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 2 3 4 Approximately 10 cm in length Conveys ova from ovaries to the uterus Site of fertilization 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. 1 2 3 Uterine Wall Endometrial layer: formed by 2 layers of cells which are as follows: basal layer- closest to the uterine wall glandular layer – inner layer influenced by estrogen and progesterone; thickens and shed off as menstrual flow Myometrium – composed of 3 interwoven layers of smooth muscle; fibers are arranged in longitudinal; transverse and oblique directions giving it extreme strength
Vagina Acts as organ of copulation Conveys sperm to the cervix Expands to serve as birth canal 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
4. 5 6 7 8
vagina (target of Kegel’s exercise) II. PUBERTAL DEVELOPMENT 1. Puberty: 1 2 3
the stage of life at which secondary sex changes begins the development and maturation of reproductive organs which occurs in female 10-13 years old & male at 12-14 yrs old 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 2 3 4 Hypothalamus Anterior Pituitary Gland Ovary 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. 2. 3. 4. 5. Amenorrhea - temporary cessation of menstrual flow Oligomenorrhea - markedly diminished menstrual flow Menorrhagia - excessive bleeding during regular menstruation Metrorrhagia - bleeding at completely irregular intervals 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
advised to use Family planning method until menses have been absent for 6 continuous months Menopause is has occurred if there had been no period for one year. natural methods 2. irregular and with diminished amount. renal disease. excessive sweating especially at night c. PROMOTE RESPONSIBLE PARENTHOOD – FAMILY PLANNING A. surgical methods Oral contraceptive Action: Types: inhibits release of FSH no ovulation Combined . varicosities o CA. apprehension i. heralds the onset of menopause. take one as soon as remembered and take next pill on schedule. Period may be ovulatory or unovulatory . Classical signs: Vasomotor changes due to hormonal imbalance a. epilepsy.
. if not done withdrawal bleeding occurs. Women who smoke more than 2 packs of cigarette per day d. insomnia e. headache f. chemical methods 4. Artificial Methods: 1. hot flushes b. depression j. physiologic method: oral contraceptives . emotional changes d. nervousness h. loss of skin elasticity and subcutaneous fat in labial folds Artificial menopause / surgically induced menopause a. Breastfeeding b. mechanical methods 3.recent hepatitis c. Certain diseases: o thromboembolism o Diabetes Mellitus o Liver disease o migraine.a transitional phase (period of 1 – 2 years) called climacteric. Monthly menstrual period is less frequent. arthralgias and muscle pains m. 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. Strong family Hx of heart attack Note: If taking pill is missed on schedule. palpitations g.o o o
Mechanism. oophorectomy or irradiation of ovaries b. tendency to lose height because of osteoporosis (dowager hump) l. panhysterectomy
III. tendency to gain weight more rapidly k.
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. o o o o o Diaphragm a disc that fits over the cervix forms a barrier against the entrance of sperms initially inserted by the doctor maybe washed with soap and water is reusable when used. Intrauterine Device . Natural Methods: a. Mechanical Methods 1. 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 first day of the beginning of one cycle to the first day of the
Standard Formula: next cycle
shortest cycle = minus 18 longest cycle = minus 11 Example: shortest cycle = 28 longest cycle = 35 Shortest cycle: Longest cycle: Fertile pd: 28 days – 18 = 10 35 days – 11 = 24 10th to 24th day of cycle = No sexual intercourse
b. no need to remove IUD. may be extended o Sexual Intercourse may be resumed after 3 – 4 days c. will not harm fetus 2. Billings Method / Cervical Mucus o woman is fertile when cervical mucus is thin and watery.B. 1 2
. 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) Condom a rubber sheath where sperms are deposited it lessens the chance of contracting STDs
3. Symptothermal Method / BBT 1 the 2 3 4 morning or doing any activity to detect time of ovulation Ovulation is indicated by a slight drop of temperature and then rises Resume Sexual intercourse after 3 – 4 days Recommended observation of BBT is 6 menstrual cycle to establish pattern of fluctuations Requires daily observation and recording of body temperature before rising in
during which time rapid cell division (mitosis) is taking place. Fertilization 1. Implantation General Considerations: o Once implantation has taken place. Union of the ovum and spermatozoon 2. Number of sperms: 120-150 million/cc/ejaculation 5. 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 needs to observe a form of contraception this time to prevent pregnancy
IV. 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. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp. Tubal Ligation: Fallopian tubes are ligated to prevent passage of sperms Menstruation and ovulation continue b. BEGINNING OF PREGNANCY A. present only during the second trimester
. Mature ovum may be fertilized for 12 –24 hrs after ovulation 6. Chemical Methods These are spermicidals (kills sperms) like jellies. suppositories E. Cytotrophoblast – inner layer Syncytiotrophoblast – the outer layer containing finger like projections called chorionic villi which differentiates into: Langerhan’s layer – protective against Treponema Pallidum. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation (life span of sperms 72 hrs) B. creams. The developing cells now called blastomere and when about to have 16 blastomere called morula. the fertilized ovum or zygote stays in the fallopian tube for 3 days. the uterine endometrium is now termed decidua o Occasionally. foaming tablets. Surgical Method a. a small amount of vaginal bleeding occurs with implantation due to breakage of capillaries o Immediately after fertilization. impregnation or fecundation 3. Stages of human prenatal development 1. 2. which implant on the uterus o Implantation is also called nidation.3
most common complaint of users
interrupts sexual act when to apply
D. takes place about a week after fertlization C. 4. Other terms: conception.
reproductive system. heart. Amniotic fluid: clear albuminous fluid. urine is added by the 4th lunar month. Respiratory Tract. Fetal Membranes •Chorion .together with the deciduas basalis gives rise to the placenta. Ectoderm – responsible for the formation of the nervous system. Oligohydramnios = less than <500 ml due to the inability of the kidneys to add urine as in congenital renal anomaly F. hair and nails and the mucous membrane of the anus and mouth
. near term is clear. colorless. develops 15 – 20 cotyledons •Purpose of Placenta: respiratory. muscles and tendons). begins to form at 11 – 15th week of gestation. kidneys and ureters. circulatory system. tonsils. Mesoderm – forms into the supporting structures of the body (connective tissues. endoderm – gives rise to lining of GIT. 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 Membranes 1. produced at rate of 500 ml/day. Known as BOW or Bag of Water E. containing little white specks of vernix caseosa. thyroid (for basal metabolism). start to form at 8th week of gestation. Wharton’s jelly 3. 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. parathyroid (for calcium metabolism). thymus gland (for development of immunity). 3. cartilage. Amnion – gives rise to umbilical cord/funis – with 2 arteries and 1 vein supported by 2. blood cells. chiefly derived from maternal serum and fetal urine. FETAL GROWTH AND DEVELOPMENT First lunar month • Germ layers differentiate by the 2nd week 1. skin. amnion and chorion
D. bladder and urethra 2.o
Syncytial Layer – gives rise to the fetal membranes.
