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OBSTETRICS
Branch of medicine concerned with management of childbirth
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
OB Terms Con’t
Gravida
A pregnant woman
Primigravida
One pregnancy
Multigravida
Multiple births
More OB Terms
Para
Means to bring forth (past the point of viability at 24 weeks)
Primipara
One birth
Multipara
Multiple births
Examples of OB HX Shorthand*
Twin girls, and 1 miscarriage
G3, T2, A1, L2
2 Children at home, 1 AB
G3, T2, L2
4 Prior pregnancies, 2 living, 2 miscarriages
G5, T2, A2, L2
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
 Myometrium*
 Muscular layer
 What tumors grow here?
 Fundus
 Upper thicker portion of uterus*
 Top portion where fallopian tubes connect
 Vagina
1. Birth canal
2. Organ of copulation
3. Excretes menstrual flow
4. Rugae
5. Bartholin’s Gland*
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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
Android pelvis is much narrower*
2. Contains & protects reproductive organs, bladder & rectum
3. Forms part of the birth canal
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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)*
The true pelvis has:
Inletentrance from false pelvis*
Cavitycurved area*
 Outletexit from True pelvis*
 The true and false pelvis are divided by an imaginary line called the Linea
Terminalis or Pelvic Inlet
 Ischial spine refers to midpelvis*
 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
 Thickens the endometrium
 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
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It inhibits uterine contractions
 Hormonal differences with &without fertilization
 With:
1.corpus luteum secretes progesterone & estrogen for 11-12 wks, then placenta takes
over production of these hormones*
2.HCG is secreted
 HCG
 Human Chorionic Gonadotropic hormone
 Secreted by embroyonic cells tocontinue to stimulate the corpus luteum
 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
44 autosomes and 2 sex
Male Y & X, Female X & X
Each ejaculate has 200 – 400 million sperm cells
 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”
Peter, show transparancy
 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 (30%)
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 (70%)
 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*
 Pregnancy tests
 HCG may show up as early as 7 – 8 days past ovulation
 Home kits will test positive around 14 days passed missed period
 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
9 months or 266 days
 Nagles calculations from LMP
 6/25/07: - 3 months = 3/25, + 7 days = 4/1/08
 2/25/08: - 3 months = 11/25, + 7 days = 12/2/08
 01/01/08: - 3 months = 10/1, + 7 days = 10/08/2008
 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
 Chloasma, Linea Nigra, Periareola darkening
 Quickening(first fetal movement)*
 Change in abdomen shape & size*
 Chadwick’s Sign*
 Probable Signs & Sx
 + urine pregnancy test
 RIA test +
 Radioimmunoassy
 Goodell’s sign*
 Softening of cervix
 Hegar’s sign*
 Softening lower uterine segment
 Ballottement
 Feeling the fetal rebound when palpating uterus
 Positive Signs & Sx
 Fetal Heart Beat*
 faint @ 10-12 wks. With doppler ultrasound
 Distinct @ 18-20 wks.
 120-160 beats/min.*
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Must take mother’s pulse at same time*
 X-ray visualization
 Interesting Stuff
 Tunic Souffle
 Swishing sound caused by pulsation of blood through unbilical cord. Rate is
same as fetal HR
 Uterine (Placental) Souffle
 Swishing sound produced by maternal blood as it flows through large vessels of
uterus. Rate is same as mother
 Maternal & Fetal Circulation
A. Placenta
 Dark red circular organ
 Weighs ~ 1-2 lbs.
