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I. Human Sexuality

a. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes and
emotions and preferences that is related to sexual self and eroticism
2. Sex is basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human
sexuality
15 – 44 y.o. – age of reproductivity CBQ

b. Definitions related to sexuality


Gender Identity – sense of feminity and masculinity – developed @age 3 or 2 -4 y.o.
Role Identity – attitudes, behaviours and attitudes that differentiate roles
Sex – biologic male or female status. sometimes referred to as specific sexual behavior
such as sexual intercourse
Sexuality - behavior of being a girl or boy and is identity subject to a lifelong dynamic
change

II. Sexual Anatomy and Physiology

a. Female Reproductive System


1. External – Vulva/ Pudenda
a. Mons pubis/ veneris – mountain of venus, a pad of fatty tissues that lies
over the symphysis pubis covered by skin and at puberty covered by pubic
hair that serves as a cushion or protection to the symphysis pubis

Stages of Pubic Hair Development (Tool Used: Tanner’s Scale/ Sexual Maturity Rating)

Stage 1 – Pre adolescence


• no pubic hair, fine body hair
Stage 2 – Occurs bet. 11 – 12 y.o
• sparse, long, slightly pigmented and curly that develop along labia
Stage 3 – Occurs bet. 12 – 13 y.o.
• hairs become darker and curlier develops along pubis symphysis
Stage 4 – 13 – 14 y.o.
• hair ssumes normal appearance of an adult but is not so thick and
does not appear to the inner aspect of the upper thigh
Stage 5 – Sexual Maturity
• assumes the normal appearance of an adult, appears at the inner
aspect of thigh

b. Labia Majora – large lips latin, longitudinal fold from perenium to pubis
symphysis
c. Labia Minora – aka Nymphae, soft and thin longitudinal fold created
between labia majora
• Clitoris – “key”, pea – shaped erectile tissue composed of sensitive
nerve endings; sight of sexual arousal in females
• Fourchet – tapers posteriorly of the labia majora. Site for episotomy
- sensitive to manipulation, torn during pregnancy
d. Vestibule – almond shaped area that contains the hymen, vaginal orifice and
batholene’s gland
• Urinary Meatus – small opening of urethra/ opening for urination
• Skene’s Gland – aka Paraurethral Gland, 2 small mucus secreting
glands for
lubrication
• Hymen – membranous tissue that covers the vaginal orifice
• Vaginal Orifice – external opening of the vagina
• Bartholene’s Gland – paravaginal gland, secretes alkaline
substance, neutralizes acidity of the vagina
o Doderleins Bacillus – responsible for vaginal acidity
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o Parumculae Mystiformes – healing of a hymen


e. Perenium – muscular structure in between lower vagina and anus

2. Internal
a. Vagina – female organ for ovulation, passageway of menstruation, ¾ inches
8 – 10 cm long containing rugae
o Rugae – permits considerable stretching withouit tearing
during delivery CBQ
b. Uterus – hollow muscular organ, varies in size, weight and shape, organ of
menstruation
Size : 1 x 2 x 3
Shape : pear shaped, pregnant - ovoid
Weight : Uterine involution CBQ
Non pregnant : 50 – 60 g
Preganant : 1000 g
4th stage of Labor : 1000 g
2nd week after of Delivery : 500 g
3rd weeks after delivery : 300 g
5 – 6 Weeks after delivery: 50 – 60 g
Three Parts of Uterus
• Fundus – upper cylindrical layer
• Corpus/ Body – upper triangular layer
• Cervix – lower cylindrical layer
Isthmus – lower uterine segment during pregnancy

Muscular Composition: 3 main Muscles making possible expansion in all direction


a. Endometrium  muscle layer for menses
o Lines the non-pregnant uterus
o Volumes the non pregnant uterus
o Decidua – slouching off of endometrium during menstruation
o Endometriosis
 Ectopic Endometrium
 Common site is ovaries
 Proliferation of abnormal growth of lining of outer part
 Persistent dysmenorrhea, low back pain
 Dx Exam: biopsy,laparoscopy
 Tx: Lupron (luprolide)  inhibits FSH & LH
 Tx: Danazol (Danacrine) DOC
Inhibits ovulation
stop menstruation
b. Myometrium
o Power of labor
o Smooth muscles is considered to be LIVING LIGATURE
(muscles of delivery, capable of closing) of the body
o Largest portion of the uterus
c. Peremetrium
o Protects the entire uterus
c. Ovaries
• 2 female sex gland
• almond shape
• Fxn: Ovulation,production of 2 hormones( estrogen and progesterone)
d. Fallopian Tube
• 2 – 3 inches long that serves as a passageway of the sperm from the
uterus to the ampulla or the passageway of the mature ovum or fertilized
ovum from the ampulla to the uterus
• 4 significant segments
o Infundibulum – most distal part, trumpet shape, has fimbrae
o Ampulla – outer 3rd or 2nd half, site of fertilization, common site
for ectopic preg.
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o Isthmus – site for sterilization, site for BTL


o Interstitial – most dangerous site for ectopic pregnancy

b. Male Reproductive System

1. External
• Penis
• The male organ of copulation and urination
• Contains of a body or shaft consisting of 3 cylindrical layers and erectile
tissues
o 2 corpora cavernosa
o 1 corpus spongiosum
• At the tip is the most sensitive area comparable to clitoris = glans penis
• Scrotum
Pouch hanging below the pendulous penis, with medial septum deviding into
2 sacs each containing testes
Requires 2 degrees celcius for continuous spermatogenesis
Cooling mechanism of testes
2. Internal
The Process of Spermatogenesis

Testes
(900 coiled seminiferous tubules)

epididymis
(site of maturation of sperm 6 m)

Vas Deferens
(conduit pathway of sperm)

Seminal Vesicle
(secreted: fructose form of glucose, nutritative value
Prostaglandin: causes reverse contraction of uterus)

Ejaculatory Duct
(conduit of semesn)

Prostate Gland
(release alkaline substances)

Cowpers Gland
(release alkaline substance)

Urethra
Hypothalamus GNRH

APG

FSH – maturation of sperm
LH – testosterone production
Leydig Cells – releases testosterone

Male & female Homologues


Male Female
Penile Glans Clitoris
Penile Shaft Clitoral shaft
Testes Ovaries
Prostate Skene’s gland
Cowper’s Glands Bartholin’s Gland
Scrotum Labia Majora
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III. Basic Knowledge on Genetics and Obstetrics

1. DNA – Deoxyribonucleic Acid – carries genetic code


2. Chromosomes – threadlike structure of hereditary material known as the DNA
3. Normal amount of ejaculated sperm – 3 – 5 cc/ 1 teaspoon
4. Ovum is capable of being fertilized within 24 – 36 hours after ovulation.
5. Sperm 48 – 72 days viability
6. Reproductive cells divide by the process of MEIOSIS (haploid number)
Spermatogenesis – process of maturation of sperm
Oogenesis – process of maturation of ovum
30 weeks AOG – 6 million immature ovum
@ birth – 1 million immature oocytes
@ puberty – 300 – 400 immature oocytes
@ 13 y/o – 300 – 400 mature oocytes
@ 23 y/o – 180 – 280 mature ovum
@ 33 y/o – 60 – 160 mature ovum
@ 36 y/o – 24 – 124 mature ovum
@46 y/o – 4 mature ovum
Gametogenesis – process of formation of two haploid into diploid
7. Age of reproductivity – 15 – 44 y/o childbearing age – 20 – 35 y/o
High risk  <18 & >35 y.o. With Risk  18 – 20; 30 – 35
8. Menstruation
• Menstrual Cycle – beginning of menstruation to the beginning of the next
menstruation
• Average menstrual cycle – 28 days
• Average menstrual period – 5 days
• Normal blood loss – 50 cc/ ¼ cup accompanied by FIBRINOLYSIS – prevents
clot formation
• Related terminologies
o Menarche – 1st menstruation
o Dysmenorrhea – painful menstruation
o Metrorrhagia – bleeding in between menstruation
o Menorrhagia – Excessive bleeding during menstruation
o Amenorrhea – absence of menstruation
o Menopause – cessation of menstruation (Average Age- 51 y.o.)
 Tofu – has isoflavone – estrogen of plant that mimics the estrogen
with a woman
9. Functions of Estrogen and Progestin
• ESTROGEN – hormone of woman
o Primary function
 Responsible for the development of secondary characteristics in
females
 inhibit production of FSH
o Other function
 Hypertrophy of the myometrium
 Spinnbarkeit and Ferning Pattern (Billings Method)
 Ductile structure of the breast
 Osteoblastic bone activity (causes increased in height)
 Early closure of the epiphysis of the bone
 Sodium retention
 Increased sexual desire
 Responsible for vaginal lubrication
• PROGESTERONE – Hormone of the mother
o Primary function – prepares the endometrium for implantation making it
thick and tortous
o Secondary Function – inhibit uterine contractibility
o Others
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 Inhibit LH (hormone of ovulation) production


 ↓ GI motility
 ↑ Permeability of kidneys to lactose and dextrose causing + 1 sugar
in urine
 Mammary gland development
 ↑ BBT
 Mood swings

10. Menstrual Cycle


4 phases of menstrual cycle
Proliferative
Secretory
Ischemic
Menses

1. On the initial phase of menstruation, the estrogen level is ↓, this level stimulates
the hypothalamus to release GnRH/ FSHRF
2. GnRH/ FSHRF stimulates the anterior pituitary gland to release FSH
• FSH Function
o Stimulate ovaries to release estrogen
o Facilitate the growth of primary follicle to become
GRAAFIAN FOLLICE  structure that secretes large amount of
estrogen that contain mature ovum
3. Proliferative Phase (↑estrogen)
Follicular Phase – responsible for the variation and irregularity of mense
Postmenstrual Period – after menstruation
Preovulatory Phase – happen before menstruation
4. 13th day of menstruation, estrogen level is PEAK while progesterone is ↓, these
stimulates the hypothalamus to release GnRH/ LHRF
5. GnRH/ LHRF stimulates the Anterior Pituitary Gland to release LH
• Functions of LH
o Stimulates the release of progesterone
o Hormone for ovulation
6. 14 day estrogen level is ↑ while progesterone level is ↑
th

