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FEU-NRMF

Department of Obstetrics and


Gynecology
 LANGER LINES
◦ orientation of dermal
fibers

◦ vertical skin incisions


 more tension, wider scars
◦ low transverse incisions
(Pfannenstiel)
 follow Langer lines;
superior cosmetic results
 Camper’s fascia
› Superficial
› predominantly fatty
layer
 Scarpa’s fascia
› Deeper
› more membranous
layer
Cephalad-
aponeuroses invest
the rectus abdominis
bellies above and
below

Caudal- all
aponeuroses lie
anterior to the rectus
abdominis muscle,
and only the thin
transversalis fascia
and peritoneum lie
A. Femoral Artery Branches:
– skin , subcutaneous layers , mons
pubis
› superficial epigastric
› superficial circumflex iliac
› external pudendal

B. External Iliac Artery :


- muscles , fascia
› inferior "deep" epigastric vessels
› deep circumflex iliac vessels-.
CLINICAL
SIGNIFICANCE:
Direct hernias-
Hesselbach
triangle
Indirect hernias-
deep
inguinal ring
 ILIOHYPOGASTRIC NERVES-
suprapubic area
 ILIOINGUINAL NERVES (L1)-
› lower abdominal wall
› upper portion of the
labia majora
› medial portion of the
thigh
 CLINICAL
SIGNIFICANCE:CAN BE
ENTRAPPED IN A
PFANNENSTEIL INCISION
AND CAUSE LOSS OF
SENSATION IN THE AREA
PUDENDA or
VULVA
 all structures
visible externally
from the pubis to
the perineum:
MONS PUBIS
 mons veneris
 fat-filled
 covered by curly hair
( escutcheon )in a
triangular area
LABIA MAJORA
 Male homologue: scrotum
 WHERE round ligaments
terminate
 Outer surface with hair
while inner surface
without hairs

 Merge posteriorly (
posterior commissure.)
EXTERNAL GENERATIVE ORGANS
LABIA MINORA
 Lacks hair follicles,eccrine
and apocrine glands
MALE HOMOLOGUE-VENTRAL
SHAFT OF PENIS
 many nerve endings

 2 lamellae superiorly
 lower pair: frenulum of
the clitoris
 upper pair: prepuce
 Inferiorly fourchette.
CLITORIS
• Male homologue: penis
• PARTS: glans, a corpus,
and two crura

• richly supplied with


nerve ending
• principal female
erogenous
organ
VESTIBULE

 almond-shaped
◦ BOUNDARIES:
 Lateral- Hart line
 Medial – hymen
 Anterior- frenulum
 Posterior-fourchette
VESTIBULE
6 openings:
◦ urethra
◦ vagina
◦ ducts of the
Bartholin glands
(2)
◦ ducts of the
paraurethral
glands/skene
glands (2)
BARTHOLIN’S
GLANDS
◦ greater vestibular
glands
 Open distal to the
hymenal ring at 5 & 7
o'clock
 INFECTION of
ducts:BARTHOLINS
CYST/ABSCESS
PARAURETHRAL
GLANDS

◦ Skene glands
◦ Minor vestibular
glands
◦ INFECTION:URETH
RAL
DIVERTICULUM
• Male homologue: Bulbocavernosus
corpus spongiosum muscle

of the penis
• aggregations of Vestibular bulb

veins beneath the


bulbocavernosus
muscle
• CLINICAL
SIGNIFICANCE:
• CAUSES VULVAR
HEMATOMA DURING
DELIVERY
VAGINAL OPENING AND
HYMEN
HYMEN
• Elastic
collagenous
connective tissue
Stratified
squamous
epithelium
Hymenal
caruncles-
remnants after
delivery
VAGINAL OPENING AND
HYMEN
• Imperforate hymen
CLINICALLY:
• Primary
amenorrhea,cyclic pelvic
pain,bulging mass at the
introitus
• Management:cruciate
incision or excision
VAGINAL OPENING AND
VAGINA HYMEN
 Embryology
 upper portion - müllerian ducts
 lower portion - urogenital sinus

 NO GLANDS WITH ABUNDANT VESSELS


VAGINAL OPENING AND
HYMEN
VAGINA
 vesicovaginal septum-
(VAGINA AND BLADDER)

 rectovaginal septum –
(VAGINA AND RECTUM)

 CLINICAL IMPORTANCE)
 Posterior fornix-(POUCH OF
DOUGLAS)surgical access of
the peritoneal cavity
 LATERAL FORNICES-BI
MANUAL EXAMINATION TO
PALPATE THE ADNEXA
VAGINAL OPENING AND
HYMEN
VAGINA

BLOOD SUPPLY LYMPHATIC DRAINAGE

cervicovaginal
External, internal
Upper branches of uterine
and common iliac
Third artery and vaginal
nodes
artery
Middle inferior vesical
Internal iliac nodes
third arteries
middle rectal and
Lower third internal pudendal Inguinal nodes
arteries
 Blood supply:
 Internal pudendal artery (inferior rectal artery and
posterior labial artery)
 NERVE SUPPLY-PUDENDAL NERVE LOCATED IN
PUDENDAL CANAL ALSO CALLED AS
 ALCOCKS CANAL
PERINEUM
ANTERIOR TRIANGLE
 Urogenital Triangle

 1.Superficial space – closed


compartment
 2.Deep space – continuous
superiorly with the pelvic cavity
CLINICAL SIGNIFICANCE:
INFECTION OR HEMATOMA IN
DEEP SPACE CAN SPREAD TO
ABDOMINAL CAVITY
POSTERIOR
TRIANGLE
 Contains:
 Ischiorectal fossa
 Anal canal
 Anal sphincter
complex
 Branches of the
internal pudendal
vessels
 Pudendal nerve
PUDENDAL NERVE
• Formed by the
anterior rami of
S2-S4
• Lies posteromedial
to the ischial
spines
MUSCLES CUT IN
EPISIOTOMY
• Levator ani
• Central tendon of
the perineum
• Bulbocavernosus
m.
• Superficial
transverse perineal
m.
• External anal
sphincter
 Two müllerian
(paramesonephric) -

 DEVELOPS INTO:
 oviducts uterus,upper
vagina
Cervix

 Majority-collagen, elastin
and proteoglycan
 10% smooth muscle
 IF WITH MORE MUSCLE
CONTENTINCOMPETEN
T CERVIX

 Ectocervix –
nonkeratinized
squamous epithelium

 Endocervix – columnar
epithelium
Uterus

 Nulliparous: fundus= cervix


 Multiparous:cervix is 1/3 of the total length
 Posterior wall completely covered by serosa
 Blood supply:
 uterine artery(from internal iliac OR HYPOGASTRIC)
 ovarian artery(direct branch of aorta)

ISTHMUS-FORMS THE LOWER UTERINE SEGMENT OF


UTERUS
Uterus: Myometrium

• More muscles in the inner wall than


the outer wall, anterior and
posterior walls than in the lateral
walls
• CLINICALLY:
• Interlacing myometrial fibers -
control of bleeding during the
third stage of labor
Uterus: Endometrium
 Uterine and ovarian
arteries  arcuate 
radial  spiral/coiled
and basal/straight
 CLINICALLY:

 SPIRAL ARTERIES –
RESPONSIVE TO
HORMONES
ROUND LIGAMENTS

 Terminate in labium majus.

 BLOOD SUPPLY:Sampson
artery

 MALE HOMOLOGUE:
gubernaculum testis
1.BROAD LIGAMENTS

 Drapes over structures :


 (FALLOPIAN TUBES)Mesosalpinx, (ROUND
LIGAMENT)mesoteres, (OVARIES)mesovarium,
(UTERUS)mesometrium

 2.SUSPENSORY LIGAMENT OR
INFUNDIBULOPELVIC LIGAMENT–
◦ fimbriated end of the fallopian tube to the pelvic wall,
where OVARIAN vessels traverse
CARDINAL LIGAMENTS

 Transverse cervical or Mackendrodt ligament

 Thick base of the broad ligament


UTEROSACRAL
LIGAMENTS
• posterior
supravaginal
portion of the
cervix to the
fascia over the
sacrum
LYMPHATICS
 Cervix
◦ hypogastric nodes
 Body of the uterus
◦ internal iliac and periaortic lymph nodes
FALLOPIAN TUBES

PARTS
 interstitial portion
 isthmus
 ampulla
 infundibulum or
fimbriated (fimbria
ovarica)
Ovaries
 Childbearing years- 2.5 to 5 cm

 Rest in a slight depression


OVARIAN FOSSA OF
WALDEYER
 Ligaments:
 Broad
ligament,uterovarian,infun
dibulopelvic ligaments
 Blood supply:ovarian
 Oocytes are located in the
CORTEX
 OVULATORY CYCLES:
◦ Predictable, regular, cyclical and spontaneous

 Average duration - 28 days.


