Ob Penta Notes

MATERNAL/OB NOTES I. Human Sexuality A. Conc Concep epts ts

A person’s person’s sexuality encompasses the complex behaviors, attitudes, emotions and preferences that are related to sexual self and eroticism. 2. Sex – is basic and dynamic aspect of life 3. During reproductive years, the nurse performs as resource person on human sexuality. 1.

B. Definiti Definitions ons relat related ed to sexua sexuality lity::

Gender identity – sense of femininity or masculinity 2 - 4 years / 3 years gender identity develops. Role identity – attitudes, behaviors and attributes a ttributes that differentiate roles. Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse. Sexuality - behavior of being boy or girl, male or female; man or woman. - It is an entity subject to a life long dynamic change. - developed at the moment of conception. II. Sexual Anatomy and Physiology A. Female Reproductive System 1. External  - vulva or pudendum

- a pad of fatty tissues tissues that lies over the symphysis pubis covered by skin and at puberty covered by short pubic hair that serves as cushion or protection to the symphysis pubis and surrounding delicate tissues from trauma.

a. Mons Mons pu pubi bis/ s/ve vene neri riss

Tannerscale -

tool used to determine sexual maturity rating.

Stages of Pubic Hair Development Stage 1 – Pre-adolescence - No pubic hair except for fine for fine body hair only Stage 2 – Occurs between ages 11 and 12 – sparse, – sparse, long, slightly pigmented & curly

hair along the labia . hair along Stage 3 - occurs between ages 12 and 13 – hair becomes darker & curly hair that hair that develops along symphysis pubis. Stage 4 – occurs between ages 13 and 14. Hair assumes the normal appearance of  an adult but is not so thick and thick and does no appear to the inner aspect of the upper thigh. Stage 5 - sexual maturity - normal adult - appear to the inner aspect of thigh. b. Labi Labia a Majo Majora ra – means “large lips” - a longitudinal fold, that extends from the symphysis

 pubis to the perineum; Two folds of skin with fat underneath; contain Bartholene’s glands c. Labia Mino inora – means “nymphae” – a soft and thin longitudinal fold that is located in  between the labia majora; two thin folds of delicate d elicate tissues; form an upper fold encircling encirc ling the clitoris called the prepuce and unite posteriorly called the fourchette.

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2 sensitive structures of labia minora: c.1. clitoris – means “key” “key”-- anterior, pea shaped erectile tissue composed of so many

nerve endings which is the sight of sexual arousal in female. (Greek-key)

c.2. fourchette - Posterior, tapers posteriorly of the labia minora

- very sensitive to manipulation, oftenly torn during vaginal delivery. - common site – episiotomy – episiotomy..

d. Vesti stibu bulle – an almond shaped , narrow space area seen when the labia minora are separated,

that contains the hymen, vaginal orifice or ifice and bartholene’s glands.

small opening of urethra that serves for urination; external opening of  i. Urinary Meatus  – small ii. iii. iv. iv. v.

the urethra; slightly behind and to the side are the openings of the Skene’s Glands.  Skenes Glands/or Paraurethral Gland  –  – two small mucous secreting substances that serve for lubrication; often involved in infections of the the external genitalia.  Hymen – a membranous tissue tissue that covers vaginal orifice, membranous tissue * Carumculae mystiforms - healing of a torn hymen Vaginal Orifice O rifice  – external opening of vagina  Bartholene’s Glands/or Paravaginal Gland or Vulvo Gland  - 2 small mucus secreting substance that secrets alkaline substances- responsible for the acidity of the vagina. ( Believed to secrete a yellowish mucous which acts as a lubricant during sexual intercourse. The openings are located posteriorly on either side of the vaginal orifice)  Alkaline – neutralizes acidity of vagina  Ph of vagina - acidic  Doderleins bacillus – responsible for acidity of vagina

e. Perineum – a muscular structure that is located in between the lower vagina & anus;

contains muscles which support the pelvic organs, the arteries that supply blood and the  pudendal nerves which are important during delivery under anesthesia.

2. Internal: A. Vagina – female organ of copulation; passageway of menstruation & fetus

- it is 3 – 4 inches or 8 – 10 cm long of dilated canal located between the bladder and the rectum. Contains* Rugae – permits considerable amount of stretching without tearing

Organ of menstruation, site of implantation and retainment and an d nourishment of  the products of conception. It is a hollow, hollow, thick walled muscular organ. It varies in size, shape and weights. Size - 1 inch thick; 2 inches wide; 3 inches long Shape: non pregnant = pear shaped or inverted avocado Pregnant = ovoid Weight : Non pregnant: – 50 - 60 grams Pregnant: - 1000 grams th 4 stage of labor - 1000 grams 2 weeks after delivery - 500 grams 3 weeks after delivery - 300 grams Normal Normal State State - 5 - 6 weeks weeks after after delivery delivery - 50 – 60 grams grams

B. Uterus -

 Entire Process is “Involution of Uterus” 

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Three parts of the uterus

- upper cylindrical cylindrical layer  1. fundus 2. cor corpus/b s/body ody - upper triangular layer  3. cervix - lower cylindrical layer  * Isthmus – known at the lower uterine segment during pregnancy * Cornua - junction between fundus & interstitial there are three main muscle layers which make expansion possible in every direction. 1. Endometr etrium ium - inside uterus, in lines the nonpregnant uterus. Muscle layer for  menstruation. Sloughs off during menstruation. * Decidua - thick layer; Once implantation has taken place, the uterine endothelium is termed decidua. Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting trophoblasts = implantation bleeding . . .  Implication: this should not be mistaken for the LMP(Last Menstrual Period) *Endometriosis – “ectopic endometrium” abnormal proliferation of endometrial lining outside uterus. Common site: ovary. ovary. Signs/symptoms: persistent dysmennorhea and low back pain. Diagnostic test: biopsy, laparoscopy Drug of choice: 1. Danazole (Danocrene) Action:: a. to stop menstruation Action b. inhibit ovulation 2. Lupreulide (Lupron) Action: a. inhibit FSH/LH production Muscular compositions:

2. Myometr etrium ium – largest part of the uterus

- it is the the muscle layer responsible for delivery process - it is a smooth muscles considered to be the living ligature of the body. - power of labor, labor, responsible for the contraction of the uterus

3. Perim rimetrium ium

– muscle layer that protects entire uterus

 Almond shape, dull white sex glands near the C. Ovaries –  Almond 2 female sex glands that serves for two functions: 1. ovulation 2. Production of two hormones

fimbrae, kept in place by b y ligaments.

– 2 - 3 inches long that serves as a passageway a passageway of the sperm from the uterus to the ampulla of the passageway the passageway of the mature ovum of fertilized ovum from the ampulla to the uterus. Widest part (ampulla) spreads into fingerlike projections pr ojections called (fimbrae) responsible for the transport of mature ovum from ovary to uterus; fertilization takes place in its outer third or outer half.

D. Fallopian tubes

4 significant segments shaped, swollen 1. Infundibulum – most distal part of Fallopian Tube, trumpet or funnel shaped,

at ovulation 2. Ampulla – outer 3rd or 2nd half, site of fertilization 3. Isthmus – site – site of sterilization – bilateral tubal ligation Interstitial – most most dangerous site of ectopic pregnancy 4. Interstitial –  * Cortex of the ovary – releases the matured ovum

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B. Male Reproductive System 1. External  Penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of 

3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – female – the glands penis. 3 Cylindrical Layers

2 corpora cavernosa 1 corpus spongiosum

 Scrotum  – a pouch hanging below the pendulous penis, with a medial septum dividing into

two sacs, each of which contains c ontains a testes. It is the cooling mechanism mechan ism of testes - < 2 degrees C than body temperature  Leydigs cell   – release testosterone * pure sperm plus secreting substance equals SEMEN* 2. Internal

The Process of Spermatogenesis Spermatogenesis –  maturation of sperm Testes – 900 coiled (½ inch long

at age 13 onwards) (Seminiferous tubules)

Hypothalamus will release

Epididymis – 6 meters coiled

tubules site for maturation of sperm

GnRH Gonadotropin releasing hormone

Vas Deferens – conduit for 

spermatozoa or pathway of sperm Entry of pure sperm

Anterior Pituitary Gland release

Seminal vesicle – secretes:

FSH

LF

1.) Fructose – form glucose that has nutritional value. 2.) Prostaglandin – causes reverse contraction of uterus

Follicle Stimulating Hormone

Luteinizing Hormone Ejaculatory duct

Function: Sperm Maturation

Function: Hormones for  Testosterone Production

– conduit of semen

Prostate gland - release alkaline substance

Cowpers gland - release alkaline substance

Urethra

Final link from anterior to posterior 

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Male and Female homologues Male Female

Penile glans Penile shaft Testes Prostate Cowper ’s Glands Scrotum

Clitoral glans Clitoral shaft Ovaries Skene’s gands Bartholene's glands Labia Majora

III. Basic Knowledge on Genetics and Obstetrics 1. DNA – carries genetic code 2. Chromosomes – threadlike strands composed of hereditary material known as DNA 3.  Normal amount of ejaculated sperm - 3 – 5 cc., 1 tsp 4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation 5. Sperm is viable within 48 – 72 hours or 2 - 3 days divides by the process of meiosis of meiosis (haploid) (haploid) 6. Reproductive cells divides

Spermatogenesis – maturation maturation of sperm Oogenesis – process - maturation of ovum Gametogenesis – Gametogenesis  – process of formation of 2 haploid into diploid 23 + 23 = 46 or diploid diploid 7. Age of Reproductivity – 15 – 15 – 44 years years old 8. Menstruation Menstrual Cycle – beginning of menstruation to the beginning of the next menstruation Average Menstrual Cycle – 28 – 28 days Average Menstrual Period - 3 – 5 days  Normal Blood loss – 50 – 50 cc or ¼ cup with fibrinolysin to prevent clot formation Related terminologies: Menarche – the beginning or the 1st menstruation  painful menstruation Dysmenorrhea –  painful  Metrorrhagia – bleeding at completely irregular intervals of menstruation Polymenorrhea –  frequent  frequent menstruation occurring at intervals of less than three weeks Menorhagia – excessive bleeding during regular menstruation Amenorrhea – absence of menstruation Oligomenorrhea – marked diminished menstrual flow, nearing amenorrhea Menopause – cessation of menstruation / average : 51 years old 9. Functions of Estrogen and Progestin Woman” * Estrogen “Hormone of the Woman”  Primary function: responsible for the development of  secondary   secondary sexual characteristic of female. enlargement of the breast  pelvic axillary  pubic hair  • • • •

Others: 1. inhibit production of FSH ( maturation of ovum) 2. responsible for the hypertrophy of myometrium 3. responsible for Spinnbarkeit & Ferning ( billings method/ cervical) 4. responsible for the development of ductile structure of the breast ac tivities of long bones causing increase 5. responsible for the increase osteoblast activities

in height in female 6. responsible for the early closure of epiphysis of long bones 7. responsible for sodium retention

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8.

responsible for the increase sexual desire

* Progestin “ Hormone of the Mother”  Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous (twisted) Secondary Function: It decreases contractility of the uterus (favors pregnancy) Others: 1. It inhibit the production of LH (hormone for ovulation) 2. It decreases GIT motility

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decreases Peristalsis ↓ increase Water Reabsorption ↓ CONSTIPATION

3. responsible for the development of mammary gland 4. responsible for the increase permeability of kidney to lactose & dextrose causing (+) sugar  5. responsible for mood swings in woman 6. responsible for the increase Basal Body Temperature 10. Menstrual Cycle: average – 28 days 4 phases of Menstrual Cycle 1.1. Proliferative 1.2. Secretory 1.3. Ischemic 1.4. Menses  Parts of body responsible for menstruation: 1. hypothalamus 2. anterior pituitary gland – masterclock – masterclock of the body 3. ovaries 4. uterus I. Initial phase – of menstruation, the estrogen level is ↓ , this level stimulates the hypothalamus to

release GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing Factor) rd 3 day – Decreased – Decreased estrogen th 13 day – Peak  – Peak estrogen, estrogen, Decrease progesterone th 14 day – Increase – Increase estrogen, Increase Increase progesterone  progesterone th 15 day – Decrease – Decrease estrogen, Increase Increase progesterone  progesterone

II.

GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing Factor)  – stimulates the anterior pituitary gland to release r elease FSH (Follicle Stimulating

Hormone)

Functions of FSH : A. Stimulate ovaries to release estrogen B. Facilitate growth primary follicle to become graffian g raffian follicle

(structures that secrets large large amount of estrogen & contains mature ovum.)

III.

– contains mature ovum (ovulation)  proliferation of tissue → follicular phase → post menstrual phase → Preovularoty Phase Follicular Phase – causing irregularities or variations of menstruation; 14th days Postmenstrual Phase – occurs after menstruation day Preovulatory Phase – happens before menstruation day Proliferativ tive Phase

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“ all phases – increase ESTROGEN ” IV. IV.

13th day of menstruation, estrogen level is peak  is peak while while the progesterone level is down down,, these stimulates the hypothalamus to release GnRH or LHRF (Luteinizing Hormone Releasing Factor)

V.

GnRH/LHRF GnRH/LH RF stimulates stimulat es the anterior pituitary gland to release LH(Luteinizing Hormone) Functions of LH: 1. LH stimulates ovaries to release progesterone 2. hormone for ovulation

VI.

14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of  ovulation. Signs and symptoms:

Mittelschmerz – slight abdominal pain on Left or Right lower Quadrant of abdomen, marks ovulation day. day. 2.) Change in Basal Ba sal Body Temperature 3.) Mood Swing 4.) Constipation 1.)

VII.

15th day, day, after ovulation day, graafian follicle starts on degenerate becoming beco ming yellowish known as corpus luteum (secretes large amount of progesterone)

VIII.

Secretory phase Lutheal Phase Postovulatory Premenstrual •

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IX.

