SIGNS AND SYMPTOMS DETECTION OF ABNORMALITIES DIAGNOSIS ,PHYSIO CHANGES ,CARE

Chief

complaints History of present illness Gravidity_ number of pregnancies including the current one Parity- number of births beyond 24 wks gestation or < 24 if live EDD Expected Delivery Date LMP- Last Menstrual Period

 -Add

7 days to the 1st day lmp -Subtract 3 months -Add 1 year Example: Sept 14,2007 Add 7 days . . .Sept. 21, 2007 Subtract 3 mos. . June 21,2007 Add 1 year . .. .. June 21, 2008 EDC . . . . . . June 21, 2008

Term

Definition

PARA - Number of pregnancies that reached viability GRAVIDA A woman who is or has been pregnant PRIMIGRAVIDA One who is pregnant for the first time MULTIGRAVIDA One who has been pregnant previously MULTIPARA one who has carried 2 or more pregnancies to viability NULLIGRAVIDA A woman who has never been preg nant.

 MENARCHE

age when period began CYCLE- interval between the first days of two consecutive periods. Any change in cycle, duration of period. Subjective Assessment of flow : pads/ tampons Dysmenorrhea and timing of pain PMS premenstrual syndrome

Parity- where, when and outcome Gestation- birth weight,sex, mode of delivery Complications ante/ intra/ postpartum Feeding Example : G1- 1990, LFT baby boy via NSD at CSM Hospital; BW=7 lbs ;no complications G1- 1994,LFT baby boy via CS at GJ Mem Hosp; BW= 7 lbs no complications

Note previous surgical procedures Cervical smears (normal treatment) Previous gynecological problems and any Surgery (e.g. PID or endometriosis) Intermenstrual/ postcoital/postmenopausal Bleeding Vaginal discharge; color, smell , amount ,itch Abdominal or pelvic pain site, duration ,radiation ,associated factors


Details

of contraceptive use . The method used , duration of use , acceptance ,current method ,side effects and plan for the future.

 Coitarche

(first sexual intercourse) Number of sexual partners Inquire if sexually active Dyspareunia, libido,arousal and satisfaction Timing of coitus and desire for pregnancy Previous sexually transmitted infections

 INSPECTION Note

the distention of the abdomen that may indirectly indicate the shape and size of the uterus. Note any asymmetry of the abdomen. Note any fetal movement observed Note any surgical scars e.g. Pfannenstiel incision

Cutaneous signs of pregnancy: Linea nigra dark pigmented line stretching from just below xiphistemum through the Umbilicus to the suprapubic area. Striae gravidarum red lines and or bands that sometimes appear on the abdomen during pregnancy. Striae albicans silvery-white and are evidences of previous parity.

 PALPATION
MEASURE

Fundic height and do Leopolds Maneuvers How to measure Fundic Height 1. Position patient semi-recumbent with bladder empty. 2. Palpate to determine fundus with two hands.Ensure the abdomen is soft (not contracted) 3. Place the zero mark of the tape measure at the uppermost border of the symphysis pubis (A) to the top of the fundus (B).

4. Record measurement in centimeters. AOG FUNDIC LEVEL 12 weeks Just above the symphysis 16 weeks Halfway between symphysis and umbilicus 20 weeks Level of umbilicus 26 weeks 2 to 3 fingers above the umbilicus 32 weeks Midway b/w umbilicus and xiphoid process 36 weeks at level of costal margin 40 weeks 1-2 fingers below the costal margin

 Conditions

when the fundic height is not compatible with the expected gestational age Shorter than normal measurement -Fetus descent into the pelvis (normal 2-4 Wks b4 delivery) -Estimated date of conception is incorrect -Small but healthy fetus -Oligohydramnios - Fetus positioned sideways

 -Breech
-Fetus

is small for gestational age Larger than normal measurement - Multiple gestation estimated date of conception is incorrect - Large but healthy fetus - Polyhydramnios - Large for gestational age - Hydatidiform mole

 1ST

Maneuver PRESENTATION The uterine fundus is palpated to determine which fetal part occupies the uterine fundus
Important: Fetal

head is hard, firm ,round and moves Independently on the trunk; Buttocks is soft, symmetric has small bony processes, moves with the trunk.

