Midwifery 101 Module

Instructor: Ria A. Lozano-Doronila, RM, BSM

Obstetrics – from the Latin word OBSTARE means to standby.

 Is the health profession or medical specialty that deals with pregnancy,
child birth, and post-partum period including care of newborn.
 The midwife and Obstetrics.

ANATOMY and PHYSIOLOGY

 Female Reproductive Organ
1. Vulva/pudendum
 Refers to the entire female external Genitalia

 External Organs

 Mons Pubis or Mons Veneris

 A pads of fats above the symphisis pubis
 An important landmark and protects the symphisis from trauma
 Richy supplied sebaceous glands
 Hairless and smooth during childhood
 Becomes covered by curly hair called ESCUTCHON during
puberty
Hair growth:
Female: Triangular shape
Male: Assumes a diamond shape patterns.
 Hair growth is stimulated with testosterone while the pattern of hair growth is
due to the influence of estrogen

2. Labia Majora
 Are two thick folds of adipose tissues.

1
  It unites to form anterior commeasure and posterior
commeasure.
 Outer surface covered by hair and its inner aspects is thin,
smooth and moist.
 Provide protection and covers the external organs located under
it.

Nulliparous :
Closed to each other.

Miltiparous:
Tend to gape wider.

3. Labia Minora
 Are two thin folds of connective tissue that joins anteriorly from
the prepuce and posteriorly to form Fourchette
 It is torn during delivery
 Moist, highly vascular, sensitive and richly supplied with
sebaceous glands.

4. Clitoris
 Accessory organ of nervous system
 Capable in enlargement once stimulated
 It is known as the seat of a woman’s sexual arousal and
orgasm
 Is highly sensitive to both touch and temperature
 Landmark during female catherezation insertion.

5. Fourchette

2
  Posterior part of labia minora
 Cut during episiotomy
6. Vestibule
 Is triangular space between the labia minora where the vaginal
introitus, urethral meatus, Bartholin’s glands and skenes glands
are located.

7. Perineum
 Distance from the vagina to the anus.

 3 Holes
 Meatus
 Vagina
 Rectum
 Clitoris (accessory)
 Episiotomy
Surgical perineal cutting
 Episiorraphy
Surgical perineal repair.

 Glands
 Bartholin’s Gland
 Pair of glands that are also known as volvuvaginal glands, paravaginal
and major vestibular glands.
 Located at each inner side of the vagina and secrets mucus that helps
to keep the vaginal introitus lubricated.

 Alkaline
Nature enhances sperm survival.

 Skene’s Glands

3
  A pair of glands that are also known as the Para urethral and minor
vestibular glands.

 It is situated at each inner side of urethral meatus.

 Vaginal Orifice
 External Opening of the vagina, located just below the urethral meatus.

 Hymen
 Thin circular membrane made of elastic tissue situated at the vaginal
opening that separates the female internal and external organs.
 Naturally torn during first sexual intercourse, which may cause pain
and bleeding.

 Urethral Meatus
 The external opening of the female urethra, located just below the
clitoris.

 Ritgens Maneuver
 Applying perineal support
 Applying upward pressure at the coccygeal area.

 Benefit
Prevents rectal sphincter injury

 Pubococygeal and Levator Ani

 Perineal muscle
 Support the pelvic organs

 2 types of episiotomy

4
 1. Midline incision
Heals faster
Prone to rectal injury
2. Medio lateral Incision
Bloody
Delay healing process
Safe from rectal injury

 Different parts of Vestibule

1. Urinary Meatus
 For urine
2. Skene’s Glands
 Major part
 Paraurethral Gland
 Secrets Lubricant
3. Meatus
 Opening
 For catheter insertion
4. Vaginal Orifice
 External opening
5. Bartholin’s Glands
 Volvuvaginal Glands
 Secrets lubricants
 Dyspareunia
Painful coitus
Due to lack of lubricant

Skene Lubricants +Mucus

Glands Bartholine alkaline Neutral

5
Environment:
Ph Levels
 Acid – sperm will not survive
 Alkaline – sperm will survive

Good Bacteria in Vagina

 Dodorlein bacilli
Normal flora
Promotes acidity
Kills bad bacteria

FEMALES INTERNAL ORGANS

 Vagina
 Birth canal
 Discharges (menstruation)
 Organ of copulation (coitus)

 Vaginal pH
 Puberty : 6.8 to 7.2 (alkaline)
 After puberty : pH becomes acidic
4-5
 Uterus
 Hallow muscular canal resembling an inverted pear
 2.5 to 3 inches long, an inch thick, two inches wide and weights between
50-70 grams.

 Nulliparous
Corpus and cervix are the same size

6
 Multiparous
The corpus is larger than the cervix
After delivery it does not return to its pre-pregnant condition.

 Function
1. Its cardinal function is an organ of reproduction
2. Organ of menstruation
3. To expel fetus during labor (uterine contraction) and to seal torn blood
vessels after delivery of placenta.

