Basics for Obstetrics & Gynecology PDF

1 BASICS FOR OBSTETRICS AND GYNECOLOGY For Physiotherapy Undergraduate Students ‫ﻧد‬ 21 ‫ى‬ Authored By 02 ‫ﻋط‬ DR. ADEL FAROUK ‫ﺎ‬ 10 ‫ﷲ‬...

1 BASICS FOR OBSTETRICS AND GYNECOLOGY For Physiotherapy Undergraduate Students ‫ﻧد‬ 21 ‫ى‬ Authored By 02 ‫ﻋط‬ DR. ADEL FAROUK ‫ﺎ‬ 10 ‫ﷲ‬ Professor of Obstetrics and Gynecology Faculty of Medicine, Cairo University 18 ‫ﻋﺑ‬ 20 ‫داﻟ‬ DR. AMIR ARABI ‫ﺣ‬ 71 ‫ﻣﯾد‬ Assistant professor of Obstetrics and Gynecology Faculty of Medicine, Cairo University 1 0 ‫اﺣ‬ ‫ﻣد‬ Co-ordinated By Dr. MAHITAB M. YOSRI Lecturer of P.T for Women’s Health, Cairo University  2 TABLE OF CONTENTS Topic P.N. Part I 4-95 Chapter 1: Introduction………………………………………….. 4 ‫ﻧد‬ 21 ‫ى‬ Chapter 2: Antenatal Care ………………………………………. 24 Chapter 3: Risk Pregnancy……………………………………… 31 02 ‫ﻋط‬ Chapter 4: Normal Labor…………………………....................... 48 ‫ﺎ‬ Chapter 5: Assisted delivery………………………....................... 69 10 ‫ﷲ‬ Chapter 6: Cesarean Section…………………………………….. 83 Chapter 7: Puerperium……………………………....................... 88 18 ‫ﻋﺑ‬ Part II 1-106 20 ‫داﻟ‬ Chapter 1: Anatomy of The Female Genital Tract…………….. 1 ‫ﺣ‬ Chapter 2: Pelvic Organ Prolapse……………………………….. 30 71 ‫ﻣﯾد‬ Chapter 3: Retroversion Flexion of The Uterus………………... 48 Chapter 4: Urinary Incontinence in Females…………………… 51 1 0 ‫اﺣ‬ Chapter 5: Dysmenorrhea……………………………………….. 66 ‫ﻣد‬ Chapter 6: Anovulatory Disturbances………………………….. 69 Chapter 7: Menopause…………………………………………… 86 Chapter 8: Operative gynecology (hysterectomy)……………… 97  3 Part I ‫ﻧد‬ 21 ‫ى‬ Basics for obstetrics 02 ‫ﻋط‬ ‫ﺎ‬ 10 ‫ﷲ‬ Dr. Adel Farouk 18 ‫ﻋﺑ‬ 20 ‫داﻟ‬ ‫ﺣ‬ 71 ‫ﻣﯾد‬ 1 0 ‫اﺣ‬ ‫ﻣد‬  4 Chapter 1 INTRODUCTION CHAPTER CONTENTS Anatomy of the female pelvis Physiological changes of pregnancy Anatomy of the fetal skull Diagnosis of pregnancy Fertilization and implantation ‫ﻧد‬ Anatomy of female pelvis 21 ‫ى‬ The female pelvis is subdivided into false pelvis & true pelvis separated by the 02 ‫ﻋط‬ pelvic brim. ‫ﺎ‬  False pelvis: Lies above the pelvic brim, it has no obstetric importance. 10 ‫ﷲ‬  True pelvis: below the pelvic brim concerned with childbirth. 18 ‫ﻋﺑ‬ The true pelvis: It is composed of inlet, cavity, and outlet and is divided into planes and segments. 20 ‫داﻟ‬ The pelvic inlet (brim): ‫ﺣ‬ 71 ‫ﻣﯾد‬ It is a plane representing an imaginary line joining the promontory of the sacrum, ala of the sacrum, the sacroiliac joint, illio- pectineal line of innominate bone, 1 0 ‫اﺣ‬ illo-pectineal eminence, upper border of superior pubic ramus, pubic tubercle, ‫ﻣد‬ upper border of pubic bone (pubic crest) and upper border of symphysis pubis and then to the other points on the opposite side. The pelvic inclination: the pelvic inlet makes an angle of 55° with the horizontal plane in standing position. Diameters of pelvic inlet: The antero-posterior diameters (A-P). (a) Anatomical antero-posterior diameter (true conjugate)  5 It extends from the upper border of symphysis pubis to the tip of sacral promontory. The degree of contracted pelvis is classified according to the length of this diameter. (b) The diagonal conjugate 12.5 cm It extends from the lower border of symphysis pubis to the sacral promontory. It is 1.5 cm longer than the true conjugate. This diameter can be measured clinically during P.V. examination then by subtracting 1.5 cm from its length the length of ‫ﻧد‬ the true conjugate can be detected. 21 ‫ى‬ The transverse diameters: (I) Anatomical transverse diameter. (13 cm) 02 ‫ﻋط‬ Extends between the two farthest points on the illio-pectineal lines on each side. ‫ﺎ‬ The oblique Diameter: (12-12.5 cm) 10 ‫ﷲ‬ Each extends from the sacroiliac joint to the opposite illio-pectineal eminence: 12 cm. The right oblique starts from the right sacroiliac joint & vice versa. It is the 18 ‫ﻋﺑ‬ widest available diameter at the pelvic inlet so in normal labor the head enters the 20 ‫داﻟ‬ pelvis in the oblique diameter (mostly the right one) ‫ﺣ‬ 71 ‫ﻣﯾد‬ Pelvic cavity: It is a segment bounded above by the brim, below by the plane of least pelvic dimensions, anteriorly by the symphysis pubis and posteriorly by the sacrum and 1 0 ‫اﺣ‬ laterally by the pelvic muscles covering the innominate bone. It is rounded with ‫ﻣد‬ all diameters are 12.5 cm. Pelvic outlet: (A) Anatomical outlet: It is lozenge shaped plane bounded by the lower border of symphysis pubis and pubic arch, ischial tuberosities, sacrotuberous and sacrospinous ligments and the tip of coccyx. The anatomical outlet is divided into 2 triangular planes at 2 different levels. [Anterior & posterior sagittal planes] with a common base at the line joining the two  6 ischial tuberosities, the apex of the anterior sagittal plane is at the lower border of symphysis pubis while the apex of the posterior sagittal plane is at the tip of sacrum. Diameters of pelvic outlet:  Antero-posterior diameters(11cm): extends between lower border of symphysis pubis & the tip of coccyx.  Transverse diameters (Bituberous diameter) (11cm): It extends between the inner aspects of ischial tuberosities. Roughly the diameter can be assessed by ‫ﻧد‬ the closed fist of the hand in-between the 2 ischial tuberosities. 21 ‫ى‬ Planes of the pelvis: 1- Plane of pelvic inlet: 02 ‫ﻋط‬ It is an imaginary surface which flushes with the bony landmark of the pelvic ‫ﺎ‬ brim it makes an angle of 55º with the horizontal in the standing position (the 10 ‫ﷲ‬ pelvic inclination). The presenting part is considered engaged if the widest transverse diameter of the presenting part passes through this plane. 18 ‫ﻋﺑ‬ 2- Plane of pelvic cavity: plane of the greatest pelvic dimensions: 20 ‫داﻟ‬ It is an imaginary surface that lies at the level of a line between the middle of ‫ﺣ‬ 71 ‫ﻣﯾد‬ symphysis pubis and the junction of the 2nd and the 3 rd sacral vertebrae. It passes laterally to the center of accetabulum, the upper part of the greater sciatic notch. Internal rotation occurs when the biparital diameter of the head occupies this 1 0 ‫اﺣ‬ wide plane of the pelvis at this time the occiput (in full flexion the lower most ‫ﻣد‬ point) lies on the pelvic floor (at the level of the plane of the least pelvic dimensions). 3- The plane of least pelvic dimensions: It is an imaginary line passing through the lower margin of the symphsis pubis, laterally to the ischial spines and posteriorly to the tip of the sacrum. The importance of the level of the ischial spines:  It is the plane of least pelvic dimensions (plane of obstetric outlet)  7  The level of the pelvic floor muscles. The levator ani muscles (the main pelvic floor muscles) are situated at this level. Origin of the ischio- coccegyeous part of the levator ani  The head is considered engaged when the vault is felt vaginally at or below this level.  Internal rotation occurs when the occiput (lowest part of the fetus is at this level). ‫ﻧد‬  Forceps should be applied only when the head is felt at this level or below this 21 ‫ى‬ level.  The anesthetic agent in pudendal nerve block is injected at the ischial spines 02 ‫ﻋط‬ on both sides (as the pudendal nerve turns around the ischial spines). ‫ﺎ‬  The external os of the cervix is normally felt at this level. Uterine prolapse is 10 ‫ﷲ‬ diagnosed if the external os descends with straining below this level.  The ring pessary that may be used for treatment of prolapse should be 18 ‫ﻋﺑ‬ introduced above this level to be retained above the levator ani muscles. 20 ‫داﻟ‬ 4- The planes of the anatomical outlet: ‫ﺣ‬ 71 ‫ﻣﯾد‬ It passes from the lower border of the symphysis pubis to the sacral tuberosity laterally and to the tip of the sacrum posteriorly. It is lozenge shaped and divided to two triangular planes connected at the common base bi-tuberous 1 0 ‫اﺣ‬ diameter. ‫ﻣد‬  The anterior sagittal plane.  The posterior sagittal plane. Variation in the shape of female pelvis According to the radiological studies 4 basic types of female pelvis are described. 1- Gynaecoid pelvis: 50% - Inlet: is slightly transverse oval.  8 - Cavity: Sacrum: is wide, short with even concavity from above downwards and from side to side Sidewalls: straight or slightly converging without projection of ischial spines. - Outlet: Sub pubic angle between 90 – 100◌ْ 2-Anthropoid pelvis 25% All antero- posterior diameters are long transverse diameters are short. Slightly ‫ﻧد‬ converging lateral walls. 21 ‫ى‬ Cavity: sacrum is long & narrow, outlet: narrow sub- pubic angle. 3- Android pelvis 20%: 02 ‫ﻋط‬ - Inlet: Triangular (heart shaped) with the base posterior (wide flat) and narrow apex anterior. ‫ﺎ‬ 10 ‫ﷲ‬ - Cavity: Sacrum is long, flat and straight with forward projection of the sacral tip. 18 ‫ﻋﺑ‬ The sacro- sciatic notches are deep & narrow. 20 ‫داﻟ‬ The sidewalls are converging downwards with Ischial spines are jutting. ‫ﺣ‬ 71 ‫ﻣﯾد‬ -Outlet: Sub-pubic angle is acute 70◌ْ or less. 4- Platyelloid (flat pelvis) (5%).  All transverse diameters are elongated. 1 0 ‫اﺣ‬ ‫ﻣد‬  All antero-posterior diameters are shortened.  Narrow sacro-sciatic notch.  Wide sub-pubic angle. 