OB GYNE
A. Reproductive development Girls: 10-13 years old
Boys: 12-14 years old REPRODUCTIVE DEVELOPMENT
Mons pubis – protect the symphysis pubis Labia Minora – covers the vagina
- Skin fold abundant with sebaceous gland
Labia Majora – middle-mucus membrane
- Protection for the external genitalia
Clitoris – erogenous zone
Vestibule – encloses the vaginal orifice Skene’s gland – paraurethral gland
- lateral to the urinary meatus Bartholin’s gland – vulvovaginal glands
- lateral to the vaginal opening - lubricate the vagina during coitus Fourchette – joins the labia minora posteriorly
Perineum – contains the vulvocavernosus muscle BLOOD VESSEL
- Pudendal Artery and a part of the inferior rectus artery - Pudendal vein
VULBAR NERVE
- Ilioinguinal and Genitofemoral nerve - Pudendal nerve
Vagina – organ of copulation VAGINAL MUCUS
- Increase glycogen - Doderlein’s bacteria
- Acidity: 4.5-5.5, prevents infection
Uterus – 5-7cm long, 5cm wide, 2.5cm deep
- Houses the fetus, maximize size at 17 years old
ISTHMUS – stretch to accommodate the fetus; 9m thin CORPUS – Body
FUNDUS – uppermost portion UTERINE LAYERS
1. Endometrium – basal layer - glandular layer 2. Myometrium
3. Perimetrium FALLOPIAN TUBE
2. AMPULLA – widest layer of the fallopian tube 3. ISTHMUS
HORMONES
Estrogen – Secondary sex characteristics - maintains productive size - prevents osteoporosis
- keep cholesterol level reduced Progesterone – milk production
- uterus thickness PREGNANCY
Fertilization – union of ovum and sperm cell
Capacitation – final process that spermatozoa undergo during fertilization
IMPLANTATION
Zygote – fusion of ovum and sperm
Morula – when zygote reaches body of uterus, it consist of 26-50 cells
Blastocyst – implants
Tropoblast cells – placenta and membrane Embryocyst – embryo
Apposition – blastocyst brushes against endometrium Adhesion – attachment
Invasion – settles down CHORIONIC VILLI
Syncytiotropoblast
Hormones: HCG, Estrogen, Progesterone, HPL-insulin Cytotropoblast
Langhan’s layer
Protect against syphilis PLACENTA and UMBILICAL CORD
- Communication arises from the tropoblast - 12th day of pregnancy: cotyledons
WHARTON’s JELLY
- Prevents compression
AMNIOTIC FLUID
Amount of term: 800-1,200ml Slightly alkaline
GERM LAYERS
1. Ectoderm – outside
- CNS, PNS, organs, skin, hair, nails, mouth, anus… 2. Mesoderm
- Heart, teeth, upper portion of GUT (kidneys, bladder) 3. Endoderm
- Lining (GI) CARDIOVASCULAR SYSTEM
First organ
Single heart tube: 16th day
Beat: 24th day
Heard: 10-12th week
RESPIRATORY SYSTEM
3rd week development
4th week: separates
TRACHEO_ESOPHEGEAL FISTULA: No separation 24-28th day: alveoli and capillaries form
12th week: respiratory movements
NERVOUS SYSTEM
3rd week: neural plate
