OBSTETRICS

4 PHASES OF HEALTHCARE

- Health Promotion – health eduction

- HEALTH MAINTENANCE – Maintain health when risk of illness is present
o Determine the status and possible risks of a particular client and provide appropriate
interventions as to not let them feel the the complications
o Importance of safeguarding homes
- Health restoration –, curative, caring during complications
o Care of child during illness
o Care of woman during pregnancy during pregnancy complications
- Health rehabilitation – preventing further complications, bringing client back to an optimal stat
eof wellness, helping client accept inevitable death
o Encourage continues
- Philippines still has a high infant mortality rate
o Infant mortality rate – important indicator of the environment CONDIITON OF A
PARTICULAR AREA
o More than 1000 per 100000 live birth

Crude birth rate (PNLE)

- Measures how fast people are added to the population thru births
- Useful measure of population
- Ncr, region 4, region 7 = highly urbanized but still has the highest infant mortality rate, the
distribution of resources is what important
- Affected by the fertility, marriage pattern,

General Fertility Rate

- More specific rate

- 15-44 years
- HFR – GFR of 200/1000
- LFR – GFR of 60/1000

Maternal Mortality rate

- # of deaths of female from any cause related to pregnancy or childbirth or within 42 days of
termination of pregnancy, irrespective of the duration and site of pregnancy
- Measures ob risk and is affected by maternal health practices, diagnostic ascertainment, and
completeness of registration of births
o Ampulla – site of fertilization, this is the most common ectopic pregnancy
 o Is head trauma after slipping in the floor causes death? – considered maternal mortality
rate due
 to chages in the center of pregnancy (prone sa dulas),
 presence of relaxing hormonecasues softening of cartilages esp in pelvic bone.
o MMR: # deaths
o Hypertensive disorders in the world, PPH due to uterine atony etc is the common casue
of maternal death in the Philippines

INFANT MORTALITY RATE - # of deaths of infants under 1 year of age in a calendar year per 1000 live
births in the same period; approximation of the risk of dying within the 1 st year of life

Good index of the level of health in a community because infants are very sensitive to adverse
environmental conditions

- Infants -
- More than 200/1000 = severe environmental condition, report
- 60-150/1000 LB = poor population
- High mortality rate = poor environmental condition and poor maternal and childbirth practices

NEONATAL MORTALITY RATE – deaths of infans less than 28 days old are due to mainly prenatal or
genetic factors

- Main reason for maternal mortality rate in PH – PPH

- Factors: maternal and environmental factors

POST NEONATAL MORTALITY RATE – deaths among infants

- Influence if environmental and nutritional factors + infection

REPRODUCTIVE AND SECUAL HEALTH

Reproductive Development – reproductive develt and change begin at the moment of conception and
continue throughout life

Testosterone – differentiates the gonads

GONADS – depends on the hormone (testosterone)

- Acquire male/female morphological in the 7 th week of development

- Appear initially as a pair of longitudinal ridges, the genital or gonadal ridges
- Ovary and testes are homologous to one another

- Presence of testorenoe, mesonephric turns to testes

- Absence of testosterone – mesonephric/wolffian ducts develop as female

pramesonephric/mullerian ducts (10th week of gestation)

- Derived from 3 sources:

o Mesothelium
o Underlying mesenchyme
o Primordial germ cells
Glans penis = clitoris

Masters and johnson – man’s genitals during sexual response cycle

Excitement – tactice/psychic causes stimulation, full erection of penis due to congestion of corpus
spongiusom and corpus cavernosum

Plateau – color of the penile glands deepens, testes elevate (tat’s usually why hindi apntay testes)

Orgasm – continues penile contraction, everything elese contracts to release tension

Resolutioin – erection withdraws to unaroused state 50%

Pattern of pubic rate – estrigen

Formation of pubic har – testoreone

ESTROGEN – sex characteristics

Ovary – common cause of female cancer deaths

Myometrium – for contraction

Endometrium –

Endometrium during pregnancy – decidua

Capsularis – encapsulates fetus

Basalis – direct communication to maternal side

VEra

Glandular – increasing level of hormone

Unterus contract – mobilizes sperm

Bartholins gland – releases highly alkalinized substance to protect the sperm

In feamles – no refractory period, can achieve multiple orgasms

No habital abortion, no history of bleeding sexual activity during labor is fine

Hyaloridinase and actosin? – dissolve

Fertilzaition porces

Closure of radiata – syngamy?

