OBSTETRIC NURSING Body Parts Involved

Hypothalamus GnRH: stimulates the

MENSTRUATION, OVULATION & CONCEPTION
APG to release FSH
Menstruation: Cyclic endometrial bleeding
Ovulation: Release of mature ovum/egg Anterior Pituitary Gland FSH: 1st APG hormone,
Conception: Fertilization stimulates ovary to
release estrogen

LH: Last APG hormone,

stimulates ovary to
produce progesterone
Ovaries Estrogen: 1st ovarian
hormone, responsible
for thickening of the
endometrium
-If increased  inhibits
FSH and stimulates LH

Ovaries Progesterone: prepares

 Site of egg maturation endometrium for
 produce estrogen and progesterone implantation
 connected to fallopian tube (site of Uterus
fertilization), which in turn is connected to Endometrium =
the uterus thickening
Fimbria
 finger-like appearance Follicle Stimulating Luteinizing Hormone
 catches the egg/ovum from the ovary Hormone (FSH) (LH)
during ovulation  ovum is propelled to 1. Maturation of ovum 1. Ovulation: release of
ampulla for fertilization -One Primordial follicle mature ovum by the
Fundus of uterus matures to Graafian Graafian follicle 
 site of implantation each cycle catched by fimbria 
 zygote will migrate from the ampulla to the Primordial: immature ampulla
fundus = pregnancy follicle
2. Stimulates ovary to
THE MENSTRUAL CYCLE 2. Stimulates ovary to produce progesterone
Cyclic endometrial bleeding due to hormonal produce estrogen (released during
changes -during maturation and ovulation)
Endometrium: innermost layer for menstruation & before ovulation,
implantation, regenerating estrogen is increased;
 Menstrual cycle: 24-38 days NO progesterone
o Average: 28 days
 Menstrual (bleeding) period: 2-7 days Board Question:
o Average: 5-6 days In a 28-day cycle, when do you expect ovulation to
 Blood loss: 5-80mL occur?
o Average: 30-60mL / ¼ cup  Day 14
 Color: dark red In a 32-day cycle?
 Iron loss: 11mg  Day 18 (do not divide by 2, subtract 14)

Report: In irregular menstruation, FSH is responsible.

 Heavy bleeding Delay in maturation = delay in ovulation (cycle is
o > 80mL blood loss longer)
o > 7 days
Calendar method – Regular cycles
o Changing napkins < 2hrs
o Risk for IDA
 Dysmenorrhea
 Amenorrhea (possible pregnancy)
 Fever (infection)
 -Fat distribution in the ovulation
 The first day of period is the first day of hips and legs -Prepares the
cycle Thelarche (breast dev) endometrium for
o If 1st day of period is August 3, end Adrenarche (pubic implantation
of cycle is August 30 (if the cycle is hair) -Thermogenic action
28) Menarche (onset of -Increases BBT (during
o Ovulation is August 16 (14th day) mens) and after ovulation,
 High chance of pregnancy if Adrenarche (axillary best evidence of
coitus happens on August 18 hair) ovulation)
since ovum can survive up to -Vaginal discharge -BBT is increased if
48 hours -Inhibits FSH puyat, so minimum 4
 For the fertilization to be -Growth of long bones hours of continued
healthy, the ovum must be (12 y.o.) sleep is needed
fertilized within 24 hours Early closure of -Best time to check:
o 3-4 days before ovulation  FERTILE epiphysis of long bones Morning before ADL
(August 12-15) (16-18 y.o.) -During ovulation: (0.3
 If bleeding stops on the 5th -↑Sexual desires – 0.6 C / 0.5 – 1 F) then
day (August 7), safe days -↑Vaginal lubrication preceded by a drop
from August 8-11 -Fertile cervical mucus  Abstain from
o 3-4 days after ovulation, possible (thin, wet, alkaline, sex if BBT is
fertile (August 17-20) clear, watery, increased + 3
abundant, slippery, (+) more days:
Normal minimum sperm count: 20 million / mL spinnbarkeit / stretchy, ovum dies after
 May survive in the fallopian tube for 3-5 (+) ferning) 48 hours
days (high chance of pregnancy if coitus  Billing’s + BBT
happened on August 14 since August 16 is Billing’s Method =
the day of ovulation) > abstain from coitus if Symptothermal
cervical mucus is (better than
Irregular Cycle (FSH is the culprit) stretchy, wet and thin alone)
Monthly period but different length cycles, not until 4 days after the -Inhibits LH
applicable to months of amenorrhea last episode of wet -Mammary gland
 Count cycle days for 6 months mucus development: lactation
 Shortest cycle: -18 (constant) > applicable to regular -Mood swings: after
o Determine the shortest cycle then and irregular cycles ovulation
subtract 18 days -Muscle relaxant:
 Longest cycle: -11 days (constant) ↓peristalsis
o Determine the longest cycle then -Infertile cervical
subtract 11 days mucus: sticky, dry,
 Results: fertile days dense, opaque, thick,
scanty, (-) ferning, (-)
Example: spinnbarkeit
If it is ruled out that -Responsible for
 25 is the shortest cycle  subtract 18 = infertile cervical mucus
Day 7
 30 is the longest cycle  subtract 11 = Day Ovarian Cycle
19 Follicular Phase (1-14)
o Fertile days: Day 7 to Day 19 2 dominant hormones: FSH and Estrogen
o Infertile days: Day 20 to Day 6 of the
next cycle (when you bleed again) Follicle-stimulating Hormone
 Stimulates ovary  maturation of ovum
OVARIES  Increased estrogen, NO progesterone
 Almond-shaped female sex glands for
production of Estrogen and Progesterone Uterine Cycle (endometrial changes)
Menstrual: bleeding (day 1-6)
Estrogen: Progesterone:  ↓Estrogen ↓Progesterone
Development of Hormone of Mother /
secondary sexual Pregnancy Low estrogen stimulates the hypothalamus 
characteristics hypothalamus releases gonadotropin-releasing
(hormone of the hormone (GnRH)  stimulates APG to release FSH
woman)  ovary (maturation of ovum)  ↑Estrogen
(responsible for thickening of the endometrium)
-Growth spurt -Increased after
 Menorrhagia (heavy menstrual bleeding)
Proliferative/Estrogenic/Post-Menstrual/Pre-  At risk for iron deficiency anemia
Ovulatory Menopause (cessation of menses w/ average age
thickening (day 7-14) 51)
 ↑Estrogen ↓Progesterone  Estrogen deficient
 Estrogenic, post-menstruation, post-  Night sweats, hot flushes, insomnia,
ovulation irritability, depression, loss of libido, vaginal
 Day 13, mature ovum: ↑Estrogen dryness, dry hair and skin
↓Progesterone (still low BBT)  Long term problem: Osteoporosis
 If estrogen is increased, FSH is inhibited
(negative feedback)  LH stimulated and Fertilization (conception/impregnation)
increased  Union of ovum and sperm = zygote
 LH  ovary  increased progesterone, day  22 pairs of autosomes and 1 pair of sex
14 is ovulation (rupture of graafian follicle chromosomes
to release the mature ovum)  Site: ampulla of fallopian tube (outer 3rd)

