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Maternal and Child Health Nursing Reviewer Complete PDF
Maternal and Child Health Nursing Reviewer Complete PDF
A. Mons pubis or mons veneris – pad of fat which lies over the symphysis pubis
covered by skin and at puberty by short hairs; protects the surrounding delicate
tissues from trauma.
B. Labia majora – two folds of skin with fat underneath; contain Bartholin’s glands
which are believed to secrete a yellowish mucus which acts as a lubricant during
sexual intercourse. The openings of the Bartholin;s glands are located posteriorly
on either side of the vaginal orifice.
C. Labia minora – two thin folds of delicate tissues; form an upper fold encircling the
clitoris )called the prepuce) and unite posteriorly (called the fourchette) which is
highly sensitive to manipulation and trauma that is why it is often torn during a
woman’s delivery.
D. Glans clitoris - small erectile structure at the anterior junction of the labia minora,
which is comparable to the penis in its being extremely sensitive.
E. Vestibule – narrow speace seen when the labia minora are separated.
F. Urethral meatus – external opening of the urethra: slightly behind and to the side
are the openings of the Skene’s glands (which are often involved in infections of
the external genitalia).
G. Vaginal orifice or Introitus – external opening of the vagina covered by a thin
membrance (called hymen) in virgins.
H. Perinuem – area from the lower border of the vaginal orifice to the anus; contains
the muscles (e.g., pubococcoygeal and levator ani muscles) which support the
pelvic organs, the arteries that supply blood to the external genitalia and the
pudendal nerves which are important during delivery under anesthesia.
C. Fallopian Tubes – 4 inches long from each side of the fundus; widest part (called
ampulla) spreadsinto fingerlike projections (called fimbriae). Responsible for
transport of mature ovum from ovary to uterus; fertilization takes place in its outer
third or outer half.
D. Ovaries – almond-shaped, dull white sex glands near the fimbriae, kept in plact by
ligaments. Produce, mature and expel ova and manufacture estrogen and
progesterone.
III. THE PELVIS (Figure 3) – although not a part of the female reproductive system but of
the skeletal system, it is a very important body part of pregnant women.
A. Structure
1. Two os coxae/innominate bones – made up of:
1.1 Ilium – upper extended part; curved upper border is the iliac crest.
1.2 Ischium – under part; when sitting, the body rests on the ischial
tuberosities; ischial spines are important landmarks.
1.3 Pubes – front part; join to form an articulation of the pelvis called
the symphysis pubis.
2. Sacrum – wedge-shaped, forms the back part of the pelvis. Consists of
5 fused vertebrae, the first having a prominent upper margin called the
sacral promontory.
3. Coccyx – lowest part of the spine; degree of movement between sacrum
and coccyx made possible by the third articulation of the pelvis called
sacroccygeal joint which allows room for delivery of the fetal head.
B. Divisions – set apart by the linea terminalis, an imaginary line from the sacral
promontory to the ilia on both sides to the superior portion of the symphysis pubis.
1. False pelvis – superior half formed by the ilia. Offers landmarks for
pelvic measurements; supports the growing uterus during pregnancy;
and directs the fetus into the true pelvis near the end of gestation.
2. True pelvis – inferior half formed by the pubes in front, the iliac and the
ischia on the sides and the sacrum and coccyx behind. Made up of three
parts:
2.1 Inlet – entranceway to the true pelvis. Its transverse diameter is
wider than its anterosposteior diameter. Thus:
2.1.1 Transverse diameter = 13.5 cm.
2.1.2 Anteroposterior diameter (AP) = 11 cm.
2.1.3 Right and left oblique diameter = 12.75 cm.
2.2 Cavity – space between the inlet and the outlet. Contains the
bladder and the rectum, with the uterus between them in an
anteflexed position towards the bladder.
2.3 Outlet – inferior portion of the pelvis, bounded on the back by the
coccyx, on the sides by the ischial tuberosities and in front by the
inferior aspect of the symphysis pubis and the pubic arch. Its AP
diameter is wider than its transverse diameter.
C. Types/Variations
1. Gynecoid – “normal” female pelvis. Inlet is well rounded forward and
back. Most ideal for childbirth.
2. Anthropoid – transverse diameter is narrow, AP diameter is lager than
normal.
3. Platypelloid – inlet is oval, AP diameter is shallow
4. Android – “male” pelvis. Intel has a narrow, shallow posterior portion
and pointed anterior portion.
D. Measurements
1. External – suggestive only of pelvic size:
1.1 Intercristal diameter – distance between the middle points of the
iliac crests.
Average = 28 cm.
1.2 Interspinous diameter – distance between the anterosuperior iliac
spines.
Average = 25 cm.
1.3 Intertrochanteric diameter – distance between the trochanters of the
femur.
Average = 31 cm.
1.4 External conjugate/Baudelocque’s diameter – distance between the
anterior aspect of the symphysis pubis and depression below L5.
Average = 18-20 cm.
HUMAN SEXUALITY
I. DEFINITION OF TERMS
A. Puberty – encompasses the physiologic changes leading to the development
of adult reproductive capacity; the process includes maturation of the
hypothalamus, pituitary gland and gonads. The role of the anterior pituitary
gland. The pituitary secretion of gonadotropin initiates growth and
maturation. It occurs initially during sleep and later in puberty throughout
wakefulness.
B. Adolescence – encompasses the physiologic, social, and
cognitive changes leading to the development of adult identity. The process
includes individual, achievement of personal independence and maturation of
cognitive reasoning skills.
C. Thelarche – budding of the breasts
D. Adrenarche – development of axillary and pubic hair
A. Excitement
1. Vaginal lubrication and vasocongestion of the genitalia.
2. Penile erection due to vasocongestion
B. Plateau
1. Formation of orgasmic platform due to prominent vasocongestion.
2. Generalized muscle tension, hyperventilation, increased BP, tachycardia
in the late plateau phase.
3. Pre-ejaculatory phase with live spermatozoa
C. Orgasmic
1. Strong rhythmic contractions of vagina and uterus.
2. In males, vas deferens, seminal vesicle, ejaculatory duct and prostate
contract 3-4 times over a few seconds causing pooling of seminal fluid
in the prostatic urethra. Rhythmic contractions in males occur at 0.8
seconds interval that assist in the propulsion process
D. Resolution – rapid decline in pelvic vasocongestion. All organs
return to previous position
E. Refractory phase – only in males; the period during which no
amount of stimulation can cause another erection. Not manifested in females
because females are multi-orgasmic. This phase lengthens with age.
PREGNANCY AND PRENATAL CARE
I. FERTILIZATION
A. Definition: the union of the sperm and the mature ovum in the
outer third or outer half of the Fallopian tube.
B. General considerations
1. Normal amount of semen per ejaculation = 3-5 cc. = 1 teaspoon.
2. Number of sperms in an ejaculate = 120-150 million/cc
3. Mature ovum is capable of being fertilized for 12-24 hours after ovulation.
Sperms are capable of fertilizing even for 3-4 days after ejaculation.
4. Normal life span of sperms = 7 days
5. Sperms, once deposited in the vagina, will generally reach the cervix within
90 seconds after deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis (haploid
umber of daughter cells); therefore, they contain only 23 chromosomes (the
rest of the body cells contain 46 chromosomes). Sperms have 22 autosomes
and 1 X sex chromosome or 1 Y sex chromosome. The union of an X-
carrying sperm and mature ovum results in a baby girl (XX); the union of a
Y-carrying sperm and a mature ovum results in a baby boy (XY).