• S/S
o Rupture of the graafian follicle - OVULATION
o Mittelschsmerz – slight abdominal pain lower right
quadrant
7. 15th day, after ovulation day, graafian follicle starts to degenerate, estrogen level
↓, progesterone ↑, causing degeneration of the graafian follicle becoming yellowinsh
known as CORPUS LUTEUM – secretes large amount of progesterone
8. Secretory Phase
Lutheal Phase (↑progesterone)
Postovulatory phase
Premenstrual Phase
9. 24th day – Corpus Albicans (whitish) corpus luteum degenerates and becomes
white
10. 28th day – if no sperm united the ovum, the uterine begins to slough off to have
the next menstruation
Note:
• if there is no fertilization, corpus luteum continues functioning
• Ovarian Cycle – from primary follicle – corpus albicans
• Stages:
o 1 – 5 days – menses
o 6 – 14 – proliferative
o 15 – 26 – secretory
o 27 – 28 – ischemic
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11. Stages of Human Sexual Response


Initial Response:
VASOCONGESTION – constriction of blood vessels
MYOTONIA – increased muscle tension
• Excitement Phase
• ↑ muscle tension, moderate VS
• erotic stimuli causing ↑ sexual tension, may last from minutes to hours
• Plateu Phase
• ↑ and sustained tension near orgasm
• may last 30 sec – 30 minutes
• Orgasm
• Involuntary release of sexual tension accompanied by physiologic and
psychologic release,
• immeasurable peak of experience 2 – 3 seconds
• Resolution
• Return to normal state
• VS return to normal

REFRACTORY PERIOD – only period present in male, wherein he cannot restimulated for
about 10 – 15 minutes

IV. Wonders of Fertilization


a. Fertilization
1. Phonones – song of sperm
2. Capacitation – ability of sperm to release proteolytic enzyme and penetrate the
ovum
b. Stages of Fetal Growth and Development
1. Pre Embryonic Stage
I. Zygote  fertilized ovum (3 – 4 days travel, 4 days floating)> from fertilization
II. Morula  mulberry-liked ball containing 16 – 50 cells
III. Blastocyst  enlarging cell forming a cavity that later becomes the embryo covered by
thropoblast which later becomes the placenta and membrane
IV. Implantation  7 – 10 days after fertilization
• Thropoblast – covering of blastocyst that become placenta
• S/Sx of Implantation  Slight pain, Slight Vaginal Spotting
• 3 Processes
o Apposition
o Adhesion
o Invasion
2. Embryonic Stage
Zygote – fertilization to 14 days
Embryo – 15th – 2 mos/ 8 weeks
Fetus – 2 mos to birth
c. Decidua – thickened endometrium, latin word for “falling off”
1. Basalis – located directly under the fetus where placenta developed
2. Caspularis – encapsulates the fetus
3. Vera – remaining portion of and endometrium
d. Chorionic Villi – 10 – 11 weeks
1. Chorionic Villi Sampling (CVS) – removal of tissue from the fetal postion of the
developing placenta
• For genetic screening
• Fetal limb defects, missing digits of toes
e. Cytothrophoblast – outer layer, LANGHAN’S LAYER, protect the fetus against syphilis
(24 weeks/ 6 months)
f. Synsitiotrophoblast – syncitial layer – responsible for hormone production
1. Amnion – inner most layer 2. Chorion
I. Umbilical cord (Funis) – whitish gray (50 – 60 cm)
• Short  abruptio placenta, uterine inversion
• Long  cord prolapse, cord coil
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3 vessels (AVA) – Artery Vein Artery
• Wharton’s Jelly – protects the umbilical cord
II. Amniotic fluid  bag of water  clear color, musty/mousy odor
• With crystallized forming pattern, slightly alkaline
• 500- 1000 cc Normal
o Oligohydramnios – kidney malformation
o Hydramnios – GIT , TEF/ TEA
Functions
Cushion the fetus against sudden blow or trauma
Maintains temperature
Facilitate muscuskeletal development
Prevents cord compression
Helps in development process

Diagnostic Test for Amniotic Fluid  Amniocentesis


Purpose: obtain sample of amniotic fluid by inserting a needle hrough the abdomen into the
amniotic sac
Fluid is tested for:
Genetic screening
Determination of fetal maturity primarily by evaluating factors indicative of lung maturity
Done with empty bladder
Complication
> Most common side effect : INFECTION
> Late : pre term labor
> Early : spontaneous abortion
Indication for Amniocentesis:
> Early in Pregnancy Advance Maternal Age
> Later in Pregnancy Diabetic Mothers
↑ - down syndrome
↓ - neural tube defect, spina befida
L/S ratio : 2:1 (Lecitin/ Spingomyelin)
Definitive test = Phosphatiglycerol: PG +  best Answer
Greenish – Meconium Stains (Fetal Distress)
Yellowish – jaundice, hyperbilirubinemia
Cloudy – Infection
Most Important Consideration  Needle insertion site
Amnioscopy – direct examination through intact fetal membrane via ultrasound
Fern Test – a test determining if bag of water has rupture or not
Nitrazine Paper Test – differentiate amniotic fluid and urine Blue geen  + rupture of bag of
H2O

2. Chorion – outermost layer


a. Placenta – AKA Secundines  chorionic Villi and basalis
Pancake in latin
500 grams in weight
15 – 28 cotyledons
15 – 20 cm in diameter and 2 – 3 cm in depth
Functions
Respiratory  02 – CO2 exchange via simple diffusion
GIT  glucose transport via facilitated diffusion
Excretory  via 2 arteries, carries unoxygenated blood then
detoxify by maternal liver
Circulatory  fetoplacental circulation by SELECTIVE
OSMOSIS
Endocrine
HCG – primary maintain corpus luteum/ secondary
basis of pregnancy test
Human Placental Lactogen – aka
Somatomammothrophin
Responsible for the development of
mammary gland
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Diabetogenic Effect – insulin antagonist


Relaxin – softening of maternal joints and bones
Serves as protective barrier against some microorganism
Can pass: HIV CMV Rubella
PINOCYTOSIS – transport of virus

Pregnancy – 266 – 288 days/ 37 – 42 weeks

FETAL STAGE: Fetal Growth and Development

First Trimester : Period of organogenesis, most critical period


First Month
FHT, CNS Develops, GIT and Respi Tract remains as single tube
Differentiation of Primary Germ Layer
• Endoderm
o Thyroid – responsible for basal metabolism
o Thymus – immunity
o Liver
o GIT
o Linings of Upper GI Tract
• Mesoderm
o Heart
o Musculoskeletal
o Reproductive Organ
o Kidney
• Ectoderm
o Brain
o CNS
o Skin
o 5 senses
o Hair, nails
o Anus
o Mouth
Second Month
• Life span of corpus luteum ends
• All vital organs are formed
• Placenta is developed
• Sex organ is developed
• Meconium is present
Third Month
• Placenta is complete
• Kidneys are functional
• Fetus begins to swallow amniotic fluid
• Buds of milk appear
• Sex is distinguishable
• FHT audible via dopples @ 10 – 12 weeks
Terratogens – any drug or irradiation, the exposure to which may cause damage to the fetus
• DRUGS
o Streptomycin – anti – TB – (quinine) damage to the 8th cranial nerve  poor learning
and deafness/ ototoxic
o Tetracycline – stoning the tooth enamel, inhibits long bone growth
o Vitamin K – hemolysis, destruction of RBC, jaundice, hyperbilirubenemia
o Iodides – enlargement of thyroid and goiter
o Thalidomides – anti-emetics  Amelia or Pocomelia  absence of distal part of
extremities
o Steroids – cleft lip or palate and even abortion
o Lithium – congenital maformation
• ALCOHOL – LBW, fetal alcohol syndrome ( characterized by microcephaly)
• SMOKING – LBW
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• CAFFEINE – LBW
• COCCAINE – LBW, abruptio placenta
• TORCH – group of infections that can cross the placenta or ascend through the birth canal
and adversely effect fetal growth
o Toxoplasmosis – cat lovers
o Others - Hepa AB, HIV, Syphillis
o Rubella – CHD,
 Rubella Titer – N @ 1:10 or ↓ = immunity to rubella = notify doctor
 Rubella vaccine after delivery for 3 mos. No pregnancy for 3 mos.
o Cytomegalo virus
o Herpes Simplex virus

Second Trimester : continuous growth and development (focus  lengh of fetus)


Fourth Month
• Lanugo begins to appear
• Buds of permanent teeth appear
• FHT audible via Fetuscope @ 18 – 20 weeks
Fifth Month
• Quickening : 1st fetal movement Primi: 18 – 20, Nulli - 16 - 18
• Lanugo covers the body
• FHT audible via stethoscope or w/out instrument
• Actively swallow amniotic fluid
• Fetus : 19 – 25 cm
Sixth Month
• Skin is red and wrinkled
• Vernix caseosa covers the skin
• Eyelids open
• Exhibits startle reflex
3rd Trimester : period of most rapid growth and development Focus: weight
Seventh Month
• Surfactant development
• Male: the testes begins to descent into the scrotal sac
• Female : clitoris is prominent and labia majora are small doesn’t cover the minora
Eight Month
• Active moro reflex
• Lanugo begins to disappear
• Sub q fats deposits, steady weight gain, nails to fingers
Ninth Month
• Lanugos and vernix caseosa is evident in body fold
• Birth position assumed
• Amniotic fluid somewhat decrease
• Sole of the foot has few creases
Tenth Month
• Bone ossification in the fetal skull
• Vernix caseosa is evident in body