6th month: Attains proportions of full term but has wrinkled skin 7th month: 28 weeks – lower limit of prematurity. lanugo disappears.urine formed . rapid increase in length Third Trimester – period of most rapid growth and development because of the deposition of subcutaneous fat
. heart beat heard by fetoscope quickening. Buds of milk teeth form . alveoli begins to form 8th month: 32 weeks – fetus viable. buds of permanent teeth form. begin bone ossification . allows amniotic fluid . vernix complete. placental fully developed. establishment of feto-placental exchange 4th month: Lanugo appears. FHR audible with
5th month: Vernix appears. meconium formed (5th –8th wk) 3rd month: Kidneys function . lanugo over entire body.12th wk. amniotic volume decrease
Focus of Fetal Development First Trimester – period of organogenesis Second Trimester – period of continued fetal growth and development.1 month: 2nd week – fetal membranes beats
16th day – heart forms
4th week – heart
2nd month: All vital organs and sex organs formed. subcutaneous fat deposition begins 9th month: Lanugo continue to disappear.
ultrasonography is used to avoid trauma from the needle to the placenta.fetal movements to be felt usually occurs in 60 minutes Fetal Heart Rate (FHR) analyzed in conjunction with
b. Rh isoimmunization 3. measurement of fetus(es) and other structures (placenta) Client must drink fluid prior to test to have full bladder to assist in clarity of image No known harmful effects for fetus or mother Noninvasive procedure
. Cardiff Method: “Count to ten” . gestational age Multiple purposes – to determine position. Non-stress Test: 20mins. Ultrasound – transducer on abdomen transmits sound waves that show fetal image on screen a.Assessing Fetal Well-being Fetal Movement: Quickening at 18 – 20 weeks . monitor for uterine contractions 4. b. e. Amniocentesis .) Measures response of FHR to fetal movement (10with 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. Contraction Stress Test: 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. infection. Complications include premature labor. Prior to the procedure. number. Monitor fetus electronically after procedure. peaks at 29 -38 weeks Consistently felt until term a. e.done to determine fetal maturity: Identify L/S ratio 16 wks – detect genetic disorder 30 wks – assess
1. Teach client to report decreased fetal movement. contractions. bladder should be emptied. Done as early as five weeks to confirm pregnancy. d. fetus 2. or abdominal discomfort after procedure. c.records time interval it takes for 10 .
systolic murmurs due to lowered blood viscosity 4. Constipation and Flatulence GI displacement slows peristalsis & gastric emptying time. Gastrointestinal Changes a. fatty foods sips of milk at intervals
. 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. Predisposition to blood clot formation -due to increased level of circulating fibrinogen as a protection from bleeding implication: no massage 2. 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. inc progesterone d. slight hypertrophy of the heart 3. 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. NORMAL ADAPTATIONS IN PREGNANCY 1. Hemorrhoids 1 due pressure of enlarged uterus 2 Management: cold compress with witch hazel and Epsom salts e. nosebleeds may occur due to congestion of nasopharynx b. Vaginal and rectal varicosities . Palpitations caused by the SNS stimulation during early part of pregnancy.due to pressure on blood vessels of the genitalia Management: side lying hips elevated on pillow modified knee chest position e. complete bed room c. Hyperemesis gravidarum 4 excessive nausea & vomiting which persists beyond 3 months causing dehydration. starvation and acidosis 5 Management: hydration in 24 hrs.VI. Heartburn 1 due to increased progesterone and decreased gastric motility causing regurgitation through gastric sphincter 2 Management: pats off butter before meals avoid fried.
oxygen consumption and production of carbon dioxide during the 1st Trimester. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine. 8. low calcium and phosphorus intake
6. HPL. Addition of the placenta as an endocrine organ producing HCG. d. and ADH which affect CHO and fat metabolism causing hyperglycemia. First Trimester 1. Pride of Pregnancy 1 due to need to change center of gravity result to lordotic position b. frequent meals taken slowly don’t bend on waist take antacids (milk of magnesia) 3. progesterone 5. Weight Change a. aldosterone. and increased uterine size pushing the diaphragm crowding chest cavity management: side lying position to promote lateral chest expansion 4. Musculoskeletal changes a. Shortness of Breath due to inc. fatigue. Emotional responses
. Urinary Changes a. b.small. estrogen and progesterone b. and inc. 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. Moderate enlargement of the thyroid due to increased basal metabolic rate c. Pattern of weight gain is more important than the amount of weight gained. e. 2nd and 3rd trimester 10 – 11 lbs per trimester is recommended c. Increased size of the parathyroid to meet need of fetus for calcium d.5 to 3 lbs normal weight gain b. Leg cramps 1 due to pressure of gravid uterus. Waddling gait 1 due to increased production of hormone relaxin. Increased size and activity of adrenal cortex increasing circulating cortisol. Endocrine Changes a. muscle tenseness. Respiratory Changes a. pelvic bones becomes more movable 2 increasing incidence of falls c. Total allowable weight gain during throughout pregnance is 20 – 25 lbs or 10 – 12 kgs. Gradual increase in insulin production but there is decreased sensitivity to insulin during pregnancy 7.
Devegan) Management: 1. treat male partner also with Flagyl 2.g. b. dark brown urine expected 4. 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.o. foul smelling. Must not be itchy. To allay fear of death let woman listen to the FHT. excessive. pH of vaginal secretions during pregnancy fall • Microorganisms that thrive in an alkaline environment: a. Under the influence of estrogen. avoid alcohol to prevent SE 3. foul smelling discharges.