Increased progesterone

Secretory Phase – secretes the most important hormone in pregnancy which is the  progesterone because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place. It is also called progestational   phase. Luteal Phase –  change from Graafian follicle to Corpus Luteum(yellowish appearance) Postovulatory Phase –  occurs just after ovulation Premenstrual Phase –  occurs after menstruation

24th day - no fertilization, fertilization, corpus luteum degenerate turning white ( whitish – corpus albicans )

28th day – no sperm in ovum – endometrium begins to to slough off to have the next menstrual period st 1 7 days – menstrual phase th 7 – 14 days days – prol prolif ifer erat ativ ivee phas phasee 14 – 28 days – secretory phase 11. Stages of Sexual Responses (EPOR) X.

Initial responses: Vasocongestion  – congestion of blood vessels Myotonia – increase muscle tension 1. E xcitement Phase – (moderate vital signs : sign present in both sexes, moderate increase in

HR, RR,BP, RR,BP, sex flush, nipple erection) – during this phase: erotic stimuli increase sexual tension that may lasts from minutes to hours. 2. Plateau Phase – (accelerated Vital Signs) – increasing & sustained tension nearing orgasm. May lasts 30 seconds – 3 minutes. 3. Orgasm – (involuntary spasm throughout the body, peak vital signs). This is the involuntary release of sexual tension accompanied by physiologic and  psychologic release known as “immeasurable peak of sexual experience ”. 7

May last from 2 – 10 secsec- most affected are is pelvic area. esolution – (vital sign return to normal, genitals return to pre-excitement phase) 4. R esolution restimulated for about Refractory Period – the only period present in males, wherein he cannot be restimulated 10 - 15 minutes IV. IV. Wonders of Fertilization

Fornix - where sperm is deposited Sperm - small head, long tail, pearly white Phonones -vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and zona pellocida. Capacitation - ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida. A. Fert Fertil iliz izat atio ion n –  union of the sperm and the mature ovum in the outer third or outer half of the Fallopian Tube. General Consideration: 1.  Normal amount of semen semen per ejaculation - 3 – 5 cc = 1 teaspoon 2.  Number of sperms in an ejaculate = 120 – 150 million/cc 3. Mature ovum is capable of being fertilized for 24 – 36 hours after ovulation. 4. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation 5. Sperm is viable within 48 – 72 hours or 2 – 3 days 6.  Normal lifespan of sperm = 7 days 7. Sperms, once deposited in the vagina, will will generally reach the cervix within 90 seconds after  deposition. 8. Reproductive cells, during gametogenesis, divide by meiosis (haploid number of daughter cells); therefore, they contain only 23 chromosomes ( the rest of the body cells have 46 chromosomes ). Sperms have 22 autosomes and 1 X sex chromosomes chr omosomes or 1 Y sex chromosome; Ovum contain 22 autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results in a baby girl (XX); the th e union of a Y-carrying Y-carrying sperm and mature ovum results in a baby boy bo y (XY). Important: Only “ fathers”  determine the sex of their children

B. Stages Stages of Fetal Fetal Growt Growth h and Develo Developme pment nt 3 - 4 days travel of zygote → during the travel → mitotic cell division begins

*Pre-embryonic Stage a. Zygote - fertilized ovum. Lifespan of zygote – from fertilization to 2 months fetus - 2 months to birth b y ciliary action and b. Morula – mulberry-like ball with 16 – 50 cells, start to travel by  peristaltic contractions of fallopian tube to the uterus where it will stay for 4 days free floating & multiplication c. Blastocyst – enlarging cells that forms a cavity in the morulla, that later becomes the embryo. Trophoblast  – fingerlike projections covering around the blastocyst that later becomes  placenta and membrane. d. Implantation other term Nidation - occurs after fertilization 7 – 10 days.  Placenta previa – implantation at the lower side of the uterus Signs of implantation : 1. slight pain 2. slight vaginal spotting - if with fertilization – corpus – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed. * 3 processes of Implantation 1. Apposition – blastocysts begin to brush the endothelial lining 2. Adhesion – blastocysts begin to attached the endothelial lining 8

3. Invasion – blastocysts begin to settle down “Proteolytic enzyme” –  for dissolving endothelial lining allowing implantation * Embryonic Stage C. Decidua – thickened endometrium (Greek word – falling off); implantation has taken place Kinds of decidua: * Basalis (base)  part of endometrium located directly beneath or under the implanted ovum/fetus

where placenta is developed. * Capsularies – encapsulate or co the fetus * Vera – remaining portion of endometrium. D. Chorionic Villi - 10 – 11th day of pregnancy; fingerlike projections 3 vessels = two arteries, one vein A – unoxygenated blood V – O2 blood A – unoxygenated blood Wharton’s jelly – protects cord Chorionic Villi Sampling (CVS) – removal of tissue sample from the fetal portion of the developing  placenta for  genetic  genetic screening . Done early in pregnancy. Common dangerous side effects: fetal limb defect such as missing digits/toes.  Advance Maternal Age – candidate for amniocentesis E. Cytot Cytotro roph phobl oblast ast – inner layer or langhans layer of the trophoblast that gives rise to the outer  surface and villi of the chorion. - protects fetus against syphilis, syphilis, however it can be capable of living for 24 weeks/6 months - life span of langhans layer layer increase. * Before 24 weeks critical, might get infected syphilis F. Syncytiotrophoblast – syncytial layer or outer layer . It erodes the uterine wall during implantation and give rise to the villi of the placenta. It is responsible production of hormones. It is also called plasmidotrophoblast; syncytial trophoblast, syntrophoblast  Two structures developed : 1. Amnion – innermost layer. It is a membrane, continuous with and an d covering the fetal side of  the placenta that forms the outer surface of the umbilical cord. 2 structures progress: a. Umbilical Cord other term chorda umbilicalis, funiculus umbilicans, funis , a flexible

structure connecting the umbilicus with the placenta in the gravid uterus and giving  passage to the umbilical arteries and a nd vein; whitish grey, “15 – 55 cm, 20 – 21”.

* Importance of determining the length of the cord: Short cord: abruptio placenta or inverted uterus. Long cord: cord coil or cord prolapse  Newborn: 2 feet long and ½ inch in diameter; 1st formed during the 5th week of   pregnancy; it contains the yolk sac and the body stalk with enclosed allatois. b. Amniotic b. Amniotic Fluid  , also known as (BOW) bag of water, clear, odor mousy/musty, mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid: 1. cushions fetus against sudden blows or trauma 2. facilitates musculo - skeletal development and symmetrical growth 3. maintains temperature 4. prevent cord compression 5. help in delivery process

normal amount of amniotic fluid – 500 – 500 to 1000cc  polyhydramnios, hydramnios - GIT malformation (TEA) Tracheoesophageeal Atresia /(TEF) Tracheoesophageal Fistula, increased amount of fluid 9

oligohydramnios- decrease amount of fluid – kidney disease; “inom → absorbed → ihi” ih i” Diagnostic Tests for Amniotic Fluid A. Amniocentesis –  aspiration of amniotic fluid - empty bladder before bladder before performing the procedure. Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen

into the amniotic sac.

Fluid is tested for: 1. Genetic screening

/ abnormality - maternal serum alpha feto-protein test (MSAFP)  – 1st trimester  2. Determination of fetal lung maturity primarily by evaluating factors indicative of  lung maturity – 3rd trimester  trimester  2.1 Testing time – time – 36 weeks decreased MSAFP(maternal serum alpha feto-protein test) = down syndrome increase MSAFP(maternal serum alpha feto-protein test) = spina bifida or open neural tube defect Common infections amniocenthesis – infection Dangerous complications – spontaneous abortion / bleeding 3rd trimester - pre term labor; indication of diabetic mother  Important factor to consider for amniocentesis - needle insertion site Aspiration of yellowish amniotic fluid – jaundice baby / hyperbilirubin Greenish – mecomium A. Amni Amnios osco copy py – direct examination thru an intact fetal membrane. B. Fern Fern Test est - determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic fluid) C. Nitrazin Nitrazinee Paper Paper Test – diff amniotic fluid & urine. Paper turns yellow- urine. Paper turns blue green/gray -(+) rupture of amniotic fluid. 2. Chorion – where placenta is developed – outermost membrane Lecithin Sphingomyelin L/S Ratio - 2:1 signifies fetal lung maturity not capable for  RDS(Respiratory Distress Syndrome) Test for Fetal Lung Maturity:  – amniotic + saline & shake Shake test  –  Foam test  –  – amniotic + saline & shake  Phosphatiglycerol: PG+ definitive test to determine fetal lung maturity a. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis.

- Size: 500g or ½ kg - 15 – 28 cotyledons -1 inch thick & 8” diameter 

Functions of Placenta: 1. Respiratory System – beginning of lung

function after birth of baby. Simple diffusion “ Higher Concentration to Lower Concentration” g lucose transport is facilitated diffusion more rapid from 2. GIT – transport center, glucose higher to lower. If mom hypoglycemic, fetus hypoglycemic “Higher to Lower Concentration but RAPID” 3. Excretory System- artery - carries waste products. Liver detoxifies waste products of  the fetus. 4. Circulating system – achieved by selective osmosis

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Endocrine System – produces hormones Human Chorionic Gonadrophin – maintains corpus luteum alive; basis of   pregnancy test Human placental Lactogen or sommamommamotropin Hormone – for  mammary gland development. Has a diabetogenic effect – serves as insulin antagonist Relaxin Hormone- causes softening joints & bones estrogen  progestin 6. It serves as a protective barrier ba rrier against some microorganisms – HIV,HBV HIV,HBV 5.

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Entire pregnancy days – 266 – 266 – 280 days 37 – 42 weeks 280 divided by 28 = 10 lunar months 280 divided by 31 days = 9.7 days (calendar months) 1st week  week counted counted “zero” Fetal Stage “ Fetal Growth and Development” First trimester:  period of organogenesis; most critical period 

First Month - Brain & heart development GIT & respiratory Tract – remains as single tube 1. Fetal heart tone begins – heart is the oldest part of the body 2. CNS develops – dizziness of mother due to hypoglycemic effect Food Food of brai brainn – glu gluco cose se comp comple lexx CHO CHO – pre pregn gnan antt wom woman an’’s foo foodd (po (pota tato to)) Differentiation of Primary Germ layers * Endoderm

1st week endoderm – primary germ layer  Thyroid – for basal metabolism; respiratory Parathyroid - for calcium metabolism Thymus – development of immunity Liver  Lining of upper Respiratory Respirator y Tract & Gastro Intestinal Tract Tract * Mesoderm – development of heart, musculoskeletal system, kidneys and reproductive organ * Ectoderm – development of brain CNS, skin and 5 senses, hair, nails, mucous membrane of anus & mouth Second Month 1. All vital organs formed, placenta developed 2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month 3. Sex organ formed 4. Meconium is formed Third Month 1. Kidneys functional 2. Fetus begin to swallow amniotic fluid 3. Buds of milk teeth appear  – Doppler –– 10 – 12 weeks 4. Fetal heart tone heard – Doppler  5. Sex is distinguishable 11

Second Trimester:

FOCUS – length of fetus

Fourth Month 1. lanugo begins to appear  2. fetal heart tone heard fetoscope fetoscope,, 18 – 20 weeks 3.  buds of permanent teeth appear  Fifth Month 1. lanugo covers body 2. actively swallows amniotic fluid 3. 19 – 25 cm fetus, 4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16 - 18 weeks – multi 5. fetal heart tone heard with or without instrument Sixth Month 1. eyelids open 2. wrinkled skin 3. vernix caseosa present Period of most rapid growth. FOCUS: weight of fetus Seventh Month  – devel develop opme ment nt of of surf surfact actant ant – leci lecith thin in

Third trimester:

Eighth Month 1. lanugo begin to disappear  2. subcutaneous fats deposit 3.  Nails extend to fingers  Ninth Month 1. lanugo & vernix caseosa completely disappear  2. Amniotic fluid decreases Tenth Month  – bone ossification of fetal skull TeratogensA. Drugs:

any drug, virus or irradiation, the exposure to such may cause damage to the fetus

Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor  hearing & deafness Tetracycline – staining tooth enamel, inhibit growth of long bone Vitamin Vitamin K – lead to hemolysis he molysis (destruction of RBC); hyperbilirubenia or jaundice Iodides – enlargement of thyroid or goiter  Thalidomides – Amelia – totally no extremities extr emities Pocomelia - absence of distal part of extremities Steroids – cleft lip or cleft palate or even abortion Lithium – congenital malformation B. Alcohol – low birth weight (vasoconstriction on mother), fetal alcohol withdrawal syndrome charterized by microcephaly C. Smoking – low birth weight D. Caffeine – low birth weight abruption placenta 12

E.

Cocaine – low birth weight

– viruses CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely effect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some cases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes Herpe s simples virus. T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat O  – others. Hepa A or infectious heap – oral/ fecal (hand washing) Hepa B, HIV – blood & body fluids Syphilis R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10 < 1:10 – less immunity to rubella, after a fter delivery, mom will be given rubella vaccine. Avoid Avoid  pregnancy for 3 for 3 months because Vaccine Vaccine is terratogenic; Notify the doctor  C – cytomegalo virus (CMV) H – herpes simplex virus TORCH (Terratogenic) (Terratogenic) Infections

V.

Phys Physio iolo logi gica call Adap Adapta tati tion on of the the Mot Mothe herr to to Pr Pregna egnanc ncy y A. Systemic Changes 1. Cardiovascular System – beginning the end of the 1st trimester, there is a gradual increase

 blood volume of mom ( plasma blood ) 30 – 50% = 1500 cc of blood - easy fatigability, fatigability, increase heart workload, slight hypertrophy of ventricles, - epistaxis due to to hyperemia of nasal membrane - palpitation due to stimulation of parasymphathetic paras ymphathetic nervous system Physiologic Anemia –  pseudo  pseudo anemia of pregnant women Normal Values

Hct 32 – 42% Hgb 10.5 – 14g/dL

Criteria

1st and 3rd trimester.- pathologic anemia if lower  Hct should not fall below 33% Hgb should not fall below 11g/dL nd 2 trimester – Hct should not fall below 32% Hgb should not fall below 10.5%  pathologic anemia if lower 

Pathogenic Anemia

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iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant women.

