Quiz 3-Crider

Oxytocin

* Contracts uterus * Contracts smooth cells around alveoli to squeeze milk into ducts (average of 2.2 let-downs or milk releases from each breast, each feed) * Secreted from the posterior lobe of the pituitary gland

Estrogen

* Decreases during pregnancy to stimulate the ductalsystem * Decreases at delivery of the placenta, which allows prolactin to be released

Postpartum Mood Disorders- Warning Signs of Postpartum Depression

* Excessive worry or fatigue * Low mood, feelings of guilt, lack of interest * Sleep disturbances * Somatic symptoms in excess of or without physical cause (e.g., headaches, breast tenderness) * Marked fear of criticism of mothering skills * Excessive concern about infant's health or the infant's failure to thrive * Unexpected failure to keep follow-up appointments * Poor concentration * Poor appetite or excessive weight gain

Prolactin

* In pregnancy it increases breast tissue growth * After delivery it stimulates milk production (highest levels between 2-6 am) * Secreted from the anterior lobe of the pituitary gland ("mothering hormone"), which gives the mother a relaxed feeling with the infant

Progesterone

* Increases during pregnancy for growth of alveoli and lobe * Decreases after delivery of the placenta for copious milk secretion

When performing the Leopold maneuvers, you want to answer four questions:

* What is at the fundus? * Where are the spine and small parts? * What is presenting at the pelvis? * Where is the cephalic prominence?

Postpartum Mood Disorders- Postpartum Depression

10% of women experience postpartum depression. It is characterized by intense feelings of depression, sadness, anxiety, and despair, which greatly impact the woman's ability to care for herself and her baby. These feelings last longer than two weeks and can appear as many as 1 -2 months following delivery. Left untreated, postpartum depression can continue for weeks or months, lasting longer than it would if treated. The signs and symptoms of postpartum depression are not different from those in depressed non-pregnant patients, but they may be difficult to differentiate from normal involutional phenomena (e.g., weight loss, sleeplessness) or from the transient postpartum blues. In addition to the more common symptoms of depression, the postpartum patient may manifest a sense of incapability of loving her family and ambivalence toward her infant. There is a high risk of recurrence (50-100%) and a 20-30% risk of postpartum depression in women who have had a previous depressive reaction not associated with pregnancy. Consequently, it is important to inquire about psychiatric illness when taking the prenatal history. Recent studies suggest that serotonin reuptake inhibitors are effective and have fewer side effects than tricyclic antidepressants.

Postpartum Mood Disorders- Postpartum Blues

50-80% of all new mothers experience the postpartum blues. Shortly after delivering a baby, there are the expected feelings of excitement and joy, along with feelings of anxiety and worry. Postpartum blues are extremely common and can occur in the first few days after delivery and often appear suddenly on the 3rd or 4th day. Symptoms of postpartum blues may include: depression weepiness moodiness impatience tearfulness anxiety anger There may be a feeling of letdown after the emotional high of delivery. For no clear reason, a new mother may feel angry with her baby or her partner. The postpartum blues usually go away on their own without treatment within a week to two weeks following delivery. There appear to be no obstetric, social, economic or personality correlates for maternity blues. While it is tempting to ascribe the symptoms of this syndrome to the changes in steroid hormone levels that occur immediately following delivery, no such correlation has been found.

Complete abortion

A complete abortion is noted when the uterus has expelled its contents, the internal os is closed, the bleeding is minimal, and the uterus has returned to near normal size.

Antenatal Testing - Fetal Movement

A normal fetal movement score is given when at least 3 gross body movements are seen in 30 minutes.

Antenatal Testing - Amniotic fluid

A single pocket of 2 cm is sufficient to give a normal score.

Apgar Scoring

A total score of 10 indicates an infant in the best possible condition. An infant with a score of 0-3 requires immediate resuscitation. A low score does not necessarily signify fetal hypoxia-acidosis. The Apgar score also does not predict neonatal mortality or subsequent cerebral palsy. Indeed, the score is normal in most patients who subsequently develop cerebral palsy, and the incidence of cerebral palsy is very low among infants with Apgar scores of 0-3 at five minutes. The one-minute Apgar score may signal the need for immediate resuscitation, and the five-, 10-, and 20-minute scores may indicate the probability of successfully resuscitating an infant. Apgar scores of 0-3 at 20-minutes predict high mortality and morbidity.

