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MATERNAL ANATOMY
EXTERNAL GENITALIA
SURFACE ANATOMY
Structure
Mons Pubis
Labia Majora
Labia Minora
Clitoris
Vestibule
Vestibular
Glands
Urethral
opening
Vestibular
bulbs
Vaginal
opening/hyme
n
escutheon
7-8x2-3x1-1.5cm
round ligaments terminate at their
upper borders
connective tissue with many
vessels, elastin fibers, and some
smooth muscle fibers
points downward and inward
toward the vaginal opening; rarely
exceeds 2 cm
functionally mature female
structure derived from the
embryonic urogenital membrane
perforated by six openings:
urethra, the vagina, two Bartholin
gland ducts, and two ducts of the
Skene glands
Bartholin glands, paraurethral
glands (Skene glands
diverticulum) minor vestibular
glands
lower two thirds of the urethra lie
immediately above the anterior
vaginal wall.
1 to 1.5 cm below the pubic arch
lie beneath the bulbocavernosus
muscle on either side of the
vestibule
vulvar hematoma.
Hymenal caruncles
Impreforate hymen
VESTIBULE
Vaginal introitus
OPENING
Urethral opening
S:
VULVOVAGINAL
GLANDS
Bartholins
glands
Greater vestibular
glands
Bulbourethral gland
Compound alveolar/
compound acinar
4 and 8 o clock of
the vagina
Bartholinss cyst/
abscess
Page 1 of 33
PERINEUM
closed
compartment
ischiocavernos
us muscle
clitoral erection
bulbocavernos
us muscles
superficial
transverse
perineal
muscles
Clinical Significance
Boundary
Landmark
Anterior
pubic symphysis
Anterolatera
l
Posterolater
al
sacrotuberous ligaments
posterior
coccyx
Continuou
s space
with the
pelvis
Ishorectal
fossae
Course
Triangle
Anterior
Superficial
and deep
Posterior
Urogenital triangle
Boundaries:
Superrior- pubic rami
Lateral-ischial tuberosities
Posterior: superficial transverse
perineal muscle
Anal triangle
ischiorectal fossa, anal canal, anal
sphincter complex, and branches of the
internal pudendal vessels and pudendal
nerve
Terminal Branches:
dorsal nerve
of the clitoris
perineal
nerve
inferior
rectal
Landmark
for pudendal
nerve block
Ischial spine
Blood Supply
Page 2 of 33
H-shaped
lower portion of the vagina is constricted
(urogenital hiatus in the levator ani)
Stratified squamous non keratinized epithelium
without glands
Upper part is more capacious
It extends from the vulva to the cervix.
Ruggae that has an accordion like distensability
Vaginal length:
Vesicovaginal septum
Prepubertal women
o Original SCJ at or near the exocervix
Reproductive Age women
o Eversion of endocervical epithelium and
exposure of columnar cells to the vaginal
environment
o Relocation of SJC down the Exocervix
Late adulthood / Post menopausal women
o SCJ at the endocervical canal
o Formation of transformation zone with
regrowth of the squamous epithelium
Page 3 of 33
UTERUS
SIZE
Nulliparous: 6 to 8 cm
(fundus=cervix) , 50-70 g
multiparous: 10 cm (cervix 1/3), 80 g
or more
Isthmus
Fallopian
tubes
Posterior
wall
Anterior
wall
ENDOMETRI
UM
MYOMETRIU
M
SEROSA
STRATUM FUNCTIONALE
Shed during
menstruation
Supplied by the
Spiral Arteries
Superficial 2/3
Zona
Spongios
a
Zona
compact
a
STRATUM BASALE
Source of
Stratum Functionale
after menstruation
Supplied by the
Straight arteries
Basal 1/3
lympathics
Inner Longitudinal
Middle oblique
Outer longitudinal
lymphatics
OVARIES
Lies on the posterior aspect of the broad ligament,
in the ovarian fossa
o lateral to the uterus in the pelvic sidewall
where the common iliac artery bifurcates
o ovarian fossa of Waldeyer
Are attached to the broad ligament by the
mesovarium.
They are not covered by peritoneum.
