OBSTETRICS

PRESUMPTIVE SIGNS (SUBJECTIVE)

 MORNING SICKNESS: HCG-----PLACENTA

1ST TRIMESTER (123): NORMAL
2ND TRIMESTER (456)- H-MOLE
-enlargement of placenta (not the fetus)
- Hyperemesis gravidarum- bec. of excessive HCG

MANAGEMENT:
> DRY CRACKERS: increase sodium bicarbonate
Neutralizes hyperacidity that causes n/v.
*increase HCG can cause increase acidity on the stomach

 AMENORRHEA- temporary loss of menstrual cycle

Recurrent of menstrual cycle:
*breastfeeding- 6 mos after delivery (Lactational
Amenorrhea Method)- exclusive for BF
*non-BF- 3 mos after delivery

Causes:
>increased estrogen- uterine contraction (mild)- aka Braxton Hick’s
Contraction
***oxytocin- strong contraction
>increased progesterone- uterine relaxation
- more elevated (HORMONE OF PREGNANCY)
***3 mos- increased estrogen can cause expulsion of product of
conception (abortion)

 BREAST ENLARGEMENT- increased estrogen

-SOYA MILK- can stimulate the ovary to produce
more estrogen.
**avoid coffee

 FATIGUE: decreased RBC (anemia)- iron deficiency anemia (IDA)

During pregnancy: fetus deposit iron to their liver (6 months)
*newborn: breastmilk doesn’t contain iron
In 6 months, introduce solid foods: CEREALS (food rich in iron)

 URINARY FREQUENCY- normal

Cause: because of the enlargement of uterus ---> compression
of urinary bladder
*1st tri- “nakakaramdam ng frequency”
*2nd tri- “nawawala ang frequency”--- because the fetus is going
upward hence no compression of the urinary bladder
If (+) frequency in 2nd tri- abnormal (H-mole)----> bec. Of
rapid placental enlargement
*3rd tri- “babalik ulit ang frequency”
 Prep for labor- the fetus is going downward---
>compression of bladder.

 QUICKENING-fetal movement felt by the mother only

**felt by the mother + nurse, midwife, doctor via palpation (confirm
movement)- (+) movement---> POSITIVE SIGN

2nd tri- start of quickening (in general: 5th month)

-the fetus moves his/her upper body
*primi- 5th month
*multi- 4th month
rd
3 tri- the fetus moves his/her lower body (legs)
**5th month- UTZ
- if breech: normal----> iikot pa sa 3rd trimester

PROBABLE SIGN (OBJECTIVE)

-observable- discoloration, softening of organ

DISCOLORATION
 CHADWICK’S SIGN- discoloration of the cervix: bluish/ purple
**non-pregnant: normal: pink
Cause: increase estrogen; increase blood supply going to the cervix
hence discoloration
To confirm: Vaginal Speculum- to open the vaginal canal via
inspection

SOFTENING OF ORGAN
 GOODELL’S SIGN- softening of the cervix
To confirm: Internal examination
** NO IE if the patient has ABRUPTIO PLACENTA
AND PLACENTA PREVIA (also no SEX)

 HEGAR’S SIGN- softening of the uterus- site of implantation of zygote

(lower segment)
>ectopic pregnancy- implant of zygote outside the uterus
INSTERTITIAL PART (NARROWEST)- most fatal site for ectopic pregnancy
(rupture: bleeding)
*fallopian tube- where fertilization process occurs
**specific site: AMPULLA
**Bitubal ligation site: ISTHMUS

PROCESS OF FERTILIZATION
1 egg + 1 sperm- determine the gender of the fetus.

Menstrual cycle: 1 egg cell is being produce by the ovaries (alternately per
month)
If 2 egg cells are produced: dizygotic twins: Fraternal twins

Sex chromosomes: female- X male- XY

 Sperm cells- 150-400 M per ejaculation

Zygote - travels to the uterus for implantation/ nidation

Normal site of implantation: UPPER SEGMENT
**if lower part- placenta previa

LAYERS OF UTERUS
>ENDOMETRIUM- normally implantation occurs
>MYOMETRIUM- if implantation occurs at the myo- Placenta Accreta
>PERIMETRIUM

During pregnancy, the upper segment becomes thicker (increase

oxygen supply) and the lower segment becomes thinner (soften). During
labor, contraction occurs to deliver the fetus, the pressure is stronger at the
upper segment.

