Conception

“Pregnancy” occurs from sexual intercourse (APOR: arousal/excitement, plateau; actual sexual intercourse, orgasm, resolution), fertilization, and implantation. Fetal development beings thereafter.

Fertilization: an egg cell is released from the ovary, caught by the fimbrae, and stored by the ampulla for 1 to 2 days while waiting to be fertilized.
- The ovum is covered in two layers: the outer Corona radiata and the zona pellucida under it.
- The sperm cell reaches the ampulla, and its head/tip, the acrosome releases hyalase, breaking down the corona radiata.
- Once it reaches the zona pellucida, the sperm releases acrosin to soften the zona pellucida until a sperm cell reaches the “egg”. Once this occurs, the zona pellucida hardens, stopping any other sperm cells from entering.
  - Each sex cell contains 23 chromosomes composed of 22 autosomes and 1 sex chromosome. The sperm determines the gender of the baby (XY: boy, XX: girl) because the sperm cell may contain X (gynosperm, big head + small tail; because of alkaline content to counter vaginal acidity) or Y (androsperm, small head + long tail) sex chromosome. The egg always contains the X sex chromosome.
Migration: the egg stays 3 to 4 days in the (ciliated) fallopian tube, and takes 3 to 4 days to move into the uterus (implantation takes 6 to 8, average 7, days after fertilization.
- During this period, estrogen starts to increase, and progesterone even more so.
  - Estrogen: encourages contraction, enlarges uterus, epistaxis, palmar erythema
    - The inside of the fallopian tube contracts, moving the fertilized egg into the uterus.
  - Progesterone: prevents contractions, provides nutrition, hormone of pregnancy, poor GI motility, pyrosis (heart burn)
Implantation: normally in the upper uterine endometrium (if myometrium, placenta acreta). The site of implantation is the site placental development.
- The combined sperm and egg cell is called the zygote, which becomes a partially divided cell: a cleavage. Multiplication into four overlapping cells becomes a blastomere. Multiplication into 16 overlapping cells becomes a morulla. Multiplication and movement into the edges of the cell results in a blastocyst (which becomes the embryo), which grows finger-like projections, in which it becomes a trophoblast (this becomes the placenta). This then becomes an embryo, fetus, then fetus.
  - The trophoblast’s finger-like projections allow it to embed into the endometrium. It contains a special structure: the chorionic villi. This is what produces human chorionic gonadotropin (HCG). This is what is detected in urinary pregnancy test.
- Once implantation occurs, the endometrium becomes called the “decidua”, which is further typed into: - Decidua Basalis: the inner layer, where the site of implantation is. This is where the development of the placenta occurs, along with the chorionic villi. - Decidua Capsularis: the portion of the endometrium that covers the implanted egg cell. - Decidua Vera: the remaining part of the endometrium.
- The placenta also produces hormones: progesterone, estrogen, human chorionic gonadotropin (HCG) normally at 50,000 to 400,000 units, human placental lactogen (HPL)
  - HCG is the main cause of morning sickness for pregnant women. Second is estrogen. HCG is high in the morning because HCG is excreted through urine.
Fetal Development: sequential stages;
- 1st month:
  - Dizziness due to nervous system development of the fetus. For this, glucose is the foremost requirement. This results in the slight hypoglycemia of the mother that results in dizziness.
  - Fetal Heart Beat begins 16 days after conception.
- 2nd month:
  - Sex Differentiation (6th week)
  - Fetal Heart Tone auscultation with a doppler, unheard with a stethoscope.
  - Placental Development (not fully functional)
- 3rd month:
  - Placenta is fully functional
  - Renal system becomes functional. This is when the fetus begins to urinate in-utero.
- 4th month:
  - Sex Differentiation is complete, but the external genitals remain small, which may lead to false determination.
  - Fetal Heart Tone auscultation with a fetoscope.
  - Lanugo: fine downy hair on the shoulder, nape, arms, etc.
  - Quickening: first fetal movement felt by multiparous women.
- 5th month:
  - The best period for sex determination through ultrasound.
  - Vernix caseosa appears: the cheese-like substance for lubrication during delivery.
  - Fetal Heart Tone auscultation with a stethoscope.
  - Quickening: first fetal movement felt by primiparous women.
- 6th month:
  - Surfactant Production for alveolar lubrication.
  - Hearing ability develops: the best time to start singing or talking to the fetus.
- 7th month:
  - Bone Ossification: fetal bone development. Calcium demand increases. This results in leg cramps for the mother. Premature occurrence of leg cramps indicate inadequate calcium intake. (Vitamin D increases Calcium absorption; Vitamin C increases Iron absorption)
- 8th month:
  - Iron is transferred to the fetus.
  - Ultrasound at this period shows high presence of calcium in the base of the placenta. Calcium may be visualized (placental grading) due to the clumping of calcium with each other.
  - Lanugo disappears.
- 9th month:
  - Vernix caseosa disappears.
- Summary by system:
  - Discomforts: Dizziness (1), Leg Cramps (7), Anemia (8)
  - Fetal Signs: FHT via doppler (2), fetoscope (4) , stethoscope (5); quickening 4 (multigravida) or 5 (primigravida)
  - Organs: Brain (1, r/t hypoglycemia and dizziness) Placenta, 2-3; Renal, 3; Surfactant, 6; Hearing, 6
  - Lanugo and Vernix caseosa: 4-8, 5-9
  - Sex Determination: 2, 4, 5

