L&D

When does the pre-embryonic stage occur

* The ovum is fertilized and now has half the chromosomes from mom and half from dad (Called a zygote)


* Undergoes mitosis
* Travels down the fallopian tube to uterus

Describe the pre-embryonic

* Btw 6-10 days after fertilization blastocyst implants/attaches to uterine wall → trophoblast becomes placenta and inner cells become embryo → Progesterone surge so the blastocyst implants strongly along uterine wall
* Endometrial lining becomes more vascular so blastocyst can attach

When does the embryonic stage occur

* 10-12 days after fertilization until 8 weeks


* Zygote becomes embryo
* Fetal pole is earliest form of embryo → seen 3-4wks after fertilization
* EDC used at this time
* Organogenesis

What is the embryonic period critical for

Organ development

Describe the embryonic period

* Highly susceptible to teratogens
* Spontaneous abortion is common here

Describe the embryonic to fetal stage

* Starts 9 weeks after fertilization/11 weeks gestation and ends at birth
* Officially a fetus at this stage

Describe the placenta

* Temporary vital organ
* Placental development starts with first contact of outer shell of developing blastocyst with uterine mucosa

What is the fx of the placenta

Circulation

Protection

Hormone Production

What is inside the umbilical cord

2 umbilical arteries

1 umbilical veins

Briefly describe fetal circulation

* The placenta is doing the work that baby’s lung will do after birth
* Placenta accepts de-O2 blood from fetus via BV leaving fetus through UC.
* Blood goes through placenta and picks up O2
* O2 rich blood goes to baby via umbilical vein in UC.
* O2 rich blood enters fetus passes through liver and enter right side of heart

What is the patent foramen ovale (PFO)

* The hole btw the R&L atrium.
* Allows for O2 rich blood to shunt from right to left atrium then left ventricle and out aorta

What is the ductus arteriosus

* Sends O2 poor blood to organs and lower half of fetal body
* Allows for low O2 blood to leave via arteries and go to placenta

Pre-natal visits trimester 1:

* 1-2 visits
* Initial bloodwork
* Initial physical assessment
* Initial dating U/S
* Nuchal translucency U/S

Pre-natal care visits trimester 2:

* 3-4 visits
* Ongoing maternal physical assessment
* Fetal assessment
* Anatomy U/S 18-20 wks
* GTT

Pre-natal assessment trimester 3:

* 3-5 visits
* Ongoing maternal and fetal assessment
* GBS swap at 35 weeks

Assessments for Fetal Well-Being

* Leopolds Manuevers
* Systematic assessment to determine: fetal lie, presentation, attitude and position
* Important to empty bladder prior
* Supine with slight head telt

If Pre-Pregnancy BMI is less than 18.5 what is the expected weight gain during

* 12.5-18kg (28-40lbs)
* 0.44-0.58kg/wk (1-1.3lbs_

If pre-pregnancy BMI is 118.5-24.9, what is expected weight gain during pregnancy

11\.5-16kg (25-35lbs)

* 0.35-0.50kg/wk (0.8-1lbs)

If pre-pregnancy BMI is 25-29.9 what is expected weight gain during pregnancy

7-11.5kg (15-25lbs)

* 0.23-0.33kg/wk (0.5-0.7lbs)

If pre pregnancy BMI is 30+, what is expected weight gain during pregnancy

5-9kg (11-20lbs)

* 0.17-0.27kg/wk (0.4-0.6lbs)

How often should you feel your baby move

6 times in every 2 hours

what is VBAC

vaginal birth after caesarean

What are the types of FHR monitorin

* Intermittent - dopplar
* Continuous - mom & baby monitor
* External fetal monitoring

What is the non-stress test?

* Women pushes button everytime she feels baby move
* Compare baby HR during movement and contractions
* Usually HR increases when baby moves

What should be the first thing you determine when looking at FHR

Baseline

What is the normal FHR activity

* Baseline - 110-160bpm
* Variability - moderate (6-25 bpms)
* Accels - present or absent
* Decels - no late/variable/prolonged

What is FHR variability

Beat-to-beat change in the FHR

What are the categories of FHR variability and their parameters

Absent = 0-1bpm

Minimal = <5bpm

Moderate = 6-25 bpm

Marked = >25 bpm

What are FHR accels

Increases of FHR of at least 15bpm above baseline

* Start and peak within 30 sec
* Not less than 15 seconds
* Should subside within 2 mins

