OBSTETRICS

Bolisay, Cathryn Iris

Bulanan, Gillian Kristine


Menarche
Interval
Duration
Amount
Symptoms
MENSTRUAL HISTORY
Menstrual or Gestational Age
Ex. LMP: Jan 1-5, 2014





EDC
Naegeles Rule

JAN 31
1 = 30
FEB 28
MAR 31
APR 30
MAY 8
127 days / 7 18-19 wks AOG
Month Day Year
-3 +7 +1
13 1 2014
-3 +7 +1

10 18 2014
OBSTETRICAL HISTORY

G = # of pregnancies (+ present)
P = Delivery of a baby of at least 28 wks
T P A L
Term Preterm Abortion
Live
>= 37 <37 <20 currently alive
Rules:
Twins = considered as
2, except when
scoring G and P
Preterm
>20 wks and >
500g
Stillbirths (minus
1 from L
Abortions
>20 wks but <
500g
HEIGHT OF THE FUNDUS
BLOOD PRESSURE AND PULSE RATE
2
nd
trimester (15-20 wks)
Arterial BP decreases due
to decrease in vascular
resistance
Heart rate increases by 10
bpm due to the increase in
plasma volume

BLOOD PRESSURE PULSE RATE
WEIGHT GAIN IN PREGNANCY
Category BMI
Recommended
weight gain (lbs)
Rate
(4 weeks)
Underweight < 19.8 28 - 40 5
Normal
weight
19. 26.9 25 - 35 4
Overweight 26.9 29 15 - 25 2.5
Obese >29 >= 15 2
Twin 35 - 40 6
NAUSEA AND VOMITING, HEADACHE AND
DIZZINESS
4
th
12
th
week
Due to increased hCG
levels
Hyperemesis gravidarum
Confine only if with
manifestation of
electrolyte balance
Advise small frequent
feeding
Frequent in early
pregnancy
Disappear by
midpregnancy
Pregnancy-induced
hypertension

Paracetamol is safe

NAUSEA and VOMITING HEADACHE and DIZZINESS
VISUAL DISTURBANCES
Decreased corneal sensitivity
Transient and reversible loss of accommodation reflex
Increase in corneal thickness and curvature

Visual disturbance + hypertension + epigastric pain +
edema = impending ecclampsia : EMERGENCY
URINE OUTPUT AND BOWELS
Anatomical:
Edema and hyperemia of the
bladder resulting in diminished
tone
Pyeloureteral dilatation
Compression of the ureter
Hormonal changes
Hypertrophy of the longitudinal
muscle bundles at the lower end

UTI
Stasis = urinary bladder
compresses on uterus
Progesterone diminishes
contractility
Tx = Amoxicillin is a safe drug
Motility is affected most (progesterone)
Pyosis (heartburn) decreased tone of
LES (Progesterone)
Epulis of pregnancy (Estrogen)
Intestinal changes:
Dec motility = better absorption of ferrous,
Ca, and H20
Flatulence and constipation ->
hemorrhoids

Advise increase in fluids and fibers
Docusate sodium + ferrous combinations
by drug companies
Side effect of iron preparation = black
stools

URINE OUTPUT BOWELS
VAGINAL BLEEDING (1
ST
HALF)
Abortion Ectopic pregnancy GTD (H Mole)
Termination of pregnancy
before 20 weeks AOG
Implantation of the fertilized
ovum outside the uterine cavity
Proliferative abnormalities of
the trophoblast w/c retains its
ability to secrete hCG
+/- passage of meaty tissues Colicky abdominal pain,
amenorrhea, vaginal spotting
Passage of grape-like tissues;
hyperemesis gravidarum
Cervix closed or dilated; uterus
compatible or incompatible with
AOG
(+) wiggling tenderness; uterus
smaller than AOG; (+) adnexal
tenderness/mass; +/- fullness
of the cul de sac
Cervix dilated; uterus enlarged
than AOG; boggy; ballooning of
the lower uterine segment
UTZ: +/- fetal cardiac activity;
retained products of conception
UTZ: (+) adnexal mass, (-)
gestationalsac when hCG >
2500mIU/mL; lower hCG &
progesterone
UTZ: snow storm appearance,
uterus larger than AOG, theca
lutein cyst; high hCG levels
Bed rest/ observation/
curettage/ prostaglandin/
cerclage(depending on the type
of abortion)
Methotrexate; salpingostomy/
salpingotomy/ salpingectomy
Suction curettage/
hysterectomy; prophylactic
chemotherapy; serial
monitoring of B-hCG
VAGINAL BLEEDING (2
ND
HALF)
Placenta previa Abruptio placenta Term (In Labor) Uterine
rupture
Painless vaginal
bleeding
Vaginal bleeding
abdominal pain
Passage of mucus
plug, rupture of the
bag of water,
contractions, cervical
dilatation and
effacement
Vaginal bleeding,
abdominal pain,
cessation of
contractions, loss of
station
Associated w/ prior
CS, multiparity,
advanced maternal
age
Associated w/
hypertensive disorders,
abnormal fetal
presentations,
smoking, PROM
Associated with prior
CS, congenital uterine
anomaly, uterine
overdistension,
Localization by UTZ History and
signs/symptoms
History, signs and
symptoms
Transvaginal UTZ, MRI
Maternal hypovolemia;
fetal demise
Shock, DIC,
Couvelaire uterus
PROM, Hypo/hyper-
tonic uterine
contractions,
malposition/malpresent
ation (Passenger)
Maternal hypovolemia;
neonatal death;
maternal death
Bacterial
Vaginosis

