MLEX

OBSTETRICS
OBSTETRICS
Branch of medicine that deals with parturition,
its antecedent and its sequelae.
Aims:
[Link] every pregnancy be wanted and culminate
in a healthy mother and a healthy baby.
[Link] maternal and infant mortality rate.
[Link] with the number and spacing of
children so that mother and offspring may enjoy
optimal physical and emotional well-being.
FEMALE EXTERNAL REPRODUCTIVE ORGAN
Pudenda or Vulva
• A. EXTERNAL ORGANS

Pudenda or Vulva & Vagina = serve for copulation

(1) Mons Pubis (Mons Veneris)

• fat filled cushion (ADIPOSE)

• Lies over symphysis pubis (protect)
• after puberty, covered by curly hair (ESCUTCHEON)
• pubic hair distribution is triangular (Female)
• Base is up
• Male - Diamond shape
 (2) Labia Majora (Labium
majus)
• 2 rounded folds of adipose tissue
• Homologue with male scrotum
• Round ligaments terminate at the upper border of labia
majora
• Repeated child bearing (less prominent)
• Old age (shrivel)
• L:7-8 cm, W: 2-3 cm, T: 1-1.5 cm
• Children / nullipara: close apposition
• Multipara: gape widely
• Rich with sebaceous glands, elastic fibers,
adipose tissue, no muscle
• Supplied with plexus of veins and as a result
of injury may rupture to create hematoma
• Inner- thin, smooth and moist
• Main function: to provide covering and
protection to external organs
 (3) Labia Minora (Nymphae)
• Two flat, reddish folds of connective tissue,
like mucous membrane
• Join at upper extremity of the vulva
• Nullipara: not visible behind nonseparated
labia majora
• Multipara: project beyond labia majora
• Covered by: stratified squamous epithelium
• No hair follicles
• With many sebaceous follicles / few sweat
glands
oInterior: connective tissue, many vessels,
some smooth muscle
oNerve endings: extremely sensitive
oTissues converge superiorly, divided in 2
lamellae:
• Lower pair – frenulum of clitoris
• Upper pair – prepuce of clitoris
oInferiorly, tissues fuse to form the
fourchette (nulliparous women)
oInferiorly in multiparous women,
imperceptibly continuous with labia majora
 (4) Clitoris
• Homologue of the penis
• Location: superior extremity of the vulva
• Erectile
• Projects downward between labia minora
• Composition:
• Glans – don’t exceed 0.5 cm diameter
• Corpus – or body, with 2 corpora cavernosa
(smooth muscles)
• Crura – 2, arise from the inferior surface of the
ischio-pubic rami and fuse just below the middle
of the pubic arc to form the corpus
• Don’t exceed 2 cm in length even when
erected
• Bent by traction of labia minora (toward
vaginal opening)
• Vessels are connected with vestibular bulbs
• Principal erogenous organ of women
• Genital corpuscles: the main structure that
are mediator of erotic sensation (labia
majora, labia minora, glans of clitoris)
(5) Vestibule
• Almond-shaped area that is enclosed by labia
minora laterally
• From clitoris to fourchette
• The functionally mature female structure of the
urogenital sinus of the embryo
• Mature state: 6 openings
• Urethra
• Vagina
• Ducts of bartholin’s glands
• Ducts of skene’s glands
• Posterior portion: between fourchette and vaginal
opening is fossa navicularis observed in
nulliparous
 (6) Bartholin’s Glands
(Vulvovaginal / paravaginal)
• 0.5 to 1 cm in diameter
• Situated beneath the vestibule on either side of vaginal opening
• Major vestibular glands
• Lie under the constrictor muscle of the vagina and can be
covered by vestibular bulbs partially
• Ducts are 1.5 to 2 cm long
• Open to the lateral margin of the vaginal orifice
• Sexual arousal: mucoid material is secreted (alkaline)
• May harbor: neisseria gonorrheae or other bacteria and may
cause suppuration and bartholin’s gland abscess
(7) Urethral Opening or Meatus
(Skene’s Glands)

• Lower 2/3 of urethra lies immediately

above the anterior vaginal wall
• Midline of vestibule (1-1.5 cm below
the pubic arch)
• Can distend 4-5 mm diameter
• FEMALE have short urethra – more
susceptible to UTI.
Skene’s Glands

• Paraurethral or minor vestibular bulbs

• Inner side of urethral meatus
• (0.5 mm in diameter)
• Secretion increase with sexual
stimulation and facilitate coitus
(8) Vestibular Bulbs
• Beneath the mucous membrane of the vestibule on either
side
• Almond shaped aggregation of veins. L: 3-4 cm, W:1-2 cm,
T: 0.5 – 1 cm
• In close apposition to ischio pubic rami & partially covered
by ischiocavernosus and constrictor vaginae muscles
• Embryologically: correspond to the anlage of corpus
spongiusum of penis
• During childbirth: pushed up beneath the pubic arch, liable
to injury & rupture which may result in vulvar hematoma
and hemorrhage
(9) Vaginal Opening and Hymen
• Vaginal opening: hidden by the overlapping labia
minora, almost completely closed by membranous
hymen
• Hymen: comprised of elastic and collagenous
connective tissue
• No glands & muscles and not richly supplied with nerve
fibers
• Newborn: very vascular and redundant
• Pregnant: thick epithelium & rich in glycogen
• After menopause: epithelium is thin & with focal
cornification
• Adult virgin: of various thickness, opening is crescentic
or circular
• Not possible to determine virginity by
examination of hymen
• As a rule: hymen can be torn during first coitus
(Posterior portion)
• Tissue remnants of hymen is Myrtiform
caruncles (CARUNCULAE HYMENALES)
• Imperforate hymen: the vaginal orifice is
covered which may cause retention of
menstrual discharge. (HYMENOTOMY/
HYMENECTOMY)
Nerve Supply to Vulva

• Anterior portion - from Lumbar 1

• Posterior portion – from Sacral 3
BLOOD SUPPLY TO THE VULVA

•By Pudendal artery and Inferior

rectus artery
•Facilitates rapid healing in
postpartum but predispose to
hemorrhages caused by lacerations.
 (11) Perineum

• Most of support is provided by the pelvic & urogenital

diaphragm
• Pelvic diaphragm – consist of levator ani muscles,
coccygeus muscles (posterior) fascial coverings
• Urogenital diaphragm – external to pelvic diaphragm
• In triangular area between ischial tuberosities & symphysis
pubis
• Comprised of deep transverse perineal muscles, constrictor
of the urethra and internal & external fascial coverings
• Major blood supply to the perineum: via internal
pudendal artery & branches (inferior rectal and posterior
labial artery)
• Nerve supply is pudendal nerve and branches with the
origin: S2, S3, S4 of spinal cord
(12) Perineal Body
• Comprised of:
• median raphe of levator ani
• central tendon of perineum
• bulbocavernous muscles
• superficial transverse perineal muscle
• external anal sphincter
• Provide much of support for the perineum
and often lacerated during delivery (unless
episiotomy is done)
 INTERNAL
REPRODUCTIVE
ORGANS
(10) Vagina

• Musculomembranous structure
• From the vulva to the uterus
• Anterior: urinary bladder and urethra; separated
by vesico vaginal septum
• Posterior: Rectum; separated by rectovaginal
septum
• Upper 4th of the vagina is separated from rectum
by rectouterine pouch called Cul-de-sac of
Douglas
• Vaginal canal on transverse section is H-shaped
• Upper portion arises from Mullerian ducts; Lower
portion from urogenital sinus
• Distended markedly during childbirth
• Upper end vault is subdivided:
• Anterior, posterior, two lateral fornices by uterine cervix
• Attached higher up on the posterior wall than
anterior wall of cervix
• Posterior fornix is greater than anterior
• Fornices are of clinical importance: internal
pelvic organs usually can be palpated through the
thin walls of the fornices, posterior fornix
provides ready surgical access to peritoneal cavity
• Length of anterior: 6-8 cm (2.75 in) / posterior: 7-
10 cm (4.5-5 in)(walls)
• Longitudinal ridges or Rugae are numerous in
nulliparous women (corrugated surface)
• Before menarche, rugae are absent, after repeated
childbirth and menopause they are obliterated
• Elderly multiparous, smooth vaginal wall
• No glands in vagina
• Parous women: vaginal inclusion cysts (not glands)
are remnants of mucosal tags that were buried
during the repair of vaginal lacerations after
childbirth
• Glycogen are present in the superficial cells of
the mucosa (infancy to after menopause)
• Nonpregnant: kept moist by small amount of
secretion from uterus; anaerobic organisms
• Pregnancy:
• Copious, acidic vaginal secretion, with curdlike
product of exfoliated epithelium and bacteria
• Lactobacillus species are recovered higher
(predominant bacteria)
• Acidic reaction due to lactic acid that arises from
metabolism of glycogen from mucosal cells by
Lactobacilli (Doderlein)
• pH of vaginal secretions
• before puberty – 6.8 – 7.2
• adult – 4.0 to 5.0
• Glycogen content of vaginal mucus is converted to lactic
acid by Doderlein bacilli
• Postpartum
• anaerobic bacteria increase dramatically and common
cause of infection in puerperal women
• Blood supply
• Upper 3rd: cervicovaginal branches of uterine
arteries
• Middle 3rd: inferior vesical arteries
• Lower 3rd: middle rectal & internal pudendal
arteries
• Vaginal artery branch directly from internal iliac
artery
• Veins empty into the internal iliac veins
• Lymphatics
• Lower 3rd of vagina and vulva – drain into
inguinal lymph nodes
• Middle 3rd – drain into internal iliac nodes
• Upper 3rd – drain into iliac nodes
• Nerve endings
• Absent of special nerves
• Free nerve endings in papillae
• Grafenberg or G-spot is a very sensitive are located at
inner anterior surface of the vagina
• Functions:
• a. Passageway for the sperm and fetus during birth
• b. Passageway for the menstrual flow
• c. Protect against infection from pathogenic organisms
 UTERUS
• Situated In pelvic cavity between the urinary bladder
anteriorly and rectum posteriorly.
• Flattened pear in shape
• With two major but unequal parts:
• UPPER TRIANGULAR – the body or corpus
• LOWER CYLINDRICAL OR FUSIFORM – the cervix (projects into
the vagina)
• ISTHMUS the portion between internal cervical os and
endometrial cavity, is of special obstetrical significance
because it forms the lower uterine segment during
pregnancy
• From the CORNUA of the uterus emerge the
oviducts or fallopian tubes
• FUNDUS is the convex upper segment between the
points of insertion of the fallopian tubes
• Round ligaments insert below the tubes on the
anterior side,
• Uterus covered by a fold (BROAD LIGAMENTS) of
peritoneum that extends to the pelvic side wall
 Size
• Prepubertal – Length is 2.5 to 3.5 cm
• Adult nulliparous – Length is 6 to 8 cm
• Adult multiparous – Length 9-10 cm
• Nonparous uterus – Ave. is 50-70 g
• Parous uterus – Ave. 80 g or more
• Premenarchal girl – the body is only half as long as the cervix
• Nulliparous women – the body & cervix are about equal in
length
• Multiparous women – the cervix is only a little more than a
third of the total length of the organ
• After menopause – uterine size decreases as a consequence of
atrophy of both myometrium & endometrium
• The bulk of the body of uterus but NOT the cervix
is composed of muscles
• The inner surface of the anterior & posterior wall
lie almost in contact, and the cavity between these
walls forms a mere slit
• Cervical canal is fusiform and is open at each end
by small apertures, the Internal os and External os
• Pregnancy Induced Uterine Changes
• Uterine growth is due to hypertrophy of muscle
fibers
• Weight is from 70 g in nonpregnant to 1100 g at
TERM
• Total volume average 5 Liters
• The convex fundus becomes dome shaped
• The fallopian tubes elongate, but the ovaries
remain unchanged
• Fundus as obstetrical landmark:
• During pregnancy – palpation of height to assess
uterine growth
• Postpartum period – to assess uterine involution
• During labor – to assess uterine contractions
and labor progress

