Obstetrics: Definitions, GTPAL, and Naegele's Rule

Obstetric Definitions

• Antepartum refers to the period before delivery or pregnancy
• Gestation lasts 40 weeks
  • First trimester: 0-13 weeks (from last menstrual period)
  • Second trimester: 14-26 weeks
  • Third trimester: 27 weeks until delivery
• Labor involves cervical changes with regular contractions
• Intrapartum is the period during delivery
• Postpartum is the period after delivery of the baby and placenta

GTPAL

• GTPAL is an obstetrical acronym that describes a patient's pregnancy history
• Gravidity (G): total number of pregnancies, with multiples counting as one
• Term Births (T): number of births at term (37 weeks or later)
• Preterm Births (P): number of births between 20-37 weeks gestation, with multiples counting as one
• Abortions (A): number of pregnancies ending before 20 weeks gestation
• Living Children (L): number of children currently living

Naegele's Rule

• Determines the estimated date of delivery (EDD)
• EDD = First day of last menstrual period - 3 months + 7 days + 1 year

Infertility and Contraception

• Infertility is the inability to conceive after one year of trying or six months if the woman is 35 or older
• Infertility affects 12-15% of reproductive-age couples
• Goals for infertility care include providing information, identifying causes, offering emotional support, and educating about treatments
• Contraception is the intentional prevention of pregnancy

Factors Associated with Infertility

• Hormonal factors include pituitary or hypothalamic disorders
• Tubal factors include occluded or malformed fallopian tubes, STIs, and ectopic pregnancies
• Uterine factors include developmental anomalies, tumors, and endometritis
• Vaginal/cervical factors include acidic vaginal pH and decreased cervical connective tissue strength
• Male infertility factors include poor sperm quality, structural/hormonal/genetic disorders, and substance use

Infertility Treatments

• Diagnostics include assessments of both partners, pelvic exams, hormone analysis, ultrasounds, endometrial biopsy, laparoscopy, semen analysis, and hysteroscopy
• Nonmedical therapeutic procedures involve lifestyle changes, exercise, yoga, and stress management
• Medical therapeutic procedures include ovarian stimulation medications and antimicrobials for infections
  • In-vitro fertilization-embryo transfer: Fertilized eggs are injected into the uterus; this is the best option for someone with endometriosis
  • Gamete intrafallopian transfer (GIFT): Eggs and sperm are surgically placed in fallopian tubes for natural fertilization
  • Zygote intrafallopian transfer (ZIFT): A fertilized egg is transferred to a fallopian tube
  • Therapeutic donor insemination (TDI): Donor sperm is used for impregnation
  • Intrauterine insemination: Sperm is injected into the uterus during ovulation
  • Reproductive alternatives include surrogacy and adoption
  • Tubal ligation is sterilization involving bilateral tubal ligation

Tubal Ligation

• Sterilization with bilateral tubal ligation
• This surgical procedure cuts, burns, or blocks fallopian tubes to prevent ovum fertilization
• If federal funding is used, the patient must be at least 21, provide informed consent, and wait 30 days after giving consent
• Advantages include permanent contraception, unaffected sexual function, reduced ovarian cancer risk, and optional performance 24-48 hours after childbirth
• Disadvantages include infection, hemorrhage, trauma, irreversibility, and no STI protection

Fetal Growth and Development

• Ovum: from ovulation to fertilization
• Zygote: from fertilization to implantation (conception-day 14)
• Embryo: day 15-8 weeks, organs form, greatest vulnerability
• Fetus: 9 weeks to birth
• Age of viability: when a premature baby needs to be delivered, about 20 weeks
• Fertilization is when the ovum and sperm unite
• Implantation occurs 6-10 days after fertilization when the conceptus contacts the uterine endometrium, becoming a zygote

Embryonic and Fetal Development

• Zygote becomes an embryo after day 14, and organs begin to form while in the embryonic stage
• Fetus from 9 weeks until birth
• The embryonic stage involves 3 primary layers
  • Ectoderm (outer layer): skin, nervous system, and external body parts
  • Mesoderm (middle layer): circulatory, urinary, reproductive, muscles, and bones
  • Endoderm (inner layer): thymus, thyroid, digestive, respiratory, and parts of the GU system