VII. b. increase to about 1000 grams at full term due to increase in fibrous and elastic Becomes ovoid in shape Softening of lower uterine segment: Hegar’s sign seen at 6th week Operculum – mucus plug to seal out bacteria Goodell’s sign – cervix becomes vascular and edematous giving it consistency of the earlobe
2. 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. vaginal epithelium & underlying tissues hypertrophic & enriched with glycogen d. even depression because of its future implication -> give health teachings on body changes and allow for expression of feelings 2nd trimester: fetus is perceived as a separate entity and fantasizes appearance 3rd trimester: best time to talk about layette. disbelief. LOCAL CHANGES DURING PREGNANCY 1. Vagisec. Acidic vaginal douche (1 tbsp vinegar:1 qt water or 15 ml: 1000 ml) 5.a. d. nor green/yellow in color. and infant feeding method. avoid intercourse to prevent reinfection a.condition is called Moniliasis or Candidiasis 6 it thrives in an environment rich in CHO and those on steroid or antibiotic
. Tricofuron. Uterus – wt tissues a.
1st trimester: some degree of rejection. or trichomonicidal cmpd suppositories (e. anxiety and empathy for partner Emotional labile – mood changes/swings occur frequently due to hormonal changes Change in Sexual Desire – may increase or decrease as a loss of interest in sexual partner needs correct interpretation… not
VIII. a. Vagina – increased vascularity occurs a. cream-colored. irritatingly itchy. Candida Albicans . c. Management: good hygiene c. vulvar edema Management : Flagyl 10 days p. c. Trichomonas – causes trichomonas vaginalis/vagnitis or trichomoniasis s/s: frothy. backache due to stress.
patchy. Mycostatin/Nystatin p. 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.
obstetrical data para past pregnancies LMP
Vaginal bleeding (any amount) Swelling of face or fingers Severe. 10. Gentian violet swab to vagina 3. Prenatal Visit History Taking: personal data gravida TPAL present pregnancy: cc medical data: hx of diseases/illnesses 3. Avoid intercourse 3. peak 60 days) conduct test 6 weeks after LMP
therapy seen as oral thrush in the NB when transmitted during delivery s/s: white. 6. 2. 7. Pregnancy 1 2 3 4 5 Prenatal care is important for prevention of infant and maternal morbidity and mortality Care is a cooperative action based on client’s understanding of treatment modalities Duration of normal pregnancy 266 – 280 days of 38 – 42 weeks or 9 calendar months or 10 lunar months. or vaginal suppositories 100. Ovaries Inactive since ovulation does not take place during pregnancy. 8. Danger Signals of Pregnancy 1. SIGNS OF PREGNANCY I. Placenta produces Progesterone and Estrogen during pregnancy 4.7 8 walls.o.000 U BID x 15 days 2. 5. 4. cheese-like particles that adhere to vaginal
smelling discharges causing irritating itchiness Management : 1. 9. Infant born < 38 weeks pre-term & 42 post term) Diagnosis: Urine examination – tests presence of HCG (present from 40th –100th day. continuous headache Dimness or blurring of vision Flashes of light or dots before eyes Pain in the abdomen Persistent vomiting Chills and fever Sudden escape of fluids from the vagina Absence of FHT after they have been initially heard on 4th or 5th month
. 3. Acidic vaginal douche 4.
Pap Smear f. Urinalysis: test for albumin. Goodell’s. 2006 or LMP: Formula: EDC: • 5 15 -3+ 7 2 22 or 5-15-06
February 22. 2007
McDonald’s Rule: Ht fundus/4 (AOG wks)
1. Weeks of pregnancy: Fundal height (cms) x 8/7 Ex. (9 standard) Solution: 35 cms – 11 = 24 x 155 =3. Hct . Assessment a. Important Estimates: a. LMP= May 15. blood typing. Measure in cms the length from the symphysis to the level of fundus 2. position. Lunar months: Fundal Height (cms) x 2/7 3.
c. Vital signs i.720 g •
b. Ballotement – on 5th month e. 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. Leopold’s Manuever: to determine fetal presentation. IE – determine Hegar’s. serological tests j. size and fetal parts h. Pelvic examination (ask client to void) c. Physical examination – review of systems b. 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) 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 Fetal Weight: 1 Johnson’s Rule: Fundic Ht – n x k ( k=155. attitude. Blood studies: CBC Hgb. Age of Gestation: Nagele’s Rule: -3 calendar months and +7 days Ex. Chadwick’s d. est.
.4. sugar & pyuria 5. Pelvic measurements (done after 6th month or 2 wks before EDC) g.
5 ml IM for all pregnant women shall be given in 2 doses. Drugs – may be teratogenic hence contraindicated unless prescribed by Doctor d. based on S-R conditioning. Smoking – lead to LBW babies b. deeply engaged presenting part e. 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. breathing exercises. Sexual activity – allowed in moderation but not during last 6 wks. Health Teachings a. pregnancy. concentration on breathing is practiced f. incompetent cervix. 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. Immunization: Tetanus Toxois (TT) = 0. labor and delivery. ruptured BOW. Drinking – can cause respiratory depression in the NB and fetal withdrawal syndrome if excessive.5.the uterine contraction
.4 wks interval with 2nd dose at least 3 wks before delivery = booster doses given during succeeding pregnancies regardless of interval. diet and comfort measures Grant-Dick Read Method: Fear leads to tension and tension leads to pain Lamaze Method: Psychoprophylactic method . ♣ counseling is important on changes in desire and positions contraindication: bleeding.high incidence of post partum infection noted. FOUR P’S OF LABOR a. hygiene. Power . THEORIES OF LABOR ONSET Uterine stretch theory Oxytocin theory Progesterone Deprivation theory Prostaglandin theory 2. alcohol has empty calories c. 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. relaxation techniques. LABOR AND DELIVERY 1. = 3 booster doses is equal to lifetime immunity g.