 Parts
1. Fundus
 Used as obstetrical landmark during pregnancy
 Sight of implantation
2. Cornua
 The eraes of the uterus at which the fallopian tubes are attached
3. Isthmus
 Upper third of the cervix which is very tiny
 Cut during ligation
4. Corpus
 Body of the uterus which makes up two-third of the said organ
 It house’s the fetus during pregnancy
5. Cervix
 2.5 cm long
 2.5 cm diameter
 10% muscle fiber

 Parts of Cervix
Internal OS which opens to the corpus
Cervical canal which is spindle shape

7
 External OS which opens to vagina.
 Layers
1. Perimentrium
 Outermost serosal layer attached to the board ligaments
2. Myometrium
 Middle muscular layer responsible for uterine contraction during
labor
3. Endometrium
 Innermost muscular layer
 Containing numerous uterine gland that secrets a thin alkaline fluid
to keep the uterine cavity moist
 2 Layers of Endometrium
Glandular Layer
Basal Layers
 2 Zones of Endometrium
Zona Functionales
 Sheds during menstruation
Zona Basalis
 The one that generates

 Uterine Ligaments
 Supports the uterus
 Permits it to move freely
 10 Ligaments

1. Cardinal / transverse – cervical / Mackenrodt / Ligaments (2)

 The lower portion of the board ligaments
 Main support of the uterus
 Damage to this ligaments may causes uterine prolapsed

2. Board Ligaments / Peritoneal Ligaments (2)

8
  Originates from the sides of the corpus and extends to the lateral pelvic
walls
3. Round Ligaments (2)
 Connects the uterus to the labia minora
 During pregnancy these ligaments give stability to the uterus
4. Uterosacral Ligaments (2)
 Helps uterus in its normal position by maintaining traction of the
cervix.
5. Anterior Ligaments
 Provides support by the connecting portion of the supravaginal cervix
to the posterior surface of the bladder.
 Overstretching of this ligament will cause the bladder to drop a
condition called “cystocele”
6. Posterior Ligament
 Connects the posterior portion of the uterus to the rectum.

 Fallopian Tubes
o Measurements 10-14 cm
o Pair of tube – like structures originating from the cornua of the uterus
with distal ends located near the ovaries.

 Functions :
 Transport ovum from ovary to the uterus.
 The site of fertilization
 Provides nourishment to the ovum during its journey.
 Parts :
 Interstitial / Intramural
Thick wall, located inside the uterus and about 1 cm long.
 Isthmus
This is the narrowest portion of the uterus and is about 1 cm long
Site of tubal ligation

9
 Ampulla
The middle portion and the widest part.
Site of fertilization
 Infundibulum
The most distal portion
Finger – like projections called “FIMBRIA”
Longest fimbria is called “Fimbria Ovarica”
o Fimbria Ovarica guides the ovum to the oviduct during ovulation.
 Connects the fallopian tubes to the ovaries
 Layers of Fallopian Tube
1. Mucosal Layer
 Assist the transformation of the ovum from the ovary to the uterus.
2. Muscular layer
 Responsible from the peristaltic movement of the fallopian tube
 Rhythmic contractions 0f the fallopian tubes are strongest of the time of
ovulation and weakest during pregnancy.
3. Peritoneal Layer
 Outermost layer attached to the ligaments that keep the fallopian tube
suspended to its normal position.

 Ovaries
 Each ovaries weights between 6 -9 grams, 1.5 inch to 3 cm wide and 2 to
5 cm long
 Almond – shape glandular organs
 Located on the other side of the uterus
 Before puberty : smooth, flat and avoid organs
 Assume a nodular and pitted appearance
 At the tine ovulation: due to development of several follicles, the ovaries
may double in size temporarily.

10
 Functions :
1. Oogenesis
 The ovaries are responsible for the development and maturation of the
ovum.
 Production of the egg cell
 Release of mature egg cell
 Estrogen and Progesterone

2. Ovulation
 Refers to the release of ovum from the ovary

3. Hormone Production
 The ovaries are the main source of Estrogen and Progesterone in none
pregnant woman.
 Layers :
1. Tunica Albuginea
 Outermost protective layer
2. Cortex
 Functional layer of the ovaries.

 Two months intrauterine

 600,000 Oogenia (egg)
 5 months intrauterine
 6,800,000 Oogenia (egg)
 At birth
 2 million Oocytes
 Pre-puberty / childhood
 300,000 to 400,000 Oocytes
 36 years old
 30,000 to 40,000 Oocytes
 Menopause

11
  ABSENT

 Terms
 Ovulation
o Release of mature egg cell
 Fertilization
o Union of egg cell and sperm cell
 Implantation
o Process of imbedding fertilized ovum.
3. Medulla
 Contains blood vessels lymphatics, nerves and muscle fibers.

ANALOGOUS STRUCTURES IN THE MALE AND FEMALE REPRODUCTIVE

SYSTEM.

MALE FEMALE
Spermatozoa Ovum
Glands Penis Glands Clitoris
Scrotum Labia Majora
Penis Vagina
Testes Ovaries
Vas Deferens Fallopian Tube
Prostate Glands Skene’s Glands
Cowper’s Glands Bartholin’s Gland

THE MAMARY GLANDS

 Female breast are accessory organs of reproduction meant to provide the infant
with the most ideal nourishment after birth.

12
 Supported by the Cowper’s ligament.

 External structures
1. Nipple / Mammary Papillae
 Located at the center of the anterior surface of each breast.
 15 – 20 opening connected to lactiferous ducts which milks flows
out.

2. Areola
 Pigmented skin surrounds the nipple
 Both nipple and areola have pigmented and wrinkled skin.
3. Montgomery Tubercles
 Glands in the areola that secretes an oily substance that keeps the
areola and nipple lubricated.
 Internal structures
1. Lobes
 15 to 20 lobes are found in each breast that are into several
lobules.
2. Lobules
 composed of clusters of acini cells
3. Acini Cells
 These are the milk secreting cells of the breast that are stimulated
by prolactin hormone.
4. Lactiferous Ducts
 Ducts that serve as passage way of milk
5. Lactiferous Sinus
 Dilated portion of the ducts located behind the nipple that serve as
reservoir.
 Hormones that influence the Mammary Glands
1. Estrogen
 Stimulates development of the ductile structures of the breast.

