organization of obstetric care. physiological duration of pregnancy, labor and post-natal period

Organization of obstetric care. Physiological duration of

pregnancy, labor and post-natal period

By I. Korda1

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• Obstetrics– Field of medicine that deals with pregnancy

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

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

• Three intervals of three months each

– Known as gestational period

Obstetrics Overview

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Calculation of Date of Birth• According of WHO : a date which we get is

considered the date of births, deducting 3 calendar months backwards from the 1th day of the last menstruation;

• Nagele’s rule for calculation: from the 1th day of the last menstruation to deduct 3 calendar months and add 7 days. For example: date of beginning of the last menstruation – on January, 26. We add 7 days – we get on February, 2. From February, 2 we deduct backwards 3 months. Term of births – on a November, 2.

Prenatal care (also known as antenatal care)

• refers to the regular medical and nursing care recommended for women during pregnancy

• the goal is providing regular check-ups that allow doctors• Promote and maintain the physical, mental and social health of mother and

baby by providing education on nutrition, personal hygiene and birthing process

• Detect and manage complications during pregnancy, whether medical, surgical or obstetrical

• Develop birth preparedness and complication• readiness plan• Help prepare mother to breastfeed successfully, • experience normal puerperium, and take good • care of the child physically, psychologically • and socially

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Prenatal care generally consists of:

• monthly visits from week 1–19

• twice from 20 to week 30 of pregnancy

• weekly after week 30 (delivery at week 38–40)

• Assessment of parental needs and family dynamic

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Essential Health Sector Interventions for Safe Motherhood

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SAFEMOTHERHOO

DFamily

PlanningPost

abortionAntenatal

CareClean/safe

Delivery

Postpartum Care

Essential Obstetric

Care

EQUITY

BASIC HEALTH SERVICES

EMOTIONAL AND PSYCHOLOGICAL SUPPORT

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Female reproductive system includes:

– Ovaries

– Fallopian tubes

– Uterus

– Cervix

– Vagina

– Breasts

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• The ovaries are two glands, one on each side of the uterus, that are similar in function to the male testes.

– Each ovary contains thousands of follicles, and each follicle contains an egg.

– Ovulation occurs approximately 2 weeks prior to menstruation.

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• The fallopian tubes

• extend out laterally from the uterus, with one tube associated with each ovary.– Fertilization usually occurs when the egg is inside the

fallopian tube.

– The fertilized egg continues to the uterus where it continues to develop into an embryo.

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The uterus, or womb is a muscular organ where the fetus grows for

approximately 9 months (40 weeks).

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The uterus– Responsible for

contractions during labor

– Helps to push the infant through the birth canal

– The birth canal is made up of the vagina and the lower third, or neck, of the uterus, called the cervix.

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The vagina• is the outermost cavity

of the female reproductive system and forms the lower part of the birth canal.– About 8 to 12 cm in

length

– Completes the passageway from the uterus to the outside world

– The perineum is the

– area of skin between the vagina and the anus.

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The breasts• produce milk that is

carried through small ducts to the nipple to provide nourishment to the infant once it is born.– Signs of pregnancy in

the breasts include increased size and tenderness.

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• The placenta attaches to the inner lining of the wall of the uterus and connects to the fetus by the umbilical cord.

– The placental barrier consists of two layers of cells.

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• After delivery, the placenta, or afterbirth, separates from the uterus and delivers.

• The umbilical cord is the lifeline of the fetus.– The umbilical vein carries oxygenated blood from the woman to the fetus.– The umbilical arteries carry deoxygenated blood from the fetus to the woman.

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• The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac, or bag of waters.– Contains about 500 to

1,000 mL of amniotic fluid

– Fluid helps insulate and protect the fetus.

– Fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

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– Union of a sperm and a mature – ovum

• Takes place in outer third of the fallopian• tube

– Zygote• Initial name for fertilized ovum

– Embryo• Name of product of conception from second through 8th week of

pregnancy

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

of gestational period

Fertilization or conception

Obstetrical Terminology• Gravida

– All current and past pregnancies

• Para – Number of past pregnancies viable to delivery

• Antepartum– Period before delivery

• Gestation– Period of intrauterine fetal development

• Grand multipara– Seven deliveries or more

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Obstetrical Terminology• Multipara

– Two or more deliveries

• Natal– Connected with birth

• Nullipara– Has never delivered

• Perinatal—occurring – At or near time of birth

• Postpartum– Period after delivery 19

• Prenatal – Before birth

• Primigravida– Pregnant for first time

• Primipara– Gave birth once

• Term– Pregnancy at 40 weeks’ gestation

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Molding refers to the cranial bones overlapping under pressure during labor

Sutures of the fetal skull are membranous spaces between the cranial bones.

