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OBSTETRIC NURSING
MERIAM DELOS REYES FLORES R.N.
10/16/09
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•In sharing what we know, we are definitely helping others and more so ourselves and for whatever good we give out………..the goodness will complete the circle and the rewards will undoubtedly come back to us. 10/16/09
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Anatomy and Physiology FEMALE REPRODUCTIVE ORGAN
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External Genitalia/Pudenda /Vulva • • • • • • • •
Mons Pubis Labia Majora Labia Minora Vestibule Clitoris Breasts (Mammary Glands) 10/16/09
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• Mons Pubis • Labia Majora • Labia Minora • Vestibule • Clitoris • Breasts • (Mammary • Glands) 10/16/09
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Stages of Pubic Hair Development • Tanner scale tool - used to determine sexual maturity rating. • Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only • Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair at pubis symphysis • Stage 3 occurs between ages 12 and 13 – darker & curlier at labia • Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. • Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh . 10/16/09 9
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Internal Genitalia • Vagina • Uterus • Fallopian tubes • Ovary
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External parts of the breast Nipple - Sinuses merge into openings on nipple - muscles and - nerves - glands - milk pores Areola - Montgomery - tubercles 10/16/09
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Male Reproductive System External Genitalia • Penis • Glans Penis • Frenulum • Scrotum
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Internal Genitalia • • • • • •
Testis Epididymis Vas Deferens Prostate Gland Seminal Vesicles Bulbourethral Glands/Cowper’s Gland • Urethra 10/16/09
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MALE REPRODUCTIVE SYSTEM: SEMEN: • Is a thick whitish fluid ejaculated by the male during orgasm, contains spermatozoa and fructose-rich nutrients. • During ejaculation, semen receives contributions of fluid from Prostate gland (60%) Seminal vesicle (30%) Epididymis ( 5%) Bulbourethral gland (5%) • • • • •
Average pH = 7.5 The average amount of semen released during ejaculation is 2.5 -5 ml. It can live with in the female genital tract for about 24 to 72 hours. (50-200 million/ml of ejaculation ave. of 400 million/ ejaculation ) 90 seconds- cervix 5 mins.- end of fallopian tube
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MALE REPRODUCTIVE SYSTEM: SPERMATOZOA are produced by: Hypothalamus Control by GnRH (+/-) feedback Anterior Pituitary gland FSH / LH Testes FSH - release of Androgen Binding Protein (ABP) which promote SPERMATOGENESIS LH - release of Testosterone.
“Spermatozoa does not survive at body temperature. They usually survive 1°F lower than body temperature”.
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Seminal Fluid Circulation Testes
Epididymis
Vas Deferens -
Seminal Vesicle
Ejaculatory Duct -
Prostate/Cowper’s Gland 10/16/09
Urethra 21
• Menarche – first menstruation • Puberty – transitional stage between childhood and sexual maturity. At around age 13. - age at which reproductive organs become functionally active
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• Menopause – the cessation of menstrual cycle • Post menopausal period – it is the time of life ff. menopause • Perimenopausal – period during which menopausal change are occurring between 44 – 50 years old
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– Amenorrhea = temporary cessation of menstrual flow – Oligomenorrhea = markedly diminished menstrual flow, nearing amenorrhea – Menorrhagia = excessive bleeding during regular menstruation – Metrorrhagia = bleeding at completely irregular intervalsor in between menstruatio n – Polymenorrhea = frequent menstruation occurring at intervals of less than three weeks
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MENSTRUAL CYCLE • Periodic recurring changes in hormonal status that prepares the body for pregnancy • To bring the ovum to maturity and renew a uterine tissue bed that wilt be responsible to its growth and should be fertilized.
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• a woman’s menstrual cycle begins on the first day of her menstruation and ends on the day before her next menstruation. • this cycle begin at puberty and continue until woman reaches menopause. • on average, cycles can range from 23 to 35 days (median length is 28 days). Some women have short cycle some women have long cycle. • Cycle can vary among women or at times may even vary in individual women. 10/16/09
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Menstruation • The periodic uterine bleeding that begins approximately 14 days after ovulation • It usually occur at monthly interval through the reproductive period except during pregnancy and lactation • Average flow is 2 -7 days
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Organs involve in Menstrual cycle • Hypothalamus • Pituitary gland • Ovary • Uterus
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Phases of Menstrual Cycle • HypothalamicPituitary Cycle • Ovarian Cycle • Endometrial Cycle
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HYPOTHALAMIC -PITUITARY CYCLE
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Menstruation
Hypothalamus Stimulates
FSHRH
APG
Secretes triggers
Low level of estrogen & Progesterone in blood
Follicular Phase
APG to Stop producing LH
Hypothalamus to Stop producing LHRH
MENSTRUAL CYCLE Proliferative High level of estrogen & Progesterone Phase in blood sends feedback
Secretes FSH Carried by blood stream Ovary causing Devt. of young cells (graafian follicles to mature) Produces estrogen Carried by blood stream Uterus lining Becomes thick
High level of Estrogen in The blood
Uterus causing further thickening of uterus (more vascular tortous & field with mucin
Ovulation (Luteal Phase) Progesterone carried by blood stream Causing matured follicle to ruptured follicle 10/16/09 called corpus luteum Produces progesterone
LH is carried by the blood stream
APG stops producing FSH instead produces LH
Sends feedback to Hypothalamus to stop released FSHRH instead produces LHRH31
HYPO-PIT
OVARIAN
ENDOMETRIAL
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Ovarian and Uterine Cycles
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Figure 16.12c, d
OVARIAN CYCLE
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OVARIAN CYCLE
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Endometrial Cycle • Menstrual Phase • Proliferative Phase • Secretory Phase • Ischemic Phase
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• When a woman is fertile the mucus helps the pregnancy to occur in 3 ways. • Functions of the Mucus: • - nourishes the sperm • - forms channels to help the sperm swim to the egg • - filters out abnormal sperm so they do not reach the egg 10/16/09
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OTHER CYCLE
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Sexual Stimulation 1. Physical Stimulation - involves touch and/or pressure to parts of the body and may be applied by one's self, by another's body contact or by inanimate objects. E.g. kissing, hugging, stroking etc. • a. Foreplay - pre-coital activity to arouse sexual desires. It. includes kissing, hugging, stroking, fondling and manipulation of all parts of the body including genitalia and breasts. 10/16/09
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• b. Orgasm - climax of sexual excitement or as prelude to sexual intercourse. • c. Masturbation - manual self stimulation. • 1. Most common in pre-school and often associated with comfort and pleasure. • 2. Men usually begin to experience masturbating often before 20's.
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Phases of Physiological Responses to Sexual Stimulation: • 1. Excitement Phase: lasts for several minutes to hours. • Heart rate and Blood pressure increases • Nipples become erect • Myotonia begins
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Changes in Female and Male – clitoris increases in diameter and swells - external genitals become congested and darkened - vaginal lubrication with 2/3 of vagina lengthens and extend. - cervix and uterus 10/16/09 pull upward
- Erection of the penis – increases in length and diameter - Scrotal skin becomes congested and thickens - Testes begin to increase in size and elevate towards the body
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• 2. Plateau Phase: the period during which sexual tension increases to levels nearing orgasm, may last from 30 seconds to 3 minutes. Formation of orgasmic platform in the vagina. • Heart rate and BP continue to increase • Respirations increases • Myotonia becomes pronounced • Grimacing occurs
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Female-Male Clitoral head retracts under the clitoral hood. Lower one third of vagina becomes engorged. Skin color changes occur-red flush may be observed across breasts, abdomen or other surfaces 10/16/09
Head of penis may enlarge slightly Scrotum continues to grow tense and thicken Testes continue to elevate and enlarge Preorgasmic emission of 2 or 3 drops of fluid appears on the head of the penis 47
• 3. Orgasmic Phase: is the involuntary climax of sexual tension, accompanied by physiologic and psychologic release. • "This is considered the measurable peak of sexual intercourse.” • It is short lasting 3 to 10 seconds. Strong rhythmic contractions of vagina and uterus. 10/16/09
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• Heart rate, blood pressure and respirations increases to maximum levels • Involuntary muscle spasms occur • External rectal sphincter contracts
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Female - Male - Strong rhythmic contractions are felt in the clitoris, vagina and uterus - Sensations of warmth spread through the pelvic area
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- Testes elevate at maximum level - Point of inevitability occurs just before ejaculation and awareness of fluid in the urethra. - Rhythmic contractions occur in the penis. - Ejaculation of semen occurs
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• 4. Resolution Phase - the period of return to the unaroused state, may last 10 to 15 minutes after orgasm, longer if there is no orgasm. Cervix dips into seminal pool in vagina; all organs returns to previous condition • Heart rate, BP and respirations return to normal. • Nipple erection subsides • Myotonia subsides
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Female Engorgement in external genitalia and vagina resolves Uterus descends to normal position Cervix dips into seminal fluid Breast size decreases Skin flush 10/16/09 disappears
50% of erection is lost immediately with ejaculation Penis gradually returns to normal size Testes and scrotum return to normal size
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• Refractory – – only in males, the period during which no amount of stimulation can cause another erection. – Not manifested in females because females are multi orgasmic. – This phases lengthens with age 10/16/09
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Male Sexual Dysfunction Erectile failure - inability of a man to attain or maintain an erection to such an extent that he can't have satisfactory intercourse. • 2. Premature ejaculation - ejaculation or orgasm before or very soon after entering the vagina. • 3. Retarted ejaculation (ejaculatory impotence) - inability to ejaculate into the vagina or to suffer with delayed intravaginal ejaculation. • 1.
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Female Sexual Dysfunction • 1. Frigid- inhibition in sexual arousal that leads to absent or minimal vaginal lubrication. • 2. Orgasmic dysfunction - persistent inability of a woman to reach orgasm. • 3. Dyspareunia - painful intercourse. • 4. Vaginismus - condition in which the vaginal opening closes tightly and prevents penile penetration.
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FETAL DEVELOPMENT
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Fetal Development • Fertilization: the union of the ovum & sperm. • - The start of Mitotic cell division & fetal sex determination • Other name: Conception, Impregnation and Fecundation
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Process of Fertilization/Implantation After ovulation ovum will be expelled from the Graafian follicles Ovum will be surrounded by Zona Pellucida (mucopolysaccharide fluid) & a circle of cells (Corona Radiata) which increases the bulk of the Ovum
Ovum expelled from the Fallopian Tube by the Fimbriae (infundibulum).
Sperms move by flagella & Penetrate the & dissolve the cell wall of the ovum by releasing a proteolytic enzyme (Hyaluronidase) 10/16/09
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After penetration Fusion will result to Zygote
Zygote migrate for 4 days in the body of the uterus (Cell division will take place - Cleavage formation will begin) After 16-50 cell formation from cell division, a mulberry & Bumpy appearance will follow morula
Implantation 10/16/09
After 3-4 days, the structure will be ball like in appearance which will be called Blastocyst.
