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MATERNAL AND CHILD HEALTH NURSING

Maternal and Child Health Nursing involves care of the woman and familythroughout pregnancy and child birth and the health promotion and illness carefor the children and families.

Primary Goal of MCN

1 The promotion and maintenance of optimal family health to ensure

cycles of optimal childbearing and child rearing

I. ANATOMY & PHYSIOLOGY

1. Ovarieso lmond shapedo Produce! mature and discharge ovao "nitiate and regulate menstrual cycleo # cm long! $ cm in diameter! %.& cm thic'o Produce estrogen and progesterone

Estrogen: promotes breast devt & pubic hair distribution prevents osteoporosis keepskeepscholesterol levels reduced & so limits efects o atherosclerosis Fallopian tubes ..

1 ppro(imately %) cm in length

2 Conveys ova from ovaries to the uterus

3 *ite of fertili+ation

4 Parts, interstitial isthmus - cutsealed in /T0

ampulla - site of fertili+ation infundibulum - most distal segment1 covered with 2mbria

$. 3terus

11 Hollow muscular pear shaped organ uterine wall layers, endometrium1 myometrium1 perimetrium

22 Organ of menstruation

33 4eceives the ova

44 Provide place for implantation 5 nourishment during fetal growth

55 Protects growing fetus

66 6(pels fetus at maturity

77 Has 7 divisions, corpus - fundus ! isthmus 8most commonly cut during C* delivery9 andcervi(

7. 3terine :all1 6ndometrial layer, formed by $ layers of cells which are as follows,

2 basal layer; closest to the uterine wall

3 glandular layer - inner layer in

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2. Repr!u"t#$e De$e%pe't

Readiness for child bearing

1 begins during intrauterine life

2 full functioning initiated at puberty

the hypothalamusreleases the GnRFwhich triggers the '() to orm and release F*+and ,+. 8B*H 5 0H initiates production of androgen and estrogen ;;; 2( )e*u+%",+r+"ter#)t#")

Role of Androgen

1 ndrogenic hormones - are produced by the testes! ovaries and adrenal corte( which isresponsible for,

muscular development physical growth inc. sebaceous gland secretions

1 testosterone -primary androgenic hormone

Related termsa. drenarche - the development of pubic and a(illary hair 8due to androgen stimulation9

b. Thelarche - beginning of breast developmentc. Menarche - 2rst menstruation period in girls 8early D y.o. or late %E y.o.9

d. Tanner *taging2 "t is a rating system for pubertal development

3 "t is the biologic mar'er of maturity

4 "t is based on the orderly progressive development of,

5 breasts and pubic hair in females

6 genitalia and pubic hair in males

-. B!y Stru"ture) I'$%$e!

1 Hypothalamus

2 nterior Pituitary Gland

3 Ovary

4 3terus

. Me')tru+% Cy"%e

1 Bemale reproductive cycle wherein periodic uterine bleeding occurs in response to cyclic

hormonal changes2 llows for conception and implantation of a new life

3 "ts purpose it to bring an ovum to maturity1 renew a uterine bed that will be responsive to thegrowth of a fertili+ed ovum

/. Me')tru+% P,+)e)

0#r)t, #;& days after the menstrual

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2. fter release of ovum and

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Or+% "'tr+"ept#$e

ction, inhibits release of B*H no ovulationTypes, Combined 1 *e>uential1 Mini pill

*ide 6=ects, due to estrogen and progesterone nausea and vomiting Headache and weight gain breast tenderness di++iness

brea'through bleedingspotting chloasma

Contraindications,a. /reastfeedingb. Certain diseases,

o thromboembolismo iabetes Mellituso 0iver diseaseo migraine1 epilepsy1 varicositieso C1 renal disease1recent hepatitis

c. :omen who smo'e more than $ pac's of cigarette per dayd. *trong family H( of heart attac'

Nte I3 t+6#' p#%% #) #))e! ' )",e!u%e7 t+6e 'e +) )' +) reebere! +'! t+6e 'e*tp#%% ' )",e!u%e8 #3 't !'e 9#t,!r+9+% b%ee!#' ""ur).

B. N+tur+% Met,!)

a. Rhythm/Calendar/Ogino Knause Formulao Couple abstains on days that the woman is fertileo Menstrual cycles are observed and charted for %$ months

*tandard Bormula, 2rst day of the beginning of one cycle to the 2rst day of the ne(t cycle

shortest cycle L minus %F longest cycle L minus %%

6(ample, shortest cycle L $F longest cycle L 7&

*hortest cycle, $F days - %F L %)0ongest cycle, 7& days - %% L $#Bertile pd, %)th to $#th day of cycle L No se(ual intercourse

b. Billings Method / Cerical Mucuso woman is fertile when cervical mucus is thin and watery1 may be e(tendedo *e(ual "ntercourse may be resumed after 7 - # days

c. !ymptothermal Method / BB"

1 4e>uires daily observation and recording of body temperature before rising in themorning or doing any activity to detect time of ovulation

2 Ovulation is indicated by a slight drop of temperature and then rises

3 4esume *e(ual intercourse after 7 - # days

4 4ecommended observation of //T is menstrual cycle to establish pattern of

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o initially inserted by the doctoro maybe washed with soap and water is reusableo when used! must be 'ept in place because sperms remains viable for hrs. in the

vagina but must be removed within $# hours 8to decrease ris' of to(ic shoc'syndrome9

-. C'!

1 a rubber sheath where sperms are deposited

2 it lessens the chance of contracting *Ts3 most common complaint of users interrupts se(ual act when to apply

D.C,e#"+% Met,!)

