Menstrual Cycle,

Management of
Preconceptual Care,
Early Pregnancy Loss,
Normal Pregnancy and
Postpartum Care

Hilary Morgan, PhD, ARNP, CNM

Nancy Robinson, MN, MPH, CNM
The Menstrual
Cycle
What organ systems are involved?
What hormones are involved?
Menstrual Cycle

Regular cyclic occurrence

of menstrual bleeding that
takes place with ovulation
and absence of
conception
Interplay between
ovaries, hypothalamus,
anterior pituitary and
uterine endometrium
 Physiology

Hypothalamus produces and

secrets hormones and
releasing factors that act
directly on pituitary
gland. It continuously
monitors hormone
levels in bloodstream
In response, the
pituitary gland
releases hormones to
stimulate ovaries (FSH, LH)
FSH & LH
◦ Follicle stimulating hormone (FSH) stimulates ovarian production of estrogen
and maturation of ova and follicles
◦ Luteinizing hormone (LH) induces mature ovum to burst from follicle and
stimulate development of corpus luteum (portion of follicle that remains after
release of ova). CL responsible for production of progesterone.
Ovulation
Endometrial Menstrual Cycle
Proliferative phase
Secretory phase
Menstrual phase
Proliferative Phase

Pituitary gland increases production of FSH, stimulating

follicles to mature and produce estrogen
Estrogen, in turn, causes endometrium to thicken
When ovarian estrogen level reaches peak, pituitary inhibits
release of FSH and stimulates LH production.
Ovulation occurs due to LH surge approximately 14 days
before start of next cycle
Estrogen also changes composition of cervical mucous
secretion (more alkaline) making conception more likely
Secretory Phase
Pituitary continues LH production leading to development of corpus
luteum from ruptured follicle
CL produces progesterone which inhibits production of cervical mucous
Estrogen and Progesterone cause endometrium to thicken and engorge in
preparation for implantation
Progesterone causes increase in temperature with ovulation
Secretory Phase

If implantation doesn’t occur, pituitary gland (in response to high E&P

levels, halts production of LH and FSH).
CL can no longer produce progesterone and disintegrates
Production of estrogen and progesterone decreases
Menstrual Phase

Estrogen & Progesterone drop off triggers endometrium sloughing

Discharge of thickened inner layer of endometrium
As E & P continue to fall, hypothalamus responds by stimulating pituitary
to release FSH
Cycle repeats itself
If conception occurs
If an ovum is fertilized, hcG produced by
blastocyst/trophoblast, triggers CL to continue to produce
estrogen (small amount) and progesterone which supports
endometrial lining and inhibits the negative feedback to
hypothalamus
CL provides this function until placenta is fully developed
and takes over hormone production
Menstrual Cycle
Normal Physiological
Adaptation to Pregnancy
Normal Physiological
Adaptation to Pregnancy
Breast Changes
Reproductive Organs
Integumentary
GI
CV/Hematologic
Respiratory
Renal
MS
Endocrine
Neurological/Psychosocial
Breast Changes
Prepare for lactation
Prolactin level rise but there is also an increase in prolactin
inhibiting factor
Keeps lactation suppressed until brith
Estrogen/Progesterone cause ducts, glandular tissue to
proliferate
Skin thinner, striae develop, areola darken, nipples more
erect and longer
Colostrum begins excretion in third trimester
Reproductive System Changes
Uterus
◦ Uterus converts from almost solid organ to thin walled,
hollow organ
◦ Holds 5 Liters at term (10 ml non pregnant)
◦ Becomes globular and dextrorotates
◦ At SP at 12 weeks, umbilicus at 20 week, then grows 1 cm
per week until 36-38 weeks
◦ Muscular organ, contracts throughout pregnancy (Braxton
Hicks)
◦ Increased uteroplacental blood flow
◦ Uterine soufflé- swishing sound
Reproductive System Changes
Cervical Changes
◦ Chadwick’s sign hyperplasia and hypertrophy = blueish color cervix 6-8
weeks
◦ Goodell’s sign - softening of the cervix 4 weeks
◦ Cervical mucous plug- protects from infection
 Reproductive System Changes
Vaginal/Vulvar Changes
◦ Increased vascularization, edema
◦ Increased libido, response
◦ Leukorrhea
◦ Vulvar varicosities

Pelvic floor changes

◦ Progesterone, relaxin soften ligament and muscles
Integumentary Changes
Increased production of sweat, sebaceous glands
Increased vascularity, pigmentation of areola, genitalia,
abdomen, face
◦ Linea negra
◦ Chloasma
Striae on breasts, abdomen, hips, thighs-breakdown of
connective tissue
Hair growth decreases; pp women may note increase
shedding of hair 1-4 months
Gastrointestinal Changes
Peristalsis slows- flatus, constipation, diminished bowel
sounds
Dyspepsia due to displacement of abdominal organs,
progesterone
Increased saliva (ptyalism), taste change
Predisposed to gallstones
 Cardiovascular and
Hematologic Changes
Heart displaced upward and to left
Inferior vena cava and aortic compression common in
supine position
Cardiac output increases 30-50%
Stroke volume increases by 20-30%
◦ Allows for 30% increase in Oxygen consumption
Heart rate increases
Cardiovascular and Hematologic
Changes
Blood volume increase 30-50%
◦ Improved blood flow to vital organs and protects against
blood loss during birth
◦ Fetal growth correlates to degree of blood volume
expansion
75% of increase in blood volume due to plasma increase
although slight increase in RBCs
◦ Result is hemodilution
◦ Physiologic anemia
Cardiovascular and Hematologic
Changes
As RBC volume increases, Iron demands increase
◦ Leukocytosis common
◦ Clotting factors increase
Systemic vascular resistance reduced due to progesterone,
prostaglandins, estrogen, prolactin
◦ Lowered BP in 2nd trimester
◦ Dependent edema
◦ Hypertrophy of gums
Respiratory System Changes
Increased edema of pharynx, larynx- respiratory congestion (stuffiness)
Nose bleeds (epitaxis) due to engorgement
Diaphragm elevated
Chest wall circumference increases
Lung capacity decreases by 5%
Respiratory rate, tidal volume (30-50%)
Renal System Changes
Kidneys displaced and increase in size
Renal tubules dilate- urinary stasis
Bladder tone decreased (progesterone) leads to urinary
frequency, incontinence
Renal vascular dilation and increased renal plasma flow
increase GFR
◦ Protein, albumin, glucose excretion affected
Musculoskeletal System
Changes
Changes due to progesterone, estrogen, relaxin
•Ligaments and joints relax
•Lordosis, kyphosis
•Carpal tunnel
•Diastasis recti separation
•Sciatica
•Symphysis pubis discomfort,
• Ligament pain (round, broad, uterosacral)
Endocrine System Changes
Thyroid enlargement (mild)
◦ TSH levels decrease initially but return to normal by birth

