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Maternal Physiology      Prenatal Care   Normal Delivery                      Gumalo, Clay Paolo
OUTLINEMaternal Physiology   I. Reproductive Tract   II. Skin   III. Metabolic changes   IV. Hematological changes   V. Ch...
OUTLINEPrenatal Care   II. Organization of prenatal care   III. Nutrition   IV. Common concerns
OUTLINE Normal Labor and delivery    I. Mechanisms of Labor    II. Characteristics of normal labor    III. Management ...
maternal physiology
MATERNAL PHYSIOLOGYI.     REPRODUCTIVE TRACTII.    SKINIII.   BREASTSIV.    METABOLIC CHANGESV.     HEMATOLOGICAL CHANGESV...
MATERNAL PHYSIOLOGYI.   REPRODUCTIVE     TRACT                     • nonpregnant woman: 50-70 g; 6-8        Uterus       ...
MATERNAL PHYSIOLOGYI.   REPRODUCTIVE     TRACT                               • 1 month after conception- undergo        U...
MATERNAL PHYSIOLOGYI.   REPRODUCTIVE     TRACT                     • ovulation ceases during pregnancy, and               ...
MATERNAL PHYSIOLOGYI.   REPRODUCTIVE     TRACT        Uterus                               • musculature of the fallopian...
MATERNAL PHYSIOLOGYI.   REPRODUCTIVE     TRACT                     • increased vascularity and hyperemia        Uterus   ...
MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
MATERNAL PHYSIOLOGYIII. BREASTS tenderness, increase in size nipples become larger, more deeply pigmented and  more erec...
MATERNAL PHYSIOLOGYIV. METABOLICCHANGES                  • uterus and its contents   Weight gain                         ...
MATERNAL PHYSIOLOGYIV. METABOLICCHANGES                  • At term, the water content of the   Weight gain            fet...
MATERNAL PHYSIOLOGYIV. METABOLICCHANGES                  • at term, the fetus and placenta   Weight gain            toget...
MATERNAL PHYSIOLOGYIV. METABOLICCHANGES                  • Normal pregnancy is   Weight gain            characterized by ...
MATERNAL PHYSIOLOGYIV. METABOLICCHANGES                  • Maternal hyperlipidemia is   Weight gain            one of the...
MATERNAL PHYSIOLOGYV. HEMATOLOGICAL CHANGES    •   Dilutional anemia increase volume due to increase plasma         incr...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS              • No actual cardiac enlargement but Cardiovascular System    ...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS              • Upward displacement of the                             diaph...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System    • Increase kidney size due to                    ...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System    Progesterone effect                              ...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS              • Mild hyperthyroid state due to                              ...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System Respiratory Tract                           • Back ...
Prenatal care
PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
PRECONCEPTION CARE Personal and Family    History   Medical History   Genetic Diseases   Reproductive History   Socia...
PRECONCEPTION CARE Personal and Family       Occupation    History                 Educational Attainment   Medical Hi...
PRECONCEPTION CARE Personal and Family       Diabetes Mellitus    History                 Hypertension   Medical Histo...
PRECONCEPTION CARE Personal and Family       Neural-Tube Defects    History   Medical History         Phenylketonuria...
PRECONCEPTION CARE Personal and Family       Infertility    History   Medical History         Abnormal pregnancy   Ge...
PRECONCEPTION CARE Personal and Family       Infertility    History                 Abnormal pregnancy   Medical Histo...
PRECONCEPTION CARE Personal and Family       Infertility    History                 Abnormal pregnancy   Medical Histo...
PRECONCEPTION CARE Personal and Family       Maternal Age    History   Medical History         Recreational Drugs and...
PRECONCEPTION CARE Personal and Family       Maternal Age    History   Medical History         Recreational Drugs and...
Maternal AgeADOLESCENT                     AFTER 35 Likely to be anemic           Likely to request for Increased risk ...
Maternal AgeADOLESCENT                     AFTER 35 Likely to be anemic           Likely to request for Increased risk ...
PRECONCEPTION CARE Personal and Family       Maternal Age    History   Medical History         Recreational Drugs and...
PRECONCEPTION CARE Personal and Family       Maternal Age    History   Medical History         Recreational Drugs and...
PRECONCEPTION CARE Personal and Family       Diet    History                 Exercise   Medical History         Domes...
PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
Diagnosis of Pregnancy Signs and symptoms        • Presumptive symptoms of                               pregnancy       ...
Diagnosis of Pregnancy Signs and symptoms        • Presumptive signs of pregnancy                            1. amenorrhe...
Diagnosis of Pregnancy  Signs and symptoms                        • Probable evidence of pregnancy                       ...
Diagnosis of Pregnancy Signs and symptoms        • Positive evidence of pregnancy                            1. Identific...
Diagnosis of Pregnancy Signs and symptoms Pregnancy Test Sonographic recognition of pregnancy
Diagnosis of Pregnancy Signs and symptoms Pregnancy Test Sonographic recognition of pregnancy
PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
Initial Prenatal Evaluation Initiate prenatal care as soon as there is  a reasonable likelihood of pregnancy. Goals:   a...
CIM-CMSS PACKAGE DEAL Requirement: minimum of 4 PNC’s Adjust PNC schedule for high-risk patients  half the  normal inte...
FIRST PNC Always get contact number and place on index card Place past or present medical or surgical problems on  upper...
FIRST PNC LABS:    1. CBC, UA, Blood Typing (if not known) for ALL     patients    If menses are irregular, LMP is uncl...
FIRST PNC MEDS   1. Vitamin B complex (Neurofort) OD: <14 week with    vomiting   2. Folic acid (Folart) 5 mg/cap OD: <...
SECOND/THIRD PNC PAP smear (let patient buy sterile gloves and pay at the counter before getting the sample)
SECOND TRIMESTER FH (cm) = AOG (weeks) at 20-34 wks If < 3 cm difference, suspect IUGR  get UTZ and follow  up after 2 ...
SCHEDULE ofROUTINE LABORATORY TESTS & PROCEDURES First PNC    CBC, U/A-MSCC, Blood typing    TVS/OB UTZ if menses are i...
SCHEDULE ofROUTINE LABORATORY TESTS & PROCEDURES At 34 weeks:    Be sure of Leopold’s At 36 weeks:    Repeat U/A – MSC...