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Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium
2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop
3rd week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form
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Early during the 4th week (28 days after implantation), cellular 61 differentiation and organization occur.
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Development from Ovulation to Implantation
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Figure 16.15
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Fertilization
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DAY 1
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First cell Division (Zygote) – Day 2
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Morula Day 3
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Blastocyst Day 4
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Fetal Development Fertilization/Preembryonic
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Early Development: Implantation
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Development After Implantation
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Figure 16.16
Uterine Changes • Conversion of the endometrium to decidua: • Decidua basalis – part of the endometrium where the embryo lies or where the throphoblast cells are establishing communication with the maternal blood vessels • Decidua capsularis – portion of the endometrium that stretches or encapsulates the surface of the trophoblast • Decidua vera – remaining portion of the uterine lining
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Developmental Stages • Ovum: From ovulation to fertilization • Zygote: From fertilization to implantation • Embryo: From implantation to 5 - 8 weeks. • Fetus: From 8 weeks until term The ovum is said to be viable for 2436 hours. 10/16/09
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Preembryonic stage: stage of the ovum – fertilization to the first 3 weeks – fertilize ovum growth and differentiates – formation of the three primary germ layers endoderm, ectoderm and mesoderm – implantation in the endometrial tissue 10/16/09
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Embryonic stage – fourth week to the eight week of development – period of organogenesis – differentiation of cells, organs and organ systems – highly vulnerable, time for congenital anomalies to occur – at the end of this period of development, embryo has features of the human body
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Fetal stage – –
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eight weeks to the time of birth characterized by growth and development of organs and organ systems
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ORIGIN OF BODY TISSUE • Tissue Layer • - Ectoderm • - Endoderm • - Mesoderm
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Ectoderm/Outer •
– Skin - Hair - Nails - Tooth enamel - Nervous system - Sense organs - Mucous membrane of the anus and mouth.
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Mesoderm/Middle Layer - Muscle - Connective Tissue - Circulatory/Heart - Blood cells - - Reproductive - Bones - Cartilage - Kidneys - Ureters 10/16/09
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Endoderm/Inner • - GI (Hepatobiliary/Pancreas) - Respiratory - Endocrine - Tonsils - Thyroid (for basal metabolism) - Parathyroid (for calcium metabolism) - Thymus glands (for development of immunity) - Bladder and urethra
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Fetal Blood Supply
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Fetal Circulation
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1 Lunar Month st
• Germ layers differentiate by the 2nd week • Entoderm • Mesoderm • Ectoderm
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• Fetal membranes (amnion and chorion) appear by the second week • Nervous system very rapidly develops by the 3rd week (Dizziness is said to be the earliest sign of pregnancy because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus causing hypoglycemia in the latter)
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1 Lunar Month st
• Fetal heart begins to form as early as the 16th day of life (To the question, “When does the fetal heart begin to heat?”, the answer is the first lunar month. But to the question, “When can fetal heart tones be first heard?” the answer is fifth month). • The digestive and respiratory tracts exist as a single tube until the 3rd week of life when they start to separate.
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Second Lunar Month • All vital organs are formed by the end of the 8th week. • Placenta develops fully. • Sex organs (ovaries and testes) are formed by the 8th week (To the question, “When is sex determined?” , the answer is at the time of conception). • Meconium first stools) are formed in the intestines by the 5th-8th week. 10/16/09
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Third Lunar Month Kidneys are able to function – urine formed by the 12th week Buds of milk teeth form Beginning bone ossification Fetus swallows amniotic fluid Feto-placenta circulation is established by selective osmosis; no direct exchange between fetal and maternal blood.
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Fourth Lunar Month
Lanugo appears Buds of permanent teeth form Heart beat audible with fetoscope
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Fifth Lunar Month Vernix caseosa appears Lanugo covers entire body Quickening (fetal movements) felt Fetal heart beats very audible
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Fifth Lunar Month • Vernix caseosa appears • Lanugo covers entire body • Quickening (fetal movements) felt • Fetal heart beats very audible
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Seventh Lunar Month Skin markedly wrinkled Attains proportions of fullterm baby Surfactant begins to produce
Sixth Lunar Month
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Alveoli begin to form (28th weeks gestation is said to be the lower limit of prematurity; if born, cries, breathes, but 93 usually dies)
Eigth Lunar Month
Fetus is viable Lanugo begins to disappear Nails extend to ends of fingers Subcutaneous fat deposition begins
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Ninth Lunar Month Lanugo and vernix disappear Amniotic fluid volume somewhat decreases
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Tenth Lunar Month •
all characteristic s of the normal newborn
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• First trimester – organogenesis • Second trimester- period of continued fetal growth and development; rapid increase in fetal length • Third trimester – period of most rapid growth and development because of rapid deposition of subcutaneous fat
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Special Structures of Pregnancy • Fetal Membranes: • - arise from the zygote • - inner (amnion) and outer (chorion) • - holds the developing fetus as well as the amniotic fluid 10/16/09
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Fetal Membranes: membranes that surround the fetus, & give the placenta the shiny appearance. Inner (amnion) - shiny membrane on the 2nd week of Embryonic Development & encloses the Amniotic Cavity and holds the amniotic fluid
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Chorion: Outer membrane that supports the sac of the amniotic fluid. Chorionic Villi: finger like projections from the chorion. This is the place where gases, nutrients and waste products between the99 maternal & fetal blood
• Syncytiotrophoblast or synytial layer – outer covering or layer of the chorionic villi. • Secretes the ff hormones: - HCG • - Estrogen • - Progesterone • - HPL (somatotrophin) • • Cytotrophoblast or langhan’s layer – inner layer. Function: • - protects the growing embryo and fetus from • infectious organisms 10/16/09
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Amniotic Fluid • clear, yellow fluid surrounding the developing fetus and surrounds the embryo, contains fetal urine, lanugo from fetal skin & epithelial cells. • Functions: • protects the fetus/shields • allows free movement • maintains temperature • provides oral fluid
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• Ph is 7. 2. • Specific Gravity: 1.005 – 1.025 Normal Amount: 500 – 1500 ml. Oligohydramnios - less than 500 ml. Polyhydramnios - more than 2000 ml. observe for congenital defects • can be aspirated and tested for various diseases and abnormality during pregnancy (genetic) • alkaline ph: can be testes when membrane ruptures
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Amniotic Fluid Colors • a. pale straw color – normal • b. yellow stained/ dark amber • = fetal hypoxia that occurred 36 hours or more before the rupture of membranes • = fetal hemolytic disease (Rh or ABO incompatability, intrauterine infection) • = Ominous sign of presence of Bilirubin, hemolytic disease • Character – thick secretions with unpleasant odor = infection 10/16/09
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• c. Greenish: Meconium Stained / FETAL DISTRESS, Also if ph is less than 7.2 • greenish brown (meconium – sustained) • = fetus had a hypoxic episode ---- relaxation of the anal sphincter ---- passage of meconium from the bowel • = normal in breech presentation If with odor: deliver within 24 hours, may indicate infection.
• d. Port Wine Color – admixture of amniotic fluid and blood - indication abruptio placenta 10/16/09
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Test for rupture of membranes • Voiding by an incontinent woman and leukorrhea should be differentiated from amniotic fluid. • Spread a drop of the fluid on a clean slide. Dried amniotic fluid will show a fern like crystalline pattern when viewed under the microscope (positive fern test).
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• Determine the pH of the vagina fluid. Amniotic fluid is slightly alkaline; urine or pus is acidic. • With sterile speculum, us sterile cotton swabs to take samples of vaginal secretions at cervical os • Test with pH paper (Nitrazine)
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Interpretation • Yellow/Olive Yellow/Olive Green = pH5 to 6 (membrane probably intact) • Blue green/blue gray/deep blue = pH 6.5 to 7.5 (ruptured membrane) • Fetal lanugo or fetal squamous cell may be seen on the microscope • Sudan III and Nile blue tests for detection of fetal fat particles and desquamated fetal aft cells
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Umbilical Cord • 21 inches in length & 2 cm in thickness, circulatory communication of the fetus to the mother. • there are no pain receptors in the umbilical cord • connecting link between fetus and placenta • contains 2 arteries and 1 vein supported by mucoid material/ mucopolysaccharide called (Wharton’s jelly) to prevent kinking and knotting
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Placenta • transient organ allowing passage of nutrients and waste materials between mother and fetus • contains 20 cotyledons, weighs 400-600 grams. • fully develops on the 3rd month. • form from Chorionic villi & deciduas basalis. Deciduas (meaning endometrial changes & growth) • acts as an endocrine organ (hormones) and as a protective barrier against some drugs or infectious agents
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Functions • Respiration – O2 , CO2 • Excretion • Nutrition • Storage - CHO, CHON, calcium and iron • Protects the growing embryo and fetus from infectious organisms • Mother also transmit immunoglobulin G (IgG) to fetus through placenta, providing limited passive immunity
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Hormones Associated with Pregnancy HCG – indicator of pregnancy - secreted by the chorionic villi and later by the placenta - lengthens the lifespan of corpus luteum
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Estrogen – initially secreted by the copus luteum – enhances fat deposition promotes sodium and water retention - mediates vascular changes - produces enlargement of uterus, breast and 111 genitals
Progesterone – initially secreted by the corpus luteum and later by the placenta - produces relaxation of smooth muscle maintains decidua 10/16/09
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•Human chorionic somatomammotropin/human placental lactogen (HCS/HPL): similar to growth hormone; •- affects maternal insulin production (diabetogenic hormone for the mother to diminish insulin efficiency) •- prepares breast for lactation, detectable in trophoblast as early as third week after ovulation. 10/16/09
Relaxin inhibits uterine activity and relax pelvic joint
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Prolactin – released from the anterior pituitary gland - Suppressed during pregnancy - milk production
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Oxytocin – released from the PPG -produces smooth muscle contraction - milk ejection 114
DIAGNOSIS OF PREGNANCY
MERIAM DELOS REYES FLORES R.N.
