Obstetrics and Neonatal Care Lecture Review

Infertility and Pregnancy Termination

  • Induced/Elective Abortion: Defined as the maternal choice to terminate a pregnancy.     * Indications: Often performed when the maternal life is in danger (e.g., myocardium myopathy).     * Pre-procedure: Correct gestational age must be assessed to determine the appropriate method.

  • Medication Abortion: Oral medications used within the first 70 days (10 weeks) of pregnancy.     * Mifepristone (Mifeprex):         * Mechanism: Blocks progesterone, rendering the endometrium unstable for the fetus.         * Dosage: 200 mg200\,\text{mg} orally.         * Contraindications: Do not administer to women on anticoagulants due to bleeding risks.     * Misoprostol (Cytotec):         * Mechanism: Softens the cervix and stimulates uterine contractions (UCs) to expel products of conception.         * Timing: Administered 24 to 48 hours after Mifeprex.         * Dosage: 800 mcg800\,\text{mcg} buccally.         * Follow-up: Patient must return in 7-14 days to verify expulsion; provide education on bleeding.

  • Surgical Abortion:     * First Trimester (1-13 weeks): Recommended window.         * Less than 8 weeks: Vacuum aspiration.         * After 8 weeks: Cervix requires dilation.     * Second Trimester (13-24 weeks): Increased risk of maternal injury; uses Cytotec to expel the fetus.

  • Infertility Overview: Defined as the failure to achieve a successful pregnancy after 12 months of unprotected intercourse.     * Female Infertility Issues:         * Ovulation Problems: The most common issue.         * Ovulation Tests: Basal body temperature, hormone analysis, and endometrial biopsy (performed 10 days after ovulation).         * Transvaginal Ultrasound (US): Used to monitor follicular development.         * Hysteroscopy: Monitors structural abnormalities in the ovaries and uterus.         * Hormonal Analysis Timing:             * FSH: Day 3.             * LH surge: Day 13.             * Progesterone: Day 21 (levels peak 8 days after LH surge).         * Cervix Problems: LEEP procedures can cause a "dry cervix." Mucus must be alkaline for sperm survival. At ovulation, mucus should be stretchable (spinbarkeit) and show ferning.         * Fallopian Tube Problems: Egg passage blocked by endometriosis or pelvic inflammatory disease (PID) scarring from STIs.     * Male Infertility Issues:         * Semen Analysis: Requires abstinence for 3 days. Assesses sperm count (quantity) and sperm quality.         * Age factors: Quality decreases with age, potentially resulting in chromosomal damage.         * Abnormality Causes: Increased temperature (hot tubs, exercise, tight underwear), pressure on testicles, trauma, infection, drugs.

Infertility Treatments and Fetal Demise

  • Infertility Medications:     * Clomid (Oral): First-line treatment. Induces ovulation by stimulating high amounts of FSH and LH.         * Side Effects: Hot flashes, fraternal twins, soreness, breast discomfort.     * Gonadotropins (IM): Stimulate ovaries to mature follicles.         * Side Effects: Multiples, Ovarian Hyperstimulation Syndrome (cyst formation/rupture).     * Letrozole (Oral): Blocks estrogen to release more FSH. Given to women with severe side effects from Clomid.     * Bromocriptine (Oral): Inhibits prolactin secretion which can sometimes block ovulation; allows FSH and LH secretion.

  • Surgical/Assisted Options:     * Intrauterine Insemination (IUI): Considered "less invasive."     * In Vitro Fertilization (IVF): Think of this for "blocked tubes."

  • Fetal Demise: Death of the fetus after 20 weeks.     * Management: Uterus must be evacuated to avoid prolonged retention.     * Risks: Sepsis, shock, maternal death.     * Induction of Labor: Performed ASAP. Use a secluded room, ripen the cervix (Cytotec), and administer IV Pitocin.     * Postmortem Care: Sign on the door for privacy, allow parents to perform normal activities, prepare them for the baby's appearance/smell. Use a "cuddle cot" and offer a post-birth evaluation. Remind the mother that bleeding and milk production will still occur.

