ANATOMY & PHYSIOLOGY OF THE FEMALE

REPRODUCTIVE SYSTEM

I. External Reproductive Organs

1. Mons Pubis or Veneris- pad of fat (adipose tissue) which lies over the
symphysis pubis covered by skin and at puberty, by short hairs, protects
the surrounding delicate tissues from trauma.

2. Labia Majora- two folds of skin with fat underneath; contains

Bartholin’s gland that secretes a yellowish mucus which acts as lubricant
during sexual intercourse.

3. Labia Minora- thinner lengthwise folds of hairless skin, extending

from the clitoris to the fourchette.

4. Clitoris- small erectile organ which is comparable to the penis in its

being extremely sensitive.

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5. Vestibule- narrow space scene when the labia minora are separated.

6. Urethral Meatus- external opening of the urethra, slightly behind and

to the side are the opening of the skene’s gland (which are often involved
in the infections of the external genitalia).

7. Vaginal Orifice/ introitus – external opening of the vagina, covered

by a thin membrane (called hymen) in virgins.

8. Perineum- area from the lower border of the vaginal orifice to the
anus, contains the muscles which support the pelvic organ, the arteries
that supply blood and pudendal nerves which are important during
delivery under anesthesia.

II. Internal Reproductive Organs

1.Vagina- a 3-4 inch long dilatable canal located between the bladder
and the rectum, contains rugae (which permit considerable stretching
without tearing), passageway for menstrual discharges, copulation and
fetus.

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2. Uterus- hollow, pear-shaped muscular organ freely movable in pelvic
cavity; organ of menstruation, site of implantation and retainment and
nourishment of the products of conception; comprised of fundus, corpus,
isthmus and cervix. Cervix has external and internal os, separated by the
cervical canal.

Wall of uterus has 3 Layers:

1. Endometrium- inner layer, highly vascular, shed during

menstruationand following delivery.

2. Myometrium- middle layer comprised of smooth muscle

fibers running in 3 directions; expels fetus during birth.

3. Peritoneum- serous outer layer.

3. Fallopian Tube- 4 inches long from each side of the fundus; widest
part called ampulla spreads into fingerlike projections (fimbrae);
responsible for the transport of mature ovum from the ovary to uterus,
fertilization takes place in its outer third or outer half.

4. Ovaries- oval, almond size organ on either side of the uterus that
produce mature and expel and manufacture hormones (estrogen and
progesterone).

III. The Pelvis

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-Although not a part of the female reproductive organs, but of the
skeletal system, it is very important body part of the pregnant women.

A. Structure

-Right and left in nominate bones, sacrum and coccyx from the bony
passage through which the baby passes during birth. Relationship
between pelvic size, shape and baby may affect the labor or make
vaginal delivery impossible.

B. Divisions

- set apart by the linea terminalis.

1. False Pelvis

- shallow upper basin of the pelvis, supports the enlarging uterus, but not
important obstetrically; offers landmark for pelvic measurement.

2. True Pelvis

- consist of the pelvic inlet , pelvic cavity and pelvic outlet; measurement
of the true pelvis influence the conduct and progress of labor and
delivery.

C. Pelvic Shapes/Types:

1. Android- narrow, heart shaped, male type of pelvis.

2. Anthropoid- narrow, oval shaped, resembles ape pelvis.

3. Gynecoid- classic female pelvis, wide and well rounded in all

directions.

4. Platypelloid- wide but flat, may still allow vaginal delivery.

D. Measurements

1. External- suggestive only of pelvic size.

2. Internal- give the actual diameter of the inlet and outlet.

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IV. Breast

-paired mammary gland on the anterior chest wall between the 2 nd and 6th
ribs, comprised of glandular tissues, fat and connective tissues.

-nipple and areola are darker in color than breast.

-responsible for lactation after delivery.

MENSTRUAL CYCLE
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-also termed as a female reproductive cycle

-defined as episodic uterine bleeding in response to cyclic hormonal

changes. It is the process that allows for conception and implantation of a
new life.

-The purpose of a menstrual cycle is to

bring an ovum and maturity to
renew a uterine tissue bed that
will be responsible for its
growth should it be fertilized.

-Four body structures are

involved in the physiology of
the menstrual cycle: the
hypothalamus, the pituitary
gland, the ovaries and the
uterus.

*Menarche - the first menstrual

period or the onset of the menstrual
cycle.

*Menopause- permanent cessation of menstruation.

*Premenstrual Syndrome- refers to symptoms that occur between

ovulation and the onset of menstruation. The symptoms include both
physical symptoms, such as breast tenderness, back pain, abdominal
cramps, headache, and changes in appetite, as well as psychological
symptoms of anxiety, depression, and unrest. Severe forms of this
syndrome are referred to as premenstrual dysphoric disorder (PMDD).
These symptoms may be related to hormones and emotional disorders.