13
 2. Progesterone
 Stimulates the development of the acinar structures of the breast
3. Human Placental Lactogen
 Promotes breast development during pregnancy
4. Oxytocin
 Let – down reflex. This hormone is inhibited by progesterone.
5. Prolactin
 Stimulates milk production
 Inhibited by estrogen

THE MALE EXTERNAL ORGANS

 Penis
 Male organ of copulation and urination
 Composed of three (3) longitudinal tissues
o Two corposa cavernosa
o One corposa spongiosum
 Blood flow in the penis is controlled by automatic nervous sytem and
blood supply is provided by penile artery.
 Connective tissue is called LEYDIG CELLS or INTERSTITIAK CELLS
which produce testosterone surround the seminiferous tissue containing
blood vessels

 Sertoli cells
o Cell transport
 Medical term
o Spermatozoon : 1 sperm
o Spermatozoa : plural
 Functions :
a. Hormone production

14
  Testes produce the hormone testosterone. Which stimulates
spermatogenesis and responsible for the development of secondary
male characteristics.
b. Spermatogenesis
 Production and maturation of sperm cell.

SPERMATOGENESIS OOGENESIS
Puberty to andropause Fetal life to menopause

 PARTS
a. Seminiferous tubules
o Long coiled where spermatogenesis takes place.
o Testes produce about 176 sperm cells a day.
o This tubes lead to the tightly coiled epididymis where the sperm
cells continue their travel and maturation.
b.Leydig cells / Intertistial Cells
o Produce testosterone, they are found around the seminiferous
tubules.
c. Sertoli Cells
o Also known as supporting cells which plays a role in sperm
transport.

d.Epididymis
o Is a long coiled tube approximately 20 feet long at which the
sperm travels for 12 to 20 days after it leaves the testis.
o It takes 64 days for the sperm to become mature.

e.Vas Deferens
o Stores the majority of sperms.

15
 o Passageway of the sperm cells from the epididymis in the testis
to the urethra.
o Surrounded by the arteries, veins and thick fibrous covering.
o It is part of the duct cut during vasectomy.
o Varicocele of blood in this area can cause congestion in the
testes that can result INFERTILITY.
f. Ejaculatory Duct
o The two ejaculatory duct pass through the urethra and then
connect the seminal vesicles
o It is the passageway of the semen.
g.Prostate Gland
o Found below the bladder
o Secrets 60% of the seminal fluid volume
o Responsible for rising the pH of the female vagina
o Provides lubricant during coitus

 pH = alkaline >7
 pH = alkaline <7

 Parts :
 Shaft of the body
 Glands Penis
o Enlarge end which is the most sensitive part.
 Prepuce of the skin
o It is a fold retractable skin covering the glands and which is
remove during circumcision

 In some cases the prepuce is to light and cannot be retracted over the
glands, this condition is called “PHIMOSIS”
 Urethral meatus

16
 o Is the slit like opening located at the tip of the penis which
serves as the passage – way of both semen and urine.
 Scrotum
 Is a saclike structure containing the testes that hang behind the penis
 Is covered by sparse hair after puberty, is wrinkled and has a darker
coloration than the rest of the body
 Supplied abundantly by sweat and sebaceous glands
 It has no sebaceous fats because the testes must be keep cool
 The skin of the scrotum is line by fascia and a smooth muscle layer.

 2 types of muscle
1. Dartos muscle
 Smooth muscle
 Causes shrinking of the scrotum. Contracts when environmental
temperature is cold to absorb more heat. Relaxes causing testes to
descend which lower the temperature when the body is too hot.
 It stabilized the temperature.
2. Cremaster Muscle
 Skeletal Muscle
 Elevates the testes
 Normal Temp of Testes: 36° C
 Rogue: scrotal wrinkles

THE MALE INTERNAL ORGANS

1 Testes
 Are oval shape glandular organs lying within the abdominal cavity in early fetal
life and descend in the scrotum after 28 weeks gestation.
 It is important for the testes to descend in the scrotum because the temperature
in the abdominal cavity is too warm.
 Each testis is about 4 to 5 cm long. Often one testis is slightly larger than other.

17
 This is usually the left testis.
 Covered with a sac serous membrane called the Tunica Vaginalis.
 The sac allows the testes free movement within the scrotum to avoid injury.
 Inflammation of tunica vaginalis accumulation of fluid within it. This condition is
called “HYDROCELE”
 The Tunica Albuginea is fibrous covering which divides the testis into 200 to 300
lobules.
 Lobules contains Semini ferrous Tubules in which sperm develops.

 Seminiferous Tubule means Spermatogenesis.

6. Cowpers Gland
 Produce 10% of seminal fluid.
 Other Name: Bolbourethral Gland.
7. Semen
 Seminal fluid is a mixture of secretions from the seminal vesicles,
prostate gland, cowpers gland, ejaculatory duct and sperm cells.
 Ejaculation is the forceful expulsion of semen

Derived Form:
Prostate Gland 60%
Seminal Vesicles 30%
Epididymis 5%
Bolbourethral Gland 5%

 Every ejaculation, the male body releases an approximate of 3-5 cc of semen

 Normal Volume: 3-5 cc or 100m/mL
 Sperm Cell Count: not less than or equal to 20m/L(≥)
 Sperm cell Motility: 50%
o It should 50% or more, if not the male is sterile. (≥50%)

