Transcript Obstetrics Review

Obstetrics Review 2
Ana H. Corona, MSN, FNP-C
Nursing Instructor
November 2007
Diagnosis of Pregnancy
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Positive Signs of Pregnancy
identification of fetal heart action
separate from the mother's (normal:
120-160 BPM).
perception of active fetal movements by
the examiner (by palpation of the
abdomen).
recognition of the embryo or fetus
sonographically (may be detected after
only 5 weeks of amenorrhea).
Probable Evidence of Pregnancy
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Enlargement of the abdomen (by 12 weeks gestation, the
uterus can be felt through the abdominal wall just above
the symphysis).
changes in the size, shape, and consistency of the uterus
(uterus becomes softened or "doughy"), softening of the
isthmus between the still firm cervix and the softened
uterus (Hegar's Sign).
changes in the cervix (softening of the cervix at 6-8 weeks
gestation-can also occur with OCPs).
Braxton Hicks contractions (palpable but ordinarily
painless contractions at irregular intervals from early
stages of gestation).
ballottement (near midpregnancy, pressure on the uterus
will cause the fetus to sink in the amniotic fluid, and with
release of pressure, the rebound to its original position will
be felt as a tap).
outlining the fetus (in the second half of pregnancy).
Presumptive Evidence of Pregnancy
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results of endocrine tests (presence of hCG in matemal
plasma and its excretion in urine).
cessation of the menses (especially after predictable
menstruation).
changes in breasts (tenderness, tingling, increase in size).
discoloration of vaginal mucosa (dark bluish or purplishred and congested- Chadwick's Sign).
increased skin pigmentation and the appearance of
abdominal striae (can be absent during pregnancy or
present with the use of OCPs).
nausea with or without vomiting (appears usually at 6
weeks, lasting 6 to 12 weeks).
frequent micturation.
easy fatigueability.
sensation of fetal movement (16-20 weeks).
Initial Obstetric Visit
Identification of Risk Factors
 History and Physical Exam
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Assess general health and risk factors.
Attempt dating of pregnancy: Last menstrual period
(LMP) - accurate if verified by calendar or coincident
with holiday, etc.; reliable if no interfering factors
present (i.e., prior menstrual irregularity, oral
contraception).
Bimanual exam for uterine size and pelvic adequacy
(esp. diagonal conjugate).
Auscultation or doppler exam for FHT
General exam of all other systems.
Prematurity Risk Factors
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Age <18, low socioeconomic status, sexual
promiscuity, DES exposure, prior premature
delivery, 2 or more spontaneous abortions,
uterine anomalies or fibroids, thin patient or
poor weight gain, multiple gestation,
polyhydramnios, UTI/renal disease, acute
infections.
Placental Insufficiency Risk Factors
Post dates, previous stillbirth, intrauterine
growth retardation,
anemia/hemoglobinopathies, medical illness
(DM, HTN, thyroid disease, renal disease,
cardiac disease, collagen vascular disease)
Congenital Anomalies/Disease Risk
Factors
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Race (Asian, Jewish, Mediterranean,
Black)
Mother >34 yers of age
Advanced paternal age
Family history of congenital anomaly
Previous delivery of child with anomalies
Teratogen exposure
Infection exposure
Diabetes.
Clinical Criteria
LMP
 Bimanual exam in first trimester
 Doppler FHTs at 10-12 weeks
 Fetoscopic FHTs at 20 weeks
 Quickening (primiparous at 18-20 weeks and
multiparous at 17-19 weeks)
 Fundus reaches umbilicus at 20 weeks, after 20 weeks
fundal height in cm = weeks gestation.
Laboratory Measures
 The UPT in the lab can be positive within 5 days postconception.
Ultrasound
 Approximate accuracy: <10 weeks - 3-7 days, <20
weeks - 10 days, <30 weeks - 2 weeks, 30-40 weeks - 3
weeks.
 Best single scan for dates and anomalies is 16-18 weeks
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Routine Screening Tests
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CBC (r/o anemia).
Sickle cell prep (Black or Hispanic patients).
Urinalysis (r/o bacteriuria, proteinuria,
glycosuria).
VDRL/RPR (r/o syphilis).
Type, Rh, and antibody (r/o potential hemolytic
disease of the newborn. If Rh- and neg antibody
screen, repeat antibody screen at 28 weeks and
administer Rhogam if still neg. Administer
Rhogam for threatened abortions. If antibody
screen is positive, consult HR OB immediately. If
positive for any other antibodies except Anti I,
Anti Lewis A, and Anti Lewis B, refer to HR OB).
Lab tests continue
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Rubella titer (r/o need for post-partum vaccination).
PAP smear (inflammation - repeat PAP in 6-8 weeks and
treat possible etiology; other abnormalities - refer for
colposcopy).
