MATERNAL/OB NOTES

I. Human SexualityA. Concepts

1. A person’s sexuality encompasses the complex behaviors, attitudes, emotions and preferences that are related to sexual self and eroticism.

2. Sex – is basic and dynamic aspect of life3. During reproductive years, the nurse performs as resource person on human sexuality.

B. Definitions related to sexuality:

Gender identity – sense of femininity or masculinity 2 - 4 years / 3 years gender identity develops.

Role identity – attitudes, behaviors and attributes that differentiate roles.

Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse.

Sexuality - behavior of being boy or girl, male or female; man or woman. - It is an entity subject to a life long dynamic change.

- developed at the moment of conception.

II. Sexual Anatomy and Physiology

A. Female Reproductive System

1. External - vulva or pudendum

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

Tannerscale - tool used to determine sexual maturity rating.

Stages of Pubic Hair Development

Stage 1 – Pre-adolescence - No pubic hair except for fine body hair onlyStage 2 – Occurs between ages 11 and 12 – sparse, long, slightly pigmented & curly hair along the labia .Stage 3 - occurs between ages 12 and 13 – hair becomes darker & curly hair that

develops along symphysis pubis.Stage 4 – occurs between ages 13 and 14. Hair assumes the normal appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh. Stage 5 - sexual maturity - normal adult - appear to the inner aspect of thigh.

b. Labia Majora – means “large lips” - a longitudinal fold, that extends from the symphysis pubis to the perineum; Two folds of skin with fat underneath; contain Bartholene’s glands

c. Labia Minora – means “nymphae” – a soft and thin longitudinal fold that is located in between the labia majora; two thin folds of delicate tissues; form an upper fold encircling the clitoris called the prepuce and unite posteriorly called the fourchette .

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2 sensitive structures of labia minora:

c.1. clitoris – means “key”- anterior, pea shaped erectile tissue composed of so many nerve endings which is the sight of sexual arousal in female. (Greek-key)

c.2. fourchette - Posterior, tapers posteriorly of the labia minora - very sensitive to manipulation, oftenly torn during vaginal delivery. - common site – episiotomy .

d. Vestibule – an almond shaped, narrow space area seen when the labia minora are separated, that contains the hymen, vaginal orifice and bartholene’s glands.

i. Urinary Meatus – small opening of urethra that serves for urination; external opening of the urethra; slightly behind and to the side are the openings of the Skene’s Glands.

ii. Skenes Glands/or Paraurethral Gland – two small mucous secreting substances that serve for lubrication; often involved in infections of the external genitalia.

iii. Hymen – a membranous tissue that covers vaginal orifice, membranous tissue * Carumculae mystiforms - healing of a torn hymen

iv. Vaginal Orifice – external opening of vagina v. Bartholene’s Glands/or Paravaginal Gland or Vulvo Gland - 2 small mucus secreting

substance that secrets alkaline substances- responsible for the acidity of the vagina.( Believed to secrete a yellowish mucous which acts as a lubricant during sexual intercourse. The openings are located posteriorly on either side of the vaginal orifice)Alkaline – neutralizes acidity of vaginaPh of vagina - acidic

Doderleins bacillus – responsible for acidity of vagina

e. Perineum – a muscular structure that is located in between the lower vagina & anus; contains muscles which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia.

2. Internal:

A. Vagina – female organ of copulation; passageway of menstruation & fetus - it is 3 – 4 inches or 8 – 10 cm long of dilated canal located between the bladder and the rectum. Contains* Rugae – permits considerable amount of stretching without tearing

B. Uterus - Organ of menstruation, site of implantation and retainment and nourishment of the products of conception. It is a hollow, thick walled muscular organ. It varies in size, shape and weights.

Size - 1 inch thick; 2 inches wide; 3 inches longShape: non pregnant = pear shaped or inverted avocado

Pregnant = ovoidWeight : Non pregnant: – 50 - 60 grams

Pregnant: - 1000 grams 4th stage of labor - 1000 grams 2 weeks after delivery - 500 grams 3 weeks after delivery - 300 grams

Normal State - 5 - 6 weeks after delivery - 50 – 60 gramsEntire Process is “Involution of Uterus”

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Three parts of the uterus

1. fundus - upper cylindrical layer2. corpus/body - upper triangular layer3. cervix - lower cylindrical layer

* Isthmus – known at the lower uterine segment during pregnancy * Cornua - junction between fundus & interstitial

Muscular compositions: there are three main muscle layers which make expansion possible in every direction.

1. Endometrium - inside uterus, in lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs off during menstruation.

* Decidua - thick layer; Once implantation has taken place, the uterine endothelium is termed decidua. Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are ruptured by the implanting trophoblasts = implantation bleeding . . .

Implication: this should not be mistaken for the LMP(Last Menstrual Period)*Endometriosis – “ectopic endometrium” abnormal proliferation of endometrial lining outside uterus.

Common site: ovary.Signs/symptoms: persistent dysmennorhea and low back pain.Diagnostic test: biopsy, laparoscopyDrug of choice: 1. Danazole (Danocrene)

Action: a. to stop menstruation b. inhibit ovulation 2. Lupreulide (Lupron)

Action: a. inhibit FSH/LH production

2. Myometrium – largest part of the uterus - it is the muscle layer responsible for delivery process

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

3. Perimetrium – muscle layer that protects entire uterus

C. Ovaries – Almond shape, dull white sex glands near the fimbrae, kept in place by ligaments. 2 female sex glands that serves for two functions:

1. ovulation 2. Production of two hormones

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

4 significant segments 1. Infundibulum – most distal part of Fallopian Tube, trumpet or funnel shaped, swollen at ovulation2. Ampulla – outer 3rd or 2nd half, site of fertilization3. Isthmus – site of sterilization – bilateral tubal ligation4. Interstitial – most dangerous site of ectopic pregnancy * Cortex of the ovary – releases the matured ovum

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B. Male Reproductive System1. External Penis – the male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – the glands penis.

3 Cylindrical Layers2 corpora cavernosa1 corpus spongiosum

Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of which contains a testes. It is the cooling mechanism of testes

- < 2 degrees C than body temperature Leydigs cell – release testosterone

* pure sperm plus secreting substance equals SEMEN*

2. Internal The Process of Spermatogenesis – maturation of sperm

Epididymis – 6 meters coiled tubules site for maturation of sperm

Vas Deferens – conduit for spermatozoa or pathway of spermEntry of pure sperm

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

Hypothalamus will release

GnRHGonadotropin

releasing hormone

Anterior Pituitary Gland release

FSHFollicle Stimulating

Hormone

LFLuteinizing Hormone

Function:SpermMaturation

Function: Hormones forTestosteroneProduction

Testes – 900 coiled (½ inch long at age 13 onwards)(Seminiferous tubules)

Ejaculatory duct – conduit of semen

Prostate gland - release alkaline substance

Cowpers gland - release alkaline substance

UrethraFinal link from anterior to posterior

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Male and Female homologuesMale FemalePenile glans Clitoral glansPenile shaft Clitoral shaftTestes OvariesProstate Skene’s gandsCowper’s Glands Bartholene's glandsScrotum Labia Majora

III. Basic Knowledge on Genetics and Obstetrics1. DNA – carries genetic code2. Chromosomes – threadlike strands composed of hereditary material known as DNA3. Normal amount of ejaculated sperm - 3 – 5 cc., 1 tsp4. Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation5. Sperm is viable within 48 – 72 hours or 2 - 3 days6. Reproductive cells divides by the process of meiosis (haploid)

Spermatogenesis – maturation of spermOogenesis – process - maturation of ovumGametogenesis – process of formation of 2 haploid into diploid 23 + 23 = 46 or diploid

7. Age of Reproductivity – 15 – 44 years old8. Menstruation -

Menstrual Cycle – beginning of menstruation to the beginning of the next menstruationAverage Menstrual Cycle – 28 daysAverage Menstrual Period - 3 – 5 daysNormal Blood loss – 50 cc or ¼ cup with fibrinolysin to prevent clot formationRelated terminologies:

Menarche – the beginning or the 1st menstruationDysmenorrhea – painful menstruationMetrorrhagia – bleeding at completely irregular intervals of menstruationPolymenorrhea – frequent menstruation occurring at intervals of less than three weeksMenorhagia – excessive bleeding during regular menstruationAmenorrhea – absence of menstruationOligomenorrhea – marked diminished menstrual flow, nearing amenorrheaMenopause – cessation of menstruation / average : 51 years old

9. Functions of Estrogen and Progestin* Estrogen “Hormone of the Woman” Primary function: responsible for the development of secondary sexual characteristic of female.

enlargement of the breast pelvic axillary pubic hair

Others:1. inhibit production of FSH ( maturation of ovum)2. responsible for the hypertrophy of myometrium3. responsible for Spinnbarkeit & Ferning ( billings method/ cervical)4. responsible for the development of ductile structure of the breast5. responsible for the increase osteoblast activities of long bones causing increase in height in female 6. responsible for the early closure of epiphysis of long bones7. responsible for sodium retention8. responsible for the increase sexual desire

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* Progestin “ Hormone of the Mother”Primary function: prepares endometrium for implantation of fertilized ovum making it thick &

tortous (twisted)Secondary Function: It decreases contractility of the uterus (favors pregnancy)Others:

1. It inhibit the production of LH (hormone for ovulation)2. It decreases GIT motility

↓ decreases Peristalsis

↓ increase Water Reabsorption

↓ CONSTIPATION

3. responsible for the development of mammary gland 4. responsible for the increase permeability of kidney to lactose & dextrose causing (+) sugar 5. responsible for mood swings in woman 6. responsible for the increase Basal Body Temperature

10. Menstrual Cycle: average – 28 days 4 phases of Menstrual Cycle

1.1. Proliferative1.2. Secretory1.3. Ischemic1.4. Menses

Parts of body responsible for menstruation:1. hypothalamus2. anterior pituitary gland – masterclock of the body3. ovaries4. uterus

I. Initial phase – of menstruation, the estrogen level is ↓ , this level stimulates the hypothalamus to release GnRH(gonadotrophin releasing hormone) or FSHRF(Follicle Stimulating Hormone Releasing Factor)

3rd day – Decreased estrogen 13th day – Peak estrogen, Decrease progesterone 14th day – Increase estrogen, Increase progesterone 15th day – Decrease estrogen, Increase progesterone

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

Functions of FSH:A. Stimulate ovaries to release estrogenB. Facilitate growth primary follicle to become graffian follicle (structures that secrets large amount of estrogen & contains mature ovum.)

III.Proliferative Phase – contains mature ovum (ovulation)proliferation of tissue → follicular phase → post menstrual phase → Preovularoty Phase

Follicular Phase – causing irregularities or variations of menstruation; 14th daysPostmenstrual Phase – occurs after menstruation dayPreovulatory Phase – happens before menstruation day “ all phases – increase ESTROGEN”

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

V. GnRH/LHRF stimulates the anterior pituitary gland to release LH(Luteinizing Hormone) Functions of LH:1. LH stimulates ovaries to release progesterone2. hormone for ovulation

VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation.