Mx:
Metronidazol
e 500mg BID
for 7 days
Thin and
gray white
Unpleasant
vaginal odor
4 criteria for diagnosis
1) homogeneous vaginal discharge
2) pH of 4.5 or higher
3) vaginal discharge has an amine-like
odor (WHIFF TEST)
4) a wet smear: clue cells more than 20%
of the number of the vaginal epithelial
cells
Candidiasis

Mx: Nystatin

Thick and
curdy,
adheres to
the vaginal
mucosa
pH is acidic <4.5

Vaginal erythema
More extensive vulvar involvement

Trichomonas
vaginalis

Mx:
Metronidazol
e for 1 week;
tx the partner
too
Foamy/
frothy, yellow
gray or green
Profuse vaginal
discharge;
copious discharge
makes them feel
wet
Vulvar skin
involvement is limited to the vestibule and
labia minora

TYPES OF VAGINAL DISCHARGES
DANGER SIGNS OF PREGNANCY
1. Vaginal bleeding
2. Persistent vomiting
3. Chills and fever
4. Sudden escape of fluid per vagina (rupture of
membranes)
5. Swelling of face
6. Blurring of vision
7. Persistent headache
LEOPOLDS MANEUVER
Information on
Position
Presenting part
Descent
LM 1
FUNDAL GRIP
LM 2
UMBILICAL GRIP
LM 3
PAWLIKS GRIP
LM 4
PELVIC GRIP
To determine which
fetal pole is present
in the fundus
To determine orientation
of the fetus by knowing
whether the back is
directed anteriorly,
transversely, or
posteriorly
To determine which
fetal pole is occupying
the pelvic inlet
Engagement?
Not engaged = (+)
cephalic prominence

Engaged = (-)
cephalic prominence
Breech
Large nodular
body
Buttocks
Lower
extremities
On one side, a hard,
resistant structure is
feltthe back.

If the presenting part
is not engaged, a
movable mass will be
felt, usually the head.
The differentiation
between head and
breech is made as in
the first maneuver.
Cephalic prominence
Same side as fetal
small parts = head
is flexed = vertex

Same side as fetal
back = head is
extended = face
Cephalic
Hard, freely
movable and
ballotable part
Fetal head
On the other, numerous
small, irregular, mobile
parts are feltthe fetal
extremities
If the presenting part
is deeply engaged,
however, the findings
from this maneuver
are simply indicative
that the lower fetal
pole is in the pelvis
BALLOTTEMENT
20
th
week; AFV > fetus
External ballottement
Side to side
Internal ballottement
with the tip of the forefinger in the vagina, a sharp tap is made
against the lower segment of the uterus; the fetus, if present, is
tossed upward and (if the finger is retained in place) will be
felt to strike against the wall of the uterus as it falls back.

FETAL PRESENTATION

Presenting part portion of fetal body that is either within
the birth canal or in closest proximity to it
Transverse shoulder
Longitudinal cephalic or breech

FETAL PRESENTATION: CEPHALIC
VERTEX SINCIPUT BROW FACE
Presenting Part Posterior
fontanel /
Occiput
Anterior
fontanel /
Bregma
Frontum Mentum
Attitude Fully flexed Partially flexed Partially
extended
Hyperextended
AP diameter
presenting into
the pelvis
Sub-occipito-
bregmatic
Occipito-frontal Occipito-
mental
Submental
Normal
diameter
9.5 cm 12.5 cm 13.5 cm 9.5 cm





