OB-GYNE ROTATION ~ NOTES

PRENATAL CARE
Prenatal care encompasses: risk assessment,
medical
care,
social
services,
nutritional
counseling, patient education, psychological
support.

Antenatal and prenatal care a planned program

of
medical
evaluation
and
management,
observation, and education of the pregnant woman
directed toward making pregnancy, labor and
delivery and the postpartum recovery, a safe and
satisfying experience.

DEFINITIONS:
Parity - The completion of any pregnancy beyond
the stage of abortion bestows parity upon a
woman. It is the number of pregnancies reaching
viability, and not the number of fetuses delivered
that determines parity. Parity is the same whether
a single fetus, twins or quadruplets were born alive
or stillborn.
Nullipara a woman who has never completed a
pregnancy beyond the age of viability or beyond an
abortion
Primipara a woman who has delivered only one
of a fetus or fetuses which reached viability.
Multipara a woman who has completed 2 or
more pregnancies to viability.
Gravida a woman who is or has been pregnant
irrespective of the pregnancy outcome. With the
establishment of the 1st pregnancy, she becomes a
Primigravida, and with successive pregnancy, a
Multigravida;
Nulligravida a woman who is not now and never
has been pregnant
Parturient a woman in labor

complete past, family history, good OB

resume
OB resume should emphasize on
menstrual history, evidence of fertility,
careful inquiry into previous pregnancies
Time in gestation when labor occurred,
duration, type of delivery, complications,
weight and sex of baby
Indications/conditions
surrounding
operative deliveries
Postpartum course of mother and fetus
and latters well-being
Symptoms during present pregnancy
Womans reaction to pregnancy
Dietary history useful in estimating the
adequacy of mothers nutritional intake

PHYSICAL EXAMINATION
includes examination of the ocular fundi,
ears, nose, heart, lungs, breasts,
abdomen, extremities, weight, BP
value of breastfeeding should be
emphasized on the patient during
examination of the breasts
venous pattern should be carefully
recorded in the examination of the
extremities;
varicosities
tend
to
worsen/appear during pregnancy
RECTAL AND RECTOVAGINAL EXAMINATION
to evaluate the integrity of the perineum
and the continence of the rectal sphincter
to detect possible presence and extent of
rectocoele and to rule out pathologic
condition of the rectum.
LABORATORY EXAMINATIONS
CBC, blood type, Rh antibody screen,
serologic test for syphilis, rubella antibody
titer, screen for Hepa B virus on the last
trimester, urinalysis (screen for bacteria),
HIV, Chlamydia, cytology, diabetes
(glucose challenge test), which is usually
done on the 24th-28th week

Puerpera a woman who had just given birth

OB SCORE
Ex: 5-1-2-5
1st digit: # of pregnancies terminating at
term
2nd digit: # of pregnancies terminating
prematurely (<37 weeks)
3rd digit: # of abortions (<20weeks)
4th digit: # of children currently alive
INITIAL COMPREHENSIVE EVALUATION
Goals:
define the health status of the mother and
the fetus
determine the gestational age of the fetus
initiate plan for continuing obstetric care
define those at risk for complications and
to minimize that risk whenever possible
HISTORY

PRENATAL INSTRUCTIONS
1. Inform the patient of any problems and discuss
the plan and management
2. Begin the antepartum educational program by
means of personal interviews, reading materials
and hospital classes
3. Explain future visits
4. Discuss the economic aspect of pregnancy
5. Give instructions about diet, relaxation and
sleep, bowel habits, exercise, bathing, taking
recreation, sexual intercourse, smoking, drug and
alcohol ingestion
6. Emphasize danger signals
Ten Danger Signs:
1. vaginal bleeding
2. swelling of the face and fingers
3. severe or continuous headache
4. dizziness or blurring of vision
5. abdominal pain/epigastric pain

6.
7.
8.
9.
10.

persistent vomiting
dysuria
decreased fetal movement
fever or chills
escape of fluid from the vagina

