Reproduction and Obstetric Nursing Review

Reproductive System and Hormonal Cycles

• Menstrual Cycle Hormonal Regulation

  • Menstrual Phase: Characterized by a decrease ($\downarrow$) in progesterone levels.

  • Follicular Phase:

    • Involvement of Follicle-Stimulating Hormone ($FSH$).

    • Increase ($\uparrow$) in Estrogen levels triggers the Luteinizing Hormone ($LH$) surge.

  • Ovulation Phase: Occurs when $LH$ and estrogen reach their peak levels.

  • Luteal Phase: Characterized by high levels of progesterone.

Methods of Contraception

• Barrier and Mechanical Methods

  • Male and female condoms.

  • Diaphragm.

  • Cervical cap.

  • Sponge.

• Hormonal and Long-Acting Methods

  • Combined Oral Contraceptive:

    • Contraindications: History of thromboembolism, Hypertension ($HTN$), and migraines with aura.

  • Minipill: Progestin-only oral contraceptive.

  • Hormonal Intrauterine Device (IUD).

  • Copper IUD.

  • Depot medroxyprogesterone shot.

• Permanent Methods

  • Male and female sterilization.

Infertility: Causes, Risk Factors, and Treatments

• Pathological and Physiological Causes/Risk Factors

  • Polycystic Ovary Syndrome ($PCOS$).

  • Tubal blockage.

  • Endometriosis.

  • Uterine fibroids or polyps.

  • Abnormal sperm production or motility.

  • Age: Specifically women in their late $30s$.

  • Body Mass Index ($BMI$): Obesity or excessively low $BMI$.

  • Medical treatments such as chemotherapy or radiation.

  • Substance use.

• Assisted Reproductive Technologies (ART)

  • Intrauterine Insemination (IUI):

    • Procedure: Sperm is inserted directly into the uterus, closer to the egg, using a thin catheter.

    • Indications: Low sperm count, low sperm motility, and cervical deformities.

  • In Vitro Fertilization (IVF):

    • Procedure: A woman's egg and sperm are combined in a laboratory dish. The resulting embryo is then placed into the uterus to develop into a pregnancy.

    • Indications: Severe male infertility, unexplained infertility, failed alternative treatments, and tubal blockage.

• Infertility Medications

  • Clomiphene citrate: Induces ovulation by blocking estrogen receptors; helps to regulate or restore ovulation.

  • Menotropin: Promotes ovarian follicular growth.

  • Follitropin: Stimulates follicles; specifically used for $IVF$.

  • Human Chorionic Gonadotropin (hCG): Mimics the natural hormonal surge to mature eggs and trigger their release.

  • Metformin: Used to improve insulin resistance in cases of infertility specifically caused by $PCOS$.

Signs and Diagnosis of Pregnancy

• Presumptive Signs (Subjective)

  • Amenorrhea: Absence of menstruation.

  • Excessive fatigue (Really tired).

  • Enlarged and sore breasts.

  • Increased frequency of urination.

  • Quickening: Perception of fetal movement by the mother.

  • Emesis (vomiting) and nausea.

• Probable Signs (Objective indicators observed by an examiner)

  • Positive pregnancy test.

  • Ballottement: The returning of the fetus when the uterus is pushed with fingers.

  • Palpable outline of the fetus.

  • Braxton Hick’s contractions.

  • Goodell’s Sign: Softening of the cervix, occurring at approximately $6-8$ weeks.

  • Chadwick’s Sign: Bluish coloration of the vulva, vagina, and cervix, occurring at approximately $4$ weeks.

  • Hegar’s Sign: Softening of the lower uterine segment, occurring at approximately $6-12$ weeks.

  • Enlarged uterus.

• Positive Signs (Definitive evidence of a fetus)

  • Fetal movement felt by an examiner.

  • Electronic device detection of heart tones.

  • The delivery of the infant.

  • Ultrasound detection of the baby.

  • Visible fetal movement.

Pregnancy Calculations and Clinical History

• Naegele’s Rule (Estimating Due Date)

  • Formula: $\text{Month of LMP} - 3 \text{ months} + \text{LMP day} + 7 \text{ days} + 1 \text{ year}$.