CHARACTERISTICS OF NORMAL MENSTRUAL CYCLES

Characteristic Description
Beginning (Menarche) Average age at onset, 11-13 years;
average range, 9-17 years
Interval between cycles Average, 28 days; cycles of 23-35
days not unusual
Duration of menstrual flow Average flow, 2-7 days; ranges of
1-9 days not abnormal
Amount of menstrual flow Difficult to estimate; average 30-

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 80 ml per menstrual period;
saturating pad or tampon in less
than an hour is heavy bleeding
Color of menstrual flow Dark red; a combination of blood,
mucus and endometrial cells
Color Similar to marigolds

PHASES OF MENSTRUAL CYCLE

Phases Number of Days Hormones

Menstrual Phase 1-5 Days Estrogen (decreased)
-also known as Progesterone
menstrual bleeding, (decreased)
menses, catamenia or a
period.
Proliferative Phase 6-14 Days Estrogen (increased)
-also known as Progesterone
estrogenic phase, (decreased)
follicular phase & post
mens.
Secretory Phase 15-21 Days Estrogen (decreased)
-also known as luteal Progesterone
phase, progesteronic (increased)
phase.
-start of ovulation.
Ischemic Phase 22-28 Days Estrogen (decreased)
Progesterone
(decreased)

Cycle Abnormalities:

Oligoovulation- infrequent or irregular ovulation.

Anovulation- absence of ovulation.

Hypomenorrhea- very little flow (less than 10ml).

Polymenorrhea- regular cycles with intervals of 21 days or fewer.

Metrorrhagia- frequent but irregular menstruation.

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Menorrhagia- sudden heavy flows or amounts greater than 80 ml.

Menometrorrhagia- heavy menstruation that occurs frequently and

irregularly.

Oligomenorrhea- the term for cycles with intervals exceeding 35 days.

Amenorrhea- refers to more than three to six months without menses

(while not being pregnant) during woman’s reproductive years.

FERTILIZATION (The Beginning of Pregnancy)

-

(Also referred as: conception, impregnation, or fecundation.)

“In just 38 weeks, a fertilized egg (ovum) matures from a single

cell carrying all the necessary genetic material to a fully developed fetus
ready to born.”

- is defined as the “union of an ovum and a spermatozoon.”

Terms used to denote fetal Growth

Name Time Period

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 Ovum From the ovulation to fertilization.
Zygote From fertilization through 1st two weeks of
pregnancy.
Embryo From end of 2nd week through the end of 8th
week.
Fetus From the end of 8th week to termination of
pregnancy.
Conceptus Developing embryo or fetus and placental
structures throughout pregnancy.

The reproductive role of the female is much more complex than

that of male. Not only must she produce the female gametes (ova), but
her body must also nurture and protect a developing fetus during nine
months of pregnancy.

The uterine or fallopian tubes form the initial part of the duct
system. Each of the uterine tube is about 10cm (4 inches) long and
extends medially from an ovary to empty into the superior region of the
uterus. They received the ovulated oocyte and provide a site where
fertilization can occur. The oocyte is carried toward the uterus by a
combination of peristalsis and the rhythmic beating of cilia. The usual
site of fertilization is the uterine tube.
Usually only one ovum reaches maturity each month. Once it is
released, fertilization must occur fairly quickly because an ovum is
capable of fertilization for only 24 hours (48 hours at he most). After that
time it atrophies and becomes nonfunctional. Because the functional life
of the spermatozoon is about 48 hours, possibly as long as 72 hours, the
total critical time span during which sexual relations must occur for
fertilization to be successful is about 72 hours (48 hours before
ovulation plus 24 hours afterwards).
Sperm transport is so efficient close to ovulation that
spermatozoa deposited in the vagina during intercourse generally reached
the cervix within 80 seconds and the outer end of a fallopian tube within
5 minutes after deposition. This is one reason why douching is not an
effective contraceptive measure. Spermatozoa move by means of their
flagella (tails) and uterine contraction through the cervix and the body of
the uterus and into the fallopian tubes, toward the waiting ovum.
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 The mechanism whereby spermatozoa are drawn toward an
ovum is probably a species-specific reaction, similar to an anti-body-
antigen reaction. Capacitation is a final process that sperm must undergo
to be ready for fertilization. This process, which happens as the sperm
move toward the ovum, consists of changes in the plasma membrane of
the sperm head, which reveal the sperm-binding receptor sites.
Under ordinary circumstances only one spermatozoon is able to
penetrate the cell membrane of the ovum.
Immediately after penetration of the ovum, the chromosomal
material of the ovum and spermatozoon fuse. The resulting structure is
called a zygote. And the fertilized ovum has 46 chromosomes.