18
REPRODUCTIVE DEVELOPMENT

 Sperm
 Male

X
Y

 Egg
 Female

 Female

 Male
X
Y

19
FETAL GROWTH AND DEVELOPMENT

A. The chromosomal sex or biological sex is formed at fertilization.

 Outline
Ovulation

Fertilization

Implantantaion

 Gonad
 Sex Gland
 Outline
 Sex Cells

 Outline

EGG CELL

OVA

OVUM

20
 OOCYTES

 Ovaries
 Graafian Follicles
 Contained egg cells

OOCYTES – primitive cells (young cells)

 Estrogen
 Corpus Luteum
Corpus means yellow
Lureum means body
 Male Gonad
 Sex cells
 Sperm cells

Spermatozoon

Spermatozoa

OVUM SPERM CELL

One day 2 days
24 hours 48-72 hours
2-3 days

 sperm cells
o smallest human body cells
o cool environment
 Egg Cells
o Warm environment

21
  TERMINOLOGIST

a. Azoospermia
Absence of sperm
Vasectomy needs 20 ejaculation before it will considered sterile.
b. Oligospermia
Inadequate amount of sperm
c. Asthenozoospermi
Non – moving sperm
d. Teratospermia
Defective shape sperm
e. Acrosome
Outer covering of sperm
f. Nyaluronidase
Enzymes release by the acrosome for penetration.
g. Zona pellucida
Inner membrane of the ovum.
The one that is penetrated.

Hyaluronidase

Zona Pellucida

 Fertilization
Penetration of sperm and egg
 Zygote
Product of fertilization

22
 Fertilized egg

Prenatal Development

 Stages
1. Fertilization
2. Zygote - 1st to 14 days
3. Embryo - 15th day to 8 weeks
4. Fetus - 9th weeks to birth

 Fertilization
 Single tone (single baby)
 Twin
Monozygotic (Identical Twins – always same sex, develops from 1
zygote, splits into 2 embryo)
Dizygotic (Fraternal twins – 2 egg cells fertilized by 2 sperm cells
mostly boy and girl.

Tanner Scale Assessment Tool

- It is use to determine the age of the female based to her pubic hair.

Stages of Pubic Hair Development

 Stage I : Preadolescene
 Stage II : Ages 11 to 12
Curly hair
Symphisis pubic
 Stage III : Darker curlier at Labia Majora
 Stage IV : Ages 13 to 14
Adult no appearance but NO inner thigh involvement
 Stage V : Sexual Maturity
Inner thigh movement

Definition of terms:

1. Adrenarche - increase secretion of androgens by the adrenal gland that

stimulates the development of pubic and axillary hair.
2. Gonadarche - initiation of hormone production by the gonads.
 Ovaries - estrogen and progesterone

23
  Testes – testosterone
3. Menarche – means first menstruation.
4. Thelarche - means breast development.

The Menstrual Cycle

Beginning of menses up to the beginning of the next menses.

Menstruation:

Normally:

1. Menarche – as early as 9 yrs old, as late as 17 yrs old.

2. Interval Between Cycle - 28 days (ideal)
3. Duration of Menses – 2 to 7 days or 1 to 9 days
4. Amount of Blood – 30 to 80 cc
5. Color – Dark Red
6. Odor – Merry – Gold (flower)
7. Iron Loss – 0.5 to 1 mg a daily

Abnormalities:

1. Hypomenorrhea – abnormal short duration of menstrual flow.

2. Hypermenorrhea – long duration of menstrual flow
3. Menorrhagia – profuse / excessive menstrual flow.
4. Metrorrhagia – profuse / excessive menstrual flow.
5. Oligomenorrhea – bleeding between periods.
6. Polygomenoria – frequent menses.
7. Amenorrhea – absence of menses.
8. Dysmenorrhea – painful menstruation.
 Intervention:
 Vitamin B6
 Vitamin E
 No Salt
 Regular Exercise
 Warm Bath
Increase temperature – vasodilation – (relieves pain)
9. Menstruation – periodic shedding of uterine lining.
10. Eunomorrhea – a term for regular menstruation.

24
  Hypothalamus - one that initiate puberty and menstruation.
 Ovaries – known as the female gonads that produce estrogen during 1 st
half of the cycle and progesterone during the 2nd half of the cycle.
 Estrogen – FSH stimulates the graafian follicles to produce estrogen.

 Effects of estrogen :
1. Inhibit follicle stimulating hormone.
2. Known as the hormone of women.
 It is the hormone that stimulates the development of female secondary
characteristics.
o Breast Growth
o Pubic Hair
o Development of Reproductive Organ
3. Stimulates proliferation of cells in the endometrium resulting in the endometrial
thickening.
4. Cause mucus to be thin, transparent and highly stretchable.
5. Stimulates the growth of ductile structures of the breast.
6. Menarche and menstruation.

 Progesterone – LH stimulates the corpus luteum to produce

progesterone.

 Effects of Progesterone.
1. Thermogenic effect.
2. Relaxes uterine muscles.
3. Promotes growth of the acini cells of the breast.
4. Causes weight gain by promoting fluid retention.
5. Is thought to be the cause of premenstrual syndrome (PMS).
6. Causes tingling sensation and feeling of fullness in the breast before
menstruation.
7. Secretory changes in the endometrium, stimulates endometrial glands to
create mucin and glycogen in the preparation of implantation.

Menstrual cycle

- Primary purpose of menstrual cycle is to prepare the uterus for pregnancy.

- Average duration for menstrual is 28 days but may vary between 20 to 40 days.

25
 - In healthy women, menstrual cycles continue from puberty to menopause,
interrupted only by pregnancy and lactation. (LAM) 6 months.

