2013-2014 Mcn Maternal Physiologic Changes

8/13/2019 2013-2014 Mcn Maternal Physiologic Changes

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SAINT GABRIEL COLLEGEKALIBO, AKLAN

2013-2014MATERNAL AND CHILD NURSING

MR. HARLEY L. DELA CRUZ RN MANInstructor

SYSTEMIC CHANGES DURING PREGNANCY

1. CARDIOVASCULAR SYSTEM

HEART

As diaphragm rises, the heart is displaced laterally

Point of Maximum Impulseo Normally located at Fifth Intercostal Space Mid-clavicular Line on the Left Side {5th ICS-MCL

(L)}o This shifts to Fourth Intercostal Space Lateral Axillary Line on the Left Side {4thICS-LAL (L)}

Exaggeration of first and second heart sounds {S1 (Lub) and S2 (Dub)} due to INCREASED CARDIACOUTPUT

Appreciation of S3 (third heart sound; ventricular filling) due to INCREASED CARDIAC OUTPUT

Appreciation of a MURMUR, which is almost always SYSTOLIC (all pathologic) in natureo Innocent in natureo As soon as mother delivers placenta, excess fluid is absorbed or excreted, then the MURMUR

DISAPPEARS

Blood Volume is INCREASED due to INCREASE IN WATER RETENTION

HIGHEST CARDIAC OUTPUT IN PREGNANCY

Twenty-eight to thirty-two weeks (28-32 wks) Age of Gestation

During labor and delivery

Immediately postpartum

Therefore, be careful and monitor pregnant cardiac patient

Supine Hypotensive Syndromeo When mother assumes supine position, she develops hypotensiono Weight of uterus presses on the VENA CAVA

This results into DECREASED VENOUS RETURN This results into DECREASED CARDIAC OUTPUT End result is HYPOTENSION

Therefore, SUPINE POSITION IN PREGNANCY IS NOT ALLOWABLE (particularly in the secondand third trimester)

POSITION OF CHOICEo Side-lying Left (so as not to impede the Vena Cava)o Left Lateral Positiono Sims Left Position

With arm flexed Leg flexed Weight of uterus would be ON THE BED

2. HEMATOLOGIC CHANGES

increase blood volume of mom (plasma blood) 3050% = 1500 cc of blood

easy fatigability, increase heart workload, slight hypertrophy of ventricles

epistaxisdue to hyperemia of nasal membrane palpitation,

Physiologic Anemiapseudo anemia of pregnant womenNormal Values

Hct 3242%Hgb 10.514g/dL

Criteria1stand 3rdtrimester.- pathologic anemia if lower

HCT should not be 33%,Hgb should not be < 11g/dL

2ndtrimesterHct should not


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HgbShdn't< 10.5% pathologic anemia if lower

PHYSIOLOGIC ANEMIA

Due to increase in plasma valueo Dilutes circulating Red Blood Cellso Therefore, take the Complete Blood Count in the initial assessment to get the blood picture of

the client Give iron supplementation

o Do this is the second trimester because this is the time when iron stores are depletedo Best taken at nighto Metallic taste is nauseuso Give with foodo A gastric irritanto Followed by orange juiceo Acidic environment provides greater absorptiono Advise that client will have black stoolo Client taking iron is constipatedo Therefore, increase oral fluid intake and iron

Pathogenic Anemia

Iron deficiency anemia- is the most common hematological disorder. It affects toughly 20% of pregnantwomen.

Assessment reveals:

Pallor, constipation

Slowed capillary refill

Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia

Nursing Care:

Nutritional instructionkangkong, liver due to ferridin content, green leafy vegetable-alugbati,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 hrsafter, black stool, constipation

Monitor for hemorrhageAlert:

Iron from red meats is better absorbed iron form other sources

Iron is better absorbed when taken with foods high in Vit C such as orange juice

Higher iron intake is recommended since circulating blood volume is increased and heme is requiredfrom production of RBCs

HEMODILUTION

Due to increase in PLASMA VOLUME

CHANGES IN PLATELET

Expected during Postpartum

Due to blood loss, there is TRANSIENT INCREASE IN PLATELET COUNT

This predisposes to THROMBOSIS due to platelet aggregation

This would then predispose to EMBOLISM

Therefore, EARLY AMBULATION is NEEDEDImportant Concept!

WHITE BLOOD CELL LEVELS INCREASE (particularly in labor)

LEUKOCYTOSIS is STRESS-INDUCEDo Increased by 20K to 30K

Therefore, DO NOT CORRELATE THIS TO INFECTION

NO FEVER

NO abdominal / uterine infection

3. RESPIRATORY SYSTEM

Diaphragm is prevented from descending in inspiration on second and third trimester

Tidal Volume is increasedo Lungs are easily filledo Client tends to hyperventilateo Therefore, RESPIRATORY ALKALOSIS OCCURS


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This is manifested by:o Tingling sensation on the lower ends of extremitieso Lightheadedness

Nursing Managemento Breathe through a paper bag or through cupped hands

Important Concepts!

During labor, there is increase in oxygen consumption by three-hundred percent (300%)o When exhaling, pursed lip breathing is practiced during labor

Swelling of mucosa during estrogeno Prone to epistaxiso Therefore, caution in picking nose!

4. GASTROINTESTINAL TRACT- 1sttrimester change

PICA

Craving for food

Unedible (i.e. rice grains)

No reason for this

May be due to hypersalivation

If not checked, this causes vomitingEPULIS OF PREGNANCY

Effect on gums

Swelling of gums due to INCREASED ESTROGEN

Therefore, CONTINUE TO USE SOFT BRISTLE TOOTHBRUSHESOPHAGUS

Progesterone is a relaxant of smooth muscleo Effect is on lower esophageal sphinctero It is more relaxed

Pressure of Lower Esophageal Sphincter (LES) is less than pressure on Cardiac Sphincter (CS)o If LES pressure is > CS pressure

No regurgitation

o If LES pressure is < CS pressureo There is HEARTBURN OR PYROSIS;

SUBSTERNAL PAIN related to eatingNausea and Vomiting

Human Chorionic Gonadotropino Primigravida

Mostly manifests this

Peaks at FIRST TRIMESTERo At two (2) to three (3) months of pregnancyo At eight (8) to twelve (12) weeks of pregnancy

Nursing Responsibilityo

Provide: Dry unsalted crackers Ice chips Small, frequent feedings

Six (6) times a day

This is the best among all the options Split food into two halves and give meals after every two (2) hours Less fatty foods in diet Do not lie supine after eating Encourage ambulation

Morning Sicknessnausea & vomiting due to increase HCG. Eat dry crackers or dry CHO diet 30 minutesbefore arising bed. Nausea afternoon - small freq feeding.Vomiting in pregemesisgravida.

Metabolic alkalosis, F&E imbalanceprimary med mgtreplace fluids.Monitor I&O

Constipation progesterone resp for constipation. Increase fluid intake, increase fiber diet- fruitspapaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.Except guavahas pectin thats constipating vegpetchy, malungay.- exercise-mineral oilexcretion of fat soluble vitamins

Flatulenceavoid gas forming foodcabbage

Heartburnor pyrosisreflux of stomach content to esophagus


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- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper bodymechanical

Increase salivationptyalsimmgt mouthwash

Hemorrhoidspressure of gravid uterus. Mgt; hot sitz bath for comfort

Interjected Concept!

Most common surgical complication of pregnancy is ACUTE APPENDICITIS!

Right Upper Quadrant pain is not expressed during pregnancy or on flank as the appendix rises inpregnancy

Nursing Management

Do not assume supine position after eating

Gradual ambulation

Small Frequent feedingImportant Concepts!