Pituitary gland increase in size

Metabolic rate increases 20-25%
Insulin secretion increases
Neurological
System/Psychosocial Changes
Emotional lability, irritability
Cognition changes
◦ Decreased attention span, concentration, memory
lapses
Sleep alternations
Optic changes due to fluid retention
◦ Corneal edema, hypersensitivity
Ear congestion
◦ Minimal hearing loss, vertigo
◦ Hoarseness, snoring
Preconceptual Care
 Preconceptual Care
Diet- eat healthy, well balanced diet
Weight- If overweight, attempt to lose weight. May be harder to conceive if overweight. If underweight,
may have difficulty conceiving and also more susceptible to giving birth to low birth weight infant
Regular exercise- walking, swimming
Smoking, alcohol consumption- Quit! Consider using nicotine aids prior to conception. No threshold for
alcohol use
Medication/Drugs- check with provider about safety of drugs in pregnancy; stop all illicit drug use
Vitamin supplements including folic acid. FA is naturally found in green leafy vegetables, orange juice,
enriched grains. Supplement should have 400 mcg daily; adequate FA levels decrease risk of development
of NTD
Environmental hazards- chemical and pollutants can be harmful to both parents
Infection- consider getting vaccines for hepatitis, HPV, rubella, varicella
Genetic screening if positive family history
Contraception- consider switching from hormonal based to barrier methods or NFP 3 months before ready
to conceive
Preconceptual Care
Make appointment with provider for complete H&P including
BP
Gyn history including past infections, menstrual cycles,
contraception use
Detailed history to evaluate medical history, family/genetic
history
Detailed history of any prior pregnancies
Pelvic exam for pap smear, genital cultures
Labs may include lipids, diabetes, CBC, Toxo, CMV, RPR, HbsAg,
HIV
Preconceptual Care
Average time to conception is 7 months (assuming
regular intercourse).
80% couples will conceive within 1 year of trying
Another 10% will conceive over next 6 months
Remaining 10% require infertility workup
Meet Jamie
Jamie
She is 26 yo, married x 18 months and has been trying to conceive for 1
year.
She calls you at your office to tell you her pregnancy test is positive
She is very excited at being pregnant and wants to come see you for
pregnancy confirmation.
How do you diagnose pregnancy?
 Pregnancy Diagnosis
Human Chorionic Gonadatropin (hCG) is excreted by
trophoblast/placenta. Tests for hCG can be either
through urine or blood. Urine hCG will test positive
approximately 2 weeks after conception or at time of
missed menses
Blood tests for hCG are either qualitative or
quantitative. Qualitative is a simple positive or
negative whereas Quantitative provides a numerical
level. hCG can be detected in blood within 7-10 days
of conception
hCG levels
In normal pregnancy, hCG levels double every 48-72 hours
3 weeks LMP: 5 - 50 mIU/ml
4 weeks LMP: 5 - 426 mIU/ml
5 weeks LMP: 18 - 7,340 mIU/ml
6 weeks LMP: 1,080 - 56,500 mIU/ml
7 - 8 weeks LMP: 7, 650 - 229,000 mIU/ml
9 - 12 weeks LMP: 25,700 - 288,000 mIU/ml
13 - 16 weeks LMP: 13,300 - 254,000 mIU/ml
17 - 24 weeks LMP: 4,060 - 165,400 mIU/ml
25 - 40 weeks LMP: 3,640 - 117,000 mIU/ml
Non-pregnant females: <5.0 mIU/ml
Pregnancy Diagnosis
By History (presumptive signs of pregnancy)
◦ Cessation of menses
◦ Breast tenderness/Nipple enlargement
◦ Nausea and/or Vomiting
◦ Fatigue
◦ Urinary frequency
By Examination (probable signs of pregnancy)
◦ Uterine enlargement
◦ Skin discoloration
◦ Chadwick’s sign (bluish tinge to vaginal mucosa/cervix)
◦ Goodell’s sign (softening of cervix)
By Testing (positive signs of pregnancy)
◦ hCG testing
◦ FHTs heard by fetone/doppler
◦ Fetal visualization by US
 Diagnosis of pregnancy can be
achieved by which of the following?
a. Visualization of the fetus on ultrasound
b. Report of fetal movement by mother
c. hCG detected in maternal serum or urine
d. Auscultation of fetal heartbeat.
Chadwick’s sign is a
a. Presumptive sign of pregnancy
b. Probably sign of pregnancy
c. Positive sign of pregnancy
Jamie has a positive home pregnancy
test
Her LMP is 8/12
When do you tell Jamie she needs to
come in for the first OB visit?
Prenatal Care
History of Obstetrical Care in the US
Women birthed accompanied by other women, family members,
midwives, birth attendants
Move to hospitals early 20th century due to advent of pain relief measures
(gases, ether). Childbirth became the realm of physicians
Infection rates increased dramatically,
no hand washing
Childbirth still very intervention
focused today
Obstetrics has highest legal liability of all
specialties; highest malpractice premiums
 Obstetrical Terms
Gestation: number of weeks since first day of LMP
Abortion: birth that occurs before end of 20 weeks or birth of
fetus weighing less than 500 grams
Term: Normal duration of pregnancy (37-42 weeks)
Antepartum: Time between conception and onset of labor
(AKA prenatal)
Intrapartum: Time between onset of labor and birth of baby
and placenta
Postpartum: Time between birth and when women’s body
returns to prepregnancy conditions (usually 6 weeks or 42
days)
Obstetrical Terms
Preterm or premature labor: labor that occurs
after 20 weeks but before 37 weeks
Postterm labor: labor that occurs after 42 weeks
 Gravida: any pregnancy regardless of
duration, including current pregnancy
Nulligravida: women who has never been
pregnancy
Primigravida: women pregnant for the first
time
Obstetrical
Terms Multigravida: women experiencing second or
more pregnancy
Para: birth after 20 weeks regardless of fetal
outcome
Stillbirth: infant born dead after 20 weeks
 Gravida & Parity refer to number of
pregnancies and births and not number of
fetuses/infants birthed

Obstetrical TPAL:
◦ T: number of term babies
Terms ◦ P: number of preterm babies
◦ A: number of abortions (spontaneous or
elective)
◦ L: number of living children
Sarah has two children who were both born at term. She
suffered a miscarriage of a twin gestation when she was
16 weeks. She is currently 5 w 5 days pregnant. What is
her gravida and parity?

