ANTEPARTUM FETAL ASSESSMENT hours is considered

normal
Antepartum fetal surveillance procedures
▪ Done at least everyday at
- Fetal movement counting the same time of the day to
- Nonstress test compare
- Vibroacoustic stimulation o Rayburn, 1980 – 80% of all
- Contraction stress tests movements observed during
- Biophysical profile sonography monitoring were
- Doppler velocimetry perceived by the mother
o Johnson, 1992 – beyond 37
Fetal Movement Counting weeks, mothers perceived only
Fetal movements 16% of the fetal movements
- Use of uterine contraction
- Observed by ultrasound as early as 8 weeks tocodynamometer
AOG but the mother can start to feel it o Tocodynamometer – composed
around weeks AOG especially for of transducers attached to the
primigravid maternal abdomen (fundal end)
- Can be either: which can record the number of
o Weak movements and reflected on a
o Strong paper strip
o Rolling movements o Cardiotocography – similar to an
- Appreciated easily by multigravida (4 ECG where you need a thermal
months) mothers compared to primigravid paper to record the FHR. Uterine
(5 months) contractions are also recorded
- Weak movements decrease as pregnancy ▪ Device is usually set at
advances – due to declining amniotic fluid 3cm/ min
and space account for diminishing activity ▪ Important to determine
at term certain changes such as
Factors affecting motility acceleration and
deceleration in the FHR
- Sleep-awake cycle - Visualization with sonography
o Most important determinant of fetal
activity Nonstress test (NST)
o Independent of maternal sleep- - Simple to perform, relatively quick and
awake state non-invasive
o Sleep cyclicity: 20-75 mins (average - Describes FHR acceleration in response
sleep cycle is 20-30 mins only) to fetal movement as a sign of fetal
- Amniotic fluid volume health
o Decreased fetal activity with o Fetal heart rate acceleration – sign
diminished amniotic fluid volumes for fetal well-being; wellness
and suggested that a restricted rather than illness
intrauterine space might physically - Widely used for primary testing method
limit fetal movements for assessment of fetal well-being
Clinical methods to quantify fetal movements - Also incorporated into the biophysical
profile
- Maternal subjective perceptions
o Let the mother count the FHR Accelerations
movement - Fetal heart rate accelerations
o Cheapest and easiest way o For fetus > 32 weeks: the
o Count of 10 (Moore, 1989) acceleration peak is 15 bpm or
▪ Perception of 10 fetal more above the baseline rate;
movements in up to 2 lasts for 15 seconds or longer but
less than 2 minutes
 ▪ 2-10 mins: prolonged Interval between testing
acceleration
- Every 7 days: ideal
▪ >10mins: used as new
- In certain cases, it can be done more
baseline
frequently (patients with comorbidities)
o For fetuses < 32 weeks: normal
o Increased if mother has
accelerations are defined as having
uncontrolled HTN and DM, as well
an acme that is 10 bpm or more
as case wherein intrauterine growth
above the baseline for 10 seconds
restriction is considered
or longer
- ACOG, 2016
- Principle behind testing:
o Frequent testing should be done
o HR of a fetus will transiently
for patients with:
accelerate in response to fetal
▪ Post-term pregnancy
movement
▪ Multifetal gestation
- Factors that cause loss of reactivity:
▪ Diabetes
o Fetal sleep
▪ Fetal growth restriction
o Medications that cause central
▪ Pregnancy HTN (twice
depression
weekly)
o Cigarette smoking
- Note!! Causes of fetal death within 7 days of normal
o Absence does not invariably predict nonstress test
fetal compromise
o Determine the baseline FHR to - Meconium aspiration syndrome
determine increase or decrease. o Most common cause
Baseline is defined as the area that o Associated with umbilical cord
is a the most stable part or no abnormality → acute asphyxia
recording of movements insult → provokes fetal gasping
- Intrauterine infections
NST interpretations - Abnormal cord position
- Malformations
- Reactive
- Placental abruption
o Requires at least 2 or more
accelerations occurring within 20 Decelerations during nonstress testing
minutes of beginning of the test
o Accelerations with or without fetal - Take note!!
movements should also accepted; a o Variable decelerations if
40 minute or longer tracing should nonrepetitive and brief (<30
be performed before concluding seconds) do not indicate fetal
nonreactive status compromise or the need for
o Other criteria: normal fetal heart obstetrical interventions
beat (110-160 bpm) with normal o On the other hand, repetitive
variability variable decelerations (at least 3
- Non-reactive (abnormal) in 20 minutes), even if mild, have
o Reactive criteria not met been associated with greater
o A 40-minute or longer should be risk of CS delivery
performed before concluding ▪ Decelerations lasting > 1
nonreactive status minute have worse
o Note!! prognosis
▪ Not always ominous; baby ▪ Correlate w/ amniotic fluid
may be asleep volume
▪ Abnormal result may be Vibroacoustic Stimulation (VAS)
attributed to patients with
preeclampsia or with - Loud external sounds are used to startle
maternal HTN the fetus and thereby provoke heart
acceleration
 - Positive (+): rapid appearance of a time when deceleration
qualifying acceleration following starts
stimulation o E.g.: 3 late decelerations in 5
- Shortens the average time of NST from 24 observed contractions
minutes to 15 minutes - Equivocal
o Suspicious
Contraction Stress Test (CST)
▪ Intermittent late
- Artificially induced decelerations or
- To observe changes to the FHR in significant variable
relation to uterine contractions decelerations; <50% of
- Rationale: evaluates the status of basal uterine contractions
fetal oxygen reserves by observing FHR o Hyperstimulatory
response to uterine contraction ▪ FHR decelerations that
- A test of uteroplacental function occur in the presence of
- Endpoint: contractions more
o Achievement of 3 uterine frequent than every 2
contractions of at least 40 seconds minutes or lasting >90
or longer duration in 10 minutes seconds
- Unsatisfactory
Ways to perform CST o Fewer than 3 contractions in 10
- Oxytocin Challenge Test minutes or an uninterpretable
o A dilute IV infusion of oxytocin (10 tracing
units in 1 L liquid) is slowly and Indications for CST
gradually initiated until the desired
uterine contractions are achieved - Vaginal delivery is CONTEMPLATED
o Usually not done, or a 2nd choice to o (-) CST = allow mother to go into
nipple stimulation test labor
- Nipple Stimulation Test o (+) = do not allow mother to go
into labor
Criteria for interpretation of CST ▪ Fetus may not tolerate the
- Negative (normal finding) stress of labor since the
o No late or significant variable uteroplacental reserves are
decelerations already compromised
- Positive ▪ Baby may get asphyxiated
o Late decelerations following → leading to death
50% or more contractions - Presence of the following prior to labor
▪ Late decelerations: decline or o Postdated pregnancy
decrease FHR in association o DM
with uterine contractions but o Severe HTN
the timing is late o Oligohydramnios
• The timing of the onset, Contraindications for CST
the nadir, and the end of
FHR is late with the onset, - Vertical uterine scar
peak, and end of the o Hx of classical CS
uterine contractions ▪ Types of CS:
o Nadir: lowest point of • Lower segment (transverse)
the tracing; time – not contraindicated
when the contraction • Classical (vertical)
ends, subsequently o Contraindicated
the FHR recovers o Risk of uterine rupture
• The peak of the uterine as scar from surgery is
contraction is only the located at fundus, area
of which the most active
 during uterine Amniotic Fluid Normal: ≥ 1 pocket that
contraction Volume measures ≥ 2cm in 2
- Known placenta previa
(no. of
measurement
pocket/
in 2
perpendicular planes;
o Implantation of placenta at the perpendicular planes) polyhydramnios
lower part of the uterus below
the presenting part or head of the Abnormal: (-) or pocket < 2
cm in 2 perpendicular planes;
baby
oligohydramnios
o There is tendency to bleed
FHR Normal: ≥ 2 episodes of
during uterine contractions (episodes of acceleration
≥15bpm with fetal
FHR acceleration of ≥ 15
- Conditions at risk for preterm delivery movement w/in 30 mins) bpm of ≥ 15 second with
o Twins fetal movement within 30
o Polyhydramnios minutes
o Incompetent cervix
o Previous preterm labor Abnormal: < 2 episodes of
- Presence of spontaneous contractions acceleration or acceleration
of < 15 seconds duration
within 30 minutes
Biophysical Profile Testing (BPT)