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Obstetrical Terms • Gravida – woman who is pregnant • Gravidity – pregnancy • Parity – number of pregnancies whose fetus have reached the age of viability • Multigravida - woman who has 2 or more pregnancies • Multipara – woman who has completed 2 or more pregnancies
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• Nulligravida – woman who has never pregnant • Nullipara - woman who has not completed pregnancy with a fetus who have reached the stage of viability • Primigravida – woman who is pregnant for the first time • Primipara – woman who has completed one pregnancy with a fetus who have reached the stage of viability • Viability – capacity to live outside the uterus which about >20 weeks or > 500 grams
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• Term – 38 – 42 weeks • Post date – Postterm - > 42 weeks • Preterm – 21 to 37 weeks • Immature – 21 to 27 weeks (----) • Abortion - < 20 weeks or < 500 grams
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Obstetrical Score • T – P – A - L (F P A L) a. Term birth or Full term b. Preterm c. Abortion d. Living children N.B. Some use G T P A L / G T P A L M 10/16/09
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PREGNANCY • gestational process, comprising the growth and development within a woman of a new individual from conception through the embryonic and fetal periods to birth • Other name: gestation, fecundation, impregnation, conception • Gestation – period from the fertilization of the ovum until birth
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• Diagnosis of pregnancy can be done by physical assessment and simple laboratory procedures: • by simple ultrasound • by urine testing or blood test – determining the HCG or Human chorionic gonadotrophin hormone • - produced by the chorionic villi of the placenta that can be tested on the urine and serum (RIA) 10/16/09
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HCG • - in serum you can test after 24 – 48 hours after implantation • in the urine 1st morning void and can be detected 26 days after conception • Peak level between 60 – 70 days. But will last until 100 – 130 days then it will go down. • In post partum women it will become negative in serum testing after 1 – 2 weeks after delivery.
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Diagnosis of Pregnancy • Presumptive – subjective – sign that suggest that do not confirm pregnancy and could be due to other condition • Probable – objective – strong indication of pregnancy not likely but still possibly due to other condition. • Positive – signs definitively confirming pregnancy 10/16/09
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PRESUMPTIVE Subjective
Amenorrhea Morning sickness Breast changes Fatigue Urinary Frequency Enlarging Uterus Quickening Leucorrhea Weight Changes Increased skin pigmentation: - Chloasma - Linea nigra - Striae gravidarum 10/16/09
PROBABLE Objective
Positive HCG Chadwick’s Goodell’s Hegar’s Ballotment Braxton Hicks contraction
POSITIVE
Ultrasound evidence Fetal heart tones Fetal movements Fetal outline on X-ray
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Psychosocial Changes • There are several psychosocial changes that occurs in pregnancy to the family. • It may affects the father, mother and of course the siblings
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CHANGES OF THE EXPECTANT FAMILY • Pregnancy is considered a normal maturational crisis and developmental stage for the expectant couple. • Pregnancy is physiologic
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Changes in the Father First trimester • 1. May feel left out of pregnancy. • 2. Confused by partner's mood swings. • 3. Couvade syndrome cause by stress, anxiety and empathy for the pregnant women and the father will also experience physical symptoms of nausea, vomiting and backache or similar symptoms of discomfort along with his partner.
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Second trimester • 1. Promote his involvement by his watching and feeling fetal movement. • 2. Needs to confront and resolve his own conflicts about the fathering he received as a child. • 3. Will decide on what he does and does not want to imitate from his father role figure. • 4. May react differently to partner's physical body changes.
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Third trimester • 1. Concerns and fears resurface.
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Maternal Adaptation to Pregnancy • Psychologic • Anatomical and Physiologic – systemic - local
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Psychological Adaptation to Pregnancy/Emotional Responses – First trimester – Second trimester - Third trimester
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Psychological responses – Ambivalence – Acceptance – Introversion – Mood swings – Body images changes
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Ambivalence • First Trimester: AMBIVALENCEabout pregnancy: pregnant woman focus only to self. • the fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, denial and disbelief, even repression. 10/16/09
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• Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy. • I am pregnant. …Accept the biological fact of pregnancy
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• Conflicting feelings about pregnancy • If women feels comfortable in addressing ambivalent feelings, the focus is usually on changed life style or the career -motherhood dilemma.
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• Indirect evidence of ambivalence: • a. Complaints of depression or physical discomfort. • b. Complaints of feeling ugly or unattractive. • 3. Some women may consider the possibility of abortion, if pregnancy is unwanted. 10/16/09
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Acceptance • Second Trimester: ACCEPTANCE---of the identification of motherhood & awareness & interest in the fetus. • - fetus is perceived as a separate entity. Fantasizes appearance of the baby. • I am going to have a baby… Accept the growing fetus as distinct from self & as person to care for 10/16/09
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• With an unplanned pregnancy, there is greater evidence of fear and conflict along with more physical discomfort and depression. • If pregnancy is well accepted, women experiences less discomfort and more tolerance to physical discomforts during the last trimester. 10/16/09
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Introversion • 1. This "turning in on oneself' focus is normal. • 2. Helps the mother plan, adjust, adapt, build, and draw strength in preparation for childbirth.
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Mood swings/Emotional lability • Can cause difficulty in the relationship if couple doesn't realize what is occurring. • Husband may feel exasperated with her tears and withdraw and ignore problem when she really needs him to be affectionate and supportive.
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• Third Trimester: EMOTIONAL LABILITYassuming already the mother, fears & fantasies & dreams about labor • has personal identification with a real baby about to the born and realistic plans for future child care responsibilities. • Best time to talk about preparation of layette and infant feeding method. •
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• Fear of death, though, is prominent to allay fears, let pregnant woman listen to the fetal heart tones. • I am going to be a mother…Prepare realistically for birth & parenting
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Body images changes • Woman may feel negative toward body, especially during 3rd trimester.
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Psychological tasks of the mother • Ensuring safe passage through pregnancy, labor, and birth. • Seeking acceptance of this child by others. • Seeking of commitment and acceptance of self as mother to the infant (binding-in). • Learning to give of oneself on behalf on one's child. 10/16/09
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Emotional Responses • First trimester: the fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, denial and disbelief, even repression. • Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy. 10/16/09
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• Second trimester: fetus is perceived as a separate entity. Fantasizes appearance of the baby.
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• Third trimester: has personal identification with a real baby about to the born and realistic plans for future child care responsibilities. • Best time to talk about preparation of layette and infant feeding method. • Fear of death, though, is prominent to allay fears, let pregnant woman listen to the fetal heart tones. 10/16/09
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Systemic Changes • 1. • 2. • 3. • 4.
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Circulatory/Cardiovascular Gastrointestinal changes Respiratory Changes Urinary changes
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• 5. • 6. • 7. • 8. • 9.
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Musculoskeletal changes Endocrine changes Temperature Metabolism Reproductive system
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Local Changes • 1. • 2. • 3. • 4.
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Cervix - Goodell’s sign Uterus - Hegar’s sign Vagina - Chadwick’s sign Abdominal Wall - Striae gravidarum
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• 5. Skin - Chloasma gravidarum - Linea nigra • 6. Breasts • 7. Ovaries
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Cardiovascular • Increase metabolic demand of new tissue growth • Expansion of the vascular channel especially the genital tract • Increased in the steroid hormones which exerts a positive effect on sodium and water balance
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• Blood volume: • a. Increases progressively throughout pregnancy, beginning in the first trimester and peaking in the middle of the third trimester at about 45% above prepregnant levels. • b. Normal blood pressure maintained by peripheral vasodilatation. • c. Extra volume of blood acts as a reserve for blood loss during delivery.
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Heart • a. Increase in heart rate; ten beats per minute by the end of the first trimester. • Blood pressure falls during the second trimester; rises slightly (no more than 15 mm in either systolic or diastolic) during the last trimester. • b. Increase in cardiac output. 10/16/09
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• c. Palpitations of the heart usually due to sympathetic nervous system disturbance; later in pregnancy due to the intraabdominal pressure of the growing uterus. • d. Cardiac enlargement and systolic murmurs.
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Red blood cells (RBC) • a. Stimulation of the bone marrow leads to a 20-30% increase in total RBC volume. • b. The plasma volume increase is greater than the RBC increase which leads to a hemodilution, typically referred to as physiologic anemia of pregnancy (pseudoanemia). 10/16/09
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- Pregnancy induced hypervolemia has several important functions: • To meet the demands of the enlarged uterus with it greatly hypertrophied vascular system
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• To protect the mother and in turn the fetus, against deleterious effects of impaired venous return in the supine and erect position • To safeguard the mother against the adverse effects of blood loss associated with partutrition 10/16/09
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Total Iron requirements • 1 gram or 6 -7 mg/day • - 300 mgs used by the fetus and placenta • - 200 mgs are excreted • - 500 mgs are used in erythrocyte production
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White blood cells (WBC): • White blood cells (WBC): 10 to 11,000 per cu mm; may increase up to 25,000 per cu mm during labor and postpartum.
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• Total plasma proteins: decrease due to fall in serum albumin level. • Sedimentation rate: increases due to the decrease in plasma proteins. • Fibrin level increases as much as 40% at term with the plasma fibrinogen level increasing as much as 50%. 10/16/09
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Respiratory Changes • Oxygen consumption increased by 15-20% between the sixteenth and fortieth weeks. • Diaphragm is elevated; change from abdominal to thoracic breathing around the twenty-fourth week. • Tidal volume increases steadily throughout pregnancy. • Tidal volume - amount of air moving in and out of the lungs in one normal breath.
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• Vital capacity increases slightly, while pulmonary compliance and diffusion remain constant. • Vital capacity-amount of air inhaled and forcibly exhaled in one breath. • Common complaints of nasal stuffiness and epistaxis due to estrogen influence on nasal mucosa. 10/16/09
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Urinary changes • Ureter and renal pelvis dilate (especially on the right side) as a result of the growing uterus. • Frequency of urination (first and last trimester). • Decreased bladder tone (due to effect of progesterone); bladder capacity increases: 1,300 to 1,500 cc.
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• Reduced renal threshold for sugar; leads to glycosuria. • Due to an increased glomerular filtration rate (GFR), as much as 50%, there is a decreased serum BUN, creatinine, and uric acid.
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GIT • Pregnancy gingivitis-gums reddened, swollen, and bleed easily. • Increased saliva (ptyalism); decreased gastric acidity . • Nausea and vomiting due to elevated human chorionic gonadotropin (HCG). • Decreased tone and motility of smooth muscles • Decreased emptying time of stomach; 10/16/09
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• Slowed peristalsis due to increased progesterone lead to complaints of bloating, heartburn, and constipation. • Pressure of expanding uterus leads to hemorrhoidal varicosities and contributes to continuing constipation.
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• Hyperemesis Gravidarum – it is a syndrome of excessive nausea and vomiting due to excessive hormonal changes of pregnancy especially HCG. • - characterized by the pernicious vomiting during pregnancy. • It occurs in every one thousand pregnancies, the cause is debatable but seems to be related to HCG and psychological factors. 10/16/09
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Clinical Manifestations •
Severe persistent vomiting which leads to dehydration or nutritional deficiency; progresses to fluid and electrolyte imbalance and alkalosis from loss of Hcl – if untreated, ketoacidosis (from loss intestinal juices), hypovolemia, hypokalemia, jaundiced and hemorrhage – hypothrombinemia and decreased urine output.
