1. Maternal Physiology
Prenatal Care
Normal Delivery
Gumalo, Clay Paolo

2. OUTLINE
Maternal Physiology
I. Reproductive Tract
II. Skin
III. Metabolic changes
IV. Hematological changes
V. Changes in organ systems

3. OUTLINE
Prenatal Care
 II. Organization of prenatal care
 III. Nutrition
 IV. Common concerns

4. OUTLINE
 Normal Labor and delivery
 I. Mechanisms of Labor
 II. Characteristics of normal labor
 III. Management of Normal Labor
and delivery
 IV. Labor Management Protocols

5. maternal physiology

6. MATERNAL PHYSIOLOGY
I. REPRODUCTIVE TRACT
II. SKIN
III. BREASTS
IV. METABOLIC CHANGES
V. HEMATOLOGICAL CHANGES
VI. CHANGES IN ORGAN SYSTEMS

7. MATERNAL PHYSIOLOGY
I. REPRODUCTIVE
TRACT • nonpregnant woman: 50-70 g; 6-8
 Uterus cm
multiparous: 70-1100g; 9-10cm; 5L-
 Cervix 20L
 Ovaries
• uterine size, shape and position
 Fallopian Tubes first few weeks- pyriform (pear
shape)
 Vagina and Perineum advance pregnancy- corpus and
fundus is more globular
12 weeks- spherical contractility

8. MATERNAL PHYSIOLOGY
I. REPRODUCTIVE
TRACT
• 1 month after conception- undergo
 Uterus pronounced softening and cyanosis
 Cervix • result from increased vascularity
 Ovaries and edema of the entire cervix
 Fallopian Tubes • hyperplasia and hypertrophy of the
 Vagina and Perineum cervical glands

9. MATERNAL PHYSIOLOGY
I. REPRODUCTIVE
TRACT • ovulation ceases during pregnancy, and
the maturation of new follicles is
 Uterus suspended.
 Cervix
• only a single corpus luteum can be
 Ovaries found in pregnant women.
 Fallopian Tubes
• functions maximally during the first 6
 Vagina and Perineum to 7 weeks of pregnancy—4 to 5 weeks
postovulation

10. MATERNAL PHYSIOLOGY
I. REPRODUCTIVE
TRACT
 Uterus
• musculature of the fallopian tubes
 Cervix undergoes little hypertrophy during
 Ovaries pregnancy but the epithelium of the
tubal mucosa becomes flattened.
 Fallopian Tubes
 Vagina and Perineum

11. MATERNAL PHYSIOLOGY
I. REPRODUCTIVE
TRACT • increased vascularity and hyperemia
 Uterus develop in the skin and muscles of the
perineum and vulva
 Cervix
 Ovaries • papillae of the vaginal epithelium
undergo hypertrophy to create a fine,
 Fallopian Tubes hobnailed appearance.
 Vagina and Perineum • pH is acidic, varying from 3.5 to 6.

12. MATERNAL PHYSIOLOGY
II. SKIN
 Blood flow in skin
 Abdominal Wall
 Hyperpigmentation
 Vascular Changes

13. MATERNAL PHYSIOLOGY
II. SKIN
 Blood flow in skin
 Abdominal Wall
 Hyperpigmentation
 Vascular Changes

14. MATERNAL PHYSIOLOGY
II. SKIN
 Blood flow in skin
 Abdominal Wall
 Hyperpigmentation
 Vascular Changes

15. MATERNAL PHYSIOLOGY
II. SKIN
 Blood flow in skin
 Abdominal Wall
 Hyperpigmentation
 Vascular Changes

16. MATERNAL PHYSIOLOGY
III. BREASTS
 tenderness, increase in size
 nipples become larger, more deeply pigmented and
more erectile

17. MATERNAL PHYSIOLOGY
IV. METABOLIC
CHANGES • uterus and its contents
 Weight gain
• the breasts
 Water Metabolism
 Protein Metabolism • increases in blood volume and
extravascular extracellular fluid
 Carbohydrate
Metabolism
 Fat Metabolism

18. MATERNAL PHYSIOLOGY
IV. METABOLIC
CHANGES • At term, the water content of the
 Weight gain fetus, placenta, and amnionic
fluid approximates 3.5 L
 Water Metabolism
 Protein Metabolism • Another 3.0 L accumulates as a
result of increases in the
 Carbohydrate maternal blood volume and in
Metabolism the size of the uterus and breasts
 Fat Metabolism • normal pregnancy is
approximately 6.5 L

19. MATERNAL PHYSIOLOGY
IV. METABOLIC
CHANGES • at term, the fetus and placenta
 Weight gain together weigh about 4 kg and
contain approximately 500 g of
 Water Metabolism protein
 Protein Metabolism
• the remaining 500 g is added to
 Carbohydrate the uterus as contractile protein,
Metabolism to the breasts primarily in the
glands, and to the maternal
 Fat Metabolism blood as hemoglobin and plasma
proteins