Phases of Ovarian Cycle

1. Follicular phase – time for ovulation, main event in this phase is the formation of
graafian follicle.

2. Luteal phase – post ovulatory phase, this period usually lasts for 14 days.
Variation range from 13 to 15 days. Corpus luteum life span is 7 days and if the
OVUM is fertilized after ovulation it will implant 6 – 7 days afterwards. The
implanted zygote will begin to produce Human Chronic Gonadotropin (HCG)
about 8 days after fertilization.

Phase of Endometrial Menstrual Cycle

1. Menstrual phase - begins on the first day of menses and extends

approximately over the first 5 days of the 28day day cycle.

 Total blood loss – 30 to 80 cc

 Losses – 10 to 20 liters of blood
 8 pads / day – full pads (blood) heavy flow.

2. Proliferative Phase – from day 6 to day 13 of a 28 day cycle, lasts for 8 – 10

days depending on the duration of cycle. This phase is also called follicular,
post menstrual and estrogen phase. Estrogen is lowest on the 3 rd day and
highest, a day before ovulation.

3. Secretory Phase – extends from 14th day to 25th day of menstrual cycle.

Signs of ovulation:

a. Mittelschmerz – refers to the lower abdominal pain felt at the side of the ovary
that releases the ovum.

26
b. Spinnbarkheit – does not indicate the exact time of ovulation but signals that a
woman is nearing ovulation or is ovulating. Watery mucus is thin, watery or
transparent. Increase basal body temperature.

c. Ischemic Phase – if fertilization does not take place, the corpus luteum shrivels
approximately 3 days before menstruation as its lifespan is only up to 7days from
ovulation. The onset of menstrual signals the beginning of another menstrual
cycle. Dysmenorrheal usually occurs in this phase.

Menopause
- Means “rang of the bladder” in Greek.
- Refers to the last menstrual period.
- Average menopausal age is 51 years old. Happens anytime between 45 to 55
years old.
- Early menarche is associated with early menopause.

Climacterium
- Means “change of life”
- Woman’s life when she undergoes a transition from the reproductive age to the
non-reproductive age.
- Fertility decreases and menstruation becomes irregular.
- Generally occurs between the ages of 45 to 55 years old and at times earlier in
some women.

Signs and Symptoms

M - Mood not stable / moody
E – Elevated LDL (prone to heart disease)
N – New allergies
O – Osteopherosis (decrease calcium)
P – Flushes
A – Appearance of facial hair
U – Urogenital dysuria and dyspareunia
S – Sleep disturbance
E – Encephalgia (headache)

Treatment:
 Hormone treatment
 Calcitonin

Pregnancy / Fetal Development

27
 Fetal Development
 20 weeks AOG
- The baby is able to survive outside the uterus.
- Depends the maturity of fetal central nervous system.
- Maturity of lungs.

 Nidation / implantation
- embedding of ovum to uterus.
- Time: 6-9 days after fertilization
- Average: 7 days

 Fundus
- Upper third segment of the uterus
- Sight of implantation.

 Zygote
- The first cell of the human body

 Ovum

- The ovum or egg cell is the female sex cell or gamete.

- Oogenesis refers to the development and maturation of the ovum.
- is regularly release by the ovary through the process of ovulation.
- It has two layers of protective covering, the Corona Radiata and the
inner layer is called Zona Pellucida.
- The egg cell has lifespan of 24hours, thus, it can only be fertilized within
this period. After 24 hours, it regresses and is reabsorbed.

 Sperm Cells
- Or a spermatozoon is the male sex cell or gamete.
- Spermatogenesis is the maturation of sperm cell. It takes about 64 days for the
sperm cells to attain maturity.
- Sperm cells has three parts.
Head – contains the chromatin materials
Neck – mid – peace that provides energy for movements
Tail – that is responsible for motility.
- It has lifespan of 28 to 72 hours or 2 to 3 days after ejaculation.

- Two kinds of sperm cell

28
 1. Gymnosperm - these are the X chromosomes carrying sperm cell with large
oval head and which produce a female offspring.
2. Andros perms – these are the Y chromosome carrying sperm cells with
small head which produce a Male offspring.
Embryonic and Fetal Structures
1. Decidua – endometrial lining during pregnancy.
2. Fetal Membranes
Chorion (outer) – closest to uterine wall and it becomes the
placenta.
Amnion – inner fetal membrane composes the amniotic sac and it
is called covering.
3. Embryonic Germ Layer
Endoderm – inner most layer and gives rise to the bladder, lining
of the gastrointestinal tract tonsils, thyroid gland and respiratory
systems.
Medosderm - it is the middle layer and the last germ layer to
develop and it gives rise to the kidney, musculoskeletal system
(bones and muscles), reproductive systems and cardiovascular
system (heart and blood vessels).
Ectoderm – outer most layer and it is the first germ layer to
develop and it gives rise to the skin, hair, nails, sense organs,
nervous system, mucous membrane of the mouth and anus.

4. Yolk sac - from blood vessels

5. Amniotic Sac / Bow – cushions (protects) the fetus, controls the

temperature, provides source of oral fluids and it contains amniotic fluids.

 Amniotic Fluid Amount : 500 to 1000 cc

 Color : clear semi – cloudy (normal)
Green – meconium stain
Yellow – blood incompatibility
Coffer Brown – Fetal Death
 Oligohydramnios – less than 500 cc
Effects: Fetal Distress.

 Polygohydramnios – more than 2000 cc

Effects: pre –term labor
Cause: GDM
29
 6. Placenta – fetal lung and it has 15-20 cotyledons (placental divisions)

Formations: 8th weeks (2 Months)

Functional Placenta: 10 – 12 weeks
Function: Hormone Producer

Two types of placenta

a. Shultz
o Shiny, bluish and smooth.
o Fetal side placental presentation.
b. Duncan
o Beefy, red and dirty
o Maternal side placental presentation.