Labor and Delivery Terminology and Calculations

  • Pregnancy Phases:     * Antepartum: Time between conception and onset of labor.     * Intrapartum: Time from onset of labor to birth.     * Postpartum: From birth until the body returns to normal, typically 6 weeks.

  • Term Definition: Full term is 39 0/739\,0/7 to 40 6/740\,6/7 weeks.

  • Naegele’s Rule (Due Date): First day of LMP−3 months+7 days\text{First day of LMP} - 3\,\text{months} + 7\,\text{days}.

  • Abortion Definition (Transcript Specific): Birth before 30 weeks or baby weight less than 500 g500\,\text{g}.

  • OB History (Gs and Ps):     * Gravida: Any pregnancy, regardless of outcome.     * Para: A woman who gave birth after 20 weeks.     * Nulligravida: Never been pregnant.     * Primigravida: First-time pregnancy.     * Multigravida: Second or more pregnancy (labor often progresses faster).

  • TPAL: Term, Preterm, Abortion, Living children.

  • Cervical Changes:     * Effacement: Thinning of the cervix; must occur before dilation progresses significantly.     * Primigravida: Cervix typically effaces first, then dilates (slow process).     * Multigravida: Effaces and dilates simultaneously (faster birth).

Fetal Positioning and Initial Assessment

  • Fetal Attitude: Position of fetal body parts.     * Presentation: Cephalic is desired.     * Types: Vertex is preferred; Brow is the hardest to deliver.

  • Fetal Head Anatomy: Two fontanelles exist: Anterior and Posterior (diamond-shaped).

  • Molding: Overlapping of cranial bones (cone head appearance); resolves within 24 hours24\,\text{hours}.

  • Station: Relationship to the ischial spine.     * Above spine: Negative numbers (e.g., −1-1).     * At spine: 00.     * Below spine: Positive numbers (e.g., +1+1).

  • Fetal Position: Occiput Anterior (OA) is the desired position for labor.

  • Contractions: Should gain strength and duration as labor progresses.     * Labor Onset Causes: Progesterone withdrawal and uterine overstretch.

  • True vs. False Labor:     * True Labor: Contractions are regular, increase in duration/intensity, and intensity increases with walking.     * False Labor: Contractions are irregular with no change in intensity.

  • Signs of Impending Labor: Lightening (fetus settles in pelvis), cervical ripening, bloody show (24−48 hours24-48\,\text{hours} before), loss of mucus plug, Rupture of Membranes (ROM), and a sudden burst of energy (24−48 hours24-48\,\text{hours} before).

  • Rupture of Membranes (ROM): Speeds up labor.     * Danger: Prolapsed umbilical cord.     * TACO Assessment:         * T (Time): Must deliver within 24 hours24\,\text{hours} to reduce infection risk.         * A (Amount): Quantity of fluid.         * C (Color): Clear vs. meconium-stained.         * O (Odor): Should be earthy.

Stages of Labor

  • First Stage (Cervical Dilation): Subdivided into three phases.     * Early/Latent Phase: Beginning of dilation/effacement. Pain is manageable; patient is talkative. Duration: 3-8 hours.     * Active Phase: Dilation 4−7 cm4-7\,\text{cm}. Station enters positive numbers. Increased anxiety and fatigue.     * Transition Phase: Dilation 8−10 cm8-10\,\text{cm}. Contractions are frequent and intense.

  • Second Stage (Expulsion): Full dilation to delivery of the baby.     * Signs: Maternal urge to push, crowning ("ring of fire").

  • Third Stage (Placental): Birth to delivery of the placenta.     * Timing: Usually 5 minutes5\,\text{minutes} after birth.     * Signs of Separation: Fundus rises, gush of blood, protrusion of the umbilical cord.     * Risk: Retained placenta if delivery takes longer than 30 minutes30\,\text{minutes}.     * Sides of Placenta: Schultze (fetal side, shiny) vs. Duncan (maternal side; associated with retained pieces and hemorrhage).

  • Fourth Stage (Recovery): 1-4 hours after delivery.     * Focus: Bonding, breastfeeding, assessment of perineum tears, blood loss, and maternal vitals.