G 4 P2 T2 P0 A2 L2

G4 P2 T0 P0 A1 L2

G5 P2 T2 P0 A1 L2

G3 P2 T2 P0 A1 L2
Determination of
Due Date
Can use LMP
Evaluation of Uterine Size
Determination of when Quickening occurs
Ultrasound (earlier done the more accurately
predicts gestational age)
Pregnancy Dating
First trimester: 0-14 weeks
Second trimester: 14-28 weeks
Third trimester: 29-42 weeks
Early Pregnancy Loss
30% of all implanted embryos
15% of clinically recognized pregnancies
Most in first trimester and related to chromosomal
abnormalities
Spontaneous Abortion
Threatened Ab- any vaginal bleeding in first half of
pregnancy; still viable pregnancy
Incomplete Ab-Not all POC passed spontaneously; not
viable
Missed Ab- fetal death has occurred but POC not passed
Recurrent Ab-occurs in 3 consecutive pregnancies
Miscarriages occur approximately 15% of pregnancies
Type Definition Symptoms Prognosis
Threatened Symptoms of SAB but Vaginal bleeding, Variable
POC intact cramping, US equal to
dates, cervical ox
closed

Inevitable Increased severity of Same but more severe Poor

symptoms, POC intact

Incomplete Symptoms of SAB Heavy bleeding, Size = Poor

including cervical os dates, dilated cervix
dilation and partial
expulsion of POC

Complete POC expelled Minimal bleeding Pregnancy loss

Missed POC retained Possible vaginal Pregnancy loss
bleeding

Recurrent Three of more SAB Need referral

occurring
consecutively.
Management of first trimester bleeding
Ultrasound, Quant hCG only provide you with a
snapshot
Both may need to be repeated within 7-10 days
Level or falling Quant hCG indicates missed or
incomplete ab
Repeat ultrasound results determine need for D&C
Order CBC, ABO and Rh
Management of first
trimester bleeding

Pelvic exam to
Do you see blood Is cervix closed
evaluate
clots or tissue? or dilated?
bleeding

Order ultrasound
Is uterus Order
to evaluate
enlarged? quantitative hCG
pregnancy
Transvaginal ultrasound
By 4 ½ weeks, gestational sac seen
By 5 weeks, yolk sac seen
By 5 ½ weeks, embryonic pole seen
By 6 weeks, fetal heartbeat seen

Fetal Pole Fetus

Gestational Sac
What is your management plan for
Jamie?
 What is your plan for Jamie?
a. Inform Jamie that she is suffering a miscarriage.
b. Order a repeat U/S and quantitative HCG for 7-10 days
c. Schedule Jamie for a D&C
d. Tell her to return in one month for re-evaluation
 Ectopic Pregnancy
Embryo usually implants in fallopian tube but refers to any pregnancy that implants
out of uterus
Risk factors: hx PID, infertility
Women present with pain and bleeding, usually around 6-7 weeks
May note adnexal mass
Follow Quant hCG results
Ultrasound usually with
empty uterine cavity
If quant >3000, should see gestational sac on US
May be managed surgically or
with methotrexate
Gestational Trophoblastic Disease
(Hydatiditiform Mole)
Abnormal proliferation of placental tissue resulting in
development of a benign or malignant tumor
Partial- nonviable fetal tissue present
Complete-no fetal tissue
Present with size>dates, severe n&v, dark red bleeding,
passage of grape like villae
Refer to MFM
Must follow hcG levels
Mary has a
positive
pregnancy test
and reports
vaginal a. Early normal pregnancy
bleeding at
approximately b. Spontaneous abortion
6 weeks by c. Ectopic pregnancy
LMP. Her u.s
shows an d. Missed abortion
empty uterus.
What is your
working
diagnosis?
Jamie
Good news!
Jamie returns in 1 week
Jamie’s quant hCG levels continue to rise and her US shows 6+6 week
size fetus and a fetal heart beating at 160 bpm.
What does a New OB exam consist of?
Jamie
Jamie returns for her NOB visit
Jamie tells you she is very healthy and has no medical issues
LMP 8/9/22
She had one pregnancy in college that she terminated
Family history significant for mother with NIDDM
Husband’s medical history significant for HTN
No genetic abnormalities noted
Feels well but some am nausea
Denies further cramping and bleeding
 Antenatal History
History to include patient past medical history, past
gynecologic history (including contraceptive use), past
obstetrical history, family history, genetic history of patient
and partner, nutrition history, present pregnancy, last
menstrual period
Estimation of EDD- Average gestation is 280 days from LMP
(or 266 from conception)
Naegele’s rule- subtract 3 months from LMP date then add 7
days to calculate EDD
 Antenatal Examination
Physical exam- Head to toe examination, including height and weight and
vital signs
Pelvic exam- noting Chadwick’s and Goodell’s sign and evaluating size of
uterus
Clinical Pelvimetry
Clinical
Pelvimetry
A clinical measurement of pelvic diameters
Uses reach of fingers to evaluate size, shape
of women’s pelvis
Most women allowed to labor regardless of
clinical pelvimetry findings
 Laboratory- initial labs include
blood type (ABO) and Rh factor,
antibody screen, CBC, RPR, Rubella
titer, HbsAg, HIV, urinalysis with
reflex culture, varicella titer, sickle
cell, PPD, GC/CT by UA
Antenatal
Labs
Pelvic exam includes obtaining Pap
smear and genital cultures for
gonorrhea and Chlamydia (if
indicated).
Jamie has a
positive a. March 16
home b. April 14
pregnancy c. May 16
test. Her
d. April 1
LMP is 8/9.
What is her
EDD?
 G1 P0000
What is
Jamie’s G1 P0010
Gravida and G2 P 0010
Parity?
G2 P 0100
Jamie
presents for
1 week
her New OB
visit at 8 2 weeks
weeks. 4 weeks
When do you 6 weeks
schedule her
for the next
visit?
Routine OB Visit Protocol
Pregnancy visits occur every 4 weeks in early
pregnancy, shortening to every 2 weeks at 28 weeks
gestation and then to every 1 week at 36 weeks
Every visit includes vital signs, weight and urinalysis
by dip stick for proteinuria or glucosuria.
Blood pressure drops in second trimester
 Your office nurses have provided Jamie with
In the teaching on diet, common discomforts,
meanwhile vaccinations, medications, tobacco and
alcohol
What vaccines are recommended in pregnancy?
Which are contraindicated?
 Vaccines
Recommended each pregnancy
◦ Influenza
◦ Tdap (3rd trimester)

Advised if at risk
◦ Hep B

COVID
◦ No increased risk of miscarriage
◦ No increased safety concerns found late in pregnancy

Contraindicated (live virus)

◦ MMR
◦ Varicella
Common Pregnancy Complaints
Morning Sickness- occurs in approximately 80% of all
pregnancies
Begins between 4-7 weeks and usually resolves by 12-14 weeks
Treated by eating upon first arising, eating small, frequent
meals, eating ginger products, using accupressure (sea bands,
relief band)
Phenergan/Zofran/Diclegis/Bonjesta can be prescribed in first
trimester
Hyperemesis gravidarum occurs <1% of patients but those
patients may require hospitalization, IV hydration, rarely TPN
Common Pregnancy Complaints
Backache (upper related to enlarging breasts; lower to growing uterus)
Constipation- slowing of peristalsis, pressure on GI tract- dietary measures,
stool softeners, no laxatives
Heartburn- can use OTC antacids
Edema- left lateral rest, increase water consumption
Varicosities (vulvar, legs, hemorrhoids)
Round Ligament- enlarging uterus
Carpal Tunnel- edema in hands, shoulders
Supine hypotension- enlarging uterus pressure on occluded vena cava return
Syncope- slow venous return due to enlarging uterus
 Nutrition

Normal weight gain in pregnancy is 25-35 lbs (BMI 18.5-24.9)

