J Clin Med Ob (Detailed)

pregnancy change - circulating blood volume

increases 40-45%

pregnancy change - H/H

decreases

hemoglobin <11 g/dL = anemia

pregnancy change - WBC count

INC 12-16,000, can INC → 20,000 in labor

cause is unknown, maybe to fight infx or reaction of stress

pregnancy change - plt count

gestational thrombocytopenia

hypercoagulable state (increase in fibrinogen and factors VII-X),

clotting and bleeding times don’t change

pregnancy change - cardiac output

INC 40% and stroke volume INC 25-30%

→ smooth muscle hypertrophy = INC heart size 12%

pregnancy change - HR

resting pulse INC 10-15 BPM

mammary souffle (splitting of S1, systolic murmur)

pregnancy change - BP

systemic arterial pressure DEC until 24 wks

→ INC , reaches pre-preg values by 36 wks

pregnancy change - peripheral vascular resistance

1st tri: DEC 30% (5-7 mmHg sys and dia) below pre-preg value

pregnancy change - functional residual capacity

DEC 20-30% (400-700 mL)

d/t diaphragm elevation (4 inch)

pregnancy change - tidal volume and arterial pH

INC 20%

→ hyperventilation → respiratory alkalosis

= blood pH 7.4-7.5

pregnancy change - GFR

INC 50%

pregnancy change - blood sugar

mild postprandial hyperglycemia

preg induced insulin resistance

→ more glucose for fetus

pregnancy change - serum lipids

last ½ of pregnancy the plasma cholesterol and TG INC

DEC after delivery

pregnancy change - prolactin

10x INC at term

pregnancy change - growth hormone levels

INC in 1st and 2nd trimester

pregnancy change - GI motility

INC progesterone throughout preg slows GI tracts → nausea/constipation

INC progesterone triggers enhancement of nitric oxide to relax smooth muscle → body absorbs more nutrients for fetus

incomplete GB emptying and slower response

pregnancy change - ptyalism

INC salivation

pregnancy change - PICA (geophagia)

ingestion of items with no nutrition

can be sign of iron deficiency anemia

pregnancy change - reflux

hormone-mediated relaxation of esophageal sphincter and INC acidity of gastric secretion

pregnancy change - chadwick’s sign

cervix is blue on exam d/t INC vascularity

pregnancy change - leukorrhea

normal thickening of vaginal secretions

pregnancy change - varicosities

INC vascular flow to genitals → vulvar varicosities

pregnancy change - skin

melasma (“mask of pregnancy”, dark sun exposed skin)

striae (d/t rapid skin stretch from collagen separation, abd)

pregnancy change - breasts

venous dilation (INC vascularity)

nipple/areolar enlarge and darken (d/t melanocyte stimulating hormone)

prominent montgomery glands

colostrum discharge after 16 wks, unilateral/B/L

pregnancy changes - bones

exaggerated lumbar lordosis

small separation of symphysis pubis

muscle cramping is common in pregnancy, why and tx

uncertain

tx: stretch, massage, heat, mag citrate 300 mg, gatorade

nutritional recommendations in pregnancy

INC protein (1g/kg + 20g in 2nd tri)

INC calorie (avg 400 cal. 1st tri = 100, 2nd = 200, 3rd = 300)

nagele’s rule

LMP + 7 days - 3 months + 1 year

weight gain recommendations for average person

<19.8 BMI = 28-40 lbs

19.8-25 = 25-35 lbs

26-29 = 15-25 lbs

>29 = no more than 15 lbs

(based on single preg, higher weight gain needed if mult)

early term definition

37 weeks-38 weeks 6 days

full term definition

39 weeks-40 weeks 6 days

late term definition

41 weeks-41 weeks 6 days

post term definition

42 weeks and beyond

1st trimester

week 1-12

2nd trimester

week 13-28

3rd trimester

week 29-40

gravity

number of pregnancy

parity

number of times pt has given birth to fetus >24 weeks

TPAL = term, preterm, abortion, living

social habits to assess risks

cigarettes

alcohol

drug use

vaping

DV

all pregnant women and partners are encouraged to get which vaccines

flu

tdap

labs for 1st trimester

CBC,

Hep B surface antigen,

syphilis,

HIV,

blood type + antibody screen,

rubella + varicella immunity

1st trimester option labs

cystic fibrosis

spinal muscle atrophy carrier

down syndrome

2nd trimester labs

GTT

CBC (H/H and plt count)

Rh antibody screen (see if anti d immunoglobulin indicated)

anatomic U/S (20 wks)

3rd trimester labs

group B strep vaginal/rectal swab (b/w 35 and 37 wks)

