1.Maternal PhysiologyPrenatal Care Normal DeliveryGumalo, Clay Paolo

2. OUTLINEMaternal Physiology I. Reproductive Tract II. Skin III. Metabolic changes IV. Hematological changes V. Changes in organ systems 3. OUTLINEPrenatal Care II. Organization of prenatal care III. Nutrition IV. Common concerns 4. OUTLINE Normal Labor and deliveryI. Mechanisms of LaborII. Characteristics of normal laborIII. Management of Normal Laborand deliveryIV. Labor Management Protocols 5. maternal physiology 6. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACTII.SKINIII. BREASTSIV.METABOLIC CHANGESV. HEMATOLOGICAL CHANGESVI.CHANGES IN ORGAN SYSTEMS 7. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT nonpregnant woman: 50-70 g; 6-8 Uteruscmmultiparous: 70-1100g; 9-10cm; 5L- Cervix20L Ovaries uterine size, shape and position Fallopian Tubesfirst few weeks- pyriform (pearshape) Vagina and Perineumadvance pregnancy- corpus and fundus is more globular12 weeks- spherical contractility 8. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT 1 month after conception- undergo Uteruspronounced softening and cyanosis Cervix result from increased vascularity Ovaries and edema of the entire cervix Fallopian Tubes hyperplasia and hypertrophy of the Vagina and Perineum cervical glands 9. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT ovulation ceases during pregnancy, and the maturation of new follicles is Uterussuspended. Cervix only a single corpus luteum can be Ovaries found in pregnant women. Fallopian Tubes functions maximally during the first 6 Vagina and Perineum to 7 weeks of pregnancy4 to 5 weeks postovulation 10. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT Uterus musculature of the fallopian tubes Cervixundergoes little hypertrophy during Ovaries pregnancy but the epithelium of the tubal mucosa becomes flattened. Fallopian Tubes Vagina and Perineum 11. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT increased vascularity and hyperemia Uterusdevelop in the skin and muscles of the perineum and vulva Cervix Ovaries papillae of the vaginal epithelium undergo hypertrophy to create a fine, Fallopian Tubes hobnailed appearance. Vagina and Perineum pH is acidic, varying from 3.5 to 6. 12. MATERNAL PHYSIOLOGY II. SKIN Blood flow in skin Abdominal Wall Hyperpigmentation Vascular Changes 13. MATERNAL PHYSIOLOGY II. SKIN Blood flow in skin Abdominal Wall Hyperpigmentation Vascular Changes 14. MATERNAL PHYSIOLOGY II. SKIN Blood flow in skin Abdominal Wall Hyperpigmentation Vascular Changes 15. MATERNAL PHYSIOLOGY II. SKIN Blood flow in skin Abdominal Wall Hyperpigmentation Vascular Changes 16. MATERNAL PHYSIOLOGYIII. BREASTS tenderness, increase in size nipples become larger, more deeply pigmented andmore erectile 17. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES uterus and its contents Weight gain the breasts Water Metabolism Protein Metabolism increases in blood volume and extravascular extracellular fluid CarbohydrateMetabolism Fat Metabolism 18. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES At term, the water content of the Weight gainfetus, placenta, and amnionic fluid approximates 3.5 L Water Metabolism Protein Metabolism Another 3.0 L accumulates as a result of increases in the Carbohydrate maternal blood volume and inMetabolism the size of the uterus and breasts Fat Metabolism normal pregnancy is approximately 6.5 L 19. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES at term, the fetus and placenta Weight gaintogether weigh about 4 kg and contain approximately 500 g of Water Metabolism protein Protein Metabolism the remaining 500 g is added to Carbohydrate the uterus as contractile protein,Metabolism to the breasts primarily in the glands, and to the maternal Fat Metabolism blood as hemoglobin and plasma proteins 20. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES Normal pregnancy is Weight gaincharacterized by mild fasting hypoglycemia Water Metabolism postprandial hyperglycemia Protein Metabolism hyperinsulinemia. CarbohydrateMetabolism Fat Metabolism 21. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES Maternal hyperlipidemia is Weight gainone of the most consistent and striking changes to take place in Water Metabolism lipid metabolism during late Protein Metabolism pregnancy. increased during the third Carbohydrate trimesterMetabolism Triacylglycerol andcholesterol levels in VLDL, Fat MetabolismLDL, HDL. 22. MATERNAL PHYSIOLOGYV. HEMATOLOGICAL CHANGES Dilutional anemia increase volume due to increase plasma increase RBC Increase reticulocyte and leukocyte count Increase blood coagulation factors, increase fibrinogen levels,increase plasminogen and fibrin degradation products Increase plasma iron binding capacity (transferrin) 23. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS No actual cardiac enlargement but Cardiovascular Systemonly slight dilatation and displacement upwards and Respiratory Tractoutwards due to gravid uterus Urinary System ECG may reveal slight axis Gastrointestinal Tract deviation, occasional T waves, and lowering of T waves Endocrine System Increase in heart rate maximal on Musculoskeletal System the 7th- 8th month~10 beats/min Increase in cardiac output by about 30-50% 24. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Upward displacement of the diaphragm by about 4 cm Cardiovascular System Increase tidal volume and resting minute ventilation Respiratory Tract Urinary System increase Vital capacity, tidal volume and respiratory rate due to Gastrointestinal Tract central effects of progesterone , low expiratory reserve volume and Endocrine System compensated respiratory alkalosis Musculoskeletal System decrease functional residual capacity and residual volume of air 25. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System Increase kidney size due to hypertrophy and increase renal Respiratory Tractblood flow causing an increase renal vascular volume Urinary System Gastrointestinal Tract Physiologic Hydroureter of pregnancymarked increase (25x) Endocrine System in diameter of ureteral lumen, hypotonicity and hypomotility of Musculoskeletal System its musculature Prone to UTI due to progesterone and pressure changes 26. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular SystemProgesterone effect Smooth muscle atony, Respiratory Tract decrease tone of loweresophageal sphincter, Urinary Systemincrease HCl production Gastrointestinal Tract Decrease responsiveness to Endocrine System CCK duodenal and biliary stasis pancreastitis Musculoskeletal System hyperlipidemia cholesterol stones 27. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Mild hyperthyroid state due toGland hyperplasia Cardiovascular System Hyperparathyroid state Respiratory Tractincrease calcium for fetus Urinary System Hyperadrenal state gland Gastrointestinal Tract hyperplasia with increase steroid production Endocrine System Musculoskeletal System Diabetogenic due to placental degradation of insulin and anti- insulin effects of placental lactogen, estrogen, progesterone 28. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System Respiratory Tract Back pain due to lordosis and Urinary System increase mobility sacal joints (relaxin) Gastrointestinal Tract Endocrine System Musculoskeletal System 29. Prenatal care 30. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits 31. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits 32. PRECONCEPTION CARE Personal and FamilyHistory Medical History Genetic Diseases Reproductive History Social History Lifestyle and WorkHabits 33. PRECONCEPTION CARE Personal and Family OccupationHistory Educational Attainment Medical History Home situation Genetic Diseases SOs Reproductive History Stress: short- and long- Social Historyterm Lifestyle and WorkHabits 34. PRECONCEPTION CARE Personal and Family Diabetes MellitusHistory Hypertension Medical History Asthma Genetic Diseases Epilepsy Reproductive History Renal Disease Social History Thyroid Disorders Lifestyle and Work Heart DiseaseHabits 35. PRECONCEPTION CARE Personal and Family Neural-Tube DefectsHistory Medical History Phenylketonuria Genetic Diseases Reproductive History Thalassemias Social