5 Obstetrics.pdf

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM E...

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT OBSTETRIC NURSING HUMAN SEXUALITY Sexuality ❖ Encompasses the complex emotions, feelings, preferences, attitude and behaviors that are related to sexual self and eroticism. ❖ Behavior of being a male or female Gender ❖ Sense of femininity or masculinity Sex ❖ Biologic male or female status FEMALE EXTERNAL GENITALIA ❖ Vulva Collective term for external female genitalia ❖ Mons pubis Also termed as Mons Veneris Pad of adipose tissue that lies over symphysis pubis covered by skin and at puberty covered by hair. ❖ Labia Majora Large lips Two folds of adipose tissue covered by loose connective tissue and epithelium. Serves as protection for the external genitalia and the distal urethra and vagina. ❖ Labia Minora Two hairless folds of connective tissue covered with mucous membrane and the external surface with skin. ❖ Clitoris Pea-shaped composed of erectile tissues and sensitive nerve endings Site of sexual arousal and eroticism in females ❖ Fourchette Formed by the posterior joining of the labia minora and majora Common site for episiotomy ❖ Vestibule Almond-shaped structure containing urinary meatus, Skene's gland, hymen, vaginal orifice and Bartholin's gland ❖ Urinary Meatus Urethral opening for urination ❖ Skene's Gland Also called Paraurethral Gland Secretes small amount of mucous which functions as lubrication during sexual intercourse or coitus ❖ Bartholin's Gland Also termed as Paravaginal Gland Secretes alkaline substance responsible for neutralizing the acidity of the vagina to keep the sperm alive. ❖ Vaginal Orifice External opening of the vagina ❖ Hymen Membranous tissue that covers vaginal orifice ❖ Perineum Muscular structure in between vagina and anus INTERNAL GENITALIA ❖ Passageway of menstruation and fetus ❖ 6-7 cm (anterior wall); 8-9 cm (posterior wall) ❖ Has dilatable canal ❖ Rugae Thick folds of membranous stratified epithelium which permits stretching without tearing. 1 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Uterus Hollow, muscular, pear-shaped organ for containment and nourishment of the fetus Function for menstruation pregnancy and labor Size (non-pregnant: 2.5 cm thick, 5 cm wide ,5-7 cm long Shape (non-pregnant): pear shape Shape (pregnant): ovoid Weight ✓ Non pregnant: 60 g ✓ Pregnant: 1000g UTERINE ANATOMY Fundus Upper cylindrical layer Portion that can be palpated at the abdomen to determine the amount of uterine growth occurring during pregnancy Isthmus Short segment between the body and the cervix Portion of the uterus that is most commonly cut when a fetus is born by a Cesarean section Corpus Portion of the structure that expands to contain the growing fetus (Body) Cervix Lower uterine segment Lowest portion of the uterus Approximately half of it lies above the vagina and half extends to the vagina UTERINE LAYERS Endometrium Innermost layer Composed of 2 layers (basal layer and glandular layer) Myometrium Muscle layer of the uterus Constricts the tubal junctions and preventing regurgitation of menstrual blood into the tubes Contracts during the labor and delivery processes Perimetrium Outmost layer or the uterus Serves the purpose of adding strength and support to the structure ❖ Decidua – Latin word for “falling off” 3 Types of Decidua Decidua basalis Endometrium that lies directly under the embryo Decidua Portion of the endometrium that stretches or encapsulates the capsularis surface of the trophoblast Decidua vera Remaining portion of the uterine lining ❖ Ovaries 4cm long by 2cm in diameter and approximately 1.5cm thick or almond shape, grayish-white, female sex gonads producing progesterone and estrogen. Function ✓ Produce, mature and discharge ova (egg cells) ✓ Produce estrogen and progesterone and initiate and regulate menstrual cycle. ❖ Fallopian Tube 10 cm long Conveys ova from the ovaries to the uterus and provides a place for fertilization of the ovum by the sperm SEGMENTS Infundibulum Approximately 2 cm long and is funnel shaped Covered by fimbria that help to guide the ovum into the fallopian tube Ampulla Longest portion on the tube Common site for fertilization; common site for ectopic pregnancy 2 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Isthmus Portion of the