Intro to Obstetric Care

Intro to OB Care

• Places a woman can have babies include levels IV, III, II, and I, as well as birthing centers or home births
• Level IV is the highest risk and is for regional perinatal centers, specialized
• Level III is high risk
• Level II is moderate risk
• Level I is low risk, up to 36 weeks to full term
• Birthing Center can only be used if pregnancy is not high-risk
• Nurses, midwives, doulas, and obstetricians play different roles in OB care
• Midwives cannot perform C-sections or treat high-risk pregnancies
• Doulas act as the advocate or support person for pregnant patients
• Obstetricians can perform C-sections and care for all pregnant patients' needs
• Maternal mortality can be a consequence of mental health issues, hemorrhage, cardiac problems, infection, DVT/PE, cardiomyopathy, and hypertensive disorders
• Social determinants of health, such as education, healthcare access, neighborhood, economic stability, and community context, can affect pregnancy outcomes

Education/Health Promotion

• During pregnancy, a healthy diet is important
• The diet can include low-mercury fish (cooked salmon, etc), lean meats (must be cooked well-done), leafy greens, and whole grains
• Recommended daily intake of folic acid is 400 mcg, and iodine is 150 mcg
• The diet should not include high-mercury fish (raw, e.g., sushi, lox), deli meat, unpasteurized dairy and juices, or more than 200mg of caffeine
• Alcohol and smoking should be avoided
• During pregnancy, alcohol and drug use can lead to developmental delays, congenital anomalies, fetal alcohol spectrum disorder (FASD), miscarriage or preterm labor, and sudden infant death syndrome (SIDS)
• During pregnancy, Kegel exercises, lifting weights (as advised by HCP), and running (as one can tolerate) is permissible
• Pregnancy activity should not include riding a horse, hot tubbing, skiing/snowboarding, or other high-risk activities
• Pregnant patients should avoid changing cat litter boxes, gardening, and handling raw meats to avoid toxoplasmosis
• No extra calories are needed during the first trimester
• One extra small snack is needed during the second trimester (340 extra calories)
• One extra small meal or two snacks are needed during the third trimester (450-500 extra calories)
• Recommended weight gain during pregnancy varies based on pre-pregnancy weight
• Underweight: 28-40 lbs
• Normal: 25-35 lbs
• Overweight: 15-25 lbs
• Obese: 11-20 lbs
• Potential Issues to report to HCP include are blurred vision, severe headaches, bleeding, leaking, abnormal swelling, absent fetal movement, severe itching, persistent vomiting, and seizures or convulsions
• Round ligament pain is sharp pain in the abdominal region that happens with subtle movement, and the health care provider should still be notified to rule out other conditions
• Sleep habits should be adjusted, pillows should be used to provide support, and the patient should lay on their side
• The pregnant patient should avoid sleeping on their back after 18 weeks because the uterus weight can compress the inferior vena cava
• Pregnancy categories:
  • Category X: The medication cannot be taken because it is detrimental to the fetus!
  • Category D: The medication does not have to be taken, but benefits outweigh the risk
  • Category C: Most drugs fall into this category. There have been adverse effects on the fetus, but potential benefits may warrant drug use
• Medications to avoid while pregnant: Ibuprofen (increases risk of bleeding)
• Acceptable medications: Tylenol, Labetalol
• Vaccines that mom can have: Flu Shot, TDAP, and Covid
• Vaccines mom should avoid: Live vaccines, Varicella, MMR, Flu Mist

Teen Pregnancy & Advanced Maternal Age

• Teen pregnancies are associated with low birth rate, hygiene issues, nutrient deficits, higher risk for STI's, need for prenatal care, and social determinants.
• Advanced maternal age (35 years and older) is associated with higher risk for genetic problems, pre-eclampsia, diabetes, and hemorrhage
• In order to ensure baby is safe ultrasounds and fluid levels/profiling for amniotic fluid is needed

Domestic Violence & Legal/Ethical

• Signs of domestic violence include giving a false identity, the person being anxious about the appointment, pt avoiding eye contact, bruises in various stages of healing, STI, and homelessness
• Legal/Ethical issues: Elements of negligence include
• Duty: The nurse has a duty to act or give care to the client.
• Breach of duty: A violation of that duty must occur.
• Damage: Actual injury or harm occurs to the client
• Proximate cause: The nurse's breach of duty must be proved to be the cause of harm to the client
• L&D nurses have one of the highest malpractice rates because everyone expects a healthy mom & baby