Ovaries: LAYERS
OUTER
Innermos
CORTEX t portion
INNER
MEDULL
A
Primordial and
Graafian follicles in
various stages of
development
Outermo
Germinal epithelium
of Waldeyer- a single
layer of cuboidal
epithelium over the
Tunica Albuginea
PELVIS
Page 4 of 33
Ovarian artery
the Aorta
Inferior mesenteric
Lateral femoral
circumflex artery
Fals
e
L INEA TERMINALIS
Tru
e
ANDROI
D
ANTHROP
OID
PLATYPELLOID
FREQUENC
Y
50%
20%
25%
5% rarest
INLET
SHAPE
Round
Heart
Shaped
Vertically
oriented
oval
SIDEWALL
S
Straight
Converg
ent
Convergent
Horizontally
oriented
oval
Divergent,
then
convergent
ISCHIAL
SPINES
Non
promin
ent
Promine
nt
Prominent
Non
prominent
SACRUM
Inclined
neither
anterior
ly nor
posterio
rly
Straight =
pelvis
deeper
than other
3 types
Well curved
and rotated
backward
SIGNIFICA
NCE
Good
prognos
is for
vaginal
delivery
Increased
incidence
of Face
Delivery
Good
prognosis
for vaginal
delivery
Poor
prognosis
for vaginal
delivery
Forward
and
straight
with
little
curvatur
e
Increase
d
incidenc
e of
Deep
Transver
se Arrest
Limited
posterior
space
for fetal
head,
poor
prognosi
s
Posterior: sacroiliac
PHALLUS
(GENITAL
TUBERCLE)
UROGENITAL
SINUS
MALE
FEMALE
Scrotum
Labia Majora
Ventral
portion of the
penis
Penis
Labia Minora
Urinary
bladder
Prostate
gland
Urinary
bladder
Urethral and
Paraurethral
glands
Vagina
Prostatic
Utricle
Bulbourethral
glands
Seminal
colliculus
Clitoris
Greater
vestibular
glands
Hymen
Page 5 of 33
Appendix of
testes
MESONEPHRIC
DUCT
Appendix of
Appendix of
epidydymis
vesiculosis
Ductus of
Duct of
epididymis
epoophoron
Ductus
Gartners
deferens
Duct
Ejaculatory
duct
Seminal
Vesicle
Ureter
Renal Pelvis
Calyces
Collecting system
Glomerulus
Renal Collecting Tubules
Testes
Ovary
METANEPHRIC
DUCT
URETERIC BUD
METANEPHRIC
MESENCHYME
UNDIFFERENTIAT
ED GONAD
CORTEX
MEDULLA
GUBERNACULUM
Seminiferous
tubules
Rete Testis
Gubernaculu
m testis
Hydatid of
Morgagni
Uterus and
Cervix
Fallopian
Tubes
Upper of
the vagina
Ovarian
Follicles
Rete Ovarii
Round
ligament of
uterus
MENSTRUAL PHYSIOLOGY
Overview of Menstrual Cycle
OVARIAN CYCLE
Average cycle duration is approximately 28 days,
with a range of 25 to 32 days.
Follicular phase (days 1 to 14) is characterized by:
o Rising levels of estrogen
o Thickening of the endometrium
Primary Oocyte
o formed by 5th fetal month
o Started their first meiotic division
o Arrested in Prophase from 5th fetal month until
the onset of puberty
o Will complete the first meiotic division at the
onset of puberty
Secondary Oocyte
o Formed after completion of Meiotic I
o Release of the first Polar Body During ovulation
o Arrested in Metaphase II until fertilization
o Completion of 2ND Meiotic Division only occurs if
there is fertilization
Page 6 of 33
HORMONE PRODUCTION
CORPUS LUTEUM
Key events:
1. Constant at 12 to 14 days.
2. Luteinization occurs after ovulation when the CL
develops.
3. Basement membrane separating the granulosalutein and theca-lutein cells breaks down
4. Day 2 postovulation, blood vessels and
capillaries invade the granulosa cell layer.
5. Increased capacity of granulosa-lutein cells to
produce progesterone is due to increased
access to steroidogenic precursors through
blood-borne LDL-derived cholesterol.