- Components Fetal breathing and pattern

o Determined by real-time UTZ - Discontinuous/ episodic
▪ Fetal tone - Diurnal
▪ Fetal breathing - Maternal meal may increase fetal
▪ Fetal body movement breathing activity
▪ Amniotic fluid volume - Conditions that may lead to ↓ or (-) fetal
o Determined by electronic FHR beathing
monitoring o Hypoxia
▪ Nonstress test/FHR o Hypoglycemia
- Each variable is given a score of 0 (not o Sound stimuli
normal) or 2 (normal) o Cigarette smoking
o Nothing more in between o Amniocentesis
Component Interpretation o Gestational age
Fetal Tone Normal: ≥ 1 episode of o Labor
(assess extension and
subsequent return to
active extremity extension Fetal body movement and tone
flexion) and subsequent return to
flexion - Truncal movement: observe the spine
for rolling
Abnormal: either slow - Extremity movement: focus on the arms
extension with return to and legs (fetal tone)
partial flexion or movement
of limb in full extension Amniotic fluid volume
Fetal Body Normal: ≥ 3 discrete
- Rationale for testing: diminished
Movement body/limb movements in 30
(limb movements in 30
mins uteroplacental perfusion → lower fetal
mins)
renal flow → ↓ urine production →
Abnormal: ≤2 movement of oligohydramnios
body/limb within 30 minutes o Amniotic fluid is primarily made
Fetal Normal: ≥1 episode with up of fetal urine; less urine → less
Breathing ≥30 seconds duration AF
Movement within 30 mins - Clinical pearls:
(breathing episodes
within 30 mins) o Diabetic mothers: increased
Abnormal: (-) FBM or no maternal blood sugar triggers
episode of >30 secs duration the fetus to urinate more
in 30 mins frequently → polyhydramnios
 - Criteria in classifying AF volume o High diastolic flow = blood
o Oligohydramnios vessel is not constricted and
▪ Score = 0 faster blood flow
▪ Single deepest vertical o High waveform
pocket: <2 cm - High resistance
▪ Amniotic fluid index (AFI) o Vasoconstriction or obstructed
(sum or four quadrants): vessels
<5 cm o Low waveform
o Polyhydramnios
Basic Principles of Velocimetry
▪ Score = 2
▪ Single deepest vertical Analysis of Waveforms and Doppler Flow Indices
pocket: >8 cm
▪ AFI: >25 cm - Ascending limb of the waveform (systole)
o Deepest vertical index o Increase in the velocity secondary
▪ 2 cm > Oligo: Poly > 8 cm to high pressure gradient
o AFI generated by cardiac systole
▪ 5 cm > Oligo: Poly > 25 cm o Produced during each heart
contraction
Biophysical Profile Interpretation - Descending limb of the waveform (diastole)
Interpretatio Recommended
o Represents blood velocity during
Score diastole, and it is determined by
n Management
Normal,
No fetal indication for downward (distal) resistance
intervention, repeat
10 nonasphyxia and vessel wall compliance
test weekly; twice for
ted
diabetic patients
Diastolic wave
Normal,
8/10 (normal No fetal indication for
nonasphyxia - Most important in waveform
AFV) intervention
ted
interpretation
8/8 Chronic fetal
Deliver o Function of distal resistance and
(NST not done) asphyxia
If AFV is abnormal – vessel compliance
deliver - Higher waveform = dilated
If normal fluid at >36
week with favorable
vessels/low resistance → good tissue
Possible fetal cervix – deliver perfusion
6
asphyxia If repeat test ≤6,
deliver Vessels studied
If repeat test ≥6,
observe and repeat Umbilical artery (UA)
protocol
Probable Repeat testing same - Most studied
4 fetal day, if BPP score ≤6, - Recommended for management of fetal
asphyxia deliver
Almost
growth restriction
0–2 certain fetal Deliver - Amount of flow increases with
asphyxia gestation, reflecting decreasing placental
Note: Scores below 8 are indicated to deliver since waiting further could result to further compromise resulting
to fetal demise impedance
Doppler Velocimetry o S/D ratio declines from 4.0 at 20
weeks to <3.0 after 30 weeks to 2.0
- Assess fetoplacental and at term
uteroplacental circulation in a non- - Abnormal waveform: S/D ratio is >95th
invasive fashion percentile for gestational age
- Evaluate fetuses at risk of increased - Absent or reversal of end-diastolic
peripheral resistance and subsequent flow
fetal hypoxia and growth retardation o Associated with >70%
- Low resistance obliteration of arterioles in the
o Secondary to vasodilation placenta
o Increase impedance to UA blood
flow
Ductus venosus
- Last vessel that is examined. Only Vaginal/IE
examine when abnormalities are found in
- Done to determine how far into labor the
the MCA and UA
patient is
- Examined to check if the pregnancy can be
- Parameters assessed:
prolonged
o Amniotic fluid
o Gives an idea if the baby is already
o Cervical dilatation and effacement
in distress due to cardiac
o Presenting part
decompensation
o Station
- Biphasic waveform
o Assessment of the bony pelvis
o First peak reflects the ventricular
systole, and the second is Amniotic fluid assessment
ventricular diastolic filling
- Reversed flow of the a-wave of the DV - Colorless and odorless
o Late finding - Diagnostics (what to expect)
o The fetus has already sustained o Actual leakage
irreversible multiorgan damage due ▪ Gross pooling of fluid
to hypoxemia and was already near ▪ Reliable sign of ruptured
death bag of water
o Nitrazine test – tests for acidity of
Uterine Artery the vagina
▪ Vagina: acidic
- Characterized by high diastolic flow
▪ Amniotic fluid: basic
velocities and markedly turbulent flow
o Sudan test
o Nile blue test

CONDUCT OF NORMAL LABOR AND Cervical dilatation and effacement

DELIVERY - Effacement
FIRST STAGE OF LABOR AND DELIVERY o Shortening of the cervical canal
o Taking up of cervix to become a
- Is the patient really in labor? part of the lower uterine
segment
FALSE LABOR (BRAXTON HIGGS) VS. REAL/TRUE
o Measured in percentage
LABOR
- Dilatation
- Braxton Higgs Contraction o Opening of diameter of external
o Contractions that do not normally cervical OS
cause cervical dilatation o Measured in centimeters
o 10 cm: adequate dilatation for
Parameters False Labor True Labor
vaginal delivery
Character of Contractions
Regularity Irregular Regular Presenting part
Interval Long, transient Shortens
Intensity Unchanged, Increase - Portion of the fetus felt through the cervix
transient gradually during IE
Radiation of Mostly Hypogastric o Vertex (head): hard structure
Pain hypogastric to
lumbosacral
with fontanelles
Effects o Breech (limbs): soft structures
Cervical Usually long Open and o Shoulder: feel the scapula
dilatation and closed effacing o Face
Cervical Does not occur Occur and o Brow
effacement progresses
Sedation Responds Continues Station