20. MATERNAL PHYSIOLOGY
IV. METABOLIC
CHANGES • Normal pregnancy is
 Weight gain characterized by
• mild fasting hypoglycemia
 Water Metabolism • postprandial hyperglycemia
 Protein Metabolism • hyperinsulinemia.
 Carbohydrate
Metabolism
 Fat Metabolism

21. MATERNAL PHYSIOLOGY
IV. METABOLIC
CHANGES • Maternal hyperlipidemia is
 Weight gain one of the most consistent and
striking changes to take place in
 Water Metabolism lipid metabolism during late
 Protein Metabolism pregnancy.
• increased during the third
 Carbohydrate trimester
Metabolism • Triacylglycerol and
cholesterol levels in VLDL,
 Fat Metabolism LDL, HDL.

22. MATERNAL PHYSIOLOGY
V. HEMATOLOGICAL CHANGES
• Dilutional anemia increase volume due to increase plasma 
increase RBC
• Increase reticulocyte and leukocyte count
• Increase blood coagulation factors, increase fibrinogen levels,
increase plasminogen and fibrin degradation products
• Increase plasma iron binding capacity (transferrin)

23. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS • No actual cardiac enlargement but
 Cardiovascular System only slight dilatation and
displacement upwards and
 Respiratory Tract outwards due to gravid uterus
 Urinary System • ECG may reveal slight axis
 Gastrointestinal Tract deviation, occasional T waves, and
lowering of T waves
 Endocrine System
• Increase in heart rate maximal on
 Musculoskeletal System the 7th- 8th month~10 beats/min
• Increase in cardiac output by
about 30-50%

24. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS • Upward displacement of the
diaphragm by about 4 cm
 Cardiovascular System • Increase tidal volume and resting
minute ventilation
 Respiratory Tract
 Urinary System • increase Vital capacity, tidal
volume and respiratory rate due to
 Gastrointestinal Tract central effects of progesterone ,
low expiratory reserve volume and
 Endocrine System compensated respiratory alkalosis
 Musculoskeletal System
• decrease functional residual
capacity and residual volume of air

25. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS
 Cardiovascular System • Increase kidney size due to
hypertrophy and increase renal
 Respiratory Tract blood flow causing an increase
renal vascular volume
 Urinary System
 Gastrointestinal Tract • Physiologic Hydroureter of
pregnancy—marked increase (25x)
 Endocrine System in diameter of ureteral lumen,
hypotonicity and hypomotility of
 Musculoskeletal System its musculature
• Prone to UTI due to progesterone
and pressure changes

26. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS
 Cardiovascular System Progesterone effect
• Smooth muscle atony,
 Respiratory Tract decrease tone of lower
esophageal sphincter,
 Urinary System increase HCl production
 Gastrointestinal Tract
• Decrease responsiveness to
 Endocrine System CCK duodenal and biliary
stasis  pancreastitis 
 Musculoskeletal System hyperlipidemia  cholesterol
stones

27. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS • Mild hyperthyroid state due to
Gland hyperplasia
 Cardiovascular System
• Hyperparathyroid state 
 Respiratory Tract increase calcium for fetus
 Urinary System
• Hyperadrenal state gland
 Gastrointestinal Tract hyperplasia with increase steroid
production
 Endocrine System
 Musculoskeletal System • Diabetogenic due to placental
degradation of insulin and anti-
insulin effects of placental
lactogen, estrogen, progesterone

28. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS
 Cardiovascular System
 Respiratory Tract
• Back pain due to lordosis and
 Urinary System increase mobility sacal joints
(relaxin)
 Gastrointestinal Tract
 Endocrine System
 Musculoskeletal System

29. Prenatal care

30. PRENATAL CARE
 Preconception care
 Prompt diagnosis of pregnancy
 Initial prenatal evaluation
 Follow-up prenatal visits

31. PRENATAL CARE
 Preconception care
 Prompt diagnosis of pregnancy
 Initial prenatal evaluation
 Follow-up prenatal visits

32. PRECONCEPTION CARE
 Personal and Family
History
 Medical History
 Genetic Diseases
 Reproductive History
 Social History
 Lifestyle and Work
Habits

33. PRECONCEPTION CARE
 Personal and Family  Occupation
History  Educational Attainment
 Medical History  Home situation
 Genetic Diseases  SOs
 Reproductive History  Stress: short- and long-
 Social History term
 Lifestyle and Work
Habits

34. PRECONCEPTION CARE
 Personal and Family  Diabetes Mellitus
History  Hypertension
 Medical History  Asthma
 Genetic Diseases  Epilepsy
 Reproductive History  Renal Disease
 Social History  Thyroid Disorders
 Lifestyle and Work  Heart Disease
Habits

35. PRECONCEPTION CARE
 Personal and Family  Neural-Tube Defects
History
 Medical History  Phenylketonuria
 Genetic Diseases
 Reproductive History  Thalassemias
 Social History
 Lifestyle and Work  Tay-Sachs Disease
Habits