Important: Only fathers, therefore, determine the sex of their children.
II. IMPLANTATION
A. Implementation after fertilization, the fertilization ovum or zygote
stays in the Fallopian tube for 3 days, during which time rapid cell division
(mitosis) is taking place. The developing cells are now called blastomere and
when there are already about 16 blastomeres, it is now termed a morula. In this
morula for, it will start to ravel (by ciliary action and peristaltic contractions of
the Fallopian tube) to the uterus where it will stay for another 3-4 days. When
there is already a cavity formed in the morula, it is now called a blastocyst.
Fingerlike projections, called trophoblasts (Table 4), form around the
blastocyst and these trophoblasts are the ones which will implant high on the
anterior or posterior surface of the uterus. Thus, implantation, also called
nidation, takes place about a week after fertilization.
B. General Considerations
1. Once implantation has taken place, the uterine endothelium is now termed
decidua.
2. Occasionally, a small amount of vaginal spotting appears with implantation
because capillaries are ruptured by the implanting trophoblasts =
implantation bleeding. Implication: this should not be mistaken for the
Last Menstrual Period (LMP)
G. Seventh Lunar Month – alveoli begin to form (28th weeks of gestation is said to be
the lower limit of prematurity because if baby is delivered at this time, will cry and
breathe but usually dies)
1.3 Because of poor circulation resulting from pressure of the gravid uterus on
the blood vessels of the lower extremities:
1.3.1. Edema of the lower extremities occurs. Management legs above hip
level. Important: Edema of the lower extremities is normal during
pregnancy; it is not a sign of toxemia
1.3.2. Varicosities of the lower extremities can also occur. Management:
Use/wear support hose or elastic stockings to promote venous flow,
thus preventing stasis in lower extremities
Apply elastic bandage – start at the distal end of the extremity and
work toward the trunk to avoid congestion and impaired circulation in
the distal part; do not wrap toes so as to be able to determine adequacy
of circulation (Principle behind bandaging: blod flow through tissues
is decreased by applying excessive pressure on blood vessels)
Avoid use of constricting garters, e.g., knee-high socks
1.4 Because of poor circulation in the blood vessels of the genitalia due to the
pressure of the gravid uterus, varicosities of the vulva and rectum can occur.
Management: side-lying position with hips elevated on pillow and modified
knee-chest position.
1.5 There is increased level of circulating fibrogen, that is why pregnant women
are normally safeguarded against undue bleeding. However, this also
predisposes them to formation of blood clots (thrombi). The implication is
that pregnant women should not be massaged since blood clots can be
released and cause thromboembolism.
2. Gastrointestinal changes
2.1 Morning sickness – nausea and vomiting during the first trimester is due to
increased human chorionic gonadotropin (HCG). It may also be due to
increased acidity or even to emotional factors. Management: Eat dry toast or
crackers 30 minutes before arising in the morning (or dry, high carbohydrate,
low fat and low spices in the diet).
2.2 Hyperemesis gravidarum = excessive nausea and vomiting which persists
beyond 3 months; results in dehydration, starvation and acidosis.
Management: D10NSS 300 ml in 24 hours is the priority treatment; complete
bed rest is also important.
2.3 Constipation and flatulence are due to displacement of the stomach and
intestines, thus slowing peristalsis and gastric emptying time. May also be
due to increased progesterone during pregnancy. Management:
2.3.1 Increase fluids and roughage in the diet
2.3.2 Establish regular elimination time
2.3.3 Increse exercise
2.3.4 Avoid enemas
2.3.5 Avoid harsh laxatives like Dulcolax; stool softeners, e.g. Colace,
are better
2.3.6 Mineral oil should not be taken because it interferes with
absorption of fat-soluble vitamins.
4. Urinary changes
4.1 Urinary frequency, the only sign in pregnancy seen during the first trimester
disappears during the second and reappears during the third trimester. Early
in pregnancy is due to increased blood supply to the kidneys and to the uterus
rising out of the pelvic cavity; in the last trimester is due to pressure of
enlarged uterus on the bladder, especially with lightning (descent of the fetus
into the pelvic brim).
4.2 Decreased renal threshold for sugar due to increased production of
glucocorticoids which cause lactose and dextrose to spill into the urine; also
an effect of the increased progesterone. (implication: it would be difficult to
diagnose diabetes in pregnancy based on the urine sample alone because a
pregnant women have sugar in their urine.)
5. Muscoloskeletal changes
5.1 Because of the pregnant woman’s attempt to change her center of gravity,
she makes ambulation easier by standing more straight and taller, resulting in
a lordotic position (“pride of pregnancy”)
5.2 Due to increased production of the hormone relaxin, pelvic bones become
more supple and movable, increasing the incidence of accidental falls due to
the wobbly gait. Implication: Advise use of low-heeled shoes after the first
trimester
5.3 Leg cramps
5.3.1 Causes
Increased pressure of gravid uterus on lower extremities
Fatigue
Chills
Muscle tenseness
Low calcium, high phosphorus intake
5.3.2 Management
Frequent rest periods with feet elevated
Wear warm, more confortable clothing
Increase calcium intake (calcium tablets and diet)
Do not massage – blood clots can cause embolism.
Most effective treatment: Press knee of the affected leg and
dorsiflex the foot.
8. Weight (Table 5)
8.1 During the first trimester, weight gain of 1.5-3 lbs is normal
8.2 On 2nd and 3rd trimesters, weight gain of 10-11 lbs. per trimester is
recommended.
8.3 Total allowable weight gain during entire period of pregnancy, therefore, is
20-25 pounds (10-12 kgs).
8.4 Pattern of weight gain is more important than the amount of weight gained.
Fetus 7lbs.
Placenta 1 lb.
Amniotic fluid 1 ½ lbs.
Increased weight of uterus 2 lbs.
Increased weight of the breasts 1/1 – 3 lbs.
Weight of additional fluid 2 lbs.
Fat and fluid accumulation 4-6 lbs.
Characteristics of pregnancy
Total 20-25 lbs.
9. Emotional responses
9.1 First trimester. The fetus is an unidentified concept with great future
implications but without tangible evidence of reality. Some degree of
rejection, disbelief, even depression. (Implication: when giving health
teachings, emphasize the bodily changes in pregnancy).
9.2 Second trimester: fetus is perceived as a separate entity. Fantasizes
appearance of the baby.
9.3 Third trimester: has personal identification with a real baby about to be born
and realistic plans for future childcare responsibilities. Best time to talk
about layette and infant feeding method. Fear of death, though is prominent
(To allay fears, let pregnant woman listen to the fetal heart sounds.)
2. Vagina
2.1 Increased vascularity causes change in color from light pink to deep purple or
violet known as Chadwick’s sign.
2.1.1 To prevent confusion as to pregnancy signs, arrange the body
parts from “out to in” and the different signs alphabetically. Thus:
Vagina – Chadwick’s sign
Cervix – Goodell’s sign
Uterus – Hegar’s sign
2.1.2 Due to increased estrogen, activity of the epithelial cell increases,
thus increasing amount of vaginal discharges called leucorrhea.
As long as the discharges are not excessive, green/yellow in color,
foul-smelling or irritatingly itchy, it is normal. Management:
maintain or increase cleanliness by taking twice daily shower
baths using cool water.