PRENATAL CARERecommended Ranges of Weight Gain during SingletonGestations Stratified by Prepregnancy Body Mass Index CATEG...
PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
PNC FOLLOW-UP SCHEDULE 0-27 6/7 weeks  every 4 weeks 28-35 6/7 weeks  every 2 weeks 36-39 6/7 weeks  every week >40...
OPD schedule         DAY      MORNING   AFTERNOONMonday         PNC, Gyne    Gyne, CIMTuesday        PNC, Gyne    PNC, Gyn...
normal delivery
NORMAL LABOR AND DELIVERYI.   MECHANISMS OF LABORII. CHARACTERISTICS OF NORMAL DELIVERYIII. MANAGEMENT OF NORMAL LABOR AND...
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie      Fetal Presentation        Cephalic Presentation
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie      Fetal Presentation        Cephalic Presentation    ...
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie      Fetal Presentation        Cephalic Presentation    ...
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie      Fetal Presentation        Cephalic Presentation    ...
NORMAL LABOR AND DELIVERY Diagnosis of Fetal Presentation and Position   1. Abdominal Palpation (Leopold Maneuvers)   2. ...
NORMAL LABOR AND DELIVERY   Abdominal Palpation (Leopold’s Maneuver)1. Fetal Pole                2. Umbilical Pole    • C...
NORMAL LABOR AND DELIVERY Vaginal Examination
NORMAL LABOR AND DELIVERY Sonography and Radiography   aid in identification of fetal position especially in obese    or...
NORMAL LABOR AND DELIVERY Mechanisms of Labor with Left Occiput Anterior Presentation
NORMAL LABOR AND DELIVERY Mechanisms of Labor with Left Occiput Anterior Presentation
NORMAL LABOR AND DELIVERY Changes in the shape of the fetal head   Caput Succedaneum                  Molding
NORMAL LABOR AND DELIVERYI.   MECHANISMS OF LABORII. CHARACTERISTICS OF NORMAL DELIVERYIII. MANAGEMENT OF NORMAL LABOR AND...
NORMAL LABOR AND DELIVERYII. CHARACTERISTICS OF NORMAL LABOR First Stage of Labor   onset of labor until full dilation a...
FIRST STAGE OF LABOR               Preparatory division                  the cervix dilates little, its                 ...
FIRST STAGE OF LABOR Latent Phase    point at which the mother perceives regular     contractions.    Prolonged Latent ...
FIRST STAGE OF LABORMonitoring of Fetal Well-being Ausculataion:    hand held Doppler    fetal stethoscope Electronic ...
FIRST STAGE OF LABORInduction of Labor to artificially initiate uterine contractions should only be implemented on a VAL...
FIRST STAGE OF LABORIndications                            ContraindicationsGest. HPN                              Malpres...
FIRST STAGE OF LABORASSESSMENT PRIOR TO INDUCTION parity age presentation Bishop’s score uterine activity nonstress ...
FIRST STAGE OF LABORMETHODS OF LABORINDUCTION Oxytocin                       Recommended regimen Membrane Sweeping/     ...
FIRST STAGE OF LABORMETHODS OF LABORINDUCTION Oxytocin                       • artificial rupture of membrane that Membr...
FIRST STAGE OF LABORSIGNS OF HYPERSTIMULATION 5 contractions in 10 mins, or more than 10 in 20 mins lasts more than 120 ...
FIRST STAGE OF LABORRESUSCITATION Stop Reposition to left lateral decubitus O2 at 10L/min Notify physician Administer...
SECOND STAGE OF LABOR Cervical dilatation complete and ends with fetal delivery   50 minutes for nulliparas   20 minute...
SECOND STAGE OF LABOR
SECOND STAGE OF LABOR Episiotomy    Reduce the risk of perineal trauma    shortened second stage of labor. Indications...
SECOND STAGE OF LABOR Characteristic       Midline     Mediolateral Surgical repair      Easy        More difficult Faulty...
SECOND STAGE OF LABOR
SECOND STAGE OF LABOR Clamping the Cord    umbilical cord is cut between two clamps placed 4 to 5     cm from the fetal ...
THIRD STAGE OF LABOR size of the uterine fundus and its consistency are  examined    uterus remains firm and there is no...
THIRD STAGE OF LABOR
THIRD STAGE OF LABOR Uterine massage following placental delivery   prevent postpartum hemorrhage Oxytocin, ergonovine,...
THIRD STAGE OF LABOR Oxytocin   1st line prophylactic uterotonic during 3rd stage of labor    in the prevention of PPH  ...
THIRD STAGE OF LABOR Use of ergot alkaloid, and ergometrine-oxytocin    valid alternatives in the absence of oxytocin   ...
FOURTH STAGE OF LABOR placenta, membranes, and umbilical cord should be  examined for completeness and for anomalies pos...
FOURTH STAGE OF LABOR First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane but not...
FOURTH STAGE OF LABOR Second-degree lacerations involve, in addition, the fascia and muscles of the perineal body but not...
FOURTH STAGE OF LABOR Third-degree lacerations extend farther to involve the anal sphincter.
FOURTH STAGE OF LABOR fourth-degree laceration extends through the rectums mucosa to expose its lumen
Episiorrhaphy Hemostasis and anatomical restoration without  excessive suturing are essential for the success of  this me...
Episiorrhaphy
NORMAL LABOR AND DELIVERY Changes in the shape of the fetal head   Caput Succedaneum                     Molding    •Edem...
CephalhematomaIt is a hemorrhage of blood betweenthe skull and the periosteum of a newbornbaby secondary to rupture of blo...
MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS              • Upward displacement of the                             diaph...
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie      Fetal Presentation        Cephalic Presentation    ...
NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR      Fetal Lie      Fetal Presentation        Cephalic Presentation
Bishop scoring is a pre-labor scoring system to assist in predicting whether induction    of labor will be required. It h...
Modified Bishop scoring Another modification for the Bishops score is the  modifiers. Points are added or subtracted acco...
Hypertensive Complications:Criterias: Gestational Hypertension: Systolic BP 140 or diastolic BP 90 mm Hg for first time ...
Criterias   Preeclampsia:   Minimum criteria:   BP 140/90 mm Hg after 20 weeks gestation   Proteinuria 300 mg/24 hours...