6. Just after ovulation, estrogen levels decrease.
7. Mid-luteal phase is a secondary rise that
reaches a peak production of 0.25 mg/day of
17B-estradiol.
8. Toward the end of the luteal phase, there is
secondary decrease in estradiol production.
9. Ovarian progesterone peaks at 25 to 50
mg/day during the midluteal phase. (With
pregnancy, CL continues progesterone
production in response to embryonic hCG)
10. CL is a transient endocrine organ that will
rapidly regress 9 to 11 days after ovulation.
LUTEOLYSIS
Luteolysis may be due to the following:
1.
Decreased levels of circulating LH in the late
luteal phase and
2.
Decrease LH sensitivity of luteal cells
3.
Apoptosis
Effects of luteolysis:
1.
Drop in circulating estradiol and progesterone
levels.
2.
Allows follicular development and ovulation
during the next ovarian cycle
3.
Signals the endometrium to initiate molecular
events that lead to menstruation.
D. Estrogen effects
Page 7 of 33
Days 11-14
window of implantation
Days 8-10
branches of the uterine vessels
MENSTRUATION
Late premenstrual phase endometrium
Role of prostaglandin:
o Vasoconstriction
o Myometrial contractions
o Upregulation of pro-inflammatory responses
PGF2-alpha
o Vasoconstriction of spiral arteries, causing the
uppermost endometrial zones to become
hypoxic
o Potent inducer of angiogenesis and vascular
permeability factors such as VEGF
Vasoactive peptides
3 parts
o Decidua basalis directly beneath blastocyst
implantation, modified by trophoblast invasion
o Decidua capsularis overlies the enlarging
blastocyst, and initially separates it from the
uterine cavity. Prominent during the 2nd month
of pregnancy.
o Decidua parietalis remainder of the uterine
lining
o Decidua vera when capsularis and parietalis
are joined later in pregnancy.
Page 9 of 33
BLASTOCYST FORMATION
1.
2.
3.
4.
5.
1.
2.
3.
Syncytiotrophoblast
o Does not divide mitotically
o Produces the HCG
o Continues its growth into the endometrium to
make contact with the endometrial blood
vessels
DERIVATIVES
LAYER
DERIVATIVES
Ectoderm
CNS and PNS
Sensory organs of seeing and hearing
Integument layer
Endoderm Lining of the GIR and Respiratory tract
Mesoderm Muscles
Cartilages
CVS
Urogenital System
RBC
EMBRYONIC PERIOD
Order of
Formation
CNS
First to develop and continues
post natal
Heart
Completed by 8 weeks
Upper limb
Completed by 8 weeks
Lower limb
Completed by 8 weeks
CLEAVAGE
External
Completed by 9 weeks
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Page 10 of 33
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PERIOD OF TERATOGENICITY
DRUGS IN PREGNANCY
Category
Examples
Adequate and well-controlled human
studies have failed to demonstrate a
A risk to the fetus in the first trimester
Folic acid
of pregnancy (and there is no
evidence of risk in later trimesters).
Animal reproduction studies have
failed to demonstrate a risk to the
fetus and there are no adequate and
well-controlled studies in pregnant
Paracetamol,
women OR Animal studies have
B
amoxicillin,
shown an adverse effect, but
cephalexin,
adequate and well-controlled studies
in pregnant women have failed to
demonstrate a risk to the fetus in any
trimester.
Animal reproduction studies have
shown an adverse effect on the fetus
and there are no adequate and wellC
controlled studies in humans, but
paroxetine
potential benefits may warrant use of
the drug in pregnant women despite
potential risks.
There is positive evidence of human
fetal risk based on adverse reaction
data from investigational or marketing Phenytoin,
D experience or studies in humans, but tetracyclne,
potential benefits may warrant use of
aspirin,
the drug in pregnant women despite
potential risks.
Studies in animals or humans have
demonstrated fetal abnormalities
and/or there is positive evidence of
human fetal risk based on adverse
Thalidomide,
X reaction data from investigational or
isotretinoin
marketing experience, and the risks
involved in use of the drug in
pregnant women clearly outweigh
potential benefits.