 POSITVE PREGNANCY TEST

-not a confirmatory of pregnancy because it can also confirm H-mole
- it only determines HCG in the urine of the mother
To confirm: UTZ

 BRAXTON HICK’S CONTRACTION

-increased estrogen (mild contraction)
False labor:
-painless
-lower abdomen
-relieved pain by walking (fetal descent, to differentiate true and
false labor)
-irregular contraction

Oxytocin (strong contraction)

True labor
-painful
-lower back
- Walking: increases/ intensify the pain
- regular contraction

 BALLOTEMENT- bouncing movement

- fetus is floating

POSITIVE SIGN (CONFIRMATORY SIGN)

 (+) UTZ result- (in general:full bladder)
>transabdominal UTZ- full bladder- for clear visualization (common)
>transvaginal UTZ- empty bladder- to prevent rupture of the bladder

 (+) FHT-
Perform Leopold’s maneuver first- to determine the landmark of the FHT
-fetal back (landmark of the FHT)
rd
>Doppler UTZ- 3 month
>Fetoscope- 4th month
 >Stethoscope (bell)- to assess cardiac tone (5th-9th month)

Normal FHT- 12-160 bpm

> 160- tachycardia- sign of fetal distress (early sign)
< 120- bradycardia- fetal distress (late sign)- most priority

 (+) FETAL MOVEMENT

--confirmed by nurses, doctor via palpation
-monitor the movement every hour
- NORMAL MOVEMENT EVER HOUR- 10-12 FM/HR
>12 FM/hr- hyperactive, fetal distress (early sign)
Decrease O2--> restlessness
<10 FM/hr- hypoactive, fetal distress (late sign)- most
priority

TRANSIENT ORGANS

1. AMNIOTIC FLUID
Amniotic sac (bag of water)
Other name: fetal urine
Functions:
1. Protection of the baby and the mother
2. Thermoregulation- provide heat to prevent hypothermia
3. Musculo-skeletal development-provide space to promote fetal movement
4. Nutrition- source of nutrients (meconium)
Color: clear straw-colored/ pale yellow
**Amniocentesis- to determine lung maturation
“Wait for the spontaneous rupture of BOW to determine the color of
amniotic fluid.”

To determine if it is urine or AF: pH (urine: acidic, AF: alkaline)

*Nitrazine paper test- to determine the pH of a fluid, put on the wet
area of vulva of laboring mother then observe the color
Blue-alkaline AF(+) RBOW
Yellow- acid urine (-) RBOW

WOF abnormal color

1. Black- fetal death; IUFC (intaruterine fetal death)- 1 month nang patay
- necrotic cell of the skin mixed with the amniotic fluid kaya
nagiging black
2. Green- meconium -stained
Aspiration- we need to suction
>Cephalic (6)- normal and good presentation; meconium going
downward causing aspiration
>Breech (9)- no aspiration, normal meconium staining
3. Dark yellow- increased bilirubin because of the destruction of RBC
- Rh incompatibility (hemolytic disorder)
4. Red (bleeding)
Bleeding disorder in pregnancy
 1. Abortion- 1st tri
2. Ectopic pregnancy- 1st tri
3. H-mole- 2nd tri
4. Abruptio placenta- dark red
5. Placenta previa- bright red

Volume: UTZ- to determine the volume

800-1,200 mL
If > 1,200 mL- polyhydramnios
- gestational DM
- GI problem (cleft lip and palate)

If <800 mL- oligohydramnios (fetus: renal problem)

2. UMBILICAL CORD- passageway of O2 and nutrients

Other name:Funis
Blood vessels: 3 blood vessels (AVA)
To know if artery or vein, observe the diameter:
>small diameter- artery
>large diameter- vein (carrier of oxygenated blood)
**Deficient umbilical artery- congenital heart defect (CHD)

