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Obstetrics Review

Obstetrics Review

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ANGEL ALBERT F.

LAMBAN, RN, MD

Human Sexuality
Concepts
A

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

 Sex – basic and dynamic aspect of life  During reproductive years, the nurse performs as

resource person on human sexuality.

Definitions related to sexuality:
 Gender identity – sense of femininity or masculinity  2-4 yrs/3 yrs gender identity develops  Role identity – attitudes, behaviors and attributes that

differentiate roles
 Sex – biologic male or female status. Sometimes referred to

a

specific sexual behavior such as sexual intercourse.

 Sexuality - behavior of being boy or girl, male or female

man/

woman. Entity life long dynamic change.

 - developed at the moment of conception

Sexual Anatomy and Physiology
A. Female Reproductive System

1. External value or pretender

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

Stages of Pubic Hair Development
 Tannerscale tool - used to determine sexual maturity rating.  Stage 1 – Pre-adolescence. No pubic hair. Fine body hair only
 Stage 2 – Occurs between ages 11 and 12 – sparse, long, slightly

pigmented & curly hair at pubis symphysis
 Stage 3 occurs between ages 12 and 13 – darker & curlier at labia  Stage 4 – occurs between ages 13 and 14, hair assumes the normal

appearance of an adult but is not so thick and does no appear to the inner aspect of the upper thigh
 Stage 5 sexual maturity- normal adult- appear inner aspect of upper

thigh .

 b. Labia Minora – 2 sensitive structures clitorisanterior. sight of sexual arousal (Greek-key) fourchettePosterior. anus  e.large lips longitudinal fold. Perineum – muscular structure – loc – lower vagina & . Labia Majora . tapers posteriorly of the labia minora.  Site – episiotomy  d.sensitive to manipulation. Vestibule – an almond shaped area that contains the hymen. extends symphisis pubis to perineum  c. pea shaped erectile tissue with lots of sensitive nerve endings. torn during delivery. vaginal orifice and bartholene’s glands.

membranous tissue  vaginal orifice – external opening of vagina  bartholene’s glands . Urinary Meatus – small opening of urethra.acidic Doderleins bacillus – responsible for acidity of vagina Carumculae mystiformes .paravaginal gland or vulvo vaginal gland -2 small     mucus secreting subs – secretes alkaline substance Alkaline – neutralizes acidity of vagina Ph of vagina . serves for urination  Skenes glands/or paraurethral gland – mucus secreting subs for lubrication  hymen – covers vaginal orifice.healing of torn hymen .

pregnant – 1.000g Pregnant/ Involution of uterus: 4th stage of labor 2 weeks after delivery 3 weeks after delivery 5-6 weeks after delivery -1000g . uterus.  Size. shape and weights.300 g .500g .2.returns to original. dilated canal  Rugae – permits stretching without tearing  B. passageway of mens & fetus.nonpregnant – 50 -60 g. Internal  A. It varies in size. state 50 – 60 gms . vagina – female organ of copulation.1x2x3  Shape: nonpregnant pear shaped / pregnant – ovoid  Weight . thick walled muscular organ.Organ of mens is a hollow. 3 – 4inches or 8 – 10 cm long.

upper cylindrical layer .upper triangular layer .  Endometrium.   Muscle layer for menstruation. lines the nonpregnant uterus. Sloughs during menstruation. .Three parts of the uterus  fundus  corpus/body  cervix .lower cylindrical layer  * Isthmus lower uterine segment during pregnancy  Cornua-junction between fundus & interstitial Muscular compositions: there are three main muscle layers which make expansion possible in every direction.inside uterus.

Lupreulide (Lupron) inhibit FSH/LH production  . inhibit ovulation 2. to stop mens  b. S/sx: dysmennorhea. Dx:  biopsy  Laparoscopy Meds: 1. Danazole (Danocrene)  a. Endometriosis .   Common site: ovary.proliferation of endometrial lining outside uterus. low back pain.

resp.contraction of the uterus   Perimetrium  protects entire uterus . Myometrium  largest part of the uterus. muscle layer for delivery process  Its smooth muscles are considered to be the living ligature of the body Power of labor.

Production of hormones  d. Function: 1. Fallopian tubes  2-3 inches long that serves as a passageway of the sperm from the uterus to the ampulla or the passageway of the mature ovum or fertilized ovum from the ampulla to the uterus. ovulation 2. c. almond shaped. . ovaries – 2 female sex glands.

Interstitial site of ectopic pregnancy – most dangerous . Isthmus site of sterilization – bilateral tubal ligation 4. trumpet or funnel shaped. site of fertilization 3. swollen at ovulation 2. Infundibulum distal part of FT.4 significant segments 1. Ampulla outer 3rd or 2nd half.

It contains of a body of a shaft consisting of 3 cylindrical layers and erectile tissues.B. External  Penis  the male organ of copulation and urination. Male Reproductive System 1. 3 Cylindrical Layers 2 corpora cavernosa 1 corpus spongiosum    . At its tip is the most sensitive area comparable to that of the clitoris in the female – the glands penis.

with a medial septum dividing into two sacs. Leydig cell – release testosterone 2.  cooling mechanism of testes < 2 degrees C than body temp. Internal  The Process of Spermatogenesis – maturation of sperm . Scrotum  a pouch hanging below the pendulous penis. each of which contains a testes.

Male and Female homologues Male Penile glans Penile shaft Testes Prostate Cowper’s Glands Scrotum Female Clitoral glans Clitorial shaft Ovaries Skene’s gands Bartholin's glands Labia Majora .

Basic Knowledge on Genetics and Obstetrics DNA carries genetic code Chromosomes threadlike strands composed of hereditary material – DNA Normal amount of ejaculated sperm 3 – 5 cc. 1 tsp Ovum is capable of being fertilized with in 24 – 36 hrs after ovulation Sperm is viable within 48 – 72 hrs.. 2-3 days Reproductive cells divides by the process of meiosis .III.

Spermatogenesis maturation of sperm Oogenesis maturation of ovum Gematogenesis formation of 2 haploid into diploid 23 + 23 = 46 or diploid Age of Reproductivity – 15 – 44yo Menstrual Cycle beginning of mens to beginning of next mens Average Menstrual Cycle 28 days .

Related terminologies:  Menarche – 1st mens  Dysmenorrhea – painful mens Metrorrhagia Menorhagia Amenorrhea Menopause bleeding between mens excessive during mens absence of mens cessation of mens/ average : 51 years old .

 * Estrogen “Hormone of the Woman”  Primary function: development secondary sexual characteristic female.  Others:          inhibit production of FSH ( maturation of ovum) hypertrophy of myometrium Spinnbarkeit & Ferning ( billings method/ cervical) development ductile structure of breast increase osteoblast activities of long bones increase in height in female causes early closure of epiphysis of long bones causes sodium retention increase sexual desire .

 *Progestin “ Hormone of the Mother”  Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortous  Secondary Function: pregnancy) uterine contractility (favors  Others:  inhibit prod of LH (hormone for ovulation)  inhibit motility of GIT  mammary gland development  increase permeability of kidney to lactose & dextrose causing (+) sugar  causes mood swings in moms  increase BBT .

Proliferative  2. Secretory  3.Menstrual Cycle  4 Phases of Menstrual Cycle  1. Ischemic  4. Menses  Parts of body responsible for mens:  hypothalamus  anterior pituitary gland – master clock of body  ovaries  uterus .

increase progesterone . Initial phase – 3rd day – decreased estrogen  13th day – peak estrogen. decrease progesterone  14th day – Increase estrogen. increase progesterone  15th day – Decrease estrogen.

 On the initial 3rd phase of menstruation . this level stimulates hypothalamus to release GnRH or FSHRF to release FSH the  GnRH/FSHRF – stimulates the anterior pituitary gland  Functions of FSH:  Stimulate ovaries to release estrogen  Facilitate growth primary follicle to become graffian follicle (secretes large amt estrogen & contains mature ovum.) . the estrogen level is decreased.

 Follicular Phase – causing irregularities of mens  Postmenstrual Phase  Preovulatory Phase – phase increase estrogen .  post mens phase.  Pre-ovulatory.Proliferative Phase  proliferation of tissue or follicular phase.  -phase of increase estrogen.

these hypothalamus to release GnRF on LHRF abdomen. stimulates the  Mittelschmerz – slight abdominal pain on L or RQ of  Change in BBT. mood swing  GnRF/LHRF stimulates the ant pit gland to release LH. . marks ovulation day.Proliferative Phase  13th day of menstruation. estrogen level is peak while the progesterone level is down.

Proliferative Phase  Functions of LH:  (13th day-decreased progesterone) LH stimulates ovaries to release progesterone hormone for ovulation  14th day estrogen level is increased while the progesterone level is increased causing rupture of graffian follicle on process of ovulation. after ovulation day. graafian follicle starts to degenerate yellowish known as corpus luteum (secrets large amount of progesterone) .  15th day.

Secretory Phase  Lutheal Phase  Postovulatory PhaseIncreased progesterone  Premenstrual Phase  24th day if no fertilization. corpus luteum degenerate ( whitish – corpus albicans) slough off to begin mens  28th day – if no sperm in ovum – endometrium begins to .

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

Stages of Sexual Responses (EPOR)  Initial responses:  Vasocongestion – congestion of blood vessels  Myotonia – increase muscle tension  Excitement Phase  – (sign present in both sexes. sex flush. RR.  Plateau Phase  – (accelerated V/S) – increasing & sustained tension nearing orgasm. . Lasts 30 seconds – 3 minutes.BP. nipple erection) – erotic stimuli cause increase sexual tension. lasts minutes to hours. moderate increase in HR.

genitals return to pre-excitement phase)  Refractory Period  – the only period present in males.most affected are is pelvic area.  Resolution  – (v/s return to normal. peak v/s) involuntary release of sexual tension with physiologic or psychologic release.Stages of Sexual Responses (EPOR)  Orgasm  – (involuntary spasm throughout body. wherein he cannot be restimulated for about 10-15 minutes . May last 2 – 10 sec. immeasurable peak of sexual experience.