Assessment reveals: • • •

Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physiologic hypoxia 13

Nursing Care: •

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 Nutritional instruction – kangkong, liver due to ferridin content, green leafy vegetablealugbati, saluyot, malunggay, horseradish, ampalaya Parenteral Iron ( Imferon) – severe anemia, give IM, Z tract- if improperly administered, hematoma. Oral Iron supplements (ferrous sulfate 0.3 g. 3 times a day) empty stomach 1 hr before meals or 2 hours after, a fter, black stool, constipation Monitor for hemorrhage

Alert: • • •

Iron from red meats is better absorbed iron form other sources Iron is better absorbed when taken with foods high in Vitamin C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and hemoglobin is required from production of RBCs

Edema – occurs because of poor circulation resulting from pressure of the gravid uterus on

the blood vessels of the lower extremities due venous return is constricted due to large belly.  Management: elevate / raise legs above hip level. Varicosities – pressure of uterus  Management: - use support stockings, stockings, avoid wearing wearing knee high socks - use elastic bandage – lower to upper  Vulbar varicosities - painful, pressure on gravid uterus,  Management: to relieve- position – side lying l ying with pillow under hips or  modified knee chest position Thrombophlebitis – presence of thrombus at inflamed blood vessel - pregnant mom hyperfibrinogenemia - increase fibrinogen - increase clotting factor  - thrombus formation candidate outstanding sign – (+) – (+) Homan's sign – pain on cuff during dorsiflexion d orsiflexion milk leg – skinny white legs due to stretching of skin caused by inflammation or   phlagmasia albadolens

2.

3.

 Management: 1.) Complete Bed rest 2.)  Never massage 3.) Assess + Homan sign once only might dislodge thrombus 4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute) 5.) Monitor APTT - Heparin toxicity : protamine sulfate(antidote for heparin) 6.) Avoid aspirin! Might aggravate bleeding. Respiratory system – common problem Shortness Of Breathing due to enlarged uterus &

increase O2 demand  Management: Position: lateral expansion of lungs or side lying position. Gastrointestinal  – 1st trimester change * Morning Sickness – nausea & vomiting due to increase HCG.  Management : •

Eat dry crackers or dry CHO diet 30 minutes before arising bed. 14

•

o o

 Nausea afternoon - small frequent feeding.

Vomiting in pregnancy  – emesisgravida. Excessive Vomiting - hyperemesisgravidarum

Metabolic alkalosis, Fluids &Electrolytes imbalance  primary medical management – Replace Fluids. - Monitor Input & Output * Constipation – progesterone responsible for constipation.  Management :

* Increase fluid intake * Increase fiber diet : fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha, except guava – has pectin for constipating vegetables – petchay petchay, malunggay malungga y, swamp cabbage (kangkong) (k angkong) * Exercise * Mineral Oil – excretion of fat soluble vitamins * Flatulence – avoid gas forming food such as cabbage, camote * Heartburn or “ pyrosis”  – reflux of stomach content to esophagus  Management:

-

small small frequ frequent ent feedi feeding, ng, avoid avoid 3 full full meals meals,, avoid avoid fatty fatty & spicy spicy food, food, sips of milk at frequent interval, proper body mechanical - increase salivation – ptyalsim – management: mouthwash * Hemorrhoids – pressure of gravid enlarged uterus.  Management: • •

hot sitz bath for comfort cold compression with witch hazel or EPSOM salts

4. Urin Urinar ary y Sys Syste tem m

frequency of urination - during 1st & 3rd trimester  management for nocturia: lateral expansion of lungs or side lying position  Nocturia –  Nocturia  – urination during night time Heat Acetic Acid test – is a test to determine the presence of albumin and protein in urine Benedict’s test – test used to determine sugar in urine

5.  Musculoskeletal  “ Lordosis”  –  – (Greek: lordos - bent forward; osis - condition) also known as the

“pride of pregnancy” - an abnorm abnormal al anter anterior ior conca concavit vityy of the lumba lumbarr part part of the the back; back; inwa inward rd curvature of the spine “Waddling Gait”  – characterized by exaggerated lateral trunk movements and hip elevation which can be observed in a pregnant patient. - awkward walking of a pregnant mother, mother, candidate for accidental fall due to relaxation and the hormone responsible responsible for this gait is Relaxin  –  responsible for softening of joints & bones; Prone Pro ne to accidental falls  Management   – wear flat / no heels shoes Pregnant mothers can develop “ Leg Cramps”  – causes: – causes: prolonged standing, over fatigue, Ca & phosphorous imbalance ( #1 cause while pregnant ), chills, oversex, pressure of gravid uterus ( labor cramps ) at lumbo sacral nerve plexus

 Note:

15

Leg cramps Leg cramps

during labor is due to pressure of gravid uterus during pregnancy is due to decrease calcium and increase phosphorus

 Management: Food That Are Rich in Calcium: 1. Increase Ca diet - milk ( Increase Ca & Increase phosphorus )

-1 pint/day or 3 - 4 servings/day. servings/day.  Note: there’s still still a tendency that a mother will experience leg cramps due to high level of phosphorus 2. Cheese, yogurt, and dairy products 3. head of fish, Dilis Dilis,, sardines with bones, broccoli, seafood such as tahong (mussels), lobster, crab. 4. Vegetable – broccoli

 Management:

Place the foot affected then dorsiflexion  Note: Vitamin D for increased Ca absorption

B. Local Changes 1. Vagina  – Chadwick’s sign (color change of the vagina from pink to violet)

 – blue violet discoloration of vagina Cervix  – Goodell's sign (softening of the cervix) cerv ix)  – change of consistency of cervix (softening of the lower uterine segment) Uterus  – Hegar's sign (softening  – change of consistency of isthmus (lower uterine segment)

LEUKORRHEA – whitish gray, mousy odor discharge ESTROGEN – hormone, responsible for leukorrhea (remember the second letter of Leukorrhea) OPERCULUM – mucus plug to seal out bacteria. PROGESTERONE  – hormone responsible for operculum ( remember the second letter of O perculum ) Problems Related to the Change of Vaginal Environment: a. Vagin ginitits tits – caused by Trichomonas Vaginalis, a flagellated protozoa,

local infection of the vagina, due to alkaline environment of vagina of pregnant mom – acidic to alkaline change to protect bacterial growth (vaginitis) “ Flagellated protozoa – wants alkaline ” Signs &Symptoms : Greenish cream colored and frothy discharge, irritatingly itchy with foul smelling odor accompanied by vaginal edema

Management Drug of Choice : FLAGYL – (Metronidazole – antiprotozoa).  Note: not to be given to pregnant mothers on her 1st trimester due to Carcinogenic effects . 1. on the 2nd and 3rd trimester – flagyl can be given 2. treat dad also to prevent reinfection 3. avoid alcohol, antabuse drus – has antibuse effect VAGINAL DOUCHE – I quart of water and 1 tbsp white vinegar 

16

b. Monil Monilias iasis is or or Cand Candidi idiasi asiss  – caused by Candida Albicans also called Candidiasis,

fungal infestation.

Signs & Symptoms: Color – white cheeselike patches adheres to the walls of vagina, extreme pruritus  Management  : antifungal  – Nistatin, gentian violet, cotrimaxole, canesten Gonorrhea

- Thick purulent discharge

Vaginal warts - condifoma acuminata due to papilloma virus  Management: cauterization 2. Abdominal Changes * striae gravidarium

(stretch marks) due to enlarging uterus brought   by destructionof destructionof subcutaneous tissue.  Nursing Care: Care: Instruct to avoid scratching and application of oil * umbilicus is protruding

3.

Skin Changes

* Chloasma/ Melasma – white or light brown pigmentation in the nose, chin, cheeks due to increased melanocytes. * Linea Nigra – Nigra – brown pinkish line running run ning from symphisis pubis to umbilicus

4.  Breast Changes – all breast changes are related to change and increase in hormones

- size and color of areola & nipple change pre colostrums present by 6 weeks, colostrums at 3rd trimester  week or 7 days days after after menstruation menstruation BSE (Breast self exam) - one week  Position:  Position: supine with pillow at back  quadrant B – upper outer – common site of cancer 

Test to determine breast cancer: Mammography – 35 to 49 years old should submit to mammography once every

50 years old and above – once a year 

5. 6.

2 years

Ovaries – rested during pregnancy; no significant changes Signs & symptoms of Pregnancy A. Presumptive  – signs and symptoms felt and observed by the mother but does not confirm  positive diagnosis of pregnancy : Subjective B. Probable – signs observed by the members of health team: Objective C. Positive Signs  – undeniable signs confirmed by the use of instrument. Ballotement sign of myoma

* + HCG – sign of H mole - trans vaginal ultrasound. Empty balder  - ultrasound – full bladder  placental grading – rating/grade

0 – immature 1 – slightly mature 2 – moderately mature 3 – placental maturity

17

What is deposited in placenta which signify maturity - there is calcium Presumptive 1 Trimester

Probable

Positive

st

Breast changes Urinary frequency

Goodel's- change of consistency of cervix Chadwick’s- blue violet discoloration of vagina

Fatigue Amenorrhea Morning sickness Enlarged uterus

Hegar's- change of consistency of isthmus Elevated BBT – due to increased progesterone Positive HCG or (+)pregnnacy test

Ultrasound evidence (sonogram) full  bladder  Transvaginal – empty  bladder 

2nd Trimester

Cloasma Linea negra Increased skin  pigmentation Striae gravidarium Quickening

Ballottement – bouncing of fetus when lower uterine is tapped sharply, sign of myoma Enlarged abdomen Braxton Hicks contractions – painless irregular  contractions

VI. Psychological Adaptation to Pregnancy First Trimester:

Fetal heart tone Fetal movement Fetal outline on x-ray Fetal parts palpable

(Emotional response of mom –Reva Rubin theory)

 No tanginal signs & symptoms, surprise, ambivalence, denial Sign of mal adaptation to pregnancy  Developmental task: is to accept biological parts of pregnancy  Health Teaching: bodily changes of pregnancy pr egnancy,, Focus: nutrition and on growth and development • •

 Second Trimester 

tangible Signs & Symptoms: mother identifies fetus as a separate entity due to presence of quickening, fantasy. fantasy.  Developmental task: to accept growing fetus as baby to be nurtured. Focus: growth & development of fetus. •

Third Trimester: - mother has personal identification on appearance of baby  Development task: prepare of birth & parenting of child.  Health Teaching: responsible parenthood Best for ‘baby’s Layette” – best time to do shopping.

Most common fear about moms moms fetus – let – let mother listen to Fetal Heart Tone to allay fear  - Lamaze classes

VII. Pre-Natal Visit: Basic Considerations: 1. Freq Freque uenc ncy y of Vis Visit it::

1st 7 months – once a month 8 – 9 months – twice a month 10 – once a week (weekly) 18

 post term - twice a week 

2. Pers Person onal al data data: Name: for identification Age: to determine if the mother is in high risk (high risk < 18 & >35 yrs old) (HBMR) Home Base Mother’s Record – tool used to determine high risk pregnancy Sex: PSEUDOCYESIS – false pregnancy common to male COUVADE SYNDROME – psychosomatic reaction wherein the father father experiences the

mother goes through; the father is the one to vomits,etc – (lihi) Religion: for their culture & beliefs with respect, non judgmental Occupation: financial condition or occupational hazards Education Background: to determine level knowledge

Address; civil status 3. Diagn Diagnosi osiss of Preg Pregnan nancy cy 1.) urine exam to determine HCG -

6 weeks after Last Menstrual Period , 40 – 100th day but  peak 60 – 70 day best to get urine exam. 2.) Elisa test – test to detect beta subunit of HCG as early as 7 – 10 days 3.) Home pregnancy kit – do it yourself  yourself 

4. Base Baseli line ne Data Data::

Vital Vital Signs especially Blood Pressure Monitor weight (increase weightt – 1st sign preeclampsia), pattern of weight gain/loss g ain/loss is important

Weight Monitoring

First Trimester: Second trimester: Thir Thirdd trim trimes este ter: r:

Normal rmal Weight gain ain Normal Weight gain Norm Normal al Weigh eightt gain gain Average weight gain – Optimal weight gain –

1.5 – 3 lbs 10 – 12 lbs 10 – 12 lbs lbs 20 – 25 lbs 25 – 35 lbs

( .5 – 1 lb/month ) (4 lbs/month) (1 lb/wk) (4 lbs/ lbs/ mont month) h) ( 1lb/ 1lb/wk wk))

5. Ob Obst stet etri rica call Data Data: nullipara – no pregnancy a. Gravida - number of pregnancies, 2 children G2 b. Para - number of viable pregnancies, 2 viable P2 Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.  Age of Viability - 20 – 24 weeks Term - 37 – 42 weeks  Preterm - 20 – 37 weeks  Abortion < 20 weeks

Sample Cases: a. 1 – abortion 1 – 2nd month pregnant  b. 1 – 40th AOG 1 – 36th AOG 2 – miscarriage 1 – twins 35th AOG

G2T0P0A1L0 G2P0 G6T1P2 A 2L4 G6 P3

19

1 – 4th month pregnant

c. 1 – 39th week  1 – miscarriage 1 – stillbirth 33 AOG (considered as para) 1 – pregnant 3rd wk d. 1 – 33rd P 1 - 41st L 1 – abortion A 1 – stillbirth 39th 1 - triplet 32nd 1 - 4th month pregnant

g.

e.

1 – 39th AOG 1 – miscarriage 1 – stillbirth 33rd AOG 1 – 3rd month pregnant

f.