Length: UTZ to determine the length of the cord during pregnancy

Normal length: 50-60 cm
If >60 cm- cord coil/ loop
** Nuchal (neck) cord
If <50 cm- absurd cord; on 3rd tri (abruptio placenta)

Special element:WHARTON’S JELLY- to prevent destruction of umbilical

cord
Cord infection: “omphalitis”
dry: 7-10 days
>10 days- wet: sign of cord infection

Fetal Circulation
Oxygen from the maternal blood---> placenta--> umbilical cord (vein-ductus
venosus-IVC)--->liver (immature)

100% oxygen= ratio of 70:30

Right atrium- 30% retained oxygen--> 70% blood circulate toward the
left atrium--->left ventricle--->ascending aorta--->promoting head
development---> unoxy from the head----->superior vena cava--->right atrium
(70%CO2 + 30% O2)---->right ventricle---->ductus arteriosus (bypass
artery)--->descending aorta(30% O2-acrocyanosis)

ascending aorta (connecting towards the head)

Descending aorta (connected to the extremities)
 **foramen ovale (not close)- atrial septal defect
**ductus arteriosus (not close)- patent ductus arteriosus (PDA)

3. PLACENTA- latin word (flat organ)

Function:
1. Protection (utero-placental barrier)
-protect the baby against teratogenic effects
2. Oxygenation (placenta serves as the lungs of the fetus)
3. Hormone production/ endocrine function
A. HCG: causes morning sickness, Pregnancy Induced HPN
B. HPL (Human placental lactogen): causes GDM
C. MSH (Melanocyte Stimulating Hormone):
increase melanin= darkening of face, armpit
*chloasma- mask of pregnancy
*linea nigra- black line of abdomen
*striae gravidarum- dark stretch mark
D. Relaxin: relaxes the pelvic bone: Lordosis-maintain the balance of the
mother
E. Estrogen & progesterone
4. Nutrition- ex. Sugar
(+)GDM---->hyperglycemia--->placenta--->fetus
(consumed by the fetus leading to macrosomia)

Shape: Pancake organ/ pie-shaped organ/ disc-like organ

Special treatment: Cotyledons- building blocks of placenta

-15-20 cotyledons
If <15: retained placental fragments
Mngt: Dilation and Curretage(D&C)- “raspa”
If >20: normal
If >45: abnormal= H-mole (grapelike vesicles)

December 05, 2021

ACETIC ACID TEST
 OB BAG (Vinegar)
 To determine proteinuria (abnormal)
 Pregnancy induced HPN (PIH)

PREGNANCY INDUCED HPN

Cause/ Pathophysiology:

 Increased BP caused by pregnancy

placenta (ability to produce hormone)---> HCG- hormone: blood:

vasoconstriction---> increased BP

1st tri: H-mole (placenta enlargement)

2nd tri: PIH (usual onset: 5th month/ 20 weeks)

Triad manifestation of PIH:

1. Hypertension: 2nd tri- 5th month

**non-pregnant- 90/60
**pregnant- 120/80- increased systolic atleast 30 mmHg, diastolic
atleast 15 mmHg

If increased systolic only- Increased ICP

2. Proteinuria (albumin: decreases----> decrease oncotic pressure--->shifting

of fluid

3. Edema
1. Lower leg- normal (because of the enlargement of uterus--> compression of
the blood vessels of leg)
Elevate (3 pillows)

2. Upper/facial- abnormal (whole body- generalized edema (ANASARCA)

CLASSIFICATION/LEVELS
BP PROTEINURIA EDEMA
Mild pre- 120/80-140/90 +1 - +2 Arm: (-) facial
eclampsia
Severe pre- 140/90-160/100 +3 - +4 Facial, anasarca
eclampsia
Eclampsia Any BP
(convulsion/ (mild/severe) with
seizure) seizure /
convulsion

Treatment/ management:
Pre-eclampsia: HPN (vasoconstriction)
*anti-HPN- vasodilator
*DOC: hydralazine