FREQUENCY OF VISITS
until 28 weeks every 4 weeks
29 weeks to 36 weeks every 2 weeks
Thereafter weekly

visit more often in patients belonging to

high risk group

WHO recommends 5 visits throughout the

pregnancy

3 visits is the minimum, with the 1 st visit

during the 1st trimester
SUBSEQUENT PRENATAL CARE
Maternal Evaluation
Fetal Evaluation
1. FHR
2. size of fetus, actual and rate of change
3. amount of amniotic fluid
4. presenting part and station (late in
pregnancy)
5. fetal activity
SUBSEQUENT LABORATORY TESTS
Nutrition During Pregnancy
Recommended Dietary Allowances (RDA)
Calories
Protein
Carbohydrates
Dietary Fiber
Fats
Minerals
Phosphorus
Iron
Zinc
Iodine
Other Minerals
Vitamins
Vitamin A
Vitamin B1 or Thiamine
Vit B2 or Riboflavin
Vit B6 or Pyridoxine
Niacin
Vit C or Ascorbic Acid
Vit D and Vit E
General Hygiene
Exercise
Bathing
Clothing
Bowel habits
Sexual relations
Douches
Care of the teeth
Prenatal Counseling
Drugs, medications and immunizations during
pregnancy
Employment
Alcohol
Caffeine
Common Complaints During Pregnancy

Nausea and Vomiting

Back pain
Varicosities
Hemorrhoids
Heartburn
Pica
Ptyalism
Fatigue
Headache
Leukorrhea
Trichomonas Vaginalis
Candidiasis or Moniliasis
Gardnerella vaginalis
MANIFESTATIONS OF PREGNANCY
I. Presumptive Evidence of Pregnancy
A. Presumptive Symptoms
1. Nausea with or without vomiting
2. disturbances in urination
3. fatigue
4. perception of fetal movement
5. breast tenderness and tingling sensation
B. Presumptive Signs
1. cessation of menstruation
2. anatomical breast changes
3. changes in the vaginal mucosa
4. skin pigmentation changes
5. thermal signs
II. Probable Evidence of Pregnancy
1. enlargement of the abdomen
2. changes in the size, shape and consistency of
the uterus
3. anatomical changes in the cervi
4. Braxton-Hicks contraction
5. ballottement
6. physical outlining of the fetus
7. positive results of endocrine tests
III. Positive Evidence of Pregnancy
1. identification of fetal heart tones
2. perception of active fetal movement by the
examiner
3. recognition of the embryo or fetus by ultrasound
4. recognition of the embryo or fetus by radiological
method
PRENATAL CHECK-UP
According to book:
0-32weeks AOG monthly
32-36weeks AOG every 2 weeks
36 weeks AOG to delivery every 1 week
FBGH-OPS:
0-28 weeks AOG monthly
29-36 weeks AOG every 2 weeks
>37 weeks AOG every 1 week
ESTIMATION OF DURATION OF PREGNANCY
1. Naegeles Rule
3 months + 7 days
2. Timing from ovulation
Date of last ovulation + 267 days =
estimated date of delivery
3. Quickening

4. Height of Fundus
12 weeks fundus above symphysis
pubis
16 weeks halfway between symphysis
pubis and umbilicus
20 weeks level of umbilicus
36 weeks below ensiform cartilage
* fundic height corresponds vis--vis to AOG from
16-32 weeks AOG
5. Ultrasound
6. Timing by trimesters
ESTIMATED FETAL WEIGHT
Johnsons rule used clinically to correlate fundic
ht w/ fetal wt
unengaged head: EFW (in grams) =
(fundic ht 12) x 155
engaged head: EFW (in grams) = (fundic
ht 11) x 155
* For patients > 200 lbs, 12 or 11 is raised by 1.
LEOPOLDS MANEUVERS
L1
- also called the fundal grip
- answers the question: What fetal pole/part
occupies the fundus?
Head: round, mobile, and balottable
Breech: irregular, nodular
L2
- also called the umbilical grip
- answers the question: On which side is the fetal
back?
- back: linear, convex, bony ridge
- small parts: numerous nodulations
L3
- also called the Pawliks grip
- answers the question: What fetal part lies above
the pelvic inlet?
- head not engaged: head recognized as round,
balottable object that can easily be displaced
forward
- head engaged: shoulder felt as a relatively fixed,
knoblike part
L4
- also called the pelvic grip
- answers the question: On which side is the
cephalic prominence?
- confirms the finding of the 3rd maneuver
- determines the attitude of the fetus in utero
- flexion attitude: cephalic prominence is on the
same side as the small parts
- extension attitudes: cephalic prominence is on the
same side as the fetal back
THE PASSAGES
Bony Pelvis

2 innominate bones: sacrum, coccyx

Joints: 2 sacroiliac, sacrococcygeal,

symphysis pubis
1. False (Major)
Boundaries: superior - Iliac crest
posterior - lumbar vertebrae
lateral - Iliac fossae
anterior - abdominal wall
2. True (Minor)

