Transcript PRENATAL CARE, LABOR AND DELIVERY!!!

Pregnancy & Prenatal Care
Jennifer McDonald DO
What is the purpose of prenatal
care?
WHEN SHOULD PRENATAL
CARE START?
History
Routine prenatal care relatively new
1900 the nurses of the instructive nursing
association in Boston began making house
calls to pregnant mothers
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Noticed that complications were
decreased. Ultimately practice adopted
by physicians
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IDEALLY, a woman planning to
have a child should have a
medical evaluation before she
becomes pregnant
The majority of pregnancies are unintended
making pre-conceptual care challenging
25% of pregnancies worldwide will end in a
termination
Why don’t women seek prenatal care?
Always Terminology
Embryo (Greek “swelling within”)
Fertilization thru 8 weeks
Fetus (Latin “Offspring”)
Beyond 8 weeks through delivery
Neonatal period = birth until 28
days of life
Terminology
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Premature infant < 37 weeks gestation
Post-mature infant > 42 weeks gestation
Low birth weight < 2500 grams at birth
Macrosomic infant > 4500 grams at birth
Spontaneous Abortion = expulsion of an
infant prior to 20 weeks of gestation
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Viability = 23-24 weeks gestation
Gravity & Parity
Gravity = Total number of pregnancies
Parity = Outcome of pregnancies
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Sometimes expressed as 4 digits
Full term deliveries
Preterm deliveries
Abortions (spontaneous or elective)
Living children
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A multiple birth is a single parous
experience
Numbers Game
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Nulligravid = never been pregnant
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Primigravid = first pregnancy
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Multigravid = achieved previous
pregnancies
Duration of Pregnancy
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Calculated from the first day of the
last menstrual period (LMP)
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Average 280 days (40 weeks)
Numbers Game
Naegele’s Rule
EDC = LMP - 3 months + 7 days
Example LMP 5/21 is due ??
Diagnosis of Pregnancy
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Presumptive Signs
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Probable Signs
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Positive Signs
Presumptive
Secondary amenorrhea
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Nausea & vomiting
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Breast changes
Skin changes (cholasma/linea nigra)
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Urinary frequency
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Fatigue
Quickening (first perception of fetal
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movement)
Probable Signs
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Abdominal enlargement – uterus rises out of the
pelvis at 12 weeks
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Braxton Hicks contractions
Uterine souffle – rushing of maternal blood in
placenta
Goodell’s sign – softening of cervix 6-8 weeks
Chadwick’s sign – bluish hue to cervix after 6
weeks
Fetal movement – felt 18 to 20 weeks, earlier in
multigravidas (14-16 weeks)
Positive Signs
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Fetal heart tones heard
Identifiable with doppler after 10 weeks
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Fetus identified on ultrasound
Palpation of the fetus (22 weeks)
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Positive hCG
Now able to be identified up to 4 days
before missed period
Estimating Gestational Age
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Uterus palpable at pubic symphysis at 8
weeks
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Rises out of pelvis at 12 weeks
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Mid to umbilicus at 15 weeks
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At umbilicus at 20 weeks
Fundal height correlates with gestational
age from 26-34 weeks
Fundal Height
Measured from pubic
symphysis to uterine fundus
Should measure +/- 2 cm
compared to weeks
gestation
Ultrasound Early Landmarks
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5 weeks
6 weeks
7 weeks
8 weeks
Chorionic sac; yolk sac
Yolk sac/embryo; cardiac activity
Embryonal movement
Extremities visible
Measurement < 12 weeks = crown rump length
hCG Levels
GS = 1000-1200
Yolk sac = 7200
Embryo/cardiac activity = 10,800
Fetal loss rate after finding cardiac activity is 5%
Ultrasound - Accuracy
5 to 6 weeks
+/- 4 days
7 to 11 weeks
+/- 5 days
12 to 16 weeks
+/- 7 days
17 to 26 weeks
+/- 10 days
27-28 weeks
+/- 2 weeks
29-40 weeks
+/- 3 weeks
Ultrasound
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After 12 weeks
Head circumference
Biparietal diameter
Femur length
Abdominal circumference
The First Visit
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Present pregnancy
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Establish dating
Previous pregnancy history
Complications, routes of delivery, etc.