Uterine Contractions: a. Posterior Left. Movement of Passenger upon birth or descent: d.5. sacrum (S). Measurements:
b. Passenger – the fetus c. Posterior Right Fetal landmarks: Occiput (O). Descent e. Flexion f. Intensity – strength of contraction.1. Psyche – the mental and emotional aspect of the woman a. closes at 2 – 3 months b. largest part of the fetus . Face (mentum) b. Fontanels . PASSENGER . Presentation –the part of the passenger that enters the pelvis is the presenting part a. Brow (sinciput). measured through a monitor or through touch of a fingertip on the fundus (mild. Duration – the beginning of one contraction to the end of the same contraction a. Fetal Skull: a. Transverse Right.b.1. temporal.6. Cephalic – Vertex (occiput) .4. POWER . Footling c. diamond shaped.2. PASSAGEWAY – maternal pelvis c.most frequent presenting part.Fetus b. occipital. least compressible Bones: sphenoid. Breech – Complete (sacrum) . mentum (M). Fetal Lie – relationship of the cephalocaudal axis of the fetus to the cephalocaudal axis of the mother. moderate or strong) b.3. Interval – pattern which increases in frequency and duration a. Posterior. Shoulder b.4. closes at 12 – 18 months posterior fontanel: smaller.3. triangular shaped. lamboidal b. External rotation/ restitution
.2. Frank.1.membrane covered spaces at the junction of the main suture lines anterior fontanel: larger. Fetal Attitude – fetal position Pelvis is divided into 6 areas: Anterior. frontal. and scapula (Sc) b. Transverse Left. Extension h. ethmoid. Passageway – the maternal pelvis d. Frequency – the beginning of one contraction to the beginning of the next contraction a. Internal Rotation g. parietal Suture lines: sagittal/ coronal.
-supports the growing uterus during pregnancy -directs the fetus into the true pelvis near the end of gestation True Pelvis: the bony canal through which the fetus will pass during delivery formed by the pubis in front. remembering.transverse diameter of the outlet (Average: 11 cm) D. hopeless.5 to 2 cm or less than the diagonal conjugate >True Conjugate/Conjugate Vera .5 cm) >Obstetrical Conjugate . 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. 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 .the distance from the inner border of the symphysis pubis to the sacral prominence .the distance between the ischial tuberosities . External – Suggestive only of pelvic size > External Conjugate/ Baudelaocque’s Diameter .most important pelvic measurement . Significant Pelvic Measurements a.2. or making decisions 8 Feeling worthless and guilty
.the distance between the anterior aspect of the symphysis pubis and the depression below lumbar 5 (Average: 18 – 20 cm) b.5 -11 cm) >Bi-Ischial/ Tuberiischial Diameter . PSYCHEFactors 1 2 3 4 5 6 7 the emotions of the mother that may increase a woman’s chance of depression: History of depression or substance abuse Family history of mental illness Little support from family and friends Anxiety about the fetus Problems with previous pregnancy or birth Marital or financial problems Young age (of mother
Signs and Symptoms of Post-partum depression: 1 Feeling restless or irritable 2 Feeling sad.1.widest AP diameter at outlet estimated on vaginal/pelvic exam (Average: 12.shortest AP diameter of the inlet through which the head must pass . the iliac and ischia on the sides and the sacrum and coccyx behind
c.diameter of the pelvic inlet (10. b.narrowest diameter of the outlet .a.the distance between the anterior surface of the sacral promontory and superior margin of the symphysis pubis .
Monitoring and Evaluating Progress of Labor b.“nesting behavior” Loss of weight ( 2-3 lbs) Braxton Hick’s Contractions Cervical Changes – effacement . f.phases: increment. Fetal Heart Tone b.PRELIMINARY/PRODROMAL SIGNS OF LABOR a. Personal data a.1.Goodell’s sign – ripening of the cervix Increase in back discomfort Bloody Show . duration
False Labor Pains o1 Remain irregular o2 Confined to abdomen o3 No increase in duration. k. frequency. Assessment – history and physical assessment a. Nursing Interventions of Woman in Labor: a. e. g. chest pains. interval.acme.2. Blood pressure b. intensity o4 Disappears on ambulation o5 No cervical changes
True Labor Pains o6 Becomes regular and predictable o7 Radiates in girdle like fashion o8 Increase in duration.characteristics: intensity.9 Loss of interest or pleasure in activities 10 Withdrawal from friends and family 11 Having headaches. station b. intensity o9 Continue regardless of activity o10 Effacement and dilatation occurs o11 Signs of True labor Effacement Dilatation
Uterine Changes– upper and lower segments. Lightening Increased activity level. or hyperventilation (fast and shallow breathing) 3. frequency.decrement .1. Observe for signs of fetal distress
.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 .3. c. h. b.pinkish vaginal discharge Rupture of Membranes– labor expect in 24 hours Sudden burst of energy Diarrhea Regular Contractions . d. frequency.a danger sign of impending rupture of the uterus if obstruction is not relieved
1. heart palpitations (the heart beating fast and feeling like it is skipping beats). i. physiologic retraction ring Bandl’s pathologic retraction ring. j. dilatation.
usually regional anesthesia (e.Assess pain status 1.2. Nursing Care before administration of anesthesia/analgesia 1.3. Pudendal block e. Paracervical block b.3. Analgesics: 5.5. Nalline 6. Peridural block: Epidural/caudal c. Analgesia – relieves pain and its perception 5.4.Check vital signs of mother and fetus 1.2. Narcotic Antagonist: Narcan. Monitor progress – fetal a) during labor check FHR b) manage fetal distress 5.12 bradycardia 13 fetal thrashing 14 meconium stained amniotic fluid in non-breech presentation b. > can increase incidence of maternal hypotension and fetal bradycardia
5.Observe safety measures Evaluate allergies Provide siderails – have call bell ready NPO (anesthesia)
5. Local anethesia Regional Anesthesia is mostly preferred because it does not enter maternal circulation nor affect fetus Xylocaine is used (NPO with IV infusion) > allows to be awake and participate in process.Explain the action of drugs 184.108.40.206. spinal) o o o Relieve uterine and perineal pain Usually safe for the fetus (potential for maternal hypotension) Types of Anesthesia: a. Anesthesia – produces local or general loss of sensation . Intradural: spinal/saddle block d. Analgesia/anesthesia during childbirth 5.3.1 Narcotics o o o o (Demerol) produces sedation/relaxation depresses NB’s respiration given in active labor 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.4.g.2. Monitor and inform patient of progress of labor b.
begins with complete dilatation of the cervix until the birth of the newborn
Duration: Primigravida – 30 mins.6. Duration: 50-90 seconds
b.the stage of true labor until the complete cervical dilatation Characteristics Extent: Primigravida – 3. Side effects: a. Active Phase
c.Record properly 1.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. Transitional Phase
Second Stage .Check time last medication was given 1. cervical dilatation Interval: 3-5 mins Duration: 30-60 seconds 8-10 cms cervical dilatation Interval: 2-3 mins.2-3 mins for 50-90 secs Mother is exhausted and has urge to push
Third Stage . postspinal headaches – place flat on bed for 12 hrs and increase fluid intake b.from delivery of the newborn to the delivery of the placenta
Still with mild contractions until the placenta is expelled.Monitor: vital signs – BP and FHR (be alert for bradycardia) 1.3 hrs
a. placenta is expelled within 30 minutes.Provide comfort measures 1.
