OBSTETRIC

Female Reproductive Organ

Parts of the System:
1. Ovaries: produces ovum, estrogen & progesterone
2. Fallopian Tube: tube that propels ovaries to uterus
3. Uterus: muscular organ which fetus grow and develop
4. Cervix: 2 parts
a. internal os: brings an opening to the uterus
b. external os: brings an opening to vagina
5. Vagina: muscular, rugaeted which stretch during delivery & sex

Menstrual Cycle
- average length: 28 days
- duration: 3 days
- 13th day of the cycle: increase estrogen & decrease progesterone
- 14th day of the cycle: increase progesterone & estrogen
- fertilization: sperm & ovum unite

1-3 Days 13th Day If No

(decrease estrogen) (decrease progesterone) Fertilization:

Hypothalamus Hypothalamus Corpus

Luteum
Follicle Stimulating Hormone Luteinizing Hormone Releasing Factor (LHRF)
Releasing Factor (FSHRF) Degenerate
Anterior Pituitary
Anterior Pituitary Decrease
Luteinizing Hormone Estrogen &
Follicle Stimulating Hormone Progesterone
(FSH) Ovaries
- 14th Day: Ovulation Starts Uterus
Ovaries Progesterone Corpus a. Increase Estrogen
Graffian Follicle Luteum b. Increase Progesterone Ischemia
Increase Estrogen (decrease
Primary Follicles Uterus Fertilization vascularity)
(remaining 14 days of the cycle)
Graffian Follicles (GF): matured PF Increase Endometrial Vascularity Sloughs Off
(due to high level estrogen)
Starts of New
Uterus Menstruation

Thickened the Endometrium

Fetal Circulation
Temporary Structures:
1. Placenta
2. Umbilical Cord
3. Ductus Venosus: vein to vein opening; bypasses the liver
4. Foramen Ovale: opening between right & left atrium
5. Ductus Arteriosus: artery to artery; bypasses the lungs
6. Hypogastric arteries
Start/ End:
O2 placenta placenta umbilical arteries unoxygenated blood hypogastric arteries lower body part

umbilical vein ductus arteriosus

ductus venosus pulmonary artery

inferior vena cava right ventricle

right atrium foramen ovale left left aorta upper body O2 brain superior right atrium
atrium ventricle part vena cava

Fetal Growth & Development

Pre-Embryonic Embryonic Fetus

th th
4 Week 8 Week 12th Week
First Trimester

- heart starts to beat - organogenesis period - kidneys are functional

- brain & spinal cord as one tube - circulatory system thru the - face is well form
- lung bud appear umbilical cord established - FHT by Doppler
- sex organs starts to form but - sex is apparent
undistinguishable
- visible on ultrasound
(gestational sac only)
16th Week 20th Week 24th Week
Second Trimester

- lanugo hair starts to appear - FHT by fetoscope - responds to sounds

- skeletal system formed - lanugo hair covers entire body - surfactant production starts
- sex differentiation is complete - vernix caseosa is present
- 16-18 weeks: multigravida ( cheesy like)
quickening - quickening is felt
(fetal movement)
28th Week 32nd Week 36th Week
Third Trimester

- alveoli of the lungs starts to form & - bones are formed - lanugo hair disappears
function - lecithin/ spingomyelin ratio: - lecithin/ spingomyelin
- if born: 1.2:1 ration: 1:2 (fetal lung
adaptation to extrauterine life is good - subcutaneous fats has collected maturity)

40th Week
- ovum: ovulation to fertilization
- zygote: fertilization to implantation
- embryo: implantation to 5-8 weeks - nails reaches the finger tips
- fetus: 5-8 weeks to term - plantar creases appears
- testes descends on the
scrotum
- labia is well formed
 Signs of Pregnancy
I. Presumptive Signs
- subjective data: reported by the client
- Melasma/ Chloasma: pigmentation on the face
- mask of pregnancy
- Breast changes: tingling sensation on the breast
- Linea nigra: pigmentation on the abdomen (vertical line)
- Striae gravidarum: pregnancy stretch marks
- Quickening: 1st perception of the fetal movement by the mother
- Frequent urination
- Unexplained fatigue
- Darkened areola
- Morning sickness (nausea & vomiting)
- Amenorrhea
- Color changes in the vagina

II. Probable Signs

- objective data: detected by the examiner
- Braxton hicks contraction: painless irregular contraction; normal
- Ballottement: bouncing of the baby
a. (+) ballottement: not engaged
b. (-) ballottement: engaged
- (+) pregnancy test: presence of Human Chorionic Gonadotropin (HCG)
- Fetal outline as detected by the examiner
- Hegar's sign: softening of the lower uterine segment
- Goodell's sign: softening of the cervix
- Chadwick's sign: purplish discoloration of the vagina, perineum & cervix

