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REVIEW ON NORMAL

OBSTETRICS
By: Viamarie B. Bulagao, RN
MALE ORGANS DESCRIPTION/FUNCTION
Scrotum A suspended, rugated, skin-covered muscular sac that aids in supporting the testes and regulating
the temperature for sperm survival
Testes To ovoid structures in the scrotum responsible for sperm formation and testosterone secretion
Seminiferous tubules: sperm production
Leydig/interstitial cells: testosterone production
Luteinizing hormone: testosterone release
Androgen-binding protein: responsible for testosterone binding, leasing to sperm formation

*Self testicular examination begins at early adolescence


Penis Urinary system and reproductive system outlet in males, composed of erectile tissues responsive
to sexual stimulation
Glans: bulging, sensitive tissue at the tip of the penis
Prepuce: covering of the glans removed during circumcision
Epididymis Passageway of testicular secretions to vas deferens
Vas Deferens Site of sperm maturation
Seminal vesicles, Organs secreting fluids that contribute to the alkalinity and motility of the sperm
ejaculatory ducts,
prostate, and
bulbourethral gland
Urethra Passageway of urine from the bladder
FEMALE ORGANS DESCRIPTION/FUNCTIONS
Mons veneris Adipose tissue padding over symphysis pubis that serves as protection of the pubic bone
Labia Majora External protection of the urethra, vagina, and external genitalia
Labia Minora Hairless connective tissue folds posterior to mons veneris
Vestibule Flat, smooth surface inside labia from which the urethra vagina arise from
Clitoris Center of orgasm and sexual pleasure for women
Skene’s and Responsible for lubrication during sexual intercourse
Bartholin’s Gland
Fourchette Tissue posterior to the labia minora and majora which is the site of incision for episiotomy
Perineal Body/ Muscle Muscles that stretch during childbirth to accommodate the delivery of the fetus
Hymen Tissue that serves as covering of the vagina during childhood
Ovaries Responsible for the production, maturation, and release of egg cells, production and release of estrogen
and progesterone, and regulation of menstrual cycle
Fallopian Tubes Serves as passageway of the egg cells from the ovaries and as site of fertilization (ampulla) of the ovum
and sperm
Parts:
1. Interstitium (Area lying within the uterine wall)
2. Isthmus (Area that is cut or stapled during tubal ligation)
3. Ampulla (Site of fertilization for the ovum and sperm)
4. Infundibulum (cone-like portion that connects that ovaries to the rest of the fallopian tube)
FEMALE DESCRIPTION/FUNCTIONS
ORGANS
Uterus Site of implantation and nourishment of fertilized ovum, housing and protecting the child until it’s mature
enough for birth
Body/corpus: uppermost part of the uterus that forms the bulk of the organ; expands to accommodate the
growing fetus
Fundus: area at the junction of the fallopian tube and the uterus that can be palpated abdominally; used in
assessing the progression of labor and postpartum uterine involution
Isthmus: similar to the body, this area expands to accommodate the growing fetus; site of incision during
cesarean delivery
Cervix: lowermost aspect of the uterus that is used in assessing the progression of labor; during pregnancy

Uterine/Cervical Layers:
1. Endometrium; Endocervix: Mucosal lining sensitive to hormonal stimulation, which improves sperm
motility for fertilization. During pregnancy, operculum formation occur at this layer vs. ascending
infections
2. Myometrium – Muscle layer that serves to strengthen the uterus to accommodate the delivery of the
fetus; to constrict tubal junction v. menstrual blood backflow/ regurgitation; and to support the internal
cervical os vs. preterm labor
3. Perimetrium – Adds support and strength to uterine structures
Vagina Organ of intercourse and passageway of sperm to meet the egg cell in the fallopian tube for fertilization;
during delivery, serves ad birth canal
Breast Organ of lactation
Reproductive System Development
Intrauterine Age Development
5 weeks AOG Primitive goal tissue formation (mesonephric/Wolffian and paramesonephric/Mullerian ducts)
7 – 8 weeks AOG Chromosomal Males: Gonodal tissue -> primitive testes and formation of testosterone
Mesonephric Duct: Male reproductive organ
10 weeks AOG Chromosomal Females: no testosterone -> gonodal tissue -> ovaries
Paramesonephric Duct: female reproductive organs (including ALL oocytes)
12 weeks AOG External genitalia formation
Males: Penile shaft elongation; closing or urogenital fold – Urethra
Females: Open urogenital fold – labia minora & majora
34 – 38 weeks AOG Males: testicular descent from pelvic cavity
*if testes do not descent from pelvic cavity, there is an increased risk for testicular cancer
Puberty – stage in life wherein hormone-mediated changes occur to
express secondary sex characteristics in both males and females