AMNIOTIC FLUID
Volume 497 Ml
Surfaces
o Fetal
Hofbauer cells
Circulation in the Mature Placenta
FUNIS
Umbilcal cord
Ave lenght: 55 cm
Trophoblast
Steroid hormones
PLACENTA
FETAL TO MATERNAL MEMBRANES
Amnion
o Avascular; provides tensile strenght; first
identifiable at 7th to 8th day of life; from fetal
ectoderm
Chorion
Myometrium
Steroid
Nonpregnant
Serosa
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Pregnant
Page 11 of 33
0.10.6
0.020.1
0.140
0.050.1
0.050.5
1030
1520
50150
250600
0.2500.600
112
1020
hCG
Glycoprotein
Similar to hGH
Findings
Fetal Demise
dec estrogen
PROGESTERONE
Source:
o First 6-7 weeks of pregnancy: Corpus luteum
(ovary)
o After 8 weeks: Placenta (Syncytiotrophoblast)
Function:
o Affects tubal motility, the endometrium,
uterine vasculature, and parturition
o Inhibits T lymphocytemediated tissue
rejection
Fetal anencephaly
Fetal adrenal
hypoplasia
absence of C19-precursors
Fetal-Placental
Sulfatase Deficiency
Fetal-Placental
Aromatase Deficiency
Trisomy 21Down
Syndrome
serum unconjugated
estriol levels were low
ESTROGEN
Fetal Erythroblastosis
Elevated
Glucocorticoid
Treatment
Dec estrogen
Maternal Adrenal
Dysfunction
Dec estrogen
Gestational
Trophoblastic Disease
placental estrogen
formation is limited to the
use of C19-steroids in the
maternal plasma
estrogen produced is
principally estradiol
ESTROG
EN
Estradiol
Estrone
Estriol
SOURCE
Maternal ovaries for weeks 1 through 6
of gestation
After T1, the placenta is the major source
of circulating estradiol.
Maternal ovaries, adrenals, and
peripheral conversion in the first 4 to
6 weeks of pregnancy
The placenta subsequently secretes
increasing quantities
Produced almost exclusively by the
placental syncytiotrophoblast
Continued production depends on the
living fetus
Marker of fetal well being
FETAL DEVELOPMENT
Terms
Perinata
l
period
Page 12 of 33
Fetal
period
Embryo
nic
period
Abortus
Naegeles Rule
36
CRL of 32
deposition of subcutaneous fat
40
HEAD DIAMETERS
3 vessels (AVA)
o 2 arteries
o 1 vein
Three Shunts:
o Ductus venosus
o Foramen ovale
o Ductus arteriosus
FETAL PERIOD
AO
G
12
16
20
24
Fetal Blood
HEMATOPOIESIS
o yolk sac first site of hematopoiesis.
embryonic period
o Liver takes over up to near term
o Bone marrow starts at 4 mos AOG and
remains as the major site of blood formation
during adulthood
Fetal Hemoglobin
Page 13 of 33
Hemoglobin F
Hemoglobin A (adult hgb)
Hemoglobin A2
testes or ovaries?
Dependent on the presence of SRY gene
present on the Y chromosome or the Testes
Determining region
Phenotypic Sex
o Is it a penis or a vagina?
o Dependent on the hormones produced
o
o
Kleihauer-Betke test
Rationale:
o Fetal RBCs are resistant to denaturating
effects of alkali.
o Motherr RBC are sensitive, thus may
hemolyze
FETAL PULMONARY SYSTEM
SEXUAL DIFFERENTIATION
MATERNAL PHYSIOLOGY
Genetic/Chromosomal Sex
o XX or XY?
o Dependent on the presence of Y chromosome
Gonadal Sex
CARDIOVASCULAR SYSTEM
Changes in cardiac function become apparent
during the first 8 weeks of pregnancy.
Cardiac output is increased as early as the fifth
week and reflects a reduced systemic vascular
resistance and an increased heart rate.
Resting pulse rate increases about 10 bpm.
Between 10 and 20 weeks, plasma volume
expansion begins and preload is increased.
