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MATERNAL AND CHILD HEALTH NURSING

Maternal and Child Health Nursing involves care of the woman and family
throughout pregnancy and child birth and the health promotion and illness care
for the children and families.

Primary Goal of MCN
1 The promotion and maintenance of optimal family health to ensure
cycles of optimal childbearing and child rearing

I. ANATOMY & PHYSIOLOGY
1. Ovaries
o Almond shaped
o Produce, mature and discharge ova
o Initiate and regulate menstrual cycle
o 4 cm long, 2 cm in diameter, 1.5 cm thick
o Produce estrogen and progesterone

Estrogen: promotes breast dev’t & pubic hair distribution prevents osteoporosis
keeps cholesterol levels reduced & so limits effects of atherosclerosis Fallopian tubes..

1 Approximately 10 cm in length
2 Conveys ova from ovaries to the uterus
3 Site of fertilization
4 Parts: interstitial
isthmus – cut/sealed in BTL
ampulla – site of fertilization
infundibulum – most distal segment; covered with fimbria

2. Uterus
1 Hollow muscular pear shaped organ
 uterine wall layers: endometrium; myometrium; perimetrium
2 Organ of menstruation
3 Receives the ova
4 Provide place for implantation & nourishment during fetal growth
5 Protects growing fetus
6 Expels fetus at maturity
7 Has 3 divisions: corpus – fundus , isthmus (most commonly cut during CS
delivery) and
cervix

3. Uterine Wall
1 Endometrial layer: formed by 2 layers of cells which are as follows:
2 basal layer- closest to the uterine wall
3 glandular layer – inner layer influenced by estrogen and progesterone; thickens and
shed off
as menstrual flow
4 Myometrium – composed of 3 interwoven layers of smooth muscle; fibers are
arranged in longitudinal; transverse and oblique directions giving it extreme strength

4. Vagina
5 Acts as organ of copulation
6 Conveys sperm to the cervix
7 Expands to serve as birth canal
8 Wall contains many folds or rugae making it very elastic
Fornices – uterine end of the vagina; serve as a place for pooling of semen following
coitus
Bulbocavernosus – circular muscle act as a voluntary sphincter at the external opening
to the
vagina (target of Kegel’s exercise)

II. PUBERTAL DEVELOPMENT

1. Puberty:
1 the stage of life at which secondary sex changes begins
2 the development and maturation of reproductive organs
which occurs in female 10-13 years old & male at 12-14 yrs old
3 the hypothalamus serve as a gonadostat or regulation
mechanism set to “turn on” gonad functioning at this age

2. Reproductive Development

Readiness for child bearing
1 begins during intrauterine life
2 full functioning initiated at puberty
-the hypothalamus releases the GnRF which triggers the APG to form and
release FSH
and LH. (FSH & LH initiates production of androgen and estrogen ---> 2°
sexual
characteristics

Role of Androgen
1 Androgenic hormones – are produced by the testes, ovaries and adrenal cortex which
is responsible for:
muscular development
physical growth
inc. sebaceous gland secretions
1 testosterone –primary androgenic hormone

Related terms
a. Adrenarche – the development of pubic and axillary hair (due to androgen
stimulation)
b. Thelarche – beginning of breast development
c. Menarche – first menstruation period in girls (early 9 y.o. or late 17 y.o.)
d. Tanner Staging
2 It is a rating system for pubertal development
3 It is the biologic marker of maturity
4 It is based on the orderly progressive development of:
5 breasts and pubic hair in females
6 genitalia and pubic hair in males

3. Body Structures Involved

1 Hypothalamus
2 Anterior Pituitary Gland
3 Ovary
4 Uterus

4. Menstrual Cycle
1 Female reproductive cycle wherein periodic uterine bleeding occurs in response to
cyclic hormonal changes
2 Allows for conception and implantation of a new life
3 Its purpose it to bring an ovum to maturity; renew a uterine bed that will be
responsive to the growth of a fertilized ovum
5. Menstrual Phases
• First: 4-5 days after the menstrual flow; the endometrium is very thin, but begins to
proliferate rapidly; thickness increase by 8 folds under the influence of increase in estrogen
level
also known as: proliferative; estrogenic; follicular and postmentrual phase

• Secondary: after ovulation the corpus luteum produces progesterone which causes the
endometrium become twisted in appearance and dilated; capillaries increase in amount
(becomes rich, velvety and spongy in appearance also known as: secretory;
progestational; luteal and premenstrual

• Third: if no fertilization occurs; corpus luteum regresses after 8 – 10 days causing
decrease in progesterone and estrogen level leading to endometrial degeneration;
capillaries rupture; endometrium sloughs off ; also known as: ishemic

• Final phase: end of the menstrual cycle; the first day mark the beginning of a new cycle;
discharges contains blood from ruptured capillaries, mucin from glands, fragments of
endometrial tissue and atrophied ovum.

Physiology of Menstruation

1. About day 14 an upsurge of LH occurs and the graafian follicle ruptures and the ovum
is released
2. After release of ovum and fluid filled follicle cells remain as an empty pit; FSH
decrease in Amount; LH increase continues to act on follicle cells in ovary to produce
lutein which is high in progesterone ( yellow fluid) thus the name corpus luteum or
yellow body
3. Corpus luteum persists for 16 – 20 weeks with pregnancy but with no fertilization
ovum atropies in 4 – 5 days, corpus luteum remains for 8 -10 days regresses and
replaced by white fibrous tissue, corpus albicans

Characteristics of Normal Menstruation Period
1. Menarche – average onset 12 -13 years
2. Interval between cycles – average 28 days
3. Cycles 23 – 35 days
4. Duration – average 2 – 7 days; range 1 – 9 days
5. Amount – average 30 – 80 ml ; heavy bleeding saturates pad in <1hour
6. Color – dark red; with blood; mucus; and endometrial cells

Associated Terms

1. Amenorrhea - temporary cessation of menstrual flow
2. Oligomenorrhea - markedly diminished menstrual flow
3. Menorrhagia - excessive bleeding during regular menstruation
4. Metrorrhagia - bleeding at completely irregular intervals
5. Polymenorrhea - frequent menstruation occurring at intervals of less than 3 weeks

Ovulation
1 Occurs approximately the 14th day before the onset of next cycle (2 weeks before)
2 If cycle is 20 days – 14 days before the next cycle is the 6th day, so ovulation is day 6
3 If cycle is 44 days – 14 days, ovulation is day 30.
4 Slight drop in BT (0.5 – 1.0 °F) just before day of ovulation due to low progesterone
level then rises 1°F on the day following ovulation (spinnbarkheit; mittelschmerz)
5 If fertilization occurs, ovum proceeds down the fallopian tube and implants on the
endometrium

Menopause
o Mechanism- a transitional phase (period of 1 – 2 years) called climacteric, heralds
the onset of menopause.
o Monthly menstrual period is less frequent, irregular and with diminished amount.
o Period may be ovulatory or unovulatory - advised to use Family planning method until
menses have
been absent for 6 continuous months
o Menopause is has occurred if there had been no period for one year.

Classical signs: Vasomotor changes due to hormonal imbalance
a. hot flushes
b. excessive sweating especially at night
c. emotional changes
d. insomnia
e. headache
f. palpitations
g. nervousness
h. apprehension
i. depression
j. tendency to gain weight more rapidly
k. tendency to lose height because of osteoporosis (dowager hump)
l. arthralgias and muscle pains
m. loss of skin elasticity and subcutaneous fat in labial folds

Artificial menopause / surgically induced menopause
a. oophorectomy or irradiation of ovaries
b. panhysterectomy

III. PROMOTE RESPONSIBLE PARENTHOOD – FAMILY PLANNING

A. Artificial Methods:
1. physiologic method: oral contraceptives ; natural methods
2. mechanical methods
3. chemical methods
4. surgical methods

Oral contraceptive

Action: inhibits release of FSH  no ovulation
Types: Combined ; Sequential; Mini pill

Side Effects: due to estrogen and progesterone
> nausea and vomiting > Headache and weight gain
> breast tenderness > dizziness
> breakthrough bleeding/spotting
> chloasma
Contraindications:
a. Breastfeeding
b. Certain diseases:
o thromboembolism
o Diabetes Mellitus
o Liver disease
o migraine; epilepsy; varicosities
o CA; renal disease;recent hepatitis
c. Women who smoke more than 2 packs of cigarette per day
d. Strong family Hx of heart attack

Note: If taking pill is missed on schedule, take one as soon as remembered and
take next pill on schedule; if not done withdrawal bleeding occurs.
B. Natural Methods:

a. Rhythm/Calendar/Ogino Knause Formula
o Couple abstains on days that the woman is fertile
o Menstrual cycles are observed and charted for 12 months

Standard Formula: first day of the beginning of one cycle to the first day of the
next cycle

shortest cycle = minus 18
longest cycle = minus 11

Example: shortest cycle = 28
longest cycle = 35

Shortest cycle: 28 days – 18 = 10
Longest cycle: 35 days – 11 = 24
Fertile pd: 10th to 24th day of cycle = No sexual intercourse

b. Billings Method / Cervical Mucus
o woman is fertile when cervical mucus is thin and watery; may be extended
o Sexual Intercourse may be resumed after 3 – 4 days

c. Symptothermal Method / BBT

1 Requires daily observation and recording of body temperature before rising in
the
morning or doing any activity to detect time of ovulation
2 Ovulation is indicated by a slight drop of temperature and then rises
3 Resume Sexual intercourse after 3 – 4 days
4 Recommended observation of BBT is 6 menstrual cycle to establish pattern of
fluctuations

