Obstetrics and Gynecological Nursing 2024-2025 PDF

Technical Institute of Nursing in Zagazig Obstetrics and Gynecological Nursing Zagazig University 2024-2025 Credit hours 2rd level...

Technical Institute of Nursing in Zagazig Obstetrics and Gynecological Nursing Zagazig University 2024-2025 Credit hours 2rd level By Staff members of Obstetrics & Gynecological nursing department 1 2  General objectives of the course:  By the end of this course, the students will be able to:  Identify the female external and internal reproductive organs & functions of each organ.  Identify characterstics of normal and abnormal menstrual cycle.  Determine phases of early developed pregnancy.  Identify function and abnormalities of placenta, umbilical cord and amniotic fluid.  Recognize the physiological changes during pregnancy.  Perform ante natal care for pregnant women.  Identify several minor discomforts that the woman may experience during pregnancy.  Describe the management of pre-eclampsia.  Mention the effect of gestational diabetes mellitus on fetus and pregnancy.  Describe the stages of labor and critical events occurring during each stage  Differentiate normal from abnormal physiologic changes during the postpartum period  Recognize lifestyle changes for Polycystic Ovary Syndrome. 3 Table of content: Chapter Title Page A. Obstetrics Part I: Anatomy of female genital tract and 5-24 physiology of menstruation 1. Anatomy of female Genital tract 5 2. Physiology of menstruation 61 Part II: Normal and high risk pregnancy 52-38 3. Fertilization 52 4. Physiological changes during pregnancy 83 5. Antenatal assessment 74 6. Minor discomforts 25 7. Preeclampsia 12 8. Gestational diabetes 41 Part III: Normal labor 84-143 9. Anatomy of female pelvis 32 10. Anatomy of fetal skull 51 11. Fetopelvic relationship 605 12. Physiology of normal labor 662 13. First stage of labor 159 14. Second stage of labor 116 15. Third stage of labor 648 16. Fourth stage of labor 144 Part IV: Puerperium 179-195 17. Postpartum adaptation 179 B. Gynecology 18. Polycystic ovarian disease 196 4  Anatomy & physiology of female reproductive system  Learning objectives: By the end of this lecture, the student will be able to:  Define the terms listed.  Identify the female external reproductive organs & functions of each organ.  Identify the female internal reproductive organs & functions of each organ.  Outlines:  External female structures.  Internal female structures.  External female structures: Collectively, the external female reproductive organs are called the Vulva: Clitoris. Mons Pubis. Vestibule. Labia Majora Perineum Labia Minora. 5 Mons pubis  Is rounded soft fullness of subcutaneous fatty tissue, prominence over the symphysis pubis that forms the anterior border of the external reproductive organs.  It is covered with varying amounts of pubic hair. Labia majora & minora  The labia Majora are two rounded, fleshy folds of tissue that extended from the mons pubis to the perineum.  It is protect the labia minora, urinary meatus and vaginal introitus. Labia minora  It is located between the labia majora, are narrow.  The lateral and anterior aspects are usually pigmented.  The inner surfaces are similar to vaginal mucosa, pink and moist.  Rich in vascularity.  The term clitoris comes from a Greek word meaning key.  Erectile organ.  Its rich vascularity, highly sensitive to temperature, touch, and pressure sensation  Is oval-shaped area formed between the labia minora, clitoris, and fourchette.  Vestibule contains the external urethral meatus, vaginal introitus, and Bartholins glands. 6  Bartholin’s glands  Two small glands on either side of the vaginal opening that provide lubrication during sexual arousal.  This prevents pain for the female during sexual intercourse.  Is the most posterior part of the external female reproductive organs.  It extends from fourchette anteriorly to the anus posteriorly.  Composed of fibrous and muscular tissues that support pelvic structures.  Internal Female Structures  Vagina  Uterus  Fallopian tubes  Ovaries 7  The two tubes extended from the cornu of the uterus to the ovary.  It runs in the upper free border of the broad ligament.  Length 8 to 14 cm average 10 cm  It’s divided into 4 parts.  The ovum is pushed through the tube by cilia and muscle contractions. 8  This is the site of fertilization if sperm is present as the egg moves through the tube.  It takes 4-7 days after fertilization for the zygote (fertilized egg) to reach the uterus. An unfertilized ovum will degenerate.  Runs into uterine cavity, passes through the myometrium between the fundus and body of the uterus. About 1-2cm in length. Isthmus  Is the narrow part of the tube adjacent to the uterus.  Straight and cord like, about 2 – 3 cm in length.  Is the wider part about 5 cm in length.  Fertilization occurs in the ampulla.  It is funnel or trumpet shaped.  Fimbriae are fingerlike processes; one of these is longer than the other and adherent to the ovary. 9   The fimbriae become swollen almost erectile at ovulation.  Gamete transport (ovum pickup, ovum transport, sperm transport).  Final maturation of gamete post ovulate oocyte maturation, sperm capicitation.  Fluid environment for early embryonic development.  Transport of fertilized and unfertilized ovum to the uterus.  5-Fimbriae  These fingerlike projections are at the end of the fallopian tubes. They will move to create a current drawing the released ovum into the fallopian tube.  Oval solid structure, 1.5 cm in thickness, 2.5 cm in width and 3.5 cm in length respectively.  Each weights about 4–8 gm.  Ovary is located on each side of the uterus, below and behind the uterine tubes  Medulla  Cortex  Hilum  Ovaries and relationship to uterine tube and uterus  The Medulla: The central core of the ovary surrounded by the cortex and continuous with the hilum. It is formed of connective tissue.  The Cortex: The outer active part of the ovary that produces hormones and oocytes. 10  The Hilum: Is the site of attachment of the mesovarium that carries blood vessels, nerves and lymphatics entering and leaving the ovary. Function of the ovary  Secrete estrogen & progesterone.  Production of ova  The uterus is a hollow, pear shaped muscular organ that houses and nourishes a fertilized egg through birth..  The uterus measures about 7.5 X 5 X 2.5 cm and weight about 50 – 60 gm.  A fertilized egg will implant itself into the side of the uterus eventually creating the placenta which houses the fetus.  A uterus can grow up to 6times its normal size during pregnancy.  Its normal position is anteverted (rotated forward and slightly antiflexed (flexed forward)  The uterus divided into three parts  The upper part is the corpus, or body of the uterus  The fundus is the part of the body or corpus above the area where the fallopian tubes enter the uterus.  Length about 5 cm.  A narrower transition zone.  Is between the corpus of the uterus and cervix.  During late pregnancy, the isthmus elongates and is known as the lower uterine segment. 11  The lowermost position of the uterus ―neck‖.  The length of the cervix is about 2.5 t0 3 cm.  It will open to be about 10cm in diameter during birth.  The os, is the opening in the cervix that runs between the uterus and vagina.  The upper part of the cervix is marked by internal os and the lower cervix is marked by the external os.  It connects the uterus to the vagina and allows sperm to enter the uterus and travels up to the fallopian tube.  The cervix helps to keep the unborn baby in the body until it is ready to be born.  Perimetrium.  Myometrium.  Endometrium.  Perimetrium  Is the outer peritoneal layer of serous membrane that covers most of the uterus.  Laterally, the perimetrium is continuous with the broad ligaments on either side of the uterus.  Myometrium  Is the middle layer of thick muscle.  Most of the muscle fibers are concentrated in the upper uterus, and their number diminishes progressively toward the cervix.  The myometrium contains three types of smooth muscle fiber:- 12 1-Longitudinal fibers (outer layer) which are found mostly in the fundus and are designed to expel the fetus efficiently toward the pelvic outlet during birth. 2- Middle layer figure-8 fibers: These fiber contracts after birth to compress the blood vessels that passes between them to limit blood loss. 3- Inner layer circular fibers Which form constrictions where the fallopian tubes enter the uterus and surround the internal os Circular fibers prevent reflux of menstrual blood and tissue into the fallopian tubes. Promote normal implantation of the fertilized ovum by controlling its entry into the uterus. And retain the fetus until the appropriate time of birth.  Endometrium Is the inner layer of the uterus. It is responsive to the cyclic variations of estrogen and progesterone during the female reproductive cycle every month. The three layers of the endometrium are: - Compact layer - The basal layer - The functional or Sponge layer this layer is shed during each menstrual period and after child birth in the lochia The Function of the uterus: Menstruation --- the uterus sloughs off the endometrium. Pregnancy --- the uterus support fetus and allows the fetus to grow. Labor and birth --- the uterine muscles contract and the cervix dilates during labor to expel the fetus. 13  It is an elastic fibro-muscular tube and membranous tissue about 8 to 10 cm long. Lying between the bladder anteriorly and the rectum posteriorly. It releases menstrual fluids. Serves as a birth canal during birth. The vagina is slightly acidic to prevent the growth of pathogens. The vaginal lining has multiple folds, or rugae and muscle layer. These folds allow the vagina to stretch considerably during childbirth. The reaction of the vagina is acidic, the pH is 4.5 that protects the vagina against infection. vagina Allow discharge of the menstrual flow. Female organs of coitus. 14  Allow passage of the fetus from the uterus. The bony pelvis support and protects the lower abdominal and internal reproductive organs. Muscle, Joints and ligaments provide added support for internal organs of the pelvis against the downward force of gravity and the increases in intra- abdominal pressure. 15  Physiology of menstrual cycle  Learning objectives: By the end of this lecture, the student will be able to:  Identify characterstics of normal menstrual cycle.  Classify phases of uterus and ovarian cycle.  Differentiate beteeen ovarian and uterine cycle.  Recognize menstrual abnorlalities.  