OB Final Exam Notes

Exam Preparation: Key Topics and Concepts

General Study Advice

• Study the workbook from front to back by separating information into smaller chunks.

Syllabus Breakdown & Nutritional Elements

• Weeks 1-2: Antenatal care (prenatal care of the mother).

• Weeks 3-4: Intrapartum care (childbirth).

• Weeks 4-5: Postpartum care.

• Week 5 onwards: Pediatrics (newborn assessment, growth and development, congenital anomalies).

Key Nutritional Elements During Pregnancy

• Protein: At least 60 grams per day.

• Iron: 30 milligrams per day (for both mother and newborn's iron stores).

• Folic Acid: 0.4 micrograms per day (prevents spina bifida).

• Start taking folic acid 3-6 months before pregnancy and continue throughout.

• Calcium: 1200 milligrams per day.

• Calcium and iron compete for absorption, so they should not be taken together.

• Take iron in the morning on an empty stomach or with orange juice to promote uptake; take calcium later in the day.

Pelvis Size and Shape (Textbook p.28, Figure 2.5)

• Four types of pelvises:

  • Gynecoid: Most favorable for vaginal delivery (widest opening).

  • Platypoid.

  • Android (male pelvis): Narrow hip.

  • Babies can still be delivered with these pelvises, but cesarean section may be necessary due to cephalopelvic disproportion.

Definition of Terms (Textbook p.51)

• Gravida: Pregnant uterus (counts current pregnancy).

  • Use slash marks to count pregnancies mentioned in exam questions.

• Para: Number of births occurring after 20 weeks gestation (age of viability).

• Abortion: Delivery of a fetus prior to 20 weeks gestation (spontaneous or induced).

• Age of Viability: 20 weeks gestation.

• Term Delivery: Baby achieves 37 completed weeks gestation.

• Preterm Delivery: Birth after 20 weeks but prior to 36 weeks and 6 days gestation.

Calculating Nagel's Rule (Textbook p.51)

• Used to determine the baby's likely delivery date.

• If the mother's last normal menstrual period was in January, February, or March, she will deliver in the same year she was tested for pregnancy.

  • If the last menstrual period was later than March, she will deliver in the following year.

• Count 28 day cycles when calculating.

Signs of Pregnancy (Textbook p.52, Box 4.3)

Presumptive Signs

• Physiologic changes consistent with pregnancy, but the woman may not be pregnant.

• Examples: Amenorrhea (missed period), nausea and vomiting.

Probable Signs

• Ghidells',

• Chadwick's,

• Hagar's,

• Braxton Hicks',

• McDonald's.

• These are based on physiological changes in the body, but the woman may not actually be pregnant.

• Descriptions of assessments on pages 53-54 of the textbook.

Positive Signs

• Only three positive signs:

  • Hear a baby.

  • See a baby.

  • Feel a baby (by practitioner, midwife, or physician).

• Positive pregnancy test is a probable sign because HCG in the blood does not guarantee a fetus in the uterus (e.g., ectopic pregnancy).

• Quickening (mother feeling fetal movement) does not count as a positive sign.

Prenatal Testing (Textbook Table 4.1, p.50)

• Understanding why tests are done in each trimester is important.

First Trimester Blood Work

• Purposes:

  • Assess for anemia (hemoglobin below 12; below 10 requires higher iron supplements).

  • Determine potential for ABO incompatibility or Rh negative mother with Rh positive baby.

  • Detect potential infections that could harm the fetus.

• Tests:

  • CBC.

  • Blood type and Rh.

  • VDRL (syphilis).

  • Rubella titer.

  • HIV.

  • Hepatitis B.

• Rubella, HIV, and Hepatitis B are part of the TORCH infections.

• Chlamydia and gonorrhea are bacterial infections treatable with penicillin; the rest are viral infections with no cure.

Second Trimester Blood Work

• Oral glucose tolerance test (between 24-28 weeks) to assess risk for gestational diabetes.

• Pregnancy is well-established.

• The test determines if the mother is overproducing glucose or consuming an overabundance, with insufficient insulin to rid it from her body.

• Uncontrolled gestational diabetes can be dangerous to the baby, causing it to get larger than normal and leading to a possible cesarean section, stillbirth, and congenital anomalies.

• One-hour glucose tolerance test: If blood glucose is over 140 mg/dL, a two or three-hour glucose tolerance test is required.

• If blood sugar is over 140 after two or three hours, the mother is diagnosed with gestational diabetes.

• The preferred drug to treat gestational diabetes is insulin if the mother cannot decrease her carbohydrate intake.