- Level to which fetal presenting part has

descended into the maternal pelvis
 - Ischial spine (landmark used) - Complete PE
o Station 0: at the level of the ischial - Skin testing
spine o If there is indication for antibiotics
o Station -1: 1 cm ABOVE the ischial - Labs (CBC, HBsAg, Urinalysis, blood
spine typing)
o Station -2: 2 cm ABOVE the ischial - !! Avoid these:
spine o Shaving of the whole pudendal
o Station 1: 1 cm BELOW the ischial area
spine ▪ Only shave the site
o Station 5: sign that the baby is where episiotomy will be
about to come out performed
- Floating – presenting part still has not o Enema
reached Station – 3 o NPO
▪ Starving mother may easily
Assessment of the bony pelvis
get tired during delivery
- Performed to determine presence or
UTERINE CONTRACTIONS
absence of cephalopelvic disproportion
(CPD) between the pelvis of the mother - First thing to monitor once the patient is
and size of the baby (head) already at the emergency room
- Inlet - Felt over the fundus
o Measured using the diagonal - Adequate contractions: occur every 2-3
conjugate – distance between the minutes lasting 40-60 seconds with
sacral promontory and lower border moderate intensity
of the symphysis pubis o Promotes cervical dilatation and
o Obstetric conjugate: subtract 1 effacement
– 1.5 cm from the diagonal
FETAL HEART RATE MONITORING
conjugate
▪ At least 10 cm in the inlet - Electronic FHR
- Midplane o Uses a transducer to measure
o Plane that passes through the pressure inside the uterus and FHR
ischial spines and marks the ▪ Non-reassuring – indicates
level of the "true" pelvis, which is C-section
the area that the baby needs to - Doppler – handheld
pass through during vaginal birth - Stethoscope
o Criteria for vaginal delivery to occur - Normal Heartbeat: 110 – 150 (120 – 160
▪ Curved sacrum for other sources)
▪ Non-converging sidewalls
▪ Non-prominent ischial POSITION DURING LABOR
spines - Ambulate
▪ Wide suprapubic angle o For low-risk patients or without
▪ Sacrosciatic notch can comorbidities
accommodate 2 fingers - No restriction of activity
- Outlet o For low-risk patients or without
o Measured by the distance comorbidities
between the intertuberous - Left lateral decubitus
diameter o Relieves pressure on the IVC →
ADMITTING FACTORS greater blood flow to the uterus and
fetus
- Review prenatal records and screening o Indications: hypertensive,
history gravidocardiac, premature rupture
o Check for Hx of UTI of the membrane
o HBS (+) or (-) o
- VS (BP, CR, RR, Temperature)
PARTOGRAM ▪ Already a descent
disorder
- Graphical representation of all data
o Cervical dilatation phase – at 6 – 8
that happens during labor
cm
- Made by Friedman
- Includes the following data Descent Disorder
o Cervical dilatation – sigmoid curve
- No descent of fetal head after one hour
o Descent – hyperbolic curve
- Diagnosis is made only during
o FHR
deceleration phase
o Contractions
o Where cardinal movements of labor
o Progress of labor
happen
- Labor is divided into 3 divisions:
- Arrest of descent
o Preparatory division – not much
o If fetal head is below station 0
cervical dilatation
- Failure of descent
▪ Cervix becomes softer to
o Fetal head is at station 0 and
prepare of dilatation
above
o Dilatation Division – cervical
dilatation
▪ Latent phase
• Mother perceives SECOND STAGE OF LABOR AND DELIVERY
regular contractions - Patient is now fully dilated, fully
▪ Active phase effaced, station +5
o Pelvic division – cardinal - Cervical dilatation to delivery of the
movements of labor will occur baby
Labor Disorders - Contractions: last 90 seconds occurring
every 1-2 mins
- Protraction disorder - Duration (varies)
o Slow rate of cervical o Nulliparas: 50 minutes
dilatation/descent o Multiparas: 20 minutes
- Arrest Disorder
o Complete cessation of cervical FETAL HEART TONES
dilatation/descent - Baby starts to show decreased heart
Cervical Dilatation rate as delivery advances
Nulliparas 1.2 cm/hr - Monitor
Multiparas 1.5 cm/hr o Every 15 mins: low risk
Descent o Every 5 mins: high risk
Nulliparas 1 cm/hr FETAL PRESENTATION
Multiparas 2 cm/hr
- 95% of all pregnancies present in vertex
presentation
Arrest Disorder
- Determined by Leopold’s maneuver
- Arrest of cervical dilatation o L1 – assess uterine fundus;
o No change in cervical dilatation permits identification of fetal lie
after 4 hours and presentation
o 6 centimeters – new standard ▪ Cephalic – large, hard,
▪ Indicates entering into round
active phase of labor ▪ Breech – large, nodular
▪ !! Do not make arrest o L2 – define the presenting part’s
disorder dx before 6 cm position
- Dilatational disorders are not made ▪ Palms are positioned on
during deceleration phase either side of the maternal
o Deceleration phase – 9 – 10 cm abdomen (umbilicus)
 ▪ Back – hard, resistant; o Anterior asynclitism – sagittal
indicates where the suture approaches the sacral
occiput lies promontory → anterior parietal
▪ Fetal extremities – small, bone presents itself during
irregular, mobile parts examination
▪ Occiput anterior – convex o Posterior asynclitism – sagittal
back is felt suture lies close to the
▪ Occiput posterior – nodular symphysis pubis → posterior
extremity parts are bone presents itself
appreciated
Descent
o L3 – confirmation of fetal
presentation and engagement - Downward passage of fetal presenting
▪ Thumb and fingers of one part through the pelvis
hand grasp the lower - Seen during the 2nd stage
portion of the maternal - Influenced by:
abdomen just above the o Contraction of the abdominal
symphysis pubis muscles
▪ Unengaged presenting part o Pressure of the fundus on the
– movable mass will be felt fetus
o L4 – determine degree of o Extension and straightening of
descent the fetal body
▪ Examiner faces the mother’s
feet, fingertips of both Flexion
hands are positioned on - Chin is drawn closer to the fetal thorax
either side of the presenting - Movement shortens the longer
part occipitofrontal diameter to shorter
▪ Descended presenting part suboccipitobregmatic diameter
– anterior shoulder or the
space created by the neck Internal Rotation
may be differentiated - Turns the occiput gradually away from
from the head the transverse axis
- Different positions of the fetal head - Occiput rotates anteriorly toward the
o Occiput anterior – PF is found symphysis pubis
directly beneath the symphysis
pubis Extension
o Right occiput transverse – occiput is
- Base of the occiput found under the
on the mother’s right and the AF
symphysis pubis
is on the mother’s left
- Occiput – serves as a hinge, allowing
- Most babes would enter the pelvis in left
extension of fetal head
occiput transverse
- Movement is essential in order avoid the
o Occiput is on the left of the mother;
head to be pushed through against the
they are facing the mother’s right
perineal tissue → prevent trauma and
side
lacerations
MECHANISMS OF LABOR
External Rotation
Engagement
- Restitution
- Passage of the biparietal diameter - Rotation of head back to its original
through the pelvic inlet (at or below the position
ischial spine) o Biacromial diameter aligns the
- Primiparas: occur at 38 weeks AOG AP diameter of the pelvic outlet
- Multiparas: during the onset of labor - Promotes delivery of the shoulders
- Asynclitism: lateral deflection to a more - Proof external rotation: baby is facing
anterior or posterior position in the pelvis one of the maternal thighs
Expulsion ESSENTIALS IN NEWBORN CARE
- Anterior shoulder: escapes below the Procedure
Drying of infant
symphysis pubis
- Prevents hypothermia
o Made possible by pulling the baby - Stimulates baby to cry
downward Skin-Skin contact
- Posterior shoulder: sweeps over the - Promotes early
Time-bound
breastfeeding
perineum procedures
Timely cord clamping
o Upward pulling motion - 1-2 minutes after the
umbilical artery stops
PREPARATION FOR DELIVERY pulsating
Non-separation of NB from mother
Position during delivery Non time-bound
Eyecare
Vit. K supplementation
procedures
- Mother can take up any position that she is Weighing
comfortable with and can facilitate normal Suctioning
Foot printing
vaginal delivery Routine separation
Unnecessary
- Dorsal lithotomy position procedures
Pre-lacteals
o Recommended position - Fluids given to baby when
the mother is not yet willing
to BF
Other types of delivery