2.2 The pH of the vagina changes from normally acidic (because of the presence
of Dederlein bacillie) to alkaline (because of increased estrogen). Alkaline
vaginal environment is supposed to protect against bacterial infection;
however, there are two microorganisms which thrive in an alkaline
environment.
2.2.1 Trichomonas, a protozoa or flagellate. The condition is called
trichomonas vaginalis or trichomonas vaginitis or trichomoniasis.
Signs and symptoms of Trichomoniasis
Frothy, cream-colored, irritatingly itchy, foul-smelling
discharges
Vulvar edema and hyperemia due to irritation from the
discharges
Management
Flagyl for 10 days p.o. or vaginal suppositories of
trichomonicidal compounds. (e.g., Tricofuron, Vagisec or
Devegan).
o Is carcinogenic during the first trimester
o Treat male partner also with Flagyl.
o Avoid alcoholic drinks when taking Flagyl – can cause
Antabuse – like reactions: vomiting, flushed face and
abdominal cramps.
o Dark brown urine a minor side effect – no need to
discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar in 1 quart of
water or 15 ml. white vinegar in 1000 ml. of water) to
counteract alkaline – preferred environment of the
protozoa.
Avoid intercourse to prevent reinfection
3. Abdominal Wall
3.1 Striae gravidarum – increase uterine size results in rupture and atrophy of
connective tissue layers, seen as pink or reddish streaks (gently rubbing oil
on the skin helps prevent diastasis)
3.2 Umbilicus pushed out
4. Skin
4.1 Linea nigra – brown line running from umbilicus to symphais pubis
4.2 Melasma or chloasma – extra pigmentation on cheeks and across the nose
due to increased production of melanocytes by the pituitary gland
4.3 Sweat glands unduly activated
6. Ovaries – no activity whatsoever since ovulation does not take place during
pregnancy. Progesterone and estrogen are being produced by the placenta.
2. Assessment
2.1 Physical examination – review of systems is indicated, including
inspection of the teeth because they are common foci of infection.
2.2 Pelvic examination (Cardinal rule: Empty the bladder first)
2.2.1 Internal exam (IE) to determine Hegar’s, Chadwick’s, and
Goodell’s
2.2.2 Ballotement – fetus will bounce when lower uterine segment is
tapped sharply (on 5th month of pregnancy)
2.2.3 Papanicolau (Pap smear) – cytological examination to diagnose
cervical carcinoma.
Classification of findings
Class 1 – absence of a typical or abnormal cells (normal)
Class 2 – atypical/abnormal cytology but no evidence of
malignancy
Class 3 – cytology suggestive of malignancy
Class 4 – cytology strongly suggestive of malignancy
Class 5 – conclusive for malignancy
Clinical stages that reflect localization or spread of malignant
cervical changes.
Stage 1 – CA confined to the cervix
Stage 2 – CA extends beyond the cervix into the vagina,
but not into the pelvic wall or lower 1/3 of the vagina
Stage 3 – Metastasis to the pelvic wall
Stage 4 – Metastasis beyond pelvic wall into the bladder
and rectum
2.2.4 Pelvic measurements are preferably done after the 6th lunar month.
X-ray pelvimetry (several flat plate X-ray pictures of the pelvis
taken from different angles) is the most effective method of
diagnosing cephalopelvic disproportion (CPD). But since X-rays
are teratogenic, the procedure can be done only 2 weeks before
EDC.
2.2.5 Leopold’s maneuvers
Purposes
To determine presentation, position, and gratitude
Estimate fetal size
Locate fetal parts
Preparatory steps
Palpate with warm hands; cold hands cause abdominal
muscles to contract
Use palms, not fingertips
Position patient on supine with knees flexed slightly
(dorsal recumbent position) so as to relax abdominal
muscles.
Apply gentle but firm motions
Procedure
First manever: Facing head part of pregnant woman,
palpate for fetal part found in the fundus to determine
presentation (a hard, smooth, ballotable mass at the fundus
means the fetus is in breech presentation
Second maneuver: Palpate sides of the uterus to determine
the location of fetal back (best place to hear fetal heart
tones) and small fetal parts
Third maneuver: Grasp lower portion off abdomen just
above the symphysis pubis to find out degree of
engagement.
Fourth maneuver: Facing the feet part of the patient, press
fingers downward on both sides of the uterus above the
inguinal ligaments to determine attitude (degree of flexion
of fetal head)
2.3 Vital signs – temperature, pulse and respiratory rates are important
especially during the initial prenatal visit. More important, however, are
the weight and blood pressure as baseline data to determine any
significant increases.
2.4 Blood studies
2.4.1 Blood Typing
2.4.2 Complete blood count, including Hgb and Hct, to determine anemia
2.4.3 Serological tests (VDRL and Kahn Wasserman) to diagnose for
syphilis
2.5 Urine examinations
2.5.1 Heat and acetic acid test to determine albuminuria. Any sign of
albumin in the urine should be reported immediately because it is a
sign of toxemia
2.5.2 Benedict’s test for glycosuria, a sign of possible gestational
diabetes. Urine should be collected before breakfast to avoid false
positive results. Should not be more than +1 sugar.
2.5.3 Determination of pyura. Urinary tract infection has been found to be
a common cause of premature delivery.
3. Important Estimates
3.1 Age of Gestation (AOG)
3.1.1 Nagele’s Rule – calculation of expected date of confinement
(EDC). Count back three months from the first day of the last
menstrual period (LMP) then add 7 days. Substitute number for
month for easy computation. E.g., LMP is September 6
September is the 9th month of the year – 3 = 6 (June)
Add 7 days to 6 = 13
EDC – June 13
3.1.2 McDonald’s Method – determine age of gestation by measuring
from the fundus to the symphysis pubis (in cm.) then divide by 4 =
AOG in months. E.G., fundic height of 16 cm. divided by 4 = 4
months AOG = 16 weeks AOG.
3.1.3 Bartholomew’s Rule – estimate AOG by the relative position of the
uterus in the abdominal cavity (Figure 4).
By the 3rd lunar month, the fundus is palpable slightly above the
symphysis pubis
On the 5th lunar month, the fundus is at the level of the umbilicus
On the 9th lunar month, the fundus is below the xiphoid process
Bartholomew’s Rule
Active Non-Pregnant
Food Pregnant Women
Women
Meat 2 servings of meat, fowl or 2-3 servings of meat, fowl
fish/day; 3-5 eggs/week or fish/day; 1 egg/day
Vegetables specially dark 1 serving/day (at least 1 serving/day
green and deep yellow 3/week)
Fruits: Citrus and others 2 or more servings/day 2-3 servings/day
Breads 1 serving/day 1 servings/day
Milk 4 or more servings/day 4 servings/day
Additional fluid 1 pint (6-8 oz. glasses /day) 1 quart (2-6 glasses/day)
4.2 Smoking – causes vasoconstriction, leading to low birth weight babies and,
therefore, is contraindicated during pregnancy
4.3 Drinking – in moderation is not contraindicated but when excessive can
cause transient respiratory depression in the newborn and fetal withdrawal
syndrome; besides, alcohol supplies only empty calories.
4.4 Drugs – dangerous to fetus especially during the first trimester when the
placental barrier is still incomplete and the different body organs are
developing. Are teratogenic (can cause congenital defects) and, therefore
contraindicated unless prescribed by the doctor.