36. PRECONCEPTION CARE
 Personal and Family  Infertility
History
 Medical History  Abnormal pregnancy
 Genetic Diseases outcome
 Reproductive History
 Social History  OB complications
 Lifestyle and Work
Habits

37. PRECONCEPTION CARE
 Personal and Family  Infertility
History  Abnormal pregnancy
 Medical History outcome
 Genetic Diseases  Miscarriage
 Reproductive History  Ectopic pregnancy
 Social History  Recurrent pregnancy
loss
 Lifestyle and Work
Habits
 OB complications

38. PRECONCEPTION CARE
 Personal and Family  Infertility
History  Abnormal pregnancy
 Medical History outcome
 Genetic Diseases  OB complications
 Reproductive History  Preeclampsia
 Social History  Placental abruption
 Lifestyle and Work  Preterm delivery
Habits

39. PRECONCEPTION CARE
 Personal and Family  Maternal Age
History
 Medical History  Recreational Drugs and
 Genetic Diseases Smoking
 Reproductive History
 Social History  Environmental
 Lifestyle and Work Exposures
Habits

40. PRECONCEPTION CARE
 Personal and Family  Maternal Age
History
 Medical History  Recreational Drugs and
 Genetic Diseases Smoking
 Reproductive History
 Social History  Environmental
 Lifestyle and Work Exposures
Habits

41. Maternal Age
ADOLESCENT AFTER 35
 Likely to be anemic  Likely to request for
 Increased risk to have preconceptional counseling
growth-restricted infants  Physically fit VS. Chronic
 Preterm labor illness
 High infant mortality rate  High mortality rate
 Higher incidence of STDs  Maternal–age fetal risks
 Fetal Aneuploidy

42. Maternal Age
ADOLESCENT AFTER 35
 Likely to be anemic  Likely to request for
 Increased risk to have preconceptional counseling
growth-restricted infants  Physically fit VS. Chronic
 Preterm labor illness
 High infant mortality rate  High mortality rate
 Higher incidence of STDs  Maternal–age fetal risks
 Fetal Aneuploidy

43. PRECONCEPTION CARE
 Personal and Family  Maternal Age
History
 Medical History  Recreational Drugs and
 Genetic Diseases Smoking
 Reproductive History
 Social History  Environmental
 Lifestyle and Work Exposures
Habits

44. PRECONCEPTION CARE
 Personal and Family  Maternal Age
History
 Medical History  Recreational Drugs and
 Genetic Diseases Smoking
 Reproductive History
 Social History  Environmental
 Lifestyle and Work Exposures
Habits

45. PRECONCEPTION CARE
 Personal and Family  Diet
History  Exercise
 Medical History  Domestic Abuse
 Genetic Diseases  Family History
 Reproductive History  Immunizations
 Social History  Screening Tests
 Lifestyle and Work
Habits

46. PRENATAL CARE
 Preconception care
 Prompt diagnosis of pregnancy
 Initial prenatal evaluation
 Follow-up prenatal visits

47. Diagnosis of Pregnancy
 Signs and symptoms • Presumptive symptoms of
pregnancy
1. nausea with or without vomiting-
 Pregnancy Test due to increase hCG
2. disturbance in urination
3. fatigue- due to increase
metabolism
 Sonographic recognition 4. perception of fetal movement
of pregnancy quickening
5. breast tenderness and tingling
sensation

48. Diagnosis of Pregnancy
 Signs and symptoms • Presumptive signs of pregnancy
1. amenorrhea
2. anatomic breast changes
 Pregnancy Test darker areola, erected nipple,
engorged breast
3. changes in vaginal mucosa
4. Skin pigmentation
 Sonographic recognition 5. Thermal signs
of pregnancy

49. Diagnosis of Pregnancy
 Signs and symptoms
• Probable evidence of pregnancy
1. Enlargement of abdomen
2. Changes in skin, shape and
 Pregnancy Test consistency of the uterus
3. Anatomical changes in cervix
Cervical mucus
 Sonographic 4. Braxton-Hick’s contractions that
are painless and irregular
recognition of 5. Ballotement
pregnancy 6. Physical outlining of the fetus
7. Positive Pregnancy test- B hCG
levels

50. Diagnosis of Pregnancy
 Signs and symptoms • Positive evidence of pregnancy
1. Identification of fetal heart tones
separately from mother
 Pregnancy Test Normal FHT:
Ultrasound
Stethoscope
Doppler
 Sonographic recognition 2. Perception of active fetal
of pregnancy movement by the examiner
3. Ultrasound or radiologic
evidence

51. Diagnosis of Pregnancy
 Signs and symptoms
 Pregnancy Test
 Sonographic recognition
of pregnancy

52. Diagnosis of Pregnancy
 Signs and symptoms
 Pregnancy Test
 Sonographic recognition
of pregnancy

53. PRENATAL CARE
 Preconception care
 Prompt diagnosis of pregnancy
 Initial prenatal evaluation
 Follow-up prenatal visits