.5. cervical dilatation Interval: 15-20 mins interval Duration: 10-30 seconds 5-7 cms.-19.Nursing Care after administration of anesthesia/analgesia 1.3. STAGES OF LABOR 1.2 hrs.7 hrs Multigravida – 0.20 mins – 1 hr.1 . 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.8.9. Multi-gravida.10.7. .14. Stages of Labor Stage First Stage . Latent Phase
0-4 cms. Usually. Contractions.
Injects Oxytocin (Methergin 0. Lactation: promote lactation by encouraging early breastfeeding to stimulate milk production *** Those mothers who cannot breastfeed: suppressing agents are given – estrogen.g. May ambulate
. tea Allow to rest/ sleep
c. Provide emotional support c. Nursing a.2 Mg/Ml Or Syntocinon 10 U/Ml Im) Inspect Cotyledons For Completeness Check Uterus For Contraction Check Perineum For Lacerations -Give perineal care.Fourth Stage . d. d. These drugs tend to increase uterine bleeding and retard involution. local/ block/ general Care of Woman in the 3rd Stage of Labor Principle Of Watchful Waiting Use Brandt Andrews Maneuver Note Time Of Delivery (20 Minutes After Delivery Of The Baby) Check Bp. f. e. Rooming-in-concept provides opportunity for developing positive family relationship promotes maternal infant bonding releases maternal caretaking responses c. (e. f. l. Parlodel or deladumone) b. Promote healing and the process of involution b. Promote responsible parenthood (FP) 3. Establish successful lactation e.the first hour after complete delivery until the woman becomes physically stable
Uterine cramping Rubra with small clots
2. apply perineal pads Change gown Place flat on bed Keep warm – provide extra warm blanket Give initial nourishment – warm milk. Prevent postpartum complications d. b. Hydration and elimination e. e. i. g.
5. c. Nursing Care of the Woman in First & Second Stage Labor a. h. Nursing Care of Woman in Fourth Stage a. 4. fundus and flow every 15 minutes. d. j. g.androgen preparations given first hours post partum to prevent milk production. b. diethylstilbestrol. Principles of Postpartum Care a. k. Assess vital signs. Monitor discomfort/exhaustion/pain control – support client in choice of pain control Relaxation techniques taught during pregnancy where breathing is taught as a relaxed response to contraction Low back pain – massage of sacral area Use different breathing techniques during the different phases of labor Encourage rest between contractions Keep couple informed of progress Administer analgesic : side effects-may prolong labor.
Presence of Lochia: uterine discharges consisting of blood.1.000/mm³ ... . Usually lasts up to 3 days after birth
Nursing Care: Explain to client cause of pain Do not apply heat Administer analgesics as prescribed 3.000 – 30.All blood values are back to prenatal levels by 3rd or 4th week 2.3.Reabsorption of the 30-50% increase in cardiac volume within 5 – 10 minutes after the third stage of labor.the 6 weeks period following delivery Involution.thinner. Categories of Lacerations 8.3 to 6 wks pp – alba . Location of the Fundus .4. Fourth degree – involves all in 3rd degree lacerations and the mucus membrane of the rectum XII. decidua..Uterine involution is measured by determining the level of the fundus in relation to the umbilicus . First degree – involves vaginal mucous membrane and perineal skin 8.Activation of the clotting factor . Vascular Changes . Genital Changes/ Discharges . vaginal mucous membrane and perineal skin 8.Characteristics: pattern should not reverse – 1-3 days – rubra . WBC and some bacteria . Perineal Pain Nursing Care: Place in Sim’s position – lessens strain on the suture line
. increased with activity with fleshy odor.WBC increases to 20. never foul smelling 4.. decreased if with breastfeeding .2.time period for the return of the reproductive organs to return to its prepregnant state 8. Second degree – involves the perineal muscles. PROMOTING HEALING AND INVOLUTION DURING POST-PARTUM 1.. Third degree – involves all in the 2nd degree lacerations and the external sphincter of the rectum 8.Puerperium .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.bright red with no or minimal clots 4-9 days – serosa. serous sanguinous blood 10..whitish discharge same amount as menstrual flow.
Provision of Emotional Support Post-partum Psychological Phases 1. etc. constipation . 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. Taking – hold: mother starts to assume her role 3. 2 Breastfeeding – menses return in 3 – 4 months. fatigue or feelings of inadequacy. 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. 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 7.8 days pp. placenta. o RR – no change is expected o Weight = 10 – 12 lbs is expected to be immediately lost. Taking – in : First 1 – 2 days. Establish Successful Lactation
. Gastrointestinal Changes . explain that it is normal 11. Could be due to hormonal changes. amniotic fluid and blood. Letting go Postpartum Blues – overwhelming sadness that cannot be accounted for. crying is therapeutic. Nursing Care: Encourage verbalization.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. This corresponds to the weight of the fetus. Menstruation 1 Breastfeeding influences return of the menstrual flow. mother focuses on herself and her experience 2. Vital Signs o Temperature: may increase because of dehydration on the first 24 hours pp.) 8. Diaphoresis will contribute to further weight loss 10.Expose to dry heat or warm Sitz bath Application of topical analgesics or oral analgesics as ordered Provide/ encourage perineal care 5. let client listen to sound of flowing water.Change is more on the delay of bowel evacuation. o CR 50 – 70 beats/min (bradycardia) is common for 6 .
effort. No Alcohol for cleaning Handwashing Insert clean OS squares/ absorbent cloth in brassiere for breast discharges b. Hygiene Wash breasts daily No soap. 96 grams protein d. Contraindications: Drugs – oral contraceptives. no massage. have less lochia and rapid involution 12. Nutrition: 3000 calories daily. apply breast binder)
. anticoagulants. no breast pump. cathartics. ASSOCIATED PROBLEMS 1. antimetabolites. cost Infant: bonding with the mother protection against common illness less incidence of GI diseases always available 13.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. tetracyclines. atropine. Advantages of Breastfeeding Mother: faster involution less incidence of CA economical. Certain disease conditions – TB because of close contact during feeding (TB germs are not transmitted thru breast milk) XIII. 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. Feeding Techniques c. Health Teachings a.time. Engorgement breast becomes full.
