Ob Maternity Notes

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Maternity nursing
care of mother from fertilization, pregnancy, labor, impregnation, fecundation. Fertilization = union of ovum & spermatozoa Pregnancy = 266 days or 280 days lunar months/ full term is 40 weeks. 1st tri. = 1-3 months or stage of organogenesis 2nd tri. = 4-6 months or stage of growth 3rd tri. = 7-9 months or stage of storage LABOR= characteristics of true & false labor 2 Types of DELIVERY NSD = normal spontaneous delivery CS = low cervical classical Gynecology = study of female reproductive organs Andrology = study of male reproductive organs 3 PERIODS OF LABOR > Antepartum = from conception to the onset of labor > Pregnancy > Intrapartum = beginning of contraction to the 1st 4 hrs. after delivery > Labor > Post-partum = period from 6 wks. After delivery > Delivery Cervical dilation = from 1 to 10 cm.
Reproductive System
FEMALE REPRODUCTIVE SYSTEM > Composed of: External Genitalia 1. Mons Veneris/ mons pubis > mound of fatty tissue over symphysis pubis that cushions & protect the bone from trauma 2. Labia Majora > longitudinal folds of pigmented skin from mons pubis-perineum > served as protection of the external genitalia, urethra, distal vagina > scrotum = homologue for male 3. Labia Minora/ Nymphae > soft, longitudinal skin folds bet. the labia majora 4. Clitoris > center of sexual arousal & orgasm, penis for male 5. Urethral Orifice > small opening of the urethra, loc. bet. the clitoris & vagina > for urination & catherization in female 6. Skenes Gland/ Paraurethral Gland > loc. Lateral to the urinary meatus & one on each > helps to lubricate the external genitalia during coitus 7. Bartholins Gland/Cowpers Gland > loc. Lateral to the vaginal opening on both sides . lubricate the external vulva during coitus 8. Hymen > membraneous tissue wringing the vaginal opening, ruptured in 1 st coitus 9. Vestibule > flattened smooth surface inside the labia 10. Perineum > area of tissue bet. the anus & vagina, site 4 episiotomy 11. Fourchette > ridge of tissue formed by the posterior joining of the 2 labia 12. Perineal Body > perineal muscle loc. At the posterior of the fourchette Some terms to remember: DYSPAREUNIA = painful intercourse EPISIOTOMY = cutting of perineum to widen the vaginal opening EPISIOGRAPHY = repair of the perineum ESCUTCHEON= pattern of pubic hair = male > diamond-shape = female > triangular-shape
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Internal Genitalia 1. Vagina > muscular, tubular, musculomembranous organ that lies bet. the rectum > depository of semen after ejaculation, part of birth canal > conveys the sperm to the cervix so sperm can meet the ovum > hollow muscular-shaped organ, located at the lower pelvis & posterior to the bladder & anterior to the rectum > site for reception, retention, implantation, nourishment to the ovum
2. Uterus
4 POSITIONS OF THE UTERUS 1. ANTEVERSION >long axis of the uterus bent forward on the long axis of the vagina, normal position, 90 2. ANTEFLEXION> long axis of the uterus bent forward on the cervix, angle of 170 3. RETROVERTED > the fundus & the uterus bent backward on the vagina 4. RETROFLEXED > body of uterus bent backward on the cervis 3 DIVISION OF THE UTERUS 1. CORPUS > uppermost portion & forms the bulk of the uterus 2. ISTHMUS > short segment bet. the body & cervix 3. CERVIX > lowest portion of the uterus, uterine outlet 3 MUSCLE LAYER OF THE UTERUS 1. ENDOMETRIUM > innermost portion of the uterus 2. MYOMETRIUM > middle portion 3. PERIMETRIUM > outermost portion MEASUREMENTS OF THE UTERUS 1. NULLIPAROUS > never given bith to a viable infant 2. MULTIPAROUS > 2 or more pregnancy 3. GRANDMULTIPARAS > more than 6 children 3. Fallopian tubes > arise from each outer cotner of the uterine body > provides nourishment for the fertilized ovum > serves as conduit pipes for spermatozoa to travel > receives the ova from the ovary
4 PARTS OF THE FALLOPIAN TUBE 1. INTERSTITIAL PORTION > part of the tube that lies w/in the uterine wall 2. ISTHMUS > next distal part of the tube, the one cut for tubal ligation 3. AMPULLA > 3rd & longest portion, fertilization of the ovum occurs here 4. INFUNDIBULAR PORTION/ INFUNDIBULUM > 4th & most distal segment of the tube 4. Ovaries > 2 female sex glands located on each side of the uterus > responsible for ovulation, secretes the hormones 2 PORTIONS OF THE OVARY 1. CORTEX >outer layer & where the ova & grafian follicles are located 2. MEDULLA > central layer containing nerves, lymphatic tissue 5. Breast / Mammary Glands A. External structure 1. Nipple > raised-pigmented area 2. Areola > pigmented skin around the nipple 3. Montgomerys tubercle > sebaceous gland of the areola B. Internal structure 1. Glandular Tissue / Parencheyna > composed of acinicells or milk-producing cells
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5. Pelvis / Pelvic Ring
2. Lactiferous ducts/ sinuses > form passageway from the lobe to the breast 3. Fibrous tissue > coopers ligament, provide support to the mammary glands 4. Adipose tissue /stroma > provide relative size & consistency of the breast > bony ring in the lower portion of the trunk, serves support & protect the reproductive & pelvic organ
4 UNITED BONES OF THE PELVIS 1. 2 innominate flaring bones innominate bone divided into 3 parts 1. ILIUM >upper lateral portion 2. ISCHIUM > interior portion 3. PUBIS > anterior portion 2. COCYX > below the sacrum, composed of fine small bones 3. SACRUM > upper posterior portion of the pelvic ring 4 TYPES OF PELVIS 1. GYNECOID > typical female pelvis w/ rounded outlet 2. ANDROID > typical male pelvis w/ heart-shaped inlet 3. ANTHROPOID > apelike pelvic w/ oval inlet 4. PLATYPELLOID > flat-female type pf pelvis w/ transverse oval Terms to remember: LIBIDO = sexual drive ORGASM = highest peak/point of sexual excitement HYSTERECTOMY = surgical removal of the uterus OXYTOCIN = aids to constrict milk gland cells GYNECOMASTIA = increase in male breast MASTITIS = inflammation of the breast MAMMOGRAPHY = genography of the mammary gland/breast examination MASTECTOMY = surgical removal /excision of the breast BREAST ENGORGEMENT = usually occurs 2-5 days after PELVIMETRY = measuring of the internal & external pelvis PERINEOGRAPHY = repair of the vagina 2 ISCHIAL TUBEROSITY = portion of the bones on w/c the person eats ISCHIAL SPINE = small projection that extends from the lateral aspect to the pelvic cavity SYMPHYSIS PUBIS = junction of the innominate bones at the front of the pelvis REPRODUCTIVE CYCLE MESTRUATION >complex cycle of events that occur in the hypothalamus, pituitary gland, uterine endometrium, cervix & ovaries MENARCHE > menstruation of a woman, 9-17 yrs old MENOPAUSE >essation of menstrual flow cycles, 40-55 yrs. Old MENSTRUAL CYCLE >eproductive cycle, periodic uterine bleeding in response to cyclic hormonal changes (estrogern, progesterone (FSH, LH) 28 DAYS >average lenth of menstrual cycle 2-7 DAYS/3-5 > average flow of menstrual cycle 30-80 ml. Of blood > average amount of menstruation 11 mg. > iron loss during menstruation
PHYSIOLOGY OF MENSTRUATION: 1. ANTERIOR PITUITARY GLAND = secretes the FSH & LH hormones FSH = for maturation of the ovum & follicle stimulating hormones LH = for release of mature eggs & responsible for ovulation
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2. HYPOTHALAMUS 3. OVARY 4. UTERUS FERTILITY PERIOD
= stimulates the m. cycle, gives signals
> last for about 9 days > 7 days = before ovulation period > 1 day = during ovulation period > 1 day = day after ovulation period > maturation & release of the egg from the ovary, occurs on the day 14 > 1st day of the last normal menstrual cycle > get LMP & lenth of cycle then less 14 days > 1ST Phase: Proliferative CNS response: 5th-14th day > 2nd Phase: Secretory/ Ovarian response: 14th-16th day > 3rd Phase: Ischemic/ Endometrial response: > 4th Phase: Menses/ Cervix & Cervical mucuos
OVULATION LMP
COMPUTE FOR OVULATION DATE PHASES OF MENSTRUAL CYCLE
SECONDARY SEX CHARACTERISTICS IN FEMALE ( IN ORDER) > GROWTH SPURT > INCREASE IN DIAMETER OF THE PELVIS > BREAST DEVT. = THELARCHE > GROWTH OF PUBIC HAIR = ANDRENARCHE > ONSET OF MENSTRUATION = MENARCHE > GROWTH OF AXILLARY HAIR = ADRENARCHE > VAGINAL SECRETION SECONDARY SEX CHARACTERISTICS IN MALE > INCREASE IN WEIGHT > GROWTH OF TESTES > GROWTH OF FACES, AXILLARY HAIR > VOICE CHANGES > PENILE GROWTH > INCREASE IN HEIGHT > SPERM PRODUCTION = SPERMATOGENESIS
MALE REPRODUCTIVE SYSTEM External structure 1. PENIS 2. GLANS 3. PREPUCE 4. SCROTUM Internal Organ > male organ of copulation, 4-7 inches > bulging sensitive ridge tissue of the penis, most sensitive > retractable casing of the skin, removed in circumcision > rugated skin covered muscular pouch suspended in the perineum
1. TESTES > 2 ovoid glands that lies in the perineum, diff. In size 2. EPIDIDYMIS > seminifirous tubule of each testes, 2 feet long > reservoir for sperm storage & maturation > responsible for absorption of seminal fluid > responsible for the addition of substances to the s. fluid 3. VAS DEFERENS > carries sperm from the epididymis thru the inguinal canal 4. SEMINAL VESICLE> secretes a viscos portion of semen w/c has a high content of basic sugar, protein & alkaline in ph 5. EJACULATORY DUCT > 2 ducts passed to the prostate gland, joined the
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seminal vesicle w/ the urethra > drain seminal fluid into the prostatic urethra 6. PROSTATE GLAND > base of the urethra & ejaculatory duct > secretes clear fluid w/ a slightly ph FX>production of the thin, milky fluid containing citric acid & acid phosphate 7. URETHRA > passageway of the urine & semen, 8 cm. Long 8. COWPERS GLAND/B.G. > helps to lubricate the urethra & ensures safe passage of the spermatozoa, homologue skenes gland 9. URETHRAL MEATUS > the urine & semen passed out > used for catherization purposes Terms to remember: SEMEN > thick, whitish fluid ejaculated by man during orgasm > composed of spermatozoa, fructose, protein > 2.5-3.5 ml. ASPERMIA > absence of sperm OLIGOSPERMIA >fewer than 20 million of sperm/ml 12-20 days > for spermatozoa to travel 64-75 days > to reach maturity VASECTOMY > surgical removal of the vas deferens HCG > human chorionic gonadotrophin PROSTATECTOMY > surgical removal of the prostate gland
COMPUTE FOR AGE OF GESTATION (AOG) AOG > period bet. conception & birth of a baby > time measured from conception to the current date & measured in weeks. > get LMP & date of prenatal visit, divided by 7 COMPUTE FOR EDD,EDC NAGELES RULE
> subtract 3 months & add 7 days, get only the LMP
GRAVIDA & PARA SYSTEM

