OB GYNE

A. Reproductive development Girls: 10-13 years old Boys: 12-14 years old REPRODUCTIVE DEVELOPMENT Mons pubis protect the symphysis pubis Labia Minora covers the vagina - Skin fold abundant with sebaceous gland Labia Majora middle-mucus membrane - Protection for the external genitalia Clitoris erogenous zone Vestibule encloses the vaginal orifice Skenes gland paraurethral gland - lateral to the urinary meatus Bartholins gland vulvovaginal glands - lateral to the vaginal opening - lubricate the vagina during coitus Fourchette joins the labia minora posteriorly Perineum contains the vulvocavernosus muscle BLOOD VESSEL - Pudendal Artery and a part of the inferior rectus artery - Pudendal vein VULBAR NERVE - Ilioinguinal and Genitofemoral nerve - Pudendal nerve Vagina organ of copulation VAGINAL MUCUS - Increase glycogen - Doderleins bacteria - Acidity: 4.5-5.5, prevents infection Uterus 5-7cm long, 5cm wide, 2.5cm deep - Houses the fetus, maximize size at 17 years old ISTHMUS stretch to accommodate the fetus; 9m thin CORPUS Body FUNDUS uppermost portion UTERINE LAYERS 1. Endometrium basal layer - glandular layer 2. Myometrium 3. Perimetrium FALLOPIAN TUBE 1. Infandibulum fimbriae

2. AMPULLA widest layer of the fallopian tube 3. ISTHMUS HORMONES Estrogen Secondary sex characteristics - maintains productive size - prevents osteoporosis - keep cholesterol level reduced Progesterone milk production - uterus thickness PREGNANCY Fertilization union of ovum and sperm cell Capacitation final process that spermatozoa undergo during fertilization IMPLANTATION Zygote fusion of ovum and sperm Morula when zygote reaches body of uterus, it consist of 26-50 cells Blastocyst implants Tropoblast cells placenta and membrane Embryocyst embryo Apposition blastocyst brushes against endometrium Adhesion attachment Invasion settles down CHORIONIC VILLI Syncytiotropoblast Hormones: HCG, Estrogen, Progesterone, HPL-insulin Cytotropoblast Langhans layer Protect against syphilis PLACENTA and UMBILICAL CORD - Communication arises from the tropoblast - 12th day of pregnancy: cotyledons WHARTONs JELLY - Prevents compression AMNIOTIC FLUID Amount of term: 800-1,200ml Slightly alkaline

GERM LAYERS 1. Ectoderm outside - CNS, PNS, organs, skin, hair, nails, mouth, anus 2. Mesoderm - Heart, teeth, upper portion of GUT (kidneys, bladder) 3. Endoderm - Lining (GI) CARDIOVASCULAR SYSTEM First organ Single heart tube: 16th day Beat: 24th day Heard: 10-12th week RESPIRATORY SYSTEM 3rd week development 4th week: separates TRACHEO_ESOPHEGEAL FISTULA: No separation 24-28th day: alveoli and capillaries form 12th week: respiratory movements NERVOUS SYSTEM 3rd week: neural plate 24th week: hear and see with papillary reaction ENDOCRINE SYSTEM Fetal adrenal glands supply a precursor for estrogen synthesis Insulin production DIGESTIVE SYSTEM 4th week: GIT and RT separates 6th week: a portion of the intestines enters the base of the umbilical cord 10th week: fetal trunk extends 16th week: meconium formation 32nd week: sucking and swallowing MUSCULOSKELETAL SYSTEM 2nd week: Cartilage prototype 11th week: Fetal movement 12th week: bone ossification 20th week: quickening REPRODUCTIVE SYSTEM 6th week: Gonads 12th week: sedimentary urine 16th week: urination

FETAL GROWTH and DEVELOPMENT 9-12 weeks Sex determination First and second movement Nail beds are forming Heart sound is heard through Doppler technology 13-16 weeks Fetal heart sound auscultated Liver and pancreas functions Sex is determined by ultrasonography 17-20 weeks Fetal kicking Meconium is present in the upper intestine Mother experiences fatigue, dizziness and SOB 21-24 weeks Passive Ab Eyebrows and Eyelashes are well defined Pupils capable of reacting to light Vernix and Fingernails development 24-28 weeks Lung alveoli begin to mature Surfactant is produced in the lungs Testes begun to descend Maternal: Leg cramps 29-32 weeks Active Moro reflex Birth position may be assumed Iron stores Fingernails grow to reach the end of the fingertips GIT matures Maternal: Ankle swell, Constipation 33-36 weeks Lanugo disappears Maternal: Backache, urinary frequency, uterine contractions 37-40 weeks Iron and Ca stored Fetal Kicking causes discomforts Vernix Caseosa is fully formed

