OBSTETRICS

NOTES ON OBSTETRICS

NORMAL LABOR (THEORIES OF LABOR ONSET)

  1. Oxytocin Stimulation Theory​
    2 .Uterine Stretch Theory
  2. Progesterone Deprivation Theory
  3. Prostaglandin Theory
  4. Theory of the Aging Placenta
    6 .Fetal Adrenal Response Theory

SIGNS OF LABOR (WRISLIR)
• Weight Loss – 2-3 pounds (progesterone)
• Ripening of the Cervix – “soft”
• Increased Braxton Hicks – “irregular, painless”
• Show – “ruptured capillaries + operculum = pinkish color”
• Lightening – “the baby dropped”
​- 2 weeks (primi) and before or during (multi)
● Relief of respiratory discomfort
● Increased frequency of urination
● Leg pains
● Muscle spasms
● Increased vaginal discharge
● Decreased fundal height
• Increased Level of Activity – large amount of epinephrine (AG)
• Rupture of Membranes – gush or steady trickle of clear fluid

FALSE LABOR
CANDAC
✓ Contraction disappear with ambulation
✓ Absence of cervical dilation
✓ No ↑ DIF (duration, intensity, frequency)
✓ Discomfort @ abdomen
✓ Absence of show
✓ Contraction stops when sedated

TRUE LABOR
CUPPAD
✓ Contraction persists when sedated
✓ Uterine contraction ↑ DIF (duration, intensity, frequency)
✓ Progressive cervical dilation
✓ Presence of show
✓ Ambulation increase contractions
✓ Discomfort radiates to lumbosacral area

LENGTH OF LABOR
STAGE OF LABOR
PRIMI (VIRGIN)
MULTI (DIS-VIRGIN)
1ST STAGE
10 – 12 HOURS
6 – 8 HOURS
2ND STAGE
30 MINS – 2 HOURS
Ave: 50 mins
20 – 90 MINS
Ave: 20 mins
3RD STAGE
5 – 20 MINS
5 – 20 MINS
4TH STAGE
2 – 4 HOURS
2 – 4 HOURS

ESSENTIAL FACTORS OF LABOR (5Ps)

  1. Passages
  2. Power
  3. Passenger
  4. Person
  5. Position

PASSAGES
FUNCTIONS (Sit Sit)
○ Serves as birthcanal
○ It proves attachment to muscles, fascia and ligaments
○ Supports uterus during pregnancy
○ It provides protection to the organs found within the pelvic cavity
TYPES (GAPA)
○ Gynecoid – normal female type of pelvis
​- most ideal for childbirth
​- round shape, found in 50% of women
○ Android – male pelvis
​- presents the most difficulty during childbirth
​- found in 20% of women
○ Platypelloid – flat pelvis, rarest, occurs to 5% of women
○ Anthropoid – apelike pelvis, deepest type of pelvis found in 25% of women
DIVISION OF PELVIS

  1. False Pelvis – “provide and direct”
  2. True Pelvis – “the tunnel” IPO
    ○ Inlet or Pelvic Brim – entrance to true pelvis
    ANTEROPOSTERIOR DIAMETER DOT
  3. Diagonal Conjugate – midpoint of sacral promontory to the lower margin of symphysis pubis (12.5 cm)
  4. Obstetric Conjugate – midpoint of sacral promontory to the midline of symphysis pubis (11 cm)
  5. True Conjugate – midpoint of sacral promontory to the upper margin of symphysis pubis (11.5 cm)
    ○ Pelvic Canal – situated between inlet and outlet
    ​- designed to control the speed of descent of the fetal head
    ○ Outlet – most important diameter of the outlet.
    POWERS 3I’s
    ⦿ Involuntary – not within the control of the parturient
    ⦿ Intermittent – alternating contraction and relaxation
    ⦿ Involves discomfort (compression, stretching and hypoxia)
    ⦿ PHASES OF UTERINE CONTRACTIONS
    ​1. Increment/Crescendo – “ready, get set”
    ​2. Acme/Apex – “go”
    ​3. Decrement/Decrescendo – “stop”
    ⦿ INTENSITY – strength of uterine contraction
    ○ Mild – slightly tensed fundus
    ○ Moderate – firm fundus
    ○ Strong – rigid, board like fundus
    ⦿ FREQUENCY – rate of uterine contraction
    ​- measured from the beginning of a contraction to the beginning of the next contraction
    ⦿ DURATION – length of uterine contraction
    ​- measured from the beginning of a contraction to the end of the same contraction
    ⦿ INTERVAL – measured from the end of contraction to the beginning of the next contraction

PASSENGER
⦿ HEAD ​(BOTu)
​- Biggest part of the fetal body
​- Olways the presenting part
​- Turn to present smallest diameter

⦿ CRANIAL BONES ​1 FOSE, 2 PaTe
​1 frontal bone​2 parietal bone.