• Ideal site for implantation of zygote

 Cervix
• Anteriorly, the upper boundary of the cervix is the
internal os
• Has a supravaginal segment and lower vaginal
portion of the cervix, called PORTIO VAGINALIS
• Before childbirth: external cervical os is a small,
regular, oval opening
• After childbirth: the orifice is converted into a
transverse slit that is divided such that there are the
so-called anterior & posterior lips of the cervix ( will
tell if a woman has borne children by vaginal
delivery)
• Mucosa of cervical canal is highly ciliated,
numerous cervical glands extends from the
surface of the endocervical mucosa, these
glands furnish the thick, tenacious cervical
secretions. If DUCTS ARE OCCLUDED
retention cysts (NABOTHIAN CYST) is
formed.
•3 functions of cervical mucosa
•to provide lubrication for the vaginal
canal
•to act as bacteriostatic agent
•to provide an alkaline environment
to shelter deposited sperm from the
acidic vagina
LAYERS OF THE UTERUS
• Body of the Uterus
• The wall of the body of the uterus is composed of
serosal, muscular, and mucosal layers.
• Endometrium
• mucosal layer that lines the uterine cavity in
nonpregnant woman
• Thickness – 0.5 mm to 5 mm
• With tubular uterine glands,, the glands secrete a
thin, alkaline fluid.
• After menopause, the endometrium is atrophic,
flattens, glands gradually disappear & becomes
fibrous.
• Coiled arteries supply most of the midportion and
all of the superficial third of endometrium
• Myometrium
• major portion of the uterus
• Composed of muscles, connective tissue with
elastic fibers
• Inner wall of the body has more muscle than
outer layer, and in anterior & posterior walls
than lateral walls
• During pregnancy, the upper myometrium
undergoes marked hypertrophy, but no
significant change in cervical muscle content
• Perimetrium
• Outermost layer
• Function of Uterus:
• To provide a safe environment for fetal development (organ
of reproduction)
• Organ of menstruation
• Uterine contraction to expel the fetus, to seal torn blood
vessels after placental delivery
• Uterine Positions
• anteversion – fundus tipped forward
• retroversion – fundus tipped backward
• anteflexion – body of uterus bent sharply forward at the
junction with the cervix
• retroflexion – the body is bent slightly back
LIGAMENTS
 Ligaments

• Broad Ligaments
• made of two winglike structures that
extend from the lateral margins of the
uterus to pelvic walls;
• divide the pelvic cavity into anterior &
posterior compartments;
• each broad ligament consists of a fold of
peritoneum
• keeps the uterus centrally placed and
provides stability within the pelvic cavity
• the inner 2/3 of the superior margin form the
mesosalphinx, to which fallopian tubes are
attached
• the outer 1/3 of the superior margin, extends from
fimbriated end of the oviduct to the pelvic wall,
forms the infundibulopelvic ligament or
suspensory ligament of the ovary, the ovarian
vessel traverse, suspends and supports the ovaries
• Cardinal ligament or transverse
cervical ligament or Mackendrodt
ligament
• composed of connective tissue medially
united firmly to the supravaginal
portion of the cervix
• chief uterine support
• Round Ligaments
• Extend from the lateral portion of the
uterus, arising below and anterior to the
origin of the oviduct.
• Each round ligament is located in a fold
of peritoneum continuous with the broad
ligament and extends outward and
downward to the inguinal canal, through
which it passes to terminate in the upper
portion of the labium majus.
• This corresponds embryologically to the
gubernaculums testis of men.
• During pregnancy, this undergo
considerable hypertrophy and increase
appreciably in length & diameter.
• Keep the uterus in place, during labor
keeps steady the uterus, pulling
downward and forward so that the
presenting part of the fetus is forced into
the cervix
• Uterosacral Ligaments
• extends from an attachment
posterolaterally to the supravaginal
portion of the cervix to encircle the
rectum and inserts into the fascia over the
sacrum.
• Provide support for uterus and cervix at
level of ischial spines
 Bloodvessels
• Vascular supply derived principally from UTERINE & OVARIAN
ARTERIES.
• Uterine artery: a main branch of the internal iliac artery,
referred to in the past as hypogastric artery, enters the base of
the broad ligament and makes its way medially to the side of
the uterus.
• Immediately adjacent to the supravaginal portion of the cervix,
the uterine artery divides:
• Smaller cervico-vaginal artery supplies blood to the lower
cervix & upper vagina
• Main branch turns abruptly upward and extends as
convoluted vessels traverses along the margin of the uterus,
before reaching the oviducts divides into 3 terminal branches:
• Ovarian Branch anastomose with terminal branch of ovarian artery
• Tubal branch through mesosalpinx & supplies part of oviduct
• Fundal branch to uppermost uterus
• 2 cm lateral to the cervix, the uterine artery
crosses over the ureter (might be ligated
during hysterectomy) (great surgical
significance)
• Major portion of blood supply to the pelvis
is via branches of internal iliac artery.
• Ovarian artery
• Direct branch of aorta
• Enters the broad ligament through the
infundibulopelvic ligament
• Anastomose with ovarian branch of uterine
artery
Nerve Supply

•Derives principally from the

sympathetic nervous system, partly
from cerebrospinal & parasympathetic
systems
•11th & 12th thoracic nerve roots, there
are sensory fibers from uterus that
transmit the painful stimuli of
contractions to the CNS.
•Sensory nerves from cervix & upper
part of the birth canal pass through the
pelvic nerves to the 2nd, 3rd, 4th sacral
nerves
•Sensory nerves from lower part of birth
canal pass primarily through pudendal
nerves.
OVIDUCTS
OVIDUCTS

• Or fallopian tubes
• Length vary from 8-14 cm
• Covered by peritoneum
• Lumen is lined by numerous mucous
membrane
• Parts:
• Interstitial / Intramural– embodied within the muscular wall of
the uterus
• Isthmus – narrow portion of the tube adjoins the uterus
(Thickness:2-3 mm)
• Site of sterilization
• Ampulla – wider, lateral portion, width 5-8 mm
• Site of fertilization
• Infundibulum (Fimbriated End) - funnel shaped opening, distal
end, opens to abdominal cavity, with one projection called
FIMBRIA OVARICA (longer), reaches the ovary
• - Tube is muscular, contraction affected by
hormones, greatest frequency and intensity during
transport of ova.
• - Ducts are ciliated (more in fimbriated end)
•- Current of cilia towards uterine cavity
• - Sympathetic innervation
• - Diverticula may extend from lumen and play a
role in development of ectopic pregnancy
• Uterus and tubes arise from the Mullerian ducts
embryologically.
• Layers:
• Mucosal
• With secretory cells, alkaline mucus and cilia (transport of ovum)
• Muscular
• Peristalsis of tube
• Strongest at ovulation and weak during pregnancy
• Peritoneal
• Outermost
• Attached to ligaments that keep fallopian tube suspended in normal
position
•Functions:
• Transport of ovum from ovary to uterus
• Site of fertilization
• Provides nourishment to the ovum during
its journey
OVARY
 OVARIES
• Size
• Childbearing : 2.5 to 5 cm in length, 1.5 to 3 cm breadth,
0.6 to 1.5 cm thickness
• After menopause: diminishes
• Location
• Upper part of pelvic cavity, on a slight depression on lateral
wall of pelvis
• Ovarian Fossa of Waldeyer: in the divergent external &
internal iliac vessels
• Attached to the broad ligament by the mesovarium
• Utero-sacral ligament from lateral and posterior portion of the
uterus
• Infundibulo-pelvic or suspensory ligament of ovary from upper
or tubal pole to the pelvic wall
•Surface of Ovary
• Young women – smooth, with dull white
surfaces, several clear follicles
• As women ages – corrugated
• Elderly – exterior become convoluted
•Two portions:
•Cortex
• outer layer becomes thin as one ages
• ova and graafian follicles are located
(primordial & graafian follicles)
• as women ages follicles become less
numerous
• outermost portion, dull and whitish is
designated as the tunica albuginea,
surface: single layer of cuboidal epithelium,
the Germinal Epithelium of Waldeyer
• Medulla
• central portion, with loose connective tissue
• large number of arteries & veins
• Onset of puberty – no. of oocytes estimated at 200,000 to
400,000
• Glandular elements of ovaries of adult women:
• Interstitial – formed from cells of theca
interna of degenerating or atretic follicles
• Thecal – formed from theca interna of
ripening follicles
• Luteal – from granulose cells of ovulated
follicles & undifferentiated stroma
• The number of follicles decrease as woman
ages:
• Two months intrauterine – 600,000 oogonia
• 5 months intrauterine – 6,800,000 oogonia
• At birth – 2 million oocytes
• Menopause – absent
• Young girls less than 15 y.o - ,mean oocytes is
439,000
• Women older than 36 y.o. – mean oocytes is
34,000
• Young girls – greater portion of ovary is cortex
with large number of primordial follicle
• Young women – cortex is thin but still with large
number of primordial follicle
• Each primordial follicle is made of an oocyte
• Functions of the Ovaries:
• OOgenesis (development and maturation of
ovum)
• Ovulation
• Hormone production (estrogen and
progesterone)
PELVIS
BONY PELVIS

• Forms the bony ring through which body weight is

transmitted to the lower extremities
• It has importance for women: Childbearing
• 4 Bones
• 1 sacrum
• 1 coccyx
• 2 innominate bones
• Ilium
• Ischium
• Pubis
• Sacroiliac joint- joins the innominate bone to the sacrum
• Symphysis pubis- joins the 2 innominate bones
• False Pelvis
• lies above linea terminalis
• Boundaries:
• Posterior: lumbar vertebra
• Lateral: iliac fossa
• Front: lower portion of anterior abdominal
wall
• True pelvis
• lies below the false pelvis
• important in childbearing
• boundary:
• Above: promontory & alae of sacrum, linea
terminals
• Upper margins: pubic bones
• Below: Pelvic outlet
• Posterior: anterior of sacrum. Surface of ischial
bones, sacrosciatic notch & ligaments
• Front: pubic bones, ascending superior rami of
ischial bones & obturator foramen
• Cavity
• Obliquely truncated
• Bent cylinder
• Height is greatest posteriorly
• Anterior wall at symphysis pubis – 5 cm
• Posterior wall – 10 cm
• Walls
• Partly bony and partly ligamentous
• Ischial Spines
• Middle of posterior margin
• Great obstetrical significance: because the
distance between them represents the shortest
diameter of pelvic cavity
• Serve as landmark in assessing the level to which
the presenting part of the fetus has descended to
the true pelvis
• Sacrum
• Posterior wall of pelvic cavity
• Promontory may be felt during bimanual pelvic
exam in women with small pelvis
• Provide a landmark for clinical pelvimetry
• Pelvic Joints
• Symphysis pubis – joins the pelvic bones
anteriorly
• Sacroiliac – joins the pelvic bones posteriorly
• Relaxation of Pelvic Joints
• Related to hormonal changes
• Symphysis pubis
• Start in woman in 1st half of pregnancy & increase
during the last 3 months
• Regress relaxation after parturition
• Increase in width during pregnancy
• Dorsal lithotomy position
• Increase in diameter of outlet by 1.5-2.0 cm,
gliding movement, displacement of sacroiliac joint
• Main justification for this position