CBC (h/h and plts)

leopold maneuvers

optional U/S for growth

methods of screening for down syndrome in 1st trimester

Nuchal translucency + serum screening (pregnancy associated plasma protein A + HCG) (done 11-12 weeks)

Cell-free DNA prenatal screen (can be drawn from 10 weeks forward)

Chorionic villus sampling (done between 9-13 weeks)

screening methods for neural tube defects (2nd Trimester)

Maternal serum alpha-fetoprotein (MSAFP) – screen for open neural tube defects → done btwn 15 + 22 wks

purpose of leopold’s maneuvers

Used to determine the position, presentation, and engagement of the fetus in utero

first leopold maneuver

(fundal grip) - upper pole

feeling for head or feet

second leopold maneuver

hands on sides to feel back and limbs

third leopold maneuver

lower pole to assess if feet or head is facing down

fourth leopold maneuver

confirmatory of lower pole

how to evaluate pelvic shape (pelvimetry)

diagonal conjugate

interspinous diameter

diagonal conjugate definition

Distance from sacral promontory to symphysis pubis → adequate is >11 cm

interspinous diameter definition

Distance between ischial tuberosities → adequate is ≥10 cm

when to start measuring fundal height?

start 2 trimester (20 weeks)

umbilicus = 20 weeks

after 36 weeks, not accurate!

what is a “non stress test?” (NST)

way to evaluate fetal health after 28 weeks (3rd tri)

mom in semi-reclined position, 2 belts around abd, marks when she feels fetal movement

performed @ 32 weeks (if HTN, preeclamspia, DM, autoimmune, less fetal mvmt)

results of a non-stress test (NST)?

reactive: fetal HR accelerates (15 BPM above baseline lasting for >15 secs) 2x in 20 mins (good!)

nonreactive: no accelerations for 40 mins, can apply vibroacoustic stimulation w device on moms abdomen, sugar, change position

labor definition

sequential uterine contractions causing cervical dilation + effacement

→ results in voluntary urge to push, leading to expulsion of fetus/products of conception through the vagina

primary vs. secondary power of labor

primary power of labor is uterine contractions!

(2ndary is maternal pushing and uterotonic agents)

frank breech position

criss cross applesauce (hips flexed)

cerviced dilation definition

opening of cervix, fully dilated 10 cm

cervical effacement

shortening of cervix

fully effaced is 100%

station definition

location of fetal head in relation to maternal ischial spines

values are -3 to +3, 0 is when top of fetal head is at ischial spines

most ideal position for vaginal delivery

#1: occiput anterior

(used in cephalic presentation)

#2: occiput posterior (vaginal delivery can happen but hard)

rupture of membranes (ROM) definition

when amniotic sac around baby breaks and there is release of amniotic fluid

pooly of fluid in vagina

ferning pattern

premature rupture of membranes (PROM) definition

when ROM occurs before the onset of uterine contractions

stages of labor

1st stage: onset of consistent contractions → 10 cm (latent = 0-6 cm, active is 6-10) - cervical exam q2-4 hrs

second stage (10 cm-delivery) - fetal heart tracing continuously, primigrav 3 hrs, multigrav 2 hrs, epidural +1 hr

third stage: delivery until placenta out (30 mins)

Signs of placenta separation

Fresh bloody show

Umbilical cord lengthens

Uterus becomes firm and globular

maternal indications of inducting of labor

preeclampsia

pre-gestational

gestational DM

fetal indications for inducing labor

post-date preg

PROM

placental insufficiency

suspected intrauterine growth restriction

fetal abnormality that needs intervention

contraindications for inducting labor (IOL)*

prior “classic” c-section (vertical cut)

prior uterine rupture during attempted VBAC

HSV

placenta/vasa previa

transverse/breech

prolapsed umbilical cord

h/o transmural uterine incision (ie fibroid removal)

bishop score*

Score ≤6 is “unripe” cervix + induction needs to start w/ cervical ripening agents

Score ≥8 is “ripe” cervix + induction can start w/ uterotonic agents

based on cervical dilation and effacement, fetal station, consistency of cervix + position of cervix

what is the bishop score used for

determines if induction needs to start with cervical ripening or uterotonic agents

options to cervical ripen

PGNs (prostaglandins)

balloon catheters

hygroscopic dilators

PGNs (prostaglandins) for cervical ripening

misoprostol (PGE-1): off-label, 25 mcg q4-6 hrs, tablet can be given vaginal/rectally/PO

dinoprostone (PGE-2): AKA Cervidil, 10 mg vaginal insert in posterior fornix, removes after 12 hrs, must stay supine 2 hrs after inserting

