OB Case 4
Prenatal Care / Teratology & Drugs /
Overview of Pregnancy / ID of High Risk
Pregnancy
A.T. 38 year/old consulted because of 8 weeks
delay in menstruation (+) smoker since 20 years
old. FH: Both parents are diabetic 5 days ago she
had (+) exposure to an officemate who had
Rubella.
OB Hx: 1999- spontaneous abortion
2001- by 38-39 weeks, NSD, BW- 8.5 lbs.
2003- IUFD 7 months, NSD
PPE: BMI- 27 Vital Signs: BP 120/70 PR 84 RR
20/min
Temp. 36.8C
Speculum: cervix- violaceous, (+) whitish,
frothy, fishy Vaginal discharge
IE: cervix- soft, long, closed
Uterus: enlarged symmetrically to 2
months AOG
Prenatal Care
- a planned program of medical evaluation and
management, observation, and education of
the pregnant woman directed toward making
pregnancy, labor, delivery and postpartum
recovery, a safe and satisfying experience.
- A.k.a. Antenatal care
- Begins before conception
o Preconceptual Care, because healthe
during pregnancy depends on health
during pregnancy.
- Not only includes the pregnant woman and
the physician but also the husband
Good Prenatal Care Should provide the f
Opportunities:
1. For the physician and patient to become
better acquainted
2. For the physician to learn more about the
patients attitude towards pregnancy and
labor
3. For instructions of the patient and husband in
optimal care for herself and for the upcoming
baby
4. For optimal instruction to the patient and
husband in a prepared childbirth program.
Definition of Terms:
1. Primipara A woman who has been delivered
once of a fetus which reach viability
2. Multipara A woman who has completed two
or more pregnancies to viability
3. Nullipara A woman who has never
completed a pregnancy beyond the stage of
viability.
4. Gravida A woman who has been pregnant
irrespective of the pregnancy outcome
a. Primigravida 1 pregnancy
b. Multigravida 2 or more
5. Nulligravida A woman who has never been
pregnant
6. Parturient A woman in labor
7. Puerpera A woman who had just given birth
The Obstetrical Score
- composed of a series of digits (4) separarted
by hyphens
- first digit refers to the number of pregnancy
terminating at term
- second digit refers to the number of preterm
pregnancies
- third digit refers to the number of abortions
(< 20 weeks)
- forth digit refers to the number of children
currently alive.
- Gives a more complete obstetric information
than the mere designation of (G1P0)
Normal Pregnancy Duration
- The mean duration of pregnancy calculated
from the first day of the last normal menstrual
period
- Very close to 280 days or 40 weeks
Estimation of the duration of pregnancy
- pregnancy begins with fertilization of the
ovum
- cannot duration of pregnancy cannot be
ascertained
- several methods can be used to estimate the
duration of a pregnancy with reasonable
accuracy.
1. Naegels Rule
- a convenient method of estimating the
date of confinement (EDC)
- calculated from the first day of the last
menstrual cycle
- Add 7 days to the first day of the last
menstrual cycle, Deduct 3 months to the
month of the last menstrual cycle and Add
1 year.
- Apparently erroneous because pregnancy
is considered to have started 2 weeks
before ovulation
2. Timing of Ovulation
- Last date of ovulation should be known
- Add 267 days to the last date of ovulation
3. Timing from Quickening
- This method is useful more as a
confirmation of the other parameters
rather than as a primary method of
assessing gestational age
- Usually occurs 16 to 18 weeks in a
multipara and 2 weeks later for a
primagravida
4. Height of the Fundus
- Around 20 31 weeks the height of
uterine fundus in cm correlates with the
age of gestation in weeks
- At 12 weeks usually felt at the level of
pubic symphysis
- At 16 weeks usually halfway between
symphysis and umbilicus.
- At 20 weeks usually at the level of the
umbilicus
- At 36 weeks usually at the level below the
ensiform cartilage
- Measured from the superior border of the
symphysis pubis to the top most part of
the fundus measured by palpation.
5. Fetal Heart Sounds
- The fetal heart can first be heard in most
women around 16 to 19 weeks with
careful auscultation of DeLee fetal
stethoscope
6. Ultrasound
- Transvaginal ultrasound can detect a
pregnancy at 4-5 weeks which
corresponds to the b-hCG concentration of
1500-2000mIU/ml
- If b-hCG exceeds 4000mIU/ml the embryo
should be visualized by all techniques

