Notes-Maternal Health Nursing

MATERNAL AND CHILD HEALTH NURSING

Primary Goal of MCN >The promotion and maintenance of optimal family health to ensure cycles of optimal childbearing childbearing and child rearing

Vagina -Acts as organ of copulation -Conveys sperm to the cervix -Expands to serve as birth canal --Wall contains many folds or rugae making it very elastic Fornices – uterine end of the vagina; serve as a place for pooling of semen following coitus Bulbocavernosus Bulbocavernosus – circular muscle act as a voluntary sphincter at the external opening to the vagina (target of Kegel’s exercise)

ANATOMY & PHYSIOLOGY 

II. PUBERTAL DEVELOPMENT

Ovaries o Almond shaped o Produce, mature and discharge ova o Initiate and regulate menstrual cycle o 4 cm long, 2 cm in diameter, 1.5 cm thick o Produce estrogen and progesterone Estrogen: promotes breast dev’t & pubic hair distribution prevents osteoporosis keeps cholesterol levels reduced & so limits effects of  atherosclerosis

Puberty: the stage of life at which secondary sex changes begins the development and maturation of reproductive organs which occurs in female 1013 years old & male at 12-14 yrs old the hypothalamus serve as a gonad stat or regulation mechanism set to “turn on” gonad functioning at this age

Maternal and Child Health Nursing involves care of the woman and family throughout pregnancy and child birth and the health promotion and illness care for the children and families.

Fallopian tubes. Approximately Approximately 10 cm in length Conveys ova from ovaries to the uterus Site of fertilization fertilization Parts: interstitial isthmus – cut/sealed in BTL ampulla – site of fertilization fertilization infundibulum – most distal segment; covered with fimbria Uterus -Hollow muscular pear shaped organ -uterine wall layers: endometrium; myometrium; perimetrium -Organ of menstruation -receives the ova -Provide place for implantation implantation & nourishment during fetal growth -Protects growing fetus -Expels fetus at maturity -Has 3 divisions: corpus – fundus , isthmus (most commonly cut during CS delivery) and cervix Uterine Wall -Endometrial layer: formed by 2 layers of cells which are as follows: basal layer- closest to the uterine wall glandular layer – inner layer influenced by estrogen and progesterone; thickens and shed off as menstrual flow -Myometrium – composed of 3 interwoven layers of smooth muscle; fibers are arranged in longitudinal; longitudinal; transverse and oblique directions giving it extreme strength

Reproductive Development Readiness for child bearing -begins during intrauterine life -full functioning initiated at puberty -the hypothalamus releases the GRF which triggers the APG to form and release FSH and LH. (FSH & LH initiates production of androgen and estrogen --->2° Sexual characteristics Role of Androgen Androgenic hormones – are produced by the testes, ovaries and adrenal cortex which is responsible for: muscular development physical growth inc. sebaceous gland secretions  Testosterone –primary –primary androgenic androgenic hormone Related terms a. Adrenarche – the development of pubic and axillary hair (due to androgen stimulation) b. Thelarche – beginning of breast development c. Menarche – first menstruation period in girls (early 9 y.o. or late 17 y.o.) d. Tanner Staging -It is a rating system for pubertal development -It is the biologic marker of maturity -It is based on the orderly progressive development of: breasts and pubic hair in female’s genitalia and pubic hair in males Body Structures Involved 1 Hypothalamus 2 Anterior Pituitary Gland 3 Ovary 4 Uterus 4. Menstrual Cycle -Female reproductive cycle wherein periodic uterine bleeding occurs in response to cyclic hormonal changes

-Allows for conception and implantation implantation of a new life -Its purpose it to bring an ovum to maturity; renew a uterine bed that will be responsive to the growth of a fertilized ovum Menstrual Phases • First: 4-5 days after the menstrual flow; the endometrium is very thin, but begins to proliferate rapidly; thickness increase by 8 folds under the influence of increase in estrogenlevel also known as: proliferative; proliferative; estrogenic; follicular and postmentrual phase • Secondary: after ovulation the corpus luteum produces progesterone which causes the endometrium become twisted in appearance appearance and dilated; capillaries capillaries increase in amount (becomes rich, velvety and spongy in appearance also known as: secretory;progestational; secretory;progestational; luteal and premenstrual • Third: if no fertilization fertilization occurs; corpus luteum regresses after 8 – 10 days causing decrease in progesterone progesterone and estrogen level leading to endometrial degeneration; degeneration; capillaries capillaries rupture; endometrium sloughs off ; also known as: ischemic • Final phase: end of the menstrual cycle; the first day mark the beginning of a new cycle; discharges discharges contains blood from ruptured capillaries, capillaries, mucin from glands, fragments of  endometrial tissue and atrophied ovum. Physiology of Menstruation 1. About day 14 an upsurge of LH occurs and the graafian graafian follicle ruptures and the ovum is released 2. After release of ovum and fluid filled follicle cells remain as an empty pit; FSH decrease in Amount; LH increase continues to act on follicle cells in ovary to produce lutein which is high in progesterone ( yellow fluid) thus the name corpus luteum or yellow body 3. Corpus luteum persists for 16 – 20 weeks with pregnancy but with no fertilization fertilization ovum atropies in 4 – 5 days, corpus luteum remains for 8 -10 days regresses and replaced by white fibrous tissue, corpus albicans Characteristics of Normal Menstruation Period 1. Menarche – average onset 12 -13 years 2. Interval between cycles – average 28 days 3. Cycles 23 – 35 days 4. Duration – average 2 – 7 days; range 1 – 9 days 5. Amount – average 30 – 80 ml ; heavy bleeding saturates pad in <1hour 6. Color – dark red; with blood; mucus; and endometrial cells Associated Terms

1. Amenorrhea - temporary cessation of  menstrual flow 2. Oligomenorrhea - markedly diminished menstrual flow 3. Menorrhagia - excessive bleeding during regular menstruation 4. Metrorrhagia - bleeding at completely irregular intervals 5. Polymenorrhea - frequent menstruation occurring at intervals of less than 3 weeks Ovulation 1 Occurs approximately the 14th day before the onset of next cycle (2 weeks before) 2 If cycle is 20 days – 14 days before the next cycle is the 6th day, so ovulation is day 6 3 If cycle is 44 days – 14 days, ovulation is day 30. 4 Slight drop in BT (0.5 – 1.0 °F) just before day of  ovulation due to low progesterone level then rises 1°F on the day following ovulation (spinnbarkheit; (spinnbarkheit; mittelschmerz) mittelschmerz) 5 If fertilization occurs, ovum proceeds down the fallopian tube and implants on the endometrium Menopause o Mechanism- a transitional phase (period of 1 – 2 years) calledcl i macte ri c, heralds the onset of menopause. o Monthly menstrual period is less frequent, irregular and with diminished amount. o Period may be ovulatory or unovulatory advised to use Family planning method until menses have been absent for 6 continuous months o Menopause is has occurred if there had been no period for one year. Classical signs: Vasomotor changes due to hormonal imbalance a. hot flushes b. excessive sweating especially at night c. emotional changes d. insomnia e. headache f. palpitations g. nervousness h. apprehension i. depression  j. tendency tendency to gain weight weight more rapidly rapidly k. tendency to lose height because of  osteoporosis (dowager hump) l. arthralgias and muscle pains m. loss of skin elasticity and subcutaneous fat in labial folds Artificial menopause / surgically induced menopause a. oophorectomy or irradiation of ovaries b. panhysterectomy panhysterectomy

III. PROMOTE RESPONSIBLE PARENTHOOD – FAMILY PLANNING A. Artificial Methods:

1. physiologic method: oral contraceptives ; natural methods 2. mechanical methods 3. chemical methods 4. surgical methods Oral contraceptive Action: inhibits release of FSH  no ovulation  Types: Combined ; Sequential; Mini pill Side Effects: due to estrogen and progesterone > nausea and vomiting > Headache and weight gain > breast tenderness > dizziness > breakthrough bleeding/spotting > chloasma Contraindications: a. Breastfeeding b. Certain diseases: o thromboembolism o Diabetes Mellitus o Liver disease o migraine; epilepsy; varicosities o CA; renal disease;recent hepatitis c. Women who smoke more than 2 packs of  cigarette per day d. Strong family Hx of heart attack Note: If taking pill is missed on schedule, take one as soon as remembered and take next pill on schedule; if not done withdrawal bleeding occurs. B. Natural Methods: a. Rhythm/Calendar/Ogino Knause Formula o Couple abstains on days that the woman is fertile o Menstrual cycles are observed and charted for 12 months Standard Formula: first day of the beginning of one cycle to the first day of the next cycle shortest cycle = minus 18 longest cycle = minus 11 Example: shortest cycle = 28 longest cycle = 35 Shortest cycle: 28 days – 18 = 10 Longest cycle: 35 days – 11 = 24 Fertile pd: 10th to 24th day of cycle = No sexual intercourse b. Billings Method / Cervical Mucus o woman is fertile when cervical mucus is thin and watery; may be extended o Sexual Intercourse may be resumed after 3 – 4 days c. Symptothermal Method / BBT