 2nd

Maneuver FETAL LIE Palpate each side of the maternal abdomen to determine which side is fetal back and which is the extremities.
Impt: Fetal

back will feel firm and smooth Fetal extremities will feel like small irregularities and protrusions.

 3rd

Maneuver ENGAGEMENT Palpate the area above the symphysis pubis to determine the presenting part and if fetus is engaged .This will validate the findings of the first maneuver.
Impt: Floating-

presenting part can be gently pushed back and forth. Engaged presenting part immovable.

 4th

Maneuver Palpate in the direction of the pelvic inlet using 3 fingers of each hand and Determine the presenting part. This maneuver is less informative if the presenting part is breech.
Impt:

Vertex

cephalic prominence is on the same side as the small parts. Face- cephalic prominence is on the same side as the back.


Longitudinal

fetal spine is parallel to the long axis of the mother.

Transverse

fetal spine is perpendicular ( 90 degrees) to the long axis of the mother.

 Characteristic

posture which the fetus assumes inside the uterus during the third trimester. Types of Fetal Attitudes 1. complete flexion 2. moderate flexion 3. poor flexion 4. hyperextension Normal- moderate flexion of the head ,flexion of arms unto chest and flexion of legs to abdomen.

 The

part of the fetus that overlies the pelvic brim. Types of Fetal Presentations 1. Vertex 2. Breech 3. Shoulder

 1.

The first letter of the code tells which side of the pelvis the fetus reference point is On (R for right, L for left) 2. The second letter tells what reference point on the fetus is being used. O-occiput F-Fronto M-Mentum S- Breech Sc /A- Shoulder

 3.

The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior- P, transverse or in the middle-T

4.

Each presenting part are normally recognized for each position using occiput as the reference point.

ROP,

ROT, ROA, LOP, LOT, LOA,

 Complete

Breech Frank Breech Footling Breech

At about 20 weeks ,the heartbeat can be heard without Doppler amplification. 1. Use fetoscope or the bell of a regular stethoscope and press firmly into patients abdomen. 2.The heartbeat is best heard over the babys back (use L maneuver) 3. After the fetal heartbeat is located ,count for 30 secs then multiply it by two to obtain the number of beats per minute. 4. Remember to check the womans pulse against the fetal sounds. If rate is the same re adjust the Doppler.

 A-Estimating

Pelvic Inlet 1.Insert the gloved two fingers into the vagina until the tip reaches sacral promontory. 2. Mark with the finger of the other hand where the inferior border of the symphysis pubis meets the examining hand. 3. Compare the hand measurement to a ruler To determine the diagonal conjugate diameter.

1. Gynecoid pelvis- blunted ischial spine, straight side walls, pelvic brim is a transverse ellipse, wide subpubic arch, most favorable for delivery. 2. Platypelloid pelvis blunted ischial spine, straight side walls, pelvic brim is flattened Anteroposteriorly, wide subpubic arch 3. Android Pelvis- prominent ischial spine, convergent side walls, pelvic brim is heart shaped 4. Anthropoid Pelvis prominent ischial spine, straight side walls, pelvic brim is an

 Anteroposterior

ellipse,narrow subpubic arch. B- Measuring Cervical Dilatation and Effacement Cervical Dilatation- is assessment of how open the cervix is at the level of the internal Os. To gauge cervical dilatation, place the index and middle fingers against the cervix and determines the size of the opening. Measurement range from 0 cm to 10 cm or fully dilated.

 Cervical

effacement is assessment of how effaced(thinned out) the cervix becomes As the presenting part pushes on it. Measurement is reported in percent. FETAL STATION -the position of the presenting part in relation to the maternal ischial spine.Station is negative if it is above the ischial spine and positive if below the IS.

