OBSTETRICS (Note-Taking Guide)

Notes Compiled by: Joseph Jansen Chokee A. Aragon, RN, RM, LPT

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THE MENSTRUAL CYCLE- cyclic uterine bleeding in response to hormonal changes.

Normal menstrual cycle
 Having a cycle anywhere from 24-38 days
 Bleeding anywhere from 4-7th day
 Losing 5-80 mL over the course of menstrual period

Body Parts Involved

Body parts involved Hormones involved
1. Uterus None

2. Hypothalamus GnRH Gonadotropin Releasing Hormone

3. Anterior Pituitary a. FSH
Gland

b. LH

4. Ovaries a. Estrogen

b. Progesterone
Ovulation- monthly release of the mature ovum by the Graafian follicle.

OVARIES produce
ESTROGEN- development of secondary PROGESTERONE- prepares the
sexual characteristics endometrium for implantation
Fat distribution in the hips and legs INCREASES BBT

T- helarche =
A- drenarche =
M- enarche=
A- drenarche =
Estrogen is the hormone responsible for MOOD SWINGS
height

Responsible for fertile cervical mucus Responsible for infertile cervical mucus
Characteristics: Characteristics:

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 OVARIAN CYCLE (hormone production, UTERINE CYCLE (endometrial changes)
maturation of ovum, and ovulation)

FOLLICULAR (1-14) MENSTRUAL= bleeding (Day 1-6)

PROLIFERATIVE = thickening (Day 7-14)

LUTEAL (15-28) SECRETORY= twisted and spongy (Day 15-26)

ISCHEMIC= vasoconstriction (Day 27-28)

Day 3 Day 7 Day 12/13 Day 14 Day 15 Fertilization No

fertilization

Estrogen is The ovary The estrogen Rupture of the The ruptured After 7-10 days After 8-10 days,
at lowest begins to is at highest Graafian follicle Graafian follicle the Corpus
point. produce point but becomes Luteum becomes
(menstrual Estrogen progesterone Corpus Luteum Corpus Albicans
Implantation
phase) is low under the
influence of LH
Ovulation No production of
HCG production
Stimulates Estrogen E and P
The Signs
the stimulates the Corpus Luteum
Hypothala endometrium Hypothalamus secretes
mus to begins to Progesterone Maintains
thicken No P that will
release 1. Spinnbarkeit corpus luteum
(Secretory maintain the
GNRH for the first 6-8
(proliferative Hypothalamus phase) endometrium
weeks of
phase) releases
pregnancy
GNRH to 2. Mittelschmerz
GNRH stimulate APG
Progesterone Vasoconstriction
stimulates
prepare the of spiral arteries
APG to Production of
3. Increased endometrium for of the
release estrogen and
The ovum also APG releases BBT implantation endometrium
FSH progesterone
begins to LH making it twisted
mature (ischemic phase)
and spongy.

Progesterone
LH stimulates
maintains Menstruation
FSH the ovary to
endometrium
stimulates produce
the Ovary Progesterone
to produce
Estrogen No more
menstruation

(Secondary
amenorrhea)

#CORPUS LUTEUM= endocrine organ EARLY in Pregnancy.

Related terminologies
1. Menarche First menstruation

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 2. Dysmenorrhea Painful menses
3. Amenorrhea Absence
a. Primary
b. secondary
4. Metrorrhagia bleeding in between menses/ bleeding at irregular
intervals.
5. Menorrhagia Losing more than 80 mL or more in each period.
Bleeding that lasts more than 7 days.
6. Menopause Cessation of menses. Average age 51

______________________________________________________________________

FERTILIZATION= union of ovum and sperm

Site= Ampulla of Fallopian Tube

FRATERNAL TWIN IDENTICAL TWIN / Monozygotic twin

Or Types
Dizygotic twin
DICHORIONIC DIAMNIONIC
2 placentas, 2 amniotic sacs, 2 fetuses

MONOCHORIONIC DIAMNIONIC
1 placenta, 2 amniotic sacs. 2 fetuses

MONOCHORIONIC MONOAMNIONIC
1 placenta, 1 amniotic sac, 2 fetuses

CONJOINED TWIN = cleavage is incomplete

INFERTILITY
Lack of conception despite unprotected intercourse for at least _____________.

Methods of Managing Infertility

1. Pharmacologic Method=
a. Clomiphene Citrate (Clomid, Serophene)- increasing secretions of FSH and
LH. The woman takes 50-250mg per day orally for 3 to 5 days. Then
ovulation will occur 5 to 10 days after the last dose.
b. Menotropins (Pergonal, Humegon, Repronex)= second line of therapy in
women who fail to ovulate with Clomid. Menotropin is a combination of FSH
and LH. Given IM.
2. Artificial insemination= depositing sperm at the cervical os or in the uterus by
mechanical means. Indicated for Low sperm count, decreased motility, abnormal
morphology, anatomic defects.
3. In Vitro Fertilization (IVF)- woman’s eggs are collected from her ovaries,
fertilized in the laboratory and placed into her uterus after normal embryo
development has begun.