1 Requires daily observation and recording of  body temperature before rising in the morning or doing any activity to detect time of  ovulation 2 Ovulation is indicated by a slight drop of  temperature and then rises 3 Resume Sexual intercourse after 3 – 4 days 4 Recommended observation of BBT is 6 menstrual cycle to establish pattern of  fluctuations C. Mechanical Methods 1. Intrauterine Device - prevents implantation by non-specific cell inflammatory reaction inserted during menstruation (cervix is dilated) SE: increased menstrual flow spotting or uterine cramps increased risk of infection Note: when pregnancy occurs, no need to remove IUD, will not harm fetus 2. Diaphragm oa disc that fits over the cervix of  orms a barrier against the entrance of sperms o initially inserted by the doctor o maybe washed with soap and water is reusable o when used, must be kept in place because sperms remains viable for 6 hrs. in the vagina but must be removed within 24 hours (to decrease risk of  toxic shock syndrome) 3. Condom 1 a rubber sheath where sperms are deposited 2 it lessens the chance of contracting STDs 3 most common complaint of users interrupts sexual act when to apply D. Chemical Methods  These are spermicidals (kills sperms) like jellies, creams, foaming tablets, suppositories E. Surgical Method a.  Tubal Ligation: Fallopian tubes are ligated to prevent passage of  sperms Menstruation and ovulation continue b. Vasectomy: Vas deferens is tied and cut blocking the passage of sperms Sperm production continues Sperms in the cut vas deferens remains viable for about 6 months hence

couple needs to observe a form of contraception this time to prevent pregnancy

IV. BEGINNING OF PREGNANCY  A.F e rti l i z ati on 1. Union of the ovum and spermatozoon 2. Other terms: conception, impregnation or fecundation 3. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp. 4. Number of sperms: 120-150 million/cc/ejaculation 5. Mature ovum may be fertilized for 12 –24 hrs after ovulation 6. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation (life span of sperms 72 hrs) B.Im pl antati on General Considerations: o Once implantation has taken place, the uterine endometrium is now termed decidua o Occasionally, a small amount of vaginal bleeding occurs with implantation due to breakage of capillaries o Immediately after fertilization, the fertilized ovum or zygote stays in the fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking place. The developing cells now called blastomere and when about to have 16 blastomere called morula. o Morula travels to uterus for another 3 – 4 days o When there is already a cavity in the morula called blastocyt o finger like projections called trophoblast form around the blastocyst, which implant on the uterus o Implantation is also called nidation, takes place about a week after fertlization C. Stages of human prenatal development 1. Cytotrophoblast – inner layer 2. Syncytiotrophoblast – the outer layer containing finger like projections called chorionic villi which differentiates into: oL angerhan’s layer – protective against Treponema Pallidum, present only during the second trimester o Syncytial Layer – gives rise to the fetal membranes, amnion and chorion D. Fetal Membranes 1. Amnion – gives rise to umbilical cord/funis – with 2 arteries and 1 vein supported by 2. Wharton’s jelly 3. Amniotic fluid: clear albuminous fluid, begins to form at 11 – 15th week of gestation, chiefly

derived from maternal serum and fetal urine, urine is added by the 4th lunar month, near term is clear, colorless, containing little white specks of  vernix caseosa, produced at rate of 500 ml/day. Known as BOW or Bag of Water E. Amniotic Fluid Purposes of Amniotic Fluid Protection – shield against pressure and temperature changes Can be used to diagnose congenital abnormalities intrauterine– amniocentesis Aid in the descent of fetus during active labor Implication: Polyhydramios = more than >1500 ml due to inability of the fetus to swallow the fluid as in trachoesophageal fistula. Oligohydramnios = less than <500 ml due to the inability of the kidneys to add urine as in congenital renal anomaly F. Fetal Membranes •Chorion - together with the deciduas basalis gives rise to the placenta, start to form at 8th week of gestation; develops 15 – 20 cotyledons •Purpose of Placenta: respiratory; exchange of  nutrients and oxygen •Renal system •Gastrointestinal system •Circulatory system •Endocrine system: produces hormones (before 8th week-corpus luteum produces these hormones) hCG keeps corpus luteum to continue producing estrogen and progesterone •HPL or human chorionic somatomammotropin which promotes growth of mammary glands for lactation •Protective barrier: inhibits passage of some bacteria and large molecules

V. FETAL GROWTH AND DEVELOPMENT First lunar month •Germ layers differentiate by the 2nd week 1. endoderm – gives rise to lining of GIT, Respiratory Tract, tonsils, thyroid (for basal metabolism), parathyroid (for calcium metabolism), thymus gland (for development of  immunity), bladder and urethra 2. Mesoderm – forms into the supporting structures of the body (connective tissues, cartilage, muscles and tendons); heart, circulatory system, blood cells, reproductive system, kidneys and ureters. 3. Ectoderm – responsible for the formation of the nervous system, skin, hair and nails and the

mucous membrane of the anus and mouth 1 month: 2nd week – fetal membranes 16th day – heart forms ; 4th week – heart beats 2nd month: All vital organs and sex organs formed; placental fully developed; meconium formed (5th –8th wk) 3rd month: Kidneys function - 12th wk- urine formed ; Buds of milk teeth form ; begin bone ossification ; allows amniotic fluid ; establishment of feto-placental exchange 4th month: Lanugo appears; buds of permanent teeth form; heart beat heard by fetoscope 5th month: Vernix appears; lanugo over entire body; quickening; FHR audible with stethoscope 6th month: Attains proportions of full term but has wrinkled skin 7th month: 28 weeks – lower limit of prematurity; alveoli begins to form 8th month: 32 weeks – fetus viable; lanugo disappears, subcutaneous fat deposition begins 9th month: Lanugo continue to disappear; vernix complete; amniotic volume decrease Focus of Fetal Development First Trimester – period of organogenesis Second Trimester – period of continued fetal growth and development; rapid increase in length  Third Trimester – period of most rapid growth and development because of the deposition of  subcutaneous fat Assessing Fetal Well-being Fetal Movement: Quickening at 18 – 20 weeks , peaks at 29 -38 weeks Consistently felt until term a. Cardiff Method: “Count to ten” - records time interval it takes for 10 - fetal movements to be felt  usually occurs in 60minutes b. Contraction Stress Test: Fetal Heart Rate (FHR) analyzed in conjunction with contractions Nipple stimulation done to induce gentle contractions ***3 contractions with 40 sec duration or more must be present in 10 minutes window Normal Result  no fetal decelerations with contractions c. Non-stress Test: Measures response of FHR to fetal movement (1020mins.) with fetal movement  FHR increase by 15 beats and

remain for 15 seconds then decrease to average rate (no increase means poor oxygen perfusion to fetus) d. Amniocentesis - done to determine fetal maturity: Identify L/S ratio 16 wks – detect genetic disorder 30 wks – assess 1. Prior to the procedure, bladder should be emptied; ultrasonography is used to avoid trauma from the needle to the placenta, fetus 2. Complications include premature labor, infection, Rh isoimmunization 3. Monitor fetus electronically after procedure, monitor for uterine contractions 4. Teach client to report decreased fetal movement, contractions, or abdominal discomfort after procedure. e. Ultrasound – transducer on abdomen transmits sound waves that show fetal image on screen a. Done as early as five weeks to confirm pregnancy, gestational age b. Multiple purposes – to determine position, number, measurement of fetus(es) and other structures (placenta) c. Client must drink fluid prior to test to have full bladder to assist in clarity of  image d. No known harmful effects for fetus or mother e. Noninvasive procedure