• Alpha fetoprotein (AFP) test as part of the quad test of hormones and proteins, assessing for Down syndrome, where low AFP is an indicator.

• Ultrasound around 16 weeks to confirm estimated date of delivery and to assess fetal anomalies, including Down syndrome (scanning the back of the baby's neck for extra folds).

• Amniocentesis is rarely done today.

Third Trimester of Pregnancy

• Vaginal and rectal swab for GBS (group beta strep).

• GBS exposure during vaginal birth can cause massive infection in the baby and lead to death.

• If GBS is present, the mother will need an antibiotic protocol during labor and after rupture of membranes.

Fetal Diagnostic Tests (Textbook Table 5.1, p.88)

• Kick Count: After a meal, lay on the left side and feel for fetal movements for at least 30 minutes up to an hour or more.

  • Decreased fetal movement is an indication to do a nonstress test (NST).

• AFP: High levels are associated with spina bifida, and low levels are associated with Down syndrome or hydatidiform mole.

• Nonstress Test (NST):

  • Assesses fetal well-being by looking at fetal movement or contractions and how the baby reacts.

  • Reactive/positive test: Fetal heart rate elevates above its baseline at least 15 beats per minute and stays up for at least 15 seconds or longer within a 20-minute period (15x15 in 20).

• Biophysical Profile (BPP):

  • Composed of five different assessments, including the nonstress test.

  • Performed when NST is nonreactive.

  • Four other measurements:

    • Pocket of amniotic fluid: A certain amount should be present, indicating sufficient production and that the baby is drinking and peeing into the fluid.

    • Fetal movement: Arms and legs moving.

    • Fetal tone: Arms and legs pulled in close to the body (not flaccid).

    • Fetal breathing movement: Chest rises and falls, simulating breathing movements.

  • NST gives 0 or 2 points. The ultrasound gives 0-2 points to the other four measurements.

  • Possible total score is 10.

  • Below 7: Redo the test.

  • 8-10: Baby is fine.

  • 4: Most likely a C-section due to fetal distress.

Discomforts of Pregnancy (Textbook Table 4.6, p.70)

• Nausea and Vomiting: Avoid an empty stomach, eat dry toast or crackers before getting up in the morning.

• Heartburn: Sit up for at least 30 minutes after eating, avoid gas-forming and greasy foods, and contact the healthcare provider before taking over-the-counter medications.

• Constipation: Increase fluid intake, avoid caffeinated drinks, walk for at least 30 minutes a day.

• Hemorrhoids: Use witch hazel to shrink them.

• Varicose Veins: Avoid lengthy standing or sitting, use less elastic waist clothing, and walk frequently.

• Edema of the Feet and Ankles: Elevate the legs when sitting.

Early and Late Bleeding Disorders

• Early Pregnancy Complications involving bleeding: Hydatidiform mole, ectopic pregnancy, and abortion.

Placenta Previa vs. Placental Abruption

• Placenta Previa: Placenta is over or within 2 centimeters of the cervical opening.

  • Bright red, painless bleeding (placenta has no nerves).

• Placental Abruption: Placenta is in the upper part of the uterus.

  • Dark red blood, severe pain (blood builds up against the wall of the uterus, which has many nerve endings).

• Hydatidiform Mole: Brown discharge (chorionic villi).

Characteristics

• Previa: Bright red blood, no pain.

• Abruption: Dark red blood, pain.

• Hydatidiform Mole: Brown discharge, rapid uterine growth, signs of hyperemesis gravidarum, no heartbeat, high hCG level.

Care for Patients After D&C or D&E (Textbook pp. 92-93)

• Contact health care provider if there is continued bleeding.

• Do not use tampons.

• Take temperature every 8 hours for 3 days post-op and contact the healthcare provider if it is above 100.4 degrees Fahrenheit.

• Report foul or brownish discoloration of vaginal discharge.

• Continue taking iron pills.

• Use contraception until having a normal regular period.

• With a hydatidiform mole, wait 6 months to a year before attempting pregnancy again due to the risk of trophoblastic cancer disease.

Late Pregnancy Bleeding: Ectopic Pregnancy

• Bright red bleeding.

• Ultrasound and pregnancy test are done.

• Rule out appendicitis (symptoms are the same).

• hCG level is lower than normal.

Manifestations of Gestational Hypertension and Preeclampsia

• Determined after 20 weeks gestation.

• Blood pressure at or above 140/90, assessed four hours apart or on two separate occasions.