PHYSIOLOGIC ADAPTATION TO PREGNANCY

Systemic Changes
1. Cardiovascular System
• ↑ blood volume 30 – 50%
• 1500 cc; additional 500 cc for multiple pregnancy
• ↑ plasma volume
• ↑ cardiac workload – easy fatigability/ slight ventricular hypertrophy
• Epistaxis due to hyperemia of nasal membrane
• Palpitation due to SNS stimulation
• Physiologic Anemia/ pseudoanemia in pregnacy
o Normal Value
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Hct : 32 – 42%
Hgb: 10.5 – 14 g/dl
o Criteria
1st & 3rd Trimester : Hct > 33% Hgb > 11 g/dl
2nd Trimester : Hct > 32% Hgb > 10.5 g/dl
o Pathologic Anemia
 Iron Defficiency Anemia is the most common hematologic disorder. It
affects 20% of pregnant women
 Assesment reveals:
• Pallor
• Slowed capillary refill = Normal = 2 – 3 sec
• Concave fingernails (late sign of progressive anemia) –
clubbing = chronic tissue hypoxia
• constipation
 Nursing care
• Nutritional instruction
o Source of iron
 Kangkong
 Liver = best source due to FERRIDIN Content
 Red and lean meat
 Green Leafy Vegetables
• Parenteral Iron (Imferon)
o Z tract IM
o incorrect causes hematoma
o best given 1 hour before meals (causes GI irritation)
o Maybe given 2 hours after meal (results to poor
absorption)
 Given with orange juice to ↑ absorption
• Oral Iron Supplements (ferrous sulfate 0.3 g 3 x a day)
• Monitor for hemorrhage
 Alert
• Iron from red meat is better absorbed iron from other sources
• Iron is better absorbed when taken with foods high in Vitamin C
such as orange juice
• Higher iron intake is recommended since circulating blood
volume is increased and heme is required from production of
RBCs
• Edema
o Impeded venous return due to the gravid uterus
o Nursing Intervention
 Elevate legs above the hips level
• Varicosities
o Wear support stockings
o Elevate legs
• Vulvar Varicosities
o D/t pressure of gravid uterus
o Side –lying with pillow under the hips
o Modified knee – chest position
• Thrombophlebitis
o Presence of thrombus in inflamed blood vessels
o + Homan’s Sign – pain on the calf upon dorsiflexion
o Medical Management
 Anticoagulant/ HEPARIN
• Does not cross the placental barrier
• Monitor APTT
• Antidote: PROTAMINE SULFATE
• No aspirin
• Milk Leg/ Plagmasia Alba Dolens
o Shiny white legs due to stretching of skin & hyperfibrinogenemia
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o Nursing intervention
 Check dorsalis pedis pulse (compare both)
 Never massage
 Assess for Homan’s sign only once

2. Respiratory System
• Shortness of Breath d/t gravid uterus
• Nursing intervention: Side-lying – lateral expansion of the lungs

3. Gastrointestinal System
• Nausea and vomiting
• Morning Sickness
o Due to ↑ HCG levels
o Crackers 30 min before arising
o AM – Carb diet 30 mins
o PM – small frequent meal
• Constipation
o Due to PROGESTERONE = ↑ fluid reabsorption due to ↓ GIT motility
o Nursing intervention
• ↑ Fluid
• ↑ Fiber
• Exercise
• Flatulence
o Due to increased progesterone
o Avoid gas forming foods
• Heartburn (pyrosis)
o Reflux of stomach content into esophagus
o Nursing Intervention
• Small frequent meals
• Sips of milk
• Avoid fatty and spicy foods
• Proper body mechanics
o Waist Above – Acid
o Waist Below – Base
• Hemorrhoids
o Due to gravid uterus
o Hot sitz bath for comfort
• Ptyalism
o ↑ salivation
o Mouthwashes to relieve
4. Urinary System
• Normal = + 1 sugar due to Progesterone via BENEDICT’S TEST
• First Trimester - Frequency
• Second Trimester - normal
• Third Trimester - Frequency
5. Muscoloskeletal
• Calcium sources
o Milk - ↑ Ca ↑ P – 1 pint/ day or 3 – 4 servings/ day
o Cheese, Yogurt, Head of Fish, Sardines, Anchovies, Brocolli
• Lordosis
o Pride of Pregnacy
• Waddling Gait
o Awkward gait while walking due to relaxin
o Prone to accidental falls
 Wear low healed shoes
• Leg Cramps
o Ca – P Imbalance during pregnancy
o Lumbo-sacral nerves by pressure of gravid uterus during labor
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o Over sex
o Dorsiflex the foot affected
o 3-4 servings/ 4 cups/day sa milk, sardines, dilis

A. Local Changes

• Vagina
o Chadwick’s Sign – bluish discoloration
o Leukorrhea – whitish gray, moderate in amount, mousy odor
• Cervix
o Goodel’s Sign – change in consistency of uterus
o Operculum – mucus plug to seal bacteria/ progesterone
• Uterus
o Hegar’s Sign – change in consistency

Vagina Chadwick’s
Cervix Goodel’s
Uterus Hegar’s

Problems related to the changes of Vaginal Environment


a. Vaginitis - AVOCADO
• Trichomonas Vaginalis
o Flagellated protoxzoan, Loves alakaline environment
• Signs and Symptoms
o Greenish, cream, colored, frothy, irritably itchy, foul smelling vaginal discharge
o Vaginal edema
• Management
o Drug of choice: METRONIDAZOLE (Flagyl)
 Antiprotozoan
 Carcinogenic
 Not given in 1st trimester
• vaginal douche as substitue
o 1 qt Water = 1 tbsp white vinegar
Treat partner as well to prevent reinfection
No alcohol – due to antabuse effect
b. Moniliasis - CHEESE
• Candida Albicans
• Transvaginal transfer in fetus – Oral Trush
• Signs and Symptoms
o White Cheeselike patches that adheres to the walls of the vagina
• Management
o Antifungals
 Mycostatin
 Contrimazole – Canisten
 Gentian Violet

1. Abdominal Changes
• Striae Gravidarum
o Due to destruction of the subcutaneous tissue by the enlarge uterus

2. Skin Changes
• Melasma/ Chloasma
o White light brown pigmentation related to ↑ melanocytes
• Linea Nigra
Brown pinkish line from symphysis pubis to umbilicus

3. Breast Changes
Due to hormonal changes
Change in color and size of nipple and areola
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Precolostrum – 6 weeks
Colustrum – 3rd trimester
Supine with pillow under the back
4. Ovaries – rest period, no ovulation
5. Signs and Symptoms of Pregnancy
Presumptive Probable Positive
S/sx felt and observed by the Signs observed by Undeniable signs confirmed
mother but does not confirm the members of the by the use of instrument
the diagnosis of pregnancy health care team
First Breast changes Goodel’s sign Ultrasound Evidence
trimester Urinary changes Chadwick’s sign
Fatigue Hegar’s sign
Amenorrhea Elevated BBT
Morning sickness Positive HCG
Enlarge uterus
Second Chloasma Ballotement
Trimester Linea Nigra Enlarge Abdomen etal Heart Tone
Increase Skin Pigmentation Braxton Hicks etal movement
Striae gravidarum Contraction etal outline
Quickening etal parts palpable

CBQ Cancer of the Breast  quadrant B


Mamography 35 and above  1/ year
Ballotement  bouncing of the fetus
 may be present in uterine myoma
Transvaginal Ultrasound – empty bladder
Abdominal ultrasound – full bladder

Placenta Grading System


• Grade 0 – immature
• Grade 1 – slightly mature
• Grade 2 – moderately mature
• Grade 3 – fully mature
• What is deposited?  calcium

VI. Psychological Adaptation to Pregnancy – Reva Rubin

First Trimester
No tangible s/sx
Feeling of surprise
Ambivalence
Denial of pregnancy  maladaptation
Developmental Task: Accept biological facts of pregnancy
Health Teaching: Body changes of pregnancy and Nutrition

Second Trimester
• Tangible s/sx
• Mother identifies fetus as separate entity due to quickening
• Fantasy
Developmental Task: Accept growing fetus as a baby to nurture
Health Teaching: Growth and development of fetus

Third Trimester
• Mother has personally identifies with the appearance of the baby
Developmental Task: Prepare child birth and parenting the child
Health Teaching: responsible parenthood, prepare baby’s layette, Lamaze Class
Address Mother’s fear  let she hear the FHT

VII. Pre – Natal Visit


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Basic Consideration
1. Frequency of Visit
• 1 – 7th mos.  once a month
• 8 – 9th mos.  twice per month
• 10th month  every week
2. Personal Data
• Home Based Mother’s Record/ HBMR  determines high risk pregnancy
• Pseudocyesis  false pregnancy  appearance of presumptive & probable signs
• Comade Syndrome  psycosomatic disorder, father experience what the mother
goes through
3. Diagnosis of Pregnancy
• Urine Exam HCG  40 – 100th day; peak 60 – 70th day
• ELISA  beta subunits of HCG is detected as early as 7 – 10th day
• RIA  beta subunits of HCG is detected as early as 8th day
• Home Pregnancy Kit
4. Baseline Data
• Roll – Over Test  test of pre-eclampsia by the use of BP
• Weight monitoring
Normal Weight Gain
1st Trimester = 1.5 – 3 lbs  1 lb/ mo
2nd Trimester = 10 – 12 lbs  4 lbs/mo
3rd Trimester = 10 – 12 lbs  4 lbs/mo

Minimum allowable weight gain  20 – 25 lbs


Optimal weight gain  25 – 35 lbs

5. Obstetrical Data

a. Gravida  no. of pregnancy


b. Para  no. of viable pregnancy

Viability  the ability of the fetus to live outside the uterus at the earliest possible gestational age

1 abortion 1 39TH Week, 1 miscarriage, 1 still birth, 1 2nd mo. preg


1 pregnancy 3rd mos. G4P2 G4 T1 P1 A1 L1

G2P0 G2 T0 P0 A1 L0

c. Important Estimates
1. Nagele’s Rule
• Use to determine expected date of delivery
• Jan – Mar  +9 months +7 days
• Apr – Dec  -3 months +7 days + 1 year

2. McDonald’s Rule
Determines age of gestation in weeks
Fundic Height x 7/8 = AOG in weeks
3. Bartholomew’s Rule
• Determines age of gestations
o 3 mos – above pubis symphysis
o 5 mos – level of umbilicus
o 9 mos – below xiphoid process
o 10 mos – level of 8th mos

4. Haases Rule
• Determines the length of fetus in cm.
• 1st half  square each month
• 2nd half  month x 5
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d. Tetanus Immunization
• TT1 – anytime or early during pregnancy
• TT2 – 1 month after TT1  3 years protection
• TT3 – 6 months after TT2 – 5 years of protection
• TT4 – 1 year after TT3  10 years of protection
• TT5 – 1 year after TT4  lifetime protection