1 – 40th AOG 1 – Abortion 1 – twin 37th AOG 1 – 4th month pregnant

1 – 38th AOG 1 – 37th AOG 1 – Abortion

G4P2 G4T1P1A1L1

G6T2P2A1L5 G6P4

G4P1 G4T1P1A1L1

G4P2 G4T1P1A1L3

1 – Triplets 30th AOG 1 – 32nd AOG 1 – Stillbirth 42nd AOG

G6P5 G6T3P2A1L6

c. Impo Import rtan antt Esti Estima mate tes: s: 1. Nage Nagele le’’s Rule Rule – used of determine expected date of delivery January, February and March - +9+7 while

April to December - -3+7+1

Get Last Menstrual Period -3+ 7 +1 Apr-Dec LMP – Jan – Jan Feb Mar  M D Y +9 +7 no year   Example: a. LMP January 03, 2005 01 03 05 + 09 07___  10-10-05 10-10-05= = Expected Expected Date Date of Conf Confine inemen mentt October October 10, 10, 2005  b. LMP August 04, 2005 08 04 05 -03+07+01 05-11-06= EDC May 11, 2006 ag e of gestation IN WEEKS 2. McDo McDona nald ld’’s Rule Rule – used to determine age Get the length in cm x 7/8 = AOG in weeks  FUNDIC HT X 7/8=AOG in weeks 20

Fundic Ht X 7 = AOG in weeks 8 From symphysis pubis to fundus 24 X 7 =21 wks 8

3. Bart Bartho holo lome mew’ w’ss Rule Rule – used to determine age of gestation of the fetus

 by proper location of fundus at abdominal cavity cavity.. 3 months – above symphysis pubis 5 months – level of umbilicus 9 months – below xiphoid 10 months – level of 8 months due to lightening

cm. 4. Haases ses rul rulee – used to determine length of the fetus in cm. Formula: 1st ½ of preg , square @ month 2nd ½ of preg, x @ month by 5 3mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 5 x 5 = 25 cm

1st ½ of preg

6 x 5 = 30 cm 7 x 5 = 35 cm 2nd ½ of preg 8 x 5 = 40 cm 9 x 5 = 45 cm d. Tetanu etanuss Immun Immuniza izatio tions ns – prevents tetanus neonatum - mother with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3 TT1 – any time during pregnancy TT2 – 4 weeks after TT1 – 3 yrs protection TT3 – 6 months after TT2 – 5 yrs protection TT4 – 1 year after TT3 – 10 yrs protection TT5 – year after TT4 – lifetime protection  Note: if the mother received 3 doses of DPT during childhood, she will be given TT3. 5. Physi Physical cal Exam Examina inatio tion: n: Cephalocaudal including the teeth

* Examine teeth: sign of infection Danger signs of Pregnancy:

C - chills/ fever - infection - Cerebral disturbances ( headache – preeclampsia) A – abdominal pain ( epigastric pain) – aura/alert of impending convulsions B – boardlike abdomen – sign of abruption placenta Increase BP – HPN(hypertension) Blurred vision – pre eclampsia Bleeding : 1st trimester - abortion, ectopic pregnancy 2nd trimester – H mole, incompetent cervix 3rd trimester – any placental anomalies such as abruption placenta, placenta,  placenta previa S – sudden gush of fluid – PROM (premature rupture of membrane) prone to infection. - swelling/edema of upper extremities (pre eclampsia) 21

6. Pelv Pelvic ic Exa Examina minati tion on : Internal Examination empty bladder    Preparation: 1. 2. universal precaution

On the first visit the mother will examined internally in order to determine the presence of   probable signs such as Chadwick, Goodels and Hegar’s Hegar ’s sign. sign. Pap Smear – cytological examination to determine the presence of cancer cells External OS of cervix – site for getting specimen ; composed of squamous columnar tissue; Site for cervical cancer  Vaginal Speculum will be needed, to avoid contact from other organ Result:

Class I - normal Class IIA – suggestive of inflammation B - acytology but no evidence of malignancy Class III – cytology suggestive of malignancy Class IV – cytology strongly suggestive of malignancy Class V – cytology cytology conclusive of malignancy Stages of Cervical Cancer

Stage 0 – carcinoma insitu 1 – cancer confined to cervix 2 - cancer extends to vagina 3 – pelvis metastasis 4 – affectation to bladder & rectum

7. Leopold’s Maneuver

Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone; use palm! Warm Warm palm. Preparation for mothers: 1. Empt Emptyy blad bladde der  r  2. Positi Position on of mom-su mom-supin pinee with with knee knee flex flex (dorsal recumbent – to relax abdominal muscles)

Procedure: po sition with knees slightly flexed; Put towel under head 1st maneuver: Place patient in supine position

and right hip; With both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part. In dorsal recumbent position – to relax the abdominal muscles. To To determine presentation pre sentation parts.

with both hands moving down, identify the back of the fetus (to hear fetal heart sound) where the ball of the stethoscope is placed to determine Fetal Heart Tone. Get Vital Vital nd Signs (before 2 maneuver) Pulse Rate to differentiate fundic soufflé (Fetal Heart Rate) & uterine soufflé (Maternal Heart Rate). To determine fetal back. 2nd Maneuver:

22

3rd Maneuver: using the

right hand, grasp the symphysis pubis part using thumb and fingers. To determine degree of engagement. (Assess whether the presenting pr esenting part is engaged in the  pelvis ) Alert : if the head is engaged it will not be movable.

the Examiner changes the position by facing the patient’s feet. With two hands, assess the descent of the presenting part by locating the cephalic prominence or brow. When the brow is on the same side as the back, the head is extended. When the brow is on the same side as the small parts, the head will be flexed and vertex presenting. To determine attitude – relationship of fetus to 1 another.  Attitude – refers to the relationship of fetus to each part into one another ( degree of flexion ) Full flexion – when the chin touches the chest 4th Maneuver:

8. Assessment of Fetal Well-BeingA. Daily Daily Fetal Fetal Movement Movement Counti Counting ng (DFMC) (DFMC) –  begin  begin 27 weeks

Mother - begin after meal – breakfast

a. Cardiff count to 10 method – one method currently available (1) Begin at the same time each day (usually in the morning, after breakfast) breakfast) and count

each fetal movement, noting how long it takes to count 10 fetal movements (FMs) (2) Expected findings – 10 movements in 1 hour or less (3) Warning signs a.) more than 1 hour to reach 10 movements b.) less than 10 movements in 12 hours (non-reactive- fetal distress) c.) longer time to reach 10 (FMs) fetal movements than on previous days d.) movement are becoming weaker, less vigorous * Movement alarm signals - < 3 FMs in 12 hours (4.) Warning signs should be reported re ported to healthcare provider pr ovider immediately; often require further testing. Examples: non stress test (NST), biophysical b iophysical profile (BPP)

b. Nonstress test – to determine the response of the fetal heart rate to activity  Indication – pregnancies at risk for placental insufficiency Postmaturity a.) Pregnancy Induced Hypertension (PIH), diabetes b.) Warning signs noted during DFMC c.) Maternal history of smoking, inadequate nutrition Procedure:

Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor);external monitor is applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels fetal movement.

Attach external noninvasive fetal monitors 1. Tocot ocotra rans nsdu duce cerr over fundus to detect uterine contractions and fetal movements

(FMs)

2. Ultra Ultrasou sound nd Transdu ransduce cerr

over abdominal site where most distinct fetal heart sounds

are detected 3. Monitor until at least 2 FMs are detected in 20 minutes

23

•

•

if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated, such as a CST

Result:

 Noncreative  Nonstress  Not Good

R eactive eactive R esponsive esponsive is eal Good R eal

Interpretation of results i. Reactive Result 1. Baseline FHR between 120 and 160 beats per minute 2. At least two accelerations of the FHR of at least 15 beats per minute, minute, lasting at

ii.

least 15 seconds in a 10 to 20 minutes period as a result of Fetal Movement 3. Good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip. ner vous system 4. result indicates a healthy fetus with an intact nervous Nonreactive Result 1. 2.

Stated criteria for a reactive result are not met Could be indicative of a compromised fetus. Requires further evaluation with another ano ther nonstress test NST, NST, biophysical profile, (BPP) or Contraction Stress Test (CST)

9. Health Teachings : do nutritional assessment a. Nutrition – daily food intake High risk mothers: Pregn ant teenagers teenager s – very long compliance complian ce to health regimen. 1. Pregnant 2. Extreme weight Underweight: malnourished like elite model Over weight : candidate for HPN, DM Mother s with low socio – economic econo mic status – refer to DSWD 3. Mothers 4. Vegetarian egeta rian mothers mother s – decrease decre ase CHON – needs Vitamin Vitamin B12/folic B12/fo lic

acid –  cyanocobalamin – formation of folic acid – needed for cell ce ll DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect, meningocele umphalocele) Types of Vegetarian: Vegetarian rian – vegetables vegetab les only ( with rigid 1. Strict Vegeta Lactov egetarian rian – vegetables/mi veget ables/milk  lk  2. Lactovegeta 3. Lactoovoveg Lactoo vovegetari etarian an – vegetables/m vege tables/milk/egg ilk/egg

personalit pers onality) y)

CHO x 4, CHON x 4, FATS FATS x 9 How many calorie : Daily Calorie Intake : Non Pregnant – 2,200 24

Add - 300 Pregnant – 2,500 During Lactation Add - 500

VIII. Recommended Nutrient Requirement that increases During Pregnancy Nutrients

Requirements

300 calories/day above the preEssential to supply energy for   pregnancy daily requirement to - incr increa eassed met metabol aboliic rat ratee maintain ideal body weight and - uti utiliza lizattion ion of nut nutrien rientts meet energy requirement to activity - prot protei einn spa spari ring ng so itit can can level  be used for  - Begi Beginn inc incre reas asee in in sec secon ondd - Growth of fetus trimester  - Deve Develo lopm pmen entt of stru struct ctur ures es - Use Use wei weigh ghtt – gain gain pat pattern tern as required for pregnancy an indication of adequacy of  including placenta, calorie intake. amniotic fluid, and tissue - Fail Failur uree to to me meet cal caloric oric growth. requirements can lead to ketosis as fat and protein are used for energy; ketosis has  been associated with fetal damage.

Calories

Food Source

Caloric increase should reflect - Food Foodss of of hig highh nutr nutrie ient nt valu valuee suc suchh as protein, complex carbohydrates (whole grains, vegetables, fruits) - Varie ariety ty of of food foodss repr repres esen enti ting ng foods sources for the nutrients requiring during pregnancy - No mo more th than 30 30% fat

Protein increase should reflect Essential for: - Lean Lean meat eat, pou poult ltry ry,, fis fishh - Fetal tissue gro growth - Eggs, cheese ese, milk  - Mat Materna ernall tiss tissue ue grow growth th - Drie Driedd bean beans, s, lent lentil ils, s, nuts nuts including uterus and Adolescents have a higher protein - Whole grins  breasts requirement then mature women * vegetarians must take note of the - Deve Develo lopm pmen entt of of ess essen enttial since adolescents must supply amino acid content of CHON foods  pregnancy structures  protein for their own growth as well consumed to ensure ingestion of  - Form Format atio ionn of red red bloo bloodd as protein t meet the pregnancy sufficient quantities of all amino acids cells and plasma proteins requirement * Inadequate protein intake has  been associated with onset of   pregnancy induces hypertension (PIH) Calcium increases of  Calcium increases should reflect: Calcium-Phosphorous Essential for  - 1200 mg/day representing an - dair dairyy pro produ duct ctss : mil milk, k, yog yogur urt, t, ice ice - Growth and increase of 50% of 50% above precream, cheese, egg yolk  development of fetal  pregnancy daily requirement. - whole ole grai rains, tofu skeleton and tooth buds - 1600 1600 mg/ mg/da dayy is is rec recom omme mend nded ed - gree greenn leaf leafyy vege vegeta tabl bles es - Maintenance of  for the adolescent. 10 mcg/day - cann canned ed salm salmon on & sard sardin ines es w/ mineralization of  of vitamin of vitamin D is required since  bones Protein

60 mg/day or an increase of 10% of 10% above daily requirements for age group

25

maternal bones and teeth - Curren rrentt res researc earchh is is : Demonstrating an association  between adequate calcium intake and the prevention of   pregnancy induce hypertension

it enhances absorption of both calcium and phosphorous

-

Ca fort fortif ifie iedd foo foods ds such such as as ora orang ngee  juice - Vitam itamin in D sou sourc rces es:: for forti tifi fied ed milk, margarine, egg yolk, butter, liver, seafood

30 mg/day representing a doubling Essential for  of the pregnant daily requirement - Expansion of of bl blood - Begi Beginn sup suppl plem emen enta tati tion on at 3030Iron increases should reflect volume and red blood mg/day in second trimester, - live liverr, red meat meat,, fis fish, h, poul poultry try,, cells formation since diet alone is unable to eggs - Esta Establ blis ishm hmen entt of of fet fetal al iron iron meet pregnancy requirement - enri enrich ched ed,, who whole le grai grainn cer cerea eals ls stores for first few months - 60 – 120 120 mg/da g/dayy alon alongg wi with and breads of life copper and zinc - dark dark gree greenn lea leafy fy vege vegeta tabl bles es,, supplementation for women legumes who have low hemoglobin - nuts, dried ried fruits values prior to pregnancy or  - vita vitami minn C sou sourc rces es:: citr citrus us fru fruit itss who have iron deficiency & juices, strawberries, anemia. cantaloupe, broccoli or  - 70 mg/day of vitamin C which cabbage, potatoes enhances iron absorption - iron iron from from food food sour source cess is is mor moree - inad inadeq equa uate te iro ironn int intak akee resu result ltss in in readily absorbed when served maternal effects – anemia with foods high in Vitamin Vitamin C depletion of iron stores, decreased energy and appetite, cardiac stress especially labor  and birth - feta fetall ef effect fectss dec decre reas ased ed availability of oxygen thereby affecting fetal growth * iron deficiency anemia is the most common nutritional disorder  of pregnancy. Zinc 15 mcg/day representing an increase Zinc increases should reflect Essential for  of 3 mg/day over pre-pregnant daily - liver, meats * the formation of enzymes requirements. - shell fish * may be important in the - eggs, milk, che cheese  prevention of congenital - whol wholee gra grain ins, s, legu legume mes, s, nuts nuts malformation of the fetus. 400 mcg/day representing an Increases should reflect Folic Acid, Folacin, Folate Essential for  increase of more then 2 times the - live liverr, kidn kidney ey,, lea leann beef beef,, veal veal - form format atio ionn of red red bloo bloodd daily pre-pregnant requirement. - dark dark gree greenn lea leafy fy vege vegeta tabl bles es,, cells and prevention of  300mcg/day supplement for women  broccoli, legumes. anemia with low folate levels or dietary - Whole gr grain ains, pe peanut nuts - DNA DNA synt synthe hessis and and cel celll deficiency formation; may play a 4 servings of grains/day role in the prevention of  neutral tube defects (spina bifida), abortion, Iron

