OB Exam 1 notes
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CNM
o Can independently care for low risk patients
o Prenatal and post-natal care
o Does not need to consult with physician but should have one available in the case that they need one
Doula
o NO MEDICAL TRAINING OR CERTIFICATION
o Do not release any patient info to doula
Hospital admission
o Vaginal birth-48 hours
o C-section- 96 hours
Prenatal care
o Number one reason for lack of care are financial barriers
o Offered to lessen anxiety
o Lamaze breathing
o Hypnobirthing
Infertility
o Primary- cannot conceive first child
o Secondary- cannot conceive second or third child
o Men are 40% of the reason for infertility
Semen analysis
o Do not ejaculate for 1-2 days prior to obtaining specimen
o Easier to test men than women, less invasive
Estrogen
o Cause for hyperpigmentation
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Linea nigra, chloasma
o Can cause stuffy nose, epistaxis and nasal congestion
o Encourage humidifiers
o Highest levels before ovulation
o Prepares breasts for lactation
Progesterone
o Peaks during secretory phase
o Causes relaxation throughout the body
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Can increase risk of UTI and yeast infections
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Inhibits uterine contractions
o Decreases GI motility and slows digestion
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Encourage fluids, mobility, fiber miralax may be used as last resort
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Monitor for hemorrhoids
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Sitz bath
o Pregnancy hormone
o Necessary for maintaining pregnancy
o Raises basal metabolic rate
o Causes the cervix to secrete thick mucus to create
mucous plug
o Plays a role in endometrial proliferation
o Decreased blood pressure
HCG
o Hormone looked for on pregnancy test
o Highest during secretory phase
o Keeps corpus luteum open
o Causes N/V, hemmroids, relux and heartburn
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Avoid straining
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Antacids can be taken but limited
amount
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Encourage small frequent meals
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HPL (human placental lactogen)
o Insulin antagonist
o Mother becomes resistant to her own insulin
o Test for gestational diabetes
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Relaxin
o Causes relaxation of tendons, ligaments and joints of pelvis
o Caution exercising/lifting --- get out of car slowly
Ovulation
o Basal body temp should be raised 0.5-1.0 degrees Fahrenheit
o Thin, clear and watery cervical mucous to increase sperm mobility
o Mittleshmerz
Degeneration of corpus luteum
o Occurs during the ischemic phase (days 27/28)
o Hcg will keep corpus luteum open if an ovum is fertilized
o Scar tissue will grow over this
o Maintains pregnancy until placenta can take over (8 weeks)
Negative feedback
o When estrogen and progesterone are high there will be no ovulation
o The production of LH and FSH are interrupted when an egg has been fertilized
Spotting can occur in ischemic phase
Fertilization
o Occurs in the fallopian tubes
Fertile window
o 2 days before and 24 hours after ovulation
o Sperm can live for 48-72 hours
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Only healthy for 24
Implantation
o Occurs in the upper anterior portion of the uterus
o Occurs 7-10 days after fertilization
Important gestational milestones
FIRST TRIMESTER
o Week 3
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brain, spinal cord and heart develop (Big 3)
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GI tract develops
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Leg and arm buds appear
o Week 4
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Heart beat at 28 days
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Heart begins to pump blood
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Heart beat can be seen on ultrasound but NOT HEARD
o Week 6
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Liver produces RBC’s
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Brain waves are detectable
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Lungs begin to develop
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Circulation is established
o Week 8
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Baby resembles a human
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Heart development is complete
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Circulation through umbilicus is established
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First ultrasound to verify pregnancy and pregnancy location
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Blood typing is done here
o Weeks 9-12
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Fetal heartbeat can be heard on ultrasound at week 12
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Genitals are well formed but cannot be picked up on ultrasound
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GU tract complete, kidneys re producing urine
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Eyelids are closed
o Weeks 13-16
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Beginning of second trimester
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Gender reveal is done (16 weeks)
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Quickening is felt (if this isn’t first pregnancy)
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Lanugo is developed, skin is still transparent
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Identifiable skeleton ossification
o Weeks 21-24
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Surfactant production starts
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Blood is shunted away from lungs because baby does not need to use them right now
o Weeks 25-28
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Baby assumes head down position
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Brain development continues
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Fetus can respond to light and sound
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Eyelids open and close
o Weeks 29-32
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Start of third trimester
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Rhythmic breathing and partial temperature control
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Fetus stores Pb, Ca, and Ph
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Lungs are not fully mature yet
o Weeks 33 and on
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Fetus has routine for eating and sleeping