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Dev. From both embryonic & maternal tissue
Totally formed and functioning by 12 wks.*
Expands for 20 weeks, then grows only in thickness
Maternal side (decidua basalis)
Shiny Schultz
Fetal side has chorionic villi
Dirty Duncan
Time Lines*
3rd month Placenta is complete
4th month Sex is differentiated
6th month Fingernails, eyebrows, eyelashes
8th month Embryo becomes a fetus and is viable
9th month Fat is stored
Peter, show the movie”Nine Month Miracle
Placental Functions:
Provides for nutrition, excretion & respiration of fetus
Secretes progesterone*
Inhibits uterine contractions
Secretes estrogen *
Aids in lactation and fetal development
Secretes HCG
Acts as protective barrier
Placental Transfer
Exchange of nutrients, excrement & respiration*
via osmosis and difusion
There is NO intermixing of fetal & maternal blood ….*
2 separate systems
B. Umbilical Cord
Attaches fetus to placenta
Contains 2 arteries & 1 vein (intertwined & covered by Wharton’s jelly)*
2 cm in diameter, 55 cm length
C. Fetal Circulation
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
Peter, show “Fetel Circulation” transparancy
 Fetal Circulation
 Umbilical vein passes through liver and the Ductus Venosus
 The blood goes to the RA
 Then shunted to left side via Foramen Ovale (RA to RV)
 Ductus Arteriosis ( PA and Aorta)
 The fetus does not use lungs, 02 is derived from placenta
 Fetal Circulation Con’t
 From Aorta, blood goes to head, trunk, extremities, internal iliac arteries to 2
umbilical arteries to placenta
 Fetal circulation at birth
 Lung function is established
 Umbilical arteries clot and turn into fibrous cords
 Umbilical vein forms round ligament of liver
 Foramen Ovale closes
 Ductus Venosus and Ductus Arteriosis shriven up
 Physiological Changes & Common Discomforts of Pregnancy
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A. Cardiovascular
 Blood volume up 30-40 %*
 Heart rate up
 BP remains unchanged
 Varicose veins*
 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*
 Digestive con’t
 Constipation d/t decrease in peristalsis from progesterone. Teach to increase
fluids and roughage*
 Heartburn d/t stomach contents flowing up esophagus. Teach not to recline for 30
min PP*
 Nausea d/t hormones. Teach to eat dry toast or crackers
 D. Endocrine
 Glands increase in size & activity
 Metabolic rate increases
 From increase in thyroxine
 Endocrine problems:
 Morning sickness, headaches, N&V, food cravings, breast enlargement
 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.
 If mother is Rh (-)
 She will receive Rhogam at 28 weeks
 Erythroblastosis Fetalis
 Rh (+) fetus in Rh (-) mother
 Rh protein crosses placental barrier and invades mother
 Mother makes antibodies
 Antibodies cross over to fetus and destroys blood cells
 Treated with special gamma globulin called RhoGAM
 B. NUTRITIONAL NEEDS
 Diet based on Food Guide Pyramid
 Increase calories by 300 daily*
 Increase calcium
 3 – 4 cups milk daily
 Meats ^zinc, iron and protein
 Folic acid supplements
 Reduces neural defects
 Nutrition con’t
 Desirable weight gain is 25 – 30 lbs*
 Calcium is important for bone growth and blood clotting of fetus
 Zinc helps the body with metabolism. It is an enzyme. Best source is meats.*
 Increase protein intake for fetus & mother
 Avoid empty calories
 Iodized salt
 Variety of foods
 No laxatives/enemas
 Use stool softeners instead
 Nutrition con’t
 Meats are best source of proteins and are good source of iron*
 Iron is stored by fetus for post birth, also used for new tissue growth.
 Iron is essential for production of Hgb and building and repair body tissues
 Increase fluids
 Increase vitamins
 Weight gain varies w/ weight of mother
 Do not diet
 Appetite ( Pica )*
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C. GENERAL HEALTH
PRACTICES
Left side lying
Coping with stress
Role/Relationship changes
Self-perception/self concept changes
Seat Belts
Place beneath abdomen, over thigh and shoulder and between breasts
Peter, transparency on lateral position
D. TERATOGENIC FACTORS
Teratogen is an environmental agent or factor that causes defects in fetus.