IMPLANTATION
Once
fertilization
is complete,
the zygote
migrates
over the next
3 to 4 days
toward the
body of the
uterus, aided
by the
currents
initiated by
the muscular contractions of the fallopian tubes.
During this time, mitotic cell division, or cleavage, begins. The
first cleavage occurs at about 24 hours; cleavage divisions continue to
occur at a rate of one about every 22 hours. By the time the zygote
reaches the body of the uterus, it consists of 16 to 50 cells. At this stage,
because of its bumpy outward appearance, it is termed as morula. T he
morula continues to multiply as it floats free in the uterine cavity for 3 to
4 days.

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 Large cells tend to collect at the periphery of the ball, leaving a
fluid space surrounding an inner cell mass. At this stage, the structure is
termed a blastocyst. It is this structure that attaches to the uterine
endometrium. The cell in the outer ring is known as trophoblast cells.
They are the part of the structure that will later form the placenta and
membranes. And the inner cell mass (embryoblast cell) is the portion of
the structure that will form the embryo.
Implantation, or contact between the growing structure and and
the uterine endometrium, occurs approximately 8 to 10 days after
fertilization. After the third and fourth day free floating (about 8 days
since ovulation), the last residues of the corona and zona pellucid are
shed by the growing structure. The blastocyst brushes against the rich
uterine endometrium ( in the second [secretory] phase of the menstrual
cycle), a process termed apposition.
The blastocyst is able to invade the endometrium because, as the
trophoblast cells on the outside of the structure touch the endometrium,
they produce proteolytic enzymes that dissolve the tissue they touch.
This action allows the blastocyst to burrow deeply in the endometrium
and received some basic nourishment of glycogen and mucoprotein from
the endometrial glands.
The touching or implantation point is usually high in the uterus,
on the posterior surface.

SPECIAL STRUCTURES OF PREGNANCY

Fetal Membranes
-arise from zygote.
-Inner (amnion) and outer (chorion).
-it holds the developing fetus as well as the amniotic fluid.

Amnion- gives rise to:

a. Umbilical Cord

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- (also called the birth cord or funiculus umbilicalis) is the
connecting cord from the developing embryo or fetus to the
placenta.
- contains 2 arteries (return the deoxygenated, nutrient-depleted
blood) and 1 vein (supplies the fetus with oxygenated, nutrient-
rich blood from the placenta) which are supported by Wharton’s
jelly.
LENGTH-It is about 50 to 55 cm long and 2 cm in diameter.

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ORIGIN- The umbilical cord develops from and contains
remnants of the yolk sac and allantois (and is therefore derived
from the same zygote as the fetus). It forms by the fifth week of
fetal development, replacing the yolk sac as the source of
nutrients for the fetus.

Problems and Abnormalities of the Umbilical Cord

A number of abnormalities can affect the umbilical cord, which
can cause problems that affect both mother and child:

1. Nuchal cord- when the umbilical cord becomes wrapped

around the fetal neck.
2. Single umbilical artery
3. Umbilical cord prolapse
4. Umbilical cord knot
5. Umbilical cord entanglement
6. Vasa previa- fetal vessels crossing or running in close
proximity to the inner cervical os. These vessels course
within the membranes (unsupported by the umbilical cord or

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 placental tissue) and are at risk of rupture when the
supporting membranes rupture.
7. Velamentous cord insertion- the umbilical cord inserts into
the membranes, then travels within the membranes to the
placenta (between the amnion and chorion). The exposed
vessels are not protected by Wharton's jelly and hence are
vulnerable to rupture.

b. Amniotic Fluid
- is a clear, slightly yellowish liquid that surrounds the unborn
baby (fetus) during pregnancy. It is contained in the
amniotic sac.

-begins to form at 11-15 weeks of gestation.

-At term the amniotic fluid within the amniotic and in which the
fetus floats is continuously at a rate of 500 ml/hr with the fetus
swallowing it at an equally rapid rate. Daily exchange of
amniotic fluid at 6 months is 6 gallons. Normal amniotic fluid
has the ff. Characteristics:

VOLUME- 800 to 1200 ml, average is 1000 ml.

-The volume of amniotic fluid increase from the first trimester

until the 38th week then, it diminish slightly until term

APPEARANCE

 It should be clear and colorless

 Green tinged meconium stained amniotic fluid in
nonbreech presentation signifies fetal distress.
 Golden colored amniotic fluid signifies hemolytic
disease such as RH or ABO incompatibility.
 Gray colored amniotic fluid indicates infection.

FUNCTIONS OF AMNOITIC FLUID

 Protects the fetus from trauma blows and pressure
 Maintain constant temperature
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  Prevents pressure on the cord
 Provides protective cushioning
 Protects the baby from and uterus from infection
 Serves as the backup nutrients and fluids of the fetus
 The developing baby to move in the womb, which
allows for proper bone growth
 To develop lungs properly
 Acts as an excretion and secretion

*Polyhydramnios- An excessive amount of amniotic fluid.

This condition can occur with multiple pregnancy (twins or
triplets), congenital anomalies (problems that exist when the
baby is born), or gestational diabetes.