Signs of Ovulation
1. Mittelschmerz = mid-cycle pain (ovulation)
2. ↑BBT (sudden)
1. Dispermy + ovum = abnormal = partial H-
Luteal Phase (15-28) mole (paternal)
After ovulation, ↑LH + ↑Progesterone 2. Sperm + empty ovum = complete H-mole
(maternal)
Secretory: twisted and spongy o 40+ is at risk because follicles are
Day 15-26 = corpus luteum (↑Progesterone, damaged
↓Estrogen)
Pregestational post-ovulation pre-menstruation Multifetal Pregnancy
Dizygotic Twins (Fraternal twins; same/different
6-8 days after fertilization  implantation (fundus) sex)
 hCG production  maintains corpus luteum for  More common than monozygotic
the first trimester  corpus luteum produces  2 Placentas + 2 bags of water = bigger
↑Estrogen ↑Progesterone (maintains endometrium uterus
= amenorrhea = pregnancy)  Multiple ovulation
 Taking ovulatory drug
Ischemic: vasoconstriction o Clomid: stimulates FSH & LH
Day 27-28 = corpus albicans (white)  no o Could be a factor for complete H-
production of progesterone (to maintain mole
endometrial lining) in preparation for next menses
Monozygotic Twins (identical)
Related terminologies Only one ovum is present, splitting/division
Menarche (first menstruation) happens
 9 y.o., 12-13 y.o., 17 y.o. Same sex, identical
 Pregnancy is possible 2 years after  Dichorionic Diamniotic
menarche o Splitting: 1st - 3rd day after
Dysmenorrhea (excessive menstrual pain) fertilization
 Primary = idiopathic o 2 placentas, 2 BOW, 2 fetuses
 Secondary = due to pelvic pathology  Monochorionic Diamniotic
 Endometriosis = growth of endometrium o Splitting: 4th - 7th day after
outside the uterus fertilization
 Pain: sex, urination, menstruation o 1 placenta, 2 BOW, 2 fetuses
Amenorrhea (absence of menstruation)  Monochorionic monoamniotic
 Primary: menses have never occurred o Splitting: 8th - 13th day after
>17y.o.
fertilization
 Secondary: previously menstrual bleeding
o 1 placenta, 1 BOW, 2 fetuses
has occurred
 Conjoined twins
 Regular cycles = 3 missed cycles
o Splitting: > 13 days after fertilization
 Irregular cycles = 6 missed cycles
o Cleavage is incomplete
Metrorrhagia (bleeding in between menses)
 Bleeding at irregular intervals o Rare
 IUD / Depo Povera [injectable] / Implanon
[implant]
External version: abdominal manipulation to
change the presentation especially in cephalic-
breech fetuses

Trophobla
Amnio st
n
Complications of Multifetal Gestations
 Pre-eclampsia
 Polyhydramnios
 Overdistension of uterus
o Uterine atony  PPH
 Prematurity and low birth weight
o < 37 weeks
o Low BW: < 2500g
o Very low BW: < 1500g
 Postpartum hemorrhage
 Malpresentation
 Cord prolapse
 Dystocia
o The number of fetuses and
malpresentation
o Shoulder: most common in GDM
 Placenta previa Treat syphilis ASAP during 1st trimester =
 Maternal anemia Benzathine Penicillin G
 Structural abnormalities
Inner cell mass:
Fetal Growth  Amnion (inner and thinner membrane) 
4 to 40 weeks, 10 lunar months BOW and umbilical cord
20-36: pre-term o Facing the fetus
37-42: term  Embryo  fetus
40: full-term
>43 weeks: post-term Embryo (2-8 weeks): production of organogenesis
Age of viability: 20 weeks / 5 months (most critical stage)

Zygote: fertilization  2 weeks (cell division) Fetus (8 weeks  term)

 Cleavage: 2 cell
 Blastomeres: 4-cell / 8-cell Implantation / Nidation
After 3-4 days 6 to 8 days after fertilization
 Morula: 16-50 cells 7 to 10 days
After 3-4 days
 Blastocysts: floating in the uterus Signs of Implantation:
Implantation 1. Vaginal spotting (Hartman’s sign)
2. Slight pain

Site: Fundus (uppermost portion of uterus,

posterior)

The Growing Fetus (cephalocaudal approach)

Month 1
 All systems in rudimentary form (one tube)
 With arms and leg buds, beginning
Trophoblast  chorion (outer and thicker formation of eyes, ears and nose
membrane)  placenta  HEART chambers formed. Heart beating.
o 1st functional organ = as early as 14
days
  End of first month: fetus is 1cm long,  The arms, hands, fingers, feet and toes are
weighs 400mg fully formed
 All organs and limbs are present
PRIMARY GERM LAYERS (starts as early as 2nd  By the end of 3rd month, fetus is about 4
week) inches long and weighs 45 grams

ECTODERM (eCsternal, CNS)

Epidermis, sweat glands, sebaceous glands, hair
follicles, sense organs, mouth, oral glands, tooth
enamel, pituitary gland, mammary gland, CNS.