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Treatment • a. antivomiting – Bendectin (Doxylamine succinate plus pyridoxine). • b. Dietary – NPO for first 48 hours, after condition improves, then six small feedings alternated with liquid nourishment in small amounts every one to two hours, • - if vomiting reoccurs, NPO and IVFluids started
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• c. Effective psychological support can be offered in the form of reassurance to the pregnant woman that these symptoms will disappear by the fourth month • d. prompt correction of fluid and electrolytes imbalances. • Stress and emotional factors have been found to play a major role in hyperemesis gravidarum, psychotherapy is recommended 10/16/09
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Musculoskeletal System • Increase in the normal lumbosacral curve leads to backward tilt of the torso. • Center of gravity is changed which often leads to leg and back strain and predisposition to falling. • Pelvis relaxes due to the effects of the hormone relaxin; leads to the characteristic "duck waddling" gait.
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Endocrine changes Placenta. • a. Functions include transport of nutrients and removal of waste products from the fetus. • b. Produces human chorionic gonadotropin (HCG) and human placental lactogen (HPL). • c. Produces estrogen and progesterone after two months of gestation.
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• Thyroid gland. • a. May increase in size and activity. • b. Increase in basal metabolic rate. Parathyroid glands-increase in activity • (especially the last half of the pregnancy) due to increased requirements for calcium and vitamin 10/16/09
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• Pituitary gland. • a. Enlargement greatest during the last month of gestation. • b. Production of anterior pituitary hormones: FSH, LH, thyrotropin, adrenotropin, and prolactin. • Production of posterior pituitary hormones: oxytocin which promotes uterine contractility and stimulation of milk let-down reflex.
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• 4. Adrenal glands. • a. Hypertrophy of the adrenal cortex. • b. Increase in aldosterone, which retains • sodium, results in a decreased ability of the kidneys to handle salt during pregnancy; consequently, improper control of dietary sodium can lead to fluid retention and edema. 10/16/09
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Metabolism • Weight gain. • a. Normal weight gain: 25 to 35 lb b. Pattern of weight gain. • (1) First trimester- 3 to 4 lb • (2) Second trimester- 12 to 14 lb. • (3) Third trimester-8 to 10 lb.
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• • • • • • • •
c. Total weight gain is accounted for as follows: (1) Fetus: 7.5 lb. (2) Placenta and membranes: 1.5 lb. (3) Amniotic fluid: 2 lb. (4) Uterus: 2.5 lb. (5) Breasts: 3 lb. (6) Increased blood volume: 2-4 lb. (7) Remaining 4-9 lb. is extravascular fluid and fat reserves.
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Local Changes • • • •
1. Uterus - Hegar’s sign 2 . Cervix - Goodell’s sign 3. Vagina - Chadwick’s sign 4. Abdominal Wall - Striae gravidarum • 5. Skin - Chloasma gravidarum - Linea nigra • 6. Breasts • 7. Ovaries 10/16/09
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Uterus • Increase in size due to hypertrophy of the myometrial cells (increase seventeen to forty times their prepregnant state) as a result of the stimulating influence of estrogen and the distention caused by the growing fetus. • Weight increases from 50 to 1,000 grams. • Increase in fibrous and connective tissues which strengthen the elasticity of the uterine muscle wall.
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• Hegar's sign - Softening of the lowe uterine segment (Hegar's sign). • Irregular, painless uterine contractions (Braxton-Hicks) begin in the early weeks of pregnancy; contraction and relaxation assist in accommodating the growing fetus. • Multigravidas tend to report a greater incidence of Braxton-Hicks than primigravida 10/16/09
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Cervical changes • Softening of the cervix due to increased vascularity, edema, and hyperplasia of cervical glands (Goodell's sign). • Formation of the mucous plug to prevent bacterial contamination from the vagina. 10/16/09
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Vagina • Influence of estrogen leads to hypertrophy and hyperplasia of the lining along with an increase in vaginal secretions. • (Chadwick's sign) - a blue purple hue of the vaginal walls is seen very early. • Vaginal secretions: acidic (pH is 3.5 to 6.0) and thickish white. 10/16/09
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Breasts • Increase in breast size accompanied by feelings of fullness, tingling, and heaviness. • Superficial veins prominent; nipples erect; darkening and increase in diameter of the areola. • Thin, watery secretion, precursor to colostrum, can be expressed from the nipples by the end of the tenth week.
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Skin • Increased skin pigmentation in various areas of the body. • a. Facial: mask of pregnancy (chloasma). • b. Abdomen: striae (red purple stretch marks) and linea nigra (darkened vertical line from umbilicus to symphysis pubis). • Appearance of vascular spider nevi, especially on the neck, arms and legs. • Acne vulgaris, dermatitis, and psoriasis usually improve during pregnancy. 10/16/09
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PRENATAL CARE • Major Goals: • - to define the health status of the mother and fetus • - to determine the gestational age of the fetus • - to initiate plan for continuing maternal care 10/16/09
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• Assessment • A. Initial visit. • 1. Complete history and physical. • 2. Obstetric history . • a. Past pregnancies (date, course of pregnancy, labor and postpartum; information about infant and neonatal course). • b. Present pregnancy. 10/16/09
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Prenatal Surveillance • Fetal – • a. heart rate (s) • b. size – actual and fate change • c. amount of amniotic fluid • d. presenting part and station in late pregnancy • e. activity 10/16/09
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Maternal • A. blood pressure – actual and extent change • B. weight – actual and extent change • C. symptoms including headache, altered vision, abdominal pain, nausea and vomiting, bleeding, fluid from vagina and dysuria • D. height in cm. of uterine fundus from sumphysis
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• E. vaginal examination in late pregnancy often provides valuable information: • - confirmation of presenting part • - station of the presenting part • - clinical estimation of pelvic capacity and its general configuration • - consistency, effacement and dilatation of the cervix • - position of presenting part
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• B. Schedule of return prenatal visits. • 1. Frequency of return visits. • a.. Monthly for first thirty-two weeks. • b. Every two weeks to the thirty-sixth week. • c. After the thirty-sixth week, weekly until • delivery. 10/16/09
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• 2. Subsequent assessment data follow-up. • a. Vital signs. • b. Urinalysis-check for protein and sugar. • c. Monitor weight. • d. Measurement of height of uterine fundus • e. Auscultation of fetal heart rate (FHR).
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Physical Assessment • Vital signs • Cephalocaudal assessment • Abdomino/Pelvic exam: • - Leopold’s maneuver • - Speculum • -IE • - Pelvic measurement 10/16/09
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Leopolds Manuever • - determine the orientation of the fetus through abdominal palpation • Purpose: • - to determine presentation, position and atttiude - estimate fetal size - locate fetal parts/FHB or FHT 10/16/09
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Preparatory Steps • Palpate with warm hands, cold hands cause abdominal muscle to contract • Use palms not fingers – educate them • Position patient on supine with knee flex slightly (dorsal recumbent) so as to relax abdominal muscles • Apply gently but firm motions • Abdominal examination should be conducted systematically employing the 4 maneuver’s. • The mother should be in with her abdomen bared. 10/16/09
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L 1-Palpation of the fundus • The fundus is gently palpated between the palms of two hands • The upper pole (in this case the breech) is identified • Characteristically the breech is softer than the head, there is no angle formed by the neck and the surface continues smoothly with the back 10/16/09
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L 2 - Palpation of the body • The palpation continues down the body of the uterus • The smooth back is palpated and identified • The irregular surface created by the limbs, hands and feet is identified 10/16/09
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L 3 - Palpation of the vertex • The head is identified (in the case in the lower pole) • The head feels hard and rounded
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L 4 - Assessing engagement • Facing the woman’s feet • The vertex is palpated using both hands • An assessment is made of how much of the head can be palpated and whether the head is engaged, fixed or mobile
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© Dr Paul Bradley, Clinical Skills Resource Centre, University of Liverpool, UK
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Fundic Height
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Symphysis-fundal height • More accurate assessment of fundal height involves direct measurement in centimetres of the distance from the symphysis pubis to the top of the fundus 10/16/09
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Technique Measuring tape Gentle pressure applied
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Tape zero held against pubic symphysis
Uterus
• The woman lies supine • The pubic symphysis is identified • The zero end of the tape measure is held against it • Tape is stretched over the abdomen • A hand on top of the tape applies gentle pressure to palpate the top of the fundus • An estimate of fundal size can thus be made 204
Diagnostic - CBC, Blood typing - Urinalysis - Hep. B Profile - HIV - Vaginal Smear – GbS/Paps smear - UTZ - Rubella titer - OGTT (DM) 10/16/09
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Estimations • Naegele’s Rule • McDonald’s Method • Bartholomew’s Rule • Haase’s Rule • Johnson’s Rule • Ultrasound - BPD
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• Naegele’s Rule (EDC) - estimation of AOG by LMP • McDonald’s Method (Age of gestation) - – determines age of gestation by measuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months.
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General Assessment of the Obstetric Patient • Physical Examination – Asses fundal height to determine gestation.
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Bartholomew’s Rule (Age of
)
gestation
• Estimates AOG by the relative position of the uterus in the abdominal cavity. • By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis • On the 5th lunar month, the fundus is at the level of the umbilicus • On the 9th lunar month, the fundus is below the xiphoid process
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Assessing fundal height
34 28 20 16 12
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• Uterine fundal height can indicate pregnancy duration • It is a crude method depending on body build, examiner technique, foetal growth, accurate dates, etc • It is better to measure the height of the fundus to the pubic bone and compare to a standard chart • Even better estimation of gestation and foetal development is obtained by ultrasonography • 34 weeks just below xiphisternum • 28 weeks midway between umbilicus and xiphisternum • 20 weeks at the umbilicus • 16 weeks midway between pubic bone and umbilicus • 12 weeks just above pubic bone
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Haase’s Rule (Fetal Length) • Determines the length of the fetus in centimeters. • During the first half of pregnancy, square the number of the month (E.g., first lunar month: 1 x 1 = 1 cm.) • During the second half of pregnancy, multiply the month by 5 (E.g., 6th lunar month: 6 x 5 = 30 cm. 10/16/09
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Johnson’s Rule • Estimate the weight of the fetus in grams. • Formula: fundic height in cm. – n x k • “k” is a constant, it is always 155 • “n” is = 12 ( if fetus is engaged) • = 11 (if fetus is not yet engaged) 10/16/09
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Thank you!!!
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MERIAM DELOS REYES FLORES R.N.