Fertilization  Stages of Fetal Growth and Development 3-4 days travel of zygote – mitotic cell division begins .

– covering of blastocys that later becomes placenta & trophoblast d. Pre-embryonic Stage a. Lifespan of zygote – from fertilization to 2 months b. Implantation/ Nidation. Morula – mulberry-like ball with 16 – 50 cells.Fertilization A. Blastocyst – enlarging cells that forms a cavity that later becomes the embryo. . 4 days free floating & multiplication c. Zygote .fertilized ovum.occurs after fertilization 7 – 10 days.

slight pain  2.2 months to birth.Fertilization B. Fetus . placenta previa – implantation at low side of uterus Signs of implantation:  1. slight vaginal spotting . .if with fertilization – corpus luteum continues to function & become source of estrogen & progesterone while placenta is not developed.

Adhesion  3. Invasion .Fertilization 3 processes of Implantation  1. Apposition  2.

C.   D. finger life projections 3 vessels=  A – unoxygenated blood  V – O2 blood  A – unoxygenated blood .10 – 11th day. Chorionic Villi. Decidua – thickened endometrium ( Latin – falling off)  Basalis (base) part of endometrium located under fetus where placenta is delivered Capsularies – encapsulate the fetus Vera – remaining portion of endometrium.

Before 24 weeks critical. Cytotrophoblast – inner layer or langhans layer – protects fetus against syphilis 24 wks/6 months – life span of langhans layer increase. . Ex missing digits/toes. E. might get infected syphilis .Wharton’s jelly – protects cord Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for genetic screening Done early in pregnancy Common complication fetal limb defect.

with crystallized forming pattern. clear. 15 – 55cm.  b.F. Umbilical Cord  whitish grey. Amnion – inner most layer  a. slightly alkaline. odor mousy/musty. Syncitiotrophoblast – synsitial layer – responsible production of hormone 1. Amniotic Fluid  . 20 – 21”  Short cord: abruptio placenta or inverted uterus  Long cord:cord coil or cord prolapse bag of H2O.

prevent cord compression 5. maintains temp 4.*Function of Amniotic Fluid: 1. facilitates musculo-skeletal development 3. help in delivery process normal amt of amniotic fluid – 500 to 1000cc polyhydramnios.GIT malformation TEF/TEA.decrease amt of fluid – kidney disease . cushions fetus against sudden blows or trauma 2. hydramnios . increased amt of fluid oligohydramnios .

Purpose obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac. fluid is tested for: Genetic screening maternal serum alpha feto-protein (MSAFP) .Diagnostic Tests for Amniotic Fluid A. Amniocentesis empty bladder before performing the procedure.Determination of fetal maturity primarily by evaluating factors indicative of lung maturity test .

Diagnostic Tests for Amniotic Fluid Testing time – 36 weeks decreased MSAFP = down syndrome increase MSAFP = spina bifida or open neural tube defect Common complication of amniocentesis – infection .

needle insertion site Aspiration of yellowish amniotic fluid – jaundice baby Greenish – meconium .pre term labor Important factor to consider for amniocentesis .Diagnostic Tests for Amniotic Fluid Dangerous complications – spontaneous abortion 3rd trimester .

urine.blue paper turns green/grey .Amnioscopy – direct visualization or exam to an intact fetal membrane.Paper turns yellow. Fern Test .determine if amniotic fluid has ruptured or not .Paper turns blue green/gray-(+) rupture of amn fluid.+ ruptured amniotic fluid Nitrazine Paper Test . . . .diff amniotic fluid & urine.

Chorion – where placenta is developed Lecithin Sphingomyelin L/S Ratio.2:1 signifies fetal lung maturity not capable for RDS Phosphatidylglycerol : PG+ definitive test to determine fetal lung maturity .

. combination of chorionic villi + deciduas basalis.Size: 500g or ½ kg -1 inch thick & 8” diameter .Placenta – (Secundines) Greek – pancake.

glucose transport is facilitated. fetus hypoglycemic  Excretory System  . diffusion more rapid from higher to lower.  If mom hypoglycemic. Simple diffusion  GIT  – transport center.  Circulating system  – achieved by selective osmosis .artery .carries waste products.  Liver of mom detoxifies fetus.Functions of Placenta:  Respiratory System   – beginning of lung function after birth of baby.

 Has a diabetogenic effect – serves as insulin antagonist Relaxin Hormone. Human placental Lactogen or sommamommamotropin Hormone  for mammary gland development.causes softening joints & bones estrogen progestin barrier against some  It serves as a protective microorganisms – HIV.HBV . Endocrine System – produces hormones      Human Chorionic Gonadrophin  maintains corpus luteum alive.

for calcium  Thymus – development of immunity  Liver – lining of upper RT & GIT .Fetal Stage “ Fetal Growth and Development” Entire pregnancy days – 266 – 280 days 37 – 42 weeks Differentiation of Primary Germ layers Endoderm 1st week endoderm – primary germ layer  Thyroid – for basal metabolism  Parathyroid .

kidneys and repro organ Ectoderm – development of brain. mucus membrane or anus & mouth . skin and senses.Mesoderm – development of heart. hair. nails. musculoskeletal system.

First trimester: 1st month  Brain & heart development  GIT& resp Tract – remains as single tube  1. Fetal heart tone begins – heart is the oldest part of the body  2. CNS develops – dizziness of mom due to hypoglycemic effect  Food of brain – glucose complex CHO – pregnant women food (potato) .

First trimester: Second Month  All vital organs formed. placenta developed  Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2nd month  Sex organ formed  Meconium is formed .

First trimester: Third Month  Kidneys functional  Buds of milk teeth appear  Fetal heart tone heard – Doppler – 10 – 12 weeks  Sex is distinguishable .

Second trimester: FOCUS – length of fetus Fourth Month  lanugo begins to appear  fetal heart tone heard fetoscope. 18 – 20 weeks  buds of permanent teeth appear .

18.Second trimester: Fifth Month  lanugo covers body  actively swallows amniotic fluid  19 – 25 cm fetus.  Quickening.1st fetal movement. 1618 wks – multi  fetal heart tone heard with or without instrument .20 weeks primi.

Second trimester: Sixth Month  eyelids open  wrinkled skin  vernix caseosa present .

FOCUS: weight of fetus Seventh Month  development of surfactant – lecithin Eighth Month  lanugo begin to disappear  sub Q fats deposit  Nails extend to fingers .Third trimester: Period of most rapid growth.

Third trimester: Ninth Month  lanugo & vernix caseosa completely disappear  Amniotic fluid decreases Tenth Month  bone ossification of fetal skull .

Terratogens any drug. the exposure to such may cause damage to the fetus Drugs:  Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8th cranial nerve – poor hearing & deafness  Tetracycline – staining tooth enamel. virus or irradiation. inhibit growth of long bone  Vitamin K – hemolysis (destr of RBC). absence of extremities . hyperbilirubenia or jaundice  Iodides – enlargement of thyroid or goiter  Thalidomides – Amelia or pocomelia.

 Steroids – cleft lip or palate  Lithium – congenital malformation  Alcohol – lowered weight (vasoconstriction on mom). fetal alcohol withdrawal syndrome char by microcephaly  Smoking – low birth rate  Caffeine – low birth rate  Cocaine – low birth rate. abruption placenta .

influenza like findings. and jaundice (hepatic involvement)  In some chases the infection may go unnoticed in the pregnant woman yet have devastating effects on the fetus virus. Cytomegalo . Rubella.  TORCH: Toxoplasmosis.TORCH (Terratogenic) Infections – viruses  CHARACTERISTICS  group of infections caused by organisms that can cross the placenta or ascend through birth canal and adversely affect fetal growth and development  These infections are often characterized by vague. Other. enlarged lymph nodes. rashes and lesions. Herpes simples virus.

T – toxoplasmosis mom takes care of cats. Feces of cat go to raw vegetables or meat O – others. Hepa A or infectious heap – oral/ fecal (hand washing) Hepa B. HIV – blood & body fluids Syphilis R – rubella – German measles – congenital heart disease (1st month) normal rubella titer 1:10 .

Vaccine is terratogenic C – cytomegalo virus H – herpes simplex virus . mom will be given rubella vaccine.<1:10 – less immunity to rubella. Don’t get pregnant for 3 months. after delivery.

easy fatigability. epistaxis – due to hyperemia of nasal membrane palpitation. slight hypertrophy of ventricles. increase heart workload. Physiologic Anemia – pseudo anemia of pregnant women . Systemic Changes 1. Cardiovascular System – increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood .Physiological Adaptation of the Mother to Pregnancy A.

A. HCT should not be 33%.5 – 14g/dL Criteria 1st and 3rd trimester. Hgb should not be < 11g/dL 2nd trimester – Hct should not <32% . . Systemic Changes Normal Values Hct 32 – 42% Hgb 10.pathologic anemia if lower.Hgb Shdn't < 10.5% pathologic anemia if lower .

 .Pathologic Anemia iron deficiency anemia is the most common hematological disorder.Assessment reveals:  Pallor. constipation  Slowed capillary refill  Concave fingernails (late sign of progressive anemia) due to chronic physio hypoxia . It affects toughly 20% of pregnant women.

hematoma Oral Iron supplements (ferrous sulfate 0. Z tract. ampalaya  Parenteral Iron ( Imferon) – severe anemia.Pathologic Anemia  Nursing Care:  Nutritional instruction – kangkong. give IM.3 g. liver due to ferridin content. black stool.if improperly administered. green leafy vegetablealugbati.saluyot. malunggay. horseradish. constipation Monitor for hemorrhage   . 3 times a day) empty stomach 1 hr before meals or 2 hrs after.

