 Welcome to
 OBSTETRICS
 Rev. 5/2009
 Antepartum-betw. Conception to the onset of labor
 Intrapartum-labor & delivery
 Postpartum/Puerperium-from delivery up to 6 wks.
 Obstetric Terminology
 Gravida
 Primigravida
 Multigravida
 Para
 Primipara
 Multipara
 Five Digit System
 G – Gravidity
 T – Term
 P – Preterm births
 A – Abortions
 L – Living Children
 Factors Influencing Modern Maternity Care
•
Emphasis on prenatal care
•
Natural Childbirth
•
Epidural Analgesia
•
Education of Parents
•
Birthing Center/Midwives

Uterus
 Has 3 layers:
1. Perimetrium
2. Myometrium
3. Endometrium
Provides housing & nourishment
Fertilized ovum implants there
 Vagina
1. Birth canal
2. Organ of copulation
3. Excretes menstrual flow
4. Rugae
5. Bartholin’s Gland

Perineum
 Area bet. Posterior vaginal wall & anus
 Provides muscular support for pelvic organs
 Structures that Support the Uterus
 Broad Ligament
 Round Ligament
 Uterosacral Ligament
***Support the uterus in it’s proper position……
 Terms Used in reference to the Female Pelvis

A.Gynecoid Pelvis
1. Wider than male pelvis
2. Contains & protects reproductive organs, bladder & rectum
3. Forms part of the birth canal
 4. Larger than male pelvis
 5. Formed by: coccyx, sacrum, hip bones(ilium,ishium & pubis)
 6. 50% of woman have a
gynecoid pelvis
 2. False Pelvis
 The upper flaring part of pelvis
 Supports growing uterus during pregnancy
 Offers landmarks for pelvic measurement
 Directs fetus toward True Pelvis
 3. True Pelvis
 Formed by pubis(front), the ilia/ischia(sides) and sacrum/coccyx(behind)
 Inletentrance from false pelvis
 Cavitycurved area
 Outletexit from True pelvis
 Hormonal Control/Menstrual Cycle
 Menstrual Cycle
*usually 28 days
*day 1menses begins
*day 14ovulation occurs
 Fertilization
 Must occur w/I 48 hrs. of ovulation
After fertilization6-8dys for zygote to travel for implantation
Without fertilizationhormone levels drop, menstruation occurs.
 Hormonal Control
 FSHsecreted by ant. Pituitary
 Stimulates graafian (ovarian) follicle in ovary
 Ovum matures in graafian follicle
 Estrogen
 secreted by graafian follicle as ovum matures
 Prepares uterus for pregnancy
 Inhibits FSH
 Stimulates LH
 LH
 secreted by anterior pituitary
 Causes ovulation
 Transforms graafian follicle to corpus luteum
 Progesterone
 Secreted by corpus luteum
 Causes endometrium to thicken
 Essential in maintenance of pregnancy
 Hormonal differences with &without fertilization
 With Fertilization:
1.corpus luteum secretes progesterone & estrogen for 11-12 wks, then placenta takes over production
of these hormones
2.HCG is secreted
 Without Fertilization:
 corpus luteum dies
 Estrogen & progesterone levels decrease
 Endometrial degeneration occurs & menstruation begins….
 Conception & Implantation
 Conception
•
Takes place in fallopian tubes
•
Occurs after ovum & sperm unite
There are 23 chromosomes each
46 chromosomes = Zygote
 Implantation
o
Zygote  morula (mulberry) when it reaches the uterus
o
Morula  Blastocyte when it enters uterus
o
Blastocyte implants into the endometrium & is now called the
“Embryo”
 Determination of Sex
 Determined by father’s sperm
 Female ovum has only “x” chromosome
 Male sperm has both “x” & “y” chromosome
 2 Types of Multiple Births
 Monozygotic
A. Identical Twins
1.single ovum & sperm
2.fertilized egg dev.2 embryos
3.usually 1 placenta (2 sacs)
4.always the same sex
 B. Fraternal Twins
 1. Dizygotic Twins
 2 ova & 2 sperm, both implant
 2. 2 placentas (separate or fused) w/ 2 sacs
 May/may not be same sex
 May/may not look alike
 Lab Tests to Determine Pregnancy
 Most based on presence of HCG in blood or urine
 HCG is present anywhere from 8-15 days after conception
 Home test are 95% accurate
 Use first void in morning
 E.D.C.- Estimated Date of Confinement
 Calculated by Nageles rule:
1.count back 3 mos. From the 1st day of LMP
2.Add 7 days
 Determination of Pregnancy
3 Degrees of Certainty based on
Symptoms
a. Presumptive
b. Probable
c. Positive
 Presumptive Sx
 Amenorrhea
 Nausea & vomiting
 Frequent urination (1st & 3rd trimester)
 Fatigue
 Breast changes
 Pigmentation Changes
 Quickening(first fetal movement)
 Change in abdomen shape & size
 Chadwick’s Sign
 Probable Signs & Sx
 + urine pregnancy test
 RIA test +
 Goodell’s sign
 Hegar’s sign
 Ballottement
 Positive Signs & Sx
 Fetal Heart Beat

faint @ 10-12 wks. With doppler ultrasound

Distinct @ 18-20 wks.