7. Timing by Trimesters
- usual practice of dividing pregnancy in
three equal parts
- 42 weeks divided into 3 periods giving 14
weeks per trimester
- Majority of spontaneous abortion occurs at
the 1st trimester
- Most cases of pregnancy- induced
hypertension become clinically evident
during the 3rd trimester
- Very inaccurate
- Precise knowledge of the age of fetus is
imperative for ideal obstetrical
management
Initial Comprehensive Evaluation
Goals:
1. To define health status of mother and
fetus
2. To determine gestational age o fetus
3. To initiate a plan for continuing obstetric
care
4. To define those at risk for complications
and to minimize whenever possible
Includes:
1. History
- should include a complete past and family
history, and a good obstetric resume
- an obstetric resume should include:
a. menstrual history
b. evidence of infertility
c. careful inquiry of previous
pregnancies
- take note of the patients reaction to her
current pregnanacy
- a dietary history is useful in estimating the
adequacy of her nutritional intake.
2. Psychosocial Screening
- Addressing psychosocial issues is an
essential step toward improving womens
health and birth outcomes
- Cigarette Smoking
o Various adverse outcomes have been
linked to smoking during pregnancy.
Included are spontaneous abortion, low
birth weight due to preterm delivery of
fetal growth restriction, infant and fetal
deaths and placental abruption.
o Suggested Pathophysiological
mechanism includes inc. fetal
carboxyhemoglobin, reduced
uteroplacental blood flow and fetal
hypoxia.
- Alcohol and Illicit Drug
o Ethanol is a potent teratogen and
causes fetal alcohol syndrome, which
is characterized by growth restriction,
facial abnormalities and CNS
dysfunction.
o Chronic use of large quantities of
drugs, including opium derivatives and
amphetamines os harmful to the fetus
and causes fetal distress, low birth
weight and fetal drug withdrawal soon
after birth
3. Domestic Violence Screening
- Domestic violence usually refers to
violence against adolescent and adult
female within the context of family or
intimate relationships
- recognized as a major public health
problem
4. Physical Examination
- a thorough P.E. should be done
- The value of breast feeding should be
impressed on the patient
- In the examination of the lower
extremities, the vemous pattern should be
carefully recorded at the initial visit
- Leopolds maneuver
o A series of maneuvers to determine
the fetal position usually done in mid-
pregnancy where the fetus is usually
palpated.
o First 3 maneuvers are done facing the
patients head and the last, facing the
patients feet
o First maneuver
Aka fundal grip
Answers the question What fetal
pole or part occupies the fundus?
Distinguishes between the
irregular, nodular breech and the
round, mobile and ballotable head.
o Second Maneuver
Aka umbilical grip
Answers the question On which
side is the fetal back?
Distinguishes between a linear,
convex, bony ridge (the back) and
on the other side a numerous
nodulation (small parts)
o Third Maneuver
Aka Pawlicks grip
Answers the question What fetal
part lies above the pelvic inlet?
If fetal head is not engaged, it can
be readily recognized as a round,
ballotable object.
If fetal head is engaged, the
shoulder is felt as a relatively fixed,
knoblike part
o Fourth Maneuver
Aka Pelvic grip
Answers the question On which
side is the cephalic prominence?
Confirms the findings of the 3rd
maneuver
In flexion attitude the cephalic
prominence is on the same side as
the small parts
In extension attitude the cephalic
prominence is on the same side as
the fetal back
5. Pelvic Examination
- Early months purpose of vaginal
examination is to diagnose pregnancy and
uterine or adnexal pathology
- 7th month, one can measure and evaluate
the obstetric pelvis and palpate landmarks
such as the sacral promontory
- Observe perineum if it is anatomically
intact or lacerated
- Cytologic studies is now a routine prenatal
care (Pap smears)
 - Observe characteristics of vaginal
secretion
a. yellowish in Trichomonas infection
b. curd-like in Candida infection
c. grayish in Gardnerella infection
6. Rectal and Rectovaginal Examination
- done to evaluate the integrity of perineum
and competence of rectal sphincter
- to detect possible rectocoele and other
pathology in the rectum
- consist of the simultaneous introduction of
the middle finger into the rectum and
index finger into the vagina.
7. Routine Antepartal Tests (p.131 APMC)
- the initial visit shall include the first eight
of the antepartal test.
a. CBC
b. Urinalysis
c. Urine culture
d. Blood Group, Rh
e. Serologic test for Syphilis
f. Hepatitis B surface Ag
g. Rubella Titer
h. Cervical cytology (Pap Smear)
e. Fetal activity
3. Subsequent Laboratory Test
- CBC along with Syphilis should be
repeated at about 28-32 weeks
- Determination of Alpha-fetoprotein at 16-
18 weeks to screen for neural tube defects
- Screening for glucose intolerance at 24-28
weeks for those at risk for gestational
diabetes
- Identification of chronic carriers of
Hepatitis B Ag carriers and administration
during the last trimester of Hepatitis B
immune Globulin (HBIG) and a course of
Hepatitis B vaccine to newborn infants
- Vaginal and rectal Group B streptococcal
(GBS) cultures should be obtained by 35
37 weeks and an intrapartum
antimicrobial prophylaxis should be given
to those positive.
- Special screening for genetic diseases can
be offered based on maternal age, family
history, or ethnic or racial background of
the couple.

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

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

Subsequent Prenatal Care/ Prenatal

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

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