Boundaries: superior - linea terminalis

posterior - sacral prominence & ala of sacrum
anterior superior border of pubic bones
Ligaments: sacroiliac joints and symphysis
pubis; relaxes during pregnancy & increases in
diameter by 1.5 - 2cm; then regresses postpartum,
complete by 5th month postpartum
PEVIC PLANES
A. Pelvic Inlet
- brim of true pelvis
1. Anteroposterior Diameter
a. Diagonal conjugate
- lower border of symphysis pubis to midpoint of
sacral promontory
~ 12cm; only A-P diameter measured clinically
b. True Anatomic conjugate
- upper margin of inner border of symphysis pubis
~ 11cm; measured indirectly; equal to diagonal
conjugate 1.2cm
c. Obstetric conjugate
- midline of inner surface of symphysis pubis to
midpoint of sacral promontory
~ 10cm; equal to diagonal conjugate 1.5 to 2 cm
- can also be measured by
2. Transverse Diameter
- distance between 2 farthest points of the pelvic
brim over the iliopectineal line; ~ 13cm
- at ~ 4cm from the prominence, it bisects the
obstetrical conjugate and the segment that
corresponds to the distance between this junction
and the prominence is posterior sagittal of the
inlet
3. Right and Left Oblique Diameters
- from sacroiliac joints to opposite iliopubic
eminences
~ 13cm
B. Plane of Greatest Pelvic Diameter
- roomiest plane
- boundaries: posterior S2 to S3
lateral ischial bones
anterior middle surface of smphysis
pubis
equal to A-P and Transverse diameters
~12.5cm
C. Midpelvis
- clinical assessment not possible
- (+) midpelvic contraction if any of the ff is elicited
on IE:
- prominence of ischial spine, pelvic side
walls, convergent, concavity of sacum shallow, biischial diameter of outlet < 8cm
D. Pelvic Outlet
- boundaries: anterior pubic arch
lateral ischio-pubic rami, ischial tuberosity,
sacrotuberous ligaments
posterior tip of coccyx
- with 2 triangular planes with common base
formed by joining 2 ischial tuberosities

PELVIC
SHAPES
(CALDWELL-MALLOY
Classsification)
- posterior segment determines more the type of
pelvis
- anterior segment determines more the tendency
1. Gynecoid round
2. Anthropoid anteroposterior oval
3. Android triangular
4. Platypelloid transversely oval
X-RAY PELVIMETRY
Acceptable Indications:
1. previous pelvic injury or disease affecting the
bony pelvis
2. breech position when vaginal delivery is
anticipated
Soft Parts of the Pelvis
Pelvic Floor
- muscular portion of pelvic cavity and perineum, 3
sets of levator ani composed of ilio-, ischio-,
pubococcygeus
- upper surface is concave, covered by parietal
layer of the pelvic fascia; inferior surface is convex,
covered also by fascia
- fascia and muscles: comprise the pelvic
diaphragm
Pelvic Diaphragm
- supplied by S4, inferior rectal nerve, perineal
branch of pudendal nerve
- support pelvic organs; puborectalis helps in
control of external anal sphincter; iliococcygeus
helps stabilize sacroiliac and sacrococcygeal joints
- 2 Hiatus of Pelvic diaphragm
1. Hiatus urogenitalis where urethra and vagina
pass
2. Hiatus rectalis transmits rectum
Perineum
- resembles a diamond divided into 2 triangles
1. Urogenital triangle
- anterior; pierced by terminal portions of vagina
and urethra
2. Anal triangle
- contains terminal portion of rectum, external anal
sphincter, anococcygeal body, ischiorectal fossa
Perineal Body
- central part of perineum; pyramid-shaped; 4x4cm
- cut during medial episiotomy
THE PASSENGER
A. Fetal Attitude
- relation of the fetal parts to one another
B. Lie
- relation of the long axis of the fetus to the long
axis of the mother
1. longitudinal
2. transverse
3. oblique
C. Presentation
- part of the fetus lying over the inlet
1. Cephalic
a. Vertex / Occiput
- fetal head is fully flexed