III. Positive Signs

- confirmatory
- FHT
- Fetal movement as felt by the examiner
- Outlined in the ultrasound

*When quickening can be felt: end of 20th week (HAAD)

*Gum bleeding during pregnancy due to estrogen
- Management:
1. soft bristle toothbrush
2. dental check-up
3. increase OFI

Physiologic Adaptation & Discomfort in Pregnancy

I. Cardiovascular
- increase blood volume (40-50%)
- increase plasma volume
- increase cardiac work load
- heart rate slightly increase: 10-15 bpm

1. Physiologic Anemia
- excess production of plasma volume than RBC
- normal hgb: 11-14 g/dL
- normal hct: 33-42% ( times 3 with hgb)
-Management:
a. Iron: diet & supplement
-foods high in iron: green leafy vegetables & meat organs
- supplements: capsule & tablet
- Health teachings:
1. Taken with empty stomach or with vit. C (increase absorption)
 2. SE: dark stool & constipation
3. increase fiber diet & fluid intake
4. exercise (promote peristalsis)

2. Supine Hypotension Syndrome

- S/Sx: gravid uterus
lightheadedness
dizziness compress inferior vena cava
faintness
- Management: decrease blood flow
1. Left lateral position
2. Slowly change the position decrease cardiac output

3. Ankle edema/ Varicosities

- Management: gravid uterus
1. Wear supportive stocking
2. Avoid constrictive clothing compress lower extremities
3. Exercise
4. Avoid prolong standing decrease venous return
5. Rest with your legs elevated
decrease in blood flow

ankle edema/ varicosities

II. Gastrointestinal System

1. Nausea & Vomiting
- due to increase HCG
- Management:
a. small frequent meals
b. eat dry toast/ crackers upon arising
c. drink fluids in between meals

2. Heartburn
- Management: gravid uterus increase Progesterone
a. eat small frequent meals increase Relaxin
b. stay upright for 30 mins. after eating compress stomach
c. avoid spicy & fatty foods
heartburn relax lower esophageal sphincter
(LES)

3. Constipation
- Management: increase progesterone
a. high fiber diet
b. increase fluid intake: decrease peristalsis
- 8 to 10 glasses of fluid/ day
- 4 to 6 of it is water constipation
c. exercise

4. Hemorrhoids
- Management: gravid uterus
a. avoid prolong sitting
b. provide hot sitz bath for comfort compress anal veins
c. place on Sims position
hemorrhoids

III. Respiratory System: increase oxygen requirement

 1. Shortness of breath
- Management: gravid uterus
a. sitting position/ fowlers
b. if lying, left lateral position compress diaphragm

shortness of breath

IV. Renal System

1. Urinary frequency gravid uterus
- Management:
a. drink adequate fluids during the day compress the bladder
b. empty the bladder regularly
c. Kegel's exercise increase urination
- strengthen pubococcygeal muscles

V. Endocrine System
1. Thyroid slightly enlarges: normal
a. increases thyroid hormones
b. increases basal metabolic rate

VI. Reproductive System

1. Godell's sign: increase estrogen softening of the cervix
2. ovaries: stops to produce ovum
3. Hegar's sign: increase estrogen softening of the uterus
4. uterus: enlarges

Bartholomew's Rule: estimate AOG by fundic height

- Location of fundus:
- 12 weeks: slightly above the symphysis pubis
- 16 weeks: between symphysis pubis & umbilicus
- 20 weeks: at the level of the umbilicus
- 36 weeks: at the level of xiphoid process
- 38- to 40 weeks: decrease 2 cm. (due to lightening)
- Computation:
AOG 18-32 weeks +2 or -2 (fix value) = range of fundic height in cm.

VII. Integumentary System: increase melanocyte stimulating hormone (MSH)

1. Melasma/ Chloasma
2. Striae gravidarum
3. Linea nigra

VIII. Musculoskeletal System

- change in the center of gravity
- Lordosis: excessive curvature of lower lumbosacral area
1. Low back pain
- Management:
a. bend on knees not on waist
b. avoid prolong standing
c. firm mattress
d. encourage the mother to wear low heeled shoes
2. Leg cramps: due to hypocalcemia
- Management:
a. calcium supplement: 1,200 mg/ day
*pregnant adolescent: 1,600 mg/ day
b. dorsiflexion of the foot

Psychological Adaptation to Pregnancy

Tasks of Pregnancy:
 1. 1st Task: Accepting the pregnancy
- initially shock, disbelief, ambivalent
2. 2nd Task: Accepting the baby
- enhanced when the mother sees an image/ FHT of the baby
- shop for clothes, naming the baby
3. 3rd Task: Preparation to parenthood
- attend birth classes
- interaction to other couples