Different Discomforts of Pregnancy

Morning Sickness (GI)
- Causes: high levels of HCG, Estrogen
- Signs and Symptoms: Nausea and Vomiting in the morning
- Management:
  - Consumption of crackers 30 minutes before arising from the bed. The crackers absorb hydrochloric acid, which decreases symptoms.
  - Small feedings to reduce hydrochloric acid production.
  - Avoid fatty, spicy, acidic foods and drinks.
  - Avoid sudden positional change
Pyrosis (GI)
- Causes: high levels of progesterone; decreases GI motility/slower stomach emptying; increased hydrochloric acid production due to slower gastric emptying + compression of the stomach from the uterus results in reflux.
- Signs and Symptoms: chest-like pain.
- Management:
  - Small feedings, avoid fatty, spicy, acidic foods and drinks.
  - Bend by her knees when necessary (avoid compression of the abdomen/stomach)
  - Antacids as ordered by the physician.
  - Stay upright after meals by at least 20 to 30 minutes.
Constipation (GI)
- Causes: high levels of progesterone decreases GI motility.
- Signs and Symptoms: straining during defecation, dry hard stool
- Management: increase fluids (soften), fiber (bulk), and activity/exercise (improves GI motility). Establish a regular schedule for bowel movement. Avoid the use of laxatives.
Urinary Frequency: occurring during the first and third trimester, vanishing during the second trimester during its unique retroverted uterus, due to the round ligament.
- Causes: pressure of uterus on the bladder.
- Signs and Symptoms: frequent urination.
- Management: urinate before going to bed to counteract nocturia. Fluids are not restricted except before bed.
Leg Cramps: third trimester predisposition to cramps due to hypocalcemia.
- Causes: hypocalcemia from increased demand due to fetal bone ossification, occurring on the seventh month of pregnancy (early third trimester).
- Signs and Symptoms: muscle cramps/leg spasms (often the calf)
- Management:
  - Calcium (and vitamin D) consumption. Fluid oral intake should also be increased to reduce risk for kidney stones. In the Philippines, malunggay is rich in calcium, iron, and folic acid.
  - Dorsiflexion of the foot, extend the knee.
  - Warm therapy for muscle relaxation.
  - The use of liniments (topical pain killer; Omega, Bengay)
Varicosities
- Causes: caused by the pressure of the uterus on the femoral vein/vena cava, resulting in a pooling of blood in the legs and distended veins. This is a component of supine hypotensive syndrome.
- Management:
  - Position the mother lying left lying recumbent (LLR).
  - Elevate lower extremities
  - Hip-high stockings
  - Avoid standing for long periods
Edema
- Causes: high level of progesterone that increases aldosterone production, causing sodium and water retention. Edema follows.
- Signs and Symptoms: Swelling, pallor, and coldness around the site of edema. Often pedal.
- Management:
  - Avoid standing for long periods
  - Elevate lower extremities
  - Hip-high stockings
Low Back Pain:
- Causes: the lordotic change in posture of the mother.
- Signs and Symptoms: lumbosacral pain
- Management:
  - Avoid standing for long periods
  - Utilize flat shoes. Shoes with heels are only permitted during the first trimester.
  - Pain relief may be achieved with a massage, liniment, and/or warm compresses.
Shortness of Breathing (SOB)
- Causes: from increased intradiaphragmatic pressure caused by the growing gravid uterus, often exacerbated in long travel and commutes.
- Management: semi-fowler’s position or left-lateral position.
Physiologic Anemia; Hemodilution
- Causes: 30% to 50% increase in blood volume (normally ~5L) of the pregnant woman, particularly of plasma volume.
- Signs and Symptoms: pallor (check the skin, nail beds, lips lower conjunctival area)
- Management:
  - Increase dietary iron, folic acid (may be supplemented), and supplement with vitamin C for iron absorption.
    - Iron: meat, liver, green leafy vegetables (malunggay, spinach)
    - Iron is best absorbed in an acidic environment (hence vitamin C supplementation)
  - Differentiate pathologic with physiologic anemia with a CBC.
    - Non-pregnant: Hgb: 12-16 g/dL; Hct: 37 - 47%
    - Pregnant: Hgb: 11 g/dL; Hct: 33 - 34%
    - Pathologic: Hgb <11 g/dL
      - Mild Pathologic Anemia: 9 to 11 g/dL
      - Moderate Pathologic Anemia: 7 to 9 g/dL
      - Severe Pathologic Anemia: <7 g/dL
        
