1. Organization of obstetric care. Physiological duration of pregnancy, labor and post-natal period By I. Korda 1

2. 2 Obstetrics –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 Obstetrics Overview

3. 3 Calculation of Date of Birth According of WHO : a date which we get is considered the date of births, deducting 3 calendar months backwards from the 1th day of the last menstruation; Nagele’s rule for calculation: from the 1th day of the last menstruation to deduct 3 calendar months and add 7 days. For example: date of beginning of the last menstruation – on January, 26. We add 7 days – we get on February, 2. From February, 2 we deduct backwards 3 months. Term of births – on a November, 2.

4. Prenatal care (also known as antenatal care) refers to the regular medical and nursing care recommended for women during pregnancy the goal is providing regular check-ups that allow doctors Promote and maintain the physical, mental and social health of mother and baby by providing education on nutrition, personal hygiene and birthing process Detect and manage complications during pregnancy, whether medical, surgical or obstetrical Develop birth preparedness and complication readiness plan Help prepare mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically and socially 4

5. Prenatal care generally consists of: monthly visits from week 1–19 twice from 20 to week 30 of pregnancy weekly after week 30 (delivery at week 38–40) Assessment of parental needs and family dynamic 5

6. Essential Health Sector Interventions for Safe Motherhood 6 SAFE MOTHERHOOD Family Planning Post abortion Antenatal Care Clean /safe Delivery Postpartum Care Essential Obstetric Care EQUITY BASIC HEALTH SERVICES EMOTIONAL AND PSYCHOLOGICAL SUPPORT

7. 7 Female reproductive system includes: –Ovaries –Fallopian tubes –Uterus –Cervix –Vagina –Breasts

8. 8 The ovaries are two glands, one on each side of the uterus, that are similar in function to the male testes. –Each ovary contains thousands of follicles, and each follicle contains an egg. –Ovulation occurs approximately 2 weeks prior to menstruation.

9. 9 The fallopian tubes extend out laterally from the uterus, with one tube associated with each ovary. –Fertilization usually occurs when the egg is inside the fallopian tube. –The fertilized egg continues to the uterus where it continues to develop into an embryo.

10. 10 The uterus, or womb is a muscular organ where the fetus grows for approximately 9 months (40 weeks).

11. 11 The uterus –Responsible for contractions during labor –Helps to push the infant through the birth canal –The birth canal is made up of the vagina and the lower third, or neck, of the uterus, called the cervix.

12. 12 The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal. –About 8 to 12 cm in length –Completes the passageway from the uterus to the outside world –The perineum is the –area of skin between the vagina and the anus.

13. 13 The breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the infant once it is born. –Signs of pregnancy in the breasts include increased size and tenderness.

14. 14 The placenta attaches to the inner lining of the wall of the uterus and connects to the fetus by the umbilical cord. –The placental barrier consists of two layers of cells.

15. 15 After delivery, the placenta, or afterbirth, separates from the uterus and delivers. The umbilical cord is the lifeline of the fetus. –The umbilical vein carries oxygenated blood from the woman to the fetus. –The umbilical arteries carry deoxygenated blood from the fetus to the woman.

16. 16 The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac, or bag of waters. –Contains about 500 to 1,000 mL of amniotic fluid –Fluid helps insulate and protect the fetus. –Fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

17. 17 –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 8 th week of pregnancy –Fetus Name of product of conception from 9 th week through duration of gestational period Fertilization or conception

18. Obstetrical Terminology Gravida –All current and past pregnancies Para –Number of past pregnancies viable to delivery Antepartum –Period before delivery Gestation –Period of intrauterine fetal development Grand multipara –Seven deliveries or more 18

19. Obstetrical Terminology Multipara – Two or more deliveries Natal –Connected with birth Nullipara –Has never delivered Perinatal—occurring –At or near time of birth Postpartum –Period after delivery 19

20. Prenatal –Before birth Primigravida –Pregnant for first time Primipara – Gave birth once Term – Pregnancy at 40 weeks’ gestation 20

21. Molding refers to the cranial bones overlapping under pressure during labor Sutures of the fetal skull are membranous spaces between the cranial bones. Fontanelles are the intersections of the cranial sutures. These sutures allow for molding of the fetal head. 21 Fetal head

22. Fontanelles 22 The anterior fontanelle is diamond shaped and measures about 2-3cm. It permits growth of the brain by remaining unossified for as long as 18 months. The posterior fontanelle is much smaller and closes within 8-12 weeks after birth

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24. The Fetal Skull 24

25. Fetal attitude Fetal attitude is the relation of the fetal parts to one another. The normal attitude of the fetus is one of moderate flexion of the head, flexion of the arms onto the chest, and flexion of the legs onto the abdomen 25

26. Fetal Lie Fetal lie refers to the relationship of the cephalocaudal (spinal column) axis of the fetus to the cephalocaudal axis of the woman. A longitudinal lie occurs when the cephalocaudal axis of the fetus is parallel to the woman’s spine A transverse lie occurs when the cephalocaudal axis of the fetus is at a right angle to the woman’s spine 26