Ectopic pregnancy

About 1% of all pregnancies end as ectopic pregnancies, but this figure varies from group to group. An ectopic pregnancy is defined as one that is implanted outside of the endometrial cavity. Ectopic pregnancies often cause vaginal bleeding and pain. If the ectopic pregnancy is ruptured, intraperitoneal hemorrhage may occur, and the patient may exhibit signs and symptoms of hypovolemia. Women who have had assisted reproductive technology procedures such as IVF and GIFT are at an increased risk for ectopic pregnancy.

Abnormal Stages of Labor - Active Phase Dysfunction

Active phase dysfunction is defined as dilatation that occurs at a rate less than the 5th percentile. This value is 1.2 cm/hour in nulliparous and 1.5 cm/hour in multiparous women. Dysfunctional labor is a frequent predecessor of arrest of labor and a risk factor for perinatal mortality. An arrest of dilatation is defined as cessation of dilatation for a period of two hours. If, arrest persists for over 2-4 hours despite anmiotomy and oxytocin augmentation, most authorities consider this an indication for cesarean delivery.

Stages of Labor - External Rotation

After the delivery of the head, the fetus rotates back to transverse, with the occiput and spine back in the same plane.

Threatened abortion

Bleeding in the first trimester of pregnancy is not uncommon. About 20-25% of all pregnant women will spot or bleed in the first trimester. If the bleeding can be observed to be coming from the cervix and the cervix is closed, a diagnosis of threatened abortion should be made. A threatened abortion becomes inevitable when the cervix dilates and products of conception pass through the internal os or when the bleeding is profuse.

Stages of Labor - Engagement

Descent of the biparietal diameter of the fetal head to a level below the plane of the pelvic inlet is known as engagement. Clinically, this is determined by palpation of the occiput at or below the level of the ischial spines. Although engagement is classically listed as one of the cardinal movements of labor, it often occurs before the onset of true labor, especially in nulliparous women.

Stages of Labor - Descent

Descent of the fetus is not continuous, with the greatest rate of descent in the deceleration phase of the first stage of labor and during the second stage of labor.

Antenatal Testing - Fetal Tone

Fetal tone is motion of a limb from flexion to extension and back again, pursing of fetal lips, or opening or closing of fetal hand.

Stages of Labor - Flexion

Flexion is the placement of the fetal chin on the thorax, a position in which the presenting diameters of the fetal head to the maternal pelvis are optimized.

Stages of Labor - Expulsion

Further descent brings the anterior shoulder under the symphysis pubis, and the rest of the body quickly follows.

Gestational Age

Gestational age is first estimated by dates, and then by measuring the biometric parameters to estimate the ultrasonographic gestational age. Biparietal diameter (BPD) Head circumference (HC) Abdominal circumference (AC) Femur Length (FL) Sonographic assessment of gestational age is most accurate in the first trimester. After 20 weeks, environmental and genetic factors influence the growth of the fetus.

trophoblastic disease

Gestational trophoblastic disease refers to the spectrum of abnormalities of the trophoblast associated with pregnancy. These neoplasias secrete human chorionic gonadotropin (HCG).

Apgar Evaluation of the Newborn Infant

Heart rate - (0)absent (1)<100 (2)>100 Respiratory effort- (0)absent (1)slow, irregular (2)good, crying Muscle tone- (0)limp (1)some flexion of extremities (2)active motion Irritability- (0)no response (1)grimace (2)cough or sneeze Color- (0)blue, pale (1)body pink, extremities blue (2)completely pink

Advantages to Breastfeeding

Human breast milk is the ideal food/nutrition for human babies. In addition, breastfeeding is thought to enhance development of the baby's GI tract, decrease infections in the infant (ear, respiratory, gut), enhance protection against juvenile diabetes, SIDS, allergies and asthma, foster intellectual development of the infant and shape proper development of facial and jaw muscles. The risks of not breastfeeding include possible increased incidence of later obesity, juvenile diabetes, food allergies, and risk of infections, especially necrotizing enterocolitis, sepsis, and meningitis in premature infants.

Cephalic Prominence

In cephalic presentations, a point of the fetal head may be noted as a protuberance that arrests the hand outlining the fetus. As the hands are moved along the lateral walls of the fetus toward the pelvis, either the occiput or the chin will be encountered.

