Chapter18 obstetrics

Obstetrics

CHAPTER 18

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• Obstetrics– Field of medicine that deals with pregnancy

(prenatal), delivery of the baby, and the first six weeks after delivery (postpartum period)

• Pregnancy– Nine calendar months or 10 lunar months– Forty weeks or 280 days– Divided into trimesters

• Three intervals of three months each

– Known as gestational period

Obstetrics Overview

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• Fertilization or conception– Union of a sperm and a mature ovum

• Takes place in outer third of the fallopian tube

– Zygote• Initial name for fertilized ovum

– Embryo• Name of product of conception from second

through 8th week of pregnancy

– Fetus• Name of product of conception from 9th week

through duration of gestational period

Pregnancy

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• Two major accessory structures of pregnancy– Amniotic sac

• Strong, thin-walled membranous sac that envelops and protects the growing fetus

• Also known as the fetal membrane• Outer layer of sac is called the chorion• Inner layer of sac is called the amnion• Amniotic fluid within sac cushions and protects

fetus during pregnancy

Pregnancy

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• Accessory structures of pregnancy – Placenta

• Temporary organ of pregnancy• Provides for fetal respiration, nutrition, excretion• Functions as an endocrine gland by producing

hormones necessary for normal pregnancy• Human chorionic gonadotropin (HCG), estrogen,

progesterone, and human placental lactogen (HPL)

Pregnancy

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• Accessory structures of pregnancy – Maternal side of placenta

• Attached to wall of uterus• Has a “beefy” red appearance

– Fetal side of placenta• Has shiny, slightly grayish appearance• Contains arteries and veins that intertwine to form

umbilical cord• Umbilical cord arises from center of placenta and

attaches to umbilicus of fetus

Pregnancy

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• Amenorrhea– Absence of menstruation

• Menstruation stops as a result of hormonal influence during pregnancy

• Changes in the uterus– Small, pear-shaped organ before pregnancy– Grows to accommodate growing fetus,

placenta, amniotic sac, and amniotic fluid during pregnancy

Physiological Changes During Pregnancy

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• Changes in the cervix– Chadwick’s Sign

• Cervix and vagina take on a bluish-violet hue due to local venous congestion

– Goodell’s Sign• Cervix softens in consistency in preparation for

childbirth


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• Changes in the vagina– Vagina takes on same bluish-violet hue of the

cervix during pregnancy– Increase of glycogen in vaginal cells

• Causes increased vaginal discharge and heavy shedding of vaginal cells

– Leukorrhea• Thick, white vaginal discharge during pregnancy


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• Changes in breasts– Increase in size and shape– Nipples increase in size and become more

erect– Areola become larger and more darkly

pigmented• Montgomery’s tubercles become more active and

secrete substance that lubricates the nipples


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• Changes in breasts– Colostrum is secreted

• Thin, yellowish discharge from nipples throughout pregnancy

• Forerunner to breast milk


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• Changes in blood pressure– May experience hypotension during second

and third trimesters (4th – 9th month)– Weight of pregnant uterus presses against

descending aorta and inferior vena cava• When woman is lying on her back (supine)• May complain of faintness, lightheadedness, and

dizziness


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• Changes in urination– First trimester

• Urinary frequency due to increasing size of uterus, creates pressure on bladder

– Second trimester• Uterus rises up out of the pelvis and pressure on

bladder is relieved

– Third trimester• Frequency returns due to pressure of baby’s head

on the bladder


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• Changes in posture– Waddling gait

• Manner of walking in which the feet are wide apart and the walk resembles that of a duck

• Due to softening of pelvic joints and relaxing of pelvic ligaments

• Pregnant woman’s center of gravity is offset


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• Changes in the skin– Possible increased feeling of warmth and

sweating• Due to increased activity of the sweat glands

– Possible problems with facial blemishes• Due to increased activity of sebaceous glands

– Chloasma• Hyperpigmentation (brown patches) seen on

forehead, cheeks, and bridge of nose• Known as the “mask of pregnancy”


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• Changes in the skin – Linea Nigra

• Darkened vertical midline between the fundus and the symphysis pubis on the abdomen

– Areola• Becomes darker as pregnancy progresses

– Stria Gravidarum• Stretch marks on the abdomen, thighs, and breasts

that occur during pregnancy


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• Changes in weight– Recommended weight gain during pregnancy

• Ranges from 25 to 30 pounds

– Pattern of weight gain is important• 1st – 3rd month = 3 - 4 pounds total• 4th – 9th month = 1 pound per week

– Critical to monitor weight gain for unexpected increases

– Fluid retention– Pregnancy-induced hypertension


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Signs and Symptoms of Pregnancy

• Presumptive signs– Expectant mother

• Suggests pregnancy but are not necessarily positive

• Include amenorrhea, nausea and vomiting, fatigue, urinary disturbances, and breast changes