4.4.1 Thalidomide – auses Amelia or phocomelia (short or no
extremeties)
4.4.2 Steroids – can cause cleft palate and even abortion
4.4.3 Iodine – contained in many over-the-counter cough suppressants,
cause enlargement of the fetal thyroid gland, leading to tracheal
compression and dyspnea at birth
4.4.4 Vitamin K – causes hemolysis and hyperbilirubinemia
4.4.5 Aspirin and Phenobarbital – cause bleeding disorder
4.4.6 Streptomycin and quinine – cause damage to the 8th cranial nerve
(nerve deafness)
4.4.7 Tetracycline – causes staining of tooth enamel and inhibits growth
of long bones (not given also to children below 8 years for the same
reasons)
4.5.2 Sex in moderation is permitted during pregnancy but not during the
last 6 weeks since there is increased incidence of postpartum
infection in women who engage in sex during the last 6 weeks.
4.5.3 Counsel the couple to look for more comfortable positions.
Definitely, the missionary (man-on-top) position is not advisable
4.5.4 Sex is contraindicated in the following situations
Spotting or bleeding
Ruptured BOW
Incompetent cervical os
Deeply-engaged presenting part
4.6 Employment – as long as the job does not entail handling toxic substances, or
lifting heavy objects, or excessive physical or emotional strain, there is no
contraindication to working. Advise pregnant women to walk about every
few hours of her work day long periods of standing or sitting to promote
circulation.
4.7 Traveling – no travel restrictions but postpone a trip during the last trimester.
On long rides, 15-20 minute rest periods every 2-3 hours to walk about or
empty the bladder is advisable.
4.8 Exercises
4.8.1 Chief aim: To strengthen the muscles used in labor and delivery
4.8.2 Should be done in moderation
4.8.3 Should be individualized: according to age, physical condition,
customary amount of exercises (swimming or tennis not
contraindicated unless done for the first time) and the stage of
pregnancy)
4.8.4 Recommended exercises
Squatting (Figure 5) and Tailor Sitting (Figure 6) – to stretch
and strengthen perineal muscles; increase circulation in the
perineum; make pelvic joints more pliable. When standing from
squatting position, raise buttocks first before raising the head to
prevent postural hypotension.
Pelvic rock – maintains good posture; relieved pressure
abdominal pressure and low backache; strengthens abdominal
muscles following delivery
Modified knee-chest position - relieves pelvic pressure and
cramps in the thighs or buttocks; relieves discomfort from
hemorrhoids
Shoulder-circling – strengthens muscles of the chest
Walking – said to be the best exercises
Kegel – relieves congestion and discomfort in pelvic region;
tones up pelvic floor muscles
4.9 Prepared Childbirth/Childbirth Education – preparing the pregnant couple for
childbearing
4.9.1 Operates basically on the “Gate Control Theory” of pain: pain is
controlled in the spinal cord. To ease pain in one body part, the
“gate” to this pain should be “closed”.
4.9.2 Premises
Discomfort during labor can be minimized if the woman comes
into labor informed about what is happening and prepared with
breathing exercises to use during labor
Discomfort during labor can be minimized if the woman’s
abdomen is relaxed and the uterus is allowed to rise freely
against the abdominal wall during contractions.
4.10 Tetanus immunization – given 0.5 ml IM (deltoid region of the upper arm) to all
pregnant women anytime during pregnancy. It shall be given in two doses at least 4
weeks apart, with the second dose at least 3 weeks before delivery. Booster doses
shall be given during succeeding pregnancies regardless of the interval. Three booster
doses will confer lifelong immunity.
4.11 Clinic appointments
4.11.1 First 7 lunar month – every month
4.11.2 On 8th and 9th lunar month – every other week or twice a month
4.11.3 On 10th lunar month – every week until labor pains set in
A. Importance: From an obstetrical point of view the fetal skull is the most
important part of the fetus because it is the:
1. largest part of the body
2. most frequent presenting part
3. least compressible of all parts
B. Cranial bones - the first 3 are not important part of the fetus because it is the:
1. Sphenoid
2. Ethmoid
3. Temporal
4. Frontal
5. Occipital
6. parietal
C. Membrane space – suture lines are important because they allow the bones to
move and overlap, changing the shape of the fetal head in order to fit through
the birth canal, a process called molding.
1. Sagittal suture line – the membranous interspace which joins the parietal
bones
2. Coronal suture line – the membranous interspace which joins the frontal
bone and the parietal bones
3. Lambdoid suture line – the membranous interspace which joins the
occiput and the parietals.
Which one of these diameters is presented at the birth canal depends on the degree of
flexion (known as attitude) the fetal head assumes prior to delivery. In full flexion (very
good attitude when the chin is flexed on the chest), the smalles suboccipitobregmatic
diameter (A) is the one presented at the birth canal. If in poor flexion, the widest
occipitomental diameter (D) will be the one presented and will give mother and the baby
more problems.
B. Increased activity evel – due to increased epinephrine secreted to prepare the body
for the coming “work” ahead. Advise the preganant woman no to use this
increased energy for doing household chores.
C. Loss of weight – about 2-3 lbs. 1 to 2 days before labor onset; probably due to
decrease in progesterone production leading to decrease in fluid retention.
D. Braxton Hicks contractions – painless, irregular practice contractions.
E. Ripening of the cervix – from Goodell’s sign, the cervix becomes “butter-soft”
F. Rupture of the membranes – it is important to remember that one membranes
(BOW) have ruptures:
1. Labor is inevitable. It will occur within 24 hours.
2. The integrity of the uterus has been destroyed. Infection, therefore, can
easily set in. That is why once membranes have rupture:
2.1 Aseptic techniques should be observed in all procedures
2.2 Doctors do less obstetric manipulations (e.g. IE)
2.3 Enema is no longer ordered
2.4 Temperature should be taken regularly so that fever, a sign
of infection, can be detected.
G. Effacement – shortening and thinning of the cervical canal as distinct from the
uterus. It is expressed in percentage.
H. Dilatation – enlargement of the external cervical os up to 10 cm primarily as a
result of uterine contractions and secondarily as a result of pressure of the
presenting part and the BOW.
I. Uterine Changes
1. The uterus is gradually differentiated into two distinct portions
4.1. Upper uterine segment – becomes thick and active to expel out fetus
4.2. Lower uterine segment – become thin-walled, supple and passive so that
fetus can be pushed out easily.
5. Physiological retraction ring is formed at the boundary of the upper and lower
uterine segments. In difficult labor when the fetus is larger than the birth canal, the
round ligaments of the uterus become tense during dilatation and expulsion, causing
an abdominal indentation called Bandl’s pathological retraction ring, a danger sign
of labor signifying impending rupture of the uterus if the obstruction is not relieved.
6. Nursing Care
III.1 Hospital admission – provide privacy and reassurance from the very start
III.1.1 Personal data – name, age, address, civil status
III.1.2 Obstetrical data – determine EDC; obstetrical score (gravida, para,
TPAL); amount and character of show; and whether or not membranes
have ruptured.