GRAVIDA NULLIGRAVIDA PRIMIGRAVIDA MULTIGRAVIDA PARITY >the # of pregnancies including the present & abortion =woman who has never been pregnant =woman w/ first pregnancy = woman w/ 2nd pregnancy or more > refers to past pregnancies (not the # of babies) that reached viability whether or not born alive (abortion & miscarriages not included) NULLIPARA = woman who has not carried a pregnancy to viability PRIMIPARA = woman who carried one pregnancy to viability MULTIPARA = woman who had 2 or more pregnancy that reached viability GRANDMULTIPARA= woman who has had 6 or more viable pregnancies
GTPALM SYSTEM: G TERM PRETERM ABORTION LIVING > the # of pregnancies including the present > the # of full term birth born @ 38-40 wks. Gestation > the # of preterm birth born @ 20-37 wks. Gestation > the 3 of abortion > the # of living children
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MULTIPLE 20 wks. Below 20-37 wks. 38-40 wks. 42 wks. Up
> the # of multiple pregnancy > considered abortion > preterm > term > post-term
SEXUALITY
SEXUALITY > multidimensional phenomenom that includes feelings, attitudes & actions. Both biologic & cultural components, gives direction to a persons physical,emotional,social & intellectual responses throughout life.
3 DEVELOPMENTAL TASKS: 1. BIOLOGIC GENDER 2. GENDER/ SEXUAL IDENTITY 3. GENDER ROLE >term used to denote chromosomal sexual devt. > inner sense a person has of being male or female, or sense of masculinity & femininity > is the behaviour a person coveys about being male or female
4 TYPES OF SEXUAL ORIENTATION: >a person who finds sexual fulfillment with a member of the opposite sex. ( male-female) 2. HOMOSEXUALITY > one who finds sexual fulfillment w/ the same sex > male-male, female-female 3. BISEXUAL > the one who achieve sexual satisfaction from both homosexual & heterosexual relationship 4. TRANSSEXUAL > an individual who although of one biologic gender, feels as if he or she should be of the opposite gender. Goes for sex change 10 TYPES OF SEXUAL EXPRESSION: 1. CELIBACY > abstinence from sexual activity 2. MASTURBATION > self-stimulation for erotic pleasure, offers sexual release 3. EROTIC STIMULATION > the use of visual materials (magazines) for arousal 4. FETISHISM > the sexual arousal by the use of certain objects/situations 5. TRANSVESTISM > an individual who dresses to take the role of the opposite sex 6. VOYEURISM >sexual arousal by looking at anothers body 7. SADOMASOCHISM > involves inflicting pain (sadism), or receiving pain (masochism) to achieve sexual satisfaction. 8. EXHIBITIONISM >revealing genitalia in public 9. PEDOPHILES > individuals interested in sexual encounters w/ children 10. BESTIALITY > brutal & inhuman sexual activity, ex. To animals DISORDERS OF SEXUAL FUNCTIONING: PRIMARY SEXUAL DYSFUNCTION 1. ERECTILE DYSFUNCTION> the inability to produce or maintain an erection long enough for vaginal penetration or partner satisfaction 2. PREMATURE EJACULATION> ejaculation before penile-vaginal contact 3. FAILURE TO ACHIEVE ORGASM> can be due to poor sexual technique, concentrating too hard on achievement or possible (-) attitudes towards sexual relationships 1. HETEROSEXUALITY
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4. VAGINISMUS
> involuntary contraction of the muscles at the outlet of the vagina when coitus is attempted. 5. DYSPAREUNIA > pain during coitus ( those w/ cervicitis) 6. INHIBITED SEXUAL PLEASURE >lack of desire for sexual relations, maybe a concern of young or middle age adults SECONDARY DYSFUNCTION 1. Chronic diseases such as peptic ulcers or CPD that cause frequent pain may interfere w/ the overall being & interest in sexual activity
BEGINNING OF PREGNANCY
BASIC GENETIC COMPONENTS 1.CHROMOSOMES > elements w/in the cell nucleus carrying genes & composed of DNA & protein DNA > nucleic acid that carries genetic information into the cells DIPLOID > 46 chromosomes (23 pairs =22 somatic cells, 1 sex cell) HAPLOID > 23 chromosomes 2. GENES >factors on a chromosome responsible for hereditary characteristics of offspring. > small segments of DNA contained in the chromosomes, some recessive, some dominant, some sex-linked Dominant Recessive Sex-linked 3. ALLELES > dwarfism > sickle-cell anemia, deafness recessive > hemophilia A & B, color blindness
> pair of genes, 2 genes for every human trait (1 from ovum, 1from sperm) 4. PHENOTYPE> an individuals physical appearance, determined by the alleles 5. GENOTYPE > refers to individuals actual gene composition XX XY >female > male
SEX DETERMINATION
> established at the time of fertilization by the male sex chromosome.
MATURE OVUM > contains haploid # of 23 chromosomes, one is always an X MATURE SPERMATOZOAN> contains haploid # of 23 chromosomes, either an X or Y
FERTILIZATION
> union of the ovum & spermatozoan >life span of 24 hours after ovulation or 1 day > life span of 48-72 hours or 2-3 days after ejaculation into the vagina ZONA PELLUCIDA & CORONA RADIATA> serves as protection of the ovum from injuries 3 STAGES BEFORE FERTILIZATION 1. ACROSOME FERTILIZATION >release of proteolytic enzymes that enable the sperm to digest the cumulus cells & penetrate the zona pellucida. > process that enables the sperm to bind to the ovum. OVUM SPERMATOZOAN
2. CAPACITATION
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> the final process that sperm must undergo to be ready for fertilization * After one sperm has entered, changes occur w/in the zona pellucida that prevent other sperm from entering.
CONCEPTION
(FERTILIZATION)
IMPLANTATION (NIDATION)
> usually occurs w/in 12-24 hrs. after ovulation, in the outer third (ampullar region) of the fallopian tube. >usually occurs 8-10 days after fertilization > about day 20 of a 28-day menstrual cycle
EARLY HUMAN DEVELOPMENT: IN ORDER 1. OVUM 2. ZYGOTE 3. BLASTOMERES 4. MORULA 5. BLASTOCYCST 6. EMBRYO 7. FETUS 8. CONCEPTUS >from ovulation to fertilization = 12-24 hrs. > fertilization to implantation > mitotic division of the zygote > when there is a solid ball of cells formed by 16-50 blastomeres > when the morula reaches the lining of the uterus or endometrium on the 4th-5th day > from implantation to 5-8 wks. > from 8 wks. Until term > when there is developing embryo & fetus & placental structures thru pregnancy, from all the products of conception
STAGES OF PRENATAL/ FETAL DEVELOPMENT: PRE-EMBRYONIC STAGE > period until primary villi appeared, usually 1214 days after conception
3 GERM LAYER OF THE EMBRYO: 1. ECTODERM > outermost portion/layer of the embryo Body portions formed: > CNS > PNS > SKIN, HAIR,NAILS > SEBACIOUS GLANDS > SENSE ORGANS > MUCUOS MEMBRANES OF THE ANUS, MOUTH, NOSE > TOOTH ENAMEL > MAMMARY GLANDS 2. MESODERM > middle portion/ layer of the embryo Body portions formed: > SUPPORTING STRUCTURES OF THE BODY >(CONNECTIVE TISSUE, BONES, CARTILAGE, MUSCLES, > LIGAMENTS & TENDONS ) > DENTIN OF TEETH > UPPER PRTION OF THE URINARY SYSTEM (KIDNEYS & URETERS) > REPRODUCTIVE SYSTEM > HEART > CIRCULATORY SYSTEM > BLOOD CELLS > LYMPH VESSELS
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3. ENDODERM/ENTODERM > innermost portion of the embryo Body portions formed: > LINING OF PERICARDIAL, PLEURA & PERITONEAL CAVITIES > LINING OF THE GASTROINTESTINAL TRACT, RESPIRATORY TRACT, TONSILS, PARATHYROID, THYROID, THYMUS GLANDS > LOWER URINARY SYSTEM (BLADDER & URETHRA) EMBRYONIC STAGE FETAL STAGE > period from end of ovum stage until measurement reaches 3 cm or 54-56 days > from week 9 to birth
SUMMARY OF FETAL DEVELOPMENT: 1. 1ST TRIMESTER 2. 2nd TRIMESTER 3. 3rd TRIMESTER >rapid growth, susceptible to teratogens > less danger from teratogens, FHB heard thru stethoscope > iron stored
Terms to remember: QUICKENING > first fetal movement felt by the mother > 18 wks. For multipara > 20 wks. For nullipara VERNIX CASEOSA > a cream-cheese like structure covering the fetal skin > for lubrication & prevent the skin from macerating LANUGO > translucent, soft downy hair charaterstics of a new born
EMBRYONIC & FETAL SUPPORT STRUCTURES 1. CORPUS LUTEUM > supplies most of the estrogen & progesterone in the 1st 2 months before placenta is fully developed > the one that functions prior to the placenta > optimal site for blastocyst implantation > specialized, highly magnified endometrium of pregnancy
2. DECIDUA
3 SEPARATE AREAS OF DECIDUA: 1. DECIDUA BASALIS > portion lying directly under the blastocyst & establishes comm.w/ the maternal blood vessels 2. DECIDUA CAPSULARIS> portion covering the blastocyst 3. DECIDUA VERA > remaining portion of the uterine lining 3. CHORIONIC VILLI >becomes the placenta, the throphoblastic layer of cells of the blastocyst 2 LAYERS OF CHORIONIC VILLI: 1. SYNCYTIOTROPHOBLAST/ SYNCYTIAL LAYER > outer layer of the chorionic villi, is instrumental in the production of various placental hormones 2. CYTOTROPHOBLAST / LANGHANs LAYER > inner layer of the chrionic villi & protects the growing embryo & fetus from certain infectious organisms, appear at day 12 of pregnancy 4. PLACENTA > soul of pregnancy, transmits nutrients & oxygen to the fetus & removes waste & CO2 by diffusion
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> begins to function by the 4th week of gestation, by 14th week, it is complete & independently functioning organ HORMONES OF PREGNANCY 1. ESTROGEN (PRIMARILY ESTRIOL) > stimulates the growth of muscle & induces the synthesis of receptors of progesterone > stimulates uterine growth, breast devt, > enhances growth of all organs > indicates placental function, fetal maturity 2. PROGESTERONE > helps for development of deciduas > stimulates growth of acinicells for lactation > promotes thickening & increased viscosity of cervical mucous, relaxes uterine smooth muscle 3. HUMAN CHORIONIC GONADOTROPIN (HCG) >1st indicator of + pregnancy test & detected in the urine (14 days) & plasma by day 8 > stimulates the male testes, responsible for maintaining the corpus luteum 4. HUMAN PLACENTAL LACTOGEN/ HUMAN CHORIONIC SOM. > facilitates glucose transport across the placenta > stimulates breast devt. to prepare for lactogen > antagonizes insulin 5. PROLACTIN (milk production) > increased concentration at 8 months > suppressed by estrogen & progesterone > increased level after placenta is delivered > ensures lactation 6. OXYTOCIN (milk ejection) > causes uterus to contract when oxytocin levels exceed those of estrogen & progesterone 7. MELANOTROPIN > responsible for chloasama ( mask of pregnancy), linea nigra, deeper color of the areola & genitalia 8. FOLLICLE-STIMULATING HORMONE (FSH) > no ovulation during pregnancy Terms to remember: DECIDUALIZATION > process of deciduas, pregnancy outside the uterine cavity DIFUSION > oxygen diffuses from maternal blood across the placental membrane into the fetal Blood SIGNS & SYMPTOMS OF PREGNANCY 1. PRESUMPTIVE SIGNS (SUBJECTIVE SIGNS) > those that are least indicative of pregnancy > experienced by the mother but cannot be documented by the examiner 2. PROBABLE SIGN ( OBJECTIVE SIGNS) > experienced by the mother that can be documented by the examiner, more reliable than presumptive signs 3. POSITIVE SIGNS (ONLY 3) > are positive or true diagnostics findings of pregnancy PRESUMPTIVE FINDINGS: 2 WKS. >feelings of tenderness, fullness, tingling, enlargement & darkening if the areola 2 WKS. >AMENORRHEA >absence of menstruation 2 WKS. > NAUSEA, VOMITING >nausea, vomiting on arising 3 WKS > FREQUENT URINATION > sense of having to void frequently 12 WKS > FATIGUE > general feeling of tiredness 12 WKS. > UTERINE ENLARGEMENT> uterus can be palpated over the symphysis pubis 18 WKS. > QUICKENING > fetal movement felt by the mother
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>BREAST CHANGES
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22 WKS. 24 WKS. 24 WKS.
> LINEA NIGRA > MELASMA > STRIAE GRAVIDARUM
> line of dark pigment on the abdomen > dark pigment on the face > red streaks on the abdomen
PROBABLE FINDINGS: 1 WK. > SERUM LABORATORY TESTS > test of blood serum reveal the presence of HCG
6 WKS. 6 WKS. 6 WKS. 6 WKS. 6 WKS. 16 WKS.
20 WKS. 20 WKS.
> CHADWICKS SIGN > color change of the vagina from pink to violet > GOODELLS SIGN > softening of the cervix > HEGARS SIGN > softening of the lower uterine segment > SONOGRAPHIC EVIDENCE > characteristic ring is evident OF GESTATIONAL SAC > PISKACEK SIGN > enlargement & softening of the uterus > BALLOTEMENT > when lower uterine segment is tapped on a bimanual examination, the fetus can be felt to rise against abdominal wall > BRAXTON HICKS SIGN > periodic uterine tightening occurs > FETAL OUTLINE FELT > fetal outline can be palpated thru the abdomen BY THE EXAMINER
POSITIVE FINDINGS: 8 WKS. 8-12 WKS. 20 WKS. > SONOGRAPHIC EVIDENCE > fetal outline can be seen & measured by OF FETAL OUTLINE sonogram > FETAL HEART AUDIBLE > Doppler ultrasound revelals heart beat > FETAL MOVEMENT FELT > fetal movement can be palpated thru the BY EXAMINER abdomen
FETAL MEMBRANES, AMNIOTIC FLUID & UMBILICAL CORD FETAL MEMBRANES: 2 TYPES 1. CHORIONIC MEMBRANES ( CHORION) > outermost fetal membrane of the bag of water > develops from the trophoblast & contains the c.v. on its surface 2. AMNIOTIC MEMBRANE (AMNION) > innermost fetal membrane of the bag of water > develop from interior cells of the blastocyst > covers the u. cord & covers the chorionon fetal surface of the placenta AMNIOTIC FLUID >cushions the fetus, allows freedom of movement & permits skeletal development > helps maintain body temp., acts as a source of oral fluid as well as waste repository, serves as lubrication bet. fetus & membranes. 800-1,200 ml. = average amount HYDRAMNIOS/ POLYHYDRAMNIOS> excessive amniotic fluid (more than 2,000 ml) OLIGOHYDRAMNIOS > reduction of amniotic fluid ( less than 300 ml) UMBILICAL CORD /FUNIS > extends from fetus to the center of placenta > formed from the amnion & chorion & ppprovides a circulatory connecting the embryo to the chorionic
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villi, spiraling or twisting > transports O2 & nutrients to the fetus from placenta > the babys u-cord will fall off 7-10 days after delivery > 50-53 cm (18-21 inches) long and 1-2 cm (1/2 inch) in diameter > 32 cm considered abnormally short Contains 2 arteries & 1 vein: Arteries > carry deoxygenated blood & fetal waste from the fetus to placental villi Vein > carries oxygen & nutrition from placental villi to fetus WHARTONS JELLY > protects umbilical vessels from pressure, cord kinking & interference w/ fetal-placental circulation > the 3 vessels of umbilical cord are characterized by spiraling or twisting (dextral direction) - serves to alternate from snarling What to watch out for: If the cord doesnt fall off in 2 weeks time The cord smells bad There is drainage from the bottom of the cord There is a red area on the skin around the bottom of the cord If the newborn develops fever or app4ears unwell If the navel and surrounding area becomes swollen or red If pus appears at the base of the stump
PREGNANCY
PREGNANCY >normal physiologic process , 280 days/ 142 weeks >9 calendar months / 10 lunar months Subsequent prenatal visit assessment: 1st 28 wks. / 7 months. > every 4 weeks From 7-9 months/ 28-36 wks.> every 2 weeks until delivery PATTERN OF WEIGHT GAIN: 1.5 lbs. > 1st 10 weeks 9 lbs. > 20 weeks 19 lbs. > 30 weeks 27.5 lbs. > 40 weeks 24-30 lbs. > average weight gain during pregnancy Physiologic changes . characterized as local changes and systemic changes Local changes / reproductive system changes > vagina, uterus, cervix, ovaries, breast Breast > first physiologic changes Systemic changes > affecting the entire body REPRODUCTIVE SYSTEM CHANGES A. VAGINAL CHANGES 1. CHADWICKS SIGN > due to increase vascularization of the vagina causes a blue-purple discoloration 2. VAGINAL SECRETIONS > fall from a ph of over 7 (alkaline) to 4-5 ph (acidic) 3. CANDIDA ALBICANS > a species of yeast-like fungi, manifested by itching, burning sensation in addition to cheese-like discharge
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4. THRUSH OR ORAL MONILIA in newborn
> candidal infection
B.UTERUS CHANGES >hegars sign, ballottement, Braxton hicks, amenorrhea, weight increases from 50 1,000 grams FUNDUS HEIGHT AT WEEKS OF PREGNANCY: 12TH WKS. OF PREGNANCY > under the abdominal wall just above the symphysis pubis 16th WKS. OF PREGNANCY> palpated bet. the symphysis pubis & umbilicus 20-22 WKS. OF PREGNANCY> palpated & reach the level of the umbilicus 36 WKS. OF PREGNANCY > to be palpated & touch the xiphoid process C. CERVICAL CHANGES 1. OPERCULUM > mucous plug before the onset of labor > seals the endocervical canal & prevents the contamination of the uterus by bacteria
2. GOODELLS SIGN 3. BECOMES MORE VASCULAR & EDEMATUS D. OVARIAN CHANGES > ovulation stops > corpus luteum takes place 2 months > placenta take over as the chief provider of progesterone and estrogen and to provide for the growing fetus
E. BREAST CHANGES > Montgomerys tubercles > colostrum may leak of be expressed from the breast as early as 16th week of pregnancy > may experience feeling of fullness, tingling sensation & tenderness > areola & nipples darken in color
STRUCTURE OF THE FETAL SKULL

