Ob/Peds - Midterm (Obstetrics)

Infertility

inability to conceive after 12mo

What percentage of infertility is due to identifiable causes

85%

Good nutrition for fertility

omega-3 FA (anti-inflammatory)

protein (plant > animal)

vitamin D

folic acid

Bad nutrition for fertility

trans-fatty acids (inflammatory)

high caffeine consumption

added sugars

refined carbs

alcohol

Sources of Omega-3s

fish

flaxseed oil

fortified foods

Sources of folic acid

leafy greens and supplementation

Factors to increase chances of conceiving

maintain healthy body

abstain/quit smoking

prenatal vitamins

ovulation tracking

getting adjusted

Medical means to increase chances of conceiving

oral medications

intrauterine insemination

in vitro fertilization

third party reproduction (donor or surrogacy)

When to refer for an infertility consultation

<35 after 12mo

>35 after 6mo

What two individuals can deliver a baby

ob/gyn or midwife

Ob/Gyn

MD or DO

trained in medical problems during pregnancy

trained in surgeries (C-section)

manage high risk pregnancies

pay some of the highest malpractice rates

Midwife

specialist in care of healthy women anticipating normal pregnancy/birth

focus on wellness

encourage family participation in decision making

trained to identify problems in pregnancy

work w/Ob related to complicated pregnancy/birth

Certified Nurse Midwife (CNM) vs Certified Midwife (CM)

CNM = need a bachelors or RN degree

CM = completed midwife training but background in another health field

Doula

“a woman who serves” (advocate for mom + baby)

provides emotional support + advice for mom/family

provides suggestions for easing discomfort

Research about a partner or doula

reduce occurrence of C-sections

improves birth outcomes

decreases interventions

lower rates of PPD

Cesarean section indications + pre-procedure

indications: placenta previa, fetal distress, breech or elective

pre-procedure: fasting, IV, antibiotics, spinal/general anesthesia

Cesarean section procedure

horizontal incision just above pubic hairline

baby is lifted out and cord is clamped

placenta is detached and removed

uterine/abdominal incisions are stitched/stapled closed

Cesarean section post-procedure

recovery room - monitor vitals and pain

hospital stay - 3-4days

limited lifting/physical activity for several weeks

Risks: infection, blood clots, bleeding, potential future pregnancy complication

VBAC (vaginal birth after cesarean)

suitable for women w/low-transverse uterine scar

Risks: uterine rupture, emergency C-section

How does VBAC post-procedure monitoring differ from a regular vaginal birth

extra vigilance for any signs of complications like uterine rupture

Stages of Labor and Delivery

Stage 1 = labor (early, active, transition)

Stage 2 = delivery of baby

Stage 3 = delivery of placenta

True Labor VS Braxton Hicks/prelabor contractions

True - contractions are regular, progressively stronger, closer together

BH - irregular, do not increase intensity, may stop w/change in position or activity

When are Braxton Hicks contractions felt

as early as the 2nd trimester

MC in 3rd trimester

Purpose of Braxton Hicks contractions

helps tone uterus for actual labor

softens cervix in preparation for dilation (cervical ripening)

Stage 1 - Early Labor

hours to days

0-6cm cervical dilation

mild-moderate, irregular, become regular over time contractions

LBP, cramping, bloody show (mucus plug release)

Stage 1 - Active Labor

4-8hrs

6-8cm cervical dilation

stronger, more regular, closer together (3-5min) contractions

intense, nausea, water breaking

Stage 1 - Transition

30min-2hr

8-10cm cervical dilation

very strong, close together (2-3min) lasting 60-90sec contractions

intense pressure, shaking, irritability

Effacement of cervix

thinning of cervix

Stage 2 - Delivery of baby

min-hrs

full 10cm cervical dilation

very strong, close together (2-3min) lasting 60-90sec contractions

mother actively pushes w/each contraction

crowning (baby’s head visible)

delivery + cord clamped/cut

Stage 3 - Delivery of placenta

5-30min after baby is born

mild contractions to help detach and expel placenta

placenta and membranes expelled

uterus is massaged to reduce bleeding + stitches if needed

Stage 4 - Recovery

first 1-2hr after delivery

mother and baby are closely monitored

skin-to-skin contact and initiation of breastfeeding

uterus continues to contract while bleeding gradually decreases

Vertex fetal position

normal head down position

occiput anterior (posterior = sunny side up birth)

Transverse lie position

baby lying sideways across abdomen

not able to deliver vaginally!!