III.2 General physical examination, internal exam and Leopold’s maneuvers are done
to determine:
III.2.1 Effacement and dilatation
III.2.2 Station – relationship of the fetal presenting part to the level of the ischial
spine (Figure 14)
Station 0 – at the level of the ischial spines; synonymous to engagement
Station -1 – presenting part above the level of the ischial spines
Station +1 – presenting part below the level of the ischial spines
Station +3 or +4 – synonymous to crowning (encircling of the largest
diameter of the fetal head by the vulvar ring)
III.2.3 Presentation – relationship of the long axis of the mother to the long axis
of the fetus; also known as lie. Presenting part if the fetal part which
enters the pelvis first and covers the internal cervical os
I. VERTICAL
A. Cephalic – head is the presenting part
1. Vertex – head sharply flexed, making the parietal bones the presenting parts
2. If in poor flexion
2.1 Face
2.2 Brow
2.3 Chin
C. Footling
1. Single – one leg unflexed and extended; one foot presenting
2. Double – legs unflexed and extended; feet are presenting
3.4 Emotional support is provided for the woman in labor by keeping her constantly
informed of the progress labor
3.5 --------------------------------------------
3.5.3 Solid or liquid foods are to be avoided because
Digestion is delayed during labor
A full stomach interferes with proper bearing down
May vomit and cause aspiration
3.5.4 Enema – not a routine procedure
Purposes
A full bowel hinders the progress of labor – effectiveness of enema
in labor can be determined by evaluating change in uterine tone
and the amount of show
Expulsion of feces during second stage of labor predisposes mother
and baby to infection
Full bowel predisposes to postpartum discomfort
Procedure of enema administration
Enema solution may either be soap suds or Fleet enema
(contraindicated in patients with toxemia because of its sodium
content)
Optimum temperature of the solution – 105°F to 115°F (40.5 °C –
46.1°C)
Patient on side – lying position
When there is resistance while inserting rectal catheter, withdraw
the tube slightly while letting a small amount of solution enter
Clamp rectal tube during a contraction
Important nursing action: Check FHR after enema administration
to determine fetal distress
Contraindications to enema in labor
Vaginal Bleeding
Premature labor
Abnormal fetal presentation or position
Ruptured membranes
Crowning
3.5.5 Encourage the mother to void every 2 – 3 hours by offering the bedpan
because
A full bladder retards fetal descent
Urinary stasis can lead to urinary tract infection
A full bladder can be traumatized during delivery
3.5.6 Perineal prep – done aseptically. Use “No. 7” method, always from front
to back
3.5.7 Perineal shave – not a routine procedure; maybe done to provide a clean
area for delivery. Muscles at the symphysis pubis should be kept taut and
razor moved along the direction of hair growth
3.5.8 Encourage Sim’s position because it:
Favors anterior rotation of the fetal head
Promotes relaxation between contractions
Prevents continual pressure of the gravid uterus on the inferior vena
cava (the blood vessel which brings unoxygenated blood back to the
heart); pressure results in Supine Hypotensive Syndrome, also called
Vena Cava Syndrome (Figure 16). Hypotension is due to the reduced
venous return resulting in decreased cardiac output and therefore, a fall
in arterial BP.
3.5.9 Woman in labor should not be allowed to push or bear down
unnecessarily during contractions of the first stage because
It leads to unnecessary exhaustion
Repeated strong pounding of the fetus against the pelvic floor will lead
to ce4rvical edema, thus interfering with dilatation and prolonging
length of labor.
3.5.10 Abdominal breathing – advised for contractions during the first stage
in order to reduce tension and prevent hyperventilation
3.6 Administer analgesics as ordered. The dosage is based on the patient’s weight, status
of labor and age of gestation.
3.6.1 Narcotics are the most commonly used, specifically Demerol.
Pharmacologic effect: depresses the sensory portion of the cerebral
cortex. It is not only a potent analgesic, it is also a sedative and an
antispasmodic.
It is not given early in labor because it can retard, progress (is an
antispasmodic), but cannot also be given if delivery is only one hour
away because it causes respiratory depression in the newborn (that is
why it can be given only if cervical dilatation is 6 – 8 cm.)
Given 25 – 100 mg., depending on body weight
Takes effect in 20 minutes – patient experiences a sense of well – being
and euphoria
Narcotic antagonist (e.g. Narcan, Nalline) are given to counteract any
toxic effects of Demerol
3.7 Assist in administration of regional anesthesia – preferred over any other form of
anesthesia because it does not enter maternal circulation and so does not affect the
fetus. Patient is completely awake and aware of what is happening. Does not depress
uterine tone, thus optimal uterine contraction is achieved.
3.7.1 Xylocaine is the anesthetic of choice
3.7.2 Patient on NPO with IV to prevent dehydration, exhaustion and aspiration
and because glucose aids in proper functioning of the fetus
3.7.3 Types of Anesthesia
(purplish discoloration of the skin due to blood in subcutaneous tissues)
area or hematoma in the perineum may be an aftermath. No special
treatment is needed: ice bag applied to the area on the first day may reduce
the swelling
3.7.4 Forceps are generally needed in delivery of patient under anesthesia
because of loss of coordination in second – stage pushing.
3.7.5 Postspinal headaches maybe due to leakage of anesthetic into the CSF or
injection of air at time of needle insertion. Management: Flat on bed for 12
hours and increase fluid intake
3.7.6 Common side effects
Hypotension – because Xylocaine is vasodilator. Management – turn to
side; prompt elevation of legs; administration of vasopressor and oxygen, as
ordered.
Fetal bradycardia
Decreased maternal respirations
3.8 A sure sign that the baby is about to be born is the bulging of the perineum. In
general, primigravidas are transported from the Labor Room to the Delivery Room
when the cervix is fully dilated or when there is bulging of the perineum. Mutiparas,
on the other hand, are transported when cervical dilataton iis 7 – 8 cm.
B Transition Period – when the mood of the woman suddenly changes and the nature of
contractions intensify
1. Characteristics
1.1 If membranes are still intact, this period is marked by a sudden gush of amniotic
fluid as fetus is pushed into the birth canal. If spontaneous rupture does not
occur, amniotomy (snipping of BOW with a sterile pointed instrument, e.g.,
Kelly or Allis forceps or amniohook to allow amniotic fluid to drain) is done to
prevent fetus from aspirating the amniotic fluid as it makes its different fetal
position changes. Amniotomy, however, can not be done if station is still
“minus”, as this can lead to cord compression
1.2 Show becomes more prominent.
1.3 There is an uncontrollable urge to push with contractions, a sign of
impending second stage of labor. Profuse perspiration and distention of neck
veins are seen.
1.4 Nausea and vomiting is a reflex reaction due to decreased gastric motility and
absorption.
1.5 In primis, baby is delivered with 20 contractions (40 minutes); in multis, after
10 contractions (20 minutes).
2. Nursing actions are primarily comfort measures
2.1 Sacral pressure (applying pressure with the heel of the hand on the sacrum)
relieves discomfort from contractions
2.2 Proper bearing down techniques: push with contractions
2.3 Controlled chest (costal) breathing during contractions
2.4 Emotional support
C Second Stage (Stage of expulsion) – begins with complete dilatation of the cervix and
ends with the delivery of the baby.
1. Powers/forces: involuntary uterine contractions and contractions of the
diaphragmatic and abdominal muscles
2. Mechanisms of labor/Fetal Position Changes (D FIRE ERE)
3.1 Descent – may be preceded by engagement.
3.2 Flexion- as descent occurs, pressure from the pelvic floor causes the chin to
bend forward onto the chest.
3.3 Internal Rotation – from AP to transverse, the AP to AP
3.4 Extension – as head comes out, the back of the neck stops beneath the pubic
arch. The head extends and the forehead, nose, mouth and chin upper.