Fontanelles are the intersections of the cranial sutures. These sutures allow for molding of the fetal head.

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Fetal head

Fontanelles

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The anterior fontanelle is diamond shaped and measures about 2-3cm. It permits growth of the brain by remaining unossified for as long as 18 months.The posterior fontanelle is much smaller and closes within 8-12 weeks after birth

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The Fetal Skull

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Fetal attitude

• Fetal attitude is the relation of the fetal parts to one another.

• The normal attitude of the fetus is one of moderate flexion of the head, flexion of the arms onto the chest, and flexion of the legs onto the abdomen

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Fetal Lie

• Fetal lie refers to the relationship of the cephalocaudal (spinal column) axis of the fetus to the cephalocaudal axis of the woman.

• A longitudinal lie occurs when the cephalocaudal axis of the fetus is parallel to the woman’s spine

• A transverse lie occurs when the cephalocaudal axis of the fetus is at a right angle to the woman’s spine

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Fetal Presentation

• Fetal presentation is determined by fetal lie and by the body part of the fetus that enters the pelvic passage first, the presenting part

• Fetal presentation may be cephalic (most common), breech, or shoulder

• Breech and shoulder presentations are referred to as malpresentations as they are associated with difficulties during labor

• Of note, some cephalic presentations are considered malpresentations, i.e. military or face. However, the overall cephalic category is the PREFERRED presentation. 29

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Fetal Position

• Fetal position refers to the relationship of a designated landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis

• The landmark on the fetal presenting part is related to 4 imaginary quadrants of the pelvis: left anterior (LA), right anterior (RA), left posterior (LP), and right posterior (RP)

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Leopold's Maneuvers

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Position of patient-The pregnant lies on the back. The doctor sitting to the right from pregnant.

The first maneuver. • The hands of both hands

very tightly are laid horizontally, in the area of uterine fundus. Carefully press on a uterine fundus.

• The level of uterine fundus location and part of fetus, located in a fundus, is determined. Gestational age is

determined.33

The second maneuver.• Both hands are placed on

the lateral surfaces of uterus at the level of umbilicus. By turns by a right and left hand palpation of fetal parts is performed. Carefully pressing by hands and fingers of hands on the lateral surfaces of uterus, dense, smooth, wide and shiny part is determined from one side - the back of fetus, from opposite – small parts are palpated .

By this maneuver the lie, position,variety, and also uterine tone, quantity of amniotic fluid waters and fetal movement, are determined.

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The third maneuver.

• By a right hand presented part of fetus is grasped (large finger from one side and four - from the opposite side of lower segment of uterus). The character of presented part and its station is determined.

Presented part station is determined.

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Fourth maneuver.

• A doctor is standing towards patient’s feet. The hands of both hands are located on the lateral surfaces of lower uterine segment and carefully try to insert the fingers between presented part and pelvic inlet.

Presented part station is determined.

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Station

• Station – degree of descent of the presenting part of the fetus, measured in centimeters from the ischial spines in negative and positive numbers.

• -5 is a floating baby, • 0 station is said to be

engaged in the pelvis, • and +5 is crowning.

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Determination of the expected fetal weight

• For determination of the expected weight of fetus (EFW) it is necessary to know the height of standing of uterine fundus (UF) and circumference of abdomen(AC) of pregnant.

• Volscov’ formula:

• EFW = UF x AC

• For example: UF= 32 cm, AC = 100 cm. Multiply: 32х100, we received 3200cm. The expected weight of fetus is 3200 g.

• Yacubova’ formula: EFW= (AC+UF) : 4 x 100

• For example: UF= 32 sm, AC = 100 sm. Adding 32+100, we get 132, dividing on 4, we get 33, multiply on 100, we have the expected fetal weight – 3300 g.