-more than 2,000 ml in total, or pockets of fluid larger than

8cm on ultrasound.

*Oligohydramnios- An abnormally small amount of

amniotic fluid. This condition may occur with late
pregnancies, ruptured membranes, placental, or fetal
abnormalities.

-less than 300 ml in total, or no pocket on ultrasound lager

than 1cm.

Abnormal amounts of amniotic fluid may cause the health

care provider to watch the pregnancy more carefully.
Removal of a sample of the fluid, through amniocentesis,
can provide information about the sex, health, and
development of the fetus.

Too much amniotic fluid (polyhydramnios or

hydramnios) stretches the uterus and puts pressure on the
diaphragm of pregnant women. This complication can lead
to severe breathing problems for women or to labor that
begins before 37 weeks of pregnancy (preterm labor).

Chorion- together with the decidua basalis, gives rise to:

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Placenta- arises out of tr ophoblast. It starts to form on the 8 th
week of gestation.

-Its growth parallels that of the fetus, growing from a few

identifiable cells at the beginning of the pregnancy to an organ
15-20 cm in diameter and 2-3 cm depth at term. It covers about
half of the surface area of the internal uterus.

-Placenta serves the following purpose:

1. Respiratory System- exchange of gases takes place in the

placent not in the fetal lungs.
2. Renal System- waste products are being excreted through the
placenta.

3. Circulatory System- feto-placental circulation is established

by selective osmosis.

4. Endocrine System- it produces the ff. hormones:

a.hCG (Human Chorionic Gonadotropin)- the
purpose of hCG is to act as fail-safe measure to ensure
that the corpus luteum of the ovary continues to produce
progesterone and estrogen.

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 b. HPL (Human Placental Lactogen)- promotes
growth of the mammary gland necessary for lactation.
c. Estrogen and Progesterone- necessary for
continuation of pregnancy.

5. Gastrointestinal System- nutrients pass to the fetus via

placenta by diffusion thru placental tissues.

6. Protective Barrier- inhibits passage of some bacteria and

large molecules.

LENGTH OF PREGNANCY

1. Days : 267-280

2. Weeks: 40, plus or minus 2

3. Months (lunar): 10

4. Months (calendar): 9

5. Trimester: 3

FETAL DISTRESS
 the term “fetal distress” is commonly used to describe fetal
hypoxia (low oxygen levels in the fetus).
 it can be detected due to abnormal slowing of labor, the presence
of meconium.

Signs and Symptoms

 Decreased movement felt by the mother
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  Meconium in the amniotic fluid
 Cardiotocography signs
 Increased or decreased fetal heart rate (tachycardia and
bradycardia), especially during and after a contraction.
 Decreased variability in the fetal heart rate.
 Biochemical signs, assessed by collecting a small sample of
baby’s blood from a scalp prick through the open cervix labor.
 fetal acidosis
 elevated blood lactate levels indicating the baby has a
lactic acidosis.
Causes
 breathing problems
 abnormal position and presentation of the fetus
 multiple births
 shoulder dystocia
 umbilical cord prolapse
 nuchal cord
 placental abruption
 premature closure of the fetal ductus arteriosus

Nursing Management
1. Administer oxygen
2. Reposition the mother to her left side.
3. Monitoring fetal heart rate continuously.

Complication
1. Seizures

Medical Treatment
 Caesarean section may be performed.

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 PRECIPITATE LABOR (PRECIPITOUS LABOR)
-Is defined as a labor that is completed in fewer than 3 hours

Predisposing Factors:
-Women with roomier pelvis

-Grand multiparity

-Cocaine use during pregnancy

-Women who had precipitous labor in the past pregnancy

-Induction of labor through:

1.Oxytocin- a drug used to speed up the birth process.

2.Amniotomy- an artificial rupture of membranes.

Signs and Symptoms:

-True contractions without intermissions.

-Contractions tend to directly follow another without time interval.

-Forceful contractions.

Complications:
-Unintended unassisted births.

-Tearing of cervix, vagina & perineum

-Abruptio Placenta-Premature separation of the placenta.

-Fetal distress.
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-Fetal Hypoxia- because of intense contractions.

-Meconium staining of the amniotic fluid/aspiration of the meconium.

-Pneumothorax- (accumulation of air/gas in the pleural cavity) as a

result of rapid movement through the birth canal.

-Subdural hemorrhage.
Due to sudden
-Bruising on baby’s face & head. intense pressure

*Can be predicted from a labor graph. Rate is:

- > 5cm/hr (1cm every 12 minutes) in a nullipara.

- 10cm/hr (1cm every 6 minutes) in a multipara.

Management:
1.Caution a multiparous women by week 28 of pregnancy that, because a
past labor was so brief, her labor this time may also be brief.

