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Pregnancy, Labor & Delivery, Postpartum & Newborn Care

Pregnancy Periods

  • First trimester: Week 1–12

  • Second trimester: Week 13–27

  • Third trimester: Week 28–40 (extending to delivery)

OBGYN Risks Associated with Pregnancy

  • Gestational diabetes

  • Hypertension/preeclampsia

  • Infection (e.g., TORCH, Group B Streptococcus (GBS))

  • Preterm labor

  • Hemorrhage (antepartum/postpartum)

  • Fetal growth restriction or anomalies

  • Multiple gestation risks (e.g., twins, triplets)

  • Venous thromboembolism (VTE)

Presumptive, Probable, and Positive Signs of Pregnancy

  • Presumptive (Subjective; felt by the patient):

    • Amenorrhea (absence of menstruation)

    • Nausea/vomiting (morning sickness)

    • Breast tenderness

    • Urinary frequency

    • Fatigue

    • Quickening (fetal movement felt by the mother, typically around weeks 16–20 for primigravidas and weeks 13–16 for multigravidas)

  • Probable (Objective; observed by the examiner):

    • Enlarged uterus

    • Hegar’s sign: Softening of the lower uterine segment

    • Goodell’s sign: Softening of the cervix

    • Chadwick’s sign: Bluish discoloration of the cervix and vaginal mucosa due to increased vascularity

    • Positive pregnancy test (detects human chorionic gonadotropin, hCG)

    • Uterine enlargement

  • Positive (Definitive, Diagnostic):

    • Fetal heart tones heard via Doppler or fetoscope

    • Ultrasound visualization of a fetus or gestational sac

    • Fetal movement palpated directly by the healthcare provider

Expected Findings, Assessments, and Labs During Pregnancy

  • First Trimester (Weeks 1–12):

    • Baseline labs: Complete Blood Count (CBC), blood type & screen (for Rh factor and antibodies), HIV, Hepatitis B, Rubella titer (to check immunity), Syphilis screening (RPR/VDRL).

    • Urine tests: For protein (indicating potential preeclampsia) and glucose (indicating gestational diabetes).

    • Dating ultrasound: To confirm gestational age and estimated due date.

    • Nausea/vomiting is common due to hormonal changes.

  • Second Trimester (Weeks 13–27):

    • Fundal height: Typically corresponds to weeks of gestation (e.g., 24 cm roughly equals 24 weeks) after approximately 20 weeks.

    • Anatomy scan: A detailed ultrasound performed between weeks 18–22 to assess fetal development and screen for anomalies.

    • Fetal heart tones checked at each prenatal visit.

    • Glucose tolerance testing: Performed between weeks 24–28 to screen for gestational diabetes.

  • Third Trimester (Weeks 28–40):

    • More frequent prenatal visits.

    • Group B Strep (GBS) screening: Vaginal and rectal swab performed between weeks 35–36 to screen for GBS colonization, which can be transmitted to the newborn during delivery.

    • RhoGAM administration: At 28 weeks if the mother is Rh-negative and not sensitized, to prevent isoimmunization.

    • Fetal movement monitoring (e.g., kick counts) by the mother.

    • Labor education and preparation for childbirth.

Fundal Measurement vs. Weeks of Gestation

  • Fundal height, measured in centimeters from the pubic symphysis to the top of the fundus, approximately equals gestational age in weeks (with a variation of \pm2 cm).

    • Example: A fundal height of 24 cm suggests approximately 24 weeks of gestation.

  • If the measurement is significantly off (greater than \pm2 cm), it may indicate potential complications such as:

    • Fetal growth restriction (smaller than expected)

    • Oligohydramnios (low amniotic fluid volume)

    • Polyhydramnios (excess amniotic fluid volume)

    • Macrosomia (larger than expected fetus)

Pregnancy & Prenatal Care Practices – Patient Teaching

  • Hot tubs/saunas: Avoid prolonged use. Elevated maternal core temperature can increase the risk of neural tube defects and maternal hypotension.