• Sacroiliac joint mobility

• Modified squatting position to hasten 2nd stage of
labor
• McRoberts maneuver has same principle, the
releasing of obstructed shoulder in a case of
shoulder dystocia
•Pelvic Inlet

•Boundary
• Posterior – promontory & alae of the sacrum
• Laterally – linea terminals
• Anteriorly – horizontal pubic rami & symphysis
pubis
 PELVIS
•Antero -posterior diameters:
•Anatomical antero-posterior diameter
(true conjugate) = 11cm
• From the tip of the sacral promontory to the upper
border of the symphysis pubis.
•Obstetric conjugate = 10.5 cm
• from the tip of the sacral promontory to the most
bulging point on the back of symphysis pubis which is
about 1 cm below its upper border. It is the shortest
antero-posterior diameter.
OBSTETRIC CONJUGATE

• shortest distance between promontory of

sacrum and symphysis pubis
• shortest AP diameter through which the
head must pass in descending through
pelvic inlet
• cannot be measured directly with
examining fingers
• estimated indirectly by subtracting 1.5 to
2 cm from diagonal conjugate
•Diagonal conjugate = 12.5 cm
• i.e. 1.5 cm longer than the true
conjugate. From the tip of sacral
promontory to the lower border of
symphysis pubis.
•External conjugate = 20 cm
• From the depression below the last
lumbar spine to the upper anterior
margin of the symphysis pubis
measured from outside by the
pelvimeter. It has no true obstetric
importance.
Transverse diameter:
• Anatomical transverse diameter =13cm
• Between the farthest two points on the iliopectineal
lines.
• It lies 4 cm anterior to the promontory and 7 cm
behind the symphysis.
• It is the largest diameter in the pelvis.
• At right angle to obstetrical conjugate
• Greatest distance between linea terminals on
either side
• Intersects the obstetrical conjugate at a point
above 4 cm in front of promontory
• Posterior sagittal diameter of inlet
• is the segment of the obstetrical conjugate from
the intersection of these two lines to the
promontory
• From the lower border of the symphysis to the
center of the bituberous diameter
• 7.5-10 cm from tip of the sacrum to the center of
the bituberous diameter
Two Oblique Diameters
• Extend from one of the sacroiliac
synchondroses to the ileopectineal eminence
on the opposite side
• Less than 13 cm
• Midpelvis
• At level of ischial spines, the midplane
• Important following engagement of the fetal head
in obstructed labor
• Interspinous diameter: smallest diameter of the
pelvis (10 cm above)
• AP diameter at the level is 11.5 cm
• Posterior sagittal diameter is 4.5 cm, between the
sacrum and iliac created by the interspinous
diameter.
• Pelvic Outlet

•Accessible for clinical measurement is the

diameter between ischial tuberosities, [8
cm above]
• Bi-ischial diameter
• Intertuberous diameter
• Transverse diameter of outlet
•Place a closed fist at perineum
• Classification (Caldwell-Moloy)
• Based on shape

• Gynecoid – round
• Android – heart shape
• Anthropoid – AP diameter of inlet is greater
than the transverse, oval
• Plattypeloid – flattened gynecoid, short AP
and wide transverse diameter
• Abnormal Pelves
• AP or obstetrical conjugate is shortened
• Entire anterior surface of sacrum is palpable
• Normal Pelves
• only 3 last sacral vertebra are palpable
• Diagonal conjugate above 11.5 cm
• justifies to assume that the pelvic inlet is of adequate size
for a vaginal delivery of a normal sized fetus

• measured by imaging pelvimetry

• pelvic contraction is possible even if AP diameter is
adequate
MAMMARY GLANDS
• Accessory organ of reproduction for
nourishment of infant after child birth
• Situated over pectoralis major muscles
between 2nd and 6th ribs
• Supported by the Cowper’s ligaments
External Structures

• Nipple or Mammary Papillae

• At the center of anterior surface, with 15-20
openings connected to lactiferous ducts from
which milk flows out
• Areola
• Pigmented skin surrounds nipple

• Montgomery Tubercles
• Glands in areola, secrete oily substance
(lubrication)
Internal Structures
• Lobes
• 15-20 lobes
• Lobules
• Composed of clusters of acini cells
• Acini cells
• Milk secreting cells of the breasts stimulated by
prolactin
• Lactiferous ducts
• Passageway of milk
• Lactiferous sinus
• Dilated portion of the ducts located behind the
nipple serve as reservoir of milk
Hormones

• Estrogen
• Development of ductile structures
• Progesterone
• Development of acinar structures
• Human Placental Lactogen
• Breast development during pregnancy
• Oxytocin
• Let-down reflex, can be inhibited by progesterone
• Prolactin
• Milk production, inhibited by estrogen
• SUCKLING – the best stimulus for milk
production and ejection
MALE REPRODUCTIVE
SYSTEM
 A. External Genitalia
• 1) Penis - organ of copulation & urination. It contains of a
body or a shaft consisting of 3 cylindrical layers and erectile
tissues:
• 2 corpora cavernosa – two lateral columns of erectile tissue; made
of spongy tissue which is filled with blood during sexual arousal
• 1 corpus spongiusum – a column of erectile tissue on the
underside of the penis that encases urethra

• Penis supports the urethra as it passes from the seminal vesicles,

through the Corpora Cavernosa, to the meatus at the glans of the
penis
• Tip is the glans penis which is the most sensitive
area comparable to the clitoris
• Consist of a body (shaft) and glans
• Glans at distal end
• Prepuce is retractable, protects the glans at
birth
• Deposits spermatozoa in the female
reproductive tract
• With sensory nerve endings for sexual pleasure
• Outlet for urinary tract
• Penile artery supplies the blood
Scrotum
• pouch below the pendulous penis, with a
median septum dividing it into 2 sacs,
each contain testis, smooth muscle fibers
• Houses the testes, epididymis, lower part
of spermatic cord
• Protects the testes & spermatozoa from
high body temperature
B. Internal Genitalia

• Testes
• Two oval shaped glandular organs inside the
scrotum
• Seminiferous tubules – produce spermatozoa
• Sertoli cells – nurture & support the developing
spermatocytes
• Leydig’s cell – produce testosterone &
androgens
• Hypothalamus releases GnRH, which then
influences the anterior pituitary to release FSH
& LH
• FSH – release androgen producing hormone
• LH – for releasing testosterone
• Epididymis
• Tightly coiled, length is 6 m
• Conduct sperm from testis to vas
deferens or stores the sperm for
maturation
• Takes 12 to 20 days for the sperm to
travel the length of epididymis, 64 days
to reach maturity
• Vas deferens (Ductus deferens)
• Connects the epididymal lumen and the
prostatic urethra
• Carries sperm from epididymis through
inguinal canal into abdominal cavity
where it ends at seminal vesicle into
ejaculatory duct
• Blood vessels and vas deferens
referred to as spermatic cord
• Ejaculatory duct
• Located between the seminal vesicles and
urethra
• Seminal vesicles
• two pouch like structures between the bladder
and the rectum
• empty into urethra by way of ejaculatory duct
• secrete viscous fluid of semen aid in
spermatozoa motility & metabolism
• Prostate gland
• glandular, muscular gland
• below the bladder
• urethra pass through it
• homologue to skene’s gland
• secrete alkaline fluid, enhance spermatozoa
motility & lubricates the urethra during
sexual activity
• Bulbourethral gland (Cowper’s gland)
• Pea-sized glands that lie beside prostate and
empty into urethra
• Urethra
• From the bladder to the penis to the external
urethral opening
• Excretory duct for urine and semen
• With mucous membrane
• Secrete a thick alkaline fluid that neutralizes
acidic secretions in female reproductive tract
(sperm survival)
• Sperm life span – 48-72 hours, can fertilize the ovum
only within this time
• Seminal volume per ejaculation – 3-5 ml
• Normal sperm count – more than 20 million per ml of
semen
• Seminal fluid is alkaline
• Prostate gland
• Seminal vesicles
• Bulbourethral gland
• Seminal vesicles – produce yellowish
viscous fluid rich in fructose and other
substances (65-75%)
• Prostate – whitish, thin fluid
containing proteolytic enzymes, citric
acid, phosphatase and lipids (25-30%)
• Testes – 2-5%
• Bulbourethral glands secretes a clear
secretion into the lumen of the urethra
(<1%)
• Semen analysis to assess adequacy of
sperm to cause pregnancy
• Volume: 2.5 to 5 ml
• Sperm count: at least 60 million t0 120million
sperm per ml of semen or 50 million per
ejaculation
• Motility: more than 50% with forward
progression, normal pattern
• Morphology: More than 50% with normal oval
and single tail for optimum fertility
• WBC count less than 1 million per ml
Homologue structures – male
and female
Male Female
Spermatozoa Ovum
Glans penis Glans clitoris
Scrotum Labia majora
Penis Vagina
Testes Ovaries
Vas deferens Fallopian tubes
Prostate glands Skene’s glands
Cowper’s glands Bartholin’s glands
HORMONES
• GnRH/FSHRF – stimulates the anterior
pituitary gland to release FSH
• FOLLICLE STIMULATING HORMONE
• Functions of FSH:
• Stimulate ovaries to release estrogen
• Facilitate growth primary follicle to
become graffian follicle (secretes large
amt estrogen & contains mature
ovum.)
• LUTEINIZING HORMONE
• (13th day-decreased progesterone)
LH stimulates ovaries to release
progesterone
• hormone for ovulation
•* Estrogen- “Hormone of the Woman”
•Primary function: development
secondary sexual characteristic female.
•Others:
• inhibit production of FSH ( maturation of
ovum)
• hypertrophy of myometrium
• Spinnbarkeit & Ferning ( billings method/
cervical)
• development ductile structure of breast
• increase osteoblast activities of
long bones
• Increase in height in female
• causes early closure of epiphysis of
long bones
• causes sodium retention
• increase sexual desire
*Progestin -“ Hormone of the Mother”
Primary function: prepares endometrium for
implantation of fertilized ovum making it thick & tortous
(twisted)
Secondary Function: uterine contractility (favors
pregnancy)
Others:
[Link] prod of LH (hormone for ovulation)
[Link] motility of GIT
3. mammary gland development
4. increase permeability of kidney to lactose &
dextrose causing (+) sugar
5. causes mood swings in moms
6. increase BBT
REPRODUCTIVE AND
MENSTRUAL CYCLE
MENSTRUATION

• PROCESS, involve reproductive , endocrine,

nervous system
• Structures involved: Hypothalamus, pituitary gland,
uterus, ovaries
• In response to cyclic hormonal changes
• The process that allows for conception and
implantation of new life
PURPOSES OF MENSTRUATION

•MATURITY OF OVUM

•RENEW UTERINE TISSUE BED

CHARACTERISTICS – NORMAL MENSTRUAL
CYCLE

• MENARCHE – AVE. 12-13 Y.O (ONSET)

AVE. range 9-17 years
• INTERVAL – Ave. 28 days
23 – 35 days
• DURATION – 2-7days / 3-5 days
1-9 days
• AMOUNT – 30 -80 ml per period
• COLOR – dark red ( blood, mucus, endometrial cells, bacteria,
leukocytes, cellular debris)
• BLEEDING – BY VASOSPASM
• FACTORS THAT AFFECT –emotions, illness, stress, excessive fatigue,
anxiety, rigorous exercise, temperature, altitude
A. MENSTRUAL PHASE