VI. NORMAL ADAPTATIONS IN PREGNANCY  1. Cardiovascular/ Circulatory changes: a. Physiologic anemia of pregnancy -30-50% gradual increase in total cardiac volume (peak 6th month) causing drop in Hemoglobin and Hematocrit values (inc only in plasma volume) Consequences of increased cardiac volume: 1. easy fatigability & shortness of breath due increase cardiac workload 2. slight hypertrophy of the heart 3. systolic murmurs due to lowered blood viscosity 4. nosebleeds may occur due to congestion of  nasopharynx b. Palpitations caused by the SNS stimulation during early part of pregnancy; increased pressure of  the uterus against the diaphragm during the second half of  pregnancy c Edema of the lower extremities & varicosities due to poor circulation caused by the pressure of  the gravid uterus on the blood vessels of the lower extremities

d. Vaginal and rectal varicosities - due to pressure on blood vessels of the genitalia Management: side lying hips elevated on pillow modified knee chest position e. Predisposition to blood clot formation -due to increased level of circulating fibrinogen as a protection from bleeding implication: no massage 2. Gastrointestinal Changes a. Morning sickness 2 nausea and vomiting in the 1st trimester due to HCG or due to increased acidity or emotional factors 3 Management: dry toast 30 mins before get up in AM b. Hyperemesis gravidarum 4 excessive nausea & vomiting which persists beyond 3 months causing dehydration, starvation and acidosis 5 Management: hydration in 24 hrs; complete bed room c. Constipation and Flatulence GI displacement slows peristalsis & gastric emptying time; inc progesterone d. Hemorrhoids 1 due pressure of enlarged uterus 2 Management: cold compress with witch hazel and Epsom salts e. Heartburn 1 due to increased progesterone and decreased gastric motility causing regurgitation through gastric sphincter 2 Management: pats off butter before meals avoid fried, fatty foods sips of milk at intervals small, frequent meals taken slowly don’t bend on waist take antacids (milk of magnesia) 3. Respiratory Changes a. Shortness of Breath due to inc. oxygen consumption and production of carbon dioxide during the 1st  Trimester; and increased uterine size pushing the diaphragm crowding chest cavity management: side lying position to promote lateral chest expansion 4. Urinary Changes a. Urinary frequency felt during the 1st trimester due to the increase blood supply to the kidneys and then on the 3rd trimester due to pressure on the bladder. b. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine; and inc. progesterone

5. Musculoskeletal changes a. Pride of Pregnancy 1d ue to need to change center of gravity result to lordotic position b. Waddling gait 1 due to increased production of hormone relaxin, pelvic bones becomes more movable 2 increasing incidence of falls c. Leg cramps 1d ue to pressure of gravid uterus, fatigue, muscle tenseness, low calcium and phosphorus intake 6. Endocrine Changes a. Addition of the placenta as an endocrine organ producing HCG, HPL, estrogen and progesterone b. Moderate enlargement of the thyroid due to increased basal metabolic rate c. Increased size of the parathyroid to meet need of fetus for calcium d. Increased size and activity of adrenal cortex increasing circulating cortisol, aldosterone, and ADH which affect CHO and fat metabolism causing hyperglycemia. e. Gradual increase in insulin production but there is decreased sensitivity to insulin during pregnancy 7. Weight Change a. First Trimester 1.5 to 3 lbs normal weight gain b. 2nd and 3rd trimester 10 – 11 lbs per trimester is recommended c. Total allowable weight gain during throughout pregnance is 20 – 25 lbs or 10 – 12 kgs. d. Pattern of weight gain is more important than the amount of weight gained. 8. Emotional responses a. 1st trimester: some degree of rejection, disbelief, even depression because of its future implication -> give health teachings on body changes and allow for expression of feelings b. 2nd trimester: fetus is perceived as a separate entity and fantasizes appearance c. 3rd trimester: best time to talk about layette, and infant feeding method. To allay fear of death let woman listen to the FHT.

VII. COMMON EMOTIONAL RESPONSES DURING PREGNANCY  •Stress –decrease in responsibility taking is the reaction to the stress of pregnancy not the pregnancy itself affects decision  making abilities •Couvade – syndrome – men experiencing nausea/vomiting, backache due to stress, anxiety and empathy for partner

•Emotional labile – mood changes/swings occur frequently due to hormonal changes •Change in Sexual Desire – may increase or decrease  needs correct interpretation… not as a loss of interest in sexual partner

VIII. LOCAL CHANGES DURING PREGNANCY  1. Uterus – wt increase to about 1000 grams at full term due to increase in fibrous and elastic tissues a. Becomes ovoid in shape b. Softening of lower uterine segment: Hegar’s sign seen at 6th week c. Operculum – mucus plug to seal out bacteria d. Goodell’s sign – cervix becomes vascular and edematous giving it consistency of the earlobe 2. Vagina – increased vascularity occurs a. Chadwick’s sign – purplish discoloration of the vagina b. Leukorrhea – increased amount of vaginal discharges due to increased activity of estrogen and of the epithelial cells. a. Must not be itchy, foul smelling, excessive, nor green/yellow in color. b. Management: good hygiene c. Under the influence of estrogen, vaginal epithelium & underlying tissues  hypertrophic & enriched with glycogen d. pH of vaginal secretions during pregnancy fall •Microorganisms that thrive in an alkaline environment: a. Trichomonas – causes trichomonas vaginalis/vagnitis or trichomoniasis s/s: frothy, cream-colored, irritatingly itchy, foul smelling discharges, vulvar edema Management : Flagyl 10 days p.o. or trichomonicidal cmpd suppositories (e.g. Tricofuron, Vagisec, Devegan) Management: 1. treat male partner also with Flagyl 2. avoid alcohol to prevent SE 3. dark brown urine expected 4. Acidic vaginal douche (1 tbsp vinegar:1 qt water or 15 ml: 1000 ml) 5. avoid intercourse to prevent reinfection a.Candida Albicans - condition is called Moniliasis or Candidiasis 6 it thrives in an environment rich in CHO and those on steroid or antibiotic therapy 7 seen as oral thrush in the NB when transmitted during delivery 8 s/s: white, patchy, cheese-like particles that adhere to vaginal walls, foul smelling discharges causing irritating itchiness

Management : 1. Mycostatin/Nystatin p.o. or vaginal suppositories 100,000 U BID x 15 days 2. Gentian violet swab to vagina 3. Acidic vaginal douche 4. Avoid intercourse 3. Ovaries Inactive since ovulation does not take place during pregnancy. Placenta produces Progesterone and Estrogen during pregnancy 4. Abdominal Wall 1 Striae Gravidarum – due to rupture and atrophy of connective tissue layers on the growing abdomen 2 Linea Nigra 3 Umbilicus is pushed out 4 Melasma or Chloasma – increased pigmentation due increased production of  melanocytes by the pitutitary 5 Unduly activated sweat glands

IX. SIGNS OF PREGNANCY  I.Pre gna ncy 1 Prenatal care is important for prevention of  infant and maternal morbidity and mortality 2 Care is a cooperative action based on client’s understanding of treatment modalities 3 Duration of normal pregnancy 266 – 280 days of 38 – 42 weeks or 9 calendar months or 10 lunar months. 4 Infant born < 38 weeks pre-term & 42 post term) 5 Diagnosis: Urine examination – tests presence of HCG (present from 40th –100th day, peak 60 days) conduct test 6 weeks after LMP 2. Prenatal Visit History Taking: personal data obstetrical data gravida para  TPAL past pregnancies present pregnancy: cc LMP medical data: hx of diseases/illnesses 3. Danger Signals of Pregnancy 1. Vaginal bleeding (any amount) 2. Swelling of face or fingers 3. Severe, continuous headache 4. Dimness or blurring of vision 5. Flashes of light or dots before eyes 6. Pain in the abdomen 7. Persistent vomiting 8. Chills and fever 9. Sudden escape of fluids from the vagina 10. Absence of FHT after they have been initially heard on 4th or 5th month 4.As se ss me nt a. Physical examination – review of systems

b. Pelvic examination (ask client to void) c. IE – determine Hegar’s, Goodell’s, Chadwick’s d. Ballotement – on 5th month e. Pap Smear f. Pelvic measurements (done after 6th month or 2 wks before EDC) g. Leopold’s Manuever: to determine fetal presentation, position, attitude, est. size and fetal parts h. Vital signs i. Blood studies: CBC Hgb, Hct , blood typing, serological tests  j. Urinalysis: test for albumin, sugar & pyuria 5. Important Estimates: a. Age of Gestation: Nagele’s Rule: -3 calendar  months and +7 days Ex. LMP= May 15, 2006 or 5-15-06 LMP: 51 5 Formula: -3+ 7 EDC: 2 22 or February 22, 2007 • McDonald’s Rule: Ht fundus/4 (AOG wks) 1. Measure in cms the length from the symphysis to the level of fundus 2. Lunar months: Fundal Height (cms) x 2/7 3. Weeks of pregnancy: Fundal height (cms) x 8/7 Ex. Fundal Height = 14 cms Lunar Month: 14cms x 2 = 28 / 7 = 4 months Weeks Pregnant: 14 cms x 8 = 112 / 7 = 16 weeks AOG • Bartholomew’s Rule: based on position of fundus in abdominal cavity 3rd month = above symphysis 5th month = umbilical level 9th month = below xiphoid process) b. Fetal Length: 1 Haase’s Rule: 1st half of pregnancy – square number of  months Example : 2 months = 2x2 = 4 cm 2nd half of pregnancy – number of months multiplied by 5 Example: 7 months x 5 = 35 cm c. Fetal Weight: 1 Johnson’s Rule: Fundic Ht – n x k ( k=155; n = 11 not engaged/12 engaged) Example for a not engaged fetus Fundic Height given = 35 cms n = 11 (standard for not engaged fetus)