These are spermicidals 8'ills sperms9 li'e Kellies! creams! foaming tablets! suppositories

E.Sur#"+% Met,!a. Tubal 0igation,

Ballopian tubes are ligated to prevent passage of spermsMenstruation and ovulation continue

b. ?asectomy,

?as deferens is tied and cut bloc'ing the passage of sperms*perm production continues*perms in the cut vas deferens remains viable for about months hence coupleneeds to observe a form of contraception this time to prevent pregnancy

IV. BEGINNING O0 PREGNANCY

. 0ert#%#;+t#'

1. 3nion of the ovum and spermato+oon

2. Other terms, conception! impregnation or fecundation

3. Normal amount of semeneKaculationL 7;& cc L % tsp.

4. Number of sperms, %$);%&) millioncceKaculation

5. Mature ovum may be fertili+ed for %$ -$# hrs after ovulation

6. *perms are capable of fertili+ing even for 7 - # days after eKaculation 8life span of spermsE$ hrs9

/. Ip%+'t+t#'

General Considerations,o Once implantation has ta'en place! the uterine endometrium is now termed deciduao Occasionally! a small amount of vaginal bleeding occurs with implantation due to brea'age

of capillarieso "mmediately after fertili+ation! the fertili+ed ovum or +ygote stays in the fallopian tube for 7

days! during which time rapid cell division 8mitosis9 is ta'ing place. The developing cellsnow called blastomere and when about to have % blastomere called morula.

o Morula travels to uterus for another 7 - # dayso :hen there is already a cavity in the morula called blastocyto 2nger li'e proKections called trophoblast form around the blastocyst! which implant on the

uteruso "mplantation is also called nidation! ta'es place about a wee' after fertli+ation

C. St+e) 3 ,u+' pre'+t+% !e$e%pe't

%. Cytotrophoblast - inner layer$. *yncytiotrophoblast - the outer layer containing 2nger

li'e proKections called chorionic villi which di=erentiatesinto,

o 0angerhans layer - protective against Treponema Pallidum! present onlyduring the second trimester

o *yncytial 0ayer - gives rise to the fetal membranes! amnion and chorion

D. 0et+% Mebr+'e)

1. mnion - gives rise to umbilical cordfunis - with $ arteries and % vein supported by

2. :hartons Kelly

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3. mniotic uic'ening1 BH4 audible with stethoscope

=t, 't,, ttains proportions of full term but has wrin'led s'in

>t, 't,, $F wee's - lower limit of prematurity1 alveoli begins to form

?t, 't,, 7$ wee's - fetus viable1 lanugo disappears! subcutaneous fat deposition begins

@t, 't,, 0anugo continue to disappear1 verni( complete1 amniotic volume decrease

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Focus of Fetal #eelopment

Birst Trimester - period of organogenesis

*econd Trimester - period of continued fetal growth and development1 rapid increase in length

Third Trimester - period of most rapid growth and development because of the deposition ofsubcutaneous fat

Assessing Fetal $ell%being

Betal Movement,uic'ening at %F - $) wee's ! pea's at $D ;7F wee'sConsistently felt until term

a. Cardi= Method, @Count to tenA ; records time interval it ta'es for %); fetal movements to be felt usually occurs in )minutes

b. Contraction *tress Test, Betal Heart 4ate 8BH49 analy+ed in conKunction with contractionsNipple stimulation done to induce gentle contractions7 contractions with #) sec duration or more must be

presentin %) minutes window

Normal 4esult no fetal decelerations with contractions

c. Non;stress Test, Measures response of BH4 to fetal movement 8%);$)mins.9 with fetal movement BH4 increase by %& beats andremain for %& seconds then decrease to average rate 8noincrease means poor o(ygen perfusion to fetus9

d. mniocentesis ; done to determine fetal maturity, "dentify 0* ratio % w's - detect genetic disorder

7) w's - assess

1.Prior to the procedure! bladder should be emptied1 ultrasonography is used to avoidtrauma from the needle to the placenta! fetus

2.Complications include premature labor! infection! 4h isoimmuni+ation

3.Monitor fetus electronically after procedure! monitor for uterine contractions

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4.Teach client to report decreased fetal movement! contractions! or abdominal discomfortafter procedure.

e. 3ltrasound - transducer on abdomen transmits sound waves that showfetal image on screen

a. one as early as 2ve wee's to con2rm pregnancy! gestational age

b. Multiple purposes - to determine position! number! measurement of fetus8es9 and otherstructures 8placenta9

c. Client must drin' uences of increased cardiac volume,%. easy fatigability 5 shortness of breath due increase cardiac wor'load

$. slight hypertrophy of the heart7. systolic murmurs due to lowered blood viscosity#. nosebleeds may occur due to congestion of nasopharyn(

b. (alpitationscaused by the *N* stimulation during early part of pregnancy1 increased pressure of the uterus

against the diaphragm during the second half of pregnancy

c Edema o the lower e"tremities & varicositiesdue to poor circulation caused by the pressure of the gravid uterus on the blood vessels of thelower e(tremities

d. 1aginal and rectal varicosities; due to pressure on blood vessels of the genitalia

Management, side lying hips elevated on pillow modi2ed 'nee chest position

e. (redisposition to blood clot ormation;due to increased level of circulating 2brinogen as a protection from bleeding implication, no

massage

$. Gastrointestinal Changes

a. 2orning sickness

2 nausea and vomiting in the %st trimester due to HCG or due to increased acidity or emotionalfactors

