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contraindicated.
F. Nausea and v omiting. F irst-trimester m orning sick ­
nessm ayberel ievedby eating frequent,sm allm eals,
getting out of bed sl owly after eati ng a few crac kers,
and by avoi ding spi cyor greasy foods. Promethazine
(Phenergan) 12.5-50 m g PO q4-6h prn or
diphenhydramine(B enadryl)25-50m gti d-qidi suseful .
G. Constipation. A high-fiber d iet wi th p syllium
(Metamucil), i ncreased fl uid i ntake, and regul ar ex er­
ciseshoul dbeadvi sed.D ocusate (Colace) 100 mg bid
mayprovi derel ief.
IV. Clinicalassessm entatsecondtr imesterv isits
A. Questionsfor each follow-upv isit
1. First detection of fetal m ovement (quickening)
shouldoccurataround17w eeks in am ultigravida
and at 19 weeks i n a pri migravida. Fetal m ove­
mentshoul d be documented ateachvi sitafter17
weeks.
2. Vaginalbleedingor sy mptomsof preterm labor
shouldbesought.
B. Fetalhear tr atei sdocum entedateachvi sit
C. Maternalser umtesting at15-16weeks
1. Triple scr een ( "-fetoprotein, hum an chori onic
gonadotropin [hC G], and estri ol). I n w omen under
age 35y ears,screeni ngforfetal D own syndrome is
accomplished with atri plescreen.M aternal serum
alpha-fetoproteini s elevated in 20-25%ofal lcases
ofD ownsy ndrome,andi t is elevated infetal neural
tube defi cits. Level s of hCG are hi gher i n D own
syndrome and l evels of unconj ugated estriol are
loweri nD ownsy ndrome.
2. If levels are abnorm al, an ul trasound ex amination
isperform edand geneticam niocentesisi soffered.
Thetri plescreeni dentifies60% ofD ownsy ndrome
cases. Low levels of all th ree se rum analytes
identifies60-75% ofal lcasesoffetal tri somy18.
D. At 15-18 weeks, genetic am niocentesis shoul d be
offered to pati ents > 35 y ears ol d, and i t shoul d be
offered i f a bi rth defect has occurred i n the m other,
father,ori nprevi ousoffspri ng.
E. Screeningul trasoundshoul d usuallybeobtai nedat
16-18w eeks.
F. At 2 4-28 weeks, a one-hour Gl ucola (bl ood gl ucose
measurement 1 ho ur after 50-gm oral gl ucose) i s
obtainedtoscreenfor gestational diabetes. Thosew ith
a par ticular ri sk (eg, previ ous gestati onal di abetes or
fetal macrosomia),requi reearl iertesti ng.I fthe 1 hour
testresul ti sgreaterthan 140 mg/dL, a 3-hourgl ucose
tolerancetesti snecessary .
G. Second tr imester education . Discom forts include
backache, round ligament pain, consti pation, and
indigestion.
V. Clinicalassessm entatthir dtr imesterv isits
A. Fetalm ovementi sdocum ented.V aginal bleeding or
symptoms of preterm l abor shoul d be sought.
Preeclampsia sy mptoms (bl urred vi sion, headache,
rapidw eightgai n,edem a)aresought.
B. Fetalhear tr atei sdocum entedateachvi sit.
C. At 26-30 weeks, repeat hem oglobin and hem atocrit
are obtained to determ ine the need for i ron
supplementation.
D. At28-30weeks, an antibody screeni sobtai nedi nR h­
negativew omen,andD immunegl obulin(R hoGAM)i s
administeredi fnegati ve.
E. At 36 weeks, repeat serologic testing for sy philis is
recommendedforhi ghri skgroups.
F. Gonorrheaandchlam ydiascr eeningis repeatedin
thethi rd-trimesteri nhi gh-riskpati ents.
G. Screening for groupB str eptococcuscolonization
at35-37weeks
1. Lower vagi nal and rec tal cul tures are recom­
mended; cu ltures shoul d not be col lected by
speculum ex amination. The opti mal m ethod for
GBS screeni ng i s col lection of a si ngle standard
culturesw abofthedi stalvagi naandrectum .
H. Thirdtr imestereducation
1. Signs of labor . The pati ent shoul d cal l phy sician
when rupture of m embranes or contracti ons have
occurredevery 5m inutesforonehour.
2. Danger signs. P reterm l abor, rupture of m em­
branes,bl eeding,edem a,si gnsofpreecl ampsia.
3. Commondiscom forts. Cramps,edem a,frequent
urination.
I. At 3 6 weeks, a cervi cal ex am m ay be com pleted.
Fetal posi tion shoul d be asse ssed by pal pation
(Leopold sM aneuvers).