24th week: hear and see with papillary reaction
ENDOCRINE SYSTEM
Fetal adrenal glands supply a precursor for estrogen synthesis Insulin production
DIGESTIVE SYSTEM
4th week: GIT and RT separates
6th week: a portion of the intestines enters the base of the
umbilical cord
10th week: fetal trunk extends
16th week: meconium formation
32nd week: sucking and swallowing
MUSCULOSKELETAL SYSTEM
2nd week: Cartilage prototype
11th week: Fetal movement
12th week: bone ossification
20th week: quickening
REPRODUCTIVE SYSTEM
6th week: Gonads
12th week: sedimentary urine
FETAL GROWTH and DEVELOPMENT 9-12 weeks
Sex determination
First and second movement Nail beds are forming
Heart sound is heard through Doppler technology 13-16 weeks
Fetal heart sound auscultated Liver and pancreas functions
Sex is determined by ultrasonography 17-20 weeks
Fetal kicking
Meconium is present in the upper intestine Mother experiences fatigue, dizziness and SOB 21-24 weeks
Passive Ab
Eyebrows and Eyelashes are well defined Pupils capable of reacting to light Vernix and Fingernails development 24-28 weeks
Lung alveoli begin to mature
Surfactant is produced in the lungs Testes begun to descend
Maternal: Leg cramps 29-32 weeks
Active Moro reflex
Birth position may be assumed Iron stores
Fingernails grow to reach the end of the fingertips GIT matures
Maternal: Ankle swell, Constipation 33-36 weeks
Lanugo disappears
Maternal: Backache, urinary frequency, uterine contractions 37-40 weeks
Iron and Ca stored
Fetal Kicking causes discomforts Vernix Caseosa is fully formed
PRENATAL CARE Gynecology History a. Naegele’s rule -3 +7 +1 b. Mcdonald’s rule AOG in week Fundal Height(cm) x 8/7 AOG in lunar months Fundal Height x 2/7
If LMP is known add all the number of days covered by the pregnancy DIAGNOSIS of Pregnancy Presumptive: Subjective Probable: Objective Positive sign ASSESSMENT Leopold’s maneuver LM1: Cephalic LM2: Umbilical-presentation LM3: Follyp grip-Engagement LM4: Attitude INTRAPARTAL CARE Psychological changes
First trimester: Ambivalence
Second trimester: Accepting the pregnancy Quickening
Imagines during birth
Feels they are left standing in their wings Third trimester: preparing for parenthood
Nest building
Role playing and fantasizing Nutrition
a. Carbohydrates
RDA: 2200 cal additional 300 cal b. Protein
950 grams – 6 months
Pregnant Adult: 68 grams/day
c. Minerals
Ca and phosphorus: 1200-1500 mg Iron: 30mg/day
Dietary supplement: 15mg/day
Foods to avoid: Caffeine, artificial sweeteners, weight loss diets MANAGEMENT
Nausea and Vomiting -dry crackers
-ice chips -low fats Heart burn
-small frequent feeding Flatulence
-no cabbage, onion rings… Edema/Varicose veins/SOB -frequent rest periods -elevate legs
