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Obstetrics and Gynecology Ebook Notes PDF
Obstetrics and Gynecology Ebook Notes PDF
A. Bones of female pelvis- pelvis is made up of three type of bones which are four un number these are:
One coccyx
1. Innominate bones- are the widest bones of the pelvis. Each innominate bone is constituted by the
fusion of three bones namely the illium, ischium and pubis around a cup like cavity called
acetabulem. All the three part of the bone contribute to the acetabulemin the following proportion:
two fifth ilium, two fifth ischium and one fifth pubic bone.
The ilium-is the large flared out part of the pelvic bone. When the hand is placed on the hip it
rests on the iliac crest which is the upper border of the bone. At the front of iliac crest is a bony
prominence known as anterior superior iliac spine. A short distance below it is anterioinferior
iliac spine. There are two similar points at the posterior end of the iliac crest namely the
posteriosuperior and posteriorinferior iliac spines. The concave anterior surface of the ilium is
the called iliac fossa.
The ischium- is the thick lower pare of the innomonate bones. It has a large prominence known
as the ischial tubiresity on which the body rests when setting. Behind and a little above the
tuboresity is an inward projection of the bone called the ischial spine. During labour the station of
the fetal head is estimated in relation to the ischial spines.
The pubis- is the anterior part of the innominate bones. It has a body and two oars like projection,
the superior ramus and the inferior ramus. The two pubic bones meet at the symphysis pubis and
the two inferior rami forms the pubic arch merging in to the similar ramus in the ischium. The
space enclosed by body of pubic bone, rami and ischium is called obturator foramina.
2. Sacrum- is a triangular shaped bone having its base above and its apex below. It is formed by fusion
of five sacral vertebras. The upper border of the first sacral vertebra forms a prominence called sacral
promontory. At the side the side the sacrum has two wings like processes called ‘ala’ of the sacrum
which articulate with innominate bones. The anterior surface of the sacrum is concave and is referred
to us the hollow of the sacrum. It has four pairs of opening in which nerves that are emerged from the
cauda equine passes through to supply the pelvic viscera called sacral foramina. The posterior
surface of the sacrum is roughened to receive attachments of muscle.
3. Coccyx- is formed by the fusion of four vertebrae and it articulate superiorly with tip of sacrum.
B. Joints of the pelvis- there are four joints with in the pelvis that joins the four pelvic bones in to one.
The sacroiliac joint-is a joint in which the sacrum is articulated with the innominate bones. It is
the strongest joint in the body.
The symphisis pubis- is a cartilaginous joint formed by the junction between the two pubic bones
along the mid line.
The sacro-coccygeal joint- is formed where the base of coccyx articulate with the tip of the
sacrum. It has a great obstetric importance during delivery. During pregnancy the hormone
progesterone relaxes the ligaments and allows greater mobility and increase the available space in
the pelvis.
C. Pelvic ligaments- each of the pelvic joints is held together by ligaments for example:
Sacrotuberous ligament- runs from the sacrum to the ischial tuberosity and
D. Parts of the pelvis-the female pelvis consists of two parts; the false pelvis and the true pelvis.
False pelvis- is the part of the pelvis above the pelvic brim. It is formed by the upper flaired
out part of the iliac bones and it does not play any significant role in the process of child
birth.
True pelvis- is the true bony birth canal through which the baby must pass during birth. It
has a brim, a cavity and an out let.
1. The pelvic brim- id rounded except where the sacral promontory project in to it. The promontory
forms its posterior border, the iliac bones its lateral border and the pubic bones its anterior border.
The nurse needs to be familiar with the fixed points on the pelvic brim which are known as land
marks. Starting from the posterior these are:
Sacral promontory
Sacro-iliac joint
Iliopestineal line
Iliopectinial eminence
The anterioposterior diameter- is a line from the sacral promontory to the upper border of
symphysis pubis. When the line is taken to the upper most point of symphysis pubis it is
called the anatomical conjugate and is 12cm. when it is taken to the posterior border of the
upper part of sumphysis pubis it is called the obstetric conjugate (true conjugate) and
measured to be 11cm. the obstetric conjugate tells us the true available space for the passage
of the fetus. The diagonal conjugate is also measured anterio posteriorly from the lower
border of the symphsis pubis to the sacral promontory. It may be estimated per vaginum as
part of pelvic assessment and should measure 12-13cm.
The transverse diameter-is a line between the points furthest apart on the iliopectineal lines
and measures 13cm.
The oblique diameter- is a line from one sacroiliac joint to the iliopectineal eminence on the
opposite side of the pelvis and it measures 12cm. There are two oblique diameters each takes
its name from the sacroiliac joint it arises that is, the left oblique diameter arises from the left
iliac joint.
2. The pelvic cavity- extends from the brim above to the out let below. The anterior wall is formed by
the curve of sacrum which is 12cm in length. The cavity is circular in shape and although it is
difficult to measure its diameters exactly they are all considered to be 12cm.
3. The pelvic out let – there are two out lets in the pelvis; the anatomical and obstetric out let. The
anatomical outlet is formed by the lower border of each bone; lower border of symphysis pubis, the
ischial tuberosity, and the tip of the coccyx while the obstetric out let is formed by the lower border
of symphysis pubis, the two ischial spines, and the sacro coccygial joint. The obstetrical out let has
great obstetric significance because it is the narrow pelvic outlet through which the baby must pass.
This out let is a diamond shape and its three diameters are as follows.
The anterioposterior diameter- is a line from the lower border of symphysis pubis to the
sacrococcygeal joint. It measures 13cm.
The oblique diameter- is said to be between the obturator foramina and the sacrospinous
ligament although there is no fixed point. The measurement is taken to be 12cm.
The transverse diameter- is a line between the two ischial spines and measures 10-11cm. it is
the narrowest diameter in the pelvis.
E. Types of pelvis- can be grouped in to four categories according to the shape of the pelvis brim.
The gynacoid pelvis is the ideal pelvis for child bearing. Its main feature are rounded brim,
straight side wall, shallow cavity with a broad, well curved sacrum, blunt ischial spine, a wide
sciatic notch and pubic arch of 90o. It is found in women of average build and height.
The android pelvis- is so called because it resembles the male pelvis. Its brim is heart shaped. It is
found in short and heavy build women who have a tendency to hirsute. This type of pelvis
predisposes for OPP (ociputoposterior position) and is least suited for child bearing.
The anthropoid pelvis –has long oval brim in which the AP diameter is longer than the
transverse. Women with this type of pelvis tend to be tall with narrow shoulder. Labour does not
usually present any difficulty.
The platiploid pelvis- is flat with kidney shaped brim in which the AP diameter is reduced and the
transverse one increased. In this type of pelvis the head must engage with the sagital seture in the
transverse diameter but descends with the pelvic cavity with out any difficulty.
NB:-keeping all the above measurements in mind the fetal head is the best pelvimeter.
1.1.2. Anatomy of genital organs
A. External genitalia (syn: vulva, pudendum)- is a term used to describe the externally visible pat of
female genitalia and is composed of mones pubis, labia majora, lavia mainora, clitoris, vestibule and
perineum. This vulva is bounded by mones pubis anteriorly, labua majora laterally, and the perineum
posteriorly.
Mons pubis (monis veneris) - is a pad of subcutaneous fatty tissue above the pubic bone. In adults
it is covered by pubic hair in an inverted triangle fashion.
Labia majors- are also called the greater lips of vagina. They are an elevation of skin and
subcutaneous tissue arising from monis pubis anteriorlly and will fuse medially to form the
posterior commeasure. It contains the sebaceous gland and the hair follicule. It is richly supplied
with venous plexus and it is homologus with scrotem of male.
Labia manors- are also called the lesser lip of vagina. It is a thick fold of skin devoid of fat lying on
either sides and with in the labia majora. It is composed of two devided lip that will fuse at some
points with in the vulva for example the upper part of labia minoras fuses in front and behind the
clitoris to form pre puse and franulem respectively and the lower part of labia manor fuse
posteriorly to form forchette. Alike the labia majoras it doesn’t contain hair follicle and it is
homologues with the veneral aspect of penis.
Clitoris- is a small cylindrical erectile body situated in the most anterior part of the vulva. It
consists of glans, body, and two crura. The glans is richly supplied with nerves. Clitoris is
homologues with penis of male.
Vestibule- is a triangular space bounded by clitoris anteriorly, forchette posteriorly, and the two
labia majors laterally. There are four openings with in the vestibule.
1. Urethral opening- mid line just in front (above) the vaginal orifice.
2. Vaginal orifice- is an opening situated in the posterior end of the vestibule and it is of varying
size and shape. In virgins, it is incompletely closed with septum of mucus membrane called
hymen. The membrane will rupture during six, child bearing and rarely during stranious
exercise. There are different types of hymen.
3. Openings of bartholin’s gland- bartholin’s glands are two pea sized glands situated on either
sides of the vaginal orifice. During sexual excitement it secret an alkaline mucous which helps
in lubrication. Each gland has got a duct that opens in the vestibule out side the hymen opening
but with in the labia minora. It is homologues with the bulbo urethral gland of the male.
