REFERENCE:

Reproductive Development
~ start: during intra-uterine life
~ full maturity: puberty
Intra-uterine Development
*Gonads  organs that produce sex cells
~ Testes ~ Ovaries
> sperm cell > egg cell
* 22 autosomes * 22 autosomes
* 1 sex chromosome * 1 sex chromosome
(X or Y) ( X only )
23 chromosomes 23 chromosomes
Note:
* fertilized ovum (conceptus)
~ 22 pairs of autosomes = 44 autosomes
~ 1 pair of sex chromosomes = 2 sex chromo.
23 pairs of chromosomes = 46 chromosomes
* NOTE: after fertilization…
~ 5 weeks AOG: development of undifferentiated ducts
 mesonephric (Wolffian)
 paramesonephric (Mullerian)
~ if XY  testosterone @ 7-8 weeks
 development of Wolffian into male repro.
~ if XX  no increase in testosterone
 development of Mullerian into female repro.
~ 12 weeks AOG  sex organ is present
~ 16 weeks AOG  sex determination thru ultrasound
Pubertal Development
*Puberty
~ development of secondary sexual characteristics
~ influenced by hormones:
* androgen
* estrogen
 E1 (Estrone)
 E2 (Estradiol)
 E3 (Estriol)
~ onset:
* female: 9 – 12 y/o
* male: 12 – 14 y/o
Sexual Characteristics (Female)
1. increase in height
2. broadening of hips
3. breast development (thelarche)
4. growth of pubic hair (adrenarche)
5. menstruation (menarche)
 9 – 17 y/o (ave. 12 ½ y/o)
 true ovulation happens after 2 years
6. growth of axillary hair (adrenarche)
7. increase in vaginal secretions
Sexual Characteristics (Male)
1. increase in weight
2. enlargement of testicles
3. adrenarche (growth of pubertal hair)
4. vocal changes
5. penile growth
6. increase in height
7. spermatogenesis
- sperm production
- note: starts from puberty and lasts a lifetime
ANDROLOGY
study of male reproductive system
1. Penis  organ of copulation
 “glans” – ridge of sensitive tissue
 abnormal curvature:
*congenital ~ Chordee
- painless erection
- no indentation
*acquired ~ Peyronie’s Dse
- painful erection
- with indentation
2. Testes  2 ovoid glands
 protected by muscular pouch (scrotum)
 has 2 cells:
*Sertoli Cells  in the seminiferous tubule
 produces ABP (androgen-
binding protein)
*Leydig’s Cell  in the interstitial tissues
 produces testosterone

Note: ABP + Testosterone  Spermatogenesis

*site: seminiferous
tubules
COMPOSITION OF SEMEN

* sperm cell
= 20 million / mL or;
= 50 million / ejaculate
= viability: 48 – 72 hours
= hyaluronidase
 enzyme that dissolves the corona of the egg cell
* seminal fluid
= average of 2.5 mL
*5 %  epididymis
- tightly coiled tube (20 ft)
*30 %  seminal vesicle
- pouch that produces “nutrient” for
sperm cells (sugar, protein, prostaglandin)
*60 %  prostate
- produces PSA (prostate specific antigen)
* causes liquefaction of semen
(within 30 – 60 min)
*5 %  Cowper’s gland (bulbourethral gland)
Epididymis
NOTE:
Vas Deferens
 “ductus deferens”
 site of vasectomy
* safe: after at least
10 – 20 ejaculations and/or
2 negative sperm counts
GYNECOLOGY
study of the female reproductive system
1. Mons Pubis
 “mons veneris”
2. Labia
 “majora” and “ minora”
3. Clitoris
 ridge of sensitive tissue
4. Fourchette
 posterior union of the labia
 site of episiotomy
*** pudendal nerve block @ perineum
5. Perineum
 muscular structure at the back of the fourchette

Note:
* Bartholin’s Gland ~ vulvovaginal
* Skene’s Gland ~ paraurethral
6. Vagina
 hallow musculo-membranous structure
 lined with glycogen
 normal flora: Doderlein bacilli (Lactobacilli)
- converts glycogen into lactic acid
- pH 3.5 – 4.5
7. Uterus
 pear – shape
 anteverted (forward bending)
 parts:
* fundus
* corpus (body)
* isthmus
* cervix
 cervical os (internal & external)
 cervical canal containing mucus
* pregnancy: operculum – hardened cervical
mucus
 layers:
* perimetrium ~ outer layer
* myometrium ~ main source of contraction
* endometrium ~ site of implantation
* average: 8 – 10 days
* sign: implantation bleeding
* pregnant endoM: decidua
 DECIDUA
BASALIS