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 4. Gamete Intra Fallopian Transfer= retrieval of oocytes by laparoscopy, placed in
catheter with motile sperm and placed in the fallopian tube. Fertilization occurs in
the fallopian tube.
5. Zygote Intra Fallopian Transfer
6. IVF Utilizing Donor Oocytes

FETAL GROWTH AND DEVELOPMENT

ZYGOTE---CLEAVAGE----BLASTOMERES---after 3-4 days---MORULA----after 3-4 days---

BLASTOCYSTS---implantation--- EMBRYO (2-8 weeks) ----FETUS (8 weeks-term)

IMPLANTATION
SIGNS OF IMPLANTATION: Vaginal spotting and slight pain
SITE- posterior fundus
WHEN= 7-10 days after fertilization

PERIOD OF ORGANOGENESIS= 2-8 weeks. #The most critical stage is _________

After implantation, the endometrium is called= DECIDUA

Decidua Capsularis - covering
Decidua Vera- remaining
Decidua Basalis (base and maternal portion) + Chorionic Villi (fetal portion) =________

FETAL GROWTH AND DEVELOPMENT

Month 1 Month 2

All systems in the rudimentary form. HEART
chambers formed. Heart beating.
Beginning formation of eyes, ears nose
With arms and leg buds
By the end of first month, the fetus is about ¼
inch long
Head is large in proportion to the rest of the body
Rapid BRAIN development
The neural tube (brain, spinal cord and other
neural tissues in the CNS is well formed).
External genitalia is formed
By the end of the second month, the fetus is
about one-inch long

Month 3 Month 4

Placenta is complete, FHT is audible by Doppler QUICKENING.

#SEX is distinguishable, Fetus begins to swallow Formed eyes ears nose. Scalp hair develops,
FHT by Fetoscope, lanugo begins to appear
Kidneys begin to excrete urine. Liver produces
bile. Circulatory System is working. Meconium in bowels

The arms, hands, fingers, feet and toes are fully

formed. All organs and limbs are present By the end of 4th month, the fetus is about 6
inches long
By the end of 3rd month, fetus is about 4 inches
long.

Month 5 Month 6

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Lanugo completely appears, QUICKENING

FHT by STETHOSCOPE, Bones hardening Body well proportioned. Skin is red and wrinkled

Age of Viability= Eyebrows and eyelashes appear, vernix caseosa

appears
End of 5th month= fetus is about 10 inches.
HEARING ESTABLISHED

Fetus= 12 inches

Month 7 Month 8

Surfactant SUBCUTANEOUS FAT DEPOSITS, iron

deposits, calcium deposits, skin is smooth and
Body is less wrinkled, hearing fully developed pink, more kicking
NAILS APPEAR Birth position assumes
Fetus= 14 inches Fetus= 18 inches

Month 9 Month10

Nails firm, with definite sleep and wake pattern, Little lanugo,
lanugo disappearing
if male, testes descend
lecithin and sphingomyelin ratio (L/S) is 2:1=
LUNGS ARE MATURE (35 WEEKS) with good muscle tone and reflexes

presence of phosphatidyl glycerol (PG) confirms

lung maturity (36 WEEKS)

lung maturity occurs late in pregnancy

fetus= 17-19 inches

AMNIOTIC FLUID/ BAG OF WATER/ AMNIOTIC SAC

AOG VOLUME OF AMNIOTIC FLUID

10 WEEKS 30 ml

20 WEEKS 350 ml

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AFTER 20 WEEKS Normal Volume: 500-1000ml or 700-1000ml or
800-1200ml
The fetus actively swallows amniotic fluid at 5
mos. #Less than 500 ml=
Indication=
Fetus swallows 600ml each day and 400ml flows #More than 1500ml=
out of the lungs each day. Indication=

The major sources of amniotic fluid after 20 weeks

are the FETAL KIDNEYS pH= 7-7.25

Normal color- CLEAR ______________________________________

FUNCTIONS GREEN AMNIOTIC FLUID= MECONEUM

STAINING.
1. protection from trauma
2. maintains temperature ______________________________________
3. prevents cord compression
4. helps in delivery GOLDEN YELLOW AMNIOTIC FLUID= due to
5. fetal drink destruction of fetal RBCs. This is related to Rh
6. for musculoskeletal development Incompatibility

UMBILICAL CORD/ FUNIS

Average length= 50-55cm  DuctusVenosus= connects
Less than 35 cm= short umbilical vein to inferior vena
More than 70cm= long cava
Arteries= 2 Vein= 1  Foramen Ovale= opening
In Fetal Circulation, the ______ side ofbetween the two atria
the heart is more powerful.  Ductus Arteriosus= connects
pulmonary artery and aorta
 NO nerve Supply
 Wharton’s Jelly
1. OXYGENATED BLOOD FROM PLACENTA → UMBILICAL VEIN → DUCTUS
VENOSUS → IVC →RIGHT ATRIUM → FORAMEN OVALE→ LEFT ATRIUM
BICUSPID VALVE→LEFT VENTRICLE →ASCENDING AORTA→ BRAIN AND
LOWER PARTS OF THE BODY.

2. BLOOD RETURNING TO THE HEART (Co2 or waste products) →RIGHT

ATRIUM→ TRISCUSPID VALVE → RIGHT VENTRICLE → PULMONARY
ARTERY→DUCTUS ARTERIOSUS→DESCENDING AORTA→ UMBILICAL
ARTERIES→BACK TO PLACENTA→THE CO2 AND WASTE PRODUCTS ARE
RELEASED INTO MOTHER’S CIRCULATORY SYSTEM AND THE CYCLE
STARTS AGAIN.

PLACENTA= attaches to the uterine wall and allows metabolic exchange between the
fetus and the mother.
Which Part of the mother nourishes the fetus during pregnancy? __________

Placenta expands on the first 5 months. (Placental Migration)

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 A normal placenta is round, or oval-shaped and about 22cm in diameter. It is 2-2.5cm
thick. Placenta weighs up to ____________ at term.

PLACENTAL HORMONES FUNCTIONS and EFFECTS

HCG- human chorionic 1. prolongs the life of corpus luteum for the 1 st 6-8 weeks
gonadotropin
2. basis for pregnancy
Gradually increase until
around 10 weeks 60,000 to
140,000 m IU / ML then
declines sharply

HPL- human placental Function- anti insulin hormone.

lactogen or
HUMAN CHORIONIC Effect: the diabetogenic effect of pregnancy.
SOMATOMAMMOTROPIN
All placental hormones are anti-insulin.
Appears on ___________

RELAXIN It increases joint mobility. The gait of a pregnant woman

is______________.