Due Progesterones relaxing effect on smooth muscles, there IS INCREASED GASTRIC EMPTYINGTIME

o Water and electrolytes absorbed by wallso This gives rise to hard stoolso This eventually leads to constipation

Managemento Increase fluid intakeo Provide high fiber diet

Tendency is to do valsalva maneuvero This leads to hemorrhoids

Progesterone also decreases stretchability of vessels.o This also causes hemorrhoids

5. RENAL OR EXCRETORY SYSTEM

5.1) Due to Progesterone

There is relaxation of renal pelvis and the ureter

Therefore, URINE STAGNATION occurs in the URETER (no longer peristaltic)

Therefore, the PATIENT IS PRONE TO URINARY TRACT INFECTION5.2) Glomerular Filtration Rate in Pregnancy

Increased Cardiac Output

Increased Glomerular Filtration Rate

But absorptive capacity of nephrons is not increased (NO CHANGE IN ABSORPTION)

Therefore, the following will be spilled in the urine:o Sugaro Carbohydrateso Protein

Changes in Urination

Urinary frequencyo Present in First and Third Trimestero No Urgency

Second Trimestero This disappearso Uterus starting to enlarge in First Trimester

o Uterus becomes abdominal organ in the second trimestero This releases pressure on the bladder

Third Trimestero Uterus enlarges and presses again against the bladder in the Third Trimester

Frequency during 1st& 3rdtrimester lateral expansion of lungs or side lying pos mgt for nocturia

Acetyace testalbumin in urine

Benedicts testsugar in urine

Important Concepts!

Carbohydrates in the urine is NORMAL

Acceptable level of Carbohydrates in the urineo Qualitative analysiso Trace = +1 sugar


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Protein in the urine is NORMAL

Acceptable level of Proteins in the urineo Trace = +1 Proteino Or less than 250 mg / dl

If Protein level in the urine is greater than 250 mg / dl, CONSIDER PREGNANCY INDUCEDHYPERTENSION

Edemalower extremities due venous return is constricted due to large belly, elevate legs above hip level.

Important Concepts!

If you LOSE PROTEIN and RETAIN WATER, this leads to EDEMAo This is Physiologic Edemao This type of edema is normal and expected in pregnancy

TYPE OFEDEMA

PHYSIOLOGIC PATHOLOGIC

LOCATION OFEDEMA

Dependent portion of thebody; leg or lowerextremity

Independent portion; Upper extremities,face, arms

TIME OFOCCURRENCE

Afternoon or PM Althroughout the day but evident in themorning

Ring cannot be removed

Important Concepts!

No management for PHYSIOLOGIC EDEMAo Supportiveo Leg raises

For Pathologic Edemao Identify the cause of the edemao Most common cause is PREGNANCY INDUCED HYPERTENSION

6. ENDOCRINE SYSTEM

Hypertrophy is present in most of the endocrine system organs Thyroid Gland is hyperthrophied

Increased production of thyroid hormones

Therefore, there is RISK FOR HYPERTHYROIDISMo Patient may die when in labor with hyperthyroidismo Thyroid Storm leads to arrhythmiao Arrhythmia leads to DEATH

Therefore, monitor so that client goes EUTHYROID (with normal thyroid hormonal level)

7. NEUROLOGIC SYSTEM

This is the only system UNAFFECTED during pregnancy

The following are normal during pregnancy:o Blurring of vision

Headache

8. MUSCULOSKELETAL SYSTEM

PLACENTA IS CAPABLE OF PRODUCING RELAXIN

Relaxes pelvic joints

Therefore, the pelvis is more movableDIASTASIS RECTI

Separation of rectus abdominis muscle

Only fascia remains in between

This is normal

Rectus abdominis muscle goes back after pregnancy (coarctate)PHYSIOLOGIC LORDOSIS


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Known as the PRIDE OF PREGNANCY

Increased outward curvatureo There is back pain

Nursing Managemento Do PELVIC ROCKING

Place direct pressure on lumbar areao Prevent supine position

Increases pressure on the spineo No analgesics

Waddling Gait

Awkward walking due to relaxationcauses softening of joints & bonesProne to accidental fallswear low heeled shoes

Leg Cramps

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

Mgt:o Increase Ca diet-milk(IncCa&Inc phosphorus)-1pint/day or 3-4 servings/day. C

heese, yogurt,head of fish, Dilis, sardines with bones, brocolli, seafood-tahong (mussels), lobster, crab.

Vit D for increased Ca absorption

dorsiflexion

9. Skin Changes

Brought about by hormonal changes - ESTROGENo Cloasma

Mask of pregnancy Brown pigmentation of nose, chin, cheeks

o Melasma Darkening of the neck

o Linea Negra From the symphysis pubis to the umbilicus; brown pinkish line

o Striae Gravidarum Silvery in color Due to distention of the collagen of the abdomen as the uterus enlarges

Varicositiespressure of uterus- use support stockings, avoid wearing knee high socks- use elastic bandagelower to upper-

Vulbar varicosities- painful, pressure on gravid uterus, to relieve- positionside lying with pillow under hipsor modified knee chest position

10. Problems Related to the Change of Vaginal Environment:

a. Vaginititstrichomonasvaginalis due to alkaline environment of vagina of pregnant momFlagellated protozoawants alkaline

S&Sx:

Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema

Mgt:FLAGYL(metronidazoleantiprotozoa). Carcinogenic drug so dont give at 1sttrimester

1. treat dad also to prevent reinfection

2. no alcoholhas antibuse effectVAGINAL DOUCHEIQ H2O : 1 tbsp white vinegar

b. Moniliasis or candidiasisdue to candida albicans, fungal infection.Colorwhite cheese like patches adheres to walls of vagina.ManagementantifungalNistatin, genshan violet, cotrimaxole, canesten

Gonorrhea -Thick purulent discharge

Vaginal warts- condifomaacuminatadue to papilloma viruso Mgt: cauterization

11. Abdominal Changesstriae gravidarium (stretch marks) due enlarging uterus-destruction of sub Qtissueavoid scratching, use coconut oil, umbilicus is protruding

12. Breast Changesincrease hormones, color of areola & nipple


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precolostrums present by 6 weeks, colostrums at 3rdtrimester

Breast self exam- 7 days after menssupine with pillow at back

Quadrant Bupper outercommon site of cancer

Test to determine breast cancer:

20-39 years old women-monthly BSE and CBE every 3 years

women 40 years and older- annual mammogram, monthly BSE and yearly CBE

NOTE: Ovariesrested during pregnancy

1. Pelvic Examinationinternal exam1. empty bladder2. universal precaution

EXT OS of cervixsite for getting specimen

Site for cervical cancer

Pap Smearcervical cancer

- composed of squamous columnar tissue

Result:Class I - normalClass IIAacytology but no evidence of malignancy

Bsuggestive of infl.Class IIIcytology suggestive of malignancyClass IVcytology strongly suggestive of malignancyClass Vcytology conclusive of malignancy

Stages of Cervical Cancer

Stage 0carcinoma insitu1cancer confined to cervix2 - cancer extends to vagina3pelvis metastasis4affection to bladder & rectum

Psychological Adaptation to Pregnancy(Emotional response of momReva Rubin theory)

First Trimester: No tanginal signs &sx, surprise, ambivalence, denialsign of maladaptation to

pregnancy. Developmental task is to accept biological facts of pregnancyFocus: bodily changes of preg, nutrition

Second Trimestertangible S&Sx. mom identifies fetus as a separate entitydue to presence ofquickening, fantasy. Developmental taskaccept growing fetus as baby to be nurtured.Health teaching: growth & development of fetus.

Third Trimester: - mom has personal identification on appearance of babyDevelopment task: prepare of birth & parenting of child. HT: responsible parenthood babys Layette best time to do shopping.Most common fearlet mom listen to FHT to allay fearLamaze classes

Pre-Natal Visit:1. Frequency of Visit: 1st7 months1x a month

89 months2 x a month10once a weekpost term 2 x a week

2. Personal dataname, age (high risk < 18 &>35 yrs old) record to determine high riskHBMR. Homebase moms record. Sex ( pseudocyesis or false pregnancy on men & women)

Couvade syndromedad experiences what mom goes throughlihi)Address, civil status, religion, culture & beliefs with respect, non judgmentalOccupationfinancial condition or occupational hazards, education backgroundlevel knowledge

3. Diagnosis of Pregnancy


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1.) urine exam to detect HCG at 40100thday. 6070 day peak HCG. 6 weeks after LMP- best toget urine exam.