- Water birth: prevents potential shock as

THIRD STATE OF LABOR
the surrounding water mimics the uterine
environment - Delivery of the infant to placental
- Home delivery expulsion
- Self-birth/delivery
SIGNS OF PLACENTAL SEPARATION
DELIVERY OF THE HEAD
- Calkin’s sign: uterus becomes globular
Crowning and firmer
- Sudden gush of blood
- Encirclement of the head by the
- Uterus rises in the abdomen
thinnest portion of the vulvar rig
- Baby is as station +5 - Cord lengthens

Events during normal labor and delivery MAIN MECHANISMS OF PLACENTAL SEPARATION
- Shultz “Shiny Shultz”
- Ritgen maneuver
o Technique used to control - Duncan “Dirty Duncan”
delivery of baby’s head and Feature Shultz Duncan
minimize perineal trauma Site of Central Peripheral
separation
o Applying upward pressure on the
Hematoma Forms centrally, Blood escapes
fetal chin through the perineum formation pushes placenta as separation
while simultaneously guiding outward begins at the
edges
the head with the other hand
Presenting Fetal side (shiny, Maternal side
- Extension surface smooth) (rough
- External rotation cotyledons)
o Baby is facing the maternal thigh Amount of Minimal at first More obvious
external bleeding
o Nuchal cord – loop of cord found at bleeding
the neck of the baby; may hinder Appearance of Shiny Dirty, cotyledons
the delivery of the baby Placenta membranes/ visible
amnions left behind
- Expulsion
- Cord clamping
ACTIVE MANAGEMENT OF THE THIRD STAGE OF • Less pain
LABOR (AMTSL) • Better anatomical
results
- Protocols established by the Philippine
▪ Disadvantage
Board of Obstetrics and Gynecology to
• More prone to 4th
prevent maternal hemorrhage
degree laceration
- Attendance by providers with the
– involves the rectal
training and skills to actively manage the
lumen →
third stage
rectovaginal fistula
- Use of Uterotonics
(untreated)
o 10 units of oxytocin IM after the
o Mediolateral
delivery of the baby’s anterior
shoulder Lacerations
▪ Prevents excessive vaginal
- 1st degree: vaginal mucosa, fourchette,
bleeding by promoting
perineal skin
uterine contractions →
- 2nd degree: fascia and muscle surrounding
constricts vessels at the
the perineal body; most common
placental site
- 3rd degree: external anal sphincter
▪ Effective only in singleton
- 4th degree: rectal lumen
pregnancies; relatively CI
in multifetal gestations as it
may trap the other baby
during the process FOURTH STAGE OF LABOR
- Gentle traction on the umbilical cord - After the placenta has been delivered
o Prevents uterine inversion due to - Observe for postpartum hemorrhage
forceful pulling of the cord - Complications to observe:
- Timing of clamping of the umbilical o Vulvar hematoma – occurs when
cord a lacerated vestibular bulb vein
was not ligated properly
- Always check the episiotomy site if patient
EPISIOTOMY
complains of pain
- Surgical incision made in the mother’s
OXYTOCIC AGENTS
pudenda to assist in the delivery of the
baby and prevent severe lacerations - Promote uterine contractions
- Selective episiotomy: making the - Oxytocin
decision based in specific factors and o Given during pre-partum,
indications intrapartum, or postpartum period
o NOT ALL WOMEN in labor o Transient but marked fall in arterial
undergo episiotomy BP
- Routine episiotomy: performing the o Diluted IV or IM
incision regardless of individual ▪ Never give as IV bolus
circumstances o Directly to the uterus, vagina to
- Indications: control postpartum bleeding
o Expedite delivery o Antidiuretic action may lead to
o Spontaneous laceration is likely water intoxication
o Maternal/fetal distress o First line prophylactic uterotonic
o Breech position during 3rd stage labor
o Forceps delivery - Methylergometrine
o Large baby o Given only during the postpartum
o Maternal exhaustion period
- Types of incision o Ergot alkaloid
o Median/Midline o IM or Oral route
▪ Advantages o Side effects: IV route – HTN
• Easier to repair
 - Misoprostol Qualities of smooth muscle aiding uterine
o Initially intended to manage contraction and fetal delivery
gastric symptoms; later found to
- Degree of smooth muscle shortening
stimulate uterine contractions
during contraction is greater
o Synthetic prostaglandin analogue
- Forces can be exerted in smooth muscle
o Not FDA approved
cells in multiple directions
▪ Used as abortifacient
- Thick and thin filaments of smooth
(abortive agent)
muscle are found in long, random
- Carbetocin
bundles
o Long-acting synthetic oxytocin
- Greater multidirectional force
analogue
generation in uterine fundus than lower
o Induces uterine contraction
uterine segment

Decidua
PARTURITION - Endometrium that is transformed by
- Encompasses the entire physiological pregnancy hormones
process of giving birth - Composed of stromal cells and maternal
- 4 phase process immune cells
- Maintain pregnancy by
LABOR immunoregulation that suppress
inflammatory signals during gestation
- Subset of parturition
o Prevents rejection of the foreign
- Begins with the onset of regular uterine
fetus
contractions and ends with delivery of
- At the end of pregnancy, transitions to
NB and expulsion of the placenta
induce inflammatory signals and withdraw
MATERNAL AND FETAL COMPARTMENTS immunosuppression
Uterus Cervix (function)
- Composed of 3 layers - Maintain epithelial barrier to protect
o Serosa from infection
o Myometrium - Sustain competence despite
▪ Composed of bundles of gravitational forces as the fetus grows
smooth muscle cells - Orchestrates ECM changes allowing
surrounded by connective greater tissue compliance
tissue
Placenta
▪ Smooth muscle cells are
not terminally - Area for nutrient and waste exchange
differentiated between mother and fetus
▪ Adaptable to - Source of steroid hormones, growth
environmental changes factors and other mediators that maintain
o Endometrium pregnancy
- Stimuli, such as stretch, inflammation, and - Amnion and chorion, and decidua serve as
hormones modulate transition of these shield against untimely parturition
cells into phenotypes that provide: initiation
o Cell growth
AMNION CHORION
o Proliferation
- Towards the fetal - Maternal side
o Secretion side - Provides
o Contractility - Provide tensile immunological
strength to fetal acceptance
membrane to resist - Rich with enzyme
tearing and rupture that inactivate
- Avascular; highly uterotonins in the
resistant to early part of pregnancy:
penetration by
 leukocytes, o Prostaglandin
microorganisms, dehydrogenase
neoplastic cells o Oxytocinase FOUR PHASES OF PARTURITION
- Selective filter to o Enkephalinase
protect maternal - Phase 1: Quiescence
tissues from amniotic
fluid content
- Phase 2: Activation
o Prevents - Phase 3: Stimulation
amniotic fluid - Phase 4: Involution
embolism
PHASE 1: QUIESCENCE AND CERVICAL
SOFTENING – PRELUDE TO PARTURITION
ROLE OF HORMONES
- 95% of pregnancy
- Estrogen
- Myometrial cells are in a noncontractile
o Promotes parturition
state
o Enhance progesterone
o Uterine muscle is unresponsive to
responsiveness
natural stimuli
- Progesterone
- Braxton Hicks may occur
o Inhibits parturition
o Low amplitude contractions
o Removal of progesterone precedes
o Not cause cervical dilatation
progression of parturition
- Prostaglandins Quiescence is achieved through:
o Lipid-derived molecules
- ↓ intracellular crosstalk and ↓
o Role:
intracellular Ca2+ levels
▪ Myometrial contractility
o prevents muscle contraction by
▪ Relaxation
lowering calcium needed for actin-
▪ Inflammation
myosin interaction.
o Amnion is the major source of
- Ion channel regulation of cell
prostaglandins in amniotic fluid
membrane potential
Side note o Keeps the uterus electrically stable
and less excitable, preventing
Prostaglandin Synthesis
contractions
- Arachidonic acid in phospholipid stores is - Activation of stress-unfolded protein
released from membrane phospholipids by response by the uterine endoplasmic
Phospholipase A2 (PLA2) or Phospholipase reticulum
C (PLC) o ↑ caspase activity (anti-
- Arachidonic acid is converted into PGH2 contractile agent) → degrades actin
by: and gap junction Connexin 43
o Prostaglandin H synthetase – 1 ▪ Caspase 3: muscle
(PGHS-1/COX1) wasting and reduced
o Prostaglandin H synthetase – 2 muscle tension; degrades
(PGHS-2/COX2) connexin 43
- PGH2 is acted upon by PG isomerase to ▪ Connexin 43: cell-cell
convert it to: communication through
o Prostaglandin E2, F2a, and I2 – gap junctions
active prostaglandins involved in o Limits protein misfolding and
parturition inflammation, helping maintain a
- PGE2, PGF2a, PG12 are converted into relaxed state.
inactive metabolites mediated by - Uterotonin degradation
prostaglandin dehydrogenase (PGDH) o Decreases stimulatory hormones
o Ensures uterine quiescence is (e.g., prostaglandins, oxytocin),
maintained when labor is not reducing contraction signals.
imminent
Myometrial Contractility is achieved by: Uterine Relaxation