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•In sharing what we know, we are definitely helping others and more so ourselves and for whatever good we give out………..the goodness will complete the circle and the rewards will undoubtedly come back to us. 10/16/09
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Anatomy and Physiology FEMALE REPRODUCTIVE ORGAN
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External Genitalia/Pudenda /Vulva • • • • • • • •
Mons Pubis Labia Majora Labia Minora Vestibule Clitoris Breasts (Mammary Glands) 10/16/09
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• Mons Pubis • Labia Majora • Labia Minora • Vestibule • Clitoris • Breasts • (Mammary • Glands) 10/16/09
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Stages of Pubic Hair Development • Tanner scale tool - used to determine sexual maturity rating. • Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only • Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair at pubis symphysis • Stage 3 occurs between ages 12 and 13 – darker & curlier at labia • Stage 4 – occurs between ages 13 and 14, hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. • Stage 5 sexual maturity- normal adult- appear inner aspect of upper thigh . 10/16/09 9
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Internal Genitalia • Vagina • Uterus • Fallopian tubes • Ovary
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External parts of the breast Nipple - Sinuses merge into openings on nipple - muscles and - nerves - glands - milk pores Areola - Montgomery - tubercles 10/16/09
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Male Reproductive System External Genitalia • Penis • Glans Penis • Frenulum • Scrotum
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Internal Genitalia • • • • • •
Testis Epididymis Vas Deferens Prostate Gland Seminal Vesicles Bulbourethral Glands/Cowper’s Gland • Urethra 10/16/09
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MALE REPRODUCTIVE SYSTEM: SEMEN: • Is a thick whitish fluid ejaculated by the male during orgasm, contains spermatozoa and fructose-rich nutrients. • During ejaculation, semen receives contributions of fluid from Prostate gland (60%) Seminal vesicle (30%) Epididymis ( 5%) Bulbourethral gland (5%) • • • • •
Average pH = 7.5 The average amount of semen released during ejaculation is 2.5 -5 ml. It can live with in the female genital tract for about 24 to 72 hours. (50-200 million/ml of ejaculation ave. of 400 million/ ejaculation ) 90 seconds- cervix 5 mins.- end of fallopian tube
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MALE REPRODUCTIVE SYSTEM: SPERMATOZOA are produced by: Hypothalamus Control by GnRH (+/-) feedback Anterior Pituitary gland FSH / LH Testes FSH - release of Androgen Binding Protein (ABP) which promote SPERMATOGENESIS LH - release of Testosterone.
“Spermatozoa does not survive at body temperature. They usually survive 1°F lower than body temperature”.
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Seminal Fluid Circulation Testes
Epididymis
Vas Deferens -
Seminal Vesicle
Ejaculatory Duct -
Prostate/Cowper’s Gland 10/16/09
Urethra 21
• Menarche – first menstruation • Puberty – transitional stage between childhood and sexual maturity. At around age 13. - age at which reproductive organs become functionally active
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• Menopause – the cessation of menstrual cycle • Post menopausal period – it is the time of life ff. menopause • Perimenopausal – period during which menopausal change are occurring between 44 – 50 years old
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– Amenorrhea = temporary cessation of menstrual flow – Oligomenorrhea = markedly diminished menstrual flow, nearing amenorrhea – Menorrhagia = excessive bleeding during regular menstruation – Metrorrhagia = bleeding at completely irregular intervalsor in between menstruatio n – Polymenorrhea = frequent menstruation occurring at intervals of less than three weeks
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MENSTRUAL CYCLE • Periodic recurring changes in hormonal status that prepares the body for pregnancy • To bring the ovum to maturity and renew a uterine tissue bed that wilt be responsible to its growth and should be fertilized.
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• a woman’s menstrual cycle begins on the first day of her menstruation and ends on the day before her next menstruation. • this cycle begin at puberty and continue until woman reaches menopause. • on average, cycles can range from 23 to 35 days (median length is 28 days). Some women have short cycle some women have long cycle. • Cycle can vary among women or at times may even vary in individual women. 10/16/09
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Menstruation • The periodic uterine bleeding that begins approximately 14 days after ovulation • It usually occur at monthly interval through the reproductive period except during pregnancy and lactation • Average flow is 2 -7 days
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Organs involve in Menstrual cycle • Hypothalamus • Pituitary gland • Ovary • Uterus
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Phases of Menstrual Cycle • HypothalamicPituitary Cycle • Ovarian Cycle • Endometrial Cycle
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HYPOTHALAMIC -PITUITARY CYCLE
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Menstruation
Hypothalamus Stimulates
FSHRH
APG
Secretes triggers
Low level of estrogen & Progesterone in blood
Follicular Phase
APG to Stop producing LH
Hypothalamus to Stop producing LHRH
MENSTRUAL CYCLE Proliferative High level of estrogen & Progesterone Phase in blood sends feedback
Secretes FSH Carried by blood stream Ovary causing Devt. of young cells (graafian follicles to mature) Produces estrogen Carried by blood stream Uterus lining Becomes thick
High level of Estrogen in The blood
Uterus causing further thickening of uterus (more vascular tortous & field with mucin
Ovulation (Luteal Phase) Progesterone carried by blood stream Causing matured follicle to ruptured follicle 10/16/09 called corpus luteum Produces progesterone
LH is carried by the blood stream
APG stops producing FSH instead produces LH
Sends feedback to Hypothalamus to stop released FSHRH instead produces LHRH31
HYPO-PIT
OVARIAN
ENDOMETRIAL
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Ovarian and Uterine Cycles
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Figure 16.12c, d
OVARIAN CYCLE
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OVARIAN CYCLE
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Endometrial Cycle • Menstrual Phase • Proliferative Phase • Secretory Phase • Ischemic Phase
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• When a woman is fertile the mucus helps the pregnancy to occur in 3 ways. • Functions of the Mucus: • - nourishes the sperm • - forms channels to help the sperm swim to the egg • - filters out abnormal sperm so they do not reach the egg 10/16/09
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OTHER CYCLE
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Sexual Stimulation 1. Physical Stimulation - involves touch and/or pressure to parts of the body and may be applied by one's self, by another's body contact or by inanimate objects. E.g. kissing, hugging, stroking etc. • a. Foreplay - pre-coital activity to arouse sexual desires. It. includes kissing, hugging, stroking, fondling and manipulation of all parts of the body including genitalia and breasts. 10/16/09
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• b. Orgasm - climax of sexual excitement or as prelude to sexual intercourse. • c. Masturbation - manual self stimulation. • 1. Most common in pre-school and often associated with comfort and pleasure. • 2. Men usually begin to experience masturbating often before 20's.
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Phases of Physiological Responses to Sexual Stimulation: • 1. Excitement Phase: lasts for several minutes to hours. • Heart rate and Blood pressure increases • Nipples become erect • Myotonia begins
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Changes in Female and Male – clitoris increases in diameter and swells - external genitals become congested and darkened - vaginal lubrication with 2/3 of vagina lengthens and extend. - cervix and uterus 10/16/09 pull upward
- Erection of the penis – increases in length and diameter - Scrotal skin becomes congested and thickens - Testes begin to increase in size and elevate towards the body
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• 2. Plateau Phase: the period during which sexual tension increases to levels nearing orgasm, may last from 30 seconds to 3 minutes. Formation of orgasmic platform in the vagina. • Heart rate and BP continue to increase • Respirations increases • Myotonia becomes pronounced • Grimacing occurs
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Female-Male Clitoral head retracts under the clitoral hood. Lower one third of vagina becomes engorged. Skin color changes occur-red flush may be observed across breasts, abdomen or other surfaces 10/16/09
Head of penis may enlarge slightly Scrotum continues to grow tense and thicken Testes continue to elevate and enlarge Preorgasmic emission of 2 or 3 drops of fluid appears on the head of the penis 47
• 3. Orgasmic Phase: is the involuntary climax of sexual tension, accompanied by physiologic and psychologic release. • "This is considered the measurable peak of sexual intercourse.” • It is short lasting 3 to 10 seconds. Strong rhythmic contractions of vagina and uterus. 10/16/09
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• Heart rate, blood pressure and respirations increases to maximum levels • Involuntary muscle spasms occur • External rectal sphincter contracts
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Female - Male - Strong rhythmic contractions are felt in the clitoris, vagina and uterus - Sensations of warmth spread through the pelvic area
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- Testes elevate at maximum level - Point of inevitability occurs just before ejaculation and awareness of fluid in the urethra. - Rhythmic contractions occur in the penis. - Ejaculation of semen occurs
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• 4. Resolution Phase - the period of return to the unaroused state, may last 10 to 15 minutes after orgasm, longer if there is no orgasm. Cervix dips into seminal pool in vagina; all organs returns to previous condition • Heart rate, BP and respirations return to normal. • Nipple erection subsides • Myotonia subsides
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Female Engorgement in external genitalia and vagina resolves Uterus descends to normal position Cervix dips into seminal fluid Breast size decreases Skin flush 10/16/09 disappears
50% of erection is lost immediately with ejaculation Penis gradually returns to normal size Testes and scrotum return to normal size
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• Refractory – – only in males, the period during which no amount of stimulation can cause another erection. – Not manifested in females because females are multi orgasmic. – This phases lengthens with age 10/16/09
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Male Sexual Dysfunction Erectile failure - inability of a man to attain or maintain an erection to such an extent that he can't have satisfactory intercourse. • 2. Premature ejaculation - ejaculation or orgasm before or very soon after entering the vagina. • 3. Retarted ejaculation (ejaculatory impotence) - inability to ejaculate into the vagina or to suffer with delayed intravaginal ejaculation. • 1.
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Female Sexual Dysfunction • 1. Frigid- inhibition in sexual arousal that leads to absent or minimal vaginal lubrication. • 2. Orgasmic dysfunction - persistent inability of a woman to reach orgasm. • 3. Dyspareunia - painful intercourse. • 4. Vaginismus - condition in which the vaginal opening closes tightly and prevents penile penetration.
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FETAL DEVELOPMENT
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Fetal Development • Fertilization: the union of the ovum & sperm. • - The start of Mitotic cell division & fetal sex determination • Other name: Conception, Impregnation and Fecundation
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Process of Fertilization/Implantation After ovulation ovum will be expelled from the Graafian follicles Ovum will be surrounded by Zona Pellucida (mucopolysaccharide fluid) & a circle of cells (Corona Radiata) which increases the bulk of the Ovum
Ovum expelled from the Fallopian Tube by the Fimbriae (infundibulum).
Sperms move by flagella & Penetrate the & dissolve the cell wall of the ovum by releasing a proteolytic enzyme (Hyaluronidase) 10/16/09
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After penetration Fusion will result to Zygote
Zygote migrate for 4 days in the body of the uterus (Cell division will take place - Cleavage formation will begin) After 16-50 cell formation from cell division, a mulberry & Bumpy appearance will follow morula
Implantation 10/16/09
After 3-4 days, the structure will be ball like in appearance which will be called Blastocyst.