2.) Elisa testtest for preg detects beta subunit of HCG as early as 7 10days3.) Home preg kitdo it yourself

4. Baseline Data: V/S esp. BP, monitor wt. (increase wt1stsign preeclampsia)

Weight Monitoring

First Trimester: Normal Weight gain 1.53 lbs (.51lb/month)Second trimester: normal weight gain 1012 lbs (4 lbs/month) (1 lb/wk)Third trimester: normal weight gain 1012 lbs (4 lbs/ month) ( 1lb/wk)Minimum wt gain2025 lbsOptimal wt gain2535 lbs

Danger signs of PregnancyC - chills/ fever - infection

Cerebral disturbances ( headachepreeclampsia)

Aabdominal pain ( epigastric painaura of impending convulsions

Bboardlike abdomenabruption placenta

Increase BPHPN

Blurred visionpreeclampsia

Bleeding1sttrimester, abortion, ectopic pre/2ndH mole, incom

petent cervix3rdplacental anomalies

Ssudden gush of fluidPROM (premature rupture of membrane) prone to inf.

Eedema to upper ext. (preeclampsia)

FETAL CIRCULATION

PLACENTA

Functions of the Placenta

Mnemonic is NIMEEN is for:

NUTRITION or NIDATIONo Supplying nutritional requirements of the fetuso Nutrients and oxygen exchangedo THE BLOOD IS NOT EXCHANGEDo Modes of Exchange

Active transport from mother to baby Diffusion Pinocytosis

I is for:

IMMUNOLOGICo If not pregnant, all foreign matterantigens are rejectedo Baby is a foreign matter

o But immunologic function of the placenta removes the MAJOR HISTOCOMPANITIBILITYCOMPLEX TYPE 2 (MHC TYPE 2)o This is responsible for rejecting the foreign body

M is for:

METABOLIC FUNCTIONo In Fetal Circulation

Nutrient exchange occurs NO PORTAL CIRCULATION EXISTS Liver is bypassed as METABOLISM (by the liver) is NOT NEEDED

E is for:

ENDOCRINOLOGICo Hormones are secreted only during pregnancy:

Human Placental Lactogen Human Chorionic Gonadotropin Relaxin

E is for:


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EXCRETORY

Metabolites excreted by Placenta and NOT BY THE KIDNEY NOR THE LIVER

Question:

In the fetal circulation, which part has the higher pressure?Answer:

Right Side

Important Concepts!!!

There is ONE-WAY flow of blood from the RIGHT ATRIUM to the LEFT ATRIUM

Therefore, Right AtriumPressure> Left AtriumPressure

SHUNTS

When the baby is delivered, the shunts are normally removedo Ductus Venosuso Foramen ovale

Two (2) types of Closure

Functional Closure

Anatomic Closure

FORAMEN OVALE

Closed functionally immediately after birth or IMMEDIATELY AFTER CORD IS CLAMPED

Anatomically, it can persist up to one (1) year after delivery

Important Concept!o Therefore, in auscultation in twenty-eight (28) day old baby

There is a MURMUR This is Normal This is NOT A PATHOLOGIC MURMUR It is a SYSTEMIC / INNOCENT MURMUR

o A PHYSIOLOGIC MURMUR IN NEONATES

DUCTUS ARTERIOSUS

Functional Closureo Ten to ninety-six hours (1096 hrs) after birth or approximately four (4) days

Anatomicallyo Two to three months (23 mos.)

DRUGS TAKEN DURING PREGNANCY

NSAIDs Indomethacin

o Not advisableo Causes premature closure of the Ductus Arteriosuso Not compatible with lifeo No supply to the lower half of the body of the fetus

PARACETAMOL IS ALLOWED

ASPIRIN Causes persistence of Ductus Arteriosus even after delivery

No functional / anatomic delivery of Ductus Arteriosus

Important Concept!o Stop taking about four (4) weeks prior to confinement

ANESTHESIA OF CHOICE

EPIDURAL ANESTHESIA

Upon active labor (3 cm)

Check Blood Pressure

Side effect is hypotensionImportant Concepts!

No Oxytocin

No Methergine No augmentation of labor

All natural labor


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Rationale:

Client loses sense of control in this most uncomfortable phase of the first stage of labor

In Latent Phaseo Client is still able to smile

In Active Phaseo Client is unable to smile

In Transitional Phaseo

Mother is now frowningo Remove fingers from the uteruso This gives additional pain to the mothero Mother loses sense of time

Mom has headachecheck BP, if same BP, let mom rest. If BP increase, notify MDpre-eclampsia

Health teachings:

Ok to shower

NPOGIT stops function during labor if with food- will cause aspiration

Enema administer during labor

To cleanse bowel

Prevent infection

Sims position/side lying1218 inchht enema tubing

Check FHT after adm enema

Normal FHT= 120-160

Signs of fetal distress:

Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute)

mecomium stain amnion fluid- stained amniotic fluid in nonbreech presentation

fetal thrushing hyperactive fetus due to lack O2; hyperactivity of the fetus as it struggles for more

oxygen

Emotional support is provided for the woman in labor by keeping her constantly informed of the progresslabor

Solid or liquid foods are to be avoided becauseDigestion is delayed during laborA full stomach interferes with proper bearing downMay vomit and cause aspiration

Enemanot a routine procedure

Purposes A full bowel hinders the progress of labor effectiveness of enema in labor can bedetermined by evaluating change in uterine tone and the amount of show Expulsion of feces during second stage of labor predisposes mother and baby to

infection Full bowel predisposes to postpartum discomfort

Procedure of enema administration

Enema solution may either be soap suds or Fleet enema (contraindicated in patientswith toxemia because of its sodium content)

Optimum temperature of the solution105F to 115F (40.5 C46.1C)

Patient on sidelying position

When there is resistance while inserting rectal catheter, withdraw the tube slightly whileletting a small amount of solution enter

Clamp rectal tube during a contraction Important nursing action: Check FHR after enema administration to determine fetal

distress

Contraindications to enema in labor Vaginal Bleeding Premature labor Abnormal fetal presentation or position Ruptured membranes Crowning

Encourage the mother to void every 23 hours by offering the bedpan because

A full bladder retards fetal descent

Urinary stasis can lead to urinary tract infection

A full bladder can be traumatized during delivery

Perineal prepdone aseptically. Use No. 7 method, always from front to back


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Perineal shavenot a routine procedure; maybe done to provide a clean area for delivery. Musclesat the symphysis pubis should be kept taut and razor moved along the direction of hair growth

Encourage Sims position because it:

Favors anterior rotation of the fetal head

Promotes relaxation between contractions

Prevents continual pressure of the gravid uterus on the inferior vena cava (the bloodvessel which brings unoxygenated blood back to the heart); pressure results in SupineHypotensive Syndrome, also called Vena Cava Syndrome (Figure 16). Hypotension isdue to the reduced venous return resulting in decreased cardiac output and therefore, afall in arterial BP.

Woman in labor should not be allowed to push or bear down unnecessarily during contractionsof the first stage because

It leads to unnecessary exhaustion

Repeated strong pounding of the fetus against the pelvic floor will lead to ce4rvicaledema, thus interfering with dilatation and prolonging length of labor.

Abdominal breathing advised for contractions during the first stage in order to reducetension and prevent hyperventilation

Supine Hypotensive Syndrome

Administer analgesics as ordered. The dosage is based on the patients weight, status of labor and ageof gestation.

Narcotics are the most commonly used, specifically Demerol.