5. Physical Examinations
a. Danger Signs of Pregnancy
Chills & Fever
Cerebral Disturbances
Abdominal Pain  epigastric pain  auro of impending convulsion
Boardlike Abdomen  Abruptio placenta
Blurred Vission  pre eclampsia
Bleeding  abortion/ ectopic pregnancy – 1st trimester
 H Mole/ Incompetent Cervix – 2nd trimester
 Placental Anomalies – 3rd Trimester
BP ↑
Swelling
Scotoma – spots in the eye
Sudden gush of fluid – PROM – premature rupture of membrane

6. Pelvic Examination
 Pelvic examination or IE – empty bladder, precaution
 1st visit – Chadwicks, Goodle’s sign, etc.
 Position : dorsal recumbent, lithotomy
 Pap smear – done 1st visit
 Cytological exam – determine presence of cancer cells.
 Result :
o Class I – normal
o Class II A – cytology without evidence of malignancy
B – suggestive of inflammation
o Class III – cytology suggestive of malignancy
o Class IV – cytology suggestive og malignancy
o Class V – conclusive for malignancy
 Most common cancer report organ : cervical cancer
 Most common site for pap smear – external OS of cervix (squamocolumnar tissue)
 Common site of cervical cancer. maternal – speculum (open)
 Stages of cervical cancer
o 0 – carcinoma in situ
o 1 – Ca strictly confined to cervix
o 2 – from cervix extends to the vagina
o 3 – pelvic metastasis
o 4 – affectation to bladder & rectum

7. Leopolds Maneuver
Purpose: Done to determine the attitude, fetal presentation, lie, presenting part, degree of
descent an estimate of the size, and no. of fetuses
Procedure
1st maneuver
place patient in supine position with knees slightly flexed. Put towel under head and right
hip. With both hands palpate uppe4r abdomen and fundus. Assess size, shape,
movement and firmness of the part
determine the presenting parts:
2nd maneuver
with both hands moving down, identify the back of the fetus where the ball of the
stethoscope is placed to determine FHT.
PR of mother : uterine soufflé – MHR
fundic soufflé – FHR
3rd maneuver
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using the right hand, grasp the symphysis pubis part using the thumb and fingers.
Assess whether the presenting part is engaged in the pelvis.
Alert! If the head is engaged it will not be movable
th
4 maneuver
the examiner changes the position by facing the patient’s feet. With two hands, assess the
descent of the presenting part by locating the cephalic prominence or brow.
When the brow is on the same side as the back, the head is extended. When the brow is
on the same side as the small parts, the head 8is flexed and vertex presenting.
Attitude – relationship of fetus to one another.
Full Flexion – when the chin touches the chest

8. Assessment of Fetal Well-being

a. Daily fetal Movement Counting (DFMC)


 Done starting 27th week
 Consideration
 fetal sleep wake pattern
 maternal food intake
 drug-nicotine use
 environmental stimuli
 maternal dose
 Cardiff count to 10 method – one method currently available
o begin at the same time each day (usually in the morning after breakfast ) and
count each fetal movement, noting how long it takes to count 10 fetal
movements (FMs)
o expected findings – 10 movements in 1hrs or less
o warning signs – 10-12 movements in 1hr or less
 more than 1hr to reach 10 movements
 less than 10 movements in 12hrs
 longer time to reach 10 FMs than on previous days.
 movements are becoming weaker, less vigorous
 movement alarm signal <3 FMs in 12hrs
o warning signs should be reported to healthcare provider immediately; often
require further testing. Eg. Non stress test (NST), biophysical profile (BPP)

b. Nonstress Test
to determine the response of the fetal heart rate to the stress to activity.
Indications – pregnancies at risk for
placental insufficiency
Postmaturity
• pregnancy induced hypertension (PIH), diabetes
• warning signs noted during DFMC
• maternal history of smoking, inadequate nutrition
Procedure :
• Done within 30mins wherein the mother is in semifowlers position; external
monitor is applied to document fetal activity; mother activates the “mark button”
on the electronic monitor when she feels fetal movement. Attach external
noninvasive fetal monitors
• tocotransducer over fundus to detect uterine contractions and fetal movements
(FMs)
• ultrasound transducer over abdominal site where most distinct fetal heart
sounds are detected
• monitor until at least 2 FMs are detected in 20mins.
if no FM after 40mins provide women with a light snack or gently stimulate fetus through
abdomen
If no FM after 1hr further testing may be indicated, such as a CST
Result :
• Noncreative Nonstress Not Good
• Reactive Response is Real Good
Interpretation of results
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• Reactive result – real good


baseline FHR between traction beteen 120 and 160 beats per min.
at least two accelerations of the FHR of at least 15 beats per min., lasting at
least 15secs in a 10 to 20 min period as a result of FM
good variability – normal irregularity of cardiac rhythm representing a
balanced interaction between the parasympathetic (↓ FHR) and
sympathetic (↑ FHR) nervous system; noted as an uneven line on the
rhythm strip
result indicates a healthy fetus with an intact nervous system
Nonreactive result – not good
 stated criteria for a reative result are not met
 could be indicative of a compromised fetus requires further evaluation
with another NST, biophysical profile, (BPP) or contraction stress test
(CST)

9. Health Teachings
o do nutritional assessment
o daily food intake
o determine habit
o if ↓ folic acid – lead to spina bifida/open neural tube defect
o HIGH RISK MOTHERS
• pregnant teenagers – poor compliance to health regimen
• extremes in wt – underwt – eg. Elite models overwt – eg. DM/HPN
• low social economic status. Refer to OSWD
• vegetarian mothers because ↓ intake of vit B12 (Cyanocobalamin) – formation
of folic acid (cell DNA & RNA formation)
• types :
 strict vegetarian – prone to develop anemia
 lacto vegetarian – milk
 lacto-ovo vegetarian – milk & egg

a. Recommended Nutrient Requirement that Increases During Pregnancy


Nutrients Requirements Food sources
Calories
Essential to supply energy for 300 calories/day above the Caloric ↑ should reflect
↑metabolic rate prepregnancy daily requirement • foods of high nutrient value
Utilization of nutrients to maintain ideal body weight such as protein, complex
• Protein sparing so it can be and meet energy requirement of carbohydrates (whole grains,
used for : activity level vegetables, fruits)
growth of fetus • begin ↑ in 2 Trimester
nd
• variety of foods representing
o development of • use wt-gain pattern as an food sources for the nutrients
structures requires indication of adequacy of required during pregnancy
for pregnancy calories intake • no more than 30% fat
including placenta, • failure to meet caloric
amniotic fluid, tissue requirements can lead to Na – 3gms/day – eat in
growth ketosis as fat & protein are moderation
used for energy, ketosis has CHON x 4K Cal
been associated with fetal CHO x 4K Cal
damage. Fats x 9K Cal

Non pregnant: 2200 calories


Pregnant: 2500 calories
2200+500 @ lactation=2700 cal
Protein
Essential for 60mg/day or an ↑ of 10% above Protein ↑ should reflect
• fetal tissue growth daily requirements for age • Lean meat, poultry, fish
• maternal tissue growth group • Eggs, cheese, milk
including uterus and • Dried beans, lentils, nuts
breasts. Adolescents have a higher • Whole grains
• Development of essential protein requirement than mature
women since adolescents must Vegetarians must take note of
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pregnancy structures supply protein for their own the amino acid content of
• Formation of RBC and growth as well as protein to CHON foods consumed to
plasma proteins meet the pregnancy ensure ingestion of sufficient
requirement quantities of all amino acids
Inadequate protein intake has
been associated with onset of
pregnancy induced
hypertension (PIH)
Calcium-Phosphorous
Essential for Calcium ↑ of Calcium ↑ should reflect
Growth and development of 1200mg/day representing an ↑ • Dairy products, milk, yogurt,
fetal skeleton and tooth of 50% above pre pregnancy ice cream, cheese, egg yolk
buds daily requirement • Whole grain, tofu
Maintenance of mineralization 1600mg/day is recommended • Green leafy vegetables
of maternal bones and teeth for adolescent • Canned salmon & sardines
Current research is 10mcg/day of vitamin D is with bones
demonstrating an required since it enhances • Ca fortified foods such as
association between absorption of both calcium orange juice
adequate calcium intake and phosphorous
• Vitamin D sources fortified
and the prevention of
milk, margarine, egg yolk,
pregnancy induced
butter, liver, seafood
hypertension

Iron
Essential for Non Pregnat:15mg/day
• Expansion of blood volume & Pregnant : 30mg/day Iron ↑ should reflect
RBC formation - representing a doubling • liver, red meat, fish, poultry,
• Establishment of fetal iron of the prepregnant daily eggs
stores for first few months of life requirement • enriched, whole grain cereals
Begin supplementation at & breads
30mg/day in second • dark green leafy vegetables,
trimester, since diet alone is legumes
unable to meet pregnancy • nuts, dries fruits
requirement
• vitamin C sources: citrus
60 – 120mg/day along with
fruits & juices, strawberries,
copper and zinc
cantaloupe, tomatoes, green
supplementation for women
peppers, broccoli or
who have low Hgb values
cabbage, potatoes
prior to pregnancy or who
have iron deficiency anemia • iron form food sources is
70mg/day of vitamin C which more readily absorbed when
enhances iron absortion served with foods high in vit
o Inadequate iron intake C
results in maternal effects
anemia, depletion of iron
stores, ↓ energy and
appetite, cardiac stress
especially during labor &
birth
o fetal effects ↓ availability
of oxygen thereby
affecting fetal growth
iron deficiency anemia is the
most common nutritional
disorder of pregnancy

Zinc
Essential for 15 g/day representing an ↑ of Zinc ↑ should reflect
• the formation of enzymes 3mg/day over prepregnant daily • liver, meats
• maybe be important in the requirement • shell fish
prevention of congenital • ↑grains, legumes, nuts
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malformation of the fetus


