INTRO TO CLINICAL MEDICINE: OB

Breasts Hormones by Placenta

External Structures: HCG
• Nipple • 1st hormone produced
o Located at the center of the anterior • Basis of pregnancy
surface of each breast • Prolongs the life of the corpus luteum
o Has approximately 20 openings through
which milk is secreted Estrogen
• Areola • Hormone of women
o Dark pigmented skin that surrounds the • Promotes breast growth
nipple • Stimulates uterine growth
• Montgomery Tubercle
o Sebaceous glands in the areola Progesterone
• Hormone of mothers
Internal Structures • Maintains endometrial lining
• Acinar Cells / Alveolar / Acini • Reduces contractility of uterine muscles
o Produces milk
• Lactiferous Duct Fetal Membranes
o Passageway of milk • Chorionic
• Lactiferous Sinus o Outermost membrane
o Dilated portion of the duct located behind • Amniotic
the nipple that serves as reservoir of milk o Encloses the fetus
o Produces amniotic fluid
Hormones § 800-1,200 mL
• 99% water
Estrogen/Progesterone • 1% solid particles
• Stimulates development of the ductile and acinar § Protective mechanism
structures of the breast § Maintains constant temp
HPL § Aids in muscular development
• Stimulates breast development during pregnancy § Prevents pressure on cord
Oxytocin Umbilical cord
• Let-down reflex • 2 Arteries, 1 Vein (AVA)
• A PPG hormone that causes the lactiferous sinuses • Formed from amnion and chorion
to contract and forces milk forward through the • Connects fetus to placenta
nipple • About 21 inches at term
Prolactin • Functions:
• Milk production reflex o Transports O2 and nutrients to the fetus
• A APG hormone stimulated by decrease in estrogen o Return deoxygenated blood and waste
and progesterone levels after delivery of the product to the placenta
placenta
FETAL CIRCULATION
Fetal Growth and Development
UMBILICAL VEIN
Ovulation to Fertilization Ovum • Carries oxygenated blood
Fertilization to Implantation Zygote DUCTUS VENOSUS
Implantation – 5-8 weeks Embryo • Bypasses the fetal liver
5-8 weeks – Term Fetus FORAMEN OVALE
Embryo – fetus- Placental Conceptus • Bypasses fetal lungs
structures DUCTUS ARTERIOSUS
• Bypasses fetal lungs
Placenta UMBILICAL ARTERY
• Serves as fetal lungs, kidneys, GIT and as separate • Carry deoxygenated blood
endocrine organ
• Aries from trophoblast cells
• 500 g at term
• Matures at 12th week AOG

PREPARED BY: ARLEX C. ALTO 1 of 7

INTRO TO CLINICAL MEDICINE: OB
MILESTONE PHYSIOLOGIC CHANGES OF PREGNANCY

End of 4th Week Reproductive System

• Rudimentary organs Uterine Chnages
• Bud-like arms and legs • End of 12th week: above symphysis pubis
End of 8th Week • 20th – 22nd week: level of umbilicus
• Organogenesis is complete • 36th – 28th week: level of xiphoid process
• Resembles a human form
• Sonogram shows a gestational sac • Hegar’s Sign
End of 12th week o 6th week
• Sex is distinguishable o Extreme softening of lower uterine segment
• Placenta is fully developed • Braxton Hicks Contraction
• FHT is audible by Doppler o 12th week
End of 16th week o Practice contractions
• Quickening felt by mother o No cervical dilation
• Lanugo is well formed • Ballottement
• FHT is audible by Stethoscope o 16-20 weeks
End of 20th week o To toss about
• Quickening felt by examiner
• Vernix caseosa begins to form Cervical Changes
End of 24th week • Goodle’s Sign
• Lung surfactant production begins o Softening of the Cervix
• Hearing can be demonstrated o Resembles an ‘earlobe’
• Pupils react to light • Operculum
End of 28th week o Mucous plug in cervical canal
• Testes begin to descend o Seals out bacteria and helps prevent
infection
• Retinal blood vessels susceptible to damage from
high 02
Vaginal Changes
End of 32nd week
• Chadwick’s Sign
• Subcutaneous fat is present
o Bluish discoloration of the vulva
• Birth position assumed
o Increased sensitivity, heightened sexual
End of 36th week
responses
• Lanugo begins to diminish
• Lecithin/sphingomyelin ratio: 2:1
Breast changes
End of 40th week
• Increase in size, areola darkens
• Vernix caseosa is fully formed
• Blue vein becomes prominent
• Creases on the soles of the feet
• Colostrum can be expelled 16th week
• Weight: 3000g
INTEGUMENTARY SYSTEM
PSYCHOLOGICAL AND PHYSIOLOGICAL CHANGES OF
• Chloasma / Melasma
PREGNANCY
o Mask of pregnancy
1st trimester: Accepting the Pregnancy
o Darkened areas on the face
• Surprise, shock
o Increase MSH
• Ambivalence
• Linea Nigra
• Couvade syndrome o A narrow, dark line from umbilicus to
2nd Trimester: Acceptance of the baby symphysis
• Quickening • Striae gravidarum
• Narcissism o Pink, reddish streak on the abdominal wall
• Introversion/Extroversion o Rupture and atrophy of small segments of
• Fantasizing connective layer of the skin
3rd Trimester: Preparing for Parenthood
• Impatient with pregnancy RESPIRATORY SYSTEM
• Nest-building activities • Stuffiness of the nasopharynx
• Ensuring safe passage • Shortness of breath

