs

• Urine screen for mom
• Infants first meconium is sent to lab for drug screen
• Notify social if drug screen is positive (CPS involvement is mandatory)

Narcan should not be given to a mother on methadone or heroin as it may precipitate drug withdrawal

• Hyperactivity
• Persistent shrill cry
• Tremors
• Increased muscle tone
• Sneezing, hiccups, yawning
• Short, unquiet sleep
• Fever
• Disorganized, vigorous suck
• Poor feeding
• Vomiting
• Drooling
• Diarrhea
• Flushing, sweating
• Tachypnea ( > 60 bpm)

• Microcephally --> small head, small brain
• Growth retardation
• Short palpebral fissures
• Maxillary hypoplasia --> small chin
• Smooth philtrum --> small ridges

• Decrease environmental stimuli 
• Provide gavage feedings if neonate has uncoordinated sucking and swallowing

• Mental retardation
• Poor coordination
• Facial abnormalities
• Behavioral deviations (irritability)
• Cardiac and joint abnormalities

• Blood pressure --> preeclampsia?
• CBC --> # of times can vary
• Weight --> every time
• Abdominal exam -->
• Assess FHR --> 110-160, variability good?
• Assess fetal position --> right position? breech?

• Non-stress test (NST)
• Contraction stress test (CST)
• Ultrasound (US)
• Alpha-fetoprotein (AFP)
• Amniocentesis
• Amniotic fluid index (AFI)
• Chorionic villi sampling (CVS)

• 36 weeks --> xyphoid process (high as it goes)
• 20-22 weeks --> umbilicus
• 12 weeks --> pubic bone

used to evaluated fetal status without uterine contractions

Monitors FHR with fetal movement, which should accelerate 15 beats per minute for 15 seconds. Then would be considered “reassuring”

Uterus is made to contract artificially with the use of pitocin or nipple stimulation

Fetal heart rate monitoring evaluated the respiratory function (02 / C02 exchange)

No longer commonly used

Amniotic fluid removed from amniotic sac

• Genetic information
• Sex of fetus
• Chromosomal abnormalities
• Determine health of maturity of fetus
• Lecithin/sphingomyelin ratio
•      

(L/S ratio) to determine lung maturity. Ratio of 2:1 confirms fetal lung maturity

20 gauge spinal needle

Ultrasound

Full <20 weeks

Empty >20 weeks

• Sampling of tissue (chorionic villi) from the edge of the placenta
• Detects genetic disorder, done at 8-12 weeks
• Aspiration catheter or biopsy forcep is introduced through cervix
• Guided/monitored by ultrasound

Test to confirm fetal well being

• ultrasound
• electronic fetal monitor

• Uterus: enlarges (X 20); irregular, painless contractions occur
• Ovaries: ovulation stops due to high levels
• of placental estrogen and progesterone
• Vagina: becomes softer, mucosa thickens, vascularity increases, vaginal discharge increases and becomes more acidic
• Breasts: increases in size and become full and tender, areola darken; colostrum is excreted
• Cervix: softens (Goodell’s Sign), becomes congested with blood (Chadwick’s Sign), mucus plug forms

• Relaxation of joints due to relaxin hormone
• Widening of symphsis pubis
• Waddling gait
• Lordosis
• Increased back spain

Blood volume increases by 30-50%      

• Pulse rate increases by 10-15 beats/minute       
• Clotting factors increase which helps prevent hemorrhage however increases risk of DVT
•     
• RBC mass increases (plasma portion faster…therefore causing physiological
• anemia)
•      
• BP basically remains essentially unchanged due to peripheral vasodilation related to progesterone  

• 500-1,000 mLs of blood to the uterus per minute!      
• Supine hypotension a major problem

Hgb < 11g/dL Hct <  33% indicates anemia

The pregnant uterus compressing the aorta and the inferior vena cava (aortocaval compression). Patient in supine position.

Uterine displacement with wedge under hip to relieve aortocaval compression.

• 02 consumption increases by 20%
• Dyspnea is common
• Nosebleeds and nasal stuffiness are common and related to estrogen
• Rib cage widens
• Respiratory depth increases

• Gums appear red and swollen and bleed easier, caused by elevated levels of estrogen
• N/V occurs in 50% of women and common in 1st trimester
• Delayed gastric emptying and reduced tone of esphageal sphincter allows reflux, producing heartburn --> progesterone
• Decreased motility in large intestine causes constipation and hemorrhoids
• Gallbladder emptying time prolonged - may lead to gall stone formation
• Increased thirst and appetite

• Frequent urination is common, particularly in the first and third trimesters
• Urinary stasis predisposition to UTIs
• Increased renal plasma flow
• Glucosuria may occur --> may be normal finding

• LOC
• HA
• DTRs
• Light-headedness/fainting may be due to
•        hormones
•        B/P
•        Blood sugar
•        Cardiac problems
•        Anemia

• Placenta becomes an endocrine organ and produces large amounts of hormones
• Heat intolerance due to vasodilatation, fetal and maternal heat production

• Thyroid gland --> increases 25%
• BMR --> increases 25%

Oxytocin and prolactin are secreted by the pituitary gland

Increased vascularity. Level remains high during pregnancy

Relaxed all smooth muscle. Maintains the endometrium and prevents abortion by relaxing uterine muscles.

Hormone measured in pregnancy tests. Stimulates the corpus luteum to produce estrogen and progesterone until the placenta can assume that function

Acts as a insulin antagonist; increases availability of glucose for fetal growth and development

Softens connective tissue and relaxes pelvic joints

• Protein demands increase
• Carbohydrate demands increase
• Glycosuria may be present
• Iron needs increase
• Water requirements increase

Fluid retention common

Dependent edema

Lower extremities

Weight gain should be approximately 25-35 pounds

Clients should gain 1 pound per week in the 2nd and 3rd trimesters

• Nutritious, well-balanced meals
• Prenatal vitamins usually perscribed. Megadoses of Vit A & D --> tetrogenic

PICA --> Unexplained urge to eat non-nutritive substances such as dirt, starch, ice, clay, freezer frost. Thought to be related to an iron deficiency

N/V are common. Related to hCG and estrogen. Ginger --> safe anti-emetic

• Should not consume soft cheeses as they harbor listeria monocytogenes, the organism
• that causes listeriosis

Maternal effects of listeriosis includes meningitis, pneumonia and sepsis

Increased risk of delivering stillborn babies

Another concern? Fish…mercury poisoning

• Protein --> 60-65 g/day
• Calcium --> 1,200 mg/day
• Average 2,500 cal/day (only 300 extra)

Before conception: 400 mcg/day of folic acid to prevent neurotube defects.

During pregnancy: 600 mcg/day recommended.

• Liver (chicken, turkey, goose, lamb, beef)
• Fortified cereals and breads
• Spinach
• Broccoli
• Peas
• Beans

Rupture of membranes

Placenta abruption, previa, bloody show

Premature labor, placenta abruption

Infection

Hypertension, preeclampsia

Hypertension, preeclampsia

Hypertension, preeclampsia

Preeclampsia, HELLP

UTI

compromised fetal well-being

• Ambivalence
• Acceptance
• Introversion
• Mood swings
• Changes in body image

Ensuring safe passage through pregnancy, labor and birth

Seeking acceptance of this child by others

Seeking commitment and acceptance of self as mother to infant (binding in)

Learning to give of oneself on behalf of one's child