Antepartum Basics

• Signs of pregnancy: Presumptive, Probable, Positive
• Presumptive signs of pregnancy include nausea, vomiting, amenorrhea, breast tenderness, and weight gain
• Probable signs of pregnancy include positive pregnancy test, uterine enlargement, Goodell's sign (cervical softening), ballottement, and Chadwick's sign (increased cervix vascularity)
• Positive signs of pregnancy include fetal heart rate, palpation of fetal outline, and visualization on ultrasound
• The placenta secretes hormones to maintain pregnancy (hCG, hPL, estrogen, progesterone, and relaxin), exchanges nutrients, oxygen, and waste, and blocks some harmful substances
• The umbilical cord connects mom and baby, carries deoxygenated and oxygenated blood, and is cushioned by Wharton's jelly to prevent compression
• Fetal membranes hold the fetus and create amniotic sac
• Amniotic fluid cushions the baby, regulates temperature, and provides for fetal lung development
• Fetal development occurs in stages:
• Weeks 5-14 ("developing phase"): major organs start to form. teeth/genitals form, baby starts to swim, spine, and umbilical cord grows, and soft bone formation
• Weeks 14-28 ("learning phase"): baby can swallow, eyes can move, baby can roll, can make a fist, suck thumb
• Weeks 28-40 ("getting fat phase"): eyes can open, the baby can urinate, toes grow, head molds

Antepartum Basics Continued

• GTPAL is an acronym used to obtain a more detailed breakdown of parity to assess a woman's full obstetric history
• G = # of times a woman has been pregnant
• T = # of babies born that reached full term
• P = # of pregnancies delivered preterm
• A = # of pregnancy loss before 20 weeks
• L = # of current living children
• Ex) A 32 year old female is pregnant with twins. She has a 5-year old born at 37 weeks gestation, and had a miscarriage at 8 weeks gestation: G3 T1 P0 A1 L1
• Naegele's Rule is used to calculate the Estimated Delivery Date (EDD)
• Formula: 1st day of LMP (- 3 months) (+ 7 days)
• The 1st day of the last menstrual period then subtract three months, then add seven days
• Expected lab changes:
• Blood volume increases by 50%
• RBCs increase by 20-30%
• Hgb/Hct decreases (10.5-11)
• Clotting factors increase
• Platelets are worried about if below 150,000
• Hct increases
• Fibrinogen decreases
• Expected Vital Signs during pregnancy:
• Temp: Remain within normal limits
• Pulse/HR: Increase 10-15 bpm from baseline (shouldn't be tachy though)
• RR: Deeper, more rapid -- w/in norm or slightly above
• BP: Initially decreases then returns to pre-pregnancy in the 2nd half of pregnancy

Important Prenatal Tests

• GBS is a strep infection in the vagina
• It is not harmful to the mom, but it is very harmful to the baby, it can cause sepsis if not treated!
• Give first dose of antibiotics when they first come in Q4H during birthing labor
• Fetal wellbeing can be traced by heart tones, if after 13 wks then can be heard on doppler and should be 110-160
• Kick counts should be 2-3x a day, or 10 kicks in 2 hrs, and should start 26-28 wks
• 2nd-trimester, uterus is now present in abdomen, and height should be the same as gestation from 20-32 wks
• Fundal height should be measured from top of fundus to symphysis
• DR visits should be every 4 wks till 30, then every 2 wks up to 36, then, every week until
• Rh Factor refers to an Rh- blood type
• If they are not Rh(-) then no antigens
• 1st baby is safe, but other babies after are at risk without treatment
• Rh (-) needs Rhogam @ 28 wk
• Amniocentesis: check/evaluate lung
• If complications, it can cause bleeding, cramping, labor, or loss of baby
• Why do we do this? - To check/evaluate lung maturity for baby
• Make sure to monitor baby before & after procedure

