OBSTETRIC

NURSING

Dante Roel Fernandez, RT, MD

NORMAL MENSTRUAL FLOW

• Mean interval – 28 days(+/- 7 days)

• Duration – 4 to 7 days

• Mean amount of menstrual blood

loss – 35 mL
 Days
Name of phase

menstrual phase 1–4

follicular phase (coincides with proliferative phase) 5–13

ovulation (not a phase, but an event dividing phases) 14

luteal phase (coincides with secretory phase) 15–26

ischemic phase (some sources group this with secretory phase) 27–28
MENSTRUAL CYCLE
 Endometrial changes
Proliferative (Follicular) phase
 depends on ESTROGEN produced by
GRANULOSA CELLS of the ovarian
follicles under the stimulation of FSH
Secretory (Luteal) phase
 depends on PROGESTERONE produced
by the LUTEAL CELLS of the CORPUS
LUTEUM
 Endometrial changes
Menstrual phase
 depends on withdrawal of PROGESTERONE
assuming pregnancy does not occur
 the entire endometrial zona functionalis layer
sheds
 Understanding…

• Menstrual Cycle
• ..\..\..\OTHERS\Menstrual Cycle.s
 NORMAL
Regular frequency
Normal amount and duration

MENORRHAGIA
Regular frequency
Increased in amount and duration
Cycle 21-35 days

HYPOMENORRHEA
Regular frequency
Decreased in amount and duration
Cycle 21-35 days

POLYMENORRHEA
Regular frequency
Normal amount and duration
Cycle<21 days

OLIGOMENORRHEA
Regular frequency
Normal amount and duration
Cycle>35 days

METRORRHAGIA
Menstrual bleeeding between
normal cycles

MENOMETRORRHAGIA
Irregular frequency
Increased in amount and duration
At what age does menstruation
typically begin?
• Average age of 12
• However, girls can begin menstruating as
early as 8 years of age or as late as 16 years
of age
• Women stop menstruating at menopause,
which occurs at about the age of 50
What are some of the symptoms
of a normal menstruation?
Moodiness
Trouble sleeping
Food cravings
Development of cramps
Bloating
Tenderness in the breasts
What symptoms may indicate a
need to contact my doctor about my
period?
You have not started menstruating by the age of
16
Your period stops suddenly
You are bleeding for more days than usual
You are bleeding more heavily than usual
What symptoms may indicate a
need to contact my doctor about my
period?
You have bleeding between periods that is
more than just a few drops
You suddenly feel sick after using tampons
You think you might be pregnant—for
example, you have had sex and your period is
at least five days late
 FERTILIZATION
• Per ejaculation the average of 2.5 ml of
seminal fluid contains 50-200 million
spermatozoa per ml or 400 million per
ejaculation
• Occurs in the outer third of fallopian
tube
• Upon fertilization, the resulting structure
is called the ZYGOTE!
 IMPLANTATION
• It takes 3-4 days for the ZYGOTE to journey to
the uterus(where implantation takes place) and
during such journey mitotic division occurs.
• Zygote free floats for the next 3-4 days, the
morula grows to become a BLASTOCYTES
with TROPOBLAST.
• Implantation occurs at high and posterior
portion of the uterus.
• Structure is called EMBRYO until 5-8 weeks
when it begin to be referred to as FETUS.
 Fetus

• From the eight week to birth,

the growth and development of
systems essential to life.
 Neonate

• An infant that is between birth

and 28 days of age.
 Antenatal or Antepartum

• The period from conception to

the onset of labor
 Intrapartum

• The period of time from the

onset of labor until the birth of
the baby and delivery of the
placenta
 Postpartum

• The period from birth to 42 days

(6weeks) after birth
WHAT IS GOODELS SIGN?
• IT IS THE SOFTENING OF THE
CERVIX
• OBSERVABLE BY 6-8 WEEKS
GESTATION.
WHAT IS HEGARS SIGN?
• SOFTENING OF THE LOWER
UTERINE SEGMENT, BEGINS AS
EARLY AS 5 WEEKS
GESTATION
WHAT IS CHADWICKS
SIGN?

• VAGINAL MUCOSAL CHANGE

IN COLOR FROM PINKISH TO
PURPLISH OR DARK-BLUISH.
EASY WAY TO REMEMBER
THE SIGNS:
• CHADWICKS
 VAGINA
• GOODELS
 CERVIX
• HEGARS
 UTERUS
 Estimated Date of Delivery

• The date is determined by using

Naegel’s rule
 Naegel’s rule

• Method for calculating the estimated date of

confinement (EDC/EDD)

• EDC/EDD = - 3 months + 7 days + 1 year

 OB Scoring

• Flight  Full term

• Philippine  Preterm
• Air  Abortion
• Lines  Living children
 BARTOLOME’S RULE
• FUNDIC HEIGHT IS MEASURED
BY PALPATION AND BY
RELATING TO THE DIFFERENT
LANDMARKS IN THE
ABDOMEN, UMBILICUS,
SYMPHYSIS PUBIS AND XIPHOID
PROCESS.
 LOCATION OF THE
FUNDUS
• 12 WEEKS- at the level of symphysis pubis
• 16 WEEKS- halfway between symphysis pubis
and umbilicus
• 20 WEEKS- at the level of the umbilicus
• 24 WEEKS- two fingers above umbilicus
• 30 WEEKS- midway between umbilicus and
xiphoid process
• 36 WEEKS – at the level of xiphoid process
• 40 WEEKS- two fingers below xiphoid process
 Gestation
• This is the condition of being pregnant
and usually refers to the number of
weeks of pregnancy based on the first
day of the last normal menstrual period
or on ultrasound dating of the
pregnancy.
 Gravida

• The number of times the mother

has been pregnant regardless of
outcome
 Primigravida

• A woman who is pregnant for the

first time
 Multigravida

• A woman who is pregnant for

at least the second time of has
been pregnant two or more
times.
 Parity

• Number of pregnancies that

reach viability
 Multipara

• A woman who experienced two or

more pregnancies which where
more than 20 weeks age of
gestation.
 Nulligravida

• A woman who has zero

pregnancies (never been
pregnant).
 Nullipara

• A woman who has experienced

pregnancies but never reached
viability
 Quickening

• Maternal perception of the first

fetal movements.