– Quickening• Movement of fetus felt by the mother• Occurs around 18 – 20 weeks gestation• Described as a faint abdominal fluttering

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• Probable signs– Observable by examiner

• Much stronger indicators of pregnancy, but can be due to other pathological conditions

• Should not be used as sole indicator of pregnancy• Include Goodell’s sign, Chadwick’s sign, uterine

enlargement, hyperpigmentation of skin, abdominal stria, palpation of fetal outline, positive pregnancy tests

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• Probable signs – Hegar’s sign

• Softening of the lower segment of the uterus

– Braxton Hicks contractions• Irregular contractions of the uterus • May occur throughout the pregnancy and are

relatively painless

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• Probable signs – Ballottement

• Technique of using the examiner’s finger to tap against the uterus, through the vagina, to cause the fetus to “bounce” within the amniotic fluid and feeling it rebound quickly

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• Positive signs– Fetal Heartbeat

• Detected by ultrasound at approximately 10 weeks gestation

• Detected by fetoscope at 18 to 20 weeks gestation• Rate can vary from 120 to 180 beats per minute

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• Positive signs– Identification of embryo or fetus by ultrasound

• Can be detected as early as 5 to 6 weeks with 100 percent reliability

• Provides earliest positive confirmation of a pregnancy

– Fetal movements felt by examiner• Palpable by physician/examiner by the second

trimester of pregnancy

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Calculation of Date of Birth• Birth date for the baby

– Expected Date of Confinement (EDC)– Expected Date of Delivery (EDD)– Expected Date of Birth (EDB)

• Nagele’s rule for calculation of date– Subtract three months from beginning of last

menstrual period (LMP)– Add seven days to date = expected date of

delivery

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Discomforts of Pregnancy• Temporary discomforts of pregnancy

– Backache• Common during second and third trimester

– Edema• Swelling of lower extremities not uncommon

– Fatigue• Usually occurs during first trimester

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• Temporary discomforts of pregnancy – Heartburn

• Mainly during last few weeks of pregnancy

– Hemorrhoids• Develop as result of increasing pressure on area

– Nausea• Usually occurs during first trimester

– Varicose veins• Occur as result of blood pooling in the legs

Discomforts of Pregnancy

COMPLICATIONS OF PREGNANCY

Obstetrics

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Abortion

• Pronounced– (ah-BOR-shun)

• Defined– Termination of a pregnancy before the fetus

has reached a viable age, that is, an age at which the fetus could live outside of the uterine environment

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Abruptio Placenta

• Pronounced– (ah-BRUP-she-oh pla-SEN-tah)

• Defined– Premature separation of a normally implanted

placenta from the uterine wall• After the pregnancy has passed 20 weeks

gestation or during labor

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Ectopic Pregnancy

• Pronounced– (ek-TOP-ic PREG-nan-see)

• Defined– Abnormal implantation of a fertilized ovum

outside of the uterine cavity– Also called a tubal pregnancy

• Approximately 90 percent of all ectopic pregnancies occur in the fallopian tubes

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Gestational Diabetes

• Pronounced– (jess-TAY-shun-al diy-ah-BEE-teez)

• Defined– Disorder in which women who are not diabetic

before pregnancy develop diabetes during the pregnancy

• Develop an inability to metabolize carbohydrates (glucose intolerance), with resultant hyperglycemia

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Gestational Diabetes

• Risk factors– Obesity– Maternal age over 30 years– History of birthing large babies

• Usually over 10 pounds

– Family history of diabetes– Previous, unexplained stillborn birth– Previous birth with congenital anomalies

(defects)

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HELLP Syndrome

• Pronounced– HELLP SIN-drom

• Defined– Serious obstetrical complication that occurs in

approximately 10 percent of pregnant women with pre-eclampsia or eclampsia

• HELLP stands for Hemolytic anemia, Elevated Liver enzymes, and Low Platelet count

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HELLP Syndrome

• Early diagnosis is critical– Any woman who presents with malaise or a

viral-type illness in third trimester of pregnancy should be evaluated for possibility of HELLP Syndrome

• Laboratory diagnosis necessary to confirm HELLP syndrome– Complete blood cell count– Liver function tests

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• Pronounced– (high-dah-TID-ih-form mohl)

• Defined– Abnormal condition that begins as a

pregnancy and deviates from normal development very early

• Diseased ovum deteriorates (not producing a fetus)

• Chorionic villi of placenta changes to a mass of cysts resembling a bunch of grapes

Hydatidiform Mole

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Hydatidiform Mole• Hydatidiform mole

– Molar pregnancy– Hydatid mole– Growth of this mass progresses much more

rapidly than uterine growth with a normal pregnancy

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Hyperemesis Gravidarum

• Pronounced– (high-per-EM-eh-sis grav-ih-DAR-um)