Signs and symptoms:1.) Mittelschmerz – slight abdominal pain on Left or Right lower Quadrant of abdomen,

marks ovulation day.2.) Change in Basal Body Temperature 3.) Mood Swing 4.) Constipation

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

VIII. Secretory phase Lutheal Phase Postovulatory Increased progesterone Premenstrual

Secretory Phase – secretes the most important hormone in pregnancy which is the progesterone because it makes the uterus nutritionally abundant with blood in order for the fertilized zygote to survive should conception take place. It is also called progestational phase.

Luteal Phase – change from Graafian follicle to Corpus Luteum(yellowish appearance) Postovulatory Phase – occurs just after ovulation Premenstrual Phase – occurs after menstruation

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

X. 28th day – no sperm in ovum – endometrium begins to slough off to have the next menstrual period1st 7 days – menstrual phase7 – 14th days – proliferative phase14 – 28 days – secretory phase

11 . Stages of Sexual Responses (EPOR)Initial responses:

Vasocongestion – congestion of blood vesselsMyotonia – increase muscle tension

1. E xcitement Phase – (moderate vital signs : sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) – during this phase: erotic stimuli increase sexual tension that may lasts from minutes to hours. 2. P lateau Phase – (accelerated Vital Signs) – increasing & sustained tension nearing orgasm. May lasts 30 seconds – 3 minutes.3. O rgasm – (involuntary spasm throughout the body, peak vital signs). This is the involuntary release of sexual tension accompanied by physiologic and psychologic release known as “immeasurable peak of sexual experience”. May last from 2 – 10 sec- most affected are is pelvic area. 4. R esolution – (vital sign return to normal, genitals return to pre-excitement phase)Refractory Period – the only period present in males, wherein he cannot be restimulated for about

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10 - 15 minutes IV. Wonders of Fertilization

Fornix - where sperm is deposited Sperm - small head, long tail, pearly white Phonones -vibration of head of sperm to determine location of ovum Sperm should penetrate corona radiata and zona pellocida. Capacitation - ability of sperm to release proteolytic enzyme to penetrate corona radiata and zona pellocida.

A. Fertilization – union of the sperm and the mature ovum in the outer third or outer half of the Fallopian Tube.

General Consideration:1. Normal amount of semen per ejaculation - 3 – 5 cc = 1 teaspoon2. Number of sperms in an ejaculate = 120 – 150 million/cc3. Mature ovum is capable of being fertilized for 24 – 36 hours after ovulation.4. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation5. Sperm is viable within 48 – 72 hours or 2 – 3 days6. Normal lifespan of sperm = 7 days7. Sperms, once deposited in the vagina, will generally reach the cervix within 90 seconds after

deposition.8. Reproductive cells, during gametogenesis, divide by meiosis (haploid number of daughter cells);

therefore, they contain only 23 chromosomes ( the rest of the body cells have 46 chromosomes ). Sperms have 22 autosomes and 1 X sex chromosomes or 1 Y sex chromosome; Ovum contain 22 autosomes and 1 X sex chromosome. The union of an X-carrying sperm and a mature ovum results in a baby girl (XX); the union of a Y-carrying sperm and mature ovum results in a baby boy (XY).Important: Only “fathers” determine the sex of their children

B. Stages of Fetal Growth and Development 3 - 4 days travel of zygote → during the travel → mitotic cell division begins

*Pre-embryonic Stagea. Zygote - fertilized ovum. Lifespan of zygote – from fertilization to 2 months fetus - 2 months to birthb. Morula – mulberry-like ball with 16 – 50 cells, start to travel by ciliary action and

peristaltic contractions of fallopian tube to the uterus where it will stay for 4 days free floating & multiplication

c. Blastocyst – enlarging cells that forms a cavity in the morulla, that later becomes the embryo. Trophoblast – fingerlike projections covering around the blastocyst that later becomes

placenta and membrane. d. Implantation other term Nidation - occurs after fertilization 7 – 10 days.

Placenta previa – implantation at the lower side of the uterusSigns of implantation:1. slight pain2. slight vaginal spotting

- if with fertilization – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed.

* 3 processes of Implantation1. Apposition – blastocysts begin to brush the endothelial lining2. Adhesion – blastocysts begin to attached the endothelial lining3. Invasion – blastocysts begin to settle down

“Proteolytic enzyme” – for dissolving endothelial lining allowing implantation* Embryonic Stage

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C. Decidua – thickened endometrium (Greek word – falling off); implantation has taken placeKinds of decidua:* Basalis (base) part of endometrium located directly beneath or under the implanted ovum/fetus

where placenta is developed.* Capsularies – encapsulate or co the fetus* Vera – remaining portion of endometrium.

D. Chorionic Villi - 10 – 11th day of pregnancy; fingerlike projections3 vessels = two arteries, one veinA – unoxygenated bloodV – O2 bloodA – unoxygenated blood

Wharton’s jelly – protects cordChorionic Villi Sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening. Done early in pregnancy. Common dangerous side effects: fetal limb defect such as missing digits/toes.Advance Maternal Age – candidate for amniocentesis

E. Cytotrophoblast – inner layer or langhans layer of the trophoblast that gives rise to the outer surface and villi of the chorion.

- protects fetus against syphilis, however it can be capable of living for 24 weeks/6 months

- life span of langhans layer increase. * Before 24 weeks critical, might get infected syphilis

F. Syncytiotrophoblast – syncytial layer or outer layer . It erodes the uterine wall during implantation and give rise to the villi of the placenta. It is responsible production of hormones. It is also called plasmidotrophoblast; syncytial trophoblast, syntrophoblast

Two structures developed:1. Amnion – innermost layer. It is a membrane, continuous with and covering the fetal side of

the placenta that forms the outer surface of the umbilical cord. 2 structures progress:

a. Umbilical Cord other term chorda umbilicalis, funiculus umbilicans, funis, a flexible structure connecting the umbilicus with the placenta in the gravid uterus and giving passage to the umbilical arteries and vein; whitish grey, “15 – 55 cm, 20 – 21”.

*Importance of determining the length of the cord:Short cord: abruptio placenta or inverted uterus. Long cord: cord coil or cord prolapse

Newborn: 2 feet long and ½ inch in diameter; 1st formed during the 5th week of pregnancy; it contains the yolk sac and the body stalk with enclosed allatois.

b. Amniotic Fluid , also known as (BOW) bag of water, clear, odor mousy/musty, with crystallized forming pattern, slightly alkaline. *Function of Amniotic Fluid:

1. cushions fetus against sudden blows or trauma2. facilitates musculo - skeletal development and symmetrical growth3. maintains temperature4. prevent cord compression 5. help in delivery processnormal amount of amniotic fluid – 500 to 1000ccpolyhydramnios, hydramnios - GIT malformation (TEA) Tracheoesophageeal Atresia /(TEF) Tracheoesophageal Fistula, increased amount of fluidoligohydramnios- decrease amount of fluid – kidney disease; “inom → absorbed → ihi”

Diagnostic Tests for Amniotic Fluid 9

A. Amniocentesis – aspiration of amniotic fluid - empty bladder before performing the procedure.

Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac. Fluid is tested for:

1. Genetic screening / abnormality - maternal serum alpha feto-protein test (MSAFP) – 1 st trimester

2. Determination of fetal lung maturity primarily by evaluating factors indicative of lung maturity – 3 rd trimester

2.1 Testing time – 36 weeksdecreased MSAFP(maternal serum alpha feto-protein test) = down syndromeincrease MSAFP(maternal serum alpha feto-protein test) = spina bifida or open neural

tube defectCommon infections amniocenthesis – infectionDangerous complications – spontaneous abortion / bleeding3rd trimester- pre term labor; indication of diabetic motherImportant factor to consider for amniocentesis - needle insertion siteAspiration of yellowish amniotic fluid – jaundice baby / hyperbilirubinGreenish – mecomiumA. Amnioscopy – direct examination thru an intact fetal membrane.B. Fern Test - determine if amniotic fluid has ruptured or not

(blue paper turns green/grey - + ruptured amniotic fluid)C. Nitrazine Paper Test – diff amniotic fluid & urine.

Paper turns yellow- urine. Paper turns blue green/gray -(+) rupture of amniotic fluid. 2. Chorion – where placenta is developed – outermost membrane

Lecithin Sphingomyelin L/S Ratio - 2:1 signifies fetal lung maturity not capable for RDS(Respiratory Distress Syndrome)Test for Fetal Lung Maturity:Shake test – amniotic + saline & shakeFoam test – amniotic + saline & shake Phosphatiglycerol: PG+ definitive test to determine fetal lung maturity

a. Placenta – (Secundines) Greek – pancake, combination of chorionic villi + deciduas basalis. - Size: 500g or ½ kg

- 15 – 28 cotyledons -1 inch thick & 8” diameter

Functions of Placenta:1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion

“ Higher Concentration to Lower Concentration”2. GIT – transport center, glucose transport is facilitated diffusion more rapid from

higher to lower. If mom hypoglycemic, fetus hypoglycemic “Higher to Lower Concentration but RAPID”

3. Excretory System- artery - carries waste products. Liver detoxifies waste products of the fetus.

4. Circulating system – achieved by selective osmosis

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5. Endocrine System – produces hormones Human Chorionic Gonadrophin – maintains corpus luteum alive; basis of

pregnancy test Human placental Lactogen or sommamommamotropin Hormone – for

mammary gland development. Has a diabetogenic effect – serves as insulin antagonist

Relaxin Hormone- causes softening joints & bones estrogen progestin

6. It serves as a protective barrier against some microorganisms – HIV,HBV

Entire pregnancy days – 266 – 280 days 37 – 42 weeks280 divided by 28 = 10 lunar months280 divided by 31 days = 9.7 days (calendar months)1st week counted “zero”

Fetal Stage “ Fetal Growth and Development”First trimester: period of organogenesis; most critical period

First Month - Brain & heart developmentGIT & respiratory Tract – remains as single tube

1. Fetal heart tone begins – heart is the oldest part of the body2. CNS develops – dizziness of mother due to hypoglycemic effect

Food of brain – glucose complex CHO – pregnant woman’s food (potato)Differentiation of Primary Germ layers

* Endoderm1st week endoderm – primary germ layerThyroid – for basal metabolism; respiratoryParathyroid - for calcium metabolismThymus – development of immunityLiver Lining of upper Respiratory Tract & Gastro Intestinal Tract* Mesoderm – development of heart, musculoskeletal system, kidneys and reproductive organ* Ectoderm – development of brain CNS, skin and 5 senses, hair, nails, mucous membrane of anus & mouth

Second Month1. All vital organs formed, placenta developed2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month 3. Sex organ formed4. Meconium is formed

Third Month1. Kidneys functional2. Fetus begin to swallow amniotic fluid3. Buds of milk teeth appear4. Fetal heart tone heard – Doppler – 10 – 12 weeks5. Sex is distinguishable

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Second Trimester: FOCUS – length of fetusFourth Month

1. lanugo begins to appear2. fetal heart tone heard fetoscope, 18 – 20 weeks3. buds of permanent teeth appear

Fifth Month 1. lanugo covers body2. actively swallows amniotic fluid3. 19 – 25 cm fetus, 4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16 - 18 weeks – multi 5. fetal heart tone heard with or without instrument

Sixth Month 1. eyelids open2. wrinkled skin3. vernix caseosa present

Third trimester: Period of most rapid growth. FOCUS: weight of fetusSeventh Month