Developmental Milestones

• Embryonic Stage: starts at week 3 and lasts until week 8
  • 3 weeks: heart starts beating and blood circulates
  • 4 weeks: 2-chamber forms a 4-chamber heart, and the respiratory system begins
  • 5 weeks: umbilical cord develops
  • 8 weeks: testes and ovaries are distinguishable
• Fetal Stage: begins at week 9 and lasts until birth
  • 9 weeks: fingers, toes, eyelids, nose, and jaw are evident
  • 12 weeks: placenta complete, gender is distinguishable, organ systems complete, thumb sucking, and the fetus urinates in amniotic fluid
  • 16 weeks: Meconium in bowel
  • 20 weeks: hearing develops, quickening occurs, lanugo covers the body, and wake/sleep cycles are evident
  • 24 weeks: circulation visible, with rapid brain growth and thick vernix caseosa
  • 28 weeks: eyes open and close, senses develop, and hair grows
  • 32 weeks: fingernails, toenails, and fingerprints are present, subcutaneous fat develops, and fetal movement is vigorous
  • 36 weeks: lanugo disappears and amniotic fluid decreases
  • 40 weeks: fetal development complete

Hormones During Pregnancy

• Human chorionic Gonadotropin (hCG): maintains the corpus luteum's production of estrogen and progesterone until the placenta takes over
• Progesterone helps maintain pregnancy by relaxing smooth muscles, decreasing uterine contractility, and increasing fat deposits; decreased ability to use insulin;
• Estrogen has the same functions as progesterone as well as being associated with skin changes
• Prolactin prepares the breast for lactation
• Oxytocin stimulates uterine contractions and milk ejection
• Human Chorionic Somatomammotropin (hCS) acts as a growth hormone; it contributes to breast development, decreases glucose metabolism, and increases fatty acids
• Insulin production increases to compensate for placental hormones
• Cortisol production increases to compensate for insulin resistance

Diagnosis of Pregnancy (Signs)

• Three categories of pregnancy signs: presumptive, probable, and positive

• Presumptive Signs

  • Subjective experiences reported by the woman
  • missed period, breast changes, nausea/vomiting, fatigue, quickening
    • 3-4 weeks: breast changes
      • alternate causes: premenstrual changes, oral contraceptive
    • 4 weeks: amenorrhea
      • alternate causes: stress, vigorous exercise, early menopause, endocrine problems, malnutrition
    • 4-14 weeks: nausea/vomiting
      • alternate causes: GI virus, food poisoning
    • 6-12 weeks: urinary frequency
      • alternate causes: infection, pelvic tumors
    • 12 weeks: fatigue
      • alternate causes: stress, illness
    • 16-20 weeks: quickening
      • alternate causes: gas, peristalsis

• Probable Signs

  • Objective changes observed/perceived by an examiner
    • 5 weeks: positive pregnancy test
      • alternate causes: pelvic congestion
    • 6-8 weeks: Chadwick's sign
      • alternate causes: pelvic congestion
    • 6-12 weeks: Hegar's sign
      • alternate causes: pelvic congestion
    • 4-12 weeks: positive serum pregnancy test
      • alternate causes: hydatidiform mole, choriocarcinoma
    • 6-12 weeks: positive urine pregnancy test
      • alternate causes: pelvic infection, tumors
    • 16 weeks: Braxton Hicks contractions
      • alternate causes: myomas, other tumors
    • 16-28 weeks: ballottement
      • alternate causes: tumors, cervical polyps

• Positive Signs

  • Objective changes observed by an examiner as proof of pregnancy
    • 5-6 weeks: visualization of fetus by real-time ultrasound
    • 6 weeks: fetal heart tones detected by ultrasound
    • 16 weeks: visualization of fetus by radiographic study
    • 8-17 weeks: fetal heart tones detected by Doppler ultrasound stethoscope
    • 17-19 weeks: fetal heart tones detected by fetal stethoscope
    • 19-22 weeks: fetal movements palpated
    • Later pregnancy: fetal movements visible