​1 occipital bone​2 temporal bone
​1 sphenoid bone
​1 ethmoid bone
⦿ SUTURE LINES – allow skull bones to overlap (molding) and for further brain development (SFC La)
● Sagittal Suture – between 2 parietal bones
● Frontal Suture – between 2 frontal bones
● Coronal Suture – between frontal and parietal
● Lamdiodal Suture – between parietal and occipital
⦿ FONTANELS – intersection of suture lines
● Anterior Fontanel or Bregma – intersection of SFC
​- diamond shaped, closes b/n 12 – 18 months
​- 3 x 4 cm
● Posterior Fontanel or Lambda – intersection of Sla​- triangular shaped, closes b/n 2 – 3 months
⦿ DIAMETERS OF THE FETAL HEAD
AP > T (fetal head)
1.Tranverse Diameters BBB
● Biparietal – most important TD
​- greatest diameter presented to the pelvic inlet’s AP and at the outlet’s TD
​- average measurement is 9.5 cm
● Bitemporal – average measurement is 8 cm
● Bimastoid – average measurement is 7 cm

  1. Anteroposterior Diameters SOO
    ● Suboccipitobregmatic – smallest APD
    ​- fully flexed (presenting part)
    ​- measured from the inferior aspect of occiput to the ​anterior fontanel
    ​- average measurement is 9.5 cm
    ● Occipitofrontal – head partially extended and presenting part is the anterior fontanel
    ​- average size is 12. 5 cm
    ● Occipitomental – head is extended and the presenting part is the face
    ​- measured from the chin to the posterior fontanel
    ​- average size is 13.5 cm
    ⦿ FETAL LIE – relationship of the long axis of the fetus to the long axis of the mother
    ● Longitudinal Lie – “parallel”
    ● Transverse Lie – “right angle/lying crosswise”
    ● Oblique Lie – “slanting”
    ⦿ Attitude or Habitus – degree of flexion or relationship of the fetal parts to each other.

PRESENTATION AND PRESENTING PART
LIE
PRESENTATION
ATTITUDE
A. Longitudinal Lie
1. Cephalic (head)

 2. Breech (butt)

B. Transverse Lie
Causes:
1. relaxed abdominal wall
2. placenta previa

Vertex – most ideal
– suboccipitobregmatic is presented (9.5 cm)

Brow – occipitomental is presented (13.5 cm)

Sinciput – occipitofrontal is presented (12.5 cm)

Face presentation

Chin presentation

Complete breech – feet & legs flexed on the thighs and the thighs are flexed on the abdomen

Frank breech – hips flexed and legs extended (MOST COMMON)

Footling Breech – one or both feet are the presenting parts

Shoulder Presentation – fetus is lying perpendicular to the long axis of the mother
– vaginal delivery is NOT POSSIBLE

*Compound Presentation – when there is prolapsed of the fetal hand alongside the vertex, breech or shoulder.
Complete flexion

Moderate flexion

Partial flexion (military position)

Extension

Hyperextended

Good flexion

Moderate flexion

Very poor flexion

Flexion

POSITION
⦿ LOA (Left Occipitoanterior) – most favorable & common fetal position
​- fetus in vertex presentation (occiput)
​- fetus usually accommodates itself on the left because the placement of the bladder is at the right
⦿ LOP/ROP – mother will suffer more back pains
⦿ FHT Breech: Upper R or L Quadrant (above Umbilicus)
⦿ FHT Vertex: Lower R or L Quadrant (below Umbilicus)
⦿ STATION – relationship of the presenting part of the fetus to the ischial spine of the mother.
● Minus (-) station – presenting part is above the ischial spine
● Zero (0) station – presenting part is at the level of the ischial spine
● Positive (+) station – presenting part is below the level of the ischial spine
● FLOATING – head is movable above the pelvic inlet
● +1 station – fetus is engaged
● +2 station – fetus is in midpelvis
● +4 station – perineum is bulging

⦿ THE PERSON

FACTORS affecting labor PRC PCP
● Perception & meaning of childbirth
● Readiness & preparation for childbirth
● Coping skills.