What are FHR decels

Periodic decreases in FHR from baseline

Early onset decelerations

Occurs before onset of uterine contraction

Usually benign - no intervention required

Gradual drop in FHR

What is a cause of early decels

Head compressions

What are late decels

Occur after onset of uterine contraction

Uniform shape that reflects associated contraction

Drop in FHR gradual

What is a cause of late decels

Disruption of O2 transfer

What are variable decels

Onset varies in timing with onset of contraction

Variable shape

Abrupt drop in FHR

What is a cause of variable

Umbilical cord compression

Initial Newborn Assessment

* Done within first minutes of birth
* Determine need for resusciation
* Delay cord clamping for 60 secs
* Done by L&D primary nurse

What are normal VS for babys

HR = 120-160

RR = 30-60

Temp = 36.5-37.2

What is heat loss by conduction example

Heat loss d/t cold stethoscope

Heat loss due to radiation

Baby warmer

Describe vitamin K prophylaxis tx for newborns

0\.5mg to 1.0mg depending on wt

Given IM

Prevention of hemorrhagic disease of the newborn

NEED CONSENT

What is nageles rule

Assumes a gestational age of 280 days

* Add 7 days to LMP, subtract 3 months then add a year

When is trimester 1

Conception to 13 weeks

When is trimester 2

Week 13-26

When is trimester 3

Week 27-40

What is GTPAL

G - Gravida

T - Term

P - Preterm

A - Abortion

L - Living

Define gravida

Number of times a women has been pregnant regardless of pregnancy outcome

Define term

Number of pregnancies delivered at 37w0d gestation and beyond

Define preterm

Number of pregnancies delivered from 20w0d throguh 36w6d gestation

Define abortion

Number of pregnancies ending before 20w0d gestation

* may be spontaneous (miscarriage) or induced abortions

Define living

Number of currently living children

Define parity

Number of pregnancies carried to viable gestational age (20-24wk gestation)

Integumentary changes: Linea nigra

Dark line btw belly-button and pubic bone

Hormone induced excess production of melanin

After delivery may never disappear

Integumentary changes: Cholasma

Brownish pigmentation of the skin over the face and forehead (known as mask of pregnancy)

Begins about week 16 of pregnancy and gradually increases

Usually fades after deliver

Integumentary changes: stretch marks

D/t weight increase over abdomen thighs and breasts

Usually fade after delivery but never completely disappear

Integumentary changes: sweat glands

Activity of sweat glands increase during pregnancy so you sweat more

Urinary System changes:

Kidneys work extra hard causing amount of urine to increase

Renal pelvis and ureters dilate causing more frequent urination

GI Changes:

Acid reflux - d/t enlarges/displaced uterus disrupting lower esophageal sphincter and progresterone relaxes it

Slowed digestive process - muscle walls in GI relax slightly and slows it down

Respiratory changes

* Minute ventilation increases about 50%
* Increased tidal vol., slight increased RR
* Functional residual capacity, expiratory reserve vol., and residual vol decrease
* ALL d/t displacement of diaphragm

Cardiovascular changes

Increased blood volume and enhanced coagulation

* Increased circulatory needs of uterus, fetus and placenta
* Mom is protected from bleeding at time of delivery

Why is CO increased during pregnancy

Bc needs to pump so much more to feed fetus and placenta

CO for non-pregnant women

2\.5L/min

CO end of 1st trimester

5L/min

CO end of 2nd trimester

6L/min

CO Full term

7L/min

Hormones in pregnancy

HCG

Prolactin

Insulin

Oxytocin

Estrogen

Progesterone

What is HCG

Stimulates the corpus luteum to secrete estrogen and progesterone for up to approx. 14 weeks until placent takes over

Indicator for being pregnant

What is prolactin

Prepares breasts for lactation and secreted by anterior pituitary gland

Insulin

Production of insulin increases in response to antagonistic effects of estrogen and progesterone

Oxytocin

Stimulates uterine contractions, milk ejection from breasts

Secreted from posterior pituitary gland

Estrogen

Increase in estrogen enables uterus and placenta to further vascularize, transfer nutrients, and support growth of fetus

Progesterone

Helps uterus grow, keeps mom from having cx, helps prepare breasts for milk production