Fetal skull is the largest anatomical pary of the fetus through the birth canal, usually if the head can pass, the rest of the body can be delivered Consists of 7 bones 2 frontal presenting part 2 parietal presenting part 2 temporal not a presenting part 1 occipital Suture lines of the skull 1. Sagittal suture a membranous interspace, joins the 2 parietal bones of the skull 2. Coronal suture is the line of the junction of the frontal bones and the 2 parietal bones 3. Lambdoidal suture is the line of junction of the occipital bone and the 2 parietal bones Closed anterior fontanelle (diamond) 12-18 months posterior fontanelle (triangular) Fontanelles 1. Anterior fontanelle (Bregma) - is at the junction of the 2 parietal bones and the two fused frontal bones - diamond-shaped - normally closes at age 12-18 months measures 2 cm to 3 cm and 3 cm to 4 cm in length 2. Posterior fontanelle - is at the junction of the parietal bones, and occipital bones triangular-shaped - normally closes by age of 2 months
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- measures approximately 2 cm across its widest part FETAL PRESENTATION - denotes the body parts that will first contact the cervix or deliver first - determined by fetal lie, or the degree of flexion or the attitude or habitus 3 Types of fetal presentation 1. Cephalic presentation means that the head is the body part that 1st contacts the cervix and it is the most frequent type of presentation 4 Types of Cephalic Presentation 1. Vertex head is sharply flexed, making the parietal bones or the space between the fontanelles and the presenting part 2. Brow head moderately flexed, the presenting part is the brow 3. face head is extended, presenting part is the face 4. sinciput the head is completely hyperextended, the head is nor flexed, the presenting part is the sinciput 2. Breech presentation - means either the buttocks or feet are the first body parts to contact the cervix 3 Types of breech presentation 1. Complete thighs tightly flexed on the abdomen, the presenting part are both the buttocks and tightly flexed feet 2. Frank the hips are flexed but the knees are extended to rest on the chest, the presenting part is the buttocks alone. 3. Footling (incomplete breech presentation) neither the thigh nor the lower legs are flexed, presenting part is the foot - single footling breech one foot is present - double footling breech both feet is present 3. Shoulder presentation - fetus is lying horizontally in the pelvis so that its long axis is perpendicular to that of the mother, presenting part is the shoulder acromion process iliac crest, elbow, hand
ATTITUDE / DEGREE OF FLEXION - term used to describe the degree of flexion the fetus assumes or the relation of fetal parts to each other Four types 1. Complete flexion (normal fetal position) - the spinal column is bowed forward, the head is flexed forward, the chin touches the sternum, arms are flexed and folded on the chest, thighs are flexed on the abdomen and the calves of the legs are pressed against the posterior aspect of the thighs 2. Moderate flexion (military position) sinciput - the chin is not touching the chest (frank, sinciput) 3. Partial extension (brow presentation) - presents the brow of the head to the birth canal 4. Complete extension (face presentation/incomplete footling) - presents the face and the back is arched, the neck is entended FETAL LIE - is the relationship between the long axis of the featl body and the long axis of the womans body 1. Transverse lie fetus is lying horizonally. Ex. Shoulder presentation 2. Longitudinal lie fetus is lying vertically POSITION - is the relationship of the fetal presenting part to the maternal bony pelvis - is determined by locating the presenting part in relation to the pelvis
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Means of assessing fetal position 1. Leopolds maneuver method of palpating the maternal abdomen to determine information about the fetus such as presentation, engagement and rough estimate of fetal size 2. Vaginal examination 3. Auscultation of FHT 4. Sonography diagnostic tool that is helpful in assessing a fetus for general size and structural disorders or internal organs and limbs 6 Most Common Fetal Positions 1. LOP FHT heard in LLQ 2. LOT LLQ 3. LOA LLQ 4. ROP RLQ 5. ROT RLQ 6. ROA RLQ Most Common Fetal Position 1. Left occipito anterior (LOA) - occiput of the fetus points to the left side of the maternal pelvis and towards front, face down 2. left occipito posterior (LOP) - occiput of the fetus points to the left side of the maternal pelvis and towards rear or face up 3. Left occipito transverse - occipot of the fetus is parallel to the left maternal pelvis 4. Right occipito anterior - occiput of the fetus points to the right side of the maternal pelvis, towards front face down 5. right occipito posterior - occiput of the fetus points to the right side of the maternal pelvis and toward the rear or face up 6. Right occipito transverse (ROT) - occiput of the fetus is parallel to the right maternal pelvis Position measured in numeric terms: Station- is the relationship of the presenting part of the fetus to the level of the ischial spines 0 station presenting part is at the level of the ischial spines (engagement) -1 to 4 cm presenting part is above the ischial spines +1 to +4 cm presenting part is below the ischial spines +3 to +4 cm presenting part is at the perineum (crowning) Other terms to denote station: High presenting part not engaged Floating presenting part freely moveable in inlet Dipping entering pelvis Fixed no lnger moveable in inlet but not engaged Engaged bipareital plane is passed through the pelvic inlet Engagement - refer to the settling of the presenting part of the fetus (midpoint of the pelvis) - largest diameter / widest diameter of the presenting part - usually take place two weeks before labor - maybe assessed by Leopolds maneuver, vaginal / rectal examination / cervical examination CERVICAL CHANGES: Two major signs a. Effacement shortening and thinning of the cervical canal b. Dilatation is the enlargement of the cervical cananl - there is an increase in the amount of vaginal secretions
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3 PHASES OF CONTRACTIONS 1. Increment when the intensity of the contractions increase 2. Acme when the contraction is at its strongest peak 3. Decrement when the intensity of the contraction decreases Assesment of uterine contraction (power) 1. frequency time from beginning of one contraction to the beginning of the next contraction 2. Duration time from the beginning of contraction to its relaxation 3. Strength (Intensity) resistance to indentation Contractions L 20-24 sec 3-5 minutes A 40 60 sec T 60 90 sec 2-3 minutes Labor rhythmic cervical contractions ! Effacement ! Dilatation ! Oxytocin ! Labor normally begins 2 weeks prior or after EDC Average normal labor 12 14 hours Subsequent labor 6-8 hours shorter Parturient a woman in labor Puerpera woman who has just given birth Puerperium post-partum client NSD (normal spontaneous delivery) - Spontaneous in onset, low risk at the start of labor and remaining throughout the labor and delivery. Infant is born whether cephalic or breech or in longitudinal lie. - The infant is born between 38 to 40 weeks gestation. After birth, the mother and the infant are in good condition and not having any complications. PAIN MANAGEMENT DURING LABOR a. 1st stage of labor pain visceral caused by dilatation of the cerviz and uterine ischemia visceral pain refer to abdomen b. 2nd stage of labor pain is somatic (pain from back to the abdomen - caused by hypoxia of the uterus, distention of the vagina and perineum, and pressure on adjacent tissues c. 3rd stage of labor pain is similar in origin to that of the 1st stage of labor
WARNING SIGNS during labor 1. Contraction hypertonic, poor relaxation or titanic (>90 seconds long and <2 minutes apart) 2. Abdominal pain sharp, rigid abdomen or boardlike abdomen and shock 3. Vaginal bleeding profuse, marked vaginal bleeding 4. Normal FHT 120 to 160 bpm FHR periodic pattern decelerations FHR late decelerations, prolonged variable decelerations, bradycardia, tachycardia Decelerations periodic decrease of featl heart rate 5. Maternal Hypertension
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PIH pregnancy induced hypertension - preeclampsia - eclampsia 6. Meconium-stained amniotic fluid (MSAF) 7. Prolonged rupture of membrane (PROM) NORMAL LABOR a. Intra-partum care - refer to the medical and nursing care given to a pregnant woman and her family during labor and delivery Intra-partum period - extends from the beginning of contractions that cause cervical dilatation to the 1st 1-4 hours after delivery of the newborn and placenta Labor / parturition - is the process by which the fetus and products of conception are expelled as the result of the regular, progressive and strong uterine contractions - is the last few hours of human pregnancy characterized by thunderous uterine contractions that affect dilatation of the cervix and the force of the fetus through the birth canal - myometrial contractions of labor are painful that is why pains is used to describe labor B. Factors affecting labor / components of labor 1. passageway refers to the adequacy of the pelvis and birth canal in allowing fetal descent Factors include: a. type of pelvis b. structure of pelvis c. pelvic inlet diameters d. pelvic outlet diameters e. ability of the uterine segment to distend the cervix and dilate and the vaginal canal and introitus to distend 2. passenger refers to the fetus and its ability to move through the passageway which is based on the following: a. size of the fetal head b. fetal presentation c. fetal attitude d. fetal position 3. power refers to the frequency, duration, strength of uterine contractions to cause complete cervical effacement and dilatation 4. placental factors refers to the site of placental insertion 5. Psyche refers to the clients psychological state, available support system, preparation for childbirth, experiences and coping strategies C. Signs and symptoms of impending labor / premonitory signs of labor 1. Lightening is the descent of the fetus and uterus into the pelvic cavity 2-3 weeks before the onset of labor 2. Braxton Hicks contractions are irregular, intermittent contractions that have occurred throughout the pregnancy, becomes uncomfortable and produce a drawing pain in the abdomen groin 3. Cervical changes include softening, ripening and effacement of the cervix that will cause expulsion of the mucous plug (bloody show) 4. Rupture of amniotic membranes may occur before the onset of labor. If the woman suspects that her membranes have ruptured, she should contact her OBGyne and go to the labor suite immediately so that she may be examined for prolapsed cord a threatening condition for the fetus * Premature rupture of membranes
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5. Burst of energy or increased tension and fatigue may occur right before the onset of labor 6. Weight loss of about 1 3 lbs may occur 2-3 days before the onset of labor Characteristics of false labor 1. Contractions are irregular, occur at irregular intervals decreased frequency and intensity, longer intervals between contractions 2. contractions located chiefly in the abdomen - intensity remains the same or variable - intervals remain long 3. Walking does not intensify contractions and often gives relief - either no effect or decreases contractions 4. bloody show usually not present. If present, usually brownish in color 5. There is no cervical changes 6. Contractions disappear while sleeping 7. Sedation decreases or stops contractions 8. Discomfort in lower abdomen and groin Characteristics of true labor 1. Contractions occur at regular intervals 2. Contractions start at the back and sweep around to the abdomen - increased intensity and duration or progressive - shortened intervals between contractions 3. Walking (activity) intensifies contractions 4. Bloody show present (pink-tinged mucus released from the cervical canal and as labor starts) 5. Contractions continue while sleeping 6. Cervix becomes effaced and dilated. -progressive thinning and opening of the cervix 7. Sedation does not stop contractions 8. Discomfort begins in the back and radiates to the abdomen Length of labor a. 1st stage nullipara 8-12 hrs multipara 6-8 hrs b. 2nd stage nullipara 1-2 hrs multipara 30 minutes C. 3rd stage nullipara 5-60 minutes multipara 5-60 minutes Separation of placenta 5 to 6 minutes Cardinal movements of normal delivery (DFIERE) 1. descent 2. flexion 3. internation rotation 4. extention 5. restitution (external rotation) 6. expulsion STAGES OF LABOR 1. 1st stage of labor - begins with the onset of regular contractions which cause progressive cervical dilatations and effacement and it ends when the cervix is completely effaced and dilated