Vagina: - is a fibro-muscular membranous sheet communicating the uterine cavity with the external
environment at the valve.
Position-The canal of vagina is upward and backward forming 90% with cervix and 450with the
horizontal in erect position. The diameter of the canal is about 2.5 cm being wider in the upper
part and narrow at the introits.
Function of vagina: - is excretory channel for the uterine secretion and menstrual blood
Walls: - vagina has get and anterior, posterior and two lateral walls. The length of the anterior
wall is about 7cm and that of posterior wall is 9cm
Farnices: - the projection of cervix through the anterior vaginal wall at the top of vagina forms a
cleft known as fornices. There are four fornicel (anterior , posterior and two lateral), the posterior
one being deeper and the anterior one is the most shallow.
Layer: - the vaginal wall is composed of 4 layers. The four layers from within to out ward are:
1. Mucous layer: - is lined by stratified squamous epithelium with out any secreting
gland.
4. Fibrous coat
Epithelium: - the vaginal epithelium is under the action of sex hormone especially estrogen.
At birth and up to 10-14 days, the epithelium is stratified squamous under the action of
maternal estrogen circulating in the newborn
Form puberty till menopause the vaginal epithelium is stratified squamous and is composed
of 3 district layers; the basal call, intermediate call and superficial call. The intermediate
and superficial cells contain glycogen. The superficial calls exfoliate constantly and
replacement occurs from basal calls when they become exposed to the dry external
environment during which karatinization will occur. Unlike it does not contain hair follicle,
sweet and sebaceous gland.
Secretion:- the vaginal secretion is vary small in amount but it become little excess
The pH of the vagina- ranging form 4- 5.5 the average being 4.5 secretion is acidic but it varies
during phases of life. The acidic nature of vaginal is because of the conversion glycogen to lactic
acid by the red shaped bacteria known as dodaril’s bacillus which is dependant on estrogen.
Relations
Postariarly:- it is related with rectal wall separated with pouch of Douglas, recto
vaginal septum & perennial body
1. Body or corpus: - is apart of uterus found above the isthmus and is further divided in to
fundus (dome shaped part that lies above the opening of the tubes) and body proper (a part
found b/n the opening of the tube and the isthmus). carnua is the upper outer angle of the
body and it is the site of attachment for fallopian-tube, round ligament and ovaries ligament.
3. Cervix: - is the lower most part of the uterus which is cylindrical in shape. it is divided in
to supra vaginal part, a part that lies about the vaginal and a vaginal part, a part found with in
the vagina each measuring 1.25 cm. in null parous the vaginal parts is conical with the
external 0s looking circular where as in parous it cylindrical with the external as having
bilateral slit, a slit formed by the damage of inner circular muscles of cervix during child
birth which will form anterior and posterior lip of cervix.
Structure of the uterus: - the wall of the body of the uterus consists of three layers the layers. The
layers from outside to in ward are:
3. The endometrium- is the mucus lining of the cavity of the uterus.it consists of
laminaproper and surface epithelium. The surface epithelium is ciliated simple columenar
while the lamina proper contain stromal cells, endometrial gland , vessels and nerves. During
the time of pregnancy the endometrium is called deciduas. The cervix is mainly composed of
fibrous connective tissue only 10-15%is smooth muscle,the endocervix is lined by tall
columenar epithelium while the exocervix or the vaginal part is covered by stratified
squamous epithelium. Between the two there is a space which consists of endocervical glands
and stroma covered by squamous epithelium which is known as squamocolumnar junction or
transitional zone.the zone is not static rather it changes with hormonal level of estrogen. This
site irritated not only by estrogen but also by infection and trauma. Thus there is a high risk
of CIN or even invasive cancer.
Secretion- the endometrial secretion is scanty and watery while the physical and chemical
property of cervical secretion changes with menstrual cycle and with pregnancy.the cervix secrets
alkaline mucus with PH of 7.8 which is rich in fructose, glycoprotine and muco polysacride. The
fructose has nutritive value for the spermatozoa.
Position of the uterus- the normal position of the uterus is anti version (the long axis of the uterus
especially the cervix makes 900 with the long axis of the vagina which means it leans forward)
anti flexion (the long axis of the body of the uterus forms 1200 with the long axis of the cervix
which means it is curved by itself at the level of internal os)
Function- mainly the uterus shelters the fetus during pregnancy and it expels its content when it
is contracted during labour.
Support of the uterus-the uterus is supported by pelvic floor and maintain in position by several
ligaments of which those at the level of cervix are the most important.
The transcervical ligament- is some times known as cardinal ligament. It runs out from the
side wall of pelvis to side wall of cervix.
The pubocercical ligament- passes forward from cervix under bladder to the pubic bone.
The broad ligament- is a double fold of peritoneum which spreads from the side of the
uterus to the lateral pelvic wall of the pelvis.
The broad ligament- arise from cornua and passes through broad ligament inserted in labia
majora. They have little value as a support but used to maintain the antiverted position of the
uterus.
Fallopian tube (syn:uterine tube or oviduct)- are paired structure found in the pelvic cavity. Each
tube has got two opening one communicating with the uterine cavity called the uterine opning and the
other on the lateral end of the tube called pelvic opning or abdominal ostium.
Parts- the tube has four parts. The part from medial to lateral are:
2. Isthmus
The abdominal ostium of the tube is surrounded by a number of finger like projections called
fimbria. One of which is longer than the other and is attached to the outer pole of the ovary called
the ovarian fimbrea.
1. Serous coat
Transporting male gamete to the site of fertilization and zygote to the uterine
cavity by its cilliary function.
Ovaries- are paired sex glands or gonads in the female which are concerned with two function.
Steroidogenesis
Relation
Anteriorly the ovary is attached to the posterior wall of the broad ligament by mesovarium
Posteriorly it is free
Laterally it is attached to the cornua and pelvic wall by ovarian and suspensery ligaments
respectively.
Structure- the ovary is covered by single layer of cubical cel known as germinal epithelium. The
ovary consists of the outer cortex and inner medulla. The cortex is the functional unit of the ovary
and it is composed of primordial follicle, primary follicle, secondary follicle, mature (graafian
follicle), corpus luteum and corpus albican. While the medulla consists of losse connective tissue,
muscle, blood vessel and nerve.
1.1.3. Anatomy of fetal skull
The fetal head is the most difficult part to deliver weather it comes first or last. It is large in comparison
with the pelvis and some adaption must be take place during labour. An understanding of the landmarks
and measurements of the fetal skull enable the nurse to recognize the normal presentation and position
and to facilitate delivery with least trauma to the mother and the fetus.
A. Bones of the fetal skull- the skull is divided in to three regions the vault, the base and the face.
1) The vault- is the large dome shaped part above the imaginary line drowns from the orbit to the
nape of the neck. There are five main bones in the vault of the fetal skull.
One occipital bone- lies at the back of the head and forms the occipital region. At the center
of this bone is a prominence called occipital protuberance. Below this prominence there is a
large opening for the passage of spinal cord called foramen magnum.
The two parital bones- lie on either side of the skull. At the center of each parital bones there
is an ossification center called parital eminence.
The two frontal bones- lie on the front of thr skull and forms the forehead or sinciput. At the
center of each is frontal eminence (frontal boss) which is the ossification center of these bines.
The frontal bones fuse in to one bone by the age of 8 years.
2) The face
3) The base
B. Sutures of fetal skull- sutures are cranial joints which are firmed where two bones adjoin. There are
several sutures in the fetal skull. That of the most obstetric important ones are:
Lambdoidal suture- is so called because it resembles the greek leter lambda (λ ). It separates the
occipital bone fron the two parital bones.
Coronal suture- separates the frontal bones from the parital bones.
Frontal suture- rummes between the two halves of the frontal bone.
C. Fontanelles- are membranious gaps between skull bones formed where two or more suture meets.
There are two major fontanels in the fetal skull.
Posterior fontanelle (lambda)- is the small triangular junction of sagital and lambdoidal sutures.
It can be recognized vaginally because sutures leave from each of the three angles. It normally
closes by the age of 6 weeks.
Anterior fontanelle (bregma)- is a diamond shaped fontanel found at the junction of sagital,
coronal and frontal sutures. It also can be recognized vaginally because a suture leave from each
of the four corners. It normally closes by the time of 18 months.
⇒ Because they consist of membraninos space, they allow some degree of overlapping of the
skull bones during labour and delivery the process called moulding.
⇒ Are used as land mark to identify the presenting part and position of the fetus during
cephalic (head) presentation.
D. Region and land markes of the fetal skull
The occiput- is a region between foramen magnum and posterior fontanelle. The part below the
occipital protuberence is called the suboccipital region.
The vertex- is the area bounded by the posterior fontanelle, the two parital eminence and anterior
fontanelle. It is the most common and normal presenting part of the fetus (95%).
The sinciput or brow- extends from the anterior fontanelle and coronal suture to the orbit ridg.
The face- extendes from the orbit ridge to the junction of neck and chin.
E. Diameters of the fetal skull- the measurement of the skull are important because a nurse need a
special understanding of the relation ship between fetal head and maternal pelvis. It will become clear
that some diameters are more favorable for easy passage through pelvis canal.