5- Other mixed types.  9 Anatomy of the fetal skull It consists of face base, vault. It consists of face base, vault. The vault: is composed of - 2 frontal bones separated by frontal suture. - 2 parietal bones separated by sagittal suture. - The 2 squamotemporal bones. ‫ﻧد‬ - The occipital bone. 21 ‫ى‬ - The cornal suture separates the 2 frontal bones from the 2 parietal bones. - The lambodid suture separates the squamous portion of occipital bone from the 02 ‫ﻋط‬ 2 parietal bones. ‫ﺎ‬ Anterior fontanelle (bregma) Posterior fontanelle (lambda) 10 ‫ﷲ‬ Item Size It is large It is small. 18 ‫ﻋﺑ‬ Shape It is lozenge shaped. Triangular. 20 ‫داﻟ‬ Floor Membranous floor Bony floor ‫ﺣ‬ Surrounding Surrounded by 4 bones [2 Surrounded by 3 bones. 2 parietal 71 ‫ﻣﯾد‬ bones frontal and 2 parietal] and occipital] Surrounding Connected with frontal, Connected with the sagittal and the sutures sagittal and 2 halves of coronal 2 halves of lambodid suture. 1 0 ‫اﺣ‬ suture. ‫ﻣد‬ Ossification The floor is completely The floor is completely ossified at ossified 1.5 years after full term. Molding The surrounding bones do not Molding of the head at birth leads to override when molding occurs overriding of the surrounding bones  The fontanelles: - The anterior fontanelle (bregma) between sagittal, frontal sutures and the 2 halves of coronal suture and posterior fontanelle (lambda) between the sagittal suture and the 2 halves of the lambdoid suture. - The anterior & posterior fontanelles are of obstetric importance for:  10 - Diagnosis of vertex presentation. - Diagnosis of the position of the occiput (anterior – posterior – transverse). Diameters of the fetal skull: A) Longitudinal diameters:  Sub-occipto bregmatic diameter: 9.5 cm - From below the occipital protuberance to the center of the anterior fontanelle (bregma) it is the diameter of engagement in occipto anterior position with ‫ﻧد‬ complete flexion. 21 ‫ى‬  Sub- occipto frontal diameter: (10 cm) From below the occipital protuberance to the anterior end of the bregma. 02 ‫ﻋط‬ - It is the diameter that distends the vulva when the head is allowed to extend ‫ﺎ‬ 10 ‫ﷲ‬ after crowning in vertex presentation occipto- anterior position.  Occipto- frontal diameter: (11.5 cm) 18 ‫ﻋﺑ‬ It extends from the occipital protuberance to the root of the nose. 20 ‫داﻟ‬ - It is the diameter that distends the vulva if the head extends before crowning in vertex presentation occipto- anterior position. ‫ﺣ‬ 71 ‫ﻣﯾد‬ B) Transverse diameters:  Biparietal diameter 9.5 cm 1 0 ‫اﺣ‬ It extends between the 2 parietal eminences. ‫ﻣد‬ It is the largest transverse diameter it is the engaging diameter in all-cephalic presentations.  Supra- parietal- sub parietal diameter (9 cm): From above one of the parietal eminences to below the opposite one. It is the engaging diameter in case of asynclitism. Some degree of asynclitism occurs in every vaginal delivery.  Bitemporal diameter (8 cm).  Bimastoid diameter (7.5 cm).  11 Fertilization and implantation Fertilization:  Oocyte production: The primordial germ cells of any female originate in the yolk sac and migrate to the ovary in intrauterine life where it starts meiosis is started and is arrested till ‫ﻧد‬ before ovulation. 21 ‫ى‬ A- Ovulation: Ovulation occurs about day 14 of the average 28 days menstrual cycle, the oocyte 02 ‫ﻋط‬ surrounded with a single layer of corona radiata and Zona pellucida into the ‫ﺎ‬ 10 ‫ﷲ‬ peritoneal cavity to be picked by the fallopian tube and remains ready for fertilization for 36 hours. 18 ‫ﻋﺑ‬  Sperm ascent in the female genital tract: 20 ‫داﻟ‬ At the end of sexual intercourse millions of sperms are deposited in the posterior ‫ﺣ‬ fornix of the vagina, some of these sperms pass through the cervical mucus, which 71 ‫ﻣﯾد‬ is abundant and has low viscosity in the ovulatory period helping penetration by the sperms. 1 0 ‫اﺣ‬ Millions of sperms are laid in the upper vagina, only hundreds of thousands reach ‫ﻣد‬ the uterine and only thousands pass into the tubes. Less than one hundred reach the portion of the fallopian tube. Only few succeed to penetrate the zona pelluicda and only one capacitated sperm enters the ovum. The sperms ascend in the uterine cavity by its own motility helped by uterine peristalsis, which is stimulated by the prostaglandin content of the seminal fluid. The sperms reach the fallopian tube within 30-40 minutes of its deposition. The sperms become capable of fertilizing the (sperm capacitation) after a period of 2-6 hours.  12 Sperm capacitation involves removal of substance that coat the sperm surface and the sperm becomes capable of penetration of the ovum such capasitation occurs in the uterine cavity and is completed in the fallopian tube. B- Fertilization:  Changes at fertilization Fertilization occurs in the outer ampullary portion of the fallopian tube by penetration of a capacitated sperm into the ovum through the following changes: ‫ﻧد‬ - The acrosome liberates Hyaluronidase enzyme that facilitate the passage of 21 ‫ى‬ the sperm through the corona radiate. - The acrosome also liberates the acrosin enzyme that enables the sperm to 02 ‫ﻋط‬ penetrate the zona pelluicda. ‫ﺎ‬ 10 ‫ﷲ‬ - After entry of the sperm into the oocyte a reaction spread from the entry site over the zona pellucida preventing further sperm penetration to avoid the risk of 18 ‫ﻋﺑ‬ polyploidy. 20 ‫داﻟ‬  Changes after fertilization: ‫ﺣ‬ - The sperm changes: disappearance of the cp and detachment of the tail. 71 ‫ﻣﯾد‬ - Second maturation division of the ovum with elimination of the second polar body. 1 0 ‫اﺣ‬ - Fusion of the ovum (23 chromosomes) and sperm (23 chromosomes) to form ‫ﻣد‬ the zygote with (46 chromosomes). - The nucleoli disappear. - Cleave division occurs in 24 hours of fertilization.  Ovum transport: The movement of the tubal cilia propelled the fertilized ovum towards the uterine cavity; on its way the fertilized ovum divides to form the morula.  13 Sex determination: The mature spermatozoon carries 22 autosomes and either X or Y chromosomes, while the mature ovum carries 22 autosomes and one X chromosome. Therefore after fertilization the zygote contains either 44 autosomes & XX (females) or 44 autosomes & XY (males). So the sex is determined by the X or the Y chromosomes of the spermatozoon. C-Implantation: ‫ﻧد‬ On its way to the uterine cavity the fertilized ovum divides into 2 cells and each 21 ‫ى‬ cell is dividing into two, then repeated division occurs to form a solid mass of about 16 cells (the morula) within 3-4 days. The morula reaches the uterine 02 ‫ﻋط‬ cavity after about 4 days from fertilization. ‫ﺎ‬  Blastocyst formation: 10 ‫ﷲ‬ The morula becomes cystic by appearance (blastocyst) and the cells become 18 ‫ﻋﺑ‬ arranged into an inner cell mass arranged inside the cyst and an outer cell layer 20 ‫داﻟ‬ lining this cyst (the outer cell mass) (the trophoblast). The blastocyst remains free in the endometrial cavity for 3-4 days and is ‫ﺣ‬ 71 ‫ﻣﯾد‬ nourished from the endometrial secretion (uterine milk). The blastocyst is embedded into the endometrium on the 6th or 8th days after fertilization. 1 0 ‫اﺣ‬  Chrionic villi: ‫ﻣد‬ By the 7th day the blastocys is in the uterine cavity covered with trophoplast which consists of 2 layers, outer structreless layer without cell wall between called (syncytiotrophblasts) and inner cells called (cytotrophplasts), the functions of the trophoblasts is to attach the embryo to the embryo to the decidua and to nourish the zygote.  The decidua: It is the thickened endometrium mucosa of the pregnant uterus. The glands become enlarged, tortuous and filled with secretion. The stroma cells become  14 enlarged polygonal cells contain lipids in their cytoplasm (modified into the decidual cells). The well-developed decidua consists of 3 layers: Functions of the decidua: 1. It is the site of implantation of the fertilized ovum. 2. Nutrition of the early growing ovum. 3. It shares in the formation of the placenta (the decidua basalis). After implantation, the decidua becomes differentiated into decidua covering the ‫ﻧد‬ ovum (decidua capsularis), decidua underlying the ovum, between it and the 21 ‫ى‬ uterine muscle (decidua basalis) and decidua lining the rest of the & uterine cavity (decidua vera or parietalis). 02 ‫ﻋط‬ At the end of 12 weeks, the decidua capsularis and Vera fuse due to the growth ‫ﺎ‬ of the fetus and thus the uterine cavity is obliterated. 10 ‫ﷲ‬ The syncytotrophoblasts invade the decidua, stripping the spiral vessels thus Lacunae filled with blood are formed ‘maternal sinusoids”. 18 ‫ﻋﺑ‬ 20 ‫داﻟ‬ ‫ﺣ‬ 71 ‫ﻣﯾد‬ 1 0 ‫اﺣ‬ ‫ﻣد‬  15 Physiological changes of pregnancy I.The genital organs: A. The uterus: Increases in size and weight of the uterus: The size of the uterus increases from 7.5 cm in length to 35 cm. The weight of the uterus is increases: 50 grams to 1000 gms. It is due to pregnancy hormones leading to hypertrophy (mainly) and hyperplasia and stretching. ‫ﻧد‬  Shape: Globular until 14 weeks then pear shaped. 21 ‫ى‬  Ligaments: Hypertrophy. 