OB CLASS 1 NOTES - 05/03/2021

● Fetal monitoring content is NOT on the first exam

● Module is due May 8th
● Have 2 chances to take dose calc exam
○ Need to get 100%
● Class warmup before friday
● Quiz to orient us to course shell
● Clinical prep packet & med charts are due on the 1st day of clinical scholar
○ They will review them & give us feedback
○ We won’t be turning them in to OB class
● Dose calc quiz
● Module navigation quiz
● Worksheets for Thursday
● Cultural diversity project -- big project
○ In clinical group
● Will post topic selection
○ Email with top 3 selections
○ First come first serve
● Tests are open book / open note / open resources
●
●

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Fetal Circulation (Before Birth) Video Notes

● Major Adaptations
○ Umbilical Vein
○ Ductus Venosus
○ Foramen Ovale
■ Sending blood from right atrium to left atrium
○ Ductus Arteriosus
○ Umbilical Artery
● Baby still in the uterus (in utero)
● Placenta -- partially mom, partially fetus
● Baby sticks capillaries into the portion of the placenta where mom’s blood is pooling
○ Oxygen is being picked up
○ Blood is getting oxygenated & returning to the baby via the umbilical vein
● Umbilical vein
○ Carries oxygenated blood back towards liver area
○ One of the first adaptations
● Blood branches at the umbilical vein → can go to right or left
○ If it branches left → enters liver
■ Takes a while for blood to come out the other side
○ There’s a “shortcut” → ductus venosus
 ■ Connects blood from the umbilical vein to the IVC (inferior vena cava)
■ Ductus venosus = another adaptation
● IVC is a large vein
○ Picks up blood from right and left legs
○ IVC is not oxygenated
● Where the ductus venosus connects to the IVC → blood is very oxygenated
○ Mixes with deoxygenated blood → not as oxygen rich as blood from umbilical
vein
○ Blood dumps into the right atrium
● Simultaneously → blood from SVC (superior vena cava) -- head & arm region
○ SVC blood ends up in the right atrium
○ Also deoxygenated blood
● Blood in right atrium
○ Some goes into right ventricle → gets squeezed → pulmonary artery → goes to
lungs
■ Air sacs in baby’s lungs → not full of air (bc in utero)
■ Air sacs are full of fluid -- not much oxygen
○ Hypoxic pulmonary vasoconstriction
■ Alveolus tries to help constrict the arteriole → bc there’s no oxygen →
alveolus causes arteriole to contract → increases the resistance of that
arteriole
■ Bc it’s happening in the millions of alveoli → entire lung will have a lot of
resistance
■ High pressure in pulmonary artery (bc of the high resistance)
● Pulmonary artery came from right ventricle
○ For forward flow of blood, need a lot of pressure in the right ventricle
● Pressure is high on the right side of the heart bc of the resistance in the lungs
● Right atrial pressure starts getting higher than pressure in the left atrium
○ Start getting blood flow from the right atrium across the foramen ovale
○ Since some blood can go across, see some blood continue into right ventricle &
some crossing into the left ventricle
○ Beneficial bc when blood is going across → don’t have much blood coming back
through pulmonary vein (bc it’s hard to get blood flow through the lungs bc of the
high resistance)
● Left atrium
○ Has a little bit of blood from pulmonary veins
○ Some blood from right atrium
○ From left atrium → blood goes down into left ventricle → left ventricle squeezes
blood into the aorta → aorta distributes blood all the way down
● Ductus Arteriosus
○ 4th adaptation
○ Little vessel that allows blood to go from the pulmonary artery to the aorta
○ Pulmonary artery has high pressure (d/t high resistance in the lungs) → blood
typically goes from high P to low P
 ○ Explains why there isn’t much blood coming back through pulmonary veins → a
lot of the blood goes into the pulmonary artery trunk → ends up going into the
aorta
■ Doesn’t even go into the lungs because of the high resistance
● Blood from ductus venosus goes into legs and into the internal iliac arteries
○ Lots of branches of the internal iliac arteries
■ One major branch → umbilical artery
● Umbilical Artery
○ Brings blood back towards the placenta
○ Placenta has a very low resistance → makes blood divert towards it

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IN CLASS NOTES 05/03/2021

● U.S. ranks 60th in maternal mortality

● Evidence-based elective options for health pregnant women
○ Waterbirth
○ Epidural anesthesia
○ Home birth
○ Midwife assisted birth
● Childbirth in the U.S. is NOT safer now than it was before
●
● Ignacius -- midwife?
○ Handwashing

History of Childbirth Practices in America

● 1800-1900
○ >95% deliveries at home, majority by midwives
○ Midwives trained in home countries (Europe and Africa) and as apprentices
○ Birth exposure/trust in women’s bodies AND fear
○ First hospitals opening -Childbed fever increasing
● Early 1900’s
○ Prejudice against the intelligence and capability of women, immigrants, black and
poor people (midwives)
○ Fear regarding those with knowledge of herbs, contraception and abortion

An interesting twist
● 1910 and 1912
○ Flexner Reports –evaluating medical student education
○ Recommend abolition of midwifery and hospitalization for all deliveries in order
to better train doctors
■ …but needed consumer “buy in”

The Plot Thickens

● 1914 - Twilight sleep introduced – scopolamine/Morphine
 ○ “Blissful Birth”…as far as they could remember
■ Twilight sleep became more “fashionable” with Queen Elizabeth
○ A few modifications
■ Restraints, lithotomy, episiotomy
■ Forceps (on live babies), hospitals
● High forceps delivery → pulling baby out from high in the pelvis
● Risk for neonatal death, neurological damage, cerebral palsy, etc.
■ **starting to manage care more & more; also intervening more & more**
○ This increased reliance on technology provided the consumer buy in → MDs now
seen as skilled providers)
■ Away from idea of “giving birth” to babies needing to be “delivered”
● Dramatic paradigm shift
● 1915 - Dr. DeLee described childbirth as a pathologic process that required intervention
to “save women from the evils natural to birth.”
○ Birth being seen as an abnormal part of life → creates more complication

The Perfect (Very Ugly) Storm

● 1920
○ “Pain-free” birth seen as status symbol -women’s rights issue
○ Feminist movement fueled Twilight Societies to force hospitals to offer services
to all (Despite U.S. MDs against!)
● 1915-1929
○ 41% increase in infant mortality and birth injuries
○ Childbed fever at epidemic rates (20-40% in hospitals)
○ The more we manage → the more complications that come from it

Impact of Twilight Movement

● Birth moved to hospitals
● Sedation became the norm
● Physicians became the norm
● Midwives began their decline
○ 1915 DeLee “I am heart and soul opposed to any measure which is calculated to
perpetuate the midwife.”

Pendulum continues to swing…

● 1935 - Advent of sulfa antibiotics to prevent childbed fever
○ Revolutionary to save life
● 1940’s - Epidural anesthesia introduced
● 1960’s
○ Less than 70 midwives practicing in the U.S.
○ 97% of births in hospitals
● These remaining midwives and a group of male OBs were largely responsible for:
○ Family centered care (dads in delivery room)
○ Childbirth education
○ Rooming-in and the resurgence of breastfeeding
○ Natural childbirth movement
 ○ End of twilight era

…and swing
● 1960s - Research showed cost-effectiveness and improved outcomes with CNM’s
● 1960 - Electronic fetal monitoring introduced
● 1970 - Rise to 25% women in medical schools
● 1973 - Roe v. Wade (more into women’s bodily rights)
● 1987 - Maternal Mortality rate hit all time low at 7.2/100,000
○ As trends were moving towards a less medical model / fewer interventions with
birth

Modern Trends
● 2007 - 97% of labors used Electronic fetal monitoring (87% continuous)
● 2008 - 61% Epidural rate (higher in young white women - 75%)
○ Higher epidural frequency in affluent women
● 2012 - 23.3% Induction rate- recent steady decrease
● 2013 - 32.7% Cesarean rate
○ NOT OK
○ Impact of overmanaging care

^^^All these increased interventions with no improvement in statistics for moms or babies in last
25 years – MMR now 18.0/100,000 (2014)**

Contemporary Childbirth
● Attitude - public, celebration, decreased trust in birth
○ Birth seen more as a norm → celebrated
● Emphasis on family centered childbirth without our “wise women”
● Increasing number of childbirth options
● Practice dependent on technology
● Information overload
● Increased medical-legal influence
● Healthcare Reform in process
● Use of complementary and alternative medicine (CAM) growing
○ Should be a balance of eastern medicine & western medicine → should be
combined into a holistic approach for best patient experience
● Special ethical issues

Options
● Caregivers – OB/GYN, CNM, FP, NP, CPM, lay midwife
○ Caution with lay midwife (no real certification / training)
● Where to birth – home, birth center, hospital, unattended
● Attendants – FOC (father of child), Doula, Friends, unattended
● Baby provider – Pediatrician, PNP, FPP, PA
● Newborn nutrition – breast, formula, banks, milk sharing
● Childbirth education – Bradley, Lamaze, hypno-birthing
2 steps forward, 1 step back?

1900s Now

Attitudes Women’s work, lots of dangerous Family centered / fear

exposure, dangerous

Providers Poor, no formal training “granny -Collaborative OB/CNM/FP

midwives” -Only 8% are cared for by
midwives

Values “Puritan Values” – prejudice Evidence Based Care

against black, poor, women, Medical-legal
immigrants Healthcare reform
Positive birth experience

Techniques Hands-off -High tech - use of EFM (external

fetal monitoring) / CLE (epidural)
/ IOL (inductions of labor) /
Cesarean
-CAM resurgence

Location 98% home birth 98% hospital birth

Special Ethical Issues in OB

● Maternal-fetal conflict:
○ Does the fetus have rights?
○ Do women/parents have the right to refuse treatment for their fetuses?
■ Yes they do
● Assisted reproductive technology
○ Selective reduction
● Abortion
● Stem cell research
● When to resuscitate a preterm baby on the edge of viability?
○ About 24 weeks – depending on the circumstances

So how are we doing now?!?

● U.S. spends more than any other country on maternal health care!
● Approximately $98 billion spent annually, but the U.S. maternal mortality rate has more
than doubled in the past 27 years.
● U.S. is the only developed country and one of only 8 countries worldwide to show an
increase in maternal mortality
● Where does the U.S. rank in the world for maternal mortality?
○ 60th!!!
 ■ meaning 59 countries were better at keeping new mothers alive.
■ Triple the U.K’s rate and 8 times that of Iceland
● Blacks -- highest maternal mortality rate

Why Do Women Die? Worldwide: 2014

● Pre-existing conditions (28%)
● Hemorrhage (27%)
● Hypertensive disorders of pregnancy (14%)
● Infections
● Obstructed labor/other
● Abortion complications
● Blood clots/embolisms

**Need to consider what we can do before, during, after pregnancy to prevent these
complications → most of it starts with listening**

Colorado Statistics 2015

● 29th in the U.S.
● Pregnancy until 6 weeks after
○ Accidental drug overdose
○ Pulmonary embolism
■ Pregnancy puts women in a hypercoagulable state
○ MVA
● Up to 1 year post delivery
○ Accidental drug overdose
○ MVA
○ Suicide
● Other
○ CVA conditions
○ Hemorrhage
○ Infection

What About Our Babies?

● Rank in the industrialized world
● 26th out of 29 countries
● Highest preterm birth rate of the 19 countries studied
● Figure 1: International Comparisons of Infant Mortality and Related Factors: United
States and Europe, 2010. National Vital Statistics Reports 60 (5).