ESTROGEN VASCULARIZATION =increase in blood supply

(primarily, estriol)
a. CHADWICK’S SIGN- bluish discoloration of vagina #starts on
_________
b. NASAL CONGESTION, GUM PAIN, PALMAR ERYTHEMA

EXPANSION OF BLOOD/ INCREASED BLOOD VOLUME starting on

____________

ENLARGEMENT OF UTERUS= hypertrophy to myometrium

 Non pregnant weight:

 Non pregnant shape:
 Pregnant weight: 1000-1100 grams containing a maximum of
5kgs.
 Pregnant Shape:

SECRETIONS =

 L-EUCORRHEA (whitish vaginal discharge)

 E-XCESSIVE SALIVATION (PTYALISM)
mgt. ____________

 O-PERCULUM (cervical mucus plug) due to hyperplasia to

mucosal glands of the cervix. It has ________________

SOFTENING OF CERVIX _____________________ starts on ______

SOFTENING OF LOWER UTERINE SEGMENT________________

starts on _______

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5.PROGESTERONE Muscle relaxant
Decreases peristalsis.
Fluid retaining hormone
Increases BBT
Mammary gland development for lactation

COMMON DISCOMFORTS OF PREGNANCY

DISCOMFORT RELIEF MEASURES

1. Morning Sickness Eat dry crackers 30 minutes before arising,

due to suck on popsicles, eat small frequent meals
separate liquids from solids alternate every 2-3 hours
sip on ginger tea/ale
2. Heartburn Maintain on upright position after eating. Avoid highly
due to seasoned food. Avoid sweets. Avoid fatty and fried foods

3. Flatulence Avoid gas forming food. Avoid sweets.

due to

4. Urinary Frequency Limit caffeine (less than 200 mg per day. This is equal to
due to about one 12oz. cup of coffee)
High levels of caffeine in pregnancy can result in babies
having LBW.
5. Fatigue Increase amount of rest and sleep. Go to bed earlier.
due to

6. Constipation Increase fluid and fiber, no laxatives and enemas, mild stool
due to softeners are allowed as prescribed

7. Supine Hypotension Lie on left side

due to

8. #Leg cramps Increase calcium ________________________

due to and dorsiflexion (immediate relief)

9. Varicose veins Elevate the legs higher than the heart.

Due to

10. #Back pain Sleep on #Firm mattress, pelvic rocking exercise

Due to

11. Pedal edema Increase protein 60 grams per day

Due to

12. Shortness of Breath Maintain proper posture when sitting, elevate the head when
Due to lying down

13. #Hemorrhoids Warm sitz bath and #cold compress, push by gentle finger
Due to pressure, lie with legs elevated

14. Increased vaginal discharge Bathe daily, wear cotton underwear, avoid douching, avoid
Due to nylon panties
15. Breast tenderness Wear a well-fitting bra
due to

16. Vena-caval syndrome
17. Difficulty sleeping
Avoid lying flat on the back, elevate head of the bed, place a
small pillow under the right hip when woman needs to be in
a back-lying position.
Drink a warm caffeine-free beverage before bedtime,
relaxation techniques.
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 SIGNS OF PREGNANCY
PRESUMPTIVE____________ PROBABLE_______________ POSITIVE____________
Fatigue Goodell’s Sign Fetal heart tone
Amenorrhea Ballottement Ultrasound
Quickening ___________________________ Transabdominal
Increase urinary frequency Braxton Hicks Contraction Position= semi fowlers with
Chloasma = _______________________ small pillow under the right
Morning sickness Starts on________ stronger on _____ hip.
Linea Nigra Advantage______________________ Vaginal
Breast changes starting on Elevated BBT Position= lithotomy
_______ Chadwicks sign
Uterine enlargement Hegars sign
Striae Gravidarum Urine with HCG
Abdominal enlargement
#COUVADE syndrome - signs of pregnancy felt by the husband

ANTEPARTAL PERIOD: Duration of pregnancy

Days= 267-280 days Weeks= 37-42 weeks
Calendar months= 9 Lunar months= 10
ESTIMATING the EXPECTED DATE OF BIRTH
RULE FORMULA

1. MOST POPULAR #LMP= FIRST DAY OF LAST MENSTRUAL PERIOD

RULE= NAEGELE’S If LMP is January to March= =+9mos +7days +the same year
RULE If LMP is from April to December= -3mos +7days +1year

2. if LMP is unknown? Use PRIMI= Date of QUICKENING (5 months) + 4 months= EDB

the DATE OF QUICKENING MULTI= Date of QUICKENING (4 months) + 5 months= EDB

ESTIMATING the AGE OF GESTATION

RULE FORMULA

1. BARTHOLOMEW’S RULE just below xiphoid process= 36 weeks

 Starts on 3rd month 2 fingers below the xiphoid process= 40 weeks
 Rule of 4 due to lightening
 Position of the woman= Dorsal At the level of Umbilicus= 20 weeks
Recumbent Midway between SP and U= 16 weeks
Just above the symphysis pubis= 12 weeks

2. MC DONALD’S RULE
 Starts on ________ AOG in weeks= FH in cm x 8/7
 Instruct the mother to void. AOG in months= FH in cm x 2/7
3. FUNDIC HT in CENTIMETERS 20-36cm = 20-36 weeks of pregnancy
Starts on ____________

ESTIMATING the FETAL LENGTH in CENTIMETERS

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RULE FORMULA
HAASE’S RULE First 5 lunar months =
6-10 lunar months =

Estimated Fetal Weight

Weeks Weight
12 weeks 45 grams
20 weeks 1 lb / 435 g
24 weeks 1.5 lbs / 680 g
28 weeks 2.5 lbs / 1200 g
36 weeks 5 to 6 lbs / 1800-2800g
40 weeks 6.5 to 8lbs / 3000-3600g

OBSTETRICAL NOTATION
Gravida = total number of pregnancies, Para = total number of births 20 weeks and
irrespective of outcome, regardless of AOG above, irrespective of outcome

NULLI= never, PRIMI= one, MULTI= 2 or more, GRANDMULTI= 5 or more

CASES GRAVIDA PARA

Ectopic pregnancy

H mole

Abortion

Stillbirth- a fetus born 20

wks. and above without
life.