2. Administer tocolytics (drugs used to suppressed labor).

3.C-section delivery- under certain circumstances doctors decide to do

caesarian section delivery to end precipitous labor quickly. But not all
doctors agree on this stepb ecause it may pose increase risk to both
mother and child.

4.Emotional support- mothers often feel in emotional shock after

precipitous labor and birth.

PREMATURE LABOR (PRETERM LABOR)

-A labor that begins prior to 37th week of gestation.

-The World Health Organization (WHO) defined it as the onset of

contractions of the uterus before 37 th completed week of pregnancy that
are:

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 1. Frequent

2. Regular

3. Painful

4. Palpable (that can be felt by a health care professional).

Causes:
-Abruptio placenta ( premature separation of the placenta).

-Pre-eclampsia

-Urinary Tract Infection (UTI).

-Problems with uterus or cervix.

-Polyhydramnios (excessive amount of amniotic fluid).

-Extreme stress (both physical & emotional).

-Using recreational drugs, such as cocaine or amphetamines

-Smoking

-Fever (> 101oF).

-Dehydration- what happen in dehydration is that blood volume

decreases, therefore increasing the concentration of oxytocin (a hormone
that causes uterine contractions).

Signs And Sypmtoms:

-Contractions/ cramps >5 in one hour.

-Sudden gush of clear, watery fluid.

-Pain during urination.

-Low, dull backache.

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-Intense pelvic pressure.

Complications:
-Difficulty of breathing (mother& baby).

-Increase heartbeat, dizziness/nausea.

-Muscle weakness.

-Intracranial Hemorrhage.

-Apnea.

-Neurologic problems.

-Vision and intestinal problems.

-Developmental delays.

-Learning disabilities.

-Hearing problems.

Management:
-Hydration.

-Bed rest (especially left side lying).

-Medications to help prevent or stop labor (tocolytics).

-Medications to help prevent infections.

-Evaluation of the body.

-Medications to help the baby’s lung develop more quickly.

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Facts About Premature Labor:
-About 8% of all deliveries are preterm. Premature labor is responsible
for about 75% of stillbirths and deaths of babies in the first 7 days of life.

-Despite improved technology and skill of eneonatal pediatricians, about

10% of those babies who survive (usually the most immature) will suffer
some degree of lasting physical or mental handicap.

-Most cases of premature labor can be treated to allow the baby to

become more mature in the uterus.

CORD PROLAPSE

- the umbilical cord lies in front of or beside the presenting part in the
presence of ruptured membranes.

- is when the umbilical cord exits the birth canal prior to baby. If cord
prolapse occurs, the blood and oxygen flow to the baby can be
interrupted or severed, which can cause tissue, oxygen or brain damage.

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\
Causes

 Malpresentation (flexed breach/shoulder presentation)

 High fetal head

 Premature pregnancy associated with premature ruptured of

membrane (PROM) or premature prelabor ruptured of membrane
(PPROM).

·         Intrauterine growth restriction.

 Genetically small fetus.

 Polyhydramnios.

 Unduly long cord.

Risk Factors

 high/ill fitting presenting part

 high parity

 prematurity

 multiple pregnancy

 polyhydramnios

 malpresentations

 obstetric manipulation

Type of Cord Prolapse

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  Overt cord prolapse - if the presenting part of the fetus does not
fit the pelvis snugly after membrane rupture, there is a risk that
the umbilical cord can slip past and present at the cervix or
descend into the vagina. This is known as overt cord prolapse. It
represents an acute obstetric emergency as prolapse exposes the
cord to intermittent compression compromising the fetal
circulation. Depending on its duration and degree of
compression, fetal hypoxia, brain damage and even death can
occur.

 Occult cord prolapse - where the umbilical cord lies alongside

the presenting part.

 Funic presentation - where the cord can be felt to prolapse

below the presenting part before membranes have ruptured. The
cord may slip to one side of the head and disappear as the
membranes rupture.

Signs and Symptoims

 Abdominal examination: an ill-fitting or non-engaged presenting
part should alert one to the possibility of cord prolapse.

 Vaginal examination (VE) - examine for the cord at every VE

during labour and specifically after rupture of membranes if risk
factors:

Ø  With an overt prolapse, the cord can be seen

protruding from the introitus or loops of cord can be
palpated within the vaginal canal. If the cord is
pulsating, the fetus is alive.

Ø  Occult prolapses are rarely felt on pelvic examination

and only indication may be fetal heart rate changes.

Ø  With a funic presentation, loops of cord are palpated

through the membrane.

Diagnosis

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  History collection

 Physical examination

 Visual sight

 Ultra sound

 Color Doppler

Management

 Summon urgent medical assistance.