Pharmacologic effect: depresses the sensory portion of the cerebral cortex. It is not onlya potent analgesic, it is also a sedative and an antispasmodic.

It is not given early in labor because it can retard, progress (is an antispasmodic), butcannot also be given if delivery is only one hour away because it causes respiratory

depression in the newborn (that is why it can be given only if cervical dilatation is 68 cm.)

Given 25100 mg., depending on body weight

Takes effect in 20 minutespatient experiences a sense of wellbeing and euphoria

Narcotic antagonist (e.g. Narcan, Nalline) are given to counteract any toxic effects ofDemerol

Assist in administration of regional anesthesia preferred over any other form of anesthesia because itdoes not enter maternal circulation and so does not affect the fetus. Patient is completely awake andaware of what is happening. Does not depress uterine tone, thus optimal uterine contraction is achieved.

Xylocaine is the anesthetic of choicePatient on NPO with IV to prevent dehydration, exhaustion and aspiration and because glucoseaids in proper functioning of the fetus

(purplish discoloration of the skin due to blood in subcutaneous tissues) area or hematomain the perineum may be an aftermath. No special treatment is needed: ice bag applied to thearea on the first day may reduce the swelling

Forceps are generally needed in delivery of patient under anesthesia because of loss ofcoordination in secondstage pushing.Postspinal headaches maybe due to leakage of anesthetic into the CSF or injection of air at time ofneedle insertion. Management: Flat on bed for 12 hours and increase fluid intakeCommon side effects

Hypotension because Xylocaine is vasodilator. Management turn to side; promptelevation of legs; administration of vasopressor and oxygen, as ordered.

Fetal bradycardia

Decreased maternal respirationsA sure sign that the baby is about to be born is the bulging of the perineum. In general,primigravidas are transported from the Labor Room to the Delivery Room when the cervix is fullydilated or when there is bulging of the perineum. Mutiparas, on the other hand, are transportedwhen cervical dilatatoniis 78 cm.

NOTE: SECOND STAGE OF LABOR

FROM FULL CERVICAL DILATATION UP TO DELIVERY OF THE FETUS

In Primigravidao One (1) to four (4) hours long

In Multigravidao Twenty (20) to forty-five (45) minutes only

Main Problem in Second Stage of Labor is STILL PAIN


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Nursing management is focused on the ALLEVIATION OF PAIN!!!Transition Period when the mood of the woman suddenly changes and the nature of contractionsintensify1. Characteristics

1.1 If membranes are still intact, this period is marked by a sudden gush of amniotic fluid as fetus ispushed into the birth canal. If spontaneous rupture does not occur, amniotomy (snipping of BOWwith a sterile pointed instrument, e.g., Kelly or Allis forceps or amniohook to allow amniotic fluid todrain) is done to prevent fetus from aspirating the amniotic fluid as it makes its different fetalposition changes. Amniotomy, however, cannot be done if station is still minus, as this can lead tocord compression

1.2 Show becomes more prominent.1.3 There is an uncontrollable urge to push with contractions, a sign of impending second stage of

labor. Profuse perspiration and distention of neck veins are seen.1.4 Nausea and vomiting is a reflex reaction due to decreased gastric motility and absorption.1.5 In primis, baby is delivered with 20 contractions (40 minutes); in multis, after 10 contractions (20

minutes).2. Nursing actions are primarily comfort measures

2.1 Sacral pressure (applying pressure with the heel of the hand on the sacrum) relieves discomfortfrom contractions

2.2 Proper bearing down techniques: push with contractions2.3 Controlled chest (costal) breathing during contractions2.4 Emotional support

MAL-PRESENTATIONS:Breech - Complete Breechthigh breast on abdomen, breast lie on thigh

Incomplete Breechthigh rest on abdominalFranklegs extend to headFootlingsingle, doubleKneeling

Transverse Lie (Perpendicular) or Perpendicular lie.

Shoulder presentation.

OccipitoLOA left occipitoant (most common and favorable position)side of maternal pelvisLOPleft occipito posteriorLOPmost common mal position, most painfulROPsquatting pos on mom

Breech- use sacrum LSAleft sacro anterior

- put stet above umbilicus LST, LSP, RSA, RST, RSP

Shoulder/acromniodorso

LADA, LADT, LADP, RADA

Chin / MentoLMA, LMT, LMP, RMP, RMA, RMT, RMP

IN SECOND STAGE:

78 multibring to delivery room

10cm primibring to delivery room

Lithotomy positionput legs same time up

Bulging of perineumsure to come out

Breathingpanting ( teach mom)

Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, shorten 2ndstage of labor.

Episiotomymedianless bleeding, less pain easy to repair, fast to heal, possible to reach rectum (urethroanal fistula)

Mediolateralmore bleeding & pain, hard to repair, slow to heal-use local or pudendal anesthesia.

Ironing the perineumto prevent laceration

Modified Ritgens maneuverplace towel at perineum1.)To prevent laceration2.) Will facilitate complete flexion & extension. (Support head & remove secretion, check

cord if coiled. Pull shoulder down & up. Check time, identification of baby.

Nursing Care:When positioning legs on lithotomy, put them up at the same time to prevent injury to the

uterine ligaments


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As soon as the fetal head crowns, instruct mother not to push, but to pant (rapid and shallowbreathing to prevent rapid expulsion of the baby). If panting is deep and rapid, calledhyperventilation, the patient will experience lightheadedness and tingling sensation of thefingers leading to carpopedal spasms because of respiratory alkalosis. Management: let thepatient breathe into a brown paper bag to recover lost carbon dioxide; a cupped hand overthe mouth and nose will serve the same purpose.

Assist in episiotomy (incision made in the perineum primarily to prevent lacerations).o Other purposes

Prevent prolonged severe stretching of muscles supporting the bladder orrectum

Reduce duration of second stage when there is hypertension or fetal distress Enlarge outlet, as in breech presentation or forceps delivery

NOTE: THIRD STAGE OF LABOR

DELIVERY OF BABY TO DELIVERY OF PLACENTA

Lasts for five (5) to ten (10) minutes

Maximum waiting time is thirty (30) minutes Beyond thirty (30) minutes is ALREADY ABNORMAL

SIGNS OF PLACENTAL EXPULSION:1. Calkinss Sign

Uterus becomes firm and globular2. Lengthening of the Cord3. Sudden Gush of Blood4. Rising of the Uterus into the Abdomen

Up to the level of the umbilicus or one centimeter (1 cm) after umbilicus after the delivery of theplacenta

Drugs for Third Stage of LaborThese drugs cause contraction of the uterus

1. ERGOTRATES

Includes METHERGINE I.V. or I.M.

Best given immediately after delivery of placenta

Massive contraction of the uterus traps placenta inside

Therefore, do not give before placental expulsion

2. OXYTOCIN

Given prior to expulsion of placenta to add to contraction

Given at minimal amounts

Normally at a rate of eleven to twelve drops per minute (11-12 gtts / min)

After delivery of placenta, give oxytocin at GREATER AMOUNTS

Important Nursing Considerations!

Methergineo Prior to administration, check blood pressureo If BP is greater than 140/90, WITHHOLD METHERGINE

Oxytocino Never given in direct boluso Never pusho Causes UTERINE HYPERTONUS

Tetanic contractions of the uterus or UTERINE ATONYo Always dripped

Ten (10) units with one (1) litero Duration and Interval of Contraction in Uterine Atony / Hypertonuso Duration of Contraction

Greater than seventy seconds (>70 secs) In Transitional Phase of First Stage of Labor, duration of contraction is about sixty (60)

secondso

Interval Less than two (2) minutes This means that rest period is decreased Maximum interval must be maintained at two (2) to three (3) minutes


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Therefore, STOP INFUSION OF OXYTOCIN AS SOON AS POSSIBLE

DO PROCEDURES IN LATE DECELERATION

Additional Important Concepts!