U.S. Variations in Infant Mortality

● Wide variations between states:
○ Highest: Mississippi- 9.25/1,000
○ Lowest: Massachusetts-4.21/1,000
● ~16% black babies born preterm vs. 10% of white infants
Figure 5. Infant mortality rates for the 10 leading causes of infant death in 2016: United States,
2015 and 2016

OH NO!!!!!!
● What can we do?!?!?!?
● Utilize appropriate providers- collaborative approach of midwives, OB’s, family practice
doctors and NURSES!
● Use technology appropriately
○ Decrease rates of unnecessary inductions, epidurals, electronic fetal monitoring,
cesarean sections
● Address our biggest problems

Morbidity and Mortality

● Maternal
○ Infection
○ Hemorrhage
○ Hypertension
○ Emboli
● Neonatal / Fetal
○ Congenital anomalies
○ Short gestation/low birth weight
○ SIDS
○ Consequences of maternal disease
○ Unintentional injuries
● 600 maternal death
● 65,000 women suffer severe pregnancy tcomplications
● IPV (intimate partner violence)
○ Increases during pregnancy
● Smoking
○ 1 in 5 before
○ 1 in 10 in 3rd trimester
● 15% have substance abuse problems
● 1 in 9 -- major depression
○ 1/2 treated
● 1/2 obese or overweight
● 20-30% drink alcohol at some time in pregnancy

Risk Factors
● Socioeconomic status (SES)
● Marital status
● Homelessness / houselessness
● Substance use and abuse
● Employment
● Culture: female circumcision
● Religion: Jehovah’s Witness & blood products
 ● Ethnicity: African American, Jewish, Hispanic
● Age: teens; advanced maternal age (AMA)
● Educational level
● Past and current medical history
● Previous Ob/Gyn history
● Domestic violence *escalates with pregnancy
● Barriers to health care
● Nutrition
● Obesity
● Mental health

Nursing Implications
● Pay attention to the constant pendulum
● Know where you are coming from, both in terms of historical perspective and your own
personal bias
● Keep your mind open to the possibility that we don’t have this all worked out yet
● Always be on the lookout for ways to improve care for women and their families

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REPRODUCTIVE SYSTEM

Breast Anatomy
● Breast tissue primarily composed on fatty tissue & granular tissue
● Amount of breast tissue does not correlate with amount of breast milk
● Costochondritis
○ Lower rib flaring
● Nipple does not have a single opening
○ Have anywhere from 10-20 openings that milk is released from
● Breasts enlarge during pregnancy
● Montgomery’s tubercles
○ Goosebump like protrusions
○ May become bigger during pregnancy
○ Tubercles secrete sebum to protect the nipple during pregnancy & after → help
keep skin integrity intact
● Areola becomes darker, may become bigger

Breast Anatomy
● Breast
○ Granular Tissue for milk production
○ Connect Tissue for support
○ Adipose Tissue for cushion
● Areola
○ Montgomery’s tubercles for lubrication
● Nipple
○ 15-20 Lactiferous duct openings
Uterus
● Vagina tissue → folds of tissue, meant to stretch
● Cervix - natural opening to the uterus inside the vagina
○ Darker color than vaginal wall
○ Looks like a tight circle
○ 2 openings
■ External os
■ Internal os
● Closes more firmly
● Fallopian tubes
● Fundus = top of the uterus
○ Fundal height -- point of pubic symphysis to top of uterus
● Isthmus - lower uterine segment
● Endometrium - uterine lining that grows, thickens with every menstrual cycle
○ If conception happens →this is where implantation occurs
○ If conception does not happen → sheds -- monthly period
● Uterine muscle layers
○ Outer
■ Longitudinal muscle layer
■ Contract for expulsion of the fetus
○ Middle
■ Interlacing muscle fibers
■ Constricts blood vessels
○ Inner
■ Circular muscle fibers
■ Form sphincters at the fallopian tubes
■ Key for maintaining cervical integrity during pregnancy & dilation in
labor

Hormones
● 3 major cycles
○ HPO axis
■ Feedback system happening in the body to promote regulation
○ Ovarian cycle
■ What's happening in the ovaries
■ Maturation of the eggs that are pushed out in ovulation
○ Endometrial cycle
■ Preparing uterus for an egg

Control of the FRC

● Hypothalamus → Pituitary → Ovary
○ H-P-O (or H-P-A axis)
○ System of regulation
○ Typically negative feedback loop
■ Occasionally some positive feedback
 ● Hypothalamus
○ GnRH (gonad releasing hormone)
● Anterior Pituitary
○ FSH, LH
● Ovaries
○ Estrogen, progesterone
○ Elevations of Estrogen and Progesterone inhibit GnRH

Anterior Pituitary
● FSH – Follicle Stimulating Hormone
○ Stimulates the follicle (which houses the eggs) to grow and mature
● LH – Luteinizing Hormone
○ After ovulation, converts the empty follicle into the corpus luteum and supports
this structure (which in turn supports an early pregnancy until the placenta forms)

Primary “Female” Hormones

● Estrogens – 3 predominant
○ Estradiol
■ Available only during reproductive years
○ Estriol
■ Available only during pregnancy
○ Estrone
■ The estrogen of menopause
■ Made from fat cells
● Progesterone
○ The hormone of pregnancy
○ Progesterone → “pro gestation”
○ Sustains uterine environment for pregnancy
● Prostaglandins
○ PGE: vasodilatory; smooth muscle relaxant
○ PGF: vasoconstrictive; smooth muscle contractor

● Never want to give estrogen unopposed → could increase incidence of endometrial

cancer
○ Progesterone opposes estrogen
○ Helps control lining so it doesn’t become problematic
● Progesterone used in IUDs bc it inhibits growth of uterine lining
● Progesterone alone = OK
● IUDs
○ Thicken cervical mucus to inhibit sperm from getting through
○ Creates hostile environment for sperm that kills them if they get into the uterus
○ Progesterone-based IUDs can inhibit ovulation to an extent

Ovarian Cycle

● Follicular Phase (days 1-14)

 ○ First phase → follicular
○ Growth of follicle from primary to mature
■ One follicle becomes dominant
■ LH surge → release of the egg
● Helps grow & maturate egg
● Release of egg = ovulation
■ Estrogen dominance
● Helps get uterine lining ready for an egg
● Uterine lining proliferation
■ Variable phase (variable length)
● Luteal Phase (days 15-28)
○ Conversion of empty follicle into the corpus luteum
■ Produces progesterone
○ Progesterone dominance
○ Relatively constant (average 14 days)
■ Constant 14 days -- typically
● 21-35 day cycle is normal
○ 28 day cycle is average

Uterine/Menstrual Cycle
● Ischemic/Menstrual Phase (bleed)
○ 1st day of bleeding
● Proliferative Phase
○ Estrogen dominance → building up the lining
● Secretory Phase
○ Progesterone dominance
■ More proliferation
■ Preparing for an egg
○ Ready for the EGG
● If no pregnancy → Menstrual Phase again
○ No progesterone → endometrial lining sloughs off
● If egg fertilizes → sends chemical messengers to ovaries telling it to keep good
environment
● Ovarian cysts
○ Usually start with follicle rupturing
○ Rupture to release the egg
○ Should breakdown (if not pregnant)
○ Sometimes doesn’t breakdown → ovarian cyst
Menstrual Cycle Length

● Conceiving with the window before period

○ Like 14 days before
○ Ovulation occurs 2 weeks before period
 ● Period cramps
○ D/t uterine contractions → r/t prostaglandins
○ NSAIDs are helpful → inhibit prostaglandins
○ Endometrium does not have pain receptors
■ Muscle layers do have pain receptors
● One of the primary reasons for irregular periods → PCOS
○ Higher risk of endometrial cancer, gestational diabetes, infertility issues

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CONCEPTION & FETAL DEVELOPMENT

Basics
● In a 28 day cycle, conception occurs 2 weeks after 1st day of the LMP (last menstrual
period)
○ Aka 2 weeks before the period would occur
● Gestational age → includes the LMP and the following week (pre-ovulation) for
STANDARDIZATION
○ Adds 2 weeks to pregnancy
● Pregnant for 266 post-conceptual days
● Pregnant for 280 gestational days
○ 40 weeks
○ 10 lunar months
○ 9ish calendar months
○ 4-8% born on exact due date, 80% born +/- 2 weeks

Gestational timeline
● Embryogenesis
○ Dominant part of 1st trimester
● Fetal development around 11-12 weeks
● Second trimester until about 26-27 weeks
● Around 24 weeks → about 50% survival chance (if baby born at that time)
● Before 37 weeks = preterm
● 37 weeks = term
● 37 - 42 weeks = term window
● After 42 weeks = postmature
○ Placentas have shelf lives

Fertilization: The Key Players

● Eggs
● Sperm

300 million deposited in the vagina. Why so many?!?!

● Lots of things can impact quality of sperm
● Not all of them will be formed perfectly
● Diet, health, medication, heat sources, underwear, if male is a cyclist
Conception/Fertilization
● Mature egg meets remaining sperm in the ampulla (outer 1/3 of fallopian tube)
○ Egg survives 12-24 hours (fertile period 6-12 hours)
○ Sperm survive up to 72 hours (some say longer)
○ Conception happens in the outer 1/3 of fallopian tube
● Capacitation:
○ Removal of sperm’s plasma membrane which allows acrosomal reaction
● Acrosomal reaction:
○ Allows production of enzymes to weaken corona radiata
○ Zona reaction – blocks penetration of other sperm
● Great video:
http://www.nucleuscatalog.com/fertilization-2012-siggraph-computer-animation-festival/
view-item?ItemID=75011 (link in class 1 resources and readings)

Fertilization and Pre-Embryonic Stage

● Ovary supported by ligaments
● Ovary & fallopian tubes are not connected
○ Fallopian tubes → finger like tubes around ovary

Two processes of growth occur

● 1. Cellular multiplication
● 2. Cellular differentiation

Cellular Multiplication
● 46 chromosomes
● Zygote
● Blastomere
● Morula of 12-16 cells
○ The inner & outer cell mass
● Inner cell mass is the blastocyst (100 cells)
○ Embryonic disc + amnion
● Outer cell mass is the trophoblast
○ Chorion + placenta

Zygote – 1st 2 days

● 46 chromosomes

Cleavage begins
● Mitotic cellular replication begins in the tube
● In fallopian tubes
● Peristalsis gently sweeping

Morula - Day 3
● 16 cell ball
● No change in size, about the size of the head of a pin
 ● Fertilized egg has NOT implanted yet
● Cell multiplication in fallopian tube → still making its way to the uterus
● Cellular sex if being determined → but can NOT see on US at this point

Blastocyst and Trophoblast formation – Day 4-5

● Blastocyst: inner mass cells (stem cells) become:
○ Embryo
○ Amnion
○ Yolk sac
● Trophoblast: outer cell layer becomes:
○ Chorion
○ Placenta

Implantation – Trophoblasts → Day 6-10

● Burrow into endometrium
● Early placenta
● Formation of chorionic villi
○ Secrete hCG, maintains Estrogen and Progesterone
○ Inhibits ovarian and menstrual cycles → to prevent shedding of uterine lining
& to prevent ovulation so another cycle doesn’t occur while egg is maturing

Cellular Differentiation: days 10-14

● Primary germ layers differentiate
○ Ectoderm, endoderm, mesoderm
■ These germ cells determine all of our organ systems
● Embryonic membranes form
○ Chorion, amnion
■ Chorion side = maternal side
■ Amnion side = fetal side
● Amniotic fluid
● Yolk sac for primitive RBCs
○ Yolk sac is supportive of pregnancy until the placenta takes over
● Umbilical cord
● Very fast time for development
● Also a very sensitive time for embryo → time where a lot can go wrong

Chorion
● Chorionic villi extend into maternal blood filled endometrium
○ Intervillous space is site for gas, nutrient and waste exchange
● Maternal circulation vs. fetal circulation
○ Mom & baby’s blood should NOT mix
○ Gas nutrition exchange happens in intervillous space
○ Exchange does NOT happen within the blood

Chorionic Villi
● Where the gas & waste exchange happens
 ● Is part of the placenta

Amnion
● Inner cell mass (blastocysts)
○ Amniotic cavity
● Adheres to chorion
● Umbilical cord
○ 2 umbilical arteries
○ 1 umbilical vein

Embryo’s critical developmental stage (10-14 days after conception)

● Very sensitive time
○ Where things can go wrong
● This is the MOST sensitive time
● Teratogens
○ Anything that could impact development of embryo
● 3 Germ layers
○ Ectoderm
■ Epidermis, hair, teeth, nose & CNS
○ Mesoderm
■ Dermis, muscles, bones, kidneys, CVS, lymphatic tissue, spleen
○ Endoderm
■ Respiratory & digestive tract linings, bladder, liver, pancreas

Morphologic Development after Conception (also, when these structures most vulnerable to
damage)
● Week 1 –Fertilization-blastocyst
● Week 2 – Implantation
● Week 3-10 – Mesoderm, Ectoderm, Endoderm differentiate to form ALL organ systems
● Embryo is most likely to be damaged during this time
● There is an all-or-none effect for the first 2 weeks of pregnancy prior to the implantation
○ Before woman knows she’s pregnant
○ If the damage happens → either 2 things will occur
■ Embryo will not implant
■ OR the development will resolve the impact
○ Recurrent use of alcohol after implantation can lead to fetal alcohol syndrome

Teratogens
● About 20% of pregnancies result in miscarriages
● Cause of abnormal development in an embryo
○ Chromosomal
■ Majority happen at the chromosomal level
○ Drug related
■ Prescription (Category D or X)
● Testosterone -- cat X
● Accutane -- cat X (black box warning)
 ■ OTC, Herbal, Caffeine
■ Recreational drugs
● Cannot support use of THC or CBD during pregnancy
■ ALCOHOL – no documented safe minimum
○ Radiation or other environmental related exposure
○ Infectious agents – TORCH
● Website for consumers otispregnancy.org
● A miscarriage does not put them at risk for a future one
● Category A Drugs
○ Safe with pregnancy
○ Few in number
○ Synthroid, folic acid, certain supplements
● Most meds during pregnancy → Category B
○ Tylenol, Colace, lots of OTC
● Category C
○ Likely newer medications
○ Probably safe → still evaluating

Drug Classification
●
●

Fetal Developmental Milestones

● Heart beats 28 days after conception
○ Able to see this on US at 6 weeks gestations
● Male differentiation begins @ 4-6 weeks
○ Though this is typically not detectable on US until 16-20 weeks gestations
○ Due to sex region determining gene on the ”short” arm of the Y chromosome
● All organ structures formed by 8 or 10 weeks
○ Organogenesis
● Fetal breathing movements and fetal hearing develops by about 16 weeks
● Youngest preterm survivor: 21 4/7 weeks
● Key points (27-281) lists embryonic and fetal development points parents most interested
in

Crown to rump length

Limb buds → arms, legs

Fetus at 9 weeks
● Placenta formation
● Umbilical cord is becoming more defined
● Starting to see earbuds
● Limb buds starting to become fingers and toes
● Starting to see movement on US
● CRL → crown to rump length
20 weeks
● Big US → review the major organ systems
● Sometimes can tell sex at this point
● Fetal movements strong enough for the mother to feel

