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○ Decent
○ Flexion
○ Internal Rotation
○ Extension
○ External Rotation
○ Expulsion
• Breast
○ Breast tissue
○ Arreola
▪ Lactiferous duct > Lactiferous sinuses > nipple opening
○ Acinar cells
○ Pituitary gland:
▪ APG: prolactin
□ Stimulates milk production
▪ PPG: oxytocin
○ Sucking nipples stimulates PPG to release oxytocin and contracts ampulla to excrete milk
○ Latching promotes high milk flow and minimizes nipple discomfort for the mother
○ Warm water without soap to clean nipples
Menstruation
• Discharge of blood coming from uterus
• Menstrual period:
○ Days that there is menstruation
○ 3−7 days
• Menstrual cycle:
○ Start of first day of period to first day of next period
○ 23−35 days
• Length of cycle determines day of ovulation
○ Could change any time
○ Cycle − 14 = day of ovulation
○ Minimum of 6 weeks in computation to determine if irregular or regular
• Fertile week
○ Should be regular
○ Ovulation − 5 then ovulation plus 3
• Day of ovulation
○ Compute 2 weeks before the mens
• If irregular
○ L − 11
○ S − 18
• Different structures that control menstrual cycle
○ Hypothalamus
▪ Produces gonadotropic releasing hormone
□ Follicle stimulating hormone releasing factor
□ Luteinizing hormone releasing factor
○ ABG
▪ FSH
□ Maturation of egg cells
▪ LH
○ Ovaries
▪ Estrogen 3 low E 13 low P
□ Converts follicle of ovary to graafian follicle
▪ Progesterone 13 high E 14 high P
□ Coverts GF to corpus luteum
□ Increased 02, h2O, glucose
○ Uterus
▪ Estrogen thickens endo and myo when there is low E
○ Placenta appears on 2nd month of pregnancy
○ CL extends lifespan within 2w to 2m
Pre menstrual syndrome
• Release of prostaglandin makes PMS painful
• Don'ts
○ Caffeine Foodƒbeverages
○ No salty food as it causes fluid
○ retention Smoking
• Do's
○ Exercise
○ Warm compress
Menopause
• Ceases of menstruation
• 45−50 yƒo • Bilateral tubal ligation
• Stops producing estrogen ○ Area is isthmus
• sƒs:
○ Hot flushes
○ Mood swings
○ Sagging of boobs
○ Dyspareunia
▪ Lubricant use
○ Decreased want in sex
○ Kidney stones
○ Prone to fracture
• Emphasize MMR
▪ Flat shoes ○ Mutual monogamous relationship
○ Osteoporosis
▪ Calcium supplement
Fetal development
• Pre embryonic
○ First 2 weeks after fertilization
• Embryonic
○ 2 weeks to 2 months
• Fetal stage
○ 2 months to birth
○ Organogenesis
○ Self medication is not allowed
• Ammon
○ Inner
○ 2 structures:
▪ Funisƒ umbilical cord
▪ Amniotic sac
• Chorion
○ Outer
○ Placenta will arise
Rh Incompatibility
• Inside the placenta, fetal blood is only found since maternal blood cant be mixed becos of placental barrier
• Rhesus factor as determinant
• Could be a problem if placenta is damaged
• Isoimmunization
○ Mother produces antibodies
○ Must be prevented
○ Coomb's test
▪ To determine if mother produced antibodies
▪ Direct: fetal blood
▪ Indirect: maternal blood
▪ Should have (−) result (not yet produced antibodies)
□ Give RhoGAM to prevent antibody production
• If not prevented, might cause hyperbilirubinemia
○ Phototherapy
▪ Turn from time to time
▪ Cover eyes and genital
▪ Increase feeding
2 sides of placenta
• Fetal side