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Fetus receives antibodies from mom
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Assumes head down positions
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Baby gains weight
Fetal circulation
o AVA
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Two arteries carrying waste away from baby
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One vein carrying blood/oxygen/nutrients to baby
3 adaptations
o Ductus venosus
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Found at liver and umbilical vein
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Shunts oxygenated blood to inferior vena cava
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Liver is not fully functional yet
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Most blood is shunted AWAY from the liver to IVC
o Foramen ovale
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Found in right atrium
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Oxygenated blood will be shunted through foramen ovale to the left atrium
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Blood from left atrium enters left ventricle to the aorta
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Foramen ovale useful for shunting oxygenated blood back to the rest of the body (avoiding the
lungs)
o Ductus arteriosus
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A mix of both oxygenated and deoxygenated blood are shunted through pulmonary artery to the
umbilical arteries
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From here blood will leave baby and go back to placenta so mom can clear waste and resupply it
with fresh O2 and nutrients
Diagnostic testing/ Screening
o CVS
Offered at 10-14 weeks
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Does not test for neural tube defects
o MSAFP
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Offered at 15-20 weeks
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Only test that screens for neural tube defects
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NOT DIAGNOSTIC – risk for false negatives and positives
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If results are abnormal, follow up with amniocentesis or ultrasound
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Low results are linked to down syndrome (trisomy 21)
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High levels are linked to neural tube defects
o Quad screen
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Offered at 15-20 weeks
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Tests for MSAF, estradiol, HCG and inhibin A
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Diagnostic
o Amniocentesis
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Offered at 15-20 weeks
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Tests amniotic fluid
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Diagnostic
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Mother must receive rho-gam after procedure
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Report fever, chills or any leakage
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At risk for termination of pregnancy
o Percutaneous umbilical blood sampling (PUBS)
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Done <16 weeks (as early as 11 weeks)
o Fetal kick counts
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Done after 28 weeks
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Report decreased or absent movement
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Baby can be sleeping – time specific
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If baby is sleeping, drink OJ to wake them up
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Maternal perception of movement may vary
o Contraction stress test
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Done in the third trimester
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Have tocolytic medication available to reverse contractions
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Contraindicated
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History of preterm labor
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PROM
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Placenta previa
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Unexplained vaginal bleeding
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Multifetal pregnancy
o Non stress test
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Increase FHR with fetal movement indicates adequate oxygen
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High false positives related to sleep cycle
o Nuchal translucency
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Measures thickness of fluid at the back of fetal neck
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Increased fluid is associated with abnormalities
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Offered between 11-13 weeks
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Any abnormalities do not immediately mean abortion- mothers right to choose
Scheduled Testing
o Ultrasound-- 10-20 weeks
o Cell free DNA-- earliest is 10 weeks
o CVS—10-14 weeks
o PUBS--- as early as 11 weeks
o MSAFP--- 15-20 weeks
o Quad screen --- 15-20 weeks
o Amniocentesis--- 15-20 weeks
o Glucose tolerance --- 24-28 weeks (>35 requires additional
testing)
o Fetal kick counts--- 28 weeks and on
o Antibody screening and RhoGam--- 28 weeks
o CBC and STD screen--- 28 weeks
o GBS- 35-37 weeks
Immunizations
o Can receive most immunizations
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Avoid MMR and varicella vaccine
o Tdap is recommended
Presumptive indicators of pregnancy
o Amenorrhea
o Nausea, vomiting
o Urinary frequency
o Quickening
o Fatigue
o Montgomery glands/ breast changes
Probable indicators of pregnancy
o Chadwick’s sign
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Purplish/bluish color of the cervix due to increase vascularity
o Goodells sign
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Cervix will feel mushy during digital exam
o Ballottement
o Hegar’s sign
o Enlargement of uterus
o Pregnancy test
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Not diagnostic because other factors can contribute to a false positive
o Braxton hicks
Positive indicators of pregnancy
o Ultrasound
o Fetal heart beat
o Skilled physician feels movement (20-22 weeks)
Abdomen
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Gallstones can occur due to delayed emptying
Kidneys enlarge due to increased blood volume
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Urinary frequency and increased GFR should be seen
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If decreased, suspect a UTI