C. Mechanical Methods

1. Intrauterine Device - prevents implantation by non-specific cell
inflammatory reaction
inserted during menstruation (cervix is dilated)

SE: increased menstrual flow
spotting or uterine cramps
increased risk of infection
Note: when pregnancy occurs, no need to remove IUD, will not harm
fetus

2. Diaphragm
o a disc that fits over the cervix
o forms a barrier against the entrance of sperms
o initially inserted by the doctor
o maybe washed with soap and water is reusable
o when used, must be kept in place because sperms remains viable for 6 hrs.
in the vagina but must be removed within 24 hours (to decrease risk of
toxic shock syndrome)

3. Condom
1 a rubber sheath where sperms are deposited
2 it lessens the chance of contracting STDs
3 most common complaint of users  interrupts sexual act when to apply

D. Chemical Methods

These are spermicidals (kills sperms) like jellies, creams, foaming tablets,
suppositories

E. Surgical Method
a. Tubal Ligation:
Fallopian tubes are ligated to prevent passage of sperms
Menstruation and ovulation continue

b. Vasectomy:
Vas deferens is tied and cut blocking the passage of sperms
Sperm production continues
Sperms in the cut vas deferens remains viable for about 6 months hence
couple
needs to observe a form of contraception this time to prevent pregnancy

IV. BEGINNING OF PREGNANCY

A. Fertilization
1. Union of the ovum and spermatozoon
2. Other terms: conception, impregnation or fecundation
3. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp.
4. Number of sperms: 120-150 million/cc/ejaculation
5. Mature ovum may be fertilized for 12 –24 hrs after ovulation
6. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation (life
span of sperms 72 hrs)
B. Implantation

General Considerations:
o Once implantation has taken place, the uterine endometrium is now termed
decidua
o Occasionally, a small amount of vaginal bleeding occurs with implantation due to
breakage of capillaries
o Immediately after fertilization, the fertilized ovum or zygote stays in the
fallopian tube for 3 days, during which time rapid cell division (mitosis) is
taking place. The developing cells now called blastomere and when about to
have 16 blastomere called morula.
o Morula travels to uterus for another 3 – 4 days
o When there is already a cavity in the morula called blastocyt
o finger like projections called trophoblast form around the blastocyst, which
implant on the uterus
o Implantation is also called nidation, takes place about a week after fertlization

C. Stages of human prenatal development

1. Cytotrophoblast – inner layer
2. Syncytiotrophoblast – the outer layer containing
finger like projections called chorionic villi which
differentiates into:
o Langerhan’s layer – protective against Treponema Pallidum,
present only during the second trimester
o Syncytial Layer – gives rise to the fetal membranes, amnion and
chorion

D. Fetal Membranes
1. Amnion – gives rise to umbilical cord/funis – with 2 arteries and 1 vein supported by
2. Wharton’s jelly
3. Amniotic fluid: clear albuminous fluid, begins to form at 11 – 15th week of gestation,
chiefly derived from maternal serum and fetal urine, urine is added by the 4th lunar
month, near term is clear, colorless, containing little white specks of vernix caseosa,
produced at rate of 500 ml/day. Known as BOW or Bag of Water

E. Amniotic Fluid

Purposes of Amniotic Fluid
Protection – shield against pressure and temperature changes
Can be used to diagnose congenital abnormalities intrauterine– amniocentesis
Aid in the descent of fetus during active labor

Implication:
Polyhydramios = more than >1500 ml due to inability of the fetus to swallow the fluid
as in
trachoesophageal fistula.

Oligohydramnios = less than <500 ml due to the inability of the kidneys to add urine
as in
congenital renal anomaly
F. Fetal Membranes
•Chorion - together with the deciduas basalis gives rise to the placenta, start to form at
8th
week of gestation; develops 15 – 20 cotyledons

•Purpose of Placenta: respiratory; exchange of nutrients and oxygen
•Renal system
•Gastrointestinal system
•Circulatory system
•Endocrine system: produces hormones (before 8th week-corpus luteum produces these
hormones) hCG keeps corpus luteum to continue producing estrogen and progesterone
•HPL or human chorionic somatomammotropin which promotes growth of mammary
glands for
lactation
•Protective barrier: inhibits passage of some bacteria and large molecules

V. FETAL GROWTH AND DEVELOPMENT

First lunar month
• Germ layers differentiate by the 2nd week
1. endoderm – gives rise to lining of GIT, Respiratory Tract, tonsils, thyroid (for basal
metabolism),
parathyroid (for calcium metabolism), thymus gland (for development of
immunity),
bladder and urethra

2. Mesoderm – forms into the supporting structures of the body (connective tissues,
cartilage, muscles and tendons); heart, circulatory system, blood cells, reproductive
system, kidneys and ureters.

3. Ectoderm – responsible for the formation of the nervous system, skin, hair and nails
and the
mucous membrane of the anus and mouth
1 month: 2nd week – fetal membranes 16th day – heart forms ; 4th week – heart
beats

2nd month: All vital organs and sex organs formed; placental fully developed;
meconium formed (5th –8th wk)

3rd month: Kidneys function - 12th wk- urine formed ; Buds of milk teeth form ; begin
bone ossification ; allows amniotic fluid ; establishment of feto-placental exchange

4th month: Lanugo appears; buds of permanent teeth form; heart beat heard by fetoscope

5th month: Vernix appears; lanugo over entire body; quickening; FHR audible with
stethoscope

6th month: Attains proportions of full term but has wrinkled skin

7th month: 28 weeks – lower limit of prematurity; alveoli begins to form

8th month: 32 weeks – fetus viable; lanugo disappears, subcutaneous fat deposition begins

9th month: Lanugo continue to disappear; vernix complete; amniotic volume decrease

Focus of Fetal Development

First Trimester – period of organogenesis

Second Trimester – period of continued fetal growth and development; rapid increase in
length

Third Trimester – period of most rapid growth and development because of the deposition
of
subcutaneous fat
Assessing Fetal Well-being

Fetal Movement:
Quickening at 18 – 20 weeks , peaks at 29 -38 weeks
Consistently felt until term

a. Cardiff Method: “Count to ten” - records time interval it takes for 10
- fetal movements to be felt  usually occurs
in 60
minutes

b. Contraction Stress Test: Fetal Heart Rate (FHR) analyzed in conjunction with
contractions
Nipple stimulation done to induce gentle contractions
***3 contractions with 40 sec duration or more must
be present
in 10 minutes window
Normal Result  no fetal decelerations with
contractions

c. Non-stress Test: Measures response of FHR to fetal movement (10-
20mins.) 
with fetal movement FHR increase by 15 beats and
remain for 15 seconds then decrease to average rate
(no increase means poor oxygen perfusion to fetus)

d. Amniocentesis - done to determine fetal maturity: Identify L/S ratio
16 wks – detect genetic disorder
30 wks – assess

1. Prior to the procedure, bladder should be emptied; ultrasonography is used
to avoid
trauma from the needle to the placenta, fetus

2. Complications include premature labor, infection, Rh isoimmunization

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

4. Teach client to report decreased fetal movement, contractions, or abdominal
discomfort
after procedure.

e. Ultrasound – transducer on abdomen transmits sound waves that show
fetal image on screen

a. Done as early as five weeks to confirm pregnancy, gestational age
b. Multiple purposes – to determine position, number, measurement of fetus(es)
and other structures (placenta)
c. Client must drink fluid prior to test to have full bladder to assist in clarity of
image
d. No known harmful effects for fetus or mother
e. Noninvasive procedure
VI. NORMAL ADAPTATIONS IN PREGNANCY

1. Cardiovascular/ Circulatory changes:

a. Physiologic anemia of pregnancy
-30-50% gradual increase in total cardiac volume (peak 6th month) causing drop in
Hemoglobin
and Hematocrit values (inc only in plasma volume)
Consequences of increased cardiac volume:
1. easy fatigability & shortness of breath due increase cardiac workload
2. slight hypertrophy of the heart
3. systolic murmurs due to lowered blood viscosity
4. nosebleeds may occur due to congestion of nasopharynx

b. Palpitations
caused by the SNS stimulation during early part of pregnancy; increased pressure of
the uterus
against the diaphragm during the second half of pregnancy

c Edema of the lower extremities & varicosities
due to poor circulation caused by the pressure of the gravid uterus on the blood vessels
of the
lower extremities

d. Vaginal and rectal varicosities
- due to pressure on blood vessels of the genitalia
Management: side lying hips elevated on pillow modified knee chest position

e. Predisposition to blood clot formation
-due to increased level of circulating fibrinogen as a protection from bleeding
implication: no
massage