balloon catheters for cervical ripening

passed into endocervix above internal os and fill balloon, left for 8-12 hours

balloon falls out when cervix is 2-3 cm dilated

hygroscopic dilators for cervical ripening

dissicated stems of seaweed (laminaria digiata or laminaria japonica) that absorb water → stretches cervical os

placed in cervix, left 6-12 hrs

uterotonic options for IOL

amniotomy (amniohook punctures amniotic sac)

oxytocin (pitocin)

stripping of membranes (sweep to separate fetal membranes from uterus)

fetal heart monitoring

transabdominal

fetal scalp electrode

oxytocin (pitocin) for IOL

given IV

adequate meds is contractions 50-60 mmHg lasting 40-60 secs every 2.5-4 mins

fetal heart monitoring for IOL

monitoring fetal wellbeing during labor

want to see accelerations 15 BPM rise above baseline for 15 seconds, changes 6-25 BPM from baseline

want to see absence of late decelerations

what is the longest stage of labor*

first stage (specifically latent stage)

what to keep in mind for delivering placenta?

apply GENTLE traction on cord with counter pressure b/w symphysis pubis and uterus to prevent descent of uterus

what is episiotomy and what incision is preferred?

cut into the vaginal tissue to give fetal head more space to pass through

mediolateral preferred

(routine no longer done)

1st degree vaginal lacerations

skin and subq tissues of vagina and perineum

no muscle involvement

2nd degree vaginal lacerations

fascia and mscle

no anal sphincter involvement

3rd degree vaginal lacerations

fascia nad muscle

extends into external or internal anal sphincter

4th degree vaginal lacerations

perineal structures

extends into external and internal anal sphincter/rectal mucosa

immediate postpartum changes (first 24 hrs after delivery)

• uterus reduces to 20 wks right away delivery

• placental site contracts to half size to provide hemostasis

• “afterpains” (mild contractions, worse with breastfeeding)

• lochia rubra

• bladder is edematous/distended → urinary retention

• decrease in maternal weight

• WBC 25000/mL

• in 3 hours, estradiol levels fall to 10% of antepartum values

lochia rubra definition

postpartum bloody discharge

early postpartum changes (first week)

• uterus continues to inovulate

• 3-4 days PP, lochia rubra is darker brown → mucopurulent and lighter (lochia serosa)

• BP may rise

• CO declines

• lung capacity INC

• hCG falls

• day 3-4, PP breast engorgement occurs

• if no breastfeed, estrogen is high enough for follicular dev by 19-20 PP

• if breastfeeding, estrogen suppressed first 180 days PP

postpartum changes (first few months)

• uterus returns to pre-pregnancy size by 6 wks after delivery (a little larger)

• 2-3 weeks PP: vaginal discharge thicker and yellowish (lochia alba)

• blood volume DEC

• if not breastfeeding, PLN → normal 2 weeks PP

• FSH and LH INC to follicular phase levels by 3 wks PP

• if no breastfeed, may ovulate in 6 wks

• if breastfeed, ovulates after weaning infants

care in postpartum period

• get out of bed

• regular voiding <6 hrs

• good fluid/fiber intake d/t GI delayed motility

• can resume regular diet (breastfeeding need +300-500 cals and Ca intake 1000 mg daily)

• perineum care (ice packs, witch hazel, nsaids, sitz baths)

• rho-D immune globulin if needed

• MMR, tdap, flu, covid vaccine

postpartum office visit

6 weeks PP

examine laceration/epiostomy repair

discuss contraception (no estrogen for breastfeeding pts)

depression screening

gestational DB need to be screened with 2 hour oral glucose tolerance test

spontaneous abortion (miscarriage)

loss of pregnancy before 20 weeks

majority happen first 12 weeks, show a chromosomal abnormality

early pregnancy loss

loss of pregnancy <12 weeks, 6 days

complete = complete passage of all products of conception

asymptomatic pregnancy loss = no vaginal bleeding, nonviable intrauterine pregnancy

septic abortion = embyronic demise occured and intrauterine infx developed

anembryonic pregnancy

egg is fertilized and implanted

does NOT develop into an embyro

fetal demise

unintended loss of pregnancy beyond 20 weeks

most common cause of early pregnancy loss

chromosomal abnormality

RF of spontaneous abortion

hx of previous loss

chromosomal abnormality

older

uterine anomalies (bicornuate uterus, septum, fibroid)

tobacco/alc/drug

thyroid dz

bleeding issues

management if pt has no confirmation of preg with spontaneous abortion

order HCG (if preg = 2000, should double every 48 hours)

if bleeding, order blood typing (if RH neg → antibody screen)

other mgmt: up to 12w6d, give mifepristone and then Cytotec to induce uterine contractions, or D&C