Underweight women may gain more (28-40 lbs); Overweight women may
gain less (15-25 lbs); Obese women (11-20lbs)
Most of weight gained is in second half of pregnancy
Women should gain approximately 10 lbs by 20 weeks gestation, with the
remaining weight gained at a rate of 1 lb per week
 Meal Planning
Consume a variety of foods including grains, vegetables,
fruits, milk and dairy products, oils, meat and beans
Use myplate.gov
to tailor a meal planner
that accommodates
woman’s weight, activity level and age
Avoid excessive sweets, fried or junk foods
Vitamin Supplements
Consume one multi-vitamin with iron and folic acid
daily
Folic acid consumption is approximately 400mcg
daily for prevention of neural tube defects
Fe supplements based on woman’s dietary intake,
Hgb & Hct results
 Foods to Avoid
Avoid deep sea fish such as swordfish, mackerel, shark due to high
mercury levels
Albacore tuna also has higher mercury levels
Avoid raw fish and shellfish (sushi, oysters and clams)
Raw meats, eggs
Avoid medium cooked or raw meat and sausage. Also avoid hot dogs
and deli meats. Undercooked foods may contain bacteria listeriosis
Avoid unpasteurized dairy products, especially soft cheeses such as
brie, feta, camembert, blue cheese
Limit consumption of caffeine
Pica- the urge to eat non food items such as starch, clay, dirt, ice.
Cigarettes, Drugs & Alcohol

18% of women smoke cigarettes regularly but

only 13% smoke during pregnancy
Doubles risk of having low birth weight infant
Increases risk of preterm delivery and stillbirth
Increases risk of SIDS after delivery
Infants of smokers more ill, more frequently and more likely to smoke as adults
Critical threshold is around 9 cigarettes daily
If women quit smoking before end of 2nd trimester, risk of low birth weight infant equals that of
non smoker
The more a woman smokes the greater the risk of complications
Second hand smoke also found to be harmful
Cessation options include behavioral teaching and NRT and/or pharmaceuticals (Zyban, Chantix).
Cigarettes, Drugs & Alcohol
Illicit drugs such as cocaine, amphetamines, inhalants, marijuana can cause
placental aging decreasing amount of oxygen to fetus.
Can result in spontaneous abortion, small for gestation age (SGA), intrauterine
growth retardation (IUGR) infants, preterm labor and birth, placental abruption
and stillbirth
Cocaine and inhalants may also cause birth defects
Cocaine has been shown to cause fetal stokes in utero
Pain medications containing opioids may cause fetal growth retardation and
developmental delays.
Infant can be born drug dependent requiring treatment. Drug withdrawals
results in infants who are irritable, cry frequently and are inconsolable. Long
term developmental delays also likely
 Cigarettes, Drugs & Alcohol
Alcohol abuse can lead to Fetal Alcohol Syndrome (FAS) resulting in deformed
facial features and developmental delay
Consuming 3 ounces of absolute alcohol daily increases risk of FAS 30-50% (2
drinks)
3 ounces of alcohol equals 2 beers or 2 glasses of wine
No clear recommendation on how much alcohol is safe in pregnancy so advice is
to avoid totally
Known or suspected teratogens
Infectious agents: CMV, herpes, Rubella, Toxoplasmosis,
Treponema pallidum, varicella, herpes, Zika
Drugs/Chemicals: Alcohol, DES, Lead, Mercury, Phenytoin
(Dilantin), Tetracyclines, Thalidomide, Valproic acid, PCBs,
Coumarin (warfarin), Isotretinoin (Accutane), Trimethadione
(Tridione)
Physical Agents: Hyperthermia, ionizing radiation
Which
vaccinations a. Influenza
are b. HPV
recommended c. MNMF
during
d. Tdap
pregnancy?
Check all that e. COVID 19
apply
Cigarette
smoking is a. Sudden Infant Death Syndrome
known to b. Preterm birth
cause which c. Stillbirth
of the
d. Low birth weight
following?
e. Spontaneous abortion
Check all that
apply.
Routine OB Visit
Provider evaluates weight gain/loss, blood pressure and urine
results at each visit
Measurement of uterine size
Auscultation of Fetal Heart Tones (FHTs); not usually heard
until approximately 12 weeks
Quickening occurs approximately 18-20 weeks
Evaluates patient complaints of headaches, abdominal pain,
edema, vaginal bleeding/discharge, uterine contractions
 Routine OB Visit
Uterine Measurement

Not usually palpated abdominally until approximately 12 weeks;

fundus found then at level of symphysis pubis
At 16 weeks, uterine fundus found midway between symphysis and
umbilicus
At 20 weeks, uterine fundus found at level of umbilicus
After 20 weeks, uterine fundus measures in centimeters the same as
patient’s weeks gestation (+/- 2 cms). Measurement begins at
symphysis and extends to top of uterine fundus. For example, at 28
weeks gestation, the uterus will measure approximately 28 cms.
Measurement may decrease in last month of pregnancy as fetus
begins descent into maternal pelvis.
Measurement obtained using a paper tape measure
Fundal Height Measurements
First trimester uterine size comparison
Non pregnant: Pear
Week 6: Small orange or tennis ball
Week 8: Large orange or softball
Week 12: Grapefruit size (palpable at suprapubic area)
Week 14: Cantaloupe size
Jamie
Jamie says she has been reading about special tests that you can do in
pregnancy that let’s you know that your baby is okay
She asks what you recommend
What do you tell her?
 Genetic Screenings & Referrals
Prenatal screening for potential
genetic abnormalities and birth defects

Approximately 3-5% of babies born with birth defect

Who to refer for screening?
Advanced maternal age (age 35)- woman’s risk of carrying a fetus with genetic or
chromosomal abnormality increases with age. (At age 25, 1:1000, age 35, 1:300, age 40, 1:80)
Family history of genetic abnormally or birth defect, especially in first degree relative such as
parents, siblings, grandparents of either parent or previous child with genetic abnormality or
birth defect
Ancestry associated with certain abnormalities such as Tay-Sachs, sickle cell disease,
Thalasemmia
Personal history of prior multiple miscarriages or stillbirths
Personal history of maternal diabetes or epilepsy prior to conception
Environmental exposures from chemicals, drugs or radiation
Known exposure to certain infectious diseases in current pregnancy
Abnormal genetic test or ultrasound
 Genetic Screenings Testing
Integrated/Sequential screening
◦ Screens for DS, trisomy 18, spina bifida
◦ Combines first trimester US and two blood tests
◦ Blood test done between 11 and 13+6 weeks and then 15-18 weeks

Nuchal translucency (measurement of fluid filled space) done between 11-14 weeks
gestation. NT may be done in correlation with serial blood tests
Quad screen (maternal serum alpha fetoprotein-MSAFP, estriol, hCG, inhibin A)
measures levels of proteins/hormones between 15-20 week of pregnancy. Elevated
levels associated neural tube defects; low levels associated with Down Syndrome;
Abnormal results may be associated with multiple gestation or incorrect dating
Non invasive prenatal testing (NIPT) –
◦ Cell free fetal DNA - not diagnostic
◦ 10 week gestation