3 Management, dry toast 7) mins before get up in M

b. +!peremesis gravidarum

4 e(cessive nausea 5 vomiting which persists beyond 7 months causing dehydration! starvationand acidosis

5 Management, hydration in $# hrs1 complete bed room

c. -onstipation and FlatulenceG" displacement slows peristalsis 5 gastric emptying time1 inc progesterone

d. +emorrhoids

1 due pressure of enlarged uterus

2 Management, cold compress with witch ha+el and 6psom salts

e. +eartburn

1 due to increased progesterone and decreased gastric motility causing regurgitation throughgastric sphincter

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2 Management, pats o= butter before mealsavoid fried! fatty foodssips of mil' at intervals

small! fre>uent meals ta'en slowlydont bend on waistta'e antacids 8mil' of magnesia9

7. 4espiratory Changes

a. *hortness o reathdue to inc. o(ygen consumption and production of carbon dio(ide during the %st Trimester1and increased uterine si+e pushing the diaphragm crowding chest cavitymanagement, side lying position to promote lateral chest e(pansion

#. 3rinary Changes

a. 3rinar! re4uenc!felt during the %st trimester due to the increase blood supply to the 'idneys and then on

the 7rd trimester due to pressure on the bladder.

b. 5ecreased renal threshold or sugardue to increased production of glucocorticoids which cause lactose and de(trose to spillinto the urine1 and inc. progesterone

&. Musculos'eletal changesa. (ride o (regnanc!

1 due to need to change center of gravity result to lordotic position

b. 6addling gait

1 due to increased production of hormone rela(in! pelvic bones becomes more movable

2 increasing incidence of falls

c. ,eg cramps

1 due to pressure of gravid uterus! fatigue! muscle tenseness! low calcium and phosphorusinta'e

. 6ndocrine Changes

a. ddition of the placenta as an endocrine organ producing HCG! HP0! estrogen and

progesteroneb. Moderate enlargement of the thyroid due to increased basal metabolic rate

c. "ncreased si+e of the parathyroid to meet need of fetus for calcium

d. "ncreased si+e and activity of adrenal corte( increasing circulating cortisol! aldosterone!and H which a=ect CHO and fat metabolism causing hyperglycemia.

e. Gradual increase in insulin production but there is decreased sensitivity to insulin duringpregnancy

E. :eight Change

a. Birst Trimester %.& to 7 lbs normal weight gain

b. $nd and 7rd trimester %) - %% lbs per trimester is recommended

c. Total allowable weight gain during throughout pregnance is $) - $& lbs or %) - %$ 'gs.

d. Pattern of weight gain is more important than the amount of weight gained.

F. 6motional responses

a. %st trimester, some degree of reKection! disbelief! even depression because of its future

implication ; give health teachings on body changes and allow for e(pression offeelings

b. $nd trimester, fetus is perceived as a separate entity and fantasi+es appearance

c. 7rd trimester, best time to tal' about layette! and infant feeding method. To allay fear ofdeath let woman listen to the BHT.

VII. COMMON EMOTIONAL RESPONSES DURING PREGNANCY

*tress -decrease in responsibility ta'ing is the reaction to the stress of pregnancy not the pregnancyitself a=ects decision ma'ing abilities

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Couvade - syndrome - men e(periencing nauseavomiting! bac'ache due to stress! an(iety andempathy for partner

6motional labile - mood changesswings occur fre>uently due to hormonal changes

Change in *e(ual esire - may increase or decrease needs correct interpretationR not as a loss ofinterest in se(ual partner

VIII. LOCAL CHANGES DURING PREGNANCY

%. 3terus - wt increase to about %))) grams at full term due to increase in 2brous and elastic tissues

a. /ecomes ovoid in shape

b. *oftening of lower uterine segment, Hegars sign seen at th wee'

c. Operculum - mucus plug to seal out bacteria

d. Goodells sign - cervi( becomes vascular and edematous giving it consistency of theearlobe

$. ?agina - increased vascularity occurs

a. Chadwic's sign - purplish discoloration of the vagina

b. 0eu'orrhea - increased amount of vaginal discharges due to increased activity ofestrogen and of the epithelial cells.

a. Must not be itchy! foul smelling! e(cessive! nor greenyellow in color.b. Management, good hygiene

c. 3nder the int water or %& ml, %))) ml9

&. avoid intercourse to prevent reinfection

a. C+'!#!+ A%b#"+') : condition is called M'#%#+)#) r C+'!#!#+)#)

6 it thrives in an environment rich in CHO and those on steroid or antibiotictherapy

7 seen as oral thrush in the N/ when transmitted during delivery

8 ss, white! patchy! cheese;li'e particles that adhere to vaginal walls! foulsmelling discharges causing irritating itchiness

Management ,

1. MycostatinNystatin p.o. or vaginal suppositories %))!))) 3 /" ( %& days

2. Gentian violet swab to vagina

3. cidic vaginal douche

4. void intercourse

7. Ovaries"nactive since ovulation does not ta'e place during pregnancy. Placenta produces Progesterone

and 6strogen during pregnancy

#. bdominal :all

1 *triae Gravidarum - due to rupture and atrophy of connective tissue layers on the growingabdomen

2 0inea Nigra

3 3mbilicus is pushed out

4 Melasma or Chloasma - increased pigmentation due increased production of melanocytes by thepitutitary

5 3nduly activated sweat glands

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I. SIGNS O0 PREGNANCY". Pre'+'"y

1 Prenatal care is important for prevention of infant and maternal morbidity and mortality

2 Care is a cooperative action based on clients understanding of treatment modalities

3 uration of normal pregnancy $ - $F) days of 7F - #$ wee's or D calendar months or %) lunarmonths.