PREPARED BY: ARLEX C. ALTO 2 of 7

INTRO TO CLINICAL MEDICINE: OB
§ 24th week – linea nigra, melasma,
CARDIO SYSTEM striae gravidarum
• Blood Volume • Probable
o Total circulatory increased 30-50% o Objective
o Pseudoanemia o More reliable
• Heart § 1st week – serum laboratory test
o Increased cardiac output (RIA, ELISA, RRA)
o Innocent heart murmurs; palpitations § 6th week – Chadwick, Goodle,
• BP Hegar’s, Ultrasound (Gestational
o Remains pre-pregnancy level Sac)
o Supine Hypotension Syndrome § 16th week – ballottement
• Blood Constitution § 20th week – Braxton Hicks, fetal
o Increased fibrinogen outline felt by examiner
o Increased WBC • Positive
o True diagnostic findings
GI SYSTEM § 8th week – UTZ (fetal outline)
• Slow emptying time of stomach and intestinal § 12th week – FHT audible by doppler
peristalsis § 20th week – fetal movement felt by
• Morning sickness examiner

URINARY SYSTEM Follow up Visit Schedule:

• Increased Urinary frequency, Output • Every 4 weeks through the 28th week
• Every 2 weeks through the 36th week
SKELETAL SYSTEM • Every week until delivery
• Gradual softening of pelvic ligaments and joints
• Pride of pregnancy – Lordosis of pregnancy
History of Pregnancies – GP
ENDOCRINE – placenta Gravidity (G)
• Estrogen • Number of pregnancies irrespective of gestational
o Breast and uterine enlargement age
• Progesterone Parity (P)
o Maintains the endometrium • Number of pregnancies that reached viability
o Inhibits uterine contraction • Not the number of fetus born
• Relaxin
o Inhibits uterine activity GTPAL (# of times delivered)
o Softens the cervix, and joints • G- number of pregnancies irrespective of AOG
• HCG • P- is broken down into:
o Stimulates progesterone and estrogen o T- Term BIRTH
synthesis o P- Preterm BIRTH
o Secreted by trophoblasts cells of placenta o A- Abortion
• HPL o L – Living Children
o Antagonist to insulin; making insulin less
effective GTPALM (# of infants delivered)
• G- number of pregnancies irrespective of AOG
SIGNS OF PREGNANCY • P- is broken down into:
o T- Term INFANT
• Presumptive o P- Preterm INFANT
o Subjective o A- Abortion
o Least indicative o L- Living children
§ 2nd week – breast changes, N&V, o M- Multiple Pregnancies
amenorrhea Estimated Date of Delivery (EDD)
§ 3rd week – urinary frequency Nagele’s Rule
§ 12th week – fatigue, uterine • Standard method used to predict a length of
enlargement pregnancy
§ 18th week – quickening • Get the 1st day of LMP, +7 Days -3 months