● Past experiences
● Cultural & social background
● Presence of significant others and support system

STAGES OF LABOR
⦿ STAGE 1 – DILATATION STAGE
● Starts from first true uterine contraction until the cervix is completely effaced and dilated.
○ Dilatation – widening of cervical os to 10 cm
○ Effacement – thinning to 1- 2 cm
● CAUSES: ​1. Pergusion Reflex
​2. Fetal head and intact BOW serves as a wedge to dilate the cervix
● Maternal Assessment During Labor
​1. PIPIT PEPA HF
​2. Check V/S q 4hrs during the first stage
​- temp q hour if membranes are already ruptured (risk of infection)
​- BP b/n contractions, in left lateral pos, q 15 – 20 mins after giving anesthesia
​- a rapid pulse indicates hemorrhage & dehydration

  1. Uterine contraction
    Manual: fingers over fundus, you feel it about 5 secs before the client feels it
    Techniques:
    ​1. assess contraction (DIIF)
    ​2. check contraction q 15 – 30 mins during the first ​stage
    ​3. refer immediately if:
    ​- duration more than 90 secs
    ​- interval less than 30 secs
    ​- uterus not relaxing completely after each ​contraction
  2. Show – slightly blood-tinged mucus discharge
  3. Internal Examination – to assess status of amniotic fluid, consistency of cervix, effacement/dilatation, presentation, station and pelvic measurement.
    ​- do it during relaxation
    ​- less IE done once membrane have ruptured
    ​- start with middle finger then index finger
  4. Status of Amniotic Fluid (if ruptured)
    ● Danger of cord prolapse if fetal head is not yet engaged.
    ● Danger of serious intrauterine infection if delivery does not occur in 24 hours
    NITRAZINE PAPER TEST
    ​- used to assess whether membrane ruptured or not.
    ● Procedure: “Insert and Touch”
    ○ Yellow – intact BOW
    ○ Blue – ruptured
    ● Normal Color of AF – clear, colorless to straw colored
    ● Green tinged – meconium stain (fetal distress in non – breech presentation)
    ● Yellow/Gold – hemolytic disease
    ● Gray/Cloudy – infection
    ● Pinkish/Red stained – bleeding
    ● Brownish/Tea Colored/Coffee Colored – fetal death
    OTHER TEST TO DETERMINE STATUS OF AMNIOTIC FLUID
    ⦿ Ferning pattern of cervical mucus
    ​ (“swab – dry – view”)
    ⦿ Nile blue sulfate staining of fetal squammous cells
    FETAL ASSESSMENT DURING LABOR FHT Monitoring
    ● Latent Phase – every hour
    ● Active Phase – every 30 minutes
    ● Second Stage of Labor – every 15 minutes
    ● FHT is taken more frequently in high – risk cases
    ⦿ Normal FHT Pattern
    ● Baseline rate: 120 – 160 bpm
    ● Early Deceleration – FHT @ contraction, Normal @ end of contraction (head compression)
    ● Acceleration – FHT when fetus moves
    ⦿ Abnormal FHT Pattern
    ● Bradycardia – 100 – 119 bpm – moderate
    ​- below 100 bpm – marked
    ​CAUSES: ​1. fetal hypoxia (analgesia & ​anesthesia)
    ​2. maternal hypotension
    ​3. prolonged cord compression
    ​MGT: ​1. place mother on left side
    ​2. assess for cord prolapse
    ​3. administer oxygen
    Tachycardia – 161 – 180 bpm – moderate
    ​- above 180 bpm – marked
    CAUSES:​1. maternal fever, dehydration
    ​2. drugs (atrophine, terbutaline, ritodrine, etc.
    MGT: ​1. D/C oxytocin, position on LLP
    ​2. give 02 at 8 – 10 lpm
    ​3. prepare for birth if no improvement

● Variable Pattern – deceleration at unpredictable times of uterine contraction
​CAUSE: sign of cord compression
​MGT: release pressure on the cord
● Sinusoidal Pattern – no variability in FHT
​CAUSE: hypoxia, fetal anemia & prematurity

