OB Notes:

Fetal Development

- Know the difference bet. Ovulation age and Gestational age/ AOG (2 weeks before of OA)
- 3rd week Ovulatory age (OA) = most pregnancy test can detect hCG
- 6th week OA = Heart is completely formed
- 16th week AOG = Gender determined by UTZ
- 28 week AOG - 90% chance of survival, skin is covered by vernix caseosa
- CRL (Crown-Rump Length) is more impt. Determinant of Gestational Age than Fetal Weight
- Biparietal Diameter = Greatest transverse diameter of the fetal head
- Chorionic Villi and Intervillous space = function together as lung, GIT and kidney of the fetus
- Liver, Muscle and Adipose = 3 major maternal storage depots
- Glucose = major nutrient for fetal growth and energy
- Leptin = Regulators of energy homeostasis in adipocytes
- IgG and RBP (Retinol Binding Protein) = ONLY 2 proteins that can cross the placenta
- After 20 weeks, Amniotic fluid is mostly Fetal urine (AF: cushion fetus, maintain temp, minimal nutritive function)
- First fetal RBC: Nucleated and macrocytic, has lifespan of 90 days at term
- Vitamin K given at birth to prevent Hemorrhagic disease of the NB
- IgM are adult levels by 9 months, IgA ingested via colostrum
- Fetal Kidneys start to produce urine by 12 weeks
- Renal agenesis may cause pulmonary hypoplasia (AF needed for lung development)
- Fetal Cortisol = natural stimulus for lung maturation
- If with RDS, Bethamethasone (Steroid) given to MOM; Surfactant given to BABY
- Testis-determining factor/Sex-Determining Region (TDF/SRY) determines gender
-

Fetal Health Assessment

● 3 categories (Deceleration)
● 1) Early deceleration (head compression)
● 2) late deceleration (uteroplacental insufficiency)
● 3) variable deceleration (cord compression)
●
● early deceleration > due to increased fetal ICP (head compression)
● late deceleration > due to insufficient blood flow through the uterus and placenta
● prolonged deceleration > lasts more than 2 minutes
● variable decelerations > usually caused by cord compressions
● presence of persistent variable decelerations indicates the need for close monitoring
● Fetal pulse oximetry = lower limit is at 30 percent, and if below 30% and > 2 minutes or longer - associated w/ increased
risk of potential fetal compromise

Anesthesia

● request for pain relief

● should be ROLE OF Obstetrician (knowns local and pudendal analgesia)
● But prefer for anesthesiologist to provide this care so OB can focus on laboring woman
● Non-pharma pain controls

a. relaxed breathing
b. partner's psychological support
c. presence of spouse or family member
d. attendant who instills confidence
e. motivated women (well prepared = less pain and anxiety and shorter labor)
Analgesia is MAXIMAL after 30 - 45 mins if IM, and IMMEDIATELY if IV

Meperidine is the most common opioid used worldwide for pain relief in labor.

● Fentanyl - disadvantage is SHORT duration of action

Early Labor Pain (uterine contractions) - predominantly from T11 and T12 nerves (frankenhauser ganglion)

Vaginal delivery pain - comes from the pudendal nerve (S2-S4 nerves)

Drugs that control convulsions (Succinylcholine, Thiopental, Diazepam, Magnesium sulfate - for eclampsia too)

Local Anesthetics Toxicity: Seen mainly in CNS and Cardiovascular systems

● Epidural analgesia provides superior pain relief

- Emergency cesarean delivery should be considered if maternal vital signs have not been restored within 5 minutes of
cardiac arrest

● Pudendal block - relatively safe and simple method of providing analgesia for spontaneous delivery (review slide 24)
○ BENEFICIAL: Infiltrate fourchette, with 5 to 10 ml of 1% LIDOCAINE SOL. in area where EPISIOTOMY is to be
made
○ Common complications of pudendal block (Systemic toxicity, Hematoma formation and Severe infection)

● Paracervical block
○ - effective in pain relief for FIRST STAGE OF LABOR
○ use lidocaine or chloroprocaine
○ NEVER bupivacaine (cardiotoxic and is CONTRAINDICATED)
○ Complication: Fetal bradycardia

● Spinal (Subarachnoid) Block (Advantages - short procedure time, rapid onset of block and high success rate) - should
extend to T10 dermatome (blocks uterine contraction pain) (IF forceps or vacuum delivery)
○ if Cesarean Deliver (t4 dermatome) for SAB
○ Complications of SAB (Hypotension, spinal headache, high spinal blockade, convulsions, bladder dysfunction)
○ In preeclampsia - EPIDURAL analgesia is preferred to SAB > GA

● EPIDURAL BLOCK - Labor and vaginal pain (t10- s5), for CS (T4-S1)
● Timing of Epidural placement (Less than 4-5 cm cervical dilation OK)

Puerperium/NB infant

- SEE QUIZ IN FOLDER!