– development of surfactant – lecithin

Eighth Month 1. lanugo begin to disappear2. subcutaneous fats deposit3. Nails extend to fingers

Ninth Month 1. lanugo & vernix caseosa completely disappear2. Amniotic fluid decreases

Tenth Month – bone ossification of fetal skull

Teratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetusA. Drugs:

Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing & deafnessTetracycline – staining tooth enamel, inhibit growth of long boneVitamin K – lead to hemolysis (destruction of RBC); hyperbilirubenia or jaundiceIodides – enlargement of thyroid or goiterThalidomides – Amelia – totally no extremities Pocomelia - absence of distal part of extremitiesSteroids – cleft lip or cleft palate or even abortion

Lithium – congenital malformationB. Alcohol – low birth weight (vasoconstriction on mother), fetal alcohol withdrawal syndrome

charterized by microcephalyC. Smoking – low birth weightD. Caffeine – low birth weight abruption placentaE. Cocaine – low birth weight

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TORCH (Terratogenic) Infections – virusesCHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely effect fetal growth and development. These infections are often characterized by vague, influenza like findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some cases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella, Cytomegalo virus, Herpes simples virus. T – toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meatO – others. Hepa A or infectious heap – oral/ fecal (hand washing) Hepa B, HIV – blood & body fluids SyphilisR – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10 < 1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Avoid

pregnancy for 3 months because Vaccine is terratogenic; Notify the doctorC – cytomegalo virus (CMV)H – herpes simplex virus

V. Physiological Adaptation of the Mother to PregnancyA. Systemic Changes1. Cardiovascular System – beginning the end of the 1st trimester, there is a gradual increase

blood volume of mom ( plasma blood ) 30 – 50% = 1500 cc of blood

- easy fatigability, increase heart workload, slight hypertrophy of ventricles, - epistaxis due to hyperemia of nasal membrane - palpitation due to stimulation of parasymphathetic nervous system

Physiologic Anemia – pseudo anemia of pregnant womenNormal Values Hct 32 – 42%

Hgb 10.5 – 14g/dLCriteria

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

2nd trimester – Hct should not fall below 32% Hgb should not fall below 10.5%

pathologic anemia if lowerPathogenic Anemia

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

Assessment reveals: Pallor, constipation Slowed capillary refill Concave fingernails (late sign of progressive anemia) due to chronic physiologic

hypoxia

Nursing Care:13

Nutritional instruction – kangkong, 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 hours after, 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 Vitamin C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and

hemoglobin is required from production of RBCs

Edema – occurs because of poor circulation resulting from pressure of the gravid uterus on the blood vessels of the lower extremities due venous return is constricted due to large belly.

Management: elevate / raise legs above hip level. Varicosities – pressure of uterus

Management: - use support stockings, avoid wearing knee high socks - use elastic bandage – lower to upper

Vulbar varicosities - painful, pressure on gravid uterus, Management: to relieve- position – side lying with pillow under hips or modified knee chest position Thrombophlebitis – presence of thrombus at inflamed blood vessel

- pregnant mom hyperfibrinogenemia - increase fibrinogen - increase clotting factor - thrombus formation candidate

outstanding sign – (+) Homan's sign – pain on cuff during dorsiflexion milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens Management:

1.) Complete Bed rest 2.) Never massage 3.) Assess + Homan sign once only might dislodge thrombus4.) Give anticoagulant to prevent additional clotting (thrombolytics will dilute)5.) Monitor APTT - Heparin toxicity : protamine sulfate(antidote for heparin)6.) Avoid aspirin! Might aggravate bleeding.

2. Respiratory system – common problem Shortness Of Breathing due to enlarged uterus & increase O2 demand

Management: Position: lateral expansion of lungs or side lying position. 3. Gastrointestinal – 1st trimester change

* Morning Sickness – nausea & vomiting due to increase HCG. Management: Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small frequent feeding.

o Vomiting in pregnancy – emesisgravida.o Excessive Vomiting - hyperemesisgravidarum

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Metabolic alkalosis, Fluids &Electrolytes imbalance primary medical management – Replace Fluids.

- Monitor Input & Output* Constipation – progesterone responsible for constipation.

Management:* Increase fluid intake* Increase fiber diet : fruits – papaya, pineapple, mango, watermelon, cantaloupe,

apple with skin, suha, except guava – has pectin for constipating vegetables – petchay, malunggay, swamp cabbage (kangkong) * Exercise * Mineral Oil – excretion of fat soluble vitamins* Flatulence – avoid gas forming food such as cabbage, camote* Heartburn or “ pyrosis” – reflux of stomach content to esophagus

Management:- small frequent feeding, avoid 3 full meals, avoid fatty & spicy food,

sips of milk at frequent interval, proper body mechanical - increase salivation – ptyalsim – management: mouthwash

* Hemorrhoids – pressure of gravid enlarged uterus. Management:

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

4. Urinary System frequency of urination - during 1st & 3rd trimester

management for nocturia : lateral expansion of lungs or side lying position Nocturia – urination during night time

Heat Acetic Acid test – is a test to determine the presence of albumin and protein in urine Benedict’s test – test used to determine sugar in urine5. Musculoskeletal

“Lordosis” – (Greek: lordos - bent forward; osis - condition) also known as the “pride of pregnancy”

- an abnormal anterior concavity of the lumbar part of the back; inward curvature of the spine

“Waddling Gait” – characterized by exaggerated lateral trunk movements and hip elevation which can be observed in a pregnant patient.

- awkward walking of a pregnant mother, candidate for accidental fall due to relaxation and the hormone responsible for this gait is Relaxin – responsible for softening of joints & bones; Prone to accidental falls

Management – wear flat / no heels shoes Pregnant mothers can develop “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

Note:Leg cramps during labor is due to pressure of gravid uterus

Leg cramps during pregnancy is due to decrease calcium and increase phosphorus

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

-1 pint/day or 3 - 4 servings/day.15

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

4. Vegetable – broccoli Management:

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

B. Local Changes

1. Vagina – Chadwick’s sign (color change of the vagina from pink to violet) – blue violet discoloration of vagina

Cervix – Goodell's sign (softening of the cervix) – change of consistency of cervix

Uterus – Hegar's sign (softening of the lower uterine segment) – change of consistency of isthmus (lower uterine segment)

LEUKORRHEA – whitish gray, mousy odor dischargeESTROGEN – hormone, responsible for leukorrhea (remember the second letter of Leukorrhea)OPERCULUM – mucus plug to seal out bacteria. PROGESTERONE – hormone responsible for operculum ( remember the second letter of Operculum )

Problems Related to the Change of Vaginal Environment:a. Vaginitits – caused by Trichomonas Vaginalis, a flagellated protozoa, local infection

of the vagina, due to alkaline environment of vagina of pregnant mom – acidic to alkaline change to protect bacterial growth (vaginitis)

“Flagellated protozoa – wants alkaline” Signs &Symptoms: Greenish cream colored and frothy discharge, irritatingly itchy with foul smelling odor accompanied by vaginal edema

Management Drug of Choice :FLAGYL – (Metronidazole – antiprotozoa).

Note: not to be given to pregnant mothers on her 1st trimester due to Carcinogenic effects.

1. on the 2nd and 3rd trimester – flagyl can be given2. treat dad also to prevent reinfection3. avoid alcohol, antabuse drus – has antibuse effect

VAGINAL DOUCHE – I quart of water and 1 tbsp white vinegar

b. Moniliasis or Candidiasis – caused by Candida Albicans also called Candidiasis, fungal infestation.

Signs & Symptoms: Color – white cheeselike patches adheres to the walls of vagina, extreme pruritus

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Management : antifungal – Nistatin, gentian violet, cotrimaxole, canesten

Gonorrhea - Thick purulent discharge

Vaginal warts - condifoma acuminata due to papilloma virus Management: cauterization

2. Abdominal Changes* striae gravidarium (stretch marks) due to enlarging uterus brought

by destruction of subcutaneous tissue. Nursing Care: Instruct to avoid scratching and application of oil

* umbilicus is protruding

3. Skin Changes * Chloasma/ Melasma – white or light brown pigmentation in the nose, chin, cheeks

due to increased melanocytes. * Linea Nigra – brown pinkish line running from symphisis pubis to umbilicus

4. Breast Changes – all breast changes are related to change and increase in hormones - size and color of areola & nipple change

pre colostrums present by 6 weeks, colostrums at 3rd trimester BSE (Breast self exam) - one week or 7 days after menstruation Position: supine with pillow at back

quadrant B – upper outer – common site of cancer Test to determine breast cancer: Mammography – 35 to 49 years old should submit to mammography once every 2 years

50 years old and above – once a year

5. Ovaries – rested during pregnancy; no significant changes

6. Signs & symptoms of PregnancyA. Presumptive – signs and symptoms felt and observed by the mother but does not confirm

positive diagnosis of pregnancy : SubjectiveB. Probable – signs observed by the members of health team: ObjectiveC. Positive Signs – undeniable signs confirmed by the use of instrument.

Ballotement sign of myoma* + HCG – sign of H mole - trans vaginal ultrasound. Empty balder - ultrasound – full bladder

placental grading – rating/grade 0 – immature

1 – slightly mature2 – moderately mature3 – placental maturity

What is deposited in placenta which signify maturity - there is calcium

Presumptive Probable Positive1 st Trimester

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Breast changesUrinary frequency

FatigueAmenorrheaMorning sicknessEnlarged uterus

2 nd Trimester CloasmaLinea negraIncreased skin pigmentationStriae gravidariumQuickening

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

Hegar's- change of consistency of isthmusElevated BBT – due to increased progesteronePositive HCG or (+)pregnnacy test

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

Ultrasound evidence (sonogram) full bladderTransvaginal – empty bladder

Fetal heart toneFetal movementFetal outline on x-rayFetal parts palpable

VI. Psychological Adaptation to Pregnancy (Emotional response of mom –Reva Rubin theory) First Trimester:

No tanginal signs & symptoms, surprise, ambivalence, denial Sign of mal adaptation to pregnancy

Developmental task: is to accept biological parts of pregnancyHealth Teaching: bodily changes of pregnancy, Focus: nutrition and on growth and development

Second Trimester tangible Signs & Symptoms: mother identifies fetus as a separate entity due to presence

of quickening, fantasy. Developmental task: to accept growing fetus as baby to be nurtured.Focus: growth & development of fetus.

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

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

VII. Pre-Natal Visit:Basic Considerations:1. Frequency of Visit: 1st 7 months – once a month

8 – 9 months – twice a month10 – once a week (weekly)post term - twice a week

2. Personal data: Name: for identification

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Age: to determine if the mother is in high risk (high risk < 18 & >35 yrs old) (HBMR) Home Base Mother’s Record – tool used to determine high risk pregnancySex: PSEUDOCYESIS – false pregnancy common to male COUVADE SYNDROME – psychosomatic reaction wherein the father experiences the mother goes through; the father is the one to vomits,etc – (lihi)

Religion: for their culture & beliefs with respect, non judgmental Occupation: financial condition or occupational hazards

Education Background: to determine level knowledge Address; civil status3. Diagnosis of Pregnancy

1.) urine exam to determine HCG - 6 weeks after Last Menstrual Period , 40 – 100th day but peak 60 – 70 day best to get urine exam.