Bi parietal diameter- is a diameter between the two parietal eminences and is measured to be
9.5cm.
Bi temporal diameter- is between the furthest point of the coronal suture and is measured to be
8.2cm.
Suboccipito bregmatic- is from the below of occipital protuberance (sub occipital region) to
the center of bregma. It is measured to be 9.5cm.
Sub occipito frontal- is from the below of the occipital protuberance to the center of frontal
suture. It measures 10cm.
Mento vertical- is from the point of the chin to the highest point of vertex (slightly nearer to
kposterior than anterior fontanelle). It measure the longest diameter in the skull which is
13.5cm.
Submento vertical- is from the point where the chin joins the neck to the highest point on the
vertex. It is 11.5cms long.
Submento bregmatic- is from the point where the chin joins the neck to the cnter of bregma. It
is 9.5cms long.
F. Attitude of the fetal head- is the relation ship berween the long axis of the body of the ferus with
fetal head. It is a term used to descrihe the degree of flexion and extension of the head on the neck.
The attitude of the head determine which diameter and part will present in labour and there fore
influence the out come. For example when the head fully flexes, the vertex presents and the
presenting diameter will be suboccipito bregmatic. Flexion of the fetal head enable the smallest
diameter possible resulting in easear labour.
G. Presenting diameters- are diameters of the fetal head at right angle with the curve of carus.
H. Presenting- is part of the presenting part (mostly the head) which lies first at the brim of the pelvis on
the lower pole of the uterus. The most common presentation of the head are:
Vertex presentation
face presentation
1.2. Physiology of female reproductive system- The physiology of female reproductive system is
mainly dependant on the action of the three organs the hypothalamus, pituitary, and ovary commonly
known as the H-P-O axis. All must function appropriately for normal reproduction to occur.
1. Hypothalamus- is a small neural structure situated at the base of the brain above the optic chiasm
and below the third ventricle. the hormonal products of this gland are:
⇒ Gonadotrophic releasing hormone (GnRH) - is concerned with the release of FSH and LH
from pituitary.
⇒ Thyrotrophic releasing hormone (TRH)- stimulate the release of TSH
⇒ Corticotrophin releasing hormone (CRH)-stimulate the release of ACTH
⇒ Growth hormone releasing hormone (GHRH)- stimulate the release of GH
⇒ Prolactine releasing hormone (PRH)- stimulate the release of prolactine
⇒ Prolactine inhibiting factor (PIF)- inhibits the release of prolactine
⇒ Somatostatine- inhibit GH and TSH secretion
2. Pituitary- is suspended from the hypothalamus by a stalk called infundibrum and is housed in
selaturcica of the sphenoid bone. It is composed of two structures, the amterior lobe also called the
adeno hypophysis and the posterior lobe also called neuro hypophysis.
The anterior lobe (adeno hypophysis) - constitute the anterior ¾ of the pituitary. Because it is
connected to the hypothalamus by blood vessels (hypophysusl portal system), it synthesizes and
secret six principal hormones by the command of the hypothalamus.
⇒ Follicle stimulating hormonr (FSH)
⇒ Lutenising hormone (LH)
⇒ Thyroid stimulating hormone (TSH)
⇒ Adreno cortico tropic hormone (ACTH)
⇒ Growth hormone (GH) and
⇒ Prolactin(PRL)
The posterior lobe (nurohypophysis)- constitute the posterior ¼ of the pituitary. It is not a true
gland rather a mass of nuroglia and nerve fibers that arise from the cell body in the hypothalamus.
The hypothalamus neurons synthesize, transport them down a stalk and store them in the posterior
lobe. Finally the posterior lobe releases them when command arises.
⇒ Oxytocin- read the function
⇒ Arginine-vasopressin (AVP) also known as anti-diuretic hormone (ADH).
3. Ovaries- are both endocrine and exocrine glands. Their exocrine products are eggs and their
endocrine products are:
⇒ Estrogen by the granulose cell of the ovary
⇒ Progesterone also by the granulose cell of the ovary
⇒ Androgen by theca cells of the ovary
⇒ Inhibin and relaxin
1.2.1. Puberty
During early time of pregnancy the two sexes are indistinguishable. But after 8 to 10 wks the two female
reproductive tracts develop from the para mesonephric duct because of the absence of testestrone and
mulerian inhibiting factor (MIF). During the time of birth the ovarian cortex contains one to two million
oocytes with in primordial follicles but they are dormant till the time of sexual maturity.
From infancy onwards the hypothalamus is very much sensitive to negative feedback by even a small
amount of estrogen (estrogen produced by peripheral conversion of testestrone produced by the adrenal
gland) hence FSH and LH secretion are inhibited. But approximately around age of 12-13years, the
hypothalamus is very much insensitive to the negative feed back. Hence increased amount of GnRH will
be secreted by it. This will stimulate the pituitary to secret:
FSH and LH- which intern stimulate the ovary to secret estrogen and progesterone.
GH- which will either directly act on muscle and bones or will act on the liver to stimulate the
secretion of (IGF) insulin like growth factor.
This will eventually results in dramatic growth of the body of the girl and maturation of the reproductive
organs. This stage of spurt growth and maturation is called puberty. It is a stage of life in which
secondary sexual characteristics develop.
Although there is a wide variation in the time that adolescents move through developmental stages, the
sequential order however is fairly constant. In girls the pubertal changes typically occur in order of:
4) Adrenarche (pubarche), the appearance of pubic and axillary hair and finally
Menstrual Cycle is the orderly cyclic hormone production and parallel proliferation of the uterine lining
prepare it for implantation of the embryo. The normal human menstrual cycle can be divided into two
segments: the ovarian cycle and the uterine cycle, based on the organ under examination.
A. The ovarian cycle- is the cyclic hormonal changes and other serious of changes that occur in the
ovary to mature the immature follicle and recruit the oocyte. It may be further divided into:
Follicular phase extends from the beginning of menstruation (day 1) to the onset of ovulation. The
average length of the human follicular phase ranges from 10 to 14 days, and variability in this
length is responsible for most variations in total cycle length. the principal processes in this phase
are:
1) Rise in FHS secretion stimulates 20 to 25 primordial oocytes to begin meiosis I.
2) The follicle around the oocyte develop and become primary follicle the cell of the follicle
further enlarge and become condensed to form teca folliculi. Its other layer the teca externa,
become fibrous capsule while the internal layer, the teca interna, secrets androgen which the
granulose cell the granulasa cells convert it to estrogen.
3) In fewer day of the follicular phase the follicular cells began to secret estrogen rich follicular
fluid. Thus the follicle will form a fluid filled cavity called antrum. The follicle is now called
secondary or antral follicle and follicular cells lining it are called granulose cell. The
granulose cell secrets a clear layer of gelll between themselves and the oocyte called zona
pelucida. The inner most layer of the granulose cell in contact with the zona pelucida is
called corona radiate, this is a state of development around 5 days.
4) The growing follicle secret increasing amount of estrogen which at same time reduces FSH
secretion by pituitary and makes the follicle more sensitive to FSH by producing increasing
amount of FSH receptors on the granulose cell of its own follicle. FSH intern stimulates this
follicle to produce still more amount of estrogen but the most advanced follicle reduce FSH
supply to other follicles while at the same time it makes itself more sensitive to FSH.
5) The less developed, less sensitive follicle undergoes atresia while the most developed follicle
protrudes from the surface of the ovary like blister. This follicle is called mature (graafian)
follicle.
6) As the follicle mature the primary oocytes complets meiosis I and become secondary oocyte.
This cell began miosis II but it stops at metaphase II. The ovum is now ready for ovulation.
7) FSH and estrogen stimulste the mature follicle to produc the LH receptors.
8) In the last one or two day of the follicular phase because the estrogen level is very high it
stimulate the anterior pituitary LH the hypothalamus to secret GnRH which intern stimulates
the anterior pituitary to secret FSH and LH because of this the LH level will increase
markedly 36 hours before the time of ovulation and is called LH surg.
9) The LH increases the blood flow to follicle allowing more serous fluid from the capillary to
the antrum which causes the follicle to swell. Meanwhile LH also stimulate the teca interna
to secret collaginase (lytic enzyme), an enzyme that weakens the ovarian wall.
10) Follicular fluid slips from the nipple like appearance on the ovarian surface over the
follicle for 1-2 min and then the follicle rupture. This process is called ovulation. The
remaining fluid oozes out carrying the oocyte and the surrounding cells of corona radiate.
luteal phase (post ovulstory phase) extends from ovulation to the beginning of menstruation.
Unlike the follicular phase this phase is most predictable and constant (14 days) in length. the major
development of this phase assuming pregnancy does not occur are as follows:
11) After the follicle expels the oocyte to the fallopian tube, it collapses and the granulose and
teca interna cells multiply to fill the antrum. The ovulated follicle now become corpus luteum
(yellow body)
12) The anterior pituitary continues to secret LH which regulates the further growth of corpus luteum.
13) The cprpus luteum produce mainly androgen which the granulose cells of the ovary convert to
progesterone and small amount of estrogen. The corpus luteum also secret innhibin which suppresses FSH
secretion which prevents new follicles development.