54. Initial Prenatal Evaluation
 Initiate prenatal care as soon as there is
a reasonable likelihood of pregnancy.
 Goals:
a) Define health status of mother and fetus
b) Estimate gestational age
c) Initiate continuing obstetrical c

55. CIM-CMSS PACKAGE DEAL
 Requirement: minimum of 4 PNC’s
 Adjust PNC schedule for high-risk patients  half the
normal interval
 Remind patients to bring all receipts on admission for
refund

56. FIRST PNC
 Always get contact number and place on index card
 Place past or present medical or surgical problems on
upper right corner of PD Form
 For previous CS: secure OR Record and early UTZ for
aging
 Fetal Heart Tone:
 <10 wks  no FHT
 >13 wks  (+) FHT by Doppler

57. FIRST PNC
 LABS:
 1. CBC, UA, Blood Typing (if not known) for ALL
patients
 If menses are irregular, LMP is unclear, or previous CS
(for aging: reliable up to 26 weeks):
 A. <12 weeks – TVS UTZ
 B. >12 weeks – OB UTZ

58. FIRST PNC
 MEDS
 1. Vitamin B complex (Neurofort) OD: <14 week with
vomiting
 2. Folic acid (Folart) 5 mg/cap OD: <20 wks
 3. MV + Fe (Fer-Essence) OD: without vomiting
 If Hgb < 11 mg/dl  Increase MV + Fe BID  repeat Hgb/Hct
at 28-32 weeks  if Hgb still < 11 mg/dl  Increase MV + Fe
TID
 4. Calcium (Calciumade) 500 mg/tab TID PC: with HPN
or family hsitory of hypertension
 5. Anmum/Enfamama 1 glass BID

59. SECOND/THIRD PNC
 PAP smear (let patient buy sterile gloves and pay at the
counter before getting the sample)

60. SECOND TRIMESTER
 FH (cm) = AOG (weeks) at 20-34 wks
 If < 3 cm difference, suspect IUGR  get UTZ and follow
up after 2 wks
 For IUGR:
 Increase caloric intake (3 meals, 2 snacks/day)
 Increase milk to 1 glass TID
 Left lateral decubitus position while asleep
 Rpt OB UTZ at 32-34 wks (or after 4 wks) to check fetal
growth
 If > 3 cm difference  get UTZ to R/O LGA or
polyhydramnios

61. SCHEDULE of
ROUTINE LABORATORY TESTS & PROCEDURES
 First PNC
 CBC, U/A-MSCC, Blood typing
 TVS/OB UTZ if menses are irregular, LMP is unclear, or
previous CS for fetal aging
 Second/third PNC
 PAP smear
 At 24-28 weeks:
 50 g OGCT  100g OGTT
 At 28-32 weeks:
 Repeat hematocrit
 HBsAg-IC
 At 32-36 weeks:
 OB-UTZ

62. SCHEDULE of
ROUTINE LABORATORY TESTS & PROCEDURES
 At 34 weeks:
 Be sure of Leopold’s
 At 36 weeks:
 Repeat U/A – MSCC
 Advise walking exercises and fetal kick counting (>10 in one hour, esp after
eating)
 At 37 weeks:
 Remind patients to seek admission for signs of labor (bloody show with uterine
contractions every 5 mins) or watery vaginal discharge
 At 38 weeks:
 IE and cervical stripping (C/I in patients with history of spotting or low-lying
placenta
 At 39 weeks:
 NST, IE and cervical stripping
 At 40 weeks:
 IE, stripping & biophysical profile
 At >41 weeks:
 IE and repeat BPP if 1 wk since 1st BPP was taken

63. PRENATAL CARE
Recommended Ranges of Weight Gain during Singleton
Gestations Stratified by Prepregnancy Body Mass Index
CATEGORY BMI KG LB
Low < 19.8 12.5–18 28–40
Normal 19.8–26 11.5–16 25–35
High 26–29 7–11.5 15–25
Obese > 29 >7 >15

64. PRENATAL CARE
 Preconception care
 Prompt diagnosis of pregnancy
 Initial prenatal evaluation
 Follow-up prenatal visits

65. PNC FOLLOW-UP SCHEDULE
 0-27 6/7 weeks  every 4 weeks
 28-35 6/7 weeks  every 2 weeks
 36-39 6/7 weeks  every week
 >40 weeks  every 3 days

66. OPD schedule
DAY MORNING AFTERNOON
Monday PNC, Gyne Gyne, CIM
Tuesday PNC, Gyne PNC, Gyne, CIM
Wednesday PNC, Gyne PNC, Gyne, CIM
Thursday PNC, Gyne Gyne, CIM
Friday PNC, Gyne PNC, Gyne, CIM
Saturday PNC, Gyne

67. normal delivery

68. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
II. CHARACTERISTICS OF NORMAL DELIVERY
III. MANAGEMENT OF NORMAL LABOR AND
DELIVERY

69. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie

70. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie
 Fetal Presentation
 Cephalic Presentation

71. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie
 Fetal Presentation
 Cephalic Presentation
 Breech Presentation

72. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie
 Fetal Presentation
 Cephalic Presentation
 Breech Presentation
 Shoulder Presentation

73. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie
 Fetal Presentation
 Cephalic Presentation
 Breech Presentation
 Shoulder Presentation
 Fetal Attitude
 Fetal Position

74. NORMAL LABOR AND DELIVERY
 Diagnosis of Fetal Presentation and Position
1. Abdominal Palpation (Leopold Maneuvers)
2. Vaginal Examination
3. Sonography and Radiography

75. NORMAL LABOR AND DELIVERY
 Abdominal Palpation (Leopold’s Maneuver)
1. Fetal Pole 2. Umbilical Pole
• Cephalic
• Podalic
3. Pawlick’s grip 4. Pelvic grip

76. NORMAL LABOR AND DELIVERY
 Vaginal Examination

77. NORMAL LABOR AND DELIVERY
 Sonography and Radiography
 aid in identification of fetal position especially in obese
or in women with rigid abdominal walls.

78. NORMAL LABOR AND DELIVERY
 Mechanisms of Labor with Left Occiput Anterior
Presentation

79. NORMAL LABOR AND DELIVERY
 Mechanisms of Labor with Left Occiput Anterior
Presentation

80. NORMAL LABOR AND DELIVERY
 Changes in the shape of the fetal head
Caput Succedaneum Molding

81. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
II. CHARACTERISTICS OF NORMAL DELIVERY
III. MANAGEMENT OF NORMAL LABOR AND
DELIVERY

82. NORMAL LABOR AND DELIVERY
II. CHARACTERISTICS OF NORMAL LABOR
 First Stage of Labor
 onset of labor until full dilation and effacement

83. FIRST STAGE OF LABOR
 Preparatory division
 the cervix dilates little, its
connective tissue components
change considerably
 Dilatational division
 during which dilatation
proceeds at its most rapid rate,
is unaffected by sedation or
conduction analgesia.
 Pelvic division
 deceleration phase of cervical
dilatation. The classic
mechanisms of labor that
involve the cardinal fetal
movements of the cephalic
presentation

84. FIRST STAGE OF LABOR
 Latent Phase
 point at which the mother perceives regular
contractions.
 Prolonged Latent Phase
 exceeding 20 hours in the nullipara
 14 hours in the multipara
 Active Labor
 cervical dilatation of 3 to 5 cm or more
 presence of uterine contractions

85. FIRST STAGE OF LABOR
Monitoring of Fetal Well-being
 Ausculataion:
 hand held Doppler
 fetal stethoscope
 Electronic Fetal Monitoring (EFM) superior to intermittent
auscultation.
 Intermittent ausculatation
 every 15-30 minutes in the first stage of labor
 every 5 mins in the second stage of labor OR at least 30 seconds after
each contraction.
 Admitting CTG not recommended for healthy women at term, in labor,
in the absence of risk factors for adverse perinatal outcomes
 Continuos EFM is recommended when risk factors for fetal
compromise is identified.

86. FIRST STAGE OF LABOR
Induction of Labor
 to artificially initiate uterine contractions
 should only be implemented on a VALID indication.
 administered only in the hospital setting

87. FIRST STAGE OF LABOR
Indications Contraindications
Gest. HPN Malpresentation
Pre eclampsia, Eclampsia Absolute CPD
Premature rupture of membranes Placenta previa
Maternal Medical Condition ( DM, Previous major uterine surgery, or
renal disease,chronic hypertensive) C/S delivery
More than 41 1/7 weeks Invasive Ca of cervix
Evidence of fetal compromise ( Cord presentation
severe feta growth restriction,
isoimmunization)
Intraamnionic infection ACTIVE genital herpes
Fetal demise Gyne, ob, or medical conditions that
preclude vaginal birth
Logistic factors ( eg: distance from OB’s convenience
hospital)

88. FIRST STAGE OF LABOR
ASSESSMENT PRIOR TO INDUCTION
 parity
 age
 presentation
 Bishop’s score
 uterine activity
 nonstress test

89. FIRST STAGE OF LABOR
METHODS OF LABOR
INDUCTION
 Oxytocin
Recommended regimen
 Membrane Sweeping/ • starting dose of 1-2 mU/min,
Stripping increased at intervals of 30
mins or more
 Amniotomy • Fetal heart rate should be
recorded every 15-30 mins, and
with each incremental increase
of oxytocin.
• Continuous intrapartum
electronic fetal monitoring

90. FIRST STAGE OF LABOR
METHODS OF LABOR
INDUCTION
 Oxytocin
• artificial rupture of membrane that
 Membrane Sweeping/ may be used as a method for labor
Stripping induction if condition of the cervix
is favorable
 Amniotomy • However, if used alone in inducing
labor, it can be associated with
UNPREDITABLE, and sometimes
LONG INTERVALS before the onset
of contractions

91. FIRST STAGE OF LABOR
SIGNS OF HYPERSTIMULATION
 5 contractions in 10 mins, or more than 10 in 20 mins
 lasts more than 120 seconds
 Excessive uterine activity with an atypical abnormal
fetal heart rate
 OXYTOCIN SHOULD NOT BE CONTINUED or
INCREASED in the presence of abnormal fetal heart
rate, or tetanic contractions.