02 ‫ﻋط‬  Endometrium: is differentiated to the decidua.  Dextrorotation: deviation of the uterus to the right side (80% of cases). ‫ﺎ‬ 10 ‫ﷲ‬  Braxton Hicks contractions: Irregular, usually painless, with no effect on cervical dilatation. Promoting placental circulation. 18 ‫ﻋﺑ‬  The lower uterine segment: 20 ‫داﻟ‬ Is formed from the isthmus, starting from the fourth month. To reach 10cm ‫ﺣ‬ by full term. 71 ‫ﻣﯾد‬ Item Upper uterine segment Lower uterine segment 1 0 ‫اﺣ‬ Thickness Thick formed inner Thin, the middle oblique ‫ﻣد‬ circular, middle oblique layer is defective and outer longitudinal Peritoneum Adherent peritoneum Loose peritoneum Membranes Firmly adherent Loosely adherent At labor Active (contracts and Passive (relax and dilates retracts and become and become progressively progressively thicker) thinner)  16 Obstetric importance of the lower uterine segment: I. It is the site of L.S.C.S. 2. It is the site of rupture in obstructed labor. 3. It is the site of implantation of placenta previa. B. The cervix: - Edema. - Increased vascularity. ‫ﻧد‬ - Hypertrophy of glands. 21 ‫ى‬ - The cervix becomes soft and bluish. - The secretions form the mucus plug in the cervical canal. 02 ‫ﻋط‬ - Near term, prostaglandin induce changes in collagen fibers making the ‫ﺎ‬ 10 ‫ﷲ‬ cervix softer and easily dilatable. C. The vulva: vulval Varicosities may develop. 18 ‫ﻋﺑ‬ D. The vagina: Increased vascularity makes it soft, moist, bluish and warm. 20 ‫داﻟ‬ E. The ovaries: One of the ovaries contains the corpus Luteum, which ‫ﺣ‬ degenerates at the 12th week. 71 ‫ﻣﯾد‬ II.The breasts: - Breast changes are induced by estrogen. 1 0 ‫اﺣ‬ - Breasts show increased size and vascularity. ‫ﻣد‬ - Breasts become warm, tense, nodular and slightly lender. - Increase pigmentation of the nipple and 1ry areola, 2ry areola appears later (less pigmented area around the 1 ry areola) - Montgomery’s tubercles appear around the areola (abortive accessory lactiferous ducts). - Colostrum can be expressed from the end of the 3rd month. III. Cutaneous changes: Pigmentation: skin pigmentations may increase. These increased  17 pigmentations may be due to melanocyte stimulating hormone secreted by the placenta or estrogen, and may take one of the following forms: Liniea nigra: Pigmentation appears in the midline of the abdomen, more evident below the umbilicus. Striae Gravidarum: (stretch marks) Red lines in the flanks due to stretch of the abdominal wall which causes rupture of the subcutaneous elastic tissue, also increased cortisol may play a role in its ‫ﻧد‬ development. After labor, the color turns to white; “striae albicans” due to 21 ‫ى‬ fibrosis. Chloasma: Pigmentation of the face with butterfly distribution. 02 ‫ﻋط‬ Signs of malnutrition and vitamin deficiency may be evident, sometimes loss of hair. ‫ﺎ‬ 10 ‫ﷲ‬ IV. Cardio-vascular system: The apex: 18 ‫ﻋﺑ‬ Is displaced upwards and outwards in late pregnancy by elevation of the diaphragm 20 ‫داﻟ‬ by the pregnant uterus. ‫ﺣ‬ 71 ‫ﻣﯾد‬ Cardiac output: = (stroke volume [SV] x heart rate [HR]) Increases by 30 - 50% to reach a maximum at 32-34 weeks and then it is 1 0 ‫اﺣ‬ maintained up to full term. ‫ﻣد‬ Blood volume: Increases by about 45%, half of this rise is achieved by 8 weeks and the maximum increase occurs at 32-34 weeks, then it remains constant up to full term. The increase in the blood volume is mainly due to expansion of plasma volume more than the increase in R.B.C.s. volume resulting in physiological hydremia and drop of hemoglobin level.  18 Blood pressure: It remains normal during the first trimester and drops during the 2nd trimester to return to normal during the 3rd trimester. The drop of the blood pressure during the 2nd trimester is due to: -Decrease in the peripheral resistance (vasodilatation). -Hydremia of pregnancy (decrease in the blood viscosity). Any rise to the level of 140/90 or increase 30 mmHg in the systolic or 15 mmHg ‫ﻧد‬ in the diastolic (above the base line reading; before pregnancy or during the first 21 ‫ى‬ trimester) is considered abnormal. Supine hypotension syndrome: 02 ‫ﻋط‬ Hypotension may develop in supine position especially during late pregnancy due ‫ﺎ‬ 10 ‫ﷲ‬ to pressure by the gravid uterus on the inferior vena cava with subsequent reduction in cardiac output. 18 ‫ﻋﺑ‬ Veins: 20 ‫داﻟ‬ Venous stasis in the lower body (compression of pelvic veins) by the uterus, this lead ‫ﺣ‬ to varicose veins, ankle edema. 71 ‫ﻣﯾد‬ Leucocytes: Increase to about 16.000/cc. Platelets and fibrinogen: Increase. 1 0 ‫اﺣ‬ V. Urinary system: ‫ﻣد‬ Frequency of micturition: - Early in pregnancy: due to congestion and pressure on the bladder by the enlarged uterus. - Late in pregnancy: due to pressure by the presenting part after engagement. Dilatation of the ureter due to: - Pressure against the pelvic brim by the uterus especially oh the right side (due to dextero-rotation). - Effect of progesterone and relaxin hormone (causing relaxation of the smooth muscles of the uterus). - Hypertrophy of the wall of the lower end of the ureter caused by estrogen  19 N.B. Dilatation of the ureter leads to stasis of urine, which in turn predisposes to infection. VI. Respiratory system: Dyspnea is common due to: - Hyperventilation (progesterone effect). - Elevation of the diaphragm (especially during the 8th month). VII.Gastro-intestinal tract: - Hypertrophy of the gums (sometimes bleeding gums). ‫ﻧد‬ - Morning sickness in early pregnancy. 21 ‫ى‬ - Decreased gastric acidity and motility that may cause flatulence and interference with iron absorption. 02 ‫ﻋط‬ - Heartburn due to reflux esophagitis secondary to relaxation of the cardiac sphincter. ‫ﺎ‬ 10 ‫ﷲ‬ - Tendency to constipation due to relaxation of the smooth muscles of the colon. 18 ‫ﻋﺑ‬ VIII.Musculo-skeletal system: 20 ‫داﻟ‬ - Increased lumbar lordosis. ‫ﺣ‬ 71 ‫ﻣﯾد‬ - Relaxation of pelvic joints and ligaments (progesterone and relaxin). IX. Endocrine system: 1 0 ‫اﺣ‬ 1. Pituitary: Anterior pituitary increases in size and activity. Posterior pituitary ‫ﻣد‬ produces oxytocin. 2. Thyroid: Increased size and activity; physiological goiter may occur. Total T3 and T4 are increased. 3. Parathyroid: Increased size and activity; to regulate the increased calcium metabolism. 4. Adrènals: Increased activity; total cortisol is increased but the free portion is unchanged. 5. Placental hormones:  20 X. Metabolic changes: 1.Proteins: Tendency to nitrogen retention. 2.Carbohydrates: Carbohydrate metabolism is slightly disturbed. Alimentary glycosuria: due to rapid absorption of glucose. Renal glycosuria: due to lowering of renal threshold. Anti-insulin hormones are increased: as HPL (human placental Iactogen) cortisol, ‫ﻧد‬ estrogen, progesterone and insulinase enzyme. All (except cortisol) are produced 21 ‫ى‬ by the placenta. Fasting blood sugar is lowered due to transport of glucose to the fetus through 02 ‫ﻋط‬ the placenta. ‫ﺎ‬ 3.Fats: Fat metabolism is disturbed secondary to disturbance of carbohydrate 10 ‫ﷲ‬ metabolism. 4.Minerals: lncreased requirements of: iron, calcium, phosphorus and iodides. 18 ‫ﻋﺑ‬ Tendency to NaCI retention. 20 ‫داﻟ‬ 5. Water: Tendency to salt and water retention. ‫ﺣ‬ 71 ‫ﻣﯾد‬ XI.Weight: The average total weight gain is 10—12 Kg, most of it occurs during the 3rd trimester. 1 0 ‫اﺣ‬ ‫ﻣد‬  21 Diagnosis of pregnancy Diagnosis in the first trimester (up to12 weeks) Symptoms: 1. Amenorrhea: (Missed period): Cessation of previously regular menstruation is suggestive pregnancy. Amenorrhea is due to increased estrogen and progesterone production by the corpus ‫ﻧد‬ Luteum. 21 ‫ى‬ 2. Morning sickness: Nausea, sometimes vomiting especially in the morning. Usually disappears after 02 ‫ﻋط‬ the 3rd month. ‫ﺎ‬ 10 ‫ﷲ‬ 3. Frequency of micturition: Due to congestion, and irritation of the bladder by the pregnant uterus. Usually 18 ‫ﻋﺑ‬ disappears after the 3rd month. 20 ‫داﻟ‬ 4. Breast symptoms: Enlargement, tenderness, discomfort and tingling sensation. ‫ﺣ‬ 71 ‫ﻣﯾد‬ 5. Appetite changes: Craving for certain types of food or odors (pica) and refusal of other types. 1 0 ‫اﺣ‬ Signs: ‫ﻣد‬ General examination: Breast signs: (evident in a primigravida) (see breast changes with pregnancy) Abdominal examination: nothing detected. Pelvic examination: Vulva: blue or violet color (Chadwick’s or Jacquemier’s sign) at 8 weeks. Vagina: blue or violet color (Chadwick’s or Jacquemier’s sign) at 8 weeks.  22 Uterine signs: Size: Enlarged. Consistency: Soft. Shape: Globular. Palmer sign: Uterine contractions detected by bimanual examination. Investigations: 1. Pregnancy tests: All depend on the detection of HCG either in urine or in ‫ﻧد‬ serum: 21 ‫ى‬ Estimation of beta subunit of HCG in the serum: Using radioimmunoassay. The sensitivity of the test is: 5 m lU/ml so it is Positive 1 week before the expected 02 ‫ﻋط‬ menstruation (1 week after fertilization). ‫ﺎ‬ 10 ‫ﷲ‬ 2. Ultrasonography: By the use of the Abdominal probe: it can detect the following event: 18 ‫ﻋﺑ‬ - Gestational sac: 5 weeks. 