2. Gastrointestinal Changes

a. Morning sickness
2 nausea and vomiting in the 1st trimester due to HCG or due to increased acidity or
emotional
factors
3 Management: dry toast 30 mins before get up in AM

b. Hyperemesis gravidarum
4 excessive nausea & vomiting which persists beyond 3 months causing dehydration,
starvation and acidosis
5 Management: hydration in 24 hrs; complete bed room

c. Constipation and Flatulence
GI displacement slows peristalsis & gastric emptying time; inc progesterone

d. Hemorrhoids
1 due pressure of enlarged uterus
2 Management: cold compress with witch hazel and Epsom salts

e. Heartburn
1 due to increased progesterone and decreased gastric motility causing regurgitation
through gastric sphincter
2 Management: pats off butter before meals
avoid fried, fatty foods
sips of milk at intervals
small, frequent meals taken slowly
don’t bend on waist
take antacids (milk of magnesia)

3. Respiratory Changes

a. Shortness of Breath
due to inc. oxygen consumption and production of carbon dioxide during the 1st
Trimester;
and increased uterine size pushing the diaphragm crowding chest cavity
management: side lying position to promote lateral chest expansion

4. Urinary Changes

a. Urinary frequency
felt during the 1st trimester due to the increase blood supply to the kidneys
and then on
the 3rd trimester due to pressure on the bladder.

b. Decreased renal threshold for sugar
due to increased production of glucocorticoids which cause lactose and
dextrose to spill
into the urine; and inc. progesterone

5. Musculoskeletal changes
a. Pride of Pregnancy
1 due to need to change center of gravity result to lordotic position

b. Waddling gait
1 due to increased production of hormone relaxin, pelvic bones becomes more
movable
2 increasing incidence of falls

c. Leg cramps
1 due to pressure of gravid uterus, fatigue, muscle tenseness, low calcium and
phosphorus intake

6. Endocrine Changes
a. Addition of the placenta as an endocrine organ producing HCG, HPL, estrogen
and progesterone
b. Moderate enlargement of the thyroid due to increased basal metabolic rate
c. Increased size of the parathyroid to meet need of fetus for calcium
d. Increased size and activity of adrenal cortex increasing circulating cortisol,
aldosterone, and ADH which affect CHO and fat metabolism causing
hyperglycemia.
e. Gradual increase in insulin production but there is decreased sensitivity to
insulin during pregnancy

7. Weight Change
a. First Trimester 1.5 to 3 lbs normal weight gain
b. 2nd and 3rd trimester 10 – 11 lbs per trimester is recommended
c. Total allowable weight gain during throughout pregnance is 20 – 25 lbs or 10 –
12 kgs.
d. Pattern of weight gain is more important than the amount of weight gained.

8. Emotional responses
a. 1st trimester: some degree of rejection, disbelief, even depression because of
its future implication -> give health teachings on body changes and allow for
expression of feelings
b. 2nd trimester: fetus is perceived as a separate entity and fantasizes
appearance
c. 3rd trimester: best time to talk about layette, and infant feeding method. To
allay fear of death let woman listen to the FHT.

VII. COMMON EMOTIONAL RESPONSES DURING PREGNANCY

• Stress –decrease in responsibility taking is the reaction to the stress of pregnancy not the
pregnancy itself  affects decision making abilities

• Couvade – syndrome – men experiencing nausea/vomiting, backache due to stress, anxiety
and empathy for partner

• Emotional labile – mood changes/swings occur frequently due to hormonal changes

• Change in Sexual Desire – may increase or decrease  needs correct interpretation… not
as a loss of interest in sexual partner

VIII. LOCAL CHANGES DURING PREGNANCY

1. Uterus – wt increase to about 1000 grams at full term due to increase in fibrous and elastic
tissues
a. Becomes ovoid in shape
b. Softening of lower uterine segment: Hegar’s sign seen at 6th week
c. Operculum – mucus plug to seal out bacteria
d. Goodell’s sign – cervix becomes vascular and edematous giving it consistency
of the earlobe

2. Vagina – increased vascularity occurs
a. Chadwick’s sign – purplish discoloration of the vagina
b. Leukorrhea – increased amount of vaginal discharges due to increased activity
of estrogen and of the epithelial cells.
a. Must not be itchy, foul smelling, excessive, nor green/yellow in color.
b. Management: good hygiene
c. Under the influence of estrogen, vaginal epithelium & underlying tissues 
hypertrophic & enriched with glycogen
d. pH of vaginal secretions during pregnancy fall

• Microorganisms that thrive in an alkaline environment:
a. Trichomonas – causes trichomonas vaginalis/vagnitis or trichomoniasis
s/s: frothy, cream-colored, irritatingly itchy, foul smelling discharges,
vulvar
edema
Management : Flagyl 10 days p.o. or trichomonicidal cmpd
suppositories
(e.g. Tricofuron, Vagisec, Devegan)
Management:
1. treat male partner also with Flagyl
2. avoid alcohol to prevent SE
3. dark brown urine expected
4. Acidic vaginal douche (1 tbsp vinegar:1 qt water or 15 ml: 1000 ml)
5. avoid intercourse to prevent reinfection

a. Candida Albicans - condition is called Moniliasis or Candidiasis
6 it thrives in an environment rich in CHO and those on steroid or
antibiotic
therapy
7 seen as oral thrush in the NB when transmitted during delivery
8 s/s: white, patchy, cheese-like particles that adhere to vaginal
walls, foul
smelling discharges causing irritating itchiness
Management :
1. Mycostatin/Nystatin p.o. or vaginal suppositories 100,000 U BID x 15
days
2. Gentian violet swab to vagina
3. Acidic vaginal douche
4. Avoid intercourse

3. Ovaries
Inactive since ovulation does not take place during pregnancy. Placenta produces
Progesterone and Estrogen during pregnancy

4. Abdominal Wall
1 Striae Gravidarum – due to rupture and atrophy of connective tissue layers on the
growing abdomen
2 Linea Nigra
3 Umbilicus is pushed out
4 Melasma or Chloasma – increased pigmentation due increased production of
melanocytes by the pitutitary
5 Unduly activated sweat glands

IX. SIGNS OF PREGNANCY
I. Pregnancy

1 Prenatal care is important for prevention of infant and maternal morbidity and
mortality
2 Care is a cooperative action based on client’s understanding of treatment modalities
3 Duration of normal pregnancy 266 – 280 days of 38 – 42 weeks or 9 calendar months
or 10 lunar months.
4 Infant born < 38 weeks pre-term & 42 post term)
5 Diagnosis: Urine examination – tests presence of HCG (present from 40th –100th day,
peak 60 days) conduct test 6 weeks after LMP

2. Prenatal Visit
History Taking:
personal data obstetrical data
gravida para
TPAL past pregnancies
present pregnancy: cc LMP
medical data: hx of diseases/illnesses

3. Danger Signals of Pregnancy

1. Vaginal bleeding (any amount)
2. Swelling of face or fingers
3. Severe, continuous headache
4. Dimness or blurring of vision
5. Flashes of light or dots before eyes
6. Pain in the abdomen
7. Persistent vomiting
8. Chills and fever
9. Sudden escape of fluids from the vagina
10. Absence of FHT after they have been initially heard on 4th or 5th month
4. Assessment
a. Physical examination – review of systems
b. Pelvic examination (ask client to void)
c. IE – determine Hegar’s, Goodell’s, Chadwick’s
d. Ballotement – on 5th month
e. Pap Smear
f. Pelvic measurements (done after 6th month or 2 wks before EDC)
g. Leopold’s Manuever: to determine fetal presentation, position, attitude, est.
size and fetal parts
h. Vital signs
i. Blood studies: CBC Hgb, Hct , blood typing, serological tests
j. Urinalysis: test for albumin, sugar & pyuria

5. Important Estimates:
a. Age of Gestation:
 Nagele’s Rule: -3 calendar months and +7 days

Ex. LMP= May 15, 2006 or 5-15-06

LMP: 5 15
Formula: -3+ 7
EDC: 2 22 or February 22, 2007

• McDonald’s Rule: Ht fundus/4 (AOG wks)
1. Measure in cms the length from the symphysis to the
level of fundus
2. Lunar months: Fundal Height (cms) x 2/7
3. Weeks of pregnancy: Fundal height (cms) x 8/7

Ex. Fundal Height = 14 cms

Lunar Month: 14cms x 2 = 28 / 7 = 4 months
Weeks Pregnant: 14 cms x 8 = 112 / 7 = 16 weeks
AOG

• Bartholomew’s Rule: based on position of fundus in abdominal
cavity
3rd month = above symphysis
5th month = umbilical level
9th month = below xiphoid process)
b. Fetal Length:
1 Haase’s Rule: 1st half of pregnancy – square number of
months
Example : 2 months = 2x2 = 4 cm
2nd half of pregnancy – number of months multiplied
by 5
Example: 7 months x 5 = 35 cm
c. Fetal Weight:
1 Johnson’s Rule: Fundic Ht – n x k ( k=155; n = 11 not engaged/12
engaged)

Example for a not engaged fetus
Fundic Height given = 35 cms
n = 11 (standard for not engaged fetus)
k= 155 gms. (9 standard)
Solution: 35 cms – 11 = 24 x 155 =3,720 g
5. Health Teachings

a. Smoking – lead to LBW babies
b. Drinking – can cause respiratory depression in the NB and fetal withdrawal
syndrome if
excessive; alcohol has empty calories
c. Drugs – may be teratogenic hence contraindicated unless prescribed by Doctor
d. Sexual activity – allowed in moderation but not during last 6 wks- high
incidence of post
partum infection noted.
♣ counseling is important on changes in desire and positions
 contraindication: bleeding, ruptured BOW, incompetent
cervix, deeply engaged presenting part
e. Prepared childbirth/Childbirth education
1 Based on Gate Control Theory: pain is controlled in the spinal cord and
there
is a gate that can be closed to ease pain felt.
2 Information and breathing techniques help minimize discomfort of labor
experience
3 Discomfort can be lessened if abdomen is relaxed and allows uterus to
rise freely against it during contractions

