OBSTETRICSOBSTETRICSOBSTETRICSOBSTETRICSThe branch of medicine that deals with the The branch of medicine that deals with the

care of women during pregnancy, childbirth, care of women during pregnancy, childbirth, and the recuperative period following and the recuperative period following

delivery. delivery.

ESSENTIAL PROCEDURES IN NORMAL PREGNANCY

Estimating Ovulation TimeWhat is Ovulation???

- Discharge of an ovum or ovule from the ovary. - Occurs approx. 14 days before the first day of the

succeeding menstrual bleeding- SIGNS AND SYMPTOMS

- abrupt slight rise in basal body temperature- presence of mittelschmerz- identification of fertile cervical mucus

TAKING COMPLETE MENSTRUAL HISTORY

What to include?????a. Menarche – irregular, anovulatory,infertileb. Duration of Mensesc. Intervals between mensesd. Characteristics of menstrual flowe. Presence of mittelschmerzf. Date of onset of last menstrual periodg. Date of past/ previous menstrual periodh. Ask about any menstrual abnormalities:

1.Amenorrhea2. Dysmenorrhea3. Metrorrhagia4. Menometrorrhagia5. Premenstrual Syndrome ( PMS )

DETERMINING GRAVIDITY AND PARITY

GRAVIDA is the number of pregnancies regardless of duration or outcomes

GRAVIDITY – refers to the total number of pregnancies, past and present, irrespective of the outcome

PARA OR PARITY – refers to the total number of pregnancies in which the fetus has reached the age of viability and subsequently delivered whether dead or alive at birth

PRINCIPLES IN IDENTIFYING PARITY

A. The number of pregnancies is countedB. Abortion is not included in parity countC. Live birth or stillbirth is counted in parity countEXERCISE A: A nurse is taking the obstetrical history of 22-year-old, 4 month

pregnant Mrs. Chan. Which of the following statements correctly applies given this OB history of Mrs. Chan : first pregnancy at age 15, complicated with PIH, ended in the birth of a SGA; second pregnancy at age 18 resulted in the birth of twins, a boy and a girl; a third pregnancy at age 20 ended in the birth of a stillborn with gestational age of 35 weeks.

a. Mrs. Chan is a low-risk maternity clientb. Mrs. Chan is currently G4P2c. Since a stillbirth is not included in parity count, Mrs. Chan is G4P2d. The presence of a twin is counted as ! Parity making Mrs. Chan

G4P3

OBSTETRICAL SCORING:CODING RESULTS OF PREVIOUS PREGNANCIES

• Four-digit systemT – P – A – L / F – P – A – L

“ T ” - term or “ F “ for full term- refers to the total number of infants born at 37 completed weeks gestation or beyond

“ P ” - preterm- number of infants born before 37 completed weeks gestation, or any infant born between 20 and 37 weeks.

“ A” - abortion- number of pregnancies terminated before the age of viability or before 20 weeks

“ L” – currently living• Five-digit sytem

G – T – P – A – L “ G” – GRAVIDITY – total pregnancy

ESTIMATING EXPECTED DATE OF DELIVERY (EDD):

NAEGELE’S RULE

PROCEDUREA. Determine the last normal menstrual period

(LMP).B. Consider the first day of the LMP.C. Consider the month in numeric terms. For the

1st three months of the year, add 12 to the numerical value

D. Now use Naegele’s formula-3 +7 +1

EXERCISES: a. The given LMP is March 5 – 10, 2008. b. The given LMP is June 12 – 17, 2008.

ESTIMATING EDD: MITTENDORF’S RULE

PROCEDUREA. Determine the first day of the LMPB. Categorize the woman as Caucasian or non-Caucasian

( race ).C. Identifying her gravidity: primigravida ( G1) or multigravida

(G2 or above)For primigravid Caucasian women:Formula: LMP + 15 days (constant) – 3 mos = EDDFor multigravid non-Caucasian women:Formula: LMP + 10 days (constant) - 3 mos = EDDEXERCISES: a. What is the EDD of Mrs. Smith , a G1 Caucasian

with LMP of May 14b. What is the EDD of Mrs. Peralta, G2 Filipino woman with LMP

of Aug. 10?