CARE OF THE PARTURIENT

  1. LATENT PHASE
    ○ Cervical Dilation: 0 – 4 cm
    ○ Nature of Contraction: ​Duration: < 30 secs
    ​Interval: 3 – 5 mins
    ○ Length of Latent Phase:​Primis – 6 hours
    ​Multis – 4 – 5 hours
    ○ Attitude of mother: feel comfortable, walking and sitting at this time
    ○ Nsg Responsibilties:​TGC
    ​1. Teach breathing techniques
    ​2. Give instructions
    ​3. Conversation is possible (cooperative & focus mother)
  2. ACTIVE PHASE
    ○ Cervical Dilation: 4 – 7 cm.

○ Nature of contractions: ​Duration: 30 – 50 secs
​Intensity: moderate to strong
○ Length of Active Phase:​Primis – 3 hours
​Multis – 2 hours
○ Attitude of mother:​prefer to stay in bed, withdraws from her environment and self – focused
○ Nsg Responsibilities:​ CPIC
​1. Coach woman on breathing and relaxation techniques
​2. Prescribed analgesics given during active phase
​3. Instruct woman to remain in bed, minimize noise, raise side rails, NPO
​4. Check BP 30 mins after giving analgesics ​(hypotension)

  1. TRANSITION PHASE
    ○ Cervical Dilatation: 8 – 10 cm
    ○ Nature of Contractions:​Duration: 50 – 60 secs
    ​Interval: 2 -3 mins
    ​Intensity: moderate to strong
    ○ Length of Transition Phase:
    ​Primis – 1 hour (baby delivered within 10 contractions or 20 mins)
    ​Multis – 30 mins (baby delivered within 10 contractions or 20 mins)
    ○ Attitude of mother: feel discouraged, ask midwife/nurse repeatedly when labor will end, not in control of her emotions and sensations, irritated, may not want to be touched
    ○ Nsg Responsibilities: RRE
    ​1. Reassure woman that labor is nearing end & baby will be born soon
    ​2. Reinforce breathing and relaxation techniques
    ​3. Encourage fast-blow breathing to remove the urge to bear down
    ⦿ CARE OF THE BLADDER – encourage the woman to void q 2 hrs to: DIPC
    ○ Delay fetal descent
    ○ Increases the discomfort of labor
    ○ Predispose to UTI
    ○ Can be traumatized during labor
    ⦿ FOODS & FLUIDS – NPO on active phase
    ○ Clear fluids on latent phase
    ⦿ POSITIONING – LLP – best position bcoz J RIPES
    ○ Relieves pressure – IVC
    ○ Improves urinary function
    ○ Prevent hypotensive syndrome
    ○ Encourage anterior rotation of the fetal head
    ○ Squatting is ideal position – directs presenting part towards the cervix promoting dilatation
    ⦿ AMBULATION – during the latent phase to shorten the first stage, to decrease the need for analgesia, FHT abnormalities & to promote comfort​
    ○ NO WALKING IF BOW IS RUPTURED
    ⦿ IV FLUIDS – reasons: PLUA
    ○ Prevent dehydration/fluid & electrolyte imbalances
    ○ Life – line for emergencies
    ○ Usually required before administration of A/A
    ○ Administration of oxytocin after delivery to prevent atony
    ⦿ PERINEAL PREP
    ○ Clean & disinfect the external genitalia
    ○ Provide better visualization of the perineum
    ⦿ ENEMA – emptying the colon of fecal matters to:
    ○ Prevent infection
    ○ Facilitate descent of fetus
    ○ Stimulate uterine contractions
    ○ CONTRAINDICATIONS: NIRVAA
    ● Not given during active phase
    ● If premature labor bcoz of danger of cord prolapse
    ● Rupture of BOW
    ● Vaginal bleeding
    ● Abnormal fetal presentation & position
    ● Abnormal fetal heart rate pattern
    SECOND STAGE – EXPULSIVE STAGE
    ​MECHANISM OF LABOR: EDFIRE ERE
    ● Engagement
    ● Descent – entrance of the greatest biparietal diameter of the fetal head to the pelvic inlet
    ● Flexion – the chin of the fetus touches his chest enabling the smallest diameter (suboccipitobregmatic) to be presented to the pelvis for delivery
    ● Internal Rotation – when the head reach the level of the ischial spine, it rotates from transverse diameter to AP diameter so that its largest diameter is presented to the largest diameter of the outlet. This movement allows the head to pass through the outlet.
    ● Extension – the head of the fetus extend towards the vaginal opening. As the head extend, the chin is lifted up and then it is born.
    ● External Rotation – when the head comes out, the shoulder which enters the pelvis in transverse position turns to anteroposterior position for it become in line with the anteroposterior diameter of the outlet & pass through the pelvis.
    ● Expulsion – when the head is born, the shoulder & the rest of the body follows without much difficulties.
    ● Duration of Second Stage: Primis – 50 mins
    ​Multis – 20 mins
    ● Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high risk cases if not yet delivered.

