Obstetrics and Gynecology Maternal Changes (PDF)

Obstetrics and gynecology [email protected] [email protected] [email protected] Maternal Changes Due to Pregnancy THE GENITAL SYSTEM...

Obstetrics and gynecology [email protected] [email protected] [email protected] Maternal Changes Due to Pregnancy THE GENITAL SYSTEM A. The Ovaries: ▪ Both ovaries are enlarged. ▪ Corpus luteum starts to degenerate after the 10th week when the placenta is formed. Corpus luteum secretes estrogen, progesterone and relaxin. ▪ Ovulation ceases during pregnancy due to pituitary inhibition by the high levels of estrogen and progesterone. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ B. The Uterus: 1. Size: increases in length, width and thickness. 2. Weight: increases from 50 gm in non-pregnant state to 1000 gm at term. 3. Capacity: increases from 4 ml in non-pregnant state to 4000 ml at term. 4. Shape: becomes globular by the 8th week and pyriform by the 16th week till term. 5. Position: with ascent from the pelvis, the uterus usually undergoes rotation with tilting to the right, probably due to presence of the recto-sigmoid colon on the left side. 2024/2025 2024/2025 2024/2025 6. Consistency: becomes progressively softer due to: (i) Increased vascularity, (ii) The presence of amniotic fluid. 7. Contractility: from the first trimester onwards, the uterus undergoes irregular contractions called Braxton Hicks Contractions, which normally are painless. They may cause some discomfort late in pregnancy and may account for false labor pain. 8. Uteroplacental blood flow: uterine and ovarian vessels increase in diameter, length and tortuosity. 9. 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. 1  Obstetrics and gynecology [email protected] [email protected] [email protected] Upper Uterine Segment Lower Uterine Segment Peritoneum Firmly-attached Loosely-attached. Myometrium 3 layers; outer longitudinal 2 layers; outer longitudinal inner circular. , middle and inner circular oblique. The middle layer forms 8- shaped fibers around the blood vessels to control postpartum haemorrhage (living ligatures). ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Decidua Well-developed Poorly-developed. Membranes Firmly-attached. Loosely- attached Activity Active, contracts, retracts Passive, dilates stretches during labor and becomes thinner during labor. (D) The Cervix: It becomes 2024/2025 hypertrophied, soft and bluish2024/2025 in color. Soon after conception,2024/2025 a thick cervical secretion obstructs the cervical canal forming a mucous plug. (E) The Vagina: The vagina becomes soft, warm, and moist. (F) The Vulva: It becomes soft, violet in color. Edema and varicosities may develop. THE BREASTS In the early weeks, the pregnant woman experiences tenderness and tingling of the breasts. After the second month the breasts increase in size and become nodular as a result of hypertrophy of the mammary alveoli. The primary areola becomes deeply pigmented. The nipples become larger, deeply pigmented and more erectile. Montgomery’s follicles, which are hypertrophic sebaceous glands, appear as non-pigmented elevations in the primary areola. 2  Obstetrics and gynecology [email protected] [email protected] [email protected] 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 secondaryareola. THE SKIN (A) 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. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Breasts: increased pigmentation of the nipples and primary areola andappearance of the secondary areola. Linea nigra: A dark line extending from the umbilicus to the symphysis pubis. (B) Striae gravidarum: These are reddish lines appear in the later months of pregnancy in the abdomen and sometimes breasts and thighs. It may be due to mechanical stretching which results in rupture of the elastic fibers in the dermis and exposure of the vascular subcutaneous tissues. 2024/2025 After delivery, they become white2024/2025 in color but do not disappear and called 2024/2025 "striae albicans". (C) Vascular changes: There is increase in the skin blood flow and temperature. (D) Secretions: Increase in sweat and sebaceous glands activity. HEMATOLOGIC CHANGES (A)Blood Volume: The total blood volume increases steadily from early pregnancy to reach a maximum at 32 weeks. Plasma volume increases by 40% whereas red cell mass increases by 20% leading to haemodilution(Physiological anemia). CARDIOVASCULAR SYSTEM (A) Heart Rate:The resting pulse rate increases by 10-15 beats per minute during pregnancy. 3  Obstetrics and gynecology [email protected] [email protected] [email protected] (B) Arteries: Arterial blood pressure usually declines during the second trimester due to peripheral vasodilatation caused by estrogens and prostaglandins. The posture of the pregnant woman affects arterial blood pressure. Typically, it is highest when she is sitting, lowest when lying in the lateral recumbent position and intermediate when supine. Supine hypotensive syndrome may develop in some women late in pregnancy in supine position. This is due to compression of the inferior vena cava by the large pregnant uterus resulting in decrease venous return, decrease cardiac output and low blood pressure that fainting may occur. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ (C) Veins: Varicosities in the lower limbs and vulva may occur due to: (i) back pressure from the compressed inferior vena cava by the pregnant uterus, (ii) Relaxation of the smooth muscles in the wall of the veins by progesterone. (iii) Sedentary life of pregnant female (VI) RESPIRATORY 2024/2025 SYSTEM 2024/2025 2024/2025 Dyspnea may occur due to: (i) increase sensitivity of the respiratory center to CO2 possibly due to high progesterone level, (ii) elevation of the diaphragm by the pregnant uterus. (VII) GASTROINTESTINAL TRACT 1-Gingivitis: There is increased vascularity and tendency for bleeding. 2-Ptyalism: It is excessive salivation. 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: 4  Obstetrics and gynecology [email protected] [email protected] [email protected] (i) decreased gastric acidity caused by regurgitation of alkaline secretion from the intestine to the stomach, (ii) decreased gastric motility. 6- Hurt burn: Due to reflux of the acidic gastric contents to the esophagus. 7- Constipation: due to:- i- reduced motility of large intestine (progesterone effect), ii- increased water reabsorption from the large intestine (aldosterone effect), iii- pressure on the plevic colon by the pregnant uterus, ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ iv- sedentary life during pregnancy. 