ESTIMATING GESTATIONAL AGE

• Using certain clinical milestonesa. Early Prenatal Careb. Quickeningc. Auscultation of FHTd. Fundic heightd. Ultrasound

ESTIMATING FUNDIC HEIGHT: McDonald’s MethodEQUIPMENT

A centimeter tape measurePROCEDURE

a. Explain the procedure to the mother.b. Ask the mother to empty her bladder.c. Position the mother on dorsal recumbent.d. Drapee. Measure the distance abdominally from the top of the symphysis pubis over the curve of the abdomen to the top of the uterine fundus.

LIMITATIONobesity, polyhydramnios and uterine fibroids

ESTIMATING GESTATIONAL AGE:

McDONALD’S RULEPROCEDUREa. Explain the procedure to the clientb. Instruct the woman to voidc. Measure the fundic height using McDonald’s ruleFORMULAa. Computing in lunar months, multiply the fundic height by two, then

divide by seven.b. Computing in weeks, multiply the fundic height by eight, then

divide by seven.EXERCISES:a. What is the estimated gestational age in months if the fundic

height is 31.5 cm?b. What is the estimated gestational age in weeks if the fundic height

is 36 cm?

ESTIMATING FETAL LENGTH: HAASE’S

RULEA prerequisite to the use of Haase’s rule is the

identification of the lunar month of pregnancy.

Formulaa. From 1-5 lunar months, square the month of

pregnancyb. From 6-10 lunar months, multiply the month

by 5.EXERCISES: a. How long is a 4 month old fetus?b. What is the estimated length of a 10 month

old fetus?

ESTIMATING FETAL WEIGHT: JOHNSON’S RULE

• Can only be used in cephalic vertex presentationPROCEDURE1. Determine the FH2. Identify stationFORMULAa. For vertex above the IS: subtract 12 (constant) from the FH, then

multiply by 155 (constant).b. For vertex below the IS: subtract 11 (constant) from the fundic

height, then multiply by 155 (constant).EXERCISESa. What is the estimated wt.in gms of the fetus of Mrs. Y, given the ff

data: FH: 32 cm; station -2b. What is the estimated wt in gms of the fetus of Mrs. Z, given the ff

data: FH- 34cm; station +1

PREPARING A CLIENT FOR A PREGNANCY TEST

a. Explain the procedureb. Collect first-voided urinec. Do not drink fluids from 8pm the night

before to concentrate the urine.d. Refrain from taking any drug 24 hours

before the test.e. Labelf. Bring specimen to lab immediatelyg. Refrigerate urine specimen

MAKING OTC PREGNANCY TESTS RELIABLE

a. Perform the test in the morningb. Hold the strip in the urine stream

for 3 secondsc. Read the stick within 10 minsd. Confirm the positive result by

taking another test a day or two later

PREVENTING COMMON DISCOMFORTS OF PREGNANCY

A. Nausea and VomitingB. Heartburn/ PyrosisC. Frequency of VoidingD. ConstipationE. HemorrhoidsF. Leg CrampsG. Leg VaricositiesH. Supine Hypotension Syndrome/ Vena Caval SyndromeI. Pedal Edema/Swelling of the legsJ. DyspneaK. LeukorrheaL. Backache

NAUSEA AND VOMITING

1. Causes- Increase in HCG- Relaxing effect on the GI tract by hormones of pregnancy- Pressure on and displacement of the GIT result in poor

digestion and constant feeling of fullness- Decreased glycogen reserve- Emotional factors2. Preventiona. Take dry carbohydrates 30 mins before getting out of

bedb. Avoid fatty foods and other offenders c. Take small, frequent mealsd. Increase fluids, but best tolerated between meals.