Breech position (high risk) types

Complete (cannonball position)

Franks (both legs up by head)

Incomplete (one leg up by head)

Breech position causes an increased risk for

intracranial hemorrhage

dislocation/injury to neck, hip, shoulder

prolapsed umbilical cord

genital injury

premature placental rupture/apnea for baby

death

What way are breech babies attempted to be flipped

external cephalic version

External cephalic version of flipping breech babies risks include

umbilical cord entanglement

abruption of placenta

preterm labor

premature rupture of membrane

severe maternal discomfort

Delivery interventions

episiotomy, vacuum, forceps, C-section

Three reasons for an intervention

too tired

labor stops progressing

fetal distress

Episiotomy

surgical cut to perineum

• prevents internal tissue damage

Vacuum

side effects to mom - episiotomy, urination issues, vaginal tears

side effects to baby - head swelling, shoulder dystocia, bleeding/fx in skull

• shoulder dystocia: anterior shoulder gets stuck on pubic symphysis

Forceps

side effects to mom - episiotomy, vaginal tears, hemorrhage, pelvic flood dysfunction

side effects to baby - bruising, shoulder dystocia, trauma from forceps

APGAR Scoring

Activity, Pulse, Grimace, Appearance, Respiration

scoring done 1min + 5min after birth

• 7-10 - excellent condition

• 4-6 - moderately depressed

• 0-3 - severely depressed

Cord clamping

10-15sec after birth

delayed = after 30sec

can continue pulsating up to 5min after birth

Significant health benefits for baby when cord clamping btw ___ and ___

30-60sec

A new mother with a ____ is a clinical red flag!!

fever

Post birth interventions

vitamin K shot (blood clotting)

hepatitis B vaccine

erythromycin in eyes (prevents infection)

The first 1000 days - conception to age 2 is the most critical time for

proper nutrition leading to growth and development

Iron

27mg/d pregnant and 60mg/d postpartum

supports hemoglobin production, fetal growth, reduces risk of low birth weight

take with vitamin C (increase absorption)

SE - constipation

Why is the amount of iron intake recommended increased during pregnancy

due to expanded blood volume and fetal demands

Folate (vitamin B9)

600ug DFE/d pregnant (start >3mo preconception)

prevents neural tube defects

supplements recommended (only 50% of food folate bioavailable)

Calcium

1000mg/d pregnant and lactation

fetal skeletal development (esp. in 3rd tri)

low intake linked to increased bone loss and pre-eclampsia

Magnesium

350mg/d pregnant

supports neuromuscular function + reduces leg cramps

Iodine

220-250ug/d pregnant and 250-290ug/d lactation

thyroid hormone production and fetal brain development

Zinc

11mg/d pregnant and 19mg/d lactation

supports DNA synthesis, growth, immune function

deficiency linked to low birth weight and congenital anomalies

What supplements can inhibit zinc absorption

iron

Vitamin D

400-600 IU/d pregnant and 6400 IU/d lactation

supports calcium metabolism and fetal bone development

Vitamin A

770ug RAE/d pregnant

important for cell differentiation, organ development, vision

Vitamin B12

2.6ug/d pregnant and 2.8ug/d lactation

required for DNA synthesis and myelination of fetal nervous system

supplementation essential for vegetarians

Vitamin B6

1.9mg/d pregnant and 2mg/d lactation

supports neurotransmitter synthesis and reduces nausea

Vitamin C

85mg/d pregnant and 130mg/d lactation

Vitamin E

15mg/d pregnant

Omega-3 Fatty acids (DHA)