- occiput/posterior fontanel is the presenting part

- suboccipito bregmatic diameter is presented
(9.5cm at term) as the shortest anteroposterior
diameter
b. Sinciput / Military
- fetal head is partially flexed
- bregma / anterior fontanel is the presenting part
- occipitofrontal plane (12.5cm at term) is
presented
- gradually changes to full flexion (vertex) as the
head advances into the pelvis unless mobility is
impaired in the fetal neck or in the atlanto-occipital
articulation
c. Brow
- fetal head partially extended
- occipitofrontal plane is presented (13.5cm at
term)
- almost always converted into face presentation by
extension and does not advance through the pelvis
unless the head is extremely small or the pelvis is
huge.
d. Face
- fetal neck sharply extended so that occiput and
back of fetus come in contact
- face is foremost in the birth canal
- submentobregmatic diameter (9.5cm at term) is
presented
- permits advancement through the pelvis but
vaginal delivery may result in injury to the cervical
spinal cord; in general, evidence for marked
hypertension of the fetal head after labor has
begun is considered an indication of CS
2. Breech
a. Frank
- thighs are flexed on the abdomen and the legs
are extended over the anterior surfaces of the
body, thus the feet of the fetus lie in proximity to the
head
b. Complete
- thighs are flexed on the abdomen, legs are flexed
upon the thighs, and the feet present at the level of
the buttocks
c. Incomplete
- one or both thighs are extended so that the feet
and legs are below the level of the buttocks
- possibility of compression of a prolapsed cord, or
a cord entangled around the extremities as the
breech fits the pelvis is a threat to the fetus
1.) Single footling 1 leg is completely
extended and the other flexed
2.) Double footling both legs are
extended below the level of the buttocks
3. Shoulder
- a shoulder or an acromion is usually presenting
into the pelvic inlet in a transverse lie
4. Compound
- prolapse of the fetal hand alongside the
presenting vertex, or breech or foot alongside the
head
D. Position

- relation of the point of direction to 1 of the 4

quadrants or to the transverse diameter of the
maternal pelvis
Cephalic: left occipito-anerior; left occipitoposterior; left occipito-transverse; right occipitoanterior; right occipito-posterior; right occipitotransverse
Face: left mento-anterior; left mentoposterior; left mento-transverse; right mentoanterior; right mento-posterior; right mentotransverse
Shoulder: left sacro-anterior; left sacroposterior; left sacro-transverse; right sacro-anterior;
right sacro-posterior; right sacro-transverse
LABOR
Differentiation of Labor
Parameters
False
Labor
Character
of
Contraction
Regularity
Irregular

True Labor

Regular

interval

Long, may
disappear

Increases
gradually

intensity

Unchange,
may
disappear
Mostly
hypogastri
c

Increases
gradually

Radiation of pain

Effect
on
dilatation

cervical

Effect
on
cervical
effacement
Effect of sedation

Usually
long
&
closed
cervix
Does not
occur
May stop
contraction

Hypogastric
to
lumbosacra
l
Open and
effacing
cervix
Occurs and
progresses
Contraction
persists

Early Signs of Labor

1. Lightening
- decrease of fundic height which is the
consequence of the development of a well-formed
lower uterine segment, the descent of the fetal
head to or even through the pelvic inlet, and the
reduction of amniotic fluid volume
2. False Labor
- uterine contractions are characterized by
irregularity in occurrence and by brevity of duration;
often, discomfort produced is confined to the lower
abdomen and groin
3. Show
- a dependable sign of impending onset of labor;
consists of discharge from the vagina of a small
amount of blood-tinged mucus representing the
extension of the plug or mucus that was filling the
cervical canal during pregnancy
Characteristics of Uterine Contractions During
Labor:
1. painful
2. become more frequent

3.
4.

involuntary and independent of any

extrauterine control
enhanced by mechanical stretching of the
cervix
phenomenon referred to as Ferguson
reflex

Patterns of Cervical Dilatation

1. Latent Phase
- more variable, can be affected by a lot of
extraneous factors such as sedation (prolongation
of the latent phase) and myometrial stimulation
(shortening of latent phase; duration has little
bearing on the subsequent course of labor
2. Active Phase
A. Accelerated Phase
- usually predictive of the outcome of a particular
labor
B. Phase of Maximum Slope
- good measure of the over all efficiency of the
machine
C. Deceleration Phase
- reflective of fetopelvic relationship
Functional Divisions of Labor
1. Preparatory
- comprises the latent and acceleration phase
- only the cervical dilatation occurs while significant
changes take place in the ground substance
(collagen & other connective tissue substance) of
the cervix; can be affected by sedation &
conduction analgesia
2. Dilatation
- comprises the phase of maximum slope
- the time when dilatation occurs at its most rapid
rate and is principally unaffected by sedation or
conduction analgesia
3. Pelvic
- from deceleration phase to the 2nd stage
- where the Cardinal movements of the fetus
principally take place
Stages of Labor
A. 1st Stage from regular uterine contractions up
to full cervical dilatation
Dilatation
- refers to the degree of opening or diameter of
external os; expressed in cm
- maximum dilatation in labor is 10cm at which
point the cervix allow passage of a term-sized
infant
Effacement
- expressed in terms of shortening of the cervical
length
- average length of cervix is about 2 cms; if length
is reduced by half, it is said to be 50% effaced; if
cervix becomes as thin as the adjacent lower
uterine segment then it is said to be fully effaced
Station
- level to which the fetal presenting part has
descended into the maternal pelvis