Umbilical Cord
● From the connecting stalk
● 2 arteries + one vein
○ Arteries Away from fetus
■ Arteries more muscular & large
○ Vein to fetus
■ Vein is longer, smaller
■ Bring nutrients to the fetus
○ Wharton’s jelly
■ Supports the vessels so they don’t kink / get compressed
● Fetal nutrition via umbilical cord

Amniotic Fluid
● The fluid cushions the fetus from injury
● The fluid enables the fetus to grow
● The fluid provides the fetus with a stable thermal environment
● The fluid enables the fetus to practice swallowing
● Amniotic fluid is primarily made of… baby’s urine

My Swimming Pool: Amniotic Fluid

● Early pregnancy: diffusion from maternal blood
● After 20 weeks: largely fetal urine
○ Fetus swallows & urinates = up to 1000 mls by term
● Functions:
○ Temperature stability, prevents adherence to membranes, allows for MS
(musculoskeletal), GI, breathing “practice,” protects fetus, keeps umbilical cord
from crimping
● Contains
○ Urea, uric acid, bilirubin, fructose, fat, leukocytes, proteins, epithelial cells,
enzymes, and lanugo (hair)

Placenta
● New, temporary organ
● Composed of cells from 2 individuals
● Part maternal (decidua) and part fetal (chorion)
● Uterine lining develops “decidua basalis” that is receptive to chorionic villi
● Trophoblast differentiates into:
○ Cytotrophoblast (inner layer)
○ Syncytiotrophoblast (outer layer)
Placenta: functions
● Endocrine: hormone production
○ Human placental lactogen (hPL)
■ Can impact circulating glucose & insulin resistance → gestational
diabetes
○ Human chorionic gonadotropin (hCG)
○ Progesterone, Estrogen
● Metabolic
○ Facilitates hydrostatic & osmotic pressure gradients for active & facilitated
transport of nutrients & waste

Placenta
● Fetal surface is smooth
● Amniotic fluid = baby side
● Maternal side = beefy, vascularized wall
Vascular arrangement of placenta

● The ductus arteriosus lies between the aorta & the pulmonary artery
● The ductus venosus is the structure that allows the blood to bypass the liver
● Umbilical vein contains oxygen rich blood

Goals of Fetal Circulation

● -Maintain flow to the placenta
● -To shunt blood away from lungs and liver
● Accomplished by 3 holes:
○ Ductus venosus (liver bypass) umbilical vein to IVC
○ Foramen ovale (right ventricle bypass) hole b/t right & left atria
○ Ductus arteriosus (pulmonary artery/lung bypass) hole b/t pulmonary artery &
descending aorta
● These must close AFTER birth

Twins
● Dizygotic (Fraternal): occurs 1:80 pregnancies
○ More common
○ 2 follicles form in follicular formation
○ 2 separate eggs released in chromosomal eggs → fertilized by 2 different sperm
○ 2 eggs, 2 sperm
● Monozygotic (Identical): 4/1000 live births
○ Egg & sperm → fertilized → separate
○ Chromosomally identical
● Monozygotic monoamniotic is very dangerous
 ○ Babies in the same amniotic sac
● Usually monozygotic diamniotic sacs

Case Study
● Tammy is a 23 year old who has come in for her 1st prenatal visit.
● What date would you use for her LMP?
● What is the most likely cause of the spotting on the 24th?
● Who’s the (most likely) daddy?
● When is the most likely time of conception?
● She’s freaked out that she’s harmed her baby. What do you tell her?
● It’s June 10th today, so how far along is she in gestational weeks?
●
●
●
●
●

→→→
 OB DAY 2 - 05/06/2021

***Exam review Sunday from 7-8

-Do a case study → walk through concepts together, will be recorded

Physiologic Changes, Common Discomforts and Psychosocial Adaptations to Pregnancy

● Hcg → good indicator that client is pregnant

● Oxytocin comes into play towards the end of pregnancy
○ Released with breastfeeding
○ Helps the uterus contract down after birth to reduce bleeding
● Luteinizing hormone
○ Part of the menstrual cycle that maintains endometrial lining until conception

Signs of pregnancy
● Presumptive
○ Subjective
○ Those things the woman experiences and reports
● Probable
○ Objective
○ Those things the provider can observe/measure
● Positive
○ Can’t be anything else

Positive Signs
● Fetal heartbeat per doppler of fetoscope
● Fetal movement (per trained provider)
● Visualization of fetus on US

Presumptive
● Symptom
○ Amenorrhea
○ Nausea
○ Vomiting
○ Urinary frequency
○ Breast tenderness
○ Darkened areola
○ Quickening
○ Weight gain
○ Fatigue
● Other causes
○ Malnourished
○ Stress, weight changes
○ Athletes
○ PCOS
 ○ UTI
○ Weight gain

Probable
● Symptoms
○ Goodell’s, Hegar’s sign
○ Chadwick’s sign
■ Discoloration of the cervix
■ Dustiness to the cervix
○ Braxton Hicks
■ Can be menstrual like cramping, or LBP cramping
○ Uterine souffle
■ Soft, blowing sound heard using a stethoscope
■ Distinct upon auscultation
○ Linea nigra
■ Line of darkening pigmentation that bisects the abdomen
○ Abdominal striae
○ Ballottement
■ When the lower uterine segment or the cervix is tapped by the examiner's
finger and left there, the fetus floats upward, then sinks back and a gentle
tap is felt on the finger
○ Palpation of fetal outline
○ Abdominal enlargement
○ Positive pregnancy test
● Other Causes
○ Pelvic congestion
○ Infertility medications
○ Fibroids
○ Maternal pulse
○ Birth control pills
○ Sudden weight gain
○ Tumor, Ascites
○ Didn’t use test correctly, Hcg diet, Hcg-secreting tumors, false result
○ Medications - valium, phenobarb...

Family Changes a.k.a. “This is Amazing/OMG, what have we done?!”

● Happiness
● Worry
● Role “Crisis”
○ Are we financially ready, will we change who’s home or not
● Body image
● Financial concerns
● Concern over relationship with partner
● Concern over hurting fetus
● Hensley’s Rules:
○ 1. Include the partner.
 ○ 2. Don’t assume the gender of the partner.

Psychosocial Adaptations to Pregnancy: The Mother

● 1st Trimester
○ Surprise, even when planned
○ Ambivalence Acceptance
○ Focus on discomforts of pregnancy
○ Fears and fantasies
● 2nd Trimester
○ Accept growing fetus as separate from self
○ Introversion, self engrossment, mood swings
○ Starting to feel a bit more like herself
○ Start feeling fetal movement
○ Reassurance that things are normal
● 3rd Trimester
○ Prepare for birth
○ Focus on physical discomforts
○ Contemplation of her assumption of maternal role
○ Starting to get uncomfortable again
■ Pushing on bladder
■ Back pain
■ Difficulty sleeping

Psychosocial Adaptations to Pregnancy: The Partner

● 1st Trimester
○ Excitement
○ Feel excluded
○ Partner wants a job through all of this
● 2nd Trimester
○ **Sense of engagement with felt fetal movement
○ Adapt to physiologic changes in mother
● 3rd Trimester
○ Prepare for role of “coach” for birth / delivery
○ Assumption of role of parent, may not occur until after birth
○ Encourage birth classes
○ Keep partner included, get them involved

Partner Couvade
● Unintentional taking on the physical symptoms of the pregnant partner
● Low back pain
● Nausea
● Weight gain

Physiologic Causes of Common Pregnancy Discomforts

● Hormonal Causes
 ○ Estrogen
○ Progesterone
○ Relaxin
■ Relaxes ligaments & joints
■ To accommodate for delivery
■ More sensitive to injury → sprains & falls
○ Human placental lactogen
■ Produced by the placenta
■ May lead to insulin resistance over time
○ Prolactin
○ Oxytocin
○ Human chorionic gonadotropin

● Mechanical Issues
○ Enlarging uterus
○ Weight gain
○ Postural changes
■ Lumbar curvature as uterus grows out
● Impacts walking
○ *Emotional stress (nausea, HA, difficulty sleeping, etc.)
■ Headaches common in 1st trimester

Normal Physiologic Changes

● Vagina and uterus
● HEENT
○ Adequate dental care is important
○ Link between gum disease & early labor..?
● Skin and hair
● Breasts
● Respiratory
● Cardiovascular
● Hematologic
● Gastrointestinal
● Renal
○ As baby growing → pushes down on bladder
○ Decreased renal threshold for sugar
○ Increased GFR
○ Decreased BUN, creatinine, uric acid
● Musculoskeletal
● Most likely pregnancy symptom to present in the first trimester
○ Constipation
● Swollen ankles → seen more 3rd trimester with fluid shift
● Which of the following recommendations is NOT an effective & safe evidence-based
nausea treatment in pregnancy?
○ Castor oil
■ Could cause a women to go into labor
■ Causes bowels to empty → vicious diarrhea (impacts fluid balance)
● OK for Nausea tx in pregnancy
○ Doxylamine (Unisom)
○ IV fluids (NS)
○ Pyridoxine (vitamin B6)
● NOT a recommended intervention for the following pregnancy related discomforts
○ Swollen ankles - imit fluid & salt intake
● OK interventions
○ Maternity support belt for backache
○ Fatigue & SOB → check H&H (hemoglobin & hematocrit)
Vagina and Uterus
● Caused by estrogen & progesterone
○ Chadwick’s sign (blue tinge to cervix/vagina)
○ Goodell’s sign (cervical softening)
○ Hegar’s sign (softening lower segment)
● Enlarging uterus (see following) - hypertrophy estrogen
● Leukorrhea - estrogen
○ Thin, nonsymptomatic, white discharge
● Braxton Hicks - estrogen & oxytocin
● Mucus plug - estrogen
○ Passing of a mucus plug does NOT mean labor is imminent

The Enlarging Uterus

● Pay special attention to the effects on:
○ Lungs/diaphragm
○ Intestines
○ Bladder
○ Spine curvature

● 20 weeks 28 weeks
● 36 weeks 40 weeks

● 40 weeks
○ Pelvic & bladder pressure become more noticeable

HEENT
● Eyes may change shape – vision changes
● Ptyalism (Hyper salivation)
● Bleeding gums - estrogen & progesterone
● Nose bleeds - estrogen & progesterone
○ Do NOT want to use vaseline
■ Not water soluble
■ Can get into the lungs → impact gas exchange
● Feeling of fullness/stuffiness in ears, nose and sinuses
○ Humidifier
○ Saline sprays are ok
● Senses
○ Heightened taste, smell – may lead to food aversions

Skin and Hair

● Due to estrogen & progesterone
○ linea nigra*
■ Usually fades after pregnancy
○ Melasma (aka Chloasma)*
○ Darkening areolae, vulva, axilla
 ○ Acne vulgaris
● Spider nevi* - progesterone
○ Aka cherry angiomas
○ Should be small & circumscribed
● Striae -50-90%*
○ Depend on genetics, collagen, growth spurt, etc.
○ Most of the time fade after pregnancy → fade to be more in tone
○ May be very itchy & annoying
■ Can use hypoallergenic creams to soothe them
● Increased hair and nail growth (prolonged growth phase, less in resting phase) - estrogen
● Palmar erythema - progesterone

Breasts
● Estrogen & progesterone cause
○ Enlargement - glandular hypertrophy
○ Tenderness and sensitivity
○ Nipple sensitivity
■ Wear a nice supportive jog bra
● Human Placental Lactogen also causes breast development
● Vein prominence - Progesterone
● Nipples become more erect
● areolar changes – darkening, enlargement - Estrogen
● Montgomery’s tubercles
● Colostrum – from 12 weeks - prolactin
○ Development of breast milk

Respiratory
● Respiratory alkalosis - r/t increased RR, increased O2 consumption
● Capillary engorgement and swelling nasal passages, epistaxis → Estrogen
● Upward displacement of diaphragm
● Rib cage flare
● Increased respiratory rate
● 20% increased oxygen consumption

Cardiovascular
● Left lateral displacement of heart
● Increased stroke volume, heart rate, cardiac output
● Vasodilation with subsequent drop in BP → Progesterone
○ Recovers as pregnancy progresses
● Increase in resting heart rate by 10-15 bpm
● Systolic murmur up to 90%
○ Should be benign
● Increase in blood volume , max at 32 weeks (50% increase in plasma volume)
○ Most of blood volume will be plasma
○ Physiologic anemia of pregnancy → bc BV increase isn’t r/t RBCs
■ In the THIRD trimester
 ○ Normally do CBC around 28 weeks to check for anemia
● Increase in clotting factors

Hematologic
● Increase in plasma and RBCs but it’s NOT proportional
○ “physiologic” anemia of pregnancy
■ Low Hemoglobin (treat at <11)
■ Fetus begins to store iron after 20 weeks
● Starts storing iron from the mom
● Anemia from fetus storing iron & the hemodilution
○ Related to hemodilution
■ RBC increase is not proportional
● Immunocompromised
○ Elevated WBC - normal (to an extent)
○ More susceptible to coughs, cold, flu, GI issues
● Increase in clotting factors

Gastrointestinal
● Displaced stomach/intestines
● Decreased GI motility and emptying (gas, constipation) → Progesterone
● Nausea and vomiting → HCG
● Decreased gallbladder emptying *risk for stones → Progesterone
● Progesterone causes “valve” between stomach and esophagus to “soften” -heartburn
● Dilated vessels - hemorrhoids
○ R/t Progesterone & mechanical impact of uterus affecting blood flow to
extremities
● Elevated alkaline phosphatase – no clinical significance