• Days 1-6
• Estrogen is low
• Cervical mucus scanty, viscous, opaque
(not clear)
• Shedding of endometrium
 B. PROLIFERATIVE PHASE
• Days 7-14
• Endometrium – myometrium thickens
• Estrogen – peaks (13th day)
• OVULATION – is the monthly growth and release of
mature non-fertilized ovum
• At ovulation- cervical mucus characteristics:
1. clear, thin, watery, alkaline
2. Favorable sperm
3. Elastic (SPINNBARKHEIT), greater than 5 cm
4. Ferning pattern
•Prior to ovulation – temperature drop / at ovulation
increase (0.3 – 0.6 C)
•MITTELSCHMERZ / MIDCYCLE spotting
C. SECRETORY PHASE / LUTEAL /
POST OVULATORY / PREMENSTRUAL
• DAYS 15-26
• Estrogen drop – progesterone high
• Endometrium vascular
• Tissue glycogen increase
• Graafian follicle starts to degenerate to
become yellowish (known as corpus luteum,
secrete large amount of progesterone)
• 24th day – corpus luteum become corpus
albicans
D. ISCHEMIC PHASE

• Days 27-28
• Estrogen / progesterone decrease
• Spiral arteries – vasoconstriction
• Endometrium pale
• Blood vessels rupture
• Blood escapes into uterine stromal cells
• No sperm – endometrium sloughs off
CHROMOSOMES

• Structures within the cell nuclei that contain an

individual’s genetic make-up
• Made of DNA [Deoxyribonucleic acid] & PROTEIN
• Exist in PAIRS except in the germ cells (gametes)
• One come from male germ cell and the other from female
germ cell
• Normal human cells contain 23 pairs
• 22 pairs are homologous.
• 23rd pair has X & Y chromosome

• XX – produce a genetic female

• XY – produce a genetic male
GENES
•Individual carrier of heredity
information.
•Arranged in linear fashion on
double stranded chain of DNA &
Occur in pair (homologous
chromosome)
 CELL REPRODUCTION
• MITOSIS
• The equal division of nuclear material
(KARYOKINES) followed by division of cell body
(CYTOKINES).
• All cells of the body undergo mitosis except
GAMETES.
• Occurs in five phases:
a. Interphase
b. Prophase
c. Metaphase
d. Anaphase
e. Telophase
•MEIOSIS
• Germ cells or gametes

• Gametogenesis is the production of

specialized sex cells called GAMETES.
• As gametes mature, the number of
chromosomes they contain is halved
(through meiosis) from 46 to 23
SPERMATOGENESIS
OOGENESIS
 FETAL LIFE

•FERTILIZATION
• Chromosomal sex & biologic sex is
formed.
• Females – XX
• Males - XY
•Primitive Germ Cells
• Formed – 6th to 10th week (Yolk Sac),
migrate by amoeboid movement into
the gonads
• Develop to mature sperm and egg
cells (Puberty)
• 8-10 weeks
• Human embryo has neutral gonads with
2 pairs of duct system, at lower end.
a. Mullerian ducts (paramesonephric)
b. Wolffian ducts (mesonephric)

• The gonads develop into a sac with a

core:
• If germ cells are XX, the gonads become
ovaries.
• If germ cells are XY, the gonads become
testes
NEONATAL PERIOD

• GIRLS:
• Sudden withdrawal of placental hormones
after birth can result:
• Slight vaginal bleeding
• Temporary nipple discharge (witch milk)
• Fall in estradiol levels in the first week of life &
gradual minimal rise during the first two years
• BOYS:
• Testosterone levels rapidly decrease in
the first week of life and increase to
pubertal levels for 2-4 months before
declining
CHILDHOOD

•Characterized by very low levels of

gonadotropins and gonadal
steroids
PUBERTY

• Time of physical growth and sexual maturation.

• A dynamic process.
• Take 2.5-5 years to complete
• Girls: begin at 8 years
• Boys: 10 years
• Growth spurt for some are early; for others late
• Initiation is controlled by the
hypothalamus
• Pituitary gland secrete gonadotropins
which are the same for girls and boys
• Gonadotropins stimulate the GONADS
(testes & ovaries & adrenals) to release
the hormone necessary for growth and
function of the organs
• Gonadotropins induce different sex
hormones:
• Males – androgens & testosterone
• Females – estrogen and progesterone
• FEMALES:
• First sign of pubescence is breast bud
formation with its onset at 8-14 y.o
(Thelarche)

• Menarche – end of puberty and occur 2 years

after thelarche

• Menarche is a result of fluctuating estrogen

associated with follicle development
• During puberty and years after 1st menses, the
following secondary sexual development occur:
1. Pubic and axillary hair appear
2. Growth spurt – weight gain occur with increase
in height
3. Increase in body fat – breasts, mons pubis, hips
and thighs
4. Vagina lengthens and becomes rugated
5. Labia majora and minora thickened & rugated
• Males
• 1st sign of pubescence is testicular
enlargement (onset 11.5 years or ranges
from 9-14 years)
• Under the stimulation of testosterone:
1. Testicular enlargement is followed in the next 2
years by pubic hair
2. Development of penis and scrotum to adult size
& shape is achieved between 12 and 17 years
3. Deepening of the voice due to hormonal
influence to vocal cords
4. Onset of spermatogenesis
5. Growth spurt with development of more
muscles
• W. MARSHALL & J.M. TANNER
• Tanner Puberty or Sexual Maturity Rating

a. Pubic hair growth

b. Male genital development
c. Female breast development
• Excess hormone production
• Precocious puberty
• Insufficient hormone production
• Delayed puberty
• Premature puberty
• Onset of puberty before age of 8 y.o. for female and 9
y.o for male
• Abnormal hormone production in female like
increase androgens develop male characteristics
called: VIRILIZATION
• Absent/ Insufficient production in males –
feminizing character occur
• ADRENARCHE
• Increase in androgens (adrenal) for pubic and axillary
hair development
• GONADARCHE
• Initiation of hormone production of gonads
• Female – estrogen & progesterone
• Males - Testosterone
•MENARCHE
• First menstruation
•THELARCHE
• Breast development
•CHROMOSOMAL SEX
• XX – 46 – female
• XY – 46 – male
• GENETIC SEX
• Determine sexual differentiation

• GONADAL SEX
• Presence of ovaries or testes
• Both arise from mesodermal gonadal tissues
• PUBERTAL SEX
• Refers to secondary characteristics that
develop during puberty
• GENITAL SEX
• Penis and Scrotum – male
• Vagina - female

• PSYCHOLOGICAL SEX
• Sexual orientation and gender roles and
largely culturally determined.
HUMAN SEXUAL RESPONSE

• Feelings & attitudes about sex vary

widely
• Sexual experience is unique to each
individual
• Sexual physiology has common features

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• WOMEN • MEN
• Clitoris - size • Penis – erection
• Vaginal wall – mucoid • Scrotum – thickens
fluid • Testes – elevates
• Vagina – widen diameter
& increase length
• BOTH
• Nipples - erection • HR, RR, BP -

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3-183
a division of Thomson Learning, Inc.
• PLATEAU

- clitoris drawn forward & retracts under

- Vagina (lower part: extremely congested with orgasmic
platform formed)
- Nipple elevates

- Penis: distended
Both: HR (100-175 bpm) RR (40 bpm)

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• ORGASM
• Shortest stage
• Sudden discharge of accumulated
sexual tension
• Highly personal experience
• Intense pleasure affecting the whole
body
• Vigorous contraction of muscle in the
pelvic area.

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3-185
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• Woman:
• Average no. of contraction is 8-15 at
intervals of one every 0.8 sec
• Men:
• Contractions surrounding the seminal
vessels and prostate project semen into
the proximal urethra
• 3-7 propulsive ejaculatory contractions
occur at same time interval with the
woman forcing the semen out

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3-186
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• RESOLUTION:
• External and internal genital organs return to
unaroused state
• Male: Refractory Period – further orgasm is
impossible
• Female: Properly stimulated / interested –
another orgasm
• Both: 30 min

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PREGNANCY
OVUM CHARACTERISTICS

• Two Layers surrounding the Cell

membrane
a. Zona pellucida – closest, clear, non
cellular
b. Corona radiata – surrounds the z
pellucida, with elongated cells
* Healthy & highly fertile for only first 24
hours

* Cells are held by HYALURONIC ACID

PARTS OF THE SPERM

• Head – contain Acrosome / Nucleus

• Tail
• Middle Piece – mitochondria
• Tail – flagellum

• Sperm can be stored for 42 days in the male genital

system
 FLOW OF SPERM & SEMEN
• Testes Epididymis Vas Deferens
• Seminal Vesicle Ejaculatory duct
• Prostate gland Cowper’s gland

Urethra
PROCESS OF FERTILIZATION

• Preparation for Fertilization

Ampulla
Ovulation – high estrogen/ increase
progesterone / increase peristalsis in FT,
thinning of the cervical mucus
* Ejaculation OF millions of sperm into
vagina
* Transit time from cervix into FT is 5 min,
average of 4 -6 hrs
• Fallopian tubes have dual ciliary action
• Two processes sperm undergo before
fertilization:
A. Capacitation
– removal of plasma membrane &
glycoprotein coat (acrosome), loss of
seminal plasma protein
- in female reproductive tract (uterine
enzyme) / 7 hours
Sperm’s Three Characteristics:
1. ability to undergo acrosomal reaction
2. ability to bind to the zona pellucida
3. acquisition of hypermotility
B. Acrosomal Reaction

- acrosomes of the millions of sperm

surrounding the ovum release their
enzymes (hyaluronidase-acrosin, corona-
dispersing enzymes)

- at the moment of penetration,

(BLOCK TO POLYSPERMY), followed
by CORTICAL REACTION
•Moment of Fertilization
- true moment, when nuclei
unite
- individual nuclear
membranes disappear,
chromosomes pair up
(diploid zygote)
PRE-EMBRYONIC STAGE
• Stage of ovum
• First 14 days of human development, starting on
the day the ovum is fertilized
• Two Phases of Development After Fertilization
A. Cellular Multiplication
* The process of implantation (nidation) occurs
between
B. Cellular (embryonic membrane) differentiation

* Characterized by rapid cellular multiplication and

differentiation and establishment of embryonic
membranes and primary germ layers

.
 CELLULAR MULTIPLICATION
• Begins as zygote moves FT toward uterus (3 days
or more)
• Zygote goes rapid mitotic division (cleavage) – 2
cells, 4 cells, 8 cells and so on, called blastomere.
• Blastomere eventually form a solid ball of 12 to 16
cells (Morula)
• As morula enters uterus, intracellular fluid in morula
increases and a central cavity forms within the cell mass.
• The inner solid mass of cells called BLASTOCYST.

• ZYGOTE – BLASTOMERE – MORULA –

BLASTOCYST – EMBRYO - FETUS
• The outer layer of cells that surround the cavity
and have replaced the zona pellucida is the
TROPHOBLAST.

• Eventually, the trophoblast develops into one of

the embryonic membranes called CHORION.