DECIDUA
CAPSULARIS

DECIDUA
VERA
8. Fallopian Tubes
 “oviducts”
 10 cm long

 parts:
~ interstitial (1 cm) - shortest and narrowest
~ isthmus (2 cm) - site of tubal ligation
~ ampulla (5 cm) - site of fertilization
~ infundibulum (2 cm) - contains fimbriae which
catches egg cell from ovary
9. Ovaries
 2 ovoid glands
 produces egg cells
* in-utero: 5-7 million
* @ birth: 2 million
* 7 y/o: 500, 000
* 22 y/o: 300, 000
* menopause: 0 functional egg cells
 40 – 55 y/o (ave of 50)
 stages of oocyte development
1. Primordial Follicle  primitive / immature
2. Graafian Follicle  produces estrogen
3. Corpus Luteum  produces progesterone
 viability: 24-48 hrs
4. Corpus Albicans  “unfertilized”  ischemic cell
MENSTRUAL (4) PROLIFERATIVE (1) SECRETORY (2) ISCHEMIC (3)
Day 1 - 5 Day 6 - 14 Day 15 - 21 Day 22 - 28
>>endomet. Primordial Follicle Graafian Follicle >>no fertil’n
Corpus
sloughs off Graafian Follicle Corpus Luteum
Albicans
estro estro proges estro
proges - Estrogenic - Progestational proges
- Follicular - Luteal
- Post – menstrual - Pre – menstrual
MENSTRUAL (4) PROLIFERATIVE (1) SECRETORY (2) ISCHEMIC (3)
estro HYPOTHALAMUS
proges FSRH (GnRH) LHRH
PITUITARY

FSH LH
OVARIES
Primordial  Graafian  Corpus Luteum  Corpus
estro proges Albicans
UTERUS “unfertilized
>> thickening of >> vascularity of &
endometrium ischemic”
endometrium
>> “cork-screw”
Pelvis
* Gynecoid
- rounded
- most suitable birth canal
* Anthropoid
- oval (ape-like)
* Android
- heart-shape
- “male pelvis”
* Platypelloid
- flat
Example:
In a 30-day cycle, when will ovulation occur?
*** 30 – 14 = 16
16th day from first day of mens.

In what day will conception most probably happen in a

28 days cycle?
*** 28 – 14 = 14
14th day from firsts day of mens.
Reproductive Life Planning
(Family Planning)
Reproductive Life Planning (Family Planning)
 involves the decision of an individual or a couple about having
children
* timing of having a child
* number of children
* proper spacing
 uses contraception that is:
* acceptable to couple
* safe
* comfortable
* obtainable
* affordable
 methods:
Natural
1. Rhythm Method / Calendar Method
 regular mens: identify the ovulation day
* (+/-) 3 to 4 days
***Ovulation
 release of matured ovum
 14 days before menstruation begins
# of days in a cycle
- 14
Ovulation Day
Natural
1. Rhythm Method / Calendar Method
 regular mens: identify the ovulation day
* (+/-) 3 to 4 days
 irregular mens: record at least 6 cycles
* shortest cycle – 18
* longest cycle – 11

e.g. 28, 30, 29, 25, 27, 26

25 – 18 = 7th
30 – 11 = 19th
2. BBT Method (Basal Body Temp)
 everyday monitoring of temp
 morning before getting up from bed
* body temp by 0.5 – 1.0 deg F (day before ovul’n)
* body temp by 1.0 deg F (day of ovul’n)
 98.5 >> 98.5 >> 98.5 >> 98 >> 99
 unsafe on the next 3 – 4 days
3. Cervical Mucus Method
 aka: Billing’s Method
 check Spinnbarkeit property of the cervical mucus
* thick, viscous, non-stretchy  NOT fertile = SAFE
* thin, watery, stretchy  FERTILE = NOT safe

4. Sympto-thermal Method
 combination of BBT & Billing’s
5. LAM
 Lactational Amenorrhea Method
 principle: lactation suppresses ovulation
 3 parameters:
* exclusive breastfeeding
* amenorrheic
* first 6 months

NOTE: Coitus Interruptus

 withdrawal method  NOT effective
Artificial
1. Oral Contraception
 types:
* COC
- combined oral contraceptive (estro + proges)
- estrogen suppresses lactation
 C/I in breastfeeding
* POP
- progestin only pill (proges only)
- OK w/ breastfeeding
 remember:
* S/E
- nausea, weight gain, breast tenderness
* C/I
- smoker, > 35 y/o, CVD, DVT, cancer
* 21 active pills + 7 placebo
Note: “morning after” pill
- emergency contraceptive pill