Renal
● Increased renal blood flow
● Dilation and urinary stasis in renal pelvises (droopy ureters)
○ *Risk for UTI/pyelonephritis
○ Progesterone
● Increased glomerular filtration rate (though “sloppy” so glucose and traces of protein may
be spilled)
● Increased frequency
○ Mechanical compression of bladder
○ Increased urine out of 200 mL more urine per day

Musculoskeletal
● Loosening of joints → relaxin, P, E
○ Widening /increased mobility of pubic symphysis and sacroiliac joints, useful to
fit out babies
■ Can cause discomfort / severe pain
○ Cause loosening of knees, ankles, wrists, other joints
○ Postural changes with associated lower back pain
 ○ Exaggerated lordosis
● Altered center of gravity
● *SAFETY - prone to slips, trips and falls

Round Ligaments
● Get loose with activity
● Round ligament pain
● Persistent or worsening pain → more concerning

Special Concerns
● Edema → E, P, mechanical
● Hands – Carpal Tunnel (pseudo CT)
○ Could get carpal tunnel splints from pharmacy at night
● Feet – “Cankles”
● Vena Cava Syndrome
○ Enlarged uterus compresses the inferior vena cava and the lower aorta when
patient is supine
■ Reduced venous return to heart
■ Symptoms include decreased BP, lightheadedness, syncope, racing heart,
sweating, fetal heart rate changes
■ *implications for prenatal care and LABOR!
● Around 20 weeks → don’t want pts to be flat on their backs
○ Don’t do exercises where they’d be flat on back
○

How do you know if it is…Common Discomfort OR Significant Problem

● Good history
● OLD CARTS
● QRST
● Good physical
● It’s always serious until it’s proven not
● Pregnancy is one time that it’s okay to “chase zebras”

----------

GS & PS (GRAVITY & PARITY)

Describing the pregnancy

● Gravidity
○ Any PREGNANCY, regardless of duration
■ How many times you’ve been pregnant
○ Includes current pregnancy (if currently pregnant)
● Parity
○ Number of times the uterus has emptied after 20 weeks, regardless of outcome
○ Just the number of birth events
 ■ Does NOT count babies // does not differentiate between vaginal &
surgical delivery
■ Twins → counts as 1
○ Just the labor & delivery event
● Nulligravida: Never been pregnant
● Nullipara/ Nullip: Never given birth to a fetus >20 weeks
○ Could have had a miscarriage
● Primigravida: Pregnant for the first time
● Primipara/ Primip: Has given birth once to a fetus > 20 weeks (uterus has opened 1x)
○ *In L&D, you may hear nurses loosely refer to those in labor that are about to
become a Primipara as “Primip” as well
● Multigravida: Pregnant more than once, irrespective of outcome
● Multipara/ Multip: Two or more births > 20 weeks gestation
● Grand multipara: five or more births > 20 weeks gestation

Two digit system of describing pregnancy

● Two digit – Gravidity and Parity “Gs & Ps”
○ Gravidity or “G”: refers to the number of pregnancies the woman has had,
including the current one
○ Parity or “P”: refers to the number of births after 20 weeks
■ Does not include miscarriages or abortions before 20 weeks
● Ex: 2 births 1 miscarriage
○ Gravity 3
○ Para 2

Five digit system for describing pregnancy

● Five digit- “G TPAL”
● Typically written GX PXXXX--the “P” still refers to parity but the numbers listed after
this “P” further define the outcome of each pregnancy and include the number of term,
preterm (which add up to the # of births after 20 wks), abortions, and living children
● G (gravidity): refers to the number of pregnancies the woman has had, including the
current one
● Term: number of births ≥ 37 weeks, regardless of the outcome
● Preterm: number of births from 20 weeks to < 37 weeks (36 & 6 days)
● Abortions: loss of the pregnancy less than 20 weeks; spontaneous (miscarriage) or
therapeutic (lay definition of abortion)
○ Ectopic pregnancies are included in “A”
● Living: number of children currently living

Examples
● Example #1
○ W.C. is pregnant for the 4th time
○ She lost the 1st pregnancy at 12 weeks
○ She has 2 children at home
■ One was born at 38 2/7 weeks, living
■ One born at 34 5/7 weeks, living
 ○ How would you describe her pregnancies using both systems?
■ G4P2
■ G: 4, Term: 1, Preterm: 1, Abortions: 1, Living: 2
● If pregnant currently → G will be 1 more than TPA combined

● Example #2
○ T.J. is pregnant for the 3rd time
○ She had a fetal demise at 36 weeks
○ She has a 3 year old at home who was a term pregnancy
○ How would you describe her pregnancies using both systems?
■ G: 3 / P: 2
■ G: 3, T: 1, P: 1, A: 0, L: 1 OR G3 P1101

● Example # 3- “Kate plus 8”

○ She has been pregnant 2 times
○ She had 1 twin pregnancy (we will assume that these were term)
○ She had the sextuplets (we know that these were preterm)
○ How would you describe her pregnancies?
○ G2 P2
○ G 2 T 1 P 1 A 0 L 8 OR G2 P1108

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PRENATAL CARE

● Preconception care goals

(in my own little perfect world)
● Normal BMI –nutrition
○ Underweight: 18.5 and below
○ Normal: 19-25
■ *24 in asian ethnicities
○ 30 is obese
● Regular daily exercise
○ 30 min moderate daily
● Vaccines up to date
○ Rubella, varicella
● Dental work up to date
○ Preterm labor
● GYN care up to date
○ std, pap screening
● Begin tracking menses
○ Accurate dating
● Prenatal Vitamin(folic acid)
○ Neural Tube Defects → like spina bifida
● D/C caffeine, tobacco, ETOH, illegal drugs, some Rx meds
○ Withdrawal
 ○ Better to wean off of these things
● F/U on chronic health, including psychiatric, issues
○ Effects of pregnancy
● Genetic testing/counseling
○ Planning

Prenatal Care Goals

● Unfortunately, most of these “preconception” goals are not addressed until after
pregnancy is established at the first prenatal visit.
● At that visit, as well as subsequent prenatal visits, we also have the following goals…
○ Establish and accurately date the pregnancy
○ Evaluate for risk factors and try to prevent risk
○ Give support for common discomforts
○ Provide anticipatory guidance for birth, parenting, role change, breastfeeding, etc.

Establishing the pregnancy

● Missed menses
● Positive home urine pregnancy test
● Positive lab urine hCG
● Positive lab blood hCG-qualitative or quantitative
● Fetus noted on ultrasound

Dating the pregnancy

● How long does pregnancy last?
○ It’s supposed to last 37-42 weeks
■ Due Date is 40 weeks after the LMP or
■ 280 days from the LMP
● Due date:
○ EDD-Estimated Due Date
○ EDC-Estimated Date of Confinement
○ EDB-Estimated Date of Birth
● Nursing Caveat: only 4% of babies are actually born on their exact EDD, 96% are born a
different day!

Naegele’s Rule:
● LMP + 1 year - 3 months + 7 days = EDD
● Example:
○ LMP was 12/10/17

● So EDD is 9/17/18
 ● Always do it in this order and always check yourself…count ahead 9 months, does it
make sense?
● Problems:
○ Does not account for cycle length (late ovulation)
○ Does not account for variation in length of months or leap years (not always
exactly 280 days from LMP)
● Calculate the EDD using Naegele’s Rule
○ LMP 7/4/17 (28 day cycle)
■ +1 year = 7/4/18
■ -3 months = 4/4/18
■ +7 days = 4/11/18
■ EDD: 4/11/18
○ LMP 2/1/18
■ EDD: 11/08/18
■ Conception: Valentine’s Day
○ LMP 8/31/17
■ EDD: 06/07/18

Naegele’s Nemesis – the wheel

● Benefits:
○ Quick
○ Can use conception date, adjust for cycle length
○ Can estimate current gestation within pregnancy
○ Online versions are used often in hospitals

Ultrasound Accuracy
● 1st trimester – within 7 days
● 2nd trimester – within 14 days
● 3rd trimester – may be off 3 weeks
● So, if an EDD is calculated based on an earlier ultrasound, DON’T CHANGE IT based
on a SUBSEQUENT scan.
○ The earlier we do an US, the more accurate it is
● Instead, keep the EDD and suspect ...what?!

Examples
● LMP 6/23/17, sure, cycles q 28 days
● EDD by LMP:
○ +1 year = 6/23/18
○ -3 months = 3/23/18
○ +7 days = 03/30/18
○ EDC: 03/30/18
● What is her gestational age today (Sept. 1st) based on her LMP?
○ 10 weeks 0/7
● First ultrasound done 9/1/17
○ EDD by U/S is 3/20/18; measures 11 2/7 weeks
○ Keep or change the original EDC?
 ■ Change bc discrepancies of more than a week → 10 day difference
■ She ovulated earlier than expected by her LMP
○ Measure crown to rump length → to get gestational age

Examples, cont.
●
●
●
●
●

Evaluating Risk - Health History

● Identifying data
○ Age
○ Ethnicity
■ Can place fetus at higher risks for various conditions
○ Occupation
○ Marital Status
○ Sexual orientation
● OB/GYN History
○ LMP, Menstrual History
○ Previous pregnancies & outcomes (table*)
○ Sexually transmitted infections
○ Abnormal Paps
● Genetic and Birth Defect History
○ Woman & her partner (or sperm donor)
○ Include genetic history of immediate and extended family
○ Screening preferences
○ Teratogen exposures, consanguinity
● Past Medical History
○ Diabetes, HTN, clotting disorder, thyroid disease, etc.
● Past Surgical History
○ Especially previous Cesarean Birth or other abdominal surgery
● Medications
○ Prescription AND non-prescription, herbs
○ Illegal drugs, alcohol, tobacco, marijuana use
● Family, Social, Lifestyle History
○ Genetic health issues-thyroid disease
○ Family structure/red flags (mom died from O.D. and dad died from cirrhosis)
■ Increased incidence of intimate partner violence during pregnancy
○ Diet
○ Exercise
■ Keep doing what they’re doing
■ Don’t amp it up
■ With aerobic activity bring it to a conversational level
 ■ No hot tubs or jacuzzis
■ Activity below 10,000 feet
■ Don’t do anything where you could fall → horseback riding, rock
climbing, etc.
○ Health maintenance – dental, breast exams, safety
○ Religious/cultural

----------

SEE DAY 3 VIDEO LECTURE (05/07/2021)

Evaluating risk – Labs

● Initial labs:
○ CBC (hgb/hct/plt)
■ Platelets really important
■ If pt can’t clot, do not want her to have an epidural → could clot into the
epidural space
○ Blood Type, Rh, ABS
■ A, B, O, AB
■ Rh antibodies
● Issues if mom is Rh- and fetus is Rh+
○ Syphilis (RPR/VDRL)
○ Rubella status
■ Dangerous during pregnancy
■ MMR can’t be given during pregnancy
○ Hepatitis
○ HIV
○ Urine culture
■ Standard
■ Can have silent UTIs
● Can lead to preterm labor, pyelonephritis, etc.
○ Gonorrhea & Chlamydia
○ Pap smear
○ *cystic fibrosis carrier screen
■ Optional
○ *TB testing
○ *varicella
● 28 week labs:
○ CBC
○ Glucose tolerance test
○ ABS (if Rh negative)
■ ABS = antibody screening
● 36-37 week labs:
○ GBS testing
■ Vaginal rectal culture
● Other optional testing:
 ○ Antenatal screening
○ Hep C (waterbirth)
○ TORCH

Rh negative status
● Rh- mom & Rh+ dad → 50% chance baby will be Rh+
● Anytime we have bleeding during pregnancy → going to be concerned about Rh status
● Most blood mixing is during delivery
● Mom can become sensitized to those cells
○ Mom has Rh antibodies that will attack Rh+
○ Can lead to miscarriage, severe fetal conditions like hydrops fetalis in future
pregnancies
● Rhogam
○ Neutralizes development of antibodies
○ Give it to Rh- mother
■ If there’s bleeding during the pregnancy
■ Routinely at 28 weeks
○ Baby’s blood is checked through the cord to check baby’s blood type
○ If baby is Rh - → don’t need rhogam postpartum
○ Will need it if baby is Rh+
○ Rhogam stays in body for 12 weeks → which is why it’s given at 28 weeks
○ Want to give within 72 hours of delivery or a bleed/accident
● Have to have confirmed Rh status by lab
● Highest potential of maternal fetal blood mixing is during delivery
● NOB = new OB
● PP = postpartum

TORCH Infections
● “TORCH”- acronym for the following infections:
○ T – Toxoplasmosis
■ Found primarily in litter boxes
■ Also found in topsoil
○ O – Other: Varicella, Parvovirus, Syphilis, Listeria, & Coxsackie Virus, Zika
■ Listeria - can be found in meat, dairy
○ R – Rubella
○ C – Cytomegalovirus (CMV)
○ H – Herpes Simplex Virus (HSV)
● All are associated with potential for significant negative fetal outcomes including fetal
death if infection occurs during pregnancy
● Often mild or even NO symptoms in mother
● Often limited or no treatment available
● **PREVENTION, PREVENTION, PREVENTION!!!!!!!
● COVID
○ Hypercoagulability exaggerated in moms
○ More severe infections
○ BP & preeclampsia
 ○ Something happening at placental level
○ Small for gestational age
○ Not good
○ Vaccine is safe...but guarded
■ Not able to do retrospective research at this point
■ Support vaccination & women’s choice
■ May be better in 2nd trimester
● Not during organogenesis
● Earlier in 2nd trimester
■ Also lets them get Tdap around 28 weeks bc it can’t overlap with covid
vaccine

