

MATERNAL HEALTH NURSING -EXAM

STUDY NOTES
 December 27, 2017
 SHINCY MANU
 4
 Blog, NCLEX STUDY
 a quick study to maternal health nursing, abruptio placents, DHA STUDY MATERIAL, fetal
development, haad study material, maternal health nursing study materials, mechanism of
labor, nursing examination study related to maternal health nursing, obstetric and gynecology
lecture notes, placenta previae, pregnancy complications, stages of labor

MATERNAL AND CHILD HEALTH:

 Gametogenesis : Process in which germ cells are produced (ovum and sperm).
 Meiosis : Cell division 46=23. XX (FEMALE)-XY(MALE)
 Menstrual cycle of 28 days, ovulation is at 14th
 Menstrual cycle of 34days, ovulation is at 20th day.
 Conception occurs outer one third of fallopian tube.
 Zygote –fertilized ovum
 Zygote changes through a process = cleavage-morula-blastomere-blastocyst.
 Pre embryo-first 2 week
 Embryo-3 week to 8 week
 Fetus –until birth.
 Embryonic membranes –amnion and chorion formed at time of implantation.
 Amniotic fluid volume -500 to 1000ml after 20 weeks of gestation . it is alkaline. It is constantly
replaced.
 Fetus swallow 400-500ml of amniotic fluid per day.
 Amniotic fluid contains albumin, bilirubin ,creatinine, fat enzymes,sphingomycin, epithelial cells
, lecithin.
  Couvades: Father may suffer physiological symptoms with mother like nausea, vomiting and
fatigue.
 Nulligravida : A women who has never been pregnant.
 Primigravida – pregnancy for first time
 Multigravida- In at least her 2ndpregnancy
 Parity : number of births past 20 weeks gestation.
 Obstertrical history –GTPAL method

G-Gravida
T-Term birth (38-42weeks)
P- Preterm birth
A-Abortion
L-Living children.

FETAL DEVELOPMENT:
WEEKS CHANGES

1st week Free floaty blastocyst

Ø 2mm crown to rump

2-3 week Ø Groove is formed

Ø Beginning of blood circulation
,tubular heart
Ø 4-6mm
Ø 0.4g.
4 week
Ø Noticeable limb buds
Ø Tubular heart is beating
Ø 3cm
Ø 2gm
Ø Clearly resembles a human
being
8 week
Ø Eyelids begins to fuse
Ø Circulatory system through
umbilical cord is well established

Ø 8cm(3.2inch)
12 week
Ø 45g
 Ø Face well formed
Ø Limbs long and slender
Ø Kidneys begins to form urine
Ø 14cm
Ø 200g
Ø Active movements present

16week Ø Fetal skin appears transparent

Ø Skeletal ossification
Ø Lanugo hair develops
Ø Sex of fetus can be determined
visually.
Ø 19cm
Ø 465g
Ø Lanugo covers entire body
Ø Skin less transparent
20 week
Ø Has nails on fingers, toes
Ø muscles well developed
Ø Heart beat can be detected by
fetoscope
Ø Women can feel baby more.
Ø 28cm
Ø 780 gm
Ø Hair on head well formed
24week Ø Skin covering body is reddish
and wrinkled
Ø Reflex hand grasp
Ø Vernix caseosa covers entire
body
Ø 30cm
Ø 1200g
28 week Ø Limbs well flexed
Ø Brain develops rapidly
Ø Eyelids open and close
 Ø Lungs still, Physiologically
immature
Ø Eyes reopen
Ø 38cm
Ø 2000g
Ø Bones are fully developed, but
32 week are soft and flexible.
Ø Lungs are not fully mature
Ø Fetud begins storing iron ,
calcium and phosphorous.
Ø 42-48cm
Ø 2500g
Ø Body and extremities are filling
out
36 week
Ø Fetus looks less wrinkled
Ø Nails reach end of finger tips
Ø Vernix continues to cover most
of body.
Ø 48-52cm
Ø 3000-3600g
Ø Skin is pinkish and smooth
Ø Lanugo presentation on upper
40 week
arms and shoulders
Ø Vernix caseosa increases and
folds of skin
Ø Finger nails extends beyond
finger tips.
Placental development:
 Begins at 3 week
 Fully formed and functioning at 3 months of gestation
 40 weeks-placenta have 15-20 cotyledons.
 It has 2 surfaces-maternal and fetal surfaces.
 Placenta produce 4 hormones
 1. Progesterone – decreases uterine contractility
2. Estrogen or estriol- stimulate uterine contraction
3. Human placental lactogen (HPL)
4. Human chorionic gonadotrophin(HCG)

