Professional Documents
Culture Documents
Human Sexuality
A. Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes emotions and preferences that are
related to sexual self and eroticism.
2. Sex – basic and dynamic aspect of life
3. During reproductive years, the nurse performs as resource person on human sexuality.
Sex – biologic male or female status. Sometimes referred to a specific sexual behavior such as sexual intercourse.
Sexuality - behavior of being boy or girl, male or female man/ woman. Entity life long dynamic change.
- developed at the moment of conception.
a. Mons pubis/veneris - a pad of fatty tissues that lies over the symphysis pubis covered by skin and at puberty
covered by pubic hair that serves as cushion or protection to the symphysis pubis.
b. Labia Majora - large lips longitudinal fold, extends symphysis pubis to perineum
d. Vestibule – an almond shaped area that contains the hymen, vaginal orifice and bartholene’s glands.
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EXTERNAL REPRODUCTIVE ORGANS
2. Internal Structures
a. Vagina – Female organ of copulation, passageway of mens & fetus, 3 – 4inches or 8 – 10 cm long, dilated
canal.
b. Uterus- Organ of mens is a hollow, thick walled muscular organ. It varies in size, shape and weights.
Size -1x2x3
Shape: Nonpregnant - pear shaped / pregnant - ovoid
Weight - nonpregnant – 50 - 60 kg/pregnant – 1,000g
Muscular compositions: There are three main muscle layers which make expansion possible in every direction.
a. Endometrium - inside uterus, lines the nonpregnant uterus. Muscle layer for menstruation. Sloughs during
menstruation.
b. Myometrium – largest part of the uterus, muscle layer for delivery process
Its smooth muscles are considered to be the living ligature of the body.
Power of labor, responsible contraction of the uterus
Function: 1. ovulation
2. Production of hormones
4. Fallopian tubes – 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
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FEMALE INERNAL REPRODUCTIVE ORGANS
1. External Structures
a. Penis
The male organ of copulation and urination. It contains of a body of a shaft consisting of 3 cylindrical layers
and erectile tissues. At its tip is the most sensitive area comparable to that of the clitoris in the female – the
glans penis.
3 Cylindrical Layers
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2 corpora cavernosa
1 corpus spongiosum
b. Scrotum – a pouch hanging below the pendulous penis, with a medial septum dividing into two sacs, each of
which contains the testes.
cooling mechanism of testes
< 2 degrees C than body temp.
Leydig’s cell – release testosterone
2. Internal Structures
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Testes – 900 coiled (½ meter long at
age 13 onwards)
(Seminiferous tubules)
Hypothalamus
Epididymis – 6 meters coiled tubules
site for maturation of sperm
GnRH
Urethra
Male Female
Penile glans Clitoral glans
Penile shaft Clitorial shaft
Testes ovaries
Prostate Skene’s gands
Cowper’s Glands Bartholin's glands
Scrotum Labia Majora
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2. Chromosomes – threadlike strands composed of hereditary material – DNA
3. Normal amount of ejaculated sperm 3 – 5 cc., 1 tsp
4. Ovum is capable of
being fertilized with
in 24 – 36 hrs after
ovulation
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5. Sperm is viable within 48 – 72 hrs, 2-3 days
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Spermatogenesis – maturation of sperm
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Dysmenorrhea – painful menstruation
Metrorrhagia – bleeding between menstruation
Menorhagia – excessive during menstruation
Amenorrhea – absence of menstruation
Menopause – cessation of menstruation/ average : 51 years old
Primary function: prepares endometrium for implantation of fertilized ovum making it thick & tortuous (twisted)
I. On the initial 3rd phase of menstruation, the estrogen level is decreased; this level stimulates the hypothalamus
to release GnRH or FSHRF
III. Proliferative Phase – proliferation of tissue or follicular phase, post mens phase. Pre-ovulatory.
phase of increase estrogen.
IV. 13th day of menstruation, estrogen level is peak while the progesterone level is down, these stimulates the
hypothalamus to release GnRF on LHRF
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VI. 14th day estrogen level is increased while the progesterone level is increased causing rupture of graafian
follicle on process of ovulation.
VII. 15th day, after ovulation day, graafian follicle starts to degenerate yellowish known as corpus luteum (secrets
large amount of progesterone)
IX. 24th day if no fertilization, corpus luteum degenerate (whitish – corpus albicans)
X. 28th day – if no sperm in ovum – endometrium begins to slough off to begin mens
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11. Stages of Sexual Responses (EPOR)
Initial responses:
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Vasocongestion – congestion of blood vessels
Myotonia – increase muscle tension
1. Excitement Phase – (sign present in both sexes, moderate increase in HR, RR,BP, sex flush, nipple erection) –
erotic stimuli cause increase sexual tension, lasts minutes to hours.
2. Plateau Phase – (accelerated V/S) – increasing & sustained tension nearing orgasm. Lasts 30 seconds – 3 minutes.
3. Orgasm – (involuntary spasm throughout body, peak v/s) involuntary release of sexual tension with physiologic
or psychologic release, immeasurable peak of sexual experience. May last 2 – 10 sec- most affected are is pelvic
area.
Refractory Period – the only period present in males, wherein he cannot be restimulated for about 10-15 minutes
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IV. Pregnancy & Prenatal Care
A. Fertilization
The union of the sperm and the mature ovum in the outer third or outer half of the fallopian tube.
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B. Implantation
Immediately after fertilization, the fertilized 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 16 – 50 blastomeres, it is now termed as morula. In this morula form, it will start to
travel (by ciliary action and peristaltic contraction 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 blastocyst. Fingerlike
projections, called trophoblasts, form around the blastocysts and these trophoblasts are the one 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.
Implantation occurs 8-1 days after fertilization. Implantation must be in the upper portion of the
endometrium. The fertilized ovum will embed itself into the rich endometrial lining.
General Considerations:
o Once implantation has taken place, the uterine endothelium is now termed as DECIDUA.
o Occasionally, a small amount of vaginal spotting appears with implantation because capillaries are
ruptured by the implanting trophoblasts = Implantation bleeding.
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Implication: this should not be mistaken for the last menstrual period (LMP)
Signs of implantation:
1. Slight pain
2. Slight vaginal spotting
- If with fertilization – corpus luteum continues to function & become source of estrogen & progesterone
while placenta is not developed.
3 processes of Implantation
1. Apposition
2. Adhesion
3. Invasion
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Chorionic villi sampling (CVS) – removal of tissue sample from the fetal portion of the developing placenta for
genetic screening. Done early in pregnancy. Common complication fetal limb defect. Ex missing digits/toes.
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1. Cytotrophoblast – inner layer or langhan’s layer – protects fetus against syphilis. Life span is 24 wks/6 months. Before
24 weeks critical, might get infected syphilis
2. Synsitiotrophoblast – synsitial layer – responsible production of hormone. Gives rise to the fetal membranes:
“3 vessels”
A – unoxygenated blood
V – O2 blood
A – unoxygenated blood
b. Amniotic Fluid – bag of H2O, clear, odor is mousy/musty, with crystallized forming pattern, slightly
alkaline.
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Polyhydramnios, hydramnios – “More
than 1500cc” - GIT malformation
TEF/TEA, increased amt of fluid
Oligohydramnios –
“Less than 500cc” - decrease amt of
fluid – kidney disease
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Kidneys are the source of amniotic fluid in the baby.
Purpose – obtain a sample of amniotic fluid by inserting a needle through the abdomen into the amniotic sac. The
fluid is tested for:
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B. Amnioscopy – direct visualization or exam to an intact fetal membrane.
C. Fern Test - determine if amniotic fluid has ruptured or not (blue paper turns green/grey - + ruptured amniotic
fluid)
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Lecithin Sphingomyelin L/S
Ratio- 2:1 signifies fetal lung maturity not capable for RDS
b.1 Placenta – (Secundines) Greek – pancake, combination of chorionic villi + decidua basalis. Size:
500g or ½ kg
1 inch thick & 8” diameter
Functions of Placenta:
1. Respiratory System – beginning of lung function after birth of baby. Simple diffusion
2. GIT – transport center, glucose transport is facilitated, diffusion more rapid from higher to lower. If
mom hypoglycemic, fetus hypoglycemic.
3. Excretory System- artery - carries waste products. Liver of mom detoxifies fetus.
Human Chorionic Gonadotropin – maintains corpus luteum alive. It is also called the basis
of pregnancy.
Human placental Lactogen or somatomammotropin Hormone – for mammary gland
development. Has a diabetogenic effect – serves as insulin antagonist
Relaxin Hormone- causes softening joints & bones
estrogen
progestin
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C. Fetal Stage “Fetal Growth and Development”
Zygote – from fertilization till the 14th day.
Embryo – 15th day to 2 months
Fetus – From 2 mos. Until birth
Days of normal pregnancy - 266 – 280 days or equivalent to 10 lunar months or 9 Calendar months
Normal Pregnancy in weeks – 37 to 42
* Ectoderm – development of brain, skin and senses, hair, nails, mucus membrane or anus & mouth
First trimester:
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Second Month
1. All vital organs formed, placenta developed
2. Corpus luteum – source of estrogen & progesterone of infant – life span – end of 2 nd month
3. Sex organ formed
4. Meconium is formed
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Third Month
1. Kidneys functional
2. Buds of milk teeth appear
3. Fetal heart tone heard – Doppler – 10 – 12 weeks
4. Sex is distinguishable
Health Teaching!
Terratogens- any drug, virus or irradiation, the exposure to such may cause damage to the fetus
A. Drugs:
Streptomycin – anti TB & or Quinine (anti malaria) – damage to 8 th cranial nerve – poor hearing &
deafness
Tetracycline – staining tooth enamel, inhibit growth of long bone
Vitamin K – hemolysis (destr of RBC), hyperbilirubenia or jaundice
Iodides – enlargement of thyroid or goiter
Thalidomides – Amelia or pocomelia, absence of extremities
Steroids – cleft lip or palate
Lithium – congenital malformation
B. Alcohol – lowered weight (vasoconstriction on mom), fetal alcohol withdrawal syndrome char by
microcephaly
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TORCH (Terratogenic) Infections – viruses
CHARACTERISTICS: group of infections caused by organisms that can cross the placenta or ascend through birth canal
and adversely affect fetal growth and development. These infections are often characterized by vague, influenza like
findings, rashes and lesions, enlarged lymph nodes, and jaundice (hepatic involvement). In some chases the infection may
go unnoticed in the pregnant woman yet have devastating effects on the fetus. TORCH: Toxoplasmosis, Other, Rubella,
Cytomegalo virus, Herpes simples virus.
T – Toxoplasmosis – mom takes care of cats. Feces of cat go to raw vegetables or meat
O – Others. Hepa A or infectious heap – oral/ fecal (hand washing)
Hepa B, HIV – blood & body fluids
Syphilis
R – Rubella – German measles – congenital heart disease (1 st month) normal rubella titer 1:10
<1:10 – less immunity to rubella, after delivery, mom will be given rubella vaccine. Don’t get pregnant for 3
months. Vaccine is terratogenic
C – Cytomegalo virus
H – Herpes simplex virus
Second Trimester:
FOCUS – length of fetus
Fourth Month
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1. Lanugo begins to appear
2. Fetal heart tone heard fetoscope, 18 – 20 weeks
3. Buds of permanent teeth appear
Fifth Month
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2. actively swallows amniotic fluid
3. 19 – 25 cm fetus,
4. Quickening- 1st fetal movement. 18- 20 weeks primi, 16- 18 wks – multi
5. Fetal heart tone heard with or without instrument
Sixth Month
1. eyelids open
2. wrinkled skin
3. vernix caseosa present
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Third trimester: Period of most rapid growth.