Folic acids, folacin, folate
Essential for 400mcg/day representing an ↑ ↑ should reflect
• Formation of RBC & of more than 2x the daily Liver. Kidney, lean beek, veal
prevention of anemia prepregnant requirement • Dark, green leafy vegetables,
• DNA synthesis & cell broccoli, asparagus,
formation; may play a role in 300mcg/day supplement for artichokes, legumes
the prevention of neural women with low folate levels or Whole grains, preanuts
tube defects (spina bifida), dietary deficiency
abortion, abruption placenta
Additional requirements
Minerals ↑ requirements of pregnancy
• Iodine 175mcg/day can easily be met with a
• Magnesium 320mg/day balanced diet that meets the
• selenium 65mcg/day requirement for calories and
includes food sources high in
the other nutrients needed
during pregnancy
Vitamins
E 10mg/day
Thiamine 1.5mg/day
Riboflavin 1.6mg/day
Pyridoxine (B6) 2.2mg/day
B12 2.2mcg/day
Niacin 17mg/day

b. Sexual Activity
• Principles of sex in Pregnancy
o Should be done in moderation
o Should be done in a private place
o That the mother should be placed in a comfortable position
o It must be avoided 6 weeks prior to EDD
o Avoid blowing of air during cunnilingus
• Contraindication in sex:
o vaginal spotting – 1st tri
o incompetent cervix – 2nd tri
o placenta previa, abruption placenta – 3rd tri
o pre-term labor R: prostaglandin – oxytocin – contraction
o PROM – infection
• Changes in sexual appetite during pregnancy:
o 1st tri - ↓
o 2nd tri - ↑
o 3rd tri - ↓

c. Exercise
• strengthen muscle to be used during the delivery process
• Walking – best form of exercise
• Squatting – strengthen perineum & ↑circulation to the perineum (raise the buttocks before head
to prevent postural hypotension)
• Tailor sitting – same purpose with squatting
• Kegel exercise – strengthen pubococcygeal muscle
• Abdominal exercise – muscle of the abdomen ( done as if blowing a candle)
• Shoulder circling exercise – strengthen muscle of the chest
• Pelvic rocking exercise or pelvic tilt – relieve low back pain & maintain good posture (arching
back for 3 sec)
• Principles of exercise
o must be done in moderation
o must be individualized

d. Childbirth Preparation
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• Overall goal: To prepare patents physically & psychologically while promoting wellness
behavior that can be used by parents & family thus, helping them achieved a satisfying &
enjoying childbirth experiences.

• Psychological
o Bradley Method – Dr. Robert Bradley – discoverer
 advocated active participation of husband during labor & delivery to serve as
coach, based on “imitation of nature”
 Features:
• darkened room
• quiet & calm environment
• relaxation technique
• close eyes
o Grantly Dick Read Method
 fear can lead to tension while tension can lead to pain. (break cycle by
removing the fear-by abdominal breathing exercises & relaxation technique)
• Psychosexual
o Kitzinger Method – Dr. Shiella Kitzinger
 pregnancy, labor & birth & the care of the newborn is an important turning point
in a woman’s life cycle. “flowing with contractions rather than struggle with
contractions”
• Psychoprophylaxis
o Lamaze – Dr. Ferdinand Lamaze
 Prevention of pain thru mind & requires discipline, conditioning & concentration
with the husband’s help.
 Features:
• conscious relaxation
• cleansing breathe – inhaling thru nose & exhaling thru mouth
• effleurage – gentle circular massage
• over abdomen to relieve pain
• imaging
• Different methods of delivery
o birthing chain – semi-fowlers – mother
o bathing bed – dorsal recumbent
o squatting – position relieve on back pain & maintain good posture
o Leboyer’s method
 features :
• darkly lighted room
• quiet & calm environment
• room temp.
• soft music
o Birth under water

IX. INTRAPARTAL NOTES


A. Admitting the laboring Mother
• Personal data
• Baseline data
• Obstetrical data
• Physical exams
• Pelvic exams
B. Basic knowledge in intrapartum
Theories of the Onset of Labor
Uterine Stretch Theory – any hollow organ once stretched to its maximum potential will
always contract & expel its content
Oxytocin Theory – released by PPG, contraction effect
Prostaglandin Theory – stimulation by Arachidonic acid, causes contraction of uterus
Aging Placenta – 42wks (lifespan) by 36wks placenta begins to degenerate causes
contraction
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Progesterone deprivation theory - ↓ level of progesterone will facilitate contraction of the


uterus
The 4 Ps of Labor
Passenger – fetus
fetal head
is the largest presenting part
¼ of its length
Bones – 6 bones (sphenoid, temporal, ethmoid) Frontal, occipital & 2
parietal bones
Sutures/intermembranous spaces – allows molding
Molding – the overlapping of the sutures of the skull to permit passage of
the head to the pelvis
Sagittal bones – connect to parietal bones
Cororontal bones – connect to parietal & frontal bones
Lambdoidal bones – connect to parietal & occipital bones
Fontanels
6 fontanels only 2 palpable
anterior fontanel/Bregma
diamond in shape
3cm x 4cm size
close 12-18 mos post delivery
↑ 5cm – hydrocephalus
posterior fontanel/lambda
triangular in shape
1 x 1cm size
close 2-3mos post delivery
Measurements of fetal head :
transverse diameter
Bi-parietal - largest transverse diameter- 9.25cm
Bi-temporal - 8cm
Bi-mastoid - smallest transverse diameter - 7cm
AP diameter
Suboccipitobregmatic – complete flexion
Occipitofrontal – partial flexion - 12cm
Occipitotemporal – largest AP diameter; hyperextended
(13.5cm)
Submentobrgmatic - face presentation; poor flexio
Passageway – vagina & pelvis
Pelvis
4 main pelvic types
gynecoid – round, wide, deeper, most suitable for pregnancy
android – heart shape “male pelvis” – anterior pointed post part –
shallow
Anthropoid – oval “ape-like pelvis“ AP wider transverse narrow
Platypelloid – flat transverse oval AP narrow transverse – wider –
c/s for delivery
Problem :
mother who encounter accident
↓ 4’9”
↓ 18y/o – R: pelvis not achieve its full pelvic growth
Bones of pelvis
4bones
2 hips (2 innominate bones)
3parts of 2 innominate bones
Ileum – lateral/side of hips
Iliac crest – flaring superior border that forms
prominence of hips; common site for bone
marrow aspiration
Ischium – inferior portion
Ischial tuberosities of the area where we
Sit; basis in getting external measurement of
pelvis
Pubis – anterior portion
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Symphysis pubis – junction in between


sacrum – posterior portion
Sacral prominence – basis internal measurement of pelvis
1 coccyx - 4 small bones that compresses during vaginal delivery
universal precaution in measurement of pelvis is to empty bladder first
Important Measurements
Diagonal Conjugate
measure between Sacral promontory & inferior margin of the
symphysis pubis
Measurement 11.5-12.5 cm
Basis in getting the true conjugate.
True Conjugate/Conjugate Vera
Measure between the anterior surface of the sacral
promontory & superior margin of the symphysis pubis.
Measurement: 11.0 cm
Diagonal conjugate: 1.5 cm = true conjugate.
Obstetrical Conjugate
smallest AP diameter of the pelvis measuring 10cm or more.
Tuberoischii Diameter
transverse diameter of the pelvic outlet.
Approx by a fist- 8cm & above.
Power
the forces acting to expel the fetus & placenta
involuntary contractions
voluntary bearing down efforts
characteristics: wave like
timing: frequency, duration, intensity
myometrium – power of labor
Psyche/person
psychological stress exist when the mother is fighting the labor experience.
cultural interpretation preparation
past experience
support system
Pre-eminent signs of labor
Preeminent Signs
lightening
settling of the presenting part into the pelvis brim (shooting pain radiating to
the legs, urinary frequency)
primi- early 2 weeks prior to EDD
engagement – settling of presenting part into pelvic inlet (not signs of labor)
Braxton Hicks Contractions – painless irregular contractions
Increase Activity of the Mother – Nesting
Instinct (mgt: save energy)
epinephrine production (hormone that ↑ the activity of the mother)
Ripening of the cervix –butter softness
Decrease in weight – 1.5-3 lbs.
Bloody show
pinkish vaginal discharge (blood + leucorrhea + operculum = pink in color)
Rupture of membranes
check FHT
IE check for cord prolapse
after several hrs – check temp.
Premature Rupture of Membranes (PROM)
contraction drop in intensity even though very painful
contraction drop in frequency
uterus tense &/or contracting between contractions
abdominal palpitations
Nursing Care:
administer analgesics (morphine)
attempt manual rotation for ROP or LOP
bear down with contractions
adequate hydration
sedation as ordered
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cesarean delivery may be required, especially if fetal distress is noted


Cord Prolapse
a complication when the umbilical cord falls or is washed through the cervix into
the vagina.
Danger Signs:
PROM
Presenting part has not yet engaged
Fetal distress
Protruding cord from vagina – cerebral palsy – ↑ 5 mins., irreversible brain
damage mgt: CS
Nursing Care
Positioning – knee chest or trendelenberg, place wet sterile gauze R: to
make it slippery
Observe for fetal distress
Provide emotional support
Prepare for cesarean section

Difference Between True and False Contraction


True False
• No in intensity • There is an in intensity
• Pain confined in the abdomen • Pain begins @ the lower back
• Pain is relieved by walking to abdomen
• No cervical changes • Pain is intensified by walking
• Cervical effacement (thinning of
the cervix, measured thru %) &
dilatation (widening of the
cervix, measurement thru cm)
*best/major sign of true labor

Duration of Labor
Primipara – 14 hrs but not more than 120 hrs
Multipara – 8 hrs but not more than 14 hrs
Nursing Interventions in Each Stage of Labor
First Stage: onset of contractions to full dilatation & effacement of the cervix
stage of effacement & dilatation
Latent Phase:
Assessment:
Dilatations 0-3 cm
Frequency 5-10 mins
Duration 20-40 mins
Intensity mild
Mother is excited, apprehensive but can communicate
Nursing Care:
Encourage walking : shortens 1st stage of labor
Encourage to void q 2-3 hrs : full bladder inhibits uterine contraction
breathing (chest breathing technique)
Active Phase:
Assessment:
Dilatations 4-8 cm
Frequency q 3-5 mins lasting for 30-60 secs
Duration 30-60 secs
Intensity moderate
Nursing Care:
M – edications – have meds ready
A – ssessment include: v/s, cervical dilatation & effacement, fetal
monitor, etc
D – ry lips – oral care (ointment), dry linens
Breathing – abdominal breathing
Transitional Phase:
Assessment:
Dilatations 8-10cm
Frequency q 2-3 mins contractions
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Duration 45-90 sec