PRENATAL CARE Gynecology History a. Naegeles rule -3 +7 +1 b. Mcdonalds rule AOG in week Fundal Height(cm) x 8/7 AOG in lunar months Fundal Height x 2/7 If LMP is known add all the number of days covered by the pregnancy DIAGNOSIS of Pregnancy Presumptive: Subjective Probable: Objective Positive sign ASSESSMENT Leopolds maneuver LM1: Cephalic LM2: Umbilical-presentation LM3: Follyp grip-Engagement LM4: Attitude INTRAPARTAL CARE Psychological changes First trimester: Ambivalence Second trimester: Accepting the pregnancy Quickening Imagines during birth Feels they are left standing in their wings Third trimester: preparing for parenthood Nest building Role playing and fantasizing Nutrition a. Carbohydrates RDA: 2200 cal additional 300 cal b. Protein 950 grams 6 months Pregnant Adult: 68 grams/day Pregnant Adolescence: 73 grams/day

c. Minerals Ca and phosphorus: 1200-1500 mg Iron: 30mg/day Dietary supplement: 15mg/day Foods to avoid: Caffeine, artificial sweeteners, weight loss diets MANAGEMENT Nausea and Vomiting -dry crackers -ice chips -low fats Heart burn -small frequent feeding Flatulence -no cabbage, onion rings Edema/Varicose veins/SOB -frequent rest periods -elevate legs -ambulate Hemorrhoids -increase fiber and fluid

Leg cramps -Ca and exercise Backache -exercise Vaginal discharge -change underwear frequently -use cotton Abdominal Tightening -tailor sitting: perineum -chin to chest: Abdomen -pelvic rocking: pain

COMPONENTS OF LABOR POWERS 1. Primary power: uterine contractions 2. Secondary power: abdominal contractions 3. PASSENGER Fetal head Fontanelles Fetal Head diameters Suboccipitobregmatic: complete flexion, small diameter of head enters the pelvis, 9.5cm Occipitofrontal: moderate extension, larger diameter of head enters the pelvi, 9.5cm Occipitomental: marked extension, head is too large PASSAGEWAY False pelvis True pelvis Types: Gynecoid, Anthropoid, Android and Platypoid POSITION OF THE MOTHER PSYCHOLOGIC RESPONSE

STAGES OF LABOR First stage Latent phase Contraction: 20-40s Cervix dilates: 0-3cm Active: Contractions: 40-60s Cervix dilates: 4-7cm Transitional Contractions: 60-90s Cervix dilates: 8-10cm Second stage Full dilation to Delivery of the baby Mechanism of labor Descent, Flexion, Internal rotation, Extension, External rotation, expulsion Third stage Placenta is delivered 15-20 min. Signs of placental separation -blood gushes out -fundus becomes globular -lengthening of the cord

Rubins postpartal phase Taking-in phase -First 2-3 days -focused on self Taking-hold phase -3rd-2nd week -concern is focused on ability to assume mother roles -tends to outworn herself Letting-Go phase -realizes that infant is a separate individual -experiences a feeling of love -adjust herself and lifestyle to meet the needs of the child OB ABNORMALS Complications of pregnancy 1. Bleeding disorders of pregnancy Hemorrhage Hypovolemic shock (1.5-2 liters) Retinal Hemorrhage Abortion (loss before 20 weeks) Management -Tocolytics Prevent contraction (terbutaline, isoxuprine) -sexual intercourse (2 weeks after the last day of bleeding) 2. Ectopic pregnancy Pregnancy outside the uterus Causes Mechanical factors Functional factors Assisted production

 Failed contraception Management Medical: Methotrexate (chemotherapeutic: acts on the embryo) Salphyngectomy Treat hemorrhage, pain and give emotional support 3. Hydatidiform mole Brownish discharges Fundic height is not congruent to AOG Causes Age Asian Bleeding Management D&C Methotrexate Monitoring HCG Hysterectomy 4. Incompetent cervix Habitual abortion Causes Cerclage: suture the cervix (Mcdonald,Shirodkan) 5. Placenta previa Painless vaginal bleeding Types a. Low lying b. Partialis c. Totalis Causes Multiple pregnancy Multiparity Previous surgery Management IE in double set-up Assess blood loss Watchful waiting if <36 weeks CBR without BRPs Nursing Interventions CBR Tocolytics Betamethasone Amniocentesis OPD: live 5-10 minutes away from the hospital

6. Abruptio placenta Painful vaginal bleeding Board-like rigidity of abdomen Causes Multiple pregnancies Short umbilical cord Hypertension Management Refer immediately Caesarean section 7. Premature rupture of membrane Rupture of bag of water before age of term Watery vaginal discharges Fern test Litmus paper Pooling of fluid in the posterior Vaginal examination Causes Poor nutrition Incompetent cervix Infection Management Asked history CBR Antibiotic 8. Premature Labor LBW: <2 VLBW: <1.5 ELBW: <1 LGA: >90% SGA: <90% Causes History of PTL 2nd trimester abortion Epidemiological Overdistention Uterine abnormalities Maternal infections Management Tocolytics Delivered: prepare incubator