Birth 2 million oocytes

Puberty 400,000 follicles

Rate of depletion of follicle 1000


per month until 35 years old follicles/month
# of follicles ovulated during 400 follicles
the entire reproductive age
percentage of follicles which 99.9 %
underwent atresia during
lifetime
EARLY FOLLICULAR
PHASE:
 Inhibin B( granulosa
cells) inhibit FSH
 only 1 follicle to
reach maturity
Estrogen 34 – 36 hours
Surge before ovulation
precise predictor
of ovulation

LH 10 – 12 hours
Surge before ovulation
Luteal (Postovulatory) Phase

 Corpus luteum
maintained by LH

 Estrogensecondary RISE
at midluteal phase

 Progesterone peaks in
the midluteal phase
Human Corpus Luteum

Regresses 9 –11 days after


ovulationDECREASED estradiol and
progesterone MENSTRUATION

WHAT WILL MAINTAIN THE CORPUS


LUTEUMHCG IN CASE OF PREGNANCY
EARLY PROLIFERATIVE
PHASE:
 THIN ENDOMETRIUM
 Narrow and tubular glands,with
 Mitotic figures
 NO extravascular blood or
leukocyte infiltration
LATE PROLIFERATIVE
PHASE:

 Endometrium thickens,

 glandular hyperplasia

 increase in stromal
ground substance
(edema and
proteinaceous material).
EARLY SECRETORY
PHASE:

 DATING OF
endometrium
POSSIBLE histology of
the glandular epithelium
DAY FIRST SIGN OF OVULATION
17 Glycogen accumulates
SUBNUCLEAR VACUOLES
21 to Stroma becomes edematous.
24

22 to predecidual transformation of
25

extensive coiling and


secretions of glands
 PREMENSTRUAL PHASE

 Infiltration of the stroma by


polymorphonuclear leukocytes

 pseudoinflammatory appearance to the


tissue
 SEVERE coiling of the spiral arteries 
hypoxia of the endometriumstasis/ischemia

 VASOCONSTRICTION most constant and


striking event
 MENSTRUAL BLOOD –MORE OF ARTERIAL
BLOOD
 Prostaglandin F2 (PGF2) vasoconstrictor 

 myometrial contractions and uterine


ischemia-DYSMENORRHEA
Decidua Basalis beneath blastocyst implantation

Decidua • Overlying the enlarging blastocyst


Capsularis
• CHORION LAEVE- Internally, avascular
extraembryonic fetal membrane

Decidua • Remainder of uterus


Parietalis • Fused with capsularis(14-16
weeks)DECIDUA VERA
3 layers
1. zona
compacta zona
functionalis
2. zona
spongiosa

3. zona basalis gives rise to


new
endometrium
after delivery
 NITABUCH LAYER-zone of fibroid
degeneration
◦ if defective – Placenta accreta
 The blood of the mother and baby DOES NOT
mix in a HEMOCHORIAL placenta

 MATERNAL BLOOD IN THE INTERVILLOUS


SPACE BATHE THE SYNCITIOTROPHOBLAST
BEFORE IT ENTERS THE
 ENDOTHELIAL WALL OF THE FETAL
CAPILLARIES
 6 – 7 days after fertilization

STAGE AT THE TIME OF IMPLANTATION


 Villous trophoblast

 Extravillous trophoblast

 intervillous trophoblast

 endovascular trophoblast
 Penetrates the spiral artery lumen .IMPORTANT
CLINICALLY IN PRE ECLAMPSIA PREVENTION
 Umbilical cord
◦ Originates from the body stalk
 Innermost avascular fetal membrane

 Provides the tensile strength

 IN CASE OF INFECTION MAY WEAKENED


 PROM preterm delivery
 AF INCREASE UP TO 34 WEEKS then it
declines

 1,000 ml. at term


Syncitiotrophoblast – major site of steroid
production
• Fetal adrenal secretion of C-19 steroids,
precursor of estrogen synthesis

• LDL-cholesterol from maternal plasma for


progesterone biosynthesis
HUMAN CHORIONIC GONADOTROPIN (hCG)

Alpha sub unit is similar to FSH,LH,TSH

• Detected in blood and urine either in pregnancy or in


neoplastic disease
•Early pregnancy produced by syncitiotrophoblast and
cytotrophoblast
• Detectable in plasma 7 to 9 days after the
midcycle LH surge

• Doubling TIME every 2 days


• Maximal levels 8 to 10 weeks’ gestation
• 60th and 80th days after the last menses -
peak levels 100,000 mIU/mL
• HIGH hCG LEVELS  LOW hCG LEVELS
– Multifetal pregnancy ◦ Early pregnancy
– Erythroblastosis wastage
fetalis ◦ Ectopic Pregnancy
(Fetal hemolytic
anemia)
– Gestational
Trophoblastic
Disease
– Fetus w/ Down
Syndrome
• Also called human chorionic
somatomammotropin or chorionic growth
hormone
– potent lactogenic and growth hormone-like
bioactivity
1. Maternal lipolysis and increase in the levels
of circulating free fatty acids

2. Anti-insulin or "diabetogenic" action

3. Potent angiogenic hormone


• myometrial smooth muscle to promote
uterine relaxation and the quiescence
observed in early pregnancy
• secreted by adipocytes
• an anti-obesity hormone - food intake
• regulates bone growth and immune function

• correlated positively with fetal birthweight


• fetal development and growth
UTERINE ENLARGEMENT:
◦ Stretching and hypertrophy of muscle cells
 not hyperplasia

◦ INCREASE Fibrous tissue AND elastic tissue


Braxton Hicks
 irregular, painlesss
contractions
 Unpredictable, sporadic,
non-rhythmic, and
intensity 5-25 mmHg
SOFTENING OF
CERVIX(GOODELS SIGN)
ISTHMUS(HEGARS SIGN)

CYANOSIS

Cervical Eversion
Beading Mucus plug
progesterone
pattern (Normal)

Amniotic Ferning
estrogen
fluid pattern
CORPUS LUTEUM
functions maximally 6-7 weeks
CLINICAL SIGNIFICANCE:DON’T REMOVE
ASYMPTOMATIC OVARIAN TUMORS AT THIS
TIMEABORTION
• DUE TO HIGH HCG
(hyperreactio
luteinalis)
BILATERAL
ASSOCIATED WITH
1.Gestational
trophoblastic diseases
2. DM,
3. D-isoimmunization,
4.multiple fetuses)
5.chronic renal failure,
hyperthyroidism)
• Maternal virilization- • Diagnosis:
30% Ultrasound of
enlarged ovaries
with multiple cysts
• solid ovarian tumor

• maternal virilization, but usually female


fetus is NOT affected!!!
• WHY?BECAUSE OF THE CAPACITY OF THE
PLACENTA TO CONVERT ANDROGEN TO
ESTROGEN

NB: 23rd ed Williams


NORMAL PREGNANCY:
 Mild fasting hypoglycemia

 Postprandial hyperglycemia
 Hyperinsulinemia
INSULIN SENSITIVITY is LOWER in
pregnancy to about 45-70%

Mediated by:
 Estrogen and Progesterone
 Human Placental Lactogen
MATERNAL
HYPERLIPIDEMIA
 HYPERVOLEMIA
◦ metabolic demands
◦ support the growing placenta & fetus
◦ protect FROM blood loss
SUMMARY
INCREASED
Blood volume
40-45% near term

Hgb and Hct DECREASED


concentration (Hgb <11.0 g/dl = IDA)
INCREASED
Iron Requirement (6-7 mg/day after
Midpregnancy)
Hyperventilationdecreased maternal PCO2
transport of carbon dioxide from the fetus to the
mother and facilitates release of oxygen from
maternal blood to the fetus.
Glucosuria may not be
abnormal, and is common.

Proteinuria is abnormal.