FOCUS: weight of fetus
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Eighth Month
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Ninth Month
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Tenth Month – bone ossification of fetal skull
A. Systemic Changes
1. Cardiovascular System
Increase blood volume of mom (plasma blood) 30 – 50% = 1500 cc of blood
Easy fatigability, increase heart workload, slight hypertrophy of ventricles, epistaxis – due to hyperemia
of nasal membrane palpitation,
Palpitations due to stimulation of Sympathetic nerves.
Normal Values
Hct 32 – 42%
Hgb 10.5 – 14g/dL
Criteria
Pathogenic Anemia
Iron deficiency anemia is the most common hematological disorder. It affects toughly 20% of pregnant
women.
o Assessment reveals:
Pallor, constipation
Slowed capillary refill
Concave fingernails (late sign of progressive anemia) due to chronic hypoxia
Nursing Care:
Nutritional instruction – kangkong, liver due to ferritin content, green leafy vegetables such as
alugbati,saluyot, malunggay, horseradish, and ampalaya.
Parenteral Iron (Imferon) – severe anemia, give IM, Z tract- if improperly administered, it will result in
hematoma.
Oral Iron supplements (ferrous sulfate 0.3 gm, 3 times a day) empty stomach 1 hr before meals or 2 hrs after,
black stool, constipation
Monitor for hemorrhage
Alert:
Iron from red meats is better absorbed iron form other sources
Iron is better absorbed when taken with foods high in Vit C such as orange juice
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Higher iron intake is recommended since circulating blood volume is increased and heme is required from
production of RBCs
Edema – lower extremities due venous return is constricted due to large belly, elevate legs above hip level.
Vulbar varicosities - painful, pressure on gravid uterus, to relieve- position – side lying with pillow under hips or
modified knee chest position
Milk leg – skinny white legs due to stretching of skin caused by inflammation or phlagmasia albadolens
Management:
2. Respiratory System Changes – common problem SOB due to enlarged uterus & increase O2 demand
Management:
o Position - lateral expansion of lungs or side lying position.
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o Eat dry crackers or dry CHO diet 30 minutes before arising bed. Nausea afternoon - small frequent
feeding. Vomiting in pregnancy – hyperemesis gravidarum.
o Hyperemesis Gravidarum – excessive nausea and vomiting which persists beyond 3 months; may
result in Metabolic alkalosis, F&E imbalance
Primary Management
Replace fluids.
Monitor I&O
Complete bed rest is also a complete aspect of treatment
Constipation – progesterone
responsible for constipation.
o Increase fluid intake, increase fiber diet
o Fruits – papaya, pineapple, mango, watermelon, cantaloupe, apple with skin, suha.
o Except guava – has pectin that’s constipating
o Encourage/Increase exercise
o Avoid mineral oil – It interferes with absorption of fat soluble vitamins.
Flatulence – avoid gas forming food – cabbage
Heartburn – or pyrosis – reflux of stomach content to esophagus
o small frequent feeding, avoid 3 full meals, avoid fatty & spicy food, sips of milk, proper body mechanical
Increase salivation – ptyalsim – Management is mouthwash
Hemorrhoids – pressure of gravid uterus.
o Management is hot sitz bath for comfort.
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4. Urinary System – frequency during 1st & 3rd trimester lateral expansion of lungs or side lying position.
6. Emotional responses
First Trimester: No tangible signs & symptoms, surprise, ambivalence, denial – sign of maladaptation to
pregnancy.
Second Trimester – Tangible Signs & Symptoms. mom identifies fetus as a separate entity – due to presence of
quickening, fantasy.
B. Local Changes
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ESTROGEN – hormone, responsible for leukorrhea
OPERCULUM – mucus plug to seal out bacteria.
PROGESTERONE – hormone responsible for operculum
PREGNANT – acidic to alkaline change to protect bacterial growth (virginities)
a. Vaginitits – caused by trichomonas vaginalis due to alkaline environment of vagina of pregnant mother.
Flagellated protozoa – wants alkaline
Signs & Symptoms:
Greenish cream colored frothy irritatingly itchy with foul smelling odor with vaginal edema
Management:
FLAGYL – (metronidazole – antiprotozoa). Carcinogenic drug so don’t give at 1 st trimester
1. treat dad also to prevent reinfection
2. no alcohol – has antibuse effect
VAGINAL DOUCHE – IQ H2O: 1 tbsp white vinegar
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Facts:
2. Abdominal Changes – striae gravidarium (stretch marks) due enlarging uterus-destruction of subcutaneous
tissue – avoid scratching, use coconut oil, umbilicus is protruding.
3.Skin Changes – brown pigmentation nose chin, cheeks – chloasma/melasma due to increased melanocytes.
Brown pinkish line- linea nigra- symphisis pubis to umbilicus
4. Breast Changes – increase hormones, color of areola & nipple. Pre colostrums present by 6 weeks, colostrums
at 3rd trimester
Breast self exam - 7 days after menstruation –– supine with pillow at back
Quadrant B – upper outer – common site of cancer
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1. Mammography – 35 to 49 yrs once every 1 to 2 yrs
50 yrs and above – 1 x a yr
A. Presumptive – s/s felt and observed by the mother but does not confirm positive diagnosis of pregnancy .
Subjective
B. Probable – signs observed by the members of health team. Objective
C. Positive Signs – undeniable signs confirmed by the use of instrument.
o – Immature
1 – Slightly mature
2 – Moderately mature
3 – Placental maturity
A. Diagnosis of Pregnancy
1. Urine Examination
Urine exam to detect HCG at 40 – 100th day. 60 – 70 day peak HCG. 6 weeks after LMP- best to get urine
exam.
Elisa test – test for pregnancy detects beta subunit of HCG as early as 7 – 10days
Home pregnancy kit – do it yourself
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1. History taking
a. Personal data – name, age (high risk < 18 & > 35 yrs old) record to determine high risk – HBMR.
Home based mother record. Sex (pseudocyesis or false pregnancy on men & women)
Couvade syndrome – dad experiences what mother goes through – lihi
Address, civil status, religion, culture & beliefs with respect, non judgmental
Occupation – financial condition or occupational hazards, education background – level knowledge
b. Baseline Data: V/S especially BP, monitor weight (increase weight – 1st sign preeclampsia)
Weight Monitoring
c. Obstetrical Data:
nullipara – no pregnancy
Gravida - # of pregnancy
Para - # of viable pregnancy
Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age.
Sample Cases:
1 – abortion GTPAL
1 – 2nd months 20 010
G–2
P–0
1 – 39th week
1 – Miscarriage GP GTPAL
1 – Stillbirth 33 AOG (considered as para) 42 4111 1
1 – Pregnant, 3rd wk
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d. Medical Data – is there a history of kidney, cardiac or liver diseases, hypertension, tuberculosis, or sexually
transmitted diseases.
2. Assessment
a. Physical Examination
Increase BP – HPN
Blurred vision – preeclampsia
Bleeding – 1st trimester, abortion, ectopic preg/2nd – H mole, incompetent cervix
3rd – placental anomalies
b. Pelvic Examination
Result:
Class I - normal
Class IIA – cytology but no evidence of malignancy
B – suggestive of inflammation
Class III – cytology suggestive of malignancy
Class IV – cytology strongly suggestive of malignancy
Class V – cytology conclusive of malignancy
Purpose: is done to determine the attitude, fetal presentation lie, presenting part, degree of descent, an estimate of
the size, and number of fetuses, position, fetal back & fetal heart tone
Use palm! Warm palm
1. Empty bladder
2. Position of mom-supine with knee flex (dorsal recumbent – to relax abdominal muscles)
Procedure:
1st maneuver: place patient in supine position with knees slightly flexed; put towel under head and right hip; with
both hands palpate upper abdomen and fundus. Assess size, shape, movement and firmness of the part to
determine presentation
2nd Maneuver: with both hands moving down, identify the back of the fetus (to hear fetal heart sound) where the
ball of the stethoscope is placed to determine FHT. Get V/S(before 2 nd maneuver) PR to diff fundic soufflé (FHR)
& uterine soufflé.
Uterine soufflé – maternal H rate
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3rd Maneuver: using the right hand, grasp the symphis pubis part using thumb and fingers.
To determine degree of engagement.
Assess whether the presenting part is engaged in the pelvis) Alert : if the head is engaged it will not be movable).
4th 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. To determine attitude – relationship of fetus to
1 another.
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 will be flexed and vertex presenting.
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c. Urine Examination
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Heat Acetic Acid test –To test for protein in the urine
Denatured Alcohol is used, test tube, test tube holder, 10 drops of urine, 3-5 ml of acetic acid.
After heating for 3 minutes
o Clear (-) for albumin
o Cloudy (+) for albumin precipitate
Both solution may expire if Acetic Acid (Brown), Benedicts (Violet), then discard.
3. Important Estimates
FUNDIC HT X 7/8=AOG in WK
4. Health Teachings
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- Maintenance of - 1600 mg/day is recommended for - green leafy vegetables
mineralization of maternal the adolescent. 10 mcg/day of - canned salmon & sardines w/ bones
bones and teeth vitamin D is required since it - Ca fortified foods such as orange
- Current research is : enhances absorption of both juice
Demonstrating an association calcium and phosphorous - Vitamin D sources: fortified milk,
between adequate calcium intake and margarine, egg yolk, butter, liver,
the prevention of pregnancy induce seafood
hypertension
b. Sexual Activity
Contraindication in sex:
1. Vaginal spotting
1st trimester – threatened abortion
2nd trimester– placenta previa
2. Incompetent cervix
3. Preterm labor
4. Premature rupture of membrane
Principles of exercise
Done in moderation
Must be individualized
Squatting – strengthen muscles of perineum. Increase circulation to perineum. Squat – feet flat on floor
Raise buttocks 1st before head to prevent postural hypotension – dizziness when changing position
d. Childbirth Preparation:
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Overall goal: to prepare parents physically and psychologically while promoting wellness behavior that can be
used by parents and family thus, helping them achieved a satisfying and enjoying childbirth experience.
“Psychophysical”
1. Bradley Method – Dr. Robert Bradley – advocated active participation of husband at delivery process. Based
on imitation of nature.
Features:
2. Grantly Dick Read Method – fear leads to tension while tension leads to pain
“Psychosexual”
1. Kitzinger method – preg, labor & birth & care of newborn is an important turning pt in woman’s life cycle
flow with contraction than struggle with contraction
Features:
1. Conscious relaxation
2. Cleansing breathe – inhale nose, exhale mouth
3. Effleurage – gentle circular massage over abdominal to relieve pain
4. imaging – sensate focus
5. Tetanus Immunization
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A. Daily Fetal Movement Counting (DFMC) –begin 27 weeks
Mom- begin after meal - breakfast
(1) 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)
(4) Warning signs should be reported to healthcare provider immediately; often require further testing. Examples:
nonstress test (NST), biographical profile (BPP)
B. Nonstress test – to determine the response of the fetal heart rate to activity
Postmaturity
Procedure:
Done within 30 minutes wherein the mother is in semi-fowler’s position (w/ fetal monitor); external monitor is
applied to document fetal activity; mother activates the “mark button” on the electronic monitor when she feels
fetal movement.
1. tocotransducer over fundus to detect uterine contractions and fetal movements (FMs)
2. ultrasound transducer over abdominal site where most distinct fetal heart sounds are detected
3. monitor until at least 2 FMs are detected in 20 minutes
if no FM after 40 minutes provide woman with a light snack or gently stimulate fetus through abdomen
if no FM after 1 hour further testing may be indicated, such as a CST
Result:
Nonreactive
Nonstress
Not Good
Reactive
Responsive is
Real Good
Interpretation of results
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A. Reactive result
B. Nonreactive result
Requires further evaluation with another NST, biophysical profile, (BPP) or contraction stress test (CST)
1.) Uterine stretch theory (any hallow organ stretched, will always contract & expel its content) – contraction
action
2.) Oxytocin theory – post pit gland releases oxytocin. Hypothalamus produces oxytocin
3.) Prostaglandin theory – stimulation of arachidonic acid – prostaglandin- contraction
4.) Progesterone theory – before labor, decrease progesterone will stimulate contractions & labor
5.) Theory of aging placenta – life span of placenta 42 wks. At 36 wks degenerates (leading to contraction – onset
labor).