Intensity strong
Mood of mother suddenly change accompanied by hyperesthesia
(hypersensitivity of mother to touch) of the skin
Management
sacral pressure, cold compress
Nursing care:
T – tires
I – inform of progress (to relieve emotional support)
R – restless support her breathing technique
E – encourage & praise
D – discomfort
Pelvic Exams
Effacement & Dilatation
Station – relationship of the presenting part to the ischial spine
5 - -1 = the presenting part is above the ischial spine
Engagement 10 = the presenting part is in line with the ischial spine
(-) fetus is floating
(+) below the ischial spine
Presentation
the relationship of the long axis of the fetus to the long axis of the
mother.
spine relationship of the spine of the mother & the spine of the fetus

Two Types
Longitudinal Lie (Parallel)/ Vertical
Cephalic – when the fetus is completely flexed
Vertex
Face
Brow
Chin
Breech
Complete breech – thigh rest on abdomen
while legs rest on thigh
Incomplete breech
Frank – thigh resting on abdomen
while legs extend to the head
Footling
Kneeling
Transverse Lie (Perpendicular)/Horizontal lie
Position – relationship of the fetal presenting part to
specific quadrant of the mother’s pelvis.
ROA/LOA
left occipito anterior
most common & favorable position
ROT/LOT – left occipito transverse
ROP/LOP – left occipito posterior

L/R- side of maternal pelvis


Middle – presenting part

ROP/ROT – most common malposition


ROP/LOP – most painful mgt: pelvis squatting

Breech – sacro
place the stethoscope above the
umbilicus
Chin – mentum
Shoulder – acromnio dorso
Monitoring the contractions & fetal heart tone
spread the finger lightly over the fundus to monitor the contraction
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Increment/Cresendro - beginning of contraction until it increases


Apex/Acne – height of contraction
Decrement/Decresendro – from height of contraction until it decreases
Duration – beginning of contraction to the end of the same contraction
Interval – from end of contraction to the beginning of the next contraction
Frequency – from the beginning of 1 contraction to the beginning of next
contraction
Intensity – strength of contraction
if contract – blood vessel constricts; the fetus will get the oxygen on the
placenta reserve which is capable of giving oxygen to the fetus up to
1min.
Duration of placenta to the fetus should not exceed 1min.
Significance During active phase, if ↑ to 1min should notify the AMD
↑ BP; ↓ FHT : best time to get BO & FHT just after a contraction

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR


 Bath is necessary
 Monitor VS especially BP
o Same BP = rest
o Elevated = notify the physician
 NPO
o Prevent aspiration  chemical pneuminitis
 Enema (per hospital policy)
o Purpose
 Cleanse the bowel
 Prevent infection
o 12 – 18 inches normal length of tube
o 18 inches optimal length
o Lateral sims position
o If there is contraction  clump the tube
o If there is resistance  slowly remove
o Before and after administration: check FHT (120 – 160) and contractions
 Encourage mother to void
 Perennial preparation (rule of 7)
 Rest on left side lying position
o Prevent supine vena cava syndrome or supine hypotension
 If membrane doesn’t rupture  amniotomy
 FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen
 For Pain
o Systemic analgesic
 DEMEROL (Meperidine HCl)
• Narcotic and antispasmonic
• Don’t give during latent phase
• Given @ 6-8 cm dilated
• WOF : Respiratory depression
• Narcan (Naloxone, nalorfan, nalline)
o Antidote for toxicity
o Injected on the baby
 Epidural Anesthesia
• WOF : Hypotension
• Prehydrate the client to prevent hypotension
• In case of Hypotension
o Elevate leg
o Fast Drip IV

SECOND STAGE OF LABOR (FETAL STAGE)


 Complete dilatation and effacement to birth
 Crowning occurs
 PRIMI – transfer to DR @ 10 cm dilatation
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 MULTI – transfer to DR @ 7 – 8 cm dilatation


 Position in lithotomy both legs at the same time
 BULGING OF PERENIUM  surest sign of delivery initiation
 PANT & BLOW Breathing, fetal pushing should be done on an open glottis
 Respiratory alkalosis
o Due to incorrect breathing
o Hyperventilation
o S/sx
 ↑ RR
 Lightheadedness
 Tingling sensation
 Carpopedal spasm
 Circumoral numbness

Episiotomy
 Prevent laceration
 Widen the vaginal canal
 Shortens the 2nd stage of labor
 2 types
o MEDIAN
 Less bleeding
 Less pain
 Easy repair
 Possible urethroanal fistula  major disadvantage
o MEDIOLATERAL
 More bleeding
 More pain
 Hard to repair and slow healing
 Ironing the Perenium  prevent laceration

Mechanism of Labor (ED FIRE ERE)


 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion

PELVIS
 3 Parts
o Inlet – AP diameter narrow, transverse wider
o Cavity – between inner and outer
o Outlet – AP diameter wider, transverse narrow
 LINEA TERMINALES

Nursing Care

 MODIFIED RIGEN’S MANEUVER


o Done by supporting the perenium with a towel during delivery
o Facilitates complete flexion
o Avoids laceration
 First intervention: Support the head and suction secretion
 Do not milk the cord, wait for pulsation to stop before cutting
o Milking may cause too much blood going to the baby that may cause cardiac overload
 When there is still birth, let the mother see the baby to accept the finality of death

THIRD STAGE OF LABOR (PLACENTAL STAGE)


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 3 – 10 minutes after child birth


 1st sign  Fundus rises  CALKIN’S SIGN
 Signs of Placental Separation
o Fundus becomes globular and rises  calkin’s sign
o Lengthening of the cord
o Sudden gush of blood
 BRANT – ANDREW’S MANEUVER
o slowly pulling the cord and wind at the clamp
o rapidly  may cause uterine inversion

Types Placental Delivery


 SHULTZ (Shiny)
o From center to the edges
o Presenting fetal side
 DUNCAN (Dirty)
o Form edges to center
o Presenting the maternal side

Nursing Considerations during placental delivery


 Check placental completeness
o Should be 500 g
 Check Fundus – Massage if Boggy
 BP Check
 Methergine, methylergonovine mallate (IM)
 Oxytocin (IV) if methergine is not present
 Check perenium for lacerations
 Assist in episioraphy
 Vaginoplasty/ Vaginal Landscape – Virgin again

FOURT STAGE OF LABOR (Recovery Stage)


 First 1 – 2 hours after delivery of placenta
 Maternal observation – body system stabilize
o 1st hour – q15 min 2nd hour - q 30 min
 Placement of fundus
o In between umbilicus and pubis symphysis
o Check bladder, assist in voiding, May lead to uterine atony  hemorrhage
 Lochia
 Perineum
o Check REEDA
 R edness
 E dema
 E cchymosis
 D ischarge
 A pproximation
o Fully saturated – 30 – 40 cc
o Weighing – 1 cc = 1 gram Common Board Question

Nursing Consideration during Recovery


 Flat on bed to prevent dizziness
 If with Chills  give blanket due to dehydration
 Give nourishment (progression of meal)
o Clear liquids – gatorade, ginger juice, gelatins
o Full liquid – milk, ice cream
o Soft diet
o Regular diet
 Check VS/ Pain
 Pychic State
 Bonding – interaction between mother and newborn
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o Strict – 24 hours with mother


o Partial – morning with mother, night nursery

COMPLICATIONS OF LABOR

Dystocia
 Difficult labor related to mechanical factor
 Primary cause is Uterine Inertia

Uterine Inertia
 Sluggishness of contraction
 Types
o Primary/ Hypertonic
 Intense contraction resulting to ineffective pushing
 Management : Sedation
o Secondary/ Hypotonic
 Slow, irregular contraction resulting to ineffective pushing
 Management : Oxytocin Augmentation
Prolonged Labor
 > 20 H for primi
 > 14 H for multi
 proper pushing should be encourage if inappropriate:
o may cause fetal distress
o caput succedaneum
o cephalhematoma
o maternal exhaustion
 monitor contractions and FHT

Precipitate Labor
 labor less than 3 hours
 causes excessive laceration leading to profuse bleeding  hypovolemic shock
 s/sx of hypovolemic shock HYPO TACHY TACHY
o HYPOtension
o TACHYpnea
o TACHYcardia
o Cold clammy skin
o Management
 Modified trendelenburg
 Fast Drip IV

Inversion of Uterus
 Situation in which uterus is turn inside out due to:
o Short cord
o Hurrying of placental delivery
o Ineffective fundal push
 Cause profuse bleeding  hypovolemic
 Hysterectomy

Uterine Rupture
 Rupture of uterus
 Caused by
o Previous classical CS
o Very large baby
o Improper use of oxytocin
 S/sx
o Sudden pain
o Profuse bleeding
 Prepare fore TAHBSO
Physiologic Retraction Ring  boundary between upper and lower uterine segment
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Bandl’sPathologic Ring  suprapubic depression sign of uterine rupture

Amniotic Fluid/ Placental Embolism


 Anaphylactic syndrome of pregnancy
 Situation in which placental fragment and amniotic fluid enters maternal circulation
 S/Sx
o Dyspnea
o Chest Pain
o Frothy Sputum
o End Stage – DIC
 Prepare for CPR, Suction and emergency etc

Trial Labor
 Fetal head measurement = measurement of pelvis
 6 hours labor allowance given to mother
 monitor FHT and contractions

Preterm Labor
 labor after 20 weeks and before 37 weeks
 Triad signs
o Premature conditions every 10 minuets
o Effacement of 60 – 80%
o Dilatation of 2 – 3 cm
 Home Management
o CBR
o Avoid Sex
o Empty bladder
o Drink 3 – 4 Glasses of H2O
 Full bladder inhibit contraction
 Hospital Management
o If Cervix Close (Criteria: cervix is closed if it is 2 – 3 cm dilated only)
 2 – 3 cm dilated, pregnancy can be saved
 Tocolytic Therapy
• Yutupar (Ritodine HCl)
o Side effect maternal BP < 90/60
o Check Impt. Presence of crackles
• Brethine (terbutaline) Bricanyl
o DOC
o Side effect: sustained tachycardia
o Antidote: propanolol/ inderal
• Mg SO4
o If cervix is dilated ( > 4cm)
 Give steroid dexamethasone
• Promote surfactant maturation
• Immediately cut the cord after delivery to prevent jaundice/
hyperbilirubinemia