Cystic fibrosis screening

Screening Test Components Detects Increased Risk for…. Timing

Maternal Serum 2 hormones Trisomy 13, 18, 21 10-14 weeks

Nuchal Translucency US evaluation of thickness of nuchal Aneuploidy, fetal anomalies 10-14 weeks (best
(NT) fold by 11 weeks)

Noninvasive prenatal Examination of cell free fetal DNP within Aneuploidy, limited fetal gene 10 weeks +
testing (NIPT) maternal blood disorders
Trisomy 13, 18, 21

Quad screen Serum markers from maternal blood Neural tube defects (NTDs), 15-22 weeks
trisomies 13, 18, 21

Anatomy Ultrasound US of fetus, placenta, amniotic fluid, Fetal structural anomalies, 18+ weeks
umbilical cord aneuploidy
 Genetic Diagnostic testing
Chorionic Villus Sampling- obtains tissue sample from placenta between 10-12
weeks
Amniocentesis- Sample of amniotic fluid obtained abdominally and cultured for
chromosomal analysis.
Done between 15-23 weeks
Jamie
Jamie opts to have the integrated screening
What do you tell her?
Ultrasound
Ultrasound- done either abdominally or pelvic- uses sound waves to evaluate
structure of fetal organs. May look for markers for certain genetic
abnormalities.
Routine OB Visit
Ultrasonography

Usually one ultrasound done routinely each

pregnancy
Indicated to diagnose viable pregnancy, confirm
dating, diagnose multiple pregnancy, assess fetal
anatomy, determine placenta localization, amniotic
fluid volume and fetal presentation
Routine ultrasounds done between 16-20 weeks
gestation
Jamie is asking when she will find out the sex
of her baby
What do you tell her?
Jamie is starting to feel fetal movement
She is a runner and wants to know if it is okay
Sushi is one of her favorite meals
Also, she asks, is it still okay to have sex
Pregnancy Dos & Don’ts
Obtain prenatal care
Proper nutrition
Regular exercise
No heavy lifting over 25 lbs after 20 weeks gestation
Curtail travel after 26 weeks
Avoid environmental exposures to chemicals, drugs known to be
carcinogenic
Avoid persons with known infectious disease
No restriction on intercourse unless specified by provider
No work restrictions unless specified by provider and doesn’t involve
environmental exposure or heavy lifting
Jamie and her husband are planning a vacation for
Barbadas next month
What do you tell her?
Perinatal Infection
Infections caused by microorganisms, primarily viruses,
bacteria, fungi, rickettsias, protozoons and animal parasites
Direct effect on mother/indirect on fetus (maternal
dehydration/electrolyte imbalance)
Direct effect on fetus (congenital malformations)
Primary infections more lethal to fetus than subsequent
infections
Zika Virus
Contracted by virus carried by mosquito but can be sexually
transmitted
Pregnancy loss, microcephaly, brain/eye abnormalities
Timing of infection- immediate preconception vs first
trimester
? 30% risk of adverse outcome
No local spread in US since 2017
 Zika Virus
Screening based on risk factors
◦ Travel to or partner travel to high risk areas (93 listed countries)
◦ Use of condoms
(3 months post visit)

Refer to MFM
◦ Virus screening
◦ Serial US
◦ https://wwwnc.cdc.gov/travel/page/zika-information
 COVID- 19
Higher risk of severe disease for pregnant and PP women
Certain underlying conditions increase risk (includes age)
COVID dx in pregnancy increases risk of preterm birth & C section
More likely admitted to ICU and be intubated
Worse for Black, Hispanic women
Presenting symptoms similar (cough, SOB, fever) but less likely to have HA, muscle ache,
chills, diarrhea, loss of smell/taste
Increase in spontaneous abortion or congenital anomalies (fever) with severe disease
Newborns typically healthy other than prematurity
Rare cases of vertical transmission
Mom –baby separation?
Lactation possible for infected mother- should wear mask
Urinary Tract Infections
Asymptomatic bacteriuria
Cystitis
Acute pyelonephritis

UTIs common in pregnancy due to hydronephrosis

and urinary stasis
Urinary Tract Infections
Asymptomatic bacteriuria
Most common organisms include e. coli, proteus, klebsiella,
staph aureus, beta-hemolytic strep, enterococcus
E coli most common bacteria
Obtain culture and sensitivity
Treat if >50,000 single organism
Most common antibiotics used for UTIs are Penicillins,
Nitrofurantoin, Septra (Sulfa drugs contraindicated in 3rd
trimester)
Vaginal Infections
Bacteria Vaginosis
Bacteria Vaginosis- bacterial imbalance
Overgrowth of bacteria normally controlled by
lactibacilli
Symptoms include grayish-white vaginal discharge
with fishy odor; vaginal burning or irritation
Diagnosed by identification of clue cells under wet
mount microscopy
Associated with preterm labor, PROM
Vaginal Infections
Bacterial Vaginosis
Not routinely screened for unless patient at
risk for preterm labor
Treatment with Metrogel .75%
(Metronidazole) vaginally BID x 5 days-
helps restore normal vaginal flora
Can use in first trimester?
No alcohol while using drug
Vaginal Infections
Monilia Infection
Monilia Infection (candida albicans)
More common in pregnancy secondary to
hormonal changes
Symptoms include slight vaginal discharge
with pruritis
Diagnosis by hyphae identification by wet
mount microscopy; pH>4.5
Treatment with OTC meds or Diflucan 150 mg
x1
Vaginal Infections
Trichomoniasis
Trichomoniasis- vaginal protozoa that causes heavy
yellow green discharge with much pruritis
Sexually transmitted; partner must be treated
concurrently
Diagnosed by identifying trichmonad under wet
mount microscopy; pH > 4.5
May contribute to preterm labor, PROM
Treated with metronidazone (Flagyl) 2 grams po x 1
No alcohol use
Infections- TORCH
Toxoplasmosis
Other infections (Syphilis)
Rubella
Cytomegalovirus
Herpes
Toxoplasmosis
Protozoal infection caused by parasite Toxoplasma gondii.
Primary infection during pregnancy causes severe
congenital anomalies by crossing placenta
Can cause death, prematurely, CNS defects, anencephalus,
hydrocephalus
Vague symptoms include fever, malaise, muscle pain,
swollen lymph nodes
Organism acquired from handling
cat feces or eating raw meat
Advise pregnancy women to
avoid changing cat litter box
 Rubella
Infection with rubella virus causes the most
severe damage when the mother is infected
early in pregnancy, especially in the first 12
weeks (first trimester)
Congenital rubella syndrome (CRS) Pregnant
women who contract rubella are at risk for
miscarriage or stillbirth, and their developing
babies are at risk for severe birth defects
Cytomegalovirus
CMV is microorganism associated with congenital
malformation if contracted by mother during
pregnancy
Contracted through sexual contact, blood
transmission
Symptoms for mother include fever,
lymphoadenopathy, fatigue
Infants may suffer from enlarged livers, hearing
loss, developmental delays, CP
Very common 1:100 infected, 1:5 symptomatic
Viral Infections
Herpes Simplex
Herpes Simplex

Lesions are thin walled vesicles that may occur singularly or in

clusters over cervix, vagina or vulva

Primary infection more painful and associated with

lymphoadenopathy

Secondary infection not as painful

Active lesions at time of labor results in C-section delivery due to

risk of contracting herpes infection by neonate

Patient must receive a careful perineal examination when presents

in labor to r/o presence of lesions

Prophylactic anti-viral medication begun at 34 weeks gestation.