• Usually occurs about 20 week in

primigravida
 BRAXTON HICKS
CONTRACTION
• PAINLESS PALPABLE
CONTRACTIONS OCCURING AT
IRREGULAR INTERVAL AND FELT
BY THE MOTHER AS SENSATION OF
TIGHTNESS OVER HER ABDOMEN.
• BEGIN AS EARLY AS 8TH WEEKS AND
TEND TO BECOME STRONGER AS
PREGNANCY ADVANCES.
 Chloasma

• The mask of pregnancy caused

by a change in skin pigmentation
 Linea Nigra

• The pigmentation of the line

dividing the abdomen into left
and right halves
 Internal Examination
• Presentation
• Effacement
• Cervical dilatation
• Station
 Effacement

• Thinning and shortening of the

cervix that occurs just before
birth
 Station

• The relationship of the

presenting part to an imaginary
line between the ischial spines
of the pelvis
THE HEAD OF THE FETUS IS THE
MOST IMPT PART OF ITS BODY
BECAUSE:
• It is the largest part of the fetal body so it is the
part that would likely encounter difficulty
during delivery
• It is often the presenting part so its
measurement, structure , position and
presentation are impt factor to consider when
determining labor outcome
• Least compressible of all fetal parts
 LONGITUDINAL LIE
• The long axis of the fetus is parallel
to the long axis of the mother,
meaning THE FETUS IS LYING
LENGTHWISE IN THE
MOTHER’S ABDOMEN.
 TRANSVERSE AXIS
• The long axis of the fetus is at right
angle to the long axis of the mother,
meaning, THE FETUS IS LYING
CROSSWISE IN THE MOTHERS
ABDOMEN.
 OBLIQUE LIE
• The fetus assuming this lie usually
rotates to transverse or longitudinal
lie in the course of labor.
DIAGNOSIS OF PREGNANCY
 PRESUMPTIVE SIGNS

 PROBABLE SIGNS

 POSITIVE SIGNS

 DANGER SIGNS
 PRESUMPTIVE SIGNS &
SYMPTOMS OF PREGNANCY:
• M – MORNING SICKNESS
• A- AMENORRHEA
• C-CHANGE IN BREAST
• F- FATIQUE
• L-LASSITUDE (fatigue)
• U-URINARY FREQUENCY
• Q-QUICKENING
• S-SKIN CHANGES
PROBABLE SIGNS:
• C – CHADWICKS
• H – HEGAR
• U- UTERINE ENLARGEMENT
• P- POSITIVE PREGNANCY TEST
• B – BALLOTEMENT
• O-OUTLINING OF FETAL BODY
• G- GOODELLS
• S- SOUFFLE CONTRACTION
AND BRAXTON HICKS
 DANGER SIGNS
(1) Pelvic complaints
• Vaginal bleeding
– Which could signify spontaneous
abortion, placenta previa, or abruptio
placenta
• Vaginal leakage of fluid
– Which could signify rupture of
membranes
 DANGER SIGNS
(2) Abdominal complaints
• Epigastric pain
– Occurs in women who have severe
preeclampsia
• Uterine cramping
– Occur in women undergoing preterm
labor
 DANGER SIGNS
(2) Abdominal complaints
• Decreased fetal movements
– Occurs when the fetus is in
jeopardy
• Persistent vomiting
– In cases of hyperemesis
gravidarum
 DANGER SIGNS
(3) Swelling

• Seen on the fingers or face

• Occurs in women who have severe
preeclampsia
 DANGER SIGNS
(4) Cerebral disturbances

• Dizziness
• Mental confusion
• Visual disturbances
 DANGER SIGNS
(4) Cerebral disturbances

• Persistent headache
• Occurs in women who have severe
preeclampsia
 DANGER SIGNS
(5) Urinary complaints

• Painful urination
• Decreased urine output
• May signify cystitis or pyelonephritis
 DANGER SIGNS

(6) Chills or fever

• Occur in women who have

pyelonephritis or chorioamnionitis
 Interventions
• PRENATAL CARE

• A. Time Frame
1. First Visit:
– may be made as soon as woman suspects she
is pregnant; frequently after first missed
period.
 Interventions
2. Subsequent Visits:
– Every month until the 8th month, every 2 weeks during
the 8th month, and weekly during the 9th month; more
frequent visits are scheduled if problems arise.

– < 32 weeks AOG - every month

– 32 – 36 weeks AOG - every 2 weeks
– >36 weeks AOG - every week
 Physiologic Changes in
Pregnancy
A. Alimentary tract
2. Appetite
 Pica  dietary cravings or aversion for non-
nutritional substances
1. Mouth
 Ptyalism  usually associated with nausea of
pregnancy
 A. Alimentary Tract
3. Stomach
 tone and motility  smooth muscle –
relaxing effect of progesterone
 GE junction sphincter  leads to acid
reflux causing heartburn
 PUD  increased gastric mucous
secretion
 Alimentary Tract
5. Colon
 motility  constipation
 hemorrhoidal veins dilate  hemorrhoids

6. Gallbladder
 emptying time
 biliary cholesterol saturation  inc risk
of gallstone formation
 Alimentary Tract
7. Nausea and vomiting
 onset: 4 – 8 weeks AOG lasting 14 – 16
weeks
 caused by stomach tone and hCG
 supportive treatment
 frequent small meals
 Respiratory system
 TV, but all lung volumes decrease
 Vital Capacity, but other lung
capacities remain unchanged
 “dyspnea of pregnancy”  Oxygen
consumption
 Skin
1. Vascular changes  Estrogen levels
 Spider angioma  face, thorax, and arms
 Palmar erythema  skin blood flow to the
hands
1. Striae gravidarum  normal stretching of the
skin (pink purple  silvery white)
2. Pigmentation changes  MSH stimulated
by Estrogen and Progesterone
 Urinary system
1. Kidney
 size of renal pelvis  physiologic
hydronephrosis
1. Ureter
 Dilates  hydroureter and urinary stasis
1. Consequence
 risk pyelonephritis
 Urinary system
GFR by 50%
creatinine clearance
creatinine and urea by 25%
Glucosuria  common in normal
pregnancy  risk of UTI
Proteinuria NOT normal in pregnancy
 Cardiovascular system
By 20 weeks AOG CO by 35%
CO is dependent on maternal position
Optimal CO  left lateral position (the
IVC is not compressed by the uterus)
 Hematologic changes
Plasma volume 50% by term
RBC mass 30% by term
Physiologic anemia  hemoglobin
value that results from a smaller in
RBC than in plasma volume
 Hematologic changes
 Pregnancy is a hypercoagulable state
 clotting factors
 Venous stasis thromboembolism
 Vessel wall injury
Endocrine and Metabolic
changes
size of the thyroid gland
Thyroid-binding globulin (TBG) 
from estrogen stimulation, T3 and T4
Note: Active unbound hormone forms
remain unchanged (free T3 andT4)
 Musculo – skeletal changes
 Relaxin  increased ligamental
laxity, contributing to back pain
 Shift in posture with exaggerated
lumbar lordosis
• CAUSES OF BLEEDING
DURING PREGNANCY
 ABORTION
• The expulsion or removal of an embryo or
fetus from the uterus at a stage of pregnancy
when it is incapable of independent survival.