tube that is cut or sealed in a tubal ligation or tubal sterile procedure Interstitial Most dangerous site for ectopic pregnancy MALE ❖ Penis Male organ for copulation and urination Layers ✓ 2 corpus cavernosa - lateral column of erectile tissue ✓ 1 corpus spongiosum -located on the underside of the penis ❖ Scrotum Pouch hanging below the penis Contains the testes Temperature regulator of the testes ❖ Testes Two ovoid glands, 2-3 cm wide, that lie in the scrotum. INTERNAL GENITALIA ❖ Epididymis Responsible for conducting sperm from the testis to the vas deferens Site of maturation of the sperm ❖ Vas Deferens Carries sperm from the epididymis through the inguinal canal into the abdominal cavity Sperm matures as it passes the vas deferens. ❖ Seminal Vesicle Secretes viscous portion of the semen. Contains: ✓ Fructose ✓ Protein ✓ Prostaglandin ❖ Ejaculatory Duct Conduit of semen and joins the seminal vesicles to the urethra. ❖ Prostate Gland Produces alkaline substance for the protection of the sperm Reduces the acidity of the vagina ❖ Cowper’s gland Also termed as bulbourethral gland. Secretes lubricant into the urethra to facilitate transport of sperm during ejaculation ❖ Urethra Vessels of transport of urine and semen. MENSTRATION AVERAGE CYCLE: 28 days (23-35days) Duration of menstrual flow 4-6days (normal) 1-9 days (abnormal) Normal blood loss: 30-80 cc, ¼ cup Interplay of 4 major organs: Hypothalamus Anterior pituitary gland Ovaries Uterus 3 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Hypothalamus Produces GnRH or gonadotropin-releasing hormone to stimulate the anterior pituitary gland for the release of hormones ❖ Anterior pituitary gland Also termed as adenohypophysis Secretes Gonadotropins (Hormones that stimulate the Gonads or Ovaries) Stimulates the ovaries to secrete estrogen and progesterone ❖ Gonadotropins ❖ Follicle-stimulating Hormone (FSH) ✓ Hormone that is active early in the cycle and is responsible for maturation of the primordial follicle. ❖ Luteinizing Hormone (LH) Hormone most active at the midpoint of the cycle and is responsible for ovulation. ❖ Ovary Release of the ovum (egg cell) ❖ Uterus Stimulation from the hormones Develops stratum functionalis in preparation for pregnancy – sheds of as menstruation if ovum not fertilized MENSTRUAL CYCLE ❖ Proliferative Phase Other terms: follicular phase/ estrogenic phase / post-menstrual phase 6 to 14 days First phase of menstrual cycle Always variable in length Immediately after the menstrual flow, the endometrium is very thin, approximately once cell layer in depth Endometrium begins to proliferate as the ovary begins to produce estrogen Levels of estrogen will increase in this phase ❖ Graafian follicle Most mature of all follicles With cavity and ovum ready to be extruded With clear fluid rich in estrogen Only 1 follicle matures per menstrual cycle Primordial follicle Immature follicle ESTROGEN: secretion effect in Uterus Thickens the uterine lining approximately eight-fold ✓ From one millimeter to eight millimeters Peak of uterine lining coincides with ovulation Peaking of estrogen will signal luteinizing hormone surge (increase in blood levels of luteinizing hormone) LH Surge Coincides with ovulation Extrusion of ovum from the Graafian follicle signals OVULATION ❖ Luteal Phase Other terms: Secretory Phase / Progestational Phase / Premenstrual Phase Second phase of menstrual cycle Remains constant: always 14 days in length Production of corpus luteum occurs Secretion of luteinizing hormone (LH) peaks in this phase Cavity is left inside the follicle Stimulates change in fluid in Graafian follicle (yellowish, milky white fluid high in progesterone) PROGESTERONE EFFECT Maintains and organizes uterine lining If estrogen is present, the uterine lining would continue to thicken Under the influence of luteinizing hormone, the progesterone in the corpus luteum causes the glands of the uterine endometrium to become corkscrew or twisted in appearance. 