Ventricular performance is influenced by both the
decrease in systemic vascular resistance and
changes in pulsatile arterial flow.
A. Heart
Page 14 of 33
F.
Prostaglandins
Renal medullary prostaglandin E2 synthesis is
increased markedly during late pregnancy and is
presumed to be natriuretic.
Prostacyclin (PGI2), the principal prostaglandin of
endothelium, is increased during late pregnancy
and regulates blood pressure and platelet
function. It also has been implicated in the
angiotensin resistance characteristic of normal
pregnancy.
G. Endothelin
Tidal
volume
Residual
volume
Expirator
y reserve
volume
Inspirator
y
capacity
Inspirator
Nonpregna
nt
Term
Pregnan
cy
4,200
4,000
450
600
1,000
800
700
550
2,500
2,650
2,050
2,050
Etiology
Resting minute
ventilation is also
increased. Can be
due to enhanced
respiratory drive
due to stimulatory
effects of
progesterone, low
expiratory reserve
volume and
compensated
respiratory
alkalosis.
Elevated
diaphragm
Page 15 of 33
1,700
1,350
3,200
3,200
Elevated
diaphragm
UNCHANGED
Total haemoglobin mass, and in turn total oxygencarrying capacity, increases appreciably.
DECREASED
7.38
7.42 (a)
7.36
7.52 (v)
Second
trimest
er
Third
trimest
er
Not
reported
16-22
Not
reported
25-33
90-98
92-107
7.40
7.52 (v)
7.41
7.53
7.39
7.45
(v)
(a)
REPRODUCTIVE SYSTEM
A. Uterus
Page 16 of 33
endocervical
gland
hyperplasia and hypersecretory appearance
C. Ovaries
Linea nigra
Palmar erythema
METABOLIC CHANGES
3rd trimester maternal basal metabolic rate is
INCREASED by 10 to 20%
WHO (2004) estimate of additional energy
demands:
o 1st tri 85 kcal/day
o 2nd tri 285 kcal/day
o 3rd tri 475 kcal/day
a. Weight gain
Protein metabolism
1.
2.
3.
4.
d. Carbohydrate metabolism
INCREASED
Iodine requirement
DECREASED
Sodium
Page 17 of 33
Potassium
Total serum calcium
(ionized & non-ionized)
Serum magnesium
HEMATOLOGIC CHANGES
a. Blood volume
Functions of hypervolemia:
o Meets the metabolic demands of the enlarged
uterus and its greatly hypertrophied vascular
system
o Provides abundant nutrients and elements to
support the rapidly growing placenta and fetus
o Protects the mother and fetus against the
deleterious effects of impaired venous return in
the supine and erect positions
o Safeguards the mother against the adverse
effects of parturition-associated blood loss
URINARY SYSTEM
a. Kidney
Maintenan
ce of acidbase
Decreased
bicarbonate
threshold;
Progesterone
stimulates
respiratory center
Plasma
osmolality
Osmoregulation
altered;
Osmotic
thresholds for
vasopressin (AVP)
release and thirst
decrease
Hormonal
disposal rates
increase
borderline);
Protein, amino
acid, and glucose
excretion all
increase
Serum
bicarbonate
decreased by 4-5
mEq/L;
PCO2 decreased
10 mmHg;
PCO2 or 40
mmHg already
represents CO2
retention
Serum osmolality
decreases 10
mOsm/L (serum
Na 5 mEq/L)
during normal
gestation
Increased
placental
metabolism of
AVP may cause
transient diabetes
insipidus during
pregnancy.