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29. Fetal Presentation Fetal presentation is determined by fetal lie and by the body part of the fetus that enters the pelvic passage first, the presenting part Fetal presentation may be cephalic (most common), breech, or shoulder Breech and shoulder presentations are referred to as malpresentations as they are associated with difficulties during labor Of note, some cephalic presentations are considered malpresentations, i.e. military or face. However, the overall cephalic category is the PREFERRED presentation. 29

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31. Fetal Position Fetal position refers to the relationship of a designated landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis The landmark on the fetal presenting part is related to 4 imaginary quadrants of the pelvis: left anterior (LA), right anterior (RA), left posterior (LP), and right posterior (RP) 31

32. Leopold's Maneuvers 32

33. Position of patient-The pregnant lies on the back. The doctor sitting to the right from pregnant. The first maneuver. The hands of both hands very tightly are laid horizontally, in the area of uterine fundus. Carefully press on a uterine fundus. The level of uterine fundus location and part of fetus, located in a fundus, is determined. Gestational age is determined. 33

34. The second maneuver. Both hands are placed on the lateral surfaces of uterus at the level of umbilicus. By turns by a right and left hand palpation of fetal parts is performed. Carefully pressing by hands and fingers of hands on the lateral surfaces of uterus, dense, smooth, wide and shiny part is determined from one side - the back of fetus, from opposite – small parts are palpated. By this maneuver the lie, position,variety, and also uterine tone, quantity of amniotic fluid waters and fetal movement, are determined. 34

35. The third maneuver. By a right hand presented part of fetus is grasped (large finger from one side and four - from the opposite side of lower segment of uterus). The character of presented part and its station is determined. Presented part station is determined. 35

36. Fourth maneuver. A doctor is standing towards patient’s feet. The hands of both hands are located on the lateral surfaces of lower uterine segment and carefully try to insert the fingers between presented part and pelvic inlet. Presented part station is determined. 36

37. Station Station – degree of descent of the presenting part of the fetus, measured in centimeters from the ischial spines in negative and positive numbers. -5 is a floating baby, 0 station is said to be engaged in the pelvis, and +5 is crowning. 37

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39. Determination of the expected fetal weight For determination of the expected weight of fetus (EFW) it is necessary to know the height of standing of uterine fundus (UF) and circumference of abdomen(AC) of pregnant. Volscov’ formula: EFW = UF x AC For example: UF= 32 cm, AC = 100 cm. Multiply: 32х100, we received 3200cm. The expected weight of fetus is 3200 g. Yacubova’ formula: EFW= (AC+UF) : 4 x 100 For example: UF= 32 sm, AC = 100 sm. Adding 32+100, we get 132, dividing on 4, we get 33, multiply on 100, we have the expected fetal weight – 3300 g. 39

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41. Passage Passage = Pelvis Consists of the bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature) Small pelvic outlet can result in cephalopelvic disproportion Bony pelvis can be measured by pelvimetry but it not accurate and thus has been replaced by a clinical trial of labor 41

42. 42 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 Physiological Changes During Pregnancy

43. 43 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 Physiological Changes During Pregnancy

44. 44 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 Physiological Changes During Pregnancy

45. 45 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 Physiological Changes During Pregnancy

46. 46 Changes in breasts –Colostrum is secreted Thin, yellowish discharge from nipples throughout pregnancy Forerunner to breast milk Physiological Changes During Pregnancy

47. 47 Changes in blood pressure –May experience hypotension during second and third trimesters (4 th – 9 th 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 Physiological Changes During Pregnancy

48. 48 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 Physiological Changes During Pregnancy

49. 49 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 Changes in posture

50. 50 –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” Changes in the skin

51. 51 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

52. 52 –Recommended weight gain during pregnancy Ranges from 25 to 30 pounds –Pattern of weight gain is important 1 st – 3 rd month = 3 - 4 pounds total 4 th – 9 th month = 1 pound per week –Critical to monitor weight gain for unexpected increases –Fluid retention –Pregnancy-induced hypertension Changes in weight

53. 53 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

54. 54 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

55. 55 Braxton Hicks contractions Irregular contractions of the uterus May occur throughout the pregnancy and are relatively painless

56. 56 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

57. 57 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

58. 58 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

59. 59 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 Discomforts of Pregnancy

60. 60 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

61. 61 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

62. 62 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”

63. 63 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

64. 64 False Labor versus True Labor Contractions (False)Contractions (True) IrregularRegular Not too frequentMore frequent Shorter durationLonger duration Not too intenseMore intense

65. 65 Discomfort (False)Discomfort (True) Felt in abdomenFelt in lower back Felt in groin areaRadiates to lower abdomen ---Feels like menstrual cramps False Labor versus True Labor

66. 66 Walking (False)Walking (True) May relieve or decrease contractions May strengthen contractions False Labor versus True Labor

67. 67 Effacement/ Dilatation (False) Effacement/ Dilatation (True) Dilatation and effacement of cervix does not change Cervix progressively effaces (thins) and dilates (enlarges) False Labor versus True Labor

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69. 69 LaborNulliGMultiG 1 st Stage Activephase Duration 6-18 h2-10 h Dilation ~1 cm/h~1.5 cm/h 2 nd Stage 0.5-3 h5-30 min 3 rd Stage 0-30 min

70. 70 Thank you for your attention!