-ambulate Hemorrhoids
-increase fiber and fluid
Leg cramps
-Ca and exercise Backache
-exercise
Vaginal discharge
-change underwear frequently -use cotton
Abdominal Tightening
-tailor sitting: perineum -chin to chest: Abdomen -pelvic rocking: pain
COMPONENTS OF LABOR POWERS
1. Primary power: uterine contractions 2. Secondary power: abdominal contractions 3.
PASSENGER Fetal head Fontanelles
Fetal Head diameters
Suboccipitobregmatic: complete flexion, small diameter of head enters the pelvis, 9.5cm
Occipitofrontal: moderate extension, larger diameter of head enters the pelvi, 9.5cm
Occipitomental: marked extension, head is too large PASSAGEWAY
False pelvis True pelvis
Types: Gynecoid, Anthropoid, Android and Platypoid POSITION OF THE MOTHER
STAGES OF LABOR
First stage Second stage Third stage
Latent phase Contraction: 20-40s Cervix dilates: 0-3cm Active: Contractions: 40-60s Cervix dilates: 4-7cm Transitional Contractions: 60-90s Cervix dilates: 8-10cm Full dilation to Delivery of the baby Mechanism of labor Descent, Flexion, Internal rotation, Extension, External rotation, expulsion Placenta is delivered 15-20 min. Signs of placental separation
-blood gushes out -fundus becomes globular
-lengthening of the cord
Rubin’s postpartal phase Taking-in phase
-First 2-3 days -focused on self Taking-hold phase -3rd-2nd week
-concern is focused on ability to assume mother roles -tends to outworn herself
Letting-Go phase
-realizes that infant is a separate individual -experiences a feeling of love
-adjust herself and lifestyle to meet the needs of the child OB ABNORMALS
Complications of pregnancy
1. Bleeding disorders of pregnancy Hemorrhage
Hypovolemic shock (1.5-2 liters) Retinal Hemorrhage
Abortion (loss before 20 weeks) Management
-Tocolytics
Prevent contraction (terbutaline, isoxuprine)
-sexual intercourse (2 weeks after the last day of bleeding) 2. Ectopic pregnancy
Pregnancy outside the uterus Causes
Mechanical factors Functional factors Assisted production
Failed contraception Management
Medical: Methotrexate (chemotherapeutic: acts on the embryo) Salphyngectomy
Treat hemorrhage, pain and give emotional support 3. Hydatidiform mole
Brownish discharges
Fundic height is not congruent to AOG Causes Age Asian Bleeding Management D&C Methotrexate Monitoring HCG Hysterectomy 4. Incompetent cervix Habitual abortion Causes
Cerclage: suture the cervix (Mcdonald,Shirodkan) 5. Placenta previa
Painless vaginal bleeding Types a. Low lying b. Partialis c. Totalis Causes Multiple pregnancy Multiparity Previous surgery Management IE in double set-up Assess blood loss
Watchful waiting if <36 weeks CBR without BRP’s Nursing Interventions CBR Tocolytics Betamethasone Amniocentesis
6. Abruptio placenta
Painful vaginal bleeding
Board-like rigidity of abdomen Causes
Multiple pregnancies Short umbilical cord Hypertension
Management
Refer immediately Caesarean section
7. Premature rupture of membrane
Rupture of bag of water before age of term Watery vaginal discharges
Fern test Litmus paper
Pooling of fluid in the posterior Vaginal examination Causes Poor nutrition Incompetent cervix Infection Management Asked history CBR Antibiotic 8. Premature Labor LBW: <2 VLBW: <1.5 ELBW: <1 LGA: >90% SGA: <90% Causes History of PTL 2nd trimester abortion Epidemiological Overdistention Uterine abnormalities Maternal infections Management Tocolytics
9. Post term pregnancy More than 42 weeks AOG Management
Induced labor (Cytotec)
Delivered: Tracheal suctioning Warm infant
Assess for hypoglycemia: irritable infant 10. Hydramnios
High fundic height Increase AFI
Causes
Fetal – problem in GI tract
Maternal – produce more amniotic fluid Management
Instructions on relief of symptoms Hospitalization
Indomethacin (NSAID: inhibit prostaglandin synthesis) Amniocentesis 11. Oligohydramnios <500mL Causes Urinary problem-fetal Management
Observe for cord compression, fetal hypoxia and prolonged labor Increase fluid intake
12. Hyperemesis Gravidarum Nausea and dehydration Causes
HCG
Thyroid dysfunction Psychological stress Management
Small frequent feeding IVF and fluids
Antiemetics
Emotional support 13. PICA
Intake of non-edible foods Effect: Imbalance nutrition Management