4 "nfant born I 7F wee's pre;term 5 #$ post term95 iagnosis, 3rine e(amination - tests presence of HCG 8present from #)th -%))th day! pea' )days9 conduct test wee's after 0MP

$. Pre'+t+% V#)#tHistory Ta'ing,

personal data obstetrical datagravida paraTP0 past pregnanciespresent pregnancy, cc 0MP

medical data, h( of diseasesillnesses

7.#anger !ignals of &regnancy

1. ?aginal bleeding 8any amount9

2. *welling of face or 2ngers

3. *evere! continuous headache4. imness or blurring of vision

5. Blashes of light or dots before eyes

6. Pain in the abdomen

7. Persistent vomiting

8. Chills and fever

9. *udden escape of

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&thmonth L umbilical levelDthmonth L below (iphoid process9

b. Betal 0ength,

1 Haases 4ule, %st half of pregnancy - s>uare number of months6(ample , $ months L $($ L # cm

$nd half of pregnancy - number of months multiplied by &6(ample, E months ( & L 7& cm

c. Betal :eight,

1 ohnsons 4ule, Bundic Ht - n ( ' 8 'L%&&1 n L %% not engaged%$ engaged9

6(ample for a not engaged fetusBundic Height given L 7& cms

n L %% 8standard for not engaged fetus9'L %&& gms. 8D standard9

*olution, 7& cms - %% L $# ( %&& L7!E$) g

5. He+%t, Te+",#')

a. *mo'ing - lead to 0/: babies

b. rin'ing - can cause respiratory depression in the N/ and fetal withdrawal syndrome ife(cessive1 alcohol has empty calories

c. rugs - may be teratogenic hence contraindicated unless prescribed by octor

d. *e(ual activity - allowed in moderation but not during last w's; high incidence of postpartum infection noted.

counseling is important on changes in desire and positions contraindication, bleeding! ruptured /O:! incompetent cervi(!

deeply engaged presenting part

e. Prepared childbirthChildbirth education

1 /ased on G+te C'tr% T,ery, pain is controlled in the spinal cord and thereis a gate that can be closed to ease pain felt.

2 "nformation and breathing techni>ues help minimi+e discomfort of labore(perience

3 iscomfort can be lessened if abdomen is rela(ed and allows uterus to rise freelyagainst it during contractions

2a7or 'pproaches to prepared childbirth

1 Teaching about anatomy! pregnancy! labor and delivery! rela(ation techni>ues!breathing e(ercises! hygiene! diet and comfort measures

Grant;ic' 4ead Method, Bear leads to tension and tension leads to pain0ama+e Method, Psychoprophylactic method 1 based on *;4 conditioning1

concentration on breathing is practiced

f. "mmuni+ation, Tetanus To(ois 8TT9 L ./ % IM for all pregnant women shall begiven in $ doses; # w's interval with $nddose at least 7 w's

before deliveryL booster doses given during succeeding

pregnanciesregardless of interval.

L 7 booster doses is e>ual to lifetime immunity

g. Clinic ?isits for Pre:'+t+% ",e"6:up

2 Birst E lunar months - e$ery 't,

3 On Fthand Dthlunar month - e$ery 9ee6

4 On %)thlunar month - e$ery 9ee6 u't#% %+br

. LABOR AND DELIVERY

0. 8+E9E* 9F ,'9 9

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c. Passageway - the maternal pelvisd. Psyche - the mental and emotional aspect of the woman

a. &O$'R % 3terine Contractions,a.%. Bre>uency - the beginning of one contraction to the beginning of the ne(t contractiona.$. "nterval - pattern which increases in fre>uency and durationa.7. uration - the beginning of one contraction to the end of the same contractiona.#. "ntensity - strength of contraction! measured through a monitor or through touch of a 2ngertip

on the fundus 8mild! moderate or strong9

b. &A!!'(G'R % Betus

b.%. Betal *'ull,a. largest part of the fetus ; most fre>uent presenting part1 least compressible

/ones, sphenoid! ethmoid! temporal! frontal! occipital! parietal*uture lines, sagittal coronal! lamboidal

b.$. Bontanels ; membrane covered spaces at the Kunction of the main suture linesanterior fontanel, larger! diamond shaped1 closes at %$ - %F monthsposterior fontanel, smaller! triangular shaped! closes at $ - 7 months

b.7. Betal 0ie - relationship of the cephalocaudal a(is of the fetus to the cephalocaudal a(is of the

mother.Measurements,

b.#. Betal ttitude - fetal positionPelvis is divided into areas, nterior! Posterior! Transverse 0eft! Transverse

4ight! Posterior 0eft! Posterior 4ightBetal landmar's, Occiput 8O91 mentum 8M9! sacrum 8*9! and scapula 8*c9

b.&. Presentation -the part of the passenger that enters the pelvis is the presenting parta. Cephalic - ?erte( 8occiput9 1 /row 8sinciput91 Bace 8mentum9b. /reech - Complete 8sacrum9 1 Bran'1 Bootlingc. *houlder

b.. Movement of Passenger upon birth or descent,

d. escente. Ble(ionf. "nternal 4otationg. 6(tensionh. 6(ternal rotation restitution

c. &A!!AG'$A) - maternal pelvis

c.%. ivisions

a. Balse Pelvis ;supports the growing uterus during pregnancy;directs the fetus into the true pelvis near the end of gestation

b. True Pelvis, the bony canal through which the fetus will pass during delivery formed by the

pubis in front! the iliac and ischia on the sides and the sacrum and coccy( behind

c.$. *igni2cant Pelvic Measurements

a. 6(ternal - *uggestive only of pelvic si+e 6(ternal ConKugate /audelaoc>ues iameter