• Less than 20 weeks age of gestation

• Embryo weighs less than 500 grams

 TYPES

Missed Abortion
Threatened Abortion
Inevitable Abortion
Incomplete Abortion
Complete Abortion
Septic Abortion
MISSED ABORTION

• Diagnosed if there is
sonographic evidence of a
nonviable pregnancy without
bleeding or cramping
MISSED ABORTION
• Abnormal sonographic findings

– Gestation sac that is collapsing or

irregularly shaped
– Yolk sac that is not seen
– Embryo that is absent or amorphous
– Cardiac activity that is absent
MISSED ABORTION

• Management

– Scheduled suction
dilatation and
curettage (D&C)
THREATENED ABORTION

• Minimal bleeding is the

key element
THREATENED ABORTION

• Diagnostic criteria

– Minimal bleeding with or

without mild cramping
– Closed internal cervical os
– Normal sonographic findings
THREATENED ABORTION
• Management

– Expectant observation
– Bed rest
– SAVE ALL PADS
– NO COITUS UPTO 2 WEEKS AFTER
BLEEDING STOPPED
– Tocolytic agents
Tocolytic Agents

B – Adrenergic Agonist
Magnesium Sulfate
Prostaglandin Synthesis
Inhibitors
Calcium Channel
Blockers
INEVITALBE ABORTION

• Indicates that pregnancy is

doomed to end shortly

• Progressive cervical dilatation

without the passage of tissue
INEVITALBE ABORTION

• diagnostic criteria

heavy, profuse bleeding

severe cramping
dilated internal cervical os
( - ) BOW
assessment of blood loss
assessment of internal cervical os
INEVITALBE ABORTION

• Management

– HOSPITALIZATION
– D AND C
– OXYTOCIN AFTER D AND C
– EMOTIONAL SUPPORT
INCOMPLETE ABORTION

• Internal cervical os is open

• The patient has passed

some tissue
INCOMPLETE ABORTION

• diagnostic criteria

ability to pass ring

forceps through the
internal cervical os
passing of the tissue
INCOMPLETE ABORTION
• Management
Monitor vital signs for
tachycardia and hypotension
Monitor I and O. Oliguria is a
sign of decreased renal
perfusion which occurs with
shock
Emergency suction D&C
COMPLETED ABORTION

• Diagnosed if the patient has

passed tissue

• But now bleeding and

cramping is only minimal
COMPLETED ABORTION
• diagnostic criteria

historical finding of bleeding,

cramping, and passage of tissue
dilated internal cervical os
minimal current bleeding
sonographic findings of empty
uterus
COMPLETED ABORTION

• Management

supportive
SEPTIC ABORTION

Abortion with concomitant sepsis

Usually happens in induced abortion

(+) fever
 EXERCISE

• Complete the following table.

 TYPES VariabiliBleeding Cervix BOW Tissue Febrile?
ty passed?

MISSED

THREATENED

IMMINENT

INEVITABLE

INCOMPLETE

COMPLETE

SEPTIC
 TYPES VariabilitBleeding Cervix BOW Tissue Febrile?
y passed?

MISSED NO NO CLOSED ( -) NO NO

THREATENED YES YES CLOSED (+) NO NO

IMMINENT VARIAB YES OPEN (+) VARIAB NO

LE LE
INEVITABLE VARIAB YES OPEN ( -) VARIAB NO
LE LE
INCOMPLETE N/A YES OPEN ( -) YES NO

COMPLETE N/A YES OPEN ( -) YES NO

SEPTIC N/A VARIAB OPEN ( -) YES YES

LE
INDUCED ABORTION

The deliberate termination of a

pregnancy in a manner that
ensures the death of the embryo
or fetus
Ethical issues
General Risks of Abortion
• Uterine perforation
 intrauterine instrumentations
• Cervical trauma
 excessively rapid cervical dilatation
 resulting in incompetent cervix
LAMINARIA  hydrophilic rods which absorb cervical
fluid and to enlarge to many times their original volume,
thus dilating the cervix
General Risks of Abortion
• Bleeding and hemorrhage
 occur from the placental site before
uterine contractions can close the vessel
• Infection
 from normal genital flora
Medical methods of
induced abortion
• MIFEPRISTONE (RU486)
 a progesterone antagonist
 an oral preparation used with a
prostaglandin agent to induced
contractions
 when administered before 10 weeks
AOG, 95% of pregnancies are interrupted
Medical methods of
induced abortion
• METHOTREXATE
 a folic acid antimetabolite
 has similar action to mifepristone
 Ectopic Pregnancy
• Occurs when the site of implantation is outside of
the womb.
• It can occur in several places
Ovary
Abdomen
Cornua
Cervix
Fimbria
Fallopian tube
Sites of Ectopic Pregnancy
 Risk Factors
• Pelvic Inflammatory Disease
– the most common risk factor for ectopic pregnancy
– 8x increased risk
– infection causes scar tissue adhesions in the tube and
may damage the cilia.
• Previous ectopic pregnancy
– the chances of another one in the same Fallopian
tube and in the other tube are increased.
– 5x increased risk
 Risk Factors
• Tubal ligation in the past 2 years
• Previous tubal surgery
• Intrauterine device in place
• Prolonged infertility
• Diethystilbestrol (DES) exposure
in utero
Clinical Findings

Clinical Triad (3As)

• Amenorrhea
• Abdominal pain
• Abnormal vaginal
bleeding
• Signs and symptoms

• Before Rupture
 abdominal pain & tenderness
 amenorrhea
 abnormal vaginal bleeding.
 palpable pelvic mass
• Rupture
 exacerbation of pain
• After Rupture
 faintness / dizziness
 referred shoulder pain
 signs of shock
 Diagnosis
Pelvic exam
Blood tests
Ultrasound
Culdocentesis
Laparoscopy
Medical Management

METHOTREXATE
 A folic acid antagonist that is
metabolized in the liver and
excreted in the kidney

 This makes the ectopic

pregnancy shrink away by
stopping the cells dividing
Surgical Management

Salpingectomy
Salpingotomy
Salpingostomy
INCOMPETENT CERVIX

 presence of uterine
contractions of sufficient
frequency and intensity to
effect progressive
effacement and dilation of
the cervix prior to term
gestation
ETIOLOGY
 Hx of tears or lacerations in
cervix during childbirth
 Forceful D&C
 Exposure of mother to
diethylstilbestrol (DES)
 Short cervix
 Uterine abnormalities
 Hx of early cervical dilation in
previous pregnancies
 Cervical surgery
Signs and symptoms

 Pressure in the lower abdomen

or vaginal pressure
 Unusual urinary frequency
 Vaginal discharge (with or
without blood)
 Sensation of a lump in the
vagina
Diagnosis
The most accurate diagnosis
is a retrospective one
History of painless mid-
trimester cervical dilatation
resulting in expulsion of a
non-viable fetus
Medical Treatment