Perform comfort measures during menstruation  Outlines  Definition  Normal menstrual cycle  The hypothalamic-pituitary-ovarian axis:  Cycle abnormalities  ovarian and uterine cycle  Care comfort measures during menstruation  Cycle abnormalities Definition:  Menstruation means cyclic uterine bleeding caused by shedding of progestational endometrium it occurs between menarche and menopause  Menstruation (also called menstrual bleeding, menses, or a period)  Shedding of the sloughed endometrium with mucous and blood through the vagina externally, following failure of fertilization or implantation 16   The cycle depends on changes occurring within the ovaries and fluctuation in the ovarian hormones levels, that are themselves controlled by the pituitary gland and hypothalamus (hypothalamic - pituitary – ovarian axis). Normal menstrual cycle  Mean 28 days (only 15%)  Range 21-35  3-7 days  Ovulation occurs usually day 14(36 hrs after the onset of mid-cycle LH surge). Characteristics of normal menstruation:- 1- Menarche: 10-16 years. Average 13 years. 2- Duration: 2-7 days (7 days is menorrhagia. 3- Amount: 30-80 ml., uses 3 napkins per day, >80 mi. is menorrhagia and < 30 ml. is hypomenorrhea. 4- Normally menstrual blood doesn't coagulate as a result of secretion of fibrinolysin enzyme (plasmin) secreted by the endometrium. 5- Menstrual molimina refers to mild symptoms of 7-10 days before menstruation relieved once menstruation occurs exaggerated condition called (premenstrual syndrome). The hypothalamic-pituitary-ovarian axis: in the ovaries in response to pituitary hormones (the ovarian cycle) and the variations that take place in the uterus, but it is important to remember that both cycles work together simultaneously to produce the menstrual cycle. 17 cycle. During the course of a normal menstrual cycle: The ovaries go through 3 phases: 1. Follicular. 2. Ovulation. 3. Luteal. The endometrium goes through 3 phases: 1. Proliferative. 2. Secretory. 3. Menstruation. Ovarian Cycle: during the S reproductive life. hormones: o Follicle-stimulating hormone(FSH) o Luteinizing hormone (LH). Ovarian follicular development  Fetus:6-7 million in 20 wks.  " At birth: 1-2 million  At puberty:300,000  " Release during ovulation: 400-500  At menopause: rare 18  The changes that occur in the ovary during each cycle can be divided into three phases: 1. Follicular phase (day 1-13 ) 2. Ovulatory phase (day 13-15) 3. The luteal phase (day 15-28).  These phases run in parallel with the phases of the uterine cycle and together comprise the menstrual cycle  At the beginning of each menstrual cycle, the hypothalamus secretes GnRh in a pulsatile manner to stimulate ant. Pit.gland to secretes FSH & LH.  FSH is responsible for the growth of several primary follicle  The follicular phase is controlled by FSH. encompasses days 1 to 13 of a 28 day cycle.  Only one follicle on one of the ovaries reaches maturity (graafian follicle) which secretes estrogen.  Estrogen has negative feedback on the pituitary to stop FSH.  Estrogen causes the uterine lining (endometrium) to grow thicker  The estrogen peak stimulates secretion of LH. The LH peak leads to: bdominal cavity a process called (ovulation). and corpous luteum formation. -day cycle. Note: High estrogen also suppress FSH secretion so no further follicles grow 19  After ovulation, LH levels remain elevated and cause the remnants of the follicle to develop into a yellow body called the corpus luteum. progesterone. when progesterone reaches a high level it inhibits the secretion of LH leads to: oestrogen and progesterone drop & separation of the endometrium (menstruation) stimulates the hypothalamus to secrete more GRH,a new cycle is started. 20  Uterine Cycle: The uterine cycle refers to the changes that are found in the uterine lining of the uterus. These changes come about in response to the ovarian hormones estrogen and progesterone. There are 4 four phases to this cycle: 1. Menstrual, 2. Proliferative, 3. Secretory and 4. Ischemic. 1- Menstrual Phase  Day 1 of the menstrual cycle is marked by the onset of menstruation. During the menstrual phase of the uterine cycle, the uterine lining is shed because of low levels of progesterone & estrogen. At the same time, a follicle is 21  beginning to develop and starts producing. 'The menstrual phase ends when the menstrual period stops on approximately day 5.  Duration 1-5 days 2- Proliferative Phase  When estrogen levels are high enough, the endometrium begins to regenerate.  Estrogen stimulates blood vessels to develop. The blood vessels in turn bring nutrients and oxygen to the uterine lining and it begins to grow and become thicker.  The proliferative phase ends with ovulation on day 14. 3-Secretory Phase  After ovulation, the corpus luteum begins to produce progesterone.  This hormone causes the uterine lining to become rich in nutrients in preparation for pregnancy.  Estrogen levels also remain high so that the lining is maintained. If pregnancy doesn't occur, the corpus luteum gradually degenerates, and the woman enters the ischemic phase of the menstrual cycle. 4-Ischemic Phase  'On days 27 and 28, estrogen and progesterone levels fall because the corpus luteum is no longer producing them.  Without these hormones to maintain the blood vessel network, the uterine lining becomes ischemic.  When the lining start slough, the woman has come full cycle and is once again at day 1 of the menstrual cycle. 22  Cervical mucus changes:  Changes in cervical mucus takes place over the course of the menstrual cycle. Some women use these characteristics to help determine when ovulation is likely to happen. During the menstrual phase the cervix doesn't produce mucus. As the proliferative phase begins, the cervix begins to produce a tacky, crumbly type of mucus that is yellow or white.  As the time of ovulation becomes near, the mucus becomes progressively clear, thin and lubricative, with the properties of raw egg white. At the peak of fertility (ie., during ovulation), the mucus has a distensible, stretchable called spinbarkheit. After ovulation the mucus becomes scanty, thick, and opaque. Estrogen causes:  Mild mvometrial contraction  Rhythmic contraction in the fallopian tube.  Production of thin elastic mucous that attracts sperm.  In the vagina, causes cornifcation of its epithelium with increasing acidity. Progesterone causes:  Relaxation of the myometrium.  The fallopian tube epithelium to be rich with nutrients for the zygote.  Thick cervical mucous.  In the vagina decrease cornification.  In negative feedback, rising levels of hormones feedback to the hypothalamus and pituitary gland to decrease the production of the hormones.  In positive feedback, rising levels of hormones feedback to increase hormone production. 23 Care comfort measures during menstruation Menstrual hygiene: 1. Sanitary pads and tampons: 2. Wash hands before & after giving self-perineal care. 3. Washing or wiping the perineium should be always done from front to back. 4. Reduce use of tampons by substituting sanitary pads especially at night. 5. Use tampon only for heavy menstrual flow. 6. Vaginal spray and douching: 7. Spray should be used externally only not with pads. 8. Should not be applied with broken irritated or itched skin. 9. Douching washes away the natural mucus and upsets the vaginal ecology, thus make it liable to infection. Cycle abnormalities 1. Anovulation. 2. Oligomenorrhea. 3. Anovulatory cycle 4. Amenorrhea. 5. Hypomenorrhea. 6. Polymenorrhea 7. Metrorrhagia. 24  Fertilization  Learning objectives: By the end of this lecture, the student will be able to:  List phases of early developed pregnancy.  Identify abnormalities of placenta, umbilical cord and amniotic fluid.  Determine function of placenta and amniotic fluid.  Identify fetal growth and development in all trimester of pregnancy.  Outlines  Early developed pregnancy (3 phases).  Placenta.  Umbilical cord  Fetal membranes.  Amniotic fluid.  Fetal growth and development. I- Early developed pregnancy (3 phases)  It consisted of: 1. Pre implantation phase. A. Transport and capacitation of spermatozoa. B. Transport and maturation of the ovum. C. Development of the fertilized ovum. 2. Implantation phase. 3. Post implantation phase. 25  1- Pre implantation phase: the phase of fertilization and transport of the zygote. A. Transport and capacitation of spermatozoa:- 1- The sperm enters the uterus and left the seminal plasma in the vagina after sexual intercourse. It must reach the tube in 30-40 m after deposit in the vagina. N.B: Semen consists of spermatozoa (23 chromosome) suspended in the secretion of semenal vesicles, prostate and bulbo uretheral glands.  Capacitation of the sperm  It means morphological and non-morphological changes that occur in the sperm and include: - Activation of acrosomal enzymes as neuroamidase and hyaluronidase. N.B: The sperm must be mature and capacitated to become fertilizable after period 2-6 hours.  Factors affecting the ascent of the sperms in the female genital tract: 1. Forward motility of the sperms. 2. The cervical mucus penetrability by the estrogenic effect. 3. Uterine contractility by prostaglandins in the uterus and semen. 4. Peristaltic and ciliary movements of the tubes. B- Transport and maturation of the ovum.  At ovulation…. the ovum leaves the ovary after the first meiotic division.  The ovum is surrounded by the perivitelline space, the zona pelluicida and the corona radiata.  The ovum is picked up by the fimbrial end of the fallopian tube. Fertilization is the fusion of mature capacitated sperm with the mature ovum. This occurs in the outer portion of the fallopian tube. 26 Fertilization of the ovum: 1. Release of neuroamidase enzyme leads to lysis of the corona radiata. 2. Release of hyaluronidase enzyme leading to lysis of the zona pelluicida surronding the ovum. 3. Loss of sperm tail and acrosomal cap during passage to the ovum. 4. Stimulation of the zona pelluicida receptor site (the inner layer) allowing penetration of the zona pelluicida by only one sperm. 5. Re-blockage of the zona pelluicida receptor site to prevent other sperm penetration. N.B: The entry of the sperm into the ovum stimulates the second meiotic division of the ovum. 27  C- Development of the fertilized ovum.  Nuclear membrane of the sperm disappears.  Chromosomes from the sperm and ovum unite to form the zygote (46 chromosomes) which migrates towards the uterine cavity.  The process of migration is partly due to ciliary movement and partly due to peristalsis of the tube.  On its way it divides until it is formed of a solid mass of about 16 cells (morula).  Cleavage is a series of rapid divisions by zygote after fertilization.  