Criterias: Eclampsia: Seizures that cannot be attributed to other causes in a woman with preeclampsia
Criterias Superimposed Preeclampsia On Chronic  Hypertension: New-onset proteinuria 300 mg/24 hours in  hypertensive wom...
Criterias Chronic Hypertension: BP 140/90 mm Hg before pregnancy or diagnosed  before 20 weeks gestation not attributabl...
Preeclampsia The basic management objectives for any pregnancy complicated by preeclampsia are:   Termination of pregnan...
Some Indications for Delivery withEarly-Onset Severe Preeclampsia Maternal   Persistent severe headache or visual change...
Some Indications for Delivery withEarly-Onset Severe Preeclampsia Fetal    Severe growth restriction—< 5th percentile fo...
Eclampsia: ImmediateManagement of Seizure Eclamptic seizures may be violent. During seizures,  the woman must be protecte...
 In more severe cases of preeclampsia, as well as in eclampsia, magnesium sulfate administered parenterally is an effecti...
Continuous Intravenous Infusion Give 4- to 6-g loading dose of magnesium sulfate  diluted in 100 mL of IV fluid administe...
Intermittent IntramuscularInjections Give 4 g of magnesium sulfate (MgSO4 · 7H2O USP) as a 20%  solution intravenously at...
Watch out! Patellar reflexes disappear when the plasma magnesium level reaches 10 meq/L—about 12 mg/dL—presumably because...
Remedy Treatment with calcium gluconate or calcium chloride, 1 g intravenously, along with withholding further magnesium ...
Exercises that a pregnant womancan do:1.    Head lift2.    Head lift with pelvic tilt3.    Pelvic tilt4.    Leg sliding5. ...
Head Lift Hook-lying with her hands crossed over midline at the  level of the diastasis for support. Have the woman exha...
Head Lift with Pelvic Tilt The arms are crossed over the diastasis for support as above. Have the patient slowly lift her...
Quadruped leg raising On hands and knees(hands may be in fists or palms open    and flat). Instruct the woman to first pe...
Modified Bicycle The woman is supine with one lower extremity flexed and the other partially extended. The lower abdomina...
Standing Push-Ups Standing, facing a wall, feet pointing straight forward,  shoulder-width apart, and approximately an ar...
Maternal physiology, prenatal care,normal labor and delivery
Maternal physiology, prenatal care,normal labor and delivery
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Maternal physiology, prenatal care,normal labor and delivery

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Maternal physiology, prenatal care,normal labor and delivery

  1. 1. Maternal Physiology Prenatal Care Normal Delivery Gumalo, Clay Paolo
  2. 2. OUTLINEMaternal Physiology I. Reproductive Tract II. Skin III. Metabolic changes IV. Hematological changes V. Changes in organ systems
  3. 3. OUTLINEPrenatal Care II. Organization of prenatal care III. Nutrition IV. Common concerns
  4. 4. OUTLINE Normal Labor and delivery I. Mechanisms of Labor II. Characteristics of normal labor III. Management of Normal Labor and delivery IV. Labor Management Protocols
  5. 5. maternal physiology
  6. 6. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACTII. SKINIII. BREASTSIV. METABOLIC CHANGESV. HEMATOLOGICAL CHANGESVI. CHANGES IN ORGAN SYSTEMS
  7. 7. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT • nonpregnant woman: 50-70 g; 6-8  Uterus cm multiparous: 70-1100g; 9-10cm; 5L-  Cervix 20L  Ovaries • uterine size, shape and position  Fallopian Tubes first few weeks- pyriform (pear shape)  Vagina and Perineum advance pregnancy- corpus and fundus is more globular 12 weeks- spherical contractility
  8. 8. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT • 1 month after conception- undergo  Uterus pronounced softening and cyanosis  Cervix • result from increased vascularity  Ovaries and edema of the entire cervix  Fallopian Tubes • hyperplasia and hypertrophy of the  Vagina and Perineum cervical glands
  9. 9. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT • ovulation ceases during pregnancy, and the maturation of new follicles is  Uterus suspended.  Cervix • only a single corpus luteum can be  Ovaries found in pregnant women.  Fallopian Tubes • functions maximally during the first 6  Vagina and Perineum to 7 weeks of pregnancy—4 to 5 weeks postovulation
  10. 10. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT  Uterus • musculature of the fallopian tubes  Cervix undergoes little hypertrophy during  Ovaries pregnancy but the epithelium of the tubal mucosa becomes flattened.  Fallopian Tubes  Vagina and Perineum
  11. 11. MATERNAL PHYSIOLOGYI. REPRODUCTIVE TRACT • increased vascularity and hyperemia  Uterus develop in the skin and muscles of the perineum and vulva  Cervix  Ovaries • papillae of the vaginal epithelium undergo hypertrophy to create a fine,  Fallopian Tubes hobnailed appearance.  Vagina and Perineum • pH is acidic, varying from 3.5 to 6.
  12. 12. MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
  13. 13. MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
  14. 14. MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
  15. 15. MATERNAL PHYSIOLOGY II. SKIN  Blood flow in skin  Abdominal Wall  Hyperpigmentation  Vascular Changes
  16. 16. MATERNAL PHYSIOLOGYIII. BREASTS tenderness, increase in size nipples become larger, more deeply pigmented and more erectile
  17. 17. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES • uterus and its contents  Weight gain • the breasts  Water Metabolism  Protein Metabolism • increases in blood volume and extravascular extracellular fluid  Carbohydrate Metabolism  Fat Metabolism
  18. 18. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES • At term, the water content of the  Weight gain fetus, placenta, and amnionic fluid approximates 3.5 L  Water Metabolism  Protein Metabolism • Another 3.0 L accumulates as a result of increases in the  Carbohydrate maternal blood volume and in Metabolism the size of the uterus and breasts  Fat Metabolism • normal pregnancy is approximately 6.5 L
  19. 19. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES • at term, the fetus and placenta  Weight gain together weigh about 4 kg and contain approximately 500 g of  Water Metabolism protein  Protein Metabolism • the remaining 500 g is added to  Carbohydrate the uterus as contractile protein, Metabolism to the breasts primarily in the glands, and to the maternal  Fat Metabolism blood as hemoglobin and plasma proteins
  20. 20. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES • Normal pregnancy is  Weight gain characterized by • mild fasting hypoglycemia  Water Metabolism • postprandial hyperglycemia  Protein Metabolism • hyperinsulinemia.  Carbohydrate Metabolism  Fat Metabolism
  21. 21. MATERNAL PHYSIOLOGYIV. METABOLICCHANGES • Maternal hyperlipidemia is  Weight gain one of the most consistent and striking changes to take place in  Water Metabolism lipid metabolism during late  Protein Metabolism pregnancy. • increased during the third  Carbohydrate trimester Metabolism • Triacylglycerol and cholesterol levels in VLDL,  Fat Metabolism LDL, HDL.