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Medical/Social history
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Surgical history
Previous gyn surgery very important
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Family history
Teratogens
Cigarette Smoking
Only 20% of patients quit during
pregnancy
Low birth weight, increased risk of fetal
death, placental abruption, placenta previa
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Alcohol Exposure
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Alcohol crosses easily across the placenta
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One of leading causes of mental
retardation
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Facial abnormalities
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Cardiovascular defects
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CNS dysfunction
Fetal Alcohol Syndrome
(1) CNS dysfunction
low intelligence
microcephaly
behavioral abnormalities
(2) Growth restriction
(3) Facial anomalies
(4) Congenital heart defects
Daily ETOH not as important as max
concentration at critical periods
FAS
3rd leading cause of birth defects
Significant Maternal Disorders
Seizure disorders
Pre-gestational diabetes
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Cardiac disease
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Psychiatric disorders
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Thyroid disease
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Initial Routine Lab Evaluation
CBC
Blood type & antibody screen
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Rubella
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Hepatitis B
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RPR (serologic test for syphilis)
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HIV (not mandatory)
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Urinanalysis
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Genetic Screening
Advanced maternal age > 35 years old
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Cystic fibrosis screening
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Sickle cell screening
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Hemoglobinopathies
TaySachs Ashkenazi Jewish (1 in 27 carriers)
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Baseline risk of major congential malformations is 3.4%
Baseline risk for genetic disorders is 0.5%
Prenatal Diagnosis
Chorionic villous
sampling (CVS)
Amniocentesis
Frequency of Visits
Monthly until 30 weeks
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30-36 weeks  every 2 weeks
36 weeks to delivery  every week
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Every visit:
Weight/blood pressure
Urine dip: protein/glucose
Fetal heart tones/fundal height
Labor symptoms/Hypertension
symptoms
Other Testing
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Routine screening GC/chlamydia
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Pap smear
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Glucose challenge test
28 weeks
50 gram load/Not fasting/1 hour > 135 indicates
need for 3 hour test
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Group B Strep
(36 weeks)
Glucose Challenge Test
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Used for diagnosis when screening
test (1 hour) abnormal
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Overnight fast/100 gram load
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Two or more abnormal values
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Fasting > 95 mg/dL
1 hour > 180 mg/dL
2 hour > 155 mg/dL
3 hour > 140 mg/dL
Rubella
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Infection can be communicated 7 days before and
4 days after rash appears
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If develops will be 2-3 weeks after exposure
Rate of infection depends on trimester
< 11 weeks = 90% chance congenital infection
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11-12 weeks = 33%
13-14 weeks = 24%
15-16 weeks = 11%
>16 weeks = Less than 1%
Vaccinations in Pregnancy
Contraindicated
measles
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mumps
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rubella
yellow fever
Case Dependent
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polio
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influenza
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rabies
hepatitis A/B
pnuemococcal
tetanus toxoid
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HIV Testing
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AZT in pregnancy and labor decreases
transmission from 25% to 8%
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Scheduled C-section (before onset of labor)
decreases transmission to 2%
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IV AZT 3 hours prior to c-section
Avoid amniocentesis or other invasive procedures
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Viral load at baseline and every 3 months
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Breast feeding contraindicated
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ACOG recommends testing for all
pregnant women
Group B Streptococcus
Leading cause of life threatening perinatal
infection
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15-30% women asymptomatic carriers
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Early onset (80% within 6 hours of delivery)
carries 6% chance neonatal mortality
GBS bacturia on initial urinanalysis implies heavy
bacterial load
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Routine screening perfomed 34-36 weeks
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Prophylaxis at delivery if positive
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Quad Screen
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Screening for Down’s, neural tube defects,
Trisomy 18
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16-20 weeks
AFP
Estriol
hCG
Inhibin A
Detection with
ultrasound
Trisomy 21
Decreased
Decreased
Increased
Increased
Trisomy 18
Decreased
Decreased
Decreased
Increased
NTD
Increased
60-70%
60%
75-80%