 Initiate immediate assessment of clinical circumstances;
gestation, presentation, cervical dilatation, fetal wellbeing.
Immediate delivery is necessary when the fetus is viable.
 Place the woman in eit her knee to chest position.
 O r a l t e r n

supported
with 2 pillows).
 Prevent cord compression: the presenting part is pushed out of
the pelvis upward by fingers in the vagina. This is to continue
until delivery is undertaken. Note if the cord is pulsating.
 In certain circumstances (i.e. when there is likely to be a long
delay before delivery), the urinary bladder may be filled with

26
 warmed normal saline to elevate the presenting part off the
compressed cord.
 Avoid over-handling of umbilical cord as it can cause vasospasm
 dminister oxygen to the woman via a mask (oxygenation pre-
caesarean section/birth).
 Discontinue oxytocics if present.
 Continue efforts to hold the presenting part off the cord
 Delivery must be expedited to reduce morbidity and mort
mortality to the fetus:

- undertake immediate LUSCS if vaginal birth not imminent.

- undertake assisted vaginal birth (if conditions are suitable [e.g.

fully dilated, MG, presenting part at spines or below]).

 Deep Trendelenburg position may also be useful to add gravity

to other efforts to elevate the fetus off the cord
 Monitor and document fetal heart rate
 Consider tocolysis with terbutaline if there is a delay in
caesarean section/birth
 Paired umbilical cord blood samples to be collected following
delivery/birth.

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 PLACENTA PREVIA

-an abnormal implantation of the placenta where instead of being

normally implanted in the upper uterine segment, all or part of it is
located in the uterine segment and either overlies or reaches the vicinity
of the internal os.

Types:

1.Low-lying- a portion of the placenta lies in the lower uterine segment

but the edge of the placenta does not reach the margin of the internal os.

2.Marginal- the placental edge just reaches but does not cover the
internal os.

3.Incomplete or partial- the placenta partly covers the internal os.

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4.Complete or Total- the placenta completely covers the internal os.

Causes

1. Defective blood supply in the upper uterine segment such as the

placenta spreads out during implantation to cover the wider area. This
may due to:

 Previous infection of the endometrium (endometritis).

 Atrophic changes in the endometrium- seen in women in
advanced age.
 Repeated abortions with vigorous curettage.
 Multiparity especially when the pregnancies come in succession.

2.A large placenta covering a wider area of the uterus as in:

 Multiple pregnancies
 Erythroblastosis fetalis

3.Atrophy of the chorion with the chorionic villi implanting in the lower
segment.

Mechanisms of Placental Separation: Source of Bleeding:

 During the last trimester of pregnancy, Braxton-Hicks

contractions bring about the development of the lower uterine
segment with thinning and stretching of the placental site.
Because the placenta cannot stretch and adapt to the changes
taking place in the lower segment, unavoidable premature
separation or cleavage of part of the placenta occurs. Bleeding
comes from torn maternal sinuses at the placental site where
separation has occurred. Because it occurs in the lower pole of
the uterus, blood easily escapes to the outside.
 Initially, with minor degrees of separation, bleeding is scanty
and is easily controlled by the normal process of coagulation.
With more separation, bleeding becomes too profuse to be
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 stopped by this mechanism. Also, the muscles of the lower
uterine segment are not capable of sufficient contractions and
retraction to control the bleeding.

Signs and Symptoms

1. History of painless fresh vaginal bleeding in a gravid during the

second half or last trimester of pregnancy.

2.Abdominal Examination- suspect placenta previa if:

 There is fetal malpresentation- breech presentation or transverse

lie.
 The presenting part is high and away from the midline.
 The uterus is of normal consistency being neither hard nor tender
on palpation.

3.Vaginal Examination- a reliable method of establishing a diagnosis by

feeling the placenta at the internal os.

 Avoid frequent internal examination since it may provoke

sudden uncontrolled bleeding.
 Only a physician may perform IE at the proper time and in the
hospital.

4. Laboratory Procedure

 Ultrasound is used to determine the location of the placenta.

Dangers

1.To the mother:

 Antepartum hemorrhage

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  Postpartum hemorrhage-because the placental site is in lower
segment which cannot contract and retract efficiently to control
bleeding from the open sinuses.
 Puerperal sepsis- this is more likely to occur because of blood
loss and placental proximity to the vagina.

2.To the fetus:

 Anoxia which may lead to fetal death.

 Prematurity- delivery maybe done early if bleeding is profuse.

Management

1. If the initial bleeding does not stop or is massive, an immediate

caesarian delivery is done to save the life of the woman and her fetus.

2. If the initial bleeding stops and the fetus is still immature,

hospitalization with bed rest is indicated.

3. Blood transfusion if indicated.

4. Institute perineal pad count so that bleeding can be qualified.

5. Serial non-stress test (NSTs) are done to monitor fetal well being.

6. Listen to fetal heart rate at least every 4 hours.

7. Instruct the woman to record fetal kick counts at least daily.

8. Encourage the mother on bed rest (usually with bathroom privileges)

while at home.

9. Instruct the mother to do no house work or lifting moderate-vigorous

activity could bring about a bleeding episode.