20 ‫داﻟ‬ - Fetal heart activity: 8 weeks ‫ﺣ‬ By the use of the Vaginal probe: The previous findings can be detected 1-2 71 ‫ﻣﯾد‬ weeks earlier. 1 0 ‫اﺣ‬ Diagnosis in the second trimester 13-28 weeks ‫ﻣد‬ Symptoms: 1.Amenorrhea. 2.Morning sickness and urinary symptoms gradually decrease. 3.‘Quickening”: perception of fetal movements by the pregnancy women: * 18-20 weeks in primigravida. * 16-18 weeks in Multipara. 4. Abdominal enlargement.  23 Signs: General examination: Breast signs: becomes more evident. Abdominal examination: - The uterus is abdominally felt. Stria gravidarum are detected in the 2nd half of pregnancy. - Braxton Hicks contractions: intermittent painless contractions detected abdominally. ‫ﻧد‬ - External ballottement: elicited at 20 weeks through abdominal 21 ‫ى‬ examination by pushing the fetal head with one hand. - Palpation of the fetal parts: first detected at 20 weeks. 02 ‫ﻋط‬ - Palpation of fetal movements: by the obstetrician at 20 weeks. ‫ﺎ‬ Auscultation of the F.H.S. at 20-24 weeks by the Pinard’s fetal stethoscope. 10 ‫ﷲ‬ Vaginal examination: Signs of the 1st trimester are more evident. 18 ‫ﻋﺑ‬ Diagnosis in the 3rd trimester (28-40 weeks) 20 ‫داﻟ‬ All the signs of pregnancy become very evident; sonography is diagnostic. ‫ﺣ‬ 71 ‫ﻣﯾد‬ Sure evidence of pregnancy 1. Palpation of fetal parts. 1 0 ‫اﺣ‬ 2. Palpation of fetal movements. ‫ﻣد‬ 3. Auscultation of FHS. 4. Auscultation of umbilical soufflé. 5. Visualization of fetal parts, fetal movements, and fetal heart movements by ultrasonography. 6. Visualization of fetal skeleton by X-ray.  24 Chapter 2 Introduction ANTENATAL CARE Antenatal care (prenatal care) is a program of preventive obstetrics, the objectives of which are: 1. Early detection and if possible prevention of complications of pregnancy e.g. ‫ﻧد‬ eclampsia or hemorrhage 21 ‫ى‬ 2. Detection and management of any complicating general disease as anemia and diabetes. 02 ‫ﻋط‬ 3. Detection of complications, which may affect labor as disproportion and ‫ﺎ‬ malpresentation. 10 ‫ﷲ‬ 4. Giving instructions to the patient about the hygiene and diet during pregnancy 18 ‫ﻋﺑ‬ and the warning symptoms, which may occur. 20 ‫داﻟ‬ 5. Laboratory investigations to evaluate the patient general health.  Frequency of examination: ‫ﺣ‬ 71 ‫ﻣﯾد‬ Every month until the 7 th month then every 2 weeks until the last month and every week in the last month till the time of delivery. 1 0 ‫اﺣ‬  The first visit: ‫ﻣد‬  History taking: Present history: any problems of pregnancy as vomiting and vaginal bleeding. Past history: of general medical disease (hypertension, heart disease ore diabetes Menstrual history: last menstrual period for calculation of expected date of delivery. Obstetric history: of previous pregnancy in details.  Examination:  25 General examination: to detect evidence of a general disease, measure and record the body weight and the blood pressure. Abdominal examination: to detect any abdominal swelling. Pelvic examination: in the first visit to exclude any pelvic lesions or anomalies. Investigations: number of routine investigations may be needed as blood sugar, complete blood count (C.B.C), urine analysis, blood sugar and Rh typing and blood group if not known. ‫ﻧد‬ Some other investigations maybe ordered (not routine) as VDRL and 21 ‫ى‬ toxoplasma antibody titre if needed  Return visits: 02 ‫ﻋط‬ Ask the patient about any Warning symptoms (see later), ‫ﺎ‬ Measure and record the body weight and the blood pressure. 10 ‫ﷲ‬ Test for lower limb edema. Abdominal examination to detect if the size of the uterus equal to the period of 18 ‫ﻋﺑ‬ amenorrhea or not. 20 ‫داﻟ‬ At 36 weeks tests for disproportion may be done (see contracted pelvis for the ‫ﺣ‬ 71 ‫ﻣﯾد‬ indications). Instructions to the patient: 1 0 ‫اﺣ‬ 1. Diet during pregnancy: ‫ﻣد‬ a. As the increased metabolism is compensated for by the decreased activity, the caloric requirement is only slightly increased in late pregnancy (2500 calories). b. Protein requirement is increased about 25 gram/ day and at least half should be 1st class proteins [high biological value] (containing the essential amino- acids (most of the animal proteins). c. Carbohydrates and fats should not be markedly increased. d. Vitamin A, B, D, C K, folic acid and vitamin B12 should be provided by diet in sufficient amounts.  26 e. Calcium and iron, there is increased demands for both of them during pregnancy and need for supplementations of both minerals. Calcium is needed for fetal bone growth and the requirements are increased with gestational age. Iron is needed for formation of hemoglobin. f. Sufficient amounts of fluids but avoid excess coffee and tea, alcohol is avoided due to the risk f fetal alcohol syndrome. ‫ﻧد‬ g.Excess salt is avoided. 21 ‫ى‬ So a suitable daily diet should include: One liter of milk or its derivatives. 02 ‫ﻋط‬ 120gm of red meat substituted once a week by fish and once by calf’s liver. ‫ﺎ‬ Fresh fruits and vegetables 10 ‫ﷲ‬ One egg Supplementation of diet with iron, calcium and vitamins is usually needed. 18 ‫ﻋﺑ‬ The daily allowances of nutrients for pregnant woman: 20 ‫داﻟ‬ Calories: 2500, Protein: 65 grams. ‫ﺣ‬ 71 ‫ﻣﯾد‬ Calcium: 1000mg Iron: 6o mg, Vitamin A:6000 I.U. 1 0 ‫اﺣ‬ Vitamin D: 400 I.U. ‫ﻣد‬ Thiamine: 1mg, Riboflavine: 1.5mg, Nicotinic acid: 15mg. Ascorbic acid: 50mg, Folic acid: 1 mg.  27 Effect of malnutrition on Pregnancy: A. Effect on the mother:  Weight loss.  Anemia and other nutritional deficiency.  Higher risk of abortion and premature labor.  Higher risk of Preeclampsia. ‫ﻧد‬  Higher risk of pyelonephritis 21 ‫ى‬  Prolonged labor and postpartum hemorrhage. 02 ‫ﻋط‬  Decalcification of bones, caries of teeth. ‫ﺎ‬  Deficient lactation. 10 ‫ﷲ‬  Lowered resistance against infection. 18 ‫ﻋﺑ‬ B. Effect on the fetus: 20 ‫داﻟ‬  Low birth weight. ‫ﺣ‬ 71 ‫ﻣﯾد‬  Higher incidence of dental caries, rickets and anemia. 2. Rest:  Sleep for 8 hours in the evening and for 2 hours in the after noon that may increase 1 0 ‫اﺣ‬ towards full term. ‫ﻣد‬  Lying in bed is preferably in the lateral position to avoid compression of the uterus on the great vessels if lying in the dorsal position. 3. Exercise:  Mild exercise preferably walking for ½ -1 hour/ day).  Housework short of fatigue is allowed.  Special exercises in the pre-natal period (in ante-natal classes), breathing exercises and exercises for the back and abdomen may help at time of delivery and decrease pain of labor.  28 4. Care of teeth:  To avoid caries caused by increased acidity of the oral secretions.  Teeth should be examined by a dentist at least twice.  Allow any dental treatment up to tooth extraction; antibiotic therapy may be needed under supervision and guidance of the obstetrician. 5. Care of the breasts:  Should be supported by proper brassiere. ‫ﻧد‬  Daily washes. 21 ‫ى‬  Massage of the nipples using a mixture of glycerin and alcohol to reduce the incidence of cracking. 02 ‫ﻋط‬  Retracted nipple is withdrawn by the thumb and finger using a lubricant or ‫ﺎ‬ sometimes a metal breast shield with an opening in the center is used. It is 10 ‫ﷲ‬ applied so that the nipple projects through it. 6. Care of the bowel: 18 ‫ﻋﺑ‬  Avoid constipation by: 20 ‫داﻟ‬  Increase intake of fresh vegetable and fruits intake. ‫ﺣ‬ 71 ‫ﻣﯾد‬  Increased exercise.  Increase fluid intake.  Mild laxtive may be needed. 1 0 ‫اﺣ‬ ‫ﻣد‬ 7. Care of weight:  Avoid excessive weight gain.  Weights gain more than 6 pounds / month indicates occult edema and favors the development of pre-eclampsia.  The total weight gain during pregnancy is 24 pounds or around 11 Kg (no marked weight gain in the first 16 weeks and around 1 pound / week in the last 24 weeks).  Component of weight gain are: 3.5 KG weight of the fetus, 0.5 Kg weight of the placenta, 0.5 Kg weight of the placenta, 1-1.5 Kg weight of the amniotic  29 fluid, 0.5 –1 Kg weight of the uterus, 0.5 Kg breast growth, 1.5-3 Kg increase in the blood volume, 2 Kg protein retention, 2Kg water retention and variable amount of fat. 8. Clothes: Should be loose, avoiding high heals. 9. Sexual intercourse: Better be avoided in the first three months to avoid abortion and in the last ‫ﻧد‬ two months to avoid ascending infection. It should be avoided completely if 21 ‫ى‬ there is risk of abortion. 10. Bathing 02 ‫ﻋط‬ Shower bath is only allowed (no tab path). ‫ﺎ‬ Vaginal douches are avoided as it increases the risk of embolism (air or fluid) 10 ‫ﷲ‬ 11. Traveling: 18 ‫ﻋﺑ‬ Only comfortable traveling may be allowed. 20 ‫داﻟ‬ Traveling should be avoided in the last month and it is completely prevented ‫ﺣ‬ 71 ‫ﻣﯾد‬ in patients with a history of habitual abortion or premature labor. 12. Warning symptoms of pregnancy: They demand immediate report to the obstetrician regardless to the schedule of 1 0 ‫اﺣ‬ antenatal visits: ‫ﻣد‬  Severe persistent headache.  Blurring of vision.  Severe persistent nausea and vomiting.  Abdominal pain (epigastric pain and lower abdominal pain).  Vaginal bleeding.  Sudden escape of liquor amnii.  Swelling of the lower limbs, face or fingers.  