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Implantation occurs at the end of the 1st week after fertilization, when the blastocyst attaches to the endometrium
2nd week (14 days after implantation), implantation progresses and two germ layers, cavities, and cell layers develop
3rd week of development (21 days after implantation), the embryonic disk evolves into three layers, and three new structures — the primitive streak, notochord, and allantois — form
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Early during the 4th week (28 days after implantation), cellular 61 differentiation and organization occur.
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Development from Ovulation to Implantation
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Figure 16.15
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Fertilization
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DAY 1
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First cell Division (Zygote) – Day 2
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Morula Day 3
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Blastocyst Day 4
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Fetal Development Fertilization/Preembryonic
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Early Development: Implantation
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Development After Implantation
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Figure 16.16
Uterine Changes • Conversion of the endometrium to decidua: • Decidua basalis – part of the endometrium where the embryo lies or where the throphoblast cells are establishing communication with the maternal blood vessels • Decidua capsularis – portion of the endometrium that stretches or encapsulates the surface of the trophoblast • Decidua vera – remaining portion of the uterine lining
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Developmental Stages • Ovum: From ovulation to fertilization • Zygote: From fertilization to implantation • Embryo: From implantation to 5 - 8 weeks. • Fetus: From 8 weeks until term The ovum is said to be viable for 2436 hours. 10/16/09
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Preembryonic stage: stage of the ovum – fertilization to the first 3 weeks – fertilize ovum growth and differentiates – formation of the three primary germ layers endoderm, ectoderm and mesoderm – implantation in the endometrial tissue 10/16/09
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Embryonic stage – fourth week to the eight week of development – period of organogenesis – differentiation of cells, organs and organ systems – highly vulnerable, time for congenital anomalies to occur – at the end of this period of development, embryo has features of the human body
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Fetal stage – –
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eight weeks to the time of birth characterized by growth and development of organs and organ systems
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ORIGIN OF BODY TISSUE • Tissue Layer • - Ectoderm • - Endoderm • - Mesoderm
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Ectoderm/Outer •
– Skin - Hair - Nails - Tooth enamel - Nervous system - Sense organs - Mucous membrane of the anus and mouth.
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Mesoderm/Middle Layer - Muscle - Connective Tissue - Circulatory/Heart - Blood cells - - Reproductive - Bones - Cartilage - Kidneys - Ureters 10/16/09
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Endoderm/Inner • - GI (Hepatobiliary/Pancreas) - Respiratory - Endocrine - Tonsils - Thyroid (for basal metabolism) - Parathyroid (for calcium metabolism) - Thymus glands (for development of immunity) - Bladder and urethra
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Fetal Blood Supply
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Fetal Circulation
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1 Lunar Month st
• Germ layers differentiate by the 2nd week • Entoderm • Mesoderm • Ectoderm
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• Fetal membranes (amnion and chorion) appear by the second week • Nervous system very rapidly develops by the 3rd week (Dizziness is said to be the earliest sign of pregnancy because as the fetal brain rapidly develops, glucose stores of the mother are depleted, thus causing hypoglycemia in the latter)
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1 Lunar Month st
• Fetal heart begins to form as early as the 16th day of life (To the question, “When does the fetal heart begin to heat?”, the answer is the first lunar month. But to the question, “When can fetal heart tones be first heard?” the answer is fifth month). • The digestive and respiratory tracts exist as a single tube until the 3rd week of life when they start to separate.
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Second Lunar Month • All vital organs are formed by the end of the 8th week. • Placenta develops fully. • Sex organs (ovaries and testes) are formed by the 8th week (To the question, “When is sex determined?” , the answer is at the time of conception). • Meconium first stools) are formed in the intestines by the 5th-8th week. 10/16/09
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Third Lunar Month Kidneys are able to function – urine formed by the 12th week Buds of milk teeth form Beginning bone ossification Fetus swallows amniotic fluid Feto-placenta circulation is established by selective osmosis; no direct exchange between fetal and maternal blood.
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Fourth Lunar Month
Lanugo appears Buds of permanent teeth form Heart beat audible with fetoscope
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Fifth Lunar Month Vernix caseosa appears Lanugo covers entire body Quickening (fetal movements) felt Fetal heart beats very audible
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Fifth Lunar Month • Vernix caseosa appears • Lanugo covers entire body • Quickening (fetal movements) felt • Fetal heart beats very audible
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Seventh Lunar Month Skin markedly wrinkled Attains proportions of fullterm baby Surfactant begins to produce
Sixth Lunar Month
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Alveoli begin to form (28th weeks gestation is said to be the lower limit of prematurity; if born, cries, breathes, but 93 usually dies)
Eigth Lunar Month
Fetus is viable Lanugo begins to disappear Nails extend to ends of fingers Subcutaneous fat deposition begins
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Ninth Lunar Month Lanugo and vernix disappear Amniotic fluid volume somewhat decreases
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Tenth Lunar Month •
all characteristic s of the normal newborn
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• First trimester – organogenesis • Second trimester- period of continued fetal growth and development; rapid increase in fetal length • Third trimester – period of most rapid growth and development because of rapid deposition of subcutaneous fat
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Special Structures of Pregnancy • Fetal Membranes: • - arise from the zygote • - inner (amnion) and outer (chorion) • - holds the developing fetus as well as the amniotic fluid 10/16/09
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Fetal Membranes: membranes that surround the fetus, & give the placenta the shiny appearance. Inner (amnion) - shiny membrane on the 2nd week of Embryonic Development & encloses the Amniotic Cavity and holds the amniotic fluid
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Chorion: Outer membrane that supports the sac of the amniotic fluid. Chorionic Villi: finger like projections from the chorion. This is the place where gases, nutrients and waste products between the99 maternal & fetal blood
• Syncytiotrophoblast or synytial layer – outer covering or layer of the chorionic villi. • Secretes the ff hormones: - HCG • - Estrogen • - Progesterone • - HPL (somatotrophin) • • Cytotrophoblast or langhan’s layer – inner layer. Function: • - protects the growing embryo and fetus from • infectious organisms 10/16/09
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Amniotic Fluid • clear, yellow fluid surrounding the developing fetus and surrounds the embryo, contains fetal urine, lanugo from fetal skin & epithelial cells. • Functions: • protects the fetus/shields • allows free movement • maintains temperature • provides oral fluid
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• Ph is 7. 2. • Specific Gravity: 1.005 – 1.025 Normal Amount: 500 – 1500 ml. Oligohydramnios - less than 500 ml. Polyhydramnios - more than 2000 ml. observe for congenital defects • can be aspirated and tested for various diseases and abnormality during pregnancy (genetic) • alkaline ph: can be testes when membrane ruptures
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Amniotic Fluid Colors • a. pale straw color – normal • b. yellow stained/ dark amber • = fetal hypoxia that occurred 36 hours or more before the rupture of membranes • = fetal hemolytic disease (Rh or ABO incompatability, intrauterine infection) • = Ominous sign of presence of Bilirubin, hemolytic disease • Character – thick secretions with unpleasant odor = infection 10/16/09
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• c. Greenish: Meconium Stained / FETAL DISTRESS, Also if ph is less than 7.2 • greenish brown (meconium – sustained) • = fetus had a hypoxic episode ---- relaxation of the anal sphincter ---- passage of meconium from the bowel • = normal in breech presentation If with odor: deliver within 24 hours, may indicate infection.
• d. Port Wine Color – admixture of amniotic fluid and blood - indication abruptio placenta 10/16/09
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Test for rupture of membranes • Voiding by an incontinent woman and leukorrhea should be differentiated from amniotic fluid. • Spread a drop of the fluid on a clean slide. Dried amniotic fluid will show a fern like crystalline pattern when viewed under the microscope (positive fern test).
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• Determine the pH of the vagina fluid. Amniotic fluid is slightly alkaline; urine or pus is acidic. • With sterile speculum, us sterile cotton swabs to take samples of vaginal secretions at cervical os • Test with pH paper (Nitrazine)
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Interpretation • Yellow/Olive Yellow/Olive Green = pH5 to 6 (membrane probably intact) • Blue green/blue gray/deep blue = pH 6.5 to 7.5 (ruptured membrane) • Fetal lanugo or fetal squamous cell may be seen on the microscope • Sudan III and Nile blue tests for detection of fetal fat particles and desquamated fetal aft cells
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Umbilical Cord • 21 inches in length & 2 cm in thickness, circulatory communication of the fetus to the mother. • there are no pain receptors in the umbilical cord • connecting link between fetus and placenta • contains 2 arteries and 1 vein supported by mucoid material/ mucopolysaccharide called (Wharton’s jelly) to prevent kinking and knotting
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Placenta • transient organ allowing passage of nutrients and waste materials between mother and fetus • contains 20 cotyledons, weighs 400-600 grams. • fully develops on the 3rd month. • form from Chorionic villi & deciduas basalis. Deciduas (meaning endometrial changes & growth) • acts as an endocrine organ (hormones) and as a protective barrier against some drugs or infectious agents
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Functions • Respiration – O2 , CO2 • Excretion • Nutrition • Storage - CHO, CHON, calcium and iron • Protects the growing embryo and fetus from infectious organisms • Mother also transmit immunoglobulin G (IgG) to fetus through placenta, providing limited passive immunity
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Hormones Associated with Pregnancy HCG – indicator of pregnancy - secreted by the chorionic villi and later by the placenta - lengthens the lifespan of corpus luteum
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Estrogen – initially secreted by the copus luteum – enhances fat deposition promotes sodium and water retention - mediates vascular changes - produces enlargement of uterus, breast and 111 genitals
Progesterone – initially secreted by the corpus luteum and later by the placenta - produces relaxation of smooth muscle maintains decidua 10/16/09
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•Human chorionic somatomammotropin/human placental lactogen (HCS/HPL): similar to growth hormone; •- affects maternal insulin production (diabetogenic hormone for the mother to diminish insulin efficiency) •- prepares breast for lactation, detectable in trophoblast as early as third week after ovulation. 10/16/09
Relaxin inhibits uterine activity and relax pelvic joint
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Prolactin – released from the anterior pituitary gland - Suppressed during pregnancy - milk production
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Oxytocin – released from the PPG -produces smooth muscle contraction - milk ejection 114
DIAGNOSIS OF PREGNANCY
MERIAM DELOS REYES FLORES R.N.