Major Approaches to prepared childbirth

1 Teaching about anatomy, pregnancy, labor and delivery, relaxation
techniques,
breathing exercises, hygiene, diet and comfort measures

Grant-Dick Read Method: Fear leads to tension and tension leads to
pain
Lamaze Method: Psychoprophylactic method ; based on S-R
conditioning;
concentration on breathing is practiced

f. Immunization: Tetanus Toxois (TT) = 0.5 ml IM for all pregnant women
shall be
given in 2 doses- 4 wks interval with 2nd dose at
least 3 wks
before delivery
= booster doses given during succeeding
pregnancies
regardless of interval.
= 3 booster doses is equal to lifetime immunity

g. Clinic Visits for Pre-natal check-up
2 First 7 lunar months – every month
3 On 8th and 9th lunar month – every week
4 On 10th lunar month – every week until labor

X. LABOR AND DELIVERY

1. THEORIES OF LABOR ONSET
Uterine stretch theory
Oxytocin theory
Progesterone Deprivation theory
Prostaglandin theory

2. FOUR P’S OF LABOR
a. Power - the uterine contraction
b. Passenger – the fetus
c. Passageway – the maternal pelvis
d. Psyche – the mental and emotional aspect of the woman

a. POWER - Uterine Contractions:
a.1. Frequency – the beginning of one contraction to the beginning of the next contraction
a.2. Interval – pattern which increases in frequency and duration
a.3. Duration – the beginning of one contraction to the end of the same contraction
a.4. Intensity – strength of contraction, measured through a monitor or through touch of
a fingertip
on the fundus (mild, moderate or strong)

b. PASSENGER - Fetus

b.1. Fetal Skull:
a. largest part of the fetus - most frequent presenting part; least compressible
Bones: sphenoid, ethmoid, temporal, frontal, occipital, parietal
Suture lines: sagittal/ coronal, lamboidal

b.2. Fontanels - membrane covered spaces at the junction of the main suture lines
anterior fontanel: larger, diamond shaped; closes at 12 – 18 months
posterior fontanel: smaller, triangular shaped, closes at 2 – 3 months

b.3. Fetal Lie – relationship of the cephalocaudal axis of the fetus to the cephalocaudal
axis of the
mother.
Measurements:

b.4. Fetal Attitude – fetal position
Pelvis is divided into 6 areas: Anterior, Posterior, Transverse Left,
Transverse
Right, Posterior Left, Posterior Right
Fetal landmarks: Occiput (O); mentum (M), sacrum (S), and scapula (Sc)

b.5. Presentation –the part of the passenger that enters the pelvis is the presenting part
a. Cephalic – Vertex (occiput) ; Brow (sinciput); Face (mentum)
b. Breech – Complete (sacrum) ; Frank; Footling
c. Shoulder

b.6. Movement of Passenger upon birth or descent:
d. Descent
e. Flexion
f. Internal Rotation
g. Extension
h. External rotation/ restitution

c. PASSAGEWAY – maternal pelvis

c.1. Divisions
a. False Pelvis -supports the growing uterus during pregnancy
-directs the fetus into the true pelvis near the end of gestation
b. True Pelvis: the bony canal through which the fetus will pass during delivery formed
by the pubis in front, the iliac and ischia on the sides and the sacrum and
coccyx behind

c.2. Significant Pelvic Measurements

a. External – Suggestive only of pelvic size
> External Conjugate/ Baudelaocque’s Diameter
- the distance between the anterior aspect of the symphysis pubis and the
depression
below lumbar 5 (Average: 18 – 20 cm)

b. Internal – the actual diameters of the pelvic inlet and outlet
> Diagonal Conjugate
- the distance between the sacral promontory and inferior/lower margin of the
symphysis pubis
- widest AP diameter at outlet estimated on vaginal/pelvic exam (Average:
12.5 cm)

>Obstetrical Conjugate
- the distance from the inner border of the symphysis pubis to the sacral
prominence
- most important pelvic measurement
- shortest AP diameter of the inlet through which the head must pass
- 1.5 to 2 cm or less than the diagonal conjugate
>True Conjugate/Conjugate Vera
- the distance between the anterior surface of the sacral promontory and superior
margin
of the symphysis pubis
- diameter of the pelvic inlet (10.5 -11 cm)

>Bi-Ischial/ Tuberiischial Diameter
- the distance between the ischial tuberosities
- narrowest diameter of the outlet
- transverse diameter of the outlet (Average: 11 cm)

D. PSYCHE- the emotions of the mother

Factors that may increase a woman’s chance of depression:
1 History of depression or substance abuse
2 Family history of mental illness
3 Little support from family and friends
4 Anxiety about the fetus
5 Problems with previous pregnancy or birth
6 Marital or financial problems
7 Young age (of mother

Signs and Symptoms of Post-partum depression:
1 Feeling restless or irritable
2 Feeling sad, hopeless, and overwhelmed
3 Crying a lot
4 Having no energy or motivation
5 Eating too little or too much
6 Sleeping too little or too much
7 Trouble focusing, remembering, or making decisions
8 Feeling worthless and guilty
9 Loss of interest or pleasure in activities
10 Withdrawal from friends and family
11 Having headaches, chest pains, heart palpitations (the heart beating fast
and
feeling like it is skipping beats), or hyperventilation (fast and shallow
breathing)

3.PRELIMINARY/PRODROMAL SIGNS OF LABOR

a. Lightening
b. Increased activity level- “nesting behavior”
c. Loss of weight ( 2-3 lbs)
d. Braxton Hick’s Contractions
e. Cervical Changes – effacement
- Goodell’s sign – ripening of the cervix
f. Increase in back discomfort
g. Bloody Show - pinkish vaginal discharge
h. Rupture of Membranes– labor expect in 24 hours
i. Sudden burst of energy
j. Diarrhea
k. Regular Contractions - phases: increment,acme,decrement
- characteristics: intensity, frequency, interval,
duration

False Labor Pains True Labor Pains

o1 Remain irregular o6 Becomes regular and predictable
o2 Confined to abdomen o7 Radiates in girdle like fashion
o3 No increase in duration, frequency, o8 Increase in duration, frequency, intensity
intensity o9 Continue regardless of activity
o4 Disappears on ambulation o10 Effacement and dilatation occurs
o5 No cervical changes o11 Signs of True labor
Effacement
Dilatation

1 Uterine Changes– upper and lower segments; physiologic retraction ring
2 Bandl’s pathologic retraction ring- a danger sign of impending rupture of the
uterus if obstruction is not relieved

1. Nursing Interventions of Woman in Labor:

a. Assessment – history and physical assessment
a.1. Personal data
a.2. Obstetrical data
1 determine EDC
2 obstetrical score
3 amount/ character of show
4 status of the BOW
5 general physical examination
6 Leopold’s Maneuver: presentation
7 Internal examination: effacement ; dilatation; station

b. Monitoring and Evaluating Progress of Labor
b.1. Blood pressure
b.2. Fetal Heart Tone
b.3. Observe for signs of fetal distress
12 bradycardia
13 fetal thrashing
14 meconium stained amniotic fluid in non-breech presentation
b.4. Monitor and inform patient of progress of labor
b.5. Monitor progress – fetal
a) during labor check FHR
b) manage fetal distress

5. Analgesia/anesthesia during childbirth

5.1. Analgesia – relieves pain and its perception

5.2. Anesthesia – produces local or general loss of sensation ;
- usually regional anesthesia (e.g. spinal)

o Relieve uterine and perineal pain
o Usually safe for the fetus (potential for maternal hypotension)
o Types of Anesthesia:
a. Paracervical block
b. Peridural block: Epidural/caudal
c. Intradural: spinal/saddle block
d. Pudendal block
e. Local anethesia

o Regional Anesthesia is mostly preferred because it does not enter
maternal circulation nor affect fetus
o Xylocaine is used (NPO with IV infusion)
> allows to be awake and participate in process;
> can increase incidence of maternal hypotension and fetal
bradycardia

5.3. Analgesics:

5.3.1 Narcotics (Demerol)
o produces sedation/relaxation
o depresses NB’s respiration
o given in active labor
o Special Considerations:
Demerol is most commonly used
Has sedative and antispasmodic effect
Dose is usually 25 –100 mg depends on body weight
Not given early in labor due to possible effect on contractions
Not given too late (1 hr before delivery) can cause
respiratory depression in the newborn
Given if cervical dilatation is 6 – 8 cms.