- point of reference is the ischial spines

- ischial spine: Station 0
- ischial spine up: Station -1 to -3
- ischial spine down: Station +1 to +3
- if presenting part is descending from the inlet to
the level of the ischial spines then the Station is
designated at -3 to -1 and from the spines at +1 to
+3; each level differs by 1 cm
B. 2nd Stage from full cervical dilatation to
expulsion of fetus
Cardinal Movements of Labor:
1. engagement
2. descent
3. flexion
4. internal rotation
5. extension
6. external rotation
7. expulsion
C. 3rd Stage from expulsion of fetus to expulsion
of placenta
Signs of Placental Separation:
a. Calkins sign uterus becomes globular and
firmer
b. Sudden gush of blood
c. Uterus rises high up in the abdomen as the
detached placenta drops to the lower segment and
vagina
d. Umbilical cord lengthens or protrudes out of the
introitus
Mechanism of Placental Extrusion
1. Schultze Mechanism
- usual type; central type of placental separation;
blood from the placental site pours into the inverted
sac, not escaping externally until after extrusion of
the placenta
- Mnemonic: Shiny Schultze
2. Duncan Mechanism
- separation of placenta occurs first at the
periphery, with the result that blood collects
between the membranes and the uterine wall and
escapes from the vagina
- Mnemonic: Dirty Duncan
Degrees of Vaginal Laceration:
1st Degree: (vaginal mucosa)
- involves the fourchette, perineal skin & vaginal
mucosa
2nd Degree: (muscles)
- involves the fascia and muscles of the perineal
body
3rd Degree: (anal sphincter)
- extend from the vaginal mucosa, perineal skin &
fascia up to the anal sphincter but not the rectal
mucosa
4th Degree: (rectal mucosa)
- encompasses extension up to the rectal mucosa
D. 4th Stage from expulsion of placenta to 1hour
post-partum

Cevical Dilatation: Primigravid vs Multigravid

Primigravid
Multigravid
Latent phase
8 hours
5 hours
1st stage
20 hours
14 hours
2nd stage
50mins 1hour 20 - 50mins
3rd stage
20 30mins
20 30mins
Dilatation
1.2cm/hr
1.5cm/hr
Descent
1cm/hr
2cm/hr
MONITORING OF UTERINE CONTRACTION
Sample Monitoring Form
Tim
Durati Inter
Inten
FH IE
Me
e
on
val
sity
T
ds
080
50
3min mod
14 3cm;
0H
secs
s
2
80%
effac
ed
Interval: ideal is 3 contractions in 10mins
- every 3-4mins good stimulation
Duration: ideal is 45-60secs
>60secs: titrate Oxytocin drip in decrements of 5
drops (Oxytocin is usually started at 20gtts/min)
<80secs: titrate Oxytocin drip in increments of 5
drops
>1min hyperstimulation
Problem: uterine contraction decreases blood
supply to fetus and there is decreased O2 which
may lead to:
1. hypoxia fetal distress
2. uterine rupture
3. abruption placenta
Intensity: mild, moderate, strong
FHT: monitor q 1hr
IE REPORTING
Normal: cervix firm, closed, nontender; uterus and
adnexae negative
PU: note dilatation, effacement, station, position,
BOW (intact or ruptured)
Example: cervix dilated to 7cm, 70% effaced,
station 0, cephalic, intact BOW
Threatened Abortion: cervix closed, uterus
enlarged to __ weeks AOG/ to 2-3months size,
adnexae
(-)
mass/tenderness,
with
minimal/moderate bleeding
Incomplete Abortion: cervix open, uterus slightly
enlarged, adnexae (-) mass/tenderness, with
minimal/moderate bleeding
NSD Discharge IE: episiorrhaphy dry and wellcoaptated, uterus well-contracted, with minimal
bleeding, no packing
NORMAL SPECULUM EXAM REPORTING
cervix is pinkish, smooth, no polyps, no
erosions, no bleeding, with scanty,