1. Loss of nutrients
o Amino acids and water-soluble vitamins
are lost in urine in greater amounts
2. Tests of renal function
o Serum creatinine DECREASED. Values above
0.9 mg/dl suggest underlying renal disease and
prompt investigation
o Creatinine clearance INCREASED about 30%
3. Urinalysis
o Glucosuria may NOT be abnormal. It can be
due to increase in GFR, together with impaired
tubular reabsorptive capacity for filtered
glucose. About 1/6 of pregnant women spill
glucose, but the possibility of DM should not be
ignored.
o Proteinuria NOT evident during pregnancy
except occasionally in slight amounts during or
soon after vigorous labor.
o Albumin excretion is minimal and ranges from
5 to 30 mg/day
o Hematuria is often a result of contamination
during collection. Common after difficult labor
and delivery because of trauma to the bladder
and urethra.
b. Ureters
Bladder
Bladder trigone is elevated by (>12 weeks):
o Increased uterine size
o Hyperemia
o Hyperplasia of bladders muscle and
connective tissue
Note: Elevation of trigone causes thickening of
posterior, or intraureteric origin
No mucosal changes
a. Liver
Increased levels:
o Total alkaline phosphatase almost doubles
o Total albumin
o Serum globin
Decreased levels:
o AST
o ALT
o GGT
o Bilirubin
o Serum albumin
Page 19 of 33
c.
Page 20 of 33
Eyes
Page 21 of 33
Palmar erythema
17 weeks: stethoscope
heart tone
10 weeks: doppler equipment
Fetal
movemen
ts
Presumptive
Probable
Positive
Symptoms
Nausea,
vomiting
Bladder
frequency/urgen
cy
Perception of
fetal movement
Breast
enlargement
Symptoms
Abdominal
distention
Braxton-Hicks
Signs
Secondary
amenorrhea
Chadwicks sign
Chloasma (face)
Linea nigra,
striae
Spider
telangiectasia
Breast changes
Thermal
changes
Signs
(+) Pregnancy
test
Abdominal
enlargement
Outlining of the
fetal parts
Hegars sign
Goodells sign
Ballotment
Signs
Fetal heart tone
Perception of
fetal movement
by examiner
Ultrasound
evidence
Pregnancy Test
1. Chorionic gonadotrophin
2. Ultrasound recognition (Transvaginal
ultrasound)
Major goals:
1. Define the health status of the mother and
fetus.
2. Estimate the gestational age.
3. Initiate a plan for continuing obstetrical
care.
COMPONENT
First
visit
+
+
+
+
+
History
Complete PE
Blood pressure
Maternal weight
Pelvic/cervical
exam
Fundal height
+
FHT & position
+
Hemoglobin
+
(Hgb) & Hct
Blood type & Rh
+
factor
Antibody screen
+
Pap smear
+
Urine protein
+
Urine culture
+
Rubella titer
+
Syphillis test
+
(VDRL)
Hepatits B
+
surface Ag
(HbsAg)
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15-20
weeks
24-28
weeks
29-41
weeks
+
+
+
+
+
+
+
+
+
+
+
+
+
Page 22 of 33
+
*
Menstrual history
Psychosocial screening
Nonbiomedical factors that affect mental and
physical well-being.
Screening for barriers to care:
1. lack of transportation
2. child care or family support
3. unstable housing
4. unintended pregnancy
5. communication barriers
6. nutritional problems
7. cigarette smoking, substance abuse
8. depression
9. domestic violence
Page 23 of 33
E.
Maternal surveillance:
o Vital signs: BP, weight
o Symptoms: headache, altered vision,
abdominal pain, nausea and vomiting,
bleeding, vaginal fluid leakage, dysuria
o Abdominal Exam: fundal height
o Vaginal exam: confirms presenting part &
station, pelvic capacity, and cervical
consistency, effacement and dilatation
C. Assessment of Gestational Age
Category
Underwei
ght
Normal
Overweig
ht
Obese
BMI
(AsiaPacific)
<18.5
BMI
(ACOG)
Kilogra
ms
Pound
s
<19.8
28
40
25
35
15
25
11 20
18.5
24.9
25 29.9
19.8 26
26 - 29
12.5 18
11.5 16
7 11.5
>30
>29
5 9.1
III. Nutrition
Calories
Protein
Carbohydr
ates
Fats
Dietary
fiber
Page 24 of 33
Casein
lactalbumin 0.5%
Amino acids Enough for
Cysteine
growing brain
Enough
Taurine
Fats (Total)
4% average
Enough
Saturati
UNsaturated
on
Fatty acids
Enough for
linoleic acid
growing brain
(essential)
Enough
Cholesterol
Lipase to digest
Present
fat
Lactose (sugar)
7% (enough)
Salts (mEq/L)
Sodium
Chloride
Potassiu
m
Iron colostrum
Mature milk
6.5
12
14
Milk
Cow milk
More required
Likely
Antibodies not
active, absent
lactoferrin
4% too much
3% too much
0.5%
Not enough
Not present
4%
Too much
saturated
Not enough
Not enough
None
3% - 4% (not
enough)
25 (too much)
29 (too much)
35 (too much)
Let the mother hold the baby close and let him
suck at the breast.
