Maternity audio

Abnormal Presentations

  • Normal presentation: Baby comes head first (cephalic presentation).

  • Abnormal presentation: Any presentation that is not head first. Examples include:

    • Breech: Baby presents with buttocks or feet first.

    • Transverse: Baby is lying horizontally in the uterus.

    • Face or brow: Head is partially extended.

  • Presented part: The part of the baby that will come out of the uterus first during delivery.

Breech Presentation

  • Risk of Umbilical Cord Prolapse:

    • The umbilical cord can slip down into the vagina before or during delivery.

    • A prolapsed cord can be twisted or compressed, which stops blood flow and endangers the baby, leading to fetal hypoxia or death.

  • Management:

    • If the presentation is not cephalic (head first), a Cesarean section (C-section) is usually performed to avoid complications such as birth trauma or cord compression.

    • External Cephalic Version (ECV): A manual procedure to turn the baby to a head-first position, but this is not always possible or safe.

Cephalic Presentation

  • Definition: Cephalic means the head is the presenting part, which is the normal and safest presentation for vaginal delivery.

  • Types of Cephalic Presentation:

    • Vertex: The most common cephalic presentation, where the back of the baby's head (occiput) is the presenting part.

    • Face: The baby's face is the presenting part, which can lead to a more difficult delivery.

Pelvis Differences

  • Female Pelvis:

    • Wider and broader than the male pelvis to accommodate childbirth.

    • More circular pelvic inlet.

    • Wider subpubic angle.

  • Compatibility with Baby's Head Size:

    • The female pelvis must be compatible with the baby's head size to allow for vaginal delivery.

  • Contracted Pelvis:

    • When the dimensions of the pelvis are not adequate for the baby's head to pass through.

    • This condition is known as cephalopelvic disproportion (CPD).

    • Often requires a C-section.

  • Causes of Contracted Pelvis:

    • Genetic factors.

    • Nutritional deficiencies during development.

    • Previous pelvic injuries.

  • Incompatibility (Cephalopelvic Disproportion - CPD):

    • The baby's head cannot pass through the pelvis.

    • Diagnosed via clinical examination and imaging techniques (e.g., X-ray pelvimetry, although less common now).

  • Risk Factors:

    • Common in diabetic women where babies tend to be larger than normal (macrosomia).

    • Advanced maternal age.

    • Obesity.

  • Female Pelvis Characteristics:

    • Wider

    • More flared iliac bones

    • Greater distance between ischial spines and ischial tuberosities

    • Shorter and flatter sacrum curvature

Indications for C-Section

  • Abnormal Placenta Position (Placenta Previa):

    • Normal Placenta Position: Placenta is up, away from the cervix, allowing the umbilical cord and the baby to be in the cephalic position.

    • Abnormal Position: Placenta is low, partially or completely covering the cervix. This is a serious situation because the placenta would be delivered first while the baby is still inside, leading to severe hemorrhage and fetal distress.

  • Abnormal Fetal Position:

    • If the baby is not in the normal (cephalic) position, such as breech or transverse lie.

    • Failed external cephalic version (ECV).

  • Cephalopelvic Disproportion (CPD):

    • Incompatibility between the baby's head size and the mother's pelvis, measured via ultrasound and clinical assessment.

  • Fetal Distress:

    • C-section is performed right away (without clear cause) if there's fetal distress to save the baby's life.

    • Monitored during delivery by measuring fetal heart sound and uterine contraction.

    • Signs of fetal distress include abnormal heart rate patterns (bradycardia, tachycardia, late decelerations).

  • Maternal Distress:

    • Any abnormality or distress during delivery (e.g., low blood pressure, loss of consciousness) requires an immediate C-section to save the mother and/or baby.

    • Examples: Severe preeclampsia, uterine rupture, uncontrolled hemorrhage.

  • Other Indications:

    • Multiple gestation (twins, triplets, etc.) where vaginal delivery is deemed risky.

    • Previous C-section with contraindications to vaginal birth after cesarean (VBAC).

    • Active genital herpes infection.

    • Umbilical cord prolapse.

  • Elective Cesarean:

    • Planned C-section.

    • Labor may be induced using medication (e.g., oxytocin) to start contractions before the C-section.

    • Scheduled before the due date, typically at 39 weeks gestation to ensure fetal lung maturity.

Twins

  • Two Types: Identical and fraternal.

  • Fraternal Twins (Dizygotic):

    • Two different ova are fertilized by two different sperm, resulting in two zygotes.