The zygote divides as it travels through the oviduct.  By the time the cilia of the oviduct deliver the embryo to the uterus, the embryo is a ball of cells called a blastocyst.  The blastocyst implants in the endometrium.  Formation of the zygote and early post-fertilization events II- Implantation phase. Definition: embedding of fertilized ovum in decidua (endometrium of pregnant uterus). 28  Timing : begins at end of the 1st week and ends completely by the end of the 2 nd two week after fertilization. Normal site: upper part of body of uterus near funds, 60% posterior, 40% anterior.  Abnormal sites of implantation: 1- Lower part of body of uterus, near internal os (placenta previa). 2- Uterine tube (tubal pregnancy). 3- Ovary (ovarian pregnancy). 4- Peritoneum (abdominal pregnancy).  Mechanism of implantation:  Stage of apposition of blastula to decidua.  Stage of adhesion of blastula to decidua.  Stage of penetration of blastula to decidua and its covering by decidua capsularis.  Decidua  Definition: endometrium of pregnant uterus.  Control : Progestrone of corpus leuteum. Decidual reaction: makes decidua suitable for implantation as:  Endometrial glands increase secretion of mucin and glycogen for nutrition of blastula.  Stroma cells become loaded with glycogen.  Increased vascularity of stroma. After implantation decidua becomes differentiated into: 1- Decidua capsularis : Decidua covering the ovum. 2- Decidua basalis : Decidua underlying the ovum. 29  3- Decidua parietalis or vera : Decidua lining rest of the uterine cavity. Fate:  Decidua basalis: forms maternal part of placenta.  Decidua capsularis and parietalis fuse together at 12 weeks when cavity is filled by concepts and thus the uterine cavity is obliterated.  Placenta Anatomy of placenta at term  It is formed of decidua basalis + chorion frondosoum or outer layer of blastocyst.  Shape: discoid, disc like organ.  Diameter: 15 – 20 cm.  Thickness: 1 inch at the center and 0.5 inch at the periphery.  Weight: 500 – 600 gm.  Surfaces of placenta: I- Maternal surface:  Rough  Dull red in color  Contains 15 – 20 cotyledons covered by thin layer od decidua basalis. II- fetal surface:  Smooth.  Covered by amniotic membrane.  Umbilical cord is inserted at or near the center of this surface. 30  Functions of Placenta 1. Respiratory: The fetus obtain O2 and excrete CO2 through placental. 2. Nutritive:  Water and electrolyte pass by simple diffusion.  Glucose passes by facilitated diffusion.  Amino acids pass by active transport. 3. Excretory of fetus: excretion of waste products of the fetus. 4. Enzymatic production: production of enzymes as oxytinase ,insulinase ….. 5. Endocrine function: Production of Hormones as Human chorionic gonadotropin(HCG), estrogen, progesterone,….  Action of HCG: Maintains corpus luteum in early (8-10 weeks) pregnancy to secrete progesterone & estrogen.  HCG has 2 amino acid chain subunit:  B-Subunit….+ve in serum(5-7 d before first missed period).  +ve in urine(7-10 d after first missed period) 6. Production of group of Protein. 7. Barrier action: Allow passage of small molecule e.g. some viruses ( e.g. rubella) ,some bacteria (e.g. treponema). some parasites(e.g. toxoplasma gondi). Not allow passage of large molecules (e.g. heparin & insulin).  Placental barrier Definition: barrier between maternal blood & fetal blood. 31  Structure: 4 layers of 3ry villi : Syncitiotrophoblast, cytotrophoblast, mesoderm, blood vessels.  Abnormities of placenta I- Abnormities in shape : 1. Membranous placenta: Placenta is large and thin. 2. Bilobate or multilobate (Bipartite) placenta: Placenta is made of 2 or more lobes connected by placental tissues. 3. Bipartite or multipartite placenta: Placenta is made of 2 or more separate equal lobes connected by membranes. : 4. Succenturiate placenta: Placenta is formed of large lobe and small accessory lobe connected by membranes. 5. Circumvalate placenta: A whitish ring is surrounding the edge of placenta on its fetal surface. II- Abnormities in site : Lower part of body of uterus , near internal os (placenta previa). III- Abnormities in attachment to uterus: (Placenta accreta, increta , percreta). IV- Abnormities in attachment of cord: Marginal attachment (Battledore insertion).  Velamentous insertion in the membranes not in placenta. V- Abnormities in size & weight : placenta in Twins , diabetes and syphilis. 32   Umbilical cord  Development: connecting stalking.  Umbilical cord at term :  Length: 50 cm (55-60cm).  Diameter: 1-2 cm.  Covered by amnion.  Content: Wharton jelly, 2 arteries carrying deoxygenated blood & one vein carrying oxygenated blood.  Insertion: Attached to fetus at umbilicus, to placenta (70% eccentric, 30% centric).  Anomalies of umbilical cord  Abnormal insertion: Marginal insertion, velamentous insertion.  Abnormal length : Too long : leads to prolapse , coiling around neck, true knots. Too short : leads to premature separation of placenta , delayed descend of fetus during labor , inversion of uterus.  Knots : True knots : fetus pass through loop , leads to asphyxia. False knot : localized collection of Wharton's, kinking or dilatation of blood vessels. 33  Hematoma: rupture of one vessel.  Torsion of cord.  Single umbilical artery.  Fetal membranes  Outer chorion & inner amnion. — Chorion : leave ,lines uterine wall ,attached to margins of placenta. — Amnion : lines chorion leave ,covers fetal surface of placenta & cord, forms amniotic sac that contains amniotic fluid & fetus  Amniotic Fluid (liquor amnii)  It is not astatic medium but it is continuously renewed.  500 ml of amniotic fluid replaced every hour.  Origin (Source) :  Fetal:  Transudation from fetal circulation transudation.  Fetal urine.  Active secretion by the amnion.  Maternal: Transudation from maternal circulation.  Characters:  Color: clear.  Reaction: slightly alkaline (PH 7-7.5).  Volume: 0.5-1.5 liter at term. 34  Composition: 1. 99% water. 2. Organic substances  CHO( Glucose& fructose)  Protein lipid  Enzymes  hormones(estrogen progesterone) 3. Inorganic substance: Na,K,Cu,Cl 4. Suspended material: lango hair, vernix caseosa.  Anomalies :  Polyhydramnios : excess volume > 2 liters.  Oligohydramnios: little volume < 0.5 liter.  Functions of amniotic fluid during pregnancy: 1. Protection of fetus from external trauma. 2. Protects fetus from adhesion to amnion. 3. Mildly bacteriostatic. 4. Keep fetal body temperature constant. 5. Provides a medium of fetal excretion. 6. Provides a medium for fetal movement. 7. Nutrition of the fetus.  Functions of amniotic fluid during labor: 1. The bag of forewater helps cervical dilatation. 35  2. Sterilization of the birth canal after rupture of membrane.  Fetal growth and development: Growth refers to an increase in size. Development is the continuous process by which an individual changes from one life phase to another. These phases includes the prenatal period and the postnatal period. A trimester is a time period of 3 months.  Fetal growth and development in first trimester: At the end of the first trimester, the following changes have or are occurring: (1) All organs are formed. (2) The fetus becomes less vulnerable to the effects of most drugs, most infections, and radiation. (3) Facial features are forming and the fetus becomes human in appearance. (4) External sex organs are visible, but positive sex identification is difficult. (5) Well-defined neck, nail beds beginning, and tooth buds form. (6) Rudimentary kidneys excrete small amounts of urine into the amniotic sac. (7) There is movement but just not strong enough to be felt. (8) The fetus is about 2.9 inches long and weighs about 14 grams. 36  Fetal growth and development in second trimester: During these months (4th, 5th, and 6th) the fetus grows fast. At the end of the second trimester, the fetus: (1) Fetal heart tone (FHT) can be heard with a stethoscope. (2) Skin is wrinkled, translucent, and appears pink. (3) Sex is obvious. (4)Looks like a miniature baby. (5) Skeleton is calcified. (6) Birth survival is possible, but the fetus is seriously at risk.  Fetal growth and development in third trimester: At the end of the third trimester (7th, 8th, and 9th month), the fetus: (1) Skin is whitish pink. (2) Hair in single strands. (3) Testes are in the scrotum, if a male child. (4) Bones of the skull are firmer, comes closer at the suture lines. (5) Lightening occurs. (6) Fetus is about 20 inches long and weighs about 3300 grams. 37  Physiological changes during pregnancy  Learning objectives: By the end of this lecture, the student will be able to:  Define the physiological changes that occur during pregnancy.  Mention the physiological changes during pregnancy concerning genital system.  List the physiological changes during pregnancy concerning cardio-vascular system.  Illustrate the physiological changes during pregnancy concerning gastrointestinal system.  Enumerate the physiological changes during pregnancy concerning respiratory tract.  Outlines  Definition of the physiological changes that occur during pregnancy.  Physiological changes that occur during pregnancy concerning genital system.  Physiological changes that occur during pregnancy concerning cardio-vascular system.  Physiological changes that occur during pregnancy concerning gastrointestinal system and respiratory tract. 38 Introduction During pregnancy, the pregnant mother undergoes significant anatomical and physiological changes in order to accommodate the developing fetus. These changes begin after conception and affect every organ system in the body. For most women experiencing an uncomplicated pregnancy, these changes resolve after pregnancy with minimal residual effects. It is important to understand the normal physiological changes occurring in pregnancy as this will help differentiate from adaptations that are abnormal. Items of physiological changes that occur during pregnancy include:- The genital system The ovaries  Both ovaries are enlarged due to increase vascularity and oedema particularly that containing the corpus luteum. 39   Corpus luteum starts to degenerate after the 10th week when the placenta is formed.  Corpus luteum secretes oestrogen and progesterone.  Ovulation ceases during pregnancy due to pituitary inhibition by the high levels of oestrogen and progesterone. The fallopian tubes: The musculature hypertrophies and the epithelium become flattened. The uterus  Size: increases from 7.5, 5, 2.5 cm in non-pregnant state to 35, 25, 20 cm at term.  