whitish,
non-foul
discharge

smelling

vaginal

ULTRASOUND
Look for:
1. General Survey
- # of fetus (ex: singleton)
- presentation (ex: cephalic)
- FHR
- AFI/SVP (ex: 12.5cm)
<10cm = oligohydramnios
- Placenta (ex: posterofundal)
Grade (ex: II)
- cervix shape
- cervix length
2. Biometry BPD, HC, AC, FL, EDD, EFW
3. Non-biometric cerebellum, colonic grade,
distal fem ep., proximal tib ep., proximal hum
ep.
4. Ratios CI, FL/BPD, HC/AC, FL/AC
5. Diagnosis shows if PU and with information
on amniotic fluid, placenta and grading
6. Doppler indices uterine artery R, uterine
artery L, umbilical artery, FDTA, MCA,
umbilical artery/MCA ratio, uterine artery notch
7. Fetal Anatomic Survey face, lateral ventricle,
trans cerebral diameter, cisterna magna, post.
nuchal fold, 4-C heart, stomach, kidney, spine,
bladder
0-15 weeks AOG transvaginal
16-35 weeks AOG transabdominal/pelvic
>36 weeks AOG BPS with NST
Preferred by Maj Cayetano:
<8 weeks AOG transvaginal
8 weeks AOG and above transabdominal/pelvic
TEN DANGER SIGNS:
1. vaginal bleeding
2. swelling of face and fingers
3. severe or continuous headache
4. dizziness or blurring of vision
5. abdominal pain/epigastric pain
6. persistent vomiting
7. chills or fever
8. dysuria
9. escape of fluid from the vagina
10. marked change in intensity
frequency of fetal movement
Movements
(FBM)
Gross
Body
Movement

Fetal Tone

FBM at least
30sec duration
in
30mins
observation
At
least
3
discrete
body/limb
movements in
30mins
(episodes
of
activity
continuous)
At
least
1
episode
of

Qualitative
AFV

return of partial
flexion
or
movement of
limb
in
full
extension
or
absent
fetal
movement
<2 episodes of
acceleration of
FHR
or
acceleration of
<15 bpm in 30
mins
Either no AF
pockets
or
pocket <1cm in
2 perpendicular
planes

GRADING OF PLACENTA
Grade 0 no calcification, no indentation on
chorionic plate
I few calcification throughout the
placenta
II calcification along the uterine wall and
indentations on the chorionic plate
III significant calcium deposits and
indentations on the chorionic plate that appear to
outline individual cotyledons
ELECTRONIC FETAL MONITORING
Contraction Stress Test
- also known as Oxytocin Challenge Test;
measures of the uteroplacental function; evaluates
reaction of the fetal heart rate to contractions
induced by either nipple stimulation or oxytocin
administration
- testing initiated once with frequency of 3
contractions/10mins

and/or

Episodes
>30sec
30mins

Reactive FHR

active
extension with
return to flexion
of fetal limb(s)
or
trunk.
Opening
&
closing of hand
considered
normal tone
At
least
2
episodes
of
FHR
acceleration of
>15bpm & of at
least
15sec
duration
At
least
1
pocket of AF
measures 1cm
in
2
perpendicular
planes

of
in

2
or
fewer
episodes
of
body/limb
movements in
30 mins

Either
slow
extension with

1. Positive there is consistent & persistent late

deceleration (>50%) of the fetal heartbeat in the
absence of uterine hypertonus or supine
hypertension
2. Negative at least 3 contractions in 10mins,
each lasting for 40secs, without late deceleration
3. Suspicious inconstant late deceleration
4. Hyperstimulation uterine contractions occur
more frequent than every 2mins, or lasting >
90secs, or presence of uterine hypertonus
5. Unsatisfactory frequency of contractions is <3
per min, or the tracing is poor
NON STRESS TEST
- relies on fetal heart rate reactivity

1. Reactive at least 2 accelerations of the fetal

heart rate occurs for at least 15beats/min, lasting
for 15secs within 20-minute observation
2. Non-reactive when fetal heart rate pattern
does not satisfy the criteria for reactivity
BIOPHYSICAL PROFILE
A. Complete 5 components:
1. size of AF pockets
2. presence of fetal breathing movement
3. presence of gross body movement
4. presence of extremity extension, flexion
B. Modified BPP
1. NST most predictive for immediate
assessment of placental function
2. AF measurement most predictive for long term
assessment of placental function
Interpretation:
a.
b.
c.