    • Each twin has its own placenta (two placentas) and amniotic sac, but sometimes the placentas can fuse.

    • Genetically no more similar than any siblings; can be different sexes.

  • Identical Twins (Monozygotic):

    • One ovum is fertilized by one sperm, and the resulting zygote divides into two separate embryos.

    • Usually share a single placenta, but each twin has its own amniotic sac (monochorionic diamniotic).

    • If the division occurs very early (days 1-3), twins may have separate placentas and sacs (dichorionic diamniotic, similar to fraternal twins).

    • Always the same sex and have identical genetic material.

  • Complications in Twin Pregnancies:

    • Higher risk of preterm labor and delivery.

    • Twin-to-twin transfusion syndrome (TTTS) in monochorionic pregnancies.

    • Increased risk of preeclampsia and gestational diabetes.

Birth Definitions

  • Late Birth (Premature/Preterm Infant):

    • Less than 37 weeks gestation or less than 5.5 pounds (2500 grams).

    • Premature infants may have respiratory problems due to lack of surfactant.

    • Surfactant: Helps the alveoli to inflate and deflate, reducing surface tension in the lungs.

    • Other potential complications: difficulty regulating body temperature, feeding problems, increased risk of infection, and neurological issues.

  • Abortion:

    • Loss of embryo or fetus before 20 weeks gestation or less than 1.1 pounds (500 grams).

  • Miscarriage (Spontaneous Abortion):

    • Spontaneous abortion (happens by itself).

    • Causes:

    • Abnormal fetus incompatible with life (e.g., chromosomal abnormalities).

    • Abnormal maternal reproductive organs (e.g., uterine abnormalities, incompetent cervix).

    • Placental factors/development problems.

    • Infections (e.g., TORCH infections) or chronic disorders (kidney, heart).

    • Endocrine disorders (e.g., thyroid problems, uncontrolled diabetes).

    • Not induced.

  • Threatened Abortion:

    • There might be spotting or bleeding and pain, but pregnancy may continue (might happen, might not).

    • Cervix is closed.

    • Treatment: Rest, progesterone supplementation, and close follow-up.

  • Inevitable Abortion:

    • Severe bleeding and pain indicate that it will happen no matter what; the cervix is dilated.

    • Membranes may have ruptured.

    • Follow-up: Ultrasound to check if the uterus is clean; Dilation and Curettage (D&C) might be needed to remove residues to prevent infection.

  • Habitual Abortion (Recurrent Pregnancy Loss):

    • Recurrent miscarriages (usually defined as three or more consecutive miscarriages).

    • Requires further investigation to find the cause. Common investigations include:

    • Genetic testing of both parents.

    • Evaluation of uterine anatomy.

    • Blood tests to check for autoimmune disorders (e.g., antiphospholipid syndrome).

    • Endocrine evaluation.

  • Missed Abortion (Silent Miscarriage):

    • The pregnancy is lost, but the woman doesn't realize it.

    • No symptoms of miscarriage (e.g., bleeding, pain).

    • Diagnosed via ultrasound when no fetal heartbeat is detected or no gestational sac is visible in the uterus anymore.

  • Septic Abortion:

    • Abortion complicated by infection of the uterus and surrounding tissues.

    • Can be life-threatening.

    • Requires immediate treatment with antibiotics and evacuation of the uterus.

  • Induced Abortion (Therapeutic Abortion):

    • Abortion performed to save the mother's life or health.

    • Example: Woman with severe heart problems who cannot sustain a pregnancy.

    • Also performed in cases of severe fetal abnormalities incompatible with life.

Fetal Death

  • Definition: Death of a fetus at any time during pregnancy.

  • Stillbirth: Fetal death after 20 weeks gestation. Baby dies due to immaturity or other complications.

  • Causes of Stillbirth:

    • Placental problems.

    • Umbilical cord accidents.

    • Maternal health conditions (e.g., diabetes, hypertension).

    • Fetal infections.

    • Genetic abnormalities.

    • Often, the cause is unknown.

Age of Viability

  • Definition: The age at which a fetus has a reasonable chance of survival outside the womb.

  • Generally Considered: More than 20 weeks gestation.

  • Survival Rate: After 24 weeks or 2.2 pounds, the baby has a 50% chance of survival with intensive medical care.

  • Goal: Keep the baby inside the mother's womb as long as possible to provide an optimal environment (40 weeks).

