1. MATERNAL DEATH
REVIEW
Evelina Rosario – Castro, MD, FPOGS,
FPSUOG, FPCS
24 October 2013

2. How to tell if it is
true contractions…
TRUE LABOR
FALSE LABOR or
BRAXTON HICKS
CONTRACTIONS
O Come every few minutes
O Come every few
and get more frequent
over time.
O Don’t go away, even
when you rest.
O Get stronger and more
painful over time.
minutes, but they don’t
get more frequent over
time.
O Usually go away when
you rest.
O Usually don’t get
stronger or more painful
over time

3. Determination of AOG and EDC
1.
2.
If discrepancy of
sonar aging and
menstrual date is
7 days or less
If discrepancy is
more than 7 days
1.
Follow menstrual
age all throughout
pregnancy.
2.
USE sonar age all
throughout
pregnancy.*
* EDC that has been set early on should not be changed
based on subsequent scans done in the 2nd and 3rd trimester.

4. Acceptable Error of Aging
O 12 – 20 weeks:
+/- 7
days
O 24 – 28 weeks :
+/- 14
days
O > 29 weeks:
+/- 21 days

5. What happens during the
first prenatal visit?
O Ask about:
O health and medical history
O figure out EDC
O Do a complete physical examination
O Include: speculum and internal examination

6. What happens during the
first prenatal visit?
O History
O Personal and demographic information
O Past obstetrical history
O Personal and family medical history
O Past surgical history
O Genetic history
O Menstrual and gynecological history
O Current pregnancy history
O Psychosocial information

7. What happens during the
first prenatal visit?
O Estimated date of delivery
O A tentative estimated date of delivery (EDD) can be calculated
from the menstrual history in women with 28-day cycles by:
ONAEGELE’S RULE:
ADD 7 days to the first day of the last menstrual period (LMP) and
then SUBTRACTING 3 months
Example:
1)
2)
LMP: February 20th
EDD: November 27th
LMP: May 28th
EDD: March 4th

8. What happens during the
first prenatal visit?
O Physical examination
O blood pressure
O Weight and height
O Calculating body mass index (BMI) helps to identify at
risk populations and enables counseling of the amount
of appropriate weight gain in pregnancy.
O Assess uterine size and shape and evaluation of the
adnexa
O uterine fibroids, uterine malposition (eg, retroverted uterus),
multiple gestation, and incorrect date of LMP

9. What happens during the
first prenatal visit?
O LABORATORY TESTS
O Routine
O Rhesus type and antibody screen — This test will
detect antibodies potentially causing hemolytic disease of the
newborn.
O Hematocrit or hemoglobin and mean corpuscular
volume — detect anemia and provide screening for
thalassemia
- An MCV <80 femtoliters (fL) in the absence of iron
deficiency suggests thalassemia; further testing with
hemoglobin electrophoresis is indicated

10. What happens during the
first prenatal visit?
O Cervical cytology cancer screening
O 21 years or older who are due for screening according
to standard guidelines
O Pregnancy is not an indication for a change in the
frequency of cervical cancer screening, but
management of an abnormal test is different for
pregnant women
O Rubella immunity
O If nonimmune, the patient should be counseled to
avoid exposure to individuals with rubella and receive
postpartum immunization.

11. What happens during the
first prenatal visit?
O Varicella immunity
O Women who do not have evidence of immunity to
varicella should be counseled to avoid exposure to
individuals with varicella, may be candidates for
passive immunization during pregnancy if exposed to
varicella, and are candidates for varicella vaccine
postpartum
O Urine protein
O useful as a baseline for comparison if assessment of
renal function is performed later in pregnancy.

12. What happens during the
first prenatal visit?
O Urine culture
O Routine urine culture is recommended because
pregnant women with untreated asymptomatic
bacteriuria (ASB) are at high risk of developing
pyelonephritis and rapid tests for bacteriuria do not
have adequate sensitivity and specificity
O For women with ASB:
O retesting monthly until delivery, or
O giving suppressive therapy for the remainder of
pregnancy if they have recurrent or persistent bacteriuria.

13. What happens during the
first prenatal visit?
O Syphilis testing
O Hepatitis B antigen testing
O Chlamydia testing
O Human immunodeficiency virus

14. What will happen at each
prenatal visit?
O Ask symptoms and answer any questions
of patient
O Ask about fetal movement
O Check :
O BP
O Weight
O Fundic height
O FHT (heard at about 12 weeks of pregnancy)
O Fetal position (Leopold’s Maneuver)
O Test your urine to check for sugar or protein

15. Schedule of Visits
O Every 4 weeks until about 28 weeks AOG
O Every 2 to 3 weeks until 36 weeks AOG
O Every week until delivery

16. FOLLOW-UP VISITS
O
Routine assessments at each prenatal visit typically
consist of:
O Measurement of maternal blood pressure and weight
O Urine dipstick for protein (although the value of this test is
O
O
O
O
questionable in women with normal blood pressure)
Measurement of the uterine size or fundal height to
assess fetal growth
Documentation of fetal cardiac activity
Assessment of maternal perception of fetal activity (in the
second and third trimesters)
Assessment of fetal presentation (in the third trimester)