8- Gall stones: More tendency to stone formation due to atony and delayed emptying of the gall bladder. 9- Haemorroids: Due to: i- Mechanical pressure on the pelvic veins, ii- Laxity of the veins walls by progesterone, 2024/2025 2024/2025 2024/2025 iii- Constipation. 10- Appendix: Is displaced upwards by the enlarged uterus. (VIII) URINARY SYSTEM (A) Kidney: Renal blood flow and glomerular filtration rate increases by 50%. (B) Ureters: Dilatation of the ureters and renal pelvis due to: i- Relaxation of the ureters by the effect of progesterone, ii- Pressure against the pelvic brim by the uterus particularly on the right side. (C) Bladder: Frequency of micturition in early pregnancy due to: i- Pressure on the bladder by the enlarged uterus, ii- Congestion of the bladder mucosa. 5  Obstetrics and gynecology [email protected] [email protected] [email protected] (IX) MUSCULO-SKELETAL SYSTEM Progressive lordosis to compensate for the anterior position of the enlarged uterus. Increased mobility of the pelvic joints due to softening of the joints and ligaments caused by progesterone and relaxin. (X) ENDOCRINE SYSTEM (A) Pituitary gland: The anterior pituitary enlarges due to an increase in prolactin secreting cells (B) Thyroid gland: ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ There is diffuse slight enlargement of the gland. (C) Parathyroid glands: Increase in size and activity to regulate the increased calcium metabolism. (D) Adrenal glands: Hypertrophy particularly the cortex resulting in increased mineralocorticoids (aldosterone) and glucocorticoids (cortisol). (X) METABOLIC CHANGES (A) Weight 2024/2025 gain: 2024/2025 2024/2025 ▪ The average weight gain in pregnancy is 10-12 kg. ▪ This increase occurs mainly in the second and third trimesters at a rate of 350- 400 gm/week. ▪ Six 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. (B) Water metabolism: There is tendency to water retention secondary to sodium retention. (C) Protein metabolism: There is tendency to nitrogen retention for fetal and maternal tissues formation. (D) Carbohydrate metabolism: Pregnancy is potentially diabetogenic. Renal glucosuria may occur in the middle of pregnancy. (E) Fat metabolism: There is increase in plasma lipids with tendency to acidosis. (F) Mineral metabolism: There is increased demand for iron, calcium, phosphate and magnesium. 6  Obstetrics and gynecology [email protected] [email protected] [email protected] Diagnosis of pregnancy (I) THE FIRST TRIMESTER (0-12 WEEKS) Symptoms: 1. Amenorrhoea : sudden cessation of a previously regular menstruation 2. Morning sickness: nausea with or without vomiting in the morning. It usually appears about 6 weeks after onset of the last menstrual period and usually disappears 6-12 weeks later. 3. Frequency of micturition: due to congestion and pressure on the bladder and disappear after the first trimester to reappear again near the end of pregnancy when ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ the foetal head descends into the maternal pelvis. 4. Breast symptoms: as enlargement, sensation of fullness, tingling and tenderness. 5. Appetite changes and sleepiness. Signs: (I)Breast signs: Breast signs are diagnostic only in primigravidae. In multigravidae , it may be due to the previous pregnancies. (II) Uterine 2024/2025 signs: 2024/2025 2024/2025 The uterus becomes enlarged, globular and soft. (III) Cervix :soft, hypertrophied and violet. (IV) Vagina:&vulva: violet, moist, warm with increased acidity. (V) Maternal Skin Changes ▪ Over time, there is a darkening of the maternal skin, in predictable ways. ▪ Chloasma ▪ Stretch marks (STRIA gravidarum, rubra, alba) ▪ A "linea nigra". Investigations: (I) Pregnancy tests: These depend on presence of human chorionic gonadotrophin (hCG) in maternal serum and urine. 1- Urine pregnancy tests : becomes positive 1 week after missed peroid 7  Obstetrics and gynecology [email protected] [email protected] [email protected] Causes of false positive results: 1. Proteinuria. 2. Haematuria. 3. At time of ovulation (cross reaction with LH). 4. HCG injection for infertility treatment within the previous 30 days. 5. Thyrotoxicosis (high TSH). 6. Premature menopause (high LH & FSH). 7. Early days after delivery or abortion. 8. Trophoblastic diseases. 9. hCG secreting tumours. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Causes of false negative results: 1. Too early pregnancy. 2. Urine stored too long in room temperature. 3. Interfering medications. Serum pregnancy tests: Become positive 1 week befor missed peroid The pregnancy test becomes negative about: one week after labour, 2024/2025 2024/2025 2024/2025 2 weeks after abortion, and 4 weeks after evacuation of vesicular mole. (II) Ultrasonography: Gestational sac can be detected after 4-5 weeks of amenorrhoea. Foetal heart pulsation can be detected as early as 7 weeks. (II) THE SECOND TRIMESTER (13-28 WEEKS) ▪ Symptoms: 1.Amenorrhoea. 2. Morning sickness and urinary symptoms decrease. 3.Quickening : The first sensation of the fetal movement by the mother, occurs at 18-20 weeks in primigravida and at 16-18 weeks in multiparas. 4. Abdominal enlargement. ▪ Signs: 1.Breast signs: become more manifested. 2. Skin signs : Cloasma, lineanigra and striaegravidarum appear. 8  Obstetrics and gynecology [email protected] [email protected] [email protected] 3. Uterine signs: i-The uterus is felt abdominally. ii-Braxton Hick's contractions: intermittent painless contractions can be felt by abdominal examination. 4-Foetal signs: i- Palpation of foetal parts and movement: by the obstetrician at 20 weeks. ii-Foetal heart sound: can be auscultated at 20-24 weeks by the Pinard's stethoscope. ▪ Investigations: ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 1. Pregnancy tests. 2. Ultrasonography. 3. X-ray: It shows the foetal skeleton starting from the 16th week of pregnancy. It has been replaced by ultrasonography due to the teratogeniceffct (III) THE THIRD TRIMESTER (29-40 WEEKS) All signs of pregnancy become more evident. Pregnancy tests are positive, sonar and X- 2024/2025 2024/2025 2024/2025 ray are diagnostic. ▪ Sure Signs of Pregnancy: 1. Palpation of foetal parts. 2. Palpation of foetal movements. 3. Auscultation of foetal heart sounds. 4. The occasional auscultation of the umbilical souffle. 