1. Passenger
a. Fetal head – is the largest presenting part – common presenting part – ¼ of its length.
Bones – 6 bones
S – Sphenoid
E – Ethmoid
T – Temporal Bones (2)
F – Frontal/Sinciput
O – Occuputal/occiput
P – Parietal (2)
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Measurement fetal head:
1. Transverse diameter
a. biparietal – 9.25cm, largest transverse
b. bitemporal - 8 cm
c. bimastoid 7cm smallest transverse
2. Anteroposterior diameters
a. suboccipitobregmatic - 9.5 cm, complete flexion, smallest AP
b. occipitofrontal - 12cm partial flexion
c. occipitomental – 13.5 cm hyper extension, submentobragmatic - face presentation
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Sutures – intermembranous spaces that allows molding.
Sagittal suture – connects 2 parietal bones
Coronal suture – connect parietal & frontal bone (crown)
Lambdoidal suture – connects occipital & parietal bone
Molding: the overlapping of the sutures of the skull to permit passage of the head to the pelvis; usually reserved
by 3 days after birth.
Fontanels: membrane - covered spaces at the junction of the main suture lines.
a. Anterior fontanels – bregma, diamond shape, 3 x 4 cm,( > 5 cm – hydrocephalus), 12 – 18 months after
birth – close
b. Posterior fontanel or lambda – triangular shape, 1 x 1 cm. closes – 2 – 3 months.
2. Passageway
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Mom
1. Gynecoid – round, wide, deeper most suitable (normal female pelvis) for pregnancy
2. Android – heart shape “male pelvis”- anterior part pointed, posterior part shallow
3. Anthropoid – oval, ape like pelvis, oval shape, AP diameter wider transverse narrow
4. Platypelloid – flat AP diameter – narrow, transverse – wider
Pelvimetry – x ray of the pelvis to determine if the fetus can pass through NSD.
Pelvis is a bony ring interposed between the trunk and the thigh. It serves to both support and protect the
reproductive and other pelvic organs.
Structures :
It composed of four bones: 2 innominate bones or hip bones, 1 sacrum and 1 coccyx.
1. Ilium – the largest portion of the bones forming the upper and back part of the pelvis.
iliac crest – the curved boarder which gives grace to the female figure.
anterior superior and posterior superior iliac spine – the terminal point of ilium.
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ischial tuberosities – a pair of large prominence at the lower most part of the ischia on which the bone
rests when in sitting position.
ischial spine – a pair of small projections.
4. SACRUM - wedge- shaped bone composed of 5 sacral vertebral. It serves as the back part of the
pelvis.
COCCYX – a small movable bone consists of 4 coccygeal vertebral. It forms as tail end to the spine.
Important Measurements
1. Diagonal Conjugate – measure between sacral promontory and inferior margin of the symphysis pubis.
Measurement: 11.5 cm - 12.5 cm basis in getting true conjugate. (DC – 11.5 cm=true conjugate)
2. True conjugate/conjugate vera – measure between the anterior surface of the sacral promontory and superior
margin of the symphysis pubis.
Measurement: 11.0 cm
3. Power – the force acting to expel the fetus and placenta – myometrium – powers of labor
a. Involuntary Contractions
b. Voluntary bearing down efforts
c. Characteristics: wave like
d. Timing: frequency, duration, intensity
4. Psyche/Person – psychological stress when the mother is fighting the labor experience
a. Cultural Interpretation
b. Preparation
c. Past Experience
d. Support System
Nursing Care:
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 form vagina
Nursing Care:
Cover cord with sterile gauze with saline to prevent drying of cord so cord will remain slippery & prevent
cord compression causing cerebral palsy.
Slip cord away from presenting part
Count pulsation of cord for FHT
Prep mom for CS
Duration of Labor
Primipara – 14 hrs & not more than 20 hrs
Multipara – 8 hrs & not > 14 hrs
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Nursing Interventions in Each Stage of Labor
D. Stages of
Labor
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1. First Stage: onset of true contractions to full dilation and effacement of cervix.
Latent Phase:
Active Phase:
Assessment: Dilations 4 -8 cm
Intensity: moderate Mom - fears losing control of self
Frequency – q 3-5 mins lasting for 30 – 60 seconds
Nursing Care:
M – edications – have meds ready
A – ssessment include: vital signs, cervical dilation and effacement, fetal monitor, etc.
D – dry lips – oral care (ointment)
Dry linens
B – Abdominal breathing
Transitional Phase:
Intensity: strong Mom – mood changes with hyperesthesia
Assessment: Dilations 8 – 10 cm
Frequency q 2-3 min contractions
Durations 45 – 90 seconds
Nursing Care:
T – ires
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I – nform of progress
R – estless support her breathing technique
E – ncourage and praise
D – iscomfort
Pelvic Exams
Effacement
Dilation
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b. Presentation/lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother
spine of mom and spine of fetus
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Two types:
“Breech”
Complete Breech – thigh breast on abdomen, breast lie on thigh
Incomplete Breech – thigh rest on abdominal
Frank – legs extend to head
Footling – single, double
Kneeling
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b.2. Transverse Lie (Perpendicular) or Perpendicular lie. Shoulder presentation.
c. Position – relationship of the fatal presenting part to specific quadrant of the mother’s pelvis.
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“Vertex”
Occiput – LOA Left Occiput Anterior (most common and favorable position) – side of maternal pelvis
LOP – left occipito posterior
LOP – most common mal position, most painful
“Breech”
“Shoulder/acromniodorso”
“Chin / Mento”
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Parts of contractions:
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Contraction – vasoconstriction
Increase BP, decrease FHT
Best time to get BP & FHT just after a contraction or midway of contractions
Mom has headache – check BP, if same BP, let mom rest. If BP increases, notify MD –preeclampsia
Health teachings
1.) Ok to shower
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2.) NPO – GIT stops function during labor if with food- will cause aspiration
3.) Enema administer during labor
a.) To cleanse bowel
b.) Prevent infection
c.) Sims position/side lying
Assist doc in doing episiotomy- to prevent laceration, widen vaginal canal, and shorten 2 nd stage of labor.
Episiotomy – median – less bleeding, less pain easy to repair, fast to heal, possible to reach rectum (urethroanal
fistula)
Mediolateral – more bleeding & pain, hard to repair, slow to heal
use local or pudendal anesthesia.
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Mechanisms of labor
1. Engagement
2. Descent
3. Flexion
4. Internal Rotation
5. Extension
6. External rotation
7. Expulsion
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Three parts of Pelvis
Linea Terminales diagonal imaginary line from the sacrum to the symphysis pubis that divides the false and true pelvis.
Nursing Care:
Shultz “shiny” – begins to separate from center to edges presenting the fetal side shiny
Dunkan “dirty” – begin to separate form edges to center presenting natural side – beefy red or dirty
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Check completeness of placenta.
Check fundus (if relaxed, massage uterus)
Check BP
Administer methergine IM (Methylergonovine Maleate) “Ergotrate derivatives”
Monitor Hypertension (or give oxytocin IV)
Check perineum for lacerations
Assist MD for episioraphy
Flat on bed
Chills-due dehydration. Blanket, give clear liquid-tea, ginger ale, clear gelatin. Let mom sleep to regain energy.
3. Fourth Stage: the first 1-2 hours after delivery of placenta – recovery stage.
Monitor v/s q 15 for 1 hr. 2nd hr q 30 minutes.
Nursing Management:
E. Complications of Labor
Dystocia
difficult labor related to:
2.) Hypotonic – secondary uterine inertia- slow irregular contraction resulting to ineffective pushing. Give oxytocin.
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Prolonged labor
normal length of labor in primi 14 – 20 hrs
Multi 10 -14 hrs
> 14 hrs in multi & > 20 hrs in primi
Maternal effect – exhaustion. Fetal effect – fetal distress, caput succedaneum or cephal hematoma
Nursing Care: monitor contractions and FHR
Precipitate Labor
Labor of < 3 hrs. Extensive lacerations, profuse bleeding, hypovolemic shock if with bleeding.
Causes:
1.) Previous classical CS
2.) Large baby
3.) Improper use of oxytocin (IV drip)
Management: Hysterectomy
Trial Labor – measurement of head & pelvis falls on borderline. Mom given 6 hrs of labor
Multi: 8 – 14, primi 14 – 20
Preterm Labor
Home Management:
1. Complete bed rest
2. Avoid sex
3. Empty bladder
4. Drink 3 -4 glasses of water – full bladder inhibits contractions
5. Consult MD if symptoms persist
Hosp:
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1. If cervix is closed 2 – 3 cm, dilation saved by administer Tocolytic agents- halts preterm
contractions.YUTOPAR- Yutopar Hcl)
150mg incorporated 500cc Dextrose piggyback.
Monitor: FHT > 180 bpm
Maternal BP - <90/60
Crackles – notify MD – pulmo edema – administer oral yutopar 30 minutes before d/c IV
Tocolytic (Phil)
Terbuthaline (Bricanyl or Brethine) – sustained tachycardia
Antidote – propranolol or inderal - beta-blocker
VI. Puerperium
A. Definitions:
Hyperfibrinogenia
b. Genital Changes
Cervix – cervical opening
Vaginal and Pelvic Floor
Uterus – return to normal 6 – 8 wks. Fundus goes down 1 finger breath/day until 10 th day – no longer palpable due
behind symphisis pubis
3 days after post partum: sub involuted uterus – delayed healing uterus with big clots of blood- a medium for
bacterial growth- (puerperal sepsis)- D&C
After, birth pain:
1. Position prone
2. Cold compress – to prevent bleeding
3. mefenamic acid
Lochia - blood, wbc, deciduas, microorganism. NSD & CS Both have Lochia.
Dysuria
urine collection
alternate warm & cold compress
stimulate bladder
Perineal area – painful – episiotomy site – sim’s position, cold compress for immediate pain after 24 hrs, hot sitz bath, not
compress
c. Urinary Changes: Bladder – freq in urination after delivery- urinary retention with overflow
d. Gastrointestinal Changes - Colon: Constipation – due NPO, fear of bearing down
Psychological Responses:
a. Taking in phase – dependent phase (1st three days) mom – passive, cant make decisions, activity is to tell child
birth experiences.
b. Taking hold phase – dependent to independent phase (4 to 7 days). Mom is active, can make decisions
Health Teaching:
c. Letting go – interdependent phase – 7 days & above. Mom - redefines new roles may extend until child grows.
3. Prevent complications
a. Early postpartum hemorrhage – bleeding within 1st 24 hrs. Baggy or relaxed uterus & profuse bleeding - uterine
atony.
Management:
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1st degree laceration – affects vaginal skin & mucus membrane.
2nd degree – 1st degree + muscles of vagina
3rd degree – 2nd degree + external sphincter of rectum
4th degree – 3rd degree + mucus membrane of rectum
Breast feeding – post pit gland will release oxytocin so uterus will contract.