  22. 22. MATERNAL PHYSIOLOGYV. HEMATOLOGICAL CHANGES • Dilutional anemia increase volume due to increase plasma  increase RBC • Increase reticulocyte and leukocyte count • Increase blood coagulation factors, increase fibrinogen levels, increase plasminogen and fibrin degradation products • Increase plasma iron binding capacity (transferrin)
  23. 23. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS • No actual cardiac enlargement but Cardiovascular System only slight dilatation and displacement upwards and Respiratory Tract outwards due to gravid uterus Urinary System • ECG may reveal slight axis Gastrointestinal Tract deviation, occasional T waves, and lowering of T waves Endocrine System • Increase in heart rate maximal on Musculoskeletal System the 7th- 8th month~10 beats/min • Increase in cardiac output by about 30-50%
  24. 24. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS • Upward displacement of the diaphragm by about 4 cm Cardiovascular System • Increase tidal volume and resting minute ventilation Respiratory Tract Urinary System • increase Vital capacity, tidal volume and respiratory rate due to Gastrointestinal Tract central effects of progesterone , low expiratory reserve volume and Endocrine System compensated respiratory alkalosis Musculoskeletal System • decrease functional residual capacity and residual volume of air
  25. 25. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System • Increase kidney size due to hypertrophy and increase renal Respiratory Tract blood flow causing an increase renal vascular volume Urinary System Gastrointestinal Tract • Physiologic Hydroureter of pregnancy—marked increase (25x) Endocrine System in diameter of ureteral lumen, hypotonicity and hypomotility of Musculoskeletal System its musculature • Prone to UTI due to progesterone and pressure changes
  26. 26. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System Progesterone effect • Smooth muscle atony, Respiratory Tract decrease tone of lower esophageal sphincter, Urinary System increase HCl production Gastrointestinal Tract • Decrease responsiveness to Endocrine System CCK duodenal and biliary stasis  pancreastitis  Musculoskeletal System hyperlipidemia  cholesterol stones
  27. 27. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS • Mild hyperthyroid state due to Gland hyperplasia Cardiovascular System • Hyperparathyroid state  Respiratory Tract increase calcium for fetus Urinary System • Hyperadrenal state gland Gastrointestinal Tract hyperplasia with increase steroid production Endocrine System Musculoskeletal System • Diabetogenic due to placental degradation of insulin and anti- insulin effects of placental lactogen, estrogen, progesterone
  28. 28. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS Cardiovascular System Respiratory Tract • Back pain due to lordosis and Urinary System increase mobility sacal joints (relaxin) Gastrointestinal Tract Endocrine System Musculoskeletal System
  29. 29. Prenatal care
  30. 30. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
  31. 31. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
  32. 32. PRECONCEPTION CARE Personal and Family History Medical History Genetic Diseases Reproductive History Social History Lifestyle and Work Habits
  33. 33. PRECONCEPTION CARE Personal and Family  Occupation History  Educational Attainment Medical History  Home situation Genetic Diseases  SOs Reproductive History  Stress: short- and long- Social History term Lifestyle and Work Habits
  34. 34. PRECONCEPTION CARE Personal and Family  Diabetes Mellitus History  Hypertension Medical History  Asthma Genetic Diseases  Epilepsy Reproductive History  Renal Disease Social History  Thyroid Disorders Lifestyle and Work  Heart Disease Habits
  35. 35. PRECONCEPTION CARE Personal and Family  Neural-Tube Defects History Medical History  Phenylketonuria Genetic Diseases Reproductive History  Thalassemias Social History Lifestyle and Work  Tay-Sachs Disease Habits
  36. 36. PRECONCEPTION CARE Personal and Family  Infertility History Medical History  Abnormal pregnancy Genetic Diseases outcome Reproductive History Social History  OB complications Lifestyle and Work Habits
  37. 37. PRECONCEPTION CARE Personal and Family  Infertility History  Abnormal pregnancy Medical History outcome Genetic Diseases  Miscarriage Reproductive History  Ectopic pregnancy Social History  Recurrent pregnancy loss Lifestyle and Work Habits  OB complications
  38. 38. PRECONCEPTION CARE Personal and Family  Infertility History  Abnormal pregnancy Medical History outcome Genetic Diseases  OB complications Reproductive History  Preeclampsia Social History  Placental abruption Lifestyle and Work  Preterm delivery Habits
  39. 39. PRECONCEPTION CARE Personal and Family  Maternal Age History Medical History  Recreational Drugs and Genetic Diseases Smoking Reproductive History Social History  Environmental Lifestyle and Work Exposures Habits
  40. 40. PRECONCEPTION CARE Personal and Family  Maternal Age History Medical History  Recreational Drugs and Genetic Diseases Smoking Reproductive History Social History  Environmental Lifestyle and Work Exposures Habits
  41. 41. Maternal AgeADOLESCENT AFTER 35 Likely to be anemic  Likely to request for Increased risk to have preconceptional counseling growth-restricted infants  Physically fit VS. Chronic Preterm labor illness High infant mortality rate  High mortality rate Higher incidence of STDs  Maternal–age fetal risks  Fetal Aneuploidy
  42. 42. Maternal AgeADOLESCENT AFTER 35 Likely to be anemic  Likely to request for Increased risk to have preconceptional counseling growth-restricted infants  Physically fit VS. Chronic Preterm labor illness High infant mortality rate  High mortality rate Higher incidence of STDs  Maternal–age fetal risks  Fetal Aneuploidy
  43. 43. PRECONCEPTION CARE Personal and Family  Maternal Age History Medical History  Recreational Drugs and Genetic Diseases Smoking Reproductive History Social History  Environmental Lifestyle and Work Exposures Habits
  44. 44. PRECONCEPTION CARE Personal and Family  Maternal Age History Medical History  Recreational Drugs and Genetic Diseases Smoking Reproductive History Social History  Environmental Lifestyle and Work Exposures Habits
  45. 45. PRECONCEPTION CARE Personal and Family  Diet History  Exercise Medical History  Domestic Abuse Genetic Diseases  Family History Reproductive History  Immunizations Social History  Screening Tests Lifestyle and Work Habits
  46. 46. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