- Enhanced interactions between the Activation of adenylyl cyclase

actin and myosin proteins ↓
o Increases force of uterine muscle Increase cAMP
contraction by enhancing sliding of ↓
muscle filaments. Activation of Protein Kinase A → promoting
- Heightened excitability of individual dephosphorylation of MLCK
↓
myometrial cells
MLCK dephosphorylation → ↓ myosin-actin
o Makes the uterus more responsive
interaction
to stimuli, allowing easier initiation ↓
of contractions Inhibition of contraction
- Promotion of intracellular crosstalk
that allow synchronous contractions to
develop Factors Responsible for Uterine Quiescence
o Promotes coordinated, wave-like
contractions across the uterus for - Progesterone
o ↓ sensitivity of receptors to
effective labor.
uterotonins
Side Notes: Myometrial Contractility o Decrease contraction-
- Actin must pair with myosin to produce contraction
- Actin forms:
associated proteins (CAP)
o G-actin (globular) → promotes relaxation ▪ Oxytocin receptor
o F-actin (filamentous) → promotes ▪ Prostaglandin F receptor
contraction; actin must be transformed
▪ Connexin 43
to filamentous form for contraction to
occur o Maintains Caspase 3
- Myosin o ↓ expression of gap junction
o Heavy chain (head portion): binds to actin to
- Receptors: G Protein-Coupled Receptors
perform the power stroke
o Light chain (tail): where phosphorylation (GPCR)
occurs to elicit contraction o ↑ cAMP → ↓ intracellular levels
Ca2+ levels
o Inhibits oxytocin receptors
Uterine Contractions
o Receptors for:
Medication like oxytocin or factors like ▪ LH-hCG
thrombin (F2) trigger a receptor that activates • hCG activates
the release of phospholipase C adenylyl cyclase
↓ → ↓ contraction
Release of Ca2+ from intracellular stores frequency and
↓ force; ↓ number of
Formation of Ca2+-Calmodulin complex tissue-specific
↓ myometrial cell gap
Activation of myosin light chain kinase junctions
(MLCK) ▪ CRH
↓
▪ PGE2
Phosphorylation of myosin light chain
• Act through Gαs to
↓
Formation of cross-bridges maintain
↓ myometrial cell
Contraction occurs quiescence
• Switches to a
Gαq/11 calcium-
activating pathway
during labor
▪ B2-sympathomietics
• Mediate Gαs-
stimulated
 myometrial cell preventing voltage-
relaxation gated calcium influx →
• Agents binding to preventing contraction
these receptors are
Cervical softening
used for tocolysis
of preterm labor - Initial stage of cervical remodeling
(ritodrine and - Greater tissue compliance yet remains
terbutaline) firm and unyielding
- Relaxin - Hegar’s sign: softening of the lower
o Bind to GPCR → ↑ adenylyl uterine segment
cyclase → ↓ Ca2+ o 4-6 weeks AOG
- Corticotropin-releasing hormone (CRH)
o Synthesized in the placenta and Cervical Connective Tissue
hypothalamus - Composed of 10-15% smooth muscle
o Binds with CRHR1 → activates Gs- cells; the remaining are connective
adenylate cyclase-cAMP tissue within the ECM
signaling pathway → inhibits o Type I and III collagens
inositol triphosphate (IP3) → o Matricellular proteins
stabilize Ca2+ levels o GAG
- Cyclase guanylyl monophosphate o Proteoglycans
o Guanylyl cyclase activation raises o Elastic fibers
intracellular cGMP levels → - Collagen: main structural protein;
promote relaxation undergoes conformational changes that
o Stimulated by ANP, BNP, and NO alter cervical stiffness and flexibility
- ↑ degrading enzymes - At early pregnancy
o Oxytocinase: oxytocin o Mature cross-links between
o Prostaglandin dehydrogenase: newly synthesized collagen
prostaglandin monomers are reduced due to:
o Enkephalinase: endothelins ▪ Diminished expression
o Diamine oxidase: histamine and activity of lysyl
- Decidua: Immune tolerance hydroxylase and lysyl
o ↓ synthesis of PGF2a oxidase
o Changes in myeloid and lymphoid o Resulting collagen will have
immune cells reduced stiffness due to ↓ cross-
- Regulation of membrane potentials link-forming enzymes
o Before labor, myocyte maintain a o Decorin and Biglyan
relatively high interior ▪ Collagen-binding
electronegativity → less excitable proteoglycan
state ▪ Ensures the new, poorly
o Sodium leak channels cross-linked collagen is
▪ Contributes to a sodium leak appropriately assembled
current in myometrial and deposited in the ECM
smooth muscles - Balance between synthesis and breakdown
o BKCa (Ca2+-activated K+ channels of collagen, rather than loss, achieves
▪ Plays dual promoting and cervical remodeling
opposing roles to maintain - Defects in collagen synthesis may
balance between uterine present with cervical insufficiency →
quiescence and contractility premature dilatation → increasing risk
▪ Opening BKCa channels → of preterm labor
allows K+ to leave the o Ehlers-Danlos Syndrome
cell → maintaining the o Marfan syndrome
interior
electronegativity →
PHASE 2: ACTIVATION ▪ Hydrophilic, space-filling
molecule that increases
Preparation for Labor
viscoelasticity,
- Uterine preparedness for labor hydration, and matrix
o Myometrial tranquility of Phase 1 is disorganization
suspended - Proteoglycans
o Occurs around 6-8 weeks before o Enable cervical dilatation
the end of pregnancy without tearing
o Uterine awakening or activation - Inflammatory changes
- Cervical ripening o Invasion of stroma by inflammatory
cells → increased matrix
Myometrial Changes metalloproteinases → collagen
- Due to shift in the expression of breakdown → cervical ripening
proteins that control uterine quiescence Induction of Cervical Ripening
to an expression of CAPs
o CAPs: ↑ uterine responsiveness - PGE2 and PGF2α
to uterotonins o Promotes cervical ripening for
- Formation of the lower uterine labor induction
segment from the isthmus - Prostaglandins
o The development promotes fetal o modify ECM structure to aid
head descent to or even through ripening
the pelvic inlet – lightening o Dinoprostone Gel - Used to induce
abortion or augment labour and
Oxytocin Receptors to minimize blood loss from the
- Levels increased during phase 2 of placental site
parturition - Progesterone antagonists
- Inhibited by progesterone; Induced by o Cause cervical ripening
estradiol Endocervical Epithelia
o effective labor
- Proliferation of endocervical epithelial
Side Notes: Events during Oxytocin receptor
binding
cells leads to:
o ↑ endocervical glands →
Binding of oxytocin to its receptor contributes to the cervical mass
activates phospholipase C
↓
- Endocervical canal is lined with mucus-
PIP2 is cleaved by PLC → IP3 and DAG secreting columnar and stratified
↓ squamous epithelia
IP3 → triggers Ca2+ influx
↓
o Form both a mucosal barrier and
Ca2+ binds with calmodulin → Ca2+- tight junctional barrier that
calmodulin complex protect against microbial
↓
invasion
Activate MLCK → actin-myosin cross-
bridge
↓
Factors Responsible for Phase 2
contraction
- Progesterone Withdrawal
o Essential for the transition to phase
Cervical Ripening 2 labor
o Changes associated:
- Before contractions, cervix must shift ▪ ↑ estrogen:progesterone
from a state of competence to one of ratio
compliance ▪ ↑ sensitivity of receptors
- ↑ GAGs to uterotonins
o Hyaluronan (high molecular weight ▪ ↑ gap junction proteins
GAG) (connexin 43) → promotes
 intracellular o Uterine stretch
communication ▪ Induces specific CAP
- Estrogen ▪ Increases expression of:
o ↑ oxytocin myocyte receptor • Connexin 43
- Prostaglandin • Oxytocin receptors
o ↑ production from myometrium, ▪ Increases levels of
decidua, amnion, and chorion gastrin-releasing
leading to uterine irritability and peptide
cervical ripening • Stimulatory agonist
- Fetal endocrine cascade for smooth
o Fetal hypothalamicpituitary- muscle
adrenal-placental axis (HPAP axis) ▪ Mechanotransduction
▪ Critical component of • Cell signaling
normal parturition pathway
▪ Premature activation is influenced by
considered to prompt stretch
many cases of preterm
PHASE 3: STIMULATION
labor
o Placental CRH 3 Stages of Labor
▪ Produced in large
amounts by the placenta Stage Description
▪ Stimulated by cortisol Cervical effacement Active uterine
and dilatation contractions up to 10
(placental CRH)
cm cervical dilatation
▪ ↑ fetal cortisol production
Fetal expulsion Complete cervical
to provide positive
dilatation and ends
feedback → more CRH is with fetal delivery
produced Placental separation Fetal delivery and
▪ Later pregnancy and expulsion ends with delivery
• CRH receptors are of the placenta
