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 >The promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and child rearing
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 vagina (target of Kegel’s exercise)
ANATOMY & PHYSIOLOGY
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. 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 Uterus -Hollow muscular pear shaped organ -uterine wall layers: endometrium; myometrium; perimetrium -Organ of menstruation -receives the ova -Provide place for implantation & nourishment during fetal growth -Protects growing fetus -Expels fetus at maturity -Has 3 divisions: corpus – fundus , isthmus (most commonly cut during CS delivery) and cervix 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
II. PUBERTAL DEVELOPMENT
Puberty: the stage of life at which secondary sex changes begins the development and maturation of reproductive organs which occurs in female 1013 years old & male at 12-14 yrs old the hypothalamus serve as a gonad stat or regulation mechanism set to “turn on” gonad functioning at this age Reproductive Development Readiness for child bearing -begins during intrauterine life -full functioning initiated at puberty -the hypothalamus releases the GRF 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 Androgenic hormones – are produced by the testes, ovaries and adrenal cortex which is responsible for: muscular development physical growth inc. sebaceous gland secretions 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 -It is a rating system for pubertal development -It is the biologic marker of maturity -It is based on the orderly progressive development of: breasts and pubic hair in female’s genitalia and pubic hair in males Body Structures Involved 1 Hypothalamus 2 Anterior Pituitary Gland 3 Ovary 4 Uterus 4. Menstrual Cycle -Female reproductive cycle wherein periodic uterine bleeding occurs in response to cyclic hormonal changes
-Allows for conception and implantation of a new life -Its purpose it to bring an ovum to maturity; renew a uterine bed that will be responsive to the growth of a fertilized ovum 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 estrogenlevel 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: ischemic • Final phase: end of the menstrual cycle; the first day mark the beginning of a new cycle; discharges contains blood from ruptured capillaries, mucin from glands, fragments of endometrial tissue and atrophied ovum. Physiology of Menstruation 1. About day 14 an upsurge of LH occurs and the graafian follicle ruptures and the ovum is released 2. After release of ovum and fluid filled follicle cells remain as an empty pit; FSH decrease in Amount; LH increase continues to act on follicle cells in ovary to produce lutein which is high in progesterone ( yellow fluid) thus the name corpus luteum or yellow body 3. Corpus luteum persists for 16 – 20 weeks with pregnancy but with no fertilization ovum atropies in 4 – 5 days, corpus luteum remains for 8 -10 days regresses and replaced by white fibrous tissue, corpus albicans Characteristics of Normal Menstruation Period 1. Menarche – average onset 12 -13 years 2. Interval between cycles – average 28 days 3. Cycles 23 – 35 days 4. Duration – average 2 – 7 days; range 1 – 9 days 5. Amount – average 30 – 80 ml ; heavy bleeding saturates pad in <1hour 6. Color – dark red; with blood; mucus; and endometrial cells Associated Terms
1. Amenorrhea - temporary cessation of menstrual flow 2. Oligomenorrhea - markedly diminished menstrual flow 3. Menorrhagia - excessive bleeding during regular menstruation 4. Metrorrhagia - bleeding at completely irregular intervals 5. Polymenorrhea - frequent menstruation occurring at intervals of less than 3 weeks Ovulation 1 Occurs approximately the 14th day before the onset of next cycle (2 weeks before) 2 If cycle is 20 days – 14 days before the next cycle is the 6th day, so ovulation is day 6 3 If cycle is 44 days – 14 days, ovulation is day 30. 4 Slight drop in BT (0.5 – 1.0 °F) just before day of ovulation due to low progesterone level then rises 1°F on the day following ovulation (spinnbarkheit; mittelschmerz) 5 If fertilization occurs, ovum proceeds down the fallopian tube and implants on the endometrium Menopause o Mechanism- a transitional phase (period of 1 – 2 years) calledcl i macte ri c, heralds the onset of menopause. o Monthly menstrual period is less frequent, irregular and with diminished amount. o Period may be ovulatory or unovulatory advised to use Family planning method until menses have been absent for 6 continuous months o Menopause is has occurred if there had been no period for one year. Classical signs: Vasomotor changes due to hormonal imbalance a. hot flushes b. excessive sweating especially at night c. emotional changes d. insomnia e. headache f. palpitations g. nervousness h. apprehension i. depression j. tendency to gain weight more rapidly k. tendency to lose height because of osteoporosis (dowager hump) l. arthralgias and muscle pains m. loss of skin elasticity and subcutaneous fat in labial folds Artificial menopause / surgically induced menopause a. oophorectomy or irradiation of ovaries b. panhysterectomy
III. PROMOTE RESPONSIBLE PARENTHOOD – FAMILY PLANNING
A. Artificial Methods:
foaming tablets. Symptothermal Method / BBT
1 Requires daily observation and recording of body temperature before rising in the morning or doing any activity to detect time of ovulation 2 Ovulation is indicated by a slight drop of temperature and then rises 3 Resume Sexual intercourse after 3 – 4 days 4 Recommended observation of BBT is 6 menstrual cycle to establish pattern of fluctuations C. Strong family Hx of heart attack Note: If taking pill is missed on schedule. creams. B. no need to remove IUD. epilepsy. Surgical Method a. Certain diseases: o thromboembolism o Diabetes Mellitus o Liver disease o migraine. Diaphragm oa disc that fits over the cervix of orms a barrier against the entrance of sperms o initially inserted by the doctor o maybe washed with soap and water is reusable o when used. Breastfeeding b.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. 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
. surgical methods Oral contraceptive Action: inhibits release of FSH no ovulation Types: Combined . Tubal Ligation: Fallopian tubes are ligated to prevent passage of sperms Menstruation and ovulation continue b. chemical methods 4.recent hepatitis c. must be kept in place because sperms remains viable for 6 hrs. Chemical Methods These are spermicidals (kills sperms) like jellies. natural methods 2. renal disease. Sequential. in the vagina but must be removed within 24 hours (to decrease risk of toxic shock syndrome) 3. physiologic method: oral contraceptives . Billings Method / Cervical Mucus o woman is fertile when cervical mucus is thin and watery. take one as soon as remembered and take next pill on schedule. Women who smoke more than 2 packs of cigarette per day d. Intrauterine Device . will not harm fetus 2. 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. may be extended o Sexual Intercourse may be resumed after 3 – 4 days c. Mechanical Methods 1. if not done withdrawal bleeding occurs. Condom 1 a rubber sheath where sperms are deposited 2 it lessens the chance of contracting STDs 3 most common complaint of users interrupts sexual act when to apply D.1. Natural Methods: a. suppositories E. mechanical methods 3. Rhythm/Calendar/Ogino Knause Formula o Couple abstains on days that the woman is fertile o Menstrual cycles are observed and charted for 12 months Standard Formula: first day of the beginning of one cycle to the first day of the next cycle shortest cycle = minus 18 longest cycle = minus 11 Example: shortest cycle = 28 longest cycle = 35 Shortest cycle: 28 days – 18 = 10 Longest cycle: 35 days – 11 = 24 Fertile pd: 10th to 24th day of cycle = No sexual intercourse b. varicosities o CA.