14) The corpus luteum grows secret more and more progesterone but if there is no sexual
intercource in this period, the increased amount of progesterone will inhibit LH and FSH
secretion by negative feed back. When the LH level falls critically low, the corpus lutem
involutes or atrophy (24-26 day). The atrophy of corpus lutem will result in decline of
progesterone secretion. By the day 26 or so, the atrophy completes and the corpus lutem has
become an inactive scar called the corpus albican.
B. The uterine cycle- is the periodic endometrial growth to prepare itself for the implantation of the
fertilized ovum. it can be divided into corresponding proliferative and secretary phases.
Proliferative phase- is the time from first day of menstrual flow till ovulation which is
characterized by rebuilding of the endometrium but the true proliferation is from the end of
menstruation. the principal processes in this phase are:
At the end of menstruation (at around 5th day), the endometrium is about 0.5cms thick
and consists of only stratum basalis. The stratum functionalis is bult by this phase by
mitotic division.
Estrogen from the ovary stimulates the mitotic division of the stratum basalis and the proliferative
growth of the blood vessels.
Estrogen also stimulates the endometrium to produce progesterone receptors to prepare itself for
the next phase. Now the endometrium is about 2-3cms thick.
Secretary phase- is a period of further endometrial thickening. It extends from day 15 (after
ovulation) to the onset of menses. The principal processes in this phase are:
The corpus lutem formed after ovulation secrets progesterone. Progesterone stimulates the glands
of the endometrium to accumulate glycogen. The endometrial gland become longer, wider and
more coiled and secret a glycogen rich fluid in to the lemun.
Know (at around 26th day)m, the endometrum is about 5-6 cm thick, asoft, wet, nutritious bed
available for embryonic development in the event of pregnancy.
In the absence of pregnancy, the corpus luteum atrophies and progesterone level falls sharply. In
the absence of progesterone the spiral artery of the endometrium exhibits spasmodic contraction
that causes endometrial ischemia. Ischemia leads to tissue necrosis.
Necrotic endometrium falls away from the uterine wall, mixes with blood in the lemun and forms
the menstrual fluid.
Menstruation- is a periodic sloughing of endometrium which accompanied by bleeding.A Menstruation
to be normal:
The cyclic length must be 21 to 35 days on average 28 days
The duration of flaw must be 2 to 7 days on average 5 days
The amount of blood loss must be 10 to 80 ML on average 30 ml
The color of the bleeding must be dark red.
1.2.3. Fertilization- is the process of union of sperm (male gamete) and ovum (female gamete). It
occurs in the ampula of the tube. When the sperm encounters an egg it releases an enzymes needed to
penetrate the egg. The two acrosomal enzymes are:
Hayaluronidase- which digests the hayaluronic acid that binds the granulose cells together &
Acrosin- which is a protease
When the path has been cleared, the sperm binds to zona pellucida and release its enzyme, digesting it
until it contacts the egg itself. When it reaches the egg the head and mid pice will enter to the egg but the
egg destroys the mitochondria of the sperm and only the maternal mitochondria will pass to the offspring.
The two nucleuses will fuse combining the haploid (n) set of chromosome of the sperm with the haploid
chromosome of the egg producing a cell with a diploid (2n) set of chromosome called zygote.
After fertilization of the egg by sperm, the zone reaction prevents entry of any more sperm. The egg has
two mechanisms to prevent this, the sloe block and the fast block.
a) Fast block- the binding of a sperm to the egg will open the Na+ channels of the egg membrane.
The rapid inflow of Na+ ion depolarizes the membrane that inhibits the entry of any more sperm
to it.
b) Slow block- involves secretary vesicles called cortical granules just beneath the membrane. Sperm
penetration triggers a cortical reaction in which the cortical granules release their secretion
beneath the zona pellucida. The secretion swells the membrane and pushes any remaining sperm
away from the egg and creates an impenetrable membrane.
1.2.4. Development of the fertilized ovum (zygote) - the prenatal development of the fertilized ovum
goes through three phases.
1. Ovular or germinal phase- it extends from the time of fertilization for the next 2 weeks. During this
period the zygote is designated as ovum. This phase involves three major processes cleavage,
implantation and embryogenesis.
A. Cleavage-refers to the mitotic division that occurs in the 1st 3 days. The 1st cleavage occurs about 30
hours after fertilization and produces two daughter cells called blastomer. These blastomers divide
and re divide doubling the number of blastomers each times by the time the zygote reaches the
uterus (about 72 hour after ovulation), it forms a cluster of cells consisting of 160 or more cells and
is now called morula. For few days the morula lies free on the uterine cavity and divides in to 100 or
so. During this time it is nourished by nutrients that were stored in the egg cytoplasm and
endometrial secretion called uterine milk. During this nourishment the morula will form a fluid filled
cavity which separates the cells inn to two groups.
The outer cell mass- is also called trophoblast. It lines the inside of the zona pellucida. In the
future they will form the placenta and chorion.
The inner cell mass- the remaining cells clumped together at one end forming the inner cell
mass (embryo blast) which will become fetus and amnion. A cavity appears between these two
groups of cells. The zygote is now called blastocyst. The zona pellucida thins out and
disappears and the trophoblast especially the part which lies over the inner cell mass becomes
sticky.
B. Implantation- about 6 days after ovulation, the blastocyst attaches to the endometrium usually on
the posterior wall of the fundus. This is the beginning of the imbedding of the blastocyst in to the
endometrium a process called implantation (nidation). The most important steps are
The trophoblastic cells adjacent to the inner cell mass separate in to two layers. The deeper
layer contains cells divided by membrane and is called cytotrophoblast. the superficial
layer however break down their plasma membrane and fuse in to a multi-nucleated cell
called syncytiotrophoblast which will grow in to the uterus like roots and digest
endometrial cells along the way.
The trophoblast forms finger like projection around all surface of blastocyst called
chorionic villi. The villi at the site of embedding become profound and branches rapidly to
form chorionic frondosum which will penetrate deeper in to the underlying endometrium to
eventually form placenta. The chorionic villi over the rest of the blastocyst gradually
degenerate to form chorionic leve.
The cytotrophoblast also secret a hormone called human gonadotrophic hormone (HCG)
which is responsible to inform the corpus luteum that pregnancy has began so that it will
continue producing estrogen and progesterone.
Progesterone maintain the integrity of the endometrium so that shedding does not takes
place, in other words menstruation will be suppressed.
High level of estrogen and progesterone suppresses the secretion of FSH so that no other
follicles will not grow and ovulation will suppressed.
As the trophoblast will be converted to chorion by the end of 2 month, the chorion will take
over the function of trophoblast as well as corpus luteum meaning the ovary becomes
inactive for the rest of the time.
C. Embryogenesis- during implantation the inner cell mass (embryo blast) undergoes arrangement of
the cells in to three primary germ layers: ectoderm, mesoderm and endoderm. This process is called
embryogenesis. Embryogenesis began with the inner cell mass and cytotrophoblast called amniotic
cavity. As the amniotic cavity formed the embryo blast flattens in to an embryonic disc composed of
ectoderm and endoderm. Later, as the disc elongates, a raised groove called the primitive streak
forms along the midline of the ectoderm. Cells on the surface of the ectoderm migrate medially
towards this groove and laterally between the ectoderm and endoderm. At the conclusion of the
embryogenesis the conceptus become 2 mm long and 2wks old and is now called embryo.
2. Embryonic phase- lasts from the 2nd wk to 8th week of amenorrhea or 6 wks post ovular. This is a
period of cell division and tissue differentiation. This phase also involves three major processes.
A. Placentation- is the process of formation of placenta which extends from 11th day through 12
weeks after conception. Most developments of this process occur in the embryonic stage. It
begins where extension of the syncytotrophoblast, called chorionic villi; penetrate more and more
deeply in to endometrium like the root of the tree penetrating in to the nourishing soil. As they
digest their way through uterine blood vessels the villi become surrounded by pool free blood that
eventually merge to form the placental sinus and ensure nourishment of the zygote.
The mature placenta is a fleshy discoid organ. It has two surfaces:
1) Fetal surface, the surface facing the fetus is smooth and the amnion covering this surface
give it a white color. Under the amnion the fetal blood vessels merges out ward at the
center of this surface forming the umbilical cord. The cord is sheathed by amnion and it
measure 35-50 cm in length. It contains two umbilical arteries and one umbilical vein.
2) Maternal surface, the surface attached to the uterine wall is rough and the mother blood
gives this surface a dark color. It is divided by sulcai in to 15 to 20 cotyledons.
Function of placenta
Nutritive- it provide the embryo with nutrient like amino acid, glucose, fatty acid, H2O,
mineral and vitamin from maternal blood to fetus.
Respiratory-it fevers gas exchange(provide O2 to the fetal circulation and removes CO2
from the fetal circulation)
Excretory- it helps to clear the fetal metabolic wastes like urea and uric acid and bilirubun.
Protection- placenta provides a limited barrier to infection with the
exceptions: T.palidum (syphilis), TB and all viruses.
- It transports maternal antibody especially IgG.