Ex: Rubella, ETOH, smoking, drugs, dietary deficiencies
Rubella*
(-) rubella titer are not immune to rubella
Will receive a rubella shot prior to discharge and told not to get pregnant for 3-6
months. Could cause fetal abnotmalies
 Smoking?*
 LBW
 Prematurity
 ETOH
 Fetal Alcohol Syndrome
 E. MINOR DISCOMFORTS
1. Morning sickness
2. Heartburn
3. Gingivitis
4. S.O.B.
5. Leg cramps
6. Varicose veins*
7. Vaginal discharge*
Do not douche
8. Constipation
9. Supine hypotension
10. Backaches
11. Yellowish discharge from breasts*
(colostrum)
 F. Danger Signals to Report
 Refer to page 657 Box 24-7
 Number one danger signal?
 Vaginal bleeding
 Complications of Pregnancy
 1.
ABORTIONS
A. Spontaneous
B. Therapeutic
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Spontaneous Abortions
• Threatened
• Complete
• Septic
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Habitual
Inevitable
Incomplete
Missed*
Fetal demise but remainsin utero, may need D&E or oxytoxin
Therapeutic Abortions
Interruption of pregnancy for medical or social reasons.
Some may be criminal or illegal
Complications of Abortion
Infection
Hemorrhage
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:
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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*
Symptoms
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
Destroys the rapidly dividing cells
II. Maternal Disorders Affecting Pregnancy
A. Hyperemesis Gravdiarum*
Excessive vomiting
Exact cause is unknown
HCG is suspected
Common nutrition-related discomforts of pregnancy
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
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Classic Signs…..
Edema*
Hypertension
Proteinuria (albuminurea)*
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
Daily weights*
Monitor BP every 4 hrs.
Quiet environment & bed rest*
Magnesium Sulfate-> used to prevent convulsions*, & lower BP*
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
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C.
Gestational Diabetes
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Diabetes during pregnancy
Screened at 26-28 wks
Ranges from diet controlledinsulin
Most gestational diabetes return to normal after delivery
Fetus will suffer from hyperglycemia in early pregnancy. Controlled glucose
levels are very important
 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*
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Kitty litter
 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 *
 Problems: Mom Rh (-), Dad and baby Rh(+)*
 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
 Low implantation is the placenta situated in the lower uterine segment away
from the internal os
 Predisposing Factors
 Numerous or closely spaced pregnancies
 Abnormalities in uterine structure
 Late fertilization
 Symptoms
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Painless vaginal bleeding occurring after 20 wks. *
The separation of placenta from uterine wall is painless
Diagnosed by:
Ultrasound
TX :
Bedrest/observation
vag birth not preferred
C-section preferred
Fetal death may occur d/t hypoxia +/or prematurity*
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*
Predisposing factors
Hypertension
Pre-eclampsia*
Substance abuse
Grand multip
Numerous Abs
Physical trauma
Complications are:
Fetal dangershypoxia,anemia, death*
Bleeding into uterine muscle
Loss of uterine tone
DIC maternal death
Treatment/Management is:
Continuous fetal monitoring
Monitor fundal height (marking to check for upward movement.
Freq. VS
If no fetal distress vag delivery
In severe form  C- section
Read chap 27 to tie in RDS
Assessing Fetal Status
A. Amniocentesis
B. Chorionic Villi Sampling
C. Ultrasound Scanning
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D. Oxytocic Challenge Test
(Stress Test)
E. Nonstress Test (NST)
Oxytoxic Challenge Test
Evaluates fetal cardiac response to contractions
Oxytoxin given until contractions are 3 in 10 minutes
Late decels indicate utero-placental placement insufficient
+ outcome means that > 50% are late decels
Non-Stress Test
Fetal heart rate should go up with activity
Fetal monitor placed on Mom
Mom signals when she feels movement
If FHR >, this is good
If FHR does not change or <, this is bad
? O2 or think of placental insufficiency
F. Fetal Biophysical Profile
Non-Stress Test and ultra sound used together
Monitors fetal breathing movements, fetal tone, brady moments and
amniotic fluid volume
G. Alphafetalprotein
Done on mother
Done 16 – 18 weeks of pregnancy
Measures antigen carried by fetus
Elevated levels indicate neural tube defects
Low levels indicate Down’s Syndrome
May also be measured in amniotic fluid
Low levels = Down’s Syndrome
High levels = Spina Bifida