A&P of labour

Obstetrical terminology (Know these terms)

  • Understanding the following terms is essential to the study of maternity care:

  • Gravida

  • Person who is pregnant 

  • Gravidity

  • Pregnancy 

  • Nulligravida

  • A person who has never been pregnant 

  • Primigravida

  • A person who is pregnant for the first time 

  • Multigravida

  • Person who has had two or more pregnancies 

  • Parity

  • Number of pregnancies in which fetus or fetuses have reached 20 weeks of gestation, not number of fetuses (ex: twins) born. Pregnant with twins is still just 1 pregnancy 

  • Nullipara

  • A person who has not completed pregnancy with a fetus or fetuses beyond 20 weeks of gestation hasn't reached 20 weeks yet 

  • Primipara

  • A person who has completed one pregnancy with a fetus or fetuses who have reached 20 weeks of gestation has reached 20 weeks 

  • Multipara

  • A person who has completed two or more pregnancies to 20 weeks gestation or more 

  • Viability 

  • Capacity to live outside the uterus; about 22 to 25 weeks of gestation 

  • 20 weeks baby = viable (can survive outside of the uterus)

  • Below 20 weeks = miscarriage (baby would not survive outside of uterus)

  • Preterm

  • Pregnancy that has reached 20 weeks of gestation but before completion of 36 weeks of gestation deliver before 36 weeks 

  • Late preterm 

  • Term

  • Pregnancy from the beginning of week 37 of gestation to the end of week 40 plus 6 days of gestation 

  • Early term 37-38 weeks + 6 days 

  • Full term 39-40 weeks + 6 days 

  • Late-term 41st week 

  • Post-term Pregnancy after 42 weeks 


GTPAL Will be questions on exam 

  • G: Gravidity – Number of pregnancies 

  • T: Term – Total number of term births (37 weeks or more)

  • P: Preterm – Number of preterm births (between 20-36 weeks)

  • A: Abortions – Therapeutic or spontaneous (miscarriage = spontaneous abortion)

  • L: Living children – The number of live births (living children)



GTPAL Example

  1. Debbie is pregnant for the first time, what is her GTPAL? Has not given birth yet 

  2. Debbie goes on and carries this pregnancy to term and the infant lives and survives, what is her GTPAL now? She has now given birth 

  3. A year later Debbie gets pregnant again, what is her GTPAL? Hasn't given birth to her new baby yet 

  4. The second pregnancy, unfortunately, ends in a miscarriage at 10 weeks, what is her GTPAL? 

  5. A year later Debbie delivered twins at 36 weeks, what is her GTPAL? Has delivered the baby 

  6. Debbie has her 4th pregnancy and delivers a stillbirth baby at 38 weeks, what is her GTPAL


Pregnancy tests 

  • Human chorionic gonadotropin (hCG) is the earliest biochemical marker of pregnancy (blood or urine test)

  • 8-10 days after fertilization hCG rises

  • hCG peaks at 9-10 weeks gestations and then levels off

  • Early morning urine samples have the highest amount of HCG

  • Many different pregnancy tests are available:

  • Enzyme-linked immunosorbent assay (ELISA) testing is the most popular method of testing for pregnancy 

  • ELISA technology is the basis for most over-the-counter home pregnancy tests 

  • Medication interferences 


What can cause false negatives and positives 

  • Medications can interfere 

  • Taking a test too early into the pregnancy, may not pick up the hCG because it is too low 

  • Not collecting the specimen properly 

  • Human error 


hCG can estimate gestational age 

  • Really low levels of hCG can indicate a miscarriage or an abnormality in the pregnancy (the fetus could be developing chromosomal abnormalities, such as Down syndrome 

  • Really high levels of hCG can indicate twins or Trophoblastic gestational disease also referred to as molar pregnancy 


Molar pregnancy 

  • A molar pregnancy occurs when an egg and sperm join incorrectly at fertilization and create a tumor. The tumor looks like tiny water-filled sacs, similar to a cluster of grapes. The tumor can't support a developing embryo and the pregnancy ends. Some people have a miscarriage


Adaptations to Pregnancy: Signs of pregnancy 

  • Presumptive (assume they are pregnant)

  • Subjective, the person is telling you they notice changes, she feels different 

  • Breast changes (they feel full and different)

  • No period (amenorrhea), could also be due to stress, over-exercising, being sick, early menopause, malnutrition 