● Transfer to the DR: ​Primis – cervix fully dilated
​Multis – cervix is 8 cm dilated
Delivery Position

  1. Lithotomy – used when forcep delivery & episiotomy are to be performed.
  2. Dorsal Recumbent – head of the bed is 35 – 45˚ elevated, knees are flexed & feet flat on bed. This position facilitates the pushing effort of the mother.
  3. Left Lateral Position – indicated for woman with heart disease.
    ⦿ ASSISTING THE MOTHER IN THE DR
  4. Coach the mother to push effectively
  5. Instruct the woman to pant
  6. Dorsiflex the affected foot and straigthen the leg until the cramps disappear
  7. Perform ironing on vaginal orifice if the presenting part moves towards the outlet
  8. When the head is crowning, instruct the mother to pant.
  9. Perform Ritgen’s Maneuver while delivering the fetal head to:
  10. Slows down delivery of the head
  11. Lets the smallest diameter of the head to be born
  12. Facilitates extension of the head
  13. Just after delivery, immediately wipe the nose & mouth of secretions then suction.
  14. Take note of the exact time of baby’s birth
  15. After the delivery of the baby, place the newborn in dependent position to facilitate drainage of secretions.
  16. Place the infant over the mother’s abdomen to help contract the uterus.
  17. Clamping the cord:
    ● After the pulsation stops
    ● Clamp the cord twice and cut in between 8 – 10 inches from umbilicus
    ● After cutting the cord, look for 2 arteries & 1 vein
  18. Wrap the infant & bring to the nursery

THIRD STAGE – PLACENTAL DELIVERY
METHODS OF PLACENTAL SEPARATION:

  1. Schultz Mechanism – separation of the placenta starts from the center
    ​- the shiny & smooth fetal side is delivered first
    ​- 80% of placental separation
  2. Duncan Mechanism – separation begins from the edges of placenta
    ​- the dirty maternal side is delivered first
    ​- 20% of placental separation
    MANAGEMENT:
  3. Watchful waiting.
    a) Do not hurry placental delivery.
    b) Rest a hand over the fundus to make sure the uterus remains firm
    c) Wait for signs of placental delivery
    • Calkin’s sign – uterus is firm, globular & rising to the level of umbilicus
    • Sudden gush of blood from vagina
    • Lengthening of the cord
  4. Manage the uterus to keep it contracted.
  5. Administer methergin as prescribed.
  6. Never leave the client unattended.
  7. Oxygen & emergency equipment made available.

THE FOURTH STAGE – PUERPERIUM
MANAGEMENT:

  1. Repair of lacerations.
    ​CLASSIFICATION OF PERINEAL LACERATIONS
    ​First Degree – fourchette, vaginal mucous membrane, perineal skin
    ​Second Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body
    Third Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body & anal sphincter
    Fourth Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body, anal sphincter & mucous membrane of rectum
  2. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered from stirrups at the same time.
  3. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next 2 hours until stable.
  4. Check uterus & bladder q 15 mins.
    HYPEREMESIS GRAVIDARUM
    Causes:​(UTEP)
    ​1. Unknown
    ​2. Thyroid dysfunction
    ​3. Elevated HCG
    ​4. Psychological stress
    S/Sx:
    ​1. Excessive N/V – persist beyond 12 weeks
    ​2. Signs of dehydration (thirst, dry skin, weight loss, concentrated and scanty urine)
    Management:
    ​1. Differential diagnosis (liver & thyroid function studies, urinalysis, Hct/Hgb and WBC)
    ​2. Conservative management
    ​a. dry, low fat, high carbohydrate and bland diet
    ​- dry crackers
    ​- small frequent feedings & sips of water (gastric distention – trigger vomiting reflex)
    ​- avoid very hot or very cold food & beverages
    ​b. avoid noxious stimuli
    ​- motion and pressure around the stomach (tight waistbands)
    ​- temporary cessation of iron supplement (gastric upset)