3.5 External Rotation (also called restitution) – anterior shoulder rotates externally
to the AP position.
3.6 Expulsion – delivery of the rest of the body.
3. Nursing Care
3.1 When positioning legs on lithotomy, put them up at the same time to prevent
injury to the uterine ligaments
3.2 As soon as the fetal head crowns, instruct mother not to push, but to pant (rapid
and shallow breathing to prevent rapid expulsion of the baby). If panting is deep
and rapid, called hyperventilation, the patient will experience lightheadedness
and tingling sensation of the fingers leading to carpopedal spasms because of
respiratory alkalosis. Management: let the patient breathe into a brown paper
bag to recover lost carbon dioxide; a cupped hand over the mouth and nose will
serve the same purpose.
3.3 Assist in episiotomy (incision made in the perineum primarily to prevent
lacerations).
3.3.1 Other purposes
Prevent prolonged severe stretching of muscles supporting the bladder
or rectum
Reduce duration of second stage when there is hypertension or fetal
distress
Enlarge outlet, as in breech presentation or forceps delivery
3.3.2 Types of episiotomy
Median – from middle portion of the lower vaginal border directed
towards the anus
Mediolateral – begun in the midline but directed laterally away from the
anus. Often done because it prevents 4th degree laceration should it
occur despite episiotomy.
3.3.3 Natural Anesthesia jis used in episiotomy, i.e., no anesthetic is injected
because pressure of fetal presenting part against the perineum is so intense
that nerve endings for pain are momentarily deadened
3.4 Apply the Modified Ritgen’s Maneuver
3.4.1 Cover the anus with sterile towel and exert upward and forward pressure
on the fetal chin, while exerting gentle pressure with two fingers on the
head to control emerging head. This will not only support the perineum,
thus preventing lacerations, but will also favor flexion so that the smallest
suboccipitobregmatic diameter of the fetal head is presented.
3.4.2 Ease the head out and immediately wipe the nose and mouth of secretions
to establish a patent airway (remember: the first and most important
principle in the care of the newborn is establish and maintain a patent
airway). The head should be delivered in between contractions.
3.4.3 Insert 2 fingers into the vagina so as to feel for the presence of a cord
looped around the neck (nuichal cord). If so, but loose, slip it down the
shoulders or up over the head; but if tight, clamp the cord twice, an inch
apart, and then cut it in between.
3.4.4 As the head rotates, deliver the anterior shoulder by exerting a gentle
3.5 Immediately after delivery, the newborn should be held below the level of the
mother’s vulva for a few minutes to encourage flow of blood from the placenta
to the baby
3.6 The infant is held with is head in a dependent position (head lower thatn the rest
of the body) to allow for drainage of secretions. Remember: never stimulate a
baby to cry unless you have drained him out of his secretions.
3.7 Wrap the baby in a sterile towel to keep him warm. Remember: Chilling
increase the body’s need for oxygen
3.8 Put the baby on the mother’s abdomen. The weight of the baby will help
contract the uterus.
3.9 Cutting the cord is postponed until the pulsations have stopped because it is
believe that 50 – 100 ml. of blood is flowing from the placenta to the baby at
this time. After cord pulsations have stopped, clamp it twice, an inch apart and
then cut in between.
3.10 Show the baby to the mother, inform her of the sex and time of delivery then
give the baby to the circulating nurse.
D Third Stage (Placental Stage) – begins with the delivery of the baby and ends with
delivery of placenta.
1. Signs of placental separation
1.1 Uterus becoming round and firm again, rising high to the level of the umbilicus
(Calkin’s sign) – the earliest sign of placental separation
1.2 Sudden gush of blood from the vagina
1.3 Lengthening of the cord
2. Types of placental delivery
2.1 Schultz – if placenta separates first at its center and last at its edges, it tends to
fold on itself like an umbrella and presents the fetal surface which is shiny
(“Shiny” for Schultz); 80% of placentas separate in this manner.
2.2 Duncan – if placenta separates first at its edges, it slides along the uterine
surface and presents with the maternal surface which is raw, red, beefy, and
irregular and “dirty” (“Dirty” for Duncan). Only about 20% of placentas
separate this way.
3. Nursing Care
3.1 Do not hurry the expulsion of the placenta by forcefully pulling out the cord or
doing vigorous fundal push as this can cause uterine inversion. Just watch for
the signs of placental separation.
3.2 Tract the cord slowly, winding it around the clamp until the placenta
spontaneously comes out, slowly rotating it so that no membranes are left inside
the uterus, a method called Brandt – Andrews maneuver.
3.3 Take note of the time of placental delivery. It should be delivered within 20
minutes after the delivery of the baby. Otherwise, refer immediately to the
doctor as this can cause severe bleeding in the mother.
3.4 Inspect for completeness of cotyledons; any placental fragment retained can
also cause severe bleeding and possible death.
3.5 Palpate the uterus to determine degree of contraction. If relaxed boggy or non -
contracted, first nursing action is to massage gently and properly. An ice cap
over the abdomen will also help contract the uterus since cold causes
vasoconstriction.
3.6 Inject oxytocin (Methergin = 0.2 mg./ml. or Syntocinon = 10U/ml) IM to
maintain uterine contractions, thus prevent hemorrhage. Note: oxytocins are not
given before placental delivery.
3.7 Inspect the perineum for lacerations. Any time the uterus is firm following
placental delivery, yet bright red vaginal bleeding is gushing forth from the
vaginal opening, suspect lacerations (tend to heal more slowly because of
ragged edges)
3.7.1 Categories of lacerations
First degree – involves the vaginal mucous membranes and perineal
skin
Second degree – involves not only the muscles, vaginal mucous
membranes and skin, but also the muscles.
Third degree – involves not only the vaginal mucous membranes and
skin, but also the external sphincter of the rectum
Fourth degree – involves not only the external sphincter of the rectum,
the muscles, vaginal mucous membranes and skin, but also the m
mucous membranes of the rectum.
3.7.2 Assist the doctor in doing episiorrhaphy 9repair of episiotomy or
lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure
on the suture line, thus prevent further bleeding. Note: Vaginal packs have
to be removed after 24 – 48 hours
3.H Make mother comfortable by perineal care and applying clean sanitary napkin
snugly to prevent its moving forward from the anus to the vaginal opening.
Soiled napkins should be removed from front to back.
3.I Position the newly – delivered mother flat on bed without pillows to prevent
dizziness due to decrease in intraabdominal pressure.
3.J The newly – delivered mother may suddenly complain of chills due to
decreased blood pressure, fatique or cold temperature in the delivery room.
Management: provide additional blankets to keep her warm.
3.KMay give initial nourishment; e.g., milk, coffee or tea
3.L Allow patient to sleep in order to regain lost of energy.
E Fourth Stage – first 1 – 2 hours after delivery which is said to be the most critical stage
for the mother because of unstable vital signs.
1. Assessment
1.1 Fundus – should be checked every 15 minutes for 1 hour then every 30
minutes for the next 4 hours. Fundus should be firm, in the midline, and
during the first 12 hours postpartum, is a little above the umbilicus. First
nursing action for a non- contracted uterus: massage.
1.2 Lochia – shuld be moderate in amount. Immediately after delivery, a
perineal pad can be completely saturated after 30 minutes. If saturated in 15
minutes or earlier, may mean hemorrhage.
1.3 Bladder – a full bladder is evidenced by a fundus which is to the right of
the midline and dark – red bleeding with some clots. Will prevent adequate
uterine contraction.
