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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
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
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
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
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
DEVELOPS INTO:
oviducts uterus,upper
vagina
Cervix
Majority-collagen, elastin
and proteoglycan
10% smooth muscle
IF WITH MORE MUSCLE
CONTENTINCOMPETEN
T CERVIX
Ectocervix –
nonkeratinized
squamous epithelium
Endocervix – columnar
epithelium
Uterus
SPIRAL ARTERIES –
RESPONSIVE TO
HORMONES
ROUND LIGAMENTS
BLOOD SUPPLY:Sampson
artery
MALE HOMOLOGUE:
gubernaculum testis
1.BROAD LIGAMENTS
2.SUSPENSORY LIGAMENT OR
INFUNDIBULOPELVIC LIGAMENT–
◦ fimbriated end of the fallopian tube to the pelvic wall,
where OVARIAN vessels traverse
CARDINAL LIGAMENTS
PARTS
interstitial portion
isthmus
ampulla
infundibulum or
fimbriated (fimbria
ovarica)
Ovaries
Childbearing years- 2.5 to 5 cm
LH 10 – 12 hours
Surge before ovulation
Luteal (Postovulatory) Phase
Corpus luteum
maintained by LH
Estrogensecondary RISE
at midluteal phase
Progesterone peaks in
the midluteal phase
Human Corpus Luteum
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
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
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
TIMEABORTION
• 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
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
Proteinuria is abnormal.
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
Uterine souffle
• Rush of blood through dilated uterine vessels
• Soft blowing sound that is synchronous with maternal pulse
Maternal pulse
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
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.
◦ Category D
Indomethacin and other PG inhibitors
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
SIMILAR TO THALIDOMIDE
Limb-reduction defects (es.upper limbs)
Testosterone
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:
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
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
AFI ( 5 – 24 cm)
deepest vertical pocket ( 2- 8 cm)
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
-
Accelerations are always reassuring and
always confirm that the fetus is not acidemic
at that time
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
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
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:
Complications are
similar to those of
amniocentesis
•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
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
◦ 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
Anterior
-undersurface of Pubic Arch
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
25
8
LIGTHENING
25
9
Stages of Labor
◦ First stage
26
0
Stages of Labor
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.”
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:
26
5
Uterine Changes during Labor
◦ physiological retraction ring-junction between the
lower and upper segment
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
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
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.
◦ 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
3. ACUPUNCTURE
1. Meperidine is the most common opioid used worldwide
for pain relief in labor.
NITROUS OXIDE
• 50% nitrous oxide and oxygen provides satisfactory
analgesia during labor
REGIONAL ANALGESIA
Uterine Innervation
• Convulsions
• Bladder dysfunction
• hypotension
• coagulopathy
• bacteremia
• Skin infection
• Increased intracranial pressure
EPIDURAL ANESTHESIA
Continuous Lumbar Epidural Block
• Ineffective analgesia
• Hypotension
• Maternal pyrexia
• Back pain
•Effects on Labor
•
EPIDURAL ANESTHESIA
Contraindications
• Hemorrhage
•
•Infection at or near the sites of puncture
•
•Suspicion of neurological disease
• Anticoagulation
EPIDURAL ANESTHESIA
• Severe Preeclampsia-Eclampsia
ANTACIDS
UTERINE DISPLACEMENT
•Lateral uterine displacement
Preoxygenation
Thiopental
Ketamine
•USES:
ASPIRATION