Pathologic Anemia  Alert:  Iron from red meats is better absorbed iron form other sources  Iron is better absorbed when taken with foods high in Vit C such as orange juice Higher iron intake is recommended since circulating blood volume is increased and heme is required from production of RBCs  .

 to relieve. avoid wearing knee high socks  use elastic bandage – lower to upper  Vulvar varicosities.position – side lying with pillow under hips or modified knee chest position .painful. pressure on gravid uterus.Edema lower extremities due venous return is constricted due to large belly.  Varicosities – pressure of uterus  use support stockings. elevate legs above hip level.

 Thrombophlebitis – presence of thrombus at inflamed blood vessel  pregnant mom hyperfibrinogenemia  increase fibrinogen  increase clotting factor  thrombus formation candidate dorsiflexion  outstanding sign – (+) Homan's sign – pain on calf during  milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens .

Edema  Mgt:  Bed rest  Never massage  Assess + Homan sign once only might dislodge thrombus  Give anticoagulant to prevent additional clotting (thrombolytics will dilute)  Monitor APTT antidote for Heparin toxicity. . protamine sulfate  Avoid aspirin! Might aggravate bleeding.

Respiratory system – common problem SOB due to enlarged uterus & increase O2 demand Position. F&E imbalance – primary med mgt – replace fluids.lateral expansion of lungs or side lying position. Monitor I&O . Nausea afternoon small freq feeding. Gastrointestinal – 1st trimester change Morning Sickness – nausea & vomiting due to increase HCG. Vomiting in pregnancy – hyperemesis gravidarum Metabolic alkalosis. Eat dry crackers or dry CHO diet 30 minutes before arising bed.

suha. apple with skin. mango.fruits – papaya. . cantaloupe. watermelon.exercise -mineral oil – excretion of fat soluble vitamins * Flatulence – avoid gas forming food – cabbage .constipation – progesterone resp for constipation Increase fluid intake. Except guava – has pectin that’s constipating – veg – petchy. increase fiber diet . pineapple. malungay.

avoid fatty & spicy food. Mgt. sips of milk. proper body mechanical increase salivation – ptyalsim – mgt mouthwash *Hemorrhoids – pressure of gravid uterus.small frequent feeding.* Heartburn – or pyrosis – reflux of stomach content to esophagus . hot sitz bath for comfort . avoid 3 full meals.

Urinary System – frequency during 1st & 3rd trimester lateral expansion of lungs or side lying pos – mgt for nocturia Acetyace test – albumin in urine Benedicts test – sugar in urine Musculoskeletal Lordosis – pride of pregnancy Waddling Gait – awkward walking due to relaxation – causes softening of joints & bones Prone to accidental falls – wear low heeled shoes .

pressure of gravid uterus (labor cramps) at lumbo sacral nerve plexus Management|: Increase Ca diet-milk(Inc Ca & Inc phosphorus)1pint/day or 3-4 servings/day. brocolli. Cheese. lobster. yogurt. Dilis.Leg Cramps – causes: prolonged standing. chills. over fatigue. Ca & phosphorous imbalance(#1 cause while pregnant). head of fish. seafood-tahong (mussels). Vit D for increased Ca absorption . sardines with bones. crab. oversex.

B. Local Changes Local change: Vagina: V – Chadwick’s sign – blue violet discoloration of vagina C – Goodel's sign – change of consistency of cervix I – Hegar's – change of consistency of isthmus (lower uterine segment) .

mousy odor discharge ESTROGEN – hormone.B. PROGESTERONE – hormone responsible for operculum PREGNANT – acidic to alkaline change to protect bacterial growth (vaginitis) . resp for leucorrhea OPERCULUM – mucus plug to seal out bacteria. Local Changes LEUKORRHEA – whitish gray.

Problems Related to the Change of Vaginal Environment: Vaginitits – trichomonas vaginalis due to alkaline environment of vagina of pregnant mom Flagellated protozoa – wants alkaline S&Sx: Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema Mgt: FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1st trimester treat dad also to prevent reinfection no alcohol – has antibuse effect VAGINAL DOUCHE – IQ H2O : 1 tbsp white vinegar .

Problems Related to the Change of Vaginal Environment: Moniliasis or candidiasis due to candida albecans. fungal infection. Color – white cheese like patches adheres to walls of vagina.condifoma acuminata due to papilloma virus Mgt: cauterization . cotrimaxole. Signs & Symptoms: Management – antifungal – Nistatin. canesten Gonorrhea -Thick purulent discharge Vaginal warts. genshan violet.

cheeks  chloasma melasma due to increased melanocytes.  Brown pinkish line. Abdominal Changes –  striae gravidarium (stretch marks) due enlarging uterus-destruction of sub Q tissue  avoid scratching.symphisis pubis to umbilicus . use coconut oil.linea nigra. umbilicus is protruding  Skin Changes –  brown pigmentation nose chin.

colostrums at 3rd trimester  Breast self exam    7 days after mens supine with pillow at back quadrant B – upper outer – common site of cancer . color of areola & nipple  pre colostrums present by 6 weeks. Breast Changes  increase hormones.

 Presumptive            Breast changes Urinary freq Fatigue Amenorrhea Morning sickness Enlarged uterus Chloasma Linea negra Increased skin pigmentation Striae gravidarium Quickening .

change of consistency of isthmus Elevated BBT – due to increased progesterone Positive HCG or (+)preg test  Ballottement – bouncing of fetus when lower uterine is tapped sharply  Enlarged abdomen  Braxton Hicks contractions – painless irregular contractions .change of consistency of cervix Chadwick’s. Probable      Goodel's.blue violet discoloration of vagina Hegar's.

 Positive  Ultrasound evidence (sonogram) full bladder     Fetal heart tone Fetal movement Fetal outline Fetal parts palpable .

 Positive Signs – undeniable signs confirmed by the use of instrument. . mammography – 35 to 49 yrs once every 1 to 2 yrs 50 yrs and above – 1 x a yr Ovaries – rested during pregnancy  Signs & symptoms of Pregnancy  Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy . Subjective Objective  Probable – signs observed by the members of health team.Test to determine breast cancer: 1.

trans vaginal ultrasound.ultrasound – full bladder  placental grading – rating/grade     o – immature 1 – slightly mature 2 – moderately mature 3 – placental maturity . Empty bladder  . Ballotment sign of myoma  * + HCG – sign of H mole  .

 Developmental task – accept growing fetus as baby to be nurtured.  mom identifies fetus as a separate entity – due to presence of quickening. nutrition  Second Trimester – tangible S&Sx. ambivalence. . fantasy.  Developmental task is to accept biological facts of pregnancy Focus: bodily changes of preg. denial – sign of maladaptation to pregnancy. Health teaching: growth & development of fetus.  surprise.Psychological Adaptation to Pregnancy  (Emotional response of mom –Reva Rubin theory)  First Trimester: No tangible signs & sx.

mom has personal identification on appearance of baby Development task: prepare of birth & parenting of child. Most common fear – let mom listen to FHT to allay fear Lamaze classes .Psychological Adaptation to Pregnancy  Third Trimester: . HT: responsible parenthood ‘baby’s Layette” – best time to do shopping.

Sex ( pseudocyesis or false pregnancy on men & women) . Frequency of Visit:  1st 7 months – 1x a month  8 – 9 months – 2 x a month  10 – once a week  post term 2 x a week • • 2. Home base mom’s record.Pre-Natal Visit: 1. age (high risk < 18 & >35 yrs old) record to determine high risk – HBMR. Personal data – name.

Diagnosis of Pregnancy  urine exam to detect HCG at 40 – 100th day. culture & beliefs with respect. 60 – 70 day peak HCG.  Elisa test – test for preg detects beta subunit of HCG as early as 7 – 10days  Home preg kit – do it yourself . education background – level knowledge 3.   Couvade syndrome – dad experiences what mom goes through – lihi) Address. civil status. religion. 6 weeks after LMP. non judgmental Occupation – financial condition or occupational hazards.best to get urine exam.

4. Baseline Data: V/S esp. BP, monitor wt. (increase wt – 1st

sign preeclampsia)

 

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

 Third trimester:
 normal weight gain 10 – 12 lbs  ( 1lb/wk)

(4 lbs/ month)

 Minimum wt gain – 20 – 25 lbs

 Optimal wt gain

– 25 – 35 lbs

5. Obstetrical Data:

nullipara – no pregnancy  Gravida- # of pregnancy  Para - # of viable pregnancy Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age. age of viability Term Preterm abortion 20 – 24 wks 37 – 42 wks, 20 – 37 weeks <20 weeks

    

Important Estimates:

Nagele’s Rule – use to determine expected date of delivery Get LMP -3+ 7 +1 Apr-Dec LMP – Jan Feb Mar M D Y +9 +7 no year

LMP Jan 25, 04 +9 +7 10 / 32 / 04 - 1 add 1 month to month 11/31/04 EDD

 McDonald’s Rule – to determine age of gestation IN WEEKS
FUNDIC HT X 7/8=AOG in WK

From symphysis pubis to fundus

3 months – 5 months – 9 months – 10 months – above sym pub level of umbilicus below xiphoid level of 8 months due to lightening . Bartholomew’s Rule – to determine age of gestation by proper location of fundus at abdominal cavity.

 Haases rule – to determine length of the fetus in cm. square @ month 2nd ½ of preg. x @ month by 5 3mos x 3 = 9cm 4 mos x 4 = 16 cm 5 x 5 = 25 cm 6 x 5 = 30 cm 7 x 5 = 35 cm 8 x 5 = 40 cm 9 x 5 = 45 cm 1st ½ of preg 2nd ½ of preg . Formula: 1st ½ of preg .

 tetanus immunizations – prevents tetanus neonatum  -mom with complete 3 doses DPT young age considered as TT1 & 2. Begin TT3  TT1 – any time during pregnancy  TT2 – 4 wks after TT1 – 3 yrs protection  TT3 – 6 months after TT2 – 5 yrs protection  TT4 – 1 yr after TT3 – 10 yrs protection  TT5 – yr after TT4 – lifetime protection .