Antenatal Testing - Non-Stress Test

In late pregnancy, the healthy fetus exhibits accelerations in heart rate above the baseline heart rate many times each hour. These accelerations require an intact neurologic coupling between the fetal CNS and the fetal heart. Fetal hypoxia will disrupt this pathway. Absence of fetal heart rate accelerations is most often due to a quiet fetal sleep state. Therefore, the NST is most predictive when normal or reactive. The perinatal mortality rate associated with a nonreactive NST is significantly higher than for a fetus with a reactive NST. The most widely applied definition of a reactive test requires that at least two accelerations of the fetal heart rate of 15 beats per minute amplitude and 15 seconds duration be observed in 20 minutes of monitoring.

Incomplete abortion

Incomplete abortion occurs when a part of the products of conception has been expelled but some remain within the uterus. The cervix is generally dilated, and there is usually bleeding, which may be profuse. Most gestations of 6 weeks or less from the time of the last menstrual period will abort completely. Incomplete abortions become more common after 6 weeks gestation. In these cases, a dilatation and curettage (D&C) can be performed.

Postpartum Mood Disorders- Normal Postpartum Feelings

It is common for parents who are stressed, overtired, sleep-deprived and caring for a fussy baby to have feelings of frustration, and even to have thoughts of harming the baby (throwing the baby out of the window, hitting the baby, shaking the baby). Of course, doing any of this is NOT OKAY. However, these feelings and thoughts, under the circumstances, are fairly universal and normal. I mention this because parents often have these thoughts and then feel enormously guilty that they are even capable of having them. Again, it is NOT normal or okay to act on the feelings.

Stages of Labor

Labor is divided into three stages

Abnormal Stages of Labor - Prolonged Latent Phase

Latent phase is defined as the period of time starting with the onset of regular uterine contractions and terminated by the onset of the active phase. This phase is considered prolonged if it exceeds 20 hours in nulliparous women and 14 hours in multiparous women.

Obstetric Anesthesia - Hypotension

Low blood pressure can occasionally occur at the onset of the epidural block as a result of sympathetic blockade. Local anesthetics block not only pain fibers but also sympathetic fibers, which normally maintain blood vessel tone. Hypotension threatens the fetus by decreasing uterine blood flow. Prophylaxis is routinely performed by intravenous infusion of 500 to 1,000 ml of isotonic crystalloid solution to the mother prior to epidural placement. Low blood pressure can be easily and safely treated by administration of IV lactated isotonic crystalloid solution, and if needed, an intravenous dose of ephedrine.

Obstetric Anesthesia - Narcotics

Narcotics are drugs possessing morphine-like pharmacological actions. All narcotics provide pain relief and a sense of euphoria, hence their use in obstetrics. All narcotics freely cross the placenta to the newborn. Therefore, the risk associated with narcotics for obstetrics include respiratory depression in both mother and newborn. In the past, because large doses of the long-acting narcotics such as morphine were given throughout labor, depressant effects on the infant were observed. Currently, morphine is rarely used. Instead, intramuscular or intravenous injections of smaller doses of other narcotics such as meperidine, fentanyl, butorphanol, and nalbuphine are given. Recent reports detail little neonatal depression.

Obstetric Anesthesia - Adverse Effects of Narcotics

Narcotics may "take the edge off" pain but do not completely eliminate it. In fact, at the doses used, their efficacy is no greater than 30-40%. Maternal sedation, nausea/vomiting, and the risk of respiratory depression are possible undesirable features. Because of a highly effective uteroplacental circulation, the fetus is also exposed to the opioids. Fetal effects include loss of beat-to-beat variability in the fetal heart rate tracing, respiratory depression at birth (especially if the opioid is given close to delivery), and adverse neonatal neurobehavioral scores.

Obstetric Anesthesia - Neuraxial Block

Neuraxial block by epidural blockade is a regional anesthetic technique in which local anesthetic is injected into the epidural space. A combination of low doses of opioids and local anesthetics, deposited close to the nerve roots, enables safer and effective (>95%) doses to be given.

Obstetric Anesthesia - Paralysis Concerns

One of the common reasons that patients decline epidural anesthesia is fear of paralysis. However, since their introduction in the mid-1960s, epidurals have had an excellent safety record. All forms of nerve injury (including minor injuries such as foot-drop and segmental loss of sensation) occur in less than 1 in 10,000 applications, and paralysis is extremely rare.