Well contracted uterus + bleeding = laceration
assess perineum for laceration
degree of laceration
Management: Episiorraphy
Management:
1.) cold compress every 30 minutes with rest period of 30 minutes for 24 hrs
2.) shave
3.) incision on site, scraping & suturing
a. Sources
c. General Management:
Supportive care – CBR, hydration, TSB, cold compress, paracetamol, VITC, culture & sensitivity – for
antibiotic
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o Prolonged use of antibiotic lead to fungal infection
Specific Symptoms:
2 to 3 stitches dislocated with purulent discharge
Management:
Endometritis
Symptoms:
a. Abdominal tenderness
b. Uterus is not contracted and Painful to touch
Specific Management:
Basal Body Temperature - 13th day temp goes down before ovulation – no sex
get before arising in bed
Social Method
OVULATION –count minus 14 days before next mens (14 days before next mens)
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Origoknause formula –
- monitor cycle for 1 year
- -get short test & longest cycle from Jan – Dec
- shortest – 18
- longest – 11
June 26 Dec 33
- 18 -11
8 - 22 unsafe days
Physiologic Method
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Pills – combined oral contraceptives prevent ovulation by inhibiting the anterior pituitary gland production of FSH and
LH which are essential for the maturation and rupture of a follicle. 99.9% effective. Waiting time to become pregnant- 3
months. Consult OB-6mos.
In case a mother who is taking an oral contraceptive for almost long time plans to have a baby, she would wait for
at least 3 months before attempting to conceive to provide time for the estrogen and progesterone levels to return
to normal.
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 is an indication of hypertension
associated with increase incidence of CVA and subarachnoid hemorrhage.
Signs of hypertension
Immediate Discontinuation
A – Abdominal pain
C – chest pain
H - headache
E – eye problems
S – Severe leg cramps
If mom HPN – stop pills STAT!
Adverse effect: breakthrough bleeding
Contraindicated:
chain smoker
extreme obesity
HPN
DM
Thrombophlebitis or problems in clotting factors
If forgotten for one day, immediately take the forgotten tablet plus the tablet scheduled that day. If forgotten for
two consecutive days, or more days, use another method for the rest of the cycle and the start again.
Norplant – has 6 match sticks – like capsules implanted subdermally containing progesterone.
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Mechanism and Chemical Barriers
Health Teachings:
Check for string daily
Monthly checkup
Regular pap smear
Alerts:
prevents implantation
most common complications: excessive menstrual flow and expulsion of the device (common problem)
Others:
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P eriod late (pregnancy suspected)
Abnormal spotting or bleeding
A bdominal pain or pain with intercourse
I nfection (abnormal vaginal discharge)
N ot feeling well, fever, chills
S trings lost, shorter or longer
Uterine inflammation, uterine perforation, ectopic pregnancy
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Alerts:
Disadvantage:
it lessen sexual satisfaction
it gives higher protection in the prevention of STDs
Diaphragm – rubberized dome shaped material inserted to cervix preventing sperm to get to the uterus.
REVERSABLE
Health Teachings:
1.) proper hygiene
2.) check for holes before use
3.) must stay in place 6 – 8 hrs after sex
4.) must be refitted especially if without wt change 15 lbs
5.) spermicide – chem. Barrier ex. Foam (most effective), jellies, creams
S/effect: Toxic shock syndrome
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Cervical Cap – most durable than diaphragm no need to apply spermicide
C/I: abnormal Pap smear
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Surgical Method – BTL, Bilateral Tubal Ligation – can be reversed 20% chance. HT: avoid lifting heavy objects
1.) CBR
2.) Avoid sex
3.) Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)
4.) Ultrasound to determine integrity of sac
5.) Signs of Hypovolemic shock
6.) Save discharges – for histopathology – to determine if product of conception has been expelled or not
Cause:
1.) Chromosomal alterations
2.) Blighted ovum
3.) Plasma germ defect
Classifications:
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a. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
b. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)
Types:
1.) Complete – all products of conception are expelled. No mgt just emotional support!
2.) Incomplete – Placental and membranes retained. Mgt: D&C
Incompetent cervix – abortion
McDonald’s procedure – temporary circlage on cervix
S/E; infection. During delivery, circlage is removed. NSD
Sheridan – permanent surgery cervix. CS
c. Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2nd
trimester
d. Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg
test, scanty dark brown bleeding
Mgt: induced labor with oxytocin or vacuum extraction
5.) Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser evil.
C. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity.
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Administer IV fluids Surgery depending on side
Monitor for vaginal bleeding Ovary: oophrectomy
Monitor I & O Uterus : hysterectomy
Gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of
the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46
XX, it grows & enlarges the uterus vary rapidly.
Assessment:
Early signs
vesicles passed thru the vagina
Hyperemesis gravidarium increase HCG
Fundal height
Vaginal bleeding( scant or profuse)
Early in pregnancy
High levels of HCG
Preeclampsia at about 12 weeks
Late signs
hypertension before 20th week
Vesicles look like a “ snowstorm” on sonogram
Anemia
Abdominal cramping
Serious complications
Hyperthyroidism
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Pulmonary embolus
Nursing care:
Prepare D&C
Do not give oxytoxic drugs
Teachings:
a. Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising
titer could indicative of choriocarcinoma
b. Avoid pregnancy for at least one year
D. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes
covering the cervical os. Abnormal lower implantation of placenta.
candidate for CS
Dx:
Ultrasound
Avoid: sex, IE, enema – may lead to sudden fetal blood loss
Double set up: delivery room may be converted to OR
Assessment:
Engagement (usually has not occurred)
Fetal distress
Presentation (usually abnormal)
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- MD explain to patient
Complication: sudden fetal blood loss
Nursing Care
NPO
Bed rest
Prepare to induce labor if cervix is ripe
Administer IV
E. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It usually occurs after the
twentieth week of pregnancy.
Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.
Assessment:
Concealed bleeding (retroplacental)
Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.
Severe abdominal pain
Dropping coagulation factor (a potential for DIC)
Complications:
Sudden fetal blood loss
placenta previa & vasa previa
Nursing Care:
Infuse IV, prepare to administer blood
Type and crossmatch
Monitor FHR
Insert Foley
Measure blood loss; count pads
Report s/sx of DIC
Monitor v/s for shock
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Strict I&O
F. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained
placental fragments if vessel is cut.
H. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
K. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
C. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.
3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.
Cause of preeclampsia
1.) idiopathic or unknown common in primi due to 1st exposure to chorionic villi
2.) common in multiple pre (twins) increase exposure to chorionic villi
3.) common to mom with low socioeconomic status due to decrease intake of CHON
Nursing care:
P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate.
Fetal effect:
Newborn Effect: DM
1.) hyperinsulinism
2.) hypoglycemia
normal glucose in newborn 45 – 55 mg/dL
hypoglycemic < 40 mg/dL
Heel stick test – get blood at heel
Sx:
Hypoglycemia high pitch shrill cry tremors, administer dextrose
Recommendation
Therapeutic abortion
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If push through with pregnancy
1.) antibiotic therapy- to prevent sub acute bacterial endocarditis
2.) anticoagulant – heparin doesn’t cross placenta
Heart disease
Class III - moderate limitation of physical activity. Ordinary activity causes discomfort
Recommendation:
1.) Early hospitalization by 7 months
Class IV. Marked limitation of physical activity. Even at rest there is fatigue & discomfort.
Recommendation: Therapeutic abortion
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a. Multiple gestation
b. Diabetes
c. Active herpes II
d. Severe toxemia
e. Placenta previa
f. Abruptio placenta
g. Prolapse of the cord
h. CPD primary indication
i. Breech presentation
j. Transverse lie
Procedure:
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DISORDERS OF SEXUAL FUNCTIONING
Causes :
a. psychosomatic – anxiety
b. social and economic difficulties
c. local lesion, rigid hymen
3. Impotence / erectile dysfunction – inability to achieve a sustained erection sufficient to allow vaginal penetration.
Causes :
a. drugs and alcohol
b. psychologic – stress, depression
c. congenital
Mgt:
a. depends on the causes
b. sexual counseling
4. Premature ejaculation – ejaculation before penile – vaginal contact. It can cause unsatisfactory for both partners.
Causes :
a. psychologic
b. masturbating to orgasm
c. doubt about masculinity
d. fear of impregnating
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Mgt :
sexual counseling
5. Female orgasmic dysfunction – woman who does not attain orgasm during their entire life span.
Factors :
a. religious prohibition
b. being raised in a protective environment that excluded acknowledgement of sexual feeling or behavior.
c. Inability to identify with one’s inadequate partner
d. Marriage with inadequate man
6. Vaginismus - involuntary contraction of the muscles at the outlet of vagina when coitus is attempted. It may occur in woman
who has been raped.
Dx:
Pelvic exam.
Factors :
a. married to impotent men
b. family background reflect the attitude that sex was considered “ dirty or sinful “
Predisposing factors :
a. death of family member
b. divorce
c. stressful job
Types of infertility :
a. Primary infertility – there have been no previous conception.
b. Secondary infertility – there have been a previous viable pregnancy but unsuccessful .
c. Idiopathic infertility – no definite cause for the infertility can be found.
Components of fertility :
1. The husband must produce sperm of adequate quantity and quality.
2. The sperm must gain entry not only into the vagina but into the womb itself during the wife’s fertile period.
3. The wife must ovulate.
4. The egg must be of good quality.
5. The wife’s tube must be open to received the egg each month and to permit the entry of sperm.
6. The tubes and womb must not be obstructed to permit a fertilized egg free passageway into the uterus and it should also
have a lining favorable for the implantation.
7. The various glands concerned with reproduction must be working harmoniously.
Causes of infertility :
A. Male
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1. Inadequate sperm count
Azoospermia - absence of sperm
Oligospermia
Factors contributing to infertility :
1. Genetic or developmental factors
a. production of deformed sperm
b. abnormalities of testicle
c. epispadias or hypospadias
d. chromosomal trisomy ( xxy )
2. Hormonal factors
3. Mechanical obstructions
a. retrograde ejaculation
b. spinal cord injury or disease
c. adhesion from previous surgery
d. salphingitis
e. endometriosis
f. repair of ectopic pregnancy
4. Chemical or environmental factors
a. drug abuse
b. alcoholism
c. excessive hot tub use
d. strenuous exercises
e. obesity or extreme underweight
5. Inflammatory process and immunologic factors
a. gonorrhea
b. prostatitis
c. epididymitis
d. post abortion sepsis
6. Psychogenic factors
a. physical or mental stress
b. poor information regarding sexual technique
c. anorexia nervosa
Causes of Infertility :
A. Male
1. Inadequate sperm count
Azoospermia – absence of sperm
Oligospermia – decrease sperm count
Asthenospermia – decrease motility
Teratospermia – low percentage, abnormal morphology
Causes :
1.1. chronic disease such as PTB or recurrent sinusitis because of slightly elevated temperature, there is a decrease in
spermatozoa
1.2. orchitis that follows mumps
1.3. exposure to excessive x – rays or radioactive substance
1.4. excessive use of alcohol or drugs ( alcohol causes erectile problem )
1.5. low vitamin intake
1.6. surgery near the testes
1.7. presence of varicocele ( varicosity of the spermatic vein )
1.8. Heavy use of marijuana, alcohol or cocaine with 2 years of testing – can depress sperm count and testosterone level.
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1.9. Cigarette smoking may depress sperm motility
2. Obstruction of sperm motility may occur at any point in the pathway that spermatozoa must travel to reach the outside.
3. Changes in seminal fluid – infection of the prostate gland through which seminal fluid passes or infection of the seminal
vesicles change the composition of seminal fluid to reduce sperm motility.
4. Dificulty with ejaculation – too frequent intercourse may reduce sperm count. Abnormalities of the penis such as
hypospadias ( urethral opening in the ventral surface of the penis ) or epispadias ( opening in the dorsal surface may
cause deposition of spermatozoa too far from the cervix to allow for cervical penetration.) Psychological problems and
premature ejaculation may affect the proper deposition of sperm.
Assessment :
a. history taking - ask the client on :
congenital problem
coital position used
contraceptive method used
occupation and work habit
frequency of intercourse and masturbation
ever fathered by a previous marriage or relationship
b.physical assessment – observation of secondary sexual characteristics and genital abnormalities.