 Physical Examination: A.chills/ fever – infection Cerebral disturbances ( headache – preeclampsia)  A – abdominal pain ( epigastric pain – aura of impending convulsions . Examine teeth: sign of infection Danger signs of Pregnancy  C .

incompetent cervix 3rd – placental anomalies  S – sudden gush of fluid – PROM (premature rupture of membrane) prone to inf.  E – edema to upper ext. ectopic pre/2nd – H mole. abortion.Danger signs of Pregnancy  B – boardlike abdomen – abruption placenta Increase BP – HPN    Blurred vision – preeclampsia Bleeding – 1st trimester. (preeclampsia) .

composed of squamous columnar tissue . Pelvic Examination – internal exam  empty bladder  universal precaution EXT OS of cervix – site for getting specimen Site for cervical cancer  Pap Smear – cervical cancer  .

 Class III – cytology suggestive of malignancy  Class IV – cytology strongly suggestive of malignancy  Class V – cytology conclusive of malignancy . Result:  Class I – normal  Class IIA – acytology but no evidence of malignancy B – suggestive of infl.

 Stages of Cervical Cancer Stage 0 – carcinoma insitu 1 – cancer confined to cervix 2 .cancer extends to vagina 3 – pelvis metastasis 4 – affection to bladder & rectum .

 Prep mom:  Empty bladder  Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles) . position. fetal presentation lie. presenting part. an estimate of the size. Leopold’s Maneuver  Purpose: is done to determine the attitude. and number of fetuses. fetal back & fetal heart tone  .use palm! Warm palm.7. degree of descent.

Uterine soufflé – maternal H rate  2nd Maneuver: with both hands moving down. Procedure:  1st maneuver: place patient in supine position with knees slightly flexed. Get V/S(before 2nd maneuver) PR to diff fundic soufflé (FHR) & uterine soufflé. put towel under head and right hip. movement and firmness of the part to determine presentation the back of the fetus ( to hear fetal heart sound) where the ball of the stethoscope is placed to determine FHT. shape. with both hands palpate upper abdomen and fundus. Assess size. identify .

Assess whether the presenting part is engaged in the pelvis Alert : if the head is engaged it will not be movable). Procedure:  3rd Maneuver: using the right hand. grasp the symphis pubis part using thumb and fingers. assess the descent of the presenting part by locating the cephalic prominence or brow. To determine attitude – relationship of fetus to 1 another. To determine degree of engagement. . With two hands.  4th Maneuver: the Examiner changes the position by facing the patient’s feet.

 When the brow is on the same side as the back. the head will be flexed and vertex presenting.  When the brow is on the same side as the small parts.  Attitude – relationship of fetus to a part – or degree of flexion  Full flexion – when the chin touches the chest . the head is extended.

after breakfast) and count each fetal movement.Assessment of Fetal Well-Being  Daily Fetal Movement Counting (DFMC) begin 27 weeks Mom.begin after meal – breakfast  a.8. noting how long it takes to count 10 fetal movements (FMs)  (2) Expected findings – 10 movements in 1 hour or less . Cardiff count to 10 method – one method currently available  (1) Begin at the same time each day (usually in the morning.

< 3 FMs in 12 hours  warning signs should be reported to healthcare provider immediately.) less then 10 movements in 12 hours(non-reactive. biophysical profile (BPP) . often require further testing.fetal distress) c.) more then 1 hour to reach 10 movements b.) movement are becoming weaker. less vigorous Movement alarm signals .) longer time to reach 10 FMs than on previous days d. Warning signs     a.  Examples: nonstress test (NST).

diabetes warning signs noted during DFMC maternal history of smoking. mother activates the “mark button” on the electronic monitor when she feels fetal movement. inadequate nutrition  Procedure:  Done within 30 minutes wherein the mother is in semi- fowler’s position (w/ fetal monitor). . Nonstress test – to determine the response of the fetal heart rate to activity      Indication – pregnancies at risk for placental insufficiency Postmaturity pregnancy induced hypertension (PIH). external monitor is applied to document fetal activity.

such as a CST . Attach external noninvasive fetal monitors  tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)  ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected  monitor until at least 2 FMs are detected in 20 minutes   if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen if no FM after 1 hour further testing may be indicated.

 Result: Noncreative Nonstress Not Good Reactive Responsive is Real Good .

 Interpretation of results  Reactive result  Baseline FHR between 120 and 160 beats per minute  At least two accelerations of the FHR of at least 15 beats per minute. noted as an uneven line on the rhythm strip . lasting at least 15 seconds in a 10 to 20 minute period as a result of FM  Good variability – normal irregularity of cardiac rhythm representing a balanced interaction between the parasympathetic (decreases FHR) and sympathetic (increase FHR) nervous system.

biophysical profile. Interpretation of results  Nonreactive result  Stated criteria for a reactive result are not met  Could be indicative of a compromised fetus.  Requires further evaluation with another NST. (BPP) or contraction stress test (CST) .

9. . over wt – candidate for HPN. DM  Low socio – economic status  Vegetarian mom decrease CHON needs Vit B12 – cyanocobalamin – formation of folic acid – needed for cell DNA & RBC formation. Health teachings Nutrition – do nutritional assessment – daily food intake  High risk moms:  Pregnant teenagers low compliance to heath regimen  Extremes in wt underweight.

amniotic fluid. and tissue growth. .Recommended Nutrient Requirement that increases During Pregnancy Calories  Nutrients  Essential to supply energy for      increased metabolic rate utilization of nutrients protein sparing so it can be used for Growth of fetus Development of structures required for pregnancy including placenta.

ketosis has been associated with fetal damage. .Recommended Nutrient Requirement that increases During Pregnancy Calories  Requirements  300 calories/day above the prepregnancy daily requirement  Begin increase in second trimester  Use weight – gain pattern as an indication of adequacy of to maintain ideal body weight and meet energy requirement to activity level calorie intake.  Failure to meet caloric requirements can lead to ketosis as fat and protein are used for energy.

fruits)  Variety of foods representing foods sources for the nutrients requiring during pregnancy  No more than 30% fat . complex carbohydrates (whole grains.Recommended Nutrient Requirement that increases During Pregnancy Calories  Food Source  Caloric increase should reflect  Foods of high nutrient value such as protein. vegetables.

Recommended Nutrient Requirement that increases During Pregnancy Protein  Nutrients  Essential for: Fetal tissue growth Maternal tissue growth including uterus and breasts Development of essential pregnancy structures Formation of red blood cells and plasma proteins  * Inadequate protein intake has been associated with onset of pregnancy induces hypertension (PIH)     .

Recommended Nutrient Requirement that increases During Pregnancy Protein  Requirements  60 mg/day or an increase of 10% above daily requirements for age group  Adolescents have a higher protein requirement than mature women since adolescents must supply protein for their own growth as well as protein t meet the pregnancy requirement .

nuts Whole grains  * vegetarians must take note of the amino acid content of CHON foods consumed to ensure ingestion of sufficient quantities of all amino acids     . milk Dried beans. poultry. lentils. fish Eggs.Recommended Nutrient Requirement that increases During Pregnancy Protein  Food Source  Protein increase should reflect Lean meat. cheese.

Recommended Nutrient Requirement that increases During Pregnancy Calcium-Phosphorous  Nutrients  Essential for  Growth and development of fetal skeleton and tooth buds  Maintenance of mineralization of maternal bones and teeth  Current research is :  Demonstrating an association between adequate calcium intake and the prevention of pregnancy induce hypertension .

Recommended Nutrient Requirement that increases During Pregnancy Calcium-Phosphorous  Requirements  Calcium increases of  1200 mg/day representing an increase of 50% above prepregnancy daily requirement.  1600 mg/day is recommended for the adolescent. 10 mcg/day of vitamin D is required since it enhances absorption of both calcium and phosphorous .

cheese. egg yolk. ice cream. liver. seafood . egg      yolk whole grains.Recommended Nutrient Requirement that increases During Pregnancy Calcium-Phosphorous  Food Source  Calcium increases should reflect:  dairy products : milk. butter. margarine. yogurt. tofu green leafy vegetables canned salmon & sardines w/ bones Ca fortified foods such as orange juice Vitamin D sources: fortified milk.

Recommended Nutrient Requirement that increases During Pregnancy Iron  Nutrients  Essential for  Expansion of blood volume and red blood cells formation  Establishment of fetal iron stores for first few months of life .

mg/day in second trimester.Recommended Nutrient Requirement that increases During Pregnancy Iron  Requirements  30 mg/day representing a doubling of the pregnant daily requirement  Begin supplementation at 30. . since diet alone is unable to meet pregnancy requirement  60 – 120 mg/day along with copper and zinc supplementation for women who have low hemoglobin values prior to pregnancy or who have iron deficiency anemia.

cardiac stress especially labor and birth  fetal effects decreased availability of oxygen thereby affecting fetal growth  * iron deficiency anemia is the most common nutritional disorder of pregnancy. decreased energy and appetite.  70 .Recommended Nutrient Requirement that increases During Pregnancy Iron  Requirements mg/day of vitamin C which enhances iron absorption  inadequate iron intake results in maternal effects – anemia depletion of iron stores.

legumes nuts. poultry. eggs enriched. cantaloupe. fish. red meat. whole grain cereals and breads dark green leafy vegetables. potatoes  iron from food sources is more readily absorbed when served with foods high in vit C      . strawberries.Recommended Nutrient Requirement that increases During Pregnancy Iron  Food Source  Iron increases should reflect liver. dried fruits vitamin C sources: citrus fruits & juices. broccoli or cabbage.

.Recommended Nutrient Requirement that increases During Pregnancy Zinc  Nutrients  Essential for  * the formation of enzymes  * maybe important in the prevention of congenital malformation of the fetus.

Recommended Nutrient Requirement that increases During Pregnancy Zinc  Requirements  15mcg/day representing an increase of 3 mg/day over prepreganant daily requirements. .

legumes. cheese whole grains. nuts . milk.Recommended Nutrient Requirement that increases During Pregnancy Zinc  Food Source  Zinc increases should reflect     liver. meats shell fish eggs.