2.) Elisa test – test to detect beta subunit of HCG as early as 7 – 10 days 3.) Home pregnancy kit – do it yourself

4. Baseline Data: Vital Signs especially Blood Pressure Monitor weight (increase weightt – 1 st sign preeclampsia), pattern of weight gain/loss is important

Weight Monitoring First Trimester: Normal Weight gain 1.5 – 3 lbs ( .5 – 1 lb/month )Second trimester: Normal Weight gain 10 – 12 lbs (4 lbs/month) (1 lb/wk)Third trimester: Normal Weight gain 10 – 12 lbs (4 lbs/ month) ( 1lb/wk)

Average weight gain – 20 – 25 lbsOptimal weight gain – 25 – 35 lbs

5. Obstetrical Data:nullipara – no pregnancy

a. Gravida - number of pregnancies, 2 children G2b. Para - number of viable pregnancies, 2 viable P2

Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age. Age of Viability - 20 – 24 weeks Term - 37 – 42 weeksPreterm - 20 – 37 weeksAbortion < 20 weeks

Sample Cases: a. 1 – abortion G2T0P0A1L0 1 – 2nd month pregnant G2P0 b. 1 – 40th AOG G6T1P2 A 2L4 1 – 36th AOG G6 P3 2 – miscarriage 1 – twins 35th AOG 1 – 4th month pregnant

c. 1 – 39th week19

1 – miscarriage 1 – stillbirth 33 AOG (considered as para) G4P2 1 – pregnant 3rd wk G4T1P1A1L1

d. 1 – 33rd P 1 - 41st L 1 – abortion A 1 – stillbirth 39th G6T2P2A1L5 1 - triplet 32nd G6P4 1 - 4th month pregnant

e. 1 – 39th AOG 1 – miscarriage G4P1 1 – stillbirth 33rd AOG G4T1P1A1L1 1 – 3rd month pregnant

f. 1 – 40th AOG1 – Abortion G4P21 – twin 37th AOG G4T1P1A1L31 – 4th month pregnant

g. 1 – 38th AOG 1 – Triplets 30th AOG1 – 37th AOG 1 – 32nd AOG G6P51 – Abortion 1 – Stillbirth 42nd AOG G6T3P2A1L6

c. Important Estimates:

1. Nagele’s Rule – used of determine expected date of deliveryJanuary, February and March - +9+7 whileApril to December - -3+7+1

Get Last Menstrual Period -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar M D Y +9 +7 no year

Example: a. LMP January 03, 2005 01 03 05

+ 09 07___ 10-10-05= Expected Date of Confinement October 10, 2005

b. LMP August 04, 2005

08 04 05 -03+07+01

05-11-06= EDC May 11, 2006

2. McDonald’s Rule – used to determine age of gestation IN WEEKSGet the length in cm x 7/8 = AOG in weeksFUNDIC HT X 7/8=AOG in weeks Fundic Ht X 7 = AOG in weeks

8From symphysis pubis to fundus 24 X 7 =21 wks

8

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3. Bartholomew’s Rule – used to determine age of gestation of the fetus by proper location of fundus at abdominal cavity.

3 months – above symphysis pubis5 months – level of umbilicus9 months – below xiphoid

10 months – level of 8 months due to lightening

4. Haases rule – used to determine length of the fetus in cm. Formula: 1st ½ of preg , square @ month

2nd ½ of preg, x @ month by 53mos x 3 = 9cm 4 mos x 4 = 16 cm 10 x 5 = 50 cm 1st ½ of preg5 x 5 = 25 cm

6 x 5 = 30 cm 7 x 5 = 35 cm 2nd ½ of preg

8 x 5 = 40 cm9 x 5 = 45 cm

d. Tetanus Immunizations – prevents tetanus neonatum- mother with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3TT1 – any time during pregnancyTT2 – 4 weeks after TT1 – 3 yrs protectionTT3 – 6 months after TT2 – 5 yrs protectionTT4 – 1 year after TT3 – 10 yrs protectionTT5 – year after TT4 – lifetime protectionNote: if the mother received 3 doses of DPT during childhood, she will be given TT3.

5. Physical Examination: Cephalocaudal including the teeth * Examine teeth: sign of infection

Danger signs of Pregnancy:C - chills/ fever - infection

- Cerebral disturbances ( headache – preeclampsia)A – abdominal pain ( epigastric pain) – aura/alert of impending convulsions B – boardlike abdomen – sign of abruption placenta

Increase BP – HPN(hypertension)Blurred vision – pre eclampsiaBleeding :

1st trimester - abortion, ectopic pregnancy 2nd trimester – H mole, incompetent cervix 3rd trimester – any placental anomalies such as abruption placenta, placenta previa

S – sudden gush of fluid – PROM (premature rupture of membrane) prone to infection. - swelling/edema of upper extremities (pre eclampsia)

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6. Pelvic Examination : Internal ExaminationPreparation: 1. empty bladder 2. universal precautionOn the first visit the mother will examined internally in order to determine the presence of probable signs such as Chadwick, Goodels and Hegar’s sign.Pap Smear – cytological examination to determine the presence of cancer cellsExternal OS of cervix – site for getting specimen ; composed of squamous

columnar tissue; Site for cervical cancerVaginal Speculum will be needed, to avoid contact from other organ

Result:Class I - normalClass IIA – suggestive of inflammation B - acytology but no evidence of malignancy Class III – cytology suggestive of malignancyClass IV – cytology strongly suggestive of malignancyClass V – cytology conclusive of malignancy

Stages of Cervical Cancer Stage 0 – carcinoma insitu

1 – cancer confined to cervix2 - cancer extends to vagina3 – pelvis metastasis4 – affectation to bladder & rectum

7. Leopold’s Maneuver Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of the size, and number of fetuses, position, fetal back & fetal heart tone; use palm! Warm palm.

Preparation for mothers: 1. Empty bladder2. Position of mom-supine with knee flex

(dorsal recumbent – to relax abdominal muscles) Procedure: 1st maneuver: Place patient in supine position with knees slightly flexed; Put towel under head and right hip; With both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part. In dorsal recumbent position – to relax the abdominal muscles. To determine presentation parts.

2nd Maneuver: with both hands moving down, identify the back of the fetus (to hear fetal heart sound) where the ball of the stethoscope is placed to determine Fetal Heart Tone. Get Vital

Signs (before 2nd maneuver) Pulse Rate to differentiate fundic soufflé (Fetal Heart Rate) & uterine soufflé (Maternal Heart Rate). To determine fetal back.

3rd Maneuver: using the right hand, grasp the symphysis pubis part using thumb and fingers. To determine degree of engagement. (Assess whether the presenting part is engaged in the pelvis ) Alert : if the head is engaged it will not be movable.

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

8. Assessment of Fetal Well-Being-A. Daily Fetal Movement Counting (DFMC) – begin 27 weeks

Mother - begin after meal – breakfast

a. Cardiff count to 10 method – one method currently available (1) Begin at the same time each day (usually in the morning, after breakfast) and count each fetal movement, noting how long it takes to count 10 fetal movements (FMs)(2) Expected findings – 10 movements in 1 hour or less(3) Warning signs

a.) more than 1 hour to reach 10 movements b.) less than 10 movements in 12 hours (non-reactive- fetal distress)c.) longer time to reach 10 (FMs) fetal movements than on previous daysd.) movement are becoming weaker, less vigorous* Movement alarm signals - < 3 FMs in 12 hours

(4.) Warning signs should be reported to healthcare provider immediately; often require further testing. Examples: non stress test (NST), biophysical profile (BPP)

b. Nonstress test – to determine the response of the fetal heart rate to activityIndication – pregnancies at risk for placental insufficiency

Postmaturitya.) Pregnancy Induced Hypertension (PIH), diabetesb.) Warning signs noted during DFMCc.) Maternal history of smoking, inadequate nutrition

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

Attach external noninvasive fetal monitors1. Tocotransducer over fundus to detect uterine contractions and fetal movements

(FMs) 2. Ultrasound Transducer over abdominal site where most distinct fetal heart sounds

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

if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen

if no FM after 1 hour further testing may be indicated, such as a CST

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Result:

NoncreativeNonstress Not Good

ReactiveResponsive is Real Good

Interpretation of resultsi. Reactive Result

1. Baseline FHR between 120 and 160 beats per minute2. At least two accelerations of the FHR of at least 15 beats per minute, lasting at

least 15 seconds in a 10 to 20 minutes period as a result of Fetal Movement 3. Good variability – normal irregularity of cardiac rhythm representing a balanced

interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system; noted as an uneven line on the rhythm strip.

4. result indicates a healthy fetus with an intact nervous systemii. Nonreactive Result

1. Stated criteria for a reactive result are not met2. Could be indicative of a compromised fetus.

Requires further evaluation with another nonstress test NST, biophysical profile, (BPP) or Contraction Stress Test (CST)

9. Health Teachings : do nutritional assessment a. Nutrition – daily food intake

High risk mothers: 1. Pregnant teenagers – very long compliance to health regimen. 2. Extreme weight

Underweight: malnourished like elite modelOver weight : candidate for HPN, DM

3. Mothers with low socio – economic status – refer to DSWD 4. Vegetarian mothers – decrease CHON – needs Vitamin B12/folic acid –

cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. (Decrease folic acid – spina bifida/open neural tube defect, meningocele umphalocele)

Types of Vegetarian:1. Strict Vegetarian – vegetables only ( with rigid personality)2. Lactovegetarian – vegetables/milk3. Lactoovovegetarian – vegetables/milk/egg

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

Add - 300 Pregnant – 2,500

During Lactation Add - 500

VIII. Recommended Nutrient Requirement that increases During Pregnancy24

Nutrients Requirements Food SourceCaloriesEssential to supply energy for

- increased metabolic rate- utilization of nutrients - protein sparing so it can be

used for- Growth of fetus- Development of structures

required for pregnancy including placenta, amniotic fluid, and tissue growth.

300 calories/day above the pre-pregnancy daily requirement to maintain ideal body weight and meet energy requirement to activity level

- Begin increase in second trimester

- Use weight – gain pattern as an indication of adequacy of calorie intake.

- Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy; ketosis has been associated with fetal damage.

Caloric increase should reflect - Foods of high nutrient value such

as protein, complex carbohydrates (whole grains, vegetables, fruits)

- Variety of foods representing foods sources for the nutrients requiring during pregnancy

- No more than 30% fat

Protein Essential for:

- Fetal tissue growth - Maternal tissue growth

including uterus and breasts- Development of essential

pregnancy structures- Formation of red blood cells

and plasma proteins* Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH)

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

Adolescents have a higher protein requirement then mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement

Protein increase should reflect- Lean meat, poultry, fish- Eggs, cheese, milk- Dried beans, lentils, nuts- Whole grins

* vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids

Calcium-PhosphorousEssential for

- Growth and development of fetal skeleton and tooth buds

- Maintenance of mineralization of maternal bones and teeth

- Current research is :Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension

Calcium increases of - 1200 mg/day representing an

increase of 50% above pre-pregnancy daily requirement.