k= 155 gms. (9 standard) Solution: 35 cms – 11 = 24 x 155 =3,720 g 5. Health Teachings a. Smoking – lead to LBW babies b. Drinking – can cause respiratory depression in the NB and fetal withdrawal syndrome if  excessive; alcohol has empty calories c. Drugs – may be teratogenic hence contraindicated unless prescribed by Doctor d. Sexual activity – allowed in moderation but not during last 6 wks- high incidence of post partum infection noted. ♣ counseling is important on changes in desire and positions 

contraindication: bleeding, ruptured BOW, incompetent cervix, deeply engaged presenting part e. Prepared childbirth/Childbirth education 1 Based on Gate Control Theory: pain is controlled in the spinal cord and there is a gate that can be closed to ease pain felt. 2 Information and breathing techniques help minimize discomfort of labor experience 3 Discomfort can be lessened if abdomen is relaxed and allows uterus to rise freely against it during contractions Major Approaches to prepared childbirth 1 Teaching about anatomy, pregnancy, labor and delivery, relaxation techniques, breathing exercises, hygiene, diet and comfort measures Grant-Dick Read Method: Fear leads to tension and tension leads to pain Lamaze Method: Psychoprophylactic method ; based on S-R conditioning; concentration on breathing is practiced f. Immunization: Tetanus Toxois (TT) =0.5 ml IM for all pregnant women shall be given in 2 doses- 4 wks interval with 2nd dose at least 3 wks before delivery = booster doses given during succeeding pregnancies regardless of interval. = 3 booster doses is equal to lifetime immunity g. Clinic Visits for Pre-natal check-up 2 First 7 lunar months – every month 3 On 8th and 9th lunar month – every week 4On 10th lunar month – every week until labor

X. LABOR AND DELIVERY  1. THEORIES OF LABOR ONSET

Uterine stretch theory Oxytocin theory Progesterone Deprivation theory Prostaglandin theory 2. FOUR P’S OF LABOR a. Power - the uterine contraction b. Passenger – the fetus c. Passageway – the maternal pelvis d. Psyche – the mental and emotional aspect of  the woman a. POWER -Uterine Contractions: a.1. Frequency – the beginning of one contraction to the beginning of the next contraction a.2. Interval – pattern which increases in frequency and duration a.3. Duration – the beginning of one contraction to the end of the same contraction a.4. Intensity – strength of contraction, measured through a monitor or through touch of  a fingertip on the fundus (mild, moderate or strong) b. PASSENGER -Fe t us b.1. Fetal Skull: a. largest part of the fetus - most frequent presenting part; least compressible Bones: sphenoid, ethmoid, temporal, frontal, occipital, parietal Suture lines: sagittal/ coronal, lamboidal b.2. Fontanels - membrane covered spaces at the  junction of the main suture lines anterior fontanel: larger, diamond shaped; closes at 12 – 18 months posterior fontanel: smaller, triangular shaped, closes at 2 – 3 months b.3. Fetal Lie – relationship of the cephalocaudal axis of the fetus to the cephalocaudal axis of the mother. Measurements: b.4. Fetal Attitude – fetal position Pelvis is divided into 6 areas: Anterior, Posterior,  Transverse Left,  Transverse Right, Posterior Left, Posterior Right Fetal landmarks: Occiput (O); mentum (M), sacrum (S), and scapula (Sc) b.5. Presentation –the part of the passenger that enters the pelvis is the presenting part a. Cephalic – Vertex (occiput) ; Brow (sinciput); Face (mentum) b. Breech – Complete (sacrum) ; Frank; Footling c. Shoulder b.6. Movement of Passenger upon birth or descent: d. Descent e. Flexion f. Internal Rotation g. Extension h. External rotation/ restitution c. PASSAGEWAY – maternal pelvis c.1. Divisions

a. False Pelvis -supports the growing uterus during pregnancy -directs the fetus into the true pelvis near the end of gestation b.  True Pelvis: the bony canal through which the fetus will pass during delivery formed by the pubis in front, the iliac and ischia on the sides and the sacrum and coccyx behind c.2. Significant Pelvic Measurements a. External – Suggestive only of pelvic size > External Conjugate/ Baudelaocque’s Diameter - the distance between the anterior aspect of the symphysis pubis and the depression below lumbar 5 (Average: 18 – 20 cm) b. Internal – the actual diameters of the pelvic inlet and outlet > Diagonal Conjugate - the distance between the sacral promontory and inferior/lower margin of the symphysis pubis - widest AP diameter at outlet estimated on vaginal/pelvic exam (Average: 12.5 cm) >Obstetrical Conjugate - the distance from the inner border of the symphysis pubis to the sacral prominence - most important pelvic measurement - shortest AP diameter of the inlet through which the head must pass - 1.5 to 2 cm or less than the diagonal conjugate >True Conjugate/Conjugate Vera - the distance between the anterior surface of the sacral promontory and superior margin of the symphysis pubis - diameter of the pelvic inlet (10.5 -11 cm) >Bi-Ischial/ Tuberiischial Diameter - the distance between the ischial tuberosities - narrowest diameter of the outlet - transverse diameter of the outlet (Average: 11 cm) D.PSYCHE- the emotions of the mother Factors that may increase a woman’s chance of  depression: 1 History of depression or substance abuse 2 Family history of mental illness 3 Little support from family and friends 4 Anxiety about the fetus 5 Problems with previous pregnancy or birth 6 Marital or financial problems 7 Young age (of mother Signs and Symptoms of Post-partum depression: 1 Feeling restless or irritable 2 Feeling sad, hopeless, and overwhelmed 3 Crying a lot 4 Having no energy or motivation

5 Eating too little or too much 6 Sleeping too little or too much 7 Trouble focusing, remembering, or making decisions 8 Feeling worthless and guilty 9 Loss of interest or pleasure in activities 10 Withdrawal from friends and family 11 Having headaches, chest pains, heart palpitations (the heart beating fast and feeling like it is skipping beats), or hyperventilation (fast and shallow breathing) 3.PRELIMINARY/PRODROMAL SIGNS OF LABOR a. Lightening b. Increased activity level- “nesting behavior” c. Loss of weight ( 2-3 lbs) d. Braxton Hick’s Contractions e. Cervical Changes – effacement - Goodell’s sign – ripening of the cervix f. Increase in back discomfort g. Bloody Show - pinkish vaginal discharge h. Rupture of Membranes– labor expect in 24 hours i. Sudden burst of energy  j. Diarrhea k. Regular Contractions - phases: increment,acme,decrement - characteristics: intensity, frequency, interval, duration False Labor Pains  True Labor Pains o1 Remain irregular o2 Confined to abdomen o3 No increase in duration, frequency, intensity o4 Disappears on ambulation o5 No cervical changes o6 Becomes regular and predictable o7 Radiates in girdle like fashion o8 Increase in duration, frequency, intensity o9 Continue regardless of activity o10 Effacement and dilatation occurs o11 Signs of True labor Effacement Dilatation 1 Uterine Changes– upper and lower segments; physiologic retraction ring 2 Bandl’s pathologic retraction ring- a danger sign of impending rupture of the uterus if obstruction is not relieved 1. Nursing Interventions of Woman in Labor: a. Assessment – history and physical assessment a.1. Personal data a.2. Obstetrical data 1 determine EDC 2 obstetrical score 3 amount/ character of show 4 status of the BOW 5 general physical examination

6 Leopold’s Maneuver: presentation 7 Internal examination: effacement ; dilatation; station b. Monitoring and Evaluating Progress of Labor b.1. Blood pressure b.2. Fetal Heart Tone b.3. Observe for signs of fetal distress 12 bradycardia 13 fetal thrashing 14 meconium stained amniotic fluid in nonbreech presentation b.4. Monitor and inform patient of progress of  labor b.5. Monitor progress – fetal a) during labor check FHR b) manage fetal distress 5. Analgesia/anesthesia during childbirth 5.1. Analgesia – relieves pain and its perception 5.2. Anesthesia – produces local or general loss of  sensation ; - usually regional anesthesia (e.g. spinal) o Relieve uterine and perineal pain o Usually safe for the fetus (potential for maternal hypotension) o  Types of Anesthesia: a. Paracervical block b. Peridural block: Epidural/caudal c. Intradural: spinal/saddle block d. Pudendal block e. Local anethesia o Regional Anesthesia is mostly preferred because it does not enter maternal circulation nor affect fetus o Xylocaine is used (NPO with IV infusion) > allows to be awake and participate in process; > can increase incidence of maternal hypotension and fetal bradycardia 5.3. Analgesics: 5.3.1 Narcotics (Demerol) op roduces sedation/relaxation od epresses NB’s respiration og iven in active labor o Special Considerations: Demerol is most commonly used Has sedative and antispasmodic effect Dose is usually 25 –100 mg depends on body weight Not given early in labor due to possible effect on contractions Not given too late (1 hr before delivery) can cause respiratory depression in the newborn Given if cervical dilatation is 6 – 8 cms.