Oxytocino A potent vasoconstrictoro Side effect

Initially is HYPERTENSIONo If given in bolus

Hypertension will be REVERSED TO HYPOTENSION

Therefore, DO NOT GIVE OXYTOCIN IN BOLUS

Also causes WATER INTOXICATIONo Therefore, assess lungs of cliento Crackles will be present due to pulmonary edema due to water retention by oxytocin

Primary Problem in Third Stage of Labor

Bleeding or Hemorrhage

Important Concepts!

Uterus must be at level of umbilicus or about one centimeter (1 cm) above

If it is three centimeters (3 cm) above the umbilicus, UTERUS IS NOT CONTRACTEDo There would be BLEEDING

First thing to do:o Massage the uterus to attempt contractiono Increase the rate of oxytocin drip

Nurse does this Rate is increased from ten drops per minute (10 gtt/min) to twelve to fifteen drops per

minute (1215 gtt/min)o Place icepack over the abdomen

Remove compress every ten minutes and replace This prevents necrosis and blackening of the tissues

Inspect Perineumo How to measure amount of bleeding?o Utilize the PADS

Count and Weigh Guide: One gram is equivalent to one milliliter (1 g = 1 ml)

o Qualitative Approach Mild Bleeding

One (1) pad saturated in one (1) hour Moderate Bleeding

One (1) pad saturated in thirty (30) minutes

Heavy Bleeding One (1) pad saturated in fifteen (15) minutes

Heavy Bleeding

Perineal pads saturated at one (1) hour and if blood clots are presento Palpate Abdomen

Uterus contracted Perineum has bleeding Bleeding from episiotomy (done if there is crowning or +4 station)

Laceration not appraisedo Bleeding from cervical laceration

Most common cause of bleedingo Vaginal wall bleeding

Important Concept!

DO NOT ENCOURAGE PUSHING IF CERVIX IS NOT FULLY DILATEDQuestion

When is the best time to ask client to push?AnswerSecond Stage of LaborImportant Concepts!Main purpose of pushing

o To shorten the Second Stage of Labor Ask client to PANT-BREATHE if there is an urge to push

This prevents VALSALVA MANEUVER


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Remember, FIRST STAGE PUSHING IS NOT ADVISABLE

In the Third Stage of Labor, the NURSING RESPONSIBILITY is to PROVIDE MEASURES TOPREVENT HEMORRHAGE

Other Causes of Bleeding

Bladder Distentiono Therefore, MOTHER MUST VOID AFTER GIVING BIRTHo Offer bedpan every hour or accompany the mother to the bathroom (patient has

HYPOTENSION)o First twelve (12) hours post partum

It is NORMAL for mother to go into DIURESIS Absorbed water must be eliminated

o After twelve (12) hours, there is difficulty in voiding due to FATIGUE of TRIGONE of BLADDERbecause of CONSTANT PRESSURE EXERTED BY CONTRACTING UTERUS

This results to a DISTENDED BLADDER Therefore, UTERUS CANNOT CONTRACT EFFECTIVELY This causes UTERINE ATONY (Uterus is deflected either to the LEFT or to the RIGHT) Therefore, assure voiding so uterus stays at center

Place warm water in containero Do not place warm water in abdomen or at the hypogastric areao This will cause bleeding

Nursing Responsibilityo Do alternate pouring of warm and cold water over the perineum to promote uterine contraction

FOURTH STAGE OF LABOR

FIRST ONE (1) TO TWO (2) HOURS AFTER DELIVERY OF THE PLACENTA

Crucial Problem or Main Problem at this stageo BLEEDING

All the retained water retained previously will be reabsorbed into the circulationo Increase in Cardiac Outputo Increase in Oxygen Consumption

Therefore, it is the most detrimental or difficult stage of labor in GRAVIDOCARDIAC PATIENTS!!!

EPISIOTOMY

Episiotomy is performed at the PERINEUM

Perineum is the muscular portion between the vagina and the rectum

Episiotomy is performed too Prevent laceration (secondary)o Shorten the duration of the second stage of labor (this is the MOST IMPORTANT PURPOSE)

as the head of the fetus will emerge quickly

Two (2) ways of EPISIOTOMY

Median Episiotomyo Cut is made from the vagina direct to the anus

Mediolateral Episiotomyo To the right or left

Advantages of Median Episiotomy

Has lesser blood loss because area cut has more fibrous tissue

Less pain due to less nerves

Disadvantages of Median Episiotomy Promotes extension to the rectum

Therefore, there is greater degree of laceration

Therefore, this is used most of the time

This is the more common cut among the two types

Advantages of Mediolateral Episiotomy

Cut is done on the side of the perineal body

This prevents extension (of the cut) into the rectum

Therefore, there is less degree of laceration

Important Concepts!For Meconium staining

Use NITRAZINE TEST


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o To determine whether fluid is amniotic fluid or urine

pH Nitrazine paper is placed in contact with vaginal secretion

Amniotic Fluid is ALKALINEo If pH nitrazine paper turns GREEN (ANY TINGE OF GREEN), IT IS AMNIOTIC FLUID

Urine is ACIDICo If pH nitrazine paper turns RED (ANY TINGE OF RED / ORANGE)

Important Concept! Note the time when Rupture of Membrane occurs (ROM)

Golden Period is twenty-four (24) hours

If membrane has ruptured for greater than twenty-four hours (and STILL NO BIRTHING FROMLABOR), INFECTION WILL OCCUR.

Therefore, a CAESARIAN SECTION IS NEEDED

DEGREES OF LACERATION

First Degree Laceration

Skin

Fourchette

Posterior portion of vagina

Posterior tip

Subcutaneous tissuesSecond Degree of Laceration

First three structures (mentioned in First degree laceration) plus PERINEAL MUSCLESThird Degree Laceration

All of the structures in the second degree laceration plus RECTAL SPHINCTERFourth Degree Laceration

All the structures in the third degree laceration plus RECTAL MUCOSAImportant Concept!

The greater the severity of the laceration, the longer recovery period is needed, the greater the chancesfor obtaining infections

PUERPERIUM

Main Responsibilityo Achieve INVOLUTION

Return of reproductive organs to pre-pregnancy state

Usually achieved after six (6) weeks

PRINCIPLES

1. PROMOTE HEALING

Uteruso At level of umbilicuso After the delivery of the placenta

One (1) day aftero One (1) finger breadth below the umbilicus

Two (2) days aftero Two (2) finger breadths below the umbilicus

Three (3) days aftero Three (3) finger breadths below the umbilicus

Four (4) days aftero Four (4) finger breadths below the umbilicus

Five (5) days aftero Five (5) finger breadths below the umbilicus

Six (6) days aftero Six (6) finger breadths below the umbilicus

Seven (7) days aftero Seven (7) finger breadths below the umbilicus

Eight (8) days aftero Eight (8) finger breadths below the umbilicus

Nine (9) days aftero Nine (9) finger breadths below the umbilicus

Ten (10) days after


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o Ten (10) finger breadths below the umbilicus or at the level of the symphysis pubis

Eleven (11) days aftero Uterus at the pelvic cavity

Important Concept!

After six (6) weeks, upon Internal Examination. . .o If Uterus is midway between the umbilicus and symphysis pubis, this is ABNORMAL

This means that there is something left inside

SUB-INVOLUTION or POST PARTUM HEMORRHAGE

Uterus has not gone back to original size

Caused by retained placental fragment

LOCHIA

Rubra

Day one (1) to day three (3)

Day two (2) to day three (3)

Bright red in color

Serosa

Day three (3) to day ten (10)

Pinkish in color

Actually, brown in color

Alba

Day ten (10) until third (3rd) week up to sixth (6th) week post-partum

Important Concept! After six (6) weeks, THERE IS NO MORE LOCHIA

CHARACTERISTICS OF NORMAL LOCHIA

Normal Odoro Musty but not FOUL SMELLINGo Foul smell indicates infection

Coloro Should not be YELLOWISHo Yellowish color indicates infection

Order of Appearanceo Should never be reversedo Reversal in appearance indicates RETAINED PLACENTAL FRAGMENTS

LACTATIONAL AMENORRHEA

Lactating Fully

Not ovulating

Six (6) months effectivity

TO BE EFFECTIVE

There must be complete emptying of the breast without supplementation (baby receives no bottlefeeding)

Four (4) to six (6) months Start Supplementation

Important Concepts!