Oligohydramnios = less than <500 ml due to the inability of the kidneys to add urine as in congenital renal anomaly F. Ectoderm – responsible for the formation of the nervous system. colorless. Fetal Membranes •Chorion . takes place about a week after fertlization C. Mature ovum may be fertilized for 12 –24 hrs after ovulation 6. 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. kidneys and ureters. skin. Stages of human prenatal development 1. 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. Other terms: conception. FETAL GROWTH AND DEVELOPMENT
First lunar month •Germ layers differentiate by the 2nd week 1. Number of sperms: 120-150 million/cc/ejaculation 5. reproductive system. Known as BOW or Bag of Water E. Wharton’s jelly 3. endoderm – gives rise to lining of GIT. Sperms are capable of fertilizing even for 3 – 4 days after ejaculation (life span of sperms 72 hrs) B. a small amount of vaginal bleeding occurs with implantation due to breakage of capillaries o Immediately after fertilization. tonsils. 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. Union of the ovum and spermatozoon 2.couple needs to observe a form of contraception this time to prevent pregnancy
derived from maternal serum and fetal urine. begins to form at 11 – 15th week of gestation. heart. Respiratory Tract.Im pl antati on General Considerations: o Once implantation has taken place. Amnion – gives rise to umbilical cord/funis – with 2 arteries and 1 vein supported by 2. BEGINNING OF PREGNANCY
A. thyroid (for basal metabolism). Mesoderm – forms into the supporting structures of the body (connective tissues. Normal amount of semen/ejaculation= 3-5 cc = 1 tsp. develops 15 – 20 cotyledons •Purpose of Placenta: respiratory. containing little white specks of vernix caseosa. muscles and tendons). amnion and chorion D. impregnation or fecundation 3. during which time rapid cell division (mitosis) is taking place. near term is clear. Syncytiotrophoblast – the outer layer containing finger like projections called chorionic villi which differentiates into: oL angerhan’s layer – protective against Treponema Pallidum. 4. Cytotrophoblast – inner layer 2. thymus gland (for development of immunity). which implant on the uterus o Implantation is also called nidation. present only during the second trimester o Syncytial Layer – gives rise to the fetal membranes. the fertilized ovum or zygote stays in the fallopian tube for 3 days.F e rti l i z ati on 1. The developing cells now called blastomere and when about to have 16 blastomere called morula. Amniotic fluid: clear albuminous fluid. urine is added by the 4th lunar month. start to form at 8th week of gestation. bladder and urethra 2. circulatory system. hair and nails and the
. blood cells. Fetal Membranes 1. 3.together with the deciduas basalis gives rise to the placenta. cartilage. produced at rate of 500 ml/day. parathyroid (for calcium metabolism). the uterine endometrium is now termed decidua o Occasionally.
contractions. 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
. lanugo disappears. Cardiovascular/ Circulatory changes: a. lanugo over entire body. Teach client to report decreased fetal movement. measurement of fetus(es) and other structures (placenta) c. meconium formed (5th –8th wk) 3rd month: Kidneys function . buds of permanent teeth form. subcutaneous fat deposition begins 9th month: Lanugo continue to disappear.mucous membrane of the anus and mouth 1 month: 2nd week – fetal membranes 16th day – heart forms . Noninvasive procedure
VI.) with fetal movement FHR increase by 15 beats and
remain for 15 seconds then decrease to average rate (no increase means poor oxygen perfusion to fetus) d. nosebleeds may occur due to congestion of nasopharynx b. systolic murmurs due to lowered blood viscosity 4. bladder should be emptied. establishment of feto-placental exchange 4th month: Lanugo appears. heart beat heard by fetoscope 5th month: Vernix appears. quickening. Done as early as five weeks to confirm pregnancy. allows amniotic fluid . alveoli begins to form 8th month: 32 weeks – fetus viable.records time interval it takes for 10 . Non-stress Test: Measures response of FHR to fetal movement (1020mins. Monitor fetus electronically after procedure. begin bone ossification .done to determine fetal maturity: Identify L/S ratio 16 wks – detect genetic disorder 30 wks – assess 1. Multiple purposes – to determine position. Amniocentesis . Rh isoimmunization 3. 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. 4th week – heart beats 2nd month: All vital organs and sex organs formed. or abdominal discomfort after procedure.12th wk. easy fatigability & shortness of breath due increase cardiac workload 2. Prior to the procedure. e. monitor for uterine contractions 4. NORMAL ADAPTATIONS IN PREGNANCY
1. Palpitations caused by the SNS stimulation during early part of pregnancy. ultrasonography is used to avoid trauma from the needle to the placenta.urine formed . Ultrasound – transducer on abdomen transmits sound waves that show fetal image on screen a. slight hypertrophy of the heart 3. infection. placental fully developed. Buds of milk teeth form . gestational age b. Client must drink fluid prior to test to have full bladder to assist in clarity of image d. fetus 2. Complications include premature labor. number. amniotic volume decrease Focus of Fetal Development First Trimester – period of organogenesis Second Trimester – period of continued fetal growth and development. peaks at 29 -38 weeks Consistently felt until term a. Contraction Stress Test: Fetal Heart Rate (FHR) analyzed in conjunction with contractions Nipple stimulation done to induce gentle contractions ***3 contractions with 40 sec duration or more must be present in 10 minutes window Normal Result no fetal decelerations with contractions c. rapid increase in length Third Trimester – period of most rapid growth and development because of the deposition of subcutaneous fat Assessing Fetal Well-being Fetal Movement: Quickening at 18 – 20 weeks .fetal movements to be felt usually occurs in 60minutes b. vernix complete. FHR audible with stethoscope 6th month: Attains proportions of full term but has wrinkled skin 7th month: 28 weeks – lower limit of prematurity. No known harmful effects for fetus or mother e. Cardiff Method: “Count to ten” .
Gastrointestinal Changes a. fatigue. 8. Musculoskeletal changes a. Respiratory Changes a. frequent meals taken slowly don’t bend on waist take antacids (milk of magnesia) 3. anxiety and empathy for partner
. Decreased renal threshold for sugar due to increased production of glucocorticoids which cause lactose and dextrose to spill into the urine. 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. even depression because of its future implication -> give health teachings on body changes and allow for expression of feelings b. Leg cramps 1d ue to pressure of gravid uterus. Addition of the placenta as an endocrine organ producing HCG. e. disbelief. pelvic bones becomes more movable 2 increasing incidence of falls c. starvation and acidosis 5 Management: hydration in 24 hrs. Constipation and Flatulence GI displacement slows peristalsis & gastric emptying time. First Trimester 1. 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. Heartburn 1 due to increased progesterone and decreased gastric motility causing regurgitation through gastric sphincter 2 Management: pats off butter before meals avoid fried. muscle tenseness. To allay fear of death let woman listen to the FHT. Endocrine Changes a. backache due to stress. Pride of Pregnancy 1d ue to need to change center of gravity result to lordotic position b. Hemorrhoids 1 due pressure of enlarged uterus 2 Management: cold compress with witch hazel and Epsom salts e.5 to 3 lbs normal weight gain b. 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. Weight Change a. aldosterone. and infant feeding method. and increased uterine size pushing the diaphragm crowding chest cavity management: side lying position to promote lateral chest expansion 4. Pattern of weight gain is more important than the amount of weight gained. Shortness of Breath due to inc. Emotional responses a. Urinary Changes a. 2nd trimester: fetus is perceived as a separate entity and fantasizes appearance c.d. Waddling gait 1 due to increased production of hormone relaxin.
