1. CHAPTER 18
Obstetrics

2. Obstetrics Overview Obstetrics Pregnancy
Field of medicine that deals with pregnancy (prenatal), delivery of the baby, and the first six weeks after delivery (postpartum period)
Pregnancy
Nine calendar months or 10 lunar months
Forty weeks or 280 days
Divided into trimesters
Three intervals of three months each
Known as gestational period

3. Pregnancy Fertilization or conception
Union of a sperm and a mature ovum
Takes place in outer third of the fallopian tube
Zygote
Initial name for fertilized ovum
Embryo
Name of product of conception from second through 8th week of pregnancy
Fetus
Name of product of conception from 9th week through duration of gestational period

4. Pregnancy Two major accessory structures of pregnancy Amniotic sac
Strong, thin-walled membranous sac that envelops and protects the growing fetus
Also known as the fetal membrane
Outer layer of sac is called the chorion
Inner layer of sac is called the amnion
Amniotic fluid within sac cushions and protects fetus during pregnancy

5. Pregnancy Accessory structures of pregnancy Placenta
Temporary organ of pregnancy
Provides for fetal respiration, nutrition, excretion
Functions as an endocrine gland by producing hormones necessary for normal pregnancy
Human chorionic gonadotropin (HCG), estrogen, progesterone, and human placental lactogen (HPL)

6. Pregnancy Accessory structures of pregnancy Maternal side of placenta
Attached to wall of uterus
Has a “beefy” red appearance
Fetal side of placenta
Has shiny, slightly grayish appearance
Contains arteries and veins that intertwine to form umbilical cord
Umbilical cord arises from center of placenta and attaches to umbilicus of fetus

7. Physiological Changes During Pregnancy
Amenorrhea
Absence of menstruation
Menstruation stops as a result of hormonal influence during pregnancy
Changes in the uterus
Small, pear-shaped organ before pregnancy
Grows to accommodate growing fetus, placenta, amniotic sac, and amniotic fluid during pregnancy

8. Physiological Changes During Pregnancy
Changes in the cervix
Chadwick’s Sign
Cervix and vagina take on a bluish-violet hue due to local venous congestion
Goodell’s Sign
Cervix softens in consistency in preparation for childbirth

9. Physiological Changes During Pregnancy
Changes in the vagina
Vagina takes on same bluish-violet hue of the cervix during pregnancy
Increase of glycogen in vaginal cells
Causes increased vaginal discharge and heavy shedding of vaginal cells
Leukorrhea
Thick, white vaginal discharge during pregnancy

10. Physiological Changes During Pregnancy
Changes in breasts
Increase in size and shape
Nipples increase in size and become more erect
Areola become larger and more darkly pigmented
Montgomery’s tubercles become more active and secrete substance that lubricates the nipples

11. Physiological Changes During Pregnancy
Changes in breasts
Colostrum is secreted
Thin, yellowish discharge from nipples throughout pregnancy
Forerunner to breast milk

12. Physiological Changes During Pregnancy
Changes in blood pressure
May experience hypotension during second and third trimesters (4th – 9th month)
Weight of pregnant uterus presses against descending aorta and inferior vena cava
When woman is lying on her back (supine)
May complain of faintness, lightheadedness, and dizziness

13. Physiological Changes During Pregnancy
Changes in urination
First trimester
Urinary frequency due to increasing size of uterus, creates pressure on bladder
Second trimester
Uterus rises up out of the pelvis and pressure on bladder is relieved
Third trimester
Frequency returns due to pressure of baby’s head on the bladder

14. Physiological Changes During Pregnancy
Changes in posture
Waddling gait
Manner of walking in which the feet are wide apart and the walk resembles that of a duck
Due to softening of pelvic joints and relaxing of pelvic ligaments
Pregnant woman’s center of gravity is offset

15. Physiological Changes During Pregnancy
Changes in the skin
Possible increased feeling of warmth and sweating
Due to increased activity of the sweat glands
Possible problems with facial blemishes
Due to increased activity of sebaceous glands
Chloasma
Hyperpigmentation (brown patches) seen on forehead, cheeks, and bridge of nose
Known as the “mask of pregnancy”

16. Physiological Changes During Pregnancy
Changes in the skin
Linea Nigra
Darkened vertical midline between the fundus and the symphysis pubis on the abdomen
Areola
Becomes darker as pregnancy progresses
Stria Gravidarum
Stretch marks on the abdomen, thighs, and breasts that occur during pregnancy

17. Physiological Changes During Pregnancy
Changes in weight
Recommended weight gain during pregnancy
Ranges from 25 to 30 pounds
Pattern of weight gain is important
1st – 3rd month = pounds total
4th – 9th month = 1 pound per week
Critical to monitor weight gain for unexpected increases
Fluid retention
Pregnancy-induced hypertension