        Medical Management: blood transfusion with packed RBC.

Assessment of the Pregnant Women

Skin:
- Pallor
- Chloasma: mask of pregnancy, darkening of the cheeks and neck due to increased melanin production during pregnancy.
- Striae Gravidarum: “stretch marks”. Collagen affects formation of striae. In early pregnancy, the stretch marks are silvery, but become brown later on.
  - Management: collagen consumption (carrots, fish, tendons/ligaments)
Head:
- Headaches: may often be caused by hypertension; PIH. Otherwise, they may consult an ophthalmologist.
- Seborrhea
- Facial Pallor
- Eyes: pallor; check for vision changes.
- Nose: enlargement (due to hormones), epistaxis (Mgmt: lean head forward)
Neck: slight enlargement of the thyroid gland (normal)
Chest:
- Palpitations
- Shortness of Breathing due to compression of the diaphragm (lay side-lying when in bed)
Abdomen: pyrosis, morning sickness, constipation
Urinary: urinary frequency
Lower Extremities: edema, varicosities
Posture: lordosis AKA the “pride of pregnancy”.
- In later pregnancy, the mother begins to lean back due to the shift in center of gravity.
- Predisposes the mother to lower back pain. Provide rest periods and the use of liniment at the lumbosacral area.

Ultrasound	Amniocentesis
Visualization	Aspiration
Non-invasive	Invasive
Does not require informed consent	Requires informed consent
- Locates the placenta - Determine number, size, lie, attitude, position, presentation of baby/ies - Determines amount of amniotic fluid - Determines gross fetal abnormalities	- Determine fetal lung maturity - Determine chromosomal defect - Determine neural tube defect
- Increase fluid intake for pregnant mothers less than 20 weeks by 1,000 to 1,500 mL given as one cup of water every 15 minutes, 90 minutes before the ultrasound (total of 1,440 mL). - Positioned dorsal recumbent or semi-fowler’s with one pillow or rolled towel under one buttock to prevent SHS/VCS	- The site of puncture is on the lower abdomen. - Due to the proximity to the bladder, instruct the client to void prior to the procedure. - Establish baseline maternal and fetal vital signs. - Sterility is required. Skin prep. by a physician and sedation is used. - During insertion, ultrasound is used to aid in locating the fetus and placenta. - Aspiration of 15 to 30 mL.
	Monitor uterine contraction (should not occur) and fetal heart rate (should be normal).