26

abruption placenta Additional Requirements Minerals

-

iodine Magnesium Selenium

Vitamins

E Thiamine Riboflavin Pyridoxine ( B6) B12  Niacin

175 mcg/day 320 mg/day 65 mcg/day

10 mg/day 1.5 mg/day 1.6 mg/day 2.2 mg/day 2.2 mg day 17 mg/day

Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during  pregnancy. Vitamin stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.

d aily ( FAT FAT SOLUBLE ) Vitamin A,D,E,K - - - No need to take it daily 2. Sexual Activity a.) b.) c.) d.) e.) f.)

should be done in moderation should be done in private place that the mother should be placed in comfortable position; sidelying or mother on top it must be avoided 6 weeks prior to Expected Date of Delivery avoid blowing or air during cunnilingus to prevent air embolism changes in sexual desire of mom during pregnancy a.) 1st trimester – decrease desire – due to to bodily changes nd b.) 2 trimester – increased desire due to increase estrogen that enhances lubrication c.) 3rd trimester – decreased desire – due to bodily changes

Contraindication in sex: 1. vaginal spotting

1st trimester  – threatened abortion 2nd trimester – placenta previa 2. incompetent cervix 3. preterm labor  4. premature rupture of membrane – prone to infection

3. Exercise – to strengthen muscles that will be used during delivery process

- it must be done in moderation principles of exercise - it must be individualized – case to case basis * Walking – best exercise * Squatting – strengthen muscles of perineum and increase circulation to perineum. Done feet flat on floor  * Tailor Tailor Sitting – same with squatting – done d one by placing one leg in front of other leg ( Indian seat) st Raise buttocks 1 before head to prevent postural hypotension – dizziness when changing position * Shoulder Circling Exercise – to strengthen chest muscles * Pelvic Rocking/Pelvic Tilt Exercise – to relieve low back pain & maintain good posture - can be used to Lordosis * Arch Back – standing or kneeling. knee ling. Four extremities on floor  27

* Kegel Exercise – to strengthen pubococcygeal muscles - as if hold urine, release 10x or muscle contraction * Abdominal Exercise – to strengthen the muscles of the abdomen – done as if blowing candle

4. Childbirth Preparation: Overall goal: to prepare parents physically physically

and psychologically while while promoting wellness wellness behavior  that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical 1. Bradley Method

– discovered by Dr. Robert Bradley , advocated active participation of  husband during delivery process to serve as a coach. Based on imitation of nature.

 Features: 1.) darkened room 2.) quiet environment 3.) relaxation tech 4.) closed eye & appearance of sleep 2. Grantly Dick Read Method

 – that fear leads to tension while while tension leads to pain - to remove fear fear by relaxation technique and abdominal exercises

b. Psychosexual 1. Kitzinger Method

– discovered by Dr. Shiela Kitzinger , that pregnancy pregnan cy,, labor, birth & the care of the newborn ne wborn is an important turning point in a woman’s life cycle - for a mother to achieve the satisfying satisfying childbirth experiences, flow with contraction rather than struggling with contraction c. Psychoprophylaxis – prevention of pain 1. Lamaze – discovered by  Dr. Ferdinand Lamaze - prevention of pain in the brain  Features: discipline, conditioning & concentration with the help of the Husband 1. Conscious relaxation 2. Cleansing breathe – inhaling through the nose and exhaling through the mouth 3. Effleurage – gentle circular massage over abdomen to relieve pain 4. Imaging – sensate focus

5. Differ Different ent Met Method hodss of delive delivery ry::  – bed convertible to chair – “semifowlers” position 1.)  Birthing Chair  –  – “dorsal recumbent” position 2.)  Birthing Bed  – 3.) Squatting Position – position that facilitates descent and relieves low back pain during labor pain  features: warm, quiet, darkened room, calm and comfortable environment, 4.)  Leboyers Method  –   –  features:

room temperature, soft music. - After delivery, delivery, baby gets warm bath. 5.)  Birth Under Water  – warm water in a bathtub – labor & delivery delivery – warm water, soft music. - After After delive delivery ry the the baby should should be be kept kept warmt warmth, h, prepar preparee for bath bathing ing

IX. Intrapartal Notes  – inside Emergency Room

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A.

Admitting the laboring Mother: * Personal Data: name, age, address, etc * Baseline Data: v/s especially BP, BP, weight * Obstetrical Data: gravida # pregnancy, pregnancy, para- viable pregnancy – 22 – 24 weeks * Physical Examination * Pelvic Examination

B.

Basic knowledge in Intrapartum. b. 1 Theories of the Onset of Labor 1.) Uterine Stretch Theory - any hollow organ once stretched to its maximum potential

will always contract & expel its content – contraction action 2.) Oxytocin Theory  – posterior pituitary gland releases oxytocin oxytocin that produce by hypothalamus. 3.) Prostaglandin Theory – stimulation of Arachidonic Acid which causes contraction to the onset of labor. – prostaglandin “male” 4.) Progesterone Theory  – before labor, decrease progesterone will stimulate contractions and labor  5.) Theory of Aging Placenta – lifespan of placenta is 42 weeks. By 36 weeks the placenta is beginning to degenerate hence causes the uterus to contract to the onset of labor.

b.2. The 4 P’s of Labor

1. Passenger - FETUS  a. Fetal head – is the largest largest and common presenting part comprises of Bones – 6 – 6 fetal bones ( in all = 8 bones ) S – sphenoid F – frontal - sinciput E – ethmoid O – occuputal - occiput T – temporal P – parietal 2 x Important Measurement fetal head: 1. Transverse Diameter 

¼ of its length.

Biparietal – largest – largest transverse  – 9.25cm Bitemporal - 8 cm Bimastoid - 7cm smallest transverse 2. Anterior Posterior Diameter (AP ) Suboccipitobregmatic – from occiput to bregmatic ( smallest AP diameter) - complete flexion Occipito Frontal – 12 cm partial flexion Occipito Mental – 13.5 cm hyperflexion ( largest AP )  Submentobregmatic ( face presentation )

Sutures – intermembranous spaces that allow molding. a) Sagittal Sagitt al Suture – connects 2 parietal bones ( sagitna ) b) Coronal Suture – connect parietal & frontal bone ( crown ) c) Lambdoidal Suture – connects occipital & parietal bone Moldings: the overlapping of the sutures of the skull to permit passage of the

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head to the pelvis Fontanels: Anter ior 1.) Anterior

fontanel – “bregma”, – “bregma”, diamond shape, 3 x 4 cm,( > 5 cm –  hydrocephalus), hydrocephalus), Closes – 12 – 18 months after birth 2.) Posterior fontanel – “lambda” – “lambda” – triangular shape , 1 x 1 cm. Closes – 2 – 2 – 3 months.

2. Passageway –  Vagina / Pelvis Candidate for C/S  =

1.) Below 4’9” tall 2.) Below 18 years old – pelvic not yet achieve fully 3.) Underwent cephalo pelvic dislocation

a. Pelvis 4 main pelvic types 1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy 2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow 3. Anthropoid – oval, ape like pelvis, p elvis, oval shape, AP diameter wider transverse narrow 4. Platypelloid – flat AP diameter – narrow, transverse – wider  b. Bones of Pelvis 2 hip bones –  2 innominate bones 3 Parts of 2 Innominate Bones Ileum – lateral lateral side of hips hips * iliac crest  – flaring superior border forming prominence of hips Ischium – inferior portion *ischial tuberosity – areas where we sit , the basis in getting external

measurement of pelvis Pubes in the anterior portion *symphysis pubis - junction between 2 pubis 1 sacrum – posterior portion *sacral prominence – basis for internal measurement of pelvis 1 coccyx – composed of 5 small bones compresses during vaginal delivery

Important Measurements: 1. Diagonal Conjugate – measure between sacral promontory and inferior margin of 

the symphysis pubis.

basis in getting true conjugate. (DC – 11.5 11.5 cm = true conjugate) 2. True conjugate/conjugate vera – measure between the anterior surface of the sacral  promontory and superior margin of the symphysis  pubis. Measurement:

Measurement: 3. Obstetrical conjugate

11.5 cm - 12.5 cm

11.0 cm

– smallest AP diameter. d iameter. Pelvis measuring at 10 cm or more. 4. Tuberoischi Diameter – transverse diameter of the pelvic outlet. – approximated with use of fist *Ischial tuberosity  – 8 cm & above. above. 3. Power –  the force acting to expel the fetus and placenta  – myometrium  – powers of labor  a. Involuntary Contractions

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b. Voluntary Voluntary bearing down efforts c. Characteristics: wave like frequency, duration, intensity d. Timing: frequency, e. Support System

4. Psyche/Person –  (mother) psychological stress exist when the

mother is fighting the labor experience ( effective pushing ) a. Cultural Interpretation b. Preparation c. Past Experience d. Support System

b.3 Pre-eminent Signs of Labor 1. Lightening – settling of presenting part into pelvic ring

- 2 weeks prior to EDD

Signs &Symptoms:

- shooting pain radiating to the legs - urinary frequency (plexus/bladder) - pressure at the lumbo sacral nerve * Engagement- settling of presenting part of the fetus far enough into the pelvis to be at the level of ischial spine, a midpoint of the pelvis. 2. Braxton Hicks Contractions – painless irregular contractions 3. Increase Activity of the Mother- “nesting instinct” (due to epinephrine). Let the mother reserve the energy, energy, will be used for delivery deliver y. 4. Ripening of the Cervix – comparable to butter softness 5. decreased body weight – 1.5 – 3 lbs pinkish vaginal discharge ( combinatiuon of blood & leukorrhea ) 6. Bloody Show – pinkish 7. Rupture of Membranes – rupture of water bag. Check Fetal Heart Tone PROBLEMS: Premature Rupture Rupture of Membrane ( PROM) PROM) -

do Internal Examination to check for cord  prolapse * Contraction drop in intensity even though very painful * Contraction drop in frequently * Uterus tense and/or contracting between contractions * Abdominal palpations

Nursing Care:

* Administer Analgesics (Morphine) * Attempt manual rotation for ROP or LOP – most common mal position * Bear down with contractions * Adequate hydration – prepare for Cesarean Section * Sedation as ordered * Cesarean delivery may ma y be required, especially if fetal distress is noted

NOTE: Do internal examination when the umbilical cord falls or is washed through the cervix into the vagina.

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Cord Prolapse

– a complication when the umbilical cord falls or is washed through the cervix into the vagina.

Danger signs:

* PROM * Presenting part has not yet engaged * Fetal distress * Protruding cord form vagina

Nursing care: 1. Slip cord away from presenting part 2. Count pulsation of cord for Fetal Heart Tone 3. Positioning – trendelenberg or knee chest position 4. Observe for fetal distress 5.  provide emotional support 6. Prepare mother for Cesarean Section

Cover cord with sterile gauze with saline saline solution - to prevent drying of cord so cord will remain slippery. * NOTE: five minutes cord compression can lead to irreversible brain damage such as cerebral palsy. palsy.

•

b.4. Difference Between True Labor and False Labor False Labor True Labor

* Irregular contractions * No increase in intensity * Pain – confined on abdomen * Pain – relived by walking * No cervical changes

* Contractions are regular  * Increased intensity * Pain – begins lower back radiates to abdomen * Pain – intensified by walking * Cervical effacement & dilatation - major symptom of true labor.

Use % in unit of measurement Effacement – softening & thinning of cervix. Use Dilatation – widening of cervix. Unit used is cm. b.5 Duration of Labor  – 14 hours not more than 20 hours Primipara  – 14 Multipara –  8 hours not more than 14 hours b.6 Nursing Interventions in Each Stage of Labor 2 segments of the uterus 1. upper uterine - fundus fundus 2. lower uterine – isthmus 1. First Stage: onset of true contractions to full dilation and effacement of cervix. cervix. Latent Phase: ( The mother is excited but apprehensive and can communicate) Assessment: Dilatations: 0 – 3 cm

Frequency:

every 5 – 10 min

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Intensity :

mild

Nursing Care: 1. Encourage walking - to shorten the 1st stage of labor  2. Encourage to void every 2 – 3 hours – full bladder inhibit inhibit uterine contractions 3. Breathing – chest breathing

Active Phase: ( Mother feels losing control Assessment: Dilatations: 4 - 8 cm

of herself )

Intensity: moderate Frequency : every 3 - 5 minutes lasting for 30 – 60 seconds

Nursing Care: M – medications – have medicines ready A – assessment include: vital signs, cervical dilatation and effacement, fetal monitoring, D – dry lips – oral care (ointment)

etc.

- dry linens, change the wet linen B – abdominal breathing

Transitional Phase:

Assessment:

( the mood of the mother suddenly change accompanied by hyperesthesia – hypersensitivity to touch )

Dilatations: 8 – 10 cm Frequency : every 2 - 3 minutes contractions Durations : 45 – 90 seconds Intensity: Strong

 Hyperesthesia – increase sensitivity to touch, pain a ll over  Nursing Care: T – tires I – inform of progress- best way to give emotional support to the mother  R  –  – restless, support her to do breathing technique (chest breathing) E – encourage and praise D – discomfort – due to sacral pressure Health Teaching :

* teach the father about sacral pressure technique on lower back to inhibit transmission of pain * keep informed of progress * controlled chest breathing

Contractions: Increment/ Crescendo – beginning of contraction until it increases Acme/ Apex – height of contraction Decrement/ Decresendo – from height of contraction until it decreases * Pelvic Exams  Effacement:  – softening & thinning of cervix.  Dilatation: - widening of cervix. a. Station –  relationship of the presenting part to the ischial spine landmark used : ischial spine Floating   – negative station - 1 station = presenting part 1cm above ischial spine if (-) floating - 2 station = presenting part 2 cm above ischial spine if (-) floating

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- 0 station = level at ischial spine – engagement + 1 station = below 1 cm ischial spine +3 ,+4, +5 = crowning – occurs at 2nd stage of labor 

b. Pres Presen enta tati tion on/l /lie ie – the relationship of the long

axis (spine) of the fetus to the long axis of the mother - spine of mom and spine of fetus

Two types: b.1. Longitudinal Lie ( Parallel) Cephalic - Vertex – when the fetus is completely flex

Face Brow Chin

Poor Flexion

 Breech - Complete Breech –

thigh rest on abdomen, while leg rest on thigh

Incomplete Breech Frank – thigh rest on abdomen while leg rest on the head Footling – presenting part – foot : single, double Kneeling – presenting part - knees

b.2. Transverse Lie (Perpendicular) or Perpendicular lie .