30 13. Vaccination (immunization) in pregnancy:  Live attenuated vaccines (as measles and Rubella vaccine) are contraindicated during pregnancy.  Killed vaccine (as cholera, diphtheria and typhoid has no effect on the fetus, the fetus is only slightly affected by the febrile reaction.  Toxoid can be safely given during pregnancy.  The vaccines for the following diseases may be given if needed, preferably after ‫ﻧد‬ the 1st trimester: Tetanus, poliomyelitis, rabies, influenza, cholera and 21 ‫ى‬ typhoid.  Passive immunization by antibodies against hepatitis A and B may be given 02 ‫ﻋط‬ if needed. ‫ﺎ‬ 10 ‫ﷲ‬ 18 ‫ﻋﺑ‬ 20 ‫داﻟ‬ ‫ﺣ‬ 71 ‫ﻣﯾد‬ 1 0 ‫اﺣ‬ ‫ﻣد‬  31 Chapter 3 RISK PREGNANCY CHAPTER CONTENTS Hypertensive disorders in pregnancy Diabetes mellitus in pregnancy ‫ﻧد‬ 21 ‫ى‬ Hypertensive disorders in pregnancy 02 ‫ﻋط‬ Definition: hypertension with pregnancy is defined by rise of the blood pressure during pregnancy reaching ≥140/ 90 or rise of systolic blood pressure of 30 mmHg ‫ﺎ‬ 10 ‫ﷲ‬ or more or the diastolic pressure 15 mmHg or more. Classification of hypertensive disorders during pregnancy: 18 ‫ﻋﺑ‬ I. Pregnancy-induced hypertension: 20 ‫داﻟ‬ II. Coincidental hypertension: ‫ﺣ‬ III- Pregnancy-aggravated hypertension: 71 ‫ﻣﯾد‬ PREECLAMPSIA  Definition: hypertension with edema and / or proteinuria occurring after 20 weeks, 1 0 ‫اﺣ‬ it may occur before 20 weeks in cases of twins, molar pregnancy or acute ‫ﻣد‬ hydramions.  Incidence: 5-10% of all pregnancies.  Predisposing factors:  Age: at the extremis of reproductive age.  Parity: the disease is more common in primigravidas.  Socio-economic: the disease is more common in low socio-economic standard.  Previous history of pre-eclampsia.  32  Familial tendency: the condition is more common in certain families.  Maternal medical disease: the disease is more common in those with previous history of hypertension (6- 10 times), diabetes (4-5 times), renal disease & obesity.  Fetal and pregnancy factors: the condition is more common in twins and others.  Etiology: The exact nature of the disease is not known, it is a disease of theories. ‫ﻧد‬  Immunological theory 21 ‫ى‬  Prostaglandin theory  Abnormal placentation 02 ‫ﻋط‬  Dietetic theory ‫ﺎ‬ 10 ‫ﷲ‬  Uteroplacental ischemia:  Pathology: 18 ‫ﻋﺑ‬  Pathological physiology: 20 ‫داﻟ‬  Vasospasm: ‫ﺣ‬ - It is basic to the pathology. It affects segment of the arteriole small and 71 ‫ﻣﯾد‬ medium sized arterioles (Segmental vasospasm).It increases the total peripheral resistance resulting in hypertension. 1 0 ‫اﺣ‬  Pathological anatomy: ‫ﻣد‬  Kidney changes  Liver changes  Uterine changes  Placental changes  Brain changes  Retinal changes  Pathological biochemistry: Blood volume changes  33  Diagnosis of a case of pre-eclampsia:  Preeclampsia is a disease of signs. Symptoms develop in severe cases (late and rare). The disease usually develops after 20 weeks pregnancy except in cases of twins, it may develop earlier.  Symptoms: Symptoms of pre-eclampsia are late and rare and occur only in severe cases. 1. Headache: It is due to hypertension and cerebral edema. It is usually frontal, ‫ﻧد‬ rarely occipital. 21 ‫ى‬ 2. Visual symptoms: - Blurring of vision, flashes of light, diplopia or complete blindness. 02 ‫ﻋط‬ - It is due to retinal changes; vascular spasm, retinal hemorrhage, retinal ‫ﺎ‬ 10 ‫ﷲ‬ exudates, retinal detachment or pathological changes in occipital lobe of the brain. 18 ‫ﻋﺑ‬ - Most of these changes are reversible after delivery. 20 ‫داﻟ‬ 3. Nausea and vomiting: due to peripheral gastric congestion or central due to ‫ﺣ‬ cerebral edema. 71 ‫ﻣﯾد‬ 4. Epigastric pain: Caused by stretch of the liver capsule due to subcapsular hematoma of the liver. 1 0 ‫اﺣ‬ 5. Oliguria or Anuria: due to kidney pathology. ‫ﻣد‬  34  Signs: Item Hypertension Edema Proteinuria Time It is an early sign Occult edema is the earliest It’s the latest sign sign Manifest edema is late Etiology Vasoconstriction Salt and water retention& Kidney pathology Increase capillary ‫ﻧد‬ permeability & 21 ‫ى‬ Decrease plasma osmotic pressure due to Proteinuria. 02 ‫ﻋط‬ Definition B.P ≥140/90 mmHg OR Occult edema means More than 0.3 ‫ﺎ‬ 10 ‫ﷲ‬ & rise of systolic Bp by 30 abnormal weight gain > 2 gm/L in 2 random Detection mmHg or rise of pounds (900 gm) / week or 6 midstream urine 18 ‫ﻋﺑ‬ diastolic Bp 15 mmHg pounds/ month samples at least 6 20 ‫داﻟ‬ above the pre -pregnancy Manifest edema soft pitting hours apart ‫ﺣ‬ level Measured at least against a bony land mark at Boiling test to 71 ‫ﻣﯾد‬ twice with 6 hours rest in ankle, leg, lower abdomen, detect precipitation between, adequate cuff face and vulva after addition of 1 0 ‫اﺣ‬ size, cuffed hand at the acetic acid to ‫ﻣد‬ heart level, using the4th prevent phosphate sound for diastolic precipitation pressure (not 5th) Sulphosalycilic acid test Severe Systolic Bp > 160 mmHg Generalized edema with 5 gm or more causes Diastolic Bp > 110 ascites proteins in 24 mmHg hours urine  35  Complications of preeclampsia:  Accidental hemorrhage.  Broncho-pneumonia.  Coma and Convulsions.  Cerebral hemorrhage.  Death.  Eclampsia. ‫ﻧد‬  Fetal death. 21 ‫ى‬  Growth retardation.  Hellp syndrome. 02 ‫ﻋط‬  Retinal detachment. ‫ﺎ‬ 10 ‫ﷲ‬  Renal failure (tubal necrosis.  Residual hypertension. 18 ‫ﻋﺑ‬  Recurrence. 20 ‫داﻟ‬  Clinical varities of pre-eclampsia (Severity of pre-eclampsia): ‫ﺣ‬ 71 ‫ﻣﯾد‬ Pre-eclampsia is divided into mild, severe and imminent eclampsia 1 0 ‫اﺣ‬ ‫ﻣد‬  36 Mild Severe Blood pressure ≥ 140/90 mmHg ≥ 160/110 mmHg Proteinuria Mild (trace to +) > 300mg/L Persistent > 5gm / 24 hours urine urine Oliguria Absent Present Headache Present Absent Visual disturbance Absent Present Epigastric pain Absent Present ‫ﻧد‬ Serum creatinine Normal Elevated 21 ‫ى‬ Hyperbilirubineamia Absent Present Liver enzymes Minimal elevation Marked elevation 02 ‫ﻋط‬ Pulmonary edema Absent Present Fetal growth retardation Absent Present ‫ﺎ‬ 10 ‫ﷲ‬  Imminent eclampsia: the combination of severe pre-eclampsia and hyper-reflxia  Fulminating preeclampsia: rapidly deterorating severe pre-eclampsia. 18 ‫ﻋﺑ‬  Differential diagnosis: 20 ‫داﻟ‬ Pre-eclampsia should be differentiated from other causes of hypertension, edema ‫ﺣ‬ and proteinuria during pregnancy. 71 ‫ﻣﯾد‬ A. Causes of Hypertension in pregnancy: 1 0 ‫اﺣ‬ 1. Preeclampsia. ‫ﻣد‬ 2. Essential hypertension. 3. Chronic nephritis. 4. Pheochromocytoma. 5. Thyrotoxicosis 6. Coarctation of aorta B. Causes of edema of the lower limbs with pregnancy: 1. Pressure by the gravid. 2. Congestive heart failure.  37 3. Renal edema. 4. Severe malnutrition. 5. Allergic edema. 6. Deep venous thrombosis. C. Causes of proteinuria during pregnancy: 1. Contamination. 2. Urinary tract infection. ‫ﻧد‬ 3. Chronic nephritis. 21 ‫ى‬ 4. Congestive heart failure. 5. Severe anemia. 02 ‫ﻋط‬ 6. Orthostatic proteinuria. ‫ﺎ‬ 10 ‫ﷲ‬  Investigations of a case of pre-eclampsia: 1. Complete urine analysis: 2. Kidney function tests: 18 ‫ﻋﺑ‬ 3. Liver function tests 4. Fundus examination 20 ‫داﻟ‬ 5. Ultrasonography: 6. Placental insufficiency tests. ‫ﺣ‬ 71 ‫ﻣﯾد‬ 7. Doppler of the uteroplacental and umbilical circulation.  Prevention of pre-eclampsia: 1 0 ‫اﺣ‬  Low dose aspirin: Baby aspirin given in a dose of 60 75 mg / day. ‫ﻣد‬  Diet: Adequate dietary supplementation with proteins, calcium, fish oil and low salt intake.  Ante-natal care: Pregnant females having high risk to develop pre- eclampsia should be attend more frequent ante-natal visits for earl detection of any rise of blood pressure or abnormal increase in the body weight gain.  Body weight: Avoid excessive body weight gain during pregnancy.  38  Treatment of preeclampsia: General considerations: Delivery is the only curative measure of pre-eclampsia. - Immediate termination of pregnancy offer maternal cure but may affect neonatal outcome (results into significant pre-maturity). - Prolongation of pregnancy may improve neonatal outcome so long that the placental perfusion is not affected (no placental insufficiency) ‫ﻧد‬ placental insufficiency and fetal well-being show normal results. 21 ‫ى‬ However, prolongation of pregnancy may significantly increase the maternal risks (cerebral hemorrhages, renal failure and eclampsia). 02 ‫ﻋط‬ A-General lines: Should be tried in all cases of pre-eclampsia ‫ﺎ‬ - Bed rest: 10 ‫ﷲ‬ Hospital admission and bed rest. It increases the venous return, improves 18 ‫ﻋﺑ‬ the cardiac output, increases the kidney circulation and improves the 20 ‫داﻟ‬ kidney functions, it increases the utero-placental circulation and ‫ﺣ‬ decreases the edema of the lower limbs. 71 ‫ﻣﯾد‬ - Diet: Diet rich in proteins with restricted salt and rich in proteins to replace the lost proteins 1 0 ‫اﺣ‬ - Observations: ‫ﻣد‬ Maternal observations: Vital signs: blood pressure / 6 hours. Daily: inquiry about symptoms (as headache, vomiting and abdominal pain), proteinuria, body weight and fetal movement. Weekly: liver and kidney functions, urine analysis, blood glucose, C.B.C & coagulation studies. Fetal observations.  