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N.A. due vaginal examination to detect if there is cervical dilatation - frequency of vaginal exam: once every 4 hours 3 Phases of the 1st stage of labor a. Latent phase this phase begins with the onset of regular contractions and effacement and dilatation of the cervix to 1 to 3 cms. Contractions become increasingly stronger, shortened and more frequent lasting for abour 20 to 40 seconds occurring approximately 3-5 minutes intervals - walking is recommended - effacement and dilatation 1 to 3 cm - contractions last for 20-40 seconds (duration) - contraction interval 3-5 minutes (frequency) b. Active phase - dilatation from 4 7 cm -contractions lasts 40 60 seconds - contractions becomes stronger, more frequent, longer and more painful c. Transition phase - the culmination of the 1st stage of labor is the transition phase during which the cervix dilates from 8 to 10 cm - intensity, frequency and duration of contractions peak and there is an irresistible urge to push lasting for about 60-90 seconds -dilatation 8-10 cm - contractions lasts 60-90 seconds -intervals of 2-3 minutes 2. 2nd stage of labor (expulsive stage, including episiotomy) - this phase begins with the complete dilatation of the cervix and ends with delivery of the newborn -woman feels the urge to bear down a. contractions are severe at 2-3 minutes intervals, with a duration of 50 seconds or less - membranes rupture spontaneously b. newborn exits into the birth canal with the help of the mechanism of normal labor or cardinal movements c. crowning occurs when the newborns head or presenting part appears at the vaginal opening d. Episiotomy surgincal incision of the perineum, may be done to facilitate delivery and avoid laceration of the perineum e. Clamping the umbilical cord. The cord is but between 2 clamps placed 4 to 5 cms from the fetal abdomen and later on an umbilical cord clamp is applied 2-3 cm from the fetal abdomen MECHANISMS OF NORMAL LABOR / CARDINAL MOVEMENTS 1. Descent 1st requisite for birth of the infant, brought about by one or more four forces: a. pressure of the amniotic fluid b. direct pressure of the fundus upon the breech c. contraction of the abdominal muscles d. extension and straightening of the fetal body 2. Flexion a movement which the chin is broight about into more intimate contact with the fetal thorax 3. Internal rotation turning of the head in such a manner that the occiput gradually moves from its original position anteriorly toward the symphysis pubis 4. Extension back of neck pivots under s.p. allows head to be born by extension
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5. Restitution (external rotation) head returns to normal alignment with shoulders, presents smallest diameter of shoulders to outlet 6. Expulsion borth of neonate completed (3rd stage) EPISIOTOMY a surgical procedure or an incision performed to facilitate the delivery of the infant Rationale: 1. surgical incisions reduces laceration 2. heals more easily than lacerations 3. protects infants head from pressure exterted by resistance 4. protect infants from signs of fetal distress 5. gives sufficient progress of delivery 6. shortens the 2nd stage of labor Side effects of episiotomy 1. infections 2. longer healing time Types / degree of lacerations / perineal tear / birth canal 1. 1st degree involves the fourchette, perineal skin and vaginal mucous membrane but not the underlying faschia and muscle 2. 2nd degree skin and mucous membrane, the faschia and muscle of the pernial body but not the rectal spinchter thus forming triangular injury, usually can be sutured under local anaesthesia 3. 3rd degree extends to the skin, mucous membrane and perineal body and involved the anal spinchter can be sutured by an expert obstetrician. Complications: fecal incontinence and fistulas 4. 4th degree extends to the rectal mucosa to expose the lumen of the rectum and it bleeds profusely Health teachings 1. cold packs to the perineum 2. sitz bath 3. using medication Two types of episiotomy 1. Midline 2. Mediolateral Comparison Characteristics 1. surgical repair 2. faulty healing 3. post-operative pain 4. anatomical results 5. blood loss 6. dyspareunia 7. extensions
Midline easy
Mediolateral more difficult rare more common minimal common excellent occasionally faulty less more rare occasional common* uncommon * only disadvantage of midline
NURSING MANAGEMENT OF THE NEWBORN IMMEDIATELY AFTER BIRTH 1. ensure patent airway
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2. suction with bulb syringe 3. maintain body tempterature 4. identify infant 5. prevent eye infection 6. facilitate prompt identification 7. intervention in hemolytic problems of the newborn (vit. K) 3. 3rd Stage of labor Placental Stage - this phase begins with the delivery of the newborn and ends with the delivery of the placenta. Some bleeding is inevitable during this stage. It occurs in two phases - 5-6 minutes gap before placenta comes out - order oxytocin 10 in (IM) or IV push - increased blood loss if placenta comes out after 30 minutes a) Signs of placental separation 1. Uterus becomes globular or firmer. It is the earliest sign to appear. Calkins Sign 2. Sudden gush of blood from the vagina 3. Lengthening of the imbilical cord, 1-5 minutes after delivery of the infant 4. Fundus rises up in the abdomen b) Placental expulsion 1. Placenta is deliver by natural bearing down effort of the mother 2. Credes maneuver is performed by the doctor or nurse by gentle pressure over the contracted uterine fundus 3. Duncan placenta / mechanism as the placenta separates, the blood from the implantation site may escape into the vagina immediately. It looks raw and red in color - edges, meaty, everted, maternal side Hysterectomy 3,000 3,500 ml blood loss 4. Schultzes placenta / mechanism concealed behind the placenta and membranes until the placenta is delivered, appears shiny and glistening from the fetal membranes (fetal side) -NSD blodd loss = 500 ml to less than 1,00 ml -CS blood loss = 1,000 ml to 1,400 ml 4. 4th stage of labor (recovery or bonding stage) a. This stage lasts from 1-4 hours after birth of the newborn b. The mother and newborn recover from the physical process of birth c. The maternal organs undergo initial readjustment to the nonpregnant state d. The newborn body systems begin to adjust to extrauterine life and stabilize e. The uterus contracts in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis NURSING CARE OF THE WOMAN IN THE 1ST 24 HOURS POSTPARTUM 1. Provide pain relief for afterpains 2. Relieve muscular aches 3. Give episiotomy care 4. Promote perneal exercises 5. Administer sitz bath 6. Provide perineal care 7. Promote perineal self-care Postpartum warning signs to report to the physician 1. Increased bleeding, clots or passage of tissue 2. bright red vaginal bleeding anytime after birth
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3. pain greater than expected 4. temperature elevation to 110.4 F 5. Feeling of full bladder accompanied by inability to void 6. enlarging hematoma 7 feeling restless 8. pain, redness and warmth accompanied by a firm area in the calf 9. difficulty breathing, rapid HR, chest pain, cough, feeling of apprehension, pale, cold blue or blue skin color Postpartum sexual activity 1. sexual intercourse may be resumed at 2-3 weeks after birth 2. Sexual intercourse should not resume until vaginal bleeding has stopped and the episiotomy has healed 3. sexual arousal may cause milk to leak from the breast 4 longer periods of foreplay will encourage lubrication 5. when the infant is weaned from the breast, sex drive will usually return to normal 6.the contraceptive meethid of choice should be used as directed, at the initiation of sexual activity APGAR score: Newborn assessment A = appearance > color P = pulse > heart rate G = grimace > reflex irritability to a gentle slap A = activity > muscle tone R = respiratory effort Points of status : APGAR - Good = 7 to 10 - Fair = 4 to 6 - Needs resuscitation = 0 to 3 APGAR scoring chart Sign Heart rate Respiratory effort Muscle tone Reflex 0 absent absent flaccid no response 1 slow (<100) slow, irregular weak cry some flexion of extremities grimace 2 > 100 good, strong cry well flexed cough, sneeze, cry & withdrawal of foot completely pink
Color
blue, pale
body pink, extremities blue
DECELERATION - periodic decrease of featl heart rate (FHR) - normal FHR is 120 to 160 bpm Three types of Decelerations 1. early decelerations - FHR begins to slow with the onset of the uterine contractions and returns to baseline when contractions are over (drop to 100 bpm but not lower) - indicates Fetal Head Compression (FHC) - no nursing intervention is needed, continue observation 2. Late Decelerations
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- FHR begins to fall and the height of UC and returns to baseline after contraction has ceased - 70 bpm - indicates Utero Placental Insufficiency (not enough supply from the placenta) 3. Variable Deceleration - abrupt transitory decrease of FHR - indicates Umbilical Cord Compression (UCC) Nursing Interventions 1. Change maternal position to the left 2. turn off pitocin (oxytocin) 3. begin 02 mask @ 8-10 L/min 4. check BP & PR 5. possible candidate for CS ****** Interventions for Late deceleration 6. observe perineum for blob show & appearance of amniotic fluid 7. assess for fetal distress 8. assess for bright red vaginal discharge / bleeding ***** interventions for variable deceleration
NURSING MANAGEMENT OF THE NEWBORN AFTER DELIVERY a. assessment - mucus in nasopharynx, oropharynx - note and record apgar score - # of vessels in the umbilical stump - passage of meconium stool, urine - general physical appearance b. analysis / ND 1 ineffective airway clearance related to excessive nasopharyngeal mucus 2. ineffective breathing pattern related to CNS depression secondary to intrauterine hypoxia and prematurity 3. impaired gas exchange related to respiratory distress 4. fluid volume deficit related to birth trauma, hemolytic jaundice 5. impaired skin integrity related to cord stump 6. high risk for injury related to impaired thermoregulation (incubation & drop light) 7. ineffective thermoregulation related to environmental condition c. NCP / implementation - ensure patent airway - suction with bulb syringe - maintain body temp - identify infant - prevent eye infection - facilitate prompt identification / vigilance for potential neonatal complications 1. history of pregnancy 2. history of delivery - facilitate prompt identification / intervention in hemolutic problems of the newborn NURSING ACTIONS DURING THE 4TH STAGE OF LABOR a. assessment - every 15 minutes, 4 times, then every 30 minutes, 2 times or until stable - to monitor response to physiologic stress of labor / birth 1. vital signs 2. location and tone of fundus - midline - firm & slightly lower than the umbilicus 3. perineum edema / rectal pain
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4. bladder initial nursing action is to alternate warm & cold packs - fullness of bladder 5. rate of IV, I&O 6. interactions between parents, newborn, signs of bonding 7. assess for signs of postpartal emergencies - hemorrhage - uterine atony Nursing care plan - comfort measures 1. maternal position supine 2. pad change 3. perineal care 4. ice pack to perineum as ordered - nutritional hydration offer oral fluid, 4-6 hours -urinary elimination - promote bonding - health teachings - signs to report to physician 1. uterine cramps 2. increased vaginal bleeding, passage of large clots 3. nausea, dizziness (Kegel exercise eliminate urination) 4. pain greater than expected 5. temp elevation at 110.4 F 6. enlarging hematoma 7. feeling of full bladder accompanied by inability to void