​- avoid highly seasoned and spicy foods
​- avoid strong odors (perfumes)
​- avoid loud noises, bright and blinking lights
​​c. take vitamin supplement to correct nutritional deficiencies from decreased food intake
​d. have enough relaxation & rest
​e. take prescribed medications
​- Promethazine (Phenergan)
​- Prochlorperazine (Compazine)
​- Ondansentron (Zofran)
​- Droperidol (Inapsine)
​- Metoclorpramide (Reglan)
​- Diphenhydramine (Benadryl)
​- Meclizine (Antivert)
​3. Hospitalization (correct dehydration and F&E imbalances)
​a. IV fluids (lactated ringers)
​b. Vitamin supplementation
​c. NPO for 24 – 48 hours (rest GIT)
​d. Oral fluid intake after hydrated and nausea subside
e. when patient begins oral intake of foods:
​- administer antiemetics before meals
​- see patient is relaxed & comfortable
​- introduce food gradually starting with clear liquids
​- small frequent feedings
​- do not serve odorous, spicy & greasy foods
​- do not force patient to eat
​4. Parenteral or enteral therapies
​5. Complementary therapies
​a. acupressure (pericardium 6 or P6)
​b. herbal remedy (ginger – carminative effect/aroma)
​c. vitamin supplementation
​6. Provide emotional support
​a. show sincere concern for the women’s welfare
​b. empower patient with knowledge & encouragement
​c. provide necessary referrals (counseling)
ABORTION
Definition of Terms:

  1. Abortion – most common bleeding d/o of early pregnancy (before 20 weeks/fetus weighs 500 grams)
  2. Early Abortion – before 12 weeks pregnancy.
  3. Late Abortion – between 12 – 20 weeks
  4. Abortus – fetus that is aborted weighing less than 500 grams
  5. Occult Pregnancy – zygotes that were aborted before pregnancy is diagnosed or recognized
  6. Clinical Pregnancy – pregnancies that were diagnosed
  7. Blighted Ovum – small macerated fetus, sometimes there is no fetus, surrounded by a fluid inside an open sac.
  8. Carneous Mole – zygote that is surrounded by a capsule of clotted blood
  9. Fetus Compressus – fetus compressed upon itself and desiccated with dried amniotic fluid
  10. Fetus Papyraceous – fetus that is so dry that it resembles a parchment
  11. Lithopedion – a calcified embryo
  12. Immature Infant – having a birth weight b/n 500 – 1000 grams
  13. Full Term Infant – born between 38 – 42 weeks

Types of Abortion:

  1. Elective/Therapeutic Abortion – “the deliberate termination of pregnancy”
    a. EA – initiated by personal choice
    b. TA – recommended by the healthcare provider
  2. Spontaneous Abortion – “loss of a fetus due to natural causes”
    Causes of Spontaneous Abortion:
    A. Fetal Causes (80% – 90%)
  3. Developmental anomalies
  4. Chromosomal abnormalities (Trisomy 16)
    B. Maternal Causes (congenital/acquired conditions)
  5. Advanced maternal age (after 35 years of age)
  • <35 y/o (15% miscarriage rate)
  • b/n 35 – 39 y/o (20 – 25% miscarriage rate)
  • b/n 40 – 42 y/o (about 35% miscarriage rate)
  • >42 y/o (about 50% miscarriage rate)
  1. Structural abnormalities of the reproductive tract
  2. Inadequate progesterone production (corpus luteum/placenta)
  3. Maternal infections (rubella virus, cytomegalovirus, listeria infection, toxoplasmosis)
  4. Chronic and systemic maternal diseases
  5. Exogenous factors (tobacco, alcohol, cocaine, caffeine, radiation)
    Complications of Abortion:
    ​1. Hemorrhage
    ​2. Infection or septic abortion
    ​3. Disseminated intravascular coagulation (DIC)
    Types of Spontaneous Abortion:
  6. Threatened Abortion – “possible”
    ​- (+) bleeding, (-) cervical dilatation
    S/Sx:
    ​​-Light vaginal bleeding (bright red)
    ​-None to mild uterine cramping
    ​Management:
    ​1. Assess for:
    ​- LMP
    ​- Save all pads for examination
    ​- ask for presence of clots
    ​- abdominal pain
    ​2. Conservative management
    ​- bedrest until 3 days after bleeding has stopped
    ​- no coitus up to 2 weeks after bleeding stopped
    ​3. Educate mothers.