39 B- Medical treatment: It is given for cases of severe pre-eclampsia or imminent eclampsia or mild cases not responding to the general measures alone. I-Sedatives: These drugs are not used now as it passes the placenta and decrease the fetal activity. II-Hypotensives: They effectively decrease the risk of maternal complications but does not ‫ﻧد‬ decrease the risk of fetal complications. 21 ‫ى‬ Emergency anti- hypertesives: 02 ‫ﻋط‬ Hydralazine (Aprezoline): Other emergency antihypertensive drugs: Diazoxide (hyperstate) , Sodium ‫ﺎ‬ 10 ‫ﷲ‬ nitroprusside.  Other anti-hypertensives: 18 ‫ﻋﺑ‬ 1-α-Methyl-dopa (Aldomet). 2-β-blockers 20 ‫داﻟ‬ 3-α and β blockers (Labetalol). 4-Calcium channel blcokers ‫ﺣ‬ III-Diurtics: it is not in common use in the treatment of pre-eclampsia 71 ‫ﻣﯾد‬ IV-Mg So4: The main role of MgSo4 in the treatment of pre-eclampsia is the prevention of 1 0 ‫اﺣ‬ occurrence of convulsions ‫ﻣد‬ *Indications: It is indicated in cases of sever –pre-eclampsia and imminent eclampsia. Mechanism of action: Routes of administration: MgSo4 is given by either I.M. or I.V., whatever the route of administration it is given in the form of initial (loading dose) and maintenance dose.  40  Precautions during MgSo4 administration: Whatever may be the method of administration of MgSo4 the following precautions should be considered before the administration of any subsequent dose:  The knee jerk should be present.  The respiratory rate is not less than 16/ minute.  The urine output since the previous dose is not less than 100 ml. ‫ﻧد‬ C-Obstetric treatment: 21 ‫ى‬ Time of termination: 02 ‫ﻋط‬ Some cases of pre-eclampsia are indicated for immediate termination as cases with mature fetus, retinal hemorrhage, HELLP syndrome or placental ‫ﺎ‬ 10 ‫ﷲ‬ isufficiency. 18 ‫ﻋﺑ‬ Cases of imminent eclampsia: are indicated for termination if there is no 20 ‫داﻟ‬ response to medical treatment within24 hours. ‫ﺣ‬ Cases of severe pre-eclampsia are terminated immediately if the fetus is mature 71 ‫ﻣﯾد‬ or within 1 week of start of medical treatment, during this week administration of steroids may be tried to facilitate fetal surfactant production. 1 0 ‫اﺣ‬ ‫ﻣد‬ Cases of mild pre-eclampsia are terminated immediately if the fetus is mature, otherwise it is kept under conservative management till the fetus becomes mature at end of 37 weeks. In some cases, with good fetal condition and adequate control of the maternal condition some may allow pregnancy to continue to term but never allow post maturity.  41 - Method of termination: It depends upon the fetal condition, severity of the problem and the (condition of the cervix, capacity of the pelvis & presentation). The methods of termination include: Artificial rupture of membranes and oxytocine drip: if the conditions are favorable for vaginal delivery (favorable cervix, adequate pelvis and vertex presentation). Cesarean section: ‫ﻧد‬ If the induction fails or the conditions are unfavorable for induction (prostaglandins 21 ‫ى‬ may be used to ripen the cervix) or the need for rapid termination as (fetal distress or retinal hemorrhage) or other indications for C.S 02 ‫ﻋط‬  Management during vaginal delivery: ‫ﺎ‬ 10 ‫ﷲ‬  During the first stage: Routine management of the first stage of labor. 18 ‫ﻋﺑ‬ More relaxation and breathing exercise. 20 ‫داﻟ‬ Vital signs of the mother should be observed more frequently especially blood pressure / ½ hour. ‫ﺣ‬ 71 ‫ﻣﯾد‬ Continuous electronic fetal monitoring for early detection of fetal distress.  During the second stage: 1 0 ‫اﺣ‬ Careful observation of the maternal blood pressure. ‫ﻣد‬ Shorten the second stage by forceps to avoid marked rise of the maternal B P with straining. Adequate effective analgesia and anesthesia but epidural analgesia is better to be avoided because of the marked drop of the blood volume, which is already reduced.  During the third stage: Avoid methergine administration (vasoconstrictor).  During the fourth stage of labor  42 Uterine massage and careful observation alter delivery to avoid post-partum hemorrhage, as patients with preeclampsia are sensitive to any blood loss (due to hypovolemia).  Management after delivery: Proper sedation to avoid rise of the blood pressure and post-partum eclampsia. If MgSo4 is used before labor , it should be continued for 24 hours after. Check the blood pressure and proteinuria every day until it subsides. ‫ﻧد‬ Cases of persistent high blood pressure 2 weeks after delivery are considered 21 ‫ى‬ residual cases. Proper spacing of pregnancy is needed. 02 ‫ﻋط‬ Any future pregnancy is considered high risk for pre-eclampsia. ‫ﺎ‬ 10 ‫ﷲ‬ Diabetes mellitus in pregnancy 18 ‫ﻋﺑ‬  Incidence: it is about 1: 350 pregnancy the incidence of diabetes with 20 ‫داﻟ‬ pregnancy is increasing due to delayed age of marriage and the use of insulin ‫ﺣ‬ with proper control of diabetes allows more diabetic females to become 71 ‫ﻣﯾد‬ pregnant in contrast to before the insulin era.  Changes in the carbohydrate metabolism during pregnancy: 1 0 ‫اﺣ‬ - Lowering of the fasting blood sugar below the average normal due to rapid ‫ﻣد‬ utilization of glucose by the fetus. - Alimentary glycosuria: Rapid rise in blood glucose post- prandial due to its rapid absorption. - Renal glycosuria: appearance of glucose in urine due to lowering of renal threshold. -Disturbance in carbohydrate metabolism (pregnancy is diabetogenic) it may unmask diabetes or make the control of the already present diabetes difficult, this can be explained by production of insulin antagonists (anti-insulin  43 hormones) as:  Human placental lactogen: it increases the blood glucose to favors transport of glucose from the mother to the fetus through the placenta. Estrogen and progesterone. Placental insulinase enzyme. Increased maternal cortisol.  Effects of pregnancy on diabetes: ‫ﻧد‬ 1. Pregnancy is diabetogenic in predisposed patient; it may unmask latent diabetes 21 ‫ى‬ or aggravate already existing diabetes. 2. Diabetes becomes difficult to control, insulin requirements increase during 02 ‫ﻋط‬ pregnancy and decrease after delivery, this due to (high levels of anti-insulin, ‫ﺎ‬ and decrease renal threshold), thus urine testing is not an ideal method to 10 ‫ﷲ‬ evaluate diabetic control in pregnancy. 3. There is liability to hypoglycemia and ketoacidosis. 18 ‫ﻋﺑ‬  Effects of diabetes on pregnancy: 20 ‫داﻟ‬ A-Maternal: ‫ﺣ‬ 71 ‫ﻣﯾد‬ During pregnancy: there is higher incidence of  Abortion. 1 0 ‫اﺣ‬  Pre- eclampsia (4 times the usual incidence) ‫ﻣد‬  Polyhydramions in 25-50%.  Maternal infection (monilial vulvo-vaginitis) and urinary tract infection in 15% of cases. During labor: there is higher incidence of:  Pre-term labor due to over distension of the uterus by the macrosomic baby & polyhydramions.  Inertia, difficult and obstructed labor with all its complications.  44 During puerperium: there is higher incidence of  Post-partum hemorrhage.  Failure of lactation.  Breast infection.  Puerperal sepsis. B-Fetal complications: there is higher incidence of  Abortion (especially with poor control). ‫ﻧد‬  Birth injuries. 21 ‫ى‬  Congenital anomalies (with poor control) as Cardiac [V.S.D], renal and sacral agenesis 02 ‫ﻋط‬  Death I.U.F.D due to congenital anomalies, pre-eclampsia, maternal ketosis, ‫ﺎ‬ placental insufficien. 10 ‫ﷲ‬  Enlargement.  Fetal asphyxia (distress). 18 ‫ﻋﺑ‬  Glucose (neonatal hypoglycemia). 20 ‫داﻟ‬  Hyaline membrane disease (respiratory distress syndrome). ‫ﺣ‬ 71 ‫ﻣﯾد‬  Increased risk of perinatal morbidity and mortality.  Jaundice (hyperbilurbinemia)  Diagnosis of a case of diabetes with pregnancy: 1 0 ‫اﺣ‬ ‫ﻣد‬ 1. History of diabetes or clinical symptoms of diabetes eg: polydypsia, polyuria, polyphagia and weight loss. 2. Obstetric history suggestive of diabetes repeated fetal or neonatal problems as macrosomia, I.U.F.D or congenital anomalies. 3. Sugar in urine is NOT diagnostic but it may be used as a screening test. N.B. Other causes of positive urine test for sugar: Lactosuria, alimentary glycosuria, renal glycosuria. 4. Fasting blood sugar and 2 hours post-prandial.  45 5. Glucose tolerance test (G.T.T.): it is the main line of diagnosis: Management: I. Proper antenatal care: 1. Frequent ante-natal visits. 2. Repeated measurement of blood sugar. 3. Urine analysis: repeated testing of urine for sugar, albumin and acetone. ‫ﻧد‬ 4. Avoid excessive weight gain. 21 ‫ى‬ 5. Avoid infection (may result in insulin resistance). 6. Proper vitamin supplementation: especially vitamin B complex and 02 ‫ﻋط‬ minerals. ‫ﺎ‬ II. Proper control of diabetes: 10 ‫ﷲ‬ 1. Proper diet: Containing not more than 200 gm of carbohydrates/ day. 18 ‫ﻋﺑ‬ 2. insulin therapy: in cases not responding to diet alone (no place for 20 ‫داﻟ‬ oral hypoglycemic drugs. The Dose is empirically started as follows: ‫ﺣ‬ 71 ‫ﻣﯾد‬ 0.6 units/Kg: in the 1st trimester. 0.7 units/Kg: 2nd trimester. 0.8 units/Kg: 3rd trimester. 