Cerclage
 Shirodkar method
 McDonald procedure
McDonald cerclage
The Shirodkar
Gestational Trophoblastic
Neoplasia (GTN)
• Hydatidiform moles (H – mole)
Benign
Consists of a nonviable embryo which implants
and proliferates within the uterus
Presence of multiple grape – like vesicles filling
the uterus
• Gestational trophoblastic tumor (GTT)
Malignant
 Complete hydatidiform mole

The grape-like villi of a

hydatidiform mole are seen here.
With molar pregnancy, the uterus
becomes large for dates as the
pregnancy progresses, but no fetus
is present
Etiology

 chromosomal problems
 poor nutrition
 problem w/ the ovaries
or the uterus
 placental fragments
following miscarriage or
childbirth
Risk Factors

 Maternal age extremes

(<20, >40 years old)
 Diet (low in beta
carotene, folate
deficiency)
 Large uterus
Signs and symptoms
 Bleeding during the first half
of pregnancy (usually prior to 16
weeks AOG)
 Severe hyperemesis
 Abnormal growth in the size
of the uterus for the stage of the
pregnancy
 Passage of vesicles, ( - ) FHT
 Symptoms of hyperthyroidism
Diagnosis

  HCG levels
 Histologic examination
 Ultrasonography
 (+) grapelike clusters
 snowstorm pattern
 Doppler ultrasonography
 (−) fetal heart tones
Surgical Treatment

Dilation and curettage

(D & C) with suction
evacuation

Hysterectomy
- ovaries usually are not
removed
Medical Treatment

 Chemotherapeutic
agents
 Weekly B-hCG titers
until they are negative for
3 weeks
 Monthly titers until
they are negative for 12
months
 Abruptio Placenta

• Premature partial or complete

separation of normally implanted
placenta.
• The placenta appear to have been
implanted correctly, suddenly,
however, it begins to separate and
bleeding results.
Abruptio Placenta (TYPES)

Partial Abruptio Placenta

Marginal Abruptio Placenta
Complete Abruptio Placenta
TYPES

Partial Marginal Complete

Risk factors
• High parity
• Chronic hypertensive disease
• Hypertension of pregnancy
• Direct traumas
• Vasoconstriction from cocaine use
• Cigarette smoking
Clinical manifestations

• Sharp, stabbing pain high in the

uterine fundus
• Heavy bleeding
• Signs of shock
• The uterus becomes tense and rigid to
touch
Diagnosis

• Best made clinically

• Ultrasound often fails to detect
retroplacental bleeding, causing false
negative diagnoses.
Hemorrhage occurs into the
decidua basalis, separating part
of the placenta from the uterus.
Blood from forming hematoma may
remain retroplacental
(concealed) or may progress to the
edge of the placenta.
Therapeutic Management

• Fluid replacement and oxygen

by mask to limit fetal anoxia.

• Monitor fetal heart sounds

externally and record maternal
vital signs every 5-15 minutes.
Therapeutic Management
• Keep the woman in a lateral, not
supine position

• Do not give an enema to the

woman with a diagnosed or
suspected placental separation.
Intervention

• Blood and fluids replacement

• Cesarean birth
 NEXT…

• Placenta Previa…
 Placenta Previa

• Abnormal
implantation of
placenta in lower
uterine segment
Risk factors

• Increased parity
• Advanced maternal age
• Past caesarian births
• Past uterine curettage
• Multiple gestations
Degrees of Placenta Previa
• Partial
– Placenta partially covers the
internal cervical os.
• Complete
– Placenta totally covers the cervical
os (caesarian birth necessary)
• Low-lying or marginal
– Placenta encroaches on margin of
internal cervical os.
Degrees of Placenta Previa

Normal Low - lying Partial Total

Clinical Manifestations

• Painless, bright red, vaginal bleeding

in the third trimester (often begins
during the seventh month)
• Soft uterus
• Manifestations of hemorrhage, shock
DIAGNOSIS

• Ultrasound
The passive lower uterine segment
stretches and thins, which alters
the lower uterine segment
implantation site of the placenta.

The venous sinuses are exposed as

the placental anchoring villi are
avulsed from the decidua
Timing of the first bleed is
determined by:
◦ how early in pregnancy the lower
uterine begins to form
◦ how low the placenta is implanted
The extent of the first bleed
is variable, and each
successive bleed tends to
be heavier
 Therapeutic Management
• Place woman immediately on bed rest in
a side-lying position.
• Inspect the woman’s perineum for
bleeding.
• Never attempt a pelvic exam with
painless bleeding late in pregnancy
• Obtain baseline vital signs to determine
whether symptoms of shock are present.
 Therapeutic Management
• Vaginal examinations (actual
investigation of dilation) to
determine whether placenta previa
exists are done in an operating room

• Have oxygen equipment available in

case the fetal heart sounds indicate
fetal distress
 Intervention

• Blood and Fluid replacement

• Caesarian birth if placental
placement prevents vaginal
birth of fetus.
Abruptio Placenta VS Placenta Previa
CLINICAL
CHARACTERISTICS
Clinical Finding Suggestive of Suggestive of
Bleeding Placenta Previa Abruptio
Characteristics Placentae
 Onset May be gradual, Often abrupt,
progressive unexpected

 How evident Always external May be either

external or
concealed.
 Color Bright red Dark
CLINICAL
CHARACTERISTICS
Clinical Finding Suggestive of Suggestive of
Placenta Previa Abruptio
Fetal Status Placentae
 FHT Usually present May be absent (if
fetal demise)
 Engagement Absent May be present
(placenta obstruct)
 Presentation Often Unaffected by
malpresentation bleeding
CLINICAL
CHARACTERISTICS
Clinical Findind Suggestive of Suggestive of
Uterine Placenta Previa Abruptio
Characteristics Placentae
 Pain Painless unless Intense and
labor steady
 Tenderness Absent Present

 Tone and Soft and relax, Firm to stony hard,

Shape Normal May enlarge and
change shape
• OBSTETRIC COMPLICATIONS
and
• MEDICAL COMPLICATION
RH INCOMPATIBILITY OR
ISOIMMUNIZATION

A condition which develops

when a pregnant woman has
an Rh-negative blood type
and the fetus she carries has
Rh-positive blood type.
Requirements for maternal
RBC Isoimmunization
FETUS  antigen – positive RBC
MOTHER  antigen – negative RBC
Sufficient fetal RBC must have gain access
to the maternal circulation
 Mother must have the immunogenic
capacity to produce antibodies against fetal
RBC antigen
MANAGEMENT:

Explain about Rh incompatibility

Give Rh D immune globulin (RHIG)
at 28 weeks during pregnancy and
72 hours after the delivery
Offer support to the client.
A complication of pregnancy
because a woman’s body must
adjust to the effects of more
than one fetus
The higher the woman’s parity
and age the more likely she is to
have a multiple gestation
The use of IN VITRO
FERTILIZATION
The use of fertility drugs
clomiphine citrate
gonadotropin
 Increase in the size of the uterus at a rate
faster than the normal
Elevated alpha-fetoprotein
In quickening – flurries of action at different
portion of the woman’s abdomen rather than at
one consistent spot
Multiple sets of fetal heart sounds may be
heard upon auscultating the abdomen
In sonogram, multiple gestation sacs
Maternal
 Pregnancy Induced
Hypertension
 Hydramnios
 Placenta previa
 Anemia
 Post-partum bleeding
Fetal
 Low birth babies
 Birth defects
 Congenital anomalies in
twins
NSD / VSD
CS
 Pregnancy Induce Hypertension
(PIH)
• also called “Toxemia”
• Refers to a potentially severe and even
fatal elevation of blood pressure that
occurs during pregnancy.
• The cause is unknown (idiopathic)
• A condition in which vasospasm occurs
during pregnancy.
SPECTRUM
✦ Mild Preeclampsia
BP >= 140/90 mmHg
Proteinuria of 1 – 2 + on dipstick or >=
300 mg in 24 hour urine collection
✦ Severe Preeclampsia
BP >= 160/110 mmHg
Proteinuria of >= 3 – 4 + on dipstick or
>= 5g in 24 hour urine collection
✦ Eclampsia
PIH
✦ occurs only in pregnant
women beyond 20 weeks’
gestation
✦ About 5% of pregnant women
develop preeclampsia (toxemia of
pregnancy
Risk Factors
✦ Nulliparity
(most common risk factor)
✦ Age extremes
(<20, >40 years old)
✦ Multiple gestation
✦ Diabetes Mellitus
✦ Chronic hypertension
Assessment Findings
 Rapid weight gain
 Over 2 lbs/wk in the 2nd trimester
 1 lb/wk in 3rd trimester
 Due to abnormal tissue fluid retention
Assessment Findings
 Swelling of face or fingers
 Hands – ask the women if she notice
that her rings are tight
 Face – difficulty opening eyes in the
morning due to edema of the eyelids
Assessment Findings
 Dimness or blurring of vision
and severe, continuous headache
 This signal cerebral edema or
acute hypertension
Assessment Findings

Severe epigastric pain, nausea and

vomiting due to abdominal edema or
ischemia to the pancreas and liver.
Feeling shortness of breath due to
pulmonary edema.
Eclampsia
• Tonic – clonic seizure
• Not good candidate for surgery,
the preferred method for birth
then is vaginal
HELLP syndrome
 Hemolysis
 Elevated levels of liver enzymes 
liver damage
 Low platelet count  making blood
less able to clot and increasing the risk
of bleeding during and after labor.
Nursing Diagnosis:
• Ineffective tissue perfusion related to
vasoconstriction of blood vessels
• Deficient fluid volume related to fluid loss to
subcutaneous tissues.
• Risk for fetal injury related to reduced placental
perfusion secondary to vasospasm.
• Social isolation related to prescribed bed rest.
Nursing Interventions
Monitor Fetal Well-Being
Support a Nutritious Diet
 moderate to high in protein and
moderate in sodium to compensate for
the protein she is losing in the urine.
Pharmacologic Treatment

✦ HYDRALAZINE
✦ direct arteriolar vasodilator
✦ lowers the blood pressure
✦LABETOLOL
✦ non selective B blocker
✦ lowers the blood pressure
Magnesium Sulfate
✦ Prevention of convulsion
✦ Loading dose of 5g IV over 20
minutes
✦ Maintenance infusion at 2g/hr
✦ WOF clinical evidence of
magnesium toxicity
✦ Absence of toxicity is ensured as
long as DTR are obtainable
 Magnesium Sulfate
DOSE EFFECT

5 – 8 mg/dL Therapeutic level

10 mg/dL Loss of DTR

15 mg/dL Respiratory

paralysis
25 mg/dL Cardiac arrest
✦What is the antidote for
Magnesium toxicity?
What is the antidote for
Magnesium toxicity?

✦CALCIUM GLUCONATE
✦ 1g IV push
GRAVIDO CARDIACS

 The danger of pregnancy is a

woman with cardiac disease
occurs primarily due to the
increase in circulatory volume.
 Weeks 28-32, most dangerous
time for woman, just after the
blood volume peaks.
Structural
Classification
 Acquired Heart Disease
 MS, MI
 Congenital Heart Disease
 ASD, TOF
 Peripartum
Cardiomyopathy
Assessment Findings:

Severe or progressive
dyspnea
Paroxysmal nocturnal dyspnea
Progressive orthopnea
Syncope with exertion
Chest pain related to effort or
emotion
PRINCIPLES of Prenatal
Mgt
Fluid retention should
be avoided
Strenuous activity
should be avoided
Anemia should be
avoided
PRINCIPLES of Intrapartum
Mgt
Reassurance and sedation
Use of epidural analgesia
Left Lateral position
Forceps delivery
PRINCIPLES of Postpartum
Mgt
Close observation for
volume overload
A condition of abnormal
glucose metabolism that arises
during pregnancy

 There is progressive
resistance to the efforts of
insulin
Diabetogenic effect of human
placental lactogen (hPL)

 Placental insulinase, elevated

free cortisol, and
progesterone  glucose
intolerance
Risk Factors:
 Obesity
 Age over 25 years old
 History of large babies (10 lbs. or
more)
 History of unexplained fetal or
perinatal loss
 History of congenital anomalies in
previous pregnancies
 Family history of diabetes
1 hour OGTT
3 hour OGTT
Non valid screening include:
urine glucose values
glycosylated hemoglobin
3 hour OGTT
 Two or more values equal or
greater than the following are
necessary for positive diagnosis:
Fasting: 95 mg/dL
1 – hour: 180mg/dL
2 – hour: 155 mg/dL
3 – hour: 140 mg/dL
 PNCU
 Dietary management
 Management of maternal
glycemic control  central goal
 SQ long acting human insulin
 OHA  contraindicated
 No need to induce labor
before 40 weeks AOG
 Macrosomic risk
 Risk of shoulder dystocia
 Blood glucose level should
be monitored
 Hypoglycemia  result of
hyperinsulinemia from in utero
hyperglycemia
 Hypocalcemia  immature
parathyroid hormone function
 Hyperbilirubinemia  liver
enzyme immaturity and inc
breakdown of RBC
 Respiratory distress 
delayed pulmonary surfactant
production
Polycythemia  increased
erythropoietin due to relative
intrauterine hypoxia
 Postpartum hemorrhage
resulting from uterine atony
 Evaluate for overt diabetes
Prenatal Care and Assessment
 LEOPOLDS MANEUVER
• Systematic method of observation and
palpation to determine fetal position
• Empty the bladder, lie in supine position
with her knees flexed so abdominal muscles
are relaxed
• Warm hands to avoid contraction of the
abdominal muscles
• Gentle but firm touch
 LEOPOLDS MANEUVER