o Any abdominal pain during pregnancy is NOT normal
o Diastisis Rectii is measured in finger breaths
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Measures how far muscle has separated
o Linea nigra and striae are normal
o Uterus becomes and abdominal organ at 12 weeks
Fundal height
o Can only be measured between 20-32 weeks when determining gestational age
o Measured in cm
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From symphysis pubis to top of uterus
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Number of cm is accurate plus or minus two
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Size will be greater than gestational age in multifetal pregnancies
Vagina and vulva
o Leukorrhea is normal
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Increased secretion of thick, white acidic mucous
o Acidic environment increase risk for yeast infections
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Very common in pregnancy, but only treated if mother states it bothers her
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Miconazole
o Avoid douching
Breasts
o Montgomery glands
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Teach not to pop
o Increased mammary vascularization
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Veins can be seen through skin
o Colostrum
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Sticky, white-yellow
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Can be produced before baby is born
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Filled with antibodies and nutrients
o Women can start pumping right after birth if baby is in NICU
o People with inverted breasts CAN breast feed
Pre-eclampsia
o Creeping blood pressure, epigastric pain, edema in hands and face, one sided headaches, migraines and visual
disturbances should all be reported to the provider
o Blood pressure should not raise during pregnancy
Cardiovascular system
o C/O and HR will increase due to the increase in blood volume
o Blood pressure should decrease
o Stroke volume will increase
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HR will increase 15-20 BPM. Peaks at 28-32 weeks
o Palpitations are not normal
Maternal hypotension
o Lightheaded, dizziness, pallor, clamminess occurs when lying flat on back
o Teach to lay on left side or semi fowlers with knees slightly flexed
o Caused by pressure being placed on inferior vena cava
o Encourage use of pillows when sleeping
o Not an emergency
o Orthostatic hypotension is normal
Blood components
o Size of RBC’s will increase causing blood volume to increase
o Increased need for iron because baby will store its own
o CBC is obtained on first visit, a small drop in HGB and HCT is anticipated, obtained again after 28 weeks
Physiologic anemia
o Because plasma volume increases more than the size of RBC’s HGB and HCT will decrease
Blood clots and DVT’s
o Increased risk due to the rise in plasma fibrinogen and fibrin levels
o Hypercoagulable state
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Teach to avoid sitting for long periods of times
o Dependent edema may occur
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Swelling in feet
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Teach to elevate feet
Avoid coumadin if pregnant
Iron
o Take with vitamin C
o Avoid taking with milk, antacids and caffeine
o If stomach ache occurs- take at night
Promote dental hygiene
o Poor dental hygiene has been linked to preterm labor
o Encourage dental visits
o Soft tooth brush
Bladder
o Main concern is pyelonephritis
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Patient can become septic
o Pressure on bladder is caused by baby placing pressure on uterus/bladder
Average weight gain
o 25-35 pounds if normal BMI
o 28-40 if underweight
o 15-25 if overweight
o Weight gain should increase gradually
Skin changes
o Telangiectasias
o Linea Nigra
o Chloasma
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Facial pigment change
o Palmar erythema
o Hyperpigmentation
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Cocoa butter only helps top layer
Education for musculo-skeletal system
o Encourage comfy shoes
o PT tape or sports tap e
o Support weight (belly band)
Muscle cramps
o Increase magnesium and potassium
o Dorsiflex foot
o Massage
Lessening anxiety
o Prenatal classes
o Birth plan- specific for pain tolerance
o Nutrition
Folic acid and prenatal vitamins
o Normal dose for folic acid is 0.4mg – 400mcg
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Folic acid is necessary to prevent neural tube defects
o Continue taking prenatal if breast feeding
o If prenatal cannot be tolerated
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Recommend taking at night
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Take folic acid instead
Initial office visit
o H&P
o Risk assessment – assessed at every visit
o Nutrition assessment
o Verify pregnancy
o Calculate EDD
o Negotiate plan of care
o Lab testing
o Ultrasound or CRL
Nageles rule
o How to calculate EDD
o Subtract 3 months and add 7 days
Prenatal education
o Sex- yes
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Travel – yes unless you are term
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If driving, stop to ambulate frequently
o Hot tubs/ saunas- no
o Douching- no
o Immunizaitons
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Promote the flu and Tdap vaccine
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Discourage MMR and varicella (live vaccines)
Check-up schedule
o Q4 weeks until 28 weeks
o Q2 weeks until 36 weeks
o Q1 week until delivery
Teratogens
o Prescribed medication
o Illicit drugs
o Alcohol
o Caffeine
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Do not consume any more than 300mg/ day
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One cup is equivalent to 100 mg
o Tobacco/cocaine
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Vasoconstrictors
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Leads to low birth weights
o Herbals
Category D medication
o Continue to take (ex: seizure meds)
o Benefits outweigh the risks
Diet
o Avoid foods high in mercury
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Shark, swordfish
o Avoid raw meats
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Sushi, deli meats unless steaming hot
o Tuna is okay in moderation. Light tuna is recommended
o NO more than 6oz of light tuna/ week
o Increase 300 calories/ day
o If patient does not like milk encourage green leafy veggies
o Promote tofu, eggs and beans for vegetarians
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No raw eggs
Listeriosis
o Unpasteurized milk and dairy products, meat and, poultry and seafood can be harmful
o NO hot dogs or deli meats unless fried/ cooked
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