• The blastocyst develops into a double layer of

cells called the EMBRYONIC DISC, from which the
embryo develops and the other embryonic
membrane called AMNION.
 IMPLANTATION

• Uterine glands (lipids, mucopolysaccharides,

glycogen) nourish blastocyst as it floats in uterine
cavity
• Trophoblast attaches to endometrium
• Upper part of the posterior uterine wall (site)
• Between days 7&10 after fertilization,
• Lining of uterus below implanted blastocyst
thickens, with cells of trophoblast grow down into
the thickened lining, forming processes called
VILLI.
• Decidua is the name of the endometrium
•PROCESS OF IMPLANTATION
A. APPOSITION
B. ADHESION
C. INVASION
• Decidua
a. Basalis – portion directly under the implanted
blastocyst
b. Capsularis – portion that covers the blastocyst
c. Vera – or parietalis, the portion that lines the rest
of the uterine cavity.
DECIDUAL CELLS SECRETE:
a. Prolactin - lactation
b. Relaxin – symphysis pubis, pelvic ligament, cervical
dilatation
c. Prostaglandin – many physiologic functions
•Maternal part of the placenta develops
from decidua basalis (blood vessels)
•The chorionic villi in contact with the
decidua basalis will form the fetal
portion of the placenta
EMBRYONIC STAGE

•Weeks 4-7, begins on 3rd week

after conception and continuous
until embryo reached crown-to-
rump length of 3 cm at about 8th
week
CELLULAR DIFFERENTIATION

•PRIMARY Germ Layers

- about 10-14 days after conception,
the mass of blastocyst cells
differentiates
- Ectoderm, mesoderm, endoderm are
formed at the same time as the
embryonic membranes
ECTODERM
• Central and peripheral
nervous system
• Nasal cavity
• Oral glands and tooth
enamel
• Pituitary gland
• Mammary glands
 MESODERM

• Dermis • Skeleton
• Wall of Digestive tract • Muscles (all types)
• Kidneys and ureter • Cardiovascular system
(suprarenal cortex) (heart, arteries, veins,
• Reproductive organs blood, bone marrow)
(gonads, genital ducts) • Pleura
• Connective tissue • Lymphatic tissue and
(cartilage, bone, joint cells
cavities) • Spleen
 ENDODERM

• Respiratory tract • Primary tissue of liver

epithelium and pancreas
• Epithelium (except nasal), • Urethra and associated
including pharynx, tongue,
glands
tonsils, thyroid,
parathyroid, thymus, • Urinary bladder (except
tympanic cavity trigone)
• Lining of digestive tract • Vagina
 EMBRYONIC MEMBRANES
• Begin to form at time of implantation
• Protect and support the embryo as it grows and
develops
A. CHORION
- 1st to form
- outermost, encircles amnion, embryo, yolk sac
- a thick membrane that develops from trophoblast
and has many fingerlike projections (CHORIONIC
VILLI) on its surface
• Chorionic villi - early genetic testing of embryo at 8-
10 weeks by Chorionic Villi Sampling
 AMNION
• B.
- 2nd membrane
- originates from the ectoderm, during
early stages of embryonic development
- a thin protective membrane that
contains the amniotic fluid
- the space between the amniotic
membrane and the embryo is called
AMNIOTIC CAVITY
AMNIOTIC FLUID
• FUNCTIONS:
1. Cushion the embryo against injury.
2. Helps control embryo’s temperature.
3. Permits symmetric external growth of
embryo.
4. Prevents adherence to the amnion.
5. Allows free movement – to change position
freely
(musculoskeletal development)
6. Prevent cord compression
7. Help in the delivery process
• OLIGOHYDRAMNIOS / HYDRAMNIOS /
POLYHYDRAMNIOS

• Early in 1st trimester, AF secreted by developing

trophoblast or embryo
• After 25 weeks, fetal kidneys major source of fluid.
• Fetal lungs also contribute, fetal breathing movement,
bidirectional flow through trachea – outflow of lung &
tracheal fluid is used as basis for fetal lung maturity
• The major mechanism by which amniotic fluid is
removed in the last half of pregnancy is FETAL
SWALLOWING.
 YOLK SAC
• Yolk sac is small and functions only in early embryonic
life
• Develops a second cavity in the blastocyst, about day 8
or 9 after conception
• Forms primitive RBC during the first 6 weeks of
development until the embryo’s liver takes over the
process.
• As embryo develops, the yolk sac is incorporated in the
umbilical cord (degenerative structure) after birth
 PLACENTA

• The means of metabolic & nutrient exchange

between the embryonic & maternal
circulations.
• 3rd week of embryonic development:
- placental development & maternal
circulation,
- expansion continue until 20 weeks.
•Development begins with chorionic villi
- trophoblast cells of CV form spaces in the
tissue of decidua basalis (chorionic villi +
decidua basalis = placenta)
- As chorionic villi differentiate, 2
trophoblastic layer develops:
a. Syncytium (consist of
syncytiotrophoblast ) – direct
contact with maternal blood/
functional layer of placenta &
secrete the placental hormones
b. Cytotrophoblast
• Two parts:
a. Maternal – decidua basalis and its
circulation / red, flesh like
b. Fetal – chorionic villi and circulation /
covered by amnion, shiny, gray appearance
•By 4th week, the placenta begin to function
as means of metabolic exchanges.
•Maternal-placental-fetal circulations occurs
about 17 days after conception when
embryonic heart begins to function
•Average weight at term – 500 gm
• FUNCTIONS:
A. RESPIRATORY
B. NUTRITION
C. EXCRETION
D. PROTECTION / IMMUNOLOGIC
E. ENDOCRINE
• METABOLIC ACTIVITIES
1. Produces glycogen, cholesterol, fatty acids
continuously for fetal use and hormone
production.
2. Produces enzymes required for fetoplacental
transfer
3. Breaks down certain substances like
epinephrine and histamine
4. It stores glycogen and iron
• Transport Functions:
1. Simple diffusion (oxygen)
2. Facilitated transport (glucose)
3. Active transport (amino acids, calcium, iron,
iodine, water-soluble vitamins & glucose)
4. Pinocytosis (albumin, gamma globulin)
5. Hydrostatic & osmotic pressure (water &
solutes)
ENDOCRINE FUNCTIONS OF PLACENTA

• 1. hCG
• cause the corpus luteum to secrete increased amounts
of estrogen & progesterone,
• play a role in the trophoblasts immunologic
capabilities (ability to exempt the placenta & embryo
from rejection by the mother’s system),
• Basis for pregnancy
• Present in maternal serum 8 to 10 days after
fertilization, detectable in maternal urine at the time
of missed menses, peak at 50-70 days gestation
2. Progesterone (syncytiotrophoblast)

3. Estrogen (proliferative function)- placenta

secretes estriol while ovaries secrete
estradiol
4. Human Placental Lactogen
- or hCS (human chorionic
sommatomammotropin)
- stimulates changes in mother’s
metabolism
UMBILICAL CORD

• Formed from amnion

• The body stalk that attaches the embryo to

the yolk sac, contains blood vessels that
extend into the chorionic villi

• Body stalk fuses with the embryonic portion

of the placenta to provide a circulatory
pathway from chorionic villi to embryo.
• As the body stalk elongates to become the
umbilical cord, the vessels in the cord decrease to
Artery Vein Artery
• Wharton’s jelly + high blood pulsating through the
vessels prevents compression

• Cord has no innervation; 2 cm across; 55 cm long

• Insertion into the placenta is at its center.

PLACENTAL CIRCULATION

• In the fully developed placenta’s umbilical

cord, fetal blood flows through the AVA
• Funic Souffle - (umbilical cord), synchronous
with fetal heart beat & flow through arteries
• Uterine Souffle – timed precisely with the
mother’s pulse & heard just above the
mother’s symphysis pubis, caused by the
augmented blood flow entering the dilated
uterine arteries
INTRAUTERINE GROWTH &
DEVELOPMENT • Beginning formation of
eyes, nose, heart
• 4 WEEKS chambers are formed,
heart beating (14 days),
arm & leg buds, (Brain
& heart formed)

• Head large,
• 8 WEEKS Neuromuscular
development, Brain
development rapid,
external genitals, Every
organ system present
12 WEEKS 16 WEEKS
• Placenta, Kidneys- • More human
urine, appearance
• Centers of • Quickening
ossification (bones), • Meconium in bowels
• Sucking & swallowing, • Obvious external
• Sex distinguishable genitalia
• FHT detected • Scalp hair
• Lanugo (begins)
• Eyes, ears, nose
(formed)
20 WEEKS 24 WEEKS
• Vernix caseosa / lanugo • Body well proportioned
• FHT • Skin red & wrinkled
• Quickening (stronger) • Hearing established
• Bones harden • May breathe
• 28 WEEKS • 32 WEEKS
• Brain develops • Bones are fully
rapidly developed
• Eyelids open-close • Subcutaneous fat
• Lungs (developed) collected
• 36 WEEKS • 40 WEEKS
• Skin pink, body round • Skin pinkish & smooth
• Less wrinkled • Lanugo
• Lanugo disappears • Vernix caseosa
disappears
• 2500 gms • Fingernails beyond
finger tips
• Sole (plantar) creases
down to heel
• Testes in scrotum
• Labia majora
(developed)
• FIRST TRIMESTER
- Organogenesis
• SECOND TRIMESTER
- Continued fetal growth
• THIRD TRIMESTER
- Rapid growth
TERATOGENS

• Drugs, Viruses, Chemicals, Radiations

• Effects of teratogen depends:

a. Maternal & fetal genotype
b. Stage of development when exposure occurs
c. Dose & duration of exposure
TERATOGENS - DRUGS

• Streptomycin – anti TB/ Quinine = damage to 8th cranial

nerve
• Tetracycline – staining of tooth enamel, inhibit growth
of long bones
• Vitamin K – hemolysis, hyperbilirubinemia or jaundice
• Iodides – enlargement of thyroid or goiter
• Thalidomide – absence of extremities (pocomelia or
amelia)
• Steroids – cleft lip or palate
• Lithium – congenital malformation
TERATOGENS - CHEMICALS

•Alcohol – low birth weight/ fetal alcohol

withdrawal syndrome (microcephaly)
•Smoking – LBW
•Caffeine – LBW
•Cocaine – LBW, abruptio placenta
 T-O-R-C-H

•T - Toxoplasmosis
•O - Others (Hepa A/ B, HIV, Syphilis)
•R - Rubella / Vaccines
•C - Cytomegalo virus
•H - Herpes simplex virus
PHYSIOLOGIC MATERNAL
CHANGES DURING
PREGNANCY
CARDIOVASCULAR CHANGES

• Circulating blood volume increases, plasma increases,

total volume increase by 40-50%
• Total red cell volume increases
• Physiologic anemia (pseudo)
• Heart size increase – LV hypertrophy
• Heart is elevated upward & to the left
• Pulse beats increase (10 beats), palpitations
• BP decline (2nd tri)
• Iron requirement increased
• Sodium & water retention
• Epistaxis (estrogen’s effect)
• Hct – 32 – 42% / Hgb – 10.5 – 14 g/dl
• 1st trimester – pathologic anemia if less 11g/dl - Hgb
• 2nd & 3rd tri – pathologic anemia if less 10.5 g/dl - Hgb
 RESPIRATORY CHANGES

• Oxygen consumption increase

• Diaphragm elevated
• Respiratory rate remain unchanged
• Shortness of breath
 GASTROINTESTINAL CHANGES

• Nausea and vomiting (hCG)

• Poor appetite
• Alterations in taste and smell
• Constipation
• Flatulence and heartburn
• Hemorrhoids
• Gum tissue swollen & easily bleeds
• Ptyalism (increase salivation)
RENAL SYSTEM CHANGES