- Shoulder presentation is very rare – 1 %

c. Position – relationship of the fatal presenting part to

mother’s pelvis.

specific quadrant of the

Variety: Occipito/ Occiput LOA left occipito anterior (most common and favorable position) position)  – side of maternal pelvis LOP – left occipito posterior  LOP – most – most common mal position, position, most painful ROP – squatting pos on mom ROT ROA A – Anterior L – Left – side of maternal pelvis O – Occipito – denominator

ROP; LOP : most painful position; best – squatting position position LOA – most favorable position FACE –  Mentum LMA, LMT, LMP, RMA, RMT, RMP Shoulder – Acromio Dorso – LADA, LADT, LADP, LADP, RADA, RADT, RADP Breech- SACRO - LSA – left sacro anterior LST, LSP, LSP, RSA, RST, RSP Shoulder/acromniodorso: LADA, LADT, LADP, RADP Chin / Mento: LMA, LMT, LMT, LMP, RMP, RMP, RMA, RMT, RMT, RMP  In cases of breech presentation –  place the stethoscope above the umbilicus • Sign of fetal distress:

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• • •

< 120 or > 160 bpm meconium stain fetal trushing – hyperactivity of fetus due to lack of oxygen.

Monitoring the Contractions and Fetal heart Tone

Spread fingers lightly over fundus – to monitor contractions

Parts of contractions :

Increment or crescendo – beginning of contractions until in increases Acme or apex – height of contraction Decrement or decrescendo – from height of contractions until it decreases Duration – beginning of contractions to end of same contraction Interval – from the end of 1 contraction to beginning of next contraction Frequency – beginning of 1 contraction to beginning of next contraction Intensity – the strength of contraction

Once contraction occur, the blood vessel will constrict – vasoconstriction – decrease the oxygen/circulation hence, maternal BP increases - Increase BP – while Fetal Heart Hea rt Tone Tone decreases. has placental reserve for 60 seconds What will happen to the fetus? = The fetus has placental Best time to get BP of the mother = just after the contraction Best time to get FHT = midway of contraction Placental reserve = 60 seconds for fetus during contractions Duration of contractions shouldn’t > 60 sec  Notify MD Health Teachings: Mom has Headache  – check BP, if same BP, let mom rest. • • • •

•

If BP increases, notify MD – preeclampsia Hungry mother – NPO - no meals GI is not functioning thus to prevent aspiration Bathe – mother can bathe after the delivery Enema – optimum rectal tube – 12 - 18 inches a.) To cleanse bowel b.) Prevent infection c.) Sims position/side lying Constipated mother –  slowly pulling the rectal tube * During insertion of rectal tube – contraction – clamp – after insertion –  check the FHT after administration of enema Normal FHT = 120-160 bpm * Perineal Preparation – method ( 7 method ) Position : Left lateral position –  to prevent supine hypotension or the supine vena caval syndrome. 35

•

Pain during labor – can give Meperidine HCL ( Demerol )

– narcotic antispasmodic ( during active phase 6 – 8 cm ) Toxic Effect: respiratory depression  Antidote :  Narcan ( Naloxone )

 Note: Amniotomy – artificial rupture of the membrane Respiratory Alkalosis – signs and symptoms ( increase RR, Tingling sensation,

light headedness,

2. Second Stage : fetal stage, complete dilation and effacement to birth. The mother will be transferre to the delivery room when : 7 – 8 cm for the multi – bring to delivery room 8 – 10 cm for the primi (fully (fully dilated) – bring to delivery delivery room mother ’s legs at the same time up Position: Lithotomy by placing the mother’ Bulging of perineum – sure to come out Breathing – panting panting ( teach mother) Assist the doctor in doing episiotomy - to prevent laceration

- widen vag vaginal nal canal nd - shorten 2 stage of labor. fast to heal, possible to Episiotomy – median – less bleeding, less pain easy to repair, fast reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain, hard to repair, slow to heal - use local or pudendal anesthesia. Ironing the perineum – to prevent laceration Modified Ritgens maneuver – place towel at perineum 1.) To prevent laceration flexion & extension. (Support head & remove 2.) Will facilitate complete flexion secretion, check cord if coiled. Pull shoulder down & up. Check time, identification of baby. baby.

Mechanisms of labor 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External rotation 7. Expulsion Three parts of Pelvis narrow, transverse diameter dia meter wider  1.  Inlet – AP diameter narrow, 2. Cavity – area of inlet and outlet 3. Outlet  –  – AP wider, transverse narrow Two Major Divisions of Pelvis 1. True pelvis – below the pelvic inlet 2.  False pelvis – above the pelvic inlet; supports uterus during pregnancy * Linea Terminales

- diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis. 36

* Episiotomy – is a surgical incision of the perineum in order to prevent laceration; to widen the vaginal canal; to shorten the second stage of labor. Two Types of episiotomy: 1. Midline – incise the midline of the perineum  Advantage: Easy to repair, fast healing, less blood loss, less postpartum discomfort  Disadvantage: incision may extend to anus that leads lead s to urethroanal fistula

( use sometimes )

b ut directed laterally 2. Medi Mediol olat ater eral al – incision is made beginning to the midline but

away from the rectum.  Advantage: less danger of complication from rectal mucosal tear   Disadvantage: more bleeding (more blood vessels hit), hard to repair, slow healing, more discomfort  Note:

Once the head is crowning – ironing the perineum (to prevent laceration) Modified Ritgens Maneuver – support the perineum (prevent laceration) Once the head is out – support the head and remove secretions, check the cord by inserting 2 fingers.

Nursing Care:

 Note the time of delivery Placing the baby below the vulva Place un dependent part Place in the abdomen of the mother – for bonding and the weight of the baby facilitates the contraction of the uterus Clamp the baby’s cord – wait for pulsation to stop before clamping the cord since 60 60  – 100 cc of blood will be going to baby ba by.. Proper identification, footprinting If in case the baby is dead, show the baby to the mother for acceptance of the finality of dead. To prevent puerperal puerper al sepsis - < 48 hours only o nly – vaginal pack   Note: Bolus of  Ptocin  Ptocin can lead to hypotension. • • • •

•

• •

•

3. Third Stage: birth to expulsion of Placenta -  placental stage The Placenta should be expelled 3-10 minutes after the delivery of the baby Signs of placental separation

1. Fundus Fundus rises rises – become becomess firm firm & glob globular ular “ Calkins sign” sign” if not – Uterine Atony 2. Lengthening Lengthening of the the cord – Brandt Andrew’s Andrew’s maneuver maneuver – slowly pulling pulling of the cord 3. Sudd Sudden en gus gushh of of blo blood od

Types of placental delivery Shultz “shiny” – begins to separate from center to edges presenting the •

fetal side – shiny Dunkan “dirty” – begins to separate form edges to center presenting maternal side – beefy red or dirty  Note: Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER  Hurrying of placental delivery will lead to inversion of uterus. •

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Nursing care for placenta: • • •

• • •

• • •

•

Check completeness of placenta.- placenta has 15 – 28 cotyledons Check fundus (if relaxed, massage uterus – if not firm) Check blood pressure - Administer Methergine IM (Methylergonovine Maleate) as ordered. It should be given IM, check the BP before administration. “Ergotrate derivatives. Monitor hypertension (or give oxytocin IV) Check perineum for lacerations Assist MD in doing episiorapy , vaginal pack should be used for 48 hours to prevent  puerperal sepsis. In recovery room, should be Flat on bed If chilling occurs – due – due to dehydration – just give additional Blanket Give clear liquid – ( tea, ginger ale, clear gelatin, Gatorade) – once regulated, can be given full liquid such as milk, ice cream, soup then soft diet to regular diet. Let mother sleep to regain energy.

4. Fourth Stage: the first 1 - 2 hours after delivery of placenta – recovery stage . a. Matern Maternal al Ob Obse serva rvatio tions ns – body system stabilizes

Check the vital signs q 15 for 1 hour. 2nd hour q 30 minutes. b. Place Placemen mentt of of the the Fund Fundus us – just above the umbilicus or level of umbilicus. If   palpated on the right side – it means full bladder therefore there fore – empty the bladder. If fundus above umbilicus, deviation of fundus 1.) Empty bladder to prevent prevent uterine uterine atony atony 2.) Chec Checkk loch lochia ia c. Lochia – vaginal discharges after the delivery process  Rubra – red  – red,, 1 - 3 days moderate  pink to brown, 4 – 9 days , decrease in amount, with musty odor   Serosa  –  pink to  Alba – creamy  – creamy white, white, 10 days – 3 weeks d. Perineum – check the perineum for : R -- redness R  E- edema E - ecchymosis D – discharges A – approximation of blood loss. * Count pad & saturation * Fully soaked pad : 30 – 40 cc weigh pad. 1 gram = 1cc e. Bonding – interaction between mother and newborn Types of rooming:

1.) Strict rooming: rooming: 24 hours - baby stays with mother. mother. 2.) Partial rooming rooming in: baby baby stays with with mother mother in the morning and stays in the nursery at night .

Complications of Labor Dystocia  – difficult labor related to mechanical factor  •

 – due to uteri uterine ne inerti inertiaa which which means means sluggi sluggishn shness ess of of contract contraction ion 2 Types of uterine inertia:

1.) hypertonic hypertonic or primary uterine uterine inertia inertia - intense excessive excessive contractions contractions resulting to ineffective pushing  Management: sedation – MD administer sedative Valium/Diazepam – muscle relaxant 2.) hypotonic hypotonic – secondary uterine uterine inertia, inertia, slow irregular irregular contraction contraction 38

•

•

resulting to ineffective pushing.  Management: Administer Oxytocin Prolonged labor –  resulting to:  Maternal  Effect:  Effect: exhaustion ( overpushing ) Fetal Effect: fetal distress, cephalohematoma or caput succedaneum 20 hours – Primi 14 hours – Multi * normal length of labor in primi 14 – 20 hours ; Multi 10 - 14 hours Contrac tion and Fetal Heart Tone  Management: Check and monitor Contraction

- labor of < 3 hours. extensive lacerations to mother that leads to  profuse bleeding → hypovolemic shock → hypotension, h ypotension, Tachypnea, Tachypnea, Tachycardia, Tachycardia, cold clammy skin Note: Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing diagnosis: fluid volume deficit Position of mother: Modified Trendelenberg IV – fast drip due fluid volume vo lume deficit Precipitate Labor

Signs of Hypovolemic Shock:

Hypotension Hypotension Tachycardia Tachy cardia Tachy pnea Cold clammy skin

Inversion of the Uterus  – uterus is turned inside out due to the following factors: a. hurrying pull out of the placenta b. ineffective fundal pressure c. short cord  Management: MD will push uterus back inside or not hysterectomy. hysterectomy. Uterine Rupture  –  Possible causes: • 1.) Previous classical Cesarean Section 2.) Large baby 3.) Improper use of oxytocin (IV (IV drip) drip)  Symptoms: a.) sudden pain b.)  profuse bleeding c.) hypovolemic shock  d.) TAHBSO  Note: Physiologic Retraction – boundary between upper and lower uterine segment •

Suprapubic Depression – sign of impending rupture of the uterus Bandl’s Pathologic Ring – bleeding that leads to hypovolemic h ypovolemic to TABHBSO TABHBSO

•

Amniotic Fluid Embolism  –

a situation of amniotic fluid fluid or fragments of placenta enters natural circulation resulting to embolism.

If NSD – Signs and Symptoms:

a. b.

dyspnea chest pain

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c. frothy sputum  Prepare: suctioning end stage: stage : DIC disseminated intravascular coagopathy * intravascular coagopathy - bleeding to all portions of the body such as

eyes, nose, etc. Trial Labor –  when the head measurement and pelvis measurement falls on the borderline.  Management: Give the mother 6 hours of labor allowance: Multi: 8 – 14; primi : 14 – 20 Monitor Fetal Heart Heart Tone and Contraction •

•

Pre Term Labor –  labor after 24 weeks before the 37 th week  Triad of Preterm Symptoms: 1. Premature contractions every 10 minutes 2. Effacement of 60 – 80 % 3. Dilatation of 2 - 3 cm Home Management:

1. complete bed rest 2. avoid sex 3. empty bladder  4. drink 3 - 4 glasses of water – full bladder inhibits contractions 5. consult MD if symptoms persist

Hospital Management:

1. If cervix cervix is closed closed (2 – 3 cm), dilation dilation saved by administer  administer  Tocolytic agents - to halts the preterm contractions of the uterus. (YUTOPAR - Yutopar Hcl) 150 mg incorporated 500 cc Dextrose piggyback. Monitor: FHT > 180 bpm Maternal BP - < 90/60 Crackles – notify MD Pulmonary edema – administer oral yutopar 30 minutes before d/c IV PreTerm: Magnesium PreTerm: Magnesium Sulfate

Before delivery mother will be given : DEXAMETHASONE –to facilitate surfactant maturation. Tocolytic (Phil) Terbuthaline (Bricanyl or Brethine) – sustained tachycardia Antidote – propranolol or inderal - beta-blocker   Note : * If cervix is open – MD – steroid dexamethsone (betamethazone) to facilitate surfactant maturation preventing Respiratory Distress Syndrome * Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia. * Term – suction suction at once •

• • •

X. Postpartal Period 5th stage of labor  after 24hours:  Normal increase WBC up to 30,000 mm3 Puerperium   – covers 1st 6 wks post partum Involution – return of reproductive organ to its non pregnant or normal state. Hyperfibrinogenia

- prone to thrombus formation

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- early ambulation

Principles Underlying Puerperium I. To return to Normal and Facilitate Healing A. Physiologic Changes a.1. Systemic Changes 1. Cardiovascular System The first few minutes after delivery is the most critical period in

mothers because the increased in plasma volume return to its normal state and thus adding to the workload of  the heart. This is critical especially to gravidocardiac mothers.( 1st one hour after delivery  – monitor the vital signs every 15 minutes ) Increase of temperature on the 1st 24 hours is normal. Increase in WBC (30,000mm3 ) immediately after delivery results to – encourage early ambulation, ambulation,  Hyperfibrogenemia. To prevent Thromboplebitis – encourage sometimes, may experience Postural Hypotension – gradually position the patient from semi to high fowlers

a.2. Genital Tract a. Cervix – cervical opening b. Vaginal and Pelvic Floor  c. Uterus – return to normal 6 – 8 weeks.