Semen is collected after 2 – 3 days of abstinence and usually by masturbation to avoid contamination or loss of any ejaculate
and brought to the lab. In a sealed container within of ejaculation. Exposure to excessive heat or cold is avoided. Repeated semen
analysis maybe required to assess the male’s fertility potential adequately. Because of the cycle of spermatogenesis is 72 days, semen
collection should be repeated at least 74 days apart to allow for new sperm maturation.
III. Post coital test – for adequacy of coital technique, cervical mucus, sperm and degree of sperm penetration through cervical
mucus. It is performed within 2 hours after ejaculation of semen into the vagina and performed only in the absence of vaginal
infection.
Therapy :
1. Drug therapy - testosterone enanthate ( Delatestryl ) and testosterone cypionate ( Depo – testosterone ) by injection - to
stimulate virilization.
hCG ( Pregnyl ) – to restore leydig cell function and spermatogenesis.
FSH and hMG – aid hCG for completion of spermatogenesis.
B. Female
1. Anovulation -
Causes :
a. pituitary or thyroid disturbance
b. immaturity or disease of the ovaries
c. excessive wt. Gain
d. excessive exercise
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e. extreme emotional stress
f. excessive hair growth, acne, oily skin
Test :
1.1 Basal body temperature - aid in identifying follicular, ovulatory and luteal phase abnormalities. It should be taken every
morning before getting out of bed . ( after at least 3 hours of sleep ) Basal temperature in the preovulatory phase is usually
below 36.7 C ( 98 F ) . As ovulation approaches, production of estrogen increase and at its may cause a slight drop, then rise,
in the basal temperature. When ovulation occurs, there is s surge of LH and progesterone is produced by the corpus luteum
causing 0.3 C to 0.6 C ( 0.5 F to 1.0 F ) increase in basal temperature.
1.2 Fern test – usually done at midcycle and again before midcycle and again before menstruation. When high level of estrogen
are present in the body, as they are just prior to ovulation, the cervical mucus forms fern like patterns when it is smeared and
dried in a glass slide. When progesterone is the dominant hormone, a fern pattern is no longer discernible.
1.3 Spinnbarkeit test or mucus elasticity – at the height of estrogen secretion, the cervical mucus becomes thin and watery and can
be stretched and when progesterone is the dominant hormone, it is contrast to its state.
1.4 Uterine endometrial biopsy – provides information about ovulation by assessing the adequacy of corpus luteum function and
endometrial receptivity. A corkscrew like appearance of the endometrium suggest ovulation has occurred. It is done by
introducing a thin probe and biopsy forcep through the cervix. It is usually done during the 24th – 26th day of a typical
menstrual cycle and contraindicated if pregnancy and infection is suspected.
1.5 Culdoscopy – a sterile procedure performed to permit visualization of the organ of reproduction through a culdoscope inserted
into the posterior fornix of the vaginal canal. Both ovaries can be inspected grossly for the presence of a graafian follicle,
corpus luteum or corpus albicans.
2. Tubal factors
Causes :
a. chronic pelvic inflammatory disease
b. rupture appendix or abdominal surgery
c. congenital webbing or strictures of the fallopian tube
Test :
1.1. Rubin test - done in the 3rd day following cessation of menstrual flow, before the ovum has entered the fallopian tube. Carbon
dioxide is instilled into the cervix under pressure. It passes through the uterus and fallopian tube into the pelvic cavity if the
tubes are patent. After few hours, as the carbon dioxide is diffused into the peritoneum and collects under the diaphragm, the
woman experience sharp pain one or both shoulders. This is normal. It is contraindicated when uterine bleeding or infection is
present.
1.2. Hysterosalpingography (HSG) or Hysterogram – involves an instillation of a radiopaque substance into the uterine cavity. As
the substance fills the uterus and fallopian tube and spills into the peritoneal cavity, it is viewed with x – ray technique. It
should be performed in the proliferative phase of the cycle to avoid interrupting an early pregnancy. It causes moderate
discomfort and serious recurrence of PID.
1.3. Hysteroscopy – allow further evaluation on any areas of suspicion within the uterine cavity revealed by HSG.
1.4. Laparoscopy – direct visualization of the pelvic organs and is usually done 6 – 8 mos. After HSG unless symptoms suggest
the need for earlier evaluation.
3. Uterine factors
Causes :
a. tumors
b. congenital deformed uterine cavity
c. Inadequate endometrium formation resulting from poor secretion of estrogen and progesterone.
d. previous D and C
e. induced abortion
f. recurrent abortion
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g. menorrhagia
Test :
same with tubal test
4. Cervical factors - wherein the sperm is in hostile environment or cannot penetrate the cervix to pass into the uterus.
Causes :
a. infection of the cervix
b. tight cervical OS
c. previous cervical surgery
d. postpartum D and C
e. douching
Test:
4.1. Sims – Huhner test – help to assess abnormalities in cervical mucus and sperm motility. The basal body temperature is
taken and during ovulation, the couple should have intercourse. After intercourse, woman lies on her back for at least 30 mins.
To ensure that spermatozoa will reach the cervix.
5. Vaginal factors
Causes :
a. infection
b. blood incompatibility
Test :
5.1. Pelvic examination
6. Pelvic factors
Causes :
a. history of appendectomy, abdominal surgery
b. PID
c. IUD insertion
d. Premenstrual bleeding, dysmenorrhea, dyspareunea
Assessment :
1. History taking - ask the client on :
menstrual history including age of menarche, length and frequency of menstrual period, amount of flow
present or past infection
over all health
abdominal or pelvic operation
previous pregnancy or abortion
family planning device used
occupational hazard
2. Physical assessment
3. Laboratory test - urinalysis
CBC
Serologic test
3. Parlodel – act directly on the prolactin secreting cells in the anterior pituitary. It inhibit the pituitary’s secretion of FSH and
LH. This restores normal menstrual cycles and induces ovulation by allowing FSH and LH production.
4. Danazol ( Danocrine ) – maybe given to suppress ovulation and menstruation and to effect atrophy of the ectopic endometrial
tissue.
5. Gonadotropin- releasing hormone ( GnRH ) – a therapeutic tool for ovulation stimulation. It is used for women who have
insufficient endogenous release of GnRH. The length of treatment varies from 2 – 4 wks. and HCG is also given to stimulate
ovulation.
OPERATIVE OBSTETRICS
A. FORCEP DELIVERY
Obstetric forcep is an instrument designed to deliver the head of the fetus .
Parts of forcep:
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4. Handle
NURSING CARE:
1. Explain the procedure.
2. Encourage pt. To maintain breathing tech.
3. Monitor contraction and FHR
to the mother :
a. extensive laceration
b. hemorrhage
c. infxn
to the baby :
a. intracranial injuries
b. disfigurement
B. VACUUM EXTRACTOR
Instrument designed to facilitate the delivery of the fetal head by using suction ,applied to the fetal head and the traction
gained with the uterine contraction.
CONTRAINDICATION:
C. CAESARIAN OPERATION
Defined as delivery of the fetus through incision in the abdominal wall and uterine wall.
SURGICAL TECH.
A. SKIN INCISION
1. Transverse ( pfannensteil )- made across the lowest and narrowest part of the abdomen.
bec. The incision is made just below the pubic hair line, it is almost invisible after healing.
2. Vertical ( infraumbilical /midline ) – made between the navel and symphysis pubis.
Incision is quicker and preferred in cases of fetal distress.
The type of skin incision is determined by time factor, client pref. Or physician pref.
B. UTERINE INCISION
1. lower uterine segment incision - most commonly used is a transverse incision although a vertical incision may also
be used.
Disadvantage:
1.a. takes longer to make transverse incision.
1.b. limited in size bec. of the (+) of major bld vessels on
either side of uterus.
1.c. greater tendency to extend laterally into uterine vessel.
vertical incision :
preferred for multiple gestation, abnormal pres., placenta previa. Fetal distress and preterm and macrosomic fetus.
Disadvantages:
1.incision may extend downward into cervix.
3 2.More extensive dissection of the bladder is needed.
INDICATION:
1. placenta previa
4 2. abruptio placenta
5 3. breech pres.
6 4. CPD
7 5. Active genital herpes
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8 6. Umbilical cord prolapse
9 7. Failure to progress in labor
INFLAMMATORY DISTURBANCE
A. MALE
1. Orchitis - inflammation of the testes. Results from complication of mumps. If occur after puberty, it may lead to sterility.
S/Sx:
a. Pain in the scrotal sac
b. Nausea and vomiting
c. Chills
Tx:
a. Bed rest
b. Hot and cold application
c. Scrotal support
d. Gamma globulin
2. Epididymitis - infection from urine, urethra, prostate gland and seminal vesicles.
S/Sx:
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a. Difficulty in walking
b. Severe pain
c. Dysuria
c
Causes: organism as streptococci, gonococci
Tx:
a. Antibiotic
b. Bed rest
b. Scrotum should be elevated with cold towel – to relieved pain
S/Sx:
a. Enlarged prostate
b. Inflammation of inguinal area and scrotal area
Tx:
a. Antibiotic
b. Rectal irrigation of warm saline soln
Tx:
a. Systemic antibiotic
d b. Oral fluid
B. FEMALE
S/Sx :
e a. Presence of leukorrhea – primary symptom. During pre and postmenstrual days, the flow is often milky and
may appear as small, white clumps of “material”.
f b. vulvar irritation
g c. Burning, pruritus esp. after urination
h d. Redness
i e. Edema of surrounding tissues
Tx:
a. Douching with tbsp. Of vinegar to 1 qt. water or
lactacyd
b. To restore normal acidity.
j c. Hot sitz – to decrease inflammation
k d. Topical cream – may relieve discomfort
l e. Antibiotics – to eradicate the microorganism
S/Sx:
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m a. Presence of thin, gray or yellowish – greenish frothy foamy or bubbly discharge.
n b. Vulva is usually irritated, edematous
o c. Pruritus
p d. Urinary frequency
q e. Dysuria
r f. Lower abdominal pain
s g. dyspareunia
Tx:
- use of Flagyl IV or vaginally 500 mg BID for 5 days
S/E: GI disturbance
S/P: not to be used during the first trimester
Nursing Intervention:
t a. Sexual abstinence
u b. Douche
v c. Sunshine, rest and good nutrition
w d. tampoon - to absorb discharge
x e. Good perineal hygiene
S/Sx :
Tx:
S/Sx:
dd a. Offensive discharge with little or no discomfort or itching
ee b. Local evidence of infection in the epithelium
ff c. Very slight creamy discharge
gg
Tx:
hh a. Local therapy with Sulfonamides
ii b. Sulfa cream –at least 3 – 4 wks.
jj c. Terramycin supp.
kk d. Ampicillin 500 mg. q 6 hrs. x 5 days
S/Sx:
ll a. Thin, blood – tinged discharge
mm b. dyspareunia
Tx:
nn a. Estrogen therapy
oo b. Vaginal suppositories or cream (Stilbestrol 0.5 mg) 2
pp – 3 x a wk.
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6. Bacterial vaginosis/non – specific vaginitis - the most common cause of vaginal symptoms among childbearing women caused by
Gardnerella vaginalis.