○ Where cord is
○ Shiny and plain looking
• Maternal side
○ Dark and dirty looking
2 types of placental separation
• Schultz
○ Fetal side first
○ Center to periphery
• Duncan
○ Maternal side first
○ Periphery to center
○ Cx:
▪ Retained placental fragment
Pre natal check up
• Facility based check up
• Min reqt is health center
• Manned by competent and trained staff
• Main goal: decrease maternal morbidity and neonatal mortality rate
○ Demographic danger
▪ Age
□ <18, >35
◆ Pregnancy induced hypertension (young, primiƒ old, multipara)
◆ Normal: 2.5−4kgs
▪ Height
□ <5ft
□ Cephalopelvic disproportion dƒt small pelvis
◆ Determine by xray pelvimetry only by 3rd trimester, 2 weeks before EDC
▪ Weight
□ <90lbs, >150lbs
□ 24−30lbs normal weight gain during pregnancy
□ 1st tri: 1lbƒmonth (3)
□ 2nd tri and 3rd tri: 1lbƒwk (24)
□ 24−30
▪ Sudden weight gain
□ Check for edema on lower extremities
□ Attain BP
○ Hx of previous pregnancy
▪ Gravida: number of pregnancies
▪ Paraƒparity: number of viable pregnancies delivered regardless of outcome
□ Nulli: 0
□ Primi: 1st
□ Multi: 2−4
□ Grand multi: >5
□ <20 abortion
□ 20−36 weeks preterm delivery
□ 27−42 weeks full term delivery
□ >42 weeks post term delivery
□ Parity should be used as best obstetrical score
• 3 common dx that makes pregnancy dangerous as per DOH
○ Hpn
○ Diabetes
○ Anemia
• Pre menstrual hx
○ Age of menarche (usually at 12)
○ PMS
• Dx of pregnancy
○ Urinary pregnancy test best taken at 2 weeks after first missed period
• sƒsx
○ Presumptive
▪ subjective
○ Probable
▪ objective
○ Positive
▪ objective
▪ >11 normal
▪ 9− <11 mild pathologic anemia
▪ 7 but < 9 moderate pathologic anemia
▪ <7 severe pathologic anemia
• Check lower conjunctival sac, nails, lips for anemia
• Head assessment
○ Headache
○ Hair: dryness
▪ If oily, healthy
○ Face
▪ edema
▪ chloasma
□ Nose, cheek, neck
○ Nose: epistaxis
▪ dƒt high level of estrogen as it causes nasal congestion
▪ Tilt forward to prevent aspiration
○ Neck
▪ Thyroid gland is slightly enlarged
○ Chest
▪ SOB (normal)
▪ DOB (abnormal)
○ Palpitations
▪ Normal
▪ Left lateral position
○ Pyrosis is normal
▪ SFF
▪ Antacid as prescribed
• GI
○ Constipation
▪ High progesterone, decreases GI motility
▪ Inc fluid and fiber and exercise
▪ Malunggay is good
○ Striae gravidarum
▪ Stretch marks
▪ Not applicable to everyone becos others can have high levels of collagen on skin
• Musculoskeletal
○ Leg cramps
▪ Increase calcium intake
▪ Dorsiflex to relax muscles
○ Lordosis
▪ Low back pain
▪ Rest periods
▪ Flat shoes
○ Edema
▪ High amt of progesterone > increased aldosterone > fluid and sodium retention
▪ elevate
○ Varicosities
▪ Knee high stockings
• Diagnostic exams
UTZ amniocentesis
Visualization Aspiration of amniotic fluid
Non invasive Invasive
No consent With consent
Inc OFI <20w pregnancy Puncture sire at lower
>20w no need unless suspected with oligohydramnios abdomen
1 cup of water q15
1 1ƒ2 hr before utz
Total: 1140mL
Do not void Void
15−30mL of AF
• Fetal lung maturity
• Neural tube
defect
○ Spina bifida
• Chromosomal defect
○ Down syndrome
Ç fiber, OFI
$ salt, fats
• Placental factor
○ Type of separation
▪ Schulz (common?)