Glucose screening (Patients at risk, i.e., age >25, family
history of DM, previous stillbirth, previous anomalous
child, previous child >4000 gm, obesity, HTN, glycosuria.
O'Sullivan abn if 1 hour glucose >140. Do at first prenatal
visit if very high risk; follow up at 26-28 weeks if normal.)
Triple Screen (should be done at 15-19 weeks; if patient
declines, a disclaimer should be signed.)
Hepatitis screening (r/o chronic hepatitis carriers).
Patient Education
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Avoidance of possible teratogens; i.e.,
cigarettes, ethanol, medication, illicit drugs,
radiation, work hazards.
Healthy diet and appropriate weight gain
(ideally 20#-28# total), prenatal vitamins.
Physiologic changes in pregnancy - quickening
should occur at 17-20 weeks.
Sexuality during pregnancy.
Warn of potential hazards that may require
immediate attention.
Schedule prenatal classes.
Follow-up Prenatal Care
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Frequency - monthly until 28 - 32
weeks (weekly from 17-20 weeks if
necessary for dating), then biweekly
until 36 weeks, then weekly.
Brief history
Parameters to follow each visit
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Weight (ideal - 20-28 pounds; think PIH for rapid
weight gain).
Blood pressure (Think PIH if B/P >140/90 or if
systolic increases >30 or diastolic increases >15
from first trimester B/Ps).
Urine protein (if >1+, think PIH; if no signs of
PIH, think UTI).
Fundal height (ultrasound if EGA <36 weeks and
size > or < dates by 3 cm, fundal height not
increasing over a 2-week period, or fundal height
increases by more than 3 cm in 1 week).
Fetal heart tones (120-160).
Fetal presentation (after 32 weeks).
Parameters to follow: continue
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New problems/patient complaints.
Repeat Rh antibody screen and titer on Rh
negative mothers following any episode of
supracervical vaginal bleeding or abdominal
trauma, and at least once during second trimester
and twice during third trimester. Rh negative
mothers should receive Rhogam at 28-32 weeks.
Repeat pelvic exam at 36-38 weeks and as
indicated.
Encourage preparation for breast feeding of
infant.
Explain false labor and onset of labor (i.e., when
to come to the hospital).
Schedule parenting classes.
Previous Cesarean Section
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Previous Cesarean Section (C/S)
1. Eligible for vaginal trial (Vaginal Birth After
Cesarean - VBAC): Candidates with two or
fewer low transverse C/S or undocumented
scar in a patient who underwent an
uncomplicated term vertex C/S for failure to
progress.
2. Ineligible for vaginal trial are refer to
HROB at 35 weeks for evaluation.
Post Dates
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Non-Stress Test at 41 weeks with referral to HR
OB. Arrange at 40 weeks.
Family History of Congenital Anomaly, Genetic
Disease, or Advanced Maternal Age
Less than 16 weeks EGA are referred to
genetic counselor
Greater than 16, less than 22 weeks EGA are
immediately referred to genetic counselor
Greater than 22 weeks EGA (make certain
dates are correct and encourage genetic
counseling).
Herpes
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Herpes
Culture prenatally only if patient
complains of symptoms near term
and/or confirmation of the diagnosis
has not been previously established.
Hypertension
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1st or 2nd trimester: Consider chronic
HTN and obtain OB evaluation.
3rd trimester: Consider pre-eclampsia.
Refer to OB ER if B/P >140/90 and/or
if symptoms of scotomata, headache,
or abdominal pain.
Referred to HR OB for mild disease
after obtaining CBC, BUN, creatinine,
and LFTs.
Vaginal Bleeding
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(More than bloody show)
1st trimester: THINK ECTOPIC PREGNANCY.
Check cervical os with ring forceps to assess for
inevitable abortion, check Hct and quantitative
B-Hcg, check for doptones if >10 weeks,
ultrasound only if patient is having evidence of
abdominal cramping/pain, 2nd trimester: Assess
for fetal cardiac activity; are refer for ultrasound
exam.
3rd trimester: THINK PLACENTA PREVIA.
Refer to OB ER immediately. Do not perform
cervical exam unless the placenta has already
been evaluated by ultrasound and is not a
placenta previa
High Risk OB Criteria
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Present OB
Complications
Age <14 or> 34
Preterm labor this
pregnancy
Premature rupture of
membranes
Third trimester bleeding
Fetal anomaly
Post-term>41 weeks
Pre-eclampsia
Incompetent cervix
Polyhydramnios
Poor weight gain
Fetal growth retardation
Mutiple gestation
Fetal demise/missed
abortion
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Prior OB Complications
Previous stillborn
> 2 miscarriages
History of preterm delivery
Prior C/S (VBAC eval)
High Risk (HR) criteria
Maternal Medical Problems
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Diabetes
High blood pressure
Asthma (COPD)
Thyroid disease
Liver disease
Chronic renal disease
Acute pyelonephritis
Cardiac disease (not
murmur)
Hematologic disorders
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severe anemias
sickle cell
hemoglobinopathies
thrombocytopenia
Rh sensitization
Seizure disorders
Lupus
Active tuberculosis
Active hepatitis
Active mumps, rubella
Premature Labor
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OB ER evaluation for abnormal cervical
exams or complaints of possible
uterine activity.