POSTPARTUM (puerperium) - six weeks after delivery or beginning with the termination of labor and ending with the return of the reproductive organ to its non-pregnant state - sometimes called as 4th trimester of pregnancy Uterus contracts firmly, reducing its size by more than half Lochia discharge from the uterus during the first 3 weeks of delivery 3 types of lochia = RSA 1. Lochia rubra color dark red duration 1-3 days after delivery composition blood, epithetial cells, erythrocytes, leukocytes & fragments of decidus odor characteristic odor 2. locahia serosa color pinkish to brownish duration 3-10 days after delivery composition blood, decidus, erythrocytes, leukocytes, cervical mucus & microorganisms odor strong odor 3. lochia alba color colorless to creamy yellowish duration 10 days to 3 weeks after composition leukocytes, decidus, epithelial cells, fat, cervical mucus, cholesterol crystals & bacteria odor no odor Fundal height & consistency after delivery
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1. after birth / delivery - fundus is palpated halfway between the umbilicus & symphysis pubis, or @ the level of the umbilicus, size & consistency of firm grapefruit 2. day 1 (first 12 hours) - one firngerbreath (1 cm) below the umbilicus 3. descends by 1 fingerbreath daily until day 10 4. day 10 to 14 - palpated behind symphysis pubis, non-palpable abdominally 5. 4-6 weeks - returns to its non-pregnant size 6. 6-7 weeks - to heal site of placental attachment GOALS of post-partum care 1 promote normal involution & return to the non-pregnant state - involution of the uterus pregressive changes of the uterus after delivery 2. prevent or minimize post partum complications - profuse bleeding -puerpera infection - mastitis - thrombophebitis - UTI - sub-involution 3. promote comfort & healing of pelvic, perianal and pernienal tissues 4. assist in restoration of normal body function 5. increased understanding of physiologic & psychological changes 6. facilitate new born care & self-care of the mother 7. promote the new borns successful integration into the family unit 8. support parenting skills & parent-newborn attachment 9. provide effective discharge planning including appropriate referral for home-care follow up Post-partum psychological adaptation By Reva Rubin 3 phases of puerperium 1. taking-in phase 2. taking-hold phase 3. letting go phase Taking-in phase - occurring 1-2 days after delivery - time for reflection talkative - mother typically passive & dependent - review her labor & delivery experience frequently Taking-hold phase - extending 2-4 days after delivery - time for initiating action - expressed little interest in caring for her child - strives to master newborn care skills Letting go phase - this phase generally occirs after the new mother returns home - time of family reorganization; time for a new role - assumes responsibility for newborn care - adapt to the demands of newborn dependency - post partum depression most commonly occur during this phase
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Post partum depression - a let down feeling after giving birth related to the magnitude of the birth experience & doubts about the ability to cope effectively with the demands of childrearing - begins 2-3 days after delivery & resolving pain within 1-2 weeks Post-partum blues - also known as baby blues - due to hormonal changes - evidenced by tearfulness, feelings of inadequacy, moody, anorexia & sleep disturbance - serious depression, postpartal psychosis requiring formal counseling or psychiatric care Rooming-in - the infant stays in the room with the mother rather than staying in the central nursery Two types of rooming-in 1. complete - implies that the mother & the child are together 24 hours a day 2. partial - in which the infant remains in the mothers room for part of the time
CONTRACEPTION
- voluntary prevention of pregnancy - intentional prevention of conception through the use of various devices, agents, drugs, sexual practice or synthetic products CONTRACEPTIVE - device, drug or chemical agent that prevents conception or acapbale of preventing pregnancy Factors to be considered in using and choosing contraceptives 1. religious orientation 2. social & cultural values 3. medical contraindication 4. psychological contraindication 5. individual sexual orientation 6. cost 7. availability of bathroom facilities and privacy 8. partners support and willingness to cooperate 9 personal lifestyle * coitus interuptus (withdrawal) least effective * IUD most effective A. Assessment 1 determine interest and present knowledge of method of family planning 2. identify factors affecting choice of contraceptive method b. ND 1. knowledge deficit regarding family planning methods c. NCP GOAL: health teachings to 1) facilitate informed decision-making; 2) selection of options appropriate to individual needs and desires
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Health teachings 1. describe, explain, discuss options available & appropriate to the woman, include information on advanatagse and disadvanatages of each option 2. demonstrate as necessary method selected 3. quick health teachings reminders for missed oral hormone preparations a. 1 pill should be taken at the same time every day for 21 days b. if woman misses 1 pill, she should take it as soon as she remembers it and then take the next pill about the usual time c. if woman missed 2 or more pills in a row, in the 1 st 2 weeks of her cycle, she should take 2 pills for 2 days and use a backup method of contraception for the next 7 days d. Evaluation: Woman avoids / achieves a pregnancy as desired CONTRACEPTIVE DEVICES a. Hormonal contraceptives 1. Combination of estrogen and progesterone actions: - suppresses ovulation by suppressing production of FSH & LH - most efficient form of contraception advantages - convenient, easy to take, withdrawal bleeding cycles are predictable - not related to sex act, safe for older non-smoking women until menopause - many contraceptives health benefits disadvantages 1. absolute CI: thromboembolic, or CAD (coronary artery disease), some cancer (CA) and liver disease 2. relative CI: migraines, HPN, abnormal genital bleeding, immobility 3. no protection against STD 4. effectiveness decreased during use of barbiturates, phenotoin, antibiotics 5. some decrease in glucose tolerance 2. Estrogen only = morning-after pill action of estrogen - anti-feritlity: taken within 72 hours of unprotected coitus during fertile period advantages - available, PRN disadvanatages - because of DES effect on fetus, elective abortion advised if method fails DES = diethylstilbestrol 3. Progestin only minipill, depo-provera, norplant action - impairs fertility, thickens cervical mucus, decreases sperm penetration - alters endometrial maturation - effectiveness: undertermined, can reach 100% reliability if used exactly advantages - (O) convenient, easy to take -(IM) 2-4 times/ year. Lactation ok during this time - subdermal - not related to sex act disadvantages - ovulation may occur - irregular bleeding - may change glucose and insulin values - no protection against STD
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B. Intrauterine devices (IUDs) - small T-Shapaed device inserted into uterine cavity medicated with copper and progesterone action - prevents fertility: damages sperm in-transit to the fallopian tube - effectiveness: 90-99% advantages - can be used by women who cannot use hormonal contraceptives - no disruption of ovulation pattern - less blood loss during menses and decreased primary dysmenorrheal - copper can be used effectively for 10 years; progesterone: yearly disadvantages - Hx of PID (pelvic inflammatory disease), pregnancy, unDx genital bleeding, genital malignancy, ANG - uterine perforation, infection - heavy flow, spotting between periods, cramping within few months of insertion - must check for string after each menses and before intercourse - no protection against STDs C. Mechanical barriers 1. Diaphragm - shallow rubber device that fits over cervix action - barrier preventing sperm from entering cervix - effectiveness: 83-90%, 99% in highly motivated women advantages - does not interrupt sex act - insert 6 hours before intercourse and leave in place for 6 hours after last intercourse - no SE from well-fitted device - decreased incidence of vaginitis, cervicitis, PID disadvantages - require careful cleansing with warm water and mild soap - size/fit needs to be checked after term birth, and or 3rd trimester abortion, weight gain or loss of 20 lbs or more - spermicide must be inserted for additional acts that may follow initial intercourse - no protection against STDs 2. Cervical cap - 1 - 1 in soft, natural rubber dome with a firm but pliable rim action - physical barrier to sperm - spermicide inside cap adds a chemical barrier - effectiveness: same with diaphragm advantages - worn for 8 hours but not longer than 48 hours - no need to add spermicide for repeated acts of intercourse disadvantages - needs a yearly papsmear - if in place for over 48 hours it produces an odor - cannot be worn during menstrual flow (menses) or up to 6 weeks postpartum - CI abnormal papsmear, hard to fit, genital infection, allergy - must be checked regularly
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- no protection against STDs 3. Female condom - vaginal sheath of natural latex rubber with flexible rings at both the closed and the open areas action - barrier preventing sperm from entering the vagina - effectiveness: similar to other mechanical methods used with spermicide note: male and female condoms should not be used at the same time advantages - apply well in advance of intercourse, spermicide added just before sex - heightens sensation for man - about as satisfying for both woman and man as intercourse without it - provides protection from STDs disadvantages - cost is high - a new one must be used for every act of intercourse 4. Male condom - thin, stretchable latex sheath to cover penis action - barrier preventing sperm from entering vagina - applied over erected penis before loss of preejaculatory drops - spermicidal foan or jelly or cream is also used - effectiveness: 64-98% when used with spermicide advantages - increased effectiveness of mechanical barriers - ease of application - aids in the lubrication of the vagina - requires no medical exam or Rx - maybe used during lactation - backup for missed or oral contraceptive pills - may provide some protection from STDs disadvantages - messy - some people are allergic to preparations - tablets/suppositories take 10-15 mins to dissolve - if it is the method being used, each intercourse should be preceded (by 30 mins) by a fresh application E. Other methods 1. Calendar method (rhythm) - recommended for women with regular menses - 9 days - this method relies on abstinence from sexual intercourse during fertile period - pregnancy is prevented by not having coitus during the unsafe fertile period - effectiveness: 80% advantages - requires a fairly predictable menstrual cycle - requires knowledhe of cycle lengths, fairly predicatble menstrual cycle and formula - effectiveness depends on high level of motivation and diligence - no protection against STDs
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- research 8-10 months if cycle is normal 2. Basal body temperature (BBT) - measured by taking and recording the temp orally or rectally each morning before rising 0.4 to 0.8 F = increase during ovulation 3. Cervical mucus method (CMM) - uses the appearance, characterisitic and amount of cv to identify ovulation - during ovulation = appearance of cv is clear and slippery, more abundant - after ovulation = cv is yellowish and thick in characteristic, less abundant 4. Symptothermal method - combination of BBT and CMM disadvantage - more complex and difficult to learn and requiring regular and daily effort 5. Mittleschmerz - pain experienced by women in between menstrual cycle (time when the ovary releases eggs) - rarely, the pain may be accompanied by discharge 6 Coitus interruptus - requires withdrawal of the penis from the vagina before ejaculation disadvantage - highly ineffective because sperm exists in pre-ejaculatory fluid - unreliable, interrupts sexual excitation or the plateau phase and diminishes satisfaction ALERT TO DISCONTINUE the use of oral contraceptive Signs and symptoms of potential problems = ACHES A = abdominal pain:possible problem with liver or gallbladder C = chect pain or shortness of breath, possible clot problems w/in the lungs or heart H = headaches (sudden or persisitent) possible caused by CVA (cerebro vascular accident or HPN) E = eye problem : possible cause by CVA or HPN S = severe leg pain: possible thromboembolic process ALERT woman of signs of potential problems related to IUD = PAINS P = period (menstrual) late, abnormal clotting, spotting or bleeding A = abdominal pain, pain with coitus (dyspareunia) I = infection, abnormal vaginal discharge N = not feeling well, fever or chills S = string is missing (non-palpable on vaginal self-exam) or not seen on speculum exam Toxic Shock Syndrome (TSS) Alert woman of signs of TSS = FHRSC F = fever of sudden onset (over 38.9C or 102 F) H = hypotension systolic pressure (less or equal) 90 mmHg or orthostatic dizziness, disorientation R = rash, diffuse, macular,, erythroderma (resembling sunburn) S = sore throat, sever nausea, vomiting C copius vaginal discharge