  47. 47. Diagnosis of Pregnancy Signs and symptoms • Presumptive symptoms of pregnancy 1. nausea with or without vomiting- Pregnancy Test due to increase hCG 2. disturbance in urination 3. fatigue- due to increase metabolism Sonographic recognition 4. perception of fetal movement of pregnancy quickening 5. breast tenderness and tingling sensation
  48. 48. Diagnosis of Pregnancy Signs and symptoms • Presumptive signs of pregnancy 1. amenorrhea 2. anatomic breast changes Pregnancy Test darker areola, erected nipple, engorged breast 3. changes in vaginal mucosa 4. Skin pigmentation Sonographic recognition 5. Thermal signs of pregnancy
  49. 49. Diagnosis of Pregnancy  Signs and symptoms • Probable evidence of pregnancy 1. Enlargement of abdomen 2. Changes in skin, shape and  Pregnancy Test consistency of the uterus 3. Anatomical changes in cervix Cervical mucus  Sonographic 4. Braxton-Hick’s contractions that are painless and irregular recognition of 5. Ballotement pregnancy 6. Physical outlining of the fetus 7. Positive Pregnancy test- B hCG levels
  50. 50. Diagnosis of Pregnancy Signs and symptoms • Positive evidence of pregnancy 1. Identification of fetal heart tones separately from mother Pregnancy Test Normal FHT: Ultrasound Stethoscope Doppler Sonographic recognition 2. Perception of active fetal of pregnancy movement by the examiner 3. Ultrasound or radiologic evidence
  51. 51. Diagnosis of Pregnancy Signs and symptoms Pregnancy Test Sonographic recognition of pregnancy
  52. 52. Diagnosis of Pregnancy Signs and symptoms Pregnancy Test Sonographic recognition of pregnancy
  53. 53. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
  54. 54. Initial Prenatal Evaluation Initiate prenatal care as soon as there is a reasonable likelihood of pregnancy. Goals: a) Define health status of mother and fetus b) Estimate gestational age c) Initiate continuing obstetrical c
  55. 55. CIM-CMSS PACKAGE DEAL Requirement: minimum of 4 PNC’s Adjust PNC schedule for high-risk patients  half the normal interval Remind patients to bring all receipts on admission for refund
  56. 56. FIRST PNC Always get contact number and place on index card Place past or present medical or surgical problems on upper right corner of PD Form For previous CS: secure OR Record and early UTZ for aging Fetal Heart Tone:  <10 wks  no FHT  >13 wks  (+) FHT by Doppler
  57. 57. FIRST PNC LABS:  1. CBC, UA, Blood Typing (if not known) for ALL patients  If menses are irregular, LMP is unclear, or previous CS (for aging: reliable up to 26 weeks):  A. <12 weeks – TVS UTZ  B. >12 weeks – OB UTZ
  58. 58. FIRST PNC MEDS  1. Vitamin B complex (Neurofort) OD: <14 week with vomiting  2. Folic acid (Folart) 5 mg/cap OD: <20 wks  3. MV + Fe (Fer-Essence) OD: without vomiting  If Hgb < 11 mg/dl  Increase MV + Fe BID  repeat Hgb/Hct at 28-32 weeks  if Hgb still < 11 mg/dl  Increase MV + Fe TID  4. Calcium (Calciumade) 500 mg/tab TID PC: with HPN or family hsitory of hypertension  5. Anmum/Enfamama 1 glass BID
  59. 59. SECOND/THIRD PNC PAP smear (let patient buy sterile gloves and pay at the counter before getting the sample)
  60. 60. SECOND TRIMESTER FH (cm) = AOG (weeks) at 20-34 wks If < 3 cm difference, suspect IUGR  get UTZ and follow up after 2 wks For IUGR:  Increase caloric intake (3 meals, 2 snacks/day)  Increase milk to 1 glass TID  Left lateral decubitus position while asleep  Rpt OB UTZ at 32-34 wks (or after 4 wks) to check fetal growth If > 3 cm difference  get UTZ to R/O LGA or polyhydramnios
  61. 61. SCHEDULE ofROUTINE LABORATORY TESTS & PROCEDURES First PNC  CBC, U/A-MSCC, Blood typing  TVS/OB UTZ if menses are irregular, LMP is unclear, or previous CS for fetal aging Second/third PNC  PAP smear At 24-28 weeks:  50 g OGCT  100g OGTT At 28-32 weeks:  Repeat hematocrit  HBsAg-IC At 32-36 weeks:  OB-UTZ
  62. 62. SCHEDULE ofROUTINE LABORATORY TESTS & PROCEDURES At 34 weeks:  Be sure of Leopold’s At 36 weeks:  Repeat U/A – MSCC  Advise walking exercises and fetal kick counting (>10 in one hour, esp after eating) At 37 weeks:  Remind patients to seek admission for signs of labor (bloody show with uterine contractions every 5 mins) or watery vaginal discharge At 38 weeks:  IE and cervical stripping (C/I in patients with history of spotting or low-lying placenta At 39 weeks:  NST, IE and cervical stripping At 40 weeks:  IE, stripping & biophysical profile At >41 weeks:  IE and repeat BPP if 1 wk since 1st BPP was taken
  63. 63. PRENATAL CARERecommended Ranges of Weight Gain during SingletonGestations Stratified by Prepregnancy Body Mass Index CATEGORY BMI KG LB Low < 19.8 12.5–18 28–40 Normal 19.8–26 11.5–16 25–35 High 26–29 7–11.5 15–25 Obese > 29 >7 >15
  64. 64. PRENATAL CARE Preconception care Prompt diagnosis of pregnancy Initial prenatal evaluation Follow-up prenatal visits
  65. 65. PNC FOLLOW-UP SCHEDULE 0-27 6/7 weeks  every 4 weeks 28-35 6/7 weeks  every 2 weeks 36-39 6/7 weeks  every week >40 weeks  every 3 days
  66. 66. OPD schedule DAY MORNING AFTERNOONMonday PNC, Gyne Gyne, CIMTuesday PNC, Gyne PNC, Gyne, CIMWednesday PNC, Gyne PNC, Gyne, CIMThursday PNC, Gyne Gyne, CIMFriday PNC, Gyne PNC, Gyne, CIMSaturday PNC, Gyne
  67. 67. normal delivery
  68. 68. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABORII. CHARACTERISTICS OF NORMAL DELIVERYIII. MANAGEMENT OF NORMAL LABOR AND DELIVERY
  69. 69. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie
  70. 70. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie  Fetal Presentation  Cephalic Presentation
  71. 71. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie  Fetal Presentation  Cephalic Presentation  Breech Presentation
  72. 72. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie  Fetal Presentation  Cephalic Presentation  Breech Presentation  Shoulder Presentation
  73. 73. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie  Fetal Presentation  Cephalic Presentation  Breech Presentation  Shoulder Presentation  Fetal Attitude  Fetal Position
  74. 74. NORMAL LABOR AND DELIVERY Diagnosis of Fetal Presentation and Position 1. Abdominal Palpation (Leopold Maneuvers) 2. Vaginal Examination 3. Sonography and Radiography
  75. 75. NORMAL LABOR AND DELIVERY  Abdominal Palpation (Leopold’s Maneuver)1. Fetal Pole 2. Umbilical Pole • Cephalic • Podalic3. Pawlick’s grip 4. Pelvic grip
  76. 76. NORMAL LABOR AND DELIVERY Vaginal Examination
  77. 77. NORMAL LABOR AND DELIVERY Sonography and Radiography  aid in identification of fetal position especially in obese or in women with rigid abdominal walls.