Pre-natal Care
1. 28 to 32 weeks (7th-8th months)
- every month/ monthly
2. 32 to 36 weeks
- every 2 weeks
3. 36 weeks to labor
- every week

Obstetrical Assessment
I. Naegel's Rule
- ask: 1st day of the last menstruation
- estimation of date of delivery or confinement
- -3 +7 +1 (April to December)
- +9 +7 (January to March)

II. Gravity & Parity

a. Gravidity: all numbers of pregnancies regardless of the outcome
b. Parity: number of deliveries after weeks of viability (20weeks)
c. Terms: number of deliveries longer than 37 weeks AOG
d. Pre-term: number of deliveries before 37 weeks AOG
e. Abortion: number of pregnancies that ended at 20 weeks AOG
f. Living: number of children alive

III. Leopold's Maneuver

1. 1st Maneuver: locate presenting part on the fundus
- head: globular, hard
- buttocks: soft, irregular
2. 2nd Maneuver: determine fetal back
- back: long, smooth, curved
- extremities: nodular, irregularities
3. 3rd Maneuver: to know the fetal descent
- (+) ballottement: not engaged
- (-) ballottement: engaged
4. 4th Maneuver: confirm the 3rd maneuver
- face the foot part of the mother

- Nurse: warm hands

- Mother:
a. empty the bladder
b. dorsal recumbent position

Diagnostic Test
1. Rubella Titer Test: check presence of antibodies against rubella
- Result:
a. less than 1:8: negative titer
- increase susceptibility
- Prevention: rubella vaccination
a. given postpartum
 b. contains live attenuated virus (crosses placenta): place a risk to the fetus
c. avoid pregnancy for 3 months after immunization
d. avoid contact with immunocompromised patient
b. more than 1:9: positive titer
- immunity
2. Chorionic Villi Sampling: determine chromosomal abnormalities
- done 8-12 weeks AOG
- Preparation:
a. consent
b. baseline vital signs
- Procedure: 2 Ways
a. transcervical: insertion of catheter
b. transabdominal: insertion of needle

- Post procedure:
a. light activities for 24 hours
b. avoid coitus
c. WOF:
- bleeding
- infection
- leakage of fluid

3. Amniocentesis: aspiration of amniotic fluid

- done 12-18 weeks AOG
- Purpose:
a. detect chromosomal abnormalities
b. fetal lung maturity
- Preparation:
a. consent
b. baseline vital signs
- Procedure: insertion of needle
- Post-procedure:
a. light activities for 24 hours
b. increase oral fluid intake
c. WOF:
- bleeding
- infection
- leakage of fluid
- risk for premature rupture of membrane (PROM)

4. Alpha-Feto Protein: measures the quantity of fetal serum CHON

- done at 15 to 18 weeks AOG
- Intervention:
a. more than normal: neural tube defects (e.g. spinal bifida)
b. less than normal: chromosomal abnormalities (e.g. Down syndrome)

Fetal Well Being Tests

1. Non-stress Test: know the FHR in response to fetal movement
- Preparation:
a. give high CHON snack
b. stimulate the fetus by vibroacoustic application (application of sound)
- During:
a. position left lower position
b. attached to external transducer (FHT monitor)
c. instruct the mother to push the button every time the baby moves
- Interpretation:
a. Reactive: Normal
- 2 or more acceleration at least 15 bpm lasts for 15 secs.
b. Non-reactive: Abnormal
- acceleration of less than 2, less than 15 bpm and less than 15 secs.
 - no acceleration

2. Contraction Stress Test: to know FHR with regards to uterine contraction

- done if non-stress test is abnormal
- Procedure:
a. place mother on external fetal monitor (monitor FHR & uterine contraction)
b. place on left lateral position
c. stimulate uterine contraction by:
- nipple stimulation
- oxytocin
- Interpretation:
a. Positive: Abnormal
- presence of late deceleration
b. Negative: Normal
- no late deceleration

3. Biophysical Profile: combination of ultrasound & non-stress test

- non-invasive procedure
- normal FHT: 120-160 bpm
1. ultrasound:
a. fetal movement
b. fetal breathing movement
c. fetal tone
d. amniotic fluid index
2. non-stress test: FHT pattern

Types of Deceleration
1. Early Deceleration: head compression
- mirror image: beginning of the contraction (increase), FHR starts to decrease
- normal
- Management: continue monitoring
2. Late Deceleration: uteroplacental insufficiency
- contraction starts with late fetal deceleration
- Management:
a. position: left lateral position
b. give oxygen
c. monitor
d. if cause by oxytocin infusion: discontinue oxytocin

3. Variable Deceleration: umbilical cord compression

- varies: no pattern between contraction & FHR
- Management: change the position

*Nadir: lowest point of deceleration

* Peak: highest point of acceleration