• Defined– Abnormal condition of pregnancy

characterized by severe vomiting that results in maternal dehydration and weight loss

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• Pronounced– (in-COMP-eh-tent SER-viks)

• Defined– Condition in which cervical os dilates before

the fetus reaches term, without labor or uterine contractions

• Usually occurs during second trimester of pregnancy

• Results in spontaneous abortion of fetus

Incompetent Cervix

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Placenta Previa

• Pronounced– (plah-SEN-tah PRE-vee-ah)

• Defined– Condition of pregnancy in which the placenta

is implanted in the lower part of the uterus• Precedes the fetus during the birthing process

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Pregnancy-Induced Hypertension (PID)

• Pronounced– (PREG-nan-see induced high-per-TEN-

shun)

• Defined– Development of hypertension during

pregnancy, in women who had normal blood pressure readings prior to pregnancy

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• Three categories of PID– Gestational hypertension

• Develops after 20 weeks gestation with no signs of edema or proteinuria

– Pre-eclampsia• Develops after 20 weeks gestation with proteinuria

or edema

– Eclampsia• Most severe form of hypertension during

pregnancy• Evidenced by presence of seizures

Pregnancy-Induced Hypertension (PID)

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Rh Incompatibility• Pronounced

– (Rh Incompatibility)

• Defined– Incompatibility between and Rh negative

mother’s blood with her Rh positive baby’s blood

• Causes mother’s body to develop antibodies that will destroy the Rh positive blood

SIGNS AND SYMPTOMS OF LABOR

Obstetrics

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Signs and Symptoms of Labor• Bloody show

– Vaginal discharge that is a mixture of thick mucus and pink or dark brown blood

• Occurs as a result of the softening, dilation, and thinning (effacement) of the cervix in preparation for childbirth

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Signs and Symptoms of Labor• Braxton Hicks contractions

– Mild, irregular contractions that occur throughout pregnancy

• Increased vaginal discharge– Clear, nonirritating vaginal secretions– Occurs as result of congestion of vaginal

mucosa

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Signs and Symptoms of Labor• Lightening

– Settling of the fetal head into the pelvis• Occurs a few weeks prior to the onset of labor

• Rupture of the amniotic sac– Rupture of fetal membranes, releasing

amniotic fluid inside• May result in a sudden gush of amniotic fluid• Women may say their “water broke”

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Signs and Symptoms of Labor

• Sudden burst of energy– Occurs in some women shortly before onset

of labor– May have energy to do major housecleaning

duties

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False Labor versus True Labor

Contractions (False) Contractions (True)

Irregular Regular

Not too frequent More frequent

Shorter duration Longer duration

Not too intense More intense

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Discomfort (False) Discomfort (True)

Felt in abdomen Felt in lower back

Felt in groin area Radiates to lower abdomen

--- Feels like menstrual cramps


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Walking (False) Walking (True)

May relieve or decrease contractions

May strengthen contractions


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Effacement/Dilatation (False)

Effacement/Dilatation (True)

Dilatation and effacement of cervix does not change

Cervix progressively effaces (thins) and dilates (enlarges)

False Laborversus True Labor

DIAGNOSTIC TECHNIQUES, TREATMENTS

AND PROCEDURES

Obstetrics

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Diagnostic Techniques, Treatments, and Procedures

• AFP screening– Serum screening test for birth defects such as

spina bifida, Down syndrome, and Trisomy 18• Test is offered to pregnant women between 15 and

21 weeks gestation

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• Amniocentesis– Surgical puncture of the amniotic sac for the

purpose of removing amniotic fluid

• Cesarean section– Surgical procedure in which the abdomen and

uterus are incised and a baby is delivered transabdominally

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• Contraction stress test– Stress test used to evaluate ability of fetus to

tolerate stress of labor and delivery• Also known as oxytocin challenge test

• Fetal monitoring– Use of an electronic device to monitor fetal

heart rate and maternal uterine contractions

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• Nipple stimulation test– Noninvasive technique that produces same

results as contraction stress test • Pregnant woman stimulates the nipples of her

breasts by rubbing them between her fingers• Causes natural release of oxytocin that causes

contractions of uterus


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• Obstetrical ultrasound– Noninvasive procedure that uses high-

frequency sound waves to examine internal structures and contents of the uterus

– Ultrasonography

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• Pelvic ultrasound– Noninvasive procedure that uses high-

frequency sound waves to examine the abdomen and pelvis

• Pelvimetry– Process of measuring the female pelvis,

manually or by x-ray to determine its adequacy for childbearing


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• Pregnancy testing– Tests performed on maternal urine and/or

blood to determine presence of hormone HCG (human chorionic gonadotropin)

• HCG is detected shortly after first missed menstrual period

Diagnostic Techniques and Procedures

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Chapter18 obstetrics

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