FETAL PRESENTATION: BREECH

ID OF FETAL HEART ACTION SEPARATE AND
DISTINCT FROM THE MOTHER
Ways to listen to the FHT:
6
th
wk: Real time sonography
6 8
th
wk: Echo
10 12
th
wk: Doppler UTZ
18
th
wk: Stethoscope
Other sounds:
Uterine souffle soft blow
Funic souffle sharp whistle
MOM BABY
60 80 110 - 160
RECOGNITION OF THE EMBRYO OR FETUS BY
UTZ TECHNIQUES
5
th
wk: gestational sac
6
th
wk: fetus within the sac and FHT detected
6-12
th
wk: CRL = AOG
DIAGNOSIS OF PREGNANCY
Presumptive Probable Positive
Nausea w/ or w/o vomiting Abdominal enlargement ID of fetal heart action
separate and distinct
from the mother
Disturbances in urination Changes in uterine shape,
size, and consistency
Fatigue Changes in the cervix
Perception of fetal
movement
Braxton-Hicks contraction Perception of active fetal
movement by the
examiner

Breast symptoms Ballottement
Cessation of menstruation Outlining the fetus
Anatomical breast changes Positive endocrine tests Recognition of the
embryo or fetus by
ultrasonographic
techniques

Changes in vaginal mucosa
Skin pigmentation changes

HAIR GROWTH

Altered by hormones

Increased shedding of hair 3-4 months after
delivery
main continue for 6-24 weeks

ACNE VULGARIS

May be aggravated during the 1st trimester

Often improves in the 3rd trimester
CHLOASMA
Mask of Pregnancy
70% of pregnant women
Hyperpigmentation
forehead, cheeks, bridge
of nose, and chin
Blotchy, usually symmetric pattern
SKIN PIGMENTATION CHANGES

ANATOMICAL BREAST CHANGES
6 - 8
th
wk
Veins
Sebaceous glands/
Montgomerys tubercles
Areola
Nipples
16
th
wk - colostrum
ANATOMIC CHANGES
Lower ribs flare and chest expands
increased transverse diameter (2 cm)
Increased circumference (5-7 cm)

Costal angle
68 degrees ~> 103 degrees
(before PG) (3rd trimester)

Diaphragm rises as much as 4 cm above its usual
resting position

Diaphragmatic movement increases

CARDIO
Increased heart rate and stroke volume
Left ventricle increases wall thickness and mass
Aorta, pulmonary artery, and mitral orifice increase
in size by 12 weeks of pregnancy
maximum size by 32-38 weeks

As the uterus enlarges, the diaphragm moves
upward and the heart is shifted toward a horizontal
position with slight axis rotation

Apical pulse
upward and 1-1.5 cm more lateral


HEART SOUNDS
Changes are expected because of the increased
blood volume and extra effort of the heart

Audible splitting of S1 and S2
S3 may be heard after 20 weeks
Grade II systolic ejection murmurs
heard over the pulmonic area in 90% of PG
women
intensified during inspiration or expiration
OFFSETTING THE INCREASED VOLUME
Vascular resistance decreases with peripheral
vasodilation
Palmar erythema
Spider telangiectases

Blood pressure decreases during the 2
nd
trimester
but returns to pre-pregnancy levels in the 3
rd

trimester
BLOOD PRESSURE
Gradually falls until 16-20 weeks
Then, gradually rises to pre-pregnancy levels at
term

Pregnancy Induced Hypertension
sustained systolic BP >140 mm Hg or diastolic pressure
>90 mm Hg
ABDOMEN
Auscultation
Bowel sounds will be diminished as a result of
decreased peristaltic activity

Inspection
Striae and linea nigra may be present

Linea nigra: midline band
of pigmentation
Assessment of the abdomen includes:
Uterine size estimation for gestational age
Fetal growth
Position of the fetus
Monitoring of fetal well-being

MEASUREMENT OF FUNDAL HEIGHT
Have the patient empty her bladder
Patient lies supine
Measure from the upper part of the
pubis symphysis to the superior fundus (over the midline)
Recorded in cm.
MEASUREMENT OF FUNDAL HEIGHT
Most accurate between 20-30 weeks
Fundal height (cm)=gestational age (weeks)

1cm. increase per week is expected
Larger than expected?
-Consider twins or other conditions that enlarge
the uterus

Smaller than expected?
-Possible intrauterine growth retardation
HEIGHT OF THE FUNDUS
PELVIC EXAMINATION
Inspection
Pubic hair lice?
Skin of perineum redness,
excoriation, warty or
neoplastic growths?
Clitoris size and shape
Hymen intact, imperforate
or open?
Perineal body focal point
of support for pernieum
Perianal area hemorrhoids,
warts