Negative test score of 8-10

Equivocal test 4-6
Positive 0-2

INTRAPARTUM ELECTRONIC FETAL

MONITORING
1. Early Deceleration decelerations begin with
the onset of a contraction & return to baseline at
the end of the contraction with the nadir occurring
at the peak of each contraction seen during early
active phase of labor and after rupture of
membranes
- 2o to head compression and usually not
associated with hypoxia or acidosis
2. Late Deceleration onset of deceleration
occurs after the onset of the contraction (usually at
the peak); the nadir occurs after the peak of
contraction and the baseline rate recovers after the
end of the contraction
- connotes uteroplacental insufficiency
3. Variable Deceleration most common type of
periodic deceleration
- occurs before, during, or after the contraction, or
even w/o contraction
- due to cord compression and sudden cessation of
umbilical flow
- most frequently associated with clinical diagnosis
of fetal distress
DIAGNOSIS OF FETAL DISTRESS
1. Warning signals
a. mild cord compression (variable deceleration)
b. tachycardia - > 160 bpm
2. Ominous Signs
a. cord compression (variable decelerations)
lasting for > 1min and drops to < 60 bpm and even
becomes progressively worse
b. uteroplacental insufficiency (persistent late
decelerations) of any magnitude with or without
tachycardia with decreased baseline variability; a
very smooth baseline is associated with more
serious condition
c. sinusoidal patterns baseline oscillations at a
frequency of 2-5/min, varying from 1-15 bpm, with
the absence of heart activity; a rare pattern, usually
seen in fetuses with severe fetomaternal bleeding

Ectopic pregnancy = implantation

blastocyst anywhere else; 95% oviduct

of

the

Etiology:
1. Mechanical factors prevent/retard the
passage of ovum into uterine canal
a. Salphingitis (decrease ciliation of
tubal mucosa)
b. Peritubal adhesion (kinking of tube
and narrowing of lumen)
c. Developmental abnormalities of tube
(Des exposure in utero)
d. Previous ectopic pregnancy risk:
7-15% recurrence
e. Previous OR in the tube
f. Previous induced abortion
g. Tumor
h. Previous CS
2. Functional factors delayed passage
a. External migration of ovum
b. Menstrual influx
c. Altered tubal motility
i. High dose estrogen pill
Hypertensive Disorder:
1. Pregnancy-induced Hypertension
hypertension that develops as a consequence of
pregnancy and regresses post-partum
a. Hypertension w/o proteinuria or pathologic
edema
a.1 Mild Pre-eclampsia

BP of >140/90 mmHg

Proteinuria of 2+ or >300mg in 24-hour

collection

Edema
a.2 Severe Pre-eclampsia

BP of >160/90 mmHg

Proteinuria of 3-4+ or >5g in 24-hour urine

collection

Headache, visual disturbances, epigastric pain

Lab: 1. thrombocytopenia sec. to vasospasm,
microangiopathic hemolysis
2. Inc. liver enzymes hepatocellular
neurocirc edema & ischemia
Clinical Findings:
1. pulmonary edema inc. capillary
membrane fragility
2. oliguria intra-renal vasospasm
3. cyanosis R heart failure
2. Eclampsia neglected PIH. The seizure is
grand-mal. May appear before (in 25%), during
(50%) and after (25%).
3. Chronic HTN:
1. HTN (140/90) antecedent pregnancy
2. HTN detected before 20 weeks
3. Persistent HTN long after delivery
ROLL-OVER TEST: Patient placed in lateral
decubitus for at least 15mins and placed in prone
position. Take BP. If increase of 20mmHg or more,
an indication of PIH or preeclampsia

ABORTION
- termination of pregnancy by any means before 20
weeks AOG
- birth with < 500g (1.1lbs)
- crown-rump length of < 160mm (<16cm)
Incomplete Abortion
Symptoms: hypogastric pain, profuse vaginal
bleeding
History: passage of meaty material per
vagina/retention of placenta
IE: cervix soft, open with minimal bleeding, uterus
enlarged to 3 months size
P.E.: profuse bleeding, orthostatic dizziness,
decreased BP and PR
Diagnostics: CBC and Urinalysis
Management: - completion curettage;
- D5 LR with 10u Oxytocin at 30gtts/min
- Methylergometrine maleate if there is
continued moderate bleeding
Inevitable Abortion
Symptoms: hypogastric pain, menstrual-like
symptoms
History: passage of tissue or rupture of membrane
IE: cervix open, with dilated bleeding
Differential
Diagnosis:
incomplete
abortion,
threatened abortion, incompetent cervix
Management: - bed rest
D&C
Missed Abortion
Symptoms: vaginal bleeding/spotting
History: retention of dead products of conception
for > 8weeks which can lead to severe
coagulopathy
IE: cervix closed, uterus size not proportional to
AOG
Other clues: cessation of early signs & symptoms
of pregnancy, regression of breast size
Diagnostics: transvaginal ultrasound confirm
diagnosis
CBC, platelet count, PTT, blood typing,
Management: suction curettage
Threatened Abortion
Symptoms: vaginal bleeding during the 1 st half/20
weeks of pregnancy, nausea/vomiting, w/ or w/o
abdominal pain
History: w/o passage of tissue or rupture of
membrane
IE: cervix is closed, uterus is soft and size is
enlarged & compatible with AOG
Diagnostics: CBC
- Transabdominal UTZ detect fetal heart motion
by 7 weeks AOG; to determine consideration of
curettage
- serum quantitative HCG if <1000 IU/mL
unlikely the chance of fetal existence (non-viable)
Differential Diagnosis: H-mole, ectopic pregnancy
Management: bed rest
analgesic (Mefenamic Acid 500mg)
close monitoring; watch out for increased
bleeding, passage of tissue, fever
D&C