Hematuria is usually a result of


contamination.
 Prolonged gastric
emptying
timeconstipation

 Pyrosis (heartburn)
AMENORRHEA 10 days or more after the time of expected
menses

CHANGES IN FERN
CERVICAL MUCUS PATTERN increased concentration of sodium
chloride
estrogen
BEADED
PATTERN

progesterone
DISCOLORATION CHADWICK SIGN
OF VAGINAL • vaginal mucosa appears dark blue and
MUCOSA congested

CHANGES IN THE Increased softening as pregnancy advances


CERVIX
CHANGES IN THE
UTERUS
6 – 8 weeks Hegar sign – softening of isthmus
12 weeks Uterus almost globular
Uterine Souffle Soft blowing sound synchronous with the maternal
pulse

Funic souffle Whistling sound synchronous with the fetal pulse

PERCEPTION OF Primigravid: 18 – 20 weeks


FETAL MOVEMENT Multigravid: 16 – 18 weeks
FETAL HEART 17 – 19 weeks stethoscope
ACTION
10 weeks Doppler
(110-160 bpm)
5 weeks Transvaginal
Funic (umbilical cord) souffle
• Rush of blood in the umbilical arteries
• Sharp, whistling sound synchronous with fetal pulse

Uterine souffle
• Rush of blood through dilated uterine vessels
• Soft blowing sound that is synchronous with maternal pulse

Sounds resulting from fetal movement

Maternal pulse

Sounds from maternal intestinal peristalsis


4-5 Gestational sac by
weeks transabdominal UTZ
5-6 Yolk sac
weeks
6 weeks Embryo with cardiac
activity
12 weeks CRL is predictive of
gestational age within 4
days
NULLIGRAVIDA A woman who is not now and never has been
pregnant
GRAVIDA A woman who is or has been pregnant,
irrespective of the pregnancy outcome
NULLIPARA A woman who has never completed a pregnancy
beyond 20 weeks’ age of gestation
PRIMIPARA A woman who has been delivered only once of a
fetus or fetuses born alive or dead with an
estimated length of gestation of 20 or more weeks
MULTIPARA Completed 2 or more pregnancies to 20 weeks or
more
PARITY Number of pregnancies reaching 20 weeks and not
by the number of fetuses delivered
*same for singleton or multifetal delivery or
delivery of a live or stillborn infant
MEAN DURATION FROM 280 days or 40 weeks
LAST NORMAL MENSTRUAL
PERIOD
(GESTATIONAL AGE OR
MENSTRUAL AGE)
EXPECTED DATE OF LMP + 7 days then count
DELIVERY back 3 months
(NAEGELE’s RULE)
OVULATORY AGE OR 2 weeks short of the
FERTILIZATION AGE menstrual age
3 TRIMESTERS
1st TRIMESTER Extended through completion of 14
weeks
2nd TRIMESTER Through 28 weeks
3rd TRIMESTER 29th through 42nd weeks
 MONTHLY UP TO 28 WEEKS

 EVERY 2 WEEKS 28 WEEKS TILL 36 WEEKS

 WEEKLY THEREAFTER
FUNDAL HEIGHT
FH in cms correlates with AOG at 24-34
weeks

FETAL HEART
SOUNDS
10 weeks – doppler; 5 weeks - TVS
ULTRASOUND 8 – 16 weeks was accurate by 2 days
for predicting the actual date at delivery
CALORIES Requires 80,000 Kcal
Increase intake of 100 –
300kcal/day

PROTEIN
Preferably supplied from animals
MINERALS
IRON

I
Daily ferrous iron supplement = 27 mg

Increase to 60 – 100 mg/day if


• large woman
• twin fetuses
• late iron supplementation
• irregular intake
• depressed hemoglobin levels
Ingest at bedtime or on empty stomach
VITAMINS
FOLIC Prevents NTD
ACID Daily intake of 400mcg --> periconceptional period

4mg folic acid IF with prior child with NTD

VITAMIN A Associated w/ birth defects  >10000IU/ day


Isotretinoin is potent teratogen in humans

Deficiency --> increased risk of maternal anemia and


preterm birth, night blindness
FISH Avoid shark, swordfish, king mackerel, tile
CONSUMPTION fish
CONTAINS:MERCURY
LEAD screening Exposure effects: gestational HPN
- spontaneous abortion
- low birthweight
- neurodevelopmental impairmentS
DENTITION
Pregnancy is NOT a contraindication for
dental treatment
CAFFEINE

300 mg daily or three 5 oz cups coffee


/day
IMMUNIZATION
VACCINES MMR
CONTRAINDICATED
DURING PREGNANCY Yellow fever
Varicella , smallpox
TRICHOMONIASI Foamy leukorrhea, pruritus
S and irritation
Metronidazole
CANDIDIASIS
Extremely profuse, irritating
vaginal discharge with
pruritic, tender, and
edematous vulva
miconazole, clotrimazole,
and nystatin

 STRUCTURAL abnormalities
HADEGEN
 AFFECTS THE FUNCTION of an organ

TROPHOGEN
 an agent that alters GROWTH
 Category A:
◦ Studies in pregnant women have not shown an
increased risk for fetal abnormalities.

◦ Examples :Levothyroxine, Potassium


supplementation, and Prenatal multivitamins , when
taken at recommended doses.
 Category B:

◦ Animal studies have shown an adverse effect, but


adequate and well controlled studies in pregnant
women have failed to demonstrate a risk to the
fetus
◦ Examples include many antibiotics, such as
penicillins, macrolides, and most cephalosporins
 Category C:
◦ Animal reproduction studies have shown that this
medication is teratogenic (Or embryocidal or has
other adverse effect), and there are no adequate and
well controlled studies in pregnant women.
◦ Approximately two thirds of all medications are in this
category.
 Category D:
◦ This medication can cause fetal harm when
administered to a pregnant woman.

◦ systemic cortocosteroids, azathioprine, Phenytoin,


Carbamazepine, Valproic acid, and Lithium.
 Category X:
◦ This medication is contraindicated in women who
are or may become pregnant.
◦ May cause fetal harm.
◦ EXAMPLE: rubella vaccine.
 Minimum amount of alcohol to produce
adverse fetal consequences is UNKNOWN.
 BINGE drinking- high risk for birth defects
and increased risk for stillbirth
ACE Inhibitors and ARBs
 Enalapril, captopril, lisinopril

 prolonged fetal hypotension and


hypoperfusionrenal ischemia, renal tubular
dysgenesis, anuria oligohydramnios lungs
& limbs
Fluconazole
 Antley Bixler syndrome

◦ oral clefts, abnormal facies, and cardiac, skull,


long-bone, and joint abnormalities

◦ 3 fold increase for tetralogy of Fallot

◦ Category D
 Indomethacin and other PG inhibitors

 1.Constriction of fetal ductus arteriosus


2.persistent fetal circulation
 3. pulmonary hypertension in the neonate
Aminoglycosides
 gentamicin or streptomycin 
nephrotoxicity and ototoxicity
Chloramphenicol
 Gray baby syndrome in preterm neonates
◦ abdominal distention,
◦ respiratory abnormalities,
◦ an ashen-gray color
◦ vascular collapse
Nitrofurantoin

 Hyperbilirubinemi a in G6PD deficiency


Sulfonamides
- Hyperbilirubinemia of a preterm infant

Tetracyclines
 yellowish brown discoloration of deciduous
teeth
Testosterone and Anabolic Steroids
 virilization and may result in ambiguous
genitalia
Diethylstilbestrol
 vaginal and cervical intraepithelial neoplasia
 Genital tract abnormalities
 earlier menopause and breast cancer
Danazol
 virilization
 not a drug, but is a known teratogen
 developmental delay and mild neurological
abnormalities to microcephaly and severe
brain damage
• May be concentrated in large fishes
– Tuna
– King mackerel
– Tile fish

FDA recommendation: DO NOT EAT: shark,


swordfish, king mackerel & tilefish and more than 6
oz of tuna
Vitamin A
 vitamin A supplements may be safe during
pregnancy
 Doses higher than the recommended daily
allowance of 5000 IU should be avoided
Isotretinoin
 anti-acne medication

 ONE OF THE MOST POTENT TERATOGEN IN


COMMON USE

 SIMILAR TO THALIDOMIDE
 Limb-reduction defects (es.upper limbs)

Days 27 to 30: upper limb phocomelia


Days 30 to 33: lower limb phocomelia
 time elapsed since the first day of the
last menstrual period

 280 days or 40 weeks or 9 1/3 calendar


months duration
 centers of ossification

 external genitalia are


beginning to show definitive
signs of male or female gender
 gender can be correctly
determined by experienced
observers by inspection of the
external genitalia
 Cochlear function - 22 and 25WEEKS
90% chance of survival without
physical or neurological impairment.
Sutures
 Frontal - between the two
frontal bones
 Sagittal - between the two
parietal bones
 Coronal - between the frontal
and parietal bones
 Lambdoid - between the
posterior margins of the
parietal bones and upper
margin of the occipital bone
 Occipitofrontal (11.5 cm)- root of the nose
to the most prominent portion of the
occipital bone.
 Biparietal (9.5 cm) - from one parietal boss
to the other.
 Bitemporal (8.0 cm)- the greatest distance
between the two temporal sutures
 Occipitomental (12.5 cm)- from the chin to
the most prominent portion of the occiput.
 Suboccipitobregmatic (9.5 cm) - from the
middle of the large fontanel to the
undersurface of the occipital bone
 Greatest circumference of the head-
corresponds to the plane of the
occipitofrontal diameter , averages 34.5 cm

 Smallest circumference - corresponding to


the plane of the suboccipitobregmatic
diameter is 32 cm.
 fetal hyperinsulinemia
 insulin-like growth factor and fibroblast
growth factor

↑ maternal glucose ↑ fetal glucose ↑ fetal insulin

Fetal macrosomia ↑ fetal growth


 early pregnancy ultrafiltrate of maternal
plasma.

 second trimester extracellular fluid that


diffuses through the fetal skin(fetal plasma)

 After 20 weeks amnionic fluid fetal urine.