Normally, after eight (8) weeks or two (2) months, MENSTRUATION RETURNS

If the mother is breastfeeding, it would take six (6) months BEFORE MENSTRUATION RETURNS

After three (3) to four (4) weeks, COITUS IS ALLOWABLE

2. PROVIDE EMOTIONAL SUPPORT

a. TAKING IN

First two (2) days post-partum


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Mother is very dependent for care for self and the newborn

Rejecting rooming-in is NORMALb. TAKING HOLD

After second dayo Mother is now independent of self care and newborn careo Time of evidence of POST PARTUM BLUES / DEPRESSION IS OVERTo If poor support system is present, this predisposes to POST PARTUM BLUES / DEPRESSION /

PSYCHOSISo Brief Psychotic episode lasts for three (3) months

c. LETTING GO

Completely accepted role as a new mother

3. PREVENTION OF POST-PARTUM. . .

3.1) MATERNAL HEMORRHAGE

Early post-partum hemorrhage

Occurs within the first twenty-four (24) hours after delivery

Uterine atony is most common cause Lacerations are the second most common cause

Inherent clotting disorders occur:o Thrombocytopeniao Leukopenia

Late post-partum hemorrhageo Occurs after first twenty-four hours of delivery

Common causes:o Primary Cause

Retained placental fragment/so Secondary Cause

Hematoma (vaginal)

3.2) INFECTION

Endogenous infection

Normal flora causes infection

These travel up the uterus

TORCHES (Teratogenic) Infectionsviruses

CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend throughbirth canal and adversely affect fetal growth and development. These infections are often characterized byvague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement).In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on thefetus. TORCHES: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus, SYPHILIS

Ttoxoplasmosismom takes care of cats. Feces of cat go to raw vegetables or meatOothers. Hepa A or infectious heaporal/ fecal (hand washing)

Hepa B, HIVblood & body fluidsSyphilis

RrubellaGerman measlescongenital heart disease (1stmonth) normal rubella titer 1:10


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3.4) ENDOMETRITIS

Infection of the lining of the uteruso With maternal fever > 38

C (37.5C is common due to dehydration)o With foul-smelling vaginal discharge

With uterine or abdominal tenderness

Management for Endometritis

Antibiotics

Positiono Semi-Fowlers position

Oxytocin is giveno Promotes contractionso Promotes release of secretion

Important Concept!

ENDOMETRITIS is a PRELUDE to THROMBOPHLEBITIS

3.5) THROMBOPHLEBITIS

Most common site are the vessels of the LOWER EXTREMITIES

Positive (+) for HOMANS SIGN

How is Homans Sign elicited?o Ask patient to dorsiflex footo Upon lying supine, legs extendedo Stretching of the blood vessels causes pain on calf muscle (gastrocnemius muscle)

Management of Thrombophlebitiso Antibioticso Anticoagulant

Heparin Larger molecule than warfarin Less likely to enter breast milk

Important Concepts! Discontinue breastfeeding whether heparin or warfarin is administered

Antidoteso For Heparin

Protamine Sulfateo For Warfarin

Vitamin K

HEART DISEASE IN PREGNANCYFour (4) Functional Classifications of Heart Disease

Class Io Heart Disease is presento But uncompromised

Class IIo Heart Disease is presento Slightly compromised

Class IIIo Heart Disease is presento Markedly compromised

Class IVo Heart Disease is present

Severely compromisedImportant Concepts!

If you belong to Class I and Class IIo You can go through normal pregnancy

If you belong to Class III and Class IVo You cannot go through normal pregnancyo You are not a good candidate

Heart Disease In Pregnancy

Labor and delivery should be:


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Use the bell of the stethoscopeo Purpose is for greater amplification

Hand / Dominant Hando On area being auscultated

Non-Dominant Hando Palpates radial pulses for the mother

Therefore, you can correlateo FETAL HEART TONE IS DISTINCT

TUGTUGTUGTUGo Radial pulse of the Mother is

Tug - - - - - - Tug - - - - - - Tug

FETAL MOVEMENT Two (2) schools of thought

o Cardiff Count to Teno Sandovsky Method

CARDIFF COUNT TO TEN

Normal Fetal Movemento At least one (1) movement every five (5) to six (6) minuteso About ten (10) to twelve (12) movements per hour

First Instructiono Instruct the client to eat LIGHT MEAL one (1) hour before monitoring for fetal movement

Have short walk or massage abdomen as baby may be asleep or is hungry Ask mother to assume left lateral position A clock must be at the bedside with pencil and paper Dominant hand of mother palpates most prominent part of abdomen Note for any fetal movement FETAL MOVEMENT SHOULD BE ASSESSED WHEN THERE IS QUICKENING (AT TWENTY-FOUR

MONTHS AGE OF GESTATION ONWARDS)

Mother notes for ten (10) fetal movements and NOTES THE TIME THAT THE TEN (10) FETALMOVEMENTS HAVE BEEN COMPLETED

o Should be completed in one (1) houro Approximately five (5) movements in thirty (30) minutes

You MUST get at LEAST ONE HALF OF NORMAL Therefore, AT LEAST FIVE (5) FETAL MOVEMENTS PER HOUR IS ACCEPTABLE

Important Concepts! Approximate number of growing follicles:

o At twenty-eight (28) weeks Age of Gestation 6,000,000

o At Term 1,000,000

o At menarche 400,000

o At forty (40) years of age 8,000

SANDOVSKY METHOD Same procedure as in Cardiff Count to Ten Mother monitors fetal movement three (3) times a day These are done:

o

After breakfasto After luncho After dinner

Normal You should appreciate two (2) to three (3) fetal movements in one hour

OTHER WAYS TO ASSESS: DIAGNOSTICS

AMNIOCENTESIS

Best done at sixteen to eighteen (1618) weeks Age of Gestation or during second (2

nd

) trimester This is the time when the baby is SMALL and there is MUCH AMNIOTIC FLUID


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Information Obtained:

A) FETAL LUNG MATURITY Analyzed for lung surfactant: Dipalmytoyl Phosphatidylcholine L : S Ratio

o Lecithin : Sphingomyelin Ratio Lecithin is a specific component of lung surfactant

o Lecithin should be greater than Spinglomyelino Normal Ratio is 2L : 1S

If there is anticipated premature delivery, amniocentesis is done to know if delivery is viable

PHOSPHATIDYL GLYCEROL (PG) Most potent of all lung surfactants Usually appreciated at amniotic fluid at THIRTY-FOUR to THIRTY SIX (34 36) WEEKS AGE OF

GESTATION Therefore, it is safe to deliver fetus if Phosphatidyl Glycerol is present There is decreased risk of respiratory distress

POLYHYDRAMNIOS Amniotic fluid greater than 2,000 ml

o A teratogenic effect Therefore, remove part of amniotic fluid

IDENTIFICATION OF GENETIC OR CHROMOSOMAL PROBLEM

HOW TO PREPARE THE CLIENT FOR AMNIOCENTESIS Explain what to do to the client

Get Consent Remember, CONSENT IS NEEDED as this procedure is INVASIVE! Client must have I. V. fluid

o Plain Normal Saline Solutiono Side drip of Tocolytic to relax the uterus

Ask client to void before the procedure so as not to puncture bladdero Ultrasound-guided procedureo Needle should not puncture the placenta

Abdomen is prepared aseptically Specific Site

o Pocket of abdomen containing highest amount of Amniotic Fluido Done by OBSTETRIC SONOLOGIST