Surfactant Secretion

  • Timing: Respiratory system secretes surfactant at the end of pregnancy to prepare the lungs for breathing after birth.

  • Function:

    • Surfactant lowers the surface tension in the alveoli, preventing them from collapsing during exhalation.

    • Surfactant is composed primarily of phospholipids, including lecithin and sphingomyelin (ratio should be 2:1).

  • Clinical Significance:

    • Premature infants often lack sufficient surfactant, leading to respiratory distress syndrome (RDS).

    • RDS is treated with artificial surfactant administration and respiratory support.

Apgar Score

  • Purpose: Evaluates the newborn's condition immediately after delivery.

  • Timing: Assessed at 1 minute and 5 minutes after birth.

  • Parameters (each scored from 0 to 2):

    • Respiration and crying: Effort and regularity of breathing.

    • Reflexes and irritability: Response to stimulation (e.g., flicking the soles of the feet).

    • Pulse/Heart rate: Number of heartbeats per minute.

    • Skin color: Overall color of the baby (e.g., pink, blue, pale).

    • Muscle tone: Degree of flexion and movement.

  • Interpretation:

    • A score of 10/10 is the best.

    • A score of 7-10 is considered normal.

    • A score of 4-6 indicates moderate distress.

    • A score of 0-3 indicates severe distress and requires immediate resuscitation.

  • Suction:

    • Very important to clear the baby's airway of amniotic fluid and secretions.

    • Hold the baby from his legs down, and gently suction the back of the throat.

    • Wrap his back very, very gently and hold the baby upside down to use gravity to assist with drainage.

  • Thyroid Function Check:

    • Checks for thyroid gland function because the thyroid hormones are crucial for brain development.

    • If thyroid secretion is not normal (congenital hypothyroidism), thyroid hormone replacement is needed to prevent mental retardation.

  • Other Newborn Screening Tests:

    • Blood tests to screen for metabolic disorders (e.g., phenylketonuria).

    • Hearing screening.

    • Screening for critical congenital heart defects (CCHD).

Potty Training

  • Timing:

    • Don't push kids to be potty trained too early because it requires brain development and physical readiness.

    • Most children are ready for potty training between 18 months and 3 years.

  • Readiness Signs:

    • Showing interest in the toilet.

    • Staying dry for longer periods (at least 2 hours).

    • Expressing awareness of when they need to go.

    • Following simple instructions.

  • Brain Development:

    • Brain is not ready to perform fine motor skill. (i.e tying shoelaces.)

  • Approach:

    • Be patient and supportive.

    • Use positive reinforcement.

    • Avoid punishment or shaming.

Lactation

  • Hormonal Control:

    • Prolactin stimulates lactation; estrogen and progesterone suppress prolactin during pregnancy.

    • Once the placenta is delivered, estrogen and progesterone levels drop, allowing prolactin to stimulate milk production.

  • Colostrum:

    • In the first 2-3 days postpartum, the secretion is colostrum (yellowish) and rich in antibodies (especially IgA).

    • Provides passive immunity to the newborn.

    • Also contains growth factors and other beneficial substances.

Milk Secretion

  • Suckling Reflex:

    • Suckling causes oxytocin release, leading to uterine contraction and milk ejection reflex (let-down reflex).

  • Uterine Contraction:

    • Per herium: The residuals inside the uterus which take about 40 days after delivery to get rid of by contraction.

    • Oxytocin released causes contraction which helps rid of residuals and cause milk ejection towards the nipple.

  • Benefits of Breast Milk:

    • Current formulas cannot replace human milk because breast milk contains antibodies and has an optimal ratio balance of nutrients.

    • Provides numerous health benefits for the infant, including:

    • Enhanced immune function.

    • Reduced risk of allergies and asthma.

    • Improved cognitive development.

    • Lower risk of obesity and chronic diseases later in life.

Breast Milk

  • Composition:

    • Has a laxative effect, helps colonize beneficial bacteria in the infant's intestine, is easily digestible, and has balanced protein.

    • Contains essential fatty acids, vitamins, and minerals tailored to the infant's needs.

  • Medications and Lactation:

    • Medications can be secreted through milk, so avoid taking any medication without a doctor's guidance during lactation.

    • Some medications are safe to use during lactation, while others may be contraindicated.

  • Essential Amino Acids:

    • The amino acid, which is a protein building blocks.

  • Dietary Considerations for Lactating Mothers:

    • Adequate hydration.