• Psyche
○ Mental, emotional preparation when undergoing delivery
○ If possible, bring COC to provide emotional support
2. Expulsion
○ CCD to delivery of bb
3. Placental
○ Delivery of bb to delivery of placenta
4. Recovery
○ 1st 2−4h post delivery
• Gloves 2 pieces
○ Double gloving
• Towels 2 pieces
○ Lower abdomen to catch bb
○ Towel #1 first 30 s dry the bb to prevent hypothermia
○ Towel #2 back of the bb after ssc
• Bonnet 1
○ Put bonnet after utilizing both towels
• Oxytocin
○ Don’t give if BP >140ƒ90
○ Check for possible second baby
○ Press abdomen and massage to stimulate contraction
• Cord dressing materials
○ 1−3 mins after delivery
○ Max waiting time 3 mins before clamping
○ CC 2 cm from base
○ Kelly 3cm from CC
• Empty kidney basin
○ Waste receptacle
• KB with 5% chlorine solution
○ Active mgt of TSL begins after administration of oxy Oxy: rhythmic UC
○ Disinfect placenta in this KB Methergine: sustained UC
• space for bf
• Eye prophylaxis
○ Erythromycin ophthalmic ointment
○ Inner to outer
○ Prevent ophthalmia neonatorum
▪ rƒt gonorrhea
• Vitamin K (vastus lateralis)
○ Promote blood coagulation
○ Promote blood clotting
E. Coli normal flora that stimulates clotting
• Heparin
• Hep B vaccine (vastus lateralis)
• BCG vaccine (ID)
• Stethoscope
• Tape measure
○ HC: 33−35cm
○ ACƒCC: 31−33cm
○ Birth length: 47−54cm
Postpartum
• Puerperium
○ 1st 5w period after delivery
• Involution
○ Return of uterus from pregnant to non pregnant
○ Fundus at level of umbilicus after delivery of bb and placenta
○ Height of fundus decreases one fingerbreadthƒday after delivery
○ At 10th day, fundus is no longer palpable
○ Sluggish involution if uterus descent is slow
Ways of promoting UC
• Massage fundus
• Bladder emptying
○ To prevent uterus displacement
• Early bf
• Early ambulation
○ ASAP after delivery (nsvd)
○ 24h after delivery (CS)
Haase's rule
• Determines length of the baby during pregnancy
• 1−5mos squared
○ 1x1, 2x2 and so on
• 6−9mos x 5
Johnson's rule
• Estimated fetal weight in grams
• FH in cm − 11 (or 12) x 155
○ Minus 11 if not
engaged Determined through ballotement
○ Minus 12 if engaged
Family planning
Natural Artificial
Abstinence Hormonal
Regular
Strict
Lactational amenorrhea method Chemical
6m protection from pregnancy
BF inc estrogen
Inc estrogen > APG will not release Follicle stimulating hormone
If no FSH > no ovulation
LAM must be used exclusively (regular and full time)
Fertility awareness method Surgical
• Calendar method
• Cervical mucus test
• Symptothermal method
• Basal body temp
○ Progesterone inc BT
• 2−day method
○ 2 consecutive dry days = safe
Mechanicalƒbarrier
Fertile cervical mucus
• Clear
• Watery
• Abundant
• Slippery
• Thin
Artificial
• Hormonal
• Suppressesƒinhibits ovulation
○ Levels of EƒP will remain high = no hypothalamic actƒno ABGƒno ovarian activity = no hormones released
○ Uterine activity will remain
• SƒE
• cƒI
○ >35
○ Pregnant
○ Lactating
○ HPN
○ DM
○ CV problems
○ Thromboembolic disease
○ Liver problem
• Danger signs when taking the pill
○ Jaundice
○ Abdominal pain ➢ Could indicate liver problem
○ Chest pain ➢ Heart problem
○ Headache ➢ Possible HPNƒdiabetes
○ Eye problems
○ Severe leg pain ➢ Thromboembolic disease
• Types:
○ Oral
▪ Pills are best taken during menstruation
▪ In case of a missed pill, if remembered on the same day, take 1 as usual
□ If missed a day, 2 pills a day (1AM, 1PM)
□ If missed 2 days, take 2 pills for 2 days then go on as usual
□ If missed for 3 days, discard the whole pack as this seems confusing
□ 28 day pill:
◆ 21 hormonal tablets
◆ 7 placebo pills
◆ 1 tabletƒ dayƒsame time
◆ Back to hormonal tablets after mens
◆ E+P
□ 21 day pill
◆ All hormonal tablets
◆ Categorized as POP
◆ After consuming an entire pad, rest for a week then start again after the end of mens
□ COC
◆ cƒi in BF becos it will affect milk