3.a spirochete transmitted thru sexual 2. Varicella/ Shingles Hepatitis B. AIDS Ubella
Effect: if contracted early. 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. Hepatitis A. TORCH test series Oxoplasmosis (protozoa)
avoid eating uncooked meat and handling cat litter box Rx – Zoster Immune Globulin .1. slows down cell division during organogenesis causing congenital defects NB can carry and transmit the virus for about 12 – 24 months after birth
. 9. lumps in the breasts.2. 4. swelling.Penicillin
thers: Syphilis.8 million units of Penicillin (or 30 – 40 gms Erythrocin) readily cross placenta thus prevent congenital syphilis Cause mid-trimester abortion Cause CNS lesions Can cause death
1. 5. 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 3.2. HIGH RISK PREGNANCY CONDITIONS 1. 8. 7. INFECTIONS 1. Infections Bleeding / Hemorrhage/ PIH Diabetes Mellitus Heart Disease Multiple Pregnancy Blood Incompability Dystocia Induced Labor Instrumental Deliveries
1. redness. milk becomes scanty Nursing Care: Ice compress Supportive brassiere . 2.4 – 4. Mastitis inflammation of the breast
Signs & Symptoms: pain. Syphilis Cause: intercourse Treatment: x 10 days Untreated:
Treponema pallidum . 6.
3. chills and headache Management: Complete Bedrest Proper Nutrition Increased Fluid Intake Analgesics Antipyretics and antibiotics as ordered 1. feeling of pressure. sitz bath & warm compress 1. Infection of the perineum Signs & Symptoms: pain. Endogenous/primary sources . Exogenous sources . anorexia. whereas late infections may result in active systemic disease and/or CNS involvement causing severe neurological impairment or death of newborn Sources/ Cause: 1.C H
Ytomegalovirus erpes type 2
(CMV) (DNA virus)
Group of maternal systemic infections that can cross the placenta or by ascending infection (after rupture of membranes) to the fetus.normal bacterial flora 2.An infection/inflammation of the lining of the uterus Signs & Symptoms: Abdominal tenderness painful to touch Dark brown Management: Oxytocin administration Fowler’s position to drain out lochia Prevent pooling of discharges 1. heat.5. inflammation of suture line with 1 –2 stitches sloughed off temperature elevation Management: drain area & resuturing . 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 Foul smelling lochia Uterus not contracted and
. coitus late in pregnancy premature rupture of membranes General symptoms: malaise. excessive obstetric manipulations breaks in aseptic techniques.hospital personnel. Endometritis .4. fever. Thrombophlebitis -infection of the lining of a blood vessel with formation of clots. Infection early in pregnancy may produce fetal deformities.
relaxed or boggy (most frequent cause) Lacerations Hypofibrinogenemia Clotting defect Management Bleeding in Pregnancy blood transfusion
Late Postpartum Hemorrhage Retained Placental Fragments
D & C (Dilatation and Curettage
Predisposing factor: Overdistension of the uterus (multiparity.350 cc) *** Leading cause of maternal mortality associated with childbearing
2. polyhydramnios. Dicumarol or Heparin) to prevent formation or extension of a thrombus Side effect of Anticoagulant: hematuria.1. 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.o4 Skin is stretched to a point of shiny whiteness.2.g. large babies. ( normal blood loss 250. 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. 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)
. Late Postpartum Hemorrhage
Early Post-partum hemorrhage Cause Uterine Atony – uterus is not well contracted. Early Post-partum hemorrhage – first 24 hrs after delivery 2. HEMMORRHAGE/ BLEEDING Definition: blood loss more than 500 cc.
Pregnancy Induced Hypertension (PIH) . patient is prone to Toxemia Types of Pregnancy Induced Hypertension (PIH): a. Pre-eclampsia. 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. Hematoma . multiple pregnancy or H mole e.4. poor nutrition f. renal and vascular disease g.Occurs anytime after the 24th wk of gestation up to 2 wks PP . Family history Diagnosis: Roll – over test : Assess the probability of developing toxemia when done between the 28th and 32nd week of pregnancy. weight gain of 1. large fetus b. (normal UO/day 1500 ml) o Cerebral or visual disturbances d. Pre-eclampsia. Morbid obesity or weight less than 100 lb h. Transient hypertension . 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. Hx of DM.Obstetrical Emergency o HPN o Proteinuria o Convulsions o Coma
.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. primigravida d. Older than 35. younger than 17 c.Develops during pregnancy and resolves during postpartum period Predisposing Factors: a.2.A vascular disease of unknown cause .5 lbs/wk c. 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.without proteinuria or edema b.3. Eclampsia .
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. Education on self – assessment e. 5 gms/buttock. sedatives e. antihypertensives. Barbiturates – sedation by CNS depression d. Monitor fetal status h. Magnesium Sulfate – drug of choice Action: CNS depressant .g Magnesium sulfate. Apresoline. Type and cross match for blood i. Vasodilator Antidote: Calcium Gluconate.
Nursing Intervention: a. Advised bedrest. left lateral b. Valium) f.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. Minimize stimuli d. Have airway and oxygen available e. Diversion f. Postpartum. before administration: Deep tendon reflexes are present Respiratory rate = 12 / min UO = at least 100 ml / 6 hrs. anticonvulsants.monitor vital signs and watch for seizure Management for Eclampsia: a. Potassium supplements – prevent arrhythmias c. Weigh daily. then an IV drip of 1 gm per hour (1 gm/100 ml D10W).Immediate Intervention for Eclampsia: a. keep daily log d. Analgesics. Check 1 2 3 first the ff. antibiotics. Give medications as ordered (e. Maintain IV line with large-bore needle b. 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. Prepare for possible delivery of fetus g. Family support
. Monitor fluid balance c. Encourage a well-balanced diet c.
May administer if : 4 Deep tendon reflexes are present 5 Respiratory rate = 12 / min 6 UO = at least 100 ml / 6 hrs. Anterior Pituitary hormones. 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. Vasodilator Antidote: Calcium Gluconate. Chronic hereditary disease characterized by marked hyperglycemia Due to lack or absence of insulin abnormalities in CHO. 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. b. DIABETES MELLITUS a. Barbiturates – sedation by CNS depression d.e. Cathartic – cause shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: deep IM.