modified to favor a
switch from cAMP
formation to 1st Stage: Cervical Effacement and Dilatation
increased - Labor initiation
myometrial cell o May start with sudden
calcium levels via contractions or a bloody show
protein kinase C (extrusion of the mucus plug)
activation - Suggested causes of painful
▪ Oxytocin contractions:
• Attenuate CRH- o Hypoxia of the contracted
stimulated myometrium
accumulation of o Compression of nerve ganglia in
cAMP in myometrial the cervix and lower uterus
tissue o Cervical stretching during dilatation
o Fetal lung surfactant o Stretching of the peritoneum
▪ Surfactant protein A - Contractions are involuntary and
(SP-A) – produced by fetal independent of extrauterine control
lung; required for lung - Ferguson reflex
maturation o Increased uterine activity due
▪ Activates uterine to mechanical stretching of the
contractions cervix
▪ present in amniotic fluid - Manipulation of the cervix and stripping
▪ platelet-activating the fetal membranes
factor (uterotonic)
 o Associated with ↑ blood levels of o Contraction of abdominal muscle
prostaglandin F2α metabolites simultaneously with forced
o Stripping – separating the respiratory effort with closed glottis
amniotic sac from the decidua
3rd Stage: Delivery of Placenta and
- Interval: narrows gradually from the
Membranes
initial 10 minutes to 1 minute or less in the
second stage - Begins immediately after delivery of the
o Periods of relaxation is seen in baby
between contractions and is - Uterine cavity is nearly obliterated
essential for fetal welfare - Uterine fundus lies just below the level
o Unremitting contractions of the umbilicus
compromise uteroplacental blood - Uterus begins to diminish in size → ↓
flow → may cause fetal implantation site → placenta thickens
hypoxemia and buckles → tension pulls the
- Events in the uterine segments decidua spongiosa (weakest layer of the
o Upper segment thickens placenta)
(contracts and retracts), while the
lower segment thins out Mechanisms of Placental Delivery
o Physiological retraction ring: a - Schultze Mechanism
boundary between the upper and o Blood from the placental site
lower segment, marked by a ridge pours after extrusion of the
(insignificant) on the inner placenta
uterine surface - Duncan Mechanism
o Pathological retraction ring o The placenta separates first at
(Bandl ring): the periphery and blood collects
▪ Retraction ring becomes between the membranes and the
excessively elevated and uterine wall and escapes from the
prominent vagina
▪ May be seen or felt across
the abdomen Uterotonins
▪ indicates uterine rupture - Oxytocin
Cervical Changes o Synthesized in the magnocellular
neurons of the supraoptic and
- Effacement: obliteration or paraventricular neurons
shortening of the cervix as it is drawn up o Transported with its carrier,
into the LUS neurophysin, along the axons to the
o Cervix shortens neural lobe of the posterior
o Cervical canal shortens pituitary gland
approximately 3cm or less o Why oxytocin plays a role in labor:
- Dilatation ▪ ↑ oxytocin receptors in
o Pressure from the presenting part myometrial tissues and
or the amniotic sac/fetus exerts decidua near the end of
force on the cervix → opening the gestation
cervix ▪ Promotes prostaglandin
2nd Stage: Fetal Expulsion release in decidual tissue
▪ Oxytocin synthesis in
- Complete cervical dilatation and ends decidual and
with fetal delivery extraembryonic fetal tissues
- Maternal intraabdominal pressure o Elevated during:
o Ancillary force ▪ Stage 2 labor
o Most important force in fetal ▪ Early puerperium
expulsion after cervix is fully dilated ▪ Breastfeeding for milk
letdown
 - Prostaglandin endometrial responsiveness
o Produced within the myometrium, to normal hormonal cyclicity
decidua, fetal membranes, and o Lactogenesis and milk letdown
placenta during labor begin
o Clinical importance: Overly o Ovulation may occur 4-6 weeks
stretch uterus promotes after birth
production of PG ▪ Dependent on the duration
▪ Hydramnios of BF and lactation,
▪ Bid baby (diabetes) prolactin-mediated
▪ Multifetal gestation anovulation and
- Endothelin 1 amenorrhea
o From myometrium of term
gestation PRENATAL CARE AND MATERNAL
o Family of 21-amino-acid peptide NUTRITION
that induce myometrial
PRECONCEPTIONAL COUNSELLING
contractions
o Receptor activation ↑ - Integral part of prenatal check-ups
intracellular calcium considering the high-risk patients
o Induce synthesis of other - Things that the health provider needs to
contractile factors know during the visit:
- Angiotensin 2 o Significant medical conditions
o Potent vasoconstrictor that helps o Prior surgery
modulate uteroplacental flow o Hx of reproductive disorder
o Receptors: o Genetic conditions
▪ AT1R - Preconceptional counselling during the 4th
• Predominates in trimester (postpartum) is essential to
nonpregnant women optimize postpartum care and
▪ AT2R contraception
• Preferentially o Early intervention and referral to
expressed in specialist
gravidas o Elicit other comorbidities
• AT2R-mediated o Elicit hx of twins in the family
effects on vascular
PRENATAL CARE
smooth muscle
leads to - Aimed at decreasing complications
vasodilation during pregnancy and improving its
• ↓ expression is outcomes
associated with - Planned antepartum program involved in:
preeclamptic o Evaluation and management
pregnancies o Continuous risk assessment
o Education
PHASE 4: INVOLUTION
o Psychosocial support
- Puerperium o Labor and delivery
o Myometrium contracts up to an o Postpartum care
hour after delivery
Benefits of Prenatal Care
▪ Compresses the large
uterine vessel and allows - Lowers risk of low birth weight,
thrombosis → prevent premature birth, and neonatal death
hemorrhage - Promotes mother’s health
o Uterine involution and cervical - Spots complication early on
repair - Ensures healthy weight gain
▪ Protect from microbial - Offers counselling
invasion and restore
Good prenatal care - P (parity): Number of deliveries,
regardless of outcome
- Schedules
- T (term): Pregnancy carried at or
o Weeks 1-28 (1-7 months):
beyond 37 weeks of gestation
monthly
- P (preterm): Birth before 37 weeks but
o Weeks 28-36 (7-9 months): 2x a
above 20 weeks AOG
month
- A (abortion): Pregnancy losses before
o Weeks 36 and beyond: weekly
20 AOG (H. mole, ectopic pregnancy,
- Prenatal testing
miscarriages before 20 weeks)
o Routine
- L (living children): number of children
▪ CBC, HBsAg, anti-
who are alive
treponemal for syphilis, and
HIV testing ESTIMATION OF DURATION OF PREGNANCY
o Specialized
Naegele’s Rule
- Wholesome practices
o Vitamins - EDD: expected date of delivery
o Diet - Add 7 days to the date of the first day of
o Exercise the last normal menstruation period
o Stress relief - Count back 3 months
- Subsequent Prenatal Visits - Add 1 year
o Normal pregnancy: stated above
o Complicated: 1-2 weeks interval Timing of Ovulation
o WHO recommendation - If the woman’s date of the last ovulation is
▪ Once in the 1st trimester known
and screened for risk o Add 267 days to estimate the date
▪ Without anticipated of delivery
complications - Shortcut: Ovulation date + 1 year – 3
• 80% of those months – 6 days = EDD
screened were seen
again at 26, 32, and Timing of quickening
38 weeks - Quickening: the first maternal perception
• Basically, at least 3 of fetal movement
prenatal visits o Earlier in multipara than in nullipara
DEFINITION OF TERMS - Fetal movements could be felt by:
o 16th – 18th weeks: multipara
- PRIMIpara: delivered once of a fetus/ o 20th weeks: primipara
fetuses regardless of its status with as
estimated AOG of ≥ 20 weeks Fundal height
- MULTIpara: a woman who completed 2 - 12 weeks: level of/above symphysis
or more pregnancies to viability pubis
- NULLIpara: never completed a - 16 weeks: between the symphysis pubis
pregnancy beyond 20 weeks gestation and umbilicus
- Gravida: a woman who is currently - 20 weeks: level of umbilicus
pregnant or has been in the past, - 36 weeks: below the sternum/xiphoid
regardless of the outcome process
- NULLIgravida: a woman who is not
currently pregnant nor has ever been Ultrasound
- Parturient: a woman in labor
- Crown-rump length: most accurate
- Puerperia: a woman who had just given
tool for gestational age determination
birth
o Done during the 1st trimester of
OB SCORE gestation