PREPARED BY: ARLEX C. ALTO 3 of 7

INTRO TO CLINICAL MEDICINE: OB
b. Uteroplacental insufficiency
Estimate the Fetal Growth 2. Variable Deceleration (¯ FHT)
McDonald’s Rule a. Unpredictable
• Common method of determining fetal growth b. Cord compression
• Symphysis-fundic ht measurement
• Distance from symphysis pubis to the uterine fundus DISCOMFORTS
in cm is = to the week of gestation between 20 and
31st week of pregnancy • Constipation
• To estimate AOG o Evacuate bowel regularly
o Fundic Ht in cm X 2/7 = AOG in months o Increase fiber in diet
o Fundic Ht in cm X 8/7 = AOG in weeks o Avoid gas forming foods, mineral oils,
Bartholomew’s Rule laxatives
• 12th week – symphysis pubis • N/V
• 16th week – halfway to umbilicus o Sensitivity to HCG
• 20th week – umbilicus o ­ E/P
• 30th week – halfway to xiphoid process o Mgt: eat dry crackers, small frequent
• 36 weeks – xiphoid process feeding
• 40th week – halfway to xiphoid process • Pyrosis
o Pressure of the uterus
LEOPOLDS Maneuver o Do not lie down immediately
• Systematic method of observation and palpation of o Maalox may be prescribed
the abdomen to determine the presentation and
position DANGER SIGNS OF PREGNANCY
• Vaginal bleeding
1st Maneuver: Fundal Grip • Persistent vomiting
Determines: whether fetal head or breech is in fundus • Chills and fever
(Presentation) • Sudden escape of clear fluid from vagina
• Abdominal / chesr pain
2nd Maneuver: Umbilical Grip • Increase / decrease Fetal movement
Determines: position • Painful urination
Locates: fetal back for FHT measurement • PIH

3rd Maneuver: Pawlick grip TERATOGENS

Determines: Engagement: fetal part at the inlet and its Maternal Infections (TORCH)
mobility • Toxoplasmosis
• Others (Syphilis, HBV, HIV)
4th Maneuver: Pelvic Grip • Rubella
Determines: Fetal Attitude • Cytomegalovirus
• Herpes Simplex Virus II

Normal FHT – 120-160 bpm HIGH RISK PREGNANCY

1. Acceleration (­ FHT) • Bleeding Disorders:
a. Temporary increase in FHT o 1st trimester
b. Fetal movement § Miscarriage
2. Early Deceleration § Ectopic Pregnancy
a. Periodic decreases in FHT o 2nd Trimester
b. Begins when contraction begins, ends when § Gestational Trophoblastic Disease
contraction ends § Premature Cervical Dilation
c. Head Compression o 3rd Trimester
§ Placenta Previa
Abnormal FHT pattern § Abruptio Placenta
1. Late deceleration (¯ FHT) § Preterm Labor
a. Delayed by 30-40 seconds at the
contraction and continue beyond the end of
contraction

PREPARED BY: ARLEX C. ALTO 4 of 7

INTRO TO CLINICAL MEDICINE: OB
Spontaneous Miscarriage: LABOR AND BIRTH
Types: Preliminary Signs
• Threatened – spotting; still pregnant • Lightening
• Inevitable – uterine contraction and cervical dilation; o Descent of the fetal presenting part into the
loss pelvis
• Complete – expulsion of entire product of o Relief from shortness of breath; increase in
conception urinary frequency
• Incomplete - retained • Increase in Level of Activity
• Missed – dies in uterus but not expelled o Release of epinephrine that prepares the
woman’s body for labor
GTD – Hydatidiform mole • Braxton Hicks Contractions
• Abnormal proliferation and degeneration of o Stronger uterine contractions before labor
trophoblastic villi begins
• PIH symptoms (less than 20 weeks) • Ripening of the cervix
o Goodle’s sign
Placenta Previa o Butter soft
• Low implantation of placenta
• Painless bleeding; bright red Signs of True Labor
o Low lying – lower uterus • Show
o Marginal – near cx oz o Pink-tinged vaginal discharge
o Partial – portion of cx oz • Uterine contractions
o Total – total cx oz o Productive uterine contractions that can
achieve cervical dilatation
Abruptio Placenta • Rupture of Membrane
• Painful bleeding o Sudden gush of clear fluid from the vagina
• Couvelaire Sign
False Labor True Labor
Betamethasone – hasten fetal lung maturity NO increase in Frequency, Increase in F, I, D
Intensity, Duration
PIH Disappears with ambulation Continues no matter what
• Proteinuria and sleep the activity
• Edema 1st felt abdominally and 1st felt in lower back,
• Hypertension remain confined in sweeps to abdomen
abdomen (girdling)
Types: Absence of cervical dilation Cervical effacement and
• Gestational Hypertension dilation
o BP 140/90
o No edema, No proteinuria 4 components of Labor
• Mild Preeclampsia • Passage – pelvis
o BP 140/90 • Passenger – fetus
o Mild edema • Power – uterine contractions
o Mild proteinuria • Psyche – psychological state of woman in labor
• Severe Preeclampsia
o BP 160/110 Fetal presentation and Position
o Extensive edema • Attitude
o Proteinuria +3 or +4 o Degree of flexion the fetus assumes during
o Visual Disturbances labor
• Eclampsia o Relation of fetal parts to each other
o With seizure • Engagement
o Settling of the presenting part to be at the
DOC: MagSu level of ischial spines
Antidote: CalGlu o 0 station
• Station
o Relationship of the fetal presenting part to
be at the level of ischial spine