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Obstetrical Terms • Gravida – woman who is pregnant • Gravidity – pregnancy • Parity – number of pregnancies whose fetus have reached the age of viability • Multigravida - woman who has 2 or more pregnancies • Multipara – woman who has completed 2 or more pregnancies
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• Nulligravida – woman who has never pregnant • Nullipara - woman who has not completed pregnancy with a fetus who have reached the stage of viability • Primigravida – woman who is pregnant for the first time • Primipara – woman who has completed one pregnancy with a fetus who have reached the stage of viability • Viability – capacity to live outside the uterus which about >20 weeks or > 500 grams
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• Term – 38 – 42 weeks • Post date – Postterm - > 42 weeks • Preterm – 21 to 37 weeks • Immature – 21 to 27 weeks (----) • Abortion - < 20 weeks or < 500 grams
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Obstetrical Score • T – P – A - L (F P A L) a. Term birth or Full term b. Preterm c. Abortion d. Living children N.B. Some use G T P A L / G T P A L M 10/16/09
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PREGNANCY • gestational process, comprising the growth and development within a woman of a new individual from conception through the embryonic and fetal periods to birth • Other name: gestation, fecundation, impregnation, conception • Gestation – period from the fertilization of the ovum until birth
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• Diagnosis of pregnancy can be done by physical assessment and simple laboratory procedures: • by simple ultrasound • by urine testing or blood test – determining the HCG or Human chorionic gonadotrophin hormone • - produced by the chorionic villi of the placenta that can be tested on the urine and serum (RIA) 10/16/09
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HCG • - in serum you can test after 24 – 48 hours after implantation • in the urine 1st morning void and can be detected 26 days after conception • Peak level between 60 – 70 days. But will last until 100 – 130 days then it will go down. • In post partum women it will become negative in serum testing after 1 – 2 weeks after delivery.
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Diagnosis of Pregnancy • Presumptive – subjective – sign that suggest that do not confirm pregnancy and could be due to other condition • Probable – objective – strong indication of pregnancy not likely but still possibly due to other condition. • Positive – signs definitively confirming pregnancy 10/16/09
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PRESUMPTIVE Subjective
Amenorrhea Morning sickness Breast changes Fatigue Urinary Frequency Enlarging Uterus Quickening Leucorrhea Weight Changes Increased skin pigmentation: - Chloasma - Linea nigra - Striae gravidarum 10/16/09
PROBABLE Objective
Positive HCG Chadwick’s Goodell’s Hegar’s Ballotment Braxton Hicks contraction
POSITIVE
Ultrasound evidence Fetal heart tones Fetal movements Fetal outline on X-ray
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Psychosocial Changes • There are several psychosocial changes that occurs in pregnancy to the family. • It may affects the father, mother and of course the siblings
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CHANGES OF THE EXPECTANT FAMILY • Pregnancy is considered a normal maturational crisis and developmental stage for the expectant couple. • Pregnancy is physiologic
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Changes in the Father First trimester • 1. May feel left out of pregnancy. • 2. Confused by partner's mood swings. • 3. Couvade syndrome cause by stress, anxiety and empathy for the pregnant women and the father will also experience physical symptoms of nausea, vomiting and backache or similar symptoms of discomfort along with his partner.
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Second trimester • 1. Promote his involvement by his watching and feeling fetal movement. • 2. Needs to confront and resolve his own conflicts about the fathering he received as a child. • 3. Will decide on what he does and does not want to imitate from his father role figure. • 4. May react differently to partner's physical body changes.
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Third trimester • 1. Concerns and fears resurface.
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Maternal Adaptation to Pregnancy • Psychologic • Anatomical and Physiologic – systemic - local
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Psychological Adaptation to Pregnancy/Emotional Responses – First trimester – Second trimester - Third trimester
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Psychological responses – Ambivalence – Acceptance – Introversion – Mood swings – Body images changes
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Ambivalence • First Trimester: AMBIVALENCEabout pregnancy: pregnant woman focus only to self. • the fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, denial and disbelief, even repression. 10/16/09
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• Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy. • I am pregnant. …Accept the biological fact of pregnancy
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• Conflicting feelings about pregnancy • If women feels comfortable in addressing ambivalent feelings, the focus is usually on changed life style or the career -motherhood dilemma.
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• Indirect evidence of ambivalence: • a. Complaints of depression or physical discomfort. • b. Complaints of feeling ugly or unattractive. • 3. Some women may consider the possibility of abortion, if pregnancy is unwanted. 10/16/09
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Acceptance • Second Trimester: ACCEPTANCE---of the identification of motherhood & awareness & interest in the fetus. • - fetus is perceived as a separate entity. Fantasizes appearance of the baby. • I am going to have a baby… Accept the growing fetus as distinct from self & as person to care for 10/16/09
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• With an unplanned pregnancy, there is greater evidence of fear and conflict along with more physical discomfort and depression. • If pregnancy is well accepted, women experiences less discomfort and more tolerance to physical discomforts during the last trimester. 10/16/09
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Introversion • 1. This "turning in on oneself' focus is normal. • 2. Helps the mother plan, adjust, adapt, build, and draw strength in preparation for childbirth.
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Mood swings/Emotional lability • Can cause difficulty in the relationship if couple doesn't realize what is occurring. • Husband may feel exasperated with her tears and withdraw and ignore problem when she really needs him to be affectionate and supportive.
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• Third Trimester: EMOTIONAL LABILITYassuming already the mother, fears & fantasies & dreams about labor • has personal identification with a real baby about to the born and realistic plans for future child care responsibilities. • Best time to talk about preparation of layette and infant feeding method. •
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• Fear of death, though, is prominent to allay fears, let pregnant woman listen to the fetal heart tones. • I am going to be a mother…Prepare realistically for birth & parenting
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Body images changes • Woman may feel negative toward body, especially during 3rd trimester.
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Psychological tasks of the mother • Ensuring safe passage through pregnancy, labor, and birth. • Seeking acceptance of this child by others. • Seeking of commitment and acceptance of self as mother to the infant (binding-in). • Learning to give of oneself on behalf on one's child. 10/16/09
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Emotional Responses • First trimester: the fetus is an unidentified concept with great future implications but without tangible evidence of reality. Some degree of rejection, denial and disbelief, even repression. • Implication: when giving health teachings, be sure to emphasize the bodily changes in pregnancy. 10/16/09
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• Second trimester: fetus is perceived as a separate entity. Fantasizes appearance of the baby.
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• Third trimester: has personal identification with a real baby about to the born and realistic plans for future child care responsibilities. • Best time to talk about preparation of layette and infant feeding method. • Fear of death, though, is prominent to allay fears, let pregnant woman listen to the fetal heart tones. 10/16/09
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Systemic Changes • 1. • 2. • 3. • 4.
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Circulatory/Cardiovascular Gastrointestinal changes Respiratory Changes Urinary changes
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• 5. • 6. • 7. • 8. • 9.
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Musculoskeletal changes Endocrine changes Temperature Metabolism Reproductive system
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Local Changes • 1. • 2. • 3. • 4.
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Cervix - Goodell’s sign Uterus - Hegar’s sign Vagina - Chadwick’s sign Abdominal Wall - Striae gravidarum
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• 5. Skin - Chloasma gravidarum - Linea nigra • 6. Breasts • 7. Ovaries
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Cardiovascular • Increase metabolic demand of new tissue growth • Expansion of the vascular channel especially the genital tract • Increased in the steroid hormones which exerts a positive effect on sodium and water balance
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• Blood volume: • a. Increases progressively throughout pregnancy, beginning in the first trimester and peaking in the middle of the third trimester at about 45% above prepregnant levels. • b. Normal blood pressure maintained by peripheral vasodilatation. • c. Extra volume of blood acts as a reserve for blood loss during delivery.
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Heart • a. Increase in heart rate; ten beats per minute by the end of the first trimester. • Blood pressure falls during the second trimester; rises slightly (no more than 15 mm in either systolic or diastolic) during the last trimester. • b. Increase in cardiac output. 10/16/09
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• c. Palpitations of the heart usually due to sympathetic nervous system disturbance; later in pregnancy due to the intraabdominal pressure of the growing uterus. • d. Cardiac enlargement and systolic murmurs.
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Red blood cells (RBC) • a. Stimulation of the bone marrow leads to a 20-30% increase in total RBC volume. • b. The plasma volume increase is greater than the RBC increase which leads to a hemodilution, typically referred to as physiologic anemia of pregnancy (pseudoanemia). 10/16/09
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- Pregnancy induced hypervolemia has several important functions: • To meet the demands of the enlarged uterus with it greatly hypertrophied vascular system
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• To protect the mother and in turn the fetus, against deleterious effects of impaired venous return in the supine and erect position • To safeguard the mother against the adverse effects of blood loss associated with partutrition 10/16/09
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Total Iron requirements • 1 gram or 6 -7 mg/day • - 300 mgs used by the fetus and placenta • - 200 mgs are excreted • - 500 mgs are used in erythrocyte production
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White blood cells (WBC): • White blood cells (WBC): 10 to 11,000 per cu mm; may increase up to 25,000 per cu mm during labor and postpartum.
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• Total plasma proteins: decrease due to fall in serum albumin level. • Sedimentation rate: increases due to the decrease in plasma proteins. • Fibrin level increases as much as 40% at term with the plasma fibrinogen level increasing as much as 50%. 10/16/09
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Respiratory Changes • Oxygen consumption increased by 15-20% between the sixteenth and fortieth weeks. • Diaphragm is elevated; change from abdominal to thoracic breathing around the twenty-fourth week. • Tidal volume increases steadily throughout pregnancy. • Tidal volume - amount of air moving in and out of the lungs in one normal breath.
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• Vital capacity increases slightly, while pulmonary compliance and diffusion remain constant. • Vital capacity-amount of air inhaled and forcibly exhaled in one breath. • Common complaints of nasal stuffiness and epistaxis due to estrogen influence on nasal mucosa. 10/16/09
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Urinary changes • Ureter and renal pelvis dilate (especially on the right side) as a result of the growing uterus. • Frequency of urination (first and last trimester). • Decreased bladder tone (due to effect of progesterone); bladder capacity increases: 1,300 to 1,500 cc.
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• Reduced renal threshold for sugar; leads to glycosuria. • Due to an increased glomerular filtration rate (GFR), as much as 50%, there is a decreased serum BUN, creatinine, and uric acid.
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GIT • Pregnancy gingivitis-gums reddened, swollen, and bleed easily. • Increased saliva (ptyalism); decreased gastric acidity . • Nausea and vomiting due to elevated human chorionic gonadotropin (HCG). • Decreased tone and motility of smooth muscles • Decreased emptying time of stomach; 10/16/09
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• Slowed peristalsis due to increased progesterone lead to complaints of bloating, heartburn, and constipation. • Pressure of expanding uterus leads to hemorrhoidal varicosities and contributes to continuing constipation.
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• Hyperemesis Gravidarum – it is a syndrome of excessive nausea and vomiting due to excessive hormonal changes of pregnancy especially HCG. • - characterized by the pernicious vomiting during pregnancy. • It occurs in every one thousand pregnancies, the cause is debatable but seems to be related to HCG and psychological factors. 10/16/09
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Clinical Manifestations •
Severe persistent vomiting which leads to dehydration or nutritional deficiency; progresses to fluid and electrolyte imbalance and alkalosis from loss of Hcl – if untreated, ketoacidosis (from loss intestinal juices), hypovolemia, hypokalemia, jaundiced and hemorrhage – hypothrombinemia and decreased urine output.