Clinical signs:
qq a. Vaginal fluid pH is elevated
rr b. Amine (fishy) odor when mixed with 10% KCL
ss c. Milk like discharge
tt d. Itching, burning sensation
uu e. Pain maybe present in the vagina
Predisposing factors:
vv a. Amniotic fluid infection
ww b. PROM
xx c. Preterm labor and delivery
yy d. Post partum endometritis
zz e. PID
Tx:
aaa a. Oral Metronidazole – should be given in the 2nd and 3rd trimester
bbb b. Topical prep. Of Metronidazole and Clindamycin
S/Sx:
ccc a. Backache
ddd b. leukorrhoea
eee c. Irregular mens
Dx:
a. Speculum exam. of the cervix
fff b. cytologic smear – to R/O CA
ggg c. Biopsy
Tx:
hhh a. Cauterization
iii b. Vaginal suppositories
jjj c. Antibiotic
2. Chronic cervicitis
S/Sx:
kkk a. Persistent leukorrhea
lll b. Thick, viscid discharge
mmm c. Abdominal discomfort
nnn d. dyspareunia
ooo e. Spotting of blood between period and / after intercourse
Tx:
ppp a. cryotherapy – destruction of cervical epithelium by freezing
qqq b. Cauterization – complete healing requires 7 – 8 wks.
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3. Cervical polyp - usually small tumors arising from the cervical canal extending downward toward or through the cervical os.
Generally, benign and maybe single or multiple characterized by bright red growths.
S/Sx:
- Bleeding after coitus or may cause slight bleeding after defecation
Dx:
rrr a. Pap smear
sss b. Inspection of polyp
ttt c. Biopsy of cervix and endometrium if bleeding persist
4. Ectoplasia or erosion - deep red appearance on the face of the cervix resulting from trauma or infection.
Tx:
uuu a. electrocautery
vvv b. Use of vinegar ( acid ) douches
5. Laceration - deep extensive laceration either bilateral or stellate.
6. Cervical stenosis - may occur after laceration, cone biopsy, cryotherapy or cervical cauterization, and in cervical CA during
radiation therapy. If due to atrophy, it is not symtomatic. If malignancy occur, blood or mucus may fill the cavity and cause pain and
cramping.
S/Sx::
dysmenorrhea
Tx: drainage
A. Inflammatory diseases:
The vulvar skin maybe the site of any and all of the common dermatologic diseases caused of local irritants like vaginal
discharges, menstrual fluids, urine, feces and secretion from skene gland.
Clinical signs:
www a. Skin is erythematous ( initial phase )
xxx b. Linear fissuring
yyy c. Thickening and cracking skin
Tx:
zzz a. Drying powders
aaaa b. Elimination of tight undergarments
2. Seborrhea and seborrheic dermatitis - excessive secretion of the sebacious glands into both labial folds produces an irritation
and later, demonstrate crushing and scaling of the skin.
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Tx:
bbbb a. Bed rest
cccc b. Analgesic – to relieve pain
dddd c. Local thermotherapy ( ice pack or hot sitz )
eeee d. Antibacterial therapy
ffff e. I and D - if abcess formation is noted
2. Sebaceous or inclusion cysts - results from inflammatory blockage of the ducts of sebaceous glands and are usually small, most
commonly on the inner surfaces of the labia majora and minora.
They contain a cheesy sebaceous material with formation of small furuncle like abscess.
Tx:
if it is small and asymptomatic – no treatment required
gggg if it is large and annoying – excision is required
1. Myoma - muscle tumor, which composed chiefly of, unstripped muscled fibrous connective tissue.
Often called fibroids
They occur single or multiple
Cause is unknown
Location maybe cervical or corporal
S/Sx :
hhhh 1.hypermenorrhea – due to excessive estrogen effect
iiii 2. Bearing down sensation
jjjj 3. Pressure symptoms
kkkk 4. Pelvic pain
llll 5. Bladder disturbance
mmmm 6. Presence of mass upon palpation
1. Simple cysts
a. Follicular cysts - varies from a small, pea sized structure to a size of an egg. It may be unilateral or bilateral. It
contains a clear, serous fluid. It represent an altered graafian follicle
b. Corpus luteum cysts – lined with slightly yellowish epithelium and filled with a pale yellowish – stained clear
fluid. It is usually unilateral.
2. Dermoid cysts – there is filled with sebaceous material elaborated by the skin – like lining. It contains abundant hair, cartilage,
bone, teeth, brain cells and other tissues. It can be unilateral or bilateral and usually seen in young women.
these involve the uterus, fallopian tubes, ovaries, peritoneum or any extension from these organs.
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Etiology:
a. Gonorrheal – due to infection by Neisseria gonorrheae
b. pyogenic - due to infection by a large variety of organism like E. coli and streptococci
S/Sx :
a. Severe pain in the pelvis and lower abdominal region
nnnn b. Muscular rigidity and tenderness
oooo c. Abdominal distention
pppp d. Nausea and vomiting
qqqq e. Fever
rrrr f. Rapid pulse
Tx :
a. Bed rest e. avoid sexual relation
b. Adequate IVFf. Hot compress at lower back
c. Analgesic g. sitz bath
ssss d. Antibiotic
VII. ENDOMETRIOSIS
A condition characterized by presence of endometrial tissue outside the endometrial cavity. This occurs at any age after
puberty.
Symptoms:
vvvv a. dysmenorrhea
wwww b. Pain on defication during the time of menstrual cycle
xxxx c. Pelvic heaviness
yyyy d. dyspareunia
zzzz e. Abnormal uterine bleeding
Dx:
aaaaa a. laparoscopy - exam. of the interior of the abdomen
bbbbb by inserting a small telescope through anterior abdl. Wall.
ccccc b. laparotomy
ddddd c. Bimanual exam.- may reveal a fixed, tender, retroverted uterus and
eeeee Palpable nodules.
Tx:
a. Depends on the severity of symptoms:
fffff b. Mild - require analgesic
ggggg c. Severe – treated with low estrogen to progestin ratio oral
hhhhh d. Contraceptive - to shrink endometrial tissue
Danazol – a mildly synthetic androgenic steroid that suppress FSH and LH secretion
S/E:
a. masculinizing traits in woman
iiiii b. Weight gain
jjjjj c. Decrease breast size
kkkkk d. Edema
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lllll e. Migraine headaches
mmmmm f. Decrease libido
nnnnn g. Dizziness
a. Not in used in pregnant woman – can produce pseudohermaphroditism in female fetus
ooooo b. Contraindicated with liver disease
ppppp c. Should used in caution with cardiac and
qqqqq renal disease
S/Sx :
rrrrr a. Often asymptomatic
sssss b. Thin or purelent discharge
ttttt c. Burning and frequency of urination
uuuuu d. dyspareunia
vvvvv e. Lower abdominal pain
Tx :
zzzzz a. Non pregnancy: doxycycline or tetracycline
aaaaaa b. Pregnancy: erythromycin or amoxycillin
2. Gonorrhea - caused by Neisseria gonorrheae spread by direct contact and indirect contact through inanimate object or fomites.
(Secretion on fomites such as washcloths, towels, blood linens and clothing often are implicated)
S/Sx :
bbbbbb a. dysuria and urinary frequency
cccccc b. Heavy green – yellow purelent discharge
dddddd c. Cervical tenderness
eeeeee d. dyspareunia
ffffff e. Post – coital bleeding
gggggg f. Lower abdominal pain
hhhhhh g. In some cases, swollen and inflammation of the vulva
iiiiii Occur
Tx:
a. For non-pregnancy and pregnancy: antibiotic therapy such as cefriaxone 250 mg IM OD + doxycycline 100 mg PO BID
x 7 days. If allergy with cefriaxone, spectinomycin is given followed by doxycycline
b. Sexual partners should be treated
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Neonatal effect:
jjjjjj a. Ophthalmia neonatorum
kkkkkk b. Pneumonia
3. Syphilis – caused by treponema pallidum. It can be acquired congenitally through transplacental inoculation (16th – 18 wks of
gestation).
S/Sx :
c. Tertiary stage- Clinical evidence of disease throughout the body especially bones, cardiac and neurologic.
wwwwww
Fetal / neonatal effect:
Primary and secondary stages of untreated syphilis lead
to stillbirth, preterm birth and neonatal death.
Dx :
xxxxxx a. Dark field exam.
yyyyyy b. Blood test such as VDRL (venereal disease
zzzzzz Research lab)
Tx: penicillin
4. Herpes simplex virus (HSV) type 2 - is usually associated with genital infection and can occur as oral lesion after oral genital
sexual contact.
S/Sx:
A. Primary:
ddddddd 1. Multiple blister like vesicle usually in the genital
Area and sometimes affecting the vaginal wall,
Cervix, urethra and anus.
eeeeeee 2. Painful blister form, rupture and drain leaving
fffffff Shallow ulcers that crust over and disappear after 2 – 6 wks.
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ggggggg 3. Fever
hhhhhhh 4. Malaise
iiiiiii 5. Anorexia
jjjjjjj 6. dysuria
kkkkkkk 7. dyspareunia
B. Recurrent:
1. pruritus
lllllll 2. Burning sensation the genital area
mmmmmmm 3. Slight increase in vaginal discharge
Effects on pregnancy:
nnnnnnn a. Spontaneous abortion
ooooooo b. preterm labor
ppppppp c. IUGR
Dx:
a. cytologic testing
b. b. pap smear
Tx :
ttttttt a. Zovirax ointment – to reduce viral shedding and
uuuuuuu Healing time of lesion
b. Cleansing with betadine solution – to prevent
vvvvvvv Secondary infection
wwwwwww c. Burow’s solution – to relieve discomfort
xxxxxxx d. Keeping genital area clean and dry
yyyyyyy e. Wear loose clothing and cotton underwear
zzzzzzz f. Advised to abstain from sexual activity while lesion
aaaaaaaa are present
bbbbbbbb g. Bed rest
S/Sx :
jjjjjjjj a. wartlike exposure on the vulva, vagina, cervix,
kkkkkkkk Rectum, buttocks and inner thigh
llllllll b. Chronic vaginal discharge
mmmmmmmm c. dyspareunia
nnnnnnnn d. pruritus
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Dx : a. colposcopy
oooooooo b. Direct visualization of growth
pppppppp c. Biopsy
Tx :
qqqqqqqq a. cryotherapy – to destroy the lesion
rrrrrrrr b. Knife excision
ssssssss c. Application of podophyllin topically then wash it off 4
tttttttt Hrs. after
uuuuuuuu d. Application ( for pregnant : trichloroacetic acid )
vvvvvvvv e. Laser therapy
Caused by Phythirus thay lays eggs and attach to the hair shaft. It can be transmitted through shared towels and
bed linens.
S/Sx :
wwwwwwww a. Intense pruritus in areas covered by pubic hair
xxxxxxxx b. “ crabs” or brown – red spots may be noted in the
yyyyyyyy Underwear.
Tx :
zzzzzzzz a. Application of 1 % Permethrin cream for 10 mins.
aaaaaaaaa Plus combing of the pubic hair with fine toothcomb.
bbbbbbbbb b. Should be instructed to launder or dry clean all
ccccccccc Contaminated linens or clothing.
Caused by HIV. The HIV enters the body through blood, blood products and other fluids such as semen, vaginal fluid
and breast milk. Although the virus has been isolated in urine, tears, CSF, lymph nodes, brain tissue and bone marrow.
Individuals generally develop antibodies and test ( + ) for HIV within 2 – 12 wks. after exposure, although some people will
take up to mos. To develop antibodies. A person with HIV ( + ) are usually asymptomatic and remain for 5 – 7 yrs. or more .
MODERATELY SAFE:
a. french kissing ( wet ) d. fellatio interruptus
b. Anal intercourse with condom e. cunnillingus
c. Vaginal intercourse with condom
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UNSAFE SEX PRACTICE:
a. Anal intercourse without condom
b. Vaginal intercourse without condom
c. Fisting (manual - anal contact)
d. Fellatio with semen ingestion
e. Rimming (oral – anal contact)
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I. DYSTOCIA – refers to difficulty in labor characterized by abnormally slow progress of labor.
Factors which causes dystocia ( 3 P’s )
1. Power 2. Passenger 3. Passage
POWER – during the first stage of labor, the latent phase is said to be prolonged if it is > 20 hours in the nullipara and > 14
hours in parous women.