Hydantiform mole – chorion carcinoma

REPRODUCTIVE LIFE PLANNING

Usual pacing – 2 ½ years

Cpuples who can’t conceive – receive education on fertilization process

FAMILY PLANNING – basic human right

- Enable couples to freely choose how many

Contraceptions

- Natural family planning/awareness mehod

o Rely on temporary abstinence
o It is important to educatate both the wife and the husband
o Couple determines fertile days and abstain from sex
o Abstinenc
 100%
 Partners do not engage In sex
 Communication is important
o Coitus interruptus
 High Failure rate (5-20%) = not practiced nowadays anymore acc to some
 Pre-ejacualtion can still induce fertilization
 Conatus interruptus – withdrawal with ejaculation taking place afterwards
 Coitus reservatus withdrawal without ejacualiton; safer
 Perfect: 4%, imperfect: 19%
o Fam USES BARRIER METHODS during fertile time
o Perfect: 91
o Typical - 75
- Artificial family planning
- Permanent methods

MENTRUAL CYCLE

Menstrual phase – 1-5 days

- Low
- Functional layer responds to hormones

Proliferative - presence of estrogen 6-14

Secretory – corpus luteum secretes progesterone – responsible for proliferation of edomentrial lining for
implantation;

Ischemic – stropize, lining elads to mestruation

conpus luteum produce progesterone

Human chorionic gonadotropin – important in – gives positive result to tests, send signals to
hypothalamus to increase production of progesterone

Corpus luteum – conrpus albicans

FSH -

LH – final rupture of ruffian follicle, stimulate , ovulation, middle smears?

Signs of ovulation

- Spinnbarkeit – ability of cervical mucus to stretch into 1 inch

- Ferning pattern – determined tru microscope
- Mittleschemrz – unilateral phase felt by woman; suggests ovulaitoin
- Breast terndernnes
- Increase libido
- Most reliable sign: BBT

Calendar/rhythm method

- Record 6 monhts, do not ask pt to recall but record

- Require practice and time before you cn start this method
- Abstain on fertile periods unless you have back up

BBT

- Encourage client to take bbt at the same time everyday

- Activites can alter temp of client

Cervical mucus

- Luteal – infertile, cervical mucus is thick and sticky, sperm is having a difficulty

Artificial family planning

- Hormonal contraceptives
- oral contraceptives
 Birth control pill – safe and effective when taken properly
 Prevents ovulation
 Contraindicated: pap smear – estrogen has a role in cancer
o Combine oral contraceptices
 Gonadotropic hormon suppresses follicle by incrasing estrogen
 Regulates period – important
- Injectibles
o If patient failed to, take 1 as soon asyou remember and then the others will be on
regular time
o Cons: if mamalimutin si client
 o Very 3 mos
o High acceptance rate, but clients amenorrhea, menorrhagia,

Implants

- Good candistae: 2 years

- Common: levonorgestrel
- Norplant: depression, irregular period, alopecia
- When is best time in implanting Norplant: 6weeks?
- In phil, six capsules is common
- Long term birth control, 5 years is the susual lifespan of Norplant
- 99%

Vaginal ring

- Raised risk of heart attack and stroke due to increase hormonal porduciton/maintenance

Skin patch

- Deltoid, buttocks,
- 3 patches in 3 cycles (1 patch for 7 days)
- Do not re-apply once removed
- Less applicatin of lotion

Spermicides

- Vaginal douching – not acceptable, sperm can reach uterus as fast as 90 seconds, and fallopian
tbe as fast as 5 mins

Barrier methods

- Sponges

condom

- No method to check the patency

- No female condom with a male condom as it will cause friction thus tearing the condoms

IUD – prevents fertilization

- Copper T3A – 8 yrs protection; PH most common

Tubal ligation – cutting of east-most fallopian tubes, cauterized

- Good candidates: those who achivered desirable number of children and those righ risks
- Mini laparotomy –
- Anastomosis is dangerous – casue ectopic pregnancy
Vasectomy – failure rate – 0.1%