5.3.2. Narcotic Antagonist: Narcan; Nalline

6. Nursing Care before administration of anesthesia/analgesia

1.1.Assess pain status
1.2.Explain the action of drugs
1.3.Check vital signs of mother and fetus
1.4.Observe safety measures
Evaluate allergies
Provide siderails – have call bell ready
NPO (anesthesia)
Check time last medication was given
1.5.Nursing Care after administration of anesthesia/analgesia
1.6.Monitor: vital signs – BP and FHR (be alert for bradycardia)
1.7.Record properly
1.8.Provide comfort measures
1.9.Remember that the use of Forceps is needed in delivery of patient under
anesthesia due
to loss of coordination in bearing down during 2nd stage
1.10. Side effects:
a. postspinal headaches – place flat on bed for 12 hrs and increase
fluid intake
b. common side effect is hypotension (xylocaine –vasodilator):
Nursing Intervention:
turn to side
elevate legs
administer vasopressor and oxygen as ordered
Fetal bradycardia
Decreased maternal respirations

(Observe for bulging of the perineum)

XI. STAGES OF LABOR

1. Stages of Labor

Stage Characteristics

First Stage Extent:
- the stage of true labor until the Primigravida – 3.3.-19.7 hrs
complete cervical dilatation Multigravida – 0.1 - 14.3 hrs

a. Latent Phase 0-4 cms. cervical dilatation
Interval: 15-20 mins interval
Duration: 10-30 seconds

b. Active Phase 5-7 cms. cervical dilatation
Interval: 3-5 mins
Duration: 30-60 seconds

c. Transitional 8-10 cms cervical dilatation
Phase Interval: 2-3 mins.
Duration: 50-90 seconds

Second Stage Duration:
- begins with complete dilatation Primigravida – 30 mins. - 2 hrs.
of the cervix until the birth of the Multi-gravida- 20 mins – 1 hr.
newborn
Contractions- 2-3 mins for 50-90 secs
Mother is exhausted and has urge to
push

Third Stage Still with mild contractions until the
- from delivery of the newborn to placenta is expelled.
the delivery of the placenta Usually, placenta is expelled within 30
minutes.
Fourth Stage Uterine cramping
- the first hour after complete Rubra with small clots
delivery until the woman becomes
physically stable

2. Principles of Postpartum Care
a. Promote healing and the process of involution
b. Provide emotional support
c. Prevent postpartum complications
d. Establish successful lactation
e. Promote responsible parenthood (FP)
3. Nursing Care of the Woman in First & Second Stage Labor

a. Monitor discomfort/exhaustion/pain control – support client in choice of pain
control
b. Relaxation techniques taught during pregnancy where breathing is taught as a
relaxed
response to contraction
c. Low back pain – massage of sacral area
d. Use different breathing techniques during the different phases of labor
e. Encourage rest between contractions
f. Keep couple informed of progress
g. Administer analgesic : side effects-may prolong labor; local/ block/ general

4. Nursing Care of Woman in the 3rd Stage of Labor
a. Principle Of Watchful Waiting
b. Use Brandt Andrews Maneuver
c. Note Time Of Delivery (20 Minutes After Delivery Of The Baby)
d. Check Bp; Injects Oxytocin (Methergin 0.2 Mg/Ml Or Syntocinon 10 U/Ml Im)
e. Inspect Cotyledons For Completeness
f. Check Uterus For Contraction
g. Check Perineum For Lacerations -Give perineal care; apply perineal pads
h. Change gown
i. Place flat on bed
j. Keep warm – provide extra warm blanket
k. Give initial nourishment – warm milk, tea
l. Allow to rest/ sleep

5. Nursing Care of Woman in Fourth Stage
a. Lactation: promote lactation by encouraging early breastfeeding to stimulate
milk
production
*** Those mothers who cannot breastfeed:
suppressing agents are given – estrogen- androgen preparations given
first hours
post partum to prevent milk production. These drugs tend to increase
uterine
bleeding and retard involution. (e.g. diethylstilbestrol, Parlodel or
deladumone)

b. Rooming-in-concept
provides opportunity for developing positive family relationship
promotes maternal infant bonding
releases maternal caretaking responses

c. Assess vital signs, fundus and flow every 15 minutes.
d. Hydration and elimination
e. May ambulate
Puerperium - the 6 weeks period following delivery
Involution- time period for the return of the reproductive organs to return to its
pre-
pregnant state

8. Categories of Lacerations
8.1. First degree – involves vaginal mucous membrane and perineal skin
8.2. Second degree – involves the perineal muscles, vaginal mucous membrane
and
perineal skin
8.3. Third degree – involves all in the 2nd degree lacerations and the external
sphincter of
the rectum
8.4. Fourth degree – involves all in 3rd degree lacerations and the mucus
membrane of the
rectum

XII. PROMOTING HEALING AND INVOLUTION DURING POST-PARTUM

1. Vascular Changes
- Reabsorption of the 30-50% increase in cardiac volume within 5 – 10 minutes after
the third
stage of labor.
- WBC increases to 20,000 – 30,000/mm³
- Activation of the clotting factor
- All blood values are back to prenatal levels by 3rd or 4th week

2. Location of the Fundus
- Uterine involution is measured by determining the level of the fundus in relation to
the
umbilicus
- Nursing care:
 Assess condition and level of the fundus
 Position in prone or knee chest

1 Occurrence of afterpains – it is an indication of uterine contractions and are
normal. Usually
lasts up to 3 days after birth

Nursing Care:
 Explain to client cause of pain
 Do not apply heat
 Administer analgesics as prescribed

3. Genital Changes/ Discharges
- Presence of Lochia: uterine discharges consisting of blood, decidua, WBC and some
bacteria
- Characteristics:
pattern should not reverse –
1-3 days – rubra - - - bright red with no or minimal clots
4-9 days – serosa- - - thinner, serous sanguinous blood
10- 3 to 6 wks pp – alba - - - whitish discharge
same amount as menstrual flow, decreased if with breastfeeding , increased
with activity
with fleshy odor; never foul smelling

4. Perineal Pain
Nursing Care:
 Place in Sim’s position – lessens strain on the suture line
 Expose to dry heat or warm Sitz bath
 Application of topical analgesics or oral analgesics as ordered
 Provide/ encourage perineal care

5. Sexual Activity
1 sexual stimulation may be decreased due to emotional factors and hormonal
changes
2 it may be resumed if bleeding has stopped and episiorrhaphy has healed by
the 3rd or
4th week
6. Menstruation
1 Breastfeeding influences return of the menstrual flow.
2 Breastfeeding – menses return in 3 – 4 months;
o some do not menstruate throughout lactation period
o ovulation is also possible with lactational amenorrhea
3 Non-Breastfeeding Mothers – menstrual flow return within 8 weeks

7. Urinary Changes
o marked diuresis occurs within 12 hours postpartum to eliminate excess tissue
fluids during pregnancy
o frequent urination in small amounts may be experienced by some
o others have difficulty of urination

Nursing Care:
 Explain cause of urinary changes
 Assist to promote voiding utilizing appropriate measures (encouraging
voiding, let client listen to sound of flowing water, etc.)

8. Gastrointestinal Changes
- Change is more on the delay of bowel evacuation; constipation
- Cause: decreased muscle tone
lack of food intake
dehydration
fear of pain

-Nursing Care: encourage early ambulation
increase fluids
increase fibers in the diet
9. Vital Signs
o Temperature: may increase because of dehydration on the first 24 hours pp.
o CR 50 – 70 beats/min (bradycardia) is common for 6 - 8 days pp.
o RR – no change is expected
o Weight = 10 – 12 lbs is expected to be immediately lost. This corresponds to the
weight of the fetus, placenta, amniotic fluid and blood. Diaphoresis will
contribute to further weight loss

10. Provision of Emotional Support
Post-partum Psychological Phases
1. Taking – in : First 1 – 2 days; mother focuses on herself and her experience
2. Taking – hold: mother starts to assume her role
3. Letting go

Postpartum Blues – overwhelming sadness that cannot be accounted for. Could be due
to
hormonal changes, fatigue or feelings of inadequacy.

Nursing Care: Encourage verbalization; crying is therapeutic, explain that it is normal

11. Establish Successful Lactation
Physiology of Lactation:
Estrogen & progesterone levels  stimulates APG to produce Prolactin  acts on
acinar cells to
produce foremilk  stored in collecting tubules -> infant sucking  stimulates
PPG to
produce oxytocin  causes contraction of smooth muscles of collecting tubules
 milk
ejected forward (milk ejection reflex or let down reflex  hindmilk is produced

Implications of lactation:
1 Breast milk will be produced postpartum
2 Lactation do not occur during pregnancy due to levels of estrogen and progesterone
3 Lactation suppressing agents are to be given immediately after placental delivery to be
effective
4 Oral contraceptives decrease milk supply and are contraindicated in lactating mothers
5 Afterpains are felt more by breastfeeding mothers due to oxytocin production; have
less lochia and rapid involution

12. Advantages of Breastfeeding
Mother: faster involution
less incidence of CA
economical- time, effort, cost

Infant: bonding with the mother
protection against common illness
less incidence of GI diseases
always available
13. Health Teachings
a. Hygiene
Wash breasts daily
No soap; No Alcohol for cleaning
Handwashing
Insert clean OS squares/ absorbent cloth in brassiere for breast discharges

b. Feeding Techniques

c. Nutrition: 3000 calories daily; 96 grams protein
d. Contraindications:
Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites,
cathartics,
tetracyclines.
Certain disease conditions – TB because of close contact during feeding
(TB germs are not transmitted thru breast milk)

XIII. ASSOCIATED PROBLEMS

1. Engorgement
 breast becomes full, tense and hot with throbbing pain
 expected to occur on the 3rd post partum day accompanied by fever (milk fever)last
for 240 due to increased lymphatic and venous circulation