>200mg/d pregnant and 100mg/d lactation

supports brain and visual development

deficiency linked to low birth weight and cognitive delays

What are ginger and vitamin B6 (10-25mg 3x/d) specifically good for in pregnancy

natural remedy for morning sickness

Exercise guidelines for pregnant women

150min/wk of moderate intensity aerobic activity

Typical term of pregnancy lasts 40wks - how to calculate due date

first day of last menstrual period

count back 3mo

add 1 year and 7 days

Premature

<37wks

What is considered a viable pregnancy

20-22wks development

Most pregnancies will be induced at or before

42wks to post-term

What three exams are done at EVERY pregnancy related doctor visit

maternal blood pressure

maternal weight

baby heartbeat

Pregnancy screenings

HCG

PAPP-A (pregnancy associated plasma protein)

STI

Genetic testing

down syndrome (trisomy 21)

trisomy 18 or 13 (severe intellectual and physical disability, poor survival rate)

neural tube defects

Maternal constraint

pathological sacropelvic constriction

• poor development or nutritional deficiency

soft tissue abnormalities

• bicornate uterus or placenta previa

structural/functional sacropelvic subluxation

Fetal constraint

excessive size

• post-term or gestational diabetes

fetal positioning

• breech or transverse

multiple pregnancies

oligohydramnios

Vena cava syndrome

vena cava compressed by baby (usually after 20wks)

relieved by laying on LEFT SIDE

Pregnant cervical/occiput adjusting notes

avoid over rotation and lateral bending (hypermobile)

Pregnant thoracic adjusting notes

considered changes to DPL = increased kyphosis or posterior translation

Pregnant lumbar adjusting notes

consider changes to DPL = increased lumbar lordosis

All major pediatric organizations recommend _____ breastfeeding for the first 6 months of life

exclusive

What is the primary source of nutrition in the first year of a baby’s life

milk (breast or formula)

Breastfeeding decreases the risk of … (maternal benefits)

PPD

breast and ovarian cancer

T2DM

HTN and MI

Colostrum (initially after birth)

establishes healthy bowel flora for digestion

contains high levels of protein for rapid growth in first few days

contains mothers antibodies

Transitional milk (days 7-14)

increasing levels of lactose

Mature milk begins after day (highest levels of lactose)

14

What hormone stimulates tissue growth and milk production

prolactin

What hormone is released when infant starts sucking and stimulates milk let down

oxytocin

What hormones inhibit secretion of prolactin

stress hormones (epi and cortisol)

When should you refer a ppd mother to a lactation consultant

poor weight gain in baby

How to increase breast milk supply

express milk frequently

hydration

sleep

regular skin to skin contact

calories

oats and leafy greens

Baby blues

common, short-term emotional response experienced by new mothers

affects up to 80%

begins a few days after birth + lasts up to 2wks

Causes of baby blues

hormonal changes - rapid drop in estrogen and progesterone levels

physical/emotional factors - fatigue, stress, recovery from birth

Postpartum depression (PPD)

more severe, long-lasting form of depression after childbirth

affects 10-15%

begin anytime within first year after birth and last several months+

Differences btw baby blues and postpartum depression

BB - few days after birth, lasts up to 2wks

• mild and temporary symptoms

PPD - start anywhere within first year, lasts longer

• severe and persistent symptoms

Ectopic pregnancy

occurs when a fertilized egg implants outside the uterus

MC in fallopian tubes

Symp = sharp/stabbing abdominal pain and vaginal bleeding

Dx = ultrasound or blood tests (low hCG)

RF = tubal surgery, PID, infertility tx, 35-44yo, smoking

Tx = laparoscopy or laparotomy

Miscarriage (spontaneous abortion)

spontaneous loss of a pregnancy before the 20th week

Symp = cramping abdominal pain, back pain and vaginal bleeding

Dx = ultrasound or blood tests (decrease in hCG levels)

RF = >35yo, diabetes, smoking, structural issues, genetic factors

Tx = dilation and curettage or manual vacuum aspiration

Threatened miscarriage

pregnancy complicated by bleeding before 20wks

Inevitable miscarriage

cervix has dilated, but product of conception have not been expelled

Complete miscarriage

all products of conception have been passed without need for surgical/medical intervention

Incomplete miscarriage

some (not all) products of conception have been passed

retained products may be part of fetus, placenta, or membrane

Missed miscarriage

pregnancy in which there is a fetal demise but no uterine activity to expel the products of conception