Eclampsia- Seizure
*anti-convulsion
*DOC: MgSO4- safe for the baby (non teratogenic effect)
**if paulit ulit binibigay kay mother- WOC: s/sx of MgSO4 toxicity

MgSO4 toxicity
1. Disappearance/ Depression of deep tendon reflex- earliest sign
2. Fatal: respiratory depression, cardiac depression
3. Monitor
a) RR
b) HR
c) Urine output (oliguria)
4. Magnesium level increases: calcium decreases- (Ca Gluconate)

Acetic acid Test Procedure

Mixture:
1/3 acetic acid solution: clear
2/3 urine + heat (1-2 mins)
After heating: observe if it is:
*clear- no reaction- (-) for proteinuria
*cloudy- (+) reaction- (+) for proteinuria

BENEDICTS TEST
*OB bag (blue solution)
**it determine glycosuria (abnormal)
**gestational DM

Gestational DM- 6th month / 24 weeks

Cause:
Placenta---> HPL---> X insulin

*mother- hyperglycemia (normal blood sugar: 70-110 mg/dl)

*polyuria
*polydipsia
*polyphagia
*baby-
*macrosomia (CS delivery)
CS
1. Classic- vertical- always CS delivery (because the muscle of the uterus is
horizontal)
*muscles are damage
*x uterine contraction
2. Bikini- horizontal- next delivery via NSD
*hypoglycemia- check blood sugar
 Normal BG of baby: 40-60 mg/dl

Treatment for GDM:

*Insulin injection- not OHA because it has teratogenic effect

Process:
5mL benedict solution + heat (1-2 mins) + 8-10 gtts of urine using
medication dropper

Interpretation: WOF
Blue- no reaction
Green- +1 level of glycosuria
Yellow- +2
Orange- +3
Red- +4

ALPHA FETO PROTEIN

*Blood exam: maternal blood
*Disorder: baby
1. Down syndrome
2. Neural tube defect
*Spina biffida occulta- Dimpling; tuft hair
*Spina biffida cystica- sac formation
**promote proper positioning (prone: head turn to
side)
**cover the sac with moist dressing (to prevent
drying of the spinal cord)- PNSS
*Normal value: 38-42 mg/dL
<38 mg/dL- Down Syndrome
<42 mg/dl- neural tube defect (decreased folic acid)

In the US: decreased AFP----> pinapapili ang parents if they continue to

conceive or to abort

COOMB’S TEST
 Blood exam
2 types:
  Direct- newborn
 Indirect- mother
 Ct: (+)- if antibodies are present, rhogam is useless
 CT: (-) if antibodies are not present, administer rhogam
 Results:
 (+)- there is Rh antibody
 (-)- there is no Rh antibody

RH INCOMPATIBILITY

During pregnancy- maternal and fetal blood

Rh (rhesus)- involve in the reaction of incompatibility of the blood
(+)- common Rh type
(-)- rare for Asians, but common for Caucasians

Other name: Eryhtro Blastosis fetalis

Problem: RBC destruction (Hemolysis) of the fetus
Onset : Starts at 2nd child up to succeeding pregnancy (not the 1 st
child)
Occurence: **mother Rh-, fetus Rh+

M (Rh -), f (Rh+)= incompatible

1-9 months- no reaction
After 9 months- mother undergoes labor/delivery
Open wound on the uterus due to placental separation, in
which after delivery of the placenta, the wound serves as an opening-----
>entry of fetal blood to meet the maternal blood
(+)- stronger, (-) weaker
Maternal blood will then stimulates its immune system to produce Rh
antibodies. These antibodies will then enter on the placenta on the 2 nd child.

Manifestations:
RBC destruction---> increased bilirubin---> CNS (brain damage)
 Anemia
 Hyperbilirubinemia
 Jaundice (pathologic)
 Physiologic jaundice- normal
>24 hrs (2-5 days)
 Pathologic jaundice- abnormal
<24 hrs (within the day)
 Kernicterus- brain damage
 Mental retardation (intellectual disability)

Treatment:
 Rhogam- preventive treatment
*prevention of formation of Rh antibodies
*mother
First dose- 7th month of pregnancy
 2nd dose- within 48-72 hrs after delivery (2 nd-3rd day
postpartum)
First pregnancy if detected: Rh-:: pag hindi nag administer ng
rhogam, its useless because it will start to produce Rh antibodies.