  • Douching: Avoid. It disrupts the natural vaginal flora, increasing the risk of infection and preterm labor.

  • Exercise: Continue if active before pregnancy. Avoid supine positions after 20 weeks (due to vena cava compression), high-risk activities (e.g., contact sports), and dehydration. Walking, swimming, and yoga are generally encouraged.

  • Working: Safe unless involving heavy lifting, prolonged standing, or chemical exposure. Monitor for fatigue, ensure adequate hydration, and take regular breaks.

  • Sexual activity: Generally safe unless contraindicated (e.g., placenta previa, risk of preterm labor, rupture of membranes).

  • Seat belt use: Wear the lap belt under the belly, across the hips. Position the shoulder belt between the breasts.

  • Immunizations: Avoid live vaccines (e.g., Measles, Mumps, Rubella (MMR); Varicella). Inactivated flu shot and Tdap (Tetanus, diphtheria, acellular pertussis) vaccine (given between weeks 27–36) are recommended.

  • Over-the-counter (OTC) drugs: Many are contraindicated. Acetaminophen is generally preferred for pain relief. Avoid NSAIDs (e.g., ibuprofen, naproxen) unless specifically ordered by a provider, especially in the third trimester.

  • Tobacco: Contraindicated. Increases risks of fetal growth restriction, placental abruption, and Sudden Infant Death Syndrome (SIDS).

  • Alcohol: Contraindicated. Increases the risk of Fetal Alcohol Spectrum Disorders (FASD).

  • Illegal drugs: Contraindicated. Risks include fetal growth restriction, placental abruption, and neonatal abstinence syndrome (NAS).

Folic Acid

  • Importance: Prevents neural tube defects (e.g., spina bifida, anencephaly), which are serious congenital abnormalities of the brain and spinal cord.

  • Recommendation: 400–800 mcg (micrograms) daily before conception and throughout early pregnancy.

  • Sources: Leafy green vegetables (e.g., spinach, kale), fortified cereals and bread, citrus fruits, beans, liver.

Managing Nausea/Vomiting (Morning Sickness)

  • Eat small, frequent meals throughout the day.

  • Consume dry crackers or toast before rising in the morning.

  • Avoid greasy or spicy foods.

  • Stay well-hydrated.

  • Consider natural remedies like ginger, peppermint, or lemon.

  • If iron in prenatal vitamins causes nausea, take the vitamin at night.

Fetal Circulation

  • Key Shunts for bypassing non-functional organs:

    • Foramen ovale: An opening between the right and left atria, allowing blood to bypass the pulmonary circulation (lungs).

    • Ductus arteriosus: A vessel connecting the pulmonary artery to the aorta, also shunting blood away from the lungs.

    • Ductus venosus: A shunt connecting the umbilical vein to the inferior vena cava (IVC), allowing oxygenated blood to bypass the fetal liver.

  • Closure at birth: When the baby takes its first breaths, pulmonary resistance decreases, and left heart pressure increases. This leads to functional closure of the foramen ovale and ductus arteriosus within 24–48 hours, and eventual anatomical closure.

  • Oxygenation: Occurs in the placenta, not the fetal lungs.

  • Umbilical cord: Contains 3 vessels: 2 umbilical arteries (carrying deoxygenated blood and waste products away from the fetus to the placenta) and 1 umbilical vein (carrying oxygenated, nutrient-rich blood from the placenta to the fetus).

  • Flow summary: Umbilical vein carries O\text{_2} blood to the fetus; umbilical arteries carry deoxygenated blood to the placenta.

Labor & Delivery (L&D) Drugs

  • Oxytocin (Pitocin):

    • Action: Stimulates uterine contractions; used for labor induction/augmentation and to control postpartum hemorrhage.

    • Adverse effects: Uterine tachysystole (excessive contractions), fetal distress (due to reduced oxygenation), water intoxication (due to antidiuretic effect).

    • Nursing considerations: Continuous fetal heart rate (FHR) and uterine contraction monitoring.

  • Cervadil (dinoprostone):

    • Action: Prostaglandin used for cervical ripening (softening and thinning of the cervix) as a prelude to labor induction.