*Ovral (estro + proges) = 4 tablets

2 tablets (w/in 72 hours)
2 tablets (after 12 hours)
- S/E: N/V
- premedicate w/ Metoclopramide

*Levonorgestrel (proges only) = 2 tablets

1 tab asap
1 tab (after 12 hours)
2. Subcutaneous / Subdermal Implant
 made of silastic implants
 Levonorgestrel (Norplant) – proges only
 5 years
3. IM Injection
 Lunelle (estro + proges)
- monthly (30 days)
 Depo-Provera
- (Medroxyprogesterone Acetate) – proges only
- every 3 months
4. IUD (Intra-Uterine Device)
 T-shape device that causes local inflam reaction
 check the string periodically: monthly after menstruation
 types:
* Mirena  plastic device containing Levonorgestrel
* 5 yrs
* Paragard has Copper – can immobilize sperm cells
* 10 yrs
 C/I:
* nulligravida / nullipara
* STD
* multiple sexual partner
* PID (pelvic inflammatory disease)
5. Barrier
~ Spermicide (Nonoxynol-9)
 kills sperm cells
 non – teratogenic
~ Diaphragm
 rubber disk
*** wait for 6 hrs before removal
*** max of 24 hrs
~ Cervical Cap
 softer than diaphragm
*** max of 48 hrs
Note: (+/-) 15 lbs in weight  re-fit
~ Condom
 male or female
6. Surgical
~ in female: BTL (Bilateral Tubal Ligation)
- site: isthmus of FT
~ in male: Vasectomy
- site: vas deferens / ductus deferens
NOTE:
* safe: after at least
10 – 20 ejaculations and
2 negative sperm counts
Fetal Growth & Development
Ovulation Fertilization Implantation 5-8 weeks Term
[ampulla] [endometrium]

Ovum Z ygote E mbryo Fetus

“BLASTOCYST”
 2 parts:
1. Embryoblast
2. Trophoblast
1. Embryoblast
 origin of embryonic germ cells:
* Ectoderm
 neuro, sense organs, integumentary
* Mesoderm
 musculo-skeletal, circulatory, repro, kidney
* Endoderm
 GIT, respiratory, bladder, lining of cavities
2. Trophoblast  source of:
1. chorionic villi
 finger-like structures used to attach the
blastocyst to endometrium
 has Syncytial Layer that produces hormones:
*hCG  Human Chorionic Gonadotropin