Endocrine- placenta synthesize many hormone like:
- HCG (human chorionic gonadotrophin)
- Estrogen
- Progesterone
- Human placenta lactogen (HPL)
Storage the placenta metabolizes glucose, stores it in the form of glycogen and reconverts
it to glucose as required. The placenta can also store nutrients such as CHO, protein, Ca,
Fe and fat soluble vitamins in early pregnancy and release them to the fetus later when
fetal demand is greater than the mother can absorb from diet.
B. Development of embryonic membrane- the placenta and umbilical cord are not the only
accessory organs of the conceptus. There are two membranes that surround the fetal sac.
1) The amnion- it is the inner most of the two membranes. It is a transparent sac that develops from
the dorsal amniotic cavity of the embryonic disk. It grows to completely enclose the embryo and
is penetrated only by umbilical cord. it becomes filled with amniotic fluid which is at first formed
by ultra filtration of mothers blood plasma but beginning at 8 to 9 wks the fetus urinate in to the
amniotic cavity about once an hour contributing substantially to the fluid volume. Secretions of
pulmonary epithelium and amnion cells also have some contribution.
Composition of amniotic fluid- amniotic fluid is a straw colored mid alkaline turbid fluid. It
contains 98-99% water and 1-2% solid constitutes. These include protein, glucose, lipid,
hormone, fetal metabolic wastes like urea, uric acid, creatinin and minerals like Na+, K+ and Cl-.
Function of amniotic fluid-
1. It allow free movement and growth of the fetus
2. Protect the fetus from injury
3. Maintain constant To around the fetus
4. Protect the fetus and placenta from compression at the time of uterine contraction
5. It aids effacement and dilatation of the cervix
6. It keeps some organs of the fetus moist like skin, eye
2) The Chorion- is a thick outer membrane of the embryo. It lasts at the margin of the placenta.
C. Organogenesis- it is the formation of organ system from primary germ layers. The major
structure that arise from the primary germ layers are:
The ectoderm- mainly forms the skin and nervous system
The mesoderm- forms bones and muscle. The heart, blood vessels and certain internal
organs are also originated from the mesoderm.
The ectoderm- forms the mucous membrane and the glands of the body.
At the end of 8 wks all of the organ systems are formed and the individual is about 3cm. it is
considered as the fetus.
3. Fetal phase- lasts from the 8th gestational wk up to term. During this period less tissue differentiation
occurs; the principal activities are tissue growth and maturation. The fetus is the final stage of
prenatal development extending from the end of 8th wk till birth. The organ that formed during
embryonic stage now undergoes growth and differentiation and acquires the functional capacity to
support life out side the mother. Some aspects of the development of the development of fetal organs
and their physiology are special relevant to the nurses because their effect on the newborn.
The liver- from 3rd to 6th month of intra uterine life the liver is responsible for the
formation of RBC, after which they are formed in the red bone marrow. Towards the end
of pregnancy iron stores are laid in the liver
The renal system- the kidney begins to function and the fetus passes urine from 10 wks of
GA. But urine is very much diluted and does not constitute a rout for excretion since the
mother eliminates waste products through placenta.
The adrenal gland- the fetus adrenal glands produce precursors for placenta formation of
estrogen.
The alimentary cannel-the fetal digestive tract is mainly non functional before birth
except swallowing of the amniotic fluid about 12 wks after conception.
The fetal circulation- the fetal hemoglobin is of different type from adult hemoglobin and
is termed as hemoglobin F. it has much higher affinity for oxygen and is found in greater
concentration (18-20g/dl at term). The reason for this is that oxygen must be obtained
from mother blood in the placenta site where the oxygen tension is lower than the
atmosphere. There are 4 other temporary structures of the fetal circulation that enable
fetal circulation to take place.
Ductus venoses- is vein that connects the umbilical vein to the inferior vena cava
by bypassing in the liver because the liver is not yet functional to detoxify the
content of the blood. At this point the blood mixes with deoxygenated blood
returning from the lower part of the body making it partially oxygenated.
The foramen ovale- is a temporary oval opening between the two atrials which
allows majority of blood from the inferior vena cava to pass to the left atrium
because the blood does not need to pass through the lungs since it is already
oxygenated and the lungs are not doing so.
Ductus arteriosus- is an artery that passes blood from pulmonary artery to the
descending aorta by bypassing the lungs because of the reasons listed above.
The hypogastric artery- are branches of the iliac artery which become the
umbilical cord.
The blood takes about half a minute to circulate the following course.
The lung
The CNS
The skin
Unit two- Normal pregnancy
Definition of terms
Pregnancy (Gestation) – is a condition of having a developing embryo or fetus with in the body after
conception. The period from conception to birth
Labour - is a process by which delivery of fetus placenta and membrane occurs through the birth canal.
Multigravida: A woman who has been pregnant more than one time
Multipara: A woman who has had two or more pregnancies which suited in viable foetus
Term: The time of gestation from 37 completed weeks to 42 completed weeks from 1st day of LMP
Conceptus: The sum of derivatives of fertilized ovum at any stage of development from fertilization to
birth
Embryo: The developing organism from the end of the 2nd week after fertilization to the end of the 8th
week
Fetus: The unborn offspring from the 9th week of gestation to birth
Neonatal death: Death of the baby with in the first 4 weeks after delivery
ABBREVIATIONS
All changes in a mother’s body during pregnancy are associated with the effect of specific hormones.
Thus changes enable her to nurture the fetus, prepare her body for labour and develop her breast for
production of breast milk during the puriperium.
A) Body of the uterus-after conception progesterone and estrogen produced by the enlarged corpus
luteum cause the deciduas to become thicker and more vascular especially at the fundus which is the
usual site of implantation. The muscle fibers also grow up to 15-20 times their non-pregnant length.
Each muscle fiber increases by 10 xs in length and 5 xs in thickness. This hyper trophy and
hyperplasia of the uterine muscle fiber is due to the effect of estrogen and progesterone.
Growth of the uterus-
12th- week- the Fundus reaches just above the symphysis pubis
16th week mid way between the symphysis pubis and the umbilicus
36th week- at the level of xiphesternum. It is the maximum growth of the uterus.
B) The cervix of the uterus- it acts as an effective barrio against infection during pregnancy, protects
the fetus by remaining firmly closed and by providing resistance to pressure from above when the
mother is up right position.
Under the influence of progesterone the cervical cells secret mucus which become ticker and
more viscous during pregnancy which forms cervical plug called operculum which provide
protection from ascending infection.
C) The vagina- estrogen cause changes in muscle layer and in the epithelium of the uterus the muscle
layer hypertrophy and the capacity of the vagina increase. These changes enable the uterus to dilate
during the time of delivery. There is an increased amount of normal white vaginal discharge known
as leucorrhoea.
2) Physiologic changes in the cardiovascular system – profound changes takes place in the
cardiovascular system during pregnancy and understanding of these changes is important in care of
the women with preexisting cardiovascular disease
A) The heart- owing to an increase in work load, the heart muscle hypertraoophy particularly in the left
ventricle leading to an enlargement of heart. Heart sounds are changed and mormor sound is some
times common.
B) Cardiac out put- during pregnancy there is an increased HR and cardiac out put resulting in raised
cardiac out put. This is due to increased blood volume and increase requirement of oxygen by all
maternal tissue as well as by the growing fetus.
C) Blood pressure- although the cardiac out put is increased in pregnancy, the blood pressure does not
rise because of the reduction in peripheral resistance to about 50% of non pregnant value. The
capacity of the vein can increase by liters. The most obvious cause for this is progesterone which
relaxes smooth muscle in the blood vessels.
D) Blood volume- the increase in blood volume in pregnancy may be as little as 20% or as much as
100% and varies according to the size of the women, the number of pregnancy she has had, her
parity, and weather the pregnancy is singleton or multiple the average being 40%. Raised level of
aldostrone, estrogen and progesterone during pregnancy are thought to contribute to increased blood
volume.
To supply the extra metabolic need of the maternal organs like kidney
E) Red cell mass- increase as a result of accelerated production of RBC in response to the extra oxygen
requirement by the maternal and fetal tissue.
NB:- as the increase in blood volume (plasma volume) is much higher than that of red cell mass increase,
hemodilution occur.
3) Physiologic changes in GIT
Progesterone relax smooth muscle of the GIT; this will slow the gastric empting and peristalaysis
in order to maximize the absorption of nutrients
Heart burn is common and is associated with gastric reflex due to the relaxation of cardiac
sphincter
Linea nigra
Stria gravida
Chloasma
5) Physiologic changes in MSS- progesterone and relaxine encourage relaxation of ligaments and
muscle reaching maximum effect during the last week of pregnancy. This relaxation allows the pelvis
to increase its capacity in readiness to accommodate the fetal presenting part at the end of pregnancy
and labour.
Diagnosis of pregnancy
Sign & symptom of pregnancy- Sign & symptom of pregnancy can be classified in to three
- Presumptive
- Probable &
- Positive
1) Possible (presumptive) signs –they are not true signs rather they are symptoms because it includes
what the mother will recognize. Examples of such a symptom are:
- Amenorrhea
- Morning sickness
- Early breast change - increase in size
- Darkening of areola.