5. Detection of foetal skeleton by X-ray. 6.Sonographic detection of fetal parts, movements and heart movements. 9  Obstetrics and gynecology [email protected] [email protected] [email protected] Antenatal or Prenatal Care Program of preventive obstetrics which include investigations, observations ,medical care, management and education of pregnant female with aim of making pregnancy, labour and puerperium as normal and as safe as psossible for mother and baby. Objectives: 1.Prevention, early detection and treatment of pregnancy related complications as pre- eclampsia, eclampsia and haemorrhage. 2.Prevention, early detection and treatment of medical disorders as anaemia and diabetes. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 3.Detection of malpresentations, malpositions and disproportion that may influence the decision of labour. 4. Instruct the pregnant woman about hygiene, diet and warning symptoms. 5.Laboratory studies of parameters may affect the foetus as blood group, Rh typing, toxoplasmosis and syphilis. 6-All antenatal care visits should be problem oriented and go within a plan Frequency of routine antenatal visits: - Every month till 28 weeks gestations 2024/2025 2024/2025 2024/2025 - Every 2 weeks 28 week till 36 weeks gestations. - Every week during the last month. More frequent visits are indicated in high risk pregnancy. THE FIRST ANTENATAL VISIT This visit is usually the patient's first contact with the medical services during her pregnancy. She must, therefore, be treated with kindness and understanding in order to gain her confidence and to ensure her future co-operation. This opportunity must be taken to book the patient for antenatal care and, thereby, ensure the early detection of treatable complications. THE FIRST ANTENATAL VISIT TIMING As early as possible, preferably when the second menstrual period has been missed, i.e. at a gestational age (duration of pregnancy) of 8 weeks. WHAT ARE THE AIMS OF THE FIRST ANTENATAL VISIT? 1. A full history must be taken. 2. A full physical examination must be done. 3. The duration of pregnancy must be established. 4. Important screening tests must be done. 10  Obstetrics and gynecology [email protected] [email protected] [email protected] -Blood grouping, Rh typing, Haemoglobin, common infections - Urine analysis particularly for albumin and sugar. 5. Some high risk patients can be identified. Return visits: a-History : Ask the patient about any complaint. b-Examination : Checkfor:Blood pressure, Weight, Oedema , Abdominal examination, c-Investigation: To check blood and urine for albumin and sugar. d-Give some instructions d-Mention minor ailments that may occur and highlight danger signs ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Subsequent lab tests consists of: Hemoglobin or hematocrit at 28 weeks Presence of glucose or protein in urine Serum glucose at 1-hour post 50g glucose load at 28 weeks Estimating Gestational Age ▪ The estimated delivery date is calculated by adding 280 days to the first day of 2024/2025 the last menstrual period. An alternative 2024/2025method of determining the due date is 2024/2025 to add 7 days to the LMP, subtract three months, and add one year. ▪ At 12 weeks, the uterus is just barely palpable above the pubic bone, using only an abdominal hand. ▪ At 16 weeks, the top of the uterus is 1/2 way between the pubic bone and the umbilicus. ▪ At 20-22 weeks, the top of the uterus is right at the umbilicus. ▪ At full term, the top of the uterus is at the level of the ribs. (xyphoid process). ▪ Ultrasound can be used to determine gestational age. a. Measurement of a crown-rump length & gestational sac during the first trimester (1-13 weeks) give accurate date. b. During the second trimester (14-28 weeks), measurement of the biparietal diameter & femur length c. In the third trimester, the accuracy of ultrasound is less 11  Obstetrics and gynecology [email protected] [email protected] [email protected] INSTRUCTIONS TO THE PREGNANT WOMAN 1) Nutrition A pregnant woman should eat a normal, balanced diet for one person. These women may find they do better by having more frequent (but smaller) meals, or snacks between meals of relatively nutritious but low caloric foods. Calories 2500 Kcal Proteins: 60 gm , Carbohydrates:200- 400 gm, Lipids: Restrict them Vitamins ▪ Vitamin A : 5000 IU., Vitamin B1 ( Thiamine): 1mg. ▪ Vitamin B2 (Riboflavin): 1.5 mg., Nicotinic acid: 15mg., ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ ▪ vit. C : 50mg., ▪ Vitamin D: 400 IU., ▪ Folic acid: 0.5 mg. Minerals - Iron : 15 mg., Calcium: 1000 mg. 2) Smoking: should be avoided as it may cause intrauterine growth retardation or premature labour and all bad obstetric conditions. 3) 2024/2025 Rest and sleep: 2024/2025 2024/2025 2 hours in the midday and 8 hours at night. 4) Exercises: ▪ violent exercises as diving and water sports should be avoided. ▪ House work short of fatigue and walking are encouraged. Exercise restrictions in Pregnancy Women should not start a new sport or exercise while pregnant, but may continue previous activities. Activities, which require a fine sense of balance to preserve the woman’s personal safety (horseback riding, downhill skiing, etc.), are inadvisable because pregnant women are inherently and unavoidably unstable in their balance. 5) Traveling: ▪ long and tiring journeys should be avoided particularly if the woman is prone to abortion or preterm labour. ▪ Flying is not contraindicated but not the long ones and near term. 6) Exposure to infections: 12  Obstetrics and gynecology [email protected] [email protected] [email protected] is to be avoided particularly those of documented teratogenicity e.g. rubella, cytomegalovirus, herpes huminis and varicella zoster viruses. 7) Exposure to Medications: not to be taken without obstetrician advice due to risk of teratogenicity 8) Exposure to physical and chemical agents that may be harmful ▪ Thermal Stress pregnant women are generally restricted from saunas and Jacuzzis. ▪ Noise Pregnant women should wear hearing protection when exposed to ambient noise levels above 84dB. ▪ Mobile and Pregnancy There is no good evidence that working in front ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ ofor near stations of mobile waves or chronic users of mobile phones, to support any harmful fetal effect. ▪ X-rays during Pregnancy it is better to avoid x-rays while pregnant. If indicated,try to shield the baby with a lead apron to minimize the fetal exposure. ▪ Radiation Exposure There appears to be a threshold for fetal malformation or death of at least 5Rads, below which, biologic effects cannot be demonstrated. ▪ Chemical Solvents Organic solvents, such as turpentine, fuel, oils, lubricants, 2024/2025 and paint thinner may have adverse effects on a developing fetus.2024/2025 2024/2025 ▪ Heavy Metals It is very important to avoid maternal exposure to lead, cadmium and mercury. 