5.3.2. Narcotic Antagonist: Narcan; Nalline 6. Nursing Care before administration of  anesthesia/analgesia 1.1.Assess pain status 1.2.Explain the action of drugs 1.3.Check vital signs of mother and fetus 1.4.Observe safety measures Evaluate allergies Provide siderails – have call bell ready NPO (anesthesia) Check time last medication was given 1.5.Nursing Care after administration of  anesthesia/analgesia 1.6.Monitor: vital signs – BP and FHR (be alert for bradycardia) 1.7.Record properly 1.8.Provide comfort measures 1.9.Remember that the use ofF orce ps is needed in delivery of patient under anesthesia due to loss of coordination in bearing down during 2nd stage 1.10. Side effects: a. postspinal headaches – place flat on bed for 12 hrs and increase fluid intake b. common side effect is hypotension (xylocaine – vasodilator): Nursing Intervention: turn to side elevate legs administer vasopressor and oxygen as ordered Fetal bradycardia Decreased maternal respirations (Observe for bulging of the perineum)

XI. STAGES OF LABOR 1. Stages of Labor Stage Characteristics First Stage - the stage of true labor until the complete cervical dilatation a. Latent Phase b. Active Phase c. Transitional Phase Extent: Primigravida – 3.3.-19.7 hrs Multigravida – 0.1 - 14.3 hrs 0-4 cms. cervical dilatation Interval: 15-20 mins interval Duration: 10-30 seconds 5-7 cms. cervical dilatation Interval: 3-5 mins Duration: 30-60 seconds 8-10 cms cervical dilatation Interval: 2-3 mins. Duration: 50-90 seconds Second Stage - begins with complete dilatation of the cervix until the birth of the newborn

Duration: Primigravida – 30 mins. - 2 hrs. Multi-gravida- 20 mins – 1 hr. Contractions- 2-3 mins for 50-90 secs Mother is exhausted and has urge to push Third Stage - from delivery of the newborn to the delivery of the placenta Still with mild contractions until the placenta is expelled. Usually, placenta is expelled within 30 minutes. Fourth Stage - the first hour after complete delivery until the woman becomes physically stable Uterine cramping Rubra with small clots 2. Principles of Postpartum Care a. Promote healing and the process of involution b. Provide emotional support c. Prevent postpartum complications d. Establish successful lactation e. Promote responsible parenthood (FP) 3. Nursing Care of the Woman in First & Second Stage Labor a. Monitor discomfort/exhaustion/pain control – support client in choice of pain control b. Relaxation techniques taught during pregnancy where breathing is taught as a relaxed response to contraction c. Low back pain – massage of sacral area d. Use different breathing techniques during the different phases of labor e. Encourage rest between contractions f. Keep couple informed of progress g. Administer analgesic : side effects-may prolong labor; local/ block/ general 4. Nursing Care of Woman in the 3rd Stage of  Labor a. Principle Of Watchful Waiting b. Use Brandt Andrews Maneuver c. Note Time Of Delivery (20 Minutes After Delivery Of The Baby) d. Check Bp; Injects Oxytocin (Methergin 0.2 Mg/Ml Or Syntocinon 10 U/Ml Im) e. Inspect Cotyledons For Completeness f. Check Uterus For Contraction g. Check Perineum For Lacerations -Give perineal care; apply perineal pads h. Change gown i.Place flat on bed  j.Keep warm – provide extra warm blanket k. Give initial nourishment – warm milk, tea l.Allow to rest/ sleep 5. Nursing Care of Woman in Fourth Stage

a. Lactation: promote lactation by encouraging early breastfeeding to stimulate milk production *** Those mothers who cannot breastfeed: suppressing agents are given – estrogenandrogen preparations given first hours post partum to prevent milk production. These drugs tend to increase uterine bleeding and retard involution. (e.g. diethylstilbestrol, Parlodel or deladumone) b. Rooming-in-concept provides opportunity for developing positive family relationship promotes maternal infant bonding releases maternal caretaking responses c. Assess vital signs, fundus and flow every 15 minutes. d. Hydration and elimination e. May ambulate Puerperium - the 6 weeks period following delivery Involution- time period for the return of the reproductive organs to return to its prepregnant state 8. Categories of Lacerations 8.1. First degree – involves vaginal mucous membrane and perineal skin 8.2. Second degree – involves the perineal muscles, vaginal mucous membrane and perineal skin 8.3. Third degree – involves all in the 2nd degree lacerations and the external sphincter of  the rectum 8.4. Fourth degree – involves all in 3rd degree lacerations and the mucus membrane of the rectum

XII. PROMOTING HEALING AND INVOLUTION DURING POST-PARTUM 1. Vascular Changes - Reabsorption of the 30-50% increase in cardiac volume within 5 – 10 minutes after the thirdstage of labor. - WBC increases to 20,000 – 30,000/mm³ - Activation of the clotting factor - All blood values are back to prenatal levels by 3rd or 4th week 2. Location of the Fundus - Uterine involution is measured by determining the level of the fundus in relation to the umbilicus - Nursing care: 

Assess condition and level of the fundus 

Position in prone or knee chest 1 Occurrence of afterpains – it is an indication of  uterine contractions and are normal. Usually lasts up to 3 days after birth Nursing Care: 

Explain to client cause of pain 

Do not apply heat 

Administer analgesics as prescribed 3. Genital Changes/ Discharges - Presence of Lochia: uterine discharges consisting of blood, decidua, WBC and some bacteria - Characteristics: pattern should not reverse – 1-3 days – rubra - - - bright red with no or minimal clots 4-9 days – serosa- - - thinner, serous sanguinous blood 10- 3 to 6 wks pp – alba - - - whitish discharge same amount as menstrual flow, decreased if  with breastfeeding , increased with activity with fleshy odor; never foul smelling 4. Perineal Pain Nursing Care: 

Place in Sim’s position – lessens strain on the suture line 

Expose to dry heat or warm Sitz bath 

Application of topical analgesics or oral analgesics as ordered 

Provide/ encourage perineal care 5. Sexual Activity 1 sexual stimulation may be decreased due to emotional factors and hormonal changes 2 it may be resumed if bleeding has stopped and episiorrhaphy has healed by the 3rd or 4th week 6. Menstruation 1 Breastfeeding influences return of the menstrual flow. 2 Breastfeeding – menses return in 3 – 4 months; o some do not menstruate throughout lactation period o ovulation is also possible with lactational amenorrhea 3 Non-Breastfeeding Mothers – menstrual flow return within 8 weeks 7. Urinary Changes

o marked diuresis occurs within 12 hours postpartum to eliminate excess tissue fluids during pregnancy o frequent urination in small amounts may be experienced by some o others have difficulty of urination Nursing Care: 

Explain cause of urinary changes 

Assist to promote voiding utilizing appropriate measures (encouraging voiding, let client listen to sound of flowing water, etc.) 8. Gastrointestinal Changes - Change is more on the delay of bowel evacuation; constipation - Cause: decreased muscle tone lack of food intake dehydration fear of pain -Nursing Care: encourage early ambulation increase fluids increase fibers in the diet 9. Vital Signs o Temperature: may increase because of  dehydration on the first 24 hours pp. o CR 50 – 70 beats/min (bradycardia) is common for 6 - 8 days pp. o RR – no change is expected o Weight = 10 – 12 lbs is expected to be immediately lost. This corresponds to the weight of the fetus, placenta, amniotic fluid and blood. Diaphoresis will contribute to further weight loss 10. Provision of Emotional Support Post-partum Psychological Phases 1. Taking – in : First 1 – 2 days; mother focuses on herself and her experience 2. Taking – hold: mother starts to assume her role 3. Letting go Postpartum Blues – overwhelming sadness that cannot be accounted for. Could be due to hormonal changes, fatigue or feelings of  inadequacy. Nursing Care: Encourage verbalization; crying is therapeutic, explain that it is normal 11. Establish Successful Lactation Physiology of Lactation: Estrogen & progesterone levels stimulates APG to produce  Prolactin acts on acinar cells to produce foremilk  stored in collecting tubules -> infant sucking stimulates PPG to produce oxytocin causes contraction of smooth muscles of collecting tubules milk 

ejected forward (milk ejection reflex or let down reflex  hindmilk is produced Implications of lactation: 1 Breast milk will be produced postpartum 2 Lactation do not occur during pregnancy due to levels of estrogen and progesterone 3 Lactation suppressing agents are to be given immediately after placental delivery to be effective 4 Oral contraceptives decrease milk supply and are contraindicated in lactating mothers 5 Afterpains are felt more by breastfeeding mothers due to oxytocin production; have less lochia and rapid involution 12. Advantages of Breastfeeding Mother: faster involution less incidence of CA economical- time, effort, cost Infant: bonding with the mother protection against common illness less incidence of GI diseases always available 13. Health Teachings a. Hygiene Wash breasts daily No soap; No Alcohol for cleaning Handwashing Insert clean OS squares/ absorbent cloth in brassiere for breast discharges b. Feeding Techniques c. Nutrition: 3000 calories daily; 96 grams protein d. Contraindications: Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics, tetracyclines. Certain disease conditions – TB because of close contact during feeding (TB germs are not transmitted thru breast milk)