Weight: increases from 50 gm in non-pregnant state to 1000 gm at term. This is due to: o Hypertrophy of the muscle fibres (oestrogen effect) and their multiplication (progesterone effect). o Increase in the mass of elastic connective tissue.  Capacity: increases from 4 ml in non-pregnant state to 4000 ml at term.  Shape: becomes globular by the 8th week and pyriform by the 16th week till term.  Position: with ascent from the pelvis, the uterus usually undergoes rotation with tilting to the right (dextro-rotation), probably due to presence of the rectosigmoid colon on the left side.  Contractility: from the first trimester onwards, the uterus undergoes irregular contractions called Braxton Hicks Contractions, 40  which normally are painless. They may cause some discomfort late in pregnancy and may account for false labor pain.  Uteroplacental blood flow: uterine and ovarian vessels increase in diameter, length and tortuosity.  Formation of lower uterine segment: After 12 weeks, the isthmus (0.5cm) starts to expand gradually to form the lower uterine segment which measures 10 cm in length at term. The cervix  It becomes hypertrophied, soft and bluish in colour due to edema and increased vascularity.  Soon after conception, a thick cervical secretion obstructs the cervical canal forming a mucous plug. The vagina The vagina becomes soft, warm with increased secretion and violet in colour (Chadwick’s sign) due to increased vascularity. The breasts  In the early weeks, the pregnant woman experiences tenderness and tingling of the breasts.  The primary areola becomes deeply pigmented. The nipples become larger, deeply pigmented and more erectile. 41  Montgomery’s follicles, which are hypertrophic sebaceous glands, appear as non- pigmented elevations in the primary areola.  Nearly after the third month colostrum, which is a thick yellowish fluid, can be expressed from the nipples.  During the fifth month, a pigmented area appears around the primary areola called secondary areola. The skin 1. Pigmentation: This is due to increased production of melanocyte stimulating hormone (MSH).  Chloasma gravidarum (pregnancy mask): Butterfly pigmentation appears on the checks and nose. It usually disappears few months after labor.  Breasts: increased pigmentation of the nipples and primary areolae and appearance of the secondary areolae.  Linea nigra: A dark line extending from the umbilicus to the symphysis pubis. 2. Striae gravidarum: These are reddish, slightly depressed streaks appear in the later months of pregnancy in the abdomen and sometimes breasts and thighs. It may be due to mechanical stretching of the skin. 3. Vascular changes: There is increase in the skin blood flow and temperature. 4. Secretions: Increase in sweat and sebaceous glands activity. 42  Hematologic changes Blood Volume  The total blood volume increases steadily from early pregnancy to reach a maximum of 35-45% above the non-pregnant level at 32 weeks.  Plasma volume increases by 40% whereas red cell mass increases by 20% leading to haemodilution (Physiological anaemia). Cardiovascular system Heart  Position: As the diaphragm is elevated progressively during pregnancy the apex is displaced upwards and to the left so that it lies in the 4th intercostal space outside the midclavicular line.  Rate: The resting pulse rate increases by 10-15 beats per minute during pregnancy.  Cardiac output: increases mainly by increased stroke volume rather than increased heart rate reaching a maximum of 40% above the non-pregnant level at 20 weeks to be maintained till term. o During labor cardiac output increases more, particularly during the second stage due to pain, uterine contractions and expulsive efforts pushing the blood into the general circulation. Respiratory system Dysponea may occur due to: Elevation of the diaphragm by the pregnant uterus. 43 Gastrointestinal system 1. Gingivitis: There is increased vascularity and tendency for bleeding as well as hypertrophy of the interdental papilla. 2. Ptyalism: It is excessive salivation and more common in association with oral sepsis. 3. Nausea and vomiting: Nausea (morning sickness) and vomiting (emesis gravidarum) occur in early months. 4. Appetite changes (longing or craving): The pregnant woman dislikes some foods and odors while desires others. Deviation may be so extreme to the extent of eating blackboard chalk, coal or mud (pica). 5. Indigestion and flatulence: This is probably due to:  Decreased gastric acidity caused by regurgitation of alkaline secretion from the intestine to the stomach.  Decreased gastric motility. 6. Hurt burn due to reflux of the acidic gastric contents to the oesophagus. 7. Constipation due to:  Reduced motility of large intestine (progesterone effect).  Increased water reabsorption from the large intestine (aldosterone effect).  Pressure on the pelvic colon by the pregnant uterus.  Sedentary life during pregnancy. 8. Haemorroids due to:  Mechanical pressure on the pelvic veins.  Laxity of the veins walls by progesterone. 44   Constipation. Urinary system Kidney: Renal blood flow and glomerular filtration rate increases by 50%. Ureters: Dilatation of the ureters and renal pelvis due to:  Relaxation of the ureters by the effect of progesterone.  Pressure against the pelvic brim by the uterus particularly on the right side. Bladder 1. Frequency of micturition in early pregnancy due to:  Pressure on the bladder by the enlarged uterus.  Congestion of the bladder mucosa. 2. Urinary stress incontinence may develop for the first time during pregnancy and spontaneously relieved later on. Musculo-skeletal system  Progressive lordosis to compensate for the anterior position of the enlarged uterus. Metabolic changes 1. Weight gain  The average weight gain in pregnancy is 10-12 kg. 45  6 kg of the average 11 kg weight gain is composed of maternal tissues (breast, fat, blood and uterine tissue) and 5 kg of fetus, placenta and amniotic fluid. 2. Water metabolism: There is tendency to water retention secondary to sodium retention. 3. Carbohydrate metabolism  Pregnancy is potentially diabetogenic.  Glucosuria may occur in early pregnancy.  Renal glucosuria may occur in the middle of pregnancy. 4. Mineral metabolism: there is increased demand for iron, calcium, phosphate and magnesium. 46  Antenatal care  Learning objectives: By the end of this lecture, the student will be able to:  Mention the components of antenatal care.  Obtain complete history from the pregnant woman during antenatal visits.  Perform general and abdominal examination.  Auscultate FHR and identify its abnormalities.  Follow ethical issues while examining the pregnant woman.  Outlines  Aims of antenatal care  Components of antenatal care  History from the pregnant woman during antenatal visits.  General and abdominal examination  Auscultation of FHR and its abnormalities  Ethical issues while examining the pregnant woman. Aims of antenatal care: To screen the high risk cases To prevent or detect or treat at the earliest complication To ensure continued medical surveillance and prophylaxis To educate the mother about the physiology of pregnancy and labor by demonstrations, charts and diagrams so that fear is removed and psychology is improved. 47  To discuss with the couple about the place, time and mode of the delivery, provisionally and care of the newborn To motivate the couple about the need of family planning To advice the mother about breast-feeding, post-natal care and immunization Schedule for antenatal visits: Monthly up to 28 weeks Two weekly between 28 and 36 weeks Weekly 36 weeks onwards. (This equals about 15 visits)  High-risk cases need more frequent visits. Components of antenatal care: Careful antenatal assessment (history taking and examination and investigation). Advice given to the pregnant woman. 48 Antenatal assessment includes: Antenatal Assessment History taking Physical examination Investigations Present pregnancy General examination Optional tests history. Past history (medical Abdominal examination Routine tests and surgical). - Inspection Personal history. - Palpation (Fundal height- leopold’s Obstetric history maneuver) - FHR auscultation. Menstrual history Vaginal examination Family history History taking include:  Personal history which include: name, age, education, occupation, address, marital status and duration of marriage.  Present pregnancy history of any complaint as: nausea & vomiting, increased frequency of micturition, constipation, heaviness of breast, rise of temperature, edema, pain in the abdomen, backache and vaginal bleeding.  Past medical history: which include any medical disorder as hypertension, DM, renal, hepatic, cardiac or psychiatric disease. If the woman is taking any drugs as antihypertensives, hypoglycemics, antidepressants, corticosteroids and anticoagulants. Allergy to certain foods or drugs are also considered. 49   Obstetrical history which include details related to: Gravidity: number of pregnancies, any complications encountered during previous pregnancy, onset of pregnancy (spontaneous, induced or ART). Parity: number of deliveries, onset of labor (spontaneous, induced), mode of delivery ( NVD or CS), GA at the onset of labor( preterm, full term or postdate), any complications encountered during labor or postpartum, sex of children. Abortion: number, GA at the onset of abortion and management techniques.  Menstrual History: age of menarche, duration of menstrual period, LMP to calculate EDD.  Family history of HTN, DM, renal, hepatic or cardiac diseases, multiple pregnancy or pregnancy complications. Physical examination:  General examination: include vital signs, breast, heart sound, lungs, appearance, height of patient, weight of patient, pallor, jaundice, edema and cyanosis.  Abdominal examination:  Inspection of the shape of the uterus, striae gravidarum, linea nigra and scar marks.  Palpation  Assessment of fundal height 50  Loepold’s maneuver: Fundal grip: While facing the woman, palpate the woman's upper abdomen with both hands. Often determine the size, consistency, shape, and mobility of the form that is felt. The fetal head is hard,, round, and moves independently of the trunk. The buttocks feels softer, is symmetric, and has small bony prominences; it moves with the trunk. 51 Umbalical ( Lateral grip): The maneuver attempts to determine the location of the fetal back. Facing the woman, the health care provider palpates each side of the abdomen with gentle but deep pressure using the tips of his or her hands. The fetal back is firm and smooth, hard, resistant surface. Fetal extremities feels like small irregularities and protrusions. 