* Progesterone  hormone of pregnancy

 uterine relaxation

* Estrogen  uterine & breast development

* HPL  Human Placental Lactogen

 aka: somatomammotropin
 breast development & lactation
 problem: insulin antagonist
2. Amnion Origin of:
3. Chorion ~ placenta
~ umbilical cord
~ amniotic sac
~ amniotic fluid
Placenta
 has 2 sides:
* maternal side  dirty
 has 30 cotyledons
* fetal side  shiny
 note:
* NO mixing of fetal & maternal blood during pregnancy
* “placental barrier”  responsible for selective osmosis
CAN CROSS CAN’T CROSS
OHA insulin
Warfarin Heparin
ASA Paracetamol
tobacco marijuana
cocaine
alcohol
TORCH infection
*Vertical
- mother-to-baby (placental)
T oxoplasmosis
O ther dses
- Syphilis, HIV, Hepa B
R ubella
- German Measles
C MV (Cytomegalovirus)
H SV (Herpes Simplex Virus)
*HSV-I (oral)
*HSV-II (genital).
Umbilical Cord
 “lifeline”
 approx. 21 inches long
 has 3 blood vessels (AVA)
 protected by Wharton’s Jelly
Amniotic Sac
 aka: BOW (bag of water)
 protects the baby & other intra-uterine structures
 releases “prostaglandin” during labor
 causes uterine contraction & cervical ripening
 amniotomy – artificial ROM
Amniotic Fluid
 amount: 800 -1200 mL
* oligohydramnios – potential kidney problem
* polyhydramnios – potential GI problem (esophageal atresia)
 color: clear / transparent
* greenish  meconium stain d/t respi distress
* golden yellow  Rh incompatibility
* pinkish  bleeding
* grayish with foul odor  infection
Highlights of Fetal G & D (in weeks)
3  nervous system
8  complete organogenesis
10-12 FHT via doppler
16  sex determination via UTZ
18-20 quickening (fetal movement felt by the mother)
 FHT via stethoscope
20-24 age of viability (weighing > 400 g)
28  lung surfactant
32  subQ tissue / fat
36  testes descend to scrotum
*** CRYPTORCHIDISM – undescended testis
PREGNANCY
aka: Conception / Fecundation / Gestation
3 trimesters:
* 1st Tri (1st – 3rd month)
* 2nd Tri (4th – 6th month)
* 3rd Tri (7th – 9th month)
 full term:
* 38 – 42 weeks (average: 40 weeks or 280 days)
Psychological Tasks of Pregnancy
* 1st Tri
 Accepting the Pregnancy
* 2nd Tri
 Accepting the Baby
* 3rd Tri
 Preparing for Parenthood
Emotional Response of a Pregnant Woman
* Ambivalence #1
 simultaneous existence of opposing feelings
wanting & unwanting pregnancy = fantasy & fear
* Narcissism
 self-admiration
* Egocentrism
 self-centeredness
* Introversion
 focuses on inner thought and ideas
* Sexual Response ~ “libido”
 1st Tri: ↓ libido – due to ↑estrogen
 2nd Tri: ↑ libido – due to ↑ blood supply to pelvic area
 3rd Tri: ↓ / ↑ libido
Signs of Pregnancy
1. Presumptive  experienced by the mother
* N/V
* amenorrhea
* breast engorgement
* uterine enlargement
* fetal movement felt by the mother [ quickening ]
* melasma / chloasma [ mask of pregnancy ]
* linea nigra
* striae gravidarum
* palmar erythema & itchiness d/t estro
* spider veins  “telangiectasia” d/t estro
2. Probable
* Chadwick – bluish/purplish discoloration of vagina
* Goodell – softening of the cervix
* Hegar – softening of the lower uterine segment (isthmus)
* Braxton-Hicks Contraction – irregular, abd’l, relieved by walking
- “practice contraction”
* Ballottement – passive bouncing of the fetus
* (+) Pregnancy Test
 hCG
3. Positive
* fetal movement felt by examiner
* audible FHT
 normal: 120 – 160 bpm
* fetal outline seen thru ultrasound
Danger Signs of Pregnancy
* vaginal bleeding
* escape of clear vaginal fluid (sign of PROM)
 test the fluid
~ Nitrazine Paper Test
* yellow  blue = (+) amniotic
~ Fern Test
* “ferning” = (+) amniotic
* persistent vomiting ( > 12 weeks )
 hyperemesis gravidarum
 risks:
- F & E imbalance
- metabolic alkalosis
* fever & chills infection
* abnormal increase / decrease in FHR and fetal activity
* edema, proteinuria and HTN
 triad of pre-eclampsia
High Risk Pregnancy
* < 18 y/o
* > 35 y/o
* obesity
* small body stature – prone to CPD (cephalo-pelvic disproportion)
* results to dystocia
– prolonged & difficult labor
* substance abuse – ex. Cocaine  can cause abruptio & abortion
* Smoking
* Inherited d/o – ex. Cystic Fibrosis
* PID (pelvic inflammatory disease)
Physiologic Changes
* Cardiovascular
~ ↑ plasma volume by 30-50%
*normal blood loss during delivery
 NSD: 300-400 mL
 CS: 800-1000 mL
* effects:
 pseudo-anemia  “physiologic”
 headache
~ ↑ fibrinogen by 50 %  for clotting
~ ↑ WBC (up to 20,000 cells / cu mm)  for immunity
*Respiratory
~ nasal congestion / “stuffiness” d/t ↑ estrogen
~ dyspnea d/t compression of the diaphragm
* normal: 3rd Tri
*Digestive
~ ↓ gastric motility d/t relaxin delayed digestion
~ ↓ intestinal peristalsis d/t proges morning sickness
* normal in 1st Tri
constipation
flatulence
~ hemorrhoid d/t pressure from gravid uterus
*Integumentary
~ Melasma / Chloasma  ‘mask” of pregnancy
~ Linea Nigra  dark vertical line
~ Striae Gravidarum  stretch marks
~ Palmar Erythema & Itchiness d/t estro
~ Spider Veins  “telangiectasia” d/t estro
*Breast
~ engorgement & tenderness
~ darkening of areola
~ enlargement of Montgomery’s Tubercle (sebaceous gland)
Discomforts of Pregnancy
~ headache
 elevate HOB, cold compress on the forehead
~ lightheadedness
 due to supine hypotensive syndrome
*** turn to left side
~ DOB
 elevate HOB
~ backache
 d/t Lordosis ( “pride” of pregnancy )
 pelvic rocking exercise, tailor sitting
 note: waddling gait – d/t relaxation of pelvic joints
*** hormone: relaxin
~ leg cramps
 d/t hypocalcemia
 knee extension + foot dorsiflexion
~ ankle edema and varicose veins
 risk: thrombophlebitis
 elevate the legs
 if with thrombophlebitis: prepare to administer blood thinner
~ morning sickness (N/V)
 dry crackers, limit fluid intake in the morning,
small frequent meals
 Rx: Metoclopramide (Reglan, Plasil)
~ constipation (due to progesterone)
 OFI & fiber, X laxative
~ breast soreness / tenderness
 cotton bra w/ wide shoulder straps
 wash w/ lukewarm water
 avoid irritating soap
~ leukorrhea
 daily bath
 cotton underpants @ daytime
 no undergarments @ night
 if with whitish, creamcheese-like and itchy discharge
* notify the physician
* sign of Moniliasis (fungal infection by Candida albicans)
PRE-NATAL CHECK – UP