CAUTION: Excessive vomiting must be reported immediately. Principles of management:

- Hospitalization- Privacy- Fluids and Electrolytes- Nourishment- Psychological support

HEARTBURN/ PYROSIS• Is also known as acid reflux, is a

painful and burning sensation in the esophagus, just behind the breastbone, usually associated with regurgitation of gastric acid (gastric reflux).[1] The pain often rises in the chest and may radiate to the neck, throat, or angle of the jaw

1. CAUSESa. Poor tone of the cardiac sphincter of the stomach causes easy esophageal reflux of acidic gastric secretions, resulting in burning sensation behind the sternum from esophageal irritationb. Poor digestive ability of the stomach from decreased HCL and poor muscle tonec. Decreased peristalsis

2. Preventiona. Take small, frequent mealsb. Refrain from taking indigestible, fatty and spicy foodsc. Maintain an upright positiond. Refrain from taking gas-forming foodse. To neutralize gastric acidity, take antacid

FREQUENCY OF VOIDING

1. CausePressure on the bladder by the gravid uterus in the first and third trimester

2. Managementa. Increase fluid intakeb. Use perineal pad to absorb leakagec. Flush the perineum every after voiding

CAUTION: Burning sensation requires prompt reporting

CONSTIPATION1. Causes

a. Pressure on bowels exerted by the gravid uterusb. Relaxing effect of hormonesc. Decreased physical exercised. Oral iron

2. Preventiona. Increase fluid intakeb. Increase roughage or bulk in the dietc. Defecate regularlyd. Have regular exercisee. A mild laxative is the last resort

HEMORRHOIDS1. Causes

a. constipationb. increased intra-abdominal pressure from frequent heavy liftingc. pressure on the rectal region/ veins by the gravid uterusd. distention of veins by increased blood volume due to increased estrogen

2. Preventiona. Avoid straining b. avoid lifting heavy obj.

3. Managementa. Avoid spicy foods for comfortb. Ice packs or warm water sitz bath c. Prolapsed hemorrhoids are lubricated and may be replaced gentlyd. Hemorrhoidectomy is not performed during pregnancy

LEG CRAMPS1. Causes

a. Calcium and phosphorusimbalanceb. Muscle fatiguec. Pressure on the nerves supplying the lower extremities

2. Preventiona. Increase dietary intake of calciumb. small amt. of Amphogel ( aluminum hydroxide gel)c. avoid fatigue of leg muscled. No constricting garters

3. Managementa. Flexing the mother’s foot toward her knee to hyperextend the involved muscles offers immediate relief

CAUTION: The presence of calf pain on hyperextension of the involved muscles is Homan’s Sign

LEG VARICOSITIES1. Causes

a. Primarily due to pressure on the pelvic girdle by the gravid uterus

b. Increased vascularity because of estrogen

c. Constricting gartersd. Prolonged standing and sitting

2. Preventiona. wear support or elastic stockingsb. elevate legs and hips frequentlyc. avoid prolonged sittingd. avoid wearing round garters andknee-high stockings

CAUTION: A pregnant woman may have feelings of faintness due to resultant pooling of blood in the lower extremities from wearing constricting garters, dilation of the vessels of lower extremities and the dilatation of the various surface vessels.

SUPINE HYPOTENSION SYNDROME/ VENA CAVAL

SYNDROME1. Causes

The pressure exerted by the gravid uterus on the big blood vessels on the right side ( descending aorta and inferior vena cava) impedes venous return

2. Preventiona. Gradual positional changesb. Left side lying position in bed; left lateral recumbentc. Gradual rising from bed in the morning on the left side

PEDAL EDEMA1. Causes

a. pressure on the pelvic girdleb. prolonged standing or sittingc. constricting garters

2. Prevention a. avoid prolonged sitting and standingb. wear comfortable shoes: avoid round gartersc. elevate legs against the wall

CAUTION: swelling of the hands and face is a danger sign of preeclampsia and MUST be reported right away

DYSPNEA1. Cause

Pressure on the diaphragm2. Prevention

a. assume a semi- Fowler’s positionb. wear loose clothes and brac. have frequent rest periods

CAUTION: Increasing dyspnea with minimal exertion, or dyspnea before fundal pressure on the diaphragm, is a danger signal of cardiac disease

LEUKORRHEA1. Cause

Elevate levels of estrogen stimulate increased activity of cervical gland, resulting in the production of whitish, mucoid, and non-foul vaginal discharge

2. Managementa. Flush perineum after every voidingb. Wear cotton perineal pad for more comfort

CAUTION: Itchines, burning sensation, and abnormal characteristics of discharges indicate Vaginal infection:

• Whitish, cheesy discharge with local irritation is due to the fungus Candida albicans, which causes moniliasis

-Treatment: Nystatin (Mycostatin) vaginal suppository

• Yellowish, profuse,purulent discharge with burning or vulvar itching is due to the bacterium Neisseria gonorrheae