1.4 Perineum – is normally tender, discolored and edematous. It should be
clean, with intact sutures.
1.5 Blood pressure and pulse rate may be slightly increased from excitement
and effort of delivery, but normalize within one hour.
2. Lactation – suppressing agents – estrogen – androgen preparations given within the
first hours postpartum to prevent breast milk production in mothers who will not (or
cannot) breastfeed. E.g., diethylstilbestrol, TACE, Parlodel and deladumone. These
drugs tend to increase uterine bleeding and retard menstrual return
3. Rooming – in concept – mother and baby are together while in the hospital. The
concept of a family, therefore, is felt from the very beginning because parents have
the baby with them, thus providing opportunities for developing a positive
relationship between parents and newborn (maternal – infant bonding). Eye – to –
eye contact is immediately established, releasing the maternal caretaking responses.
PUERPERUM
I. DEFINITION OF TERMS
A. Puerperium/Postpartum – refers to the six – week period after delivery of the
baby
B. Involution - return of the reproductive organs to their prepregnant state
26 32
18 11
8 21
RISK CONDITIONS
I. INFECTIONS
A. Syphilis
1. Cause: Treponema pallidum – a spirochete which enters the body during
coitus or through cuts and breaks in the skin or mucous membrane
2. Treatment: 2.4-4.8 million units of Penicillin (if allergic, 30-40 gms.
erythrocin) will usually prevent congenital syphilis in the newborn because
penicillin readily crosses the placenta. If untreated, syphilis can cause
midtrimester abortion, CNS lesions in the newborn or even death.
3. The newborn with congenital syphilis
3.1 Signs and symptoms
3.1.1 Jaundice at 2 weeks of life – first sign of the
disease
3.1.2 Anemia and hepatosplenomegaly
3.1.3 “Snuffles” (persistent rhinorrhea); coppery
rashes on palms and soles; mucous patches;
condylomas; pseudoparalysis due to bone inflammation
3.1.4 If untreated, can progress on to deformed bones,
teeth, nose, joints and CNS syphilis
3.2 Management: Penicillin IM for 10 days or one long-acting
Penicillin (Penadur LA)
B. Rubella/German Measles
1. Incidence
1.1 Mother – the earlier the mother contracted the disease, the greater
the likelihood that the baby will be affected. The rubella virus slows
down division of infected cells during organogenesis, thus causing
congenital defects
1.2 Newborn – can carry and transmit the virus for as long as 12-24
months after birth
2. Signs and symptoms of Congenital Rubella Syndrome
2.1 Low birth weight; jaundice; petechiae; anemia; thrombocytopenia;
hepatosplenomegaly
2.2 Classic seequelae
2.2.1 Eyes: chorioretinitis, cataract, glaucoma
2.2.2 Heart: Patent Ductus Arteriousus,
stenosis, coarctations
2.2.3 Ear: Nerve deafness
2.2.4 Dental and facial clefts
C. Postpartum Infection
1. Sources
1.1 Endogenous (primary) sources – bacteria in the normal flora become
virulent when tissues are traumatized and general resistance is
lowered.
1.2 Exogenous sources – pathogens introduced from external sources.
(Most common is anaerobic streptococci). Common exogenous
sources:
1 Hospital personnel
2 Excessive obstetric manipulations
1.2.3 Breaks in aseptic techniques – faulty
handwashing, unsterile equipments and supplies
4 Coitus in late pregnancy
5 Premature rupture of the membranes
2. General symptoms: malaise anorexia, fever, chills and headache
3. General management
3.1 Complete bed rest (CBR)
3.2 Proper nutrition
3.3 Increased fluid intake
3.4 Analgesics
3.5 Antipyretics and antibiotics, as ordered
4. Types of infection
4.1 Infection of the perineum
4.1.1 Specific symptoms
Pain, heat and feeling of pressure in the perineum
Inflammation of the suture line, with 1 or 2 stitches
sloughed off
With or without elevated temperature
4.1.2 Specific management
Doctor removes sutures to drain area and resutures
Hot sitz bath or warm compress
4.2 Endometritis
4.2.1 Specific symptoms
Abdominal tenderness
Uterus not contracted and painful to touch
Dark brown, foul-smelling lochia
4.2.2 Specific management
Oxytocin administration
Fowler’s position to drain out lochia and prevent
pooling of infected discharge
4.3 Thrombophlebitis – infection of the lining of a blood vessel with
formation of clots; usually an extension of endometritis
4.3.1 Specific symptoms
Pain, stiffness and redness in the affected part of the
leg
Leg begins to swell below the lesion because venous
circulation has been blocked
Skin is stretched to a point of shiny whiteness, called
milk leg or phlegmasia alba dolens
Positive Homan’s sign – pain in the calf when the
foot is dorsiflexed
4.3.2 Specific management
Bed rest with affected leg elevated
Anticoagulants, e.g., Dicumarol or Heparin, to
prevent further clot formation or extension of a
thrombus
o Analgesics are given but never Aspirin
because it inhibits prothrombin formation
therefore causes hemorrhage
4.4 Mastitis – inflammation of breast tissues
4.4.1 Pathophysiology – local inflammatory response to
bacterial invasion; suppuration may occur; organism can
be recovered from breast milk.
4.4.2 Etiology – most common: Staphylococcus aureus
4.4.3 Assessment
Signs of infection (may occur several weeks
postpartum).
Fever
Chills
Tachycardia
Malaise
Abdominal pain
Breast
Reddened areas
Localized/generalized swelling
Heat, tenderness, palpable mass.
4.4.4 Nursing care – goal: prevent infection. Health teaching
in early postpartum
Handwashing
Breast care
Wash with warm water only (no soap)
Let breast milk dry on nipples to prevent
drying of tissue.
Clean bra (with no plastic pads or liners) to
support breasts, reduce friction, minimize
exposure to microorganisms.
Good breastfeeding techniques
II. BLEEDING/HEMORRHAGE
A. Bleeding in pregnancy (Table 13)
Tissue
Glomerular degeneration Glomerular Filtiration Tissue ischemia
Table 14. Classification of Toxemia ischemia
Tubular reabsorption
Glomerular permebility Vascular stasis
of sodium
PROTEINURIA
EDEMA OLIGURIA
Premature placental
deterioration
Fluid diffuses from
circulatory system to
extracellular spaces Fetal Abruptio
nutrient placenta
Generalized
water retention
LUNGS BRAIN
Fetal Distress
Cerebral
Pulmonary edema cyanosis hypoxia
edema
Premature Labor
Cerebral and Delivery
CHF irritability
CONVULSIONS
1.1.2 Generalized vasoconstriction and associated
microangiopathy disease of capillaries
1.1.3 Abnormal retention of sodium and water by body tissues
1.2 Medical complications
1.2.1 Cerebrovascular hemorrhage
1.2.2 Acute pulmonary edema
1.2.3 Acute renal failure
1.3 Types
1.3.1 Mild preeclampsia – signs and symptoms
Sudden, excessive weight gain of 1-5 lbs. per
week (earliest sign of preeclampsia) due to
edema which is persistent and found in the upper
half of the body (e.g. inability to wear the
wedding ring)
Systolic BP of 140, or an increase of 30mm.
Hg. or more and a diastolic of 90, or a rise of
15 mm. Hg. or more, taken twice 6 hours apart.