Present pregnancy

Twins, Triplets

T-erm infantss- born 37 weeks and above dead or alive

P-reterm infants- born 20 weeks to 36 weeks dead or alive
A-bortuses- (less than 20 weeks.)
L-iving (currently)
M-ultiple pregnancies

Sample Exercises:
1. A pregnant client reveals two pregnancies delivered prematurely, both living, one
pregnancy aborted, one pregnancy delivered term, living. And one stillbirth at 43
weeks. What is the GP TPALM score? __________________________
2. The pregnant woman discloses that her first pregnancy was the birth of her twins
at 35 weeks, both living. Her second pregnancy was ectopic pregnancy. What is
the GP TPALM Score? ________________________
3. A woman who had term twins, then one preterm infant, and is now pregnant
again would be a?_____________________ (GTPALM)

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 #WEIGHT GAIN for Singleton PREGNANCY
NON-PREGNANT WEIGHT TOTAL
WEIGHT
GAIN
AVERAGE (BMI 18.5 – 24.9)
UNDERWEIGHT (BMI less than 18.5)
OVERWEIGHT (BMI 25.0- 29.9)
OBESE (BMI more than 29.9)
Distribution of Weight gain for Singleton pregnancy
First trimester ___________________
Second Trimester ________________
Third Trimester __________________

#CALORIES for Singleton Pregnancy

CALORIES PER DAY
NON-PREGNANT
DURING PREGNANCY
DURING LACTATION

For Multiple Pregnancies

Twins Triplets Quadruplets
Calories 3500 4000 4500
Weight gain BEFORE 1 lb per week 1 ½ lb per week 2 lb per week
20 weeks
Weight gain AFTER 2 lb per week 2 ½ lb per week 3 lbs per week
20 weeks
Total weight gain 40-50 lbs 50-60 lbs 65-80 lbs
Average length of 36 weeks 32 weeks 30 weeks
gestation

Nutrients Needed During Pregnancy

Protein= To support the embryonic- 60g/day or 1g/kg/day.
fetal growth and development,
prevention of pre-eclampsia
Carbohydrates 175g/day
Iron Non Pregnant _____________
Pregnant= _____________.
Twin Pregnancy _______________
Vitamin C is needed to absorb iron
Caffeinated beverages should be avoided

Fats- for tissue formation especially Omega 6 and Omega 3

the neuron system and the eyes.
Folate= essential for cell division
such as fetus, placenta, maternal
red blood cell synthesis .
400mcg/day- 600mcg/day
________________________
4mg/day- ____________________________

Zinc= for normal growth and 11-12mg/day

development, DNA synthesis and
immune function
Sodium 1.5-2.3g/day
Calcium Non pregnant- 800mg/day

Pregnant- 1000-1200mg/day.

Intake greater than 2500mg/day is associated

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 with incidence of kidney stone.
Vitamin A 2500IU/day.
More than 10,000 IU per day may be
teratogenic
Vitamin D= promotes calcium Vitamin D- 400-800IU/day with sun exposure
absorption and bone mineralization.
Fluids Fluids- 3L/day
Iodine Non-pregnant= 150 mcg/day
Pregnant= 175 mcg/day
Lactating= 200mcg/day
Phosphorus 1200mg/day

MATERNAL ADAPTATIONS TO PREGNANCY

Cardiovascular System
Increase in Cardiac Output by 30-50 percent. Increase in plasma 50 percent starting on last week of
first trimester
Increase in RBC volume by 20 percent.
Hematocrit ____________, to prevent drop _________________________.
Physiologic Anemia of Pregnancy or ______________________________________________
Increase in WBC count on pregnancy is NORMAL due to Estrogen
Increase in WBC count on the first 24 hours after delivery is ________
Increase in the Heart Rate during pregnancy ____________ . Mild Tachycardia during pregnancy is
___________
During Pregnancy, there is also an increase in platelet and fibrinogen clotting factors of the mother
Respiratory System
The mother changes from being abdominal breather to thoracic breather
The lungs adjust to provide increased amount of oxygen. The lungs expand laterally; RR increases,
Diaphragm is displaced upward. Nasal congestion due to ______.
Total oxygen consumption increases by 20 % to meet fetal needs.
Skin- All skin changes (Linea Nigra, Chloasma, Striae Gravidarum) are presumptive starting on
____________
Phlegmasia alba dolens known as ____________is most often seen during ______________
resulting from compression of the left iliac vein against the pelvic rim by the__________________.

GIT System
A hypotonic gastrointestinal tract. The smooth muscle of stomach and intestines relaxes due to
_______________.
The stomach is compressed upward and backward. Delayed emptying. Decrease hydrochloric acid.