XIII. ASSOCIATED PROBLEMS 1. Engorgement breast becomes full, tense and hot  with throbbing pain expected to occur on the 3rd post partum day accompanied by fever (milk fever)last  for 240 due to increased lymphatic and venous circulation Nursing care: o encourage breastfeeding o advise use of firm-supportive brassiere o (if not going to breastfeed – apply cold compress; no massage; no breast pump; apply breast binder) 2. Sore Nipples Nursing care: encourage to continue BF expose nipples to air for 10 – 15 minutes after feeding (alternative) exposure to 20 watt bulb placed 12 – 18 inches away promotes

vasodilation and therefore promote healing do not use plastic liners use nipple shield 3. Mastitis inflammation of the breast Signs & Symptoms: pain, swelling, redness, lumps in the breasts, milk becomes scanty Nursing Care: Ice compress Supportive brassiere , empty breast with pump Discontinue BF in affected breast Apply warm dressing to increase drainage Administer antibiotics as prescribed *** Postpartum Check-up: 6th week postpartum to assess involution

XIII. HIGH RISK PREGNANCY  CONDITIONS 1. Infections 2. Bleeding / Hemorrhage/ PIH 3. Diabetes Mellitus 4. Heart Disease 5. Multiple Pregnancy 6. Blood Incompability 7. Dystocia 8. Induced Labor 9. Instrumental Deliveries 1. INFECTIONS 1.1.Syp hi l i s Cause:  Treponema pallidum - a spirochete transmitted thru sexual intercourse  Treatment: 2.4 – 4.8 million units of Penicillin (or 30 – 40 gms Erythrocin) x 10 days readily cross placenta thus prevent congenital syphilis Untreated: Cause mid-trimester abortion Cause CNS lesions Can cause death 1.2. TORCH test series  TOxoplasmosis (protozoa) avoid eating uncooked meat and handling cat litter box Others: Syphilis, Varicella/ Shingles Hepatitis B; Hepatitis A; AIDS Rx – Zoster Immune Globulin ,Penicillin RUbella Effect: if contracted early, slows down cell division during organogenesis causing congenital defects NB can carry and transmit the virus for about 12 – 24 months after birth CYtomegalovirus (CMV) (DNA virus) Herpes type 2

Group of maternal systemic infections that can cross the placenta or by ascending infection(after rupture of membranes) to the fetus. Infection early in pregnancy may produce fetal deformities, whereas late infections may result in active systemic disease and/or CNS involvement causing severe neurological impairment or death of newborn Sources/ Cause: 1. Endogenous/primary sources - normal bacterial flora 2. Exogenous sources - hospital personnel, excessive obstetric manipulations breaks in aseptic techniques, coitus late in pregnancy premature rupture of membranes General symptoms: malaise, anorexia, fever, chills and headache Management: Complete Bedrest Proper Nutrition Increased Fluid Intake Analgesics Antipyretics and antibiotics as ordered 1.3. Infection of the perineum Signs & Symptoms: pain, heat, feeling of  pressure, inflammation of suture line with 1 –2 stitches sloughed off  temperature elevation Management: drain area & resuturing ; sitz bath & warm compress 1.4.End o me t ri ti s - An infection/inflammation of the lining of the uterus Signs & Symptoms: Abdominal tenderness Uterus not contracted and painful to touch Dark brown Foul smelling lochia Management: Oxytocin administration Fowler’s position to drain out lochia Prevent pooling of discharges 1.5.Thro mb o p hl e b it i s -infection of the lining of a blood vessel with formation of clots, usual an extension of  endometritis Signs & Symptoms: o1 Pain o2 Stiffness and redness in the affected part of  the leg o3 Leg begins to swell below the lesion because venous circulation has been blocked o4 Skin is stretched to a point of shiny whiteness, called milk leg

of  Phlegmasia alba dolens o5 Positive Homan’s sign: calf pain on dorsiflexing the foot Specific Management: 1bed rest with affected leg elevated 2a nticoagulants (e.g. Dicumarol or Heparin) to prevent formation or extension of a thrombus Side effect of Anticoagulant: hematuria, increased lochia Considerations: 1 discontinue breastfeeding 2 monitor prothrombin time 3 have Protamine Sulfate at bedside to counter act severe bleeding 4 analgesics are given but not ASPIRIN because it prevents prothrombin formation which may lead to hemorrhage 2. HEMMORRHAGE/ BLEEDING Definition: blood loss more than 500 cc. ( normal blood loss 250- 350 cc) *** Leading cause of maternal mortality associated with childbearing 2.1. Early Post-partum hemorrhage – first 24 hrs after delivery 2.2. Late Postpartum Hemorrhage Early Post-partum hemorrhage Late Postpartum Hemorrhage Cause Uterine Atony – uterus is not well contracted, relaxed or boggy (most frequent cause) Lacerations Hypofibrinogenemia Clotting defect Retained Placental Fragments Management Bleeding in Pregnancy blood transfusion D & C (Dilatation and Curettage Predisposing factor: Overdistension of the uterus (multiparity, large babies, polyhydramnios, multiple pregnancies) Cesarean Section Placental accidents (previa or abruptio) Prolonged and difficult labor Management: Massage –first nursing action Ice compress Oxytocin administration Empty bladder Bimanual compression to explore retained placental fragments Hysterectomy (last alternative) 2.3.He mat o ma - Due to injury to blood vessels in the perineum during delivery

Incidence: Commnon in precipitate delivery and those with perineal varicosities  Treatment: 1 Ice Compress in first 24 hours 2 Oral Analgesics as prescribed 3 Site is incised and bleeding vessel ligated 2.4. Pregnancy Induced Hypertension (PIH) - A vascular disease of unknown cause - Occurs anytime after the 24th wk of gestation up to 2 wks PP - Develops during pregnancy and resolves during postpartum period Predisposing Factors: a. large fetus b. Older than 35, younger than 17 c. primigravida d. multiple pregnancy or H mole e. poor nutrition f. Hx of DM, renal and vascular disease g. Morbid obesity or weight less than 100 lb h. Family history Diagnosis: Roll – over test : Assess the probability of  developing toxemia when done between the 28th and 32nd week of pregnancy. Procedure of Roll-over test: 1 Patient in lateral recumbent position for 15 minutes until BP Stable 2 Rolls over to supine position 3 BP taken at 1 minute and 5 minutes after roll over 4 Interpretation: If diastolic pressure increases 20 mmHg or more, patient is prone to Toxemia  Types of Pregnancy Induced Hypertension (PIH): a. Transient hypertension - without proteinuria or edema b. Pre-eclampsia, mild o BP of 140/90 mmHg or increase of 30/15mmHg o 2+ to 3+ proteinuria o begins past 20th week o slight generalized edema may be present, weight gain of 1- 5 lbs/wk c. Pre-eclampsia, severe o BP of 150-160/100-110 mmHg o 4+ proteinuria (5 gm/L or more in 24 hrs o Headache and epigastric pain(aura to convulsions) o Oliguria of 400 ml or less in 24 hrs. (normal UO/day 1500 ml) o Cerebral or visual disturbances d. Eclampsia - Obstetrical Emergency o HPN o Proteinuria o Convulsions o Coma Immediate Intervention for Eclampsia: a. Maintain IV line with large-bore needle

b. Monitor fluid balance c. Minimize stimuli d. Have airway and oxygen available e. Give medications as ordered (e.g Magnesium sulfate, Apresoline, Valium) f. Prepare for possible delivery of fetus g. Monitor fetal status h. Type and cross match for blood i. Postpartum- monitor vital signs and watch for seizure Management for Eclampsia: a. Digitalis (with Heart Failure) Increase the force of contraction of the heart  decrease heart rate Nursing Considerations: Check CR prior to administration ( do not give if  CR <60/min) b. Potassium supplements – prevent arrhythmias c. Barbiturates – sedation by CNS depression d. Analgesics; antihypertensives, antibiotics, anticonvulsants, sedatives e. Magnesium Sulfate – drug of choice Action: CNS depressant ; Vasodilator Antidote: Calcium Gluconate- given 10% IV to maintain Cardiac and vascular tone Earliest sign of MgSO4 toxicity  disappearance of  knee  jerk/patellar reflex Method of delivery – preferably Vaginal but if not possible CS Prognosis: the danger of convulsions is present until 48 hrs postpartum f. Cathartic – cause shift of fluid from the extra cellular spaces into the intestines from where the fluid can be excreted Dosage: 10 gms initially –either by slow IV push over 5 – 10 minutes or deep IM, 5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100 ml D10W), Check first the ff. before administration: 1 Deep tendon reflexes are present 2 Respiratory rate = 12 / min 3 UO = at least 100 ml / 6 hrs. Nursing Intervention: a. Advised bedrest, left lateral bb . . Encourage a well-balanced diet c. Weigh daily, keep daily log