- G (gravida): Number of pregnancies,

regardless of outcomes
INITIAL COMPREHENSIVE EXAMINATION ▪ Persistence of short
palpebral fissures
- Define the health status of the mother
▪ Thick upper vermillion
and fetus
border
- Estimate the gestational age of the fetus
▪ Flat midface hypoplastic
- Initiate plan for continuing obstetric
philtrum
care
▪ Epicanthal folds
- Define those at risk for complications and
to minimize the risk Illicit Drugs
History - Results to:
o Fetal growth restriction
- Check for comorbidities, medical or
o Low birth weight
surgical disorders
o Drug withdrawal soon after birth
- Details of previous pregnancies
- Substance abuse Intimate Partner Violence
- Psychosocial issues
- Pattern of assaultive and coercive
- Maternal abuse
behaviors that may include:
Psychosocial Screening o Physical injury
o Psychological abuse
- Non-biomedical factors that affect
o Sexual assault
mental and physical well-being
o Progressive isolation
- Screen for:
o Stalking
o Barriers to care
o Deprivation
o Communication obstacles
o Intimidation
o Nutritional status
o Reproductive coercion
o Unstable housing
- Associated risk for the neonate:
o Desire for pregnancy
o Preterm delivery
o Safety concerns
o Fetal growth restriction
▪ Violence
o Perinatal death
▪ Depression
▪ Stress Physical Examination
▪ Substance abuse
- Provides information about the
Cigarette Smoking presentation and position of the fetus
and the extent to which the presenting part
- 2x increase risk of placenta previa,
has descended
placental abruption, PROM
- Leopold’s Maneuver: refer to previous
- Neonate risks:
lessons
o Preterm
o Lower birth weights Pelvic Examination
o SIDS
- Vaginal examination
- Pathophysiology
- Speculum: cervical examination
o Fetal hypoxia from increased
- Pap smear: cytological examination
carboxyhemoglobin
- Bimanual examination: completed by
o Reduced uteroplacental flow
palpation with special attention given to
o Direct toxic effects of nicotine in
the:
smoke
o Consistency, length, and dilatation
Alcohol of the cervix
o Uterine and adnexal size
- Potent teratogen
o Bony pelvic architecture
- Fetal alcohol syndrome
o Vaginal or perineal anomalies
o CNS abnormality
o Growth restrictions
o Facial abnormalities
Routine Antepartal Test ROUTINE VISITS
- Recommended routine test Prenatal Surveillance
o CBC, blood type with Rh status,
- Maternal BP
antibody screen
- Maternal weight
o Routine urinalysis with culture
- FHR
o FBS/75 grams OGTT
- Fundal height
o Hepatitis B virus
- Fetal activity
o HIV testing
- AFV
o Syphilis
- Identify for the following S/S
Protocol for the Evaluation of Diabetes in o Headache
Pregnant Filipino Women o Altered vision
o Abdominal pain
- Fasting blood sugar (FBS)
o N&V
o Normal: ≤92 mg/dL
o Bleeding
o GDM, no further testing: ≥92
o Vaginal fluid leakage
mg/dL but <126 mg/dL
o Dysuria
o Overt DM, no further testing: ≥126
- In late pregnancy (≥37 weeks), vaginal
mg/dL
examination provides information that
▪ With DM prior to
includes:
pregnancy
o Presentation and station
- Oral glucose tolerance test (OGTT)
confirmation
o Diagnosed with GDM if:
o Estimation of pelvic capacity and
▪ FBS ≥92 mg/dL
configuration
▪ 1 hr ≥180 mg/dL
o AFV adequacy
▪ 2 hr ≥153 mg/dL
o Cervical consistency,
- Recommendations
effacement, and dilatation
o FBS ≥92 mg/dL, Low-risk
▪ 75 gm OGTT
▪ If normal, repeat 75 gm
Intrapartum Antimicrobial Prophylaxis
OGTT at 32 weeks or
(indications)
anytime if with
maternal/fetal signs of DM - GBS infection
o FBS ≥92 mg/dL, High-risk o Vaginal and rectal GBS cultures at
▪ Subject for 75 gm OGTT 35 and 37 weeks of gestation
immediately - Women with GBS bacteriuria
▪ If normal, repeat 75 gm - Previous infant with invasive disease
OGTT at 24-28 weeks - Delivery <37 weeks
▪ If normal, repeat 75 gm - Ruptured membranes ≥18 hours
OGTT at 32 weeks or - Intrapartum temperature ≥ 38 degrees
anytime if with Celsius
maternal/fetal signs of DM
- POGS-CPG Antimicrobial prophylaxis regimen for perinatal
o Diagnose GDM if: GBS disease
▪ FBS ≥92 mg/dL or - Recommended
▪ 2-hour OGTT ≥140 mg/dL o Penicillin G: 5 million units IV
Other laboratory tests initial dose, then 2.5 – 3 million
units IV Q4 until delivery
- TB screening - Alternative
- Chlamydia screening o Ampicillin: 2 g IV initial dose, then
- Gonococcal screening 1 g every hour or 2 g Q6 until
- Fetal aneuploidy screening delivery
- NTD screening
 - Penicillin allergy Recommended Dietary Allowances
o Cefazolin: 2g IV initial dose, then
Calories
1 g Q8 until delivery
o Clindamycin: 900 g IV Q8 until - Additional 80, 000 kcal: mostly in the last
delivery 20 weeks
- Additional 100-300 kcal/day
Cervical Infection
Protein
- Screen for Chlamydia
o First prenatal visit, with - Needed for the demands for growth and
additional third-trimester remodeling of the fetus, placenta, uterus,
testing for those at increased risk and breast as well as increased maternal
▪ Multiple sexual partners blood volume
o Following treatment, a second - 1000 g of protein is deposited during 2nd
testing (test of cure) is half of pregnancy, amounting to:
recommended in pregnancy 3-4 o 5-6g/day
weeks after treatment - Recommendation: 1g/kg/day
completion
- N. gonorrhea screening Iron
o Initial prenatal visit and again in - Elemental iron: 7 mg/day
the 3rd trimester - 60-100 mg/day if:
MATERNAL NUTRITION DURING PREGNANCY o Large women
o Multiple gestation
Nutritional Counselling o Supplementation started late in
pregnancy
- Weight gain recommendations: 25 lbs
o Irregular iron intake
(11-12 kg)
o Low hemoglobin level
o The amount of weight a woman
- Causes of anemia in pregnancy (except
needs to gain during pregnancy is
physiologic)
based on her pre-pregnancy BMI
o Parasitism
o High BMI = less weight gain
o Blood dyscrasias
required, vice versa
BMI Total Pounds/week Pounds/week
Calcium