CATEGORIES OF DYSTOCIA
A. UTERINE DYSTOCIA
Causes:
1. Uterine dysfunction/ dysfunctional labor – problem of inadequate force described or characterized by abnormal uterine
contraction that prevent normal progress of cervical dilatation, effacement and descent.
Causes:
a. malposition
b. fetopelvic disproportion
c. Overstretched uterus due to twin, big baby, hydramnios
d. Lax uterus due to grand multi.
Maternal risk:
a. Intrauterine infection – due to vaginal exam.
b. Post-partal hemorrhage – due to inadequate uterine that has been present and may persist after
birth.
c. Maternal exhaustion
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Fetal risk:
a. Fetal and neonatal distress
b. Sign of sepsis
Management:
1 1.amniotomy maybe done
2 2.intravenous fluid
3.oxytocin IV – to improve quality of uterine
Contraction
4.C/S – if fetal descent does not occur
Management:
a. Bed rest
b. Monitor progress of labor and FHB
c. Sedation
d. Administered adequate fluid
e. C/S – if fetal distress occur
NOTE: Oxytocin is not administered because it is likely to accentuate the abnormal labor pattern.
2. Pathologic retraction ring / Bandl’s ring – marked stretching and thinning of the lower uterine segment. It occur at any
stage of labor. When it occurs during the 1st stage, it is the result of uncoordinated contraction. During 2nd stage, it is
caused by obstetric manipulation. During 3rd stage, it is the result of administration of oxytocin.
Management:
a. C/S
b. Administration of IV morphine sulfate – to relieve the retraction ring.
3. Prolonged labor- labor lasting >24 hrs. The cervix fails to dilate within a reasonable period of time. Labor was not
considered prolonged unless 24 – 48 hrs. Had lapsed.
Principal causes:
a. CPD
b. Malpresentation
c. Malposition
d. Labor dysfunction
e. Cervical dystocia
Other causes:
f. excessive use of analgesia / sedative
g. PROM in the present of uneffaced, closed cervix
h. Reduced pain tolerance
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Maternal risk:
a. Maternal exhaustion
b. Infection and hemorrhage from uterine atony
Fetal risk:
a. Fetal distress
b. PROM – increase risk of infection
c. Prolapsed cord
Management:
a. adminitration of oxytocin
b. amniotomy
c. intravenous fluid
d. rest and sedation
e. forcep delivery or C/S
Causes:
a. prolonged labor f. VBAC
b. faulty presentation g. weakened C/S scar
c. multiple pregnancy
d. unwise use of oxytocin
e. traumatic maneuver – version or difficult forcep
Classification:
2.1. complete – extend through the 3 muscle layer of uterus
2.2. incomplete – involves the whole myometrium but the peritoneum remain intact
2.3. spontaneous – occurs during labor
2.4. traumatic – associated with manipulation
Fetal-neonatal risk:
a. fetal distress
b. fetal mortality
Management:
a. medical mgt. of shock
b. STAT C/S then hysterectomy
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S/S:
a. Woman in strong labor suddenly sit up
b. Grasps her chest – due to dyspnea
c. Sharp pain
d. Pale and cyanotic
e. Death may occur in minutes
Management:
a. O2 administration
b. Maintenance of cardiac output
Maternal risk:
a. May experience respiratory distress
b. Increased maternal mortality
Maternal risk:
a. may experienced shortness of breath and edema in the lower extremities.
b. Intrapartal uterine contraction
c. Post partum hemorrhage
Fetal-neonatal risk :
a. Fetal malformation
b. preterm birth
Management:
a. Hospitalization is required
b. Removal of fluid – amniocentesis with the aid of UTZ
Diagnosed on UTZ – when the largest vertical pocket of amniotic fluid is 5 cm or less.
Found in cases of postmaturity with IUGR secondary to placental insufficiency.
2. During labor and birth period – cord compression is more likely to occur because of the lessened
amount of fluid reduce the cushioning effect for the umbilical cord.
Medical therapy:
1. During antepartal period - fetus can be assessed by biophysical profiles, NST and serial UTZ.
2. During labor – continuous EFM – to detect cord compression. ( by baseline bradycardia and / or moderate
or severe variable deceleration.)
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B. FETAL DYSTOCIA
Causes:
1.) Malpresentation
Classification:
1. A. Breech presentation
Complication to be anticipated:
a.1. perinatal morbidity and mortality
From difficult delivery
a.2. LBW from prematurity, growth
Retardation
a.3. Prolapsed cord
a.4. Placenta previa
a.5. Multiple fetuses
Sub – classification:
a.1. Frank breech – lower extremities are flexed at
The hips and extended at the knee.
a.2. Complete breech – one or both knees are flexed
a.3. Footling breech – one or both feet is at the
Lowermost in the birth canal.
Diagnosis:
1. abdominal exam. – leopold’s maneuver
LM 1 – hard, round, readily ballotable fetal head is
found to occupy the fundus.
LM 2 – indicates the back to be on one side of the
abdomen and the small parts on the other.
LM 3 – breech is movable above the pelvic inlet.
LM 4 – firm breech to be beneath the symphysis.
2. Vaginal exam. – Both ischial tuberosities, sacrum and the anus are palpable.
3. X – ray and ultrasound
b. Prague maneuver – this is used in case the back of the fetus fails to rotate to the anterior. A strong
traction on the fetal legs is applied with 2 fingers of one hand grasping the shoulder of the back down
the fetus from below, while the other hand draws the feet up over the abdomen of the mother.
d. Pinard maneuver – used in extraction of frank breech and maybe accompanied by modified traction
exerted by a finger in each groin and facilitated by a generous episiotomy. Two fingers are carried up
along one extremity to the knee to push it away from the midline.
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Maternal risk: prolonged labor
Fetal risk:
a. head entrapment
b. high incidence of perinatal mortality – associated with trauma to the head
c. cord prolapsed – if BOW is ( - )
Management:
a. perform version
VERSION – turning the fetus; a procedure used to change the fetal position by abdominal or
intrauterine manipulation.
Types of version:
a. 1.external version – usually done after 37th wks. gestation. This is an external manipulation of the
maternal abdomen.
Requirement:
a. presenting part is not engaged
3 b. normal amount of amniotic fluid
4 and intact BOW
5 c. no sign of fetal distress
6 d.the woman is not obese
Contraindication:
a. ruptured membrane
b. ( + ) of uterine contraction
c. IUGR
d. Placenta previa
e. Previous C/S
a.2.internal version – turning the fetus by inserting a hand into the uterine cavity. This is used only
with the 2nd twin during a vaginal delivery.
b.fetal monitoring
c. C/S – if version is unsuccessful
Fetal risk:
a. may develop caput succedaneum
5 b. edema of the face after birth
6 c. infection
Management:
a. vaginal delivery if no evidence of fetal distress
b. C/S – in case of CPD
Management:
a. forcep delivery
b. C/S – if fetal distress is suspected
4.A. Shoulder presentation or transverse lie
The infant’s long axis lies across the woman’s abdomen and on inspection, the contour of the maternal
abdomen appears widest from side to side.
Etiology:
a. grandmulti with lax uterine musculature
b. preterm fetus
c. obstruction – placenta previa; neoplasm
d. hydramnios
e. contracted pelvis
Diagnosis:
a. Leopold’s maneuver
LM 1 – no fetal pole is detected in the fundus
LM 2 – ballottable head is found in one iliac fossa and the breech in the other.
LM 3 – negative
LM 4 – negative
FHB are heard just below the midline of umbilicus.
b. vaginal exam. – in early stages of labor, the side of the thorax may be recognized.
Maternal risk:
a. uterine rupture
b. infection in case of prolonged labor
Fetal risk :
a. prolapsed cord
b. prolapsed fetal arm
c. may die from asphyxia and trauma
Management:
C/S
Management: C/S
Occult cord prolapse – when the umbilical cord lies besides or just ahead of the fetal head.
Most likely to occur in :
a. malpresentation
b. LBW
c. Multipara
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d. Multiple gestation
e. Presence of long cord
Fetal risk:
a. umbilical cord compression
b. bradycardia and persistent variable deceleration may develop
Management:
a. put patient in bed STAT and in T – berg position – because the possibility of cord compression is
high and reduce pressure on the cord.
b. Monitor FHB
c. Apply a warm, saline saturated OS on the cord
d. C/ S
Division of fertilized ovum at various early stages of development as follows ( Genesis of monozygotic twin):
a. If the fertilized ovum divides within the 1st 72 hours past fertilization, the twin will be diamniotic,
dichorionic monozygotic twin.
b. If the division occurs from the 4th – 8th day past fertilization, the embryos will develop each in separate
amniotic sacs termed as diamniotic , monochorionic, monozygotic twin.
c. If the division happens after the 8th day, the twin will share both common amniotic sac termed as
monoamniotic, monochorionic, monozygotic twin.
Etiology :
a. Fraternal – occur from 2 separate ova ( dizygotic ) and they maybe the same sex or different sexes. –
diamniotic, dichorionic ( 2 amnion and chorion )
b. Identical – occur from 1 fertilized ovum ( monozygotic ) and are always of the same sex.
2. During labor
2.a. uterine dysfunction – due to over stretched
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myometrium
2.b. abnormal fetal presentation
2.c. preterm labor
7 3. perinatal mortality
8 4. LBW
9 5. Uterine atony
10 6. Hydramnios
Medical therapy:
a. comprehensive prenatal
b. ultrasound – to assess the growth of each fetus
c. bed rest in lateral position – enhance uterine placental- fetal blood flow and decrease the risk of preterm
labor.
d. Non stress test – at 30 – 34 wks AOG
e. During intrapartal – anesthesia and x – matched blood should be readily available.
- electronic fetal monitoring
3.) Malposition
Management:
a. vaginal delilvery is possible as follows:
1. await spontaneous birth
2. forcep – assisted
3. forcep rotation using Scanzoni maneuver or manual rotation to OA
b. C /S – in case of CPD
Factors to be considered:
a. large size of the parents especially the mother
b. multiparity
c. maternal diabetes
d. maternal obesity
e. prolonged gestation
f. previous delivery of an infant weighing >4000g
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Maternal risk:
a. may lead to dysfunctional labor – due to distention of the uterus
b. increase incidence of post partum hemorrhage
c. increase chance of uterine rupture
d. increase incidence of perineal laceration
Fetal risk:
a. asphyxia
b. brachial plexus injury – due to improper or excessive traction applied to the fetal head.
c. Shoulder dystocia – difficulty in the birth of shoulder or impaction of the shoulder.
Management:
a. ultrasound or x – ray pelvimetry
b. use of Mc Robert’s maneuver
c. enlarge the episiotomy
d. assess FHB for fetal distress
4.2. Hydrocephalus
Excessive accumulation of cerebrospinal fluid in the ventricles of the brain with consequent
enlargement of the cranium. The volume of fluid is usually between 500 – 1,500 ml.
Maternal risk:
a. obstruction of labor
b. uterine rupture may occur if the uterus is allowed to continue contracting.
Diagnosis: ultrasound
Management:
a. cephalocentesis – removal of CSF
b. C/S
Sites:
a. thoracopagus – shared body site is anterior
b. pyopagus – posterior
c. craniopagus - cephalic
d. ischiopagus – caudal
3 groups:
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a. incomplete formation at the upper or lower half of the body ( diprosopus dipygus )
b. twins that are united at the upper or lower end of the body (craniopagus, pygopagus)
c. Double monster – united at the trunk ( dicephalus )
Management: a vaginal delivery is possible although dystocia is common and if the fetuses are
mature, traumatic delivery may experience.
4.4. Anencephaly
Condition in which the fetal cerebrum and cranium fail to develop.
Appearance of the fetus sometimes referred to as “ anencephalic monster”
Face is prominent with protruding eyes and cranial vault is absent.