Tanner’s Scale of Reproductive System Maturity


Males Females
1. ↑ weight 1. Thelarche (first)
2. Testicular growth (first) 2. Pubic, axillary hair growth
3. Facial, axillary, pubic hair growth 3. Growth spurt
4. Voice chage 4. ↑ pelvic transverse diameter
5. Penile growth 5. Vaginal secretions
6. ↑ height 6. Menarche (last)
7. Spermatogenesis
Menstruation: uterine bleeding caused by cyclic hormonal
changes
Menstrual cycle: occurs to bring an ovum into maturity and
to renew the uterine lining conducive for fertilized egg
implantation and nourishment

• Average length of cycle: 28 days


• Average length of menstruation: 4-6 days
• Average amount: 30 – 80 ml
• Average Iron Loss: 11mg
ORGANS INVOLVED IN MENSTRUATION
Organs Description/Function
Hypothalamus Responsible for the cyclic secretions of gonadotropin-releasing hormone (GnRH); reacts to
levels of estrogen in the body (if high, release is repressed and vice versa)
Pituitary Gland By GnRH stimulation, products FSH and LH
Follicle-stimulating hormone (FSH): ovum maturation
Luteinizing Hormone (LH): mature ovum release and uterine lining growth
Ovaries By FSH influence, allows maturation of an egg cell per cycle which is called Graafian follicle
(GF); with LH influence, GF is released approximately 14 days before the beginning of next
cycle.
Mittleshmerz: unilateral, lower abdominal pain felt as sign of ovulation because Graafian
follicle release
Uterus Its inner lining is affected by changes in hormonal levels, in effect causing its
thickening/thinning
Cervix Thin and copious secretions lining the cervix due to estrogen secretion will be conducive
form sperm survival.
Fern test: with high estrogen levels signifying fertility, ferning of crystallization of cervical
mucus upon drying occurs because of sodium chloride in mucus fibers
Spinnbarkeit test: With high estrogen levels, cervical mucus is thin, watery and stretchable
into long strands, signifying fertility
PHASES OF MENSTRUAL CYCLE
Phases Description
1st Proliferative, • Four to five days after the end of the menstrual cycle
Estrogenic Follicular, • The thin lining of the endometrium proliferates eightfold upon increase in estrogen
Post-Menstrual levels until 14 days before the next cycle
2nd Secretory, • Progesterone formation by the corpus luteum (with the influence of LH) causes the
Progestational, corkscrew appearance of the endometrium. This layer also, at this phase, is rich in
Luteal, Pre- glycogen and mucin. These collectively makes this uterus at this phase the best time for
menstrual fertilized egg to implant.
• The endometrium will continue to thicken until it assumes a spongy, velvety appearance
3rd Ischemic • If fertilization does not occur, the corpus luteum will regress. Progesterone and
estrogen levels will decrease, leading to the degeneration of endometrial lining
4th Menses • The endometrial lining will slough off, which presents itself as menses.

Health Promotion for Menstruating Women:


• Moderate exercises
• Prostaglandin inhibitors or warm compress against uterine area for pain relief
• More rest, especially with dysmenorrhea
• Iron supplementation, as needed
Fetal Development

PREEMBRYONIC EMBRYONIC FETAL

Fertilization 2 Weeks 8 Weeks Birth


Intercourse

Sperms travel to the ampulla of the fallopian tube

Capacitation – Upon sperm approach to the egg, the sperm releases hyaluronidase which dissolves the
protective layer of the egg allowing penetration of one sperm for normal fertilization

Fertilization – Joining of the sperm and the egg; Zygote – Product of fertilization

Zygote travels toward the uterus approx. 3 days. Meanwhile its cells are multiplying.
Zygote ( 1-8cells)
Morula ( 16-50 cells);
Blastocyst (when large cells begin to travel to the periphery, leaving a fluid-filled cell mass; in this form, the
fertilized egg will attach to the thick endometrial lining during the secretory phase); Trophoblasts: Cells on the
blastocyst’s outer ring that will develop into placenta and membranes; Emryoblasts: Inner cell mass that will form
the embryo

Implantation - Contact between the growing fertilized cell and the uterine lining
Apposition - Process by which the fertilized egg brushes the endometrial lining
Embryo – term used for the fertilized egg that has implanted.
• Decidua Basalis – Layer that lies directly below the embryo the trophoblast to the maternal circulation
Decidua • Decidua Capsularis – Layer of the decidua that “encapsulates”/cover the trophoblast
• Decidua Vera – remaining portion of the lining that fuses with the decidua capsularis

Chorionic • Structure to which the trophoblasts develop into


• Syncytiotrophpblasts – responsible for the production of placental hormones

Villi • Cytotrophoblasts/Langhan’s layer – serves to protect the fetus from infectious organisms for the first
trimester until the 20th – 24th week of pregnancy.