Umbilical cord:

 2 artery and one vein

 It contains wharton’s jelly
 50-55cm length
 Umbilical cord attaches to center of fetal side of placenta.

Note : Battledone insertion: umbilical cord attaches to edge of placenta.

Fetal circulation:

1. Umbilical vein- carry oxygen and nutrients to fetus

2. Umbilical arteries-carry deoxygenated blood and waste products from fetus
3. Ductus venosus- shunts umbilical vein to the inferior venacava , by passing liver and organs of
digestion.
4. Foramen ovale-shunts blood from right atria to left atria , by passing ventricles and lungs.
5. Ductus arteriosus-shunts blood from pulmonary artery to aorta, by passing lung
Pregnancy :
Fundal height :

 During the second and third trimesters (weeks 18 to 30), fundal height in centimeters
approximately equals the fetus’ age in weeks ± 2 cm.
 At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus.
 At 20 to 22 weeks, the fundus is at the umbilicus, and at 36 weeks the fundus is at the xiphoid
process.
Pregnancy signs and symptoms:

1. Subjective /presumptive signs:

 Amenorrhea
 Nausea and vomiting
 Urinary frequency
 Breast tenderness

2. Objective /probable signs:

 Uterine enlargement
 hegar’s sign (softening and thinning of the lower uterine segment that occurs at about week 6
 goodell’s sign (softening of the cervix that occurs due to increased vasularization at the
beginning of the second month). This softening also causes easy flexion of uterus against
cervix(Mc Donald’s sign).
 chadwick’s sign (bluish or purple coloration of the mucous membranes of the cervix, vagina,
and vulva due to increased vasularization, that occurs at about week 6)
 ballottement (rebounding of the fetus against the examiner’s fingers on palpation)
  braxton hicks contractions( irregular contractions)
 positive pregnancy test for the presence of human chorionic gonadotropin (hcg).
 Pigmentation of skin
 Abdominal stria etc
 Linea nigra: dark line pigmentation from umbilicus to pubis.
 Chloasma : mask of pregnancy , pigmentation over forhead , cheek and nose.
 Montgomerys tubercle : over the areola of breast ,darkening of the areolas, the skin around the
nipples. The bumps on areolas (called Montgomery’s tubercles) may look more prominent.
 Striae –reddish ,purple stretch mark around abdomen called gravidarum, whitish stretch mark
called albicans.
 Recommended weight gain during pregnancy =25-35Ib(pound) .(1Ib=0.453592kg)

Tests during pregnancy:

Non stress test(NST):

 It is done last 8 week of pregnancy

 A reactive non stress test is a normal result.
 To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160
beats/min) with good long-term variability.
 In addition, two or more fetal heart rate accelerations of at least 15 beats/min must occur, each
with a duration of at least 15 seconds, in a 20-minute interval.
 Non reactive test: accelerations are not present.

Contraction stress test:

 Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or
equivocal.
 A negative test result indicates that no late decelerations occurred in the fetal heart rate,
although the fetus was stressed by three contractions of at least 40 seconds’ duration in a 10-
minute period.

Doppler blood flow (umbilical velocimetry):

 To interpret the wave forms

 (S)-Systolic peak
 D-End diastolic
 Normal systolic to diastolic ratio (S/D)=2.8 at 20 week and 2.2 at term.
 If ration is above 3.0 , it is abnormal , due to decreased uteroplacental perfusion).