7. umbilical cord
- 53 cm length
- 2 cm think
- Absence of pain receptor
- Blood flow: 400ml/min.
- 2 arteries and 1 vein

 Blastocyst - is a ball like structures composed of an inner cells mass

called embryonic disc blastocoels.
 Trophoblasts - it surrounds the blastocyst.
 Chorionic villi – tiny projection around the zygote.

Fetal Growth

1. Zygote – the cells that results from the fertilization of the ovum by the sperm
cells. The fertilized ovum from conception to two weeks.

2. Blastomere – mitotic divisions of the zygote gives rise to the daughter cells.

3. Morula – the solid ball of cells formed by 16 or more blastomere.

4. Blastocyst - after the morula reaches the uterus it is called blastocyst.

5. Embryo - extends from the 7th say to 7th week post conception. The zygote is
consider an embryo after the appearance of villi.

30
 6. Fetus – from the 8th week until the term.

7. Conceptus – refers to all productions of conception.

Assignment: Enumerate the product of conception.

Research : Easy guide for Fetal Development

Milestone in Fetal Development

Pregnancy Life

 Calendar months : 9 Months

 Lunar months : 10 Lunar Months
 Days : 280 Days
 Weeks : 40 Weeks
 Trimester : 3 Trimesters

 Psychological Changes During Pregnancy

1. HCG
- Human Chorionic Gonadotropin
- Increase progesterone

Intervention / Management

 Vomiting – (5x) small frequent feeding of crackers.

31
 2. Amenorrhea – absence of menses for 9 months.
3. Changes of Breast

4. Fatigue - body weakness

5. Lassitude – lack of energy

6. Urinary Frequency

7. Quickening – fetal movement at 18th – 20th week. Abdominal fluttering.

Changes in the Reproductive System

1. Uterus – changes in the uterine measurement.

Pre – Pregnancy Term Pregnancy

Weight 50 g 1100 g
Thickness 2 cm 0.5 cm
Length 6.5 cm 32 cm
Depth 2.5 cm 20 cm
Width 4 cm 24 cm
Capacity 10 ml 5000 ml

Growth of Fundic Height:

- As the products of conception grow, the fundic height also
increases during the duration of pregnancy.

12 weeks: at the level of the symphisis pubis.

16 weeks: halfway between symphisis pubis and umbilicus.
20 weeks: two fingers above the imbilicus
24 weeks: two fingers above the umbilicus.
28 – 30 weeks: midway between umbilicus and xiphoid process.
32 – 34 weeks: two fingers below xiphoid process.
36 weeks: at the level of the xiphoid process.
40 weeks: two fingers below umbilicus, drops at 34 weeks level
because of the lightning.

32
Psychological Changes during Pregnancy

Signs and Symptoms:

1. Presumptive Signs
- Subjective discomfort feels by patient.
- Morning sickness during first trimester
- Nausea and vomiting during pregnancy.
2. Probable Signs
- Objective, observe by midwife
3. Positive signs
- Confirmatory
 Hyperemesis Gravidarum
- If the pregnant women is still vomiting for 4 months. Increase in
progesterone.

 Presumptive Signs
1. Morning sickness
2. Amenorrhea
3. Changes in breast
4. Fatigue
5. Lassitude
6. Urinary frequency
7. Quickening

 Probable Signs

1. Ballotment / Braxton Hicks

o Ballotmeans means sinking and rebound of fetus
o Braxton means painless uterine contraction – 28
weeks (false Labor)

2. Uterine enlargement

3. Chadwicks / Choasma
o Bluish discoloration of vagina and cervix

4. Hegar Sign
o Softening of the lower uterine segment

33
 5. Outlining of the fetal body

6. Goodells Sign
o Softening of the cervix.
7. Soufflé Sign
o Murmurs auscultated n the uterus.
8. Positive Sign
o Positive pregnancy test.

 Linea Negra – black line on the belly.

 Chloasma – Mask of pregnancy.

 Positive signs :
1. Fetal Heart tone
 120 – 160 bpm
 UTZ 9ultra sound) 10 weeks of gestation.
 Fetoscope at 18 – 20 weeks.
2. Movement felt by the examiner – 20 weeks
3. Fetal skeleton visible in X-ray.

1. Neagles Rule
- using the LMP (Last Menstrual Period)

How to get:

- From the last menstruation to the first day of the next

menstruation.

Two ways to use the Neagles Rule:

a. January – March
Months : Add 9 months
Days : Add 7 Days

Example: LMP: February 14, 2012, compute for the EDC / EDD.

02 14
+9 +7
11 21
EDC / EDD: November 21, 2012

34
 b. April – December
Month : Subtract 3
Days : Add 7
Year : Add1

Example: LMP: September 05, 2012, compute the EDD / EDC.

9 5 12

-3 +7 +1

6 12 13

EDC /EDD June 12, 2013

2. Mc Donalds Rule
- From the fundus to symphysis Pubis
- The distance in centimeters will determine the age of gestation
(AOG) from 16 – 38 weeks. Using a tape measure.
3. John son’s Rule
Formula:
FH in Cm – n x k
 K (constant) 155
 N – Engaged : 12
Not engaged : 11
 Using weight
4. Bartholomew’s Rule
 3rd Lunar Month : 12 weeks
th
 5 Lunar Month : 20 weeks
th
 9 Lunar Months : 36 weeks
 Using Landmarks

Term Related in Pregnancy:

1. Gravida - # of times a woman has been pregnant.

# Of Delivery.

35
 2. Para - # of pregnancy/cies a woman has completed past 20wks, regardless of
whether the infant is born alive or dead. # Of pregnancy.
3. Abortion – any pregnancy loss before the 20th week or weighing less than 500
grams.