VII. Hyperemesis gravidarum 4 excessive nausea & vomiting which persists beyond 3 months causing dehydration. low calcium and phosphorus intake 6. 3rd trimester: best time to talk about layette. and inc. HPL. oxygen consumption and production of carbon dioxide during the 1st Trimester. and ADH which affect CHO and fat metabolism causing hyperglycemia. 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. Predisposition to blood clot formation -due to increased level of circulating fibrinogen as a protection from bleeding implication: no massage 2. d. Gradual increase in insulin production but there is decreased sensitivity to insulin during pregnancy 7. progesterone
5. Total allowable weight gain during throughout pregnance is 20 – 25 lbs or 10 – 12 kgs. inc progesterone d. fatty foods sips of milk at intervals small. Moderate enlargement of the thyroid due to increased basal metabolic rate c. Increased size and activity of adrenal cortex increasing circulating cortisol. Vaginal and rectal varicosities . b. complete bed room c. estrogen and progesterone b.due to pressure on blood vessels of the genitalia Management: side lying hips elevated on pillow modified knee chest position e. 1st trimester: some degree of rejection.
excessive. cheese-like particles that adhere to vaginal walls. Chadwick’s sign – purplish discoloration of the vagina b. 4 Infant born < 38 weeks pre-term & 42 post term) 5 Diagnosis: Urine examination – tests presence of HCG (present from 40th –100th day. foul smelling. Devegan) Management: 1. Prenatal Visit History Taking: personal data obstetrical data gravida para TPAL past pregnancies present pregnancy: cc LMP medical data: hx of diseases/illnesses 3. Vagisec. Trichomonas – causes trichomonas vaginalis/vagnitis or trichomoniasis s/s: frothy. Pain in the abdomen 7. Avoid intercourse 3. Acidic vaginal douche 4. or trichomonicidal cmpd suppositories (e. vulvar edema Management : Flagyl 10 days p. foul smelling discharges causing irritating itchiness
Management : 1. Tricofuron.o. Swelling of face or fingers 3. or vaginal suppositories 100. Uterus – wt increase to about 1000 grams at full term due to increase in fibrous and elastic tissues a. foul smelling discharges. 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. Management: good hygiene c. Sudden escape of fluids from the vagina 10. Operculum – mucus plug to seal out bacteria d. dark brown urine expected 4. avoid intercourse to prevent reinfection a. a.Candida Albicans . patchy. Vaginal bleeding (any amount) 2. SIGNS OF PREGNANCY
I. Softening of lower uterine segment: Hegar’s sign seen at 6th week c. Persistent vomiting 8.000 U BID x 15 days 2. treat male partner also with Flagyl 2. Ovaries Inactive since ovulation does not take place during pregnancy. Acidic vaginal douche (1 tbsp vinegar:1 qt water or 15 ml: 1000 ml) 5. Must not be itchy. Gentian violet swab to vagina 3. Under the influence of estrogen. cream-colored. Dimness or blurring of vision 5. Placenta produces Progesterone and Estrogen during pregnancy 4. Chills and fever 9.o. Danger Signals of Pregnancy 1. b. Physical examination – review of systems
. avoid alcohol to prevent SE 3.condition is called Moniliasis or Candidiasis 6 it thrives in an environment rich in CHO and those on steroid or antibiotic therapy 7 seen as oral thrush in the NB when transmitted during delivery 8 s/s: white. continuous headache 4. Leukorrhea – increased amount of vaginal discharges due to increased activity of estrogen and of the epithelial cells.Pre gna ncy 1 Prenatal care is important for prevention of infant and maternal morbidity and mortality 2 Care is a cooperative action based on client’s understanding of treatment modalities 3 Duration of normal pregnancy 266 – 280 days of 38 – 42 weeks or 9 calendar months or 10 lunar months. Vagina – increased vascularity occurs a. Mycostatin/Nystatin p. peak 60 days) conduct test 6 weeks after LMP 2. LOCAL CHANGES DURING PREGNANCY
1. nor green/yellow in color. irritatingly itchy. Severe. Goodell’s sign – cervix becomes vascular and edematous giving it consistency of the earlobe 2. Becomes ovoid in shape b. Absence of FHT after they have been initially heard on 4th or 5th month 4. vaginal epithelium & underlying tissues hypertrophic & enriched with glycogen d.As se ss me nt a.g. pH of vaginal secretions during pregnancy fall •Microorganisms that thrive in an alkaline environment: a. Flashes of light or dots before eyes 6.•Emotional labile – mood changes/swings occur frequently due to hormonal changes •Change in Sexual Desire – may increase or decrease needs correct interpretation… not as a loss of interest in sexual partner
Weeks of pregnancy: Fundal height (cms) x 8/7 Ex. alcohol has empty calories c. est. IE – determine Hegar’s. Fetal Length: 1 Haase’s Rule: 1st half of pregnancy – square number of months Example : 2 months = 2x2 = 4 cm 2nd half of pregnancy – number of months multiplied by 5 Example: 7 months x 5 = 35 cm c. Vital signs i. (9 standard) Solution: 35 cms – 11 = 24 x 155 =3. incompetent cervix. 2007 • McDonald’s Rule: Ht fundus/4 (AOG wks) 1. size and fetal parts h. ♣ counseling is important on changes in desire and positions contraindication: bleeding.b. Pap Smear f.720 g 5. THEORIES OF LABOR ONSET
. Age of Gestation: Nagele’s Rule: -3 calendar months and +7 days Ex. Leopold’s Manuever: to determine fetal presentation. Clinic Visits for Pre-natal check-up 2 First 7 lunar months – every month 3 On 8th and 9th lunar month – every week 4On 10th lunar month – every week until labor
X. pregnancy. Urinalysis: test for albumin. Hct .high incidence of post partum infection noted. position. labor and delivery. diet and comfort measures Grant-Dick Read Method: Fear leads to tension and tension leads to pain Lamaze Method: Psychoprophylactic method .4 wks interval with 2nd dose at least 3 wks before delivery = booster doses given during succeeding pregnancies regardless of interval. Important Estimates: a. Chadwick’s d. 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. Fetal Weight: 1 Johnson’s Rule: Fundic Ht – n x k ( k=155. Measure in cms the length from the symphysis to the level of fundus 2. relaxation techniques.5 ml IM for all pregnant women shall be given in 2 doses. 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. serological tests j. Immunization: Tetanus Toxois (TT) =0. hygiene. Fundal Height = 14 cms Lunar Month: 14cms x 2 = 28 / 7 = 4 months Weeks Pregnant: 14 cms x 8 = 112 / 7 = 16 weeks AOG • Bartholomew’s Rule: based on position of fundus in abdominal cavity 3rd month = above symphysis 5th month = umbilical level 9th month = below xiphoid process) b. Smoking – lead to LBW babies b. LABOR AND DELIVERY
1. = 3 booster doses is equal to lifetime immunity g. LMP= May 15. Drinking – can cause respiratory depression in the NB and fetal withdrawal syndrome if excessive. attitude. Sexual activity – allowed in moderation but not during last 6 wks. Pelvic measurements (done after 6th month or 2 wks before EDC) g. 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. ruptured BOW. Health Teachings a. breathing exercises. based on S-R conditioning. concentration on breathing is practiced f. Lunar months: Fundal Height (cms) x 2/7 3. Blood studies: CBC Hgb. Ballotement – on 5th month e. 2006 or 5-15-06 LMP: 51 5 Formula: -3+ 7 EDC: 2 22 or February 22. Goodell’s. deeply engaged presenting part e. blood typing. Pelvic examination (ask client to void) c. Drugs – may be teratogenic hence contraindicated unless prescribed by Doctor d. sugar & pyuria 5.