Bio physical profile:

5 variables:

1. Fetal breathing movement

2. Fetal body movement or limbs
3. Amniotic fluid volume
4. Reactive FHR
Each variable score 0,1,2 .
Maximum score is 10.
Oxytocin challenge test (OCT): Contraction pattern of 3 contractions with duration of at least 40
seconds in 10 minutes.

Premonitory signs of labor:

 Lightening occurs as fetus settles or descends into pelvic inlet.
 Braxton Hicks contractions increased in frequency and may become uncomfortable.
 Softening of cervix (ripening).
 Bloody show-pink tinged mucus
 Rupture of amniotic membranes
 Experience sudden burst of energy
 Some women experience diarrhea.

‘Kick’ counts measurement:

 The client should sit or lie quietly on her side to perform kick counts.
 Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and
presents a risk of vena cava (hypotensive) syndrome.
 The client is instructed to place her hands on the largest part of the abdomen and concentrate
on the fetal movements.
 The client records the number of movements felt during a specified time period.
 The client needs to notify the physician or nurse-midwife if there are fewer than 10 kicks in a 12-
hour period or as instructed by the physician or nurse-midwife.

Fetal heart rate monitoring by Doppler:

 The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the
fetal heart rate (FHR) to differentiate the two.
 If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate
for the FHR.
 Noting whether the heart rate is more than 140 beats/min or placing the diaphragm of the
Doppler on the mother’s abdomen will not ensure accuracy in obtaining the FHR.
 Leopold’s maneuver may help the examiner locate the position of the fetus but will not ensure a
distinction between the two heart rates.

Issues in pregnancy :

1. Pica :Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin level

2. Heart burn management:

 Lying down is likely to lead to reflux of stomach contents, especially immediately following a
meal.
 The client should be instructed to avoid spices, along with salt, because spices will trigger
heartburn. Salt will produce edema.
 The client should be encouraged to eat between-meal snacks and should be instructed that to
control heartburn, eating smaller, more frequent portions is preferred over eating three large
meals.
 The client also should limit or avoid gas-producing and fatty foods.

3. Varicose veins:

 Elevate legs frequently during day

 Wear supportive hose
 Avoid crossing legs while sitting.
 Varicose veins often develop in the lower extremities during pregnancy.
 Any constricting clothing such as knee-high hose impede venous return from the lower legs and
thus place the client at higher risk for developing varicosities.
 Clients should be encouraged to wear panty hose or support hose.
 Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain
proper posture and balance and minimize the risk for falls.
 Pants with an elastic waistband are comfortable and are not constricting.
 4. Hemorrhoids:

 Increase exercise
 Maintain fluid intake at 2-3 litre per day
 Increase fiber in diet.

Hemorrhoids management:

 Avoiding constipation and straining during bowel movements;

 Applying ice packs to reduce the hemorrhoidal swelling;
 Gently replacing the hemorrhoids into the rectum;
 Using stool softeners, ointments, or sprays as prescribed;
 and assuming certain positions to relieve pressure on the hemorrhoids
5. Leg cramps:

 Do not use milk as only source of calcium

 Release cramp by dorsi flexion.
 6. Back ache:

 Some measures that will assist in relieving a backache include maintaining good posture and
body mechanics, resting and avoiding fatigue, wearing flat-heeled shoes, and sleeping on a firm
mattress.
 The back discomfort that occurs in a pregnant client is often caused by the exaggerated lumbar
and cervicothoracic curves resulting from a change in the center of gravity because of the
enlarged uterus.
 Performing more exercises to strengthen the back muscles could be harmful to a pregnant
client.