• Frequency of urination
• Decreased bladder tone
• Decreased bladder capacity
• Renal function increases
• Renal threshold for glucose reduced
 ENDOCRINE SYSTEM CHANGES

• Basal Metabolic Rate rise

• Anterior lobe of pituitary gland enlarges
• Thyroid enlarges – activity increases
• Aldosterone levels gradually increase
• Parathyroid increase in size
 REPRODUCTIVE SYSTEM
CHANGES
• UTERUS
- Enlarge (60-1000 g)
- Size & number of blood vessels & lymphatics increase
- Irregular contractions occur
• CERVIX
- Shorter, elastic, large in diameter
- Endocervical glands secrete a mucus plug
(operculum)
- Increased vascularization (CHADWICK’S)
• OVARIES
- Maturation of new follicle blocked
- Ovum production cease
• VAGINA
- Hypertrophy & thickening of the muscle
- Increase vaginal secretions (thick, white,
acidic)
• BREASTS
- Size increase
- Nipples are pronounced
- Areola darker in color
- Superficial veins are prominent
- Hypertrophy of Montgomery follicles
- Colustrum appear from the breast
 SKIN CHANGES

• Pigmentation increases
• Linea nigra
• Chloasma
• Striae gravidarum
• Rate of hair growth decrease
 SKELETAL SYSTEM CHANGES

•Center of gravity changes

•Postural changes occur as the increased
weight of the uterus causes a forward
pull of the bony pelvis (lordosis)
 METABOLISM CHANGES

• Metabolic function increase

• Body weight increase
Total weight gain – 20 – 25 lbs (minimum)
25-35 lbs (optimum)
1st TRI – 1 lb per month
2nd & 3rd TRI – 1 lb per week

* Pattern of weight gain

* Weight is the measure of health
 PSYCHOLOGICAL MATERNAL
• AMBIVALENCE CHANGES
- Occurs early in pregnancy
- Experience dependence – independence conflict related to
role changes
- Father may also experience

• ACCEPTANCE
- The woman’s readiness for the experience and her
identification with the motherhood role

• EMOTIONAL LABILITY
- Changes in emotional state or extremes

• BODY IMAGE CHANGES

- Perception of image either positive or negative
- Related to the physical changes and symptoms
 PSYCHOLOGIC TASKS OF THE MOTHER

• Ensuring safe passage through pregnancy, labor and

birth

• Seeking acceptance of this child by others

• Seeking of commitment and acceptance of self as a

mother to the infant (binding-in)

• Learning to give of oneself on behalf of one’s child

 FIRST TRIMESTER

• AMBIVALENCE / DENIAL

• ACCEPT BIOLOGICAL FACTS OF PREGNANCY

• FOCUS IS BODILY CHANGES OF PREGNANCY /

NUTRITION
 SECOND TRIMESTER

• ACCEPT GROWING FETUS AS BABY TO BE NURTURED

• GROWTH AND DEVELOPMENT OF FETUS

 THIRD TRIMESTER

• BIRTH PREPARATION, PARENTING

• BABY’S LAYETTE

• LAMAZE CLASSES
SIGNS AND SYMPTOMS OF
PREGNANCY
• PRESUMPTIVE

AMENORRHEA CHADWICK’S SIGN

BREAST CHANGES QUICKENING
NAUSEA & VOMITING URINARY FREQUENCY
LEUKORRHEA EXCESSIVE FATIGUE
SKIN CHANGES
Striae Gravidarum Melasma / Chloasma
Linea gravidarum Hair grows rapidly
 PROBABLE

• ABDOMINAL CHANGES BALLOTEMENT

• LABORATORY TESTS UTERINE SOUFFLE
• HEGAR’S SIGN BRAXTON-HICKS
• GOODEL’S SIGN FETAL OUTLINE
• UTERINE GROWTH (+) PREGNANCY TEST
• ELEVATED (BBT)
• BALLOTEMENT
• BRAXTON HICKS CONTRACTION
• CHADWICKS SIGN
• UTERINE SOUFFLE
• FETAL OUTLINE (PALPATION)
• ELEVATED BBT
POSITIVE / ABSOLUTE

 FETAL PARTS – OUTLINE (X-RAY OR

ULTRASOUND)
 FHT
 FETAL MOVEMENT FELT BY EXAMINER
 COMMON DISCOMFORTS OF
PREGNANCY

• FIRST TRIMESTER

a. Nausea / vomiting - hCG , CHO metabolism,

emotions, fatigue

b. Urinary frequency – pressure on bladder (1 st & 3rd

TRI)

c. Fatigue – Specific cause unknown, probably R/T

nocturia (increase urination at night)
d. Breast tenderness – Estrogen & progesterone

e. Increased vaginal discharge – Hyperplasia of

vaginal mucosa, endocervical mucus production
(estrogen)

f. Nasal stuffiness / nosebleed – estrogen

g. Ptyalism (specific cause unknown)

• SECOND TRIMESTER

a. Heartburn – progesterone, motility, relaxed cardiac

sphincter, displaced stomach, regurgitation

b. Ankle edema – standing/ sitting, sodium level, lower

extremity circulatory congestion, increase capillary
permeability, varicose veins

c. Varicose veins – venous congestion, hereditary,

increase age and weight gain
d. Hemorrhoids – constipation, pressure on
hemorrhoidal veins
e. Constipation – Progesterone, pressure on
intestines, iron supplements, diet, lack of
exercise, decreased fluids
f. Backache - curvature of lumbosacral
vertebrae, hormones, fatigue, poor body
mechanics
g. Leg cramps – calcium/phosphorus ratio,
pressure on nerves, fatigue, poor circulation,
pointing toes
• THIRD TRIMESTER

a. Faintness – postural hypotension, standing

for long periods in warm area, anemia

b. Dyspnea – decreased vital capacity from

pressure of enlarging uterus
[Link] – GI motility & emptying,
pressure on large intestine, air swallowing

d. Carpal tunnel syndrome – compression of

median nerve in carpal tunnel of the wrist /
repetitive hand movement
 PRENATAL CARE
• SCHEDULE OF CLINIC VISITS
- First visit – as soon as mother missed a menstrual period
when pregnancy is suspected
- Every 4 weeks – first 28 to 32 weeks
- Every 2 weeks – from 32 to 36 weeks
- Every week – from 36 to 40 weeks
 CARE DURING
REGULAR PRENATAL
VISIT
PROCEDURES DURING FIRST
PRENATAL VISIT

• BASELINE DATA COLLECTION (Age, sex, occupation, educational

background) (HBMR)

• OBSTETRICAL HISTORY
a. G – T – P – A – L (Preceding pregnancies and prenatal
outcomes)
b. Current pregnancy
- LMP (date of pregnancy)
- Presence of problems
- Discomforts / concerns or questions
- Signs / symptoms of pregnancy
- Woman’s attitude
- Result of pregnancy test
• Pregnancy test
- Urine exam (at 40-100th day), Peak of HCG,
6 weeks after LMP is best to get urine exam

- ELISA test – detect beta subunit of HCG (7-

10 days)
[Link] of past pregnancies
- Number
- Abortions
- Living children
- Type of delivery, Labor, Length of
pregnancy
- Neonatal status
- Blood type and Rh factor
- Prenatal education classes
d. Gynecological history
- Papsmear
- Previous infection
- Previous surgery
- Age of menarche
- Menstrual history
- Sexual history
- Contraception
e. Current (Immunization) / Past medical history
• DPT complete at young age (TT1-TT2) begin TT3
• TT1 – anytime during pregnancy
• TT2 – 4 weeks after TT1 - 3 yrs protection
• TT3 - 6 months after TT2 - 5 yrs protection
• TT4 - 1 yr after TT3 - 10 yrs protection
• TT5 - 1 yr after TT4 - lifetime

e. Family medical history

f. Religious / cultural history
g. Occupational history
h. Partner’s history
i. Risk factors
 ESTIMATING DATE OF
PREGNANCY
•NAEGELE’S RULE

Count back three calendar months from

the first day of LMP then add 7 days
• DATE OF QUICKENING
Primigravida – date of quickening + 4
months and 20 days = EDC

Multigravida – date of quickening + 5

months and 4 days = EDC
DETERMINING AGE OF GESTATION

• MCDONALD’S RULE (WEEKS)

Used in 2nd / 3rd TRI

Take fundic height from notch of the

symphysis pubis to the fundus

Fundic height x 7 / 8 = AOG in weeks

 BARTHOLOMEW’S RULE

To determine AOG by proper location of

fundus at abdominal cavity.

3 months - above symphysis pubis

5 months - level of umbilicus
9 months - below xiphoid
10 months - level of 8 months
• PERFORMED TO EVALUATE FETAL GESTATIONAL
AGE

• 2ND – 3RD TRIMESTER – WEEKS 18 TO 30 – FUNDAL

HEIGHT IS EQUAL TO THE FETAL AGE IN WEEKS +/- 2
CM

• 16 WEEKS – FUNDUS HALFWAY BETWEEN

SYMPHYSIS PUBIS & UMBILICUS

• 20-22 WEEKS – FUNDUS AT UMBILICUS

• 36 WEEKS – XIPHOID PROCESS

 FETAL LENGTH ESTIMATES

• HAASE’S RULE

FIRST HALF OF PREGNANCY- SQUARE

THE MONTH;
SECOND HALF OF PREGNANCY -MULTIPLY
THE MONTH BY 5
 ESTIMATED FETAL WEIGHT

•CROWN-TO-RUMP LENGTH IN
UTERO (CM) MULTIPLIED BY 100
= EFW in gms
 DANGER SIGNS OF PREGNANCY
•C - chills, fever / cerebral disturbance
•A - abdominal pain (epigastric)
•B - boardlike abdomen
•I - increase BP
•B - blurring of vision
•E - edema
•B - bleeding
•A - absence of fetal movement
•M - muscular irritability / convulsion
•O - oliguria / dysuria
•S - sudden gush of fluid
• INITIAL PRENATAL PHYSICAL EXAMINATION
- Vital signs
- Height and weight
- Urinalysis (proteinuria, glycosuria,
hematuria)
- CBC, Hct, Hgb, VDRL, ABO-Rh typing,
Rubella titer(N-1:10)
 LEOPOLD’S MANEUVER
• PURPOSES: To determine
1. attitude
2. fetal presentation
3. lie
4. presenting part
5. degree of descent
6. estimate size / number of fetuses
7. position
8. fetal back (FHT)
• Preparation:
• Instruct woman to empty her bladder first.
• Place woman in dorsal recumbent position,
supine with knees flexed to relax abdominal
muscles. Place a small pillow under the head
for comfort.
• Drape properly to maintain privacy.
• Explain procedure to the patient.
• Warms hands by rubbing together. (Cold hands
can stimulate uterine contractions).
• Use the palm for palpation not the fingers.
1st maneuver
- size, shape, firmness (fundus) / presentation

2nd maneuver
- Back of fetus, FHT (funic / uterine soufflé)