Nursing care:
o encourage breastfeeding
o advise use of firm-supportive brassiere
o (if not going to breastfeed – apply cold compress; no massage; no breast
pump; apply
breast binder)
2. Sore Nipples
Nursing care:
encourage to continue BF
expose nipples to air for 10 – 15 minutes after feeding
(alternative) exposure to 20 watt bulb placed 12 – 18 inches away promotes
vasodilation
and therefore promote healing
do not use plastic liners
use nipple shield

3. Mastitis - inflammation of the breast

Signs & Symptoms: pain, swelling, redness, lumps in the breasts, milk becomes
scanty
Nursing Care:
Ice compress
Supportive brassiere , empty breast with pump
Discontinue BF in affected breast
Apply warm dressing to increase drainage
Administer antibiotics as prescribed

*** Postpartum Check-up: 6th week postpartum to assess involution

XIII. HIGH RISK PREGNANCY CONDITIONS

1. Infections
2. Bleeding / Hemorrhage/ PIH
3. Diabetes Mellitus
4. Heart Disease
5. Multiple Pregnancy
6. Blood Incompability
7. Dystocia
8. Induced Labor
9. Instrumental Deliveries

1. INFECTIONS

1.1. Syphilis
Cause: Treponema pallidum - a spirochete transmitted thru sexual
intercourse
Treatment: 2.4 – 4.8 million units of Penicillin (or 30 – 40 gms Erythrocin)
x 10 days
readily cross placenta thus prevent congenital syphilis
Untreated: Cause mid-trimester abortion
Cause CNS lesions
Can cause death

1.2. TORCH test series
T Oxoplasmosis (protozoa) avoid eating uncooked meat and handling cat
litter box

O thers: Syphilis, Varicella/ Shingles Rx – Zoster Immune Globulin ,Penicillin
Hepatitis B; Hepatitis A; AIDS

R Ubella Effect: if contracted early, slows down cell
division during organogenesis causing
congenital defects NB can carry and transmit
the virus for about 12 – 24 months after birth
C Ytomegalovirus (CMV) (DNA virus)

H erpes type 2

Group of maternal systemic infections that can cross the placenta or by ascending
infection
(after rupture of membranes) to the fetus.

Infection early in pregnancy may produce fetal deformities, whereas late infections
may result in
active systemic disease and/or CNS involvement causing severe neurological
impairment or
death of newborn

Sources/ Cause:
1. Endogenous/primary sources - normal bacterial flora
2. Exogenous sources - hospital personnel, excessive obstetric manipulations
breaks in aseptic techniques, coitus late in pregnancy
premature rupture of membranes

General symptoms: malaise, anorexia, fever, chills and headache

Management:
Complete Bedrest
Proper Nutrition
Increased Fluid Intake
Analgesics
Antipyretics and antibiotics as ordered

1.3. Infection of the perineum
Signs & Symptoms: pain, heat, feeling of pressure,
inflammation of suture line with 1 –2 stitches sloughed off
temperature elevation

Management: drain area & resuturing ; sitz bath & warm compress

1.4. Endometritis
- An infection/inflammation of the lining of the uterus

Signs & Symptoms: Abdominal tenderness Uterus not contracted and
painful to touch
Dark brown Foul smelling lochia

Management: Oxytocin administration
Fowler’s position to drain out lochia
Prevent pooling of discharges

1.5. Thrombophlebitis
-infection of the lining of a blood vessel with formation of clots, usual an
extension of
endometritis

Signs & Symptoms:
o1 Pain
o2 Stiffness and redness in the affected part of the leg
o3 Leg begins to swell below the lesion because venous circulation
has been blocked
o4 Skin is stretched to a point of shiny whiteness, called milk leg
of Phlegmasia alba dolens
o5 Positive Homan’s sign: calf pain on dorsi-flexing the foot

Specific Management:
1 bed rest with affected leg elevated
2 anticoagulants (e.g. Dicumarol or Heparin) to prevent
formation or extension of a thrombus

Side effect of Anticoagulant: hematuria, increased lochia

Considerations:
1 discontinue breastfeeding
2 monitor prothrombin time
3 have Protamine Sulfate at bedside to counter act severe bleeding
4 analgesics are given but not ASPIRIN because it prevents
prothrombin formation
which may lead to hemorrhage

2. HEMMORRHAGE/ BLEEDING

Definition: blood loss more than 500 cc. ( normal blood loss 250- 350 cc)
*** Leading cause of maternal mortality associated with childbearing

2.1. Early Post-partum hemorrhage – first 24 hrs after delivery

2.2. Late Postpartum Hemorrhage

Early Post-partum hemorrhage Late Postpartum Hemorrhage
Cause
Uterine Atony – uterus is not Retained Placental Fragments
well contracted, relaxed or boggy
(most frequent cause)

Lacerations
Hypofibrinogenemia
Clotting defect

Management blood transfusion D & C (Dilatation and
Bleeding in Pregnancy Curettage

Predisposing factor:
Overdistension of the uterus (multiparity, large babies, polyhydramnios,
multiple pregnancies)
Cesarean Section
Placental accidents (previa or abruptio)
Prolonged and difficult labor

Management: Massage –first nursing action
Ice compress
Oxytocin administration
Empty bladder
Bimanual compression to explore retained placental fragments
Hysterectomy (last alternative)
2.3. Hematoma
- Due to injury to blood vessels in the perineum during delivery

Incidence: Commnon in precipitate delivery and those with perineal
varicosities
Treatment:
1 Ice Compress in first 24 hours
2 Oral Analgesics as prescribed
3 Site is incised and bleeding vessel ligated

2.4. Pregnancy Induced Hypertension (PIH)
- A vascular disease of unknown cause
- Occurs anytime after the 24th wk of gestation up to 2 wks PP
- Develops during pregnancy and resolves during postpartum period

Predisposing Factors:
a. large fetus
b. Older than 35, younger than 17
c. primigravida
d. multiple pregnancy or H mole
e. poor nutrition
f. Hx of DM, renal and vascular disease
g. Morbid obesity or weight less than 100 lb
h. Family history
Diagnosis:
Roll – over test : Assess the probability of developing toxemia when done
between the
28th and 32nd week of pregnancy.

Procedure of Roll-over test:
1 Patient in lateral recumbent position for 15 minutes until BP Stable
2 Rolls over to supine position
3 BP taken at 1 minute and 5 minutes after roll over
4 Interpretation: If diastolic pressure increases 20 mmHg or more,
patient is prone to Toxemia

Types of Pregnancy Induced Hypertension (PIH):

a. Transient hypertension - without proteinuria or edema

b. Pre-eclampsia, mild
o BP of 140/90 mmHg or increase of 30/15mmHg
o 2+ to 3+ proteinuria
o begins past 20th week
o slight generalized edema may be present, weight gain of 1- 5
lbs/wk

c. Pre-eclampsia, severe
o BP of 150-160/100-110 mmHg
o 4+ proteinuria (5 gm/L or more in 24 hrs
o Headache and epigastric pain(aura to convulsions)
o Oliguria of 400 ml or less in 24 hrs. (normal UO/day 1500 ml)
o Cerebral or visual disturbances

d. Eclampsia - Obstetrical Emergency
o HPN
o Proteinuria
o Convulsions
o Coma
Immediate Intervention for Eclampsia:
a. Maintain IV line with large-bore needle
b. Monitor fluid balance
c. Minimize stimuli
d. Have airway and oxygen available
e. Give medications as ordered (e.g Magnesium sulfate, Apresoline,
Valium)
f. Prepare for possible delivery of fetus
g. Monitor fetal status
h. Type and cross match for blood
i. Postpartum- monitor vital signs and watch for seizure

Management for Eclampsia:
a. Digitalis (with Heart Failure)
Increase the force of contraction of the heart  decrease heart
rate
Nursing Considerations: Check CR prior to administration ( do
not give if
CR <60/min)

b. Potassium supplements – prevent arrhythmias

c. Barbiturates – sedation by CNS depression

d. Analgesics; antihypertensives, antibiotics, anticonvulsants,
sedatives

e. Magnesium Sulfate – drug of choice
Action: CNS depressant ; Vasodilator
Antidote: Calcium Gluconate- given 10% IV to maintain
Cardiac and vascular tone
Earliest sign of MgSO4 toxicity  disappearance of knee
jerk/patellar reflex
Method of delivery – preferably Vaginal but if not possible CS
Prognosis: the danger of convulsions is present until 48 hrs
postpartum

f. Cathartic – cause shift of fluid from the extra cellular spaces into the
intestines from where the fluid can be excreted

Dosage:
10 gms initially –either by slow IV push over 5 – 10 minutes or
deep IM,
5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100 ml
D10W),

Check first the ff. before administration:
1 Deep tendon reflexes are present
2 Respiratory rate = 12 / min
3 UO = at least 100 ml / 6 hrs.

Nursing Intervention:
a. Advised bedrest, left lateral
b. Encourage a well-balanced diet
c. Weigh daily, keep daily log
d. Education on self – assessment
e. Diversion
f. Family support
e. Post-delivery PIH
o with Disseminated Intravascular Coagulation – anticoagulant
therapy
o Monitor blood pressure for 48 hours

Diagnosis: Roll – over test : Assess the probability of developing toxemia when done
between the 28th and 32nd week of pregnancy.