Recommended Nutrient Requirement that increases During Pregnancy Folic Acid. abortion. Folate  Nutrients  Essential for  formation of red blood cells and prevention of anemia  DNA synthesis and cell formation. Folacin. may play a role in the prevention of neutral tube defects (spina bifida). abruption placenta .

300mcg/day supplement for women with low folate levels or dietary deficiency  4 servings of grains/day . Folacin.Recommended Nutrient Requirement that increases During Pregnancy Folic Acid. Folate  Requirements  400 mcg/day representing an increase of more then 2 times the daily prepregnant requirement.

peanuts .  Whole grains. kidney. Folate  Food Source  Increases should reflect  liver. broccoli. Folacin.Recommended Nutrient Requirement that increases During Pregnancy Folic Acid. lean beef. veal  dark green leafy vegetables. legumes.

Recommended Nutrient Requirement that increases During Pregnancy Additional Requirements Minerals  Nutrients  Iodine  175 mcg/day 320 mg/day 65 mcg/day  Magnesium   Selenium  .

.Recommended Nutrient Requirement that increases During Pregnancy Additional Requirements Minerals  Food Source  Increased requirements of pregnancy can easily be met with a balanced diet that meets the requirement for calories and includes food sources high in the other nutrients needed during pregnancy.

Recommended Nutrient Requirement that increases During Pregnancy Vitamins E  10 mg/day  Thiamine  1.6 mg/day  Pyridoxine ( B6)  2.2 mg/day  B12  2.5 mg/day  Riborlavin  1.2 mg day  Niacin  17 mg/day .

Taking it not needed – fat soluble vitamins. Hard to excrete. .Recommended Nutrient Requirement that increases During Pregnancy Vitamins  Food Source  Vit stored in body.

air embolism  Changes in sexual desire:  1st tri – decrease desire – due to bodily changes  2nd trimester – increased desire due to increase estrogen that enhances lubrication  3rd trimester – decreased desire .Sexual Activity       should be done in moderation should be done in private place mom placed in comfy pos. sidelying or mom on top avoided 6 weeks prior to EDD avoid blowing or air during cunnilingus changes in sexual desire of mom during preg.

Sexual Activity
 Contraindication in sex:
 1. vaginal spotting
 1st trimester – threatened abortion  2nd trimester– placenta previa

 2. incompetent cervix  3. preterm labor  4. premature rupture of membrane

Exercise – to strengthen muscles used during delivery process
 principles of exercise
 Done in moderation.  Must be individualized

 Walking – best exercise  Squatting – strengthen muscles of perineum. Increase

circulation to perineum. Squat – feet flat on floor

 Tailor Sitting – 1 leg in front of other leg ( Indian seat)

Exercise
Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position
 shoulder circling exercise- strengthen chest muscles  pelvic rocking/pelvic tilt- exercise – relieves low back pain &

maintain good posture  * arch back – standing or kneeling. Four extremities on floor
 Kegel Exercise – strengthen pubococcygeal muscles

- as if hold urine, release 10x or muscle contraction
 Abdominal Exercise – strengthens muscles of abdominal – done

as if blowing candle

Childbirth Preparation:
 Overall

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

 a. Psychophysical

 1. Bradley Method – Dr. Robert Bradley – advocated active

participation of husband at delivery process. Based on imitation of nature.

Features:  1.) darkened rm  2.) quiet environment  3.) relaxation tech  4.) closed eye & appearance of sleep
 2. Grantly Dick Read Method – fear leads to tension

while tension leads to pain

disciple. conditioning & concentration.Childbirth Preparation:  b. labor & birth & care of newborn is an impt turning pt in woman’s life cycle . Psychosexual  1.flow with contraction than struggle with contraction  c. exhale mouth  Effleurage – gentle circular massage over abdominal to relieve pain  imaging – sensate focus . Psychoprophylaxis – prevention of pain  1. Lamaze: Dr. Ferdinand Lamaze req. Husband is coach Features:  Conscious relaxation  Cleansing breathe – inhale nose. Kitzinger method – preg.

Different Methods of delivery:  birthing chair – bed convertible to chair – semifowlers  birthing bed – dorsal recumbent pos  squatting – relives low back pain during labor pain  leboyers – warm.  Birth under H20 – bathtub – labor & delivery – warm . comfy room. baby gets warm bath. quiet. soft music. water. After delivery. dark.

para. Intrapartal Notes – inside ER  A. 20 – 24 wks  Physical Exams. weight  Obstetrical Data: gravida # preg. Admitting the laboring Mother:  Personal Data: name.viable preg. etc  Baseline Data: v/s especially BP.IX. age. address. Pelvic Exams .

) uterine stretch theory ( any hallow organ stretched.  3. B. decrease progesterone will stimulate contractions & labor  5.contraction  2. At .) prostaglandin theory – stimulation of arachidonic acid –  4.) oxytocin theory – post pit gland releases oxytocin.) theory of aging placenta – life span of placenta 42 wks.) progesterone theory – before labor. 1 Theories of the Onset of Labor  1. Basic knowledge in Intrapartum  b. will always contract & expel its content) – contraction action Hypothalamus produces oxytocin prostaglandin.

 Bones – 6 bones  S – sphenoid  E – ethmoid  T – temporal F – frontal . b. Passenger  a.sinciput O – occuputal .occiput P – parietal 2 x . Fetal head – is the largest presenting part – common presenting part – ¼ of its length. 2 The 4 P’s of labor  1.

25cm  biparietal – largest transverse  bitemporal 8 cm  bimastoid 7cm smallest transverse  Sutures – intermembranous spaces that allow molding.    sagittal suture – connects 2 parietal bones ( sagitna) coronal suture – connect parietal & frontal bone (crown) lambdoidal suture – connects occipital & parietal bone .Passenger  Measurement fetal head:  transverse diameter – 9.

Passenger  Moldings: the overlapping of the sutures of the skull to permit passage of the head to the pelvis  Fontanels:  Anterior fontanel – bregma.( > 5 cm – hydrocephalus).  Anteroposterior diameter –  suboccipitobregmatic 9.5 cm. 12 – 18 months after birth.5 cm hyper submentobragmatic-face presentation extension   . 3 x 4 cm. 1 x 1 cm. Closes – 2 – 3 months. complete flexion. smallest AP occipitofrontal 12cm partial flexion occipitomental – 13. diamond shape.close  Posterior fontanel or lambda – triangular shape.

Android – heart shape “male pelvis”. deeper most suitable (normal female pelvis) for pregnancy  2. wide. AP diameter wider transverse narrow  4.anterior part pointed.) < 4’9” tall 2. posterior part shallow  3.) < 18 years old 3. 2.) Underwent pelvic dislocation 4 main pelvic types  1. Passageway  Mom  Pelvis 1. Platypelloid – flat AP diameter – narrow. transverse – wider . oval shape. Anthropoid – oval. Gynecoid – round. ape like pelvis.

ischial tuberosity where we sit – landmark to get external measurement of pelvis  Pubes – ant portion – symphisis pubis junction between 2  Ischium .inferior portion  Ileum . b.lateral side of hips pubis  1 sacrum – post portion – sacral prominence – landmark to get internal measurement of pelvis . Pelvis 2 hip bones – 2 innominate bones 3 Parts of 2 Innominate Bones .iliac crest – flaring superior border forming prominence of hips .

5 cm . Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis. Ischial tuberosity – approximated with use of fist – 8 cm & above.5 cm=true conjugate) 2.5 cm basis in getting true conjugate. .Important Measurements 1. Measurement: 11. Measurement: 11. (DC – 11.0 cm 3. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior margin of the symphysis pubis. Pelvis at 10 cm or more. Obstetrical conjugate – smallest AP diameter.12. Tuberoischi Diameter – transverse diameter of the pelvic outlet.

Timing: frequency. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor  a. Characteristics: wave like  d. Involuntary Contractions  b. Voluntary bearing down efforts  c. duration. intensity . 3.

 4. Psyche/Person – psychological stress when the mother

is fighting the labor experience
 a. Cultural Interpretation
 b. Preparation  c. Past Experience  d. Support System

 Pre-eminent Signs of Labor

S&Sx:
 - shooting pain radiating to the legs  - urinary freq.

 1. Lightening – setting of presenting part into pelvic brim - 2

weeks prior to EDD * Engagement- setting of presenting part into pelvic inlet

 2. Braxton Hicks Contractions – painless irregular contractions  3. Increase Activity of the Mother- nesting instinct. Save energy,

will be used for delivery. Increase epinephrine

 Pre-eminent Signs of Labor

S&Sx:
 4. Ripening of the Cervix – butter soft  5. decreased body wt – 1.5 – 3 lbs  6. Bloody Show – pinkish vaginal discharge – blood &

leukorrhea

 7. Rupture of Membranes – rupture of water. Check FHT

 Premature Rupture of Membrane ( PROM) - do IE to

check for cord prolapse

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

 Premature Rupture of Membrane ( PROM)

Nursing Care;
 Administer Analgesics (Morphine)  Attempt manual rotation for ROP or LOP – most common

malposition

 Bear down with contractions  Adequate hydration – prepare for CS

 Sedation as ordered
 Cesarean delivery may be required, especially if fetal distress is

noted

 Cord Prolapse – a complication when the umbilical cord falls or is washed through the cervix into the vagina. Danger signs:  PROM  Presenting part has not yet engaged  Fetal distress  Protruding cord form vagina .

 Cord Prolapse Nursing care:  Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent cord compression causing cerebral palsy.  Slip cord away from presenting part  Count pulsation of cord for FHT  Prep mom for CS  Positioning – trendelenberg or knee chest position  Emotional support  Prepare for Cesarean Section .

 False Labor      Irregular contractions No increase in intensity Pain – confined to abdomen Pain – relived by walking No cervical changes  True Labor      Contractions are regular Increased intensity Pain – begins lower back radiates to abdomen Pain – intensified by walking Cervical effacement & dilatation * major sx of true labor. .