• Preeclampsia vs. Gestational Hypertension: Involves other systems of the body.

  • Edema (more than 3+ in the ankle, above the waist, around the eyes, thick fingers).

  • Proteinuria (kidneys spilling protein in the urine).

  • Severe: CNS involvement includes visual disturbances and headaches that get progressively worse.

Treatment

• Oral labetalol (Trandate) to control the cardiovascular system.

• IV labetalol is done in the hospital to try and get the blood pressure down.

• Labetalol can't be used in patients that have asthma or heart failure.

• Decrease activity, weigh themselves (gaining more than 2 pounds per week means that their disease is getting worse), and contact their health care provider if the symptoms get worse.

• Pregnant women with hypertension should not be given diuretics, because they can lead to nonreactive NSTs and poor BPPs.

Preeclampsia Worsening

• Decreased urine output (less than 50 milliliters per urine per hour).

• Respiratory system: Crackles in the lungs (fluid is now getting spaced to their lungs).

• GI and liver: Epigastric pain that the patient is complaining of pain on the right side of their abdomen, particularly when they take a deep breath.

• GI symptoms and liver symptoms indicate HELLP syndrome.

HELLP Syndrome (Lab Complication)

• Hemolysis (red blood cells exploding).

• Elevated liver enzymes (ALT and AST above 20 milligrams per deciliter).

• Low platelets (typically below 100,000).

Rh Factor

• Rh positive: Has the rhesus protein on their red blood cell. - Rh negative: Does not have the rhesus protein on their red blood cell.

• If an Rh negative mother has an Rh positive baby: Give RhoGAM to try and tell her body not to make antibodies against the baby.

• Small dose of RhoGAM at 28 weeks gestation and a full dose within 72 hours of birth.

Childbirth: Intrapartal Care

• Contraction Pattern: Allow at least a 30-second resting period between contractions to allow the resurgence of blood flow from the uterus to the placenta.

Four Stages of Labor

• Stage 1: Dilatation and effacement of the cervix.

• Stage 2: Pushing of mom with contractions to push the baby out through the vagina.

• Stage 3: Placenta detaching from the wall of the uterus and being delivered.

• Stage 4: Two to four-hour period to assess stabilization of both mom and baby following birth.

Impending Signs of Labor

• Braxton Hicks Contractions: Uterine muscles getting ready for birth.

• Lightening: The baby will fall down in the pelvic rim in preparation for labor.

• Increase in vaginal discharge: Normal sign, it should be clear.

• Cervical changes: Softening of cervix pulling towards the vagina so that it's perpendicular with the vagina.

• Bloody Show: Is when a mucus plug will come out in one piece, and there's old dark blood in it. The purpose of the mucus plug is to prevent any organisms in the vagina from getting up to the baby.

• Rupture of the membranes: If this occurs and there's no contractions for around eighteen hours, the practitioner will typically start the mom on Pitocin.

• Energy spurt: Nesting desire.

• Some women can lose up to three to five pounds in the hours and days before they actually start into labor.

Leopold Positions

• Determine the fetal position and presentation.

• Helpful to determine where to put the Doppler of the fetal monitor.

Fetal Heart Rate Patterns: VILLE CHOP MIND

• Mnemonic to determine any abnormal fetal heart rate patterns that could indicate low or decreased oxygenation coming from the placenta to the baby.

Variable Deceleration of the Fetal Heart Rate

• An indication that the umbilical cord is being wrapped around the neck or somewhere around the body.

• Reposition the mom to make the decelerations not as deep.

• Put mom on oxygen or use poison for responding to a variable deceleration.

Early Deceleration of the Fetal Heart Rate

• Indication of the baby's head is getting squeezed.

• Mirrors the contraction.

• Never goes below 30 beats per minute.

• No loss of oxygenation, so identify it and document it on the chart.

Accelerations

• Great because it shows that the baby is doing well.

• You don't have to do anything.

Late Deceleration

• Indication, the placenta is not working the way it should.

• A gradual decrease in the fetal heart rate after the peak of the contraction.

• You have to do poison.

Postpartum Care

• Assess the fundus: It will go down one fingerbreadth or one sonometer per day.

• The bladder can actually push the uterus off to the left or right of the abdomen, and that's an indication that the mother needs to be straight cath.

• Lochia is a combination of blood, mucus, and debris from birth, over the course of the twenty-one days postpartum.

Types of Lochia

• Lochia Rubra: This occurs from zero to seventy two hours following birth, and it's mainly blood. It's gonna be a little heavier than period blood.