  • Exception: If the Last Menstrual Period ($LMP$) occurred in January, February, or March, do not add the extra year in the final step.

  • Example: $LMP$ is $12/10/2022$.

    • Month: $12 - 3 = 9$

    • Day: $10 + 7 = 17$

    • Year: $2022 + 1 = 2023$

    • Estimated Date of Delivery ($EDD$): $9/17/2023$.

• GTPAL Obstetric History

  • G (Gravida): Total number of pregnancies, regardless of outcome.

  • T (Term): Pregnancies delivered between $37-40$ weeks.

  • P (Preterm): Pregnancies delivered between $20-36$ weeks.

  • A (Abortions/Losses): Spontaneous or elective losses occurring prior to $20$ weeks.

  • L (Living): Number of currently living children.

High-Risk Pregnancy Factors

• Genetic and History Factors

  • Family history of conditions like Cystic Fibrosis ($CF$) or Sickle Cell anemia.

  • Previous history of a high-risk pregnancy.

  • Pregnancies achieved with fertility assistance.

• Age-Related Risks

  • Age >35: Increased risk for Preeclampsia ($pre-E$), Down syndrome, and late-term loss.

  • Age <18: Increased risk for Sexually Transmitted Infections ($STI$), premature birth, malnutrition, anemia, and Hypertension ($HTN$).

• Substance Use Risks

  • Small for Gestational Age ($SGA$).

  • Premature birth.

  • Fetal Alcohol Syndrome ($FAS$).

  • Developmental delays.

  • Stillbirths.

  • Neonatal Abstinence Syndrome ($NAS$) withdrawal.

Laboratory Tests and Diagnostics

• Blood Work and Screening

  • Blood Type and Rh Factor (Type & Screen):

    • Rhogam: Administered at $28$ weeks gestation and within $72$ hours of delivering an $Rh+$ baby to an $Rh-$ mother.

  • STI Screening: Testing for Herpes Simplex Virus ($HSV$), gonorrhea, and chlamydia.

  • RPR/VDRL: Specific screening for Syphilis.

  • Group B Streptococcus (GBS): Screened at $36$ weeks. If positive ($+$), requires $IV$ antibiotics (Penicillin) during labor.

  • CBC/WBC: Complete Blood Count and White Blood Cell count.

  • Urinalysis (UA): Screened for the presence of protein.

• Fetal Assessment

  • Ultrasound: Includes the Anatomy scan conducted at $20$ weeks.

  • Amniocentesis: Testing amniotic fluid for genetic conditions, fetal infections, or neural tube defects.

  • Alpha-Fetoprotein (AFP):

    • High ($\uparrow$) levels indicate potential Neural tube defects (e.g., Spina bifida).

    • Low ($\downarrow$) levels are associated with Down syndrome.

  • Non-stress Test (NST): Performed after $28$ weeks to test fetal Heart Rate ($HR$) in response to natural movements to gauge oxygenation and nervous system function.

Gestational Diabetes Screening

• Glucose Tolerance Test (GTT): Conducted between $24-28$ weeks.

  • 1-hour screening: Blood sugar taken $1$ hour after consuming a sugary drink.

    • Normal: < 140 \text{ mg/dL}.

    • Requires further testing: > 140 \text{ mg/dL}.

  • 3-hour screening: Requires a fasting baseline blood sugar, then consumption of a high-concentration glucose drink. Blood sugar is tested at $1$, $2$, and $3$ hours after.

    • Diagnosis of Gestational Diabetes: Requires > 2 abnormal values based on the following reference ranges:

      • Fasting: $\le 95 \text{ mg/dL}$.

      • 1 hour: $\le 180 \text{ mg/dL}$.

      • 2 hour: $\le 155 \text{ mg/dL}$.

      • 3 hour: $\le 140 \text{ mg/dL}$.

Placental and Hypertensive Disorders

• Placenta Previa

  • Pathology: The placenta covers the cervix.

  • Symptoms: Bright red blood; painless.