Management:
​1. Monitor V/S
​2. monitor closely for bleeding or signs of infection
​3. regular diet (high in iron foods)
​4. rest for a few days to 2 weeks (coitus&douching for approx 2 weeks)
​5. may experience intermittent menstrual-like flow and cramps (next menstrual period occurs after 4 – 5 weeks)
​6. Reassure patient that her next pregnancy is likely to last to term if she is young and has no other risk factors. (no pregnancy for the next 3 months)
​7. determine woman’s Rh factor
​8. Advise patient to return if:
​- profuse vaginal bleeding
​- severe pelvic pain
​- temperature greater than 100˚F

  1. Inevitable or Imminent Abortion – “can not be prevented”, (+) complete dilatation
    ​S/Sx:
    ​1. Moderate to profuse bleeding
    ​2. moderate to severe uterine cramping
    ​3. open cervix or dilatation of cervix
    ​4. rupture of membranes
    ​5. no tissue has passed yet
    ​Management:
    ​*Avoiding complications of infection or excessive blood loss
    ​1. Hospitalization
    ​2. D&C
    ​3. Oxytocin after D&C
    ​4. Sympathetic understanding and emotional support
  2. Complete Abortion – “spontaneous expulsion”
    ​S/Sx:
    ​1. Vaginal bleeding, abdominal pain and passage of tissue
    ​2. On examination:
    ​- light bleeding or some blood in the vaginal vault
    ​- no tenderness in the cervix, uterus or abdomen
    ​- none to mild uterine cramping
    ​- closed cervix
    ​- empty uterus on utrasound
  3. Incomplete Abortion – “expulsion of some parts and retention of other parts of conceptus in utero”
    ​S/Sx:
    ​1. heavy vaginal bleeding
    ​2. severe uterine cramping
    ​3. open cervix
    ​4. passage of tissue
    ​5. ultrasound shows some products of conception
    ​Management:
    ​1. D&C
    ​- uterus must kept contracted after D&C
    ​- inspect fundus frequently
    ​- a danger of D&C (uterine perforation)
    ​2. Monitor blood loss
    ​- inspect perineal pads (60 – 100ml of blood)
    ​- monitor v/s (BP & PR)
    ​- monitor the blood studies of patient’s clotting factors
    ​- monitor I & O (Oliguria – decrease renal perfusion – shock)
    ​3. Sympathetic understanding and emotional support.
    ​- encourage verbalization of feelings
  4. Missed Abortion – “retention after death”
    ​S/Sx:
    ​1. Absence of FHT
    ​2. Signs of pregnancy disappear
    ​- uterus fails to enlarge
    ​- no FHT
    ​- serum or urine test for the subunit of HCG is negative
    ​- ultrasound showing no cardiac activity
    ​Management:
    ​1. Product of conception be removed to prevent DIC
    ​2. Insert 20mg Dinoprostone (Prostaglandin E) suppository into the vagina q 3 or 4 hours PRN (<28 weeks gestation)
    ​3. Oxytocin IV infusion (late missed abortion)
  5. Habitual Abortion – “repeated 3 or more”
    ​Causes:
    ​1. incompetent cervix
    ​2. IUGR
    ​3. congenital, genetic & chromosomal abnormalities
    Management:
    ​1. Treating the cause
    ​2. Specific treatment according to cause:
    ​a. Cervical Cerclage (modified Shirodkar, Mc Donald’s) – suturing ​the cervix
    ​b. Fertility drugs (Clomiphene, Pergonal, etc.)
    ​c. Aspirin or Mini – Heparin
    ​d. Luteal Phase Progesterone Support
    ​e. correction of defects
    ​f. treatment of medical illness
  6. Infected Abortion – “infection @ POC & MRO”
  7. Septic Abortion – “dissemination of bacteria in maternal circulatory and organ system
    ​Causative Organisms:
    ​1. E. Coli
    ​2. Enterobacter Aerogenes
    ​3. Proteus Vulgaris
    ​4. Hemolytic Streptococci
    ​5. Staphylococci
    S/Sx:
    ​1. foul smelling vaginal discharges
    ​2. uterine cramping
    ​3. fever, chills and peritonitis
    ​4. leukocytosis – WBC count 16, 000 – 22,000/uL
    ​5. critically ill patients
    ​Management:
    ​1. Treat abortion
    ​2. high dose IV antibiotic therapy (Penicillin – gram negative, Clindamycin/Tobramycin – gram positive)
    ​3. D&C if accompanied by incomplete abortion
    ​4. Infertility may occur