Fetal Attitude – fetal position Pelvis is divided into 6 areas: Anterior.2.1. ethmoid. Fontanels . least compressible Bones: sphenoid. temporal. False Pelvis -supports the growing uterus during pregnancy -directs the fetus into the true pelvis near the end of gestation b. moderate or strong) b. Movement of Passenger upon birth or descent: d.shortest AP diameter of the inlet through which the head must pass . closes at 2 – 3 months b. sacrum (S).3. closes at 12 – 18 months posterior fontanel: smaller. External rotation/ restitution c. Brow (sinciput).the distance between the anterior surface of the sacral promontory and superior margin of the symphysis pubis .1. parietal Suture lines: sagittal/ coronal.PSYCHE. Posterior.the emotions of the mother Factors that may increase a woman’s chance of depression: 1 History of depression or substance abuse 2 Family history of mental illness 3 Little support from family and friends 4 Anxiety about the fetus 5 Problems with previous pregnancy or birth 6 Marital or financial problems 7 Young age (of mother Signs and Symptoms of Post-partum depression: 1 Feeling restless or irritable 2 Feeling sad.2.membrane covered spaces at the junction of the main suture lines anterior fontanel: larger. Interval – pattern which increases in frequency and duration a. Fetal Lie – relationship of the cephalocaudal axis of the fetus to the cephalocaudal axis of the mother. Flexion f. Frequency – the beginning of one contraction to the beginning of the next contraction a. Footling c. Divisions
a. Fetal Skull: a. Shoulder b. Extension h. FOUR P’S OF LABOR a. frontal.2.5 cm) >Obstetrical Conjugate . triangular shaped. Psyche – the mental and emotional aspect of the woman a. and overwhelmed 3 Crying a lot 4 Having no energy or motivation
. Posterior Right Fetal landmarks: Occiput (O). Breech – Complete (sacrum) .most important pelvic measurement .3.5. diamond shaped. lamboidal b. Power . Frank.1. Passageway – the maternal pelvis d. measured through a monitor or through touch of a fingertip on the fundus (mild.5 to 2 cm or less than the diagonal conjugate >True Conjugate/Conjugate Vera .widest AP diameter at outlet estimated on vaginal/pelvic exam (Average: 12.the distance between the sacral promontory and inferior/lower margin of the symphysis pubis .the distance between the anterior aspect of the symphysis pubis and the depression below lumbar 5 (Average: 18 – 20 cm) b. Passenger – the fetus c. Significant Pelvic Measurements a.the distance from the inner border of the symphysis pubis to the sacral prominence .1. Descent e. Posterior Left.the distance between the ischial tuberosities . Internal Rotation g. True Pelvis: the bony canal through which the fetus will pass during delivery formed by the pubis in front.the uterine contraction b. PASSENGER -Fe t us b. Transverse Right.most frequent presenting part. Transverse Left. Duration – the beginning of one contraction to the end of the same contraction a. Measurements: b.4. Internal – the actual diameters of the pelvic inlet and outlet > Diagonal Conjugate . occipital. External – Suggestive only of pelvic size > External Conjugate/ Baudelaocque’s Diameter . Intensity – strength of contraction. POWER -Uterine Contractions: a. Presentation –the part of the passenger that enters the pelvis is the presenting part a. largest part of the fetus . and scapula (Sc) b. the iliac and ischia on the sides and the sacrum and coccyx behind c. PASSAGEWAY – maternal pelvis c. Cephalic – Vertex (occiput) .narrowest diameter of the outlet .Uterine stretch theory Oxytocin theory Progesterone Deprivation theory Prostaglandin theory 2.transverse diameter of the outlet (Average: 11 cm) D.5 -11 cm) >Bi-Ischial/ Tuberiischial Diameter . Face (mentum) b.4. mentum (M). hopeless.6.diameter of the pelvic inlet (10.
Goodell’s sign – ripening of the cervix f. Analgesia – relieves pain and its perception 5. Paracervical block b. physiologic retraction ring 2 Bandl’s pathologic retraction ring. Nursing Interventions of Woman in Labor: a.characteristics: intensity. interval. > can increase incidence of maternal hypotension and fetal bradycardia 5. frequency. Blood pressure b. Regular Contractions . 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). spinal) o Relieve uterine and perineal pain o Usually safe for the fetus (potential for maternal hypotension) o Types of Anesthesia: a. Rupture of Membranes– labor expect in 24 hours i. Braxton Hick’s Contractions e. Diarrhea k.3. or making decisions 8 Feeling worthless and guilty 9 Loss of interest or pleasure in activities 10 Withdrawal from friends and family 11 Having headaches. duration False Labor Pains True Labor Pains o1 Remain irregular o2 Confined to abdomen o3 No increase in duration. Sudden burst of energy j.pinkish vaginal discharge h.PRELIMINARY/PRODROMAL SIGNS OF LABOR a. Intradural: spinal/saddle block d. chest pains. Assessment – history and physical assessment a. Increase in back discomfort g. .5 Eating too little or too much 6 Sleeping too little or too much 7 Trouble focusing. Monitor and inform patient of progress of labor b.2. Cervical Changes – effacement .188.8.131.52. Monitoring and Evaluating Progress of Labor b.1 Narcotics (Demerol) op roduces sedation/relaxation od epresses NB’s respiration og iven in active labor o Special Considerations: Demerol is most commonly used Has sedative and antispasmodic effect Dose is usually 25 –100 mg depends on body weight Not given early in labor due to possible effect on contractions Not given too late (1 hr before delivery) can cause respiratory depression in the newborn Given if cervical dilatation is 6 – 8 cms.3. remembering.4. Anesthesia – produces local or general loss of sensation . station b. intensity o9 Continue regardless of activity o10 Effacement and dilatation occurs o11 Signs of True labor Effacement Dilatation 1 Uterine Changes– upper and lower segments. or hyperventilation (fast and shallow breathing) 3. frequency. Analgesia/anesthesia during childbirth 5. Local anethesia o Regional Anesthesia is mostly preferred because it does not enter maternal circulation nor affect fetus o Xylocaine is used (NPO with IV infusion) > allows to be awake and participate in process. Peridural block: Epidural/caudal c.phases: increment. dilatation. Analgesics: 5.g. Bloody Show .3. intensity o4 Disappears on ambulation o5 No cervical changes o6 Becomes regular and predictable o7 Radiates in girdle like fashion o8 Increase in duration.2. Lightening b.acme.1. Observe for signs of fetal distress 12 bradycardia 13 fetal thrashing 14 meconium stained amniotic fluid in nonbreech presentation b. Personal data a. Increased activity level. Fetal Heart Tone b.
. Pudendal block e.“nesting behavior” c.usually regional anesthesia (e. Monitor progress – fetal a) during labor check FHR b) manage fetal distress 5. Loss of weight ( 2-3 lbs) d.decrement . 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 .