- 1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous

Calcium increases should reflect:- dairy products : milk, yogurt, ice

cream, cheese, egg yolk- whole grains, tofu- green leafy vegetables - canned salmon & sardines w/

bones- Ca fortified foods such as orange

juice- Vitamin D sources: fortified milk,

margarine, egg yolk, butter, liver, seafood

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Iron Essential for

- Expansion of blood volume and red blood cells formation

- Establishment of fetal iron stores for first few months of life

30 mg/day representing a doubling of the pregnant daily requirement - Begin supplementation at 30-

mg/day in second trimester, since diet alone is unable to meet pregnancy requirement

- 60 – 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia.

- 70 mg/day of vitamin C which enhances iron absorption

- inadequate iron intake results in maternal effects – anemia depletion of iron stores, decreased energy and appetite, cardiac stress especially labor and birth

- fetal effects decreased availability of oxygen thereby affecting fetal growth

* iron deficiency anemia is the most common nutritional disorder of pregnancy.

Iron increases should reflect- liver, red meat, fish, poultry,

eggs- enriched, whole grain cereals

and breads- dark green leafy vegetables,

legumes- nuts, dried fruits- vitamin C sources: citrus fruits

& juices, strawberries, cantaloupe, broccoli or cabbage, potatoes

- iron from food sources is more readily absorbed when served with foods high in Vitamin C

Zinc Essential for * the formation of enzymes* may be important in the prevention of congenital malformation of the fetus.

15 mcg/day representing an increase of 3 mg/day over pre-pregnant daily requirements.

Zinc increases should reflect- liver, meats- shell fish- eggs, milk, cheese- whole grains, legumes, nuts

Folic Acid, Folacin, FolateEssential for

- formation of red blood cells and prevention of anemia

- DNA synthesis and cell formation; may play a role in the prevention of neutral tube defects

(spina bifida), abortion, abruption placenta

400 mcg/day representing an increase of more then 2 times the daily pre-pregnant requirement. 300mcg/day supplement for women with low folate levels or dietary deficiency4 servings of grains/day

Increases should reflect- liver, kidney, lean beef, veal- dark green leafy vegetables,

broccoli, legumes.- Whole grains, peanuts

Additional RequirementsMinerals

- iodine- Magnesium- Selenium

175 mcg/day320 mg/day65 mcg/day

Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy.

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Vitamins EThiamineRiboflavinPyridoxine ( B6)B12Niacin

10 mg/day1.5 mg/day1.6 mg/day2.2 mg/day2.2 mg day17 mg/day

Vitamin stored in body. Taking it not needed – fat soluble vitamins. Hard to excrete.

Vitamin A,D,E,K - - - No need to take it daily ( FAT SOLUBLE )

2. Sexual Activitya.) should be done in moderationb.) should be done in private placec.) that the mother should be placed in comfortable position; sidelying or mother on

topd.) it must be avoided 6 weeks prior to Expected Date of Deliverye.) avoid blowing or air during cunnilingus to prevent air embolismf.) changes in sexual desire of mom during pregnancy

a.) 1st trimester – decrease desire – due to bodily changesb.) 2nd trimester – increased desire due to increase estrogen that enhances

lubricationc.) 3rd trimester – decreased desire – due to bodily changes

Contraindication in sex: 1. vaginal spotting 1st trimester – threatened abortion 2nd trimester – placenta previa2. incompetent cervix3. preterm labor4. premature rupture of membrane – prone to infection

3. Exercise – to strengthen muscles that will be used during delivery process - it must be done in moderation principles of exercise - it must be individualized – case to case basis

* Walking – best exercise * Squatting – strengthen muscles of perineum and increase circulation to perineum. Done feet flat on floor * Tailor Sitting – same with squatting – done by placing one leg in front of other leg ( Indian seat) Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position

* Shoulder Circling Exercise – to strengthen chest muscles * Pelvic Rocking/Pelvic Tilt Exercise – to relieve low back pain & maintain good posture

- can be used to Lordosis * Arch Back – standing or kneeling. Four extremities on floor * Kegel Exercise – to strengthen pubococcygeal muscles

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

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4. Childbirth Preparation: Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.

a. Psychophysical 1. Bradley Method – discovered by Dr. Robert Bradley , advocated active participation of husband during delivery process to serve as a coach. Based on imitation of nature.

Features:1.) darkened room2.) quiet environment 3.) relaxation tech4.) closed eye & appearance of sleep

2. Grantly Dick Read Method – that fear leads to tension while tension leads to pain - to remove fear by relaxation technique and abdominal

exercises b. Psychosexual

1. Kitzinger Method – discovered by Dr. Shiela Kitzinger , that pregnancy, labor, birth & the care of the newborn is an important turning point in a woman’s life cycle - for a mother to achieve the satisfying childbirth experiences, flow with contraction rather than struggling with contraction c. Psychoprophylaxis – prevention of pain

1. Lamaze – discovered by Dr. Ferdinand Lamaze - prevention of pain in the brain

Features: discipline, conditioning & concentration with the help of the Husband 1. Conscious relaxation2. Cleansing breathe – inhaling through the nose and exhaling through the mouth3. Effleurage – gentle circular massage over abdomen to relieve pain4. Imaging – sensate focus

5. Different Methods of delivery:1.) Birthing Chair – bed convertible to chair – “semifowlers” position2.) Birthing Bed – “dorsal recumbent” position3.) Squatting Position – position that facilitates descent and relieves low back pain during labor pain4.) Leboyers Method – features: warm, quiet, darkened room, calm and comfortable environment,

room temperature, soft music. - After delivery, baby gets warm bath.

5.) Birth Under Water – warm water in a bathtub – labor & delivery – warm water, soft music.- After delivery the baby should be kept warmth, prepare for bathing

IX. Intrapartal Notes – inside Emergency RoomA. Admitting the laboring Mother:

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

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B. Basic knowledge in Intrapartum.

b. 1 Theories of the Onset of Labor1.) Uterine Stretch Theory - any hollow organ once stretched to its maximum potential will always contract & expel its content – contraction action2.) Oxytocin Theory – posterior pituitary gland releases oxytocin that produce by hypothalamus.3.) Prostaglandin Theory – stimulation of Arachidonic Acid which causes contraction to the onset of labor. – prostaglandin “male”4.) Progesterone Theory – before labor, decrease progesterone will stimulate contractions and labor5.) Theory of Aging Placenta – lifespan of placenta is 42 weeks. By 36 weeks the placenta is beginning to degenerate hence causes the uterus to contract to the onset of labor.

b.2. The 4 P’s of Labor

1. Passenger - FETUSa. Fetal head – is the largest and common presenting part comprises of ¼ of its length.

Bones – 6 fetal bones ( in all = 8 bones )S – sphenoidF – frontal - sinciputE – ethmoidO – occuputal - occiputT – temporalP – parietal 2 x

Important Measurement fetal head:1. Transverse Diameter

Biparietal – largest transverse – 9.25cm Bitemporal - 8 cm Bimastoid - 7cm smallest transverse

2. Anterior Posterior Diameter (AP ) Suboccipitobregmatic – from occiput to bregmatic ( smallest AP diameter)

- complete flexionOccipito Frontal – 12 cm partial flexionOccipito Mental – 13.5 cm hyperflexion ( largest AP )

Submentobregmatic ( face presentation )

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

head to the pelvisFontanels: 1.) Anterior fontanel – “bregma”, diamond shape, 3 x 4 cm,( > 5 cm –

hydrocephalus), Closes – 12 – 18 months after birth2.) Posterior fontanel – “lambda” – triangular shape, 1 x 1 cm. Closes – 2 – 3

months.

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2. Passageway – Vagina / Pelvis Candidate for C/S = 1.) Below 4’9” tall

2.) Below 18 years old – pelvic not yet achieve fully 3.) Underwent cephalo pelvic dislocation

a. Pelvis 4 main pelvic types1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow4. Platypelloid – flat AP diameter – narrow, transverse – wider

b. Bones of Pelvis2 hip bones – 2 innominate bones

3 Parts of 2 Innominate BonesIleum – lateral side of hips* iliac crest – flaring superior border forming prominence of hips

Ischium – inferior portion *ischial tuberosity – areas where we sit , the basis in getting external measurement of pelvis

Pubes in the anterior portion *symphysis pubis - junction between 2 pubis1 sacrum – posterior portion *sacral prominence – basis for internal measurement of pelvis1 coccyx – composed of 5 small bones compresses during vaginal delivery

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

Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm = true conjugate)

2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis.

Measurement: 11.0 cm 3. Obstetrical conjugate – smallest AP diameter.

Pelvis measuring at 10 cm or more. 4. Tuberoischi Diameter – transverse diameter of the pelvic outlet. *Ischial tuberosity – approximated with use of fist – 8 cm & above.

3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor

a. Involuntary Contractionsb. Voluntary bearing down effortsc. Characteristics: wave liked. Timing: frequency, duration, intensitye. Support System

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4. Psyche/Person – (mother) psychological stress exist when the mother is fighting the labor experience ( effective pushing )

a. Cultural Interpretationb. Preparationc. Past Experienced. Support System

b.3 Pre-eminent Signs of Labor1. Lightening – settling of presenting part into pelvic ring - 2 weeks prior to EDD

Signs &Symptoms:- shooting pain radiating to the legs- urinary frequency (plexus/bladder)- pressure at the lumbo sacral nerve

* Engagement- settling of presenting part of the fetus far enough into the pelvis to be at the level of ischial spine, a midpoint of the pelvis.2. Braxton Hicks Contractions – painless irregular contractions3. Increase Activity of the Mother- “nesting instinct” (due to epinephrine). Let the mother reserve the energy, will be used for delivery. 4. Ripening of the Cervix – comparable to butter softness5. decreased body weight – 1.5 – 3 lbs6. Bloody Show – pinkish vaginal discharge ( combinatiuon of blood & leukorrhea )7. Rupture of Membranes – rupture of water bag. Check Fetal Heart Tone

PROBLEMS:Premature Rupture of Membrane ( PROM) - do Internal Examination to check for cord prolapse

* Contraction drop in intensity even though very painful* Contraction drop in frequently * Uterus tense and/or contracting between contractions* Abdominal palpations

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

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

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Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger signs:

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

Nursing care:1. Slip cord away from presenting part2. Count pulsation of cord for Fetal Heart Tone 3. Positioning – trendelenberg or knee chest position4. Observe for fetal distress5. provide emotional support6. Prepare mother for Cesarean Section Cover cord with sterile gauze with saline solution - to prevent drying of cord so cord will remain slippery. * NOTE: five minutes cord compression can lead to irreversible brain damage such as cerebral palsy.