  78. 78. NORMAL LABOR AND DELIVERY Mechanisms of Labor with Left Occiput Anterior Presentation
  79. 79. NORMAL LABOR AND DELIVERY Mechanisms of Labor with Left Occiput Anterior Presentation
  80. 80. NORMAL LABOR AND DELIVERY Changes in the shape of the fetal head Caput Succedaneum Molding
  81. 81. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABORII. CHARACTERISTICS OF NORMAL DELIVERYIII. MANAGEMENT OF NORMAL LABOR AND DELIVERY
  82. 82. NORMAL LABOR AND DELIVERYII. CHARACTERISTICS OF NORMAL LABOR First Stage of Labor  onset of labor until full dilation and effacement
  83. 83. FIRST STAGE OF LABOR  Preparatory division  the cervix dilates little, its connective tissue components change considerably  Dilatational division  during which dilatation proceeds at its most rapid rate, is unaffected by sedation or conduction analgesia.  Pelvic division  deceleration phase of cervical dilatation. The classic mechanisms of labor that involve the cardinal fetal movements of the cephalic presentation
  84. 84. FIRST STAGE OF LABOR Latent Phase  point at which the mother perceives regular contractions.  Prolonged Latent Phase exceeding 20 hours in the nullipara 14 hours in the multipara Active Labor  cervical dilatation of 3 to 5 cm or more  presence of uterine contractions
  85. 85. FIRST STAGE OF LABORMonitoring of Fetal Well-being Ausculataion:  hand held Doppler  fetal stethoscope Electronic Fetal Monitoring (EFM) superior to intermittent auscultation. Intermittent ausculatation  every 15-30 minutes in the first stage of labor  every 5 mins in the second stage of labor OR at least 30 seconds after each contraction. Admitting CTG not recommended for healthy women at term, in labor, in the absence of risk factors for adverse perinatal outcomes Continuos EFM is recommended when risk factors for fetal compromise is identified.
  86. 86. FIRST STAGE OF LABORInduction of Labor to artificially initiate uterine contractions should only be implemented on a VALID indication. administered only in the hospital setting
  87. 87. FIRST STAGE OF LABORIndications ContraindicationsGest. HPN MalpresentationPre eclampsia, Eclampsia Absolute CPDPremature rupture of membranes Placenta previaMaternal Medical Condition ( DM, Previous major uterine surgery, orrenal disease,chronic hypertensive) C/S deliveryMore than 41 1/7 weeks Invasive Ca of cervixEvidence of fetal compromise ( Cord presentationsevere feta growth restriction,isoimmunization)Intraamnionic infection ACTIVE genital herpesFetal demise Gyne, ob, or medical conditions that preclude vaginal birthLogistic factors ( eg: distance from OB’s conveniencehospital)
  88. 88. FIRST STAGE OF LABORASSESSMENT PRIOR TO INDUCTION parity age presentation Bishop’s score uterine activity nonstress test
  89. 89. FIRST STAGE OF LABORMETHODS OF LABORINDUCTION Oxytocin Recommended regimen Membrane Sweeping/ • starting dose of 1-2 mU/min, Stripping increased at intervals of 30 mins or more Amniotomy • Fetal heart rate should be recorded every 15-30 mins, and with each incremental increase of oxytocin. • Continuous intrapartum electronic fetal monitoring
  90. 90. FIRST STAGE OF LABORMETHODS OF LABORINDUCTION Oxytocin • artificial rupture of membrane that Membrane Sweeping/ may be used as a method for labor Stripping induction if condition of the cervix is favorable Amniotomy • However, if used alone in inducing labor, it can be associated with UNPREDITABLE, and sometimes LONG INTERVALS before the onset of contractions
  91. 91. FIRST STAGE OF LABORSIGNS OF HYPERSTIMULATION 5 contractions in 10 mins, or more than 10 in 20 mins lasts more than 120 seconds Excessive uterine activity with an atypical abnormal fetal heart rate OXYTOCIN SHOULD NOT BE CONTINUED or INCREASED in the presence of abnormal fetal heart rate, or tetanic contractions.
