Maternal Care

(Obstetrics)

I. Terminology:

1.Gestation – pregnancy or maternal condition ofhaving a developing fetus inside the body.

2.Embryo – human conceptus up to 10th week ofgestation (8thweek postconception)

3.Fetus - human conceptus from 10th week of gestationuntil delivery.

4.Viability – capability of living outside the uterus

–designated at 20 weeks gestation. (Although SurvivalRate is Rare)

5.Gravida (G) –is been pregnant, regardless ofoutcome.

6.Nulligravida – is not now and has never beenpregnant.

7.Primigravida – pregnant for the first time.

8.Multigravida – has been pregnant more than once.

9.Para (P) – refers to past pregnancies that havereached viability.

10.Nullipara – has never completed a pregnancy to theperiod of viability.

11.Primipara – has completed one pregnancy to theperiod of viability.

12.Multipara –has completed two or morepregnancies to the period of viability.

II. Manifestations of [Presumptive Signs and Symptoms]

(Physical Signs and Symptoms that suggest, but do notprove pregnancy)

1.ABRUPT CESSATION OF MENSES –uspected if morethan 10 days have elapsed.

2.BREAST CHANGES- Becomes large and tender

b. Veins become increasingly visible

c. Nipples become larger and pigmented. Nipple tinglingmay also be present

d. Colostrum, a thin milky fluid, may be expressed in thesecond half of pregnancy.

e. Montgomery’s glands, small elevations of the areola may appear.

3.Skin Pigmentation Changes

a.Chloasma/Melasma Gravidarum (Mask ofPregnancy)

– brownish pigmentation appearing on theface in a butterfly pattern in 50% to 70% of women.- is more
common in dark-haired, brown-eyed womenand is progressive throughout the pregnancy.

b.Linea Nigra

– dark vertical line on the abdomenbetween the sternum and the symphysis pubis.c.

Abdominal Striae (Striae Gravidarum) – reddish orpurplish marks sometimes appearing on the
breasts,abdomen, buttocks, and thighs because of thestretching, rupture, and atrophy of the deep
connectivetissue of the skin.d.

Spider Angioma – spiderlike projection in the skin.

4.NAUSEA AND VOMITING (Morning Sickness)

– occursmainly in the morning, but may occur anytime of theday, lasting a few hours. Begins 2
to 6 weeks afterconception and usually disappears spontaneously nearthe end of the first
trimester (12 weeks).

5.FREQUENCY OF URINATION

A. Caused by pressure of the expanding uterus on thebladder.

B. Decreases when the uterus rises out of the pelvis(around 12 weeks).

C. Reappears when the fetal head engages in the pelvisat the end of pregnancy.

6.FATIGUE – characteristics of early pregnancy inresponse to increased hormonal levels.

Probable Signs and Symptoms (Objective findings detected by 12 to 16 weeks ofgestation)

1.Enlargement of the Abdomen – at about 12 weeksgestation the uterus can be felt through the
abdominalwall, just above the symphysis pubis.

2.Changes in shape, size, and consistency of theuterus

a. Uterus enlarges, elongates, and decreases inthickness as pregnancy progresses. The uterus
changesfrom pear shape to a globe shape.
b.Hegar’s Sign – lower uterine segment softens 6 to 8weeks after the onset of the last menstrual period.

3.Changes in the Cervix:

a.Chadwick’s Sign – bluish or purplish discoloration ofthe cervix and vaginal wall.

b Goodell’s Sign – softening of the cervix; may occur asearly as 4 weeks.

4.Braxton Hicks Contractions – painless, palpablecontractions occurring at irregular intervals,

morefrequently felt after 28 weeeks. They usually disappearwith walking or exercise.

5.Ballotement – sinking and rebounding of the fetus inits surrounding amniotic fluid.

6. Changes in levels of HCG (Human ChorionicGonadotropin) in maternal plasma and urine.

7. Increase in vaginal discharges.

8. Quickening –sensation of fetal movement in theabdomen (between 16-20 weeks)

9.Positive (+)HCG

Positive Signs and Symptoms (Diagnostic of Pregnancy)

1.Fetal Heart Tones (FHT) – usually heard between 16th and 20th week of gestation (Fetoscope) or 10th
to 12th Week of gestation with a Doppler Stethoscope.

2. Fetal movements felt by the examiner after about 20weeks gestation.

3. Outlining of the fetal body through the maternalabdomen in the second half of pregnancy.

4.Sonographic Evidence –After 4 weeks gestationusing vaginal ultrasound. Fetal Cardiac Motion can
bedetected by 6 weeks gestation.

Female Reproductive System

A. External Organs

1.Mons Pubis: a mound of fatty tissue over thesymphysis pubis that cushions and protects the bone.

2.Labia Majora: longitudinal folds of pigmented skinextending from the mons pubis to the per

3.Labia Minora: soft longitudinal skin folds betweenthe labia majora.