- prickling sensation from 3-4 wks
- Bladder irritability and frequency of micturation
- Quickening - is the first fetal movement felt by the mother
premigravid - feels it at 18-20 week
Multigravid - feels it at 16-18 week.
2) Probable signs are true signs in which the health professional will find
Visualization of fetus by
@ Ultrasound - 6weeks of gestation
@ X - ray after 12 weeks of gestation
Hearing of Fetal heart beat by
@ Ultrasound
@ Fetoscope (20th to 24th weeks of gestation)
Fetal movement by
@ palpation
@ Visualization
Antenatal care /ANC/
Aim of ANC-generally the aim of ANC is delivery of a healthy infant and maintaining the health of the
mother by:
A. Risk assessment- risk is any condition that will expose a person to possible danger.
According to WHO all pregnant mothers are risk mothers (they need special care) but there are mothers
who are high risk.
They are Mothers who need special care than normally pregnant mothers during their pregnancy,
labour, delivery and puriperium.
• Medical problem like- heart disease, DM, renal disease, TB, HIV/AIDS………
o Twin pregnancy
o APH
o PROM
o Repeated abortion
o IUGR/IUFD
o HDP
A. Antenatal care assessment- Pregnancy is not a disease; it is a normal physiologic state but because
of the different reasons/objectives we will follow the mother as a patient. This follow up includes:
History taking
Basic recording
Lab investigation
Physical examination
follow up
1) History taking- is assessing the health of the mother to find out any problem which may affect child
bearing.
A. Social history (biographic data) it includes age, name, marital status, occupation
B. Family history- mostly you should ask hereditary transmittable disease like;
a. Diabetes mellitus
b. Hypertension
c. Heart disease
d. Multiple pregnancy
e. Psychiatric history
f. Family history
a. HTN
b. DM
c. HIV/AIDS
d. TB
D. Surgical history
a. C/S
b. Genital surgery
c. Pelvic surgery
E. Obstetric history- this includes any problem of labour, pregnancy, delivery and/ or puriperium
of the current or past pregnancy.
Hyper emesis
Anemia
Pre eclampsia
APH
place of delivery
Infection
PPH
Psychiatric history
– If the mother does not use contraceptive for the previous 6 months
EDD=10/2/2006
+
7/9/0000
=17/11/2006
EDD=10/01/20002
+
10/009/0000
=20/10/2002
EDD=28/09/2001
+
05/09/0000
=03/07/2002
EDD=18/08/1999
+
04/09/0000
=24/05/2000
GA=arrival date-LMP
Example: if the mothers LMP is at 4/5/99, and the arrival date is at 10/10/99
GA=10/10/99
-
4/5/99
=6/5/00 (5 months+6 days)
=22wks+2days
2) Basic recording
B. Weight- will be taken monthly to know the increased weight per month
3) Laboratory investigation
o Blood tests
Blood group
RH factor
HIV status
VDRL
HCT and Hgb- shoud be checked and recorded per each visit.
o Urine analysis
Protine
Suger
Bacteri
Ketone body
NB:- normally urine does not contain any protine, suger, bacteria or ketone body or they are trace.
4) Physical examination- during the first visit of ANC, we should do a complet (heas to toe) physical
examination which includes:
⇒ Trought(teeth)
Lympadenitis
o Breast examination
Inspection- symmetry
⇒ Skin
⇒ Areola
⇒ Milk expression
Circular palpation
Quadrant palpation
o Abdominal examination
Maintaining privacy
Positioning
a. Shape of the uterus- shape of the mother is different in different situations.if the mother is:
b. Size of the uterus- the size of the uterus must be compaired with GA and it may be either
appropriate for GA, small for GA or large for GA.
Example if the 24 wks fetus is at the level of umbilicus, it is small for gestational age.
Differential diagnosis of LGA- large for gestational age can be mistaken by:
o Multiple pregnancy
o Full blader
o Tumor
o Big baby
Differential diagnosis of SGA- small for gestational age can also be mistaken by:
o Wrong date
o IUGR
o IUFD or it may be
o Small baby
NB: multiple pregnancy and poly hydraminous will enlarge both the length and breadth of the uterus
whereas large baby increase only the length of the uterus.
c. Skin of the uterus- skin change during pregnancy shoud be noticed llike:
o Linia nigra- dark line pigmentation running longtudnally in the center of the abdomen below
and some times above the umbilicus.
o Streagravida- white line in the abdomen formed due to stretch of the abdomen.
2. Palpation- before palpation, the hands shoud be clean and warm not to induce contraction of abdomen
and uterine muscles, arms and hands shoud be relaxed and you have to use the pads not the tip of the
fingers.
We usually use the four steps of palpation (leopolds manover) for abdominal examination.
@ Know what is occupied on the fundus; weither it contains breach or head. This
information will help to diagnose the lie and presentation of the futus. To do so you have
to lay both hands on the side of the fundus, fingers held together and curving around the
upper border of the uterus. Then gently appling pressure using the palmar surface of the
fingers to determine the softness (butuck) or the hardness (head) of the mass. But some
times buttuc may feel firm; in such a case,you have to asses the mobility of the mass. The
breach can not be moved indipendantls as the head can because of the free movement of
the neck joint.
@ Estimate period of gestation- does not always produce an accurate result because the size
and number of the fetus, amont of the amniotic fluid and maternal size and parity may
vary. You can use two methods to determin the height of the uterus.the first (sypphisis
fundal height) is the assumption of the height of the fundus will corelaate well with
gestational age especially during early wks of pregnancy. It can be done using measuring
tape (measuring from pubic bone to syphisis pubis) or by using your fingers. When using
your fingers you have to assume the umbilicus as 20 wks and one finger below the level of
the umbilicus will be recorded as 1 wks and one finger above umbilicus will be recorded
as 2wks. The second method is the estimation of the distance between the umbilicus and
the curved upper border of the fundus by placing your finger. This method will assume
xiphisternum as a 36 wks of gestation.
b. Lateral palpation- is used to locate the fetal back in order to determine the position. To do
so the hands should be plased on either side of the uterus at the level of umbilicus and
gentle pressure should be applied with alternative hands to detect which side of the uterus
offers the greater resistance (which is the back)
c. Pelvic palpation- is the palpation of the lower pole of the uterus to know what is occupied
on the pelvis, attitude and engagement. To do so the side of the uterus just below the level
of umblicusshould be grasped snougly between the palm of the hand with the fingers held
closer, pointing downward & inward. If the head presenting a hard distinctive & round
mass & smooth surface will be felt in order to know the attitude, the sinciput & occiput
should be palpated. If the head is flexed, the sinciput will be felt on the opposite side of
back & higher than the occiput if the head is deflexed, the two prominence will be at the
same level. If the head is extensed as in the face presentation, siciput will be felt on the
same side of the back
d. Pawlik’s grip(4th leopalds manuover): is used to judge size, flexion, and mobility of the
head. To do so you have to grip the lower pole of the uterus between your tumb and your
finger which should be spreed wide apart to accommodate the fetal head. Do not apply
undue pressure because it is painfull.
3. Auscultation- the fetal heart beat must be auscultated. Like all heart beats, it is a double sound but is
faster than adults (120-160). It is mostly heard clearly at the left part of fetal scapula. While listning
the ears most be closed by the total contact with the fetescope but hand should not touch it to avoide
extraneous sound.
Lie- is the relationship between the long axis of the fetus with the long axis of the uterus. There
are three types of lies.
A. Longitudinal lie- when the long axis of the fetus is in line with long axis of the
uterus. It can be breach or cephalic. 99.5% of all pregnancy are with longtudnal
lie.
B. Transverse lie- when the fetus lies at the right angle across the long axis of the
uterus.
C. Oblique lie- is when the fetus lies diagonally across the long axis of the uterus.
NB: oblique lie and obliquity of the uterus (the tilting of the whole uterus to one
side) are not similar.
Attitude – is the relation of the head to its trunk. The attitude of the fetus shoud be one of flexion
(well felexed, deflexed or extenced).
Presentation- refers to the part of the fetus which lies at the pelvic bream or in the lower pol of the
uterus. The presentation of the fetus can be cephalic (when the head become the presenting
part),breach (when the butuckbecome th presenting part) or sholder. Vertex, face and brow
presentation are all head or cephalic presentations. When the head fully flexes, the vertex
presents; when the head fully extenced, the face presents and when the head partially extenced
(deflexed) the brow presents. It is more common for the head to present because the bulky breach
finds space in the fendus which is the widest diameter of the uterus and the heavy head lies in the
narrowlower pole.
Denominator is the name of the part of the presenting part which is used as a reference point to
know the fetal position. Each presentation has difference denominators; those are:
Engagement- is the widest presenting transverse diameter (biparital diameterin the cephalic and
bitrochontric diameter in the breach) has passed through the brim of the pelvis. It is an important
sign of adequacy of the pelvis for the specific fetus. In primigravida it will occure early (between
36 and 38th weak) but in multi this may not occur because of the lax uterus.
Only less than half of the fetal head is palpable above pulvic brim
The anterior sholder is little more than 5cm above the brim
Presenting part- is the part which lies over the cervical os during labour.