Procedure on Roll-over test:
5 Patient in lateral recumbent position for 15 minutes until BP Stable
6 Rolls over to supine position
7 BP taken at 1 minute and 5 minutes after roll over
8 Interpretation: If diastolic pressure increases 20 mmHg or more, patient
is prone to Toxemia
Management:
a. Digitalis (with Heart Failure)
Increase the force of contraction of the heart  decrease heart rate
Nursing Considerations: Check CR prior to administration ( do not give if
CR <60/min)

b. Potassium supplements – prevent arrhythmias

c. Barbiturates – sedation by CNS depression

d. Analgesics; antihypertensives, antibiotics, anticonvulsants, sedatives

e. Magnesium Sulfate – drug of choice
Action: CNS depressant ; Vasodilator
Antidote: Calcium Gluconate- given 10% IV to maintain Cardiac and
vascular tone
Earliest sign of MgSO4 toxicity  disappearance of knee jerk/patellar
reflex
Method of delivery – preferably Vaginal but if not possible CS
Prognosis: the danger of convulsions is present until 48 hrs
postpartum

f. Cathartic – cause shift of fluid from the extracellular spaces into the
intestines from where the fluid can be excreted

Dosage: 10 gms initially –either by slow IV push over 5 – 10 minutes or
deep IM,
5 gms/buttock, then an IV drip of 1 gm per hour (1 gm/100
ml D10W),
May administer if :
4 Deep tendon reflexes are present
5 Respiratory rate = 12 / min
6 UO = at least 100 ml / 6 hrs.

3. DIABETES MELLITUS

a. Chronic hereditary disease characterized by marked hyperglycemia
b. Due to lack or absence of insulin  abnormalities in CHO, fat and protein
metabolism
c. Effects of pregnancy – may develop abnormalities in glucose tolerance decreased
renal threshold for sugar due to increased estrogen, inc. production of
adenocorticoids, Anterior Pituitary hormones, and thyroxin which affect CHO
concentration in blood (hyperglycemia)
d. Rate of insulin secretion is increased but sensitivity of the pregnant body to insulin
is decreased
Pregnancy Risks:
1 Toxemia
2 Infection
3 Hemorrhage
4 Polyhydramnios
5 Spontaneous abortion – because of vascular complications
which affect placental circulation
6 Acidosis – because of nausea and vomiting
7 Dystocia – due to large baby

Diagnosis : Glucose Tolerance Test (GTT)

Procedure for GTT:
NPO after midnight
2 ml of 50% glucose / 3 kg of pre-pregnant body weight given IV (oral glucose not
advisable due to decreased gastric motility and delayed
absorption of sugar during pregnancy)

Interpretation of Results:
a. If less than 100 mg% = normal
b. If 100 – 120 mg% possible GDM
c. If more than 120 mg% - overt gestational diabetes

Management:
a. Diet - highly individualized- adequate glucose intake (1,800 –
2200 calories) to prevent intrauterine growth retardation
b. Insulin requirements – individualized; increased during 2nd
and 3rd trimester because of more pronounced effect of
hormones
c. Method of Delivery – Cesarian Section

d. Postpartum Period – more difficult to control Blood Glucose
because of hormonal changes

Effect on Infant:
a. Typically longer and weighs more due to: excessive supply of
glucose from the mother
b. Increased production of growth hormone from maternal pituitary
gland
c. Increased secretion of insulin from the fetal pancreas
d. Increased action of adrenocortical hormone that favor the passage
of glucose from mother to fetus congenital anomalies are often
seen
e. Cushingoid appearance (puffy, but limp and lethargic)
f. Born premature more often – RDS common
g. Greater weight loss because of loss of extra fluid
h. Prone to hypoglycemia (BG <30 mg%)

Signs and symptoms of Diabetic Babies/ Hypoglemic Infant:
a. Shrill, high pitched cry
b. Listlessness/jitteriness/tremors
c. Lethargy/poor suck
d. Apnea/cyanosis
e. Hypotonia; hypothermia

***Consequence of hypoglycemia: untreated hypos  brain damage and even death

***Management: feed with glucose water earlier than usual, or administer IV of glucose
4. HEART DISEASE

Classification:
Class I - no physical limitation
Class II - slight limitation of physical activity
- Ordinary activity causes fatigue, palpitation, dyspnea, or angina
Class III - moderate to marked limitation of physical activity; less than ordinary
activity causes fatigue
Class IV -unable to carry on any activity without experiencing discomfort

Prognosis: Classes I & II – normal pregnancy & delivery
Classes III & IV – poor candidates

Signs & Symptoms:
Heart murmur due to increased total cardiac volume
Cardiac output decreased  nutritional and oxygen requirements not
met
Incomplete emptying of the left side of the heart  Pulmonary edema
and HPN (moist cough in Gravidocardiacs  danger sign)

Congestion of liver and other organs due to inadequate venous return  increased
venous pressure  fluid escapes through the walls of engorged capillaries and cause edema
and ascites CHF is a high probability due to increased CO during pregnancy  dyspnea,
exhaustion, edema, pulse irregularities, chest pain on exertion and cyanosis of
nailbeds are obvious

Management: (depends on cardiac functional capacity)

a. Bed rest – especially after 30th week of gestation
b. Diet – gain enough (consider effect on cardiac workload)
c. Medications: Digitalis, Iron preparations
d. Avoid lithotomy position to avoid increase in venous return, place in semi-
sitting position
e. Not allowed to bear down; Birth is via low forceps or Cesarean section
f. Anesthetic choice – caudal anesthesia
g. Ergotrate and other oxytoxics, scopolamine, diethylstilbestrol and oral
contraceptives –
h. contraindicated  can cause fluid retention and promote thromboembolism
i. Most critical period: immediate postpartum period when 30 – 50% increased
blood volume
j. is reabsorbed back in 5 – 10 minutes and the weak heart needs to adjust

5. MULTIPLE PREGNANCY

Risks: Increased Blood Loss
Small for Gestational Age Infants
Premature Birth
Dystocia

Management:
a. Monitor FHT, VS, weight
b. Cesarean Section
c. Health Teaching on importance of regular pre-natal check-up visits
d. Educate regarding proper nutrition and exercise

6. BLOOD INCOMPATIBILITY
- An antigen-antibody reaction which causes excessive destruction of fetal red blood
cells
Mother Fetus
Rh- negative Rh Positive (Father is homozygous
or heterozygous Rh positive)
BloodType O Either Type A or B (From father)

7. DYSTOCIA - broad term for abnormal or difficult labor and delivery

Uterine Inertia – sluggishness of contractions
Cause: Inappropriate use of analgesics
Pelvic bone contraction
Poor fetal position
Overdistention – due to multiparity, multiple pregnancy,
polyhydrmanios or excessively large baby
Management: Stimulation of labor by oxytocin administration or amniotomy

7.1. Precipitate Delivery
- labor and delivery that is completed in < 3 hours due to multiparity or
following
oxytocin administration or amniotomy

Effects: Extensive lacerations
Abruptio placenta
Hemorrhage due to sudden
Release of pressure shock

7.2. Prolonged Labor - Usually occurs in primi gravida
- Labor lasting more than 18 hrs and in multigravidas, more
than 12 hours

Effects: Maternal exhaustion
Uterine atony
Caput succedaneum

7.3. Uterine Inversion - fundus is forced through the cervix so that the uterus is
turned inside out
- Insertion of placenta at the fundus, so that as fetus is
rapidly delivered, fundus is pulled down
- Strong fundal push, attempts to deliver the placenta before
signs of separation
-Management: Hysterectomy

8. INDUCED LABOR
- Stages of labor and birth occurs due to chemical or mechanical means which is
usually performed to save the mothe or fetusr from complications which may cause death

Indications:
Maternal – toxemia
Placental accidents
Premature Rupture Of Membrane
Fetal: DM – terminated at about 37 wks AOG if indicated
Blood incompatibility
Excessive size
Postmaturity
Prerequisites to Induce Labor :
No Cephalo- Pelvic Dislocation
Fetus is already viable >32 weeks AOG
Single fetus in longitudinal lie and is engaged
Ripe cervix – fully or partially effaced; Cervical Dilatation at least 1=2 cm

Procedure for Induced labor:
1. Oxytocin Administration; 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8
gtts/min given initially  no fetal distress in 30 minutes  rate 16 -20 gts/min

2. Amniotomy – done with Cervical Dilatation = 4 cm ; Check FHR and quality of amniotic
fluid

Nursing Considerations:
Monitor uterine contractions  potential for rupture
Monitor flow rate regularly
Turn off IV with any abnormality in FHR or contractions
Watch out for complications: HPN, Antidiuresis
Prostaglandin administration: Route: oral or IV (never IM causes irritation);
effect is slower than oxytocin

9. INSTRUMENTAL DELIVERIES

a. Forceps Delivery
- Use of metal instruments to extract the fetus from the birth canal, when at +3 / +4 and
sagittal suture line is in an AP position in relation to the outlet (e.g. Simpson, Elliot, Piper for
breech presentation)

Purposes:
shorten second stage of labor because of fetal distress; maternal exhaustion;
maternal disease – cardiac, pulmonary complication
ineffective pushing due to anesthesia
prevent excessive pounding of fetal head against perineum (low forceps for
prematures)
poor uterine contraction or rigid perineum

Prerequisites:
Pelvis adequate, no disproportion
Fetal head is deeply engaged
Cervix is completely dilated and effaced
Membranes have ruptured
Vertical presentation has been established
The rectum and bladder are empty
Anesthesia is given for sufficient perineal
Relaxation and to prevent pain

Types: Low or Mid Forceps Delivery

Complications:
Forceps marks – noticeable only for 24 – 48 hrs
Bladder or rectal injury
Facial paralysis
Ptosis
Seizures
Epilepsy
Cerebral Palsy

a. Cesarean Section – birth through a surgical incision on the abdomen

Indications:
o Cephalo-pelvic disproportion (CPD)
o Severe Toxemia
o Placental Accidents
o Fetal Distress
o Previous classic CS – done prior to onset of labor pains; scheduled birth

Types:

1. Low Segment – the method of choice.
Incision is made in the lower uterine segment, which is the thinnest and most
passive
Part during active labor.