    • Balanced diet with sufficient calories and nutrients.

    • Avoid excessive caffeine and alcohol.

Cardiovascular Adjustments

  • Fetal Circulation:

    • Fetal circulation differs from postnatal circulation.

      *Umbilical vein $\rightarrow$ Inferior vena cava $\rightarrow$ Right side of the heart

      *Right side have oxygenated blood. But blood supply cells in your body requires 0xygenated blood to come to right.

      *So a window is created from the Right to Left side called the Foramen Ovale. After delivery, the pressure forces the vessel called the Fossa Ovale

      Connection between to veins has ductus venosus become the ligamentum venosum

      connection between two arteries has ductus arteriosus

  • Foramen Ovale:

    • The oxygenated blood gets shunted to the left side via the foramen ovale (window between atria), which becomes the fossa ovale after delivery.

      *Ductus arteriosus. See? Between pulmonary because the blood gonna go here, but we need this oxygenated to go to aorta. So we have duct here. This duct or connection between these two arteries, the blood gonna go through it to aorta.

      *After delivery, the lung starts to work, and the oxygenated blood flows to the left side, eliminating the need for these connections.

  • Lung Expansion:

    • The lung must now expand. This causes higher pressure to move the window to close on the atrial system.

      \text{Umbilical vein } \rightarrow \text{ Ligamentum teres}

      \text{Ductus venosus } \rightarrow \text{ Ligamentum venosum}

      \text{Foramen ovale } \rightarrow \text{ Fossa ovalis}

      \text{Ductus arteriosus } \rightarrow \text{ Ligamentum arteriosus}

      \text{Umbilical arteries } \rightarrow \text{ Lateral umbilical ligaments}

Pregnancy Disorders

  • Early Pregnancy Loss:

    • 10-15% of zygotes do not implant, leading to spontaneous abortions (miscarriages) due to fetal abnormalities, improper implantation, or premature detachment.

  • Ectopic Pregnancies

    • *Definition: A condition where abnormal or abnormal means. Abnormal location of the pregnancy occurring outside the uterine wall.

    • Ectopic Pregnancy: Implantation occurs outside the uterus. *Empty cavity in the uterus.

    • Diagnosed via the Ultra Sound.

    • Most Common Causes/ Risk Factors: Sexually transmitted diseases and pelvic inflammatory disease.

*Breaks up over the walls with peristaltic movements of the muscles pushing and pushing the OVa towards the correct place.

  • Pre-Eclampsia:

    • Defintion: Condition where the pregnancy causes convulsion that can lead to death if the mom isn't treated or if the baby stays inside for too long.

    • Line of treatment is to terminate the pregnancy right away

    • Also called toxemia (toxicity of pregnancy), may lead to convulsions and death of both mother and baby.

    • Preeclampsia: High blood pressure, edema in legs, and protein in urine

*If severe case occurs of a mom who is pre eclampsia and baby is still Young: give her magnesium and sulfate.

  • Eclampsia:

    • Best line of treatment is to terminate the pregnancy right away because otherwise Mom and baby both dy due to convolutions.

    • Eclampsia: Convulsions, kidney failure, coma, and death.

  • Placenta Previa:

    • Placenta is in an abnormal position because the birth normally comes out with the baby first, not food.

Defintion:

Low position of the placenta in regards to the os. (opening)

* Placenta Previa: The placenta is in a low position, covering the internal os (cervical opening).

* If there is placenta Previa we need to preform a C section

* Dilation means that the connection will cause separation so there is no nutrients for the baby

* Can be complete (covering the whole area), partial, or marginal (at the edge of the internal os).

*internal VS external os meaning the opening and the closing

Three Types of Placenta Positions

1)Complete covers every part

2)Partial covers parts of the area

3)Maginal : is in the mass.

Because D and C IS very commmon why do we dilation?

*Cause must dilate before. That's why the stage of delivery this internal ass is closed but if dialysis will hapeen, okay, so the placenta okay will be separated. Severe bleeding and no blood supply anymore for the baby inside the hips.

  • Placental Abruption (Abruptio Placenta):

    • Separation of the placenta from the uterine wall before delivery.

    Why:

    Defintion:

    A separation of the placenta from the uterine wall from the delivery due to any trauma.

    *Car Accident

    * Very common with car accidents or trauma.

    * Can be concealed (hidden bleeding) or clear (external bleeding).

Tender Abdomen: Can show that there is concealed abruption as diagnosed by ultrasound