    • Adverse effects: Uterine tachysystole.

    • Nursing considerations: Monitor contractions; remove the vaginal insert if hyperstimulation occurs.

  • Cytotec (misoprostol):

    • Action: Prostaglandin for cervical ripening and labor induction (off-label use).

    • Adverse effects: Uterine hyperstimulation, increased risk of uterine rupture (especially in women with previous uterine surgeries).

  • Magnesium Sulfate:

    • Action: Prevents and treats seizures in women with preeclampsia/eclampsia; also provides neuroprotection for the fetus in preterm labor.

    • Adverse effects: Respiratory depression, diminished deep tendon reflexes (DTRs), hypotension, flushing, lethargy.

    • Nursing considerations: Monitor respiratory rate, DTRs, urine output (risk of toxicity if renal function is impaired); keep calcium gluconate readily available as the antidote.

    • Toxicity signs: Respiratory rate less than 12 breaths/min, absence of DTRs, urine output less than 30 mL/hr.

  • Epidural Anesthesia:

    • Action: Provides pain relief for labor and delivery by blocking nerve impulses in the epidural space.

    • Adverse effects: Maternal hypotension (most common), limited mobility, urinary retention, fever.

    • Nursing considerations: Pre-load with intravenous fluids (e.g., 500–1000 mL of crystalloid) to counteract hypotension; continuously monitor maternal blood pressure and FHR.

  • Spinal Anesthesia:

    • Action: Provides rapid and complete pain relief with a single dose injected into the subarachnoid space, primarily used for cesarean sections.

    • Adverse effects: Maternal hypotension, spinal headache (post-dural puncture headache) due to CSF leakage.

    • Nursing considerations: Monitor blood pressure closely; pre-load with intravenous fluids.

Definitions Related to Labor and Delivery

  • Dilation: The opening of the cervix, measured from 0 to 10 cm.

  • Effacement: The thinning and shortening of the cervix, expressed as a percentage from 0% to 100%.

  • Station: Describes the descent of the fetal head in relation to the maternal ischial spines, measured in centimeters from -3 (above the ischial spines) to +3 (below the ischial spines). 0 station means the fetal head is engaged at the level of the ischial spines.

  • ROM (Rupture of Membranes):

    • SROM: Spontaneous rupture of membranes (water breaks naturally).

    • AROM: Artificial rupture of membranes (amniotomy, performed by a healthcare provider).

  • Mucous Plug: A protective barrier of mucus that seals the cervical canal during pregnancy. It is often expelled before labor begins, sometimes referred to as 'bloody show'.

  • Fetal Lie: The relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother (longitudinal, transverse, or oblique).

  • Fetal Presentation: The part of the fetus that enters the maternal pelvis first.

    • Cephalic: Head-first (most favorable).

    • Breech: Buttocks or feet first.

    • Shoulder: Shoulder first.

Most Favorable Presentation/Position for Vaginal Delivery

  • Cephalic (head-first), vertex (head flexed, occiput presenting), occiput anterior (OA) position is ideal. In this position, the occiput (back of the baby's head) is anterior (towards the mother's abdomen), allowing the smallest diameter of the fetal head to pass through the pelvis.

Stages of Labor

  • Stage I – Dilation:

    • Duration: From the onset of true labor contractions until full cervical dilation (10 cm).

    • Characteristics: This is the longest stage of labor.

    • Phases:

      • Latent Phase: Cervical dilation from 0–3 cm. Contractions are mild, and the mother is often talkative and excited.

      • Active Phase: Cervical dilation from 4–7 cm. Contractions become stronger, more frequent, and longer in duration. The mother becomes more focused and serious.

      • Transition Phase: Cervical dilation from 8–10 cm. Contractions are very strong, intense, and close together. The mother may experience nausea/vomiting, shivering, and an urge to push.

  • Stage II – Expulsion:

    • Duration: From full cervical dilation (10 cm) until the delivery of the baby.

    • Characteristics: The mother actively pushes with contractions. The