 Exchange transfusion- curative (baby)

-done at the umbilical cord

OBSTETRIC FORMULA

1. NAEGEL’S RULE
 To determine EDC/EDD
 Ask for LMP (1st day of LMP)
 1st 3 months (Jan, Feb, March)- +9, +7
 April-December: -3, +7,+1

2. HAASE’S RULE
 To estimate fetal length
1- x1= 1 cm
2- X2=4 cm
3-x3= 9 cm
4-x4= 16 cm
5-x5= 25 cm
6-x5= 30 cm
7-x5= 35 cm
8-x5= 40 cm
9-x5= 45 cm

3. JOHNSON’S RULE
 To determine fetal weight
 Mother- fundic height: symphysis pubis up to fundus: use cm.
 Fetus- check if floating/ engaged

Engaged: fundic height (cm) -12 x 155

Floating: fundic height (cm) -11 x 155

Example:
FH: 20 cm, LM: engaged
20-12= 8 x 155= 1,240 grams

4. MCDONALD’S RULE
 To determine the AOG of the mother (in months)
 Collect: Fundic height (cm)

FH (cm) x 2 / 7= AOG in months

Example: 20 cm x 2= 40/7= 5.7 or 5 months and 7 days

**whole number- months
**decimal number- days
5. BARTHOLOMEW’S RULE
 To determine AOG
 Palpate the fundus (superior part)

Landmarks:
A. Symphisis pubis- 3rd month
B. Umbilicus- 5th month
C. Xiphoid process- 8th month
**1-2 cm below the xiphoid process- 9th month

6. MATERNAL WEIGHT GAIN

 Total: 25-35 lbs
> 35 lbs: manifestation of edema, PIH

1st trimester 1 lb/ month (3 lbs)

2nd trimester 1 lb/ week (12 lbs)
3rd trimester Labor: downward- decrease
amniotic fluid---> weight
decreases

0.8-0.9 lbs/ week (8-11 lbs)

December 12, 2021

 Everyday in 2017, approximately 810 woman died from preventable

causes related to pregnancy and childbirth.
  Between 2000 and 2017, the maternal mortality ratio (MMR, number
of maternal deaths per 100,000 liver births) dropped by about 38%
worldwide.
 94% of all maternal deaths occur in low and middle-income countries.
 Young adolescents (ages 10-14) face a higher risk of complications
and death as result of pregnancy than other women.
 Skilled care before, during and after children can save lives of women
and newborns.

Introduction
 Maternal and neonatal mortality is a worldwide problem. Too many
mothers and newborns are dying especially in the underdeveloped
and developing countries.
 In 2000- the Philippine MMR was 209, followed by 162 in 2006. In
2011, the rate was 221. In 2017, the MMR was 121. All these ratios
are per 100,000 live births.
 In 2000, 189 heads of states endorsed the MDGs to be achieved by
2015. there were 8 MDGs and MDG4 and 5 relate to the reduction of
child mortality and improvement of maternal health and access to
reproductive health service.
 MDG5 ended in 2015 with the Philippines missing its targets
 SGDs was launched immediately after to end by 2030 with MMR
target 0f 70/ 100,000 LB.

DOH administrative order

 2008-0029- maternal, newborn, child health and nutrition strategy was
ordered for rapid reduction of maternal and neonatal mortality.
 2009-0025- Essential Newborn Care
 RA 10354- Responsible Parenthood and Reproductive Health Law
 2012-0012- Health Facilities regarding Classification

MNCHN Strategy (Immediate goals)

-every pregnancy is wanted, planned and supported
-every pregnancy is adequately managed
-every delivery is facility based and managed by SBA
-all mothers and newborn, received postpartum and postnatal care