14. Anemias in Pregnancy IDA: hgb <11, hct <33
Vitamin B12 deficiency Anemia due to blood loss Folate deficiency Paleness Episodes of dizziness Hypotension Management Iron supplementation 15. Hemolytic Diseases ABO incompatibility -Rh: coombs test Management
RHOGAM: 28 weeks AOG to 3 days after delivery Newborn: Phototherapy
Exchange transfusion
MEDICAL CONDITIONS in PREGNANCY 1. Diabetes Mellitus
Insulin resistance due to HPL Diagnostics
FBS: 70-110
OGTT: FBS+ 75 grams of glucose, then take blood sugar after 3 hours Management
Insulin SQ
Measure caloric need Blood Glucose Monitoring Exercise
2. Cardiac condition
Cardiac classification Class I: no symptoms
Class II: less than ordinary activities Class III: ordinary activities
Class IV: even at rest
Pregnancy Induced Hypertension Pre-ecclampsia
Ecclampsia Nursing Management
Bed rest in left lateral recumbent position Monitor BP
Daily weight and I&O High protein diet Monitor FHT
Antihypertensive
Seizure precaution for the next 48 hours
Meds: Magnesium sulfate, Diazepam and hydralazine (methyldopa) 3. Uterine Dysfunction
Hypotonic uterine dysfunction: poor uterine contraction Hypertonic uterine dysfunction: intense uterine contraction Management
Rule out CPD Vaginal Delivery Maintain F and E Therapeutic rest Keep bladder empty Side lying
Bandl’s ring: pathologic indentation
If bandl’s ring occurs during 2nd stage, manual extraction of
placenta
4. Precipitate Labor
Precipitate dilatation: >5cm Descent: more than 5 minutes 5. Uterine rupture
Sudden sharp tearing pain Palpable fetus, no FHT
Causes
Scar rupture from previous CS Prolonged obstructed labor Malposition malpresentation Overdistended uterus External trauma Management IVF, BT Oxygen Emergency laparotomy 6. Uterine Inversion Nonpalpable fundus Sudden gash of blood Uterus in the vagina
Causes
Pulling of umbilical cord in a contracted uterus Uterine relaxation due to analgesia
Management
Prevention
Replace uterus and give oxytocin If placenta attached: anesthesia BT, IVF
7. Prolapsed Umbilical Cord
Early, late and variable desceleration Causes Polyhydramnios Long cord Malposition/malpresentation Prematurity Management
If cord is already outside: Cover with gauze
Trendelenburg position Knee chest position 8. Pelvic dystocia
Severe pain at the back
Inlet contracture: AP diameter <10cm
Transverse diameter <12cm Outlet contracture: Bi ischial diameter <8cm Management Backrubs 9. Shoulder dystocia Turtle sign Management HELPERR
Help, Legs: Mcroberts’s maneuver, Pubic: Suprapubic pressure, Enter maneuver: Internal rotation, Remove the posterior arm, roll the mother
COMPLICATIONS DURING THE POSTPARTUM PERIOD 1. Postpartum Hemorrhage
Assessment Hypotension Increase RR
Palpate fundus, inspect vagina, monitor urine output, monitor LOC Management
Keep warm Oxygen BT
2. Uterine Atony Management
Massage uterine packing
Bladder empty Laparotomy
Bimanual compression Oxytocins 3. Uterine subinvolution Fails to contract Foul smelling Causes Placental fragment Ongoing infection Management Ergoverine maleate 4. Sheehan’s syndrome
Pituitary gland-Decrease blood supply Management
Hormonal replacement therapy 5. Puerperial Infections
Fever: 2 or more days after the first 24 hours postpartum Foul smelling
Abdominal pain tenderness, body malaise Lack of appetite
Perineal discomfort Management
Hygiene perineal lamp Analgesics
6. Endometritis
3-4 or 7 days after delivery Causes
Poor aseptic technique Frequent IE
Poor hygiene Management
Suture removal semi-fowler
Antibiotic analgesic and oxytocin Perineal hygiene
7. Post partum Blues
3-5 days after childbirth
Periodic drying spells, sadness, confusion, insomnia anxiety Self-limiting
Supportive care and education 8. Post partum depression
Months after childbirth
Anorexia, weight loss, fear of harming the baby, neglect of personal care, self-destructive
Management
Counselling Group therapy
Therapeutic communication Assistance in doing ADL’s Monitor suicidal tendencies 9. Post partum psychosis
2-4 weeks following childbirth
Early symptom depression but may escalate to delirium and hallucinations
Bizarre behavior and anger to baby Management
Hospitalization Psychotherapy