Nursing Interventions in Each Stage of Labor  2 segments of the uterus  1. lower uterine – isthmus . Use % in unit of measurement  Dilation – widening of cervix. upper uterine .Duration of Labor  Primipara – 14 hrs & not more than 20 hrs  Multipara – 8 hrs & not > 14 hrs  Effacement – softening & thinning of cervix.fundus  2. Unit used is cm.

First Stage: onset of true contractions to full dilation and effacement of cervix. Latent Phase:  Assessment:  Dilations: 0 – 3 cm mom – excited. apprehensive.shorten 1st stage of labor  Encourage to void q 2 – 3 hrs – full bladder inhibit  Nursing Care: contractions  Breathing – chest breathing . can communicate  Frequency: every 5 – 10 min  Intensity mild  Encourage walking .Nursing Interventions in Each Stage of Labor  1.

etc. fetal monitor.  D – dry lips – oral care (ointment) dry linens  B – abdominal breathing .fears losing control of self  Frequency q 3-5 min lasting for 30 – 60 seconds  Nursing Care:  M – edications – have meds ready  A – ssessment include: vital signs. Active Phase:  Assessment:  Dilations 4 -8 cm  Intensity: moderate Mom. cervical dilation and effacement.

 Transitional Phase:  intensity: strong hyperesthesia Mom – mood changes with  Assessment:  Dilations  Frequency  Durations 8 – 10 cm q 2-3 min contractions 45 – 90 seconds .

 Hyperesthesia – increase sensitivity to touch. pain all over Health Teaching : teach: sacral pressure on lower back to inhibit transmission of pain keep informed of progress controlled chest breathing  Nursing Care:      T – ires I – nform of progress R – estless support her breathing technique E – ncourage and praise D – iscomfort .

 Pelvic Exams  Effacement  Dilation  a.1 station = presenting part 1cm above ischial spine if (    ) floating . Station – landmark used: ischial spine  .2 station = presenting part 2 cm above ischial spine if (-) floating 0 station = level at ischial spine – engagement + 1 station = below 1 cm ischial spine +3 to +5 = crowning – occurs at 2nd stage of labor .

Presentation/lie  the relationship of the long axis (spine) of the fetus to the long axis of the mother  -spine of mom and spine of fetus  Two types:  b. Longitudinal Lie ( Parallel)  Cephalic .1. b.Vertex – complete flexion Face Brow Chin Poor Flexion .

2. Breech .Complete Breech – thigh breast on abdomen. double Kneeling  b. breast lie on thigh Incomplete Breech – thigh rest on abdominal Frank – legs extend to head Footling – single. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation. .

most painful ROP – squatting pos on mom ROT ROA . Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis. c.  Variety:  Occipito – LOA left occipito ant (most common and      favorable position)– side of maternal pelvis LOP – left occipito posterior LOP – most common mal position.

 Breech.put stet above umbilicus      LSA – left sacro LST. LMP. RST. LADT. RSA. LADP. RMA. LSP. RMT. RSP] Shoulder/acromniodorso LADA. RADA Chin / Mento LMA. LMT.use sacrum anterior  . RMP . RMP.

 Monitoring the Contractions and Fetal heart Tone  Parts of contractions:  Spread fingers lightly over fundus – to monitor contractions  Increment or crescendo – beginning of contractions until it increases  Acme or apex – height of contraction  Decrement or decrescendo – from height of contractions until it decreases contraction contraction  Duration – beginning of contractions to end of same  Interval – end of 1 contraction to beginning of next .

decrease FHT  Best time to get BP & FHT just after a contraction or midway of contractions  Placental reserve – 60 sec o2 for fetus during contractions  Duration of contractions shouldn’t >60 sec  Notify MD . Contraction – vasoconstriction  Increase BP.

)Sims position/side lying  12 – 18 inch – ht enema tubing . if same BP.)Prevent infection  c.)Enema administer during labor  a. notify MD –preeclampsia  Health teachings  1.)To cleanse bowel  b. If BP increase .)NPO – GIT stops function during labor if with food- will cause aspiration  3. Mom has headache – check BP. let mom rest.) Ok to shower  2.

) <120 & >160  2.) mecomium stain amnion fluid  3.) fetal thrushing – hyperactive fetus due to lack O2 . Check FHT after adm enema  Normal FHT= 120-160  Signs of fetal distress 1.

 2. widen nd vaginal canal. . shorten 2 stage of labor. complete dilation and effacement to birth.  7 – 8 multi – bring to delivery room  10cm primi – bring to delivery room  Lithotomy pos – put legs same time up  Bulging of perineum – sure to come out  Breathing – panting ( teach mom)  Assist doc in doing episiotomy . Second Stage: fetal stage.to prevent laceration.

slow to heal  -use local or pudendal anesthesia. . check cord if coiled. less pain easy to repair. fast to heal. hard to repair.)To prevent laceration  2.  Ironing the perineum – to prevent laceration  Modified Ritgens maneuver – place towel at perineum  1. possible to reach rectum ( urethroanal fistula) Mediolateral – more bleeding & pain.) Will facilitate complete flexion & extension. Check time. identification of baby. Episiotomy – median – less bleeding. (Support head & remove secretion. Pull shoulder down & up.

 Mechanisms of labor        Engagement Descent Flexion Internal Rotation Extension External rotation Expulsion  Three parts of Pelvis – 1. Inlet – AP diameter narrow. transverse diameter wider 2. Cavity .

 Nursing Care:  To prevent puerperal sepsis . supports uterus during pregnancy   Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis. Two Major Divisions of Pelvis  True pelvis – below the pelvic inlet  False pelvis – above the pelvic inlet. .< 48 hours only – vaginal pack  Bolus of Ptocin can lead to hypotension.

 Third Stage: birth to expulsion of Placenta -placental stage placenta has 15 – 28 cotyledons  Placenta delivered from 3-10 minutes Signs of placental separation  Fundus rises – becomes firm & globular “ Calkins sign”  Lengthening of the cord  Sudden gush of blood .

 Hurrying of placental delivery will lead to inversion of . Types of placental delivery  Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny  Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty  Slowly pull cord and wind to clamp – BRANDT ANDREWS MANEUVER uterus.

massage uterus) Check bp Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives Monitor hpn (or give oxytocin IV) Check perineum for lacerations Assist MD for episiorapy Flat on bed Chills-due dehydration. . ginger ale. clear gelatin. Let mom sleep to regain energy. give clear liquid-tea. Nsg care for placenta:          Check completeness of placenta. Check fundus (if relaxed. Blanket.

Monitor v/s q 15 for 1 hr.  Check placement of fundus at level of umbilicus. 2nd hr q 30 minutes. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage. deviation of fundus  Empty bladder to prevent uterine atony  Check lochia    Maternal Observations – body system stabilizes Placement of the Fundus Lochia .  If fundus above umbilicus.

edness E.cchemosis D – ischarges A – approximation of blood loss.  Partial rooming in: baby in morning .Perineum – R . Count pad & saturation   Fully soaked pad : 30 – 40 cc weigh pad.dema E . 1 gram=1cc  Bonding – interaction between mother and newborn – rooming in types  Straight rooming in baby: 24hrs with mom. at night nursery .

Complications of Labor  Dystocia – difficult labor related to: Mechanical factor – due to uterine inertia – sluggishness of contraction  hypertonic or primary uterine inertia intense excessive contractions resulting to ineffective pushing  MD administer sedative valium. Give oxytocin.slow irregular contraction resulting to ineffective pushing.  ./diazepam – muscle relaxant  hypotonic – secondary uterine inertia.

 Prolonged labor  normal length of labor in primi 14 – 20 hrs Multi 10 -14 hrs  > 14 hrs in multi & > 20 hrs in primi  maternal effect – exhaustion. Fetal effect – fetal distress. caput succedaneum or cephal hematoma  nsg care: monitor contractions and FHR .

 Precipitate Labor      labor of < 3 hrs. Earliest sign: tachycardia & restlessness Late sign: hypotension Outstanding Nursing dx: fluid volume deficit Post of mom – modified trendelenberg IV – fast drip due fluid volume def  Signs of Hypovolemic Shock:     Hypotension Tachycardia Tachypnea Cold clammy skin . extensive lacerations. hypovolemic shock if with bleeding. profuse bleeding.

 Factors leading to inversion of uterus    short cord hurrying of placental delivery ineffective fundal pressure .  MD will push uterus back inside or not hysterectomy. Inversion of the uterus – situation uterus is inside out.

 Uterine Rupture  Causes:  1.)Previous classical CS  2.)Large baby  3.) Improper use of oxytocin (IV drip)  Sx:     sudden pain profuse bleeding hypovolemic shock TAHBSO .

) sign of impending uterine rupture . Physiologic retraction ring  Boundary bet upper/lower uterine segment  BANDL’S pathologic ring – suprapubic depression  a.

etc.  Trial Labor – measurement of head & pelvis falls on borderline. Amniotic Fluid Embolism or placental embolism  amniotic fluid or fragments of placenta enters natural circulation resulting to embolism  Sx:  dyspnea. nose. primi 14 – 20 . chest pain & frothy sputum  prepare: suctioning  end stage: DIC disseminated intravascular coagopathybleeding to all portions of the body – eyes. Mom given 6 hrs of labor  Multi: 8 – 14.

dilation 2-3 cm  Home Mgt:  1. avoid sex  3. premature contractions q 10 min  2. drink 3 -4 glasses of water – full bladder inhibits contractions  5. Preterm Labor – labor after 20 – 37 weeks) ( abortion <20 weeks)  Sx:  1. complete bed rest  2. effacement of 60 – 80%  3. consult MD if symptoms persist . empty bladder  4.

If cervix is closed 2 – 3 cm. Hosp:  1.Yutopar Hcl) 150mg incorporated 500cc Dextrose piggyback.       administer Tocolytic agentscontractions.YUTOPAR.beta-blocker dilation saved by halts preterm . Monitor: FHT > 180 bpm  Maternal BP .<90/60 Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV Tocolytic (Phil) Terbuthaline (Bricanyl or Brethine) – sustained tachycardia Antidote – propranolol or inderal .