3rd maneuver
- Degree of engagement

4th maneuver
- Descent / attitude / engaged (Flexed, extended)
• Guide questions in recording the result of
the maneuver:
1. What lies at the fundus?
2. Where does the baby’s back lie in relation
to the R/L side of the mother?
3. Where is the cephalic prominence felt in
relation to the back of the baby?
4. If patient is on the 9th month, has
engagement occurred?
 First Maneuver: Fundal Grip
• Purpose:To determine fetal part lying in
the fundus.
• Procedure: To determine presentation.
Using both hands, feel for the fetal part
lying in the fundus.
• Findings: Head is more firm, hard and
round that moves independently of the
body.
Breech is less well defined that moves
only in conjunction with the body
SECOND MANEUVER: UMBILICAL GRIP
• PURPOSE:
• To identify location of fetal back.
• To determine position.
• PROCEDURE: One hand is used to steady the uterus on
one side of the abdomen while the other hand moves
slightly on a circular motion from top to the lower
segment of the uterus to feel for the fetal back and
small fetal parts.
Use gentle but deep pressure.
• FINDINGS: Fetal back is smooth, hard, and resistant
surface
Knees and elbows of fetus feel with a number of
angular nodulation
 Third Maneuver: Pawlik’s Grip
• PURPOSE: To determine
engagement of presenting part.
• PROCEDURE: Using thumb and
finger, grasp the lower portion
of the abdomen above
symphysis pubis, press in
slightly and make gentle
movements from side to side.
The presenting part is not
engaged if it is movable.
• FINDINGS: It is not yet engaged
if it is still movable.
 Fourth Maneuver : Pelvic Grip
• PURPOSE: To determine the degree of flexion of fetal head.
• To determine attitude or habitus.
• PROCEDURE: Facing foot part of the woman, palpate fetal head
pressing downward about 2 inches above the inguinal ligament.
Use both hands.
• FINDINGS:
• Good attitude – if brow correspond to the side (2nd maneuver)
that contained the elbows and knees.
Poor atitude – if examining fingers will meet an obstruction on
the same side as fetal back (hyperextended head)
• Also palpates infant’s anteroposterior position. If brow is very
easily palpated, fetus is at posterior position (occiput pointing
towards woman’s back)
 INITIAL PSYCHOSOCIAL
ASSESSMENT
• Helps to determine:
a. The woman’s attitude about
pregnancy.
b. Teaching needs
c. Support system available to her
d. Cultural or religious preferences
e. Economic status
f. Living conditions
• For further evaluation / Intervention
a. Marked anxiety, apathy, fear, anger
b. Isolated home environment
c. Language barrier
d. Cultural practices that may endanger the
child
e. Long-term family problems
f. Unstable or limited economic status /
limited prenatal care
g. Crowded or questionable living condition
 CRITICAL RESPONSIBILITIES

1. WEIGH THE WOMAN 4. Collect dipstick urine

- Inadequate gain (less 1 specimen:
kg/mo)
- Proteinuria
- Excessive gain (more
than 3 kg/mo) - Glycosuria
2. Monitor Vital signs 5. Glucose screen
- BP, PR - 50 g 1 hour glucose
- Rapid Pulse screen (24-28 weeks)
- Elevated BP 6. Danger signs
3. Assess for EDEMA 7. Minor discomforts
- Hands, face, legs
 Prenatal Nutrition

• Recommended dietary allowance for most nutrients increase

• Food Guide Pyramid

• Calories – 300 cal/day above the pre pregnancy daily requirement

 CALORIES

• Energy – BMR
• Utilization of nutrients
- Protein sparing
- Development of structures required for pregnancy
• Begin in 2nd trimester
• Prevent ketosis (fetal damage)
PREGNANT VEGETARIAN

• LACTO-OVOVEGETARIAN
-milk, dairy products, eggs, fish, poultry

• LACTOVEGETARIANS
- dairy products but no eggs

• VEGANS (Pure vegetarians)

- daily 4 gm B12 supplement
ANEMIA IN PREGNANCY

• Meat, poultry, fish

• Iron fortified cereals
• Vit c
• Iron rich vegetables
 PRENATAL CARE CONCERNS

• BATHING
- Daily shower or tub; if with ROM or vaginal
bleeding avoid tub bath
• EMPLOYMENT
- Major problems { hazards, physical strain, over
fatigue, medical-pregnancy related complicationsb,
balance}
- Break, rest on her side, dorsiflex foot, walk
around, low heeled shoes
• TRAVEL
- plane, train, walk (phlebitis), car [stop every 2 hours, walk
10 min / seat belts –lap belt, under the abdomen
• EXERCISE (strengthen muscles for delivery)
- regular, swimming, walking, cycling, squatting, tailor
sitting, kegel’s, abdominal exercise(candle), shoulder circling

- supportive bra, appropriate shoes, avoid hyperthermia,

fluids
- moderation, individualized
- report unusual s/s
• SEXUAL ACTIVITY • MEDICATIONS /
- desires changes SMOKING / ALCOHOL
- change position [side - avoid drugs / ask
lying, woman superior] doctor
- Contraindicated if - smoking (LBW)
membranes have - alcohol (neurologic
ruptured, vaginal deficits, fetal alcohol
bleeding, history of syndrome, LBW)
preterm
 NUTRITION
DURING
PREGNANCY
Importance of Good Diet During
Pregnancy

•Fetal growth
• Early in pregnancy (HYPERPLASIA)
• Late in pregnancy (HYPERTROPHY)

• Small for gestational age (fetus is deprived of adequate

nutrition)
• Childbearing age women should follow a balanced diet
before pregnancy
RECOMMENDED WEIGHT GAIN

•Average weight gain in pregnancy

•11.2 to 15.9 kg (25 to 35 lbs)

• Weight in pregnancy
• Fetal growth
• Accumulation of maternal stores

• Breast (1.5 to 3 lbs)

• Blood volume (4 lbs)
• Uterus (2.5 lbs)
• Fetus (7.5 lbs)
• Body fluid (4 lbs)
• Placenta (1.5 lbs)
• Body fat (7 lbs)
• Amniotic fluid (2 lbs)
Weight Gain Pattern

•Average weight woman

• 1 lb / month for 1st trimester
• 1 lb / week for last 2 trimesters
• {3-12-12 pattern)
• Excessive: if more than 3 kg per month in
last 2 trimesters
• Less than usual: if under 1 kg per month
during the second and third trimester
•Avoid dieting
•Sudden increase must be
carefully evaluated
Components of Healthy Nutrition
for the PREGNANT Woman
•Eat just enough for the growing
fetus
•Foods eaten should represent the
foods in food pyramid
CALORIE NEEDS
• Childbearing Age
• 2,200 Cal
• Pregnant
• 2,500 Cal (+300 Cal)

• Adequate intake of CHO (prevent

ketoacidosis, cause of fetal & neurologic
disorders)
• No sugar substitutes
• Consider her lifestyle
• Monitoring her weight gain
PROTEIN NEEDS

• Women is 44 to 50 g (60 g daily during pregnancy)

• Complete protein ( 9 essential AA: meat, poultry,
fish, milk)
• Inadequate protein intake will lead to inadequate
Iron, vitamins, calcium and phosphorus
• B 12 is found exclusively in animal protein
FAT NEEDS

•LINOLEIC ACID is essential fatty acid

necessary for new cell growth, cannot
be manufactured in the body

•Linoleic acid must be obtained from

food
 VITAMIN NEEDS
• Fat-soluble and Water-soluble
• Taking oral contraceptives, include good sources of
vitamins A, B, Folic Acid

• Avoid taking megadoses of vitamins (water-

soluble / fat soluble)
• Vitamin C (withdrawal scurvy in infant at birth)
• Vitamin A (fetal malformation) (Isotretinoin-Accutane
for acne)
•Folic Acid (Folacin), in fresh fruits &
green leafy vegetables is needed for
RBC formation, deficient cause
neural tube defect
 MINERAL NEEDS

• Calcium and Phosphorus

• Tooth formation (8 weeks) and Bone calcification (12
weeks)
• Vitamin D (calcium absorption in GIT; to enter bones)
• High in protein is high in phosphorus
• Iodine
• For thyroxine
• Deficiency cause thyroid enlargement (goiter),
hypothyroidism in fetus (COGNITIVELY CHALLENGED)
CRETINISM – MENTAL RETARDATION
• Iodized salt (ASIN LAW)
•Iron
• Fetus at term has a hemoglobin level of 17
to 21 g per 100 mL of blood, a level that is
necessary to oxygenate the blood during
intrauterine life
• After week 20 fetus begins to store iron in
the liver
• Absorption increase in an acid
environment
•Fluoride
• Fluoridated water, large amounts
however cause brown-stained teeth
•Sodium
• Acts to maintain fluid in the body
•Zinc
• Synthesis of DNA and RNA
• Deficiency (preterm birth)
• With adequate protein intake also has
adequate zinc intake because zinc is found
in meat, liver, eggs and seafoods.
•FLUID NEEDS
•Six glasses or more

•FIBER NEEDS
•Fruits and vegetables to prevent
constipation
FOODS TO AVOID DURING
PREGNANCY

•With caffeine
•Artificial sweeteners
(aspartame)
•Weight loss diets
Assessment of Nutritional
Health
•Best method is “TYPICAL DAY”
History or 24-hour nutrition
recall
•Hemoglobin or hematocrit
determination
 ASSESSMENT OF
FETAL WELL-BEING
• TRANSVAGINAL / ABDOMINAL U.S.
Use:
1. Early identification of pregnancy
2. Identify no. of fetus
3. Measure bi-parietal diameter
4. Detect fetal anomalies
5. Locate / grade placenta
6. Observe FHT, movement, respirations, position
and presentation, fetal death
Nursing Responsibility:
1. Inform client 3. T – empty the bladder
2. Positioning 4. A – full bladder
• NONSTRESS TEST

Use:
Assess fetal status, electronic fetal monitor observe
baseline variability & acceleration of FHR with
movement. FHR acceleration – CNS/ ANS not
affected by lack of O2 to fetus, intact NS

Preparations:
1. Inform to stop smoking
2. Positioning – semi-Fowler’s, side-lying, reclining
chair
3. Two belts placed on abdomen – monitor
4. Instruct what to do (press button)
5. Fetus not moving – drink a glass of juice
6. Record / report findings
• Result:
a. REACTIVE – 2 0r more accelerations of
15 bpm, lasting 15 sec or more, over 20
min
b. NONREACTIVE - lack sufficient FHR
accelerations over 40 min
c. Unsatisfactory – data can’t be
interpreted, inadequate fetal activity
• VIBROACOUSTIC STIMULATION TEST

- application of sound & vibration to

mother’s abdomen to stimulate
movement in fetus
- used to improve specificity & efficiency
of interpretation of FHR monitoring
patterns because of nonreactive NST
- device that deliver 1-3 sec sound to
fetus to change fetal behavioral state
- TYPICAL: 10 bpm rise in baseline in 10
sec and lasting from 5-10 min
• BIOPHYSICAL PROFILE
- A collection of information about
selected fetal measurements and
assessments of the fetus and AF.
- Ultrasound
1. Fetal breathing movements
2. Body movement
3. FHR activity
4. Fetal tone
5. AF volume
• AMNIOTIC FLUID ANALYSIS (AMNIOCENTESIS)
Uses:
1. Genetic information – done between 14-16
weeks
2. Fetal lung maturity – done after 35 weeks

1. Instruct to void if AOG (more 20 wks)

2. Position – supine
3. Report: Hyperactivity, hypoactivity, vaginal
bleeding, chills, fever, fluid leakage, vaginal
discharge
4. Alert for complications: Placental, bladder
and cord puncture
 Phospholipids – L/S ration (2:1 or
greater), two components of surfactant
 Diabetic mothers – delayed lung
maturity, (L/S – 3:1)
 Phosphatidyl glycerol (phospholipid) – in
AF after 35 weeks and increases til term)
/ lamellar body counts present when PG
appear in AF indicative of surfactant
(count of 3500/microliter)
• ALPHA-FETO PROTEIN LEVELS
Use
- assess the presence of neural tube
defects and down syndrome