 ORGAN

SYSTEM CHANGES EFFECTS Cardiovascular heart rate, cardiac out stroke volume put Respi tract tidal volume hyperven minute venti tilation minute O2 uptake Respi alkalosis GIT low motility reflux eso phagitis constipation

 Urinary

tract Changes: Renal size,Renal bld flow Effect: Urinary stasis,risk of UTI
Skin Change:

Pigmentation Effect: Linea Nigra, Chloasma Hematologic C:Plasma volume, Erythropoiesis,low hgb,low hct, E: Dilutional Anemia

 Musculoskeletal
C:

Lordosis E: Lower back ,discomfort

 1.

Chills and fever pyelonephritis,chorioamnionitis 2. Persistent vomiting hyperemesis gravidarum 3. Dysuria- UTI 4. swelling of face & fingers severe PE 5. severe headache- severe pre-eclampsia 6. Blurring of vision- same as above 7. Vaginal bleeding- P-Previa,PAbruptia,Spontaneous Abortion

 8.
9.

Fluid leakage from vagina- ROM

Abdominal Pain- Pre-term labor,severe pre-Eclampsia (epigastric pain)

10.

Sudden change in frequency &intensity of fetal movement fetal compromise.

 True

Labor (pains) Contractions: Interval-regular Frequency- progressively increasing Duration progressively increasing Intensity- progressively increasing
Cervix

progressive effacement and dilatation Discomfort- back and abdomen, not releived

 by

sedation. False Labor Contractions: Interval irregular Frequency inconsistent Duration inconsistent Intensity unchanged
Cervix

no significant change Discomfort- mostly lower abdomen

 First

stage Onset of regular contractions to complete dilatation. There are 3 phases: (1)Latent -0-3 cms. primi- 20 hrs,multi- 14 hrs, may have irregular contractions-short, mild to moderate. (2) Active phase-4-7 cms. primi 5 hrs, dilatation at least 1.2 cm/hr

 Multipara-

4 hrs, dilatation at least 1.5 cm per hr, uterine contractions every 2-5 minutes.40- 80 secs interval,moderate to strong. (3) Transition phase 8-10 cms primi- 3.8 hrs multi variable uterine contractions every 1 -2 mins, 60-90 secs ,moderate to strong

 Second

stage complete dilatation (10 cms.) to delivery of the fetus. primi- 60 mins, multi 30 minutes Affected by epidural anesthesia, maternal pushing , position of presenting part and size of pelvis. Third stage delivery of fetus to delivery of placenta. placenta is 5 -30 mins after delivery of fetus

 Signs

of Placental Separation 1. Uterus becomes globular and firmer 2. Sudden gush of blood 3. Uterus rise in abdomen 4. umbilical cord lengthens

1.ENGAGEMENT this occurs when the biparietal diameter is at or below the inlet of the true pelvis

2.DESCENT

-the downward passage of the presenting part through the pelvis. Occurs as a result of active forces of labor.

 3.

FLEXION as the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor ,resulting in passive flexion of the fetal occiput.
4.

INTERNAL ROTATION Occurs as a result of the impingement of the presenting part on the bony and soft tissues of the pelvis making the AP

 diameter

of the pelvic outlet.

5.EXTENSION 6.

this is the mechanism by which the head normally negotiates the pelvic curve. RESTITUTION AND EXTERNAL ROTATION this is the spontaneous realignment of the head with the shoulders.

 7.

EXPULSION After the fetus head is delivered , further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis followed by the posterior shoulder , trunk and extremities.

 First

Degree extends through vaginal and perineal skin Degree extends into soft tissue of perineum (bulbocavernosus and perineal muscles

Second

Third

Degree through the sphincter Fourth Degree- through the rectal mucosa

TYPES: External and internal examination Position: Dorsal Lithotomy or Sims position

EXTERNAL

EXAMINATION 1. Inspect external genitalia.Describe the mons pubis, pubic hair distribution, labia majora, minora, clitoris, urethral meatus and vaginal introitus. Note for any mass, scars, color change. Palpate the Skenes and Bartholins glands .Note any tenderness And discharge.

 2.