. sedatives e. 3. ml D10W). anticonvulsants. and thyroxin which affect CHO concentration in blood (hyperglycemia) Rate of insulin secretion is increased but sensitivity of the pregnant body to insulin is decreased 10 gms initially –either by slow IV push over 5 – 10 minutes or 5 gms/buttock. production of adenocorticoids. patient is prone to Toxemia Management: a. then an IV drip of 1 gm per hour (1 gm/100
d. fat and protein metabolism Effects of pregnancy – may develop abnormalities in glucose tolerance decreased renal threshold for sugar due to increased estrogen. antihypertensives. 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. c. Analgesics. antibiotics. inc.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. Potassium supplements – prevent arrhythmias c. Magnesium Sulfate – drug of choice Action: CNS depressant .
Diet . Apnea/cyanosis e. d.highly individualized. increased during 2nd and 3rd trimester because of more pronounced effect of hormones Method of Delivery – Cesarian Section Postpartum Period – more difficult to control Blood Glucose because of hormonal changes
Effect on Infant: a. Hypotonia. c. h. If more than 120 mg% .
Typically longer and weighs more due to: excessive supply of glucose from the mother Increased production of growth hormone from maternal pituitary gland Increased secretion of insulin from the fetal pancreas Increased action of adrenocortical hormone that favor the passage of glucose from mother to fetus congenital anomalies are often seen Cushingoid appearance (puffy. Lethargy/poor suck d.
c.800 – 2200 calories) to prevent intrauterine growth retardation Insulin requirements – individualized. d.
e. Shrill.overt gestational diabetes Management: a. b. but limp and lethargic) Born premature more often – RDS common Greater weight loss because of loss of extra fluid Prone to hypoglycemia (BG <30 mg%)
Signs and symptoms of Diabetic Babies/ Hypoglemic Infant: a.Pregnancy Risks: 1 2 3 4 5 6 7
Toxemia Infection Hemorrhage Polyhydramnios Spontaneous abortion – because of vascular complications which affect placental circulation Acidosis – because of nausea and vomiting 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. b. If 100 – 120 mg% possible GDM c. g.adequate glucose intake (1. high pitched cry b. If less than 100 mg% = normal b. or administer IV of glucose
. Listlessness/jitteriness/tremors c. f. hypothermia ***Consequence of hypoglycemia: untreated hypos brain damage and even death
***Management: feed with glucose water earlier than usual.
scopolamine. e. h. j. place in semisitting position Not allowed to bear down. pulse irregularities. b. i. BLOOD INCOMPATIBILITY . diethylstilbestrol and oral contraceptives – contraindicated can cause fluid retention and promote thromboembolism Most critical period: immediate postpartum period when 30 – 50% increased blood volume is reabsorbed back in 5 – 10 minutes and the weak heart needs to adjust
5. palpitation. Cesarean Section c. c. edema. chest pain on exertion and cyanosis of nailbeds are obvious Management: (depends on cardiac functional capacity) a. Monitor FHT. Bed rest – especially after 30th week of gestation Diet – gain enough (consider effect on cardiac workload) Medications: Digitalis.4. Iron preparations Avoid lithotomy position to avoid increase in venous return. g. dyspnea. weight b. or angina moderate to marked limitation of physical activity. d. Educate regarding proper nutrition and exercise 6. MULTIPLE PREGNANCY Risks: Increased Blood Loss Small for Gestational Age Infants Premature Birth Dystocia Management: a. f. exhaustion. Birth is via low forceps or Cesarean section Anesthetic choice – caudal anesthesia Ergotrate and other oxytoxics. less than ordinary
Signs & Symptoms: Heart murmur due to increased total cardiac volume Cardiac output decreased nutritional and oxygen requirements not met Pulmonary edema Incomplete emptying of the left side of the heart 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. VS. Health Teaching on importance of regular pre-natal check-up visits d.An antigen-antibody reaction which causes excessive destruction of fetal red blood cells
. HEART DISEASE Classification: Class I Class II
Class III 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
no physical limitation slight limitation of physical activity Ordinary activity causes fatigue.
1.negative BloodType O 7. DYSTOCIA -
Fetus Rh Positive (Father is homozygous or heterozygous Rh positive) Either Type A or B (From father)
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.Pelvic Dislocation Fetus is already viable >32 weeks AOG Single fetus in longitudinal lie and is engaged
.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. Precipitate Delivery . Prolonged Labor .Strong fundal push.Insertion of placenta at the fundus.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. polyhydrmanios or excessively large baby Management: Stimulation of labor by oxytocin administration or amniotomy 7. so that as fetus is rapidly delivered. fundus is pulled down . multiple pregnancy. INDUCED LABOR . Uterine Inversion turned inside out fundus is forced through the cervix so that the uterus is .2.Labor lasting more than 18 hrs and in multigravidas. attempts to deliver the placenta before signs of separation -Management: Hysterectomy 8.Usually occurs in primi gravida .3.Mother Rh. more than 12 hours Effects: Maternal exhaustion Uterine atony Caput succedaneum 7.
when at +3 / +4 and sagittal suture line is in an AP position in relation to the outlet (e. Amniotomy – done with Cervical Dilatation = 4 cm . 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. 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. Forceps Delivery . Piper for breech presentation) Purposes: shorten second stage of labor because of fetal distress. Oxytocin Administration. Simpson. maternal exhaustion. Antidiuresis Prostaglandin administration: Route: oral or IV (never IM causes irritation).
Cesarean Section – birth through a surgical incision on the abdomen Indications: o Cephalo-pelvic disproportion (CPD)
. effect is slower than oxytocin 9.Use of metal instruments to extract the fetus from the birth canal. maternal disease – cardiac. 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.Ripe cervix – fully or partially effaced. Cervical Dilatation at least 1=2 cm Procedure for Induced labor: 1. Elliot. INSTRUMENTAL DELIVERIES a. 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.g.