120-160 beats/min.

X-ray visualization
 Maternal & Fetal Circulation
A. Placenta
 Dark red circular organ
 Weighs ~ 1-2 lbs.
 Dev. From both embryonic & maternal tissue
 Totally formed and functioning by 12 wks.
 Maternal side (decidua basalis)
 Fetal side has chorionic villi
 Placental Functions:
A. Provides for nutrition, excretion & respiration of fetus
B. Secretes progesterone
C. Secretes estrogen
D. Secretes HCG
E. Acts as protective barrier
 Placental Transfer
 Exchange of nutrients, excrement & respiration
 There is NO intermixing of fetal & maternal blood ….
 B. Umbilical Cord
1. Attaches fetus to placenta
2. Contains 2 arteries & 1 vein (intertwined & covered by Wharton’s jelly)
 C. Fetal Circulation
1. Umbilical veincarries oxygenated blood & nutrients from placenta to fetus
2. Umbilical arteriescarry waste products from fetus to placenta
 Know…..
1.Ductus Venosus
2.Foramen Ovale
3. Ductus Arteriosis
 Physiological Changes & Common Discomforts of Pregnancy

A. Cardiovascular
 Blood volume up 30-40 %
 Heart rate up
 BP remains unchanged
 B. Respiratory
•
Rate is increased
•
Lung capacity is decreased
 C. Digestive
 Stomach & intestines displaced upwards
 Peristalsis slows constipation
 Nauseau cau. By hormones
 Heartburn due to reflux of stomach contents
 D. Endocrine
 Glands increase in size & activity
 Metabolic rate increases
 E. Musculoskeletal
 Lordosis
 Pubic symphysis & sacroiliac joints become more pliable
 Pendulous abdomen strains M/S system
 F. Urinary
•
Kidney activity increases
•
Urinary frequency ( 1st and 3rd)
trimesters
 G. Integumentary
 Striae on abdomen, hips, thighs, & breasts
 Pigmented mask on face
(chloasma)
 Increase pigmentation abdomen (linea nigra)
 Prenatal/Antepartal Care
GOAL:
**Maximum physical & mental fitness of woman with an uncomplicated delivery & healthy
newborn…**

A. Routine Exams….
a. Q 4 wks  32 wks.
b. Q 2 wks  36 wks.
c.
Weekly until 6 wks. Postpartum
Exams include BP, wt, fundal ht, fetal heart rate.
 B. NUTRITIONAL NEEDS
 Diet based on Food Guide Pyramid
 Increase calories by 300 daily
 Increase calcium
 Meats ^zinc, iron and protein
 Folic acid supplements
 Increase protein intake for fetus & mother
 Avoid empty calories
 Iodized salt
 Variety of foods
 No laxatives/enemas
 Increase fluids (8-10 glasses/day of water
 Increase vitamins
 Weight gain varies w/ weight of mother
 Appetite ( Pica )
 C. GENERAL HEALTH

PRACTICES
Left side lying
 Coping with stress
 Role/Relationship changes
 Self-perception/self concept changes
 Seat Belts
 D. TERATOGENIC FACTORS
 Teratogen is an environmental agent or factor that causes defects in fetus.
 Ex: Rubella, ETOH, smoking, drugs, dietary deficiencies
 E. MINOR DISCOMFORTS
1. Morning sickness
2. Heartburn
3. Gingivitis
4. S.O.B.
5. Leg cramps
6. Varicose veins
7. Vaginal discharge
8. Constipation
9. Supine hypotension
10. Backaches
11. Yellowish discharge from breasts
(colostrum)
 F. Danger Signals to Report
 Refer to page 793 Box 25-9
 Complications of Pregnancy

1.
ABORTIONS
A. Spontaneous
B. Therapeutic

Spontaneous Abortions
•
Threatened
•
Complete
•
Septic
•
Habitual
•
Inevitable
 Incomplete
 Missed

Therapeutic Abortions
 Interruption of pregnancy for medical or social reasons.
 Complications of Abortion
1. Infection
2. Hemorrhage
3. Rh sensitization (occurs only with Rh- woman carrying an Rh+ fetus)
 2. Premature Dilation of the Cervix

“Incompetent Cervix”
Caused by :
*Previous cervical lacerations
*Cervical or vaginal CA
*Multiple D & C’s or biopsies
 Congenital (maternal exposure to DES (Diethylstilbestrol)
TREATMENT:
Cervical Cerclage
 3. Ectopic Pregnancy
 Implantation occurs somewhere other than the uterus
 Other sites abdominal cavity, ovaries, ligaments or cervix
 95% occur in fallopian tubes

Clinical Manifestations
 Sharp, localized, one-sided pain or pain referred to the shoulder
 Rigid and tender abdomen
 Slight vaginal bleeding
 Signs of hypovolemic shock
 Treatment
 Surgical treatment must be prompt
 Salpingectomy
 Salpingostomy
 Methotrexate
 II. Maternal Disorders Affecting Pregnancy