52 Pelvic grip: To determine which part of the fetus occupy the lower uterine segment Pawlick grip:  Done at 36 weeks to determine engagement of the fetal head.  Determine what fetal part is lying above the inlet, or lower abdomen.  The individual performing the maneuver first grasps the lower portion of the abdomen just above the symphysis pubis with the thumb and fingers of the right hand. 53 Auscultation of FHR:  Explain the procedure to the woman.  Assist the woman to a supine position.  By palpation, determine the following fetal position , fetal presentation and fetal lie  Place the head of the fetoscope on the woman’s abdomen where you are most likely to find fetal heart tones.  In cephalic presentation, FHR is auscultated below the umbilicus on the side of the fetal back.  In breech presentation, FHR is auscultated above the umbilicus on the side of the feta back.  Normal FHR is 120-160 b/m, foetal tachycardia (>160 b/m), foetal bradycardia (, consider pre- eclampsia 5. GCT 24-48 weeks --- 130 mg/dL or more, do a GTT 6- culture swabs if infection is from vagina and suspected cervix 55 Ultrasound: Benefits:  Determine gestational age  Detect multiple pregnancies  Help with later screening for Down's syndrome.  Determine the amount of amniotic fluid (average, oligohydramnios, polyhydramnios).  Localize site of the placenta and evaluation of the retro placental space.  Determine fetal sex.  Determine fetal viability.  Identify fetal presentation, position, lie and attitude.  Localize fibroid with pregnancy.  Diagnosis of cervical incompetence by vaginal ultrasonography. Optional tests:  Amniocentesis  Alpha fetoprotein to screen for birth defects.  Non stress test.  Screening for syphilis. In subsequent visits:  Patient complains  General examination  Gestational age to be calculated  Identification of problem  Foetal movement  Health education 56   Prophylaxis & treatment of anemia  Developing individualized birth plan Antenatal advice: Following advices are to be given: 1- Diet should be: nutritious, balanced, light, easily digestible, rich in protein, mineral and vitamin and with woman’s choice. The woman needs extra 300kcal/day from 2nd trimester onwards, Calcium: 1.5 g daily, Vit. C, folic acid, Vit. B12. 2- Rest and sleep: 8 hour sleep at night, at least 2 hour sleep after mid-day meal. Hard strenuous work should be avoided in first trimester and last 4 weeks. 3- Bowel: Regular bowel movement may be facilitated by regulation of diet, taking plenty fluid, vegetable and milk. 4- Coitus: should be avoided in 1st trimester and in the last 6 weeks. 5- Travelling: should be avoided in 1st trimester and in the last 6 weeks. Air travelling is contraindicated in placenta praevia, preeclampsia, severe anemia and history of abortion and preterm labor. Immunization: Indicated TT, HAV, HBV and Rabies. Contraindicated immunizations are live virus vaccine (rubella measles, mumps, and varicella). Warning signals of pregnancy!!! Bleeding p/v at any time in pregnancy Head ache, blurring vision, epigastric pain & oliguria oedema, severe, not subsiding with rest, or on face & hands 57  Decrease/ loss of fetal movements Abdominal pain Urinary infection with vulvovaginitis Clear fluid p/v (PROM). 58  Minor complaints during pregnancy  Learning objectives: By the end of this lecture, the student will be able to:  Identify several minor ailments that the woman may experience during pregnancy.  Mention the causes of each ailment or discomfort.  Determine the relief measures of each discomfort.  Outlines  Several minor ailments that the woman may experience during pregnancy.  Causes of each ailment or discomfort.  Relief measures of each discomfort. (1) Bckache: Causes:  Lumbar lordosis.  Relaxation of ligaments and intervertebral joints by progesterone effect. Relief measures:  Adequate rest and support the back when sitting in a chair with a pillow.  Avoid wearing high heeled shoes. (2) Nausea and vomiting: It is called morning sickness.  Having vomiting and nausea and feeling tired are normal during pregnancy due to the adjustment of your body’s hormone level.  This usually all happens in early pregnancy from 4-12 wks. 59 Relief measures:  Add dry foods like crackers, cereal and toast before waking up from the bed.  Avoid fried and fatty foods.  Eat small frequent meals.  In case, your vomiting is constant and severe and to have anemia test, consult your doctor. (3) Gingivitis: Increased vascularity and hypertrophy of the interdental papillae. It is improved usually after pregnancy termination. Sequelae:  Increased tendency for bleeding.  Retention of food debris predisposes to sepsis and dental caries. Relief measures: Proper dental hygiene. (4) Ptyalism (Sialorrhoea) Causes: Increased salivation may occur early in pregnancy and subsides later. It is due to failure of the patient to swallow the saliva rather than increase in its amount. Relief measures:  Care of dental hygiene.  Discontinue smoking.  Anticholinergic drugs as belladonna, which induce dryness of the mouth, may be needed. 60 (5) Heartburn Causes: A common complaint caused by reflux of gastric contents into the lower oesophagus due to mechanical relaxation of the cardiac sphincter caused by upward displacement and compression of the stomach by the pregnant uterus, and by the action of progesterone. Relief measures:  More frequent but smaller meals. Avoid salty and spicy foods.  Avoidance of bending over or lying flat.  Antacids containing aluminium hydroxide are preferable as they buffer the gastric contents. (6) Constipation Causes  Reduced intestinal motility by the action of progesterone.  Increased fluid resorption from the large bowel.  Reduced exercise.  Mechanical compression by the gravid uterus. Relief measures:  Evacuate the bowel at the same time every day. Increase fluid intake.  Diet rich in green vegetables and fruits.  Mild laxative as. Liquid paraffin interferes with absorption of fat soluble vitamins, so better to be avoided. 61 (7) Hemorrhoids Causes  Laxity of the rectal veins by progesterone effect.  Pressure by the gravid uterus.  Tendency to constipation. Relief measures:  Avoid constipation.  Soothing agents.  Local anaesthetics.  Surgical and local injection treatment has to be avoided. (8) Varicosities Causes:  Increased venous pressure in the lower limbs by compression with the pregnant uterus.  Prolonged standing.  Relaxation of veins walls by steroid hormones. Relief measures:  Avoid prolonged standing.  Encourage active exercise.  Elevate the legs in higher level than the body during sitting and sleeping.  Elastic stocking are worn while the patient is lying down and veins are empty.  Surgical or injection treatment should be avoided during pregnancy. 62 (9) Dyspnoea: Causes:  It may occur early in pregnancy due to hyperventilation caused by progesterone.  Late in pregnancy, it occurs due to pressure on the diaphragm by the pregnant uterus. Relief measures:  Avoid tight clothes around the chest.  Sleeping in the semi- sitting position.  Well ventilated areas. (10) Dependent edema Causes: Shift of fluids from the intravascular compartment to the extravascular compartment. Relief measures:  Avoid standing for long periods.  Elevate legs when laying or sitting.  Avoid tight stockings. (11) Faintness Relief measures:  Rise slowly from sitting to standing.  Evaluate hemoglobin and hematocrit.  Avoid hot environments 63 (12) Urinary symptoms: Frequency and stress incontinence may occur during pregnancy. Causes  Increased intra-abdominal pressure.  Pressure on the bladder by the enlarging uterus reducing its capacity. (13) Leucorrhoea Causes: Increased vaginal discharge is a common complaint during pregnancy due to excess oestrogen production. Relief measures: No treatment is needed except if there is associated infection. Monilial infection is common. (14) Leg Cramps Sustained involuntary painful contractions, usually affecting the calf and peroneal muscles may occur in the second half of pregnancy, particularly at night. Causes  Depletion of serum calcium as well as sodium and chloride due to excessive vomiting, sweating or salt restriction.  Local vascular insufficiency. Relief measures:  Massage of the contracted muscles and passive stretching.  Calcium gluconate may be helpful. (15) Paraethesia: Tingling sensation of the fingers and sometimes weakness of small muscles of the hand caused by edema of the carpal tunnel. 64  Preeclampsia (PET)  Learning objectives: By the end of this lecture, the student will be able to:  Define Preeclampsia.  Identify etiology of Preeclampsia.  Mention the clinical pictures of pre-eclampsia.  Explain the investigations for preeclampsia.  Describe the management of pre-eclampsia.  List the prognosis of pre-eclampsia.  Outlines  Definition of preeclampsia.  Incidence of preeclampsia.  Etiology of preeclampsia.  Clinical pictures of pre-eclampsia.  Investigations for preeclampsia.  Management of pre-eclampsia.  Prognosis of pre-eclampsia. Definition of preeclampsia: Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs after 20 weeks' gestation and can present as late as 4-6 weeks postpartum. It is clinically defined by hypertension and proteinuria, with or without pathologic edema. Incidence: Hypertensive disorders complicate 6.0% to 8.0% of all pregnancies, preeclampsia accounts for 80% of these cases. The rate of preeclampsia has risen 65 steadily by approximately 30% to since 1990 for all ages, races, and ethnic groups to the rate of 39.9 per 1000 live births. It is the most common medical complication of pregnancy and the second leading cause of maternal morbidity and mortality in the United States. Etiology: Not exactly known, but it is common in certain groups of females (toxemia prone). 1- Primigravida especially elderly primigravida. 2-Hypertension, chronic nephritis 3-Diabetes mellitus 4- Hydatidiform mole 5- Twin pregnancy 6- Hydramnios 7- Malnutrition 8- Fetal hydrops 9- Maternal genetic: PET runs in families because PET is dependent upon single recessive genes. Diagnosis: (A) Clinical picture of pre-eclampsia; 1) Hypertension:  It is an early sign due to vasospasm, usually precedes clinical edema and proteinuria.  The position of the person in whom the blood pressure is measured is important in pregnancy. The supine and right lateral positions are not recommended —» the effect of the gravid uterus on venous return leading to 66  postural hypotension. Sitting or lying in the left lateral position with the sphygmomanometer cuff at the level of the heart. Diagnosed by: * BP > 140/90 on 2 occasions, 6 hours or more apart. * There is a rise 15 mmHg in diastolic blood pressure or there is a rise 30 mmHg in systolic blood pressure compared to baseline reading before pregnancy or during 1st trimester. * Mean Arterial Pressure (MAP) = Diastolic + (Systolic - Diastolic) /3  A rise of 20 mmHg in MAP is ominous compared with 1st trimester.  