MESODERM (connective tissues)

Walls of digestive tract, dermis, kidneys, ureter,
reproductive organs, musculoskeletal system,
cardiovascular system, spleen, pleura, blood, bone
marrow.
Amelia: absence of limbs caused by Thalidomide
ENDODERM (“ay”) (anti-emetic drug)
Respiratory system, lungs, pharynx, tongue,
tonsils, thyroid, parathyroid, thymus, liver,
pancreas, urethra, urinary bladder

Month 2
 Head is large
o At birth: head is largest
o CC & AC: 31-33cm
 Report if abnormal
 The neural tube: brain, spinal cord and
other neural tissues in the CNS is well- Month 4
formed  Quickening: 1st fetal movement felt by
 Folic Acid to prevent neural tube defects multigravida (primi is for 5th month)
o B9, Folate  Formed eyes ears nose
 NTDs: anencephaly (no brain), spinal bifida  Scalp hair develops
o Delivery via cesarean section  FHT by Fetoscope
o Can be detected through
 Lanugo begins to appear (fine hair =
amniocentesis
 Alpha fetoprotein (16-20wks) warmth)
 >20wks = false high  Meconium in bowels (green, intestinal
result secretions, 1st stool)
 Bloody tap = false o Day 1 newborn stool: dark green,
high result thick and tarry
 ↑= Neural tube defect o Day 2-3 transitional stool: watery
(may butas: AFP is
lumalabas) and thin, green
 ↓= Down syndrome o Day 4+ BF stool: yellow, soft, sweet-
 External genitalia is formed smelling
 Sonogram shows a gestational sac o Meconium staining: post-term is at
 Pregnancy Diagnostic: 6 weeks risk, suffers from uteroplacental
 End of the 2nd month insufficiency  chronic hypoxia 
o Fetus is 2.5cm, weighs 20g
meconium staining
 Organogenesis is ongoing  critical!
 MS + pink skin = acute
Month 3 hypoxia
 Pla-cen-ta is complete  MS + green skin = chronic
 FHT by electronic Doppler (10-12wks) hypoxia (post-term)
 Sex is distinguishable by UTZ  A sign of fetal distress except
 Kidneys excrete urine = amniotic fluid in breech presentation
 Fetus begins to swallow
 Absence of meconium stools
 Liver produces bile (green)
 Circulatory system is working at birth:
  Imperforate anus / no  The skin is covered with vernix caseosa
anal opening o cheese-like substance responsible
o Check the for thermoregulation, a form of
urine for lubrication
greenish  DO NOT REMOVE but spread!
characteristics  A newborn’s temp only
(fistula) becomes stable after 6hrs
 Hirschsprung’s o thick vernix and lanugo: pre-term
disease: NO peristalsis (compensatory mechanism for
(aganglionic) protection from hypothermia)
 Cystic fibrosis: NO o thin vernix and lanugo: term
pancreatic enzyme  o absent vernix and lanugo: post-term
hardened meconium  Hearing is established (can stimulate fetal
 By the end of 4th month, the fetus is about 6 movement)
inches long and weighs 55-120g.  Fetus: 28-36cm. long, Weight: 780g

Month 7
 Surfactant in the amniotic fluid
o Amniotic fluid = lung expansion
o Insufficient amount = fetal lung
Fetal Alcohol Syndrome has craniofacial deformity collapse
 Body is less wrinkled
 Hearing fully developed
 Testes begin to descend in the scrotal sac
 Thin retinal blood vessels (pre-term)
o Will constrict if exposed to ↑O2 
retinopathy of prematurity
(retinopathy is reversible through
surgery)
 Fetus is 35 to 38cm long, weight: 1200g
 Daily counting of fetal movement increases
Month 5
 Lanugo completely appears between 28-38 weeks (10-12 FMs/hr)
 Quickening for Primigravida o Ways: eat / move / sounds /
 FHT by ordinary STETHOSCOPE (Bell) massage
 Bones hardening o Time: daytime hours  active
 Nipples appear over the mammary gland o Position: left-side / reclining
(pre-term babies have little areolas) o Rule: < 10 FMs in 1 hour = extend 1
 Fetus actively swallows amniotic fluid: hour (only count the lacking
600mL/day numbers)
 Age of Viability: survival is possible if at  < 10 FMs in 2 hours =
least 500g BW REPORT (uteroplacental
 End of 5th month: fetus 25cm long insufficiency)
 Note: In women with a multifetal
Month 6 gestation, daily fetal movements are
 Body well proportioned significantly increased.
 Skin is red and wrinkled
At birth: Month 8 (& above focus: fetal weight gaining)
o Preterm: wrinkled skin 1st Tri: Organogenesis
o Term: smooth 2nd Tri: Fetal length
 Subcu8taneous fats begin to deposit (brown
o Post-term: dry and desquamating
fats = heat insulators); pre-terms lack fat
(peeling) due to fetal malnutrition
depositions  difficulty producing body
 Eyebrows and eyelashes are well defined
heat  at risk for hypothermia
 Eyelids are open
  Dexamethasone: 6mg IM
q12x2
 Fetus: 42-48 cm. long, weight: 1800grams-
2700grams

Amniocentesis (2nd tri: 15 to 12 wks)

 Drink water, urinate before procedure
 Iron deposits (in fetal liver) (prevent bladder puncture)
o Ubos na by 6 months  may start  Guided by ultrasound
complimentary food (rice/cereals,  Spinal needle
pasteurized juice)  Consent
o 7th month – veggies  Observe for streaming or leakage of
amniotic fluid in the puncture site
o 8th month – fruits
 HT: no lifting of heavy object for 2 days
o 9th month – red meat (red meat post-op
before white)
o 1st year of life = difficulty in fat Month 10
absorption  Little lanugo (term)
 Calcium deposits  Testes have descended.
 Skin is smooth and pink  With good muscle tone and reflexes
 Fingernails grow o Preterm
 Birth position assumes  Partial flexion
o Can do Leopold’s maneuver  Cryptorchidism (undescended
 CNS has matured enough (29-32 weeks) TT)
 Active moro reflex  Thick lanugo
 Fetus: 38cm long, 1600kg o Lanugo gradually disappears in 2
weeks
Month 9  Fetus kicks actively
 Nails are firm (term)  Fingernails extend over the fingertips
o Soft nails (pre-term)  Creases on the soles of the feet cover at
o Long nails (post-term) least two thirds of the surface.
 With definite sleep and wake pattern o Preterm: Smooth soles
 Lanugo disappearing  Lightening occurs two weeks before labor
 Most babies turn into vertex position (baby drops, settles  increased urination,
(occiput: back of the head) relief of dyspnea)
o 2 weeks before = primigravida
o 1 day before = multigravida
 Fetus: 48-52cm long, weight: 3000grams