History Lifestyle and Work Tay-Sachs DiseaseHabits 36. PRECONCEPTION CARE Personal and Family InfertilityHistory Medical History Abnormal pregnancy Genetic Diseases outcome Reproductive History Social History OB complications Lifestyle and WorkHabits 37. PRECONCEPTION CARE Personal and Family InfertilityHistory Abnormal pregnancy Medical Historyoutcome Genetic Diseases Miscarriage Reproductive History Ectopic pregnancy Social History Recurrent pregnancyloss Lifestyle and WorkHabits OB complications 38. PRECONCEPTION CARE Personal and Family InfertilityHistory Abnormal pregnancy Medical Historyoutcome Genetic Diseases OB complications Reproductive History Preeclampsia Social History Placental abruption Lifestyle and Work Preterm deliveryHabits 39. PRECONCEPTION CARE Personal and Family Maternal AgeHistory Medical History Recreational Drugs and Genetic DiseasesSmoking Reproductive History Social History Environmental Lifestyle and WorkExposuresHabits 40. PRECONCEPTION CARE Personal and Family Maternal AgeHistory Medical History Recreational Drugs and Genetic DiseasesSmoking Reproductive History Social History Environmental Lifestyle and WorkExposuresHabits 41. Maternal AgeADOLESCENT AFTER 35 Likely to be anemic Likely to request for Increased risk to have preconceptional counselinggrowth-restricted infants Physically fit VS. Chronic Preterm laborillness High infant mortality rate High mortality rate Higher incidence of STDs Maternalage fetal risks Fetal Aneuploidy 42. Maternal AgeADOLESCENT AFTER 35 Likely to be anemic Likely to request for Increased risk to have preconceptional counselinggrowth-restricted infants Physically fit VS. Chronic Preterm laborillness High infant mortality rate High mortality rate Higher incidence of STDs Maternalage fetal risks Fetal Aneuploidy 43. PRECONCEPTION CARE Personal and Family Maternal AgeHistory Medical History Recreational Drugs and Genetic DiseasesSmoking Reproductive History Social History Environmental Lifestyle and WorkExposuresHabits 44. PRECONCEPTION CARE Personal and Family Maternal AgeHistory Medical History Recreational Drugs and Genetic DiseasesSmoking Reproductive History Social History Environmental Lifestyle and WorkExposuresHabits 45. PRECONCEPTION CARE Personal and Family DietHistory Exercise Medical History Domestic Abuse Genetic Diseases Family History Reproductive History Immunizations Social History Screening Tests Lifestyle and WorkHabits 46. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits 47. Diagnosis of Pregnancy Signs and symptoms Presumptive symptoms of pregnancy1. nausea with or without vomiting- Pregnancy Test due to increase hCG2. disturbance in urination3. fatigue- due to increase metabolism Sonographic recognition 4. perception of fetal movement of pregnancyquickening5. breast tenderness and tingling sensation 48. Diagnosis of Pregnancy Signs and symptoms Presumptive signs of pregnancy1. amenorrhea2. anatomic breast changes Pregnancy Testdarker areola, erected nipple,engorged breast3. changes in vaginal mucosa4. Skin pigmentation Sonographic recognition 5. Thermal signs of pregnancy 49. Diagnosis of Pregnancy Signs and symptoms Probable evidence of pregnancy1. Enlargement of abdomen2. Changes in skin, shape and Pregnancy Testconsistency of the uterus3. Anatomical changes in cervixCervical mucus Sonographic4. Braxton-Hicks contractions that are painless and irregularrecognition of5. Ballotementpregnancy 6. Physical outlining of the fetus7. Positive Pregnancy test- B hCG levels 50. Diagnosis of Pregnancy Signs and symptoms Positive evidence of pregnancy1. Identification of fetal heart tones separately from mother Pregnancy TestNormal FHT:UltrasoundStethoscopeDoppler Sonographic recognition 2. Perception of active fetal of pregnancymovement by the examiner3. Ultrasound or radiologic evidence 51. Diagnosis of Pregnancy Signs and symptoms Pregnancy Test Sonographic recognition of pregnancy 52. Diagnosis of Pregnancy Signs and symptoms Pregnancy Test Sonographic recognition of pregnancy 53. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits 54. Initial Prenatal Evaluation Initiate prenatal care as soon as there isa reasonable likelihood of pregnancy. Goals: a) Define health status of mother and fetus b) Estimate gestational age c) Initiate continuing obstetrical c 55. CIM-CMSS PACKAGE DEAL Requirement: minimum of 4 PNCs Adjust PNC schedule for high-risk patients half thenormal interval Remind patients to bring all receipts on admission forrefund 56. FIRST PNC Always get contact number and place on index card Place past or present medical or surgical problems onupper right corner of PD Form For previous CS: secure OR Record and early UTZ foraging Fetal Heart Tone: 13 wks (+) FHT by Doppler 57. FIRST PNC LABS: 1. CBC, UA, Blood Typing (if not known) for ALL patients If menses are irregular, LMP is unclear, or previous CS (for aging: reliable up to 26 weeks): A. 12 weeks OB UTZ 58. FIRST PNC MEDS 1. Vitamin B complex (Neurofort) OD: 10 in one hour, esp aftereating) At 37 weeks: Remind patients to seek admission for signs of labor (bloody show with uterinecontractions every 5 mins) or watery vaginal discharge At 38 weeks: IE and cervical stripping (C/I in patients with history of spotting or low-lyingplacenta At 39 weeks: NST, IE and cervical stripping At 40 weeks: IE, stripping & biophysical profile At >41 weeks: IE and repeat BPP if 1 wk since 1st BPP was taken 63. PRENATAL CARERecommended Ranges of Weight Gain during SingletonGestations Stratified by Prepregnancy Body Mass Index CATEGORYBMIKGLB Low < 19.8 12.518 2840 Normal19.82611.516 2535 High2629711.51525 Obese > 29 >7>15 64. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits 65. PNC FOLLOW-UP SCHEDULE 0-27 6/7 weeks every 4 weeks 28-35 6/7 weeks every 2 weeks 36-39 6/7 weeks every week >40 weeks every 3 days 66. OPD schedule DAYMORNING AFTERNOONMonday PNC, GyneGyne, CIMTuesdayPNC, GynePNC, Gyne, CIMWednesdayPNC, GynePNC, Gyne, CIMThursday PNC, GyneGyne, CIMFriday PNC, GynePNC, Gyne, CIMSaturday PNC, Gyne 67. normal delivery 68. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABORII. CHARACTERISTICS OF NORMAL DELIVERYIII. MANAGEMENT OF NORMAL LABOR AND DELIVERY 69. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie 70. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie Fetal Presentation Cephalic Presentation 71. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie Fetal Presentation Cephalic Presentation Breech Presentation 72. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie Fetal Presentation Cephalic Presentation Breech Presentation Shoulder Presentation 73. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie Fetal Presentation Cephalic Presentation Breech Presentation Shoulder Presentation Fetal Attitude Fetal Position 74. NORMAL LABOR AND DELIVERY Diagnosis of Fetal Presentation and Position 1. Abdominal Palpation (Leopold Maneuvers) 2. Vaginal Examination 3. Sonography and Radiography 75. NORMAL LABOR AND DELIVERY Abdominal Palpation (Leopolds Maneuver)1. Fetal Pole2. Umbilical Pole Cephalic Podalic3. Pawlicks grip4. Pelvic grip 76. NORMAL LABOR AND DELIVERY Vaginal Examination 77. NORMAL LABOR AND DELIVERY Sonography and Radiography aid in identification of fetal position especially in obeseor in women with rigid abdominal walls. 78. NORMAL LABOR AND DELIVERY Mechanisms of Labor with Left Occiput Anterior Presentation 79. NORMAL LABOR AND DELIVERY Mechanisms of Labor with Left Occiput Anterior Presentation 80. NORMAL LABOR AND DELIVERY Changes in the shape of the fetal head Caput SuccedaneumMolding 81. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABORII. CHARACTERISTICS OF NORMAL DELIVERYIII. MANAGEMENT OF NORMAL LABOR AND DELIVERY 82. NORMAL LABOR AND DELIVERYII. CHARACTERISTICS OF NORMAL LABOR First Stage of Labor onset of labor until full dilation and effacement 83. FIRST STAGE OF LABOR Preparatory division the cervix dilates little, its connective tissue components change considerably Dilatational division during which dilatation proceeds at its most rapid rate, is unaffected by sedation or conduction analgesia. Pelvic division deceleration phase of cervical dilatation. The classic mechanisms of labor that involve the cardinal fetal movements of the cephalic presentation 84. FIRST STAGE OF LABOR Latent Phase point at which the mother perceives regular contractions. Prolonged Latent Phase exceeding 20 hours in the nullipara 14 hours in the multipara Active Labor cervical dilatation of 3 to 5 cm or more presence of uterine contractions 85. FIRST STAGE OF LABORMonitoring of Fetal Well-being Ausculataion: hand held Doppler fetal stethoscope Electronic Fetal Monitoring (EFM) superior to intermittentauscultation. Intermittent ausculatation every 15-30 minutes in the first stage of labor every 5 mins in the second stage of labor OR at least 30 seconds after each contraction. Admitting CTG not recommended for healthy women at term, in labor,in the absence of risk factors for adverse perinatal outcomes Continuos EFM is recommended when risk factors for fetalcompromise is identified. 86. FIRST STAGE OF LABORInduction of Labor to artificially initiate uterine contractions should only be implemented on a VALID indication. administered only in the hospital setting 87. FIRST STAGE OF LABORIndicationsContraindicationsGest. HPNMalpresentationPre eclampsia, Eclampsia Absolute CPDPremature rupture of membranes Placenta previaMaternal Medical Condition ( DM, Previous major uterine surgery, orrenal disease,chronic hypertensive)C/S deliveryMore than 41 1/7 weeks Invasive Ca of cervixEvidence of fetal compromise ( Cord presentationsevere feta growth restriction,isoimmunization)Intraamnionic infectionACTIVE genital herpesFetal demise Gyne, ob, or medical conditions that preclude vaginal birthLogistic factors ( eg: distance from OBs conveniencehospital) 88. FIRST STAGE OF LABORASSESSMENT PRIOR TO INDUCTION parity age presentation Bishops score uterine activity nonstress test 89. FIRST STAGE OF LABORMETHODS OF LABORINDUCTION Oxytocin Recommended regimen Membrane Sweeping/ starting dose of 1-2 mU/min,Strippingincreased at intervals of 30 mins or more Amniotomy Fetal heart rate should be recorded every 15-30 mins, and with each incremental increase of oxytocin. Continuous intrapartum electronic fetal monitoring 90. FIRST STAGE OF LABORMETHODS OF LABORINDUCTION Oxytocin artificial rupture of membrane that Membrane Sweeping/ may be used as a method for laborStrippinginduction if condition of the cervix is favorable Amniotomy However, if used alone in inducing labor, it can be associated with UNPREDITABLE, and sometimes LONG INTERVALS before the onset of contractions 91. FIRST STAGE OF LABORSIGNS OF HYPERSTIMULATION 5 contractions in 10 mins, or more than 10 in 20 mins lasts more than 120 seconds Excessive uterine activity with an atypical abnormalfetal heart rate OXYTOCIN SHOULD NOT BE CONTINUED orINCREASED in the presence of abnormal fetal heartrate, or tetanic contractions. 92. FIRST STAGE OF LABORRESUSCITATION Stop Reposition to left lateral decubitus O2 at 10L/min Notify physician Administer tocolytic Prepare for possible C/S if fetal pattern remainsabnormal 93. SECOND STAGE OF LABOR Cervical dilatation complete and ends with fetal delivery 50 minutes for nulliparas 20 minutes for multiparas dorsal lithotomy position vulvar and perineal cleansing 94. SECOND STAGE OF LABOR 95. SECOND STAGE OF LABOR Episiotomy Reduce the risk of perineal trauma shortened second stage of labor. Indications: Expedite delivery in the second stage of labor When spontaneous laceration is likely Maternal or fetal distress Breech Assisted forceps delivery Large baby Maternal exhaustion 96. SECOND STAGE OF LABOR Characteristic Midline Mediolateral Surgical repairEasyMore difficult Faulty healing RareMore common Postoperative pain Minimal Common Anatomical results Excellent Occasionally faulty Blood loss LessMore DyspareuniaRareOccasional ExtensionCommonUncommon 97. SECOND STAGE OF LABOR 98. SECOND STAGE OF LABOR Clamping the Cord umbilical cord is cut between two clamps placed 4 to 5 cm from the fetal abdomen umbilical cord clamp is applied 2 to 3 cm from the fetal 99. THIRD STAGE OF LABOR size of the uterine fundus and its consistency