Promote responsible parenthood (FP) 3. apply perineal pads h.Monitor: vital signs – BP and FHR (be alert for bradycardia) 1. Nursing Care of Woman in the 3rd Stage of Labor a. . Promote healing and the process of involution b.Allow to rest/ sleep 5. Nursing Care of Woman in Fourth Stage
. Nalline 6. Inspect Cotyledons For Completeness f. Check Bp. Principle Of Watchful Waiting b. Keep couple informed of progress g. Stages of Labor Stage Characteristics First Stage . Multi-gravida.5. cervical dilatation Interval: 15-20 mins interval Duration: 10-30 seconds 5-7 cms. Monitor discomfort/exhaustion/pain control – support client in choice of pain control b. local/ block/ general 4.Place flat on bed j. Nursing Care of the Woman in First & Second Stage Labor a.2-3 mins for 50-90 secs Mother is exhausted and has urge to push Third Stage .14.4.20 mins – 1 hr. Use Brandt Andrews Maneuver c.the first hour after complete delivery until the woman becomes physically stable Uterine cramping Rubra with small clots 2.Provide comfort measures 1.10.Remember that the use ofF orce ps is needed in delivery of patient under anesthesia due to loss of coordination in bearing down during 2nd stage 1.3 hrs 0-4 cms. Duration: 50-90 seconds Second Stage .-19. Fourth Stage .Check vital signs of mother and fetus 1. Check Perineum For Lacerations -Give perineal care.2 Mg/Ml Or Syntocinon 10 U/Ml Im) e.1.6. Give initial nourishment – warm milk.3. Encourage rest between contractions f.8. postspinal headaches – place flat on bed for 12 hrs and increase fluid intake b. Side effects: a.3. Change gown i. Provide emotional support c. cervical dilatation Interval: 3-5 mins Duration: 30-60 seconds 8-10 cms cervical dilatation Interval: 2-3 mins. Low back pain – massage of sacral area d.Explain the action of drugs 1.Keep warm – provide extra warm blanket k. tea l. Administer analgesic : side effects-may prolong labor. Contractions. Establish successful lactation e.begins with complete dilatation of the cervix until the birth of the newborn
Duration: Primigravida – 30 mins. STAGES OF LABOR
1. Latent Phase b.from delivery of the newborn to the delivery of the placenta Still with mild contractions until the placenta is expelled.Nursing Care after administration of anesthesia/analgesia 1.7 hrs Multigravida – 0.1 . Usually.7.2. 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. Narcotic Antagonist: Narcan.9. Injects Oxytocin (Methergin 0. placenta is expelled within 30 minutes. Note Time Of Delivery (20 Minutes After Delivery Of The Baby) d. Check Uterus For Contraction g.Assess pain status 1.Observe safety measures Evaluate allergies Provide siderails – have call bell ready NPO (anesthesia) Check time last medication was given 1.5. Relaxation techniques taught during pregnancy where breathing is taught as a relaxed response to contraction c. Principles of Postpartum Care a. Use different breathing techniques during the different phases of labor e.the stage of true labor until the complete cervical dilatation a. Active Phase c.2 hrs. Nursing Care before administration of anesthesia/analgesia 1.2.3. Transitional Phase Extent: Primigravida – 3. Prevent postpartum complications d.Record properly 1.
Categories of Lacerations 8..WBC increases to 20. increased with activity with fleshy odor. decreased if with breastfeeding . vaginal mucous membrane and perineal skin 8. First degree – involves vaginal mucous membrane and perineal skin 8.time period for the return of the reproductive organs to return to its prepregnant state 8.the 6 weeks period following delivery Involution. Genital Changes/ Discharges .All blood values are back to prenatal levels by 3rd or 4th week 2. decidua. d. . Assess vital signs.2. Lactation: promote lactation by encouraging early breastfeeding to stimulate milk production *** Those mothers who cannot breastfeed: suppressing agents are given – estrogenandrogen preparations given first hours post partum to prevent milk production.thinner. Fourth degree – involves all in 3rd degree lacerations and the mucus membrane of the rectum
XII. Second degree – involves the perineal muscles. serous sanguinous blood 10.000 – 30..a.. (e. Vascular Changes . 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.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. Urinary Changes
. never foul smelling 4.3 to 6 wks pp – alba . 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. May ambulate Puerperium . Perineal Pain Nursing Care: Place in Sim’s position – lessens strain on the suture line Expose to dry heat or warm Sitz bath Application of topical analgesics or oral analgesics as ordered Provide/ encourage perineal care 5. Rooming-in-concept provides opportunity for developing positive family relationship promotes maternal infant bonding releases maternal caretaking responses c.1... Parlodel or deladumone) b. Location of the Fundus . fundus and flow every 15 minutes. WBC and some bacteria .Uterine involution is measured by determining the level of the fundus in relation to the umbilicus .4. 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.whitish discharge same amount as menstrual flow.3..000/mm³ .g. 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.Activation of the clotting factor .bright red with no or minimal clots 4-9 days – serosa.Reabsorption of the 30-50% increase in cardiac volume within 5 – 10 minutes after the thirdstage of labor. These drugs tend to increase uterine bleeding and retard involution. diethylstilbestrol. 2 Breastfeeding – menses return in 3 – 4 months.Characteristics: pattern should not reverse – 1-3 days – rubra . Hydration and elimination e. Menstruation 1 Breastfeeding influences return of the menstrual flow.Presence of Lochia: uterine discharges consisting of blood.
Could be due to hormonal changes. o RR – no change is expected o Weight = 10 – 12 lbs is expected to be immediately lost. no massage. Letting go Postpartum Blues – overwhelming sadness that cannot be accounted for. Contraindications: Drugs – oral contraceptives. Nursing Care: Encourage verbalization. Establish Successful Lactation Physiology of Lactation: Estrogen & progesterone levels stimulates APG to produce Prolactin acts on acinar cells to produce foremilk stored in collecting tubules -> infant sucking stimulates PPG to produce oxytocin causes contraction of smooth muscles of collecting tubules milk
ejected forward (milk ejection reflex or let down reflex hindmilk is produced Implications of lactation: 1 Breast milk will be produced postpartum 2 Lactation do not occur during pregnancy due to levels of estrogen and progesterone 3 Lactation suppressing agents are to be given immediately after placental delivery to be effective 4 Oral contraceptives decrease milk supply and are contraindicated in lactating mothers 5 Afterpains are felt more by breastfeeding mothers due to oxytocin production. No Alcohol for cleaning Handwashing Insert clean OS squares/ absorbent cloth in brassiere for breast discharges b. Diaphoresis will contribute to further weight loss 10. have less lochia and rapid involution 12. Provision of Emotional Support Post-partum Psychological Phases 1. 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. Taking – hold: mother starts to assume her role 3. let client listen to sound of flowing water. anticoagulants. Vital Signs o Temperature: may increase because of dehydration on the first 24 hours pp.) 8. Advantages of Breastfeeding Mother: faster involution less incidence of CA economical. This corresponds to the weight of the fetus. effort. mother focuses on herself and her experience 2. explain that it is normal 11. tetracyclines. constipation . Certain disease conditions – TB because of close contact during feeding (TB germs are not transmitted thru breast milk)
XIII. crying is therapeutic. cost Infant: bonding with the mother protection against common illness less incidence of GI diseases always available 13.time. cathartics. atropine. o CR 50 – 70 beats/min (bradycardia) is common for 6 . 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
. placenta. fatigue or feelings of inadequacy. Taking – in : First 1 – 2 days.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. Feeding Techniques c. 96 grams protein d. ASSOCIATED PROBLEMS
1. Hygiene Wash breasts daily No soap. antimetabolites. Health Teachings a. apply breast binder) 2. amniotic fluid and blood. Nutrition: 3000 calories daily. no breast pump.8 days pp. Engorgement breast becomes full. Gastrointestinal Changes .Change is more on the delay of bowel evacuation. etc.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.