Amniotic Fluid
 Major sources of AF after 20 weeks: fetal
kidney
o In pre-term, fetus is at risk for  Normal volume: 500 to 1000mL / 800 to
breech presentation 1200 mL
 Lecithin and sphingomyelin ratio (L/S) is 2:1 o Assessed via ultrasound
= 35 weeks: mature lungs  pH: 7 – 7.25 (neutral to slightly alkaline)
 Presence of phosphatidyl glycerol (PG) o Nitrazine paper, a pH paper
confirms lung maturity (36 weeks)  Yellow = acidic = urine
o Pre-terms are at risk for ARDS  Blue/Green = alkaline = BOW
o Antenatal Corticosteroids to increase  Normal color: clear
lung surfactant (will be prone to  If BOW ruptures + unengaged head
infection) o At risk for cord prolapse
 Betamethasone: 12mg IM o Check FHR (priority)
q24hx2 o Time of rupture
 o Delivery within 24hrs  risk for
infection
o If ruptures < 20 weeks = fetus is not
viable
 If cord is exposed = cover with wet gauze
to prevent drying
o Dry cord  atrophy of umbilical
vessels
o DO NOT re-insert
o Reposition: Trendelenburg, Knee-
Chest, Hands and knees, Sims
 To decompress the cord
 Push the head and
accompany the mother to the
OR

Functions of Amniotic Fluid: Watch video for DAY 2

1. Protection from trauma (major)
2. Maintains temperature
3. Prevents cord compression DAY 3
4. Helps in delivery
5. For musculoskeletal development Complications
a. Oligohydramnios  underdeveloped HELLP Syndrome (Hepatic & Hemolytic problems)
 Hemolysis
 Elevated
 Liver Enzymes (↑AST/ALT = liver damage)
 Low
 Platelet Count (Thrombocytopenia)
Best management: DELIVERY!

PIH Management
Criteria for home management:
Abnormal colors  Blood pressure is less than 150/100,
 Green proteinuria less than 1g/24 hours,
o Meconium staining  Normal platelet count, and no fetal growth
 Golden yellow  byproduct: Bilirubin restrictions.
o Due to destruction of fetal RBCs /
Hospital care for Pre-Eclampsia. The woman is
Hemolytic disease
placed in bed rest
o Related to Rh Incompatibility
 Rh(-) mother & Rh(+) fetus  POSITION: left lateral recumbent (↑venous
 Mgmt: RHOGAM/RhIg/Anti-D return)
 Given 28 weeks, repeat 48-72  DIET: high protein (70-80g/day, to replace
hrs after delivery protein loss), moderate sodium (3g/day, for
 Check indirect comb’s test electrolyte balance)
(mother’s blood) = result  ROOM: dim and quiet, non-stimulating
should be negative (reduce visual and auditory stimulation)

ANTIHYPERTENSION: Hydralazine (Apresoline),

Aldomet (Methyldopa), Normodyne (Labetadol),
and Nifedipine (Procardia)
 Given to severe pre-eclampsia (DO NOT
GIVE to mild pre-eclampsia)
  Therapeutic Goal: decrease BP slightly
lower than 140/90 Postpartum Management:
1. Monitor The Patient for 48 Hours After
ANTICONVULSANT: Magnesium Sulfate (CNS Delivery
depressant, muscle relaxant) 2. A woman will continue to receive the
 Blocks acetylcholine infusion of MgSO4 for about 24 hours
 If RR < 12/14, DO NOT GIVE postpartum.
 Route: IV Piggyback / IM Z-track (gluteus, to
distribute, do not massage) DIABETES MANAGEMENT DURING
 Therapeutic level: 4-7 mEq/L; 5-8 mEq/L PREGNANCY
 Monitor ANKLE CLONUS every hour Woman with established diabetes
o Dorsiflex the foot Good diabetic control
o Normal: Absent  Maintain normal blood glucose 1-2 months
o Present: REPORT! prior to pregnancy
 Monitor DEEP TENDON REFLEX/PATELLAR Folate supplements
REFLEX every hour (first sign) Frequent visits
o Normal: Present (+2)
o Absent: REPORT Hyperglycemia (1st trimester)
 Teratogenic
EVALUATE MAGNESIUM TOXICITY  Congenital anomalies
Obtain serum Mg levels every 6-8hrs  Miscarriage
Blood Pressure: ↓hypotension
Urine Output: ↓ (<30cc/hr) Maternal Risks
Respiratory Rate: ↓ (<12/min)  Polyhydramnios (d/t fetal polyuria)
Patellar Reflex: Disappears first sign  Pre-eclampsia
Somnolence: Sleepy (Mg = sedating effect)  Shoulder dystocia (d/t macrosomia)
 Maternal infections (UTI, Candidiasis)
9-12 mEq/L = DTR disappears
15-20 mEq/L = RR depression Excessive glucose transport to fetus
>20 mEq/L = Cardiac arrest  Fetal hyper-insulin production 
macrosomia  shoulder dystocia  at risk
ANTIDOTE for Magnesium Toxicity: Calcium for birth trauma
Gluconate  Fetal hyper-insulin production  newborn is
Management for seizure: Priorities at risk for hypoglycemia within 1 hour (fetus
got used in producing too much insulin)
DURING o All newborns will suffer
1. Side rails should be up hypoglycemia but only after 2-3 hrs
2. Position the woman on her side o Management: breastfeed the baby
3. Magnesium IV Stat to terminate the ASAP
convulsion.  Fetal hyper-insulin production delays lung
AFTER (Postictal); Semi-comatose surfactant production  delayed lung
4. The airway should be maintained. maturity  newborn is at risk for
5. The woman should be observed for onset of respiratory distress syndrome
labor o Give Dexamethasone or
6. Monitor FHR Betamethasone
7. The woman is monitored for signs of  Macrosomia delivery method: NSD  not CS
abruption placenta because the mother is at risk for poor
8. Check the woman every 15 minutes for wound healing and infection
vaginal bleeding
Fetal Risks
Intrapartum Management  Congenital anomalies: Heart defect (most
1. REAL CURE: BIRTH is the only known cure common) / Caudal Regression Syndrome
for PIH because it is pregnancy-induced (hypoplasia of lower extremities)
(NSD)  LGA/Macrosomia (>4000g)
2. Labor may be induced by intravenous  Increased risk for birth trauma
oxytocin when there is evidence of fetal o Broken clavicle, damaged neck,
maturity and cervical readiness (butter soft: brachial nerve injury
ready to dilate) (must be term: 37 weeks)  Increased incidence of RDS
3. In severe cases, CS may be necessary (fetal o Delays lung surfactant production
distress) because fetal hyper-insulin
4. Oxygen administration production delays cortisol production
 o Dexamethasone or Betamethasone
o Hyaline Membrane Disease Fetus of L:S Ratio Lung
 Newborn is at risk for hypoglycemia Maturity
o Management: BF ASAP Non-Diabetic 2:1 35 weeks
Mother
Screening for GDM Diabetic 3:1 38 weeks
 Between 24-28 weeks (toward the end of Mother 2.5:1
2nd trimester) Give:
o The body’s insulin resistance, a Dexamethaso
hallmark of GDM, typically increases ne,
due to placental hormones Betamethason
 50g oral glucose tolerance test (no fasting) e
 Check blood glucose after 1 hour
 More than 140mg/dL, the woman is Checking via propylene glycerol (PG) is more
scheduled for a 100g 3hr, OGTT (fasting 8- accurate than L:S ratio to check for lung maturity
14 hrs)
o If 2 of the 4 blood samples collected Postpartum Considerations
are abnormal or if FBS is above  Woman with GDM should maintain a normal
95mg/dL, a diagnosis of diabetes is BMI after to reduce the risk of type 2 DM
made
BLEEDING DISORDERS OF PREGNANCY
 Abortion: term for any interruption of
pregnancy before 20 weeks
o Spontaneous / Miscarriage
o Induced / Intentional