9) Clothing: Lighter and looser clothes of non synthetic materials are more comfortable due to increased BMR and sweating. ▪ Clothes which hang from the shoulders are more comfortable than that requiring waste bands. ▪ Breast support is required. ▪ Avoid tight elastic hosiery or its bands. 10) Shoes: High - heeled shoes should be discouraged as they increase lumbar lordosis, back strain and risk of falling. 11) Bathing: Shower bathing is preferable than tube or sea bathing for fear of ascending infection. Vaginal douching should be avoided. 13  Obstetrics and gynecology [email protected] [email protected] [email protected] 12) Coitus: Whenever abortion or preterm labor is a threat, coitus should be avoided. Otherwise, it is allowed with less frequency and violence. 13) Exposure to Immunization: Vaccine Allowance Live virus vaccines Measles Contraindicated. Mumps Contraindicated. Rubella Contraindicated. Measles Contraindicated. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Poliomyelitis Contraindicated. Yellowfever Contraindicated. Inactivated virus vaccines Influenza Same as non pregnant Rabies Same as non pregnant Hepatitis B Same as non pregnant. Inactivated bacterial vaccines Anthrax 2024/2025 not 2024/2025 contraindicated 2024/2025 Cholera not contraindicated Typhoid fever not contraindicated Plague not contraindicated Pneumococcal not contraindicated Meningitis Contraindicated Toxoid Tetanus Same as non-pregnant. Diphtheria Same as non-pregnant. Immune globulins Rabies not contraindicated Tetanus not contraindicated Varicella not contraindicated Measles not contraindicated Hepatitis A not contraindicated Hepatitis B not contraindicated 14  Obstetrics and gynecology [email protected] [email protected] [email protected] 14) Bowels : Constipation is avoided by increasing vegetables, fluids and milk intake and mild exercise. 15) Teeth : Regular cleansing. Consult the dentist when needed. 16) Breasts: to reduce the incidence of retracted and/ or cracked nipples postpartum, the patient is instructed to massage them with a mixture of glycerine and alcohol during the last 6 weeks of pregnancy. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ High risk pregnancy High-risk pregnancy is broadly defined as one in which the mother, fetus, or newborn is at or may possibly be at increased risk of morbidity or mortality before, during, or after delivery. The warning symptoms: which indicate immediate contact to the obstetrician are: 2024/2025 2024/2025 2024/2025 (i) Vaginal bleeding, (ii) Gush of fluid per vaginum, (iii) Abdominal pain, (iv) Persistent headache, (v) Blurring of vision, (vi) Edema of lower limbs or face, (vii) Persistent vomiting. risk factors: 1. MATERNAL AGE Extremes of maternal age increase risks of maternal or fetal morbidity and mortality. Adolescents are at increased risk for preeclampsia-eclampsia, intrauterine growth restriction (IUGR), and maternal malnutrition. Elderly primigravida: Primigravida whose age is above 35 years had increased risk of preeclampsia –eclampsia and inertia. 15  Obstetrics and gynecology [email protected] [email protected] [email protected] The grand multipara: Woman who had 5 or more previous deliveries had increased risk of anemia , placenta previa , Malpresentation and malposition. 2. MODALITY OF CONCEPTION It is important to differentiate spontaneous pregnancy from that resulting from assisted reproductive technologies (ART). Use of ART increases the risks of multiple gestation, pregnancy-induced hypertension, and preterm delivery. 3. PAST MEDICAL HISTORY Such as DM, Hypertension, chronic renal diseases, autoimmune, pulmonary diseases, Hemoglobinopathies and serious infections as AIDS. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 4. FAMILY HISTORY A detailed family history is helpful in determining any increased risk of heritable disease states (eg, cystic fibrosis, sickle cell disease) which may affect the mother or fetus during the pregnancy or the fetus following delivery. 5. PAST OBSTETRIC HISTORY 1. Habitual abortion. 2. Previous stillbirth or neonatal death. 3. Previous preterm delivery. 2024/2025 2024/2025 2024/2025 4. Rh isoimmunisation or ABO incompatibility. 5. Previous preeclampsia-eclampsia. 6. Previous infant with genetic disorder or congenital anomaly. 7. Teratogen exposure. a. Drugs b. Infectious agents c. Radiation 8. History of gynecological surgery as myomectomy or metroplasty or pelvic trauma. PRECONCEPTIONAL EVALUATION Preconceptional evaluation and counseling of women of reproductive age has gained increasing acceptance as an important component of women's health. Care given in family planning and gynecology centers provides an opportunity that is rarely seen in the prenatal visits. Aims to maximize maternal and fetal health benefits before conception and hence decrease incidence of high risk pregnancy. 16  Obstetrics and gynecology [email protected] [email protected] [email protected] Investigate Issues of potential consequence to a pregnancy such as medical problems, lifestyle, or genetic issues should be investigated and interventions devised prior to pregnancy. Preeclampsia ▪ Is the disease of second half of pregnancy , occurring only in pregnant females as the pathology of preeclampsia is dependent on the presence of placental tissue ▪ Any pregnant female should be considered predisposed to preeclampsia but female at risk are : 1. Primegarivada ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 2. Chronic hypertensive patients 3. Chronic renal disease 4. Chronic DM 5. Patient with auto immune disease like SLE and thrombophilias 6. Any pregnant female with large placenta like in case of multiple pregnancy , or trophoblastic disease ▪ It is characterized by : 2024/2025 7. Hypertension: elevation of2024/2025 blood pressure above 140 systolic and 90 2024/2025 diastolic. the condition considered severe if blood pressure above 160 systolic , 110 diastolic 8. Oedema : generalized oedema , begin on the legs and then spread to other areas like arms , anterior abdominal wall and