MNCHN SERVICE DELIVERY NETWORK

 COMMUNITY PROVIDER/ SERVICE PROVIDER
 Pregnancy tracking, home visits and follow up
 BF support, IEC, FP nutrition
 BEMONC FACILITY
 NSD imminent breech delivery, emergency drugs, ENC, FP services,
Basic NB resuscitation
 CEMONC (end referral)-
 End referral facility (Provincial Hospital, etc.)
 BEMONC Service and blood Transfusion
 Caesarean section, OB/Surgeon, pedia, Nurse, midwife, med tech
EMERGENCY OBSTETRICAL AND NEWBORN CARE (EMONC)
 Set of life saving interventions that are done at the primary health care
level to address maternal and newborn causes of morbidity and
mortality.
 Levels of care:
 BEMONC (basic)
 CEMONC (comprehensive)

BEMONC SERVICES
1. Administration of parenteral antibiotics to prevent infections
2. Administration of parenteral anticonvulsant to treat eclampsia.
3. Administration of parenteral uterotonic drug for postpartum hemorrhage.
4. Manual removal of placenta
5. Assisted vaginal delivery for imminent breech
6. Manual removal of placenta removal of retained secundines
7. Neonatal resuscitation
8. EINC

ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC)

 Evidence based standard that are recommended for adoption in
Philippine hospitals with maternal and newborn care services of
birthing facilities both the government and private sections by the
DOH, PhilHealth, and the WHO


ESSENTIAL INTRAPARTAL CARE

 For mothers in normal labor and delivery
1. Mobility during labor- facilitates faster labor by virtue of gravity
2. Companion in labor- less anxious, more relax hence faster labor
3. Nonpharmacologic pain relief
 A. breathing exercises,
B. F-flaurage- massage the head, uterus, sacral area- common source
of pain
C. Water therapy (hot and cold)
D. music therapy,
E. hypnosis
4. Partograph to monitor labor- gold standard to monitor labor
5. Food in labor- on the 1st satge of labor, the woman needs food to have
energy when pushing.
- something needs to be easily digested like hot soup
6. Spontaneous pushing in semi-upright position- to allow the woman to
do the pushing
7. Active management of the 3 rd stage of labor (AMTSL)- as soon as the
baby is out, inject the oxytocin and expel the placenta thru cord traction
8. Antenatal steroids in preterm labor-give at least one dexamethasone to
promote lung expansion

Unnecessary practices
 Enema
 Shaving-caused by abrasion, more prone to infection
 Restriction of food and fluid- NPO only in woman that is high risk
 Routine IVF- not needed in normal labor and will hampere the movement
of mother
 Routine episiotomy- only indicated when necessary
 Fundal pressure- the fetus will become aspixiated and can cause abruptio
placenta.

Safe maternal and newborn care

GOAL 1: reduce practices that are unnecessary and harmful to women
and newborns during childbirth
GOAL 2: strengthen capacity and support of health workers for safe
maternal and newborn care
GOAL 3: promote respectful care for safe childbirth
1. Importance of companion
2. Answering the mother truthfully
3. Informing the mother everything you do to her
4. See to it that they are comfortable
5. Safe waiting are for companions
GOAL 4: improve safe use of medication and blood transfusion during
childbirth- preventing errors
GOAL 5: report and analyze safety incidents in childbirth.

Essential newborn care

Unang yakap
- Is a series of time bound, chronologically-ordered, standard procedures that
a baby receives at birth; designed to improve the health of newborn through
evidence based practices to ensure the survival of the newborn from birth to
the first 28 days of life
Decemebr 7, 2009- an administrative order was signed by Sec. Francisco
Duque III, “ Adopting New Policies and Protocol on Essential Newborn Care”
(AO 2009-0025)

Aims: to cut down infant mortality rate in the Philippines by at least half.

APPROACH IN THE IMPLEMENTATION CAMPAIGN OF ENC

 Hospital reform agenda
 Forming a network of centers of excellence
 Curriculum changes
 Social marketing campaign (stakeholders)
4 CORE STEPS OF ESSENTIAL NEWBORN CARE
1. Immediate and thorough drying of the baby
2. Skin to skin contact
3. Properly timed cord clamping and cutting
4. Non-separation of newborn and mother for early initiation of breastfeeding

CS- 1,3,2,4