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FAMILY PLANNING
Fertility Awareness-based (FAB) Methods
II.
III.
IV.
V.
Hormonal Contraceptives
I.
Combination hormonal contraceptives.
A. Mechanism of Action
Progestins action:
i. Prevent ovulation by suppressing
LH
ii. Thicken cervical mucus, thereby
retarding sperm passage.
iii. Render the endometrium
unfavourable for implantation.
Estrogen action:
1. Prevents ovulation by suppressing
FSH release.
2. Stabilizes the endometrium, which
prevents intermenstrual bleeding
also known as breakthrough
bleeding.
B. Composition
ESTROGEN
o Features:
Side effects:
1. Breast tenderness
2. Fluid retention
3. Weight gain
4. Nausea
5. Headache
PROGESTIN
o Features:
Structurally related to
progesterone, testosterone, or
spironolactone
Structurally similar to
spironolactone and have similar
effects to 25 mg of this diuretic
hormone.
Displays antiadrogenic
activities
Antimineralocorticoid properties
that may cause potassium
retention and hyperkalemia.
Serum potassium level
monitoring for the first month is
recommended. Likeswise for
the following drugs:
NSAIDS, ACE inhibitors,
angiotensin II antagonists,
herparin, aldosterone
antagonists, and
potassium-sparing
diuretics.
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Thrombophilias
Hypertension
Obesity
Diabetes
Smoking
Sedentary lifestyle
o COCs are NOT recommended for
women within the first 4 weeks after
delivery.
E.
Neoplasia
o Overall, COCs are not associated with
an increased risk for cancer.
o Protective effect against ovarian and
endometrial cancer
o Relative risk of cervical dysplasia and
cervical cancer is increased in current
COC users, but following 10 or more
years of disuse, risk returns to that of
never users.
o No evidence for increased risk of
hepatocellular cancer.
o Women with known tumores, COCs are
AVOIDED in those with benign hepatic
adenoma and hepatocellular
carcinoma.
o Women who are carriers of the BRCA1
and BRCA2 gene mutation, risks for
breast cancer are NOT INCREASED by
COC use.
o COCs appear to lower rates of benign
breast disease.
II.
III.
Implants
Etonogestrel implant
o Thin, pliable progestin-containing cylinders
that are implanted subdermally and release
hormone over many years.
o Implanon
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o
o
Insertion timing
o Etonogestrel implant: Ideally inserted within
5 days of menses. If inserted later in the
cycle, alternative contraception is
recommended for 7 days following
placement.
o Levonogestrel implant: Contraception is
established within 24 hours if inserted
within the first 7 days of the menstrual
cycle.
o Transitioning methods:
4.
TONE
(Abnormal
uterine
contractilit
y)
TISSUE
(Retained
products
of
conception
)
Uterine
distortion/abnorma
lity
Accreta/Increta/Per
creta
Retained
placenta/membran
es
Laceration of the
cervix, vagina or
perineum
Surgical Methods
Tubal ligation
Vasectomy
Definition
The following are suggested definitions but there is a
lack of agreement on what constitutes excessive blood
loss:
1. Blood loss >500 ml for vaginal delivery and 1,000
ml for cesarean section (CS).
2. Blood loss >500 ml in the first 24 hours following
delivery.
3. Ten percent (10%) decrease in hemoglobin or
hematocrit level.