  • Management: Delivery via C-section; outpatient monitoring for active bleeding; transabdominal or transvaginal ultrasound; abstinence from intercourse or heavy activity.

• Placenta Abruption

  • Pathology: The placenta separates from the uterine wall prematurely.

  • Symptoms: Painful; dark blood; uterine tenderness.

  • Management: This is an acute complication/emergency requiring an emergency C-section.

• Hypertensive Disorders

  • Chronic HTN: Hypertension present before pregnancy or before $20$ weeks gestation; persists after $12$ weeks postpartum ($PP$).

  • Gestational HTN: Occurs after $20$ weeks and resolves after delivery.

  • Preeclampsia (> 20 weeks):

    • Signs/Symptoms: Blood Pressure ($BP$) above $140/90 \text{ mmHg}$, proteinuria ($+$), edema, visual disturbances, Right epigastric pain (liver involvement indicated by elevated $LFTs$), pulmonary edema (crackles, Shortness of Breath), low urine output (monitored via $BUN$ and $Creatinine$), and hyperreflexia (increased Deep Tendon Reflexes or $DTR$).

    • Treatment:

      • Labetalol: Lowers Blood Pressure.

      • Magnesium Sulfate: Used for seizure prevention and fetal neuroprotection (reduces risk of cerebral palsy). Administered via loading and maintenance doses.

      • Magnesium Toxicity Signs: Lethargy, urine output < 30 \text{ mL}, Deep Tendon Reflexes at $0$, and altered mental status. Antidote: Calcium gluconate.

  • Eclampsia: Emergency characterized by seizures. Management includes preventing aspiration, addressing high $BP$, and proceeding to delivery.

  • HELLP Syndrome: Characterized by Hemolysis ($H$), Elevated Liver enzymes ($EL$), and Low Platelets ($LP$). Carries risks of organ damage and hemorrhage.

Labor Complications and Management

• Uterine and Labor Progress Issues

  • Tachysystole: More than $5$ contractions in a $10$-minute period. Risks include placental abruption, postpartum hemorrhage, or fetal hypoxia. Management: Discontinue Pitocin, place mother in left lateral position, administer $IV$ fluids and oxygen.

  • Precipitous Labor: Delivery within $3$ hours. Risks include maternal lacerations, placental abruption, postpartum hemorrhage, fetal hypoxia, and fetal injury.

  • Labor Dystocia ("Failure to Progress"): Risks for infection and neonatal sepsis. Management: Pitocin administration, Artificial Rupture of Membranes ($AROM$), operative or cesarean delivery.

• Fetal Presentation and Infection

  • Breech: Baby is positioned bottom or feet first. Requires C-section.

  • Fetal Position:

    • Occiput Posterior: More painful, tighter fit, higher risk for injury.

    • Occiput Anterior: The desired position.

  • Chorioamnionitis: Infection of the amniotic fluid.

    • Signs/Symptoms: Maternal fever, tachycardia (maternal or fetal > 160 \text{ bpm}), uterine tenderness, and itchy palms.

    • Treatment: Broad-spectrum antibiotics and drawing bile acids.

    • Risk Factors: Prolonged rupture of membranes and frequent cervical exams (increased bacteria exposure).

• Abortion Classifications

  • Spontaneous Abortion: Occurs after early initiation of labor without illness. Causes include infections, organisms in the lower genitals, or periodontal disease.

  • Indicated Abortion: Causes include gestational diabetes, $HTN$, preeclampsia, obstetric disorders, advanced maternal age, polyhydramnios, or oligohydramnios.

Clinical Assessment of Labor

• Suspected Labor Tests

  • Preterm Screening: Fetal fibronectin ($fFN$) swab of the cervix. Requires nothing in the cervix for at least $24$ hours prior.

  • Dilation: Measurement of how wide the cervix has opened ($0-10 \text{ cm}$).

  • Effacement: Measurement of how thin the cervix is ($0-100 \text{\%}$).

  • Station: Position of the baby's head relative to the ischial spines on the pelvis.

    • Negative ($-$) Station: Above the ischial spine. Warning: Do not rupture membranes if station is too high, as the gush of fluid can cause Cord Prolapse.