9. Post term pregnancy More than 42 weeks AOG Management Induced labor (Cytotec) Delivered: Tracheal suctioning Warm infant Assess for hypoglycemia: irritable infant 10. Hydramnios High fundic height Increase AFI Causes Fetal problem in GI tract Maternal produce more amniotic fluid Management Instructions on relief of symptoms Hospitalization Indomethacin (NSAID: inhibit prostaglandin synthesis) Amniocentesis 11. Oligohydramnios <500mL Causes Urinary problem-fetal Management Observe for cord compression, fetal hypoxia and prolonged labor Increase fluid intake 12. Hyperemesis Gravidarum Nausea and dehydration Causes HCG Thyroid dysfunction Psychological stress Management Small frequent feeding IVF and fluids Antiemetics Emotional support 13. PICA Intake of non-edible foods Effect: Imbalance nutrition Management Patient centered-stress

14. Anemias in Pregnancy IDA: hgb <11, hct <33 Vitamin B12 deficiency Anemia due to blood loss Folate deficiency Paleness Episodes of dizziness Hypotension Management Iron supplementation 15. Hemolytic Diseases ABO incompatibility -Rh: coombs test Management RHOGAM: 28 weeks AOG to 3 days after delivery Newborn: Phototherapy Exchange transfusion MEDICAL CONDITIONS in PREGNANCY 1. Diabetes Mellitus Insulin resistance due to HPL Diagnostics FBS: 70-110 OGTT: FBS+ 75 grams of glucose, then take blood sugar after 3 hours Management Insulin SQ Measure caloric need Blood Glucose Monitoring Exercise 2. Cardiac condition Cardiac classification Class I: no symptoms Class II: less than ordinary activities Class III: ordinary activities Class IV: even at rest Pregnancy Induced Hypertension Pre-ecclampsia Ecclampsia Nursing Management Bed rest in left lateral recumbent position Monitor BP

Daily weight and I&O High protein diet Monitor FHT Antihypertensive Seizure precaution for the next 48 hours Meds: Magnesium sulfate, Diazepam and hydralazine (methyldopa) 3. Uterine Dysfunction Hypotonic uterine dysfunction: poor uterine contraction Hypertonic uterine dysfunction: intense uterine contraction Management Rule out CPD Vaginal Delivery Maintain F and E Therapeutic rest Keep bladder empty Side lying Bandls ring: pathologic indentation If bandls ring occurs during 2nd stage, manual extraction of placenta 4. Precipitate Labor Precipitate dilatation: >5cm Descent: more than 5 minutes 5. Uterine rupture Sudden sharp tearing pain Palpable fetus, no FHT Causes Scar rupture from previous CS Prolonged obstructed labor Malposition malpresentation Overdistended uterus External trauma Management IVF, BT Oxygen Emergency laparotomy 6. Uterine Inversion Nonpalpable fundus Sudden gash of blood Uterus in the vagina Causes Placenta previa

 Pulling of umbilical cord in a contracted uterus Uterine relaxation due to analgesia Management Prevention Replace uterus and give oxytocin If placenta attached: anesthesia BT, IVF 7. Prolapsed Umbilical Cord Early, late and variable desceleration Causes Polyhydramnios Long cord Malposition/malpresentation Prematurity Management If cord is already outside: Cover with gauze Trendelenburg position Knee chest position 8. Pelvic dystocia Severe pain at the back Inlet contracture: AP diameter <10cm Transverse diameter <12cm Outlet contracture: Bi ischial diameter <8cm Management Backrubs 9. Shoulder dystocia Turtle sign Management HELPERR Help, Legs: Mcrobertss maneuver, Pubic: Suprapubic pressure, Enter maneuver: Internal rotation, Remove the posterior arm, roll the mother COMPLICATIONS DURING THE POSTPARTUM PERIOD 1. Postpartum Hemorrhage Assessment Hypotension Increase RR Palpate fundus, inspect vagina, monitor urine output, monitor LOC Management Trendelenburg

Keep warm Oxygen BT 2. Uterine Atony Management Massage Bladder empty Bimanual compression Oxytocins 3. Uterine subinvolution Fails to contract Foul smelling Causes Placental fragment Ongoing infection Management Ergoverine maleate 4. Sheehans syndrome Pituitary gland-Decrease blood supply Management Hormonal replacement therapy 5. Puerperial Infections Fever: 2 or more days after the first 24 hours postpartum Foul smelling Abdominal pain tenderness, body malaise Lack of appetite Perineal discomfort Management Hygiene perineal lamp Analgesics 6. Endometritis 3-4 or 7 days after delivery Causes Poor aseptic technique Frequent IE Poor hygiene Management Suture removal semi-fowler Antibiotic analgesic and oxytocin Perineal hygiene

uterine packing Laparotomy

7. Post partum Blues 3-5 days after childbirth Periodic drying spells, sadness, confusion, insomnia anxiety Self-limiting Supportive care and education 8. Post partum depression Months after childbirth Anorexia, weight loss, fear of harming the baby, neglect of personal care, self-destructive Management Counselling Group therapy Therapeutic communication Assistance in doing ADLs Monitor suicidal tendencies 9. Post partum psychosis 2-4 weeks following childbirth Early symptom depression but may escalate to delirium and hallucinations Bizarre behavior and anger to baby Management Hospitalization Psychotherapy Remove infant from mother ECT