Important Prenatal Tests Continued

• NST (Non-Stress Test) is for fetal monitoring without encouraging contractions - On monitor for 20 mins
• Should have a baseline of 110-160 bpm
• There should be 2 accelerations – above baseline by 15 and over by 15 secs-
• Variability (We want moderate, little squiggle for at least 6 bpm – 25 bpm)
• Contraction Stress Test (CST)
• Do this to see if baby will tolerate labor
• Induce through Pitocin or Nipple stimulation
• If the results are negative then the baby is tolerating & can have induction, but if it's positive then the baby demonstrates decelerations on the monitor & they'll need a C-section

Ectopic & Molar Pregnancy

• Ectopic pregnancy is implantation outside of the uterus
• Risk factors: IUD, Endometriosis, Hx of ectopic pregnancy, STI's
• Treatment: Remove pregnancy, preserve fertility, Methotrexate, surgery, follow-up HCG's,
• Molar pregnancy is when the placenta starts replicating out of control = Tumor
• Treatment: Serial HCGs until zero, 1 yr until metastasized, start chemo, Methotrexate (stop cell division),

Placenta Previa vs Abruption

• Placenta Previa (Chronic)
  • Placenta implants and grows over the cervix
  • Cervix becomes irritated & tears (bright red painless bleeding!)
  • Risk Factors: Hx of C-section, Hx of Previa, Short interval pregnancy
  • Intrauterine scarring (STI's, cysts)
  • What do we need to do? Pelvic rest, Get them on a monitor
  • No prenatal care or cervical exams until after placenta location is verified (via ultrasound)
  • Need C-section if not resolved!
• Abruption (Sudden)
  • Acute event -- sudden emergency (premature separation of the placenta)
  • Causes: Trauma (falls, DV, MVA), Significant vasoconstriction
  • Symptoms: Sharp, severe abd pain, bleeding
  • Need to prepare for C-section!

Hypertensive Disorders

• Chronic HTN is BP (BP: 140/90 (Before 20 weeks), Labetalol)
• Avoid Calcium channel blockers (hypocalcemia) & Lasix
• Gestational HTN (BP: 140/90 (After 20 weeks), manage w/Labetalol)
• Want to monitor for pre-eclampsia & Newborn potential hypoglycemia
• Pre-eclampsia & eclampsia
• HTN & protein in the urine or other change in labs (kidney/liver function)
• Systemic issues
  • CNS irritability & Capillary permeability in hands & face
• If their epigastric pain indicates liver is working too hard, if severe- risk for seizure -HELLP Syndrome-
• H: hemolysis: Breakdown of RBC's
  • EL: Elevated Liver Enzymes: Liver damage LP: Low Platelet Count: (↓) blood clotting cells-
• If they start seizing then Turn mom on her side, call out time, make sure baby is on monitor, & start MAG!
• What do we do?START MAG!-(↓) stimulation (dark room), NST, BP monitoring, Labetalol, MAG, & Prevent seizures

Infections

• HSV: Are there active lesions? If so... Need to have baby via C-section Have to get one of the "virs" If baby came out vag. could cause baby blindness!
• HIV: Check viral load (want dec.(↓)) - Retrovir Avoid C-section/ deliver vaginally if viral load is (↓)
• Cannot give during pregnancy! Hep B/C: Need any treatment? Bathe baby at birth, give vaccine possibly give immunoglobulin Chlamydia: Bathe baby at birth Erythromycin (always give to babies w/consent)
• Rubella: If non-immune or equivocal (body sesitized) Offered postpartum MMR Trichomoniasis: causes premature labor and is treated with Metronidazole.
• Bacterial Vaginosis: causes preterm contractions and is treated with Metronidazole
• Yeast Infection (candidiasis) Antifungal, Fluconazole (only in certain times in pregnancy) and is More common in diabetic & obese pts

Gestational Diabetes

• Risk Factors include Obesity, Hx or relative with it, PCOS, & >25 yrs old
  • Testing:
• Glucose Challenge Test (GCT) Everyone gets this! · Drink 50g glucose and Test 1 hr later · If they don't do well, then they need GTT · -Glucose Tolerance Test (GTT) · Fast · Drink 100g glucose (doubled) ( 0 1 hr > 180 mg/dL · How to help educate mom: Vomits 24/7 than need an NG tube or TPN
• If can then get the small to educate them and to make sure that they are eating