​-

HYDATIDIFORM MOLE

  • benign disorder of the placenta characterized by degeneration of the chorion and death of the embryo.

Types:

  1. Complete Molar Pregnancy – “only placental parts, no embryo”
  2. Partial Molar Pregnancy – “2 fathers, 1 mother”
    ​- “placenta and fetus formed but incomplete”
    Risk Factors/Incidence:
  3. Geography
  4. High in women below 18 and above 40 years old
  5. High in low socioeconomic status (low protein intake)
  6. History of molar pregnancy
    S/Sx:
  7. Excessive N/V due to elevated HCG levels
  8. Bleeding from spotting to profuse (brown bleeding)
  9. Passage of grape like vesicles around the 4th month
  10. Rapid increase in uterine size (out of proportion)
  11. Signs of preeclampsia before 24 weeks (HEP)
  12. Absence of FHT and fetal skeleton
  13. Ultrasound (mass of fluid filled vesicles – “snowflake pattern”)
  14. Elevated plasma thyroxine levels
  15. Elevated serum gonadotropin level (>100 days)
    Management:
  16. D&C
  17. Methotrexate (Choriocarcinoma)
  18. HCG monitoring for 1 year
    ​- HCG should be negative 2-8 weeks after removal of mole (every 2 weeks)
    ​- monthly for 6 months.

​- every 2 months for another 6 months
​- chest x-ray every 3 months for 6 months

  1. Woman advised not to be pregnant for one year
    ​- contraceptives should not contain estrogen
  2. Hysterectomy
    ​- above 40 years old
    ​- who have completed child bearing
    ​- who desire or require sterilization
    Complications of H – Mole:
  3. Gestational Trophoblastic Tumors – “trophoblastic proliferation”
    a. Choriocarcinoma – most severe complication
    ​- conversion of chorionic villi into cancer cells that erode blood vessels and uterine muscles.
    ​- “lungs”
    b. Invasive Mole – developed during the first 6 months
    ​- excessive formation of trophoblastic villi that penetrates the myometrium
    c. Placental Site Trophoblastic Tumor – composes of cytotrophoblastic cells arising from the site of the placenta.
  • produce both prolactin and HCG
    ​- main symptom is “bleeding”

**Management of all trophoblastic tumors is HYSTERECTOMY

INCOMPETENT CERVIX
Diagnosis:

  1. Pelvic examination or IE
  2. Ultrasonography – (cervical os is >2.5cm or length is shortened to <20mm)
    ​- “funneling”

Predisposing Factors/Causes:

  1. DES exposure in utero
  2. Cervical trauma from previous difficult deliveries (forcep deliveries)
  3. Hormonal influences
  4. Congenitally short cervix
  5. Forced D&C
  6. Uterine anomalies
    S/Sx:
  7. Painless vaginal bleeding or pinkish show accompanied by cervical dilatation (first sign)
  8. Rupture of membranes and passage of amniotic fluid
    Management:
  9. Cervical cerclage @ 14 weeks (“earlier the better”)
  10. Prerequisites of cervical cerclage:
    cervix not dilated beyond 3 cm
    ​- intact membranes
    ​- no vaginal bleeding and uterine cramping
  11. Types of cervical cerclage:
    ● Shirodkar Suture – “permanent suture”
    ● Mc Donald Suture – “temporary suture”
  • 38 – 39 weeks removal of suture
  1. After suturing the cervix:
    ​- place woman on bedrest for 24 hours – several days
    ​- observe for bleeding, contraction and rupture
    ​- report passage of fluid or signs of PROM
    ​- if uterine contracts, RITODRINE may be given
    ​- restrict activities after application for the next 2 weeks including coitus

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