Fundus goes down 1 finger breath/day until 10th day – no longer palpable due behind symphysis pubis 3 days after post partum: subinvolution uterus – delayed healing uterus containing big, quarters or deep clots of blood - a medium for bacterial growth - (puerperal sepsis)

 Management:  Dilatation & Curettage After - birth pain : 1. position prone 2. cold compress – to prevent bleeding 3. mefenamic acid d. Lochia - bld, wbc, deciduas, microorganism. NSD & C/S with lochia.

1. Ruba – red 1st 3 days present, present, musty/mousy, musty/mousy, moderate modera te amount th 2. Serosa – pink to brown 4 – 9 day day,, limited amount 3. Alba – creamy white 10 – 21 days very decreased amount

a.3. a.3. Urin Urinar ary y tra tract ct:: Blad Bladde derr Frequency in urination after delivery (postpartum)

- urinary retention with overflow  Dysuria  – trigone of bladder 

 Nursing Action:

- urine collection - alternate warm & cold compress - stimulate bladder  Colon:Constipation – due to NPO, fear of bearing down; episiotomy 41

Perineal area : – painful –  Position: Sim’s position

episiotomy site

Cold compress for immediate pain after 24 hours, Hot sitz bath, Hot compress for immediate pain after 24 hours  Sex Act  - when perineum has healed • •

– Reva Rubia II. Provide Emotional Support – Reva 1. Psychological Responses:

a. Taking in phase – dependent dependent phase (1st three days) mother – passive, cannot make decisions, activity is to tell childbirth experiences.  Nursing Care: - proper hygiene  b.  b. Takin akingg hold hold pha phase se –  – dependent to independent phase (4 to 7 days). Mother is active, can make decisions 1. Care of newborn  Focus: 2. Insert Insert family family planti planting ng method method  Note: common post partum blues/ baby blues present 4 – 5 days 50 - 80 % moms – overwhelming feeling of depression characterized by crying, despondence - inability to sleep & lack of appetite. - let mom cry, cry, it is therapeutic. c. Letting Letting go – interdepen interdependent dent phase – 7 days & above. above. Mother - redefines new roles may extend until child grows.

III. Prevent complications 1. Hemorrh rrhage – bleeding of  > 500cc CS –  600 – 800 cc normal NSD - 500 cc I.

uterus

Early postpartum hemorrhage – bleeding within 1st 24 hours. a. Uterine Atony - Boggy or relaxed uterus & profuse bleeding Complications: hypovolemic shock. Modified Trendelenberg  Position: Management:

1.) massage massage uterus uterus until until contracted contracted 2.) cold cold comp compre ress ss 3.) modifi modified ed trendelen trendelenber bergg 4.) IV fast fast drip/ oxytocin oxytocin IV drip as ordered  Note: * If no effect after massage → cold compress → position → then let the newborn suck the mother ’s breast in order to stimulate the pituitary to release oxytocin for the contraction of the uterus. * Breast feeding – posterior pituitary gland will release oxytocin so will contract. * Well Well contracted uterus uteru s + bleeding = laceration 42

b. Laceration  Nursing Action:

Contracted uterus but with profuse bleeding assess episiotomy assess perineum for laceration degree of laceration Management : Episiorapy st 1 degree laceration – affects vaginal skin & mucus membrane. 2nd degree – 1st degree + muscles of vagina 3rd degree – 2nd degree + external sphincter of rectum 4th degree – 3rd degree + mucus membrane of rectum

Hematoma - bluish / purplish discoloration of subcutaneous vagina or  Perineum. May be due to : too much manipulation large baby pudendal anesthesia Management: * Cold compress every 30 minutes with rest period of 30 minutes repeat for 24 hours * Shave * Incision on site, site, scraping & suturing c.

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen

- failure to coagulate bleeding to any part of body  Note: hysterectomy if with abruption placenta Management: Blood Transfusion , cryoprecipitate or fresh frozen plasma II.

Late Po Postpartum hemorrhage – bleeding after 24 hours 1. Retai Retaine ned d Place Placent ntal al Frag Fragmen ments ts Management: Dilatation & Curettage or manual extraction of

fragments

& massaging of uterus :   Except: * Placenta Placenta Accreta - unusual attachment to myometrium myometrium * Placenta * Placenta Increta - deeper attachment of placenta to myometrium * Placenta Percreta – invasion of placenta to perimetrium

2. Infection- sources of infection 1.) endogenous – from within body 2.) exogenous – from outside General signs:

1. Inf Inflam lammati mation on – calor – calor (heat), rubor (red), dolor (pain) tumor(swelling) and loss of function. anaerobic streptococci – most common: 1. from members health team 2. break break in in the the chai chainn of inf infec ecti tion on 3. unheal unhealth thyy sexu sexual al prac practi tice ce 4. puru purule lent nt dis disch char arge gess 5. fever  

General Management:  Supportive Care: Complete Bed Rest , hydration/ fluid intake, TSB, cold c old

compress, paracetamol, VITC, culture & sensitivity – before taking antibiotic * prolonged use of antibiotic lead to fungal infection

43

2 to 3 stitches stitches dislodged with purulent discharge coming out Management: Removal of sutures & drainage  Endometritis  – inflammation of endometrial lining Signs of infection plus abdominal tenderness  Position : Fowlers to facilitate drainage Administration of oxytocin as ordered Antibiotic – if not treated – lead to thrombophlebitis  Infection of Perineum :

IV. Motivate the use of Family Planning 1.) determine one’s own 1ST beliefs 2.) never advice a permanent method of family planning 3.) method of choice is an individuals choice/ own decision. 4.) Informed consent Natural Method – the only method accepted by the Catholic Church •

estrogen ) clear, watery, Billings / Cervical mucus  – test spinnbarkeit ( estrogen

stretchable, elastic – long spinnbarkeit ferning  – microscopic fern pattern •

to progesterone Basal Body Temperature –  due to progesterone 13th day temp temp goes down before ovulation – no sex - get get bef befor oree ari arisi sing ng in bed bed

•

•

LAM -

Lactation Amenorrhea Method - related to breast feeding Prolactin – hormone that inhibits menstruation/ovulation Bottle Feeding – the mother will menstruate after 2 – 3 months Breastfeeding – the mother will menstruate after 4 - 6 months  Disadvantage : might get pregnant Symptothermal –  combination of BBT & cervical. Best method

Social Method:

coitus interuptus/ withdrawal - least effective method method o coitus reservatus – sex without ejaculation ; common to callboy/callgirl o coitus interfemora – “ipit” o calendar method – 28 days cycle ( REGULAR ) OVULATION – count minus 14 days before next menstruation (14 days before next menstruation) MENSTRUATION - get the longest and shortest cycle Origoknause formula – IRREGULAR MENSTRUATION Shortest minus 18 an longest minus 11 – unsafe period REGULAR MENSTRUATION MENSTRUATION – 28 days minus 14 days plus 3 – 4 days days before and after  menstruation monitor cycle for 1 year  get short test & longest cycle from January – December  shortest – 18 longest – 11 44 o

• • • •

June 26 Dec 33 - 18 -11 8 22 unsafe days th 21 day pill- start 5 day of menstruation 28 day pill- start 1st day of menstruation missed 1 pill – take 2 next day Physiologic Method  Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary

gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective.  Waiting time to become pregnant- 3 months.  Consult OB – 6 months. Alerts on Oral Contraceptive: •

•

•

In case a mother who is taking an oral contraceptive for almost long time plans to have a baby bab y, mother would wait for at least 3 months before attempting to conceive to  provide time for the estrogen and progesterone levels to return to normal. If a new oral contraceptive is prescribed the mother should continue taking the  previously prescribed contraceptive and begin taking the new one on the first day of  the next menses. Discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA CVA and subarachnoid hemorrhage. Immediate Discontinuation

•



A – abdominal pain C – chest pain H - headache E – eye problems S – severe leg cramps ACHES – signs of hypertension hence if the Blood Pressure of the mother is increased – stop the pills STAT! if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another  method for the rest of the cycle and the start again.  Adversed Effect: breakthrough bleeding Contraindicated: chain smoker  extreme obesity Hypertension Diabetes Mellitus Thrombophlebitis or problems in clotting factors

DMPA – Depot Provera Medroxy Progesteron Acetate - depoproveda – has progesterone

inhibits LH – inhibits ovulation Depomedroxy progesterone acetate – has progesterone inhibits LH – inhibits ovulation - IM every month - never massage injected site, it will shorten duration ( it can easily absorbed ) 45



 Norplant – has 6 matchsticks like capsule/rod dermally implanted containing progesterone.  Note : 5 years – disadvantage if keloid skin as soon as removed – can become pregnant

Mechanical and Chemical Barriers Intrauterine Device (IUD)  Action: prevents implantation – affects motility of sperm & ovum

- right time to insert is after delivery or during menstruation  primary indication for the use f IUD : parity or # of children MULTIARITY if 1 child only don’t use IUD

Health Teaching: a. Check for string daily b. Monthly checkup c. Regular pap smear  Alerts:     

 prevents implantation inserted during menstruation and after delivery because the cervix is open most common complications: excessive menstrual flow most common problem: expulsion of the device others complications – uterine infection uterine perforation and ectopic pregnancy Period late (pregnancy (pregnanc y suspected) Abnormal spotting or bleeding A bdominal pain or pain with intercourse Infection (abnormal vaginal discharge) Not feeling well, fever, chills Strings lost, shorter or longer 



Condom –

made up of latex inserted to erected penis or lubricated vagina - it less lessen en sexu sexual al sat satis isfa fact ctio ionn - it gives gives high higher er prote protecti ction on in in the the preve preventi ntion on of of STD’ STD’ss Alert : female condom - give the most most and highest protection against STD



Diaphragm  – made up of rubberized dome shaped material inserted to the cervix

Alert:

 preventing sperm to get to the uterus. REVERSABLE

proper hygiene hygiene should should be observed observed since since it is reusable reusable check for for holes holes before before using using itit must be be kept in place place for about 6 – 8 hrs hrs after after sex must be refitted refitted especially especially if weight weight change, ↑or ↓ by 15 lbs spermicide spermicide – chemical chemical Barrier  example: Foam (most effective), jellies, creams Side effect: Toxic shock syndrome 

1.) 2.) 3.) 4.) 5.)

Cervical Cap –

most durable than diaphragm - no need need to app apply ly sperm permiicide cide - should should be kept kept 24 hours hours,, no need to reapp reapply ly spermic spermicide idess 46

Contraindication: 

abnormal pap smear 

Foams, Jellies, Creams, Spermicidal agents – to kill spermicides Foam –  most effective Spermicidal agents –  toxic effect – Toxic Shock Syndrome

Surgical Method  BTL ( Bilateral Tubal Ligation ) women ( tie, cut, cautery ) immediate sterilization – cut

 –



can be reversed 20% chance. ( 20 – 30 reanastamosis ) - isthmus - is the site for sterilization Health Teaching Teaching : Avoid lifting heavy object

cut vas deferense. not not imm immed edia iate te ster steril iliz izat atio ionn need to ejac ejaculat ulatee 30 X for 0 sperm sperm before before cons conside iderin ringg a safe safe sex Health Teaching : > 30 ejaculations before safe sex O – zero sperm count, safe Vasectomy

( men ) -

XI. High Risk Pregnancy 1. He Hemo morrh rrhag agic ic Diso Disorde rders rs • • • •

To determine the integrity of sac Prepare the mother for ultrasound Save discharges for histopathology Assess for complications like hypovolemic shock 

General Management

1.) Complet Completee Bed Bed Rest Rest 2.) Avoid void sex sex 3.) Assess Assess for blee bleeding ding Fully saturated pad (per pad 30 – 40 cc) (weight – 1 gm =1 cc) 4.) Ultrasound Ultrasound to determi determine ne integrity integrity of sac 5.) Signs of Hypovolemic Hypovolemic shock  6.) Save discharges discharges – for histopatholo histopathology gy – to determine if product product of conception conception has been expelled or not

First Trimester Bleeding  – abortion or eptopic

– termination of pregnancy before age of viability (before 20 weeks) Age of viability – 20 – 20 - 24 weeks  Intrauterine death or Stillbirth – after the age of viability

A. Abor Aborti tion onss

1. Spontaneous Abortion –  also known as miscarriage Causes: 1.) chromosomal alterations 2.) blighted ovum 3.) plasma germ defect Classifications:

a. Threatened Threatened – pregnancy pregnancy is jeopardized jeopardized by bleeding bleeding and cramping cramping but the cervix cervix is closed; can give progesterone 47

 b. Inevitable Inevitable – moderate moderate bleeding, bleeding, cramping, cramping, tissue tissue protrudes protrudes form form the cervix cervix (Cervical dilation) cervix is open Types:

 b.1. Complete – all products of conception are expelled.  Nursing Management: no need for D & C, just emotional support!  b.2 Incomplete – Placenta and membranes retained. Management: for D& C  b.3 Habitual – 3 or more consecutive pregnancies result in in abortion usually nd related to incompetent cervix. Present 2 trimester 

Incompetent cervix – abortion

Surgery: a. McDonalds procedure – temporary circlage on cervix * During delivery, circlage is removed. NSD Side Effects: infection. b. Shirodkar – permanent surgery on cervix. CS  b.4 Missed – fetus dies; product of conception remain in uterus 4 weeks or  longer; signs of pregnancy pregnanc y cease. (-) pregnancy pregnanc y test, scanty, scanty, dark   brown bleeding Management: induced labor with oxytocin or vacuum extraction c. Induced Abortion Abortion – therapeutic therapeutic abortion abortion to save save life of mother mother based based on the principles of twofolds twofolds effect - choose between lesser evil. B. Ec Ectop topic ic Pregn Pregnan ancy cy – occurs when gestation is located outside the uterine cavity. tubal or ampular  Common site : Dangerous site : interstitial