Methods of Abortion
 Medical termination
o Avoids an anesthesia
o More effective at earlier gestation
(49 days or less)
 GDM first therapy: Diet (calory-deficit, 1800- o Mifepristone (Anti-Progesterone) 
2400 calories/day) after 3 days  Misoprostol (Cervical
 If diet is inadequate: Insulin (safe) ripener, Prostaglandin)
 Oral hypoglycemics are never used during  Surgical Termination
pregnancy o Requires anesthesia
o >49 days
Perinatal Insulin Requirements (varies
o Suction evacuation (menstrual
throughout)
extraction)
 1st tri: decreased (fetal organogenesis, brain
 5-7 weeks after LMP
development, ↓appetite)
Prior to dilatation, Misoprostol is given to
 2nd tri: increased (↑placental hormones =
ripen the cervix
insulin antagonist)
o Dilatation and curettage
 3rd tri: increased
 < 13 weeks
o By 36 weeks, insulin may be
o Dilatation and vacuum extraction
decreased because placental
 Between 12-16 weeks
hormones are decreased
TYPES DESCRIPTION
 Labor and delivery: decreased because we
THREATENED Possible loss/ foundation of all
need energy -Closed cervix types of abortions/
o Regular insulin IV (only) -Mild bleeding painless/ mild cramps/ mild
 Immediate postpartum: rapid return to pre- bleeding/vaginal spotting/non-
pregnant levels tender uterus
o Due to the delivery of placenta  No sex for 2 weeks / no lifting
NO antagonist heavy objects / bed rest until
 Breastfeeding: decreased (to decrease bleeding subsides / observe for
increasing blood loss.
insulin dose)
INEVITABLE Imminent, loss cannot be
o Carbohydrates are needed for milk -Dilated cervix prevented, moderate bleeding. Mild
production -Moderate to painful uterine contractions,
bleeding membranes may rupture. No
Timing of birth passage of abortus yet.
 Fetal lung maturity is delayed INCOMPLETE Some products are expelled,
 -Dilated cervix severe bleeding due to retained d. Scarring of the fallopian tube due to
-Severe placenta complication
bleeding  Dilatation and curettage
 Most painful Classic Symptoms
COMPLETE All products are expelled from the BEFORE RUPTURE
-Closed/dilated uterus  Lower and unilateral (one-side) abdominal
cervix  Bleeding is not severe pain, amenorrhea, abnormal vaginal
(uterus contracts) bleeding on 6-8th week due to low
HABITUAL Recurrent (3 or more consecutive
progesterone
-Dilated cervix pregnancies have ended in
spontaneous abortion)  Low HCG, estrogen, progesterone
SEPTIC Abortion complicated by infection: AFTER RUPTURE
incomplete abortion (foul smelling  Deep, sharp, stabbing, unilateral, acute
vaginal discharge, fever) lower quadrant ABDOMINAL PAIN
MISSED Retention (dead fetus syndrome),  Cullen’s sign: bluish navel /
-Closed cervix the fetus died before 20 weeks but
retained for 4 weeks or more.
hematoperitoneum / indicative of internal
 HCG is negative bleeding
 All signs of pregnancy  Kehr’s sign: referred pain (pain radiating to
disappear shoulders) due to stimulation to phrenic
No FHT. Regression of Breast nerve (diaphragmatic nerve)
changes. No uterine growth. No
fetal movement.
Management
Unruptured Ectopic
Post-Abortion
Oral Methotrexate (Anti-Folic Acid): when HCG
 Expect spotting for 2 weeks
becomes negative, followed by Leucovorin
 Report heavy bleeding, and signs of
Pre-requisite
infection
1. Ectopic sac is < 3.5cm in diameter
 Do not douche, no tampons
 No lifting heavy objects in 3 days 2. Serum hCG levels < 5000mIU/mL
 Menstruation will return after 6 weeks 3. Liver function test within normal levels,
normal kidney function, no evidence of
ECTOPIC PREGNANCY / TUBAL PREGNANCY thrombocytopenia
 Any blastocyst implantation outside the 4. Hysterosalpingogram or Ultrasound is
uterus performed after the therapy
 Common site: Ampulla of the fallopian tube
a. Tubal patency
TYPE DURATION Surgical Treatment for unruptured tubal pregnancy:
Ampullar 6-12 weeks Laparoscopic Salpingostomy
Isthmic 6-8 weeks Surgical Treatment for ruptured tubal pregnancy:
(narrowest, rupture Laparoscopic Salpingectomy (50% sterile)
the earliest)
Fimbriated 6-12 weeks HYDATIDIFORM MOLE/GESTATIONAL
Interstitial 12-14 weeks TROPHOBLASTIC PREGNANCY/MOLAR
PREGNANCY
-The chorionic villi develop into avascular
Risk Factors
transparent grapelike vesicles
 Previous Pelvic Inflammatory Disease
-Does not last >20 weeks
o Due to scarring  ovum cannot
-Cause: UNKNOWN
migrate
o Causes of PID: chlamydia,
Signs and Symptoms
gonorrhea, postpartum endometritis,  Big uterus (rapid growth of trophoblastic
post-abortal uterine infections) clusters/vesicles)
 Previous ectopic pregnancy, previous  Snowstorm pattern in ultrasound
bilateral tubal ligation, previous tubal,  No FHT
pelvic surgeries  Excessive hCG (1-2 million IU)
 Maternal smoking at the time of conception  Hyperemesis gravidarum  Met. Alkalosis
 Hypertension before 20 weeks
Board Question o PIH develops after 20 weeks
Given Bella’s history of gonorrhea, which of the
 Ovarian enlargement
flowing might contribute to her sterility?
 Dark brown vaginal discharge
a. Infection of the cervix
 Passage of clear fluid-filled vesicles
b. Infection of the uterus
o 16 weeks
c. Infection of the uterus and cervix
 o G1, A1 -1st symptom: bloody show < 20 weeks (pinkish
vaginal discharge due to mixture of tuberculum
[white] and blood) = sign of cervical dilatation
-To detect: Transvaginal UTZ