Obstetric Anesthesia - Spinal Headache

Patients should be reassured and made aware of the more common (1-3%) but less serious risks of a spinal headache. This can occur after an uncomplicated spinal block, and a "wet tap" where the dura is punctured during an epidural placement and spinal fluid leaks out into the epidural space. The headache may be treated with simple analgesics, consumption of caffeinated beverages, and bed rest. Resistant headaches can be treated with an epidural blood patch.

Feedback inhibitor of lactogenesis

Protein contained in breast milk which inhibits milk production if the milk is not removed

Human Placental Lactogen

Released by the placenta during pregnancy to enhance growth of nipple, breast and areola

Spine and Small Parts

Still facing the maternal head, you then examine the lateral walls of the uterus to determine which side the fetal back and small parts occupy.

Stages of Labor - Internal Rotation

The fetal head gradually rotates from its original position (usually occiput transverse) to either direct occiput anterior or less commonly to direct occiput posterior.

Stages of Labor - First stage

The first stage of labor is the interval between the onset of labor and full cervical dilation.

Anatomic Survey

The first step will be to use ultrasound to: assess gestational age evaluate for any anomalies assess the fetal position The best time to perform an anatomic survey of the fetus is at 18-20 weeks gestational age because the size of the fetus is large enough for the organs to be well evaluated, and there is still a relatively large amount of amniotic fluid surrounding the fetus to ensure good visualization of the anatomy. However, amniocentesis is performed at approximately 16 weeks gestational age. Usually the anatomy is adequately assessed at this time and a follow-up scan is not needed.

Stages of Labor - Cardinal Movements of Labor

The mechanisms of labor, also known as the cardinal movements of labor, refer to the changes in the position of the fetal head during passage through the birth canal. Because of the asymmetry of the shape of both the fetal head and the maternal bony pelvis, such rotations are required for the average size fetus to accomplish passage through the birth canal. Rotation of the fetal head is a result of the propulsive force of uterine activity during labor.

Fundus

The patient lies supine and you stand at her side facing her head. You place your hands on the fundus to determine the presence or absence of a fetal pole (vertical versus transverse lie), and the nature of the pole (vertex or breech). The fetal breech is larger, less well defined, and less ballottable than the head (ballottement is a palpatory maneuver to test for a floatable object).

Stages of Labor - Second Stage

The second stage of labor is the interval between full cervical dilatation and the delivery of the infant.

Molar pregnancy

The terms complete mole and partial mole are used to describe the variations of molar pregnancies. With a complete mole, all placental villi are swollen and the fetus is absent. With a partial molar pregnancy, only some chorionic villi are swollen, and fetal tissues are present. They both frequently present with vaginal bleeding. The classic molar pregnancy may include vaginal bleeding and a uterus enlarged beyond the size expected for gestational age. Diagnosis may be suspected by an elevation of HCG greater than 100,000 mIU/ml.

Stages of Labor - Third Stage

The third stage of labor encompasses the period between the delivery of the infant and the delivery of the placenta.

The triple test

The triple test measures three hormones in the maternal serum: alpha-fetoprotein HCG estriol The measurements of these hormones, along with maternal age, are analyzed with computer software to produce a likelihood ratio. For example, if the age specific risk for a 25-year-old woman to have a child with Down syndrome is 1 in 581, a revised risk can be calculated based upon additional information from the serum analytes. If an elevated risk is determined, amniocentesis can be offered to women under 35. However, there is a significant false positive incidence, and approximately 5% of women will undergo amniocentesis.

Stages of Labor - Usual presentation

The usual presentation of the fetus to the birth canal is the vertex presentation with the fetal occiput the lowermost part, occurring in approximately 95% of all term labors.

Postpartum Mood Disorders- Other Postpartum Disorders

There are a range of other postpartum disorders, including: * postpartum anxiety/panic disorder * postpartum obsessive-compulsive disorder * postpartum psychosis the latter of which is rare.