17. First Trimester
O First trimester screening and diagnostic
testing may include tests for:
O Red cell antibodies
O Current or past infection (eg, sexually transmitted
O
O
O
O
diseases, bacteriuria, rubella immunity)
Inherited disorders (eg, cystic fibrosis, fragile X, spinal
muscular atrophy, hemoglobinopathy)
Fetal aneuploidy (eg, trisomy 21)
Thyroid disease
Lead

18. 15 - 22 weeks AOG
O Neural tube defects
O maternal serum alpha-fetoprotein
O Ultrasound
O Trisomy 21
O 2nd trimester: quadruple test ( ie, level of alpha-
fetoprotein (AFP), unconjugated estriol (uE3), hCG,
and inhibin A in maternal serum)

19. 15 - 22 weeks AOG
O Fetal anomalies
O between 18 and 22 weeks of gestation
O additional testing may be needed to confirm the
suspected diagnosis
O Cervical length
O TVUS measurement of short cervical length between
16 to 28 weeks of gestation is associated with an
increased risk of spontaneous preterm birth <35
weeks.

20. 24 - 28 weeks AOG
O Gestational diabetes
O universal screening for gestational diabetes is recommended
at 24 to 28 weeks of gestation (in the US)
O Screening considered in the first trimester in women with
significant risk factors (eg, body mass index
>30 kg/m2, gestational diabetes or baby >4500 g in a
prior pregnancy, family history of diabetes in a first degree
relative)
O RBC antibodies —
O In Rh(D)-negative women, red cell (RBC) antibody screening
is repeated at 28 weeks of gestation and anti-D immune
globulin is administered.

21. 24 - 28 weeks AOG
O Hemoglobin or hematocrit
O To assess for anemia
The Centers for Disease
Control and Prevention (CDC)
The World Health Organization
(WHO)
1 ST
TRIMESTER
Hgb: < 11 g/dL
Hct: < 33%
Anemia
Hgb: < 11 g/dL
Hct: < 33%
2 ND
TRIMESTER
Hgb: < 10.5 g/dL
Hct: < 32%
Severe
Anemia
Hgb: < 7 g/dL
Hct: < 33%
requires medical
treatment
3 RD
TRIMESTER
Hgb: < 11 g /dL
Hct: < 33%
Very
Severe
Anemia
Hgb: < 4 g/dL
Hct: < 33%
medical
emergency due
to the risk of
congestive heart
failure

22. 28 - 36 weeks AOG
O Sexually transmitted disease (STD)
O The CDC recommends testing for STD (eg, HIV, syphilis,
hepatitis B surface antigen, chlamydia, gonorrhea) in women
O Were diagnosed with a STD earlier in pregnancy
who:
O Continue to have risk factors for acquiring a STD
O Acquired a new risk factor during pregnancy (eg, a new or
more than one sex partner, evaluation or treatment for a
STD, injection of nonprescription drugs)
O All women ≤25 years of age be retested for Chlamydia
trachomatis late in pregnancy

23. 28 - 36 weeks AOG
O Group B beta-hemolytic
streptococcus testing
O 35 to 37 weeks of gestation
O colonization with swabs of both the lower
vagina and rectum
O Excluded from screening:
O (+) GBS bacteriuria earlier in the current
pregnancy
O those who gave birth to a previous infant with
invasive GBS disease.

24. 28 - 36 weeks AOG
O Group B beta-hemolytic
streptococcus testing
O Those excluded from screening should receive
intrapartum antibiotic prophylaxis regardless of
the colonization status.
O Intrapartum chemoprophylaxis of colonized
women has been proven to reduce the incidence
of early-onset neonatal GBS.

25. 28 - 36 weeks AOG
O Estimated fetal weight
O Fetal assessment
O High risk of fetal hypoxemia/acidosis.
O ≥28 weeks of gestation, but may be initiated earlier if
the fetus is believed to be at increased risk of death
and delivery or another intervention is an option.
O External cephalic version
O 36 weeks of gestation or earlier (34 to 35 weeks) to
improve the success rate

26. 37 - 41 weeks AOG
O Patient education in preparation for
labor and delivery
O Management of and support during labor
O Route of delivery
O Induction of labor
O Postterm pregnancy
O For women ≥41 weeks of gestation, we suggest induction
rather than expectant management

28. How to compute for Ocytocin drip
OStep 1:
Determine the concentration of
oxytocin/mL:
1 unit = 1,000 miliunits (mU)
10 units = 10,000 miliunits (mU)
10,000 mU = 10 mU (10 mU/1 mL)
1,000 mL
1mL
OR
= 1mU / 0.1 mL
OStep 2:
Calculate (at this
concentration) how many mL/hour will
be given:
1 mU/minute = 60 mU/hour
(1 mU X
60mins/hour)
OStep 3: Using ratio & proportion to
calculate mL/hour:
10 mU:1 mL = 60 mU: X mL
10X = 60
X = 6 mL/hour

30. Friedman’s Curve

31. 1
2
L.T.
No
(intact)
7:56pm
4:35 pm
4:35 pm
WHO Partograph

32. Precipitate Labor and Delivery
O refers to a rapid labor and delivery of the
fetus
O defined as expulsion of the fetus within 2 –
3 hours of commencement of contractions