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OB Case 4 - third digit refers to the number of abortions

Prenatal Care / Teratology & Drugs / (< 20 weeks)


Overview of Pregnancy / ID of High Risk - forth digit refers to the number of children
Pregnancy currently alive.
A.T. 38 year/old consulted because of 8 weeks - Gives a more complete obstetric information
delay in menstruation (+) smoker since 20 years than the mere designation of (G1P0)
old. FH: Both parents are diabetic 5 days ago she
had (+) exposure to an officemate who had Normal Pregnancy Duration
Rubella. - The mean duration of pregnancy calculated
from the first day of the last normal menstrual
OB Hx: 1999- spontaneous abortion period
2001- by 38-39 weeks, NSD, BW- 8.5 lbs. - Very close to 280 days or 40 weeks
2003- IUFD 7 months, NSD
PPE: BMI- 27 Vital Signs: BP 120/70 PR 84 RR Estimation of the duration of pregnancy
20/min - pregnancy begins with fertilization of the
Temp. 36.8C ovum
Speculum: cervix- violaceous, (+) whitish, - cannot duration of pregnancy cannot be
frothy, fishy Vaginal discharge ascertained
IE: cervix- soft, long, closed - several methods can be used to estimate the
Uterus: enlarged symmetrically to 2 duration of a pregnancy with reasonable
months AOG accuracy.