Inspect anus. note for any varicosities,size and location. INTERNAL EXAMINATION Steps in Speculum Examination of the cervix 1. Instruct the patient to empty her bladder 2. Explain the procedure to the patient. Always do IE chaperoned. 3. Position pt into lithotomy pos. 4.Select proper speculum size and warm it with water.

 5.

Wear gloves..do not lubricate ur fingers as it may interfere with Pap smear. 6. Gently press down on the perineal body using two fingers placed just inside or at the introitus. 7. Introduce the speculum using your other hand at a 45 degree angle. Hold up the blades obliquely and pressure should be exerted towards the posterior vaginal wall not the sensitive anterior wall & urethra.

 8.
9.

Remove your fingers from the introitus after a speculum has entered the vagina then rotate the blades of the speculum into a horizontal position.
After insertion, open the blades and maneuver speculum gently so that the cervix come into full view. With the blades open, secure the speculum by tightening the thumb screw.

 10.

Inspect the vaginal walls for changes in color, discharge, rugae, and bulging. Inspect the cervix. Take specimen for Papanicolau or Pap Smear.

 Facts:

Loss of a fetus of less 20 wks GA or weighing less than 500 g.= an abortus. Approximately 30 % of pregnancies result in spontaneous abortion.60 % of s.a. In the 1st trimester are a result of chromosomal abnormalities. Top etiologies of s.a. 1. chromosomal ab normalities 2. unknown

 3.

Infection 4. Anatomic defects 5. Endocrine factors Definition: The termination of pregnancy resulting in expulsion of an immature , non viable fetus .

 Types

of Spontaneous Abortion : 1.Threatened- minimal bleeding , possible pain ,closed cervix, no product of conception expelled. 2. Inevitable profuse bleeding , severe pain, cervix open, no POC expelled 3. Incomplete profuse bleeding, minimal/ severe pain , open cervix, some POC expelled .

 4.Complete
5. 6.

minimal bleeding , min pain, open cervix , all POC expelled

Missed abortion- no bleeding, no pain, closed cervix, no POC expelled. Septic abortion abortion resulting in utrine infection , presents with fever, chills and peritoneal signs.

 Painless

bleeding- Placenta Previa and Vasa

Previa PLACENTA PREVIA Mechanism: abnormal placental implantation in close proximity ,extending or covering the cervix. Risk Factors: multiparity, multiple gestation, advance maternal age , previous placenta previa, previous caesarian section.

 Source

of bleeding: maternal blood Management: NO vaginal exam, stabilize patient with premature fetus, emergency CS
VASA

PREVIA Mechanism: rupture of fetal vessel that cross placental membrane overlying the cervix. RiskFactors: multiple gestation, velamentous cord insertion, accesory lobe of placenta.

 Management:
Painful

Emergency CS

bleeding-ABRUPTIO PLACENTA Mechanism: premature separation of placenta Risk Factors : hypertension, abdominal or pelvic trauma, premature rupture of membranes, previous placenta abruptia, tobacco or cocaine use. Mgt: stabilize esp if premature fetus,e-CS

UTERINE RUPTURE laceration of uterine wall Risk Factors: previous uterine scar, excessive oxytocin , overdistended uterus. Mgt: emergency CS

 LOCATIONS:
1.Cornual

-2-3% 2. Isthmus -12 % 3. Ampullary 78 % 4. Infundibular 5 % 5. Ovarian 1 % 6. Abnormal 1-2 % 7. Cervical - < 0.5 %

 Signs

and Symptoms of Ectopic Pregnancy 1. Abdominal or pelvic pain

2.

Amenorrhea with abnormal uterine bleeding

3.

Signs of early pregnancy 4. Vaginal bleeding

5.

Low BP when bleeding is severe

 Risk

Factors 1. previous tubal surgery 2. previous ectopic pregnancy 3. In utero diethylstilbestrol exposure 4. previous genital infection 5. infertility 6. current smoking 7. previous IUD use

 Differential

Diagnosis 1.acute appendicitis 2. miscarriage 3. ovarian torsion 4. pelvic inflammatory disease 5. ruptured corpus luteum 6. tuboovarian abcess 7. urinary stones