Pregnancy & Childbirth Notes PDF

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Okay, here is the converted text from the images you sent, formatted in markdown. I have done my best to retain the original information, formatting and language. ## PRECONCEPTION & ANTEPARTUM | Condition | Description | Tx | | :--------------------------- | :---------------------------------------------------------------------------------------------------------------------------------------------------------- | :--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | NTD (neural tube defect) | Neural tube is structure of the embryo that turns into brain/spinal cord. NTD can lead to problems in fetus like spina bifida & anencephaly | Folic acid supplements before & during early pregnancy (FA promotes DNA synthesis & division → Allows for proper neural closure) | | Quickening | First baby flutters a preggo mama feels. Usually around 16-20 wks | | | Chadwick's sign | Blue discoloration of cervix, vagina, & labia from increased blood flow and hormonal changes | | | Hegar's sign | Softening of the cervix at 6wks | | | Increased Nuchal translucency (NT) | Enlargement of hypoechoic space posterior to fetal neck → Associated w fetal abnormalities (ex down syndrome) | | | Pattern of CO in gravid pt | - Increases → Beginning of pregnancy (6-8wks) - Peak increase → 32wks - CO dec. tremendously due to compression of uterus on sup VC (< venous return)→ late in pregnancy - Increase by 40% → During labor contractions - CO increases again from release of pressure on VC → After fetus is born | | Systemic changes in pregnant pt | Mostly = Hyperdynamic CV changes CV: Hyperdynamic; Increased CO ↑ 2nd <3 sound, split w/ inspiration Low grade systolic ejection murmur ↑ HR 10-15 bpm above normal Distended neck veins HEME: Hypercoagulation Renal system: Enlarged from increased flow GI: Istenstines + stomach displaced, Acid reflux (progesterone lowers esophageal sphincter tone), Morning sickness, Hemorrhoids | | | Routine US provides what info? | Pneumonic: "New little baby creates sweet adventures" fetal Number fetal Lie Biometry (aka growth parameters) fetal Cardiac activity Survey fetal anatomy assess Amniotic fluid volume | | | Pregnancy screenings | Fetal nuchal translucency + PAPP-A OR free/total B-hCG Screens for trisomy 21, 18, 13→ By end of 1st trimester Option maternal serum AFP (screens for neural defects) → 15-18wks Quad screen (serum BhCG, unconjugated estriol, AFP, inhibin) → 15-20 wks ONLY IF 1st trimester screening was missed | | Fetal monitoring tests: * Non stress test * Contraction stress test * Oxytocin challenge test * Biophysical profile Fetal monitoring: * Non-stress test (NST) → 26-28wks or as needed --- * Contraction stress test → Done after abnormal NST * Biophysical profiles (BPP) → Done after 32wks for women at risk of pregnancy lost → Detects fetal HYPOXIA * What does it measure? Fetal breathing, movement, tone, and amniotic fluid volume * Naegele's rule → EDD → LMP + 1yr, -3M, +7D Weeks breakdown: * 1st trimester 0-14wks * 2nd trimester 14-27wks * 3rd trimester 28-40+ * 4wks after LMP → Urine pregnancy (+) * 4.5-5→ Gestational sac visualized through TVUS * 4-8wks → Morning sickness * 5-6 wks → Gestational sac visualized through abd. US * 5-10wks → Cardiac activity noted on TVUS * 6wks → (+) Hegar's sign * 6-8wks Moms blood volume increases * 8-12 wks → (+) chadwick's sign * 8-14wks → Hear fetal <3 tone (external U.S. doppler) * 15-18wks → Maternal serum AFP done (checks for neural deficits) * 15-20wks → Quad screening option ONLY if↑ 1st trimester screening was missed * 16-20wks → Quickening flutters * 20wks → Height of fetus at umbilicus * 32wks → Moms blood volume peaks ## INTRAPARTUM & POSTPARTUM | Condition | Description | Tx | | :---------------------------- | :-------------------------------------------------------------------------------------------------------------------------------------------- | :----------------------- | | Braxton hicks "False contractions" | Short and mild contractions/ discomfort in lower abdominal/ groin area, not related to uterus dilation. | Ambulation & hydration | | Lightning | Shape of the abdomen changes, sensation of baby being "lighter" and fetal head descends into the pelvis | | | Ruptured membranes | Sudden gush of liquid or constant leakage of fluid "water broke" | | | Bloody