MAP 100 abnormal.  MAP 105 indicates hypertension. 2) Edema: 2 types: * Occult edema: Usually develops before hypertension in the form of excessive weight gain (gain of 2 pounds. or more/week or 6 pounds or more/month are suggestive). * Manifest edema: Usually develops after hypertension at lower limb, lower abdomen, e. It is due to salt retention. 3) Proteinuria: Always develops after hypertension and is caused by anoxia of the glomerular capillaries due to spasm of the afferent arterioles. (presence of > 300 mg / litre in a 24-hour collection or presence of > 1 gm / litre in at least 2 random urine specimens 6 hours or more apart). Urine samples must be midstream or by catheterization. 67 Detection of proteinuria: a- Boiling test: - 10 cc urine in a test tube. - Boiling upper 1/3 of tube -> A cloud is formed. - Add few drops of acetic acid. - If the cloud dissolves -> phosphate. - If the cloud persists ->albuminuria b- Sulpha salicylic acid test: 10 drops sulpha salicyclic acid + 5 ml lear urine -> white cloud the amount and density of the cloud roughly indicates the amount of proteins. Trace or + or ++ or +++ or++++. c- Albustix (colour strips): If albuminuria is present -> green color. The depth of green color correlates with the amount of protein in urine. In severe cases, the following manifestation (symptoms) may occur: (a) Eye symptoms: As blurring of vision, flashes of light or complete blinding due to retinal changes: * Vascular spasm. * Hemorrhage and exudates (cotton wool and fluffy appearance). * Edema of the optic disc. * Accumulation of sub retinal fluid. Retinal detachment in severe cases. Prognosis is good as they are reversible once pregnancy termination. (b) Headache (frontal): due to hypertension. (c) Oliguria and anuria: due to kidney pathology. (d) Epigastric pain: due to rapid enlargement and subcapsular hemorrhage of the liver, which stretch Glisson's capsule. (e) Severe nausea and vomiting: due to congestion of gastric mucosa or cerebral edema. 68 Investigations: 1- Complete urine analysis: to exclude urinary tract infection, and to detect and measure proteinuria. 2-Kidney function tests: blood urea, Serum creatinine, creatinine clearance test and serum uric acid. Serum uric acid increases as an early and sensitive indicator of the onset of pre- eclampsia. Level > 6 mg% is abnormal in pregnancy but gradually increasing levels are more significant. 3- Liver function tests: serum albumin, bilirubin and liver enzymes (SGOT and SGPT). 4- Tests of placental functions: daily fetal movement count, non-stress test, Oxytocin challenge test, fetal biophysical profile and Doppler velocimetry. 5- Ultrasound assessment of fetal growth by repeated measurement of biparietal diameter, femur length, abdominal circumference, estimated fetal weight and amount of amniotic fluid to detect intra-uterine growth retardation. 6- Fundus examination (by ophthalmologist): spasm, hemorrhage, papilledema, or retinal detachment. 7- Estimation of coagulation index: PT, PIT, FDP and platelet count. Management of pre-eclampsia 1- Prophylactic treatment: 1- Proper antenatal care. 2- Proper diet, decrease salt intake (2-4 gm daily), LOW carbohydrate, more protein, vitamins and minerals e.g. calcium and magnesium. 3- Prevent excessive weight gain. 4- Avoid prophylactic diuretics, as the circulating blood volume is already low. 69  5- Regular examination for BP, urine for albumin, and weight. 6- Antithrombic agent (low dose aspirin) 40-100 mg orally/day. It inhibits the production of platelet aggregating agent. II-Active treatment: The definitive treatment of PE is delivery of the fetus. Our policy is to manage conservatively pre-eclampsia occurring before 37 weeks provided that: 1- Mother is asymptomatic. 2- Blood pressure can be controlled. 3- Normal liver and renal function. 4- No signs of fetal distress. (A) General measures: 1) Bed rest:  Physical and mental rest. 12 hours sleep in lateral recumbent position each night and rest periods during the day to facilitate renal and placental perfusion by mobilizing the movement of extracellular fluid back into the intravascular space.  At home in mild pre-eclampsia.  Hospitalization in severe pre-eclampsia however many centers preformed hospitalization in all cases of pre-eclampsia. 2) Balanced diet containing at least 60 to 70 g of protein, 400 mcg of folic acid, 1200 mg of calcium, adequate zinc, magnesium and vitamins is greatly recommended. There is no sodium restriction; however excessively salty foods should be avoided. Foods with roughage (whole grains, raw fruits, and vegetables) 70 are encouraged. The woman is advised to drink six to eight glasses of water per day and avoid alcohol and caffeine intake. 3) Observation: On admission, history, general and physical examination followed by daily search for development of such symptoms and signs -> headache, visual disturbance, epigastric pain and rapid weight gain. Weight measure on admission then every 2 days. Blood pressure every 4 hours. Urine: * Protein on admission then every 2 days. * Casts and cells indicative of underlying renal disease. Measurement of serum creatinine, uric acid and urea nitrogen repeat every week. Measurement of hematocrit, serum SGOT, repeated every week. Coagulation profile (PT, PTT, FDP and platelet count) repeated every week. Frequent evaluation of fetal size by serial sonography. Estimation of placental function and assessing fetal well-being by non-stress test (repeated according to severity of PE). Fundus examination (repeated every 2-3 days). (B) Medical measures: 1) Sedative: 30-60 mg phenobarbitone 4 times daily. 2) Diuretics: Lowers blood pressure and reduces edema. But, do not significantly reduce the incidence of proteinuric pre-eclampsia or improve perinatal outcome and are not useful in established pre-eclampsia: - They cause hyperuricemia obscuring a useful sign. - Aggravate hypovolemia. - Reduced placental perfusion. 71 So, we avoid their use except in management of pulmonary edema, which is a rare complication of pre-eclampsia. 3) Plasma volume expansion: Expansion of the blood volume may be required to improve the maternal systemic and uteroplacental circulation, thereby preventing hypoxia and reducing the effect of hemorrhage. Clear fluids will leak out and aggravate pre-existing edema, therefore, colloid solution such as hemaccel and gelofusine are used. These solutions increase the colloid osmotic pressure and pull fluid back into the circulation there by reducing the edema and increasing blood volume. (4) Hypotensives: given only when blood pressure > 160/110. Aim: to decrease maternal complications i.e. not curative. a) Methyl dopa (Aldomet): It is the first line of treatment. No evidence of long- term adverse effects in exposed infants. It has short half-life and slow onset of action. It inhibits vasoconstriction by a centrally mediated effect. Treatment starts with a loading dose 500-750 mg orally followed by a maintenance dose of between 250 twice daily and 1 gm three times daily. b) Calcium channel blockers e.g. nifedipine which is the second line of treatment with no evidence of harm to the fetus. It is a Ca channel blocker which inhibits influx of Ca ions to vascular smooth muscle, resulting in arterial vasodilatation. The initial dose is 10 mg twice daily and may be increased to 40 mg twice daily. c) Other antihypertensive drug as: Reserpin injection, Apresolin = hydralazin by IV infusion then oral tablet, Labetalol (combined alpha and beta adrenergic blocker) and MgSO4 for imminent eclampsia. (c) Obstetric measures: Termination of pregnancy. 72 Advantages: to minimize immediate and remote complications on the mother and fetus. Disadvantage: Prematurity and risk of termination method. Methods:  If the cervix is favorable: artificial rupture of the membranes + pitocin drips.  If the cervix is unfavorable: or obstetric indication for CS: LSCS. Indication: Mild pre-eclampsia: with improvement termination of pregnancy at the end of 37 Weeks or at term not beyond. Severe pre-eclampsia: termination of pregnancy. 1- All cases of pre-eclampsia when the fetus pass the hazards of prematurity (> 37 weeks). 2- Maternal blood pressure can't be safety controlled. 3- Mother will become symptomatic with signs of imminent eclampsia. 4- Mother will develop biochemical or hematological abnormality indicating that pregnancy cannot be safely controlled. 5- Severe pre-eclampsia + retinal changes. 6-Signs of fetal distress. (D) Management during labor: 1- Careful observation of the mother e.g. BP, pulse and proper sedation. 2- FHR monitoring during labor. 3- Shorten 2nd stage of labor by forceps or ventouse. 73 4- No ergometrine in the 3rd stage of labor except if there is postpartum hemorrhage. 5- Ergometrine will cause peripheral vasoconstriction and increase hypertension. (E) Care of the baby: Most babies are premature or growth retarded, so they should be handled by pediatrician. (F) Postpartum interventions for preeclampsia include close monitoring of the blood pressure and maternal condition. If blood pressure remains high after puerperium, the same antihypertensive drugs that are used during pregnancy seem to be the safest during breast feeding as long as they are taken at the lowest dose possible for hypertensive management. (G) If the woman remains hypertensive, all types of contraception are available to her, provided that compliance and close follow up are guaranteed. The risks of oral contraceptives must be discussed completely if that method is considered. Prognosis: Depends on severity and duration of' PE. Immediate complication: 1- Convulsion and coma (eclampsia). 2- Bilateral renal cortical necrosis with renal failure. 3- Accidental hemorrhage. 4- Intrauterine fetal death due to placental insufficiency. 5- Cerebral hemorrhage. 6- Coagulation failure. 7- Premature birth and IUGR. 74 8- PP hemorrhage and shock. 9- HELLP syndrome: Hemolytic anemia, Elevated liver enzymes, Low Platelets. Remote complication: 1- Residual chronic hypertension (1/3 of cases). 2- Recurrent of PE in the following pregnancy. 75  Gestational Diabetes Mellitus (GDM)  Learning objectives: By the end of this lecture, the student will be able to:  Define gestational diabetes mellitus  Identify risk factors for gestational diabetes mellitus  Mention the effect of gestational diabetes mellitus on pregnancy  Explain the diagnosis for gestational diabetes mellitus during pregnancy.  