POSTPARTAL PERIOD

Puerperium – 5th stage of labor, 1st 6 weeks post partum


Characterize by involution
Involution - return to the normal stage of reproductive organ after pregnancy

Return to Normal Healing


Physiologic Changes
Systemic Changes
Cardiovascular System
↑plasma volume
sudden ↓ in blood volume
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elevated WBC’s up to 30, 000 mm3


hyperfibrinogenemia
orthostatic hypertension can be possible
early ambulation prevents thrombos formation
steps in ambulation
Flat
Semifowlers
Fowlers with dangling
Walk with assist

Genital Tract
Fundus
goes down 1 finger breadth a day
10th day – non palpable behind the symphysis pubis
Subinvolution
delayed healing of uterus containing quarters or clots of blood
may lead to puerperal sepsis
Management : D&C
After Pains
After birth pains
Multiparous breastfeeding – most common to develop
Position = prone
Cold compress
Mefenamic acid
Lochia
Components
Blood
Deciduas
WBC
Microorg
3 types
Rubra – 1 – 3 days, musty, moderate amount
Serosa – 4 – 10th day, pink or brown
Alba – 10 – 21th day, crème white, ↓ amount

Urinary Tract
Urinary Frequency – due to urinary retention with overflow
Dysuria
Damage to trigone of the bladder
Urine collection for culture and sensitivity
Stimulate navel to urinate
Palpate bladder
Running water listening
Pull pubic hair - stimulate cremasteric reflex

Colon
Constipation
Due to NPO
Bearing down may cause pain
Perenium
Pain relieved by sim’s position
Cold compress 1st 24 hours if there is pain at episioraphy followed by warm

EMOTIONAL SUPPORT

1. Taking phase
• 1st 3 days
• dependent phase
• passive, can’t make decision
• tells about childbirth experience
• focus on: Hygiene
2. Taking Hold
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• 4 – 7th day
• dependent to independent phase
• active, decides actively
• focus: care of newborn
• health teaching : Family planning
3. Letting Go
• Interdependent phase
• Redefines goals, new roles as parents
• May extend till the child grows

Post Partum Blues


• 4th – 5th days
• overwhelming feeling of depression, inability of sleep and lack of appetite
• 50 – 80% incidence rate
• cause by sudden hormaonal change – progesterone suddenly decreases
• allow crying: therapeutic
• may lead to postpartum psychosis/ depression

Postpartal Complications

Hemorrhage
 bleeding within 24 hours postpartum

Early Pospartal Hemorrhage

1. Uterine Atony
 boggy fundus
 profuse bleeding
 interventions
o massage the uterus
o cold compress
o modified trendelenburg
o fast drip IV
o breastfeeding – to release oxytocin

2. Laceration
 well contracted uterus with profuse bleeding
 assess perenium for laceration
 degrees of laceration
o 1st degree – vaginal skin and mucus membrane
o 2nd degree – 1st degree + muscles
o 3rd degree – 2nd degree + external sphincter of rectum
o 4th degree – 3rd degree + mucus membrane of rectum

3. Hematoma
 bluish discoloration of subQ tissues of vagina or perenium
 candidates
o delivery of very large babies
o pudendal block
o excessive manipulation due to excessive IE
 intervention
o cold compress 10 – 20 min then allow 30 minutes rest period for 24 h

4. DIC – disseminated intravascular coagulation


 Consumption of pregnancy (otherterm)
 Failure to coagulate
 Bleeding in the eyes, ears, nose
 Oozing blood
 Seen in cases with
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o Abruptio placenta
o Still birth / IUFD
 Management
Blood transfusion of cryoprecipitate or fresh frozen plasma
hysterectomy

Late Postpartum Hemorrhage

Retained placental fragments


 manual extraction of fragments is done
 uterine massage
 D&C except for cases of
o Placenta Acreta – umusual attachment of the placenta to the myometrium
o Placenta Increta – deeper attachment of placemat to the myometrium
o Placenta Percreta – invasion of placenta to the perimetrium
 Candidates of these disorders are
• Grand multiparous
• Post CS
 All these requires hysterectomy

Infection
Sources
o Endogenous – from normal flora of the body
o Exogenous – from the health care team
 Most common – Anaerobic Streptococci
Management
o Supportive care
o ↑ Fluid intake
o TSB if there is fever/ cold compress + paracetamol may also be given
o Analgesics
 Given on time to achieve maximum effect
o Culture and sensitivity

Perenial Infection
Same s/ sx with infection
2 – 3 stitches are dislodges
with purulent drainage
Tx – resuturing

Endometritis
 Inflammation of the endometrium
 Gen s/sx of infection + abdominal tenderness
 Management
o High fowler’s – facilitates drainage & localize infection
o Administer oxytocin

FAMILY PLANNING METHOD

Guiding Principles
1. determine your own beliefs first
2. never advise a permanent method of family planning
3. informed concent
4. the method is an individual decision

Natural Method – accepted by the church

Billing’s/ Cervical Mucus/ Spinnbarkeit


clear watery & stretchable
13th day – longest due to estrogen
Basal Body Temp – in the morning before arising/ 13th – 14th day due to peak of progesterone
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LAM – Lactational Amenorrhea Method


 prolactin – inhibits ovulation
 breastfeeding – 4 – 6 months no menstrual cycle
 bottle fed – 2 – 3 months
Sympthothermal – combination of Billings and BBT – most effective method

Social Methods

Coitus Interuptus
withdrawal
least effective method
Coitus Reservatus
sex w/o ejaculation
Coitus interfemora
between femor
Calendar Method
14 days before menstrual cycle – ovulation day (regular)
- 4, + 4 days – unsafe period
Origoknause Formula ( irregular menstrual cycle)
get the longest and shortest cycle
subtract 18 to shortest
11 to the longest
the difference is the unsafe period

PILLS
combined oral contraceptives preventovulation by inhibiting the anterior pituitary gland roduction
of FSH and LH which are essential for he maturation and rupture of a follicle.
Estrogen inhibit FSH which is responsible in the mturation of ovum. Progesterone inhibit LH which
is responsible for ovulation.
contains estrogen that inhibits FSH and progesterone that inhibit LH
99.9% effective
21 day feel on the 5th day of mense start taking
28 day – 1st day of mense
if forgotten, take 2 tablets the following day
adverse effect : breakthrough bleeding
if mother wants to get pregnant
wait 3 monts
another 3 months if unsuucessful before consulting gyne
contraindications
chain smoking
Hypertension
DM
Extreme obesity
Thrombophlebitis
Side effects (ressembles Hypertension)/ Immediate Discontinuation
Abdominal paon
Chest pain
Headache
Eye problem
Severe leg cramp
Alerts on oral contraceptives :
In case a Mother who is taking an oral contraceptive for almost a long time and plans to
have a baby, she would wait for at least 3mos before attempting to conceive to provide
time for estrogen and progesterone levels to return to normal. If after 6months the
mother did not get pregnant, consult AMD.
If a new oral contraceptive is prescribed, the mother should continue taking the previously
prescribed contraceptive and begin taking the new one on the first day of the next
menses.
Discontinue oral contraceptive if there is signs of severe headache as this are an
indication of hypertension associated with increase incidence of CVA and
subarachnoid hemorrhage.
If forget to drink pill for 1 day, take 2 pills the next day. If forget to drink pills for 2days, stop
the pill and wait for the next mens.
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Adverse reaction : breakthrough bleeding

DMPA – Depoprovera
Contains progesterone
Depomedroxy progesterone Acetate
IM q 3 months – never massage the site  may decrease effectiveness

NORPLANT
6 match stick like capsules/ rod
contain progesterone
sub Q planted
good for 5 years

Mechanical Device
IUD
 prevent implantation
 alters mobility of sperm and ovum
 99.7% effective
 best inserted after delivery and during menstruation
 Common complication – EXCESSIVE MENSTRUAL FLOW
 Common problem – EXPULSION OF THE DEVICE
 No protection against STD
 Side effects include
o Uterine infection
o Uterine perforation
o Ectopic pregnacy
 Major indication for the use is PARITY
 HT: monthly check up and regular pap smear

CONDOM
 Made up of latex
 Put in erected penis or lubricated vagina
 Prevents sperm to enter the uterus
 FEMALE CONDOM – higher protection than that of male

DIAPRAGHM
 Dome shaped rubberied material inserted at the cervix to prevent sperm getting inside the
uterus
 Reusable
 HT : Proper hygiene
o Check for holes
o Must be refitted in case of weight gain of 15 lbs - - board question
o Kept in place for about 6-8 Hours – Board question
 Contraindicated to
o Frequent UTI

CERVICAL CAP
 More durable than the diaphram
 Could stay on place for more than 24 hours
 No need to apply spermicides
 Contraindicated to – abnormal papsmear

CHEMICAL
SPERMICIDES
 FOAMS – most effective
 Jellies
 Creams
 These may cause toxic shock syndrome
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SURGICAL METHOD
 Bilateral tubal Ligation
o @ isthmus
o 20% probability of reversal
 Vasectomy
o Vas deferens is cut
o More than 30 x or 0 sperm count or 2 x negative sperm count before it could be
consider safe sex

HIGH RISK PREGNANCY


HEMORRHAGIC DISORDERS

General management
 CBR
 Avoid sex
 Prepare ultrasound – determine the sac integrity
 Assess bleeding and approximation
 Assess hypovolemia
 Save discharge for histopathology
o Determine whether the product of labor has been expelled