Normal Pregnancy Signs and Physiological Changes

  • Signs of Pregnancy:     * Presumptive (Subjective): Symptoms reported by the woman (N/V, breast tenderness, fatigue, weight gain).     * Probable (Objective): Goodell’s sign (softening of cervix), Chadwick’s sign (bluish cervix), skin pigmentation, home pregnancy tests.     * Positive (Diagnostic): Fetal heartbeat (6 weeks), Ultrasound (10 weeks), fetal movement felt by provider (20 weeks).

  • Clinical Assessments:     * Danger Signs: Loss of amniotic fluid, vaginal bleeding, contractions, decreased fetal movement.     * Fundal Height: Measured using the McDonald method starting at 20 weeks.         * $20\,\text{weeks}$: Level of the umbilicus (20 cm20\,\text{cm}).         * Symphysis pubis: Marked at 10 weeks.         * Normalization: A measurement of 26 cm26\,\text{cm} for 26 weeks26\,\text{weeks} (within ±2 cm\pm 2\,\text{cm}) is normal.

  • Nutrition and BMI:     * Caloric Intake: Extra 300 calories300\,\text{calories} in 2nd and 3rd trimesters (protein and dairy).     * Folic Acid: 600−800 mcg600-800\,\text{mcg} daily to prevent spina bifida.     * Iron: 27 mg27\,\text{mg} daily (increase absorption with Vitamin C).     * Weight Gain Targets:         * Normal: 25−35 lbs25-35\,\text{lbs}.         * Overweight: 15−25 lbs15-25\,\text{lbs}.         * Obese: 11−20 lbs11-20\,\text{lbs}.         * Gain Rate: 1−4 lbs1-4\,\text{lbs} in 1st trimester, then 1 lb1\,\text{lb} per week in 2nd/3rd trimesters.

  • Systemic Changes:     * Respiratory: Tidal volume increases 30−40%30-40\%. Chest circumference may increase. Progesterone increases oxygen flow.     * Cardiovascular: Increased venous pressure leads to edema and supine hypotension.     * Hematological: Plasma volume increases more than RBC volume (pseudo-anemia). Platelets stay the same; high risk of DVT.     * Endocrine: First 20 weeks see increased insulin production; second 20 weeks see secretion of hPL (accelerated starvation/ketones in urine).     * Integumentary: Linea nigra (dark line from pubis to umbilicus), Chloasma ("mask of pregnancy"), Striae (stretch marks).     * Musculoskeletal: Relaxin softens connective tissue; Lordosis (posture change); Diastasis recti (resolves after 3rd trimester).

Prenatal Screening and Diagnostics

  • Screening Tests (Non-Invasive):     * Cell-free DNA: DNA fragments in maternal plasma; tests for Trisomies 21, 13, and 18.     * Nuchal Translucency (NT): Performed at 11-13 weeks via US; fluid fold in fetal neck > 3\,\text{mm} is abnormal.     * Quad Screen: Maternal serum at 15-20 weeks.         * AFP (Alpha-fetoprotein): Elevated = neural tube defects/multiples; Decreased = Down syndrome.         * UE (Estriol): Decreased = anemia, Down syndrome, Trisomy 18, Turner syndrome.         * hCG/Inhibin A: Elevated = Down syndrome; Decreased = Trisomy 18.     * Anatomical US: 20 weeks; screens for heart defects, cleft lip, neural tube defects.     * Fetal Echo: 18-22 weeks US of heart valves/rhythm.

  • Diagnostic Tests (Invasive):     * Chorionic Villus Sampling (CVS): 10-12 weeks. Tests DNA/genetics. Cannot detect neural tube defects. Risk of infection/miscarriage.     * Amniocentesis: 14-20 weeks. Removes 10−20 ml10-20\,\text{ml} fluid for Alpha-protein and chromosomes. Later in pregnancy, used for surfactant levels.