Describe the management steps for gestational diabetes mellitus during pregnancy.  List the nursing care for gestational diabetes mellitus during pregnancy.  Outlines  Definition of gestational diabetes mellitus.  Risk factors for gestational diabetes mellitus.  Effect of gestational diabetes mellitus on pregnancy.  Diagnosis for gestational diabetes mellitus during pregnancy.  Management steps for gestational diabetes mellitus during pregnancy.  Nursing care for gestational diabetes mellitus during pregnancy. Introduction Insulin is a hormone which enable glucose in the bloodstream to enter the cells of the body, where used as a source of energy. Placenta produces hormones that make the mother resistant to her own insulin. Most pregnant women produce more insulin to compensate and keep their blood sugar level normal. Some 76 pregnant women cannot produce enough extra insulin and their blood sugar level rises, a condition called gestational diabetes. Definition of GDM: It is any degree of glucose intolerance with onset of pregnancy or first recognition during pregnancy and considers the second most common medical disorders during pregnancy. Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Incidence: Gestational diabetes mellitus is a common complication of pregnancy with short and long-term maternal, fetal, and newborn adverse outcomes and the prevention of pathological hyperglycemia during pregnancy is meaningful for global public health. The pooled global standardized prevalence of GDM was 14.0% ranged between 7.1% and 27.6% worldwide. Time of testing: Testing for gestational diabetes is usually done between 24th and 28th week of pregnancy for low risk women. However, testing may be done earlier in the pregnancy (first prenatal visit) if the woman has risk factors for gestational diabetes, such as:  Maternal age above 35 years or over  previous history of gestational diabetes in a previous pregnancy  Personal history of diabetes  Family history of type 2 diabetes or a first-degree relative (mother or sister) who has had gestational diabetes 77   Overweight or obesity  Polycystic Ovary Syndrome. Causes for gestational diabetes mellitus: Although the cause of GDM is not known, there are some theories as to why the condition occurs. In pregnancy the placenta supplies a growing fetus with nutrients and water, and also produces a variety of hormones to maintain the pregnancy. Some of these hormones (estrogen, cortisol, and human placental lactogen) can have a blocking effect on insulin. This is called contra-insulin effect or insulin resistance, which usually begins about 20 to 24 weeks into the pregnancy. As the placenta grows, more of these hormones are produced, and the risk of insulin resistance becomes greater. Normally, the pancreas is able to make additional insulin to overcome insulin resistance, but when the production of insulin is not enough to overcome the effect of the placental hormones, gestational diabetes results. Effect of pregnancy on diabetes:  Pregnancy is diabetogenic due to increased production of human placental lactogen, placental insulinase, cortisol and progesterone.  Insulin requirements: increases during pregnancy due to increased production of placental hormones while it decreases postpartum. 78  Effect of diabetes on pregnancy (complications):  Maternal complications: 1-During pregnancy: Preeclampsia, preterm labour, monilial vulvo vaginitis, urinary tract infection and Placenta previa: due to large placenta. 2- During labor:  Prolonged and obstructed labor due to large sized baby.  Shoulder dystocia  Birth canal injuries 3-During puerperium:  Puerperal sepsis  Postpartum hemorrhage  Increase risk of type 2 diabetes  Breast infection and lactation failure.  Fetal complications:  Abortion.  Polyhydramnios: due to large placenta and fetal size.  Congenital anomalies: due to uncontrolled diabetes during fetal organogenesis.  Preterm labor: with its complications. (RDS)  Intrauterine fetal death: especially in the last 4 weeks due to: ketosis, hypoglycaemia, pre-eclampsia, congenital anomalies, and placental insufficiency.  Fetal macrosomia: it is defined as fetal birth weight is>4.1kg.  Causes: maternal hyperglycemia → fetal hyperglycemia →increase fetal insulin secretion (hyper insulinaemia) leads to 79  excessive deposition of fat, glycogen &protein and enlargement of fetal organs because insulin is growth factor.  Neonatal Hypoglycemia: due to hyperinsulinaemia.  Neonatal morbidity and mortality. Assessment of gestational diabetes  History  Examination  Investigation History  Previous GDM  Family history of diabetes  Preeclampsia 80   Polyhydramnos  Abortion  Preterm labor  Delivery of large baby. Screening tests for G.D:  First method: woman taken 50gm glucose which ingested orally and venous blood samples withdrawn 1hour later.  Result: normal screen if blood glucose level is 140mg \dl and If >140mg\dl, oral glucose tolerance test G.T.T must be done  Oral glucose tolerance test: it is done by measuring blood sugar level when the woman is (fasting 8-14 hours), then again after one, two, and three hours after the ingestion of 100gm of glucose orally and a venous blood samples were taken (when the patient is fasting and after1, 2 and 3 hours). Diagnostic Criteria for 100-g glucose Challenge Test: Two or more of the following indicates diagnosis of gestational diabetes mellitus:  95 mg/dl or higher fasting blood glucose  180 mg/dl or higher at 1-hour postprandial blood glucose  155 mg/dl or higher at 2-hour postprandial blood glucose  140 mg/dl or higher at 3-hour postprandial blood glucose Second method: Measuring blood sugar level when the woman is (fasting 8-14 hours), then again after one and two hours after the ingestion of 75gm of glucose orally and a venous blood samples were taken (when the patient is fasting and after1 and 2 hours). 81 Antenatal care  Women should be seen at a combined antenatal and diabetic clinic  Frequent antenatal visits: for maternal and fetal follow up.  Diet: restriction of carbohydrates, less fat and more proteins and vitamins.  Exercises  Insulin therapy  Oral hypoglycemics are contraindicated during pregnancy; labor and early puerperium as they are not adequate for controlling diabetes, have teratogenic effects and may result in neonatal hypoglycemia. Keeping blood sugar level under control Management of labor and delivery: 1. Timing: pregnancy is terminated at 37 completed weeks to avoid intrauterine fetal death. 82 2. Mode of delivery: vaginal delivery is induced in normal presentation, favorable cervix, average sized baby and no fetal distress. Otherwise, caesarean section is indicated. 3. Monitor fetal condition throughout the labor 4. Careful observation for PPH Neonatal care: The neonate is managed as a premature baby as it is more liable for RDS.  Newborn should be examined carefully for congenital abnormality.  The baby should be fed soon after delivery to prevent hypoglycemia as the baby continues to produce insulin than he needs (to avoid brain damage). Post-natal care:  Carbohydrate metabolism returns to normal within 24 hours after delivery and insulin requirements will fall rapidly.  Careful observation for PPH  Diabetic mother is liable to infection: advice women to change pads frequently and keep any wound clean and dry. Contraception  Barrier methods ( condom and diaphragm) ….The best  Combined hormonal contraceptive pills: are contraindicated as it increases hyperglycemia.  Progestin only pills can be used as it not causes metabolic changes.  Intra uterine device (IUD): increase risk of pelvic infection. 83  Normal labor  Learning objectives: By the end of this lecture, the student will be able to:  Define normal labor  Identify the main causes of onset of labor  Compare and contrast true versus false labor  Discuss the critical factors affecting labor and birth  List the cardinal movements of labor  Recognize the normal physiologic changes occurring during all four stages of labor  Delineate the nurse’s role throughout the labor and birth process.  Outlines  Definition of normal labor  Causes of onset of labor  Comparison between true versus false labor  Critical factors affecting labor and birth  Cardinal movements of labor  Normal physiologic changes occurring during all four stages of labor  Nurse’s role throughout the labor and birth process. 84  Anatomy of the female pelvis The Bony Pelvis: The bony pelvis is composed of 4 bones: 1- Two innominate or hip bones 2- One sacrum 3- One coccyx Innominate or hip bone is divided into: A) Ilium parts: -Iliac fossa. -Iliac crest. -Anterior iliac spine. -Posterior iliac spine. - 2/5 acetabulum. 85 B) Ischum parts: -Ischeal tuberosity -Ischeal spine - 2/5 acetabulum C) Pubis parts: -Body and superior and inferior rami -Symphysis pubis - 1/5 acetabulum Sacrum: - 5 sacral vertebrae fused together. - Sacral promontory and ala on each side of it. Coccyx: - 4 small rudimentary coccygeal vertebrae fused together. 86 Differences between the male and female pelvis: Characteristic Male Female Bones Heavier, rougher Lighter, delicate Size Smaller Larger Sacrum Narrow, curved Broader, less curved Symphysis pubis Deeper Shallower Ischeal tuberosity Inverted Everted Inferior pubic angle Narrower Wider (90°) Ischeal spine Bigger Smaller Coccyx Less movable Movable False pelvis Tall Flaired Pelvic inlet Android Gynecoid Pelvic vavity Funnel-shaped Less funnel shaped Pelvic outlet Smaller Larger True Conjugate diagonal Obstetric a- Inlet Measurements Oblique Transverse b- Cavity Transverse c- Outlet Measurements Transverse mid plane antero posterior 87  ** Birth Canal is divided into: (1) Major (greater or false) pelvis (2) Minor (Lesser, deep or true) pelvis Measurements of the true pelvis: Anteroposterior Oblique Transverse Inlet 11 cm. 12 cm. 13 cm Cavity 12 cm. 12 cm. 12 cm. Outlet 13 cm. 12 cm. 11 cm (1) The major (greater or false) pelvis : Is that portion of the bony pelvis between the iliac crests and the pelvic brim: a. Laterally, the alar plates of the ilia. b. Posteriorly L3, L4 and L5. c. Anteriorly, the anterior abdominal wall. (2 ) The minor (Lesser, deep or true) pelvis: Lies inferiorly to the pelvic brim. A- The pelvic inlet = pelvic brim: Demarcates the minor from the major pelvis. It is defined by the sacral promontory and the linea terminalis of the innominate bone.  Measurement of the female pelvic inlet:  Conjugate diameters: * The true conjugate diameter (10 cm). 