• Structure that is involves in mediating between maternal and fetal circulation and producing essential
hormone during pregnancy
• hCG – Human Chorionic Gonadotropin – first present for first 100 days
Placenta • Estrogen – responsible for uterine growth and mammary gland development during pregnancy
• Progesterone – responsible for maintaining the endometrial lining of the uterus
• hPL - Human Placental Lactogen – responsible in promoting mammary gland growth and regulating
maternal glucose, protein, and fat levels
• Serves as cushion against pressure on the maternal abdomen which may injure the fetus
Amniotic • Regulates temperature changes conducive for fetal survival
• Supports fetal muscular development by allowing spontaneous movements
Fluid • Serves as support to the umbilical cord against compression, which may compromise
delivery of oxygen and nutrients to the fetus

Amniotic • Provides support and produces the amniotic fluid


• Produces precursors to prostaglandin, which initiates contractions during labor
Membrane • No nerve supply, which is evident during the painless rupture of membranes

• Serves as pathway to transport oxygen and nutrients to and waste [products from the
fetal circulation to the maternal circulation
• Mostly composed of Wharton jelly, which acts as support for the blood vessels linking the

Umbilical fetal and maternal circulation


• In part, is also composed of smooth muscles which constrict upon fetal delivery, naturally
clamping the blood vessels and preventing bleeding
Cord • Consists of two arteries, which carry deoxygenated blood and one vein, which carry
oxygenated blood
• Smilar to amniotic membrane, has no nerve supply; hence, cord cutting is painless for
both the mother and child.
Fetal Organ System Development
Primary Germ Layers and Originating Structures
Ectoderm Nervous system, integument system, sensory organs, tooth enamel, mucous
membranes of anus, nose, and mouth, mammary glands
Mesoderm Supporting structures of the body, teeth dentin, upper urinary system, reproductive
system, cardiovascular and lymphatic system
Entoderm Lining of internal cavities, glands, digestive system, and respiratory tract and lower
urinary system
Fetal Growth Estimation
• McDonald’s rule: the use of symphysis-fundal height measurement to
estimate fetal AOG through landmarks in maternal abdomen
• For every cm = +1 week AOG
• Level of symphysis pubis = 12 weeks AOG
• Level of Umbilicus = 20 weeks
• Level of xiphoid process = 36 weeks
Fetal Well-being
• Fetal Movement
• At least 10 times a day
• Sandovsky method: with the mother in left recumbent position after a meal,
fetal movements are measured for an hour. Usually, the fetus will move twice
every 10 minutes, and the test may be extended to another hour if the
number of fetal movements are less than the normal.
• Cardiff method: The time it takes for 10 fetal movements to occur is counted.
It is important to know if the child is on active time for the accuracy of the
test.
Fetal Well-being
• Fetal Heart Rate
• Normal: 120 – 160bpm
• Rhythm Strip Testing: With the mother in semi-fowler’s position, an external
fetal heart monitor is attached to her abdomen to check FHT for 20 mins
• Non-stress Test: This measures the response of FHR to fetal movement.
Reactive if two accelerations of FHR lasting for 15 seconds occur after
movement.
• Vibroacoustic stimulation: An acoustic stimulator is used to produce a sharp
sound expected to wake a sleeping fetus, eliciting FHR changes
• Contraction Stress Test: With nipple stimulation, the FHR is assessed in
relation to uterine contractions. Contractions are stimulated thrice within 10
minutes, lasting 40 seconds or longer.
Fetal Well-being
• Ultrasonography
• Best results are achieved when the mother has full-bladder during the test.
• Place a towel under the mother’s right buttock to avoid supine hypotension
syndrome during the test
• Maternal Serum Alpha-fetoprotein
• If abnormally high, fetus has open spinal or abdominal effect
• If low, fetus has chromosomal anomaly
• Amnioscopy
• Performed to assess for meconium staining
• Fetoscopy
• Used to perform fetus-related procedures
Fetal Well-being
• Amniocentesis
• Aspiration of amniotic fluid for testing at 14-16th week AOG
• Instruct the mother to void prior to testing
• Place towel under the mother’s right buttocks to avoid supine hypotension
syndrome during the test.
Components analyzed:
a) Alpha-Fetoprotein
b) Bilirubin (blood compatibility)
c) Fetal Fibronectin (to determine preterm labor)
d) Lecithin/sphingomyelin ration (to determine lung maturity)
Fetal Well-being
• Percutaneous Umbilical Cord Sampling
• Aspiration of fetal blood via the umbilical vein for analysis
• Kleihauer-Betke Test: used to determine of sample if fetal or maternal blood
• Biophysical Profile
• Assessment procedure combining 5 parameters to determine fetal well-being
• Includes: 1) fetal reactivity 2) fetal breathing movements 3) fetal body
movements 4) fetal tone 5) amniotic fluid volume
• Each parameter is given as its highest score, and cumulatively the highest
score is 10.
• More accurate vs. other tests
Diagnosis of Pregnancy
Presumptive Signs Probable Signs Positive Signs
Least indicative sign of These signs are objective, these Confirmatory signs of pregnancy
pregnancy; may be caused by are not always indicative of
other conditions; subjective pregnancy
 Breast engorgement and  Laboratory test: Urine hCG,  (+)Fetal heart tone
uterine enlargement Serum/Blood hCG ECG: 5 weeks AOG
 Flu-like symptoms: nausea,  Chadwick’s sign Doppler: 10-12 weeks AOG
vomiting, fever, fatigue  Goodell’s sign Stethoscope: 18-20 weeks
 Frequent urination  Hegar’s sign AOG
 Quickening  Presence of gestation sac on  (+) Fetal movement by
 Skin Changes: Linea nigra, utz examiner (20 – 24 weeks
Chloasma, striae gravidarum  Ballottment AOG)
 Braxton-Hicks contraction  (+) Fetal outline upon
 Palpable Fetal Outline ultrasound
Maternal Changes during
Pregnancy
1. Psychological Task of Pregnancy
2. Physiologic Changes of Pregnancy
Psychological Tasks of Pregnancy
Trimester Description
1st: Accepting • Ambivalence is normal felt by both the pregnant woman and their
the pregnancy partner. Adjustments must be made to accommodate the coming
change in their lives, which may or may not be easily accepted
• The idea of having a child may be farfetched because the signs of
pregnancy are not as obvious as compared to the later trimesters.
2nd: Accepting • The child becomes distinct person and a part of the mother, especially
the baby when quickening is felt by the latter
• A measure of mother’s acceptance of her baby is how well she follows
prenatal instructions
• Health education is important for the father of the child to foster
acceptance of his role in the child’s life even at this stage
3rd: Preparing • Period of “nest-building” and childbirth classes
for parenthood
Physiologic Changes of Pregnancy
• Reproductive Changes
• Uterus: Enlargement due to stretching of fibers to accommodate growing
fetus
• Lightening: engagement of the fetal presenting part to the pelvis causing a derease in
fundal height
• Primigravid: 38 weeks
• Multigravid: during labor
• Hegar’s sign
• Ballotment
• Amenorrhea d/t elevated estrogen levels
• Goodell’s sign
• Operculum Formation
• Acidity of vaginal secretions
• Elevated Progesterone and estrogen levels
• Breast engorgement, fullness and tenderness
Physiologic Changes of Pregnancy
• Integumentary Changes
• Striae gravidarum
• Diastasis or separation of the rectus muscles in the abdominal wall as it stretches
during pregnancy, which appears as a bluish groove at separation site
• Linea Nigra
• Chloasma/ Melisma “mask of pregnancy”
• Umbilical Stretching
• Telangiectasis formation due to increased estrogen levels
• Palmar Erythema
• Increased scalp hair growth
Physiologic Changes of Pregnancy
• Respiratory Changes
• Nasal congestion
• SOB due to diaphragmatic compression of the enlarging uterus
• Decreased PaCO2 levels, facilitating diffusion of carbon dioxide from fetal
(higher concentration) to maternal (lower conc.) circulation
• Increased PaO2 for oxygen diffusion to the fetal circulation
• Resp. alkalosis (Increase blood pH and PaO2 levels, decrease PaCO2 level),
compensated by HCO3 excretion in the urine by polyuria
Physiologic Changes of Pregnancy
• Cardiovascular Changes
• Inc blood volume, particularly plasma volume, inc cardiac output
• Pseudoanemia, d/t increase plasma volume
• Inc iron, folic acid demand
• Innocent heart murmurs with changes in the heart position
• Palpitations
• Slight decline in BP
• Inc peripheral blood flow, leading to vasocongestion
• Supine hypotension syndrome with supine positioning d/t venous congestion
with uterine compression of the inferior vena cava
• Inc clotting factors d/t increase estrogen levels