4 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Depo Pro-Vera — this drug contains progesterone and used for dysfunctional uterine bleeding. ❖ Ischemic Phase If fertilization does not occur, the corpus luteum in the ovary begins to regress after 8 to 10 days. Production of progesterone and estrogen in this phase also decreases The decrease in these hormones makes the endometrium to degenerate Capillaries rupture with minute hemorrhages and the endometrium sloughs off ❖ Menstrual Phase Low levels of Estrogen & Progesterone Passage of menstrual flow TERMINOLOGIES ❖ Zygote Product of fertilization < 2 weeks aog ❖ Embryo Intrauterine growth period from the time following implantation until organogenesis is complete 2 to < 8 weeks aog ❖ Fetus 8 weeks to birth ❖ Viability Fetus can be delivered and capable of living outside the utero Period of viability: 24 weeks and above (Pillitteri, 2010) ❖ Gravida number of pregnancies that reach the age of viability regardless of the outcome of the pregnancy. TPAL T- term (38- 42 weeks) P- preterm ( 10 minutes, Cesarean section may be necessary. 6. Chorionic villi sampling ❖ It is a diagnostic technique that involves the retrieval and analysis of chorionic villi from the growing placenta for chromosomes or DNA analysis ❖ Done at 8 to 10 weeks Post procedure: Instruct to report chills or fever suggestive of infection or threated miscarriage. 7. Alpha-fetoprotein (AFP) ❖ Alpha-fetoprotein is a glycoprotein produced by the fetal liver that reaches a peak in maternal serum between the 13th and 32nd week of pregnancy, Results: Elevated: Neural tube defect Decreased: Fetal Chromosomal Disorder (e.g. Down syndrome) 12 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT PSYCHOLOGICAL TASKS OF THE MOTHER First Trimester ❖ Mother should accept that she is pregnant (though ambivalence may be present) ❖ Concern of the mother towards herself is greater than her concern towards the baby Second Trimester Acceptance of the baby is the main task Concern towards the self is equal to concern for the baby Third Trimester Acceptance of parenthood Concern for the self is less than concern for the baby LABOR Theories of Parturition 1. Fetal sign The baby feels that it is already capable of living outside the utero 2. Oxytocin theory of parturition Receptors for oxytocin in the uterus increase as term approaches. 3. Progesterone Withdrawal Theory Level of progesterone assayed in preterm and term pregnancy Preterm: Progesterone level is still high Approaching Term: Level of progesterone decreases causing contraction of uterus 4. Prostaglandin Theory Prostaglandin stimulates uterine contraction FACTORS AFFECTING LABOR 1. Pelvic Dimension Android Pelvis Male pelvis. The pubic arch in this pelvis type forms an acute angle, making the lower dimensions of the pelvis extremely narrow. "Ape-like" pelvis. Anthropoid Pelvis The transverse diameter is narrow, and the anteroposterior diameter of the inlet is larger than normal. Gynecoid Pelvis "Normal" female pelvis. The inlet is well-rounded forward and backward Ideal for childbirth. "Flattened" pelvis. Platypelloid Pelvis The inlet is an oval, smoothly curved, but the anteroposterior diameter is shallow. 2. Fetal Dimensions ❖ Fetal Size Correlation of size of baby to pelvic size Cephalopelvic Disproportion (CPD) Head of the baby is INCONGRUENT with the maternal pelvis. Size of the fetal head is greater than the maternal pelvis. Important Concepts: Despite the presence of CPD, there is a trial of Labor and not an absolute Cesarean Section Number of Cesarean Section in hospitals should not be more than 20% of all deliveries ❖ Fetal Attitude This describes the degree of flexion a fetus assumes during labor or the relationship of the fetal parts to each other If in complete extension, labor may not progress since this does not allow an adequate fetal movement ❖ Fetal Lie The relationship between the long axis of the fetal body and the long axis of a woman's body. Types of fetal lie: Longitudinal, transverse, oblique If in a transverse lie, dilatation will not progress 13 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Fetal Presentation Denotes the body part that will first contact the cervix. This is determined by a combination of fetal lie and the degree of fetal flexion/fetal attitude ❖ Fetal Position It is the relationship of the presenting part to specific quadrant or a woman pelvis Examples: Right occipitoposterior (ROP), Left sacroanterior (LSA) ❖ Fetal Station Relationship of the presenting part to the level of ischial spines Level of ischial spine Station 3cm above ischial spine -3 (floating) 2cm above ischial spine -2 1cm above ischial