Interpretation:
Elevated – Neural Tube Defect
Decreased – Down syndrome
• Monitoring Fetal Activity (CARDIFF-COUNT TO TEN)

- Begin at 27 weeks AOG

- Specified time each day until count 10 reached (after
breakfast)
- Note how long it takes for fetal movement
- Expected finding: 10 movements in 1 hour or less

Warning signs:
1. more 1 hour to reach 10 movements
2. less than 10 movements in 12 hour (Non-reactive fetal
distress)
3. longer time to reach 10 FM than on previous days
4. movements becoming weak
• CONTRACTION STRESS TEST (OCT)
- Indicates uteroplacental insufficiency
and identifies pregnancy at risk.
Result:
Negative – indicates absence of abnormal
decelerations with all contractions
Positive – indicates abnormal FHR
decelerations with contractions
• FETAL HEART MONITORING
- assess FHR abnormalities
Interpretation:
1. Early decelerations – fetal head
compression.
2. Late decelerations - placental
insufficiency.
3. Variable decelerations – cord
compression, reflects U or W shape
image in the monitor, change
position.
CHILD BIRTH PREPARATION
 PSYCHOPHYSICAL
BRADLEY METHOD - ACTIVE PARTICIPATION
OF THE HUSBAND DURING DELIVERY
BASED ON IMMITATION OF NATURE
 DARKLY LIGHTED ROOM
 QUIET ENVIRONMENT
 RELAXATION TECHNIQUE
 CLOSE EYES

GRANTLY DICK READ METHOD

FEAR LEADS TO TENSION TO PAIN
ELIMINATE PAIN BY RELAXATION TECHNIQUE &
ABDOMINAL BREATHING
 PSYCHOSEXUAL
 KITZINGER METHOD – SHEILA
KITZINGER
 PREGNANCY, LABOR, BIRTH & CARE
OF NEWBORN IS AN IMPORTANT
TURNING POINT OF A WOMAN’S
CYCLE
 MOTHER SHOULD FLOW WITH
CONTRACTION RATHER THAN
STRUGGLE

 PSYCHOPROPHYLAXIS
 PREVENTION OF PAIN
 LAMAZE METHOD – DR. FERDINAND
LAMAZE
 REQUIRES DISCIPLINE, CONDITIONING
&CONCENTRATION.
 Husband coach the mother
 Features:
 Conscious relaxation
 Cleansing breathe – inhale nose,
exhale mouth
 Effleurage – gentle circular
massage over abdomen to relieve
pain
 Imaging
EXERCISE DURING
PREGNANCY
• Goal of Performing Prenatal Exercises:
To strengthen the muscle that will be used in
labor and delivery.
• Guidelines in Performing Exercises
during pregnancy:
• Exercise should be done in moderation.
Recommend that moderate exercise should
be done 30 or more minutes daily.
• The pregnant woman should avoid strenuous
activity or intensifying training.
• Exercises where there is a risk of falling
or abdominal trauma should be
avoided.
• Pre-natal exercises should NOT be done
during a hot or humid weather.
• All exercises in supine position after
the first trimester of pregnancy should
not be done by the pregnant woman as
this position increases the risk of
supine hypotensive syndrome.
• Should be individualized. Meaning the
exercises recommended for each pregnant
woman should be according to ones age,
physical condition, customary amount of
exercise and the stage of pregnancy.
• Adequate fluid intake before and after
exercise should be practiced by the
pregnant woman.
 Exercises that cause fatigue should
be stopped.
 It is important to follow the health
care provider’s advice about taking
the pulse rate during the exercise
and keeping it within a certain range.
• Squatting and
tailor sitting
• Strengthen perineal
muscle
• Increase perineal
circulation
• Make more pelvic
joints pliable
• Pelvic Rock
• Maintains good posture
• Relieves abdominal
pressure and low
backaches
• Strengthen abdominal
muscles following
delivery
• Modified knee-
chest position
• Relieves pelvic
pressure and
cramps in thighs or
buttocks
• Relieves discomfort
from hemorrhoids
•Shoulder
circling
•Strengthens
muscles of the
chest
•WALKING • BEST EXERCISE
• PROMOTES
CIRCULATION
• Kegel’s • Strengthen the
• 10 seconds pubococcygeus
contraction, 10 muscle and increase
seconds relaxation its elasticity.
(30 times a day)
• Relieves congestion
and discomfort in
pelvic region
• Tones up pelvic floor
muscles
COMMUNITY MANAGED
MATERNAL-NEWBORN
CARE
Major Causes of Maternal Deaths
(direct causes)
• Post-partum hemorrhage
• Eclampsia
• Obstructed labor
• Complications from abortions
Indirect Causes of Maternal Deaths

•Anemia
•Malaria
•Diabetes
•Sepsis
Three Delays
a. Delay in deciding to seek medical care
1. Failure to recognize danger signs
2. Absence of skilled attendants
3. Lack of money for medical expenses
4. Pregnancy is unplanned or unwanted
5. Poor quality of obstetric care
6. Fear of being ill-treated in the health
facility
7. Reluctance from the mother or family due
to cultural constraints
8. The woman or family member present at
childbirth lack power to make a decision
9. Lack of encouragement from relatives and
community members to seek care
10. No available person to take care of the
children, the homes and livestock
11. Lack of companion in going to the health
facility
B. Delay in identifying and reaching the
appropriate facility
1. Distance from woman’s home to the
health provider.
2. Lack of roads or Poor condition of the
roads
3. Lack of emergency transportation
4. Lack of awareness of existing services
5. Lack of referral system
6. Lack of communication with referral
facility
7. Lack of moral, financial and logistical
support from neighbors, LG officials
C. Delay in receiving appropriate and
adequate care at the facility.
1. Lack of health Care personnel
2. Unprofessional attitudes of health
providers
3. Shortage of supplies
4. Lack of basic equipment
5. Poor skills of health care provider
6. Health is not prioritized by the
barangay and municipal officials
7. Lack of budget from the LGU
EMERGENCY OBSTETRIC CARE
(EmOC)
• A strategy that can be used to combat
the three delays. Generally, all obstetric
complications can be treated especially if
danger signs are recognized earlier and
prompt treatment is given.
• Basic Emergency Obstetric Care (BEmOC)
(health facilities)
• Involves levels of obstetric care provision
starting from the midwife for normal
pregnancies and deliveries to higher
levels of facilities that can manage
complicated cases
• Obstetric complications can be treated if
danger signs are recognized earlier and
prompt treatment given
BIRTH PLAN
• A document prepared during the prenatal care
visit which states:
the woman’s conditions during
pregnancy
her preferences for her place of delivery
and choice of birth attendant
her available resources for her childbirth
and newborn baby
the preparations needed should an
emergency situation arise during
pregnancy, childbirth and postpartum.
Mother Baby Package Interventions
(WHO)
• A LIST OF ESSENTIAL SERVICES
THAT SHOULD BE MADE AVAILABLE
TO WOMEN AND NEWBORNS TO
ATTAIN REDUCTION IN MATERNAL
AND PERINATAL/ NEONATAL
DEATHS, MORBIDITIES AND
DISABILITIES.
END
CMMNC

• A community-managed approach is a direct intervention to prevent

maternal and perinatal/ neonatal deaths, illnesses and disabilities.
FEATURES

• Availability of maternal and child health services in the context of

PHC, bringing it closer to the home of the mothers.
• Established or strengthened referral systems.
• Community education and mobilization for a common understanding
of the issues on MCH
• ELEMENTS:
1. PREGNANT woman has:
- correctly accomoplished maternal child birth
plan (delivery and emergency plan)
- PhilHealth membership and is able to avail of
benefits
- saved / allotted money for childbirth and
services for newborn
- plans for desired family planning services
2. Partner/ spouse and family members:
- provide care and support
- is a PhilHealth member and knows how to avail benefits
- saved / allotted money for childbirth and services for newborn
3. Health providers who are:
- clinically skilled, competent, compassionate in providing care
- efficient in establishing a systematic referral system
- skilled in providing quality health education and counseling
- interested in expanding/ updating their skills
4. Health facilities that are:
- managed by competent and compassionate health care
providers
- licensed according to required regulatory policies
- PhilHealth accredited
5. Local government officials
- Empowered, committed and actively involved in promoting safe
motherhood and healthy newborns
- Take action for universal enrolment of all indigents to the Sponsored
Program of PhilHealth and upgrading of health facilities for
accreditation
Before and During Pregnancy
• Education and counseling and actual services for
family planning
• STD/HIV prevention and management
• Tetanus toxoid immunization
• Antenatal registration and care
• Treatment of existing conditions (malaria)
• Iron/folate supplementation
• Recognition, early detection and management of
complications
• Health education and counseling with emphasis on
nutrition
During Delivery

• Clean and safe delivery

• Recognition, early detection and management of complication at
health center or hospital wit EmOC capabilities
After Delivery: MOTHER

• Recognition, early detection and management of

complication at health center or hospital wit EmOC
capabilities
• Postpartum care (Breastfeeding)
• Education and counseling and actual service for FP
• STI/ HIV/ AIDS prevention and management
• Tetanus toxoid immunization based on schedule
• Health education and counseling
After Delivery: NEWBORN

• Resuscitation
• Prevention and management of hypothermia,
opthalmia neonatorum, cord infections
• Breastfeeding initiation within one hour after birth
• Exclusive breastfeeding up to 6 months
• Prevention and management of infections
• Newborn screening
• Health education and counseling
BIRTH PLAN

• A document prepared during the prenatal care visit

which states the woman’s conditions during
pregnancy, her preferences for her place of delivery
and choice of birth attendant, her available
resources for her childbirth and newborn baby and
the preparations needed should an emergency
situation arise during pregnancy, childbirth and
postpartum.
MILLENIUM DEVELOPMENT GOALS

• A measurable goals to be achieved by 2015 agreed

upon to by the international community in Year
2000 to an expanded vision of development, one
that vigorously promotes human development as
the key to sustaining social and economic progress
in all countries and recognizes the importance of
creating global partnership for development.
INTER LOCAL HEALTH ZONES

• Are mechanisms to organize and mobilize individuals, communities,

health providers and health facilities in well defined geographical
areas to provide quality, equitable and accessible health care with
inter-LGU partnerships as the basic framework
HEALTH SECTOR REFORM AGENDA
(HSRA)
• AIM: to revitalize the decentralized health care
system in a comprehensive and sustainable
manner.
• To improve:
• Health financing
• Health regulation
• Hospital systems
• Local health systems
• Public health programs
HSRA Will address
• Barriers to utilization of health services:
• Limited access to health services
• Poor quality of health services
• Inadequate healthcare financing
• Inefficient health systems
• Ineffective mechanisms for public health programs
• Uneven distribution of health professionals
• Weak enforcement of health standards and regulations
• Lack of community participation at the barangay level
FourMULA One for Health

• A framework for better health outcomes, more responsive health

system and equitable health care financing, especially for the poor.
Component of Fourmula one
• HEALTH CARE FINANCING
• To secure better and sustained investment in health
• HEALTH REGULATION
• To assure access to quality and affordable essential drugs,
health products, devices, facilities and services
• HEALTH SERVICE DELIVERY
• To improve accessibility, availability and equity of basic and
essential health care for all
• HEALTH GOVERNANCE
• To improve local and central health system management and
coordination, enhance public-private partnership and build
capacities for health leadership