show | -passage of blood-tinged cervical mucus, occurs when the cervix begins to thin (effacement), is expressed as a % -This is normal & means labor is near | | | True Labor | -Regular, painful uterine contractions causing cervical dilation and birth increasing and frequent -Felt over uterine fundus with radiation to low back and low abd | | Decelerations are classified by * Uniform shape of HR drops * Timing → If decelerations is at same time as peak of contraction | Deceleration | Description | Tx | | :---------------------- | :------------------------------------------------------------------------------------------------------------------------------- | :------------------------------------------------------------------------------------------------------------------------ | | Accelerations (Good) | Abrupt increase in fetal heart rate. Baby is moving or well-oxygenated. This is normal and reassuring. | Rasurance | | Early deceleration | Mild decrease in FHR → Normal and due to baby's head descending into pelvis Uniform shape, lowest point at SAME time of peak of contraction | Continued monitoring | | Variable Decelerations (Could be bad) | -Sudden drop in heart rate that varies in timing. -Umbilical cord compression (cord might be squeezed, reducing oxygen). Sometimes. If mild, it's okay; if severe, interventions may be needed (position change, oxygen, fluids). VARIES in shape, No consistency with peak of contraction | Put mom in knee-chest position (gets baby's head off cord) | | Late Decelerations (Dangerous) | -Heart rate gradually drops after the contraction starts and recovers after it ends. -Placental insufficiency (baby isn't getting enough oxygen) -This is a sign of fetal distress and needs urgent intervention (position change, oxygen, fluids, possible delivery). Uniform shape but gradual change, lowest point RIGHT AFTER peaks of contraction | -Reposition mom -IV fluids To help decrease contractions: Discontinue or reduce oxytocin Administer tocolytic | * Incomplete delivery of placenta * DANGEROUS!!! Can lead to: * Infection +/- SEPSIS * Hemorrhage +/- DIC (as a response to hemorrhage) * Evaluating for maternal blood loss: * Palpate uterus to see if it is firm (normal) or "boggy"/atony (abnormal → means its weakened and is not contracting the placenta out like it should) * External cephalic version * Procedure to try and manually fixed breech presentation (risk of fetomaternal hemorrhage) * Rhogam in case fetus blood enters moms bloodstream, you don't want moms immune system to overreact * Epidural block * Local anesthetic + opioid → Continuous IV infusion pumps into epidural space * Bilateral Pudendal block * Numbs perineal area → Quick pain relief, mostly for delivery * General anesthesia (GA) * Used during labor and delivery only in emergent situations → LAST RESORT * C-section * Failed epidural & pudendal block * Severe maternal complications (ex shoulder dystocia) * DANGEROUS B/C: Puts mom & baby to sleep → Aspiration risk for baby * Cervical effacement * Thinning, softening, and shortening of the cervix → leads to bloody show → Labor is near * Fetal descent (pelvic) stations * Station is the level of fetal presenting part to level of ischial spine * -5 station: "Floating" * O station: "Engaged" → Presenting part has reached the ischial spine * +1 - +5 station: Presenting part is moving into the introitus * +5 = crowning * Stages of labor * Stage 1- From onset of cervical contractions, to FULL cervical dilation (10cm) * Latent phase: Cervical effacement + gradual cervical dilation * Active phase: Rapid cervical dilation * Stage 2- From full dilation (10cm), to delivery of fetus * Passive phase: From complete dilation, to active maternal pushing * Active phase: From active pushing to actual delivery * Stage 3: From post partum to delivery of placenta * Stage 4: Mother assess for complications for 1-2 hrs NOTE: Stage 4 mother is at highest risk → Readjusting to non-pregnant state ## HTN & GESTATIONAL DIABETES | Condition | Description | Tx | | :---------------------- | :------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | :------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | | • Preeclampsia = High blood pressure + organ damage in pregnancy • Eclampsia = Preeclampsia + seizures (life-threatening) | | | Transient HTN | Occurs late in pregnancy w/o any other features of preeclampsia + normalization of BP postpartum Short term and due to stress or labor related | | | Chronic HTN (in pregnancy) | BP ≥140 mm Hg systolic &/or 90 mm Hg diastolic Before pregnancy, or Before 20 wks gestation, or Use of antihypertensive meds before pregnancy, or Persistence of HTN >12 wks after delivery Criteria: Mild: Systolic BP 140-159 mmHg; Diastolic 90-109mmHg Severe: Systolic BP ≥ 160mmHg; Diastolic ≥ 110mmHg | Goal Reduce risk of CV & cerebrovascular events Medication ONLY for severe Major risk of developing preeclampsia or eclampsia later on | | Pregnancy induced HTN (aka Gestational HTN) | Happens within 2nd half of pregnancy (>20wks) w/ NO proteinuria → RESOLVES by 12wks postpartum Systolic BP ≥ 140 OR Diastolic BP ≥ 90 on 2 readings in one week at least 4 hours apart 20% will progress to preeclampsia Develops in: 5-10% pregnancies 30% in multiple generations Increased risk of: Perinatal morbidity (chronic health issues) Mortality for mother & fetus Causes 20% of maternal deaths in US | | | Pre-eclampsia | HTN WITH proteinuria (0.3g (300mg) or higher in 24hr urine collection; Urine dipstick reading of +1) Systolic BP ≥ 140 OR Diastolic BP ≥ 90 Develops: After 20w gestation Criteria: (same as in chronic HTN + proteinuria Mild: Systolic BP 140-159 mmHg; Diastolic 90-109mmHg 300 mg/24 hr urine or 1+ on dipstick Severe: Systolic BP ≥ 160mmHg; Diastolic ≥ 110mmHg ≥5,000 mg (5g) protein/24 hr urine | Management of MILD: Before 37wks- Rest, frequent monitor Labetalol, methyldopa, or Nifedipine Test fetal growth restrictions 2x weekly Asses amniotic fluid e/3wks At or over 37wks- Induce labor or schedule C-section | | | Risk factors: Nullipara or multiple gestation (ex twins) Age >35 FMH of eclampsia Pre-gestational DM Pre existing HTN, renal disease, or obesity S&S: Proteinuria + HTN duhhhhhh EDEMA → Common in pregnancy, but would be WORSE in preeclampsia ESPECIALLY in hands or face!! H/A or visual disturbances (ex blurred vision or spots) Extensive weight gain | Management of SEVERE: Admit to L&D $MgSO_4$ → Prevents seizures (loading dose followed by maintenance dose) HTN meds: Hydralazine, Labetalol IV, Nifedipine PO IV fluids \*DELIVERY is ultimate tx > 35wks → Induce labor or CS <34 → Hospital admission Corticosteroids for fetal lung maturity | | ECLAMPSIA | -Convulsions in women w/ preeclampsia (that is not explained by another neurological disorder) -Occurs in 0.5-4% of pts w/ preeclampsia, usually W/I delivery | Seizure precaution: Protect airway → O2 via face mask Fetal monitoring aft. mom is stable BP management: Hydralazine and/or Labetalol $MgSO_4$→ Seizures Await delivery until seizures subside | | HELLP SYNDROME | Life threatening Preeclampsia WITH - Hemolysis (abn. PBS w/ schistocytes or burr cells) Elevated Liver enzymes (2x) | To dx: Must have >2 of the criteria Tx: Delivery is best therapy (BEST) | | | | | :-------------------------------------------------------------- | :----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | | - Low platelets (<100,000) Occurs in 4-12% of pts with SEVERE preeclampsia or eclampsia Usually before 37wks NOTE: can be an imposter → 20% of pts will be normotensive or lack proteinuria Higher mortality in fetus (10-60%) S&S: H/A, Fatigue, Malaise Visual disturbances Worsening N/V, RUQ pain/ tenderness Similar to preeclampsia symptoms Most S&S subside w/i 2-3d after delivery | | | - - - - Corticosteroids (betamethasone) MGSO4 → Seizures BP med + platelet transfusion delivery deliver - - - - - withhold - - monitor - - diabetes - : - - Complications for mom: Placental abruption → Placenta detaches too early Pulmonary edema DIC→ Uncontrolled clotting + severe bleeding ARDS (Adult Respiratory Distress Syndrome) → Respiratory failure Acute renal failure (ARF) Hepatic rupture Retinal detachment → Vision loss Death → If not treated urgently Complications for baby: IUGR (Intrauterine Growth Restriction) → Baby doesn't grow properly Infant Respiratory Distress Syndrome (RDS) → If born preterm, lungs may not fully developed -Usually asymptomatic -Lifetime risk of DM after pregnancy (>50%) → Screenings -Baby 8x more likely to develop T2DM & obesity as teen or adult drink glucose 130 mg/dL glucose 95 mg/dL 180 mg/dL 130 140 and - - -Goal: - - - - Patho: Placenta secretes hormones → causes mom to become insulin resistant + pancreas not making enough insulin → High blood sugar -