TORCH – Prevention Counseling

● Toxoplasmosis
○ Avoid eating raw or undercooked meat, avoid contact with feces of infected cats
● Parvovirus (Fifth’s disease), Coxsackie (Hand, Foot & Mouth), CMV
○ Check status of those with high exposure risks → day care workers, etc.
Precautions if non-immune.
● Listeria
○ Avoid eating unpasteurized cheeses (cantaloupe outbreak in 2011)
○ Heating up deli meats before eating them
● Rubella, Varicella
○ Immunization available but not given during pregnancy – check status,
precautions if non-immune, immunize postpartum.
○ Can NOT do MMR or varicella vaccine during pregnancy
○ Can check blood & do titers?
● Syphilis, Herpes
○ Safe sex practices (condoms), suppressive therapy for HSV in the weeks before
labor to prevent an active outbreak and transmission to baby.
● Zika
○ Avoid travel to high risk countries, use bug sprays/clothes to prevent mosquito
bites, avoid contact with infected individuals

Prevention – Immunizations
● No live virus immunizations during pregnancy due to the theoretical risks of congenital
infection
● Influenza vaccine
○ Highly encouraged
○ Given in pregnancy at any time during flu season
○ Flu during pregnancy is a deadly combo
● Tdap (Tetanus, Diphtheria, & Pertussis)
○ Given at 27-36 weeks to pregnant women and all newborn care givers
○ Prevention of Pertussis (whooping cough) infection
■ Caregivers/parents are protected so they don’t get it
■ Newborns are protected– some immunity occurs in utero AND decreases
risk of exposure through caregivers/parents who have pertussis
 ○ Encourage anyone close to baby to have the vaccine

Evaluating risk –Physical Exam

● Physical exam
○ Vital signs
○ Basic measurements – height, weight, BMI*
■ BMI risks with too high or too low
○ Head to toe exam
○ OB/GYN specific assessment
■ Abdominal exam:
● Fundal height, Leopold’s (presentation), FHT’s*
○ Fundal heights every visit
○ Leopolds to assess where head & bottom are
■ Pelvic exam:
● Vulva, vagina, cervix, ovaries
○ pap, GC/CT (gonorrhea & chlamydia cultures)

Evaluating risk – High Risk symptoms

● Headache?
○ Yes – esp during 1st trimester
○ Caveat -- persistent or worsening
○ Risk for preeclampsia or other
● Scotomata (visual changes)?
○ Going from hot to cold, changing position
○ Persistent → concern for preeclampsia
● Vaginal bleeding?
○ Little spotting ok
○ With more → concern
○ Never do digital vaginal exam unless you know where placenta is
● Decreased fetal movements?
○ Instruct mom on monitoring fetal activity
○ Concern for baby’s well being
● Uterine contractions?
○ Term or preterm?
○ Braxton Hicks
■ Irregular, come & go
○ Should not be patterned, getting closer together, & stronger → concern
● Fever?
○ Covid, flu, etc.
● Water leaking?
○ Clock is ticking
○ Risk of infection once water breaks
○ Err on the side of caution

Evaluating risk – Fetal Wellbeing

● Fetal heart beat should be SEEN on US after 6 weeks
 ○ Often “dating US” done between 6-12 weeks
● Fetal heart beat should be HEARD via doppler at 10-12 weeks
○ Assessed at each prenatal visit
● Fetal movement should be FELT after 18-22 weeks
○ Maternal education and “fetal movement counts” in 3rd trimester
● Other assessments:
○ Antenatal screening
○ Anatomy and growth ultrasounds -- 20 weeks
■ May be repeated with various concerns

Continued Assessment: F/U visits

● Initial visit usually occurs @ 8-12 weeks
● Return visits allow the practitioner to continue to monitor moms(BP, weight, labs) and
babies (FH, FHT) for problems as well as to offer anticipatory guidance, support and
education
○ Visits Q 4 weeks until 28 weeks
○ Visits Q 2 weeks until 36 weeks
○ Visits Q 1 week until birth

Anticipatory guidance, support and education

● Support for common discomforts
● Anticipatory guidance for pregnancy, birth, parenting, role change, breastfeeding, etc.
● Examples of common questions (know nursing talking points):
○ Is it safe to travel? What precautions do I need to take?
■ 32 weeks on → want them staying close to home
■ Increased coagulation with travel → drink fluids, walk frequently
○ Are hair treatments, massage, hot tubs, pedicures, etc. safe?
■ Hair color → less is more in 1st trimester
■ Massage → ok if massage therapist is comfortable working with pregnant
lady & knows pressure points to avoid
■ Hot tub → NO
■ Pedicures → ok if clean place
○ Can we still have sex?
■ Yes unless concern for certain issues
○ What work restrictions do I need to follow?
○ Can I paint the baby room?
■ Make sure it’s well ventilated
■ Don’t work alone
■ Don’t get on ladders / things that put at risk of a fall
○ What can I do to help my 2 year old adjust to his new role as a big brother?

Weight Gain Recommendations

● Desirable weight gain in pregnancy based on pre-pregnancy BMI
○ Underweight (less than 18.5) = 28-40 lbs
○ Normal weight (18.5-24.9) = Gain 25-35 lbs
○ Overweight (25-29.9) = 15-25 lbs
 ○ Obese (greater than 30) = 11-20 lbs
● Maternal and fetal complications related to weight
○ Underweight – increased risks of preterm labor, low birth weight infants
○ Obesity – increased risks of HTN, DM/GDM, macrosomia, injury, c/s,
postpartum hemorrhage, stillbirth, miscarriage
● Inadequate weight gain → increased risk of fetal growth restriction
○ Do NOT want women actively dieting during pregnancy

Summary
● You are responsible for putting together the puzzle of how the mother’s health & social
milieu affect the pregnancy.
● The outpatient (or clinic) records are an invaluable source of information.

----------

See risk factor activity

 OB EXAM 1 DAY 3 - PROCESSES OF LABOR & BIRTH

*Fetal monitoring will not be on exam 1

*group portion of exams will be with our clinical groups

----------

Labor Process: What starts it all?

● Theories of Labor Onset
○ Uterine Distention
○ Placental Aging
■ Placenta has a shelf life → has an age
■ Starts to calcify
○ Hormonal Mediation
■ Progesterone withdrawal
■ Prostaglandin synthesis
■ Corticotropin releasing hormone
○ Psychological aspects
○ Fetal Adrenals

Signs of impending labor

● ‘Lightening’
○ The fetus drops into the pelvis
■ Easier to breathe, harder to walk
■ Increase in Braxton-Hicks push the fetus down into ‘ready’ position
● Irregular contractions
● Cervical mucous / bloody show
○ Mucous plug not a definitive sign of labor
○ Blood show → more pressure on cervix
● Weight loss due to increase in loose stools
○ Prostaglandins
● Burst of energy
● Nesting
○ Cleaning house, packing bags, lots of planning
● Increase in Braxton-Hicks contractions (practice contractions)
● Change in sleep cycles
○ Can be more or less

Are membranes ruptured?

● Most of the time water breaks during the labor process
○ Less than 10% of water break outside of the labor process
● Definitions:
○ SROM: spontaneous rupture of membranes
■ Broadly used → actually in labor
○ AROM: artificial rupture of membranes
■ Provider does a sterile vaginal exam & breaks the water
 ● Carefully uses barb to make a small hole → break water →
hold/support baby’s head as water comes down
■ Make sure women is laboring well before breaking water artificially
○ PROM: prelabor rupture of membranes
■ Prior to the onset of labor
■ Only happens about 10% of the time
○ pPROM: preterm prelabor rupture of membranes
● Descriptions:
○ Clear: straw colored +/- flecks of vernix
○ Meconium stained: greenish color from fetus’ BM
■ Baby had a bowel movement in utero
■ Could be r/t fetal distress
■ Want to assess for complications
○ Non-malodorous vs. Malodorous: you can’t miss it
○ Amount
● Want to know about the amniotic fluid…
○ When did it happen
○ Describe the fluid
■ Clear, straw colored
○ Amount of fluid
○ Oceany, salty smell
● When water breaks → infection risk increases
○ Go to hospital / birthing center

SROM
● Increased risk:
○ Infection
○ Prolapsed cord
○ Cord compression → variable decelerations
● Always check FHTs! (fetal heart tones)
○ Make sure baby is tolerating things well
● Confirm SROM
○ Nitrazine or pH paper
■ Turns blue when water breaks
○ Ferning
■ Take collection of fluid → place on microscopic slide → let it dry
■ Once dry → looks like a fern / christmas tree patter
○ Pooling
○ Valsalva
■ Look for gush or trickle of fluid
● Document
● Amnicator color chart
● If concern about water breaking → everything should be sterile
○ Sterile vaginal exam
Stages of Labor
● First Stage: Cervical Change (dilation/effacement)
○ Onset of regular contractions to complete effacement & dilation:
■ 0-10 centimeters dilation (opening)
● Mom needs to be 10 cm for her to start pushing
■ 0-100% effacement (thinning)
● With first labors → woman tends to efface before dilation
● After first pregnancy → see together
● Second Stage: Birth of the BABY
○ Full dilation until delivery of the neonate
■ 10 centimeters with descent of presenting part to birth
■ Do NOT want pushing before 10 cm
● Third Stage: Birth of the PLACENTA
○ Delivery of neonate to delivery of placenta
○ Usually happens within 10-15 minutes
○ If longer than 30 minutes → considered prolonged
● Fourth Stage: Recovery
○ Postpartum Stabilization: 1st 4 hours after delivery
○ Maternal-newborn bonding & breastfeeding
■ Really crucial during the 1st hour after delivery

First Stage of Labor: Nursing Care

● Educate women AND support people
 ● Encourage ambulation and help with selecting and changing positions (q 30 min)
○ Very important / helpful for labor
○ Being stuck in bed makes it harder for woman to cope with pain & labor
● Assist with a birth ball, squat bar, rocking chair, etc.
● Encourage hydrotherapy: tub/shower
● Teach/perform massage (effleurage, hand/foot, counter pressure, double hip squeeze)
● Hydrate/light meals
● Support non-pharm pain relief techniques (breathing techniques, visualization, warm/cold
compresses, etc.)
● Empty bladder regularly (q2h)
○ Important for comfort & descent of baby through labor process
● Provide a comfortable environment (adjusting lights, music, people, smells, etc. PRN)
● Hygiene (chux, washcloth, mouthwash)
● Support the support people
● Medications PRN

--

**Nowadays → 1st stage only has 2 phases -- latent & active

● Latent is anything prior to 6
● Active starts at 6
● Transition 8

**underscore cervical change

--

Is it true labor?

● Pre-labor (“False”)
○ No rupture of membranes
○ Irregular
○ Space-out when lying down
○ NO CERVICAL CHANGE

● True Labor
○ Increase in U/C (uterine contraction)
■ Frequency
■ Duration
■ Intensity (strength)
○ Progressive cervical dilation, effacement & descent of presenting part
○ Rupture of membranes
● Can you have true labor with membranes intact?
○ Yes → very variable

OB Triage
 ● Chief Complaint: “I think I’m in labor”; “My water broke”
● Review history- this pregnancy and prior ones; significant medical history
● Brief Physical Exam or systems assessment
● Interpretation of baseline EFM strip
● Labs
● Maternal vital signs
○ Anything above 101.6 (38.7) → we do not like
● Abdominal exam/ultrasound for presentation
● Psychosocial
○ Support, preparation, cultural assessment
● Cervical exam (if membranes intact)
○ Dilation, effacement, station, presenting part

The P’s associated with labor and birth

● Powers
● Passageway
● Passenger
● Position
● Psyche
● Pee pee
● Placenta
● Partner
● Powerful parents or in-laws
● Pain

Powers
● Role of the uterus is to contract, pushing baby down on to the cervix, then out through the
vagina
○ Helpful for expulsion
● Secondary powers are the bearing down efforts of the mother

Contractions
● Start at fundus & push down → most power to get baby out
● Contractions gradually push the baby’s head into the cervix
● NOT a good method: hold breath & push to the count of ten
○ Decreases O2 to the baby

Secondary Powers: Pushing

● Physiologic Pushing
○ Grunting
○ More O2 to uterine muscle, placenta & baby
○ May take more time
○ More instinctive pushing
● Closed glottis pushing
○ Take a deep breath & push to the count of 10
○ Less O2 to baby, muscle, & placenta
 ○ Not enough O2 in system → not perfusing baby well

Passageway: Soft Tissues

● Pelvic Soft Tissue
○ Cervix
■ Must come forward, soften, efface (thin), & dilate (open)
■ Needs to move from more posterior to a more anterior location → helps
with straight shoot out lol
■ Remodeling of cervix → cervical ripening
○ Pelvic Floor Muscles
■ Must be taut enough to help passenger’s head flex to fit through
○ Vagina
■ Must be elastic
○ Amount of adipose tissue must not impede passageway
■ In vagina, thighs, etc.