Primary level of prevention

Nutrition

Comfort

Sexual health

Knowledge

Coping

Secondary Level of Prevention

Screening for maternal and fetal well being

Maternal - weight, physical, urine, blood, US

Fetal - HR, growth, movement

Tertiary Level of Prevention

Management of pregnancy related concerns

Gestational HTN & GDM

Antenatal bleeding

First trimester lab testing and imaging

* Initial lab work: CBC, PLT, ABO/RH, Rubella, Varicella, Syphillis, STI screening
* A1C if risk for diabetes
* Genetic screening offered
* Early dating US
* Urine for protein

Second trimester lab testing and imaging

* Anatomy US 18-20wks
* Quad screen
* Glucose screening followed by GTT 24-28wks

Third trimester lab testing and imaging

RH immunoglobulin if needed at 28 weeks

Re-screen for syphillis if at risk

GBS culture 35-36weeks

Describe WinRho immunoglobulin

Given IM

At any point if bleeding

At 28 wks routinely if NO bleeding

another at delivery

MUST be an RN or LPN with special competency to give

What is the nuchal translucency screening

* Can be done 11w4d until 13w6d pregnancy
* US and maternal BW are done within 24 hrs of each other
* US - looking for neck thickness, extra fluid (trisomy 13 or 18), ensuring nasal bone
* BW - hCG, PAPP-A and AFP
* Results: indicate a risk for down syndrome of trisomy 13 or 18 condition

Vaccinations in pregnancy

* Whooping cough vaccine
* Flu vaccine
* Covid-19 can be given

What is hyperemesis gravidarum

* Vomiting to point of dehydration causing electrolyte imbalance
* Nausea
* Cannot hold any food, water, fluids
* Thinner women at risk of this

Bleeding and Miscarriage in Pregnancy

* Always treated as irregular
* Do a cervical exam
* Post-coidal bleeding is acceptable, anything more than 1-2 tsps is not good

Hypertension in pregnancy

140/90 without protein in urine or signs of end organ dysfx

dx at 20wks gestation and onward

What is pre-eclampsia

* Characterized by high BP, signs of damage to another organ system
* Usually begins after 20wks of pregnancy in women whose BP has been normal
* Difference between gestational HTN is protein in urine

Patients at risk for pre-eclampsia start what med in the first trimester

Aspirin

What happens with severe pre-eclampsia

Leads to induction of pre-term birth

* After 34 weeks if baby will do better outside than inside
* If not deliver imminently are treated with IV magnesium sulfate

Management of pre-eclampsia

Antihypertensives for BP >160/11-mmhg

Mag-sulfate to prevent eclampsia

Continued lab and urine analysis

LOTS of education

Ongoing assessments: fetal-well being, BPP, US, NST

May need induction

What does HELLP syndrome stand for

H - Hemolysis (Destruction of RBC)

E - Elevated →

L - Liver enzymes indicating liver damage

L - Low →

P - Platelet count - risk of bleeding

What is HELLP syndrome

* Complication of pre-eclampsia
* Only cure is delivery
* If after 34wks baby delivered ASAP

What happens if you have HELLP syndrome prior to 34 wks

* Delivery is imminent but wait 48 hrs to deliver
* Give mom beta (2 doses of corticosteriod given 24 hrs apart)
* Helps w fetal lung development

Pathophysiology of GDM

* Insulin resistance IS necessary for securing glucose for fetal G&D
* GDM patients cannot compensate for normal insulin resistance d/t Beta cell dysfx
* Leads to hyperglycemic state and fat metabolis causing ketosis

Diagnosing GDM

* Test done 24-28 wks gestation *NOT PERFORMED AFTER 35 WKS*\*
* GTT is warranted if 1 hr glucose val is 7.8-11mmol/L
* GDM is dx if 1 hr glucose val is greater than or equal to 11.1 mmol/L

Polyhydramnios

* Excess amniotic fluid
* Can lead to pre-term, PPH
* TX = Amnio-reduction

Oligohydramnious

* Lower than expected vol of amniotic fluid
* Etiology: PROM and fetal anomalies
* Maternal dehydration can be a factor
* Fundal height smaller than expected is a sign
* TX = Amniofusion

What are the 5 P’s

Passenger

Passageway

Powers

Position

Psyche

Passenger =

Fetus, placenta

Passageway =

birth canal (bony pelvis, soft tissues

Powers =

Contractions, pushing/bearing down

Position =

Woman, fetus