Danger signs of pregnancy:

1. PROM –Premature rupture of membrane: Sudden gush of clear fluid from vagina. Vaginal
examinations should not be done routinely on a client with premature rupture of the
membranes because of the risk of infection.
2. Abruption placenta and placenta previae-bleeding from vagina and cervical lesions
3. Hyperemesis gravidarum -persistent vomiting.
4. Pre eclampsia-severe headache, blurring of vision or spots before eyes , hypertension.
5. Premature labor-abdominal pain
6. Infection –oral temperature greater than 101 degree F or 38.3 degree C.
7. Pregnancy induced hypertension-swelling of lower legs, hands and face.
8. Fetal death-absence of fetal movement

Notes :
  Fundus reaches level of umbilicus at 20th week
 Quickening -18 to 20 week in primipara and 16 th week in multipara
 FHR ia audible through fetoscope at 18-20th

Nagele’s (Expected date of confinement):

 Substract 3 months from 1st day of LMP and add 7 days and change year.
 Eg: LMP=JUNE -10-2015
 EDD= JUNE 10-3 MONTHS+7 DAYS
 MARCH 10 +7 DAYS
 MARCH 17 &change year
 EDD=March 17 2016.

Nutritional requirement in pregnancy:

 Calorie increase=300cal/day
 Protein increase =60g/day
 Calcium increase =1200mg
 Iron =18mg+
 Folic acid =400mg

DIABETES IN PREGNANCY:
s/s:

 Hyperemesis
 Glycosurea
 Ketonuria
 Increase RBS, Increase GTT
 Polydypsia, polyphagia,polyuria
 Rapid weight gain
 Previous large babies weighly 4000g or more.

Treatment :

 Regular insulin
 Avoid oral hypoglycemic. They cross placenta and are teratogenic
 Calorie 2200-2400kcal/day
 CHO-45% of calorie
 Protein -20%
 Fat -35%

Complications :

 Hydramnios
 Pre eclampsia
 Eclampsia
 Still birth
  Neonatal respiratory distress syndrome
 Hyper bilirubinemia
 Hypoglycemia
 Congenital anomalies
 PPH
 infection

Dietary modifications:

 The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal
and metabolic requirements, with consideration of such factors as prepregnancy weight and
dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of
nutrition, and insulin therapy.
 Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes
and energy needs.
 In the third trimester, insulin needs increase.
 Dietary management during diabetic pregnancy must be based on blood, not urine, glucose
changes.
 Insulin needs decrease in the first trimester because of increased insulin production by the
pancreas and increased peripheral sensitivity to insulin.

PREGNANCY INDUCED HYPERTENSION(PIH):

s/s:

 Edema, hypertension,proteinuria, convulsion and coma

 Eclampsia –at point of convulsions.

Treatment :

 Antihypertensives –aldomet,apresoline
 Sedatives-phenobarbital (Avoid valium as it is associated with increased risk of aspiration if
seizures occurs.
 Prevent convulsions:
 Administer magnesium sulphate(loading dose 4-6g and maintain at 1-2g/hr).
 Obtain magnesium sulphate blood levels every 4 hours
 If magnesium sulphate overdose ,administer calcium gluconate
 Continue magnesium sulphate for 24 hours after birth.

CARDIAC DISEASES IN PREGNANCY:

Assess for :

 Pedal edema, progressive generalized edema

 Exertional dyspnea
 Basilar rales
 Moist cough
 Tachy cardia,irregular pulse
 Increase fatigue
  Cyanosis of lips and nail beds
 Heart murmers
 Severe fungal infections.

Dietary modification:

 Constipation can cause the client to use Valsalva’s maneuver. This maneuver can cause blood to
rush to the heart and overload the cardiac system. Therefore, high-fiber foods are important.
 A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus.
 Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of
nutrients, so adequate fluid intake and high-fiber foods are important.
 Sodium should be restricted somewhat, as prescribed by the physician, because excess sodium
will cause an overload to the circulating blood volume and contribute to cardiac complications.

AIDS in pregnancy:-treatment of AIDS-zidovudin

HYPERTENSION IN PREGNANCY:

 TREATMENT –Methyl dopa(aldomet)

 Avoid diuretics

Dietary modification:

 No added salt diet

 High protein
 Maintain fluid intake .