Valtrex 500 mg daily given
Varicella
25-40% fetuses explosed develop congenital
varicella syndrome, especially if exposure in
1st 20 weeks
Congenital varicella syndrome – cataracts,
chorioretinitis, limb hypoplasia,
microcephaly, mental retardation
If varicella occurs near birth, not enough time
for mother to develop immunity and pass to
infant; 5% mortality
Varicella pneumonia develops in 10-30% of
cases with maternal death in 40% of cases
Parvovirus B 19
(Fifth Disease)
If infection during pregnancy, 20-30%
placental transfer
Mild rash, polyarthropathy
Affected fetuses develop aplastic anemia,
hydrops, death
If exposed obtain IgM and IgG
If seroconversion, monitor fetus weekly by
ultrasound
Syphilis
Caused by bacteria treponoma pallidum
If transmitted to fetus can cause congenital
syphilis
Tested for in early pregnancy
Sooner the treatment, less sequelae
Doesn’t cross placenta until 16 weeks
gestation
Treatment of choice: Penicillin
Gonorrhea
Caused by bacteria Neisseria gonorrhoeae
Can cause Spontaneous Abortion, Preterm
ROM, Premature birth
Newborns can develop neonatal eye
gonorrhea; state law requires all newborns
receive antibiotic eye ointment
prophylactically (erythromycin)
Treated with Ceftriaxone (Rocephin) 500 mg
IM single dose
Chlamydia
Caused by bacteria Chlamydia trachomatis
Can cause preterm birth, low birth weight
infants
May cause newborn pneumonia, eye and ear
infection
Treated with Azithromycin 1 g orally single
dose
Hepatitis B
Greater risk of vertical transmission later in
pregnancy
Not teratogenic but can cause low birth
weight, prematurity
No treatment but follow fetal well being
closely
Many infants develop chronic hepatitis
Infant given HBIG and HBV vaccine
Condyloma
Caused by HPV virus
Can be treated in pregnancy with either
Imiquimod 5% (Aldara) cream or TCA
Surgical excision may be indicated
Not a contraindication to vaginal delivery
unless obstructive
Minimal risk to neonate (anogenital, oral, and
laryngeal)
Jamie’s
fundal height
is located
halfway
between her a. 12 weeks
symphysis
and b. 16 weeks
umbilicus. c. 20 weeks
You estimate
her
gestational
age to be:
A 32 yo G2
P1 presents at
12 weeks.
Her previous a. Quad screen

infant has b. Cell free DNA

Trisomy 21. c. Integrated screen
What genetic d. Chorionic Villi sampling (CVS)
screening
tests will you
offer?
This organism can contribute
to preterm labor
a. Candida
b. Bacterial vaginosis (BV)
c. Syphilis
d. Human Papilloma Virus ( HPV)
Jamie is now 28 weeks
What tests and teaching will you do for Jamie today?
 Return OB visit
Laboratory Screening
Glucose screening performed at 24-28 weeks. Initial screening consists of
a 1 hour glucose tolerance test. Patient consumes 50 grams glucola, non
fasting. Blood is drawn 1 hour later. Value should be less than 140 mg
If screen positive (≥135-140 mg), the patient undergoes a 3 hour GTT.
Test is performed fasting. Patient consumes 100 grams glucola. Normal
values for this test are:
FBS< 95
1 hour< 180
2 hour< 155
3 hour< 140
If two out of four values abnormal, patient diagnosed with gestational
diabetes.
May elect 1 step process- 75 gr glucose load and FBS and 1&2 hr; one
abnormal results is gest DM
Return OB visit
Laboratory Screening
Additional labs ordered with glucose screening may include CBC and
Antibody Screen if woman Rh negative.
Rhogam given to all Rh negative women between 28-30 weeks
gestation
Repeat dose given postpartum if infant Rh positive and mother’s
indirect Coombs negative.
Jamie
Jamie’s labs come back
1 hr GTT 142
She is O negative
What is your management plan?
Jamie
Jamie is now 30 weeks gestation
Her 3 hr GTT was WNL
Today she presents with lower abdominal pain
What is your plan?
Preterm Labor
Occurs prior to 37 weeks
Regular uterine contractions that cause cervical
change
Increase vaginal discharge and secretions; vaginally
bleeding may be present
Dull, low backache, pelvic pressure
12% of births are premature; increase risk if patient
with previous PTD
Preterm Labor
If suspect PTL, advise women to lie down, drink 16 ounces of
water
If contractions continue coming at rate of q 10 minutes or less
(approximately 6 per hour), contact provider or hospital
Evaluate contractions on fetal monitor, perform cervical exam
Differentiation between uterine irritability and preterm labor
Oftentimes, uterine irritability caused by maternal
dehydration, BV or UTI; Must r/o infectious cause of PTL
(including genital infections)
History
When did this start? Does the pain continue all day or is it intermittent? Is it
worse with movement? Describe the pain, is it sharp, dull, achy? Where is the
pain worse? Does it radiate to your lower back?
Are you having contractions? Any discharge or blood from your vagina?
Any trauma to your abdomen? Have you fallen on your abdomen or been
struck in your belly?
Any history of previous uterine surgery? Previous C-section?
What have you tried to make the pain better?
Are you eating well? Have you had any nausea or vomiting? Recent bowel
movement? Diarrhea? Is pain related to eating?
Any dysuria, blood in urine?
Exam
Perform abdominal exam, palpating entire area,
noting especially lower right quadrant
Observe for uterine tightening
Observe for uterine hardness
Check for CVA pain
Perform pelvic exam noting cervical dilation
Preterm Labor
Fetal fibronectin (fFN) is a vaginal sample that identifies present of
protein associated with uterine contractions and labor. Absence of fFN
in vaginal swab indicates delivery within next two weeks unlikely. Test
must be done prior to any vaginal exam
Cervical length can be measured by US in 2nd trimester- normal length is
35 mm. Shorter lengths associated with PTD
Progesterone treatment
(Makena 250mg) weekly IM
injection between 16-37 weeks
Preterm labor Testing
Urinalysis
CBC with diff
fFN (if indicated)
Ultrasound to R/O abruption
What other differentials do you consider?
Differential Diagnoses
Preterm Labor
M/S pain such as round ligament pain, pelvic relaxation
Appendicitis
UTI/Kidney stones
Gas/Constipation/Gastroenteritis/Gall stones
Placental Abruption
Uterine rupture
Fetal Movement
 Florida Administrative Code 64D-3.042, STD Testing Related
to Pregnancy

 1.Practitioners attending a woman for prenatal care shall cause

the woman to be tested for chlamydia, gonorrhea, hepatitis B,
HIV and syphilis as follows:

 (a) At initial examination related to her current pregnancy; and

again

 (b) At 28 to 32 weeks gestation.