4.Clitoris: erectile tissue located at the upper end ofthe labia minora; primary site of sexual arousal.
5.Urethral Meatus (Urethral Orifice): small opening ofthe urethra located between clitoris and vaginal
orificefor the purpose of urination.

6.Skene’s Glands : small mucous glands that open intothe posterior wall of the urinary meatus and
providevaginal lubrication.

7.Vestibule: an almond-shaped are between the labiaminora containing the vaginal introitus, hymen,
andBartholin’s Glands.

8.Vaginal Introitus: external opening of the vagina

9.Hymen: membranous tissue ringing the vaginalintroitus.

10.Bartholin’s Glands: mucous-secreting glands locatedon either side of the vaginal orifice.

11.Perineal Body: muscles and fascia that supportpelvic structures.

12.Perineum: tissue between the anus and vagina; thearea where episiotomy is performed

B Internal Organs

1.Vagina: the female organ of copulation lying betweenthe urethra and rectum. Also known as the birth
canal.

2. Uterus: a hollow muscular organ with three muscularlayers (perimetrium, myometrium, and
endometrium.Located between the bladder and the rectum andconsisting of

three parts (3)

a. Fundus –upper round segment that extends abovethe insertion of the fallopian tubes; fetalgrowth
ismeasured by fundal height.

b. Body (Corpus) – main portion between fundus andcervix.

c. Cervix– divided into two segments.

Supravaginal– portion that extends inside the uterus;contains internal os that opens into the uterine
cavity.ii.

Vaginal – portion that extends outside the uterus intothe vagina; contains the external os that is the
visibleopening of the cervix; portion that is felt during vaginalexamination in assessing cervical dilation.

Uterine Functions

Include:

A.Menstruation: sloughing away of spongy layers ofendometrium with bleeding from torn vessels.

B Pregnancy: development of embryo and fetus afterfertilization

 C. Labor: powerful contractions of muscular uterine wallthat result in expulsion of fetus

3.Fallopian Tubes

: tubes extending from the upperouter angles of the uterus and end near the ovary;serves as
passageway for the ovum from the ovary tothe uterus and for the sperm from the uterus to
theovary

4 Ovaries: female sex gonads located on each side ofthe uterus with two functions

a. Ovulation (Release of Ovum

b. Section of Hormones (Estrogen and Progesterone)

C. Pelvis1. Is a bony ring located in the lower portion of thetrunk

Parts (3):

A. Iliumb.

B. Ischiumc.

C. Pubis

Bones(4):

Hipbones

Sacrum

Coccyx

Types of Pelvis:

a. Gynecoid (50%): Typical female pelvis with roundedinlet.- Optimal Diameters in All Three (3)
Planesb.
b. Android (20%): Normal male pelvis with heart-shapedinlet.- Posterior segments are decreased
in all three planes.Note:* Deep Transverse arrest of descent and rotation of thefetus are
common.

c. Anthropoid (25%): “ape like” pelvis with oval inlet.

d. Platypoid (5%): flat female-type pelvis withtransverse oval inlet.

NArrest of fetal descent at the pelvic inlet iscommon. Labor progress can be poor.

Divisions of the Pelvis

1.False Pelvis – lies above an imaginary line called thelinea terminalis or pelvic brim.*

Function: Support the Enlarged Uterus

2.True Pelvis: lies below the linea terminalis.*

Function: the bony canal through which the fetusmust pass.

* It is divided into three planes:

a. Inlet b. Midpelvis c. Outlet

A. Inlet:Upper boundary of the true pelvis– bounded byupper margin of symphysis pubis

in front lineaterminalis on sides and sacral promontory (first sacralvertebra) In back.

Largest Diameter – Transverseiii.

Smallest Diameter–Anteroposterioriv. Anteroposterior Diameter:

Most important diameter of inlet: Measured clinically by diagonal conjugate whichis the lower margin of
symphysis pubis to thesacral promontory. 5 ½ Inches or 14 cm.v.

Obstetrical Conjugate - distance between innersurface of symphysis pubis and sacral promontory-
measured by substracting 1.5 – 2cm (thickness ofsymphysis pubis) from the diagonal conjugate.-
adequate diameter is usually 11.5 cm. shortest anteroposterior diameter through whichthe fetus must
pass.

B. Midpelvis: Bounded by inlet above and outlet below- true bony cavity- contains narrowest portion of
the pelvisii. Diameters cannot be measured clinicallyiii. Clinical evaluation of adequacy is by noting
theischial spines.m

Prominent spines that potrude into the cavityindicate a contracted midpelvic space.

The interspinous diameter is 4 inches (10cm).

C.Outlet Lowest boundary of the true pelvis.Bounded by lower margin of symphysis pubis infront, ischial
tuberosities on sides, tip of sacrum atback.