• FIRST MANEUVER: FUNDAL GRIP

• SECOND MANEUVER: UMBILICAL
GRIP
• THIRD MANEUVER: PAWLIKS GRIP
• FOURTH MANEUVER: PELVIC GRIP
 Leopold’s Maneuver
 1st  What fetal part is in the
fundus? LPr
 2nd  On which side are the fetal
back or small parts located? Po
 3rd  To what degree has the
presenting part descended into the
pelvis? S
 4th  On which side is the cephalic
prominence located? A
Leopold’s Maneuver
Utero-placental Orientation
Fetal Lie
Fetal Presentation
Fetal Position
Fetal Station
Fetal Attitude
 FETAL LIE

– Relationship of the fetus to

the long axis of mother
 FETAL LIE
• Normal Lie:
Longitudinal

– Fetus long axis in

line with mother
long axis
 FETAL LIE

• Abnormal lie
– Transverse Lie
– Oblique Lie
(unstable lie)
 FETAL PRESENTATION
• Presentation: Breech (Head is not
presenting part)

– Occurs in 25% of pregnancies at 30

weeks
– Abnormal after 32 weeks
– Types of Breech Presentation
 FETAL PRESENTATION

• FRANK BREECH PRESENTATION

– Thighs are flexed on the abdomen
– So that the legs are extended over the
anterior surface of the body
 FETAL PRESENTATION
• COMPLETE BREECH
– Thighs are flexed on the
abdomen
– And the legs are flexed upon the
thigh
 FETAL PRESENTATION
• INCOMPLETE BREECH
– One or both thighs are
extended
– So that the feet and legs
are below the level of the
buttocks
FETAL PRESENTATION
 FETAL PRESENTATION
• Presentation: Cephalic
(Head is presenting part)
 FETAL POSITION
Relationship between a reference
point on the presenting fetal part and
maternal bony pelvis
Position of the Fetal denominator to
mother's pelvis
Fetal Denominator: Occiput of Vertex
FETAL POSITION
FETAL POSITION
 STATION (Fetal Descent)
• Definition: Fetal Station

The degree of descent of the

presenting part through the birth
canal, expressed in cm.

The presenting part is above or

below the maternal ischial spine.
 STATION (Fetal Descent)
• Zero Station Notation (presenting part level)

Presenting part in relation to ischial spines

Reported in centimeters from ischial spines
Negative numbers are behind the ischial spines
 STATION (Fetal Descent)

• Engagement

Refers to
presenting part
meeting pelvic floor
Occurs at 0 station
 FETAL ATTITUDE
• Degree of flexion or
extension of fetal head
• Most common
subcategory: Vertex
– Complete flexion
– Chin against the chest
– Suboccipito-bregmatic
FETAL ATTITUDE
Normal Attitude:
Fetus is in full flexion
Every fetal joint is
flexed
Smallest fetal head
diameter:
Suboccipito-
bregmatic
Diameter is 9.5 cm.
 FETAL ATTITUDE

• Sinciput Presentation
– Occipito-frontal
– Diameter is 12. 5 cm
 FETAL ATTITUDE
Abnormal presentations: Extended
Attitude
General
• Abnormal Attitude: Fetal head is
extended
• Results in largest head diameter:
Occipito-mental (Brow)
• Diameter is 13.5 cm.
• May results in Failure to progress
 FETAL ATTITUDE

• Face Presentation

– Submento-bregmatic
– Diameter is 9.5 cm
– Fetal head is hyper extended
 CONTRACTION
• Frequency
• Duration
• Interval
Labor and Delivery
TRUE versus FALSE LABOR
TRUE FALSE
CONTRACTION • Regular • Irregular
• Increasing • No change in
frequency, duration, frequency,
and intensity duration, and
• Shortening of intensity
interval

DISCOMFORT • Pain begins in • Pain focused

back and radiates to in the abdomen
abdomen
TRUE versus FALSE LABOR
TRUE FALSE

REST / • Contraction does • Contraction

ACTIVITY not decrease with rest may lessen with
or activity activity or rest

CERVIX • Progressive • Cervix changes

effacement and do not occur yet
dilation of cervix
Cardinal Movements of Labor
 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion
 Stages of Labor

First Stage of Labor

Second Stage of Labor
Third Stage of Labor
Fourth Stage of Labor
 First stage of labor
• Begins with onset of uterine
contraction until full cervical dilatation
• Contains the latent and active phase
• Duration of cervical dilatation varies
(≥1.5 cm/hr in multiparas and
≥ 1.2 cm/hr in primiparas)
Phases of the First Stage of Labor:

1. Latent
2. Active
3. Transitional
 Latent phase
 Early part in labor characterized by:
 Cervical dilatation of about 2-3 cm.
 Mild, regular uterine contractions
 Intervals of 5-10 minutes apart
 Duration of 30 seconds
 Mother becomes talkative, alert, excited
but in control
 Active phase
Characterized by:
 Cervical dilatation of 4-8 cm.
 Frequency of 3-5 minutes
 Rapid increase in duration of 45-60 seconds
 Intensity becomes moderate
 Mother less talkative, more anxious, restless
and fears losing control
Transition phase
Nursing Care and Management
during the First Stage of Labor
• Admit the patient
• Check the vital signs and FHT
• Physical examinations
• Perineal preparation
• Monitor and assess uterine contraction
• Avoid giving food
Nursing Care and Management
during the First Stage of Labor
• Encourage the parturient to void at least
within 2 hours.
• Woman during labor may ambulate
• Monitor danger signs
• Comfort measures
• Transfer to DR table
 Second stage of labor

• Begins with complete cervical dilatation

and ends with the delivery of the baby

• Duration for multiparas and primiparas

are 30 and 60 minutes respectively
 Mechanisms of Labor
• Refers to the changes of position of the
fetus will undergo as it pass the birth
canal
• D  F  IR  Ext  ER  Exp
Nursing care and Management
during the Second Stage of Labor
• Proper positioning
• Cleanse vulva thoroughly with soap and water or any
surgical antiseptic
• Instruct the parturient to take a deep breath as soon as
the next uterine contraction begins and with her breath
hold, to exert downward pressure as though she were
straining a stool.
Nursing care and Management
during the Second Stage of Labor
• Upon the delivery of the baby, milk the
cord towards the infant, clamp an inch
apart and cut in between.
• Clamping the cord should be done when
pulsations had stopped to allow the
passage of blood from the placenta to the
cord and to the fetus.
Nursing care and Management
during the Second Stage of Labor
• Show the baby to the mother (eye to eye
contact to facilitate bonding).
• Inform the mother about the sex of the baby.
• Hand in the baby to the assisting nurse (in
the OR circulating nurse) so that the ID
bond is immediately put on the baby.
 Third stage of labor