Cervical Effacement
● 0% (5 cm long) to 100% (paper thin)
● Measure how long the cervix is
● Measure from external to internal os
○ Internal os opening before external os
Dilation
● From external to internal presenting part
● From 0 cm (closed) to 10 cm (fully dilated or complete)

● Introduce at 45º angle

○ Urethra is right above vaginal opening → sensitive area
○ Go along posterior vaginal vault to uterus until you feel cervix
● For safety & maternal comfort → don’t overdo vaginal exam

Passageway: Hard Structures

● Remember: relaxin acts on joints to allow extra room
● SI joint loosens
● Pubic arch loosens
● Allows for expansion → help for head’s descent
● Pubic arch → landmark for station
● 0 station → flushed with ischial spine

Passenger (fetus)
● Number: Singleton or multiple babies
● Lie
● Presentation
● Station
 ○ Passenger + Passageway

Definitions
● Fetal Lie: Relationship of long axis of fetus to long axis of mother
○ Longitudinal
○ Transverse

● Fetal Presentation:
○ What enters the pelvis first, “the presenting part”
■ Cephalic (Vertex)
● 97% births are cephalic & flexed
■ Breech
■ Shoulder (Acromion)
○ *Malpresentation if not cephalic
The Passenger: Attitude
● Attitude: Definition- Relationship of the fetal parts to one another

longitudinal lie, cephalic, flexed

--

longitudinal, cephalic, military

The Passenger: Attitude
● Fetal Presentation: Breech
○ Attitude:
■ Complete: knees & hips flexed
■ Frank: hips flexed, knees extended
■ Footling: oops!
● Single footling (incomplete)– 1 knee & hip flexed
● Double footling--full extension

Breech Presentation, different attitudes

The Passenger: Position

● Fetal Position: relationship of presenting part to maternal pelvis
○ right or left side of maternal pelvis
■ First letter
○ occiput (o), mentum (m), sacrum (s)
■ Refers to presenting part of baby → baby’s like to be the center to
attention
■ Head down → occiput
■ Breech → sacrum
■ Mentum → face presentation
○ anterior (a), posterior (p), transverse (t)
■ Refers to angle within presenting part
■ ROP ROA ROT
■ LOP LOA LOT
■ Direct OA, Direct OP

● Anterior → facing pubic symphysis

● Posterior → facing spine
● Transverse - baby is presenting to mom’s sides
● Positions other than occiput ARE MALPOSITIONS
● Don’t orient yourself based on baby’s face
● Label A over pubic symphysis → anterior side of mom
● Label mom’s Lt & Rt
 ● Ideal world
○ Occiput anterior
● Sunny Side up delivery (occiput posterior / OP baby) → baby is facing up
○ More difficult
● Occiput = vertex = cephalic

● Hands & knees = best maternal position for rotating a baby that is in an occiput posterior
position

Stations
● Engaged = 0 station
○ Decreases risk of prolapsed umbilical cord
○ Higher the head when water breaks = greater risk for prolapsed cord

Effacement, Dilation & Descent – 3 processes in tandem

● Effacement
○ 0 – 100%
● Dilation
○ 0 to 10 cms
● Descent
○ -2, -1, 0, +1, +2, +3
● Cervical change comes with strong contractions
Maternal Position
● Upright
● Ambulating
○ Provides mechanical pressure → encourages opening of the cervix
○ Pushing on cervical opening → releasing more prostaglandin → helps cervix
open
● Left lateral
● Semi-recumbent
● Hands and knees
● Squatting
● Sitting on Birth ball

Psyche
● Role of Psychological Stress
○ If mom is stressed → not going to drop a baby
● Role of Readiness
● Cultural Beliefs
● Support Persons Available

**Intense rectal pressure “I have to poop” → examine

-rectal pressure = good sign change is happening
-very common for women to defecate when pushing

Pee Pee
● A full bladder:
○ Displaces the presenting part in the pelvis
○ Interferes with the uterus’ ability to contract in a functional pattern
○ Can block baby’s progression downward
○ Critical to make sure bladder is empty
■ Especially with pt under anesthesia / who’s had an epidural
● So…
○ Empty q2h
○ Place a Foley or perform q2 hour straight catheterization with an epidural
● Toilet laboring
○ Can be great
○ Natural relaxation on the toilet
■ Especially if she’s having trouble relaxing down there

People: Partner, Parents, etc.

● Facilitate positive energy in the room
● Send others off to “boil water”
● Be a positive addition to the experience
○ Model positive behavior
○ Intimate experience
○ Talk quietly
 ○ Don’t chat / ask her questions when she’s having a contraction
○ Tell her “You ARE doing it!”

Pain
● Labor pain is different from all other pain.
● Pain
○ Purposeful
○ Anticipated
○ Intermittent
○ Normal

Passageway + Passenger: The Negotiation

● The largest diameters of the fetal head must negotiate past the smallest diameters
(planes) of the bony pelvis
● Main cause of C-section
○ Cephalopelvic disproportion → head is too large to pass through mother’s pelvis

Initial & On-going Nursing Interventions

● Orient to environment
● Obtain informed consents
● Maintain hydration (PO or IV)
○ If getting an epidural → prob limit oral intake
● Provide reassurance & information
● Encourage bladder emptying q 2 hours
● Assess pain or coping; provide comfort measures
● Encourage position changes q 30 min
○ Do NOT want mom flat on her back → TILT HER
● Prevent supine hypotension
● Prepare emergency equipment
● Monitor maternal and fetal well-being

Second stage: Pushing to birth of the BABY

 ● Ring of Fire as head emerges
○ Great deal of relief after head emerges

2nd Stage of Labor: Nursing Care

● Call MD, CNM
● Provide comfortable environment
● Support her in different positions
● Support non-pharm pain relief techniques (cold cloth, etc.)
● Keep bladder empty
● Get a delivery table/warmer ready (need resuscitation gear ready for every birth) → Tell
them what you are doing!
○ Everything we need for delivery
○ Just in case of an emergency
○ Keep them actively involved!!
● “Police” family & other visitors she might not want in the room
● Pericare, pericare, pericare
● To minimize risk of tearing → counter pressure

Cardinal Movements
● Descent
● Flexion
● Internal rotation
● Extension
● External rotation
● Expulsion
● Or “tuck, turn and out”
The Passenger: The Fetal Head
● Still pretty tight, so babies do things to adjust to fit
● Fontanels
○ Anterior & posterior ‘soft’ spots
● Bones of the cranium are soft
● Sutures between the bones are non-calcified
○ All allow soft tissue “swelling” → caput
■ Natural swelling
○ And overriding of the bones → “molding”
■ Without damage to the brain
● Molding
○ Evens out over time
● Molding
● Caput
Third stage: Birth of the PLACENTA

**insert table**

Breastfeeding releases natural oxytocin → can help uterus contract down

3rd Stage of Labor: Nursing Care

● Prevent hemorrhage
○ Pitocin 10-40 U in IV 500-1000 ml LR fast
■ Preferred → IV
○ Pitocin 10 Units IM
● Treat hemorrhage
○ Pitocin
○ Methergine 0.2 mg IM
○ Hemabate 250 mcg IM, intracervical, intrauterine
○ Cytotec (misoprostol) 800-1000 mcg rectally
● Urinary catheter to empty bladder
○ Full bladder can displace uterus
● Fundal massage AFTER the placenta is out
○ If done with placenta in place → could cause placental separation which could
lead to postpartum hemorrhage
● *Placental massage BEFORE the placenta has detached may cause partial
separation -> postpartum hemorrhage

Fourth stage: Immediate RECOVERY

**insert table**

Time to kick everyone out → 1st hour is about family coming together & bonding!!
Crucial time for family
Use this time for nursing if mom desires
If baby is stressed → sleep cycle → miss out on crucial time for breastfeeding
Shakes very common in active stage of labor & postpartum
Perineal hygiene

4th Stage of Labor: Nursing Care

● Anticipate need for:
○ Suture
○ Sponges
○ New sterile gloves
○ Local anesthesia
■ 1% Lidocaine
● Once repair is finished: basin of warm water, washcloths, clean chux, clean gown, water
to drink, and warm blanket
● Tear is likely with first delivery
Lacerations & Episiotomy
● Lacerations
○ Despite adequate support of the perineum, the fetal head will take the room it
needs
● Episiotomy
○ “Cut” performed to facilitate faster delivery of the fetal head due to:
■ Maternal exhaustion
■ Fetal distress
○ OR in the case of:
■ Vacuum or forceps assisted birth
■ Shoulder dystocia (to allow room for hand maneuvers -- if shoulder gets
stuck)
○ Not the better way to go
○ ONLY used in case of an emergency

Podcast rec: creogs over coffee

Laceration Locations
● Periurethral
● Cervical lacerations
○ Bleed profusely
○ Not common
● Vaginal wall (sulcus)
● Labial tears
● Clitoral tears
● Perineum

Lacerations Degrees
● First Degree
○ vaginal mucosa or perineal skin
● Second Degree
○ 1st degree + bulbocavernosus muscle, transverse & deep transverse muscles &
fascia
○ More common – esp with 1st baby
● Third Degree
○ 1st + 2nd + anterior anal sphincter (but not through)
● Fourth Degree
○ 1st + 2nd + 3rd + anterior rectal mucosa
○ Complete tear through rectal tissue
● **Lacerations heal as well or better than episiotomies

Episiotomies
● Midline episiotomy (MLE)
○ Same structures as a 2nd Degree Laceration
● Mediolateral episiotomy
 ○ Deeper muscles of the perineal floor
● Increased risk for extensions (3rd or 4th degree)
● Associated with longer postpartum pain and dyspareunia (compared to lacerations)
○ Dyspareunia – pain with intercourse
● Benefit?!?! History?!?
○ Benefit → in case of an emergency

Is the progress okay?

● As long as mom & baby are tolerating things well → yes!!
○ Progression is happening
○ Mom & baby are good
● Interventions breed interventions
○ Could cause more problems by trying to rush things
● Here to support through labor process & intervene only if it is in the mom or baby’s best
interest

Contemporary Labor Progress

● Rate of dilation in the active phase is much slower than that described by Freidman
● Maximum slope in rate of change often doesn’t start until 6 cm