Obstetric Anesthesia - epidural injection

There are nerve roots in your lower back that carry pain sensation during labor. An epidural injection is placed below the point at which your spinal cord ends. Fortunately the nerve roots that transmit the pain are below this level. This makes the procedure both effective and safe. T10-L1 nerve roots conduct the pain of the first stage of labor, whereas S2-4 roots transmit the pain of second stage of labor. The spinal cord ends at the lower border of the L-1 vertebra, while the dura mater continues caudad to end at the level of the S-2 vertebra. The epidural space extends from the foramen magnum to the sacral hiatus. Its contents are nerve roots, variable amounts of fat and fibrous tissue, and venous plexi. These veins are especially engorged in pregnancy; they act as alternative conduits for blood returning from the lower extremities, since the gravid uterus may compress the inferior vena cava. Epidurals given during labor are usually performed at the L2/3, L3/4 or L4/5 interspace for 2 reasons: to avoid injury to the spinal cord, which ends at the lower border of L1 because the nerve roots that need to be blocked for labor analgesia are accessible at these levels

Antenatal Testing - Fetal Breathing

We next look for 30 seconds of sustained fetal breathing movements by watching for fetal diaphragm motion. The fetal breathing movements tend to become abnormal before gross body movements and limb movements decrease.

Stages of Labor - Extension

When the fetus has descended to the level of the maternal vulva, the fetal head is delivered by extending the head around the symphysis pubis.

Amniocentesis

When you are ready to begin the amniocentesis, a fluid pocket without fetal parts is first identified. The placenta is usually avoided, but a transplacental amniocentesis can be done as long as a 22-gauge needle, instead of the standard 20-gauge, is used. The needle is advanced, under continuous monitoring, into the amniotic cavity and 20 ccs of fluid are removed. After an amniocentesis, ultrasound is used to confirm cardiac activity.

Postpartum Mood Disorders- Effect of a Miscarriage

Women who have a history of pregnancy loss tend to feel more anxious and worried in subsequent pregnancies. Those who have experienced early miscarriage tend to feel anxious until they have passed the gestational age of the previous loss(es). Women may be reticent to become attached to a subsequent pregnancy until they have passed the anniversary gestational age. It is normal for both the mom and the dad to experience ambivalence, worry, and excitement upon learning that they are pregnant. Pregnancy represents a major life change with changes in roles, responsibilities, finances, etc. Most often, with planned and wanted pregnancies (and even with unplanned but wanted ones), these ambivalences are resolved within the first few weeks of learning of the pregnancy.

Pelvis

You now turn toward the patient's feet and place your hands laterally above the symphysis and bring them toward the midline. You are trying to determine the nature of the fetal pole (vertex or breech) and the degree of descent of the pole, indicating the station of the presenting part.

Antenatal Testing - biophysical profile

an ultrasound exam performed when a pregnant woman is past her due date, or earlier if she has other issues placing her at increased risk for complications, in order to determine fetal well being. It includes the following measurements: Amount of amniotic fluid - 2 points Fetal movements - 2 points Fetal tone - 2 points Fetal breathing movements - 2 points The fetus is scanned for up to 30 minutes. Each of 4 criteria is given a score of 2 (if normal) or 0 (if abnormal). The maximum total score is 8. The examination is ended when components meet normal criteria or 30 minutes have elapsed.

Implantation bleeding

caused by the invasion of the conceptus into the vascular endometrium, is common. It usually consists of minimal bleeding at about the time of the first missed menstrual period and generally lasts a very short time.

Chorionic villis sampling

involves sampling the chorionic villi, tiny parts of the placenta, either through the vagina or through the abdomen under ultrasound guidance. Chorionic villus sampling can be performed in the first trimester, usually between 10 and 12 weeks, so the results are obtained earlier than amniocentesis. The disadvantage is that it carries a slightly higher risk of miscarriage than amniocentesis. The pregnancy loss rates after chorionic villus sampling are estimated at 1/100. In addition, it does not evaluate alpha-fetoprotein, and therefore does not give information about neural tube defects.

Abnormal Stages of Labor - Protraction of Descent

rotraction of descent has been defined as descent occurring at less than 1 cm/hour in nulliparous and 2 cm/hour in multiparous woman. An arrest of descent is defined as no descent for 2 hours. However, there are no strict policies for time limits requiring operative interventions as long as electronic fetal monitoring is reassuring. Interventions may be avoided provided that descent is progressive.

Amniocentesis

the aspiration of amniotic fluid under ultrasound guidance, usually performed at 16 weeks gestation. It is offered to women aged 35 and above to detect chromosomal problems such as Down syndrome. It may also detect other genetic diseases such as cystic fibrosis, Tay-Sachs disease, and sickle cell disease. In addition, the amniotic fluid is also tested for the protein alpha-fetoprotein. Too much alpha-fetoprotein in the amniotic fluid can be a sign of neural tube defects. The fetal loss rate related to the procedure is about 0.5 percent.