Management
Cervical Cerclage
 Performed at 12-14 weeks under regional
anesthesia
 Success rate is 85-90%
Types of H-Mole  Types
Partial H-Mole o Mc Donald: simple procedure
 1 set of chromosomes of maternal in origin  Hospitalized for 48hrs
and 2 sets of paternal in origin (Dispermy)  Temporary - NSD
 69, (XXX, YXX, YYX) Triploid karyotype o Shirodkar: complicated operation
 Done if Mc Donald procedure
fails
 Hospitalized for 5-7 days
 May be left in place - CS
 Removal of the cerclage: 37-38 weeks 
NSD
After Cerclage
 Position in modified/slight trendelenburg for
Complete H-Mole a few days to reduce pressure
 A sperm fertilizes an EMPTY ovum  Observe: rupture of membranes,
 Androgenesis (duplication of paternal set) contraction, V/S, infections
o Ovum never participated  No sex, no heavy lifting
 46, Diploid karyotype  No prolonged sitting and standing
 20% risk for developing cancer (>90mins)

Management PLACENTA ABRUPTIO

 Remove the moles by suction evacuation PREVIA PLACENTA
 Oxytocin after evacuation to prevent (risk for (risk for
bleeding malpresentati uteroplacental
 Monthly hCG test for 6-12 months on) insufficiency)
o Complete H-Mole (at risk for cancer) (do not delay
o Goal: ↓hCG levels delivery!)
o If ↑hCG levels = malignancy (risk for
 Methotrexate is given prematurity)
 Regular chest x-ray and pelvic examinations Abnormal IMPLANTATIO Normal
(to check for metastasis) N
 DOC for choriocarcinoma: Methotrexate 1. complete TYPES 1. covert
2. partial (central,
 If metastasis occurs, Dactinomycin is added
-Classical CS, clot=concealed,
Other considerations not bikini = board-like)
 No pregnancy for 1 year placenta will be central
o To check for malignancy cut separation,
o Difficulty in recognizing increasing 3. marginal common
hCG for cancer or [pregnancy (NSD) 2. overt
 Use contraception 4. low lying (marginal)
 Abdominal hysterectomy (optional) (NSD) edge separation
Sudden external BLEEDING Internal or
bleeding only external
(around 30 (usually late)
weeks/ after 20
Premature Cervical Dilatation; Incompetent weeks)
Cervix (former term) Bright red COLOR Dark red or
-Most common cause of habitual abortion bright red
-Painless, occurring <20 weeks Soft and non- UTERUS Board-like and
-Due to incompetency tender tender
-Congenital: short cervix (<2cm) Painless PAIN Painful
-Acquired: cervical trauma MULTIPARITY MOST HYPERTENSION
(fundal scarring) COMMON (vasoconstrictio
 CAUSE n) Theories of labor:
Smoking  Uterine stretch
Previous CS & Smoking o most acceptable due to ↑E =
abortion Cocaine use
myometrial irritability
Age >35 y.o. Age >35 y.o. /
Multiple Accidents
 Prostaglandin
pregnancy Multiple o Uterine irritants
pregnancy  Progesterone deprivation
-Sufficient Expectant  Aging placenta starting 36 weeks
migration of Management  Oxytocin
placenta o Uterine irritants
-Prevent and o PPG stimulation
control bleeding
-No IE (ALL
BLEEDING
Preliminary Signs of Labor
DISORDERS) LIGHTENING Signs- increase urinary
-No sex Pain radiating to legs frequency, shooting pain
-Bed rest (sciatic nerve), increased radiating to legs, relief
- vaginal secretions of dyspnea, increase
Betamethasone/ vaginal discharges.
Dexamethasone BRAXTON HICK’S Tightening and pulling
may be CONTRACTION sensation
administered increases 3-4 weeks before
(lung labor, fades Mgmt: Walk
surfactant)
-Double set up True labor: does not fade
for marginal WEIGHT LOSS 1-2 lbs. prior to labor
type ↓P = fluid excretion
RIPE CERVIX Butter-soft: ready to
Abruptio Placenta Grading dilate
Grade 0: no symptoms of separation from INCREASING ENERGY Nesting period: birth
maternal and fetal signs, the diagnosis made preparation
after birth when the placenta is examined RUPTURE OF Occasional sign
MEMBRANES
showing an adherent clot.
(N) rupture of BOW: 2nd
Grade 1: No fetal distress stage of labor