92. FIRST STAGE OF LABOR
RESUSCITATION
 Stop
 Reposition to left lateral decubitus
 O2 at 10L/min
 Notify physician
 Administer tocolytic
 Prepare for possible C/S if fetal pattern remains
abnormal

93. SECOND STAGE OF LABOR
 Cervical dilatation complete and ends with fetal
delivery
 50 minutes for nulliparas
 20 minutes for multiparas
 dorsal lithotomy position
 vulvar and perineal cleansing

94. SECOND STAGE OF LABOR

95. SECOND STAGE OF LABOR
 Episiotomy
 Reduce the risk of perineal trauma
 shortened second stage of labor.
 Indications:
 Expedite delivery in the second stage of labor
 When spontaneous laceration is likely
 Maternal or fetal distress
 Breech
 Assisted forceps delivery
 Large baby
 Maternal exhaustion

96. SECOND STAGE OF LABOR
Characteristic Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing Rare More common
Postoperative pain Minimal Common
Anatomical results Excellent Occasionally faulty
Blood loss Less More
Dyspareunia Rare Occasional
Extension Common Uncommon

97. SECOND STAGE OF LABOR

98. SECOND STAGE OF LABOR
 Clamping the Cord
 umbilical cord is cut between two clamps placed 4 to 5
cm from the fetal abdomen
 umbilical cord clamp is applied 2 to 3 cm from the fetal

99. THIRD STAGE OF LABOR
 size of the uterine fundus and its consistency are
examined
 uterus remains firm and there is no unusual bleeding,
watchful waiting until the placenta separates is the usual
practice
 Signs of Placental Separation
 uterus becomes globular and as a rule, firmer
 sudden gush of blood
 uterus rises in the abdomen
 The umbilical cord protrudes farther out of the vagina

100. THIRD STAGE OF LABOR

101. THIRD STAGE OF LABOR
 Uterine massage following placental delivery
 prevent postpartum hemorrhage
 Oxytocin, ergonovine, and methylergonovine are all
employed widely in the normal third stage of labor

102. THIRD STAGE OF LABOR
 Oxytocin
 1st line prophylactic uterotonic during 3rd stage of labor
in the prevention of PPH
 add 20 units (2 mL) of oxytocin per liter of infusate
 10 mL/min (200 mU/min) for a few minutes
 half-life of intravenously infused oxytocin is
approximately 3 minutes
 May cause fall in BP if given in large bolus
 May cause water intoxication

103. THIRD STAGE OF LABOR
 Use of ergot alkaloid, and ergometrine-oxytocin
 valid alternatives in the absence of oxytocin
 powerful stimulants of myometrial contraction
 AVOIDED in hypertensive patients due to ability to
cause transient hypertension
 In low resource area, misoprostol may be administered
orally, sublingually, or rectally.

104. FOURTH STAGE OF LABOR
 placenta, membranes, and umbilical cord should be
examined for completeness and for anomalies
 postpartum hemorrhage as the result of uterine atony
is more likely at this time

105. FOURTH STAGE OF LABOR
 First-degree lacerations
involve the fourchette,
perineal skin, and
vaginal mucous
membrane but not the
underlying fascia.

106. FOURTH STAGE OF LABOR
 Second-degree
lacerations involve, in
addition, the fascia and
muscles of the perineal
body but not the anal
sphincter

107. FOURTH STAGE OF LABOR
 Third-degree lacerations
extend farther to involve
the anal sphincter.

108. FOURTH STAGE OF LABOR
 fourth-degree laceration
extends through the
rectum's mucosa to
expose its lumen

109. Episiorrhaphy
 Hemostasis and anatomical restoration without
excessive suturing are essential for the success of
this method.
 Blunt needles are suitable and likely decrease the
incidence of needlestick injury; 2-0 Chromic gut

110. Episiorrhaphy

111. NORMAL LABOR AND DELIVERY
 Changes in the shape of the fetal head
Caput Succedaneum Molding
•Edematous swelling of •Change in the fetal head
the fetal scalp due to external compressive
•Formed when the head forces.
is in the lower portion •There is seldom
of the birth canal and overlapping of the parietal
frequently only after bones.
resistance of a rigid •Locking mechanisms at the
vaginal outlet is coronal nad lambdoidal
encountered. connections prevents
•It normally, crosses the overlapping.
suture lines.