● check quiz @ end and middle

● puerperium duration (involution , mass changes = uterus, vagina and tubes)
● types of lochia
● breast changes
 ● 4th stage of labor (IPP) what to do
● factors that cause failure of uterus to contract
● know CLINICAL aspects of puerperium
● Breast feeding and lactation
● 12 recommendations of WHO
● Newborn care ( see answers to questions)
● NB resucitation
● Preventive NB care( focus here)
● Routine NB care (Read this well)
● EO 51 and IRRs

Genetics/Fertilization/Embryogenesis

● Chargaff's rule (A=T C=G base pairing)

● Times of gene mutations
● Inheritance types
● Very powerful dominant humans (ADD)

○
● Turner's syndrome (45X) - most common chromosomal abnormality
● Trisomy 16 - accounts for 1/3 of trisomic abortuses
● Complete (46,XX) vs Partial Mole (69, XXX)
● Capacitation - Functional changes that causes the tail of the sperms to beat vigorously
● SRY GENE or Testis Determining Factor - primary determinant of Sex differentiation coded on the the Y chromosome
● Focus on Clinical Correlations!
○ Failure of sinovaginal bulb to form may cause vaginal agenesis
○ remnants of mesonephric duct system seen in broad ligament: Gartner's duct cyst
○ Cyst of epoophoron also known as Paraovarian cyst
○ paramesonephric duct remnants: Hydatid cyst of Morgagni
○ failure of anal membrane to rupture: imperforate anus
○ defect of urethral fold fusion: hypospadias
○ Mullerian/Agenesis or Mayer-Rokitansky-Kuskter Syndrome: Failure of mullerian duct to form = NO uterus and
Upper Vagina

Endocrine

● GNRH pulse generation (E v P)

○ Estrogen decreases pulse AMPLITUDE
○ Progesterone decreases pulse FREQUENCY
○ Low GnRH pulse: favors FSH synthesis
○ High GnRH pulse: favors LH synthesis
● Stimulatory and inhibitory signals
○ Stimulatory (Norepi, Glutamate, Neuropeptide Y)
○ Inhibitory (GABA, Dopamine, B endorphin, CRH)
● Leptin (high: good for reproduction)
● Half life of gonadotropins
○ LH: 20 mins
 ○ FSH: 3-4 hrs
○ HCG: 24 hrs
● Shares same alpha sub unit (LH, FSH, TSH and HCG)
● Beta unit = confers activity
● FSH and LH functions ( YOU should know this)
● Aromatase enzyme (Androgens > Estradiol)
● FSH is greater than LH during puberty and menopause
● Ovulation occurs:
○ 24 hours after first estradiol peak
○ 32 hours after the initial rise in LH
○ 12-16 hours after peak LH levels in the srum
● Menstruation
○ Duration (2-7 days normal)
○ Interval (28 +/- 7 days)
○ Blood loss (35ml; 10-80ml)

Medical-Legal Risk Management

● 3 basic elements of medical negligence (slide 20)

DEVIATION FROM STANDARD OF CARE –a failure to act reasonably as compared with another hearth care provider in the
same or similar circumstance.

PROXIMATE CAUSATION - With appropriate or reasonable treatment, the injury would have not occurred

- ECONOMIC DAMAGES– quantifiable losses as past and future medical bills and wage loss

- NON ECONOMIC DAMAGES– past and future physical pain, emotional suffering, wrongful death

● Define malpractice case (Slide 24)

Is typically a review of case facts applied to the standard of care, proximate cause through medical testimony to
determine if care was simply reasonable

● Key principles for valid consent (Slide 29)

○ Pt. must have capacity to make INFORMED DECISION
○ Consent must be VOLUNTARY
○ Pt. must be FULLY INFORMED (benefits, risks…) and allowed time reflect and ask questions

● Prevention of medico-legal in OBP

Communication, Documentation, Training and Education, Risk Management