Cause is unknown
Commonly accompanied by hydramnios
Diagnosis can be confirmed by UTZ and amniocentesis.
Maternal implication:
tend to be prolonged and induction of labor is difficult – uterus may not be responsive to oxytocin.
Nursing responsibilites:
1. Provide physical and emotional support
2. Provide information sensitively
3. Acknowledge the loss and grieving of family members
C. PELVIC CONTRACTION
Causes:
Maternal effect:
a. abnormal cervical dilatation
b. danger of uterine rupture and pathologic retraction ring
c. intra partum infection
Fetal effect:
a. caput succedaneum
b. fetal head molding – can result in skull fracture or intracranial hemorrhage
c. cord prolapse – if membranes ruptured and fetal head has not entered the inlet
Maternal risk:
a. prolonged labor in the presence of CPD
b. PROM
c. Uterine rupture
Management: C /S
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D. SOFT TISSUE ABNORMALITIES OF THE REPRODUCTIVE TRACT
1. VULVAR ABNORMALITIES
1.1. Edema – venous thrombosis and hematoma may cause edema and significant pain and make an episiotomy
difficult to perform but dystocia rarely results.
1.2. bartholin abcess – cause pain and discomfort and can be starting point of puerperal infection.
2. CYSTOCELE
Protrussion of the bladder downward into the vagina that develops when supporting structure in the vesicovaginal
septum are injured.
Anterior wall relaxation gradually develops often after several babies. When the woman stands, the weakened
anterior vaginal wall cannot support the weight of the urine in the bladder, the vesicovaginal septum is forced
downward.
It is recognized as bulging of the anterior wall of vagina.
3. RECTOCELE
Herniation of the anterior rectal wall through the relaxed or ruptured vaginal fascia and rectovaginal septum.
It can cause disturbance in bowel function, the sensation of “ bearing down”.
4. DISPLACEMENT
4.1. uterine prolapse – occurs when the cardinal ligaments that supports the vagina and uterus donot return to
normal after delivery and when the relationship of the axis of the uterus to that of the vagina is altered.
Always accompanied with cystocele and rectocele.
4.2. retroversion
most common displacement
maybe congenital or a sequel to childbirth
5. Presence of tumor
Etiology:
During fetal development, the female reproductive tract is formed by the fusion of the 2 mullerian
ducts. Anomalies arise primarily from the alteration of the fusion process. Failure of the duct to fuse
normally results in 2 partially or completely separated tracts.
Structural abnormalities:
10.1 Uterine abnormalities
4 types:
a. Septate uterus – appears normal from the exterior, but it contains a septum that extends
partially or completely from the fundus to the cervix, dividing the uterine cavity into 2
separate compartment.
b. Bicornuate uterus – roughly Y –shaped. The fundus is notched to various depth and the
patient may even appear to have a “ double uterus” however, there is only 1 cervix.
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c. Double uterus – results from lack of midline fusion, and 2 complete uterine, each with its
own cervix are formed.
d. Uterus didelphys – when both are fully formed.
e. Hemiuterus – results when one mullerian duct fails to develop during embryonic growth,
resulting in 1 uterine cavity and 1 oviduct.
Malformation of the uterus may cause difficulty when pregnancy occurs. The uterus may not be able to
stretch sufficiently to accommodate the growing fetus.
If the woman has abnormal external genitals – surgical reconstruction of abnormal tissue and
construction of functional vagina may permit normal intercourse.
Surgical intervention depends entirely on the anatomic devt.
May affect labor and birth depending on the ability of the cervix to dilate and efface.
Tx:
a. surgical tx for structural abnormalities
b. C / S
Nursing Responsibilities:
a. assessment and close monitoring of progress of labor
b. monitor for sign of dystocia
11 II. Precipitate labor – extremely rapid labor that last for <
3 hrs.
Causes:
a. Abnormal low resistance in maternal tissues
b. Strong uterine contraction
c. Lack of pain sensation
d. multiparity
e. oxytocin overdose
f. Large pelvis
Maternal risk:
a. severe laceration
b. possibility of uterine rupture
c. post partum hemorrhage
d. amniotic fluid embolism
Fetal-neonatal risk:
a. subdural hemorrhage
b. increased intracranial pressure
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c. injury secondary to fall
d. laceration or rupture of the cord
Management:
a. Allow the baby to be born and to catch the baby
b. Do not hold the baby back nor “ lock” the mother’s leg in an attempt to delay delivery – may result in damage
to the maternal soft part and baby’s brain.
Precipitate delivery –refers to sudden, unexpected and unprepared delivery under unsterile condition.
When the oxygen supply is insufficient to meet the physiologic demands of the fetus.
Contributing factors:
a. Cord compression
b. uteroplacental insufficiency associated by pre existing maternal / fetal disease.
Signs:
a. Changes in FHT
b. meconium stained amniotic fluid
c. Late or severe variable deceleration or progressive acceleration – indication of hypoxia
Fetal risk:
a. Fetal hypoxia which may lead to mental retardation or cebreral palsy
b. Fetal demise (fetal death )
Management:
a. O2 inhalation
b. Positioned patient
c. Electronic fetal monitoring
d. D/C oxytocin
Causes:
1. Maternal factors
a. Cardiovascular or renal disease
b. Diabetes
c. PIH
d. Abdominal surgery during pregnancy
e. Uterine anomalies
f. Cervical incompetence
g. DES exposure
h. Maternal infection
2. Fetal factors
a. Multiple pregnancy
b. hydramnios
c. Fetal distress
3. Placental factors
a. Placenta previa
b. abruptio placenta
Maternal risk:
a. psychologic stress factors related to the concern for her unborn child
b. Physiologic maternal risk related to possible medical tx such as tocolysis and prolonged bed rest.
Management:
a. Avoid hypoxia
b. Avoid depressing the fetal respiratory center with excessive analgesic drugs
c. Use epidural analgesia
d. Use C/S particularly in breech presentation
e. Reduce trauma to the fetus particularly the skull in vaginal delivery
Etiologic factors:
Hormonal changes of estrogen, progesterone and prostaglandin
Maternal risk:
a. Increase incidence of operative birth
b. oligohydramnios may be present
Diagnosis:
1. (-) fetal movement
2. (-) FHB
3. Uterine growth ceases
4. Uterine size decrease
5. Fetal heart movement cannot be visualized by UTZ
6. x – ray detected by the appearance of intravascular or intra abdominal fetal gas ( Robert’s sign )
Etiology:
associated with severe maternal DM, pre eclampsia, placenta previa and umbilical cord accident.
Management:
A. At 12 wks.
1. Confirmation of diagnosis – to diagnose fetal death ASAP through UTZ
2. D/C of uterine contents – to evacuate
3. Prescription of analgesic
B. 13 – 28 wks
1. Confirmation
2. Induction of labor after 3 wks of fetal death
3. Labor and delivery of product of conception
4. Prescription of analgesic and methergin
5. Uterine curettage – to ensure removal of all tissue
6. Cervical inspection for trauma
C. > 28 wks.
Same as above
Classification of hemorrhage:
1.1. Early post partum hemorrhage – or immediate post partal hemorrhage.
Occur within the 1st 24 hrs. After birth.
Causes:
A. Uterine atony - failure of the uterus to contract adequately. This is the most common cause of
early post partum hemorrhage.
Predisposing factors:
a.1. overdistention of the uterus
a.2. Dysfunctional labor
a.3. Excessive analgesia during labor or
Prolonged anesthesia after sedation
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a.4. oxytocin use
a.5. Trauma due to obstetric procedure or
Manipulation
a.6. grandmultiparity
Management:
a.1. Massage the uterus – initial action
a.2. Ice compress
a.3. oxytocin administration
a.4. emptying the bladder
a.5. Bimanual uterine compression – if
Bleeding is excessive
a.6. O2 via mask
a.7. Check the cervix and vagina for Laceration
Can be detected when bright red bleeding persists in the presence of firmly contracted uterus.
Management:
episiorrhaphy
C. Retained placenta – the most common cause is due to massage of the fundus prior to placental
separation.
Management:
c.1. manual removal of the placenta
1.2. Late post partum hemorrhage - generally occurs 1 – 2 wks after delivery and most often results of abnormal
involution of the placental site.
Predisposing factors:
retained placental fragments
Management:
curettage
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2. Boggy fundus that does not respond to massage
3. Abnormal clots
4. Any unusual pelvic discomfort or backache
5. Persistent bleeding in the presence of firmly contracted uterus
6. Rise in the level of the fundus of the uterus
7. Increase pulse rate or decrease BP
8. hematoma formation or bulging/ shiny skin in the perineal area
9. Decrease level of consciousness
2. HEMATOMA / PUERPERAL HEMATOMA – occur as a result of injury to a blood vessel, often without noticeable
trauma to the superficial tissue.
Predisposing factors:
a. PIH
b. Genital varicosities
c. Increase vascularity
d. Use of pudendal regional anesthesia
e. Precipitate labor
f. Prolonged 2nd stage of labor
g. Forcep – assisted birth
Classification:
2.1.Vulvar - most opften involve branches of
12 the pudendal artery including the posterior
13 rectal, transverse perineal or posterior labial
14 artery.
2.2.Vaginal – may involve the descending branch
of the uterine artery.
2.3.Vulvovaginal
15 2.4.Retroperitoneal
Management:
a. small vulvar hematoma may be treated with the application of ice pack.
b. Large hematoma require surgical intervention
c. Antibiotic
d. Vaginal packing
Predisposing factors:
A. Antepartum
a. Anemia
b. Nutrition
c. Sexual intercourse
B. Intrapartum
a. Bacterial contamination
b. Trauma
c. Blood loss
d. PROM
e. Excessive i.e. during labor
Types of infection :
3.1. Lesion of the perineum, vulva, vagina and cervix
is a localized infection of repaired laceration or
episiotomy.
most common puerperal infection.
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Clinical sign: red, brawny and swollen
Necrotizing fasciitis – an infection of the superficial fascia and subcutaneous tissue arising from an
episiotomy site.
Early sign:
erythema , edema and induration at the
episiotomy site with later devt. Of skin
Discoloration.
Tx:
1. Analgesic
2. Antibiotic therapy
3. Stitches should be removed
4. sitz bath
3.2.Endometritis / metritis
After placental expulsion, the placental site provides an excellent culture medium for bacterial growth.
Clinical sign:
a. Fever
b. Abdominal pain or tenderness on one or both side of abdomen
c. After pain
d. Foul smelling lochia
Tx: analgesic
Nursing care:
1. Place patient in fowler’s or semi – fowler’s position
2. Fluid intake 3000 – 4000 ml ( if not contraindicated )
3. Provide high caloric foods
Clinical sign:
a. Pain may be severe
b. Marked bowel distension
Tx:
a. IVF
b. Broad – spectrum antibiotic
c. Should be treated surgically
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Sign:
a. Puerperal fever c. chills
b. Engorged breast d. abcess ( if untreated )
Classification:
4.3.1. Milk stasis – a mild, short – lived condition, usually without fever and not requiring antibiotic.
Causes:
a. Tight clothing
b. Missed feeding
c. Poor support of pendulous breast
4.3.3. Infectious mastitis – a more serious infection with fever, headache, flulike symptoms and warm,
reddened, painful area of the breast.
Tx:
a. Bed rest
b. Increased fluid intake
c. Supportive bra
d. Feeding the baby frequently
e. Local application of heat
f. Analgesic
4. SUB INVOLUTION
Occurs when the uterus fails to follow the normal pattern of involution.
Causes:
a. Retained placental fragments
b. Infection
Tx:
a. Methergin 0.2 mg every 4 hrs. for 24 – 48 hrs.
b. when metritis is present – antibiotics
c. curettage – if treatment is not effective
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