face , in severe cases the oedema will occur in internal organs like brain , liver and kidneys causing characteristics symptoms to the patients 9. Protinuria : more than 300 mg in 24 hour collection urine , or + , ++ Protinuria in single dipstick test , preeclampsia considered severe if more than 5 gm protein in 24 hours collection urine , or +++ , ++++ Protinuria in single dipstick test. ▪ Mild preeclampsia is not symptomatic , so detected only by routine antenatal care ▪ Severe preeclampsia had many symptoms : 1. Headache due to brain oedema 2. Blurred vision due to retinal oedema 3. Epigastric pain due to hepatic oedema 17  Obstetrics and gynecology [email protected] [email protected] [email protected] 4. Nausea and vomiting due to gastric oedema 5. Oliguria due renal pathology ▪ Preeclampsia is dangerous disease and may cause maternal or fetal mortality ▪ Complications of preeclampsia is : 1. Renal failure 2. Hepatic affection and progress to hepatic failure 3. DIC 4. Retinal detachment 5. Eclampsia 6. Accidental heamorrhage ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 7. Intrauterine growth restriction 8. Intrauterine fetal death Treatment of preeclampsia depends on : 1. Hospitalization 2. High protein diet 3. Anti hypertensive drugs : but controlling blood pressure had no rule in controlling ongoing pathology 2024/2025 4. Continuous follow up for the fetus and the mother 2024/2025 2024/2025 5. The only definitive treatment of preeclampsia is termination of pregnancy , but we try to postpone the decision for sake of bay and outweigh the risk Indications for termination of pregnancy: 1. Full term pregnancy 2. Maturity of the baby 3. Fetal or maternal complications 4. Severe preeclampsia Eclampsia ▪ Sever preeclampsia can lead to eclampsia which characterized by generalized fits ▪ The pathology is unknown but may be due to association of brain oedeam and barian anoxia due to hypertension ▪ Eclamptic fits are generalized tonic and colonic convulsions Diabetes mellitus 18  Obstetrics and gynecology [email protected] [email protected] [email protected] ▪ Can occur for first time with pregnancy (gestational diabetes) ▪ Diagnosed by glucose tolerance test ▪ Had many fetalcomplications like IUGR,IUFD, congenital anomalies, polyhydraminos ▪ Maternal complications likepyelonephritis, retinopathy and nephropathy Preterm labour ▪ Frequent uterine contaction before maturity. ▪ Occur at any time of pregnancy before completed 37 weeks gestations ▪ Fetal complications is directed mainly towards prematurity of baby Premature rupture of membranes ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ ▪ Rupture of amniotic sac before second stage of labour ▪ If occur before fetal maturity it is called preterm premature rupture of membrane ▪ It is major risks infection (chorioamnoitis) and prematurity Hyperemesis gravidarum ▪ Vomiting affecting general condition of mother ▪ Sever cases had the same manifestations of dehydration and hunger ▪ The female vomit many frequent times without eating , day and night , with 2024/2025 intolerability to eat or drink and detoriation 2024/2025 of general conditions2024/2025 ▪ Severe cases need termination of pregnancy Anemia ▪ Diagnose if HB level below 11 gm/dL ▪ Had many complications like postpartum hemorrhage, inertia and increase susceptibility to infections. 19  Obstetrics and gynecology [email protected] [email protected] [email protected] Normal labour The disposition of the foetus in utero Presentation: The part of the foetus related to the pelvic brim and first felt by vaginal examination. The presentation may be: (a) Cephalic 96%. (vertex when the head is flexed, face when extended and brow when it is midway between flexion, and extension), (b) Breech 3.5%, (c) Shoulder 0.5%. Cephalic presentation is much more common than other presentations as the foetus is adapted to the pyriform-shaped uterus (with the larger breech lies in the wide fundus ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ and the smaller head in the narrow lower part of the uterus). N.B.: The vertex: is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture; posteriorly by the posterior fontanelle and the lamboidal suture and laterally by 2 lines passing by the parietal eminences. The face: is the area from the junction of the chin and neck to the root of the nose and supra-orbital ridges. The brow: is the area from the root of the nose and supra-orbital ridges to the 2024/2025 2024/2025 2024/2025 anterior fontanelle and coronal suture. Position The relation of the back of the foetus to the right or to the left sides of tile mother and whether it is directed anteriorly or posteriorly. The denominator is a Landmark on the presenting part used to denote the position. In vertex it is the occiput, in face it is the chin and in breech it is the sacrum. There are 4 common classical positions in vertex presentation: ▪ 1st = Left occipito anterior (LOA) 60%. ▪ 2nd = Right occipito anterior (ROA) 20% ▪ 3rd = Right occipito posterior (ROP) 15% ▪ 4th = Left occipito posterior (LOP) 5% Occipito anterior positions ore more common than occipito posterior positions because in occipito anterior positions the concavity at the front of the foetus (due to its flexion) fits into the convexity of the vertebral column (the lumbar lordosis) at the back of the mother. 20  Obstetrics and gynecology [email protected] [email protected] [email protected] LOA is more common than ROA, and ROP is more common than LOP as in cases of LOA and ROP the head enters the pelvis in the right oblique diameter which is more favorable than the left oblique because: (a) The pelvic colon reduces the length the left oblique (b) Anatomically the right oblique is usually slightly longer than the left oblique. N.B.: In addition there are other 4 positions: right and left occipito transverse and direct occipito anterior and posterior. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 2024/2025 2024/2025 2024/2025 Lie: The relation between long axis of foetus to that of the mother (Longitudinal in cephalic and breech. Transverse or oblique in shoulder). Attitude: The relation of foetal parts to each other (usually complete flexion, in face it is complete extension of the head). Engagement: It is the passage of the widest transverse diameter of the presenting port (the biparietal in cases of the head) through the plane of the pelvic inlet. 