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LEOPOLDS MANUEVER
- is a systematic abdominal palpation of the pregnant woman to determine position and presentation of the fetus. It is done by about 32 weeks and over. The nurse should develop skills related to this. 1. explain the procedure to the client - 1st nursing intervention in any procedure - assures the mother, allays anxiety and gain maternal cooperation 2. instruct the client to empty the bladder if full - the bladder lies anterior to the uterus - means abdominal discomfort if the bladder is full - to get the desired results esp for M. 3&4 3. position client in a supine position - to be comfortable 4. drape client for privacy 5. wash hands, warm hands by briskly rubbing each other before placing them on the abdomen - prevents tension and hardening of abdominal muscles 6. palpate gently: 1st maneuver - outline the contour of the uterus - ascertain how nearly the fundus approaches the xyphoid process - palpates the fundus with tips of fingers of both hands to define which fetal pole is present a. normal: if buttocks, soft, nodular body, non-ballotable b. breech: head, hard, round, ballottable 2nd maneuver - put palms on either side of the abdomen - gentle but deep pressure is exerted - palpates the sides to detect location of fetal back and fetal small parts a. back: hard, resistant structure, smooth * best site for auscultation b. small parts: numerous small, irregular, nodular with bony prominences, mobile parts 3rd maneuver - using the thumb and fingers of one hand, the nurse grasps the lower portion of the maternal abdomen, just above the symphysis publis - to detect if the presenting part is engaged or not engaged a. if not engaged: get the attitude of the head - cephalic prominence same side with the small parts - is the head is flexed, vertex presenting - if same side with the back, head is extended - moveable body b. if deeply engaged - the lower pole of the fetus is fixed in the pelvis 4th maneuver - face the mothers feet - with the tips of 1st fingers of each hand, exert deep pressure in the direction of the axis of the pelvic inlet - to detect degree of flexion, position and station a. if head presents: one hand is arrested sooner than the other by a rounded body, the cephalic prominence, while the other hand descend more deeply into the pelvis b. vertex: same side as the back
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ANTEPARTUM COMPLICATIONS
1. spontaneous abortion 2. gestational trophoblastic disease (hydatidiform mole) 3. ectopic pregnancy 4. incompetent cervix 5. hyperemesis gravidarum 6. placenta previa 7. abruption placentae 8. pregnancy-induced hypertension (PIH) Most common causes of bleeding: 1st trimester = spontaneous abortion, ectopic pregnancy 2nd trimester = gestational trophoblastic disease, incompetent cervix 3rd trimester = placenta previa, abruptio placenta ANTERPARTUM COMPLICATIONS 1. Spontaneous abortion (miscarriage) - expulsion of the feyus and other products of conception from the uterus before the fetus is viable - the termination of pregnancy before 20 weeks based upon the date of the 1 st day of the last normal menses - the delivery of the fetus-neonate that weigh less than 500 grams (2,500 4,250 grams normal) * products of conception 1. fetus 2. membranes (amniotic membranes) 3. placenta etiology and pathophysiology - spontaneous abortion may result from unidentified natural causes from fetal, placental or maternal factors A. fetal factors (most frequent cause of spontaneous abortion) -defective embryogic development * most morphological finding in early spontaneous abortion or blighted ova macerated ova (half of the body is absent) - faulty ovum implantation - rejection of the ovum by the endometrium - chromosomal abnormalities B. placental factors - premature separation of the normally implanted placenta (abruption placenta) - abnormal placental implantation (ectopic pregnancy) - abnormal platelet function C. maternal factors - infection (measles, rubella) - severe malnutrition - reproductive system abnormalities - endocrine problems (DM, hyperthyroidism) - trauma (accidents) - drug ingestion (tobacco, alcohol, marijuana) * resumption of ovulation after abortion - ovulation may resume as early as 2 weeks after abortion, therefore, it is important that effective contraception be initiated soon after abortion
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Types of spontaneous abortion 1. threatened abortion 2. inevitable / imminent abortion 3. incomplete abortion 4. complete abortion 5. missed abortion 6 . habitual / recurrent abortion 1. threatened abortion S/S - cramping and vaginal bleeding in early pregnancy - abdominal pain - slight bright red vaginal bleeding that persist for days or weeks * coming from uterus of the mother * minimal bleeding - persistent low backache - no cervical dilatation (closed) - pregnancy test + - it may subside or an incomplete abortion may follow * 50% may subside * 50% incomplete abortion may follow NCP Goal: Health teaching - suggest to avoid coitus and orgasm to present the possibility of infection and to avoid possibility inducing further bleeding Case: if an IUD is still present and the string is visible: - device should be removed results in = late abortion = sepsis = preterm birth Case: if string is not visible: - no attempt to locate & remove the device = abortion = sepsis = offered to an option of a pregnancy termination 2. Inevitable / imminent abortion - sudden discharge of fluid, suggesting ruptured of membranes Signs - vaginal bleeding * inevitable = moderate * imminent = profuse -cramping abdominal pain - fever - urge to bear down - cervix is dilated (open) - termination cannot be prevented - PT + - nitrazine test + = ruptured amniotic fluid = dark blue in color 3. Incomplete abortion - expulsion of only one part of the products of conception (fetus first, placenta and membranes likely to be expelled together in abortion occurring before 10 weeks but separately thereafter) Signs
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- vaginal bleeding is moderate (occurs with c.d) - cervical dilatation 4. Complete abortion - complete expulsion of all products of conception - the entire products of conception are expelled spontaneously w/o any assistance Signs: - vaginal bleeding minimal - cervical dilatation 5. Missed abortion - defined as the retention of dead products of coneption in utero for several weeks (4-6 weeks) Signs: - early fetal intrauterine death w/o expulsion of the products of conception - client may report dak brown vaginal discharge - uterus seems to remain stationary in size - fetal heart sound cannot be heard - cervix is closed - PT negative NCP Goal: safeguard status - save all perineal pads, clots, tissue for expert Dx - report STAT any changes in status, excessive bleeding, signs of infection, shock - prepare for surgey dilatation & curettage (D&C) Medical management - endomterium scraped with metal curetter or flexible aspiration tip under local anesthesia. (paracervical block) procedure for 15 minutes - replace blood loss, maintain IV fluid levels note: - if pregnancy is over 14 weeks labor may be induced by means of prostaglandin / oxytocin to dilate cervix - replace blood loss, maintain fluid levels with IV 6. Habitual / recurrent abortion - 3 or more consecutive spontaneous abortion - Hx of spontaneous loss of 3 or more successive progrnancy that occurred and same gestation age in 3 pregnancies etiology - defective spermatozoa or ova - endocrine factors luteal phase defect - deviations of the uterus - infections - autoimmune disorder ND a. fluid volume deficit b. anticipatory grieving c. dysfunctional grieving d. risk for infection Signs 1. anorexia loss of appetite 2. body malaise 3. headache
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4. mother complains of cramping in the lower abdominal region 5. there is vaginal bleeding 2. Gestational trophoblastic disease (GTD) hydatidiform mole, molar pregnancy - an alteration of early enryonic growth causing placental disruption, rapid proliferation of abnormal cells and destruction of the embryo - developmental anomally of the placenta that converts the chorionic villi into a mass of clear vesicles (hydatid vessels) - multiplication / degeneration / proliferation of trophoblastic villi (outer layer of blastocyst) - prone to high-risk pregnancy etiology - the embryo dies and the trophoblastic cells continue to grow forming an invasive tumor * choriocarcinoma = because it produces an increase in HCG = extremely malignant form of trphoblastic villi - placental tumor that develops after pregnancy has occurred, a hydatidiform mole maybe benign or malignant - blood vessles are absent, as are the fetus & amniotic sac - sperm enters empty egg and its chromosome replicate (complete) or triplicate (incomplete) - characterized by proliferation of placental villi that becomes edematous and form grapelike clusters vesicle or snowstorm - genetic abnormalities at the time of fertilization are thought to be responsible for trophoblastic disease - PT + or 2 types of GTD a. complete mole - theres neither an embryo nor an amniotic sac - this phenomenon is referred to as androgenesis - 46 xx chromosomes contributed by the paternal material - karyotype = haploid sperm b. partial more - there is an embryo (multiple abnormalities) & an amniotic sac - typically has stigma of triploidy which includes multiple congenital malformation and growth restriction it is nonviable - karyotype haploid findings - 69 chromosomes from the father Signs 1. severe nausea and vomiting = because of severe increase in HCG due to the proliferation of trophoblastic villi 2. PIH before 20 weeks gestation (convulsion, edema) 3. vaginal bleeding - brownish in color prune juice - as early as 14 weeks or 3 months 4. uterus larger than expected for the duration of the pregnancy 5. inconsistent fundal height w/ gestational estimate 6. abdominal cramping from uterine distention 7. no fetal heart sounds will be heard 8. infection because te woman is at risk of a perforation of the abdominal wall associated findings 1. abnormal high serum levels of HCG normal = 400,000 intl unit abnormal 1-2 million intl unit
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2. characteristic appearance of molar growth on ultrasound tracing, x-ray, sonogram can be detected age: the most pronounced effect is seen in women over 45-50 yrs old * in GTD, should not be pregnant in 1 year Dx procedure 1. ultrasound to see the appearance of the mole = uterine myoma = early pregnancy = multiple pregnancy / fetus Hysterectomy = if choriocarcinoma is present Medical management 1. D&C to evacuate grapelike vesicles 2. hysterectomy choriocarcinoma 3. suction curettage NCP 1. monitor signs for PIH (preeclampsia & eclampsia) 2. strict contraception for at least 1 year to enable accurate assessment of status (discuss contraceptive options) 3. observe for hemorrhage, passage of retained vesicles and abdominal pain 4. explain. Discuss tests, prepare for tests 5. facilitate grieving 3. Ectopic pregnancy - implanatation of products of conception in a site other than the endometrium - implantation outside the uterine cavity or outside the uterus - 1st trimester 4 types of ectopic pregnancy 1. fallopian tube (tubal) common site of EP - 95% - ampullar portion 2. cervix 60% 3. abdomen 25% 4. ovary 5% etiology 1. presence of IUD 2. tubal or uterine anomalies, tubal spasm 3. PID (pelvic inflammatory disease 4. 43% caused by STD 5. adhesion from PID of past surgeries 6. endometritis 7. use of progestin only associated findings 1. early signs - abnormal menstrual period - vaginal bleeding - spotting - dizziness 2. impending or post-tubal upture - sudden & acute, sharp lower abdominal pain - nausea & vomiting - signs of shock * Kehrs sign referred to neck and shoulder-strap sharp pain, neck pain due to the presence of blood in the peritoneal cavity * Cullens sign ecchymotic blueness of the umbilicus which is indicative of hematoperitoneum Medical management