areexamined uterus remains firm and there is no unusual bleeding,watchful waiting until the placenta separates is the usualpractice Signs of Placental Separation uterus becomes globular and as a rule, firmer sudden gush of blood uterus rises in the abdomen The umbilical cord protrudes farther out of the vagina 100. THIRD STAGE OF LABOR 101. THIRD STAGE OF LABOR Uterine massage following placental delivery prevent postpartum hemorrhage Oxytocin, ergonovine, and methylergonovine are all employed widely in the normal third stage of labor 102. THIRD STAGE OF LABOR Oxytocin 1st line prophylactic uterotonic during 3rd stage of laborin the prevention of PPH add 20 units (2 mL) of oxytocin per liter of infusate 10 mL/min (200 mU/min) for a few minutes half-life of intravenously infused oxytocin isapproximately 3 minutes May cause fall in BP if given in large bolus May cause water intoxication 103. THIRD STAGE OF LABOR Use of ergot alkaloid, and ergometrine-oxytocin valid alternatives in the absence of oxytocin powerful stimulants of myometrial contraction AVOIDED in hypertensive patients due to ability to cause transient hypertension In low resource area, misoprostol may be administered orally, sublingually, or rectally. 104. FOURTH STAGE OF LABOR placenta, membranes, and umbilical cord should beexamined for completeness and for anomalies postpartum hemorrhage as the result of uterine atonyis more likely at this time 105. FOURTH STAGE OF LABOR First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane but not the underlying fascia. 106. FOURTH STAGE OF LABOR Second-degree lacerations involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter 107. FOURTH STAGE OF LABOR Third-degree lacerations extend farther to involve the anal sphincter. 108. FOURTH STAGE OF LABOR fourth-degree laceration extends through the rectums mucosa to expose its lumen 109. Episiorrhaphy Hemostasis and anatomical restoration withoutexcessive suturing are essential for the success ofthis method. Blunt needles are suitable and likely decrease theincidence of needlestick injury; 2-0 Chromic gut 110. Episiorrhaphy 111. NORMAL LABOR AND DELIVERY Changes in the shape of the fetal head Caput Succedaneum MoldingEdematous swelling ofChange in the fetal headthe fetal scalp due to external compressiveFormed when the head forces.is in the lower portion There is seldomof the birth canal andoverlapping of the parietalfrequently only after bones.resistance of a rigid Locking mechanisms at thevaginal outlet is coronal nad lambdoidalencountered.connections preventsIt normally, crosses the overlapping.suture lines. 112. CephalhematomaIt is a hemorrhage of blood betweenthe skull and the periosteum of a newbornbaby secondary to rupture of blood vesselscrossing the periosteum. Because the swellingis subperiosteal its boundaries are limited bythe individual bones 113. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Upward displacement of the diaphragm by about 4 cm Cardiovascular System Increase tidal volume and resting minute ventilation Respiratory Tract Urinary System increase Vital capacity, tidal volume and respiratory rate due to Gastrointestinal Tract central effects of progesterone , low expiratory reserve volume and Endocrine System compensated respiratory alkalosis Musculoskeletal System decrease functional residual capacity and residual volume of air 114. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie Fetal Presentation Cephalic Presentation Breech Presentation 115. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR Fetal Lie Fetal Presentation Cephalic Presentation 116. Bishop scoring is a pre-labor scoring system to assist in predicting whether inductionof labor will be required. It has also been used to assess the odds ofspontaneous preterm delivery. a score that exceeds 8 describes the patient most likely to achieve asuccessful vaginal birth. Bishop scores of less than 6 usually requirethat a cervical ripening method be used before other methods. Cervical dilation Cervical effacement Cervical consistency Cervical position Fetal station Pneumonic : PEDS 117. Modified Bishop scoring Another modification for the Bishops score is themodifiers. Points are added or subtracted according tospecial circumstances as follows: One point is added for: 1. Existence of pre-eclampsia 2. Every previous vaginal delivery One point is subtracted for: 1. Postdate pregnancy 2. Nulliparity (no previous vaginal deliveries) 3. PPROM; preterm premature (prelabor) rupture ofmembranes 118. Hypertensive Complications:Criterias: Gestational Hypertension: Systolic BP 140 or diastolic BP 90 mm Hg for first timeduring pregnancy No proteinuria BP returns to normal before 12 weeks postpartum Final diagnosis made only postpartum May have other signs or symptoms of preeclampsia, forexample, epigastric discomfort or thrombocytopenia 119. Criterias Preeclampsia: Minimum criteria: BP 140/90 mm Hg after 20 weeks gestation Proteinuria 300 mg/24 hours or 1+ dipstick Increased certainty of preeclampsia: BP 160/110 mm Hg Proteinuria 2.0 g/24 hours or 2+ dipstick Serum creatinine >1.2 mg/dL unless known to be previously elevated Platelets < 100,000/L Microangiopathic hemolysisincreased LDH Elevated serum transaminase levelsALT or AST Persistent headache or other cerebral or visual disturbance Persistent epigastric pain 120. Criterias: Eclampsia: Seizures that cannot be attributed to other causes in a woman with preeclampsia 121. Criterias Superimposed Preeclampsia On ChronicHypertension: New-onset proteinuria 300 mg/24 hours inhypertensive women but no proteinuria before 20weeks gestation A sudden increase in proteinuria or blood pressure orplatelet count < 100,000/L in women withhypertension and proteinuria before 20 weeksgestation 122. Criterias Chronic Hypertension: BP 140/90 mm Hg before pregnancy or diagnosedbefore 20 weeks gestation not attributable togestational trophoblastic disease or Hypertension first diagnosed after 20 weeks gestationand persistent after 12 weeks postpartum 123. Preeclampsia The basic management objectives for any pregnancy complicated by preeclampsia are: Termination of pregnancy with the least possible traumato mother and fetus Birth of an infant who subsequently thrives Complete restoration of health to the mother. Termination of pregnancy is the only cure forpreeclampsia. Once severe preeclampsia is diagnosed, laborinduction and vaginal delivery have traditionally beenconsidered ideal. 124. Some Indications for Delivery withEarly-Onset Severe Preeclampsia Maternal Persistent severe headache or visual changes; eclampsia Shortness of breath; chest tightness with rales and/orSaO2 < 94 percent breathing room air; pulmonary edema Uncontrolled severe hypertension despite treatment Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL Persistent platelet counts < 100,000/L Suspected abruption, progressive labor, and/or rupturedmembranes 125. Some Indications for Delivery withEarly-Onset Severe Preeclampsia Fetal Severe growth restriction< 5th percentile for EGA Persistent severe oligohydramniosAFI < 5 cm Biophysical profile 4 done 6 hr apart Reversed end-diastolic umbilical artery flow Fetal death 126. Eclampsia: ImmediateManagement of Seizure Eclamptic seizures may be violent. During seizures,the woman must be protected, especially her airway. In severe cases, coma persists from one convulsion toanother, and death may result. 127. In more severe cases of preeclampsia, as well as in eclampsia, magnesium sulfate administered parenterally is an effective anticonvulsant that avoids producing central nervous system depression in either the mother or the infant. It may be given intravenously by continuous infusion or intramuscularly by intermittent injection 128. Continuous Intravenous Infusion Give 4- to 6-g loading dose of magnesium sulfatediluted in 100 mL of IV fluid administered over 1520min Begin 2 g/hr in 100 mL of IV maintenance infusion.Some recommend 1 g/hr Monitor for magnesium toxicity: Assess deep tendonreflexes periodically Some measure serum magnesiumlevel at 46 hr and adjust infusion to maintain levelsbetween 4 and 7 meq/L (4.8 to 8.4 mg/dL) Measureserum magnesium levels