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

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

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

Effacement – softening & thinning of cervix. Use % in unit of measurementDilatation – widening of cervix. Unit used is cm.

b.5 Duration of LaborPrimipara – 14 hours not more than 20 hoursMultipara – 8 hours not more than 14 hours

b.6 Nursing Interventions in Each Stage of Labor2 segments of the uterus 1. upper uterine - fundus2. lower uterine – isthmus

1. First Stage: onset of true contractions to full dilation and effacement of cervix. Latent Phase: ( The mother is excited but apprehensive and can communicate) Assessment: Dilatations: 0 – 3 cm

Frequency: every 5 – 10 min Intensity : mild Nursing Care:

1. Encourage walking - to shorten the 1st stage of labor2. Encourage to void every 2 – 3 hours – full bladder inhibit uterine contractions3. Breathing – chest breathing

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Active Phase: ( Mother feels losing control of herself ) Assessment: Dilatations: 4 - 8 cm Intensity: moderate

Frequency : every 3 - 5 minutes lasting for 30 – 60 secondsNursing Care:M – medications – have medicines readyA – assessment include: vital signs, cervical dilatation and effacement, fetal monitoring, etc.D – dry lips – oral care (ointment) - dry linens, change the wet linenB – abdominal breathing

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

Assessment: Dilatations: 8 – 10 cm Frequency : every 2 - 3 minutes contractions

Durations : 45 – 90 seconds Intensity: Strong

Hyperesthesia – increase sensitivity to touch, pain all over

Nursing Care:T – tiresI – inform of progress- best way to give emotional support to the mother

R – restless, support her to do breathing technique (chest breathing)E – encourage and praiseD – discomfort – due to sacral pressure

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

Contractions:Increment/ Crescendo – beginning of contraction until it increasesAcme/ Apex – height of contractionDecrement/ Decresendo – from height of contraction until it decreases

* Pelvic ExamsEffacement: – softening & thinning of cervix.Dilatation: - widening of cervix.

a. Station – relationship of the presenting part to the ischial spine landmark used: ischial spine Floating – negative station

- 1 station = presenting part 1cm above ischial spine if (-) floating- 2 station = presenting part 2 cm above ischial spine if (-) floating- 0 station = level at ischial spine – engagement+ 1 station = below 1 cm ischial spine

+3 ,+4, +5 = crowning – occurs at 2nd stage of labor

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b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother - spine of mom and spine of fetus

Two types:b.1. Longitudinal Lie ( Parallel)

Cephalic - Vertex – when the fetus is completely flex Face Brow Poor Flexion Chin

Breech - Complete Breech – thigh rest on abdomen, while leg rest on thigh

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

b.2. Transverse Lie (Perpendicular) or Perpendicular lie. - Shoulder presentation is very rare – 1 %

c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.

Variety: Occipito/ Occiput LOA left occipito anterior (most common and favorable position)

– side of maternal pelvisLOP – left occipito posteriorLOP – most common mal position, most painfulROP – squatting pos on momROT ROA A – AnteriorL – Left – side of maternal pelvisO – Occipito – denominatorROP; LOP : most painful position; best – squatting positionLOA – most favorable positionFACE – Mentum LMA, LMT, LMP, RMA, RMT, RMPShoulder – Acromio Dorso – LADA, LADT, LADP, RADA, RADT, RADPBreech- SACRO - LSA – left sacro anterior LST, LSP, RSA, RST, RSPShoulder/acromniodorso: LADA, LADT, LADP, RADPChin / Mento: LMA, LMT, LMP, RMP, RMA, RMT, RMP In cases of breech presentation –place the stethoscope above the umbilicus

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

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Monitoring the Contractions and Fetal heart ToneSpread fingers lightly over fundus – to monitor contractions

Parts of contractions:Increment or crescendo – beginning of contractions until in increasesAcme or apex – height of contractionDecrement or decrescendo – from height of contractions until it decreasesDuration – beginning of contractions to end of same contractionInterval – from the end of 1 contraction to beginning of next contractionFrequency – beginning of 1 contraction to beginning of next contractionIntensity – the strength of contraction

Once contraction occur, the blood vessel will constrict – vasoconstriction – decrease the oxygen/circulation hence, maternal BP increases - Increase BP – while Fetal Heart Tone decreases. What will happen to the fetus? = The fetus has placental reserve for 60 secondsBest time to get BP of the mother = just after the contraction Best time to get FHT = midway of contractionPlacental reserve = 60 seconds for fetus during contractionsDuration of contractions shouldn’t > 60 secNotify MD

Health Teachings: Mom has Headache – check BP, if same BP, let mom rest. If BP increases, notify MD – preeclampsia Hungry mother – NPO - no meals GI is not functioning thus to prevent aspiration Bathe – mother can bathe after the delivery Enema – optimum rectal tube – 12 - 18 inches

a.) To cleanse bowelb.) Prevent infectionc.) Sims position/side lying

Constipated mother – slowly pulling the rectal tube* During insertion of rectal tube – contraction – clamp – after insertion – check the FHT after administration of enema Normal FHT = 120-160 bpm* Perineal Preparation – method ( 7 method )

Position : Left lateral position – to prevent supine hypotension or the supine vena caval syndrome. Pain during labor – can give Meperidine HCL ( Demerol ) – narcotic antispasmodic

( during active phase 6 – 8 cm ) Toxic Effect: respiratory depressionAntidote : Narcan ( Naloxone )

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

light headedness,

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2. Second Stage: fetal stage, complete dilation and effacement to birth. The mother will be transferre to the delivery room when:

7 – 8 cm for the multi – bring to delivery room8 – 10 cm for the primi (fully dilated) – bring to delivery roomPosition: Lithotomy by placing the mother’s legs at the same time upBulging of perineum – sure to come outBreathing – panting ( teach mother) Assist the doctor in doing episiotomy- to prevent laceration

- widen vaginal canal- shorten 2nd stage of labor.

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

Mediolateral – more bleeding & pain, hard to repair, slow to heal - use local or pudendal anesthesia. Ironing the perineum – to prevent lacerationModified Ritgens maneuver – place towel at perineum

1.) 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.

Mechanisms of labor1. Engagement 2. Descent3. Flexion4. Internal Rotation5. Extension6. External rotation7. Expulsion

Three parts of Pelvis 1. Inlet – AP diameter narrow, transverse diameter wider 2. Cavity – area of inlet and outlet 3. Outlet – AP wider, transverse narrow

Two Major Divisions of Pelvis1. True pelvis – below the pelvic inlet2. False pelvis – above the pelvic inlet; supports uterus during pregnancy

* Linea Terminales - diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis. * Episiotomy – is a surgical incision of the perineum in order to prevent laceration; to widen the vaginal canal; to shorten the second stage of labor.

Two Types of episiotomy:1. Midline – incise the midline of the perineumAdvantage: Easy to repair, fast healing, less blood loss, less postpartum discomfortDisadvantage: incision may extend to anus that leads to urethroanal fistula

( use sometimes )

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2. Mediolateral – incision is made beginning to the midline but directed laterally away from the rectum.

Advantage: less danger of complication from rectal mucosal tearDisadvantage: more bleeding (more blood vessels hit), hard to repair, slow healing, more discomfort

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

inserting 2 fingers.Nursing Care: Note the time of delivery Placing the baby below the vulva Place un dependent part Place in the abdomen of the mother – for bonding and the weight of the baby

facilitates the contraction of the uterus Clamp the baby’s cord – wait for pulsation to stop before clamping the cord since 60

– 100 cc of blood will be going to baby. Proper identification, footprinting If in case the baby is dead, show the baby to the mother for acceptance of the finality

of dead. To prevent puerperal sepsis - < 48 hours only – vaginal packNote: Bolus of Ptocin can lead to hypotension.

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

Signs of placental separation1. Fundus rises – becomes firm & globular “ Calkins sign” if not – Uterine Atony2. Lengthening of the cord – Brandt Andrew’s maneuver – slowly pulling of the cord3. Sudden gush of blood

Types of placental delivery Shultz “shiny” – begins to separate from center to edges presenting the fetal side – shiny Dunkan “dirty” – begins to separate form edges to center presenting maternal side – beefy red or dirtyNote: Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER

Hurrying of placental delivery will lead to inversion of uterus.Nursing care for placenta: Check completeness of placenta.- placenta has 15 – 28 cotyledons Check fundus (if relaxed, massage uterus – if not firm) Check blood pressure - Administer Methergine IM (Methylergonovine Maleate) as

ordered. It should be given IM, check the BP before administration. “Ergotrate derivatives.

Monitor hypertension (or give oxytocin IV) Check perineum for lacerations Assist MD in doing episiorapy , vaginal pack should be used for 48 hours to prevent

puerperal sepsis. In recovery room, should be Flat on bed

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If chilling occurs – due to dehydration – just give additional Blanket Give clear liquid – ( tea, ginger ale, clear gelatin, Gatorade) – once regulated, can be

given full liquid such as milk, ice cream, soup then soft diet to regular diet. Let mother sleep to regain energy.

4. Fourth Stage: the first 1 - 2 hours after delivery of placenta – recovery stage. a. Maternal Observations – body system stabilizes

Check the vital signs q 15 for 1 hour. 2nd hour q 30 minutes. b. Placement of the Fundus – just above the umbilicus or level of umbilicus. If

palpated on the right side – it means full bladder therefore – empty the bladder. If fundus above umbilicus, deviation of fundus

1.) Empty bladder to prevent uterine atony2.) Check lochia

c. Lochia – vaginal discharges after the delivery process Rubra – red , 1 - 3 days moderateSerosa – pink to brown, 4 – 9 days , decrease in amount, with musty odorAlba – creamy white , 10 days – 3 weeks

d. Perineum – check the perineum for : R - rednessE- edemaE - ecchymosisD – discharges A – approximation of blood loss. * Count pad & saturation

* Fully soaked pad : 30 – 40 cc weigh pad. 1 gram = 1cce. Bonding – interaction between mother and newborn

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

Complications of Labor Dystocia – difficult labor related to mechanical factor

– due to uterine inertia which means sluggishness of contraction2 Types of uterine inertia:

1.) hypertonic or primary uterine inertia - intense excessive contractions resulting to ineffective pushing Management: sedation – MD administer sedative Valium/Diazepam – muscle relaxant

2.) hypotonic – secondary uterine inertia, slow irregular contraction resulting to ineffective pushing.

Management: Administer Oxytocin Prolonged labor – resulting to:

Maternal Effect: exhaustion ( overpushing ) Fetal Effect: fetal distress, cephalohematoma or caput succedaneum

20 hours – Primi 14 hours – Multi

* normal length of labor in primi 14 – 20 hours ; Multi 10 - 14 hours Management: Check and monitor Contraction and Fetal Heart Tone

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Precipitate Labor - labor of < 3 hours. extensive lacerations to mother that leads to profuse bleeding → hypovolemic shock → hypotension, Tachypnea, Tachycardia, cold clammy skin

Note: Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing diagnosis: fluid volume deficit Position of mother: Modified Trendelenberg IV – fast drip due fluid volume deficit

Signs of Hypovolemic Shock:HypotensionTachycardiaTachypneaCold clammy skin

Inversion of the Uterus – uterus is turned inside out due to the following factors:a. hurrying pull out of the placentab. ineffective fundal pressurec. short cord

Management: MD will push uterus back inside or not hysterectomy. Uterine Rupture – Possible causes:

1.) Previous classical Cesarean Section2.) Large baby3.) Improper use of oxytocin (IV drip)

Symptoms:a.) sudden painb.) profuse bleeding c.) hypovolemic shock d.) TAHBSO

Note: Physiologic Retraction – boundary between upper and lower uterine segmentSuprapubic Depression – sign of impending rupture of the uterusBandl’s Pathologic Ring – bleeding that leads to hypovolemic to TABHBSO

Amniotic Fluid Embolism – a situation of amniotic fluid or fragments of placenta enters natural circulation resulting to embolism.

If NSD – Signs and Symptoms:a. dyspneab. chest painc. frothy sputum

Prepare: suctioningend stage: DIC disseminated intravascular coagopathy* intravascular coagopathy - bleeding to all portions of the body such as eyes, nose, etc.