dd . . Education on self – assessment e. Diversion f. Family support e.Post-delivery PIH o with Disseminated Intravascular Coagulation – anticoagulant therapy o Monitor blood pressure for 48 hours Diagnosis:Roll – over test : Assess the probability of developing toxemia when done between the 28th and 32nd week of pregnancy. Procedure on Roll-over test: 5 Patient in lateral recumbent position for 15 minutes until BP Stable 6 Rolls over to supine position 7 BP taken at 1 minute and 5 minutes after roll over 8 Interpretation: If diastolic pressure increases 20 mmHg or more, patient is prone to Toxemia Management: a. Digitalis (with Heart Failure) Increase the force of contraction of the heart  decrease heart rate Nursing Considerations: Check CR prior to administration ( do not give if  CR <60/min) b. Potassium supplements – prevent arrhythmias c. Barbiturates – sedation by CNS depression d. Analgesics; antihypertensives, antibiotics, anticonvulsants, sedatives e. Magnesium Sulfate – drug of choice Action: CNS depressant ; Vasodilator Antidote: Calcium Gluconate- given 10% IV to maintain Cardiac and vascular tone Earliest sign of MgSO4 toxicity disappearance  of knee jerk/patellar reflex Method of delivery – preferably Vaginal but if not possible CS Prognosis: the danger of convulsions is present until 48 hrs postpartum f. Cathartic – cause shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: 10 gms initially –either by slow IV push over 5 – 10 minutes or deep IM, 5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100 ml D10W), May administer if : 4 Deep tendon reflexes are present

5 Respiratory rate = 12 / min 6 UO = at least 100 ml / 6 hrs. 3. DIABETES MELLITUS a. Chronic hereditary disease characterized by marked hyperglycemia b. Due to lack or absence of insulin  abnormalities in CHO, fat and protein metabolism c. Effects of pregnancy – may develop abnormalities in glucose tolerance decreased renal threshold for sugar due to increased estrogen, inc. production of  adenocorticoids, Anterior Pituitary hormones, and thyroxin which affect CHO concentration in blood (hyperglycemia) d. Rate of insulin secretion is increased but sensitivity of the pregnant body to insulin is decreased Pregnancy Risks: 1  Toxemia 2I nfection 3 Hemorrhage 4 Polyhydramnios 5 Spontaneous abortion – because of vascular complications which affect placental circulation 6 Acidosis – because of nausea and vomiting 7 Dystocia – due to large baby Diagnosis : Glucose Tolerance Test (GTT) Procedure for GTT: NPO after midnight 2 ml of 50% glucose / 3 kg of pre-pregnant body weight given IV (oral glucose not advisable due to decreased gastric motility and delayed absorption of sugar during pregnancy) Interpretation of Results: a. If less than 100 mg% = normal b. If 100 – 120 mg% possible GDM c. If more than 120 mg% - overt gestational diabetes Management: a. Diet - highly individualized- adequate glucose intake (1,800 – 2200 calories) to prevent intrauterine growth retardation b. Insulin requirements – individualized; increased during 2nd

and 3rd trimester because of more pronounced effect of  hormones c. Method of Delivery – Cesarian Section d. Postpartum Period – more difficult to control Blood Glucose because of hormonal changes Effect on Infant: a.  Typically longer and weighs more due to: excessive supply of  glucose from the mother b. Increased production of growth hormone from maternal pituitary gland c. Increased secretion of insulin from the fetal pancreas d. Increased action of adrenocortical hormone that favor the passage of glucose from mother to fetus congenital anomalies are often seen e. Cushingoid appearance (puffy, but limp and lethargic) f.Born premature more often – RDS common g. Greater weight loss because of loss of extra fluid h. Prone to hypoglycemia (BG <30 mg%) Signs and symptoms of Diabetic Babies/ Hypoglemic Infant: a. Shrill, high pitched cry b. Listlessness/jitteriness/tremors c. Lethargy/poor suck d. Apnea/cyanosis e. Hypotonia; hypothermia ***Consequence of hypoglycemia: untreated hypos brain damage  and even death ***Management: feed with glucose water earlier than usual, or administer IV of glucose 4. HEART DISEASE Classification: Class I - no physical limitation Class II - slight limitation of physical activity - Ordinary activity causes fatigue, palpitation, dyspnea, or angina Class III

- moderate to marked limitation of physical activity; less than ordinary activity causes fatigue Class IV -unable to carry on any activity without experiencing discomfort Prognosis: Classes I & II – normal pregnancy & delivery Classes III & IV – poor candidates Signs & Symptoms: Heart murmur due to increased total cardiac volume Cardiac output decreased  nutritional and oxygen requirements not met Incomplete emptying of the left side of the heart Pulmonary edema and HPN (moist cough in Gravidocardiacs  danger sign) Congestion of liver and other organs due to inadequate venous return  increased venous pressure  fluid escapes through the walls of  engorged capillaries and cause edema and ascites CHF is a high probability due to increased CO during pregnancy  dyspnea, exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of  nailbeds are obvious Management: (depends on cardiac functional capacity) a. Bed rest – especially after 30th week of  gestation b. Diet – gain enough (consider effect on cardiac workload) c. Medications: Digitalis, Iron preparations d. Avoid lithotomy position to avoid increase in venous return, place in semisitting position e. Not allowed to bear down; Birth is via low forceps or Cesarean section f. Anesthetic choice – caudal anesthesia g. Ergotrate and other oxytoxics, scopolamine, diethylstilbestrol and oral contraceptives – h. contraindicated  can cause fluid retention and promote thromboembolism i. Most critical period: immediate postpartum period when 30 – 50% increased blood volume  j. is reabsorbed back in 5 – 10 minutes and the weak heart needs to adjust 5. MULTIPLE PREGNANCY Risks: Increased Blood Loss Small for Gestational Age Infants Premature Birth Dystocia Management: a. Monitor FHT, VS, weight b. Cesarean Section

c. Health Teaching on importance of regular prenatal check-up visits d. Educate regarding proper nutrition and exercise 6. BLOOD INCOMPATIBILITY - An antigen-antibody reaction which causes excessive destruction of fetal red blood cells Mother Fetus Rh- negative Rh Positive (Father is homozygous or heterozygous Rh positive) BloodType O Either Type A or B (From father) 7. DYSTOCIA - broad term for abnormal or difficult labor and delivery Uterine Inertia – sluggishness of contractions Cause: Inappropriate use of analgesics Pelvic bone contraction Poor fetal position Overdistention – due to multiparity, multiple pregnancy, polyhydrmanios or excessively large baby Management: Stimulation of labor by oxytocin administration or amniotomy 7.1. Precipitate Delivery - labor and delivery that is completed in < 3 hours due to multiparity or followingoxytocin administration or amniotomy Effects: Extensive lacerations Abruptio placenta Hemorrhage due to sudden Release of pressure  shock 7.2. Prolonged Labor - Usually occurs in primi gravida - Labor lasting more than 18 hrs and in multigravidas, more than 12 hours Effects: Maternal exhaustion Uterine atony Caput succedaneum 7.3. Uterine Inversion - fundus is forced through the cervix so that the uterus is turned inside out - Insertion of placenta at the fundus, so that as fetus is rapidly delivered, fundus is pulled down - Strong fundal push, attempts to deliver the placenta before signs of separation -Management: Hysterectomy 8. INDUCED LABOR - Stages of labor and birth occurs due to chemical or mechanical means which is usually performed to save the mothe or fetusr from complications which may cause death Indications: Maternal – toxemia Placental accidents