Needle Inserted

o Local anesthesiao Abdominal wall through the uterus to amniotic sac

Post Procedureo Check Vital Signs (every fifteen (15) minutes)o Check Blood Pressureo Check Fetal Heart Toneo Client then rests for two (2) to three (3) hourso Mother is then sent home

DISCHARGE INSTRUCTIONSo Note for UTERINE TONEo Note for Fetal Activityo Client may be:

Hyperactive

In distress Hypoactive

In distresso Note for vaginal bleeding or spottingo Vaginal spotting is acceptable

DANGER SIGNS Persistent uterine contraction Hyper / Hypoactive


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Vaginal Spotting to Bleedingo Therefore, ask mother to come back if she observes any of the above signs

MATERNAL SERUM ALPHA FETOPROTEIN A special kind of protein produced in the yolk sac of the liver of baby / fetus Specimen is blood Consent is needed

Normal value of Maternal Serum Alpha Feto Protein (MS AFP)o 2.02.5 MOM (measurements of the mean)

If MS AFP is higher than normal, THERE IS A NEURAL TUBE DEFECT:o Spina bifidao Meningocoelo Myelomeningocoelo Anencephaly

If MS AFP is lower than normal, THERE IS DOWNS SYNDROME Therefore, you must be able to know exact Age of Gestation Fifteen to Twenty (15 20) weeks Age of Gestation is the IDEAL TIME FOR MS AFP or during the

SECOND (2nd) TRIMESTER, not on the First or the Third Trimesters If early high result

o Yolk sac and liver gives false elevated result If late low result

o Liver only gives false low result

CHORIONIC VILLUS SAMPLING (CVS) Get part of chorionic villi from the placenta Done at nine to twelve (912) weeks Age of Gestation Approach is INTRAVAGINAL Ultrasound-guided A part of chorionic villi near maternal attachment will be suctioned to the catheter for KARYOTYPING

and GENETIC ANALYSIS

Purpose of this procedure is for detection of genetic and chromosomal problems Nursing Responsibility

o Bleeding is common in CVSo Instruct mother to observe SPOTTING to BLEEDINGo Ask mother to come back if bleeding occurs

Therefore, not much done; increases chance of abortion or fetal loss

PERCUTANEOUS UMBILICAL BLOOD SAMPLING (PUBS) Also known as CORDOCENTESIS Get sample Ultrasound-guided

Sonologist identifies umbilical veino Vein has larger lumen than the artery

Catheter is inserted Approach is through the abdomen Information obtained:

o For identification of blood incompatibilitieso For exchange transfusiono For isoimmunization

Needed in instances of an Rh+baby and an Rh- mother

ULTRASOUND

Types of Ultrasound Transabdominal Ultrasound Transvaginal Ultrasound

TRANSABDOMINAL ULTRASOUND Ask the client to FILL BLADDER Full bladder will push uterus to pelvic cavity for better visualization at abdomen

ULTRASOUND IN FIRST TRIMESTERInformation obtained:


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Stressor is the contraction of the uterus There should be NO CONTRACTION Compare

o Fetal Heart Tone and Fetal Movement If baby moves, FHT INCREASES!

With two (2) transducers placed near FHT at fundus of uterus Leopolds maneuver Water soluble lubricant

o KY jelly amplifies FHT TOCO

o No lubricant at fundus of uterus So that it is verified There is no contraction

FHT 150

140

BASELINE130

120

110

100

FLAT LINE (NO CONTRACTION)

UC

(MEASURED IN PRESSURE)

Push buttono If mother feels fetal movement

CRITERIA TO SAY NST IS NORMAL

Period of Observation should beo Greater than or equal to twenty (20) minutes

You must get at least two (2) accelerations in twenty (20) minutes Acceleration should be at least fifteen (15) beats above baseline Duration of acceleration should be

o Greater than or equal to fifteen (15) secondso One (1) small square = one (1) second

Therefore, IF ALL CRITERIA ARE MET, NON-STRESS TEST IS NORMAL

KEY CONCEPT!!! If NST is NORMALIT IS REACTIVE

Therefore, the chances of fetal survival is greater than 99% in the next week You can assure the mother

If NOT ALL CRITERIA ARE MET

(i.e. Criteria No.3 with 10 beats per minute only), Repeat NST after two (2) to three (3) hours

FHT 150

140

BASELINE130

120

110


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100

UC

(MEASURED IN PRESSURE)

Important Concept! If NST is NON-REACTIVE, it is ABNORMAL

CONTRACTION STRESS TEST (CST)

Best done when mother is at thirty-eight (38) weeks Age of Gestation

Done when NST is NON-REACTIVE Then, proceed with Contraction Stress Test If CST could not be withstood by baby, IT NEEDS IMMEDIATE DELIVERY Introduce a STRESSORCONTRACTION if ABNORMAL CST

OXYTOCIN CHALLENGE TEST Rub nipples

o Nipple stimulation if uterus is NOT contracting When assessing

o Hide your thumbo If you are a male so as not to be sued for sexual harassment

NIPPLE STIMULATIONo Give warm pack / warm soaks for ten (10) minutes prior to stimulation to increase circulation /

vascularityo Explain procedureo Starto Four (4) cycles per stimulationo 1, 2, 3, 4 stimulations REST x4

First Cycleo If after these and there are NO CONTRACTIONSo Stop and rest for two (2) to four (4) minuteso Then stimulateo Up to four (4) cycles

If NO CONTRACTIONS AFTER THE FOURTH (4th

) CYCLEo Stop stimulationo Proceed with Oxytocin Challenge Test

OXYTOCIN CHALLENGE TEST

Give diluted form of oxytocino Five units (5U) or ampule + 1 liter D5LR or D5H2O

Give at a titrating dose Start at ten to twelve (10-12) drops per minute to a maximum of forty (40) drops per minute Observe for Uterine Contraction Wait for two (2) consecutive uterine contractions Stop Oxytocin Challenge Test if two (2) uterine contractions are obtained Now compare Uterine Contractions with Fetal Heart Tone

FHT 150

140

BASELINE130

120 CST IS NORMAL OR NEGATIVE

110

100


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UC

NEGATIVEo In the presence of uterine contraction, tracing is NEGATIVE FOR DECELERATION

Vagus Nerveo Parasympathetic Stimulation gives rise to bradycardia

Carotid Stimulation results intoo Bradycardiao Hypotension

Important Concept! Abnormal if POSITIVE (+) FOR DECELERATION

FHT 150

140

BASELINE130

120

110 CST IS ABNORMAL

100

UC

Note for timing of deceleration in relationship to contraction

o Deceleration is before contractiono Shape of deceleration is U-SHAPEDo Deceleration has early recovery to baseline level

Important Concepts! If (1), (2) and (3) above are present, it is called EARLY DECELERATION

o The most NORMAL of all the ABNORMAL If mother is in TRANSITIONAL PHASE

o Cervix is 810 cm dilatedo Head / presenting part in vaginal vault

In the dura of the brain is the innervation of the vagus nerve

If head of baby is in the pelvis If vagus nerve is stimulated, there is BRADYCARDIA If head is released, there is normalization Therefore, EARLY DECELERATION is NOT PRESENT in the EARLY STAGE of the FIRST STAGE of

LABOR If NORMAL, DO NOTHING!!!!

o JUST OBSERVEo This is NORMAL!