New Guidelines for Assessing the Progress of Labor

● In 2014 ACOG and the Society for Maternal and Fetal Medicine came up with the
Obstetric care consensus: Safe prevention of the primary cesarean delivery.
● According to these new guidelines, 6 cm is when the active phase of labor begins.
○ “Thus, before 6 cm of dilation is achieved, standards of active phase progress
should not be applied.” (ACOG, 2014, p. 700).
● HOWEVER, the classic definitions for each phase of labor have not changed.
●
●
Type of Infection Transmission Symptoms Effects Treatment/ Delivery,
and causative Prevention Pregnancy &
organism other
Considerations
Chlamydia Transmitted to -Often -most common Treatment: -may be
fetus via infected asymptomatic cause of ophthalmia - Azithromyci responsible for
Bacterium: birth canal (direct neonatorum n preterm labor &
Chlamydia contact -Untreated, may -chlamydial fetal death
trachomatis cause PID leading pneumonia (Tx partners: -all pregnant
to infertility & doxycycline) women should be
increased ectopic tested early in
pregnancy risk -prevent pregnancy → with
conjunctivitis with positive cultures,
erythromycin tx at dx
ophthalmic ointment -avoid intercourse
until tx is complete
→ testing done
again 3 weeks after
tx is complete
(“test of cure”)
Gonorrhea Transmission to Asymptomatic, esp Ophthalmia Treatment: -Tx all sexual
fetus through in women (80%) neonatorum, sepsis, - Usually partners
Bacterium: contact in the joint injection ceftriaxone -Test of cure
Neisseria birth canal First indication is (re-culture to
gonorrhoeae often positive, Ophthalmia Prevention: verify cure)
routine prenatal neonatorum causes - Safer sex -Safe sex
cervical culture significant - E-mycin education
conjunctivitis & ophthalmic
Symptoms include: discharge from the ointment
purulent vaginal eyes
discharge, dysuria,
urinary frequency,
inflammation &
swelling of the
vulva, cervix may
appear eroded
HSV Direct contact Genital lesions Neonatal infection Treatment: -If primary
with lesion during -50-60% mortality - Acyclovir outbreak occurs in
Viral: birth Can be with exposure to (zovirax; 500 1st trimester,
HSV1 and symptomatic primary lesion mg BID) increased risk for
HSV2 Ascending -neuro spontaneous
infection during complications, -Tx to prevent miscarriage
birth (after sepsis, death outbreaks near time -C-section if active
membranes of birth lesions (either
rupture) -50% of infants -Prophylactic primary or
develop HSV antiviral meds secondary or
Transplacental: infection if mother beginning at 35-36 prodromal
rare has primary genital weeks symptoms of
 HSV & delivers -begin antiviral outbreak at the
vaginally meds if 2-3 time of labor)
outbreaks during -vaginal delivery --
-risk drops to 1-5% pregnancy no active lesions
if recurrent infection for 7 days
HPV Transmission to Genital warts -juvenile laryngeal Treatment: -tx reduces risk of
fetus is unclear -Nontender, soft, papillomatosis - TCA transmission, but
Viral: over 60 grayish pink (trichloroace does not totally
genotypes -sexually -May be -more of a risk with tic acid), eliminate exposure
-transplacental anywhere on vulva, initial outbreak HPV laser, surgery (likely r/t cont viral
(only about 30 transmission vagina, cervix, or & direct contact - Often shedding)
affect genital tract) remains anus with genital warts resolves -C-section delivery
controversial -pregnancy may without NOT warranted
cause proliferation treatment -may impede
& make them bleed Prevention: vaginal delivery if
more easily - HPV vaccine warts are very
large & obstruct
vaginl canal
-rec vaginal
delivery
-vaccine prevents
transmission of
highest risk
genotypes, but
doesn’t completely
prevent all types
 -best admin before
intercourse -- get
in preteen years
-not rec in
pregnancy
-may be given
during
breastfeeding
Syphilis -sexually Chancres can occur Fetal-neonatal Usually Penicillin G -serologic testing
transmitted in primary stage effects (if mom rec on all pregnant
Spirochete: -transplacentally untreated): -may be done as a
Treponema -sores usually -2nd trimester loss single dose, or as a
pallidum *highest appear where -still birth at term repeated dose over
transmission spirochete entered -congenital infection several weeks
occurs during body (causes cataracts, (depending on stage
primary & -firm, round, deafness, seizures) & length of
secondary stages painless -live unaffected infection)
of infection infant
-screen & tx all
partners
Trichomoniasis -sexually -may be -Increased risk of Metronidazole
asymptomatic preterm labor, birth, (flagyl)
Protozoan: -malodorous or premature rupture
Trichomonas yellow-green of membranes -1x dose
vaginalis discharge -Tx can also lead to
preterm labor (low
 -vulvar irritation; risk) -- still tx of
strawberry patches choice
on cervix
Bacterial -not sexually -asymptomatic -Can cause preterm Metronidazole -douching at any
Vaginosis (BV) transmitter, but (50%) labor, birth, or (flagyl) time in woman’s
sex contributes to premature rupture of life can cause the
Bacterial imbalance imbalance of -if symptoms, typ membranes -can be given at any imbalance of
vaginal flora fishy odor & thin, -chorioamnionitis time in pregnancy bacteria in vagina
(don’t know actual watery yellow-grey (infection in chorion -studies fail to prove -avoid douching in
cause / how some discharge & amnion) teratogenic effects general, esp.
women get it; -most common During pregnancy
linked to imbalance vaginal infection *Prevention
of good & bad in women 15-44 measures
bacteria in vagina)
Toxoplasmosis -eating raw or Usually mild Fetal-neonatal risks: Recent infection: -When a pregnant
undercooked flu-like symptoms -fetal infections - Spiramycin woman becomes
Protozoan: meats/game meats --severe neonatal *decreases infected, there’s a
Toxoplasma gondii -contact with -May be disorders (blindness, transmission to fetus 40% chance the
(single-celled feces of infected asymptomatic deafness, but does not cross fetus will get
parasite) cats retardation, seizures) placenta to treat congenital
--highest risk in fetus toxoplasmosis
Fetus -- 3rd trimester -In the US, 38% of
transplacental Fetal infection: pregnant women
have antibodies &
 -severe fetal disease - Sulfadiazine, 40-50% of the
or death pyrimethami general population
--hydrocephalus, ne and have antibodies
microcephaly folinic acid
--highest risk of *given after 1st
death in 1st trimester trimester
Varicella -Can be spread -Chickenpox Maternal: Treatment of active -If unknown
from person to lesions -high risk of death maternal infection: immunity, check
Viral: Member of person(direct d/t pneumonia - Acyclovir, titer
the herpes family contact) -Generalized, (50%) valacyclovir -Maternal
-inhalation of pruritic rash or antibodies do not
aerosols from Fetal: Famciclovir cross placental
vesicular fluid of -progression of -infection in 1st 20 **reduce symptoms, barrier
skin lesions of macular to to weeks can lead to duration, & intensity
acute varicella or papular to congenital varicella **safe for use in
zoster vesicular lesions syndrome (1-2%) pregnancy Exposure (for
-possibly through before crusting -limb hypoplasia, non-immune):
infected contractures, eye & Prevention: Give
respiratory -usually appears CNS involvement - Vaccination Varicella-Zoster
secretions that first on chest, back, Immune Globulin
also may be & face Neonatal: (VZIG) within 96
aerosolized -highest if maternal hours – may help
infection w/in 5 days prevent
of delivery & less development of an
than 2 days after active infection
delivery
Parvovirus -transplacentally Symptoms in Fetal-Neonatal Avoidance of -Very common in
– affects 33% of adults: Risks: exposure daycares & schools
Viral: fetuses exposed to -usually mild -fetal death – 10%
Human B19 it -may develop (usually occurs 4-12 NO TREATMENT -Greater than 50%
parvovirus “slapped cheek” weeks after of pregnant women
rash, low grade infection) are already
Aka Fifth’s disease fever, nasal -non-immune immune
in children discharge, hydrops & marked
headaches, nausea, fetal anemia
-virus that targets joint pain --approx ⅓ will
rapidly dividing resolve
cells spontaneously
--may need
intrauterine fetal
transfusion
-dev is normal if
fetus survives
infection
-fetal surveillance
w/ US eval of peak
systolic velocity of
the middle cerebral
artery (can signal
that fetus is dev
severe anemia)
Listeria -Often associated Can cause death of Fetal-Neonatal Avoid eating high -Pregnant women
with eating soft individual Effects: risk foods are more
Bacterium: cheeses; -miscarriage; fetal susceptible
Listeria cantaloupe death
Monocytogenes outbreak in 2011 -neonatal death r/t
pyogenic meningitis
-Assoc w/ eating
foods
contaminated w/
bacteria – esp
unpasteurized
dairy products
Transmission:
transplacentally
Coxsackie -Transmitted Fetal-Neonatal None known at this -no tx to prevent
“Hand, foot, and through contact Effects: time fetal or neonatal
mouth disease” with upper -death effects
respiratory -chorioamnionitis, -Only tx is really
Viral secretions placental infection geared to alleviate
-myocarditis, s/s of infection
Less common -common in encephalitis
children, esp those Prevention: good
younger than 5 handwashing,
disinfecting toilets
& frequently
touched surfaces, &
avoiding close
 contact with
infected individuals
Rubella Transplacental Clinical signs in Vaccination of all -Greatest risk is
neonate: children and the 1st 10 weeks;
Viral -Contact with -congenital cataracts non-immune 90% of fetuses
nasopharyngeal -sensorineural individuals affected
secretions then deafness -In weeks 11 and
transmitted across -congenital heart Childbearing 12, risk drops to
placenta to fetus defects (PDA) women: 50%
-mental retardation, Vaccination prior to
cerebral palsy pregnancy or in -Rubella vaccine is
postpartum period a live vaccine →
-Isolate infants with cannot give during
rubella -- can shed pregnancy (due to
virus for 12 months pot risk of
→ to decrease congenital rubella
chances of infection)
transmission to
non-immune
individuals
CMV -Transplacentally Usually harmless Fetal-Neonatal No known treatment -most common
-Ascending in adults & Risks: or vaccine at this viral cause of
Viral: belongs to infection (during children -fetal death time intrauterine
the herpes family vaginal birth) -small for infection
-common to be gestational age
-close contact asymptomatic -microcephaly, Diagnosis:
with infected -viral shedding can hydrocephalus -Sero-conversion
individual occur for several -cerebral palsy (via blood test)
-transmission in years -mental retardation -Amniocentesis
daycare centers is -no damage at all (when fetal
very high infection is
suspected)
Hepatitis B -blood exposure Prevention of Hepatitis B vaccine Diagnosis:
(direct contact transmission to -Hep B surface
Viral during delivery) newborn: Neonatal: antigen part of
-bathe asap - HBIG initial OB labs
-NOT transmitted -Hep B immune - Hepatitis B --then further
transplacentally globulin (HBIG) vaccine testing for active or
-Hep B vaccine latent if positive
-Other family -Hep e antigen
members should be positive = dx of
tested & vaccinated active infection
also
HIV Transplacentally **AZT rec in Pregnancy: -Serum testing
pregnancy** - AZT (ZVD) should be offered
Viral: human --70% reduction Labor: to all women
Immuno-deficiency transmission to fetus - IV AZT -2 methods of
virus --w/o AZT, Neonatal: rapid testing blood
13-30% of neonates - highly active or saliva:
will be infected, & antiretroviral --OraQuick
100% will die therapy Rapid HIV
antibody test
Neonatal Care: Prevention: --results in 20
-wipe off secretions -encourage safer sex min; 90% accuracy
immediately after -mother can be -monitor CD4
birth reinfected & cause count
-bathe asap once new viral load
stable Labor
-use strict infection considerations:
control techniques -IV zidovudine
-HIV = -Rec: C-section,
breastfeeding esp. w/ intact
contraindicated in membranes can
US population decrease vertical
transmission by
50% (dep on CD4
count)
-avoid FSE (fetal
spiral electrode),
scalp pH, forceps,
 & vacuum
extraction
-observe for other
infections in
immunosuppressed
women
-if no tx in preg,
testing done
postpartum to
determine therapy
need
TB Active TB: -skin test or blood
- Isoniazid, test
Bacterium: rifampin, -if positive, chest
Mycobacterium ethambutol XR → gives dx of
tuberculosis No direct contact w/ TB
newborn until
non-infectious
-no breastfeeding
Inactive (Latent
TB):
- May delay tx
until PP
-OK to breastfeed
 OTHER NOTES

TORCH Infections

● TORCH – acronym for the following infections

○ T – toxoplasmosis
○ O – other: varicella, human B19 parvovirus, syphilis, listeria, & coxsackie virus
○ R – rubella
○ C – CMV
○ H - HSV
● Exposure to infections at any time during the pregnancy may impact the fetus
●

→→→
→→

Quiz Questions:

1. A pregnant woman is being seen in the prenatal clinic with diarrhea, fever, stiff neck and
headache. Upon inquiry, the nurse learns that the woman drinks unpasteurized milk and
eats soft cheese daily. For which of the following bacterial infections should this woman
be assessed?
a. Listeria monocytogenes
i. These symptoms are consistent with an infection by Listeria
monocytogenes. She was most likely exposed to this bacteria by drinking
unpasteurized milk and eating soft cheeses
2. Ms. S who is 28 weeks pregnant has been diagnosed with syphilis. Her initial lab testing
at the beginning of pregnancy was negative so it is determined that she is in the primary
stage of the syphilis infection. Which of the following statements by the nurse is
appropriate to give to Ms. S about the effects of this infection on her and her unborn
child?
a. "Taking Penicillin now to treat your infection will help to decrease the chance
your baby is affected by syphilis."
i. Usually a single shot of penicillin, administered to the mother, will cure
her and protect the baby
3. The public health nurse calls a woman and states, "I am afraid that I have some disturbing
news. A man who has been treated for gonorrhea and chlamydia by the health
department has told them that he had intercourse with you. It is very important that you
seek medical attention." The woman replies, "There is no reason for me to go to the
doctor! I feel fine!" Which of the following replies by the nurse is appropriate at this
time?
 a. "That certainly could be the case. Women often report no symptoms with these
infections."
i. This client is exhibiting signs of denial. The nurse must empathize with
the woman regarding the unexpected and unwanted news, but the nurse
also must convince the woman to seek care. Giving her the information
that many women have no signs or symptoms of these diseases is
essential.
4. A woman is to receive 2.4 million units of penicillin G IM to treat syphilis. The
medication is available as 1,200,000 units/ml. How many ml should the nurse
administer? 2 mL .
5. During her initial OB labs, Ms. V's Hepatitis B surface antigen (HBsAG) was positive.
Further lab testing at that time revealed a diagnosis of active Hepatitis B infection. Her
due date is next week and she is asking what is going to be done after her son is born to
help prevent him from being infected with Hepatitis B. Which of the following will you
tell her? (Choose all that apply)
a. "Your baby will be given a bath as soon as we are able. This will help decrease
exposure to blood that may be on him from birth."
b. "I will give him an injection called Hepatitis B Immune Globulin which will help
prevent him from developing the infection."
c. "We will give him the first of the Hepatitis B vaccinations which will help prevent
him from being susceptible to infection by this infection in the future."
d. "All family members should also be tested for this infection and given the
Hepatitis B vaccine if they don't have the infection already. This will help to
prevent a Hepatitis B infection in them and decrease the chance they pass on
Hepatitis B to your son."
6. Which of the following is a true statement?
a. A woman with active TB at delivery is not allowed contact with her newborn until
she is no longer infectious. But if the TB is inactive (latent) at this time she is
allowed to see, hold, and breastfeed her newborn right away.
7. Because of the availability of medications in the U.S. for the treatment of HIV infection,
HIV positive women are encouraged to breastfeed their babies. True or False??
a. False!
i. HIV infection in the U.S. is a true contraindication for breastfeeding
because there are safe water sources and quality infant milk formulas
8. Ms. H has a history of herpes simplex virus infection. She usually has 2-3 outbreaks a
year and her last outbreak was 4 months ago. She is currently in the clinic for her first
OB appointment. Of the following, choose the best statement that applies to Ms. H's
HSV diagnosis and treatment.
a. Ms. H should be offered prophlyactic anti-viral medications beginning at 35-36
weeks to help prevent an HSV outbreak and active lesions at delivery. This will
 thereby decrease the risk of exposure for her child to this virus at the time he/she
is born.
b. Acyclovir is the tx of choice for HSV prophylaxis
c. If Ms. H has any active HSV lesions or prodromal signs at the time of labor, it is
recommended that she have her baby by c-section.
d. If Ms. H has more than 2-3 outbreaks during this pregnancy she should be started
on Acyclovir at that time to help prevent any further outbreak especially near the
time she is due.
e. The risk of transmission of HSV to Ms. H's child is much lower due to her prior
history of this infection than if she developed a primary HSV infection during this
pregnancy.
9. Which of the following is true about Bacterial vaginosis (BV)? Choose all that apply
a. It is caused by an imbalance of the normal vaginal flora.
b. It may be asymptomatic but it may also cause a fishy odor and thin watery,
yellow-grey discharge.
c. Having BV may cause preterm labor/birth, an infection in the uterus, and
premature rupture of the membranes.
d. Flagyl is used to treat BV and may be given at any time in the pregnancy.
e. Women should be encouraged to avoid douching because that can increase the
risk of developing BV.
10. True or False – Gonorrhea and Chlamydia are the two most common sexually transmitted
infections in the U.S. and Colorado
a. True!
 GBS MODULE NOTES