PREPARED BY: ARLEX C. ALTO 5 of 7

INTRO TO CLINICAL MEDICINE: OB
o Degree of engagement Assess amniotic fluid:
o (-) above • Clear – normal
o (+) below • Yellow-stained – blood incompatibility
• Lie • Green – meconium stained
o Relationship of the long axis of the fetal • Gray – infection
body and the long axis of the woman’s body • Pink – bleeding
§ Longitudinal Lie – parallel • Brown – fetal death
§ Transverse / Horizontal Lie – FHR
perpendicular • Cephalic – heard loudest in the abdomen
o Below umbilicus; lower quadrant
Presentation o ROA- RLQ
• Denotes the body part that will first contact the o LOA- LLQ
cervix or be born first • Breech – heard loudest high in the uterus
• Cephalic Presentation – most common o Above umbilicus; upper quadrant
• Breech Presentation – either buttocks, feet o RSA – RUQ
o Complete – full flexion o LSA- LUQ
o Frank – moderate flexion; hips
flexed but knees extended Pain Mgt: Demerol
o Footling – poor flexion Antidote: Narcan (Naloxone)
o Neither the thigh nor the legs are
flexed 2. Second Stage: EXPULSIVE STAGE – full cervical
Position dilatation to birth of the infant
• Relation of the fetal presenting part to a specific a. Cardinal Movement of Labor (EDFIREERE)
quadrant of a woman’s pelvis i. Engagement
• 3 letter abbreviation ii. Descent
o Middle letter – fetal landmark (O, M, S, A) iii. Flexion
o First letter – mother’s R/L quadrant iv. Internal Rotation
o Last letter – mother’s anterior or Posterior v. Extension
§ LOA (Left Occipito Anterior) vi. External Rotation
• Most common fetal vii. Expulsion
position
§ ROA 3. Third Stage: PLACENTAL STAGE – birth of infant to
• Second most common delivery of the placenta
a. Signs of Placental Separation
STAGES of LABOR i. Change in the shape of uterus
ii. Lengthening of the cord
1. Cervical Stage – begins with true labor contractions iii. Sudden gush of vaginal blood
and end with full cervical dilatation b. Shultze Placenta – shiny; center first
a. Effacement – shortening and thinning c. Duncan Placenta – dirty; edges first
b. Dilation – enlargement or widening
Oxytocin – stimulates uterine contraction; control hemorrhafe
3 phases: Methylergonovine Maleate –(Methergine) – prevent bleeding
Criteria LATENT ACTIVE TRANSITION due to atony
Dilatation 0-3 4-7 8-10
Durtion 20-40 sec 40-60 sec 60-90 seec POSTPARTUM PHASE
Intensity Mild Moderate Strong • Taking-in
Frequency Every 5 min Every 3-5 Every 2-3 o Passive, sleep
min min • Taking-hold
o Mothering role
Stage of Labor Primipara Multipara • Letting-go
1st stage 12 ½ hr 7 hrs, 20 min o Role transition
2nd stage 80 min 30 min o Feeling of loss
3rd stage 10 min 10 min
TOTAL 14 hrs 8 hrs Postpartum blues – temporary feeling of sadness

PREPARED BY: ARLEX C. ALTO 6 of 7

INTRO TO CLINICAL MEDICINE: OB
PHYSIOLOGICAL CHANGES
• Involution – reproductive organ returns to their non-
pregnant state
• Lochia – uterine discharge following delivery

Type Color Day Composition

Rubra Red 1-3 Blood,
decidua,
mucus
Serosa Pink / 3-10 Leukocytes,
brownish blood,
mucus
Alba White / 10 days – 6 Mucus,
clear weeks leukocytes

COMPLICATIONS
• Uterine Atony
o Abnormal relaxation of uterus
o Most common cause of hemorrhage
• Laceration
o Tearing of the birth canal
• Retained placental fragments
o Portion of placenta is retained in the uterus
o Factors:
§ Placenta succenturiata – main
placenta with accessory lobe
§ Placenta accreta – deep
attachment to the myometrium

PREPARED BY: ARLEX C. ALTO 7 of 7