A. Hyperemesis Gravdiarum

Excessive vomiting
 Exact cause is unknown
 HCG is suspected
 Common nutrition-related discomforts of pregnancy
 Clinical Manifestations
 Vomiting & retching
 Severe dehydration
 Acid base inbalance
 Hypokalemia
 Vitamin deficiencies may lead to jaundice and hemorrhage
 Nursing Assessment
 Frequency, amount & character of emesis.
 I&O
 Skin turgor and mucous membranes
 Psychosocial assessment
 Assess fetal status
 Medical Management

Meet nutritional needs
 Balance electrolytes with IV

TPN used in severe cases
 Reintroduce solid foods slowly
 Prognosis is good
 B. Pregnancy Induced Hypertension ( PIH)
 Includes:
Preeclampsia ( Mild or Severe)
AND
Eclampsia

Classic Signs…..
1) Edema
2) Hypertension
3) Proteinuria (albuminurea)
4) Signs generally occur after 20th wk of pregnancy

Mild Preelampsia
 Few clinical symptoms
 BP of 140/90
 Generalized edema of face, hands and ankles
 Weight increase, & 1-2+ albumin in urine
 Severe Preeclampsia
 Symptoms appear suddenly
 BP of 160/110 or greater
 Increased edema
 Dramatic increase in weight
 Increase urine albumin & decrease in urine amount

Eclampsia
 Most severe form of PIH
 Characterized by seizures & coma
 Elevated BP, albuminuria and oliguria are common also
 Nursing Interventions
•
I & O and dly weights
•
Monitor BP every 4 hrs.
•
Quiet environment & bedrest
•
Magnesium Sulfate-> used to prevent convulsions, & lower BP
•
Main purpose for trmt is to prevent convulsions

TEACH….

Importance of compliance with therapy

Importance of bedrest
 Continuous care is mandatory
 Nursing Alert :
HELLP Syndrome
 H  Hemolysis (destruction of RBC’s)
 EL Elevated Liver Enzymes
 LP  Low Platelet Count

C. Gestational Diabetes
 Diabetes during pregnancy
 Screened at 26-28 wks
 Ranges from diet controlledinsulin
 Most gestational diabetes return to normal after delivery
 Clinical Manifestations
 Blood glucose levels > 120 mg/dl
 Classic symptoms of diabetes
 See Box 28-8
 Nursing Interventions
 Maintain normal blood glucose
 Teach how to administer insulin & regulate blood sugars
 Insulin may be required by both NIDDM and GDM
 Insulin will not cross placenta
 III. DISORDERS AFFECTING THE FETUS
 1. INFECTIONS
 T  Toxoplasmosis
 O  Other
 R  Rubella
 C  Cytomegalovirus
 H  Herpes
 2. Rh Sensitization
 Less frequent today
 Rh+ proteins enter maternal circulation of Rh- mother & she now produces Rh+ antibodies.
 Antibodies destroy the fetus’ RBC’s causing “ Erythroblastosis Fetalis”
 Trmt  Rhogam injections
 3. ABO Incompatability
 Mother A  fetus B or AB
 Mother B  fetus A or AB
 Mother O  fetus A, B, or AB
 Usually see jaundice w/i 24 hrs
 Rx with phototherapy
 IV.
PLACENTAL & AMNIOTIC DISORDERS
 1. Placenta Previa
Placenta partially or completely covers the cervical os
 Complete with “total” coverage
 Partial with incomplete coverage
 Marginal
 Predisposing Factors
 Numerous or closely spaced pregnancies
 Abnormalities in uterine structure
 Late fertilization
 Symptoms
 Painless vaginal bleeding occurring after 20 weeks usually during last trimester
 The separation of placenta from uterine wall is painless
 Diagnosed by:
o
Ultrasound
TX :
Bedrest/observation
vag birth not preferred
C-section preferred
 2. Abruptio Placenta
 Abrupt premature separation of normally implanted placenta
 Grave complication of late pregnancy
 Cause is unknown
 Predisposing Factors
•
Hypertension
•
Pre-eclampsia (PIH)
•
Substance abuse
•
Grand multipara
•
Numerous abortions
 Symptoms are:
 Pain, dark red blood, tender uterus usually in last trimester
 Strong, consistent contractions
 Rising fundus (uterine rigidity) may indicate retroplacental hemorrhage
 Complications are:
 Fetal dangershypoxia,anemia, death
 Bleeding into uterine muscle
 Loss of uterine tone
 DIC maternal death
 Treatment/Management is:
a) Continuous fetal monitoring
b) Monitor fundal height (marking to check for upward movement.
c) Freq. VS
d) If no fetal distress vag delivery
e) In severe form  C- section
 Assessing Fetal Status
 A. Amniocentesis
 B. Chorionic Villi Sampling
 C. Ultrasound Scanning
 D. Oxytocic Challenge Test( Stress Test)
 E. Nonstress Test (NST)
 F. Fetal Biophysical Profile
 G. Alphafetaprotein
 Done with Unit 1 OB…
 On to Unit 2 ….. 