spine -1 At the ischial spine 0 (engaged) 1cm below ischial spine -1 2cm below ischial spine -2 3cm below ischial spine -3 (crowning) Linea terminalis- divides the false from true pelvis ✓ Above linea terminalis = false pelvis o Support uterus during the late months of pregnancy o Aids in directing the fetus into the pelvis for birth ✓ Below the linea terminalis = true pelvis 3. Fetal diameters ❖ Suboccipitobregmatic diameter Narrowest/Smallest diameter Approximately 9.5 cm wide Measurement is from the inferior aspect of the center of the anterior fontanelle ❖ Occipitofrontal diameter Measurement is from the occipital prominence to the bridge of the nose. Approximately 11 cm wide ❖ Occipitomental diameter Widest/Largest anteroposterior diameter Approximately 13.5 cm wide Measurement is from the posterior fontanelle to the chain 4. Fetal Head ❖ Anterior fontanelle Diamond shape Closes at 12-18 months of age ❖ Posterior fontanelle Triangle shape Closes at 2-3 months of age PRELIMINARY SIGNS OF LABOR ❖ Lightening Primigravida= 2 weeks prior to labor Multigravida= at time of labor ❖ Braxton-Hicks contractions Starting at 28 weeks AOG (or last week/ days before labor begins), Braxton Hicks contractions are strong ❖ Increase in level of activity Increase in activity is related to an increase in epinephrine release initiated by a decrease in progesterone produced by the placenta ❖ Slight loss of weight As progesterone level falls, body fluid is more easily excreted from the body This increase in urine production can lead to a weight loss between 1 and 3 pounds 14 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Ripening of the cervix Internal sign seen only on pelvic examination Goodell’s sign = cervix feels softer than normal to palpation (“butter-soft”) Sign of True Labor True Labor False Labor Start at lumbar or back Confined to hypogastric area Regular interval Irregular interval Progressive cervical dilation and effacement No cervical dilation and effacement Intensity is increasing No change on intensity Ambulation intensifies uterine contraction in true labor Ambulation stop the contraction Sedation has no effect Sedation stop false labor ❖ Uterine contraction The surest sign that labor has begun is productive uterine contractions. ❖ Bloody show As the cervix soften and ripens, the mucus plug that filled the cervical canal during pregnancy (operculum) is expelled ❖ Rupture of membranes a sudden gush or a scanty, slow seeping of clear fluid from the vagina ❖ Cervical dilation STAGES OF LABOR FIRST STAGE ❖ Starts from true contraction to full cervical dilatation (10cm) PHASES (LAT) LATENT PHASES Begins at the onset of uterine contractions. Contraction quality: Mild Duration: 20 to 40 seconds, every 5 to 10 minutes Cervical effacement occurs Cervical dilation: 0 to 3 cm. Nullipara: 6 hours Multipara: 4.5 hours ACTIVE PHASE Contraction quality: Moderate, stronger Cervical dilation: 4 to 7 cm Duration: 40 to 60 seconds, every 3 to 5 minutes TRANSITION PHASE Contraction quality: Strongest Cervical dilation: 8 to 10 cm Duration: 60 to 90 seconds, every 2 to 3 minutes NITRAZINE TEST ❖ Used to determine whether fluid is amniotic or not ❖ Nitrazine paper is in contact with the vaginal secretions. ❖ Results: o Blue (alkaline): Amniotic fluid o Red (acidic): Urine Important Concepts: If membrane has ruptured for greater than 24 hours and still no birthing occurred, infection will most likely occur and immediate Cesarean Section is needed. SECOND STAGE ❖ Starts from full cervical dilatation (10 cm) up to delivery of the fetus ❖ Primigravida: 1-4 hours ❖ Mutigravida: 20-45 minutes Important Concepts: Do not encourage pushing if cervix is not fully dilated and if there is no presence of contraction. 