5) follow up- a women who had high number of risk factors identified during the intial assessment visit
or who develops complication during pregnancy will attend her antinatl care at the hospital but
womens who had no or little risk factor will follow their antenatal by appointment. There are two
type of appointment (traditional and focus nantinatal care).
A. traditional appointment-is a method of appointing amother with same frequency of time in some
duration of time in which the frequency increases as the GA advances that is:
B. Focused antenatal care- is a method that assumes four visits are enough fetal as well as
maternal well being. i.e.
B. Care provision- is a method of treating the identified existing problems. These problems can be
simple like minor disorder of pregnancy which can be managed by our selves or can need referral.
C. Health promotion- is maintaining the health of the mother by different methods like:-
Health education
Immunization
Tetanus toxoid: - because tetanus neonatorium is a great killer of new born babies the baby gets
infected when the umbilical stamp or any part of the baby’s body is invaded by tetanus organism
We can prevent the disease by immunizing the mother so that she pass antibody to her baby before
delivery
Unit three- abnormal pregnancy
Minor disorders of pregnancy
They are minor complaints of the mother due to the physiological and anatomical changes of the
pregnancy. They are minor and are not lives threatening which can be resolved by education that is why
they are called minor disorders.
1. Morning sickness- some degree of nausea and vomiting is common compliant during the 1st
trimester. It can appear in any time of the day but it becomes worse early in the morning thus the
name morning sickness.
Cause- the most likely cause is the hormonal change during pregnancy that is the rising level of
HCG.
Avoiding fatty foods and foods whose smell aggravates the symptom
Rest
2. Heart burn: - is a burning sensation in the epigastric area especially during the late weeks of
pregnancy.
If not relived use anti acids like Al (OH)3, Mg3Si2, or the combination of the two
3. Constipation-
Cause- the cause of this condition is delay of peristalysis which can be due to:-
Fluid
Fibrous diet
If it is not still relived by the above management give her stool softners
4. Hemorrhoids: - is the varicosity of the rectal vein. It can be asymptomatic or may be present with
rectal bleeding, rectal pain or prolapsed mass through the uterus.
Taking laxatives
5. Pica:- is craving of pregnant mother for items of low nutritional value like:-
Clay
Soap
Coal
Soil
6. Varicose vein:- is the dilatation of the superficial vein of the lower extremities.
@ Decrease venous return due to the compressing effect of the growing uterus
7. Leg cramp
8. Urinary frequency
9. Ptyalism
It is vomiting that starts before the 20th week of pregnancy and requires intervention.
Severe nausea and vomiting leads to dehydration electrolyte imbalance and weight loss.
It is a condition affecting approximately 1 in 100 pregnant women.
Causes of hyper emesis gravidarum -The etiology of hyper emesis is uncertain endocrine and
psychological factors are proposed
Management
Initially nothing is given by mouth (NPO ) to allow time for the vomiting to be controlled gradual
introduction of fluids and diet as he condition improves
Hypovoluemia and electrolyte in balance are corrected by intravenous infusion.
Vitamin supplements can be given parenterally.
The mother should be encouraged to rest and may be cared for in a private room.
Some women may be given mild sedatives if they appear agitated.
A small palatable meal on regular basis helps to regain her appetite.
The use of anti emetics in pregnancy causes severe mal formation of children born so on anti
emetic being approved for Rx.
Termination of pregnancy reverse the condition ( preventing MM)
Complication -If hyper emesis is left untreated, the mother’s condition worsens.
Type- multiple pregnancy can be twin pregnancy, triplet, quadruplet of other but the most common ones
are twins. There are two types of twins. This are:
A. Monozygotic /uniovular/ identical twins- is the formation of twin from single ovum and
spermatozoa. The twins are formed by mitotic division of ovum after fertilization. The two twins will
have the same sex, blood group, physical feature, ear shape, genetic composition, and eye and hair
color e.t.c. this type of twins account 30% of all twins.
B. Diazygotic /diovular/ fraternal twins- it is the formation of twin from separate ovum and
spermatozoa. The twins may have same or different sex, blood group, and physical feature but they
will have different genetic composition. This type of twins Account 30% of all twins.
All dizygotic and triplets are DADC (will have separate amnion and chorion)
For all monozygotic the number of placenta (chorionisity) depends on the time when the mitotic
devision starts. If it starts:
Etiology- the etiologies listed below are for diazygotic twins than monozygotic once.
History- Ask the presence or absence of all condition that will predispose the mother like:
Race
Parity
Age
Family history
- Ask 1st trimester history and unexpected weight gain during pregnancy.
Abdominal examination
Inspection- you will found big for date abdomen with round shape
Auscultation-the presence of two FHB at two different place which is confirmed by two
persons is an indication of twin pregnancy.
Ultra sound- if you are not shure by the above diagnostic criterias, you can confirm it by
sonography.
Poly hydraminous
Malpresentation
Pre eclampsia-increase by 4 times because of the increased size and number of placenta.
Cord prolapse
Locked twins
Preterm labour- because uterine size is one stimulus for initiation of labour.
Anemia - Polycytemia
- Cardiac failure
Antenatal management
More nutrition
Intrapartem management
You should prepare as for two delivery(two cord tie, two delivery and episotomy set, and two
neonatal bed)
If twin A is vertex but twin B is non vertex (has a chance of 40%), we can deliver twin A by SVD
and can augment twin B.
Definition: - is bleeding from genital tract of the pregnant mother after the fetus has reached viability
(which is after 28 complete weeks or fetal weight of 100 gm or more in our country or 20 wks according
to WHO) and before the fetus is delivered.
1. Placenta previa- is the bleeding from the placenta that is implanted in the lower uterine segment.
A. Grade I (is also called low lying placenta previa)- is when the placenta is implanted in the lower
uterine segment but not reach the internal os.
B. Grade II (is also called marginalis) - is when the placenta reaches the margin of the internal os
but doesn’t cover the internal os.
C. Grade III (also called partialis) - placenta covers the partial of the internal os.
D. Grade IV (also called totalis) - is when the center of placenta lies at the center of internal os and
when it covers the whole internal os even at full dilatation.
Cause- there is no single exact cause of placenta previa but the predisposing factors are;
Diagnosis- this condition is majorly diagnosed by the clinical manifestation but U/s can be used to
confirm and grade it. Vaginal examination is alternative only when U/s is not available and termination
of pregnancy is planed.
Definition- is a premature separation of normally implanted placenta before the third stage of labour or
before the delivery of the baby but after the 20 wks of GA.
Cause- there is no exact single cause of abraptio placenta but there are a number of factors that will
increase the risk of getting abraptio placenta.
Clinical manifestation
Abdominal tenderness-
NB:-the maternal vital sign change is not proportional to the degree of blood loss. Why?
Diagnosis- it is usually diagnosed by the clinical manifestation. If the mother comes with the above
clinical manifestation, the health personnel should ask for any history of:
♫ History of trauma
Secure IV
If do not start spontaneously and if the GA is less than 37 wks and if the mother
and fetal condition is well, continuing pregnancy till term is possible. But if the GA is
greater than 37 wks and if the maternal and fetal condition is not well, induction of labour is
mandatory.
Complication
Sever bleeding
Shock
Fetal distress
IUFD
3. Vasa previa- is a bleeding from the fetal circulation secondary to velmentosa insertion of cord. It is a
rare condition but it is associated with a high degree of fetal death.
Clinical manifestation
May confuse with placenta previa but in this case the bleeding usually follows rupture of
membrane.
Diagnosis
♫ Apt test will be done to detect the presence of fetal blood in the bleeding
Some amount of vaginal blood will be mixed with same amount of 25% sodium
hydroxide.
Maternal blood will turn light brown where as that of the fetus will not be because of its
resistance to alkali.
Management- emergency cesarean section because even small amount of bleeding is fatal to the fetus.
Rh and ABO incompatibility
Rh incompatibility
Definitions
Rh incompatibility- is the presence of different Rh types in the blood of two persons. in obstetrics
women and her fetus mostly when the fetus is Rh positive (possess D antigen in his RBC) and when the
mother is Rh negative (her RBC lacks the surface antigen D).
Table 6.1 -if the father is heterozygous Table 6.2- if the father is homozygous
D D D d
d Dd Dd d Dd Dd
d Dd Dd d Dd Dd
Trauma
Abortion
Ectopic pregnancy
APH
Manipulation of the uterus like:
Amniocentesis
External cephalic version
Complications
Hemolytic anemia
Erythroblastosis fetalis- the presence of large number of nucleated RBC in fetal circulation to
cope the hemolytic anemia
Hydrops fetalis- is a generalized edema and collection of serous fluid in the body cavity of the
fetus which may be secondary to:
♫ Monitor the combs test and report it during the 28th and 36th weeks of pregnancy
If negative:
♫ Provide 300 µg anti D gamma globulin at 28, before procedures that will increase the risk of
FMH like amniocentesis, APH, ECV, abortion (if less than 12 wks, 50µg) etc with in 72
hours of the procedure.
♫ Immediately the baby is born, the cord must be clamped in order to prevent further Rh
antibodies from entering the circulation.