  92. 92. FIRST STAGE OF LABORRESUSCITATION Stop Reposition to left lateral decubitus O2 at 10L/min Notify physician Administer tocolytic Prepare for possible C/S if fetal pattern remains abnormal
  93. 93. SECOND STAGE OF LABOR Cervical dilatation complete and ends with fetal delivery  50 minutes for nulliparas  20 minutes for multiparas dorsal lithotomy position vulvar and perineal cleansing
  94. 94. SECOND STAGE OF LABOR
  95. 95. SECOND STAGE OF LABOR Episiotomy  Reduce the risk of perineal trauma  shortened second stage of labor. Indications:  Expedite delivery in the second stage of labor  When spontaneous laceration is likely  Maternal or fetal distress  Breech  Assisted forceps delivery  Large baby  Maternal exhaustion
  96. 96. SECOND STAGE OF LABOR Characteristic Midline Mediolateral Surgical repair Easy More difficult Faulty healing Rare More common Postoperative pain Minimal Common Anatomical results Excellent Occasionally faulty Blood loss Less More Dyspareunia Rare Occasional Extension Common Uncommon
  97. 97. SECOND STAGE OF LABOR
  98. 98. SECOND STAGE OF LABOR Clamping the Cord  umbilical cord is cut between two clamps placed 4 to 5 cm from the fetal abdomen  umbilical cord clamp is applied 2 to 3 cm from the fetal
  99. 99. THIRD STAGE OF LABOR size of the uterine fundus and its consistency are examined  uterus remains firm and there is no unusual bleeding, watchful waiting until the placenta separates is the usual practice Signs of Placental Separation  uterus becomes globular and as a rule, firmer  sudden gush of blood  uterus rises in the abdomen  The umbilical cord protrudes farther out of the vagina
  100. 100. THIRD STAGE OF LABOR
  101. 101. THIRD STAGE OF LABOR Uterine massage following placental delivery  prevent postpartum hemorrhage Oxytocin, ergonovine, and methylergonovine are all employed widely in the normal third stage of labor
  102. 102. THIRD STAGE OF LABOR Oxytocin  1st line prophylactic uterotonic during 3rd stage of labor in the prevention of PPH  add 20 units (2 mL) of oxytocin per liter of infusate  10 mL/min (200 mU/min) for a few minutes  half-life of intravenously infused oxytocin is approximately 3 minutes  May cause fall in BP if given in large bolus  May cause water intoxication
  103. 103. THIRD STAGE OF LABOR Use of ergot alkaloid, and ergometrine-oxytocin  valid alternatives in the absence of oxytocin  powerful stimulants of myometrial contraction  AVOIDED in hypertensive patients due to ability to cause transient hypertension In low resource area, misoprostol may be administered orally, sublingually, or rectally.
  104. 104. FOURTH STAGE OF LABOR placenta, membranes, and umbilical cord should be examined for completeness and for anomalies postpartum hemorrhage as the result of uterine atony is more likely at this time
  105. 105. FOURTH STAGE OF LABOR First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane but not the underlying fascia.
  106. 106. FOURTH STAGE OF LABOR Second-degree lacerations involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter
  107. 107. FOURTH STAGE OF LABOR Third-degree lacerations extend farther to involve the anal sphincter.
  108. 108. FOURTH STAGE OF LABOR fourth-degree laceration extends through the rectums mucosa to expose its lumen
  109. 109. Episiorrhaphy Hemostasis and anatomical restoration without excessive suturing are essential for the success of this method. Blunt needles are suitable and likely decrease the incidence of needlestick injury; 2-0 Chromic gut
  110. 110. Episiorrhaphy
  111. 111. NORMAL LABOR AND DELIVERY Changes in the shape of the fetal head Caput Succedaneum Molding •Edematous swelling of •Change in the fetal head the fetal scalp due to external compressive •Formed when the head forces. is in the lower portion •There is seldom of the birth canal and overlapping of the parietal frequently only after bones. resistance of a rigid •Locking mechanisms at the vaginal outlet is coronal nad lambdoidal encountered. connections prevents •It normally, crosses the overlapping. suture lines.
  112. 112. CephalhematomaIt is a hemorrhage of blood betweenthe skull and the periosteum of a newbornbaby secondary to rupture of blood vesselscrossing the periosteum. Because the swellingis subperiosteal its boundaries are limited bythe individual bones
  113. 113. MATERNAL PHYSIOLOGYVI. CHANGES INORGAN SYSTEMS • Upward displacement of the diaphragm by about 4 cm Cardiovascular System • Increase tidal volume and resting minute ventilation Respiratory Tract Urinary System • increase Vital capacity, tidal volume and respiratory rate due to Gastrointestinal Tract central effects of progesterone , low expiratory reserve volume and Endocrine System compensated respiratory alkalosis Musculoskeletal System • decrease functional residual capacity and residual volume of air
  114. 114. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie  Fetal Presentation  Cephalic Presentation  Breech Presentation
  115. 115. NORMAL LABOR AND DELIVERYI. MECHANISMS OF LABOR  Fetal Lie  Fetal Presentation  Cephalic Presentation
  116. 116. Bishop scoring is a pre-labor scoring system to assist in predicting whether induction of labor will be required. It has also been used to assess the odds of spontaneous preterm delivery. a score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth. Bishop scores of less than 6 usually require that a cervical ripening method be used before other methods. Cervical dilation Cervical effacement Cervical consistency Cervical position Fetal station Pneumonic : PEDS
  117. 117. Modified Bishop scoring Another modification for the Bishops score is the modifiers. Points are added or subtracted according to special circumstances as follows: One point is added for:  1. Existence of pre-eclampsia  2. Every previous vaginal delivery One point is subtracted for:  1. Postdate pregnancy  2. Nulliparity (no previous vaginal deliveries)  3. PPROM; preterm premature (prelabor) rupture of membranes
  118. 118. Hypertensive Complications:Criterias: Gestational Hypertension: Systolic BP 140 or diastolic BP 90 mm Hg for first time during pregnancy No proteinuria BP returns to normal before 12 weeks postpartum Final diagnosis made only postpartum May have other signs or symptoms of preeclampsia, for example, epigastric discomfort or thrombocytopenia
  119. 119. Criterias Preeclampsia: Minimum criteria: BP 140/90 mm Hg after 20 weeks gestation Proteinuria 300 mg/24 hours or 1+ dipstick Increased certainty of preeclampsia: BP 160/110 mm Hg Proteinuria 2.0 g/24 hours or 2+ dipstick Serum creatinine >1.2 mg/dL unless known to be previously elevated Platelets < 100,000/L Microangiopathic hemolysis—increased LDH Elevated serum transaminase levels—ALT or AST Persistent headache or other cerebral or visual disturbance Persistent epigastric pain
  120. 120. Criterias: Eclampsia: Seizures that cannot be attributed to other causes in a woman with preeclampsia
  121. 121. Criterias Superimposed Preeclampsia On Chronic Hypertension: New-onset proteinuria 300 mg/24 hours in hypertensive women but no proteinuria before 20 weeks gestation A sudden increase in proteinuria or blood pressure or platelet count < 100,000/L in women with hypertension and proteinuria before 20 weeks gestation
  122. 122. Criterias Chronic Hypertension: BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks gestation not attributable to gestational trophoblastic disease or Hypertension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum
  123. 123. Preeclampsia The basic management objectives for any pregnancy complicated by preeclampsia are:  Termination of pregnancy with the least possible trauma to mother and fetus  Birth of an infant who subsequently thrives  Complete restoration of health to the mother. Termination of pregnancy is the only cure for preeclampsia. Once severe preeclampsia is diagnosed, labor induction and vaginal delivery have traditionally been considered ideal.