; the distance between the anterior aspect of the symphysis pubis and the depressionbelow lumbar & 8verage, %F - $) cm9

b. "nternal - the actual diameters of the pelvic inlet and outlet iagonal ConKugate; the distance between the sacral promontory and inferiorlower margin of the

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symphysis pubis; widest P diameter at outlet estimated on vaginalpelvic e(am 8verage, %$.& cm9

Obstetrical ConKugate; the distance from the inner border of the symphysis pubis to the sacral prominence; most important pelvic measurement; shortest P diameter of the inlet through which the head must pass; %.& to $ cm or less than the diagonal conKugate

True ConKugateConKugate ?era; the distance between the anterior surface of the sacral promontory and superior marginof the symphysis pubis

; diameter of the pelvic inlet 8%).& ;%% cm9

/i;"schial Tuberiischial iameter; the distance between the ischial tuberosities; narrowest diameter of the outlet

; transverse diameter of the outlet 8verage, %% cm9

D. &!)C*'; the emotions of the mother

Bactors that may increase a womans chance of depression,

1 History of depression or substance abuse

2 Bamily history of mental illness

3 0ittle support from family and friends

4 n(iety about the fetus5 Problems with previous pregnancy or birth

6 Marital or 2nancial problems

7 Uoung age 8of mother

*igns and *ymptoms of Post;partum depression,

1 Beeling restless or irritable

2 Beeling sad! hopeless! and overwhelmed

3 Crying a lot

4 Having no energy or motivation

5 6ating too little or too much

6 *leeping too little or too much

7 Trouble focusing! remembering! or ma'ing decisions

8 Beeling worthless and guilty

9 0oss of interest or pleasure in activities

10 :ithdrawal from friends and family

11 Having headaches! chest pains! heart palpitations 8the heart beating fast andfeeling li'e it is s'ipping beats9! or hyperventilation 8fast and shallow breathing9

>.(E,2uency! intensityoD Continue regardless of activityo%) 6=acement and dilatation occurs

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o%% *igns of True labor6=acementilatation

1 3terine Changes- upper and lower segments1 physiologic retraction ring

2 /andls pathologic retraction ring; a danger sign of impending rupture of the uterus ifobstruction is not relieved

1. Nursing "nterventions of :oman in 0abor,

a. ssessment - history and physical assessmenta.%. Personal dataa.$. Obstetrical data

1 determine 6C

2 obstetrical score

3 amount character of show

4 status of the /O:

5 general physical e(amination

6 0eopolds Maneuver, presentation

7 "nternal e(amination, e=acement 1 dilatation1 station

b. Monitoring and 6valuating Progress of 0aborb.%. /lood pressureb.$. Betal Heart Toneb.7. Observe for signs of fetal distress

12 bradycardia

13 fetal thrashing

14 meconium stained amniotic

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Has sedative and antispasmodic e=ectose is usually $& -%)) mg depends on body weightNot given early in labor due to possible e=ect on contractionsNot given too late 8% hr before delivery9 can cause respiratory

depression in the newbornGiven if cervical dilatation is - F cms.

&.7.$. Narcotic ntagonist, Narcan1 Nalline

. Nursing Care before administration of anesthesiaanalgesia

%.%. ssess pain status%.$. 6(plain the action of drugs%.7. Chec' vital signs of mother and fetus%.#. Observe safety measures

6valuate allergiesProvide siderails - have call bell readyNPO 8anesthesia9Chec' time last medication was given

%.&. Nursing Care after administration of anesthesiaanalgesia%.. Monitor, vital signs - /P and BH4 8be alert for bradycardia9%.E. 4ecord properly%.F. Provide comfort measures%.D. 4emember that the use of 0r"ep)is needed in delivery of patient under anesthesia due to loss of coordination in bearing down during $nd stage%.%). *ide e=ects,

a. postspinal headaches - place

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T,#r! St+e; from delivery of the newborn to thedelivery of the placenta

*till with mild contractions until the placentais e(pelled.3sually! placenta is e(pelled within 7)minutes.

0urt, St+e; the 2rst hour after complete deliveryuntil the woman becomes physically

stable

3terine cramping4ubra with small clots

$.Principles of Postpartum Care

a. Promote healing and the process of involution

b. Provide emotional support

c. Prevent postpartum complications

d. 6stablish successful lactation

e. Promote responsible parenthood 8BP97. Nursing Care of the :oman in Birst 5 *econd *tage 0abor

a. Monitor discomforte(haustionpain control - support client in choice of pain control

b. 4ela(ation techni>ues taught during pregnancy where breathing is taught as a rela(edresponse to contraction

c. 0ow bac' pain - massage of sacral area

d. 3se di=erent breathing techni>ues during the di=erent phases of labor

e. 6ncourage rest between contractions

f. eep couple informed of progress

g. dminister analgesic , side e=ects;may prolong labor1 local bloc' general

#. Nursing Care of :oman in the 7 rd *tage of 0abora. Principle Of :atchful :aitingb. 3se /randt ndrews Maneuverc. Note Time Of elivery 8$) Minutes fter elivery Of The /aby9d. Chec' /p1 "nKects O(ytocin 8Methergin ).$ MgMl Or *yntocinon %) 3Ml "m9e. "nspect Cotyledons Bor Completenessf. Chec' 3terus Bor Contractiong. Chec' Perineum Bor 0acerations ;Give perineal care1 apply perineal pads