● GBS = group B streptococcus

GBS Facts
● History
○ Emerged in the 1970s as the leading cause of neonatal sepsis
● Type of organism
○ Gram positive beta hemolytic cocci
○ Reservoir
○ Likes to live in GI tract
● Colonization
○ Because of woman’s anatomy, becomes source of colonization of GU tract too
○ 10-30% of woman are colonized
○ Possible that all women are colonized at some point in their lives
○ Rates vary by ethnicity & age
■ African american women are 2x as likely to have GBS colonization as
white women
■ Young women in hispanic populations are more frequently colonized
● Usually asymptomatic
○ May cause maternal UTI, intraamniotic infections, or infection in endometrium
after birth
○ Also associated with preterm labor & stillbirth
● May be chronic, intermittent, or transient
● Transmission to newborn occurs
○ Primary risk factor → colonization of maternal GU & GI tract
○ Vertically
■ Direct exposure during birth or ascending infection from vagina (after
membranes have ruptured)
○ Horizontally
■ Cross contamination → usually d/t poor handwashing by caregivers
● Transmission rate is influenced by:
○ How heavily colonized the woman is
○ Site of colonization
○ Chronic colonization
○ Risk factors
■ Preterm status
■ Prolonged rupture of membranes
■ Low birth weight
■ Presence of intra amniotic infection
■ Increase likelihood that newborn will develop early onset GBS disease due
to exposure to this organism
● GBS is still the leading cause of early onset neonatal sepsis in the U.S.
○ Measures have lead to more than 80% reduction in disease incidence in the
newborn
○ 0.23 cases per 1,000 live births in 2015
 ○ Catastrophic consequences

Universal Screening

● 2018 CDC guidelines for universal screening:

○ All pregnant women should be cultured between 36-37 6/7 weeks with a
vaginal-rectal culture
■ Negative result at this time will remain negative in most cases through 41
0/7 weeks
■ 5% false negative rate
○ Very accurate culture results for predicting GBS colonization status at time of
delivery if birth occurs within 5 weeks of obtaining culture
● Exceptions to universal screening:
○ GBS bacteria
■ Treat UTI at diagnosis
○ Hx of infant with invasive GBS sepsis
● Exceptions in cases where risk of transmission is very high → mom will receive
antibiotics prophylactically in labor
○ Increased risk of again having heavy colonization
○ Will receive antibiotics prophylactically
● GBS of any amount in clean catch urine sample indicates high colony counts in GU & GI
tracts
○ Treatment at time of diagnosis
○ Abx prophylactically during labor to prevent transmission to the newborn

Culture Procedure
● Vaginal-rectal culture
○ The swab is inserted into the outer third of the vagina, swiped down the perineum,
and then inserted into the rectum past the anal sphincter
○ Not recommended to use a speculum or to do a cervical culture
○ With adequate education, patient can perform culture themselves
■ Usually more comfortable doing so
● Susceptibility testing for patients with PCN allergies
○ To ensure correct antibiotics are used^

Intrapartum Prophylactic Antibiotics

● Who should be treated with intrapartum prophylactic antibiotics?
○ Any positive GBS vaginal-rectal culture in the CURRENT pregnancy
○ History of:
■ GBS bacteria at any time during this pregnancy
■ Infant affected by invasive neonatal GBS infection
■ Universal screening cultures are not done because of the high risk of
transmission
● What if she hasn’t had the universal screening or you don’t have results?
○ Antibiotics should be given for these factors (high risk for early neonatal onset
disease)
 ■
Gestation less than 37 weeks
■
Preterm prelabor rupture of membranes (pPROM)
■
Rupture membranes ≥ 18 hours
■
Intrapartum temperature of ≥ 100.4 F
● Indicator of infection
● If suspected or confirmed to be an intraamniotic infection, broad
spectrum antibiotics that provide coverage for polymicrobial
infections & antibiotics for GBS should be used
○ Typically involves combo of ampicillin & one of the
aminoglycosides
■ History of GBS colonization in previous pregnancy
● 50% chance she’s colonized with GBS again → increased risk of
transmitting it to newborn
○ Uncommon – but some facilities have rapid screening tests for these situations
■ Not as reliable
■ No info about antibiotic sensitivity

Prophylactic Treatment
● Reasons for prophylactic treatment
○ Prevention
○ Not the same as giving the newborn antibiotics for a GBS infection
○ Should be started once the decision to admit mom to L&D is made & continue
through baby’s delivery
● When is treatment started?
○ On admission
● SCHEDULED C-section patients
○ Universal screening culture done at 36-37 6/7 weeks
○ If GBS positive
■ Not in labor & membranes intact → no treatment needed
● Because risk of infection is very low
■ In labor or rupture membranes → treat with antibiotics prior to delivery
(via sched c-section)

2018 Treatment Guidelines

● Thought that intrapartum treatment…
○ Prevents neonatal GBS infection by temp decreasing maternal vaginal GBS
colony counts
○ Prevents newborn surface & mucous membrane colonization
○ Lets antibiotics reach levels in newborn’s bloodstream to effectively kill Group B
streptococcus (GBS)
● Recommended first-line agent:
○ Penicillin G
■ Dosing
● Initial dose: 5 million units IVPB x1
● Then 3 million units IVPB q4h until delivery
■ Specifically targets gram positive bacteria
 ■ Less likely to cause antibiotic resistance in other vaginal organisms
● Acceptable alternative:
○ Ampicillin
■ 2 g IVPB load, then 1g q4h until delivery
● When is treatment considered adequate?
○ Highest effective in preventing neonatal disease → obtained when at least 4 hours
pass from initial dose of antibiotics to birth of baby
○ Rapid reduction in maternal GBS colony count
○ Neonatal sepsis is less frequent with 2 hours of antibiotic exposure
■ But effectiveness of treatment is much greater with at least 4 hours of
prophylaxis before birth
● Emphasizes the importance of prompt initiation of antibiotic
treatment for max prevention of GBS disease

Penicillin Allergies
● Important to determine type of reaction to PCN
○ High-risk for anaphylaxis
■ History of anaphylaxis, angioedema, respiratory distress, or urticaria after
being given penicillin or cephalosporin, recurrent reactions, reactions to
multiple beta-lactam antibiotics, positive skin testing, or rare delayed
reactions (like Steven-Johnson Syndrome)
○ Low-risk for anaphylaxis
■ Non-urticarial maculopapular rash without systemic symptoms
■ Family history of penicillin allergy but no personal history
■ Non-specific symptoms such as nausea, diarrhea, and yeast vaginitis
■ Or a patient reports a history but cannot recall the symptoms or treatments
● Consider Penicillin allergy skin testing
○ For women at low-risk for anaphylaxis
○ Or unknown severity of allergic reaction
○ Beneficial for determining absence of type I hypersensitivity reaction → helps
eliminate need to use alternatives to PCN for prevention of early onset disease
○ Also beneficial for future healthcare management if treatment with a beta lactam
antibiotic is indicated
● Anaphylaxis with PCN is rare
○ Incidence between 4 in 10,000 to 4 in 100,000 recipients

Alternative Antibiotics for PCN Allergy

● Crucial for sensitivity testing to be done on vaginal rectal culture whenever woman
reports PCN allergy → determines the alternative antibiotics to use in these cases

● Low-risk for anaphylaxis

○ Cefazolin 2 g IVPB load, then 1 g IVPB q8h until delivery
■ Low risk of allergic reaction to cefazolin with PCN allergy

● High-risk for anaphylaxis and identified sensitivity of the GBS isolates

○ Clindamycin 900 mg IV q8h until delivery
 ● High-risk for anaphylaxis and GBS is not sensitive to Clindamycin (or don’t have
sensitivity testing)
○ Vancomycin 20 mg/kg q8h
○ Max single dose is 2 g
○ Infuse over a minimum of 1 hour or 500 mg/30 mins a dose for a dose > 1 g
● Unknown risk for anaphylaxis
○ No info for guiding best choice of antibiotics in this case
○ Best option prob to perform penicillin allergy testing → provides info about
anaphylaxis risk
■ If not possible, can use any of the above antibiotics
● 20% of GBS isolates are resistant to clindamycin

Why is this important?

● Neonatal implications of GBS disease
○ Mortality – less than 10% of neonates affected by GBS sepsis
■ Term neonates → 2.1% of babies die because of early onset GBS disease
■ Preterm infants → 19.2% of newborns under 37 weeks dying due to GBS
sepsis
○ Morbidity – long-term neurological complications are common → can die
● Early onset neonatal sepsis
○ Occurs in the first 7 days of life
○ Most common causative organism = group B streptococci
○ Symptoms
■ Temperature instability (can’t maintain temp in normal range)
■ Hypothermia
■ Poor feeding
■ Lethargy
■ Respiratory distress
■ Pneumonia
■ Apnea
■ Shock
■ **Newborns are NOT likely to be febrile or hyperthermic**
● Late onset neonatal sepsis
○ 7 days to 3 months
○ Often results in meningitis
○ Can be caused by GBS
○ More frequently caused by other organisms

Nursing Considerations
● Review record on admission for GBS status
○ Includes vaginal rectal culture results at 36 - 37 6/7 weeks
○ History of GBS urinary infection at any time during this pregnancy
○ Pertinent past history of delivering newborn that developed GBS sepsis
● Prophylactic treatment if indicated
● Communicate
 ○ Info to those caring for newborn
○ Pertinent history, treatment given, # of doses, length of time elapsed since first
dose
● Care of the neonate:
○ Determine estimated risk of developing early onset sepsis using a neonatal sepsis
calculator
■ https://neonatalsepsiscalculator.kaiserpermanente.org
● Also provides rec clinical actions to be taken based on infant’s
predicted risk of developing early onset sepsis & current
assessment findings
■ Intrapartum prophylactic antibiotic treatment is able to prevent the
majority of neonatal GBS sepsis cases – but not all
■ Newborns are at a greater risk for developing early onset neonatal sepsis if
treatment is inadequate → not enough time elapsed since first dose was
given
○ Monitor for s/s of neonatal infection
■ Primary responsibility of caregivers**
○ Administer antibiotics if indicated – symptomatic

----------

GBS Quiz Questions

1. D.E. is a 28 y.o. G5P4004, woman at 37 2/7 weeks' gestation, who is in the OB clinic for
a routine prenatal visit. She has a history of positive GBS cultures in each of her
previous pregnancies. Her urine culture at 10 weeks was negative. Currently her fetus is
in the breech position and she is scheduled for a c-section at 39 weeks. Which of the
following statements is true?
a. She needs the screening culture done.
2. D.E. is a 28 y.o., G5P4004, woman at 38 5/7 weeks' gestation,and presents to the labor
unit with complaints of regular contractions that are occurring every five minutes for the
past two hours. She denies any leaking of fluid. She is allergic to Penicillin. She is
dilated to 7 cm/90% effaced and the fetus is in a vertex presentation. Her GBS culture at
37 2/7 weeks was positive. You are admitting D.E. and know that based on her history:
a. She needs prophylactic treatment.
3. D.E. states she is allergic to Penicillin because it gives her nausea, vomiting, and
diarrhea. Penicillin allergy skin testing is not available for this patient. Which antibiotic
will you give her as prophylactic treatment?
a. Cefazolin
i. Cefazolin is used when a patient is allergic to penicillin and there is a low
risk of anaphylaxis.
1. Nausea, vomiting, and diarrhea are signs that she is at low risk for
anaphylaxis and Cefazolin is the recommended medication to be
used in this case for prophylactic treatment.
 2. It is likely she is not truly allergic to Penicillin but without having
skin testing to confirm this it is recommended to use an alternative
antibiotic instead of PCN G.
3. There is a small risk of a cross allergic reaction between Penicillin
and Cefazolin, however the risk is very small due to the unique
configuration of Cefazolin.
4. D.E. receives Cefazolin 2 grams IVPB and delivers 20 minutes later. Which of the
following statements is true:
a. This is not adequate treatment and the newborn will be monitored closely for
signs and symptoms of GBS sepsis and he will be given antibiotics if he exhibits
signs of the infection.
i. If the newborn develops any signs and symptoms of GBS sepsis
antibiotics will be given to treat this infection.
5. D.E.'s baby boy is now 4 hours old. The nurse obtained the following vital signs during
her assessment of him: RR-76, P HR 156, Temp 96.9 F. She also noted some nasal
flaring and retractions. D.E. states that she has not been able to wake him up to feed.
a. The findings are abnormal and could be symptoms of early onset GBS sepsis.
i. Symptoms of GBS sepsis are respiratory distress, pneumonia, apnea,
shock, temperature instability, hypothermia, poor feeding, and lethargy.