Second type of Deceleration

FHT 150

140


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130

BASELINE120

110

100

UC

Decelerationo Occurs anytime (variable) during contractiono W-shaped Decelerationo Decrease in baseline from 130 to 125

Therefore, TYPICAL VARIABLE DECELERATION Significance:

o Signifies CORD COMPRESSION but not necessarily Cord Prolapseo Therefore, INTERVENE IF THERE IS CORD COMPRESSION

INTERVENTIONSIf in labor:

Turn client to left lateral position

Stop oxytocin immediatelyo No contractions are wanted

Give oxygen to mothero Rate is 810 liters per minute

Hydrate with plain watero No incorporation of oxytocin to increase circulating blood volumeo Mother is on NPO during labor and there could be DEHYDRATION

ADH secretion is increased to conserve watero ADH is released from the posterior pituitaryo Oxytocin is released from the posterior pituitaryo Cross reaction of ADH and Oxytocin in the Uteruso ADH binds in OXYTOCIN RECEPTORS in Uterus resulting to CONTRACTIONo Therefore, hydrate so as not to increase ADH secretion

If variable deceleration is >10 minutes, then CAESARIAN SECTION may be NECESSARY

Third Type of Deceleration

FHT 150

140

BASELINE130

120

110

100

UC


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Rh and ABO blood typing

Important Concepts! Asians NOT COMMONLY Rh- Caucasians are COMMONLY Rh-

BLOOD NOMENCLATURE ABO Typing

o Type A, B, Oo A or B antigens

Rh Typingo Rh (C, D, E)o Three antigens

C D E

o In incompatibility, the concern is the D antigen

Rh

Mother is Rh- Father is Rh+

No D antigens

Rh-or Rh0

(zero for D)

Baby is Rh+ or Rh(D)

Antigen D is present in the blood

Important Concept! The first pregnancy is spared The first baby is born Blood enters mothers circulation Therefore, mother PRODUCES ANTI-D antibody

Interaction During time of delivery when the placenta starts to detach from maternal attachment Abortion / Dilatation and Curettage Some fragments of placenta are retained in the uterus Ancillary Procedures like AMNIOCENTESIS Interaction of blood of baby entering mother occurs and stimulates antigen-antibody reaction

Second Pregnancy Anti-D antibody of mother hemolyzes the Antigen D of second baby

o This results into erythroblastosis fetalis or death of the RED BLOOD CELLS

o

Second baby would have SEVERE ANEMIA HEART FAILURE ANASARCOUSDEATH

RHOGAM Gamma globulin A pre-formed antibody Given within seventy-two (72) hours If to undergo amniocentesis

o Rhogam is given before the procedure If mother undergoes abortion

o Rhogam is given within seventy-two (72) hours after abortion

If pregnant nowo Give at twenty-eight to thirty-two (2832) weeks Age of Gestationo to Rh-mother REGARDLESS OF Rh of Baby


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Important Concept! Rhogam is repeated prior to term at forty (40) weeks Rhogam has a half life Rhogam may be out of circulation

COOMBS TESTTwo (2) types

Direct Coombs Test Indirect Coombs Test

DIRECT COOMBS TEST Concerns the Baby PUBS Identify if RBC of baby has hemolysis and has attached antibody Therefore, sensitization has occurred on the mother

INDIRECT COOMBS TEST Concerns the mother Identify for titer of antibody

o Get blood sampleo Identify titer of Anti-Do Zero titer if Rh+o If Rh- individual

1 : 8 or 1 : 16 If titer is less than 1 : 8 this means that MOTHER IS NOT YET SENSITIZED

o Therefore, blood of the mother is FREE OF ANTI-D antibodyo There is a need for Rhogam

If titer is greater than 1 : 16 this means that there is SENSITIZATIONo It has ANTI-D antibodyo Then, Rhogam is NOT neededo Rhogam CANNOT REVERSE SENSITIZATION

Interjected Concepts G3P2 Cervix is 9 cm dilated EEFM

TWO (2) ABSOLUTE CONTRAINDICATIONS FOR CONTRACTION STRESS TEST If client is premature (Biophysical Score is used instead) History of problem in the placenta (placentation)

Situation Mother is Type O Rh- Baby is Type A Rh+

Question What type of blood do you give?

Answer Give type A blood

Rationale Hemolysis is present Baby has anti-D that is why there is hemolysis If Rh+ is given

o There is continuous antibody giventhere is confirmed hemolysiso Therefore, give Rh-

KEY CONCEPT! ALWAYS GIVE THE BLOOD TYPE OF THE MOTHER (as far as Rh is concerned)

Important Concept! If mother is Rh+ and father is Rh+, then the baby is Rh+ and there is no problem


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ABO BLOOD GROUPSBlood Type Antigen Antibody

A A Anti-B

B B Anti-A

AB A and B None

O None Anti-A andAnti-B

Important Concepts! Type O blood causes hemolysis If baby is type A, B, AB

Question What type of blood in mother will cause hemolysis in ABO?

Answer Type O

Question What type of blood will be given to the baby if there is ABO incompatibility?

Answer Blood type of mother

Important Concepts! Most common cause of PATHOLOGIC JAUNDICE is ABO INCOMPATIBILITY

Pathologic Jaundice is prolonged jaundice Normal Value of Bilirubin

o 15 mg / dl If greater than 15 mg / dl, transformation is needed ABO INCOMPATIBILITY is protective against Rh INCOMPATIBILITY

o If Mother is type Oo If Baby is type A

RBC carries Rh(D)o RBC of baby contains D antigeno Since hemolysis has already occurred, Anti-D of mother will no longer hemolyze any RBC with

Anti-D

URINALYSIS Note for infection White Blood Cells

o Pus Cellso Common minute amount of pus cellso Normal Value is 5 / hpf (high power field)o In Females

5 / hpf means there is INFECTION < 5 / hpf means NO INFECTION

o In males 5 / hpf is SIGNIFICANT

URINE SAMPLES Wash perineum Dry perineum Let first stream pass out

o This is done to flush bacteria outside urethra Get midstream void Given sterile container with pack with iodine

GLUCOSE CONTENT OF BLOOD

Glomerular Filtration Rate is increased Normal to see trace and +1 Glucose Normal to see trace and +1 protein or < 250 mg / dl


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GLUCOSE TESTING IN BLOOD Screening Procedure

GLUCOSE CHALLENGE TEST For diagnosis of GESTATIONAL DIABETES MELLITUS Best timing is twenty-four to twenty-eight (2428) weeks Age of Gestation This is the PEAK PERIOD FOR INSULIN RESISTANCE No need for fasting Give mother concentrated glucose solution (orange juice)

o 50 grams per orem Wait for one (1) hour Blood sample is drawn from the mother Two (2) probable results:

o Glucose level < 140 mg / dl Normal Therefore, STOP There is remote risk of GESTATIONAL DIABETES MELLITUS

o Glucose level > 140 mg / dl Abnormal

There are chances of developing GESTATIONAL DIABETES MELLITUS Therefore, PROCEED WITH ORAL GLUCOSE TOLERANCE TEST

ORAL GLUCOSE TOLERANCE TEST (OGTT) Fasting is needed for 810 hours or 812 hours Example:

o NPO by 12 midnighto Be at clinic by 8:00 AM

Draw specimen for Fasting Blood Sugar (FBS) Give concentrated glucose solution

o 100 grams per orem Wait for one (1) hour Draw blood sample

Wait for another hour Draw another blood sample Wait for another hour Draw another blood sample

o Therefore, four (4) drawings of blood

1 2 3 4

FBS 1st

Hour

2ndHour 3rd

Hour

Normal Normal Normal Normal


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HbSAg(+) and HbE(+)o Give vaccination to the babyo Active

Hepatitis B vaccine 0.5 ml via I.M. Within 24 hours of delivery

o Passive Hepatitis B immunoglobulin 0.5 ml I.M. Within 24 hours after delivery

o Site of Choice Vastus lateralis

Vitamin K Best site for administration

o Rectus femoris Do not give vaccination on medial nerve (sciatic nerve) will be hit

Do not give on gluteuso Not developedo This is developed only when baby has begun to sit

Do not give at deltoido Deltoid is not developed

Rectus femoris is the anterior muscle of the thigh

Question HbSAg(+) mother Can she breastfeed?

Answer

Yes, provided baby should have received BOTH ACTIVE and PASSIVE VACCINATION PRIOR TOBREASTFEEDING


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2013-2014 Mcn Maternal Physiologic Changes

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