Chorioamnionitis
Uterine relaxing
drugs
Barrier Methods
Male Condoms
Diaphragm
Uterine muscle
fatigue
TRAUMA
(Genital
tract
trauma)
Extension/lacerati
on at CS
Uterine rupture
Uterine inversion
THROMBIN
(Abnormali
Preexisting
clotting
Risk Factors
Multiple gestation
Polyhydramnios
Macrosomia
Prolonged labor
Augmented labor
Prior PPH
Prolonged rupture
of membranes
(ROM)
Fibroids (myoma),
placenta previa
B-mimetics,
MgSO4,
anesthetic drugs
Prior uterine
surgery
Placenta previa
Multiparity
Manual placenta
removal
Succinturiate/acc
essory lobe
Precipitous
delivery
Macrosomia
Shoulder dystocia
Operative
delivery
Episiotomy (e.g.
mediolateral)
Deep
engagement
Malposition
Malpresentation
Prior uterine
surgery
Fundal placenta
Grand multiparity
Excessive
traction on
umbilical cord
History of
Coagulopathy or
Page 29 of 33
ties of
coagulatio
n)
abnormalities (e.g.
hemophilia,
vonWillebrands
disease,
hypofibrinogenemi
a)
DIC
HELLP
Anticoagulation
liver disease
Sepsis
Intrauterine
demise
Hemorrhage
DYSTOCIA
DYSTOCIA: PROBLEMS IN PASSENGER
Fetal Presentations and Conditions
1. Breech
2. External cephalic version
3. POP, OT
4. Brow and Face
5. Transverse/Oblique
6. Compound
7. Macrosomia
8. Shoulder dystocia
1. Breech
Suspected breech
o Pre- or early labor ultrasound to assess type of
breech, fetal growth, EFW, attitude of fetal
head.
o If ultrasound is not available, CS is
recommended.
2. External cephalic version
ABSOLUTE Contraindications
o Where CS is required
o Anterpartum bleeding within the last 7 days
o Abnormal CTG
o Major uterine anomaly
o Ruptured membranes
o Multiple pregnancy (except delivery of the 2nd
twin)
RELATIVE Contraindications
o SGA fetus with abnormal Doppler
o Proteinuric preeclampsia
o Oligohydramnios
o Major fetal anomalies
o Scarred uterus
o Unstable lie
Page 30 of 33
8. Shoulder Dystocia
Shouder Dystocia Drill:
1. Call for HELP!
2. Generous EPISIOTOMY
3. SUPRAPUBIC pressure
4. McRoberts maneuver
If the Drill fails, attempt the following:
1. Delivery of posterior arm
2. Woods screw maneuver
3. Rubin maneuver
4. Zavanelli maneuver
5. Cleidotomy
6. Symphysiotomy
(supplementary)
Shoulder dystocia drill to better organize
emergency management:
1.
Other maneuvers:
o Zavanelli maneuver replaces or flexes the
fetal head back into the vagina, then CS is
performed.
o
o
Vasa previa
o Elective CS between 35-37 weeks AOG
o Emergency CS for bleeding vasa previa
Placenta previa
o Any degree of placental overlap (>0 mm) at
the internal os after 35 weeks is an indication
for CS
o Previa within 1 cm of the internal os is an
indication for CS
o Elective CS for asymptomatic woman with
previa >37 weeks and for suspected accreta
>36 weeks
Abruptio placenta
o Emergency CS for abruptio placenta with fetal
compromise, severe uterine hyprtonus, life
Page 31 of 33
4. Infection in pregnancy
Hepatitis B virus
o Scheduled CS at 39 weeks with HBV profile as
follows:
HbeAg positive
HIV
o Elective CS at 39 weeks to reduce risk of
MTCT provided:
Hypertensive complications
o Maternal indications
HELLP syndrome
Placental abruptio
o Fetal indications
Severe IUGR/FGR
Cardiac disease
o CS reserved for high-risk cardiac patients.
Gestational DM
Obesity
o Increased risk for CS
Macrosomia
6. IUGR/FGR
o
o
o
o
Elective CS
o Fetus with hypoplastic left heart syndrome
o Transposition of great arteries with intact
intraventricular septum that require urgent
neonatal atrial septostomy
8. Maternal request (CDMR)
Scheduled at 39 weeks
Pre-operative preparation for CS
Hemoglobin determination
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