  • Nausea and vomiting (Could just be flu)

  • Frequent urination 

  • Fatigue 

  • Quickening – feel something moving in the uterus (could be peristalsis or gas) (16 weeks for pregnancy)

  • Probable (positive pregnancy test, blood or urine)

  • Objective, we can see it. Such as a pregnancy test 

  • Things the examiner can see 

  • Goodell sign – when the vaginal portion of the cervix is softening 

  • Chadwick's sign – change in color of cervix, vagina, and vulva (purple/blue/red) (around 6-8 weeks)

  • Hegar sign – Softening of the lower segment (narrowing of the uterus)

  • Pregnancy tests (even if positive may not mean pregnancy, could mean tumor)

  • Braxton hicks – false labor contractions (painless) (feel belly getting tight) 

  • Ballottement – can palpate something (could be baby, tumor…

  • Mucous plug

  • Positive (ultrasound)

  • Actually see the outline of the baby and the heart rate of fetus 

  • Ultrasounds usually occur at 18 weeks 

  • Can hear baby's heart rate 

  • Can see baby making movements 


Amniotic fluid 

  • Maintains fetus body temp 

  • The baby drinks and pees it out 

  • Produced all the time (no such thing as a dry birth)

  • Cushions the fetus 

  • Helps with musculoskeletal development 

  • Acts as a barrier to infection 


Oligohydramnios

  • Not enough amniotic fluid, less than 30mL

  • A healthy pregnancy should have 700-1000mL

  • It can be caused by not enough blood flow to the placenta, premature rupture, something wrong with the baby's kidneys (not peeing)


Polyhydramnios 

  • Too much amniotic fluid, more than 2000mL

  • Healthy pregnancy should have 700-1000mL

  • Can be caused by twins (multiples), the fetus could have swallowing issues (can't drink fluid), mother may have diabetes 


Adaptations to Pregnancy: Reproductive system and breasts 

  • Uterus 

  • Changes in size, shape, and position 

  • Hegar signs 

  • Changes in contractility 

  • Uteroplacental blood flow 

  • Cervical changes 

  • Goodell sign – when the vaginal portion of the cervix is softening 

  • Changes related to fetal presence 

  • Ballottement 


Height of fundus                                       

  • 40 weeks is lower than 36 weeks because the baby dropped to the pelvis to get ready for birth (engagement)

  • If baby doesn't engage then we get concerned (their is a problem)

  • 7 weeks = hens egg 

  • 10 weeks = Orange 

  • 12 weeks = Grapefruit 

  • When measuring fundus have person laying on their back but make sure you have a towel or pillow tucked in on their left side because it takes pressure off the blood vessels supplying the placenta and the uterus 



Adaptations of pregnancy: Reproductive system and breast 

 Vagina and vulva 

  • Chadwick sign – change in color of cervix, vagina, and vulva (purple/blue/red) (around 6-8 weeks)

  • Leukorrhea – mucus 

  • Mucous plug – so nothing can get up into the uterus to cause infection (sometimes women think this is their water breaking)


Adaptations of pregnancy: Reproductive system and breast 

Breasts 

  • Fullness, heaviness 

  • Heightened sensitivity from tingling to sharp pain 

  • Areolae become more pigmented 

  • Montgomery's tubercles 

  • Little sebaceous glands that secrete moisturizing fluid to prepare the nipple for breastfeeding 

  • Colostrum 

  • Women can produce this weeks before giving birth 

  • Full of vitamins and nutrients 

  • Can wear breast pads but make sure they are cotton 


Adaptations of pregnancy: General body systems 

Cardiovascular system 

  • Cardiac output 

  • We have a placenta, fetus and growing uterus that we must now supply so the cardiac output goes up by 30%-50%  up until 32 weeks 

  • Once it reaches 32 weeks it starts to drop down by 20% 

  • Blood pressure 

  • The systolic blood pressure may slightly increase or decrease from pre pregnant levels 

  • The diastolic is the the same thing, slight decrease to mid pregnancy (24-32 weeks) and as pregnancy progresses it gradually returns to pre pregnant levels 

  • Blood volume and composition 

  • Significant increase in blood volume (increase of 1500mL of blood above pre pregnant levels)

  • Circulation and coagulation times 

  • Increase of blood clotting during pregnancy due to the increase of clotting factors