1st – 7th month  every month =7

8th month  every 2 weeks =2
9th month  every week =4
13
NOTE: DOH
* 1 per trimester = 3
* 1 before delivery = 1
4
Nutrition During Pregnancy
* normal weight gain: 25 – 35 lbs
 1st Tri: 1 lb/mo = 1 lb x 3 months = 3 lbs
 2nd Tri: 1 lb/wk = 1 lb x 12 weeks = 12 lbs
 3rd Tri: 1 lb/wk = 1 lb x 12 weeks = 12 lbs
27 lbs
 alert: weight gain of > 1-2 lbs/week  report
* caloric intake:
 childbearing age: 2,200 cal / day
 pregnant: +300 cal (total of 2500 cal/day)
 breastfeeding: +500 cal (total of 2700 cal/day)
* vit and mineral supplementation
 folic acid (Vit B9) – for neural tube development
(brain & spinal cord)
*** Spina Bifida (Neural Tube Defect)
 iron, calcium, zinc
Remember:
Pica
 abnormal, compulsive craving and/or consumption of
nonfood substances
 common substances:
- ice, cornstarch, chalk, clay, dirt, paper.
 often accompanied by iron deficiency anemia
- check: Hgb and Hct
Fundic Height Measurement
* landmark: symphysis pubis  tip of fundus
* estimation of AOG based on fundic height
~ Bartholomew’s Rule
 xiphoid = 36 wks (9 mo)
 umbilicus = 20 wks (5 mo)
 symphysis pubis = 12 wks (3 mo)
~ McDonald’s Rule
 used for AOG bet 20 to 31 weeks
 fundic height in cm -/+ 2 = AOG in weeks
Nagele’s Rule
 used to determine EDD
* Estimated Date of Delivery
 get the first day of LMP, then:
* + 9, + 7 days (Jan-Mar)
or
* -3, + 7 days (Apr-Dec)
 e.g.
* Jan. 10, 2018 [ 01-10-2018]
- EDD: Oct 17, 2018
OB Score / OB History
* Gravida
 # of pregnancy
* nulli – 0
* primi – 1
* multi – 2 or more
* Para
 # of viable pregnancy delivered
*** do not include abortion
* TPALM
T erm ( > 37 weeks)
P reterm ( < 37 weeks)
A bortion (before viability)
L iving children
M ultiple pregnancy
a woman who has had two previous pregnancies, has given birth to two
term children, and is pregnant again
 G3 P 2
 G3 T2 P0 A0 L2 M0
a woman who has had two miscarriages at 12 weeks and is pregnant again
 G3 P 0
 G3 T0 P0 A2 L0 M0
a woman who had term twins, then one preterm infant, and is now
pregnant again
G3P2
 G 3 T2 P1 A0 L3 M1
a pregnant woman who had a boy born at 39 weeks’ gestation; a girl born
at 40 weeks’ gestation; a girl born at 33 weeks’ gestation
 G4 P 3
 G4 T2 P1 A0 L3 M0
Labor & Delivery
 Theories of Labor
- Placental Degeneration Theory
- Progesterone Deprivation
- Prostaglandin Release Theory
- Oxytocin Release Theory
- Uterine Stretch Theory
 Preliminary Signs of Labor
* Braxton-Hicks
* cervical ripening
- “ripe” cervix  as soft as butter
- cervical changes
 dilatation – opening
 effacement – thinning
* lightening
- baby descends to birth canal
- signs: relief of DOB
urinary frequency
↑ vaginal discharge
pelvic pressure
- expect true labor in 10 – 14 days
 Signs of True Labor
* Progressive Uterine Contraction #1
~ “lumbo-sacral” / “girdle”
~ intensified by walking
~ regular
~ increasing duration & frequency
* Bloody Show
~ expulsion of operculum w/ blood
* ROM (Rupture of Membrane)
~ (-) BOW
~ baby should be delivered w/in 24 hrs  Chorioamnionitis!
~ reminder:
 check FHR
 check for cord prolapse
* risk: cord compression
* mng’t:
- X push back the cord
- Trendelenberg / knee chest / supine with
hip elevation
- cover protruding cord with sterile saline-
soaked dressing
Stages of L & D
1. Dilatation
* onset true labor  complete cervical dilatation
2. Expulsion
* cervical dilatation  expulsion (delivery of baby)
3. Placental Delivery
* expulsion  delivery of placenta
4. Recovery
* up to 4 hours post-patum
1. Dilatation
 3 phases (LAT)
 LATENT ACTIVE TRANSITIONAL
Duration 4-6 hrs 2-3 hrs 1 hr
Contraction
*Intensity Mild Mod-strong Strong-very S.
*Duration 20 – 40 sec 40 – 60 sec 60 – 90 sec
*Frequency q 15 – 30 min q 3 – 5 min q 2 – 3 min
Cervical Dilation 0 – 3 cm 4 – 7 cm 8 – 10 cm
Maternal Behavior Excited, Irritable Uncontrollable
cooperative
*** EPIDURAL ANESTHESIA***
- monitor BP
- causes hypotension
*** Rx to promote Uterine Contraction:
 Uterotonic
* ex:
Oxytocin [Syntocinon, Pitocin]
Methylergonovine maleate [Methergine]
* monitor:
- BP
 risk for hypertension
- uterine contraction
 risk for tetanic contraction (during labor)
 risk for uterine atony (after delivery)
Uterine Contraction