- Treatment: Penicillin (erythromycin if allergic to penicillin

- May cause ophthalmia neonatorum

• Green, frothy discharge and a friable erythematous cervix, are rarely seen in Trichomonas vaginalis-complaints are pruritus, burning sensation, white to greenish or grayish, normal to copious, bubbly or frothy vaginal discharge

- Treatment: Metronidazole (Flagyl)NOTE: Teratogenic in the first trimester, tx lasts 7 days

c. Douching is usually not necessary because the levels of estrogen remains high in pregnancy, causing leukorrhea

PRECAUTIONARY MEASURES:- The douche bag should not be more than two feet high to avoid pressure, which can wash away the protective cervical mucus plug- Insert no more than three inches of the vaginal tube in order not to injure the tip of the cervix- Do not use bulb syringe in order not to introduce air ( thus to prevent air embolism).

BACKACHE

1. Causesa. faulty posture, fatigueb. relaxed sacro-iliac jointc. prolonged standing/ sittingd. strained on the back muscles from an increased lumbar curve (lordosis)

2. Preventiona. Maintain a good posture: do pelvic rock/ tilt exercisesb. Wear firm, supportive maternity girdlec. Use a firm, comfortable bed

PROMOTING GOOD NUTRITIION

• The fetus receives water and electrolytes through the process of diffusion, whereby low molecular substances move from an area of higher concentration (maternal blood) to that of lower concentration ( fetal blood)

• With enzymatic activity, glucose moves to the fetus by facilitated transport

• Amino acids, calcium and iron move into the fetal circulation by means of active transport

• Fat globules are engulfed across the cell wall

STEPS IN PROMOTING GOOD NUTRITION

A. Start with diet historyB. Provide nutritional instruction.C. RDA vary with weight, age, health,

activity, and health status1. Increase calories for energy

- Additional 300 kcal/24 hr. or a total 2,300 to 2, 500 calories per day

- For deposition, synthesis and maintenance of new tissue

2. Increase protein- growth and repair of maternal tissues, breasts, uterus and placenta- increased maternal blood volume- growth and development of the fetus

70-80 gm./day ( or an addition of 30 g to the normal daily requirement)

Additional 20 g for lactating mothers- Adolescent and younger pregnant

women need more protein ( 1.7 g/kg of preg.wt) than older and more mature woman (1.3 g/kg preg.wt)

3.Decrease fats- 90 g fat coming mainly from animal sources- promote absorption and utilization of fat soluble vitamins

4. Decrease carbohydratesThe human placental lactogen (HPL)

- major insulin antagonist5. Increase major minerals

a. Iron – total iron is about 800 to 1000 mg. split into:- 50% (500mg): form more hemoglobin in order

to minimize physiologic anemia of pregnancy- 30% (300mg): transferred to the placenta and

the fetus-20% (200mg): replace natural losses in skin,

sweat and hair- 18 mg non-pregnant req./day, rises to 30-60 mg- 60-100 mg is recommended for women carrying twins

who are large or whose hemoglobin is depressed- 200 mg for severely anemic gravid women

b. Calcium and Phosphorus1,200 mg: 400 mg more than the non pregnant

req. of 800 mg.Expectant mother retains 30 g of calciumc. Iodine

-prevent cretinism or hypothyroidism-175 micrograms/day-Non-pregnant: 150+ Pregnant: 25 = 175ug/day-Non-pergnant: 150 + Lactating Mother: 50 = 200 ug/day-Severe iodine deficiency can result in cretinism and marked mental retardation-Intramuscular injection of iodized oil early in pregnancy can prevent cretinism in infants-The iodine allowance of 175 ug/day can be met by using iodized salt

d. Zinc – RDA is 20 mg-Excellent sources of zinc include milk, liver, wheat bran and shellfish-Severe zinc deficiency may cause dwarfism and hypogonadism.