1. Cushions the fetus
- allows musculoskeletal development
- protection from trauma
2. Maintains temperature

3. Minimal Nutritive function

4. Presence of growth factors

5. Growth and differentiation of tissues


- lungs, GIT
 Umbilical veins oxygenated blood
 Umbilical arteriesunoxygenated blood

 CRISTA DIVIDENS preferentially shunts the


well-oxygenated blood through the foramen
ovale
 hypogastric arteries  umbilical ligaments

 umbilical vein  ligamentum teres.

 ductus venosus ligamentum venosum


 yolk sac-first trimester
 liver-mid pregnancy
 bone marrow-third trimester
 fetal erythrocytes( hemoglobin F) bind to

 oxygen more than hemoglobin A because


hemoglobin A binds 2,3-diphosphoglycerate
(2,3-DPG) which

 lowers the affinity of hemoglobin A for oxygen .


 Factors II, VII, IX, X, XI, prekallikrein, protein S,
protein C, antithrombin and plasminogen- 50
% of adult levels
CLINICAL APPLICATION:
 Vit. K is routinely given to newborn after
delivery
 Transfer of IgG from the motherPREVENT
INFECTION IN NEONATES BUT CAN BE
HARMFUL IN CASE OF:

Ex. Hemolytic Disease of the


Newborn (resulting from D-antigen
alloimmunization)
 IgM is increased in newborns with congenital
infection such as rubella, cytomegalovirus, or
toxoplasmosis
 dark greenish-black ( biliverdin)

 1. normal bowel peristalsis in the mature


fetus
 2. vagal stimulation.
3.Hypoxia stimulates arginine vasopressin
(AVP)  CONTRACTION OF smooth muscle
of the colon  defecation
 Formed by type II Pneumocytes
 90% - lipid
◦ 50% dipalmitoylphosphatidylcholine
(DPPC) – principal active
component(lecithin)
◦ 8-15% phosphatidylglycerol (PG)- capable
of reducing surface tension in the alveolus
◦ 5% phosphatidyl ethanolamine
◦ 4% phosphatidyl inositol
 10% - protein
 Fetal cortisol is the natural stimulus for lung
maturation

 Glucocorticosteroids (24-34 weeks)


 ( betamethasone & dexamethasone )
 accelerate fetal lung maturity
Genetic gender—XX or XY—is established at the time of
fertilization.
 If Y chromosome is present(6 weeks )after
conception TESTES
 WITH TESTES male phenotypic sexual
differentiation

 WITHOUT TESTES female differentiation


ensues irrespective of the genetic gender.
Müllerian-inhibiting substance

 prevents the development of uterus, fallopian tube, and
upper vagina

Testosterone

 virilization of the external and internal genital anlagen.


 Excessive androgen action in female fetus ,
or inadequate androgen in one destined to
be male.

 Rarely, genital ambiguity indicates true


hermaphroditism.
1. Müllerian-inhibiting substance is NOT
produced.
2. Androgen exposure of the embryo-fetus
is excessive
3. The karyotype is 46,XX.
4. Ovaries are present.
 MOST COMMON CAUSE :congenital
adrenal hyperplasia
 Production of müllerian-inhibiting substance.
 Incomplete but variable androgenic
representation for a fetus predestined to be
male.
 A 46,XY karyotype.
 The presence of testes or no gonads.
 MOST COMMON CAUSE:ANDROGEN
INSENSITIVITY SYNDROME OR REINFENSTEIN
SYNDROME
 Müllerian-inhibiting substance is NOT
produced.
 Fetal androgen exposure is variable.
 The karyotype varies among subjects and is
commonly abnormal.
 Neither normal ovaries nor testes are present
 MOST COMMON CAUSE :TURNERS
SYNDROME(46X)
PHENOTYPICALLY FEMALE WITH SEXUAL
INFANTILISM
 both ovarian and testicular tissues,
 Independent of the maternal sleep-awake
state

 Sleep cyclicity - 20 minutes -75 minutes


 Best practice recommendations
◦ ACOG (2002): Daily fetal movement count after 28
weeks' gestation.
◦ Perception of 10 distinct movements in 2 hours is
considered reassuring.
1min
Normal FHR: between 110 to
160
Bradycardia: below 110
Tachycardia: above 160

Heart rate during a 10min segment rounded to the nearest 5bpm


increment
Absent
Minimal : <5 bpm
Moderate: normal, >5 to <25
bpm
Marked: >25 bpm

 Fluctuations in the baseline FHR, visually quantitated as the amplitude of the peak-
to-trough in beats per minute (bpm)
 Examine a 1min segment and determine the highest peak and lowest trough.
FETAL HEART
ACCELERATION
Visually apparent abrupt
increase in FHR
Abrupt - <30 sec from
10bpm onset to peak
Peak must be ≥15bpm
20bpm above the baseline
Must last ≥15 seconds
from the onset to the return
1min 10min
 Test of fetal condition

INTERPRETATION:

 Reactive NST-at least 2 accelerations of 15


beats per min lasting for 15 secs in a 20 min
observation
 INTERVAL OF TESTING:7 DAYS UNLESS HIGH
RISK
NON REACTIVE NST:
1. hypoxia
2.neurologic depression
3. fetal sleep
4. medications (magnesium sulfate)
5. maternal cigarette smoking)
Repetitive variable decelerations 
do an ultrasound to check for the amount of
amniotic fluid volume
 Loud external sounds used to startle the fetus
acceleration of the heart rate

 Positive response fetal heart accelerations


following acoustic stimulation
 Test of uteroplacental function

 Fetal heart rate characteristics in


response to uterine contractions
EARLY DECELERATION
Visually apparent usually
symmetrical gradual
decrease and return of
the FHR to baseline
associated with a uterine
Uterine contraction
contraction. The nadir of
the deceleration occurs
Fetal head compression
at the same time as the
peak of the contraction.
Increased ICP

Stimulation of vagal nerve • SIGNIFICANCE:HEAD


COMPRESSION

Decrease FHR
LATE DECELERATION
symmetrical gradual
decrease and return of
the FHR to the baseline
associated with a uterine
Uterine contraction
contraction. The nadir of
the deceleration occurs
Decreased uteroplacental after the peak of the
oxygen transfer
contraction.
Chemoreceptor stimulus

Stimulation of vagal
nerve
Significance :Uteroplacental insufficiency

Decrease FHR
Negative No late or significant variable decelerations
Positive Late decelerations following 50% or more of
uterine contractions – even if the contractions are
fewer than 3 in 10min

Equivocal- Intermittent late decelerations or significant


suspicious variable decelerations

Equivocal- Decelerations in the presence of contractions


hyperstimulatory occuring more frequently than every 2min or
lasting more than 90 sec

Unsatisfactory Fewer than 3 contractions in 10min or


uninterpretable tracing

16
7/13/2017 9
 FETAL BIOMETRY 
monitor lag of growth
or absence of growth

 BIOPHYSICAL SCORE
 monitor amniotic
fluid and fetal behavior

 DOPPLER
VELOCIMETRY 
assess the adequacy of
blood flow in maternal
and fetal vessels
5 biophysical components

 (1) fetal heart rate acceleration (NST)


 (2) fetal breathing
 (3) fetal movements
 (4) fetal tone ultrasound
 (5) amnionic fluid volume
Components and Their Scores for the Biophysical Profile
Component Score 2 Score 0
Nonstress testa ≥2 accelerations of ≥15 0 or 1 acceleration
beats/min for ≥15 sec in 20– in 20–40 min
40 min
Fetal breathing ≥1 episode of rhythmic < 30 sec of
breathing lasting ≥30 sec breathing in 30 min
within 30 min
Fetal movement ≥3 discrete body or limb < 3 discrete
movements within 30 min movements
Fetal tone ≥1 episode of extension of a 0 extension/flexion
fetal extremity with return to events
flexion, or opening or closing
of hand within 30 min