ACME
REMEMBER:
Contraction
pushes the baby
and causes
pressure on fetal
head.

Pressure on fetal
DURATION INTERVAL head causes ↓ FHR.

FREQUENCY
FHR Variability
1. Acceleration
 ↑ FHR
 due to ↑ fetal movement
2. Deceleration
 ↓ FHR
 types:
a. Early Deceleration
b. Late Deceleration
c. Variable Deceleration
a. Early Deceleration
- ↓FHR from increment to acme
- return to normal during decrement
- due to fetal head compression
- continuous monitoring
b. Late Deceleration
- ↓FHR from increment to decrement
- due to utero-placental insufficiency
- left side-lying, O2, possible CS
c. Variable Deceleration
- ↓FHR varies in the course of contraction
- due to cord compression
- trendelenburg position
2. Expulsion
* perineal cleaning
- use warmed anti-septic
- X shaving (EINC)
* assume comfortable position (EINC)
* push during contraction ( X fundal pressure )
* birth
- “crowning”  pant
 Ritgen’s Maneuver
- head’s out  avoid routine suctioning --- PRN only (EINC)
 palpate the neck (nuchal cord)
 record the time of birth
* cord clamping  after pulsation stops (EINC)
3. Placental Delivery
 expulsion of baby up to delivery of placenta
*Placental Separation
~ types:
> Schultz: from center (Shiny)
> Duncan: from border (Dirty)
~ signs:
> lengthening of cord
> sudden gush of blood
> rigid fundus
>globular uterus (Calkin’s Sign)
~ Note:
> Brandt-Andrew Maneuver
> Check the completeness of placental cotyledons.
4. Recovery
 first 4 hours post-partum
* Oxytocin / Methergine
* monitor uterine contraction
 if NO contraction
- check the bladder
- massage the fundus
- apply cold compress
- breastfeeding
 expect elevated temperature within 24 hours d/t dehydration
* fever after 24 hours  infection
 “lochia” ~ vaginal discharge post-partum
Rubra
 day 1 – 3
 red
 blood, mucus, decidual fragments, small clots
Serosa
 day 4 – 10
 pinkish
 blood, mucus, WBC
Alba
 day 11 – 14 or until uterine wall heals
 whitish
 mucus, WBC
ALERT!!!
 reversal of lochia = bleeding
 blood loss L & D
NORMAL HEMORRHAGE
NSD 300 – 400 mL > 500 mL (NSD)
CS 800 – 1000 mL > 1000 mL (CS)
INVOLUTION
return of the uterus into a non-pregnant state
takes around 6 weeks
check the uterine fundus
* day of delivery  level of umbilicus
* decrease in fundic height by 1 fingerbreadth everyday
* 10th day  fundus should no longer be palpable
 Post-partum Adaptation
( Reva Rubin )
1. Taking – in
 self- centered mother
2. Taking – hold
 baby – centered
3. Letting – go
 letting go of the fantasized image of baby
 transition to parenthood
PIH (Pregnancy-Induced Hypertension)
aka: Toxemia of Pregnancy
cause: unknown
classifications:
* Gestational HPN
HPN (140/90)  get 2 readings at least 6 hours apart
(-) proteinuria
(-) edema
* Pre-eclampsia
MILD SEVERE
HPN 140/90 160/110
(+) proteinuria 1+ / 2+ 3+ / 4+
(+) edema upper limbs upper limbs & face
oliguria
“aura”
* Eclampsia
 acute cerebral edema  seizure  coma
 risk: fetal hypoxia  distress  death
complication: HELLP
H emolysis
E levated
L iver enzyme
L ow
P latelet

