Women's Health EOR: Prenatal Care and Normal Pregnancy (Smarty PANCE)

What is the Apgar score and when is it assessed?

Rapid assessment of newborn status at 1 and 5 minutes after birth (repeat at 10, 15, 20 min if <7) - scores 0-2 for each of 5 components

What are the 5 components of Apgar score? Use mnemonic APGAR

Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), Respiration (breathing effort)

What Apgar scores indicate normal, moderate, and severe depression?

7-10: normal/vigorous newborn; 4-6: moderate depression (stimulation, oxygen needed); 0-3: severe depression (resuscitation required)

How is each Apgar component scored?

0 points: absent/blue/limp; 1 point: partially present/some flexion/HR<100; 2 points: fully present/pink/good tone/HR>100/vigorous cry

What is the clinical significance of 1-minute vs 5-minute Apgar?

1-minute: immediate condition/need for resuscitation; 5-minute: response to resuscitation/neurologic prognosis (low 5-min associated with increased morbidity)

What interventions are indicated for low Apgar scores?

Score 4-6: stimulation, oxygen, suction; Score 0-3: positive pressure ventilation, possible intubation, chest compressions, medications per NRP protocol

What factors can affect Apgar scores independent of newborn status?

Prematurity, maternal sedation/anesthesia, congenital anomalies, birth trauma, infection

What is fetal lie?

Relationship of fetal long axis to maternal long axis - longitudinal (99%), transverse, or oblique

What is fetal presentation?

Fetal part overlying the pelvic inlet - cephalic (vertex, face, brow), breech (frank, complete, footling), shoulder

What is fetal position?

Relationship of fetal presenting part to maternal pelvis using landmarks - occiput for vertex, sacrum for breech, mentum for face

What does LOA mean in fetal position?

Left Occiput Anterior - occiput on maternal left side, anterior position (most common and favorable position for delivery)

What are the most common fetal positions at delivery?

LOA and ROA (occiput anterior positions) - together account for ~90% of deliveries

What is Leopold's maneuvers?

Four-step systematic abdominal palpation to determine fetal lie, presentation, position, and engagement - performed in third trimester

What position requires cesarean delivery?

Transverse lie (shoulder presentation), persistent brow presentation, face presentation with mentum posterior

What are the types of twin gestations?

Dizygotic (fraternal - 2 placentas, 2 amnions, 2 chorions) vs Monozygotic (identical - varies by timing of embryo division)

What determines chorionicity and amnionicity in monozygotic twins?

Division <3 days: dichorionic/diamniotic; 3-8 days: monochorionic/diamniotic; 8-13 days: monochorionic/monoamniotic; >13 days: conjoined

What complications are unique to monochorionic twins?

Twin-to-twin transfusion syndrome (TTTS), twin reversed arterial perfusion (TRAP), selective intrauterine growth restriction

What are maternal complications of multiple gestation?

Preeclampsia (2-3x risk), gestational diabetes, anemia, preterm labor (50% deliver <37 weeks), postpartum hemorrhage, cesarean delivery

What is twin-to-twin transfusion syndrome?

Unbalanced blood flow through placental vascular anastomoses in monochorionic twins - donor twin (oligohydramnios, growth restricted), recipient twin (polyhydramnios, cardiac overload)

When should delivery be planned for uncomplicated twin gestation?

Dichorionic/diamniotic: 38 weeks; Monochorionic/diamniotic: 36-37 weeks; Monochorionic/monoamniotic: 32-34 weeks (higher risk)

What is the recommended mode of delivery for twins?

Depends on presentation - both vertex: vaginal delivery; Twin A non-vertex or monoamniotic: cesarean delivery recommended

What are the four stages of labor?

Stage 1: onset of contractions to complete cervical dilation; Stage 2: complete dilation to delivery of baby; Stage 3: delivery of baby to delivery of placenta; Stage 4: first 2 hours postpartum

What are the phases of Stage 1 labor?

Latent phase (0-6cm dilation, slow/variable) and Active phase (6-10cm dilation, faster/predictable at ~1cm/hr)

What is the normal duration of Stage 2 labor?