    • Cord Prolapse Management: Push the baby's head up to decompress the cord.

    • Positive ($+$) Station: Below the ischial spine.

• Fetal Distress and Size Issues

  • Meconium Aspiration: Fetus has a bowel movement in utero, staining amniotic fluid dark green or yellow.

  • Macrosomia (> 4000 \text{ g}): Also known as Large for Gestational Age ($LGA$).

    • Risks: Shoulder dystocia, maternal tears, and neonatal hypoglycemia (shaking, lethargy, poor appetite).

    • Hypoglycemia Treatment: Glucose gel and re-feeding.

  • Shoulder Dystocia:

    • Signs/Symptoms: Clavicular fracture, weak reflex, brachial plexus injury.

    • Risk Factors: Fetal placement, $LGA$, previous shoulder dystocia, cephalopelvic insufficiency, and post-term baby.

    • Treatment Positions: McRoberts position (knees to chest), all fours position, and suprapubic pressure.

Labor Monitoring and Contractions

• Monitoring Tools

  • Tocodynamometer: External sensor strapped to the abdomen.

  • Intrauterine Pressure Catheter (IUPC): Small catheter inserted into the uterus for internal monitoring.

• Contraction Parameters

  • Frequency: The time from the onset of one contraction to the onset of the next.

  • Duration: The time from the onset of one contraction to the end of the same contraction.

  • Intensity: Measured by subjective palpation.

Fetal Heart Rate (FHR) Patterns

• Variable Deceleration: Caused by cord compression.

  • Management: Discontinue Pitocin, change maternal position (feet to head), administer oxygen; C-section is probable.

• Early Deceleration: Caused by head compression.

  • Management: Sign of labor progress; continue to monitor.

• Acceleration: Sign of a healthy fetus.

• Late Deceleration: Caused by placental perfusion insufficiency.

  • Management: Discontinue Pitocin, place in lateral side position, administer oxygen, increase $IV$ fluids, and palpate for tachysystole.

Mechanics of Labor

• Fetal Movements and Preparation

  • Kick Count: If decreased, the mother should drink a sugary drink (e.g., Orange Juice), count after a meal or in the evening, and focus on achieving $10$ movements within $2$ hours.

  • Braxton Hicks Contractions: Felt in the upper abdomen; localized cramping; usually dissipate with activity.

  • True Contractions: Characterized by a squeezing sensation that is painful and wraps around the entire uterus.

• The Birthing Process

  • Labor Pushing: Typically involves $3$ pushes and deep breaths per contraction.

  • Ferguson’s Reflex: The natural urge to bear down caused by pressure from the baby’s head.

Stages of Labor

• Stage 1: Dilation and Effacement

  • Contains three phases: Latent, Active, and Transition.

  • Goal: Cervical dilation from $0-10 \text{ cm}$ and $100 \text{\%}$ effacement.

  • Phase 1: Latent

    • Dilation: $1-4 \text{ cm}$.

    • Contractions: Every $5-30$ minutes, lasting $30-45$ seconds. Mild intensity.

    • Duration: Longest phase for first-time mothers (> 14 \text{ hours}).

    • Recommendation: Stay home until active labor or water breaks.

  • Phase 2: Active

    • Dilation: $4-7 \text{ cm}$.

    • Contractions: Every $3-5$ minutes, lasting $45-60$ seconds.

    • Duration: $4-8 \text{ hours}$. Water usually breaks.

  • Phase 3: Transition

    • Dilation: $8-10 \text{ cm}$.

    • Contractions: Intense, back-to-back (every $2-3$ minutes), lasting $60-90$ seconds.

    • Duration: $30 \text{ minutes}$ to $2 \text{ hours}$.

• Stage 2: Delivery of the Baby

  • Starts at full dilation ($10 \text{ cm}$) and ends with delivery.

  • Crowning: Fetal station at $+1$ to $+5$.

• Stage 3: Delivery of the Placenta

  • Ends with the full delivery of the placenta; lasts $5-15$ minutes.