Teratogens and Substance Use During Pregnancy

• Teratogens are environmental factors that can cause abnormalities in the embryo or fetus
• The first 3 months are the most critical period
• Teratogens during days 15-60 of gestation can cause miscarriage or affect brain growth/development and the CNS
• Cigarette smoking, lead, lithium, rubella, syphilis, cocaine, varicella, valproic acid, drugs, chemicals, infection, exposure to radiation, maternal conditions, and malnutrition are examples of teratogens

Teen Pregnancy

• Teen pregnancy often introduces additional stress and a lack of resources for the mother
• Children of teen mothers may be at risk for neglect or abuse due to inadequate knowledge of parenting
• Teen patients need double the nutrition and may try to hide the pregnancy

Umbilical Cord

• The umbilical cord is approximately 2 cm in diameter and 20-90 cm in length at term
• The cord is surrounded by Wharton's jelly, which prevents compression of the blood vessels
• Nuchal cord occurs when the cord is wrapped around the fetal neck
• In the 3rd week, blood vessels develop in the embryo to supply it with maternal nutrients and oxygen
• In the 5th week, the embryo curves inward on itself, bringing the connecting stalk to the ventral side
• There are two arteries that carry deoxygenated blood from the embryo to the chorionic villi
  • One vein returns oxygenated blood to the embryo
  • Approximately 1% of cords contain one artery and one vein

Amniotic Fluid

• Amniotic fluid, with a normal volume of 700-1000 mL at term, consists of maternal fluid and fetal urine
• The amniotic fluids maintains the fetal body temperature, provides oral fluid, acts as a repository for respiratory wastes, and supports fluid and electrolyte balance
• Allows freedom of movement for musculoskeletal development
• Cushions the fetus from trauma
• Prevents membranes from tangling
• Provides auditory stimulation
• Includes antibacterial factors
• Amniotic fluid volume is an important factor in assessing fetal well-being
  • Less than 300 mL is associated with fetal renal problems
  • More than 2 L is associated with GI and other malformations

Placenta

• The maternal-placental-embryonic is defined when embryonic heart beats, complete by week 12
• Functions as a metabolic exchange
• Endocrine gland function: produces 4 hormones necessary to maintain pregnancy and support the embryo and feus
• Human chorionic Gonadotropin (hCG) is detectable 8-10 days after conception and is the basis for pregnancy tests; hCG preserves the corpus luteum
• Human placental Lactogen (hPL) stimulates maternal metabolism to supply fetal growth
• Metabolic Function includes respiration, nutrition, excretion, and storage
• The placenta functions as fetal lungs with oxygen diffusion from maternal to fetal blood, and carbon dioxide diffuses in the opposite direction
• The placenta stores carbohydrates, protein, calcium, and iron to meet fetal needs
• Circulatory effects

Nutrition During Pregnancy

• Neural tube defects are common in infants when mothers have poor folic acid intake
• Increase caloric intake: +340 calories during 2nd trimester and +452 calories during 3rd trimester
• Increase protein intake
• Consume leafy vegetables, dried peas/beans, seeds, orange juice, breads, cereals, and other grains; 600 mcg of folic acid
• Fat-soluble vitamins: A, D, E, and K should be consumed
• Water-soluble vitamins: folate/folic acid, pyroxidone, vitamin C, vitamin B6, and vitamin B12 should be consumed
• Iron supplements and calcium are recommended
  • 1000 mg/day of Calcium for ages 19-50
  • 1300 mg/day for under 19
• Drink 8-10 glasses of water, fruit juice, or milk per day (2.3 L)
• Limit caffeine to no more than 300 mg per day and avoid alcohol entirely
• At-risk patients include adolescents, those with poor nutritional habits/diets low in vitamins and protein, vegetarians (decrease intake of protein, calcium, iron, zinc, vitamin B12), and those experiencing nausea and vomiting, anemia, eating disorders, or PICA