- Very effective after 3 mos – maturation of sperm

- 20 ejacualtion

CARE OF MOTHERS DURING PREGNANCY

EDUCAITON OF FAMILY PLANNING IS BEST AFTER POST-PARTUM

Cervix – close due to operculum formation brought about by __ to prevent ascending infection

Softening of cervic

Effacement nad dilatation

Indicator for miscarriage/abortion – opening of cervix

If it is open, it will expel product of conception (incompetent cervix)

Vagina –

- Chadwick’s sign – probable

9-10th day – fundus is ot palpated, involution. If you can palpate: subinvolution

Production is influenced by lactogen

Preogesteron causes fluid retention and increses blood volume

Pseudoanemia

Iron supplementation addresses iron deificiency/anemia

Blood pressure – individualized, based on each baseline of each aptient

Profuse bleeding – sidelying due to impaired blood supply

Placenta is a peripheral organ = blood supply is constricted, increaased rr and pr to compensate the bod
yfor oxygen

Cold clammy sikn – PVR

Estrogen – casues nasal and phraryngeal conestion and fullness in ears

Shortness of breath –

Renal system

Glucose spillage, normal findings: 1 in pregnancy

Increased urination in st and third trimester due to gravity induced; no burning sensation – main reason
for sleep disturbance thus causing fatigue

Presence of protein in urine is abnormal

Eating drycrsckers decrease te production of HCL and decrease episodes of vomiting and nausea

Quickening – subjective/presumptive

Leucorrhea – brought about by increased estrogen

Weight changes – increased fuid volume, presecen of product of conception, hormone

Positive

- Fetal outline palpation – leopold’s

- FHT
- Fetal movemnts
- X-ray/UTZ
- Progesterone –
- Human gonadotropic ormone – maintains pregnancy
- Client with DM – increase dosage of insulin

PIH – 20th week beyond with presence of protein in urine less than that, it may show
PHYCHOSOCIAL CHANGES

First trimester

- D

2nd trimester

3rd trimester

Weight and heighet – determine wight gain if related to DM

Blood uring tests

Personal data includes work – there re work tht are hazardous to pregnancy

Alcohol – fetal heart syndrome

Smoking - =

Overdistention of the muscles – releases oxytocin

Aging placenta – progesterone deprivation

Hypotonic labor patterns – early administration of analgesia in some cases

Danger for umbilical cord prolapse if pt continued to ambulate despite ruptured membrane

Ruptured uterus – presence of pathologic retraction ring

Internal monitor – risks: infection

Administering medicaitons during labor can alter contractions

Acme during uterine contractions – episiotomy, decrease perception of pain sensation, to minimize pain

Imbalance in csf – casues spinal headache – flat on bed

Prevent tearing or perineum:

1. Episiotomy
- Median
 o No painful sexual intercourse
o Easily repaired
- Media lateral
o Prone to infection
o We can extend the episiotomy
o Hard to repair
2. Ritgen’s maneuver – applying pressure to

Uterine inversion can happen if you pull the cord

In home delivery, facilitate the

PUERPERIUM

Mother is showing interest – the best time to educate pt on

Foull smelling lochia – infection

Large clots – bleeding

Priority assessment is towards bleeding (uterine atony)

Continues bleeding – possible lacerations

Vagoina

- Hematoma formation – active bleeding, ligation of blood vessls

Do not wash breasts with soap and water – can cause unilateral mastitis

Bilateral – fetus is the cause

Assess lochia to determine infection because WBC count is not reliable since it is normal that in
puerperium, WBC count increases

Not all those who have difficulty in voiding is for catheterization, it is normal that many may have
difficulty voiding

N: proteinuria in 1-2 days after delivery due to muscle contraction which breaks down protein

Presence of gonadotropin – retained placental fragments

Taking-in – very passive, education is not possible

Taking-hold phase – mother is ready for education, feeling of jealousy due to the attention

“what are you feeling right now that the attention is currently directed towards the NB?”

Letting go phase – redefines new role as mother

Cold compress, not hatzi’s bath to prevent bleeding

Hatzi’s bath – promotote vasodilation which promotoes healing of perineum

Hematoma – vessels need to ligate or there is bleeding

Pulmonary embolism –

Evaluate the reason for PPblues.. validate the reason

If it progresses with auditory hllucinaitons – PP psychosis; needs pshychiatric interventions