• Begins with delivery of the baby and ends

with the delivery of the placenta
Phases of the Third Stage of Labor
• Placental Separation Phase
 caused primarily by the disproportion of
the placenta from the placental implantation
site

• Placental Expulsion Phase

Signs of placental separation:
 Calkin’s sign.
 discoid  firm and globular in shape
 Sudden gush of blood from the introitus
Apparent lengthening of the umbilical cord as the
placenta get closer to the introitus.
 As the umbilical cord slowly extends out, it can
be winded to the clamp or forceps and this is
called as the Brandt Andrews Method.
Type of Placental Mechanisms:
Schultze mechanism
80% of all deliveries
Begins at the center

Duncan’s mechanism
20% of all deliveries
Begins at the edges / periphery
Nursing Care and Management
during the Third Stage of Labor
• Careful management of placental expulsion
• Watch for the signs of placental separation
• Deliver the placenta with Brandt Andrews
method
• Note the time the placenta is delivered
Nursing Care and Management
during the Third Stage of Labor
• Check for the completeness of the placenta
• Check and evaluate the blood pressure
• Administer oxytocin medicine after the placenta
has been completely expelled to prevent and
control hemorrhage
• Inspect perineum, vagina and cervix for
laceration, extension of the episiotomy or
hematomas.
Types of Laceration:
First degree
 vaginal mucous membranes and the skin of the perineum

Second degree
 levator ani and perineal body

Third degree
 entire perineum and external sphincter of the rectum

Fourth degree
 entire perineum, rectal sphincter and mucous membrane of
the rectum
Episiotomy
Nursing Care and Management
during the Third Stage of Labor
Carefully examine the uterine cavity manually
Assist the physician in episiorrhaphy
Note down vaginal packing if any:
the number of vaginal pack in placed
the time of removal (endorse) at least within 24-
48 hours.
Cleanse the vulva with sterile water.
Nursing Care and Management
during the Third Stage of Labor
• Apply perineal pad (application should be from
front to back).
• Lower legs of the woman simultaneously from the
stirrup to avoid injury to the uterine ligaments.
• Change the woman’s gown.
• Transfer the newly delivered mother to the ward.
 Fourth stage of labor

• Begins with the delivery of the placenta

and ends after 1 – 4 hours.
• Watch out for bleeding
• Keep uterus contracted
Nursing Care and Management
in the Fourth Stage of Labor
• Check the fundus every 15 minutes for its
contractility.
• What is the FIRST nursing action for a soft
and boggy uterus?
• Check lochia every 15 minutes in conjunction
with assessment of the fundus.
• Will you report a heavy flow with a
uterus well contracted?
Nursing Care and Management
in the Fourth Stage of Labor
• Check perineum and episiotomy
• Check BP every 15 minutes for the first
hour until stable
• Immediate medical intervention will be
necessary if any of the following occur:
Marked bleeding persists
Complaints of lightheaded and blurring of
vision.
Ashen color / pallor
Cold clammy skin
Exhibits air hunger
Restlessness
Decreased BP
Increased PR and RR
Dyspnea
Emergency
management/interventions:
Check the fundus of the uterus for firmness
Increase IV flow rate and add oxytocin as per
doctor’s order
Elevate the foot part of the bed to allow the fast
return of the blood to the upper part of the body.
Administer oxygen
Call for help
Puerperium
 POSTPARTUM
• The period of time, usually six weeks, in
which the mother’s body experiences
anatomic and physiologic changes that
reverses the body’s adaptation to
pregnancy.

• May also be called INVOLUTION.

 POSTPARTUM
• Begins with the delivery of the placenta

• Ends when all body systems are

returned to, or nearly to, their pre-
pregnancy state.
UTERUS
A rapid reversal in size

At the level of the UMBILICUS

immediately post delivery

The uterus regresses

approximately 1 fingerbreadth
(1cm) per day.
 Endometrial regeneration
• LOCHIA
• The debris discharged by the
uterus following delivery
 LOCHIA RUBRA

• Dark red in color

• Normal 1 – 3 days after delivery
• Discharge may contain small clots, but
large clots are abnormal and may
indicate hemorrhage
• Also contain cellular debris from decidua
 LOCHIA SEROSA

• Brownish to pinkish in color

• Lasts from 4th to the 10th day
• Contain mostly serum, some blood, and
tissue debris
 LOCHIA ALBA

• Cream colored discharged

• Begins around the 10th day and last for a
week or two
• Mostly leukocytes, with decidua, and
mucus
 CERVIX

Flabby immediately after delivery;

closes slowly
Admits one fingertip by the end of
one week after delivery
 VAGINA
Edematous after delivery
May have small lacerations
Smooth-walled for 3 – 4 weeks, then
rugae reappear
 Abdominal Wall / Skin
May need six weeks to reestablish
good muscle tone.

Stretch marks gradually disappear

 Gastrointestinal System
Mother usually hungry after
delivery; good appetite is expected.
May still experience constipation
from the lack of muscle tone in the
abdomen and perineal soreness.
 BREASTS

Initial secretion of colostrum,

with increasing amounts of true
breastmilk appearing between
48 – 96 hours.
Milk “let – down” reflex caused by
oxytocin from posterior pituitary
released by sucking
 Cardiovascular System
Normal blood loss in vaginal delivery
is 500 mL up to 1000 mL for cesarean
section.
Hematocrit normally returns to
prepregnancy value within 4 – 6
weeks.
Varicosities regress.
 Urinary System
Bladder base may be traumatized by
labor and delivery
Epidural anesthesia may decrease
the sensation of fullness
Perineal pain may inhibit voiding
Postpartum Emotional Responses
• Postpartum blues
 feelings of inadequacy, tearfulness,
mood swings
• Postpartum depression
 feelings of despair, hopelessness, and
anxiety
• Postpartum psychosis
 impairment of reality perception
 Management
• Reassurance
• Rooming – in
• No medications needed
 Psychotherapy
 Anti depressants
 Anti psychotic medications
Hospitalization required
PHASES OF
PUERPERIUM
TAKING-IN PHASE
Time of reflection
Prefers having a nurse administer
to her (bath towel/night gown) and
make decisions for her dependence
Usually wants to talk about her
pregnancy, especially about her
pregnancy  labor and delivery
PHASES OF
PUERPERIUM
TAKING-HOLD PHASE
Begins to initiate action
Expressed interest in caring for
her child
Still feels insecure about her
ability to care for her new child
Needs positive reinforcement
PHASES OF
PUERPERIUM
LETTING-GO PHASE