  • Cord Care: Clamp cord twice, wait for pulsing to stop, cut in the middle. Gentle traction used.

  • Placenta Sides: "Dull" is the mother’s side; "Shiny" is the baby’s side.

• Stage 4: Postpartum Recovery

  • $1-4 \text{ hours}$ post-delivery. Monitoring Vital Signs ($BP$, $HR$, temp) and fundal firmness/position.

Postpartum Complications

• Uterine Atony

  • Signs/Symptoms: Boggy (soft) uterus, displaced uterus, excessive bleeding, decreased $BP$, tachycardia.

  • Risk Factors: Full bladder, multiple gestations, gestational diabetes, polyhydramnios, fetal macrosomia, retained placenta, tocolytics, or infection.

  • Treatment: Empty the bladder, fundal massage, medications (Oxytocin, Carboprost, Misoprostol, Methylergonovine), surgery, or blood transfusion.

• Lacerations

  • Signs/Symptoms: Localized pain, tenderness, redness, swelling, irritation, or visible tear.

  • Treatment: Ice for the first $24$ hours, sitz baths, pericare, and stool softeners.

• Hematoma

  • Localized collection of blood under skin. Signs include pressure, excessive bleeding, and bluish bruising.

  • Treatment: Ice, non-opioid pain meds, and drainage.

Postpartum Assessment and Care

• Breasts: Mastitis vs. Engorgement

  • Mastitis: Infection or clogged duct (usually one breast). Painful, warm, red, with flu-like symptoms. Treatment: Antibiotics, continue breastfeeding, and pain relievers.

  • Engorged Breast: Affects both breasts; they feel hard and firm. Treatment: Warm compresses, cool packs, use of a lactation consultant.

• Physical Monitoring

  • Uterus: Check for firmness (firm vs. boggy) and location (midline to umbilicus).

  • Bladder: Monitor for distention or inability to void.

  • Bowel: Assess sounds and prevent constipation with stool softeners.

  • Lochia (Discharge):

    • Rubra: Bright red (days $1-4$).

    • Serosa: Pink/brown (days $4-10$).

    • Alba: White/yellow (after day $10$).

    • Alert: Saturated pad in < 15 \text{ minutes} or large clots.

  • REEDA Scale (for lacerations/episiotomy): Redness, Edema, Ecchymosis, Drainage, Approximation.

• Postpartum Mental Health

  • Baby Blues: Very common; occurs $2-3$ days postpartum; resolves within $2$ weeks.

  • Postpartum Depression: Occurs weeks to months later; persistent sadness and hopelessness.

  • Postpartum Anxiety: Excessive worry about the baby.

  • Postpartum Psychosis: Typically $2$ days to $6$ weeks postpartum; hallucinations/delusions; psychiatric emergency.

Neonatal Considerations

• Thermoregulation

  • Evaporation: Heat loss when moisture from amniotic fluid evaporates. Prevention: Dry the baby immediately.

  • Conduction: Heat loss or gain via skin-to-skin contact.

Comprehensive Medication Summary

• Oxytocin ($IV$): Stimulates uterine contractions to induce or speed up labor.

• Magnesium Sulfate ($IV$): Used for fetal neuroprotection and maternal seizure prevention.

• Betamethasone ($IM$): Administered in $2$ doses, $12$ hours apart to promote fetal lung maturation.

• Rhogam: Prevents $Rh$ incompatibility; given at $28$ weeks and after delivery if baby is $Rh+$ status.

• Labetalol ($PO$): Antihypertensive for gestational hypertension.

• Hydralazine ($IV$): Short-term management for severe pre-eclampsia/eclampsia.

• Penicillin ($IVP$): Antibiotic given if mother is $GBS+$ to protect the newborn.

• Morphine ($IV$): Pain management in early labor; avoided in active labor to prevent respiratory distress in the neonate.

• Misoprostol ($PO$): Softens the cervix and stimulates contractions.

• Terbutaline ($SQ$): Delays preterm contractions or manages tachysystole by relaxing the uterus.

• Dinoprostone: Softens, thins, and opens the cervix for induction.