112. Cephalhematoma
It is a hemorrhage of blood between
the skull and the periosteum of a newborn
baby secondary to rupture of blood vessels
crossing the periosteum. Because the swelling
is subperiosteal its boundaries are limited by
the individual bones

113. MATERNAL PHYSIOLOGY
VI. CHANGES IN
ORGAN SYSTEMS • Upward displacement of the
diaphragm by about 4 cm
 Cardiovascular System • Increase tidal volume and resting
minute ventilation
 Respiratory Tract
 Urinary System • increase Vital capacity, tidal
volume and respiratory rate due to
 Gastrointestinal Tract central effects of progesterone ,
low expiratory reserve volume and
 Endocrine System compensated respiratory alkalosis
 Musculoskeletal System
• decrease functional residual
capacity and residual volume of air

114. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie
 Fetal Presentation
 Cephalic Presentation
 Breech Presentation

115. NORMAL LABOR AND DELIVERY
I. MECHANISMS OF LABOR
 Fetal Lie
 Fetal Presentation
 Cephalic Presentation

116. Bishop scoring
 is a pre-labor scoring system to assist in predicting whether induction
of labor will be required. It has also been used to assess the odds of
spontaneous preterm delivery.
 a score that exceeds 8 describes the patient most likely to achieve a
successful vaginal birth. Bishop scores of less than 6 usually require
that a cervical ripening method be used before other methods.
 Cervical dilation
 Cervical effacement
 Cervical consistency
 Cervical position
 Fetal station
 Pneumonic : PEDS

117. Modified Bishop scoring
 Another modification for the Bishop's score is the
modifiers. Points are added or subtracted according to
special circumstances as follows:
 One point is added for:
 1. Existence of pre-eclampsia
 2. Every previous vaginal delivery
 One point is subtracted for:
 1. Postdate pregnancy
 2. Nulliparity (no previous vaginal deliveries)
 3. PPROM; preterm premature (prelabor) rupture of
membranes

120. Hypertensive Complications:
Criterias:
 Gestational Hypertension:
 Systolic BP 140 or diastolic BP 90 mm Hg for first time
during pregnancy
 No proteinuria
 BP returns to normal before 12 weeks postpartum
 Final diagnosis made only postpartum
 May have other signs or symptoms of preeclampsia, for
example, epigastric discomfort or thrombocytopenia

121. Criterias
 Preeclampsia:
 Minimum criteria:
 BP 140/90 mm Hg after 20 weeks' gestation
 Proteinuria 300 mg/24 hours or 1+ dipstick
 Increased certainty of preeclampsia:
 BP 160/110 mm Hg
 Proteinuria 2.0 g/24 hours or 2+ dipstick
 Serum creatinine >1.2 mg/dL unless known to be previously elevated
 Platelets < 100,000/L
 Microangiopathic hemolysis—increased LDH
 Elevated serum transaminase levels—ALT or AST
 Persistent headache or other cerebral or visual disturbance
 Persistent epigastric pain

122. Criterias:
 Eclampsia:
 Seizures that cannot be attributed to other causes in a
woman with preeclampsia

123. Criterias
 Superimposed Preeclampsia On Chronic
Hypertension:
 New-onset proteinuria 300 mg/24 hours in
hypertensive women but no proteinuria before 20
weeks' gestation
 A sudden increase in proteinuria or blood pressure or
platelet count < 100,000/L in women with
hypertension and proteinuria before 20 weeks'
gestation

124. Criterias
 Chronic Hypertension:
 BP 140/90 mm Hg before pregnancy or diagnosed
before 20 weeks' gestation not attributable to
gestational trophoblastic disease
 or
 Hypertension first diagnosed after 20 weeks' gestation
and persistent after 12 weeks postpartum

125. Preeclampsia
 The basic management objectives for any pregnancy
complicated by preeclampsia are:
 Termination of pregnancy with the least possible trauma
to mother and fetus
 Birth of an infant who subsequently thrives
 Complete restoration of health to the mother.
 Termination of pregnancy is the only cure for
preeclampsia.
 Once severe preeclampsia is diagnosed, labor
induction and vaginal delivery have traditionally been
considered ideal.

126. Some Indications for Delivery with
Early-Onset Severe Preeclampsia
 Maternal
 Persistent severe headache or visual changes; eclampsia
 Shortness of breath; chest tightness with rales and/or
SaO2 < 94 percent breathing room air; pulmonary edema
 Uncontrolled severe hypertension despite treatment
 Oliguria < 500 mL/24 hr or serum creatinine 1.5 mg/dL
 Persistent platelet counts < 100,000/L
 Suspected abruption, progressive labor, and/or ruptured
membranes

127. Some Indications for Delivery with
Early-Onset Severe Preeclampsia
 Fetal
 Severe growth restriction—< 5th percentile for EGA
 Persistent severe oligohydramnios—AFI < 5 cm
 Biophysical profile 4 done 6 hr apart
 Reversed end-diastolic umbilical artery flow
 Fetal death

128. Eclampsia: Immediate
Management of Seizure
 Eclamptic seizures may be violent. During seizures,
the woman must be protected, especially her airway.
 In severe cases, coma persists from one convulsion to
another, and death may result.