Advantages:
Minimal blood loss
Incision is easier to repair
Lower incidence of post partum infection
No possibility of uterine rupture

2. Lower vertical incision – recommended in:
Bladder or lower uterine segment
Adhesions from Previous operations
Anterior Placenta Previa
Transverse lie

Preoperative Care
a. The patient is both a surgical and an OB patient
b. Check vital signs, uterine contractions, and FHR
c. Physical examination; routine laboratory tests; blood typing and cross
matching
d. Abdomen is shaved from the level of the xiphoid process below the
nipple line,
extending out to the flanks on both sides up to the upper thirds of the
thighs
e. Retention catheter is inserted to constant drainage to keep the bladder
away from
the operative site
f. Preoperative medication is usually only atropine sulfate.
No narcotics are given  causes respiratory depression in the NB

Postoperative Care
a. Deep breathing, coughing exercises, turning from side to side
b. Ambulate after 12 hours
c. Monitor vital signs
d. Watch for signs of hemorrhage – inspect lochia; feel fundus (if
boggy, massage
with proper abdominal splinting and give analgesics as ordered)
e. Breastfeeding should be started 24 hrs after delivery
f. Most common complication: Pelvic thrombosis

10. OTHER RISK FACTORS:

10.1. Age:
- Maternal and infant mortality rates tend to be high in age below 15
and older
than 40 years

Adolescent pregnancy Advanced age
Most common problems: A precipitating factor in:
Toxemia Placental accidents
Iron-deficiency anemia Toxemia
Uterine atony or inertia
Varicosities; hemorrhoids
Low birth weight babies
Chromosomal Abnormalities like Down’s
Syndrome / Trisomy 21 (associated
with menopause)

10.2. Parity – first pregnancy is the period of high risk
Multiparity G5 and above and age is over 40

10.3. Birth Interval – 3 months from previous delivery or more than 5 years

10.4. Weight
Pre-pregnant weight < 70 lbs or > 180 lbs
Weight gain < 10 lbs  LBW babies
Weight gain > 30 lbs = sign of toxemia; DM; H-mole; polyhydramnios;
multiple pregnancy
10.5. Height
Short stature < 4 feet, 10 inches = contracted pelvis or CPD

XIV. MATERNAL COMPLICATIONS

1. Spontaneous Abortion
Termination of pregnancy spontaneously at any time before the fetus has attained
viability
Assessment:
1. Persistent uterine bleeding and cramplike pain
2. Laboratory finding – negatively or weakly positive urine pregnancy test
3. Obtain history, including last menstrual period

2. Ectopic Pregnancy
- Any gestation outside the uterine cavity

Causes of Ectopic Pregnancy:
a. Pregnancy Induce Hypertension
b. Previous tubal surgery
c. Congenital anomalies of the fallopian tubes

Signs & Symptoms:
1 Severe, sharp, knife-like stabbing pain
2 Rigid abdomen
3 Positive Cullen’s sign (bluish umbilicus)
4 Excruciating pain on IE
5 Signs of shock

Management: Ruptured Ectopic Pregnancy is an emergency requiring immediate
intervention
Salpingostomy – if Fallopian tube can still be replaced and preserved,pregnancy
is terminated
Saphingectomy – removal of FT and BT
Nursing Interventions:
1 Help woman to combat shock
2 Elevate foot of the bed
3 Maintain body heat
4 Prepare for surgery
5 Monitor for shock preoperatively and postoperatively
6 Provide emotional support and expression of grief
7 Administer Rhogam to Rh negative women
8 Discharge teaching

3. Hydatidiform Mole (H-Mole)
-Degenerative anomaly of chorionic villi

Signs & Symptoms:
1. Elevated hCG levelsmarked nausea & vomiting
2. Uterine size greater than expected for dates
3. No FHR
4. Minimal dark red/brown vaginal bleeding with passage of grapelike clusters
5. No fetus by ultrasound
6. Increased nausea and vomiting and associated with PIH

Management:
1. Curettage to completely remove all molar tissue that can become malignant
2. Pregnancy is discouraged for 1 year
3. hCG levels are monitored for 1 year (if continue to be elevated, may require
hysterectomy and chemotherapy)
4. Contraception discussed; IUD not used

4. Incompetent Cervical Os
One that dilates prematurely
Chief cause of habitual abortion ( 3 or more)
Causes:
1 Congenital Developmental Factors
2 Endocrine factors
3 Trauma to the cervix

Signs & Sypmtoms:
1 Presence of show and uterine contractions
2 Rupture of membranes, Painless cervical dilatation
5. Incompetent Cervix

6. Placenta Previa – the placenta is the presenting part

1. First and second trimester spotting
2. Third trimester bleeding that is sudden, profuse, painless
3. Ultrasonography – classified by degree of obstruction

Management:
1 Hospitalization, initially
2 Bedrest side-lying or Trendelenberg position for at least 72
hrs.
3 Ultrasound to locate placenta
4 No vaginal, rectal exam unless delivery would not be a
problem (if necessary must be done in OR under sterile
conditions)
5 Amniocentesis for lung maturity; monitor for changes in
bleeding and fetal status
6 Daily Hgb and Hct
7 Two units of crossmatched blood available
8 Monitor amount of blood loss
9 Send home if bleeding ceases and pregnancy is maintained
10 Limit activity
11 No douching, enemas, coitus
12 Monitor fetal movement
13 NST at least every 1 – 2 weeks
14 Monitor complications
15 Delivery by cesarean if evidence of fetal maturity, excessive
bleeding, active labor, other complications
7. Abruptio Placenta

Signs & Symptoms:
1. Painful vaginal bleeding
2. Abdomen (uterus) is tender, painful, tense (couvelaire uterus)
3. Possible fetal distress
4. Contractions

(Occurrence increased with maternal HPN and cocaine abuse; sudden release of
amniotic fluid; short cord; advanced age; multiparity; direct trauma;
hypofibroginemia)

Management:
a. Monitor maternal and fetal progress
b. Blood loss seen may not match symptom
c. Could have rapid fetal distress
d. Prepare for immediate delivery
e. Monitor for post partal complications

Predisposing Factors:
b. Disseminated intravascular coagulation
c. Pulmonary emboli
d. Infection
e. Renal failure
f. Transfusion hepatitis

Nursing Intervention:
Bedrest
Vital signs, FHT
Monitor intake and output
Seizure precautions
Medications (Magnesium sulfate, Apresoline, Valium)

8. Uterine Rupture -occurs when the uterus undergoes more straining than it is capable of
sustaining

Cause: Scar from previous CS
Unwise use of oxytocins
Overdistention
Faulty presentation
Prolonged labor

Signs & Sypmtoms:
Sudden severe pain
Hemorrhage and clinical signs of shock
Change in abdominal contour (two swelling on the abdomen due to retracted
uterus and the extrauterine fetus)
Management: Hysterectomy
9. Amniotic Fluid Embolism – (Obstetric Emergency)
– occurs when amniotic fluid is forced into an open maternal uterine flood sinus
through some defect in the membranes or after partial premature separation of the
placenta. Solid particles in the amniotic fluid enter maternal circulation and reach the
lungs as emboli

Signs and symptoms: Dramatic
Sudden inability to breathe, sits up, grasps chest and sharp chest pain
Turns pale then  bluish gray color
Death may occur in a few minutes

Management:
Emergency measures to maintain life: IV, oxygen, CPR
Provide intensive care in the ICU
Keep family informed
Provide emotional support

XVI. PREMATURE LABOR AND DELIVERY

- Uterine contractions occur before 38th week of gestation
Cause:
a. Pre-eclampsia
b. Placenta Previa
c. Age: Adolescent or 40 yrs old above primigravids

Management:
o If no bleeding; no CD, Good FHT, medication is given
Ethyl alcohol (Ethanol) IV – blocks release of Oxytocin
Vasodilan IV – vasodilator
Ritodrine – muscle relaxant per orem
Bricanyl – bronchodilator

o If premature delivery is evident pain meds are kept to a minimum to prevent
respiratory depression

o Steroids (glucocrticoids) for maturation of fetal lung  surfactant production

o Anesthesia preferred – caudal, spinal or infiltration – do not affect the infant

o Respiration forceps may be applied gently
o Cord is cut immediately – prevents transfer of extra amounts of blood because
prematures have difficulty excreting large amounts of bilirubin that will come the
extra blood.