6. Increase essential vitamins.a. Vitamin C (ascorbic acid)

- 80 to 100 milligrams- excess vitamin C

supplementation (1g/day) may prove harmful in pregnacy

- excess vitamin C can result in a functional deficiency in vitamin B12

b. Folic Acid/ Folate- prevent fetal malformation and neural tube defects

• Non-pregnant: 0.4mg + pregnant: 0.4 mg= 0.8 mg (400 ug – 800 ug)

• Food sources : fresh, green leafy vegetables, fresh asparagus, liver, kidney, peanuts, food yeasts/ brewer yeast, fish, poultry and eggs

• Folic acid is a water-soluble vitamin• Deficiency may result in spontaneous abortion,

megaloblastic anemia of pregnancy, abruptio placenta and other late bleeding complications

• Supplementation of 4 mg daily prior to conception lowers the risk of neural tube defects

c. Vitamin B12 – To help in red blood cell formation and to provide a coenzyme in protein metabolism, 4 ug vit.B12 daily is recommended

- Vit. B12 occurs naturally in foods of animal origin

- Sources include meat, liver and dairy products such as milk, eggs and cheese

C. Emphasize the number of daily servings of essential foods1. Protein- rich foods: 4 servings2. Milk and dairy products: 4 servings3. Grain and grain products: 4 servings4. Fruits and vegetables: 4 servings divided into:

- 2 servings of green, leafy vegetables’- 1 serving of vit.C-rich fruit or vegetable- 1 serving of other fruit or vegetable, as desired

D. Provide guidance in selection of proper foods emphasizing quality and not quantity

E. Identify nutrition risk factors1. Low socioeconomic status2. Bizarre food patterns3. Smoking4. Alcoholism and drug addiction

Fetal Alcohol SyndromeCharacterizedby:1. Alcohol withdrawal signs: difficult to feed, irritable or

fretful2. Intrauterine growth restriction which causes the fetus

failure to thrive3. Microcephaly4. Dysmorphic facial features:

-small eyes with exaggerated epicanthal folds-shallow or absent philtrum with a poorly formed nasal bridge ( low or wide nasal bridge )-thin upperlip- large ears]

5. Congenital heart defects6. Congenital gut atresia7. Musculoskeletal sys. Defects8. Cleft palate9. Developmental delays

5. A vegetarian diet leads to inadequate intake of complet protein and vitamin B12

6. The adolescent age group’s diet is usually inadequatein nutritious foods

7. A short interval between pregnancies results in deplted maternal nutrient reserves

8. Underweight and obesity

MONITORING WEIGHT OF PREGNANT WOMEN

Normal total wt gain range from 20-30 lb, with the average total wt. gain of 24 lb.

1st trimester – 2 lb( 1 kg)2nd and 3rd trimester – 11lb (5 kg)* Wt gain during the first half of

pregnancy is reflective of increasing maternal stores, while gain in the second half of pregnancy is attributed primarily to fetal growth

HIGH RISK PREGNANCY

HIGH RISK FACTORSA. Demographic factors

1. Maternal age: under 18 and above 352. Pre-pregnant wt: under 90 lb. and 150 lb and above3. Height: 5 ft4. Family history of severe inherited disorders

B. Maternal Habits1. Smoking2. Alcohol3. Drug addiction4. Food fads

C. Socioeconomic factors1. Low socio-economic status:

a. Poor nutritionb. Poor financesc. Poor housingd. Parental occupation

2. Unwed condition/ marital status3. Poor support system

D. Maternal Obstetric factors: past and present1. History of infertility2. Primigravidity/ grand multiparity3. Birth interval4. Late or no prenatal care5. Rh sensitization

6. Past or present obstetric complications:a. Abortionb. Ectopic pregnancyc. Placenta previa/ abruptio placentad. PIHe. Multiple Gestationf. Prematue/ Postmature laborg. PROMh. Maternal Anemiai. Dystocia/ precipitate laborj. Abnormal presentationk. Operative OB: csl. Fetus small or large for gestationm. Stillbirth/ neonatal deathn. Polyhydramnios

E. Maternal medical history, including coincidental diseases of pregnancy1. Cardiac d/o / hx of RF in childhood2. Metabolic Dis.: DM / thyroid d/o3. Chronic hypetension/ renal d/o: UTI, bacteruria4. Pulmonary dis.5. Venereal and other infectious diseases6. Malignancy7. MR/ severe emotional instability8. Congenital anomalies of the Reproductive tract

F. Maternal surgical history/ status1. Previous cesarean section2. Other reproductive tract surgery