Urinary-
Kidneys increase renal plasma flow by 30-50%.
decrease glucose threshold due to increased renal blood flow =
_____________________________________________
Increased urination (1st tri and 3rd tri)
Increased bladder capacity and decrease the tone due to the influence of ____________ ,

Musculoskeletal System
The hormones _____________ and ______________ soften and relax the ligaments and joints of the
pelvis.
The enlarging uterus may cause diastasis recti, the separation of the rectus muscles of the abdominal
wall. This may persist in the postpartum period until the muscle tone of the abdomen is regained.
Lordosis- ________________________

Reproductive System
The uterus increases 20 times

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The cervix softens, more vascular, and produces increased mucus
Mucus plug seals the cervix
Egg production stops in the ovaries
The vagina increases vascularity, mucosa thickens
Vaginal secretions become more acidic

TRIMESTERS OF PREGNANCY
1ST TRI 2ND TRI 3RD Tri
(1-14th week) (15th - 28th week) (29th- 42nd week)
TASKS

MOST

FOCUS

Prenatal Visits

Estrogen LEVEL

Progesterone LEVEL

BP LEVEL

URINARY
FREQUENCY
SEXUAL DESIRES

BLEEDING
DISORDERS

Pregnancy Related Disorders

RH INCOMPATIBILITY- Mother is RH negative and Fetus is RH positive

NOTE:

1. If the mother and the fetus are both Negative= COMPATIBLE

2. If the Mother and the fetus are both Positive= COMPATIBLE
3. If the mother is RH positive and the fetus is RH negative = COMPATIBLE
On 28th week Rhogam will be given, ___________________.

Within 48-72 hours after placental delivery, Rhogam will be given to

prevent____________________________.

Before giving Rhogam, Check INDIRECT COOMBS TEST

If the result is ( - indirect ) _____________________

If the result is ( + indirect ) _____________________

Rhogam is also given to an RH negative woman after amniocentesis, CVS, abortion.

Rhogam is only a prevention not a treatment.

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PREGNANCY INDUCED HYPERTENSION
CAUSE=
WHEN=
FORMER NAME=
TYPES
 Gestational HPN-
 Pre-Eclampsia-
 Eclampsia -

3 MAJOR SYMPTOMS
P= I= H=

MAJORBODY PARTS affected

B- rain (CNS irritation and HYPERREFLEXIA)
U- terus (Uteroplacental insufficiency)
K- idneys (Oliguria and Proteinuria)

MILD PRE ECLAMPSIA SEVERE PRE ECLAMPSIA

BP 140/90 160/110

proteinuria +1 and +2 +3 and +4

Edema digital periorbital
weight gain 2 lbs. per week 5 lbs. per week
urine output More than 500cc in 24 hours Less than 500cc in 24 hours
visual disturbances none Present
epigastric pain none Aura for convulsion
headache Occasional Persistent

COMPLICATIONS
H-emolysis
E-levated
L- Liver Enzymes
L-ow
P-latelet count

Management:
 REAL CURE: ___________________________
 POSITION________________________________________
 DIET___________________________________________________
 ROOM_________________________________
 ANTIHYPERTENSION= Hydralazine.
 Given to___________________________
 ANTICONVULSANT___________________
Before giving the first dose, check___________
Given through__________________
Therapeutic level ________________

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  EVALUATE TOXICITY (BURPS)
o B-P ___________________
o U-rine Output ________________
o R-R ________________
o P-atellar Reflex _________________
o S- omnolence____________________________
What is the first sign of toxicity? _____________
 ANTIDOTE for Magnesium Toxicity _______________________

 Monitor The Patient for 48 Hours After Delivery

Because_____________________________________________

GESTATIONAL DIABETES

Pre-conception and Maintaining blood sugar in normal range 1-2 months before
early pregnancy conception because fluctuations in the blood glucose levels
increase the risk of miscarriage and fetal abnormalities in
(for Women with the first trimester.
Chronic Diabetes)

Maternal Risks Hydramnios= due to excessive fetal urination

PIH
Dystocia
Monilial vaginitis and UTI
Fetal Risks Congenital Anomalies
LGA/Macrosomia
Increased risk for birth trauma
RDS (high levels of fetal insulin inhibits enzymes necessary
for surfactant production)
Screening for GDM If the result is 200 mg/dL or more =

All women regardless of If the result is 140mg/dL or more= indicates a need for
risk factors, should be further diagnostic test __________________________
screened for diabetes
towards the end of The mother should fast at least 8 hours, then FBS will be
second trimester by taken in the morning. The mother will take 100g oral
50g oral glucose glucose solution then blood glucose will be monitored at 1,
tolerance test. 2, 3 hours.

Values
FBS= 105mg/dl
One hour= 190 mg/dl
2-hour= 165mg/dl
3-hour = 145mg/dl

GDM is positive _____________________

GDM is borderline abnormal if
__________________________
GDM is negative if _____________________________
Antepartal The first therapy for GDM is ______________________
Management If Diet is inadequate- INSULIN (HUMAN INSULIN SHOULD
BE USED)
Oral hypoglycemic are never used during pregnancy.

15
 PERINATAL INSULIN FIRST TRI= ___________ due to inhibition of anterior
NEEDS during pituitary hormones, growth of the embryo, decreased
pregnancy maternal intake.

(for insulin-dependent SECOND TRI= gradually ____________ due to insulin-

women) resistant properties of placental hormones.

THIRD TRI= continue to _____________ until 36 weeks

then may decrease slightly as placental functioning
diminishes.

LABOR AND DELIVERY= ____________ during active

labor due to increased metabolism. The only type on insulin
that can be used during labor is regular insulin

POSTPARTUM= _________________ because of the loss

of placental hormones.

BREASTFEEDING= _______________ because of

carbohydrate use in milk production.

Timing of birth Women with good control of their diabetes and no signs of
complications are allowed to continue pregnancy until term.

Fetal lung maturity is delayed with DM. Assessment of

surfactant levels is recommended to help determine
delivery time.

What is the most common problem associated on labor?

___________________________

The NEWBORN of a diabetic mother is at risk for?