Weight Gain During Pregnancy

• An average patient should gain 25-35 lbs throughout pregnancy
  • 2-4 lbs per month during the first trimester
  • 1 lb per week during the last 2 trimesters
• Suggested weight gain for normal BMI: 25-35 lbs
• Underweight: 28-40 lbs
• Overweight: 15-25 lbs
• Assess for food allergies and dietary practices

Physiological Changes in Pregnancy

• The uterus increases in size, shape, and position
  • Contractility changes, including Braxton Hicks contractions (no cervical changes), occur; these can be characterized as 'fake contractions'
  • Uterine changes are related to the presence of the fetus, including ballottement and quickening
• Fundal height is an important measure of fetal well-being
  • McDonald's Rule can apply, but only within 18-30 weeks. Height of the fundus in cm = number of weeks gestation + 2 weeks
  • Fundal height can be also measured through ultrasound
• Breast changes include fullness, heaviness, heightened sensitivity from tingling sharp pain, areolae become more pigmented, striae gravidarum, and colostrum production
• Cardiovascular system
  • Cardiac output increases by 30-50%
  • Blood volume increases by 30-45% at term
  • Pulse increases 10-15/min
  • Blood pressure can present supine hypotensive syndrome with symptoms including pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy skin, and sweating; this is called "CM"
    • Supine Hypotension: as pregnancy advances, the weight of the uterus presses on abdominal vessels (vena cava & aorta), causing low blood pressure
  • RBCs increase, increasing the risk of blood clots
• Oxygen needs increase 20-40%
• The GI system experiences nausea, vomiting, abdominal discomfort, and pica
• The musculoskeletal system experiences increased weight and changes to posture and gait
• The urinary system experiences increases in filtration rate and excretion of protein and albumin
• The integumentary system experiences melasma, linea nigra, striae gravidarum, and palmar erythema
• The endocrine system experiences increased thyroid gland (T3 nd T4 levers)

Biophysical and Biomedical Assessments

• Determine fetal well-being, estimate fetal growth and gestational age, and decrease unnecessary interventions

• Biophysical Assessment (Noninvasive)

  • Biologic and physical assessment of the fetus using technology or not
  • Ultrasound/biophysical profiles
  • Non-stress testing
  • Fetal kick count - Assess biophysically any risks

• Abdominal Ultrasound

  • 30 minute session
    • Fetal breathing movements
      • Downward movement of diaphragm
      • Contraction of diaphragm.
      • (1 episode of contraction of less than 30 seconds)
    • Gross body movement
      • 3 body movements or leg extensions (~ 30 minutes)
    • Fetal tone
      • Least 1 Flexion/extension of baby’s extremities
    • Amniotic fluid index
      • (Oligohydramnios – decreased fluid volume; Polyhydramnios – increased amniotic fluid)
    • NonStressTest
      • (10-15 minutes long) test for FHR

• Kick Counts

  • The fetus should be active when awake and is reassuring
  • 5-6 movements felt within 30 min- 1 hour/ 10 movements in 12 hours
  • Less than 5 movements then perform NST/BPP

• Non-stress Test

  • Fetal monitoring (20-30 mins)
    • Reactive = accelerations x2 (CNS intact) or more in FHR within testing time (increases in fetal heart rate above the baseline)
    • Nonreactive = more assessments needed
      • Flat straight line

• Contraction Stress Test (CST)

  • To evaluate fetal response to uterine contractions

    • Nipple-stimulated

      • Gently brushing palm to nipple for 2 mins, stimulates pituitary to release oxytocin.