21  Obstetrics and gynecology [email protected] [email protected] [email protected] ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ In the primigravida engagement of the head occurs in the last 3 or 4 weeks of pregnancy due to the tonicity of the abdominal and uterine muscle. In the multipara, due to the decreased 2024/2025 tonicity, the head commonly 2024/2025 engages at the onset of labour2024/2025 or even at the beginning of the 2nd stage of labour. Normal labour Labour: is the process by which a viable foetus (at the end of 28 weeks pregnancy or more) is expelled from the uterus. Normal labour: when there is a single mature foetus, presenting by the vertex, the process of labour terminates spontaneously. Through the birth canal, without any interference ( except episiotomy)and without complications to the mother or foetus, and within 24 hours. Premature labour: when the duration of pregnancy is between the end of 28 and the end of 37 weeks (The normal duration of pregnancy is 40 weeks or 280 days calculated from the first day of the last menstruation). Postmaturelabour: when the duration of pregnancy is 42 weeks or more. Prolonged labour: lasting more than 24 hours. Precipitate labour:lasting less than 3 hours. 22  Obstetrics and gynecology [email protected] [email protected] [email protected] Clinical Course labour The prodromal stage (before the onset of labour) The following clinical manifestations may occur in the last weeks of pregnancy before the onset of labour in some cases. (1) Lightening: This is the relief of upper abdominal pressure symptoms as dyspnea, palpitation and dyspepsia due to descent of the level of the fundus after engagement and due to shelfing of the uterus as at that time the fundus of the uterus descends slightly and falls forward giving the upper part of the abdomen a special form simulating a shelf detected in the standing position. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ N.B.: In the standing position, shelfing brings the foetus in the direction of the axis of the pelvic inlet and also shelfing is one of the factors that lead to lightening. (2) Pelvic pressure symptoms as frequency of micturition, difficulty in walking and rectal tenesmus. These occur after engagement. (3) False labour pains: which are intermittent uterine contractions accompanied by variable degree of pain. They are differentiated from the true labour pains by being irregular; of short duration, do not increase progressively and if the cervix can admit the finger we notice that the membranes do not bulge during the contractions. These pains 2024/2025 2024/2025 do not cause progressive cervical dilatation and they are usually relieved2024/2025 by sedatives. (4) Increased vaginal discharge. Diagnosis of onset of labour: - Symptoms: (1) True labour pains, (2) the show. - Signs: (1) Dilation of internal cervical os. (2) Formation of the bag of forewater. True labor pains: During pregnancy there are painless intermittent uterine contractions which are felt on palpating the uterus. These are known as palmer sign in early pregnancy and as Braxton Hicks contractions in late pregnancy. True labour contractions are: 1. Painful causing colicky pain in lower abdomen and backache (cervical dilation): 2. They are regular and increase gradually in strength, duration and frequency. 3. they are effective, i.e. cause dilation of the internal os 4. They are accompanied by hardening of the uterus. 23  Obstetrics and gynecology [email protected] [email protected] [email protected] 5. they are usually increased by enema because a full rectum reflexly inhibits uterine contractions 6. The bag of forewater becomes tense during contraction. The show: It is a blood stained mucous discharge noticed at the start of labour. The mucus is the cervical mucous plug which normally fills the cervical canal and is expelled when the cervix start to dilate. The blood is caused by separation of the membranes from the lower uterine segment or minute laceration of cervical mucosa. Labour usually starts with in 24 hours after the passage of the show. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Dilatation of the internal cervical os:- A closed internal os means that labour has not started, however, the external or even internal os may admit 1or 2 fingers before the onset of labour, especially in a multi gravida. Formation of the bag of forewaters:- The lower pole of the fetal membranes (chorion and amnion), separates form the lower uterine segment to form a bag of water which bulges through the cervix and becomes tense during uterine contraction (a sure sign). 2024/2025 2024/2025 2024/2025 False labour pains: Sometimes the intermittent uterine contractions of pregnancy cause some degree of abdominal pain for several days or weeks before the onset of true labour pains. Stages of normal labour First stage (stage of cervical dilatation): Starts with the onset of true labour pains and ends when the cervix becomes fully dilated (about 10 cm diameter or 5 fingers). With full cervical dilatation the whole birth canal in felt as one continuous canal. The end of first stage of labour is marked by rupture of membrane and drainage of amniotic fluid, In primigravida the duration of the first stage in about 14-16 hours and in multipart about 8 hours. Second stage (stage of expulsion of the foetus): Starts with full cervical dilatation and ends with delivery of the foetus (1-2 hours in primipara, 1/2-1 hours in multipara. 24  Obstetrics and gynecology [email protected] [email protected] [email protected] Third stage (stage of expulsion of the placenta and membranes): Stats with complete delivery of the foetus and ends with expulsion of the placenta and membranes (10 minutes both primipara and multipara). ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Forces of labor 1- Uterine contractions and retractions (true labour pains): They are regular, involuntary, intermittent, increase in frequency, strength and duration as labour progresses (at 1st they recur every 10-20 minutes and last few seconds but later on they recur every few minutes and last one to two minutes). Uterine contractions during labour are accompanied by retraction (contraction 2024/2025 2024/2025 2024/2025 followed by permanent shortening; the values of which are: (a) to dilate the cervix, (b) to expel the foetus. (c) to separate the placenta, (d) to control postpartum hemorrhage). The uterus during labour shows the phenomenon of polarity (the upper segment is more active and lower segment is more passive so as to dilate the cervix and expel the foetus). During labour the uterine contractions are felt by the patients as colicky pain in the abdomen which is referred to the lower back. During contractions the uterus becomes hard when felt abdominally. True labour pains are accompanied by progressive dilatation of the cervix and the membranes bulge through the cervix when felt during the contraction. 