_________________________

Postpartum The woman with GDM should maintain a normal weight to

considerations reduce the risk of future type 2 DM

Breastfeeding The composition of breastmilk is not altered by diabetes,

and infants of mothers with diabetes gain weight
appropriately.

Blood glucose levels maybe lower.

BLEEDING DISORDERS OF PREGNANCY

ABORTION 1. Induced 2. Spontaneous or _____________________

TYPES OF SPONTANEOUS ABORTION

TYPES DESCRIPTION CERVIX
#Threatened possible loss/ foundation of all types of abortions/
painless/ mild cramps/ mild bleeding/vaginal spotting
non-tender uterus
no sex for 2 weeks/
no lifting heavy objects.
Inevitable Imminent, loss cannot be prevented, moderate bleeding. Mild to

16
 painful uterine contractions
Incomplete Some products are expelled, severe bleeding due to
_______________
Complete All products are expelled from the uterus
Habitual Recurrent ( 2 or more consecutive pregnancies have ended in
spontaneous abortion)
Septic Abortion complicated by infection (foul smelling vaginal
discharge)
Missed Retention (dead fetus syndrome), the fetus died before 20
weeks but retained for 4 weeks or more.
Regression of Breast changes, No uterine growth
No fetal movement. Hcg is _______ Bleeding is __________
At risk for ___________________due to __________________
AFTER AN ABORTION, REPORT, _______________ ____________ _____________

ECTOPIC PREGNANCY/TUBAL PREGNANCY= any blastocyst implantation outside

the uterus.
Most common site= Ampulla of the fallopian tube= largest portion of the tube
Next most common site= isthmus of the fallopian tube
97%= Fallopian Tube 0.5%= Ovary. 0.3%= cervix. 1.5% abdominal cavity)

Highest risk factors

Previous PID (chlamydia, gonorrhea, postpartum endometritis, postabortal uterine
infections)
Previous Ectopic Pregnancy, Previous BTL, Previous Tubal or Pelvic Surgeries

Lesser risk
Maternal Smoking at the time of conception
Signs and symptoms
BEFORE RUPTURED-
1.CLASSIC SYMPTOMS= lower and unilateral abdominal pain, delayed menses,
abnormal vaginal bleeding (dark red/ brown) on 6-8 th week
2. low hcg, low estrogen, low progesterone, etc

AFTER TUBAL RUPTURE

1. Deep, generalized, unilateral, acute lower quadrant ABDOMINAL PAIN
2. Cullen’s sign= bluish navel / hematoperitoneum / indicative of
_____________________
3. Kehr’s sign= referred pain (pain radiating to neck and right shoulder due to
stimulation to phrenic nerve or diaphragmatic irritation from the blood in the
peritoneal cavity)
4. Pain on IE due to bleeding in the cul-de-sac of Douglas

MANAGEMENT
 Non- Surgical treatment= Methotrexate
(ectopic sac is smaller than 3.5cm in diameter, serum hcg levels < 5000Miu/Ml,
liver function test within normal levels, normal kidney function, no evidence of
thrombocytopenia)
 Surgical Treatment for unruptured tubal pregnancy=
Laparoscopic Salphingostomy- incision is made over the pregnancy site and
the product of conception is carefully removed. Test hcg levels after surgery.

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  Surgical Treatment for ruptured tubal pregnancy= Salphigectomy

HYDATIDIFORM MOLE = the chorionic villi develop into edematous, cystic, avascular
transparent vesicles that hang in a grapelike cluster.
OTHER TERMS=
CAUSE:

SIGNS AND SYMPTOMS

1. uterus larger than the estimated gestational age.
2. snowstorm pattern seen in UTZ
3.passage of vesicles
4. excessive hcg
5. hyperemesis gravidarum
6. HPN before 20 weeks
7. no fetal heart tone
8. ovarian enlargement
9. prune juice/ brown bleeding

TYPES OF H-MOLE
PARTIAL H-MOLE COMPLETE H-MOLE

Localized areas of chorionic villi become Generalized areas of the chorionic villi
hyperplastic and avascular become hyperplastic and avascular

69, (XXY, XXX, XYY) Triploid karyotype, 46, Diploid karyotype,

One set of chromosomes of maternal in A sperm fertilizes an ovum with no

origin and 2 sets of paternal in origin genetic material

(Dispermy) Androgenesis (duplication of paternal

There is an embryo/ non-viable fetus and
an amniotic sac with multiple congenital
anomalies and never matures
set of chromosomes)
History of clomid therapy.
No embryo or the embryo dies very
early. No Fetus, No amniotic sac

High risk for choriocarcinoma

after surgical evacuation of a complete

H-mole, there is 20 percent risk for
developing cancer.

Diagnostic test: transvaginal ultrasound and serum hCG

MANAGEMENT

1. Remove the moles = suction evacuation/D and C.

2. Oxytocin after evacuation. Do not give oxytocin before surgery because of the
increased risk for trophoblastic embolization
3. follow up visits=check hcg levels for 6-12 months.
___________________________________
4. regular chest X-ray and regular pelvic examinations

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 5. anti-cancer drugs. ________________________

Other considerations
 No pregnancy for at least 1 year. Recommend to use contraception.
 Abdominal Hysterectomy if _______________

INCOMPETENT CERVIX- Painless premature cervical dilatation Before 20 weeks.

SIGN= bloody show before 20 weeks.