Unruptured

o

o

missed period abdominal pain within 3 -5 weeks of missed  period (maybe generalized or one sided)

Tubal rupture

o

o

o

scant, dark brown, vaginal bleeding

o

o

vague discomfort

o

Nursing Care:

sudden , sharp, shar p, severe seve re pain pa in. Unilateral radiating to shoulder. shoulder pain (indicative of intraperitoneal  bleeding that extends to diaphragm and phrenic nerve) + Cullen’s Sign – Sign – bluish tinged umbilicus –  signifies intra peritoneal bleeding syncope (fainting)

Surgery:

48

   

Vital Signs Administer IV fluids Monitor for vaginal bleeding Monitor I and O

* Fallopian - Sa S alphingectomy * Abdominal - Exploratory Laparotomy * Uterus - Hysterectomy

Second trimester bleeding –  small and incompetent cervix C. Hyda Hydatid tidifo iform rm Mole Mole “bunch or grapes” or gestational trophoblastic disease. – with

-

fertilization. Progres Progressiv sivee degene degenerati ration on of of chori chorioni onicc villi villi.. Recur Recurs. s. Gestat Gestation ional al anomal anomalyy of the the placent placentaa consist consisting ing of a bunch bunch of clea clearr vesicle vesicles. s. This neoplasm neoplasm is is formed formed form form the the selling selling of the the chronic chronic villi villi and lost lost nucleus nucleus of the the fertilized egg. The nucl nucleus eus of of the the sperm sperm dupli duplicat cates, es, produ producin cingg a diploi diploidd number number 46 46 XX It grows grows & enlarge enlargess the uterus vary rapidly rapidly.. ( progressiv progressivee degeneration degeneration of corionic corionic villi villi ) Use: methotrexate to prevent choriocarcinoma

Assessment:  Early signs

-

vesicles passed thru the vagina Hyperemesis gravidarium due to increase HCG Fundal height Vaginal bleeding ( scant or profuse)

Earl Early y in preg pregna nanc ncy y -

-

Late signs:

High levels of HCG Pre Pre ecl eclam amps psia ia at abou aboutt 12 12 wee weeks ks

hypertension before 20th week  Vesicles look like a “ snowstorm” on sonogram Anemia Abdominal cramping

-

Serious Late complications

:

-

hyperthyroidism Pulmonary embolus

Nursing care: • •

Prepare for D & C Do not give oxytoxic drugs – may cause embolism

Teachings: a. Return for pelvic exams as scheduled for one year to monitoring HCG

and assess for enlarged uterus and rising titer could indicative of  choriocarcinoma b. Avoid pregnancy for at least one year . Can have sex provided the partner  will use condom for protection

Third Trimester Bleeding “Placenta Anomalies” D. Place Placenta nta Previ Previa a – it occurs when the placenta is improperly implanted in the lower uterine

segment,

sometimes covering the cervical os. - Abnormal lower implantation of placenta. * candidate for CS Total – complete cover of o f the cervical os Partial – 5% Low 49

Assessment:

Outstanding signs and symptoms:  FRANKBRIGHT RED PLEEDING, PAINLESS BLEEDING  Engagement (usually has not occurred)  Fetal distress  Presentation ( usually abnormal )

Complications:  

Internal examination Sudden fetal blood loss

Diagnostic Examination:

Ultrasound Note: Avoid: sex, IE, enema – may lead to sudden fetal blood loss Double set up: delivery room may be converted to OR  

Nursing Care:

 NPO  Bed rest  Prepare to induce labor if cervix is ripe  Administer IV Note Alert : Surgeon – in charge of sign consent, RN as witness MD explain to patient 

E. Abru Abrupti ptio o Place Placenta nta -

site.

•

it is the premature the premature separation of the placenta form the implantation

- It usua usually lly occurs occurs afte afterr the the twent twentiet iethh week week of pregnanc pregnancyy. (due to use of cocaine ) – PIH

Assessment:      

dark red, painful bleeding  board like or rigid uterus/abdomen Concealed bleeding/hemorrhage (retroplacental) Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage. Severe abdominal pain Dropping coagulation factor (a potential for DIC)

Complications:  

Sudden fetal blood loss  placenta previa & vasa previa

General Nursing Care:        

Infuse IV, IV, prepare to administer blood Type Type and crossmatch Monitor FHR  Insert Foley Measure blood loss; count pads Report signs and symptoms of DIC Monitor v/s for shock  Strict I & O 50

F. Place Placenta nta suc succe centu nturia riata ta

– 1 or 2 more lobes connected to the placenta by a blood vessel which may lead to retained placental fragments if vessel is cut.

G. Placenta Placenta Circum Circumvala valata ta

– fetal side of placenta covered by chorion

H. Place Placenta nta Margi Margina nata ta – fold side of chorion reaches just to the edge of placenta I. Batt Battle ledo dorre Plac Placen enta ta – cord inserted marginally rather then centrally J. Plac Placen enta ta Bipa Bipart rtit ita a

– placenta divides into 2 lobes

K. Placenta Placenta Tripartit ripartita a

– placenta divides into 3 lobes

L. Vilamento ilamentous us Insert Insertion ion of cord cord- cord divides into small vessels before

it enters the placenta

M. Vasa Previa Previa – velamentous insertion of cord has implanted in cervical OS

2. Hyper Hyperten tensiv sivee Disor Disorde ders rs I. Pregnancy Induced Hypertension (PIH ) •

Hypertension after 24 wks of pregnancy pr egnancy,, solved 6 weeks post po st partum.

1.) Gestational hypertension - HPN without edema & protenuria 2.)  Pre-eclampsia – HPN with edema & protenuria or albuminuria

-

H without EP HEP/A

idiopathic 3.)  HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count - common common in in primi primi becau because se of of increa increase se expos exposure ure to to chroni chronicc villi villi - multiple pre pregnan nancy - Mo Moth ther er low low soc socio io-e -eco cono nomi micc stat status us - Increa Increase se sen sensi siti tivi vity ty to to Ang Angio iote tens nsin in II II ↓ main effect   peripheral vascular vasospasm ↓ decrease Oxygen supply → Hypertension ( main denominator ) ↓ KIDNEYS ↓ ↓

↓

↓

↓

EYES Glomerular Degeneration Glomerular Filtration Placenta ↓ ↓ ↓ ↓ Retina Retinall vassoc vassocons onstri tricti ction on increas increasee permeab permeabili ility ty increas increasee sodium sodium absorpt absorption ion IUGR  IUGR  ↓ ↓ ↓ (intrauterine growth retardation) Blurred Vision proteinuria increase water retention └   ┘ ↓ EDEMA SCOTOMA ↓ ↓ ANASARCA 51

BLINDNESS

LIVER – Tissue Ischemia ↓ Liver Edema ↓ Epigastric Pain

↓ BRAIN ↓ Cerebral Edema

↓

↓ LUNGS ↓ Pulmonary Edema ↓ HEART ( CHF ) ↓

PRE TERM LABOR 

CONVULSION

II. Transissional Hypertension –  HPN between 20 – 24 weeks III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum. Three types of pre-eclampsia 1.) Mild preeclampsia – earliest sign of preeclampsia a.) increase wt due to edema b.) BP 140/90 c.) protenuria +1 - +2 2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110, protenuria +3 - +4  – with seizure! seizure! Increase BUN – glomerular damage. Provide safety. 3.) Eclampsia  – with Cause of pre eclampsia 1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi 2.) common in multiple pre (twins) increase exposure to chorionic villi 3.) common to mom with low socioeconomic status due to decrease intake of 

CHON

Nursing care:

P – promote bed rest to decrease O2 demand, facilitate, sodium excretion, - water immersion will cause to urinate. P - prevent convulsions by nursing measures or seizure precaution 1.) maintain dimly lit room 2.) quiet calm environment 2.) minimal handling – planning procedure 3.) avoid jarring bed * Right Place of the patient: across the nursing station P- prepare the following at bedside - tongue depressor  - side rail up before the seizure - turning to side done d one AFTER seizure (to facilitate facilitate drainage of secretion) 52

- prepare suction machine - Observe only! for safely. E – ensure high protein intake ( 1g/kg/day) - Na – in moderation (replace the protein loss) A – anti-hypertensive drug Hydralazine ( Apresoline) C – convulsion, prevention by : Mg S04 – CNS depressant or anti convulsant (absence of seizure) E – valuate physical parameters for Magnesium sulfate Magnesium SO4 Toxicity:

1. 2. 3. 4.

BP dec decreas ease Urin Urinee outp output ut decre decreas asee Resp < 12 Patell Patellaa reflex reflex absent absent – 1st sigh Mg SO4 toxicity. Antidote : Ca gluconate

3.Diabetes Mellitus - absence of insufficient insulin (Islet of Langerhans of pancreas) Function of insulin:

-

facilitates transport of glucose to cell glucose - energizer of cell insulin – key for glucose Diagnostic Test: 1 hour 50 grams (glucose tolerance test ) GTT Normal glucose   – 80 – 120 mg/dl ( euglycemia) < 80 – hypoclycemic > 120 - hyperglycemia 3 hours GTT of > 130 mg/dL • •

Maternal Effect Diabetes Mellitus 1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic * hpl – serves as insulin antagonist 2.) Frequent infection- moniliasis/candidiasis 3.) Polyhydramnios 4.) Dystocia - difficult birth due to abnormalities in fetus or mother is big 5.) Insulin requirement, decrease in insulin by 33 % in 1st tri; 50 % increase

insulin at 2nd – 3rd trimester. Post partum decrease 25% due placenta out. No more hormone (hpl) - given by shots, not oral because it is teratogenic

Fetal effect 1.) 1.) hype yper & hypoglycemia 2.) macro macroso somia mia   – large for gestational age

 – baby baby deli delive vere redd > 400 40000 g or or 4 kg kg – largest 80 8000 g 3.) prete preterm rm birt birth h to prevent stillbirth 4.) IUGR (Intrauterine Growth Retardation) Newborn Effect : Diabetes Mellitus 1.) hyperinsulinism 2.) hypoglycemia normal glucose in newborn 45 – 55 mg/dL 53

 borderline – 40 mg/dL hypoglycemic < 40 mg/Dl * glucose – food for the brain Management:

Heel stick test – get blood at heel - adm administer de dextro xtrosse - monitor   Signs and Symptoms : - Hypoglycemia - hig high pi pitch shril rill cry cry - tremors 3.) hypocalcemia - < 7 mg% Signs and Symptoms:

Calcemic tetany Trousseau sign

Management : Give calcium gluconate if decrease calcium Recommendation

Therapeutic abortion If push through with with pregnancy 1.) antibiotic therapy- to prevent sub acute bacterial endocarditis 2.) anticoagulant – heparin doesn’t cross placenta Class I & II- good prognosis for vaginal delivery Class III & IV- poor prognosis, for vaginal delivery, delivery, not CS! - genera nerall ane anesthesi esia - anti anti coagu coagulan lantt thera therapy py – “Hep “Hepari arin” n” – if pregnant pregnant only only - Anti Antibi biot otic ic – to to preve prevent nt sub subacu acute te endo endoca cardi rditi tiss  NOT lithotomy! High semi-fowlers or sidelying position during delivery (best (be st position)  No valsalva maneuver  Regional anesthesia! Caudal (anesthesia of choice) Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.

Heart disease

Mothers with RHD at childhood Class I – no limitation of physical activity Class II – slight limitation of physical activity. - Ordinary activity causes fatigue & discomfort. Recommendation of class I & II 1.) sleep 10 hours a day 2.) rest 30 minutes & after meal Class III - moderate limitation of physical activity. activity. - Ordinary activity activity causes discomfort and fatigue Recommendation: 1.) early hospitalization by 7 months Class IV. marked limitation of physical activity for even at a t rest there is fatigue & discomfort. Recommendation: Therapeutic abortion XII. Intrapartal complications

54

1. Cesarean Delivery Indications: a. Multiple gestation b. Diabetes c. Active herpes II d. Severe toxemia e. Placenta previa f. Abruptio placenta g. Prolapse of the cord h. CPD primary indication i. Breech presentation  j. Transverse lie Procedure: a. Classical – vertical insertion. Once classical always classical b. Low se segment ent – bikini line type – “aesthetic use” - transverse after CS – low segment VBAC – vaginal birth after

INFERTILITY •

inability to achieve pregnancy. pregnancy. Within Within a year of attempting attempting it Manageable

STERILITY

irreversible  Impotency – inability to have an erection •

2 types of infertility

1.) Primary – no pregnancy at all 2.) Secondary – 1st pregnancy, no more next pregnancy

Test Male 1st

more practical & less complicated o need: sperm only o sterile bottle container ( not plastic has chem.) o Sims Huhner test – or post coital test. Procedure: sex 2 hours before test mother – remains supine 15 minutes after ejaculation  Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If > 15 – low sperm count Best criteria - sperm motility for impotency Factors: low sperm count 1.) Occupat Occupation ion - truck truck driver  driver  2.) chain chain smok smoker  er  Administer: clomid ( chomephine citrate) to induce spermatogenesis o

↓ if not effective Transfer” Management : GIFT = “Gamete Intra Fallopian Transfer”

for low sperm count

Implant sperm in ampula 1.) Mom: anovulation – no ovulation. Due to increase prolactin  – hyperprolactinemia ( inhibit ovulation ) Administer:  parlodel ( Bromocryptice Mesylate) Action: antihyper prolactineuria (antiparkinsonian) Give mom clomid: action: to induce oogenesis or ovulation

55

Side Effects: multiple pregnancy 2.) Tubal ubal Occlu Occlusion sion – tubal blockage – 

History of PID that has scarred tubes o Use of IUD (peritonitis) o Appendicitis (burst) & scarring Diagnostic Test: hysterosalphingography – used to determine tubal patency with use of  radiopaque material Management: IVF – invitrofertilization (test tube baby)  England  1st test tube baby o

To shorten 2 nd stage of labor: 1.) fundal pressure 2.) episiotomy 3.) forcep delivery

56