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10. Vaginal rest is essential. Do not insert anything into the vagina ( no
sexual intercourse, no douching, no tampons). These activities could
stimulate bleeding episodes tend to be more severe than the first.

ABRUPTIO PLACENTA

-the premature separation of normally implanted placenta after the 20 th

week of pregnancy and before the birth of the fetus, resulting to
accidental or unexpected hemorrhage.

Causes

The primary cause is unknown but the following conditions have been
associated with occurrence of abruption placenta:

1.Hypertension

 Pregnancy induce as in pre-eclampsia

 Chronic hypertensive vascular diseases or essential hypertension.
 Hypertension secondary to kidney disease.
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2.Physical trauma or injury- a blow in the abdomen, or a fall with the
mother landing on her abdomen.

3.Shortness of the umbilical cord- during labor, descent of the fetus

may cause the short umbilical cord to pull on the placenta and cause its
premature separation.

4.Sudden decompression of the uterus- rapid drainage of amniotic

fluid when the amniotic sac is ruptured may pull the placenta to separate
maturely.

5.Uterine anomaly or tumor

Types

1.Abruptio Placenta with External or Revealed Hemorrhage

-The blood finds its way between the uterus and the membranes and
escapes through the cervix into the outside.

2.Abruptio Placenta with Concealed Hemorrhage

-There is blood behind the placenta but the placental margin is attached.

-The placenta is completely separated but the membranes are firmly

attached to the uterine wall.

-The blood find its way to the amniotic cavity by breaking through the
membrane.

-The fetal head is closely positioned to the lower segment that the blood
cannot pass through.

3.Mixed Type with both Revealed and Concealed Hemorrhage;

predominantly concealed

-The membranes gradually separate from the uterine wall and blood
escapes through the cervix.

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Clinical presentations

History of:

 Previous or present pre-eclampsia; chronic hypertension.

 Physical trauma or injury involving the abdomen.
 Sudden occurrence of severe continuous pain in the abdomen.
 Vaginal bleeding which may vary from slight to profuse, usually
dark in color and maybe with small dark clots.
 Appearance of signs of shock which is out of proportion to the
amount of external blood loss which include:
-Fainting, collapse or syncope
-Pallor
-Cold clammy perspiration
-Rapid pulse
-Hypotension

Upon Physical Examination:

 Signs of shock- this is usually out of proportion to the amount of

external blood loss.
 Abdominal tenderness- the patient complains of pain when the
abdomen is palpated
 Condition of the uterus:
-Hypertonicity- the duration of contractions is prolonged with
short interval periods during which the uterus does not
completely relax but retains a certain degree of muscle tone.
-Tetanic or sustained uterine contractions without relaxation.
-Hard, bread-like uterus which may enlarge due to accumulated
retro placental blood.
 Inability to map out the fetal outline because of abdominal and
uterine rigidity.
 Absent FHT.

Laboratory Findings:

 Abnormal clot retraction test.

 Fibrinogen level in the blood.

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  Fibrin degradation (breakdown) in the blood.

Danger

1.Shock-this is initially caused by severe blood loss or hemorrhage from

placental separation and made worst by the occurrence of a blood
clotting or coagulation defect. Shock can occur in the antepartum period
or in the post partum period.

2.Blood coagulation defects- Disseminated Intravascular Coagulation

(DIC), Consumptive Coagulopathy (CC).

3.Renal or Kidney failure- this may result from diminished blood supply
to the kidney resulting to kidney damage and impairment of function.

Management

1.Assess and watch out for signs and symptoms of hemorrhage.

2.If the client manifest shock, put the client on trendelenberg position.

3.Provide oxygen therapy, IV fluids and blood transfusion if indicated.

4.Amniotomy is done to reduce intra-uterine tension which lessen the

pressure on the placenta by the intact BOW and to hasten the labor and
delivery process.

5.Assess bleeding tendencies by monitoring the clotting and bleeding

time.

6.Caesarian section if indicated.

7.Monitor the amount of blood loss before and after surgery and urine
output.

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 Difference Between Placenta Previa and Abruptio Placenta

Placenta Previa Abruptio Placenta

-Antepartum bleeding is due to -Antepartum bleeding is due to

premature separation of premature separation of normally
abnormally implanted placenta implanted placenta in the upper
in the lower segment. segment.

-Unavoidable hemorrhage -Accidental hemorrhage.

-Painless bleeding unless patient is -Bleeding is accompanied by pain.

in labor.
-The blood is usually dark and
-The blood is fresh and bright red. clots may be present.

-Several intermittent or recurrent -Continuous episode of bleeding.

episodes of bleeding.
-Shock is out of proportion to
-Amount of external bleeding and amount of external blood loss or
degree of shock are comparable. bleeding.

-Uterus is soft but may be -Uterus is hypertonic/tetanically

contracting intermittently if contracted/woody or boar-like in
patients is in labor. consistency.