Best diagnostic tool to detect: Transvaginal Ultrasound

Management: Cervical Cerclage: cervical suturing

Types of Cervical Cerclage

Shirodkar
Mc Donald’s

AFTER SUTURING:
1. POSITION= Modified Trendelenburg to _______________________
2. WHAT TO OBSERVE= ROM, contraction, V/S

#3RD TRIMESTER BLEEDING DISORDERS

PLACENTA PREVIA Abruptio PLACENTA
IMPLANTATION
1. complete TYPES 1. covert
2. partial 2. overt
3. marginal

BLEEDING
COLOR
UTERUS
PAIN
MOST
COMMON
CAUSE
Other causes Other Causes
S- S
P- C-
A- A-
M-
#Placenta Previa cannot be diagnosed on
the first 5 months of pregnancy.
#no IE Abruptio placenta Grading
#no SEX
Grade 1= less than 1/2 of the placental separates
prematurely with mild bleeding, no painful contractions,
Expectant Management vague lower back discomfort, no fetal distress, no
boardlike abdomen. Total blood loss less than 500ml.
1. Sufficient migration of placenta
this can progress to a more advanced form.
away from the cervix.
2. Prevent and control minimal Grade 2= ½ of the placenta separates prematurely,

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 bleeding moderate bleeding, with painful contractions, tender on
3. Increase maturity of the fetus palpation, with possible fetal distress, with Board-like
4. Bed rest abdomen. Uterine tenderness and maternal
5. Double set up tachycardia are present. Total blood loss is 1000-
1500ML

Grade 3= more than ½ of the placenta separates

prematurely. FHR shows fetal distress. Knifelike
abdominal pain, uterus fails to relax, Severe bleeding
which may lead to shock and fetal death can occur.
Moderate to profound sock common. Total blood loss is
more than 1500ml

#in Abruptio Placenta delivery of the baby is the

best management.

THE INTRAPARTAL PERIOD

REAL CAUSE: unknown The woman in labor is called: Parturient

Theories of Labor
1. Uterine stretch Theory/ Uterine Myometrial Irritability =
2. Prostaglandin Theory
3. Progesterone Deprivation Theory
4. Aging Placenta starting on ____________
5. Oxytocin Theory due to stimulation of Posterior Pituitary Gland

Preliminary signs of labor

LIGHTENING/BABY DROP Signs- increase urinary frequency, shooting pain radiating to

legs due to stimulation to_____________, relief of dyspnea,
increase vaginal discharges.

It occurs ______ weeks before labor for PRIMI

and ______________ for MULTI.

Braxton hick’s contraction- Tightening and pulling sensation sensation

increases 3-4 weeks before
labor
weight loss 1-2 lbs due to ______________
ripe cervix Buttersoft means______________________
increasing energy due to ___________________
ROM Occasional sign

SIGNS OF TRUE AND FALSE LABOR

CRITERIA TRUE LABOR FALSE LABOR

contraction

discomfort

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cervix with changes no changes
DILATATION- widening of external os
Do IE every _____
EFFACEMENT- thinning of the cervical
canal
MULTI=___________________________
PRIMI=___________________________
walking

Show- pinkish vaginal discharge

DURATION- from the beginning of

contraction to end of the same
contraction.
FREQUENCY-from the beginning
of contraction to the beginning of
the next contraction.
INTENSITY- strength of
contraction
What is?
INCREMENT/ crescendo
#ACME= peak of contraction
DECREMENT/ decrescendo

INTERVAL- from the end of one

contraction to the beginning of the
next contraction.

TOCOLYTIC AGENTS
= use to stop/halt labor for a short time (up to 48 hours) if you begin labor TOO EARLY
in your pregnancy to provide window for administration of antenatal corticosteroid.

CONTRAINDICATIONS
1. Cervical dilatation is greater than 3 cm
2. Cardiac disease
3. Fetal distress
4. Abruption placenta
5. PROM
6. chorioamnionitis

PAIN MANAGEMENT DURING LABOR

The pain and stress of the mother during labor increases woman’s oxygen consumption
decreasing the amount of Oxygen to the fetus.

1. Administration of Analgesia- administered to nulliparas when the active phase

of labor is well established (5-6cm dilated) and to multiparas when the cervix is at
4cm. the fetal presenting part must be engaged and meconium staining is not
present.
2. Analgesia given too early can prolong labor and depress the fetus
3. Analgesia given too late can lead to neonatal respiratory depression
4. Oral analgesics are not used because they are poorly absorbed and gastric
time is prolonged in labor. IM and IV are used instead.

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 FETAL STATION- the relationship of presenting part to ischial spine. Most important
criterion before allowing the mother to walk on labor

MINUS STATION= above the ischial spine, floating

PLUS STATION= below the ischial spine

(- 1 to – 5) = Floating (0 +1 +2) = Engaged (+3 +4 +5) = Crowning

STATION STATUS OF THE Is AMBULATION

BOW allowed?

minus intact
minus ruptured
0 +1 +2 ruptured
0 +1 +2 intact
+3 +4 +5 ruptured/ intact

DECELERATIONS
TYPES COMMON CAUSE and management
EARLY Head compression. Mirror image.
Management:
LATE Utero placental insufficiency. Uniform image.
Management:
VARIABLE Cord compression. Unpredictable image.
Management:

SIGNS OF FETAL DISTRESS

 hyperactive fetus due to ____________ which increases the FHR
 meconium staining except for ___________

STAGES OF LABOR
1ST STAGE OFLABOR/ CERVICAL DILATATION STAGE
LATENT ACTIVE TRANSITION
DILATATION 0-3 cm 4-7 cm 8-10 cm
DURATION 20-40 sec 40-60 sec 60-70 sec
FREQUENCY Every 5-10 min Every 3-5 min Every 2-3 min
INTENSITY mild moderate strong
BEHAVIOR excited Fear of losing control Resistance to
touch
CONSIDERATIONS Give instructions Give analgesia Reassure the
mother

2ND STAGE OF LABOR= FETAL EXPULSION STAGE

temperature of delivery room

transfer to delivery room primipara _______multipara_______
wear double sterile gloves
wash hands just before delivery