◆ production Estrogen and progesterone
◆ Combined oral contraceptive
□ POP
◆ Pwede for BF mother
◆ Progestogen−only contraceptive pill
○ Implant:
▪ Implanon
□ 99.8% protection
□ 3 years protection
▪ Ortho evra
□ Patch
□ 1 pack = 3 patches
□ □
□ 1 patch = 7 days
□ Rest for a week after 3
○ Injectable patches Applied on deltoid
area
96% protection
▪ Depo provera
□ Progesterone−based
□ 3 months protection
□ No mens
□ Don’t massage injection site as this increases absorption and protection timeline becomes shorter
• Chemical
• Spermicide
○ Increasing VC acidity
○ 80% efficacy rate
○ Once itchiness occurs, discontinue
○ Use with condom for increases efficacy
○ Forms:
▪ Spray
▪ Tablet
▪ Gel
▪ Foam
• Barrierƒmechanical method
• Blocks sperm from entering
• Types:
○ Condom: vaginal canal ➢ Check under the light to see if there is a hole
○ Cervical capƒdiaphragm: cervical canal ➢ Latex allergy
▪ Retain for 6−8h post sex
○ IUD: fallopian tube
▪ Sterile inflammatory response in the FT protects from pregnancy
▪ Mostly uses Copper T
IUD BTL
Done During mens During mens
Mens Continue Continue
Ovulate ƒ ƒ
Protection ƒ ƒ
STD protection X X
Permanent X ƒ
Abnormal OB
• Antepartal
○ Bleeding
▪ 1st
tri Abortion
□ Ectopic pregnancy
□
▪ 2nd tri
□ Abortion
□ Incompetent cervix
□ H−mole
▪ 3rd tri
□ Abruptio placenta
□ Placenta previa
▪ Assess first how many months is the gestation period
▪ Abortion occurs when there is termination before period of viability (20 weeks)
○ Abortion
▪ Types
□ Spontaneous
◆ Non intentional
◆ Types:
Q Threatened
◗ Pregnancy is in danger, but if controlled, pregnancy may continue
◗ Only type of abortion to be saved
◗ No IE
◗ Bed rest (left lateral position)
◗ Tocolytic drugs
◗ Sedative drugs are ok
Q Imminent
Q Complete
◗ Everything is out
Q Incomplete
◗ Placenta remains
◗ Uterus relaxes
Q Missed
◗ Intra uterine fetal deathƒdemise
◗ Decreasing abdominal girth
◗ Brownish vaginal discharge
◗ 4−6w staying
Q Habitualƒrecurrent
◗ 3 or more consecutive abortions
◗ Mostly caused by incompetent cervix
– Cervix cant remain close during
pregnancy
– LGA, IC are prone thereof
– Usually on 2nd tri, 4th month Painless vaginal bleeding on 3rd tri: PP
– Painless vaginal bleeding 1st,2nd tri
– Kegel's exercise
– Management:
◆ Cerclage suturing
○ Temporary: McDonald's
❖ Removed at 37w or is showing signs of true labor (whichever comes first)
○ Permanent: Shirodkar
❖ Not removed
❖ BB delivered via CS
Q Septic
◗ Incomplete and missed abortion could lead to septic abortion
◗ an infection of the placenta and fetus, or products of conception, of a pre−viable pregnancy
Q Bethametasone (celestone)
Cervix BOW UC
TA Close Intact mild
IA Open Ruptured Mild to moderate
CA
IncA
Missed
Septic
Habitual
□ Induced
◆ Intentional
◆ Types:
Q Therapeuticƒlegal
◗ Done to save life of mother
◗ E.g. cardiac condition, ectopic pregnancy
Q Non−therapeuticƒcriminal
◗ Get rid of unwanted pregnancy
○ Ectopic pregnancy
▪ Pelvic inflammatory disease (1st)
▪ IUD use (2nd)
▪ Types:
□ Tubal
◆ Common
◆ Ampulla (widest)
□ Ovarian
◆ Interstitial (narrowest)
□ Abdominal
◆ dangerous
□ Cervical
◆ Rare
▪ FT is expected to rupture between 10th−12th week
▪ Kehr's sign (best sign)
□ Sharp stabbing pain from lower quadrant of abdomen to same−side shoulder
□ Unilateral
▪ Diagnosed through UTZ
▪ DOC: methotrexate
□ Used on H−mole
▪ Surgery: ExLap followed by oophorectomy
○ H−mole
▪ Gestational trophoblastic disease
□ Over production of trophoblastic cell = more chorionic villi = more vesicles (fluid filled) = rapid enlargement of uterus
▪ Causes:
□ Poverty: protein deficiency
□ Overfertilization
▪ 4 classical signs:
□ Uterus bigger than date
□ HCG is abnormally high 1m−2m
□ No fetal signs
□ Passage of vesicles (cardinal sign)
▪ Management:
□ D&C
□ Suction and curettage
□ Avoid pregnancy for at least 1yr
□ DOC: methotrexate
3rd trimester bleeding