Complete Abortion
Symptoms: hypogastric pain, profuse vaginal
bleeding
History: complete passage of products of
conception
IE: cervix closed, uterus well-contracted
Diagnostics: CBC and Urinalysis
Management: Completion curettage especially in
8-14 weeks AOG
Conjugated Estrogen, 2 tabs OD
DILATATION & CURETTAGE
Completion Curettage
Fractional Curettage
>Therapeutic: stops
> Diagnostic:
bleeding
investigates the cause
of bleeding (ex: AUB,
hormonal intolerance,
post-menopausal
bleeding)
> Therapeutic: stops
bleeding
> Procedure:
> Procedure:
- dont scrape
- scrape endocervical
endocervical portion
portion
-insert hysterometer
- insert hysterometer
- scrape endometrial
- scrape endometrial
portion
portion
> only with 1 specimen
> with 2 specimens
(endometrial)
(endocervical &
endometrial)
PLACENTA PREVIA
Signs & Symptoms:
painless bleeding at late 2nd or 3rd
trimester
(+) uterine contraction
IE: should not be done with risk of torrential
hemorrhage
Diagnostic: UTZ accurate diagnosis
Management:
CS if >36 weeks AOG
Types :
1. Total placenta covers cervical os
completely
2. Partial internal os partially covered by
placenta
3. Marginal edge of placenta is at margin
of internal os
4. Low-lying placenta implanted in the
lower uterine segment
ABRUPTIO PLACENTA
- premature separation of normally implanted
placenta prior to onset of delivery
Signs & Symptoms:
vaginal bleeding (painful uterine bleeding)
uterine tenderness/back pain, fetal
distress, fetal death, frequent uterine
contraction
titanic
or
hypertonic
contraction
IE: should not be done
Diagnostics: no lab test nor diagnostic may
accurately detect diagnosis, diagnosis is based on
clinical grounds

pain usually sudden in onset, constant &

localized to the uterus
localized
or
generalized
uterine
tenderness
increase uterine tone
Management:
Mild: fetal monitoring, tocolysis with MgSO4, if
fetus is immature
Moderate to Severe: a.) blood replacement
because of possible massive bleeding
b.) delivery vaginal: preferred route if fetus is
already dead
- CS when with live, distressed fetus
Abruptio Placenta:
1. External (Overt) Abruption
a. blood (bright red/dark/clotted)
b. mild pain
c. degree of anemia & shock is equivalent to
blood loss
2. Internal (Concealed) Abruption
a. little vaginal bleeding (blood is trapped in
uterus)
b. pain is severe; uterus hard & tender
c. FH tone may be absent due to fetal demise
d. degree of shock is more than expected from
the amount of visible blood loss
MYOMA UTERI
most common uterine tumor
prevalent in age >35 yrs old
Signs & Symptoms:
1. abnormal menstrual bleeding
2. hypogastric pain mimic acute abdomen
3. constipation & urinary frequency
4. infertility
P.E.:
(+) firm mass upon bimanual pelvic examination;
uterus usually nontender and asymmetrical
Diagnosis: by transabdominal ultrasound
TYPES
Types
1. submucous
2. subserous
3. intramural
4.
interligamentous
5. pedunculated

Diagnosis
HSGhysteroscopy
Pelvic exam/
laparascopy/
UTZ
UTZ
UTZ
HSG/
laparoscopy

Management
Hysteroscopical
resection
GnRH agonist
suppression
Laparoscopic
resection
Laparoscopic
resection
Resection

Management:
1. GnRH agonist Leuprolide
2. Hysterectomy only definitive treatment