Nutritional Requirements of Pregnancy

Caloric: 2,000 cal/d; 2,300 - 2,500 cal/d
- If socioeconomic status is significant, attempt for achievable goals i.e. minimum requirements.
Iron: 30 mg/d, 60 mg/d
Folic Acid: <400 mcg/d, 450 mcg/d
Calcium: 800 - 900 mg/d, 1200 mg/d
Phosphorus: 700mg/d
Protein: +60 grams/d
Vitamin A: 10,000 IU; use starts on the 4th month due to its teratogenic effects.
Elemental Iodine: 1 capsule (250 mg) per pregnancy. It is used for brain development, and can be taken on the second month of pregnancy.
Increase fluid and fiber
Decrease fat, sodium, and carbohydrates. (CHO especially for patients prone to GDM.)

Prenatal Checkup

This must be a facility-based checkup, at minimum, at a health center level as certified and trained health workers. The ultimate goal of prenatal checkups is to decrease total maternal and neonatal morbidity and mortality rates.

There should be minimum 4 visits in a pregnancy: <4, 6, 8, and 9th month of pregnancy (1st, 2nd, 3rd trimester, final month).

History Taking
- Biographic Profile of the Client:
  - Age: <18 and >35 are at risk, especially hypertension. Hypertension may result in vasoconstriction and subsequent smaller-than-gestational age (<2.5 kg) of the neonate.
  - Height: <5’ are at risk due to a small pelvis.
    - Best time for pelvic x-ray: 2 weeks before EDC
  - Pre-pregnant weight: <90 or >150 lbs
    - <90 lbs: may result in anemia, resulting in SGA.
    - >150 lbs: may result in diabetes, resulting in LGA.
    - Normal weight gain for pregnancy:
      - 24 lbs to 30 lbs, average of 27 lbs. Maximum is 35 lbs. This includes the uterus enlargement, amniotic fluid, fetus, edema, etc.
      - 1st Trimester: 1 lb per month; 3 lbs
      - 2nd Trimester: 1 lb per week (0.8 - 1.2); 12 lbs
      - 3rd Trimester: 1 lb per week (0.8 - 1.2); 12 lbs
    - Monitor for pattern of weight gain. Sudden weight gain is often caused by edema, following proteinuria, edema, and hypertension.
- Socioeconomic Status
- Educational Status
OB History
- Menarche: the onset of menstruation
- Menstrual Cycle: regular or irregular
- Menstrual Period: days 1 to 5
  - Days of ovulation: 15 (-5 + 3 for fertile days)
  - Fertile days: 10 to 18; safe from 1 to 9 and 19 to 29
- Problems, Number of Pads Consumed
- LMP: last menstrual period
  - 03/28/2023
  - EDC: LMP (3/7/1) → 01/4/2024
  - AOG:
- Estimates of Pregnancy
  - McDonald’s Rule:
    - $AOG (wk) = FH (cm) * 8/7$
    - $AOG (mo) = FH (cm) * 2/7$
    - Measure the fundic height by starting from the upper border of the symphysis pubis to the fundus.
  - Bartholomew’s Rule:
    - Locate the fundus.
    - At the symphysis pubis: 0 months
    - Above the symphysis pubis: 3 months
    - Between the umbilicus and symphysis pubis: 4 months
    - At the umbilicus: 5 months
    - Above the umbilicus: 6 months
    - Between the umbilicus and xiphoid process: 7 months
    - Just below the xiphoid process: 8 months or late 9th month.
      - Recession of the fundus back to this level is caused by lightening, the setting of the fetus into the pelvic inlet. In primipara, they experience it 1 to 2 weeks before labor and delivery, but multipara experience it 1 to 2 days before labor and delivery.
    - At the xiphoid process: early 9th month
    - Pelvic diameters:
      - Pelvic Inlet: 11 13 12
      - Pelvic Cavity: 12 12 12
      - Pelvic Outlet: 13 11 12
    - Engagement: along the ischial spines, the station is 0. Above is negative, and below is positive. Station goes from -5 to +5, 11 centimeters of range. Engagement beings at station 0.
  - Haase’s Rule:
    - Estimated fetal length (cm)
    - $First five months^{2}$
    - $Next four months * 5$
  - Johnson’s Rule:
    - Estimated fetal weight (grams); check for ballottement
    - Not Engaged: $Wt (g) = (FH (cm) - 11) 155$
    - Engaged: $Wt (g) = (FH (cm) - 12) 155$
  - Factors affecting Fundic Height
    - Number of fetuses: multiple fetuses
    - Size of the baby: SGA, LGA
    - Amount of amniotic fluid: poly/oligohydramnios
    - Size of mother
- OB Score: GPTPALM; Gravida (pregnancy), Parity (viable deliveries regardless of number and outcome), Term (37 weeks), Preterm (<37 weeks), Abortion (<20 weeks), Living (only value counting total babies), Multiple (tuples). When answering, if the question is GPTPALM, write G#P######. If the question is GTPALM, write G#P_##### (take note of the space).
  - Nulli-: 0
  - Primi-: 1
  - Multi-: 2 to 4
  - Grand Multi-: 5 or more
  - If both numbers are the same i.e. in G3P3, multiparity also denotes multigravidity, so it is a better OB description.