Monitor  signs of bleeding

Mng’t
*Bed rest
* environmental stimuli
*Anti-hypertensive
~ Hydralazine (Apresoline)
~ Labetalol (Normodyne)
*Anti-convulsant
~ Magnesium Sulfate (Mg SO4)
*monitor: toxicity
BP
UO
RR
P atellar Reflex

ANTIDOTE:
- Calcium Gluconate
PROBLEMS DURING LABOR

Dysfunctional Labor
Precipitate Labor
DYSFUNCTIONAL LABOR
 aka: “inertia”
 sluggish labor
 associated with:
*hypotonic uterus
*hypertonic uterus
*hypotonic uterus – weak and infrequent contractions
- factors:
* early administration of analgesia
* overstretched uterus  multiparity & multiple preg.
 LGA
 hydramnios
- risks:
* prolonged labor  exhaustion
 bleeding
* prolonged cervical dilation  infection
(chorioamnionitis)
- Rx: Oxytocin (Pitocin, Syntocinon)
- promotes uterine contraction
- monitor: BP
- possible AMNIOTOMY
– artificial ROM
*hypertonic uterus - (+) tetanic contraction w/o uterine relax’n.
- risks:
fetal anoxia
maternal pain
- mng’t:
rest
pain relief (Morphine SO4)
decrease environmental stimuli
monitor FHR
***if (+) late deceleration  CS!!!
PRECIPITATE LABOR
 Labor completed in < 3 hours
 Factors:
* grand-multiparity
* oxytocin induction
* amniotomy
 Risks:
* abruptio
* laceration
Sign: “rapid cervical dilatation”
- primi: 1 cm every 12 min (5cm / hr)
- multi: 1 cm every 6 min (10 cm/ hr)
Rx: TOCOLYTIC
- Terbutaline (Bricanyl, Duvadilan)
 INTRA-PARTAL BLEEDING
1st Trimester
- Abortion
- Ectopic Pregnancy
2nd Trimester
- Gestational Trophoblastic Disease
- Premature Cervical Dilatation
3rd Trimester
- Placental Problems (Previa and Abruptio)
- Preterm Labor
 INTRA-PARTAL BLEEDING
1st Trimester
- Abortion
- Ectopic Pregnancy
2nd Trimester
- Gestational Trophoblastic Disease
- Premature Cervical Dilatation
3rd Trimester
- Placenta Previa
- Abruptio Placenta
ABORTION
 expulsion of the conceptus before viability
 factors:
* abnormal fetal formation #1
* infection (Toxoplasmosis, Syphilis, Rubella, Polio)
* teratogenic drugs
* alcohol
 note:
* miscarriage  “spontaneous”
 types:
*threatened  spotting; cramping; (-) cervical dilatation
*imminent  “inevitable”: bright red vaginal bleeding;
(+) uterine contraction
(+) cervical dilatation
*complete  complete expulsion of conceptus
*incomplete  (+) retained conceptus
*missed  no apparent loss of conceptus
*risk for sepsis
mng’t:
* Bed rest (24-48 hours)
* X sex for 2 weeks from the time bleeding stops
* if threatened:
~ Rx:
Tocolytic  causes uterine relaxation
- Terbutaline (Bricanyl, Brethine)
- Isoxsuprine (Duvadilan)
- Dydrogesterone (Duphaston)
- Ritodrine (Yutopar)
*if imminent / incomplete / missed:
~ Rx:
Uterotonic  increases uterine contraction
- Oxytocin (Syntocinon, Pitocin)
- Methylergonovine maleate (Methergine)

~ MVA (Manual Vacuum Aspiration)

ECTOPIC PREGNANCY
implantation of the conceptus outside the uterine body
site: fallopian tube
* most common site: ampulla
factors:
* obstruction in FT d/t adhesions
- salphingitis, PID
* IUD
* smoking
 S/Sx:
* stabbing, unilateral lower quadrant pain (right or left)
* vaginal bleeding
* signs of rupture
 severe abdominal and shoulder pain
 hypo – tachy – tachy
 Cullen’s Sign
 ecchymosis around the umbilicus