• Lochia Serosa: Is just leftover junk from the birth, and it's gonna be lighter, pinkish in discharge.

• Lochia Alba: Is when the site where the placenta was attached to the wall of the uterus has completely healed over, and so there's no bright red bleeding.

Postpartum Hemorrhage

• Early postpartum hemorrhage can happen anytime after that placenta has been delivered.

Causes of Early Postpartum Hemmorrhage

• Early postpartum hemorrhage is commonly caused by uterine atony or basically loss of muscle tone in the uterus.

• Lacerations or tears of the reproductive tract can also lead to post partum hemmorhage.

Causes of Late Postpartum Hemmorrhage

• Retained placental fragments that are still stuck to the wall of the uterus is a common cause of late postpartum hemmorhage.

• A mom where, she's had, like, three to four, pregnancies that she's delivered at term and, a big baby and so their uterus just doesn't go all the way back down within those weeks postpartum, and that leads to that site where the placenta was to start bleeding again.

The Four T's of Postpartum Hemmorhage

• Toned: Toned, so we're gonna check her fundus frequently.

• Lacerations or tears of the reproductive tract.

Treatment of Postpartum Hemorrhage

• Massage and give medications. With lacerations and hematoma, the mom's gonna be taken to the OR to repair and extract any blood.

• Check the muscle tone in the uterus.

Postpartum Hemorrhage Drugs

• Oxytocin: hormone that your body makes to put you into labor that can be given IV or I'm.

• Methergine: An ergot that contracts the arterial bed, and it can only be given I'm or PO.

• Cytotec: This, the only thing with with that is that both Cytotec and methadone can cause some wicked cramping.

• Hemabate or CarboHost: That particular drug can't be given to a mom that has asthma.

Newborn Assessment

• There are seven systems of the body. We're just looking for different things in the baby.

Neurologic Assessment

• rooting by stroking your cheek.

• put my thumb in my mouth for sucking.

• palmar grasp.

• marrow reflex, if I leave my thumb in the hands and pull the arms out to the side.

• Also sole of the baby's foot.

Newborn Hypoglycemia

• Any baby born of a mother with gestational diabetes, any baby born of a mom with a complication like preeclampsia or any other medical complication is at risk for hypoglycemia, not hyperglycemia.

Signs of Hypoglycemia at Birth

• check a heel stick if we suspect that the baby could be at risk for this every hour for the three hours postpartum and that if the blood sugar drops below 44 milligrams per deciliter in the newborn, the baby needs to be fed.

Symptoms of Hypoglycemia

Hypo Symptoms:

• A flaccid baby with poor muscle tone.

• difficulty breathing.

• Their temperature is gonna be lower than normal.

• They won't eat well, so they'll have a poor suck, and they're lethargic.

Hyper Symptoms:

• baby's gonna be jittery.

• they're gonna be sweating because they're basically trying to increase their metabolic rate, and they're gonna have a high pitched cry.

The Apgar Score

Is based on doing what is needed with assessing vital signs, the categories for babies are:

*Cardiac

• Respiratory

• Neuro.

Newborn Anomalies

• Hydrocephalus: when the two ventricles in the brain are filling up with water. So if there is a problem in the overmanufacturing of that fluid, what's gonna happen is the baby's anterior fontanel is gonna bulge.
  the Cleft lip: musculoskeletal.

• Cleft Palate: Means that there's a separation in the hard palate of the roof of the mouth.

Down Syndrome

• Chromosomal problem.

• Low alpha fetal protein tells what the baby will have.

Five assessments or symptoms: of all, their eyes are are
close together, and that's because the bridge of their nose is flat, so the eyes really appear as if they're close together. *One finger, the the *little finger, is substantially shorter than, the next finger.

• They will also have, like, a a short neck and their feet.
  The large toe and the toe next to that will also be unusually separated apart.

Inborn errors of metabolism

• Basically defects of the baby.

PKU

• Phenylketonuria, is an excess buildup of the amino acid phenylalanine. And, essentially, we need to keep that within two to ten milligrams per deciliter.

Maple Syrup

• L I v, to identify the three amino acids, leucine, isoleucine, and valine.

Hemolytic

Disease of the Newborn

• ABO incompatibility.
  This is true, Then After birth, then what you're going to see that indicates that this is going on is that the baby is jaundiced.

Pediatrics

• Vital signs, like adults will be what to see in school aged kids.

• Play: What's needed for the kind of age.

Prenatal:

• Preeclampsia.
  Terbutaline

Labor Induction Medications.

Pain Medications.

Meds For Newborn.