Amnionic fluid Single vertical pocket > 2 cm Largest single


NORMAL VALUE

AFI ( 5 – 24 cm)
deepest vertical pocket ( 2- 8 cm)

Significance of AFI < 5 cm:


- increased risk of fetal distress
- low 5 minute apgar score
- increased perinatal morbidity and mortality
- a non-invasive technique to assess fetal and
maternal blood flow

BEST TEST FOR IUGR

Goal: TO OPTIMIZE TIME OF DELIVERY


 There is no "best test" to evaluate fetal well-
being (ACOG,1999)

 Three testing systems—contraction stress test,


nonstress test, and biophysical profile
Definitions of the FHR patterns
Baseline

Normal baseline FHR: 110 -160 bpm

Bradycardia FHR < 110 bpm

Tachycardia FHR > 160 bpm


 Head Compression
 Congenital Heart Block
 Fetal Compromise
 Maternal HypoThermia
 Maternal fever*MOST COMMON
 Fetal compromise
 Cardiac arrhythmias
 Medications:
◦ Parasympathomimetic medications (
Atropine )
◦ Sympathomimetic ( terbutaline)
Baseline FHR variability

1. Absent – amplitude
range is undetectable
2. Minimal – amplitude
range is 5 bpm or fewer
3. Moderate – amplitude
range of 6 – 25 bpm
4. Marked – amplitude
range > 25 bpm
Baseline FHR variability

1. Absent – amplitude
range is undetectable
2. Minimal – amplitude
range is 5 bpm or fewer
3. Moderate – amplitude
range of 6 – 25 bpm
4. Marked – amplitude
range > 25 bpm
Baseline FHR variability

1. Absent – amplitude
range is undetectable
2. Minimal – amplitude
range is 5 bpm or fewer
3. Moderate – amplitude
range of 6 – 25 bpm
4. Marked – amplitude
range > 25 bpm
Baseline FHR variability
1. Absent – amplitude
range is undetectable
2. Minimal – amplitude
range is 5 bpm or fewer
3. Moderate – amplitude
3
range of 6 – 25 bpm
4. Marked – amplitude
range > 25 bpm
Excellent
indicator of
good fetal well
being
 Fetal acidemia, Maternal acidemia
 Fetal sleep
 Prematurity
 Drugs (MgSO4, diazepam, meperidine
 Vagal blockade (atropine)
 Defective cardiac conduction system
…reduced baseline
heart rate variability is
the SINGLE MOST
RELIABLE SIGN OF FETAL
COMPROMISE.
Definitions of the FHR patterns

Sinusoidal smooth, sine wave-like undulating


Fetal Heart pattern ,frequency of 2-5/minute
Rate Pattern for ≥ 20 minutes

Usually associated with FETAL


ANEMIA
Definitions of the FHR patterns
Accelerations
Visually apparent increase in the
FHR
A T
C I
- >/=15bpm above baseline,
C O
lasting >/=15 secs,
E N
L S
E
R
A

-
Accelerations are always reassuring and
always confirm that the fetus is not acidemic
at that time

Absence of acceleration is not necessarily


an unfavorable sign
Definitions of the FHR patterns
Decelerations

Nadir of the deceleration


E D T
occurs at the same time as the
A E I
peak of the contraction.
R C O
HEAD COMPRESSION
L E N
Y L
E
R
A
Definitions of the FHR patterns
Decelerations

Onset, nadir, and recovery of


L D O deceleration occur AFTER
the
AE the
N beginning, peak, and end
T C of the contraction, respectively.
E E UTEROPLACENTAL INSUFFICIENCY
L
E
R
A
T
I
Definitions of the FHR patterns
Decelerations
An abrupt decrease in
V D
E O
the FHR below the
A E N
baseline,LESS THAN 30
R C
SECS from onset to nadir
I E
UMBILICAL
A L
COMPRESSION
B E
L R
A
T
I
Definitions of the FHR patterns

Prolonged
deceleratio
Isolated decrease
n
in FHR
≥ 15 bpm from
baseline, ≥ 2
minutes
but < 10
minutes in
 Cervical examination  Conduction analgesia
 Uterine hyperactivity  Maternal hypothermia

 Cord entanglement  Abruption


 Umbilical cord prolapse
 Maternal supine
 Maternal seizure
hypotension
 Valsalva maneuver

Common Causes Other Causes


PROTOCOL TO CONFIRM FETAL DISTRESS:
 pH > 7.25, observe

 pH 7.20 - 7.25, repeat within 30 minutes.

 pH is < 7.20, another scalp blood sample is


collected if < 7.20  DELIVER
The Three-Tier Fetal Heart
Interpretation System
Recommended By The 2008
NICHD Workshop On Electronic
Fetal Monitoring
Category • Clearly abnormal requiring

III immediate action

Category • Indeterminate requiring


careful evaluation and
II possible corrective measures

Category • Clearly normal requiring no

I change in management
Baseline rate: 110–160 bpm
Baseline FHR variability:
moderate
Late or variable
decelerations: absent
Early decelerations: present
or absent
Accelerations: present or
absent

“No specific action is required”


Baseline rate
•Bradycardia not
accompanied by
absent baseline
variability
•Tachycardia
Baseline FHR
variability
•Absent baseline variability
not accompanied by
recurrent decelerations
•Minimal baseline variability
•Marked baseline variability
Accelerations
•Absence of induced
accelerations after
fetal stimulation
Periodic or episodic
decelerations
• Recurrent variable
decelerations accompanied
by minimal or moderate
baseline variability
• Prolonged deceleration 2
minutes but < 10 minutes
• Recurrent late decelerations
with moderate baseline
variability
Not predictive of
abnormal fetal acid-
base status
Requires continued
surveillance and re-
evaluation
Do resusitative
measures or do ancillary
tests to ensure fetal
well-being
Absent FHR variability along
Recurrent
with any of thelate
following:
decelerations
Recurrent variable
decelerations

Bradycardia
Sinusoidal pattern
Associated with abnormal fetal
acid-base saturation at the time
of observation

Maternal O2
Discontinue of labor stimulation
Treatment of maternal
hypotension
Change of maternal position
Treatment of tachysystole
DELIVER
INDICATIONS:
 prolonged variable
decelerations.
 oligohydramnios and with
PROM
 dilute or wash out thick
meconium.
PATTERNS OF UTERINE ACTIVITY:
 Montevideo units to define uterine activity
 Total uterine pressure per contractions in a 10
minute observation
New Terminology for Uterine
Contractions:

 Normal Uterine Activity: five or less


uterine contractions in 10 minutes

 Tachysystole: more than 5


contractions in 10 minutes
1. MALFORMATION - an intrinsic abnormality
"programmed" in development
Example: Spina bifida
2. DEFORMATION - genetically normal fetus develops
abnormally because of mechanical forces imposed by the
uterine environment.
Ex:prolonged oligohydramnios->contractures
3. DISRUPTION
 a more severe change in form or function

Ex: amnionic band causing a cephalocele or limb-


reduction abnormality.
• SYNDROME - a cluster of several anomalies
or defects that have the same cause
• Example: Trisomy 18
• SEQUENCE - anomalies that all develop
sequentially as result of one initial insult
• Example: Oligohydramnios leading to pulmonary
hypoplasia, limb contractures, and facial
deformities.
MULTIPLE STRUCTURAL OR
DEVELOPMENTAL ABNORMALITIES