Pre eclampsia in pregnancy:

 Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the
widespread damage to vascular integrity.
 Bleeding is an early sign of DIC and should be reported to the health care provider if noted on
assessment

DIC(Disseminated Intravascular coagulation):

 Dead fetus syndrome is considered a risk factor for DIC.
 Severe preeclampsia is considered a risk factor for DIC; a mild case is not.
 Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting
factors are consumed, leading to widespread bleeding.
 Platelets are decreased because they are consumed by the process, coagulation studies show no
clot formation (and are thus normal to prolonged), and fibrin plugs may clog the
microvasculature diffusely, rather than in an isolated area.
 The presence of petechiae, oozing from injection sites, and hematuria are signs associated with
DIC.
CESEAREAN DELIVERY:

 Indications : breech presentation, pre term, fetal distress, dysfunctional labor, CPD, prolapsed
cord, abruption placenta, placenta previa, active herpes, transverse lie, previous LSCS.
 Complication: maternal infection, hemorrhage, blood clots, injury to bladder, preterm birth,
TTN(Transient Tachypnea of the Newborn).
 Abdominal exercises should not start immediately following abdominal surgery, and the client
should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision.

Oxytocin use in labor:

 A normal fetal heart rate is 120 to 160 beats/min. Bradycardia or late or variable decelerations
indicate fetal distress and the need to discontinue the oxytocin.
 The goal of labor augmentation is to achieve three good-quality contractions (appropriate
intensity and duration) in a 10-minute period.
 The uterus should return to resting tone between contractions, and there should be no evidence
of fetal distress.
Contraction monitoring by external monitor:’
 Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood
flow between the placenta and the fetus.
 Early decelerations result from pressure on the fetal head during a contraction.
 Late decelerations are an ominous pattern in labor because they suggest uteroplacental
insufficiency during a contraction.
  Short-term variability refers to the beat-to-beat range in the fetal heart rate.

Use of magnesium sulfate to stop preterm labor:

 Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience
adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe
hypotension, and absent deep tendon reflexes (DTRs).
Placenta previae:
  The placenta is implanted in the lower uterine segment, which does not contain the same
intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
 Placenta implanted near or over the maternal cervical Os.
 Complete or central
 Incomplete or partial
 Marginal or low implantation
 Signs and symptoms:
 Painless unexplained uterine bleeding after 20th week, each succeeding vaginal bleed greater
than previous.
 Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of
placenta previa.
 The client will have a soft, relaxed, nontender uterus, and the fundal height may be more than
expected for gestational age.

Management:

 Don’t perform vaginal examination or rectal examination or enemas.

 Do sonogram
 Double set up vaginal examination in OT
 Cesarean section
 Arrange for blood transfusion
 Count perineal pad (1gm weight=1ml)
 Administer IVF.

Abruptio placentae
 Abruptio placentae is associated with conditions characterized by poor uteroplacental
circulation, such as hypertension, smoking, and alcohol or cocaine abuse.
 The condition also is associated with physical and mechanical factors, such as overdistention of
the uterus, which occurs with multiple gestation or polyhydramnios.
 In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are
risk factors.
 In abruptio placentae, severe abdominal pain is present.
 Uterine tenderness accompanies placental abruption, especially with a central abruption and
trapped blood behind the placenta.
 The abdomen will feel hard and board-like on palpation as the blood penetrates the
myometrium and causes uterine irritability.
 Observation of the fetal monitor often reveals increased uterine resting tone, caused by failure
of the uterus to relax in an attempt to constrict blood vessels and control bleeding.
UTERINE RUPTURE:

 Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and
shoulder dystocia can place a client at risk for traumatic uterine rupture.

Schultz presentation : Schultz presentation is the expulsion of the placenta with the fetal side
presenting first .
fetal or maternal compromise: Signs of a fetal or maternal compromise include a persistent,
nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium
LABOUR MANAGEMENT:

 Length -6-18 hrs in primi

 3-10hrs in multi

4 stages:
First stage:
3 phases:

1. Latent phase:

 True labor until 4cm cervical dilation.

 Contraction range from every 15-30minutes and last 15-30seconds.

2. Active phase

 4-7cm
 Contractions are every 3-5minute and last about 60seconds

3. Transition phase.
  8-10cm dilatation
 Contractions every 2-3minute and last 45-90 seconds.

Second stage:

 Begins with complete cervix dilation and end with birth of baby.
 Length: 0.5-2hours in primi and 10-60minutes in multigravida.