Nulliparous without epidural: <3 hours; Nulliparous with epidural: <4 hours; Multiparous without epidural: <2 hours; Multiparous with epidural: <3 hours

What are the cardinal movements of labor?

Engagement → Descent → Flexion → Internal rotation → Extension → External rotation (restitution) → Expulsion

What is the most common cause of prolonged Stage 1 labor?

Inadequate uterine contractions (power) - also cephalopelvic disproportion (passenger/passage mismatch), malposition

What fetal heart rate patterns are reassuring during labor?

Baseline 110-160 bpm, moderate variability (6-25 bpm), presence of accelerations, absence of decelerations

What are the three types of fetal heart rate decelerations?

Early: mirror contractions, head compression (benign); Variable: abrupt, cord compression (common); Late: after contraction peak, uteroplacental insufficiency (concerning)

What interventions are used for Category II/III fetal heart tracings?

Maternal repositioning, IV fluid bolus, oxygen, decrease/stop oxytocin, consider amnioinfusion for variables, prepare for delivery if no improvement

What are normal cardiovascular changes in pregnancy?

Increased blood volume (40-50%), increased cardiac output (30-50%), decreased systemic vascular resistance, physiologic anemia of pregnancy

What are normal hematologic changes in pregnancy?

Plasma volume increases more than RBC mass (dilutional anemia), WBC increases (up to 15,000), hypercoagulable state (increased fibrinogen, clotting factors)

What are normal respiratory changes in pregnancy?

Increased tidal volume, decreased functional residual capacity, increased minute ventilation, decreased PaCO2 (28-32 mmHg), respiratory alkalosis compensated by renal bicarbonate excretion

What are normal renal changes in pregnancy?

Increased GFR (50%), decreased serum creatinine (0.4-0.8 mg/dL), physiologic hydronephrosis (right>left), glucosuria common

What are normal gastrointestinal changes in pregnancy?

Decreased gastric motility, delayed gastric emptying, decreased lower esophageal sphincter tone (reflux), increased risk of gallstones

What hormones are produced by the placenta?

Human chorionic gonadotropin (hCG), human placental lactogen (hPL), estrogen, progesterone, relaxin

What is the function of hCG in pregnancy?

Maintains corpus luteum in early pregnancy (produces progesterone until placenta takes over at 8-10 weeks), basis for pregnancy tests

What is the recommended prenatal visit schedule?

Every 4 weeks until 28 weeks, every 2 weeks from 28-36 weeks, weekly from 36 weeks until delivery

What screening tests should be offered in first trimester?

Cell-free fetal DNA or first trimester screen (nuchal translucency + PAPP-A + hCG for aneuploidy), CBC, blood type/Rh, antibody screen, rubella immunity, hepatitis B, HIV, syphilis, gonorrhea/chlamydia, urinalysis/urine culture

What screening tests are performed in second trimester?

Quad screen (AFP, hCG, estriol, inhibin A) at 15-20 weeks for neural tube defects/aneuploidy, anatomy ultrasound at 18-22 weeks, glucose challenge test at 24-28 weeks

What screening is performed in third trimester?

Group B Streptococcus culture at 35-37 weeks, repeat HIV/syphilis in high-risk patients, assess fetal position, discuss birth plan

What is the recommended folic acid supplementation in pregnancy?

400-800 mcg daily for all women; 4 mg daily for women with previous neural tube defect or on antiepileptic drugs

When should Rh immune globulin (RhoGAM) be administered?

At 28 weeks gestation and within 72 hours of delivery (if baby is Rh+), also after any sensitizing event (bleeding, amniocentesis, trauma)

What prenatal diagnostic tests are available?

Chorionic villus sampling (10-13 weeks), amniocentesis (15-20 weeks), cordocentesis/PUBS (after 18 weeks) - all provide fetal karyotype

What conditions are screened by maternal serum alpha-fetoprotein?

Elevated AFP: neural tube defects, abdominal wall defects, multiple gestation; Low AFP: Down syndrome, trisomy 18&