2 types of abortion
a. Spontaneous abortion
b. Therapeutic abortion

4. Term birth – birth occurring between the 38th and 42nd weeks.

5. Pre-Term Birth – birth occurring at the 20th week and before 38th week.

6. Post – term – birth occurring after 42nd week.

7. Trimester – division of pregnancy into 3 equal parts of 13th weeks each.

Example: Luna has had 2 miscarriages in the 1 st trimester. She has one son born at 35
weeks and twins age 3 born at 40weeks. She is now pregnant again at 16 weeks.

What is the GTPALM?

G-5 (3 of pregnancy)

T-1 (38th – 42nd week)

P – 2 (20th to 38th week)

A -2 (before 20 weeks)

L-3 (living children)

M-1 (twin)

Abortion is counted in Gravida, not counted in Para

 Perinatal Care
- Covers the whole duration of pregnancy up to delivery.

36
Phases of pregnancy

1. Antepartum – before giving birth

2. Intra – partum – during giving birth
3. Post – partum – after giving birth

Midwife involvement during prenatal

 Educator : Health teaching

Goal of Prenatal

 Safe birth for mother and child.

Prenatal Visit.

 Establishment of estimated time.

1st visit: ASAP – as soon as pregnant

1st trimester: 3 months

2nd visit: 2nd trimester: 3 months

3rd visit: 3rd trimester: 3 months

4th visit: every two weeks, after 8th month of pregnancy until delivery

Routine Visit:

1. Review of history including GTPALM

2. Vital signs including RR, BP, PR
3. Weight
4. Urine analysis

Benedict Test Head Acetic Acid Test

Color: blue Color: colorless
GDM (glucosuria) PIH (proteinuria)
High Risk: Obese

Specimen: Urine

37
 Edema – Fluid

5. Glucose screening
Note: not on every visit

6. Fundal height
- Johnson Rule
- Mc Donald’s Rule
- Naegle’s Rule
- Bartholomew’s Rule
7. Fetal position
8. Fetal heart rate (120-180 bpm)
9. Vaccination

Leopold’s Maneuvers

 Empty the bladder to lessen the discomfort.

 Position is Dorsal Recumbent (both legs are flexed), for proper abdominal
visualization.
 Use palms, warm palms first to avoid startle.

Maneuvers:

1st maneuvers: Fundal Grip Identify fetal presentation, the first fetal part to touch
the cervix.

2nd maneuvers: Umbilical Grip Identify fetal back Fetal position.

3rd maneuvers: Pawlicks Grip Identify the fetal part lying above the pelvic inlet or
lower abdomen. Fetal station

4th maneuvers: Pelvic Grip Identify the fetal attitude. The degree of flexion.

Special nutritional consideration

1. Pica – eating an edible substances

2. Ptyalism – salivation during pregnancy
3. Couvades syndrome – craving experience by the father.

38
Labor and Delivery

 Partograph
 Assessment tool
 Use at the first stage of labor
 Program and tool adapted by WHO
 Represent key events in labor monitoring
 Early warning system
Why Partograph?

 To prevent obstructed labor

History of Partograph:

 Friendman – first OB to describe the progress of labor graphically.

 Philpot – cervicograph to partograph
 Africa – partograph was first applied
 Cervical dilatation – 10 cm – 1st stage of labor.

3 phases of cervical dilatation

1. Latent phase – 0 – 3 cm
2. Active Phase – 4 – 6 cm
3. Transitional Phase – 7 – 10 cm

1cm / hr – normal dilatation

IE (international examination) – every 4 hours, 2 IE’s only for the duration of labor.

Objectives of Partograph:

1. Early detection of abnormal progress of labor

2. Prevention of prolonged labor.
3. Recognize cephalo pelvic disproportion
4. Assist in early decision or transfer, augmentation of labor.

Function:

39
  To give early warning if labor is likely to be prolonged and to indicate that the
woman should be transferred to the hospital.

Components:

Part I: Fetal condition (TOP) Used to monitor and assess fetal condition.

1. Fetal heart tone – need to monitor during labor.

2. Membrane and liquor
3. Molding the fetal skull bones.
Membrane and Liqour

1. Intact membrane I
2. Ruptured membrane + clear liquor C
3. Ruptured membrane + meconium stained liquor M
4. Ruptured membrane + blood staine liquor B
5. Ruptured membrane + absent liquor A

Molding of the Fetal Skull

1. Separated bones, suture felt easily O

2. Bones just touching each other +
3. Overlapping bones ++
4. Severely overlapping bones +++

Part II: Progress of labor.

Monitored:

- Cervical dilatation
- Descent of the fetal head
- Fetal position
- Uterine contraction
Interpretation:

- The plot must not go beyond the color green and alert line.
- Going to the right is abnormal progress of labor.
3 Colors in Partograph

40
 - Green – normal
- Yellow – semi – abnormal
- Pink – abnormal
2 lines Partograph

- Alert line – between green and yellow

- Action line – between yellow and pink.
Objectives:

- Progress of labor is normal if the plotting stays on or to the left of the alert line
(green part)
- Plotting starts during Active Phase on the first stage of labor.