swelling. Endogenous/primary sources .hospital personnel. 8.2. Hepatitis A. fever. 6. coitus late in pregnancy premature rupture of membranes General symptoms: malaise. 9. Infections Bleeding / Hemorrhage/ PIH Diabetes Mellitus Heart Disease Multiple Pregnancy Blood Incompability Dystocia Induced Labor Instrumental Deliveries
1. called milk leg
. anorexia. TORCH test series TOxoplasmosis (protozoa) avoid eating uncooked meat and handling cat litter box Others: Syphilis. INFECTIONS 1.normal bacterial flora 2. 4.Syp hi l i s Cause: Treponema pallidum . Mastitis inflammation of the breast Signs & Symptoms: pain. HIGH RISK PREGNANCY CONDITIONS
1.4. feeling of pressure. redness. AIDS Rx – Zoster Immune Globulin . Infection of the perineum Signs & Symptoms: pain. heat. excessive obstetric manipulations breaks in aseptic techniques. 7.Thro mb o p hl e b it i s -infection of the lining of a blood vessel with formation of clots. lumps in the breasts. sitz bath & warm compress 1. chills and headache Management: Complete Bedrest Proper Nutrition Increased Fluid Intake Analgesics Antipyretics and antibiotics as ordered 1.a spirochete transmitted thru sexual intercourse Treatment: 2. Infection early in pregnancy may produce fetal deformities.3.8 million units of Penicillin (or 30 – 40 gms Erythrocin) x 10 days readily cross placenta thus prevent congenital syphilis Untreated: Cause mid-trimester abortion Cause CNS lesions Can cause death 1.An infection/inflammation of the lining of the uterus Signs & Symptoms: Abdominal tenderness Uterus not contracted and painful to touch Dark brown Foul smelling lochia Management: Oxytocin administration Fowler’s position to drain out lochia Prevent pooling of discharges 1. 2. inflammation of suture line with 1 –2 stitches sloughed off temperature elevation Management: drain area & resuturing . Varicella/ Shingles Hepatitis B.1.Penicillin RUbella Effect: if contracted early. Exogenous sources .vasodilation and therefore promote healing do not use plastic liners use nipple shield 3. 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.End o me t ri ti s .5. milk becomes scanty Nursing Care: Ice compress Supportive brassiere . whereas late infections may result in active systemic disease and/or CNS involvement causing severe neurological impairment or death of newborn Sources/ Cause: 1.4 – 4. 3. usual an extension of endometritis Signs & Symptoms: o1 Pain o2 Stiffness and redness in the affected part of the leg o3 Leg begins to swell below the lesion because venous circulation has been blocked o4 Skin is stretched to a point of shiny whiteness. 5. slows down cell division during organogenesis causing congenital defects NB can carry and transmit the virus for about 12 – 24 months after birth CYtomegalovirus (CMV) (DNA virus) Herpes type 2
Group of maternal systemic infections that can cross the placenta or by ascending infection(after rupture of membranes) to the fetus.
multiple pregnancy or H mole e.without proteinuria or edema b. 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. Dicumarol or Heparin) to prevent formation or extension of a thrombus Side effect of Anticoagulant: hematuria. Older than 35.1. Early Post-partum hemorrhage – first 24 hrs after delivery 2. large babies.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.Develops during pregnancy and resolves during postpartum period Predisposing Factors: a. Transient hypertension .350 cc) *** Leading cause of maternal mortality associated with childbearing 2. large fetus b. multiple pregnancies) Cesarean Section Placental accidents (previa or abruptio) Prolonged and difficult labor Management: Massage –first nursing action Ice compress Oxytocin administration Empty bladder Bimanual compression to explore retained placental fragments Hysterectomy (last alternative) 2. renal and vascular disease g. Pregnancy Induced Hypertension (PIH) .Obstetrical Emergency o HPN o Proteinuria o Convulsions o Coma Immediate Intervention for Eclampsia: a. weight gain of 1. Eclampsia . Pre-eclampsia. Maintain IV line with large-bore needle
. relaxed or boggy (most frequent cause) Lacerations Hypofibrinogenemia Clotting defect Retained Placental Fragments Management Bleeding in Pregnancy blood transfusion D & C (Dilatation and Curettage Predisposing factor: Overdistension of the uterus (multiparity. ( normal blood loss 250. Pre-eclampsia. Hx of DM. (normal UO/day 1500 ml) o Cerebral or visual disturbances d. primigravida d.g.5 lbs/wk c. Late Postpartum Hemorrhage Early Post-partum hemorrhage Late Postpartum Hemorrhage Cause Uterine Atony – uterus is not well contracted. increased lochia Considerations: 1 discontinue breastfeeding 2 monitor prothrombin time 3 have Protamine Sulfate at bedside to counter act severe bleeding 4 analgesics are given but not ASPIRIN because it prevents prothrombin formation which may lead to hemorrhage 2. HEMMORRHAGE/ BLEEDING Definition: blood loss more than 500 cc. Family history Diagnosis: Roll – over test : Assess the probability of developing toxemia when done between the 28th and 32nd week of pregnancy. Morbid obesity or weight less than 100 lb h.3. poor nutrition f. polyhydramnios.Occurs anytime after the 24th wk of gestation up to 2 wks PP . 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.2.He mat o ma .A vascular disease of unknown cause . patient is prone to Toxemia Types of Pregnancy Induced Hypertension (PIH): a. younger than 17 c.of Phlegmasia alba dolens o5 Positive Homan’s sign: calf pain on dorsiflexing the foot Specific Management: 1bed rest with affected leg elevated 2a nticoagulants (e. 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.4.