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Treatment • a. antivomiting – Bendectin (Doxylamine succinate plus pyridoxine). • b. Dietary – NPO for first 48 hours, after condition improves, then six small feedings alternated with liquid nourishment in small amounts every one to two hours, • - if vomiting reoccurs, NPO and IVFluids started
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• c. Effective psychological support can be offered in the form of reassurance to the pregnant woman that these symptoms will disappear by the fourth month • d. prompt correction of fluid and electrolytes imbalances. • Stress and emotional factors have been found to play a major role in hyperemesis gravidarum, psychotherapy is recommended 10/16/09
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Musculoskeletal System • Increase in the normal lumbosacral curve leads to backward tilt of the torso. • Center of gravity is changed which often leads to leg and back strain and predisposition to falling. • Pelvis relaxes due to the effects of the hormone relaxin; leads to the characteristic "duck waddling" gait.
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Endocrine changes Placenta. • a. Functions include transport of nutrients and removal of waste products from the fetus. • b. Produces human chorionic gonadotropin (HCG) and human placental lactogen (HPL). • c. Produces estrogen and progesterone after two months of gestation.
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• Thyroid gland. • a. May increase in size and activity. • b. Increase in basal metabolic rate. Parathyroid glands-increase in activity • (especially the last half of the pregnancy) due to increased requirements for calcium and vitamin 10/16/09
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• Pituitary gland. • a. Enlargement greatest during the last month of gestation. • b. Production of anterior pituitary hormones: FSH, LH, thyrotropin, adrenotropin, and prolactin. • Production of posterior pituitary hormones: oxytocin which promotes uterine contractility and stimulation of milk let-down reflex.
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• 4. Adrenal glands. • a. Hypertrophy of the adrenal cortex. • b. Increase in aldosterone, which retains • sodium, results in a decreased ability of the kidneys to handle salt during pregnancy; consequently, improper control of dietary sodium can lead to fluid retention and edema. 10/16/09
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Metabolism • Weight gain. • a. Normal weight gain: 25 to 35 lb b. Pattern of weight gain. • (1) First trimester- 3 to 4 lb • (2) Second trimester- 12 to 14 lb. • (3) Third trimester-8 to 10 lb.
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• • • • • • • •
c. Total weight gain is accounted for as follows: (1) Fetus: 7.5 lb. (2) Placenta and membranes: 1.5 lb. (3) Amniotic fluid: 2 lb. (4) Uterus: 2.5 lb. (5) Breasts: 3 lb. (6) Increased blood volume: 2-4 lb. (7) Remaining 4-9 lb. is extravascular fluid and fat reserves.
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Local Changes • • • •
1. Uterus - Hegar’s sign 2 . Cervix - Goodell’s sign 3. Vagina - Chadwick’s sign 4. Abdominal Wall - Striae gravidarum • 5. Skin - Chloasma gravidarum - Linea nigra • 6. Breasts • 7. Ovaries 10/16/09
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Uterus • Increase in size due to hypertrophy of the myometrial cells (increase seventeen to forty times their prepregnant state) as a result of the stimulating influence of estrogen and the distention caused by the growing fetus. • Weight increases from 50 to 1,000 grams. • Increase in fibrous and connective tissues which strengthen the elasticity of the uterine muscle wall.
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• Hegar's sign - Softening of the lowe uterine segment (Hegar's sign). • Irregular, painless uterine contractions (Braxton-Hicks) begin in the early weeks of pregnancy; contraction and relaxation assist in accommodating the growing fetus. • Multigravidas tend to report a greater incidence of Braxton-Hicks than primigravida 10/16/09
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Cervical changes • Softening of the cervix due to increased vascularity, edema, and hyperplasia of cervical glands (Goodell's sign). • Formation of the mucous plug to prevent bacterial contamination from the vagina. 10/16/09
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Vagina • Influence of estrogen leads to hypertrophy and hyperplasia of the lining along with an increase in vaginal secretions. • (Chadwick's sign) - a blue purple hue of the vaginal walls is seen very early. • Vaginal secretions: acidic (pH is 3.5 to 6.0) and thickish white. 10/16/09
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Breasts • Increase in breast size accompanied by feelings of fullness, tingling, and heaviness. • Superficial veins prominent; nipples erect; darkening and increase in diameter of the areola. • Thin, watery secretion, precursor to colostrum, can be expressed from the nipples by the end of the tenth week.
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Skin • Increased skin pigmentation in various areas of the body. • a. Facial: mask of pregnancy (chloasma). • b. Abdomen: striae (red purple stretch marks) and linea nigra (darkened vertical line from umbilicus to symphysis pubis). • Appearance of vascular spider nevi, especially on the neck, arms and legs. • Acne vulgaris, dermatitis, and psoriasis usually improve during pregnancy. 10/16/09
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PRENATAL CARE • Major Goals: • - to define the health status of the mother and fetus • - to determine the gestational age of the fetus • - to initiate plan for continuing maternal care 10/16/09
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• Assessment • A. Initial visit. • 1. Complete history and physical. • 2. Obstetric history . • a. Past pregnancies (date, course of pregnancy, labor and postpartum; information about infant and neonatal course). • b. Present pregnancy. 10/16/09
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Prenatal Surveillance • Fetal – • a. heart rate (s) • b. size – actual and fate change • c. amount of amniotic fluid • d. presenting part and station in late pregnancy • e. activity 10/16/09
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Maternal • A. blood pressure – actual and extent change • B. weight – actual and extent change • C. symptoms including headache, altered vision, abdominal pain, nausea and vomiting, bleeding, fluid from vagina and dysuria • D. height in cm. of uterine fundus from sumphysis
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• E. vaginal examination in late pregnancy often provides valuable information: • - confirmation of presenting part • - station of the presenting part • - clinical estimation of pelvic capacity and its general configuration • - consistency, effacement and dilatation of the cervix • - position of presenting part
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• B. Schedule of return prenatal visits. • 1. Frequency of return visits. • a.. Monthly for first thirty-two weeks. • b. Every two weeks to the thirty-sixth week. • c. After the thirty-sixth week, weekly until • delivery. 10/16/09
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• 2. Subsequent assessment data follow-up. • a. Vital signs. • b. Urinalysis-check for protein and sugar. • c. Monitor weight. • d. Measurement of height of uterine fundus • e. Auscultation of fetal heart rate (FHR).
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Physical Assessment • Vital signs • Cephalocaudal assessment • Abdomino/Pelvic exam: • - Leopold’s maneuver • - Speculum • -IE • - Pelvic measurement 10/16/09
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Leopolds Manuever • - determine the orientation of the fetus through abdominal palpation • Purpose: • - to determine presentation, position and atttiude - estimate fetal size - locate fetal parts/FHB or FHT 10/16/09
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Preparatory Steps • Palpate with warm hands, cold hands cause abdominal muscle to contract • Use palms not fingers – educate them • Position patient on supine with knee flex slightly (dorsal recumbent) so as to relax abdominal muscles • Apply gently but firm motions • Abdominal examination should be conducted systematically employing the 4 maneuver’s. • The mother should be in with her abdomen bared. 10/16/09
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L 1-Palpation of the fundus • The fundus is gently palpated between the palms of two hands • The upper pole (in this case the breech) is identified • Characteristically the breech is softer than the head, there is no angle formed by the neck and the surface continues smoothly with the back 10/16/09
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L 2 - Palpation of the body • The palpation continues down the body of the uterus • The smooth back is palpated and identified • The irregular surface created by the limbs, hands and feet is identified 10/16/09
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L 3 - Palpation of the vertex • The head is identified (in the case in the lower pole) • The head feels hard and rounded
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L 4 - Assessing engagement • Facing the woman’s feet • The vertex is palpated using both hands • An assessment is made of how much of the head can be palpated and whether the head is engaged, fixed or mobile
10/16/09
© Dr Paul Bradley, Clinical Skills Resource Centre, University of Liverpool, UK
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Fundic Height
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Symphysis-fundal height • More accurate assessment of fundal height involves direct measurement in centimetres of the distance from the symphysis pubis to the top of the fundus 10/16/09
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Technique Measuring tape Gentle pressure applied
Abdo wall 10/16/09
Tape zero held against pubic symphysis
Uterus
• The woman lies supine • The pubic symphysis is identified • The zero end of the tape measure is held against it • Tape is stretched over the abdomen • A hand on top of the tape applies gentle pressure to palpate the top of the fundus • An estimate of fundal size can thus be made 204
Diagnostic - CBC, Blood typing - Urinalysis - Hep. B Profile - HIV - Vaginal Smear – GbS/Paps smear - UTZ - Rubella titer - OGTT (DM) 10/16/09
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Estimations • Naegele’s Rule • McDonald’s Method • Bartholomew’s Rule • Haase’s Rule • Johnson’s Rule • Ultrasound - BPD
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• Naegele’s Rule (EDC) - estimation of AOG by LMP • McDonald’s Method (Age of gestation) - – determines age of gestation by measuring from the fundus to the symphysis pubis (in cm.) then divide by 4 = AOG in months.
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General Assessment of the Obstetric Patient • Physical Examination – Asses fundal height to determine gestation.
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Bartholomew’s Rule (Age of
)
gestation
• Estimates AOG by the relative position of the uterus in the abdominal cavity. • By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis • On the 5th lunar month, the fundus is at the level of the umbilicus • On the 9th lunar month, the fundus is below the xiphoid process
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Assessing fundal height
34 28 20 16 12
10/16/09
• Uterine fundal height can indicate pregnancy duration • It is a crude method depending on body build, examiner technique, foetal growth, accurate dates, etc • It is better to measure the height of the fundus to the pubic bone and compare to a standard chart • Even better estimation of gestation and foetal development is obtained by ultrasonography • 34 weeks just below xiphisternum • 28 weeks midway between umbilicus and xiphisternum • 20 weeks at the umbilicus • 16 weeks midway between pubic bone and umbilicus • 12 weeks just above pubic bone
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Haase’s Rule (Fetal Length) • Determines the length of the fetus in centimeters. • During the first half of pregnancy, square the number of the month (E.g., first lunar month: 1 x 1 = 1 cm.) • During the second half of pregnancy, multiply the month by 5 (E.g., 6th lunar month: 6 x 5 = 30 cm. 10/16/09
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Johnson’s Rule • Estimate the weight of the fetus in grams. • Formula: fundic height in cm. – n x k • “k” is a constant, it is always 155 • “n” is = 12 ( if fetus is engaged) • = 11 (if fetus is not yet engaged) 10/16/09
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Thank you!!!
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