Abdomen is shaved from the level of the xiphoid process below the nipple line. Incision is made in the lower uterine segment.Maternal and infant mortality rates tend to be high in age below 15 and older than 40 years Adolescent pregnancy Most common problems: Toxemia Advanced age A precipitating factor in: Placental accidents
. feel fundus (if boggy. Check vital signs. extending out to the flanks on both sides up to the upper thirds of the thighs e. d.1. coughing exercises. turning from side to side Ambulate after 12 hours Monitor vital signs Watch for signs of hemorrhage – inspect lochia. Preoperative medication is usually only atropine sulfate. uterine contractions. blood typing and cross matching d. which is the thinnest and most passive Part during active labor. routine laboratory tests.
e. massage with proper abdominal splinting and give analgesics as ordered) Breastfeeding should be started 24 hrs after delivery Most common complication: Pelvic thrombosis
10. c. No narcotics are given causes respiratory depression in the NB Postoperative Care a. Low Segment – the method of choice. OTHER RISK FACTORS: 10. Retention catheter is inserted to constant drainage to keep the bladder away from the operative site f. f. Advantages: Minimal blood loss Incision is easier to repair Lower incidence of post partum infection No possibility of uterine rupture 2.
Deep breathing.o o o o Types:
Severe Toxemia Placental Accidents Fetal Distress Previous classic CS –
done prior to onset of labor pains. b. Physical examination. Lower vertical incision – recommended in: Bladder or lower uterine segment Adhesions from Previous operations Anterior Placenta Previa Transverse lie Preoperative Care a. and FHR c. scheduled birth
1. Age: . The patient is both a surgical and an OB patient b.
Persistent uterine bleeding and cramplike pain 2. knife-like stabbing pain Rigid abdomen Positive Cullen’s sign (bluish umbilicus) Excruciating pain on IE Signs of shock
Management: Ruptured Ectopic Pregnancy is an emergency requiring immediate intervention Salpingostomy – if Fallopian tube can still be replaced and preserved.Any gestation outside the uterine cavity Causes of Ectopic Pregnancy: a. Pregnancy Induce Hypertension b.2.Iron-deficiency anemia
Toxemia Uterine atony or inertia Varicosities. including last menstrual period 2.5. Ectopic Pregnancy .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
. Weight Pre-pregnant weight < 70 lbs or > 180 lbs Weight gain < 10 lbs LBW babies Weight gain > 30 lbs = sign of toxemia. Height Short stature < 4 feet.4. Previous tubal surgery c. Congenital anomalies of the fallopian tubes Signs & Symptoms: 1 2 3 4 5
Severe. MATERNAL COMPLICATIONS 1. H-mole. DM.3. Obtain history. Parity – first pregnancy is the period of high risk Multiparity G5 and above and age is over 40 10. hemorrhoids Low birth weight babies Chromosomal Abnormalities like Down’s Syndrome / Trisomy 21 (associated with menopause)
10. Spontaneous Abortion Termination of pregnancy spontaneously at any time before the fetus has attained viability Assessment: 1. Birth Interval – 3 months from previous delivery or more than 5 years 10. Laboratory finding – negatively or weakly positive urine pregnancy test 3. 10 inches = contracted pelvis or CPD XIV. sharp. multiple pregnancy 10. polyhydramnios.
Ultrasound to locate placenta No vaginal. Curettage to completely remove all molar tissue that can become malignant 2. monitor for changes in bleeding and fetal status Daily Hgb and Hct Two units of crossmatched blood available Monitor amount of blood loss Send home if bleeding ceases and pregnancy is maintained Limit activity No douching. Uterine size greater than expected for dates 3. painless 3. coitus Monitor fetal movement NST at least every 1 – 2 weeks Monitor complications
. Painless cervical dilatation 5. Third trimester bleeding that is sudden. Minimal dark red/brown vaginal bleeding with passage of grapelike clusters 5. Hydatidiform Mole (H-Mole) -Degenerative anomaly of chorionic villi Signs & Symptoms: 1. hCG levels are monitored for 1 year (if continue to be elevated. No FHR 4. Increased nausea and vomiting and associated with PIH Management: 1. IUD not used 4. Placenta Previa – the placenta is the presenting part 1. Contraception discussed. enemas. profuse. First and second trimester spotting 2. Elevated hCG levels marked nausea & vomiting 2. Pregnancy is discouraged for 1 year 3. 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. initially Bedrest side-lying or Trendelenberg position for at least 72 hrs. No fetus by ultrasound 6. rectal exam unless delivery would not be a problem (if necessary must be done in OR under sterile conditions) Amniocentesis for lung maturity.8
3. Incompetent Cervix 6. Ultrasonography – classified by degree of obstruction Management: 1 2 3 4
5 6 7 8 9 10 11 12 13 14
Hospitalization. may require hysterectomy and chemotherapy) 4.
FHT Monitor intake and output Seizure precautions Medications (Magnesium sulfate. Apresoline. tense (couvelaire uterus) 3. hypofibroginemia) Management: a. Painful vaginal bleeding 2. Abdomen (uterus) is tender. sits up. Contractions (Occurrence increased with maternal HPN and cocaine abuse. short cord. Pulmonary emboli d. other complications
Signs & Symptoms: 1. direct trauma. Infection e. excessive bleeding. Renal failure f. Valium) 8. Solid particles in the amniotic fluid enter maternal circulation and reach the lungs as emboli Signs and symptoms: Dramatic Sudden inability to breathe. multiparity. 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. active labor. grasps chest and sharp chest pain Turns pale then bluish gray color
. Could have rapid fetal distress d. Possible fetal distress 4. 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. Monitor maternal and fetal progress b. painful. advanced age. Prepare for immediate delivery e.15 7. Monitor for post partal complications Predisposing Factors: b. sudden release of amniotic fluid. Blood loss seen may not match symptom c. Disseminated intravascular coagulation c. Transfusion hepatitis Nursing Intervention: Bedrest Vital signs. Abruptio Placenta
Delivery by cesarean if evidence of fetal maturity.
Death may occur in a few minutes Management: Emergency measures to maintain life: IV. Age: Adolescent or 40 yrs old above primigravids Management: o If no bleeding.
.Uterine contractions occur before 38th week of gestation Cause: a. oxygen. 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 Steroids (glucocrticoids) for maturation of fetal lung surfactant production
o o o o
Anesthesia preferred – caudal. PREMATURE LABOR AND DELIVERY . Placenta Previa c. spinal or infiltration – do not affect the infant Respiration forceps may be applied gently 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. CPR Provide intensive care in the ICU Keep family informed Provide emotional support XVI. Pre-eclampsia b.