Maternal Care (Obstetrics) I. Terminology: 1. Gestation pregnancy or maternal condition of having a developing fetus inside the body. 2.

. Embryo human conceptus up to 10th week of gestation (8th week postconception) 3. Fetus human conceptus from 10th week of gestation until delivery. 4. Viability capability of living outside the uterus designated at 20 weeks gestation. (Although Survival Rate is Rare) 5. Gravida (G) is been pregnant, regardless of outcome. 6. Nulligravida is not now and has never been pregnant. 7. Primigravida pregnant for the first time. 8. Multigravida has been pregnant more than once. 9. Para (P) refers to past pregnancies that have reached viability. 10. Nullipara has never completed a pregnancy to the period of viability. 11. Primipara has completed one pregnancy to the period of viability. 12. Multipara has completed two or more pregnancies to the period of viability. II. Manifestations of Pregnancy [Presumptive Signs and Symptoms] (Physical Signs and Symptoms that suggest, but do not prove pregnancy) 1. Abrupt Cessation of Menses suspected if more than 10 days have elapsed. 2. Breast Changes: a. Becomes large and tender b. Veins become increasingly visible c. Nipples become larger and pigmented. Nipple tingling may also be present. d. Colostrum, a thin milky fluid, may be expressed in the second half of pregnancy. e. Montgomerys glands, small elevations of the areola may appear. 3. Skin Pigmentation Changes: a. Chloasma/Melasma Gravidarum (Mask of Pregnancy) brownish pigmentation appearing on the face in a butterfly pattern in 50% to 70% of women. - is more common in dark-haired, brown-eyed women and is progressive throughout the pregnancy. b. Linea Nigra dark vertical line on the abdomen between the sternum and the symphysis pubis. c. Abdominal Striae (Striae Gravidarum) reddish or purplish marks sometimes appearing on the breasts, abdomen, buttocks, and thighs because of the stretching, rupture, and atrophy of the deep connective tissue of the skin.

d. Spider Angioma spiderlike projection in the skin. 4. Nausea and Vomiting (Morning Sickness) occurs mainly in the morning, but may occur anytime of the day, lasting a few hours. Begins 2 to 6 weeks after conception and usually disappears spontaneously near the end of the first trimester (12 weeks). 5. Frequency of Urination: a. Caused by pressure of the expanding uterus on the bladder. b. Decreases when the uterus rises out of the pelvis (around 12 weeks). c. Reappears when the fetal head engages in the pelvis at the end of pregnancy. 6. Fatigue characteristics of early pregnancy in response to increased hormonal levels. Probable Signs and Symptoms (Objective findings detected by 12 to 16 weeks of gestation) 1. Enlargement of the Abdomen at about 12 weeks gestation the uterus can be felt through the abdominal wall, just above the symphysis pubis. 2. Changes in shape, size, and consistency of the uterus: a. Uterus enlarges, elongates, and decreases in thickness as pregnancy progresses. The uterus changes from pear shape to a globe shape. b. Hegars Sign lower uterine segment softens 6 to 8 weeks after the onset of the last menstrual period. 3. Changes in the Cervix: a. Chadwicks Sign bluish or purplish discoloration of the cervix and vaginal wall. b. Goodells Sign softening of the cervix; may occur as early as 4 weeks. 4. Braxton Hicks Contractions painless, palpable contractions occurring at irregular intervals, more frequently felt after 28 weeeks. They usually disappear with walking or exercise. 5. Ballotement sinking and rebounding of the fetus in its surrounding amniotic fluid. 6. Changes in levels of HCG (Human Chorionic Gonadotropin) in maternal plasma and urine. 7. Increase in vaginal discharges. 8. Quickening sensation of fetal movement in the abdomen (between 16-20 weeks) 9. Positive (+)HCG Positive Signs and Symptoms (Diagnostic of Pregnancy) 1. Fetal Heart Tones (FHT) usually heard between 16th and 20th week of gestation (Fetoscope) or 10th to 12th Week of gestation with a Doppler Stethoscope. 2. Fetal movements felt by the examiner after about 20 weeks gestation. 3. Outlining of the fetal body through the maternal abdomen in the second half of pregnancy.