♫ Following delivery determine the blood group and Rh factor of the fetus
Ife positive,
♫ If the test is positive monitor the fetus for all complications and manage the second
pregnancy as sensitized.
B. Sensitized pregnancy- because these women need special follow up early referral is the correct
approach in health center setting. But if you are in referral setting,
♫ All babies whose mother have Rh antibody should be transferred to neonatal intensive
care unit.
♫ After delivery photo therapy and exchange transfusion can also be done
ABO incompatibility
This type of incompatibility is when O blood grouped mother carry a baby of either A or B blood groups.
Unlike Rh incompatibility, in this type the mother has naturally occurring antibody against A and B
blood groups (anti-A and anti- B). Because these antibodies are of IgM type, they are too big to cross the
placenta. But if the fetus blood leaks to the maternal circulation, the mother immune system will produce
anti bodies similar to anti A and anti B but of IgG type which can pass the placenta so that they can
destroy the fetal RBCs that carry the A and B antigens.
Unlike the Rh iso-immunization, this condition may affect the first child as much as the subsequent child
but the complications are not as such severing as that of the Rh once.
Definition- is a rupture of membrane at least one hour before the onset of labour, but after 28 weeks of GA.
Latency period- is the period between the time of rupture of membrane and the onset of true labour. If
the latency period extends more than 24 hour, it is called prolonged rupture of membrane.
Classification-
It can be either preterm PROM (rupture of membrane after 28 wks of GA but before 37 complete
wks) or
Term PROM (rupture of membrane after 37 complete wks but a hour before the onset of labour)
Etiology- there is no exact single cause for PROM but, conditions that will either increase the intra
uterine pressure or that will reduce the strength of membranes may be responsible. These conditions
include-polyhydraminous
-Multiple pregnancy
-Cervical incompitence
-trauma
-Infection
Clinical manifestation-
On physical examination,
♫ moist perineum and Amniotic fluid may be seen flowing from vagina
♫ NB:-PV is contraindicated in mothers suspected of having PROM unless delivery is planned with
in 24 hour. Instead sterile speculum examination will be done to confirm the diagnosis.
o If the GA is 34 or above, the risk of intra uterine infection is higher than the risk of
prematurity. Therefore delivery of the fetus either by induction of C/S should be done.
o If the GA is less than 34wks, the risk of prematurity is higher than the risk of intra uterine
infection. Postponing pregnancy while closely monitoring the complications is the
management of choice.
chorioamnionitis- intrauterine infection of the membrane is the most common and sever
complication of PROM.
@ Adominal pain
@ Offencive amniotic fluid
@ Uterine tenderness
@ Maternal as well as fetal tachycardia
Management- administration of broad spectrum antibiotics (ampicilline and gentamycine)
- Antibiotics should continue after termination of pregnancy and to the neonate
intramuscularly.
Cord prolapsed
Preterm labour
Oligo hydraminous
Abruptioplacenta
Neonatal infection like:
Congenital pneumonia
Sepsis
Abnormality of Amniotic fluid
1) Poly hydramnious
Definition- is the prescence of abnormallu high amount of amniotic fluid (volume of more than 2000 ml)
o Gradual onset
o comes on very sudden onset (the uterus will reach xiphisternem in about 3-4 days)
Etiology
The rest arises either from the condition that increase the surface area of the placenta or disrupt
the integument of the fetus or hamper the normal swallowing process of the fetus.
Defntion- the prescence of abnormally low amount of amniotic fluid (less than 500 ml)
Etiology
Pluminary hypoplasia
Cord compression
Amniotic bandage syndrome
IUFD
Management
@ Admission
@ If there is gross fetal anomaly like renal agenesis because the baby will not survive, termination of
pregnancy is the management of choice
@ If fetal anomaly is not present, sustaining pregnancy till full term is the best management
Medical disease during pregnancy
1. Anemia in pregnancy
Definition- anemia is a reduction in the oxygen carrying capacity of the blood. During pregnancy for a
mother to be anemic the hemoglobin count must be 11g/dl or less and/or the hematocrit must be < 33.
Incidence- it affects 5-50% in developing but only <2% in developed country.
Cause
Majority of the anemia during pregnancy are nutritional anemia; from which Fe deficiency
accounts 80-95% while megaloblastic anemia (anemia from vit B12 and folate deficiency)
accounts only 3-4%
Other causes
Hemolytic anemia
Anemia of chronic illness
Leukemia
Hemoglobinopathy
Predisposing factor for Fe deficiency anemia
1. Reduced intake
Food taboos
Poor dietary habit
Low socioeconomic status
2. Reduced absorption
GI disturbance (diarrhea, hyperemisis)
Intrinsic factor deficiency
3. Excess demand
Multiple pregnancy
Chronic illness
4. Low store at the beginning of pregnancy
Short interval between gestations
5. Blood loss during pregnancy
Menorrhagia
Hookworm
Malaria
Pathophysiology
Iron requirement during pregnancy increase (to around 1000mg)
Maternal RBC and uterine muscle- 450
Fetal RBC production- 270
Placenta- 90daily loss- 190
There is an additional demand for blood loss during pregnancy (190) and lactation (1mg per day)
Assuming normal store a mother should take 3.5 mg/day avragly
Failure to meat this demand eventually leads to anemia
A women with a known cardiac illness can become pregnant or a healthy pregnant women can
develop cardiac illness while pregnancy.
The increase hemo dynamic burden of pregnancy, labour and delivery can aggravate or develop
cardiac illness
The risk is higher around 24 wks of GA, labour and immediate post partum
are one of the most important non obstetric disability and death of pregnant women
maternal mortality rate ranges from 0.4 in class I and II to 68% in class III and IV
spontaneous abortion
preterm labour
low birth weight baby
IUFD
2. Hypertensive disorder of pregnancy
Definition of terms
Two cosequative diastolic blood pressure measurements of 110 mmHg 4 hrs apart
Quantitative- urinary protein excretion of greater than 300 mg or more per 24 hour urine
collection
Pathologic oedema
Type- according to the National High Blood Pressure Education Program Classification
• Gestational hypertension- is a recurrent mild hypertension that develop between 20 WKs and 24
hour post partum with out any other sign of preeclampsia and that resolves with in 10 days
postpartum.
• Chronic hypertension – hypertension present before 20wks of gestation and persists after
six wks postpartum.
♫ Sever HTN
♫ Protein urea
o 5 gm or more quantitative
o >+3 or more qualitative
♫ Oligourea (<400 ml/24 hr)
♫ Epigastric or right upper quadrant pain
♫ Thrombocytopnea
♫ Cerebral symptoms like:
o Frontal or occipital headache
o Blurring of vision
♫ IUGR
♫ Pluminary edema
♫ Acute left ventricular failure
♫ HELLPs syndrome
o Hemolysis
o Elevated liver function test
o Low platelet count
• Eclampsia-is a tonic clonic convulsion or coma occurring during pregnancy, labour or with in 7
days post partum.
- It is a complication of preeclampsia
- It occurs antepartum 50%, intra partum25% and post partum 25%
- Must be un related to other cerebral conditions like epilepsy
• Superimposed preeclampsia upon chronic hypertension- is the worsening of hypertension (+
30/15) and worsening or development of protein urea with or with out edema.
Incidence of HDP
7-10% of all pregnancies end with HDP
Preeclampsia occurs in 5% of pregnancy accounting for 70% of HDP
Eclampsia 0.1-0.5%
Etiology of preeclampsia
The exact cause of preeclampsia is unknown
A number of theories are forwarded, so preeclampsia is called a disease of theories.
Risk factor for preeclampsia
Nulliparity
Extreme reproductive age (les than 20 and grater than 35 years)
Hyperplacentosis
Multiple pregnancy
Molar pregnancy
New paternity
Family history
Diagnosis- The diagnosis of HDP is straight forward. The major task is to differentiate and identify
presence of complication
1. History- should include
Gravidity, parity
Gestational age
History of new paternity
History of pathologic edema
Leg swelling that persists after night rest
Tightness of the ring
Puffiness of the face
Family history of HTN
Prescence of convulsion
Persistence headache
Blurring of vision
Epigastric or right upper quadrant pain
Visual symptom, neurologic symptom and cardiac symptom
2. Physical examination
B/P
Weight
Pitting Edema- pedal, peritibial, abdominal, periorbital edema and ascites
Decrease fetal movement
Decrease growth
3. Laboratory
Urine analysis
Midstream urine for dipstick >+2
24 hour urine protein >300mg
Oligourea
Low Platlet count
4. Ultrasound
Management
1. Preeclampsia
B/P
Level of consciousness and
Urine out put
B. Conservative management- if termination is not indicated, admit the mother in a hospital setting
Bed rest in left lateral position
Headache
Blurring of vision
Right upper quadrant pain
Urine out put
Fetal movement by kick’s chart
Extent of edema
FHB
Urine
Weakly monitor
Effects-
Maternal- anemia
- Puriperial sepsis
Fetal
Spontaneous abortion
Preterm labour
IUGR
IUFD
Management-once diagnosed it should be treated aggressively
The drug should be taken 1-2 wks before travel and should continue 4 wks after travel