Electronic Fetal Monitoring (EFM) and Decelerations

  • FHR Basics: Baseline 110−160 bpm110-160\,\text{bpm}.     * Tachycardia (>160): Maternal fever, dehydration, fetal anemia, infection.     * Bradycardia (<110): Hypoxia; maternal hypotension/drugs.

  • Variability: Fluctuations in baseline (Moderate: 6−25 beats6-25\,\text{beats} is reassuring).

  • Accelerations: Increase in FHR ≥15 bpm\ge 15\,\text{bpm} lasting ≥15 seconds\ge 15\,\text{seconds} (after 32 weeks). Reassuring for oxygenation.

  • Decelerations:     * Early: Mirrors contraction; caused by head compression (vagal response).     * Late: Caused by inadequate placental blood flow; returns in 2 mins.     * Variable: Sharp drop; caused by umbilical cord compression.     * Prolonged: Late deceleration lasting > 2\,\text{minutes}; fetus starved of oxygen.

  • Nursing Interventions for Decelerations:     1. Reposition the mother.     2. Administer Oxygen (10 L10\,\text{L} face mask).     3. IVF Bolus (100 ml100\,\text{ml} running at 999 ml/hr999\,\text{ml/hr}).

Postpartum Care and Complications

  • Postpartum Hemorrhage (PPH): Blood loss ≥1,000 ml\ge 1,000\,\text{ml}.     * Early PPH (within 24 hrs): Caused by the 4 Ts (Trauma, Tone, Tissue, Thrombin).         * Management: Fundal massage (#1), straight catheterization, uterine vacuum, hysterectomy.         * Medications: Oxytocin (Pitocin), Misoprostol (Cytotec), Hemabate (Contraindicated in ASTHMA), TXA (IV - Do NOT give with Oxytocin).     * Late PPH (24 hrs to 12 weeks): Lochia fails to progress; increased fundal height.

  • Maternal Discharge (Lochia):     * Rubra: Bright red, clots (Days 1-4).     * Serosa: Brown/pinkish (Days 5-9).     * Alba: Yellow/whitish (Days 10-14).

  • Breastfeeding and Milk:     * Colostrum: Initial milk; high in protein and fat.     * Transitional Milk (48-96 hrs): Foremilk (watery) and Hindmilk (high fat).     * Mature Milk (2 weeks): Complete nutrients.     * Contraindications: HIV, active TB, drug use.

  • Mothering Periods:     * Acquaintance Phase: First few days; shock/disbelief; relies on sight/touch.     * Mutual Regulation: 1 week after birth; adjustment phase.     * Reciprocity Phase: Mother and baby enjoy mutual company.

  • Postpartum Mood:     * Baby Blues: Transient depression, mood swings, difficulty sleeping.     * Postpartum Depression (PPD): Sleeplessness, anxiety, lack of care for baby wellbeing.

  • Immunizations:     * Rubella: Titer drawn; if < 1.8, vaccinate postpartum. Avoid pregnancy for 1 month.     * Tdap: Recommended at 27−36 weeks27-36\,\text{weeks}.     * RhoGAM: Given to Rh-negative mothers to protect future Rh-positive babies. Checked via Indirect Coombs test.

Newborn Care and Physiology

  • APGAR Scoring: Calculated at 1 and 5 minutes. Assesses Respiration, HR, Muscle Tone, Reflex Irritability, and Color. (Score of 10 is max).

  • Initial Nursing Actions: Vitals every 30 mins for 5 cycles. Vitamin K injection (prevent bleeding), Erythromycin eye cream (prevent gonorrhea), Hep B vaccine.

  • Newborn Vitals:     * Temperature: 97.7−99.0∘F97.7-99.0^{\circ}\text{F}.     * Heart Rate: 110−160 bpm110-160\,\text{bpm}.     * Respiration: 30−60 breaths/min30-60\,\text{breaths/min}. Period of apnea < 20\,\text{sec} is normal.

  • Thermoregulation: Newborns lose heat via Convection (air), Radiation (cooler surfaces nearby), Conduction (direct contact), and Evaporation.