References:S eepage166.
NormalLabor
Labor consi sts of the process byw hichuteri ne contractions
expelthefetus.A term pregnancy is 37 to 42w eeksfrom the
lastm enstrualperi od(LM P).
I. ObstetricalH istoryandP hysicalE xamination
A. Historyofthepr esentlabor
1. Contractions.T hefrequency ,durati on,onset,and
intensity of uteri ne cont ractions shoul d be deter­
mined. C ontractions m ay be accom panied by a
' bloodyshow "( passageofbl ood-tingedm ucusfrom
thedi latingcervi calos).B raxtonH ickscontracti ons
are often fel t by pati ents duri ng the l ast w eeks of
pregnancy.T hey areusual lyi rregular,m ild,anddo
notcausecervi calchange.
2. Rupture of m embranes. Leak age of fl uid m ay
occur al one or i n conj unction w ith uteri ne contrac ­
tions. The patient may reportal argegushoffl uidor
increased m oisture. T he col or of the l iquid shoul d
be determ ine, i ncluding the p resence of bl ood or
meconium.
3. Vaginalbleeding should beassessed.S pottingor
blood-tinged mucus i s com mon i n norm al l abor.
Heavyvagi nal bleeding may be a si gn of pl acental
abruption.
4. Fetal mo vement. A progressi ve decre ase in fetal
movementfrom basel ine,shoul dprom ptanassess­
ment of fetal w ell-being w ith a nonstress test or
biophysicalprofi le.
B. Historyofpr esentpr egnancy
1. Estimated date of confinem ent ( EDC) is ca lcu­
latedas40w eeksfrom thefi rstday oftheLM P.
2. Fetal hear t tones are fi rst he ard with a D oppler
instrument10-12w eeksfrom theLM P.
3. Quickening (m aternal percepti on of fetal m ove­
ment)occursatabout17w eeks.
4. Uterinesize before16w eeksi s anaccuratem ea­
sureofdates.
5. Ultrasound m easurement of fetal si ze before 24
weeksofgestati on is anaccuratem easureofdates.
6. Prenatal histor y. M edical probl ems duri ng thi s
pregnancy sho uld be revi ewed, i ncluding uri nary
tracti nfections,di abetes,orhy pertension.
7. Antepartum testing. Nonstr ess tests, contr action
stresstests,bi ophysicalprofi les.
8. Reviewofsy stems.S everehe adaches,scotom as,
hand and faci al edem a, or epi gastric pai n
(preeclampsia) shoul d be sought. D ysuria, uri nary
frequency or fl ank pai n m ay i ndicate cy stitis or
pyelonephritis.
C. Obstetricalhistor y.P astpregnanci es,durati ons and
outcomes, preter m del iveries, operati ve del iveries,
prolonged l abors, pregnancy -induced hy pertension
shouldbeassessed.
D. Past m edical history of asthm a, hy pertension, or
renaldi seaseshoul dbesought.
II. Physicalexam ination
A. Vitalsi gnsareassessed.
B. Head. Fundusc opy shoul d seek hem orrhages or
exudates, w hich m ay suggest di abetes or hy perten­
sion. Faci al, hand and ank le edema suggest
preeclampsia.
C. Chest. A uscultation of the l ungs for w heezes and
cracklesm ayi ndicateasthm aorheartfai lure.
D. UterineSize .U ntilthem iddleof the thirdtri mester,the
distance i n centimeters from the pubi c sy mphysis to
theuteri nefundusshoul dcorrel ate withthegestati onal
age i n w eeks. T oward term , t he m easurement be­
comesprogressi velyl essrel iablebecause ofengage­
mentofthepresenti ngpart.
E. Estimationoffetal weighti scom pleted by palpation
ofthegravi duterus.
F. Leopold's m aneuvers are used to determine the
positionofthefetus.
1. The fi rst m aneuver determ ines w hich fetal pol e
occupiestheuteri nefundus.T hebreechm ovesw ith
the fetal body . T he vertex i s rounder and harder,
feels m ore gl obular than the bree ch, and can be
movedseparatel yfrom thefetal body .
2. Second m aneuver. T he l ateral aspects of the
uterusarepal patedtodeterm ineonw hich sidethe
fetal back or fetal ex tremities (the small parts) are
located.
3. Third m aneuver. The presenti ng part i s m oved
from si de to si de. I f m ovement is difficult, engage­
mentofthepresenti ngparthasoccurred.
4. Fourth m aneuver. W ith the fetus p resenting by
vertex, the cephalicprom inencem aybepal pableon
thesi deofthefetal sm allparts.
G. Pelvic exam ination. T he adequacy of the bony [ Pobierz całość w formacie PDF ]