88 Is the anteroposterior diameter from the sacral promontory to the superior margin of the sympysis pubis. This can be measured only radiographically. Bony pelvis-brim  The diagonal conjugate (12.5cm). Is measured from the sacral promontory to the inferior margin of the pubic symphysis. This is easily noted on pelvic examination. 89   The obstetric conjugate (10.5cm). Is the least anteroposterior diameter from the sacral promontory to a point a few millimeters below the superior margin of the pubic symphysis.  The oblique diameter (12.5 cm).Is measured from the sacroiliac joint to the contralateral ilio-pectineal eminence.  The transverse diameter (13.5 cm). Is the widest distance across the pelvic brim B- The pelvic cavity: Is defined by minor pelvis, forms the birth canal, and contains portion of the gastrointestinal tract as' well as the lower portion of the urinary tract and certain reproductive organs. Pelvic inclination:By this is meant the angle that any pelvic plane makes with the horizontal. In the erect position the brim is normally inclined at 60 degrees. 90 C - The pelvic outlet: Is closed by the pelvic diaphragm and covered by the perineum. It is defined by thecoccyx, ischial tuberosities, and inferior bubic symphysis. ◙ During pregnancy the ligaments of the sacro - iliac joints and the symphysis pubis become softened and there is slightly increased mobility at these joints. The sacrococcygeal joint allows the coccyx to move freely backward during delivery. Measurements of the female pelvic outlet:  The transverse diameter (11 cm). Is between the ischial tuberosities. It is approximately aslong as a clenched fist is wide.  The transverse midplane diameter (10.5 cm). Is measured between the ischial spines  The anteroposterior (Sagittal) diameter (13.5 cm). Is measured from the lower margin of the pubic symphysis to the sacrococcygeal joint. 91  N.B. Thorn's Dictum states that for spontaneous delivery to take place, the transverse of the outlet plus the posterior sagittalmust be equal at least 15 cm.  The girdle of contact of the head  It is the circumference of the head which first comes in contact with the pelvic brim. This circumference varies according to the length of the engaging diameters.  In a well flexed vertex presentation, it forms a rounded circle, as both the antero-posterior and transverse diameters measure 9.5 cm. This rounded shape is quite.  favourable in preventing premature rupture of the membranes it fits in the lower uterine segment and effectively separates the hind waters from bag of fore waters.  In deflexed vertex and I or other abnormal presentations, the girdle of contact is oblong or uneven, allowing free communication between the hind waters and the bag of forewaters and hence predisposes to premature rupture of membranes. 92 The pelvic axis: The axis of the pelvis is an imaginary curve line which shows the path which the- centre of the fetal head follows during its passage through the pelvis. It is obtained by taking several antero-posterior diameters of the pelvis and joining their centers. Pelvic joints: a) Sacro-iliac joint: between the sacrum and ilium. b) Sacro-coccygeal joint: between the Pelvic Joints: sacrum ana coccyx. c) Symphysis pubis joint: between the two bodies of the pubis. Pelvic ligaments: *Sacrotuberous ligament *Sacroi!iac ligament * lliolumbar ligament Pelvic ligaments Ligaments support inside the pelvis:  Broad ligament: It is a peritoneal fold extending from the pelvic wall to the lateral borders of the uterus. It contains, the fallopian tube, the uterine, ovarian vessels, lymphatics and nerves, mesonephric remnants and considerable amount of connective tissues.  Round Ligament: It is a fibro-muscular band arises at the cornu of the uterus anterior to the tubal insertion and passes in the inguinal canal to be inserted into the labium majus of the vulva.  Ovarian Ligament: It is a fibro-muscular band which link the ovary to the cornu of the uterus posterior to tubal insertion. 93   Cardinal ligament "Mackenrodt's ligament": It is formed of a condensed endopelvic fascia extending from the supra-vaginal cervix and the upper vaginato the lateral pelvic wall.  Utero-sacral ligament: It is a condensed end pelvic fascia extending from the back of the supra-vaginal cervix and upper vagina to the sacrum. The pelvic floor: This is the soft tissue filling the pelvic bony outlet consists from above downwards:  The pelvic peritoneum.  The pelvic fascia.  The levator ani muscles and coccygeus muscle.  The perineal muscles.  The skin of the perineum. Subdivisions of pelvic floor muscles (pelvic diaphragm): 1-lliococcygeus 2- Pubococcygeus Levator ani 3- Puborectalis · 4- Ischiococcygeus Actions: * Supports the pelvic organs. *Acts as a sphincter tothe urethra and rectum. * Important for internal rotation of the head during labor. # N.B. Injuries to the pelvic floor during labor predisposes to genital prolapse and stress incontinence of urine. 94 The perineum Definition: The structures filling the lower pelvic aperture. Boundaries:  Anterior: Symphysis pubis.  Lateral : Ischial tuberosities.  Posterior : Coccyx Divisions: An immaginary line between the two ischial tuberosities divides the perineum into two triangles. Anal triangle: The principle structures of the anal triangle are; the anal canal, the anus and the terminal portion of the gastrointestinal canal. Urogenital triangle: The principle structure of the urogenital triangle is the external genitalia 95  Fetal Skull Fetal Skull: It Comprised of: 1) The face 2) The base 3) The vault of the cranium (roof) The bones of the face and base are ossified, firmly united and not compressible, no moulding occurs in them. The bones composing the vault are:  Two frontal bones  Two parietal bones  Two temporal bones and the occipital bone  These bones are thin, poorly ossified easily compressible and joined only by membranes (sutures). 96   The sutures of the fetal skull are membranous spaces between the cranial bones. They are useful in: (a) Making the moulding possible. (b) Determine the position of the baby's head on vaginal examination. The important Sutures are:  Sagittal suture: Located between the two parietals, divides the skull into left and right halves  Coronal suture: Separates the frontal bones from the parietal bones, Frontal Suture: Between the two frontals  Temporal Suture: Between the parietal and temporal bone  Lambdoidal Suture: Located between the two parietal bones and the occipital bone 97 Fontanels: The membranous space at the junction of two or more sutures. There are 6 fontanels but, the anterior and posterior fontanels are of obstetric important  The anterior fontanel ( bregma): Located at the junction of the sagittal, frontal, and coronal sutures. It is large, lozenge shaped, has 4 sutures running into it. It is patent at birth and closed after 18 months. No over-riding of the surrounding bones when moulding of the vault occurs as they are widely separated.  The posterior fontanelle (Lambda): Lies at the posterior end of the sagittal suture, between the two parietal bones and the occipital bone. It is triangular in shape, small, close after 6 - 8 weeks of age. It has 3 sutures running into it. Over-riding of the bones occur with moulding. Fontanels are useful in: (a) The position of these two fontanels when felt on vaginal examination indicates in which direction the occiput is pointing and the degree of flexion or extension of the head. (b) The large fontanels is examined m assessing the condition of the child after birth 98   It is depressed below the surface of the bony skull when infant is dehydrated.  It is bulging, tense, raised above the level of the skull when the intracranial pressure is elevated.  Landmarks of the fetal skull Sinciput  The anterior area known as the brow Bregma  The large diamond-shaped anterior fontanels Vertex  The area between the anterior and posterior fontanels Posterior  The intersection between posterior cranial sutures fontanel Occiput  The area of the fetal skull occupied by the occipital bone, beneath the posterior fontanel Mentum  The fetal chin.  Diameters of fetal skull: (A) Longitudinal diameters: 1. Suboccipito bregmatic diameter ( S.O.B) = 9. 5 cm is measured from the suboccipital region to the centre of the bregma. 99 2. Suboccipito frontal diameter (S.O. F) = 10 cm : Is measured from the suboccipital region to the prominence of the forehead. 3. Occipita frontal diameter (O. F) = 11 cm:-Is measured from the root of the nose (glabella) to the posterior fontanelle. 4. Mentovertical diameter (M.V) = 13.5 cm:-Is measured ' from the chin to the furthest point ofthe vertex. 5. Submento bregmatic diameter (S.B) = 9.5 cm:-Is measured from below the chin to the anterior fontanelle. 100 ( B ) Transverse diameters : 1. The biparietal diameter = 9.5 cm:It is the largest transverse diameter, lies between the two parietal eminences. 2. The bitemporal diameter = 8 cm:It is the shortest transverse diameter, lies between the anterior ends of the temporal sutures. 101  Fetopelvic relationship To understand the situation of the fetus in the uterus and pelvis, the descriptive terminology should be reviewed and clarified.  Lie: Relationship of the long axis of the fetus to the long axis of the mother. The lie may be: longitudinal and transverse or oblique.  Attitude: Relation of fetal parts to each other. The typical fetal attitude in the uterus is the attitude of flexion, to accommodate the shape of the uterine cavity. 102  The attitude of flexion is characterized by: a. The head is completely flexed, with the chin is almost in contact with the chest. b. The firms are crossed over the thorax. The thighs· are flexed over the abdomen. c. The back becomes markedly convex. d. The legs are bent at the knees. e. The arches of the feet rest upon the anterior surface of the legs.  Presentation: The part of the fetus related to the pelvic brim and first felt during vaginal examination. OR it is that part of the fetus lying lowermost and presents first to the examining finger per-vaginum.  Types :The presentation may be: (1) Cephalic presentation a. Vertex presentation :Vertex presented first when the head is fully flexed b. Face presentation: Face pre13ented first when the head is fully extended c. Brow presentation: Brow presented first when the head 1s partially extended, Vertex. Brow. Face (2) Breech presentation: means the fetal bottom is coming out first 103   Frank breech; is when the fetus's legs are folded flat up and his bottom is closest to the birth canal. The fetal legs are extended above the pubis. This is the most common breech presentation and more favorable for vaginal delivery