May administer if : 4 Deep tendon reflexes are present
. Education on self – assessment e. . Apresoline. Magnesium Sulfate – drug of choice Action: CNS depressant . Nursing Intervention: a. Postpartum. Barbiturates – sedation by CNS depression d.monitor vital signs and watch for seizure Management for Eclampsia: a. Digitalis (with Heart Failure) Increase the force of contraction of the heart decrease heart rate Nursing Considerations: Check CR prior to administration ( do not give if CR <60/min) b. antihypertensives. patient is prone to Toxemia Management: a. Encourage a well-balanced diet c. sedatives e. Magnesium Sulfate – drug of choice Action: CNS depressant . Minimize stimuli d. Analgesics.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. Monitor fluid balance c. Vasodilator Antidote: Calcium Gluconate.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. Monitor fetal status h. Analgesics. Prepare for possible delivery of fetus g. Valium) f.g Magnesium sulfate. Type and cross match for blood i. Barbiturates – sedation by CNS depression d. antihypertensives. 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.b. .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. 5 gms/buttock. Weigh daily. 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. then an IV drip of 1 gm per hour (1 gm/100 ml D10W). 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. antibiotics. Check first the ff. Give medications as ordered (e. Cathartic – cause shift of fluid from the extracellular spaces into the intestines from where the fluid can be excreted Dosage: 10 gms initially –either by slow IV push over 5 – 10 minutes or deep IM. Potassium supplements – prevent arrhythmias c. 5 gms/buttock. before administration: 1 Deep tendon reflexes are present 2 Respiratory rate = 12 / min 3 UO = at least 100 ml / 6 hrs. anticonvulsants. Have airway and oxygen available e. Potassium supplements – prevent arrhythmias c. Diversion f. Advised bedrest. then an IV drip of 1 gm per hour (1 gm/100 ml D10W). sedatives e. left lateral bb . antibiotics. Vasodilator Antidote: Calcium Gluconate. anticonvulsants. keep daily log
dd . Family support e.
Insulin requirements – individualized. Method of Delivery – Cesarian Section d. hypothermia ***Consequence of hypoglycemia: untreated hypos brain damage and even death ***Management: feed with glucose water earlier than usual. production of adenocorticoids. Listlessness/jitteriness/tremors c. DIABETES MELLITUS a. Increased action of adrenocortical hormone that favor the passage of glucose from mother to fetus congenital anomalies are often seen e. If 100 – 120 mg% possible GDM c. HEART DISEASE Classification: Class I . Chronic hereditary disease characterized by marked hyperglycemia b. and thyroxin which affect CHO concentration in blood (hyperglycemia) d. palpitation. fat and protein metabolism c. Diet . increased during 2nd
and 3rd trimester because of more pronounced effect of hormones c. but limp and lethargic) f. Anterior Pituitary hormones. Increased secretion of insulin from the fetal pancreas d. Shrill. If less than 100 mg% = normal b. Greater weight loss because of loss of extra fluid h.Ordinary activity causes fatigue. Postpartum Period – more difficult to control Blood Glucose because of hormonal changes Effect on Infant: a. Prone to hypoglycemia (BG <30 mg%) Signs and symptoms of Diabetic Babies/ Hypoglemic Infant: a. Increased production of growth hormone from maternal pituitary gland c. Rate of insulin secretion is increased but sensitivity of the pregnant body to insulin is decreased Pregnancy Risks: 1 Toxemia 2I nfection 3 Hemorrhage 4 Polyhydramnios 5 Spontaneous abortion – because of vascular complications which affect placental circulation 6 Acidosis – because of nausea and vomiting 7 Dystocia – due to large baby Diagnosis : Glucose Tolerance Test (GTT) Procedure for GTT: NPO after midnight 2 ml of 50% glucose / 3 kg of pre-pregnant body weight given IV (oral glucose not advisable due to decreased gastric motility and delayed absorption of sugar during pregnancy) Interpretation of Results: a. Typically longer and weighs more due to: excessive supply of glucose from the mother b.slight limitation of physical activity .Born premature more often – RDS common g. Apnea/cyanosis e. Cushingoid appearance (puffy. Hypotonia. Effects of pregnancy – may develop abnormalities in glucose tolerance decreased renal threshold for sugar due to increased estrogen. or administer IV of glucose 4. high pitched cry b. Due to lack or absence of insulin abnormalities in CHO.800 – 2200 calories) to prevent intrauterine growth retardation b. Lethargy/poor suck d. If more than 120 mg% .overt gestational diabetes Management: a.no physical limitation Class II . inc.highly individualized.adequate glucose intake (1. or angina Class III
. dyspnea. 3.5 Respiratory rate = 12 / min 6 UO = at least 100 ml / 6 hrs.
place in semisitting position e. exhaustion. multiple pregnancy. Diet – gain enough (consider effect on cardiac workload) c.Labor lasting more than 18 hrs and in multigravidas.3.Strong fundal push. is reabsorbed back in 5 – 10 minutes and the weak heart needs to adjust 5. less than ordinary activity causes fatigue Class IV -unable to carry on any activity without experiencing discomfort Prognosis: Classes I & II – normal pregnancy & delivery Classes III & IV – poor candidates Signs & Symptoms: Heart murmur due to increased total cardiac volume Cardiac output decreased nutritional and oxygen requirements not met Incomplete emptying of the left side of the heart Pulmonary edema and HPN (moist cough in Gravidocardiacs danger sign) Congestion of liver and other organs due to inadequate venous return increased venous pressure fluid escapes through the walls of engorged capillaries and cause edema and ascites CHF is a high probability due to increased CO during pregnancy dyspnea.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.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
.moderate to marked limitation of physical activity. Avoid lithotomy position to avoid increase in venous return. Anesthetic choice – caudal anesthesia g.An antigen-antibody reaction which causes excessive destruction of fetal red blood cells Mother Fetus Rh. edema. INDUCED LABOR . Educate regarding proper nutrition and exercise 6. DYSTOCIA . polyhydrmanios or excessively large baby Management: Stimulation of labor by oxytocin administration or amniotomy 7. Cesarean Section
c. chest pain on exertion and cyanosis of nailbeds are obvious Management: (depends on cardiac functional capacity) a. so that as fetus is rapidly delivered. contraindicated can cause fluid retention and promote thromboembolism i. pulse irregularities. Precipitate Delivery . BLOOD INCOMPATIBILITY . Health Teaching on importance of regular prenatal check-up visits d.negative Rh Positive (Father is homozygous or heterozygous Rh positive) BloodType O Either Type A or B (From father) 7. Monitor FHT.1.Usually occurs in primi gravida . fundus is pulled down . Medications: Digitalis. Iron preparations d. diethylstilbestrol and oral contraceptives – h. Most critical period: immediate postpartum period when 30 – 50% increased blood volume j. Uterine Inversion . more than 12 hours Effects: Maternal exhaustion Uterine atony Caput succedaneum 7.Insertion of placenta at the fundus.fundus is forced through the cervix so that the uterus is turned inside out . attempts to deliver the placenta before signs of separation -Management: Hysterectomy 8. Prolonged Labor .labor and delivery that is completed in < 3 hours due to multiparity or followingoxytocin administration or amniotomy Effects: Extensive lacerations Abruptio placenta Hemorrhage due to sudden Release of pressure shock 7. Bed rest – especially after 30th week of gestation b. Birth is via low forceps or Cesarean section f. MULTIPLE PREGNANCY Risks: Increased Blood Loss Small for Gestational Age Infants Premature Birth Dystocia Management: a. weight b. Not allowed to bear down. Ergotrate and other oxytoxics.2. scopolamine. VS..