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surgical removal repair (SRR) unruptured ectopic pregnancy if ruptured laparatomy with surgical removal repair probable ruptured ectopic pregnancy ligate bleeding vessels & to remove / repair damaged fallopian tube ND 1. Anxiety 2. anticipating grief 3. knowledge deficit 4. pain NCP 1. assess vital signs, bleeding & pain 2. explain the condition, describe self-care measures 3. offer emotional support as the client grieves for the lost baby 4. Incompetent cervix (dysfunctional cervix) - cervical effacement & dilatation in early 2nd trimester resulting in expulsion of the products of conception - characterized by painless dilatation of cervical OS w/o contractions of the uterus etiology 1. history of traumatic birth (abortions) 2. foreceful D&C / repeated D&C 3. clients mother treated with DES when pregnancy with the client 4. congenitally small cervix 5. uterine anomalies 6. unknown etiology Signs 1. show = pink-stained vaginal discharge 2. increased pelvic pressure 3. followed by rupture of membrane 4. discharged of amniotic fluid 5. expulsion of the immature fetus medical management 1. cervical cerclage (shirodkar / Mcdonald) - done 3 to 4 months (13 to 14 weeks) - surgical procedure to prevent incompetent cervix to happen again - if CS, cervical cerclage remove after CS, CS done 14 days before EDC to avoid dilatation & contractions - sutures serve ti strengthen the cervix & prevent it from dilating - purse string sutures are placed in the cervix by vaginal route NCP 1. avoid coitus or orgasm 2. provide routine post-op 3. maintain bed rest for 24 hours (modified trendelenburg position) 4. observe for ruptured membranes and bleeding 5. monitor FHR and Doppler ultrasound 6. avoid strenuous play activity evaluation 1. states intention of seeking immediate medical care if labor begins 2. continues pregnancy to term ND 1.body image disturbance RL to feelings of failure and feelings of guilt 2. anticipatory grieving RL to loss of expected baby 3. knowledge deficit RL to cerclage procedure and effect on pregnancy 4. pain RL to early dilation of the cervix 5. situational low self-esteem RL to inability to complete pregnancy 5. Hyperemesis gravidarum
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- severe nausea and vomiting, leading to electrolyte metabolic and nutrition imbalances in the absence of other medical problems - sometimes called pernicious vomiting during 14 to 16 weeks gestation - peak: 10th week of gestation etiology 1. signs and symptoms occur during the 1st 16 wks of pregnancy and are intractable 2. continued vomiting results to dehydration 3. secretion of HCG, decrease in free gastric HCl., decreased gastrointestinal motility 4. increased incidence in H-mole and multifetal pregnancy 5. hospitalization may be required for severe symptoms Signs 1. unremitting / intractable nausea and vomiting 2. hiccups 3. abdominal pain 4. marked weight loss 5. dehydration thrist, tachycardia, skin turgor 6. increased respiratory rate 7. elelvated blood urea nitrogen ND 1. altered nutrition, less than body requirements RL to retain oral feedings 2. fluid volume deficit RL to dehydration 3. Ineffective individual coping RL to symptoms, insecurity in role 4. personal identity disturbance RL to symptoms or perception of self as inadequate in role, sick, socially unrepresentable NCP Goal: physiological stability a. rest GI tract (keep NPO), maintain IVF, parenteral nutrition b. progress diet, as ordered, present small feedings attractively c. weigh daily, assess hydration, note weight gain Goal:minimize environmental stimuli a. limit visitors and phone calls b. bed rest with BRP Goal: emotional support a. establish accepting, supportive environment b. enouragce verbalization of anxiety, fears, concerns c. support positive self-image Evaluation a. woman s/s subsdies, she takes oral nourishment & gains weight b. womans pregnancy continued to term /o recurrence of hyperemesis Comparison Morning sickness Onset occurs in 1st trimester & resolves in 2nd
Weight is maintained Serum electrolytes remain normal Ketosis doesnt develop Skin turgor remains hydrated Serum thyroid level normal Skin color normal 6. Placenta Previa
HG onset in 1st trimester and continues throughout pregnancy weight loss serum electrolytes are abnormal ketosis occurs or maybe developed skin turgor is dehydrated serum thyroid levels are abnormal jaundice may occur
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- abnormal or low implantation of the placenta near or over the internal OS - is a condition in which the placenta attached itself to the uterine wall in the lower portion of the uterus and covers all or part of the cervix - condition in pregnancy in which the placenta lies below the babe in the uterus and may completely block the opening of the uterus (cervix) * 9-10% are associated with Placenta Accreta an abnormal attachment of the placenta to the uterine wall, that prevents the placenta from separating from the wall of the uterus at the time of delivery If placenta accreta is present = profuse bleeding = requires blood transfusion Type of placenta previa 1. Low lying or Type I when the placenta is implanted in the lower uterine segment - as early as 3 months 2. Marginal or Type II when the placenta is at the margin of the internal OS 3. Partial or Type III when the placenta partially covers the internal OS 4. Complete or Type IV when the internal cervical OS is completely covered by the placenta Type 1-3 = trial NSD Type IV = CS Predisposing factors 1. multi parity (5% in grand multiparous Px) 2. advanced maternal age (35 yrs above high risk) 3. multiple gestations twins, triplets, etc 4. previous CS 5. uterine incisions prior uterine insult or injury 6. prior placenta previa (4-8%) 7. prior induced abortion 8. smoking Assessment S/S a. bright red, painless vaginal bleeding b. soft, nontender uterus c. FHR stable and within limits normal FHT d. hypotension e. tachycardia f. absence of contractions Diagnosed by: 1. ultrasound 2. double set-up examination vaginal exam in operating room only, in preparation for CS 3. CBC 4. Speculum exam or careful spec exam to determine if bleeding is from mother or from fetus Nursing care plan 1. take and record vital signs, assess bleeding and maintain pad count 2. observe for shock 3. monitor FHR 4. enforce strict bed rest 5. explain condition and management options 6. instruct client to avoid intercourse until after birth Medical management 1. ultrasound is used to locate the placental site
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2. amniocentesis to determine if the featl lung is mature enough for delivery 3. Kleihauer-Betke Test test strip to detect if bleeding is from mother or fetus 4. vaginal birth possible if bleeding is minimal 5. cesarean birth Medications: Magnesium Sulfate used to stop uterine contractions Ritrodine Nifedipine Bethamethosome to increase fetal lung maturity if pre-term labor cant be halted Note: After delivery with placenta previa, patient is at risk for 2 complications 1. post-partal hemorrhage 2. endometritis 7. Abruptio Placenta - premature separation of normally implanted placenta from the wall of the uterus - occurs as late as during the 1st or 2nd stage of labor Types 1. partial abruption placentae small part of the placenta 2. marginal occurs at the edges, external bleeding 3. compete total placenta separates Etiology 1. Cause is unknown 2. risk factors a. uterine anomalies b. multiparity (before birth or second twin) c. PIH (preeclampsia / eclampsia) d. previous CS delivery e. renal or intravascular disease (chronic renal hypertension) f. trauma to abdomen g. previous 3rd trimester bleeding h. abnormally large placenta i. traction on umbilical cord j. cigar smoking (cocaine addiction) Signs and Symptoms - sudden, localized, sharp, stabbing uterine pain - knife-like abdominal pain - concealed or external dark red vaginal bleeding - convelaire uterus - uterine outline possibly enlarged - FHR present or absent Severe Abruptio Placentae observe for complications - hemorrhage or shock - renal failure - dissiminated intravascular coagulation (DIC) - maternal or fetal death Nursing interventions for stabilization - place on strict bed rest (LLP) - O2 therapy by nasal cannula 4.6L - fetal monitoring IV line using an 1.8 guage needle - accurately chart fluid intake (IV) and output
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- strict NPO - observe vaginal bleeding for 30 mins Planning and implementation 1. continuously evaluate maternal and fetal physiological status: vital signs bleeding electronic fetal and maternal monitoring tracings signs of shock decreased urine output 2. never perform a vaginal or rectal exam or take any action that would stimulate urine activity 3. Assess the need for immediate delivery - CS - vaginal delivery (NSD) * CS - necessary for live, distressed or uncontrolled bleeding, because the mother can die within 30 mins from severe hemorrhaging * NSD should be attempted when the fetus is dead, maternal bleeding is mild, mother is in stable condition induction of artificial labor 8. Pregnancy-induced Hypertention - a hypertensive disorder of pregnancy, developing after 20 weeks of gestation and characterized by edema, hypertension and proteinuria - associated with poor calcium in the urine and magnesium sulfate - vasospasm occur during pregnancy Etiology 1. cause is unknown 2. possible contributing factors - poor renal care, particularly inadequate nutrition - primigravid status - multiple pregnancies - preexisting maternal diabetes mellitus or hypertension - age younger than 18 or older than 35 yrs - Hydatidiform mole - low socioeconomic form Assessment Mild preeclampsia - hypertension systolic increase of 30 mmHG or more over baseline; diastolic rise of 15 mmHG or more over baseline (ex. 140/90) - proteinuria 1 g/d edema digital and periorbital; weight gain over .45 kg (1 lb) per week Severe preeclampsia increasing hypertension systolic at or above 160 mmHG or more than 50 mmHG over baseline; diastolic 110 mmHG or more WARNING SIGNS - rapid rise in BP - rapid weight gain - generalized edema - increased proteinuria - epigastric pain - severe headache - visual disturbances - oliguria - irritability - severe nausea and vomiting Eclampsia - tonic and clonic convulsions (grand malseizures), coma - renal shutdown oliguria, anuria
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- accompanied by s/s of preeclampsia WARNINGS signs of impending seizures 1. frontal headache 2. epigastric pain 3. sharp cry 4. eyes fixed, unresponsive 5. facial twitching * magnesium sulfate: drug of choice to halt contractions, CNS depressant action that slows & helps uterine contraction Goal: seizure care of eclamptic patient 1. maintain patent airway 2. administer medications / fluid as ordered 3. assess uterine activity for labor or AP 4. check perineum for impending labor 5. check HR 6. observe, report and record - onset and progression of convulsion - if followed by coma and/or incontinence Emergency: magnesium sulfate toxicity Assess for S/S - respiration less than 12/min - urinary output less than 30 ml/hr - toxic serum levels more than 9.6 mg/dl fetal distress: drop in FHR, no fetal movements - significant drop in maternal pulse or BP - significant drop in maternal pulse or BP Collaborative management 1 STAT: DC MgSO4; open maintenance IV line 2. call for assistance STAT; notify attending physican 3. antidote for Mg toxicity = administer calcium gluconate or calcium chloride as ordered 4. monitor frequently: VS, MgSO4, serum levels NCP : PIH (hospitalized) 1. VS every 2-4 hrs note, record, and report persistent HPN 2. monitor FHR 3. I&O, to identiy diuresis 4. urinalysis (clean catch) 5. observe for signs of labor (AP 6. daily weight, amount and distribution of edema (pitting, pedal, digital, periorbital) to identify signs of mobilization of fluid, diuresis Nutrition 1. increased protein intake to increase blood osmolority 2. do not eliminate sodium, but avoid food increase in salt (potato chips, pickles) 3. avoid alcohol & smoking 4. fluid intake: 8-10 glasses/day 5. food with roughage to stimulate peristalsis ND 1. anxiety RL to cause of pregnancy and possible death of the fetus 2. fluid volume deficit RL to fluid shift from intravascular to extravascular space secondary to vasospasm 3. risk for injury to mother RL sedation and seizures 4. risk for trauma to mother RL to magnesium toxicity
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COMPLICATIONS OF INTRAPARTUM PERIOD