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Passage

Passage = Pelvis

• Consists of the bony pelvis and soft tissues of the birth canal (cervix, pelvic floor musculature)

• Small pelvic outlet can result in cephalopelvic disproportion

• Bony pelvis can be measured by pelvimetry but it not accurate and thus has been replaced by a clinical trial of labor 41

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• Amenorrhea– Absence of menstruation

• Menstruation stops as a result of hormonal influence during pregnancy

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

placenta, amniotic sac, and amniotic fluid during pregnancy

Physiological Changes During Pregnancy

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• Changes in the cervix– Chadwick’s Sign

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

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

Physiological Changes During Pregnancy

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

cervix during pregnancy– Increase of glycogen in vaginal cells

• Causes increased vaginal discharge and heavy shedding of vaginal cells

– Leukorrhea• Thick, white vaginal discharge during pregnancy

Physiological Changes During Pregnancy

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• Changes in breasts– Increase in size and shape

– Nipples increase in size and become more erect

– Areola become larger and more darkly pigmented• Montgomery’s tubercles become more active and

secrete substance that lubricates the nipples

Physiological Changes During Pregnancy

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• Changes in breasts– Colostrum is secreted

• Thin, yellowish discharge from nipples throughout pregnancy

• Forerunner to breast milk

Physiological Changes During Pregnancy

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• Changes in blood pressure– May experience hypotension during second

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

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

dizziness

Physiological Changes During Pregnancy

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• Changes in urination– First trimester

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

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

is relieved

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

bladder

Physiological Changes During Pregnancy

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• Waddling gait• Manner of walking in which the feet are wide apart and

the walk resembles that of a duck• Due to softening of pelvic joints and relaxing of pelvic

ligaments• Pregnant woman’s center of gravity is offset

Changes in posture

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– Possible increased feeling of warmth and sweating

• Due to increased activity of the sweat glands

– Possible problems with facial blemishes

• Due to increased activity of sebaceous glands

– Chloasma• Hyperpigmentation (brown patches) seen

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

Changes in the skin

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Changes in the skin – Linea Nigra

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

– Areola• Becomes darker as pregnancy progresses

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

and breasts that occur during pregnancy

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– Recommended weight gain during pregnancy• Ranges from 25 to 30 pounds

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

– Critical to monitor weight gain for unexpected increases

– Fluid retention– Pregnancy-induced hypertension

Changes in weight

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Signs and Symptoms of Pregnancy

• Presumptive signs– Expectant mother

• Suggests pregnancy but are not necessarily positive

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

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

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Signs and Symptoms of Pregnancy

• Probable signs– Observable by examiner

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

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

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

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

painless

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Signs and Symptoms of Pregnancy

• Positive signs– Fetal Heartbeat

• Detected by ultrasound at approximately 10 weeks gestation

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

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Signs and Symptoms of Pregnancy

• Positive signs– Identification of embryo – or fetus by ultrasound

Can be detected as

early as 5 to 6 weeks with

100 percent reliability• Provides earliest positive confirmation of a pregnancy

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

trimester of pregnancy

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Discomforts of Pregnancy

• Temporary discomforts of pregnancy– Backache

• Common during second and third trimester

– Edema• Swelling of lower extremities not uncommon

– Fatigue• Usually occurs during first trimester

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• Temporary discomforts of pregnancy – Heartburn

• Mainly during last few weeks of pregnancy

– Hemorrhoids• Develop as result of increasing pressure on area

– Nausea• Usually occurs during first trimester

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

Discomforts of Pregnancy

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Signs and Symptoms of Labor• Bloody show

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

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

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Signs and Symptoms of Labor• Braxton Hicks contractions

– Mild, irregular contractions that occur throughout pregnancy

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

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Signs and Symptoms of Labor• Lightening

– Settling of the fetal head into the pelvisOccurs a few weeks prior to the onset of labor

• Rupture of the• amniotic sac

– Rupture of fetal membranes, releasing amnioticfluid Inside

May result in a sudden gush of amniotic fluidWomen may say their “water broke”

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Signs and Symptoms of Labor• Sudden burst of energy

– Occurs in some women shortly before onset of labor

– May have energy to do major housecleaning duties

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False Labor versus True Labor

Contractions (False) Contractions (True)

Irregular Regular

Not too frequent More frequent

Shorter duration Longer duration

Not too intense More intense

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Discomfort (False) Discomfort (True)

Felt in abdomen Felt in lower back

Felt in groin area Radiates to lower abdomen

--- Feels like menstrual cramps

False Labor versus True Labor

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Walking (False) Walking (True)

May relieve or decrease contractions

May strengthen contractions

False Labor versus True Labor

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Effacement/Dilatation (False)

Effacement/

Dilatation (True)

Dilatation and effacement of cervix does not change

Cervix progressively effaces (thins) and dilates (enlarges)

False Laborversus True Labor

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Labor NulliG MultiG

1st Stage Active phase

Duration 6-18 h 2-10 h

Dilation ~1 cm/h ~1.5 cm/h

2nd Stage 0.5-3 h 5-30 min

3rd Stage 0-30 min 0-30 min

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Thank you for your attention!