2- Auxiliary forces of labour: The secondary force concerned in labour consists of the voluntary bearing down effort brought about by strong contractions of the diaphragm and abdominal muscles. When the head stretches the pelvic floor, bearing down occurs involuntary by a reflex mechanism. This bearing down is needed for spontaneous expulsion of the foetus during the 2nd stage, and also may occasionally expel the separated placenta in the 3rd stage. 25  Obstetrics and gynecology [email protected] [email protected] [email protected] dilation of the cervix Cervical dilation is due to: (a) Contraction and retraction of the uterus. (b) Contractions and retractions also push the bag of forewaters before rupture of membranes or the presenting part after rupture of the membranes through the cervix helping in its dilation. (c) The changes in the cervix during pregnancy (glandular hypertrophy, oedema and increased vascularity) make the cervix more readily dilatable. In primigravida ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ The internal os dilates at 1st and the cervical canal becomes opened up from above downwards and becomes incorporated into the lower uterine segment so that the cervix becomes thin and the external os only remains undilated. This is called taking up or effacement of the cervix and it is followed by dilatation of the external os. In multiparous effacement and dilation of cervix occur simultaneously. expulsion of the placenta and membranes After delivery of the foetus the uterus retracts, the area of the placental site diminishes, the inelastic placenta does not diminish in size so it separates. 2024/2025 2024/2025 2024/2025 Effect of labour on the mother (A) 1st stage: little effect. (B) 2nd stag: pulse may increase- up to 100, slight rise of temperature (37.5), systolic B.P. may slightly increase during pains, edema and congestion of the conjunctiva , minor injuries to the birth canal (as minor cervical lacerations, perinea! tears especially in primigravidae) (C) 3rd stage: blood loss from the placental site 100 - 200 cc, blood loss from laceration or episiotomy 100 cc. Neonatal aspect Effect of labour on the fetus (1) Slowing of the F.H.S. during contractions to return to normal between pains. (2) Moulding: The compression to which the foetal head is subjected during labour, may result in a variable degree of overlap of the flat bones of the vault of the skull leading to alteration in the shape the of the foetal head. This is called moulding. If it is 26  Obstetrics and gynecology [email protected] [email protected] [email protected] slight, it is physiological and beneficial as it helps in easy passage of the head through the birth canal, but if marked, it is dangerous as it may result in intracranial hemorrhage. (3) Caput succedaneum: Soft swelling due to collection of serous exudates under the scalp due to compression of the head at the girdle of contact (between the head and cervical rim) interfering with the venous return It usually occurs in prolonged labour after rupture of membranes and it disappears within one or two days after delivery. Care of the newly born (1) Put the infant with the head lower to drain the respiratory passages and aspirate the mucus in the mouth and throat by mucus catheter. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ (2) Ligate the umbilical cord by 2 thick silk ligature about 4 and 5 cm. from the umbilicus to avoid the possibility of tying an umbilical hernia and then cut distal to the 2nd ligature , inspect for bleeding, paint with alcohol and apply antiseptic powder (3) Put penicillin drops in the eyes to avoid ophthalmianeonatorum. (4) Inspect the infant for any congenital anomalies. Weight the infant, dress it and put any mark to identify it 2024/2025 2024/2025 2024/2025 Caesarean section Definition: Delivery of fetus after 20 weeks of pregnancy ( after viability) through abdominal and uterine incision Incidence: The rising rate of cesarean section is considered problem all over the world, due to complications of presence of uterine scar in subsequent pregnancy including rupture uterus and placenta accrete. The rate of cesraen section reach 25-30%in USA , and in Egypt reach 42-50%. 27  Obstetrics and gynecology [email protected] [email protected] [email protected] Indications: Absolute : 1. Absolute contracted pelvis 2. Soft tissue tumour obstructing labour 3. Pelvic bone tumour 4. Placenta previacentralis 5. Active lower genital tract infection with herpes 6. Stricture of cervix or vagina Relative: ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Maternal: a. Cephalopevicdisproportion b. Other types of placenta previa c. Abnormal uterine action in normal labour d. Previous uterine scar e. Previousrepair of genital descend f. Certain case of DM or preeclampsia g. Old primegravida Fetal : 2024/2025 2024/2025 2024/2025 a. Large fetus b. Malpresentations c. Fetal distress d. Repeated intrauterine fetal death before last week of pregnancy e. Some case of Rh isoimmunization Timing of operation: 10. Elective cesarean section : The operation is done before onset of labour usually one or two weeks before expected date of delivery 11. Selective cesarean section : after onset of labour. Pfannenstiel incision: Skin incision for cesarean section 28  Obstetrics and gynecology [email protected] [email protected] [email protected] Transverse semilunar incision, made in subcutaneous tissue and skin, 2-3 cm above the symphysispupis. Had less postoperative pain, with rapid recovery for intestinal movement. Leave strong scar with more cosmetic appearance. But take long time to open the abdomen , had more bleeding and more liability to develop hematoma, less exposure to the abdomen Midline skin incision can be used in some cases of cesarean section instead of Pfannenstiel incision ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ Types of cesarean section: 1. lower segment cesarean section : Incision is done in lower uterine segment , in transvers direction about 10 cm , and closed later into double layer closure, it had many advantages over upper segment : produce less bleeding strong scar with less liability to rupture less liability to infection 2024/2025 2024/2025 2024/2025 less liability to paralytic ileus less liability to postoperative adhesion lower rate of mortality Mostly all cesarean sections id done by that technique 2. Upper segment cesarean section : Vertical incision done in the upper segment of uterus about 10 cm. the uterus after that closed into three layers, it is easy to be done and take short time , but had many disadvantages : produce more bleeding weak scar with more liability to rupture more liability to infection more liability to paralytic ileus more liability to postoperative adhesion higher rate of mortality. 