18. Signs and Symptoms of Pregnancy
Presumptive signs
Expectant mother
Suggests pregnancy but are not necessarily positive
Include amenorrhea, nausea and vomiting, fatigue, urinary disturbances, and breast changes
Quickening
Movement of fetus felt by the mother
Occurs around 18 – 20 weeks gestation
Described as a faint abdominal fluttering

19. Signs and Symptoms of Pregnancy
Probable signs
Observable by examiner
Much stronger indicators of pregnancy, but can be due to other pathological conditions
Should not be used as sole indicator of pregnancy
Include Goodell’s sign, Chadwick’s sign, uterine enlargement, hyperpigmentation of skin, abdominal stria, palpation of fetal outline, positive pregnancy tests

20. Signs and Symptoms of Pregnancy
Probable signs
Hegar’s sign
Softening of the lower segment of the uterus
Braxton Hicks contractions
Irregular contractions of the uterus
May occur throughout the pregnancy and are relatively painless

21. Signs and Symptoms of Pregnancy
Probable signs
Ballottement
Technique of using the examiner’s finger to tap against the uterus, through the vagina, to cause the fetus to “bounce” within the amniotic fluid and feeling it rebound quickly

22. Signs and Symptoms of Pregnancy
Positive signs
Fetal Heartbeat
Detected by ultrasound at approximately 10 weeks gestation
Detected by fetoscope at 18 to 20 weeks gestation
Rate can vary from 120 to 180 beats per minute

23. Signs and Symptoms of Pregnancy
Positive signs
Identification of embryo or fetus by ultrasound
Can be detected as early as 5 to 6 weeks with 100 percent reliability
Provides earliest positive confirmation of a pregnancy
Fetal movements felt by examiner
Palpable by physician/examiner by the second trimester of pregnancy

24. Calculation of Date of Birth
Birth date for the baby
Expected Date of Confinement (EDC)
Expected Date of Delivery (EDD)
Expected Date of Birth (EDB)
Nagele’s rule for calculation of date
Subtract three months from beginning of last menstrual period (LMP)
Add seven days to date = expected date of delivery

25. Discomforts of Pregnancy
Temporary discomforts of pregnancy
Backache
Common during second and third trimester
Edema
Swelling of lower extremities not uncommon
Fatigue
Usually occurs during first trimester

26. Discomforts of Pregnancy
Temporary discomforts of pregnancy
Heartburn
Mainly during last few weeks of pregnancy
Hemorrhoids
Develop as result of increasing pressure on area
Nausea
Usually occurs during first trimester
Varicose veins
Occur as result of blood pooling in the legs

27. COMPLICATIONS OF PREGNANCY
Obstetrics

28. Abortion Pronounced Defined (ah-BOR-shun)
Termination of a pregnancy before the fetus has reached a viable age, that is, an age at which the fetus could live outside of the uterine environment

29. Abruptio Placenta Pronounced Defined (ah-BRUP-she-oh pla-SEN-tah)
Premature separation of a normally implanted placenta from the uterine wall
After the pregnancy has passed 20 weeks gestation or during labor

30. Ectopic Pregnancy Pronounced Defined (ek-TOP-ic PREG-nan-see)
Abnormal implantation of a fertilized ovum outside of the uterine cavity
Also called a tubal pregnancy
Approximately 90 percent of all ectopic pregnancies occur in the fallopian tubes

31. Gestational Diabetes Pronounced Defined
(jess-TAY-shun-al diy-ah-BEE-teez)
Defined
Disorder in which women who are not diabetic before pregnancy develop diabetes during the pregnancy
Develop an inability to metabolize carbohydrates (glucose intolerance), with resultant hyperglycemia

32. Gestational Diabetes Risk factors Obesity Maternal age over 30 years
History of birthing large babies
Usually over 10 pounds
Family history of diabetes
Previous, unexplained stillborn birth
Previous birth with congenital anomalies (defects)

33. HELLP Syndrome Pronounced Defined HELLP SIN-drom
Serious obstetrical complication that occurs in approximately 10 percent of pregnant women with pre-eclampsia or eclampsia
HELLP stands for Hemolytic anemia, Elevated Liver enzymes, and Low Platelet count

34. HELLP Syndrome Early diagnosis is critical
Any woman who presents with malaise or a viral-type illness in third trimester of pregnancy should be evaluated for possibility of HELLP Syndrome
Laboratory diagnosis necessary to confirm HELLP syndrome
Complete blood cell count
Liver function tests

35. Hydatidiform Mole Pronounced Defined (high-dah-TID-ih-form mohl)
Abnormal condition that begins as a pregnancy and deviates from normal development very early
Diseased ovum deteriorates (not producing a fetus)
Chorionic villi of placenta changes to a mass of cysts resembling a bunch of grapes

36. Hydatidiform Mole Hydatidiform mole Molar pregnancy Hydatid mole
Growth of this mass progresses much more rapidly than uterine growth with a normal pregnancy

37. Hyperemesis Gravidarum
Pronounced
(high-per-EM-eh-sis grav-ih-DAR-um)
Defined
Abnormal condition of pregnancy characterized by severe vomiting that results in maternal dehydration and weight loss