Monitor vital signs
. and FHR c. Oxytocin Administration.Preoperative medication is usually only atropine sulfate. Lower vertical incision – recommended in: Bladder or lower uterine segment Adhesions from Previous operations Anterior Placenta Previa Transverse lie Preoperative Care a. scheduled birth Types: 1. Advantages:Minimal blood loss Incision is easier to repair Lower incidence of post partum infection No possibility of uterine rupture 2. uterine contractions. Cervical Dilatation at least 1=2 cm Procedure for Induced labor: 1.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. Simpson. when at +3 / +4 and sagittal suture line is in an AP position in relation to the outlet (e. 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. maternal disease – cardiac.Pelvic Dislocation Fetus is already viable >32 weeks AOG Single fetus in longitudinal lie and is engaged Ripe cervix – fully or partially effaced. coughing exercises. INSTRUMENTAL DELIVERIES a. which is the thinnest and most passive Part during active labor. Retention catheter is inserted to constant drainage to keep the bladder away from the operative site f. Deep breathing. maternal exhaustion. Low Segment – the method of choice. 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. routine laboratory tests. turning from side to side b. Cesarean Section – birth through a surgical incision on the abdomen Indications: o Cephalo-pelvic disproportion (CPD) o Severe Toxemia o Placental Accidents o Fetal Distress o Previous classic CS – done prior to onset of labor pains. No narcotics are given causes respiratory depression in the NB Postoperative Care a. Amniotomy – done with Cervical Dilatation = 4 cm . Piper for breech presentation) Purposes: shorten second stage of labor because of fetal distress. Elliot. 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 . effect is slower than oxytocin 9. Physical examination.g. Incision is made in the lower uterine segment. blood typing and cross matching d. Check vital signs. extending out to the flanks on both sides up to the upper thirds of the thighs e. The patient is both a surgical and an OB patient b. Abdomen is shaved from the level of the xiphoid process below the nipple line. Antidiuresis Prostaglandin administration: Route: oral or IV (never IM causes irritation). Ambulate after 12 hours c.Use of metal instruments to extract the fetus from the birth canal. Check FHR and quality of amniotic fluidNursing 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.
Height Short stature < 4 feet.d.Watch for signs of hemorrhage – inspect lochia. DM.5. OTHER RISK FACTORS: 10.4. Previous tubal surgery c. Weight Pre-pregnant weight < 70 lbs or > 180 lbs Weight gain < 10 lbs LBW babies Weight gain > 30 lbs = sign of toxemia. polyhydramnios. feel fundus (if boggy. Persistent uterine bleeding and cramplike pain 2. MATERNAL COMPLICATIONS
1. Obtain history. 10 inches = contracted pelvis or CPD
XIV. Congenital anomalies of the fallopian tubes Signs & Symptoms: 1 Severe.Ag e : . Hmole.3.1.2. Breastfeeding should be started 24 hrs after delivery f. including last menstrual period 2. hemorrhoids Low birth weight babies C Ch hr ro om mo os so om ma al lA Ab bn no or rm ma al li it ti ie es sl li ik ke eD Do ow wn n’ ’s s S
Sy yn nd dr ro om me e/ /T Tr ri is so om my y2 21 1 (associated with menopause) 10. Birth Interval – 3 months from previous delivery or more than 5 years 10. massage with proper abdominal splinting and give analgesics as ordered) e. Ectopic Pregnancy . Most common complication: Pelvic thrombosis 10. knife-like stabbing pain 2 Rigid abdomen 3 Positive Cullen’s sign (bluish umbilicus) 4 Excruciating pain on IE 5
. sharp.Any gestation outside the uterine cavity Causes of Ectopic Pregnancy: a. Pregnancy Induce Hypertension b. Spontaneous Abortion Termination of pregnancy spontaneously at any time before the fetus has attained viability Assessment: 1. multiple pregnancy 10. Laboratory finding – negatively or weakly positive urine pregnancy test 3.Maternal and infant mortality rates tend to be high in age below 15 and older than 40 years Adolescent pregnancy Advanced age Most common problems: Toxemia A precipitating factor in: Placental accidents Iron-deficiency anemia Toxemia Uterine atony or inertia Varicosities.Pari t y – first pregnancy is the period of high risk Multiparity G5 and above and age is over 40 10.
Ultrasonography – classified by degree of obstruction Management: 1 Hospitalization. painful. short cord. hypofibroginemia) Management: a. Contractions (Occurrence increased with maternal HPN and cocaine abuse. Painful vaginal bleeding 2. rectal exam unless delivery would not be a problem (if necessary must be done in OR under sterile conditions) 5 Amniocentesis for lung maturity. profuse. Pregnancy is discouraged for 1 year 3. Increased nausea and vomiting and associated with PIH Management: 1. other complications 7. Incompetent Cervix
6. multiparity. First and second trimester spotting 2. IUD not used 4.Signs of shock Management: Ruptured Ectopic Pregnancy is an emergency requiring immediate intervention Salpingostomy – if Fallopian tube can still be replaced and preserved. Minimal dark red/brown vaginal bleeding with passage of grapelike clusters 5. tense (couvelaire uterus) 3. sudden release of amniotic fluid. Elevated hCG levels marked nausea & vomiting 2. excessive bleeding. Possible fetal distress 4. Incompetent Cervical Os One that dilates prematurely Chief cause of habitual abortion ( 3 or more) Causes: 1 Congenital Developmental Factors 2 Endocrine factors 3 Trauma to the cervix Signs & Sypmtoms: 1 Presence of show and uterine contractions 2 Rupture of membranes. Monitor maternal and fetal progress
.pregnancy is terminated Saphingectomy – removal of FT and BT Nursing Interventions: 1 Help woman to combat shock 2 Elevate foot of the bed 3 Maintain body heat 4 Prepare for surgery 5 Monitor for shock preoperatively and postoperatively 6 Provide emotional support and expression of grief 7 Administer Rhogam to Rh negative women 8 Discharge teaching 3. Abdomen (uterus) is tender. Abruptio Placenta Signs & Symptoms: 1. Hydatidiform Mole (H-Mole) -Degenerative anomaly of chorionic villi Signs & Symptoms: 1. 3 Ultrasound to locate placenta 4 No vaginal. direct trauma. coitus 12 Monitor fetal movement 13 NST at least every 1 – 2 weeks 14 Monitor complications 15 Delivery by cesarean if evidence of fetal maturity. initially 2 Bedrest side-lying or Trendelenberg position for at least 72 hrs. enemas. Painless cervical dilatation 5. may require hysterectomy and chemotherapy) 4. Placenta Previa – the placenta is the presenting part 1. Uterine size greater than expected for dates 3. No fetus by ultrasound 6. Contraception discussed. advanced age. hCG levels are monitored for 1 year (if continue to be elevated. Third trimester bleeding that is sudden. No FHR 4. painless 3. active labor. Curettage to completely remove all molar tissue that can become malignant 2. monitor for changes in bleeding and fetal status 6 Daily Hgb and Hct 7 Two units of crossmatched blood available 8 Monitor amount of blood loss 9 Send home if bleeding ceases and pregnancy is maintained 10 Limit activity 11 No douching.
Valium) 8. Prepare for immediate delivery e. Infection e. FHT Monitor intake and output Seizure precautions Medications (Magnesium sulfate. 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. Disseminated intravascular coagulation c.b. sits up. 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. Could have rapid fetal distress d. Monitor for post partal complications Predisposing Factors: b. Transfusion hepatitis Nursing Intervention: Bedrest Vital signs. Apresoline. Solid particles in the amniotic fluid enter maternal circulation and reach the lungs as emboli Signs and symptoms: Dramatic Sudden inability to breathe. Renal failure f. Blood loss seen may not match symptom c. Pulmonary emboli d. grasps chest and sharp chest pain Turns pale then bluish gray color