•ASSOCIATION - particular anomalies occur


together frequently but do not seem to be
linked etiologically
Example: VACTERL association: includes
three or more of the following – vertebral
defects, anal atresia, cardiac defects,
tracheoesophageal fistula, renal anomalies,
limb abnormalities
PRENATAL DIAGNOSIS OF NEURAL-TUBE
DEFECTS
 NEURAL TUBE DEFECTS
(NTD’S)
◦ second most common
class of birth defect
◦ Open neural-tube defects
include:
 Anencephaly
 Spina bifida
 Cephalocele
 Other rare spinal fusion
(schisis) abnormalities
◦ 95% occur without risk
factor or family history
1. Family history
2. environmental agents
3. genetic syndrome or anatomical anomalies
associated with NTDs
4. high-risk racial or ethnic group
5. anti-folate receptor antibodies
 The American College of Obstetricians and
Gynecologists (2003) recommends that ALL PREGNANT
WOMEN BE OFFERED SECOND-TRIMESTER MATERNAL
SERUM AFP SCREENING
 15 - 20 weeks
 Normal Value: =/< 2-2.5 MoM
 Abnormal screening test - Genetic Counseling
◦ consideration for a Diagnostic test(ULTRASOUND)
Obesitya
Diabetesa
Chromosomal trisomies
Gestational trophoblastic disease
Fetal death
Overestimated gestational age
• low maternal serum
AFP levels at 15 to 20
weeks
between 11 and 13 6/7 weeks
1. Maternal serum screening
◦ free beta hCG
◦ Pregnancy-associated
plasma protein A (PAPP-A)
2. Sonographic evaluation:
Nuchal translucency (NT)
 The American College of Obstetricians and
Gynecologists (2007b) recommends that when the
NUCHAL TRANSLUCENCY MEASUREMENT IS 3.5 MM
OR GREATER with a normal fetal karyotype, targeted
sonographic examination, fetal echocardiography, or
both should be considered.
• Multiple Maternal Serum Markers could reliably
differentiate pregnancies affected by trisomy
18 and 21 from unaffected pregnancies
Serum markers: Triple Test &Quad Test*
– AFP
– Human chorionic gonadotropin (hCG)
– Unconjugated estriol concentration
– Dimeric inhibin alpha*
15 and 20 weeks
Complications:
transient vaginal
spotting or amnionic
fluid leakage and
chorioamnionitis
• Between 11 and 14 weeks
• Same technique

• Many centers no longer perform


amniocentesis before 14 weeks
• 10 to 13 weeks
• transcervically or
transabdominally,

 Complications are
similar to those of
amniocentesis

PRIMARY ADVANTAGE : results


available earlier
• 1. viability
• 2. anembryonic gestation / embryonic demise
• 3.Multifetal gestation - OPTIMAL TIME to
determine chorionicity
• 4.BEST TIME to evaluate the uterus, adnexal
structures, and cul-de-sac
•Transabdominal scanning
 Gestational sac – 6 weeks
 Fetal echoes & cardiac
activity – 7 weeks

•Transvaginal examination
 Cardiac motion – embryo
is 5 mm in length
(CRL= 6wks)
Components of Standard Ultrasound Examination by Trimester
FIRST TRIMESTER SECOND AND THIRD TRIMESTER
Gestational sac location Fetal number
Embryo or yolk sac identification Presentation
Crown-rump length Fetal heart motion
Cardiac activity Placental location
Fetal number, including number of Amnionic fluid volume
amnions and chorions of multiples
when possible
Gestational age assessment
Fetal weight estimation
Uterus, adnexal, and cul-de-sac Evaluation for maternal pelvic
evaluation masses
Fetal anatomic survey
 Gestational sac (GS) -
4 – 6 weeks
 Crown-Rump
Length(CRL) - 8-10
weeks
 Biparietal Diameter
(BPD) - 14- 26 weeks
most accurate
parameter
• Femur length
(FL) - variation
of 7 to 11 days
in the second
trimester
• Abdominal
circumference
(AC) - fetal
growth
Diminished blood flow may be reflected such
as
the following:
1. Diastolic notch
2. Increased SD ratio (Stuart Index)
3. Pulsatility index; Resistance index
4. Absence or reversed end diastolic (ARED)
blood flow
PELVIC ANATOMY

• LINEA TERMINALIS separates


the true and false pelvis
 distance between them usually represents
the shortest diameter of the pelvic cavity

 valuable landmarks for fetal head descent


 Four Imaginary Planes
 Plane of the Pelvic Inlet—the Superior strait
 Plane of the Pelvic Outlet—the Inferior strait
 Plane of the Midpelvis—the LEAST pelvic
dimensions
 Plane of Greatest Pelvic dimension—of no
obstetrical significance
PELVIC INLET
 Boundaries:
 Posterior: Sacrum -
promontory and alae

 Lateral: Linea terminalis

 Anterior: horizontal
pubic rami and the
symphysis pubis

 Shape: round or
gynecoid in 50 % of
white women
A,Anteroposterior
Diameter

1.Obstetrical conjugate
(OC)

◦ midposition of the
symphysis pubis to
promontory of the
sacrum

◦ shortest anteroposterior
diameter of the inlet

◦ Measures >/=10 cm

◦ OC= Diagonal conjugate


– 1.5-2 cm
 2. Diagonal
conjugate (DC)
◦lower margin of the
symphysis to the
promontory of the
sacrum
◦N.V. = 12 cm

3. True conjugate


(TC)
◦Superior portion of
symphysis pubis to
promontory of the
sacrum
◦N.V. = 11 cm

◦ TC= Diagonal
conjugate-1.2cm
 B. Transverse diameter
◦greatest transverse diameter
(GTI) - distance between the
linea terminalis

◦ = 13.5 cm
•Boundaries:
 Anterior - inferior
portion of
symphysis pubis
 Lateral - Ischial
spines
 Posterior – tip of
sacrum
 AnteroPosterior
(1)
diameter (APM) =
11.5 cm
• from symphysis pubis to
tip of sacrum(4 to 5th
sacral vertebrae)

 (2) Interspinous
diameter (IS)= 10 cm
• between 2 ischial spines
• Smallest pelvic diameter

 (3) Posterior sagittal


diameter of the
midplane (PSM) = 4.5
cm
• between sacrum and the
line created by the
interspinous diameter
 Boundaries:

 Anterior
 -undersurface of Pubic Arch

 Posterior - tip of the Sacrum

 Lateral –
 Sacrosciatic ligaments &
 the Ischial tuberosities
 Anteroposterior
diameter of the outlet
(APO) – undersurface of pubic arch to tip of the
sacrum
 AP: 9.5-11.5 cm

 Intertuberous diameter (IT) - between 2


ischial tuberosities
 IT – 11 cm

 Posteriorsagittal diameter of the outlet*


(PSO) – between the tip of the sacrum and the
line created by the intertuberous diameter
 PS: =/> 7.5 cm
 Caldwell and Moloy classification

 Posterior segment determines the type of


pelvis

 Anterior segment determines the tendency

 Many pelvis are not pure but are mixed


 Ex: a Gynecoid pelvis with an android
tendency
 suited for delivery of most fetuses
 found in almost 50 percent of women
 oval anteroposteriorly
 > AP diameter than Transverse diameter

>AP DIAMETER THAN


TRANSVERSE
 poor prognosis for vaginal delivery

 Short AP and wide Transverse diameters
 Descent of the biparietal plane of the fetal head to a level
below that of the pelvic inlet

 IF HEAD is engaged the INLET is adequate

 ascertained by vaginal exam and by abdominal palpation

 When the lowermost portion of the fetal head is at or below


the ischial spines, it is usually engaged EXCEPT if there is
molding or caput formation
 Intertuberous diameter (IT) = >8cm

 Distance between two ischial tuberosities

 Place a closed fist against the perineum


between two ischial tuberosities
 Suspicious findings for MIDPELVIC
CONTRACTION

Prominent ischial spines


sidewalls are convergent
shallow concavity of the sacrum
25
6
25
7
 Uterine Quiescence
◦ Braxton Hicks contractions or False labor

 Low-intensity myometrial contractions felt by the


mother but DO NOT cause cervical dilatation

25
8
 LIGTHENING

◦Abdomen undergoes a shape change, described by


women as “THE BABY DROPPED.”

25
9
 Stages of Labor
◦ First stage

 Stage of cervical effacement and dilatation

 Ends when the cervix is fully dilated( 10 cm)

26
0
 Stages of Labor

◦ The Second stage


 Stage of fetal expulsion
 Begins when cervical dilatation is complete(10cms) and
ends with delivery

◦ Third stage of labor


 Stage of placental separation and expulsion
 Begins after delivery of the fetus and ends with the
delivery of the placenta

26
1
 2 Phases of cervical dilatation:
◦ Latent phase
 variable and sensitive to extraneous factors , sedation
and myometrial stimulation

◦ Active phase
 Acceleration phase
 predictive of the outcome of a particular labor
 Phase of maximum slope
 good measure of over – all efficiency of the uterus
 Deceleration phase
 reflective of feto-pelvic relationship

26
2
 First Stage of Labor: Clinical Onset of Labor
◦ “Show” or “bloody show.”