2. Exceptions to the testing outlined in subsection (1) above are

as follows: 

 (a) A woman, who tested positive for hepatitis B surface antigen

STI testing in (HbsAg) during the initial examination related to her current
pregnancy, need not be re-tested at 28-32 weeks gestation.
pregnancy  (b) A woman, with documentation of HIV infection or AIDS need
not be re-tested during the current pregnancy.

3. Women who appear at delivery or within 30 days postpartum

with:

 (a) No record of prenatal care; or

 (b) Prenatal care with no record of testing;

 (c) Prenatal care with no record of testing after the 27th week of
gestation shall be considered at a high risk for sexually
transmissible diseases and shall be tested for hepatitis B surface
antigen (HBsAg), HIV and syphilis prior to discharge.
Jamie is now 35 weeks gestation
What will her prenatal visit consist of today?
Routine OB Visit
Laboratory Screening
Group Beta Strep testing performed at 35-37 weeks
gestation
Vaginal/rectal swab performed to screen for
presence of GBS in women’s vaginal/GI track
If GBS positive, patient is given IV antibiotics in labor
to prevent transmission of GBS to newborn and
development of GBS pneumonia
Jamie
Jamie is now 37 weeks
She reports lots of swelling in her hands and ankles
She also is having more headaches
What other information to you want to obtain?
Pregnancy Induced Hypertension
Evaluate BP, urine protein and weight gain, edema
at each visit
Normal BP drops in second trimester. Compare late
pregnancy readings with first trimester
Concern for BP >140/90 or rise of 30 mm systolic
and 15 mm diastolic from baseline
Assess patient for headache, abdominal pain
(epigastric pain), visual disturbances
 Term Pregnancy
Evaluate fetal presentation at each visit after 35 weeks- usually cephalic
but can be breech or shoulder. Grip fetal part between fingers. Head will
be harder than breech, harder to maneuver
Feel for fetal back. Usually FHTs are heard best here. Back feels smooth,
no fetal parts
Estimated fetal weight- (small 6 lbs or less, medium 7-8 lbs, large greater
than 9 lbs). Practice on turkeys at grocery store
Fetal Kick Counts- counsel women on performing kick counts if normal
fetal movement pattern altered. Woman should lie or sit after consuming
meal and count using pencil and pad. Minimum of 10 separate kicks
within 2 hours is sign of fetal well being. If 10 kicks not counted, woman
should contact provider or hospital. NST generally ordered
Leopold’s Manuevers
Jamie 39 wks
Jamie’s labs for pre eclampsia have come back
normal and her BP and edema are much improved.
She is now 39 weeks pregnant
She reports lots of back pain and spotting
She says she is very wet “down there”
What do you do next?
Term Pregnancy
Full term pregnancy after 37 weeks (37-42 weeks)
Usually allow to deliver if labor commences or
SROM after 36 weeks
 Labor Signs & Symptoms
Regular uterine contractions occurring at least every 5 minutes resulting
in progressive cervical change
Contractions becoming more intense, increased duration and frequency
over time
Increase in vaginal secretions, light bleeding or spotting
 Assessment of Contractions
Frequency-time between beginning of one contraction to the
beginning of the next
Duration- time between beginning of one contraction to
completion of same contraction
Intensity-strength of contraction during acme
◦ Evaluated by palpating uterine muscle
◦ Mild, moderate, strong based on how much uterine wall can be indented at peak of contraction
Term Pregnancy-
Cervical Exam
Dilatation- how much cervix has opened
(from closed to 10 cm)
Effacement- shortening of cervical length
(0-100%). Cervix usually 2-3 cms in
length
Station- position of fetal head relative to
ischial spines of maternal pelvis (-3 to +3)
Also done to confirm fetal presentation
Rupture of
Membranes
May occur at any point in
gestation but usually at
term
May be slight discharge
or large amount of copius
fluid eminating from
vagina
Rupture of Membranes
Clinical testing consists of pH testing, fern test, and vagina
pooling
pH testing- amniotic fluid is alkaline (vs vaginal discharge
and urine being more acidic). pH paper (nitrazene paper or
Amnisure) used to evaluate discharge. If paper turns blue
(pH > 7; yellow color when not in use), amniotic fluid
suspected. Blood and semen may cause change in color.
Ferning test- Sample of amniotic fluid put on slide and
dried. Will form a fern like pattern after a few minutes.
Vaginal pooling- amniotic fluid will pool in vaginal cul de sac
Jamie 40 w 2 d
Jamie’s membranes were not ruptured last week
and her cervix was closed, long, posterior
She is now 40+2 weeks gestation and wants to
know when she will be induced
Her mother is visiting but has to leave to return
home and to work on Friday
Induction Scheduling
Scheduled for post dates gestation or maternal or
fetal complication
Post dates induction usually done after 41 weeks
Social inductions scheduled between 40-41 weeks
gestation
Done for convenience of provider and patient
Each facility has own policy on inductions
Cervical Readiness
Labor induction more successful if cervix softened
and effaced
Bishop’s score used to predict labor success
Components include cervical dilatation,
effacement, consistency, position and station
Score of 8 or greater, favorable for labor induction
Bishop’s
Score
Would your management plan change if Jamie
had had a previous Cesarean section birth?
 VBACs/TOLACs
No longer done routinely
Risk of uterine rupture approximately 1%
What was indication of previous C-section?
Obtain operative note with report of low transverse uterine incision
Women with previous diagnosis of failure to progress, CPD not good candidates for VBAC
Women with previous diagnosis of breech presentation or fetal distress better candidates
Recommendation that women who wish to attempt VBAC be delivered at tertiary care
center with 24 hour immediate availability of obstetrician, anesthesia personnel and
pediatric support
Spontaneous labor; rare use of pitocin
Most women with history of previous C-section are scheduled for repeat C-section 7-10
days prior to EDC
Jamie 41 weeks
At her prenatal visit today she reports increasing
contractions but still irregular
Denies any fluid leaking
Her cervical exam is 2 cm/50%/-2/vertex
What is your management plan?
Antenatal Testing
Non stress tests (NST) non invasive test done after 28 weeks to evaluate fetal
well being. Fetal movement elicits fetal heart rate response 15-20 beats
higher than baseline. Two such responses in 20 minutes indicates fetal well
being
Amniotic Fluid Indexes (AFI) measurement of amniotic fluid volume. Normal
range between 8-18 cm. Measurement done by ultrasound; Measures all
four quadrants. Can also use single deepest pocket (2-8cm)
Biophysical Profile (BPP) combination of above tests along with ultrasound
evaluation of fetal movement, fetal tone and fetal breathing movements.
Fetus receives 2 points for each component of test for total score of 10
points.
If fetus scores less than 8/10, testing may be repeated or delivery may be
indicated.
Indications for Antenatal Testing
Postdates- beginning at 41 weeks gestation- begin with NST
and AFI and repeat biweekly until delivery