First Trimester Bleeding


Abortion – termination of labor before age of viability
 SPONTANEOUS
o AKA miscarriage
o Causes
1. Chromosomal aberrations due to advanced maternal age
2. Blighted ovum
3. germ plasm defect
o Natures way of expelling defective babies
o Classifications :
1. Threatened
• pregnancy is jeopardized by bleeding and cramping but the cervix is
closed and can be saved.
2. Inevitable
• moderate bleeding, cramping, tissue protrudes from the cervix and the
cervix is open.
o Types :
1. Complete
• all products of conception are expelled.
• Mgt : emotional support
2. Incomplete
• placenta and membranes retained.
• Mgt : D&C
 HABITUAL
o 3 or more consecutive pregnancies result in abortion usually related to incompetent
cervix.
o Management (suture of cervix)
1. McDonald procedure
• Temporary circlage
• Side effect – infection
• May have NSD
2. Shirodkar
• CS delivery
 MISSED
o fetus dies; product of conception remain in uterus 4 weeks or longer
o signs of pregnancy cease
1. (-) pregnancy test
2. Dark brown
3. Scanty bleeding
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o Mgt : induction of labor/ vacuum extraction

 INDUCED
o Therapeutic abortion  principle of 2 fold effect
1. Done when mother has class 4 heart disease

Ectopic Pregnancy
• occurs when gestation is location outside the uterine cavity
• Common site : Ampulla or Tubal
• Dangerous site: Interstitial
Unruptured Ruptured
• Missed period • sudden, sharp severe unilateral
• Abdominal pain within 3- 5wks of pain, knife like
missed period (maybe generalized • shoulder pain (indicative of
of one sided) intraperitoneal bleeding that extends
• Scant, dark brown vaginal bleeding to diaphragm & phrenic nerve)
• Vague discomfort • (+) Cullen’s sign – bluish tinged
umbilicus
• syncope/fainting

• Nursing Care :
o vital signs
o administer IV fluids
o monitor for vaginal bleeding
o monitor I&O
o prepare for culdocentesis to determine
o hemoperitoneum
• Mgt : non-surgical Methotrexate

SECOND TRIMESTER BLEEDING


Hydatidiform Mole / “bunch of grapes”
Gestational Trophoblastic Disease – progressive degeneration of Chorionic Villi
gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is
formed from the swelling of the chronic villi and lost nucleus of the fertilized egg. The nucleus
of the sperm duplicates, producing a diploid number 46xx. It grows and enlarges the uterus
very rapidly.
Cause : Unknown
Assessment :
Early signs
vesicles passed thru the vagina
Hyperemesis gravidarum due to ↑ HCG
Fundal height
Vaginal bleeding (scant or profuse)
Early in pregnancy
high levels of HCG
Pre ecclampsia at about 12wks
Vesicles look like a “snowstorm” on sonogram
Anemia
Abdominal cramping
Serious late complications
Hyperthyroidism
Pulmonary embolus
Nursing care :
prepare for D&C
do not give oxytocin drugs due to proneness to embolism
Health Teaching:
return for pelvic exams as scheduled for one year to monitor HCG and assess for
enlarged uterus and rising titer could be indicative of choriocarcinoma
Avoid pregnancy for at least one year
Methotrexate therapy
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Incompetent Cervix Management:


McDonald procedure
temporary circlage of incompetent cervix.
Delivery : NSVD
SE: infection
Health teaching
observe for signs of infection
signs of labor
Shhirodkar procedure
permanent procedure.
Delivery : caesarian section required.

THIRD TRIMESTER BLEEDING “PLACENTAL ANOMALIES”

Placenta Previa
• it occurs when the placenta is improperly implanted in the lower uterine segment, sometime
covering the cervical os.
• Assessment
o Outstanding sign : frank, bright red, painless bleeding
o enlargement (usually has not occurred)
o fetal distress
o abnormal presentation
• Nursing care :
o Initial mgt : NPO candidate for CS
o Bedrest
o prepare to induce labor if cervix is ripe
o administer IV
o No IE, No Sex, No enema – complication : Sudden fetal blood loss
o prepare Mother for double set –up –DR is converted to OR

Abruptio Placenta
• it is the premature separation of the placenta from the implantation site.
• It usually occurs after the twentieth week of pregnancy
• Cause:
o Cocaine user
o Severe PIH
o Accident
• Assessment:
o Outstanding sign : dark red & painful bleeding
o concealed hemorrhage (retroplacental)
o couvelaire uterus (caused by bleeding into the myometrium) (-) contraction
o rigid boardlike abdomen
o severe abdominal pain
o dropping coagulation factor (a potential for DIC)
o sx : bleeding to any part of the body. Mgt : for hysterectomy
• General Nursing care :
o infuse IV, prepare to administer blood
• type and crossmatch
o monitor FHR
o insert Foley catheter
o measure bllod loss; count pads
o report s/s of DIC
o monitor v/s for shock
o strict I&O

Placental Succenturiata – 1 or 2 lobes connected to the placenta by a blood vessel


Placenta Bipartita – placenta divided into 2 lobes
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HYPERTENSIVE DISORDER

Pregnancy Induced Hypertension


HPN after 24wks resolved 6wks postpartum which cause pregnancy.
Types :
Gestational HPN
HPN without edema & proteinuria.
Mgt : monitor BP
Pre-eclampsia – triad
sx : HPN with edema, proteinuria or albuminuria (HEP/A) which cause is unknown or
idiopathic but multifactoral
primis d/t 1st exposure to chorionic villi
multiple pregnancies due to ↑ exposure to chorionic villi
Mothers of low socio-economic status due to ↓ protein intake
Teenagers d/t low compliance to protein intake
HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

Transitional Hypertension – HPN between 20-24wks


Chronic or Pre-existing Hypertension
o HPN before the 20th wk not resolved 6wks postpartum
o 3 types of pre-eclampsia
o Sign of pre-eclampsia :
o > 30mmHg systolic
o > 15mmHg diastolic
o Roll over test
 10-15min side lying
 Then supine
 Then take BP
o mild pre-ecclampsia
 140/90mmHg, w/ +1 O2, +2 proteinuria Early signs : ↑ wt, inability to wear
wedding ring due to developing edema
 Signs present
• cerebral & visual disturbances, epigastric pain to liver edema and
oliguria usually indicates an impending convulsion
• Before convulsion : if you see sign of epigastric pain, 1º mgt is to place
tongue depressor and put the side rales up
• During convulsion : observe the Mother for safety
• After convulsion – turn to side to facilitate drainage
o Severe pre-ecclampsia
 160/110, +3 or +4, proteinuria, visual disturbances
 Nursing care
 P – promote bedrest
 Prevent convulsions by nursing measures
• to ↑ O2 demand & facilitate Na excretion
• Management: quiet & calm environment, minimal handling, avoid
moving the bed
• Heat Acetic Acid – determine protein in the urine
• Prepare the following at bedside
o tongue depressor, Suction machine & O2 tank
 E – ensure high protein intake (1g/kg/day)
• Na in moderation
 A – antihypertensive drug with hydraluzine
 C – CNS depressant with Mg Sulfate for anti-convulsion
• Mgt : evaluate for hypermagnesiumenimia
 E – evaluate physical parameters for Magnesium Sulfate toxicity :
• B – BP ↓
• U – Urine output ↓
• R – RR ↓
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•P – Patellar reflex is absent


• Antidote : Ca gluconate
o Eclampsia – with seizure
 ↑ BUN – sign of glumerular damage

Diabetes Mellitus
cause by absent & lack of Insulin
Action of Insulin is to facilitate transfer of glucose into the cell
Dx test : 50gm 1hr Glucose Tolerance Test
↑ 130 – hyperglycemia
↓ 70 – hypoglycemia
80-120 – euglycemia
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if > 130mg/dl, the Mother needs to undergo a 3hr GTT


Maternal Effects :
hypoglycemia during the 1st trimester development of the brain sinisipsip ng fetus yung
glucose ng nanay.
Hyperglycemia during the 2nd & 3rd trimester
HPL effect Mgt : give insulin. OHA are teratogenic.
1st trimester - ↓ insulin, 2nd trimester - ↑ insulin, post partum – drop suddenly
Frequent infections eg. Moniliasis
Polyhydramnios
Dystocia
Fetal Effects :
hypoglycemia during the 1st trimester and Hyperglycemia during the 2nd & 3rd trimester
thru facilitated diffusion
Macrosomia/LGA .4000gms
IUGR due to prolonged DM
Preterm birth promote still birth
Newborn Effects :
Hyperinsulinism and Hypoglycemia
40mg/dl
Normal : 45-55mg/dl
Borderline : 40mg/dl
Sx : ↑ pitched shrill cry, tremors, jitteriness
Dx test : heel stick test to check glucose levels
Hypocalcemia
< 7mg/dl
Calcemic tetany
Tx : Ca gluconate

Heart Disease
o Classification :
o I – no limitation
o II – Slight limitation, ordinary activity causes fatigue
 good prognosis can deliver vaginally
 Mgt : sleep of 10hrs/day, rest 30mins after meals
o III – moderate limitation, less than ordinary activity causes discomfort
 poor prognosis. Good for vaginal delivery
 Mgt : early hospitalization by 7-8mos
o IV – marked limitation of physical activity for even at rest there is fatigue
 poor prognosis. Good for vaginal delivery only with regional anesthesia.
 Low forceps delivery when unable to push & to shorten the stage of labor
 Mgt :
• therapeutic abortion, high semi- fowlers position, left side lying, no
valsalva maneuver - may trigger cardiac arrest, heparin therapy
required, antibiotic therapy for prevention of sub acute bacterial
endocarditis

INTRAPARTAL COMPLICATIONS

Cesarean Delivery
Indications
a. multiple gestation
b. diabetes
c. active herpes II
d. severe toxemia
e. placental previa
f. abruption placenta
g. prolapse of the cord
h. cephalo pelvic disproportion and primary indication
i. breech presentation
j. transverse lie
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procedure :
classical – vertical incision
low segment – “bikini”, for aesthetic purposes. Can have vaginal birth after c/s

Genotype – genetic make-up


Phenotype – Physical appearance
Karyotype – pictorial analysis of individual chromosome for detecting chromosomal abnormalities
Autosomal Dominant
huntington’s chorea
retinoblastoma
achondroplasia
polydactyl
Autosomal Recessive
sickle cell
Cystic fibrosis
Celiac
PKU
Galactosemia
X- Linked Recessive
• Hemophilia
• Duchenne’s muscular dystrophy
• Color blindness
X – Linked Dominant
• Rickette’s