1 0 ‫اﺣ‬ 3. Follow up of the diabetic control: It is done either by capillary glucose ‫ﻣد‬ testing before every meal or by estimation of glycosylated hemoglobin level that can assess the control of diabetes during the last 2-3 months. Normally it constitutes 3-4% of the total hemoglobin, more than 10% indicates poor control. III. Assessment of the fetal well being: stating from 28 weeks of pregnancy  Placental insufficiency tests starting from 32 weeks.  Frequent sonographic assessment for estimation of the fetal weight,  46 congenital anomalies and Fetal well being by Biophysical profile  Detection of lung maturity: by detection of PG or L/S ratio more than 3:1 in amniocentesis. IV. Termination of pregnancy: 1. Induction of abortion: Is rarely required with diabetic nephropathy or retinopathy. 2. Delivery: Termination of pregnancy may be required during the last ‫ﻧد‬ month to avoid complications especially I.U.F.D. 21 ‫ى‬  Timing of delivery: Usually at 37 weeks after determining fetal lung maturity by estimation of 02 ‫ﻋط‬ L: S ratio (3:1OR >2) or appearance of phosphatidyl glycerol or if placental ‫ﺎ‬ insufficiency is detected at any time. 10 ‫ﷲ‬  Method of termination: 18 ‫ﻋﺑ‬ By induction of labor or cesarean section. Thus C.S is indicated in (most of primigravidas, unfavorable conditions for 20 ‫داﻟ‬ vaginal delivery or in presence of other indications for CS) ‫ﺣ‬ 71 ‫ﻣﯾد‬  Management during labor: Administration of glucose 5% together with units of insulin to prevent 1 0 ‫اﺣ‬ hypoglycemia and ketosis. ‫ﻣد‬ Repeated estimation of the capillary glucose. Administration of antibiotics to guard against infection.  Care of the newborn: - Managed as a premature.  Management of the puerperium: - The dose of insulin is reduced to half the original dose until a new G.T.T. is obtained. - Proper control of diabetes is essential to allow for lactation.  47 - Prophylactic antibiotics.  Contraception: The best is barrier methods or sterilization (no oral contraception as it worsens diabetic state and I.U.C.D. is associated with higher risk of pelvic infection). ‫ﻧد‬ 21 ‫ى‬ 02 ‫ﻋط‬ ‫ﺎ‬ 10 ‫ﷲ‬ 18 ‫ﻋﺑ‬ 20 ‫داﻟ‬ ‫ﺣ‬ 71 ‫ﻣﯾد‬ 1 0 ‫اﺣ‬ ‫ﻣد‬  48 Chapter 4 NORMAL LABOR CHAPTER CONTENTS Definitions and terms of labor Diagnosis of the onset of labor Theories of onset of labor Mechanism of normal labor Physiology of uterine contractions Effect of labor Forces of labor Management of stages of normal labor ‫ﻧد‬ Clinical course of labor 21 ‫ى‬ 02 ‫ﻋط‬ Definitions and terms of labor ‫ﺎ‬ 10 ‫ﷲ‬ Fetal attitude: It is term used to describe the relation of fetal parts to each 18 ‫ﻋﺑ‬ other. 20 ‫داﻟ‬ ‫ﺣ‬ Flexion attitude: is the rule. 71 ‫ﻣﯾد‬ Extension attitude: is the exception. 1 0 ‫اﺣ‬ In flexion attitude the flexion is full, so the fetus becomes folded upon itself to ‫ﻣد‬ the degree that the back becomes markedly convex. The head is flexed so that the chin is almost in contact with the chest. The arms are crossed over the thorax. The thighs are flexed over the abdomen. This results from accommodation of the fetus to the shape of the uterine cavity to decrease the size of the fetus to fit to the small size of the uterus.  49 Fetal lie: It is term used to describe the relation of the long axis of the fetus to that of the mother. There are two possibilities. Longitudinal lie: 99.5% When the long axis of the fetus lies parallel to that of the mother in cephalic or breech presentations. Transverse lie: 0.5% ‫ﻧد‬ When the long axis of the fetus is perpendicular to that of the mother in shoulder 21 ‫ى‬ presentation. Presentation: It is that part of the fetus that lies in closest proximity to the pelvic 02 ‫ﻋط‬ brim or that portion of the fetus first felt through the cervix on vaginal ‫ﺎ‬ 10 ‫ﷲ‬ examination. There are 4 possibilities. Cephalic presentation 96% the fetus is presenting by the head. According to the 18 ‫ﻋﺑ‬ attitude of the head the presenting region may be: 20 ‫داﻟ‬ Vertex presentation: The vertex is the area of the fetal skull bounded anteriorly ‫ﺣ‬ by the anterior fontanel & coronal suture, posteriorly by the posterior fontanel & 71 ‫ﻣﯾد‬ 1 0 ‫اﺣ‬ ‫ﻣد‬  50 lambdoids suture, laterally by two lines passing by the parietal eminencies, vertex presentation occurs when the head is fully flexed. Face presentation: Face presentation occurs when the fetal head is fully extended. Brow presentation: when the head is midway between full flexion, full extension. Complex presentation: It is cephalic presentation with prolapse of one or more limbs. The predominance of cephalic presentation can be explained by: ‫ﻧد‬ 1. The pyriform shape of the uterus 21 ‫ى‬ 2. The effect of gravity. Breech presentation (3.5%) 02 ‫ﻋط‬ Shoulder presentation (0.5%) ‫ﺎ‬ Cord presentation: a loop of the umbilical card below any one of the above- 10 ‫ﷲ‬ mentioned parts. Malpresentation: Is the term used to describe any presentation rather than 18 ‫ﻋﺑ‬ vertex. 20 ‫داﻟ‬ Fetal position: ‫ﺣ‬ 71 ‫ﻣﯾد‬ It is the term used to describe the relation between the fetal back (vertebral column) to the mother’s side and back. In longitudinal lie (cephalic or breech presentation) there are 4 classical positions. 1 0 ‫اﺣ‬ First position: left anterior (L.A.) (60%). ‫ﻣد‬ The back of the fetus is felt on left side of the mother and anterior (away from her back) Second position: Right anterior (R.A.) (20%). The back is felt to the right side of the mother and anterior (away from her back). Anterior positions are more common (80%) than posterior positions (20%) due to better accommodation between the concavity of the front of the body of the fetus (caused by the fetal flexion attitude), and the convexity of the anterior  51 surface of the maternal lumbar spines (caused by the lumbar lordosis which is exaggerated during pregnancy). Third position: Right posterior (R.P.) 15% The back of the fetus is felt to the right side of the mother and posterior Fourth position: left posterior (L.P.) 5% The back of the fetus is felt to the left side of the mother and posterior L.A. is more common than R.A. and R.P. is more common than L.R. & the fetus ‫ﻧد‬ uses the right oblique diameter in 75% of cases 60% in case of left anterior 21 ‫ى‬ position and 15% of right posterior position. The denominator of the presenting part: 02 ‫ﻋط‬ It is a bony landmark on the presenting part used to determine the position of the ‫ﺎ‬ fetus during labor when vaginal examination is allowed, and cervix is partially 10 ‫ﷲ‬ dilated. The denominator in vertex presentation is the occiput, 18 ‫ﻋﺑ‬ Engagement: 20 ‫داﻟ‬ Definition: It is the term used to describe the passage of the widest transverse ‫ﺣ‬ 71 ‫ﻣﯾد‬ diameter of the presenting part through the pelvic brim. The engaging diameter: It is the biparietal diameter in cases of cephalic presentation 9.5cm. 1 0 ‫اﺣ‬ Timing: In primigravida engagement usually occurs in last 2,3 weeks due to good ‫ﻣد‬ tone of abdominal& uterine muscles while in multipara engagement occurs at the onset of labor or even at the beginning of second stage of labor. Station: It describes the level of the fetal head in the pelvis in relation to the pelvic bony landmark. If the lowest part of the vertex (occiput in full flexion attitude) is felt vaginally at the level of the ischial spines, consider this as station 0, at this time the Biparietal diameter is at the level of the pelvic inlet (engaging head).  52 The ischial spines are halfway between the pelvic inlet & outlet. It is about 3cm from each so, If the lowermost part of the fetal head is one cm, 2cm or 3 cm below the level of the ischial spines thus the station is + 1, + 2, + 3 respectively. If the lowermost part of the fetal head is felt 1 cm, 2 cm, 3cm above the level of the ischial spine the station is –1, -2 or –3 respectively. Synclitism & Asynclitism. ‫ﻧد‬ Synclitism 21 ‫ى‬ It is the term used to describe the fetal head when both parietal bones are felt vaginally at the same level. In such case the sagittal suture of the skull is felt 02 ‫ﻋط‬ midway between symphysis pubis and the sacral promontory in such case the ‫ﺎ‬ biparietal diameter is 9.5 cm is the diameter of engagement. 10 ‫ﷲ‬ Asynclitism: It is the term used to describe the fetal head when one of the parietal bones is felt 18 ‫ﻋﺑ‬ at lower level than the other, in such as the sagittal suture is not midway between 20 ‫داﻟ‬ the Symphysis pubis and sacral promontory. The sub parietal-supra parietal ‫ﺣ‬ 71 ‫ﻣﯾد‬ diameter (9 cm) is the diameter of engagement. There are two types of asynclitism: Labor: It is the process of spontaneous expulsion of viable fetus from the uterus. 1 0 ‫اﺣ‬ ‫ﻣد‬ Normal labor: It is the process of spontaneous expulsion of a single, living, mature, fetus presenting by vertex with the occiput anterior through the natural birth canal without any interference (rather than episiotomy) and the process of expulsion  53 should not be less than 3 hours or more than 24 hours and the process of expulsion should be terminated without complications to the mother or the fetus. Theories of onset of labor The exact cause of onset of labor is not definitely known there are many theories. ‫ﻧد‬ 1- Prostaglandins 21 ‫ى‬ Evidence: Prostaglandins are normally formed in the decidua and membranes 02 ‫ﻋط‬ and their level increases markedly near term, they can induce uterine contractions when given by any route. ‫ﺎ‬ 10 ‫ﷲ‬ 2- Fetal cortisol theory. 