Psychological Task of Pregnancy

 First Trimester
Accepting pregnancy
“I AM PREGNANT”

 Second Trimester
Accepting the baby
“I AM GOING TO HAVE A BABY”

 Third Trimester
Preparing for parenthood
“I AM GOING TO BE A MOTHER/FATHER”

LABOR
- The process by which the parts of conception are expelled thru birth canal.
- Painful experience.
o Parts of Conception
1. Fetus
2. Fetal Membrane
3. Placenta
Cause of Pain in Labor

1. Dilatation of cervix
2. Uterine hypoxia, distention of perineum and vagina
3. Uterine contraction.
- Frequency
- Interval

41
 - Duration
- Intensity
STAGES OF LABOR:

1. First Stage: true contraction to fully cervical dilatation (FCD).

Primipara: 6 – 18hrs

Multipara: 2 – 10hrs

 1cm/hr
False Labor True Labor
Uterine Contraction Irregular Contraction Regular Contraction
Pain Abdomen Abdomen and lower sacral
region
Sedation Painless Painful
Ambulation Decrease uterine Worsen uterine contraction
contraction
I.E (-) dilatation and (+) dilatation and
effacement effacement

Phase Dilatation Duration/Interval Intensity

Latent 0.3 cm 20 – 40 sec / 5 – 30 Mild to moderate
P: 6hrs minutes.
M: 4.5hrs
Active: 4 – 6 cm 60 – 90 sec / 2 – 3 Moderate to strong
P: 3 hrs minutes.
M: 2 hrs
Transitional 7 – 10 cm 60 – 90 sec / 2 – 3 Strong
Uncomfortable minutes.
feeling

2. Second Stage: from FCD to baby delivery

Duration: 2 – 60 mins
Average:
P: 40 mins (20 contractions)
M: 20 mins (10 contraction)

42
 Cardinal Movement of Labor:

1. Engagement
Presenting part of fetus is level with the mother’s ISCHIAL SPINE

- NO ENGAGEMENT
0 ENGAGEMENT
+
STATION

+ CROWNING

2. Descent
Downward movement of the fetus

3. Flexion
Movement of the fetal head forward so that chin is pressed to chest.

4. Internal Rotation
Rotation of the head that enables passage through the Ischial spine.

5. Extension
Occiput is delivered, head extends

6. External Rotation (Restitution)

Head rotates from antero posterior position back to diagonal or transverse
position.

7. Expulsion
Delivery of remained of the fetal body.
(Signifies the end of 2nd stage of Labor)

 Laceration
Tears of birth canal

 Types of laceration
1. Small Laceration
2. Large Laceration

 3 specific type of laceration

43
 1. Cervical
Occurs after placenta delivery

2. Vaginal
- Visible
- Easier to view

3. Perineal
Lithotomy position X
May cause perineal laceration

 Degree of Laceration
 1st: Skin, perineum and fourchette
 2nd: Transperineal, muscle and bulbocavernous
 3rd: Anal sphincter muscle
 4th: Rectum (anal incontinence)

3. Third Stage: (placental separation)

Signs of placental separation:

1. Calkin’s Sign
- Earliest sign
- Globular shape uterus
- Raising at the level of umbilicus
- Firm and globular and palpable at the level of umbilicus
2. Sudden gush of blood
3. Lengthening of the cord

Involution – uterus goes back to the non-palpable state after 6 weeks.

Episiotomy – it is made to prevent multiple lacerations. Speed up the
delivery of the baby.

1 Types of Episiotomy

1. Midline
4 – 5 incision
2. Midiolateral

44
 Midline Advantages / Disadvantages

1. Heals more easily

2. Less blood loss
3. Increase change of anal sphincter damage.

Midiolateral Advantages / Disadvantages

1. Avoid sphincter and Bartholin’s glands

2. More difficult to repair

 Where to bare down?

- If fully cervical dilatation
- If crowning
- Active uterine contraction

 If mother bare down during active phase

- Cervical laceration
- Fetal damage

4. Fourth Stage: Recovery period, beginning of the post – partum period and
secondary mother and child bonding

 Types of Lochia
Lochia – vaginal discharge

Composition:

1. Rubra – first 3 days post-partum (shreds decidua) red from dark to light
2. Serosa – fourth – 10th day post – partum, brownish vaginal discharge.
3. Alba – 10th day – 6th week. Whitish to yellowish, non-foul smelly vaginal
discharge.

 Components of Labor
1. Passage – maternal fetus
2. Passenger – fetus
3. Powers – uterus – myometrium
4. Psyche – psychological condition of the mother. (Behavior)
45
PELVIC DIAMETER INLET

Anterior

Posterior

Oblique

Transverse

 2 Major types of Pelvis

1. True Pelvis
- Inferior half
- Passage way

2. False Pelvis
- Superior half
- Supports the uterus

 TYPES OF PELVIS
1. Android – male pelvis, poorest among pelvis.
2. Gynecoid – ideal female pelvis, well round
3. Anthropoid – ape like pelvis. Larger AP diameter.
4. Platepyloid – narrow AP diameter and oval shape.

 Features that can affect the passenger

1. Skull
2. Presentation
3. Lie
4. Attitude
5. Position
6. Station

 Will the fetal skull pass?

Depends on:
1. Cranial bones
2. Fontanels

46
 3. Suture lines

 Fetal Skull:
 Sphenoid Frontal
 Ethmoid Parietal
 Temporal 1 Parietal
 Temporal 2 Occipital

Frontal Bones – sinciput

Occipital – occiput (the most prominent part)

 Suture Lines (Separator) where the skull bones meet.

1. Sagittal – joins the 2 parietal bones.
2. Coronal – joins the frontal and the 2 parietal bones
3. Lambdoid – joins the occipital and the 2 parietal bones
4. Bregma – combination of sagittal and coronal, 4 bones connect.
5. Lambda – Connect 2 parietal bones and occipital.

47