if serum creatinine 1.0 mg/dL Magnesium sulfate is discontinued 24 hr after delivery 129. Intermittent IntramuscularInjections Give 4 g of magnesium sulfate (MgSO4 7H2O USP) as a 20%solution intravenously at a rate not to exceed 1 g/min Follow promptly with 10 g of 50% magnesium sulfate solution,one-half (5 g) injected deeply in the upper outer quadrant ofboth buttocks through a 20-gauge needle. If convulsions persistafter 15 min, give up to 2 g more intravenously as a 20% solutionat a rate not to exceed 1 g/min. If the woman is large, up to 4 gmay be given slowly Every 4 hr thereafter give 5 g of a 50% solution of magnesiumsulfate injected deeply in the upper outer quadrant of alternatebuttocks, but only after ensuring that: a. The patellar reflex is present, b. Respirations are not depressed, and c. Urine output the previous 4 hr exceeded 100 mL Magnesium sulfate is discontinued 24 hr after delivery 130. Watch out! Patellar reflexes disappear when the plasma magnesium level reaches 10 meq/Labout 12 mg/dLpresumably because of a curariform action. This sign serves to warn of impending magnesium toxicity. When plasma levels rise above 10 meq/L, breathing becomes weakened, and at 12 meq/L or more, respiratory paralysis and respiratory arrest follow. 131. Remedy Treatment with calcium gluconate or calcium chloride, 1 g intravenously, along with withholding further magnesium sulfate, usually reverses mild to moderate respiratory depression. 132. Exercises that a pregnant womancan do:1.Head lift2.Head lift with pelvic tilt3.Pelvic tilt4.Leg sliding5.Trunk curls6.Modified bicycle7.Standing push ups8.Supine Bridging9.Quadruped leg raising10. Modified squatting11. Scapular Retractions12. Self stretching 133. Head Lift Hook-lying with her hands crossed over midline at thelevel of the diastasis for support. Have the woman exhale and lift only her head off thefloor or until the point just before a bulge appears. Atthe same time, her hands should gently approximatethe rectus muscles toward midline (Fig. 23.8). Thenhave the woman lower her head slowly and relax. This exercise emphasizes the rectus abdominis muscleand minimizes the obliques. 134. Head Lift with Pelvic Tilt The arms are crossed over the diastasis for support as above. Have the patient slowly lift her head off the floor while approximating the rectus muscles and performing a posterior pelvic tilt, then slowly lower her head and relax. All abdominal contractions should be performed with an exhalation so that intra-abdominal pressure is minimized. 135. Quadruped leg raising On hands and knees(hands may be in fists or palms openand flat). Instruct the woman to first perform a posteriorpelvic tilt, and then slowly lift one leg, extending the hip toa level no higher than the pelvis while maintaining theposterior pelvic tilt. She then slowly lowers the leg andrepeats with the opposite side. The knee may remain flexed or can be straightened throughout the exercise. Monitor this exercise and discontinue if there is stress on the sacroiliac joints or ligaments. If the woman cannot stabilize the pelvis while lifting the leg, have her just slide one leg posteriorly along the floor and return 136. Modified Bicycle The woman is supine with one lower extremity flexed and the other partially extended. The lower abdominals stabilize the pelvis as the lower extremities flex and extend in an alternating pattern as if cycling. The further the lower extremities extend, the greater the resistance. In order to not strain the back, the woman must keep it flat against the floor by controlling the arc of the cycling pattern. 137. Standing Push-Ups Standing, facing a wall, feet pointing straight forward,shoulder-width apart, and approximately an arm-length away from the wall. The palms are placed on thewall at shoulder height. Have the woman slowly bendthe elbows, bringing her upper body close to the wall,maintaining a stable pelvic tilt, and keeping the heelson the floor. Her elbows should be shoulder height.She then slowly pushes with her arms, bringing thebody back to the original position.