Premature Rupture Of Membrane Fetal: DM – terminated at about 37 wks AOG if  indicated Blood incompatibility Excessive size Postmaturity Prerequisites to Induce Labor : No Cephalo- Pelvic Dislocation Fetus is already viable >32 weeks AOG Single fetus in longitudinal lie and is engaged Ripe cervix – fully or partially effaced; Cervical Dilatation at least 1=2 cm Procedure for Induced labor: 1. Oxytocin Administration; 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8 gtts/min given initially no fetal distress in 30 minutes  rate 16 -20 gts/min 2. Amniotomy – done with Cervical Dilatation = 4 cm ; Check FHR and quality of amniotic fluidNursing Considerations: Monitor uterine contractions  potential for rupture Monitor flow rate regularly  Turn off IV with any abnormality in FHR or contractions Watch out for complications: HPN, Antidiuresis Prostaglandin administration: Route: oral or IV (never IM causes irritation); effect is slower than oxytocin 9. INSTRUMENTAL DELIVERIES a. Forceps Delivery - Use of metal instruments to extract the fetus from the birth canal, when at +3 / +4 and sagittal suture line is in an AP position in relation to the outlet (e.g. Simpson, Elliot, Piper for breech presentation) Purposes: shorten second stage of labor because of fetal distress; maternal exhaustion; maternal disease – cardiac, pulmonary complication ineffective pushing due to anesthesia prevent excessive pounding of fetal head against perineum (low forceps for prematures) poor uterine contraction or rigid perineum Prerequisites: Pelvis adequate, no disproportion Fetal head is deeply engaged Cervix is completely dilated and effaced Membranes have ruptured Vertical presentation has been established  The rectum and bladder are empty Anesthesia is given for sufficient perineal Relaxation and to prevent pain  Types: Low or Mid Forceps Delivery Complications: Forceps marks – noticeable only for 24 – 48 hrs Bladder or rectal injury Facial paralysis

Ptosis Seizures Epilepsy Cerebral Palsy a. Cesarean Section – birth through a surgical incision on the abdomen Indications: o Cephalo-pelvic disproportion (CPD) o Severe Toxemia o Placental Accidents o Fetal Distress o Previous classic CS – done prior to onset of  labor pains; scheduled birth  Types: 1. Low Segment – the method of choice. Incision is made in the lower uterine segment, which is the thinnest and most passive Part during active labor. Advantages:Minimal blood loss Incision is easier to repair Lower incidence of post partum infection No possibility of uterine rupture 2. Lower vertical incision – recommended in: Bladder or lower uterine segment Adhesions from Previous operations Anterior Placenta Previa  Transverse lie Preoperative Care a.  The patient is both a surgical and an OB patient b. Check vital signs, uterine contractions, and FHR c. Physical examination; routine laboratory tests; blood typing and cross matching d. Abdomen is shaved from the level of the xiphoid process below the nipple line, extending out to the flanks on both sides up to the upper thirds of the thighs e. Retention catheter is inserted to constant drainage to keep the bladder away from the operative site f.Preoperative medication is usually only atropine sulfate. No narcotics are given causes respiratory  depression in the NB Postoperative Care a. Deep breathing, coughing exercises, turning from side to side b. Ambulate after 12 hours c. Monitor vital signs

d.Watch for signs of hemorrhage – inspect lochia; feel fundus (if  boggy, massage with proper abdominal splinting and give analgesics as ordered) e. Breastfeeding should be started 24 hrs after delivery f. Most common complication: Pelvic thrombosis 10. OTHER RISK FACTORS: 10.1.Ag e : - Maternal and infant mortality rates tend to be high in age below 15 and older than 40 years Adolescent pregnancy Advanced age Most common problems:  Toxemia A precipitating factor in: Placental accidents Iron-deficiency anemia  Toxemia Uterine atony or inertia Varicosities; hemorrhoids Low birth weight babies C Ch hr ro om mo os so om ma al lA Ab bn no or rm ma al li it ti ie es sl li ik ke eD Do ow wn n’ ’s s S

Sy yn nd dr ro om me e/ /T  Tr ri is so om my y2 21 1 (associated with menopause) 10.2.Pari t y – first pregnancy is the period of high risk Multiparity G5 and above and age is over 40 10.3. Birth Interval – 3 months from previous delivery or more than 5 years 10.4. Weight Pre-pregnant weight < 70 lbs or > 180 lbs Weight gain < 10 lbs  LBW babies Weight gain > 30 lbs = sign of toxemia; DM; Hmole; polyhydramnios; multiple pregnancy 10.5. Height Short stature < 4 feet, 10 inches = contracted pelvis or CPD

XIV. MATERNAL COMPLICATIONS 1. Spontaneous Abortion  Termination of pregnancy spontaneously at any time before the fetus has attained viability Assessment: 1. Persistent uterine bleeding and cramplike pain 2. Laboratory finding – negatively or weakly positive urine pregnancy test 3. Obtain history, including last menstrual period 2. Ectopic Pregnancy - Any gestation outside the uterine cavity Causes of Ectopic Pregnancy: a. Pregnancy Induce Hypertension b. Previous tubal surgery c. Congenital anomalies of the fallopian tubes Signs & Symptoms: 1 Severe, sharp, knife-like stabbing pain 2 Rigid abdomen 3 Positive Cullen’s sign (bluish umbilicus) 4 Excruciating pain on IE 5

Signs of shock Management: Ruptured Ectopic Pregnancy is an emergency requiring immediate intervention Salpingostomy – if Fallopian tube can still be replaced and preserved,pregnancy is terminated Saphingectomy – removal of FT and BT Nursing Interventions: 1 Help woman to combat shock 2 Elevate foot of the bed 3 Maintain body heat 4 Prepare for surgery 5 Monitor for shock preoperatively and postoperatively 6 Provide emotional support and expression of grief  7 Administer Rhogam to Rh negative women 8 Discharge teaching 3. Hydatidiform Mole (H-Mole) -Degenerative anomaly of chorionic villi Signs & Symptoms: 1. Elevated hCG levels marked  nausea & vomiting 2. Uterine size greater than expected for dates 3. No FHR 4. Minimal dark red/brown vaginal bleeding with passage of grapelike clusters 5. No fetus by ultrasound 6. Increased nausea and vomiting and associated with PIH Management: 1. Curettage to completely remove all molar tissue that can become malignant 2. Pregnancy is discouraged for 1 year 3. hCG levels are monitored for 1 year (if  continue to be elevated, may require hysterectomy and chemotherapy) 4. Contraception discussed; IUD not used 4. Incompetent Cervical Os One that dilates prematurely Chief cause of habitual abortion ( 3 or more) Causes: 1 Congenital Developmental Factors 2 Endocrine factors 3  Trauma to the cervix Signs & Sypmtoms: 1 Presence of show and uterine contractions 2 Rupture of membranes, Painless cervical dilatation 5. Incompetent Cervix

6. Placenta Previa – the placenta is the presenting part 1. First and second trimester spotting 2. Third trimester bleeding that is sudden, profuse, painless 3. Ultrasonography – classified by degree of  obstruction Management: 1 Hospitalization, initially 2 Bedrest side-lying or Trendelenberg position for at least 72 hrs. 3 Ultrasound to locate placenta 4 No vaginal, rectal exam unless delivery would not be a problem (if necessary must be done in OR under sterile conditions) 5 Amniocentesis for lung maturity; monitor for changes in bleeding and fetal status 6 Daily Hgb and Hct 7  Two units of crossmatched blood available 8 Monitor amount of blood loss 9 Send home if bleeding ceases and pregnancy is maintained 10 Limit activity 11 No douching, enemas, coitus 12 Monitor fetal movement 13 NST at least every 1 – 2 weeks 14 Monitor complications 15 Delivery by cesarean if evidence of fetal maturity, excessive bleeding, active labor, other complications 7. Abruptio Placenta Signs & Symptoms: 1. Painful vaginal bleeding 2. Abdomen (uterus) is tender, painful, tense (couvelaire uterus) 3. Possible fetal distress 4. Contractions (Occurrence increased with maternal HPN and cocaine abuse; sudden release of  amniotic fluid; short cord; advanced age; multiparity; direct trauma; hypofibroginemia) Management: a. Monitor maternal and fetal progress

b. Blood loss seen may not match symptom c. Could have rapid fetal distress d. Prepare for immediate delivery e. Monitor for post partal complications Predisposing Factors: b. Disseminated intravascular coagulation c. Pulmonary emboli d. Infection e. Renal failure f. Transfusion hepatitis Nursing Intervention: Bedrest Vital signs, FHT Monitor intake and output Seizure precautions Medications (Magnesium sulfate, Apresoline, Valium) 8. Uterine Rupture -occurs when the uterus undergoes more straining than it is capable of  sustaining Cause: Scar from previous CS Unwise use of oxytocins Overdistention Faulty presentation Prolonged labor Signs & Sypmtoms: Sudden severe pain Hemorrhage and clinical signs of shock Change in abdominal contour (two swelling on the abdomen due to retracted uterus and the extrauterine fetus) Management: Hysterectomy 9. Amniotic Fluid Embolism – (Obstetric Emergency) – occurs when amniotic fluid is forced into an open maternal uterine flood sinus through some defect in the membranes or after partial premature separation of the placenta. Solid particles in the amniotic fluid enter maternal circulation and reach the lungs as emboli Signs and symptoms: Dramatic Sudden inability to breathe, sits up, grasps chest and sharp chest pain  Turns pale then  bluish gray color