Third stage :

 Begins with birth of baby and ends with birth of placenta.

 Length 5-30minutes.

Fourth stage:

 Begins from birth of placenta and ends 1-4hours after birth.

Mechanism of labor:

1. Engagement : point when bi parietal diameter of fetal head passes pelvic inlet.
2. Descent : down ward movement of fetal head into birth canal.
3. Flexion: flexion of fetal chin down onto fetal chest.
4. Internal rotation : rotation of fetal head to pass through ischial spines.
5. Extension : as fetal head passess under symphysis pubis ,fetal head extends.
6. External rotation: Rotation of fetal head to allow shoulders to pass through ischial spines.

 Effacement : Shortening,thinning of cervix (0% to 100%).

 Dilation : Opening of cervix(0-10cm)
 Lightening : Settling of fetal presenting part into pelvic inlet.

Station : Relationship of fetal presenting part to level of ischial spines.

 Above spines:-3,-2,-1
  At spines: 0
 Below spines: +1,+2,+3.
 On perineum :+4.

Fetal presentation:

 Cephalic : Any part of fetal head.

 Occiput, vertex
 Brow
 Face (mentrum or chin).
 Breech :
 Buttocks and or feet (sacrum)
 Complete –buttocks and feet present
 Footling –one or both feet present.
 Frank-buttocks only present.
 Position : Relationship of fetal presenting part to maternal pelvis.
 LOA,ROA,LSPetc.
 Show : Vaginal discharge of mucus,fluid and increasing amount of blood.
 Membranes : SROM(spontaneous rupture of membrane), AROM(Artificial rupture of
membrane).
 Contractions : Tightening of uterine muscle during labor process.
Laboratory values changes in labor :

 WBC reaches 25,000/mm3 in labor

 Increase in plasma fibrinogen and decrease in blood coagulation time.

Anesthesia in labor:
1. Epidural block:

 Cause hypotension
 Relieves pain from contraction and numbs vagina and perineum
 Assess BP, maintain side lying position
 Administer IV fluids
 Provide support during block.

2. Spinal anesthesia:
  Place rolled blanket under right hip to displace uterus from venecava
 IV fluid
 Relieves pain from contractions , numbs vagina, perineum and lower extremities.
 Cause hypotension and post partum headache.

3. Pudendal block:

 Relieves perineal discomfort and numbs area for episiotomy

4. Local anesthesia:

 Numbs perineum for episiotomy and repair.

INDUCTION OF LABOR: By IV oxytocin.

Disadvantages:

 Hypertonic labor
 Fetal distress
 Alteration in BP
 Rupture of uterus.

Indication for induction of labour are following:

 Post maturity
 PROM
 PIH
 DM
 Fetal demise

Contra indications:

 Grand multiparity
 Placental abnormalities
 Previous uterine surgeries
 Fetal distress
 Pre term fetus
 Positive CST
 Abnormal fetal presentation. Presenting part above inlet
 CPD etc.

Nursing management;

 Trace uterine contractions and FHR atleast 20 minutes

 Discontinue oxytocin if frequency is less than 2 minutes or duration is more than 90 seconds or
fetal distress noted.

Post episiotomy assessment:

REEDA:
R-E-E-D-A
Redness-Edema-Echymosis-Drainage-Approximation of skin edges.
NEW BORN:

 Caput succeedaenum: Localized swelling over the presenting part. It does cross suture lines.
 Cephalohematoma : It is a collection of blood between skull bone and periosteum. It does not
cross suture lines.
 Posterior fontanelle: Triangle shape , non pulsating , 1-2 cm , closes 8-12 weeks.
 Anterior fontanelle: Open ,soft, pulsating , diamond shape, 2-4cm long, 2-3cm wide, closes at 18
month. Depression od fontanelle indicate dehydration and bulging indicate increased ICP.
 Permanent eye color establish in new born at 3-12 months.
 Polydactyl –more than 5 digits on an extremity
 Syndactyly-fusing of 2 or more digits
 Acrocyanosis –cyanosis of hands and feet that occurs just after birth.
 Milia –clogged sebaceous glands over nose.
 Vernix caseosa- white cheese like substance present in skin creases.
 Lanugo –fine downy hair
 Telangiectatic nevi- flat , reddish marks, may be present on eye lids , between eyes and on nape
of neck.
 Erythema neonatrum toxicum-maculo popular rash may be present over body
 New born Hb level=15-20gm/dl.
Abortion:

 Spontaneous termination of pregnancy before 20th week of gestation

 Spontaneous abortion –occurs naturally during 2nd or 3rd
 Habitual –spontaneous loss of 3 or more pregnancies
 Complete –all related tissues and fetus are expelled
 Incomplete –some but not all of the parts of conception are expelled.
 Threatened –bleeding or cramping , but no cervical dilation or ROM, possible loss of the
pregnancy.
 Missed –fetus dies, but the products of conception are refained in uterus (increases risk of
DIC(Disseminated Intravascular coagulation)
 Inevitable –bleeding and cramping with cervical dilation .loss of pregnancy.
Threatened abortion management:

 The client is advised to curtail sexual activities until bleeding has ceased, and for 2 weeks
following the last evidence of bleeding or as recommended by the physician or other health care
provider
 The client is instructed to count the number of perineal pads used daily and to note the quantity
and color of blood on the pad.
 The client also should watch for the evidence of the passage of tissue.
 Strict bed rest throughout the remainder of the pregnancy is not required

HYDATIDIFORM MOLE:
Developmental anomaly of placenta that result in changing chorionic villi into a mass of clear
vesicles. Edematous grape like cluster may be benign or may develop into a
choriocarcinoma(cancer).
Signs and symptoms:

 Bright red or dark brown vaginal bleeding (12th week)

 Hyper emesis
 Fundal height is greater than expected for date
 Increase HCG levels
 In ultrasound –snow storm appearance
 No FHR
 s/s of PIH, before 20 th week (increase in BP, edema, proteinurea)
management :

 uterine evacuation
 induced abortion

ECTOPIC PREGNANCY:
It results from implantation of fertilized ovum outside the uterus , generally in the fallopian tube.
s/s:

 sharp, localized pain in lower abdomen,caused by expansion and possible rupture of the tube
 syncope, shoulder pain
 irregular vaginal bleeding
 abdominal rigidity and distension
 shock (increase heart rate and decrease in BP)
 palpable mass in cul-de –sac
 decrease HCG level.

Management :
  pain relief
 manage shock: administer oxygen, IVF, do cross matching for BT if ordered.
 Laparotomy

SUPINE HYPO TENSION IN PREGNANCY:

Symptoms:

 Decreased blood pressure, dizziness, pallor, cool clammy skin.

Cause :

 When a pregnant mother lies on her back ,occlusion of venecava by heavy uterus.

Management :’

 Turning mother to left side ,starting oxygen 7-10L/mt.

INCOMPETENT CERVIX:

 It is the premature dilation of cervix.

 Treated with shirodkar –Barter or Mc Donald procedure.
 Occurs due to cervical trauma.

s/s :

 Vaginal bleeding 18-28week

 Painless,spontaneous,3rd trimester abortion or premature labor
  Fetal membranes visible through cervix.

HYPEREMESIS :
It is pernicious vomiting in pregnancy.
s/s:

 Intractable vomiting at any time.

 Weight loss of 25% or more
 Ketosis ,ketonuria
 Dehydration –poor skin turgor, dry tongue.
 Epigastric pain
 Drowsiness and confusion
 Unco-ordinated movements, jerking
 Jaundice, coma.

HYDRAMNIOS :
-excess amniotic fluid greater than 2000ml
Predisposing factors:
-DM, PIH,ABO,Rh Incompatibility
-multiple pregnancy
PREMATURE LABOR:
20-37WEEKS
Treatment :

 Left lateral position

 IVF

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