Decrease fetal movement- done any time fetal movement in
question after 30 weeks
Maternal medical/obstetrical history such as PIH, diabetes,
previous history of stillbirth, poor fetal growth during
pregnancy, low amniotic fluid volume
Frequency of testing can be bi-weekly, weekly or one time
only. Depends on woman’s gestational age, medical
indication, results of previous testing
Jamie calls you to tell you her water has definitely
broken and her contractions are much stronger but
still not regular
What do you tell her?
Jamie delivers a healthy baby boy, 7-14oz named
Steven, who is doing well.
Jamie had a spontaneous vaginal delivery after a 6
hour labor with ROM just prior to birth
Steven is breastfeeding well
Jamie is happy but tired.
You note her temperature today is 101 Fahrenheit
Her HCT is 29 (was 32 on admission)
Immediate Postpartum Period
Begins with delivery of placenta
Evaluate physical and emotional changes
Vital signs remain stable although temperature greater than 101 within
first 24 hours not unusual. Related to maternal dehydration. After 24
hours temperature > 101 needs evaluation
Evaluate vaginal bleeding, uterine involution; uterus found just below
umbilicus immediately postpartum; Bleeding gradually slows and
lessens
Evaluate perineum for edema, bruising, hemorhoids
Breast vs bottle feeding; colostrum available immediately; let down of
milk occurs within 3-5 days
Immediate Postpartum Period
Renal changes-Women void frequently and notice excessive sweating
immediate postpartum due to body ridding excessive fluids
GI- bowels may be slower due to lack of solid foods in labor;
constipation common also due to perineal pain. Stool softeners usually
prescribed
Weight loss- immediate 12 lbs; 5 more lbs through first week due to
diruresis. The remainder over next 6 weeks to 6 months
Hematologic changes- White count elevated in labor, may be slow to
return to normal; Normal blood loss in labor 500-1000ml resulting in a
decrease in HCT of 2-4 points
Order Rhogam if indicated
Immediate Postpartum Period-
C section
NPO initially, gradually advance diet
Manage pain
Encourage Ambulation
Support with baby
Most C-sections done under epidural or spinal
anesthesia so no ill effects of general anesthesia
Jamie returns to the office for her 2 week check up
Her EPDS is 12 (Edinburgh Postnatal Depression
Scale)
She also notes a warm, red area in her right breast
What is your plan for today?
Postpartum Exam
Usually performed at 2 and 6 weeks
Evaluate physical and emotional well being
Breast exam deferred
Pelvic exam to evaluate episiotomy/laceration repair
Vaginal bleeding may continue through 3-4 weeks postpartum; timing of first menses
dependent upon breast or bottle feeding; if bottle feeding may occur by 6-8 week
postpartum
Uterus will always remain enlarged after pregnancy and delivery, however uterus will be
pelvic organ again by 6 wks
Evaluate tubal or C-section incision at 2 and 6 weeks
Discuss birth control options
Clear patient to resume normal routines including exercise, intercourse
Postpartum blues
Postpartum blues occur within first two weeks after delivery
Related to hormonal changes, adjustment to new infant, sleep
deprivation
Usually resolves with time and support
from family
Postpartum Depression
Continues beyond initial two weeks post delivery
Occurs in approximately 10% of patients
May occur at any time during the first year postpartum
Feelings of sadness, tiredness, lack of joy, energy
Requires family support
May require use of medication
Zoloft 50 mg daily is treatment of choice regardless of feeding method
Depending on severity of symptoms and patient response, may need referral to
professional
Postpartum Psychosis rarely occurs- True psychiatric disorder requiring referral to
professional
Breastfeeding
Best if initiated shortly after delivery; breast
engorgement may occur with let down by day 3.
If not breastfeeding, provide binders, tight bra for
support; cabbage leaves provide relief from
engorgement
Avoid warm/hot showers, breast stimulation
No drugs given for milk suppression
Mastitis
Occurs 1-2% of postpartum women
Infection can be weeks or months after delivery
Produces systemic illness with fever, tachycardia, malaise,
localized breast tenderness
Usually does not occur before day 5 postpartum; suspect
breast engorgement if sooner
Infected breast may be red, hard, warm. Staph aureus
usually infectious agent
Breast milk not affected; May continue nursing infant
Treat with oral antibiotics (Keflex, PCN)
Can lead to abscess or cellulitis if not treated promptly or
with MRSA
Puerperal Fever
Occurs within first 10 days postpartum (but after 24 hours); approximately 5% pregnancies
Risk factors include operative delivery, long labor (multiple vaginal exams), prolonged ROM
Staph aureus or streptococcus usually causative agents
Infection usually in genital tract (uterine lining-endometritis)
Can lead to septicemia, cellulitis, peritonitis.
H&P includes fever (>38C), chills, malaise, foul smelling discharge, uterine tenderness,
lower abdominal pain
Differential diagnosis includes urinary, respiratory, pelvic thrombophlebitis, wound
infection, mastitis
Genital cultures, CBC, urinalysis, Chest X-ray, MRI
Treat with IV broad spectrum antibiotics (gentamycin, clindamycin)
Linda is G1 P1 and
now 7 weeks
postpartum. She
had an uneventful
vaginal birth and
has a healthy baby
girl. She reports a. Postpartum psychosis
increasing feelings
of sadness and b. Postpartum blues
fatigue. She loves
her baby but c. Postpartum depression
wonders if she is
capable of caring
for her. She most
likely has:
 a. Between the end of one
contraction and the beginning of
the next
Frequency of
b. The beginning of one contraction
contractions to the end of the same contraction
is timed…
c. The beginning of one contraction
to the beginning of the next
contraction
 a. 34 yo G1 at 40+2 weeks gestation
Which of the
following b. 18 yo G2 P0 at 38 weeks with
cases should complaints of decreased fetal
movement over last one hour
be sent for
antenatal c. 28 yo G3 P1010 at 34 weeks with a
history of stillbirth in prior
testing? pregnancy
Jamie
Jamie comes in after her pp visit with complaints of
fever >101, chills, malaise
History
What type of delivery did you have? C-section or vaginal? If vaginal,
were forceps or vacuum used?
Did you have a long labor?
How long were your membranes ruptured?
Did you use epidural anesthesia? Foley catheter?
Are you breastfeeding?
Anyone else in family sick or ill?
Do you have any urinary symptoms? Dysuria?
Do you have any coughing, shortness of breath?
Any pains in your calves, legs?
Jamie’s Physical Exam
Temperature 102.2, BP 112/64, pulse 102, respirations 22
Chest CTA
CVA tenderness negative
Breast full, non tender
Abdomen slightly tender
Uterine fundus above symphasis, slightly tender, firm
Pelvic exam with moderate vaginal bleeding, no odor, no
retained sponge noted
Negative Homan’s sign, calves non tender, no redness
Diagnostic testing
Chest X-ray- negative
Urinalysis-negative
CBC- HCT 36%, WBC-10,000
 a. Mastitis
What do you b. Postpartum endometritis
think Jamie’s
c. Influenza
diagnosis is?
d. UTI
What are your take home points from this lecture?