 Causes of labor pains:


 (1) hypoxia of the contracted myometrium

 (2) compression of nerve ganglia

 (3) cervical stretching

 (4) stretching of the peritoneum

26
3
 Ferguson reflex
◦ Manipulation of the cervix and “stripping” the fetal
membranes cause the release of prostaglandin F2α
metabolite (PGFM)

26
4
 Distinct Lower and Upper Uterine Segments
UPPER SEGMENT:
 firm during contractions
 contracts,retracts and expels fetus

LOWER SEGMENT:

 Softer ,distended and more passive

26
5
 Uterine Changes during Labor
◦ physiological retraction ring-junction between the
lower and upper segment

◦ In obstructed labor--> the ring is prominent-->


pathological retraction ring or Bandl ring

26
6
 Stages of Labor
◦ 1st Stage of Labor: Clinical Onset of Labor
◦ 2nd Stage of Labor: Fetal Descent
◦ 3rd Stage of Labor: Delivery of Placenta and
Membranes

26
7
◦ MECHANISM OF PLACENTAL SEPARATION:
 SCHULTZE
 Central separation,
 blood does not escape externally
 Fetal membranes appears first at the vulva

 DUNCAN
 Separates at periphery
 blood escapes from the vagina
 placenta descends sideways
 (cotyledons)appears first

26
8
lactogenesis and milk let-down

◦ Reinstitution of ovulation
 Within 4 to 6 weeks after birth, but dependent on
lactation-induced amenorrhea(LAM)

26
9
Relation of the long axis of the fetus to that of
the mother
TYPES:
 Longitudinal
› 99% of labors at term
 Transverse lie
› Predisposing factors: multiparity, placenta previa,
hydramnios, and uterine anomalies
 Oblique Lie
› 45-degree angle
› unstable
 UNIVERSAL FLEXION
 the arms are usually
crossed over the thorax or
become parallel to the
sides.
 The umbilical cord lies in
the space between them
and the lower extremities.
 portion of the fetal body foremost within the
birth canal

CEPHALIC VERTEX or OCCIPUT PRESENTATION


FACE
BROW
SINCIPUT
BREECH FRANK
COMPLETE
INCOMPLETE or FOOTLING
As labor progresses, sinciput and brow presentations
almost always convert into vertex or face presentations
by neck flexion or extension, respectively.
Frank Breech – thighs are flexed
and the legs extended
Complete Breech – thighs AND
legs are flexed
Incomplete, or Footling Breech - if
one or both feet, or one or both
knees, are lowermost or
extended
 relationship of the
chosen portion of the
fetal presenting part to
the right or left side of
the birth canal.
 Shoulder presentations( acromion
(scapula) is the portion of the fetus

 Another term used is transverse lie, with


back up or back down.
LEOPOLD’S MANEUVER
 L1, L2 and L3 – examiner stands at the side of
the bed and faces the patient

 L4 – examiner faces patients feet


 Breech – sensation of a
large, nodular body
 Cephalic –hard and round
movable and balottable
 Back – hard, resistant
 Extremities – numerous
small, irregular and
mobile parts
 The lower portion of the
abdomen is grasped just
above the symphysis
pubis
 Engaged or not
engaged
Fourth Maneuver – Pelvic grip

 DETERMINE THE CEPHALIC PROMINENCE

 Vertex Presentation – the prominence is on


the same side as the small parts

 Face Presentations – the prominence is on


the same side as the back
Fourth Maneuver – Pelvic grip
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External Rotation
7. Expulsion
Descent
 first requisite for birth of the newborn
 Nulliparas= engagement before labor, and
further descent follow until the onset of the
second stage
 Multiparous= descent begins with
engagement
CARDINAL MOVEMENTS OF
LABOR

 Four forces FOR DESCENT


1. pressure of the amnionic fluid
2. direct pressure of the fundus upon the
breechs
3. bearing down efforts
4. extension and straightening of the fetal body
CARDINAL MOVEMENTS OF
LABOR
Flexion

 suboccipitobregmatic
diameter is substituted
for the longer
occipitofrontal diameter
CARDINAL MOVEMENTS OF
LABOR
Internal Rotation
 occiput gradually moves toward the symphysis
pubis anteriorly from its original position
CARDINAL MOVEMENTS OF
LABOR

Extension
 Head presses upon the pelvic floor
 Two forces :
1. exerted by the uterus
2. resistant pelvic floor
CARDINAL MOVEMENTS OF
LABOR

External Rotation
 bisacromial diameter into
relation with the
anteroposterior diameter
of the pelvic outlet
CARDINAL MOVEMENTS OF
LABOR
Expulsion

 anterior shoulder appears under the symphysis


pubis.

 After delivery of the shoulders, the rest of the


body quickly passes.
It is the lateral deflection of the head to a
more anterior or posterior position in the
pelvis

2 TYPES OF ASYNCLITISM
1. ANTERIOR ASYNCLITISM
2. POSTERIOR ASYNCLITISM
o Sagittal suture
approaches the
sacral promontory

o More of the
ANTERIOR parietal
bone presents
o Sagittal suture lies
close to the
symphysis
o
o POSTERIOR parietal
bone will present
CAPUT SUCCEDANEUM
 The portion of the fetal
scalp becomes
edematous
 The change in fetal
head shape from
external compressive
forces
 Mother perceives regular contractions.

 The latent phase for most women ends at


between 3 and 5 cm of dilatation.
 > 20 hours in nullipara

 >14 hours in multipara


 cervical dilatation of 3 to 5 cm or more, in the
presence of uterine contractions
 excessive sedation
 epidural analgesia
 fetal malposition
SIGNIFICANCE
1. prolapse of the umbilical cord
2. labor is likely to occur
3. increased incidence of intrauterine infection
DIAGNOSIS
1. amniotic fluid pooling
2. Testing the pH of the vaginal fluid :

 pH above 6.5 is consistent with ruptured


membranes
3. the use of the indicator Nitrazine
 yellow-->blue
4. Other Tests :
 Arborization or ferning pattern
 alpha-fetoprotein positive
 injection of various dyes into amniotic sac
 When lowermost portion of presenting part is
at level of ischial spines designated as zero

 Divisions represent cms above and below the


spines into fifths
Nullipara Multipara
FIRST STAGE
Latent Phase <20 <14 hours
hours
Active Phase 1.5cm/hr
1.2cm/hr
SECOND 50 mins 20 mins
STAGE
FETAL HEART RATE MONITORING
First stage of labor
every 30 minutes (LOW RISK) 15
MINS (HIGH RISK)
Second stage:
every 15 mins(LOW RISK) 5 MINS
(HIGH RISK)
 BENEFITS FROM AMNIOTOMY
1. Rapid Labor

2. Early detection of meconium staining

3. Opportunity to apply electrode


 Pressure on the
chin of the fetus
through the
perineum , the
other hand exerts
pressure
superiorly against
the occiput
1. Calkin’s Sign – the uterus becomes globular
The earliest SIGN to appear.
2. Sudden gush of blood
3. Uterus rises in the abdomen
4. Lengthening of the umbilical cord
 Traction on the umbilical cord must not be
used to pull the placenta out of the uterus--->
 UTERINE INVERSION
 UTERINE MASSAGE
 OXYTOCIN, ERGONOVINE, AND
METHYLERGONOVINE
Oxytocin (pitocin, syntocinon)
 Not effective by mouth
 SIDE EFFECTS: ANTIDIURETIC/HYPOTENSION
 NOT GIVEN AS IV BOLUS
Ergonovine and Methylergonovine
 From ergot
 Powerful stimulants of myometrial contraction
 SIDE EFFECTS: transient severe hypertension
NOT USED IN PATIENTS WITH BRONCHIAL
ASTHMA
Prostaglandins
 Not used routinely
 management of postpartum hemorrhage
due to uterine atony
 PG F2-NOT USED IN B. ASTHMA
 PG E2-SAFE FOR BRONCHIAL ASTHMA
First Degree Laceration
 fourchette, perineal skin and vaginal mucous
membrane
Second Degree Laceration
 skin and mucous membrane, the fascia and
muscles
Third Degree Laceration
 skin, mucous membrane, perineal body and
sphincter
Fourth Degree Laceration
 Extends through the rectal mucosa to expose
the lumen of the rectum
Characteristic Midline Mediolateral
Surgical repair Easy More difficult

Faulty hearing Rare More common

Postoperative Minimal Common


pain
Anatomical Excellent Occasionally
results faulty

Blood loss Less More

Dyspareunia Rare Occasional


 considered
to
be between 4
and 6 weeks
INVOLUTION OF THE
REPRODUCTIVE TRACT
UTERINE INVOLUTION

 4 weeks after delivery


◦ uterus regains its previous nonpregnant size

LOCHIA RUBRA- first few
days after delivery, RED color
i

LOCHIA SEROSA- After 3 or 4


days, PALE in color

LOCHIA ALBA- After about


the 10th day, WHITE or
YELLOWISH WHITE color
 Superficial layer
◦ BECOMES NECROTIC--> sloughed in the
lochia
 Basal layer
◦ adjacent to the myometrium--> the source
of new endometrium
SUBINVOLUTION
 arrest or retardation of involution
 Causes:
◦ Infection
◦ retained placental fragments
◦ incompletely remodeled uteroplacental
arteries
 SIGNS AND SYMPTOMS
 irregular or excessive uterine bleeding
 uterus is larger and softer
 Management of Subinvolution
◦ Ergonovine or methylergonovine
◦ Antibiotic therapy for infection