-Non-tender uterus. -Tender uteus.

-Uterus does not change in size. -Uterus seems larger as blood clots
accumulates.
-The placenta is felt on vaginal
examination. -The placenta is not felt on vaginal
examination.
-Usually not associated with pre-
eclampsia. -Usually associated with pre-
eclampsia.
-The blood clots normally.
-The blood may fail to clot.

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 SHOULDER DYSTOCIA

Shoulder dystocia is a specific case of dystocia whereby after

the delivery of the head, the anterior shoulder of the infant cannot pass
below the pubic symphysis, or requires significant manipulation to pass
below the pubic symphysis.

*Shoulder: the laterally projecting part of the body formed by

the bones and joints with their covering tissues.

*Dystocia: slow or difficult labor or delivery.

It is diagnosed when the shoulders fail to deliver shortly after

the fetal head. In shoulder dystocia, it is the chin that presses against the
walls of the perineum. Shoulder dystocia is an obstetrical emergency,
with fetal demise occurring within about 5 minutes if the infant is not
delivered, due to compression of the umbilical cord within the birth
canal.

Signs

One often described feature is the turtle sign, which involves the
appearance and retraction of the fetal head (analogous to a turtle
withdrawing into its shell), and the erythematous, red puffy face
indicative of facial flushing. This occurs when the baby's shoulder is
obstructed by the maternal pelvis.

Risk factors

There are well-recognized risk factors, such as:

* Diabetes
* Fetal macrosomia
*Maternal obesity

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In large babies, much of the excess growth that occurs is in the
chest and abdominal areas. In these babies the dimensions of
the shoulders and chest tend to be disproportionately larger
than those of the head. This trend is exaggerated in babies of
diabetic mothers. Multiple studies have shown that babies of
diabetic mothers more frequently have larger ratios of shoulder
circumference to head circumference than do their peers born
of nondiabetic mothers. Babies of diabetic mothers also have
greater arm circumference, larger triceps folds, and a higher
percentage of body fat. Since larger babies are more likely to
"get stuck", much of the work in the field of shoulder dystocia
has been targeted at attempting to predict which babies will be
larger than normal, especially when their mothers are diabetic.

but it is often difficult to predict. Despite appropriate obstetric

management, fetal injury (such as brachial plexus injury) or even fetal
death can be a complication of this obstetric emergency.

Complications

The major concern of shoulder dystocia is damage to the upper

brachial plexus nerves. These supply the sensory and motor components
of the shoulder, arm and hands. The etiology of injury to the fetus is
debated, but a probable mechanism is manual stretching of the nerves,
which in itself can cause injury. Furthermore, excess tension may
physically tear the nerve roots out from the neonatal spinal column,
resulting in total dysfunction. The ventral roots (motor pathway) are
most prone to injury, as they are in the plane of greatest tension (anterior,
sensory nerves are somewhat protected due to the usual inward
movement of the shoulder).

*klumpkeparalysis: it is the atrophic paralysis of the forearm and

hand, due to injury to C8-T1 nerves.

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 *Erb's Palsy: affecting the muscles of the upper arm and
shoulder upper part of the brachial plexus, an injury to C5-C7
nerves

*Fetal hypoxia
Fetal death
Cerebral palsy

*Maternal post partum hemorrhage- The mother, too, is at

some risk when shoulder dystocia occurs. The most
common complications she may suffer are excessive
blood loss and vaginal and vulvar lacerations.

Additional Fetal injuries following shoulder dystocia includes:

-fractured clavicles
-fractured humeri
- contusions and lacerations
- birth asphyxia

Brachial plexus injury

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The brachial plexus consists of the nerve roots of spinal cord
segments C5, C6, C7, C8, and T1. (See accompanying
diagram). These nerve roots form three trunks which divide
into anterior and posterior divisions. The upper trunk is made
up of nerves from C5 and C6, the middle trunk from undivided
fibers of C7, and the lowermost trunk is made up of nerves
from C8 and T1.

There are two major types of brachial plexus injury: Erb palsy
and Klumpke palsy.

Erb palsy, the more commonly occurring of the two forms of

brachial plexus injury, involves the upper trunk of the brachial
plexus (nerve roots C5 through C7). This palsy affects the
muscles of the upper arm and causes abnormal positioning of
the scapula called "winging". The supinator and extensor

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muscles of the wrist that are controlled by C6 may also be
affected. Sensory deficits are usually limited to the distribution
of the musculo-cutaneous nerve. Together, these injuries result
in a child having a humerus that is pulled in towards the body
(adducted) and internally rotated. The forearm extended. Some
have described this as the "waiters tip" position.

Klumpke palsy involves lower trunk lesions from nerve roots

C7, C8, and T1. In this injury the elbow becomes flexed and the
forearm supinated (opened up, palm-upwards) with a
characteristic clawlike deformity of the hand. Sensation in the
palm of the hand is diminished.

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