129.  In more severe cases of preeclampsia, as well as in
eclampsia, magnesium sulfate administered
parenterally is an effective anticonvulsant that avoids
producing central nervous system depression in either
the mother or the infant. It may be given intravenously
by continuous infusion or intramuscularly by
intermittent injection

130. Continuous Intravenous Infusion
 Give 4- to 6-g loading dose of magnesium sulfate
diluted in 100 mL of IV fluid administered over 15–20
min
 Begin 2 g/hr in 100 mL of IV maintenance infusion.
Some recommend 1 g/hr
 Monitor for magnesium toxicity: Assess deep tendon
reflexes periodically Some measure serum magnesium
level at 4–6 hr and adjust infusion to maintain levels
between 4 and 7 meq/L (4.8 to 8.4 mg/dL) Measure
serum magnesium levels if serum creatinine 1.0 mg/dL
 Magnesium sulfate is discontinued 24 hr after delivery

131. Intermittent Intramuscular
Injections
 Give 4 g of magnesium sulfate (MgSO4 · 7H2O USP) as a 20%
solution intravenously at a rate not to exceed 1 g/min
 Follow promptly with 10 g of 50% magnesium sulfate solution,
one-half (5 g) injected deeply in the upper outer quadrant of
both buttocks through a 20-gauge needle. If convulsions persist
after 15 min, give up to 2 g more intravenously as a 20% solution
at a rate not to exceed 1 g/min. If the woman is large, up to 4 g
may be given slowly
 Every 4 hr thereafter give 5 g of a 50% solution of magnesium
sulfate injected deeply in the upper outer quadrant of alternate
buttocks, but only after ensuring that:
 a. The patellar reflex is present,
 b. Respirations are not depressed, and
 c. Urine output the previous 4 hr exceeded 100 mL
 Magnesium sulfate is discontinued 24 hr after delivery

132. Watch out!
 Patellar reflexes disappear when the plasma
magnesium level reaches 10 meq/L—about 12
mg/dL—presumably because of a curariform action.
This sign serves to warn of impending magnesium
toxicity. When plasma levels rise above 10 meq/L,
breathing becomes weakened, and at 12 meq/L or
more, respiratory paralysis and respiratory arrest
follow.

133. Remedy
 Treatment with calcium gluconate or calcium
chloride, 1 g intravenously, along with
withholding further magnesium sulfate, usually
reverses mild to moderate respiratory depression.

134. Exercises that a pregnant woman
can do:
1. Head lift
2. Head lift with pelvic tilt
3. Pelvic tilt
4. Leg sliding
5. Trunk curls
6. Modified bicycle
7. Standing push ups
8. Supine Bridging
9. Quadruped leg raising
10. Modified squatting
11. Scapular Retractions
12. Self stretching

135. Head Lift
 Hook-lying with her hands crossed over midline at the
level of the diastasis for support.
 Have the woman exhale and lift only her head off the
floor or until the point just before a bulge appears. At
the same time, her hands should gently approximate
the rectus muscles toward midline (Fig. 23.8). Then
have the woman lower her head slowly and relax.
 This exercise emphasizes the rectus abdominis muscle
and minimizes the obliques.

136. Head Lift with Pelvic Tilt
 The arms are crossed over the diastasis for support as
above. Have the patient slowly lift her head off the
floor while approximating the rectus muscles and
performing a posterior pelvic tilt, then slowly lower her
head and relax. All abdominal contractions should be
performed with an exhalation so that intra-abdominal
pressure is minimized.

137. Quadruped leg raising
 On hands and knees(hands may be in fists or palms open
and flat). Instruct the woman to first perform a posterior
pelvic tilt, and then slowly lift one leg, extending the hip to
a level no higher than the pelvis while maintaining the
posterior pelvic tilt. She then slowly lowers the leg and
repeats with
 the opposite side. The knee may remain flexed or can be
 straightened throughout the exercise. Monitor this exercise
 and discontinue if there is stress on the sacroiliac joints or
 ligaments. If the woman cannot stabilize the pelvis while
 lifting the leg, have her just slide one leg posteriorly along
 the floor and return

138. Modified Bicycle
 The woman is supine with one lower extremity flexed
and the other partially extended. The lower
abdominals stabilize the pelvis as the lower extremities
flex and extend in an alternating pattern as if cycling.
The further the lower extremities extend, the greater
the resistance. In order to not strain the back, the
woman must keep it flat against the floor by
controlling the arc of the cycling pattern.

139. Standing Push-Ups
 Standing, facing a wall, feet pointing straight forward,
shoulder-width apart, and approximately an arm-
length away from the wall. The palms are placed on the
wall at shoulder height. Have the woman slowly bend
the elbows, bringing her upper body close to the wall,
maintaining a stable pelvic tilt, and keeping the heels
on the floor. Her elbows should be shoulder height.
She then slowly pushes with her arms, bringing the
body back to the original position.