38. Incompetent Cervix Pronounced Defined (in-COMP-eh-tent SER-viks)
Condition in which cervical os dilates before the fetus reaches term, without labor or uterine contractions
Usually occurs during second trimester of pregnancy
Results in spontaneous abortion of fetus

39. Placenta Previa Pronounced Defined (plah-SEN-tah PRE-vee-ah)
Condition of pregnancy in which the placenta is implanted in the lower part of the uterus
Precedes the fetus during the birthing process

40. Pregnancy-Induced Hypertension (PID)
Pronounced
(PREG-nan-see induced high-per-TEN-shun)
Defined
Development of hypertension during pregnancy, in women who had normal blood pressure readings prior to pregnancy

41. Pregnancy-Induced Hypertension (PID)
Three categories of PID
Gestational hypertension
Develops after 20 weeks gestation with no signs of edema or proteinuria
Pre-eclampsia
Develops after 20 weeks gestation with proteinuria or edema
Eclampsia
Most severe form of hypertension during pregnancy
Evidenced by presence of seizures

42. Rh Incompatibility Pronounced Defined (Rh Incompatibility)
Incompatibility between and Rh negative mother’s blood with her Rh positive baby’s blood
Causes mother’s body to develop antibodies that will destroy the Rh positive blood

43. SIGNS AND SYMPTOMS OF LABOR
Obstetrics

44. Signs and Symptoms of Labor
Bloody show
Vaginal discharge that is a mixture of thick mucus and pink or dark brown blood
Occurs as a result of the softening, dilation, and thinning (effacement) of the cervix in preparation for childbirth

45. Signs and Symptoms of Labor
Braxton Hicks contractions
Mild, irregular contractions that occur throughout pregnancy
Increased vaginal discharge
Clear, nonirritating vaginal secretions
Occurs as result of congestion of vaginal mucosa

46. Signs and Symptoms of Labor
Lightening
Settling of the fetal head into the pelvis
Occurs a few weeks prior to the onset of labor
Rupture of the amniotic sac
Rupture of fetal membranes, releasing amniotic fluid inside
May result in a sudden gush of amniotic fluid
Women may say their “water broke”

47. Signs and Symptoms of Labor
Sudden burst of energy
Occurs in some women shortly before onset of labor
May have energy to do major housecleaning duties

48. False Labor versus True Labor
Contractions (False)
Contractions (True)
Irregular
Regular
Not too frequent
More frequent
Shorter duration
Longer duration
Not too intense
More intense

49. False Labor versus True Labor
Discomfort (False)
Discomfort (True)
Felt in abdomen
Felt in lower back
Felt in groin area
Radiates to lower abdomen
---
Feels like menstrual cramps

50. False Labor versus True Labor
Walking (False)
Walking (True)
May relieve or decrease contractions
May strengthen contractions

51. False Labor versus True Labor
Effacement/Dilatation (False)
Effacement/Dilatation (True)
Dilatation and effacement of cervix does not change
Cervix progressively effaces (thins) and dilates (enlarges)

52. DIAGNOSTIC TECHNIQUES, TREATMENTS AND PROCEDURES
Obstetrics

53. Diagnostic Techniques, Treatments, and Procedures
AFP screening
Serum screening test for birth defects such as spina bifida, Down syndrome, and Trisomy 18
Test is offered to pregnant women between 15 and 21 weeks gestation

54. Diagnostic Techniques, Treatments, and Procedures
Amniocentesis
Surgical puncture of the amniotic sac for the purpose of removing amniotic fluid
Cesarean section
Surgical procedure in which the abdomen and uterus are incised and a baby is delivered transabdominally

55. Diagnostic Techniques, Treatments, and Procedures
Contraction stress test
Stress test used to evaluate ability of fetus to tolerate stress of labor and delivery
Also known as oxytocin challenge test
Fetal monitoring
Use of an electronic device to monitor fetal heart rate and maternal uterine contractions

56. Diagnostic Techniques, Treatments, and Procedures
Nipple stimulation test
Noninvasive technique that produces same results as contraction stress test
Pregnant woman stimulates the nipples of her breasts by rubbing them between her fingers
Causes natural release of oxytocin that causes contractions of uterus

57. Diagnostic Techniques, Treatments, and Procedures
Obstetrical ultrasound
Noninvasive procedure that uses high-frequency sound waves to examine internal structures and contents of the uterus
Ultrasonography

58. Diagnostic Techniques, Treatments, and Procedures
Pelvic ultrasound
Noninvasive procedure that uses high-frequency sound waves to examine the abdomen and pelvis
Pelvimetry
Process of measuring the female pelvis, manually or by x-ray to determine its adequacy for childbearing

59. Diagnostic Techniques and Procedures
Pregnancy testing
Tests performed on maternal urine and/or blood to determine presence of hormone HCG (human chorionic gonadotropin)
HCG is detected shortly after first missed menstrual period