  • Newborn Assessment:     * Head: Fused sutures are an emergency. Cephalohematoma (resolves 2-3 weeks). Caput succedaneum (fluid swelling).     * Mouth: Epstein's pearls (white dots) are normal.     * Skin: Mongolian spots (normal darkness), Vernix (antimicrobial coating).     * Umbilical Cord: 3 vessels (2 arteries, 1 vein). Falls off in 7-10 days.

  • Screenings: Hearing screen (complete by 1 month). Critical Congenital Heart Defect (CCHD) test after 24 hours (> 95\% passing).

  • Circumcision Care: No voiding for 6-8 hours must be reported. Use petroleum jelly. Plastibell falls off in 8 days.

High-Risk Newborn Conditions

  • Sepsis Neonatorum: Emergency characterized by behavior changes, temperature instability, mottled skin, and respiratory distress. Workup: Blood culture, CBC (low WBC, high bands).

  • Respiratory Conditions:     * TTN (Transient Tachypnea of the Newborn): Extra fluid in lungs (common in C-sections). Resolves by 72 hours.     * MAS (Meconium Aspiration Syndrome): Meconium traps air in lungs causing barrel chest and rhonchi.     * PPHN (Persistent Pulmonary Hypertension): Ductus arteriosus and foramen ovale remain open. Emergency.

  • NAS (Neonatal Abstinence Syndrome): Result of opioid exposure. Symptoms: Sneezing, jitters, high-pitched cry. Managed via "Eat, Sleep, Console" protocols.

  • Hyperbilirubinemia: Bilirubin > 0.2\,\text{mg/dL} increase. Treated with bili-lights and eye protection.

  • Hypoglycemia: Defined as < 40-45\,\text{mg/dL}. Symptoms: Jitters, lethargy, poor feeding, high-pitched cry.

High-Risk Labor and Complications

  • Fetal Wellbeing Tests:     * Nonstress Test (NST): Reactive = 2 or more 15×1515 \times 15 accelerations in 20 minutes.     * Contraction Stress Test (CST): Negative (no decelerations) is the desired result.     * Biophysical Profile (BPP): Out of 10 points (NST, breathing, movement, tone, AFI).

  • Labor Induction/Augmentation:     * Bishop Score: Needs to be > 7 for successful induction.     * Cervical Ripening: Cytotec (25−50 mcg25-50\,\text{mcg} q4) or Cervidil (slow release over 12 hours).     * Oxytocin (Pitocin): Must be on a separate pump, continuous EFM. Aim for 3-5 UCs in 10 minutes.

  • Complications:     * Preterm Labor: Before 37 weeks. Effacement > 80\%, dilation > 3\,\text{cm}.     * Tocolytics: Medications to stop labor for 24-48 hours (e.g., Procardia, Indomethacin, Terbutaline - watch for arrhythmias).     * Magnesium Sulfate: Used for neuroprotection and to prevent seizures. Toxicity (> 9\,\text{mEq/L}) causes respiratory depression and loss of DTR. Antidote: Calcium Gluconate.     * Shoulder Dystocia: OB emergency. Use McRoberts maneuver (knees to chest).     * Abruptio Placentae: Premature separation. S/S: Rigid/tender abdomen, vaginal bleeding.     * Placenta Previa: Covers cervix. S/S: Painless bright red bleeding, soft abdomen.     * Hypertensive Disorders:         * Preeclampsia: > 160/110\,\text{mmHg} with proteinuria, RUQ pain, visual disturbances.         * HELLP Syndrome: Hemolysis, Elevated Liver Enzymes, Low Platelets (< 100,000).

Pregnancy Infections (TORCH)

  • Toxoplasmosis: From raw meat/cat feces. Baby risk: Blindness, microcephaly.

  • Zika: Mosquito-borne. Causes microcephaly. Avoid conception for 2 months after exposure.

  • Rubella: Devastating in 1st trimester (deafness, cataracts). Cannot vaccinate during pregnancy.

  • GBS (Group B Strep): Maternal screening. If positive, treat with Penicillin Q4 hours during labor. Baby risk: Sepsis.

  • HIV: Antiretrovirals started before 14 weeks. No breastfeeding. Baby gets ZDV for 6 weeks.