3- Progesterone withdrawal 18 ‫ﻋﺑ‬ 4- Placental ischemia (oxytocin oxytocinase theory). 20 ‫داﻟ‬ 5- Uterine distention theory. ‫ﺣ‬ 6- The stretch of the lower uterine segment. 71 ‫ﻣﯾد‬ 7- Estrogen-oxytocin theory. 1 0 ‫اﺣ‬ Physiology of uterine contractions ‫ﻣد‬ The uterine contractions are characterized by:  Regular.  Involuntary  Intermittent.  Increasing in Frequency, intensity & duration:  In active phase of labor when labor pains are established uterine contractions becomes more frequent recurring every 2-3 minutes (3/10  54 minutes), more intense creating intrauterine pressure of 50-60 mm Hg and of prolonged duration lasting for around 60 seconds.  Painful: They are always painful hence they are called true labor pains the cause of pain may be:  Hypoxia of the contracted myometrium.  Compression of nerve ganglia.  Stretching of the cervix during dilation. ‫ﻧد‬  Stretch of the overlying peritoneum. 21 ‫ى‬  Polarity: With onset of labor, the uterus differentiates into two distinct segment the upper uterine segment [active] (U.U.S) that contracts and 02 ‫ﻋط‬ retracts and becomes progressively thicker, and the lower uterine segment ‫ﺎ‬ 10 ‫ﷲ‬ and the cervix [passive] (L.U.S) that relaxes, dilates, and becomes progressively thinner forming a fibro muscular tube through which the 18 ‫ﻋﺑ‬ fetus passes. 20 ‫داﻟ‬  Fundal dominance: there is normally a gradient of diminishing physiological activity from the fundus of the uterus to the cervix. ‫ﺣ‬ 71 ‫ﻣﯾد‬ Ferguson reflex: It is observed that mechanical stretching of the cervix reflex Lilly increases the frequency and intensity of uterine contractions; this is due 1 0 ‫اﺣ‬ to release of prostaglandin F2 α from the stretched decidua and membranes ‫ﻣد‬  Coordinated: All the muscle fibers of the upper uterine segment contract together and reaches maximum intensity of contractions at the same time thus achieve a good force. It is believed that the wave of contraction passes from the pacemaker and involves the entire uterus in short time.  Retraction: it is permanent progressive shortening or incomplete relaxation, uterine contractions of labor in the upper uterine segment are accompanied by retraction.  55 As a consequence of retraction each successive contraction starts where the previous one ended so that the upper uterine segment becomes smaller progressively thicker. Retraction serves in:  Dilation of the cervix.  Expulsion the fetus.  Separation of the placenta.  Control the placental site bleeding. ‫ﻧد‬  Involution of the uterus. 21 ‫ى‬  Physiological retraction ring: As result of progressive relaxation & thinning of L.U.S. and the concomitant progressive retraction & thickening of U.U.S, 02 ‫ﻋط‬ the boundary between both segments is marked by a ridge on the inner uterine ‫ﺎ‬ 10 ‫ﷲ‬ surface. The ridge cannot be felt (in normal conditions) abdominally. 18 ‫ﻋﺑ‬ Forces of labor 20 ‫داﻟ‬ ‫ﺣ‬ 1- Uterine contractions & retraction: true labor pains (regular, painful, 71 ‫ﻣﯾد‬ involuntary, intermittent, increasing in intensity and duration, not abolished by sedation and associated with cervical dilatation. (See the characters). 1 0 ‫اﺣ‬  Clinically true labor pains are felt as colicky lower abdominal pain ‫ﻣد‬ referred to the lower back with hardening of the uterus, progressive cervical dilatation and bulging of the bag of fore water. 2- Auxillary forces of labor (Bearing down effort): Strong contraction of the diaphragm and abdominal wall muscles to increase the intra-abdominal pressure, it is at first voluntary but later it is involuntary due to reflex stimulation from the pressure of the presenting part on the pelvic floor muscles. This bearing down is needed for expulsion of the fetus during 2 nd stage, it can be used also for expulsion of the placenta in 3rd stage of labor while it should be  56 prevented in the 1st stage of labor (useless, exhaust the mother and may predispose to genital prolapse. 3- Fetal axis pressure: After rupture of membranes, the force of uterine contraction becomes transmitted to the fetus itself pushing it downwards. Clinical course of labor ‫ﻧد‬ Labor is divided into prodromal stage and 4 stages (1st, 2nd, 3rd and 4th stages) 21 ‫ى‬  The prodromal stage 02 ‫ﻋط‬ Certain clinical manifestations, which develop before the actual onset of labor. These manifestations may occur in the last weeks or days of ‫ﺎ‬ 10 ‫ﷲ‬ pregnancy and include:  Lightening: 18 ‫ﻋﺑ‬ This is the relief of upper abdominal pressure symptoms as dyspnea, 20 ‫داﻟ‬ palpitation, dyspepsia and heartburn. This is due to descent of the presenting ‫ﺣ‬ part into the pelvis. 71 ‫ﻣﯾد‬  Pelvic pressure symptoms Such as frequency of micturition and difficulty in walking. These symptoms 1 0 ‫اﺣ‬ develop as a result of engagement of the head into the pelvis. ‫ﻣد‬  Increased vaginal discharge: Due to pelvic congestion it is of mucoid in consistency and of gradual onset. This help to differentiate if from amniotic fluid which is watery and of sudden onset (gush).  Shelfing: The fundus of the uterus descends slightly and falls forwards giving the upper abdomen a special from simulating a shelf detected in standing position.  57 False labor pains (Braxton Hicks contraction): Which are intermittent uterine contractions accompanied by variable degree of pain. They are differentiated from true labor pains by being irregular, of short duration do not increase progressively (in intensity, frequency and duration). Felt in the abdomen only, the membranes do not bulge during contractions. Do not cause progressive cervical dilation.Usually relieved by sedatives. Item True labor pains False labor pains ‫ﻧد‬ Regularity Regular Irregular 21 ‫ى‬ Increase Increasing in frequency, intensity and duration Not increasing Radiation Radiates to the back Does not radiate 02 ‫ﻋط‬ Cervix Associated with cervical dilatation (detected by Nocervical ‫ﺎ‬ P.V.) dilatation 10 ‫ﷲ‬ Show Preceded by expulsion of the show No show expulsion Forewater Associated with bulging of the bag of the No forewater bulge 18 ‫ﻋﺑ‬ forewater. 20 ‫داﻟ‬ Analgesics It is not relived by mild analgesics Relieved ‫ﺣ‬ 71 ‫ﻣﯾد‬ Diagnosis of the onset of labor 1 0 ‫اﺣ‬ ‫ﻣد‬ True labor pains: It is felt by the patient as colicky pain in the abdomen and is referred to the back during which the uterus becomes hard. The show: The expelled cervical mucous plug streaked with blood. The blood arises from rupture of small blood vessels due to detachment of the lower part of the bag of membranes from the lower uterine segment. Cervical dilation: The onset of labor is diagnosed when the internal os starts dilatation.  58 Formation of bag of forewater: As a result of uterine contractions & retraction the pressure of intra- amniotic fluid rises leading to bulging of membranes through the partially dilated cervix, the bulging is called bag of forewater, which becomes tense during contraction & relaxes in-between contractions. Mechanism of normal labor ‫ﻧد‬ 21 ‫ى‬ Delivery is divided into 3 stages  First stage (stage of cervical dilation) 02 ‫ﻋط‬  Definition: it is the stage of cervical dilatation and effacement ‫ﺎ‬ 10 ‫ﷲ‬  Onset: It starts with the onset of true labor pains.  End: it ends when the cervix is fully dilated (about 10 cm or 5 fingers). 18 ‫ﻋﺑ‬  Duration: it is 6-8 hours in multipara and about 10-16 hours in 20 ‫داﻟ‬ primrgravidas ‫ﺣ‬  Causes of cervical dilation: 71 ‫ﻣﯾد‬  Contraction & retraction of the upper active uterine segment.  The hydrostatic pressure of the bag of forewater, dilates the cervical 1 0 ‫اﺣ‬ canal in the manner of a wedge. ‫ﻣد‬  The preparatory changes in the cervix during last days of pregnancy make the cervix dilatable these changes are increased vascularity, edema, glandular hypertrophy and softness of the collagen matrix.  Pattern of cervical dilation:  Cervical dilatation: it is opening of the cervical canal from above downwards  59 The cervix is fully dilated when the cervical canal is about 5 fingers or 10 cm.  Effacement of the cervix: it is taking up of the cervix, obliteration of the cervical canal being changed from a canal structure, which is 2 cm length to a mere circular orifice (the external os) with almost paper thin edges. Effacement is expressed in %, if the canal is 2cm long the cervix is zero effaced, when the canal is 1cm long the cervix ‫ﻧد‬ is 50% effaced, if the canal is < 0.25 cm; the cervix is 100% (fully 21 ‫ى‬ effaced). - In primigravida, cervical dilation starts by effacement then followed by 02 ‫ﻋط‬ dilation. ‫ﺎ‬ - In multipara, effacement and dilation of the cervix occurs simultaneously. 10 ‫ﷲ‬  Phases of cervical dilation: The pattern of cervical dilation that takes place during the course of normal 18 ‫ﻋﺑ‬ labor takes the shape of sigmoid curve. 20 ‫داﻟ‬  Friedman’s cervical dilatation curve (cervicography): ‫ﺣ‬ 71 ‫ﻣﯾد‬ Friedman’s has plotted the cervical dilatation in centimeters a