  • With this increase of clotting factors and fibrinolytic activity (dissolving a clot), this is a protective mechanism during pregnancy so that she doesn't bleed to death

  • Increases the risk of developing a blood clot (DVT – deep vein thrombosis)

  • Women who have c sections are more at risk for clotting so they usually receive heparin (anticoagulant) or loxanox 

  • Heart rate tends to increase by 10-15 BPM


Respiratory system 

  • Pulmonary function 

  • Increased chest expansion to increase oxygen needs and get rid of infant Co2

  • Respiration rate may increase slightly 

  • Tidal volume (the amount of air that moves in and out of your lungs with each respiratory cycle), this increases by 30-40%, but vital capacity does not change (vital capacity is the greatest volume you can expel after taking in a deep breath)

  • Inspiration capacity increases 

  • Basal metabolic rate 

  • This usually increases due to the increased oxygen demands of the uterus, placenta and fetus (greater oxygen consumption)

  • By the third trimester the BMR will increase by about 10-20% over pre pregnancy levels and returns to normal about 5-6 days postpartum 

  • Women will have a decreased tolerance to heat (always warm, sweating due to high BMR)

  • Acid-base balance 


Renal system 

  • Anatomical changes 

  • Larger volume of urine to be held and urine flow rate is slower due to levels of estrogen and progesterone 

  • Slowed urine causes an increased risk for UTIs 

  • Pregnant urine tend to have more nutrients and some glucose (this is why we encourage drinking water)

  • Functional changes 

  • Bladder is susceptible to bleeding and increased frequency 

  • Fluid and electrolyte balance 

  • In early pregnancy women may feel more thirsty (dry mouth) due to kidneys excreting more water aka excess water loss 

  • Later on in pregnancy we can see pooling of fluid in the legs (called physiological edema)

  • We know this is physiological edema if she sits down and puts her legs up and the fluid dissipates 

  • If this doesn't happen then there is an issue and we must investigate 

  • Not normal for protein to be excreted in the urine, except for after birth 

  • High amounts of glucose should be investigated because it could be gestational diabetes 


Integumentary system 

  • Chloasma (mask of pregnancy)

  • Melanotropin levels increase and can cause this aka mask of pregnancy 

  • This is a darkened area on the face and can get darker with sun exposure 

  • Linea nigra 

  • Also caused by melanotropin levels, this is a line going up the belly and grows at the same rate as the fundus 

  • Striae gravidarum 

  • Stretch marks (signs of life), due to the separation of the underlying connective tissue 

  • Angiomas 

  • Vascular spider nevi (little veins that come to the surface of the skin), can get them on the nose, legs, face, and are blue in color and tend to disappear after birth 

  • Palmar erythema 

  • Red blotches on the palms of the hands, and usually due to the increase in estrogen levels 

  • Polymorphic eruption of pregnancy (PEP), also known as pruritic urticarial papules and plaques of pregnancy (PUPPP)

  • Extremely uncomfortable and itchy 


Musculoskeletal system 

  • Diastasis recti (indent in lower stomach from muscles separating)

  • Relaxin (a hormone secreted to help the joints of the pelvis move to accommodate for birth)


Neurological system 

  • Nerves – carpal tunnel (due to swelling)

  • The uterus can press on nerves and cause loss of sensation in the legs 

  • Tension headaches 

  • Syncope (fainting)


Gastrointestinal system 

  • Appetite 

  • Nausea and vomiting (recommend bland foods like dry toast, crackers, no spices, small frequent meals, fluids 

  • PICA – non food cravings (clay, detergent)

  • Hyperemesis gravidarum – Constant vomiting, dehydration, weight loss, low calcium (princess kate) could be due to thyroid problem, molar pregnancy, multiple fetuses, history of this in other pregnancies, or could be carrying a female fetus (will need to be hospitalized if severe)

  • Vitamin B6, multivitamins

  • Pregnancy cravings 

  • Mouth and teeth 

  • Increased sensitivity 

  • Increased salivation 

  • Esophagus, stomach, and intestines 

  • Mobility of smooth muscles start to slow down – slow emptying 

  • Regurgitation – heartburn (TUMS)

  • At risk for constipation (drink fluids and fiber, and movement)

  • Gallbladder and liver 

  • Bile ends up stagnating (not being used as fast as it should aka it backs up and can leak into the skin this can lead to cholestasis of pregnancy)

  • Abdominal discomfort