weight gain in 2nd and 3rd in 2nd and 3rd
(lb) trimesters trimesters - 1000mg/day
(mean) (range) - Pregnant women retain approximation
UW 28-40 1.0 1-1.13 30g
Normal 25-35 1.0 0.8-1.0
- 1500 – 2000mg/day: associated with
OW 15-25 0.6 0.5-0.7
Obese 11-20 0.5 0.4-0.6 decreased risk of preeclampsia
- HTN vs Preeclampsia vs Eclampsia
o HTN: (+) elevated BP, (-)
Severe Undernutrition albuminuria
- Complications to the neonate o Preeclampsia: (+) elevated BP
o Preterm birth observed during pregnancy, (+)
o Small for gestational age albuminuria
o Fetal growth restriction o Eclampsia: Preeclampsia with (+)
- Barker hypothesis seizures
o Concept of fetal programming by - Significance of calcium supplementation in
which adult morbidity and the prevention of preeclampsia
mortality are related to fetal o Supplementation → ↓ release of
health PTH → ↓ intracellular Ca2+ in
vascular smooth muscle → ↓
smooth muscle reactivity →
vasodilation → ↓ BP
Iodine o Congenital rickets
o Fractures in the NB
- Recommendation: 220 µg
- Required for biosynthesis of thyroid COMMON CONCERNS DURING PREGNANCY
hormone, which is responsible for:
- Employment
o Regulating growth
- Exercise
o Development
- Backache
o Metabolism
- Heartburn
- Cretinism
- Coitus
o Maternal iodine deficiency leading
- Dental care
to multiple severe neurological
o Pregnancy gingivitis
defects
- Varicosities and hemorrhoids
Zinc - Altered vision
- Automobile and air travel
- RDI: approximately 12mg
- N&V
- Deficiency may lead to:
- Caffeine
o Poor appetite
- Leukorrhea
o Sub-optimal growth
- Pica and ptyalism
o Impaired wound healing
- Sleeping and fatigue
Folic Acid - Immunization
- Cord blood banking
- Supplementation ↓ risk of NTD
o Important supplement during Nausea and Vomiting
preconception and during 1st
- Hyperemesis gravidarum: severe vomiting,
trimester
dehydration, electrolyte and acid-base
- RDI
disturbances, starvation ketosis
o 400 µg/day: Preconceptional
- Intervention
period, low risk for NTD
o Eat small frequent feeding
o 4 mg/day: high-risk for NTDs
o Avoid fatty or spicy foods
Vitamin A o Eliminate pills with iron
▪ Induces acid
- Potent teratogen at high amounts ▪ Strong smell and aftertaste
(>10,000 IU) o High protein food
- Deficiency may cause: - Pharmacologic
o Night blindness o Pyridoxine 10-25 mg Q8 daily
o ↑ risk of maternal anemia o Doxylamine 12.5 mg Q6 or Q8 daily
o Spontaneous preterm birth o Ginger capsules 250 mg Q6 daily
Vitamin B12 - For severe cases:
o Metoclopramide 10 mg oral Q8
- Sourced in foods of animal origin o Promethazine 12.5 mg oral Q4
- Deficiency may be an independent factor o Ondansetron 4-8 mg oral or IV Q8
associated with NTD - If none of previous drug works:
Vitamin B6 (pyridoxine) o Admit and administer IV
metoclopramide
- Not required in most gravidas o Investigate thyroid problems
- In women with high risk of inadequate
nutrition: Heartburn
o RDI = 2mg/day - Gastric content reflux in the lower
Vitamin D esophagus
- Burning sensation in the epigastrium and
- RDI: 15 µg/day (600 IU/day) feeling of fullness
- Deficiency causes: - Causes:
o Disorder skeletal homeostasis
 o Upward displacement and Employment
compression of the stomach
- Occupational fatigue
o Progesterone-mediated
o ↑ risk of PROM
relaxation of the LES during the
- Contraindications: Physical, emotional,
1st trimester
mental stress
- Intervention
o Preterm birth
o Avoid bending or lying flat
o PROM
o Left-side lying position to avoid
o IUGR
IVC compression
o Gestational HTN or preeclampsia
o Small frequent feeding
o Antacids Land and Air Travel
▪ Magnesium hydroxide
▪ Aluminum hydroxide - Wear proper three-point restraints when
▪ Magnesium trisilicate riding automobiles
- Women can safely fly up to 36 weeks
Hemorrhoids gestation, if non-complicated case
- ↑ uterine size → increased venous Caffeine
pressure due to impingement of rectal
vein - 5 cups or 500 mg
- Pain and swelling relieved by: o Slightly increase abortion risk
o Topically applied anesthetics - <200 mg/day
o Warm soaks, hot sitz baths o Not appear to be associated with
o Stool softening agents miscarriage or preterm birth

Exercise Coitus

- Moderate-intensity physical activity for - Usually not harmful

30 minutes or 150 minutes each week - Avoided if:
- Contraindication o Threatened abortion
o Significant CVD or pulmonary o Placenta previa
disease o Preterm labor – seminal fluid can
o Significant risk for preterm labor cause contraction
▪ Cerclage - No association between gestational age at
▪ Multiple pregnancy delivery and coital frequency during the last
▪ Significant bleeding 4 weeks of pregnancy
▪ Threatened PTL - Oral-vaginal intercourse – hazardous
▪ PROM Dental care
o Obstetrical complications
▪ Preeclampsia - Pregnancy is not a C/I for dental treatment
▪ Placenta previa Immunization
▪ Anemia
▪ Poorly controlled DM - Safe for pregnancy
▪ Morbid obesity o Tdap – tetanus toxoid, reduced
▪ IUGR diphtheria toxoid, and acellular
- Absolute C/I pertussis
o Severe heart disease ▪ 27 and 36 weeks of
o Restrictive lung disease gestation
o Incompetent cervix o Influenza vaccination
o Multifetal gestation ▪ All pregnant women
o Placenta previa – after 26 weeks regardless of trimester
o PTL o Hep A and Hep B
o Ruptured membranes ▪ Pre-exposure and post-
o Preeclampsia or gestational exposure
HTN
 o Pneumococcus
▪ Chronic metabolic liver,
cardiac, or lung disease
▪ Immunosuppressed,
general malignancy, chronic
renal disease, or asplenia
o Meningococcus
▪ Indicated in unusual
outbreaks
o Rabies
▪ Post-exposure prophylaxis
o Tetanus
▪ Postexposure prophylaxis
- C/I: LIVE VACCINES
o MMR
o Oral Polio
o Yellow fever vaccines
▪ Indicated if travelling to a
high prevalent area
- Recommended COVID 19 vaccines
o mRNA vaccines
▪ Pfizer, biotech, moderna
o Inactivated
▪ Sinovac-Coronavac
o Viral vector vaccines
▪ AstraZeneca, J&J Janssen