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Intrapartum Fetal Evaluation

Key Points The goal of intrapartum FHR monitoring is to assess the adequacy of fetal oxygenation during labor so that timely and appropriate steps can be taken when necessary to avoid fetal hypoxic injury. Fetal oxygenation involves the transfer of oxygen from the environment to the fetus. Oxygen is transported by maternal and fetal blood along the oxygen pathway, which includes the maternal lungs, heart, vasculature,…

Operative Vaginal Delivery

Key Points Rates of cesarean delivery have risen in the United States, reaching a rate of approximately 25% of all deliveries, whereas rates of forceps deliveries have declined from 17.7% in 1980 to 4% in 2000. Treat the vacuum extractor with the same respect as the forceps. The prerequisites for application of forceps or vacuum extractor are identical. When using vacuum extraction, descent of the fetal…

Abnormal Labor and Induction of Labor

Key Points Labor is a clinical diagnosis defined as uterine contractions that result in progressive cervical effacement and dilation. The most common causes of protraction or arrest disorders are inadequate uterine activity and abnormal positioning of the fetal presenting part. Under new guidelines, neither a protracted active phase nor arrest of dilation should be diagnosed in a nullipara before 6 cm cervical dilation. Before a diagnosis…

Normal Labor and Delivery

Key Points Labor is a clinical diagnosis that includes regular painful uterine contractions and progressive cervical effacement and dilation. Labor has three stages: the first stage is from labor onset until full dilation of the cervix, the second stage is from full cervical dilation until delivery of the baby, and the third stage begins with delivery of the baby and ends with delivery of the placenta.…

Antepartum Fetal Evaluation

Key Points Although the PMR has fallen steadily in the United States since 1965, the number of fetal deaths has not changed substantially in the past decade. Perinatal events play an important role in infant mortality and long-term disability of survivors in addition to their contribution to fetal death. At least 20% of fetal deaths have no obvious fetal, placental, maternal, or obstetric etiology, and this…

Genetic Screening and Prenatal Genetic Diagnosis

Key Points About 3% of liveborn infants have a major congenital anomaly due to a chromosome abnormality, single-gene mutation or multifactorial/polygenic inheritance, or exogenous factors (i.e., teratogens). Noninvasive screening tests for the common autosomal trisomies should be offered at any age, providing patient-specific aneuploidy risks. First-trimester screening using serum analytes (free hCG and pregnancy-associated plasma protein A) and an NT measurement has a detection rate of…

Obstetric Ultrasound: Imaging, Dating, Growth, and Anomaly

Key Points Sonographers should become familiar with the basic physics of ultrasound, equipment controls, and scanning techniques to optimize ultrasound images. All of the elements of the standard obstetric ultrasound exam are important for clinical management and should not be neglected. Because most birth defects occur in fetuses of low-risk women, all standard exams should include a full anatomic survey. Physicians who perform and interpret obstetric…

Drugs and Environmental Agents in Pregnancy and Lactation: Teratology and Epidemiology

Key Points The critical period of organ development extends from day 31 to day 71 after the first day of the LMP. Infants of epileptic women taking certain anticonvulsants, such as valproic acid, have double the rate of malformations of unexposed infants. The risk of fetal hydantoin syndrome is less than 10%. The risk of malformations after in utero exposure to isotretinoin is 25%, and an…

Nutrition During Pregnancy

Key Points Pregnant women may need as much as an additional 300 kcal/day for the entire pregnancy, but requirements may vary among individuals. The IOM recommendations for gestational weight gain for women are set by weight category: underweight (BMI <18.5; 28 to 40 lb), normal weight (BMI 18.5 to 24.9; 25 to 35 lb), overweight (BMI 25.0 to 29.9; 15 to 35 lb), and obese (BMI…

Preconception and Prenatal Care

Key Points The breadth of prenatal care includes both preconception and postpartum care, which extends up to 1 year after the infant’s birth. Interconception care is defined as care provided between the end of a woman’s pregnancy to the beginning of her next pregnancy and is an opportunity to assess risk, promote healthy lifestyle behaviors, and identify and treat medical and psychosocial issues that could impact…

Developmental Origins of Adult Health and Disease

Key Points Maternal influences on the in utero environment (nutrition, hormonal, metabolic, stress, environmental toxins, and drugs) are critical determinants of fetal growth and influence a wide variety of metabolic, developmental, and pathologic processes in adulthood. Both ends of the growth spectrum (i.e., both low and high birthweight) are associated with increased risk of adult obesity, metabolic syndrome, cardiovascular disease, insulin resistance, and neuroendocrine disorders. The…

Maternal-Fetal Immunology

Key Points The innate immune system uses fast, nonspecific methods of pathogen detection to prevent and control an initial infection and includes macrophages, NK cells, the complement system, and cytokines. Macrophages have critical scavenger functions that likely help to prevent bacteria from establishing an intrauterine infection during pregnancy. Decidual NK (dNK) cells are thought to play a major role in remodeling of the spiral arteries to…

Maternal Physiology

Key Points The “healthy” amount of weight to gain during pregnancy is BMI specific. Maternal cardiac output increases 30% to 50% during pregnancy. Supine positioning and standing are both associated with a fall in cardiac output, which is highest during labor and in the immediate postpartum period. As a result of the marked fall in systemic vascular resistance and pulmonary vascular resistance, pulmonary capillary wedge pressure…

Fetal Development and Physiology

Key Points Mean amniotic fluid volume increases from 250 to 800 mL between 16 and 32 weeks and decreases to 500 mL at term. Fetal urine production ranges from 400 to 1200 mL/day and is the primary source of amniotic fluid. The fetal umbilical circulation receives approximately 40% of fetal combined ventricular output (300 mL/mg/min). Umbilical blood flow is 70 to 130 mL/min after 30 weeks’…

Placental Anatomy and Physiology

Key Points The mature human placenta is a discoid organ that consists of an elaborately branched fetal villous tree bathed directly by maternal blood of the villous hemochorial type. Normal term placental weight averages 450 g and represents approximately one seventh (one sixth with cord and membranes) of the fetal weight. Continual development throughout pregnancy leads to progressive enlargement of the surface area for exchange (12…

Surgery

Prenatal Consultation and Fetal Interventions 1. Which congenital malformations can be detected prenatally? Numerous structural congential malformations can be detected prenatally, including the following: anencephaly, encephalocele, spina bifida, hydrocephalus, transposition of the great arteries, hypoplastic left heart syndrome, limb reduction defect, bilateral renal agenesis, diaphragmatic hernia, omphalocele, and gastroschisis. Prenatal diagnosis of gastrointestinal atresia and obstruction is suggested by the presence of polyhydramnios and dilated bowel…

Pulmonology

Differential Diagnosis of Neonatal Pulmonary Disorders 1. Although apnea in premature infants is often caused by the degree of immaturity (so-called apnea of prematurity), what are other causes of apnea in this population? See Table 18-1 . TABLE 18-1 CAUSES OF APNEA IN PREMATURE INFANTS SYSTEM PERTURBATION Central nervous Intracranial hemorrhage, hypoxic-ischemic encephalopathy, seizures, congenital anomalies, maternal drugs, drugs used to treat the infant Respiratory Pneumonia,…

Neonatal Ophthalmology

Normal Visual Development 1. How well does a normal term newborn see? Term newborns can often fixate on a target. The ability to track an object, however, does not generally develop until approximately 2 months after birth. Visual acuity, measured with visual evoked potentials, has been estimated around 20/400 at birth. Color vision and contrast sensitivity have only rudimentary function in the newborn. Best-corrected visual acuity…