29  Obstetrics and gynecology [email protected] [email protected] [email protected] Indications: Difficulty or dangerous to reach lower segment due to presence of fibroids , varicosities or adhesions Bad maternal condition needs rapid delivery Repaired vesicovaginal fistula Cesarean hysterectomy indicated Postmortem cesarean section 3. vertical lower segment cesarean section : Verticalincision in lower uterine segment had many advantages ovser transverse incision: ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ less bleeding as midline is the least vascular area away from uterine vessels and ureter which may be injuried in transverse incision less liability to pelvic thrombosis repair is more anatomical as the flaps are equal thickness Disadvantages: incision may extend downwards into bladder and vagina, or extend upward to upper uterine segment lead to weakening of scar. 2024/2025 4. cesarean hysterectomy : 2024/2025 2024/2025 Cesarean section is done followed by removal of uterus. Indications: uncontrollable postpartum hemorrhage some cases of rupture uterus placenta accrete multiple fibroids needing hysterectomy some case of cervical cancer with pregnancy 5. inverted T incision : Combined transverse incision in lower uterine segment, and longitudinal incision in upper segment. Very weak scar. indicatedin case of impacted shoulder. 6. Post-mortem Caesarean section: If a pregnant woman has a cardiac arrest and the fetus is viable, post-mortem Caesarean section should be carried out without delay. For speed, this would be best done via midline skin and uterine ('classical') incisions. Not only can a baby's life be saved, but 30  Obstetrics and gynecology [email protected] [email protected] [email protected] also resuscitation of the mother is facilitated (less pressure on the diaphragm and improved venous return). 7. Hysterotomy Miniature cesarean section done before 20 weeks of pregnancy , before viability of fetus. Labour following cesarean section: Patient may allowed delivering normal after cesarean section if the indication of the first cesarean section is not present in subsequent pregnancy. If vaginal ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ delivery is allowed continuous electronic fetal monitoring is indicated. Repeated cesarean section can be done if the indication of cesarean section is still present like contracted pelvis. Cesarean sterilization: Tubal sterilization can be done during cesarean section as a method of contraception. 2024/2025 2024/2025 2024/2025 Complications: 1. Shock either hemorrhagic or neurogenic 2. Primary Hemorrhage due to injury of large uterine vessels or uterine atony. 3. Secondary hemorrhage or reactionary hemorrhage 4. Thrombosis and pulmonary embolism 5. Injury to urinary bladder and ureters 6. Anesthetic complications. 7. Genital tract infections 8. Urinary tract infection and uterovesical fistula formation 9. Complications of skin incision including infection, hematoma formation or burst abdomen. 10. Rupture of uterine scar in subsequent pregnancy. 11. Placenta accrete in subsequent pregnancy. 31  Obstetrics and gynecology [email protected] [email protected] [email protected] ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 2024/2025 2024/2025 2024/2025 Normal puerprium & postnatal care Normal Puerperium Definition: It is period after delivery during which the changes produced by pregnancy regress. It takes 6 weeks (42 days). Physiological changes during puerperium: I. General changes: 1- Temperature: 32  Obstetrics and gynecology [email protected] [email protected] [email protected] ▪ Slight reactionary rise not more than 0.5oC which drops back to normal within 24 hours. ▪ Slight rise may occur at 2rd day (start of lactation). 2- Pulse: Slight slowing of pulse rate which then becomes normal except if hemorrhage or infection occur. 3- RBCs count &Hb%: Gradually becomes normal except of there is blood loss more than usual. 4- GIT: Tendency to constipation in early period due to: ▪ Atony of intestine, abdominal &perineal muscles. ▪ Loss of fluids. ‫ﺍﺑﺮﺍﻫﻴﻢ ﻋﻤﺎﺩ ﺍﺑﺮﺍﻫﻴﻢ ﺍﻟﻨﺸﺎﺭ‬ 5- Weight: Loss of weight due to: ▪ Evacuation of uterine contents (fetus, placenta & amniotic fluid). ▪ Excessive sweating. 6- Skin : there is tendency to excessive sweating 7- Postpartum psychosis : the joy after delivery is often followed in a few days by mild and transient depression and fits of cryng 8- Menstruation : 6-8 weeks after delivery if not lactating female 9- Urinary tract: 2024/2025 2024/2025 2024/2025 ▪ Polyuria in the first few days to excrete water retention during pregnancy. ▪ Retention of urine is common due to:- - Recumbent position. - Laxity of abdominal and bladder wall. - Reflex inhibition from or episiotomy. - Urethral compression by edema or hematoma. 10- Breasts:Clostrum is secrete in the first 3 days Mechanism & start & location: After placental delivery there will be withdrawal of estrogens which was inhibiting the action of prolactin on the breast acini. Thus, breast acini will respond to hyperprolactinemia by milk formation which starts on the 3 rd day. Suckling stimulates prolactin secretion from lactotrophes of anterior pituitary → milk production by breast acini. Also, suckling stimulates oxtocin release → contraction of myoepithelial cells around breast acini → milk ejection (milk let down) 33  Obstetrics and gynecology [email protected] [email protected] [email protected] 11- After pains: - Due to painful uterine contractions occurring in early puerperium and increases during suckling (oxytocin release). II. local changes : 1- Uterus: - Regressive involution till the end of puerperium. After delivery the weight of the uterus is 1000 gm and length is 20 cm and by the end of 6 weeks its weight is 50 gm