. If cervix is open – MD –  steroid dextamethzone (betamethazone) to facilitate surfactant maturation preventing RDS  Preterm-cut cord ASAP to prevent jaundice or hyperbilirubenia.

early ambulation .prone to thrombus formation  .   Hyperfibrinogenia  . Postpartal Period 5th stage of labor  after 24hrs :Normal increase WBC up to 30. X.000 cumm  Puerperium – covers 1st 6 wks post partum  Involution – return of repro organ to its non pregnant state.

Systemic Changes  1. Physiologic Changes  a. This is critical especially to gravidocardiac mothers.the first few minutes after delivery is the most critical period in mothers because the increased in plasma volume return to its normal state and thus adding to the workload of the heart.1. . Cardiovascular System  . Principles underlying puerperium  1. To return to Normal and Facilitate healing  A.

cold compress – to prevent bleeding  3. Fundus goes down 1 finger breath/day until 10th day – no longer palpable due behind symphisis pubis  3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood. Vaginal and Pelvic Floor  c. Cervix – cervical opening  b. mefenamic acid  after. Uterus – return to normal 6 – 8 wks.D&C  1. Genital tract  a. 2. position prone  2. birth pain: .a medium for bacterial growth(puerperal sepsis).

 d. limited amt  3.stimulate bladder . deciduas. musty/mousy. Ruba – red 1st 3 days present.urine collection  . microorganism. moderate amt  2. Nsd & Cs with lochia. Alba – créme white 10 – 21 days very decreased amt  dysuria  .alternate warm & cold compress  . Lochia-bld.  1. wbc. Serosa – pink to brown 4 – 9th day.

fear of bearing down  5. Urinary tract:  Bladder – freq in urination after delivery. cold compress for immediate pain after 24 hrs.urinary retention with overflow  4. hot sitz bath. Colon:  Constipation – due NPO. not compress  sex. Perineal area – painful – episiotomy site – sims pos. 3.when perineum has healed .

Provide Emotional Support – Reva Rubia  Psychological Responses:  Taking in phase  dependent phase (1st three days) mom – passive.II. experiences. activity is to tell child birth  Nursing Care: .proper hygiene . cant make decisions.

despondenceinability to sleep & lack of appetite. can make decisions  HT:  Care of newborn  Insert family planting method  common post partum blues/ baby blues present 4 – 5 days 50-80% moms – overwhelming feeling of depression characterized by crying. Taking hold phase  dependent to independent phase (4 to 7 days). . – let mom cry – therapeutic.  Letting go  interdependent phase – 7 days & above. Mom is active. Mom - redefines new roles may extend until child grows.

Complications: hypovolemic shock. Prevent complications  Hemorrhage – bleeding of > 500cc CS – 600 – 800 cc normal NSD 500 cc  Early postpartum hemorrhage– bleeding within 1st 24 hrs.III. Baggy or relaxed uterus & profuse bleeding – uterine atony. .

 Mgt:     massage uterus until contracted cold compress modified trendelenberg IV fast drip/ oxytocin IV drip  1st degree laceration – affects vaginal skin & mucus membrane.  2nd degree – 1st degree + muscles of vagina  3rd degree – 2nd degree + external sphincter of rectum  4th degree – 3rd degree + mucus membrane of rectum .

 Breast feeding – post pit gland will release oxytocin so uterus will contract.  Well contracted uterus + bleeding = laceration  assess perineum for laceration  degree of laceration  mgt episiorapy .

 DIC  Disseminated Intravascular Coagulopathy.failure to coagulate. Hypofibrinogen.cryoprecipitate or fresh frozen plasma .  bleeding to any part of body  hysterectomy if with abruption placenta  mgt:  BT.

percreta.  Increta – deeper attachment of placenta to myometrium hysterectomy  Percreta – invasion of placenta to perimetrium .  Acreta – attached placenta to myometrium. Late Postpartum hemorrhage  bleeding after 24 hrs – retained placental fragments  Mgt:  D&C or manual extraction of fragments & massaging of uterus. D&C except placenta increta.

 Hematoma  bluish or purple discoloration of SQ tissue of vagina or perineum. scraping & suturing .  too much manipulation  large baby  pudendal anesthesia  Mgt:    cold compress every 30 minutes with rest period of 30 minutes for 24 hrs shave incision on site.

rubor (red).from members health team  unhealthy sexual practices General signs of inflammation:  Inflammation – calor (heat).) exogenous – from outside  anaerobic streptococci – most common .)endogenous – from within body  2.sources of infection  1. dolor (pain) tumor(swelling)  purulent discharges  fever .Infection.

culture & sensitivity – for antibiotic  prolonged use of antibiotic lead to fungal infection  inflammation of perineum – see general signs of inflammation  2 to 3 stitches dislocated with purulent discharge . Gen mgt:  1. VITC. TSB.) supportive care – CBR. cold compress. paracetamol. hydration.

 Mgt:  Removal of sutures & drainage. saline.  Fowlers – to facilitate drainage & localize infection oxytocin & antibiotic .  Endometriosis – inflammation of endometrial lining  Sx:  Abdominal tenderness. pos. between & resulting.

Motivate the use of Family Planning  determine one’s own beliefs 1st  never advice a permanent method of planning  method of choice is an individuals choice. watery. stretchable.  Natural Method – the only method accepted by the Catholic Church  Billings / Cervical mucus– test spinnbarkeit & ferning (estrogen)  clear. elastic – long spinnbarkeit ovulation – no sex  get before arising in bed  Basal Body Temperature 13th day temp goes down before . IV.

least . Best method  Social Method – 1.menstruation will come out 4 – 6 months  bottle fed 2 – 3 months  disadvantage of lam – might get pregnant  Symptothermal – combination of BBT & cervical.) coitus interuptus/ withdrawal effective method  coitus reservatus – sex without ejaculation –  coitus interfemora – “ipit”  calendar method .  breast feeding. LAM – lactation amenorrheal method – hormone that inhibits ovulation is prolactin.

start 5th day of mens  28day pill.start 1st day of mens  missed 1 pill – take 2 next day . OVULATION –count minus 14 days before next mens (14 days before next mens)  Origoknause formula –  monitor cycle for 1 year  -get short test & longest cycle from Jan – Dec  shortest – 18  longest – 11    June 26 .18 8 Dec 33 -11 22 unsafe days  21 day pill.

Alerts on Oral Contraceptive:  -in case a mother who is taking an oral contraceptive for almost long time plans to have a baby. 99. . she would wait for at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return to normal. Consult OB-6mos.9% effective.3 months.Physiologic Method  Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and LH which are essential for the maturation and rupture of a follicle. Waiting time to become pregnant.

if a new oral contraceptive is prescribed the mother should continue taking the previously prescribed contraceptive and begin taking the new one on the first day of the next menses. headache as this is an indication of hypertension associated with increase incidence of CVA and subarachnoid hemorrhage.Alerts on Oral Contraceptive:  .  .discontinue oral contraceptive if there is signs of severe .

headache E – eye problems S – severe leg cramps  If mom HPN – stop pills STAT!  Adverse effect: breakthrough bleeding .Signs of hypertension  Immediate Discontinuation A – abdominal pain C – chest pain H .

or more days. use another method for the rest of the cycle and the start again. . Contraindicated:      chain smoker extreme obesity HPN DM Thrombophlebitis or problems in clotting factors  if forgotten for one day. If forgotten for two consecutive days. immediately take the forgotten tablet plus the tablet scheduled that day.

 5 yrs – disadvantage if keloid skin  as soon as removed – can become pregnant .never massage injected site. DMPA – depoproveda – has progesterone inhibits LH – inhibits ovulation Depomedroxy progesterone acetate – IM q 3 months  . it will shorten duration  Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.

 Mechanism and Chemical Barriers

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

ovum

right time to insert is after delivery or during menstruation
 primary indication for use of IUD

parity or # of children, if 1 kid only don’t use IUD

 HT:
  

Check for string daily Monthly checkup Regular pap smear

 Alerts

 prevents implantation  most common complications: excessive menstrual flow and

expulsion of the device (common problem)  others:

P eriod late (pregnancy suspected) Abnormal spotting or bleeding

   

A bdominal pain or pain with intercourse I nfection (abnormal vaginal discharge) N ot feeling well, fever, chills S trings lost, shorter or longer Uterine inflammation, uterine perforation, ectopic

pregnancy

 Condom – latex inserted to erected penis or lubricated

vagina  Adv; gives highest protection against STD – female condom
 Alerts:  Disadvantage:
 it lessen sexual satisfaction  it gives higher protection in the prevention of STDs

 Diaphragm – rubberized dome shaped material inserted to

cervix preventing sperm to get to the uterus. REVERSiBLE
    

 Ht:

proper hygiene check for holes before use must stay in place 6 – 8 hrs after sex must be refitted especially if without wt change 15 lbs spermicide – chem. Barrier ex. Foam (most effective), jellies, creams

 S/effect: Toxic shock syndrome  Alerts: Should be kept in place for about 6 – 8 hours

 Cervical Cap – most durable than diaphragm no need to

apply spermicide C/I: abnormal pap smear

 Foams, Jellies, Creams  Surgical Method – BTL , Bilateral Tubal Ligation – can be

reversed 20% chance. HT: avoid lifting heavy objects
 Vasectomy – cut vas deferense.  HT: >30 ejaculations before safe sex  O – zero sperm count, safe

High Risk Pregnancy  Hemorrhagic Disorders General Management  CBR  Avoid sex  Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)  Ultrasound to determine integrity of sac  Signs of Hypovolemic shock  Save discharges – for histopathology – to determine if product of conception has been expelled or not .XI.

) blighted ovum  3. First Trimester Bleeding – abortion or eptopic  A.) chromosomal alterations  2.miscarriage  Cause:  1. Abortions – termination of pregnancy before age of viability (before 20 weeks)  Spontaneous Abortion.) plasma germ defect .