Palpation
Any pus expressed from the
urethra should be submitted
for Gram stain and cultured
= gonococci
PELVIC EXAMINATION
Clinical measurement of the pelvis
Determine the presenting part, station and position
Determine consistency, effacement and dilatation of the
cervix

ADEQUATE PELVIS
Sacral promontory accessible
Ischial spines wide
Pelvic side walls not convergent
Sacrum curved
Subpubic arch wide
CERVICAL EXAMINATION
Cervical effacement
Length is compared with that of an uneffaced cervix.
50% effaced length of the cervix is reduced by one half
100% effaced cervix becomes as thin as the adjacent lower
uterine segment

Cervical dilatation
Sweeping the examining finger from the margin of the
cervical opening on one side to that on the opposite side.
10 cm full dilatation
Position and consistency of
the cervix
Relationship of the cervical os
to the fetal head and is
categorized as posterior,
midposition, or anterior.
Soft, firm, or intermediate.
Levelor station
In relationship to the ischial
spines
0 lowermost portion of the
presenting fetal part is at the
level of the spines
+5 cm corresponds to the fetal
head being visible at the
introitus


SPECULUM EXAM
Full length with blades in the posterior fornix, before the
blades are gently opened to expose the lateral walls
Vaginal canal is inspected during the insertion of the
speculum or on its removal
Vaginal epithelium = erythema?, lesions?
Fluid discharge

CERVIX
Pink, shiny, and clear
Pap smear
To sample exfoliated cells from the endocervical canal and to
scrape the transitional zone.

https://www.youtube.com/watch?v=G9IUi_Umb18

BIMANUAL EXAMINATION
To determine the size, nature of the uterus and the presence or
absence of adnexal masses.

Ovaries
Palpable in premenopausal females with a normal habitus
Postmenopausal have smaller ovaries, typically not palpable
Obesity can impair adnexal evaluation
Mass or any adnexal tenderness or lack of mobility
Guarding or tenderness should be noted
Cervix
Determine the location, position, shape, form, consistency,
amount of mobility, and any discomfort
Cervical mobility and cervical motion tenderness generally
checked last
BIMANUAL EXAMINATION
RECTO-VAGINAL EXAM
Note for any thickness or
mass palpated from the
rectovaginal septum
Any thickening or beadiness
of the uterosacral ligaments
may imply an inflammatory
reaction or endometriosis.
If the uterus is retroverted,
that organ should be
outlined for size, shape, and
consistency at this point.
CHANGES IN VAGINAL MUCOSA
Chadwicks sign
6
th
wk
Vaginal mucosa: congested and violaceous
Due to increased vascularity
CHANGES IN UTERINE SHAPE, SIZE AND CONSISTENCY
Hegars 6

8
th
wk
Goodells 4
th
wk
Cyanosis and softening of
the cervix

LABORATORY EXAM
Complete blood count Determine hematologic status
Rule out anemia
Blood type and Rh factor To determine blood type, Rh status and risk of
isoimmunization
Pap smear screen To screen for cervical dysplasia or cancer
Fasting blood sugar To detect hyperglycemia
Urinalysis, urine culture and
sensitivity
To evaluate for UTI and renal function
To check for asymptomatic bacteremia
Rubella serology To detect infection
Syphilis serology To detect infection
Gonococcal culture To detect infection
Chlamydia To detect infection
Hepatitis B To detect infection
Group B Streptococcus To detect infection
DIABETES MELLITUS
HEPATITIS B
IMMUNIZATIONS
Textbook of Obstetrics 3
rd
Edition, APMC
VACCINE COMMENTS
Tetanus-Diphtheria
(Td)
No administration within last 10 years BOOSTER
DOSE

Previously unvaccinated COMPLETE SERIES OF 3
VACCINATIONS
Schedule: after the 2
nd
trimester, within each dose
given 4 weeks apart
Hepatitis B High risk patients should be vaccinated
Influenza
inactivated
Recommended during influenza season
Tetanus-Diphtheria-
Pertussis (DPT)
Maternal pertussis antibodies may be protective to the
infants in early life
Rabies As post exposure prophylaxis
NUTRITION
RDA
Calories:
+300kcal/day
Proteins: 9g/day
Carbohydrates: 50-
100g/day
Fats:15-25g/day



Minerals:
Calcium: 900mg/day
Iron: 6 - 7 mg/day
Iodine: 0.15 -
0.30mg/day
Vitamins
Folate: 400ud/day
Vit B1: 1.3mg/day
Niacin: 1mg/day

FREQUENCY OF VISITS
< 28 wks = every 4
wks
28-36 wks = every 2
wks
>36 wks = every week





Primipara: 18
th
20
th
week
Multipara: 16
th
18
th
week
QUICKENING