Normal Postpartum

Puerperium: the first 6 weeks after delivery.
- The most important process: involution, the return of the uterus to its pre-pregnant state.

Involution

Immediately after the expulsion of the products of conception

At the level of the umbilicus, at the midline.
- If not at the midline, the uterus is displaced, often due to a full bladder. When it is displaced, the uterus relaxes. This results in bleeding and a delay in involution.
Every following postpartum day, the level of the fundus should decrease by one fingerbreadth.
On the 10th postpartum day, the fundus is expected to no longer be palpable.

Promoting Involution

Massage the fundus: press inward and massage at the level of the umbilicus. One may expect to feel the uterus contract.
Early ambulation: as soon as possible, when tolerable.
- For CS deliveries, after 24 hours.
Early breastfeeding (stimualtes oxytocin release)
Bladder emptying
Monitoring Lochia
- if lochia is not drained, blood clots may form. Large blood clots may result in infections and pain.

Lochia

Name	Date	Characteristic
Rubra	1-3	Dark red
Serosa	4-7	Pink to Brown
Alba	8 to 14	Whitish to Clear

Any foul-smelling discharges may indicate infection.
Any bright-red discharges are signs of laceration.

Signs of Pregnancy

Presumptive

Symptoms noticed by the mother, a subjective list of perceptions.

Amenorrhea
Urinary frequency
Breast changes
Chadwick’s sign
Quickening felt by the mother

Probable

Signs noticed by the health examiner, objective findings.

Ballottement
Abdominal enlargement
Chadwick’s, Goodell’s, and Hegar’s Sign
Positive urinary pregnancy test

Positive

Signs emanating from the live fetus.

Quickening felt by the examiner

Sample Question

Q: The woman, who is 7 months pregnant, lies on the bed supine. Suddenly, her systolic pressure went down by 30 mm Hg. What is this characteristic of? A: Supine Hypotensive Syndrome

Q: Which mineral is prominent in the base of the placenta? C: Iron, Magnesium, Calcium, NOTA A: Calcium

Q: Which vegetable in the Philippines is rich in iron, calcium, fiber, and folic acid? A: In the Philippines, malunggay is rich in calcium, iron, and folic acid.

Q: When is the most reliable time to perform a urine-based pregnancy test? A: Two weeks after the first missed menstrual period (secondary amenorrhea).

Q: Which specific test is required to determine fetal lung maturity? A: LS Ratio, normally 2:1.

NNN

Explorer

02-18-2024 Normal OB

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