15 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Main purpose of pushing: to shorten the Second Stage of Labor Ask client to pant-breathe if there is an urge to push Mechanisms of Labor (ED FIRE ERE) - Engagement - Descent - Flexion - Internal Rotation - Extension - External Rotation (Restitution) - Expulsion Essential Intrapartum and Newborn Care (EINC) Properly timed cord clamping (when pulsation stops or after 2 minutes) Immediate drying of baby (prevent hypothermia) Non-separation of mother and baby Early breastfeeding (within 60 minutes postpartum) THIRD STAGE ❖ Starts from the delivery of the baby to the delivery of placenta ❖ Lasts for five (5) to ten (10) minutes ❖ Maximum waiting time is thirty (30) minutes ❖ Beyond 30 minutes is already abnormal Signs of Placental Expulsion Calkin's Sign (Uterus becomes firm and globular) Lengthening of the Cord Sudden Gush of Blood Rising of the Uterus into the abdomen ✓ Up to the level of the umbilicus 1cm after the delivery of the placenta Two Types of Placental Expulsion ❖ Schultze Presentation Shiny and glistening from the fetal membranes Placenta separates first at its center and last at its edges Less chances of bleeding ❖ Duncan Presentation Raw, red, and irregular Placenta separates first at its edges Associated with more bleeding and hemorrhage Nursing Responsibilities: Assess the appearance and completeness of the cotyledons (16-20). If not complete, reclean the uterus to prevent bleeding. Measure the placental diameter. Weigh the placenta. Measure the umbilical cord. Expect presence of blood vessels. ✓ 2 arteries and 1 vein (AVA) Drugs for Third Stage of Labor Ergotrates ✓ Includes Methergine I.V. or I. M. ✓ Best given immediately after delivery of placenta ✓ Massive contraction of the uterus traps placenta inside, therefore, do not give before placental expulsion Oxytocin ✓ Give prior to expulsion of placenta to add to contraction ✓ Given at minimal amounts ✓ Normally at a rate of eleven to twelve drops per minute (11-12 gtts/min) ✓ After the delivery of placenta, give oxytocin at greater amounts Important Concept In the Third stage of Labor, priority is minimizing risk for hemorrhage. 16 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ First 1-4 hours after delivery of the placenta ❖ Priority: Achieve homeostasis and minimize bleeding risks. ❖ All water retained previously will be reabsorbed into the circulation leading to: Increased in Cardiac Output Increase in Oxygen Consumption Thus, most detrimental or difficult stage of labor in gravidocardiac patients. Postpartum Assessment (BUBBLE-HE) Breast Uterus Bladder Bowels Lochia Homan’s sign: pain upon dorsiflexion (possible deep vein thrombosis) Episiotomy HEMORRHAGIC DISORDERS IN PREGNANCY FIRST TRIMESTER 1. Abortion/Miscarriage ❖ Any interruption of a pregnancy before a fetus is viable. ❖ Viable Fetus - fetus of more than 24 weeks of gestation or one that weighs at least 500 g. Two types of Abortion ❖ Spontaneous Abortion Most common cause of spontaneous abortion is chromosomal in nature. Embryo is defective. TYPES OF SPONTANEOUS ABORTION Threatened Abortion Presence of vaginal bleeding; no cervical dilation and effacement Inevitable/imminent abortion Presence of vaginal bleeding; cervical effacement and dilation Complete abortion All products of conception have passed in the vagina Incomplete abortion Some products of conception have passed the vagina Habitual abortion Occurrence of three or more pregnancies that end in miscarriage of the fetus ❖ Induced abortion Also termed as ‘elective termination of pregnancy” A procedure performed to end a pregnancy before fetal viability Types of Induced abortion Therapeutic abortion Illegal 2. Ectopic Pregnancy ❖ Implantation occurs outside the uterine cavity ❖ Most common site: Ampulla of Fallopian tube ❖ Most common predisposing factor: Pelvic Inflammatory Disease (PID) ❖ Other factors include: Previous Surgery Presence of Intrauterine Device History of previous ectopic pregnancies Triad Manifestations Amenorrhea Vaginal bleeding or Spotting Unilateral lower abdominal pain/tenderness Clinical Manifestations Severe, sharp knife-like a pain; Unilateral pain 17 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Abdominal rigidity ✓ Bleeding inside ✓ Hemoperitoneum ✓ Peritonitis Positive (+) for Cullen's Sign ✓ Ecchymosis around due to hemoperitoneum Decreased Blood Pressure Excruciating pain when the moved (wriggling tenderness) Diagnosis for Ectopic Pregnancy Culdocentesis ✓ Refers to the extraction of fluid from the recto-uterine pouch posterior to the vagina through a needle. Medical Management ❖ Methotrexate o A sclerosing agent: Shrink and absorb products of conception. o Chemotherapeutic agent attacks and destroys fast-growing cells. o Given I.M. to the mother if ectopic pregnancy is less than 3 cm Surgical Management ❖ Salpingotomy o Limited to unruptured (