Premature Rupture of Membranes
Confirm PROM by sterile speculum
exam (pooling in vaginal vault,
nitrazine positive, ferning).
No digital exams.
Refer to OB ER ASAP
Six Week Postpartum Check-Up History
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Inquire in general about delivery; i.e., "difficult time," long,
painful bleeding, etc.
General state of mother and family
 How is she coping with the baby? mood, appetite,
exercise activities, rest and sleep
 Involvement and interest of father.
 Reactions of siblings to new baby.
Problems with baby at birth or now.
Specifically ask the mother about:
 Fever, vaginal bleeding, cramping, discharge, episiotomy
pain, breast soreness or discharge, swelling, headaches,
urinary symptoms, and bowel movement.
 Meds currently taking (particularly if breast feeding).
 Contraception (consider BCPs, diaphragm, IUD, etc.).
Menses should start 6-8 weeks after birth (longer if breast
feeding).
Physical Exam
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Vital signs (particularly BP and WT).
General PE: HEENT, breast. chest, abdomen, and
extremities.
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Brief HEENT, chest, abd. and ext.
Breast exam for infection or masses.
Pelvic examination: including
rectal exam
State of perineum (episiotomy, if done).
Character of discharge (should be scant blood or normal
menses).
Cervix - laceration, uterine size and tenderness, adnexa
for tenderness or masses.
Rectal - sphincter tone, fistula.
Uterine size - should be normal size and nontender in 6
weeks.
Time Frame Tests
Time Frame
Initial Visit
Tests
Pap Smear, GC, CT
U/Culture, Cystic Fibrosis
Prenatal Panel, CBC
HIV, RPR, blood Type
Antibody Screen,
Rubella & Hepatitis Titer
15 – 20 weeks
AFP Triple Screen
24 – 28 weeks
1 hr glucose test, CBC
34 – 36 weeks
GBS culture, CBC, RPR
GC, CT
Pregnancy-Related Disorders
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Hypertension
Preeclampsia
Multiple gestation (twins and higher)
Gestational diabetes (a condition that results in
high blood sugar levels during pregnancy).
Preterm labor
Genetic disorders in the fetus
Intrauterine growth restriction (lower than
normal fetal growth)
Advanced maternal age by itself may not make
the pregnancy "high-risk" unless there are
high-risk conditions present, such as high blood
pressure or fetal genetic disorders
Pregnancy Induced Hypertension
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HTN can restrict the flow of blood to the
developing fetus, causing growth
restriction and other problems.
There is a condition unique to pregnancy
known as preeclampsia.
Known also by the term PIH (for
"pregnancy-induced hypertension"),
preeclampsia consists of:
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Hypertension
Edema (swelling)
Significant amounts of protein in the urine
(proteinuria)
PIH
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Preeclampsia can be relatively mild,
although the term "mild" is misleading
since serious problems can develop even
with a mild form of the disorder.
Preeclampsia can evolve into severe
preeclampsia, which can be an indication
for immediate delivery of the fetus.
Eclampsia can also result. This consists
of generalized seizures and is an
obstetric emergency.
PIH
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Preeclampsia is unusual before 20-weeks
gestation, but can occur even as late as
two weeks after delivery.
Preeclampsia is more common among
women who are giving birth for the first
time, or who are pregnant for the first
time by a new partner.
Preeclampsia is also more common
among pregnant women with chronic
hypertension, as well as those who have
kidney disease, a multiple gestation, or
who are over 40.
Gestational Diabetes
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Pregnant women who are not already diabetic
may develop a pregnancy-related form of
diabetes called gestational diabetes.
Diabetes in general is the most common
medical complication of pregnancy and about
2-3% of pregnant women have some form of
diabetes. Of this, 2-3%, 90% are women with
gestational diabetes.
Gestational diabetes is also important because
it can increase the risks of certain complications
in pregnancy such as birth trauma and
excessive fetal growth.
Gestational DM
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The one-hour glucose test ("glucola") performed
between 24 and 28 weeks of pregnancy screens for
gestational diabetes.
It consists of taking a special sweetened drink and
measuring blood sugar levels one hour later.
For the purposes of this screening test, a pregnant
woman does not need to be fasting.
If the test is abnormal, it may or may not mean that a
pregnant woman has gestational diabetes, since the
one-hour test is designed so that about 2-3% of women
will have an abnormal result.
When the one-hour glucose test is abnormally high, the
next step is to take a formal three-hour glucose
tolerance test (GTT) that does require an overnight fast.