 Mng’t
* Methotrexate
 cytotoxic
* Laparoscopic Tubal Ligation if w/ rupture
PREMATURE CERVICAL DILATATION
“Incompetent Cervix”
common @ 20 weeks AOG
diagnosed only after the pregnancy is lost
S/Sx:
* painless show
* increased pelvic pressure
* ROM
 Note:
- no way to save the pregnancy
- protect the next pregnancy
 confirm a healthy fetus
 @ 12 – 14 wks AOG:
*** Cervical Cerclage
- suturing of the cervix
- under regional anesthesia
- 2 types:
Shirodkar Approaches:
- sterile tape
* vaginal
- threaded in a purse
string manner - removed
@ 37-38 wks
McDonald - via NSD
- nylon sutures * abdominal
- placed horizontally - permanent
and vertically across - via CS
the cervix

REPORT: LOW BACK PAIN OR DISCOMFORT

GTD
Gestational Trophoblastic Disease
aka:
* Hydatidiform Mole
* H-Mole
* Molar Pregnancy
 S/Sx:
* abnormally large uterus
* (-) FHT
* elevated hCG level
* normal: 400, 000 IU
* GTD: 2 million IU
* proteinuria & hypertension
* dark red to brown vaginal bleeding
* discharge with clear fluid-filled vesicles
* UTZ
- “snowstorm” / “snowflake” / “grape-like”
 Mng’t:
~ evacuation via D & C
~ Methotrexate
~ risk: H-mole is pre-cancerous (Choriocarcinoma)
~ hCG monitoring  q 2 weeks until normal then
q 4 weeks for 6 – 12 months
Rule: if hCG plateaus or increase for 3x
* indicates malignancy
* Rx: Dactinomycin
~ NO pregnancy for 1 year
PLACENTAL PROBLEMS
* Placenta Previa
 low implantation of placenta
* normal: upper uterine body
 degrees:
* low lying - lower uterine body
* marginalis - near the cervical os
* partialis - portion of cervical os
* totalis - entire cervix
NORMAL PLACENTAL IMPLANTATION
* Abruptio Placenta
 premature separation of normally implanted placenta
 occurs @ 1st or 2nd stage of labor
 factors:
* increased maternal age
* multiparity
* short umbilical cord
* PIH
* smoking
* cocaine
 PLACENTAL PROBLEMS

Placenta Previa Abruptio Placenta

low implantation  premature separation
S/Sx:  S/Sx:
* painless bleeding * painful bleeding
- bright red - dark red or occult
* (-) contraction * (+) contraction
* boggy / soft uterus * rigid / board-like /
tender uterus
 PLACENTAL PROBLEMS

Placenta Previa Abruptio Placenta

low implantation  premature separation
S/Sx:  S/Sx:
* painless bleeding * painful bleeding
- bright red - dark red or occult
* (-) contraction * (+) contraction
* boggy / soft uterus * rigid / board-like /
tender uterus
 PLACENTAL PROBLEMS

Placenta Previa Abruptio Placenta

low implantation  premature separation
S/Sx:  S/Sx:
* painless bleeding * painful bleeding
- bright red - dark red or occult
* (-) contraction * (+) contraction
* boggy / soft uterus * rigid / board-like /
tender uterus
 Mng’t for placental problems (PP / AP)
* Bed rest on left side
* No I.E. unless there is double set-up
* FHR monitoring
* X sex
* fluid replacement (IVF Therapy or BT)
* prepare for possible CS
PRETERM LABOR
delivery after 20th week up to before the end of 37th week
cause: Unknown
S/Sx:
* vaginal spotting
* low back pain (persistent and dull)
* pelvic pressure
* menstrual-like cramps
* uterine contractions
 Mng’t
* detect fetal fibronectin in vaginal mucus
 if (+) = labor and delivery is ready to occur
 if (-) = labor and delivery is unlikely to occur
for at least 14 days
*when to prolong pregnancy
 (+) fetal membrane (BOW)
 (-) bleeding
 < 4 – 5 cm cervical dilatation
 < 50% cervical effacement (thinning)
 (-) signs of fetal distress
* Bed rest
* IVF to keep hydration
 dehydration causes PG to release oxytocin  contraction!!!
* Rx:
Tocolytic
 Steroid (IM)
- if AOG is < 34 weeks
- purpose: to accelerate lung surfactant maturation
* Betamethasone
* Dexamethasone