    • Oxytocin-stimulated

      • Oxytocin, oxytocin given IV to cause contractions

    • Results

      • Negative = normal (absence of late decels)
      • Positive = late decels that occur with more than 50% of contractions - uteroplacental insufficiency (out of 10 contractions, in 5 the fetus HR drops below the baseline

• Biochemical Assessment

  • Biologic & chemical assessment fetal well-being.
  • Use blood
  • Body fluids
  • Tissue samples - Fetal aneuploidy screening - Amniocentesis, assessment of amniotic fluid - Chorionic villus sampling

• Amniocentesis

  • Invasive procedure
  • Ultrasound-guided
    • Needle thru abdomen
    • Uterus
      • To obtain sample amniotic fluid
        • Gestation (2nd trimester)
        • Assess fetal lung maturity
        • Chromosomal abnormality (Down syndrome /neural tube defect)
        • Alpha-fetoprotein
        • Nursing care
          • Empty bladder prior to procedure
          • VS, FHR
            • Uterine contractions 30 minutes after the procedure.

• Chorionic Villus Sampling (CVS)

  • Performed at 1st trimester
    • 10-13 weeks - Assessment - Portion of the developing placenta - Syringe/sterile-needle inserted: abdomen/vagina using ultrasound - 1st trimester alternative to amniocentesis with a disadvantage= diagnosis abnormalities sooner

• Maternal Serum Alpha-Fetoprotein (MSAFP)

  • Blood sample from mom
  • 15-20 weeks gestation
    • Elevated levels: neural tube defects
    • Screening tool ONLY (not diagnostic test) - Follow up is: targeted ultrasound/amniocentesis

• Indirect Coomb’s Test

  • maternal blood test
  • Screens for Rh incompatibility
    • Mom has antibodies against Rh positive blood - The baby=risk of hemolytic anemia of fetus. - negative=O-, B-, AB- A- (RBCs lack the Rh factor) - Rh pregnant= +Rh - Mom's body will identify the + blood as a foreign body and the mother target the Rh factor for antibodies

GDM- Gestational Diabetes Mellitus

• Maternal & Fetal risks (normal value 5-6%)
• Care management: early test at 24-48 weeks. Interview, Assess acute and chronic DM, lab tests.
  • baseline renal function
  • UA and culture
  • Glycosylated hemoglobin A1C
• Antepartum- Interventions:* Diet and exercise, insulin, blood glucose levels, urine and pharmacology test.
  • maternal risks are: High blood pressure, infection, preclampsia, and labor abnormalities.
  • can test the baby for abnormal development.
• Fetal risks:*
  • birth injuries
  • hypoglycemia
  • death
  • large baby
• interventions*
  • glucose and avoid dextrose hoursly; monitor blood sugar.
  • increased risk type 2, encourage contraceptive

Gestational HTN

• Most are during pregnancy, 2ndt and 3rd trimester
• Preeclampsia -5 - 10% during pregnancies. (2) need to take place- systolic (140) diagolic (90+ or both)
• without protien after the 20th week ”chronic HTN”is the trimester (< 20 weeks)

Preclampsia

• HTN after 20 weeks proteinuria Rising BP Edema severe ha Ruq in ha

visual Disturbed Decreased urine output Hyperrifixia Rapid weight gain Pathology: Placenta root course

defective artery

remodcling- Risk factor old history in pregnancy family history- inpregnancys' , medical conditions. Elampisa- Gestational with proteinuria

• and seizure activity or coma !!

Hemolysis- Elavated lioer enzymes los plactics:

diagnosed in labs

• risk for matanal death .

Pulmonary edema Acute renal failure Sepsis and stroke

Care management

expectant management antihypertensive controle pt

• measure- Proteins HA Ruq pain and disturbed visions.

Placenta Previas:

Placenta is lower close to or over the cervix os.

Normally- Implants Classifications

Complete- lower total covered. partial covering some.

• is not covering at total but side left from right.

• previa is not painless its vaginal blood with funal.

  • no vaginal exam can cause a lot of bleeding ruptured.

Placentail Aburbtion:

Premature separation of this placenta sudden onset of pain dark red ultrasound

Degree of abruption assess pattern hfr Fluids blood products. V/S u/0

Hyperemesis Gravidarum:

excessive vomiting. electrolyte imbalance. Loss of kretosis weight loss increased pulse decreased bp Iv ringers Vitamin b. antiemetic, meals.

Ectopic pergnany

Ovium outsides fallopian pain delays vaginal and ulerasuond. medical management surigcal salpigectomy..