  124. 124. Some Indications for Delivery withEarly-Onset Severe Preeclampsia Maternal  Persistent severe headache or visual changes; eclampsia  Shortness of breath; chest tightness with rales and/or SaO2 < 94 percent breathing room air; pulmonary edema  Uncontrolled severe hypertension despite treatment  Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL  Persistent platelet counts < 100,000/L  Suspected abruption, progressive labor, and/or ruptured membranes
  125. 125. Some Indications for Delivery withEarly-Onset Severe Preeclampsia Fetal  Severe growth restriction—< 5th percentile for EGA  Persistent severe oligohydramnios—AFI < 5 cm  Biophysical profile 4 done 6 hr apart  Reversed end-diastolic umbilical artery flow  Fetal death
  126. 126. Eclampsia: ImmediateManagement of Seizure Eclamptic seizures may be violent. During seizures, the woman must be protected, especially her airway. In severe cases, coma persists from one convulsion to another, and death may result.
  127. 127.  In more severe cases of preeclampsia, as well as in eclampsia, magnesium sulfate administered parenterally is an effective anticonvulsant that avoids producing central nervous system depression in either the mother or the infant. It may be given intravenously by continuous infusion or intramuscularly by intermittent injection
  128. 128. Continuous Intravenous Infusion Give 4- to 6-g loading dose of magnesium sulfate diluted in 100 mL of IV fluid administered over 15–20 min Begin 2 g/hr in 100 mL of IV maintenance infusion. Some recommend 1 g/hr Monitor for magnesium toxicity: Assess deep tendon reflexes periodically Some measure serum magnesium level at 4–6 hr and adjust infusion to maintain levels between 4 and 7 meq/L (4.8 to 8.4 mg/dL) Measure serum magnesium levels if serum creatinine 1.0 mg/dL Magnesium sulfate is discontinued 24 hr after delivery
  129. 129. Intermittent IntramuscularInjections Give 4 g of magnesium sulfate (MgSO4 · 7H2O USP) as a 20% solution intravenously at a rate not to exceed 1 g/min Follow promptly with 10 g of 50% magnesium sulfate solution, one-half (5 g) injected deeply in the upper outer quadrant of both buttocks through a 20-gauge needle. If convulsions persist after 15 min, give up to 2 g more intravenously as a 20% solution at a rate not to exceed 1 g/min. If the woman is large, up to 4 g may be given slowly Every 4 hr thereafter give 5 g of a 50% solution of magnesium sulfate injected deeply in the upper outer quadrant of alternate buttocks, but only after ensuring that:  a. The patellar reflex is present,  b. Respirations are not depressed, and  c. Urine output the previous 4 hr exceeded 100 mL Magnesium sulfate is discontinued 24 hr after delivery
  130. 130. Watch out! Patellar reflexes disappear when the plasma magnesium level reaches 10 meq/L—about 12 mg/dL—presumably because of a curariform action. This sign serves to warn of impending magnesium toxicity. When plasma levels rise above 10 meq/L, breathing becomes weakened, and at 12 meq/L or more, respiratory paralysis and respiratory arrest follow.
  131. 131. Remedy Treatment with calcium gluconate or calcium chloride, 1 g intravenously, along with withholding further magnesium sulfate, usually reverses mild to moderate respiratory depression.
  132. 132. Exercises that a pregnant womancan do:1. Head lift2. Head lift with pelvic tilt3. Pelvic tilt4. Leg sliding5. Trunk curls6. Modified bicycle7. Standing push ups8. Supine Bridging9. Quadruped leg raising10. Modified squatting11. Scapular Retractions12. Self stretching
  133. 133. Head Lift Hook-lying with her hands crossed over midline at the level of the diastasis for support. Have the woman exhale and lift only her head off the floor or until the point just before a bulge appears. At the same time, her hands should gently approximate the rectus muscles toward midline (Fig. 23.8). Then have the woman lower her head slowly and relax. This exercise emphasizes the rectus abdominis muscle and minimizes the obliques.
  134. 134. Head Lift with Pelvic Tilt The arms are crossed over the diastasis for support as above. Have the patient slowly lift her head off the floor while approximating the rectus muscles and performing a posterior pelvic tilt, then slowly lower her head and relax. All abdominal contractions should be performed with an exhalation so that intra-abdominal pressure is minimized.
  135. 135. Quadruped leg raising On hands and knees(hands may be in fists or palms open and flat). Instruct the woman to first perform a posterior pelvic tilt, and then slowly lift one leg, extending the hip to a level no higher than the pelvis while maintaining the posterior pelvic tilt. She then slowly lowers the leg and repeats with the opposite side. The knee may remain flexed or can be straightened throughout the exercise. Monitor this exercise and discontinue if there is stress on the sacroiliac joints or ligaments. If the woman cannot stabilize the pelvis while lifting the leg, have her just slide one leg posteriorly along the floor and return
  136. 136. Modified Bicycle The woman is supine with one lower extremity flexed and the other partially extended. The lower abdominals stabilize the pelvis as the lower extremities flex and extend in an alternating pattern as if cycling. The further the lower extremities extend, the greater the resistance. In order to not strain the back, the woman must keep it flat against the floor by controlling the arc of the cycling pattern.
  137. 137. Standing Push-Ups Standing, facing a wall, feet pointing straight forward, shoulder-width apart, and approximately an arm- length away from the wall. The palms are placed on the wall at shoulder height. Have the woman slowly bend the elbows, bringing her upper body close to the wall, maintaining a stable pelvic tilt, and keeping the heels on the floor. Her elbows should be shoulder height. She then slowly pushes with her arms, bringing the body back to the original position.

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