No matter the grading, deliver regardless of Duration of Labor

AOG = high percentage of premature births  Primipara: 14-20 hours
o Prolonged: >20
Grade 3: ↑Maternal shock, fetal death  Multipara: 8-14 hours
o Prolonged: >14

Factors Affecting Labor Duration

 Inadequate pelvis
o Gynecoid, anthropoid
 Multiple pregnancy
 Malpresentation
 Weak contractions
 Delayed dilatation
 Macrosomia

Prolonged Labor
Complications of Abruptio Placenta
 Fetal distress
 Prematurity
 Uterine atony
 Hemorrhage (bleeding in myometrium
uterus is very rigid)
Signs of True and False Labor
 Couvelaire uterus / Uteroplacental apoplexy
CRITERIA TRUE LABOR FALSE
 Infection LABOR
 DIC CONTRACTIO 3 contractions in 10 Decreasi
N minutes. Regular ng and
Irregular
INTRAPARTAL PERIOD DISCOMFORT Starts from the back Confined
Real cause: UNKNOWN at the
 abdomen
CERVIX with changes No
Dilated (active changes
phase) DILATATION: widening of
external os
Primi: 1cm/hr
Multi: 1.5 EFFACEMENT: thinning
cm/hr of the cervical canal.
-Primi: ED
-Multi: DE/sabay
Do IE q 4hrs +3, +4, +5 Crowning = 2nd stage of labor
only to
prevent
infection DECELERATION
WALKING Increases the pain Relieves
the
discomfo
rt
SHOW Increasing Decreasi
ng
Pinkish
discharge =
cervical
dilatation is
increasing
DURATION of Increasing Decreasi
contraction ng  Do not check FHR during contractions =
FREQUENCY Increasing Decreasi false result
of contraction ng
INTENSITY of Increasing Decreasi CAUSES OF FETAL DISTRESS  Fetal Hypoxia
contraction ng  Prolonged cord compression
INTERVAL of Decreasing Increasin
 Antepartal and intrapartal hemorrhage
contraction; g
in-between  Preeclampsia and eclampsia
contractions  Induction or augmentation of labor
 Heart conditions complicating pregnancy
Tocolytic Agents and labor
-Muscle relaxant  Hypotensive effects of anesthesia
-Use to halt/stop labor temporarily (48hrs) to
provide window for administration of antenatal SIGNS OF FETAL DISTRESS
corticosteroid (Betamethasone, Dexamethosone)  Hyperactive fetus
-For preterm labor  Fetal tachycardia and bradycardia
 IT’S- Indomethacin  Severe variable deceleration in electronic
o Least used fetal monitoring
o With fetal side effect (closes ductus  Persistent late deceleration in electronic
arteriosus of the fetus) fetal monitoring
 NOT- Nifedipine (Procardia)  Meconium staining, except for breech
 YET- Yutopar (Ritodrine) presentation
 MY- MgSO4
 TIME- Terbutaline (Brethine) COMPLICATIONS OF FETAL DISTRESS
 Mental Retardation / Intellectual Disability
CONTRAINDICATIONS (new term)
1. Dilatation is more than 3 cm  Seizures
2. Cardiac disease (rule: >115bpm = do not  Cerebral palsy
give)  Intrauterine Fetal Death
3. Fetal distress
4. Abruption placenta STAGES OF LABOR
5. PROM (BOW must be intact) 1st Stage of Labor / Cervical Dilatation Stage
6. Chorioamnionitis LATENT ACTIVE TRANSITIO
(6 hrs. (3 hrs. N
FETAL STATION / FETAL DESCENT for primi for
Relationship of presenting part to ischial spine 4.5 hrs. primi
for 2 hrs.
Most important criterion for walking
multi) for
 multi) umbilicus