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 most common birthing position
surest sign that the baby is about to be bulging of the perineum
delivered
when to push during contractions, fully dilated cervix
when not to push not fully dilated cervix, intervals, delivery
of the head

MECHANISMS OF LABOR
o Engagement
o Descent
o Flexion
o Internal rotation
o Extension= delivery of the head
o External rotation
o Expulsion

3RD STAGE OF LABOR = Placental Expulsion stage. The placenta is delivered

______ minutes after delivery of the baby. Then count for the completeness of placental
cotyledons. ________. Prolonged 3rd stage of labor = _____________________

Active Management of the Third stage of Labor

1. Administration of Uterotonic -(10 units Oxytocin, IM, within one minute of
baby’s birth)
2. Controlled Cord Traction with Counter Traction- push the fundus upward with
one hand while applying continuous traction on the cord with the other hand.
3. Uterine Massage – after placental delivery until the fundus is firm and every 10
minutes for one hour.

NOTES:

1. OXYTOCIN should be offered to all women on the third stage of labor-

= NO CONTRAINDICATION, NO SIDE EFFECT
2. Methergine 0.2 mg IM- with contraindication _____________ and side
effects= vomiting, headache, may retain placenta, increases BP, tonic
contractions.
3. Misoprostol 600 mcg PO – no contraindication but with side effects=
shivering and elevated temperature.
4. If there are no uterotonics available, do CCT and Massage
5. DO NOT WAIT for signs of placental separation. (calkin’s sign, sudden gush of
blood, lengthening of the cord)
6. DO NOT pull the cord while the placenta is not yet detached. AT RISK FOR
UTERINE INVERSION

TYPES OF PLACENTAL DELIVERY

SCHULTZ Fetal surface

DUNCAN Maternal surface

4TH STAGE OF LABOR (_____________________) MOST___________________

VITAL SIGNS checking on the first hour is every ______________

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 TEMPERATURE Increased on the first day due to _______________
BP Slightly elevated
RR Fairly rapid immediately after birth (20-24cpm)
PR Fairly rapid immediately after birth (80-90bpm) then it
decreases to 50-70bpm for the first week

Characteristics of Fundus after delivery:

Normal: firm, contracting, midline, below the umbilicus

If the fundus is soft and boggy = Uterine Atony

If the fundus is deviated to the side = Full bladder
If the fundus is firm but there is steady Laceration
trickle of blood =

Assess the Uterine fundus

1. Every 15 minutes during the first hour
2. Every hour for the first 24 hours
3. Every 4 hours for the next 24 hours
4. Every 8 hours thereafter

#LOCATION OF THE FUNDUS

after delivery of the Midway between the umbilicus and the symphysis pubis
placenta
after 1 to 2 hours At the level of umbilicus
after 24 hours One fingerbreadth below the umbilicus
10th day Non palpable

DEGREE OF LACERATION
Vagina, Fourchette, skin of perineum 1st
muscles of perineum, 2nd
anal sphincter, 3rd
rectal mucosa 4th

POSTPARTAL Period = The first 6 weeks after delivery.

INVOLUTION= Complete return of the reproductive organs to non-pregnant state

for 6 weeks
4th stage of labor 1000-1100g
After 2 weeks 500g
After 3-4 weeks 300g
After 5-6 weeks 50-60g

SUBINVOLUTION= incomplete return of the uterus to non-pregnant state after 5-6

weeks. Most common cause ______________________

Evaluating Lochia
1. Color: Red, Pinkish, Brownish, whitish
2. Odor: fleshy, musky, non-offensive, non-foul
3. Amount: heavy, moderate, light and scant

Psychological Response on Postpartum

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 Taking-In Health teaching on
(first 3 days) Dependent phase ___________________
Taking-hold Health teaching on
(4th to 6th day) Independent phase ___________________
Letting go Health teaching on
(7th day and above) Interdependent phase ___________________

OTHER NOTES
1. the placental site is healed by _______ weeks
2. a new endometrium is formed_______ weeks after delivery
3. during a vaginal birth, blood loss ranges from _________________
4. During a cesarean birth, blood loss ranges from ________________
5. VBAC is only allowed for a woman undergone ________________

6. sex can be resumed when lochia flow has stopped and episiorrhaphy is
healed.
7. cervix after delivery= transverse slit
8. the use of old diaphragm and old cervical cap after delivery is _____________
9. the use of new Diaphragm is delayed in 6 weeks if the mother is
breastfeeding. But 3 weeks for a mother who is not breastfeeding.
10. vagina returns to pre pregnant state by _______weeks
11. for non- lactating mother, ovulation resumes after_________ weeks
12. for lactating mother, ovulation resumes after _______ months
because _________ inhibits ovulation.

13. Lactation Amenorrhea Method is only effective on the first ______.

14. All contraception with ____________ are not allowed for Lactating Mothers.
15. Progesterone Only Pill (POP) is ___________ for lactating mothers.
16. Women who has a rubella titer of less than 1:10 are usually given rubella
vaccine in the postpartum period. And instruct the mother that pregnancy is not
allowed for ______ months.
17. All Rh negative women who meet specific criteria should receive RhoGAM
18. Rubella vaccine is delayed in few weeks if the mother is for RhoGAM
administration.
19. WBC is ____________if labor is prolonged
20. hunger will start to increase ____________ hours after birth
21. first bowel movement normally occurs by ________ days postpartum.
22. immediate weight loss after delivery _______________________
23. weight loss in the 1st week ____________________________
24. weight loss in the next 6 weeks _____________________
25. most women return to their pre-pregnant weight by___________ mos.
26. the best schedule for breastfeeding ______________
27. What are the 3 Es of Breastfeeding__________ ____________ ___________?

Let GOD write your story…

Congratulations!
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