Prenatal Care 1. Naegels Rule


- a planned program of medical evaluation and - a convenient method of estimating the
management, observation, and education of date of confinement (EDC)
the pregnant woman directed toward making - calculated from the first day of the last
pregnancy, labor, delivery and postpartum menstrual cycle
recovery, a safe and satisfying experience. - Add 7 days to the first day of the last
- A.k.a. Antenatal care menstrual cycle, Deduct 3 months to the
- Begins before conception month of the last menstrual cycle and Add
o Preconceptual Care, because healthe 1 year.
during pregnancy depends on health - Apparently erroneous because pregnancy
during pregnancy. is considered to have started 2 weeks
- Not only includes the pregnant woman and before ovulation
the physician but also the husband 2. Timing of Ovulation
- Last date of ovulation should be known
Good Prenatal Care Should provide the f - Add 267 days to the last date of ovulation
Opportunities: 3. Timing from Quickening
1. For the physician and patient to become - This method is useful more as a
better acquainted confirmation of the other parameters
2. For the physician to learn more about the rather than as a primary method of
patients attitude towards pregnancy and assessing gestational age
labor - Usually occurs 16 to 18 weeks in a
3. For instructions of the patient and husband in multipara and 2 weeks later for a
optimal care for herself and for the upcoming primagravida
baby 4. Height of the Fundus
4. For optimal instruction to the patient and - Around 20 31 weeks the height of
husband in a prepared childbirth program. uterine fundus in cm correlates with the
age of gestation in weeks
Definition of Terms: - At 12 weeks usually felt at the level of
1. Primipara A woman who has been delivered pubic symphysis
once of a fetus which reach viability - At 16 weeks usually halfway between
2. Multipara A woman who has completed two symphysis and umbilicus.
or more pregnancies to viability - At 20 weeks usually at the level of the
3. Nullipara A woman who has never umbilicus
completed a pregnancy beyond the stage of - At 36 weeks usually at the level below the
viability. ensiform cartilage
4. Gravida A woman who has been pregnant - Measured from the superior border of the
irrespective of the pregnancy outcome symphysis pubis to the top most part of
a. Primigravida 1 pregnancy the fundus measured by palpation.
b. Multigravida 2 or more
5. Nulligravida A woman who has never been 5. Fetal Heart Sounds
pregnant - The fetal heart can first be heard in most
6. Parturient A woman in labor women around 16 to 19 weeks with
7. Puerpera A woman who had just given birth careful auscultation of DeLee fetal
stethoscope
The Obstetrical Score
- composed of a series of digits (4) separarted 6. Ultrasound
by hyphens - Transvaginal ultrasound can detect a
- first digit refers to the number of pregnancy pregnancy at 4-5 weeks which
terminating at term corresponds to the b-hCG concentration of
- second digit refers to the number of preterm 1500-2000mIU/ml
pregnancies - If b-hCG exceeds 4000mIU/ml the embryo
should be visualized by all techniques
female within the context of family or
7. Timing by Trimesters intimate relationships
- usual practice of dividing pregnancy in - recognized as a major public health
three equal parts problem
- 42 weeks divided into 3 periods giving 14
weeks per trimester 4. Physical Examination
- Majority of spontaneous abortion occurs at - a thorough P.E. should be done
the 1st trimester - The value of breast feeding should be
- Most cases of pregnancy- induced impressed on the patient
hypertension become clinically evident - In the examination of the lower
during the 3rd trimester extremities, the vemous pattern should be
- Very inaccurate carefully recorded at the initial visit
- Precise knowledge of the age of fetus is - Leopolds maneuver
imperative for ideal obstetrical o A series of maneuvers to determine
management the fetal position usually done in mid-
pregnancy where the fetus is usually
Initial Comprehensive Evaluation palpated.
Goals: o First 3 maneuvers are done facing the
1. To define health status of mother and patients head and the last, facing the
fetus patients feet
2. To determine gestational age o fetus o First maneuver
3. To initiate a plan for continuing obstetric Aka fundal grip
care Answers the question What fetal
4. To define those at risk for complications pole or part occupies the fundus?
and to minimize whenever possible Distinguishes between the
irregular, nodular breech and the
Includes: round, mobile and ballotable head.
1. History
- should include a complete past and family o Second Maneuver
history, and a good obstetric resume Aka umbilical grip
- an obstetric resume should include: Answers the question On which
a. menstrual history side is the fetal back?
b. evidence of infertility Distinguishes between a linear,
c. careful inquiry of previous convex, bony ridge (the back) and
pregnancies on the other side a numerous
- take note of the patients reaction to her nodulation (small parts)
current pregnanacy
- a dietary history is useful in estimating the o Third Maneuver
adequacy of her nutritional intake. Aka Pawlicks grip
Answers the question What fetal
2. Psychosocial Screening part lies above the pelvic inlet?
- Addressing psychosocial issues is an If fetal head is not engaged, it can
essential step toward improving womens be readily recognized as a round,
health and birth outcomes ballotable object.
- Cigarette Smoking If fetal head is engaged, the
o Various adverse outcomes have been shoulder is felt as a relatively fixed,
linked to smoking during pregnancy. knoblike part
Included are spontaneous abortion, low
birth weight due to preterm delivery of o Fourth Maneuver
fetal growth restriction, infant and fetal Aka Pelvic grip
deaths and placental abruption. Answers the question On which
o Suggested Pathophysiological side is the cephalic prominence?
mechanism includes inc. fetal Confirms the findings of the 3rd
carboxyhemoglobin, reduced maneuver
uteroplacental blood flow and fetal In flexion attitude the cephalic
hypoxia. prominence is on the same side as
- Alcohol and Illicit Drug the small parts
o Ethanol is a potent teratogen and In extension attitude the cephalic
causes fetal alcohol syndrome, which prominence is on the same side as
is characterized by growth restriction, the fetal back
facial abnormalities and CNS
dysfunction. 5. Pelvic Examination
o Chronic use of large quantities of - Early months purpose of vaginal
drugs, including opium derivatives and examination is to diagnose pregnancy and
amphetamines os harmful to the fetus uterine or adnexal pathology
and causes fetal distress, low birth - 7th month, one can measure and evaluate
weight and fetal drug withdrawal soon the obstetric pelvis and palpate landmarks
after birth such as the sacral promontory
- Observe perineum if it is anatomically
3. Domestic Violence Screening intact or lacerated
- Domestic violence usually refers to - Cytologic studies is now a routine prenatal
violence against adolescent and adult care (Pap smears)
- Observe characteristics of vaginal e. Fetal activity
secretion
a. yellowish in Trichomonas infection 3. Subsequent Laboratory Test
b. curd-like in Candida infection - CBC along with Syphilis should be
c. grayish in Gardnerella infection repeated at about 28-32 weeks
- Determination of Alpha-fetoprotein at 16-
6. Rectal and Rectovaginal Examination 18 weeks to screen for neural tube defects
- done to evaluate the integrity of perineum - Screening for glucose intolerance at 24-28
and competence of rectal sphincter weeks for those at risk for gestational
- to detect possible rectocoele and other diabetes
pathology in the rectum - Identification of chronic carriers of
- consist of the simultaneous introduction of Hepatitis B Ag carriers and administration
the middle finger into the rectum and during the last trimester of Hepatitis B
index finger into the vagina. immune Globulin (HBIG) and a course of
Hepatitis B vaccine to newborn infants
7. Routine Antepartal Tests (p.131 APMC) - Vaginal and rectal Group B streptococcal
- the initial visit shall include the first eight (GBS) cultures should be obtained by 35
of the antepartal test. 37 weeks and an intrapartum
a. CBC antimicrobial prophylaxis should be given
b. Urinalysis to those positive.
c. Urine culture - Special screening for genetic diseases can
d. Blood Group, Rh be offered based on maternal age, family
e. Serologic test for Syphilis history, or ethnic or racial background of
f. Hepatitis B surface Ag the couple.
g. Rubella Titer
h. Cervical cytology (Pap Smear)

8. Prenatal Instructions
a. Inform patients of any problem
b. Begin the antepartum educational
program
c. Explain future visits
d. Discuss economic aspects of pregnancy
e. Give instructions about diet, relaxation
and sleep, bowel habits, exercise, bathing,
taking recreation, sexual intercourse,
smoking, drug and alcohol ingestion
f. Emphasize danger signals which must be
reported immediately, day or night

9. Frequency of Visits
- Traditionally, every 4 weeks up to 28
weeks, every 2 weeks up to 36 and every
week thereafter
- Women with complicated pregnancies
should often require return visits every 1-2
weeks
- Women should at least have 4 visits if they
have problems

Subsequent Prenatal Care/ Prenatal


Surveillance
Goal:
To asses the well being of the expectant mother
and her fetus
Includes:
1. Maternal Evaluation
a. Change in Blood Pressure
b. Change in Weight
c. Symptoms
d. Fundic Height
e. Vaginal examination during the first visit;
subsequently if only indicated
o at term vaginal examination should
be done weekly to determine the
consistency, effacement and
dilation of the cervix

2. Fetal Evaluation
a. Fetal heart Rate
b. Change in size of fetus
c. Amount of amniotic fluid
d. Presenting part and station (late in
pregnancy)