admit shortest 4% Breech point of

longest maximum impulse for
DILATATION 0-3 cm 4-7 cm 8-10 cm FHT: above the umbilicus
DURATION 20-40 sec 40-60 sec 60-90 sec
FREQUENCY Every 5-10 Every 3-5 Every 2-3 min 1% Shoulder (CS) point of
min min maximum impulse for
Uterine Tetany:
FHT: near the umbilicus
contraction of 2
minutes 
hypoxia MECHANISMS OF LABOR
INTENSITY Mild Moderate Strong  Engagement
BEHAVIOR Excited Fear of Resistance to  Descent: due to fundal contraction
losing touch
control  Flexion: the presenting part is already in
CONSIDERATIO Give Give pain Reassurance the pelvic floor
NS instruction relievers  Internal rotation
s  Extension: delivery of the head occurs
Do not give
Do not give during latent  External rotation
during phase  at o 1st anterior shoulder
latent risk for o 2nd posterior shoulder
phase  neonatal
prolongs respiratory
 Expulsion: shoulders and the rest of the
labor depression body
o Thoroughly dry the baby
UNNECESSARY INTERVENTIONS DURING o Skin-to-skin contact with mother
LABOR
[WHO-DOH] 3RD STAGE OF LABOR: Placental Expulsion stage.
 Fundal pushing  laceration (3-10 minutes)
 Perineal shaving Active Management of the Third Stage of Labor
 IV infusion (AMTSL)
 NPO (unless to undergo Gen. Anes.) 1. Administration of Uterotonic
 Strict supine position  10 units Oxytocin, IM, administered
 Artificial ROM  prolapse, infection to the mother within one minute of
 Enemas baby’s birth
 Episiotomy (unless the baby is large) 2. Controlled Cord Traction with Counter
Traction
Recommended position during the 1st stage of  wait a strong contraction (2-5mins),
labor clamp the cord when pulsation stops
 Upright Position  push the fundus upward with one
hand while applying continuous,
2nd Stage of Labor / Fetal Expulsion Stage steady and non-directional traction
Temperature of delivery 25-28 degree Celsius on the cord with the other hand.
room (prevent hypothermia)  Wait for feeding cues for
breastfeeding
Transfer to delivery room Primi: 10cm 1. Rooting
Multi: 7-8cm 2. Opening of mouth
3. Tonguing
Wear Double sterile gloves (1 4. Licking
birth attendant)
3. Uterine Massage – after placental delivery
Most common birthing Lithotomy  risk for
position hypotension
 Do not wait for signs of placental
-Doctor’s advantage separation anymore: More delayed
Surest sign that the baby Bulging of the perineum  more blood loss
is about to be delivered (check)
When to push During contractions, fully Active Management of the Third Stage of Labor
dilated cervix (AMTSL) decreases the risk of postpartum
When not to push Not fully dilated cervix, hemorrhage
intervals, delivery of the
head Types of Placental Delivery
Frequency of FHR Every 5 minutes  Schultz: fetal surface
monitoring
 Duncan: maternal surface
95% Cephalic point of
maximum impulse for After placental delivery, check the completeness of
FHT: fetal back, below the cotyledons (20-30)
4TH STAGE OF LABOR (1-2 hours) Weight of the Uterus
VITAL SIGNS MONITORING FOR THE FIRST 2 HOURS 4 stage of labor
th
1000-1100g
IS EVERY 15 MINUTES After 2 weeks 500g
 most critical because if fundus fails to After 3-4 weeks 300g
contract  uterine atony  hemorrhage After 5-6 weeks 50-60g
(Non-pregnant state)
TEMPERATU (36.2-38 degree Celsius) for the first
RE 24 hours due to dehydration Exception: Multipara (70-80g)
BP Should remain consistent with
baseline BP during pregnancy.
RR 16-22 breaths per minute
SUBINVOLUTION= incomplete return of the
PR May be bradycardia (50-70 beats per
minute) for one week  increased uterus to non-pregnant state after 5-6 weeks.
stroke volume Most common cause: UTERINE INFECTION (fishy
smell)
Report:  Frequent internal examination
 Increased temperature after 24hrs =  Retained placental fragments
Infection
 Hypotension – Tachycardia – Tachypnea = EVALUATING LOCHIA
Shock 1. Color: Red (Day 1-3 Rubra) Pinkish to
Brownish (Day 7-9 Serosa) whitish to
yellowish (Day 10-21 Alba)
NORMAL Characteristics of Fundus after 2. Odor: fleshy, musky, non-offensive, non-
delivery: firm, contracting, midline, below foul, sour
the umbilicus 3. Amount: heavy, moderate, light and scant
4. Lochia should not exceed 4-8 pads per day
If the fundus is soft, UTERINE ATONY
relaxed and boggy Report!
If the fundus is deviated FULL BLADDER  Fishy odor (infection)
to the side Urinate first before  More than 8 peri pads (heavy bleeding)
massage  may lead  Clots larger than 1cm (retained
to Uterine Atony secundines/fragments)
Above the umbilicus OVER-DISTENTION OF
UTERUS 1. A new endometrium is formed 3 weeks after
If the fundus is firm but LACERATION delivery
there is steady trickle of 2. The placental site is healed by 6 weeks
blood DEGREE OF LACERATION 3. Postpartum hemorrhage
Vagina, 1 st
Early (first 24hrs)
Fourchette, skin of  Cause: Uterine Atony
perineum Late (after 24hrs)
Muscles of 2 nd  Cause: Retained secundines
perineum,
Anal sphincter, 3 rd
4. Sex can be resumed when lochia flow has
Rectal mucosa 4 th
stopped and episiorrhaphy is healed.
5. Cervix after delivery= transverse slit
#LOCATION OF THE FUNDUS AFTER DELIVERY
After delivery of the Midway between the 6. Vagina returns to pre pregnant state by 6
placenta umbilicus and the
symphysis pubis
weeks
After 1 to 2 hours At the level of umbilicus 7. For non- lactating mother, ovulation resumes
After 24 hours One fingerbreadth below after 6 weeks
(only descends AFTER the umbilicus 8. For lactating mother, ovulation resumes after
24hrs) 6 months because prolactin inhibits ovulation.
10 day
th
Non-palpable 9. Lactation Amenorrhea Method is only effective
-Fundus is already behind on the first 6 months
the symphysis pubis 10. All contraception with estrogen are not safe
for Lactating Mothers = stops milk production
POSTPARTAL Period: the first 6 weeks after 11. Progesterone Only Pill (POP) is safe for
delivery lactating mothers (Minipill/IUD/Implant/Depo
 INVOLUTION: Complete return of the Povera)
reproductive organs to non-pregnant state 12. Women who has a rubella titer of less than
for 6 weeks 1:10 are usually given rubella vaccine in the
postpartum period. And instruct the mother that ABOVE) phase
pregnancy is not allowed for 3 months.
13. All Rh-negative women who meet specific
criteria should receive RhoGAM
14. Routine antibiotic prophylaxis is not “The difference between ordinary and
recommended for women with uncomplicated extraordinary is that little extra!”
vaginal birth and for those women with Congratulations, mga Anak!
episiotomy and 1st and 2nd degree lacerations.
15. Hunger will start to increase 1-2 hours after
birth (maternal)
16. First bowel movement normally occurs by 2nd
to 3rd day postpartum.
17. Immediate weight loss after delivery (12-
15lbs)
18. Weight loss in the 1st week (5lbs)
19. Loss in the next 6 weeks (10lbs)
20. Most women return to their pre-pregnant
weight by 6 months.
21. The best schedule for breastfeeding per
demand
22. What are the 3 Es of Breastfeeding: Early
(ASAP; prevent hypoglycemia), Exclusive (6
months), Extended (2 years or beyond)

23. General appearance of Breasts after

delivery- may be soft, full, and engorged, one
may appear larger, supple, pigmented, intact:
NORMAL FINDINGS

If breasts have fissures, cracks, and soreness:

PROBLEMS WITH BREASTFEEDING

If breasts are not erected with stimulation:

INVERTED NIPPLE

If breasts have reddened areas: MASTITIS

24. VBAC is only allowed for a woman undergone
Bikini CS (after 2 years); Not for Classical CS
(fundus, for life)

Psychological Response on Postpartum

TAKING-IN Passive Personal care
(FIRST 3 DAYS) Dependent
phase
TAKING-HOLD Active Newborn care
(4TH TO 6TH DAY) Independent
phase
LETTING GO Collaborative Parenting and
(7TH DAY AND Interdependent family planning