• Inc WBC for maternal protection and d/t increase plasma volume
• Dec total protein d/t fetal use; leads to edema on weight-bearing body parts
• Inc blood lipid content for fetal use
Physiologic Changes of Pregnancy
• Gastrointestinal Changes
• Nausea and vomiting that may be due to increase estrogen levels or decrease
glucose
• Heartburn, lower esophageal sphincter relaxation, and decrease gastric
motility associated with relaxin secretion
• Decreased bile emptying, leading to generalized pruritus (bile salt
accumulation) and gallstone formation
• Hemorrhoids d/t pressure on lower body veins
• Gingival tissue bleeding, hyperplasia
• Decrease salivary pH
Physiologic Changes of Pregnancy
• Temperature Changes
• Increase progesterone secretion by corpus luteum during 1st trimester,
causing increase maternal temperature
• Urinary Changes
• Sodium reabsorption
• Gradual urine output increase
• Decrease BUN, creatinine levels
• Skeletal Changes
• Relaxin and progesterone enforces their effects through the softening of
pelvic ligaments and joints, making it more mobile to facilitate childbirth
• Lordosis
Physiologic Changes of Pregnancy
• Endocrine Changes
• Placenta serves as an endocrine organ through the secretion of the ff hormones:
• Estrogen, Progesterone, hCG, hPL (insulin antagonist, reducing its effectiveness during
pregnancy, leading to glucose levels elevated than normal to facilitate its diffusion to fetal
circulation)
• Ovaries secrete relaxin
• Prostaglandins are present in the female reproductive tract and may be the initiator
of urine contractions during labor
• Pituitary gland:
a) anterior: inc MSH, GH, prolactin; FSH, LH; b) Posterior: Inc oxytocin
• Inc BMR d/t inc thyroid hormone secretion; if iodine is insufficient, goiter
development because thyroid will compensate for inc work
• Inc corticosteroid (vs. fetal rejection) and aldosterone secretion (K sparing)
• Increase insulin production by pancreas but decrease effectiveness
• Decrease IgG production compensated by Increase WBC levels
OB SCORING – GP TPALM
GravidaParity TermPretermAbortionLivingMultiplepregnancies
Pregnancy Discomforts
• Breast tenderness • Abdominal Discomfort
• Palmar erythema • Leukorrhea
• Constipation • Nausea and vomiting
• Fatigue • Cravings
• Muscle Cramps • Heartburn or Pyrosis
• Hypotension • Backache
• Varicosities • Headache
• Hemorrhoids • Dyspnea
• Heart Palpitations • Ankle Edema
• Frequent Urination • Braxton-Hicks Contraction
Nutrition in Pregnancy
• Normal weight gain: 25 – 35lbs (11.2 – 15.9kg)
• 1st trimester: 1lb (0.4kg /month)
• 2nd and 3rd trimester: 1lb (0.4kg/week)
• Caloric Intake
• Women of child-bearing age: 2200 cal
• Pregnant women: 2500 cal
Prenatal Exercises
Prenatal Yoga Squatting
Kegel’s Exercises Abdominal muscle contraction
Tailor-Sitting Pelvic Rocking
Labor and Delivery
Preliminary Signs of Labor
1. Lightening/fetal descent
2. Corresponding manifestations: Ease of breathing, shooting leg
pains, urinary frequency, increased volume of vaginal discharge
3. Increased activity levels (r/t increased epinephrine levels in
preparation for birth)
4. Slight weight loss (associated with urinary frequency)
5. Braxton-Hicks Contraction
6. Cervical Ripening ( with butter-soft texture)
True Labor vs False Labor
Sign True Labor False Labor
Contraction (surest sign) Regular and predictable Irregular and unpredictable
Directionality Starts from lower back Felt abdominally only
sweeping around the abdomen
Relief None; continuous Relieved by rest
Duration, frequency, intensity Increasing Not increasing
Cervical dilatation Present Absent
Bloody Show Present Absent
Rupture of Membranes Present Absent
* Remember that the amniotic fluid is produced by the amniotic membrane, and its
production does not stop until placental delivery; hence, there is no dry labor. Amniotic
Fluid can be differentiated from urine using fern test or Nitrazine paper test
Components of Labor
• Passenger
Components of Labor
• Passageway
• Route the fetus travels during childbirth
• The fetal head must pass through the narrowest diameters of the pelvic inlet
(anteroposterior diameter) and pelvic outlet (transverse diameter)
• Position of the Parturient
• First stage of labor: Left Lateral Recumbent
• Second Stage: Lithotomy Position, McRoberts's Position
• Psyche
• Women’s psychological outlook regarding pregnancy and child birth

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