4. Sonographic Evidence After 4 weeks gestation using vaginal ultrasound. Fetal Cardiac Motion can be detected by 6 weeks gestation. III. Female Reproductive System A. External Organs 1. Mons Pubis: a mound of fatty tissue over the symphysis pubis that cushions and protects the bone. 2. Labia Majora: longitudinal folds of pigmented skin extending from the mons pubis to the perineum. 3. Labia Minora: soft longitudinal skin folds between the labia majora. 4. Clitoris: erectile tissue located at the upper end of the labia minora; primary site of sexual arousal. 5. Urethral Meatus (Urethral Orifice): small opening of the urethra located between clitoris and vaginal orifice for the purpose of urination. 6. Skenes Glands : small mucous glands that open into the posterior wall of the urinary meatus and provide vaginal lubrication. 7. Vestibule: an almond-shaped are between the labia minora containing the vaginal introitus, hymen, and Bartholins Glands. 8. Vaginal Introitus: external opening of the vagina 9. Hymen: membranous tissue ringing the vaginal introitus. 10. Bartholins Glands: mucous-secreting glands located on either side of the vaginal orifice. 11. Perineal Body: muscles and fascia that support pelvic structures. 12. Perineum: tissue between the anus and vagina; the area where episiotomy is performed. B. Internal Organs 1. Vagina: the female organ of copulation lying between the urethra and rectum. Also known as the birth canal. 2. Uterus: a hollow muscular organ with three muscular layers (perimetrium, myometrium, and endometrium. Located between the bladder and the rectum and consisting of three parts (3): a. Fundus upper round segment that extends above the insertion of the fallopian tubes; fetal growth is measured by fundal height. b. Body (Corpus) main portion between fundus and cervix. c. Cervix divided into two segments. i. Supravaginal portion that extends inside the uterus; contains internal os that opens into the uterine cavity. ii. Vaginal portion that extends outside the uterus into the vagina; contains the external os that is the visible opening of the cervix; portion that is felt during vaginal examination in assessing cervical dilation. Uterine Functions Include: a. Menstruation: sloughing away of spongy layers of endometrium with bleeding from torn vessels.

b. Pregnancy: development of embryo and fetus after fertilization. c. Labor: powerful contractions of muscular uterine wall that result in expulsion of fetus. 3. Fallopian Tubes: tubes extending from the upper outer angles of the uterus and end near the ovary; serves as passageway for the ovum from the ovary to the uterus and for the sperm from the uterus to the ovary. 4. Ovaries: female sex gonads located on each side of the uterus with two functions: a. Ovulation (Release of Ovum) b. Section of Hormones (Estrogen and Progesterone) C. Pelvis 1. Is a bony ring located in the lower portion of the trunk. Parts (3): a. Ilium b. Ischium c. Pubis Bones(4): (2) Hipbones Sacrum Coccyx 2. Types of Pelvis: a. Gynecoid (50%): Typical female pelvis with rounded inlet. - Optimal Diameters in All Three (3) Planes b. Android (20%): Normal male pelvis with heart-shaped inlet. - Posterior segments are decreased in all three planes. Note: * Deep Transverse arrest of descent and rotation of the fetus are common. c. Anthropoid (25%): ape-like pelvis with oval inlet. d. Platypoid (5%): flat female-type pelvis with transverse oval inlet. Note: Arrest of fetal descent at the pelvic inlet is common. Labor progress can be poor. Divisions of the Pelvis: 1. False Pelvis lies above an imaginary line called the linea terminalis or pelvic brim. * Function: Support the Enlarged Uterus 2. True Pelvis: lies below the linea terminalis. * Function: the bony canal through which the fetus must pass. * It is divided into three planes: a. Inlet b. Midpelvis

c. Outlet A. Inlet: i. Upper boundary of the true pelvis bounded by upper margin of symphysis pubis in front, linea terminalis on sides, and sacral promontory (first sacral vertebra) In back. ii. Largest Diameter Transverse iii. Smallest Diameter Anteroposterior iv. Anteroposterior Diameter: - Most important diameter of inlet: - Measured clinically by diagonal conjugate which is the lower margin of symphysis pubis to the sacral promontory. - 5 Inches or 14 cm. v. Obstetrical Conjugate distance between inner surface of symphysis pubis and sacral promontory. - measured by substracting 1.5 2cm (thickness of symphysis pubis) from the diagonal conjugate. - adequate diameter is usually 11.5 cm. - shortest anteroposterior diameter through which the fetus must pass. B. Midpelvis: i. Bounded by inlet above and outlet below - true bony cavity - contains narrowest portion of the pelvis ii. Diameters cannot be measured clinically iii. Clinical evaluation of adequacy is by noting the ischial spines. - Prominent spines that potrude into the cavity indicate a contracted midpelvic space. - The interspinous diameter is 4 inches (10cm). C. Outlet i. Lowest boundary of the true pelvis. ii. Bounded by lower margin of symphysis pubis in front, ischial tuberosities on sides, tip of sacrum at back. iii. Most important diameter clinically is distance between the tuberosities (> 4 inches / 10cm)