h. Change gown

i. Place

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the rectumF.#. Bourth degree - involves all in 7rd degree lacerations and the mucus membrane of the

rectum

II. PROMOTING HEALING AND INVOLUTION DURING POST:PARTUM

%. ?ascular Changes; 4eabsorption of the 7);&)Q increase in cardiac volume within & - %) minutes after the third

stage of labor.; :/C increases to $)!))) - 7)!)))mmW; ctivation of the clotting factor; ll blood values are bac' to prenatal levels by 7rd or #th wee'

$. 0ocation of the Bundus; 3terine involution is measured by determining the level of the fundus in relation to theumbilicus

; Nursing care, ssess condition and level of the fundus Position in prone or 'nee chest

1 Occurrence of afterpains - it is an indication of uterine contractions and are normal. 3suallylasts up to 7 days after birth

Nursing Care,

6(plain to client cause of pain o not apply heat dminister analgesics as prescribed

7. Genital Changes ischarges; Presence of 0ochia, uterine discharges consisting of blood! decidua! :/C and some bacteria; Characteristics, pattern should not reverse -

%;7 days - rubra ; ; ; bright red with no or minimal clots#;D days - serosa; ; ; thinner! serous sanguinous blood%); 7 to w's pp - alba ; ; ; whitish discharge

same amount as menstrual

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; Change is more on the delay of bowel evacuation1 constipation; Cause, decreased muscle tone

lac' of food inta'edehydrationfear of pain

;Nursing Care, encourage early ambulationincrease

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III. ASSOCIATED PROBLEMS

%. 6ngorgementbreast becomes full! tense and hot with throbbing paine(pected to occur on the 7rd post partum day accompanied by fever 8mil' fever9last for $# )

due to increased lymphatic and venous circulation

Nursing care,o encourage breastfeedingo advise use of 2rm;supportive brassiereo 8if not going to breastfeed - apply cold compress1 no massage1 no breast pump1 apply

breast binder9

$. *ore NipplesNursing care,

encourage to continue /Be(pose nipples to air for %) - %& minutes after feeding8alternative9 e(posure to $) watt bulb placed %$ - %F inches away promotes vasodilationand therefore promote healingdo not use plastic linersuse nipple shield

7. Mastitis ; in

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C Utomegalovirus 8CM?9 8N virus9

H erpes type $

Group of maternal systemic infections that can cross the placenta or by ascending infection8after rupture of membranes9 to the fetus.

"nfection early in pregnancy may produce fetal deformities! whereas late infections may result inactive systemic disease andor CN* involvement causing severe neurological impairment ordeath of newborn

*ources Cause,%. 6ndogenousprimary sources ; normal bacterial

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4 analgesics are given but not *P"4"N because it prevents prothrombin formation which may lead to hemorrhage

2. HEMMORRHAGE BLEEDING

e2nition, blood loss more than &)) cc. 8 normal blood loss $&); 7&) cc9 0eading cause of maternal mortality associated with childbearing

$.%. 6arly Post;partum hemorrhage - 2rst $# hrs after delivery

$.$. 0ate Postpartum Hemorrhage

6arly Post;partum hemorrhage 0ate Postpartum Hemorrhage

Cause3terine tony - uterus is not well

contracted! rela(ed or boggy8most fre>uent cause9

0acerationsHypo2brinogenemiaClotting defect

4etained Placental Bragments

Management/leeding in Pregnancy

blood transfusion 5 C 8ilatation and Curettage

Predisposing factor,Overdistension of the uterus 8multiparity! large babies! polyhydramnios!

multiple pregnancies9Cesarean *ectionPlacental accidents 8previa or abruptio9Prolonged and diXcult labor

Management, Massage -2rst nursing action"ce compressO(ytocin administration6mpty bladder/imanual compression to e(plore retained placental fragments

Hysterectomy 8last alternative9

$.7. +ematoma; ue to inKury to blood vessels in the perineum during delivery

"ncidence, Commnon in precipitate delivery and those with perineal varicositiesTreatment,

1 "ce Compress in 2rst $# hours

2 Oral nalgesics as prescribed

3 *ite is incised and bleeding vessel ligated

$.#. (regnanc! nduced +!pertension #(+%; vascular disease of un'nown cause; Occurs anytime after the $#th w' of gestation up to $ w's PP

; evelops during pregnancy and resolves during postpartum period

Predisposing Bactors,

a. large fetusb. Older than 7&! younger than %Ec. primigravidad. multiple pregnancy or H molee. poor nutritionf. H( of M! renal and vascular diseaseg. Morbid obesity or weight less than %)) lbh. Bamily history

iagnosis,oll over test, ssess the probability of developing to(emia when done between the

$Fth and 7$nd wee' of pregnancy.