◦ Chlamydia trachomatis
 MOST COMMON CAUSE
 MANAGEMENT: Azithromycin or
Doxycycline
6 weeks
◦ Complete extrusion of the placental
site
 American College of Obstetricians and
Gynecologists (2013b)
◦ bleeding 24 hours to 12 weeks after
delivery
 Causes:
◦ MOST COMMON CAUSE:
◦ retention of a placental fragments
 Treatment
◦ oxytocin, ergonovine, methylergonovine,
or prostaglandins
◦ Antimicrobial – with infection
◦ Suction curettage – large clots
◦ Curettage- NON RESPONSIVE TO medical
management
COLOSTRUM
 deep lemon-yellow-colored liquid
 2nd postpartum day
 rich in immunological components(Ig A),
minerals, amino acid,protein
 but less sugar and fat
 All vitamins EXCEPT VIT K are found in human
milk
 Vitamin K after delivery is required to prevent
hemorrhagic disease of the newborn
 SECRETORY IgA

 less prone to enteric infection against


rotavirus infections,Escherichia coli
infections
 contains both T and B lymphocyte

 Milk leakage, engorgement, and
breast pain ( 3 to 5 days)
 TREATMENT:
 Ice packs
 analgesics
 Bromocriptine , for lactation inhibition
is associated with strokes,
myocardial infarctions, seizures, and
psychiatric disturbances.
Recommendations for Hormonal Contraception
if Used by Breast Feeding Women
1.Progestin-only oral contraceptives -->
started 2–3 weeks postpartum
2.Depot medroxyprogesterone acetate --> 6
weeks postpartum.a
3.Hormonal implants -->inserted at 6 weeks
postpartum.
 Breastfeeding is not contraindicated if
hepatitis B immune globulin is given to infants
of seropositive mothers.
 Hepatitis C infection is not a contraindication
to breast feeding
 Herpes simplex virus if there are no breast
lesions is NOT a contraindication to breast
feeding
breasts -->distended, firm, and
nodular
 elevation of temperature (ranged
from 37.8 to 39°)
Treatment: binder or brassiere, ice
bag, analgesic, pumping of the
breast
 unilateral, marked engorgement,
inflammation.
 chills, fever and tachycardia.
 ETIOLOGY: Staphylococcus aureus – 40 %; c
 Immediate source of organisms --> infant's
nose and throat
 culture of the expressed milk
 antimicrobial therapy:
◦ Dicloxacillin 500 mg orally four times daily,
◦ Erythromycin if penicillin sensitive
◦ Vancomycin is effective against MRSA
 treatment for 10 to 14 days
TREATMENT: surgical drainage
GALACTOCOELE
 clogging of a duct by inspissated milk
 milk accumulate in one or more lobes of the
breast

 resolve spontaneously or require aspiration


 complete lack of mammary secretion
(agalactia)

 mammary secretion is excessive


(polygalactia)
Postpartum blues- degree of depressed mood a
few days after delivery
◦ Excitement and fears during pregnancy and delivery
◦ Discomforts of the early puerperium
◦ Fatigue from loss of sleep during labor and
postpartum
◦ anxiety over the ability to provide appropriate infant
care, and body image concerns
TREATMENT
anticipation, recognition, and reassurance
Mild and self-limited to 2 to 3 days, although it
sometimes lasts for up to 10 days
 Not breastfeeding, menses usually
return within 6 to 8 weeks
COITUS - no definite time after delivery
when coitus should be resumed

-coitus may be resumed based on the


patient's desire and comfort
ANESTHESIA AND ANALGESIA

Far Eastern University


Dr. Nicanor Reyes Medical Foundation
Department of Obstetrics and Gynecology
MATERNAL RISK FACTORS THAT SHOULD PROMPT ANESTHESIA
CONSULTATION:
1. Marked Obesity
2. Severe edema or anatomical abnormalities of face, neck, or
spine,
including trauma or surgery
3. Abnormal dentition, small mandible, or difficulty opening
mouth
4. Extremely short stature , short neck, or arthritis of the neck
5. Goiter
6. Serious maternal medical problems, such as cardiac,
pulmonary or
neurological disease
7. Bleeding disorders
8. Severe preeclampsia
9. Previous history of anesthetic complications
Goals for Optimizing Obstetrical
Anesthesia Services
1.LAMAZE
• teaching pregnant women relaxed breathing and their
labor partners psychological support techniques.

2. CLINICAL HYPNOSIS – power of the mind to heal the


body; increases of beta endorphins in the peripheral
blood

3. ACUPUNCTURE
1. Meperidine is the most common opioid used worldwide
for pain relief in labor.

• Meperidine or other narcotics – cause newborn respiratory


depression
Naloxone

• Reverses respiratory depression induced by opioid


narcotics

NITROUS OXIDE
• 50% nitrous oxide and oxygen provides satisfactory
analgesia during labor
REGIONAL ANALGESIA
Uterine Innervation

•Early in labor – SENSORY T11 and T12 nerves

•Motor pathways – T7 and T8 vertebrae


Lower Genital Tract Innervation

•Pudendal nerve – sensory nerve fibers from


S2 through S4 nerves

Passes beneath the posterior surface of


the sacrospinous ligament just as the
ligament attaches to the ischial spine
ANESTHETIC AGENTS
(Table 19-3. Some Local Anesthetic Agents used in Obstetrics)

Central Nervous System Toxicity

•Bizarre behavior, slurred speech, muscle


fasciculation and excitation, generalized convulsions,
loss of consciousness
 Cardiovascular Toxicity

 Hypertension , tachycardia, hypotension and


cardiac arrhythmias
PUDENDAL BLOCK

•Relatively safe and simple

•Complications: serious systemic toxicity,


hematoma formation from perforation of a
blood vessel
• Pain relief during the first stage of
labor

• Lidocaine or Chloroprocaine at 3 and


9 o’clock

• Complication: fetal bradycardia


 Vaginal Delivery
• forceps or vacuum delivery
• T10 dermatome
• Lidocaine or Bupivacaine
 Cesarean Delivery
• T4 dermatome

•Hypotension

• High spinal blockade

• Spinal (Postural puncture) headache

• Convulsions

• Bladder dysfunction

• Oxytocics and hypertension

• Arachnoiditis and meningitis


ABSOLUTE CONTRAINDICATIONS

• hypotension
• coagulopathy
• bacteremia
• Skin infection
• Increased intracranial pressure
EPIDURAL ANESTHESIA
Continuous Lumbar Epidural Block

• VAGINAL DELIVERY - T10 to S5


•CESAREAN DELIVERY - T4 to S1
•Total spinal blockade

• Ineffective analgesia

• Hypotension

• Central nervous stimulation

• Maternal pyrexia

• Back pain
•Effects on Labor

•Prolongs active phase of labor by 1 hour

• Increases the need for instrumental delivery LIKE


FORCEPS AND VACUUM due to prolonged second-stage
labor


EPIDURAL ANESTHESIA

Contraindications

• Hemorrhage

•Infection at or near the sites of puncture

•Suspicion of neurological disease

• Anticoagulation
EPIDURAL ANESTHESIA

• Severe Preeclampsia-Eclampsia

• BEST ANESTHESIA: EPIDURAL ANESTHESIA


GENERAL ANESTHESIA
PATIENT PREPARATION

ANTACIDS

UTERINE DISPLACEMENT
•Lateral uterine displacement
Preoxygenation
Thiopental

•Ease and rapid/ minimal risk of vomiting


•Poor analgesic agents
•May cause newborn depression

Ketamine

•causes a rise in blood pressure


•Unpleasant delirium and hallucination.
INTUBATION

•Sellick maneuver – Cricoid pressure is


used to occlude the esophagus from
induction until intubation
•Morbid obesity is also a major risk factor for failed or
difficult intubation.
Volatile Anesthetics

•Most commonly used is isoflurane.


• produce remarkable uterine relaxation

•USES:

Internal podalic version of the second twin


Breech decomposition
Replacement of acutely inverted uterus
.

ASPIRATION

•Aspiration pneumonitis has been the most common


cause of anesthetic deaths in obstetrics.
FASTING

A fasting period of 8 hours or more is


preferable for uncomplicated
parturients undergoing elective
cesarean delivery.