Placenta previa Abruptio placenta (dangerous)
Site of implantation (lower uterine segment) Timing of placental separation (early)
Painless Painful
Uterusƒabdomen soft Board−like uterusƒabdomen
No uterine contraction With uterine contraction
Bright red Dark red
Obvious bleeding (overt) (duncan) Concealed bleeding (covert) (schulz separation)
Presenting part cant be engaged Presenting part can or cant be engaged
• Placenta previa
○ Types:
▪ Total
▪ Partial
▪ Marginal
▪ Low lying
○ Dx:
▪ abdominal ultrasound
▪ Transvaginal utz
□ Determine extent of obstruction
○ Management
▪ Watchful waiting
▪ Bed rest
▪ Give celestone
▪ Emergency CS asap
▪ LLP
▪ O2 therapy
▪ IVT
▪ Blood transfusion
• Abruptio placenta
○ Causes
▪ Short umbilical cord (normal: 50−55cm)
▪ Cord coil
▪ Hypertension
▪ Unwise use of oxytocic drug
○ Mgt:
▪ Tocolytic: MgSO4 (prevent contraction)
▪ Bed rest
▪ No IE
▪ External fetal monitoring
• Pregnancy−induced hypertension
○ Classical signs:
▪ Proteinuria
▪ Edema
▪ Hypertension
□ DOC: hydralazine (apresoline)
○ Predisposing factors
▪ Primigravida, young
▪ Multi, advanced maternal age
▪ Low socio economic status
▪ Stress
▪ Diabetes
○ Protein should be slightly high in the diet
○ Promote safety in labor and delivery
○ Types:
▪ Gestational hypertension
□ High BP only
□ Starts increasing >20w and above
▪ Pre eclampsia
□ PEH BP Proteinuria Edema
□ Starts increasing >20w and above MP 140ƒ90−160ƒ110 +1, +2 Mild to moderate
□ Types:
SPE >160ƒ110 +3, +4 Severe
◆ Mild
◆ Severe E Same Same Same
▪ Eclampsia
□ PEH • Blurring of vision
□ Starts increasing >20w and above • Severe headache
▪ Chronic hypertensive disease • Hyperactive reflexes > impending convulsion
□ PEH • Epigastric pain
□ Increases even before 20w old
○ Doc of hypertension: hydralazine
○ Doc of anti convulsion: MagSO4 > decreases neuromuscular irritability > z−track (prevent SQ irritation)
▪ Loading dose: 6−10g
▪ Maintaining dose: 1−2g
▪ 1gm=1mL
▪ Use upper outer quadrant
▪ Assess: not to administer if
□ RR: <12 bradypnea
□ UO: <30mL oliguria
□ Reflexes: hypoactive <1 hyporeflexia (earliest sign)
▪ Monitor
□ Blood pressure
□ Weight
□ FHR
□ Kick count
▪ Mgt:
□ Dim lit room
□ Call light within reach
□ Quit envt
□ Side rails up padded
□ Left lateral to promote drainage of secretions
□ Indwelling catheter
• GDM
○ Caused mostly by:
▪ Estrogen
▪ Progesterone
▪ Human placental lactogen
○ Screened best at 24w
○ Types:
▪ I: Insulin dependent DM
□ Child onset
□ Insulin
□ Diet and exercise
▪ II: NIDDM
□ Diet and exercise
□ Insulin
□ Oral hypoglycemic agent
▪ III: GDM
□ Insulin
□ Oral hypoglycemic agent
▪ III: GDM
□ Mgt: Normal blood glucose at birth: 40−60mgƒdL
◆ Diet and exercise
◆ Insulin
Q Contamination: intermediate mixed in regular vial
◗ Prolonged hypoglycemia as this affects duration
Q Aspirate regular then intermediate
◗ Good effect because onset of intermediate insulin becomes earlier
Type Onset Peak Duration
Reg 30m − 1h 4h 5−8hrs
If calculating time: compute onset, peak and duration
Intermediate 2h 6−8h 12−16h
• Gravido cardiac client
○ #1 predisposing client
▪ RHD < RF < Respiratory tract infection < Group A beta hemolytic streptococcus (GABHS)
□ Mitral valve stenosis damage > chronic heart failure (left−sided)
□ Dental carries
◆ Pastaƒbunot
○ Classifications
Class Damage in sƒs Activities that trigger Limitation in Physical Method of delivery
MV sƒsx activities
I Very minimal asymptomati None None NSVD
c
II minimal sƒs Heavy activities Slight NSVD to forcep delivery
III moderate sƒs Light activities Marked Forcep delivery to therapeutic
abortion
IV severe sƒs Even at rest Complete bed rest Therapeutic abortion
○ DOC to increase pumping force of LV: digitalis therapy
▪ Decreases rate of heart contraction
▪ Increased urine output
○ Best anticoagulant drug for preggo women:
▪ Heparin
□ Hindi nag cross sa PB