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Procedure of 4oll;over test,

1 Patient in lateral recumbent position for %& minutes until /P *table

2 4olls over to supine position

3 /P ta'en at % minute and & minutes after roll over

4 "nterpretation, "f diastolic pressure increases $) mmHg or more! patient isprone to To(emia

"ypes of &regnancy +nduced *ypertension ,&+*-,

a. Transient hypertension ; without proteinuria or edema

b. Pre;eclampsia! mildo /P of %#)D) mmHg or increase of 7)%&mmHgo $S to 7S proteinuriao begins past $)th wee'o slight generali+ed edema may be present! weight gain of %; & lbsw'

c. Pre;eclampsia! severeo /P of %&);%)%));%%) mmHgo #S proteinuria 8& gm0 or more in $# hrso Headache and epigastric pain8aura to convulsions9o Oliguria of #)) ml or less in $# hrs. 8normal 3Oday %&)) ml9o Cerebral or visual disturbances

d. 6clampsia ; Obstetrical 6mergencyo HPNo Proteinuriao Convulsionso Coma

"mmediate "ntervention for 6clampsia,

a. Maintain "? line with large;bore needle

b. Monitor

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deep "M!& gmsbuttoc'! then an "? drip of % gm per hour 8% gm%)) ml %):9!

Chec' 2rst the =. before administration,

1 eep tendon re

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Pregnancy 4is's,

1 To(emia

2 "nfection

3 Hemorrhage

4 Polyhydramnios

5 *pontaneous abortion - because of vascular complications which a=ect placental circulation

6 cidosis - because of nausea and vomiting

7 ystocia - due to large baby

iagnosis , Glucose Tolerance Test 8GTT9

Procedure for GTT,NPO after midnight$ ml of &)Q glucose 7 'g of pre;pregnant body weight given "? 8oral glucose not advisable

due to decreased gastric motility and delayed absorption of sugarduring pregnancy9

"nterpretation of 4esults,

a. "f less than %)) mgQ L normal

b. "f %)) - %$) mgQ possible GM

c. "f more than %$) mgQ ; overt gestational diabetes

Management,

a. iet ; highly individuali+ed; ade>uate glucose inta'e 8%!F)) -$$)) calories9 to preventintrauterine growth retardation

b. "nsulin re>uirements - individuali+ed1 increased during $nd and 7rd trimester becauseof more pronounced e=ect of hormones

c. Method of elivery - Cesarian *ection

d. Postpartum Period - more diXcult to control /lood Glucose because of hormonal changes

6=ect on "nfant,

a. Typically longer and weighs more due to, e(cessive supply of glucose from the mother

b. "ncreased production of growth hormone from maternal pituitary gland

c. "ncreased secretion of insulin from the fetal pancreas

d. "ncreased action of adrenocortical hormone that favor the passage of glucose from mother tofetus congenital anomalies are often seen

e. Cushingoid appearance 8pu=y! but limp and lethargic9

f. /orn premature more often - 4* common

g. Greater weight loss because of loss of e(tra

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*igns 5 *ymptoms,Heart murmur due to increased total cardiac volume

-ardiac output decreased nutritional and o"!gen re4uirements not met ncomplete empt!ing o the let side o the heart (ulmonar! edema and +(uate venous return increased venous pressure

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; 0abor lasting more than %F hrs and in multigravidas! more than %$ hours

6=ects, Maternal e(haustion 3terine atony Caput succedaneum

@.>. 3terine nversion; fundus is forced through the cervi( so that the uterus is turned insideout

; "nsertion of placenta at the fundus! so that as fetus is rapidlydelivered! fundus is pulled down

; *trong fundal push! attempts to deliver the placenta before signs of separation ;Management, Hysterectomy

F. INDUCED LABOR; *tages of labor and birth occurs due to chemical or mechanical means which is usually performed tosave the mothe or fetusr from complications which may cause death

"ndications,Maternal - to(emiaPlacental accidentsPremature 4upture Of MembraneBetal, M - terminated at about 7E w's OG if indicated

/lood incompatibility6(cessive si+e

Postmaturity Prere>uisites to "nduce 0abor ,

No Cephalo; Pelvic islocationBetus is already viable 7$ wee's OG*ingle fetus in longitudinal lie and is engaged4ipe cervi( - fully or partially e=aced1 Cervical ilatation at least %L$ cm

Procedure for "nduced labor, %. O(ytocin dministration1 %) "3 of Pitocin in %))) ml of &: at a slow rate of F gttsmin given

initially no fetal distress in 7) minutes rate % ;$) gtsmin

$. mniotomy - done with Cervical ilatation L # cm 1 Chec' BH4 and >uality of amniotic

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Types, 0ow or Mid Borceps elivery

Complications,Borceps mar's - noticeable only for $# - #F hrs/ladder or rectal inKuryBacial paralysisPtosis*ei+ures

6pilepsyCerebral Palsy

a. -esarean *ection - birth through a surgical incision on the abdomen

"ndications,o Cephalo;pelvic disproportion 8CP9o *evere To(emiao Placental ccidentso Betal istresso Previous classic C* - done prior to onset of labor pains1 scheduled birth

Types,

%. ,ow *egment- the method of choice.