CS . tissue protrudes form the cervix (Cervical dilation)  Types:  Complete – all products of conception are expelled. No mgt just emotional support!  Incomplete – Placental and membranes retained. infection. Mgt: D&C  Incompetent cervix – abortion  McDonalds procedure – temporary circlage on cervix   S/E. circlage is removed. During delivery. Classifications:  Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed  Inevitable – moderate bleeding. NSD Sheridan – permanent surgery cervix. cramping.

. scanty dark brown bleeding  Mgt: induced labor with oxytocin or vacuum extraction  d. Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.  5. Double effect choose between lesser evil. signs of pregnancy cease. c. product of conception remain in uterus 4 weeks or longer. Present 2nd trimester Missed – fetus dies. (-) preg test.) Induced Abortion – therapeutic abortion to save life of mom.

vaginal bleeding      Nursing care: Vital signs Administer IV fluids Monitor for vaginal bleeding Monitor I & O . Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. dark brown. common site: tubal or ampular  Dangerous site – interstitial  Unruptured  missed period  abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)  scant.

Unilateral radiating to shoulder. sharp.  shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve) peritoneal bleeding  + Cullen’s Sign – bluish tinged umbilicus – signifies intra  syncope (fainting)  Mgt:  Surgery depending on side  Ovary: oophrectomy  Uterus : hysterectomy . Tubal Rupture  sudden . severe pain.

The nucleus of the sperm duplicates. it grows & enlarges the uterus vary rapidly. Second trimester bleeding  C. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg.  . . Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. Progressive degeneration of chorionic villi. producing a diploid number 46 XX. Recurs.gestational anomaly of the placenta consisting of a bunch of clear vesicles. – with fertilization.

 Use: methotrexate to prevent choriocarcinoma  Assessment:  Early signs - vesicles passed thru the vagina Hyperemesis gravidarium increase HCG Fundal height  Vaginal bleeding( scant or profuse)  Early in pregnancy High levels of HCG Preeclampsia at about 12 weeks .

 Late signs hypertension before 20th week Vesicles look like a “ snowstorm” on sonogram Anemia Abdominal cramping hyperthyroidism Pulmonary embolus  Serious complications  Nursing care:  Prepare D&C  Do not give oxytoxic drugs  Teachings:   Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma Avoid pregnancy for at least one year .

Third Trimester Bleeding “Placenta Anomalies”  Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment. enema – may lead to sudden fetal blood loss  Double set up: delivery room may be converted to OR . IE.  candidate for CS  Bright red  Painless bleeding  Sx: frank  Dx:  Ultrasound  Avoid: sex. sometimes covering the cervical os. Abnormal lower implantation of placenta.

RN as witness  MD explain to patient  complication: sudden fetal blood loss  Nursing Care     NPO Bed rest Prepare to induce labor if cervix is ripe Administer IV . Assessment:  Engagement (usually has not occurred)  Fetal distress  Presentation ( usually abnormal)  Surgeon – in charge of sign consent.

It usually occurs after the twentieth week of pregnancy.  Outstanding Sx: dark red.  Assessment:  Concealed bleeding (retroplacental)  Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. board like or rigid uterus.  Severe abdominal pain  Dropping coagulation factor (a potential for DIC) . painful bleeding.

prepare to administer blood Type and crossmatch Monitor FHR Insert Foley Measure blood loss. Complications:  Sudden fetal blood loss  -placenta previa & vasa previa  Nursing Care:         Infuse IV. count pads Report s/sx of DIC Monitor v/s for shock Strict I&O .

Placenta Circumvalata – fetal side of placenta covered by chorion Placenta Marginata – fold side of chorion reaches just to the edge of placenta Battledore Placenta – cord inserted marginally rather then centrally Placenta Bipartita – placenta divides into 2 lobes Vilamentous Insertion of cord. Placenta succenturiata – 1 or 2 more lobes connected to the       placenta by a blood vessel may lead to retained placental fragments if vessel is cut.cord divides into small vessels before it enters the placenta Vasa Previa – velamentous insertion of cord has implanted in cervical OS .

Pregnancy Induced Hypertension (PIH).HPN without edema & protenuria H without EP Pre-eclampsia – HPN with edema & protenuria or albuminuria HE P/A HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count .HPN after 24 wks of pregnancy.    Gestational hypertension .Hypertensive Disorders  I. solved 6 weeks post partum.

) increase wt due to edema  b. Transissional Hypertension – HPN between 20 – 24 weeks  III.) Mild preeclampsia – earliest sign of preeclampsia  a.) BP 140/90  c.+2 .) protenuria +1 .  Three types of pre-eclampsia  1. II. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.

+4  3. 2.  Cause of preeclampsia  idiopathic or unknown common in primi due to 1st exposure to chorionic villi  common in multiple pre (twins) increase exposure to chorionic villi  common to mom with low socioeconomic status due to decrease intake of CHON .) Eclampsia – with seizure! Increase BUN – glomerular damage. BP 160/110 . protenuria +3 .) Severe preeclampsia  Signs present: cerebral and visual disturbances. Provide safety. epigastric pain due to liver edema and oliguria usually indicates an impending convulsion.

 Nursing care:  P – romote bed rest to decrease O2 demand.Na – in moderation . facilitate.turning to side done AFTER seizure! Observe only! for safely. water immersion will cause to urinate.  E – ensure high protein intake ( 1g/kg/day)  .prevent convulsions by nursing measures or seizure precaution  1. sodium excretion.prepare the following at bedside   .) dimly lit room . quiet calm environment  2.) minimal handling – planning procedure  3.) avoid jarring bed  P.tongue depressor .  P.

 A – anti-hypertensive drug Hydralazine ( Apresoline)  C – convulsion. prevent – Mg So4 – CNS depressant  E – valuate physical parameters for Magnesium sulfate      Magnesium SO4 Toxicity: BP decrease Urine output decrease Resp < 12 Patella reflex absent – 1st sigh Mg SO4 toxicity. antidote – Ca gluconate .

 3.absence of insufficient insulin (Islet of Langerhans of pancreas)  Function: of insulin – facilitates transport of glucose to cell  Dx: 1 hr 50gr glucose tolerance test GTT  Normal glucose – 80 – 120 mg/dl hypoclycemic < 80 – ( euglycemia) 3 degrees GTT of > 130 mg/dL > 120 .hyperglycemia .Diabetes Mellitus .

decrease in insulin by 33% in 1st tri. 50% increase insulin at 2nd – 3rd trimester. Post partum decrease 25% due placenta out. maternal effect DM  Hypo or hyperglycemia – 1st trimester hypo. Insulin requirement.moniliasis Polyhydramnios Dystocia-difficult birth due to abnormalities in fetus or mom. . 2nd – 3rd     trim – hyperglycemic Frequent infection.

 Fetal effect  hyper & hypoglycemia  macrosomia – large gestational age – baby delivered > 400g or 4kg  preterm birth to prevent stillbirth  Newborn Effect : DM  hyperinsulinism  hypoglycemia    normal glucose in newborn 45 – 55 mg/dL hypoglycemic < 40 mg/dL Heel stick test – get blood at heel .

< 7mg%  Sx:  Calcemia tetany  Trousseau sign  Give calcium gluconate if decrease calcium  Therapeutic abortion  If push through with pregnancy    Recommendation antibiotic therapy. Sx:  Hypoglycemia high pitch shrill cry tremors.to prevent sub acute bacterial endocarditis anticoagulant – heparin doesn’t cross placenta . administer dextrose  hypocalcemia .

good progress for vaginal delivery  Class III & IV. not CS!  NOT lithotomy! High semi-fowlers during delivery. for vaginal delivery. No valsalva maneuver  Regional anesthesia!  Low forcep delivery due to inability to push.poor prognosis. It will shorten 2nd stage of labor . Class I & II.

 Heart disease  Moms with RHD at childhood  Class I – no limit to physical activity  Class II – slight limitation of activity.  Recommendation of class I & II  sleep 10 hrs a day  rest 30 minutes & after meal . Ordinary activity causes fatigue & discomfort.

marked limitation of physical activity.moderate limitation of physical activity. Class III . Ordinary activity causes discomfort  Recommendation:  1. Even at rest there is fatigue & discomfort.  Recommendation:  Therapeutic abortion .) early hospitalization by 7 months  Class IV.

Intrapartal complications  Cesarean Delivery Indications:           Multiple gestation Diabetes Active herpes II Severe toxemia Placenta previa Abruptio placenta Prolapse of the cord CPD primary indication Breech presentation Transverse lie .XII.

Within a year of attempting it  Manageable  STERILITY .inability to achieve pregnancy. Procedure:  classical – vertical insertion.irreversible  Impotency – inability to have an erection . Once classical always classical  Low segment – bikini line type – aesthetic use  VBAC – vaginal birth after CS  INFERTILITY .

Procedure: sex 2 hours before test  mom – remains supine 15 min after ejaculation  Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. no more next preg      test male 1st more practical & less complicated need: sperm only sterile bottle container ( not plastic has chem.) Secondary – 1st pregnancy.) primary – no pregnancy at all  2.sperm motility for impotency . If >15 – low sperm count  Best criteria. 2 types of infertility  1.) Sims Huhner test – or post coital test.

 Factors: low sperm count  occupation.truck driver  chain smoker  administer: clomid ( chomephine citrate) to induce spermatogenesis count  Mgt: GIFT= Gamete Intra Fallopian Transfer for low sperm  Implant sperm in ampula .

parlodel ( Bromocryptice Mesylate) Action. antihyper prolactineuria Give mom clomid: action: to induce oogenesis or ovulation S/E: multiple pregnancy scarred tubes  2.) Mom: anovulation – no ovulation.) Tubal Occlusion – tubal blockage – Hx of PID that has  use of IUD  appendicitis (burst) & scarring  = dx: hysterosalphingography – used to determine tubal patency with use of radiopaque material . 1. Due to increase prolactin – hyperprolactinemia     Administer.

 Mgt: IVF – invitrofertilization (test tube baby)  England 1st test tube baby  To shorten 2nd stage of labor!  fundal pressure  episiotomy  forcep delivery .

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