Finally defines her new role

 Postpartum Hemorrhage

• Excessive blood loss

(>500 mL during the first 24
hours postpartum) after the
delivery of an infant
 CAUSES (PPH)
Uterine atony  most common cause
Genital laceration
Retained placenta
Uterine inversion
 Diagnosis to Clinical Finding Management Plan
Consider
Uterine Atony Uterus is boggy and Uterine massage
 Myometrial enlarged on Bimanual uterine
dysfunction palpation compression
 Pharmacologic Remove intrauterine
 Uterine clots
overdistension Administer oxytocin
or methergin as
ordered

Undiagnosed Bleeding is present Assist in repairing

tears involving from genital tract lacerations and
episiotomy, cervix, lacerations extensions
vagina, or uterus
 Diagnosis to Clinical Finding Management Plan
Consider

Retained Placenta is not Manual uterine

placental complete on exploration
fragments examination Assist in uterine
curettage

Uterine Uterus is not Uterine

inversion palpable on replacement by
abdominal elevation of vaginal
examination fornices
FERTILITY CONTROL
CONTRACEPTION
 Folk methods
 Barrier and Spermicidal methods
 Steroid hormone – based
methods
 IUD
 Natural family planning
FERTILITY CONTROL
STERILIZATION

BTL
Vasectomy
FOLK METHOD
 Coitus interruptus
Withdrawal of the penis from the
vagina prior to ejaculation
 Post coital douching
Water, vinegar, or other products
theoretically flush semen out of the
vagina. (spermicidal properties)
MALE CONDOM
 A sheath that is placed on the
erect penis, preventing sperm
deposition into the vagina
 Most widely used mechanical
contraception
MALE CONDOM
ADVANTAGES
Inexpensive, readily available,
and convenient
Provide major protection
against STD
One size fits all
DISADVANTAGES
Reduction of penile sensation
Sexual spontaneity is lost
Breakage is possible
Male controlled
FEMALE CONDOM
Contains polyurethane
pouch with two flexible rings
Blind pouch end fits over
the cervix, the open rests
outside the vagina on the
vulva
FEMALE CONDOM
FEMALE CONDOM
FEMALE CONDOM
 Advantages
Provide protection against STD
Female controlled
 Disadvantages
Bulkiness and awkwardness
Relatively expensive
VAGINAL DIAPHRAGM
 A mechanical and spermicidal
barrier placed between the
posterior vaginal fornix and the
symphysis pubis
 Containing spermicidal jelly
against the external cervical os
VAGINAL DIAPHRAGM
VAGINAL DIAPHRAGM
VAGINAL DIAPHRAGM
 Placement may occur up to 2
hours before intercourse
 Removal may be delayed for at
least 6 hours after ejaculation
 Prevent some STD
 Female controlled
DISADVANTAGES
Individual fitting
Placement must occur before
penile insertion
Risk for infection (TSS)
Reapplication of spermicide is
required for repeated
intercourse
CERVICAL CAP
 A cup – like
diaphragm that
is placed tightly
over the cervix
without
spermicide
CERVICAL CAP
 Insertion may occur from 30 minutes
to 48 hours before intercourse
 Left in place for a prolonged period
 May prevent some STD
 Female controlled
DISADVANTAGE
Individualfitting is required
Many women cannot feel their
own cervix
VAGINAL
CONTRACEPTIVE
SPONGE
 A spermicide – impregnated
polyurethane disk that is placed
in the proximal vagina
 Spermicide is released when the
sponge is moistened and by the
action of the intercourse
VAGINAL
CONTRACEPTIVE
SPONGE
VAGINAL
CONTRACEPTIVE
SPONGE
 Insertion may occur up to 24
hours before intercourse
 Prevent some common STD
 No need to re-apply spermicide
for repeated intercourse
 Female controlled
 Size fits all
VAGINAL
CONTRACEPTIVE
SPONGE
 The sponge offers continuous
protection for up to 24 hours after
insertion, no matter how many
times you have sex.
 Left in place for at least 6 hours
after intercourse
 Sold over-the-counter, without a
prescription.
STEROID HORMONE –
BASED METHOD
ORAL AGENTS
 Most commonly used methods of
reversible contraception
 Estrogen – progestin combination
and Progestin only forms (mini-
pill)
ADVANTAGES
Contraceptive protection is
continuous when taken correctly
Contraceptive effect is readily
reversible when the pills are
discontinued
Non-contraceptive health
benefits
Non – contraceptive
health benefits
 incidence of dysmenorrhea
decreased strength of menstrual
contractions from prostaglandin
suppression
 incidence of benign breast
disease
decreased hormonal stimulation
DISADVANTAGE
 Must be remembered and taken
daily
 Intermenstrual bleeding and
headaches
 Weight gain may be noted
 ACHES
INTRAMUSCULAR
AGENT
Depomedroxyprogesterone
acetate (DMPA)
A progestin only formulation
DMPA
 IM injections (150mg) must be
repeated every 3 months
 Return of regular ovulation and
normal menses may be delayed up
to 12 months after discontinuation
(usually 6 months)
 Irregular bleeding, fluid retention,
and weight gain
SUBCUTANEOUS DEPOT
METHODS
 Norplant
 L – norgestrel, which is contained in six
Silastic capsules
 Implanted beneath the upper arm skin
 Effective within 24 hours of insertion if
placed within 7 days of the onset of a
woman's menstruation
NORPLANT
NORPLANT
Replaced only every 5 years
SE: Irregular bleeding, fluid
retention, weight gain
IUD
Progesterone – impregnated
IUD
Copper IUD
Altered tubal motility for both
sperm and egg transport
IUD
When is an IUD inserted?
A. Before menstruation
B. During menstruation
C. After menstruation
D. Anytime the patient wants to
COMPLICATIONS
Uterine perforation
Septic abortion
PID
STERILIZATION
Men  Vasectomy
Women  Bilateral tubal
ligation
BTL
Minilaparotomy
Laparoscopy
MINILAPAROTOMY
 Defined as a laparotomy with an
incision size smaller than 5 cm.
 The operation can be performed
through a suprapubic incision in
the interval after pregnancy and
through a subumbilical incision
within the first 48 hours after
delivery.
LAPAROSCOPY
 Small incisions
 Rapid access to the oviducts
 Rapid recovery
 Limited ability to inspect
intraperitoneal organs
VASECTOMY
Objective criteria for a
successful vasectomy
is AZOSPERMIA on a
semen after 12 weeks
or 20 ejaculations
VASECTOMY
 VASECTOMY
 Make a small incisions, or cuts, in the
skin of the scrotum, which has been
numbed with a local anesthetic.
 The vas is cut, and a small piece may
be removed.
 The doctor ties the cut ends and sews
up the scrotal incision.
 The entire procedure is then repeated
on the other side.
END

 Thank you
POST TEST