"ncision is made in the lower uterine segment! which is the thinnest and most passivePart during active labor.

dvantages,Minimal blood loss"ncision is easier to repair0ower incidence of post partum infectionNo possibility of uterine rupture

$. ,ower vertical incision- recommended in,/ladder or lower uterine segment

dhesions from Previous operationsnterior Placenta PreviaTransverse lie

Preoperative Care

a. The patient is both a surgical and an O/ patient

b. Chec' vital signs! uterine contractions! and BH4

c. Physical e(amination1 routine laboratory tests1 blood typing and cross matching

d. bdomen is shaved from the level of the (iphoid process below the nipple line!e(tending out to the

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"ron;de2ciency anemia To(emia3terine atony or inertia?aricosities1 hemorrhoids0ow birth weight babiesChromosomal bnormalities li'e ownsChromosomal bnormalities li'e owns*yndrome Trisomy $%*yndrome Trisomy $% 8associated withmenopause9

%).$. (arit!- 2rst pregnancy is the period of high ris' Multiparity G& and above and age is over #)

%).7. irth nterval- 7 months from previous delivery or more than & years

%).#. :eightPre;pregnant weight I E) lbs or %F) lbs:eight gain I %) lbs 0/: babies:eight gain 7) lbs L sign of to(emia1 M1 H;mole1 polyhydramnios1 multiple

pregnancy%).&. Height*hort stature I # feet! %) inches L contracted pelvis or CP

IV. MATERNAL COMPLICATIONS

%. *pontaneous bortion

Termination of pregnancy spontaneously at any time before the fetus has attained viabilityssessment,%. Persistent uterine bleeding and crampli'e pain$. 0aboratory 2nding - negatively or wea'ly positive urine pregnancy test7. Obtain history! including last menstrual period

$. 6ctopic Pregnancy; ny gestation outside the uterine cavity

Causes of 6ctopic Pregnancy,a. Pregnancy "nduce Hypertensionb. Previous tubal surgery

c. Congenital anomalies of the fallopian tubes

*igns 5 *ymptoms,

1 *evere! sharp! 'nife;li'e stabbing pain

2 4igid abdomen

3 Positive Cullens sign 8bluish umbilicus9

4 6(cruciating pain on "6

5 *igns of shoc'

Management, 4uptured 6ctopic Pregnancy is an emergency re>uiring immediate intervention *alpingostomy - if Ballopian tube can still be replaced and preserved!pregnancy is terminated *aphingectomy - removal of BT and /TNursing "nterventions,

1 Help woman to combat shoc'

2 6levate foot of the bed

3 Maintain body heat

4 Prepare for surgery

5 Monitor for shoc' preoperatively and postoperatively

6 Provide emotional support and e(pression of grief

7 dminister 4hogam to 4h negative women

8 ischarge teaching

7. Hydatidiform Mole 8H;Mole9 ;egenerative anomaly of chorionic villi

*igns & *!mptoms:%. 6levated hCG levelsmar'ed nausea 5 vomiting$. 3terine si+e greater than e(pected for dates7. No BH4

#. Minimal dar' redbrown vaginal bleeding with passage of grapeli'e clusters&. No fetus by ultrasound. "ncreased nausea and vomiting and associated with P"H

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2anagement:%. Curettage to completely remove all molar tissue that can become malignant$. Pregnancy is discouraged for % year7. hCG levels are monitored for % year 8if continue to be elevated! may re>uire

hysterectomy and chemotherapy9#. Contraception discussed1 "3 not used

#. "ncompetent Cervical OsOne that dilates prematurelyChief cause of habitual abortion 8 7 or more9

Causes,

1 Congenital evelopmental Bactors

2 6ndocrine factors

3 Trauma to the cervi(

*igns 5 *ypmtoms,

1 Presence of show and uterine contractions

2 4upture of membranes! Painless cervical dilatation&. "ncompetent Cervi(

. Placenta Previa - the placenta is the presenting part

%. Birst and second trimester spotting

$. Third trimester bleeding that is sudden! profuse! painless7. 3ltrasonography - classi2ed by degree of obstruction

Management,

1 Hospitali+ation! initially

2 /edrest side;lying or Trendelenberg position for at least E$ hrs.

3 3ltrasound to locate placenta

4 No vaginal! rectal e(am unless delivery would not be a problem 8if necessary must bedone in O4 under sterile conditions9

5 mniocentesis for lung maturity1 monitor for changes in bleeding and fetal status

6 aily Hgb and Hct

7 Two units of crossmatched blood available

8 Monitor amount of blood loss

9 *end home if bleeding ceases and pregnancy is maintained

10 0imit activity

11 No douching! enemas! coitus

12 Monitor fetal movement13 N*T at least every % - $ wee's

14 Monitor complications

15 elivery by cesarean if evidence of fetal maturity! e(cessive bleeding! active labor!other complications

E. bruptio Placenta

*igns 5 *ymptoms,%. Painful vaginal bleeding$. bdomen 8uterus9 is tender! painful! tense 8couvelaire uterus97. Possible fetal distress#. Contractions

8Occurrence increased with maternal HPN and cocaine abuse1 sudden release of amniotic

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f. Transfusion hepatitis

Nursing "ntervention,/edrest?ital signs! BHTMonitor inta'e and output*ei+ure precautionsMedications 8Magnesium sulfate! presoline! ?alium9

F. 3terine 4upture ;occurs when the uterus undergoes more straining than it is capable of sustaining

Cause, *car from previous C*3nwise use of o(ytocins

OverdistentionBaulty presentationProlonged labor

*igns 5 *ypmtoms,*udden severe pain

Hemorrhage and clinical signs of shoc'Change in abdominal contour 8two swelling on the abdomen due to retracted uterus and

the e(trauterine fetus9Management, Hysterectomy

D. mniotic Bluid 6mbolism - 8Obstetric 6mergency9- occurs when amniotic

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o *teroids 8glucocrticoids9 for maturation of fetal lungsurfactant production

o nesthesia preferred - caudal! spinal or in2ltration - do not a=ect the infanto 4espiration forceps may be applied gentlyo Cord is cut immediately - prevents transfer of e(tra amounts of blood because prematures

have diXculty e(creting large amounts of bilirubin that will come the e(tra blood.