Proteinuria of 0.5 gms/liter or more
1.3.2 Severe preeclampsia – signs and symptoms
BP of 160/110 mm Hg.
Proteinuria of 5 gm/liter or more in 24 hours
Oliguria of 400 ml. or less in 24 hours (normal
urine output/day = 1500 ml).
Cerebral or visual disturbances
Pulmonary edema and cyanosis
Epigastric pain (considered an “aura” to the
development of convulsions)
2. Eclampsia – the main difference between preeclampsia and Eclampsia is the
presence of convulsion in eclampsia. Signs and symptoms as in
preeclampsia plus:
2.1 increased BUN
2.2 increased uric acid
2.3 decreased CO2 combining power
F. Management
1. Complete bed rest – sodium tends to be excreted at a more rapid rate if the
patient is at rest. Energy conservation is important in decreasing metabolic
rate to minimize demands for oxygen. Lowered oxygen tension in toxemia is
the result of vasoconstriction and decreased blood flow that diminishes the
amount of nutrients and oxygen in cells. In any condition wherein there is a
possibility of convulsions, bed rest should be in a darkened, non-stimulating
environment with minimal handling.
2. Diet
2.1 For mild preeclampsia – high protein, high carbohydrate, moderate
salt restriction (no added table salt, including “bagoong”, “patis”,
“tuyo”, canned goods, bottled drinks, preserved foods and cold cuts)
2.2 For severe preeclampsia – high protein, high calorie and salt-poor (3
gms of salt per day)
3. Medications
3.1 Diuretics – e.g., chlorthiazide/Diuril. Hourly urine output
should be at least 20-30 ml. (normally 50-60 ml. per hour)
3.1.1 Pharmacologic effect: decreased reabsorption of
sodium and chloride at the proximal tubules, thereby
increasing renal excretion of sodium, chloride and
water, including potassium.
3.1.2 Side effects: fatigue and muscle weakness due to
fluid and electrolyte imbalance
3.1.3 Nursing care: closely monitor intake and output
3.2 Digitalis – if with heart failure.
3.2.1 Pharmacologic action: Increase the force of
contraction of heart, thereby decreasing heart rate.
3.2.2 Important: Should not be given, therefore, if heart
rate is below 60/minute.
3.2.3 Implication: take the heart rate before giving the
drug.
3.3 Potassium supplements – patients receiving diuretics are prone
to hypokalemia; if digitalis is given at the same time,
hypokalemia increases the sensitivity of the heart to the effects
of digitalis. Potassium supplements (e.g., banana) must be
given tot prevent cardiac arrhythmias.
3.4 Barbiturates – sedation by means of CNS depression
3.5 Analgesics; antihypertensives; antibiotics; anticonvulsants;
sedatives
3.6 Magnesium sulfate – the drug of choice
3.6.1Actions
CNS depressant – lessen the possibility of
convulsions
Vasodilator – decreases the BP
Cathartic causes a shift of fluid from the
extracellular spaces into the intestines from
where the fluid can be excreted.
3.6.2 Dosage: 10 gms. initially, either by slow IV push
over 5-10 minutes, or deep IM, 5 gms/buttock, then
IV drip of 1 gm. per hour (1 gm/100 ml. D10W) IF:
Deep tendon reflexes are present
Respiratory rate is at least 12 per minute
Urine output is at least 100 ml. in 6 hours
3.6.3 Antidote for magnesium sulfate toxicity: Calcium
gluconate, 10% IV, to maintain cardiac and vascular
tone.
3.6.4 Earliest sign of magnetism sulfate toxicity:
disappearance of the knee jerk/patellar reflex.
4. Method of delivery – preferably vaginal, but if not possible, CS will
have to be done.
G. Prognosis: the danger of convulsions is present until 48 hours postpartum.
V. HEART DISEASE
A. Classification
1. Class I – no limitation physical activity
2. Class II – slight limitation of physical activity; ordinary activity causes
fatigue; palpitation, dyspnea or angina
3. Class III – moderate to marked limitation of physical activity; less than
ordinary activity causes fatigue, etc.
4. Class IV – unable to carry on any activity without experiencing discomfort
B. Prognosis
1. Classes I and II – normal pregnancy and delivery
2. Classes III and IV – poor candidates
C. Signs and symptoms
1. Because of increased total cardiac volume during pregnancy, heart murmurs
are observed
2. Cardiac output may become so decreased that vital organs are not perfused
adequately; oxygen and nutritional requirements, therefore, are not met.
3. Since the left side of the heart is not able to empty the pulmonary vessels
adequately, the latter become engorged, causing pulmonary edema and
hypertension. Moist cough in gravidocardiacs, therefore, is a danger sign.
4. Liver and other organs become congested because blood returning to the
heart may not be handled adequately, causing the venous pressure to rise.
Fluid then escapes through the walls of engorged capillaries and cause edema
or ascites.
5. Congestive heart failure is a high probability also because of the increased
cardiac pain on exertion, and cyanosis of nailbeds are obvious.
D. Management – consider the functional capacity of the heart
1. Bed rest – especially after the 30th week of gestation to ensure that pregnancy
is carried to term or at least 36 weeks gestation
2. Diet – should gain enough, but not too much as it would add to the workload
of the heart
3. Medications
3.1 Digitalis
3.2 Iron preparations, e.g., Fer-in-sol or Feosol – anemia should be
prevented because the body compensates by increasing cardiac
output, thus further increasing cardiac workload.
4. Classes III and IV are not placed in lithotomy position during delivery to
avoid increasing venous return. The semi-sitting position is preferred to
facilitate easy respirations.
5. Anesthetic of choice is caudal anesthesia for effortless, pushless and painless
delivery. Remember: Gravidocardiacs are not allowed to push with
contractions (to prevent Valsalva maneuver which increases venous return to
an already weak, damaged heart). Low forceps, therefore, is the best method
of delivery.
6. ergotrate and other oxytocics, scopolamine, diethylstilbestrol and oral
contraceptives are contraindicated because they cause fluid retention and
promote thromboembolization.
7. Most critical period – the period immediately following delivery because the
30% - 500
VI. MULTIPLE PREGNANCY (Twin Pregnancy)
A. Classification
1. Monozygotic/Identical – twins begin with a single ovum and sperm, but in
the process of fusion or in one of the first cell divisions, the zygote divides
into two identical but separate individuals.
1.1 Characteristics
1.1.1 Always of the same sex
1.1.2 With 2 amnions, 1 chorion, 2 umbilical cords and 2
placentas fused as one.
1.2 Incidence – a chance occurrence
1.2.1 More frequent among non-whites
1.2.2 More frequent among young primis and old multis
2. Dizygotic/Fraternal – two separate ova are fertilized by 2 separate sperms.
They are actually sibling growing at the same time in utero.
2.1 Characteristics
2.1.1 May or may not be of the same sex
2.1.2 With 2 amnions, 2 chorions, 2 placentas and 2 umbilical
cords
2.2 Incidence – familial maternal pattern of inheritence
B. Suspect multiple pregnancy if:
1. faster rate of increase in uterine size
2. on quickening, there are several flurries of action in different abdominal
positions
3. on auscultation, 2 sets of fetal heart tones are heard
4. there is marked weight gain, not due to toxemia or obesity
C. complications
1. Toxemia 4. Abruptio placenta
2. Polyhydramnios 5. Prematurity
3. Anemia 6. Postpartum hemorrhage