Trial Labor – when the head measurement and pelvis measurement falls on the borderline.Management: Give the mother 6 hours of labor allowance: Multi: 8 – 14; primi : 14 – 20

Monitor Fetal Heart Tone and Contraction

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Pre Term Labor – labor after 24 weeks before the 37 th week Triad of Preterm Symptoms:

1. Premature contractions every 10 minutes2. Effacement of 60 – 80 %3. Dilatation of 2 - 3 cm

Home Management:1. complete bed rest2. avoid sex3. empty bladder4. drink 3 - 4 glasses of water – full bladder inhibits contractions5. consult MD if symptoms persist

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

PreTerm: Magnesium Sulfate Before delivery mother will be given :

DEXAMETHASONE –to facilitate surfactant maturation. Tocolytic (Phil) Terbuthaline (Bricanyl or Brethine) – sustained tachycardia Antidote – propranolol or inderal - beta-blocker

Note : * If cervix is open – MD – steroid dexamethsone (betamethazone) to facilitate surfactant maturation preventing Respiratory Distress Syndrome * Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia. * Term – suction at once

X. Postpartal Period 5th stage of laborafter 24hours: Normal increase WBC up to 30,000 mm3

Puerperium – covers 1st 6 wks post partumInvolution – return of reproductive organ to its non pregnant or normal state. Hyperfibrinogenia

- prone to thrombus formation- early ambulation

Principles Underlying PuerperiumI. To return to Normal and Facilitate Healing

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A. Physiologic Changes a.1. Systemic Changes

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

a.2. Genital Tracta. Cervix – cervical openingb. Vaginal and Pelvic Floorc. Uterus – return to normal 6 – 8 weeks.

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

Management: Dilatation & Curettage After - birth pain :

1. position prone2. cold compress – to prevent bleeding 3. mefenamic acid

d. Lochia - bld, wbc, deciduas, microorganism. NSD & C/S with lochia. 1. Ruba – red 1st 3 days present, musty/mousy, moderate amount2. Serosa – pink to brown 4 – 9th day, limited amount3. Alba – creamy white 10 – 21 days very decreased amount

a.3. Urinary tract: Bladder Frequency in urination after delivery (postpartum)

- urinary retention with overflow Dysuria – trigone of bladderNursing Action:

- urine collection - alternate warm & cold compress- stimulate bladder

Colon:Constipation – due to NPO, fear of bearing down; episiotomyPerineal area: – painful – episiotomy site Position: Sim’s position Cold compress for immediate pain after 24 hours, Hot sitz bath, Hot compress for immediate pain after 24 hours

Sex Act - when perineum has healed

II. Provide Emotional Support – Reva Rubia1. Psychological Responses:

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a. Taking in phase – dependent phase (1st three days) mother – passive, cannot make decisions, activity is to tell childbirth experiences.

Nursing Care: - proper hygieneb. Taking hold phase – dependent to independent phase (4 to 7 days). Mother is active,

can make decisions Focus: 1. Care of newborn

2. Insert family planting method Note: common post partum blues/ baby blues present 4 – 5 days 50 - 80 %

moms – overwhelming feeling of depression characterized by crying, despondence - inability to sleep & lack of appetite.

- let mom cry, it is therapeutic. c. Letting go – interdependent phase – 7 days & above.

Mother - redefines new roles may extend until child grows.

III. Prevent complications1. Hemorrhage – bleeding of > 500cc

CS – 600 – 800 cc normal NSD - 500 cc

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

1.) massage uterus until contracted 2.) cold compress3.) modified trendelenberg4.) IV fast drip/ oxytocin IV drip as ordered

Note: * If no effect after massage → cold compress → position → then let the newborn suck the mother’s breast in order to stimulate the pituitary to release oxytocin for the contraction of the uterus.

* Breast feeding – posterior pituitary gland will release oxytocin so uterus will contract.

* Well contracted uterus + bleeding = laceration

b. Laceration - Contracted uterus but with profuse bleedingNursing Action: assess episiotomy

assess perineum for laceration degree of laceration

Management: Episiorapy1st degree laceration – affects vaginal skin & mucus membrane.2nd degree – 1st degree + muscles of vagina3rd degree – 2nd degree + external sphincter of rectum4th degree – 3rd degree + mucus membrane of rectum

c. Hematoma - bluish / purplish discoloration of subcutaneous vagina or Perineum. May be due to : too much manipulation

large baby42

pudendal anesthesiaManagement: * Cold compress every 30 minutes with rest period of 30 minutes repeat for 24 hours

* Shave * Incision on site, scraping & suturing

DIC – Disseminated Intravascular Coagulopathy. Hypofibrinogen - failure to coagulate bleeding to any part of bodyNote: hysterectomy if with abruption placentaManagement: Blood Transfusion , cryoprecipitate or fresh frozen plasma

II. Late Postpartum hemorrhage – bleeding after 24 hours 1. Retained Placental Fragments

Management: Dilatation & Curettage or manual extraction of fragments & massaging of uterus : Except: * Placenta Accreta - unusual attachment to myometrium

* Placenta Increta - deeper attachment of placenta to myometrium * Placenta Percreta – invasion of placenta to perimetrium

2. Infection- sources of infection1.) endogenous – from within body 2.) exogenous – from outside

General signs: 1. Inflammation – calor (heat), rubor (red), dolor (pain) tumor(swelling) and loss

of function.anaerobic streptococci – most common: 1. from members health team

2. break in the chain of infection3. unhealthy sexual practice4. purulent discharges5. fever

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

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

Infection of Perineum : 2 to 3 stitches dislodged with purulent discharge coming out

Management: Removal of sutures & drainage Endometritis – inflammation of endometrial lining

Signs of infection plus abdominal tendernessPosition : Fowlers to facilitate drainage Administration of oxytocin as orderedAntibiotic – if not treated – lead to thrombophlebitis

IV. Motivate the use of Family Planning1.) determine one’s own 1ST beliefs 2.) never advice a permanent method of family planning

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3.) method of choice is an individuals choice/ own decision.4.) Informed consent

Natural Method – the only method accepted by the Catholic Church

Billings / Cervical mucus – test spinnbarkeit (estrogen) clear, watery, stretchable, elastic – long spinnbarkeit ferning – microscopic fern pattern

Basal Body Temperature – due to progesterone 13th day temp goes down before ovulation – no sex

- get before arising in bed

LAM - Lactation Amenorrhea Method - related to breast feeding Prolactin – hormone that inhibits menstruation/ovulation

Bottle Feeding – the mother will menstruate after 2 – 3 months Breastfeeding – the mother will menstruate after 4 - 6 months

Disadvantage : might get pregnant

Symptothermal – combination of BBT & cervical. Best method

Social Method:o coitus interuptus/ withdrawal - least effective method o coitus reservatus – sex without ejaculation ; common to callboy/callgirlo coitus interfemora – “ipit”o calendar method – 28 days cycle ( REGULAR )

OVULATION – count minus 14 days before next menstruation (14 days before next menstruation)Origoknause formula – IRREGULAR MENSTRUATION - get the longest and shortest cycleShortest minus 18 an longest minus 11 – unsafe periodREGULAR MENSTRUATION – 28 days minus 14 days plus 3 – 4 days before and after menstruation

monitor cycle for 1 year get short test & longest cycle from January – Decembershortest – 18longest – 11

June 26 Dec 33 - 18 -11 8 - 22 unsafe days

21 day pill- start 5th day of menstruation28 day pill- start 1st day of menstruationmissed 1 pill – take 2 next day

Physiologic Method Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary

gland production of FSH and LH which are essential for the maturation and rupture of a follicle. 99.9% effective.

Waiting time to become pregnant- 3 months. Consult OB – 6 months.

Alerts on Oral Contraceptive:

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In case a mother who is taking an oral contraceptive for almost long time plans to have a baby, mother would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal.

If a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses.

Discontinue oral contraceptive if there is signs of severe headache as this is an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.

Immediate DiscontinuationA – abdominal painC – chest painH - headacheE – eye problemsS – severe leg cramps

ACHES – signs of hypertension hence if the Blood Pressure of the mother is increased – stop the pills STAT!

if forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for two consecutive days, or more days, use another method for the rest of the cycle and the start again.

Adversed Effect: breakthrough bleeding Contraindicated: chain smoker extreme obesity Hypertension Diabetes Mellitus Thrombophlebitis or problems in clotting factors

DMPA – Depot Provera Medroxy Progesteron Acetate - depoproveda – has progesterone inhibits LH – inhibits ovulation

Depomedroxy progesterone acetate – has progesterone inhibits LH – inhibits ovulation - IM every month

- never massage injected site, it will shorten duration ( it can easily absorbed )

Norplant – has 6 matchsticks like capsule/rod dermally implanted containing progesterone.

Note : 5 years – disadvantage if keloid skin as soon as removed – can become pregnant

Mechanical and Chemical Barriers

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

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

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Health Teaching:a. Check for string daily b. Monthly checkupc. Regular pap smear

Alerts: prevents implantation inserted during menstruation and after delivery because the cervix is open most common complications: excessive menstrual flow most common problem: expulsion of the device others complications – uterine infection uterine perforation and ectopic pregnancy

Period late (pregnancy suspected) Abnormal spotting or bleedingAbdominal pain or pain with intercourseInfection (abnormal vaginal discharge)Not feeling well, fever, chillsStrings lost, shorter or longer

Condom – made up of latex inserted to erected penis or lubricated vagina- it lessen sexual satisfaction- it gives higher protection in the prevention of STD’s

Alert : female condom - give the most and highest protection against STD

Diaphragm – made up of rubberized dome shaped material inserted to the cervix preventing sperm to get to the uterus. REVERSABLE

Alert:1.) proper hygiene should be observed since it is reusable2.) check for holes before using it3.) must be kept in place for about 6 – 8 hrs after sex4.) must be refitted especially if weight change, ↑or ↓ by 15 lbs5.) spermicide – chemical Barrier

example: Foam (most effective), jellies, creamsSide effect: Toxic shock syndrome

Cervical Cap – most durable than diaphragm - no need to apply spermicide - should be kept 24 hours, no need to reapply spermicides

Contraindication: abnormal pap smear

Foams, Jellies, Creams, Spermicidal agents – to kill spermicidesFoam – most effectiveSpermicidal agents – toxic effect – Toxic Shock Syndrome

Surgical Method BTL ( Bilateral Tubal Ligation ) women ( tie, cut, cautery )

- immediate sterilization – cut – can be reversed 20% chance. ( 20 – 30 reanastamosis )

- isthmus - is the site for sterilization Health Teaching : Avoid lifting heavy object

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Vasectomy ( men ) - cut vas deferense. - not immediate sterilization- need to ejaculate 30 X for 0 sperm before considering a

safe sex Health Teaching : > 30 ejaculations before safe sex

O – zero sperm count, safeXI. High Risk Pregnancy

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

General Management1.) Complete Bed Rest2.) Avoid sex3.) Assess for bleeding

Fully saturated pad (per pad 30 – 40 cc) (weight – 1 gm =1 cc)4.) Ultrasound to determine integrity of sac5.) Signs of Hypovolemic shock6.) Save discharges – for histopathology – to determine if product of conception has been

expelled or not

First Trimester Bleeding – abortion or eptopic

A. Abortions – termination of pregnancy before age of viability (before 20 weeks)Age of viability – 20 - 24 weeksIntrauterine death or Stillbirth – after the age of viability

1. Spontaneous Abortion – also known as miscarriage Causes: 1.) chromosomal alterations

2.) blighted ovum3.) plasma germ defect

Classifications:a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is

closed; can give progesteroneb. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix

(Cervical dilation) cervix is open

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

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Incompetent cervix – abortion Surgery: a. McDonalds procedure – temporary circlage on cervix

* During delivery, circlage is removed. NSD Side Effects: infection.

b. Shirodkar – permanent surgery on cervix. CSb.4 Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) pregnancy test, scanty, dark brown bleeding Management: induced labor with oxytocin or vacuum extraction

c. Induced Abortion – therapeutic abortion to save life of mother based on the principles of twofolds effect - choose between lesser evil.

B. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity.Common site : tubal or ampularDangerous site : interstitial

Unruptured Tubal rupture

o missed period

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

o scant, dark brown, vaginal bleeding

o vague discomfort

o sudden , sharp, severe pain . Unilateral radiating to shoulder. o shoulder pain (indicative of intraperitoneal

bleeding that extends to diaphragm and phrenic nerve)

o + Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding

o syncope (fainting)

Nursing Care: Surgery: Vital Signs * Fallopian - Salphingectomy Administer IV fluids * Abdominal - Exploratory Laparotomy Monitor for vaginal bleeding * Uterus - Hysterectomy Monitor I and O

Second trimester bleeding – small and incompetent cervixC. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with

fertilization. - Progressive degeneration of chorionic villi. Recurs.- Gestational anomaly of the placenta consisting of a bunch of clear vesicles. - This neoplasm is formed form the selling of the chronic villi and lost nucleus of the

fertilized egg. - The nucleus of the sperm duplicates, producing a diploid number 46 XX- It grows & enlarges the uterus vary rapidly. ( progressive degeneration of corionic villi )

Use: methotrexate to prevent choriocarcinoma

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Assessment:Early signs - vesicles passed thru the vagina

- Hyperemesis gravidarium due to increase HCG - Fundal height - Vaginal bleeding ( scant or profuse)

Early in pregnancy - High levels of HCG- Pre eclampsia at about 12 weeks

Late signs: - hypertension before 20th week - Vesicles look like a “ snowstorm” on sonogram

- Anemia- Abdominal cramping

Serious Late complications : - hyperthyroidism- Pulmonary embolus

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

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

and assess for enlarged uterus and rising titer could indicative of choriocarcinoma

b. Avoid pregnancy for at least one year . Can have sex provided the partner will use condom for protection

Third Trimester Bleeding “Placenta Anomalies”

D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment,

sometimes covering the cervical os. - Abnormal lower implantation of placenta.

* candidate for CSTotal – complete cover of the cervical osPartial – 5%Low

Assessment:Outstanding signs and symptoms:

FRANKBRIGHT RED PLEEDING, PAINLESS BLEEDING Engagement (usually has not occurred) Fetal distress Presentation ( usually abnormal )

Complications: Internal examination Sudden fetal blood loss

Diagnostic Examination: Ultrasound

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

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Nursing Care: NPO Bed rest Prepare to induce labor if cervix is ripe Administer IV

Note Alert : Surgeon – in charge of sign consent, RN as witness MD explain to patient

E. Abruptio Placenta - it is the premature separation of the placenta form the implantation site.

- It usually occurs after the twentieth week of pregnancy. (due to use of cocaine ) – PIH Assessment:

dark red, painful bleeding board like or rigid uterus/abdomen Concealed bleeding/hemorrhage (retroplacental) Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to

contract due to hemorrhage. Severe abdominal pain Dropping coagulation factor (a potential for DIC)

Complications: Sudden fetal blood loss placenta previa & vasa previa

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

F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel

which may lead to retained placental fragments if vessel is cut.

G. Placenta Circumvalata – fetal side of placenta covered by chorion

H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta

I. Battledore Placenta – cord inserted marginally rather then centrally

J. Placenta Bipartita – placenta divides into 2 lobes

K. Placenta Tripartita – placenta divides into 3 lobes

L. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta

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

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2. Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)Hypertension after 24 wks of pregnancy, solved 6 weeks post partum.

1.) Gestational hypertension - HPN without edema & protenuria H without EP2.) Pre-eclampsia – HPN with edema & protenuria or albuminuria HEP/A

- idiopathic3.) HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

- common in primi because of increase exposure to chronic villi- multiple pregnancy- Mother low socio-economic status- Increase sensitivity to Angiotensin II

↓ main effectperipheral vascular vasospasm

↓decrease Oxygen supply → Hypertension ( main denominator )

↓ KIDNEYS

↓

↓ ↓ ↓ ↓

EYES Glomerular Degeneration Glomerular Filtration Placenta ↓ ↓ ↓ ↓

Retinal vassoconstriction increase permeability increase sodium absorption IUGR ↓ ↓ ↓ (intrauterine growth retardation)

Blurred Vision proteinuria increase water retention

↓ └ EDEMA ┘ SCOTOMA ↓

↓ ANASARCA ↓ PRE TERM LABORBLINDNESS ↓ ↓ BRAIN LUNGS ↓ ↓ LIVER – Tissue Ischemia Cerebral Edema Pulmonary Edema ↓ ↓

Liver Edema HEART ( CHF ) ↓ ↓ Epigastric Pain CONVULSION

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II. Transissional Hypertension – HPN between 20 – 24 weeks

III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.Three types of pre-eclampsia

1.) Mild preeclampsia – earliest sign of preeclampsia a.) increase wt due to edema b.) BP 140/90 c.) protenuria +1 - +2

2.) Severe preeclampsiaSigns present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110, protenuria +3 - +4

3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.Cause of pre eclampsia 1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi2.) common in multiple pre (twins) increase exposure to chorionic villi3.) common to mom with low socioeconomic status due to decrease intake of

CHONNursing care:

P – promote bed rest to decrease O2 demand, facilitate, sodium excretion, - water immersion will cause to urinate.P - prevent convulsions by nursing measures or seizure precaution

1.) maintain dimly lit room 2.) quiet calm environment2.) minimal handling – planning procedure3.) avoid jarring bed

* Right Place of the patient: across the nursing stationP- prepare the following at bedside

- tongue depressor- side rail up before the seizure- turning to side done AFTER seizure

(to facilitate drainage of secretion) - prepare suction machine- Observe only! for safely.

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

Magnesium SO4 Toxicity:1. BP decrease 2. Urine output decrease3. Resp < 124. Patella reflex absent – 1st sigh Mg SO4 toxicity.

Antidote : Ca gluconate

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

- facilitates transport of glucose to cell glucose - energizer of cell insulin – key for glucose

Diagnostic Test: 1 hour 50 grams (glucose tolerance test ) GTTNormal glucose – 80 – 120 mg/dl ( euglycemia)

< 80 – hypoclycemic > 120 - hyperglycemia

3 hours GTT of > 130 mg/dLMaternal Effect Diabetes Mellitus

1.) Hypo or hyperglycemia – 1st trimester hypo, 2nd – 3rd trim – hyperglycemic* hpl – serves as insulin antagonist

2.) Frequent infection- moniliasis/candidiasis3.) Polyhydramnios4.) Dystocia - difficult birth due to abnormalities in fetus or mother is big5.) Insulin requirement, decrease in insulin by 33 % in 1st tri; 50 % increase

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

Fetal effect 1.) hyper & hypoglycemia 2.) macrosomia – large for gestational age

– baby delivered > 4000 g or 4 kg – largest 8000 g

3.) preterm birth to prevent stillbirth4.) IUGR (Intrauterine Growth Retardation)

Newborn Effect : Diabetes Mellitus1.) hyperinsulinism 2.) hypoglycemia

normal glucose in newborn 45 – 55 mg/dLborderline – 40 mg/dLhypoglycemic < 40 mg/Dl* glucose – food for the brainManagement:

Heel stick test – get blood at heel- administer dextrose- monitor

Signs and Symptoms:- Hypoglycemia - high pitch shrill cry - tremors

3.) hypocalcemia - < 7 mg% Signs and Symptoms:

Calcemic tetanyTrousseau sign

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Management : Give calcium gluconate if decrease calciumRecommendation

Therapeutic abortionIf push through with pregnancy

1.) antibiotic therapy- to prevent sub acute bacterial endocarditis 2.) anticoagulant – heparin doesn’t cross placenta

Class I & II- good prognosis for vaginal delivery Class III & IV- poor prognosis, for vaginal delivery, not CS!

- general anesthesia- anti coagulant therapy – “Heparin” – if pregnant only- Antibiotic – to prevent subacute endocarditis

NOT lithotomy! High semi-fowlers or sidelying position during delivery (best position) No valsalva maneuver Regional anesthesia! Caudal (anesthesia of choice)Low forcep delivery due to inability to push. It will shorten 2nd stage of labor.

Heart diseaseMothers with RHD at childhood Class I – no limitation of physical activity Class II – slight limitation of physical activity. - Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II1.) sleep 10 hours a day2.) rest 30 minutes & after meal

Class III - moderate limitation of physical activity. - Ordinary activity causes discomfort and fatigue

Recommendation:1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity for even at rest there is fatigue & discomfort. Recommendation: Therapeutic abortion

XII. Intrapartal complications1. Cesarean Delivery Indications:

a. Multiple gestationb. Diabetesc. Active herpes IId. Severe toxemiae. Placenta previaf. Abruptio placentag. Prolapse of the cordh. CPD primary indicationi. Breech presentationj. Transverse lie

Procedure:a. Classical – vertical insertion. Once classical always classical b. Low segment – bikini line type – “aesthetic use” - transverse

VBAC – vaginal birth after CS – low segment

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

STERILITY irreversible

Impotency – inability to have an erection

2 types of infertility 1.) Primary – no pregnancy at all2.) Secondary – 1st pregnancy, no more next pregnancy

Test Male 1st o more practical & less complicatedo need: sperm onlyo sterile bottle container ( not plastic has chem.)o Sims Huhner test – or post coital test.

Procedure: sex 2 hours before test mother – remains supine 15 minutes after ejaculation

Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If > 15 – low sperm count

Best criteria - sperm motility for impotencyFactors: low sperm count

1.) Occupation - truck driver2.) chain smoker

Administer: clomid ( chomephine citrate) to induce spermatogenesis ↓ if not effectiveManagement: GIFT = “Gamete Intra Fallopian Transfer” for low sperm count

Implant sperm in ampula1.) Mom: anovulation – no ovulation. Due to increase prolactin

– hyperprolactinemia ( inhibit ovulation )Administer: parlodel ( Bromocryptice Mesylate) Action: antihyper prolactineuria (antiparkinsonian)Give mom clomid: action: to induce oogenesis or ovulationSide Effects: multiple pregnancy

2.) Tubal Occlusion – tubal blockage –o History of PID that has scarred tubes o Use of IUD (peritonitis)o Appendicitis (burst) & scarring

Diagnostic Test: hysterosalphingography – used to determine tubal patency with use of radiopaque material

Management: IVF – invitrofertilization (test tube baby) England 1st test tube baby

To shorten 2nd stage of labor:1.) fundal pressure2.) episiotomy3.) forcep delivery

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