INTRAPARTUM - begins from the start of labor to 1 to 4 hours after delivery Induction of labor - is the deliberate initiation of labor before spontaneous contractions begin - means that the labor is artificially started may be either mechanical, physiologic or chemical * mechanical = amniotomy * physiologic = ambulation * chemical = methergine Primary reasons for inducing labor 1. overdue (at least 1 to 2 weeks) 2. toxemia (elevated blood pressure) 3. PROM (prolonged rupture of membrane) 4. chorioamnionitis (infection of membrane) 5. oligohydramnios 6. macrosomia 7. prior poor obstetrical Hx (prior stillborn) 8. intrauterine fetal death Reasons for not inducing labor 1. placenta previa (after birth in front of the baby's head) 2. prior classical C-section (incission is up and down on the uterus 3. breech baby or other abnormal fetal positions 4. fetal distress 5. active herpes infection (can affect fetus - opthalmia neonaturum) Before inducing labor, these conditions must be considered : 1. abscence of CPP, malpresentation or malposition 2. cervix is ripe, or ready for birth 3. engaged vertex of single gestation 4. the fetus is estimated to be matured by date Methods of inducing labor 1. induction by AROM (artificial rupture of membrane - amniotomy) - may be adequate to stimulate contractions and increased effectiveness of labor - is initiated when the cervix is soft, partially effaced, and slightly dilated, preferably when the fetal presenting part is engaged - maybe done after oxytocin administration establishes effective contraction Assessment during induction of labor 1. observe fluid - note color,amount 2. monitor FHR, assess for fetal distress 3. observe for signs of prolapsed cord 4. assess fetal activity - excessive activity may indicate distress - absence of activity may indicate distress or demise Induction of labor by prostaglandin (gel/suppositories) - this is the most commonly used method of speeding cervical ripening - have a unique ability to soften and dilate the cervix w/o painful contractions advantages - the more favorable the cervix, the less like the induction is needed - sometimes this is all that is needed disadvantages - takes longer to get into active labor - mother becomes nauseated or has headaches - trigger labor or lead to over-stimulation by the uterus - hyperstimulation results in C-section
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Induction of labor by oxytocin - initiates contractions in a uterus at pregnancy term to cause contractions - oxytocin is administered intravenously, or by dilute administration of an intravenous form - amount is increased every 15-30 mins until contraction pattern is achieved advantages - easier to control the AROM - faster effect disadvantages - can cause fetal distress - may or may not cause contractions - absent; last too long Cesarean delivery - surgical / operative by which infant or newborn is delivered through incisions in abdominal and uterine walls to give brith Indications of CS 1. previous CS 2. dystocia 3. hemorrage 4. fetal distress 5. preeclampsia 6. prolonged rupture of membrane 7. prolapsed cord 8. intrapartum infection 9. elederly primigravidas 10. Rh incompatibility 11. previous surgery 12. placenta previa / abruptio placenta 13. macrosomia 14. fetal maternal death Types of cesarean incisions 1. classic cesarean incision - a vertical midline skin incision is made in the skin and the body of the uterus - indicated in emergency situations - necessary for anterior placenta previa and transverse lie - permitting easier access to the fetus - blood is increased 2. low segment incision - this is the most common type of incision - the incision is low (bikini or Pfannestiel's incision) - the uterine incision is horizontal in the lower urterine segment - blood loss is minimal / less adhesion formed 3. porro's hysterotomy followed by hysterectormy - hemorrage from uterine atony - placenta previa, accreta - large uterine mayomas - ruptured uterus - cancer of uterus or ovary ND 1. self-esteem disturbance RL to failure to give birth vaginally 2. anxiety and fear RL to surgical operation 3. ineffective individual coping 4. fluid volume deficit RL to blood loss 5. pain RL to abdominal surgery 6. constipation RL to decreased bowel activity NCP 1. pre-operative
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a. monitor FHR continually b. notify neonatology and NICU of schedule surgical birth c. describe, discuss anticipated anesthesia d. explain procedure for preoperative antacids e. prepare for CS birth Prolapsed umbilical cord (33 - 35 cm normal length of cord) - occurs when the baby's umbilical cord falls into the birth canal ahead of the baby's head or other parts of the baby's body etiology - prematurity (SGA) - allows space for cord descent - unengaged cephalic presentation w/ ruptured membranes - shoulder and footling presentation - polyhydramnios - placenta previa assessment - signs of fetal distress may develop as the cord is compressed - the prolapse of the cord may be visible or palpable NCP Goal: reduce pressure on cord - position = place client in knee-chest position; lateral modified Sim's with hips elevated; modified Trendelenburg position - with gloved hand, suport fetal presenting part off cord Goal: increase fetal-maternal oxygenation - O2 per mask (8-10 L/min) Goal: protect exposed cord - cord with warm sterile saline dressing Goal: expedite termination of threat to infant - prepare for immediate vaginal / cesarean birth *Cervix is fully dilated @ the time of prolapsed cord - the physician may choose to deliver the infant quickly with possibly forceps delivery to prevent period of anoxia. *Incomplete dilatation - the birth method of choice is upward pressure on the presenting part to keep pressure off the cord - CS Pre-term labor (20-37 weeks) - labor that begins after 20 weeks gestation and before begining of week 38 etiology -PROM - preeclampsia - hydramnios - placenta previa - abruptio placenta - incompetent cervix - trauma - multiple gestation - intrauterine infection - uterine structural anomalies - congenital adrenal hyperplacia - fetal death Manifestations of preterm labor - rhythmic uterine contyractions - cervical effacement and dilatation - possible rupture of membranes
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- expulsion of the cervical mucus plug - bloody show Prevention A. primary - close obstetric observation; education is warning signs and symptoms of preterm labor 1. dull lower backache that radiates like a wave to the front of the abdomen 2. contractions every 10 minutes for 2 hours even after position changes 3. low back pain and light bloody discharge (bloody show) 4. pelvic pressure extending to the back and thighs B. secondary - prompt, effective treatment of associated disorders C. tertiary - suppression of preterm labor 1. bedrest 2. position: side-lying - to promote placental perfusion 3. hydration - IV fluids 4. pharmacologic - like Beta-andrenergic agents - to reduce sensitivity of uterine myometrium to oxytocic and prostaglandin stimulation; increase blood flow to teh uterus 5. may be maintained at home with adequate follow up and health teaching * magnesium sulfate - is a CNS depressant that acts to block neuromuscular transmissions to halt convulsions. IT can also be used to halt premature labor. * terbutaline - to enhance lungs (immature lungs); to prevent respiratory tract infection; to prevent obstruction airway of the lungs * ritodrine - to prevent or halt premature labor
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Ob Maternity Notes

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The Filipino Nursing Herald (http://nursingherald.blogspot.

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5. Pelvis / Pelvic Ring

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2. HYPOTHALAMUS 3. OVARY 4. UTERUS FERTILITY PERIOD

= stimulates the m. cycle, gives signals

COMPUTE FOR OVULATION DATE PHASES OF MENSTRUAL CYCLE

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GRAVIDA & PARA SYSTEM

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MULTIPLE 20 wks. Below 20-37 wks. 38-40 wks. 42 wks. Up

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> established at the time of fertilization by the male sex chromosome.

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22 WKS. 24 WKS. 24 WKS.

> LINEA NIGRA > MELASMA > STRIAE GRAVIDARUM

6 WKS. 6 WKS. 6 WKS. 6 WKS. 6 WKS. 16 WKS.

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4. THRUSH OR ORAL MONILIA in newborn

> candidal infection

STRUCTURE OF THE FETAL SKULL

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body pink, extremities blue

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COMPLICATIONS OF INTRAPARTUM PERIOD

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